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Toward Developing Clinical cut-off for the Grandiosity Scale of the Dimensional Clinical Personality Inventory 2
Hacia el Desarrollo del Punto de Corte Clínico Para la Escala de Grandiosidad del Inventario Clínico Dimensional de Personalidad 2
Lucas de Francisco Carvalho
Corresponding author
lucas@labape.com.br

Corresponding author.
, Catarina Possenti Sette, Ariela Raissa Lima Costa
Universidade São Francisco, Campinas, São Paulo, Brazil
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The narcissistic personality disorder &#40;NPD&#41; is one of the less frequent PDs&#44;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">1</span></a> presenting a mean prevalence of 0&#46;5&#37; according to 12 studies&#44; which may vary up to 6&#46;2&#37;&#44; men being more frequent&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">2</span></a> This is one of the PD more studied&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">3</span></a> However&#44; the task force of the Alternative Model for Personality Disorders &#40;AMPD&#41; has initially proposed its exclusion &#40;but NPD was sustained in the final proposition&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Section II of DSM-5 defines the NPD as a pervasive pattern of grandiosity&#44; need for admiration&#44; and lack of empathy&#46; Five of nine criteria must be reached to the NPD diagnosis&#58; grandiose sense of &#40;1&#41; fantasies of unlimited success&#44; power and ideal love &#40;2&#41;&#44; belief that he&#47;she is special and only special people as he&#47;she would be able to understand it &#40;3&#41;&#44; requiring excessive admiration from of others &#40;4&#41;&#44; belief in deserving privileges and special treatment &#40;5&#41;&#44; manipulation of others for self-gain &#40;6&#41;&#44; lack of empathy &#40;7&#41;&#44; demonstrates envy of others or believes others envy he&#47;she &#40;8&#41;&#44; and is arrogant and behaves as if he&#47;she were superior &#40;9&#41;&#46; Previous findings suggest that all NPD criteria have high discrimination&#44; but the ninth&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Although relevant&#44; the diagnostic criteria of the NPD &#40;2&#41; do not include some core psychological symptoms as vulnerable self-esteem&#44; feelings of emptiness&#44; distress&#44; and boredom&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">5</span></a> Evidence suggests that there are subgroups of people with NPD&#44; mainly&#44; one group focused on the grandiosity and other group focused on vulnerability&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">6&#8211;10</span></a> Moreover&#44; high levels of comorbidity with other PDs and other mental disorders were observed&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">11</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The NPD traits are typically measured by assessment tools as the Narcissistic Personality Inventory &#40;NPI&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">12</span></a> although this inventory has received critics as assessing healthy traits more than pathological traits&#46;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">13&#44;14</span></a> Other measures&#44; focusing on the pathological aspects are available&#44; as the Five-Factor Narcissism Inventory &#40;FFNI&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">15</span></a> the Pathological Narcissism Inventory &#40;PNI&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">16</span></a> specifics facets of the Personality Inventory for DSM-5 &#40;PID-5&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">17</span></a> and specifics dimensions&#44; and respective factors&#44; of the Dimensional Clinical Personality Inventory 2 &#40;IDCP-2&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">18</span></a> Our focus is on the dimensions and factors of the IDCP-2&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The IDCP-2<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">18</span></a> is the revised version of its previous version&#44; IDCP&#46; The IDCP-2 first version is based on Millon&#39;s Theory<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">19</span></a> and in the diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders - 4th Edition &#40;DSM-IV-TR&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">20</span></a> To the revised version of IDCP&#44; the IDCP-2&#44; the theoretical scope and traits coverage were improved by other sources&#58; session III of the DSM-5&#44;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">2</span></a> facets of the Personality Inventory for DSM-5 &#40;PID-5&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">17</span></a> factors of the Schedule for Nonadaptive Personality &#40;SNAP&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">21</span></a> and the dimensions assessed by the Shedler-Westen Assessment Procedure &#40;SWAP&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">22</span></a> The IDCP-2 is composed of 12 dimensions divided into a set of 47 facets&#46; Dimensions are Dependency&#44; Aggressiveness&#44; Mood Instability&#44; Eccentricity&#44; Attention Seeking&#44; Distrust&#44; Grandiosity&#44; Isolation&#44; Avoidance of Criticism&#44; Self-sacrifice&#44; Conscientiousness&#44; and Inconsequence&#46; A number of studies verifying the psychometric properties of the instrument were published&#44;<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">23&#8211;26</span></a> and new efforts have been undertaken to find clinical cut-off for each revised dimension&#46;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">27&#8211;29</span></a> Although the dimensional perspective avoids restricting diagnosis and classification with arbitrary boundaries&#44; cut-offs are necessary to assist clinicians in decision-making&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Grandiosity is the IDCP-2 dimension more related to the NPD traits&#44; as observed in previous studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0395"><span class="elsevierStyleSup">30&#44;31</span></a> This dimension measures traits as recognition and attention need&#44; envy of and from others&#44; disinterest in others&#8217; problems&#44; and superiority feelings&#46; Although previous evidence suggests the psychometric adequacy of the grandiosity dimension&#44; we could not find studies proposing cut-off for practical use of this dimension&#46; The present study aims to establish a clinical cut-off for the grandiosity dimension&#44; using item-level evaluation procedures&#44; and hence&#44; more evidence of the psychometric properties of the instrument&#46; The formulated hypotheses are&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0035" class="elsevierStylePara elsevierViewall">&#40;h1&#41; Items set should be more reliable in the pathological level of the trait &#40;i&#46;e&#46;&#44; extreme of the latent trait&#41; than in medium or low grandiosity range&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0040" class="elsevierStylePara elsevierViewall">&#40;h2&#41; People should be located in higher levels of the construct as they present more pathological traits related to NPD&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0045" class="elsevierStylePara elsevierViewall">&#40;h3&#41; Grandiosity dimension should be able to discriminate between people with high levels of NPD from people with low levels&#46;</p></li></ul></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Participants</span><p id="par0050" class="elsevierStylePara elsevierViewall">This study consisted of 5387 Brazilian adults&#44; aged from 18 to 90 years &#40;mean&#44; 25&#46;92<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#46;02 years&#59; 57&#37; female&#41;&#44; most college students &#40;45&#46;6&#37;&#41;&#44; accessed by convenience&#46; The sample was divided&#44; a posteriori&#44; into 4&#160;groups according to external criteria&#58; subjects without a known psychiatric diagnosis and that reported never had being under psychological and&#47;or psychiatry treatment &#40;non-patient&#59; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3963&#41;&#44; subjects without a known psychiatric diagnosis&#44; but that reported doing psychological and&#47;or psychiatry treatment &#40;mental health patients&#44; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1319&#41;&#44; patients diagnosed with other PDs &#40;non-NPD patients&#59; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>94&#41;&#44; and patients diagnosed with NPD &#40;NPD patients&#59; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>11&#41;&#46; The non-NPD patients and NPD patients were psychiatric outpatients showing a positive diagnosis of PD&#44; established by experienced psychiatrists &#40;more than 10 years of clinical experience&#41; using the Structured Clinical Interview for DSM Axis II &#40;SCID-II&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Instruments</span><p id="par0055" class="elsevierStylePara elsevierViewall">The IDCP-2 is an IDCP&#39;s reviewed version&#44;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">18</span></a> developed according to pathological traits reported in the theoretical proposal of Theodore Millon&#44;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">19</span></a> the diagnostic criteria of DSM-IV- TR Axis II&#44;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">20</span></a> and section 2 of the DSM-5&#44;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">2</span></a> as well as the traits reported in section 3 of the DSM-5 and Personality Inventory for DSM 5 &#40;PID-5&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">17</span></a> the dimensions assessed by Shedler-Westen Assessment Procedure &#40;SWAP&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">22</span></a> and the dimensions listed by Anna Clark&#44;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">21</span></a> which provide the basis for Schedule for Nonadaptive Personality &#40;SNAP&#41;&#46; The IDCP-2 is a self-report instrument for assessing pathological personality traits&#44; composed of 206 items distributed in 12 dimensions &#40;Dependency&#44; Aggressiveness&#44; Mood Instability&#44; Eccentricity&#44; Attention Seeking&#44; Distrust&#44; Grandiosity&#44; Isolation&#44; Criticism Avoidance&#44; Self-Sacrifice&#44; Conscientiousness&#44; and Inconsequence&#41;&#46; Items must be answered from a Likert scale of four points&#44; ranging from &#8220;it has nothing to do with me&#8221;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">1</span></a> and &#8220;it has a lot to do with me&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">4</span></a> Psychometric properties of dimensions&#44; validity evidence &#40;based on the internal structure and external variables&#41;&#44; and reliability indices &#40;for internal consistency&#41; have shown to be appropriate in studies that provide a basis for the IDCP-2 for each dimension&#46;<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">23&#44;24&#44;32&#44;33</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">For the present study&#44; we used the revised version of the Grandiosity<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">30</span></a> that contains 18 items divided into four factors and a total score&#46; Factors are Need for recognition &#40;4 items&#41;&#44; Superiority &#40;5 items&#41;&#44; Dominance &#40;5 items&#41;&#44; and Indifference &#40;4 items&#41;&#46; The sum of the factors composes the Grandiosity total score&#46; We also administered the original dimension&#44;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">34</span></a> consisting of twelve items&#44; as a means to perform the equating procedure&#44; as reported in the next topic&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Procedures and data analysis</span><p id="par0065" class="elsevierStylePara elsevierViewall">After being submitted to and approved by the Institutional Ethics Board Review &#40;CAAE 21992113&#46;1&#46;0000&#46;5514&#41;&#44; data collection started&#46; Data collection was from 2011 to 2017&#46; The administrations were made at a private university and in a public psychiatric hospital in the state of S&#227;o Paulo&#46; At the university&#44; the administration was conducted collectively&#44; lasting about 30<span class="elsevierStyleHsp" style=""></span>minutes in one session per class&#44; in the classrooms&#46; At the psychiatric hospital&#44; the administrations were individual&#44; in a separate room&#44; lasting about 50<span class="elsevierStyleHsp" style=""></span>minutes&#46; After explaining the research goals&#44; the participants signed the Informed Consent and then responded to the research instrument&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Not all participants responded the Grandiosity dimension of IDCP-2&#59; some of them answered the previous version&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">34</span></a> To generate scores for all participants&#44; we applied the equating procedure<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">35</span></a> to a dataset with 3997 community participants used as anchors &#40;from a total of 5387&#41;&#46; Two items are shared among the 2 versions of the Grandiosity dimension&#44; also used as anchors for generating scores &#40;i&#46;e&#46;&#44; theta&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Data were analyzed using the rating scale model&#44;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">36</span></a> a variant of the Rasch model for multiple-choice items&#46; The distinctive feature of this model is that the scalar intervals between points are deemed relatively similar for all items&#46; The difficulty parameter <span class="elsevierStyleItalic">b</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">i</span></span> represents the location of item <span class="elsevierStyleItalic">i</span>&#44; or the average intensity of the thresholds of an item&#46; Items representing extremes in the latent dimension have high average thresholds because they are localized on the most intense trait level&#46; Item and subject model parameters were calibrated by the Joint Maximum Likelihood Estimation method&#44; implemented in the Winsteps software&#46;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">37</span></a> This calibration performed considered original and revised items&#44; so the parameters were estimated by all the participants&#44; which is the purpose of the equating procedure&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The adequacy of the calibration was evaluated by the indexes fit&#44; infit&#44; and outfit&#44; calculated for all items and participants&#46; These values are directly proportional to the residuals that reflect differences between the observed and expected responses from the hypothesized knowledge of the model parameters&#44; thus providing evidence of how well the model fits the data&#46; Values greater than 1&#46;3 indicate misfit&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">38</span></a> Complementarily&#44; we verified test unidimensionality&#44; responses categories adequacy&#44; item-theta correlation&#44; general reliability &#40;&#945; and Rasch&#41;&#44; and test curve information&#46; We tested the unidimensionality of the scale through the Rasch-residual-based Principal Components Analysis &#40;PCAR&#41;&#46; In PCAR&#44; unidimensionality is reached when the variance not explained by items is eigenvalue &#8804;2&#46;0&#46; When eigenvalue is greater than 2&#46;0&#44; Linacre<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">37</span></a> indicates that simulated data were generate based on real data values &#40;i&#46;e&#46;&#44; the dataset&#41;&#46; Unidimesionality is reached eigenvalue &#8804;2&#46;0&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">We proceeded to Wright map&#44; group comparisons through ANOVA&#44; and ROC curve&#44; aiming better understanding of latent construct and establishing the dimension&#39;s cut-off&#46; The cut-off was determined for the dimension&#39;s total score&#46; ANOVA and ROC curve were proceeded through SPSS version 21&#46; Regarding the ROC curve&#44; the psychiatric sample accounted for approximately 2&#37; of the total sample&#44; which is in line with the range of prevalence of PDs in the general population&#46; Also&#44; the sample of patients with avoidant personality disorder represents 1&#46;84&#37; of the total sample&#44; close of DSM-5<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">2</span></a> report&#44; especially the subsample from Part II of the National Comorbidity Survey Replication&#46; Qualitative item map analyses were based on Elliot et al&#46; recommendations&#46;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">39</span></a> ANOVA&#39;s effect size was calculated using Cohen&#39;s <span class="elsevierStyleItalic">d</span> for peer-to-peer comparisons&#46;<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">40</span></a> Moreover&#44; the Tukey&#39;s HSD post-hoc was calculated as a deepening in the results from ANOVA&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0090" class="elsevierStylePara elsevierViewall">We first investigated psychometric assumptions of the Grandiosity dimension&#46; Data were analyzed mainly at the item level&#44; but we also considered the total score and the 4 factors previously found in the revised version of this dimension&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">30</span></a> We tested the unidimensionality to verify if the items referred to the same construct&#44; and results indicated that the items explain 11&#46;3&#37; of the people&#39;s variance&#46; Only 9&#46;3&#37; of the variance was not explained by the items&#44; equivalent to 2&#46;8 eigenvalues&#46; This value is probably due to the dimension that allows assessing four subfactors&#44; Need for Recognition&#44; Superiority&#44; Dominance&#44; and Indifference&#46; Based on Linacre&#44;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">37</span></a> we generated 5&#160;simulated data using real data values that presented variance not explained by items ranging from 1&#46;1 to 1&#46;5&#44; suggesting that the amount of 2&#46;8 eigenvalues was random&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">We also investigated the consistency of the responses provided by the subjects based on the Rating Scale Model&#44; i&#46;e&#46;&#44; the suitability of the response categories to discriminate trait levels&#46; <a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a> presents the probability of each category &#40;curves 1&#44; 2&#44; 3&#44; and 4&#41; be selected &#40;axis <span class="elsevierStyleItalic">Y</span>&#41; considering the person&#39;s latent trait &#40;axis <span class="elsevierStyleItalic">X</span>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">Based on <a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#44; we verified that the threshold values required to change the probability of response in each category &#40;represented by &#42; in the figure&#41; were<span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>&#46;82 &#40;category 1 to 2&#41;&#44;<span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>&#46;02 &#40;category 2 to 3&#41; and &#46;84 &#40;category 3 to 4&#41;&#46; This demonstrates the adequacy of categories&#44; and the gradual increase suggests the ability of subjects to discriminate categories meanings&#44; consequently&#44; favor the discrimination between people with and without PD&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> presents the difficulty level for endorsement to items &#40;&#948;&#41;&#44; standard error&#44; adjustment indices &#40;infit and outfit&#41;&#44; correlation theta-item&#44; and internal consistency reliability indices &#40;based on the Rasch model and Cronbach&#39;s alpha&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">According to <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#44; the difficulty &#40;&#948;&#41; of each item is in ascending order&#44; wherein items with greater difficulty indicate a lower likelihood of endorsement&#44; once they require higher levels in the latent trait&#46; These items assess pathological traits&#44; representing severe characteristics of Grandiosity dimension&#46; The most extreme item in the latent construct &#40;i&#46;e&#46;&#44; less endorsed&#41; was I610&#44; which assess lack of empathy&#44; and the most endorsed &#40;i&#46;e&#46;&#44; less pathological&#41; was item I616 that includes characteristic of dominance&#46; All items presented a good fit for the model&#44; with infit and outfit within the range of 0&#46;5 to 1&#46;5 considered appropriate accord&#46;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">37</span></a> Moreover&#44; the items showed a moderate to high correlation with the total score&#44; and the alfa coefficient was high&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The relationship between people and items distributions were investigated using the mean location of item and people on test information curve &#40;see <a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46; The test information curve identifies reliability indexes according to metrics of the latent construct&#44; based on the average of items and people&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">The test information curve demonstrated that the Grandiosity dimension better assess people with theta between<span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>1 e 1&#46; This range includes the people&#39;s mean &#40;&#8722;&#46;77&#41;&#44; 90&#46;90&#37; of group 4 &#40;NPD patients&#41;&#44; and 54&#46;26&#37; of group 3 &#40;non-NPD patients&#41;&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Given the adequacy of psychometric properties &#40;unidimensionality&#44; response categories&#44; and reliability indices&#41;&#44; and the estimation of the items and people&#39;s parameters&#44; the focus analyses of the study are now presented&#46; <a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a> shows the Wright map&#44; which allows observing the relationship between items and participants in a common metric scale representing the latent construct &#40;i&#46;e&#46;&#44; grandiosity functioning&#41;&#46; The difficulty of items was calculated using the total sample&#44; but for illustrative purpose&#44; the map presents the distribution of 230 people&#44; in which 1<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>non-patients &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>43&#41;&#44; 2<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>mental health patients &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>102&#41;&#44; 3<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>non-NPD patients &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>94&#41;&#44; and 4<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>NPD patients &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>11&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">Items located on top of <a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a> are the least likely to be endorsed by healthy individuals &#40;groups 1 and 2&#41; and higher by people with pathological traits &#40;groups 3 and 4&#41;&#44; the inverse is right for the items located on the bottom of the continuum&#46; We observed mean item was higher than the mean of people&#44; and 72&#46;22&#37; of the items are above mean items and 88&#46;89&#37; above the mean of people&#46; Concerning people&#39;s position&#44; 45&#46;45&#37; of group 5 &#40;patients with NPD&#41; is located above mean items and 90&#46;90&#37; above the mean of people&#46; Group 3 &#40;patients with other PDs&#41; 26&#46;60&#37; were above mean items and 47&#46;87&#37; above the mean of people&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Complementary&#44; we performed an analysis of variance between groups &#40;ANOVA&#41; and ROC curve analysis&#44; using the total sample to verify more evidence of the discriminative capacity of the dimension&#46; ANOVA demonstrated difference between groups &#40;<span class="elsevierStyleItalic">F</span>&#40;3&#46;5383&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#46;75&#59; <span class="elsevierStyleItalic">P</span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41;&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> presents the group comparison through ANOVA&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">The effects from the comparisons between groups&#44; including NPD patients&#44; were expressive&#44; indicating the dimension&#39;s capacity to discriminate NPD patients from the 3 other groups&#46; An exploratory assessment&#44; Tukey&#39;s HSD post-hoc indicated the division of participants into two groups&#44; the first with all non-patients and the second with all patients &#40;<span class="elsevierStyleItalic">P</span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05&#41;&#46; The ROC curve comprised an area below the curve of &#46;75 &#40;95&#37;IC&#44; 0&#46;64-0&#46;86&#59; <span class="elsevierStyleItalic">P</span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41;&#44; with high sensitivity &#40;91&#37;&#41; and medium specificity &#40;58&#37;&#41;&#44; considering as a cut-off <span class="elsevierStyleItalic">&#948;</span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>&#46;45&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">We analyzed the positive &#40;PPP&#41; band negative &#40;NPP&#41; predictive power for a better comprehension of scale functioning&#46; To calculate these indexes&#44; we used equations 15 and 17 of Streiner&#44;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">41</span></a> with a cut-off equal to<span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>&#46;45&#44; an NPD prevalence of 6&#46;2&#37; established by the National Epidemiologic Survey on Alcohol and Related Conditions&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">2</span></a> PPP value was 71&#37;&#44; and NPP was 79&#37;&#44; suggesting that the dimension was able to identify NPD patients in 71&#37; of cases&#44; and people without NPD in 79&#37; of cases&#46; The incremental diagnostic was calculated using equations 25 and 26 of Streiner&#44;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">41</span></a> showing that the dimension increases 24&#37; in the identification of people with NPD &#40;increase on PPP&#41;&#44; and 66&#37; in the identification of people without NPD &#40;increase on NPP&#41;&#46; The efficiency test was 58&#46;3&#37; representing the number the test was right compared to assessed people&#46;<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">42</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0145" class="elsevierStylePara elsevierViewall">NPD is one of the less frequent<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">1</span></a> and one of the more studied PDs&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">3</span></a> There is no clear accordance with NPD prevalence&#44; with studies finding a mean of 0&#46;5&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">1</span></a> while the prevalence can reach up to 6&#46;2&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">2</span></a> Despite being suggested to the exclusion by the task force of the AMPD&#44; the NPD remained after several criticisms of its elimination&#46; The traits composing this PD are related to interpersonal impairment as manipulation&#44; lack of empathy&#44; envy&#44; and arrogance&#46; In this study&#44; we seek to improve the Grandiosity dimension from the IDCP-2&#44;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">30</span></a> establishing a cut-off to discriminate between people with and without NPD diagnosis&#46; As assumption for reach this aim&#44; we first investigate the psychometric properties of the Grandiosity dimension and observed general suitability of the items to the statistical principles &#40;i&#46;e&#46;&#44; unidimensionality&#44; response categories&#44; parameter estimation&#44; and reliability&#41;&#46; Moreover&#44; we are proposing a screening cut-off for clinical use of the dimension&#44; allowing the mapping of the NPD relevant traits&#44; as well as providing an empirically established indicator of the presence &#40;or absence&#41; of NPD&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Our first hypothesis states that items should be more reliable in pathological levels of the construct in comparison to less pathological levels&#44; which was empirically corroborated by the findings&#44; agreeing with the previous evidence&#46;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">18&#44;30</span></a> A gradual and unidirectional increase in the latent trait was observed&#46; Each response category presented its information pinnacle in several continuum spots of the latent trait&#44; distributed in a crescent order &#40;1&#60;<span class="elsevierStyleHsp" style=""></span>2&#60;<span class="elsevierStyleHsp" style=""></span>3&#60;<span class="elsevierStyleHsp" style=""></span>4&#41;&#44; in which the categories with the higher values &#40;i&#46;e&#46;&#44; 3 and 4&#41; presented less probability of being chosen by people lower in the latent construct&#44; following the dimensional perspective for pathological personality traits assessment&#46;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">17&#44;43&#8211;46</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Considering the item&#39;s location regarding the people&#39;s position in the latent construct &#40;see <a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#44; we observed that most of the NPD patients are located at the top of the continuum&#44; expressing a clear tendency to endorse items&#46; These results confirm our second hypothesis&#44; i&#46;e&#46;&#44; people higher in the latent construct should have a greater probability to choose response categories of higher values &#40;i&#46;e&#46;&#44; 3 and 4&#41;&#44; showing higher scores in the pathological traits&#44; as previously observed for several pathological traits&#44; including NPD traits&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">4</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Our third hypothesis&#44; i&#46;e&#46;&#44; the dimension total score should be able to discriminate groups according to the severity of the NPD continuum&#44; which was corroborated&#46; The ANOVA&#39;s post hoc test showed discrepancies between NPD patients and all other groups&#44; wherein the higher differences were observed for NPD patients with non-NPD patients&#46; These findings indicate that the trait being evaluated by the items is closely related to NPD symptoms&#44; as expected&#44;<a class="elsevierStyleCrossRefs" href="#bib0395"><span class="elsevierStyleSup">30&#44;31&#44;47</span></a> and can be used as a screening measure in clinical settings&#46; In contrast&#44; higher means were observed for non-patient and mental health patient groups&#44; which were not expected&#44; as non-NPD patients should present more impairments&#46; However&#44; as an alternative hypothesis&#44; non-NPD patients showed only poor &#40;or none&#41; NPD symptoms&#44; while we do not have this information for the other groups &#40;i&#46;e&#46;&#44; non-patient and mental health patient&#41;&#46; Futures studies should try to replicate these findings&#44; but controlling for possible PD diagnoses of the non-patient groups&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">The clinically relevant cut-off for the measure was established through the ROC curve&#44; as well as calculating positive and negative predictive power and efficiency test values&#46; Results indicated an ideal cut-off of &#8211;&#46;45 in theta metrics&#44; showing suitable sensibility and specificity levels for screening purposes&#46;<a class="elsevierStyleCrossRefs" href="#bib0485"><span class="elsevierStyleSup">48&#44;49</span></a> In the items map &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#44; most of NPD patients are located above this cut-off&#44; corroborating our expectations&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Overall&#44; our findings suggest the use of the Grandiosity dimension for clinical practice as a screening for NPD traits&#46; However&#44; this tool should not be used for diagnostic purposes&#44; cases in which the professional should resort to diagnostic assessment tests &#40;e&#46;g&#46;&#44; SCID&#41;&#46; Limitations of this study must be considered&#58; the small cases of NPD patients&#59; the absence of knowledge on the potential diagnoses of the people in non-patient and mental health patient groups&#44; and the equating procedure&#44; that can aggregate statistical bias to the scores&#59; the use of SCID-II as the gold standard&#44; although a true gold standard is difficult to establish in the PDs field&#46; Future studies should investigate the suitableness of the cut-off determined in this study&#44; considering NPD and other clinical groups&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflict of interest</span><p id="par0175" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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            2 => "Trastorno de personalidad"
            3 => "Evaluaci&#243;n de la personalidad"
            4 => "Psicometr&#237;a"
          ]
        ]
      ]
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The present study aims to establish a clinical cut-off for the Grandiosity dimension&#44; using item-level evaluation procedures&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Participants were 5&#44;387 adults&#44; including outpatients diagnosed with narcissistic personality disorder &#40;NPD&#41;&#44; outpatients diagnosed with other personality disorders&#44; and adults from the community&#46; We administered the self-reported Grandiosity scale from the Dimensional Clinical Personality Inventory 2 &#40;IDCP-2&#41;&#46; The equating procedure was applied to generate theta scores for participants who did not answer all items&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The Wright map revealed that outpatients scored high on the latent continuum of the Grandiosity scale&#46; Group comparison showed large effect sizes for the mean difference between patients and non-patients&#46; The ROC curve supports a cut off at a &#8211;0&#46;45 score in theta standardisation&#44; which yields a high sensitivity &#40;91&#37;&#41; and moderate specificity &#40;58&#37;&#41;&#46; Moreover&#44; the PPP &#40;71&#37;&#41; and NPP &#40;79&#37;&#41; values suggest that the scale is able to identify NPD patients in 71&#37; of cases&#44; and people without NPD in 79&#37; of cases&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The findings suggest the IDCP-2 Grandiosity scale is useful as an NPD screening tool&#46; Possible clinical applications for the scale are described and the limitations of the study are discussed&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objective"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Methods"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El presente estudio tiene como objetivo establecer un corte cl&#237;nico para la dimensi&#243;n Grandiosidad&#44; utilizando procedimientos de evaluaci&#243;n a nivel de &#237;tem&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Los participantes fueron 5&#46;387 adultos&#44; entre pacientes ambulatorios diagnosticados con trastorno de personalidad narcisista &#40;NPD&#41;&#44; pacientes ambulatorios diagnosticados con otros trastornos de la personalidad&#44; y adultos de la comunidad&#46; Se administr&#243; la escala de Grandiosidad autoinformada del Inventario Dimensional Cl&#237;nico de Personalidad 2 &#40;IDCP-2&#41;&#46; El procedimiento de ecualizaci&#243;n se aplic&#243; para generar puntuaciones theta para los participantes que no respondieron a todos los &#237;tems&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">El mapa de Wright revel&#243; que los pacientes ambulatorios estaban ubicados en los niveles altos en el continuo latente de la escala de Grandiosidad&#46; La comparaci&#243;n grupal mostr&#243; tama&#241;os de efecto grandes para la diferencia de medias entre pacientes y no pacientes&#46; La curva ROC confirma un corte en &#8211;&#46;45 puntos en la estandarizaci&#243;n theta que produce una alta sensibilidad &#40;91&#37;&#41; y una especificidad moderada &#40;58&#37;&#41;&#46; Adem&#225;s&#44; los valores de PPP &#40;71&#37;&#41; y NPP &#40;79&#37;&#41; indican que la escala puede identificar a los pacientes con NPD en el 71&#37; de los casos y las personas sin NPD en el 79&#37; de los casos&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Los resultados indican que la escala de Grandiosidad del IDCP-2 es &#250;til como instrumento de evaluaci&#243;n para NPD&#46; Se describen posibles aplicaciones cl&#237;nicas para la escala y se discuten las limitaciones del estudio&#46;</p></span>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Category characteristic curves for the 4-points Likert-like response scale of IDCP-2 grandiosity dimension&#46;</p>"
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        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Test information function of grandiosity dimension items set&#46;</p>"
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      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Wright map is showing items &#40;left&#41; and people &#40;right&#41; of the IDCP Grandiosity Dimension&#46; In bold are the 11 NPD patients&#59; in italic<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>underlined are the non-NPD patients&#59; inside the brackets are the number of criteria reached by each patient with NPD&#46;</p>"
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">F1&#58; need for recognition&#59; F2&#58; superiority&#59; F3&#58; dominance&#59; F4&#58; indifference&#46;</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">We omitted items content because of copyright issues&#44; but the core meaning is presented&#46;</p>"
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                  \t\t\t\t">&#40;F2&#41; I597 superiority&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#40;F3&#41; I612 manipulation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#40;F1&#41; B115 superiority&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#40;F2&#41; I598 superiority&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#40;F2&#41; I592 superiority&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#40;F3&#41; I616 manipulation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#40;F2&#41; A059 superiority&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#40;F1&#41; A096 superiority&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#40;F3&#41; I341 manipulation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#40;F3&#41; I587 manipulation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#40;F1&#41; A062 superiority&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#40;F3&#41; I611 manipulation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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Article information
ISSN: 00347450
Original language: English
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