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Objective: In light of continuing controversies concerning the DSM-III-R system for diagnosing personality disorders, their construct validity, and the assignment of disorders to a particular axis, the authors studied patterns of axis I-axis II comorbidity., Method: Semistructured interviews were used to assess axis I and axis II disorders in 200 inpatients and outpatients. Odds ratios were calculated to determine significant comorbidity between classes of current axis I disorders and axis II personality disorders diagnosed according to two methods and defined at two diagnostic thresholds. Distributions of personality disorder traits were also compared in patients with and without axis I disorders., Results: Significantly elevated odds ratios were found for co-occurrence of current mood disorders with avoidant and dependent personality disorders; anxiety disorders with borderline, avoidant, and dependent personality disorders; psychotic disorders with schizotypal, borderline, and dependent personality disorders; psychoactive substance use disorders with borderline and histrionic personality disorders; and eating disorders with schizotypal, borderline, and avoidant personality disorders. These results held when conservative and liberal definitions of personality disorders were used. Non-specific axis I and axis II associations were confirmed for distributions of personality disorder traits., Conclusions: Significant associations occurred between most axis I classes of disorders and axis II disorders and traits in more than one cluster. All axis I classes of disorders except mood disorders co-occurred with borderline personality disorder; however, patients with mood disorders had elevated levels of borderline traits. When any personality disorder was present, there were significant odds that a mood, anxiety, psychotic, or eating disorder would also be present; psychoactive substance use disorders, in contrast, significantly co-occurred with borderline and histrionic personality disorders.

Objective: The purpose of this study was to examine patterns of co-occurrence of axis II disorders in a group of consecutive patients evaluated with two contrasting structured interviews., Method: One hundred of 106 consecutive applicants for long-term, inpatient treatment of severe personality psychopathology were assessed, face-to-face, by psychiatrists using the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) and the Personality Disorder Examination (PDE). The percent of co-occurrence of pairs of disorders diagnosed by each structured interview separately was calculated, and significance levels were determined by using chi-square tests of independence. Finally, odds ratios were computed for the odds of each pair of disorders occurring together compared with the odds for the occurrence of each disorder alone., Results: The two interview methods revealed different comorbidity patterns. Significant covariation was found for 29 pairs of disorders diagnosed with the PDE, compared with 12 pairs diagnosed with the SCID-II. Six pairs of disorders covaried significantly and were associated with odds ratios greater than 4: histrionic with borderline, histrionic with narcissistic, narcissistic with antisocial, narcissistic with passive-aggressive, avoidant with schizotypal, and avoidant with dependent., Conclusions: Substantial overlap occurred among personality disorders. In this group of patients, consistent patterns of comorbidity involving narcissistic, avoidant, and histrionic personality disorders suggest that categorical distinctions between them and certain other DSM-III-R personality disorders may be illusory. The question of which of two overlapping disorders is more valid, however, is left unanswered. For clinical purposes, a two-level diagnostic convention is proposed.

The authors gave the self-report Personality Diagnostic Questionnaire--Revised (PDQ-R) to 87 applicants for inpatient treatment of severe personality psychopathology and, blind to these results, diagnosed personality disorders in the applicants by using the Personality Disorder Examination and the Structured Clinical Interview for DSM-III-R Personality Disorders. The PDQ-R was not a substitute for a structured interview assessment of axis II disorders because many of its diagnoses were false positives. Its high sensitivity and moderate specificity for most of the axis II disorders suggest, however, that it is an efficient instrument for screening patients with DSM-III-R personality disorders.

A factor analysis of the entire item set of the DSM-III criteria was conducted to determine the extent to which the factors that emerged corresponded to the 11 personality disorders and three clusters included in DSM-III. Data were obtained from 552 patients who completed a self-report personality questionnaire and from 287 psychiatrists who rated their patients. Eleven questionnaire factors emerged that had eigenvalues greater than one, and at least three items emerged with factor loadings greater than 0.40. A correlational and multiple regression analysis of the questionnaire factors and clinicians' ratings showed few strong relationships between the factors and the 11 personality disorders but good correspondence with the three clusters.

The authors present the proposed DSM-III classification of the traditional hysterical disorders, i.e., disorders that suggest physical illness but in which psychological factors are judged to be of importance. The use of the DSM-III inclusion and exclusion criteria--physical mechanism explains the symptoms, symptoms are linked to psychological factors, symptom initiation is under voluntary control, and there is an obvious recognizable environmental goal--are discussed in the differential diagnosis of somatoform disorder, factitious disorder, malingering, psychological factors affecting physical condition, and undiagnosed physical illness.

The authors compared three methods of assessing borderline personality disorders. Test-retest reliability for the self-report Personality Diagnostic Questionnaire was adequate and compared favorably with the interrater reliability of the DSM-III-oriented clinical interview and the semistructured research interview. The overall prevalence of personality disorders scored on the questionnaire was similar to that generated by the clinical interview. The specificity and sensitivity of the questionnaire for the diagnosis of borderline personality disorder were slightly higher than 60%, which suggests that it may be a useful and economical instrument for identifying patients with borderline personality disorder.

The authors observed 20 patients over time for mal-adaptive personality traits during hospitalization and made longitudinal diagnoses to validate Structured Clinical Interview for DSM-III-R (SCID) assessments of personality disorders. The SCID assessments identified certain personality disorders better than others.