|Year : 2015 | Volume
| Issue : 1 | Page : 52-58
Hierarchical analysis of persian version of diagnostic assessment of personality pathology-basic questionnaire and efficiency of its factors in predicting personality disorders
Mehdi Rezaee1, Mohammad Reza Ahmadi2, Samira Goodarzi3, Hossein Shahahmadi4
1 Department of Psychology, Lorestan University, Khoramabad, Lorestan, Iran
2 Department of Psychiatrist, Behavioral Research Center, Loghman Hospital, Tehran, Iran
3 Department of Clinical Psychology, Shahed University, Tehran, Iran
4 Department of Clinical Psychology, Tehran University, Tehran, Iran
|Date of Web Publication||19-Dec-2014|
Dr. Mehdi Rezaee
Department of Psychology, Lorestan University, Khoramabad, Lorestan
Source of Support: None, Conflict of Interest: None
Objectives: Hierarchical personality models have potential efficiency to identify specific components of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) personality disorders (PDs). The purpose of this study was to investigate to factor structure of personality pathology as measured by the Diagnostic Assessment of Personality Pathology-Basic Questionnaire (DAPP-BQ), and to examine the capacity of the components of the DAP-BQ hierarchy to predict PDs symptoms. Materials and Methods: Students of Allame Tabatabii and Lorestan University (189 male, 176 female) and psychiatric outpatients of Loghman and Emam Hossein Hospitals (116 male, 159 female) were selected via convenient and voluntary sampling methods. Then completed the DAP-BQ and answer to Structured Clinical Interview for DSM-IV Axis II and Composite International Diagnostic Interview. The data were analyzed using multiple regression analysis and principal components analyses with bass-ackwards method used to investigate the hierarchical structure of the DAP-BQ. Results: Results showed that Level 5 of the hierarchy enhanced the capacity of the DAP-BQ for predicting DSM-IV PD symptoms beyond a four-factor structure, particularly for borderline PD. Conclusion: It can be concluded Level 5 represents an important level of analysis for predicting personality pathology, with an additional factor (Need for Approval) adding important information about symptoms of PD. The results from the current study may contribute to the refinement of the psychiatric nosology and assessment of personality pathology.
Keywords: Diagnostic Assessment of Personality Pathology-Basic Questionnaire, personality disorders, principal components analyses
|How to cite this article:|
Rezaee M, Ahmadi MR, Goodarzi S, Shahahmadi H. Hierarchical analysis of persian version of diagnostic assessment of personality pathology-basic questionnaire and efficiency of its factors in predicting personality disorders. Int J Educ Psychol Res 2015;1:52-8
|How to cite this URL:|
Rezaee M, Ahmadi MR, Goodarzi S, Shahahmadi H. Hierarchical analysis of persian version of diagnostic assessment of personality pathology-basic questionnaire and efficiency of its factors in predicting personality disorders. Int J Educ Psychol Res [serial online] 2015 [cited 2018 May 24];1:52-8. Available from: http://www.ijeprjournal.org/text.asp?2015/1/1/52/147470
| Introduction|| |
To assess personality disorders (PDs), Widiger and Samuel  recommend a two-step method in which first a self-report inventory use to screen for the potential presence of PDs, which is followed by the administration of a semi-structured interview to verify their presence. Such an integrative strategy, in which it is first established which PDs should be focused on, may often reduce the amount of time required to make a diagnosis, as the administration of an entire semi-structured interview can be avoided. But the predominant model of personality pathology in psychiatry and clinical psychology is the Diagnostic and Statistical Manual of Mental Disorders (DSM) Axis II PD classification system. This system, as codified in the DSM-IV-TR, uses a categorical approach to diagnosis and is composed of then ostensibly distinct disorders. The categorical model of PDs has been the subject of much criticism, including excessive diagnostic co-morbidity between disorders, diagnostic heterogeneity within disorders, inadequate symptom representation of personality pathology most generally, and arbitrary diagnostic thresholds.  These criticisms are well substantiated empirically, and in turn have prompted the development of alternative conceptualizations or approaches to understanding personality pathology. , Common among these various alternatives is the contention that a dimensional model better represents personality pathology than the current categorical system.  In the current investigation, we examine the hierarchical structure of one of these alternative models - Livesley's dimensional model of personality pathology  - and try to demonstrate its validity at various hierarchical levels. ,
Livesley et al.  delineated a dimensional model for classifying personality pathology using a two-staged procedure. In the first stage, a pool of self-report questionnaire items was generated; these items were derived from several sources, including DSM-III descriptions of PD symptoms and features, an extensive literature review of personality pathology, and clinical opinion. At the second stage, these items were subjected to factor analysis, the latent factors from which formed the foundation for the development of personality scales that form the Dimensional Assessment of Personality Pathology-Basic Questionnaire (DAPP-BQ). , The DAPP-BQ scales assess 18 lower-order dimensions of personality pathology, including affective instability, anxiousness, callousness, cognitive distortions, compulsivity (CO), conduct problems, identity problems, insecure attachment, intimacy problems, narcissism, oppositionality, rejection, restricted expression, self-harming behavior, social avoidance, stimulus seeking, submissiveness, and suspiciousness. These dimensions have been found to distinguish between samples with and without PDs, , and between samples with different PDs.  The pattern of correlations between the DAP-BQ dimensions and PD symptom counts has also been examined, the results from which are interpreted to provide support for the validity of the DAP-BQ. ,
The factor structure of the DAP-BQ has been extensively investigated. Livesley et al.  initially reported that the DAP-BQ lower order personality scales cluster into four higher-order latent factors or domains: (1) Emotional dysregulation (ED), (2) dissocial behaviour (DB) (3) inhibitedness (IN), and (4) CO. These factors have been extracted in subsequent factor analytic investigations, which have used diverse samples and different language groups. ,,,, Other investigators examining the underlying latent structure of the DAP-BQ, however, have recovered a five-factor solution ,,,,,, in which the DB domain parses into two separate domains. For example, Schroeder et al. reported two DB factors, one related primarily to high levels of extraversion and another related to low agreeableness. Goldner et al.  also recovered two dissocial factors, which they labeled as psychopathy and behavioral disturbance. But none of them have reported on the capacity of the DAP-BQ higher-order factors to predict DSM-IV PD symptom counts.
The different factor solutions of the DAP-BQ may be interpreted to reflect different levels in the hierarchical structure of personality. Using both meta-analytical and empirical data, Markon et al.  illustrated that different models of personality can be integrated into a single hierarchical structure. This paper was silent on the matter of which level of the hierarchy is ideal. The answer for this issue likely differs depending on the specific domain of interest.
Using the trait domains of the five-factor model (FFM), Tackett et al.  demonstrated that the higher-order levels of the personality hierarchy successfully differentiated individuals with and without internalizing disorders and individuals with different internalizing disorders. Based on these results, Tackett et al. revealed the potential applicability of hierarchical models to the development of a new, re-modeled psychiatric nosological system as well as to the enhancement of differential diagnosis in the current system. Again, the level of the hierarchy providing maximal explanatory power may differ for diagnostic groups as well as specific diagnoses.
In the current study, our aims were two-fold: (1) To delineate the hierarchical structure of personality pathology as measured by the DAP-BQ, and (2) to examine the capacity of the components of the DAPP-BQ hierarchy to predict PD symptoms. Given the replicability of the four-factor solution of the DAP-BQ. ,,,,,, we hypothesized that ED, DB, IN, and CO would clearly represent the four-factor solution in these analyses. Based on previous investigations. ,, We also hypothesized that higher-order components of the hierarchy would account for considerable variability in DSM-IV PD symptoms. Given the exploratory nature of our analyses, only tentative a priori hypotheses were made concerning the nature of the components beyond Level 4 of the hierarchy. Based on previous investigations suggesting a five-factor solution have typically delineated two DB factors, we did hypothesize that the DB factor would parse into two at Level 5 of the DAP-BQ hierarchy. As only one study has previously extracted six factors from the DAPP-BQ,  no predictions about Level 6 were made.
| Materials and Methods|| |
The present research was a correlational and psychometrics kind. Statistical population of this study was all of the Allame Tabatabii and Lorestans' students and all of Loghman and Emam Hossein Hospital outpatients.
For the investigation of hierarchical structure DAP-BQ, we selected two kinds of samples via convenient and voluntary sampling methods: (1) Nonclinical sample - Participants in the nonclinical sample were 365 undergraduate and master students of Allame Tabatabaii and Lorestan University (Human Sciences 169, Mathematics 151, and Veterinarian 36; age range, 19-25). 189 number were male, and 176 number of them were female. (2) Clinical Sample - Participants in a clinical sample were 275 psychiatric outpatients (116 male, 159 female). Enrolled in a clinical research study of mood disorders and behavior. Participant lifetime diagnoses included bipolar I disorder (n = 101), bipolar II disorder (n = 24), bipolar disorder not otherwise specified (NOS; n = 9), cyclothymic disorder (n = 3), major depressive disorder (n = 119), dysthymic disorder (n = 18), and depressive disorder NOS (n = 1). The mean age of the sample was 44.12 years (standard deviation = 10.69).
Participants in each sample were recruited as part of two separate data collection protocols. Participants in a clinical sample were solicited from the community by convenient sampling and attended a clinical research laboratory where they completed 2 days of extensive assessment of personality and psychopathology as part of a larger investigation. Participants in the nonclinical sample were solicited by a research assistant and were given a battery of questionnaires to be returned after completion. Participation in a clinical sample was limited to individuals who met DSM-IV criteria for a lifetime mood disorder as assessed by the Composite International Diagnostic Interview (CIDI). Exclusion criteria included severe mania, active psychotic symptoms, and/or diagnoses of schizophrenia or schizoaffective disorder. Participation in the nonclinical sample was not subject to prespecified inclusion/exclusion criteria.
Diagnostic assessment of personality pathology-basic questionnaire (livesley and jackson, 2009)
This questionnaire includes 290 items and four categories (ED, DB, inhibition, compulsiveness ) . As there are some subscales in each category, in general, includes 18 subscales. In addition, this questionnaire has a validity scale with eight questions. Most of the subscales include 16 questions, except self-harm and suspiciousness scales, which include 14 and 12 questions. Each of the questions has scored in the five rate scale (very like me = 5, very unlike me = 1). 272 items are marked directly and 18 inversely. The questionnaire internal consistency was in the range of 0.85 (rejection and stimuli-seeking) to 0.94 (anxiety) for the public population and 0.84 (conscientiousness) to 0.95 (anxiousness) for clinical sample.  Also, Livesley and Jackson  have reported this instrument's Cronbach Alpha with the mean of 0.92 in the range of 0.90 (rejection) to 0.95 (self-harm). They estimated the test-retest reliability in a 3-week time long, by the range of 0.84 (rejection) to 0.93 (low affiliation). In Iran, its internal consistency was in the range of 0.73 (rejection) to 0.90 (anxiousness) for nonclinical sample.  Also, Rezaee et al.  estimated the test-retest reliability in a 4-week time long, by the range of 0.51 (suspiciousness) to 0.92 (identity problems). They have reported that four extracted factors explain 72.57% of the total variance. 
Structured clinical interview for diagnostic and statistical manual of mental disorders, fourth edition axis ii (first et al. 1997)
Structured Clinical Interview for DSM-IV Axis II (SCID-II) was used to assess the presence of PDs. This semi-structured interview is organized by diagnosis and covers the ten specific DSM-IV PDs and two appendix categories Clinicians rated symptoms of PDs as absent or false ("1"), subthreshold ("2"), or present or true ("3"). The SCID-II has been shown to be reliable and internally consistent in diagnosing PDs using DSM-III-R  and DSM-IV diagnostic criteria.  Inter-rater reliability coefficients ranged from 0.48 to 0.98 for categorical diagnosis (Cohen kappa), and from 0.90 to 0.98 for dimensional judgements (Intra-class correlation coefficient). Internal consistency coefficients were satisfactory (0.71-0.94).  in Iran it translated by Mohammad Khani. To obtain an Axis II diagnosis for a given PD on the SCID-II threshold number of criteria must be coded as present and clinically significant. The SCID-II such as CIDI was administered only to the clinical sample.
Composite international diagnostic interview
The CIDI is a comprehensive and fully standardized diagnostic interview designed for assessing mental disorders according to the definitions of the Diagnostic Criteria for Research of ICD-10 and DSM-IV. The instrument contains 276 symptom questions many of which are coupled with probe questions to evaluate symptom severity, as well as questions for assessing help-seeking behavior, psychosocial impairments, and other episode-related questions. Although primarily intended for use in epidemiological studies of mental disorders (lifetime prevalence), it is also being used extensively for clinical and other research purposes. Studies have confirmed good (0.81 for Mania) to excellent (0.94 for major depression) kappa coefficients for most diagnostic sections.  It covers 17 diagnostic dominances and in Iran validated by Kaviani et al. 
| Results|| |
Goldberg's  bass-ackwards method was used to explore the hierarchical structure of the DAPP-BQ. This method involves the top-down extraction of higher order traits from a set of variables to derive a hierarchical structure. Following the application employed by Tackett et al.,  the dimensions of the DAP-BQ were subjected to PCA with varimax rotation, beginning with the first principal component and iteratively extracting successive levels of the hierarchy. Regression-based factor scores at each level were correlated to provide path estimates between factors at contiguous levels of the hierarchy. [Figure 1] displays the six levels of the hierarchy delineated using the bass-ackwards method. For each hierarchy component, dimensions with loadings greater than the absolute value of 0.60 and below 0.40 on the remaining factors were considered in the interpretation of the component.
|Figure 1: Structure of the Diagnostic Assessment of Personality Pathology-Basic Questionnaire hierarchy delineated using the bass-ackwards method|
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At Level 2, the first component was defined primarily by high loadings of the identity problems, social avoidance, anxiousness, oppositionality, cognitive distortion, submissiveness, restricted expression and self-harming behavior dimensions, and labeled ED. The second component was defined by high loadings of the rejection, narcissism, callousness, and stimulus seeking dimensions, and labeled DB.
At Level 3, ED split into an ED component (anxiousness, identity problems, affective instability, submissiveness, social avoidance, oppositionality, cognitive distortion, and insecure attachment) and an IN component (intimacy problems and restricted expression). DB (rejection, callousness, conduct problems, and stimulus seeking) was replicated at Level 3.
At Level 4, four components emerged resembling those reported in previous investigations. ,,,,, ED (anxiousness, identity problems, submissiveness, affective instability, social avoidance, cognitive distortion, oppositionality, and insecure attachment), DB (callousness, conduct problems, stimulus seeking, and rejection), and IN (intimacy problems and restricted expressiveness) were replicated at Level 4. The fourth component was defined by a high loading of the CO dimension and split off of the DB component at Level 3.
At Level 5, ED split into ED (affective instability, self-harming behavior, identity problems, anxiousness, and cognitive distortion) and a component defined by high loadings of the insecure attachment, narcissism, and submissiveness dimensions, resembling Clark et al.  "Need for Approval (NA)" factor, and labeled accordingly. IN (restricted expressiveness and intimacy problems), DB (callousness, conduct problems, stimulus seeking, and rejection), and CO were replicated at Level 5.
Level 6 ED (affective instability, anxiousness, identity problems, cognitive distortion, self-harming behavior, and oppositionality), IN (restricted expressiveness and intimacy problems), NA (insecure attachment, submissiveness, and narcissism), and CO were replicated at Level 6. DB and CO both split to contribute to the sixth component, defined primarily by high loadings of the rejection and callousness dimensions. This new component was labeled DB/disagreeable; the previous dissocial component, now defined by conduct problems and stimulus seeking dimensions, was renamed dissocial/externalizing behavior.
Later we analysis the predicting PDs by DAP-BQ component. Multiple regression analyses were conducted for each level of the personality hierarchy to assess the extent to which components of the DAP-BQ hierarchy differentially predict DSM-IV PD symptom counts, using SCID-II data from a clinical sample. [Table 1] displays the variance in personality pathology for each DSM-IV-TR PDs that was accounted for by components at each level of the hierarchy 0.2. The components of the DAPP-BQ hierarchy accounted for considerable variance in PD clusters, ranging from 32% to 39% across levels. Variance for specific PDs predicted by the hierarchy components ranged from 9% (antisocial PD) to 39% (borderline PD) across levels. ED significantly predicted most, but not all of the PDs. DB significantly predicted all Cluster B PDs, and intermittently paranoid, schizotypal, and obsessive-compulsive PDs. DB/E significantly predicted several Cluster B PDs, whereas DB/disagreeableness (DB/D) significantly predicted PDs across all clusters. IN significantly predicted all Cluster A PDs, and intermittently borderline, avoidant and obsessive-compulsive PDs. CO variably predicted paranoid, narcissistic, and obsessive-compulsive PDs. NA intermittently predicted histrionic, narcissistic, borderline, avoidant and dependent PDs.
|Table 1: Results from multiple regression examining the ability of the components of the DAP-BQ hierarchy in predicting SCID-II symptom counts for DSM-IV Axis II disorder|
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| Discussion|| |
The current analyses provide support for the validity of components of the DAPP-BQ hierarchy. Specifically, variance in symptom counts for all PDs was significantly predicted by components at each level of the hierarchy. As hypothesized, the components at the fourth level of the hierarchy were similar to those recovered in previous factor analytic investigations of the DAPP-BQ components, with ED, DB, IN, and CO emerging as robust domains across most levels of the hierarchy. At Level 5, a component representing NA separated from ED and appeared similar in content to that reported previously by Clark et al.  The five extracted components were associated with a 6% increase in the prediction of borderline PD symptoms, suggesting an improvement in the predictive capacity of Level 5 components beyond those of Level 4. Interestingly, ED actually became more predictive at Level 5 when differentiated from NA, also emerging as a significant predictor. Furthermore, the differentiation of ED and NA held important information for other Cluster B disorders as well. ED and DB became slightly less predictive of histrionic disorder with NA predicting additional unique variance. ED further moved from a significant predictor of narcissistic PD at Level 4 to not significant at all at Level 5, with NA taking over that predictive power. This shift in the personality pathology profile for Narcissistic PD is perhaps better aligned with theoretical conceptualizations of the disorder with NA, rather than ED, reflecting a core aspect of the pathology.
Although overall explained variance did not substantially improve between Levels 4 and 5 for Cluster C disorders, similar evidence for the potential importance of NA emerged. Specifically, predictive power of ED decreased for Cluster C PDs when NA was differentiated. Importantly, both of the factors continued to offer unique prediction of avoidant and dependent PD, suggesting that they capture distinct but relevant information. Taken together, prediction of both Cluster B and Cluster C disorders demonstrated a potentially important role for NA and supported distinguishing between NA and a more salient ED component. Despite overlap, it is likely that these components have distinct correlates and consequences relating to impairment and interpersonal problems; as such, these features warrant careful assessment and consideration in clinical practice. ,
At Level 6, the DB component decomposed into externalizing (i.e. conduct problems, stimulus seeking) and disagreeable (i.e. rejection, callousness) components, also reported previously. ,,, No specific improvements in the prediction of variance across PDs were observed, with negligible increases in R2 for narcissistic PD (1%) and obsessive-compulsive PD (2%) likely resulting from the addition of predictors to the regression model. Moreover, CO at Level 6 did not significantly explain the symptom counts for individual PDs or for overall clusters.
The current results suggest that the addition of NA at Level 5 of the DAPP-BQ hierarchy provides additional information of PD symptoms beyond components at Level 4, while the division of DB at Level 6 provides no considerable improvements in symptom prediction. Based on these results, we think that Level 5 represents a crucial level of analysis for PD symptoms. These results are largely in line with those reported by Markon et al.  and Tackett et al.,  which highlighted the importance of the five broad personality domains for psychopathology research, although those components were extracted from the FFM. The fifth level in these previous studies, however, is somewhat different from that in the current version. In particular, the DAPP-BQ does not have a clear analog to the typical fifth factor in personality studies, openness to experience.  Furthermore, the differentiation between types of ED may be apparent only with a wider breadth of maladaptive items tapping into this domain, such as those found in the DAP-BQ. Other similarities with previous hierarchies are also seen in these findings. Level 3 of these analyses roughly maps onto a neuroticism/negative affectivity component (ED), an extraversion/positive affectivity component (IN), and a disinhibition component (DB.  At Level 4, the structure resembles maladaptive variants of neuroticism, extraversion, agreeableness, and conscientiousness. ,, A more representative sample of items tapping into approach-motivated characteristics, such as those reflected in positive emotionality and openness to experience, or unusual sensory and perceptual experiences may be needed to provide full replication of other hierarchies. 
Although the present results provide support for the validity of the DAP-BQ hierarchy, a number of limitations of the study must be addressed as well. First, the current investigation included patients and students who responded to solicitations for research participants. Given the suggestion that individuals who volunteer for research studies may exhibit differing personality characteristics compared to those who do not,  we recommend replication using other types of clinical and community samples. Second, the clinical sample consisted of low base-rates for certain PDs. Future research should replicate these results in samples with higher base rates of PDs.
The current investigation extracted components at six levels of the DAP-BQ hierarchy and investigated the capacity of these components in predicting DSM-IV-TR PD symptoms. Based on these findings, we conclude that Level 5 represents an important level of analysis for predicting personality pathology, with NA adding important information about symptoms of histrionic, narcissistic, borderline, avoidant, and dependent PD. The results from the current study may contribute to the refinement of the psychiatric nosology and assessment of personality pathology (see 32), by identifying common and specific components of PDs.
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