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Stephan Doering2,3,4, Daniela Renn4, Stefan Höfer4, Gerhard Rumpold4, Ulrike Smrekar4, Nicola Janecke4, Dieter S. Schatz4, Chris Schotte5, Dirk DeDoncker5, and Gerhard Schüßler4 Summary Objectives: The “Assessment of DSM-IV Personality Disorders (ADP-IV)” represents a 94item questionnaire that allows for a categorical and dimensional assessment of the DSM-IV personality disorders. Methods: Psychometric properties of the German ADP-IV were investigated in 400 psychotherapy outpatients and a community sample of 385 persons. The SCID-II interview and a standardised expert consensus rating were employed for the assessment of concurrent validity. Results: The ADP-IV showed satisfactory reliability; the median Cronbach´s α for the subscales was .76 (range .65 - .87), the median retest reliability .79 (range .37 - .88). Factor analysis revealed an 11-factor solution that explained 49.4% of the variance. The median correlation of the dimensional ADP-IV subscale scores with the SCID-II and the expert consensus ratings were .51 (range: 34 - .72) and .44 (range: .27 - .62), respectively. The kappas for the chance corrected agreement of categorical ADP-IV diagnoses with the SCID-II diagnoses and the expert ratings were .35 and .29 for any personality disorder and a median of .37 and .30 for the specific personality disorders. Conclusions: The ADP-IV shows satisfactory reliability and a validity that is comparable and partly superior to other self-rating instruments. The advantages of the instrument are its brevity, the inclusion of distress ratings, and the dimensional scoring that allows for the construction of detailed profiles of personality pathology. Moreover it is freely available in the internet (download: http://zmkweb.uni-muenster.de/einrichtungen/proth/dienstleistungen/ psycho/diag/index.html). Keywords Personality disorders - diagnosis - questionnaire - Reliability - validity
This study was supported by a grant of the ”Jubiläumsfonds der Österreichischen Nationalbank“, project # 9141. 2 University of Muenster, Germany, Department of Prosthodontics 3 University of Muenster, Germany, Department of Psychosomatics and Psychotherapy 4 Innsbruck Medical University, Austria, Clinical Department of Psychological Medicine and Psychotherapy 5 University Hospital Antwerp (UZA), Belgium, Department of Psychiatry
1 1. Introduction The assessment of personality disorders represents one of the most challenging issues in psychiatry (Leibing & Doering 2006; Schüßler et al. 2006). The current conceptualization and classification of personality disorders in the DSM-IV has been criticised for its lack of empirical basis (Westen & Shedler 1999; Widiger & Sanderson 1995). Especially the categorical approach of the DSM-IV axis II (Saß et al. 2003) and ICD-10 (Dilling et al. 2004) has been opposed, because the dichotomization of continuous variables (the diagnostic criteria) into present/absent, is neither theoretically nor statistically sensible (Leibing et al. in press; Westen & Shedler 1999; Widiger & Sanderson 1995; Wöller & Tress 2005). As a consequence, the categorical approach fails to cover personality pathology of patients who seek and need treatment, but do not fall within one of the categories, because they do not fulfil enough diagnostic criteria of one and the same personality disorder (Westen & Shedler 1999; Heuft et al. 2005). Moreover, comorbid pathological personality traits of other categories than the diagnosed one are not being described by the current DSM-IV classification. In 1991 Widiger made the proposal to assess the DSM-III-R personality disorder categories on a dimensional basis. In his model six levels are provided for a rating of each personality disorder on the basis of the number of present diagnostic criteria. The rating of each of the personality disorders results in a profile of personality pathology, which provides important additional information without demanding too much effort from the diagnostician. In addition to these conceptual issues, the construction of instruments for the measurement of personality disorders represents a major problem. Since the introduction of the DSM-III diagnostic criteria for personality disorders the reliability of these diagnoses has benefited to a great deal (Perry 1992), but the validity of the assessment remains a major problem. In 1983 Spitzer stated that an expert consensus rating on the basis of all available data represents the “gold standard” for a valid diagnosis of a personality disorder (Longitudinal Experts using All Data, LEAD). As a consequence, diagnostic instruments have to prove their external validity in comparison to LEAD diagnosis on the basis of the corresponding classification, i.e. DSM-IV. A number of interviews have been presented, that showed acceptable validity, e.g., the “Structured Clinical Interview for DSM-IV, Axis II (SCID-II)” (Fydrich et al. 1997) and the “International Personality Disorder Examination (IPDE)” (Loranger et al. 1994). However, these interviews have to be learned in extensive training courses and they are quite time consuming. Thus, the assessment of personality disorders by means of questionnaires represents a widely used alternative for everyday clinical use. These self-rating instruments are easily applicable and cost saving, but they tend to show unacceptably low validity. A number of questionnaires for the assessment of personality disorders have been published. The “Personality Diagnostic Questionnaire” (PDQ; Hyler & Rieder 1987; Hyler et al. 1988; Hyler 1994) is the only one of these that has been translated into German and validated in a small sample of 60 patients (Bronisch et al. 1993). This questionnaire represents a 99-item true-false questionnaire that yields personality disorder diagnoses consistent with DSM-IV criteria and reveals categorical diagnoses, only. The SCID-II interview manual (Fydrich et al. 1997) contains a 94-item true/ false screening questionnaire. Two more self-rating instruments for the assessment of personality disorders have not yet been published in a
2 German translation: The “Millon Multiaxial Inventory” (MCMI, Millon 1977; MCMI-III, Millon et al. 1994) and the “Wisconsin Personality Disorders Inventory” (WISPI, Klein et al. 1993), that has been derived from Lorna S. Benjamin´s (1993) interpersonal theory. The disadvantage of both instruments lies in the high number of items. In 1998 a new self-rating instrument was presented by Schotte et al., that was designed to overcome the limitations of the categorical assessment of personality disorders while adhering to the DSM-IV criteria: The ”Assessment of DSM-IV Personality Disorders” (ADP-IV). Similar to the SCID-II screening questionnaire each of the 94 diagnostic criteria of the DSMIV is addressed by one question, but the rating is not a dichotomous one, but a dimensional one by means of a 7-point scale. Moreover, an assessment of distress caused by the positively rated personality trait is provided. In accordance with Widiger´s model the ADP-IV allows for a categorical and a dimensional diagnosis of DSM-IV personality disorders. In this study the German translation of the ADP-IV was validated on 400 psychotherapy outpatients and a community sample of 385 persons. The aims of the study were the evaluation of: (1) Internal consistency and factor analysis of the ADP-IV items, (2) assessment of retest reliability, and (3) concurrent validity with the SCID-II interview and an expert consensus rating. 2. Method 2.1 Subjects At the psychotherapy outpatient unit of the Clinical Department of Medical Psychology and Psychotherapy, Innsbruck Medical University, Austria, 643 outpatients were asked to participate in the study. Four hundred (62.2%) gave informed consent and were included into the investigation. Inclusion criteria were: Age ≥ 18 years, sufficient knowledge of German language. Exclusion criteria were: Cognitive impairment, acute psychotic disorder, and severe affective disorder. All patients completed the ADP-IV questionnaire, in 210 patients additionally a SCID-II interview was conducted. In addition, a representative sample of the population of the Austrian county of Tyrol, consisting of 385 persons was assessed by means of the ADP-IV questionnaire. Out of these 41 completed the questionnaire for a second time after a period of four weeks. This sample corresponds to the community of Tyrol with regard to age, gender, and education (data from http://www.statistik.at). 2.2 Instruments Assessment of DSM-IV Personality Disorders (ADP-IV) questionnaire The self assessment instrument consists of 94 items that correspond to the diagnostic criteria for personality disorders of the DSM-IV (see Figure 1 for translated sample items). Each traititem has to be assessed on a seven point scale. If the rating is 5 or above, an additional distress rating on a three point scale from 1 to 3 has to be answered (response format see Figure 1).
3 The scoring of the ADP-IV reveals a dimensional trait-score and a categorical (yes/ no) score for each of the DSM-IV personality disorders. The dimensional score is calculated by summing up the ratings of the trait questions. For the categorical scoring two different algorithms are provided: (1) an item is scored positively if the trait score is higher than 4 and the distress score is higher than 1 (T>4 and D>1), (2) an item is scored positively if the trait score is higher than 5 and the distress score is higher than 1 (T>5 and D>1). A personality disorder is diagnosed if the number of items scored positively exceeds the DSM-IV threshold. Figure 1. Design of the ADP-IV Response format of the ADP-IV items:
1. I always assume that others will take advantage of me, hurt me, or deceive me.
To what extent do you agree with this statement?
Has this characteristic ever caused you or others distress or problems? 1 = totally not 2 = somewhat 3 = most certainly
1 = totally disagree 2 = disagree 3 = rather disagree 4 = neither disagree nor agree 5 = rather agree 6 = agree 7 = totally agree
1 2 3 4
5 6 7 1 2 3
Sample items of the ADP-IV:
Item Number 2 8 19 46 77 90 DSM-IV criterion *) SZ1 AV1 NAR2 OC4 BDL6 DEP8 ADP-IV question Unlike most other people, I don´t desire intimacy or close relationships. Because I fear criticism or rejection I avoid activities at work or at school that involve a lot of contact with others. I´m very often preoccupied with fantasies of being successful, powerful, brilliant, attractive, or loved. Compared to other people I´m extremely conscientious, meticulous, and obstinate where principles, rules, or moral values are concerned. My moods or temper are very unstable and volatile; one moment I´m in normal mood and the next moment I feel totally depressed, furious, irritable, or anxious. Being continuously preoccupied by my fear of being left behind and having to face things alone typifies me.
*) SZ = schizoid, AV = avoidant, NAR = narcissistic, OC = obsessive-compulsive, BDL = Borderline, DEP = dependent; the number stands for the number of the corresponding DSM-IV criterion
The authors of the ADP-IV originally published the instrument in Dutch language (Schotte & De Doncker 1994; 1996; Schotte et al. 1998). The Dutch version was translated into German
4 by a professional translation agency in Innsbruck, Austria, before the authors of this study performed the first revision of the German version. After this, a professional translation agency in Antwerp, Belgium, performed the back-translation. Finally, the German translation was discussed among the Dutch and the Austrian authors taking into consideration the backtranslation and received a final revision. Structured Clinical Interview for DSM-IV Axis II (SCID-II) The SCID-II (Fydrich et al. 1997) represents the American Psychiatric Association’s official interview instrument for the assessment of the DSM-IV personality disorders. Each of the 94 diagnostic criteria for the 12 personality disorders provided by the DSM-IV is defined by one or more questions and a short explanation of its content. After addressing the item in a structured manner, the interviewer assesses the patients answer on a three-point scale (1 = “absent or false“, 2 = “subthreshold“, 3 = “present“). The positive items (score “3“) are added and the diagnosis of a personality disorder is given, if the threshold provided by the DSM-IV manual is exceeded. Additionally, a dimensional (D-) score is calculated by summing up the scores. Consensus Rating of Diagnoses of Personality Disorders To meet the diagnostic “gold standard“ (Spitzer 1983), in addition to the SCID-II ratings, a standardised expert consensus rating was performed. In accordance with the “prototype matching approach“ of Westen and Shedler (2000), the authors of this study discussed every case in a weekly meeting and rated the presence of every DSM-IV personality disorder on a 5 point scale (1 = “no match“, 2 = “slight match, patient has minor features of the disorder“, 3 = “moderate match, patient has features of the disorder“, 4 = “strong match, patient has the disorder; categorical diagnosis warranted“, 5 = “very strong match, patient exemplifies the disorder; prototypical case“). Thus, dimensional (1 to 5) and categorical (1-3 = absence, 4-5 = presence of the disorder) diagnoses were given blind to ADP-IV but not to SCID-II results. The expert team consisted of 1 senior psychiatrist, 3 senior psychologists, and 3 residents. 2.3 Statistics Reliability Internal consistency was assessed by means of Cronbach’s α and reproducibility (test-retest reliability) with Pearson’s correlation coefficient. Reproducibility was assessed with repeated testing of the ADP-IV in a community subsample within a four week period. A high stability is inherent to the construct of personality disorder, therefore, correlations of .70 or higher were expected for the estimates of reliability (Tabachnik & Fidell 2001). Validity To assess the factor structure a principal component analysis was conducted. Kaiser-MeyerOlkin Measure of Sampling Adequacy (KMO) and Bartlett-Test of Sphericity (BTS) were calculated to assure the applicability of factor analysis (Tabachnik & Fidell 2001). The number of factors was retained by an Eigenvalue > 1 and Catell´s scree test. The dimensional
5 diagnostic consensus rating of the DSM-IV personality disorders on the basis of the clinical and SCID-II interviews was used for the assessment of external validity. Pearson correlations were applied to assess the concurrency of the dimensional ratings of the ADP-IV and the consensus rating and SCID-II scores, respectively. Sensitivity and specificity of the questionnaire for all personality disorders were calculated for the two different scoring algorithms. In cells with an n ≥ 5 kappa statistics were used to evaluate the extent of the agreement between the categorical ratings of the ADP-IV scoring algorithms and the SCID-II and categorical consensus rating. The kappa coefficient (κ) describes the agreement of two dichotomous variables and ranges from 0 (no agreement) to 1 (total agreement). According to Fleiss (1981) kappa coefficients ≥ .70 can be regarded as good, coefficients between .40 and .69 as medium, and below .40 as insufficient. Table 1. Demographic characteristics Patients (n=400) 34.9 + 12.0 yrs f: 279 (69.8%) m: 121 (30.3%) 10 (2.5%) 18 (4.5%) 107 (26.8%) 143 (35.8%) 77 (19.3%) 14 (7.3%) 31 (7.8%) 64 (30.8%) 63 (30.3%) 53 (25.5%) 27 (13.0%) 1 (0.5%) 3. Results Demographic characteristics The characteristics of the patient and the community sample are shown in Table 1. On the DSM-IV axis I 166 (79.0%) patients had at least one clinical diagnosis, 16 (7.6%) had two or more clinical diagnoses (see Table 2a). The consensus rating revealed the diagnosis of at least one personality disorder in 82 (39.0%) of the patient group and 32 (15.2%) patients received two or more diagnoses. The T>4 and D>1 ADP-IV algorithm assigned one or more diagnoses to 90 (42.9%) patients, 64 (30.5%) received two or more diagnoses. The T>5 and D>1 ADPIV algorithm revealed one or more diagnoses in 38 (18.1%) patients and 19 (9.0%) received Community sample (n=385) 35.2 + 15.0 yrs f: 264 (68.6%) m: 121 (31.4%) 0 (0.0%) 0 (0.0%) 27 (7.0%) 112 (29.1%) 155 (40.3%) 90 (23.4%) 1 (0.3%) 88 (22.9%) 131 (34.0%) 137 (35.6%) 22 (5.7%) 5 (1.3%)
Age Sex Education still at school 8 years of school or less without school leaving certificate 8 years of school without occupational training 8 years of school with occupational training 12 years of school (≈ high school) University Missing data Marital status single unmarried with partner married or living together divorced widowed
6 two or more diagnoses (see Table 2b). Altogether the T>4 and D>1 algorithm diagnosed 281 and the T>5 and D>1 algorithm 79 personality disorders compared to 148 in the consensus rating (see Table 2b). Table 2a. DSM-IV diagnoses (n=210). Axis I clinical diagnoses (expert consensus rating); multiple diagnoses in one and the same patient possible Axis-I-disorder substance-related disorders schizophrenia or other psychotic disorders (in remission) mood disorders anxiety disorders somatoform disorders eating disorders sleep disorders adjustment disorders psychological factors affecting medical condition relational problems disorders usually first diagnosed in infancy, childhood, or adolescence n (%) 19 (9.0%) 2 (1.0%) 29 (13.8%) 33 (15.7%) 4 (1.9%) 39 (18.6%) 4 (1.9%) 34 16.2%) 1 (0.5%) 4 (1.9%) 1 (0.5%)
Table 2b. DSM-IV diagnoses (n=210). Axis-II according to consensus rating, SCID-II, and ADP-IV; multiple diagnoses in one and the same patient possible Personality disorder paranoid schizoid schizotypal antisocial Borderline histrionic narcissistic avoidant dependent obsessive-compulsive depressive passive-aggressive Cluster A Cluster B Cluster C Total score Consensus rating n (%) 12 (5.7%) 2 (1.0%) 0 (0.0%) 6 (2.9%) 23 (11.0%) 5 (2.4%) 3 (1.4%) 28 (13.3%) 3 (1.4%) 16 (7.6%) 25 (11.9%) 7 (3.3%) 14 37 47 148 SCID-II n (%) 17 (8.1%) 3 (1.4%) 0 (0.0%) 9 (4.3%) 16 (7.6%) 1 (0.5%) 3 (1.4%) 32 (15.2%) 1 (0.5%) 19 (9.0%) 23 (11.0%) 8 (3.8%) 20 29 52 132 ADP-IV (T4 and D1) n (%) 30 (14.3%) 7 (3.3%) 8 (3.8%) 35 (16.7%) 47 (22.4%) 9 (4.3%) 1 (0.5%) 40 (19%) 15 (7.1%) 50 (12.5%) 27 (12.9%) 12 (5.7%) 45 92 105 281 ADP-IV (T5 and D1) n (%) 5 (2.4%) 1 (0.5%) 2 (1.0%) 12 (5.7%) 17 (8.1%) 4 (1.9%) 1 (0.5%) 12 (5.7%) 5 (2.4%) 11 (5.2%) 5 (2.4%) 4 (1.9%) 8 34 28 79
7 3.1 Reliability Item analysis and internal consistency The analysis of the internal consistency of the ADP-IV subscales by means of Cronbach´s α revealed satisfactory values of α>.70 for all but the schizoid and antisocial subscales that ranged slightly below (r>.65) (see Table 3). The retest reliability revealed satisfactory values (rtt>.70) for the subscales paranoid, schizotypal, avoidant, antisocial, histrionic, narcissistic, and depressive. The subscales dependent, obsessive-compulsive, borderline, and passive-aggressive showed mediocre values (rtt between .50 and .70), and the subscale schizoid was again unsatisfactory (rtt=.37) (see Table 3). Table 3. Analysis of reliability of the ADP-IV (n=785) Scale paranoid schizoid schizotypal avoidant dependent obsessive-compulsive antisocial Borderline histrionic narcissistic depressive passive-aggressive Median Cluster A Cluster B Cluster C Total score
Cronbach´s α .74 .65 .78 .85 .80 .72 .68 .82 .80 .73 .87 .71 .76 .86 .91 .90
Test-retest reliability1 (n=41) .83 .37 .87 .78 .69 .64 .88 .57 .79 .82 .83 .56 .79 .77 .82 .68 .76
all correlations are significant: p<.0001; subscale schizoid: p<.05
3.2 Construct validity Factor analysis on the ADP-IV item level The factor structure of the ADP-IV items was assessed by means of a principal component analysis. The data fulfilled the prerequisites for a factor analysis (Kaiser-Meyer-Olkin = .954, Bartlet sphericity p<.001). Nineteen factors revealed an Eigenvalue > 1, the scree test did not yield a definite number of factors. Out of these a number of factors did not allow for a meaningful interpretation. An 11 factor solution was chosen that was reconcilable with the
8 scree test and explained 49.4% of the total variance. Moreover, this solution provided the greatest explanatory value and equals the number of factors of the principal component analysis of the original Dutch version by Schotte et al. (1998). Two factors did not contain any items loading ≥ .40, the remaining nine factors permitted a meaningful interpretation (see Table 4). Factor 1, negative affect and self-image, contains 17 items belonging to five different personality disorders. The items mainly represent depressive, dependent, and Borderline features; it describes traits characterised by negative experience of oneself and negative selfdirected affect. Factor 2, social anxiety and avoidance, is mainly built up by avoidant, dependent, and schizoid items and describes social withdrawal due to anxiety in interpersonal situations. Factor 3, egocentrism and exploitation of relationships, represents a mixture of six histrionic items with antisocial and narcissistic items organised around self-centredness and lack of concern for others. Factor 4 psychopathy and self-destructiveness is a combination of antisocial traits and the borderline items 4, 5A, and 5B that stand for self-damaging behaviour and suicidality. Paranoid features can be found on factor 5 distrust and factor 6 interpersonal hostility, while factor 7 distance and indifference describes schizoid detachment in combination with an antisocial lack of guilt feelings. Factor 8 obsessive-compulsiveness and factor 9 schizotypal cognitions and perceptions quite purely depict the relevant aspects of the corresponding DSM-IV personality disorders. Concurrent validity with SCID-II and standardised consensus ratings The dimensional sum scores of the ADP-IV subscales were correlated with the dimensional scores of the SCID-II interview and the dimensional consensus rating of personality disorders according to DSM-IV (Table 5). All correlations were significant (p<.01); the correlations with the SCID-II were acceptable in paranoid, avoidant, obsessive-compulsive, borderline, histrionic, and depressive personality disorder (r>.50), mediocre in dependent, antisocial, and passive-aggressive (r>.40), and low in schizoid, schizotypal, and narcissistic personality disorder (r>.30). The correlations with the consensus rating sum scores were distinctly lower than those with the SCID-II. The median of the correlations of the individual personality disorders was .51 with the SCID-II and .45 with the consensus rating. The convergence of the categorical ADP-IV diagnoses with the categorical ratings of SCID-II and the consensus rating were partly unsatisfactory. While the specificity of the ADP-IV diagnoses was quite high, the sensitivity was rather low in most of the personality disorders. The T4 and D1 algorithm revealed the higher sensitivity and somewhat lower specificity rates, while the T5 and D1 algorithm increased the specificity but showed an additional loss of sensitivity (see Table 6). The kappa for presence vs. absence of any personality disorder was .38 for the T4 and D1 algorithm and .30 for the T5 and D1 algorithm (both p<.001); for the kappas for the specific personality disorders see Table 6.
Table 4. Varimax rotated principal component analysis of the 94 ADP-IV items: 11 factor solution (n=785)
Factor 10# Factor 11#
Factor 1 Negative affect and self-image 0.61 DEP1 0.57 DE1 0.62 DE2 0.44 PA2 0.50 BDL3 0.62 DE3 0.59 DEP4 0.64 DE4 0.59 DEP6 0.64 DE6 0.46 PA6 0.60 BDL6 0.51 HIS7 0.59 DE7 0.62 BDL7 0.49 DEP8 0.41 BDL9
Factor 2 Social anxiety and avoidance 0.62 AV1 0.55 SZ2 0.59 AV2 0.62 DEP2 0.55 DEP3 0.40 DE3 0.41 SZ4 0.68 AV4 0.41 DEP4 0.65 AV5 0.62 AV6 0.51 AV7 0.56 ST9
Factor 3 Egocentrism and exploitation of relationships 0.63 HIS1 0.50 AS2 0.52 BDL2 0.67 HIS2 0.41 HIS3 0.62 HIS4 0.58 NAR4 0.40 HIS5 0.46 NAR5 0.41 AS6 0.44 NAR6 0.40 PA7 0.63 HIS8
Factor 4 Psychopathy and selfdestructiveness 0.58 AS1 0.43 BDL4 0.56 AS5 0.53 BDL5A 0.59 BDL5B 0.41 ST7 0.56 AS8
Factor 5 Distrust
Factor 6 Interpersonal Hostility 0.60 PA3 0.62 PAR5 0.66 PAR6 0.49 BDL8
Factor 7 Distance and indifference 0.65 SZ1 0.58 SZ6 0.42 SZ7 0.60 AS7
Factor 8 Obsessivecompulsiveness 0.57 OC1 0.42 OC2 0.41 OC3 0.58 OC4 0.43 OC6 0.41 OC7 0.49 NAR9
0.57 PAR1 0.60 PAR2 0.51 PAR3 0.44 PAR4 0.62 ST5
Factor 9 Schizotypal cognitions and perceptions 0.54 ST1 0.71 ST2 0.76 ST3
Salient loadings (≥ 0.40) are presented for each ADP-IV item, which represents the corresponding DSM-IV criterion: e.g. AV5 indicates the ADP-IV item representing the fifth diagnostic criterion of the DSM-IV avoidant personality disorder. PAR = paranoid, SZ = schizoid, ST = schizotypal, AS = antisocial, BDL = Borderline, HIS = histrionic, NAR = narcissistic, AV = avoidant, DEP = dependent, OC = obsessivecompulsive, DE = depressive, PA = passive-aggressive. AS8, criterion C (conduct disorder) of antisocial personality disorder; BDL5a, suicidal behaviour; BDL5b, self-mutilating behaviour. *Percentage of total variance. # None of the items loads ≥.40 on factor 10 and 11.
Table 5. Correlations of the ADP-IV dimensional subscale scores with the SCID-II interview and consensus rating (n=210) Scale paranoid schizoid schizotypal avoidant dependent obsessive-compulsive antisocial Borderline histrionic narcissistic depressive passive-aggressive Median Cluster A Cluster B Cluster C Total score
SCID-II interview subscale sum scores1 .55 .37 .38 .66 .46 .53 .48 .67 .55 .37 .66 .48 .51 .55 .63 .62 .68
Dimensional consensus rating1 .44 .29 .33 .60 .36 .54 .51 .62 .44 .27 .61 .36 .44 .48 .60 .57 .66
all correlations (Pearson) are significant: p<.01
11 Table 6. Sensitivity, specificity, and chance corrected agreement (kappa) of categorical ADP-IV diagnoses in relation to SCID-II and categorical consensus rating (n=210)
ADP-IV and SCID-II
ADP-IV algorithm and categorical consensus rating
T>4 and D>1 algorithm T>5 and D>1 algorithm T>4 and D>1 algorithm T>5 and D>1 algorithm
paranoid schizoid schizotypal avoidant dependent obsessivecompulsive antisocial Borderline histrionic narcissistic depressive passiveaggressive Median Cluster A Cluster B Cluster C
% 52.9 33.3 46.9 0 52.6 66.7 68.8 0 0 52.2 25.0
% 89.1 97.1 96.2 86 92.8 86.9 85.6 81.4 95.7 99.5 92.0 95.0
% 23.5 33.3 -
% 99.5 100 99.0 95.5 97.6 96.9 96.0 95.4 98.1 99.5 98.9 98.5
% 50.0 50.0 53.6 0
% 87.8 97.1 96.2 86.2 92.7 85.9 84.7 82.3 96.1 99.5 91.8 95.0
% 25.0 50 -
% 99.0 100 99.0 95.6 97.6 96.4 95.1 96.2 98.5 99.5 98.9 98.5
50.0 0 0
60.9 20.0 0 48.0 28.6
43.5 20.0 0
.30 29.4 32.1 37.5 94.9 94.9 84.2 .30** .33** .24** .38** 52.6 41.7 71.1 92.1 80.1 70.9
.37 20.6 .39** .15* .30** 43.4 35.9 58.9 96.0 92.9 86.1 75.6
.30 .22** .41** .24** .35** 68.4 37.5 73.7 88.9 81.5 68.4 .42** .14* .29**
any PD 57.8 79.2 diagnosis * p <.05; ** p <.01; # p<.10
4. Discussion The ADP-IV represents a new kind of self-rating instrument for the assessment of DSM-IV personality disorders. Different from earlier questionnaires it allows for a categorical and dimensional assessment and does include a rating of the distress experienced by the individual. Thus, for the first time criterion C of the DSM-IV general diagnostic criteria for a personality disorder (“The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.”) has been included into a questionnaire. The psychometric properties of the German version of the ADP-IV have been explored in great detail in this study.
12 The reliability of the instrument can be regarded as satisfying. Only two subscales yielded internal consistency levels slightly below the threshold of .70: the schizoid (α=.65) and the antisocial (α=.68) trait-scales. These numbers are very similar to those reported by Schotte et al. (1998) for the Dutch version of the ADP-IV, and clearly above those reported by Wilberg et al. (2000) for the PDQ, who found nine subscales with an α<.70. In contrast, all of the WISPI subscales revealed a Cronbach´s α above .70 (Barber & Morse 1994; Smith et al. 2003), which can be explained by the high number of items of the WISPI. The retest reliabilities of the ADP-IV ranged between .56 and .88 with the exception of the schizoid subscale (r=.37). Barber and Morse (1994) reported comparable retest reliabilities for the WISPI (r=.69 to .80). The factor analysis revealed an 11-factor solution two factors of which did not contain any item loading ≥.40. The nine remaining factors show a close relationship to the factor analysis of the original Dutch version of the questionnaire. The factors negative affect and self-image, social anxiety and avoidance, distrust, interpersonal hostility, and schizotypal cognitions and perceptions resemble the equally named factors of Schotte et al. (1998). The factor egocentrism and exploitation of relationships corresponds to instability and need for attention of the original version, with the additional aspect of exploitation while neediness is playing a less important role. Distance and indifference of the German version shows some relation to the original detachment and the psychopathy factor of the Dutch version is extended by selfmutilation. Schotte et al. (1998) did not find an obsessive-compulsiveness factor whereas we could not replicate the factors narcissism, catastrophe anticipation, and defiance and guilt. It can be stated that only four personality disorders – paranoid, obsessive-compulsive, schizoid, and schizotypal – can be related to one or two corresponding factors. Other factors do not correspond with the DSM-IV classification of personality disorders, but contain a combination of items of different personality disorders that are organised around a core feature like egocentrism, avoidance, or negative affect. On the one hand, this result can be attributed to the formulation of the single items of the ADP-IV; on the other hand, the factor solution puts into question the DSM-IV classification of personality disorders as far as cluster B and cluster C are concerned. As far as concurrent validity of the ADP-IV with the SCID-II interview and the consensus rating is concerned, the results are mostly satisfying for the dimensional scores and only partly satisfying with regard to categorical diagnoses. The correlations of the dimensional subscale scores of the ADP-IV and the SCID-II mainly range between .40 and .70 and equal the numbers reported by Schotte et al. (2004) for the Dutch version of the instrument. The median of .52 for the correlations with the dimensional SCID-II scores is distinctly higher than the median correlation of .46 that was reported for the WISPI by Barber & Morse (1994). The agreement of the categorical diagnoses of ADP-IV and SCID-II interview was below the numbers reported for the original version of the questionnaire: Schotte et al. (2004) found a median kappa of .53 and .54 for the two algorithms compared to .30 and .37 in this study. The kappas for the presence of any PD in the ADP-IV (T4 and D1) were .38 in this study and .54 in the original version of the instrument (Schotte et al. 2004; Tenney et al. 2003). In other instruments compared to the SCID-II interview the median kappas for the specific personality
13 disorders were .27 for the WISPI (Smith et al. 2003), .28 for the MCMI-II (Renneberg et al. 1992), .34 for the SCID-PQ (Nussbaum & Rogers, 1992), and .38 for the PDQ (Hyler et al. 1992). Therefore, it can be stated that only the PDQ reaches the level of convergent validity the ADP-IV revealed in this study. Questionnaires for the assessment of personality disorders tend to overdiagnose, a result that has been reported previously for the PDQ (Hyler et al. 1990; Hyler et al. 1992; Bronisch et al. 1993; Wilberg et al. 2000) and the MCMI (Renneberg et al. 1992; Soldz et al. 1993). This is also true for the T>4 and D>1 algorithm of the ADP-IV, but not for the T>5 and D>1 algorithm that revealed a similar number of diagnoses compared to the SCID-II in individual personality disorders like borderline, antisocial, histrionic, narcissistic, dependent, and obsessive-compulsive. Like it is the case in the WISPI and the MCMI the categorical diagnoses of the German ADP-IV show a high specificity and a lower sensitivity. Surprisingly, Schotte et al. (2004) found a higher sensitivity and a lower specificity for the T>4 and D>1 algorithm of the original Dutch version, whereas the T>5 and D>1 algorithm was in line with the results of this study. In conclusion, it can be stated that the ADP-IV shows a reliability and a validity that can be regarded as comparable and partly superior to those of other existing instruments. The surplus of the ADP-IV can be found in the inclusion of the distress rating, the dimensionality of the assessment, and the relatively small number of items. The dimensional assessment allows for the employment of different scoring algorithms for different purposes: The T>4 and D>1 algorithm can be recommended for screening purposes while the T>5 and D>1 algorithm might be suitable for research issues. Moreover, the dimensional scores derived from 7-point scales enable to construct a detailed profile of personality pathology including disordered dimensions that are below the DSM-IV thresholds for the specific personality disorder. Last but not least the ADP-IV can be recommended for clinical and research purposes, because it represents the only German language instrument of its kind that has been extensively validated and is available as free download on the internet (download: http://zmkweb.unimuenster.de/einrichtungen/proth/dienstleistungen/psycho/diag/index.html). References
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Correspondence Prof. Stephan Doering, M.D., Psychosomatics in Dentistry, Department of Prosthodontics, University of Muenster, Waldeyerstrasse 30, 48149 Muenster, Germany, Tel.: **49-251-83 47074, Fax: **49-251-83 45730, E-mail: Stephan.Doering@ukmuenster.de
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