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Am J Psychiatry 1992; 149:1645-1653
Copyright © 1992 by American Psychiatric Association
Problems and considerations in the valid assessment of personality disorders
JC Perry
Cambridge Hospital, Boston.
This article reviews evidence for the reliability and diagnostic
concordance of structured-interview and self-report questionnaire methods
for the diagnosis of personality disorders. The findings of nine studies
that compared two or more axis II diagnostic instruments administered to
the same groups of subjects are summarized. Across the eight studies with
sufficient data, a summary of the overall diagnostic agreement between any
two instruments yielded a low reliability (median kappa = 0.25) for making
individual personality disorder diagnoses. Diagnostic concordance was lower
between self-report questionnaire and interview methods than between
interview methods. Comparing dimensional scores of different methods did
not appreciably improve the level of agreement. The author concludes that
current methods for making personality disorder diagnoses have high
reliability but yield diagnoses that are not significantly comparable
across methods beyond chance, which is not scientifically acceptable.
Sources for the disagreement include variance due to different raters,
interview occasions, data sources (self-report versus observer report),
information bases obtained, and instrument sensitivity to state effects
(e.g., mood). Serious problems in assessment validity may also arise from
the yes/no format, which, despite probes for confirmatory examples, may
fail to distinguish adequately between sporadic occurrences and
longstanding patterns. Efforts should be made to improve and demonstrate
the validity of axis II diagnostic methods. One route to increasing
validity is to improve the clinical interview, because personality patterns
are best revealed by the recurring patterns one finds when taking a
systematic history.
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