DSM axis II: personality disorders or adaptation disorders?

Epidemiology of personality disorders in individuals with gender dysphoria

PURPOSE OF REVIEW

Prevalence estimates of personality disorders (PD) in individuals with gender dysphoria (GD) are variable and heterogeneous, as psychiatric comorbidity and long-term follow-up data from gender-diverse samples are still limited. This review aims to assess prevalence rates across age groups and discuss potential reasons for variability in PD prevalence estimates among transgender people.

RECENT FINDINGS

International epidemiological data from several countries indicate that the best available estimates of the prevalence of any PD diagnosis in transgender youth are around 20% for adolescents and tend to increase to nearly 50% in trans-adults. The paucity of available data on personality dysfunction in children and adolescents with GD precluded us from definitive conclusions on the trends of emerging PDs in this population. Estimates of PD prevalence in transgender and gender-diverse people seem to be highly affected by methodological characteristics of the studies with no universally agreed reference standards for this population.

SUMMARY

The review of epidemiological studies on PD among gender-diverse people highlights the need for using more standardized study methodologies to make findings comparable. Nevertheless, international epidemiological data seem to support the link association between the development of PD and GD.

Features, State and Context of Narcissism in Drug Misuse

Both clinical and street-based encounters with people who misuse drugs have led the authors to examine the relationship between misuse of drugs and narcissism. Widely accepted criteria for diagnosing Substance Use Disorder (SUD) suggest parallels between narcissistic traits (e.g. invulnerability to consequences and lack of empathy for others) and the characteristics of drug abusers. Because narcissism as a concept has a long and somewhat confusing history, we first reviewed its origins in the psychoanalytic tradition of psychiatry and its exegesis into current clinical concepts in order to arrive at a set of attributes that may be useful when applied to problems of drug abuse. This process required extensive review of the literature on narcissism and its interactions with the literature on drug abuse. This process led to an understanding that positive self-concept may exemplify a variety of socially beneficial narcissism, but that at the other end of narcissism's continuum of traits may be found exploitative and non-empathetic traits. Furthermore, the negative traits of narcissism, as they may arise in adolescence along with drug use, can support an individual's ongoing dependence on drugs, especially if narcissism and drug use persist into adulthood. Our investigation of narcissism and drug use revealed, through in-depth interviewing, that some drug users employ drugs and alcohol to feed their self-concepts of superiority over other people. Our findings suggest that treatment for drug abuse cannot proceed assuming that drug users have low self-concepts. Rather, their continued use of drugs may emanate from a narcissistic sense of superiority.

Biting the hand that feeds: current opinion on the interpersonal causes, correlates, and consequences of borderline personality disorder

Borderline personality disorder (BPD) is a complex psychiatric diagnosis characterized by dysregulated behaviors, emotions, cognitions, and interpersonal relationships. In recent years, developmental psychopathologists have sought to identify early origins of BPD, with the ultimate goal of developing and providing effective preventative interventions for those at highest risk. In addition to heritable biological sensitivities, many scholars assert that environmental and interpersonal risk factors contribute to the emergence and maintenance of key borderline traits. Nonetheless, many BPD researchers examine only affected individuals, neglecting the family, peer, couple, and other dynamic contextual forces that impinge upon individual-level behavior. In the past decade, however, theoretical and empirical research has increasingly explored the interpersonal causes, correlates, and consequences of BPD. Such work has resulted in novel research and clinical theories intended to better understand and improve interpersonal dynamics among those with borderline traits. A major objective for the field is to better characterize how interpersonal dynamics affect (and are affected by) the behaviors, emotions, and thoughts of vulnerable individuals to either reduce or heighten risk for BPD.

Psychopathological Functioning Levels (PFLs) and their possible relevance in psychiatric treatments: a qualitative research project

BACKGROUND

Symptoms description is often not enough to provide clinicians with guidelines for treatments and patients' clinical history does not represent an exhaustive source of data. Psychopathological dysfunctions are known to relate to the core disturbances that underlie different forms of psychopathology so the identification of such dysfunctions could be helpful for treatments. Some tools are available although highly complex and lengthy. This study aimed to provide clinicians with an easy-to-administer instrument able to capture different levels of impairment in psychopathological functioning, namely the Psychopathological Functioning Levels - Rating Scale (PFL-RS).

METHODS

The Psychopathological Functioning Level - Research and Training Committee (PFL-RTC) has been established in Turin since 2002 including psychiatrists and clinical psychologists with extensive clinical and research experience. Our research was grounded on the Qualitative Research Criteria (QRC) 1-7 and conducted with subsequent steps in order to identify those core psychopathological dysfunctions to be rated by this tool.

RESULTS

From 2002 until 2014, 316 outpatients were administered the clinical interview on at least two different occasions. Diagnoses were mixed and included: Schizophrenic and Psychotic Disorders, Depressive Disorders, Anxiety Disorders, Obsessive-Compulsive Disorder, Post- Traumatic Stress Disorder, Somatic Symptoms Disorders, Eating Disorders and Personality Disorders. Focus groups were conducted to identify those psychopathological dysfunctions which needed to be rated, according to two Phenomenological Selection Criteria (PhSC) and four Etiopathogenetic Selection Criteria (EtSC). As a result, five dysfunctional areas emerged: Identity (ID); Comprehension (CO); Negative Emotions (NE); Action-Regulation (AR); Social Skills (SS). After checking such dimensions for consistency with the existing instruments, 7 levels of severity were identified for each area. Finally, a provisional Italian schedule of Psychopathological Functioning Levels - Rating Scale (PFL-RS) was obtained and checked for semantic comprehension and then administered gathering preliminary data.

CONCLUSIONS

Psychopathological dysfunctions underlying mental disorders have been recognized in the present study with the PFL-RS. This instrument seems promising to inform in a specific way treatments strategies and goals, specifically concerning psychotherapy. Notwithstanding, further research is needed in order to confirm validity, sensitivity and reliability of this instrument.

Bendelow G. Diagnosing vulnerability and “dangerousness”: police use of Section 136 in England and Wales

Purpose

– Police in England and Wales are empowered, under Section 136 of the Mental Health Act 1983 (s136), to detain individuals thought to be a danger to themselves or to others. Use of this authority is widespread, but varies across districts and attracts controversy because of inconsistent application and the fact that it requires police to make judgements about mental health. The purpose of this paper is to examine police attitudes to and criteria for using s136.

Design/methodology/approach

– The authors conducted focus groups with 30 officers in urban and rural areas of three different regions across England and Wales. Group interviews were audio-recorded, transcribed, and analysed using open and axial coding.

Findings

– Use of s136 authority has major implications for police work; liaison with mental health services is seen as desirable but often ineffective due to resource constraints and the latter's lack of availability. The decision to invoke s136 depends on social context and other particulars of individual cases.

Research limitations/implications

– Although the findings have limitations with respect to generalisability across the whole of the UK, there are patterns of responses which have major implications for policy recommendations.

Practical implications

– Police decisions to apply s136 reflect an implicit values-based classification of and response to emotionally disturbed behaviour, in light of available institutional and social supports.

Social implications

– Tasked primarily with protecting the public and keeping the peace, police “diagnoses” of risk often contrast with that of mental health professionals.

Originality/value

– A highly original piece of research which has attracted further funding from BA/Leverhulme.

Attachment, affective temperament, and personality disorders: a study of their relationships in psychiatric outpatients

BACKGROUND

As the result of extensive translational and cross-disciplinary research, attachment theory is now a construct with significant neuropsychiatric traction. The correlation of attachment with other influential conceptual models (i.e. temperament and personality) is therefore of interest. Consequently, we explored how two attachment dimensions (attachment anxiety and attachment avoidance) correlated with measures of temperament and personality in 357 psychiatric outpatients.

METHODS

We performed a retrospective review of four questionnaires (the Experiences in Close Relationship scale (ECR-R), Temperament and Character inventory (TCI), Temperament Evaluation of the Memphis, Pisa, Paris and San Diego questionnaire (TEMPS-A), and Personality Self-Portrait Questionnaire (PSQ)). Frequency measures and correlations were examined, as was the predictive value of attachment security for a personality disorder (PD).

RESULTS

Significant, robust correlations were found between attachment anxiety and (1) several negative affective temperaments (dysthymic and cyclothymic); (2) several indices of personality pathology (low self-directedness (TCI), DSM-IV paranoid, borderline, histrionic, avoidant and dependent personality traits). Attachment avoidance had fewer large correlations. In an exploratory model, the negative predictive value of attachment security for a PD was 86%.

LIMITATIONS

Subjects were a relatively homogeneous subset of ambulatory psychiatric outpatients. PD diagnoses were via self-report.

CONCLUSIONS

Clinically, these findings highlight the significant overlap between attachment, affective temperament, and personality and support the value of attachment as a screen for PDs. More broadly, given our growing understanding of the neurobiology of attachment (i.e. links with the oxytocin system), these results raise interesting questions about underlying biological systems and psychiatric treatment.

Differentiating Army suicide attempters from psychologically treated and untreated soldiers: a demographic, psychological and stress-reaction characterization

BACKGROUND

Suicide is the leading cause of death in most armies during peace-time. The recent dramatic rise in suicides in the US Army further focuses attention on the causes of suicidal behavior in the military.

METHODS

This study investigated demographic characteristics, psychological profile and stress-related risk factors associated with suicide attempts in Israelis aged 18-21 years, who served in the Army in 2009. Soldiers who attempted suicide (N=60) were compared to soldiers treated by a mental health professional, but reported no suicidal behavior (N=58), and to controls (N=50).

RESULTS

Suicide attempters had lower socioeconomic status and less cognitive ability compared with treated soldiers and untreated control soldiers. Only 25% of the suicide attempters had received mental healthcare prior to the attempt. The majority of the attempts were non-lethal (86.2%), and only 5.2% used firearms. Attempters had more previous suicide attempts (37.9%) and deliberate selfharm incidents (19.3%), compared to almost no such behaviors in the other two groups. Following the suicide attempt, 77% were diagnosed with moderate to severe mental disorders, 44.8% personality disorders and 8.6% mood disorders. Attempters reported higher levels of general stress compared to their peers in the other two groups. Being away from home and obeying authority were especially more stressful in attempters.

CONCLUSIONS

Young soldiers are less prone to seek mental health assistance, despite suffering from higher levels of stress. Screening is required to detect soldiers at risk for suicidal behavior and preventive intervention will require active outreach.

Personality disorders in DSM-5

A substantive revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM) last occurred in 1994; therefore, the mental health field should anticipate significant changes to the classification of mental disorders in the fifth edition. Since DSM-5 Work Groups have recently proposed revisions for the major diagnostic classes of mental disorders, an article on the current status of the personality disorders (PDs) is timely. This article reviews scientific principles that have influenced the development of proposed changes for the assessment and diagnosis of personality psychopathology in DSM-5, presents the proposed model as of the summer of 2011, summarizes rationales for the changes, and discusses critiques of the model. Scientific principles were articulated for DSM-5 more than a decade ago; their application to the process has not been straightforward, however. Work Group members have labored to improve the DSM-5 approach to personality and PDs to make the classification more valid and more clinically useful. The current model continues to be a work in progress.

Cross-cultural validation of the revised Temperament and Character Inventory: Serbian data

OBJECTIVE

In this work, we report data on construct validity and cross cultural applicability of the revised Temperament and Character Inventory (TCI R) (Cloninger, C.R., Przybeck, T.R., Svrakic, D.M., & Wetzel, R.D. (1999). The Temperament and Character Inventory-revised, Washington University, St. Louis), a 5-point scale scoring formatrevision of the original, true-false version TCI (Cloninger, C.R., Przybeck, T.R., Svrakic, D.M., & Wetzel, R.D. (1994). The Temperament and Character Inventory-A guide to its development and use, Washington University, St. Louis). Both versions are based on the seven factor Psychobiological Model of Personality (Cloninger CR, Svrakic, DM & Przybeck TR (1993). A Psychobiological Model of temperament and Character, Archives of General Psychiatry, 50, 975-990).

METHODS

The sample consisted of 473 normal adult subjects representing a number of Serbian cities and towns, recruited consecutively while registering at the National Employment Center, located in Belgrade, Serbia. The sample was the designed to be highly representative of urban and suburban population in Serbia to match to TCI R sample in the US. The 240-item, 5-point scale scoring TCI R was used to assess temperament and character traits. In addition to a number of other revisions, the scoring format in the TCI R was changed into a 5-point Likert scale to increase its sensitivity to subtle variations in personality expression. The TCI R mean scores and standard deviations were compared between Serbian and US subjects, internal consistency of the TCI R scales was estimated using Cronbach's alpha coefficients, and principal component analysis was used separately for temperament and character (because of their non-linear relationship) to test the underlying factorial structure of the TCI R. Parallel analysis and randomized simulation data were used to determine the number of factors for temperament and character.

RESULTS

The results generally supported the construct validity and the cross cultural applicability of the TCI R in Serbia. With a few exceptions, the observed internal consistency for the TCI R scales was acceptable. For the most part, the US and Serbian subjects manifested comparable temperament traits, whereas US subjects had higher character scores. The observed differences are understood as partly reflective of local culture and partly of dramatic socio-economic change in Serbia over the last 20 years. Principal component analysis fully supported the four factor structure of temperament and the three factor structure of character, as postulated by theory. The inadequacy of using linear statistical methods in studying complex non-linear systems such as personality is discussed in some detail.

Ethical aspects of personality disorders

PURPOSE OF REVIEW

To review recent literature around the controversial diagnosis of personality disorder, and to assess the ethical aspects of its status as a medical disorder.

RECENT FINDINGS

The diagnostic currency of personality disorder as a psychiatric/medical disorder has a longstanding history of ethical and social challenges through critiques of the medicalization of deviance. More recently controversies by reflexive physicians around the inclusion of the category in the forthcoming revisions of International Classification of Diseases and Diagnostic and Statistical Manual of Mental Disorders classifications reflect the problems of value-laden criteria, with the diagnostic category being severely challenged from within psychiatry as well as from without.

SUMMARY

The clinical diagnostic criteria for extremely value-laden psychiatric conditions such as personality disorder need to be analyzed through the lens of values-based medicine, as well as through clinical evidence, as the propensity for political and sociolegal appropriation of the categories can render their clinical and diagnostic value meaningless.