psychology

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Original Paper

Psychopathology 2014;47:185–193 DOI: 10.1159/000355062

Assessment of Personality Functioning: Validity of the Operationalized Psychodynamic Diagnosis Axis IV (Structure)

Stephan Doering a Markus Burgmer b Gereon Heuft b Dina Menke c

Brigitta Bäumer e Margit Lübking d Marcus Feldmann f Gudrun Schneider b

a Department of Psychoanalysis and Psychotherapy, Medical University of Vienna, Vienna , Austria; b Department of Psychosomatics and Psychotherapy, University of Münster, c Private Practice, and d Alexianer Krankenhaus Münster, Münster , e Private Practice, Senden , and f St. Vinzenz Hospital Rhede, Rhede , Germany

Introduction

Current psychiatric diagnostics focuses more and more on domains beyond symptoms. Especially person- ality functioning has been accepted as highly important for indication and treatment planning. The new revisions of the two international classification systems, i.e. the Di- agnostic and Statistical Manual for Mental Disorders (DSM-5) and the upcoming International Classification of Diseases (ICD-11), both include severity measures for the diagnosis of personality disorders. ICD-11 will focus mainly on interpersonal functioning that will cover 4 or 5 levels from no personality disorder to severe personal- ity disorder [1] . DSM-5 contains a Personality Function- ing Scale with 2 domains and 4 subdomains [2–4] . The domain ‘self’ comprises the subdomains ‘identity’ and ‘self-direction’, the domain ‘interpersonal’ the subdo- mains ‘empathy’ and ‘intimacy’. The subdomains are op- erationalized on 5 levels, and 1 single global rating is made on a 5-point scale from healthy functioning (0) to extreme impairment (4). Since these approaches have been newly developed, corresponding reliability and va- lidity studies for the assessment of severity and personal- ity functioning have not yet been published.

From a clinical point of view, these changes represent a considerable step towards a more sophisticated diagno-

Key Words

Personality functioning · Personality disorder · Severity of personality disturbance · Operationalized Psychodynamic Diagnosis · Reliability · Validity

Abstract

Background: The assessment of personality functioning has recently become a focus of psychiatric diagnostics. The in- terview-based Operationalized Psychodynamic Diagnosis (OPD-2) provides a ‘structure axis’ for the assessment of per- sonality functioning. Methods: One hundred twenty-four psychiatric patients were diagnosed by means of the Struc- tured Clinical Interviews for DSM-IV (SCID-I and SCID-II), un- derwent OPD-2 interviews, and completed 9 questionnaires. Results: The OPD-2 structure axis shows good interrater reli- ability (intraclass correlation = 0.793). Correlations between the OPD-2 structure axis domains and a priori selected ques- tionnaire scales were of medium size and significant. Pa- tients with a personality disorder (PD) showed significantly worse personality functioning than those without. In cluster B PD, personality functioning was more severely impaired than in cluster C PD. Discussion: The OPD-2 structure axis shows good reliability as well as concurrent and discriminant validity and can be recommended for clinical use and re- search purposes. © 2013 S. Karger AG, Basel

Received: November 28, 2012 Accepted after revision: August 15, 2013 Published online: October 26, 2013

Prof. Stephan Doering, MD Department of Psychoanalysis and Psychotherapy Medical University of Vienna Währinger Gürtel 18–20, AT–1090 Wien (Austria) E-Mail stephan.doering   @   meduniwien.ac.at

© 2013 S. Karger AG, Basel 0254–4962/13/0473–0185$38.00/0

www.karger.com/psp

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sis and indication for treatment. One and the same axis I or axis II disorder might occur with different degrees of impairment in personality functioning. There are, e.g., patients suffering from borderline personality disorder who are able to function sufficiently in their job or main- tain a number of relationships. In contrast, other border- line patients are completely unable to work or build up interpersonal relationships. The diagnostic information about these domains is highly relevant for treatment planning and will guide decision making during the ther- apeutic process. Moreover, it allows for the anticipation of problems within the therapeutic relationship, non- compliance, or troubles in the patient’s real life.

The concept of personality functioning is closely re- lated to what is called personality structure or personal- ity organization in the psychoanalytic tradition. While structure or organization represent theoretical concepts of the intrapsychic makeup of a person, personality functioning refers to the observable manifestations of the structural conditions. In other words: structure stands for the basic availability of capacities while func- tioning describes the actual use of these capacities that can be assessed.

The dimension of personality structure has been part of the psychoanalytic/psychodynamic theory and re- search since Sigmund Freud presented his first structural model in 1900 [5] . Later he pointed out that the aim of psychoanalysis was the ‘practical recovery of the patient, the restoration of his ability to lead an active life and of his capacity for enjoyment’ [6] . These capacities can be regarded the precursors of what we today call personality functioning. Kernberg [7] developed the most influential conceptualization of personality structure, which he calls personality organization, with the aim to differentiate be- tween mature, less severe personality disorders (e.g. ob- sessive-compulsive) and severe personality disorders (e.g. borderline personality disorder). For this purpose, he ini- tially defined 3 criteria: identity diffusion, primitive de- fense mechanisms, and reality testing that were comple- mented by quality of object relations, integration of ag- gression, and super-ego functioning (moral values) [7, 8] . For the assessment of these dimensions, he created the Structural Interview [9] that was recently transformed into the Structured Interview for Personality Organiza- tion [10] .

In reaction to the publication of DSM-IV [11] and ICD-10 [12] and their neglect of etiological factors and psychopathology beyond symptoms, the Operational- ized Psychodynamic Diagnosis (OPD) was developed by a large group of German-speaking psychiatrists and

clinical psychologists in the 1990s. The aim of this diag- nostic system was to complement the phenomenological classification systems of DSM-IV and ICD-10 by psy- chodynamic dimensions. This approach resulted in an interview-based instrument covering 5 axes: (I) experi- ence of illness and prerequisites for treatment, (II) inter- personal relations, (III) conflict, (IV) structure, and (V) mental and psychosomatic disorders [13–15] . The 2nd revision, OPD-2, was published in 2006 [16] ; the English translation came out in 2008 [17] . The observer-rated diagnostic system is based on a clinical interview and can be employed in clinical and research settings. The OPD-2 has been translated into English, Spanish, Russian, Chinese, Italian, and Hungarian. It has been used in numerous empirical studies (for an overview, see OPD Task Force [ 17 ; pp. 19–30], and http://www.opd- online.net/).

The OPD-2 axis IV aims at the assessment of psychic structure [16–18] . It refers to the concept of Kernberg mentioned above, but also adopts ego psychological as- pects of personality functioning like Hartmann’s [19] concept of the functions of the ego helping an individual adjust and adapt to his or her reality. According to the OPD-2, structure becomes visible in the shape of capaci- ties or abilities of the self. As a consequence, the 8 do- mains of the axis cover the capacities for self and object recognition, regulation, communication, and attach- ment.

In this study, we evaluated the reliability and validity of the OPD-2 structure axis in 124 psychiatric patients. Structured Clinical Interviews for DSM-IV (SCID-I and -II) were used for diagnosing psychiatric disorders and for the determination of discriminant validity. Scales from 9 well-validated questionnaires served as external criteria for the assessment of concurrent validity.

Methods

Study Design This study was approved by the ethics committee of the medi-

cal faculty of the Westfälische Wilhelms University Münster, Germany; all subjects gave written informed consent after detailed information about the study had been given. Every patient was di- agnosed according to the DSM-IV [11] by means of the SCID-I and -II [20, 21] and underwent an OPD-2 interview that was vid- eotaped. An additional interview, the Structured Interview for Personality Organization [10] , was conducted, the results of which are not reported here. Moreover, all participants of the study com- pleted 9 self-rating questionnaires (see below).

The SCID interviews were done by 4 clinically experienced in- terviewers (2 psychiatrists and 2 psychologists). Two out of these

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interviewers performed the OPD-2 interviews (D.M., M.F.). They underwent extensive OPD-2 training (curriculum of 3 × 20 h) be- fore the study and were certified for sufficient reliability by the OPD Task Force. All interviews were videotaped, and every inter- view was rated by 1 out of 4 senior members of the OPD Task Force (S.D., M.B., G.H., G.S.). Consensus ratings between the interview- er’s and the expert’s ratings were gathered by discussing every vid- eotape.

Patients One hundred twenty-five psychiatric patients were recruited

between October 2007 and November 2009 at a psychiatric hospi- tal and a private practice in Münster (Germany). Inclusion crite- rion was the presence of a psychiatric disorder according to DSM- IV, and exclusion criteria were (1) cognitive deficit due to severe organic, psychotic, or substance abuse disorder, mental retarda- tion, or psychotropic medication and (2) insufficient knowledge of the German language.

Assessments Operationalized Psychodynamic Diagnosis (OPD-2). The OPD

[13, 14] was developed in the 1990s to allow for a multidimension- al interview-based diagnosis of psychiatric disorders; in 2006, the second revision, OPD-2, was published [16, 17] . In addition to the symptomatic diagnosis according to ICD-10 [12] or DSM-IV [11] , 4 axes are provided: (I) experience of illness and prerequisites for treatment, (II) interpersonal relations, (III) conflict, and (IV) structure. Axis I covers aspects like severity and chronicity of the disease, lay etiology, psychological strain, motivation for treat- ment, social support, psychological mindedness, and secondary gain. Axis II is based on classical circumplex models of interper- sonal behavior and focuses on dysfunctional relationship patterns. Axis III provides operationalization of 7 neurotic conflicts: (a) in- dividuation versus dependency, (b) submission versus control, (c)  need for care versus self-sufficiency, (d) self-worth conflict, (e) guilt conflict, (f) oedipal conflict, and (g) identity conflict. Axis

IV is designed for the evaluation of psychic structure. It contains 8 domains with 3 structural facets each ( table 1 ). A detailed opera- tionalization of the 24 items is provided for 4 levels of structural integration: high, moderate, low, and disintegrated. Based on the operationalizations of the 3 facets, ratings for each of the 8 do- mains are given on a 7-point scale (1 = high; 1.5; 2 = moderate; 2.5; 3 = low; 3.5; 4 = disintegrated). Finally, a 7-point general assess- ment of psychic structure is provided.

Data for the rating are collected during an unstructured, partly semi-structured clinical interview of 60–90 min that contains some obligatory questions, like the exploration of relationship ep- isodes and self and object description. The interviewer is asked to keep a neutral attitude and to pose open questions, with the aim to support the emergence of aspects of transference during the inter- view. In certain phases of the interview, the interviewer adapts a more exploratory style to collect specific information. For clinical use, the interviewer performs the rating immediately after the in- terview. For research purposes, the interview is videotaped and rated by 2 independent certified OPD raters with a concluding consensus rating. For training as well as for rating purposes, the OPD-2 manual [16, 17] is used.

Structured Clinical Interviews for DSM-IV. SCID-I and -II [20, 21] represent the official diagnostic tools for the Diagnostic and Statistical Manual of Mental Disorders [11] . SCID-I aims at symp- tom disorders, and SCID-II at personality disorders. The instru- ment is established as gold standard for the reliable assessment of psychiatric disorders.

Borderline Personality Inventory. The Borderline Personality Inventory (BPI; German: ‘Borderline Persönlichkeitsinventar’) [22] was developed for the assessment of personality organization (i.e., personality functioning) according to Kernberg [7] . The questionnaire contains 53 dichotomous items which cover the di- mensions (1) identity diffusion, (2) primitive defense mechanisms and object relations, (3) reality testing, and (4) fear of closeness. Satisfactory reliability and validity have been demonstrated for the instrument [22–24] .

Table 1. The domains and items of the OPD-2 structure axis

Cognitive ability: self-perception Cognitive ability: object perception Self-reflection Self/object differentiation Affect differentiation Whole object perception Identity Realistic object perception

Capacity for regulation: self-regulation Capacity for regulation: regulation of object relationship Impulse control Protecting relationships Affect tolerance Balancing of interests Self-worth regulation Anticipation

Emotional ability: internal communication Emotional ability: communication with the external world Experiencing affects Making contact Use of fantasies Communication of affect Bodily self Empathy

Attachment capacity: internal objects Attachment capacity: external objects Internalization Ability to make attachments Use of introjects Accepting help Variable attachments Severing attachments

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Coping with Conflict Questionnaire. This questionnaire ( German: ‘Fragebogen zu Konfliktbewältigungsstrategien’) [25] was developed in the style of the Defense Mechanism Inventory [26] . It assesses defense and coping styles by means of 10 short narrations of conflictual social situations. Subjects have to judge 10 possible emotional and behavioral reactions of one of the act- ing persons on a 4-point scale. The reporting reveals 5 dimen- sions: (1) reversal, (2) turning against self, (3) turning against ob- ject, (4)  intellectualization/rationalization, and (5) projection. The German version of the questionnaire shows good reliability and validity [25] .

State-Trait Anger Expression Inventory. The State-Trait Anger Expression Inventory [27] (German: ‘State-Trait-Ärgerausdrucks- Inventar’ [28] ) represents a well-established 44-item self-rating in- strument for the assessment of state and trait anger as well as 3 different types of anger expression: (1) anger out (describes the amount of the overt and direct expression of anger), (2) anger in (covers avoidance of anger expression and the suppression of an- ger), and (3) anger control (evaluates the ability to control feelings and expression of anger).

Scales of Emotional Experience. The Scales of Emotional Expe- rience [29] (German: ‘Skalen zum Erleben von Emotionen’) emerged from client-centered theory of personality and concepts of emotional intelligence. The questionnaire contains 42 items that are rated on a 5-point scale. It covers the domains (1) acceptance of emotions, (2) overwhelming emotions, (3) lack of emotions, (4) somatic symbolization of emotions, (5) imaginative symbolization of emotions, and (6) self-control. The German version of the ques- tionnaire yielded satisfactory reliability and validity.

Toronto Alexithymia Scale. The Toronto Alexithymia Scale [30] (German: ‘Toronto-Alexithymie-Skala’ [31] ) is a widely used instrument for the assessment of the capacity to experience and express internal processes and emotions, i.e. alexithymia. The 26 items of the questionnaire are rated on a 5-point scale. The German version of the instrument contains 3 scales: (1) problems with identification of feelings, (2) problems with expression of feelings, and (3) and externalizing cognitive style, as well as a total alexi- thymia score.

Frankfurt Self-Concept Scales. This questionnaire (German: ‘Frankfurter Selbstkonzeptskalen’) [32] was developed to assess an individual’s attitudes, cognitions, emotions, and behavior towards him- or herself. It is assumed that a stable personality goes along with a positive self-concept. The 78 items of the self-rating instru- ment are answered on a 6-point scale. The questionnaire provides 10 subscales representing different self-concepts: (1) general fit- ness, (2) general ability to solve problems, (3) confidence concern- ing conduct and decisions, (4) general self-esteem, (5) sensitivity and mood, (6) firmness against others, (7) contact and ability to communicate, (8) esteem by others, (9) irritability by others, and (10) feelings and relations to others. The test shows satisfactory characteristics [32] .

Frankfurt Body Concept Scales. This instrument (German: ‘Frankfurter Körperkonzeptskalen’) [33] is closely related to the Frankfurt Self-Concept Scales and aims at the individual’s atti- tudes, cognitions, experience, emotions, and behavior towards the own body. Sixty-four items are rated on a 6-point scale. The 9 di- mensions of the instrument are: (1) state of health, (2) body care and outer appearance, body functioning, (3) fitness of the body, (4) body contact, (5) sexuality, (6) self-acceptance of the body, (7) ac- ceptance of the body by others, (8) aspects of bodily appearance,

and (9) self-acceptance of body smell. The test shows satisfactory characteristics [33] .

Experiences in Close Relationships Questionnaire. The Experi- ences in Close Relationships questionnaire [34] (German: ‘Bo- chumer Bindungsfragebogen’ [35] ) aims at the assessment of at- tachment in intimate relationships. Thirty-six items are rated on a 7-point scale. Attachment is evaluated on the 2 dimensions anxiety and avoidance with low scores in healthy persons. Reliability and validity of the German version of the questionnaire have been re- ported to be satisfying [35] .

Rosenberg Self-Esteem Scale. The Rosenberg Self-Esteem Scale [36] (German: ‘Rosenbergskala’ [37] ) assesses self-esteem and self- derogation by means of 10 self-rating items. The instrument is in- ternationally well established; the German version shows good re- liability and validity [37] .

Hypotheses All of the 9 questionnaires used for the determination of con-

current validity of the OPD structure axis were chosen because they aim at different aspects of personality functioning that cor- respond to the underlying domains of personality structure. The BPI is the only instrument that explicitly focuses on personality structure; the other instruments assess capacities (e.g. self-esteem, affect regulation, self-concept, body concept, coping with stress, or attachment) mostly without conceptually relating them to person- ality structure. However, it was made sure that the theoretical con- cepts underlying the questionnaire scales are consistent with the corresponding OPD-2 structure axis domains.

For the determination of the construct validity correlations of the OPD-2 structure axis domains with specific scales of the ques- tionnaires were hypothesized a priori. Table 2 contains the OPD-2 domains and the questionnaire scales; scales that were assumed to correlate are marked in gray. The hypothesized correlations cor- respond with the direction of the correlations reported in table 2 .

Due to the fact that the OPD-2 domains are based on one and the same construct, i.e. personality structure, it was expected that significant intercorrelations among the 8 subdimensions of the OPD-2 structure axis would appear.

Moreover, it was assumed that patients with personality disor- der show higher total OPD-2 scores than patients without person- ality disorder, and that patients with solely cluster B personality disorder reveal a worse personality structure than those with clus- ter C personality disorder only (discriminant validity).

Statistics Internal consistency of the OPD-2 structure axis was assessed

by means of Crohnbach’s α, including the ratings of the 8 subdi- mensions. For the determination of interrater reliability, intraclass correlations (one-way random intraclass correlation for single measures) were calculated. According to the hypotheses ( table 2 ), Spearman correlations were calculated. t tests were used for group comparisons (discriminant validity). IBM SPSS Statistics 20.0 (IBM Corporation, Armonk, N.Y., USA) was employed.

Sample Characteristics One inpatient had to be excluded from the study because she

did not complete the OPD-2 interview; thus, 124 patients were in- cluded in the analyses. Ninety-three patients (75.0%) were psychi- atric inpatients and 31 (25.0%) were outpatients of a psychothera- pist’s private practice. Demographic data and diagnoses according

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to DSM-IV [10] are given in table 3 . Considering axis I disorders, 1.6% received no diagnosis, 43.2% had one diagnosis, and 55.2% had more than one diagnosis. Considering axis II disorders, 37.1% had no diagnosis, 29.8% had one, and 33.1% had more than one diagnosis.

Results

Interrater Reliability Interrater reliability was determined by calculating in-

traclass correlation (one-way random intraclass correla- tion for single measures) of the interviewer’s and the se- nior rater’s assessments before the consensus rating was made. Intraclass correlation was 0.793 for the global rat- ing of structural integration and 0.629–0.822 for the 8 di-

mensions (self-perception 0.703, object perception 0.732, self-regulation 0.822, regulation of object relationship 0.789, internal communication 0.814, communication with the external world 0.629, attachment to internal ob- jects 0.772, and attachment to external objects 0.725).

Correlations of OPD-2 and Questionnaire Scales Table 2 shows the correlations of the OPD-2 struc-

ture axis domains and the a priori selected question- naire scales. All but one correlation are significant in the predicted direction. If a Bonferroni correction is em- ployed, the level of significance is reduced to p < 0.002, which results in 4 out of 22 correlations that failed to reach significance. The correlations vary between 0.178 and 0.523. Most of them can be regarded as medium size (0.3–0.5).

Table 2. Intercorrelations among OPD-2 domains and corresponding questionnaire scales

ODP-2 domains

se lf- perception

object perception

self- regulation

regulation of object relationship

internal communication

communication with the external world

attachment to internal objects

attachment to external objects

OPD – Self-perception – OPD – Object perception 0.895** – OPD – Self-regulation 0.838** 0.826** – OPD – Regulation of object relationship 0.861** 0.873** 0.887** – OPD – Internal communication 0.884** 0.855** 0.855** 0.861** – OPD – Communication with the external world 0.887** 0.873** 0.851** 0.900** 0.866** – OPD – Attachment to internal objects 0.877** 0.872** 0.868** 0.898** 0.896** 0.874** – OPD – Attachment to external objects 0.871** 0.887** 0.858** 0.899** 0.886** 0.893** 0.920** – BPI – Primitive defense mechanisms and relations to others 0.403** 0.374** 0.416** 0.359** 0.438** 0.370** 0.430** 0.427** BPI – Identity diffusion 0.404** 0.377** 0.401** 0.358** 0.437** 0.369** 0.417** 0.445** BPI – Fear of closeness 0.466** 0.421** 0.508** 0.453** 0.531** 0.443** 0.501** 0.497** FSKN – Feelings and relations to others –0.322** –0.347** –0.341** –0.313** –0.323** –0.268** –0.344** –0.301** FSKN – Contact and ability to communicate –0.215* –0.191* –0.222* –0.187* –0.235* –0.178a –0.241** –0.191* FSKN – Confidence concerning conduct and decisions –0.209* –0.167 –0.202* –0.226* –0.220* –0.182 –0.264**, a –0.300** FSKN – Esteem by others –0.295** –0.266** –0.304** –0.248** –0.242** –0.285** –0.347** –0.332** FKKS – Aspects of bodily appearance –0.183 –0.153 –0.111 –0.102 –0.222*, a –0.079 –0.221* –0.148 FKKS – Turning against object 0.336** 0.360** 0.455** 0.406** 0.393** 0.348** 0.383** 0.381** STAXI – Anger out 0.316** 0.313** 0.348** 0.349** 0.365** 0.323** 0.320** 0.318** SEE – Overwhelming emotions 0.358** 0.301** 0.451** 0.392** 0.376** 0.382** 0.421** 0.422** SEE – Lack of emotions 0.409** 0.327** 0.341** 0.371** 0.365** 0.344** 0.375** 0.408** Rosenberg Scale – Self-derogation 0.441** 0.401** 0.523** 0.424** 0.477** 0.397** 0.497** 0.480** TAS – Problems with identification of feelings 0.454** 0.436** 0.492** 0.417** 0.454** 0.386** 0.483** 0.461** TAS – Problems with expression of feelings 0.325** 0.264** 0.271** 0.268** 0.276** 0.260**, a 0.274** 0.243** BoBi – Avoidance 0.401** 0.329** 0.354** 0.341** 0.372** 0.356** 0.468** 0.392** BoBi – Anxiety 0.321** 0.329** 0.404** 0.323** 0.363** 0.328** 0.405** 0.412**

FSKN = ‘Frankfurter Selbstkonzeptskalen’ (Frankfurt Self-Concept Scales); FKKS = ‘Frankfurter Körperkonzeptskalen’ (Frankfurt Body Concept Scales); STAXI = ‘State-Trait-Ärgerausdrucks-Inventar’ (State-Trait Anger Expression Inventory); SEE = ‘Skalen zum Erleben von Emotionen’ (Scales of Emotional Experience); TAS = ‘Toronto-Alexithymie-Skala’ (Toronto Alexithymia Scale); BoBi = ‘Bochumer Bindungsfragebogen’ (Experiences in Close Relationships questionnaire). Hypothesized correlations are marked in gray. * p < 0.05; ** p < 0.01; a p ≥ 0.002, not significant after Bonferroni correction.

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The correlation between the total scores of the OPD-2 structure axis and the BPI, which represents the only questionnaire employed here that assesses personality structure in a narrower sense, was r = 0.600 (p < 0.001). All OPD-2 subdimensions of the structure axis correlate significantly among each other. All correlations were found to be above 0.8 ( table 2 ).

Correlations of OPD-2 and Personality Disorders Table 4 displays the differences between patients with

and without a personality disorder regarding the OPD-2 structure domains. Patients with a personality disorder yielded significantly worse personality functioning in all domains compared to patients without a personality dis- order. The between-group effect size of the total score was d = 1.31.

In addition, patients with cluster B personality disor- ders only (n = 30) were compared to patients with cluster C personality disorders only ( table 5 ). Since only 1 patient had an isolated cluster A personality disorder, no cluster A group could be included in the analysis. Cluster B pa- tients showed a significantly less integrated personality structure throughout all domains. The between-group ef- fect size of the total score was d = 1.15.

To assure that the OPD-2 structure axis determines personality structure and not just general psychosocial functioning, all of these analyses were controlled for psy- chosocial functioning assessed by the Global Assessment of Functioning Scale of the DSM-IV [11] by means of analyses of covariance. All comparisons between patients with and without a personality disorder as well as be- tween cluster B versus cluster C personality disorders re- mained significant.

Discussion

The validity of the structure axis of the OPD [16, 17] was evaluated in a sample of 124 psychiatric patients. The interrater reliability was satisfying with an intraclass cor- relation of 0.793 for the global rating of structural inte- gration and 0.629–0.822 for the 8 OPD-2 dimensions. These results are in line with previous studies: Benecke et al. [38] reported a weighted κ of 0.609–0.817 for the di- mensions and 0.826 for the total score; Freyberger et al. [39] reported a mean interrater reliability for the struc- ture dimensions of the OPD-1, the first edition of the OPD [13, 14] , of 0.72, and Rudolf et al. [40] found a weighted κ of 0.75 for the total score. Taken together, these results demonstrate a good interrater reliability for

Table 3. Sample characteristics (n = 124)

Age, years 40.87±14.63 (18–70) Gender

Female 85 (68.5) Male 39 (31.5)

Education No compulsory school 9 (7.3) Compulsory school 36 (29.0) Apprenticeship/vocational school 29 (23.4) A-level 33 (26.6) Academic 9 (7.3) Other 8 (6.5)

Employment In occupational training 13 (10.5) Unemployed 31 (25.0) Part-time 18 (14.5) Full-time 34 (27.4) Homemaker 7 (5.6) Retired (due to disorder) 17 (13.7) Other 4 (3.2)

Family status Single 38 (30.6) Unmarried with partner 15 (12.1) Married 44 (35.5) Divorced/separated 18 (14.5) Widowed 3 (2.4) Missing values 6 (4.8)

Diagnoses on DSM-IV axis Ia Substance abuse disorders 35 Mood disorders 108 Brief psychotic disorder 1 Anxiety disorders 38 Posttraumatic stress disorder 16 Obsessive-compulsive disorder 8 Somatoform disorders 13 Eating disorders 11 Other 10

Diagnoses on DSM-IV axis II (personality disorders)a Paranoid 14 Schizoid 4 Schizotypal 1 Obsessive-compulsive 20 Histrionic 4 Dependent 14 Antisocial 13 Narcissistic 15 Avoidant 24 Borderline 36 Depressive 8 Passive-aggressive 3

OPD-2 level of structural integration 1 (high) 1 (0.8) 1.5 18 (14.5) 2 (moderate) 56 (45.2) 2.5 15 (12.1) 3 (low) 32 (25.8) 3.5 2 (1.6) 4 (disintegrated) 0

Figures are numbers with percentages in parentheses or mean ± SD with range in parentheses.

a More than one diagnosis per patient included.

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the OPD, particularly if it is taken into consideration that OPD-2 is a clinical and not a structured interview like SCID-I and -II.

The main part of this study dealt with concurrent va- lidity, i.e., the correlation of OPD-2 dimensions with oth- er, previously validated instruments that aim at the as- sessment of similar concepts. Twenty-two scales from 9 questionnaires covering different aspects of personality functioning were a priori selected, and hypothesized cor- relations were tested. After Bonferroni correction, all but 4 scales correlated significantly with the corresponding OPD-2 dimensions. The correlations were consistently of medium size. This seems acceptable when considering that OPD-2 is an expert rating and the employed psycho- metric scales are self-rated, and that the underlying con- cepts are not identical. Let us take the example of the di- mension capacity for regulation: self-regulation com-

prises the facets impulse control, affect tolerance, and self-worth regulation, but only the latter is included in the Rosenberg Self-Esteem Scale. The correlation of the total scores of the OPD-2 structure axis and the BPI was high (r = 0.600), which confirms the fact that both instru- ments aim at the assessment of personality structure. These results approve the external validity of the OPD-2 dimensions. Similar results were reported for the OPD-1 structure axis [17] .

We have found high intercorrelations among the 8 OPD subdimensions (>0.8). This indicates that the 8 scales are not at all independent from each other, a fact that was expected because all dimensions originate in the same basic construct, i.e. personality structure. Kernberg [7] , as one of the most prominent authors, assumed that all dimensions of personality structure are different man- ifestations of an underlying core pathology, namely iden-

Table 4. OPD-2 structure ratings in patients with and without personality disorders (t test)

OPD-2 domain Personality disorder (mean ± SD) Statistics

no (n = 46) yes (n = 78) t d.f. p

Self-perception 1.90±0.39 2.41±0.53 –5.68 122 <0.001 Object perception 1.91±0.45 2.44±0.54 –5.55 122 <0.001 Self-regulation 2.02±0.43 2.50±0.46 –5.78 122 <0.001 Regulation of object relationship 1.95±0.45 2.53±0.48 –6.73 122 <0.001 Internal communication 1.97±0.39 2.46±0.52 –5.59 122 <0.001 Communication with the external world 1.90±0.40 2.46±0.52 –6.22 122 <0.001 Attachment to internal objects 1.85±0.39 2.40±0.49 –6.54 122 <0.001 Attachment to external objects 1.81±0.41 2.41±0.50 –6.86 122 <0.001

Total score 1.88±0.40 2.49±0.50 –6.99 122 <0.001

Table 5. OPD-2 structure ratings in patients with cluster B and cluster C personality disorder (t test)

OPD-2 domain Personality disorders (mean ± SD) Statistics

cluster B (n = 30)

cluster C (n = 20)

t d.f. p

Self-perception 2.60±0.48 2.20±0.44 4.27 48 <0.001 Object perception 2.62±0.49 2.10±0.53 3.56 48 0.001 Self-regulation 2.68±0.45 2.20±0.34 4.12 48 <0.001 Regulation of object relationship 2.72±0.45 2.28±0.44 3.43 48 0.001 Internal communication 2.68±0.44 2.10±0.45 4.53 48 <0.001 Communication with the external world 2.67±0.46 2.15±0.46 3.88 48 <0.001 Attachment to internal objects 2.60±0.48 2.10±0.38 3.89 48 <0.001 Attachment to external objects 2.60±0.42 2.10±0.48 3.89 48 <0.001

Total score 2.70±0.48 2.18±0.41 4.00 48 <0.001

Doering/Burgmer/Heuft/Menke/Bäumer/ Lübking/Feldmann/Schneider

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tity diffusion, which represents the result of a disturbed development during childhood due to genetic disposition and mainly adverse early relationships. Theoretically, one could argue that 1 dimension would be sufficient to de- termine personality structure or functioning. However, to reduce the OPD-2 structure axis to 1 or 2 dimensions might reduce the reliability of the instrument, since an erroneous scoring of 1 or 2 dimensions is remediated by the scoring of the remaining 6 or 7 OPD-2 dimensions. From a clinical point of view, one is reluctant to relin- quish the essential clinical information derived from each of the 8 dimensions.

The question whether the OPD-2 structure axis can differentiate between patients with and without personal- ity disorders is of particular interest, since the DSM-5 provides the Levels of Personality Functioning Scale par- ticularly for the diagnosis of personality disorders [4] . Our results impressively confirm the DSM-5 assumption that patients with personality disorders do suffer from deficits in personality functioning. The OPD rating of 1.88 in patients without personality disorder denotes a slightly better than moderate level of integration, whereas the 2.49 of the patients with personality disorder stands for moderate to low levels of integration (between-group effect size d = 1.31).

According to Kernberg [7] , patients with cluster B personality disorders are characterized by more severe deficits in personality functioning than patients with cluster C personality disorders. This hypothesis was also confirmed by our results: the group of patients who suf- fered from cluster B personality disorder yielded a sig- nificantly worse structural integration than the cluster C group (d = 1.15). These results for the differential valid- ity of the OPD-2 structure cannot be explained solely by general psychopathology, since the group differences re- mained significant after controlling for general psycho- social functioning (Global Assessment of Functioning

Scale score). Taken together, these analyses show that the OPD-2 structure axis is characterized by good dis- criminant validity. This was already reported previously for the OPD-1 structure axis, which detected worse per- sonality functioning in patients with personality disor- ders, addiction disorders, and self-mutilating behavior [41–43] .

The OPD-2 structure axis represents a reliable and valid tool for the assessment of personality functioning. In a clinical setting, OPD-2 allows a complete multidi- mensional diagnosis and treatment planning on the basis of a modified unstructured, partly semi-structured clini- cal interview. The instrument has also proven its useful- ness for quality assurance [44] . For research purposes, the OPD-2 demands expert ratings on the basis of video- taped interviews, which implicates a considerable effort. However, the OPD-2 assessment of personality function- ing is of proven high reliability and validity. As a conse- quence, the OPD-2 can be regarded as a first-choice in- strument for future studies on personality functioning according to DSM-5. It might serve as a tool for valida- tion of the DSM-5 Levels of Personality Functioning Scale. First results demonstrated that the OPD-2 struc- ture axis is well suited for this purpose and might add important information to the DSM-5 diagnosis [45] . Moreover, the OPD-2 can serve the purpose to determine deficits in personality functioning in different psychiatric disorders, and thus facilitate treatment planning and modification. In psychotherapy research, it can be em- ployed in future studies for the evaluation of changes in personality functioning during treatment.

Disclosure Statement

The authors declare no commercial or financial conflicts of in- terest in regard to the submitted article.

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