Gender differences in personality disorders in psychiatrically hospitalized young adults

Diagnose- und Behandlungsbereitschaft der Borderline-Persönlichkeitsstörung im Jugendalter unter Therapierenden

Zusammenfassung: Theoretischer Hintergrund: Eine eingeschränkte Diagnosebereitschaft der Borderline-Persönlichkeitsstörung (BPS) im Jugendalter verhindert möglicherweise deren Früherkennung und -behandlung. Fragestellung: Die Studie zielt auf eine Quantifizierung von Diagnose- und Behandlungsbereitschaft der BPS im Jugendalter bei kinder- und jugend-/psychotherapeutischen/-psychiatrischen Therapierenden ab. Methode: Die Studie basiert auf einer Onlinebefragung von 207 Therapierenden. Ergebnisse: 32 % der Therapierenden würden ab dem 14. Lebensjahr, 56 % ab der Volljährigkeit und 12 % gar keine Diagnose einer BPS vergeben. Die Vorbehalte „mangelnde Stabilität der Persönlichkeit“ und „Sorge um Pathologisierung“ waren mit geringer Diagnosebereitschaft assoziiert. Insgesamt sind 72 % der Therapierenden bereit, Jugendliche mit BPS-Symptomatik zu behandeln. Diskussion und Schlussfolgerung: Mixed-Methods Ansätze könnten die Diskrepanz zwischen der Diagnose- und Behandlungsbereitschaft aufklären.

Gender-related distribution of personality disorders in a sample of patients with panic disorder

Objective

We examined gender differences in the frequency of DSM-IV personality disorder diagnoses in a sample of patients with a diagnosis of panic disorder (PD).

Method

One hundred and eighty-four outpatients with a principal diagnosis of PD (DSM-IV) were enrolled. All patients were evaluated with a semi-structured interview to collect demographic and clinical data and to generate Axis I and Axis II diagnoses in accordance with DSM-IV criteria.

Results

Males were significantly more likely than females to meet diagnoses for schizoid and borderline personality disorder. Compared to males, females predominated in histrionic and cluster C diagnoses, particularly dependent personality disorder diagnoses. A significant interaction was found between female sex and agoraphobia on personality disorder (PD) distribution.

Conclusions

Male PD patients seem to be characterized by more severe personality disorders, while female PD patients, particularly with co-morbid agoraphobia, have higher co-morbidity rates with personality disorders belonging to the ‘anxious-fearful cluster’.

Differential Change of Borderline Personality Disorder Traits During Dialectical Behavior Therapy for Adolescents

Despite the expansion of treatment options for adults with borderline personality disorder (BPD), research on treatment options for adolescent BPD is scarce. The aim of this study was to investigate the impact of dialectical behavior therapy for adolescents (DBT-A) on the individual trait level as primary outcome; and the frequency of suicide attempts and nonsuicidal self-injury, self-reported BPD core pathology, and general psychopathology as secondary outcomes. Seventy-two adolescents (aged 12-17 years) with full- or subsyndromal BPD were treated with DBT-A (25 single sessions, 20 sessions of skills training), and 13 patients (18.1%) withdrew during treatment. From baseline to post-treatment, the number of BPD traits decreased significantly (p ≤ .001). All secondary outcomes decreased significantly as well (p ≤ .001). Results of this uncontrolled study suggest that beside self-harm, DBT-A may also have a beneficial impact on other features of BPD.

Personality disorders and accentuations in at-risk persons with and without conversion to first-episode psychosis

AIM

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Cluster A personality disorders (PDs), particularly schizotypal PD, are considered a part of the schizophrenia spectrum and a risk factor of psychosis. The role of PDs and personality accentuations (PAs) in predicting conversion to psychosis was studied in patients symptomatically considered at risk, assuming a major role of the schizotypal subtype.

METHODS

PDs and PAs, assessed at baseline with a self-report questionnaire, were compared between risk-, gender- and age-matched at-risk patients with (n = 50) and without conversion to psychosis (n = 50).

RESULTS

Overall, Cluster A-PDs were the least frequent cluster (14%), and schizotypal PD was rare (7%). Yet, PDs in general were frequent (46%), especially Cluster B- (31%) and C-PDs (23%). Groups did not differ in frequencies of PDs, yet converters tended to have a higher expression of schizoid (P = 0.057) and Cluster A-PAs (P = 0.027). In regression analyses, schizoid PA was selected as sole but weak predictor of conversion (OR = 1.685; 95% CIs: 1.134/2.504).

CONCLUSIONS

Unexpectedly, schizotypal PD was infrequent and did not predict conversion. Conversion was best predicted by schizoid PA, indicating more severe, persistent social deficits already at baseline in later converters. This corresponds to premorbid social deficits reported for genetic high-risk children and low social functioning in at-risk patients later converting to psychosis. Further, PDs occurred frequently in at-risk patients irrespective of conversion. As psychopathology and personality relate closely to one another, this result highlights that, beyond the current narrow focus on schizotypal PD, personality-related factors should be considered more widely in the prevention of psychosis.

The relationship between impulsivity and vocational outcome in outpatient youth with borderline personality features

AIM

This study aims to examine the relationship between each Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) borderline personality feature and vocational outcome (i.e. employment and education) in a sample of young people diagnosed with borderline personality pathology.

METHODS

The sample comprised 60 young people registered with a specialist early intervention programme for borderline personality disorder (BPD). Diagnostic data and vocational information were obtained from a standardized semistructured assessment and medical record review for a period of 12 months from entry into the treatment programme.

RESULTS

DSM-IV criterion 4 'impulsivity' upon entry to the treatment programme was associated with poor vocational outcome 12 months after index assessment.

CONCLUSIONS

Although the results of the present study suggest that impulsivity is an important feature predictive of vocational functioning in BPD, and that specific intervention in impulsivity might be a critical goal for early intervention of BPD to maximize functional recovery for such patients, further studies are required to test the reliability and validity of the role of impulsivity in relation to vocational outcome of these patients.

Factor structure and diagnostic efficiency of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for avoidant personality disorder in Hispanic men and women with substance use disorders

OBJECTIVE

This study examined the internal consistency, factor structure, and diagnostic efficiency of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), criteria for avoidant personality disorder (AVPD) and the extent to which these metrics may be affected by sex.

METHOD

Subjects were 130 monolingual Hispanic adults (90 men, 40 women) who had been admitted to a specialty clinic that provides psychiatric and substance abuse services to Spanish-speaking patients. All were reliably assessed with the Spanish-Language Version of the Diagnostic Interview for DSM-IV Personality Disorders. The AVPD diagnosis was determined by the best-estimate method. After evaluating internal consistency of the AVPD criterion set, an exploratory factor analysis was performed using principal components extraction. Afterward, diagnostic efficiency indices were calculated for all AVPD criteria. Subsequent analyses examined men and women separately.

RESULTS

For the overall group, internal consistency of AVPD criteria was good. Exploratory factor analysis revealed a 1-factor solution (accounting for 70% of the variance), supporting the unidimensionality of the AVPD criterion set. The best inclusion criterion was "reluctance to take risks," whereas "interpersonally inhibited" was the best exclusion criterion and the best predictor overall. When men and women were examined separately, similar results were obtained for both internal consistency and factor structure, with slight variations noted between sexes in the patterning of diagnostic efficiency indices.

CONCLUSIONS

These psychometric findings, which were similar for men and women, support the construct validity of the DSM-IV criteria for AVPD and may also have implications for the treatment of this particular clinical population.

The HYPE Clinic: an early intervention service for borderline personality disorder

Borderline personality disorder (BPD) emerges during adolescence and young adulthood and has profound effects throughout this vulnerable developmental phase and beyond. Hitherto, clinical interventions for BPD have focused on individuals with established and/or chronic forms of the disorder. However, over the past 15 years, a body of evidence has developed supporting the reliability, validity, and clinical importance of the diagnosis of BPD in adolescence, underscoring the need for prevention and early intervention for BPD. This paper describes the work of the Helping Young People Early (HYPE) Clinic in Melbourne, Australia. HYPE is a novel indicated prevention and early intervention service for BPD in youth (15 to 25 y of age). It uses an integrated, team-based intervention model comprising time-limited cognitive analytic therapy as developed by Ryle, case management, and general psychiatric care. The HYPE intervention is supported by effectiveness data.

Co-occurrence of Axis I and Axis II disorders in female and male patients with panic disorder with agoraphobia

OBJECTIVE

The aim of this study is to compare female and male patients with panic disorder with agoraphobia (PDA) for the co-occurring Axis I and Axis II (personality) disorders, to better understand sex differences in PDA.

METHODS

The Structured Clinical Interview for Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV) Axis I Disorders, Clinician Version and the Structured Clinical Interview for DSM-IV Axis II Personality Disorders were administered to 157 consecutive outpatients (112 females and 45 males) with principal diagnosis of PDA, who sought treatment at the 2 anxiety disorders clinics. Women and men with PDA were then compared with regard to the type and frequency of the co-occurring Axis I and Axis II disorders.

RESULTS

Women with PDA had a statistically greater tendency to receive co-occurring Axis I diagnoses and a greater number of Axis I diagnoses than men. Such a difference was not found for personality disorders. However, no sex difference was found for the mean number of co-occurring Axis I and Axis II diagnoses per patient. There were significantly more women with at least one co-occurring anxiety disorder. Women had a significantly higher frequency of specific phobia, whereas men were diagnosed with hypochondriasis and past alcohol abuse or dependence significantly more often. With regard to Axis II disorders, the only significant sex difference pertained to the higher frequency of dependent personality disorder among women.

CONCLUSIONS

The results of this study suggest that there are more similarities than differences between sexes in the co-occurring Axis I and Axis II disorders. Still, the relatively specific relationships between PDA and excessive alcohol use in men and between PDA and dependent personality traits and personality disorder in women seem important and have implications for clinical practice and treatment.

Heritability of borderline personality disorder features is similar across three countries

BACKGROUND

Most of our knowledge about borderline personality disorder features has been obtained through the study of clinical samples. Although these studies are important in their own right, they are limited in their ability to address certain important epidemiological and aetiological questions such as the degree to which there is a genetic influence on the manifestation of borderline personality disorder features. Though family history studies of borderline personality disorder indicate genetic influences, there have been very few twin studies and the degree of genetic influence on borderline personality disorder remains unclear.

METHOD

Data were drawn from twin samples from The Netherlands (n=3918), Belgium (n=904) and Australia (n=674). In total, data were available on 5496 twins between the ages of 18 and 86 years from 3644 families who participated in the study by completion of a mailed self-report questionnaire on borderline personality disorder features.

RESULTS

In all countries, females scored higher than males and there was a general tendency for younger adults to endorse more borderline personality disorder features than older adults. Model-fitting results showed that additive genetic influences explain 42% of the variation in borderline personality disorder features in both men and women and that this heritability estimate is similar across The Netherlands, Belgium and Australia. Unique environmental influences explain the remaining 58% of the variance.

CONCLUSION

Genetic factors play a role in individual differences in borderline personality disorder features in Western society.

Borderline personality disorder and migraine

BACKGROUND

Borderline personality disorder (BPD) may be disproportionately common in the migraine patient population, but specific migraine features in the BPD subgroup remain incompletely characterized.

PURPOSE

To define more clearly the clinical characteristics of migraine patients with BPD, to evaluate their clinical response to aggressive headache management, and to assess the sensitivity of an instrument intended to screen for the presence of BPD.

METHODS

We evaluated 50 consecutive patients with migraine and previously documented BPD, 50 consecutive patients with migraine of all types and no history of BPD, and 50 patients with migraine and no history of BPD matched to the first group for age, gender, and headache frequency. We assessed a variety of demographic and clinical variables at baseline, and to all patients we administered the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD). Patients in Groups 1 and 3 were treated for their headaches via a uniform pharmacologic management program. Treatment outcome was assessed after 6 months.

RESULTS

In this series of migraine patients, coexisting BPD was associated with female gender, more pervasive headache, more migraine-related disability, a higher prevalence of medication overuse headache, more unscheduled visits for acute migraine treatment, a higher prevalence of active, self-reported depression, and a lower likelihood of responding to pharmacologic therapy intended for headache management. The MSI-BPD was insensitive in detecting BPD.

CONCLUSIONS

Migraine patients with coexisting BPD are clinically distinct from the migraine patient population as a whole; in particular, they are more severely affected by their headache disorder and more treatment refractory. Simple screening instruments used to detect BPD may be ineffective in the headache clinic setting.

Discriminant efficiency of antisocial and borderline personality disorder criteria in Hispanic men with substance use disorders

The authors examined the discriminant efficiency of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition ( DSM-IV ) criteria for borderline personality disorder (BPD) and antisocial personality disorder (APD). Subjects were 74 men admitted to an outpatient substance abuse program for monolingual Hispanic adults. All were reliably assessed with the Spanish-language version of the Diagnostic Interview for DSM-IV Personality Disorders. Conditional probabilities were calculated to determine the diagnostic efficiency and discriminant efficiency of BPD and APD symptoms. Twenty-five (34%) subjects met diagnostic criteria for BPD, and 16 (22%) met criteria for APD. The diagnostic co-occurrence of these disorders was statistically significant. Whereas the diagnostic efficiency of the BPD criterion set was comparable to that reported in other clinical studies, these criteria were not significantly more efficient in diagnosing BPD than APD. By contrast, the APD criteria were more efficient in diagnosing APD than BPD; this was true for both the "adult" and the "conduct disorder" APD criterion subsets. In male Hispanic outpatients with substance use disorders, BPD and APD show significant diagnostic overlap. The APD criteria are useful in discriminating these 2 disorders, whereas the BPD criteria are not. These findings have implications for the discriminant validity of the BPD and APD criteria and support the value of the conduct disorder criteria in predicting APD in adulthood.

The dearth of psychological treatment studies for anorexia nervosa

OBJECTIVE

Anorexia nervosa (AN) was first described more than 130 years ago, yet few psychological treatments have been formally studied. Our objective was to review the available studies to understand whether these may highlight directions for future investigation.

METHOD

Medline and PsycINFO were consulted to identify relevant treatment studies. Twenty psychotherapy treatment studies were identified for review. These were divided in terms of patient age (adolescent vs. adult) and type of study (uncontrolled vs. controlled).

RESULTS

Without exception, adolescent studies (uncontrolled or controlled) involved the parents or family in the treatment. The adult studies were much more varied in terms of treatments that were compared. Most studies were statistically underpowered and only one utilized manualized treatments. More recent investigations have attempted to remedy these methodologic shortcomings.

DISCUSSION

The review highlights the effectiveness of one particular treatment modality for adolescents, but emphasizes the compelling need for further and larger systematic investigation into treatments for both adolescent and adult AN.

Disclosure of a diagnosis of borderline personality disorder

OBJECTIVE

Borderline personality disorder (BPD) is a common psychiatric disorder with a prevalence of 1%-2% in the general population. BPD also has the potential to cause significant distress in the lives of patients with BPD and their families. The diagnosis of BPD, however, is often withheld from patients. The purpose of this article is to explore the history of diagnostic disclosure in medicine and psychiatry and then discuss reasons why clinicians may or may not disclose the diagnosis of BPD.

METHODS

The authors review medical literature about diagnostic disclosure and other issues that may affect the decision to disclose a diagnosis of BPD.

RESULTS

The authors discuss the historical precedents for diagnostic disclosure and reasons a clinician may not disclose the diagnosis of BPD to a patient: questions regarding the validity of BPD as a diagnosis, worries about the stigma of the diagnosis being harmful to the patient, and transference/countertransference issues common in the treatment of patients with BPD. The authors cite factors promoting disclosure, such as the ideal of patient autonomy, possibilities for psychoeducation and collaboration with the patient toward more specific and effective therapies, and the increasing availability of diagnostic information available to patients from sources other than their clinicians.

CONCLUSIONS

There are compelling reasons to make the diagnosis the subject of open examination and discussion between clinician and patient, and reasons to believe that disclosure would serve to advance the patient in his or her recovery.

Is there evidence for a male depressive syndrome in inpatients with major depression?

BACKGROUND

The question is investigated whether atypical depressive symptoms such as irritability, anger attacks, aggressiveness or abusive behavior, which are hypothesized to indicate a hypothetical male depressive syndrome are more prevalent in male than in female inpatients with unipolar major depression.

METHODS

Data were obtained from 2411 patients who had been consecutively admitted to the Department of Psychiatry of the Ludwig-Maximilians-University of Munich. Psychopathological symptoms had been assessed by a standardized documentation system (AMDP).

RESULTS

Neither frequency nor mean scores of most of the symptoms describing a male depressive syndrome differed between males and females. There were no gender differences in symptoms with respect to severity of depression, first hospitalization and duration of illness. However, gender differences emerged when regarding symptom patterns by factor analysis.

LIMITATIONS

Only inpatients were studied, and comorbidity was not considered.

CONCLUSIONS

The hypothesis of a male depressive syndrome needs further research, focusing on the gradual development of (masked) depression by men in mainly non-clinical samples.

Ethnicity and four personality disorders

The current study examined the relationship between ethnicity and DSM-IV personality disorders. The distribution of four personality disorders--borderline (BPD), schizotypal (STPD), avoidant (AVPD), and obsessive-compulsive (OCPD)--along with their criteria sets, were compared across three ethnic groups (Caucasians, African Americans, and Hispanics) using both a clinician-administered diagnostic interview and a self-report instrument. Participants were 554 patients drawn from the Collaborative Longitudinal Personality Disorders Study (CLPS) who comprised these three ethnic groups and met personality disorder criteria based on reliably administered semistructured interviews. Chi-square analyses revealed disproportionately higher rates of BPD in Hispanic than in Caucasian and African American participants and higher rates of STPD among African Americans when compared to Caucasians. Self-report data reflected similar patterns. The findings suggest that in treatment-seeking samples, Caucasians, Hispanics, and African Americans may present with different patterns of personality pathology. The factors contributing to these differences warrant further investigation.

Gender differences in borderline personality disorder: findings from the Collaborative Longitudinal Personality Disorders Study

A majority of the literature on borderline personality disorder (BPD) focuses on its occurrence in women or does not specifically assess for gender differences in clinical presentations. Some studies report that men with BPD may be more likely to be diagnosed with substance use disorders, as well as paranoid, passive-aggressive, narcissistic, sadistic, and antisocial personality disorders (PDs). Additionally, women with BPD appear to be more likely to report histories of adult physical and sexual abuse and to meet diagnostic criteria for post-traumatic stress disorder (PTSD) and eating disorders. The purpose of the present study was to further examine gender differences in BPD. Using baseline data from the Collaborative Longitudinal Personality Disorders Study (CLPS), men and women who met criteria for BPD were compared on current axis I and II disorders, BPD diagnostic criteria, childhood trauma histories, psychosocial functioning, temperament, and personality traits. Men with BPD were more likely to present with substance use disorders, and with schizotypal, narcissistic, and antisocial PDs, while women with BPD were more likely to present with PTSD, eating disorders, and the BPD criterion of identity disturbance. Generally speaking, women and men with BPD displayed more similarities than differences in clinical presentations. The differences that did emerge are consistent with those found in epidemiological studies of psychopathology and therefore do not appear unique to BPD. Additionally, many gender differences traditionally found in epidemiological samples did not emerge in BPD subjects. For example, no difference was found in rates of major depressive disorder, a condition that is more prevalent in females. Thus, BPD pathology may be a prevailing characterization that can attenuate usual gender-based distinctions.

Personality traits and personality disorders in early onset versus late onset major depression

BACKGROUND

We aimed to determine the relationship between certain personality disorders and/or personality traits and early onset major depression.

METHODS

A total of 400 depressed primary care patients were assessed for personality disorders using the SCID screen and for personality traits using the Karolinska Scales of Personality (KSP) questionnaire. Early onset was defined as onset of the first episode before the age of 26. Logistic regressions were performed to reveal relationships after adjustment for sex, age and number of previous episodes.

RESULTS

Both groups had a similar severity of current illness determined by the Montgomery-Asberg Depression Rating Scale. Those with an early onset presented with a more debilitating course, seen in the form of more depressive episodes and previous hospitalisations in spite of their younger age. Early onset was also an independent predictor for avoidant, borderline and paranoid personality disorders. It also predicted increased scores on the KSP scales Psychic anxiety, Psychasthenia, Muscular tension, Suspicion and Irritability, and decreased Socialisation.

LIMITATIONS

The evaluation was performed as a self-assessment, subjects had a superimposed major depressive episode when assessed, and subgroups of individuals were not eligible.

CONCLUSIONS

Early onset major depression is a predictor for personality pathology and deviant personality traits. A better understanding of the interplay between genetics and environment that underlies this phenomenon will help to improve the long-term course in afflicted individuals.

The Spanish-Language Version of the Diagnostic Interview for DSM-IV personality disorders: development and initial psychometric evaluation of diagnoses and criteria

We describe the development of the Spanish-Language Version of the Diagnostic Interview for DSM-IV Personality Disorders (S-DIPD-IV). Initial descriptive (frequency and gender distribution of personality disorders [PDs]) and psychometric findings (inter-rater reliability of diagnoses, internal consistency, and criteria inter-relatedness) are reported based on administration of the S-DIPD-IV to 95 adult monolingual Hispanic patients. The S-DIPD-IV had adequate inter-rater reliability for most PD (mean kappa =.83). Except for the significantly greater proportion of males diagnosed with antisocial PD, no significant gender differences in the distribution of PD were observed. Within-category inter-relatedness of PD criteria was evaluated by coefficient alpha and mean intercriterion correlations (MIC). Between-category criteria overlap was evaluated by intercategory mean intercriterion correlations between all pairs of PD (ICMIC). For PD criteria, alpha ranged .36 to .99 (mean =.75, median =.81), MIC ranged .07 to .95 (mean = .36), and ICMIC ranged.09 to.45 (mean = .24). Six PD (borderline, antisocial, narcissistic, avoidant, obsessive-compulsive, and depressive) had no instances in which their criteria sets correlated higher with those of other PD than their own. Two PD (histrionic and dependent PD) had some instances of overlap, and four PD (paranoid, schizotypal, schizoid, and passive-aggressive) had pervasive overlap with other PD criteria sets. These findings suggest the utility of the S-DIPD-IV for assessing PD in Spanish-speaking Hispanic outpatients. Our initial findings for this patient group suggest that, except for antisocial PD in males, specific PD diagnoses are not differentially distributed by gender. Moreover, except for cluster A PD, the criteria for specific PD tend to be more highly correlated within than across PD. The S-DIPD-IV appears to have utility to facilitate PD research with Hispanic groups.

Are there gender differences in DSM-IV personality disorders?

This study examined gender differences in DSM-IV personality disorders (PD) in outpatients. Structured diagnostic interviews were reliably administered to a consecutive series of 145 outpatients with a primary axis I diagnosis of binge eating disorder (BED). To further reduce variability due to heterogeneity of axis I, a subgroup of 75 patients with co-occurring major depressive disorder (MDD) was retested for gender differences. Overall, the proportion of males (34.4%) and females (27.4%) diagnosed with any PD did not significantly differ. Specific PD diagnoses were not differentially distributed by gender in the overall study group of patients with BED or in the subgroup of patients with BED and MDD, except for antisocial PD in males.

Borderline personality disorder and the chronic headache patient: review and management recommendations

BACKGROUND

Physicians and psychologists who treat headache not infrequently encounter patients with borderline personality disorder (BPD). BPD patients frequently suffer from headache, and often pose special problems in treatment. Few guidelines exist for the management of the BPD headache patient.

OBJECTIVES

To provide an overview of current concepts on BPD, including comorbidity, psychopathophysiology, and treatment. To provide an explicit framework for managing borderline behavior in patients with chronic headache.

METHODS

A literature review combined with clinical observations from the tertiary treatment of intractable headache in outpatient and inpatient settings.

RESULTS

BPD is found in almost 2% of the general population, with increased prevalence in patients with comorbid psychopathology and substance abuse. Severe headaches and migraine appear to be more prevalent in patients with BPD than the general population. A reported history of abuse is common, but must be interpreted with caution. Recent research has found reduced hippocampal volume in women patients with BPD; hypometabolism in the premotor, prefrontal, and anterior cingulate cortex, as well as the thalamic, caudate, and lenticular nuclei; and serotonergic dysfunction. Opioid medications may have an adverse influence on certain clinical features of BPD. Some patients show at least short-term improvement in dissociative behavior when given opioid antagonists. Treatment should combine appropriate pharmacotherapy with ongoing psychotherapy. Early identification of BPD is likely to improve the course of treatment. Treatment often requires explicit contracts, consistent limit-setting, confrontation, and communication between different treating professionals to avoid "splitting." The recognition and management of the doctor's own countertransference is important to successful management. Noncompliant patients may need to be terminated from treatment.

CONCLUSIONS

Specific management guidelines and the use of explicit treatment contracts can help sustain patients in treatment, reduce the risk of medication abuse, and minimize distress in the treating professional. Headaches and other symptoms in patients with BPD can be successfully managed over the course of a long-term relationship with clearly defined limits.

Sex differences in the contact rates and utilization of psychiatric services. A three-year follow-up study in northern Finland

Sex differences in the use of psychiatric services were studied in the Oulu University Central Hospital in Finland during a three-year follow-up. A one-year treated incidence cohort of new patients was used. The total cohort comprised 537 patients (46.7% were males). The annual incidence rate was 6.7 per 1,000 members of the adult population for both males and females. Compared to females, males were younger, more often unemployed, unmarried and lived alone or with parents, and did not as often have an apartment of their own. Males predominated among organic psychoses, personality disorders and dependencies, females among neurotic disorders. Males more often had had previous inpatient care and inpatient care at index contact, and had more admissions, compulsory admissions and emergency outpatient contacts than females. However, there were no sex differences in the use of planned outpatient contacts, in the duration of hospital care and in the total consumption of psychiatric care. Male gender was an independent predictor of hospital admissions.

Personality disorder comorbidity in early-onset versus late-onset major depression in Japan

This study explored the comorbidity of DSM-III-R personality disorders in early-onset versus late-onset major depression in Japan. The subjects were 117 consecutive outpatients with major depression, with 26 classified as having an early onset (first depressive episode at age 22 or earlier) and 91 classified as having a late onset (first depressive episode at age 23 or later). Personality disorders were assessed using the Structured Clinical Interview for DSM-III-R Personality Disorders after a 2-month antidepressant treatment. The results indicated that early-onset major depression was characterized by greater personality disorder comorbidity than late-onset major depression in Japan. Subjects with any one cluster A or B personality disorder were more prevalent in the early-onset group. In terms of each personality disorder, histrionic, narcissistic, and borderline patients were more prevalent, and the number of criteria met for schizotypal and cluster B personality disorders was significantly larger in early-onset major depression after corrections for age and gender. The results suggested that the higher prevalence of personality pathologies in early-onset major depression may reflect a higher likelihood to convert into bipolar disorders or a stronger impact of having experienced depressive episodes in young individuals. The possibility that the predisposing personality pathology may be different in early-onset and late-onset major depression is also discussed.