اختلال شخصیت در بزرگسالان که لکنت زبان دارند: نگاهی دیگر

Purpose Given reports of the frequent occurrence of personality disorders (PD) among individuals who stutter, this investigation was designed to determine the presence of personality disorders (PD) for individuals seeking treatment for stuttering, using a different self-report measure. Method The sample included 50 adults who were undergoing treatment for stuttering. The participants also completed a self-report measure (Assessment of the DSM-IV Personality Disorders, ADP-IV) that is known to have good differential validity in the assessment of personality disorders as well as good convergent validity with a structured interview administered by a skilled mental health professional. Results Four participants met threshold values for one personality disorder (PD) and one participant met criteria for two personality disorders. The remaining 45 participants (90%) did not meet criteria for a PD. Conclusion Rates of observed PDs in this sample approximated rates that have been observed in general community samples using structured clinical interviews and trained interviewers. Related reports which have claimed high levels of personality disorders among adults who stutter appear to be inflated by the use of self-report devices that overestimate the occurrence and co-morbidity of these conditions. Implications for the treatment of adults who stutter are discussed. Educational objectives: The reader will be able to (a) summarize two basic perspectives of how individuals who stutter are influenced by the possibility of personality dysfunction (b) describe the factors that influence the detection of personality dysfunction using self-report procedures, discuss the important (c) theoretical and (d) clinical implications of accurately identifying personality dysfunction for adults who stutter.

Through the first several decades of the 20th century, it was common to view stuttering as a form of psychopathology, a symptom of a repressed, neurotic, unconscious conflict (Bloodstein and Bernstein-Ratner, 2008 and Silverman, 2004). More recent research suggests that the etiology of stuttering is influenced by a combination of genetic and neurophysiological factors that affect the production of language and speech (e.g., Cykowski et al., 2010 and Dworzynski et al., 2007Kang et al., 2010 and Watkins et al., 2008). These two perspectives have attracted considerable attention in the literature, with important implications for both speech therapists and mental health professionals who work with people who stutter. Although the issue of personality traits associated with stuttering has been long-debated (Bloodstein & Bernstein-Ratner, 2008Goodstein, 1958 and Sermas and Cox, 1982), this issue continues to spark lively debate in the literature. In this article, we will present data focusing on the presence of personality disorders among individuals who are seeking speech therapy for stuttering. Our aim with this work is to provide another look at the presence of personality dysfunction among persons who stutter and to highlight the role one's choice of assessment instrument has on understanding this important issue. 1.1. The possibility of personality dysfunction Within the research on individuals who stutter, there are two perspectives concerning the relationship of stuttering and personality. One perspective argues that personality disturbance result from social exclusion and taunting during childhood, interpersonal processes that have been shown to be associated with stuttering in young children and adolescents (e.g., Blood and Blood, 2007, Blood et al., 2011 and Langevin et al., 1998). This perspective suggests that individuals who stutter are plagued by a variety of personality problems, as exemplified in research by Iverach et al. (2009a). In a sample of 92 individuals who were seeking treatment for stuttering, Iverach et al. noted that 64.1% met criteria for at least one personality disorder (PD), representing an almost threefold increased odds, relative to an age- and gender-matched control sample. Remarkably, 43.44% of the 92 individuals met the criteria for two or more personality disorders. The most frequently identified personality disorders in the sample were Anxious PD (28.26%, n = 26), Paranoid PD (26.09%, n = 24), and Impulsive PD (27.17%, n = 25). The findings of Iverach et al. (2009a) have serious implications, in light of current conceptualizations of personality dysfunction. By definition, a personality disorder is defined as, “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment” (italics added) ( American Psychiatric Association, 2000, p. 685). Specific examples of PDs noted within samples of people who stutter include Anxious PD (characterized by social avoidance, hypersensitivity to potential criticism), Paranoid PD (characterized by a pervasive distrust of others and suspicion that others are deceiving or using them), and impulsive PD (characterized by taking extreme chances and doing reckless things), Iverach et al. (2009a) used a first-stage self-report screening device, the International Personality Disorder Examination Questionnaire (IDPEQ, Loranger, Janca, & Sartorius, 1997), which could have affected the obtained results (as will be discussed below). The authors concluded that individuals who stutter have significantly greater odds of having many forms of personality disorders and argue for the assessment and treatment of personality disorders among this population. In a related study, Iverach et al. (2010) noted that a sample of 93 adults selected from waiting lists at university-related clinics in Australia scored within the average range for all five factors of the five factor inventory (NEO-FFI, Costa & McCrae, 1992) which include neuroticism, extraversion, openness, agreeableness and conscientiousness. Despite being within the normal range, Iverach et al. (2010) noted that the mean scores for those seeking treatment for stuttering were significantly higher for neuroticism and significantly lower for agreeableness and conscientiousness than normative samples from Australia and the United States. The authors interpret these findings as reflective of the interpersonal difficulties that persons who stutter experience, owing to speech dysfluency. 1.2. Anxiety as natural reaction to stuttering A second perspective asserts that anxiety, depression and fear of negative evaluation experienced by individuals who stutter is secondary to stuttering and the result of having to cope with a serious communication problem (e.g., Blumgart, Tran, & Craig, 2010Craig and Tran, 2006, Guitar, 2006 and Plexico et al., 2009; Van Riper, 1982). As Guitar (2006, p. 62) states “…the experience of stuttering generates emotions, such as frustration, fear and anger in everyone who stutters.” This perspective is noted within the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), as stuttering is mentioned as a condition which may cause excessive social anxiety but is conceptualized as reactive to this medical condition (anxiety disorder not otherwise specified). Research supporting the second perspective has shown that there is inconsistent evidence to indicate that individuals who stutter possess a particular set of personality traits and, in fact, there is great overlap between groups of people who stutter and those who do not in terms of adjustment and emotional health (Bloodstein & Bernstein-Ratner, 2008Miller and Watson, 1992 and Van Riper, 1982). For example, Iverach et al. (2009b) studied the impact of anxiety disorders, depression, and personality disorders on the outcome of speech therapy, using a sample of 64 adults who stuttered. Mental health conditions were determined by the computerized version of the Composite International Diagnostic Interview (CIDI-Auto-2.1, World Health Organization, 1997) and the IPDEQ described previously. Regression analyses indicated that having an anxiety disorder was associated with greater self-rated avoidance of speaking situations after treatment and at a 6-month follow-up. However, mood, anxiety, and personality disorders were not associated with other outcome dimensions of speech therapy (e.g., percentage of syllables stuttered, self-rated stuttering severity) immediately following therapy or at follow-up, suggesting that personality dysfunction does not influence the course of treatment for fluency disorders. In essence, the field has struggled for some time with the issue of whether stuttering is associated with notable personality dysfunction. Two distinct literatures have emerged; one suggesting that personality disorders (long-standing interpersonal difficulties that are markedly outside of social norms and create distress and interference for the individual) are unfortunately common among persons who stutter. The second literature suggests that personality dysfunction is not a notable feature of stuttering but rather, occurs with the same frequency as noted among persons without speech dysfluency. Psychological issues, when noted among persons who stutter, are likely to be a consequence of speech dysfluency and to focus on excessive anxiety, particularly social evaluative fears and concerns. In some respects, measurement issues make resolution of this conundrum difficult. 1.3. Diagnosing personality dysfunction When considering personality diagnosis, it is preferable to rely on a structured interview, administered by a skilled mental health professional who is familiar with differential diagnosis, as there are instances where other mental health conditions can be confused with Personality Disorders (e.g., Oltmanns & Carlson, 2012). Personality disorders are differentiated from personality traits, in that personality traits are found in everyone, are not maladaptive, do not cause distress, and do not interfere with successful functioning at home, work, and/or school. Clinician-administered structured interviews require considerable resources however, which are not always available. An alternative is to rely on a self-report measure which has been validated against a clinician-administered structured interview for the assessment of PDs. In considering the literature on personality and stuttering, it is salient to note that an array of self-report measures has been utilized. For example, the self-report measure (IDPEQ) used by Iverach et al. (2009a) is designed as a first-stage screening device for personality disorders. Concern has been raised that this measure results in a high rate of false positives (e.g., Lewin, Slade, Andrews, Carr, & Hornabrook, 2005; Loranger et al., 1997). This concern is highlighted by the fact that Iverach and her colleagues noted a 38.15% rate of Personality Disorders among their control sample. Epidemiologists consistently estimate PDs to occur in the range of 10–15% of the general population (Schotte et al., 2004), rates that are generally supported by community studies that rely on structured clinical interviews (Coid, Yang, Tyrer, Roberts, & Ullrich, 2006). In addition to over-identification of PDs, some instruments also tend to result in excessive rates of co-morbidity (identification of two or more PDs, Schotte, De Doncker, Van Kerckhoven, Vertommen, & Cosyns, 1998). As such, it is clear that the choice of self-report measure to assess PDs is an important factor in this line of research. In response to these concerns, Schotte and De Doncker, 1994 and Schotte and De Doncker, 1996 developed the Assessment of the DSM-IV Personality Disorders (ADP-IV). This self-report questionnaire has been shown to have good validity in the assessment of personality disorders. The questionnaire provides for both categorical and dimensional assessment of the 10 categories of DSM-IV personality disorders. The unique structure of the ADP-IV provides several advantages over other self-report measures. Trait characteristics associated with personality disorders are self-indicated using a seven-point scale (“totally disagree”—“fully agree”) and the distress resulting from the individual's traits are indicated using a three-point distress scale (“not at all”—“definitely”). The dimensional assessment is determined by summing the Trait scores for each of the 10 personality disorders. When using the ADP-IV, categorical assessment is obtained by combining the trait and distress scores using scoring algorithms, which map onto DSM-IV thresholds. As a result of this procedure, and in contrast to other self-report questionnaires, the ADP-IV results in neither over-diagnosis nor the typical high co-morbidity among PD categories (Bronisch and Mombour, 1998 and Clark et al., 1997Loranger, 1992, Perry, 1992 and Schotte et al., 2004). Moreover, the ADP-IV can differentiate between members of the general population and psychiatric inpatients (Schotte et al., 2004) and the scale has been compared with a clinician-administered interview with good results. Schotte et al. (2004) examined convergent validity by comparing the results of the ADP-IV with the Structured Clinical Interview for DSM-IV Axis II Personality Disorders, SCID-II ( First, Gibbon, Spitzer, Williams, & Benjamin, 1997). Results indicated a high level of concordance for the two measures in a sample of 59 psychiatric inpatients. Thus, the ADP-IV appears to circumvent some of the issues raised by other self-report measures of personality dysfunction. The purpose of this investigation is to examine the presence of personality disorders using the ADP-IV within a sample of individuals seeking treatment for stuttering. We hypothesize that individuals who stutter will show levels of personality functioning that will fall within normative values. Data will be compared with previously published rates of PDs, in an effort to examine the influence of assessment instrument.