Patterns of anxiety and personality disorder comorbidity

Personality, Interpersonal Problems, and Anxiety Among Older Adults

INTRODUCTION

This study examined relationships between personality disorder (PD) features, Big Five personality traits, and interpersonal problems with anxiety.

METHOD

Older adults (N = 130) completed the Geriatric Anxiety Scale, Coolidge Axis Two Inventory, Big Five Inventory-2, and Circumplex Scales of Interpersonal Problems. Pearson correlation analyses were used to assess simple relationships between anxiety with PD features (CATI scales), Big Five personality domains (BFI-2 scales), and interpersonal problems (CSIP scales). Multiple linear regression analyses were performed to determine the extent to which the PD scales of the CATI, the personality scales of the BFI-2, and the scales of the CSIP explained variance in anxiety.

RESULTS

Anxiety was positively correlated with 13 of 14 PD scales, ranging from .23 (Narcissistic) to .61 (Depressive). Regarding Big Five personality traits, anxiety was negatively associated with Agreeableness (-.23), Conscientiousness (-.30), and Extraversion (-.31) but was positively associated with Negative Emotionality (.56). Regarding interpersonal problems, anxiety was positively related to all eight CSIP scales, ranging from Self-sacrificing (.30) to Distant/Cold (.62). Regression analyses indicated that PD features accounted for the most variance in anxiety symptoms (53%), followed by interpersonal problems (46%), and Big Five personality traits (33%).

DISCUSSION

Anxiety appears to be meaningfully associated with PD features, several aspects of Big Five personality traits, and interpersonal problems, suggesting that these variables may play important roles in the development and maintenance of anxiety, or vice versa. Our findings especially speak to the growing awareness of the deleterious impact of PD features on clinical syndromes in later life, as evidenced by strong comorbidities with anxiety.

Obsessive-Compulsive Personality Disorder Co-occurring in Individuals with Obsessive-Compulsive Disorder: A Systematic Review and Meta-analysis

LEARNING OBJECTIVES

After participating in this activity, learners should be better able to:• Assess the rates of co-occurring obsessive-compulsive personality disorder (OCPD) in patients with obsessive-compulsive disorder (OCD)• Identify characteristics related to OCD with co-occurring OCPD.

ABSTRACT

The current literature discloses discrepant findings regarding the rates of co-occurring obsessive-compulsive personality disorder (OCPD) in patients with obsessive-compulsive disorder (OCD). In addition, it is not clear which characteristics are related specifically to OCD with co-occurring OCPD. We conducted the first systematic review and meta-analysis of the studies of the prevalence of OCPD in patients with OCD. We also investigated potential moderators of the prevalence, including OCD severity, age of onset of OCD, sex, current age, methodological quality, and publication date of the studies. Electronic databases and gray literature were searched by two independent reviewers. A PRISMA systematic review with a random-effect meta-analysis was conducted. Thirty-four studies were included. A significant mean effect size of 0.25 without publication bias indicated that OCPD was present in 25% of patients with OCD, suggesting that the two conditions are distinct clinical entities. This prevalence was higher than the rates found in the literature for any other personality disorders among OCD patients. OCPD that occurs in the context of OCD was more likely to be present in males and to be characterized by a later age of onset of OCD, older age at assessment, and less severe OCD symptoms. Clinicians should consider these findings when assessing and planning treatment of OCD with co-occurring OCPD.

Obsessive-compulsive personality disorder traits and personality dimensions in parents of children with obsessive-compulsive disorder

Purpose

To compare patterns of temperament and character and the prevalence of Obsessive-Compulsive Personality Disorder (OCPD) and OCPD traits in parents of children with OCD and parents of healthy controls.

Methods

TCI and SCID-II were administered to 63 parents of 32 children with OCD and 63 parents of age- and sex-matched controls with no psychiatric diagnosis. Interviewers were not blind to proband status. Personality dimension scores and frequencies of OCPD criteria in both groups were compared after excluding parents with a diagnosis of OCD. Relationships between TCI dimensions and OCPD symptoms in parents and the clinical characteristics of OCD children were also studied.

Results

Parents of OCD children presented significantly higher scores in harm avoidance and lower scores in self-directedness, cooperativeness and reward dependence than parents of healthy children. A higher incidence of OCPD was found in parents of probands (p < 0.02). Hoarding, perfectionism and preoccupation with details were significantly more frequent in parents of OCD children. Counting, ordering and cleaning compulsions in OCD children predicted elevated odds of perfectionism and rigidity in their parents.

Conclusions

The existence of the dimensional personality profile associated with OCD in parents of children with OCD and the higher number of OCPD criteria in these parents in comparison to parents of healthy children highlight the importance of the role of personality factors in familial OCD.

The Roles of Emotion Regulation Difficulties and Impulsivity in the Associations between Borderline Personality Disorder Symptoms and Frequency of Nonprescription Sedative Use and Prescription Sedative/Opioid Misuse

Despite evidence of a strong relationship between BPD and substance use problems in general, little research has examined the associations of BPD symptoms with the misuse of sedatives or opioids, and no studies have explored possible factors that may underlie these associations. Thus, this study examined the relationships of BPD symptoms (i.e., the number of BPD criteria with threshold ratings on a diagnostic interview) to nonprescription sedative use, nonprescription opioid use, and prescription sedative/opioid misuse among 194 patients with alcohol and/or cocaine dependence in a residential substance use disorder treatment facility, as well as the roles of two theoretically-relevant factors in these relationships: emotion regulation (ER) difficulties and impulsivity facets. We found significant positive associations between BPD symptoms and nonprescription sedative use, nonprescription opioid use, and prescription sedative/opioid misuse. We also found significant positive indirect relationships of BPD symptoms to nonprescription sedative use through ER difficulties, ab = .04, 95% CI [.003, .09], and to prescription sedative/opioid misuse through two facets of impulsivity: lack of perseverance, ab = .05, 95% CI [.01, .11], and negative urgency, ab = .03, 95% CI [.002, .07]. Findings highlight the differential relevance of ER difficulties and impulsivity dimensions to the relationships of BPD symptoms to nonprescription sedative use and prescription sedative/opioid misuse, respectively, among patients with alcohol and/or cocaine dependence.

Avoidant Coping Style to High Imminence Threat Is Linked to Higher Anxiety-Like Behavior

Human studies with self-reported measures have suggested a link between an avoidant coping style and high anxiety. Here, using the common marmoset as a model, we characterize the latent factors underlying behavioral responses of these monkeys towards low and high imminence threat and investigate if a predominantly avoidant behavioral response to high imminence threat is associated with greater anxiety-like behavior in a context of low imminence threat. Exploratory factor analysis (EFA) of the human intruder test of low imminence threat revealed a single factor in which a combination of active vigilance and avoidance responses underpinned anxiety-like behavior. In contrast, two negatively-associated factors were revealed in the model snake test reflecting active and avoidant coping to high imminence threat. Subsequent analysis showed that animals with a predominantly avoidant coping style on the model snake test displayed higher anxiety-like behavior on the human intruder test, findings consistent with those described in humans. Together they illustrate the richness of the behavioral repertoire displayed by marmosets in low and high imminence threatening contexts and the additional insight that factor analysis can provide by identifying the latent factors underlying these complex behavioral datasets. They also highlight the translational value of this approach when studying the neural circuits underlying complex anxiety-like states in this primate model.

Avoidant personality disorder: current insights

Avoidant personality disorder (AVPD) is a relatively common disorder that is associated with significant distress, impairment, and disability. It is a chronic disorder with an early age at onset and a lifelong impact. Yet it is underrecognized and poorly studied. Little is known regarding the most effective treatment. The impetus for research into this condition has waxed and waned, possibly due to concerns regarding its distinctiveness from other disorders, especially social anxiety disorder (SAD), schizoid personality disorder, and dependent personality disorder. The prevailing paradigm subscribes to the "severity continuum hypothesis", in which AVPD is viewed essentially as a severe variant of SAD. However, areas of discontinuity have been described, and there is support for retaining AVPD as a distinct diagnostic category. Recent research has focused on the phenomenology of AVPD, factors of possible etiological significance such as early parenting experiences, attachment style, temperament, and cognitive processing. Self-concept, avoidant behavior, early attachments, and attachment style may represent points of difference from SAD that also have relevance to treatment. Additional areas of research not focused specifically on AVPD, including the literature on social cognition as it relates to attachment and personality style, report findings that are promising for future research aimed at better delineating AVPD and informing treatment.

Borderline personality features in depressed or anxious patients

Anxiety and depression frequently co-occur with borderline personality disorder. Relatively little research examined the presence of borderline personality features and its main domains (affective instability, identity problems, negative relationships and self-harm) in individuals with remitted and current anxiety and depression. Participants with current (n=597) or remitted (n=1115) anxiety and/or depression and healthy controls (n=431) were selected from the Netherlands Study of Depression and Anxiety. Assessments included the Personality Assessment Inventory - Borderline Features Scale and several clinical characteristics of anxiety and depression. Borderline personality features were more common in depression than in anxiety. Current comorbid anxiety and depression was associated with most borderline personality features. Anxiety and depression status explained 29.7% of the variance in borderline personality features and 3.8% (self-harm) to 31% (identity problems) of the variance in the four domains. A large part of the variance was shared between anxiety and depression but both disorders also explained a significant amount of unique variance. The severity of anxiety and depression and the level of daily dysfunctioning was positively associated with borderline personality features. Individuals with a longer duration of anxiety and depression showed more affective instability and identity problems. These findings suggest that patients with anxiety and depression may benefit from an assessment of personality pathology as it may have implications for psychological and pharmacological treatment.

Emotional Functioning in Obsessive-Compulsive Personality Disorder: Comparison to Borderline Personality Disorder and Healthy Controls

Few studies have investigated emotional functioning in obsessive-compulsive personality disorder (OCPD). To explore the nature and extent of emotion difficulties in OCPD, the authors examined four domains of self-reported emotional functioning--negative affectivity, anger, emotion regulation, and emotion expressivity--in women with OCPD and compared them to a borderline personality disorder (BPD) group and a healthy control group. Data were collected as part of a larger psychophysiological experimental study on emotion regulation and personality. Compared to healthy controls, participants with OCPD reported significantly higher levels of negative affectivity, trait anger, emotional intensity, and emotion regulation difficulties. Emotion regulation difficulties included lack of emotional clarity, nonacceptance of emotional responses, and limited access to effective emotion regulation strategies. Participants with OCPD scored similarly to participants with BPD on only one variable, namely, problems engaging in goal-directed behavior when upset. Results suggest that OCPD may be characterized by notable difficulties in several emotional domains.

Personality disorders and the persistence of anxiety disorders in a nationally representative sample

BACKGROUND

Among individuals with anxiety disorders, comorbid personality disorders (PDs) increase cross-sectional symptom severity and decrease functioning. Little is known, however, about how PDs influence the course of anxiety disorders over time. The purpose of this study was to examine the effect of PDs on the persistence of four anxiety disorders in a nationally representative sample in the United States.

METHODS

Two waves of data were collected on 34,653 participants, 3 years apart. At both waves, participants were evaluated for generalized anxiety disorder (GAD), social and specific phobias, and panic disorder. Predictors of persistence included all DSM-IV PDs. Control variables included demographics, comorbid PDs, age at onset of the anxiety disorder, number of prior episodes, duration of the current episode, treatment history, and cardinal symptoms of exclusionary diagnoses for each anxiety disorder.

RESULTS

Any PD, two or more PDs, borderline PD, schizotypal PD, mean number of PD criteria met, and mean number of PDs diagnosed predicted the persistence of all four anxiety disorders. Narcissistic PD predicted persistence of GAD and panic disorder. Schizoid and avoidant PDs also predicted persistence of GAD. Finally, avoidant PD predicted persistence of social phobia. Particular patterns of cross-cluster PD comorbidity were strong predictors of the persistence of individual anxiety disorders as well.

CONCLUSIONS

In this national sample, a variety of PDs robustly predicted the persistence of anxiety disorders over 3 years, consistent with the results of recent prospective clinical studies. Personality psychopathology should be assessed and addressed in treatment for all patients with anxiety disorders.

New diagnostic perspectives on obsessive-compulsive personality disorder and its links with other conditions

PURPOSE OF REVIEW

This review examines the conceptualization of obsessive-compulsive personality disorder (OCPD), its epidemiology and efforts to better understand the relationships between OCPD and other conditions.

RECENT FINDINGS

The alternative Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders conceptualization of OCPD is radically different in that it combines categorical and dimensional diagnostic approaches and introduces a hierarchy of diagnostic criteria. OCPD is one of the most common personality disorders in the general population. The relationship between OCPD and obsessive-compulsive disorder (OCD) is important, but to a large extent obfuscated by the overlap between their diagnostic criteria. Frequent changes in the OCPD diagnostic criteria make it difficult to ascertain the 'true' relationship between OCPD and OCD. It is not uncommon for OCPD to occur with anorexia nervosa, depression, hypochondriasis, certain other personality disorders and Parkinson's disease, but further research is necessary to understand the implications of these links.

SUMMARY

OCPD is yet to be conceptualized consistently and in the manner that would make a clear and well supported distinction between its core and peripheral features. Future studies need to separate a genuine from overlap-driven co-occurrence of OCPD and other conditions, as that would give a better insight into the way in which OCPD relates to other disorders.

Comorbidity of personality disorders in anxiety disorders: a meta-analysis of 30 years of research

BACKGROUND

A comprehensive meta-analysis to identify the proportions of comorbid personality disorders (PD) across the major subtypes of anxiety disorders (AD) has not previously been published.

METHODS

A literature search identified 125 empirical papers from the period 1980-2010 on patients with panic disorders, social phobia, generalised anxiety, obsessive-compulsive (OCD) and post-traumatic stress disorder (PTSD). Several moderators were coded.

RESULTS

The rate of any comorbid PD was high across all ADs, ranging from .35 for PTSD to .52 for OCD. Cluster C PDs occurred more than twice as often as cluster A or B PDs. Within cluster C the avoidant PD occurred most frequently, followed by the obsessive-compulsive and the dependent PD. PTSD showed the most heterogeneous clinical picture and social phobia was highly comorbid with avoidant PD. A range of moderators were examined, but most were non-significant or of small effects, except an early age of onset, which in social phobia increased the risk of an avoidant PD considerably. Gender or duration of an AD was not related to variation in PD comorbidity.

LIMITATIONS

Blind rating of diagnoses was recorded from the papers as an indication of diagnostic validity. However, as too few studies reported it the validity of the comorbid estimates of PD was less strong.

CONCLUSIONS

The findings provided support to several of the proposed changes in the forthcoming DSM-5. Further comorbidity studies are needed in view of the substantial changes in how PDs will be diagnosed in the DSM-5.

The structure of common and uncommon mental disorders

BACKGROUND

Co-morbidity patterns in epidemiological studies of mental illness consistently demonstrate that a latent internalizing factor accounts for co-morbidity patterns among unipolar mood and anxiety disorders, whereas a latent externalizing factor underlies the covariation of substance-use disorders and antisocial behaviors. However, this structure needs to be extended to include a broader range of disorders.

METHOD

Exploratory and confirmatory factor analyses were used to examine the structure of co-morbidity using data from the Collaborative Psychiatric Epidemiological Surveys (n = 16 233).

RESULTS

In the best-fitting model, eating and bipolar disorders formed subfactors within internalizing, impulse control disorders were indicators of externalizing, and factor-analytically derived personality disorder scales split between internalizing and externalizing.

CONCLUSIONS

This was the first large-scale nationally representative study that has included uncommon mental disorders with sufficient power to examine their fit within a structural model of psychopathology. The results of this study have important implications for conceptualizing myriad mental disorders.

Managing the Approach-Avoidance Dialectic in Treating a Complex Veteran With Panic and Posttraumatic Stress Disorder

Cognitive-behavioral therapy (CBT) is the treatment of choice for panic disorder (PD); however, the effectiveness of the treatment is often thought to be diminished in the presence of comorbid conditions. PD and posttraumatic stress disorder (PTSD) commonly co-occur in veteran populations, potentially complicating the effective treatment of each disorder. The individual presented in this case is a female veteran in her mid-50s who received treatment for PD and presented with significant comorbidities (PTSD, histrionic personality traits, major depressive disorder, and chronic suicidality). She participated in an intensive weekend treatment for PD that involved psychoeducation, cognitive restructuring, and interoceptive exposure. This case illustrates the challenges in implementing a manualized treatment for panic with a diagnostically complex veteran and the improvement in panic symptoms despite comorbid presentation.

Psychiatric diagnosis in late adolescence and long-term risk of suicide and suicide attempt

OBJECTIVE

To investigate the associations between psychiatric diagnosis in late adolescence in an unselected population and subsequent suicide attempt and suicide during 36-year follow-up.

METHOD

A total of 49,321 Swedish men conscripted for compulsory military training in 1969/1970, born 1949-1951, were screened for psychiatric disorder and, if detected, diagnosed by a psychiatrist according to ICD-8. Data on suicides and suicide attempts 1971-2006 were collected in national registers.

RESULTS

At conscription examination, 11.7% of the cohort received a psychiatric diagnosis. Among those, increased risks of suicide 1971-2006 [HR = 2.7 (2.2-3.2), 624 cases] and suicide attempt 1973-2006 [HR = 3.5 (3.1-4.0), 1170 cases] were found. The increased relative risks persisted during the follow-up period 19-36 years after examination [1989-2006 suicide HR = 2.1 (1.6-2.7), 308 cases, and 1989-2006 suicide attempt HR = 2.6 (2.1-3.1), 484 cases]. The dominant diagnostic groups, neurosis and personality disorder, were significantly associated with suicide and suicide attempt in the early as well as the late follow-up period.

CONCLUSION

Psychiatric diagnoses made in late adolescence predicted subsequent suicide and suicide attempt over a 36-year follow-up period. The increased relative risks were not limited to young adulthood but were also evident 18-36 years after conscription examination.

Axis II comorbidity in borderline personality disorder is influenced by sex, age, and clinical severity

Borderline personality disorder (BPD) is a severe psychiatric disorder that has a high clinical heterogeneity and frequent co-occurrence with other personality disorders (PDs). Although several studies have been performed to assess axis II comorbidity in BPD, more research is needed to clarify associated factors. The aim of this study was to determine the prevalence of co-occurrent axis II disorders in a large sample of patients with BPD and to investigate the influence of sex, age, and severity on this comorbidity. Data were collected from 484 patients with BPD through 2 semistructured interviews. We analyzed the frequency of axis II comorbidity and assessed differences regarding sex, age, and severity of BPD. About 74% of patients with BPD had at least 1 co-occurrent axis II disorder. The most common were paranoid, passive-aggressive, avoidant, and dependent PDs. Significant sex differences were found. Women presented more comorbidity with dependent PD, whereas men showed higher rates of comorbidity with antisocial PD. We also observed a significant positive correlation between age and the number of co-occurrent axis II disorders in women with BPD. Another finding was the positive correlation between BPD severity and the number of co-occurrent axis II disorders. These findings suggest that comorbidity with other axis II disorders and sex, age, and severity should be taken into account when developing treatment strategies and determining the prognosis of BPD.

Comorbid obsessive-compulsive personality disorder in obsessive-compulsive disorder (OCD): a marker of severity

INTRODUCTION

Comorbid obsessive-compulsive personality disorder (OCPD) is well-described in obsessive-compulsive disorder (OCD). It remains unclear, however, whether OCPD in OCD represents a distinct subtype of OCD or whether it is simply a marker of severity in OCD.

MATERIALS AND METHODS

The aim of this study was to compare a large sample of OCD subjects (n=403) with and without OCPD on a range of demographic, clinical and genetic characteristics to evaluate whether comorbid OCPD in OCD represents a distinct subtype of OCD, or is a marker of severity.

RESULTS

Our findings suggest that OCD with and without OCPD are similar in terms of gender distribution and age at onset of OC symptoms. Compared to OCD-OCPD (n=267, 66%), those with OCD+OCPD (n=136, 34%) are more likely to present with the OC symptom dimensions which reflect the diagnostic criteria for OCPD (e.g., hoarding), and have significantly greater OCD severity, comorbidity, functional impairment, and poorer insight. Furthermore there are no differences in distribution of gene variants, or response to treatment in the two groups.

CONCLUSION

The majority of our findings suggest that in OCD, patients with OCPD do not have a highly distinctive phenomenological or genetic profile, but rather that OCPD represents a marker of severity.

Affect intensity and lability: the role of posttraumatic stress disorder symptoms in borderline personality disorder

BACKGROUND

Emotion dysregulation is likely a core psychological process underlying the heterogeneity of presentations in borderline personality disorder (BPD) and is associated with BPD symptom severity. Emotion dysregulation has also been independently associated with posttraumatic stress disorder (PTSD), a disorder that has been found to co-occur with BPD in 30.2% of cases in a nationally representative sample. However, relatively little is known about the specific relationships between emotion dysregulation and PTSD among those diagnosed with BPD. The purpose of this study was to evaluate relationships between PTSD symptom severity and negative affect intensity and affective lability among individuals with BPD.

METHOD

Participants were 67 individuals diagnosed with BPD (79% women; M(age) = 38, SD = 10), who reported one or more DSM-IV PTSD Criterion A events.

RESULTS

Hierarchical multiple regression analyses indicated that when examined concurrently with BPD symptom severity, PTSD symptom severity, but not BPD symptom severity, was related to negative affect intensity and affective lability. Re-experiencing symptoms uniquely predicted affective lability, and hyperarousal symptoms uniquely predicted negative affect intensity, lending additional support to emerging literature linking re-experiencing and hyperarousal symptoms with emotion dysregulation.

CONCLUSIONS

PTSD symptom severity among individuals with a BPD diagnosis is related to elevations in emotion dysregulation. It is important to evaluate whether early treatment of PTSD symptoms provided concurrently with BPD treatment leads to enhanced improvements in emotion regulation among individuals with co-occurring PTSD and BPD.

The association of personality disorders with the prospective 7-year course of anxiety disorders

BACKGROUND

This study prospectively examined the natural clinical course of six anxiety disorders over 7 years of follow-up in individuals with personality disorders (PDs) and/or major depressive disorder. Rates of remission, relapse, new episode onset and chronicity of anxiety disorders were examined for specific associations with PDs.

METHOD

Participants were 499 patients with anxiety disorders in the Collaborative Longitudinal Personality Disorders Study, who were assessed with structured interviews for psychiatric disorders at yearly intervals throughout 7 years of follow-up. These data were used to determine probabilities of changes in disorder status for social phobia (SP), generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), panic disorder and panic disorder with agoraphobia.

RESULTS

Estimated remission rates for anxiety disorders in this study group ranged from 73% to 94%. For those patients who remitted from an anxiety disorder, relapse rates ranged from 34% to 67%. Rates for new episode onsets of anxiety disorders ranged from 3% to 17%. Specific PDs demonstrated associations with remission, relapse, new episode onsets and chronicity of anxiety disorders. Associations were identified between schizotypal PD with course of SP, PTSD and GAD; avoidant PD with course of SP and OCD; obsessive-compulsive PD with course of GAD, OCD, and agoraphobia; and borderline PD with course of OCD, GAD and panic with agoraphobia.

CONCLUSIONS

Findings suggest that specific PD diagnoses have negative prognostic significance for the course of anxiety disorders underscoring the importance of assessing and considering PD diagnoses in patients with anxiety disorders.

Understanding the heterogeneity of BPD symptoms through latent class analysis: initial results and clinical correlates among inner-city substance users

The current study investigated the heterogeneity of borderline personality disorder (BPD) symptoms in a sample of 382 inner-city, predominantly African American male substance users through the use of latent class analysis. A 4-class model was statistically preferred, with 1 class interpreted to be a baseline class, 1 class interpreted to be a high-BPD class, and 2 classes interpreted as intermediate classes. As a secondary goal, we examined the resulting BPD classes with respect to relevant clinical correlates, including temperamental vulnerabilities (affective instability, impulsivity, and interpersonal instability), childhood emotional abuse, drug choice, and co-occurring mood and anxiety disorders. The high-BPD class evidenced the highest levels of the temperamental vulnerabilities and environmental stressors, the baseline class evidenced the lowest levels, and the 2 intermediate classes fell in between. In addition, the high-BPD class had a higher probability of cocaine and alcohol dependence, as well as mood and anxiety disorders, than did the baseline class. Rates of alcohol use and mood disorders for the intermediate classes fell in between the high-BPD and the baseline classes. Results are discussed in relation to the current diagnostic conceptualization of BPD.

Comorbidity of obsessive-compulsive disorder with obsessive-compulsive personality disorder: Does it imply a specific subtype of obsessive-compulsive disorder?

The present study examined whether the comorbidity of obsessive-compulsive personality disorder (OCPD) and obsessive-compulsive disorder (OCD) constitute a specific subtype of OCD. The study sample consisted of 146 consecutive outpatients with a DSM-IV diagnosis of OCD. Diagnoses were established using MINI, IPDE, YBOCS and YBOCS-SC. OCD patients with comorbid OCPD were compared with OCD patients without OCPD on various sociodemographic and clinical variables. Almost one third of the OCD subjects met criteria for comorbid OCPD. OCD+OCPD patients had a significantly earlier age at onset of initial OC symptoms, earlier age at onset of OCD and more obsessions and compulsions than pure obsessions compared to the patients with OCDOCPD. OCD+OCPD patients also had a higher rate of comorbidity with avoidant personality disorder and showed more impairment in global functioning. There were not differences between the two sub-groups on severity of OCD symptoms and also on type of OCD onset. Our results indicate that the comorbidity of OCD with OCPD is associated with a number of specific clinical characteristics of OCD. These findings in conjunction with of current clinical, family and genetic studies provide some initial evidence that OCD comorbid with OCPD constitute a specific subtype of OCD.

An experimental investigation of emotional reactivity and delayed emotional recovery in borderline personality disorder: the role of shame

Despite the emphasis on emotional reactivity and delayed emotional recovery in prominent theoretical accounts of borderline personality disorder (BPD), research in this area remains limited. This study sought to extend extant research by examining emotional reactivity (and recovery following emotional arousal) to 2 laboratory stressors (one general, and the other involving negative evaluation) and exploring the impact of these stressors on subjective responding across the specific emotions of anxiety, irritability, hostility, and shame. We hypothesized that outpatients with BPD (compared to outpatients without a personality disorder; non-PD) would demonstrate heightened subjective emotional reactivity to both stressors, as well as a delayed return to baseline levels of emotional arousal. Results provide evidence for context- and emotion-specific reactivity in BPD. Specifically, BPD participants (compared to non-PD participants) evidenced heightened reactivity to the negative evaluation but not the general stressor. Furthermore, results provide support for shame-specific reactivity in BPD, with BPD participants (vs non-PD participants) evidencing a significantly different pattern of change in shame (but not in reported anxiety, irritability, or hostility) across the course of the study. Specifically, not only did BPD participants report higher levels of shame in response to the negative evaluation, their levels of shame remained elevated following this stressor (through the post-recovery period at the end of the study). Findings suggest the importance of continuing to examine emotional reactivity in BPD within specific contexts and across distinct emotions, rather than at the general trait level.

Borderline personality disorder: health service use and social functioning among a national household population

BACKGROUND

It is unclear whether Axis II psychopathology or co-morbid clinical syndromes result in the treatment-seeking behaviour and social impairment of patients with borderline personality disorder (BPD). This study examined the independent associations between social functioning and service use and Axis I and Axis II disorders in persons with BPD in the national household population of Britain.

METHOD

The study was a cross-sectional survey of adults aged 16-74 years in households (n=8397). Data included self-reported consultations with health-care professionals and behavioural problems. Diagnosis was determined by computer-assisted interviews. Analyses included logistic regression adjusting for demography, co-morbid Axis I clinical syndromes and other Axis II disorders.

RESULTS

Consultation in the past year was reported by 57.5% of persons with BPD but only 13.4% reported lifetime psychiatric admission. BPD was not independently associated with impaired functioning but was associated with co-morbid psychotic, depressive and anxiety disorders. Only general practitioners (GPs) were consulted for problems independently due to BPD.

CONCLUSIONS

Functional effects of BPD are mediated through co-morbid clinical syndromes, not Axis II psychopathology. A subgroup do not have co-morbid disorders or seek treatment, and are high functioning.

Stability, change, and heritability of borderline personality disorder traits from adolescence to adulthood: a longitudinal twin study

Although personality disorders are best understood in the context of lifetime development, there is a paucity of work examining their longitudinal trajectory. An understanding of the expected course and the genetic and environmental contributions to these disorders is necessary for a detailed understanding of risk processes that lead to their manifestation. The current study examined the longitudinal course and heritability of borderline personality disorder (BPD) over a period of 10 years starting in adolescence (age 14) and ending in adulthood (age 24). In doing so, we built on existing research by using a large community sample of adolescent female twins, a sensitive dimensional measure of BPD traits, an extended follow-up period, and a longitudinal twin design that allowed us to investigate the heritability of BPD traits at four discrete ages spanning midadolescence to early adulthood. Results indicated that mean-level BPD traits significantly decline from adolescence to adulthood, but rank order stability remained high. BPD traits were moderately heritable at all ages, with a slight trend for increased heritability from age 14 to age 24. A genetically informed latent growth curve model indicated that both the stability and change of BPD traits are highly influenced by genetic factors and modestly by nonshared environmental factors. Our results indicate that as is the case for other personality dimensions, trait BPD declines as individuals mature from adolescence to adulthood, and that this process is influenced in part by the same genetic factors that influence BPD trait stability.

Prevalence, correlates, disability, and comorbidity of DSM-IV narcissistic personality disorder: results from the wave 2 national epidemiologic survey on alcohol and related conditions

OBJECTIVES

To present nationally representative findings on prevalence, sociodemographic correlates, disability, and comorbidity of narcissistic personality disorder (NPD) among men and women.

METHOD

Face-to-face interviews with 34,653 adults participating in the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions conducted between 2004 and 2005 in the United States.

RESULTS

Prevalence of lifetime NPD was 6.2%, with rates greater for men (7.7%) than for women (4.8%). NPD was significantly more prevalent among black men and women and Hispanic women, younger adults, and separated/divorced/widowed and never married adults. NPD was associated with mental disability among men but not women. High co-occurrence rates of substance use, mood, and anxiety disorders and other personality disorders were observed. With additional comorbidity controlled for, associations with bipolar I disorder, post-traumatic stress disorder, and schizotypal and borderline personality disorders remained significant, but weakened, among men and women. Similar associations were observed between NPD and specific phobia, generalized anxiety disorder, and bipolar II disorder among women and between NPD and alcohol abuse, alcohol dependence, drug dependence, and histrionic and obsessive-compulsive personality disorders among men. Dysthymic disorder was significantly and negatively associated with NPD.

CONCLUSIONS

NPD is a prevalent personality disorder in the general U.S. population and is associated with considerable disability among men, whose rates exceed those of women. NPD may not be as stable as previously recognized or described in the DSM-IV. The results highlight the need for further research from numerous perspectives to identify the unique and common genetic and environmental factors underlying the disorder-specific associations with NPD observed in this study.

Self-esteem in patients with borderline and avoidant personality disorders

This study compared self-esteem in patients with avoidant personality disorder (APD) and borderline personality disorder (BPD). Patients diagnosed with one or more personality disorders answered the questionnaire Index of Self Esteem as part of a comprehensive evaluation within the setting of a treatment trial. Our hypotheses were that (1) both patients with APD and patients with BPD would report low levels of self-esteem, (2) patients with APD would report lower self-esteem than patients with BPD. We further expected that (3) patients with higher levels of depression would report lower levels of self-esteem, but that (4) both borderline and avoidant personality pathology would contribute to explained variance in self-esteem beyond what would be accounted for by depression. All of our hypotheses were supported. The results from our study showed a significant difference in self-esteem level between the two personality disorders, patients with APD reporting lower self-esteem than patients with BPD. Subjects with both disorders were measured to have self-esteem levels within the range that presumes clinical problems. Self-esteem represents an important quality of subjective experience of the self, and the study of self-esteem in PDs can offer new and important knowledge of PDs as self-pathology.

Preliminary data on the relationship between anxiety sensitivity and borderline personality disorder: the role of experiential avoidance

Although research on the temperamental vulnerabilities associated with borderline personality disorder (BPD) has focused primarily on the role of impulsive-aggression, affective instability, and emotional vulnerability, growing evidence suggests that anxiety sensitivity (AS) also may increase vulnerability for BPD. This study provides preliminary data on the relationship between AS and BPD, examining whether AS distinguishes outpatients with BPD from outpatients without a personality disorder (non-PD), and whether the relationship between AS and BPD is mediated by experiential avoidance (i.e., attempts to avoid unwanted internal experiences, such as anxiety). Findings indicate that BPD outpatients reported higher levels of AS than non-PD outpatients and AS reliably distinguished between these two groups. Furthermore, the relationship between AS and BPD was mediated by experiential avoidance. Finally, results indicate that AS (and experiential avoidance as a mediator) accounted for a significant amount of additional variance in BPD status above and beyond both negative affect and two well-established temperamental vulnerabilities for BPD (affect intensity/reactivity and impulsivity). Findings suggest the need to further explore the role of AS in the pathogenesis of BPD.

OCD with comorbid OCPD: a subtype of OCD?

OBJECTIVE

The current study examined the validity of using comorbid obsessive-compulsive personality disorder (OCPD) to identify a subtype of individuals with obsessive-compulsive disorder (OCD).

METHOD

Data for the current study were drawn from an ongoing, longitudinal study of the course of OCD and include intake assessments for 238 subjects with primary and current DSM-IV OCD who were treatment seeking.

RESULTS

More than one fourth of the subjects (N=65, 27%) met criteria for comorbid OCPD. As compared to OCD-OCPD subjects, the OCD+OCPD subjects had a significantly younger age at onset of first OC symptoms (p=0.013), and a higher rate of symmetry and hoarding obsessions, and cleaning, ordering, repeating, and hoarding compulsions (all p's<0.01). Individuals with OCD+OCPD had higher rates of comorbid anxiety disorders (p=0.007) and avoidant personality disorder (p=0.006). The OCD+OCPD subjects also had significantly lower ratings of global functioning (p=0.001) and more impaired social functioning (p=0.004), despite a lack of significant differences on overall severity of OCD symptoms.

CONCLUSIONS

Our findings indicate that individuals with both OCD and OCPD have distinct clinical characteristics in terms of age at onset of initial OC symptoms, the types of obsessions and compulsions they experience, and psychiatric comorbidity. Our findings, coupled with data from family studies showing a higher than expected frequency of OCPD in first degree relatives of OCD probands, suggest that OCD associated with OCPD may represent a specific subtype of OCD. Additional research is warranted to further establish the validity of this subtype.

Obsessive-compulsive disorder: update on assessment and treatment

Obsessive-compulsive disorder (OCD) is a frequently debilitating and often severe anxiety disorder that affects approximately 2% of the population. This article discusses the presentation of the disorder and theories of etiology and provides an overview of assessment and treatment. A case description is included to illustrate the cognitive-behavioral assessment and treatment approach. OCD has similar prevalence rates cross-culturally around the world. Although its etiology is not established, neurobiological, genetic, cognitive, and behavioral factors have been implicated. The process of assessment for OCD plays an important role in establishing a therapeutic alliance with the patient and identifying treatment goals. The assessment of OCD can be guided by using published semi-structured interview tools, including a standardized symptom checklist and severity rating scale. Treatments that have shown efficacy for OCD are cognitive-behavioral therapy, including exposure and response prevention, and pharmacotherapy. However, up to 25% of patients fail to benefit from these evidence-based treatments. Other treatment approaches have recently been developed to further increase the effectiveness of cognitive-behavioral interventions. Strategies based on traditional cognitive approaches that challenge core beliefs have been shown to be effective. Acceptance-based therapies and treatments based on meta-cognitive principles have also shown promise and need further research.

The relationship between avoidant personality disorder and social phobia

The main explanatory hypothesis for the distinction between social phobia (SP) and avoidant personality disorder (APD) has been the severity continuum hypothesis, stating that APD only differs from SP in terms of severity of dysfunction and symptomatic distress, that is, social anxiety and depressive symptoms. This study aimed at a comprehensive evaluation of this hypothesis in a large sample (n = 2192) of thoroughly assessed patients, most of whom had a diagnosis of personality disorder. Social phobia was stronger associated with APD than with other personality disorders, and APD was stronger associated with SP than with other symptom disorders. Social phobia-pure patients had a higher level of global functioning and lower levels of general symptom distress and interpersonal problems than APD-pure patients. The 2 groups were similar on domains that pertain to social anxiety and introversion, but APD was associated with a broader array of symptoms and interpersonal problems and was substantially lower on the personality domain of conscientiousness. Avoidant personality disorder was stronger associated with eating disorders, and SP was stronger associated with panic disorder. The APD diagnosis seems to capture a broader constellation of symptoms and personality features pointing toward more severe personality dysfunction. Our findings suggest that the severity continuum hypothesis lacks specificity and exploratory power to account for both similarities and differences between SP and APD.

Relationship between personality disorder symptoms and temperament in the young male general population of South Korea

The aim of the present study was to identify the characteristics of temperament and character in personality disorder symptoms in the young male general population. A total of 585 male subjects from the same community were included in the study (mean age, 19.06 +/- 0.26 years). There was no difference in socioeconomic and educational background. Subjects completed the Personality Disorder Questionnaire-IV+ (PDQ-IV+) and Temperament and Character Inventory (TCI). There were unique correlations between each personality disorder symptom and four temperament profiles. When classification was done through three cluster symptoms by DSM-IV, cluster A symptoms were most strongly associated with low reward dependence (r = -0.46), cluster B with high novelty seeking (r = 0.33), and cluster C with high harm avoidance (r = 0.47). The character dimension, self-directedness was the most powerful predictor of the presence of any personality disorders. In homogenous male general population, unique combinations were found between temperament and each personality disorders. Although the subjects were relatively young and therefore their characters had not yet fully matured, character played an important role in the presence of personality disorder. Temperament can be used to differentiate the personality symptoms and characters used to predict the presence of personality disorder.

Psychological distress and functional impairment in patients with personality disorders

The study is aimed at investigating the impact of a personality disorder (PD) diagnosis, in terms of functional impairment and subjective distress, in order to better understand the burden of this diagnosis and its implications. Among the 462 consecutive psychiatric patients diagnosed with the DSM structured interview for Axis I, II and V diagnoses, almost 60% had PD. Patients with PD displayed considerable vulnerability and suffering in many domains, including finances and interpersonal relationships. Despite the educational and occupational similarities of PD patients and non-PD patients, the PD patients had more problems maintaining permanent job positions. They also had more symptomatic suffering and concerns about health than non-PD patients. Generally, the results were in line with findings in the literature but more thoroughly captured the challenges that PD patients face in various areas of life. Awareness of the frequent comorbidity of PD with Axis I disorders seems crucial in developing future treatment plans with an emphasis on psychosocial rehabilitation, vocational training and social support.

Interpersonal profiles in major depressive disorder

Although patients with mood disorders report interpersonal difficulties in addition to depression or anxiety, few studies have examined interpersonal patterns in those patients. Here the authors' goals were to (a) identify the interpersonal pattern in patients with major depressive disorder (MDD), (b) determine interpersonal differences between subgroups of MDD patients, and (c) examine the interpersonal patterns of comorbid MDD patients. One- hundred forty-one MDD adults participated in an ongoing randomized clinical trial of treatments for depression. Interpersonal profiles revealed that MDD patients were significantly more distressed by interpersonal problems than normative samples. Furthermore, MDD patients with depressive personality disorder reported more interpersonal distress than MDD-only patients report and were more likely to have interpersonal problems related to dominance and control than submissiveness.

Personality traits in early phases of panic disorder: implications on the presence of agoraphobia, clinical severity and short-term outcome

OBJECTIVE

To explore the relations between personality traits using the Big Five model and presence of agoraphobia, clinical severity and short-term outcome in an unbiased clinical sample of never-treated panic disorder patients.

METHOD

Panic disorder (PD) patients (n = 103) in the first stages of their illness were evaluated using the Neuroticism-Extraversion-Openness Five Factor Inventory of Personality (NEO-FFI) and were compared with a sample of healthy subjects. Severity was assessed by the Panic Disorder Severity Scale and the Clinical Global Impression Scales. Patients were evaluated after 8 weeks of naturalistic pharmacologic treatment with Selective Serotonin Reuptake Inhibitors.

RESULTS

Panic disorder patients show more neuroticism than healthy subjects. Patients suffering from agoraphobia are more introverted than controls. Extraversion, in addition to gender and distress, during panic attacks allows to correctly classifying 72% of the cases of agoraphobia.

CONCLUSION

Low scores in extraversion contribute to explain the presence of agoraphobia in panic disorder. Personality traits are neither related to clinical severity nor to short-term response to pharmacological treatment.

Personality disorders evident by early adulthood and risk for anxiety disorders during middle adulthood

Data from the Children in the Community Study, a prospective longitudinal investigation, were used to investigate the association of personality disorder (PD) traits, evident by early adulthood, with risk for development of anxiety disorders by middle adulthood. Individuals without a history of anxiety disorders who met diagnostic criteria for >or=1 PD by early adulthood were at markedly elevated risk for agoraphobia, generalized anxiety disorder, obsessive-compulsive disorder, and panic disorder by middle adulthood. Antisocial, avoidant, borderline, dependent, depressive, histrionic, obsessive-compulsive, passive-aggressive, and schizotypal PD traits, evident by early adulthood, were associated with elevated risk for >or=1 anxiety disorder during middle adulthood. These associations remained significant after a history of anxiety disorder and co-occurring Axis I psychiatric disorder was controlled statistically. Findings of this study suggest that some types of PD traits that become evident by early adulthood may contribute to increased risk for the development of anxiety disorders by middle adulthood.

Personality disorders and response to medication treatment in panic disorder: a 1-year naturalistic study

OBJECTIVE

In this naturalistic and prospective study, personality was assessed in patients with panic disorder (PD), in order to evaluate whether personality features negatively influence the outcome of pharmacological treatment.

METHOD

Before drug treatment, PD was diagnosed with the Structured Clinical Interview for DSM-IV disorders and personality was assessed with the Structured Interview for DSM-IV Personality Disorders. Moreover, all patients were evaluated with the SCL-90, the Ham-A and Ham-D. Then, patients were randomly treated with paroxetine (33.5+/-13.3 mg/day) or citalopram (34.7+/-15.2 mg/day) and were followed at monthly intervals for 1 year. Absence of full and limited-symptom attacks, anticipatory anxiety, phobic avoidance and depression for 3 months was used to establish remission. The effect of personality traits on each symptom domain was evaluated.

RESULTS

Seventy-one patients completed the study. Remission rate was 76% for panic attacks and 46% for complete remission. When the effects of age, gender, age of onset and duration of PD, baseline SCL-90 phobic anxiety, Ham-A and Ham-D scores, Axis I comorbidity and the SIDP traits on remission were analyzed in a logistic regression, only borderline traits negatively influenced remission of panic attacks (OR=0.69; 95% CI=0.49-0.96; p=0.03), whereas the number of traits of each personality Cluster and the total number of SIDP traits did not affect the outcome of treatment.

CONCLUSIONS

This study suggests that in PD patients, borderline features may negatively influence the response to monotherapy with SSRI drugs; therefore, other treatment strategies (i.e., combination of SSRI with psychotherapy) are needed to obtain remission in these patients.

Clarifying the convergence between obsessive compulsive personality disorder criteria and obsessive compulsive disorder

In this study we examined the convergence between obsessive-compulsive personality disorder (OCPD) criteria and obsessive-compulsive disorder (OCD). Baseline assessments of 629 participants of the Collaborative Longitudinal Personality Disorders Study were used to examine the associations between OCPD criteria and diagnoses of OCD. Three of the eight OCPD criteria--hoarding, perfectionism, and preoccupation with details--were significantly more frequent in subjects with OCD (n = 89) than in subjects without OCD (n = 540). Logistic regressions were used to predict the probability of each OCPD criterion as a function of Axis I diagnoses (OCD, additional anxiety disorders, and major depressive disorder). Associations between OCD and these three OCPD criteria remained significant in the logistic regressions, showing unique associations with OCD and odds ratios ranging from 2.71 to 2.99. In addition, other anxiety disorders and major depressive disorder showed few associations with specific OCPD criteria. This study suggests variability in the strength of the relationships between specific OCPD criteria and OCD. The findings also support a unique relationship between OCPD symptoms and OCD, compared to other anxiety disorders or major depression. Future efforts to explore the link between Axis I and Axis II disorders may be enriched by conducting analyses at the symptom level.

Avoidant personality disorder and social phobia: distinct enough to be separate disorders?

OBJECTIVE

Existing evidence from anxiety disorder research indicates that social phobics (SP) with avoidant personality disorder (AVPD) experience more anxiety and show more impairment than patients with SP alone. The purpose of this study was to examine whether in patients diagnosed with AVPD, the co-occurrence of SP adds to its severity. We hypothesized that the addition of SP will not add to the severity of AVPD alone.

METHOD

Two groups of patients (AVPD=224; AVPD/SP=101) were compared at baseline and 2 years later on multiple demographic and clinical variables.

RESULTS

Patients with AVPD and an additional diagnosis of SP differed little from patients with AVPD alone.

CONCLUSION

These findings suggest that AVPD and SP may be alternative conceptualizations of the same disorder.

Temperament und Charakter bei Personen mit Borderline-Persönlichkeitsstörung

High comorbidity, suicidal ideation, difficult temperament, and character are key symptoms of persons with borderline personality disorder (BPD). We investigated 478 persons, 40 of whom had a BPD according SCID-II, self-rating. Participants were examined with a semistructured interview and several self-rating questionnaires in their households. Taking the high comorbidity of persons with BPD into account, we compared the BPD group with four control groups with different axis 1 or personality disorders and one nonclinical group. Persons with BPD showed high comorbidity with affective, anxiety, and alcohol use disorders. With respect to suicidality, 75% reported that they wish to be dead at least sometimes, and about one-third said that they had already attempted suicide. Regarding temperament and character dimensions, our analyses revealed higher novelty seeking for persons with BPD compared to participants without BPD, although this difference was primarily attributable to males with BPD. Additionally, participants with BPD reported higher harm avoidance compared to control groups, while this was more distinctive for females. Finally, we found that persons with BPD had very low levels of self-directedness. This effect was independent from gender and was found in all group comparisons. Therapy of BPD should take into account high comorbidity and suicidality of patients. Moreover, our results show that low self-directedness seems to be specific for persons with BPD. Therefore, therapy must address those deficits by focusing on skills training as well as on aspects of maturation.

Comorbid personality disorders in subjects with panic disorder: do personality disorders increase clinical severity?

Personality disorders are common in subjects with panic disorder. Personality disorders have been shown to affect the course of panic disorder. The purpose of this study was to examine which personality disorders affect clinical severity in subjects with panic disorder. This study included 122 adults (71 women, 41 men) who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition ( DSM-IV ) criteria for panic disorder (with or without agoraphobia). Clinical assessment was conducted by using the Structured Clinical Interview for DSM-IV Axis I Disorders, the Structured Clinical Interview for DSM-IV Axis II Personality Disorders, and the Panic and Agoraphobia Scale, Global Assessment Functioning Scale, Beck Depression Inventory, and State-Trait Anxiety Inventory. Patients who had a history of sexual abuse were assessed with Sexual Abuse Severity Scale. Logistic regressions were used to identify predictors of suicide attempts, suicidal ideation, sexual abuse, and early onset of disorder. The rates of comorbid Axes I and II psychiatric disorders were 80.3% and 33.9%, respectively, in patients with panic disorder. Patients with panic disorder with comorbid personality disorders had more severe anxiety, depression, and agoraphobia symptoms, had earlier ages at onset, and had lower levels of functioning. The rates of suicidal ideation and suicide attempts were 34.8% and 9.8%, respectively, in subjects with panic disorder. The rate of patients with panic disorder and a history of childhood sexual abuse was 12.5%. The predictor of sexual abuse was borderline personality disorder. The predictors of suicide attempt were comorbid paranoid and borderline personality disorders, and the predictors of suicidal ideation were comorbid major depression and avoidant personality disorder in subjects with panic disorder. In conclusion, this study documents that comorbid personality disorders increase the clinical severity of panic disorder. Borderline personality disorder may be the predictor of a history of sexual abuse and early onset in patients with panic disorder. Paranoid and borderline personality disorders may be associated with a high frequency of suicide attempts in patients with panic disorder.

Co-occurrence of 12-month mood and anxiety disorders and personality disorders in the US: results from the national epidemiologic survey on alcohol and related conditions

The objective of this study was to determine the prevalence and co-occurrence of DSM-IV personality disorders (PDs) among individuals with current DSM-IV mood and anxiety disorders in the US population and among individuals who sought treatment for such mood or anxiety disorders. Face-to-face interviews were conducted with 43,093 individuals, 18 years and older, in the National Institute on alcohol abuse and alcoholism's 2001-2002 National epidemiologic survey on alcohol and related conditions (NESARC). Odds ratios (ORs) were calculated to determine the prevalence and associations between current DSM-IV axis I and axis II disorders. Associations between mood, anxiety and PDs were all positive and statistically significant. Avoidant and dependent PDs were more strongly related to mood and anxiety disorders than other PDs. Associations between obsessive-compulsive PD and mood and anxiety disorders were significant, but much weaker. Paranoid and schizoid PDs were most strongly related to dysthymia, mania, panic disorder with agoraphobia, social phobia and generalized anxiety disorder, while histrionic and antisocial PDs were most strongly related to mania and panic disorder with agoraphobia. Results of this study highlight the need for further research on overlapping symptomatology, factors giving rise to the associations and the treatment implications of these disorders when comorbid.

Associations in the course of personality disorders and Axis I disorders over time

In this study, the authors examined time-varying associations between schizotypal (STPD), borderline (BPD), avoidant (AVPD), or obsessive-compulsive (OCPD) personality disorders and co-occurring Axis I disorders in 544 adult participants from the Collaborative Longitudinal Personality Disorders Study. The authors tested predictions of specific longitudinal associations derived from a model of crosscutting psychobiological dimensions (L. J. Siever & K. L. Davis, 1991) with participants with the relevant Axis I disorders. The authors assessed participants at baseline and at 6-, 12-, and 24-month follow-up evaluations. BPD showed significant longitudinal associations with major depressive disorder and posttraumatic stress disorder. AVPD was significantly associated with anxiety disorders (specifically social phobia and obsessive-compulsive disorder). Two of the four personality disorders under examination (STPD and OCPD) showed little or no association with Axis I disorders.

Personality and anxiety disorders: a review

In this article, we summarize research on how normal personality and personality disorder traits may relate to anxiety disorders as predisposing factors, complications, and results of common underlying etiologies. We outline important questions and how these may be addressed through future research using genetically informative longitudinal and other designs, including: Are high neuroticism/cluster C personality traits causally related to the development of anxiety disorders? To what extent does the state of having an anxiety disorder influence the assessment of personality traits? Do high neuroticism/personality disorder traits and anxiety disorders co-occur because of shared genetic and environmental determinants? And, do personality disorder traits add to the prediction of anxiety disorders when normal personality traits are taken into account?

Schemata as moderators of clinical effectiveness of a comprehensive cognitive behavioral program for patients with depression or anxiety disorders

The authors examined the clinical effectiveness of a comprehensive cognitive behavior therapy (CBT) program offered to patients with depression or anxiety disorders. They also tested the prediction, based on Young's schema-focused approach to therapy, that endorsement of maladaptive cognitive schemata predicts poor response to standard CBT. One hundred thirty-four consecutive referrals were assessed on a battery of self-report measures at the commencement of the program, and 121 of these patients (90%) completed the program and provided posttreatment data. Two thirds of the patients showed statistically reliable symptom reduction, and half had large effect size (0.8 standard deviations or more) symptom reduction. Contrary to predictions, greater initial endorsement of schemata did not predict poor therapy response. The CBT program was effective for most patients, including patients with high endorsement of maladaptive schemata.

The borderline diagnosis I: psychopathology, comorbidity, and personality structure

Borderline personality disorder (BPD) is a complex and serious mental disorder associated with severe functional impairment, substantial treatment utilization, and a high rate of mortality by suicide. Recently, BPD has become a focus of intensifying study. In Part I of this three-part article meant to provide a foundation to researchers on the current status of the borderline diagnosis and prospects for its future development, we examine the psychopathology, comorbidity, and personality structure of BPD. Although the descriptive characteristics of BPD are well-represented by DSM-IV diagnostic criteria, other important aspects of BPD psychopathology are not included. The descriptive criteria in conjunction with semistructured interviews have, however, increased the ability of investigators to diagnose BPD as reliably as many Axis I disorders. Frequent comorbidity of BPD with Axis I disorders necessitates a broad assessment of psychopathology to help account for clinical heterogeneity. Because of the absence of evidence of the validity of the diagnostic threshold for a categorical diagnosis of BPD, and because of the heterogeneity within the diagnosis, investigators should also supplement their DSM-IV diagnoses with assessments of underlying personality trait structures. Although there are a number of competing models of personality structure, they have remarkable convergence on a set of three to five basic personality dimensions.

Avoidant personality disorder: current status and future directions

Avoidant Personality Disorder (APD) is the topic of a growing body of research literature. In this article, we review empirical studies of APD with the goals of identifying the themes that underlie this work and pointing to new directions for future research. In particular, we recommend that future studies evaluate several unique factors postulated by personality theorists to be central to this condition.

Personality disorders

Some general recommendations can be made, collected from these subjective descriptions of personality types. Because determining an accurate psychiatric diagnosis is not the internist's aim, it is better for him or her to have a stance that generalizes to all patients, which can be refined as personality characteristics emerge. Tolerate the patient's affect (such as anger or anxiety), being firm and kind, rather than punitive or overinvested. Accept dependency and vulnerability. Accept and respect the underlying coping style. Understand that the patient's personality style is the best (and usually only) way he or she knows to have a relationship, including a relationship with the physician. Understand that personality traits additionally may have a function (e.g., to guard against anxiety or depression). Recognize that personality traits do not come in pure form. One personality trait is likely to blend into or overlap with other traits. Identify and treat any underlying symptom disorder, such as anxiety, depression, irritability, or thought disorder. Educate the patient clearly (and without patronizing) about medical illness. Document what was explained to the patient and how the patient responded, including dispassionate observations about behavior and emotional expression. Appreciate the patient's possible attachment to medical symptoms. Avoid arguments with patients who make unreasonable demands. Make timely judgments about whether or not to accede to a demand. When in doubt about a patient's honesty, give the patient the benefit of the doubt. Do not worry about being used because all patients use their physicians to some extent. Go to the limits of your tolerance for a patient's personality, but know your limits and refer to a colleague when you cannot work with the patient. Terminate an interaction and get help if there is a risk (or fear) of violence. Given the time it takes to manage the relationship and the psychiatric elements of treatment, a referral to a psychiatrist or other mental health professional often is wise if the patient will accept it. Include the mental health professional as part of the medical team. Although these various recommendations have been emphasized in connection with certain personality types, one can be flexible about their application in a variety of patients. It is important also to reiterate the limits of subjective descriptions. It is rare to find any of the aforementioned subjective descriptions in unmodified form; characteristics of more than one personality type usually appear in the same person. The descriptions are composites that provide a starting point for the physician. The physician should edit the composites based on experience with real patients. This article has described human characteristics and rough guidelines for helpful human responses and possible pharmacologic interventions. So equipped, the primary care physician may find it less troubling and more interesting to face the wide variation in human character.

Patterns of personality pathology in patients with generalized anxiety disorder, panic disorder with and without agoraphobia, and social phobia

The relationship between co-occurring personality disorders and anxiety disorders (panic disorder with or without agoraphobia, social phobia, and generalized anxiety disorder) was examined, taking into account the effect of major depression. This article describes findings for 622 participants in the Harvard/Brown Anxiety Research Project, a longitudinal follow-up study of DSM-III-R-defined anxiety disorders. A total of 24% of participants had at least one personality disorder, with avoidant, obsessive compulsive, dependent, and borderline most common. Generalized anxiety disorder, social phobia, and major depression were positively associated with the occurrence of one or more personality disorders, whereas panic disorder with agoraphobia was not associated. Major depression was associated in particular with dependent, borderline, histrionic, and obsessive compulsive personality disorders and social phobia was associated with avoidant personality disorder. Whereas some of our findings confirm results from earlier studies, others are somewhat inconsistent with previous results and indicate the need for further investigation.

Personality disorders and normal personality dimensions in obsessive-compulsive disorder

BACKGROUND

Little is known about personality disorders and normal personality dimensions in relatives of patients with obsessive-compulsive disorder (OCD).

AIMS

To determine whether specific personality characteristics are part of a familial spectrum of OCD.

METHOD

Clinicians evaluated personality disorders in 72 OCD case and 72 control probands and 198 case and 207 control first-degree relatives. The selfcompleted Revised NEO Personality Inventory was used for assessment of normal personality dimensions. The prevalence of personality disorders and scores on normal personality dimensions were compared between case and control probands and between case and control relatives.

RESULTS

Case probands and case relatives had a high prevalence of obsessive-compulsive personality disorder (OCPD) and high neuroticism scores. Neuroticism was associated with OCPD in case but not control relatives.

CONCLUSIONS

Neuroticism and OCPD may share a common familial aetiology with OCD.