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“PRINCIPLES OF
ASSESSMENTS
IN PERSONALITY
DISORDERS”
CHAIRPERSON-DR.PARTHA CHOUDHARY
PRESENTER-DR.UDAY SHANKAR.K
PRINICIPLES OF ASSESSMENTS
IN PERSONALITY DISORDERS
• CHAIRPERSON --
----DR.PARTHA
CHOUDHARY
• PRESENTER----
----DR.UDAY
SHANKAR.K.
ASSESSMENT OF PERSONALITY
• USES—
• Assists D.D.
• Identifies prognostic factors.
• Aiding psychotherapies.
Differences
• AXIS-I DISORDERS
• TEMPORARY
• REACTIVE
• DOMINATED BY Sxs
THAN BEHAVIOR.
• DIAG.—MSE
• MAY DVP.INTO OTHER
DISORDERS.
AXIS-II DISORDERS
--PERMANENT
--GENERATIVE
--BEHAVIOR
&RELATIONSHIP
B/W OTHERS
--DIAG-LONGTERM
FUNCTION
--STABLE
GENERAL DIAGNOSTIC
CRITERIA(ICD-10&DSM-IV)
• A) Enduring pattern of inner experience
that deviates from culture.Manifest in 2 or
more
• 1) cognition.
• 2) affectivity.
• 3) I.P. functioning
• 4) impulse control.
GENERAL DIAGNOSTIC
CRITERIA(ICD-10&DSM-IV)
• B) Pattern inflexible & pervasive across
social & personal situation
• C) Pattern leads to impairment in socio-
occupational or imp. areas of functioning.
• D) Pattern is stable & long standing &
onset to adolescence or early childhood.
• E) Pattern is not better accounted for as
manifestation of another axis-I disorder.
PERSONALITY ASSESSMENT
APPROACHES
1) NOMOTHETIC/DIMENSIONAL/
UNIVERSAL.
2) IDIOGRAPHIOC/MORPHOGENIC
3) CATEGORICAL
IDIOGRAPHIC
• Based on clinical grounds & case history.
• Focus on individual.
• Provide multifaceted description of
personal attributes & behaviors.
• Weakness being subjectivity.
Nomothetic/universal/
dimensional
• Based on common features of
common groups.
• Uses laws & sets parameters.
• Predicts future behavior on basis of
resemblance to group.
Drawbacks
• “Danger of losing the human person in
everyday life.”— Allport ,1937.
• “Measure a bit of everything & not enough
of anything to give dependable &
quantifiable samples of personality.”----
--MacFarlane & Turddenham, 1951.
Categorical classification
• Followed by ICD-10 & DSM-IV
• Preferred –ease of communication &
efficiency
• Rx plan in dual(triple) diagnosis(axes-I+II
disorders ),.
• Decision making in forensic psychiatry.
Categorical classification
• Current gold standard for large number of
international comparisons and official
statistics.
• Ex: epidemiological surveys.
• Research studies in P.D. show
evidence that DIMENSIONAL
system of classifying is more valid
& reliable.---
----Clark et al 1995.
----Livesley et al 1994.
Reasons being--
• Dimensional view may be truer to the
fundamental nature of PDs as categorical
views impose an arbitrary distinctions that
may misrepresent a seamless state of
affairs.
• Categorical view may reduce researchers
capacity to assess correlates of PD &
severity related information.
• Categorical --–high degree of co-morbidity
& spurious representation
• In short
• “Categorical classification view PDs
as black & white in it’s structural
assumption , is oversimplifying &
falsely precise in it’s dichomatization
& uneconomical in it’s
diagnostics applications.”
---Nick Haslam,2003.
Dimensional classification ---
argues PD as extreme variant that
fall in a continuum with normal
personality.
• Meta analytic review by Lisa M Saulsman
et al. 2004, concludes
• PD’s conceptualized better by dimensional
classification in few disorders.
Contd…
• Dimensional ---offer practical
utility,relevant to majority of PDs.
• Related in meaningful & predictable way.
• Neuroticism & agreeableness are
dimensions across PD
• Extraversion & to certain extent
conscientiousness are unique to certain pd
categories.
• Combined CATEGORICAL-
DIMENSIONAL approach to
conceptualize & Rx PD may be more
valuable & preserve the integrity of both
classificatory systems.
---Lisa M Saulsman et al,2004.
Instruments to assess PD
• To assess individual traits, collection of
traits, constellations of traits.
• Methods---
• 1) Self-report inventories.(SRI)
• 2) Semi-structured interviews.(SSI)
• 3) Projective techniques.
SELF-REPORT INVENTORIES-SRI
• Consist of written statements or questions
ex: true-false, agree-disagree,etc.
• Most popular method
• Less expensive, less time.
• Easy to administer
• Vast samples.
• High inter-site reliabilty due to high degree
of structure.
• DISADVANTAGES.
• Being in differences in
1) Item analyses-content misrepresented due
to variety of methods & phrasing.
2) Gender,ethnic& cultural differences.
3) Individual differences.
4) Response distortion-person not
understanding or unwill or impaired to
accurate response.
SELF-REPORT INVENTORIES-SRI
SELF-REPORT INVENTORIES-SRI
• 16 personality factors questionnaire-
T/F,self-report,16 dimensions+4 second
order factors.
• IOWA personality disorder screen, Y/N,
5 min.,11 screening instruments.
• Millon clinical multi-axial inventory,MCMI,
DSM-IIIR,175 questions,20-30 min.
• PDQ-R152 questions,30 min.
Contd-SRI.
• Schedule for normal & abnormal
personality disorders,SNAP.—106
questions, 10 min.
• Tri-dimensional personality questionnaire
,100 questions,20-30 min.
• Wisconsin personality inventory ,360
questions,20 min.
Projective tests.
• Consists of relatively ambiguous stimuli or
prompts, responses to which are open-ended
to project unconscious conflicts, impulses,
needs or wishes.( Instructions to score &
interpret.)
Contd..projective tests
• Rorschach ink-blot test—10 stimulus cards –
ink-blots,5-chromatic.
• Thematic apperception test—30 stimulus
cards- ambiguous IP situations.
• Sentence completion test—part of sentence.
• Draw a person test.
Contd..projective tests
• Approach lacks empirical support of the
cognitive-perceptual scoring systems &
may encourage a return to less reliable
& subjective interpretations.
Unstructured interviews.
• Popular methods.
• Rely on training, expertise,
conscientiousness of interviewer .
• Prone for false assumptions,
attribution errors, misleading
expectations.
SEMI-STRUCTURED INTERVIEWS-
SSI
• Requires professional judgment &
discretion in administering & score.
• Responsibility of an interviewer to assess
personality trait & not just record
responses.
• Follow-up questions must be sensitive &
responsive to mood state, defensiveness &
self-awareness of the person.
Contd…ssi
• Ensures each trait is assessed in a
consistent fashion.
• Systematic biases in clinical assessments
are easily identified & corrected with
explicit nature of ssi.
SSI—EXAMPLES:-
• Diagnostic interview for p.d. (DIPD)-
Zanarini-101Q,60-120 min.
• International Personality disorder
examination-IPDE-Loranger et al.-157Q,
150 min.
• Personality assessment schedule-PAS-Tyrer
et al-24Q, 60min.
SSI…CONTd..
• Personality interview questions-
II,Widiger-375Q, 60-120 min.
• Standardized assessment of
personality,Mann et al.,10-15min.
• Structured clinical interview for DSM-
IIIR PD—SCID-II, Spitzer& Williams,
120 Q ,60-90min.
• SIPD---Pfohl etal.,136Q,90min.
Kappa(k)statistic
• --Cohen
• Corrects chance agreement by taking the
base rates into account to calculate what
proportion of maximum possible chance-
corrected rate of agreement.
• =>1—(minus)chance rate of agreement/ (divides)
max. possible rate of chance-corrected
agreement
k statistic
• To determine the level of diagnostic
agreement b/w 2 interviewers or 2
instruments.
• Values >0.75---excellent agreement
• 0.41-0.74--- fair-good ”
• <0.40---poor agreement
Personality assessment schedule.
• Tyrer & Alexander,1976.
• 25-40 minutes, trained clinical
interviewer,administer to pt. / or informant.
• Identifies personality traits &scored on 8-
point scale.
• 24 dimensions of personality assessed.
• 5 main personality classes derived,revised
to 13 classes.
International personality
disorder examination.{IPDE}
• Loranger et al, 1994.
• Semi-structured interview (157CRITERIA)
for both ICD-10 & DSM-IV PD.
• SCORES ON 3 POINT SCALE.
• Can be used for dimensional scoring.
ipde
• Screening questionnaire--self
administered-3 or more +  to interview
for that pd.
• Traits + for at least 5 yrs & some manifest
in last 1yr & 1 criterion before age 25.
• Also provides option for late onset pd.
• Requires training & clinical experience for
diagnosis.
Reliability of IPDE
Kappa statistic DSM-IIIR ICD-10
DEFINITE PD 0.57 0.65
Probable or
definite PD
O.73 0.77
Inter-rater
reliability for
dimensional
score
0.79 – 0.94 0.86– 0.93
Strengths of IPDE
• Medium to high inter-rater agreement &
temporal reliability for categorical &
dimensional scores.
• Detailed training manual for instructions &
scoring algorithms
• Dual coverage of DSM-IV & ICD-10
Strengths of IPDE
• Measures dimensional scores which
provide information about accentuation
normal traits below the threshold for pd.
• Availability in several languages across
countries & cross culturally.
Structured clinical interview for
DSM-IIIR PD{SCID-II}
• Spitzer et al., 30-45 min.
• Assessment for 11 DSM-IIIR PDs.
• Categorical or dimensional personality
assessment.
• Self-report screening questionnaire –y/n.
SCID-II
• Negative questions followed up when in
doubt.
• Can be rated using alternative sources
(observed behavior, records, informants)
• Score 0---3
• Manual available
SCID-II
• RELIABILITY—k—0.53—patients,
• 0.31 for non-patients
• Format is not disorder based but is in
primary format.
• Lack of thematically organized format
limits examiner’s choices.
Structured interview for DSM-IV
Personality Disorder. {SIPD-IV}
• Pfohl et al 1995.
• Administered by trained psychologist or
psychiatrist.
• 107Q,16 areas of personality functions
• 4 levels of severity, 60-90min.
• Drawback--Little data, no screening
questionnaire.
Standardized assessment of
personality.
• Mann et al,1981.
• Uses informants.
• 15-20min.
• Suitable as a screening instrument as it is
sensitive & not very specific.
Personality disorder interview-
IV(personality interview Q--PIQ)
• Widiger et al.,1995.
• Semi-structured, 94 criteria.
• Also assess dimensionally.
• Reliability kappa—0.65.
• May be used by lay interviewers with
manual, training required.
• No self report Questions,less no.of studies.
Instruments for diagnosis of
personality dimensionally
• Questionnaires –
• Eysenck inventory questionnaire-EPI,EPQ.
• Karolinska scales of personality-KSP
• Karolinska psychodynamic profile-KPP
• Personality assessment inventory-PAI
• Schedule for normal & abnormal personality-
SNAP
• Dimensional assessment of personality pathology-
basic questionnaire-DAPP-BQ
Interview schedule—
dimensionally
• Personality assessment schedule-PAS
• Personality disorder interview-PDI-IV
• Structured interview of DSM-IV PD-
SIDPIV
• ADD-IV—Dutch instrument
• More likely new to be added.
conclusions across
studies…Ziemmerman,1994
• 1) Reliability of unstandardized clinical
evaluations is poor to fair.
• 2) Joint-interview inter-rater reliability is
generally good-excellent –if used by
developers, unclear if otherwise.
• 3) Test-retest reliability co-efficient-- lower
if interval is greater by couple of wks.
conclusions across
studies…Ziemmerman,1994
• 4) Effect of study design on reliability
probably varies by PD.
• 5) Pt.’s & informants differ in personality
description-insufficient data for validity
comparison & cost-effectiveness
• 6) Variability among PD instruments in
terms of extent of coverage.
conclusions across
studies…Ziemmerman,1994
• 7) Comparing instruments have poor
diagnostic concordance.
• 8) Self-report personality inventories &
semi-structured interviews are biased by
acute state.
• 9) When personality changes, time frame
focus can over or under diagnose PD.
CONCLUSION
PD can be assessed & classified with some
degree of success. However, there are too
many assessment schedules in the
diagnostic kitchen & it is not surprising that
the cook gets confused & often cannot
produce right recipe. We urgently need
some international consensus in both
classification & assessment if we are to
realize some gains we have made in past yrs
THANK
YOU
Dr MRM

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Assessment of Personality Disorders.pptx

  • 2. PRINICIPLES OF ASSESSMENTS IN PERSONALITY DISORDERS • CHAIRPERSON -- ----DR.PARTHA CHOUDHARY • PRESENTER---- ----DR.UDAY SHANKAR.K.
  • 3. ASSESSMENT OF PERSONALITY • USES— • Assists D.D. • Identifies prognostic factors. • Aiding psychotherapies.
  • 4. Differences • AXIS-I DISORDERS • TEMPORARY • REACTIVE • DOMINATED BY Sxs THAN BEHAVIOR. • DIAG.—MSE • MAY DVP.INTO OTHER DISORDERS. AXIS-II DISORDERS --PERMANENT --GENERATIVE --BEHAVIOR &RELATIONSHIP B/W OTHERS --DIAG-LONGTERM FUNCTION --STABLE
  • 5. GENERAL DIAGNOSTIC CRITERIA(ICD-10&DSM-IV) • A) Enduring pattern of inner experience that deviates from culture.Manifest in 2 or more • 1) cognition. • 2) affectivity. • 3) I.P. functioning • 4) impulse control.
  • 6. GENERAL DIAGNOSTIC CRITERIA(ICD-10&DSM-IV) • B) Pattern inflexible & pervasive across social & personal situation • C) Pattern leads to impairment in socio- occupational or imp. areas of functioning. • D) Pattern is stable & long standing & onset to adolescence or early childhood. • E) Pattern is not better accounted for as manifestation of another axis-I disorder.
  • 8. IDIOGRAPHIC • Based on clinical grounds & case history. • Focus on individual. • Provide multifaceted description of personal attributes & behaviors. • Weakness being subjectivity.
  • 9. Nomothetic/universal/ dimensional • Based on common features of common groups. • Uses laws & sets parameters. • Predicts future behavior on basis of resemblance to group.
  • 10. Drawbacks • “Danger of losing the human person in everyday life.”— Allport ,1937. • “Measure a bit of everything & not enough of anything to give dependable & quantifiable samples of personality.”---- --MacFarlane & Turddenham, 1951.
  • 11. Categorical classification • Followed by ICD-10 & DSM-IV • Preferred –ease of communication & efficiency • Rx plan in dual(triple) diagnosis(axes-I+II disorders ),. • Decision making in forensic psychiatry.
  • 12. Categorical classification • Current gold standard for large number of international comparisons and official statistics. • Ex: epidemiological surveys.
  • 13. • Research studies in P.D. show evidence that DIMENSIONAL system of classifying is more valid & reliable.--- ----Clark et al 1995. ----Livesley et al 1994.
  • 14. Reasons being-- • Dimensional view may be truer to the fundamental nature of PDs as categorical views impose an arbitrary distinctions that may misrepresent a seamless state of affairs. • Categorical view may reduce researchers capacity to assess correlates of PD & severity related information. • Categorical --–high degree of co-morbidity & spurious representation
  • 15. • In short • “Categorical classification view PDs as black & white in it’s structural assumption , is oversimplifying & falsely precise in it’s dichomatization & uneconomical in it’s diagnostics applications.” ---Nick Haslam,2003.
  • 16. Dimensional classification --- argues PD as extreme variant that fall in a continuum with normal personality. • Meta analytic review by Lisa M Saulsman et al. 2004, concludes • PD’s conceptualized better by dimensional classification in few disorders. Contd…
  • 17. • Dimensional ---offer practical utility,relevant to majority of PDs. • Related in meaningful & predictable way. • Neuroticism & agreeableness are dimensions across PD • Extraversion & to certain extent conscientiousness are unique to certain pd categories.
  • 18. • Combined CATEGORICAL- DIMENSIONAL approach to conceptualize & Rx PD may be more valuable & preserve the integrity of both classificatory systems. ---Lisa M Saulsman et al,2004.
  • 19. Instruments to assess PD • To assess individual traits, collection of traits, constellations of traits. • Methods--- • 1) Self-report inventories.(SRI) • 2) Semi-structured interviews.(SSI) • 3) Projective techniques.
  • 20. SELF-REPORT INVENTORIES-SRI • Consist of written statements or questions ex: true-false, agree-disagree,etc. • Most popular method • Less expensive, less time. • Easy to administer • Vast samples. • High inter-site reliabilty due to high degree of structure.
  • 21. • DISADVANTAGES. • Being in differences in 1) Item analyses-content misrepresented due to variety of methods & phrasing. 2) Gender,ethnic& cultural differences. 3) Individual differences. 4) Response distortion-person not understanding or unwill or impaired to accurate response. SELF-REPORT INVENTORIES-SRI
  • 22. SELF-REPORT INVENTORIES-SRI • 16 personality factors questionnaire- T/F,self-report,16 dimensions+4 second order factors. • IOWA personality disorder screen, Y/N, 5 min.,11 screening instruments. • Millon clinical multi-axial inventory,MCMI, DSM-IIIR,175 questions,20-30 min. • PDQ-R152 questions,30 min.
  • 23. Contd-SRI. • Schedule for normal & abnormal personality disorders,SNAP.—106 questions, 10 min. • Tri-dimensional personality questionnaire ,100 questions,20-30 min. • Wisconsin personality inventory ,360 questions,20 min.
  • 24. Projective tests. • Consists of relatively ambiguous stimuli or prompts, responses to which are open-ended to project unconscious conflicts, impulses, needs or wishes.( Instructions to score & interpret.)
  • 25. Contd..projective tests • Rorschach ink-blot test—10 stimulus cards – ink-blots,5-chromatic. • Thematic apperception test—30 stimulus cards- ambiguous IP situations. • Sentence completion test—part of sentence. • Draw a person test.
  • 26. Contd..projective tests • Approach lacks empirical support of the cognitive-perceptual scoring systems & may encourage a return to less reliable & subjective interpretations.
  • 27. Unstructured interviews. • Popular methods. • Rely on training, expertise, conscientiousness of interviewer . • Prone for false assumptions, attribution errors, misleading expectations.
  • 28. SEMI-STRUCTURED INTERVIEWS- SSI • Requires professional judgment & discretion in administering & score. • Responsibility of an interviewer to assess personality trait & not just record responses. • Follow-up questions must be sensitive & responsive to mood state, defensiveness & self-awareness of the person.
  • 29. Contd…ssi • Ensures each trait is assessed in a consistent fashion. • Systematic biases in clinical assessments are easily identified & corrected with explicit nature of ssi.
  • 30. SSI—EXAMPLES:- • Diagnostic interview for p.d. (DIPD)- Zanarini-101Q,60-120 min. • International Personality disorder examination-IPDE-Loranger et al.-157Q, 150 min. • Personality assessment schedule-PAS-Tyrer et al-24Q, 60min.
  • 31. SSI…CONTd.. • Personality interview questions- II,Widiger-375Q, 60-120 min. • Standardized assessment of personality,Mann et al.,10-15min. • Structured clinical interview for DSM- IIIR PD—SCID-II, Spitzer& Williams, 120 Q ,60-90min. • SIPD---Pfohl etal.,136Q,90min.
  • 32. Kappa(k)statistic • --Cohen • Corrects chance agreement by taking the base rates into account to calculate what proportion of maximum possible chance- corrected rate of agreement. • =>1—(minus)chance rate of agreement/ (divides) max. possible rate of chance-corrected agreement
  • 33. k statistic • To determine the level of diagnostic agreement b/w 2 interviewers or 2 instruments. • Values >0.75---excellent agreement • 0.41-0.74--- fair-good ” • <0.40---poor agreement
  • 34. Personality assessment schedule. • Tyrer & Alexander,1976. • 25-40 minutes, trained clinical interviewer,administer to pt. / or informant. • Identifies personality traits &scored on 8- point scale. • 24 dimensions of personality assessed. • 5 main personality classes derived,revised to 13 classes.
  • 35. International personality disorder examination.{IPDE} • Loranger et al, 1994. • Semi-structured interview (157CRITERIA) for both ICD-10 & DSM-IV PD. • SCORES ON 3 POINT SCALE. • Can be used for dimensional scoring.
  • 36. ipde • Screening questionnaire--self administered-3 or more +  to interview for that pd. • Traits + for at least 5 yrs & some manifest in last 1yr & 1 criterion before age 25. • Also provides option for late onset pd. • Requires training & clinical experience for diagnosis.
  • 37. Reliability of IPDE Kappa statistic DSM-IIIR ICD-10 DEFINITE PD 0.57 0.65 Probable or definite PD O.73 0.77 Inter-rater reliability for dimensional score 0.79 – 0.94 0.86– 0.93
  • 38. Strengths of IPDE • Medium to high inter-rater agreement & temporal reliability for categorical & dimensional scores. • Detailed training manual for instructions & scoring algorithms • Dual coverage of DSM-IV & ICD-10
  • 39. Strengths of IPDE • Measures dimensional scores which provide information about accentuation normal traits below the threshold for pd. • Availability in several languages across countries & cross culturally.
  • 40. Structured clinical interview for DSM-IIIR PD{SCID-II} • Spitzer et al., 30-45 min. • Assessment for 11 DSM-IIIR PDs. • Categorical or dimensional personality assessment. • Self-report screening questionnaire –y/n.
  • 41. SCID-II • Negative questions followed up when in doubt. • Can be rated using alternative sources (observed behavior, records, informants) • Score 0---3 • Manual available
  • 42. SCID-II • RELIABILITY—k—0.53—patients, • 0.31 for non-patients • Format is not disorder based but is in primary format. • Lack of thematically organized format limits examiner’s choices.
  • 43. Structured interview for DSM-IV Personality Disorder. {SIPD-IV} • Pfohl et al 1995. • Administered by trained psychologist or psychiatrist. • 107Q,16 areas of personality functions • 4 levels of severity, 60-90min. • Drawback--Little data, no screening questionnaire.
  • 44. Standardized assessment of personality. • Mann et al,1981. • Uses informants. • 15-20min. • Suitable as a screening instrument as it is sensitive & not very specific.
  • 45. Personality disorder interview- IV(personality interview Q--PIQ) • Widiger et al.,1995. • Semi-structured, 94 criteria. • Also assess dimensionally. • Reliability kappa—0.65. • May be used by lay interviewers with manual, training required. • No self report Questions,less no.of studies.
  • 46. Instruments for diagnosis of personality dimensionally • Questionnaires – • Eysenck inventory questionnaire-EPI,EPQ. • Karolinska scales of personality-KSP • Karolinska psychodynamic profile-KPP • Personality assessment inventory-PAI • Schedule for normal & abnormal personality- SNAP • Dimensional assessment of personality pathology- basic questionnaire-DAPP-BQ
  • 47. Interview schedule— dimensionally • Personality assessment schedule-PAS • Personality disorder interview-PDI-IV • Structured interview of DSM-IV PD- SIDPIV • ADD-IV—Dutch instrument • More likely new to be added.
  • 48. conclusions across studies…Ziemmerman,1994 • 1) Reliability of unstandardized clinical evaluations is poor to fair. • 2) Joint-interview inter-rater reliability is generally good-excellent –if used by developers, unclear if otherwise. • 3) Test-retest reliability co-efficient-- lower if interval is greater by couple of wks.
  • 49. conclusions across studies…Ziemmerman,1994 • 4) Effect of study design on reliability probably varies by PD. • 5) Pt.’s & informants differ in personality description-insufficient data for validity comparison & cost-effectiveness • 6) Variability among PD instruments in terms of extent of coverage.
  • 50. conclusions across studies…Ziemmerman,1994 • 7) Comparing instruments have poor diagnostic concordance. • 8) Self-report personality inventories & semi-structured interviews are biased by acute state. • 9) When personality changes, time frame focus can over or under diagnose PD.
  • 51. CONCLUSION PD can be assessed & classified with some degree of success. However, there are too many assessment schedules in the diagnostic kitchen & it is not surprising that the cook gets confused & often cannot produce right recipe. We urgently need some international consensus in both classification & assessment if we are to realize some gains we have made in past yrs