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87 Discussion and Conclusions Frequency of personality disorder types The study had a very limited and specific objective, namely, to determine the reliability, stability, and clinical and cultural acceptability of a particular diagnostic instrument designed for worldwide use. In the absence of any prior evidence that PDs wuld be reliably and meaningfully assessed on a worldwide basis, it would have been premature and ill-advised to have broadened the scope of the project. The development of an acceptable instrument for case identification was a necessary prerequisite to any attempt at international wllaborative or comparative studies of the PDs. The study was not intended to be an epidemiological survey of residents in the community or those under treatment. The sampling did not involve consecutive admissions, and there are obviously different thresholds associated with the request for mental health care in different cultures. Therefore, it would be imprudent to make tw much of variations in the frequency with which the individual disorders were diagnosed at the various centres. It is noteworthy, however, that most of the specific personality disorders in the two classification systems were observed in the 11 nations represented in the study. It is also of some interest that the two most frequently diagnosed types in the sample as a whole are disorders that were not included in either ICD-9 or DSM-11. They are borderline (DSM-III- R) or emotionally unstable, borderline type (ICD-10). and avoidant (DSM-III-R) or anxious (ICD-10). At least one case of these two disorders occurred at every centre with the exception of Bangalore, which did not report an avoidant diagnosis. Two controversial disorders, sadistic and self-defeating, are not included in ICD-10, were relegated to the appendix of DSM-III-R, and do not appear at all in DSM-IV. Both were among the three least frequent diagnoses in the entire sample. Interestingly, the third, narcissistic, was not included in DSM-11 and is still not recognized in ICD-10. It occurred in only 1.3% of patients in the study. This contrasts with passive-aggressive, which is not included in either ICD-10 or DSM-N but was diagnosed in 5% of study patients and appeared in all centers except Bangalore. CO-occurrence of mental disorders in the same patient Not only did the majority of patients have other mental disorders in addition to PDs, but many also had more than one type of PD. Of the 366 patients with a DSM-111-R personality disorder diagnosis, 11 1 (30.3%)
A. W. Loranger had more than one personality disorder, including 55 (15.0%) with two, 32 (8.7%) with three, and 24 (6.6%) with more than three disorders. Of the 283 patients with an ICD-l0 personality disorder diagnosis, 96 (33.9%) had more than one type of disorder, including 57 (20.1%) with two, 27 (9.5%) with three, and 12 (4.2%) with more than three disorders. What are the implications of a patient having more than one form of mental disorder, particularly more than one type of PD? In some instances this may merely reflect the fact that twoor more disorders share similar symptoms or diagnostic criteria. For example, subsme abuse may be indicative of p r impulse control. a characteristic of antisocial, emotionally unstable or borderline PD. Similarly, social withdrawal is a diagnostic criterion shared by both schizoid and avoidant PDs. Another implication may be pmgnostic or therapeutic, with one disorder modifying the course or outcome of another. There is evidence, for example, that depression is less responsive to treatment, when accompanied by a PD. Comorbidity may also be a consequence of the fact that two disorders share similar etiologies. Finally, at times comorbidity may also he an indication of a defective or less thanoptimal classification system. A fundamental problem in interpreting the meaning of the comorbidity findings from various sNdies, including this one, is that they are markedly influenced by the base rates of the disorders in the sample. These in turn are a function of the admission practices of the facilities from which the patients are drawn, not to mention the selection biases for inclusion in the studies themselves. Ideally, comorbidity should he determined from epidemiological studies based on probability samples from the community. Unfortunately these rarely if ever include a suffi- cient number of cases of most disorders, to provide definitive information about the hue CO-occurrence rates of the disorders in question. ICD-10 and DSM-IICR As previously noted, ICD-10 and DSM-111-R are different but overlapping classification systems. There are slight differences in nomenclature: anankastidobsessive-compulsive, anxious/avoidant, and dissociaUantisocial. In ICD-10 borderline and impulsive are viewed as subtypes of emotionally unstable; schiwtypal is located with schizophrenia and delusional disorders; and narcissistic, passive-aggressive, and the two disorders in the appendix of DSM-111-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 wording. Except for
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Until recently, the standardization
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Assessment and diagnosis of persona
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Contents Contributors Preface Annan
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Contributors Dr Antonio Andreoli Ho
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Preface One of the major goals of t
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... Xlll Acknowledgements The IPDE
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Problems in the field of personalit
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5 Problems in the field of PD perso
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7 Problems in the field of PD In DS
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9 Problems in the field of PD cultu
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11 Review of diagnostic instruments
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19 Epidemiology of DSM-Ill PDs in c
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Table l. Prevalence rates of specif
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24 1. H. Reich and G. de Girolamo (
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26 .- 5 2 0 W C .- 0 P g F ? g e Q
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28 J. H. Reich and G. de Girolarno
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Table 3. Prevalence rates ofpersona
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Pfohl etal.. l986 (67) Pilgrim & Ma
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35 Epidemiology of DSM-Ill PDs were
Page 48 and 49: 37 Epidemiology of DSM-Ill PDs migh
Page 50 and 51: 39 Epidemiology of DSM-Ill PDs 23 R
Page 52 and 53: 4 1 Epidemiology of DSM-Ill PDs 55
Page 54 and 55: 43 International personality disord
Page 56 and 57: I 45 IPDE iner what he is actually
Page 58 and 59: 47 IPDE Sample of IPDE item The que
Page 60 and 61: 49 IPDE dimensional scores are not
Page 62 and 63: 1 9 IPDE considerable training and
Page 64 and 65: 53 Experiences with IPDE The invest
Page 66 and 67: 55 Experiences with IPDE passive ag
Page 68 and 69: 57 Field Trial
Page 70 and 71: 59 Sampling, inte~iewers, interview
Page 72 and 73: Description of centres participatin
Page 74 and 75: 63 Centres participating in IPDE fi
Page 82 and 83: P- P Table 1. Sample sizes and IPDE
Page 84 and 85: 73 Results Table 3. ICD-I0 Disorder
Page 86 and 87: 75 Results Table 5. Frequency of CO
Page 88 and 89: 77 Results Table 8. Interrater reli
Page 90 and 91: Discussion and conclusions Armand W
Page 92 and 93: 8 1 Discussion and Conclusions stab
Page 94 and 95: 83 Discussion and Conclusions Repet
Page 96 and 97: Discussion and Conclusions of princ
Page 100 and 101: 89 Discussion and Conclusions emoti
Page 102 and 103: 9 1 Discussion and Conclusions inte
Page 104 and 105: 93 Appendix Table A2 Persomlity dis
Page 106 and 107: 95 Appendix Table A4 Personality di
Page 108 and 109: 97 Appendix Table A6 Personaliry di
Page 110 and 111: 99 Appendix Table SA Personaliry di
Page 112 and 113: Table A10 Personality disorder diag
Page 114 and 115: 103 Appendix Table A12 Personality
Page 116 and 117: Table A13 (con?) Criterion B7 B8 1
Page 118 and 119: 107 Appendix Table A13 (cont) Frequ
Page 120 and 121: 109 Appendix Table A14 (cont.) Freq
Page 122 and 123: Acknowledgements 113 Manual History
Page 124 and 125: Manual History of the IPDE One of t
Page 126 and 127: 116 Manual Struchlre of the IPDE Th
Page 128 and 129: 118 Manual that is likely to enhanc
Page 130 and 131: 120 Manual data. If examiners have
Page 132 and 133: 122 Manual Scoring conventions Much
Page 134 and 135: 124 Manual Recording the scores Req
Page 136 and 137: 126 Manual Q. What do you do when s
Page 138 and 139: 128 Manual section, if there are qu
Page 140 and 141: ICD-10 criteria and corresponding I
Page 142 and 143: 132 ICD-10 criteria and correspondi
Page 144 and 145: 134 IPDE ICD-10 module screening qu
Page 146 and 147: 136 Screening questionnaire 47 1 lo
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I 138 IPDE ICD-10 module* interview
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140 Interview schedule 2. 0 1 2 7 0
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142 Inte~iew schedule 4. O 1 2 I N
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144 Interview schedule 6. O l Z ? 0
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146 Interview schedule 8. 0 1 2 1 0
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148 Interview schedule .10. 0 1 2 ?
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150 Interview schedule 12. 0 1 2 7
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152 lnte~iew schedule 14. 0 1 2 ? 0
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154 Interview schedule 16. 0 1 2 ?
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156 interview schedule 18. 0 1 2 ?
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158 Interview schedule 20. O 1 2 N
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164 Interview schedule *26. 0 1 2 ?
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166 lntewiew schedule 28. 0 1 2 ? 0
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170 lnte~iew schedule 32. O 1 2 7 N
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174 lntewiew schedule 36. 0 1 2 ? 0
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176 lnterv~ew schedule 38. 0 1 2 ?
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184 lnte~iew schedule 46. 0 1 2 7 0
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~ 186 Interview schedule 48. 0 1 2
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194 Interview schedule 56. 0 1 2 1
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196 Interview schedule VI. IMPULSE
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200 Interview schedule Have you eve
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202 Interview schedule 1 63. 0 1 2
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204 Intewiew schedule Rate the foll
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206 IPDE ICD-10 module handscoring
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+ 39+44=4, 208 Handscoring algorith
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210 Handscoring algorithms and summ
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IPDE ICD-10 module summary scoreshe
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224 Index paranoid 108 schizoid 108
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226 Index Personalily Assessment Sc
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