Complexities in complex posttraumatic stress disorder in inpatient women: evidence from cluster analysis of MCMI-III Personality Disorder Scales

Herman's (1992a) clinical formulation of complex posttraumatic stress disorder (PTSD) captures the extensive diagnostic comorbidity seen in patients with a history of repeated interpersonal trauma and severe psychiatric disorders. Yet the sheer breadth of symptoms and personality disturbance encompassed by complex PTSD limits its descriptive usefulness. This study employed cluster analysis of the MCMI-III (Millon, 1994) personality disorder scales to determine whether there is meaningful heterogeneity within a group of 227 severely traumatized women who were treated in a specialized inpatient program. The analysis distinguishes 5 clinically meaningful clusters, which we label alienated, withdrawn, aggressive, suffering, and adaptive. The study examined differences among these 5 personality disorder clusters on the MCMI-III clinical syndrome scales, as well as on the Brief Symptom Inventory (Derogatis, 1993), Dissociative Experiences Scale (E. M. Bernstein & Putnam, 1986), Adult Attachment Scale (Collins & Read, 1990), and Childhood Trauma Questionnaire (D.P. Bernstein, 1995). We present a classification-tree method for determining the cluster membership of new cases and discuss the implications of the findings for diagnostic assessment, treatment, and research.

Disorder concept scales and personality dimensions in a young adult sample

Previous research has shown correlations between normal personality variables of the Sixteen Personality Factor Questionnaire (16PF) and Axis II personality disorder scales using the Morey, Waugh, and Blashfield Minnesota Multiphasic Personality Inventory (MMPI) and Millon Clinical Multiaxial Inventory. This study (N = 37) compared variables from the adolescent version of the 16PF, the High School Personality Questionnaire, Revised, including the new Clinical Supplement and the MMPI scales of Morey, et al. and yielded results similar to those from earlier studies with other inventories. Extraversion scores correlated positively with those on Narcissistic and Histrionic scales, negatively with scores on Schizoid, Avoidant, and Schizotypal scales; scores on Independence had a similar pattern.

MMPI-2 with Mexican psychiatric inpatients: basic and content scales

This paper presents the results of a study of the Mexican Spanish version of the MMPI-2 with a clinical sample of 233 patients who were diagnosed as having psychological disturbances or personality disorders, according to DSM-III R criteria. Inpatient scores were obtained from four psychiatric hospitals, located in Mexico City. The scores of the patients were compared with those of Mexican college students, which is the largest Mexican normative sample collected to date, consisting of 813 men and 1,137 women. Results of this study show that the MMPI-2 can accurately differentiate between normal and non-normal groups in Mexican populations and demonstrate that the inventory maintains its construct validity in this clinical sample.

Relational aggression and social-psychological adjustment in a college sample

Although the understanding of aggression has been significantly advanced through the study of relational aggression, past research has been limited by its predominant focus on children. This study examines the associations between relational aggression and social-psychological adjustment in a sample of young adults. A peer-nomination instrument was constructed to assess relational aggression, and self-reports of adjustment were obtained from 225 college students (45% male; mean age = 19.5). Regression analyses showed that relational aggression provided unique information, after controlling for age and gender, about peer rejection, prosocial behavior, antisocial personality features, and borderline personality features. Interactions with gender further showed that, for women, relational aggression was linked with bulimic symptoms. The importance of relational aggression for understanding adjustment problems during young adulthood are discussed.

[Treatment for non-cognitive symptoms in Alzheimer's disease]

OBJECTIVES

To review the classical treatment for non cognitive symptoms in Alzheimer's disease and to estimate the possible future contributions.

DEVELOPMENT

The non cognitive symptoms, with a high frequency in dementia, mean a larger clinical severity, an increment of institutionalization and a larger carer's emotional burden. Several treatment frequently used has been reviewed (antipsychotic, antidepressant, antianxiety, anticonvulsive...) and the response for some of this symptoms is relatively narrow and side effects are frequent and intense. New drugs, as cholinesterase inhibitors and cholinergic agonist, that have demonstrated their efficacy for the cognitive symptoms, seem to be also effective for non cognitive ones.

CONCLUSION

The relative low effectivity of classical treatment and the frequency and intensity of side effects open new possibilities to cholinesterase inhibitors in the treatment of non cognitive symptoms in Alzheimer's disease.

Stability and change in personality disorder features: the Longitudinal Study of Personality Disorders

BACKGROUND

There exists no empirical literature documenting the long-term longitudinal stability of personality pathology comparable to that available for normal personality. A number of test-retest studies have usefully established the short-term reliability of Axis II measures. However, the test-retest design is methodologically inadequate for resolving issues related to the long-term stability of personality disorder (PD). This prospective longitudinal study evaluated the stability of PD features in multiwave perspective.

METHODS

Subjects (N = 250) drawn from a nonclinical university population were examined for PD features at 3 different time points using the International Personality Disorders Examination (IPDE) and the Millon Clinical Multiaxial Inventory II (MCMI-II) during a study period of 4 years.

RESULTS

Features of PD displayed considerable evidence of stability for individual differences and group means, at the dimensional level of analysis, on both the IPDE and the MCMI-II. Both measures revealed modest declines in PD features over time; however, the observed changes were associated with relatively small effect sizes.

CONCLUSION

Features of PD, viewed from a dimensional perspective, seem to be relatively stable in terms of individual differences and group means based on both clinical interview and self-administered PD assessments.

[Prevalence of eating disorders in secondary level students: A preliminary study]

OBJECTIVES

To determine the prevalence of eating disorders in secondary level students, as well as to determine the relationship between eating behaviour and personality traits.

SUBJECTS AND METHOD

During the 1997-98 school year, 816 secondary level students from Langreo (Asturias) were evaluated.

EVALUATION

Eating Disorder Inventory (EDI) and Eysenck Personality Questionnaire Adult Form (EPQ-A).

RESULTS

The sample was made up of 415 males and 401 females [mean age (SD): 15.91 (1.37)]. Seventy-two <<possible cases>> of eating disorders were detected, 87.5% of which were females (p= 0.0000). The <<possible cases>> scored higher (p< 0.05) than their <<control>> counterparts on all EDI subscales, except perfectionism. The <<control>> females scored higher (p< 0.05) than the <<control>> males on the drive for thinness and dissatisfaction with one's body subscales, whereas the <<control>> males scored higher than the females on the perfectionism and maturity fears subscales. In both sexes, clinical features of neuroticism, introversion, and psychoticism were associated with higher scores (p< 0,05) on various EDI subscales.

CONCLUSIONS

Greater prevalence of <<possible>> eating disorders in females. The <<control>> subjects present a different eating behaviour profile based on sex. In both sexes, neuroticism, introversion, and psychoticism features favour a possible distortion of eating behaviour.

Psychiatric comorbidity in Greek patients with generalized anxiety disorder

From a total sample of 1,448 psychiatric outpatients, 81 (5.6%) received a diagnosis of generalized anxiety disorder (GAD) according to DSM-III-R criteria. Fifty-three (65%) of them had another Axis I diagnosis, while this percentage increased to 78% (63/81) when lifetime psychiatric diagnoses were recorded. The most frequent comorbid diagnoses were panic disorder, dysthymia, major depression and social phobia. Forty-three (53%) of the GAD patients met the criteria for personality disorder. They manifested obsessive-compulsive, avoidant personality and personalities of cluster C in general significantly more frequently than the rest of the total sample. The presence of a personality disorder was related to a significantly higher score on almost all the Minnesota Multiphasic Personality Inventory clinical and research scales, to a worse level of functioning and to an earlier age of onset of GAD. The results of the present study (1) support previous findings of high rates of comorbidity of clinical syndromes in GAD, (2) indicate that GAD co-occurs frequently with cluster C personality disorders, mainly avoidant and obsessive-compulsive, and (3) that the presence of a concomitant personality disorder is related to severer psychopathology and to a worse level of functioning.

[Addiction and personality traits: sensation seeking, anhedonia, impulsivity]

This study presents the evaluation of three dimensional traits of personality (Sensation Seeking, Anhedonia, Impulsivity) among 65 patients admitted in a psychiatric ward, with or without addictive behaviors. Our objective is to establish that these personality traits are commun to all addictive behaviors and to test the hypothesis that high scores on the three scales are linked to a greater probability of presenting with addictive behaviors. The two most frequent types of addiction were alcoholism and drug abuse. The subjects presenting with one or several addictive behaviors had higher average scores on the three scales. Our results printed in the same direction for the subjects having shown an addictive behavior in their past history. The risk to present with an addictive behavior increased with the total scores of these self-report questionnaires. There was a significant relationship between 3 sub-dimensions on the Sensation Seeking Scale and addictive behavior. Each time sub-scores of boredom susceptibility, disinhibition and thrill and adventure rise by one, the risk to present with an addictive behavior is multiplied by 1.4 for the first two and by 1.3 for the third one. Subjects with high scores on the anhedonia and impulsivity scales respectively show a risk multiplied by 1.6 and 3.3 of developing an addictive behavior. These results of this transverse study confirm the link between addiction behavior and these three personality traits.

The cognitive failures questionnaire in psychiatry

As a self-report questionnaire, the Cognitive Failures Questionnaire (CFQ) was originally devised to measure perception, memory, and motor lapses in daily life. CFQ scores have been found to correlate with some psychiatric symptoms associated with stress; hence, high scores on the CFQ are considered by some as an indicator of increased vulnerability to stress. Attempts to identify a stable factor structure for the CFQ have produced disparate results. However, there is a measure of agreement with regard to the presence of a "general cognitive" factor that includes loadings from most items and accounts for the lion's share of the variance. Not enough is known about the performance of the CFQ in clinical populations to use it as a measure of change. The current study sought to explore the performance of the CFQ in three groups of patients, organic (n = 209), mixed (n = 115), and functional (n = 322), and to identify correlations with measures of psychiatric morbidity (General Health Questionnaire [GHQ]), depression (Beck Depression Inventory [BDI]), and recognition memory (Signal Detection Memory Test). In the organic and functional samples, the CFQ score significantly correlated with the BDI and GHQ but not with the recognition memory measure. Three factors were found to be common to the organic and functional samples: cognitive, dissociation, and clumsiness. No characteristic pattern of CFQ item endorsement to differentiate between the organic and functional samples was found. Seven items of the CFQ performed badly because of ceiling or floor effects. The "negative" results reported herein are of relevance to researchers who may be planning to use the CFQ in clinical research. The CFQ remains a promising instrument, particularly on account of its "ecological" features, but far more investigation is needed before it is used as a standard measure in clinical practice.

Early manifestations, personality traits and pathways into care for Asian and white first-onset cases of schizophrenia

BACKGROUND

Previous studies have shown that manifestations of symptoms and premorbid personality of patients with schizophrenia differ across cultures. However, these have only been demonstrated in cultural settings apart from each other.

METHOD

We set out to compare these across different ethnic groups from a catchment area in west London. The Asian and the white group had similar inception rates of schizophrenia and we therefore decided to compare these two groups to ascertain similarities in social, demographic and personality factors and pathways into care. First-onset cases of schizophrenia were studied on a number of parameters using previously validated instruments.

RESULTS

There were more similarities than differences between the two groups. When compared with the findings of a previous multicentre study in India, London Asians, like their counterparts in India, were more likely than the London white sample to present with loss of appetite, become more religious and behave as if hearing voices. However, compared to their Indian counterparts, the onset of symptoms was more likely to be insidious and alternative sources of healing were less likely to be approached.

CONCLUSIONS

These findings are discussed in relation to the findings for white patients and recommendations made for future research.

[Clinical peculiarities of post-withdrawal disorders in heroin abuse and approaches to their treatment]

On the basis of the observation of 62 patients with heroin addiction there was described the post-withdrawal syndrome. It was characterised by a lability of psychopathologic symptomatology and by undulate course (with exacerbation and desactualization of the drive to narcotic). Clinically there were determined 3 types of post-withdrawal syndrome's course. The 1-st type was characterised by irresistible drive to narcotic, followed by psychopathic-like behaviour. For the 2-nd type a prevalence of the depressive symptomatology with different intensity of the disorders of the affect was more typical. The 3-d type was presented by unclear polymorphic manifestations and rather deep disorders of a sleep. It was established that clinical picture of the syndrome was determined mostly by a degree of a pathological drive to heroin. Differentiated approaches to a treatment of different types of post-withdrawal disorders were described. A duration of a syndrome was 3-4 weeks.

Influence of child and adolescent psychiatric disorders on young adult personality disorder

OBJECTIVE

This study examines associations between childhood psychopathology and young adult personality disorder in a random sample of 551 youths, who were 9 to 16 years old at first assessment.

METHOD

Subjects were evaluated for DSM-III-R psychiatric disorders. Information was obtained prospectively from youths and their mothers at three points over 10 years. The predictive effects of prior axis I disorders and adolescent axis II personality disorder clusters A, B, and C on young adult personality disorder were examined in logistic regression analyses.

RESULTS

The odds of young adult personality disorder increased given an adolescent personality disorder in the same cluster. Prior disruptive disorders, anxiety disorders, and major depression all significantly increased the odds of young adult personality disorder independent of an adolescent personality disorder. In addition, comorbidity of axis I and axis II disorders heightened the odds of young adult personality disorder relative to the odds of a disorder on a single axis.

CONCLUSIONS

Assessment of personality pathology before late adolescence may be warranted. Childhood or adolescent axis I disorders may set in motion a chain of maladaptive behaviors and environmental responses that foster more persistent psychopathology over time. Identification and treatment of childhood disorder may help to reduce that risk.

Testimony based on the Millon Clinical Multiaxial Inventory: review, commentary, and guidelines

Test results from the MCMI have been ruled admissible in court for a variety of clinical and forensic issues. This article addresses MCMI issues such as the test's applicability and admissibility of test results in forensic evaluations, test administration, test scoring, malingering and deception, prediction and diagnosis of behavior, reliability, validity, operating characteristics and diagnostic efficiency statistics, and use of computer-assisted interpretation of test results for forensic presentation. Recommendations are suggested for dealing with each of these issues in a forensic context.

Person reliability of psychiatric patients' responses to a psychopathology inventory

Person-reliability indices can assist clinicians in determining the interpretability of a patient's responses to the Basic Personality Inventory (BPI). Using an initial sample of 65 psychiatric patients, we found that: (1) different person-reliability indices showed modest evidence of psychometric adequacy and tended not to be confounded with general psychopathology; (2) a content consistency index of person reliability was predictably related to other item change variables, whereas within-session profile stability was related to across-session measures of profile stability: and (3) evidence for the ability of person-reliability indices to moderate the validity of clinical criteria was weak. Results provide cautious support for a multidimensional conceptualization of the person reliability construct on the BPI but demand further evaluation of the clinical utility of person reliability indices.

A model for predicting chronic TMD: practical application in clinical settings

BACKGROUND

Substantial cost is associated with the treatment of chronic temporomandibular disorders, or TMDs, and patients with TMDs often experience significant psychosocial distress. Early intervention based on identified risk factors has potential financial and functional benefits.

METHODS

Two hundred four patients with acute TMD were evaluated via an assessment battery that included physical, psychological and social measures. All participants were diagnosed as having TMD on the basis of the research diagnostic criteria for TMD, Axis I. At the six-month follow-up assessment, patients were considered to have chronic TMD if they continued to have TMD pain. This resulted in 144 of the patients being classified in the chronic group and 60 being classified in the nonchronic group.

RESULTS

A comparison of the acute TMD data demonstrated that the group that went on to develop chronic TMD and the group that did not differed significantly in their scores on numerous biopsychosocial indexes. Although several biopsychosocial measures were found to differentiate these two groups before the onset of chronic TMD, logistic regression analysis demonstrated that a two-variable predictive model consisting of the presence of a muscle disorder and characteristic pain intensity (that is, the mean of these three ratings: patient's report of current pain, worst pain in the last three months and mean pain in the last three months) accurately classified 91 percent of the subjects who went on to develop chronic TMD.

CONCLUSIONS

During the acute phase of TMD, two variables allowed for an accurate prediction rate of 91 percent among patients who went on to develop chronic TMD.

CLINICAL IMPLICATIONS

This model provides clinicians with the opportunity to identify at-risk patients early and initiate adjunctive or alternative treatments, thus reducing the likelihood of the development of TMD chronicity.

Concurrent and predictive validity of the personality disorder diagnosis in adolescent inpatients

OBJECTIVE

The authors investigated the concurrent and predictive validity of the DSM-III-R diagnosis of personality disorder in adolescents by means of baseline and follow-up assessments of inpatients treated at the Yale Psychiatric Institute.

METHOD

One hundred sixty-five hospitalized adolescents were reliably assessed by using a structured interview for personality disorder diagnoses as well as two measures of impairment and distress--the Global Assessment of Functioning Scale and the SCL-90-R. Two years after initial assessment, 101 subjects were independently reassessed with the same measures; their functioning was also assessed at this time.

RESULTS

At baseline, adolescents with personality disorders were significantly more impaired than those without personality disorders. At follow-up, adolescents with a personality disorder diagnosis at baseline had used significantly more drugs and had required more inpatient treatment during the follow-up interval. Over time, the scores on the Global Assessment of Functioning Scale and SCL-90-R of adolescents diagnosed with a personality disorder at baseline became more similar to the scores of adolescents without a personality disorder.

CONCLUSIONS

The diagnosis of personality disorder in adolescent inpatients has good concurrent validity; however, the predictive validity of the diagnosis is mixed.

Harm avoidance and serotonin

The relationships between the Tridimensional Personality Questionnaire (TPQ) and serotonergic activity has been described in some studies with controversial results. These studies have focused on specific patient populations rather than normal controls. Therefore, the aim of the present study is to examine the relationships between the TPQ and serotonergic activity in a group of non-patient subjects. Twenty-three normal subjects answered the TPQ, and the serotonergic activity was assessed by the prolactin response to a highly potent and selective 5-HT1a agonist (flesinoxan). A positive relationship between harm avoidance and PRL response to flesinoxan was found. This study is consistent with the hypothesized link between serotonergic activity and the harm avoidance dimension of the biosocial model of Cloninger.

Personality disorder and the Temperament and Character Inventory in the elderly

OBJECTIVE

The aim of this study was to determine the prevalence of personality disorders in a group of elderly patients without an organic mental disorder and to examine the relationship between the Temperament and Character Inventory (TCI) and personality disorder symptoms in psychogeriatric clinical practice.

METHOD

A total of 91 subjects completed the Structured Clinical Interview for DSM-III-R personality questionnaire and the 125-item TCI.

RESULTS

Of the 91 subjects, 34 individuals (31%) had at least one DSM-III-R personality disorder diagnosis, with avoidant, dependent and paranoid personality disorder being the most common. The trends and correlations between the temperament and character dimensions and the correlations between individual personality disorder symptoms and the dimensions were similar to those in the original model. The most significant findings were the strong negative correlations of the character scores of self-directedness and co-operativeness with the total number of personality disorder symptoms, and the fact that the self-directedness scores predicted the number of personality disorder diagnoses.

CONCLUSION

The reported prevalence rate is comparable to studies of both younger and older patient populations using similar methodology. The TCI provides a useful framework for further research on personality disorders in the elderly.

One-year follow-up of day treatment for poorly functioning patients with personality disorders

OBJECTIVE

The study evaluated the effectiveness of day treatment for poorly functioning patients with personality disorders who participated in day treatment consisting of analytically oriented and cognitive-behavioral therapy groups as part of a comprehensive group therapy program.

METHODS

At admission, discharge, and one year after discharge, patients completed the Global Severity Index (GSI) of the Symptom Check List 90-R and the circumplex version of the Inventory of Interpersonal Problems (IIP-C) and were assessed using the Global Assessment of Functioning (GAF) scale. At one-year follow-up, patients also completed a questionnaire covering social adaptation and clinical information and participated in a telephone interview with a clinician. The clinician used the completed instruments and results of the interview to assign patients follow-up GAF scores.

RESULTS

Follow-up data were available for 96 patients who completed the study, or 53 percent of the patients who were admitted to the study. Improvements in GAF, GSI, and IIP-C scores during day treatment were maintained at follow-up. Seventy-four percent of the treatment completers improved clinically from program admission to follow-up, as indicated by change in GAF scores, and 64 percent of the treatment completers continued in the outpatient group program. For the 26 percent of patients whose change in GAF score did not indicate clinical improvement, lack of improvement was most strongly predicted by the expression of suicidal thoughts during treatment. No patients committed suicide.

CONCLUSIONS

The day treatment program appears to be effective in improving the symptoms and functioning of poorly functioning patients with personality disorders and in encouraging patients to continue in longer-term outpatient therapy.

Psychological characteristics of candidates for liver transplantation: differences according to history of substance abuse and UNOS listing. United Network for Organ Sharing

Liver transplantation for patients with a history of substance abuse remains controversial. Resumption of heavy alcohol use postoperatively is a threat to long-term survival, but recidivism among transplanted alcoholics is reportedly low. An argument against psychological evaluation prior to transplantation revolves around the speculation that candidates will attempt to portray themselves as more desirable prior to listing with UNOS (United Network for Organ Sharing). This study measured psychological distress, coping styles, optimism, selected personality features, and perception of family environment among 73 U.S. military veterans who were candidates for liver transplantation. Candidates with positive histories of substance abuse revealed significantly more distress, less adaptive coping styles, and more character pathology than their counterparts. The only significant difference according to UNOS listing was on one measure of family environment. Results support preoperative psychological assessment and intervention on a more extensive level for substance abusers and raise questions for future research.

Risk factors in violent and nonviolent offenders

Factors leading to risk for violence were evaluated in an offender population of 36 male offenders including 18 Violent, e.g., assault, threatening and 17 nonviolent (break and enter, theft), and 17 nonoffenders. Their scores on the Psychopathy Checklist Revised, Violence Risk Scale-Experimental Version 1, Minnesota Multiphasic Personality Inventory-168, and the Porteus Maze tests showed scores for the inmates with violent offenses were elevated on Psychopathic Deviate, Paranoia, Schizophrenia scales of the Minnesota Multiphasic Personality Inventory, violence risk of the Violence Risk Scale, showed psychopathic orientation on the Psychopathy Checklist Revised, and had a lower test age quotient score on the Porteus Maze test.