Comorbidity of axis I and axis II disorders

Societal costs of personality disorders among treatment-seeking patients in Norway: the relative contribution of specific DSM-5 categories

Personality disorders (PDs) are associated with high levels of societal costs, regardless of whether a single PD or a broad range of PDs have been studied. However, research on the relative contribution of specific PD-types on societal costs is limited. The aim of this study was to explore the possible contributions of the individual DSM-5 categories of PDs on the level of societal costs and its components (health service costs and productivity loss), while controlling for the impact of comorbid mental health and substance use disorders on these outcomes. Participants (n = 798) were retrieved from the quality register of the Norwegian Network for Personality Disorders-a collaboration of PD-treatment units within specialist mental health services. The patients were referred to treatment in the time-period 2017-2020. Costs were assessed using a structured interview covering the 6-month period prior to assessment. Diagnoses were determined by semi-structured diagnostic interviews (SCID-5-PD and M.I.N.I.). Statistics included multiple regression analyses. The main result was that no specific PD had a unique contribution to the high level of societal costs generally found among treatment-seeking patients with PDs. Borderline PD (BPD) was the only PD with significantly higher health service costs than the other PDs, while BPD, avoidant PD, and unspecified PD were independently associated with enhanced productivity loss. The differential cost-effects of specific PDs on the cost components were small. Several comorbid mental health and substance use disorders were significant contributors to costs, irrespective of PD status. The results underscore the importance of developing and implementing effective treatments for a broader range of PDs, to reduce the high levels of societal costs associated with all PDs.

Countertransference in the treatment of patients with personality disorders: A longitudinal study

OBJECTIVE

This study examines how therapist emotional response/countertransference (CT) develops during treatment for patients with personality disorders (PDs) and how pre-treatment patient factors (severity of personality pathology, PD category, level of symptom distress) predict CT responses. Secondly, we explored associations between patient clinical outcome and CT.

METHOD

A longitudinal, observational study including 1956 patients with personality pathology treated at psychotherapy units within specialist mental health services. Therapists' emotional response was repeatedly assessed by the Feeling Word Checklist-Brief Version (FWC-BV) with three subscales-Inadequate, Confident, and Idealized.

RESULTS

Levels of Inadequate CT were lowest and stable over time while Confident and Idealized increased over time. Greater severity of personality pathology and borderline PD predicted higher initial Inadequate, lower initial Confident and decreasing Inadequate over time. Antisocial PD predicted decreasing Confident. Number of PD criteria had higher impact on therapist CT than level of symptom distress. Clinical improvement was associated with decreasing Inadequate.

CONCLUSION

Therapists reported predominantly Confident CT when working with PD patients. More severe personality pathology, and borderline PD, specifically, predicted more negative CT initially, but the negative CT decreased over time. Patients who did not improve were associated with increasing Inadequate.

The landscape of eating disorders research: A 40-year bibliometric analysis

OBJECTIVE

Employing bibliometric methods, the present study aimed to map out the general landscape of existing research on eating disorders (EDs) over the past decades.

METHOD

Using the Web of Science database, we retrieved 41,917 research articles related to EDs published from 1981 to 2020. After removing those without an abstract, a total of 37,446 articles were retained. The study outlined the distribution of scholarship by time, languages, regions, and countries, and identified major research lines by applying latent topic modelling.

RESULTS

Results revealed a general increasing trend in the number of publications on EDs research, and researchers from Western countries dominated the production of related scholarship. The distribution of published scholarship varied significantly by languages, regions, and countries. Seven main research topics emerged from past research (i.e., animal studies of food intake, risk factors and at-risk groups for eating disorders, body image in eating disorders, studies of cognition and brain in eating disorders, symptomatology and comorbidity of eating disorders, body weight and nutrition status in eating disorders, and treatment of eating disorders), with different topics showing unique research trends across the years.

CONCLUSIONS

This bibliometric analysis presents the most complete up-to-date overview on published research on EDs. While there is an increasing trend for EDs research, the available research evidence is generally from Western countries; thus, it is suggested that cooperation on EDs research should be strengthened between Western countries and other countries in the future.

The Relationship between Maternal Personality Disorder and Early Birth Outcomes: A Systematic Review and Meta-Analysis

(1) Background: Women with personality disorder are at risk of social and emotional problems which impact deleteriously on everyday functioning. Moreover, a personality disorder diagnosis has been established to have an adverse impact upon pregnancy outcomes and child health. Understanding this impact is critical to improving both maternal and child outcomes. This systematic review and meta-analysis will evaluate the contemporary evidence regarding these relationships. (2) Methods: Prospero and Cochrane were searched for any systematic reviews already completed on this topic. Academic Search Premier, CINAHL Complete, MEDLINE, PsycARTICLES, PsycINFO via the EBSCO host, and the Web of Science Core Collection were searched to include research articles published between 1980 and 2019. A total of 158 records were identified; 105 records were screened by reviewing the abstract; 99 records were excluded; 6 full text articles were assessed for eligibility; 5 records were included in the review. (3) Results: All the included studies reported on preterm birth. The meta-analysis indicates significant risk of preterm birth in women with personality disorder (overall odds ratio (OR) 2.62; CI 2.24–3.06; p < 0.01). Three studies reported on low birth weight, with the meta-analysis indicating a raised risk of low birth weight of the babies born to women with personality disorder (overall OR 2.00 CI 1.12–3.57 (p = 0.02)). Three studies reported on appearance, pulse, grimace, activity, and respiration (APGAR) score, with the meta-analysis of OR’s indicating a risk of low APGAR score in women with personality disorder (overall OR 2.31; CI 1.17–4.55; p = 0.02). (4) Conclusions: The infants of women with personality disorder are at elevated risk of preterm birth, low birth weight and low APGAR score.

Psychotherapy of Dependent Personality Disorder: The Relationship of Patient-Therapist Interactions to Outcome

So far, only a few studies have focused on psychotherapy for Dependent Personality Disorder (DPD). DPD is marked by a repetitive pattern of efforts aiming at maintaining close relationships, which may present as a lack of assertiveness and as a difficulty in making routine decisions. The present study aims at exploring processes of change taking place during the working phase of a clarification-oriented psychotherapy (COP) by focusing on the in-session patient-therapist interaction, as it changes during treatment and their links with treatment outcome. Methods: N = 74 patients with DPD were recruited in a naturalistic setting; they underwent long-term COP. Sessions 15, 20 and 25 were video- or audio-recorded and analyzed using the Process-Content-Relationship Scale, an observer-rated instrument that measures the quality of the interaction processes from patient's and therapist's perspectives. Therapy outcomes were assessed with the Personality Inventory - Dependency Subscale, Beck Depression Inventory, Inventory of Interpersonal Problems and Self-efficacy Scale at intake and discharge of therapy. Three-level Hierarchical Linear Modeling was applied to test the hypotheses. Results: Improvement in interaction processes was observed in all patient's and therapist's variables over the sessions 15, 20, 25. Overall, this increase in quality of interaction process was unrelated with outcome, but decrease in dependency traits was predicted by increase in therapist's quality of relationship offer, understanding of content and directivity over the course of the working phase of COP. Conclusions: Studying interaction processes in DPD provides an initial understanding of differential roles of potential mechanisms of change in effective treatment.

A study of dissociation in survivors of 5 disasters

This study examined dissociation as an outcome to disaster in dissociative data collected from 423 highly-exposed survivors of 5 different disasters using consistent methodology. Ten items selected for conceptual relevance to disaster experience were administered from the Dissociative Disorders Interview Schedule, a structured interview for lifetime dissociative disorders. Structured psychiatric interviews provided data on incident somatization symptoms, disaster-related PTSD, and lifetime predisaster psychopathology. The Temperament and Character Inventory assessed personality. Observed levels of dissociation were low and not usually postdisaster. Dissociation level was associated with female sex, number of incident somatization symptoms, personality (underdeveloped executive functioning), PTSD, and predisaster psychopathology in bivariate analyses. In multiple linear regression models, dissociation was associated with the low number of incident somatoform symptoms observed independent of the effects of PTSD, hyperarousal specifically (but not intrusion or avoidance/numbing), personality, predisaster psychopathology, and demographic variables which were not independently associated with dissociation. The low levels of dissociation found in this study and the lack of association between dissociation and indicators of psychopathology point to a largely nonpathological nature of the dissociative phenomena measured. These findings do not indicate the development of dissociative psychopathology as a prevalent mental health outcome of disasters.

Co-Morbidity of DSM-IV Personality Disorder in Major Depressive Disorder Among Psychiatric Outpatients in China: A Further Analysis of an Epidemiologic Survey in a Clinical Population

Introduction: It is common that personality disorder (PD) co-occurs with major depressive disorder (MDD). In the current literature, there is a dearth of information on the co-occurrence of PD and MDD among Chinese population. Materials and Methods: 609 individuals were randomly sampled from outpatients diagnosed as MDD in Shanghai Mental Health Center. Co-morbidity of PDs was assessed using the Personality Diagnostic Questionnaire Fourth Edition Plus (PDQ-4+) and eligible subjects were interviewed with the Structured Clinical Interview for DSM-IV Axis II (SCID-II). The score of PDQ-4+ and the rate of SCID-II PD between subjects diagnosed with MDD and those with anxiety disorders (AD) were compared. Results: Two hundred fifty-eight outpatients (42.36%) with MDD were recognized to possess at least one criterion of diagnosis for PD, according to the DSM-IV. The most prevalent PD was depressive PD (14.61%), followed by avoidant (11.49%) and borderline (11.49%) PD. Cluster C PDs (anxious and panic PD) were the most common PD types (12.12%) when compared to other clusters. Compared to patients with AD, individuals with MDD were significantly more likely to have paranoid PD (6.6% vs. 3.3%, p = 0.011), borderline PD (11.5% vs. 3.7%, p = 0.000), passive-aggressive PD (5.6% vs. 2.4%, p = 0.007), and depressive PD (14.6% vs. 7.8%, p = 0.000). Discussion: The finding indicates that there is a high prevalence of PD among patients with MDD. More significant co-morbidity rates of PDs in MDD have been found when compared with AD. Further studies for the longitudinal impact of the PD-MDD co-morbidity are in need.

Community and Clinical Epidemiology of Borderline Personality Disorder

Several studies of the prevalence of borderline personality disorder in community and clinical settings have been carried out to date. Although results vary according to sampling method and assessment method, median point prevalence is roughly 1%, with higher or lower rates in certain community subpopulations. In clinical settings, the prevalence is around 10% to 12% in outpatient psychiatric clinics and 20% to 22% among inpatient clinics. Further research is needed to identify the prevalence and correlates of borderline personality disorder in other clinical settings (eg, primary care) and to investigate the impact of demographic variables on borderline personality disorder prevalence.

Comorbidity of Borderline Personality Disorder: Current Status and Future Directions

Patients with borderline personality disorder have high rates of comorbid mood, anxiety, substance use, and eating disorders. The longitudinal studies conducted on borderline patients over 10 years of prospective follow-up suggest that patients with borderline personality disorder experienced declining rates of Axis I disorders over time, but the rates of these disorders remained high compared with those with other personality disorders. In addition, patients whose borderline personality disorder remitted over time experienced a substantial decline in all comorbid Axis I disorders, but those whose borderline personality disorder did not remit over time, reported stable rates of comorbid disorders.

A pilot study on predictors of brainstem raphe abnormality in patients with major depressive disorder

BACKGROUND

Hypo/anechogenicity of the brainstem raphe (BR) structures has been suggested as a possible transcranial parenchymal sonography (TCS) marker associated with depression.

AIM

The aim of this study was to analyze possible association of the abnormal BR echogenicity in patients with major depression when compared to healthy controls, and to evaluate its clinical and genetic correlates.

METHODS

TCS was performed in 53 patients diagnosed as major depressive disorder (MDD) without psychotic symptoms and in 54 healthy matched controls.

RESULTS

The TCS detected BR abnormalities were significantly more frequent in MDD patients (35 out of 53; 66%) in comparison to matched controls (5 out of 56; 9%). The prevalence of short allele (s) homozygocity in the length polymorphism of the promoter region of the serotonin transporter gene (5-HTTLPR) was significantly higher in MDD patients relative to those with normal BR echogenicity. A stepwise statistical discriminant analysis revealed statistically significant separation between MDD patients with and without BR abnormalities groups based on the four predictors combined: the Hamilton Anxiety Rating Scale item 5 ("difficulty in concentration, poor memory"), presence of social phobia, s allele homozygocity of the 5-HTTLPR polymorphism, and presence of generalized anxiety disorder.

LIMITATIONS

Cross-sectional design and heterogenous treatment of depressed patients.

CONCLUSIONS

Reduced BR echogenicity in at least a subgroup of MDD patients may reflect a particular phenotype, characterized by more prevalent comorbid anxiety disorders, associated with particular genetic polymorphisms and neurotransmitter(s) deficits, most probably altered serotonergic mechanisms.

Co-morbidity of personality disorder in schizophrenia among psychiatric outpatients in China: data from epidemiologic survey in a clinical population

BACKGROUND

The reported rates of personality disorder (PD) in subjects with schizophrenia (SZ) are quite varied across different countries, and less is known about the heterogeneity of PD among subjects with SZ. We examined the co-morbidity of PD among patients who are in the stable phase of SZ.

METHOD

850 subjects were randomly sampled from patients diagnosed with SZ in psychiatric and psycho-counseling clinics at Shanghai Mental Health Center. Co-morbidity of PDs was assessed through preliminary screening and patients were administered several modules of the SCID-II. Evidence of heterogeneity was evaluated by comparing patients diagnosed with SZ with those who presented with either affective disorder or neurosis (ADN).

RESULTS

204 outpatients (24.0 %) in the stable phase of SZ met criteria for at least one type of DSM-IV PD. There was a higher prevalence of Cluster-A (odd and eccentric PD) and C (anxious and panic PD) PDs in SZ (around 12.0 %). The most prevalent PD was the paranoid subtype (7.65 %). Subjects with SZ were significantly more likely to have schizotypal PD (4.4 % vs. 2.1 %, p = 0.003) and paranoid PD (7.6 % vs. 5.4 %, p = 0.034), but much less likely to have borderline, obsessive-compulsive, depressive, narcissistic and histrionic PD.

CONCLUSIONS

These findings suggest that DSM-IV PD is common in patients with SZ than in the general population. Patterns of co-morbidity with PDs in SZ are different from ADN.

Incremental Validity of the DSM-5 Section III Personality Disorder Traits With Respect to Psychosocial Impairment

Traditional personality disorders (PDs) are associated with significant psychosocial impairment. DSM-5 Section III includes an alternative hybrid personality disorder (PD) classification approach, with both type and trait elements, but relatively little is known about the impairments associated with Section III traits. Our objective was to study the incremental validity of Section III traits--compared to normal-range traits, traditional PD criterion counts, and common psychiatric symptomatology--in predicting psychosocial impairment. To that end, 628 current/recent psychiatric patients completed measures of PD traits, normal-range traits, traditional PD criteria, psychiatric symptomatology, and psychosocial impairments. Hierarchical regressions revealed that Section III PD traits incrementally predicted psychosocial impairment over normal-range personality traits, PD criterion counts, and common psychiatric symptomatology. In contrast, the incremental effects for normal-range traits, PD symptom counts, and common psychiatric symptomatology were substantially smaller than for PD traits. These findings have implications for PD classification and the impairment literature more generally.

Quality of life in borderline patients comorbid with anxiety spectrum disorders - a cross-sectional study

INTRODUCTION

Borderline personality disorder (BPD) significantly reduces the quality of life (QoL) in mental, social, and work domains. Patients with BPD often suffer from depressive anxiety symptoms. The purpose of this cross-sectional study was to compare the QoL and demographic and clinical factors of inpatients diagnosed with BPD and comorbid anxiety spectrum disorders, and healthy controls.

METHODS

Ninety-two hospitalized patients treated in the psychotherapeutic department and 40 healthy controls were included. Subjects were assessed by the Quality of Life Satisfaction and Enjoyment Questionnaire (Q-LES-Q), Dissociative Experiences Scale, Beck Depression Inventory (BDI)-II, Beck Anxiety Inventory, Clinical Global Impression, demographic questionnaire, Sheehan Disability Scale (SDS), and Sheehan Anxiety Scale.

RESULTS

BPD patients suffered from comorbid anxiety disorders, panic disorder (18.5%), social phobia (20.7%), generalized anxiety disorder/mixed anxiety depression disorder (17.4%), adjustment disorder (22.8%), and posttraumatic stress disorder (8.7%); 19.6% patients had two or more anxiety disorder comorbidities. Patients score in Q-LES-Q (general) was 36.24±9.21, which was significantly lower in comparison to controls (57.83±10.21) and similar in all domains (physical health, feelings, work, household, school/study, leisure, social activities). The subjective level of depression measured by BDI and SDS (social life and family subscales) negatively correlated with all Q-LES-Q domains.

CONCLUSION

Patients suffering from BPD and comorbid anxiety disorders have a lower level of QoL compared to healthy controls in all measured domains. Negative correlations of the Q-LES-Q domains with clinical scales (Dissociative Experiences Scale, BDI, Beck Anxiety Inventory, Sheehan Anxiety Scale, Clinical Global Impression, and SDS) are noticeable.

Effect of Borderline Personality Disorder on Obstetrical and Neonatal Outcomes

BACKGROUND

Borderline personality disorder (BPD) is a serious mental disorder commonly associated with functional impairments and adverse health outcomes. Very little is known about BPD in pregnant women; hence, our study objective was to evaluate the effect of BPD on obstetrical and neonatal outcomes.

METHODS

We carried out a retrospective cohort study using the Healthcare Cost and Utilization Project, Nationwide Inpatient Sample from 2003 to 2012. We identified births using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic and procedure codes and classified women by BPD status. Multivariate logistic regression was used to evaluate the effect of BPD on obstetrical and neonatal outcomes, adjusted for subject baseline characteristics.

FINDINGS

During the study period, there were 989 births to women with BPD with an overall incidence of 11.65 in 100,000 births. Women with BPD were more likely younger, of lower socioeconomic status, smoked or used drugs, and had an underlying mental disorder. Unadjusted models revealed that BPD was associated with an increased risk of almost all adverse maternal and fetal outcomes we examined, the exception being post partum hemorrhage and instrumental delivery, which both had a null association with BPD, and induction of labor, which was negatively associated with BPD. Upon full adjustment, BPD was found to be associated with the following obstetrical and neonatal outcomes: gestational diabetes (odds ratio [OR], 1.45; 95% CI, 1.13-1.85), premature rupture of the membranes (OR, 1.40; 95% CI, 1.07-1.83), chorioamnionitis (OR, 1.65; 95% CI, 1.14-2.39), venous thromboembolism (OR, 2.11; 95% CI, 1.12-3.96), caesarian delivery (OR, 1.44; 95% CI, 1.26-1.64), and preterm birth (OR, 1.54; 95% CI, 1.29-1.83).

CONCLUSION

BPD is associated with several adverse obstetrical and neonatal outcomes. Hence, pregnant women who suffer from BPD should be monitored closely by a multidisciplinary health care team both before and during their pregnancies. This oversight would allow for the receipt of treatment for BPD and also interventions to help them to cease tobacco and drug use, which may ultimately decrease the incidence of poor obstetrical and neonatal outcomes.

Links Among High EPDS Scores, State of Mind Regarding Attachment, and Symptoms of Personality Disorder

Underlying persistent psychological difficulties have been found to moderate potential adverse effects of maternal postpartum depression (PPD) on parenting and infant development. The authors examined whether mothers presenting postpartum depressive symptoms showed higher levels of personality pathology and more insecure state of mind regarding attachment compared to nondepressed mothers. Participants (N = 85) were assessed with the Edinburgh Postnatal Depression Scale (EPDS), the Present State Examination, the Adult Attachment Interview, and the Structured Clinical Interview for DSM-IV Axis II. Mothers with high EPDS scores were more likely to have a preoccupied insecure state of mind and to have personality disorder compared with mothers scoring below clinical cutoff. Furthermore, multiple regression analysis showed that personality disorder and AAI classification were independently related to EPDS score, and that these two factors together accounted for 48% of the variance in EPDS score. Findings are discussed in terms of heterogeneity in PPD populations and underline the importance of examining potential coexisting psychological difficulties when studying PPD.

EXPLORING PERSONALITY DIAGNOSIS STABILITY FOLLOWING ACUTE PSYCHOTHERAPY FOR CHRONIC POSTTRAUMATIC STRESS DISORDER

BACKGROUND

Axis I comorbidity complicates diagnosing axis II personality disorders (PDs). PDs might influence Axis I outcome. No research has examined psychotherapy effects on PDs of treating Axis I comorbidity. Secondary analysis of a randomized controlled trial examined PD diagnostic stability after brief psychotherapy of chronic posttraumatic stress disorder (PTSD).

METHODS

Patients with chronic PTSD were randomly assigned to 14 weeks of prolonged exposure, interpersonal psychotherapy, or relaxation therapy. Assessments included the Structured Clinical Interview for DSM-IV, Patient Version (SCID-P) and Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II) at baseline, week 14, and for treatment responders (≥30% clinician-administered PTSD scale improvement, defined a priori) at week 26 follow-up. We hypothesized patients whose PTSD improved would retain fewer baseline PD diagnoses posttreatment, particularly with personality traits PTSD mimics, e.g. paranoid and avoidant.

RESULTS

Forty-seven (47%) of 99 SCID-II patients evaluated at baseline received a SCID-II diagnosis: paranoid (28%), obsessive-compulsive (27%), and avoidant (23%) PDs were most prevalent. Among 78 patients who repeated SCID-II evaluations posttreatment, 45% (N = 35) had baseline PD diagnoses, of which 43% (N = 15/35) lost at week 14. Three (7%) patients without baseline PDs acquired diagnoses at week 14; 10 others shifted diagnoses. Treatment modality and PTSD response were unrelated to PD improvement. Of treatment responders reevaluated at follow-up (N = 44), 56% with any baseline Axis II diagnosis had none at week 26.

CONCLUSION

This first evaluation of Axis I psychotherapy effects on personality disorder stability found that acutely treating a chronic state decreased apparent trait-across most PDs observed. These exploratory findings suggest personality diagnoses may have limited prognostic meaning in treating chronic PTSD.

Treatment characteristics and outcome of depression among depressed adolescent outpatients with and without comorbid Axis II disorders

In the literature, disagreement exists on the impact of Axis II comorbidity on the treatment outcome of depression. The aim of the present study was to examine in a naturalistic treatment setting the 1-year outcome and treatment characteristics of depressed adolescent outpatients with and without comorbid Axis II disorders. The 151 participants were interviewed for Axis I and II diagnoses at baseline and follow-up. Those diagnosed with a personality disorder were significantly more impaired at follow-up than those without. The given treatment did not differ between the two groups in length, intensity, or hospitalization, but the group with Axis II comorbidity received more psychotropic medication. The treatment outcome of depression was poorer for the group with Axis II disorders compared to those without. In conclusion, a personality disorder diagnosis is a sign of more severe overall symptoms. Special attention should be paid to Axis II traits when planning and conducting the treatment of adolescent depression.

Day hospital Mentalization-based treatment versus intensive outpatient Mentalization-based treatment for patients with severe borderline personality disorder: protocol of a multicentre randomized clinical trial

BACKGROUND

Borderline personality disorder (BPD) is associated with a high socioeconomic burden. Although a number of evidence-based treatments for BPD are currently available, they are not widely disseminated; furthermore, there is a need for more research concerning their efficacy and cost-effectiveness. Such knowledge promises to lead to more efficient use of resources, which will facilitate the effective dissemination of these costly treatments. This study focuses on the efficacy and cost-effectiveness of Mentalization-Based Treatment (MBT), a manualized treatment for patients with BPD. Studies to date have either investigated MBT in a day hospitalization setting (MBT-DH) or MBT offered in an intensive outpatient setting (MBT-IOP). No trial has compared the efficacy and cost-effectiveness of these MBT programmes. As both interventions differ considerably in terms of intensity of treatment, and thus potentially in terms of efficacy and cost-effectiveness, there is a need for comparative trials. This study therefore sets out to investigate the efficacy and cost-effectiveness of MBT-DH versus MBT-IOP in patients with BPD. A secondary aim is to investigate the association between baseline measures and outcome, which might improve treatment selection and thus optimize efficacy and cost-effectiveness.

METHODS/DESIGN

A multicentre randomized controlled trial comparing MBT-DH versus MBT-IOP in severe BPD patients. Patients are screened for BPD using the Structured Clinical Interview for DSM-IV Axis II Personality Disorders, and are assessed before randomization, at the start of treatment and 6, 12, 18, 24, 30 and 36 months after the start of treatment. Patients who refuse to participate will be offered care as usual in the same treatment centre. The primary outcome measure is symptom severity as measured by the Brief Symptom Inventory. Secondary outcome measures include parasuicidal behaviour, depression, substance use, social, interpersonal, and personality functioning, attachment, mentalizing capacities, and quality of life. All analyses will be conducted based on the intention-to-treat principle. Cost-effectiveness will be calculated based on costs per quality-adjusted life-year.

DISCUSSION

This multisite randomized trial will provide data to refine criteria for treatment selection for severe BPD patients and promises to optimize (cost-)effectiveness of the treatment of BPD patients.

TRIAL REGISTRATION

NTR2292 . Registered 16 April 2010.

Personality disorders and the persistence of substance use disorders: A reanalysis of published NESARC findings

The purpose of this study was to examine whether published findings regarding the association of personality disorders (PDs) with the persistence of substance use disorders (SUDs) are attributable to an artifact due to time of assessment of the PD. Two previous studies analyzed data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) and found that Antisocial PD, Schizotypal PD, and Borderline PD are unique predictors of SUDs. However, a design limitation in NESARC (assessment of PDs at different waves) can potentially compromise these findings. To assess the influence of time of assessment of PDs and to identify associations that might be robust to time of assessment, we compared the association of PDs with 2 estimates of SUD persistence that were based on different populations at risk: (a) among those who were diagnosed with SUD at baseline, the proportion who continued to meet full criteria at follow-up ("prediction"); and (b) among those who were diagnosed with SUD at follow-up, the proportion who met full criteria at baseline ("postdiction"). Differences between prediction and postdiction revealed a robust pattern of higher odds ratios for postdiction among PDs assessed at baseline, and lower odds ratios for postdiction among PDs assessed at follow-up. All published significant associations between PDs and persistence of SUDs became nonsignificant in the postdiction analyses, with the exception of obsessive-compulsive PD predicting nicotine dependence persistence. The present results raise serious doubts about the validity of published findings on PDs and SUD persistence from the NESARC. Design limitations in NESARC preclude a direct comparison among PDs measured at different waves.

Dimensions of personality structure among patients with substance use disorders and co-occurring personality disorders: a comparison with psychiatric outpatients and healthy controls

BACKGROUND

Although dual diagnosis has been a topic of great scientific interest for a long time, few studies have investigated the personality traits that characterize patients suffering from substance use disorders and co-occurring personality disorders through a dimensional approach. The present study aimed to evaluate structural personality profiles among dual-diagnosis inpatients to identify specific personality impairments associated with dual diagnosis.

METHODS

The present study involved 97 participants divided into three groups: 37 dual-diagnosis inpatients, 30 psychiatric outpatients and 30 nonclinical controls. Dimensions of personality functioning were assessed and differences between groups were tested using Kernberg's dimensional model of personality.

RESULTS

Results showed that dual diagnosis was associated with the presence of difficulties in three main dimensions of personality functioning. Dual-diagnosis inpatients reported a poorly integrated identity with difficulties in the capacity to invest, poorly integrated moral values, and high levels of self-direct and other-direct aggression.

CONCLUSIONS

The present study highlighted that a dimensional approach to the study of dual diagnosis may clarify the personality functioning of patients suffering from this pathological condition. The use of the dimensional approach could help to advance research on dual diagnosis, and it could have important implications on clinical treatment programs for dual-diagnosis inpatients.

Day Hospital Mentalization-Based Treatment (MBT-DH) versus treatment as usual in the treatment of severe borderline personality disorder: protocol of a randomized controlled trial

BACKGROUND

Severe borderline personality disorder is associated with a very high psychosocial and economic burden. Current treatment guidelines suggest that several manualized treatments, including day hospital Mentalization-Based Treatment (MBT-DH), are effective in these patients. However, only two randomized controlled trials have compared manualized MBT-DH with treatment as usual. Given the relative paucity of data supporting the efficacy and cost-effectiveness of MBT-DH, the possible influence of researcher allegiance in one of the trials, and potential problems with the generalization of findings to mental health systems in other countries, this multi-site randomized trial aims to investigate the efficacy and cost-effectiveness of manualized MBT-DH compared to manualized specialist treatment as usual in The Netherlands.

METHODS/DESIGN

The trial is being conducted at two sites in The Netherlands. Patients with a DSM-IV-TR diagnosis of borderline personality disorder and a score of ≥ 20 on the Borderline Personality Disorder Severity Index were randomly allocated to MBT-DH or treatment as usual. The MBT-DH program consists of a maximum of 18 months' intensive treatment, followed by a maximum of 18 months of maintenance therapy. Specialist treatment as usual is provided by the City Crisis Service in Amsterdam, a service that specializes in treating patients with personality disorders, offering manualized, non-MBT interventions including family interventions, Linehan training, social skills training, and pharmacotherapy, without a maximum time limit. Patients are assessed at baseline and subsequently every 6 months up to 36 months after the start of treatment. The primary outcome measure is the frequency and severity of manifestations of borderline personality disorder as assessed by the Borderline Personality Disorder Severity Index. Secondary outcome measures include parasuicidal behaviour, symptomatic distress, social and interpersonal functioning, personality functioning, attachment, capacity for mentalizing and quality of life. Cost-effectiveness is assessed in terms of the cost per quality-adjusted life year. Outcomes will be analyzed using multilevel analyses based on intention-to-treat principles.

DISCUSSION

Severe borderline personality disorder is a serious psychological disorder that is associated with high burden. This multi-site randomized trial will provide further data concerning the efficacy and cost-effectiveness of MBT-DH for these patients.

TRIAL REGISTRATION

NTR2175.

Millon clinical multiaxial inventory III (MCMI-III) and communication styles in a sample of university students

Despite the controversy generated by the conceptualization of personality disorders, it is well established that the inflexibility of coping styles and dysfunctional behaviors associated with them can lead to a considerable impairment in interpersonal relationships. Although communication is one of the most important processes in relating to others, few empirical studies have been undertaken on the influence of dysfunctional personality patterns on communication styles, which is the main objective of the present cross-sectional study. A total of 529 Spanish university students were assessed using the Millon Clinical Multiaxial Inventory III (MCMI-III), Millon, Davis, and Millon, 1997, and the Communicator Style Measure (Norton, 1978). Results show statistically significant relationships between different personality patterns and styles of communication and suggest that narcissistic, histrionic and compulsive patterns are related to positive communication styles in a non-clinical sample. The implications of this study are discussed.

Predicting response to intensive multimodal inpatient treatment: a comparison of single- and multiple-class growth modeling approaches

In a modest body of research, personality functioning assessed via performance-based instruments has been found to validly predict treatment outcome and, to some extent, differential response to treatment. However, state-of-the-science longitudinal and mixture modeling techniques, which are common in many areas of clinical psychology, have rarely been used. In this article, we compare multilevel growth curve modeling (MLM) and latent class growth modeling (LCGM) approaches with the same data set to illustrate the different research questions that can be addressed by each method. Global Assessment of Functioning (GAF) scores collected at 6 points during the course of a long-term multimodal inpatient treatment of 58 severely and persistently mentally ill adults were used to model the trajectory of treatment outcome. Pretreatment Rorschach-based markers of personality functioning and other markers of psychiatric severity were examined as covariates in each modeling approach. The results of both modeling approaches generally indicated that more psychologically impaired clients responded less favorably to treatment. The LCGM approach revealed 2 unique trajectories of improvement (a persistently low group and a higher starting, improving group). Personality functioning and baseline psychiatric variables significantly predicted group membership and the rate of change within the groups. A side-by-side examination of these 2 methods was found to be useful in predicting differential treatment response with personality functioning variables.

Structural brain features of borderline personality and bipolar disorders

A potential overlap between bipolar disorder (BD) and borderline personality disorder (BPD) has been recently proposed. We aimed to assess similarities and differences of brain structural features in BD and BPD. Structural magnetic resonance imaging (MRI) was performed in 26 inpatients with BPD, 14 with BD, and 40 age-and sex-matched healthycontrols (HC). Voxel-based morphometry analysis with Statistical Parametric Mapping (SPM) was used to localize and quantify gray (GM) and white matter (WM) abnormalities in BD and BPD compared to HC and to identify those specifically affected in each patient group. Region of interest (ROI)-based analyses were also performed for confirmation. GM density changes in BD are significantly more diffuse and severe than in BPD, as demonstrated in both SPM- and ROI-based analyses. The topography of GM alterations showed some regions of overlap, but each disorder had specific regions of abnormality (involving both cortical and subcortical structures in BD, confined mainly to fronto-limbic regions in BPD). WM density changes were less pronounced in both conditions and involved completely different regions. Although BPD and BD show a considerable overlap of GM changes, the topography of alterations is more consistent with the separate conditions hypothesis and with the vulnerability of separate neural systems.

Comorbidity between personality disorders and depressive symptomatology in women: A cross-sectional study of three different transitional life stages

This study assessed the prevalence of personality disorders (PDs), according to DSM-IV criteria, in relation to depressive symptomatology at three different periods of life in female subjects. Depressive symptoms and personality disorders were assessed in a sample of 568 women from three different transitional stages: 134 students, 314 primiparous women after childbirth and 120 women diagnosed with breast cancer. Depressive symptoms were assessed by the Hospital Depression and Anxiety Scale in the first and third groups and by the Edinburgh Post-natal Depression Scale in the second group, whereas PDs were assessed by the French version of the Vragenlijst voor Kenmerken van de Persoonlijkheid. Depressive symptomatology and rates of PD (20.4% and 6.3%) were equivalent in the three groups. The prevalence of PD was higher in the depressed group compared with the non-depressed group, with more paranoid, borderline, avoidant, obsessive-compulsive, schizotypal, antisocial, dependent and histrionic PD. Our findings support the hypothesis that PDs are more frequently associated with depressive symptoms. Borderline and avoidant PDs were more prevalent among young women. All cluster C PD (dependent, avoidant and obsessive-compulsive) co-occurred significantly with depressive symptoms.

Paranoid personality disorder and the schizophrenia spectrum-Where to draw the line?

By means of a case vignette, this study explores the clinical intersection between paranoid personality disorder and other schizophrenia-spectrum illness. Even though the patient described had paramount signs of a paranoid personality disorder and was diagnosed as such, psychopathological symptoms extended considerably beyond the common concept and diagnostic criteria of the disorder. Management strategies included psychopharmacological and non-pharmacological interventions, yet psychosocial functioning permanently appeared defective. While there is a persistent need for an opportunity to distinguish the characteristic syndromal pattern of paranoid personality attributes, the case exemplifies the challenges associated with classifying some largely suspicious and distrustful eccentrics within the schizophrenia spectrum.

Increased prefrontal cortical thickness is associated with enhanced abilities to regulate emotions in PTSD-free women with borderline personality disorder

Previous studies suggest that amygdala, insula and prefrontal cortex (PFC) disintegrity play a crucial role in the failure to adequately regulate emotions in Borderline Personality Disorder (BPD). However, prior results are confounded by the high rate of comorbidity with Posttraumatic Stress Disorder (PTSD), which itself has been associated with changes in frontolimbic circuitry. We thus scrutinized the link between PFC, amygdala, insula, and the ability to regulate emotions, contrasting 17 women with BPD without comorbid PTSD to 27 non-clinical control women and in addition to those with BPD and PTSD (n = 14). BPD women without PTSD, but not those with comorbid PTSD, had increased cortical thickness in the dorsolateral PFC (DLPFC) in comparison to control women. Furthermore, cortical thickness in the DLPFC of BPD women without PTSD positively correlated with emotion regulation scores and furthermore was positively associated with amygdala volume, as well as cortical thickness of the insula. Our findings highlight the importance of disentangling the impact of BPD and PTSD on the brain and suggest possible compensatory mechanisms for the impaired emotion regulation in BPD women without PTSD.

Comorbidity-independent risk for suicidality increases with bulimia nervosa but not with anorexia nervosa

BACKGROUND

Eating disorders are serious psychiatric illnesses with high levels of suicidality and high comorbidity. However, no study has established the extent to which suicidality is uniquely associated with eating disorders rather than attributable to comorbid mood, anxiety, or substance use disorders. The current study examined whether unique associations between eating disorders and suicidality exist and whether potential associations differ by eating disorder diagnosis.

METHODS

Participants were women (n = 364) from the second stage of a large epidemiological study examining eating and health related attitudes and behaviors. The Structured Clinical Interview for Axis I diagnoses (SCID-I) was used to determine lifetime psychiatric diagnoses and lifetime suicidality.

RESULTS

A multiple regression model including eating and comorbid disorders indicated that bulimia nervosa (BN) was significantly associated with suicidality above and beyond risk predicted by comorbid disorders. No unique association was found for anorexia nervosa (AN) or eating disorder not otherwise specified while controlling for comorbidity.

CONCLUSIONS

BN is independently associated with suicidality, and findings emphasize the need to incorporate suicide risk assessment in standardized assessments of eating disorders.

Individuals with single versus multiple suicide attempts over 10years of prospective follow-up

BACKGROUND

The study attempted to identify characteristics that differentiate multiple suicide attempters from single attempters in individuals with personality disorders (PDs) and/or major depression.

METHOD

Participants were 431 participants enrolled in the Collaborative Longitudinal Study of Personality Disorders from July 1996 to June 2008. Suicide attempts were assessed with the Longitudinal Interval Follow-up Evaluation at 6 and 12months, then yearly through 10years. Logistic regression was used to compare single attempters to multiple attempters on Axis I and II psychiatric disorders and personality trait variables.

RESULTS

Twenty-one percent of participants attempted suicide during the 10years of observation, with 39 (9.0%) reporting a single suicide attempt and 54 (12.5%) reporting multiple suicide attempts. Although no significant differences in were found in baseline Axis I disorders, multiple attempters were significantly more likely to meet criteria for borderline personality disorder and to have higher impulsivity scores than single attempters.

CONCLUSION

These results underscore the importance of considering both personality disorders and traits in the assessment of suicidality.

Treatment Characteristics and Outcome of Depression Among Depressed Adolescent Outpatients With and Without Comorbid Axis II Disorders

In the literature, disagreement exists on the impact of Axis II comorbidity on the treatment outcome of depression. The aim of the present study was to examine in a naturalistic treatment setting the 1-year outcome and treatment characteristics of depressed adolescent outpatients with and without comorbid Axis II disorders. The 151 participants were interviewed for Axis I and II diagnoses at baseline and follow-up. Those diagnosed with a personality disorder were significantly more impaired at follow-up than those without. The given treatment did not differ between the two groups in length, intensity, or hospitalization, but the group with Axis II comorbidity received more psychotropic medication. The treatment outcome of depression was poorer for the group with Axis II disorders compared to those without. In conclusion, a personality disorder diagnosis is a sign of more severe overall symptoms. Special attention should be paid to Axis II traits when planning and conducting the treatment of adolescent depression.

Exploring the clinical validity of borderline personality disorder components

Borderline personality disorder (BPD) is recognized as a complex syndrome, resulting in a heterogeneous diagnostic category. Besides the characteristics of the disorder itself, comorbid disorders play an important role in this complexity. The aim of the study is to analyze the clinical validity of 3 components for BPD Diagnostic and Statistical Manual of Mental Disorders criteria--called affective dysregulation, behavioral dysregulation, and disturbed relatedness--investigating differences in patterns of comorbidity. For this purpose, 365 patients with suspected BPD were included in the study. To test our hypothesis, patients were classified into 5 clusters using a K-cluster analysis to study the clinical validity of the 3 components based on the 3-factor model of BPD. Differences in comorbidity, previous suicide attempts, and self-harm behaviors among the defined clusters were analyzed. Between-cluster differences were observed for Axis I and Axis II disorders as well as in the frequency of suicide attempts and in self-harm behaviors. The study of BPD based on the 3 components seems to be more useful than the study of BPD as a unitary construct to help further our understanding of this complex disorder. In the present study, the 3 BPD components have allowed us to analyze the complex comorbidity of BPD patients. This solution could be considered an interesting way to clarify BPD etiology, diagnosis, and treatment efficacy.

Affective disorders among patients with borderline personality disorder

BACKGROUND

The high co-occurrence between borderline personality disorder and affective disorders has led many to believe that borderline personality disorder should be considered as part of an affective spectrum. The aim of the present study was to examine whether the prevalence of affective disorders are higher for patients with borderline personality disorder than for patients with other personality disorders.

METHODS

In a national cross-sectional study of patients receiving mental health treatment in Norway (N = 36 773), we determined whether psychiatric outpatients with borderline personality disorder (N = 1 043) had a higher prevalence of affective disorder in general, and whether they had an increased prevalence of depression, bipolar disorder or dysthymia specifically. They were compared to patients with paranoid, schizoid, dissocial, histrionic, obsessive-compulsive, avoidant, dependent, or unspecified personality disorder, as well as an aggregated group of patients with personality disorders other than the borderline type (N = 2 636). Odds ratios were computed for the borderline personality disorder group comparing it to the mixed sample of other personality disorders. Diagnostic assessments were conducted in routine clinical practice.

RESULTS

More subjects with borderline personality disorder suffered from unipolar than bipolar disorders. Nevertheless, borderline personality disorder had a lower rate of depression and dysthymia than several other personality disorder groups, whereas the rate of bipolar disorder tended to be higher. Odds ratios showed 34% lower risk for unipolar depression, 70% lower risk for dysthymia and 66% higher risk for bipolar disorder in patients with borderline personality disorder compared to the aggregated group of other personality disorders.

CONCLUSIONS

The results suggest that borderline personality disorder has a stronger association with affective disorders in the bipolar spectrum than disorders in the unipolar spectrum. This association may reflect an etiological relationship or diagnostic overlapping criteria.

Neurocognitive deficits associated with shoplifting in young adults

OBJECTIVES

Shoplifting is a relatively common behavior in young adults, but the demographic and neuropsychological correlates of shoplifting remain poorly characterized in this context.

METHOD

Non-treatment-seeking young adults (18-29 years) were recruited from the general community on the basis of having no Axis I disorders, no history of illicit substance use, and no history of conduct disorder or antisocial personality disorder. Participants were grouped according to presence or absence of shoplifting (at least 1 time over the past 12 months). Measures relating to impulsivity along with objective computerized neuropsychological measures were collected.

RESULTS

Shoplifters (n = 14) and controls (n = 95) did not differ significantly in terms of salient demographic characteristics. Compared with controls, shoplifters endorsed higher impulsivity on the Barratt Impulsiveness Scale and Eysenck Impulsivity Questionnaire, gambled significantly more points on the Cambridge Gambling Task, and showed deficits on the hardest level of difficulty on the Spatial Working Memory task. Performance on executive planning, set-shifting, and response inhibition did not differ significantly between shoplifters and controls.

CONCLUSIONS

This study identified significant cognitive deficits in those with past-year shoplifting behavior even in the absence of Axis I disorders and a history of illicit drugs or alcohol. These preliminary findings inform our understanding of the neurocognitive sequelae of shoplifting and its relationship with other impulse control problems, subclinical and clinical. Future work should use longitudinal designs to examine the temporal relationship between these deficits, shoplifting behavior, other impulsive behavior, and functional impairment.

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

OBJECTIVE

To present nationally representative findings on the prevalence, correlates, and comorbidity of and disability associated with DSM-IV schizotypal personality disorder (SPD).

METHOD

This study used the 2004-2005 Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions, which targeted a nationally representative sample of the adult civilian population of the United States aged 18 years and older and residing in households and group quarters. In Wave 2, attempts were made to conduct face-to-face reinterviews with all respondents to the Wave 1 interview.

RESULTS

Lifetime prevalence of SPD was 3.9%, with significantly greater rates among men (4.2%) than women (3.7%) (p < .01). Odds for SPD were significantly greater among black women, individuals with lower incomes, and those who were separated, divorced, or widowed; odds were significantly lower among Asian men (all p < .01). Schizotypal personality disorder was associated with substantial mental disability in both sexes. Co-occurrence rates of Axis I and other Axis II disorders among respondents with SPD were much higher than rates of co-occurrence of SPD among respondents with other disorders. After adjustment for sociodemographic characteristics and additional comorbidity, associations remained significant in both sexes between SPD and 12-month and lifetime bipolar I disorder, social and specific phobias, and posttraumatic stress disorder, as well as 12-month bipolar II disorder, lifetime generalized anxiety disorder, and borderline and narcissistic personality disorders (all p < .01).

CONCLUSIONS

Common and unique factors may underlie associations of SPD with narcissistic and borderline personality disorders, whereas much of the comorbidity between SPD and most mood and anxiety disorders appears to reflect factors common to these disorders. Some of the associations with SPD were sex specific. Schizotypal personality disorder and dependent, avoidant, and borderline personality disorders were associated with the occurrence of schizophrenia or psychotic episode. Schizotypal personality disorder is a prevalent, fairly stable, highly disabling disorder in the general population. Sex differences in associations of SPD with other specific Axis I and II disorders can inform more focused, hypothesis-driven investigations of factors underlying the comorbid relationships. Schizotypal as well as borderline, dependent, and avoidant personality disorders may be components of the schizophrenia spectrum.

Frequency of borderline personality disorder among psychiatric outpatients in Shanghai

The objective of this study was to investigate the frequency, clinical characteristics, and comorbidity of borderline personality disorder (BPD) among psychiatric outpatients in two clinics at Shanghai Mental Health Center. A cross-sectional investigation was conducted. From 3,075 outpatients screened using the Personality Diagnostic Questionnaire-IV+, 2,284 patients positive for a personality disorder were assessed using the Structured Clinical Interview for DSM-IV Personality Disorders. The frequency of BPD among the psychiatric outpatients was 5.8%, with a frequency of 3.5% among males and 7.5% among females (p < .01). BPD was found to have extensive comorbidity with Axis I and II disorders. This study proves that BPD does occur in China. The detected frequency among outpatients is lower than that reported in North America.

Comorbidity of borderline personality disorder with other personality disorders in psychiatric outpatients: how does it look at 2-year follow-up?

BACKGROUND

The rates of remission of comorbid personality disorders for patients with a primary borderline personality disorder (BPD) have previously only been addressed in samples of inpatients or former inpatients with BPD receiving treatment-as-usual.

AIMS

The aim of the current study was to assess the rates of remission of comorbid axis II personality disorders in a sample of 32 outpatients with a primary BPD receiving open-ended non-manualized psychotherapy.

METHODS

Structured psychiatric interviews for DSM-IV were conducted by independent assessors at intake, discharge and 2-year follow-up. Independent t-test, chi-square and McNemar analyses based on intent-to-treat were used.

RESULTS

The overall rate of comorbid axis II disorders was significantly reduced from intake to 2-year follow-up. Patients with non-remitted BPD had significantly more PD diagnoses and symptomatic distress on all outcome measures at follow-up.

CONCLUSION

Comorbid personality disorders among outpatients with BPD can be expected to remit with time and with remission of BPD. In the current sample of outpatients, comorbid paranoid, avoidant and obsessive-compulsive personality disorders at 2-year follow-up were associated with non-remitted BPD. The clinical implication of the results is that especially comorbid avoidant and obsessive-compulsive personality disorders may require specific attention in treatment of patients with BPD.

Personality disorders in young adult survivors of pediatric burn injury

OBJECTIVE

Life experience shapes personality and chronic trauma in childhood has been associated with risk for development of subsequent personality disorder. The purpose of this study is to determine the prevalence and character of personality disorders and traits in young adult survivors of severe pediatric burn injury. METHOD.: SCID-II and 16PF were completed by 98 young adult survivors of pediatric burn trauma.

RESULTS

48 (49%) met criteria for one or more personality disorders. The most frequent personality disorders were Paranoid (19.4%), Passive Aggressive (18.4%), Antisocial (17.3%), Depressive (11.2%), and Borderline (9.2%). Diagnosis with a personality disorder was associated with comorbid Axis I diagnoses and strongly correlated with personality traits as measured by the 16PF.

CONCLUSIONS

Pediatric burn trauma is similar to other chronic traumas of childhood in significant correlation with subsequent personality disorder.

Comorbid personality traits in schizophrenia: prevalence and clinical characteristics

Accumulating evidence suggests high rates of personality disorder (PD) in schizophrenia (Sz), and as such, the implications of PD in this context are beginning to be studied more thoroughly. We examined clinical, cognitive and experiential (i.e., reported childhood adversity) correlates of aberrant personality traits in schizophrenia and healthy controls (HC) as measured by the International Personality Disorder Examination Questionnaire (IPDEQ). Participants were 549 individuals with schizophrenia or schizoaffective disorder, and 572 healthy adults recruited to the Australian Schizophrenia Research Bank (ASRB). Schizophrenia participants were significantly more likely than healthy controls to screen positive for personality disorder across all ICD-10 subtypes, and there was substantial overlap between clusters, with ∼33% of Sz participants screening positive for all 3 personality disorder clusters. Among both Sz and HC groups, cluster B personality characteristics were significantly associated with increased suicidal behaviours, lower cognitive performance, and the experience of childhood adversity. In addition, Cluster C personality features were associated with higher overall ratings of affective blunting in schizophrenia, and Cluster A personality features were associated with childhood 'loss' in HC participants only. The cumulative effects of screening positive for more than one personality disorder in Sz was associated with higher likelihood of suicidal behaviour, earlier age of onset of Sz, and poorer cognitive functioning. The results suggest that abnormal co-occurrence of personality traits across DSM-IV clusters is evident in a significant proportion of individuals with schizophrenia, and that these personality features impact significantly on clinical and cognitive characteristics of Sz.

The relationship between illegal behaviors and borderline personality symptoms among internal medicine outpatients

BACKGROUND

In psychiatric dysfunction, illegal behaviors are frequently associated with the traditional prison personality antisocial personality disorder. However, some empirical data indicate that illegal behaviors may also be associated with borderline personality, which is the focus of the present study.

METHOD

Using a cross-sectional sample of consecutive internal medicine outpatients from a resident-provider clinic, we examined relationships between 27 illegal behaviors as delineated by the Federal Bureau of Investigation's crime-cataloguing schema and 2 measures of borderline personality disorder (BPD), the BPD scale of the Personality Diagnostic Questionnaire-4 and the Self-Harm Inventory.

RESULTS

The overall correlations between BPD and the number of the 27 illegal behaviors endorsed were r = 0.32 (P < .001, n = 375) for the Personality Diagnostic Questionnaire-4 and r = 0.47 (P < .001, n = 372) for the Self-Harm Inventory. Six specific illegal behaviors were endorsed by at least 12 participants each, and analyses indicated associations for each of these illegal behaviors with BPD (ie, aggravated and simple assault, disorderly conduct, driving under the influence, drug abuse violations, public drunkenness/intoxication). These 6 behaviors may be interrelated through alcohol/substance use. Participants who were male and younger were more likely to report having engaged in a greater number of different illegal behaviors.

CONCLUSIONS

There appear to be associations between illegal behaviors and BPD, particularly in relation to alcohol/substance abuse and in young men.

Self- and informant-reported perspectives on symptoms of narcissistic personality disorder

Because narcissistic individuals tend to have an inflated view of themselves and their abilities, the reliance on self-reported information in the assessment and diagnosis of narcissistic personality disorder (NPD) is problematic. Hence, the use of informants in the assessment of NPD may be necessary. In the current study we examined self- and informant-reported features of NPD using agreement, frequency, and discrepancy analyses. The results indicated that informants tended to report more NPD features than selves, and that there were either low or nonsignificant levels of self-informant agreement among the 9 NPD diagnostic criteria and its categorical diagnosis. Informants were increasingly more likely to report higher raw scores relative to selves, indicating that the discrepancy between self- and informant reports increases with the NPD scale. Informants also reported NPD features that selves often did not, suggesting that current prevalence estimates of NPD, which use only self-reported information, are most likely underestimates. These results highlight the importance of gathering informant-reported data in addition to self-reported data when assessing NPD. (PsycINFO Database Record (c) 2013 APA, all rights reserved).

Confirmatory Factor Analysis of Borderline Personality Disorder symptoms based on two different interviews: the Structured Clinical Interview for DSM-IV Axis II Disorder and the Revised Diagnostic Interview for Borderlines

The diagnostic criteria for Borderline Personality Disorder (BPD) are heterogeneous, and include an admixture of personality traits, behaviours, and symptoms. The BPD DSM factor structure has been extensively studied, even though results are not consistent. In this study we performed a confirmatory factor analysis (CFA) to compare the five-factor model reported by Oldham, a three-factor model, and a unidimensional model of BPD diagnosis criteria. This study validates the findings of previous studies by performing a CFA with the DSM-IV BPD criteria and information derived from the DIB-R. A sample of 338 patients referred to our outpatient BPD program participated in the study. Results of the CFA support both the hypothesized unidimensional and the three-factor models, whereas the five-factor model was not confirmed. However, the three-factor model fits better than the unidimensional model. Thus, although the DSM-IV BPD criteria conceptualize BPD as a unidimensional structure, our results give support to the idea that the three-factor model could offer a better approach to further improve the current treatment of BPD, as well as lead to a better understanding of its ethiopathogenesis and comorbidity analysis.

Distinguishing general and specific personality disorder features and implications for substance dependence comorbidity

Clinical and population-based samples show high comorbidity between Substance Use Disorders (SUDs) and Axis II Personality Disorders (PDs). However, Axis II disorders are frequently comorbid with each other, and existing research has generally failed to distinguish the extent to which SUD/PD comorbidity is general or specific with respect to both specific types of PDs and specific types of SUDs. We sought to determine whether ostensibly specific comorbid substance dependence-Axis II diagnoses (e.g., alcohol use dependence and borderline personality disorder) are reflective of more pervasive or general personality pathology or whether the comorbidity is specific to individual PDs. Face-to-face interview data from Wave 1 and Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions were analyzed. Participants included 34,653 adults living in households in the United States. We used hierarchical factor models to statistically partition general and specific personality disorder dimensions while simultaneously testing for specific PD-substance dependence relations. Results indicated that substance dependence-Axis II comorbidity is characterized by general (pervasive) pathology and by Cluster B PD pathology over and above the relationship to the general PD factor. Further, these relations between PD factors and substance dependence diagnoses appeared to largely account for the comorbidity among substance dependence diagnoses in the younger but not older participants. Our findings suggest that a failure to consider the general PD factor, which we interpret as reflecting interpersonal dysfunction, can lead to potential mischaracterizations of the nature of certain PD and SUD comorbidities.

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.

Association between a serotonin transporter promoter polymorphism (5HTTLPR) and personality disorder traits in a community sample

BACKGROUND

The serotonin transporter (SERT) polymorphism (5HTTLPR) has been reported to be associated with several psychiatric conditions. Specific personality disorders could be intermediate factors in the known relationship between 5HTTLPR and psychiatric disorders. This is the first study to test the association between this polymorphism and dimensions of all DSM-IV personality disorders in a community sample.

METHODS

374 white participants were assessed by clinical psychologists using the International Personality Disorder Examination (IPDE). Associations between dimensions of each DSM-IV personality disorder and the long (l) and short (s) alleles of the 5HTTLPR were evaluated using non-parametric tests and regression models.

RESULTS

The s allele of the 5HTTLPR polymorphism was significantly associated with higher avoidant personality trait scores in the whole sample. Males with the s allele had a significantly lower likelihood of higher obsessive-compulsive personality disorder (OCPD) trait scores, whereas females with the s allele were likely to have higher OCPD personality trait scores.

CONCLUSION

This paper provides preliminary data on the relationship between personality disorders and the 5HTTLPR polymorphism. The relationship of the s allele and avoidant PD is consistent with findings of a nonspecific relationship of this polymorphism to anxiety and depressive disorders. Concerning the unusual sexual dimorphic result with OCPD, several hypotheses are presented. These findings need further replication, including a more detailed study of additional variants in SERT.