East Asian Arch Psychiatry 2022;32:95-9 | https://doi.org/10.12809/eaap2208

ORIGINAL ARTICLE

Banafsheh Gharraee, Clinical Psychology Department, School of Behavioral Sciences and Mental Health (Tehran Psychiatry Institute), Iran University of Medical Sciences, Tehran, Iran
Amir Shabani, Mental Health Research Center, Mood Disorders Research Group, Iran University of Medical Sciences, Tehran, Iran
Samira Masoumian, Clinical Psychology Department, School of Behavioral and Mental Health (Tehran Psychiatry Institute), Iran University of Medical Sciences, Tehran, Iran.
Sciences and Mental Health (Tehran Psychiatry Institute), Iran University of Medical Sciences, Tehran, Iran
Somayeh Zamirinejad, Clinical Psychology Department, School of Behavioral Sciences and Mental Health (Tehran Psychiatry Institute), Iran University of Medical Sciences, Tehran, Iran
Hooman Yaghmaeezadeh, Clinical Psychology Department, School of Behavioral Sciences and Mental Health (Tehran Psychiatry Institute), Iran University of Medical Sciences, Tehran, Iran
Sajad Khanjani, Clinical Psychology Department, School of Behavioral Sciences and Mental Health (Tehran Psychiatry Institute), Iran University of Medical Sciences, Tehran, Iran
Susan Ghahremani, Clinical Psychology Department, School of Behavioral Sciences and Mental Health (Tehran Psychiatry Institute), Iran University of Medical Sciences, Tehran, Iran

Address for correspondence: Samira Masoumian, Mental Health Research Center, Clinical Psychology Department, School of Behavioral Sciences and Mental Health (Tehran Psychiatry Institute), Iran University of Medical Sciences, Tehran, Iran
Email: masoumian.s@iums.ac.ir

Submitted: 27 January 2022; Accepted: 1 November 2022

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Introduction

Approximately 25% of inpatients in mental health centres and 45% of outpatients meet the minimum criteria for personality disorders (PDs).^1,2 Personality disorders are associated with psychological disorders,³ higher mortality,⁴ poor therapeutic outcome,⁵ high disease burden,⁶ and high economic burden.⁷ Patients with undiagnosed personality disorders may receive ineffective or harmful treatment. Therefore, accurate and timely evaluation of personality disorders is important. The Structured Clinical Interview for DSM-IV (SCID-IV) Axis I and II disorders has acceptable validity and reliability.^8-10 In Iran, the SCID-IV has moderate to good (kappa, >0.6) diagnostic agreement with most specific and general diagnoses; the overall agreement is 0.52 for all current diagnoses and 0.55 for all lifetime diagnoses.¹¹

The latest Structured Clinical Interview for DSM-5 (SCID-5) includes five versions: clinician, research, clinical trials, personality disorders, and alternative model for personality disorders. The version of SCID-5 for personality disorders¹² (SCID-5-PD) is used to assess ten personality disorders comprising avoidant, borderline, dependent, obsessive-compulsive, paranoid, schizotypal, schizoid, histrionic, narcissistic, and antisocial.¹⁰ The SCID-5-PD can be used for dimensional or categorical diagnostics. Interview questions of the SCID-5-PD are thoroughly reviewed and revised to optimally capture the underlying construct in the diagnostic criteria, with a dimensional scoring added. This study aims to examine the psychometric properties of the Persian version of the SCID-5-PD by Amini et al¹³ among patients referred to psychiatric centres in Iran.

Methods

Between March 2017 and June 2019, 287 outpatients and inpatients aged 16 to 75 years who were referred to three psychiatric centres (Iran Psychiatric Hospital, Rasoul Akram Hospital, and Tehran Psychiatric Institute) in Tehran, Iran were invited to participate. Those with severe mental retardation or dementia or severe psychosis were excluded. Written informed consent was obtained from each participant. Patient characteristics including sex, age, level of education, marital status, occupation, and history of psychiatric disorders, drug or alcohol abuse, suicide, legal problems, medication, and hospitalisation were collected using a questionnaire. Patients were interviewed using the Persian version of the SCID-5-PD by two PhD students in clinical psychology who were blinded to patient records.

Face validity and content validity of the Persian version of the SCID-5-PD were assessed by five specialists with ≥2 years of clinical experience. For qualitative face validity, the specialists discussed about the grammar, word choice, item importance, item placement, and time to completion of the SCID-5-PD. Necessary changes were then made. For quantitative face validity, the specialists ranked the importance of each item of the SCID-5-PD in a 5-point scale ranging from 1 (not important at all) to 5 (very important). The item effect method was used for calculation; an item with an impact score of >1.5 was considered acceptable.

For qualitative content validity, the specialists assessed the Persian version of the SCID-5-PD in terms of appropriate fit and relevance of items, interpretations of phrases, and adequacy in meanings. Necessary changes were then made. For quantitative content validity, the content validity ratio (CVR) and content validity index (CVI) were determined. CVR was used to ensure that the most important and correct content (item necessity) was selected, whereas CVI was used to ensure that the items were best designed to measure content. The CVR of each item was rated by each specialist as essential, useful but not necessary, or unnecessary. The numeric value of CVR is adapted from the study by Lawshe.¹⁴ A CVR of >0.99 (minimum value for a panel of five specialists) was considered acceptable. The Waltz and Basal indices¹⁵ were used to calculate the CVI. Relevance or specificity, simplicity and fluency, and clarity or transparency of each item were rated by each specialist in a 4-part Likert scale ranging from 1 (lowest) to 4 (highest). The CVI was calculated by summing the scores that ranked 3rd and 4th (highest score) on the total number of specialists. An item with a CVI of ≥0.79 is considered acceptable, whereas an item with a CVI of 0.70 to 0.79 needs rephrasing, and an item with a CVI of <0.70 needs removal.¹⁶

For diagnostic validity, the diagnosis made by a psychiatrist in the patient record was the gold standard, which was made by a resident of psychiatry according to the DSM-5 after conducting interview with the patient, gathering data of lifetime course of the disorder and any previous treatment and recorded diagnosis in outpatient and inpatient settings, and conducting interview with accessible family members. The diagnosis was confirmed by a supervisor psychiatrist who made an independent interview with the patient. The agreement between the diagnoses made with the Persian version of the SCID-5-PD by the two PhD students in clinical psychology and the gold standard diagnoses made with DSM-5 by psychiatrists was determined, as were sensitivity, specificity, and positive and negative likelihood ratios.

109 (43.6%) patients were interviewed again after an interval of 7 to 10 days for inter-rater reliability and test- retest reliability.

Results

A total of 250 patients aged 17 to 74 (mean, 32.56) years were included in the analysis. 123 (49.2%) patients had a history of suicidal thoughts and behaviour. 74 (30%) patients had a history of substance or alcohol abuse. 241 (97.2%) patients had a history of pharmacological treatment for psychiatric disorders. 212 (85.8%) patients had been admitted to a psychiatric hospital for >1 day (Table 1).

Based on the DSM-5 (gold standard), of the 250 patients, 80 had no psychiatric diagnosis and 170 had psychiatric diagnosis, with depressive disorders being the most common (n=74), followed by bipolar disorder and related disorders (n=40), schizophrenia spectrum and other psychotic disorders (n=18), obsessive-compulsive disorder (n=13), substance-related and addictive disorders (n=12), neurodevelopmental disorders (n=4), disruptive impulse- control and conduct disorders (n=4), anxiety disorder (n=3), and trauma and stressor-related disorders (n=2).

Face validity and content validity of the Persian version of SCID-5-PD were acceptable. For face validity, the impact score of all items was >3. For content validity, all items were considered necessary by specialists, and the CVI of all items was >0.8.

For diagnostic validity, using a kappa value of 0.4 as a cut-off, the agreement between the Persian version of SCID-5-PD and DSM-5 (gold standard) was acceptable (kappa >0.4) for the diagnoses of obsessive-compulsive, paranoid, schizotypal, schizoid, histrionic, narcissistic, borderline, and antisocial personality disorders, whereas the agreement was unacceptable (kappa <0.4) for the diagnoses of avoidant and dependent personality disorders and other disorders (Table 2). Sensitivity for all diagnoses was high, except for avoidant (0.66) and dependent (0.66) personality disorders. Specificity for all diagnoses was high, except for avoidant personality disorder (0.66). The positive and negative likelihood ratios showed that the SCID-5-PD was accurate for diagnosing all (particularly histrionic, antisocial, and schizotypal) personality disorders, except for schizoid personality disorder.

Inter-rater reliability was good for all personality disorders, except for schizotypal personality disorder (0.531) and other disorders (0.007). Test-retest reliability was good for all personality disorders and other disorders (Table 3).

Discussion

The Persian version of the SCID-5-PD was acceptable for diagnosing all personality disorders, except for avoidant, dependent, schizoid, and schizotypal personality disorders (probably owing to the small sample size). In hospital settings, priority is usually given to patients with more severe symptoms who usually have psychiatric disorders of Axis 1 diagnoses, unless the clinical picture is directly related to the personality disorder such as suicidal behaviours or the personality disorder is very prominent.¹⁷Thus, patients with schizoid personality disorder may not be examined comprehensively by psychiatrists in hospitals. The lack of awareness of personality disorders may result in their underdiagnosis. The comorbidity rate of both psychiatric and personality disorders in studies that use unstructured clinical evaluations is much lower than that in studies that use structured evaluation tools. Patients with Axis I disorders are often treated similarly, and the specific symptoms of patients with personality disorder are often ignored.^18,19 Only when patients are not responsive to treatment, clinicians will then consider the possibility of a comorbid personality disorder.²⁰ People with cluster C personality disorders generally remain undiagnosed and have manifestations such as mood disorders and physical symptoms.²¹

There are limitations to the present study. Only patients with very severe symptoms were admitted to hospitals, owing to limited hospital beds. The sample was limited to a specific geographical area, and the sample size for avoidant, dependent, schizoid, and schizotypal personality disorders was small. Thus, generalisation of our findings should be cautious, particularly for the four personality disorders. Paired interview design generally provides a more optimistic estimate of the actual reliability of the instrument,²² but it is commonly used for assessing reliability between testers owing to simplicity. Nonetheless, the Persian version of SCID-5-PD is acceptable for diagnosing personality disorders classified in the Axis II diagnoses of DSM-5, with good to excellent reliability.^23,24

The test-retest reliability was high, because personality disorders are persistent and do not change much over days and weeks.²⁵

Conclusion

The Persian version of the SCID-5-PD can be used to evaluate those who seek psychotherapy for all personality disorders, except for avoidant, dependent, schizoid, and schizotypal personality disorders.

Contributors

BG, AM, and SM designed the study. All authors acquired the data. HY analysed the data. SM drafted the manuscript. All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

Conflicts of interest

All authors have disclosed no conflicts of interest.

Funding/support

This research was supported by grant (IR.IUMS.REC 1396.31156) from Iran University of Medical Sciences.

Data availability

All data generated or analysed during the present study are available from the corresponding author on reasonable request.

Ethics approval

The study was approved by ethics committee of Iran University of Medical Sciences (reference: IR.IUMS.REC 1396.31156).

Acknowledgment

We thank the Faculty of Behavioral Sciences and Mental Health for financial assistance, and personnel of Iran Psychiatric Hospital, Rasoul Akram Hospital, and Clinic of Behavioral Sciences and Mental Health (Tehran Psychiatric Institute) for their contribution.

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