DSM-IV Personality Disorders Research Articles

Moral Nature of the DSM-IV Cluster B Personality Disorders

Moral considerations do not appear to play a large role in discussions of the DSM-IV personality disorders and debates about their empirical validity. Yet philosophical analysis reveals that the Cluster B personality disorders, in particular, may in fact be moral rather than clinical conditions. This finding has serious consequences for how they should be treated and by whom.

The Validity of Cloninger's Psychobiological Model Versus the Five‐Factor Model to Predict DSM‐IV Personality Disorders in a Heterogeneous Psychiatric Sample: Domain Facet and Residualized Facet Descriptions

The validity of Cloninger's psychobiological model and the Five-Factor Model of personality to predict DSM-IV personality disorders was examined in a psychiatric in-patient sample of 130 individuals. Patients completed Dutch authorized versions of the TCI (Cloninger, Svrakic, & Przybeck, 1993) and the NEO PI-R (Costa & McCrae, 1992) and were also administered the ADP-IV (Schotte & De Doncker, 1994), a Dutch self-report questionnaire to assess Axis-II disorders. No personality-descriptive model proved to be superior in explaining personality disorder symptoms at the higher-order level: the TCI dimensions better explained the Obsessive-Compulsive and the Narcissistic disorders, whereas the FFM accounted for more variance of the Avoidant disorder. However, differences were apparent at the lower-order level with the NEO facets out performing the TCI subscales for six to four personality disorders. FFM facet-level predictions of Widiger, Trull, Clarkin, Sanderson, and Costa (2002) were partially confirmed, with substantially better results using residualized facet scores. A set of TCI subscale personality disorder relationships is suggested.

The Clinical Implications of DSM-IV Personality Disorder Comorbidity in Depressed Inpatients: A Replication Study in an Italian Setting

In order to replicate, in a naturalistic Italian setting, prior studies about the clinical implications of Axis II comorbidity in depressed inpatients, 247 unipolar inpatients were divided into two diagnostic groups to examine the sociodemographic, clinical, and psychosocial correlates of patients with a concomitant personality disorder (PD). There were 155 depressed patients with a PD (63%) versus 92 (34%) patients with depression alone. Subjects were diagnosed on Axis I and II using the SCID-I and II. Self-ratings as well as expert ratings were used for assessment. Psychopathology and psychosocial functioning were measured by the Montgomery-Asberg Depression Rating Scale (MADRS), the Hamilton Rating Scale for Depression (HAM-D), the Symptom Checklist-90 (SCL-90), and the Social Adjustment Scale (SAS). By comparison with cases of depression alone, depressed patients with concomitant PD were younger and had been significantly younger at the onset of their affective illnesses, they reported more suicidal attempts, and they were more likely to have never been married. They revealed as having severe social impairment in overall social adjustment, and in the leisure, extended family, marital role, and financial status subareas in the comparison of SAS scores between groups. The baseline-to-discharge symptom changes were evaluated between the two groups. A significant group × time interaction was found in all scores, with the exception of the HAM-D and three SCL-90 subscales: the PD patients had more severe symptoms at baseline. Finally, both groups reported a favorable treatment outcome at discharge. Then, although the PD patients showed a more seriously affected social functioning and a more severe baseline symptomatology than depressed patients without PD, the personality pathology did not appear to worsen treatment response. The main findings are discussed.

A Simplified Technique for Scoring DSM-IV Personality Disorders With the Five-Factor Model

The current study compares the use of two alternative methodologies for using the Five-Factor Model (FFM) to assess personality disorders (PDs). Across two clinical samples, a technique using the simple sum of selected FFM facets is compared with a previously used prototype matching technique. The results demonstrate that the more easily calculated counts perform as well as the similarity scores that are generated by the prototype matching technique. Optimal diagnostic thresholds for the FFM PD counts are computed for identifying patients who meet diagnostic criteria for a specific PD. These threshold scores demonstrate good sensitivity in receiver operating characteristics analyses, suggesting their usefulness for screening purposes. Given the ease of this scoring procedure, the FFM count technique has obvious clinical utility.

Higher-Order Dimensions of Personality Disorder: Hierarchical Structure and Relationships with the Five-Factor Model, The Interpersonal Circle, and Psychopathy

Two studies examined the higher-order factor structure of DSM-IV personality disorders using the International Personality Disorder Examination in male forensic psychiatric patients. In Study 1 (N = 168), exploratory factor analysis at the level of individual personality disorder criteria indicated nine primary factors. Exploratory and confirmatory factor analyses of these first-order factors supported a hierarchical structure in which two of three second-order factors covaried to yield a third-order factor. The two resulting superordinate factors were labelled Anxious-Inhibited and Acting Out. In Study 2 (N = 160), we used exploratory and confirmatory factor analyses to test hypotheses of common dimensions underlying these superordinate factors of personality disorder and superordinate factors of the five-factor model of personality, dimensions of the interpersonal circle, and psychopathy. Of three common factors, one combined Anxious-Inhibited disorders, "neurotic introversion," and hostile-submission. The other two factors of Acting Out/ psychopathy and antagonism/hostile-dominance covaried to yield a superordinate factor. Possible substrates underlying two superordinate dimensions common to normal and abnormal personality were identified in the theoretical literature.

Rating of personality disorder features in popular movie characters

BackgroundTools for training professionals in rating personality disorders are few. We present one such tool: rating of fictional persons. However, before ratings of fictional persons can be useful, we need to know whether raters get the same results, when rating fictional characters.MethodPsychology students at the University of Copenhagen (N = 8) rated four different movie characters from four movies based on three systems: Global rating scales representing each of the 10 personality disorders in the DSM-IV, a criterion list of all criteria for all DSM-IV personality disorders in random order, and the Ten Item Personality Inventory for rating the five-factor model. Agreement was estimated based on intraclass-correlation.ResultsAgreement for rating scales for personality disorders ranged from 0.04 to 0.54. For personality disorder features based on DSM-IV criteria, agreement ranged from 0.24 to 0.89, and agreement for the five-factor model ranged from 0.05 to 0.88. The largest multivariate effect was observed for criteria count followed by the TIPI, followed by rating scales. Raters experienced personality disorder criteria as the easiest, and global personality disorder scales as the most difficult, but with significant variation between movies.ConclusionPsychology students with limited or no clinical experience can agree well on the personality traits of movie characters based on watching the movie. Rating movie characters may be a way to practice assessment of personality.

Latent structure of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition personality disorder criteria

Aims This study investigated the internal construct validity of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition ( DSM-IV) personality disorders and explored alternative models to characterize the personality disorder traits. The relationship between the obtained personality disorder dimensions and measures of functioning and disability was examined. Methods The subjects in the study were 742 community-residing individuals who participated in the Hopkins Epidemiology of Personality Disorders Study. The presence of DSM-IV personality disorder traits was assessed by psychologists using the International Personality Disorder Examination (IPDE). Confirmatory factor analysis was performed on all the IPDE criteria for each of the 10 personality disorders using the Mplus program. Exploratory factor analysis of all personality disorder traits was completed using the same program. Factor scores were correlated with subjects' GAF ratings and number of missed days from work for physical and psychological reasons. Results A single underlying factor was found for the IPDE item criteria of avoidant and dependent personality disorder, with less evidence for the other 8 personality disorders. Five factors were retained as the dimensional accounting for the personality disorder criteria. These factors were named compulsive, neurotic avoidant, aloof, impulsive callous, and egocentric. Of the five factors, 4 were associated with evidence of diminished functioning. Conclusions The IPDE pathological personality traits did not empirically cluster according to the current DSM-IV axis II diagnostic system but instead defined 5 relatively independent PD symptom dimensions that were related to functional impairments.

The effect of pharmacotherapy on personality disorders in panic disorder: A one year naturalistic study

Background In this prospective study, Personality Disorders (PersD) were evaluated in patients with Panic Disorder (PD), before and after one year of pharmacotherapy to verify whether personality characteristics changed after treatment. Method Sixty PD patients and 60 sex and age-matched normal controls participated in the study. All subjects were evaluated with the SCID-IV, the Structured Interview for DSM-IV Personality Disorders (SIDP), the SCL-90, the Ham-A and the Ham-D. Patients were treated with paroxetine or citalopram and were evaluated monthly for one year to assess the remission of symptoms. The SIDP was re-administered to the patients at the end of the study. Results Before treatment, PD patients showed a higher prevalence (60%) of PersD than normal subjects (8%). After treatment, PersD rate decreased (43%) due to the reduction of the rate of paranoid, avoidant and dependent PersD. When the effect of the treatment on personality traits was evaluated, we found that avoidant traits decreased only in remitted patients, paranoid traits decreased both in remitted and in non-remitted patients, and dependent traits decreased only in patients with major depression comorbidity. Limitations The small sample size and the short length of the follow-up period of our study suggest caution in the generalization of our results. Conclusions In our PD patients, an improvement of symptoms was associated with a reduction of paranoid, avoidant and dependent traits, with a normalization of paranoid traits and a persistence of avoidant and dependent characteristics. Therefore, our data suggest that in PD patients not only paranoid traits but also avoidant and dependent traits show, at least in part, a state phenomenon.

Dimensional Representations of DSM-IV Personality Disorders: Relationships to Functional Impairment

This study compared three-dimensional representations of DSM-IV personality disorders and standard categories with respect to their associations with psychosocial functioning. Six hundred sixty-eight patients with semistructured interview diagnoses of schizotypal, borderline, avoidant, or obsessive-compulsive personality disorders or with major depressive disorder and no personality disorder completed questionnaires assessing three-factor and five-factor dimensional models of personality. Personality disorder categories, dimensional representations of the categories based on criteria counts, and three- and five-factor personality dimensions were compared on their relationships to impairment in seven domains of functioning, as measured by the Longitudinal Interval Follow-up Evaluation-Baseline Version. Both the categorical and dimensional representations of DSM-IV personality disorders had stronger relationships to impairment in functioning in the domains of employment, social relationships with parents and friends, and global social adjustment and to DSM-IV axis V ratings than the three- and five-factor models. DSM-IV dimensions predicted functional impairment best of the four approaches. Although five-factor personality traits captured variance in functional impairment not predicted by DSM-IV personality disorder dimensions, the DSM-IV dimensions accounted for significantly more variance than the measures of personality. Scores on dimensions of general personality functioning do not appear to be as strongly associated with functional impairment as the psychopathology of DSM personality disorder. A compromise in the ongoing debate over categories versus dimensions of personality disorder might be the dimensional rating of the criteria that comprise traditional categories.

The Prevalence of DSM-IV Personality Disorders in Psychiatric Outpatients

The largest clinical epidemiological surveys of personality disorders have been based on unstructured clinical evaluations. However, several recent studies have questioned the accuracy and thoroughness of clinical diagnostic interviews; consequently, clinical epidemiological studies, like community-based studies, should be based on standardized evaluations. The Rhode Island Methods to Improve Diagnostic Assessment and Services project is one of the largest clinical epidemiological studies to use semistructured interviews to assess a wide range of psychiatric disorders conducted in general clinical outpatient practice. In the present report, the authors examined the frequency of DSM-IV personality disorders in a patient group and the comorbidity among them. Eight hundred fifty-nine psychiatric outpatients were interviewed with the Structured Interview for DSM-IV Personality upon presentation for treatment. Slightly less than one-third of the patients were diagnosed with one of the 10 official DSM-IV personality disorders (N=270, 31.4%). When the patients with personality disorder not otherwise specified were included, the rate of any personality disorder increased to almost half of the group (N=391, 45.5%). The majority of patients meeting criteria for one of the specific personality disorders were diagnosed with more than one. Avoidant, borderline, and obsessive-compulsive personality disorder were the most frequent specific diagnoses. Personality disorders, as a group, are among the most frequent disorders treated by psychiatrists. They should be evaluated in all psychiatric patients because their presence can influence the course and treatment of the axis I disorder that patients typically identify as their chief complaint.

Personality-Guided Therapy in Behavioral Medicine

Back to table of contents Previous article Next article Book Forum: PsychotherapiesFull AccessPersonality-Guided Therapy in Behavioral MedicineSCOTT WETZLER, Ph.D., SCOTT WETZLERSearch for more papers by this author, Ph.D., Bronx, N.Y.Published Online:1 Oct 2005https://doi.org/10.1176/appi.ajp.162.10.1990-aAboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail According to Robert Harper’s review of the literature, the majority of major medical fatalities in the United States—50%–75%— are linked to behavior. Thus was born the field of behavioral medicine: change behavior, and morbidity and mortality will be expected to improve. But behavior is a complex phenomenon, and as the field has become more sophisticated, strategies for changing behavior have begun to take into account the patient’s individualized personality configuration. This comprehensive, cogent, and clinically relevant book is predicated on the dual ideas that behavior change can improve medical outcomes and that an understanding of individual personality is necessary for changing behavior.Major medical illness is clearly a stressor or crisis with which people must learn to cope. Although certain classes of illness pose similar psychological challenges regardless of the individual, the individual’s personality determines how he or she experiences the stressor, his or her vulnerabilities, and what emotional resources are available to help the individual cope. Harper appreciates that behavior emerges from the interaction between personality and situational factors.A senior psychologist at the Menninger Department of Psychiatry at Baylor, Harper describes how different personalities deal with different medical illnesses. The volume is well organized according to the DSM-IV personality disorder diagnostic categories and considers subclinical personality traits as well. In each case, Harper summarizes the clinical manifestations of personality in terms of social support, coping, and relationships with health care providers. He ties personality to preventive behavior (i.e., disease detection and help-seeking), diagnosis of disease, illness representation, and health behaviors (i.e., adherence, resource utilization, and secondary gain). Harper’s description of personality features is so well articulated that the clinical descriptions of patients with specific personality disorders and specific medical illnesses flow logically from the theoretical framework. One of the advantages of a single-author work is the consistency of style and theoretical framework. As such, this book is useful as a reference or textbook that readers might selectively dip into, depending on the patient’s medical and personality diagnosis. A few case studies or extended clinical anecdotes would have made it even more clinically relevant.Published by the American Psychological Association as part of a series on Personality-Guided Psychotherapy, edited by Ted Millon, the book draws heavily on Millon’s theory of personality. Millon’s influence is both a strength and a limitation. Millon defined a matrix of personality factors that generates clear hypotheses and predictions regarding behavior, specifically, how people will cope with medical illness. His ideas are quite compelling and interesting, but despite his influence on axis II nomenclature, his constructs are not wholly congruent with DSM-IV, although this book makes it appear that Harper’s theories are completely consistent with DSM-IV categories. There’s much research to be done before we can determine the degree of consistency. In sum, I found this book to be sophisticated and useful, especially for practitioners interested in the interface between psychology and medicine.By Robert Gale Harper. Washington, D.C., American Psychological Association, 2004, 352 pp., $59.95. FiguresReferencesCited byDetailsCited ByNone Volume 162Issue 10 October 2005Pages 1990-a-1991 Metrics PDF download History Published online 1 October 2005 Published in print 1 October 2005

Manualized Supportive-Expressive Psychotherapy Versus Nonmanualized Community-Delivered Psychodynamic Therapy for Patients With Personality Disorders: Bridging Efficacy and Effectiveness

Time-limited manualized dynamic psychotherapy was compared with community-delivered psychodynamic therapy for outpatients with personality disorders. In a stratified randomized clinical trial, 156 patients with any personality disorder diagnosis were randomly assigned either to 40 sessions of supportive-expressive psychotherapy (N=80) or to community-delivered psychodynamic therapy (N=76). Assessments were made at intake and 1 and 2 years after intake. Patients were recruited consecutively from two community mental health centers (CMHCs), assessed with the Structural Clinical Interview for DSM-IV Axis II Personality Disorders, and included if they had a diagnosis of any DSM-IV personality disorder. The outcome measures included the presence of a personality disorder diagnosis, personality disorder severity index, level of psychiatric symptoms (SCL-90), Global Assessment of Functioning Scale score, and number of therapy sessions. General mixed-model analysis of variance was used to assess group and time effects. In both treatment conditions, the global level of functioning improved while there were decreases in the prevalence of patients fulfilling criteria for a personality disorder diagnosis, personality disorder severity, and psychiatric symptoms. There was no difference in effect between treatments. During the follow-up period, patients who received supportive-expressive psychotherapy made significantly fewer visits to the CMHCs than the patients who received community-delivered psychodynamic therapy. Manualized supportive-expressive psychotherapy was as effective as nonmanualized community-delivered psychodynamic therapy conducted by experienced dynamic clinicians.

The relationship between the five-factor model and DSM personality disorder in a sample of child molesters

The study explored the associations between the five-factor model (FFM) of personality and DSM-IV personality disorders (PDs) in a sample of child molesters. The sample displayed high rates of PD with 21 (48%) meeting the criteria for at least one PD. Correlations showed that PD were most strongly associated with the NEO domains of Neuroticism and Agreeableness. Comparison between non-PD and PD offenders revealed that individuals with PD reported higher levels of Neuroticism and lower levels of Agreeableness. Examination of the facet scores within these domains showed that offenders with PD reported higher levels of Anger–hostility, Impulsivity and Vulnerability, and lower levels of Trust, Straightforwardness and Compliance. Results suggest that the FFM can be used to differentiate PD from the general population, however, cannot differentiate specific PDs. The implications of these findings are discussed further.

A Simplistic Understanding of the Five-Factor Model

Back to table of contents Previous article Next article Letter to the EditorFull AccessA Simplistic Understanding of the Five-Factor ModelTHOMAS A. WIDIGER, Ph.D., , and TIMOTHY J. TRULL, Ph.D., THOMAS A. WIDIGERSearch for more papers by this author, Ph.D., Lexington, Ky., and TIMOTHY J. TRULLSearch for more papers by this author, Ph.D., Columbia, Mo.Published Online:1 Aug 2005https://doi.org/10.1176/appi.ajp.162.8.1550-aAboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: Jonathan Shedler, Ph.D., and Drew Westen, Ph.D. (1), argued that the five-factor model “omits key clinical constructs and may not capture the complexity of personality syndromes seen in clinical practice” (p. 1743). To demonstrate this, they constructed an abbreviated measure of the five-factor model using a small subset (30%) of the 200 items contained within the Shedler-Weston Assessment Procedure (SWAP-200). It was a foregone conclusion that the results of a factor analysis of 30% of the SWAP-200 items would not correspond to a factor analysis of the entire SWAP-200. In addition, one should ask whether their SWAP-200 items provided an adequate assessment of the five-factor model. They never attempted to validate their five-factor model measure, and a visual inspection of the items indicates inaccurate representation of the five-factor model. Finally, it is highly unlikely that their small set of SWAP-200 items would provide anything close to a reasonably comprehensive assessment of the five-factor model. In sum, there was little reason to expect that an incomplete and inadequate assessment of the five-factor model with a subset of the SWAP-200 would account for the variance within the entire SWAP-200.Drs. Shedler and Westen suggested that the constructs assessed by the 12 SWAP-200 scales are outside of the realm of the five-factor model. They ignored many, many studies that indicated otherwise. For example, two other compelling dimensional models of personality disorder have been developed by Dr. Livesley (the Dimensional Assessment of Personality Pathology) and Dr. Clark (the Schedule for Nonadaptive and Adaptive Personality). A complete description of and references for these measures, as well as others, is provided by Widiger and Simonsen (2). The clinical constructs assessed by these scales include narcissism, identity problems, eccentric perceptions, affective lability, aggression, detachment, self-harm behaviors, and compulsivity that resemble closely the scales of the SWAP-200, and many studies have documented well that the constructs assessed by the Dimensional Assessment of Personality Pathology and the Schedule for Nonadaptive and Adaptive Personality are well within the realm of the five-factor model.Drs. Shedler and Westen (1) derogatorily characterized the five-factor model as providing a simplistic lay description of personality. What was simplistic was their characterization of the five-factor model. The five-factor model is a rich dimensional model of general personality structure that has been used successfully in many areas of science and practice, including (but not limited to) the study of temperament, gender differences, heritability, behavioral medicine, and aging. An integration of the DSM-IV personality disorder nomenclature with the five-factor model would go far in integrating DSM-IV with basic science research on personality structure (3). We regret that Drs. Shedler and Westen (1) argued instead for a distinct separation of our clinical understanding of personality disorders and basic science research on personality structure.

The Structure of Axis II Disorders in Adolescents: A Cluster- and Factor-Analytic Investigation of DSM-IV Categories and Criteria

The aim of this study was to ascertain whether the structure of personality disorder (PD) symptoms in adolescents assessed using DSM-IV diagnoses and diagnostic criteria resembles the structure intended for the diagnosis of PDs in adults. A national sample of clinicians rated DSM-IV Axis II criteria on 294 adolescent patients in treatment for enduring maladaptive personality patterns. Cluster analysis replicating procedures used in an adult sample by Morey (1988) identified considerable similarity between adult and adolescent PDs, as did exploratory factor analysis of ratings of diagnostic criteria, which yielded ten empirically derived factors that resembled the ten DSM-IV PDs. Cluster analysis and confirmatory factor analysis with indicators of Axis II symptoms produced mixed results in replicating the DSM-IV hierarchical structure of PDs (Clusters A, B, and C), although hierarchical models generally fared better than models specifying only first-order factors or clusters. The structure of personality pathology as assessed by Axis II criteria in adolescents resembles that outlined in DSM-IV Axis II for adults, suggesting that PDs can be assessed in adolescents as in adults. Whether this is an optimal way of diagnosing personality pathology in adolescence, however, requires further investigation.

From the Guest Editor

From the Guest Editor

Guideline Watch: Practice Guideline for the Treatment of Patients With Borderline Personality Disorder

Since the 2001 publication of APA’s Practice Guideline for the Treatment of Patients With Borderline Personality Disorder (1), more studies have been published on borderline personality disorder (BPD) than on any other personality disorder (2, 3). New analyses of the validity of the DSMIV-TR criteria–defined construct of BPD have been published, new data on the prevalence of BPD are available, risk factors for and biological characteristics of BPD are being elucidated, and new studies on the treatment of BPD have been carried out. This guideline watch highlights the most important of these developments.

Interpersonal Aspects of Personality Disorders in Opioid-Dependent Patients: The Convergence of the ICL-R and the SIDP-IV

This study aims to establish the convergence of the empirically based Diagnostic Statistical Manual (DSM)- and theory-based interpersonal behavioral approaches to personality, in opioid-dependent patients (n = 110), with the use of the Structured Interview for DSM-IV Personality [Pfohl et al.: Structured Interview for DSM-IV PD. Iowa City, UICM, 1995] and the Interpersonal Checklist-Revised (ICL-R) [DeJong and VandenBrink: ICL-R. St. Oedenrode/NL, Novadic, 1998]. As hypothesized, based on prior research, we found the two approaches to be complementary rather than interchangeable. However, some overlap was found between the SIDP-IV dimensions and the ICL-R, mainly with rebellious/distrustful, reserved/silent and masochistic/self-effacing styles. Results indicate that drug dependence in itself is not a predictor of interpersonal style, while personality pathology is. Patients with a personality disorder (PD) perceive themselves as hostile and submissive, while patients without a PD view themselves as friendly and controlling. The SIDP-IV seems informative in classifying PDs, in addition guidelines for behavioral change, in addicted patients, were provided based on the ICL-R.

Book Review: Personality Disorders: Cognitive Therapy of Personality Disorders

Cognitive Therapy of Personality Disorders. Second Edition. Aaron T Beck, Arthur Freeman, Denise D Davis, and Associates. New York: Guilford Press; 2004. 412 p. US$46.00. Reviewer rating: Fair This is a disappointing volume, even though it presents valuable concepts for understanding the cognitive component of personality disorder, as well as many useful interventions. The first edition, published in 1990, was a seminal contribution that offered a new perspective on the treatment of personality disorder, a topic previously dominated almost entirely by therapies based on psychoanalytic theory. In it, Beck and colleagues offered an innovative perspective that had a major impact. The limitation of the first edition was its modest evidential support for both overall approach and specific treatment strategies. Indeed, the authors noted that this was embarrassing in a mode of treatment that advocates empiricism. The widely anticipated second edition was expected to correct this deficiency by offering a theory that was more coherent and solidly grounded in empirical findings and evidence-based interventions. Alas, this volume fails to deliver. This edition has 16 chapters. The first 5 offer an overview of cognitive therapy for personality disorder, present the rudiments of a theory of personality disorder, discuss issues of assessment, outline general principles and specialized techniques, and explore the important issue of the therapeutic relationship. They are followed by 10 chapters, each describing the psychopathology and cognitive therapy of a specific disorder. All the DSM-IV personality disorders are considered, except for schizotypal and passive-aggressive personality disorder. The last chapter offers a brief synthesis and comments on prospects. Chapter 2 purports to describe a theory of personality disorder. The first edition offered a sketchy framework comprising a somewhat loosely arranged set of constructs and ideas. Although many of these ideas were useful, and probably essential, components of any theory, they were not systematically articulated. The corresponding chapter in this second edition offers little that is new. It combines the first edition's Chapters 2 and 3 and offers almost identical layout and subheadings-as if the field of personality disorder had remained unchanged for the last 15 years. In fact, ideas about the disorder's nature, origins, and classification have changed markedly and continue to do so. Many of these developments are barely referenced, let alone incorporated into the model or into intervention strategies. This is part of a more general problem: the book is written with scant attention to the context of scholarship in related fields. Particularly problematic is its neglect of current work on normal personality, especially research on cognitive approaches to personality. This research provides a body of knowledge about personality processes that could have greatly enriched the reviewed volume's framework and contributed to a more solid conceptual model. As with the first edition, much of this volume is organized in terms of DSM-IV diagnoses. …

Using the SWAP-200 in a personality-disordered forensic population: is it valid, reliable and useful?

Treatment and risk management of forensic patients relies heavily on diagnosing psychopathology, yet the reliability of clinical diagnoses of personality disorder has been found to be only fair to low. Structured instruments for the global assessment of personality disorder are infrequently used in clinical assessments possibly due to their limited validity and clinical utility. The Shedler-Westen Assessment Procedure-200 (SWAP-200) was developed in an effort to address these limitations. Although good reliability and validity in relation to clinicians' diagnosis of personality disorder has been reported, to date the validity of this instrument has not been assessed in relation to other standardized instruments or in a personality-disordered, forensic population. This study aims to establish the reliability and validity of the SWAP-200 against other diagnostic instruments and measures of interpersonal functioning in a personality disordered forensic population. This paper reports the results of 30 subjects from a high secure hospital in the UK who were assessed with the SWAP-200, the Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II), the Adult Attachment Interview (AAI) and the Chart of Interpersonal Reactions in Closed Living Environments (CIRCLE). Preliminary results suggest that the SWAP-200 is a reliable instrument for the diagnosis of personality disorder in forensic patients. Although the small sample size allows only preliminary conclusions about the validity of this instrument, early results show a reduction of the diagnosis of comorbidity compared with the SCID-II, together with an increased number of expected associations between independent measures of interpersonal functioning and categories of personality disorder.