Personality Profiles and the Prediction of Categorical Personality Disorders

Personality Profiles and the Prediction of Categorical Personality Disorders Robert R. McCrae Jian Yang Paul T. Costa, Jr. Gerontology Research Center National Institute on Aging National Institutes of Health Xiaoyang Dai Shuqiao Yao Taisheng Cai Beiling Gao Clinical Psychological Research Center 2nd Affiliated Hospital Hunan Medical University Robert R. McCrae, Jian Yang (now at Centre for Addiction and Mental Health, Toronto), and Paul T. Costa, Jr., Personality, Stress and Coping Section, Gerontology Research Center, National Institute on Aging, Baltimore, Maryland; Shuqiao Yao, Xiaoyang Dai, Taisheng Cai, and Beiling Gao, Clinical Psychological Research Center, 2nd Affiliated Hospital, Hunan Medical University, Changsha, PRC. For their assistance in conducting interviews and gathering data, we thank Chengge Gao, Department of Psychiatry, 1st Affilated Hospital, Xian Medical University; Donghua Xiu and Hongge Zhand, Hunan Provincial Mental Hospital; Huikai Zhang, Mental Health Center, Huaxi Medical University; Ren Xiaopeng, Clinical Psychological Research Center, 2nd Affiliated Hospital, Hunan Medical University; Runde Pan and Tianwei Pan, Guangxi Longquanshan Hospital; Shumao Ji and Zanli Wang, Xian Mental Health Center; Xiaochun Sheng and Xiaolin Liu, Wuhan Mental Health Center; Xiaonian Journal of Personality 69:2, April 2001.

156 McCrae et al. ABSTRACT Personality disorders (PDs) are usually construed as psychiatric categories characterized by a unique configuration of traits and behaviors. To generate clinical hypotheses from normal personality trait scores, profile agreement statistics can be calculated using a prototypical personality profile for each PD. Multimethod data from 1,909 psychiatric patients in the People s Republic of China were used to examine the accuracy of such hypotheses in the Interpretive Report of the Revised NEO Personality Inventory. Profile agreement indices from both self-reports and spouse ratings were significantly related to PD symptom scores derived from questionnaires and clinical interviews. However, accuracy of diagnostic classification was only modest to moderate, probably because PDs are not discrete categorical entities. Together with other literature, these data suggest that the current categorical system should be replaced by a more comprehensive system of personality traits and personality-related problems. Personality disorders (PDs) are apt to provoke powerfully ambivalent feelings in personality psychologists. On the one hand, the system enshrined in DSM-IV (American Psychiatric Association, 1994) has so many well-known problems that its scientific tenability is seriously in doubt. Clark, Livesley, and Morey (1997) argued that empirical research fundamentally challenges the theoretical model on which the current categorical system of personality disorder classification is based (p. 205), and Westen and Shedler (1999) asserted that attempts to fix the system have truly satisfied neither researchers nor clinicians, including members of the DSM-IV task force itself (p. 273). On the other hand, the categorical system of personality disorders is enshrined in the DSM-IV, and, until DSM-IV is replaced, it will remain the official language in which personality pathology is described and a focus of attention for clinical psychologists and psychiatrists. Researchers Luo, Department of Psychiatry, 1st Affilated Hospital, Hubei Medical University; Yiping Yu and Xiaoling Shen, Shanghai Mental Health Center; Yunping Yang, Zhenkang Jiang, and Tao Xi, Beijing Andi Hospital; Yuping Ning, Guangzhou Mental Hospital; Zhenzhu Song and Jing Li, Qiqihar 1st Neuropsychiatric Hospital; and Zhian Jiao, Shangdong Provincial Mental Health Center. We acknowledge the contribution of Richard M. Nixon in normalizing relations with China, making this collaborative research possible. Correspondence concerning this article can be addressed to Robert R. McCrae, Box 03, NIA Gerontology Research Center, 5600 Nathan Shock Drive, Baltimore, MD 21224-6825. Electronic mail may be sent to jeffm@mvx.grc.nia.nih.gov

Personality Profiles & Personality Disorders 157 who wish to address the interface of personality and psychopathology are obliged to deal with the current system of PDs in one way or another. This article describes a new method of inferring possible DSM-IV defined disorders of personality from profiles of normal personality traits. Ultimately, however, profiles of normal traits may prove to be more clinically useful when used in conjunction with a taxonomy of personality-related problems than with the discrete disorders defined in the DSM-IV. Several researchers (Ball, Tennen, Poling, Kranzler, & Rounsaville, 1997; Blais, 1997; Dyce & O Connor, 1998) have shown that PDs, as assessed by questionnaire or by clinician ratings, are systematically related to normal personality traits, although there is rarely a one-to-one correspondence with familiar dimensions of personality. Histrionic PD, for example, is related to the Angry Hostility facet of Neuroticism, the Excitement Seeking facet of Extraversion, the Fantasy facet of Openness, and the (low) Straightforwardness facet of Agreeableness (Yang et al., in press). Personality psychologists sometimes interpret such heterogeneity as evidence that DSM-IV PDs are not internally consistent and have suggested more consistent alternative configurations of PD symptoms (Livesley, Jackson, & Schroeder, 1992). But, if abnormal personality is qualitatively different from normal personality and PDs correspond to distinct abnormal conditions, they might well combine symptoms or traits in patterns that do not appear in individuals without the disorder. Indeed, it is just such unique configurations of symptoms that allow the differential diagnosis of many medical conditions. In the present article, we test the hypothesis that a system based on profiles of personality traits may be particularly useful in identifying individuals with PDs. The traits examined are those measured by the Revised NEO Personality Inventory (NEO-PI-R; Costa & McCrae, 1992), a questionnaire assessing 30 specific traits that define the five basic factors of normal personality. CLINICAL HYPOTHESES IN THE NEO-PI-R INTERPRETIVE REPORT Given that there are demonstrated associations between personality disorder diagnoses and normal personality traits, information from a personality inventory should be useful in psychiatric diagnosis. Because traits predispose individuals to experience particular kinds of social and

158 McCrae et al. emotional problems, a NEO-PI-R profile can be a rich source of hypotheses about possible disorders. Consider the profile shown in Figure 1. Domain scores, at the left side of the profile, show high levels of Neuroticism and Conscientiousness, with low levels of Extraversion and Openness, and an extremely low level of Agreeableness. Facet scores, given toward the right of the figure, show significant variation within domains. With regard to Neuroticism facets, for example, this person is very hostile, but not at all impulse-ridden; in Extraversion facets he is cold and cheerless, but very active and assertive. These extreme scores, especially the low Agreeableness facets, suggest the possibility of several PDs, including Paranoid, Antisocial, and Narcissistic. In fact, this is a profile (based on expert ratings) for Richard M. Nixon, who would probably not have met criteria for Antisocial PD, but might well have for Paranoid PD. Beyond clinical impressions, there are a number of ways in which such predictions might be quantified. Single traits could be associated with PDs in a series of rules-of-thumb; for example, very low A1: Trust scores might suggest Paranoid PD. High-point code patterns, a system used extensively in MMPI diagnosis (Dahlstrom, 1992), might be developed. Discriminant function analyses might be used to separate those with and without specific PDs on the basis of NEO-PI-R facet scores. In designing the Interpretive Report for the NEO-PI-R (Costa, McCrae, & PAR Staff, 1994), the authors chose to use a profile similarity approach. If PDs represent integral syndromes of traits and symptoms, then each should show a characteristic personality profile, and attention to the profile as a whole ought best to identify it. Such profiles might be determined empirically by administering the NEO-PI-R to large groups of individuals with each PD; the mean profile of each PD group would serve as a prototype to which new cases could be compared. At the time the Interpretive Report was designed, however, only one such study, which provided an empirical profile for Borderline PD (Clarkin, Hull, Cantor, & Sanderson, 1993), had been published. The authors used those data as the prototype for Borderline PD, but had to turn elsewhere for the nine other PDs retained in DSM-IV. Fortunately, Widiger, Trull, Clarkin, Sanderson, and Costa (1994) had identified NEO-PI-R facets that corresponded conceptually to criteria or associated features of DSM-III-R PDs, and these hypothesized facets were used to define prototypes for each PD. (Dyce and O Connor, 1998, subsequently provided empirical support for most of these hypotheses.)

Figure 1 NEO-PI-R profile of Richard M. Nixon, based on combined ratings from two experts. The solid line represents Nixon s profile; the dotted line the prototypic profile for Paranoid PD. Nixon profile provided courtesy of S. Rubenzer, T. Faschingbauer, and D. Ones (1996). Profile form reproduced by special permission of the publisher, Psychological Assessment Resources, Inc., 16204 North Florida Avenue, Lutz, FL 33549, from the Revised NEO Personality Inventory by Paul T. Costa, Jr., and Robert R. McCrae, copyright 1978, 1985, 1989, 1992 by PAR, Inc. Further reproduction is prohibited without permission of PAR, Inc.

160 McCrae et al. To operationalize the profile agreement system, it was assumed that prototypical PD cases would score very high (T = 70) or very low (T = 30) on facets related to criteria, and high (T = 60) or low (T =40) on facets related to associated features of each PD. The dotted line in Figure 1 shows the prototypical pattern for Paranoid PD, characterized by such traits as very high N2: Angry Hostility, and very low A2: Straightforwardness. Visually, it appears that Nixon s profile strongly resembles the Paranoid prototype. That impression can be quantified by calculation of the coefficient of profile agreement, r pa (McCrae, 1993; McCrae, Stone, Fagan, & Costa, 1998), across the 11 facets that are relevant to the Paranoid PD. This coefficient takes into account both the distance between corresponding elements on two profiles and their extremeness, and has been shown to be more sensitive than Cattell s (1949) coefficient of pattern similarity to agreement between knowledgeable raters. Because r pa depends upon extremeness of values, it can only be assessed with respect to a fixed distribution of scores. For the Interpretive Report, combined-sex adult norms are used. In Figure 1, the PD profile agreement coefficient, r pa, is.90, a very high value. At least in this case study, the profile similarity method seems to do an excellent job of identifying an individual in whom most of us would recognize many of the signs of Paranoid PD. In practice, r pa sas large as.90 are infrequent; if they are to be meaningfully used as a source of clinical hypotheses, lower cut-off scores are probably needed. For the NEO-PI-R Interpretive Report, the choice of cut-off scores was based on the distribution of values in the normative sample (N = 1,000; Costa & McCrae, 1992). 1 The relation between personality traits and the problems in living that define PDs is probabilistic; for example, individuals low in E2: 1. In DSM-III-R only qualitative information on prevalence was provided for most disorders. Paranoid and Schizoid PDs were said to be uncommon, whereas Schizotypal and Antisocial PDs had an estimated prevalence of about 3% (for males) in the general population. All the other PDs were characterized as common. For the Interpretive Report, cut-off scores for Paranoid and Schizoid PD were therefore set at the 99th percentile, for Schizotypal and Antisocial at the 95th percentile, and for the other, common PDs at the 90th percentile. In the normative sample, 99% of men and women had r pa s of less than.76 when compared to the Paranoid prototype, so Nixon s.90 is well beyond the cut-off score. (In the DSM-IV, numerical prevalence estimates are provided for most PDs, and all fall within the range from 0.5% to 3.0% in the general population.)

Personality Profiles & Personality Disorders 161 Gregariousness may have a Schizoid PD, but most do not. However, it seems highly unlikely that someone who is high in Gregariousness would meet criteria for Schizoid PD. In many cases, personality profiles are most useful in ruling out possible PDs. In the NEO-PI-R Interpretive Report, each r pa is compared to the value in the normative sample; values below the 50th percentile are considered contraindicative of the PD. The Interpretive Report is intended for use only in clinical settings; it offers clinical hypotheses, explains the rationale behind them, and calls attention to the specific traits that may be problematic. It must be stressed that the interpretations are merely hypotheses and that any diagnoses should be based on all available information and the best judgment of the clinician. PERSONALITY AND PERSONALITY DISORDERS IN CHINA To evaluate the utility of this profile agreement system, it is necessary to have independent PD diagnoses on a large sample of individuals for whom NEO-PI-R scores are available, and such samples are rare. With a base-rate of 3% or less for PDs in normal samples (American Psychiatric Association, 1994), only clinical samples are likely to yield enough cases to make any test of the system possible, and most clinical studies are conducted on relatively small samples. However, data have recently become available from a large clinical study in the People s Republic of China (PRC); here we use these data to evaluate the clinical hypotheses from the NEO-PI-R Interpretive Report. Yang and his colleagues (Yang et al., 1999; Yang et al., in press) conducted a multicenter study of personality traits and disorders among Chinese psychiatric patients. Yang translated and adapted two personality disorder assessment instruments: the self-report PDQ-4+ Personality Questionnaire (Hyler, 1994), and the Personality Disorder Interview-IV (PDI-IV; Widiger, Mangine, Corbitt, Ellis, & Thomas, 1995); he also adapted the Hong Kong Chinese translation of the NEO-PI-R (McCrae, Costa, & Yik, 1996) for use in the PRC. With the collaboration of psychiatrists and clinical psychologists at 13 centers throughout the PRC, the PDQ-4+ and the NEO-PI-R were administered to nearly 2,000 psychiatric in- and out-patients. Clinical interviews were conducted with about one-quarter of these patients, and spouse ratings of personality

162 McCrae et al. were obtained for a subsample. These data provide the basis for a multimethod assessment of the profile agreement system. It is reasonable to ask whether a sample from so different a culture as China can appropriately be used to evaluate clinical hypotheses that will be employed chiefly in the United States. Studies to date suggest that it can. The structure of personality traits in China closely resembles that seen in Western cultures (McCrae, Zonderman, Costa, Bond, & Paunonen, 1996), age differences follow the same trends (Yang, McCrae, & Costa, 1998), and analyses in the present sample show that psychometric properties of the PD instruments were essentially preserved. METHOD As described elsewhere (Yang et al., 1999; Yang et al., in press), patients (N = 1,926; 54.5% male) were recruited from 13 psychiatric hospitals and clinics in 10 cities in the PRC. Inclusion criteria included age (18+), education (eighth grade), definite or probable psychiatric diagnosis, and willingness to participate voluntarily. Exclusion criteria included acute psychosis, organic brain syndrome, and recent illicit drug use. Primary diagnoses, using the Chinese Classification of Mental Disorders (Psychiatric Division, 1992), were neuroses (37.5%), major depression (19.0%), schizophrenia (17.4%), bipolar mood disorder (11.8%), substance abuse (9.0%), and other (5.3%). The PDI-IV is a semi-structured interview with questions devoted to each PD criterion; it yields either dimensional scores (representing the number of criteria met) or categorical scores. Interviewers experienced clinicians who had received 10 days of intensive training in the background and methods of this study from JY were blind to scores on the NEO-PI-R and the PDQ-4+. The full interview was given to 234 patients; because of time constraints, other patients were randomly assigned to one of three groups and completed only a portion of the interview, corresponding to one of the three PD clusters. Preliminary analyses of means and correlations suggested that PD scores from the partial interviews did not differ systematically from those obtained in the full interview; data for each PD were therefore pooled across the full and partial interview subsamples. The PDQ-4+ and NEO-PI-R were administered to patients individually or in groups of 2 to 10 patients. The PDQ-4+ is a 99-item, self-administered true/false questionnaire designed to yield diagnoses consistent with DSM-IV. Items correspond to individual criteria, and the instrument yields both dimensional and categorical scores. The NEO-PI-R is a 240-item questionnaire measure of personality traits. Thirty facet scales measure traits that define the five basic personality factors. Evidence on the reliability and validity of the original

Personality Profiles & Personality Disorders 163 instrument is summarized in the manual (Costa & McCrae, 1992); studies in the present sample of its internal consistency, retest reliability, factor structure, cross-observer agreement, and construct validity suggested that the Mandarin version of the NEO-PI-R is also a valid measure of traits in the five-factor model (FFM; Yang et al., 1999). Spouse ratings on the Mandarin NEO-PI-R were obtained for 160 patients, of whom 154 had complete PDQ-4+ data. In order to generate NEO-PI-R profile agreement statistics, it is necessary to convert raw scores to standard scores, using norms from a nonclinical population. Use of the American norms was problematic because metric equivalence of the English and Mandarin versions could not be assumed (McCrae, Yik, Trapnell, Bond, & Paulhus, 1998). Chinese norms were therefore used, based on data from 237 volunteers. These norms should be considered provisional because the sample is small and nonrandom, although it did resemble the patient sample in age and gender. The patient sample, as a whole, was higher in Neuroticism and lower in Extraversion and Conscientiousness than the 237 volunteers, although the differences were modest in magnitude, none exceeding one-half standard deviation. RESULTS Analyses of Self-Reported PD Symptoms Correlations (Yang et al., in press) between individual NEO-PI-R facet scales and dimensional PD scores in this sample confirmed most of the predictions of Widiger and colleagues (1994) upon which the interpretive system was based. When these hypothesized facet scales are used as the basis for profile agreement scores, the resulting r pa s are significantly related to PD continuous scores. Table 1 reports these correlations for both the PDQ-4+ and the PDI-IV. The first column shows results when r pa s from NEO-PI-R self-reports are correlated with the self-report PDQ-4+ scores; these correlations range from.23 to.60, with a median value of.41. This value is comparable to that found when self-report PD instruments are correlated with interview-based assessments of PDs in a range of clinical and nonclinical samples (median r =.39; Clark, Livesley, & Morey, 1997). In the second and third columns, cross-observer correlations are reported, with r pa s based on spouse ratings on the NEO-PI-R predicting self-reported PD symptoms, and r pa s based on self-reported NEO-PI-R predicting clinician-rated symptoms on the PDI-IV. These data clearly

164 McCrae et al. Table 1 Correlations of NEO-PI-R PD Profile Agreement (r pa ) with Continuous Scores from Two PD Instruments PDQ-4+ Scores PDI-IV Scores With self-reported With spouse rated With self-reported NEO-PI-R r pa NEO-PI-R r pa NEO-PI-R r pa Disorder (N = 1,909) (N = 154) (Ns = 317 350) Paranoid.41**.11.29** Schizoid.20**.12.16** Schizotypal.37**.27**.16** Antisocial.44**.29**.20** Borderline (empirical).60**.33**.32** Borderline (conceptual).59**.32**.34** Histrionic.44**.21**.14* Narcissistic.37**.16*.24** Avoidant.50**.35**.50** Dependent.39**.30**.36** Obsessive-Compulsive.23**.18*.16** Median.41.27.24 *p <.05; **p <.01. confirm associations between personality trait configurations and PD symptoms that cannot be attributed to shared method bias. In the NEO-PI-R Interpretive Report, the prototypic Borderline PD profile is based on empirical data (Clarkin et al., 1993). A profile agreement score based on Widiger et al. s (1994) conceptual hypotheses can also be calculated for Borderline PD. The two r pa s are strongly correlated, r =.89, and Table 1 shows that they are equally related to PD symptoms. In all subsequent analyses, we will employ the conceptual profile so that results for Borderline PD can be compared directly to all other PDs. In practice, the continuous scores on which Table 1 is based are not used; instead, the clinician is called upon to make a categorical judgment of whether the patient does or does not have a particular PD, and that decision is based on the number of criteria met; for example, a diagnosis of Dependent PD is based on the presence of 5 or more of 8 criteria. If PDs are truly discrete syndromes of personality traits and behaviors, the

Personality Profiles & Personality Disorders 165 profile agreement metric should yield a bimodal distribution and may be particularly successful in identifying patients who meet these criteria. When these DSM-IV decision rules are applied to the self-reported symptoms in the PDQ-4+, a large number of patients receive diagnoses, ranging from 12.5% with Antisocial PD to 70.6% with Obsessive- Compulsive PD. These figures are exceptionally high, even in a psychiatric patient population, and suggest that the PDQ-4+ probably over-diagnoses cases. By contrast, the r pa decision rules classify from 1% (for Paranoid) to 27% (for Borderline) of the sample as possibly having a PD values more in line with DSM-IV prevalence estimates. Data for Avoidant PD can be used to illustrate how accuracy, sensitivity, and specificity are evaluated. NEO-PI-R hypotheses agree with PDQ-4+ diagnoses for 728 patients without the disorder and 395 patients with it, for a combined accuracy of 59%. However, given the base-rates from the two instruments (23% and 59%, respectively), we would expect 45% agreement simply by chance. The standardized difference between observed and expected agreement is kappa, the usual metric of categorical agreement. Kappa in this case is.25, p <.001. Because the NEO-PI-R system correctly identified 395 of the 1131 diagnosed cases, sensitivity (the true positive rate) = 395/1131 =.35. We can also calculate the specificity or true negative rate, which is 728/778 =.94. The profile agreement system often yields false negative hypotheses about Avoidant PD (as assessed by the PDQ-4+), but rarely gives false positive hypotheses. These statistics are summarized for all ten PDs in the first three columns of Table 2, which shows the accuracy of NEO-PI-R clinical hypotheses when PDQ-4+ diagnoses are used as criteria. In this very large sample, all kappas are statistically significant, but several are trivial in magnitude, and most are quite modest. This result is expectable, given the discrepancy in base-rate across the two instruments. Sensitivity of the r pa system is weak, but specificity is relatively good; few patients are hypothesized to have disorders who do not meet PDQ-4+ criteria. The Interpretive Report also indicates which PD diagnoses are contraindicated. The last three columns of Table 2 provide information on the accuracy of these predictions with respect to PDQ-4+ diagnoses. In these analyses, sensitivity and specificity refer to the accuracy with which the decision rules match a diagnosis of no PD from the PDQ-4+. On average, the rules correctly identify about half the cases who are free from each PD (median sensitivity =.49), and incorrectly rule out the

166 McCrae et al. Table 2 Categorical Agreement (kappa) Between NEO-PI-R r pa Hypotheses and PDQ-4+ Diagnoses Hypothesizing Diagnosis Hypothesizing No Diagnosis PDQ-4+ Diagnosis (Prevalence) κ Sensitivity Specificity κ Sensitivity Specificity Paranoid (44.8%).02.02 1.00.28.54.75 Schizoid (33.2%).03.03.99.10.49.63 Schizotypal (35.3%).15.22.91.20.45.79 Antisocial (12.5%).19.23.93.11.42.87 Borderline (41.2%).36.41.92.35.49.89 Histrionic (34.2%).17.19.95.25.61.67 Narcissistic (36.8%).18.26.90.19.48.74 Avoidant (59.2%).25.35.94.35.55.79 Dependent (28.9%).21.31.87.18.44.81 Obsessive-Compulsive (70.6%).05.13.95.14.56.60 Median.18.23.94.20.49.77 Note. N = 1,909. All kappas are significant at p <.05. disorder in only about a quarter of the cases (median specificity =.77), well beyond chance. Analyses of Clinical Diagnoses Self-report inventories like the PDQ-4+ are widely used in research, but they are not considered the gold standard for psychiatric diagnosis. Clinical judgments, based on structured or semi-structured interviews that address the criteria for each PD, provide a more definitive standard. There are, to date, no studies comparing results from the PDI-IV with other psychiatric interviews, but joint interview reliability for a small subsample (N = 20) showed reasonable agreement for all PDs except Paranoid (Yang et al., 2000). As shown next to the diagnoses in Table 3, the prevalence of PDs by PDI-IV criteria is much lower than by PDQ-4+ criteria. The first two columns of Table 3 are included as a basis of comparison. They summarize data from the two studies in which the PDQ-4+ has been used to predict psychiatric diagnoses. Kappas are generally significant, but modest in magnitude, despite the fact that both predictor and criterion

Personality Profiles & Personality Disorders 167 Table 3 Categorical Agreement (kappa) for the Prediction of Clinical Interview Diagnoses from PDQ-4+ and NEO-PI-R r pa NEO-PI-R Profile Agreement Psychiatric Diagnosis PDQ-4+ Standard Expanded (PDI-IV Prevalence) Italy China Profile Profile Paranoid (6.5%).16*.11***.02.02 Schizoid (4.7%).09.08**.16***.13* Schizotypal (0.9%).09.02.02.02 Antisocial (8.8%).12.33***.13*.16** Borderline (6.9%).28*.11**.16***.14** Histrionic (3.8%).19*.03.02.02 Narcissistic (8.1%).28*.11**.11*.17*** Avoidant (24.0%).15*.21***.49***.51*** Dependent (10.6%).24*.24***.26***.27*** Obsessive-Compulsive (19.8%).09*.08**.12*.12* Median.16.11.13.14 Note. Italian kappas are taken from Fossati et al. (1998), who used the Structured Clinical Interview for DSM-IV Axis II Personality Disorders, Version 2.0 (First, Spitzer, Gibbon, Williams, & Benjamin, 1994) for criterion diagnoses; kappas from China are taken from Yang et al. (2000). Ns = 317 350. *p <.05; **p <.01; ***p <.001. were designed to assess identical sets of PD symptoms. These data provide a baseline for evaluating the accuracy of the profile agreement approach. The third column reports kappas for the clinical hypotheses of the NEO-PI-R Interpretive Report. Prediction of seven of the ten diagnoses exceeds chance, and, of the three PDs in which kappa is not significant, psychiatric diagnosis was unreliable for Paranoid PD, and Schizotypal PD was so rare (diagnosed in only 3 patients) that prediction cannot be meaningfully assessed. On the one hand, the profile agreement system of the NEO-PI-R Interpretive Report apparently works about as well as the PDQ-4+, an instrument designed specifically to measure PD symptoms (median kappas =.13 vs..11). On the other hand, prediction of clinical diagnoses is low for most PDs, with sensitivities (not shown in Table 3) ranging

168 McCrae et al. from.00 to.62 (median =.19). Specificity, however, is high, ranging from.79 to.99 (median =.91). Supplementary Analyses It is possible that accuracy could be improved if different cut-off scores were chosen. Analyses showed that, predictably, sensitivity was increased and specificity decreased when lower cut-off scores were used, but kappas did not increase. Another possible way to improve accuracy would be to change the profile elements. An examination of correlations between NEO-PI-R facets and PDQ-4+ PD scores (Yang et al., in press) shows that there are a number of significant correlations that were not hypothesized by Widiger et al. (1994). For example, Narcissistic PD continuous scores were correlated with N1: Anxiety, N5: Impulsiveness, E5: Excitement Seeking, O3: Feelings, A1: Trust, and A4: Compliance, although none of those associations had been hypothesized. An expanded PD prototype profile was therefore created by adding all facets that correlated with the PD at.20 or higher. These new profile elements were treated as associated features and given T-scores of 40 or 60. The changes were not trivial: On average, 5.6 facets were added to each PD profile prototype. Note that these new facets were chosen on the basis of correlations with the PDQ-4+, whereas the expanded profile is tested against PDI-IV diagnoses; in this respect, the analyses can be considered cross-validations. As the last column of Table 3 shows, the addition of these profile elements had little effect on overall agreement. It seems likely that this is due to the fact that the new facets were substantially correlated with the facets already chosen for each profile, and thus contributed little additional variance. Perhaps what is needed is additional information that goes beyond the normal traits assessed by the NEO-PI-R. This argument has been made by several authors (e.g., Reynolds & Clark, this issue), and suggests that scales from a clinical instrument like the PDQ-4+ might add substantially to the predictive power of a NEO-PI-R profile. A full test of that hypothesis would require data on both the PDQ-4+ and the NEO-PI-R in the normative sample in order to establish cut-off scores, and those data are not available. As a preliminary test, we conducted multiple regressions predicting each categorical PDI-IV diagnosis from the relevant r pa and PDQ-4+ scale. In every case, the PDQ-4+ scale explained additional variance (p <.05), and it added a substantial 18% of the

Personality Profiles & Personality Disorders 169 variance to the prediction of Antisocial PD. For all the other PDs, however, the contribution was modest, ranging from 1% to 5%. 2 DISCUSSION From Pseudo-Categories to a Taxonomy of Trait-Related Problems The availability of a large clinical sample made it possible to evaluate empirically the profile agreement system used in the NEO-PI-R Interpretive Report to suggest clinical hypotheses about the presence or absence of PDs. The system worked reasonably well, showing significant associations with both self-reported and clinician-rated PD symptoms. Using the standard cut-off scores, the profile agreement system predicted PD diagnoses about as well as did the PDQ-4+, an instrument designed specifically to assess PDs. The NEO-PI-R system was effective both in detecting and in ruling out possible PD diagnoses. Yet, from an effect-size perspective, results were weak to modest for most PDs. The standard NEO-PI-R system had good levels of specificity, but generally low sensitivity. Lowering cut-off scores increased sensitivity and decreased specificity, but did little to improve overall accuracy. Adding previously unhypothesized facets to the NEO-PI-R PD prototype profiles made little difference. Preliminary analyses suggested that diagnostic accuracy might be slightly improved by adding PDQ-4+ scales to the profile. But, we believe none of these strategies is ever likely to yield high diagnostic accuracy because PDs do not correspond to discrete psychiatric entities. Clark, Livesley, and Morey (1997) noted that psychiatrists using different interviews show low agreement: They identify different groups of people as having the PD diagnosis. The clinical ratings that are used as criteria for evaluating predictive accuracy are, thus, inherently unpredictable. 2. Spouse ratings provide an alternative to self-reports that might agree more closely with clinical diagnoses. We had too few cases to predict clinical diagnoses meaningfully, but some indication of what a larger study might show can be glimpsed by examining correlations between spouse-based r pa s and symptom counts from the PDI-IV. These correlations ranged from.14 to.47, and although only three were significant in this small sample (N = 24), the median correlation of.37 is larger than that shown for self-reports in Table 1. Certainly a test of this hypothesis in a larger sample would be worthwhile.

170 McCrae et al. Low kappas by themselves would not justify the conclusion that PD categories are suspect. After all, mental status examinations are only weakly diagnostic of Alzheimer s disease in its early stages, and medical screening instruments such as the ELISA test for HIV infection often yield many false positives. But, no one doubts the existence of Alzheimer s disease or AIDS because these are relentlessly progressive disorders that ultimately make themselves known though a variety of converging indicators (Jeffries, 1996). Such is not the case for PDs. There are no alternative assays to confirm a clinician s PD diagnosis, and, despite the presumption that they are lifelong disorders, longitudinal stability of diagnostic status is weak (Grilo & McGlashan, 1999; Shea et al., 1999). Over time, the presence of a PD usually becomes less rather than more clear. Using an instrument like the PDQ-4+ or the NEO-PI-R to identify individuals likely to receive a PD diagnosis from a psychiatrist or clinical psychologist is, thus, in some respects a fool s errand. The language of true positives and true negatives is simply not appropriate unless discrete entities exist, and there is little justification for assuming that PDs are categorical entities (Trull, Widiger, & Guthrie, 1990). If they were, the profile approach used here should have been much more effective a conclusion also reached by Morey, Gunderson, Quigley, and Lyons (2000), who found no evidence of trait interactions in predicting PDs. Predicting Personality-Related Problems If PD criteria are not symptoms of a discrete disorder, what are they? We believe they should be regarded as examples of significant problems in living of which any clinician needs to be aware. Suicidal gestures, chronic feelings of emptiness, and paranoid ideation are all real and serious problems, and they remain real and serious even if the patient lacks the two other criteria needed to warrant a diagnosis of Borderline PD. Table 1 (and much other literature, e.g., Clarkin et al., 1993) shows that these kinds of problems are more likely to occur in people with particular kinds of personality traits especially, high Neuroticism. The NEO-PI-R Interpretive Report serves a useful function when it alerts clinicians to the possibility of such problems. If the DSM PDs were construed as a systematic collection of problems in living associated with different dimensions of personality, Axis II would have considerable utility. Unfortunately, the current system has a

Personality Profiles & Personality Disorders 171 number of weaknesses even when it is regarded merely as a catalog of problems. Individual symptoms do not covary to define the ten DSM-IV PDs; instead, they define four (or sometimes five) of the basic personality factors (Clark & Livesley, 1994). Because they draw on the same five underlying personality factors, the current PDs also show substantial comorbidity (Clark et al., 1997) and, thus, redundancy. Perhaps most importantly, the problems identified by DSM-IV are only a small subset of the personality-related issues that concern patients and clinicians. In a large-scale survey of psychiatrists and psychologists, Westen and Arkowitz-Westen (1998) demonstrated that 60% of patients being treated for maladaptive personality patterns did not meet DSM-IV criteria for any PD. Problems with authority, assertiveness, intimacy, guilt, perfectionism, underachievement, and shyness were among the reasons for clinical intervention in this sample. Again, Kosek (1998) asked married couples to complete a checklist of problems they perceived in their spouses, such as is whiny, too dominant, intolerant of diversity, conceited, and lazy (Piedmont, 1998, p. 179). Summary scores from this instrument showed predicted correlations with all five NEO-PI-R domain scales, demonstrating that these, too, are personalityrelated problems. The NEO-PI-R provides information on basic personality traits that may be reflected in a wide range of maladaptive behaviors, habits, and attitudes (Harkness & McNulty, in press). To predict the pseudo-categories of Axis II in DSM-IV, facets from several domains can be configured and compared to prototypical PD profiles, but the results are only modestly successful. We hope that,by the time DSM-V appears, Axis II will include a systematic taxonomy of personality-related problems, aligned with the axes of the Five-Factor Model (cf. Widiger, Costa, & McCrae, in press). At that point, clinical hypotheses about problems in living would flow directly from personality assessment. Whether or not such changes are adopted, personality assessment will remain a central aspect of clinical practice because personality affects much more than the pathology coded on Axis II. Personality traits form an important class of predispositions for the development of some Axis I disorders, such as depression (e.g., Bagby, Joffe, Parker, Kalemba, & Harkness, 1997). The patient s style of interaction with the clinician, attitude toward particular therapeutic techniques, and dedication to the work of therapy are all influenced by enduring dispositions (Miller, 1991; Piedmont, 1998). And, personality assessment can also point to strengths

172 McCrae et al. on which clinicians might capitalize. Perhaps Richard Nixon s hostility and mistrust justify the diagnosis of Paranoid PD, but Figure 1 also shows his high assertiveness, self-discipline, and achievement striving, and even a relatively high openness to ideas. These traits help explain how someone prone to so many problems in living could twice be elected President of the United States. Personality profiles are modest predictors of categorical PDs, but they are immensely informative about people. REFERENCES American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Bagby, R. M., Joffe, R. T., Parker, J. D. A., Kalemba, V., & Harkness, K. L. (1997). Major depression and the Five-Factor Model of personality. Journal of Personality Disorders, 9, 224 234. Ball, S. A., Tennen, H., Poling, J. C., Kranzler, H. R., & Rounsaville, B. J. (1997). Personality, temperament, and character dimensions and the DMS-IV personality disorders in substance abusers. Journal of Abnormal Psychology, 4, 545 553. Blais, M. A. (1997). Clinician ratings of the Five-Factor Model of personality and the DSM-IV personality disorders. Journal of Nervous and Mental Disease, 185, 388 393. Cattell, R. B. (1949). r p and other coefficients of pattern similarity. Psychometrica, 14, 279 298. Clark, L. A., & Livesley, W. J. (1994). Two approaches to identifying dimensions of personality disorder: Convergence on the Five-Factor Model. In P. T. Costa, Jr., & T. A. Widiger (Eds.), Personality disorders and the Five-Factor Model of personality. Washington, DC: American Psychological Association. Clark, L. A., Livesley, W. J., & Morey, L. (1997). Special feature: Personality disorder assessment: The challenge of construct validity. Journal of Personality Disorders, 11, 205 231. Clarkin, J. F., Hull, J. W., Cantor, J., & Sanderson, C. (1993). Borderline personality disorder and personality traits: A comparison of SCID-II BPD and NEO-PI. Psychological Assessment, 5, 472 476. Costa, P. T., Jr., & McCrae, R. R. (1992). Revised NEO Personality Inventory (NEO-PI-R) and NEO Five-Factor Inventory (NEO-FFI) professional manual. Odessa, FL: Psychological Assessment Resources. Costa, P. T., Jr., McCrae, R. R., & PAR Staff. (1994). NEO Software System [Computer software]. Odessa, FL: Psychological Assessment Resources. Dahlstrom, W. G. (1992). Comparability of two-point high-point code patterns from original MMPI norms to MMPI-2 norms for the restandardization sample. Journal of Personality Assessment, 59, 153 164. Dyce, J. A., & O Connor, B. P. (1998). Personality disorders and the Five-Factor Model: A test of facet-level predictions. Journal of Personality Disorders, 12, 31 45.

Personality Profiles & Personality Disorders 173 First, M. B., Spitzer, R. L., Gibbon, M., Williams, J. B., & Benjamin, L. (1994). Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II) (Version 2.0). New York: New York State Psychiatric Institute. Fossati, A., Maffei, C., Bagnato, M., Donati, D., Donini, M., Fiorilli, M., Novella, L., & Ansoldi, M. (1998). Criterion validity of the Personality Diagnostic Questionnaire-4+ (PDQ-4+) in a mixed psychiatric sample. Journal of Personality Disorders, 12, 172 178. Grilo, C. M., & McGlashan, T. H. (1999). Stability and course of personality disorders. Current Opinion in Psychiatry, 12, 157 162. Harkness, A. R., & McNulty, J. L. (in press). Implications of personality individual differences science for clinical work on personality disorders. In P. T. Costa, Jr., & T. A. Widiger (Eds.), Personality disorders and the Five-Factor Model of personality (2nd ed.). Washington, DC: American Psychological Association. Hyler, S. E. (1994). PDQ-4+ Personality Questionnaire. New York: Author. Jeffries, D. J. (1996). Laboratory tests for HIV. In J. Green & A. McCreaner (Eds.), Counseling in HIV infection and AIDS (2nd ed., pp. 11 20). Cambridge, MA: Blackwell Scientific Publications. Kosek, R. B. (1998). Couples critical incidents checklist: A construct validity study. Journal of Clinical Psychology, 54, 785 794. Livesley, W. J., Jackson, D. N., & Schroeder, M. L. (1992). Factorial structure of traits delineating personality disorders in clinical and general population samples. Journal of Abnormal Psychology, 101, 432 440. McCrae, R. R. (1993). Agreement of personality profiles across observers. Multivariate Behavioral Research, 28, 13 28. McCrae, R. R., Costa, P. T., Jr., & Yik, M. S. M. (1996). Universal aspects of Chinese personality structure. In M. H. Bond (Ed.), The handbook of Chinese psychology (pp. 189 207). Hong Kong: Oxford University Press. McCrae, R. R., Stone, S. V., Fagan, P. J., & Costa, P. T., Jr. (1998). Identifying causes of disagreement between self-reports and spouse ratings of personality. Journal of Personality, 66, 285 313. McCrae, R. R., Yik, M. S. M., Trapnell, P. D., Bond, M. H., & Paulhus, D. L. (1998). Interpreting personality profiles across cultures: Bilingual, acculturation, and peer rating studies of Chinese undergraduates. Journal of Personality and Social Psychology, 74, 1041 1055. McCrae, R. R., Zonderman, A. B., Costa, P. T., Jr., Bond, M. H., & Paunonen, S. V. (1996). Evaluating replicability of factors in the Revised NEO Personality Inventory: Confirmatory factor analysis versus Procrustes rotation. Journal of Personality and Social Psychology, 70, 552 566. Miller, T. (1991). The psychotherapeutic utility of the Five-Factor Model of personality: A clinician s experience. Journal of Personality Assessment, 57, 415 433. Morey, L. C., Gunderson, J., Quigley, B. D., & Lyons, M. (2000). Dimensions and categories: The Big Five factors and the DSM Personality Disorders. Assessment, 7, 203 216. Piedmont, R. L. (1998). The Revised NEO Personality Inventory: Clinical and research applications. New York: Plenum.

174 McCrae et al. Psychiatric Division, Chinese Medical Association. (1992). Chinese classification and diagnostic criteria for mental disorders (2nd ed., rev.). Changsha, Hunan, PRC: Author. Rubenzer, S., Faschingbauer, T., & Ones, D. (1996, August). Personality and the presidency: A scientific inquiry. Symposium presented at the 104th Annual Convention of the American Psychological Association, Toronto. Shea, M. T., Stout, R., Dolan, R., Skodol, A. E. II, Morey, L. C., Zanarini, M. C., & Sanislow, C. A. (1999, May). Short-term stability of personality disorder diagnoses. In Short-term stability of personality disorders. Symposium conducted at the Annual Meeting of the American Psychiatric Association, Washington, DC. Trull, T. J., Widiger, T. A., & Guthrie, P. (1990). The categorical versus dimensional status of borderline personality disorder. Journal of Abnormal Psychology, 99, 40 48. Westen, D., & Arkowitz-Westen, L. (1998). Limitations of Axis II in diagnosing personality pathology in clinical practice. American Journal of Psychiatry, 155, 1767 1771. Westen, D., & Shedler, J. (1999). Revising and assessing Axis II, Part II: Toward an empirically based and clinically useful classification of personality disorders. American Journal of Psychiatry, 156, 273 285. Widiger, T. A., Costa, P. T., Jr., & McCrae, R. R. (in press). Proposal for Axis II: Diagnosing personality disorders using the Five-Factor Model. In P. T. Costa, Jr., & T. A. Widiger (Eds.), Personality disorders and the Five-Factor Model of personality (2nd ed.). Washington, DC: American Psychological Association. Widiger, T. A., Mangine, S., Corbitt, E. M., Ellis, C. G., & Thomas, G. V. (1995). Personality Disorder Interview IV: A semi-structured interview for the assessment of personality disorders. Odessa, FL: Psychological Assessment Resources. Widiger, T. A., Trull, T. J., Clarkin, J. F., Sanderson, C., & Costa, P. T., Jr. (1994). A description of the DSM-III-R and DSM-IV personality disorders with the Five-Factor Model of personality. In P. T. Costa, Jr., & T. A. Widiger (Eds.), Personality disorders and the Five-Factor Model of personality (pp. 41 56). Washington, DC: American Psychological Association. Yang, J., Dai, X, Yao, S., Cai, T., Gao, B., McCrae, R. R., & Costa, P. T., Jr. (in press). Personality disorders and the Five-Factor Model of personality in Chinese psychiatric patients. In P. T. Costa, Jr., & T. A. Widiger (Eds.), Personality disorders and the Five-Factor Model of personality (2nd ed.). Washington, DC: American Psychological Association. Yang, J., McCrae, R. R., & Costa, P. T., Jr. (1998). Adult age differences in personality traits in the United States and the People s Republic of China. Journal of Gerontology: Psychological Sciences, 53B, P375 P383. Yang, J., McCrae, R. R., Costa, P. T., Jr., Dai, X., Yao, S., Cai, T., & Gao, B. (1999). Cross-cultural personality assessment in psychiatric populations: The NEO-PI-R in the People s Republic of China. Psychological Assessment, 11, 359 368. Yang, J., McCrae, R. R., Costa, P. T., Jr., Yao, S., Dai, X., Cai, T., & Gao, B. (2000). The cross-cultural generalizability of Axis-II constructs: An evaluation of two personality disorder assessment instruments in the People s Republic of China. Journal of Personality Disorders, 14, 249 263.