Personality Studies

Andrew E. Skodol, M.D., Director
Donna S. Bender, Ph.D., Research Scientist IV
John C. Markowitz, M.D., Research Psychiatrist II
Tracey S. Vorus, Ph.D., Research Scientist II

OVERVIEW

The Department of Personality Studies conducts research on personality traits and disorders in collaboration with investigators from other research departments at Psychiatric Institute and other university departments of psychiatry. Personality disorders are important contributors to impairment in social and occupational functioning and high mental health treatment utilization. They also have negative prognostic effects on a variety of other mental disorders.

CURRENT RESEARCH

In June 2003, Dr. Andrew Skodol began the eighth year of his NIMH-funded Collaborative Longitudinal Study of Personality Disorders (CLPS). Other collaborative sites include McLean Hospital (Harvard University) in Belmont, MA; Butler Hospital (Brown University) in Providence, RI; Yale Psychiatric Research (Yale University) in New Haven, CT; and the Department of Psychology of Texas A&M University in College Station, TX. The CLPS has recruited 733 treatment-seeking or treated patients with one of four representative personality disorders (PDs) or with major depressive disorder (MDD) and no personality disorder. As of March 2004, the majority of subjects had been followed via seven separate follow-up assessments over six years. The goal of the CLPS is to investigate the stability of personality psychopathology and associated functioning over time, in order to describe the clinical course and to understand the determinants of prognosis. During 2003-2004, the CLPS continued to generate results pertaining to the measurement and construct validity of personality disorders, and their demographic correlates, comorbidity, antecedents, clinical course, and impact.

Measurement and Construct Validity
The diagnostic efficiency of the criteria for obsessive-compulsive personality disorder (OCPD) present at baseline was calculated to determine which criteria best predicted the presence or absence of OCPD at blind two-year follow-up. The baseline criteria for OCPD that, if present, best predicted the follow-up diagnosis of OCPD were rigid and stubborn, preoccupied with details, and reluctant to delegate. Longitudinal diagnostic efficiency analyses can be used to refine diagnostic criteria sets to emphasize their more stable elements. Also, further attempts were made to describe and differentiate the four DSM-IV PDs according to alternative models of personality psychopathology, specifically the dimensional model encompassed by the Schedule for Nonadaptive and Adaptive Personality (SNAP). The dimensions of the SNAP differentiated abnormal from normal personality, particularly in the propensity of individuals with PDs to manifest negative affects and interpersonal detachment. Furthermore, this model appeared to successfully distinguish specific PDs from each other.

Demographic Correlates
Although the majority of patients in the CLPS are Caucasian, there are sufficient numbers of minority patients to enable examination of ethnic differences in aspects of personality psychopathology. The distribution of the four personality disorders, as well as of the individual criteria comprising each disorder’s criteria set, were compared across Caucasian, African American, and Hispanic patients. Disproportionately higher rates of borderline personality disorder (BPD) were found in Hispanic than in Caucasian and African American patients and higher rates of schizotypal personality disorder (STPD) were found among African Americans compared to Caucasians. Hispanic patients had higher rates of BPD criteria reflecting intense anger, affective instability, and unstable relationships than Caucasians. African American patients had higher rates of STPD criteria of social anxiety, no close friends, odd beliefs, and paranoia than Caucasians.

Comorbidity
Differences in clinical features, associated functional impairment, and types of childhood trauma were examined in women with BPD, women with BPD and posttraumatic stress disorder (PTSD), and women with other PDs and PTSD. The additional diagnosis of PTSD in borderline women did not significantly increase the degree of borderline pathology or psychiatric morbidity, but did increase general dysfunction and the occurrence of hospitalization. The additional diagnosis of BPD in women with PTSD significantly increased the features of suicide proneness and impulsiveness. Both groups of women with PTSD reported more types of childhood trauma relative to borderline women without PTSD. These findings suggest that comorbid PTSD, although associated with increased impairment, does not alter the central features of BPD.

Antecedents
The association between trauma and PDs has not been previously comprehensively examined for multiple types of trauma and different PD types. Overall, we have found that rates of childhood maltreatment of various kinds are high in patients with PDs, with 73% reporting some kind of abuse and 82% reporting neglect. Early social functioning and pathological childhood experiences were examined specifically also for patients with avoidant personality disorder (AVPD). Adults with AVPD reported poorer child and adolescent athletic performance, less involvement in hobbies during adolescence, and less adolescent popularity than patients with other PDs or with MDD and no PD. Various forms of childhood abuse were not found to be specific for AVPD. These findings suggest that different adverse psychosocial experiences in childhood contribute to the development of different types of adult personality disorder.

Clinical Course
We have demonstrated that traits of general personality functioning (e.g., five-factor traits) tend to be stable, with stability estimates in the r = .70 to .80 range over two years. In addition, when study patients change on these traits, the changes are followed by lagged changes in PD psychopathology, across the spectrum of PDs. Importantly, these relationships are non-reciprocal, in that changes in PD features are not predictive of subsequent changes in personality traits.

Impact
The CLPS has begun to explore influences on the treatment received by patients with PDs. Medication utilization by patients with BPD, assessed prospectively over a two-year period, only loosely conformed to the APA Practice Guideline for the Treatment of Patients with Borderline Personality Disorder algorithms. Physicians appeared to be influenced in their prescribing by considerations in addition to BPD symptom clusters, including levels of functional impairment and the presence of comorbid Axis I conditions. During the first two years of follow-up, 9% of study participants reported at least one definitive suicide attempt and 44% of these had multiple suicidal behaviors. Baseline diagnoses of BPD and drug use disorders predicted prospective suicide attempts. Controlling for baseline BPD diagnosis, we found that worsening in the course of MDD and of substance use disorders in the month preceding the attempt were also significant predictors.

Preliminary results in Dr. John Markowitz’ pilot trial of interpersonal psychotherapy for patients with BPD have been promising. Three of the first five patients treated completed the 32-week trial, no longer met criteria for BPD, and showed considerable improvement in co-occurring depressive symptoms. Additional patients are currently being treated.

GRANTS
• Collaborative Longitudinal Study of Personality Disorders (NIMH, PI: Andrew E. Skodol, M.D.)
• Interpersonal Psychotherapy for Borderline Personality Disorder (NARSAD, PI: John C. Markowitz, M.D.)

BIBLIOGRAPHY (April 1, 2002 – March 31, 2003)
Battle CL, Shea MT, Johnson DM, Yen S, Zlotnick C, Zanarini MC, Sanislow CA, Skodol AE, Gunderson JG, Grilo CM, McGlashan TH, Morey LC: Childhood maltreatment associated with adult personality disorders: Findings from the Collaborative Longitudinal Personality Disorders Study. J Personal Disord 18:193-211, 2004

Chavira DA, Grilo CM, Shea MT, Yen S, Gunderson JG, Morey LC, Skodol AE, Stout RL, McGlashan TH: Ethnicity and four personality disorders. Compr Psychiatry 44:483-491, 2003

Grilo CM, Sanislow CA, Shea MT, Skodol AE, Stout RL, Pagano ME, Yen S, McGlashan TH: The natural course of bulimia nervosa and eating disorder not otherwise specified is not influenced by personality disorders. Int J Eating Disorders 34:319-330, 2003

Grilo CM, Skodol AE, Gunderson JG, Sanislow CA, Stout RL, Shea MT, Morey LC, Zanarini MC, Bender DS, Yen S, McGlashan TH: Longitudinal diagnostic efficiency of DSM-IV criteria for obsessive-compulsive personality disorder: A 2-year prospective study. Acta Psychiatr Scand 110:64-68, 2004

Morey LC, Warner MB, Shea MT, Gunderson JG, Sanislow CA, Grilo C, Skodol AE, McGlashan TH: The representation of four personality disorders by the SNAP dimensional model of personality. Psychological Assessment 15:326-332, 2003

Oldham JM, Bender DS, Skodol AE, Dyck IR, Sanislow CA, Yen S, Grilo CM, Shea MT, Zanarini MC, Gunderson JG, McGlashan TH: Testing an APA Practice Guideline: Symptom-targeted medication utilization for patients with borderline personality disorder. J Psychiatr Practice 10:156-161, 2004

Rettew DC, Zanarini MC, Yen S, Grilo CM, Skodol AE, Shea MT, McGlashan TH, Morey LC, Culhane MA, Gunderson JG: Childhood antecedents of avoidant personality disorders: A retrospective study. J Amer Acad Child Adoles Psychiatry 42:1122-1130, 2003

Skodol AE, Bender DS: Why are women diagnosed borderline more than men? Psychiatr Q 74:349-360, 2003

Warner MB, Morey LC, Finch JF, Gunderson JG, Skodol AE, Sanislow CA, Shea MT, McGlashan TH, Grilo CM: The longitudinal relationship of personality traits and disorders. J Abnorm Psychol 113:217-227, 2004

Yen S, Shea MT, Pagano M, Sanislow CA, Grilo CM, McGlashan TH, Skodol AE, Bender DS, Zanarini MC, Gunderson JG, Morey LC: Axis I and Axis II disorders as predictors of prospective suicide attempts: Findings From the Collaborative Longitudinal Personality Disorders Study. J Abnorm Psychol 112:375-381, 2003

Zlotnik C, Johnson DM, Yen S, Battle CL, Sanislow CA, Skodol AE, Grilo CM, McGlashan TH, Gunderson JG, Bender DS, Zanarini MC, Shea MT: Clinical features and impairment in women with borderline personality disorder (BPD) with posttraumatic stress disorder(PTSD), BPD without PTSD, and other personality disorders with PTSD. J Nerv Ment Dis 191:706-713, 2003