[Personality disorders in a nonclinical sample of adolescents]

OBJECTIVE

To examine the comorbidity of borderline personality disorder and other personality disorders in a nonclinical sample of high-school students.

METHOD

311 high-school students who completed the French version of the CES-D (Center for Epidemiological Studies-Depression Scale), were asked to participate to interviews evaluating personality functioning: 60 subjects (19%) accepted to participate in the study. The mean CES-D score of these 60 subjects (16 boys, 44 girls, mean age=17.7 1.7) was significantly higher than the mean score of the whole sample (23.9 10.4 versus 16.7 9.8). Thus the interviewed sample was not representative of the population of high-school students. Subjects were assessed using the major depressive episode module of the MINI (Mini International Neuropsychiatric Interview) and the SIDP IV (Structured Interview for DSM IV Personality). Inter-rater reliability was determined by comparing the independent ratings of interviewers and an experienced clinician on a random sample of 20 interviews. For DSM IV borderline personality disorder diagnosis, the Cohen's kappa coefficient was 0.85. For personality disorder criteria, kappa ranged from 0.6 to 1.0 (average kappa=0.79).

RESULTS

Sixteen of these subjects (26,7%, 4 males, 12 females) received a diagnosis of borderline personality disorder according to DSM IV criteria. The mean CES-D score of borderline subjects (30.6 10.2) was significantly higher than the mean score of nonborderline subjects (21.6 10.5). Of the 16 borderline subjects, 11 (75%) received a diagnosis of major depressive disorder versus 14 (31%) of the non borderline subjects. None of the other personality disorders approached the frequency of borderline personality disorder. The next most frequent diagnoses were depressive and dependent personality disorders which occurred in respectively in 16.6% and 10% of the 60 subjects. All the personality-disorders occurred at higher rates in the group with borderline personality disorder with the exception of obsessive-compulsive personality disorder which was diagnosed only in nonborderline subjects. Of the 16 borderline subjects, 11 (68.7%) met the criteria for another personality disorder which were depressive personality disorder (N=5), paranoid personality disorder (N=4), dependent personality disorder (N=3), antisocial personality disorder (N=2), histrionic personality disorder (N=2), avoidant personality disorder (N=2), negativistic personality disorder (N=2), schizotypal personality disorder (N=1), narcissistic personality disorder (N=1), self-defeating personality disorder (N=1). The optional diagnoses (self-defeating, depressive and negati-vistic personality disorders) accounted for 8 of 23 (34.7%) cases of personality disorders diagnosed among borderline subjects. Among these 11 adolescents, 5 received 2 diagnoses of personality disorders (borderline and paranoid personality disorders, N=1; borderline and dependent personality disorders, N=1; borderline and depressive personality disorders, N=3), 3 received 3 diagnoses (borderline, antisocial and histrionic personality disorders, N=1; borderline, avoidant and negativistic personality disorders, N=1; borderline, depressive and negativistic personality disorders, N=1), 3 received 5 diagnoses (borderline, paranoid, histrionic, narcissistic and dependent personality disorders, N=1; borderline, paranoid, dependent, avoidant and depressive personality disorders, N=1; borderline, paranoid, schizotypal, antisocial and self-defeating personality disorders, N=1). Among the 44 adolescents (12 boys, 32 girls) without borderline personality disorder, 10 (22.7%) (3 boys, 7 girls) met the criteria for another personality disorder which were depressive personality disorder (N=5) or cluster C disorders -obsessive-compulsive personality disorder (N=4), dependent personality disorder (N=2), avoidant personality disorder (N=1) - with the exception of one diagnosis of histrionic personality disorder. Two subjects received 2 diagnoses (obsessive-compulsive and depressive personality disorder). The internal consistency of personality disorders criteria was assessed with Cronbach's alpha coefficient. Borderline personality disorder criteria had high internal consistency (0.82). The factor structure of borderline personality disorder criteria was studied with an exploratory factorial analysis which extracted three factors. The eigenvalues were 3.70, 1.06, and 1.01. Confirmatory factorial analyses were conducted. The correlated two-factor model and the three-factor model fit the data well but the correlation between factors was, however, judged too high, ranging from 0.70 to 0.78. The one-factor model proved to have a good fit (Goodness of Fit Index=0.89, Comparative Fit Index=0.90, Root Mean Square Residual=0.07). As a previous study showed the frequency of two schizotypal personality disorder criteria (odd beliefs/magical thinking experiences and unusual perceptual experiences), an exploratory factorial analysis was performed on the combined set of criteria of borderline and schizotypal personality disorders. It yielded 2 factors: the first factor consisted of all the borderline personality disorder criteria, odd beliefs/magical thinking, and unusual perceptual experiences and could be called the borderline factor; the second factor consisted of the paranoid and the social avoidance criteria and could be called the interpersonal hypersensitivity factor. A confirmatory factor analysis showed that this two-factor model provided a good fit to the data (GFI=0.82, CFI=0,91, RMSR=0.10). The correlation between factors was weak (0.25). These results suggest that odd beliefs/magical thinking and unusual perceptual experiences are a component of borderline symptomatology in adolescents.

DISCUSSION

The high frequency of major depressive disorder and personality disorders in the interviewed sample may be due to the possibility that adolescents with psychological problems have used the interview as a way to obtain attention and support from a psychologist. The interviewed sample, which was characterized by a high intensity of depressive symptomatology and by a high frequency of borderline personality disorder, could thus be seen as intermediate between a clinical and a community sample. Our results may be more generalizable to an outpatients population of adolescents. This study found conflicting results about the construct validity of borderline personality disorder in adolescent. The high internal consistency and the one-factor structure of the borderline personality disorder criteria argue for their validity in adolescents. However, the high rates of comorbidity of borderline personality disorder with depression and other personality disorders, extended to clusters A, B and C and to optional diagnoses, suggest the lack of construct validity of either borderline personality or cluster B disorders in adolescents.

CONCLUSION

Borderline symptomatology in adolescents appears more in adequacy with a dimensional model than with a typological classification. More studies are needed to assess and improve the construct validity of borderline personality disorder in adolescents.

Frequency of borderline personality disorder in a sample of French high school students

OBJECTIVE

To estimate the frequency of borderline personality disorder (BPD) in French high school students.

METHOD

A random sample of high school students (n = 1363) ranging in age from 13 to 20 years agreed to complete a questionnaire, the Screening Test for Comorbid Personality Disorders (STCPD); 107 of them volunteered to be interviewed. We assessed this group using the Revised Diagnostic Interview for Borderlines (DIB-R). We conducted a regression analysis to determine a cut-off for BPD diagnosis with the STCPD.

RESULTS

We estimated the overall frequency of BPD to be 10% for boys and 18% for girls. After a peak of frequency at age 14 years for both sexes, the frequency increased significantly again in late adolescence.

CONCLUSION

This study found a high frequency of BPD in French adolescents, which adds to questions regarding the validity of diagnosing this disorder in adolescents.

[Symptoms of DSM IV borderline personality disorder in a nonclinical population of adolescents: study of a series of 35 patients]

1,363 high school students were solicited to complete a personality disorder questionnaire and were encouraged to continue in the study by signing up for interviews with Master's level psychology students. 107 students (7.8%, 34 males, 73 females, mean age = 16.7 +/- 1.8) manifested themselves for the interview and were assessed by using structured diagnostic interviews for borderline personality disorder and major depressive disorder (DIB-R, Revised Diagnostic Interview for Borderlines; MINI, Mini International Neuropsychiatric Interview). The interviews were audiotaped. Interrater reliability was determined by independent ratings of 12 borderline subjects and 12 non-borderline subjects (kappa: 0.795). The distribution of the 107 subjects based on the number of DSM IV borderline personality disorder criteria indicated a gradual dispersion suggesting a continuum from normality to borderline personality disorder: 8% of the subjects met none of the criteria; 16% met one criterion; 17% met two; 12.5%, three; 13.7%, four; 8.4%, five; 5.6%, six; 9.3%, seven; 4.6%, eight; 4.6%, nine. Thirty-five of these 107 subjects (32.7%, 6 males, 29 females, mean age = 16.7 +/- 1.7) received a diagnosis of borderline personality disorder according to DSM IV criteria. The most frequent symptoms were paranoid ideation or dissociative symptoms (97.1%), affective instability (88.6%), inappropriate, intense anger (85.6%), suicidal gestures or automutilation (82.9%), followed by frantic efforts to avoid abandonment (77%), impulsivity (65.7%), unstable and intense relationships (62.9%), identity disturbance (60%), and emptiness (57.1%). The comparison between borderline and non-borderline subjects showed that all borderline personality disorder criteria discriminated significantly between the two groups. The high incidence of paranoid ideation (97.1%) and dissociative experiences (65.7%) in the borderline group suggests the pertinence of criterion 9 in the diagnosis of borderline personality disorder in adolescents. Two criteria of schizotypal personality disorder were also frequent in this group: 68.6% of the borderline group reported odd beliefs or magical thinking, in particular beliefs in clairvoyance or telepathy and 88.6% reported unusual perceptual experiences, in particular sensing the presence of a force or person and bodily illusions. Moreover, 31.4% of the borderline group reported transient "quasi" psychotic experiences, mainly "quasi" visual hallucinations. Auditory hallucinations or delusional ideas were not observed. This symptomatology suggests a "quasi" psychotic dimension of adolescent borderline personality disorder. Affective instability was the next most frequent symptom which was usually marked by a cyclothymic appearance. Comorbidity with major depressive disorder was high: 85.7% of the borderline subjects had a concurrent diagnosis of major depression versus 45.8% of the non-borderline subjects. Thus, major depression is more frequent than most of the borderline personality disorder criteria, with the exception of the already noted paranoid ideation and affective instability. Hypomanic symptoms were frequent in the borderline group (65.7%) as well as in the non-borderline group (38.8%). This symptomatology suggests that adolescent borderline personality disorder is linked to an attenuated bipolar spectrum characterised by major depressive episodes and soft signs of bipolarity. However, hypomanic symptoms, which were quite frequent in non-borderline subjects, might also be due to a mechanism of defence, i.e. the denial of depression. Comorbidity with anxiety disorders appeared also to be high: anxiety symptoms were found in 91.4% of the borderline subjects who reported symptoms of generalised anxiety disorder, panic disorder, and somatoform disorders. The overall clinical appearance of these borderline adolescents not referred for treatment seemed to be quite similar to that of borderline adolescents in clinical samples. This study shows that adolescent borderline personality disorder in non-clinical population is a serious disorder characterised by the importance of mental suffering and behavioural disturbances the disorganising power of which may fix the developmental process in a pathological pathway. Adolescent borderline personality disorder appears in this study to be strongly associated with major depressive disorder and at-risk behaviours linked to impulsivity, affective instability, and suicidal ideation. However, this study found an absence of precise cut-off between borderline and non-borderline subjects. Two factors might have contributed to the appearance of a continuum. First, some degree of impulsivity and instability in affectivity, self-images and interpersonal relationships is part of normal adolescence. (ABSTRACT TRUNCATED)

[Study of nicotine dependence among 342 adolescent smokers]

OBJECTIVE

This research evaluated nicotine dependence in adolescent smokers, their motivation to smoke and/or stop smoking, and their knowledge of how to stop smoking as well as the potential difficulties involved.

METHOD

Three hundred forty-two high school students completed questionnaires using two measures of dependence (the Fagerstrom tolerance test and a visual-analog self-evaluation scale), a test to measure motivation to smoke (the Horn test), and a questionnaire exploring motivations to stop smoking, methods used to stop smoking, and the anticipated difficulties.

RESULTS

On the Fagerstrom tolerance test, 14.6% of the students indicated strong dependence, whereas 32.3% indicated intermediate dependence. The Fagestrom score was strongly correlated to the self-evaluation test (r = 0.54, P < 0.001) and negatively correlated with the subjects' ages at the onset of smoking (r = -0.28, P < 0.001). The Horn test revealed that the main motivation to smoke is the search for relaxation and a decrease of negative emotions, indicating that cigarette smoking is primarily a means to manage stress and anxiety. Eighty-nine percent of the subjects stated that they would like to stop smoking, primarily because of the financial cost and health concerns. Among those subjects wishing to stop, 64.5% had previously tried to stop and had failed and 72% believed that it would be 'difficult' or 'very difficult' to stop. The main anticipated difficulties were an increase in stress and anxiety and, for the girls, weight gain. The anticipation of these difficulties was strongly correlated to dependence scores (r = 0.43, P < 0.001). Despite awareness of these difficulties, only 19.6% of the subjects wishing to stop smoking expected to seek medical assistance. For most of the measured variables, there was no difference between boys and girls.

CONCLUSION

This study confirms the seriousness of tobacco consumption in adolescence. The results suggest the need for early programs aimed at preventing or delaying onset of use as well as the need to develop programs to aid high school students to stop smoking.

[Epidemiological study of cannabis abuse and dependence in 256 adolescents]

A study of cannabis use in French adolescents was implemented using a questionnaire derived from the French version of the Mini International Psychiatric Interview based on DSM IV criteria for cannabis dependence, among a population of 256 high school students from two high schools with different SES backgrounds. Among the adolescents studied, 41.4% (n = 106) reported using cannabis occasionally or regularly, 51.2% had never used cannabis, and 7.4% had used cannabis and subsequently quit. Incidence of usage appeared to increase as a function of age, 51.4% for those 18 years and over, 44.6% for 17 years-old, and 30.4% for 16 years-old, girls tending to consume less than boys (36.4% to 45.2%). With regards to results of the MINI, of the regular or occasional users (n = 106), 47.2% of the subjects indicated substance dependence while the remaining subjects indicated that they were recreational users only. Among users, data concerning tolerance, withdrawal, and excessive consumption indicated that subjects were significantly affected by their addictive behavior; 33% of users reported having smoked cannabis for one year or less with 10.4% reporting that they have smoked for more than three years. Among those having smoked one year or less, 31.4% reported signs of dependence versus 68.6% who consume on a recreational basis; among those having used cannabis for three years or more, 63.6% reported dependence while 36.4% admitted to recreational usage. This study indicates the seriousness of cannabis usage among high-school students, underlining addictive and dependent behavior and their effects on daily life as well as significant the increase of usage with age and as a function of number of years of smoking.

Comparison of albuterol delivered by a metered dose inhaler with spacer versus a nebulizer in children with mild acute asthma

OBJECTIVE

In children with mild acute asthma, to compare treatment with a single dose of albuterol delivered by a metered dose inhaler (MDI) with a spacer in either a weight-adjusted high dose or a standard low-dose regimen with delivery by a nebulizer.

STUDY DESIGN

In this randomized double-blind trial set in an emergency department, 90 children between 5 and 17 years of age with a baseline forced expiratory volume in 1 second (FEV1 ) between 50% and 79% of predicted value were treated with a single dose of albuterol, either 6 to 10 puffs (n = 30) or 2 puffs (n = 30) with an MDI with spacer or 0.15 mg/kg with a nebulizer (n = 30).

RESULTS

No significant differences were seen between treatment groups in the degree of improvement in percent predicted FEV1 (P =.12), clinical score, respiratory rate, or O2 saturation. However, the nebulizer group had a significantly greater change in heart rate (P =.0001). Our study had 93% power to detect a mean difference in percent predicted FEV1 of 8 between the treatment groups.

CONCLUSION

In children with mild acute asthma, treatment with 2 puffs of albuterol by an MDI with spacer is just as clinically beneficial as treatment with higher doses delivered by an MDI or by a nebulizer.

Hospitalization patterns in severe acute asthma in children

We set out to determine associations between hospitalization and disease severity before and 2 hours after initiation of asthma therapy in the Emergency Department, and to describe the outcome of patients admitted and discharged. This is a retrospective review of data and charts from a randomized, double blind, placebo-controlled trial (R.C.T.) of 120 asthmatics 5-17 years of age with baseline forced expiratory volume in 1 second (FEV1) < 50% predicted, treated with 3 or 1 or 0 doses of nebulized ipratropium added to three albuterol nebulizations administered over 1 hour. None of the clinical parameters measured at baseline were associated with hospitalization. However, by 2 hours after initiation of therapy, both the FEV1 percent of predicted values (% pred.) and the total asthma score were associated with likelihood of hospital admission. Baseline O2 saturation < 92% indicated a longer hospital stay (75.3 +/- 51 hours vs. 43.0 +/- 24.4 hours, P = 0.015) and a later onset of infrequent nebulizations (46.7 +/- 35.1 vs. 26.6 +/- 17.4 hours, P = 0.006). By 2 hours, those with a post-treatment FEV1 % pred < or = 30% and an asthma score > or = 6 of 9 had a high likelihood of hospitalization (86 and 80%, respectively, combined probability 100%), whereas FEV1 % pred > or = 60% and total asthma score < 3 were associated with successful discharge (probability of 92 and 83%, respectively). We conclude that pre-treatment assessments were not associated with hospitalization, while patients with post-treatment FEV1 % pred < or = 30% and a score > or = 6 had high likelihood of hospitalization.

A feminist case against euthanasia. Women should be especially wary of arguments for "the freedom to die"

Feminists, among others, should not be too quick to hail assisted suicide and euthanasia as extensions of human freedom. Indeed, there are good reasons why women should be especially suspicious of such "reforms." First, it is not clear that a person has a moral right to end his or her existence. Feminists understand that suicide and murder are irretrievably linked, and that a person is not a monad. We often hear of suicide attempts in which the person's body--by vomiting up poison, for instance--overrules his or her mind. If there can be such miscommunication between a mind and a body, how are we to trust the communication between a person and the physician ready to assist his or her suicide? Ambivalent motivation and ambiguous meanings have always characterized human relations. In the past, however, an absolute taboo against suicide or euthanasia cemented a patient's right to expect the care of his or her physician, family, and community. If we were to discard that taboo, we would subtly alter these relationships and make each other more vulnerable. History suggests that women, minorities, the ill, the old, and the handicapped would be most at risk. Finally, the assisted-suicide debate has even larger social implications. Unconditional respect for the gift of life is eroding in the United States. The suicide rate is already climbing at all levels of society, especially among teenagers. Wouldn't the acceptance of suicide and euthanasia make it even more acceptable for people to check out of all kinds of uncomfortable situations--marriages or life?

Efficacy of frequent nebulized ipratropium bromide added to frequent high-dose albuterol therapy in severe childhood asthma

OBJECTIVE

The objective of this trial was to determine the efficacy of frequent nebulized ipratropium added to high-dose albuterol therapy in children with severe asthma.

METHODS

One hundred twenty children (5 to 17 years) of age) with severe acute asthma (forced expiratory volume in 1 second (FEV1), < 50% of the predicted value) were enrolled into a randomized double-blind three-arm placebo-controlled trial comparing three groups: group 1, three doses of nebulized ipratropium bromide within 60 minutes (250 micrograms/dose); group 2, one dose of ipratropium; group 3, no ipratropium. All patients were also treated with three doses of nebulized albuterol within 60 minutes (0.15 mg/kg per dose). Pulmonary function and clinical measures were assessed every 20 minutes for up to 120 minutes.

RESULTS

The groups were comparable at baseline. At 120 minutes, the mean percentage of predicted FEV1 improved from 33.4% to 56.7% in group 1, from 34.2% to 52.3% in group 2, and from 35.4% to 48.4% in group 3 (p = 0.0001). The differences between groups were larger in those children with a baseline FEV1 < or = 30% of the predicted value: FEV1 increased from 24.5% to 50.9% in group 1, from 25.0% to 39.8% in group 2, and from 25.9% to 36.5% in group 3 (p = 0.0001). In group 1, 38% of the patients were hospitalized after the study, 44% in group 2, and 46% in group 3 (p value not significant). However, in patients with FEV1 < or = 30%, the hospitalization rates were 27% in group 1, 56% in group 2, and 83% in group 3 (p = 0.027). There were no toxic effects attributable to ipratropium.

CONCLUSION

The addition of repeated doses of nebulized ipratropium to frequent high-dose albuterol therapy in patients with acute severe asthma is both safe and more effective than albuterol alone; its use in patients with very severe asthma may reduce hospitalizations.

The moral case against euthanasia. Catholics must articulate persuasive arguments to counter the cultural rush toward assisted suicide

Catholics who adhere to a consistent ethic of life are going to face tougher opposition as they struggle to defend society's most vulnerable members. The major ethical contention will concern the ethics of dying. Unfortunately, there have not been well-articulated moral arguments to counter society's rush toward physician-assisted suicide and euthanasia. Catholics must articulate a persuasive ethical ideal for dying a truly good death. It is crucial to achieve a balance: between valuing individual autonomy and protecting the common good; between affirming the goodness of life and accepting death as a reality of the life cycle. Another challenging piece of the moral argument lies in convincing people that the means and processes used to achieve a goal are rarely neutral. Another serious problem with permitting the killing of self or others is that one cannot ever be certain of the agent's motivation. And when an individual's subjective determination of a need to choose death is given ultimate validity, there is no way to call a halt. If medical mercy killing becomes acceptable, social pressure can mount for an ill person to ask for death to relieve the family burdens. Maintaining an absolute prohibition against actively taking a human life--self or other, with or without consent, dying or not--is necessary to protect human communal bonds.

Brain regional distribution of prion protein PrP27-30 in mice stereotaxically microinjected with different strains of scrapie

Stereotaxic inoculation was used to examine the role of scrapie agent strain, inoculum, and injection site on the brain regional distribution of the prion protein, PrP27-30. Neither the type of inoculum nor the injection site influenced the distribution of PrP27-30 in brains of mice. Among the parameters examined, only the strain of agent affected the pattern of distribution and the yield of PrP27-30. Although mice injected into the cerebellum had the shortest incubation period, the cerebellum gave the lowest yield of the PrP27-30 among the seven brain regions examined. The positive correlation between PrP27-30 regional distribution and lesion profile (degree of vacuolation) reinforces the role of the PrPSC protein in scrapie pathogenesis.