Co-occurrence of personality disorders with mood, anxiety, and substance use disorders in a young adult population

The purpose of this study was to determine the co-occurrence of DSM- III-R personality disorders (PDs) with mood, anxiety, and substance use disorders in a young adult population. The members of the Northern Finland 1966 Birth Cohort Project, living in the city of Oulu with an age of 31 years (N = 1,609) were invited to participate in a two-phase field study. The SCID I and II were used as diagnostic instruments. One hundred and seventy-seven out of 321 interviewed subjects met the criteria for mood, anxiety, or substance use disorders. Altogether 72 (41%) of the subjects with an Axis I disorder met the criteria for at least one PD. The weighted co-occurrence rate of any PD varied from 28% for mood disorders to 47% for anxiety disorders. PDs, especially those in Cluster C, are highly associated with Axis I psychiatric disorders in population.

Identifying adult children of alcoholics: methodological review and a comparison of the CAST-6 with other methods

Methods of identifying adult children of alcoholics are described and their psychometric properties are reviewed. These methods include self-report single questions and questionnaires and interview schedules. The CAST-6, a shortened version of the Children of Alcoholics Screening Test, is compared with a variety of these methods. The CAST-6 is confirmed as a useful brief screening measure. It was shown to be internally reliable, have good retest reliability and to agree well with other measures. Using a face to face interview as the comparison standard, however, a number of single questions performed equally as well as the CAST-6 and other more complex methods.

Characteristics of DSM-III borderline MMPI profiles

Examined the distinction between the MMPI mean profile (8-4-2) obtained for a sample of 27 psychiatric inpatients diagnosed as borderline on the basis of DSM-III criteria, and the actual frequency distribution of scale elevations and code-types within the sample. Results of this study support the findings of previous investigations of a peak on scale 8, but suggest that the heterogeneity of this population will probably preclude the specification of any two- or three-point code type which would be obtained by even a sizable minority of a given sample.

Special feature: psychobiologic perspectives on treatment of personality disorders

The neurobiology of personality dimensions provides a theoretical framework for the design of pharmacologic treatment and studies in the PD patient. Neurotransmitter mediation of specific dimensions, such as novelty seeking, impulsivity, or schizotypy, suggests the usefulness of highly selective medications as clinical treatment and, simultaneously, as confirmatory dimensions. For example, the efficacy of SSRI antidepressants against impulsivity suggests both a clinical treatment and confirmation of the role diminished serotonergic function in impulse dysregulation. Similarly, the efficacy of neuroleptics against schizotypal symptoms supports the hypothesized role in the personality disorders lies in a better understanding of neurotransmitter and receptor function, using sophisticated PET neuroimaging techniques and receptor-specific radioligands to define the biologic basis of specific dimensions. As the focus of study gets smaller, we will no longer treat whole personalities, or even dimensions as we currently view them, but receptor-related functions. The challenge for the pharmacotherapist is to discriminate interpersonal from biologic pathologies, i.e., not to "biologize" all behavior.

Test-retest reliability of the clinical, factor, and localization scales of the Luria-Nebraska Neuropsychological Battery

Comparisons were made between initial test scores of the Luria-Nebraska Neuropsychological Battery, the Factor scales and the Localization scales, and a second set of scores derived from a readministration of the battery. Thirty random, unscreened, psychiatric inpatients with a wide variety of diagnoses served as subjects. Patient condition was not controlled, and no subjects were dropped from the data pool. Sixteen males and 14 females with a mean age of 31.8 years (SD = 12.7), mean education of 9.3 years (SD = 3.2), and a test-retest interval mean of 8.1 months (SD = 6.0) participated. All patients had significant emotional difficulties which resulted in repeated hospitalization, and all were cooperative with test procedures. Test-retest scores for the 14 Luria scales ranged from .83 to .96, averaging .89 and for the eight Localization scales, and the reliability ranged from a low of .78 to a high of .95, with a mean of .89. The factor scales test-retest reliability coefficients ranged from .01 to .96, with a .75 average for the 30 scales. All the correlations, except two on the Factor Scales, were significant at p less than .001. These results support the findings of an earlier study which focused on the 14 Luria scaled scores only. The data suggest that the Luria Battery is reliable over time.

Symptoms of depression in late luteal phase dysphoric disorder: a variant of mood disorder?

BACKGROUND

In premenstrual syndrome, depressed mood in the luteal phase of the menstrual cycle is acknowledged, whereas the presence of symptoms of depression during the follicular phase remains in debate.

METHODS

On the basis of prospective daily recording of the presence and severity of symptoms for at least two menstrual cycles, 43 women were diagnosed with Late Luteal Phase Dysphoric Disorder (LLPD) according to the criteria of the third edition revision of the Diagnostic and Statistical Manual of Mental Disorders. They were compared to a group of 85 women who showed no evidence of LLPD for two menstrual cycles. Structured psychiatric interviews were administered during the follicular phase. Only those subjects without Axis I disorders were subsequently included in the study.

RESULTS

Those women with minor/moderate symptoms of depression had an odds of suffering from LLPD of 1.9 (95% CI=1.5-2.4, p<0.001) in relation to increasing severity of symptoms of depression at the total MADRS scale (1-point increase). The ORs of LLPD in relation to each dimension (1-point increase) of the emotional/affective, cognitive, and neurovegetative symptoms were 1.6 (95% CI=1.2-2.3, p=0.003), 2.8 (95% CI=0.9-8.5, p=0.077) and 3.3 (95% CI=1.9-5.9, p<0.001), respectively.

LIMITATIONS

No hormonal changes that may be associated with symptoms of LLPD were determined in this study.

CONCLUSIONS

LLPD is likely to represent a variant of a depressive disorder, where premenstrual psychobiological changes seem to exacerbate mild depressive symptoms and signs to which LLPD women are otherwise predisposed. This hypothesis opens new perspectives for prevention and of even treatment for LLPD. Further longitudinal studies with larger populations and evaluation of hormonal changes are needed to confirm these data.

Is the appendix a useful appendage? An empirical examination of depressive, passive-aggressive (negativistic), sadistic, and self-defeating personality disorders

Decisions about whether to include depressive, passive-aggressive, sadistic, and self-defeating disorders in Axis II have been made difficult by a relative dearth of data. We report the results of a study identifying potential defining features of these diagnoses and assessing their distinctiveness from other Axis II personality disorders (PDs). A national sample of experienced psychiatrists and psychologists used the SWAP-200 to describe a patient with a current axis II disorder or an appendix or deleted PD from DSM-II-R. We examined clinicians' descriptions of patients to identify their most characteristic features, and then applied an empirical clustering procedure, Q-factor analysis, to see whether versions of these disorders would emerge empirically. As currently conceptualized, only passive-aggressive PD was distinct from other PDs. When the data were subjected to Q-factor analysis, the first and largest grouping was a dysphoric (depressive) PD. A hostile-negativistic subcategory emerged that resembled passive-aggressive PD, along with a revised dependent diagnosis that included many self-defeating/masochistic features. The results suggest that a depressive or dysphoric personality may represent an internalizing spectrum of personality pathology, and that a hostile-negativistic PD may be distinct from the disorders in the text of DSM-IV. Sadistic and self-defeating PD do not appear to represent distinct disorders, although they include personality traits (sadism and revictimization) associated with distinct developmental histories.

Prevalence of DSM-III-R self-defeating (masochistic) personality disorder in normal and outpatient populations

The prevalence of DSM-III-R self defeating (masochistic) personality disorder was determined on an outpatient population (N = 82) and a normal population (N = 40) using the Personality Diagnostic Questionnaire (PDQ). Fifteen (18.3%) of the outpatients and two (5%) of normals were assessed as having the disorder. Overlap of greater than 50% with borderline, avoidant, and dependent personality disorders was found. Validation of masochistic personality disorder will require it to be of value in research and clinically in ways distinct from the other personality disorders with which it is associated.

Foulds' "Continuum of Personal Illness" and the 16 P.F

Foulds (1965) proposed that the classes of psychiatric illness can be described in terms of a continuum of increasing degrees of failure to maintain or establish mutual personal relationships. This concept of all psychiatric illness as an “illness of the person” centres on processes which occur in the mentally ill that interfere with the satisfactory establishment and relative endurance of adequate personal relationships. Foulds conceptualizes these interfering processes as barriers to achieving “personhood”: they may present as signs or symptoms of psychiatric illness or as abnormal degrees of personality traits. Thus, for example, cognitive disorder would make the schizophrenic unable to cope with the demands of interpersonal situations. Similarly, egocentricity would render the psychopath incapable of empathy and with a tendency to treat “others as objects or as organisms than as persons”. In both examples social alienation is inferred, manifested in the first case as withdrawal and in the second case as rejection. It is Foulds' thesis that this incapacity for mutual relations increases along a continuum from normality, through the personality disorders, neurosis, integrated psychosis (melancholics, manics and paranoids) to non-integrated psychosis (the schizophrenics).

Development and validation of a computerized screening test for personality disorders in DSM-III-R

The available self-report instruments designed to measure personality disorder (PD) are time-consuming to administer and/or score and can be impractical for routine clinical use. There is a need for a computerized method of personality assessment based on contemporary systems of classification. A computerized DSM-III-R-based questionnaire was developed and validated against the structured clinical interview for DSM-III-R Axis-II disorders on a sample of 60 subjects. The computerized test showed moderate validity as a diagnostic instrument (mean kappa coefficient = 0.47). With adjusted cut-off scores it was valid as a screening instrument (mean sensitivity = 0.87). Antisocial, borderline and avoidant PD scores were strongly correlated across measures and not subject to significant observer bias.

Impact of DSM-III on clinical practice

The authors compared criterion-based diagnoses (DSM-III) with clinical diagnoses (DSM-II) for 102 psychiatric inpatients. The introduction of specified diagnostic criteria represented a refinement of existing diagnostic practices rather than a qualitatively different approach to diagnoses; however, in the schizophrenia and affective disorder categories, nonwhites and women were more often assigned to worse prognostic category by the DSM-II system than were white men with similar symptoms. The authors suggest that the introduction of DSM-III criteria may ensure more appropriate diagnosis and treatment for nonwhites and women.

Patient and clinician agreement on personality using the SWAP-200

The Shedler Westen Assessment Procedure (SWAP-200; Westen & Shedler, 1999a) is a clinician-rated assessment providing descriptions of personality disorder prototypes using a Q-sort procedure. This study aims to investigate the degree to which there is agreement between patients' and clinicians' accounts of personality pathology on a modified version of the SWAP-200 using Bland Altman analysis with the data from 23 clinician-patient pairs. Poor agreement was found between clinicians and patients on personality prototypes. Even the best agreement found between patients and clinicians on the avoidant prototype was poor--the patients' ratings were up to 43.5 per cent below and 32.9 per cent above the clinicians' ratings. This is an unacceptable degree of variation. The difference between the clinician and patient ratings are large when expressed as a percentage of the possible scores (as obtained on the clinician rating scale). The patient ratings vary between being 40.8 to 91.1% below the clinician ratings, and 32.9 to 99.7% above the clinician ratings.

Depression and smoking: examining correlates in a subset of depressed patients

OBJECTIVE

The objective of this study was to examine for associations between depression and cigarette smoking.

METHOD

A sample of 92 depressed smokers was compared with a control sample of depressed non-smokers, matched for age, gender and diagnostic variables. Comparisons were made across a range of demographic, depression, family history, developmental factors, anxiety and personality style variables, as well as use of alcohol and illicit drugs.

RESULTS

We failed to find any difference between smokers and non-smokers in history or severity of depression. Cigarette smokers were distinguished principally by greater exposure to aversive experiences in childhood, disordered personality function, greater use of illicit drugs, anxiolytics and alcohol. Logistic regression identified dysfunctional personality 'domains', physical violence in childhood, long-term anxiolytic use and illicit drug use as the most significant predictor set.

CONCLUSIONS

Results favour a model of cigarette smoking and depression as linked by shared early deprivational variables, rather than cigarette smoking causing depression or the converse.

The MMPI and clinical diagnosis: a comparison of classification system outcomes with discharge diagnoses

This study examined the agreement or congruence rate between clinical-discharge diagnoses rendered by a psychiatrist, and admission and discharge MMPI-derived diagnoses from four diagnostic classification systems that have been developed for the MMPI. The four classification systems included a simple high-point code based on the most elevated clinical scale in the profile, the Henrichs revision of the Meehl-Dahlstrom rules, the Goldberg equations, and a system developed by Lachar. Subjects consisted of 150 patients selected from a larger pool of patients who had completed a 9-week adult residential treatment program. Overall, this study yielded modest hit rates between 26% and 34% for MMPI-derived diagnoses and psychiatric diagnoses across the various classification systems. In addition, stability of MMPI-based diagnoses from admission to discharge assessments ranged from 48% to 51% depending on the classification system employed. Findings are discussed in terms of their implications for the use of the MMPI in patient diagnosis. It is recommended that the MMPI be used in conjunction with other sources of clinical and test information in deriving clinical diagnoses.

Relationships between the personality beliefs questionnaire and self-rated personality disorders

OBJECTIVES

To examine relationships between specific dysfunctional beliefs and self-reported personality disorder types.

DESIGN

Cross-sectional.

METHOD

One hundred and sixty-four clinical psychology out-patients completed the Personality Beliefs Questionnaire (PBQ) and Millon Multiaxial Clinical Inventory-III (MCMI-III): 155 completed both. Avoidant, dependent, passive-aggressive and schizoid PDs, and relevant PBQ subscales were studied.

RESULTS

Presence or absence of PD was predicted by scores on the index PBQ subscale.

CONCLUSIONS

This pattern has previously been reported for PDs diagnosed by structured interview only. PBQ relationships with passive-aggressive and schizoid PD have not previously been reported.

Symptoms of specific and generalized social phobia: an examination of discriminant validity and structural relations with mood and anxiety symptoms

Current models divide social phobia into specific (SSP) and generalized (GSP) subtypes and suggest strong overlap between GSP and avoidant personality disorder (APD). Meanwhile, other research suggests reclassifying anxiety and mood disorders as fear and distress disorders. To unify these separate lines of research, this study was designed to test the hypothesis that SSP is more related to fear disorders (e.g., panic and phobias), whereas GSP and APD are more related to distress disorders (e.g., depression and generalized anxiety). Confirmatory factor analysis suggested the best-fitting model had symptoms of GSP, APD, and depression loading on one factor, and symptoms of SSP, panic, and specific phobias loading on a second factor. Key components of this model were (a) the inclusion of GAD symptoms reduced model fit and (b) GSP and APD symptoms significantly predicted SSP symptoms; this is consistent with conceptualizations of individuals with both GSP and SSP reporting performance anxiety.

Some standardization data for the Sandler-Hazari Obsessionality Inventory

Although it has been used in a number of small-scale pieces of research in recent years, there exist as yet no adequate standardization data for the Sandler-Hazari Obsessionality Inventory, a device designed to yield scores for both obsessional traits and obsessional symptoms. The present article describes research aimed at contributing towards a partial standardization of the Inventory using 736 subjects spread over six different samples. Results suggest that obsessional traits and symptoms are present in the non-clinical as well as in the clinical population, though the Inventory appears able to discriminate reliably between the two. Results also suggest that there may be a low-level correlation between traits and symptoms in both clinical and non-clinical populations, and that the presence of unscored buffer items in the Inventory may reduce the risk of clinical and non-clinical subjects faking good in their responses to it.

Sexual sadism

Definitions of sexual sadism in ICD-10 and DSM-IV will be presented as well as the historical routes of the concept. Today studies on differently selected clinical samples reveal a different distribution of sexual sadism versus masochism with masochism prevailing in general especially outpatient psychiatric facilities, and sadism prevailing in forensic settings, thus corroborating the concept of two separated diagnoses sadism versus masochism. In forensic settings the diagnosis of a sadistic character disorder (sadistic personality disorder [SPD] according DSM-III-R) is found to a much higher degree than in other clinical samples (50-fold). Our own follow-up study on a forensic sample implies that sadism as a paraphilia is of relevance for relapse-rates of sex-offenders. Symptoms of SPD can be combined with sexual sadism, or occur independently. This may corroborate arguments in favor of a dimensional concept of sexual sadism. Symptoms of SPD may then be a sign of generalization of sadistic traits at least in some cases. A concept of two factors contributing to sadistic pleasure is suggested, one taking the aspect of bodily gratification by sexual-aggressive stimuli as decisive, and the other taking inner representation of hostile objects into consideration (stressing the antisocial-anger-rage aspect).

The familial relation of personality disorders (DSM-II-R) to unipolar major depression

Four hundred and fifty directly interviewed relatives of probands with non-psychotic unipolar major depression and 320 directly interviewed relatives of controls were compared by the prevalences of personality disorders (P.D.) as defined by DSM-III-R, in relation to presence or absence of the relatives' affective disorder. Overall, there was only a trend for an increased risk for P.D. in relatives of depressed patients. However, P.D. and unipolar major depression co-occurred more frequently in relatives than expected by chance. It is suggested that this association is mainly due to non-familial factors. Compared with other P.D., the relationship of borderline P.D. to major depression was not substantially stronger.

DSM-II personality characteristics of panic disorder with agoraphobia patients in stable remission

The Personality Diagnostic Questionnaire (PDQ), a self-rating scale designed to assess DSM-III axis II personality disorders (PD), was administered to 12 panic disorder with agoraphobia patients during a 6-month stable and virtually symptom-free remission period with the aim of assessing the personality characteristics of these patients in the best possible approximation of the not-ill condition in clinical reality. The personality profile of the sample remained unchanged during remission and was predominated by avoidant PD traits. In a finer grain analysis, the stable and commonly endorsed individual PDQ items were compared with previously reported panic disorder and normal control subjects, which showed that the present sample was more like the panic patients in their tendency to see themselves as rather unassertive, indecisive, self-critical, and emotional individuals who are easily frustrated and feel rejected when criticized by others. These results suggest that avoidant behavioral and attitudinal patterns may be enduring personality characteristics of panic disorder with agoraphobia patients.

Possible link between childhood separation anxiety and adulthood personality disorder in patients with anxiety disorders in Japan

OBJECTIVE

The aim of this study was to examine whether childhood separation anxiety symptoms associate with adulthood anxiety disorders or personality disorders.

METHOD

Separation Anxiety Symptom Inventory (SASI), Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II), and Global Assessment of Functioning (GAF) were administered to 134 outpatients with anxiety disorders and SASI was administered to 176 healthy volunteers (controls) recruited in Japan from April 1999 through November 2003.

RESULTS

SASI scores were not correlated with age or sex in controls. In contrast, SASI scores were higher in patients with anxiety disorders than in controls, especially in women. SASI showed good test-retest reliability (Pearson correlation coefficient = 0.8). One hundred thirteen patients (84.3%) had no comorbid anxiety disorder while 21 (15.7%) had any, and those with comorbid anxiety disorder tended to show higher SASI scores (p = .053). In total, 60 (44.8%) of 134 patients had at least 1 personality disorder, and the most frequent disorders were from cluster C (36.6%). The subgroup with comorbid personality disorders showed earlier onset (p < .01), higher SASI scores (p < .01), and poorer recovery of global functioning (p < .05) than the noncomorbid subgroup. Stepwise multiple regression analysis revealed that SASI scores were higher in female (p < .05) and younger (p < .01) patients and most strongly correlated with number of comorbid personality disorders in adulthood (p < .01).

CONCLUSION

These results suggest that there is a continuum of anxiety disorders from childhood to adulthood, the severity of separation anxiety appears to increase the risk of severe anxious-fearful personality disorders in adulthood, and those with severe separation anxiety, particularly females, may progress to suffer from comorbid adult anxiety disorders.

An attempt to validate the psychoticism scale of the Brief Symptom Inventory

This study attempted to validate the psychoticism scale of the Brief Symptom Inventory (BSI) by comparing 31 schizophrenic patients with 98 non-schizophrenic patients. Unexpectedly, the schizophrenics did not exceed the non-schizophrenics on the psychoticism symptom dimension. None of a variety of controls and comparisons provided a basis for dismissing the finding. A rationale was introduced explaining why any attempt to match symptoms with the diagnosis of schizophrenia can at best meet with only qualified success.

Covariance in the measurement of depression/anxiety and three Cluster C personality disorders (avoidant, dependent, obsessive-compulsive)

One hundred and eight-four clients referred to a research outpatient psychological clinic, and meeting the acceptance criterion of 16 or more on the BDI at screening, were diagnosed as either-depressed and/or anxious using both Present State Examination and the Diagnostic and Statistical Manual of Mental State Disorders criteria. Clients were assessed for the presence of Cluster C personality disorders using the Personality Disorder Examination of Loranger et al. (1985). Twenty-two per cent made diagnosis of avoidant, dependent or obsessive-compulsive personality disorder. Significant correlation was found between screening/intake depression index scores and total scores on the three Cluster C personality disorders, although little correlation was found between diagnostic criteria for affective and personality disorders. Some association was shown between the clinical components of personality disorder traits in the anxious-fearful group and current anxiety symptoms, although not as clearly as expected.

Discriminant validity of the MMPI for borderline personality disorder

This study explores the discriminant validity of the MMPI in relationship to the DSM-III and the Diagnostic Interview for Borderlines (DIB) constructs of Borderline Personality Disorder (BPD). A two-way analysis of variance model assessed differences between inpatients (n = 42) and outpatients (n = 42) and between BPD and nonBPD patients. We compare the best discriminant model for the current samples with previous BPD discriminant functions. The present study assesses a wider range of psychopathology in which the MMPI appears to be relatively insensitive to the BPD construct while retaining the high specificity reported in previous studies. Implications for the use of the MMPI as a diagnostic instrument are discussed.