Psychiatry Research 215 (2014) 683–686

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Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Neither too much, nor too little. The dilemma of identifying personality
disorders in adolescents patients with self-reports
Ernesto Magallón-Neri a,b,n, José Eugenio De la Fuente a, Gloria Canalda a, Maria Forns b,
Raquel García a, Esther González a, Anais Lara a, Josefina Castro-Fornieles a,c,d
a
Department of Child and Adolescent Psychiatry and Psychology, SGR-1119, Institute of Neurosciences, Hospital Clinic Universitari of Barcelona,
and Biomedical Research Center in Mental Health Network CIBERSAM, Barcelona, Spain
b
Department of Personality, Assessment and Psychological Treatment, Faculty of Psychology, University of Barcelona, Spain
c
IDIBAPS (Institut d0 Investigacions Biomediques August Pi Sunyer), Barcelona, Spain
d
Department of Psychiatry and Clinical Psychobiology, Universitat de Barcelona, Spain

art ic l e i nf o a b s t r a c t

Article history: The study aimed to compare methods of identification of Personality Disorders (PD) in adolescent
Received 2 January 2013 patients with psychiatric disorders. A sample of 120 Spanish adolescents with clinical disorders was
Received in revised form assessed using the International Personality Disorder Examination (IPDE) interview, its Screening
19 August 2013
Questionnaires (IPDE-SQ) comprising the ICD-10 and DSM-IV modules, and also the Temperament
Accepted 15 December 2013
Available online 22 December 2013
Character Inventory (TCI) to identify risk of PD. The IPDE-SQ identified a risk of PD around 92–97% of the
sample; 61.7% when adjusting the stricter cut-off points. The TCI showed a PD risk of 20%, whereas the
Keywords: prevalence of PD identified by the IPDE clinical interview was around 36–38%. The differences between
Self-report the IPDE, IPDE-SQ and TCI were significant, and a low agreement among instruments was obtained. Large
Personality disorders
discrepancy between self-report instruments in identifying PD with regard to the clinical interview raises
Adolescents
several questions concerning the use of these instruments in clinical settings on adolescents with
Concordance (measurement)
Personality psychiatric disorders.
& 2013 Elsevier Ireland Ltd. All rights reserved.

1. Introduction Montalvo and Echeburúa, 2006) must be addressed in the assess-

The identification of pathological personality is a widely
studied field, in which increasingly sophisticated assessment
instruments are being designed (Clark, 2007). However, many of
these instruments show low levels of agreement in the identifica-
tion of the same construct and so the field is still in development
(Egan et al., 2003; Gárriz and Gutiérrez, 2009; Krueger et al., 2011;
Nestadt et al., 2012; Schneider et al., 2004; Zimmerman and
Coryell, 1990). In clinical practice the assessment of personality
pathology is broadly used self-reports or screening questionnaires
(Blasco-Fontecilla et al., 2010; Germans et al., 2012; Morse and
Pilkonis, 2007; Siefert, 2010). This practice saves consultation time,
but the accuracy of the assessments is sometimes insufficient
(Huprich et al., 2011; Lenzenweger, 2006; Fernández-Montalvo
and Echeburúa, 2006; Slade et al., 1998).
Self-reports and interviews tend to be vulnerable to manipula-
tion by patients. The risk of either simulation (increasing symp-
toms) or dissimulation (minimizing symptoms) (Fernández-
n existence of pathological personality and personality disorders
Corresponding author at: University of Barcelona, Department of Personality
Assessment and Psychological Treatment, C/Pg. Vall d Hebron, 171-08035, Barce-
lona, Spain. Tel.: + 34 93 403 11 54; fax: + 34 934 021 362.
ment of reliable profiles of personality. However, in clinical
interviews there are more chances to elucidate between psycho-
pathological features associated with other Axis I disorders and
their distinguishing from those ones that could certainly be
considered personality pathological features (Huprich et al., 2011;
Chanen et al., 2004; Fernández-Montalvo and Echeburúa, 2006).
However, these interviews require prior training, considerable
clinical experience and a profound understanding of psychopathol-
ogy (Lenzenweger, 2006; Siefert, 2010).
The appropriateness of evaluating PD in adolescents is itself
contested, because the risk of the stigma effect and the fact
that in a considerable proportion of children and adolescents
these symptoms may remit over time (Bornovalova et al., 2009;
Freeman and Reinecke, 2007; Widiger, 2005). Assessment at an
early age poses its own particular problems because the frontiers
of psychopathology are very diffuse, and comorbidity is frequent
(Chanen et al., 2004; Clark, 2007; Cheng et al., 2011; Feenstra
et al., 2011; Magallón-Neri et al., 2012; Shiner and Caspi, 2003).
Although, a great amount of empirical research ratifies the
in adolescence (Chanen et al., 2004; Feenstra et al., 2011; Westen
et al., 2003).

0165-1781/$ - see front matter & 2013 Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.psychres.2013.12.020
684 E. Magallón-Neri et al. / Psychiatry Research 215 (2014) 683–686

This study aims to compare two self-report instruments, the
International Personality Disorder Examination Screening Ques-
tionnaire (IPDE-SQ) and the Temperament Character Inventory
(TCI), with a semi-structured clinical interview (IPDE) for
identifying overall proportions of probable personality disor-
ders in a sample of adolescents treated at a public mental health
service.
2.3. Procedure
Axis I diagnoses were made by the clinical team (psychologists and psychia-
trists) in our department in accordance with DSM-IV and ICD-10 criteria. The study
was explained in detail to parents and participants who gave written, informed
consent before entering the study, and the evaluation protocol was reviewed and
approved by the hospital ethics committee. Ethics committee0 s reference
number: 5098.

2.4. Data analysis

2. Method
2.1. Participants
The adolescents recruited met the following criteria: age from 15 to 18 years
old, referred to the Department of Child and Adolescent Psychiatry and Clinical
Psychology at the Hospital Clinic of Barcelona. Patients with acute psychopathology
(severe depression, or acute psychotic state) and mental retardation that might
preclude the application of the tests were excluded. A total of 184 participants met
the inclusion criteria, though 39 refused to participate. The remaining 145 were
evaluated; 25 did not complete the assessment. This study presents the results of
the subjects (N ¼ 120) who completed both self-reports, the IPDE-SQ and the TCI,
and the IPDE clinical interview.
2.2. Instruments
International Personality Disorder Examination (IPDE): a semi-structured
clinical interview for personality disorders developed by Loranger et al. (1994)
and the World Health Organization. The interview has two modules of assessment,
based on the criteria of the International Classification of Diseases Tenth Revision
(ICD-10) with 67 semi-structured questions and the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition (DSM-IV) with 99 semi-structured
questions. This instrument shows good psychometric properties (Loranger et al.,
1997).
IPDE Screening Questionnaire (IPDE-SQ): a screening instrument developed for
the detection of the risk or probability of personality disorders from the ICD-10
(True/False; 59 items) and DSM-IV (True/False; 77 items) taxonomies. Both versions
assess a number of criteria associated with each of the PDs. The standard Spanish
guidelines set a cut-off score of three or more positive items for detailed revision of
the risk of each PD using the interview IPDE (López-Ibor et al., 1996, p. 73). Initially
this cutoff point was considered as this study0 s baseline. Moreover, due to the
absence of adjusted cut-off points for adolescent population, we decided to use
another stricter cutoff points coming from Blasco-Fontecilla et al. (2010) study,
which was performed with a Spanish adult clinical sample, recruited by emergency
services by using the IPDE-SQ module DSM-IV. The adjusted cuttoff points for each
PD were: five to Paranoid, five to Schizoid, seven to Schizotypal, five to Antisocial,
seven to Borderline, six to Histrionic, seven to Narcissistic, five to Avoidant, six to
Dependent and six in Obssessive–Compulsive.
Temperament and Character Inventory (TCI): contains 240 items that assesses
seven dimensions: four temperament (Novelty Seeking, Harm Avoidance, Reward
Dependence and Persistence) and three character (Self-directedness, Cooperation
and Self-transcendence) (Cloninger et al., 1994). This model integrates concepts of
neurobiology and behavior genetics with features derived from socio-cultural
learning (Svrakic et al., 2002). Profiles with low scores (Percentile r 33) on the
traits of Self-directedness and Cooperation have been studied and validated as
indicator traits of possible PD (Cloninger et al., 1994).
Sensitiviy (SEN), specificity (SPE), rate of False Positives (FP) and False Negatives
(FN) were calculated. Frequencies, contrast of proportions for qualitative variables,
and calculation of kappa indexes were used to assess the agreement of risk
proportions for PD between instruments. Statistical analysis of data was performed
using SPSS 16.0.
3. Results
The sample consisted of 120 participants. Most participants
were female (86.7%). Age ranged between 15 and 18 years old
(mean age¼15.88, SD ¼0.90) and most patients had one or two
Axis I diagnoses (mean ¼1.55, SD ¼0.89). The frequency of Axis I
clinical disorders are: four (3.3%) with psychotic disorders, 10
(8.3%) with substance use disorders, 17 (14.2%) anxious disorders,
17 (14.2%) with adjustment disorders, 20 (16.7%) with externaliz-
ing disorders, 21 (17.5%) with affective disorders, 88 (72.5%) with
eating disorders, and 15 (12.5%) patients with other Axis I
disorders. The high percentage of patients with eating disorders;
is because the Department of Child and Adolescents Psychiatry
and Clinical Psychology of the Hospital Clinic of Barcelona is a
national reference center for this type of pathology.
The risk proportions for PD between IPDE-SQ, TCI and the IPDE
interview are shown in Table 1. Significant differences neither
were found in PD proportions between sexes nor in the global
proportion of PDs comparing those participants who had an eating
disorder with regard to those who had no eating disorder. The
overall recorded proportions varied greatly between instruments:
while the IPDE-SQ module ICD-10 identified a risk of PD in 91.7%
(95%CI 0.85–0.96) with a SEN (0.98) and SPE (0.12) with a 54% of
FP and 1% of FN regarding to IPDE interview ICD-10 module; and
the module DSM-IV a risk in 96.7% (95%CI 0.92–0.99) with a SEN
(1.00) and SPE (0.05) with a 61% of FP and 0% of FN regarding to
IPDE interview DSM-IV module. The TCI identified a risk in only
20% (95%CI 0.13–0.28), with a SEN (0.33) and SPE (0.88) with a 8%
of FP and 26% of FN regarding to IPDE interview ICD-10 module
and a SEN (0.33) and SPE (0.87) with a 8% of FP and 24% of FN
regarding to IPDE interview DSM-IV module. Then, we applied the
adjusted cutoff points proposed by Blasco-Fontecilla et al. (2010)

Table 1
Contrasted proportions of personality disorders identified by IPDE-SQ, TCI, and IPDE interview.

Instruments contrasted % PD z-score Agreement Kappa (95% CI)

n (%) Kappa

IPDE-SQ ICD-10 vs. TCI 91.7 vs. 20.0 10.11nnn 34 (28.3) 0.04 (0.01–0.07)
IPDE-SQ DSM-IV vs. TCI 96.7 vs. 20.0 11.04nnn 28 (23.3) 0.02 (0.00–0.03)
IPDE-SQ SBF vs. TCI 61.7 vs. 20.0 5.69nnn 62 (51.6) 0.15n (0.04–0.26)
IPDE-I ICD-10 vs. IPDE-SQ ICD-10 38.3 vs. 91.7  5.97nnn 54 (45.0) 0.08 (0.01–0.15)
IPDE-I ICD-10 vs. TCI 38.3 vs. 20.0 2.71nn 80 (66.7) 0.23nn (0.06–0.39)
IPDE-I DSM-IV vs. IPDE-SQ DSM-IV 35.8 vs. 96.7  6.82nnn 47 (39.2) 0.04 (0.00–0.07)
IPDE-I DSM-IV vs. TCI 35.8 vs. 20.0 2.37nn 81 (67.5) 0.22nn (0.04–0.39)
IPDE-I DSM-IV vs. IPDE-SQ SBF 35.8 vs. 61.7  2.96nn 83 (69.2) 0.42nnn (0.29–0.56)

PD ¼Personality Disorder; IPDE-I ¼ International Personality Disorder Examination Interview; IPDE-SQ ¼ IPDE Screening Questionnaire; TCI ¼Temperament Character
Inventory; CI ¼Confidence interval; SBF ¼ Using adjusted cut-off points of Blasco-Fontecilla et al. (2010) study for IPDE-SQ DSM-IV criteria.
n
po 0.050.
nn
p o0.010.
nnn
p o0.001.
 E. Magallón-Neri et al. / Psychiatry Research 215 (2014) 683–686
used in adult clinical patients for the DSM-IV module of the IPDE-
SQ, finding that 61.7% (95%CI 0.52–0.70), with a SEN (0.93) and SPE
(0.55) with a 28% of FP and 3% of FN regarding to IPDE interview
DSM-IV module. On the other hand, the IPDE interview found an
overall prevalence of PD of 38.3% (95%CI 0.30–0.48) with the ICD-
10 module and 35.8% (95%CI 0.27–0.45) with the DSM-IV module.
In both screening instruments IPDE-SQ (ICD-10 and DSM-IV), the
sensitivity was high with low specificity. In contrast, in the TCI it is
presented high specificity and low sensitivity related to the IPDE
interview. When the screening test for DSM-IV module was
adjusted, the high sensitivity was maintained and specificity
increased, indicating the best option, but the false positive rate
was relatively high. The rates of PD among IPDE interview, IPDE-
SQ and TCI showed a poor-moderate agreement (23–69%) and
concordance (mean kappa between 0.02 and 0.42).
4. Discussion
This study found strong inconsistencies in assessing PDs using
different methods of evaluation. Our findings add to the debate on
the exclusive use of self-reports for assessing PDs (Huprich et al.,
2011), and highlight concerns already voiced in previous studies
(Egan et al., 2003; Fernández-Montalvo and Echeburúa, 2006;
Nestadt et al., 2012; Zimmerman and Coryell, 1990).
The large discrepancy found between the IPDE-SQ and the TCI
regard to IPDE interview in this study may be due to differential
structural aspects. While the IPDE-SQ expresses the DSM-IV and
ICD-10 criteria of each PD categorically with a speed screen
(Blasco-Fontecilla et al., 2010; Lenzenweger, 2006) the TCI focuses
on a dimensional assessment of temperament traits and character
(Cloninger et al., 1994). On the other hand, the clinical interview
IPDE gives the possibility to investigate further, and to make a
differential diagnosis based on information obtained from the
patient getting closer to complex nature of the personality
pathological features, and not just simply report on the existence
of clinical symptoms, that patient may confuse and that in turn
may confuse the patient with some other type of comorbid
psychiatric manifestations (Huprich et al., 2011; Loranger et al.,
1997).
The identification rate for PD with the IPDE-SQ were higher
than those identified by this instrument in the adult population
(Blasco-Fontecilla et al., 2010; Cheng et al., 2011; Huang et al.,
2009) and twice than identified in adolescent studies based on
structured interviews (Chanen et al., 2004; Feenstra et al., 2011;
Magallón-Neri et al., 2012); the prevalence of PD with the TCI was
around half that identified with a more detailed exploration based
on clinical interviews. These significant differences are less clear if
we look at other cut-off points (Blasco-Fontecilla et al., 2010) or if
we consider a broader subset of people with probable PD, rather
than those who only had clear evidence of the disorder. In either of
these nuanced situations, we are making an estimation of the risk
of probable PD, not a formal diagnosis. Even increasing the cut-offs
as Blasco-Fontecilla et al. (2010) suggested, many subjects remain
over-identified.
Regard to the TCI, perhaps the comparision with the IPDE
screening instruments and their clinical interview, were not the
most appropriate, and perhaps there should have been more
desirable comparisions with other instruments that would have
similar features such as PDQ-4 utilized in studies of Cheng et al.
(2011) or even Million (MCMI-II; Marañón et al., 2007). However,
comparision with this type of instruments in that “apparently”
saves more power comparision, because each of them identify
specific PDs and not only pathological personality traits, the level
of agreement found was moderately low (Marañón et al., 2007).
685
There are a lot of possible reasons for these discrepancies:
among these ones there are: the nature of the instruments, their
structural design and the developmental issues of age that have a
relative importance. Teenagers with clinical disturbances may be
have difficulty reaching the level of abstraction or implication
required to understand the questions, or may confuse Axis I
psychopathology with their own personality traits (Feenstra
et al., 2011). Equally, they may lack the necessary insight or have
difficulties in differentiating between what they think about
themselves and the image they feel they have to project.
The possible effect of simulation/dissimulation in adolescents
(such as in adult populations) appears to be an attempt to project
an image with others rather than an attempt to distort the results.
Given these inconsistencies, the clinician should consider in-depth
clinical assessment (applying a clinical interview such as the IPDE),
taking into account essential features such as frequency, duration,
stability and degree of involvement of the symptoms.
We advocate adjusting the IPDE-SQ cut-off points, especially in
clinical patients (Slade et al., 1998). In our group, we adjusted the
cutoff points in the case of Borderline and Impulsive PDs for
adolescents (Magallón-Neri et al., 2013), but it is necessary to
extend the research to all PDs taking into account the character-
istics of personality disorders in adolescence (Shiner and Caspi,
2003).
4.1. Strengths and limitations
The main strength of the study is the identification of the risk
of PD in a clinical sample of adolescents, comparing the individual
performance of two modules of the IPDE-SQ (ICD-10 and DSM-IV),
with the TCI, and comparing their agreement with a gold standard
(IPDE).
The study has two main limitations that should be borne in
mind in the interpretation of the results. The first is that women
with eating disorders were overrepresented in the sample; though
no significant differences were found between sexes, this pre-
dominance of women may have introduced a bias. Second, the
screening instruments were applied cross-sectionally, with the
result that we are unable to observe associations of direction, of
where pointing the trend of risk to suffer PD in this clinical
teenager sample.
4.2. Conclusions
The large discrepancy between the IPDE-SQ instruments and
TCI in identifying personality disorders with regard to the clinical
interview IPDE raises several questions concerning the use of
these instruments in adolescents with psychiatric disorders. First,
clinicians should consider the need to use different psychological
techniques and instruments to verify the discrepancies in the
identification of pathological personality features in adolescents.
Second, the use of clinical interviews allows refining the para-
meters of problem behavior under study (Frequency, Intensity,
Number, Duration and Sense) allowing a deep analysis of sympto-
matology, aspect not covered in detail in most of self-report
measures. Third, the screening are useful from the point of view
of saving clinical attention time but its use requires later an extra
exercise to precise and clarify those cases rated as positive,
verifying with the patient the discrepancies between techniques.
For these reasons, a more thorough psychiatric assessment is
needed before personality disorder can be confirmed in clinical
adolescent population.
686 E. Magallón-Neri et al. / Psychiatry Research 215 (2014) 683–686
Acknowledgments
This study was supported in part by a Grant for fellowship
research to the first author from the Commission for Universities
and Research of the Department of Innovation of the Generalitat of
Catalunya and the European Social Funds (2009 FI_EX00016), as
well as by PSI 2009.11542 from the MICIMM and FEDER Funds.
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