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The International Personality Disorder Examination.

Article  in  Archives of General Psychiatry · January 1994

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 The International Personality Disorder Examination
The World Health Organization/Alcohol, Drug Abuse, and Mental Health
Administration International Pilot Study of Personality Disorders
Armand W. Loranger, PhD; Norman Sartorius, MD, PhD; Antonio Andreoli, MD; Peter Berger, MD; Peter Buchheim, MD;
S. M. Channabasavanna, MD; Bina Coid, PhD; Alv Dahl, MD; Rene F. W. Diekstra, PhD; Brian Ferguson, MD;
Lawrence B. Jacobsberg, MD, PhD; W. Mombour, MD; Charles Pull, MD; Yutaka Ono, MD; Darrel A. Regier, MD

Background: One of the aims of the World Health
Organization/Alcohol, Drug Abuse, and Mental Health Ad-
ministration joint program on psychiatric diagnosis and
classification is the development and standardization of
diagnostic assessment instruments for use in clinical re-
search worldwide. The International Personality Disor-
der Examination (IPDE) is a semistructured clinical in-
terview compatible with the International Classification of
Diseases, Tenth Revision, and the DMS-III-R classification
systems. This is the first report of the results of a field trial
to investigate the feasibility of using the IPDE to assess
personality disorders worldwide.
Methods: The IPDE was administered by 58 psychia-
trists and clinical psychologists to 716 patients enrolled
in clinical facilities at 14 participating centers in 11 coun-
tries in North America, Europe, Africa, and Asia. To de-
termine interrater reliability, 141 of the IPDEs (20%) were
independently rated by a silent observer. To determine
temporal stability, 243 patients (34%) were reexamined
after an average interval of 6 months.
Results: The IPDE proved acceptable to clinicians and
demonstrated an interrater reliability and temporal sta-
bility roughly similar to instruments used to diagnose the
psychoses, mood, anxiety, and substance use disorders.
Conclusion: It is possible to assess personality disor-
ders with reasonably good reliability in different na-
tions, languages, and cultures using a semistructured clini-
cal interview that experienced clinicians find relevant,
meaningful, and user-friendly.
(Arch Gen Psychiatry. 1994;51:215-224)

From the Department of Psychia-

try, Cornell University Medical
College, New York, NY (Drs Lo-
ranger and Jacobsberg); World
Health Organization (Dr Sarto-
rius), and Institutions Universi-
taires de Psychiatrie-Gen\l=e'\ve
(Dr Andreoli), Geneva, Switzer-
land; Psychiatrische Universi-
t\l=a"\tsklinik,Vienna, Austria (Dr
Berger); Nervenklinik der Univer-
sit\l=a"\tMunchen, Munich, Germany
(Dr Buchheim); National Institute
of Mental Health and Neurosci-
ences, Bangalore, India (Dr Chan-
nabasavanna); Institute of Psychia-
try, London, England (Dr Coid);
Universitetet I Oslo Psychiatrisk
Institutt, Oslo, Norway (Dr Dahl);
Rijksuniversiteit Te Leiden, Leiden,
the Netherlands (Dr Diekstra);
Stonebridge Research Centre, Not-
tingham, England (Dr Ferguson);
Max-Planck-Institut f\l=u"\rPsychiat-
rie, Munich (Dr Mombour); Cen-
tre Hospitalier de Luxembourg,
Luxembourg (Dr Pull); Keio Uni-
versity School of Medicine, Tokyo,
Japan (Dr Ono); and National
Institute of Mental Health, Rock-
ville, Md (Dr Regier).
IN
1979, the World Health Orga¬
nization (WHO) and US Alcohol,
Drug Abuse, and Mental Health
Administration (ADAMHA) joined
forces in mounting a large-scale re¬
view and assessment of the knowledge base
of psychiatric diagnosis and classification.
One consequence of this review was the es¬
tablishment of a long-term program of ac¬
tivities aimed at developing a battery of stan¬
dardized diagnostic assessment instruments
for use in clinical and epidemiologie research
worldwide. ' This was intended to facilitate
comparisons of clinical and research find¬
ings from different nations and cultures.
One instrument developed in this pro¬
gram, the Composite International Diag¬
nostic Interview (CIDI) ,2 a modification of
the Diagnostic Interview Schedule (DIS) ,3
is highly structured, computer scored, and
designed for use by lay interviewers in epi¬
demiologie studies. Another, the Schedules
for Clinical Assessment in Neuropsychia-
try (SCAN) ,4 a descendant of the ninth edi¬
tion ofthe Present State Examination (PSE) ,5
is intended for use by clinicians, ie, those
capable of making independent psychiat¬
ric diagnoses. Except for the inclusion of
antisocial disorder in the CIDI, neither in¬
terview provides coverage of the person¬
ality disorders.
This is the first report of the results of
a field trial to investigate the feasibility of us¬
ing a semistructured clinical interview de¬
veloped within the WHO/ADAMHA program
to diagnose personality disorders in differ¬
ent languages and cultures. The principal ob¬
jectives ofthe trial were to determine the cul¬
tural acceptability, user friendliness, inter-

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 SUBJECTS AND METHODS
STUDY SITES
The sites for the field trial were selected to provide a broad
representation of different nations, languages, and cul¬
tures. An additional consideration was the availability of
interested and experienced investigators who were able to
devote their time and clinical resources to the venture. There
were 14 participating centers located in 11 countries in North
America, Europe, Africa, and Asia.
TRAINING
During the development of the IPDE from 1985 to 1987,
the principal investigators at each center had participated
in several meetings and workshops concerning the instru¬
ment. After they had acquired proficiency in its adminis¬
tration and scoring, they assumed responsibility for the train¬
ing and supervision of the psychiatrists and clinical
psychologists who served as examiners at their centers. In
early 1988, the coordinator of the project (A.W.L.) visited
each site and conducted workshops that used videotaped
demonstrations and lengthy discussions of principles of ad¬
ministration and problems in scoring. The examiners were
required to administer a minimum of 10 interviews before
they were considered sufficiently experienced to evaluate
study subjects. To monitor scoring practices during the study,
videotaped interviews conducted in English were circu¬
lated for rating by the participating clinicians.
PATIENT SELECTION
The investigators were asked to select approximately 50 pa¬
tients, ranging between ages 21 and 55 years, from admis¬
sions to their facilities. In the judgment of a senior screen¬
ing clinician, the patients should have had either a person¬
ality disorder according to ¡CD-10 and/or DSM-III-R criteria
or another common mental disorder important in the dif¬
ferential diagnosis of a personality disorder. To ensure an
adequate test of the discriminating properties of the IPDE,
the screening clinicians were asked to provide a sample that
rater reliability, and temporal stability of the instrument.
When the study was planned, it was considered inappro¬
priate to undertake the development of a highly structured
lay-administered interview such as the CIDI. The state of
the art ofstandardized interviews for personality disorders
was in its infancy and considerably behind that of the clini¬
cal assessment of other mental disorders. The complexity
of the diagnostic criteria and the level ofinference and clini¬
cal sophistication that is required to make personality dis¬
order diagnoses, especially in those with other mental dis¬
orders, were additional reasons for favoring an instrument
for use by clinicians rather than trained lay interviewers.
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approximated a 3:2 ratio of those with and without a person¬
ality disorder. Exclusion criteria included below-normal in¬
telligence, organic brain disease, language or communication
difficulties, alcohol or other drug intoxication that might in¬
terfere with the examination, and delusional or psychotic dis¬
orders likely to have altered personality functioning. Sampling
of consecutive admissions was not feasible, and patients were
selected within the guidelines specified above according to
their availability and at the convenience of the examiners. At
each site, the goal was to have 10 of the interviews observed
and independently rated by another clinician and to have 25
of the patients reexamined several months later.
CLINICAL AND IPDE EVALUATIONS
Without knowledge of the diagnostic conclusions of the
screening clinicians, the psychiatrists and clinical psycholo¬
gists who administered the IPDE also conducted a general
clinical evaluation of the patients and provided the ICD-10
diagnoses of any disorders other than personality disor¬
ders. At several centers, this evaluation included a semi-
structured interview: DIS5 at Rijksuniversiteit Te Leiden,
Leiden, the Netherlands; Schedule for Affective Disorders
and Schizophrenia —Lifetime version10 at Institute of Psy¬
chiatry, London, England; and Structured Interview for DSM-
ÍII-R (SCID)11 at Cornell Medical Center, New York, NY;
Stonebridge Research Centre, Nottingham, England; Uni-
versitetet I Oslo Psychiatrisk Institutt, Oslo, Norway; and
Keio University School of Medicine, Tokyo, Japan.
COURSE OF THE TRIAL
The first patients entered the study in April 1988 and the
last patient was examined in December 1990. After the
project coordinator verified all of the forms returned by the
centers, the information was entered in a computer at the
ADAMHA data processing facility in Rockville, Md. In Au¬
gust 1991, the investigators met at WHO headquarters in
Geneva, Switzerland, to analyze and discuss the results. They
also reviewed the replies to a questionnaire completed by
all the participants about the strengths and limitations of
the IPDE, including its user friendliness, cultural rel¬
evance, and apparent clinical validity.
THE INTERNATIONAL PERSONALITY DISORDER
EXAMINATION
The International Personality Disorder Examination (IPDE)
is an outgrowth of the Personality Disorder Examination
(PDE)6 that was modified for international use and com¬
patibility with the International Classification of Diseases,
Tenth Revision (1CD-10)7 and the DSM-III-R8 classification
systems. A detailed history of its development, rationale,
structure, and translations is available elsewhere.9 In brief,
the IPDE surveys the behavior and life experiences relevant
to the more than 150 criteria used in making personality
 'IPDE indicates International Personality Disorder Examination.
disorder diagnoses according to DSM-Í/I-R and ICD-10. Al¬
though it contains a prescribed set of carefully selected and
researched questions, the examiner is expected to conduct
an adequate clinical examination of the subject to provide
clarification and confirmatory examples, anecdotes, and de¬
tails. A manual defines the scope and meaning ofeach criter¬
ion and provides guidelines and anchor points for scoring.
The IPDE requires that a behavior or trait be present
at least 5 years before it should be considered a manifes¬
tation of personality. This conservative and somewhat ar¬
bitrary convention is intended to reflect the relatively en¬
during nature of personality traits and to avoid confusing
them with transient or situational phenomena and episodic
abnormalities of mental state and behavior. The IPDE also
requires that at least one criterion of a disorder be fulfilled
before age 25 years, before that particular disorder can be
diagnosed. This is in keeping with clinical tradition and DSM-
III-R and ICD-10, which date the first indications of a per¬
sonality disorder to childhood, adolescence, or the early adult
years. Age 25 years rather than an earlier age was selected
to allow more informed and accurate judgments about many
ofthe adult-oriented personality disorder criteria in the DSM
and ICD systems.
Scoring ofthe 157 items was as follows: absent or within
normal range, 0; present to an accentuated degree, 1;
pathological/meets criterion, 2. The final algorithmic inte¬
gration of the individually scored items was done clerically
or by computer. It included the following information for
each disorder: the presence or absence of each criterion,
whether the scoring of a criterion was based solely on the
interview or included information from informants, the num¬
ber of criteria met for each disorder, and the diagnostic de¬
cision about each disorder (definite, probable, or negative).
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It also provided a dimensional score for all subjects on each
disorder, regardless of whether they receive the diagnosis
or meet any of the criteria for the disorder. It is calculated
by summing the individual scores for all of the criteria on
the disorder.
RESULTS
FINAL PATIENT SAMPLE
At the conclusion of the study, 716 patients had been ex¬
amined, 243 reexamined, and 141 of the interviews rated
by an observer. The average interval between the initial
and second IPDE was 6 months, with approximately 85%
of the repetitions occurring between 2 months and 1 year.
Table 1 provides details of the sample sizes at each cen¬
ter. Tables containing the demographic characteristics of
the sample and the clinical ÍCD-J0 diagnoses, exclusive
of personality disorders, are available on request. Table 2
provides the IPDE personality disorder diagnoses in the
DSM-III-R and ÍCD-I0 systems. They are based on the
examiner's scoring of the initial interview.
IPDE INTERRATER RELIABILITY AND
TEMPORAL STABILITY
Intraclass correlation coefficients12 were used to determine
the examiner-observer agreement in scoring each of the 157
items on the IPDE and their stability from the initial to the
second examinations. To provide a more accurate estimate
of stability per se, with adjustment for the less-than-perfect
interrater reliability of the instrument, correlations with a
correction for attenuation13 are also included with the sta-

*IPDE Indicates International Personality Disorder Examination; ICD-10,
International Classification of Diseases, Tenth Revision. Personality
disorder diagnoses include patients with more than one type of personality
disorder. Of the 366 patients with a DSM-III-R personality disorder, 111
(30.3%) had more than one type of disorder, including 55 (15.0%) with
two disorders, 32 (8.7%) with three disorders, and 24 (6.6%) with more
than three disorders. Of the 283 patients with an ICD-10 personality
disorder, 96 (33.9%) had more than one type of disorder, including 57
(20.1%) with two disorders, 27 (9.5%) with three disorders, and 12
(4.2%) with more than three disorders.
\Did not fulfill diagnostic criteria for any specific personality disorder
but met 10 or more of the 110 DSM-III-R personality disorder criteria.
%Did not fulfill diagnostic criteria for any specific personality disorder
but met 10 or more of the 56 ICD-10 personality disorder criteria.
bility coefficients. The same statistics were also used to mea¬
sure the examiner-observer agreement regarding the dimen¬
sional scores and the number of criteria met on each dis¬
order and their stability from the initial to the second
examinations. These correlations are presented in Table 3.
We used 14 to measure the interrater agreement and
temporal stability of the personality disorder diagnoses. Be¬
cause of its known instability when based on samples with
an infrequent number of cases of a disorder, the recommen¬
dation was followed that itbe calculated only when the preva¬
lence of a disorder is at least 5%.15 To provide more oppor¬
tunities for the calculation of , it was also determined by
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combining definite and probable diagnoses. A probable di¬
agnosis was assigned when the subject met one criterion
less than the number required for the diagnosis. An overall
weighted is also reported for all personality disorders, in¬
cluding those with a base rate of less than 5%. It was cal¬
culated by weighing each category of personality disorder
by the total number of cases assigned a diagnosis in that cat¬
egory by either rater, regardless ofwhether the raters agreed
on the diagnosis. The numerator is the sum of the product
ofthe diagnostic weight and for each disorder; the denomi¬
nator is the sum of the weights. The values are presented
in Table 4.
COMMENT
This investigation is the first attempt to assess personality
disorders on a worldwide basis with contemporary meth¬
ods of diagnosis. To some extent, it is reminiscent of The
International Pilot Study of Schizophrenia,'10 a project un¬
dertaken by WHO more than two decades ago. The present
study, however, was more challenging in some respects. Un¬
like schizophrenia, the personality disorders have rarely oc¬
cupied center stage in psychiatry and have long been a source
offrustration to diagnosticians and nosologists. The assess¬
ments in the present study were also undertaken within the
framework and guidelines of two distinct but overlapping
classification systems: DSM-III-R, which was designed for
use in the United States, is primarily the product of Ameri¬
can psychiatric opinion, and ICD-10, which is intended for
use worldwide, reflects the views and needs of the interna¬
tional psychiatric community.
INTERRATER AGREEMENT
The validity of any diagnostic instrument presupposes a rea¬
sonable degree of interrater reliability in its application. The
IPDE was administered in different languages, in a wide va¬
riety of national and cultural settings, and by a large num¬
ber of clinicians. This was an unusually exacting test of re¬
liability to which no other interview for personality disor¬
ders has been subjected. The results, nevertheless, compare
quite favorably with published reports on semistructured
interviews that are used to diagnose the psychoses, mood,
anxiety, and substance use disorders. Such comparisons,
however, should be viewed as rough approximations. There
are differences in the heterogeneity of the patient samples
and the base rates of the individual disorders and variations
in the methods used to determine reliability.
With these caveats in mind, we compared the results
ofthe present study with those of the SCID Axis I field trial.17
That study involved 390 patients at four locations in the United
States and one in Germany. The median values for those
individual disorders with abase rate of at least 5% were 0.64
for current diagnoses and 0.68 for lifetime diagnoses. In the
present study, the median values for the individual per¬
sonality disorders (diagnosis definite) with base rates
 'IPDE indicates International Personality Disorder Examination; ICD-10, International Classification of Diseases, Tenth Revision. For temporal stability, the
average interval between test and retest was 6 months.
\For temporal stability, data in parentheses are corrected for attenuation.

of at least 5% were 0.70 in DSM-III-R and 0.72 in ICD-10.
The overall weighted values in the SCID study were 0.61
for current diagnoses and 0.68 for lifetime diagnoses. In the
present study, the overall weighted values for the defi¬
nite diagnoses ofthe specific personality disorders were 0.57
in DSM-III-R and 0.65 in ICD-10. The median values for
an IPDE diagnosis that was definite or probable were 0.73
for DSM-III-R and 0.77 for ICD-10. The corresponding
IPDE weighted values for a diagnosis that was definite
or probable were 0.65 for DSM-III-R and 0.72 for ICD-10.
The SCID study did not identify probable cases.
The SCID study involved a test-retest design in which
the interview was given by different examiners at least 1 day
but no more than 2 weeks apart. This is likely to result in
somewhat lower reliabilities than when an examiner and
observer rate the same interview, as in the present study.
The pursuit of an additional obj ective in the IPDE study (the
determination of temporal stability over an extended pe¬
riod) weighed against the use of a similar test-retest method
because of the practical and methodological problems as¬
sociated with too frequent repetitions of a lengthy interview.
The IPDE also fared well compared with other criteria-

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*IPDE indicates International Personality Disorder Examination; ICD-10,
International Classification of Diseases, Tenth Revision. The statistic was
calculated only when the base rate was 5% or greater according to both
raters; base rates in table are means of both raters. Average interval between
test and retest (temporal stability) was 6 months. Probable diagnosis assigned
when patient met one criterion less than required number. For interrater
agreement, the overall weighted values for the definite and definite/probable
diagnoses were 0.57 and 0.69 in DSM-III-R and 0.65 and 0.72 in ICD-10,
respectively. For temporal stability, the overall weighted values for the
definite and definite/probable diagnoses were 0.50 and 0.53 In DSM-III-R and
0.54 and 0.53 in ICD-10, respectively.
^Values in parentheses are percents.
based interviews for personality disorders that have been
developed in recentyears.18·19 However, reports of large-scale
reliability studies conducted outside of the facilities where
these other interviews were developed are rare or nonex¬
istent. The other interviews differ from the IPDE in several
ways: they do not provide coverage of ICD-10; are not avail¬
able in so many languages; and do not have a detailed, item-
by-item scoring manual.
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TEMPORAL STABILITY
Not only should a personality disorder instrument dem¬
onstrate adequate interrater reliability but it should also
have temporal stability. This is because "personality" re¬
fers to a person's long-term functioning. Before imputing
a particular criterion to a patient, the IPDE requires a mini¬
mum duration of 5 years, including some manifestation
of the behavior during the current year (past 12 months).
Since the study patients were reexamined after an aver¬
age interval of 6 months, temporal stability required that
they provide essentially similar information on both oc¬
casions. The only exceptions were patients who might have
failed to manifest the behavior in both segments of the
nonoverlapping portions of the previous 12 months or the
rare patient who might have fallen a few months short of
meeting the 5-year requirement at the time of the initial
interview. Naturally, these patients would adversely af¬
fect the measurement of stability. The determination of
temporal stability is also influenced by the less-than-perfect
reliability associated with the single administration of an
instrument. Adjustments for the effect on the stability of
the individual items, the number of criteria met, and the
dimensional scores were made by calculating additional
correlations with a correction for attenuation.
There are comparatively few reports on the tempo¬
ral stability of the semistructured interviews that are used
to make lifetime diagnoses of the psychoses, mood, anxi¬
ety, and substance use disorders.20 24 Table 5 summarizes
them for one popular instrument, the Schedule for Affec¬
tive Disorders and Schizophrenia-Lifetime version. The
findings reflect moderate, but at times disappointing, sta¬
bilities that are not consistently superior to many of those
obtained in this study with the personality disorders. Given
the beleaguered history of the diagnosis and classification
of personality disorders, this may come as a surprise to some.
It should be acknowledged, however, that four2124 of the
five studies involved longer time intervals than 6 months.
The one study20 within that timeframe reported a of 0.63
for the presence or absence of any Schedule for Affective
Disorders and Schizophrenia—Lifetime diagnosis. This com¬
pares with 0.62 in DSM-III-R and 0.59 in ICD-10 for the
presence or absence of any specific personality disorder
on the IPDE. The studies in Table 5 did not report an over¬
all weighted , thus precluding comparisons based on that
statistic. Another potentially relevant difference is that in
most of these studies, the initial and second interviews
were conducted by different interviewers. One study, how¬
ever, did not find significant differences in stability
when the same and different interviewers were used21;
another study22 reported an inconsistent effect.
There is very little literature on the temporal stabil¬
ity of criteria-based personality disorders diagnosed with
semistructured interviews. There appear to be only three
studies that involved more than a brief test-retest inter¬
val. One was based on an early trial version of the PDE,25
 *SADS-L indicates Schedule for Affective Disorders and Schizophrenia- Lifetime version. All coefficients are values except the study by Andreasen et al,2
which reported intraclass correlation. Four2124 of the five studies involved longer time Intervals than did one20 study. The time frame for those four studies
were 18 months and 2, 5, and 6 years, respectively.
which is no longer extant. Pfohl et al26 reported on the sta¬
bility of the Structured Interview for DSM-III Personality
Disorders in 36 depressed inpatients after 6 to 12 months.
The values, which ranged from 0.16 to 0.84, are prob¬
lematic because of the small sample sizes of the individual
disorders. Similar findings with the Structured Interview
for DSM-III Personality Disorders were obtained in a study
in the Netherlands.27
The belief that interviewers are perfectly interchange¬
able would seem naive in view of the potential influence
that the age, sex, and personality of an interviewer might
have on the information volunteered by a patient. The as¬
sumption made by those who use semistructured interviews
is that such factors ordinarily are not a major source of er¬
ror. In planning the present study, consideration was given
to a design in which halfofthe interviews would be repeated
by the same examiner and half by a different examiner. This
would have helped to determine how much the interview¬
ers themselves, in addition to their ratings, contributed to
the instability of the measures. However, concerns about
scheduling influenced the decision to use the same inter¬
viewer whenever possible. As a result, 93% of the interviews
were given by the same examiner on both occasions.
A second interview, whether conducted by the same
or a different person, may be contaminated by the experi¬
ence of the first interview. Repetitions can lead to boredom
and decreased motivation. Patients may believe that the in¬
terviews are no longer for their benefit but for that of the
examiner. Repetitions can also produce fantasies that the
interviewer is dissatisfied with the previous interview or is
checking on the consistency of the responses. Patients may
also refrain from providing as many positive replies as pre¬
viously owing to a heightened awareness that these invite
further probing and prolong the interview. Elsewhere,25 one
of us (A.W.L.) has argued that the problem of attempting
to measure the precise degree to which interviewers are in-
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terchangeable is reminiscent of the Heisenberg principle
in physics : one cannot study the phenomenon without some¬
how tampering with it in the process.
Another source of instability is the possibility that pa¬
tients in a dysphoric state may have a selective recall or
distorted perception of certain personality traits. They may
also confuse them with the symptoms of another (Axis I)
mental disorder. An earlier version of the PDE proved re¬
sistant to changes in symptoms of anxiety and depression
during the course of treatment.25 In that study, the ma¬
jority of patients had mood or anxiety disorders of mild
to moderate severity. The finding has since been replicated
with the present version of the PDE (A.W.L. and Mark F.
Lenzenweger, PhD, unpublished data, February 1992).
There is, however, a contradictory report based on a group
of depressed patients treated with cognitive therapy.28 That
study used an earlier version of the PDE and the authors
failed to specify the professional status of the interview¬
ers, a potentially relevant variable. It may require an ex¬
perienced psychiatrist or clinical psychologist to distin¬
guish personality traits from transient pathological men¬
tal states and the symptoms of other disorders. The reliability
and validity of the IPDE, like that of any semistructured
interview, cannot be judged apart from the qualifications
of the interviewers. At times, semistructured interviews
have assumed a mystique of their own, and that caveat is
all too often ignored. The IPDE is intended for use by those
who have the clinical sophistication and training required
to make psychiatric diagnoses independently, ie, without
a semistructured interview. This is not to imply that the
IPDE or any other personality disorder interview is nec¬
essarily impervious to the influence of abnormal mental
states, particularly those characterized by severe symptoms.
We are encouraged, however, by the evidence that some
clinical states do not appear to invalidate the assessment
of personality. In any event, no attempt was made to de-
 termine the extent to which trait-state artifacts may have
affected the stability of the IPDE in the present study.
CATEGORIES AND DIMENSIONS
The prevailing systems of disease classification are cat¬
egoric. They define the features of disorders, and ideally
the categories have points of rarity with normality and
other disorders. Although such nosologies sometimes fall
short of the ideal, their value as a shorthand form of com¬
munication accounts for their widespread acceptance.
However, proponents of what has come to be known as
the "dimensional" approach question the applicability of
the categorical method to personality disorders.29 31 One
argument is that if personality disorders are not truly di-
chotomous in nature, reliability should improve with the
use of dimensions because their measurement would in¬
corporate more information than that provided by cat¬
egories alone.
Critics sometimes overlook the fact that categories
and dimensions need not be mutually exclusive, witness
their harmonious coexistence in the classification of men¬
tal retardation and hypertension. Following that tradition,
the IPDE was designed to provide categorical diagnoses
and dimensional scores based on the categories. The re¬
sults of the present study demonstrate the favorable effect
of these scores on the reliability of the IPDE. This is illus¬
trated, eg, by paranoid personality, the disorder with the
least stability. Although the DSM-III-R was only 0.24,
the stability of the paranoid dimensional scores was 0.68
(0.74 with correction for attenuation). The stability of all
of the DSM-III-R dimensional scores ranged from 0.68 to
0.92 (0.74 to 0.95 corrected), with a median of 0.77 (0.83
corrected). The corresponding correlations for the ICD-10
dimensions ranged from 0.65 to 0.86 (0.71 to 0.90 cor¬
rected), with a median of 0.77 (0.82 corrected).
These findings provide a striking example of the ad¬
vantage of supplementing a categorical conclusion about
the presence or absence of a specific personality disorder
with dimensional information about the traits that under¬
lie the decision-making process. The IPDE dimensional
scores include information about accentuated normal traits
below the threshold required for a personality disorder.
A measure based on pathological traits alone consists of
the actual number of criteria that a patient meets on a par¬
ticular disorder. Table 3 reveals that this coarser measure
is almost invariably associated with lower reliabilities than
the dimensional scores, although the differences are not
usually great.
CLINICAL ACCEPTABILITY OF THE IPDE
At the conclusion of the study, a questionnaire concerning
the IPDE was completed by all of the interviewers and dis¬
cussed at length at the meeting of principal investigators
in Geneva. The only significant reservation about the in-
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strument concerned its length, a necessary consequence of
the decision to systematically inquire about all of the per¬
sonality disorder criteria in the ICD-10 and DSM-III-R clas¬
sification systems. The mean length of the interview was 2
hours 20 minutes, and there was considerable variation
around that figure. If a patient acknowledged many crite¬
ria, the subsequent inquiry for confirmatory examples and
anecdotes prolonged the interview. If few of the behaviors
were endorsed, then the IPDE went comparatively rapidly.
If it became evident that the interview was likely to exceed
1V2 to 2 hours, an effort was made to administer it in more
than one sitting to prevent erosion of the quality of the in¬
terview from fatigue or boredom.
To offset the concern about the length of the inter¬
view and to make it more acceptable to a wider range of
clinicians and investigators, it was decided to issue it in
modules. The complete IPDE would continue to assess
all of the disorders in ICD-10 and DSM-III-R. Separate
modules would also be available for those who wished
to limit the examination to only one of the two classifi¬
cation systems. There would also be modules for the in¬
dividual types of personality disorders for those whose
interests were confined to only certain disorders. A DSM-ÍV
is also now available.
Consideration was also given to the use of a self-
administered screening version of the IPDE, which would
eliminate the need to interview patients who are un¬
likely to receive a diagnosis of personality disorder. This
assumes, of course, that false-negative cases could be kept
to a minimum, something that would have to be dem¬
onstrated by additional field trials. The literature indi¬
cates that clinical interviews and inventories do not pro¬
vide equivalent information.32 The latter are especially
prone to false-positive findings. For that reason, we are
currently examining the data based on the 716 patients
in the present study to determine whether a few inter¬
view items might also be used as a screen. A limitation of
both screening methods is that they do not provide di¬
mensional scores, at least ones that are comparable with
those based on an interview. The low literacy rate in some
cultures also limits the use of inventories.
The problems associated with establishing the va¬
lidity of semistructured interviews remain intractable be¬
cause of the absence of an acceptable gold standard.33 The
ultimate validation may prove to be a pragmatic one. Does
the interview provide more replicable and useful an¬
swers to questions about etiology, course, and treatment
than the assessments provided by clinicians without one?
It was the impression of the examiners who used the IPDE
in this study that it was clinically valid. There was also
evidence that it tended to make fewer personality disor¬
der diagnoses than some of the clinicians who screened
the patients. After discussion of whether this should lead
to the adoption of less stringent scoring standards, there
was general agreement among the examiners that clini¬
cians were often inclined to diagnose personality disor-
 ders without strict adherence to the criteria and the re¬
quirement that the maladaptive behavior be relatively
enduring (with onset by early adulthood). The partici¬
pants unanimously decided not to relax or alter the pres¬
ent method of conducting and scoring the interview. There
were, however, some suggestions for minor alterations
in the wording of some items.
There are cultural variations in what is considered
maladaptive behavior. No attempt was made to modify
any of the criteria in DSM-III-R or ICD-10 to accommo¬
date a particular culture. However, the clinicians at each
site were instructed to judge the meaning of the behav¬
ior in the context of their particular culture. This proved
to be a significant issue in surprisingly few instances. Ex¬
amples include the DSM-III-R criteria pertaining to mo¬
nogamous relationships (antisocial) and harsh treat¬
ment of spouses and children (sadistic). Otherwise, the
clinicians viewed the two classification systems as appli¬
cable to their particular cultures.
FREQUENCY OF PERSONALITY
DISORDER SUBTYPES
The study was not intended to be an epidemiological sur¬
vey of residents in the community or those under treat¬
ment. The principal objective was to determine the accept¬
ability and reliability of the personality disorder compo¬
nent of the WHO instrumentation package. The sampling
did not involve consecutive admissions, and there are ob¬
viously different thresholds associated with the request
for mental health care in different cultures. We have re¬
ported the overall rates of the individual disorders for all
of the centers combined and believe that it would be po¬
tentially misleading to report the rates for each center. It
is noteworthy, however, that the overwhelming majority
of personality disorder subtypes were diagnosed in most
of the 11 nations represented in the study.
It is also of interest that the two most frequently di¬
agnosed types in the sample as a whole are disorders that
were not included in the 1CD-9, or the DSM-ÍI. They are
borderline (DSM-III-R) or emotionally unstable, border¬
line type (ICD-10), and avoidant (DSM-III-R) or anxious
(ICD-10). At least one case of these two disorders oc¬
curred at every center with the exception of Bangalore,
India (no avoidant diagnosis) and Nairobi, Kenya (no bor¬
derline diagnosis).
Two controversial disorders, sadistic and self-defeating,
are not included in ICD-10 and have been relegated to the
appendix of DSM-III-R. Both were among the three least
frequent diagnoses in the entire sample. Interestingly, the
third one, narcissistic, was not included in DSM-II and is
still not recognized in ICD-10. It occurred in only 1.3% of
study patients. This contrasts with the findings regarding
passive aggressive, which is also not included in ICD-10
but was diagnosed in 5% of study patients and appeared
in all centers but one.
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ICD-10 AND DSM-III-R
As previously noted, ICD-10 and DSM-III-R are different
but overlapping classification systems. There are slight
differences in nomenclatures: anankastic/obsessive com¬
pulsive, anxious/avoidant, and dissocial/antisocial. In ICD-
10, borderline and impulsive are viewed as subtypes of
emotionally unstable; schizotypal is located with schizo¬
phrenia and delusional disorders; and narcissistic, pas¬
sive aggressive, and the two disorders in the appendix of
DSM-III-R, sadistic and self-defeating, do not appear. There
are also several significant differences in the criteria in
the two systems and some minor variations in their word¬
ing. Except for emotionally unstable, ICD-10 requires four
of seven criteria for a diagnosis; and except for antiso¬
cial, DSM-III-R requires four or five from a list that var¬
ies from seven to nine criteria.
This report will not attempt a more detailed compari¬
son of the two classification systems for personality dis¬
orders. However, mention should be made of the extent
to which ICD-10 and DSM-III-R tend to produce similar
results. First, within the limitations imposed by the sample
sizes of the individual disorders, no statistically signifi¬
cant (P<.05) differences were observed in the base rates
with which the corresponding specific personality disor¬
ders were diagnosed in the overall sample of 716 patients.
There was a trend, albeit statistically not significant, for
DSM-III-R to identify more cases of antisocial, paranoid,
and histrionic behavior and for ICD-10 to diagnose more
cases of anxious/avoidant behavior. Both systems provide
a residual category for cases judged to have a personality
disorder that does not meet the requirements for any of
the specific types. There is no method of identifying these
patients without invoking some arbitrary standard. The
IPDE assigns a residual diagnosis to anyone who does not
meet the requirements for a specific disorder, but never¬
theless accumulates 10 or more criteria from the various
disorders. There are more opportunities to obtain the di¬
agnosis in DSM-III-R than in ICD-10 because the former
has 110 criteria and the latter only 56. It is not surprising,
then, that approximately twice as many patients received
a nonspecific diagnosis of personality disorder in DSM-
III-R as in ICD-10
(12.8% vs 6.8%).
This, of course, does not address the question of
whether the two classification systems actually identi¬
fied the same patients as having a particular disorder. That
can be determined by the statistic, particularly for those
disorders with prevalence of at least 5%. There are only
a
two of them; the ks are 0.66 (borderline) and 0.52 (anx¬
ious/avoidant), evidence of moderate but far from per¬
fect agreement. With the distribution of cases in the sample
of 716 patients, these ks were associated with 92% agree¬
ment regarding the diagnosis of borderline and 89% for
anxious/avoidant. The values for the remaining disor¬
ders should be viewed as relatively unstable because of
the base rate problem. They range from 0.32 (dissocial/
 antisocial) to 0.61 (anankastic/obsessive-compulsive dis¬
order), with a median of 0.52. The DSM-III-R and ICD-10
comparisons should not be affected by the less-than-
perfect interrater reliability of the IPDE since the same
examiner conducted the interview and rated the infor¬
mation on which the ICD-10 and DSM-III-R diagnoses
for a particular patient were based.
The substantial disagreement regarding the dissocial
and antisocial diagnoses is not entirely unexpected consid¬
ering the different approaches the two classification systems
have taken regarding the disorder. The DSM-III-R empha¬
sizes lawbreaking and criminal acts, while ICD-10 is more
concerned with generic concepts such as lack of empathy,
inability to profit from experience, and inability to main¬
tain enduring relationships.
It is also possible to judge the overall agreement be¬
tween DSM-III-R and ICD-10 for the eight disorders they
share in common. This can be done by calculating an over¬
all weighted based on all of these disorders, regardless
of whether they meet the criterion of a 5% base rate. That
is .54, an indication of only moderate agreement. In con¬
clusion, there appears to be sufficient disagreement regard¬
ing the cases of personality disorders identified by ICD-10
and DSM-III-R to justify the prior decision of the WHO/
ADAMHA steering committee to develop an instrument
that would accommodate both classification systems. The
two, however, provide roughly similar interrater agree¬
ment and temporal stability when assessed by the IPDE.
Accepted for publication September 28, 1993.
Reprint requests to The New York Hospital-Cornell
Medical Center, Westchester Division, 21 Bloomingdale
Rd, White Plains, NY 10605 (Dr Loranger).
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