Clinician diagnoses of personality disorders: evidence of a hierarchical structure

This study examined whether clinicians employ a hierarchical model in the diagnosis of personality disorders. Using a methodology developed by Morey and Ochoa (1989), the study compared how clinicians diagnose patients (clinical diagnoses) to the Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev.; American Psychiatric Association, 1987) criteria they endorsed for each patient (criterion diagnoses). A national sample of 320 clinicians served as subjects. When cases were examined in which the patients met diagnostic criteria for two or more personality disorders, clinicians used the diagnosis of borderline personality disorder more frequently. They failed to use other diagnoses whose criteria these patients met. Narcissistic personality disorder also appeared to have diagnostic dominance, although somewhat less striking than for borderline. These results suggest that clinicians do view the personality disorders as hierarchical, with borderline clearly identified as the dominant disorder.