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The DSM-IV and ICD-10 personality questionnaire (DIP-Q): Construction and preliminary validation



This paper describes the construction and preliminary validation of a new selport inventory for personality disorders — DSM-IV and ICD-10 Personality Disorder Questionnaire (DIP-Q). In a consensus process the criteria sets of DSM-IV and ICD-10 were scrutinized. Twenty-seven criteria were judged completely identical in both systems. In addition, 20 criteria were close to identical. The total number of different criteria could thus be reduced from 161 to 114. Since 24 criteria could not be covered by a single statement, the final version of the DIP-Q includes 135 statements reflecting the criteria and additionally 5 statements reflecting the general criteria. The questionnaire is generally completed within 20 min. In the preliminary validation among 33 psychiatric patients Cronbach's alpha coefficients within each personality disorder were acceptable for most personality disorders and somewhat higher for the DSM-IV personality disorders than for those in the ICD-10. The criteria set of Dissocial disorder in the ICD-10 showed a negative alpha coefficient. When analysed dimensionally, the Pearson correlation between pairs of disorders in the ICD-10 and the DSM-IV varied from 0.77 to 0.99. Kappa coefficients between pairs from each system varied from 0.47 to 0.69. In conclusion, the ICD-10 and the DSM-IV are similar enough to enable the construction of a brief and comprehensive questionnaire evaluating personality disorders from both systems. There are, however, significant differences between systems which must be further analysed in future full-scale validation studies.
Original article
Eur Psychiatry 1998 ; 13 : 246-53
0 Elsevier, Paris
DSM-IV and ED-10 personality disorders:
a comparison of a self-report questionnaire (DIP-Q)
with a structured interview
H Ottosson’, 0 Bodlundl, L Ekselius2, M Grannl, L von Knorring2,
G Kullgrenl*, E Lindstrijm2, S Sijderbergl
1 Department of Psychiatry, University of UmeH, S-901 85 UmeB:
2 Department of Psychiatry, University Hospital, Uppsala University, Uppsala, Sweden
(Received 17 June 1997; accepted 20 February 1998)
Summary - Objective: Diagnosing personality disorders according to structured expert interviews is time-consuming and costly. For
epidemiological studies, self-report instruments have several advantages. The DSM-IV and ICD-10 personality questionnaire (DIP-Q) is a self-
report questionnaire constructed to identify personality disorder according to DSM-IV and ICD- 10.
Method: The DIP-Q is validated vs a structured expert interview in a clinical sample of 138 individuals. In addition, prevalence rates yielded by
DIP-Q among 136 healthy volunteers are assessed and compared to expected prevalence.
Results: For DSM-IV the agreement for any personality disorder as measured by Cohen’s Kappa was 0.61 and 0.56 for ICD-10. Overall
sensitivity for any personality disorder was for DSM-IV 0.84 and for ICD-10 0.85. However, specificity was lower: 0.77 and 0.70, respectively.
When dimensional scores between self-report and interview for each personality disorder were compared, the intraclass correlation for the DSM-
IV entities was 0.37-0.87 and for the ICD-10 entities 0.33-0.73. Among healthy volunteers the base rate of personality disorders was found to
be 14%.
Conclusion: DIP-Q can be used as a screening instrument for personality disorders according to DSM-IV and ICD-10. Self-report
questionnaires such as DIP-Q will probably play an increasingly important role in future epidemiological studies. 0 1998 Elsevier, Paris
personality disorder / DSM-IV / ICD*lO / self-report I DIP-Q / structured interview
The third edition of the American Psychiatric Associ-
ation’s DSM classification, DSM-III [l], was the first
international system to specify diagnostic criteria for
personality disorders. The DSM-III was revised in
1987 (DSM-III-R) [2] and in 1994 (DSM-IV) [3]. The
World Health Organisation’s 9th revision of the Inter-
national Classification of Diseases [25] provided only
brief clinical descriptions for its diagnostic categories
of personality disorders, but the 10th revision, ICD-10
[26], provides a set of criteria to be evaluated for each
specified personality disorder. Also, diagnostic criteria
for research have been published, the Draft Criteria
for Research, DCR [27].
The DCR-10 (in this paper further referred to as
ICD-10) and DSM-IV are highly concordant with
regard to personality disorders. All eight diagnostic
categories in ICD-10 are also found in DSM-IV.
Analysis of the criteria sets for the categories, shows
that 70% of the ICD-10 criteria are covered by
DSM-IV and 60% of the DSM criteria are covered
by ICD [ 191. Both the DSM-IV and the ICD-10 use a
polythetic system in which a specified number of the
criteria must be fulfilled for each personality disor-
der diagnosis (with the exception of Emotionally
*Correspondence and reprints.
Validity of DIP-Q
unstable personality disorder in ICD-10). In addition
to diagnostic criteria, both DSM-IV and ICD-10
equivalently specify a set of general diagnostic crite-
ria, which must be met to warrant a personality dis-
order. In short, the general criteria state that only
when personality traits are inflexible and maladap-
tive and cause significant functional impairment or
subjective distress, they constitute a personality dis-
The process of testing and refining diagnostic
instruments of psychiatric diagnoses forms a vital
basis for reliable communication, research and treat-
ment planning. Three different types of instruments
for diagnosing personality disorders are available;
structured interviews and self-report questionnaires,
both being the interest of this paper, and lastly infor-
mant-based interviews and questionnaires. Struc-
tured interviews have improved interrater reliability
as well as test-retest reliability, compared to unstan-
dardised clinical assessments [22]. Many structured
and semistructured interviews have been developed.
Of current interest is the International Personality
Disorder Examination (IPDE), a structured inter-
view, for the assessment of both the DSM-III-R and
the ICD-10 personality disorders. In a “silent
observer” interrater design with 141 psychiatric
patients included, the overall Cohen’s Kappa was
0.57 for DSM-III-R and 0.65 for ICD-10 [16]. In a
review of Zimmerman’s [28], 15 joint-interview
studies reported similar findings with nearly 80% of
the Kappa values above 0.69. Different base rates in
the different studies, however, hamper comparisons
Comparisons of interviews and self-report ques-
tionnaires are frequent in the literature. Hyler et al
[ 141 administered the Personality Diagnostic Ques-
tionnaire Revised (PDQ-R), a self-report question-
naire for the assessment of the DSM-III-R personality
disorders, to 87 applicants for inpatient treatment for
severe personality psychopatology. Blind to these
results, diagnoses were made according to the Struc-
tured Clinical Interview for DSM-III-R Personality
Disorders (SCID-II) and the Personality Disorder
Examination (PDE). The overall agreement, as meas-
ured by Cohen’s Kappa between PDQ-R and SCID-II
was 0.41 and between PDQ-R and PDE 0.36. SCID-II
is accompanied by a self-report instrument, the
SCID-screen [12]. In a study on a Swedish version of
the SCID-screen, 69 psychiatric patients completed
the SCID screen and were subsequently interviewed
with the SCID-II [I 11. Without adjustments, the
SCID-screen was overinclusive but when cut-off lev-
els were adjusted by requiring one more criterion for
diagnosis of each of the personality disorders, the
overall kappa was as high as 0.78, quite up to the
standard of agreement reported for joint-interview
Accordingly, overall agreement of personality disor-
ders present between interviews and questionnaires has
been shown to be acceptable. However, agreement for
certain personality disorder diagnoses is less accept-
able. In general, self-report instruments tend to overdi-
agnose personality disorders, but may still be useful
for screening purposes. The constructors of both the
SCID-screen and the PDQ-R recommend positive
diagnoses according to the self-report instruments to
be verified by clinician-administered interviews. This
two-step process is still time-saving in comparison to a
complete personality disorder evaluation.
Self-administered questionnaires will probably
increase in importance in the future. They have
good screening properties, they are easily adminis-
trated, timesaving and free from systematic biases
of interviewers [28]. Furthermore questionnaires
present means of recording dimensional scores, in
addition to categorical personality disorder diag-
noses, as a more reliable and valid way of reporting
personality pathology [lo, 181. By means of com-
puter processing, dimensional scores and subthres-
hold pathology are easily presented in a graphically
accessible way.
In addition to good screening properties, self-report
assessments may provide data qualitatively disparate
from interviews. In a 5-year follow-up study of trans-
sexuals in the process of changing sex, one of the
major risk factors for negative outcome was a categor-
ical personality disorder diagnosis according to SCID-
screen, while a personality disorder only identified
from clinical interview was of lower predictive value
[7]. In addition, self-rating scales may have an advan-
tage to expert ratings when evaluating course and
effect of treatment [ 151.
Based on our previous experiences from the self-
report instrument SCID-screen [7, 101 and analyses of
ICD-10 and DSM-IV diagnostic criteria [19], a new
self-report instrument was developed, the DSM-IV
and ICD-10 Personality Questionnaire (DIP-Q). Apart
from adjusting the self-report items according to
revised and new criteria, an impairment/distress scale
was added, corresponding to the general diagnostic
criterion. Thus, in contrast to previous instruments
DIP-Q provides diagnoses from both systems and the
general criterion is assessed through the impair-
ment/distress scale.
The aim of the present study was to validate this
new DIP-Q instrument vs a fully structured interview
in a clinical sample. In addition, observed prevalence
in a healthy-volunteer sample of the specific personal-
ity disorders according to DIP-Q is compared to
expected prevalence according to the literature.
H Ottosson et al
The clinical sample consisted of 138 patients (58% women
and 42% men) with a mean age of 37.2 (range 1843, stan-
dard deviation [SD] 12.0), and was selected to cover a wide
range of clinical settings; psychiatric out patients (22%),
general psychiatric inpatients (1 l%), patients hospitalised
after suicide attempt (38%) and patients recruited from an
inpatient assessment unit for sleep disorders and pain syn-
dromes (29%). All included patients were judged to have an
intellectual and verbal capacity sufficient to allow them to
understand and respond to a self-rating questionnaire. All
patients gave informed consent to participate in the study,
which was approved by the Ethics Committees of Uppsala
and Umei Universities.
A sample of healthy volunteers, 136 individuals (69%
women and 31% men) with a mean age of 28.0 (range
18-55, SD 8.7) were recruited from a college for medical
The DSM-IV and ICD-10 Personality Questionnaire
DIP-Q is a 140 item true/false self-report questionnaire
designed to measure all ten DSM-IV and all eight ICD-10
personality disorders. Also included is the ICD- 10 schizo-
typal disorder. It requires approximately 20 min to complete
and the scoring is best done by computer. The construction
and preliminary validation has been further described by
Ottosson and co-workers [19].
Out of the 140 self-report items in the questionnaire,
135 items reflect the diagnostic criteria of the DSM-IV and
ICD-10 personality disorders. Each item constitutes a brief
statement reflecting the major aspect of the corresponding
criterion, and the respondent is asked to score the statement
as true or false. For example: the DSM-IV borderline per-
sonality disorder criterion A [3]: “identity disturbance:
markedly and persistently unstable self image or sense of
self ‘, corresponds to the DIP-Q item “I feel vev losf inside-
I don’t really know who I am”. In DIP-Q, in contrast to
SCID-screen, criteria related to observed behaviour occur-
ring in schizoid, schizotypal, histrionic and narcissistic per-
sonality disorder, are also included. Twenty-one items are
reversed in the sense that “false” as a response indicates ful-
filment of the corresponding criterion.
Five items constitute the impairment/distress scale (ID-
scale), which is based on the scale included in the Personal-
ity Diagnostic Questionnaire [13]. Complementary to the
ID-scale, a self-report version of the Global Assessment of
Functioning (GAF) Scale is included. This scale consists of
the original, O-100 point scale [3], but with fewer defining
characteristics than in the original version. The GAF self-
report version has been further described elsewhere [6].
Different cut-off levels as concerns the ID-scale and the
GAF self report scale can be applicable. In this study the
cut-off score on the ID-scale is set to two or higher. On the
GAF scale a scoring at the anchoring point of 70 indicates
some degree of psychological distress and/or some diffi-
culty in social or occupational functioning, therefore a
score of 70 or less was chosen as cut-off level. Accord-
ingly, a categorical diagnosis requires firstly that the num-
ber of criteria for the specific personality disorder reaches
the threshold specified by the DSM-IV and ICD-10 manu-
als, and secondly a scoring of two or higher on the ID-scale
or a scoring of 70 or less on the GAF self-report scale.
Dimensional scores are calculated as the number of positive
criteria for each personality disorder diagnosis, regardless
of ID or GAF scores.
The original DIP-Q is in Swedish, but it is available in
English, French, Spanish, Finnish, Danish, Icelandic, and
Norwegian on request from the author.
The DSM-IV and ICD-10 Personality Interview
(The DIP-I)
The DSM-IV and ICD-10 Personality Interview (DIP-I), is a
structured interview, developed by our group, for the assess-
ment of the DSM-IV and ICD-10 personality disorders, plus
schizotypal disorder in ICD-10. The construction is in all
essentials similar to the SCID-II [12]. In a recent study by
Maffei and co-workers [ 171 interrater reliability was shown
to be quite adequate (Cohen’s Kappa 0.48-0.98) and we
have no reason to believe that DIP-Q differs in this respect.
The interview starts with a set of overview questions and
then systematically covers each criterion of the personality
disorders in turn, making it easy for the interviewer to assess
one disorder at a time. The interviewer is encouraged to ask
questions referring to the general diagnostic criteria. Based
on the knowledge of the patients history and answers to the
questions, the interviewer makes a clinical rating of each
personality criterion.
After informed consent was obtained, the interview started
with a brief overview, focusing on the individual’s intellec-
tual capacity and self-reflection. As co-occurring Axis-I dis-
order may confound assessment of personality disorders, an
unstructured Axis I interview was also conducted. The clini-
cal sample completed both the DIP-I and the DIP-Q, and
statistical agreement measures were computed for both cate-
gorical diagnosis and personality dimensions (number of
criteria fulfilled for each personality disorder). The majority
of the subjects (83%) completed the DIP-Q from 1 day up to
a week before the interview was made, 14% completed the
DIP-Q the same day before the interview was made and 3%
2 or more days after the interview. The interviews were
Validity of DIP-Q
Table I. Prevalence of DSM-IV Axis I principal diagnoses in the
clinical sample.
NO (‘36) ofpatients {n = 138) Female Male
Substance-related disorder
Other psychotic disorder
Depressive disorder
Bipolar disorder
Anxiety disorder
Eating disorder
Sleep disorder
Pain syndromes
Adjustment disorder
No Axis I disorder present
1 (1.3) 0 -
4 (5) 2 (3.4)
3 (3.8) 0 -
27 (33.8) 17 (29.3)
4 (5) 2 (3.4)
12 (15) 8 (13.8)
3 (3.8) 0 -
9 (11.3) 14 (24.1)
3 (3.8) 2 (3.4)
2 (2.5) 2 (3.4)
12 (15.1) 11 (18.9)
performed by three psychiatrists with extensive prior experi-
ence with the SCID-II, and one psychologist provided with
initial training by passive joint-interviewing. The interview-
ers were blind to the DIP-Q results.
To roughly estimate the properties of DIP-Q in assessing
DSM-IV personality pathology among non-patients, a sam-
ple of healthy volunteers completed the DIP-Q, and preva-
lence of personality disorder was compared with expected
prevalence based on epidemiological data [24]. All healthy
volunteers completed the DIP-Q at home and mailed it back
Categorical personality disorder diagnosis were estimated
from DIP-Q scores in two ways: a) with adjustments by the
ID-scale and the GAF-self-report scale, referred to as DIP-Q-
adjusted, and b) without any adjustment, referred to as
Agreement between categorical DIP-Q diagnoses and
interview diagnoses, respectively, was calculated using
Cohen’s Kappa [9], a chance corrected measure of congru-
ence for binary ratings. The value of Kappa ranges from
-1 .O to 1 .O with higher values representing higher levels of
Dimensional agreement, ie, the number of criteria ful-
filled for each personality disorder according to DIP-Q
and interview, respectively, was calculated using the
intraclass correlation. The so-called Case 2 formula was
used [21].
Specificity was calculated as proportion of correctly clas-
sified negative personality disorder cases and sensitivity as
the proportion correctly classified positive cases.
Table I shows the distribution of the diagnostic groups
according to DSM-IV.
Table II. Prevalence rates of personality disorders in the clinical
sample (n = 138) according to DIP-interview and DIP-Q-adjusted.
The prevalence rates according to DIP-Q without adjustments by
the ID-scale and GAF self-report scale is referred to as DIP-Q-raw.
Personality disorder DIP-I, DIP-Q, DIP-Q adjusted raw
Any PD
21 34.1 39.9
4.3 13.8 15.2
8 26.8 28.3
10.1 10.1 10.9
33.3 40.6 45.7
5.8 4.3 4.3
5.1 6.5 7.2
37 39.1 44.9
9.4 18.1 21
28.3 37.7 49.3
65.9 58.7 77.5
Schizotypal disorder
Emotionally unstable PD
- Borderline type
- Impulsive type
Any PD
21 37.7 42
16.7 32.6 36.2
13 41.3 46.4
7.2 13.8 15.2
25.7 30.4 34.8
18.8 18.1 21
6.5 5.8 5.8
33.3 38.4 42
13 25.4 29.7
29.7 45.7
63 Cl 76.1
In the clinical sample, the overall prevalence of any
personality disorder according to the interview was
66% for DSM-IV and 63% for ICD-10. The preva-
lence for a specific DSM-IV diagnosis varied from 4%
for schizoid personality disorder to 37% for avoidant
personality disorder. For a specific ICD-10 diagnosis,
the prevalence varied from 7% for histrionic personal-
ity disorder to 33% for anxious personality disorder.
The highest discrepancy between DSM and ICD was
noted for schizoid personality disorder. With the
exception of histrionic personality disorder, both DIP-
Q adjusted and DIP-Q raw yielded more personality
disorder diagnoses than the interview. As expected the
prevalence rates of DIP-Q raw was throughout higher
than for DIP-Q-adjusted (table ZZ).
The mean number of DSM-IV diagnoses for those
with at least one personality disorder was for the inter-
view 2.5 and for DIP-Q-adjusted 3.9. The mean num-
ber of ICD-10 diagnoses was for the interview 3.0 and
for DIP-Q-adjusted 4.7.
The chance-corrected agreement (Kappa) for cate-
gorical diagnoses, based on interview and DIP-Q with
adjustments, showed a high degree of variance, from
0.08 for narcissistic personality disorder to 0.59 for
H Ottosson et al
Table III.
Cohen’s Kappa Coefficient of agreement between cate-
gorical DIP-I personality disorder diagnosis and categorical DIP-Q-
adjusted personality disorder diagnosis in the clinical sample
(n = 138). The Kappas between DIP-I and DIP-Q without adjust-
ments by the ID-scale and GAF self-report scale are presented as
Personality disorder DIP-Q
Any cluster A
Any cluster B
Any cluster C
Any personality disorder
Schizotypal disorder
Emotionally unstable PD
- Borderline type
- Impulsive type
Any personality disorder
0.41 0.39
0.15 0.25
0.33 0.30
0.51 0.42
0.52 0.55
0.17 0.25
0.08 0.18
0.52 0.54
0.50 0.44
0.52 0.39
0.45 0.36
0.48 0.52
0.63 0.48
0.61 0.47
0.48 0.39
0.33 0.33
0.21 0.19
0.30 0.23
anxious and borderline type of emotionally unstable
personality disorder. Kappa coefficient for “any per-
sonality disorder” was 0.61 for the DSM diagnoses
and 0.56 according to the ICD. Highest agreement,
0.63, was calculated for “any cluster C personality
disorder diagnosis” (table ZZZ).
The sensitivity of DIP-Q-raw was in general higher
than for DIP-Q-adjusted. For the occurrence of any
personality disorder, the sensitivity was 0.92 for DSM
and 0.91 for ICD. The specificity for DIP-Q-raw was
in the range of 0.58-0.90 (table IV).
The dimensional agreement, ie, the correlation
between the number of fulfilled criteria, based on
interview and DIP-Q for the specific personality dis-
orders, varied from 0.37 to 0.87 for DSM and from
0.33 to 0.73 for ICD. Highest correlation was found
for conduct disorder and avoidant/anxious personality
disorders (table V).
the healthy-volunteer sample the prevalence
was calculated only for the DSM-IV personality dis-
orders, since comparative data for ICD-10 was not
available. The overall prevalence of “any personal-
ity disorder” was reduced considerably when
ID-adjustments were done, from 38% to 14%, a
reduction roughly to the expected level of present
epidemiological data as presented by Weissman [24]
(table VZ).
A common feature in both the DSM-IV and the ICD- 10
chapter on personality disorders is the two levels of
definition, firstly, the general diagnostic criteria, and
secondly, the specific diagnostic criteria. The general
definition is required to separate personality disorders
from non-pathological personality traits. DSM-IV
states: “only when personality traits are inflexible and
maladaptive and cause significant functional impair-
ment or subjective distress do they constitute a per-
sonality disorder” [3, p 6301. The complex question of
how to evaluate this crucial criterion in self-report
questionnaires is of great importance, but often disre-
garded. Shortcomings in this respect might explain the
tendency for self-report instruments to overdiagnose
personality disorders, in relation to structured inter-
views [ 11, 141.
Modifications of self-report instruments in order to
reduce this problem can be made in several ways. One
way is to raise the threshold for the number of criteria
required for a categorical diagnosis. This can be justi-
fied by the fact that higher cut-off points probably
reflects a higher degree of social impairment. In a pre-
vious study using SCID-screen adjustment by cut-off,
ie, one more criterion for each personality disorder
requested, agreement improved between self-report
and interview diagnosis [ 111. Another option is to
assess impairment or distress of the individual as
reported by Bodlund et al [5]. In this study, diagnoses
based on SCID-screen, combined with a self-reported
GAF of 70 or less, were in good agreement with clini-
cal diagnosis.
DIP-Q allows for adjustment by the impairment/dis-
tress scale and the GAF self report scale, which repre-
sent different aspects of the general criterion and
could be regarded as complementary. As personality
traits are often egosyntonic, underreporting might be
expected from the ID-scale since it requires that the
respondent has acknowledged difficulties connected
to maladaptive personality traits. The GAF scale, on
the other hand, permits the respondent to rate himself
as malfunctioning without referring to personality
Agreement between the structured interview and the
self rating questionnaire was acceptable with regard to
Validity of DIP-Q
Table IV. Sensitivity and specificity of DIP-Q-adjusted and DIP-Q-raw (without adjustments) in relation to the diagnostic interview (DIP-I).
Personality disorder Sensitivity Sensitivity Specificity Specificity
DIP-Q-adjusted DIP-Q-raw DIP-Q-adjusted DIP-Q-raw
Paranoid 0.83 0.80 0.17 0.71
Schizoid 0.50 0.67 0.88 0.87
Schizotypal 0.90 0.83 0.78 0.77
Antisocial 0.53 0.50 0.95 0.90
Borderline 0.81 0.85 0.75 0.75
Histrionic 0.17 0.25 0.97 0.97
Narcissistic 0.17 0.29 0.93 0.94
Avoidant 0.75 0.81 0.79 0.76
Dependent 0.82 0.85 0.89 0.85
Obsessive-compulsive 0.79 0.85 0.78 0.64
Any Cluster A 0.80 0.81 0.72 0.65
Any Cluster B 0.75 0.81 0.74 0.73
Any Cluster C 0.84 0.89 0.78 0.58
Any personality disorder 0.84 0.92 0.77 0.51
Schizotypal disorder
Emotionally unstable PD
- Borderline type
- Impulsive type
Any personality disorder
0.88 0.83 0.74 0.69
0.75 0.78 0.73 0.72
0.80 0.79 0.63 0.59
0.50 0.45 0.89 0.88
0.77 0.72 0.85 0.80
0.42 0.38 0.85 0.83
0.16 0.11 0.95 0.95
0.77 0.78 0.77 0.67
0.84 0.83 0.79 0.78
0.87 0.89 0.83 0.79
0.85 0.91 0.70 0.49
the distinction of personality disorder versus no per-
sonality disorder on overall and cluster level, but low
for some of the specific personality disorders. Agree-
ment was modest in particular for, schizoid, histrionic
and narcissistic personality disorder. Obviously some
of the self-report items are inadequate in assessing the
diagnostic criteria. Items referring to histrionic or nar-
cissistic personality disorder criteria can particularly
be apprehended as challenging or offending. Agree-
ment between diagnostic criteria assessed on inter-
view and corresponding self-report items, related to
observed behaviour, was low, indicating that criteria
related to observed behaviour are not easily adapted
for self reporting [4].
Both on a cluster level and on a global level the
sensitivity of the DIP-Q without adjustments is
high. The sensitivity is also high for the specific
Cluster C personality disorders, and for paranoid,
schizotypal and borderline personality disorder.
Thus, clinicians can generally be confident that sig-
nificant Axis II pathology is uncommon in patients
who do not reach threshold on any of these disorders.
However, for schizoid, antisocial, histrionic and
narcissistic personality disorder, the sensitivity is
0.5 or lower, making the DIP-Q less useful as a
screening instrument.
When regarded from a dimensional perspective,
agreement between the DIP-Q and the interview is
high. Highest correlation is noted for the Conduct Dis-
order, probably explained by the fact that all criteria
are defined by clearly defined childhood behaviours.
When prevalence of any personality disorder in
the healthy volunteer sample was examined accord-
ing to DIP-Q, with and without adjustment, preva-
lence dropped from 37.5% to 14.0%, emphasising
the significant impact of the general criteria. This is,
of course, most pronounced in general population
studies whereas in clinical samples impairment or
distress is almost by definition to be expected. In a
previous general population study, Reich et al [20]
found a very similar drop in prevalence, from 28%
to 11% when the general criteria were applied in
addition to fulfilment of diagnostic criteria. The
overall prevalence of 14% in our sample is somewhat
H Ottosson et al
Table V. Intraclass correlation (ICC,,,) estimates between number
of criteria fulfilled for each personality disorder according to DIP-Q
and interview in the clinical sample (n = 138). All correlations are
significant at the P < 0.001 level.
Personality disorder ICC Estimate
- Adult criteria (A criteria)
- Conduct Disorder (C criteria)
Cluster A criteria
Cluster B criteria
Cluster C criteria
Schizotypal disorder
Emotionally unstable PD
- Borderline type
- Impulsive type
high but within the expected range suggested by
several studies [8, 241. However, for some diag-
noses, ie, paranoid personality disorder, DIP-Q
seems to be overinclusive. There are however, sev-
eral drawbacks when comparing our observed prev-
alence among students with studies performed in
samples using other instruments and caution is
therefore recommended when interpreting these
Categorical assessment of personality pathology with
the self-report questionnaire DIP-Q can be made with
acceptable reliability, when validated vs a structured
interview. Sensitivity and specificity is in general high
and DIP-Q shows good screening properties. The
advantage of DIP-Q in relation to previous instru-
ments is, among others, its duality in assessing the
general criterion.
Table VI. Prevalence rates of personality disorders based on
epidemiological data (expected) and among a sample of healthy
volunteers (n = 136) according to DIP-Q-adjusted. The prevalence
rates according to DIP-Q without adjustments by the ID-scale is
referred to as DIP-Q raw.
Personality disorder
Expected DIP-Q DIP-Q
[241 adjusted raw
Paranoid 0.4-0.9 3.1 8.1
Schizoid 0.4-0.9 1.6 2.2
Schizotypal 3-5.6 2.3 4.4
Antisocial 2-3 - 0.7
Borderline 4.6 6.2 8.1
Histrionic 1.3-3 1.6 1.5
Narcissistic 0.4 1.6 4.4
Avoidant 0.4-l .3 3.9 4.4
Dependent 1.64 -
Obsessive-compulsive 1.6-6 8.5 25
Any 10-13.5 14 37.5
When used for dimensionally assessing of degree of
personality pathology for the specific disorders, agree-
ment is strong between interview and self-report
diagnoses. This is particular promising, since a dimen-
sional approach is closer to the true nature of person-
ality pathology.
The study was supported by grants from Stiftelsen
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... A score of ≥ 2 on the distress/impairment scale and a GAF score of ≤ 70 is required for a diagnosis to be set. Favorable reliability and validity in clinical as well as non-clinical samples have been documented [33][34][35]. Because item responses were dichotomous, an ordinal theta coefficient was used to examine reliability [51]. ...
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Acquiring age-appropriate social skills, arguably a major prerequisite for favorable psychosocial development in children, is targeted in a range of interventions. Hence, identifying factors that limit this acquisition may inform preventative and treatment efforts. Personality disorders are characterized by pervasive and enduring dysfunctional interpersonal functioning, including parenting, and could thus entail risk for offspring in not developing adaptive interpersonal skills. However, no study has tested this possibility. A representative sample drawn from two birth cohorts of Norwegian 4-year-olds (n = 956) and their parents was followed up at ages 6, 8, and 10 years. Parents’ personality disorder symptoms were measured dimensionally with the DSM-IV and ICD-10 Personality Questionnaire, and children’s social skills were evaluated by the Social Skills Rating System. A difference-in-difference approach was applied to adjust for all unmeasured time-invariant confounders, and parental symptoms of depression and anxiety were entered as covariates. Increased Cluster B symptoms in parents of children aged 4 to 6 years predicted decreased social skill development in offspring (B = −0.97, 95% CI −1.58, −0.37, p = 0.002). On a more granular level, increased symptoms of borderline (B = −0.39, CI −0.65, −0.12, p = 0.004), histrionic (B = −0.55, CI −0.99, −0.11, p = 0.018), and avoidant (B = −0.46, CI−0.79, −0.13, p = 0.006) personality disorders in parents predicted decreased social skill development in offspring. Subclinical levels of borderline, histrionic and avoidant personality disorders in parents may impair the development of social skills in offspring. Successfully treating these personality problems or considering them when providing services to children may facilitate children’s acquisition of social skills.
... Along with the SCID interview, 78 of the patients were interviewed by the "suicidal history" interview (Karolinska Self Harm History Interview, unpublished manuscript) and all patients performed the Parasuicide History Interview (PHI) (237). Trained psychiatrists and clinical psychologists established Axis II diagnoses by DIP-I interviews (238). All self-rating scales were completed under the supervision of a research nurse. ...
... Screen, 50 the Standardised Assessment of Personality-Abbreviated Scale, 51 or indicated by self-report tools such as the Dimensional Assessment of Personality Pathology, 52 the Personality Disorder Questionnaire-4, 53 the Wisconsin Personality Disorder Inventory-IV 54 or the DSM-IV and ICD-10 Personality Questionnaire. 55 We will also include studies which have assessed PD via chart review. RCTs conducted on any sex or nationality, and published in any year, are eligible to be included in this review. ...
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Introduction Remission rates for mood disorders, including depressive and bipolar disorders, remain relatively low despite available treatments, and many patients fail to respond adequately to these interventions. Evidence suggests that personality disorder may play a role in poor outcomes. Although personality disorders are common in patients with mood disorders, it remains unknown whether personality disorder affects treatment outcomes in mood disorders. We aim to review currently available evidence regarding the role of personality disorder on pharmacological interventions in randomised controlled trials for adults with mood disorders. Methods and analysis A systematic search of Cochrane Central Register of Controlled Clinical Trials (CENTRAL) via, PubMed via PubMed, EMBASE via, PsycINFO via Ebsco and CINAHL Complete via Ebsco databases will be conducted to identify randomised controlled trials that have investigated pharmacological interventions in participants aged 18 years or older for mood disorders (ie, depressive disorders and bipolar spectrum disorders) and have also included assessment of personality disorder. One reviewer will screen studies against the predetermined eligibility criteria, and a second reviewer will confirm eligible studies. Data will be extracted by two independent reviewers. Methodological quality and risk of bias will be assessed using the Cochrane Risk of Bias tool. A systematic review, and if sufficient evidence is identified, a meta-analysis will be completed. Meta-analysis will be conducted using the standardised mean difference approach and reported with 95% CIs. A random effects model will be employed and statistical heterogeneity will be evaluated using the I ² statistic. Prespecified subgroup analyses will be completed. Ethics and dissemination As this systematic review will use published data, ethics permission will not be required. The outcomes of this systematic review will be published in a relevant scientific journal and presented at a research conference. Trial registration number CRD42018089279.
... The presented complaints included low self-esteem (97%), depressed mood (66%), anxiety (55%), and conflicts in close relationships (66%). About one-third of patients had self-reported personality disorder (DIP-Q; Ottosson et al., 1995). ...
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Objective: To explore therapists' experiences of therapeutic process in psychoanalytic psychotherapy with nonimproved young adults. Method: Eight nonimproved cases were identified according to the criterion of reliable and clinically significant change in self-rated symptoms. Transcripts of therapist interviews (8 at baseline and 8 at termination) were analyzed applying grounded-theory methodology. Results: A tentative conceptual process model was constructed around the core category Having Half of the Patient in Therapy. Initially, the therapists experienced collaboration as stimulating, at the same time as the therapeutic relationship was marked by distance. At termination negative processes predominated: the patient reacted with aversion to closeness and the therapist experienced struggle and loss of control in therapy. The therapists described therapy outcome as favorable in form of increased insight and mitigated problems, while core problems remained. Conclusions: This split picture was interpreted as a sign of a pseudo-process emerging when the therapist one-sidedly allied herself with the patient's capable and seemingly well-functioning parts. The therapists' experiences could be compared to the nonimproved patients' "spinning one's wheels" in therapy. The therapists seem not to have succeeded in adjusting their technique to their patients' core problems, despite attempts to meta-communicate.
... The participants were interviewed by a trained psychiatrist, using the SCID I research version interview to establish the DSM-IV diagnoses (First et al., 1997) as well as with a translated Swedish version of the DSM-III-R, for SCID interview for PTSD. Trained clinical psychologists and psychiatrists established Axis II diagnoses by DIP-I-interviews (Ottosson et al., 1995). The psychiatrist responsible for translation of successive DSM manuals to Swedish trained the clinicians involved in the study and all interviews were videotaped. ...
Background: This study aims to determine the validity of the Karolinska Interpersonal Violence Scale (KIVS), as a screening tool for PTSD, among women with borderline personality disorder (BPD) and severe suicidal behavior. Method: 106 women with BPD and at least two suicide attempts were assessed with the KIVS for exposure to interpersonal violence as a child and as an adult. The screening ability of the KIVS for the diagnosis of PTSD was analyzed using receiver operating characteristic curve analysis. Results: PTSD diagnosis was valid for 61 (58%) women with BPD. The KIVS - exposure of lifetime interpersonal violence, displayed fair accuracy of predicting diagnosis of PTSD (area under the curve 0.79, confidence interval [0.71, 0.88]) and performed well (sensitivity 0.90 and specificity 0.62), with a cut-off score of 4 (range 0-10). Poly-traumatization was not significantly related to PTSD diagnosis as compared to single traumatization, whereas sexual victimization was significantly more prevalent in women with PTSD diagnosis, as compared to other types of traumatic events. Conclusion: A score of 4 or more on the KIVS - exposure to interpersonal lifetime violence presents well as a screening instrument for risk of PTSD, among women with BPD.
... The most common complaints were low self-esteem (97%), depressed mood (66%), anxiety (55%), and conflicts in close relationships (66%). Further, about one-third had self-reported personality disturbance according to the DSM-IV and ICD-10 Personality Questionnaire (DIP-Q;Ottosson et al., 1995Ottosson et al., , 1998). All patients were assessed with standardized self-report measures and interview instruments administered at intake, at termination, and at two follow-up assessments: 1.5 and 3 years after termination, respectively. ...
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There are several theoretical notions of how psychoanalytic psychotherapy work, but only limited empirical evidence to support any of them. The overall aim of this thesis was to explore therapeutic action in psychoanalytic psychotherapy from different perspectives (patient, therapist, and observer), using different methodological approaches (qualitative and quantitative). Study I explores 22 young adult patients’ views of therapeutic action with qualitative, grounded theory methodology. The analysis resulted in a conceptual model indicating that talking openly in the context of a safe therapeutic relationship led to new relational experiences and expanding self-awareness. Hindering factors included difficulties “opening up”, experiencing the therapist as too passive and that something was missing in therapy, leading to an experience of mismatch. Study II investigates 16 experienced therapists’ views of therapeutic action. The results indicated that the development of a close, safe and trusting relationship was perceived as the core curative factor. This interacted with the patient making positive experiences outside the therapy setting and the therapist challenging the patients’ thinking about the self. Patients’ fears about close relationships emerged as the sole hindering factor from the therapists’ perspective, perceived as creating distance in the therapeutic relationship and leading to maintenance of patients’ problems. The results of study I and II suggest that the quality of patients’ attachment to their therapist may be important for treatment process and outcome. In order to examine attachment to therapist using quantitative methodology, a new observer-rating scale (Patient Attachment to Therapist Rating Scale; PAT-RS) was developed. Study III involves an initial examination of the psychometric properties of PAT-RS. Three raters rated a total of 70 interviews. The results indicated good inter-rater reliability for three of the subscales (Security, ICC = .74; Deactivation, ICC = .62; Disorganization, ICC = .74), while one had poor (Hyperactivation, ICC = .34). Correlations with measures of the therapeutic alliance, mental representations, and symptom distress were moderate and in the in the expected directions, suggesting construct validity for the reliable subscales. Study IV investigates the relationships between secure attachment to therapist, patient-rated alliance and outcome. A series of linear mixed-effects models, controlling for between-therapist variability and length of therapy, indicated that secure attachment to therapist at termination was related to improvements in symptoms, global functioning and interpersonal problems. The relationships with symptom change and increased functioning was maintained after the therapeutic alliance was accounted for. Further, a suppression effect was found, indicating that secure attachment to therapist at termination predicted continued improvement in functioning during follow-up, whereas the alliance predicted deterioration when both variables were modeled together. The overall result of this thesis indicates that the development of a secure attachment to the therapist may be an important mechanism of change in psychoanalytic psychotherapy. This is discussed in relation to common and specific factors in psychotherapy, as well as in established theoretical notions of therapeutic action in the psychoanalytic discourse. Implications for the measurement of secure attachment to therapist and its differentiation from the therapeutic alliance are considered. Based on the results, two tentative process models that may be useful for clinical practice and future research are proposed: a broaden-and-built cycle of attachment security development and change and a react-and-disconnect cycle of attachment insecurity maintenance. Future research should investigate the temporal development of attachment to therapist and its relation to the therapeutic alliance and outcome more closely. Specific strategies that foster a secure attachment to therapist, as well as interventions for dissolving insecure strategies, should be identified and integrated in the theory and practice of psychoanalytic psychotherapy.
... The main complaints, presented in pretreatment interviews, were low self-esteem (97%), depressed mood (66%), anxiety (55%), and conflicts in close relationships (66%) (Wiman and Werbart 2002). Further, about one-third of the patients had self-reported personality disorder according to the DSM-IV and ICD-10 Personality Questionnaire (DIP-Q; Ottosson et al. 1995Ottosson et al. , 1998. The mean treatment duration in individual therapy was 25 months (SD = 16.4; ...
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Changes in dynamic psychological structures are often a treatment goal in psychotherapy. The present study aimed at creating a typology of self-representations among young women and men in psychoanalytic psychotherapy, to study longitudinal changes in self-representations, and to compare self-representations in the clinical sample with those of a nonclinical group. Twenty-five women and sixteen men were interviewed according to Blatt’s Object Relations Inventory pretreatment, at termination, and at a 1.5-year follow-up. In the comparison group, eleven women and nine men were interviewed at baseline, 1.5 years, and three years later. Typologies of the 123 self-descriptions in the clinical group and 60 in the nonclinical group were constructed by means of ideal-type analysis for men and women separately. Clusters of self-representations could be depicted on a two-dimensional matrix with the axes Relatedness-Self-definition and Integration-Nonintegration. In most cases, the self-descriptions changed over time in terms of belonging to different ideal-type clusters. In the clinical group, there was a movement toward increased integration in self-representations, but above all toward a better balance between relatedness and self-definition. The changes continued after termination, paralleled by reduced symptoms, improved functioning, and higher developmental levels of representations. No corresponding tendency could be observed in the nonclinical group.
... Axis IV -Self-assessment Assessment of self-reported psychosocial and environmental problems was performed using the axis IV scale included in the DSM-IV and ICD-10 Personality Questionnaire [70]. It comprises 11 "yes" or "no" questions regarding psychosocial and environmental problems according to the DSM-IV axis IV categories. ...
Background Personality disorder is a severe health issue. However, the epidemiology of personality disorders is insufficiently described and surveys report very heterogeneous rates. Aims We aimed to conduct a meta-analysis on the prevalence of personality disorders in adult populations and examine potential moderators that affect heterogeneity. 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.
The objective of this study was to examine associations between childhood and adolescent psychiatric disorders and adult personality disorders in a group of former child psychiatric inpatients. One hundred and fifty-eight former inpatients with a mean age of 30.5 +/- 7.1 years at investigation had their childhood and adolescentAxis I disorders, obtained from their medical records, coded into DSM-IV diagnoses.Personality disorders in adulthood were assessed by means of the DSM-IV and ICD-10 Personality Questionnaire (DIP-Q). The predictive effects of child and adolescentAxis I disorders on adult personality disorders were examined with logistic regression analyses. The odds of adult schizoid, avoidant, dependent, borderline and schizotypalpersonality disorders increased by almost 10, five, four, three and three times, respectively, given a prior major depressive disorder. Those effects were independent of age, sex and other Axis I disorders. In addition, the odds of adult narcissistic and antisocial personality disorders increased by more than six and five times, respectively, given a prior disruptive disorder, and the odds of adult borderline, schizotypal, avoidant and paranoid personality disorders increased between two and three times given a prior substance-related disorder. The results illustrate an association between mental disorders in childhood and adolescence and adultpersonality disorders. Identification and successful treatment of childhood psychiatricdisorders may help to reduce the risk for subsequent development of an adultpersonality disorder.
Twenty-one patients with psychotic disorders completed the SCID Screen questionnaire and were interviewed by means of the Structured Clinical Interview for DSM-III-R. The Cohen's kappa of agreement between the methods was 0.50 and as concerns specific personality disorders 0.37. The SCID Screen questionnaire was somewhat overinclusive. The sensitivity was 100% while the specificity was 43%. In a series of 58 patients with psychotic disorders, 72.4% had at least one personality disorder. Paranoid, avoidant, dependent and obsessive-compulsive personality disorders were the most frequent. The results indicate that personality disorders according to DSM-III-R, Axis II can be identified in patients with psychotic disorders, that the SCID Screen questionnaire can be used in this patient sample and that there is a high frequency of personality disorders in patients with psychotic disorders.
By means of the SCID Screen questionnaire, data concerning 76 reported criteria were collected from 176 controls and 388 patients. In a principal component analysis, 23 factors emerged that explained 62.7% of the variance. After regrouping, a pattern similar to the Clusters A, B, and C could be demonstrated. However, the criteria for Borderline Personality Disorder scattered in all three clusters. After rearrangement according to the loadings in components 1 and 2, two clear axes could be demonstrated. One axis went from overconscientiousness and inflexibility in one extreme, to unstable intense relationships in the other. The second axis went from avoiding social contacts in one extreme end, to uncomfortable if not in the center of attention in the other. When the separate personality disorders were arranged according to factor loadings in component 1 and 2, Borderline and Narcissistic Personality Disorders grouped together whereas Histrionic Personality Disorder formed a separate group. Schizotypal, Schizoid, and Paranoid Personality Disorders grouped together and so did Avoidant, Obsessive-Compulsive, and Dependent Personality Disorders; Passive-Aggressive Personality Disorder grouped together with the Cluster A disorders.
The history and description of the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) is presented. The SCID-II is a clinician-administered semistructured interview for diagnosing the 11 Axis II personality disorders of the Diagnostic and Statistical Manual of Mental Disorders, pins the Appendix category self-defeating personality disorder. The SCID-II is unique in that it was designed with the primary goal of providing a rapid clinical assessment of personality disorders without sacrificing reliability or validity. It can be used in conjunction with a self-report personality questionnaire, which allows the interview to focus only on the Items corresponding to positively endorsed questions on the questionnaire, thus shortening the administration time of the interview.
The aim of the present study was to elucidate the presence of comorbidity among the separate personality disorders (PD) in DSM-III-R. By means of a modified version of the SCID Screen questionnaire, data concerning 95 reported criteria for PD were collected from 176 controls and 388 patients. Eighty-five Ss had a Cluster A personality disorder; 91.8% of the Ss had only one PD within the Cluster. However, the number of criteria fulfilled for the three PD correlated significantly (r = 0.29−0.65). One-hundred and eighteen Ss had a Cluster B PD, 73.7% had only one Cluster B PD. The intercorrelations between number of criteria fulfilled were all significant (r = 0.30−0.57). One-hundred and twenty-seven Ss had a Cluster C PD. Only 65.4% had only one PD within the Cluster. All intercorrelations between number of fulfilled criteria were significant (r = 0.39−0.66). Altogether 198 Ss had at least one PD. Only 52.0% had a PD within only one of the Clusters. Thus the comorbidity between the three Clusters is even higher then the comorbidity within the Clusters.
SCID screen questionnaire – a self-report instrument for axis-H diagnoses – was distributed to 65 psychiatric outpatients and 133 normal subjects. In addition, independent clinical DSM-III-R diagnoses were made in the patients. When cut-off was adjusted in the SCID screen, specificity was 64% and sensitivity 86%, with a Pearson's correlation coefficient of 0.52 (p<0.001). The results from the SCID screen were analysed in two different ways – a dimensional approach estimating the proportion of criteria fulfilled and a traditional categoric approach estimating the prevalence of different personality disorders. All cluster-A disorders and obsessive compulsive personality disorder were more frequent among male than female patients. When analysed dimensionally, no sex differences were identified among patients or normal subjects. Among patients 62% had at least one and 46% multiple axis-II diagnoses, avoidant being the most prevalent. Among normal subjects narcissistic and obsessive compulsive personality disorders were most frequent for males and histrionic and borderline for females. The SCID screen showed good screening properties and also turned out to be promising as sole diagnostic instrument for axis-II disorders. It could easily be administered in an epidemiologic research setting. By rating and displaying every single criterion, the SCID screen also records potentially valuable “subthreshold” personality traits.
In earlier studies, the personality disorders in DSM-III-R have been demonstrated to be continous variables, thus describing personality traits with a range from normality to severe personality pathology instead of separate disorders with defined cut-off points. Thus, it seemed of interest to relate the personality disorders in the DSM-III-R to personality traits as determined by means of the Karolinska Scales of Personality (KSP). 144 patients with somatoform pain disorders orinsomia completed the study. In general the KSP scales Somatic anxiety, Psychic anxiety, Psychasthenia, Indirect aggression, Verbal aggression, Irritability and Suspicion gave significant positive correlations with all the personality disorders and the Clusters in the DSM-III-R. The scales Social desirability and Socialization gave significant negative correlations. In a stepwise regression the scales Socialization and Suspicion turned out to be of importance as concerns all three personality disorder Clusters.
SYNOPSIS A two-stage probability sample of community subjects was developed with a full psychiatric examination employing DSM-III criteria in conjunction with the Epidemiological Catchment Area (ECA) survey conducted in Baltimore, MD. This report details the observation on those subjects diagnosed with compulsive personality disorder and compulsive personality traits. The results indicate that this condition has a prevalence of 1·7% in a general population. Male, white, married and employed individuals receive this diagnosis most often. Our data suggest a dimensional rather than categorical character for this disorder. The disorder imparts a vulnerability for the development of anxiety disorders.