Volume 44, Issue 2, Pages 154-161 (March 2003)

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The Spanish-Language Version of the Diagnostic Interview for DSM-IV personality disorders: Development and initial psychometric evaluation of diagnoses and criteria☆☆☆★

Abstract

We describe the development of the Spanish-Language Version of the Diagnostic Interview for DSM-IV Personality Disorders (S-DIPD-IV). Initial descriptive (frequency and gender distribution of personality disorders [PDs]) and psychometric findings (inter-rater reliability of diagnoses, internal consistency, and criteria inter-relatedness) are reported based on administration of the S-DIPD-IV to 95 adult monolingual Hispanic patients. The S-DIPD-IV had adequate inter-rater reliability for most PD (mean kappa = .83). Except for the significantly greater proportion of males diagnosed with antisocial PD, no significant gender differences in the distribution of PD were observed. Within-category inter-relatedness of PD criteria was evaluated by coefficient alpha and mean intercriterion correlations (MIC). Between-category criteria overlap was evaluated by intercategory mean intercriterion correlations between all pairs of PD (ICMIC). For PD criteria, alpha ranged .36 to .99 (mean = .75, median = .81), MIC ranged .07 to .95 (mean = .36), and ICMIC ranged .09 to .45 (mean = .24). Six PD (borderline, antisocial, narcissistic, avoidant, obsessive-compulsive, and depressive) had no instances in which their criteria sets correlated higher with those of other PD than their own. Two PD (histrionic and dependent PD) had some instances of overlap, and four PD (paranoid, schizotypal, schizoid, and passive-aggressive) had pervasive overlap with other PD criteria sets. These findings suggest the utility of the S-DIPD-IV for assessing PD in Spanish-speaking Hispanic outpatients. Our initial findings for this patient group suggest that, except for antisocial PD in males, specific PD diagnoses are not differentially distributed by gender. Moreover, except for cluster A PD, the criteria for specific PD tend to be more highly correlated within than across PD. The S-DIPD-IV appears to have utility to facilitate PD research with Hispanic groups. Copyright 2003, Elsevier Science (USA). All rights reserved.

Article Outline

• Abstract

• Method

• Subjects

• Procedures

• Results

• Inter-rater reliability of the S-DIPD-IV

• Frequency and distribution of DSM-IV personality disorders

• Analyses of the DSM-IV PD criteria sets

• Discussion

• Acknowledgment

• References

• Copyright

Basic questions remain regarding various aspects of the validity of personality disorders (PDs).1 This is particularly so for persons of different cultural or ethnic groups, for which there is a paucity of PD data.2, 3 In the United States, this is particularly striking for Hispanic persons—the fastest growing, and soon to be the largest, minority group.4 There is strikingly little personality research5 and even less PD research on this ethnic group.6 Conducting research on this group depends partly on the availability of appropriate diagnostic instrumentation. Insofar as many Hispanics in the United States do not speak English (roughly 50% speak English less than “very well”),4 ongoing immigration from South America continues to add to the proportion of Hispanic Americans who do not speak English, many bilingual Hispanics may prefer to be interviewed in Spanish,7 and Spanish is by far the second most commonly spoken language in the nation, the development of appropriate instrumentation in Spanish is needed. Appropriate instrumentation could also facilitate relevant research in the many countries where Hispanic persons represent the majority group. Indeed, the lack of psychometrically evaluated instruments represents one possible contributor to the low rate of international representation in the psychiatric literature.8, 9

Two recent impressive efforts to study psychopathology internationally include the study of axis I psychiatric diagnoses (major depressive disorder) in 10 countries10 and the recent World Health Organization study which developed and tested the International Personality Disorder Examination11 in 11 countries. The study of personality disorders did not include Hispanic (Spanish-speaking) groups. Some earlier investigations of axis I psychiatric disorders using structured interviews have produced data relevant to specific Hispanic groups such as Mexican-Americans.12, 13, 14 Particularly noteworthy are studies involving translations of axis I diagnostic instruments into Spanish in order to study Hispanic groups.15, 16, 17, 18 We are not aware of similar efforts at developing such standardized diagnostic instrumentation for DSM-IV axis II PDs for use specifically with Hispanic (monolingual, Spanish-speaking) patients.

Little is known regarding the question of whether Hispanic (Spanish, Latin) cultural group(s) differences are associated with differences in the nature or structure of personality or in disorders of personality at the individual level. For example, one position is that different cultures may shape different personalities, thus requiring culture-specific models of personality.19 In contrast, other work suggests little evidence for cultural differences in abnormal personality20 or normal personality structure as represented by the “Big Five” personality dimensions,5 suggesting that basic aspects of personality may be universal or invariant.21 A related position is that cross-cultural variability may depend on severity, for example, that cultural variation may be greatest for “normal” personality and less pronounced for persons with mental or personality disorders,22 or vice versa.

These intriguing questions about culture and personality notwithstanding, there are several well-documented general value and interpersonal differences between Hispanic and non-Hispanic Anglo cultures that appear to be especially relevant to the construct of personality disorders.23, 24, 25, 26 Briefly, the cultural psychology literature has documented that Hispanic/Latin groups are less individualistic than non-Hispanic Anglo groups,27, 28, 29 have a heightened need for “simpatia” or harmonious relationships,27 place a paramount value placed on the family (“familisomo”),25, 30, 31 and place a greater emphasis on the present, with less importance given to the future.24 While these global value or interpersonal factors generally differ from non-Hispanic Anglo groups, it should be stressed that there also exists marked intragroup variation,24, 32 as well as variation between different Hispanic groups.24, 27 Nonetheless, such cultural variation in factors conceptually related to interpersonal relations highlights the need to examine PDs in such groups.

Thus, the development of investigator-based diagnostic instrumentation for assessing PDs in Hispanic persons, particularly monolingual (non-English-speaking) persons, represents an important research need.33 The development of such instrumentation—if characterized by acceptable inter-rater reliability—would have potential applicability for clinical studies of PD in Hispanic groups. Such instrumentation would also produce data relevant to addressing questions at the intersection between cross-cultural investigation and psychiatric nosology.34 It would eventually help to investigate whether cultural (group) differences are associated with differences in the architecture of PDs (individual level). In addition, such instrumentation would also allow for studies pertaining to the various aspects of the construct validity of PDs.35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46

The present study represents, to our knowledge, the first report of PD diagnoses and psychometric evaluation of the PD criteria for monolingual (Spanish-speaking only) Hispanic outpatients. First, we describe the development of the Spanish-Language version of a diagnostic interview for PD. We examine the inter-rater reliability of DSM-IV-defined PDs assessed using the instrument. Second, we report the frequency of PDs diagnosed in a study group of monolingual Hispanic outpatients. Given a number of salient culturally embedded concepts regarding gender-role dynamics in Spanish cultures, such as “machismo” and “marianismo,”25, 31, 47, 48, 49 we also explore gender differences in the distribution of PD diagnoses. Third, we report on basic aspects of reliability of DSM-IV-defined PD criteria for this study group of Hispanic patients. Specifically, following our recent psychometric reports42, 46 of PD criteria for diverse patient groups, we evaluate within-category interrelatedness of criteria and the degree of between-category criterion overlap.

Method

Subjects

Participants were 95 monolingual (Spanish-speaking only) Hispanic adults evaluated at an outpatient psychiatric community-based clinic in New Haven, CT. The specific clinic, which exists within a larger community mental health clinic, provides services only to monolingual Hispanic adults and has a specialty focus on treatment for substance abuse. This specific clinic focuses on intensive aftercare and requires abstinence from substance use disorders. Participants were a nearly consecutive series of patients (with diagnoses of substance use disorders) who were assigned to a particular treatment team at the clinical assignment to this treatment team was not determined by clinical, demographic, or financial considerations but rather by case flow. Participants were excluded from participation if there were psychiatric contraindications (e.g., psychotic disorders) or mental status issues (e.g., cognitive impairments, substance withdrawal) that would preclude assessments.

Of the 95 patients, 65 (68.4%) were male and 30 (31.6%) were female. Patients had a mean age of 39.1 years (SD = 10.4), 63% (n = 60) were married, and the majority (73%, n = 69) were originally from Puerto Rico. Patients had resided in the United States for a mean of 13.3 years (SD = 9.5). Males and females did not differ significantly in these demographic features.

Procedures

Written informed consent, in Spanish, was obtained from participants. Patients were administered the Spanish version of the Diagnostic Interview for DSM-IV PD (S-DIPD-IV) described below. The original DIPD-IV50 is a semistructured diagnostic interview that assesses the 10 recognized and two “research” (passive-aggressive and depressive) DSM-IV PDs and criteria. The DIPD-IV contains several questions to assess each PD criterion and guidelines for determining presence and clinical significance. The DIPD-IV stipulates that criteria must be present and pervasive for at least 2 years and be characteristic of the person during his or her adult life. The DIPD-IV has established inter-rater and test-retest reliability,51 has been used in studies of comorbidity of axis I and axis II disorders,52, 53 and is currently being used in the National Institute of Mental Health (NIMH)-funded multisite Collaborative Longitudinal Personality Disorders Study.54, 55

The S-DIPD-IV was developed via a process of cross- and back-translation headed by one of the authors (Dr. Anez) who had received intensive training by the developer of the DIPD-IV (Dr. Mary Zanarini). After being trained in the DIPD-IV, Dr. Anez completed roughly 40 DIPD-IV assessments with patients enrolled in the Collaborative Longitudinal Personality Study.54, 55 During this time, Dr. Anez received ongoing supervision from the two authors (Drs. Grilo and McGlashan) and participated in ongoing monthly supervision calls with the DIPD-IV developer (Dr. Zanarini) aimed at preventing drift. Dr. Anez participated in an inter-rater reliability study conducted by the developer of the DIPD-IV. Inter-rater reliability kappas (based on independent ratings by 84 pairs of raters with 12 interviewers) for the 12 PDs ranged from .58 to 1.0.51

The process of translation and refinement of the S-DIPD-IV involved steps advocated by Brislin56, 57 others33, 58 and employed in similar translation efforts for other (axis I) diagnostic instruments.16, 17 Dr. Anez—a fully bilingual research clinician with over 10 years of experience working with diverse Hispanic (both monolingual and bilingual) patient groups—achieved reliability with the English version of the DIPD-IV and obtained further experience while being monitored for drift. Dr. Anez then translated the DIPD-IV into Spanish using a combination of clinical, conceptual, and linguistic approaches. A second fully bilingual Hispanic research clinician (post-MA PhD candidate) with experience with both personality disorders and with diverse Hispanic patient groups translated the instrument back to English using clinical, conceptual, and linguistic considerations. Discrepancies were identified and discussed amongst these two bilingual research clinicians and a third bilingual clinician. Appropriate revisions were instituted. The instrument was then administered to several Hispanic patients and this experience was used to refine the wording wherever needed.

Results

Inter-rater reliability of the S-DIPD-IV

The inter-rater reliability of the Spanish-DIPD-IV was evaluated using three pairs of independent ratings for 27 randomly selected taped assessments provided by three bilingual research clinicians. Kappa coefficients for the 12 PDs averaged .83; except for paranoid PD (kappa = .38), kappa coefficients were acceptable, ranging from .70 (avoidant PD) to 1.0 (schizotypal, schizoid, histrionic, antisocial). These inter-rater reliability findings compare favorably with those reported for the DIPD-IV,51 as well as with the relevant PD literature.1

Frequency and distribution of DSM-IV personality disorders

Overall, 62 (65.3%) of the 95 patients met criteria for at least one PD. Table 1 shows the frequency of specific PD diagnoses in the overall study group. Borderline PD (n = 32; 33.7%), obsessive-compulsive PD (n = 30, 31.6%), and avoidant PD (n = 30, 31.6%) were the three most frequently diagnosed PDs. If only the ten official DSM-IV PD diagnoses are considered, patients met criteria for a mean of 1.65 (SD = 1.87) PDs. Of the 95 patients, 16 (16.8%) met criteria for one PD, 22 (23.2%) met criteria for two PDs, and 24 (25.3%) met criteria for three or more PDs. If all 12 DSM-IV PD diagnoses (includes the two research categories) are considered, patients met criteria for a mean of 1.96 (SD = 2.15) PDs. Of the 95 patients, 14 (14.7%) met criteria for one PD, 14 (14.7%) met criteria for two PDs, and 34 (35.8%) met criteria for three or more PDs.

Table 1.

Frequencies of DSM-IV Personality Disorders in 95 Adult Monolingual Hispanic Outpatients


	Overall Frequency		Gender Distribution		Analysis
	No.	%	Females (n = 30)	Males (n = 65)	χ2	P
Paranoid	12	12.6	10.0	13.8	0.04	NS
Schizoid	2	2.1	0.0	3.1	0.04	NS
Schizotypal	4	4.2	6.7	3.1	0.07	NS
Antisocial	14	14.7	0.0	21.5	5.96	.015
Borderline	32	33.7	33.3	33.8	0.00	NS
Histrionic	4	4.2	0.0	6.2	0.70	NS
Narcissistic	4	4.2	0.0	6.2	0.70	NS
Avoidant	30	31.6	26.7	33.8	0.21	NS
Dependent	16	16.8	13.3	18.5	0.11	NS
Obsessive-compulsive	30	31.6	33.3	30.8	0.00	NS
Research category
Passive-aggressive	6	6.3	0.0	9.2	1.60	NS
Depressive	23	24.2	23.3	24.6	0.00	NS

Abbreviation: NS, not significant.

Overall, males and females did not differ significantly in the number of axis II PD diagnoses assigned [F(1,94) = 2.31, P = .132, not significant (NS)]. Table 1 summarizes the frequency of PDs separately for men and women, and chi-square analyses (with Yates correction for continuity) testing for differences. No significant differences were observed in the proportion of males and females diagnosed with specific PDs with the one notable exception of antisocial PD. Fourteen (21.5%) of the 65 males were diagnosed with antisocial PD versus no females [Yates corrected χ2(1) = 5.96, P < .02).

Analyses of the DSM-IV PD criteria sets

Complete criteria data for all DSM-IV PDs were available for all patients. The analytic procedures followed from recent applications to DSM-III-R42 and DSM-IV.46 Within-category inter-relatedness (or internal consistency) of criteria sets was determined by Cronbach's alpha59 and intercriterion correlation analyses. Cronbach's alpha reflects the intercorrelation between items in a set (it estimates the correlation between all possible split-half combinations of items). It varies between 0 and 1, increasing as the mean inter-item correlation increases. Since alpha increases as number of items increases,60, 61 we also calculated mean intercriterion correlations (MIC) to facilitate comparison between criterion lists of different lengths.41, 42 To examine criterion overlap between categories, we calculated inter-category mean intercriterion correlations (ICMIC) between all PDs. The ICMIC was calculated in a manner similar to the MIC: correlation coefficients were determined for all possible inter-category criterion pairs—each pair consisting of one criterion from each of the two categories being compared.

Table 2 shows the alpha and MIC values for each PD, and ICMIC values for all PD pairs.

Table 2.

Internal Consistencies, Mean Inter-item Correlations, and Intercriterion Mean Inter-item Correlations for DSM-IV Personality Disorders (N = 95)


					ICMIC
	No. of dx	No. of Items	Alpha	MIC	Paranoid	Schizoid	Schizotypal	Antisocial	Borderline	Histrionic	Narcissistic	Avoidant	Dependent	Obs-Comp	Pass-Aggr
Paranoid	12	7	.61	.18
Schizoid	2	7	.36	.07	.09
Schizotypal	4	9	.36	.14	.12	.12
Antisocial	14	22	.86	.33	.24	.19	.18
Borderline	32	9	.84	.37	.24	.17	.18	.26
Histrionic	4	8	.74	.27	.15	.09	.13	.22	.26
Narcissistic	4	9	.99	.95	.32	.33	.26	.25	.35	.32
Avoidant	30	7	.91	.59	.27	.25	.21	.24	.36	.26	.40
Dependent	16	8	.83	.37	.18	.19	.18	.20	.28	.19	.35	.42
Obs-Comp	30	8	.79	.31	.16	.13	.14	.21	.25	.20	.28	.26	.21
Pass-Aggr	6	7	.73	.29	.20	.13	.14	.27	.30	.23	.32	.31	.24	.23
Depressive	23	7	.87	.49	.26	.21	.20	.24	.37	.23	.38	.45	.37	.29	.33

Abbreviations: dx, diagnoses; MIC, mean inter-item correlations; ICMIC, intercriterion mean inter-item correlations; Obs-Comp, obsessive-compulsive; Pass-Aggr, passive-aggresive.

Alpha coefficients ranged from .36 (schizoid and schizotypal PD) to .99 (narcissistic PD) with a mean value of .75 (SD = .21; median = .81). Nine of the 12 PDs had alphas greater than .70. Specifically, 7 of the 10 official PDs (all cluster B and C diagnoses but none of cluster A) and both research PDs had alpha greater than .70. MIC ranged from .07 (schizoid PD) to .95 (narcissistic PD), with a mean of .36 (SD = .23; median = .32). ICMIC ranged from 09 to .45 (mean = .24, SD = .08; median = .24).

Thus, overall the MIC (mean and median) values were higher than the ICMIC values. Inspection of the MIC versus ICMIC values for specific PD suggests considerable variability in the degree of discriminant validity of the criteria sets. Six PDs—borderline, antisocial, narcissistic, avoidant, obsessive-compulsive, and depressive—had no instances in which their criteria sets correlated higher with those of other PDs than their own. Two PDs—histrionic and dependent—had some instances in which their criteria correlated higher with those of other PDs than their own. The remaining four PDs—paranoid, schizotypal, schizoid, and passive-aggressive—were problematic, with their criteria sets showing pervasive overlap with the criteria sets for other PDs.

Discussion

We have described the development of the Spanish-Language Version of the Diagnostic Interview for DSM-IV PD50—the S-DIPD-IV. This instrument was developed following extensive experience with the original English-version (DIPD-IV) and following established translation methods.33, 56, 57, 58 Except for paranoid PD, inter-rater reliability for the PD diagnoses was acceptable, with kappa coefficients ranging from .70 to 1.0. The present study also represents an initial psychometric evaluation of the PD diagnoses and criteria sets conducted with Hispanic patients.

In this study group of monolingual Hispanic outpatients with primary axis I diagnoses of substance use disorders, borderline, avoidant, obsessive-compulsive were the most frequently assigned PD diagnoses. The distribution of PD diagnoses did not differ significantly by gender, with the notable exception of significantly higher rates of antisocial PD in men. These findings are consistent with previous empirical findings regarding gender patterns in PDs. Specifically, in contrast to prevailing clinical lore (and statements contained in the DSM-IV), there are generally few differences in the distribution of PDs by gender (when the proportion of males and females in the study groups are considered), and when differences are found, they tend to be in men, with studies consistently reporting higher rates of antisocial PD.62, 63, 64, 65

In this study group of monolingual Hispanic outpatients, our findings suggest that some of the PD criteria sets have adequate within-category interrelatedness (reflected in the acceptable alphas and MIC). The mean alpha was .75; 7 of the 10 official DSM-IV PDs and both of the research-category PDs had alpha coefficients greater than .70 (an arbitrarily chosen convention for acceptable internal consistency (61)). These findings are generally consistent with those reported for DSM-IV criteria with diverse patient groups (44-46).

Overall, in this study group, the PD criteria sets correlated better within each PD than with criteria for other PDs. These findings are generally consistent with those reported previously for primarily non-Hispanic Caucasian outpatients.46 However, inspection of the MIC and ICMIC findings revealed considerable variability across PD diagnoses. All three cluster A PDs (paranoid, schizotypal, schizoid) and one research PD category (passive-aggressive) criteria sets had pervasive overlap with other PD criteria. Two PDs (histrionic and dependent) had some instances of overlap. However, six PDs (borderline, antisocial, narcissistic, avoidant, obsessive-compulsive, and depressive) had no instances in which their criteria sets correlated higher with those of other PDs than their own, suggesting that these specific criteria sets discriminate reasonably well.

Cluster A PDs seemed particularly problematic in this study group. Paranoid PD had unacceptable inter-rater reliability and the criteria sets for all three cluster A PDs (paranoid, schizotypal, schizoid) had unacceptable internal consistency and high overlap with criteria for other PDs. The relatively low frequency of two PDs (schizoid, schizotypal) dictates caution in drawing any conclusions. However, paranoid PD, while not infrequent, was characterized by poor inter-rater reliability, and its criteria sets showed poor internal consistency and instances of higher overlap with criteria for other PDs than with each other. While the poor performance of the cluster A PD may simply reflect a combination of chance and limited sample size, we offer some speculations that future research can address. Perhaps the items (reluctance to confide, suspects being exploited, reads hidden threats, etc.) are difficult to disentangle from the context of not speaking English, being poor, and residing in an urban setting with high crime and little accommodation for non-English-speaking persons. The DSM-IV states that immigrants may be mistakenly viewed as distant, indifferent, or odd and that certain religious beliefs may also be mistaken to reflect certain cluster A PD criteria. However, we note that the data were obtained by fully bilingual and experienced research clinicians knowledgeable of such issues and the culture. Thus, it is possible that the psychopathologic constructs reflected in the three cluster A PDs and criteria sets do not apply well in Hispanic groups. Indeed, a previous study with primarily non-Hispanic Caucasian outpatients also reported problematic overlap for schizotypal PD.46 These issues require continued empirical and clinical attention.

We note several potential limitations. Our patient study group consisted of monolingual Hispanic patients with a primary diagnosis of substance use disorders. Thus, whether our findings can be generalized to other patient groups without substance use disorders is unknown. We note that our participants were not actively using substances nor showed any substance withdrawal effects that might have confounded the assessments. The gender distribution (roughly twice as many males as females) likely reflects the substance abuse clinic sampling. Nonetheless, we note that there is a large literature documenting both the importance and the distribution of PDs in patients with substance use disorders.66, 67, 68 We also note that the limited sample size limits somewhat our findings regarding frequency and gender distribution. In particular, our limited number of females may not have allowed for detection of patterns reflecting small effect sizes. While the sample size was adequate for criterion-level reliability analyses, a different methodological issue is relevant. Specifically, our assessment interview did not involve randomized assessment of PD criteria. Since criteria for a given PD were all assessed sequentially, our assessment—while clinically ecologic—does leave open the possibility of a “halo” effect (i.e., evaluators might rate criteria within a disorder more similarly). This effect, if present, might be expected to inflate internal consistency artificially and minimize intercorrelations among PD criteria. It is worth noting that our MIC/ICMIC findings are generally consistent with those previously reported for adults based on a different diagnostic instrument that utilizes a different administration format.42

Our analysis needs to be repeated in future studies with other Hispanic groups—both heterogeneous and more homogeneous groups. Such studies should consider specific comparisons of participants from different Hispanic/Spanish countries, living in the United States versus in the country of origin, varying length of time in the United States, and bilingual versus monolingual. In such research efforts, it will be important to keep in mind that not all members of an ethnic group provide equal representation of the ethnic group.32 Research in other areas, such as substance abuse69 depression/anxiety,70 has revealed important variations within and between ethnic subgrouping. Alternatively, if PD constructs are valid across cultures, our descriptive analyses here should be reasonably similar to those of other study groups. Future research needs to focus on specific PD criteria, including examination of diagnostic efficiency of criteria to inform decisions about eliminating or revising specific criteria. Such studies may reveal criteria that are especially problematic or inappropriate for Hispanic patients.

To summarize, the S-DIPD-IV demonstrated adequate inter-rater reliability for assessing DSM-IV PDs (except paranoid PD) in monolingual Hispanic psychiatric outpatients. It is hoped that the availability of such diagnostic instrumentation leads to increased research on PDs in Hispanic groups and efforts to address the many questions at the intersection between cross-cultural psychology and psychiatric nosology.71

Acknowledgements

We wish to acknowledge Dr. Mary C. Zanarini for her training and consultation in the use of the Diagnostic Interview for DSM-IV Personality Disorders.

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Department of Psychiatry, Yale School of Medicine, New Haven, CT.

☆ Supported by NIH Grants No. MH50850 (T.H.M., C.M.G., L.M.A.) and MH 01654 (T.H.M.), and by the Personality Disorders Research Foundation (T.H.M., C.M.G.).

☆☆ Address reprint requests to Dr. Carlos M. Grilo, Yale University School of Medicine, PO Box 208098, New Haven, CT 06520.

★ 0010-440X/4402-0020$30.00/0

PII: S0010-440X(03)00026-9

doi:10.1053/comp.2003.50006

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