Personality disorders II - research

Question 1

Coid et al. (2006)

Answer 1

Method
The Structured Clinical Interview for DSM-IV Axis II disorders was used to measure personality disorder in 626 persons aged 16-74 years in households in England, Scotland and Wales, in atwo-phase survey.

Results
The weighted prevalence of personality disorder was 4.4% (95% CI 2.9-6.7). Rates were highest among men, separated and unemployed participants in urban locations. High use of healthcare services was confounded by comorbid mental disorder and substance misuse. Cluster B disorders were associated with early institutional care and criminality.

Conclusions
Personality disorder is common in the community especially in urban areas. Services are normally restricted to symptomatic, help-seeking individuals, but a vulnerable group with cluster B disorders can be identified early are in care during childhood and enter the criminal justice system when young. This suggests the need for preventive interventions at the public mental health level.

Question 2

Volkert et al. (2018)

Answer 2

Method
We searched PsycINFO, PSYNDEX and Medline for studies that used standardised diagnostics (DSM-IV/-5, ICD-10) to report prevalence rates of personality disorders in community populations in Western countries. Prevalence rates were extracted and aggregated by random-effects models. Meta-regression and sensitivity analyses were performed and publication bias was assessed.

Results
The final sample comprised ten studies, with a total of 113 998 individuals. Prevalence rates were fairly high for any personality disorder (12.16%; 95% CI, 8.01–17.02%) and similarly high for DSM Clusters A, B and C, between 5.53 (95% CI, 3.20–8.43%) and 7.23% (95% CI, 2.37–14.42%). Prevalence was highest for obsessive–compulsive personality disorder (4.32%; 95% CI, 2.16–7.16%) and lowest for dependent personality disorder (0.78%; 95% CI, 0.37–1.32%). A low prevalence was significantly associated with expert-rated assessment (versus self-rated) and reporting of descriptive statistics for antisocial personality disorder.

Conclusions
Epidemiological studies on personality disorders in community samples are rare, whereas prevalence rates are fairly high and vary substantially depending on samples and methods. Future studies investigating the epidemiology of personality disorders based on the DSM-5 and ICD-11 and models of personality functioning and traits are needed, and efficient treatment should be a priority for healthcare systems to reduce disease burden.

Question 3

Tyrer et al. (2015)

Answer 3

Personality disorders are common and ubiquitous in all medical settings, so every medical practitioner will encounter them frequently. People with personality disorder have problems in interpersonal relationships but often attribute them wrongly to others. No clear threshold exists between types and degrees of personality dysfunction and its pathology is best classified by a single dimension, ranging from normal personality at one extreme through to severe personality disorder at the other. The description of personality disorders has been complicated over the years by undue adherence to overlapping and unvalidated categories that represent specific characteristics rather than the core components of personality disorder. Many people with personality disorder remain undetected in clinical practice and might be given treatments that are ineffective or harmful as a result. Comorbidity with other mental disorders is common, and the presence of personality disorder often has a negative effect on course and treatment outcome. Personality disorder is also associated with premature mortality and suicide, and needs to be identified more often in clinical practice than it is at present.

Question 4

Grant et al. (2008)

Answer 4

Methods
Face-to-face interviews with 34,653 adults participating in the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions.

Results
Prevalence of lifetime BPD was 5.9% (99% CI: 5.4–6.4). There were no differences in the rates of BPD among men (5.6%, 99% CI: 5.0–6.2) and women (6.2%, 99% CI: 5.6–6.9). BPD was more prevalent among Native American men, younger and separated/divorced/widowed adults, and those with lower incomes and education, and less prevalent among Hispanic men and women and Asian women. BPD was associated with substantial mental and physical disability, especially among women. High co-occurrence rates of mood and anxiety disorders with BPD were similar. With additional comorbidity controlled, associations with bipolar disorder and schizotypal and narcissistic PDs remained strong and significant. Associations of BPD with other specific disorders were no longer significant or were considerably weakened.

Conclusions
Prevalence of BPD in the general population is much greater than previously recognized, equal prevalent among men and women, and associated with considerable mental and physical disability, especially among women. Unique and common factors may differentially contribute to disorder-specific comorbidity with BPD and some of these associations appear to be sex-specific. There is a need for future epidemiologic, clinical and genetically-informed studies to identify unique and common factors that underlie disorder-specific comorbidity with BPD. Important sex differences observed in rates of and associations with BPD can inform more focused, hypothesis-driven investigations of these factors.

Question 5

Fazel et al. (2008)

Answer 5

Methods and Findings
We searched for surveys of the prevalence of psychotic illness, major depression, alcohol and drug dependence, and personality disorder that were based on interviews of samples of unselected homeless people. We searched bibliographic indexes, scanned reference lists, and corresponded with authors. We explored potential sources of any observed heterogeneity in the estimates by meta-regression analysis, including geographical region, sample size, and diagnostic method. Twenty-nine eligible surveys provided estimates obtained from 5,684 homeless individuals from seven countries. Substantial heterogeneity was observed in prevalence estimates for mental disorders among the studies (all Cochran’s χ2 significant at p < 0.001 and all I2 > 85%). The most common mental disorders were alcohol dependence, which ranged from 8.1% to 58.5%, and drug dependence, which ranged from 4.5% to 54.2%. For psychotic illness, the prevalence ranged from 2.8% to 42.3%, with similar findings for major depression. The prevalence of alcohol dependence was found to have increased over recent decades.

Conclusions
Homeless people in Western countries are substantially more likely to have alcohol and drug dependence than the age-matched general population in those countries, and the prevalences of psychotic illnesses and personality disorders are higher. Models of psychiatric and social care that can best meet these mental health needs requires further investigation.

Question 6

Weissman (1993)

Answer 6

Reviews the problems in epidemiologic studies of personality disorders (PDs) and the available epidemiologic data on rates and associated risk factors. Although this 1990 update shows the availability of more data, only about 1,300 Ss with PDs have been studied, and only 6 methods of assessment have been used. The overall lifetime rate of an Axis II disorder is in the range of about 10/100–23/100. Paranoid, schizoid, and narcissistic PDs are uncommon, with a lifetime rate of less than 1/100. The data are best for antisocial personality, which suggests a lifetime rate of 2/100–3/100 in the US, Canada, and New Zealand, and a considerably lower rate in Taiwan. The possibility of developing an epidemiology of PD based on community studies is addressed.

Question 7

Paris (2003)

Answer 7

Personality disorders cause dysfunction over the course of adult life. A chronic course of disorder tends to be associated with an early onset, and personality disorders are preceded by precursor symptoms in childhood. Long-term outcome varies by personality disorder category: antisocial and borderline personality tend to remit with age, an improvement that is not seen in other diagnoses. The chronicity of personality disorders can usefully guide treatment planning, and psychotherapy for personality disorders can focus on rehabilitation.

Question 8

Doering (2018)

Answer 8

Objective Borderline personality disorder (BPD) occurs in 0.7% to 3.5% of the general population. Patients with BPD experience excessive comorbidity of psychiatric and somatic diseases and are known to be high users of health care services. Because of a range of challenges related to adverse health behaviors and their interpersonal style, patients with BPD are often regarded as “difficult” to interact with and treat optimally. Methods This narrative review focuses on epidemiological studies on BPD and its comorbidity with a specific focus on somatic illness. Empirically validated treatments are summarized, and implementation of specific treatment models is discussed. Results The prevalence of BPD among psychiatric inpatients (9%-14%) and outpatients (12%-18%) is high; medical service use is very frequent, annual societal costs vary between euro11,000 and euro28,000. BPD is associated with cardiovascular diseases and stroke, metabolic disease including diabetes and obesity, gastrointestinal disease, arthritis and chronic pain, venereal diseases, and HIV infection as well as sleep disorders. Psychotherapy is the treatment of choice for BPD. Several manualized treatments for BPD have been empirically validated, including dialectical behavior therapy, transference-focused psychotherapy, mentalization-based therapy, and schema-focused therapy. Conclusions Health care could be substantially improved if all medical specialties would be familiar with BPD, its pathology, medical and psychiatric comorbidities, complications, and treatment. In mental health care, several empirically validated treatments that are applicable in a wide range of clinical settings are available.

Question 9

Lewis et al. (2019)

Answer 9

Method

Naturalistic study of hospital presentations for mental health in a large community catchment. Mixed-effects Cox regression and survival curves were generated to examine risk of readmission for each group.

Results

Of 2894 people presenting to hospital, patients with personality disorder represented 20.5% of emergency and 26.6% of in-patients. Patients with personality disorder or psychoses were 2.3 times (95% CI 1.79-2.99) more likely than others to re-present within 28 days. Personality disorder diagnosis increases rate of readmission by a factor of 8.7 (s.e. = 0.31), marginally lower than psychotic disorders (10.02, s.e. = 0.31).

Conclusions

Personality disorders place significant demands on in-patient and emergency departments, similar to that of psychoses in terms of presentation and risk of readmission.Declaration of interestNone.

Question 10

Gawda (2018)

Answer 10

This article reviews cross-cultural research on personality disorders. The concept of personality disorders is discussed in terms of whether they are universal phenomena or specific to Western society. Then, research on the prevalence of personality disorders in North America, South America, Europe, Asia, Africa, and Australia is reviewed. The overall rates of the prevalence of personality disorders range from 2.40% to 20.00%. The data document that the prevalence of borderline and obsessive-compulsive personality disorders is the highest, especially in high-income countries. The cross-cultural differences in the prevalence of the specified personality disorders are explained by its influencing factors such as race, ethnicity, social requirements, and the dimension of individualism-collectivism. The occurrence of personality disorders across cultures suggests some degree of psychological unity, and in turn, similarities in the neurobiological mechanisms of personality disorders

Question 11

Gawda and Czubak (2017)

Answer 11

The aim of the present study is to establish the prevalence of personality disorders (PDs) in a healthy (nonclinical) Polish population, to examine sex difference in PDs, and to show the structure of clusters which PDs form with regard to men and women. A large sample of 1460 individuals of age between 18 and 65 years was examined. The Structured Clinical Interview for Axis II was used to obtain information on PDs, the Mini International Neuropsychiatric Interview to obtain information on other disorders, and an interview to record demographic data. Results show that approximately 9% of the sample had at least one PD (the overall rate is 8.9%) and rates on sex differences in PDs are similar to other European and North American countries. The most prevalent PDs are obsessive-compulsive (9.6%), narcissistic (7%), and borderline (7%). Results show the considerable comorbidity of PDs which means that about 9% of the adult population have at least one PD and in fact they display features of many specific PDs. A factor analysis revealed that 12 PDs form different clusters in men and women.

Question 12

Paris (2007)

Answer 12

Personality traits are influenced by gender, and these differences are unlikely to be artefacts. Gender effects on traits also shape differences in the prevalence of common mental disorders, so that internalizing disorders are more common in females, while externalizing disorders are more common in males. Finally, gender effects influence the prevalence of specific personality disorders. These differences have clinical implications

Question 13

Holthausen and Habel (2018)

Answer 13

Recent Findings
Empirical findings on sex differences in personality disorders are inconsistent and appear to be highly dependent on study settings. Current studies have mainly focused on borderline and antisocial personality disorder and the question whether these are sex-specific representations of a common substrate. In general, sexes differ in the manifestation of personality disorders as well as in comorbidities. Criticism of the established categorical model led to an additional dimensional model of personality disorders in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.

Summary
Investigations on sex differences in personality disorders are sparse and mainly limited to antisocial and borderline personality disorder. The introduction of a dimensional model offers the chance to re-think the construct of “personality disorder” and thereby also opens the possibility for a better understanding of sex differences.

Question 14

Logan and Taylor (2017)

Answer 14

Working with women in secure services is an infrequent subject of research and discussion in the forensic mental health literature. There are several reasons for this, which will be considered in the introduction to this paper. However, a consequence of this situation is that there remains a lack of clarity in key areas of practice in relation to working with women in secure services, and working with women with personality disorder specifically: how women with personality disorder may present in secure services compared to men, therefore, the particular skills required of the practitioners who work with women and the main design features of the services within which they are managed. The body of this paper attempts to summarise important issues in each of these areas in order to inform future debate and developments in the field.

Question 15

Feingold (1994)

Answer 15

Four meta-analyses were conducted to examine gender differences in personality in the literature (1958-1992) and in normative data for well-known personality inventories (1940-1992). Males were found to be more assertive and had slightly higher self-esteem than females. Females were higher than males in extraversion, anxiety, trust, and, especially, tender-mindedness (e.g., nurturance). There were no noteworthy sex differences in social anxiety, impulsiveness, activity, ideas (e.g., reflectiveness), locus of control, and orderliness. Gender differences in personality traits were generally constant across ages, years of data collection, educational levels, and nations.

Question 16

Smith et al. (2018)

Answer 16

Psychopathy is considered an essential construct in forensic work (Gacono, 2016). Most methodologically sound studies have involved males rather than females (Smith et al., 2014). Gender differences have been found to be, and continue to be considered important in the assessment and management of forensic populations (Cunliffe et al., 2016). Male psychopaths present as pathologically narcissistic whereas female psychopaths manifest a malignant form of hysteria. Both are pathologically self-focused; however, the grandiosity in males is contrasted by women‘s negative self-view. In the current study, male and female psychopaths (males = N = 44; PCL-R M = 33.13; females = N = 46; PCL-R M = 32.93) were compared using select Comprehensive System Rorschach variables. Female psychopaths produced more painful rumination (SumV), helplessness (SumY), and poor self-regard (EGOI ≥ .44 & Fr + rF = 0) than the males. Males were more detached (SumT) than females. Implications for future research, recommendations for these populations, and suggestions for using the PCL-R to assess female offenders are discussed.

Question 17

Grijalva et al. (2015)

Answer 17

Despite the widely held belief that men are more narcissistic than women, there has been no systematic review to establish the magnitude, variability across measures and settings, and stability over time of this gender difference. Drawing on the biosocial approach to social role theory, a meta-analysis performed for Study 1 found that men tended to be more narcissistic than women (d = .26; k = 355 studies; N = 470,846). This gender difference remained stable in U.S. college student cohorts over time (from 1990 to 2013) and across different age groups. Study 1 also investigated gender differences in three facets of the Narcissistic Personality Inventory (NPI) to reveal that the narcissism gender difference is driven by the Exploitative/Entitlement facet (d = .29; k = 44 studies; N = 44,108) and Leadership/Authority facet (d = .20; k = 40 studies; N = 44,739); whereas the gender difference in Grandiose/Exhibitionism (d = .04; k = 39 studies; N = 42,460) was much smaller. We further investigated a less-studied form of narcissism called vulnerable narcissism—which is marked by low self-esteem, neuroticism, and introversion—to find that (in contrast to the more commonly studied form of narcissism found in the DSM and the NPI) men and women did not differ on vulnerable narcissism (d = −.04; k = 42 studies; N = 46,735). Study 2 used item response theory to rule out the possibility that measurement bias accounts for observed gender differences in the three facets of the NPI (N = 19,001). Results revealed that observed gender differences were not explained by measurement bias and thus can be interpreted as true sex differences. Discussion focuses on the implications for the biosocial construction model of gender differences, for the etiology of narcissism, for clinical applications, and for the role of narcissism in helping to explain gender differences in leadership and aggressive behavior. Readers are warned against overapplying small effect sizes to perpetuate gender stereotypes

Question 18

Costa et al. (2001)

Answer 18

Secondary analyses of Revised NEO Personality inventory data from 26 cultures (N =23,031) suggest that gender differences are small relative to individual variation within genders; differences are replicated across cultures for both college-age and adult samples, and differences are broadly consistent with gender stereotypes: Women reported themselves to be higher in Neuroticism, Agreeableness, Warmth, and Openness to Feelings, whereas men were higher in Assertiveness and Openness to Ideas. Contrary to predictions from evolutionary theory, the magnitude of gender differences varied across cultures. Contrary to predictions from the social role model, gender differences were most pronounced in European and American cultures in which traditional sex roles are minimized. Possible explanations for this surprising finding are discussed, including the attribution of masculine and feminine behaviors to roles rather than traits in traditional cultures.

Question 19

Goodwin and Gotlib (2004)

Answer 19

The goal of the study was to determine the association between gender and the Big Five personality factors, and to identify the role of personality factors in the association between gender and depression among adults in the United States. Data were drawn from the Midlife Development in the United States Survey (N=3032). Multivariate analysis of variance (MANOVA) was used to examine gender differences on the Big Five personality factors (i.e. agreeableness, neuroticism, openness to experience, extraversion, and conscientiousness). Multivariate logistic regression analyses were conducted to examine the relation between gender and depression, and to test whether this association is moderated by neuroticism. Levels of neuroticism, agreeableness, extraversion, and conscientiousness were significantly higher among females than among males; in contrast, level of openness to experience was significantly higher among males. Female gender was associated with increased odds of experiencing depression. Results showed that neuroticism played a significant contributory role in the relationship between being female and major depression, though the role of gender remained statistically significant after adjustment. These data suggest that gender differences in personality factors, specifically neuroticism, may play a key role in the well-documented gender difference in depression. Our findings indicate that neuroticism may moderate the association between female gender and increased risk of depression among adults. These findings require replication using longitudinal data.

Question 20

Zai and Jan (2019)

Answer 20

The educational success of any person seems to depend on residence. It is usually seen that students residing in urban areas enjoy more facilities than rural pupils, so they show higher academic success. Along with residence,
many other factors such as students’ personality type and gender matter a lot in academic success. Personality is considered as a fundamental pattern of all-round development of a person. An attempt in this regard was made to examine difference in academic achievement of rural and urban students of secondary level according to their personality traits. Students of rural and urban areas of 9th grades enrolled in public sector schools at secondary level in district Mianwali constitute population. 935 students were selected as sample through stratified random sampling technique. 752 students responded on Big five (BFI) Personality Inventory resulting 80% response
rate. Descriptive and inferential statistics were used for data analysis. Consciousness, neuroticism, agreeableness, personality traits were higher in students of rural area. Openness, extraversion personality traits were higher
in urban students. Significant difference between openness personality trait and gender of students while no difference in consciousness, extraversion, agreeableness, neuroticism personality traits were observed.

Question 21

Madsen et al. (2018)

Answer 21

We examined the link between neuroticism and fronto-limbic white matter asymmetry.

Neuroticism showed a sex-specific relationship with cingulum FA asymmetry.

In boys, neuroticism was linked to decreased left relative to right cingulum FA.

In girls, neuroticism was linked to increased left-to-right cingulum FA.

The neurobiological significance of these sex differences needs to be elucidated.

Question 22

Shchebetenko et al. (2019)

Answer 22

The Big Five Inventory–2 (BFI-2) is a recently published 60-item questionnaire that measures personality traits within the five-factor model framework. An important aspect of the BFI-2 is that it measures the traits at both the domain and facet levels and also controls acquiescence bias via the balanced number of true- and false-keyed items across the domains and facets. The current research evaluates factorial measurement invariance of a Russian version of the BFI-2 across sex and age within samples of 1,024 university students (Study 1) and 1,029 Internet users (Study 2). Across these samples, men scored lower on the domains of negative emotionality and agreeableness and slightly higher on extraversion. Sex differences were also obtained on various facets. In the Internet sample, age correlated modestly with several Big Five domains in accordance with the well-documented maturity principle. The newly developed Russian version of BFI-2 showed good reliability and validity across both samples. Moreover, random intercept exploratory factor analyses showed that the BFI-2 displayed a hierarchical five-domain-15-facet structure that demonstrated strict measurement invariance across sex and age.

Question 23

Livesley et al. (1998)

Answer 23

Methods Eighteen lower-order traits were assessed using the Dimensional Assessment of Personality Disorder–Basic Questionnaire in samples of 656 personality disordered patients, 939 general population subjects, and a volunteer sample of 686 twin pairs.

Results Principal components analysis yielded 4 components, labeled Emotional Dysregulation, Dissocial Behavior, Inhibitedness, and Compulsivity, that were similar across the 3 samples. Multivariate genetic analyses also yielded 4 genetic and environmental factors that were remarkably similar to the phenotypic factors. Analysis of the residual heritability of the lower-order traits when the effects of the higher-order factors were removed revealed a substantial residual heritable component for 12 of the 18 traits.

Conclusions The results support the following conclusions. First, the stable structure of traits across clinical and nonclinical samples is consistent with dimensional representations of personality disorders. Second, the higher-order traits of personality disorder strongly resemble dimensions of normal personality. This implies that a dimensional classification should be compatible with normative personality. Third, the residual heritability of the lower-order traits suggests that the personality phenotypes are based on a large number of specific genetic components.

Question 24

Sher et al. (2015)

Answer 24

Gender is an important variable in the study of mental health because of the actual and perceived differences between men and women. Relatively little is known how males and females differ in their manifestations of antisocial personality disorder (ASPD). Demographic and clinical features of 323 participants with ASPD were assessed and recorded. Women had fewer episodes of antisocial behavior involving or not involving police, higher scores on the Childhood Trauma Questionnaire (CTQ) and on Emotional Abuse and Sexual Abuse subscales of the CTQ compared to men. CTQ scores positively correlated with the number of episodes of antisocial behavior involving police in men but not in women. The percentage of patients with comorbid borderline and histrionic personality disorders was higher and the percentage of participants with cocaine use disorder was lower among women compared to men. Comorbid alcohol use disorder was frequent in both groups, while a higher percentage of women had comorbid mood disorders compared to men. Logistic regression analysis demonstrates that CTQ scores, histrionic personality disorder, and antisocial behavior involving the police drive the difference between the groups. Our findings indicate that treatment of individuals with ASPD should focus on the management of comorbid psychiatric disorders

Question 25

Sylvers et al. (2010)

Answer 25

We investigated the autonomic indicators of antisocial personality disorder (APD) features in a mixed gender student sample. One hundred college students (50 men, 50 women) were administered an interview of APD and self-report measures of aggression and psychopathy. Participants completed a passive coping task and viewed emotionally valenced slideshows while their electrodermal activity (EDA), pre-ejection period (PEP), and respiratory sinus arrhythmia (RSA) were measured. Associations between APD features and autonomic reactivity were examined, controlling for aggression and psychopathy. APD features were associated with EDA hyporeactivity in men, but not women, during passive coping. While viewing threatening slides, APD features were associated with RSA hyperreactivity in women and with PEP hyperreactivity in men. APD features were associated with RSA hyperreactivity in women, but not men, while viewing slides of others in distress. These findings suggest that APD features are characterized by parasympathetic nervous system dysfunction in women but sympathetic nervous system dysfunction in men.

Question 26

Yang et al. (2014)

Answer 26

Methods: Structured interviews were conducted among 882 heroin dependent users in two compulsory isolation settings in Changsha, China. Descriptive statistics were employed to report sample characteristics by gender. Bivariate relationships were examined between co-occurring ASPD and variables measuring demographic, drug use, and psychiatric co-morbidities. Multivariate logistic regressions with stepwise forward method were conducted to determine independent predictors for co-occurring ASPD. All analyses examining correlates of co-occurring ASPD were conducted for the total, the male and the female participants respectively to detect both the common and the unique correlates of ASPD by gender.

Results: Of the total participants, 41.4% (54.2% of males and 15.4% of females) met the DSM-IV criteria of ASPD. For male participants, lower educational level, unemployment, unmarried, younger age at first heroin use, previous history of compulsory treatment, larger amounts of heroin used per day and poly-drug abuse during past month before admission, as well as psychiatric co-morbidities of lifetime major depressive disorder and borderline personality disorder were independent predictors for co-occurring ASPD; while for female participants, only three variables: younger age at first heroin use, paranoid personality disorder and borderline personality disorder were independent predictors for co-occurring ASPD.

Conclusions: Gender differences in prevalence and correlates of ASPD among heroin dependent users were detected. The findings highlight a need for gender-specific interventions

Question 27

Landheim et al. (2003)

Answer 27

Objective: Gender differences in the prevalence of Axis I and 11 disorders in poly-substance abusers and pure alcoholics and between these two groups are explored. Method. A consecutive sample (n = 260) of in- and outpatients from two Norwegian counties were assessed by CIDI (Axis I disorders) and MCMI-II (Axis 11 disorders). Results: Major depression, post-traumatic stress disorder (PTSD), and eating disorders were significantly more prevalent in women than in men. A significantly higher prevalence of antisocial, passive-aggressive, and borderline personality disorders (PD) was observed among poly-substance abusers, whereas pure alcoholics were found to have dependent PDs more often. Female poly-substance abusers differed significantly from all other substance abusers by suffering more often from major depression, simple phobia, PTSD and borderline PD. Male poly-substance abusers more often presented antisocial PD and less often Cluster C disorders than all other substance abusers. Female pure alcoholics more often had major depression and Cluster C disorders than all other substance abusers. Male pure alcoholics presented less often with Axis I disorders, major depression, and PTSD, but more often with Cluster A disorders, in particular schizoid PD, than all other substance abusers. Conclusion: The pattern of comorbid disorders is clearly different between male and female poly-substance abusers and pure alcoholics. This implies that these four subgroups have important differences in their treatment needs.

Question 28

McCredie and Morey (2019)

Answer 28

The present study was intended to assess the reliability of clinician judgments, with a particular interest in how such judgments vary by the gender of the case vignette and clinician. A national sample of 123 mental health professionals (57.7% male) provided clinical judgments on 12 case vignettes primarily representing personality pathology; two identical versions of each vignette were prepared, with the only difference being the use of masculine or feminine pronouns identifying the client. Clinical judgments included evaluations of adaptive functioning, long-term prognostic assessments, short-term risk evaluations, and treatment recommendations. Analyses included intraclass correlations between clinicians to assess reliability, as well as an examination of the variance of clinical judgments as a function of the identified gender of the case and the gender of the participating clinician. No significant two-way interactions were found between case gender and clinician gender in predicting the clinical judgments. A significant main effect of case gender in predicting vocational functioning was observed, such that female cases were rated as having better estimated vocational functioning than male cases. In addition, a significant main effect of clinician gender in predicting aggression and violence risk was found, such that ratings by female clinicians were higher than ratings by male clinicians. Results offer little if any evidence to suggest the influence of client or clinician gender on the majority of clinical judgments made in the present study. However, these results bear replication, particularly in light of the two significant main effects that did emerge

Question 29

Jane et al. (2007)

Answer 29

The authors examined gender bias in the diagnostic criteria for Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision; American Psychiatric Association, 2000) personality disorders. Participants (N=599) were selected from 2 large, nonclinical samples on the basis of information from self-report questionnaires and peer nominations that suggested the presence of personality pathology. All were interviewed with the Structured Interview for DSM-IV Personality (B. Pfohl, N. Blum, & M. Zimmerman, 1997). Using item response theory methods, the authors compared data from 315 men and 284 women, searching for evidence of differential item functioning in the diagnostic features of 10 personality disorder categories. Results indicated significant but moderate measurement bias pertaining to gender for 6 specific criteria. In other words, men and women with equivalent levels of pathology endorsed the items at different rates. For 1 paranoid personality disorder criterion and 3 antisocial criteria, men were more likely to endorse the biased items. For 2 schizoid personality disorder criteria, women were more likely to endorse the biased items.

Question 30

Dokucu and Cloninger (2019)

Answer 30

Recent findings The strong association of any personality disorders with poor health in cross-sectional and community-based studies is now confirmed by personality disorder predicting future deterioration in longitudinal studies. Borderline personality disorder has been studied most frequently, but recent data suggest that severity of any personality disorder is associated with poor and worsening health.

Summary Personality disorder is associated with the full range of physical, mental, and social disorders. Greater attention to the common features of personality disorders, which are crucial for the self-regulation of behavior, would facilitate more effective health promotion and disease prevention across all medical specialties, thereby helping to relieve the burdens of chronic common diseases.

Question 31

Quirk et al. (2016)

Answer 31

Methods:
Individual personality disorders (paranoid, schizoid, schizotypal, histrionic, narcissistic, borderline, antisocial, avoidant, dependent, obsessive-compulsive), lifetime mood, anxiety, eating and substance misuse disorders were diagnosed utilising validated semi-structured clinical interviews (Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Research Version, Non-patient Edition and Structured Clinical Interview for DSM-IV Axis II Personality Disorders). The prevalence of personality disorders and Clusters were determined from the study population (n = 768), and standardised to the Australian population using the 2011 Australian Bureau of Statistics census data. Prevalence by age and the association with mood, anxiety, eating and substance misuse disorders was also examined.

Results:
The overall prevalence of personality disorders in women was 21.8% (95% confidence interval [CI]: 18.7, 24.9). Cluster C personality disorders (17.5%, 95% CI: 16.0, 18.9) were more common than Cluster A (5.3%, 95% CI: 3.5, 7.0) and Cluster B personality disorders (3.2%, 95% CI: 1.8, 4.6). Of the individual personality disorders, obsessive-compulsive (10.3%, 95% CI: 8.0, 12.6), avoidant (9.3%, 95% CI: 7.1, 11.5), paranoid (3.9%, 95% CI: 3.1, 4.7) and borderline (2.7%, 95% CI: 1.4, 4.0) were among the most prevalent. The prevalence of other personality disorders was low (⩽1.7%). Being younger (25–34 years) was predictive of having any personality disorder (odds ratio: 2.36, 95% CI: 1.18, 4.74), as was being middle-aged (odds ratio: 2.41, 95% CI: 1.23, 4.72). Among the strongest predictors of having any personality disorder was having a lifetime history of psychiatric disorders (odds ratio: 4.29, 95% CI: 2.90, 6.33). Mood and anxiety disorders were the most common comorbid lifetime psychiatric disorders.

Conclusions:
Approximately one in five women was identified with a personality disorder, emphasising that personality disorders are relatively common in the population. A more thorough understanding of the distribution of personality disorders and psychiatric comorbidity in the general population is crucial to assist allocation of health care resources to individuals living with these disorders.

Question 32

Moran et al. (2004)

Answer 32

More than 15 years ago, findings from the Epidemiological Catchment Area Study indicated that antisocial personality disorder (APD) is more prevalent among persons with schizophrenia than in the general population. The present study analyzed data from a multisite investigation to examine the correlates of APD among 232 men with schizophrenic disorders, three-quarters of whom had committed at least one crime. Comparisons of the men with and without APD revealed no differences in the course or symptomatology of schizophrenia. By contrast, multivariate models confirmed strong associations of comorbid APD with substance abuse, attention/concentration problems, and poor academic performance in childhood; and in adulthood with alcohol abuse or dependence and deficient affective experience (a personality style indexed by lack of remorse or guilt, shallow affect, lack of empathy, and failure to accept responsibility for one’s own actions). At first admission, men with schizophrenia and APD presented a long history of antisocial behavior that included nonviolent offending and substance misuse, and an emotional dysfunction that is thought to increase the risk of violence toward others. Specific treatments and management strategies are indicated.

Question 33

Forbes et al. (2016)

Answer 33

We propose a novel developmentally informed framework to push research beyond a focus on comorbidity between discrete diagnostic categories and to move toward research based on the well-validated dimensional and hierarchical structure of psychopathology. For example, a large body of research speaks to the validity and utility of the internalizing and externalizing spectra as organizing constructs for research on common forms of psychopathology. The internalizing and externalizing spectra act as powerful explanatory variables that channel the psychopathological effects of genetic and environmental risk factors, predict adaptive functioning, and account for the likelihood of disorder-level manifestations of psychopathology. As such, our proposed theoretical framework uses the internalizing and externalizing spectra as central constructs to guide future psychopathology research across the life span. The framework is particularly flexible, because any of the facets or factors from the dimensional and hierarchical structure of psychopathology can form the focus of research. We describe the utility and strengths of this framework for developmental psychopathology in particular and explore avenues for future research.

Question 34

Asherson et al. (2014)

Answer 34

Methods:

We searched four databases, referred to the new Diagnostic and Statistical Manual of Mental Disorders, 5th edition, used other relevant literature, and referred to our own clinical experience.

Results:

ADHD coexists in 20% of adults with BD or BPD. BD is episodic, with periods of normal mood although not necessarily function. In patients with comorbid ADHD-BD, ADHD symptoms are apparent between BD episodes. BPD and ADHD are associated with chronic trait-like symptoms and impairments. Overlapping symptoms of BPD and ADHD include impulsivity and emotional dysregulation. Symptoms of BPD but not ADHD include frantically avoiding real/imagined abandonment, suicidal behavior, self-harm, chronic feelings of emptiness, and stress-related paranoia/severe dissociation. Consensus expert opinion recommends that BD episodes should be treated first in patients with comorbid ADHD, and these patients may need treatment in stages (e.g. mood stabilizer[s], then a stimulant/atomoxetine). Data is scarce and mixed about whether stimulants or atomoxetine exacerbate mania in comorbid ADHD-BD. BPD is primarily treated with psychotherapy. Principles of dialectical behavioral treatment for BPD may successfully treat ADHD in adults, as an adjunct to medication. No fully evidence-based pharmacotherapy exists for core BPD symptoms, although some medications may be effective for individual symptom domains, e.g. impulsivity (shared by ADHD and BPD). In our experience, treatment of ADHD should be considered when treating comorbid personality disorders.

Conclusions:

It is important to accurately diagnose ADHD, BD, and BPD to ensure correct targeting of treatments and improvements in patient outcomes. However, there is a shortage of data about treatment of adults with ADHD and comorbid BD or BPD.

Question 35

Shiner (2009)

Answer 35

The developmental pathways leading to personality disorders are poorly understood, but clues to these pathways come from recent research on personality disorders and normal personality development in childhood and adolescence. The first section of this paper reviews recent work on personality disorders in childhood and adolescence, and concludes that personality disorders in adolescence are already prevalent, moderately stable, and impairing. The second section draws on McAdams and Pals’ personality model to offer a taxonomy of personality differences that can account for the known patterns of emerging personality pathology. This taxonomy includes youths’ temperament and personality traits, mental representations (including attachment), coping strategies, and narrative identities. Individual differences in all of these domains may play critical roles in the development. manifestation, and course of personality disorders. Existing knowledge of normal and abnormal personality development can inform future research on the developmental pathways leading to personality pathology, the diagnostic criteria for personality disorders, and the development of validated treatments for personality disorders in the first two decades of life.

Question 36

Magid et al. (2019)

Answer 36

The present invention relates to the use of a neurotoxin, especially botulinum toxin, for use as a medicament in the treatment of a personality disorder and/or a habit and impulse disorder and/or a conduct disorder, as well as to a method for the treatment of a personality disorder and/or of a habit and impulse disorder and/or of a behavioural and emotional disorder with onset usually occurring in childhood and adolescence by administration of the neurotoxin to a patient diagnosed with this disorder. Preferably, the neurotoxin is for use as a medicament in the treatment of an emotionally unstable personality disorder and/or of another personality disorder and/or of a habit and impulse control and/or behavioural and emotional disorders with onset usually occurring in childhood and adolescence, in which the disorder is preferably characterised by emotional instability and impulsivity.

Question 37

Lilliengren et al. (2019)

Answer 37

Different forms of psychotherapy are effective for cluster C personality disorders, but we know less about what in-session processes promote change. Contrasting successful and unsuccessful cases may elucidate processes that facilitate or impede outcome and offer suggestions for clinical practice and future research. In this exploratory outcome–process study, 10 successful and 10 unsuccessful cases were selected from a randomized trial comparing cognitive therapy and short-term psychodynamic psychotherapy for cluster C personality disorders. Videotaped sessions were rated with the Psychotherapy Process Q-Set (PQS). The treatments were compared in terms of which PQS items differentiated successful and unsuccessful cases, as well as their resemblance with PQS prototypes of “ideal treatments.” Therapists’ behavior in early sessions was also explored. Results indicate that successful cases in our sample were characterized by a more active and engaged patient. In contrast, unsuccessful cases were characterized by a more directive or “controlling” therapist stance. Correlations with PQS prototypes were moderate to strong in both successful and unsuccessful cases, suggesting that optimal and suboptimal interpersonal processes may be independent of adherence to particular treatments. Exploration of therapist behaviors in early sessions indicated that therapists were more likely to adjust their way of working in the successful cases. Our result suggests that patient engagement and therapists’ early efforts to improve the therapy relationship may be pivotal for successful outcome, whereas therapist controlling behavior may obstruct the treatment process, regardless of therapy model used. The impact of these in-session processes should be examined more closely in larger samples in future studies.

Question 38

Bateman et al. (2015)

Answer 38

The evidence base for the effective treatment of personality disorders is insufficient. Most of the existing evidence on personality disorder is for the treatment of borderline personality disorder, but even this is limited by the small sample sizes and short follow-up in clinical trials, the wide range of core outcome measures used by studies, and poor control of coexisting psychopathology. Psychological or psychosocial intervention is recommended as the primary treatment for borderline personality disorder and pharmacotherapy is only advised as an adjunctive treatment. The amount of research about the underlying, abnormal, psychological or biological processes leading to the manifestation of a disordered personality is increasing, which could lead to more effective interventions. The synergistic or antagonistic interaction of psychotherapies and drugs for treating personality disorder should be studied in conjunction with their mechanisms of change throughout the development of each

Question 39

Chapman (2019)

Answer 39

Borderline personality disorder (BPD) is a severe and complex disorder characterized by instability across many life domains, including interpersonal relations, behavior, and emotions. A core feature and contributor to BPD, emotion dysegulation (ED), consists of deficits in the ability to regulate emotions in a manner that allows the individual to pursue important goals or behave effectively in various contexts. Biosocial developmental models of BPD have emphasized a transaction of environmental conditions (e.g., invalidating environments and adverse childhood experiences) with key genetically linked vulnerabilities (e.g., impulsivity and emotional vulnerability) in the development of ED and BPD. Emerging evidence has begun to highlight the complex, heterotypic pathways to the development of BPD, with key heritable vulnerability factors possibly interacting with aspects of the rearing environment to produce worsening ED and an adolescent trajectory consisting of self-damaging behaviors and eventual BPD. Adults with BPD have shown evidence of a variety of cognitive, physiological, and behavioral characteristics of ED. As the precursors to the development of ED and BPD have become clearer, prevention and treatment efforts hold great promise for reducing the long-term suffering, functional impairment, and considerable societal costs associated with BPD.

Question 40

Hertler (2016)

Answer 40

Size at birth, growth rate, age at sexual maturity, number and size of offspring, and longevity are among the variables studied in life history evolution, a mid-level branch of evolutionary biology. Long-lived, slow maturing, and highly encephalized Homo sapiens, though skewed as a group towards the very slow end of the spectrum, nevertheless show some life history variation; variation which may relate to, and to some extent explain, personality variation. When applied to extant personality disorders, the risk-taking, boldness, and impulsivity of psychopathy is explained as a fast life history strategy. Herein, it is argued that the highly heritable obsessive-compulsive personality disorder (OCPD), opposite psychopathy, is a slow life history strategy. Both OCPD and slow life history strategists exhibit anxiety and harm avoidance, risk and loss aversion, future-oriented thought and time urgency, delayed gratification, and conscientious labor and fidelity. In addition to a host of compelling correlations, the preponderance of intrinsic over extrinsic mortality that explains the evolution of slow life histories is precisely that which has been described in an ecological etiology that explains OCPD as a product of post-migration evolution from Africa into Eurasia.

Question 41

Heinz et al. (2019)

Answer 41

Neurotransmitter imaging in schizophrenia research has for a long time focused on dopaminergic neurotransmission, based on the clinical observation of the effects of neuroleptics on dopamine D2-receptors [1]. Dopaminergic neurotransmission can best be assessed using positron emission tomography (PET) or single-photon emission computed tomography (SPECT), with tracers available for dopamine synthesis capacity, dopamine D1 and D2 receptor imaging, and the assessment of transporter availability. Most schizophrenia theories suggest that dopamine dysfunction is embedded in neurocircuits linking the prefrontal cortex with the striatum and thalamus in multiple neurocircuits that control motivational and cognitive aspects of complex behavior [2, 3]. Key neurotransmitters in these neurocircuits are glutamate for excitatory and GABA for inhibitory effects, and concentrations of these neurotransmitters have mainly been assessed using spectroscopy, also in combination with PET or SPECT for simultaneous measurement of striatal dopaminergic neurotransmission [4]. Spectroscopy has the disadvantage of assessing glutamate independent of whether or not this molecule is directly involved in neurotransmission. Further neurotransmitters assessed in schizophrenia research range from serotonin to acetylcholine; however, most research to date has focused on glutamate-dopamine interactions

Question 42

Fanning and Coccaro (2018)

Answer 42

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Question 43

Kolla and Wang (2019)

Answer 43

A robust corpus of evidence supports an association between neurochemical dysfunction and violence in individuals with a history of alcohol misuse. Specifically, Type 1 alcoholics have been shown to exhibit higher levels of serotonin and decreased dopamine, whereas Type 2 alcoholics tend to display lower levels of serotonin and increased dopamine levels. Both serotonin and dopamine are neurotransmitters modulated by monoamine oxidase-A, an enzyme important to brain structure and function and which may also underlie pathological aggression. Genetic association studies further highlight certain monoamine oxidase-A polymorphisms that on their own or in combination with early adverse events make individuals more vulnerable to the negative effects of alcohol, including violence.

Structural brain changes also present a strong association with aggression and alcohol misuse. MRI analyses have found decreased hippocampal volumes in both Type 1 and Type 2 alcoholics. Different mechanisms may account for divergent findings. For example, the duration of alcohol misuse seems relevant to hippocampal deterioration in Type 1 alcoholics, whereas in Type 2 alcoholics, primary psychopathology may be the main driving force behind hippocampal reduction. These findings suggest that in Type 2 alcoholism, hippocampal alterations may relate more to the effects of antisocial personality disorder than alcohol misuse. Other structural investigations reveal that alcohol misuse and a history of violent behavior present with decreased amygdala volumes compared with nonviolent alcoholics, suggesting a potential role of the mesolimbic reward system in mediating aggressive behavior and alcohol misuse. These findings highlight the conjoint effects of neurotransmitter abnormalities, structural, and functional imaging changes, and effects of specific genes that may alter the nature of alcohol consumption on risk for violent behavior.

Question 44

Williams et al. (2010)

Answer 44

Adolescence is a risk period for offending and for traumatic brain injury (TBI) and TBI is a risk factor for poor mental health and for offending. TBI has been largely neglected from guidance on managing the mental health needs of young offenders. We sought to determine the rate of self-reported TBI, of various severities, in a male, adolescent youth offending population. We also aimed to explore whether TBI was associated with number of convictions, violent offending, mental health problems and drug misuse. Young male offenders aged 11 to 19 years were recruited from a Young Offender Institute, a Youth Offending Team and a special needs school. A total of 197 participants were approached and 186 (94.4%) completed the study. They completed self-reports on TBI, crime history, mental health and drug use. TBI with loss of consciousness (LOC) was reported by 46% of the sample. LOC consistent with mild TBI was reported by 29.6%, and 16.6% reported LOC consistent with moderate to severe TBI. Possible TBI was reported by a further 19.1%. Repeat injury was common – with 32% reporting more than one LOC. Frequency of self-reported TBI was associated with more convictions. Three or more self-reported TBIs were associated with greater violence in offences. Those with self-reported TBI were also at risk of greater mental health problems and of misuse of cannabis. TBI may be associated with offending behaviour and worse mental health outcomes. Addressing TBI within adolescent offenders with neurorehabilitative input may be important for improving well-being and reducing re-offending

Methods: A self-report survey of adult, male offenders within a prison. Of 453 offenders, 196 (43%) responded.

Results: Over 60% reported ‘Head Injuries’. Reports consistent with TBI of various severities were given by 65%. Of the overall sample, 16% had experienced moderate-to-severe TBI and 48% mild TBI. Adults with TBI were younger at entry into custodial systems and reported higher rates of repeat offending. They also reported greater time, in the past 5 years, spent in prison.

Conclusions: These findings indicate that there is a need to account for TBI in the assessment and management of offenders.

Question 45

Lazzaretti et al. (2018)

Answer 45

In this chapter we debate the case report of a patient diagnosed with psychotic disorder due to traumatic brain injury. Firstly, we describe the classification of psychotic disorders in the DSM-5 with particular regard to its innovations in the diagnostic process. In the second part of the chapter, we focus on the DSM-5 criteria for “psychotic disorder due to another medical condition”. Specifically, in some cases, a traumatic brain injury could explain the onset of psychotic symptoms. A 34-year-old patient, previously diagnosed with “paranoia schizophrenia,” was admitted to our inpatient ward for diagnostic and therapeutic reassessment. An accurate diagnostic strategy including medical history, neurological examination, MRI and PET scans allowed clinicians to revise the diagnosis of schizophrenia and to identify previous traumatic brain injuries and consequent focal cerebral frontotemporal lesions, leading to a diagnosis of psychotic disorder due to traumatic brain injury (PD-TBI). The identification of previous traumatic brain injuries is essential in the clinical evaluation of a psychiatric disorder in order to perform a correct differential diagnosis with psychosis. Indeed, this has relevant implications in both treatment and prognosis.

Question 46

Albicini et al. (2018)

Answer 46

Main Measures: Semistructured interview to obtain psychiatric diagnoses and background information, and medical records for identification of TBI.

Results: Group with moderate-severe TBI presented with significantly higher rates of any anxiety disorder (χ22 = 6.81, P = .03) and comorbid anxiety disorder (χ22 = 6.12, P < .05). Group with overall TBI presented with significantly higher rates of any anxiety disorder (χ21 = 5.36, P = .02), panic attacks (χ21 = 4.43, P = .04), specific phobias (χ21 = 4.17, P = .04), and depression (χ21 = 3.98, P < .05). Prediction analysis revealed a statistically significant model (χ27 = 41.84, P < .001) explaining 23% to 37% of the variance in having any anxiety disorder, with significant predictors being group (TBI) and gender (female).

Conclusions: Children who have sustained a TBI may be vulnerable to persistent anxiety, panic attacks, specific phobias, and depression, even 13 years after the injury event.

Question 47

McHugo et al. (2017)

Answer 47

Results:

Eighty percent screened positive for TBI, and 25% reported at least 1 moderate or severe TBI. TBI was associated with current alcohol use and psychiatric symptom severity and with lifetime institutionalization and homelessness. It was more common among participants with posttraumatic stress disorder, borderline personality disorder, and antisocial personality disorder. Men (vs women) and participants with psychotic disorders (vs those with mood disorders) had an earlier age of first TBI with loss of consciousness.

Conclusion:

TBI is common among people with co-occurring mental health and substance use disorders. Repeated and serious TBIs are common in this population. Failure to detect TBI in people with co-occurring disorders who are seeking integrated treatment could lead to misdiagnosis and inappropriately targeted treatment and rehabilitation.

Question 48

Bornstein and Natoli (2019)

Answer 48

Increasing dissatisfaction with categorical personality disorder (PD) diagnoses has led to the development of dimensional PD frameworks, which have gained influence in recent years. Although most studies contrasting the dimensional and categorical frameworks focus on issues related to construct validity, there is a burgeoning literature evaluating the clinical utility of these two approaches, with studies typically contrasting clinicians’ ratings of various dimensions of clinical utility in the 2 frameworks using case vignettes or actual patients. This study used meta-analytic techniques to synthesize extant findings in this area, integrating data from 11 studies (103 total effect sizes, N of raters = 2,033) wherein clinical utility ratings of categorical and dimensional PD frameworks were compared. Dimensional models in general, and the five-factor model in particular, received more positive clinical utility ratings than categorical PD models in the majority of clinical utility domains. Stronger results were obtained for ratings of actual patients than ratings derived from case vignettes. Implications of these findings for the conceptualization and diagnosis of personality pathology are discussed, and suggestions for future research in this area are offered.

Question 49

Skoglund et al. (2019)

Answer 49

Family and twin studies of Borderline Personality Disorder (BPD) have found familial aggregation and genetic propensity for BPD, but estimates vary widely. Large-scale family studies of clinically diagnosed BPD are lacking. Therefore, we performed a total-population study estimating the familial aggregation and heritability of clinically diagnosed BPD. We followed 1,851,755 individuals born 1973–1993 in linked Swedish national registries. BPD-diagnosis was ascertained between 1997 and 2013, 11,665 received a BPD-diagnosis. We identified relatives and estimated sex and birth year adjusted hazard ratios, i.e., the rate of BPD-diagnoses in relatives to individuals with BPD-diagnosis compared to individuals with unaffected relatives, and used structural equation modeling to estimate heritability. The familial association decreased along with genetic relatedness. The hazard ratio was 11.5 (95% confidence interval (CI) = 1.6–83.8) for monozygotic twins; 7.4 (95% CI = 1.0–55.3) for dizygotic twins; 4.7 (95% CI = 3.9–5.6) for full siblings; 2.1 (95% CI = 1.5–3.0) for maternal half-siblings; 1.3 (95% CI = 0.9–2.1) for paternal half-siblings; 1.7 (95% CI = 1.4–2.0) for cousins whose parents were full siblings; 1.1 (95% CI = 0.7–1.8) for cousins whose parents were maternal half-siblings; and 1.9 (95% CI = 1.2–2.9) for cousins whose parents were paternal half-siblings. Heritability was estimated at 46% (95% CI = 39–53), and the remaining variance was explained by individually unique environmental factors. Our findings pave the way for further research into specific genetic variants, unique environmental factors implicated, and their interplay in risk for BPD

Question 50

Coolidge et al. (2001)

Answer 50

The heritability of personality disorder features was investigated in 112 child (ages 4–15 years) twin pairs (70 monozygotic and 42 dizygotic pairs). Parents assessed personality disorder features using the Coolidge Personality and Neuropsychological Inventory for Children (CPNI; Coolidge, 1998) that measures 12 personality disorders according to the criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (American Psychiatric Association, 1994). Structural equation model-fitting methods indicated that the median heritability coefficient for the 12 scales was .75 (ranging from .81 for the Dependent and Schizotypal Personality Disorder scales to .50 for the Paranoid and Passive-Aggressive Personality Disorder scales). These results suggest that childhood personality disorders have a substantial genetic component and that they are similar to heritability estimates of personality disorder traits in adults and counter hypotheses that only temperaments and higher-order personality disorder traits have significant genetic components (Paris, 1997).

Question 51

South et al. (2017)

Answer 51

Personality disorders (PDs) can be partly captured by dimensional traits, a viewpoint reflected in the most recent Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM–5) Alternative (Section III) Model for PD classification. The current study adds to the literature on the Alternative Model by examining the magnitude of genetic and environmental influences on 6 domains of maladaptive personality: negative emotionality, detachment, antagonism, disinhibition, compulsivity, and psychoticism. In a large, population-based sample (N = 2,293) of Norwegian male and female twin pairs, we investigated (a) if the domains demonstrated measurement invariance across gender at the phenotypic level, meaning that the relationships between the items and the latent factor were equivalent in men and women; and (b) if genetic and environmental influences on variation in these domains were equivalent across gender. Multiple group confirmatory factor modeling provided evidence that all 6 domain scale measurement models were gender-invariant. The best fitting biometric model for 4 of the 6 domains (negative emotionality, detachment, disinhibition, and compulsivity) was one in which genetic and environmental influences could be set invariant across gender. Evidence for sex differences in psychoticism was mixed, but the only clear evidence for quantitative sex differences was for the antagonism scale, with greater genetic influences found for men than women. Genetic influences across domains were moderate overall (19–37%), in line with previous research using symptom-based measures of PDs. This study adds to the very limited knowledge currently existing on the etiology of maladaptive personality traits

Question 52

Gustavson et al. (2019)

Answer 52

In this study, we characterized the genetic/environmental commonality and heterogeneity of impulsivity facets and tested the hypothesis that goal-management is central to their common variance. 764 young-adult twins completed the UPPS-P Impulsive Behavior Scale and measures of goal management, personality, and psychopathology. We found common genetic influences across all impulsivity facets except sensation seeking. These impulsivity genetic influences explained 40.0% of variance in goal-management ability. Other results supported three hypotheses concerning heterogeneity: that sensation seeking is independent of other facets, that urgency is more related to psychopathology than lack of premeditation, and that lack of perseverance is more similar to urgency than lack of premeditation. Thus, impulsivity facets show considerable heterogeneity in addition to common variation related to goal-management abilities.

Question 53

Czajkowski et al. (2018)

Answer 53

Method:
A large population-based sample of adult twins was assessed for DSM-IV personality disorder criteria with structured interviews at two waves spanning a 10-year interval. At the second assessment, participants also completed the Big Five Inventory, a self-report instrument assessing the five-factor normative personality model. The proportion of genetic and environmental liabilities unique to the individual personality disorder measures, and hence not shared with the five Big Five Inventory domains, were estimated by means of multivariate Cholesky twin decompositions.

Results:
The median percentage of genetic liability to the 10 DSM-IV personality disorders assessed at wave 1 that was not shared with the Big Five domains was 64%, whereas for the six personality disorders that were assessed concurrently at wave 2, the median was 39%. Conversely, the median proportions of unique environmental liability in the personality disorders for wave 1 and wave 2 were 97% and 96%, respectively.

Conclusions:
The results indicate that a moderate-to-sizable proportion of the genetic influence underlying DSM-IV personality disorders is not shared with the domain constructs of the Big Five model of normative personality. Caution should be exercised in assuming that normative personality measures can serve as proxies for DSM personality disorders when investigating the etiology of these disorders.

Question 54

Merza et al. (2015)

Answer 54

Methods: Traumatic childhood experiences of 80 borderline inpatients, 73 depressed inpatients and 51 healthy controls were assessed with the Traumatic Antecedents Questionnaire and the Sexual Abuse Scale of Early Trauma Inventory.

Results: Adverse childhood experiences (neglect, emotional abuse, physical abuse, sexual abuse, witnessing trauma) were more prevalent among borderline patients than among depressed and healthy controls. Borderline patients reported severe sexual abuse, characterized by incest, penetration and repetitive abuse. Sexually abused borderline patients experienced more physical and emotional abuse than borderlines who were not sexually abused. The strongest predictors of borderline diagnosis were sexual abuse, intrafamilial physical abuse and neglect by the caretakers.

Conclusions: Overall, our results suggest that a reported childhood history of abuse and neglect are both common and highly discriminating for borderline patients in Hungary as well.

Question 55

Constantian and Zaborek (2018)

Answer 55

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Question 56

Veliknoja et al. (2019)

Answer 56

Method
We included 225 individuals with SPD and 127 healthy controls. Childhood trauma was evaluated using the Childhood Trauma Questionnaire, and schizotypal traits were assessed using the Schizotypal Personality Questionnaire. Standard neurocognitive assessments covered six cognitive domains.

Results
All types of reported childhood trauma were significantly associated with SPD, in a linear fashion. Severe sexual abuse showed the greatest magnitude of association with higher cognitive–perceptual load (e.g., ideas of reference, odd belief or magical thinking); severe emotional neglect was associated with interpersonal scores (e.g., excessive social anxiety, constricted affect) within the SPD group. SPD individuals who reported severe trauma showed worse cognitive functioning (i.e., working memory, verbal/visual learning and memory, as well as verbal fluency).

Conclusions
Particular severe childhood trauma types were associated with higher cognitive–perceptual and interpersonal symptoms in SPD, along with worse cognitive functioning. These findings highlight the need for clinicians to enquire about childhood trauma in SPD patients, since unaddressed early adverse experiences may carry long‐term negative consequences.

Question 57

Björkenstam et al. (2017)

Answer 57

Childhood adversity (CA) may increase the risk for later developing of personality disorder (PD). However, less is known about the association between cumulative CA and PD, and the role of childhood psychopathology and school performance. The current study examined the relationship between a range of CAs and a diagnosis of PD in young adulthood, and the roles of childhood psychopathology and school performance in this relationship. All individuals born in Stockholm County 1987–1991 (n = 107,287) constituted our cohort. Seven CAs were measured between birth and age 14: familial death, parental criminality, parental substance abuse and psychiatric morbidity, parental separation and/or single-parent household, household public assistance and residential instability. Individuals were followed from their 18th birthday until they were diagnosed with PD or until end of follow-up (December 31st 2011). Adjusted estimates of risk of PD were calculated as hazard ratios (HR) with 95% confidence intervals (CI). Associations were observed between cumulative CA and PD. During the follow-up 770 individuals (0.7%) were diagnosed with PD. Individuals exposed to 3+ CAs had the highest risks of being diagnosed with PD (HR 3.0, 95% CI 2.4–3.7). Childhood psychopathology and low school grades further increased the risk of PD among individuals exposed to CA. Cumulative CA is strongly associated with a diagnosis of PD in young adulthood. Our findings indicate that special attention should be given in schools and health services to children exposed to adversities to prevent decline in school performance, and to detect vulnerable individuals that may be on negative life-course trajectories.

Question 58

Helgeland and Torgersen (2004)

Answer 58

Developmental antecedents of borderline personality disorders (BPDs) were examined in 25 DSM-IV-diagnosed subjects with BPD and 107 non-borderline control subjects on the basis of medical records and 28 years follow-up. Abuse, neglect, environmental instability, paternal psychopathology, and lower score on protective factors differentiated significantly between the groups. Environmental instability and lower score on protective factors such as artistic talents, superior school performance, above average intellectual skills, and talents in other areas were found to be independent predictors of BPD diagnosis. The results of this study suggest that both abuse and neglect, unpredictable and unstable early environment, as well as deficit in protective factors may substantially contribute to the development of BPD in persons constitutionally predisposed for the disorder. The results of the study also suggest that future research should address the impact of social and cultural context, as well as the absence of protective factors, on the development of the BPD.

Question 59

Musser et al. (2018)

Answer 59

A core tenet of Linehan’s biosocial theory (1993) is that borderline personality disorder (BPD) emerges as a result of transactions between emotional vulnerability and an invalidating environment. Invalidation has become a popular term in the literature, but there is a lack of uniformity in its operationalization and measurement, particularly as applied to invalidating parenting practices that are non-abusive. This systematic review of 77 empirical studies examined the measurement and operationalization of parental invalidation in the BPD literature and determined the extent to which measurements used converge with Linehan’s original model. This review provides a description of methodological design features of the literature and presents the percent of studies that measured four key components of invalidation—inaccuracy, misattribution, discouragement of negative emotions, and oversimplification of problem solving. Limitations of the literature, including a dearth of studies which include measurements that align with Linehan’s model, and recommendations for future research are discussed in an attempt to encourage greater scientific rigor in the measurement of invalidation and elucidate the role of invalidation in the development of BPD.

Question 60

Miller and Lisak (1999)

Answer 60

This study investigated the relationship between childhood abuse and personality disorder symptoms in a nonclinical sample of college males (N = 584, mean age = 28.8 years). Childhood sexual and physical abuse and personality disorder (PD) symptoms, among other variables, were assessed using self-report measures. Abuse histories were categorized into no abuse, sexual abuse only, physical abuse only, and both types of abuse. Also, a dimension of severity was measured by tallying, for sexual and physical abuse scales separately, the number of items meeting abuse criteria. Multivariate analyses indicate that even when statistically controlling for possible confounding variables, childhood abuse histories are associated with greater levels of adult symptomatology. The severity dimension predicted statistically significant, although clinically negligible, portions of the variance for three PD scales.

Question 61

Hageman et al. (2015)

Answer 61

Research indicates that some types of adverse childhood experience may be involved in the development of avoidant personality disorder (AVPD). The current study examined relationships between retrospectively reported childhood maltreatment, parental bonding, and teasing on levels of adult AVPD symptomatology. The current study incorporated a cross-section research design. Four hundred and eleven, non-clinical participants (99 males
and 312 females), ranging in age from 18 to 65 years (M= 29.75 years, SD= 11.44 years), completed a survey measuring current depression, anxiety and AVPD symptoms, and retrospective reports of childhood maltreatment, parental bonding and teasing. Consistent
with hypotheses, AVPD symptomatology correlated positively with depression and anxiety symptoms, childhood maltreatment, parental overprotection and childhood teasing; while a negative association was found with AVPD and parental care. In regression, after controlling for the inÁuence of depression and anxiety, sexual abuse and social behaviour teasing signiÀcantly and uniquely predicted AVPD symptomatology. Contrary to expectations, parental bonding was not a unique predictor of AVPD symptomatology in regression modelling. This study contributes to the understanding of factors potentially inÁuencing the development of AVPD.

Question 62

Bujalski et al. (2017)

Answer 62

Among college students, Borderline Personality Disorder (BPD) features are prevalent and impairing. Different types of childhood maltreatment (CM) are associated with BPD features, though the type(s) of CM that is most robustly associated with BPD features and the mechanism by which CM leads to BPD features are not well-studied. Thus, the purpose of this study was to investigate which type(s) of CM was most robustly associated with BPD features and to test whether empathy, which is negatively correlated with CM, mediated the relationship between CM and BPD features in college students. Two thousand five hundred fifty-one undergraduate college students completed online self-report questionnaires measuring CM, empathy, and BPD features. A series of regression models were tested to explore relationships between types of CM and BPD features and CM, empathy and BPD features. Childhood physical abuse, but neither sexual abuse nor neglect, significantly predicted BPD features. Cognitive empathy partially mediated the relationship between childhood physical abuse and BPD features. These findings suggest childhood physical abuse is negatively associated with cognitive empathy, which in turn, is negatively associated with BPD features. Implications for treating BPD features in college students based on these findings are discussed.

Question 63

Costa and McCrae (1992)

Answer 63

Personality psychologists from a variety of theoretical perspectives have recently concluded that personality traits can be summarized in terms of a 5-factor model. This article describes the NEO Personality Inventory (NEO–PI), a measure of these 5 factors and some of the traits that define them, and its use in clinical practice. Recent studies suggest that NEO–PI scales are reliable and valid in clinical samples as in normal samples. The use of self-report personality measures in clinical samples is discussed, and data from 117 “normal” adult men and women are presented to show links between the NEO–PI scales and psychopathology as measured by D. N. Jackson’s (1989) Basic Personality Inventory and L. Morey’s (1991) Personality Assessment Inventory. The authors argue that the NEO–PI may be useful to clinicians in understanding the patient, formulating a diagnosis, establishing rapport, developing insight, anticipating the course of therapy, and selecting the optimal form of treatment for the patient

Question 64

Samuel et al. (2010)

Answer 64

Many personality assessment inventories provide gender-specific norms to allow comparison of an individual’s standing relative to others of the same gender. In some cases, this means that an identical raw score produces standardized scores that differ notably depending on whether the respondent is male or female. Thus, an important question is whether unisex-normed scores or gender-formed scores more 1 validly assess personality. Gender-normed and unisex-normed scores from the NEO Personality Inventory Revised (P. T. Costa & R. R. McCrae, 1992) were examined in a large clinical sample, using 2 measures of personality disorder as validating criteria. Gendernormed scores did not obtain significantly higher correlations. In fact, for 2 personality disorders (antisocial and narcissistic), gender-normed scores yielded significantly lower correlations, suggesting that personality disorder pathology relates most closely to one’s absolute level of a personality trait, rather than one’s standing relative to others of the same gender. Ramifications of this finding for personality research and clinical assessment are discussed.

Question 65

Wilberg et al. (1999)

Answer 65

A self-report measure of the Five-Factor Model (FFM) of personality, NEO-PI-R, was administered to a sample of patients with borderline (BPD, N = 29) or avoidant PD (AVPD, N = 34), admitted to a day treatment prog;ram, to investigate the NEO-PI-R profiles of the disorders, and the ability of NEO-PI-R to discriminate between the two disorders. The diagnoses were assessed according to the LEAD standard. AVPD was associated with high levels of Neuroticism and Agreeableness, and low levels of Extraversion and Conscientiousness. BPD was associated with high. levels of Neuroticism and low levels of Agreeableness, Extraversion, and Conscientiousness. Eighty-eight percent of the AVPD group had high scores on Neuroticism and low scores on Extraversion, whereas 65% of the BPD group were high on Neuroticism and low on Agreeableness, The Extraversion and Agreeableness scales of NEO-PI-R discriminated between patients with BPD and those with AVPD. Patients with BPD scored significantly higher on the Angry Hostility and Impulsiveness subscales of Neuroticism and significantly lower on three Extraversion subscales, three Agreeableness subscales, and one Conscientiousness subscale. At the DSM-TV criterion level, there were more significant relationships between the subscales of NEO;PI-R and the AVPD criteria than with the BPD criteria. The findings suggest that the FFM has good discriminating ability regarding BPD and AVPD. However, there may be a closer conceptual relationship between the FFM and AVPD than between the FFM and BPD.

Question 66

Hyatt et al. (2019)

Answer 66

Although personality traits have been linked to internalizing and externalizing psychopathology, the extent to which these traits and psychopathological phenotypes share a common neuroanatomical structure is unclear. To address this gap, we used structural neuroimaging and self-report data from 1101 participants in the Human Connectome Project to generate neuroanatomical profiles (NAPs) of FFM traits and psychopathology indices composed of the thickness, surface area, and gray matter volume of each region in the Desikan atlas, then used a profile matching approach to compare the absolute similarity of the FFM trait NAPs and psychopathology index NAPs. These analyses indicated that the NAPs derived from Neuroticism and Extraversion demonstrated medium to large positive and negative absolute similarities to the NAPs of internalizing psychopathology, respectively. Similarly, the NAPs of Agreeableness and Conscientiousness showed medium to large negative relations with the NAPs of antisocial behavior and substance use, respectively. These results suggest that similar neuroanatomical correlates underlie specific personality traits and symptoms of psychopathology, providing support for dimensional models that incorporate personality traits into the etiology and manifestation of psychopathology.

Question 67

Bagby and Widiger (2018)

Answer 67

The Five-Factor Model (FFM) is a dimensional model of general personality structure, consisting of the domains of neuroticism (or emotional instability), extraversion versus introversion, openness (or unconventionality), agreeableness versus antagonism, and conscientiousness (or constraint). The FFM is arguably the most commonly researched dimensional model of general personality structure. However, a notable limitation of existing measures of the FFM has been a lack of coverage of its maladaptive variants. A series of self-report inventories has been developed to assess for the maladaptive personality traits that define Diagnostic and Statistical Manual of Mental Disorders (fifth edition; DSM–5) Section II personality disorders (American Psychiatric Association [APA], 2013) from the perspective of the FFM. In this paper, we provide an introduction to this Special Section, presenting the rationale and empirical support for these measures and placing them in the historical context of the recent revision to the APA diagnostic manual. This introduction is followed by 5 papers that provide further empirical support for these measures and address current issues within the personality assessment literature.

Question 68

Lynam and Miller (2014)

Answer 68

The present article argues that psychopathy is best understood as a collection of traits from the Five‐Factor Model of personality (FFM). We demonstrate that specific FFM traits involved in psychopathy are well delineated; the same personality profile emerges across methods. We review research demonstrating that this FFM profile can be used to assess psychopathy, including the development of a psychopathy‐specific FFM assessment that appears to do an even better job of assessing psychopathy than the NEO PI‐R while remaining true to the basic structural model. We demonstrate the advantages to understanding psychopathy in this way. The FFM provides an assay of extant inventories, accounts for the epidemiology of psychopathy, and explains the factor structure of various inventories. The elemental view of psychopathy allows psychopathy to be built from the ground up, trait by trait. Perhaps most importantly, the FFM is unique in providing a connection to basic research in personality.

Question 69

Saulsman and Page (2004)

Answer 69

The current meta-analysis reviews research examining the relationships between each of the five-factor model personality dimensions and each of the 10 Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) personality disorder diagnostic categories. Effect sizes representing the relationships between these two constructs were compiled from 15 independent samples. Results were analyzed both within each individual personality disorder category and across personality disorders, indicating how personality disorders are different and similar, respectively, with regard to underlying personality traits. In terms of how personality disorders differ, the results showed that each disorder displays a five-factor model profile that is meaningful and predictable given its unique diagnostic criteria. With regard to their similarities, the findings revealed that the most prominent and consistent personality dimensions underlying a large number of the personality disorders are positive associations with Neuroticism and negative associations with Agreeableness. Extraversion appears to be a more discriminating dimension, as indicated by prominent but directionally variable associations with the personality disorders. The implications of these meta-analytic findings for clinical application and the advancement of future research are discussed.

Question 70

Cicero et al. (2019)

Answer 70

The associations among normal personality and many mental disorders are well established, but it remains unclear whether and how symptoms of schizophrenia and schizotypal traits align with the personality taxonomy. This study examined the joint factor structure of normal personality, schizotypy, and schizophrenia symptoms in people with psychotic disorders (n = 288) and never-psychotic adults (n = 257) in the Suffolk County Mental Health Project. First, we evaluated the structure of schizotypal (positive schizotypy, negative schizotypy, and mistrust) and normal traits. In both the psychotic-disorder and never-psychotic groups, the best-fitting model had 5 factors: neuroticism, extraversion, conscientiousness, agreeableness, and psychoticism. The schizotypy traits were placed on different dimensions: negative schizotypy went on (low) extraversion, whereas positive schizotypy and mistrust went on psychoticism. Next, we added symptoms to the model. Numerous alternatives were compared, and the 5-factor model remained best-fitting. Reality distortion (hallucinations and delusions) and disorganization symptoms were placed on psychoticism, and negative symptoms were placed on extraversion. Models that separated symptom dimensions from trait dimensions did not fit well, arguing that taxonomies of symptoms and traits are aligned. This is the first study to show that symptoms of psychosis, schizotypy, and normal personality reflect the same underlying dimensions. Specifically, (low) extraversion, negative schizotypy, and negative symptoms form one spectrum, whereas psychoticism, positive schizotypy, and positive and disorganized symptoms form another. This framework helps to understand the heterogeneity of psychosis and comorbidity patterns found in psychotic disorders. It also underscores the importance of traits to understanding these disorders.

Question 71

De Moor et al. (2015)

Answer 71

Objectives To identify genetic variants associated with neuroticism by performing a meta-analysis of genome-wide association results based on 1000 Genomes imputation; to evaluate whether common genetic variants as assessed by single-nucleotide polymorphisms (SNPs) explain variation in neuroticism by estimating SNP-based heritability; and to examine whether SNPs that predict neuroticism also predict MDD.

Results A genome-wide significant SNP was found on 3p14 in MAGI1 (rs35855737; P = 9.26 × 10−9 in the discovery meta-analysis). This association was not replicated (P = .32), but the SNP was still genome-wide significant in the meta-analysis of all 30 cohorts (P = 2.38 × 10−8). Common genetic variants explain 15% of the variance in neuroticism. Polygenic scores based on the meta-analysis of neuroticism in 27 cohorts significantly predicted neuroticism (1.09 × 10−12 

Question 72

Harkness et al. (1995)

Answer 72

The Personality Psychopathology Five (PSY-5; A. R. Harkness & J. L. McNulty, 1994) is a dimensional descriptive system for personality and its disorders. Replicated rational selection was used to generate Minnesota Multiphasic Personality Inventory-2 (MMPI-2; J. N. Butcher et al, 1989)-based scales for the PSY-5. The scales are Aggressiveness, 18 items; Psychoticism, 25 items; Constraint, 29 items; Negative Emotionality/Neuroticism, 33 items; and Positive Emotionality/Extraversion, 34 items. In three clinical samples with Ns of 328, 156, and 1,196; a college sample with an N of 2,928; and MMPI-2 normative samples with an N of 2,567, alphas ranged from .65 to .88. For 838 college students who had also completed A. Tellegen’s (1982) Multidimensional Personality Questionnaire (MPQ), correlations between PSY-5 scales and corresponding MPQ superfactors were as follows: Constraint, r = .57, p

Question 73

Stokes et al. (2019)

Answer 73

PSY-5 dimensions accounted for 54% of the variance in BPD symptom severity.

Neuroticism/negative emotionality was the strongest predictor of BPD severity.

PSY-5 aggression was a significant predictor, of BPD symptoms.

PSY-5 psychoticism seems more indirectly related to BPD symptoms in adolescents.

No gender differences emerged in relationships between PSY-5 dimensions and BPD areas.

Question 74

Arbisi (2014)

Answer 74

In this Special Section, 7 studies focusing on the PSY-5 model of individual differences relevant to adaptive functioning are presented. The first study by Harkness, McNulty, etal. (this issue) describes the development of the revised PSY-5 scales for the MMPI-2-RF, followed by another article by Harkness, Reynolds, and Lilienfeld (this issue) arguing for the adoption of a review of systems strategy for evaluating psychological functioning. McNulty and Overstreet (this issue) describe an alternative hierarchical strategy for organizing the interpretation of the MMPI-2-RF using the PSY-5 scales. Extending the PSY-5 model to adolescents, Veltri etal. (this issue) examine the convergent and discriminant validity of the MMPI-A PSY-5 in predicting violent delinquent behavior. Bagby and colleagues (this issue) examine the hierarchical structure of the PSY-5 model across nonclinical and clinical samples and, with a few notable exceptions, find the PSY-5 model to map well onto the DSM-5 personality trait dimensional model. Finn, Arbisi, Erbes, Polusny, and Thuras (this issue) examine the convergence between the DSM-5 proposed trait dimensions and PSY-5 model demonstrating the potential for the MMPI-2-RF PSY-5 scales to serve as a bridge between DSM-5 and DSM-IV personality disorder diagnoses. Finally, Sellbom, Smid, de Saeger, Smit, and Kamphuis(this issue) directly examine the convergence of MMPI-2-RF PSY-5 scales with DSM-IV personality disorder categories and proposed DSM-5 trait dimensions further establishing the potential for the PSY-5 scales to serve as a bridge between DSM categorical and dimensional diagnostic schemas.

Question 75

Wygant et al. (2006)

Answer 75

The Minnesota Multiphasic Personality Inventory-2 (MMPI-2) Personality Psychopathology-Five (PSY-5) scales were developed to measure abnormal personality symptomatology. The present study examines the incremental validity of the PSY-5 scales beyond the clinical and content scales in assessing criteria associated with personality disorders. The current sample includes 240 male and 407 female clients from private practice settings who completed the MMPI-2 and the Multiaxial Diagnostic Inventory (MDI), a self-report checklist of Diagnostic and Statistical Manual of Mental Disorders (3rd ed, revised) symptoms. Six of the MDI personality disorder scales, conceptually related to the PSY-5 scales, are used as criteria. Hierarchical regression analyses determine the incremental validity of each PSY-5 scale. In most analyses, PSY-5 scales add a significant increment of variance to the clinical and content scales. Implications of the results are discussed.

Question 76

Bolinskey et al. (2004)

Answer 76

McNulty, Harkness, Ben-Porath and Williams recently developed Personality Psychopathology Five (PSY-5) scales for the Minnesota Multiphasic Personality Inventory– A (MMPI-A). This study examined these new scales in a sample of 545 adolescents receiving inpatient psychiatric treatment. Item-level principal components analyses were employed to determine the internal structure of each PSY-5 scale and to aid in the creation of facet subscales for each PSY-5 scale. Results suggest that the MMPI-A PSY-5 scales display adequate internal consistency and our findings generally replicate the original work of McNulty et al. but also extend this work by showing that several of the PSY-5 scales may also be subdivided into meaningful lower level dimensions. These facet subscales for each of the MMPI-A PSY-5 scales are offered for further study.

Question 77

Pappalardo (2019)

Answer 77

Psychosis refers to a clinically significant impairment in reality testing. While schizophrenia is relatively rare in adolescents, psychotic symptoms and psychotic states are not, and the accurate detection and quantification of psychosis is critical to the clinical care of adolescents in mental health settings. The MMPI-A is a widely used broad-band diagnostic measure for adolescents which includes scales designed to detect psychosis. The MMPI-A-RF is a relatively new measure for adolescents that also includes scales that are capable of detecting psychosis. While the MMPI-A-RF was developed out of the item pool of the MMPI-A and it shares some of its features, such as validity scales and clinical scales, the authors of the MMPI-A-RF intend it to be an entirely new instrument for the detection of adolescent psychopathology. The data concerning the validity of the scales in the MMPI-A relevant to psychosis is quite limited and to date, no
studies specific to this issue for the MMPI-A-RF have been published. Therefore, further investigation is clearly warranted both to establish these measures’ validity for the detection and quantification of psychosis. The current study examined both the convergent and discriminant
validities of the MMPI-A and MMPI-A-RF psychosis scales by examining their relationships to other self-report measures (e.g., PAI-A scales), observer ratings (e.g., HPRS and chart diagnoses), and performance-based measures (e.g., Rorschach CS). Their discriminant validity was assessed by comparing the psychosis scales from each MMPI to measures expected to have a weaker relationship to psychosis (i.e., measures of general distress) and those expected to be relatively impervious to the presence or absence of psychosis (i.e., measures of verbal intellect).
Using data from 791 adolescent psychiatric inpatients, 333 subjects remained after excluding subjects with invalid or incomplete data across measures. The convergent validity of the MMPIA and MMPI-A-RF with measures of psychosis was comparable, while their discriminant validity was mixed. The MMPI-A-RF was superior at distinguishing between psychosis and general distress, but this appeared to be specific to self-reported general distress and not distress per se as captured by other methods. The MMPI-A appeared superior at differentiating psychosis from general intellectual ability

Question 78

Stokes et al. (2018)

Answer 78

This study explored the association between the Minnesota Multiphasic Personality Inventory (MMPI)–Adolescent-Restructured Form (MMPI-A-RF) and the MMPI-Adolescent (MMPI-A) form in a sample of 3,516 adolescents receiving inpatient psychiatric treatment, including 2,798 adolescents meeting validity inclusion cutoffs for both measures. There was 92.5% agreement rate with respect to global identification of cases as valid or invalid and some empirical support for lowering interpretive cutoffs for validity scales on the MMPI-A-RF. The MMPI-A-RF Demoralization Scale (RCd) was shown to correlate significantly less strongly with Restructured Clinical (RC) scales than with MMPI-A clinical scales. RC scales also demonstrated significantly lower mean interscale correlations than MMPI-A clinical scales. As expected, this greater level of scale independence resulted in significantly fewer profiles with multiple scale elevations. As was anticipated, with the exception of RC1 predicting MMPI-A hypochondriasis, correlational and classification agreement analyses suggested moderate associations between the RC and MMPI-A clinical scales, but somewhat stronger agreement between comparable PSY-5 scales. Changes in interpretive cutoff procedures for the RC scales, including RCd, also resulted in 5.5% fewer “within normal limits” profiles than the use of MMPI-A with all 10 clinical scales. Finally, stepwise linear regression analyses indicated that MMPI-A-RF Higher-Order scales were best predicted by those MMPI-A clinical scale combinations that they are purported to be linked with in the MMPI-A-RF manual.

Question 79

Simonsen et al. (2019)

Answer 79

Personality disorders (PD) are common and burdensome mental disorders. The treatment of individuals with PD represents one of the more challenging areas in the field of mental health and health care providers need evidence-based recommendations to best support patients with PDs. Clinical guidelines serve this purpose and are formulated by expert consensus and/or systematic reviews of the current evidence. In this review, European guidelines for the treatment of PDs are summarized and evaluated. To date, eight countries in Europe have developed and published guidelines that differ in quality with regard to recency and completeness, transparency of methods, combination of expert knowledge with empirical data, and patient/service user involvement. Five of the guidelines are about Borderline personality disorder (BPD), one is about antisocial personality disorder and three concern PD in general. After evaluating the methodological quality of the nine European guidelines from eight countries, results in the domains of diagnosis, psychotherapy and pharmacological treatment of PD are discussed. Our comparison of guidelines reveals important contradictions between recommendations in relation to diagnosis, length and setting of treatment, as well as the use of pharmacological treatment. All the guidelines recommend psychotherapy as the treatment of first choice. Future guidelines should rigorously follow internationally accepted methodology and should more systematically include the views of patients and users.

Question 80

Hall and Moran (2019)

Answer 80

The value and challenges of establishing and maintaining a successful doctor–patient relationship are thrown into sharp relief in the treatment of people with borderline personality disorder. We present an overview of this common and important condition, its epidemiology, cause, common comorbidities and neurological associations. We then propose a practical, psychologically informed framework for enhancing the therapeutic alliance for the jobbing neurologist in managing these patients.

Question 81

Lu and Temple (2019)

Answer 81

Despite the public, political, and media narrative that mental health is at the root of gun violence, evidence is lacking to infer a causal link. This study examines the temporal associations between gun violence (i.e., threatening someone with a gun and gun carrying) and mental health (i.e., anxiety, depression, stress, PTSD, hostility, impulsivity, and borderline personality disorder) as well the cross-sectional associations with gun access and gun ownership in a group of emerging adults. Waves 6 (2015) and 8 (2017) data were used from a longitudinal study in Texas, US. Participants were 663 emerging adults (61.7% female) including 33.6% self-identified Hispanics, 26.0% white, 27.0% Black, and 13.4% other, with an average age of 22 years. Multivariate logistic regression indicated that, individuals who had gun access were 18.15 times and individuals with high hostility were 3.51 times more likely to have threatened someone with a gun, after controlling for demographic factors and prior mental health treatment. Individuals who had gun access were 4.74 times, individuals who reported gun ownership were 5.22 times, and individuals with high impulsivity were 1.91 times more likely to have carried a gun outside of their homes, after controlling for prior gun carrying, mental health treatment, and demographic factors. Counter to public beliefs, the majority of mental health symptoms examined were not related to gun violence. Instead, access to firearms was the primary culprit. The findings have important implications for gun control policy efforts.

Question 82

Johnson (2019)

Answer 82

It appears that the personality and background factors identified for sexual offenders neatly fit into what I refer to as The Violent Personality. The literature strongly supports
that those who engage in violent behavior tend to engage in violence in several areas, not just one specific type of violence. For example, domestic abusers often sexually abuse/ rape their partners; engage in child abuse, animal cruelty, road rage, and other forms of violent and nonviolent criminal behavior. The personality factors and backgrounds of those who engage in violent behavior are similar. A thorough psychological and risk assessment, criminal background check, as well as interviews with those who know the offender are necessary in order fully understand the scope of the violent offender’s criminally violent
history. For example, being arrested for domestic violence should spark an investigation to assess other likely forms of violent behavior the abuser engaged in, including raping of his partner, abuse of the children in the home, as well as abuse of animals in the home, all likely having occurred but rarely assessed. Sociopathy and psychopathy should also be assessed for all violent offenders because of the serious implications for treatment interventions as well as risk for violent reoffense. Approximately 3-15% of those with APD likely have psychopathy and another 30% likely have sociopathy. As I examine the violent personality, it becomes clearer that those with any of the traits of the violent personality are likely sociopaths or psychopaths because the traits of sociopathy/psychopathy are shared with
the violent personality. In short, it is important to assess for sociopathy/psychopathy in all who present with violent behaviors, tendencies or thoughts. The term psychopath tends to be used to describe both the sociopath and psychopath and therefore the assessment of the sociopath is the same as for the psychopath, though there are differences between the two. The goal of this article is to discuss what I call the Violent Personality. Antisocial
Personality Disorder, Sociopathy, and Psychopathy will be discussed to understand how they are all part of the Violent Personality continuum. The available research literature will
be discussed.

Question 83

Kelley et al. (2018)

Answer 83

Method
We conducted a quantitative synthesis of ten juror simulation studies (combined N = 2,980) examining the meta‐analytic association between perceived defendant psychopathy and various psychologically important and legally relevant outcomes.

Results
Perceiving someone as being more psychopathic was associated with viewing that defendant as more dangerous (r W = 0.31) and evil ( r W = 0.44). Moreover, perceptions of defendant psychopathy predicted greater support for more adverse consequences in terms of capital sentencing ( r W = 0.22) and sentence length ( r W = 0.27), although not perceived treatment amenability ( r W = 0.09).

Conclusions
These findings highlight the importance of including ratings of perceived psychopathy in experimental designs to identify the circumstances under which psychopathy evidence might prejudicially impact case outcomes.

Question 84

Widiger et al. (2018)

Answer 84

The categorical model of classification in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders is sorely problematic. A proposed solution is emerging in the form of a quantitative nosology, an empirically based dimensional organization of psychopathology. More specifically, a team of investigators has proposed the Hierarchical Taxonomy of Psychopathology (HiTOP). The purpose of this article is to discuss the potential role, importance, and implications of personality within the HiTOP dimensional model of psychopathology. Suggested herein is that personality provides a foundational base for the HiTOP dimensional model of psychopathology. Implications concern the potential value of the early assessment of and screening for personality as well as the development of protocols for the treatment of personality trait domains, which may in turn contribute to substantial improvements in quality of life as well as mental and physical health.

Question 85

Watson et al. (2019)

Answer 85

Extraversion is negatively related to depression and social dysfunction and positively linked to mania/externalizing.

Different features of extraversion are responsible for these positive and negative associations with psychopathology.

Depression is associated with the aspect of Communal Extraversion and the facets of Liveliness and Positive Emotions.

Social dysfunction is linked to the aspect of Communal Extraversion and the facets of Sociability, Gregariousness & Warmth.

Mania/externalizing are linked to the aspect of Agentic Extraversion and the facets of Venturesomeness & Excitement-Seeking

Question 86

Malouff et al. (2005)

Answer 86

This paper describes a meta-analysis of 33 studies that examined the relationship between the Five-Factor Model and symptoms of clinical disorders. The typical pattern found associated with clinical disorders or measures of clinical disorders was high Neuroticism, low Conscientiousness, low Agreeableness, and low Extraversion. Comparisons of diagnostic groups and norm groups showed higher levels of Neuroticism and lower levels of Extraversion than did studies of correlations between measures of the level of a disorder and measures of the five factors. Studies of observer ratings of the five factors showed lower levels of Neuroticism and Openness than did studies of self-report ratings. These and other findings relating to type of scale and type of comparison group have possible clinical implications and raise several questions worthy of further research.