Lee Anna Clark - US grants

In recent years, clinicians have turned their attention to a previously neglected group of patients who absorb a large proportion of our mental health resources. These patients suffer from chronic and debilitating deficits in their ability to function in today's complex society. However, with a few exceptions, little is known about the nature, cause or treatment of their disorders, known collectively as the Personality Disorders (PDS). In an important step toward rectifying this situation, the APA recognized the PDs as an independent domain of psychopathology in DSM-III. Extending the categorical approach used for classifying the major psychiatric syndromes, eleven PD diagnoses were specified. Their inclusion in DSN-III was hailed as a major conceptual advance over previous versions, yet many criticisms were also voiced. Among the most important of these was that a categorical system, which implies relatively discrete entities, is inappropriate for the PDs which contain many overlapping symptoms, and are not clearly distinct from normal functioning. An alternative that has been proposed, but not yet much researched, is a dimensional approach, which would allow assessment of the basic traits that characterize the domain of PDs. With this system, individuals would be rated on a number of important attributes rather than assigned to one or more diagnostic categories. The present study is among the first to investigate a dimensional scheme for assessing the domain of PDs. Phase One of the study consists of four steps: 1) clarification of those personality characteristics important for the PDs, 2) development of scales to measure each of the dimensions identified in Step One, both those in DSM-III and in other conceptualizations, 3) psychometric evaluation of the scales on a normative sample, and 4) pilot testing of the scales on a heterogeneous clinical sample. A planned Phase Two consists of extensive testing of clinical patients using both traditional methods of clinical diagnosis, such as structure interviews, and the scales developed in Phase One. This will permit direct comparison of the categorical and dimensional approaches to diagnoses of the PDs.

The present study investigates a dimensional scheme for assessing the domain of Personality Disorder (PD) and compares such an approach to the current categorical system. Three samples of patients (state hospital inpatients, metropolitan hospital in- and out-patients, and university counseling center patients; n = 50 each) will be extensively evaluated using traditional methods of clinical diagnosis (e.g., structured interviews), measures of social and occupational functioning, and scales specifically developed to measure dimensions underlying the personality disorders. These three diverse samples are included to assure a broad representation of the relevant pathology, because they are expected to show differing prevalence rates of the various personality traits and disorders. The date will permit direct comparison of the categorical (diagnoses derived by interview) and dimensional (trait profiles generated by the scale scores) approaches to assessment of personality disorder. Given expected correspondences between certain diagnoses and scales (e.g., Paranoid PD with Mistrust), one question of primary interest will be whether the scales are bimodal, thus supporting a categorical approach; or normally distributed, indicating that continuous dimensions may more accurately describe personality pathology. Examination of the distributions will be followed by chi-square analyses to test whether the traits are specific to particular diagnoses or are broadly distributed across diagnoses. Relations between the diagnoses and trait scores will be further examined through a series od multivariate analyses, including factor and cluster analyses, and multiple regression. Finally, relations between various indicators of social/occupational adjustment and both the diagnoses and trait scores will be examined, also using multivariate techniques. It is possible that each approach--the dimensional and categorical--will provide appropriate for assessing some types of personality disorder, but not for all. In any case, the trait scale data will provide valuable information regarding personality disorder, and even if a categorical approach is supported, the scales (used individually or in configural combinations) will likely offer a convenient, cost-effective method of assessment. If, on the other hand, a dimensional approach is suggested, the scales can provide the foundation for a reconceptualization of the domain of personality disorder in subsequent DSM revisions.

DESCRIPTION (provided by applicant): Personality disorder (PD) diagnosis is at a crossroads: There is broad acknowledgment of the significant, negative impact that PD has on individuals and on the course and outcome of comorbid disorders, as well as relatively widespread dissatisfaction with the current categorical system of PD diagnosis. Nonetheless, there also is reluctance to implement an alternative trait dimensional system because: (1) there is no consensus on which set of traits to assess, (2) current trait assessment methods do not reflect either dysfunction or the full range of clinical variability, and (3) the clinical utility of a trait-based system is unknown. The proposed research is significant because it will draw from the full spectrum of the personality trait domain to identify a comprehensive set of specific traits for PD diagnosis, demonstrate how PD characteristics are manifest in both stable and clinical-state-dependent forms, and provide a clinically useful PD diagnostic system that integrates assessment of trait dimensions and psychosocial functioning. The long-term goal of this research is to develop a trait-plus-dysfunction-based clinical assessment system for the reliable and valid diagnosis of personality disorder on which to base the development of effective, more specifically targeted interventions. The specific aims of the current proposal are (1) to establish a set of specific traits that collectively define the trait dimensions of individuals with PD, (2) to establish a set of psychosocial functioning dimensions that collectively define the functional impairment of individuals with PD, and (3) to evaluate prospectively the clinical utility of this two-pronged PD diagnostic system. We plan to do this in three stages: (1) Assessing a large sample on a wide range of measures of both traits and psychosocial function to determine the structure of each domain and ensure that we have identified all components needed to assess personality disorder comprehensively;(2) testing the identified components on another large sample of patients and high-risk individuals, including information provided by family and/or friends, and Axis I symptomatology, and (3) testing the clinical utility of the developed system by assessing a sample of new patients, providing the information to their mental health-care providers, surveying the clinicians for the usefulness and acceptability of the diagnostic system, and examining its predictive validity over 6 months post-intake. We expect that the newly developed system will have high predictive validity and be judged clinically useful;specifically, to be comprehensive and accurate, and useful for communication purposes, for formulating general and specific treatment plans, and for predicting general and specific treatment difficulties. PUBLIC HEALTH RELEVANCE: The current system for diagnosing personality disorder is widely recognized to have problems with both reliability and validity, and to provide little guidance for selecting an appropriate treatment strategy. The goal of this research, therefore, is to provide clinicians and researchers of personality disorder with a revised diagnostic system that is reliable, valid, and clinically useful. It will achieve these goals by identifying and providing the means to assess both the maladaptive trait components of personality disorder in both stable and unstable manifestations, and the ways in which individuals'psychosocial functioning is maladaptive. This will facilitate the development of treatment strategies that target specific maladaptive traits and types of psychosocial dysfunction.

DESCRIPTION (provided by applicant): Personality disorder (PD) diagnosis is at a crossroads: There is broad acknowledgment of the significant, negative impact that PD has on individuals and on the course and outcome of comorbid disorders, as well as relatively widespread dissatisfaction with the current categorical system of PD diagnosis. Nonetheless, there also is reluctance to implement an alternative trait dimensional system because: (1) there is no consensus on which set of traits to assess, (2) current trait assessment methods do not reflect either dysfunction or the full range of clinical variability, and (3) the clinical utility of a trait-based system is unknown. The proposed research is significant because it will draw from the full spectrum of the personality trait domain to identify a comprehensive set of specific traits for PD diagnosis, demonstrate how PD characteristics are manifest in both stable and clinical-state-dependent forms, and provide a clinically useful PD diagnostic system that integrates assessment of trait dimensions and psychosocial functioning. The long-term goal of this research is to develop a trait-plus-dysfunction-based clinical assessment system for the reliable and valid diagnosis of personality disorder on which to base the development of effective, more specifically targeted interventions. The specific aims of the current proposal are (1) to establish a set of specific traits that collectively define the trait dimensions of individuals with PD, (2) to establish a set of psychosocial functioning dimensions that collectively define the functional impairment of individuals with PD, and (3) to evaluate prospectively the clinical utility of this two-pronged PD diagnostic system. We plan to do this in three stages: (1) Assessing a large sample on a wide range of measures of both traits and psychosocial function to determine the structure of each domain and ensure that we have identified all components needed to assess personality disorder comprehensively; (2) testing the identified components on another large sample of patients and high-risk individuals, including information provided by family and/or friends, and Axis I symptomatology, and (3) testing the clinical utility of the developed system by assessing a sample of new patients, providing the information to their mental health-care providers, surveying the clinicians for the usefulness and acceptability of the diagnostic system, and examining its predictive validity over 6 months post-intake. We expect that the newly developed system will have high predictive validity and be judged clinically useful; specifically, to be comprehensive and accurate, and useful for communication purposes, for formulating general and specific treatment plans, and for predicting general and specific treatment difficulties. PUBLIC HEALTH RELEVANCE: The current system for diagnosing personality disorder is widely recognized to have problems with both reliability and validity, and to provide little guidance for selecting an appropriate treatment strategy. The goal of this research, therefore, is to provide clinicians and researchers of personality disorder with a revised diagnostic system that is reliable, valid, and clinically useful. It will achieve these goals by identifying and providing the means to assess both the maladaptive trait components of personality disorder in both stable and unstable manifestations, and the ways in which individuals' psychosocial functioning is maladaptive. This will facilitate the development of treatment strategies that target specific maladaptive traits and types of psychosocial dysfunction.