Diagnosing personality disorders in psychiatric inpatients

Destigmatizing Borderline Personality Disorder: A Call to Action for Psychological Science

Despite recognition that borderline personality disorder (BPD) is one of the most stigmatized psychological disorders, destigmatization efforts have thus far focused on the views and actions of clinicians and the general public, neglecting the critical role that psychological science plays in perpetuating or mitigating stigma. This article was catalyzed by recent concerns about how research and editorial processes propagate stigma and thereby fail people with BPD and the scientists who study BPD. We provide a brief overview of the BPD diagnosis and its history. We then review how BPD has been stigmatized in psychological science, the gendered nature of BPD stigma, and the consequences of this stigmatization. Finally, we offer specific recommendations for researchers, reviewers, and editors who wish to use science to advance our understanding of BPD without perpetuating pejorative views of the disorder. These recommendations constitute a call to action to use psychological science in the service of the public good.

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’.

Incidence and comorbidity of personality disorders among first ever admitted psychiatric patients

During a period of one year, 157 first ever admitted psychiatric patients in the age group 18-49 years from a catchment area of 217,649 persons were interviewed with the Present State Examination 10th edition, development version and the Personality Disorder Examination, 1988 version. Of the sample, 23% received at least one DSM III-R personality disorder (PD) diagnosis. Rates avoidant PD, very few borderline PDs were found. Almost all patients with PDs also had major psychiatric disorders and the sample was biased towards younger individuals with more severe Axis I symptomatology compared with first ever admitted psychiatric patients aged 18-49 years in Denmark. Cluster A was associated with schizophrenia, cluster B with alcohol or other substance use disorders, and cluster C with anxiety disorders. Within Axis II, schizotypal PD was associated with avoidant and dependent PD, and paranoid with antisocial and dependent PD.

Psychotherapy of Dependent Personality Disorder: The Relationship of Patient-Therapist Interactions to Outcome

So far, only a few studies have focused on psychotherapy for Dependent Personality Disorder (DPD). DPD is marked by a repetitive pattern of efforts aiming at maintaining close relationships, which may present as a lack of assertiveness and as a difficulty in making routine decisions. The present study aims at exploring processes of change taking place during the working phase of a clarification-oriented psychotherapy (COP) by focusing on the in-session patient-therapist interaction, as it changes during treatment and their links with treatment outcome. Methods: N = 74 patients with DPD were recruited in a naturalistic setting; they underwent long-term COP. Sessions 15, 20 and 25 were video- or audio-recorded and analyzed using the Process-Content-Relationship Scale, an observer-rated instrument that measures the quality of the interaction processes from patient's and therapist's perspectives. Therapy outcomes were assessed with the Personality Inventory - Dependency Subscale, Beck Depression Inventory, Inventory of Interpersonal Problems and Self-efficacy Scale at intake and discharge of therapy. Three-level Hierarchical Linear Modeling was applied to test the hypotheses. Results: Improvement in interaction processes was observed in all patient's and therapist's variables over the sessions 15, 20, 25. Overall, this increase in quality of interaction process was unrelated with outcome, but decrease in dependency traits was predicted by increase in therapist's quality of relationship offer, understanding of content and directivity over the course of the working phase of COP. Conclusions: Studying interaction processes in DPD provides an initial understanding of differential roles of potential mechanisms of change in effective treatment.

The relationship between self-reported borderline personality features and prospective illness course in bipolar disorder

BACKGROUND

Although bipolar disorder (BD) and borderline personality disorder (BPD) share clinical characteristics and frequently co-occur, their interrelationship is controversial. Especially, the differentiation of rapid cycling BD and BPD can be troublesome. This study investigates the relationship between borderline personality features (BPF) and prospective illness course in patients with BD, and explores the effects of current mood state on self-reported BPF profiles.

METHODS

The study included 375 patients who participated in the former Stanley Foundation Bipolar Network. All patients met DSM-IV criteria for bipolar-I disorder (n = 294), bipolar-II disorder (n = 72) or bipolar disorder NOS (n = 9). BPF were assessed with the self-rated Personality Diagnostic Questionnaire. Illness course was based on 1-year clinician rated prospective daily mood ratings with the life chart methodology. Regression analyses were used to estimate the relationships among these variables.

RESULTS

Although correlations were weak, results showed that having more BPF at baseline is associated with a higher episode frequency during subsequent 1-year follow-up. Of the nine BPF, affective instability, impulsivity, and self-mutilation/suicidality showed a relationship to full-duration as well as brief episode frequency. In contrast all other BPF were not related to episode frequency.

CONCLUSIONS

Having more BPF was associated with an unfavorable illness course of BD. Affective instability, impulsivity, and self-mutilation/suicidality are associated with both rapid cycling BD and BPD. Still, many core features of BPD show no relationship to rapid cycling BD and can help in the differential diagnosis.

Premorbid Personality Disorders in Male Schizophrenic Patients with or without Comorbid Substance Use Disorder: Is Dual Diagnosis Mediated by Personality Disorder?

INTRODUCTION

Although substance abuse is an important clinical problem in schizophrenic patients, very little evidence explains why these patients use drugs and alcohol. This study therefore aimed to examine whether premorbid personality disorders affect substance abuse.

METHODS

The sample included 40 male schizophrenic patients with and 40 male schizophrenic patients without substance use disorder comorbidity who had applied to Ankara Numune Research and Training Hospital. Each participant and a family member were interviewed in a structured clinical interview that addressed premorbid personality disorders.

RESULTS

Altogether, 32 patients (80%) in the group with comorbidity and 28 (70%) in the group without comorbidity had a premorbid personality disorder. Antisocial (35% vs. 0%; p<.001) and borderline (37.5% vs. 5%; p=.001) personality disorders were more often detected in the group with comorbidity, while avoidant (10% vs. 35%; p=.014) and obsessive-compulsive (0% vs. 15%; p=.026) personality disorders were less frequently found in this group. Comparing the group with comorbidity with premorbid personality types, schizophrenic patients with premorbid antisocial personality disorder were more frequently unemployed and hospitalized as well as had an earlier onset age of schizophrenia (p=.034, p=.038 and p=.035, respectively). Schizophrenic patients with premorbid borderline personality disorder had a significantly earlier onset age of substance use (19±5; p=.028).

CONCLUSION

Schizophrenic patients with substance use comorbidity variously differ from those without comorbidity and some of these differences may be associated with premorbid personality disorders.

The relationship between borderline personality disorder and bipolar disorder

It is clinically important to recognize both bipolar disorder and borderline personality disorder (BPD) in patients seeking treatment for depression, and it is important to distinguish between the two. Research considering whether BPD should be considered part of a bipolar spectrum reaches differing conclusions. We reviewed the most studied question on the relationship between BPD and bipolar disorder: their diagnostic concordance. Across studies, approximately 10% of patients with BPD had bipolar I disorder and another 10% had bipolar II disorder. Likewise, approximately 20% of bipolar II patients were diagnosed with BPD, though only 10% of bipolar I patients were diagnosed with BPD. While the comorbidity rates are substantial, each disorder is nontheless diagnosed in the absence of the other in the vast majority of cases (80% to 90%). In studies examining personality disorders broadly, other personality disorders were more commonly diagnosed in bipolar patients than was BPD. Likewise, the converse is also true: other axis I disorders such as major depression, substance abuse, and post-traumatic stress disorder are also more commonly diagnosed in patients with BPD than is bipolar disorder. These findings challenge the notion that BPD is part of the bipolar spectrum.

Prevalence of premorbid personality disorder and its clinical correlates in patients with delusional disorder

The aim of this study was to investigate the presence of premorbid Personality Disorder (PD) and its relationship with clinical correlates in patients with Delusional Disorder (DD). Eighty-six outpatients with DD whose diagnoses were confirmed using the Structured Clinical Interview for DSM-IV Axis I (SCID-I) Disorders (psychosis module) were evaluated for premorbid PD utilizing the Standardized Assessment of Personality (SAP). Psychopathology was assessed using Module B of SCID-I and the Positive and Negative Syndrome Scale (PANSS); psychosocial functioning was evaluated with the Global Assessment of Functioning scale. Premorbid intelligence was assessed using the Wechsler Adult Intelligence Scale-Third Edition, vocabulary subtest. A sociodemographic-clinical questionnaire was completed. Sixty-four percent of the patients had at least one premorbid PD, the most common being paranoid PD (38.4%), followed by schizoid PD (12.8%). The presence of at least one premorbid PD was significantly associated with higher scores for psychopathology, in particular, on the affective dimension of DD symptoms. However, the presence of premorbid PD was not associated with psychosocial functioning. Each of the premorbid PD was associated with different psychopathological profiles. Premorbid PD is a relevant phenomenon in DD, given its high prevalence and comorbidity, its influence on clinical correlates and its potential ability to predict specific sub-syndromes.

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.

Affective lability in bipolar disorder and borderline personality disorder

BACKGROUND

The boundaries between the affective instability in bipolar disorder and borderline personality disorder have not been clearly defined. Using self-report measures, previous research has suggested that the affective lability of patients with bipolar disorder and borderline personality disorder may have different characteristics.

METHODS

We assessed the mood states of 29 subjects meeting Revised Diagnostic Interview for Borderlines and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for BPD and 25 subjects meeting DSM-IV criteria for bipolar II disorder or cyclothymia using the Affective Lability Scale (ALS), the Affect Intensity Measure (AIM), and a newly developed clinician-administered instrument, the Affective Lability Interview for Borderline Personality Disorder (ALI-BPD). The ALI-BPD measures frequency and intensity of shifts in 8 affective dimensions. Subjects in the borderline group could not meet criteria for bipolar disorder; subjects in the bipolar/cyclothymia group could not meet criteria for BPD.

RESULTS

Patients in the bipolar group had significantly higher scores on the euthymia-elation subscale of the ALS; patients in the BPD group had significantly higher scores on the anxiety-depression subscale of the ALS. Patients with bipolar disorder had significantly higher total AIM scores and significantly higher score on the AIM positive emotion subscale. In terms of frequency, patients in the borderline group reported the following: (1) significantly less frequent affective shifts between euthymia-elation and depression-elation on the ALI-BPD and (2) significantly more frequent shifts between euthymia-anger, anxiety-depression, and depression-anxiety. In terms of intensity, borderline patients reported the following: (1) significantly less intense shifts between euthymia-elation and depression-elation on the ALI-BPD and (2) significantly more intense shifts between euthymia-anxiety, euthymia-anger, anxiety-depression, and depression-anxiety.

CONCLUSION

The affective lability of patients with borderline and bipolar II/cyclothymic can be differentiated with respect to frequency and intensity using both self-report and clinician-administered measures.

Personality disorders: prevalence and demography at a psychiatric outpatient in North India

BACKGROUND

Even though personality disorders are common among psychiatric populations, the data from India on their prevalence and demography are sparse.

AIM

To profile the prevalence and demography of personality disorders in North India.

METHODS

The retrospective study was based on patients attending the outpatient of a general hospital psychiatric centre in North India between June 1996 and June 2006. The specified data were collected from the case records of those receiving a primary or comorbid ICD-10 diagnosis of a personality disorder.

RESULTS

Personality disorders had a prevalence of 1.07%, with a preponderance of those aged 21-40 years (69.4%), men (64.9%), employed and students (37.3% and 32.8% respectively), unmarried (56%), graduates and undergraduates (27.6% each), and referred by the family (68.7%). The most common personality disorders were anxious-avoidant and borderline. Compared with the anxious-avoidant group, the borderline group was younger (mean age 24.44 vs 29.66 years) and had a preponderance of females (60% vs 27.1%).

CONCLUSION

The prevalence of personality disorders among the psychiatric outpatients was low compared to most of the research literature reporting clinically diagnosed personality disorders. The differences between the borderline and anxious-avoidant personality disorder subjects were largely explained by interrelated demographic variables.

Medication prescribed to people with personality disorder: the influence of patient factors and treatment setting

OBJECTIVE

To examine the extent of use and clinical rationale for the prescribing of psychotropic drugs for people with personality disorder (PD) who are in contact with mental health services.

METHOD

Clinical records of 278 patients with a primary diagnosis of PD were examined.

RESULTS

Just over 80% (N = 225) of patients were being prescribed psychotropic medication. One in five was prescribed three or more drugs. People with comorbid mental disorders were more likely to receive psychotropic medication. Half those prescribed antidepressants had no record of depression in their records. While drug treatments were mostly prescribed for depressive and psychotic symptoms, they were also used to try to manage behavioural problems such as self-harm or given in response to patient requests for treatment. People receiving specialist PD services (OR = 0.35, 95% CI = 0.13-0.95) or other specialist services (OR = 0.24, 95% CI = 0.10-0.60) were less likely to be prescribed drug treatments.

CONCLUSION

Drug treatments are widely used for people with PD despite the relatively weak evidence base. Both the type of personality problem and the context in which treatment is delivered appear to have an impact on whether drug treatments are prescribed.

Reconceptualizing personality pathology in DSM-5: limitations in evidence for eliminating dependent personality disorder and other DSM-IV syndromes

The DSM-5 Personality and Personality Disorders Workgroup proposed that five DSM-IV personality disorders be eliminated as formal diagnostic categories (paranoid, schizoid, histrionic, narcissistic, and dependent), because these syndromes purportedly have low clinical utility and minimal evidence for validity. Scrutiny of studies cited in support of this proposal reveals difficulties in three areas: (1) Inadequate information regarding parameters of the literature search; (2) Mixed empirical support for proposed changes; and (3) Selective attention to certain disorders and not others. Review of validity and clinical utility data related to dependent personality disorder indicates that evidence regarding this syndrome does not differ from that of syndromes proposed for retention in DSM-5. Limitations in the research base cited by the workgroup illuminates gaps in the personality disorder literature, and may serve as a starting point for systematic research on personality pathology so that adequate empirical data are available to decide which syndromes to retain, revise, or remove in future versions of the diagnostic manual.

Examining the course and outcome of individuals diagnosed with schizophrenia and comorbid borderline personality disorder

This research examined the prevalence of comorbid borderline personality disorder (BPD) in a sample of schizophrenia inpatients, and then investigated the degree to which BPD comorbidity impacted symptom and functional outcomes after 1-year post-hospital discharge. A sample of 142 individuals with a diagnosis of schizophrenia (n = 100) or schizoaffective disorder (n = 42) from the MacArthur Violence Risk Assessment Study were administered the Structured Interview for DSM-III-R Personality (SIDP-R). Symptom and functional outcome data were gathered during hospitalization and at 1-year follow-up to analyze differences in symptom and functioning characteristics between those diagnosed with and without BPD. Results indicated that comorbid BPD was present in a non-trivial proportion (17.6%, n = 25) of the sample, based on SIDP-R assessment. Baseline analyses indicated that patients with BPD presented with modest elevations in the severity of overall psychiatric symptomatology, and higher levels of anxiety and depression, at hospitalization compared to non-BPD patients. At 1-year follow-up, results revealed that after adjusting for baseline differences, patients with schizophrenia and comorbid BPD showed significantly less improvement in psychiatric symptomatology, particularly hostility and suspiciousness, as well as global functioning, and were re-hospitalized at significantly higher rates than patients without BPD. Our findings indicate that the co-occurrence of schizophrenia and BPD is not infrequent and that BPD has a significant negative longitudinal impact on the course and outcome of patients with schizophrenia.

Is the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, histrionic personality disorder category a valid construct?

PURPOSE

The study investigated crucial aspects of the construct validity of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) histrionic personality disorder (HPD) category.

MATERIAL AND METHODS

The study included 2289 patients from the Norwegian Network of Psychotherapeutic Day Hospitals. Construct validity was assessed by means of prevalence, comorbidity with other personality disorders, internal consistency among HPD criteria, severity indices, as well as factor analyses.

RESULTS

The prevalence of HPD was very low (0.4 %). The comorbidity was high, especially with borderline, narcissistic, and dependent personality disorders. The internal consistency was low. The criteria seemed to form 2 separate clusters: the first contained exhibitionistic and attention-seeking traits and the other contained impressionistic traits.

CONCLUSION

The results indicated poor construct validity of the HPD category. Different options for the future of the category are discussed. The authors suggest the HPD category to be deleted from the DSM system. However, the clinical phenomena of exhibitionism and attention-seeking, which are the dominant personality features of HPD, should be preserved in an exhibitionistic subtype of narcissism.

Does avoidant personality disorder impact on the outcome of treatment for bulimia nervosa?

OBJECTIVE

To examine the impact of avoidant personality disorder (AVPD) on bulimia nervosa (BN) treatment outcome over 3 years.

METHOD

Women with BN were participating in a randomized treatment trial. The sample was split into: AVPD (n = 37), other PD (n = 37), and no PD (n = 60). Eating disorder symptomatology, depressive symptoms and psychosocial functioning were examined at pretreatment and follow-up. Multiple regression was conducted to control for high axis I comorbidity.

RESULTS

There were no significant differences across the groups at pretreatment or follow-up on eating disorder symptoms. AVPD had worse depressive symptoms and psychosocial functioning at pretreatment which continued 3 years post-treatment. Multiple regression analyses revealed that the presence of any lifetime mood disorder contributed to these significant results.

DISCUSSION

These findings suggest AVPD is not a significant predictor of BN outcome. However, AVPD is associated with poorer psychiatric symptoms although much of this variance appears to be attributable to the lifetime presence of any mood disorder.

[Medicolegal aspects of hospital treatment of violent mentally ill persons]

INTRODUCTION

This paper deals with medicolegal aspects of the hospital treatment of patients suffering from severe mental disorders and who are prone to violent behaviour, dangerous to self and others. Violent acts in this study were defined as deliberate and nonconsensual acts of actual, attempted or threatened harm to a person or persons, and classified into categories of any type of violence, physical violence and non-physical violence, which is in accordance with approaches used in other risk assessment researches,

OUTLINE OF CASES

The authors present four cases of mentally ill inpatients whose violent behaviour toward self or other persons resulted in self-destruction and physical aggression against other persons. The presented cases involved: 1) self-injury in a patient with acute organic mental disorder after jumping through a hospital window, 2) suicide by drowning of a patient with acute mental disorder after escaping from intensive care unit, 3) suicide in a depressive patient after escaping from a low-security psychiatry unit, 4) physical violence against body and life of other persons in a patient with chronic mental disorder.

CONCLUSION

The presented cases are considered to be rare in clinical practice and risk of violent behaviour and the consequent danger of mentally ill inpatients may be efficiently predicted and prevented with appropriate hospital management based on 1) repeated escalation of violent behaviour and 2) protection of the patient and others. Hence, if the physician in order to prevent harmful consequences, does not apply all the necessary measures, including appropriate diagnostic and therapeutic procedures, as well as treatment in an adequate setting, such act is against the Criminal Law of the Republic of Serbia which sanctions physician's negligence. Also, according to the Law on Obligations of the Republic of Serbia this presents a legal ground for damage claim and the requirement of liability for nonmaterial damage within a civil procedure.

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.

The prevalence of personality disorder in schizophrenia and psychotic disorders: systematic review of rates and explanatory modelling

BACKGROUND

Personality disorder (PD) in psychosis is poorly studied. As PD can affect outcome in mental disorders, it is important to understand its prevalence in order to plan services, understand prognosis more fully and maximize management options. MethodLiterature searching revealed 3972 potential papers. Twenty papers including 6345 patients were included in the final analysis. There was great variation in prevalence and multilevel modelling was used to identify possible reasons for this heterogeneity.

RESULTS

The prevalence of PD varied from 4.5% to 100%. Multilevel analysis suggested country of study, study type, the instruments used to diagnose PD and patient care correlated with the prevalence data explaining the study level heterogeneity, with 34.2, 33.4, 17.0 and 4.5% by each variable respectively. Personality studies in Canada and Sweden reported lower PD prevalence, whereas in Spain it was higher than the multinational study. Compared with randomized controlled trials, case-control studies reported lower prevalence [odds ratio (OR)=0.35, 95% confidence interval (CI) 0.15-0.79] and observational studies higher prevalence (OR 70.5, 95% CI 8.5-583). Primary-care patients were less likely to be diagnosed (OR 0.02, 95% CI 0-0.19) than hospital patients, and out-patients had higher prevalence (OR 12.5, 95% CI 1.77-88.6).

CONCLUSIONS

The reported prevalence of PD in schizophrenia varies significantly. Statistical modelling suggests care, country, study type and diagnostic tools for PD all bias prevalence rates. The number of papers reaching the inclusion criteria, the relative paucity of information and the difficulties in developing an accurate statistical model limited interpretation from the study.

Normal personality characteristics in schizophrenia: a review of the literature involving the FFM

Schizophrenia is generally viewed as a disruption of normal functioning because of an underlying core illness. A number of theorists have speculated that this core illness may unilaterally disrupt normal personality functioning. However, recent data suggests that the relationship may be more complex and reciprocal than previously conceptualized. Furthermore, basic personality characteristics appear to be associated with numerous clinical phenomena. This article reviews the empirical literature pertaining to normal personality characteristics [structured around the five-factor model (FFM) of personality] in individuals with schizophrenia. Evidence suggests that certain personality characteristics may be uniquely related to the etiology of psychosis, as well as symptom severity, occupational functioning, cigarette smoking, substance use and violent behavior, social isolation, and suicidality in patients with schizophrenia. The implications of these findings and suggestions for future research are discussed.

The interface between borderline personality disorder and bipolar spectrum disorders

OBJECTIVE

This review examines whether borderline personality disorder (BPD) should be considered part of the bipolar spectrum.

METHODS

A literature review examined studies of co-occurrence, phenomenology, family prevalence, medication response, longitudinal course, and etiology.

RESULTS

Borderline personality disorder and bipolar disorder co-occur, but their relationship is not consistent or specific. There are overlaps but important differences in phenomenology and in medication response. Family studies suggest clear distinctions, and it is unusual for BPD to evolve into bipolar disorder. Research is insufficient to establish whether these disorders have a common etiology.

CONCLUSIONS

Existing data fail to support the conclusion that BPD and bipolar disorders exist on a spectrum but allows for the possibility of partially overlapping etiologies.

Conduct disorder and antisocial personality disorder in persons with severe psychiatric and substance use disorders

Conduct disorder (CD) and antisocial personality disorder (ASPD) are established risk factors for substance use disorders in both the general population and among persons with schizophrenia and other severe mental illnesses. Among clients with substance use disorders in the general population, CD and ASPD are associated with more severe problems and criminal justice involvement, but little research has examined their correlates in clients with dual disorders. To address this question, we compared the demographic, substance abuse, clinical, homelessness, sexual risk, and criminal justice characteristics of 178 dual disorder clients living in 2 urban areas between 4 groups: No CD/ASPD, CD Only, Adult ASPD Only, and Full ASPD. Clients in the Adult ASPD Only group tended to have the most severe drug abuse severity, the most extensive homelessness, and the most lifetime sexual partners, followed by the Full ASPD group, compared with the other 2 groups. However, clients with Full ASPD had the most criminal justice involvement, especially with respect to violent charges and convictions. The results suggest that a late-onset ASPD subtype may develop in clients with severe mental illness secondary to substance abuse, but that much criminal behavior in clients with dual disorders may be due to the early onset of the full ASPD syndrome in this population and not the effects of substance use disorders.

Substance use in persons with schizophrenia: baseline prevalence and correlates from the NIMH CATIE study

This study examined baseline correlates of substance use in the NIMH Clinical Antipsychotic Trials of Intervention Effectiveness project. Approximately 60% of the sample was found to use substances, including 37% with current evidence of substance use disorders. Users (with and without substance use disorders), compared with nonusers, were significantly more likely to be male, be African-American, have lower educational attainment, have a recent period of homelessness, report more childhood conduct problems, have a history of major depression, have lower negative symptom and higher positive symptom scores on the Positive and Negative Syndrome Scale, and have a recent illness exacerbation. Individuals with comorbid substance use disorders were significantly more likely to be male, report more childhood conduct problems, have higher positive symptom scores on the Positive and Negative Syndrome Scale, and have a recent illness exacerbation. These analyses suggest that substance use disorders in schizophrenia are especially common among men with a history of childhood conduct disorder problems and that childhood conduct disorder problems are potent risk factors for substance use disorders in schizophrenia.

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.

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.

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.

Personality dimensions and neuropsychological performance in first-degree relatives of patients with schizophrenia and affective psychosis

Several studies have found a significant increase in the prevalence of some personality disorders in the first-degree relatives of patients with schizophrenia; other studies have found subtle neuropsychological deficits in these relatives. However, little is known about the specificity of the personality traits reported or about the relationship between these traits and the neuropsychological deficits.One-hundred first-degree relatives of patients with schizophrenia (SR) and 88 first-degree relatives of affective psychotic patients (APR) completed the Eysenck Personality Questionnaire which measures extraversion, neuroticism, and psychoticism; they were also administered the National Adult Reading Test (NART), the Trail Making Test (TMT) and a Verbal Fluency Test (VFT). The male relatives of patients with schizophrenia scored significantly higher on the psychoticism scale than the male relatives of affective psychotic patients. In the SR group, there were significant correlations between the TMT performance and the extraversion scores and, between the IQ scores and the psychoticism scores. However, when logistical regression analyses were performed, none of the three personality scores predicted any of the neuropsychological performance in either the SR or the APR group. These results indicate some specificity as well as sex differences in the psychoticism dimension. Moreover, the relationship between the personality dimensions and the neuropsychological performance could indicate that psychoticism increases vulnerability to psychosis whereas extraversion decreases it.

Predictors of stable personality disorder diagnoses in outpatients with remitted depression

This study examined the stability of comorbid personality disorder diagnoses once an outpatient's depression remitted. The sample consisted of 75 outpatients who responded to treatment in an 8-week acute treatment phase for depression, who met criteria for remission throughout a 26-week continuation phase, and who completed a personality assessment (Structured Clinical Interview for DSM-III-R-axis II Disorders) at the beginning and at the end of each treatment phase. The authors found that after a major depressive disorder is successfully treated, personality disorder diagnoses remain stable across time during continuation treatment. Gender was the only potential predictor variable that was significant: the proportion of men who had a stable personality disorder diagnosis in cluster A or cluster B was significantly greater than the proportion of women who had a stable personality disorder diagnosis in these two clusters. Among women, those with any stable personality disorder had a significantly longer duration of the current major depressive disorder compared with those who never met criteria for any personality disorder; this was also true for women with a cluster C personality disorder diagnosis.

Trauma, PTSD, and the course of severe mental illness: an interactive model

Traumatic life events, as defined by DSM-IV, are common among persons with severe mental illnesses (SMI) such as schizophrenia. Limited evidence suggests concomitantly high rates of posttraumatic stress disorder (PTSD) in this population. However, conceptual models do not exist for understanding the interactions between trauma, PTSD, and SMI. We propose a model, which is an extension of the stress-vulnerability model, in which PTSD is hypothesized to mediate the negative effects of trauma on the course of SMI. Our model posits that PTSD influences psychiatric disorders both directly, through the effects of specific PTSD symptoms including avoidance, overarousal, and re-experiencing the trauma, and indirectly, through the effects of common correlates of PTSD such as retraumatization, substance abuse, and difficulties with interpersonal relationships. We discuss the evidence supporting this model, and consider several intervening variables that are hypothesized to moderate the proposed relationships between PTSD and SMI, including social support, coping and competence, and antisocial personality disorder. Theoretical and clinical implications of the model are considered, as well as several methodological and nosological issues. We conclude with a brief discussion of directions for future research aimed at evaluating components of the model.

Personality disorder traits: prevalence and effects on health status in primary care patients

OBJECTIVE

Previous work in an academic setting has found that scoring in the higher ranges for selected personality disorders on an objective assessment tool was associated with increases in psychiatric co-morbidities, decreased satisfaction with health care, and diminished health related functional status. This study examines how often patients in primary care practices exhibit traits consistent with these selected disorders and what impact this has on their health related functional status and use of health care resources.

METHODS

Thirteen family practices agreed to distribute questionnaires to 50 consecutive patients in the spring of 1997. Questionnaires contained instruments that assess risk for personality disorders, health related functional status, health resource use, demographics, and depression. The relationships between four specific personality disorders (borderline, dependent, schizoid and schizotypal) and other assessed variables were explored.

RESULTS

Of the 250 patients returning completed survey instruments, 80 (32%) scored in the high range for traits consistent with one of the four target personality disorders. Patients in the high risk group also were noted to have more outpatient, emergency, and inpatient visits in the previous six months. Those in the high risk group also had significantly lower scores on seven of eight measures of health related functional status.

CONCLUSIONS

Patients who have several traits for borderline, dependent, schizoid, and schizotypal personality disorders are common in primary care practices. These patients utilize services at higher rates than others and are more likely to screen in the positive range for depressive symptoms and have overall lower health related functional status.

Effects of sex and sex roles on the perceived maladaptiveness of DSM-IV personality disorder symptoms

This study investigated the influence of sex on the perceived maladaptiveness of DSM-IV personality disorder criteria based on previous findings that inconsistency of symptoms with sex roles affects the perception of personality disorder symptoms. The effects of rater characteristics (i.e., sex, sex role) were also examined. A total of 161 undergraduates (65 men, 96 women) rated the diagnostic criteria according to how maladaptive they were for males (male condition), females (female condition), or without regard to sex (neutral condition that served as a baseline) using a 7-point scale. Participants' sex role was determined using the Bem Sex Role (1981a) Inventory. Dependent and depressive personality disorder criteria (trend for borderline) were rated more maladaptive for females than males, whereas obsessive-compulsive personality disorder criteria were rated more maladaptive for males than females. Participant sex and sex role had little or no significant effects on the ratings. Results are compared with those of previous research. Methodological issues and implications for the diagnosis of personality disorders are discussed.

Premorbid personality disorders in schizophrenia

Premorbid personality disorders (PD) were studied retrospectively in 40 schizophrenic patients by interviewing the parents and patients who were reliable with the SCID-II. 85% of the patients had premorbid PDs. The most frequent premorbid PDs were: avoidant PD (32. 5%), schizoid PD (27.5%), paranoid PD (20%), dependent PD (20%) and schizotypal PD (12.5%). In most of the patients, two or more PDs could be diagnosed simultaneously (47.5%), comorbilidity of the premorbid PDs in schizophrenia being the most common one. The most frequent combination was avoidant-schizoid-schizotypal PD.

Evolution of personality disorder diagnosis in the Diagnostic and Statistical Manual of Mental Disorders

This article reviews the history and evolution of the diagnosis of personality disorders according to the Diagnostic and Statistical Manual of Mental Disorders (DSM) from its first edition in 1952 through its fourth edition in 1994. The article also traces the earliest origins of personality disorders (e.g., Hippocrates) through the modern foundational works of Pritchard, Schneider, and Horney. Analysis of the changes across the editions of the DSM suggest slow but steady progress in the clarification and classification of personality disorders, although formidable challenges remain. A call for future research as to reliability and validity of personality disorders is made, and suggestions for research are offered.

Validation of the self-report questionnaire DIP-Q in diagnosing DSM-IV personality disorders: a comparison of three psychiatric samples

The DSM-IV section of the DSM-IV and ICD-10 Personality Questionnaire (DIP-Q) was used to screen for personality disorders in 448 subjects from three clinical samples (general and forensic psychiatric patients and candidates for psychotherapy) and a sample of 139 healthy volunteers. Differences between the samples with regard to patterns of personality pathology in relation to concurrent Axis I disorders and sociodemographic variables were analysed. The prevalence of personality disorders according to DIP-Q was 14% among the healthy volunteers, compared to 59% in the general psychiatric sample, 68% in the forensic psychiatric sample and up to 90% among psychotherapy candidates. Moreover, from a dimensional perspective (i.e. the number of fulfilled Axis II criteria), all clinical groups differed significantly from the control group in all specified personality dimensions and clusters. Dimensional DIP-Q cluster scores also discriminated significantly between the three clinical samples. Unexpectedly, the odds ratio for an Axis II disorder was nearly five times higher among psychotherapy applicants than among general psychiatric patients, independent of concomitant Axis I disorders, gender or age. The strongest association between DIP-Q score and Axis I disorders was found for depressive disorders, which more than doubled the odds ratio for a personality disorder diagnosis. This association could result from high true comorbidity, but could also be due to the fact that a concomitant depressive state can increase self-reported personality difficulties. The high prevalence among psychotherapy candidates may to some extent reflect help-seeking exaggeration of problems. These are aspects to consider when using the DIP-Q, which overall appears to discriminate well between different samples.

Comorbidity of personality disorders with bipolar mood disorders

The aim of the study was to assess the prevalence of personality disorders in a group of outpatients with bipolar I disorder. The Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) was administered to 90 bipolar outpatients who met the DSM-III-R criteria and 58 control subjects. Of the patients and controls, 47.7% and 15.5%, respectively, had at least one personality disorder. At least one personality disorder in clusters A, B, and C and obsessive-compulsive, paranoid, histrionic, and borderline personality disorders were significantly more prevalent in bipolars. Suicide attempts were more frequent in patients with a history of personality disorder.

Temporal stability of antisocial personality disorder: blind follow-up study at 8 years

The study objective was to examine the temporal stability of the antisocial personality disorder (ASPD) diagnosis based on whether specific antisocial symptoms were considered to be related to substance abuse. A total of 407 adults who were initially part of a family study of alcoholism and sociopathy were blindly reassessed an average of 8 years later, using the Home Environment and Lifetime Psychiatric Evaluation Record (HELPER) and basing diagnoses on the clinician's best final estimate using all sources of data. "Narrow" and "broad" ASPD diagnoses were made at both times based on whether individual symptoms were counted toward diagnosis if they occurred in the setting of significant substance abuse. kappa values varied from 0.31 to 0.68, with more restrictive methods of diagnosis being less stable. After deriving estimates of sensitivity and specificity of diagnosis, the probability of being a "case" could be assigned based on the reported number of conduct problems occurring before age 15 as a clinical covariate for diagnosis. We conclude that diagnosing ASPD without attempting to attribute the cause of individual symptoms to substance abuse results in substantially greater temporal stability. Using a broader definition, the diagnosis of ASPD is highly sensitive (P = .97) and specific (q = 0.93). These findings may allow more accurate diagnosis of ASPD in drug-abusing individuals.

Possible correlates of DSM-III-R personality disorders

An association between personality disorder (PD) pathology, including symptoms of all PD types and Axis I disorders, and suicidal behaviour was studied in a series of 90 non-schizophrenic, non-bipolar in-patients of both sexes without mental retardation or organic brain syndrome. All of these patients, who scored positively on the SCID-II-PQ, were interviewed with the PDE and SCID-P, and with the Structured interview for the study of childhood trauma provided with supplementary items reflecting suicidal behaviour. Mood disorders were found to be significantly correlated with cluster C pathology (PD pathology always being expressed by dimensional PDE scores) and eating disorders were significantly correlated with cluster B pathology in women. Psychoactive substance use disorders were mainly correlated with cluster B pathology and anxiety disorders with cluster C pathology in both sexes. Suicidal behaviour was correlated with PD pathology of all clusters in women, but not in men. In women a strong correlation was found between suicidal behaviour and history of childhood trauma, especially sexual abuse. The results of this study indicate that there is some specificity with regard to the Axis I/Axis II association, more so in relation to PD clusters than in relation to the individual PD types. However, the relationships between PD pathology and Axis I disorders and suicidal behaviour are complex, and they differ between the sexes.

Psychiatric comorbidity differences in male and female adult psychiatric inpatients with substance use disorders

To examine gender differences in the co-occurrence of DSM-III-R axis I disorders and axis II personality disorders in young adult psychiatric inpatients with substance use disorders (SUDs), a consecutive series of 70 inpatients (33 men and 37 women) with SUD were reliably assessed with structured diagnostic interviews. Higher rates of dysthymia and eating disorders were observed in SUD females and higher rates of cluster A personality disorders were observed in SUD males. No gender differences were found for depression or anxiety in our SUD inpatients; these findings contrast with gender ratios for these disorders in the general population. In conclusion, relatively few gender differences were found in young adult inpatients with SUD, even where they would be expected based on general population gender patterns.

Gender differences in personality disorders in psychiatrically hospitalized young adults

We examined gender differences in DSM-III-R personality disorders in psychiatrically hospitalized young adults. Structured diagnostic interviews were reliably performed on a consecutive series of 118 inpatients. Men were significantly more likely to meet criteria for cluster A, schizotypal, and antisocial personality disorders. To reduce variability due to axis I heterogeneity, we retested for gender differences in a subgroup of patients with major depression. Depressed men were more likely to meet criteria for cluster A, schizotypal, and cluster C personality disorders. Women were not observed to have a higher frequency of any personality disorder than men in either study group.

Personality disorders and treatment outcome in methadone maintenance patients

This study examined the relationship between personality disorder (PDs) and 7-month treatment outcome in 197 men admitted to methadone maintenance. Subjects reported pervasive improvement, and the amount of improvement did not significantly differ for those subjects with and without PDs. PD subjects entered treatment with more severe self-reported drug, alcohol, psychiatric, and legal problems, and despite progress, remained more problematic in those areas relative to subjects without PDs. Subjects with antisocial PD had admission and 7-month problem status similar to subjects with other PDs. The 7-month urinalysis results for opiates and cocaine showed no significant differences between subjects with and without PDs. Fewer PD subjects stayed in treatment continuously for the 7-month period. Several cluster B PDs-borderline, antisocial, and histrionic-predicted poorest overall outcomes. Methadone-maintained patients with PDs may warrant additional treatment services if they are to approach the functional level of patients without PDs.

Excessive dependency and depression: is the relationship specific?

Excessive dependency has been hypothesized to be both a risk factor and a complication of depression. The purpose of this study was to test the specificity of the relationship between DSM-III-R dependent personality disorder (DPD) and depressive disorders. Two hundred subjects were independently administered the Structured Clinical Interview for DSM-III-R (SCID) and the Personality Disorder Examination (PDE) face-to-face by two experienced clinicians. Comorbidity of DPD and axis I disorders of five different types was examined. Dependent personality disorder was associated with mood disorders, both bipolar disorder and major depression, but was also associated with several anxiety disorders, bulimia, and nonaffective psychotic disorders. Dependent-personality disorder was associated with borderline, avoidant, schizotypal, obsessive-compulsive, narcissistic, and paranoid personality disorder made no significant additional contribution to the association between personality disorder and axis I disorder. These results suggest the DPD represents maladaptive traits and behaviors that cut across a range of personality psychopathology and are related to a variety of types of psychological distress. Thus, a specific++ relationship od DPD to depression was not supported.