Gina Rossi

Personality Disorder Dysfunction Versus Traits: Structural and Conceptual Issues

As it stands now, the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, in press) will maintain the categorical model and criteria distinguishing the 10 personality disorders (PDs) described in the fourth edition of the manual (DSM-IV; American Psychiatric Association, 1994). An alternative diagnostic proposal based on two criteria, being impaired personality functioning and the presence of maladaptive traits, will be referred to a special section for further research and clinical evaluation. Two issues pertaining to this alternative diagnostic approach need further clarification. First, more insight is required in the specific nature of personality dysfunction, its underlying structure, and optimal operationalization. Second, confusion still exists about how personality dysfunction and traits are interconnected and how they both contribute to the PD diagnosis. The current study addresses both issues empirically in a sample of 159 psychiatric patients by (a) investigating the structure of personality functioning as assessed by the Severity Indices of Personality Problems (SIPP-118), and (b) determining the incremental validity of the resulting dysfunction factors vis-à-vis trait domains (measured by the NEO Personality Inventory-Revised [NEO-PI-R]) in explaining DSM-IV PD variance. Trait and dysfunction dimensions were strongly correlated but showed significant, though limited, incremental validity above each other. Implications for the conceptualization of personality pathology are discussed.

Issues regarding the proposed DSM-5 personality disorders in geriatric psychology and psychiatry

The official introduction of the psychiatric diagnosis of personality disorders (PDs) in the Diagnostic and Statistical Manual of Mental Disorders (DSM) began in 1952 with the publication of the first edition (American Psychiatric Association, 1952). DSM-I contained 12 main types of PDs with a total description for all types in only two paragraphs. In the following DSM-II (American Psychiatric Association, 1968), just 10 specific types of PDs were described, including a very brief general definition of PDs. The DSM-III (American Psychiatric Association, 1980) included a significant paradigm shift from the medical model by incorporating the design of a multi-axial approach, in which the combinations of symptoms of more than five primary axes were used to describe the pathological state and formulate the diagnosis. Notably, the PDs were placed on a separate axis (Axis II) to distinguish their long-standing nature from the more episodic clinical disorders placed on Axis I. PDs were recognized as important formal diagnoses and included a more comprehensive listing of polythetic diagnostic criteria for each specific PD.

HIERARCHICAL STRUCTURE OF MALADAPTIVE PERSONALITY TRAITS IN OLDER ADULTS: JOINT FACTOR ANALYSIS OF THE PID-5 AND THE DAPP-BQ

In DSM-5, the categorical model and criteria for the 10 personality disorders included in DSM-IV will be reprinted in Section II. Moreover, an alternative dimensional classification model will appear in Section III. This alternative DSM-5 proposal for the diagnosis of a personality disorder is based on two fundamental criteria: impairments in personality functioning (Criterion A) and the presence of pathological personality traits (Criterion B). In the maladaptive trait model that has been developed to operationalize Criterion B, 25 pathological traits are organized according to five higher order dimensions. The current study focuses on the convergence of the proposed DSM-5 trait model (as measured by the Personality Inventory for DSM-5 [PID-5]) with the Dimensional Assessment of Personality Pathology (DAPP) model (as measured by the Dimensional Assessment of Personality Pathology-Basic Questionnaire [DAPP-BQ]) in a sample of older people. A joint hierarchical factor analysis showed clear convergence between four PID-5 dimensions (Negative Affect, Detachment, Antagonism, Disinhibition) and conceptually similar DAPP-BQ components. Moreover, the PID-5 and the DAPP-BQ showed meaningful associations on different levels of their joint hierarchical factor structure. Methodological and theoretical implications of these initial results for the conceptualization of personality pathology are discussed.

Personality disorders in older adults: emerging research issues.

Empirical research focusing on personality disorders (PDs) among older adults is mainly limited to studies on psychometric properties of age-specific personality tests, the age neutrality of specific items/scales, and validation of personality inventories for older adults. We identified only two treatment studies—one on dialectical behavior therapy and one on schema therapy—both with promising results among older patients despite small and heterogeneous populations. More rigorous studies incorporating age-specific adaptations are needed. Furthermore, in contrast to increasing numbers of psychometric studies, the Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 pays little attention to the characteristics of older adults with PDs. Moreover, the constructs “personality change due to another medical condition” and “late-onset personality disorder” warrant further research among older adults. These needs will become even more pressing given the aging society worldwide.

Validity of the Self-Report Psychopathy Scales (SRP-III Full and Short Versions) in a community sample

The psychometric properties of the 64-item Self-Report Psychopathy Scale–III (SRP-III) and its abbreviated 28-item SRP–Short Form (SRP-SF) seem promising. Still, cross-cultural evidence for its construct validity in heterogeneous community samples remains relatively scarce. Moreover, little is known about the interchangeability of both instruments. The present study addresses these research gaps by comparing the SRP-III and SRP-SF factorial construct validity and nomological network in a Belgian community sample. The four-factor model of psychopathy was evaluated (N = 1,510) and the SRP scales’ relationship with various external correlates (i.e., attachment, bullying and victimization, right-wing attitudes, right-wing authoritarianism, and response styles) was examined (n = 210). Both SRP versions demonstrated a good fit for the four-factor model and a considerable overlap with the nomological network of psychopathy. The results suggested that the SRP-SF provides a viable alternative to the SRP-III for assessment in the community. Theoretical and practical implications are discussed.

Personality Traits and Personality Disorders in Late Middle and Old Age: Do They Remain Stable? A Literature Review

We reviewed the evidence regarding which personality traits and personality disorders remain stable into later middle and old age (age >60 years of age) and how expressions of (maladaptive) personality traits affect personality assessment among older adults. Our study was a literature review of longitudinal and cross-sectional studies of the Five Factor Model (FFM) or DSM personality disorders in old age, using PsychInfo, Psychlit, and PubMed (period 1980–2012). Combinations of the following keywords were used: personality, development, stability, five factor personality model, big 5, (borderline) personality disorder(s), aging, older adults. Of the 22 relevant articles that were found, 17 longitudinal or cross-sectional studies of the FFM mainly supported the hypothesis that personality characteristics are susceptible to change over a person’s entire lifetime. Neuroticism, Extraversion, and Openness appear to diminish as a person ages, while, conversely, Agreeableness and Conscientiousness appear to increase with age. Two longitudinal studies and three cross-sectional studies of DSM-IV personality disorders suggested there are age-related changes in the ways in which maladaptive personality traits manifest themselves. The temporal instability of personality traits in old age, both adaptive and maladaptive, affects the validity of personality assessment of older adults, especially the face validity. We recommend personality assessment measures that include only age-neutral items. Informant contributions to the personality assessment could also be helpful in improving the reliability in epidemiological research.

Effects of schema group therapy in older outpatients: a proof of concept study

BACKGROUND Short-term group schema cognitive behavior therapy (SCBT-g) showed improvements in overall symptomatology, early maladaptive schemas (EMS) and schema modes, both in adults and adolescents with personality disorder (PD) features and long-standing mood disorders. However, no research has yet been carried out on the effect in older adults. Therefore, in a proof of concept study, we explored the effect of SCBT-g in older outpatients with PD features and longstanding mood disorders. METHOD Thirty-one older outpatients, aged 60-78 years with PD features and/or longstanding mood disorders were included in a proof of concept study with pre-mid-post design. Primary outcome was psychological distress (Brief Symptom Inventory) and intermediate outcomes were EMS (Young Schema Questionnaire) and schema modes (Schema Mode Inventory), assessed at baseline, mid-treatment and end-of-treatment. Paired samples t-tests were conducted, and Cohens d effect sizes reported for pre mid- and post-treatment. As proof of concept analysis, hierarchical regression analyses with residual change scores were used to analyse whether early process changes in EMS (intermediate outcomes) predicted later outcome changes in symptoms. RESULTS SCBT-g led to significant improvement in all three measures of psychological symptoms, EMS and modes with medium effect sizes. Pre-treatment to mid-treatment changes in schema severity predicted symptom improvement from mid- to end-of-treatment. CONCLUSION This proof of concept study shows that SCBT-g has potential to change EMS and to show significant effect at symptom level in older outpatients with PD features. A control condition in a randomized controlled trial is a necessary step for further research.

Factor Analysis of the Dutch-Language Version of the MCMI–III

We analyzed the factor structure of the Dutch-language version of the MCMI–III (Millon, Millon, Davis, & Grossman, 2006) using exploratory factor analysis on data obtained from a heterogeneous White sample (n = 1,210). We identified 4 factors: General Maladjustment, Aggression/Social Deviance, Paranoid/Delusional Thinking, and Emotional Instability/Detachment. This structure was invariant across scale composition (linear dependent vs. independent scales), factor analytic method (principal factor vs. principal component solutions), and sample characteristics (gender ‘male-female’ and setting ‘clinical-forensic.’ Studies that have used previous MCMI (Millon, 1969/1983b) versions have also found 4 similar factors, whereas studies that have used the American version of the MCMI–III have only found 3 factors. However, differences between the Dutch and American version were completely determined by factor analytic decisions. The factor structure of the MCMI–III appeared to be cross-culturally invariant.

The Construct Validity of the Dutch Personality Inventory for DSM-5 Personality Disorders (PID-5) in a Clinical Sample:

The factor structure and the convergent validity of the Personality Inventory for DSM-5 (PID-5), a self-report questionnaire designed to measure personality pathology as advocated in the fifth edition, Section III of Diagnostic and Statistical Manual of Mental Disorders (DSM-5), are already demonstrated in general population samples, but need replication in clinical samples. In 240 Flemish inpatients, we examined the factor structure of the PID-5 by means of exploratory structural equation modeling. Additionally, we investigated differences in PID-5 higher order domain scores according to gender, age and educational level, and explored convergent and discriminant validity by relating the PID-5 with the Dimensional Assessment of Personality Pathology—Basic Questionnaire and by comparing PID-5 scores of inpatients with and without a DSM-IV categorical personality disorder diagnosis. Our results confirmed the original five-factor structure of the PID-5. The reliability and the convergent and discriminant validity of the PID-5 proved to be adequate. Implications for future research are discussed.

Empirical evaluation of the MCMI-III personality disorder scales

The MCMI–III personality disorder scales were empirically validated with a sample of 870 clinical patients and inmates. Prevalence rates of personality disorders were in general lower on the MCMI–III than clinical ratings, but trait prevalence was generally higher; thus a base rate of 75 on the MCMI–III could be a guideline in the screening of trait prevalence. However, the sensitivity of some MCMI–III scales was very low. Moreover, the correlations of most personality disorder scales of the MCMI–III were significant and positive with corresponding measures on clinical ratings and MMPI-2 personality disorder scales, but these were, in general, not significantly higher than some other correlations. As a consequence the discriminant validity seems to be questionable. The MCMI–III alone cannot be used as a diagnostic inventory, but the test could be useful as a screening device as a part of a multimethod approach that allows aggregation over measures in making diagnostic decisions.