3 Simple Questions Screen for Common Personality Disorders
New research on personality disorders identifies key high-yield questions.
Posted Dec 20, 2020
According to the American Psychiatric Association:
“Personality is the way of thinking, feeling and behaving that makes a person different from other people. An individual’s personality is influenced by experiences, environment (surroundings, life situations) and inherited characteristics. A person’s personality typically stays the same over time. A personality disorder is a way of thinking, feeling and behaving that deviates from the expectations of the culture, causes distress or problems functioning, and lasts over time.”
How common are personality disorders? An estimated 9 percent of the general population has one or more personality disorder, a number approaching one-third in outpatient psychiatric clinical settings.
Diagnosing Personality Disorders
There are 10 defined personality disorders1 in the current U.S. diagnostic manual, the DSM-5. The 10 personality disorders are organized into Clusters, A, B, and C. Cluster A are more socially detached, odd or eccentric, Cluster B more emotionally unstable, and Cluster C more anxious. The personality disorders are: paranoid personality disorder, schizoid personality disorder, and schizotypal personality disorder (A); antisocial personality disorder, borderline personality disorder, histrionic personality disorder, and narcissistic personality disorder (B); and avoidant personality disorder, dependent personality disorder, and obsessive-compulsive personality disorder (C ).
An alternative model for understanding personality disorders has also been proposed, identifying maladaptive traits rather than specific personalities. Seven core traits include: Compulsivity, Detachment, Negative Affect, Psychoticism, Disinhibition, Antagonism, and Submissiveness. We can all have these traits to varying degrees. It is only when they come together significantly in one individual, and are associated with distress or dysfunction, that a personality disorder diagnosis can be made.
Diagnosing personality disorders is complex, and as with diagnosing any medical condition needs to be done thoughtfully, with a positive expectation of grounding therapeutic change. For personality disorders, diagnosis is made through careful clinical history and examination, review of collateral evidence, and standardized testing. Such testing is meticulous and time-consuming, and very useful if used properly.
Validating a Brief Screen for Personality Issues
In order to address the need for a brief personality disorder screen, which would be helpful given how intensive full evaluation is, researchers from the University of Pittsburgh School of Medicine, as described in their recent paper in the Journal of Personality Disorders (2020), tested a brief scale to screen for personality issues through the degree of agreement or disagreement with three key items:
- I am too sensitive to rejection
- It is hard for me to take instructions from people who have authority over me
- I argue with other people too much
The data from 842 participants were analyzed to see how well these three items, called the Inventory of Interpersonal Problems-3 (IIP-3), correlated with estimates of personality disorder, attachment difficulty, and emotional dysregulation based on a larger battery of tests and clinical examination.
The extensive study measures included the Inventory of Interpersonal Problems (127 items); the Temperament and Character Inventory—Self-Directedness Scale (226 items); and the Structured Interview for DSM-IV Personality, among others. Attachment style was measured using the Experiences in Close Relationships Scale (36 items); a clinician-determined Adult Attachment Rating; the Hierarchy of Attachment Organization scale, which defines four severity levels for attachment difficulties2, and the Attachment Q-Sort, which measures attachment based on communication style. Emotion regulation was assessed with the Adult Temperament Questionnaire—Effortful Control Scale (35 items); the Difficulties in Emotion Regulation Scale (36 items); and the Emotion Regulation Questionnaire (10 items).
Can Three Questions Screen for Personality Dysfunction?
Results showed that the IIP-3 correlated well with self-reports from participants, their significant others, and test results and interview findings. Mathematical coefficients ranged from 0.5 to nearly 0.7. These are robust correlations, and all were statistically significant, showing the IIP-3 has significant screening utility for common personality problems, attachment issues, and emotion dysregulation.
However, the IIP-3 was better for some issues than others. First, the IIP-3 picks up Cluster B features best, capturing “dramatic, expressive” behaviors, with emotional instability and difficulty with self-control. Along similar lines, the IIP-3 was correlated with anxious and preoccupied attachment style.
It is worth noting that the participants in the study were all patients receiving psychiatric care. In that group, rates of personality disorders are higher than the 9 percent in the general population. In addition, symptoms from depression, anxiety, developmental trauma, and other psychiatric conditions can overlap with personality. Given the careful evaluation for personality disorders in this study, however, the IIP-3 correlations with personality are distinct.
Taken together, the analysis suggests that the IIP-3 is a good screening tool, especially for Cluster B personality. This is useful, as this cluster is common, resulting in significant suffering, functional issues, and hardship.
For non-clinicians, the IIP-3 items pose actionable questions, which can be used to identify problem areas, and in conjunction with therapeutic and personal development efforts may be useful targets for deliberate practice:
- Am I too sensitive to rejection?
- Is it hard for me to take instructions from people who have authority over me?
- Do I argue with people too much?
These simple questions get at underlying maladaptive traits like antagonism, negative emotions, psychopathy, and submissiveness. How one feels about these questions is also informative. Do I feel overly guilty? Do I feel remorseful or unapologetic? Do I feel pessimistic or empowered? Do I feel curious or avoidant? What do these questions evoke in me?
Rather than providing ammunition for self-blame, and especially when accompanied by recognition of positive traits and strengths, asking oneself tough questions in the spirit of compassionate inquiry can serve as a springboard to enhance personal development and improve social and professional relationships.
We can also ask these questions about those around us—avoiding diagnosing inappropriately or using them to criticize or shame others—as we consider beginning new personal and professional relationships, and in our ongoing appraisal of whether our choices about work and personal relationships are best serving long-range goals for well-being and life satisfaction.
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2) Four levels of attachment organization are included: (a) disorganization and lack of structure (with three variants—unresolved states of mind; incoherence characterized by affectively intense, shifting, and mood-dependent states of mind; and incoherence characterized by low intensity, vague, and confusing states of mind), (b) excessively rigid structure (with two variants—hostile, controlling patterns of relationships; and compulsive care-giving), (c) functional but not optimal structure (with two variants—preoccupied and dismissive attachment), and (d) flexible and balanced structure (secure attachment, with an appropriate mix of attachment and autonomy).
"Reproduction of selected IIP items by special permission of the Publisher, Mind Garden, Inc., www.mindgarden.com from the Inventory of Interpersonal Problems by Leonard M. Horowitz et al. Copyright © 2000 by Leonard M. Horowitz et al. Further Reproduction is prohibited without the Publisher's written consent."