Twelve month test retest reliability of a Japanese version of the Structured Clinical Interview for DSM-IV Personality Disorders

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1 PCN Psychiatric and Clinical Neurosciences Blackwell Science Pty Ltd 575October Japanese SCID-II A. Osone and S. Takahashi /j x Original Article532538BEES SGML Psychiatry and Clinical Neurosciences (2003), 57, Regular Article Twelve month test retest reliability of a Japanese version of the Structured Clinical Interview for DSM-IV Personality Disorders AKIRA OSONE, MD 1 AND SABURO TAKAHASHI, MD 2 1 Department of Psychosomatics, Ushiku Aiwa General Hospital, Ibaraki and 2 Saitama Kounan Hospital, Saitama, Japan Abstract The purpose of the present study was to examine the long-interval test retest reliability of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (4th edn; DSM-IV) Axis II Personality Disorders (SCID-II) Japanese version. One hundred and twenty outpatients with anxiety disorders completed the self-report SCID-II personality questionnaire (SCID-II-PQ) and structured interviews, and then again 12 months later. In the SCID-II-PQ, 70.8% and 71.7% of the patients had a personality disorder (PD) at the first evaluation and second evaluation 12 months later, respectively, and Cohen s kappas ranged from 0.29 for paranoid PD to 0.83 for histrionic PD, and overall kappa was In the SCID-II interviews, 47.5% and 41.7% of the patients fulfilled the criteria for PD at the first and the second evaluations, respectively. At least one PD was identified in 49 subjects (40.8%), of whom 65.3% had one PD, 30.6% had two PD, 2% had three PD, and 2% had four PD; the most frequently diagnosed PD were from cluster C (60.9%). The overall base rate of 12 PD was 7%, and overall kappa was Cohen s kappas ranged from 0.86 for obsessive compulsive PD to 0.93 for avoidant PD and schizoid PD, and were comparable with those in the previous interrater studies. The test retest reliability of the SCID- II-PQ was moderately good, and after the SCID-II interview the test retest reliability of the SCID- II appeared to be of almost perfect reliability. This first long-interval, large-sample, non-westernlanguage research on the test retest reliability of the SCID-II for DSM-IV indicated its usefulness and excellent reliability. Key words anxiety disorder, personality disorders, SCID-II, test retest reliability. INTRODUCTION In studies of axis I, there is relatively little disagreement about who to interview, when to interview, or even what measure to use. In contrast, the clinical diagnosis of personality disorders (PD) has shown that agreement is generally poor. 1 A number of structured interviews have been developed to standardize and improve reliability of diagnosing PD. 1 The Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (4th edn; DSM-IV) Axis II Personality Disorders (SCID-II) 2 is a frequently used Correspondence address: Dr Akira Osone, Department of Psychosomatics, Ushiku Aiwa General Hospital, 896 Shishiko-cho, Ushiku, Ibaraki , Japan. paopaco@olive.ocn.ne.jp Received 7 March 2003; accepted 20 April Regular Article instrument in Western countries. Prior to SCID-II for DSM-IV, the Structured Clinical Interview for DSM (3rd edn, revised) Personality Disorders (SCID-II for DSM-III-R) 3 has been translated into Italian, Dutch, German, Swedish, Portuguese, and Japanese and had a good interrater reliability. 4 6 There is a study on interrater reliability and internal consistency of the SCID- II for the DSM-IV Italian version, 7 but there has been little research on the long-interval test retest reliability of the SCID-II for DSM-IV. Because personality means an enduring inflexible and pervasive pattern across a broad range of people, long-interval test retest reliability is essential to a personality diagnosing instrument. This is the first long-interval research conducted with a large number of samples, and in a non- Western language, on test retest reliability of the SCID-II for DSM-IV.

2 Japanese SCID-II 533 METHODS Patients The patients who participated in the present study were selected randomly from the outpatients at the Department of Psychosomatics, Ushiku Aiwa General Hospital. The subjects were all Japanese and informed consent was obtained from all patients participating. Sex, age, duration of disorder and observation period by first author (AO) of these patients are given in Table 1. Two patients (a woman and a man) refused to participate in the second interview. Consequently, the remaining 120 patients (79 women and 41 men) participated in the present study. Of these subjects, the mean age of the women was 44.5 ± 13.8 years (range: years) and that of the men was 44.8 ± 15.1 years (range: years) at the time of second evaluation. The mean duration of disorder was 7.9 ± 7.1 years and the subjects were all observed for more than 1 year, with a mean period of 3.0 ± 1.3 years (range: years). Twenty-eight (20)% were single, 88 (73.3)% were married, four (3.3%) were divorced, and four (3.3%) were widowed. Sixty-eight (56.7%) was employed. Nine of them (7.5%) completed secondary school, 79 (65.8%) completed high school, and 32 (26.7%) completed university. The principal diagnosis of axis I was anxiety disorders. All diagnoses were made in strict accordance with Structured Clinical Interview for DSM-IV Axis I disorders (SCID-I) Clinician version 8 before the SCID-II interview was made, although the SCID-I Japanese version has not yet been published. Forty-eight patients (48.3%) had panic disorder with agoraphobia, 21 (17.5%) had generalized anxiety disorder, 17 (14.2%) had panic disorder without agoraphobia, 14 (11.7%) had social phobia, six (5%) had specific phobias, three (2.5%) had obsessive compulsive disorder, and one (0.8%) had agoraphobia without history of panic disorder. Of these subjects approximately twothirds comprise those with panic disorder, and all were outpatients. Instruments The first author (AO) translated SCID-II (User s Guide, Personality Questionnaire, and Sample Case for SCID-II) into Japanese, under the supervision of the second author (ST; who has published Japanese versions of DSM-III, DSM-III-R, DSM-IV, and DSM- IV-R in Japan), checked it and published in Japan. 9 The SCID-II Personality Questionnaire (PQ) is a selfadministered instrument with a true or false response, which consists of 119 items measuring 10 DSM-IV Axis II PD, as well as depressive PD and passive aggressive PD, which were included in DSM-IV appendix B, Criteria sets and Axes provided for further study. The SCID-II-PQ and the SCID-II interviews were administered when the patients were not in the acute psychiatric state. Cohen s simple kappa 10 was used to measure the test retest reliability of the SCID-II. Rater The first author (AO), who has worked as a psychiatrist for 18 years, administered the SCID-II-PQ and the Table 1. Sex, age, duration of disorder, observation period, and DSM-IV axis I diagnoses of the subjects (n = 120) Mean ± SD Range n % Sex Female Male Age (years) Female 43.5 ± Male 44.8 ± Duration of disorder (years) 7.9 ± Observation period (years) 3.0 ± Axis I disorder diagnoses Panic disorder with agoraphobia Generalized anxiety disorder Panic disorder without agoraphobia Social phobia Specific phobia 6 5 Obsessive compulsive disorder Agoraphobia without history of panic disorder 1 1 DSM-IV, Diagnostic and Statistical Manual of Mental Disorders 4th edn.

3 534 A. Osone and S. Takahashi SCID-II interview to all the patients recruited in the present study at the first and second times. He has an experience of administering the SCID-II to more than 250 patients to reach DSM-IV PD diagnosis. The advantage of evaluation by one rater is freedom from the rater variance in criteria interpretation and rater variance in the elicitation of information 6 to examine the repeatability of the instrument. In the present study, if the patients responded to the SCID-II-PQ within one criterion of the threshold for positive diagnosis, or within the criterion, the author asked all of the SCID-II questions for the section to generate accurate diagnosis. RESULTS SCID-II Personality Questionnaire In evaluating PD by the SCID-II-PQ only, schizotypal PD was not calculated because four of nine items in the schizotypal PD category are determined by the interviewer s observation; and in histrionic PD, because one of eight items is determined by the interviewer s observation, the item has a style of speech that is excessively impressionistic and lacking of in detail was excluded. Base rate, false positive rate (first time and second time), ratio of false positive rate (first time: second time), and Cohen s kappa of the sample in the SCID-II-PQ after administering the SCID-II interview (n = 120) are given in Table 2. As a result, 70.8% and 71.7% of the patients had at least one PD at the first evaluation and the second evaluation 12 months later, respectively. In the SCID-II-PQ, base rates ranged from 5.8% for histrionic PD to 53.3% for obsessive compulsive PD, and the overall base rate was 27.7%. The false positive rate, which has rarely been reported in previous studies, ranged from 35.3% for antisocial criterion C to 100% for passive aggressive PD, and the overall false positive rate was 70.8%. The false positive rate at the second evaluation ranged from 41.4% for antisocial criterion C to 100% for passive aggressive PD, and the overall false positive rate was 71.7%. The ratio of the false positive rates for the two occasions (first-time evaluation:second-time evaluation) ranged from 0.9 for depressive PD to 1.3 for histrionic PD, and the overall ratio was 1. Cohen s kappa ranged from 0.29 for paranoid PD to 0.83 for histrionic PD, and the overall kappa was Consequently, the SCID-II-PQ is constructed to be overinclusive to be used as a screening instrument, its test Table 2. Base rate, Cohen s kappa of the sample in SCID-II-PQ, false positive rate, and false positive ratio after administration of SCID-II interview (n = 120) Base rate (%) False positive rate (%) First time (1) Second time (2) Ratio (1):(2) Cohen s kappa Cluster C Avoidant Dependent Obsessive compulsive Cluster A Paranoid Schizotypal Schizoid Cluster B Histrionic Narcissistic Borderline Antisocial criterion C Not otherwise specified Passive aggressive Depressive Overall Schizotypal PD was not calculated because four of nine items are evaluated by the interviewer observation. In histrionic PD, one of eight items is determined by the interviewer s observation, the item has a style of speech that is excessively impressionistic and lacking of in detail was excluded. SCID-II, Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders Axis II Personality Disorders; PQ, personality questionnaire; PD, personality disorder.

4 Japanese SCID-II 535 retest reliability was moderately good and indicated to be useful in screening for PD. SCID-II interview Frequency of PD as determined by means of the SCID- II interviews (first time and second time), base rate, and Cohen s kappa of each categories are shown in Table 3. The overall base rate of 12 PD was 7%, and overall kappa was Because a larger sample size is needed to adequately assess the reliability, we used samples higher than 5% of the base rates. Consequently, three PD (obsessive compulsive, avoidant and schizoid) had Cohen s kappas of 0.86, 0.93 and 0.93, respectively. In the PD group under 5% in regard to base rate, the kappa ranged from 0.49 for paranoid PD to 1 for schizotypal PD, suggesting that moderate to perfect reliability was obtained in a small sample size as well. In the SCID-II interviews, which were administered after the SCID-II-PQ, 47.5% and 41.7% of the patients fulfilled the criteria for any PD at first time estimation and 12 months later, respectively. The DSM-IV Axis II diagnoses of the total 120 patients are shown in Table 4. In total, 49 (40.8%) of the 120 subjects had at least one PD, and the total number of PD was 69 according to the results of the SCID-II interview. Thirty-two patients had one PD, 15 had two PD, one patient had three PD and one patient had four PD. The mean PD number per patient was 0.58 (SD = 0.81) and the most frequently diagnosed PD were from cluster C (60.9%). That is, obsessive compulsive PD (34.8%) and avoidant PD (23.2%) became higher than a half of the total, followed by schizoid PD at 10.1%. The PD of cluster A and cluster B were found at the same rate (17.4%). DISCUSSION SCID-II Personality Questionnaire The SCID-II-PQ cannot be used as an independent diagnostic tool because it was constructed to be overinclusive to be used as a screening instrument, but it has been revealed to be useful as a time-saving instrument to evaluate PD by means of the SCID-II. A previous study using the SCID-II-PQ for DSM-III-R Swedish version reported that 73% of the subjects were diagnosed as having PD, 4 and there is no significant difference when comparing with our study (70.8% at the first evaluation, 71.7% at the second evaluation). One possible reason for the high rate of PD by using only the SCID-II-PQ is that despite the SCID-II user s guide emphasizing that The (personality) pattern is Table 3. Frequency of PD as determined by means of SCID-II interviews, base rate, and Cohen s kappa SCID-II interview PD First time % (n) Second time % (n) Base rate % Cohen s kappa Cluster C Avoidant 14.2 (17) 14.2 (17) Dependent 3.3 (4) 1.7 (2) Obsessive compulsive 25.0 (30) 20.0 (24) Cluster A Paranoid 1.7 (2) 1.7 (2) Schizotypal 3.3 (4) 3.3 (4) Schizoid 6.7 (8) 5.8 (7) Cluster B Histrionic 2.5 (3) 1.7 (2) Narcissistic 4.2 (5) 2.5 (3) Borderline 3.3 (4) 2.5 (3) Antisocial 4.2 (5) 3.3 (4) Not otherwise specified Passive aggressive Depressive 2.5 (3) 4.2 (5) Overall 5.9 (85) 5.6 (73) bold, >5% of base rate. SCID-II, Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders Axis II Personality Disorders; PD, personality disorder.

5 536 A. Osone and S. Takahashi Table 4. DSM-IV axis II diagnoses of the sample (n = 120) n (%) No PD 71 (59.2) At least one PD 49 (40.8) Number of PD 1 32 (65.3) 2 15 (30.6) 3 1 (2.0) 4 1 (2.0) Cluster C Avoidant 16 (23.2) Dependent 2 (2.9) Obsessive compulsive 24 (34.8) Subtotal 42 (60.9) Cluster A Paranoid 1 (1.4) Schizotypal 4 (5.8) Schizoid 7 (10.1) Subtotal 12 (17.4) Cluster B Histrionic 2 (2.9) Narcissistic 3 (4.3) Borderline 3 (4.3) Antisocial 4 (5.8) Subtotal 12 (17.4) Not otherwise specified Passive aggressive 0 Depressive 3 (4.3) Subtotal 3 (4.3) Total 69 DSM-IV, Diagnostic and Statistical Manual of Mental Disorders 4th edn; PD, personality disorder. stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood, the instructions of the SCID-II-PQ note that These questions are about the kind of person you generally are that is, how you have usually felt or behaved over the past several years. Reading these instructions, patients are actually likely to respond to the questions involving the period of their psychiatric disorders. Nevertheless, then the raters ask the patient I know that there have been times when you have been [Axis I symptoms]. I am not talking about those times in the SCID-II interview. This is the reason why the PD rate was higher in the SCID-II-PQ than after the SCID-II interview administered. Although overdiagnosis of PD is preferred in a screening instrument rather than underdiagnosis of PD, it should be solved in the following interview. In the SCID-II user s guide, the characteristic described in the SCID-II-PQ item should be pathological, persistent, and pervasive enough to be met or more than met. and all of the PD were diagnosed to have beginnings by early adulthood. From this point of view it is necessary to make the state/trait distinction by structured interview after the SCID-II-PQ has been administered. 11 SCID-II interview The test retest reliability coefficients are lower than joint interview values, especially when the interval between the interviews is greater than a couple of weeks in previous studies. 1 To the present authors knowledge, only one study has reported the interrater reliability of the SCID-II for DSM-IV Italian version. 7 In that study interrater reliability coefficients ranged from 0.48 to 0.98 for categorical diagnosis, but in the case of base rate higher than 5%, both interviewer and observer base rate, they ranged from 0.83 to 0.98, 7 and the result diverged over approximately the same range in the present study. These two studies had enough samples (231 in the Italian and 120 in the present study) and raters who were skilled at evaluating PD in DSM-IV. These factors may be possibilities for good reliability, although several other reasons could be considered in regard to the present study. First, all the SCID-II interviews were administered by its translator, who had read the manual repeatedly to understand the details of the instrument. The interviewers are frequently required to provide not only a standard set of questions but also additional probes to clarify answers, so training for interviews is essential, but it takes a long time to be able to read the SCID-II questions as if it were their native tongue. A large multicenter test retest reliability study reported the necessity of adequate training of their interviewers. 12 Second, the present study was conducted by one rater. Whereas there is only one source of unreliability in a joint-interview study (i.e. rater variance in criteria interpretation), there are three sources of error in a test retest study (i.e. rater variance in criteria interpretation, rater variance in the elicitation of information, and patient variance across interviewers). 6 If the test was conducted by one well-trained rater, the result would be free from these former two sources of error. The test retest reliability, in another word repeatability, was considered to have been higher for this reason. In contrast, this should have biased the results toward higher reliability, and methodological limitation remains in the present study. The third point, which the authors consider to be the most important, is that the rater should have a good rapport with patients at the time of interview because patients are liable to be defensive against having their personality evaluated. In the joint-interview study, observers (or some of the observers) usually do not have direct interaction with

6 Japanese SCID-II 537 the patients and therefore have little rapport with them. 5 Consequently, the authors consider not to administer the SCID-II at the time of first intake when the patients are usually in the acute state, and to have enough time to observe how the patients perceive and react in different situations, and gather more ancillary information such as from family members, because the test reliability is influenced by the quality of information. In fact, there were sometimes poor concordance between patients and their informants information in the present study. Many experienced psychiatrists and psychologists consider that the direct questions are only marginal for assessing PD, and listening to patients describing interpersonal interactions and observing their behavior with the interviewer is useful, 13 and PD diagnosed by (semi)structured interviews administered at a single point did not correspond well to the diagnoses of an expert clinician given an opportunity to closely observe patients over time and given access to a variety of information and sources of information. 14 The interviewers diagnosing PD with questionnaire and/or structured interview do their best to make not only reliable assessment but also valid assessment against these critical opinions. Because the presence of a comorbid PD associated with any anxiety disorder would be expected to influence the psychotherapeutic treatment of the axis I syndrome, 11 evaluation of PD in patients with anxiety disorder would be necessary. There were findings that suggest a relatively high prevalence of PD in panic patients and a possible relationship between panic disorder and the DSM-III cluster III PD diagnosed using the SCID-II for DSM- III. 15 Cluster III meant anxious or fearful group in DSM-III, which is termed cluster C in DSM-IV. In the SCID-II for DSM-III-R report, 35% of anxiety disorder patients had at least one PD, and the most commonly diagnosed PD were from cluster C, most notably avoidant and obsessive compulsive PD. 11 In the present study, 40.8% of anxiety disorder patients had at least one PD and there was no significant difference between Western and Eastern cultures in regard to the rate of PD in anxiety disorder diagnosed by the SCID-II. Avoidant PD and obsessive compulsive PD of cluster C were the most frequently diagnosed PD, and in the categorical diagnosis kappa was highest (0.93) in avoidant PD and schizoid PD in the present study. These results were also congruent with other studies, which reported that highest reliability was found for avoidant PD (kappa = 0.81) in the USA using the SCID-II for DSM-III-R to agoraphobic patients, 16 and interrater reliability was good in avoidant PD in Dutch patients, whose main axis I diagnosis was anxiety disorder using the SCID-II for DSM-III-R. 6 Consequently, most frequent and reliable diagnosis using the SCID-II in anxiety disorder patients is for avoidant PD in both Western and Eastern cultures. Moreover, there is a concordance with PD frequency measured by the SCID in another category of mental disorder. In anxious patients the frequency of PD (35%) was less prevalent than in patients with major depression (50%) in the same clinic in the USA; 11 and in the present study the frequency of PD (40.8%) in anxious patients was also less prevalent than the 59% obtained using the SCID-II for DSM-III-R in a previous study in a Japanese population. 17 A problem was revealed in a category of PD. A total of 21.7% of patients in base rate responded positive in the SCID-II-PQ on passive aggressive PD, but none of them was diagnosed after the interview, indicating that not a small number of the patients had a tendency to passive aggressive PD but they were not in the level of the disorder. Although several authors emphasize the usefulness and reliability of passive aggressive PD in DSM-IV, 18,19 yet passive aggressive PD is apparently rare on the basis of the present study, and evidence from this study is congruent with the fact that passive aggressive PD was dropped from DSM-IV and relegated to the criteria of not otherwise specified. Finally, the most difficult problem the authors encountered was the issue of the definition of personality itself, which was mentioned in part of the problems between the SCID-II-PQ and the SCID-II interview. As a definition, personality traits were stable and of long duration and for the purposes of the SCID- II in the SCID-II manual, the concept of long duration is operationalized in that the characteristic has been frequently present over a period of at least 5 years. Furthermore, there must be some evidence of traits going back as far as the patient s late teens or early 20s, although this rule has been kept in antisocial PD only. The SCID-II developers reported current and lifetime PD diagnosis separately according to the 5 year rule. 12 In the present study, authors evaluated lifetime personality because 5 years seem to be too short to think of it as a stable personality, and evaluating personality after recovery from axis I symptoms is not consistent with the definition of personality to be enduring from adolescence or early adulthood. Moreover, evaluating premorbid personality rather than postmorbid personality is more fruitful in understanding the disorders. In the present study, some patients suffering from chronic anxiety disorder reported that they were different from their usual personality (mostly changed to avoidant or dependent PD), although they were nearly recovered from their illness.

7 538 A. Osone and S. Takahashi They should have been diagnosed as cluster C if measured with 5 year rule. Some of the PD were different from each other in regard to their course; as described in DSM-IV-R, 20 antisocial PD tends to become less evident or to remit with age. In fact, the proportion of patients in antisocial criterion C in the present study (34.2%) were reduced to 5.8% in antisocial criterion A, indicating that only one-sixth of patients having conduct disorder in their childhood become antisocial people. There are still some theoretical and practical assessment issues, and an interrater reliability study is needed to further investigate the reliability of the SCID-II Japanese version. REFERENCES 1. Zimmerman M. Diagnosing personality disorders. Arch. Gen. Psychiatry 1994; 51: First MB, Gibbon M, Spitzer RL, Williams JBW, Benjamin LS. User s Guide for Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II). American Psychiatric Press, Washington, DC, Spitzer RL, Williams JBW, Gibbon M, First MB. Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II, Version 1.0. American Psychiatric Press, Washington, DC, Ekselius L, Lindström E, Von Knorring L, Bodlund O, Kullgren G. SCID-II interviews and the SCID Screen Questionnaire as diagnostic tools for personality disorders in DSM-III-R. Acta Psychiatr. Scand. 1994; 90: Arntz A, van Beijsterveldt B, Hoekstra R, Hofman A, Eussen M, Sallaerts S. The interrater reliability of a Dutch version of the Structured Clinical Interview for DSM-III-R Personality Disorders. Acta Psychiatr. Scand. 1992; 85: Dreessen L, Arntz A. Short-interval test retest interrater reliability of the Structured Clinical Interview for DSM-III-R personality disorders (SCID-II) in outpatients. J. Pers. Disord. 1998; 12: Maffei C, Fossati A, Agostoni I et al. Interrater reliability and internal consistency of the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID- II), version 2.0. J. Pers. Disord. 1997; 11: First MB, Gibbon M, Spitzer RL, Williams JBW, Benjamin LS. User s Guide for Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II). American Psychiatric Press, Washington, DC, (Japanese translation by Takahashi S, Osone A. The Japanese version of the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II). Igaku-Shoin, Tokyo 2002). 10. Cohen J. A coefficient of agreement for nominal scales. Educ. Psychol. Meas. 1960; 20: Sanderson WC, Wetzler S, Beck AT, Betz F. Prevalence of personality disorders among patients with anxiety disorders. Psychiatry Res. 1994; 51: Williams JBW, Gibbon M, First MB et al. The Structured Clinical Interview for DSM-III-R. (SCID) II: Multisite test retest reliability. Arch. Gen. Psychiatry 1992; 49: Westen D. Divergences between clinical and research methods for assessing personality disorders. Implications for research and the evolution of Axis II. Am. J. Psychiatry 1997; 154: Skodol AE, Oldham JM, Rosnick L, Kellman HD, Hyler SE. Diagnostic of DSM-III-R personality disorders: A comparison of two structured interviews. Int. J. Methods Psychiatr. Res. 1991; 1: Friedman CJ, Shear MK, Frances AF. DSM-III personality disorders in panic patients. J. Pers. Disord. 1987; 1: Renneberg B, Chambless DL, Dowdall DJ, Fauerbach JA, Gracely ED. A structured interview for DSM-III-R, Axis II, and the Millon Clinical Multiaxial Inventory: A concurrent validity study of personality disorders among outpatients. J. Pers. Disord. 1992; 6: Sato T, Sakado K, Uehara T, Sato S, Nishioka K, Kasahara Y. Personality disorder diagnoses using DSM-III-R in a Japanese clinical sample with major depression. Acta Psychiatr. Scand. 1997; 95: Wetzler S, Morey LC. Passive aggressive personality disorder: The demise of a syndrome. Psychiatry 1999; 62: Fossati A, Maffei C, Bagnato M et al. A psychometric study of DSM-IV passive aggressive (negativistic) personality disorder criteria. J. Pers. Disord. 2000; 14: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edn, revised. American Psychiatric Association, Washington, DC, 2000.