Validation of the “Assessment of DSM-IV Personality

Disorders (ADP-IV)” Questionnaire1

Stephan Doering2,3,4, Daniela Renn4, Stefan Höfer4, Gerhard Rumpold4, Ulrike Smrekar4,
Nicola Janecke4, Dieter S. Schatz4, Chris Schotte5, Dirk DeDoncker5, and Gerhard Schüßler4

Summary

Objectives: The “Assessment of DSM-IV Personality Disorders (ADP-IV)” represents a 94-

item questionnaire that allows for a categorical and dimensional assessment of the DSM-IV
personality disorders.
Methods: Psychometric properties of the German ADP-IV were investigated in 400
psychotherapy outpatients and a community sample of 385 persons. The SCID-II interview
and a standardised expert consensus rating were employed for the assessment of concurrent
validity.
Results: The ADP-IV showed satisfactory reliability; the median Cronbach´s α for the
subscales was .76 (range .65 - .87), the median retest reliability .79 (range .37 - .88). Factor
analysis revealed an 11-factor solution that explained 49.4% of the variance. The median
correlation of the dimensional ADP-IV subscale scores with the SCID-II and the expert
consensus ratings were .51 (range: 34 - .72) and .44 (range: .27 - .62), respectively. The
kappas for the chance corrected agreement of categorical ADP-IV diagnoses with the SCID-II
diagnoses and the expert ratings were .35 and .29 for any personality disorder and a median of
.37 and .30 for the specific personality disorders.
Conclusions: The ADP-IV shows satisfactory reliability and a validity that is comparable and
partly superior to other self-rating instruments. The advantages of the instrument are its
brevity, the inclusion of distress ratings, and the dimensional scoring that allows for the
construction of detailed profiles of personality pathology. Moreover it is freely available in
the internet (download: http://zmkweb.uni-muenster.de/einrichtungen/proth/dienstleistungen/
psycho/diag/index.html).

Keywords

Personality disorders - diagnosis - questionnaire - Reliability - validity

1
This study was supported by a grant of the ”Jubiläumsfonds der Österreichischen Nationalbank“,
project # 9141.
2
University of Muenster, Germany, Department of Prosthodontics
3
University of Muenster, Germany, Department of Psychosomatics and Psychotherapy
4
Innsbruck Medical University, Austria, Clinical Department of Psychological Medicine and Psychotherapy
5
University Hospital Antwerp (UZA), Belgium, Department of Psychiatry
 1

1. Introduction

The assessment of personality disorders represents one of the most challenging issues in
psychiatry (Leibing & Doering 2006; Schüßler et al. 2006). The current conceptualization and
classification of personality disorders in the DSM-IV has been criticised for its lack of
empirical basis (Westen & Shedler 1999; Widiger & Sanderson 1995). Especially the
categorical approach of the DSM-IV axis II (Saß et al. 2003) and ICD-10 (Dilling et al. 2004)
has been opposed, because the dichotomization of continuous variables (the diagnostic
criteria) into present/absent, is neither theoretically nor statistically sensible (Leibing et al. in
press; Westen & Shedler 1999; Widiger & Sanderson 1995; Wöller & Tress 2005). As a
consequence, the categorical approach fails to cover personality pathology of patients who
seek and need treatment, but do not fall within one of the categories, because they do not fulfil
enough diagnostic criteria of one and the same personality disorder (Westen & Shedler 1999;
Heuft et al. 2005). Moreover, comorbid pathological personality traits of other categories than
the diagnosed one are not being described by the current DSM-IV classification.
In 1991 Widiger made the proposal to assess the DSM-III-R personality disorder categories
on a dimensional basis. In his model six levels are provided for a rating of each personality
disorder on the basis of the number of present diagnostic criteria. The rating of each of the
personality disorders results in a profile of personality pathology, which provides important
additional information without demanding too much effort from the diagnostician.
In addition to these conceptual issues, the construction of instruments for the measurement of
personality disorders represents a major problem. Since the introduction of the DSM-III
diagnostic criteria for personality disorders the reliability of these diagnoses has benefited to a
great deal (Perry 1992), but the validity of the assessment remains a major problem. In 1983
Spitzer stated that an expert consensus rating on the basis of all available data represents the
“gold standard” for a valid diagnosis of a personality disorder (Longitudinal Experts using
All Data, LEAD). As a consequence, diagnostic instruments have to prove their external
validity in comparison to LEAD diagnosis on the basis of the corresponding classification, i.e.
DSM-IV. A number of interviews have been presented, that showed acceptable validity, e.g.,
the “Structured Clinical Interview for DSM-IV, Axis II (SCID-II)” (Fydrich et al. 1997) and
the “International Personality Disorder Examination (IPDE)” (Loranger et al. 1994).
However, these interviews have to be learned in extensive training courses and they are quite
time consuming. Thus, the assessment of personality disorders by means of questionnaires
represents a widely used alternative for everyday clinical use. These self-rating instruments
are easily applicable and cost saving, but they tend to show unacceptably low validity.
A number of questionnaires for the assessment of personality disorders have been published.
The “Personality Diagnostic Questionnaire” (PDQ; Hyler & Rieder 1987; Hyler et al. 1988;
Hyler 1994) is the only one of these that has been translated into German and validated in a
small sample of 60 patients (Bronisch et al. 1993). This questionnaire represents a 99-item
true-false questionnaire that yields personality disorder diagnoses consistent with DSM-IV
criteria and reveals categorical diagnoses, only. The SCID-II interview manual (Fydrich et al.
1997) contains a 94-item true/ false screening questionnaire. Two more self-rating
instruments for the assessment of personality disorders have not yet been published in a
 2

German translation: The “Millon Multiaxial Inventory” (MCMI, Millon 1977; MCMI-III,
Millon et al. 1994) and the “Wisconsin Personality Disorders Inventory” (WISPI, Klein et al.
1993), that has been derived from Lorna S. Benjamin´s (1993) interpersonal theory. The
disadvantage of both instruments lies in the high number of items.

In 1998 a new self-rating instrument was presented by Schotte et al., that was designed to
overcome the limitations of the categorical assessment of personality disorders while adhering
to the DSM-IV criteria: The ”Assessment of DSM-IV Personality Disorders” (ADP-IV).
Similar to the SCID-II screening questionnaire each of the 94 diagnostic criteria of the DSM-
IV is addressed by one question, but the rating is not a dichotomous one, but a dimensional
one by means of a 7-point scale. Moreover, an assessment of distress caused by the positively
rated personality trait is provided. In accordance with Widiger´s model the ADP-IV allows for
a categorical and a dimensional diagnosis of DSM-IV personality disorders.
In this study the German translation of the ADP-IV was validated on 400 psychotherapy
outpatients and a community sample of 385 persons. The aims of the study were the
evaluation of: (1) Internal consistency and factor analysis of the ADP-IV items, (2)
assessment of retest reliability, and (3) concurrent validity with the SCID-II interview and an
expert consensus rating.

2. Method

2.1 Subjects

At the psychotherapy outpatient unit of the Clinical Department of Medical Psychology and
Psychotherapy, Innsbruck Medical University, Austria, 643 outpatients were asked to
participate in the study. Four hundred (62.2%) gave informed consent and were included into
the investigation. Inclusion criteria were: Age ≥ 18 years, sufficient knowledge of German
language. Exclusion criteria were: Cognitive impairment, acute psychotic disorder, and severe
affective disorder. All patients completed the ADP-IV questionnaire, in 210 patients
additionally a SCID-II interview was conducted. In addition, a representative sample of the
population of the Austrian county of Tyrol, consisting of 385 persons was assessed by means
of the ADP-IV questionnaire. Out of these 41 completed the questionnaire for a second time
after a period of four weeks. This sample corresponds to the community of Tyrol with regard
to age, gender, and education (data from http://www.statistik.at).

2.2 Instruments

Assessment of DSM-IV Personality Disorders (ADP-IV) questionnaire

The self assessment instrument consists of 94 items that correspond to the diagnostic criteria
for personality disorders of the DSM-IV (see Figure 1 for translated sample items). Each trait-
item has to be assessed on a seven point scale. If the rating is 5 or above, an additional
distress rating on a three point scale from 1 to 3 has to be answered (response format see
Figure 1).
 3

The scoring of the ADP-IV reveals a dimensional trait-score and a categorical (yes/ no) score
for each of the DSM-IV personality disorders. The dimensional score is calculated by
summing up the ratings of the trait questions. For the categorical scoring two different
algorithms are provided: (1) an item is scored positively if the trait score is higher than 4 and
the distress score is higher than 1 (T>4 and D>1), (2) an item is scored positively if the trait
score is higher than 5 and the distress score is higher than 1 (T>5 and D>1). A personality
disorder is diagnosed if the number of items scored positively exceeds the DSM-IV threshold.

Figure 1. Design of the ADP-IV

Response format of the ADP-IV items:

1. I always assume that others will take advantage of me, hurt me, or deceive me.

Trait-question Distress-question
To what extent do you Has this characteristic ever
agree with this statement? caused you or others distress
or problems?
1 = totally disagree
2 = disagree 1 = totally not
3 = rather disagree 2 = somewhat
4 = neither disagree nor agree 3 = most certainly
5 = rather agree
6 = agree
7 = totally agree

1 2 3 4 5 6 7
1 2 3

Sample items of the ADP-IV:

Item DSM-IV ADP-IV question

Number criterion *)
2 SZ1 Unlike most other people, I don´t desire intimacy or close
relationships.
8 AV1 Because I fear criticism or rejection I avoid activities at work or at
school that involve a lot of contact with others.
19 NAR2 I´m very often preoccupied with fantasies of being successful,
powerful, brilliant, attractive, or loved.
46 OC4 Compared to other people I´m extremely conscientious, meticulous,
and obstinate where principles, rules, or moral values are concerned.
77 BDL6 My moods or temper are very unstable and volatile; one moment I´m
in normal mood and the next moment I feel totally depressed, furious,
irritable, or anxious.
90 DEP8 Being continuously preoccupied by my fear of being left behind and
having to face things alone typifies me.
*) SZ = schizoid, AV = avoidant, NAR = narcissistic, OC = obsessive-compulsive, BDL = Borderline, DEP = dependent; the number stands
for the number of the corresponding DSM-IV criterion

The authors of the ADP-IV originally published the instrument in Dutch language (Schotte &
De Doncker 1994; 1996; Schotte et al. 1998). The Dutch version was translated into German
 4

by a professional translation agency in Innsbruck, Austria, before the authors of this study
performed the first revision of the German version. After this, a professional translation
agency in Antwerp, Belgium, performed the back-translation. Finally, the German translation
was discussed among the Dutch and the Austrian authors taking into consideration the back-
translation and received a final revision.

Structured Clinical Interview for DSM-IV Axis II (SCID-II)

The SCID-II (Fydrich et al. 1997) represents the American Psychiatric Association’s official
interview instrument for the assessment of the DSM-IV personality disorders. Each of the 94
diagnostic criteria for the 12 personality disorders provided by the DSM-IV is defined by one
or more questions and a short explanation of its content. After addressing the item in a
structured manner, the interviewer assesses the patients answer on a three-point scale (1 =
“absent or false“, 2 = “subthreshold“, 3 = “present“). The positive items (score “3“) are added
and the diagnosis of a personality disorder is given, if the threshold provided by the DSM-IV
manual is exceeded. Additionally, a dimensional (D-) score is calculated by summing up the
scores.

Consensus Rating of Diagnoses of Personality Disorders

To meet the diagnostic “gold standard“ (Spitzer 1983), in addition to the SCID-II ratings, a
standardised expert consensus rating was performed. In accordance with the “prototype
matching approach“ of Westen and Shedler (2000), the authors of this study discussed every
case in a weekly meeting and rated the presence of every DSM-IV personality disorder on a 5
point scale (1 = “no match“, 2 = “slight match, patient has minor features of the disorder“, 3 =
“moderate match, patient has features of the disorder“, 4 = “strong match, patient has the
disorder; categorical diagnosis warranted“, 5 = “very strong match, patient exemplifies the
disorder; prototypical case“). Thus, dimensional (1 to 5) and categorical (1-3 = absence, 4-5 =
presence of the disorder) diagnoses were given blind to ADP-IV but not to SCID-II results.
The expert team consisted of 1 senior psychiatrist, 3 senior psychologists, and 3 residents.

2.3 Statistics

Reliability
Internal consistency was assessed by means of Cronbach’s α and reproducibility (test-retest
reliability) with Pearson’s correlation coefficient. Reproducibility was assessed with repeated
testing of the ADP-IV in a community subsample within a four week period. A high stability
is inherent to the construct of personality disorder, therefore, correlations of .70 or higher
were expected for the estimates of reliability (Tabachnik & Fidell 2001).

Validity
To assess the factor structure a principal component analysis was conducted. Kaiser-Meyer-
Olkin Measure of Sampling Adequacy (KMO) and Bartlett-Test of Sphericity (BTS) were
calculated to assure the applicability of factor analysis (Tabachnik & Fidell 2001). The
number of factors was retained by an Eigenvalue > 1 and Catell´s scree test. The dimensional
 5

diagnostic consensus rating of the DSM-IV personality disorders on the basis of the clinical
and SCID-II interviews was used for the assessment of external validity. Pearson correlations
were applied to assess the concurrency of the dimensional ratings of the ADP-IV and the
consensus rating and SCID-II scores, respectively. Sensitivity and specificity of the
questionnaire for all personality disorders were calculated for the two different scoring
algorithms. In cells with an n ≥ 5 kappa statistics were used to evaluate the extent of the
agreement between the categorical ratings of the ADP-IV scoring algorithms and the SCID-II
and categorical consensus rating. The kappa coefficient (κ) describes the agreement of two
dichotomous variables and ranges from 0 (no agreement) to 1 (total agreement). According to
Fleiss (1981) kappa coefficients ≥ .70 can be regarded as good, coefficients between .40 and
.69 as medium, and below .40 as insufficient.

Table 1. Demographic characteristics

Patients Community sample

(n=400) (n=385)
Age 34.9 + 12.0 yrs 35.2 + 15.0 yrs
Sex f: 279 (69.8%) f: 264 (68.6%)
m: 121 (30.3%) m: 121 (31.4%)
Education
still at school 10 (2.5%) 0 (0.0%)
8 years of school or less without
school leaving certificate 18 (4.5%) 0 (0.0%)
8 years of school without occupational
training 107 (26.8%) 27 (7.0%)
8 years of school with occupational
training 143 (35.8%) 112 (29.1%)
12 years of school (≈ high school) 77 (19.3%) 155 (40.3%)
University 14 (7.3%) 90 (23.4%)
Missing data 31 (7.8%) 1 (0.3%)
Marital status
single 64 (30.8%) 88 (22.9%)
unmarried with partner 63 (30.3%) 131 (34.0%)
married or living together 53 (25.5%) 137 (35.6%)
divorced 27 (13.0%) 22 (5.7%)
widowed 1 (0.5%) 5 (1.3%)

3. Results

Demographic characteristics
The characteristics of the patient and the community sample are shown in Table 1. On the
DSM-IV axis I 166 (79.0%) patients had at least one clinical diagnosis, 16 (7.6%) had two or
more clinical diagnoses (see Table 2a). The consensus rating revealed the diagnosis of at least
one personality disorder in 82 (39.0%) of the patient group and 32 (15.2%) patients received
two or more diagnoses. The T>4 and D>1 ADP-IV algorithm assigned one or more diagnoses
to 90 (42.9%) patients, 64 (30.5%) received two or more diagnoses. The T>5 and D>1 ADP-
IV algorithm revealed one or more diagnoses in 38 (18.1%) patients and 19 (9.0%) received
 6

two or more diagnoses (see Table 2b). Altogether the T>4 and D>1 algorithm diagnosed 281
and the T>5 and D>1 algorithm 79 personality disorders compared to 148 in the consensus
rating (see Table 2b).

Table 2a. DSM-IV diagnoses (n=210). Axis I clinical diagnoses (expert consensus rating);
multiple diagnoses in one and the same patient possible

Axis-I-disorder n (%)
substance-related disorders 19 (9.0%)
schizophrenia or other psychotic disorders (in remission) 2 (1.0%)
mood disorders 29 (13.8%)
anxiety disorders 33 (15.7%)
somatoform disorders 4 (1.9%)
eating disorders 39 (18.6%)
sleep disorders 4 (1.9%)
adjustment disorders 34 16.2%)
psychological factors affecting medical condition 1 (0.5%)
relational problems 4 (1.9%)
disorders usually first diagnosed in infancy, childhood, or 1 (0.5%)
adolescence

Table 2b. DSM-IV diagnoses (n=210). Axis-II according to consensus rating, SCID-II,
and ADP-IV; multiple diagnoses in one and the same patient possible

Personality disorder Consensus SCID-II ADP-IV ADP-IV

rating (T4 and D1) (T5 and D1)
n (%) n (%) n (%) n (%)
paranoid 12 (5.7%) 17 (8.1%) 30 (14.3%) 5 (2.4%)
schizoid 2 (1.0%) 3 (1.4%) 7 (3.3%) 1 (0.5%)
schizotypal 0 (0.0%) 0 (0.0%) 8 (3.8%) 2 (1.0%)
antisocial 6 (2.9%) 9 (4.3%) 35 (16.7%) 12 (5.7%)
Borderline 23 (11.0%) 16 (7.6%) 47 (22.4%) 17 (8.1%)
histrionic 5 (2.4%) 1 (0.5%) 9 (4.3%) 4 (1.9%)
narcissistic 3 (1.4%) 3 (1.4%) 1 (0.5%) 1 (0.5%)
avoidant 28 (13.3%) 32 (15.2%) 40 (19%) 12 (5.7%)
dependent 3 (1.4%) 1 (0.5%) 15 (7.1%) 5 (2.4%)
obsessive-compulsive 16 (7.6%) 19 (9.0%) 50 (12.5%) 11 (5.2%)
depressive 25 (11.9%) 23 (11.0%) 27 (12.9%) 5 (2.4%)
passive-aggressive 7 (3.3%) 8 (3.8%) 12 (5.7%) 4 (1.9%)
Cluster A 14 20 45 8
Cluster B 37 29 92 34
Cluster C 47 52 105 28

Total score 148 132 281 79

 7

3.1 Reliability

Item analysis and internal consistency

The analysis of the internal consistency of the ADP-IV subscales by means of Cronbach´s α
revealed satisfactory values of α>.70 for all but the schizoid and antisocial subscales that
ranged slightly below (r>.65) (see Table 3).
The retest reliability revealed satisfactory values (rtt>.70) for the subscales paranoid,
schizotypal, avoidant, antisocial, histrionic, narcissistic, and depressive. The subscales
dependent, obsessive-compulsive, borderline, and passive-aggressive showed mediocre values
(rtt between .50 and .70), and the subscale schizoid was again unsatisfactory (rtt=.37) (see
Table 3).

Table 3. Analysis of reliability of the ADP-IV (n=785)

Scale Cronbach´s α Test-retest reliability1

(n=41)
paranoid .74 .83
schizoid .65 .37
schizotypal .78 .87
avoidant .85 .78
dependent .80 .69
obsessive-compulsive .72 .64
antisocial .68 .88
Borderline .82 .57
histrionic .80 .79
narcissistic .73 .82
depressive .87 .83
passive-aggressive .71 .56

Median .76 .79

Cluster A .86 .77

Cluster B .91 .82
Cluster C .90 .68

Total score .76

1
all correlations are significant: p<.0001; subscale schizoid: p<.05

3.2 Construct validity

Factor analysis on the ADP-IV item level

The factor structure of the ADP-IV items was assessed by means of a principal component
analysis. The data fulfilled the prerequisites for a factor analysis (Kaiser-Meyer-Olkin = .954,
Bartlet sphericity p<.001). Nineteen factors revealed an Eigenvalue > 1, the scree test did not
yield a definite number of factors. Out of these a number of factors did not allow for a
meaningful interpretation. An 11 factor solution was chosen that was reconcilable with the
 8

scree test and explained 49.4% of the total variance. Moreover, this solution provided the
greatest explanatory value and equals the number of factors of the principal component
analysis of the original Dutch version by Schotte et al. (1998). Two factors did not contain
any items loading ≥ .40, the remaining nine factors permitted a meaningful interpretation (see
Table 4).
Factor 1, negative affect and self-image, contains 17 items belonging to five different
personality disorders. The items mainly represent depressive, dependent, and Borderline
features; it describes traits characterised by negative experience of oneself and negative self-
directed affect. Factor 2, social anxiety and avoidance, is mainly built up by avoidant,
dependent, and schizoid items and describes social withdrawal due to anxiety in interpersonal
situations. Factor 3, egocentrism and exploitation of relationships, represents a mixture of six
histrionic items with antisocial and narcissistic items organised around self-centredness and
lack of concern for others. Factor 4 psychopathy and self-destructiveness is a combination of
antisocial traits and the borderline items 4, 5A, and 5B that stand for self-damaging behaviour
and suicidality. Paranoid features can be found on factor 5 distrust and factor 6 interpersonal
hostility, while factor 7 distance and indifference describes schizoid detachment in
combination with an antisocial lack of guilt feelings. Factor 8 obsessive-compulsiveness and
factor 9 schizotypal cognitions and perceptions quite purely depict the relevant aspects of the
corresponding DSM-IV personality disorders.

Concurrent validity with SCID-II and standardised consensus ratings

The dimensional sum scores of the ADP-IV subscales were correlated with the dimensional
scores of the SCID-II interview and the dimensional consensus rating of personality disorders
according to DSM-IV (Table 5). All correlations were significant (p<.01); the correlations
with the SCID-II were acceptable in paranoid, avoidant, obsessive-compulsive, borderline,
histrionic, and depressive personality disorder (r>.50), mediocre in dependent, antisocial, and
passive-aggressive (r>.40), and low in schizoid, schizotypal, and narcissistic personality
disorder (r>.30). The correlations with the consensus rating sum scores were distinctly lower
than those with the SCID-II. The median of the correlations of the individual personality
disorders was .51 with the SCID-II and .45 with the consensus rating.
The convergence of the categorical ADP-IV diagnoses with the categorical ratings of SCID-II
and the consensus rating were partly unsatisfactory. While the specificity of the ADP-IV
diagnoses was quite high, the sensitivity was rather low in most of the personality disorders.
The T4 and D1 algorithm revealed the higher sensitivity and somewhat lower specificity
rates, while the T5 and D1 algorithm increased the specificity but showed an additional loss
of sensitivity (see Table 6). The kappa for presence vs. absence of any personality disorder
was .38 for the T4 and D1 algorithm and .30 for the T5 and D1 algorithm (both p<.001); for
the kappas for the specific personality disorders see Table 6.
 Table 4. Varimax rotated principal component analysis of the 94 ADP-IV items: 11 factor solution (n=785)

Factor 1 Factor 2 Factor 3 Factor 4 Factor 5 Factor 6 Factor 7 Factor 8 Factor 9 Factor 10# Factor 11#
Negative Social anxiety Egocentrism Psychopathy Distrust Interpersonal Distance and Obsessive- Schizotypal
affect and and avoidance and exploit- and self- Hostility indifference compulsive- cognitions
self-image ation of destructive- ness and percep-
relationships ness tions
0.61 DEP1 0.62 AV1 0.63 HIS1 0.58 AS1 0.57 PAR1 0.60 PA3 0.65 SZ1 0.57 OC1 0.54 ST1
0.57 DE1 0.55 SZ2 0.50 AS2 0.43 BDL4 0.60 PAR2 0.62 PAR5 0.58 SZ6 0.42 OC2 0.71 ST2
0.62 DE2 0.59 AV2 0.52 BDL2 0.56 AS5 0.51 PAR3 0.66 PAR6 0.42 SZ7 0.41 OC3 0.76 ST3
0.44 PA2 0.62 DEP2 0.67 HIS2 0.53 BDL5A 0.44 PAR4 0.49 BDL8 0.60 AS7 0.58 OC4
0.50 BDL3 0.55 DEP3 0.41 HIS3 0.59 BDL5B 0.62 ST5 0.43 OC6
0.62 DE3 0.40 DE3 0.62 HIS4 0.41 ST7 0.41 OC7
0.59 DEP4 0.41 SZ4 0.58 NAR4 0.56 AS8 0.49 NAR9
0.64 DE4 0.68 AV4 0.40 HIS5
0.59 DEP6 0.41 DEP4 0.46 NAR5
0.64 DE6 0.65 AV5 0.41 AS6
0.46 PA6 0.62 AV6 0.44 NAR6
0.60 BDL6 0.51 AV7 0.40 PA7
0.51 HIS7 0.56 ST9 0.63 HIS8
0.59 DE7
0.62 BDL7
0.49 DEP8
0.41 BDL9
9.06* 7.83* 7.63* 4.33* 4.33* 3.39* 3.24* 3.10* 2.66* 1.91* 1.90*
Salient loadings (≥ 0.40) are presented for each ADP-IV item, which represents the corresponding DSM-IV criterion: e.g. AV5 indicates the ADP-IV item representing the fifth
diagnostic criterion of the DSM-IV avoidant personality disorder.
PAR = paranoid, SZ = schizoid, ST = schizotypal, AS = antisocial, BDL = Borderline, HIS = histrionic, NAR = narcissistic, AV = avoidant, DEP = dependent, OC = obsessive-
compulsive, DE = depressive, PA = passive-aggressive. AS8, criterion C (conduct disorder) of antisocial personality disorder; BDL5a, suicidal behaviour; BDL5b, self-mutilating
behaviour.
*Percentage of total variance.
#
None of the items loads ≥.40 on factor 10 and 11.
 Table 5. Correlations of the ADP-IV dimensional subscale scores with the SCID-II
interview and consensus rating (n=210)

Scale SCID-II interview Dimensional consensus

subscale sum scores1 rating1
paranoid .55 .44
schizoid .37 .29
schizotypal .38 .33
avoidant .66 .60
dependent .46 .36
obsessive-compulsive .53 .54
antisocial .48 .51
Borderline .67 .62
histrionic .55 .44
narcissistic .37 .27
depressive .66 .61
passive-aggressive .48 .36

Median .51 .44

Cluster A .55 .48

Cluster B .63 .60
Cluster C .62 .57

Total score .68 .66

1
all correlations (Pearson) are significant: p<.01
 11

Table 6. Sensitivity, specificity, and chance corrected agreement (kappa) of categorical

ADP-IV diagnoses in relation to SCID-II and categorical consensus rating (n=210)

ADP-IV and SCID-II ADP-IV algorithm and categorical

consensus rating
scale T>4 and D>1 algorithm T>5 and D>1 algorithm T>4 and D>1 algorithm T>5 and D>1 algorithm
Sensitivity Specificity
% %
κ Sensitivity Specificity
% %
κ Sensitivity Specificity
% %
κ Sensitivity Specificity
% %
κ
paranoid 52.9 89.1 .31** 23.5 99.5 50.0 87.8 .22** 25.0 99.0

schizoid 33.3 97.1 33.3 100 50.0 97.1 50 100

schizotypal - 96.2 - 99.0 - 96.2 - 99.0

avoidant 46.9 86 .30** 12.5 95.5 53.6 86.2 .34* 14.3 95.6

dependent 0 92.8 0 97.6 0 92.7 0 97.6

obsessive- 52.6 86.9 .29** 26.3 96.9 .29** 50.0 85.9 .23** 25.0 96.4
compulsive
antisocial 66.7 85.6 44.4 96.0 66.7 84.7 33.3 95.1

Borderline 68.8 81.4 .27** 50.0 95.4 .44** 60.9 82.3 .30** 43.5 96.2 .45**

histrionic 0 95.7 0 98.1 20.0 96.1 20.0 98.5

narcissistic 0 99.5 0 99.5 0 99.5 0 99.5

depressive 52.2 92.0 .41** 13.0 98.9 48.0 91.8 .39** 12.0 98.9

passive- 25.0 95.0 12.5 98.5 28.6 95.0 14.3 98.5

aggressive

Median .30 .37 .30

Cluster A 29.4 94.9 .30** 20.6 96.0 .22**

Cluster B 32.1 94.9 .33** 52.6 92.1 .39** 43.4 92.9 .41** 68.4 88.9 .42**

Cluster C 37.5 84.2 .24** 41.7 80.1 .15* 35.9 86.1 .24** 37.5 81.5 .14*

any PD 57.8 79.2 .38** 71.1 70.9 .30** 58.9 75.6 .35** 73.7 68.4 .29**
diagnosis
* p <.05; ** p <.01; # p<.10

4. Discussion

The ADP-IV represents a new kind of self-rating instrument for the assessment of DSM-IV
personality disorders. Different from earlier questionnaires it allows for a categorical and
dimensional assessment and does include a rating of the distress experienced by the
individual. Thus, for the first time criterion C of the DSM-IV general diagnostic criteria for a
personality disorder (“The enduring pattern leads to clinically significant distress or
impairment in social, occupational, or other important areas of functioning.”) has been
included into a questionnaire. The psychometric properties of the German version of the
ADP-IV have been explored in great detail in this study.
 12

The reliability of the instrument can be regarded as satisfying. Only two subscales yielded
internal consistency levels slightly below the threshold of .70: the schizoid (α=.65) and the
antisocial (α=.68) trait-scales. These numbers are very similar to those reported by Schotte et
al. (1998) for the Dutch version of the ADP-IV, and clearly above those reported by Wilberg
et al. (2000) for the PDQ, who found nine subscales with an α<.70. In contrast, all of the
WISPI subscales revealed a Cronbach´s α above .70 (Barber & Morse 1994; Smith et al.
2003), which can be explained by the high number of items of the WISPI. The retest
reliabilities of the ADP-IV ranged between .56 and .88 with the exception of the schizoid
subscale (r=.37). Barber and Morse (1994) reported comparable retest reliabilities for the
WISPI (r=.69 to .80).
The factor analysis revealed an 11-factor solution two factors of which did not contain any
item loading ≥.40. The nine remaining factors show a close relationship to the factor analysis
of the original Dutch version of the questionnaire. The factors negative affect and self-image,
social anxiety and avoidance, distrust, interpersonal hostility, and schizotypal cognitions and
perceptions resemble the equally named factors of Schotte et al. (1998). The factor
egocentrism and exploitation of relationships corresponds to instability and need for attention
of the original version, with the additional aspect of exploitation while neediness is playing a
less important role. Distance and indifference of the German version shows some relation to
the original detachment and the psychopathy factor of the Dutch version is extended by self-
mutilation. Schotte et al. (1998) did not find an obsessive-compulsiveness factor whereas we
could not replicate the factors narcissism, catastrophe anticipation, and defiance and guilt.
It can be stated that only four personality disorders – paranoid, obsessive-compulsive,
schizoid, and schizotypal – can be related to one or two corresponding factors. Other factors
do not correspond with the DSM-IV classification of personality disorders, but contain a
combination of items of different personality disorders that are organised around a core
feature like egocentrism, avoidance, or negative affect. On the one hand, this result can be
attributed to the formulation of the single items of the ADP-IV; on the other hand, the factor
solution puts into question the DSM-IV classification of personality disorders as far as cluster
B and cluster C are concerned.
As far as concurrent validity of the ADP-IV with the SCID-II interview and the consensus
rating is concerned, the results are mostly satisfying for the dimensional scores and only
partly satisfying with regard to categorical diagnoses. The correlations of the dimensional
subscale scores of the ADP-IV and the SCID-II mainly range between .40 and .70 and equal
the numbers reported by Schotte et al. (2004) for the Dutch version of the instrument. The
median of .52 for the correlations with the dimensional SCID-II scores is distinctly higher
than the median correlation of .46 that was reported for the WISPI by Barber & Morse (1994).
The agreement of the categorical diagnoses of ADP-IV and SCID-II interview was below the
numbers reported for the original version of the questionnaire: Schotte et al. (2004) found a
median kappa of .53 and .54 for the two algorithms compared to .30 and .37 in this study. The
kappas for the presence of any PD in the ADP-IV (T4 and D1) were .38 in this study and .54
in the original version of the instrument (Schotte et al. 2004; Tenney et al. 2003). In other
instruments compared to the SCID-II interview the median kappas for the specific personality
 13

disorders were .27 for the WISPI (Smith et al. 2003), .28 for the MCMI-II (Renneberg et al.
1992), .34 for the SCID-PQ (Nussbaum & Rogers, 1992), and .38 for the PDQ (Hyler et al.
1992). Therefore, it can be stated that only the PDQ reaches the level of convergent validity
the ADP-IV revealed in this study.
Questionnaires for the assessment of personality disorders tend to overdiagnose, a result that
has been reported previously for the PDQ (Hyler et al. 1990; Hyler et al. 1992; Bronisch et al.
1993; Wilberg et al. 2000) and the MCMI (Renneberg et al. 1992; Soldz et al. 1993). This is
also true for the T>4 and D>1 algorithm of the ADP-IV, but not for the T>5 and D>1
algorithm that revealed a similar number of diagnoses compared to the SCID-II in individual
personality disorders like borderline, antisocial, histrionic, narcissistic, dependent, and
obsessive-compulsive. Like it is the case in the WISPI and the MCMI the categorical
diagnoses of the German ADP-IV show a high specificity and a lower sensitivity.
Surprisingly, Schotte et al. (2004) found a higher sensitivity and a lower specificity for the
T>4 and D>1 algorithm of the original Dutch version, whereas the T>5 and D>1 algorithm
was in line with the results of this study.

In conclusion, it can be stated that the ADP-IV shows a reliability and a validity that can be
regarded as comparable and partly superior to those of other existing instruments. The surplus
of the ADP-IV can be found in the inclusion of the distress rating, the dimensionality of the
assessment, and the relatively small number of items. The dimensional assessment allows for
the employment of different scoring algorithms for different purposes: The T>4 and D>1
algorithm can be recommended for screening purposes while the T>5 and D>1 algorithm
might be suitable for research issues. Moreover, the dimensional scores derived from 7-point
scales enable to construct a detailed profile of personality pathology including disordered
dimensions that are below the DSM-IV thresholds for the specific personality disorder. Last
but not least the ADP-IV can be recommended for clinical and research purposes, because it
represents the only German language instrument of its kind that has been extensively
validated and is available as free download on the internet (download: http://zmkweb.uni-
muenster.de/einrichtungen/proth/dienstleistungen/psycho/diag/index.html).

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Correspondence
Prof. Stephan Doering, M.D., Psychosomatics in Dentistry, Department of Prosthodontics,
University of Muenster, Waldeyerstrasse 30, 48149 Muenster, Germany, Tel.: **49-251-83
47074, Fax: **49-251-83 45730, E-mail: Stephan.Doering@ukmuenster.de