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New this Month - June 2005
Below are citations/abstracts of recently published articles and publications
that have been authored and/or co-authored by Pacific Institute staff.
Berkeley
Melina Bersamin
Bersamin, M.; Paschall, M.J.; Flewelling, R.L., Ethnic differences in
relationships between risk factors and adolescent binge drinking: a
national study. Prevention Science, 6(2): 127-138, 2005. [with M.J.
Paschall of PRC and R.L Flewelling of PIRE/Chapel Hill].
Abstract: This study examines ethnic differences in relationships
between a large number of risk factors and adolescent binge drinking
with data collected from 14 to 17 year olds who participated in the 1999
National Household Survey on Drug Abuse (NHSDA). Logistic regression
analyses were conducted to determine whether 39 risk factors in
community, family, school, and peer-individual domains were
differentially associated with past-30-day binge drinking among youth
in
ethnic minority groups (black, Hispanic and Asian) relative to whites.
Forty-three percent (17) of the risk factors examined were
differentially associated with binge drinking in at least one of the
ethnic groups relative to whites. Most of these risk factors were more
strongly associated with binge drinking among white adolescents than
Hispanic and black youth, but not Asians. The direction of the
relationships between these risk factors and binge drinking, however,
was usually the same for whites and ethnic minority groups. A
multivariate prediction model indicated that risk factors in the
community, family, school, and peer-individual domains accounted for 27%
of the variance in binge drinking for white adolescents, 22% for
Hispanics, 10% for blacks, and 39% for Asians. These findings suggest
that research is needed to identify additional risk factors that are
associated with binge drinking among adolescents, particularly blacks,
Hispanics and possibly other ethnic minority groups.
Bersamin, M.M.; Walker, S.; Waiters, E.D.; Fisher, D.A.; Grube, J.W.,
Promising to wait: virginity pledges and adolescent sexual behavior.
Journal of Adolescent Health, 36: 428-436. 2005. [with S. Walker, E.D.
Waiters and J.W. Grube of PRC/Berkeley and D.A. Fisher of
PIRE/Calverton].
Abstract: Purpose: The current study examined the association between
formal and non-formal virginity pledges and the initiation of genital
play, oral sex, and vaginal intercourse among adolescents. Methods:
Logistic regressions controlling for age, gender, race, expectancies,
academic achievement, contraceptive education, perceived peer pledging
behavior, and parental and peer attitudes were conducted to examine the
relationship between pledging behavior and genital play, oral sex, and
vaginal intercourse. A total of 870 adolescents aged 12-16 from 10
counties in northern and southern California participated in the current
study. Results: The findings indicate that making a private pledge or
promise to oneself to wait to have sexual intercourse until one is older
reduces the likelihood that adolescents will engage in sexual
intercourse and oral sex. The effect persists even when controlling for
socio-demographic variables. Making a formal pledge did not appear to
have an effect on sexual behavior. Conclusions: The findings raise
questions about the effectiveness of formal virginity pledges in
preventing adolescent sexual behavior. The findings suggest that sexual
health programs may be more effective if they encourage young people to
make a personal commitment to delay the onset of sex, foster social
norms supportive of delaying sex, and raise awareness of how early
sexual initiation may threaten future plans.
Joel Grube
Agostinelli, G.; Grube, J., Effects of presenting heavy drinking norms
on adolescents' prevalence estimates, evaluative judgments, and
perceived standards. Prevention Science, 6(2): 89-100, 2005.
Abstract: Correcting normative information about the prevalence of
heavy drinking is a key element in many prevention programs. To isolate
the influence of normative information on older high school students (n
= 230) alcohol-related judgments, the effects of delivering normative
information in different contexts (no normative information, normative
information only, normative information plus a self-focusing comparison
to ones drinking) and under different measurement conditions (public,
private) were examined. First, relative to presenting no norms,
presenting norms both with and without a self-focus reduced the
underestimation of the percent of high school students who never drink
heavily. Second, effects on both positive and negative evaluations of
heavy drinking were examined independently. Heavy drinking students more
strongly endorsed positive evaluations of heavy drinking than did
non-heavy drinking students, but this self-serving bias was limited to
the normative information only condition. Normative information failed
to impact negative evaluations of heavy drinking for students at all
drinking levels. Third, in judging the acceptable number of heavy
drinking days approved by others, presenting the normative information
in both contexts (relative to presenting no norms) led to more
conservative judgments. Yet, only the normative context that added a
self-focus to the norm led students to adopt more conservative personal
standards for the acceptable number of heavy drinking days. Finally,
public versus private measurement did not affect any of the dependent
variables. The findings are discussed as they relate to confrontational
versus empathic styles in delivering interventions.
Mallie Paschall
Paschall, M.J.; Bersamin, M.; Flewelling, R.L., Racial/ethnic
differences in the association between college attendance and heavy
alcohol use: A national study. Journal of Studies on Alcohol,
66:266-274, 2005. [with M. Bersamin and R.L. Flewelling of
PRC/Berkeley].
Abstract: Objective: This study examined racial/ethnic differences in
the association between college attendance and heavy alcohol use and
factors that amy underlie this relationship. Method: Interview data
collected from 12,993 young adults who participated in the National
Longitudinal Study of Adolescent Health were analyzed to determine if
4-
or 2-year college status is differentially associated with heavy alcohol
use for five racial/ethnic groups (white, black, Hispanic, Asian, Other)
and to assess the explanatory value of selected social and psychological
factors. Results: Four-year college status was positively associated
with heavy alcohol use among white young adults but inversely related
to
heavy drinking among blacks and Asians. Two-year college status also was
inversely associated with heavy drinking among blacks, hispanics and
Others. Among whites, the association between 4-year college attendance
and heavy drinking was partially explained by living away from parents,
friends' heavy drinking and time socializing with friends. Among blacks,
the inverse relationship between college attendance and heavy alcohol
use was partially explained by lower levels of friends' heavy drinking,
depression and delinquency. Friends' heavy drinking also partially
explained observed relationships between college attendance and heavy
drinking among Asians and Others. Conclusions: Four-year college
attendance increases the likelihood of heavy drinking among blacks and
Asians. Two-year college attendance also may reduce the risk for heavy
drinking among blacks, Hispanics and young adults who are Native
American or multi-ethnic. Social and psychological factors partly
explain these relationships and also differ for racial/ethnic groups.
Calverton
John Allen
Schwan, R.; Allen, J.P., Unhealthy alcohol use. New England Journal of
Medicine, 352: 2139-2140. 2005.
Abstract: Letter to the Editor.
Jim Derzon
Derzon, J.H.; Springer, F.; Sale, L.; Brounstein, P., Estimating
Intervention Effectiveness: Synthetic Projection of Field Evaluation
Results. Journal of Primary Prevention, 26: 321-343. 2005.
Abstract: In a 46-site, 5-year high-risk youth substance abuse
prevention evaluation, effect sizes were adjusted using a meta-analytic
regression technique to project potential effectiveness under more
optimal research and implementation conditions. Adjusting effect size
estimates to control for the impact of comparison group prevention
exposure, service intensity, and coherent program implementation raised
the mean effectiveness estimate from near zero (.02, SD = .21) to .24
(SD = .18). This finding suggests that adolescent prevention programs
can have significant positive effects under optimal, yet obtainable
conditions. Editors' Strategic Implications: The authors present a
meta-analytic technique that promises to be an important tool for
understanding what works in multi-site community-based prevention
settings. Researchers will find this to be a creative approach to model
the "noise" in implementation that may often overshadow the
potential impact of prevention programs.
Tara Kelley-Baker
Bell, M.L.; Kelley-Baker, T.; Rider, R.; Ringwalt, C., Protecting
you/protecting me: effects of an alcohol prevention and vehicle safety
program on elementary students. Journal of School Health, 75(5):
171-177, 2005. [with R. Rider of PIRE/Calverton and C. Ringwalt of
PIRE/Chapel Hill].
Abstract: This paper describes an evaluation of Protecting
You/Protecting Me (PY/PM), a classroom-based, alcohol-use prevention and
vehicle safety program for elementary students in first through fifth
grades developed by Mothers Against Drunk Driving. PY/PM lessons and
activities focus on teaching children about (1) their brains (why their
brain is important, how their brain continues to develop throughout
childhood and adolescence, what alcohol does to the developing brain,
and why it is important to protect their brain); (2) vehicle safety
(what to do to protect themselves should they ever ride with an impaired
driver); and (3) life skills (decision making, stress management, and
media literacy). Fourth- and fifth-grade students from schools in the
fourth year of PY/PM implementation were surveyed. Results indicated
that, relative to comparison students from matched schools, PY/PM
students increased their knowledge of alcohol's effect on development;
gained decision-making, stress-management, and vehicle safety skills;
and demonstrated changes in attitudes toward underage alcohol use and
its harm. Further, students retained lessons learned in previous years
and their scores improved with increased exposure to PY/PM. In addition,
the findings demonstrate that it is possible to design and implement a
program that can improve young children's knowledge regarding alcohol
and their developing brains, teach them skills to protect themselves in
dangerous situations, increase already high anti alcohol attitudes, and
change perceptions of alcohol's harmfulness.
Paul Marques
Marques, P.R.; Voas, R.B.; Allen, J.P.; Javors, M.; Wurst, F.; Pragst,
F.; Ailing, C.; Lakshman, R.; Yegles, M., Alcohol biomarker and
interlock BAC test profiles to predict risk of subsequent DUI.
Alcoholism: Clinical and Experimental Research, 29(5): 110A. 2005. [with
R.B. Voas and J.P. Allen of PIRE/Calverton].
Abstract: This study contrasts alternative combinations of behavioral
and biological markers to predict risk of alcohol-impaired driving.
Subjects are convicted DUI offenders in Alberta who will use alcohol
interlock devices on their cars as a path to license reinstatement.
Repeat DUI convictions are low sensitivity, but 100% high specificity
criteria for alcohol problem behavior. (We have previously shown that
the proportion of alcohol interlock BAC tests =>.02% (20 mg/dl) is
a
valid predictor of future DUI and a high sensitivity high specificity
proxy for alcohol problems.) In the current project, at the time of
alcohol interlock installation paid research subjects provide blood and
hair samples as well as self-report assessments of their alcohol use,
severity of alcohol dependence, and adverse consequences resulting from
their drinking. Subsequent measures are collected at six months.
Self-report items include the DIS-C, TLFB, AUDIT, and DrinC; serum
biomarkers include GGT, ALT, AST, %CDT, sialic acid residues of
Apoliprotein J (APO J). We also measure phosphatidyl ethanol (PEth) and
MCV from whole blood, and fatty acid ethyl esters (FAEE) and ethyl
glucuronide (EtG) from hair samples. Using the binary rule (a Boolean
OR
combination of two markers) with cutoff criteria 2.6 for %CDT or 70 U/L
for GGT, 39 of the 69 subjects (42%) show evidence of clinically
significant alcohol consumption. A preliminary examination of the
usefulness of %CDT and GGT to predict heavy consumption was tested by
MANOVA. The main fixed factors (predictors) tested were offense status
(first or multiple offenders) and being above cutoff on either GGT or
%CDT. Consumption was measured by three items from the TLFB that
reflected duration of drinking; neither marker by itself was
significantly predictive. Age served as a covarian in the analysis.
Status on GGT or %CDT predicted consumption reasonably well (p=.03) and
performed better as a predictor than did number of prior offenses. (The
current analysis reflects only the first series of subjects in the
study; additional marker data and data from the interlock record will
be
available and analyzed by the June meeting.) Supported by R01 AA014206.
Marques, P.R.; Voas, R.B.; Fell, J.C.; McKnight, A.S., Field and
laboratory evaluation of two transdermal ethanol sensors. Alcoholism:
Clinical and Experimental Research, 29(5): 111A. 2005. [with R.B. Voas,
J.C. Fell, and A.S. McKnight of PIRE/Calverton].
This study evaluates two different types of transdermal ethanol sensors
during continuous wear. Crimes committed while someone is impaired by
alcohol ordinarily range from DUI to various forms of violent injury to
self and others. The courts try to control this behavior with jail,
house arrest, ignition interlocks, BAC monitoring and other approaches.
There is a segment of this population that will resist all but the most
intrusive controls. Long-term jail is impractical, and periodic BAC
monitoring has limitations since many drinking episodes go undetected.
Wearable electrochemical transdermal ethanol sensors can detect some
portion of the approximately 1% of ethanol that escapes as ethanol vapor
from the skin surface. Currently with 1200 units in service, one device
the AMS SCRAM (an ankle-mounted sensor) captures data with regular
sampling as often as 30 minute intervals. The device remotely sends this
information daily via modem to a server. From there it is processed,
interpreted and can be monitored or reviewed from anywhere with an
internet browser. The other device, the Giner WrisTAS (a wrist-mounted
sensor), can sample skin ethanol continuously and then store the data
for later download to a computer. Both devices include tamper detection
protocols based on infrared and temperature sensors. Our research is
evaluating the devices on 18 subjects (male and female, ages 21-35)
wearing both concurrently and continuously for 28 days (24/7/28). During
this interval these paid volunteers, who drink regularly but
non-dependently, log all alcohol consumption, self-test with a fuel cell
based preliminary breath tester at 3-hr intervals during the waking
hours, and come in to the laboratory for alcohol dosing to -30 and -70
mg/dl on 2 or 3 occasions. The effects of warm or cool ambient air and
mild exercise are being assessed to measure the impact of these factors
on precision and accuracy. Also, circumvention strategies to obstruct
vapor flow to the sensor are being tested to evaluate the ability of
each system to detect circumvention. The research also documents subject
acceptability, and problems with extended wear. Supported by NHTSA
DTNH22-02-D-95121.
Marques, P.R.; Voas, R.B.; Timken, D.S.; Field, C.T., Alcohol interlock
BAC tests and self-report assessment as markers for change in drinking.
Alcoholism: Clinical and Experimental Research, 29(5): 110A. 2005. [with
R.B. Voas of PIRE/Calverton].
Abstract: The alcohol ignition interlock markedly reduces alcohol
impaired driving, but once the interlocks are removed, repeat DUI
offenses climb to near control levels. This study, now in its fourth
year, evaluates interlock using DUI offenders to determine if a
motivational intervention will prevent the usual return to impaired
driving that follows interlock removal. Validation of intervention
studies of this type requires years for post-program conviction data to
accumulate. In the interim, pre and post program assessments provide
some risk indication. Positive program impact can be more confidently
inferred if self-reported pre-post change in assessments is corroborated
by alcohol interlock breath test data showing a reduction in the
proportion of all BAC tests that are elevated above .02% (20 mg/dl). In
this preliminary report, 196 of 350 subjects have now completed a
manualized 12 hour, six month motivational enhancement program designed
specifically for interlock users. The intervention has both group and
individual components, which unfold over six months. Assessments include
demographics, treatment history, vehicle use, AUDIT, DrinC, URICA,
drinking quantity/frequency and other measures. All subjects were
required by the court to install the interlock as well as to attend the
interlock motivational intervention. Across all major demographic
groupings, the intervention led to strongly significant change pre to
post on all 5 DrinC subscales (P<.0001), the AUDIT (P<.001), with
some
evidence of some movement on URICA (P=.019). From 6 months of interlock
BAC test positive rates (>20 mg/dl), individuals were grouped in
terciles. The low and middle tercile subjects had an average 0.01% and
0.3% of all tests elevated, the highest tercile had 2.3% of all tests
elevated. Self-report assessments matched interlock tests in terciles
1
and 2. Tercile 3, with over ten times the rate of positive BAC tests of
the middle group reported fewer alcohol problem or consequences than
those with lighter drinking. This is a preliminary finding. If it holds
with more data it suggests that self-report should be supplemented by
more objective evidence when working with offender populations. Heavy
drinkers may try to minimize their problem behavior. Predictive studies
await more data. Supported by AA R01-12825.
Eduardo Romano
Romano, E.; Tippetts, S.; Blackman, K.; Voas, R., Acculturation,
income, education, safety belt use, and fatal motor vehicle crashes in
California. Prevention Science, 6(2): 139-148, 2005. [with S. Tippetts,
K. Blackman and R. Voas of PIRE/Calverton].
Abstract: This paper investigates the role that acculturation, income,
and education play in safety belt nonuse among Californian drivers
involved in fatal Motor Vehicle Crashes (MVCs). To achieve this goal,
measures of acculturation, income, and education were stochastically
incorporated into the Fatality Analysis Reporting System (FARS). Using
the 1990 California Tobacco Survey and U.S. Census data, we estimated
the combination of zip-code-based measures that most accurately predicts
an individual, language-based acculturation index for Hispanics and
Asians. Logistic regression was used to investigate the role of these
variables in safety belt nonuse in fatal MVCs. We found that
acculturation has a positive direct effect on safety belt use among
Hispanics. We hypothesize that this positive direct effect is caused by
Hispanic immigrants learning the benefits of wearing safety belts.
However, our study also suggests an indirect negative effect of
acculturation on safety belt use through drinking and driving.
Prevention programs aimed at increasing the safety of Hispanic drivers
not only need to take acculturation differences into account, but also
need to be comprehensive in their message, simultaneously targeting both
seat belt nonuse and drinking-and-driving problems.
Romano, E., Tippetts, S., & Voas, R., Stop sign violations: The role
of
race and ethnicity on alcohol-related fatal crashes. Alcoholism:
Clinical and Experimental Research, 29(5): 163A. 2005.
Abstract: Introduction - There are approximately 700,000
police-reported motor vehicle crashes occurring at stop signs each year.
Stop sign violation was involved in 70% of motor vehicle crashes (MVCs),
and 33% of those crashes resulted in injury. Drinking and driving was
found an important contributor to these incidents (Retting et al.,
2002). Very little is known about the demographic and socioeconomic
characteristics of those drivers who failed to stop at stop signs.
Race/ethnicity has been shown to be a explanatory factor for fatal MVCs,
particularly in association with presence of alcohol (e.g., Romano et
al., 2005). However, the role of race/ethnicity on alcohol-related fatal
MVCs at stop signs has not been studied yet. Objective - To investigate
the role of race/ethnicity on the incidence of alcohol-related fatal
MVCs occurring at stop signaled intersections. Methods - We took
advantage of the 1990-1996 Fatality Analysis Reporting System (FARS)
file with additional racial/ethnic information. For each active
participant in a fatal crash recorded in FARS, either the actual
BAC-based on an imputation system (Klein, 1986) was provided. We
identified an at-fault stop sign crash in FARS as one that (a) took
place at an intersection, (b) was controlled by a stop traffic signal,
(c) had a driver-level factor of "failure to obey traffic control
device," and (d) no police pursuit was involved in the crash.
Information on race/ethnicity and BAC was available only for deceased
victims, forcing us to restrict the file accordingly. Results - Overall,
we found that race/ethnicity did not play a direct role in stop sign
running. Drinking and driving, together with age, had the largest
explanatory power in our models. However, race/ethnicity does play an
indirect role on at-fault stop sign running through its impact on
drinking and driving and its interaction with age and gender. This study
is the first to document the relevance of race/ethnicity to the running
a stop sign problem, and we hope might serve as an incentive for more
research on this area. The authors wish to thank NIAAA, Grant Number 1
R21 AA13384-02, for their generous support of this research effort.
Bob Voas
Voas, R.B., Interlocks: An effective but underutilized component of DUI
sentencing. Alcoholism: Clinical and Experimental Research, 29(5): 112A.
2005.
Abstract: There is strong evidence that alcohol interlocks which
prevent the starting of a vehicle if the driver has been drinking are
effective in reducing the recidivism rates of impaired driving offenders
by 50 to 80%. They can be a useful adjunct to treatment, by providing
a
record of all BAC tests conducted on the driver every time the car is
started and every few minutes while driving. This information can be
used to confront the clients with their problem behavior and to track
their progress in therapy. The BAC data from the interlock recorder
provides the best predictor of future recidivism and can provide the
information required to determine the length of the sanction on the
basis of performance rather than an arbitrary time period. The principal
limitation on the use of interlocks as a sanction for convicted drinking
drivers is that only about 10% of those eligible for the sanction
actually install the devices. State laws as currently written provide
that offenders will install interlocks on any vehicle they drive. This
allows offenders to claim that they do not have a car or do not intend
to drive, while continuing to drive illicitly. A study in Indiana (Voas
et al., 2002), recently confirmed by a study in New Mexico, demonstrated
that the interlock usage rate could be increased above 60% by making the
alternative to installation, electronic monitored house arrest. Both
house arrest and interlocks are preferable to jail as drinking driver
sanctions because they permit the offender to be employed and to
continue to receive the support of family members, but state legislation
must provide for, and courts must be willing to threaten to impose house
arrest periods of 6 months or more for offenders unwilling to install
interlocks.
Clapp, J.D.; Reed, M.B.; Holmes, M.R.; Lange, J.E.; Voas, R.B., Drunk
in public, drunk in private: The relationship between college students'
drinking environments and alcohol consumption. Alcoholism: Clinical and
Experimental Research, 29(5): 121A. 2005.
Abstract: This study examines environmental differences in public
(bars) and private (parties) drinking settings among of-age (21 and up
years of age) and underage (18-20 years of age) college students
attending college near the U.S./Mexico border. A random telephone survey
of graduate and undergraduate students attending two large public
universities in the southwestern United States was conducted during the
2000-2003 academic years. A university-based social science research
laboratory conducted the telephone interviews with respondents who
reported an occasion in the past 28 days where alcohol was being
consumed were included in the study (N = 4,964). The data were analyzed
using ordinary least squares multiple regression. The results suggested
that drinking setting contributes to the amount of alcohol consumed by
respondents. Environmental factors contributing to drinking vary by
setting. In general, having many people intoxicated at an event, BYOB
parties, playing drinking games, and having illicit drugs available
contribute to heavier drinking.
Louisville
Knowlton Johnson
Johnson, K.; Kennedy, S.B.; Harris, A.O.; Lincoln, A.; Neace, W.;
Collins, D., Strengthening the HIV/AIDS service delivery system in
Liberia: An international research capacity building strategy. Journal
of Evaluation in Clinical Practice, 11(3): 257-273. 2005. [with S.B.
Kennedy, W. Neace and D. Collins of PIRE/Louisville].
Abstract: Liberia's prolonged post-conflict transition has negatively
impacted its health infrastructure, including the functioning of its
health care delivery system. Considering the current national health
crises, a study was conducted to identify research gaps and the need to
propose changes for improving the health care delivery system in the
country. The study results clearly demonstrated a lack of HIV/AIDS
research infrastructure including organizational structure, linkages,
leadership, champions, expertise, resources, and policies and
procedures. Alignment of research needs and practice, and research use
to support HIV/AIDS service delivery programmes in the country was also
limited. An international research capacity building partnership is
proposed as an effective planned change strategy to strengthen
HIV/AIDS-related research infrastructure and to inform management and
practice within the Liberian HIV/AIDS service delivery system. A
proposed capacity-building planning model can also strengthen research
infrastructure and the production and use of research to positively
impact the HIV/AIDS epidemic in Liberia and other developing countries.
Providence
Bob Stout
McGlashan, T.H.; Grilo, C.M.; Sanislow, C.A.; Ralevski, E.; Morey,
L.C.; Gunderson, J.G.; Skodol, A.E.; Shea, M. T.; Zanarini, M.C.;
Bender, D.S.; Stout, R.L.; Yen, S.; Pagano, M.E., Two-year prevalence
and stability of individual criteria for schizotypal, borderline,
avoidant, and obsessive-compulsive personality disorders. American
Journal of Psychiatry, 162(5): 883-889. 2005.
Abstract: Objective: This study tracked the individual criteria of four
DSM-IV personality disorders-borderline, schizotypal, avoidant, and
obsessive-compulsive personality disorders-and how they change over 2
years.
Method: This clinical sample of patients with personality disorders was
derived from the Collaborative Longitudinal Personality Disorders Study
and included all participants with borderline, schizotypal, avoidant,
or
obsessive-compulsive personality disorder for whom complete 24-month
blind follow-up assessments were obtained (N=474). The authors
identified and rank-ordered criteria for each of the four personality
disorders by their variation in prevalence and changeability (remission)
over time. Results: The most prevalent and least changeable criteria
over 2 years were paranoid ideation and unusual experiences for
schizotypal personality disorder, affective instability and anger for
borderline personality disorder, feeling inadequate and feeling socially
inept for avoidant personality disorder, and rigidity and problems
delegating for obsessive-compulsive personality disorder. The least
prevalent and most changeable criteria were odd behavior and constricted
affect for schizotypal personality disorder, self-injury and behaviors
defending against abandonment for borderline personality disorder,
avoiding jobs that are interpersonal and avoiding potentially
embarrassing situations for avoidant personality disorder, and miserly
behaviors and strict moral behaviors for obsessive-compulsive
personality disorder. Conclusions: These patterns highlight that within
personality disorders the relatively fixed criteria are more trait-like
and attitudinal, whereas the relatively intermittent criteria are more
behavioral and reactive. These patterns suggest that personality
disorders are hybrids of traits and symptomatic behaviors and that the
interaction of these elements over time helps determine diagnostic
stability. These patterns may also inform criterion selection for
DSM-V.
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