Further Validation and Test-Retest Reliability of the Spanish Version of the Standardised Assessment of Personality - Abbreviated Scale (SAPAS) for Personality Disorder Screening in Community Mental Health Settings
A Personality Disorder (PD) diagnosis is a frequent comorbidity found in 
patients with other psychiatric conditions . Furthermore, medical 
comorbidities are also often found in PD patients , who are also under risk 
for higher suicidality . These patients show difficulties in social, 
recreational, occupational, and global functioning and are associated with an 
increased risk of neurotic or affective disorders . One major risk factor for 
the development of PDs is having suffered stressful life events (SLEs) during 
childhood, including abuse, neglect, and other forms of early-age trauma . In 
later adult life, PDs have been related to higher rates of unemployment and 
divorce and further forms of social and psychological adversity . Several 
studies show that the prevalence of PDs ranges between 5.9% and 22.5% among the 
general population [ , , ]. Meta-analyses and systematic review studies summarize 
such prevalence between about 7.8%  and 12.16% . In Granada (Spain), a 
previous general population study estimated PD prevalence at 10.8% . 
However, prevalence among mental health patients is much higher and imprecisely 
estimated to range from 40% to 92% in Europe . Nonetheless, PDs are 
believed to be often underdiagnosed  and/or misdiagnosed . 
Furthermore, PD diagnosis is time-consuming and costly. Hence, there is evidence 
that the management and diagnosis of PDs represent an increase in the demand for 
health resources . Until now, there has been a limited amount of PD screening 
tools in Spanish. One that has proven to be clinically reliable in several 
countries is the International Personality Disorder Examination (IPDE) , a 
relatively lengthy screening instrument with 59 items, for which a Spanish 
adaptation exists . In this context, a shorter, simpler, valid and reliable self-administered 
screening scale in Spanish could prove clinically useful for the diagnosis of PD. 
A Spanish version of The Standardised Assessment of Personality - Abbreviated 
Scale (SAPAS)  could well be one such screening tool, since it has already 
shown excellent psychometric properties as a screening test for the 
English-speaking population . The SAPAS is a self-administered screening 
scale consisting of 8 yes/no questions deriving from the Standardised Assessment 
of Personality (SAP) , a larger and lengthier scale. Amongst English-speaking 
samples, the SAPAS showed 94% sensitivity and 85% specificity in its first 
validation study . Additional studies demonstrated its validity among 
patients with substance abuse , adolescent patients  and even the general 
population , although showing a lower predictive value of 58%. SAPAS adapted 
versions also exist in French , Japanese  and Bengali . This 
instrument was initially designed using the reference of the 10th Edition of the 
International Classification of Diseases (ICD-10) PD classification, which was 
rooted in a categorical paradigm. However, this scale may still hold relevance 
within the new ICD-11 classification of PD  both from a categorical and 
dimensional viewpoint. We previously published a preliminary validation study on a Spanish version of 
the SAPAS . Even though this study achieved relevant figures for a first 
validation, indeed comparable with those of the original validation study in the 
English language (0.66 Internal Consistency Area Under the Curve (AUC) of 0.89; 
84% sensitivity and 79% specificity at a 5 cut-off point), that study was 
limited in its sample size and by the fact that we did not report test-retest 
reliability. Therefore, the aim of this study is to consolidate the results 
achieved by our previous report, increasing sample size and testing for 
test-retest reliability (repeatability), which has not yet been done for this 
scale in our language. We hypothesise the SAPAS scale to be a useful tool for 
easily detecting potential PD cases, for the Spanish clinical population 
attending mental health services in outpatient clinics. 

Study Design A longitudinal study was performed to further test for reliability and validity 
of a double-translated (translated and back-translated) version of the SAPAS 
screening scale in Spanish. The study started in September 2019, but the sample 
taking stage had to be interrupted in March 2020 due to the Covid-19 pandemic. 
Thus, the study was resumed in September 2022 and was continued until May 2023. Sample Size Assuming a 95% Confidence Interval (CI) and a PD prevalence of 37% in clinical 
populations in Granada , and considering a precision of 10% as appropriate 
due to the wide range of PD prevalence estimated in Europe throughout the 
literature (40–92%) , a sample size of 90 individuals was calculated to 
provide sufficient power for this study. However, we managed to increase the 
sample size to 107 individuals, which is estimated to provide more representative 
results, along with enough power for further testing validity and reliability, as 
previously suggested . Inclusion/Exclusion Criteria Inclusion criteria were to accept any adult individual attending outpatient 
clinics at both, Clínico San Cecilio University Hospital and Virgen de las 
Nieves University Hospital (Granada, Spain), for recruitment provided they 
understood and could give informed consent to take part in the study. Exclusion criteria were to reject individuals younger than 18 years and those 
who, due to the severe nature of their symptomatology and/or psychological 
disability, were unable to provide informed consent or those could not understand 
the process of the study and questions asked during the interview. This included 
patients suffering from severe manic/delusional states and patients with 
intellectual disability. Variables/Measuring Instruments A. Sociodemographic variables of the individuals that met inclusion criteria 
(age, sex, educational level, marital and employment status). B. Full psychiatric history, including previous diagnosis and medication, using 
clinical standards. C. The SAPAS self-administered screening scale for PDs was administered twice: 
first at a first interview when entering the study and, secondly, again to test 
for repeatability 30 days later. D. The IPDE questionnaire for ICD-10-based PD diagnosis  was also used. This 
includes an initial self-administered questionnaire of 59 yes/no items, followed 
by a semi-structured hetero-administered interview with 67 questions which can be 
scored from 0 to 2 points. The IPDE questionnaire renders Negative, Probable or 
Positive diagnosis for each ICD-10 PD diagnosis, using 3 or 4 as cut-off points 
depending on each specific PD being tested, and it also provides dimensional 
scores for each PD. The previously-translated Spanish version  was used. Procedure In the first stage of the study, the Spanish SAPAS adaptation used by the 
previous validation study  (Appendix) was initially run by a psychiatrist 
during patient recruitment, who simultaneously collected information such as 
informed consent, sociodemographic information and psychiatric history. 
Subsequently, at a later moment, the diagnostic IPDE interview was also 
administered. At the second stage of the study, a second SAPAS measure was performed by the 
psychiatrist 30 days later, enabling to check for test-retest stability. During 
this study, we enlarged the original sample of 59 patients from our previous 
report to a final sample of 107 participants (n = 107). Data Analysis The statistical analysis was aimed at determining the SAPAS capacity to 
correctly identify patients with a positive ICD-10 PD diagnosis (as established 
using the IPDE questionnaire) and to identify the most optimal screening cut-off 
point for the SAPAS. To achieve this, Cronbach’s Alpha was first calculated to 
determine the internal consistency of the SAPAS, both overall and after omitting 
each item from the total score. This measurement of internal consistency aims to 
assess the reliability of the measurement and to determine whether the 
questionnaire includes only one or several constructs in its structure. It also 
shows how each of the scale items contributes to the scale’s 
overall reliability . In addition, adequacy for factor analysis was checked 
by using the Kaiser-Meyer-Olkin Test (KMO Test) and Bartlett’s Test of Sphericity 
. Furthermore, Varimax Rotation was used for Principal Component Analysis 
(PCA) to determine the factorial structure of the scale. To identify criterion validity between the SAPAS screening scale and the IPDE 
semi-structured interview, a Receiver Operating Characteristic (ROC) analysis was 
then used, which considered “positive” IPDE PD diagnosis as the gold standard. 
Thus, SAPAS performance was assessed and the ideal cut-off score for predicting a 
diagnosis of any PD was identified by comparison with the IPDE interview. An 
estimate of the scale’s discriminatory performance was calculated by analysis of 
the AUC of the ROC curve obtained after using a sensitivity-specificity plot. 
Then, Pearson’s correlation was employed to test the association between 
dimensional scores of PD as identified by the IPDE and their equivalent factors 
emerging from the PCA performed on the SAPAS scores. Finally, an Intraclass Correlation Coefficient (ICC, one-way random model, 95% 
CI) was calculated to check for test-retest stability between the two successive 
SAPAS measurements. All calculations were performed using the IBM SPSS Statistic 
24 (IBM Corp, Armonk, NY, USA) , with a 0.05 level of significance. 

A longitudinal study was performed to further test for reliability and validity 
of a double-translated (translated and back-translated) version of the SAPAS 
screening scale in Spanish. The study started in September 2019, but the sample 
taking stage had to be interrupted in March 2020 due to the Covid-19 pandemic. 
Thus, the study was resumed in September 2022 and was continued until May 2023. 

Assuming a 95% Confidence Interval (CI) and a PD prevalence of 37% in clinical 
populations in Granada , and considering a precision of 10% as appropriate 
due to the wide range of PD prevalence estimated in Europe throughout the 
literature (40–92%) , a sample size of 90 individuals was calculated to 
provide sufficient power for this study. However, we managed to increase the 
sample size to 107 individuals, which is estimated to provide more representative 
results, along with enough power for further testing validity and reliability, as 
previously suggested . 

Inclusion criteria were to accept any adult individual attending outpatient 
clinics at both, Clínico San Cecilio University Hospital and Virgen de las 
Nieves University Hospital (Granada, Spain), for recruitment provided they 
understood and could give informed consent to take part in the study. Exclusion criteria were to reject individuals younger than 18 years and those 
who, due to the severe nature of their symptomatology and/or psychological 
disability, were unable to provide informed consent or those could not understand 
the process of the study and questions asked during the interview. This included 
patients suffering from severe manic/delusional states and patients with 
intellectual disability. 

A. Sociodemographic variables of the individuals that met inclusion criteria 
(age, sex, educational level, marital and employment status). B. Full psychiatric history, including previous diagnosis and medication, using 
clinical standards. C. The SAPAS self-administered screening scale for PDs was administered twice: 
first at a first interview when entering the study and, secondly, again to test 
for repeatability 30 days later. D. The IPDE questionnaire for ICD-10-based PD diagnosis  was also used. This 
includes an initial self-administered questionnaire of 59 yes/no items, followed 
by a semi-structured hetero-administered interview with 67 questions which can be 
scored from 0 to 2 points. The IPDE questionnaire renders Negative, Probable or 
Positive diagnosis for each ICD-10 PD diagnosis, using 3 or 4 as cut-off points 
depending on each specific PD being tested, and it also provides dimensional 
scores for each PD. The previously-translated Spanish version  was used. 

In the first stage of the study, the Spanish SAPAS adaptation used by the 
previous validation study  (Appendix) was initially run by a psychiatrist 
during patient recruitment, who simultaneously collected information such as 
informed consent, sociodemographic information and psychiatric history. 
Subsequently, at a later moment, the diagnostic IPDE interview was also 
administered. At the second stage of the study, a second SAPAS measure was performed by the 
psychiatrist 30 days later, enabling to check for test-retest stability. During 
this study, we enlarged the original sample of 59 patients from our previous 
report to a final sample of 107 participants (n = 107). 

The statistical analysis was aimed at determining the SAPAS capacity to 
correctly identify patients with a positive ICD-10 PD diagnosis (as established 
using the IPDE questionnaire) and to identify the most optimal screening cut-off 
point for the SAPAS. To achieve this, Cronbach’s Alpha was first calculated to 
determine the internal consistency of the SAPAS, both overall and after omitting 
each item from the total score. This measurement of internal consistency aims to 
assess the reliability of the measurement and to determine whether the 
questionnaire includes only one or several constructs in its structure. It also 
shows how each of the scale items contributes to the scale’s 
overall reliability . In addition, adequacy for factor analysis was checked 
by using the Kaiser-Meyer-Olkin Test (KMO Test) and Bartlett’s Test of Sphericity 
. Furthermore, Varimax Rotation was used for Principal Component Analysis 
(PCA) to determine the factorial structure of the scale. To identify criterion validity between the SAPAS screening scale and the IPDE 
semi-structured interview, a Receiver Operating Characteristic (ROC) analysis was 
then used, which considered “positive” IPDE PD diagnosis as the gold standard. 
Thus, SAPAS performance was assessed and the ideal cut-off score for predicting a 
diagnosis of any PD was identified by comparison with the IPDE interview. An 
estimate of the scale’s discriminatory performance was calculated by analysis of 
the AUC of the ROC curve obtained after using a sensitivity-specificity plot. 
Then, Pearson’s correlation was employed to test the association between 
dimensional scores of PD as identified by the IPDE and their equivalent factors 
emerging from the PCA performed on the SAPAS scores. Finally, an Intraclass Correlation Coefficient (ICC, one-way random model, 95% 
CI) was calculated to check for test-retest stability between the two successive 
SAPAS measurements. All calculations were performed using the IBM SPSS Statistic 
24 (IBM Corp, Armonk, NY, USA) , with a 0.05 level of significance. 

The Sample Descriptive results of the 107 patients that took part in the study can be found 
in Table . The mean age was 39.5 years (Standard Deviation (SD) = 13.06). 40 
individuals (37.4%) were found to be potential PD cases upon performance of the 
IPDE interview. Borderline Personality Disorder (BPD) was the most frequent PD 
diagnosis and was ascertained in 14 of those identified as having a PD (F60.32, 
13.1%). Anankastic PD ranked second in frequency, with 11 potential cases 
(F60.5, 10.3%). It is worth mentioning that, out of the 40 identified by the 
IPDE as PD cases, 15 (14% of the sample) were found to have more than one PD 
diagnosis. Thus, 10 patients presented two concurrent PD diagnoses (9.3%), 2 of 
them presented three simultaneous diagnoses (1.9%), and 3 of them qualified for 
four PD diagnoses (2.8%). Reliability Table shows internal consistency of the Spanish SAPAS and its items following 
Cronbach’s α calculations. For the new sample tested, alpha coefficient 
was 0.60. The 8th item, “Generally a Perfectionist”, was the one that 
correlated the least with the other elements and omitting it from the analyses 
raised the alpha coefficient score to 0.62. Construct Validity After performing a KMO Test and Bartlett’s Test of Sphericity, we found that the 
sample was suitable for factor analysis. Thus, statistical significance was 
achieved in both tests (KMO test = 0.599; Bartlett’s Test of Sphericity = 
104.625; p ≤ 0.0001) and therefore, we proceeded with PCA. The 
solution extracted from the latter explained 58.1% of the total variance 
identifying three factors within the SAPAS items. The first and strongest factor 
(eigenvalue = 2.21) included the three first items of the scale: “Difficulty in 
making/keeping friends”, “Usually a loner” and “Trusting others”. The second 
factor (eigenvalue = 1.35) was mainly composed of items 4 “Normally loses temper 
easily” and 5 “Normally impulsive”. The last factor (eigenvalue = 1.10) 
included items 6 “Normally a worrier” and 7 “Depends on others a lot”. Item 8 
“Generally a perfectionist” did not prove enough factor loading to correlate 
with any factor (0.158) and was left separate from the grouping. The factorial 
structure of the scale is depicted in Table . Concurrent Validity and SAPAS Cut-off Points As shown in Fig. , a ROC curve  plotted the Spanish SAPAS scores as a 
screening test for PD diagnosis against the well-established IPDE-obtained 
specific diagnosis. Such ROC curve showed statistical significance ( p ≤ 0.0001), with AUC amounting to 0.84 (95% CI = 0.76–0.92), suggesting 
that Spanish SAPAS could constitute a good screening tool, considering all 
possible cut-off scores (see Table ). Table shows the performance of the SAPAS at several cut-off points. A cut-off 
point of 4 allowed for a decent balance between sensitivity (70%), and 
specificity (76%), correctly classifying 73% of the individuals. However, the 
best performance for a screening tool was found at a cut-off point of 3, trading 
specificity (52%) for a significant increase in sensibility (90%), while still 
classifying 71% of individuals correctly. When we explored the possible correlation between PD types and the three factors 
obtained by PCA on the SAPAS, we found that such factors broadly do correlate 
with the categorical splitting of PDs by clusters (A, B and C) (see Table ). Test-Retest Stability (Repeatability) The ICC calculated for testing the test-retest stability  of the Spanish 
SAPAS also exhibited statistically significant results. A 0.938 alpha coefficient 
was achieved when determining reliability of the measure, and an overall 0.88 
correlation (95% CI = 0.795–0.931) was found for the single measures. When 
taking the average measures into consideration, we found a 0.94 intra-class 
correlation coefficient (95% CI = 0.886–0.964). 

Descriptive results of the 107 patients that took part in the study can be found 
in Table . The mean age was 39.5 years (Standard Deviation (SD) = 13.06). 40 
individuals (37.4%) were found to be potential PD cases upon performance of the 
IPDE interview. Borderline Personality Disorder (BPD) was the most frequent PD 
diagnosis and was ascertained in 14 of those identified as having a PD (F60.32, 
13.1%). Anankastic PD ranked second in frequency, with 11 potential cases 
(F60.5, 10.3%). It is worth mentioning that, out of the 40 identified by the 
IPDE as PD cases, 15 (14% of the sample) were found to have more than one PD 
diagnosis. Thus, 10 patients presented two concurrent PD diagnoses (9.3%), 2 of 
them presented three simultaneous diagnoses (1.9%), and 3 of them qualified for 
four PD diagnoses (2.8%). 

Table shows internal consistency of the Spanish SAPAS and its items following 
Cronbach’s α calculations. For the new sample tested, alpha coefficient 
was 0.60. The 8th item, “Generally a Perfectionist”, was the one that 
correlated the least with the other elements and omitting it from the analyses 
raised the alpha coefficient score to 0.62. 

After performing a KMO Test and Bartlett’s Test of Sphericity, we found that the 
sample was suitable for factor analysis. Thus, statistical significance was 
achieved in both tests (KMO test = 0.599; Bartlett’s Test of Sphericity = 
104.625; p ≤ 0.0001) and therefore, we proceeded with PCA. The 
solution extracted from the latter explained 58.1% of the total variance 
identifying three factors within the SAPAS items. The first and strongest factor 
(eigenvalue = 2.21) included the three first items of the scale: “Difficulty in 
making/keeping friends”, “Usually a loner” and “Trusting others”. The second 
factor (eigenvalue = 1.35) was mainly composed of items 4 “Normally loses temper 
easily” and 5 “Normally impulsive”. The last factor (eigenvalue = 1.10) 
included items 6 “Normally a worrier” and 7 “Depends on others a lot”. Item 8 
“Generally a perfectionist” did not prove enough factor loading to correlate 
with any factor (0.158) and was left separate from the grouping. The factorial 
structure of the scale is depicted in Table . 

As shown in Fig. , a ROC curve  plotted the Spanish SAPAS scores as a 
screening test for PD diagnosis against the well-established IPDE-obtained 
specific diagnosis. Such ROC curve showed statistical significance ( p ≤ 0.0001), with AUC amounting to 0.84 (95% CI = 0.76–0.92), suggesting 
that Spanish SAPAS could constitute a good screening tool, considering all 
possible cut-off scores (see Table ). Table shows the performance of the SAPAS at several cut-off points. A cut-off 
point of 4 allowed for a decent balance between sensitivity (70%), and 
specificity (76%), correctly classifying 73% of the individuals. However, the 
best performance for a screening tool was found at a cut-off point of 3, trading 
specificity (52%) for a significant increase in sensibility (90%), while still 
classifying 71% of individuals correctly. When we explored the possible correlation between PD types and the three factors 
obtained by PCA on the SAPAS, we found that such factors broadly do correlate 
with the categorical splitting of PDs by clusters (A, B and C) (see Table ). 

The ICC calculated for testing the test-retest stability  of the Spanish 
SAPAS also exhibited statistically significant results. A 0.938 alpha coefficient 
was achieved when determining reliability of the measure, and an overall 0.88 
correlation (95% CI = 0.795–0.931) was found for the single measures. When 
taking the average measures into consideration, we found a 0.94 intra-class 
correlation coefficient (95% CI = 0.886–0.964). 

Following a previous report, in this study, we further demonstrate that the 
Spanish version of the SAPAS is a valid, consistent and reliable screening 
instrument for PDs for use in patients attending mental health services. 
Moreover, PCA determined the presence of 3 PD factors explaining most of the 
scores’ variability and that, interestingly, broadly correspond with the 
standardly established PD clusters and types . Thus, as suggested by the 
SAPAS validation studies [ , , ], the first PD factor roughly colludes with 
the “ schizo-paranoid ” group of disorders, as items included in the 
factor are intended to measure both schizoid and paranoid PDs. Accordingly, the 
second factor correlates significantly with the “ Emotional 
Instability ” PD cluster represented by SAPAS items 4 and 5 measuring mostly 
impulsivity and anger. Finally, the third PCA extracted factor correlates well 
with SAPAS items (6 and 7) measuring the “ anxious-dependent ” PD types 
(Cluster C). However, this categorical clustering distribution of the scale and its items can 
diverge from the more modern dimensional model of PD included in the newer ICD-11 
classification . Whilst the SAPAS was not designed with the ICD-11 
dimensional PD classification in mind, as it is indeed an older scale born under 
the context of a categorical paradigm of PD, the results of the factor analysis 
performed could also help to allocate this scale within the scope of the modern 
dimensional model, as each of the factors found could account for the latter’s 
different personality traits . After all, items in the SAPAS are in a way a 
summary rephrasing of PD criteria and, indeed, a larger total SAPAS score could 
be in direct relation with increasing PD severity, as suggested by our previous 
validation study for the Spanish SAPAS . This notion is certainly supported 
by findings of previous studies such as one by Ball et al .  and 
another reporting a recent translation of the SAPAS into the Japanese language 
. Item 8 of the SAPAS questionnaire enquires about perfectionism, which could be 
related to Anankastic PD. However, this item was found to be the one that 
deviated the most from the rest of the internal consistency and reliability 
measures. Omitting this item would improve the alpha coefficient when measuring 
the scale’s internal consistency, and it was also the one item that exhibited 
more inconsistency when testing for construct validity via factor analysis. Even 
though it was indeed the third most significant item when determining Factor 3, 
and therefore could potentially be paired with items 6 and 7 when defining this 
third factor, its contribution to factor loading was noticeably less than 
significance of items 6 and 7. Besides, this is not found to be an anomaly, as 
these findings are consistent with other SAPAS validation studies previously 
cited. Indeed, the original article by Moran et al .  determined a 
global reliability of the scale with an alpha coefficient of 0.68, which 
increased to 0.70 when item 8 was omitted. The same was reported by a subsequent 
study, this time among the general population, , and by our previous study in 
the Spanish population . Our factorial solution for the SAPAS can also be linked to ICD-11 dimensional 
personality dysfunction. Hence, our Factor 1, which includes items that explore 
difficulty making friends, loneliness (items 1 and 2) and (lack of) trusting 
others (item 3), could be closely related to the ICD-11 detachment domain. 
Similarly, factor 2, as it includes items related to easy loss of temper (item 4) 
and impulsivity (item 5), may be associated with both disinhibition and 
dissociality traits. And finally, factor 3, including items that account for 
anxiety (item 6) and dependence (item 7), could relate to the negative 
affectivity domain. In addition, item 8 of the scale (perfectionism) would 
undoubtedly collide with the ICD-11 domain of anankastia which, in turn, could 
explain why item 8 tends to isolate from all other SAPAS items here and in 
previous reports [ , , ]. When compared to the gold standard validated questionnaire (IPDE), concurrent 
validity found in the SAPAS was most satisfactory. We identified an AUC 
comparable to that of a previous validation study in a Spanish population  
and to the AUC reported by the first validation study in the English population 
. Sensibility and specificity values were quite adequate as well, reaching 
higher specificity values than the previous Spanish validation study, even though 
sensitivity was lower at the 4 cut-off point. This is also consistent with other 
previously published studies, in which a more representative, larger sample shows 
a small increase in the β -Error and a decrease in the number of cases 
sorted correctly . Furthermore, even though the cut-off point at 4 offers 
a decent trade between sensibility and specificity, setting the cut-off point at 
3 might offer better performance as a screening test, increasing sensibility to 
90% at the expense of lowering specificity, thus properly classifying 71% of 
the cases. This is again consistent with the original English validation study 
, in which a 4 cut-off point is related to more parallel sensitivity and 
specificity values with specificity being the higher value, and a 3 cut-off point 
excelling at screening performance with 94% sensitivity. These results are also 
consistent with those achieved by the large-scale study performed in 2019 , 
which included a sample of more than 50,000 individuals measured with the SAPAS 
to determine the links between the SAPAS factorial structure and the 5th 
Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) 
Alternative Diagnostic Model for Personality Disorders (AMPD). Similar to our 
report here, that study found that establishing a cut-off point at 3 reliably 
identified PD cases well in a clinical sample, while a cut-off point of 4 
provided a balanced trade between sensitivity and specificity, making it more 
optimal for a general sample population. Furthermore, our factorial solution 
could also relate to the one achieved by the latter study, as it consists of a 
three-factor solution that can somewhat relate to the DSM-5 AMPD. Namely, our 
three factors could be related to the detachment, xxternalizing and negative 
affectivity DSM-5 AMPD domains, respectively. Additionally, the finding that our three PD factors correlate to PD Clusters and 
dimensional scores of IPDE diagnoses, which is a key finding for the study as it 
replicates a similar report using the English version . Correlation was 
highest for the emotionally unstable PDs, both impulsive and borderline types. 
This becomes particularly relevant when considering these disorders to be the 
most prevalent and severe among PDs , suggesting that the SAPAS could 
potentially become a screening tool for clinicians dealing with such complex 
disorder. Moreover, the fact that correlation is still proven between the SAPAS 
and the IPDE dimensional score of PDs could lead to a further application in both 
clinical settings and population studies. Even though there are Spanish scales 
for specific PDs (Borderline  or Schizotypal ), personality dimensions 
 and personality traits , the SAPAS is still the shortest and most 
easily-administered scale for PD screening in different settings and, indeed, 
this scale is still being used for research and clinical purposes both, in 
Spanish  and in international settings in its original English version . However, to our mind, this study’s greatest strengths are the results achieved 
when testing for test-retest stability (repeatability) which demonstrate an 
excellent degree of intra-operator consistency. This is consistent with previous 
literature, showing even a better performance, such as a validation study by 
Germans et al . 2008 , where the SAPAS was posed as a screening tool. Limitations and Future Projects Even though subclinical and general populations are both settings where the 
SAPAS might perform at its best, further research is needed to truly test and 
validate this scale in the Spanish population outside of a clinical setting. As 
proven by the general population study performed for the English original 
version, the scale might have less discriminative power or different optimal 
cut-off points . Regarding clinical populations, further testing including 
larger sample sizes may also prove useful in addressing the scale’s validity when 
other, less prevalent PD diagnoses, are involved, such as Histrionic or 
Antisocial, for which the SAPAS has not proven to capture variance properly . 
Another caveat is the lax inclusion/exclusion criteria used in this study, and 
the authors acknowledge that the wide array of included patients may have been a 
confounding factor. Besides, the authors are aware of an issue rooted in the very conception of the 
SAPAS as a measuring tool. Thus, while this scale may excel at measuring 
interpersonal aspects of PD, it is somewhat limited at exploring the self-related 
aspects of the personality disorder construct, and hence, it may not be as 
accurate as more modern scales at capturing the severity aspect of the PD 
diagnosis, which is a relevant part of the new ICD-11 formulation. A new scale 
validation study in Spanish, that could incorporate some of the SAPAS’ ethos 
whilst enhancing its capacity to identify severity and dimensional domains could 
become a ground-breaking project leading to a more accurate, modern and complete 
screening scale. Finally, we must address the fact that determining concurrent and construct 
validity is always an arduous task regarding PDs research, due to their 
ill-defined constructual nature, unlike what might occur when studying other 
mental disorders that might be more deeply rooted in psychiatric and 
psychological research. 

Even though subclinical and general populations are both settings where the 
SAPAS might perform at its best, further research is needed to truly test and 
validate this scale in the Spanish population outside of a clinical setting. As 
proven by the general population study performed for the English original 
version, the scale might have less discriminative power or different optimal 
cut-off points . Regarding clinical populations, further testing including 
larger sample sizes may also prove useful in addressing the scale’s validity when 
other, less prevalent PD diagnoses, are involved, such as Histrionic or 
Antisocial, for which the SAPAS has not proven to capture variance properly . 
Another caveat is the lax inclusion/exclusion criteria used in this study, and 
the authors acknowledge that the wide array of included patients may have been a 
confounding factor. Besides, the authors are aware of an issue rooted in the very conception of the 
SAPAS as a measuring tool. Thus, while this scale may excel at measuring 
interpersonal aspects of PD, it is somewhat limited at exploring the self-related 
aspects of the personality disorder construct, and hence, it may not be as 
accurate as more modern scales at capturing the severity aspect of the PD 
diagnosis, which is a relevant part of the new ICD-11 formulation. A new scale 
validation study in Spanish, that could incorporate some of the SAPAS’ ethos 
whilst enhancing its capacity to identify severity and dimensional domains could 
become a ground-breaking project leading to a more accurate, modern and complete 
screening scale. Finally, we must address the fact that determining concurrent and construct 
validity is always an arduous task regarding PDs research, due to their 
ill-defined constructual nature, unlike what might occur when studying other 
mental disorders that might be more deeply rooted in psychiatric and 
psychological research. 

The SAPAS still proves to be a reliable tool for the screening of PD in the 
Spanish mental health population, and its validity and consistency are here 
further established. Our findings demonstrate that the SAPAS is a solid 
screening-tool in settings in which the dimensional aspects of personality 
disorders are gaining strength over the previously established categorical 
paradigm. 

The data that support the findings of this study are available from the 
corresponding author, Jorge A. Cervilla, upon reasonable request. 

