Personality disorders and physical comorbidities in adults from the United States: data from the National Epidemiologic Survey on Alcohol and Related Conditions

Physical multimorbidity in psychiatric patients with personality disorders: Insights within the ICD-11 framework

OBJECTIVE

Recent research has revealed poor physical health among individuals with personality disorders (PDs). We aimed to compare chronic physical illnesses (CPI) and chronic physical multimorbidity (CPM) prevalence between the general population (GEP) and PD patients, and to explore the relationship between CPM and various aspects of PD, predominantly within the ICD-11 framework.

METHODS

This cross-sectional study included 126 PD patients and 126 matched controls from the GEP. Patients were evaluated for the ICD-11 PD severity and maladaptive personality domains, subjective emptiness, and reflective functioning. CPI was assessed using a standardized self-report questionnaire.

RESULTS

PD patients had a higher mean number of CPIs (2.05 vs. 1.02) and a more frequent CPM occurrence (49.2% vs. 26.2%) compared to the matched controls (p < .001). The ICD-11 PD severity (OR = 1.143, p = .007) and maladaptive domain Negative affectivity (OR = 4.845, p = .002), and poor reflective functioning (OR = 1.694, p = .007) were significant predictors of CPM, independent of sociodemographic, clinical and lifestyle factors. Negative affectivity showed the most robust effect on CPM, while smoking did not significantly mediate these relationships.

CONCLUSION

Our study found increased CPM burden in PD patients and a link between CPM and various PD aspects under the ICD-11 framework, highlighting the need for more integrated healthcare.

A systematic review of personality and musculoskeletal disorders: evidence from general population studies

Introduction

We conducted a systematic review to evaluate the quality and extent of evidence on associations between personality disorders (PDs) and musculoskeletal disorders (MSDs) in population-based studies, since these disorders are leading causes of disease burden worldwide.

Methods

A search strategy of published, peer-reviewed and gray literature was developed in consultation with a liaison librarian and implemented for Embase, CINAHL Complete, Medline Complete, and PsycINFO via the EBSCOhost platform from 1990 to the present and CORDIS and ProQuest Dissertations & Theses Global, respectively. The inclusion criteria were as follows: I) general population participants aged ≥15 years; II) self-report, probable PD based on positive screen, or threshold PD according to the DSM-IV/5 (groupings: any, Clusters A/B/C, specific PD) or ICD-10/11; III) MSDs identified by self-report or ICD criteria (arthritis, back/neck conditions, fibromyalgia, osteopenia/osteoporosis) and III) cohort, case-control, and cross-sectional study designs. Two reviewers independently screened articles and extracted the data. Critical appraisal was undertaken using the Joanna Briggs Institute checklists for systematic reviews of etiology and risk. A descriptive synthesis presents the characteristics of included studies, critical appraisal results, and descriptions of the main findings. This review adhered to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.

Results

There were 11 peer-reviewed, published articles included in this review (n = 9 cross-sectional and n = 2 case-control studies); participants were ≥18 years in these studies. No published gray literature was identified. Semi-structured interviews were the most common method to ascertain PDs; all studies utilized self-reported measures to identify MSDs. Overall, we detected limited and conflicting evidence for associations between PDs and MSDs.

Discussion

The main result may be explained by lack of population-based longitudinal evidence, heterogenous groupings of PD, and few comparable cross-sectional and case-control studies. Strengths of the review include a comprehensive search strategy and a discussion of mechanisms underlying possible associations between PDs and MSDs.

Conclusions

The quality of most studies included in this review that examined associations between PD and MSDs in general population adults was high. However, the results demonstrated limited and conflicting evidence for these associations, in part, due to lack of comparable evidence, which should be addressed in future research.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42021243094.

Multimorbidity and the Etiology of Schizophrenia

PURPOSE OF REVIEW

A global study of multimorbidity in schizophrenia, especially of the association with physical conditions, might offer much needed etiological insights.

RECENT FINDINGS

Our review suggests that life-style factors and medication related to schizophrenia are only part of the explanation of the increase in risk for cardiovascular, metabolic, pulmonary disorders, and some cancers. Positive associations with autoimmune disorders (with the exception of rheumatoid arthritis) and epilepsy are promising avenues of research but to date have not been fully exploited. The same holds for the negative comorbidity seen for rheumatoid arthritis and some cancers (e.g., prostate). As a whole, our review suggests that most of the explored conditions have a different prevalence in schizophrenia than in the general population. Several hypotheses emerged from this review such as the role of immune and genetic factors, of sex hormones, and of more general variability factors.

An epidemiological survey on personality disorder in Andalusia (the PISMA-ep PD study)

BACKGROUND

Despite a significant clinical and social burden, there is a relative scarcity of epidemiological studies on Personality Disorder (PD).

AIM

To determine the current prevalence of PD and the psychosocial correlates associated with this in the Andalusian population.

METHOD

We carried out a cross-sectional population mental-health survey in Andalusia, southern Spain. Thus, 4,518 randomly selected participants were interviewed following sampling using different standard stratification levels. We used the Spanish version of the SAPAS to estimate PD prevalence. In addition, a full battery of other instruments was utilized to explore global functionality, childhood abuse, maltreatment, threatening life events, personality traits (neuroticism, impulsivity and paranoia), medical and psychiatric comorbidities, family history of psychological problems and other potential risk factors for PD.

RESULTS

PD prevalence (10.8%; 95% CI [9.8, 11.7]) and ran two different multivariate models for PD. We obtained the highest PD prevalence in those affected by any mental disorder plus those reporting having suffered childhood abuse, particularly sexual abuse. Additional potential risk factors or correlates of PD identified were: younger age, lower levels of functioning, less social support, poorer general health, having suffered maltreatment, threatening life events, higher suicidal risk scores and higher levels of both neuroticism and impulsivity.

CONCLUSIONS

This study reports PD prevalence and risk correlates in consonance with similar findings reported in other Western populations. However, longitudinal studies are needed to elicit a more thorough group of prospective determinants of PD.

Differentiating between intrapsychic symptoms and behavioral expressions of borderline personality disorder in relation to childhood emotional maltreatment and emotion dysregulation: an exploratory investigation

BACKGROUND

Borderline personality disorder (BPD) is a severe mental disorder, characterized by pronounced instability in emotions, self-image, and interpersonal relationships. Experiences of childhood maltreatment are among the risk factors for BPD. While self-damaging and aggressive acts often occur, not every person with the disorder shows markedly dysregulated behaviour. Internalized symptoms, such as shame, loneliness, and self-disgust tend to be more pervasive and persist after clinical remission.

OBJECTIVE

Here we investigated associations between BPD symptom severity, childhood maltreatment, and emotion regulation difficulties. We further explored if the Borderline Symptom List (BSL) could potentially be used to differentiate between internalized symptoms (intrapsychic strain) and externalized symptoms (dysregulated behaviours) in future research.

METHOD

187 women with at least mild BPD symptoms (65% having a diagnosis of BPD) completed the BSL 23 including its 11-item supplement (BSL-S), the Childhood Trauma Questionnaire (CTQ), and Difficulties in Emotion Regulation Scale (DERS). Participants further underwent a semi-structured clinical interview to assess BPD criteria (International Personality Disorder Examination, IPDE). Multivariate models and regression-based bootstrapping analyses were performed to test direct and indirect effects.

RESULTS

Childhood trauma severity, especially emotional abuse, positively predicted BPD symptom severity. A significant indirect effect through emotion regulation difficulties was found (k2=.56). When exploring associations with BPD criteria (IPDE), the BSL-23 mean significantly correlated with separation anxiety, identity and mood problems, chronic emptiness, suicidal ideation, and dissociation, while the BSL-S correlated with self-harming impulsive behaviour and anger outbursts.

CONCLUSIONS

Findings complement previous research, highlighting the role of childhood maltreatment and emotion regulation difficulties in BPD. While our findings need to be seen as preliminary and interpreted with caution, they suggest that the BSL may be used to differentiate between internalized symptoms and behavioural expressions of BPD in future research. Such a distinction might help to deepen the understanding of this complex heterogenous disorder.

Personality Pathology and Functional Impairment in Patients With Hypochondriasis

BACKGROUND

Research indicates substantial co-occurance of personality pathology and hypochondriasis, which both involve significant psychosocial impairment.

OBJECTIVE

This study sought to investigate the role of personality pathology for explaining functional impairment in patients with hypochondriasis, while accounting for the influence of health anxiety severity.

METHODS

Patients diagnosed with hypochondriasis (N = 84; 60% women) were administered interview- and self-report instruments for personality pathology, health anxiety severity, and functional impairment (general, social, and physical): The Structured Clinical Interview for DSM-IV Axis II (SCID-II), the Personality Inventory for DSM-5 (PID-5), the Short Health Anxiety Inventory (SHAI), the 36-item Short Form health survey (SF-36), and the Global Assessment of Functioning (GAF). Hierarchical regression analyses were performed with boot-strapping (1000 samples).

RESULTS

Findings overall showed that personality pathology incrementally explained functional impairment over the influence of health anxiety severity. More specifically, findings revealed that the incremental effect of PID-5 trait dimensions was substantially larger than the SCID-II personality disorder criterion-count. Functional impairment was specifically associated with SCID-II symptoms of Avoidant Personality disorder and dependent personality disorder as well as PID-5 trait domains of negative affectivity, detachment, and psychoticism.

CONCLUSIONS

The findings highlight the potential significance of personality pathology for understanding and clinical management of functional impairment in patients with hypochondriasis. The personality features that best explained functional impairment were avoidant personality disorder and dependent personality disorder and, in particular, DSM-5 and the International Classification of Diseases, 11th revision personality trait domains of negative affectivity, detachment, and psychoticism.

The role of mental disorders in precision medicine for diabetes: a narrative review

This narrative review aims to examine the value of addressing mental disorders as part of the care of people with type 1 and type 2 diabetes in terms of four components of precision medicine. First, we review the empirical literature on the role of common mental disorders in the development and outcomes of diabetes (precision prevention and prognostics). We then review interventions that can address mental disorders in individuals with diabetes or at risk of diabetes (precision treatment) and highlight recent studies that have used novel methods to individualise interventions, in person and through applications, based on mental disorders. Additionally, we discuss the use of detailed assessment of mental disorders using, for example, mobile health technologies (precision monitoring). Finally, we discuss future directions in research and practice and challenges to addressing mental disorders as a factor in precision medicine for diabetes. This review shows that several mental disorders are associated with a higher risk of type 2 diabetes and its complications, while there is suggestive evidence indicating that treating some mental disorders could contribute to the prevention of diabetes and improve diabetes outcomes. Using technologically enabled solutions to identify mental disorders could help individuals who stand to benefit from particular treatments. However, there are considerable gaps in knowledge and several challenges to be met before we can stratify treatment recommendations based on mental disorders. Overall, this review demonstrates that addressing mental disorders as a facet of precision medicine could have considerable value for routine diabetes care and has the potential to improve diabetes outcomes.

[Impact of anxiety disorders on adherence to anticoagulant therapy in patients with atrial fibrillation]

AIM

To evaluate the impact of anxiety disorders on adherence to anticoagulant therapy (ACT) in patients with atrial fibrillation (AF).

MATERIALS AND METHODS

179 outpatients (131 women, 48 men, mean age 69.96.2 years) with AF were examined. The research methods included a physical examination according to the standards of medical care in an outpatient facility, clinical and psychopathological examination using psychometric scales.

RESULTS

Based on the assessment of adherence to ACT using the MoriskyGreen test, 2 groups of patients were identified: Group 1 patients with high adherence to ACT, Group 2 patients with partial/low adherence to ACT. In group 1, anxiety disorders were verified in 51.7% of cases, in group 2 54.3%. There were no statistically significant differences in the prevalence and severity of anxiety in the study groups. In accordance with the binary logistic regression model, the probability of high adherence to therapy is determined by higher (compared with the group of patients with partial/low adherence to therapy) scores in terms of mental health (p0.001), vital activity (p=0.02) and the total score of the SF-36 scale (p=0.08), as well as the extraversion parameter (p=0.02) of the NEO-FFI scale.

CONCLUSION

In the present study, no significant association was found between anxiety symptoms and a decrease in adherence to ACT in patients with AF. However, the results obtained suggest a contribution to the adherence to therapy of personality characteristics.

Current state of the evidence on community treatments for people with complex emotional needs: a scoping review

BACKGROUND

Improving the quality of care in community settings for people with 'Complex Emotional Needs' (CEN-our preferred working term for services for people with a "personality disorder" diagnosis or comparable needs) is recognised internationally as a priority. Plans to improve care should be rooted as far as possible in evidence. We aimed to take stock of the current state of such evidence, and identify significant gaps through a scoping review of published investigations of outcomes of community-based psychosocial interventions designed for CEN.

METHODS

We conducted a scoping review with systematic searches. We searched six bibliographic databases, including forward and backward citation searching, and reference searching of relevant systematic reviews. We included studies using quantitative methods to test for effects on any clinical, social, and functioning outcomes from community-based interventions for people with CEN. The final search was conducted in November 2020.

RESULTS

We included 226 papers in all (210 studies). Little relevant literature was published before 2000. Since then, publications per year and sample sizes have gradually increased, but most studies are relatively small, including many pilot or uncontrolled studies. Most studies focus on symptom and self-harm outcomes of various forms of specialist psychotherapy: most result in outcomes better than from inactive controls and similar to other specialist psychotherapies. We found large evidence gaps. Adaptation and testing of therapies for significant groups (e.g. people with comorbid psychosis, bipolar disorder, post-traumatic stress disorder, or substance misuse; older and younger groups; parents) have for the most part only reached a feasibility testing stage. We found little evidence regarding interventions to improve social aspects of people's lives, peer support, or ways of designing effective services.

CONCLUSIONS

Compared with other longer term mental health problems that significantly impair functioning, the evidence base on how to provide high quality care for people with CEN is very limited. There is good evidence that people with CEN can be helped when specialist therapies are available and when they are able to engage with them. However, a much more methodologically robust and substantial literature addressing a much wider range of research questions is urgently needed to optimise treatment and support across this group.

Clinician perspectives on what constitutes good practice in community services for people with complex emotional needs: A qualitative thematic meta-synthesis

INTRODUCTION

The need to improve the quality of community mental health services for people with Complex Emotional Needs (CEN) (who may have a diagnosis of 'personality disorder') is recognised internationally and has become a renewed policy priority in England. Such improvement requires positive engagement from clinicians across the service system, and their perspectives on achieving good practice need to be understood.

AIM

To synthesise qualitative evidence on clinician perspectives on what constitutes good practice, and what helps or prevents it being achieved, in community mental health services for people with CEN.

METHODS

Six bibliographic databases were searched for studies published since 2003 and supplementary citation tracking was conducted. Studies that used any recognised qualitative method and reported clinician experiences and perspectives on community-based mental health services for adults with CEN were eligible for this review, including generic and specialist settings. Meta-synthesis was used to generate and synthesise over-arching themes across included studies.

RESULTS

Twenty-nine papers were eligible for inclusion, most with samples given a 'personality disorder' diagnosis. Six over-arching themes were identified: 1. The use and misuse of diagnosis; 2. The patient journey into services: nowhere to go; 3. Therapeutic relationships: connection and distance; 4. The nature of treatment: not doing too much or too little; 5. Managing safety issues and crises: being measured and proactive; 6. Clinician and wider service needs: whose needs are they anyway? The overall quality of the evidence was moderate.

DISCUSSION

Through summarising the literature on clinician perspectives on good practice for people with CEN, over-arching priorities were identified on which there appears to be substantial consensus. In their focus on needs such as for a long-term perspective on treatment journeys, high quality and consistent therapeutic relationships, and a balanced approach to safety, clinician priorities are mainly congruent with those found in studies on service user views. They also identify clinician needs that should be met for good care to be provided, including for supervision, joint working and organisational support.

Measures of Personality Pathology, Levels of Functioning, and Physical Health in an Urban Primary Care Sample

Integrative approaches in the primary care setting have grown in favor over the past few decades, with many interesting findings about the influence of personality disorders on physical health and functioning; however, less is known about how specific pathological personality traits impact patient-provider assessments of physical and mental health. Using the DSM-5 Levels of Personality Functioning Questionnaire-Short Form (DLOPFQ-SF) and Personality Inventory for DSM-5-Brief Form, these relationships were evaluated in a sample of 50 inner-city, low-income patients in a primary care clinic. Point-biserial correlations revealed significant correlations between physical and mental health morbidities, as well as personality pathology and patient response to treatment. Our findings lend further support to describing the relationships between personality pathology, medical comorbidities, and patient response to treatment.

Exploring the comorbidity between personality and musculoskeletal disorders among adults: A scoping review

INTRODUCTION

There is growing awareness of the comorbidity between mental and musculoskeletal disorders (MSDs) and their associated burden. We aimed to explore what is known regarding the existing epidemiological clinical-and population- based literature on the comorbidity between personality disorders (PDs) and MSDs specifically. In addition, we aimed to investigate their associated burden by examining a range of outcomes including morbidity/mortality, patient- and clinical-reported outcomes, work-related outcomes, hospital admissions, and financial costs. Finally, we sought to identify gaps in the literature and provide recommendations for further research.

METHODS

Studies with participants 15 years of age were eligible. Categorical PDs/features (DSM-III/IV/5 or ICD 9/10), identified by a health care professional, medical records, diagnostic interviews, or self-administered questionnaires. The definitions/groupings of MSDs were guided by the ICD-10 including conditions of the back, joints, and soft tissue, and disorders of bone density and structure. Published peer-reviewed and gray literature were considered. Eligible study designs were cohort, case-control, and cross-sectional studies, and existing reviews of observational studies. Identification and selection of articles, data extraction and the presentation of the results was conducted according to the Joanna Briggs Institute methodological guidance and the PRISMA extension for scoping reviews.

RESULTS

In total, 57 articles were eligible including 10 reviews and 47 individual studies. Across clinical and population settings, we detected evidence of comorbidity between PDs and chronic back/neck/spine conditions, arthritis, and fibromyalgia, and emerging evidence of associations between PDs and reduced bone mineral density. In terms of knowledge gaps, the burden associated with PDs and MSDs is poorly understood, as is their underlying mechanisms.

DISCUSSION

This scoping review might prompt further research into PDs and MSDs as separate groups of disorders, along with their comorbidity and the mechanisms that may link them.

SYSTEMATIC REVIEW REGISTRATION

https://osf.io/mxbr2/registrations.

Long-term physical health outcomes of obsessive-compulsive personality disorder traits

BACKGROUND

Obsessive-compulsive personality disorder (OCPD) is characterized by pervasive and persistent traits including preoccupation with orderliness, perfectionism, and control. Relatively little is known about the potential relationship between OCPD traits and physical health.

METHODS

We investigated the association between OCPD traits and several self-reported medical conditions in 249 individuals followed prospectively from 1981 until 2004/2005 as part of the Epidemiological Catchment Area.

RESULTS

The OCPD trait score was inversely related to hypertension in males, in models unadjusted (OR = 0.66; 95% CI, 0.45-0.90) and adjusted (OR = 0.70; 95% CI, 0.47-0.95) for sociodemographic variables. Perfectionism was inversely related to hypertension in the unadjusted models for men (OR = 0.34; 95% CI, 0.12-0.89). Indecisiveness was positively associated with heart conditions in adjusted models for women (OR = 3.46; 95% CI, 1.11-10.52).

CONCLUSION

OCPD traits are associated with cardiovascular health in both sexes. Further studies are needed to understand the specificity of these relationships, as well as to determine the underlying mechanism.

Exploring the comorbidity of musculoskeletal and personality disorders among adults: a scoping review protocol

BACKGROUND

Separately, mental and musculoskeletal disorders (MSDs) are prevalent across the life course and are leading contributors to disability worldwide. While people with personality disorder (PD) have been shown to have an increased risk of certain physical health comorbidities-associations with MSDs have not been thoroughly explored. The proposed scoping review aims to explore the existing clinical- and population-based literature on the comorbidity of PD and MSDs among adults ≥ 18 years and the burden associated with their comorbidity, identify knowledge gaps on this topic, and propose recommendations for future research.

METHODS

This protocol describes the methodology to undertake the scoping review. It is guided by Arksey and O'Malley's framework and the extensions recommended by the Joanna Briggs Institute. A comprehensive search strategy will be used to identify relevant articles, which will be underpinned by Population, Concept, and Context (PCC) inclusion criteria. One author will perform the search and two authors will independently screen titles/abstracts followed by a full-text review for articles considered relevant. The supervising author will confirm the final selection of articles to be included. One author will extract relevant information from the articles using a predetermined charting form, while a second will perform validation of all information entered.

DISCUSSION

Information will be synthesised to inform a discussion of what is known regarding associations between PD and MSDs, and the burden associated with their comorbidity in different contexts, with future research directions proposed.

SYSTEMATIC REVIEW REGISTRATION

This protocol is registered in Open Science Framework Registries ( https://osf.io/mxbr2/ ).

Associations between physical health conditions and posttraumatic stress disorder according to age

OBJECTIVES

Posttraumatic stress disorder (PTSD) is associated with various physical health conditions. However, it is unclear whether the relationship between PTSD and physical health conditions differs according to age. This study aims to examine the associations between PTSD and physical health conditions across four adult age categories.

METHODS

We analyzed data from the 2012 to 2013 National Epidemiologic Survey on Alcohol and Related Conditions (N = 36,309). The Alcohol Use Disorder and Associated Disabilities Interview Schedule-5 assessed past-year DSM-5 PTSD. Multiple regression analyses examined associations between PTSD (reference = no PTSD) with number and type of physical health conditions in each age category (18-34: "younger adults," 35-49: "middle-aged adults," 50-64: "young-old adults," 65+: "older adults").

RESULTS

The prevalence of nearly all physical health conditions increased according to age, whereas the prevalence of PTSD tended to decrease with age. After adjustment, PTSD was associated with a greater number of physical health conditions among all age categories (b range: 0.62-1.29). Regardless of age category, PTSD was associated with increased odds of cardiovascular and musculoskeletal conditions (AOR range: 1.54-2.34). PTSD was also associated with increased odds of gastrointestinal, hepatobiliary, endocrine/metabolic, respiratory, neurologic conditions, cancer, sleep disorders, and anemia among select age categories (AOR range: 1.70-3.31). For most physical health conditions, the largest effect sizes emerged for younger and middle-aged adults.

CONCLUSIONS

PTSD is associated with many physical health conditions across the age spectrum, particularly among younger and middle-aged adults. Results may inform targeted screening and intervention strategies to mitigate risk of physical health conditions among adults with PTSD.

Exploring the links among borderline personality disorder symptoms, trauma, and pain in patients with chronic pain disorders

OBJECTIVE

Chronic pain and borderline personality disorder (BPD) are commonly comorbid and jointly associated with increased symptoms of both disorders and clinical and functional impairment. Little is known, however, about specific links between these disorders. In a cross-sectional study of patients with chronic pain, we compared participants high or low on BPD symptoms on patterns of pain experience and types of child and adult traumas.

METHODS

Adults (N = 181) with chronic pain completed self-reports of pain severity, dimensions of pain experiencing, body coverage of pain, and clinical indicators of central sensitization (i.e., chronic hypersensitivity of the central nervous system), as well as measures of child and adult physical abuse, sexual abuse, trauma, and neglect. Participants also completed the McLean Screening Instrument for BPD.

RESULTS

Participants with clinically significant BPD symptoms (n = 32) reported more childhood sexual trauma, punishment, and neglect, as well as adult physical/sexual trauma, than those without elevated BPD symptoms. Among participants with clinically significant BPD symptoms, affective pain and central sensitization were elevated, potentially explained by heightened negative affect in BPD.

CONCLUSION

BPD symptoms are associated with increased clinical severity among patients with chronic pain as well as a unique manifestation of pain experiencing (i.e., increased affective pain and central sensitization in particular). Childhood trauma of all types is associated with chronic pain and BPD co-occurrence. Researchers and clinicians should assess for BPD in people with chronic pain to enhance conceptual models of the transaction between these disorders and to improve clinical care.

Personality and widowhood increase the risk for incident depression in the two years following the first acute coronary syndrome

Objectives: Incident depression, occurring after an acute coronary syndrome (ACS) in never depressed patients, exerts a negative effect on the cardiac prognosis. Nonetheless only a few studies have evaluated the risk factor for incident depression and, particularly, no study have investigated the role of personality disorders. Therefore, the aim of this study is to verify if personality disorders represent a risk for incident depression in patients at their first ACS.Method: The study sample was selected among never depressed patients who were consecutively admitted to the Coronary Intensive Care Unit, from January 2009 to March 2012, for the first ACS. The study sample included 262 patients. The presence of depressive disorder was assessed with the Primary Care Evaluation of Mental Disorders (DSM-IV criteria), whereas its severity was evaluated with the Hospital Anxiety and Depression Scale. Evaluations were collected at baseline and at 1, 2, 4, 6, 9, 12 and 24 months of follow-up. Moreover, at baseline personality disorders were investigated with the Structured Clinical Interview for DSM-IV Axis II disorders.Results: Out of 262 subjects, a depressive disorder was diagnosed in 56 patients (21%). At baseline risk factors for incident depression were being widowed, having a distress reaction and narcissistic personality traits.Conclusion: Clinicians should keep in mind these characteristics when facing patients at their first ACS, given the detrimental effect of depression on cardiac prognosis. A psychological support should prevent the onset of incident depression in these patients.

Physical health comorbidities in women with personality disorder: Data from the Geelong Osteoporosis Study

Background

Associations between common psychiatric disorders, psychotic disorders and physical health comorbidities are frequently investigated. The complex relationship between personality disorders (PDs) and physical health is less understood, and findings to date are varied. This study aims to investigate associations between PDs with a number of prevalent physical health conditions.

Methods

This study examined data collected from women (n = 765; ≥ 25 years) participating in a population-based study located in south-eastern Australia. Lifetime history of psychiatric disorders was assessed using the semi-structured clinical interviews (SCID-I/NP and SCID-II). The presence of physical health conditions (lifetime) were identified via a combination of self-report, medical records, medication use and clinical data. Socioeconomic status, and information regarding medication use, lifestyle behaviors, and sociodemographic information was collected via questionnaires. Logistic regression models were used to investigate associations.

Results

After adjustment for sociodemographic variables (age, socioeconomic status) and health-related factors (body mass index, physical activity, smoking, psychotropic medication use), PDs were consistently associated with a range of physical health conditions. Novel associations were observed between Cluster A PDs and gastro-oesophageal reflux disease (GORD); Cluster B PDs with syncope and seizures, as well as arthritis; and Cluster C PDs with GORD and recurrent headaches.

Conclusions

PDs were associated with physical comorbidity. The current data contribute to a growing evidence base demonstrating associations between PDs and a number of physical health conditions independent of psychiatric comorbidity, sociodemographic and lifestyle factors. Longitudinal studies are now required to investigate causal pathways, as are studies determining pathological mechanisms.

Narcissistic and Borderline Personality Disorders: Relationship With Oxidative Stress

The authors hypothesized that personality disorders characterized by interpersonal hypersensitivity would be associated with an elevated concentration of 8-hydroxy-2'-deoxyguanosine (8-OH-DG), the oxidized form of guanine, and a biomarker of oxidative stress burden. One hundred ninety-five male and female adults underwent semistructured diagnostic interviews, completed questionnaire measures of social cognition and emotional attribution, and had blood drawn for determination of plasma 8-OH-DG. A hierarchical linear regression model revealed that narcissistic and borderline personality disorders predicted 8-OH-DG level independently of the effects of age, gender, recent alcohol and cigarette use, current major depression, and posttraumatic stress disorder. In all subjects, 8-OH-DG level was also correlated with the number of borderline personality disorder symptoms present. Narcissistic and borderline personality disorders predicted oxidative stress burden independently of potentially confounding factors.

Antipsychotic Exposure in Pregnancy and the Risk of Gestational Diabetes: A Systematic Review and Meta-analysis

BACKGROUND

We have limited knowledge about the effects of antipsychotic exposure on the development of gestational diabetes mellitus (GDM). Aim of this study is to perform a systematic review and meta-analysis to assess GDM risk associated with antipsychotic exposure in pregnancy.

METHODS

Systematic literature search was performed using PubMed, Science Direct, Scopus, and Web of Science databases up to August 22, 2018. No restrictions to language or date were applied. Randomized, controlled trials, case-control, or cohort studies reporting GDM risk in antipsychotic-exposed, healthy controls or antipsychotic-ceased patients were included in the meta-analysis. The primary outcomes were study defined GDM, including number of events, odds ratios, and/or risk ratios (RR) with confidence intervals (CI).

RESULTS

Ten studies were included in the meta-analysis. The total number of subjects was 6213 for the antipsychotic-exposed group, 6836 for antipsychotic-ceased control group, and 1 677 087 for the healthy control group. Compared with the healthy controls, the unadjusted cumulative RR for GDM associated with antipsychotic use was 1.63 (95% CI = 1.20-2.22). Adjusted risk for GDM was significantly higher in antipsychotic exposure group than in healthy controls (RR = 1.30, 95% CI = 1.023-1.660). The adjusted RR for GDM was similar between the antipsychotic-exposed group and the antipsychotic-ceased group (RR = 0.78, 95% CI = 0.281-2.164). No significant association was found between study quality, smoking, alcohol use, gestational age, and cumulative GDM risk.

DISCUSSION

Our results indicate an increased risk of GDM with antipsychotic exposure in pregnant women, who may benefit from close pregnancy monitoring, early testing for GDM, targeting modifiable risk factors, and lifestyle modifications.

Incidence and temporal trends of co-occurring personality disorder diagnoses in immune-mediated inflammatory diseases

AIMS

Although immune-mediated inflammatory diseases (IMID) are associated with multiple mental health conditions, there is a paucity of literature assessing personality disorders (PDs) in these populations. We aimed to estimate and compare the incidence of any PD in IMID and matched cohorts over time, and identify sociodemographic characteristics associated with the incidence of PD.

METHODS

We used population-based administrative data from Manitoba, Canada to identify persons with incident inflammatory bowel disease (IBD), multiple sclerosis (MS) and rheumatoid arthritis (RA) using validated case definitions. Unaffected controls were matched 5:1 on sex, age and region of residence. PDs were identified using hospitalisation or physician claims. We used unadjusted and covariate-adjusted negative binomial regression to compare the incidence of PDs between the IMID and matched cohorts.

RESULTS

We identified 19 572 incident cases of IMID (IBD n = 6,119, MS n = 3,514, RA n = 10 206) and 97 727 matches overall. After covariate adjustment, the IMID cohort had an increased incidence of PDs (incidence rate ratio [IRR] 1.72; 95%CI: 1.47-2.01) as compared to the matched cohort, which remained consistent over time. The incidence of PDs was similarly elevated in IBD (IRR 2.19; 95%CI: 1.69-2.84), MS (IRR 1.79; 95%CI: 1.29-2.50) and RA (IRR 1.61; 95%CI: 1.29-1.99). Lower socioeconomic status and urban residence were associated with an increased incidence of PDs, whereas mid to older adulthood (age 45-64) was associated with overall decreased incidence. In a restricted sample with 5 years of data before and after IMID diagnosis, the incidence of PDs was also elevated before IMID diagnosis among all IMID groups relative to matched controls.

CONCLUSIONS

IMID are associated with an increased incidence of PDs both before and after an IMID diagnosis. These results support the relevance of shared risk factors in the co-occurrence of PDs and IMID conditions.

Physical Comorbidities are Independently Associated with Higher Rates of Psychiatric Readmission in a Chinese Han Population

BACKGROUND

In people with psychosis, physical comorbidities are highly widespread and leading contributors to the untimely death encountered. Readmission rates in psychiatric patients are very high. Somatic comorbidities could be one of the considerable risk factors for psychiatric rehospitalization. Nevertheless, much less is known about the relation between physical comorbidities and psychiatric readmission. We aimed to investigate the association between physical comorbidities and psychiatric readmission in Han Chinese patients with psychiatric disorders.

METHODS

We used administrative data for January 1, 2009 to December 31, 2018 from the headquarters of the Affiliated Brain Hospital of Guangzhou Medical University to identify adults with schizophrenia, unipolar depression or bipolar disorder discharged from hospital. Data were extracted on sociodemographic and clinical characteristics. The Charlson comorbidity index (CCI) was used to assess the existence of significant physical comorbidity. Cox proportional hazards regression estimated rehospitalization risk after discharge.

RESULTS

A total of 15,620 individuals were included in this study, with the mean age of 35.1 years (SD = 12.8), and readmission occurred for 23.6% of participants. Survival analysis showed that physical comorbidities were statistically and significantly associated with psychiatric readmission, even after the adjustment for the number of psychiatric comorbidities, other sociodemographic and clinical variables.

CONCLUSION

Our results suggest that somatic comorbidities are related with higher rates of psychiatric readmission. Hence, to treat psychosis more effectively and to reduce rehospitalization, it is crucial to treat physical comorbidities promptly and adequately. It is absolutely necessary to bring somatic comorbidities to the forefront of psychiatric treatment and research.

Screening for Personality Disorders: A Three-Item Screener From the Inventory of Interpersonal Problems (IIP-3)

To encourage screening for personality disorders (PDs), we developed (in previous work) self-report scales for PDs using the Inventory of Interpersonal Problems (IIP). The combined score from three of the scales-inter-personal sensitivity, interpersonal ambivalence, and aggression-requiring 15 items (IIP-15) did the best job of distinguishing between respondents with any versus no PD. The goals for the present work were (a) to cross-validate the IIP-15 by examining its performance using receiver operating characteristics (ROC) analyses in a new sample (N = 410), and (b) to investigate the utility of a brief three-item variant (IIP-3). The present results again documented the good operating characteristics of the IIP-15. Sensitivity, specificity, and positive and negative predictive values were all above. 70. The operating characteristics of the IIP-3 were nearly as good despite its brevity and support its use as an initial screen for PDs.

Associations of PTSD, chronic pain, and their comorbidity on cannabis use disorder: Results from an American nationally representative study

BACKGROUND

Cannabis can be prescribed for posttraumatic stress disorder (PTSD) and chronic pain, and comorbid cannabis use disorder (CUD) can occur in both conditions. Research demonstrates that PTSD and chronic pain commonly co-occur.

METHODS

Data were acquired from the National Epidemiologic Survey on Alcohol and Related Conditions-III (N = 36,309). Past-year CUD and PTSD were assessed using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-5. Past-year physician-confirmed chronic pain was self-reported and classified as musculoskeletal (e.g., arthritis), digestive (e.g., pancreatitis), and nerve (e.g., reflex sympathetic dystrophy) pain. Weighted cross-tabulations assessed sociodemographic, psychiatric, and chronic pain condition variables among those with PTSD versus no PTSD, among the entire sample and among those with CUD and chronic pain. Multiple logistic regressions examined the relationship between PTSD and chronic pain with CUD. CUD characteristics were also evaluated across PTSD and chronic pain groups.

RESULTS

Rates of CUD were elevated in PTSD (9.4%) compared to those without (2.2%). The odds of CUD were greater for PTSD+digestive pain, PTSD+nerve pain, and PTSD+any chronic pain compared to having neither PTSD nor chronic pain (odds ratio range: 1.88-2.32). PTSD with and without comorbid chronic pain was associated with overall elevated rates of adverse CUD characteristics, including earlier age of onset, greater usage, and greater CUD severity.

CONCLUSIONS

PTSD with and without chronic pain is associated with elevated rates and severity of CUD. These results may have implications for prescribing practices and understanding individuals at risk for developing CUD.

A population-based examination of suicidality in comorbid generalized anxiety disorder and chronic pain

BACKGROUND

Generalized anxiety disorder (GAD) and chronic pain conditions commonly co-occur, and are both independently associated with suicidality; however, little is known about the impact of chronic pain on suicidality among individuals with GAD. The aim of this study was to examine the associations between comorbid GAD and chronic pain conditions with suicide ideation, plans, and attempts in a population-based sample.

METHODS

We analyzed data from the 2012 Canadian Community Health Survey-Mental Health (CCHS-MH; N = 25,113). Multiple logistic regressions examined the associations between comorbid GAD and chronic pain conditions (i.e., arthritis, migraine, back pain; reference = GAD alone) with suicidality (i.e., ideation, plans, and attempts).

RESULTS

After adjusting for sociodemographics, other psychiatric conditions, and other chronic pain conditions, results indicated that compared to GAD alone, comorbid GAD and migraine was associated with increased odds of suicide ideation and plans (adjusted odds ratio (AOR) range: 2.55-3.00) and comorbid GAD and arthritis was associated with increased odds of suicide attempts (AOR = 4.10, 95% CI [1.05-16.01]).

LIMITATIONS

The cross-sectional nature of the survey design does not permit causal assumptions regarding the emergent associations and the self-report assessment of chronic pain conditions may be associated with response biases.

CONCLUSIONS

Results highlight the burden of chronic pain on suicidality among individuals with GAD. These results emphasize the importance of assessing risk of suicidality among individuals with comorbid GAD and chronic pain conditions, particularly migraine and arthritis.

Personality disorders and physical comorbidities: a complex relationship

PURPOSE OF REVIEW

It is not uncommon for clinicians to label patients' complaints as 'psychogenic' when they present with symptoms that are difficult to understand. This article reviews recent reports about the comorbidity of personality disorders and nonpsychiatric medical problems, which call into question the adequacy of the mind-body dichotomy in medicine.

RECENT FINDINGS

The strong association of any personality disorders with poor health in cross-sectional and community-based studies is now confirmed by personality disorder predicting future deterioration in longitudinal studies. Borderline personality disorder has been studied most frequently, but recent data suggest that severity of any personality disorder is associated with poor and worsening health.

SUMMARY

Personality disorder is associated with the full range of physical, mental, and social disorders. Greater attention to the common features of personality disorders, which are crucial for the self-regulation of behavior, would facilitate more effective health promotion and disease prevention across all medical specialties, thereby helping to relieve the burdens of chronic common diseases.

Physical health-related quality of life among older adults with personality disorders

Objectives: Personality Disorders (PDs) are associated with a multitude of negative consequences. The negative PD effects on health can be even more burdensome for older adults given the physical and social functioning changes that occur with age; however, the majority of research examining the influence of PDs focuses on younger adults. The present study seeks to investigate the relationship between PDs and physical health-related quality of life (PHRQoL) in adults over the age of 50. Methods: Data for 16,884 adults ages 50 and older from the 2001-2002 National Epidemiological Survey on Alcohol and Related Conditions (NESARC) were analyzed. Multiple linear regression models were analyzed to investigate the relationships of seven PDs and participants' PHRQoL. Results: All PDs except histrionic and avoidant PD had statistically significant negative associations with PHRQoL scores, indicating that respondents diagnosed with PDs were expected to have lower PHRQoL than those without PDs, after controlling for sociodemographic characteristics. When psychosocial covariates were added to the model, only dependent, obsessive-compulsive and paranoid PDs were significantly related to PHRQoL score. Conclusions: For adults ages 50 and older, a diagnosis of PD was weakly associated with lower PHRQoL scores for three PDs, however this is unlikely to be a causal association. The strength of the relationship between PDs and PHRQoL varies by type of PD. Given the higher rates of functional and social changes that occur with age, future research should focus on potential causes of worse physical health among older adults with PDs.

A systematic review of interventions aimed at improving the cardiovascular health of people diagnosed with personality disorders

PURPOSE

People with personality disorders have significantly reduced life expectancy and increased rates of cardiovascular disease compared to members of the general population. Given that more people die annually of cardiovascular disease across the globe than from any other cause, it is important to identify the evidence for interventions aimed at improving cardiovascular health among people with personality disorders.

METHODS

Systematic literature review. PsycINFO, MEDLINE and EMBASE were searched using NICE Healthcare Databases, as well as CENTRAL and trial registries. We sought to identify randomised controlled trials of interventions pertaining to adults with a primary diagnosis of personality disorder, where the primary outcome measure was cardiovascular health before and after the intervention.

RESULTS

A total of 1740 records were identified and screened by two independent reviewers. No papers meeting the inclusion criteria were identified.

CONCLUSIONS

This systematic review did not identify any randomised controlled trials testing interventions aimed at improving the cardiovascular health of people with personality disorders. Research in this area could have important public health implications, spanning the fields of psychiatry and general medicine.

Psychosis and Schizophrenia-Spectrum Personality Disorders Require Early Detection on Different Symptom Dimensions

Psychotic disorders and schizophrenia-spectrum personality disorders (PD) with psychotic/psychotic-like symptoms are considerably linked both historically and phenomenologically. In particular with regard to schizotypal and schizotypal personality disorder (SPD), this is evidenced by their placement in a joint diagnostic category of non-affective psychoses in the InternationaI Classification of Diseases 10th Revision, (CD-10) and, half-heartedly, the fifth edition of Diagnostic and Statistical Manual of Mental Disorders, (DSM-5). Historically, this close link resulted from observations of peculiarities that resembled subthreshold features of psychosis in the (premorbid) personality of schizophrenia patients and their biological relatives. These personality organizations were therefore called "borderline (schizophrenia)" in the first half of the 20th century. In the 1970s, they were renamed to "schizotypal" and separated from psychotic disorders on axis-I and from other PD on axis-II, including modern borderline PD, in the DSM. The phenomenological and historical overlap, however, has led to the common assumption that the main difference between psychotic disorders and SPD in particular was mainly one of severity or trajectory, with SPD representing a latent form of schizophrenia and/or a precursor of psychosis. Thus, psychosis proneness and schizotypy are often assessed using SPD questionnaires. In this perspective-piece, we revisit these assumptions in light of recent evidence. We conclude that schizotypy, SPD (and other schizophrenia-spectrum PD) and psychotic disorder are not merely states of different severity on one common but on qualitatively different dimensions, with the negative dimension being predictive of SPD and the positive of psychosis. Consequently, in light of the merits of early diagnosis, the differential early detection of incipient psychosis and schizophrenia-spectrum PD should be guided by the assessment of different schizotypy dimensions.

Arthritis in adults, socioeconomic factors, and the moderating role of childhood maltreatment: cross-sectional data from the National Epidemiological Survey on Alcohol and Related Conditions

These data present associations between socioeconomic status (SES), different types of childhood maltreatment (CM) history and family dysfunction, and arthritis in men and women across a wide age range. Arthritis was less likely among those with higher SES, regardless of CM history.

INTRODUCTION

CM has been associated with increased risk of adult-onset arthritis; however, little is known about whether socioeconomic status moderates arthritis risk in those with CM history. We investigated arthritis across education, income, and race/ethnicity and whether CM moderated associations between SES and arthritis.

METHODS

Data were drawn from Wave 2 (2004-2005) of the nationally representative (USA) National Epidemiological Survey on Alcohol and Related Conditions (NESARC, n = 34,563; aged ≥ 20 years). Self-reported CM history included physical abuse, sexual abuse, emotional abuse, emotional neglect, physical neglect, and exposure to intimate partner violence (IPV). We used descriptive statistics and logistic regression to determine relationships between SES, CM, and arthritis. Interaction terms were used to test if CM moderated relationships between SES and arthritis.

RESULTS

Arthritis prevalence was 21.1% (n = 3093) among men and 30.1% (n = 6167) among women. In unadjusted analyses, women (p ≤ 0.001) and older age (both sexes, p ≤ 0.01) were associated with increased odds of arthritis. All CM types were associated with increased odds of arthritis, except exposure to IPV among women. In sex-stratified, age-adjusted analyses, lower education and income, family dysfunction, being Hispanic or Asian/Native Hawaiian/Pacific Islander, and ≥ 1 physical comorbidity were associated with increased odds of arthritis among those with and without CM: trends were similar for both sexes. In age-adjusted two-way interaction terms, CM did not moderate associations between SES and arthritis.

CONCLUSIONS

Although CM was associated with arthritis, associations between SES and arthritis were not amplified. Arthritis was less likely among those with higher SES, regardless of CM history.

Maladaptive Eating in Posttraumatic Stress Disorder: A Population-Based Examination of Typologies and Medical Condition Correlates

Posttraumatic stress disorder (PTSD) and eating pathology are frequently comorbid, and both are independent risk factors for various medical conditions. Using population-based data collected as part of the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III; N = 36,309), the primary objectives of this study were to (a) identify eating pathology classes among PTSD and (b) investigate associations between maladaptive eating and medical conditions among PTSD. Using the Alcohol Use Disorder and Associated Disabilities Interview Schedule (AUDADIS-5), we assessed PTSD and maladaptive eating symptoms in accordance with the DSM-5. We used a latent class analysis to identify maladaptive eating typologies among adults with lifetime PTSD (n = 2,339; 6.1%) and multivariable logistic regression models to examine associations between each of the six emergent maladaptive eating typologies and medical conditions. Results revealed that over 40% of individuals with PTSD endorsed indicators of maladaptive eating. In addition, each maladaptive eating typology among PTSD was significantly associated with unique sociodemographic characteristics and increased odds of medical conditions relative to no PTSD and no eating disorder, adjusted odds ratios (AORs) = 1.34-6.55, and PTSD with no eating psychopathology, AORs = 1.43-5.11. Results of this study provide a better understanding of maladaptive eating in adults with PTSD and potential medical sequelae. Results indicate maladaptive eating may be an important mechanism in the association between PTSD and medical conditions, which may inform targeted interventions among individuals with these comorbidities.

Posttraumatic stress disorder and chronic pain are associated with opioid use disorder: Results from a 2012-2013 American nationally representative survey

BACKGROUND

Chronic pain conditions and posttraumatic stress disorder (PTSD) commonly co-occur and are associated with opioid use disorder (OUD). The aims of this paper were to identify prevalence estimates of OUD among individuals with and without PTSD and assess independent and combined contributions of PTSD and chronic pain conditions on OUD in a nationally representative sample.

METHODS

Data were extracted from 36,309 individuals from the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions. Past-year PTSD and OUD were assessed using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-5 edition. Respondents reported physician-confirmed, past-year chronic pain conditions, categorized into musculoskeletal pain (e.g., arthritis), digestive pain (e.g., pancreatitis), and nerve pain (e.g., reflex sympathetic dystrophy). We examined the weighted prevalence of OUD among those with and without PTSD. Multiple logistic regressions examined the association between PTSD and chronic pain conditions on OUD.

RESULTS

The prevalence of OUD was higher among those with PTSD than those without. Comorbid PTSD/musculoskeletal pain and PTSD/nerve pain conditions were associated with increased odds of OUD, compared to those with neither PTSD nor chronic pain conditions. Digestive pain conditions were not associated with OUD. Comorbid PTSD/musculoskeletal pain conditions demonstrated an additive relationship on OUD compared to musculoskeletal pain conditions and PTSD alone.

CONCLUSIONS

Results reveal that musculoskeletal pain and nerve pain conditions are associated with increased odds of OUD, but only musculoskeletal pain conditions display an additive relationship on OUD when combined with PTSD. These findings have implications for opioid management and screening among those with comorbid conditions.

Comorbidity in illness-induced posttraumatic stress disorder versus posttraumatic stress disorder due to external events in a nationally representative study

OBJECTIVE

The current study compared physical and mental health characteristics and quality of life of illness-induced posttraumatic stress disorder (PTSD) versus those with PTSD due to external traumatic events in a population-based sample.

METHOD

PTSD was assessed with the Alcohol Use Disorder and Associated Disabilities Interview Schedule (AUDADIS-5) using DSM-5 criteria in the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions. Participants with past-year PTSD (n = 1779) were categorized into two groups: illness-induced (6.5%) and other trauma-induced PTSD (92.9%) based on index trauma. Group differences in physical health, mental health, and quality of life were estimated using multiple logistic and linear regressions with adjustment for demographics and medical morbidity.

RESULTS

Compared to PTSD due to external events, illness-induced PTSD had higher rates of life-threatening illness in the past year. Illness-induced PTSD compared to PTSD due to external events was associated with reduced odds of depressive/bipolar disorders and antisocial personality disorder, but increased odds of cannabis use disorder. The groups did not differ on quality of life after accounting for medical morbidity.

CONCLUSION

Illness-induced PTSD is common among American adults and has a similar impact on quality of life as PTSD due to external events, but may have distinct mental health correlates.

High Prevalence of Physical Pain Among Treatment-Seeking Individuals With Borderline Personality Disorder

Research has demonstrated that about 30% of chronic pain patients suffer from borderline personality disorder (BPD), yet pain is not often discussed in research on the treatment of BPD. Sixty-five patients entering outpatient treatment for BPD were assessed at baseline for the prevalence of DSM-IV lifetime pain disorder, current medical problems, and the experience of current pain as measured by the McGill Pain Questionnaire. DSM-IV lifetime pain disorder diagnosis was present in 65% of patients. Current pain was experienced by 89% of participants, with intensity ranging from mild (19%) to excruciating (2%). Some individuals (21.5%) also reported experiencing daily medical problems in the past month prior to entering treatment. Physical pain is highly prevalent among treatment-seeking individuals with BPD. This pain phenomenon should be considered during treatment to help prevent a lifetime of functional impairment, including the possibility of abusing substances as a maladaptive coping mechanism.

Borderline personality disorder

Caretakers are often intimidated or alienated by patients with borderline personality disorder (BPD), compounding the clinical challenges posed by the severe morbidity, high social costs and substantial prevalence of this disorder in many health-care settings. BPD is found in ∼1.7% of the general population but in 15-28% of patients in psychiatric clinics or hospitals and in a large proportion of individuals seeking help for psychological problems in general health facilities. BPD is characterized by extreme sensitivity to perceived interpersonal slights, an unstable sense of self, intense and volatile emotionality and impulsive behaviours that are often self-destructive. Most patients gradually enter symptomatic remission, and their rate of remission can be accelerated by evidence-based psychosocial treatments. Although self-harming behaviours and proneness to crisis can decrease over time, the natural course and otherwise effective treatments of BPD usually leave many patients with persistent and severe social disabilities related to depression or self-harming behaviours. Thus, clinicians need to actively enquire about the central issues of interpersonal relations and unstable identity. Failure to correctly diagnose patients with BPD leads to misleading pharmacological interventions that rarely succeed. Whether the definition of BPD should change is under debate that is linked to not fully knowing the nature of this disorder.

Personality disorder is an excess risk factor for physical multimorbidity among women with mental state disorders

We examined whether mental state disorders (lifetime mood, anxiety, eating, substance misuse) with comorbid personality disorder are associated with physical multimorbidity in a population-based sample of women. Mental state and personality disorders were assessed using semi-structured diagnostic interviews. Clinical measures were performed and medical conditions, medication use and lifestyle factors were documented by questionnaire. Mental state disorders were associated with higher odds of physical multimorbidity; risk was especially high for those with comorbid personality disorder. These findings suggest that mental state and physical comorbidity might be worsened by the additional comorbidity of personality disorder.

Narcissistic Personality Disorder in Clinical Health Psychology Practice: Case Studies of Comorbid Psychological Distress and Life-Limiting Illness

Narcissistic Personality Disorder (NPD) is characterized by a persistent pattern of grandiosity, fantasies of unlimited power or importance, and the need for admiration or special treatment. Individuals with NPD may experience significant psychological distress related to interpersonal conflict and functional impairment. Research suggests core features of the disorder are associated with poor prognosis in therapy, including slow progress to behavioral change, premature patient-initiated termination, and negative therapeutic alliance. The current manuscript will explore challenges of working with NPD within the context of life-limiting illness for two psychotherapy patients seen in a behavioral health clinic at a large academic health science center. The ways in which their personality disorder affected their illness-experience shared significant overlap characterized by resistance to psychotherapeutic change, inconsistent adherence to medical recommendations, and volatile relationships with providers. In this manuscript we will (1) explore the ways in which aspects of narcissistic personality disorder impacted the patients' physical health, emotional well-being, and healthcare utilization; (2) describe psychotherapeutic methods that may be useful for optimizing psychosocial, behavioral, and physical well-being in individuals with co-morbid NPD and life-limiting disease; and (3) review conceptualizations of NPD from the DSM-5 alternative model for assessing personality function via trait domains.

The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) Waves 1 and 2: review and summary of findings

PURPOSE

The NESARC, a "third-generation" psychiatric epidemiologic survey that integrated detailed measures of alcohol and drug use and problems has been the data source for over >850 publications. A comprehensive review of NESARC findings and their implications is lacking.

METHOD

NESARC was a survey of 43,093 participants that covered alcohol, drug and psychiatric disorders, risk factors, and consequences. Wave 1 of the NESARC was conducted in 2001-2002. Three years later, Wave 2 follow-up re-interviews were conducted with 34,653 of the original participants. Scopus and Pubmed were used to search for NESARC papers, which were sorted into topic areas and summarized.

RESULT

The most common disorders were alcohol and posttraumatic stress disorders, and major depression. Females had more internalizing disorders and males had more externalizing disorders, although the preponderance of males with alcohol disorders (the "gender gap") was less pronounced than it was in previous decades. A race/ethnic "paradox" (lower risk among disadvantaged minorities than whites) remains unexplained. Younger participants had higher risk for substance and personality disorders, but not unipolar depressive or anxiety disorders. Psychiatric comorbidity was extensive and often formed latent trans-diagnostic domains. Since 1991-1992, risk for marijuana and prescription drug disorders increased, while smoking decreased, although smoking decreases were less pronounced among those with comorbidity. A nexus of comorbidity, social support, and stress predicted transitions in diagnostic status between Waves 1 and 2. Childhood maltreatment predicted psychopathology. Alcohol and drug use disorders were seldom treated; attitudinal barriers (little perceived need, perceived alcoholism stigma, pessimism about efficacy) were more important in predicting non-treatment than financial barriers.

CONCLUSIONS

Understanding comorbidity and the effects of early stressors will require research incorporating biologic components, e.g., genetic variants and brain imaging. The lack of treatment for alcohol and drug disorders, predicted by attitudinal rather than financial variables, suggests an urgent need for public and professional education to reduce the stigma associated with these disorders and increase knowledge of treatment options.