A systematic review of personality disorder, race and ethnicity: prevalence, aetiology and treatment

Trends of mental health care utilization among US adults from 1999 to 2018

BACKGROUND

Mental health disorders affect millions of US adults, however, the trends and related factors for mental health care utilization in the US remain unknown.

AIMS

Our study aimed to assess the trend of mental health utilization and related socio-demographic factors in the US.

METHODS

The study included 55,052 individuals from the National Health and Nutrition Examination Survey (NHANES) in 1999-2018. Temporal trends in the percentages of mental health care utilizers were estimated across survey cycles. Trends and linked factors of mental health care utilization were assessed by a logistic regression model, while the non-linearity was estimated by restricted cubic splines.

RESULTS

From 1999 to 2018, the percentage of mental health care utilizers in the US adult population increased from 7.0 to 11.3% (P < 0.001); meanwhile, the trends in males and females were consistent. The percentage increased positively with age in individuals aged 20-39 (P < 0.001) or aged 60 and over (P = 0.003). The trends were consistent in three race/ethnicity groups (P < 0.05). The logistic regression analysis revealed that several disparities existed in the subpopulations. Older age, female, lower family poverty-income ratio (PIR), chronic diseases, higher educational level, and smoking were estimated to be associated with a higher percentage of mental health care.

CONCLUSIONS

The percentage of mental health care utilizers took on an increasing trend in the US adult population from 1999 to 2018. These trends were also observed in the subpopulations, but with disparities. Future research for exploring factors associated with mental health care utilizations is necessary.

The Prevalence and Clinical Characteristics of Borderline Personality Disorder in South Korea Using National Health Insurance Service Customized Database

PURPOSE

The purpose of the present study was to identify the prevalence and clinical characteristics of borderline personality disorder (BPD) in South Korea using the Korean National Health Insurance database (DB).

MATERIALS AND METHODS

We used the National Health Insurance Service (NHIS)'s research DB (NHIS-2021-1-790) from January 1, 2010 to December 31, 2019, to make customized DB including sociodemographic information and absence or presence of BPD and other psychiatric disorders. The prevalence and the age of onset of BPD was estimated. To compare medical service utilization between the BPD group and the control group, a 1:1:1 propensity score matching was employed, and the regression analysis was conducted.

RESULTS

The prevalence of BPD per 10000 people was 0.96 in 2010 and 1.06 in 2019. The prevalence ratio of males to females was 1:1.38 in 2010 and 1:1.65 in 2019, showing that BPD was more prevalent in females. The patients' overall average age of onset was 33.19±14.6 years, with the highest prevalence shown in 8503 people in their 20s. By administrative district, the highest prevalence of BPD per 10000 people was shown in Seoul with 8.71 and the lowest in Jeollanam-do with 2.35. The BPD patients showed a pattern of extensive use of general and mental healthcare services.

CONCLUSION

This study identified the prevalence of BPD on a national DB set in South Korea. Although the prevalence of BPD in South Korea was relatively low compared to other countries, there was a steady increase in the number of BPD patients over a decade, which may be possibly due to an increased awareness of mental health and campaigns among healthcare providers and users in the country.

Are We Thinking about the Same Disorder? A Trifactor Model Approach to Understand Parents' and Their Adolescents' Reports of Borderline Personality Pathology

Multiple informant assessment is the norm when evaluating borderline personality pathology (BPP) in adolescence, especially by including reports from both parents and adolescents. However, these reports tend to be discrepant, and it is unclear how to integrate. The current study used a trifactor model to isolate sources of variance in parents' and adolescents' reports of BPP due to their shared and unique perspectives in a sample of 652 inpatient adolescents (63% female; Mage = 15.31, SD = 1.45) and their parents (81% mothers). Consensus/agreement was characterized by the externalizing features of BPP whereas idiosyncratic views of adolescent BPP covered the full latent BPP construct, suggesting that simple aggregation of parent and adolescent reports is inappropriate. Measurement invariance suggested that unique perspectives were characterized by slightly different operationalizations of BPP and response biases for specific features of BPP. Attachment security and parents' interpersonal problems predicted shared and unique perspectives differently for female and male adolescents. Lastly, we found that shared and unique perspectives differentially predicted interview based BPP, length of stay, and adolescent mentalizing. In sum, findings replicate previous evidence of parent-child informant discrepancy in youth psychopathology, broadly, and provide insights specific to BPP. Discussion includes practical recommendations for assessment and interpretation of BPP assessment.

Correlates of Homelessness Among Adults with Personality Disorder

Although personality disorders (PDs) are more common among persons experiencing homelessness than the general population, few studies have investigated the risk of experiencing homelessness among persons with PDs. This study seeks to identify the demographic, socioeconomic, and behavioral health correlates of past-year homelessness among persons with antisocial, borderline, and schizotypal PDs. Nationally representative data of the civilian, noninstitutionalized population of the United States was used to identify correlates of homelessness. Descriptive statistics and bivariate associations between variables and homeless status were summarized prior to conducting several multivariate logistic regression models to identify correlates of homelessness. Main findings revealed positive associations between poverty, relationship dysfunction, and lifetime suicide attempt with homelessness. In the antisocial PD (ASPD) and borderline PD (BPD) models, comorbid BPD and ASPD, respectively, were associated with higher odds of past-year homelessness. Findings underscore the importance of poverty, interpersonal difficulties, and behavioral health comorbidities on homelessness among persons with ASPD, BPD, and schizotypal PD. Strategies to promote economic security, stable relationships, and interpersonal functioning may buffer against the effects of economic volatility and other systemic factors that could contribute to homelessness and persons with PD.

Screening for borderline personality pathology on college campuses

Although borderline symptoms show a normative decline throughout adulthood, severe psychosocial impairment often remains. Identifying personality pathology in college-age students may help prevent "adaptive failure" that can occur during the critical period of development from puberty through the late 20s and thus reduce impairment later in life. The aims of the current study were to estimate the prevalence of borderline personality disorder (BPD) in a diverse college sample, determine which symptoms confer the greatest relative risk of screening positive for BPD and examine the utility of the Personality Inventory for DSM-5 brief form (PID-5-BF) in identifying BPD. Participants were 1456 undergraduate students, and 312 individuals (21.4% of the sample) screened positive for BPD. Chronic feelings of emptiness conferred the greatest relative risk of any symptom; students who endorsed this symptom were 15 times more likely to screen positive for BPD than those who did not. Scales and composite scores of the PID-5-BF demonstrated diagnostic accuracy ranging from sufficient to excellent. The current study contributes to literature concerning best practices in screening for personality pathology in young adults. Results suggest that chronic feelings of emptiness are significant for detecting at-risk students and implications for the use of the PID-5-BF are discussed.

Evaluating Measures of Externalizing Personality Pathology Traits in Black and White American Adolescents in a Program for at-Risk Youths

Adolescent personality assessment measures can aid in the identification of traits that are associated with various types of maladjustment. Externalizing personality pathology traits (e.g., antisocial, borderline, and narcissistic personality disorder features) are particularly relevant for many problematic outcomes, yet measures that assess these traits have not been validated extensively in diverse samples. The present study aimed to examine the properties of measures of externalizing personality pathology traits in a sample of White (n = 184) and Black (n = 99) adolescents participating in a residential program for at-risk youth. The fit of the proposed structure for these measures was tested in the sample as a whole and in each racial group separately. Associations between these measures and the count of disciplinary infractions received while in the program were also tested. Measures were found to have less than optimal fit in this sample, especially among Black adolescents. Suggestions for future research and clinical use of these measures are discussed.

Multidimensional conceptualization of identity and psychopathology: Assessing mental health disparities from an intersectional and dimensional framework

Black, Indigenous, and People of Color (BIPOC) currently constitute 40% of the US population and will become the majority by 2045. Current mental health systems have not sufficiently accounted for disparities, inequities, and social determinants impacting BIPOC lives. We outline several advances that could improve mental health disparities research. Research on BIPOC requires mental health assessment accurately capturing multiple facets of one's identity, taking into account the complexities of multifaceted historical oppression. Assessing (personality) psychopathology in a dimensional and hierarchical manner could provide greater insight into mental health disparities between diverse identity individuals. We encourage studying moderators that are protective assets for BIPOC-such as resiliency and community factors-as opposed to deficit-dominant, category-based, and majority-dominant assessments.

The clinical utility of the ICD-11 classification of personality disorders and related traits: A preliminary scoping review

OBJECTIVES

A diagnostic system that fails to deliver clinically useful information will not be utilized and consequently will be unable to provide valuable data for health policy and clinical decision making. Therefore, it is imperative to obtain an accurate depiction of the clinical utility of the eleventh revision of the International Classification of Diseases (ICD-11) Personality Disorder (PD) model. The current mixed-methods systematic review aimed to determine the clinical utility of the ICD-11 PD classification system.

METHOD

An electronic screening of six databases was conducted and resulting studies were subjected to specific exclusion criteria, which elicited eight studies of interest. Study characteristics were tabulated and methodological quality was appraised.

RESULTS

Four studies offered strong support for the model's clinical utility, three offered some support accompanied by notable limitations and one study could only offer criticisms.

CONCLUSION

Future investigation of the ICD-11 PD classification system's (a) communicative value between clinicians and their patients, and between clinicians and their patient's families; (b) ease of use; and (c) feasibility in terms of practical application is required to achieve a complete understanding of its clinical utility and ultimately bring clarity to the current ambiguous findings.

Clinical ethnography in severe mental illness: a clinical method to tackle social determinants and structural racism in personalised care

Ethnic inequalities in the experiences and outcomes of severe mental illness are well established. These include a higher incidence of severe mental illnesses (psychoses), adverse pathways into and through care, including crisis care, police and criminal justice systems involvement, and care under the powers of the Mental Health Act. The situation persists despite awareness and is driven by a mixture of the social determinants of poor health, societal disadvantage and structural racism, as well as conflictual interactions with care systems, which themselves are configured in ways that sustain or deepen these inequalities. Although training and education are often proposed, this is not shown to have sustained effects. Clinical processes (interviewing/assessment/formulation/intervention) need to address systemic influences and improve the cultural precision with which care is delivered, organised and commissioned. We discuss clinical ethnography and present evidence of its value in addressing systemic as well as individual care needs for diverse communities.

Personality disorder prevalence and correlates in a whole of nation dataset

PURPOSE

The epidemiology of personality disorder is poorly understood. This study aims to describe the population in contact with mental health services with a diagnosis of personality disorder and compare service use between this group and those with a diagnosis of depression.

METHODS

Investigation of a routinely collected clinical data set across New Zealand was conducted. We used data from 2008 to 2017 and 1-year data from 2016, the most complete dataset. This allowed for variation over the years and confirmation within a 1-year prevalence. These data were analysed focusing on patients with a primary diagnosis of any personality disorder and the subset with borderline personality disorder (BPD). BPD was chosen as the most common clinical personality disorder diagnosis and that most researched.

RESULTS

8884 (2.8%) of the population in contact with mental health services carried a primary diagnosis of personality disorder. Personality diagnosis other than antisocial personality disorder (ASPD) in men and borderline personality disorder (BPD) in either gender was negligible. Rates of personality pathology increased with social deprivation and were commonest in young adults. Multi-morbidity was the norm, with internalising disorder common. Maori diagnosed with PD were over-represented both in the patient group and by population.

CONCLUSION

Borderline personality disorder and antisocial personality disorder are routinely diagnosed in routine clinical practice in New Zealand; however, other categorical diagnoses are not made. Patients with PD are significant users of resources in comparison to depressed patients. Resource utilisation was significantly greater in those with PD, in particular use of inpatient services compared to those with depression.

Personality Inventory for DSM-5 in China: Evaluation of DSM-5 and ICD-11 Trait Structure and Continuity With Personality Disorder Types

The Personality Inventory for the DSM-5 (PID-5) is an established tool for assessing personality disorder (PD) traits that was developed based on section III of the DSM-5. It is composed of 220 items, organized into 25 facets, which are distributed among five domains. The psychometric properties of the Chinese version of the PID-5 remain to be demonstrated. Two samples were embodied in this study that included 3,550 undergraduates and 406 clinical patients. To probe the structure of the PID-5, parallel analyses were conducted to explore the unidimensionality of its 25 facets and a series of confirmatory factor analyses (CFAs) were carried out to confirm the 25 lower-order facets and their distribution among five higher-order domains. Then, the PID-5 was employed to measure the DSM-5 and ICD-11 trait models and to explore the relationship of DSM-IV categorical PDs with DSM-5 and ICD-11 personality traits. Correlation and regression analyses were conducted to probe how well DSM-IV categorical PDs correspond with maladaptive personality traits specified in the DSM-5 and five ICD-11 domains. The respective average internal reliability coefficients of the 25 facets obtained for undergraduate and clinical patient samples were 0.76 and 0.81, those obtained for the five DSM-5 domains were 0.89 and 0.91, and those obtained for the five ICD-11 domains were 0.87 and 0.89. Serial CFAs confirmed the rationality of the PID-5's lower-order 25-facet structure and higher-order five-domain structure in both samples. Correlation and regression analyses showed that DSM-5 specified traits explain the variance in PD presentation with a manifold stronger correlation (R ² = 0.24-0.44) than non-specified traits (R ² = 0.04-0.12). Overall, the PID-5 was shown to be a reliable, stable, and structurally valid assessment tool that captures pathological personality traits related to DSM-5 and ICD-11 PDs.

Insomnia in Patients with Borderline Personality Disorder

OBJECTIVE

Both sleep disorders and BPD are prevalent in the population, and one is often a comorbidity of the other. This narrative review aims to assess contemporary literature and scientific databases to provide the current state of knowledge about sleep disorders in patients with borderline personality disorder (BPD) and clinical suggestions for managing sleep disorders in BPD patients and future research direction.

METHODS

Articles were acquired via PubMed and Web of Science, and papers published between January 1980 and October 2020 were extracted. Authors made a series of literature searches using the keywords: Sleep problems, Insomnia, Nightmares, Obstructive sleep apnea, Borderline personality disorder. The inclusion criteria were: published in peer-reviewed journals; studies in humans; or reviews on the related topic; English language. The exclusion criteria were: abstracts from conferences; commentaries; subjects younger than 18 years. After an inspection of the full texts, 42 papers from 101 were selected. Secondary documents from the reference lists of the primary designated papers were searched, assessed for suitability, and included. In total, 71 papers were included in the review process.

RESULTS

Sleep disturbance is common among patients with BPD. Nevertheless, the number of investigations is limited, and the prevalence differs between 5-45%. Studies assessing objective changes in sleep architecture in BPD show inconsistent results. Some of them identify REM sleep changes and a decrease in slow-wave sleep, while other studies found no objective sleep architecture changes. There is also a higher prevalence of nightmares in patients with BPD. Untreated insomnia can worsen BPD symptoms via interference with emotional regulation. BPD itself seems to influence the subjective quality of sleep significantly. Proper diagnosis and treatment of sleep disorders in patients with BPD could lead to better results in therapy. Psychotherapeutic approaches can improve both sleep disorders and BPD symptoms.

CONCLUSION

Recognising and managing sleep disorders in patients with BPD may help alleviate the disorder's symptoms. Treatment of people with BPD may be more effective if the treatment plan explicitly addresses sleep problems. Further research is needed to reach reliable conclusions.

Pharmacological interventions for antisocial personality disorder

BACKGROUND

Antisocial personality disorder (AsPD) is associated with rule-breaking, criminality, substance use, unemployment, relationship difficulties, and premature death. Certain types of medication (drugs) may help people with AsPD. This review updates a previous Cochrane review, published in 2010.

OBJECTIVES

To assess the benefits and adverse effects of pharmacological interventions for adults with AsPD.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, 13 other databases and two trials registers up to 5 September 2019. We also checked reference lists and contacted study authors to identify studies.

SELECTION CRITERIA

Randomised controlled trials in which adults (age 18 years and over) with a diagnosis of AsPD or dissocial personality disorder were allocated to a pharmacological intervention or placebo control condition.

DATA COLLECTION AND ANALYSIS

Four authors independently selected studies and extracted data. We assessed risk of bias and created 'Summary of findings tables' and assessed the certainty of the evidence using the GRADE framework. The primary outcomes were: aggression; reconviction; global state/global functioning; social functioning; and adverse events.

MAIN RESULTS

We included 11 studies (three new to this update), involving 416 participants with AsPD. Most studies (10/11) were conducted in North America. Seven studies were conducted exclusively in an outpatient setting, one in an inpatient setting, and one in prison; two studies used multiple settings. The average age of participants ranged from 28.6 years to 45.1 years (overall mean age 39.6 years). Participants were predominantly (90%) male. Study duration ranged from 6 to 24 weeks, with no follow-up period. Data were available from only four studies involving 274 participants with AsPD. All the available data came from unreplicated, single reports, and did not allow independent statistical analysis to be conducted. Many review findings were limited to descriptive summaries based on analyses carried out and reported by the trial investigators. No study set out to recruit participants on the basis of having AsPD; many participants presented primarily with substance abuse problems. The studies reported on four primary outcomes and six secondary outcomes. Primary outcomes were aggression (six studies) global/state functioning (three studies), social functioning (one study), and adverse events (seven studies). Secondary outcomes were leaving the study early (eight studies), substance misuse (five studies), employment status (one study), impulsivity (one study), anger (three studies), and mental state (three studies). No study reported data on the primary outcome of reconviction or the secondary outcomes of quality of life, engagement with services, satisfaction with treatment, housing/accommodation status, economic outcomes or prison/service outcomes.   Eleven different drugs were compared with placebo, but data for AsPD participants were only available for five comparisons. Three classes of drug were represented: antiepileptic; antidepressant; and dopamine agonist (anti-Parkinsonian) drugs. We considered selection bias to be unclear in 8/11 studies, attrition bias to be high in 7/11 studies, and performance bias to be low in 7/11 studies. Using GRADE, we rated the certainty of evidence for each outcome in this review as very low, meaning that we have very little confidence in the effect estimates reported. Phenytoin (antiepileptic) versus placebo One study (60 participants) reported very low-certainty evidence that phenytoin (300 mg/day), compared to placebo, may reduce the mean frequency of aggressive acts per week (phenytoin mean = 0.33, no standard deviation (SD) reported; placebo mean = 0.51, no SD reported) in male prisoners with aggression (skewed data) at endpoint (six weeks). The same study (60 participants) reported no evidence of difference between phenytoin and placebo in the number of participants reporting the adverse event of nausea during week one (odds ratio (OR) 1.00, 95% confidence interval (CI) 0.06 to 16.76; very low-certainty evidence). The study authors also reported that no important side effects were detectable via blood cell counts or liver enzyme tests (very low-certainty evidence). The study did not measure reconviction, global/state functioning or social functioning. Desipramine (antidepressant) versus placebo One study (29 participants) reported no evidence of a difference between desipramine (250 to 300 mg/day) and placebo on mean social functioning scores (desipramine = 0.19; placebo = 0.21), assessed with the family-social domain of the Addiction Severity Index (scores range from zero to one, with higher values indicating worse social functioning), at endpoint (12 weeks) (very low-certainty evidence). Neither of the studies included in this comparison measured the other primary outcomes: aggression; reconviction; global/state functioning; or adverse events. Nortriptyline (antidepressant) versus placebo One study (20 participants) reported no evidence of a difference between nortriptyline (25 to 75 mg/day) and placebo on mean global state/functioning scores (nortriptyline = 0.3; placebo = 0.7), assessed with the Symptom Check List-90 (SCL-90) Global Severity Index (GSI; mean of subscale scores, ranging from zero to four, with higher scores indicating greater severity of symptoms), at endpoint (six months) in men with alcohol dependency (very low-certainty evidence). The study measured side effects but did not report data on adverse events for the AsPD subgroup. The study did not measure aggression, reconviction or social functioning. Bromocriptine (dopamine agonist) versus placebo One study (18 participants) reported no evidence of difference between bromocriptine (15 mg/day) and placebo on mean global state/functioning scores (bromocriptine = 0.4; placebo = 0.7), measured with the GSI of the SCL-90 at endpoint (six months) (very low-certainty evidence). The study did not provide data on adverse effects, but reported that 12 patients randomised to the bromocriptine group experienced severe side effects, five of whom dropped out of the study in the first two days due to nausea and severe flu-like symptoms (very low-certainty evidence). The study did not measure aggression, reconviction and social functioning. Amantadine (dopamine agonist) versus placebo The study in this comparison did not measure any of the primary outcomes.

AUTHORS' CONCLUSIONS

The evidence summarised in this review is insufficient to draw any conclusion about the use of pharmacological interventions in the treatment of antisocial personality disorder. The evidence comes from single, unreplicated studies of mostly older medications. The studies also have methodological issues that severely limit the confidence we can draw from their results. Future studies should recruit participants on the basis of having AsPD, and use relevant outcome measures, including reconviction.

Psychological interventions for antisocial personality disorder

BACKGROUND

Antisocial personality disorder (AsPD) is associated with poor mental health, criminality, substance use and relationship difficulties. This review updates Gibbon 2010 (previous version of the review).

OBJECTIVES

To evaluate the potential benefits and adverse effects of psychological interventions for adults with AsPD.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, 13 other databases and two trials registers up to 5 September 2019. We also searched reference lists and contacted study authors to identify studies.

SELECTION CRITERIA

Randomised controlled trials of adults, where participants with an AsPD or dissocial personality disorder diagnosis comprised at least 75% of the sample randomly allocated to receive a psychological intervention, treatment-as-usual (TAU), waiting list or no treatment. The primary outcomes were aggression, reconviction, global state/functioning, social functioning and adverse events.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

This review includes 19 studies (eight new to this update), comparing a psychological intervention against TAU (also called 'standard Maintenance'(SM) in some studies). Eight of the 18 psychological interventions reported data on our primary outcomes. Four studies focussed exclusively on participants with AsPD, and 15 on subgroups of participants with AsPD. Data were available from only 10 studies involving 605 participants. Eight studies were conducted in the UK and North America, and one each in Iran, Denmark and the Netherlands. Study duration ranged from 4 to 156 weeks (median = 26 weeks). Most participants (75%) were male; the mean age was 35.5 years. Eleven studies (58%) were funded by research councils. Risk of bias was high for 13% of criteria, unclear for 54% and low for 33%. Cognitive behaviour therapy (CBT) + TAU versus TAU One study (52 participants) found no evidence of a difference between CBT + TAU and TAU for physical aggression (odds ratio (OR) 0.92, 95% CI 0.28 to 3.07; low-certainty evidence) for outpatients at 12 months post-intervention. One study (39 participants) found no evidence of a difference between CBT + TAU and TAU for social functioning (mean difference (MD) -1.60 points, 95% CI -5.21 to 2.01; very low-certainty evidence), measured by the Social Functioning Questionnaire (SFQ; range = 0-24), for outpatients at 12 months post-intervention. Impulsive lifestyle counselling (ILC) + TAU versus TAU One study (118 participants) found no evidence of a difference between ILC + TAU and TAU for trait aggression (assessed with Buss-Perry Aggression Questionnaire-Short Form) for outpatients at nine months (MD 0.07, CI -0.35 to 0.49; very low-certainty evidence). One study (142 participants) found no evidence of a difference between ILC + TAU and TAU alone for the adverse event of death (OR 0.40, 95% CI 0.04 to 4.54; very low-certainty evidence) or incarceration (OR 0.70, 95% CI 0.27 to 1.86; very low-certainty evidence) for outpatients between three and nine months follow-up. Contingency management (CM) + SM versus SM One study (83 participants) found evidence that, compared to SM alone, CM + SM may improve social functioning measured by family/social scores on the Addiction Severity Index (ASI; range = 0 (no problems) to 1 (severe problems); MD -0.08, 95% CI -0.14 to -0.02; low-certainty evidence) for outpatients at six months. 'Driving whilst intoxicated' programme (DWI) + incarceration versus incarceration One study (52 participants) found no evidence of a difference between DWI + incarceration and incarceration alone on reconviction rates (hazard ratio 0.56, CI -0.19 to 1.31; very low-certainty evidence) for prisoner participants at 24 months. Schema therapy (ST) versus TAU One study (30 participants in a secure psychiatric hospital, 87% had AsPD diagnosis) found no evidence of a difference between ST and TAU for the number of participants who were reconvicted (OR 2.81, 95% CI 0.11 to 74.56, P = 0.54) at three years. The same study found that ST may be more likely to improve social functioning (assessed by the mean number of days until patients gain unsupervised leave (MD -137.33, 95% CI -271.31 to -3.35) compared to TAU, and no evidence of a difference between the groups for overall adverse events, classified as the number of people experiencing a global negative outcome over a three-year period (OR 0.42, 95% CI 0.08 to 2.19). The certainty of the evidence for all outcomes was very low. Social problem-solving (SPS) + psychoeducation (PE) versus TAU One study (17 participants) found no evidence of a difference between SPS + PE and TAU for participants' level of social functioning (MD -1.60 points, 95% CI -5.43 to 2.23; very low-certainty evidence) assessed with the SFQ at six months post-intervention. Dialectical behaviour therapy versus TAU One study (skewed data, 14 participants) provided very low-certainty, narrative evidence that DBT may reduce the number of self-harm days for outpatients at two months post-intervention compared to TAU. Psychosocial risk management (PSRM; 'Resettle') versus TAU One study (skewed data, 35 participants) found no evidence of a difference between PSRM and TAU for a number of officially recorded offences at one year after release from prison. It also found no evidence of difference between the PSRM and TAU for the adverse event of death during the study period (OR 0.89, 95% CI 0.05 to 14.83, P = 0.94, 72 participants (90% had AsPD), 1 study, very low-certainty evidence).

AUTHORS' CONCLUSIONS

There is very limited evidence available on psychological interventions for adults with AsPD. Few interventions addressed the primary outcomes of this review and, of the eight that did, only three (CM + SM, ST and DBT) showed evidence that the intervention may be more effective than the control condition. No intervention reported compelling evidence of change in antisocial behaviour. Overall, the certainty of the evidence was low or very low, meaning that we have little confidence in the effect estimates reported. The conclusions of this update have not changed from those of the original review, despite the addition of eight new studies. This highlights the ongoing need for further methodologically rigorous studies to yield further data to guide the development and application of psychological interventions for AsPD and may suggest that a new approach is required.

Personality disorder in an Early Intervention Psychosis cohort: Findings from the Social Epidemiology of Psychoses in East Anglia (SEPEA) study

AIM

Personality Disorders (PD) often share clinical and phenomenological overlap with psychotic disorders, especially at onset. However, there is little research on comorbid PD among people experiencing first episode psychosis. We examined the prevalence of PD recording and its sociodemographic and clinical correlates in people accepted to Early Intervention in Psychosis (EIP) services.

METHODS

Participants were aged 16-35, accepted into 6 EIP services for suspected psychosis, as part of the Social Epidemiology of Psychoses in East Anglia (SEPEA) study. PD was recorded by clinicians according to ICD-10. Multilevel logistic regression was performed.

RESULTS

Of 798 participants, 76 people (9.5%) received a clinical diagnosis of PD, with emotionally unstable PD (75.0%, N = 57) the most common subtype. In multivariable analysis, risk factors for PD included female sex (odds ratio [OR]: 3.4; 95% CI: 2.0-5.7), absence of psychotic disorder after acceptance to EIP (OR: 3.0; 95% CI: 1.6-5.5), more severe hallucinations (OR: 1.6; 95% CI: 1.2-2.1), and lower parental SES (OR: 1.4; 95% CI: 1.1-1.8). Compared with the white British, black and minority ethnic groups were less likely to receive a PD diagnosis (OR: 0.3; 95% CI: 0.1-0.7). There was no association between PD and neighbourhood-level deprivation or population-density.

CONCLUSIONS

Recording of a PD diagnosis was three times more common amongst participants later found not to meet threshold criteria for psychotic disorder, implying phenomenological overlap at referral which highlights difficulties encountered in accurate diagnostic assessment, treatment and onward referral. People with PD experienced more individual-level, but not neighbourhood-level social disadvantage in an already disadvantaged sample.

The prevalence of personality disorders in the community: a global systematic review and meta-analysis

BACKGROUND

Personality disorders are now internationally recognised as a mental health priority. Nevertheless, there are no systematic reviews examining the global prevalence of personality disorders.

AIMS

To calculate the worldwide prevalence of personality disorders and examine whether rates vary between high-income countries and low- and middle-income countries (LMICs).

METHOD

We systematically searched PsycINFO, MEDLINE, EMBASE and PubMed from January 1980 to May 2018 to identify articles reporting personality disorder prevalence rates in community populations (PROSPERO registration number: CRD42017065094).

RESULTS

A total of 46 studies (from 21 different countries spanning 6 continents) satisfied inclusion criteria. The worldwide pooled prevalence of any personality disorder was 7.8% (95% CI 6.1-9.5). Rates were greater in high-income countries (9.6%, 95% CI 7.9-11.3%) compared with LMICs (4.3%, 95% CI 2.6-6.1%). In univariate meta-regressions, significant heterogeneity was partly attributable to study design (two-stage v. one-stage assessment), county income (high-income countries v. LMICs) and interview administration (clinician v. trained graduate). In multiple meta-regression analysis, study design remained a significant predictor of heterogeneity. Global rates of cluster A, B and C personality disorders were 3.8% (95% CI 3.2, 4.4%), 2.8% (1.6, 3.7%) and 5.0% (4.2, 5.9%).

CONCLUSIONS

Personality disorders are prevalent globally. Nevertheless, pooled prevalence rates should be interpreted with caution due to high levels of heterogeneity. More large-scale studies with standardised methodologies are now needed to increase our understanding of population needs and regional variations.

Can Law Address Intersectional Sexual Harassment? The Case of Claimants with Personality Disorders

Sexual harassment across multiple grounds, including race, disability, sexuality and age, remains an entrenched problem that is poorly dealt with in law. Prevalence rates for intersectional sexual harassment are higher for certain groups, while legal redress is low. This paper examines case law on sexual harassment in Australia where there are intersectional factors and asks whether the “intersectionality” section inserted into the federal Sex Discrimination Act in 2011 has impacted legal practice and decision-making. In particular, it considers the situation of sexual harassment claimants with behavioural and personality traits that are considered “disordered” and the specifically gendered disability stereotypes that shape their treatment in law. Recent cases in Australia dealing with the sexual harassment of people with personality disorders show that intersectionality provisions of sexual harassment laws may in fact be used to undermine a legal claim by a person with disability rather than strengthen it. This article argues that an intersectional legal feminist perspective on harassment is needed for the law to work.

Ethnic inequalities in the incidence of diagnosis of severe mental illness in England: a systematic review and new meta-analyses for non-affective and affective psychoses

PURPOSE

Although excess risks particularly for a diagnosis of schizophrenia have been identified for ethnic minority people in England and other contexts, we sought to identify and synthesise up-to-date evidence (2018) for affective in addition to non-affective psychoses by specific ethnic groups in England.

METHODS

Systematic review and meta-analysis of ethnic differences in diagnosed incidence of psychoses in England, searching nine databases for reviews (citing relevant studies up to 2009) and an updated search in three databases for studies between 2010 and 2018. Studies from both searches were combined in meta-analyses allowing coverage of more specific ethnic groups than previously.

RESULTS

We included 28 primary studies. Relative to the majority population, significantly higher risks of diagnosed schizophrenia were found in Black African (Relative risk, RR 5.72, 95% CI 3.87-8.46, n = 9); Black Caribbean (RR 5.20, 95% CI 4.33-6.24, n = 21); South Asian (RR 2.27, 95% CI 1.63-3.16, n = 14); White Other (RR 2.24, 95% CI 1.59-3.14, n = 9); and Mixed Ethnicity people (RR 2.24, 95% CI 1.32-3.80, n = 4). Significantly higher risks for diagnosed affective psychoses were also revealed: Black African (RR 4.07, 95% CI 2.27-7.28, n = 5); Black Caribbean (RR 2.91, 95% CI 1.78-4.74, n = 16); South Asian (RR 1.71, 95% CI 1.07-2.72, n = 8); White Other (RR 1.55, 95% CI 1.32-1.83, n = 5); Mixed Ethnicity (RR 6.16, 95% CI 3.99-9.52, n = 4).

CONCLUSIONS

The risk for a diagnosis of non-affective and affective psychoses is particularly elevated for Black ethnic groups, but is higher for all ethnic minority groups including those previously not assessed through meta-analyses (White Other, Mixed Ethnicity). This calls for further research on broader disadvantages affecting ethnic minority people.

The effect of limited English proficiency and interpreter service use on clinical outcomes in psychiatric inpatient units

OBJECTIVE

The effects of limited English and interpreter use on clinical outcomes in mental health are poorly understood. This paper describes an exploratory study examining those effects across three adult inpatient psychiatric units, predicting it would lead to increased length of stay.

METHODS

Forty-seven patients with limited English proficiency (LEP) were retrospectively identified and compared with 47 patients with proficient English. Length of stay, number of consultant reviews and discharge diagnosis were recorded and compared.

RESULTS

An increased length of stay for those with LEP was not statistically significant (p=0.155). The LEP group did undergo more consultant reviews (p=0.036), however, and attracted different discharge diagnoses, with no primary discharge diagnoses of personality disorder made (p=0.018).

CONCLUSIONS

This study provides evidence of significant effects of limited English on both service burden and outcome.

Making a difference: ethnic inequality and severe mental illness

In this paper, we explore ethnic inequalities in severe mental illness and care experiences. We consider the barriers to progressive and cohesive action and propose ways of overcoming these. Clinical and policy leadership must bring together hidden patient voices, divergent professional narratives and quality research.Declaration of interestK.B. is Editor of the British Journal of Psychiatry, but has not played any role in the decision-making for this paper. K.B. leads and J.N. is a partner and K.H. a researcher in the Synergi Collaborative Centre.

Anxiety, Stress, and Trauma Symptoms in African Americans: Negative Affectivity Does Not Explain the Relationship between Microaggressions and Psychopathology

Prior research has demonstrated a clear relationship between experiences of racial microaggressions and various indicators of psychological unwellness. One concern with these findings is that the role of negative affectivity, considered a marker of neuroticism, has not been considered. Negative affectivity has previously been correlated to experiences of racial discrimination and psychological unwellness and has been suggested as a cause of the observed relationship between microaggressions and psychopathology. We examined the relationships between self-reported frequency of experiences of microaggressions and several mental health outcomes (i.e., anxiety [Beck Anxiety Inventory], stress [General Ethnic and Discrimination Scale], and trauma symptoms [Trauma Symptoms of Discrimination Scale]) in 177 African American and European American college students, controlling for negative affectivity (the Positive and Negative Affect Schedule) and gender. Results indicated that African Americans experience more racial discrimination than European Americans. Negative affectivity in African Americans appears to be significantly related to some but not all perceptions of the experience of discrimination. A strong relationship between racial mistreatment and symptoms of psychopathology was evident, even after controlling for negative affectivity. In summary, African Americans experience clinically measurable anxiety, stress, and trauma symptoms as a result of racial mistreatment, which cannot be wholly explained by individual differences in negative affectivity. Future work should examine additional factors in these relationships, and targeted interventions should be developed to help those suffering as a result of racial mistreatment and to reduce microaggressions.

Ethnic variation in personality disorder: evaluation of 6 years of hospital admissions

Aims and methodThere is limited evidence on ethnic differences in personality disorder prevalence rates. We compared rates of people with personality disorder admitted to hospital in East London from 2007 to 2013.

RESULTS

Of all people admitted to hospital, 9.7% had a personality disorder diagnosis. The admission rate for personality disorder has increased each year. Compared with White subjects, personality disorder was significantly less prevalent among Black and other minority ethnic (BME) groups. Personality disorder was diagnosed in 20% of forensic, 11% of general adult, 8% of adolescent and 2% of old-age in-patients.Clinical implicationsThe increasing number of personality disorder diagnoses year on year indicates the increasing impact of personality disorder on in-patient services. It is important to identify and appropriately manage patients with a personality disorder diagnosis due to the significant strain they place on resources. The reasons for fewer admissions of BME patients may reflect alternative service use, a truly lower prevalence rate or under-detection.Declaration of interestNone.

Determinants of Suicidality and of Treatment Modalities in a Community Psychiatry Sample of Asylum Seekers

A high prevalence of mental illness has been reported in asylum seekers. The present cross-sectional study examined suicidal thoughts, treatment modalities (outpatient crisis intervention, inpatient care), and their determinants in asylum seekers (n = 119) and permanent residents (n = 120) attending the same outpatient clinic in Geneva, Switzerland. The most frequent diagnoses were depressive disorders (64.7%) and posttraumatic stress disorder (34.5%) in asylum seekers and psychotic (55.0%) and depressive disorders (33.3%) in permanent residents. The frequency of suicidal thoughts was similar in both groups (>30%). Asylum seekers benefited from outpatient crisis intervention more frequently than residents did (26.9% vs. 5.8%), whereas inpatient care was less frequent (25.2% vs. 44.2%). In asylum seekers, acute suicidal thoughts were associated with increased frequency of outpatient crisis interventions, and, suicidal thoughts, psychosis, or personality disorders were associated with higher rates of hospitalization. Documenting clinical characteristics and service utilization of asylum seekers is a prerequisite to organizing targeted interventions.

Seeking to understand lived experiences of personal recovery in personality disorder in community and forensic settings - a qualitative methods investigation

BACKGROUND

Understandings of personal recovery have emerged as an alternative framework to traditional ideas of clinical progression, or symptom remission, in clinical practice. Most research in this field has focussed on the experience of individuals suffering with psychotic disorders and little research has been conducted to explore the experience of individuals with a personality disorder diagnosis, despite the high prevalence of such difficulties. The nature of the personality disorder diagnosis, together with high prevalence rates in forensic settings, renders the understanding of recovery in these contexts particularly problematic. The current study seeks to map out pertinent themes relating to the recovery process in personality disorder as described by individuals accessing care in either community or forensic settings.

METHODS

Individual qualitative interviews were utilised to explore the lived experience of those receiving a personality disorder diagnosis and accessing mental health care in either community or forensic settings. A thematic analysis was conducted to identify shared concepts and understanding between participants.

RESULTS

Fourty-one individual participant interviews were conducted across forensic and community settings. Recovery was presented by participants as a developing negotiated understanding of the self, together with looked for change and hope in the future. Four specific themes emerged in relation to this process: 1. Understanding early lived experience as informing sense of self 2. Developing emotional control 3. Diagnosis as linking understanding and hope for change 4. The role of mental health services.

CONCLUSIONS

Through considering personal recovery in personality disorder as a negotiated understanding between the individual, their social networks and professionals this study illustrates the complexity of working through such a process. Clarity of understanding in this area is essential to avoid developing resistance in the recovery process. Understanding of recovery in a variety of diagnostic categories and social settings is essential if a truly recovery orientated mental health service is to be developed.

Personality and its Relation to Mental and Psychosocial Health in Emerging Adult Sexual Minority Men: The P18 Cohort Study

Personality disorder and personality pathology encompass a dimension of psychological dysfunction known to severely impact multiple domains of functioning. However, there is a notable dearth of research regarding both the pervasiveness and correlates of personality pathology among young sexual minority males who themselves experience heightened mental health burdens. Using the self-report version of the Standardized Assessment of Personality-Abbreviated Scale we tested associations between distinct personality characteristics with sociodemographic and psychosocial factors as well as mental health states in a sample of 528 young (aged 21-25 years) sexual minority men. In multivariate analysis, personality traits varied significantly by race/ethnicity. Personality traits were also positively associated with psychosocial states, specifically, internalized anti-homosexual bias, level of connection with the gay community, and male body dissatisfaction, as well as mental health in the form of recent depressive and anxious symptomatology. These findings support the complex synergy which exists between personality characteristics, psychosocial conditions, and mental health burdens present among sexual minority men and support the need for an all-encompassing approach to both the study and care of this population that addresses the influences of both internal and external factors on well-being.

Genetic and environmental influences on the codevelopment among borderline personality disorder traits, major depression symptoms, and substance use disorder symptoms from adolescence to young adulthood

Although borderline personality disorder (BPD) traits decline from adolescence to adulthood, comorbid psychopathology such as symptoms of major depressive disorder (MDD), alcohol use disorder (AUD), and drug use disorders (DUDs) likely disrupt this normative decline. Using a longitudinal sample of female twins (N = 1,763), we examined if levels of BPD traits were correlated with changes in MDD, AUD, and DUD symptoms from ages 14 to 24. A parallel process biometric latent growth model examined the contributions of genetic and environmental factors to the relationships between developmental components of these phenotypes. Higher BPD trait levels predicted a greater rate of increase in AUD and DUD symptoms, and higher AUD and DUD symptoms predicted a slower rate of decline of BPD traits from ages 14 to 24. Common genetic influences accounted for the associations between BPD traits and each disorder, as well as the interrelationships of AUD and DUD symptoms. Both genetic and nonshared environmental influences accounted for the correlated levels between BPD traits and MDD symptoms, but solely environmental influences accounted for the correlated changes between the two over time. Results indicate that higher levels of BPD traits may contribute to an earlier onset and faster escalation of AUD and DUD symptoms, and substance use problems slow the normative decline in BPD traits. Overall, our data suggests that primarily genetic influences contribute to the comorbidity between BPD features and substance use disorder symptoms. We discuss our data in the context of two major theories of developmental psychopathology and comorbidity.

Prevalence of Personality Disorders in a General Population Among Men and Women

The aim of the present study is to establish the prevalence of personality disorders (PDs) in a healthy (nonclinical) Polish population, to examine sex difference in PDs, and to show the structure of clusters which PDs form with regard to men and women. A large sample of 1460 individuals of age between 18 and 65 years was examined. The Structured Clinical Interview for Axis II was used to obtain information on PDs, the Mini International Neuropsychiatric Interview to obtain information on other disorders, and an interview to record demographic data. Results show that approximately 9% of the sample had at least one PD (the overall rate is 8.9%) and rates on sex differences in PDs are similar to other European and North American countries. The most prevalent PDs are obsessive-compulsive (9.6%), narcissistic (7%), and borderline (7%). Results show the considerable comorbidity of PDs which means that about 9% of the adult population have at least one PD and in fact they display features of many specific PDs. A factor analysis revealed that 12 PDs form different clusters in men and women.

Cross-cultural bias in the diagnosis of borderline personality disorder

Borderline personality disorder (BPD) is an internationally recognized disorder, although it is slightly varied in its nosology in the International Classification of Diseases, 10th Revision (ICD-10), the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), and the Chinese Classification of Mental Disorders (CCMD). While it is recognized by genetic and neurobiological patterns, instability of affect, impaired interpersonal relationships, and unstable sense of self, its manifestation is extremely varied based on environmental factors, particularly culture. Several studies of the manifestation of BPD between and across countries, particularly in immigrant populations, identify variations in symptom prevalence based on culture. These findings reveal a need for more unified dimensional-based categorization of BPD to reduce cross-cultural bias and improve identification.

Personality disorder: still the patients psychiatrists dislike?

Aims and method In 1988, Lewis and Appleby demonstrated that psychiatrists hold negative attitudes towards patients with personality disorder. We assessed the attitudes of psychiatry trainees towards patients with borderline personality disorder and depression, expecting an improvement. 166 trainees were block randomised to receive one of four case vignettes that varied by diagnosis and ethnic group. We used Lewis and Appleby's original questionnaire and the Attitudes to Personality Disorder Questionnaire (APDQ). Results We received 76 responses. Lewis and Appleby's questionnaire showed more negative attitudes towards personality disorder than depression, with no significant patient ethnic group effects, and the APDQ also showed a (weak) trend towards more negative attitudes to personality disorder. In subgroup analysis, only in the White British patient group were there significantly more negative attitudes to personality disorder. Factor analysis showed significantly less sense of purpose when working with personality disorder. Clinical implications The perceived greater lack of purpose in working with personality disorder should be the target of clinical training and intervention. Targeted interventions that include training in managing personality disorder, supervision and practice in non-specialist, general psychiatry settings are important.

Patients with Borderline Personality Disorder in Emergency Departments

Borderline personality disorder (BPD) patients, when in crisis, are frequent visitors of emergency departments (EDs). When these patients exhibit symptoms such as aggressiveness, impulsivity, intense anxiety, severe depression, self-harm, and suicidal attempts or gestures, diagnosis, and treatment of the BPD becomes challenging for ED doctors. This review will, therefore, outline advice to physicians and health-care providers who face this challenging patient population in the EDs. Crisis intervention should be the first objective of clinicians when dealing with BPD in the emergency. For the patients with agitation, symptom-specific pharmacotherapy is usually recommended, while for non-agitated patients, short but intensive psychotherapy especially dialectical behavior therapy (DBT) has a positive effect. Although various psychotherapies, either alone or integrated, are preferred modes of treatment for this group of patients, the effects of psychotherapies on BPD outcomes are small to medium. Proper risk management along with developing a positive attitude and empathy toward these patients will help them in normalizing in an emergency setting after which treatment course can be decided.

Pathways to sympathies for violent protest and terrorism

BACKGROUND

Radicalisation is proposed to explain why some individuals begin to support and take part in violent extremism. However, there is little empirical population research to inform prevention, and insufficient attention to the role of psychiatric vulnerabilities.

AIMS

To test the impact of depressive symptoms, adverse life events and political engagement on sympathies for violent protest and terrorism (SVPT).

METHOD

A cross-sectional survey of a representative sample of Pakistani and Bangladeshi men and women from two English cities. Weighted, multivariable, logistic regression yielded population estimates of association (odds ratio (OR) and 95% confidence intervals) against a binary outcome of SVPT derived from a three-group solution following cluster analysis.

RESULTS

Depressive symptoms were associated with a higher risk of SVPT (OR = 2.59, 95% CI 1.59-4.23, P<0.001), but mediated little of the overall effects of life events and political engagement, which were associated with a lower risk of SVPT (death of a close friend: OR = 0.24, 95% CI 0.07-0.74; donating money to a charity: OR = 0.52, 95% CI 0.3-0.9).

CONCLUSIONS

Independent of SVPT associations with depressive symptoms, some expressions of social connectedness (measured as life events and political engagement) are associated with a lower risk of SVPT.

Likelihood and predictors of detention in patients with personality disorder compared with other mental disorders: A retrospective, quantitative study of Mental Health Act assessments

BACKGROUND

The UK guidelines on the treatment of personality disorder recommend avoiding compulsory treatment except in extreme situations. Little is known about how often patients with personality disorder are detained or how this compares with the treatment of other mental disorders.

OBJECTIVES

Our aim is to test the hypothesis that people with personality disorder are infrequently detained under the Mental Health Act (MHA) and that risk factors associated with detention are the same as those for people with other mental disorders.

METHOD

We used a retrospective, quantitative study of MHA assessments.

RESULTS

Of the 2 087 assessments undertaken, 204 (9.8%) patients had a diagnosis of personality disorder; 40.7% of assessments in the personality disorder group resulted in detention, as did 69.7% of patients with other mental disorders. A higher proportion of people with personality disorder received no intervention following assessment compared with those with other mental disorders (20.6% vs. 4.7%, p < 0.001). Study centre and a history of admission were risk factors for detention in both groups. Risk was a predictor of detention in those with other mental disorders.

CONCLUSIONS

Detention rates in patients with personality disorder are lower than those for other disorders but are still substantial. Risk factors for detention in patients with personality disorder differ from those with other mental disorders. Copyright © 2016 John Wiley & Sons, Ltd.

Racial disparities during admission to an academic psychiatric hospital in a large urban area

Multiple studies confirm that African Americans are less likely than non-Hispanic whites to receive needed mental health services. Research has consistently shown that African Americans are under-represented in outpatient mental health treatment settings and are over-represented in inpatient psychiatric settings. Further, African Americans are more likely to receive a diagnosis of schizophrenia and are less likely receive an affective disorder diagnosis during inpatient psychiatric hospitalization compared to non-Hispanic white patients, pointing to a need for examining factors contributing to mental health disparities. Using Andersen's Behavioral Model of Health Service Use, this study examined predisposing, enabling and need factors differentially associated with health service utilization among African American and non-Hispanic white patients (n=5183) during psychiatric admission. We conducted univariate and multivariate logistic regression analyses to examine both main effects and interactions. In the multivariate model, African American race at admission was predicted by multiple factors including younger age, female gender, multiple psychiatric hospitalizations, elevated positive and negative symptoms of psychosis, a diagnosis of schizophrenia and substance use, as well as having housing and commercial insurance. Additionally, screening positive for cannabis use at intake was found to moderate the relationship between being female and African American. Our study findings highlight the importance of examining mental health disparities using a conceptual framework developed for vulnerable populations (such as racial minorities and patients with co-occurring substance use).

Significado da massagem com aromaterapia em saúde mental

Objetivo Compreender o significado da intervenção de massagem com aromaterapia em saúde mental para o usuário durante a internação psiquiátrica.Métodos Pesquisa qualitativa que incluiu 22 participantes com diagnóstico de Transtornos de Personalidade internados em unidade psiquiátrica de um hospital geral. Foram realizadas entrevistas semiestruturadas, com uma questão norteadora aos participantes, os quais se submeteram a intervenções de massagem com aromaterapia. O conteúdo das entrevistas foi avaliado segundo a Análise de Conteúdo.Resultados Entre os sujeitos de pesquisa, houve predominância do sexo feminino e do diagnóstico de Transtornos de Personalidade Emocionalmente Instável. Dos dados qualitativos, emergiram duas categorias: “identificando os benefícios da aromaterapia” e “possibilitando o autoconhecimento”.Conclusão O significado da intervenção de massagem com aromaterapia foi representado por melhorias no cuidado de enfermagem e no tratamento durante a internação psiquiátrica, ao auxiliar na diminuição dos sintomas ansiosos e no enfrentamento do transtorno mental.

A systematic review of the global prevalence of personality disorders in adult Asian populations

BACKGROUND

No systematic reviews have been conducted into the prevalence of personality disorders (PD) in Asian populations. This review aims to investigate the prevalence of all PD subtypes within community and clinical Asian (Chinese, Indian, Japanese and South Korean) populations worldwide.

METHOD

Seven databases were searched in addition to manual examination and reference tracking. Exclusion criteria were applied with the remaining studies subjected to quality appraisal.

RESULTS

Nineteen studies were included for review. Results were grouped by community studies in Asian countries, clinical studies in Asian countries and comparative studies. Prevalence of PD assessed by clinical judgement was lower than that by diagnostic tools. The highest rates of PD were found in suicidal cohorts within the various countries. Four of the five comparative studies found lower prevalence rates of PD in Asians compared with the overall sample.

CONCLUSION

Insufficient consistent research has been published to ascertain the prevalence of PD in Asians and whether it is higher or lower than in Western cohorts. Asians presenting with suicidal ideation may benefit from PD assessment.

A developing world perspective on homicide and personality disorder

High rates of psychotic disorder among special populations of homicide offenders, females, youth and the mentally disordered, have received much investigation. Personality disorder, especially antisocial personality disorder, augments the relative risk ratio of violence, especially in combination with substance use disorder. Few studies of these correlates of violence and especially homicide have been reported in low- and medium-income countries (LMIC). Using the structured clinical interview for DSM diagnosis (SCID), personality disorders were identified in a cross sectional study involving 546 homicide offenders in Jimma prison, Ethiopia. Predictors of personality disorder were determined using multivariate analysis of various demographic and clinical variables, for example, age, psychiatric history and substance use. Out of the 316 offenders who completed the SCID, only 16% fulfilled DSM IV criteria for personality disorder. The rationale for killing, self-defence, anger and revenge (52% of offenders), planning involved in offending (50%) and reasonably high level of relationship functioning (57% married) were different from most data from the high-income countries. Diagnostically relevant cultural factors in LMIC, not in play in high-income countries, may explain the differences in personality disorders similar to other mental disorders and the underlying mediators of homicide.

Ethnic Differences in Personality Disorder Patterns among Women Veterans Diagnosed with PTSD

Personality Disorders (PDs) impair the ability to function socially and occupationally. PD prevalence rates among veterans who have also been diagnosed with posttraumatic stress disorder (PTSD) range from 45%–79%. This study examined ethnic differences in PDs assessed with the Millon Clinical Multiaxial Inventory-III in 260 non-Hispanic white (64%), Hispanic (27%), and African American (9%), mostly single, women veterans in treatment for PTSD. After adjusting for covariates including number and sexual-nature of trauma, findings revealed the adjusted odds ratio of having a cluster A PD was almost three times higher for African Americans (p = 0.046) then the other two ethnic groups, which may be driven by the paranoid PD scale and potentially reflects an adaptive response to racial discrimination. In cluster designation analysis, the odds were twice as high of having a cluster B PD with childhood trauma (p = 0.046), and a cluster C PD with sexual trauma (p = 0.004), demonstrating the significance of childhood and sexual trauma on long-term chronic personality patterns in women veterans. These results highlight the importance of using instruments with demonstrated diagnostic validity for minority populations.

Phenomenology of borderline personality disorder: the role of race and socioeconomic status

Little is known about racial differences in borderline personality disorder (BPD) that may influence etiology, phenomenology, and treatment of women with BPD. A total of 83 women with BPD participated in this cross-sectional study: n = 41 white and n = 42 African-American women. Structured interviews were used to assess Axis I and II disorders, and a series of interviews and questionnaires captured internalizing and externalizing symptoms. The white women with BPD reported more severe internalizing symptoms, whereas the African-American women reported more severe externalizing symptoms. Except for the association between race and number of suicide attempts, the relationship between race and internalizing/externalizing symptoms was mediated by socioeconomic status. In conclusion, African-American women with BPD may present with more severe symptoms of lack of anger control and fewer suicidal behaviors than those of white women with BPD, raising the possibility that they are misdiagnosed and receive treatments that are not optimal for BPD.

Characteristics of patients with borderline personality disorder in a state psychiatric hospital

Borderline personality disorder is common across mental health settings and associated with substantial suffering, disability, and mortality risk. However, it is often underdiagnosed and no prevalence data are available for state hospital settings. This study aims to provide a preliminary assessment of the prevalence and characteristics of borderline personality disorder (BPD) within an inpatient unit of a state psychiatric hospital. In order to improve the quality of care at a state psychiatric hospital, all patients admitted to a 40-bed unit from April 2008 to June 2009 were routinely administered a structured diagnostic interview for BPD. A total of 65 patients were screened and their charts were reviewed. Twenty patients (31%) met criteria for BPD, but only eight of them (40%) had a chart diagnosis of BPD. Compared to patients without BPD, patients with BPD were significantly more likely to be female (75%), to carry a diagnosis of major depressive disorder, and to have been admitted within the past year. Twenty-four percent of patients with a primary psychotic disorder also met criteria for BPD. BPD patients tended to have shorter lengths of stay, but they had significantly more management problems, including incidents of self-harm, episodes of restraint, and stat administrations of medications. The authors conclude that BPD can be a common but underappreciated co-occurring condition in a state psychiatric hospital. In this setting, BPD is associated with more frequent admissions and numerous management challenges, suggesting the need for comprehensive screening, coordination of care, and specialized treatment programming.

THERACOM: a systematic review of the evidence base for interventions to improve Therapeutic Communications between black and minority ethnic populations and staff in specialist mental health services

BACKGROUND

Black and Minority Ethnic (BME) groups in receipt of specialist mental health care have reported higher rates of detention under the mental health act, less use of psychological therapies, and more dissatisfaction. Although many explanations have been put forward to explain this, a failure of therapeutic communications may explain poorer satisfaction, disengagement from services and ethnic variations in access to less coercive care. Interventions that improve therapeutic communications may offer new approaches to tackle ethnic inequalities in experiences and outcomes.

METHODS

The THERACOM project is an HTA-funded evidence synthesis review of interventions to improve therapeutic communications between black and minority ethnic patients in contact with specialist mental health services and staff providing those services. This article sets out the protocol methods for a necessarily broad review topic, including appropriate search strategies, dilemmas for classifying different types of therapeutic communications and expectations of the types of interventions to improve them. The review methods will accommodate unexpected types of study and interventions. The findings will be reported in 2013, including a synthesis of the quantitative and grey literature.

DISCUSSION

A particular methodological challenge is to identify and rate the quality of many different study types, for example, randomised controlled trials, observational quantitative studies, qualitative studies and case studies, which comprise the full range of hierarchies of evidence. We discuss the preliminary methodological challenges and some solutions. (PROSPERO registration number: CRD42011001661).

Substance use disorders and comorbid Axis I and II psychiatric disorders among young psychiatric patients: findings from a large electronic health records database

This study examined the prevalence of substance use disorders (SUDs) among psychiatric patients aged 2-17 years in an electronic health records database (N=11,457) and determined patterns of comorbid diagnoses among patients with a SUD to inform emerging comparative effectiveness research (CER) efforts. DSM-IV diagnoses of all inpatients and outpatients at a large university-based hospital and its associated psychiatric clinics were systematically captured between 2000 and 2010: SUD, anxiety (AD), mood (MD), conduct (CD), attention deficit/hyperactivity (ADHD), personality (PD), adjustment, eating, impulse-control, psychotic, learning, mental retardation, and relational disorders. The prevalence of SUD in the 2-12-year age group (n=6210) was 1.6% and increased to 25% in the 13-17-year age group (n=5247). Cannabis diagnosis was the most prevalent SUD, accounting for more than 80% of all SUD cases. Among patients with a SUD (n=1423), children aged 2-12 years (95%) and females (75-100%) showed high rates of comorbidities; blacks were more likely than whites to be diagnosed with CD, impulse-control, and psychotic diagnoses, while whites had elevated odds of having AD, ADHD, MD, PD, relational, and eating diagnoses. Patients with a SUD used more inpatient treatment than patients without a SUD (43% vs. 21%); children, females, and blacks had elevated odds of inpatient psychiatric treatment. Collectively, results add clinical evidence on treatment needs and diagnostic patterns for understudied diagnoses.

Cultural psychiatry and epidemiology: researching the means, methods and meanings

This article describes my developing interest in cultural psychiatry. This is both a challenging and yet a privileged opportunity to reflect on my research and clinical work over the last 25 years. I describe cultural and interpersonal influences on my thinking and interests, and the development of my research career moving from health services research of specialist services, to primary care research to public mental health research. Specifically, social and cultural influences on risks and responses to mental illness are discussed, as are pathways to care, the recognition of mental illness, and public health and cultural psychiatry research.