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

Comorbid personality difficulties are not associated with poorer outcomes for online cognitive behaviour therapy for symptoms of anxiety and depression

Little is known about the prevalence and impact on treatment of comorbid personality disorders for adults undertaking online cognitive behaviour therapy (internet-delivered or internet-based cognitive behaviour therapy (iCBT)) for anxiety and depressive disorders. This study explored how common comorbid personality difficulties were in a large sample of consecutive patients (N = 1 132) seeking iCBT for their symptoms of anxiety and depression in routine care settings. Patients completed the Standardized Assessment of Personality-abbreviated Scale Self-Report prior to commencing an iCBT programme, as well as completing assessments of anxiety and depression symptom severity and psychological distress pre-iCBT and post-iCBT. Consistent with previous studies, a high proportion of the sample (62.6%) reported experiencing comorbid personality difficulties. However, comorbid personality difficulties were not significantly associated with poorer treatment adherence or higher post-treatment symptom severity or psychological distress (controlling for baseline symptom severity, demographic characteristics and treatment variables). Current findings support an inclusive approach to iCBT provision where comorbid personality difficulties do not appear to be a contraindication for treatment. © 2021 John Wiley & Sons, Ltd.

Role of the central autonomic nervous system intrinsic functional organisation and psychosocial factors in primary microvascular angina and Takotsubo syndrome

Introduction and objective

Dysfunctional central autonomic nervous system network (CAN) at rest may result in aberrant autonomic responses to psychosocial stressors. We hypothesised that patients with primary microvascular angina (MVA) or Takotsubo syndrome (TTS) would exhibit a peculiar functional organisation of the CAN, potentially associated with psychological patterns.

Methods

Patients underwent a psychosocial evaluation: a clinical diagnostic interview, Millon Clinical Multiaxial Inventory III, State-Trait Anxiety Inventory form Y and Short Form 36 Health Survey (SF-36). The strength of intrinsic functional connectivity (FC) between various nodes of the CAN was investigated using cerebral resting state functional MRI (RS-fMRI).

Results

We evaluated 50 (46 women) stable patients: 16 patients with MVA, 17 patients with TTS and 17 patients with previous acute myocardial infarction (AMI). Compared with AMI, patients with MVA showed a lower (higher impairment) SF-36 Body-Pain score (p 0.046) and a higher SF-36 Mental-Health score (p 0.039). Patients with TTS showed the strongest FC between two nodes of the CAN (sympathetic midcingulate cortex and parasympathetic primary motor area) (F 6.25, p 0.005) using RS-fMRI.

Conclusions

The study implements an innovative collaborative research among cardiologists, neuroscientists and psychiatrists (‘Neuro-psycho-heart Team’). MVA showed a discrepancy between the highest level of self-reported body pain and the best mental health score, which might suggest a mechanism of somatisation. TTS exhibited an increased functional integration between two areas of the CAN involved in interoceptive pain awareness and negative emotional status. We implemented an innovative research collaboration among cardiologists, neuroscientists and psychiatrists. These data are hypothesis generating and suggest potential prospective investigations on pathophysiology and implementation of psychotherapy and stress-reducing techniques as therapeutic strategies.

Trial registration number

NCT02759341.

Pathogenic beliefs among patients with schizotypal personality disorder

This study aimed to explore the differences in pathogenic beliefs (PBs) between patients with schizotypal personality disorder (PD) and those with other PDs or without any PD. The study was conducted among 212 patients treated with psychotherapy at the Psychotherapy and Personality Disorder Clinic, Chiang Mai University between 2007 and 2019. Collected data included sociodemographic information, psychiatric disorders and personality disorder as determined by the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, 5^th Edition, and the Pathogenic Belief Scale (PBS). An analysis was conducted to compare three groups, i.e., patients with schizotypal PD, patients with other PDs and patients without any PD. The PBS score was compared by two outcomes: a total score and a categorical score of individual items. The entire sample was predominantly female (62.3%) with a mean age of 31.41 years. Most participants had a bachelor's degree (76.9%), lived alone (72.6%) and received diagnoses of major depressive disorder (45.8%). No significant differences were found in participants' characteristics regarding age, sex, educational level, marital status and psychiatric clinical diagnosis among the three groups. The mean PBS total score was highest for schizotypal PD (mean = 58.74, SD = 11.54), compared with non-schizotypal PD (mean = 46.14, SD = 13.15) and non-PD (mean = 46.07, SD = 11.17). Twenty of 27 items were significantly higher in the schizotypal PD group than in other groups, after adjusting for type I error. The number of PBs was significantly prominent for schizotypal PD. Possible explanations were provided.

Borderline Personality Disorder in Patients With Medical Illness: A Review of Assessment, Prevalence, and Treatment Options

OBJECTIVE

Borderline personality disorder (BPD) occurs in 0.7% to 3.5% of the general population. Patients with BPD experience excessive comorbidity of psychiatric and somatic diseases and are known to be high users of health care services. Because of a range of challenges related to adverse health behaviors and their interpersonal style, patients with BPD are often regarded as "difficult" to interact with and treat optimally.

METHODS

This narrative review focuses on epidemiological studies on BPD and its comorbidity with a specific focus on somatic illness. Empirically validated treatments are summarized, and implementation of specific treatment models is discussed.

RESULTS

The prevalence of BPD among psychiatric inpatients (9%-14%) and outpatients (12%-18%) is high; medical service use is very frequent, annual societal costs vary between &OV0556;11,000 and &OV0556;28,000. BPD is associated with cardiovascular diseases and stroke, metabolic disease including diabetes and obesity, gastrointestinal disease, arthritis and chronic pain, venereal diseases, and HIV infection as well as sleep disorders. Psychotherapy is the treatment of choice for BPD. Several manualized treatments for BPD have been empirically validated, including dialectical behavior therapy, transference-focused psychotherapy, mentalization-based therapy, and schema-focused therapy.

CONCLUSIONS

Health care could be substantially improved if all medical specialties would be familiar with BPD, its pathology, medical and psychiatric comorbidities, complications, and treatment. In mental health care, several empirically validated treatments that are applicable in a wide range of clinical settings are available.

Borderline personality disorder among primary care depressive patients: a five-year study

BACKGROUND

Studies of depressive disorders with concurrent borderline personality disorder (BPD) in primary health care are scarce and methodologically weak. Limited epidemiological evidence suggests BPD may be common among users of primary care services. Prevalence, characteristics and outcome of primary care depressive patients with co-morbid BPD are unknown.

METHODS

The Vantaa Primary Care Depression Study is a prospective five-year cohort study. A stratified random sample of 1119 patients aged 20 to 69 years was screened for depression using the Prime-MD. SCID-I/P and SCID-II interviews were used to diagnose depressive all co-morbid axis I and II disorders. Of the 137 depressive patients at baseline, 82% completed the five-year follow-up. Characteristics and outcome of patients with or without concurrent BPD were compared.

RESULTS

BPD cases accounted for 26% at baseline and 19% at follow-up. At baseline, BPD patients had a two-fold prevalence of anxiety and previous depressive episodes; a three-fold prevalence of substance use disorders, suicidal ideation and severe economic difficulties, and a four-fold prevalence of preceding suicide attempts or unemployment compared to those without BPD. By follow-up, patients with BPD had spent more time depressed, achieved full remission slower and a higher proportion were chronically depressed.

LIMITATIONS

Diagnostic reliability of depressive disorders was excellent, but of BPD not tested. Generalizability to other primary care settings remains unknown.

CONCLUSIONS

Concurrent BPD may be relatively common among depressed primary care patients. These patients have specific, adverse characteristics and poor long-term outcome, which should be considered when developing treatments for depression in primary care.

Personality pathology as a risk factor for negative health perception

Previous findings suggest that self-perception of health relates to many physical health outcomes, including mortality. Many factors appear to shape health perceptions, such as personality. Little research, however, has focused on whether personality pathology may affect perceived health. This preliminary study examined the unique effects of personality pathology on health perceptions beyond those of objective health and normal personality factors. As part of an ongoing longitudinal study, the authors examined data from a representative sample (N = 697) of St. Louis residents (ages 55-64) who were identified using standard epidemiological methods. The Diagnostic Interview Schedule and the Health Status Inventory were used to collect reports of health perceptions, chronic illnesses, and physical functioning. Personality traits were measured with the revised NEO Personality Inventory, and personality disorders were assessed using the Structured Interview for DSM-IV Personality. Number of physical illnesses, physical functioning, normal personality, and personality disorders all predicted self-perception of health separately. Personality disorders also predicted health perception above and beyond objective health and personality variables. These findings elucidate the importance of personality pathology in understanding perceived health and suggest that certain patterns of pathology may be particularly detrimental to subjective health.

Borderline personality disorder, exposure to interpersonal trauma, and psychiatric comorbidity in urban primary care patients

OBJECTIVE

Few data are available on interpersonal trauma as a risk factor for borderline personality disorder (BPD) and its psychiatric comorbidity in ethnic minority primary care populations. This study aimed to examine the relation between trauma exposure and BPD in low-income, predominantly Hispanic primary care patients.

METHOD

Logistic regression was used to analyze data from structured clinical interviews and self-report measures (n = 474). BPD was assessed with the McLean screening scale. Trauma exposure was assessed with the Life Events Checklist (LEC); posttraumatic stress disorder (PTSD) was assessed with the Lifetime Composite International Diagnostic Interview, other psychiatric disorders with the SCID-I, and functional impairment with items from the Sheehan Disability Scale and Social Adjustment Scale Self-Report (SAS-SR).

RESULTS

Of the 57 (14%) patients screening positive for BPD, 83% reported a history of interpersonally traumatic events such as sexual and physical assault or abuse. While interpersonal trauma experienced during adulthood was as strongly associated with BPD as interpersonal trauma experienced during childhood, noninterpersonal trauma was associated with BPD only if it had occurred during childhood. The majority (91%) of patients screening positive for BPD met criteria for at least one current DSM-IV Axis I diagnosis and exhibited significant levels of functional impairment.

CONCLUSION

Increased awareness of BPD in minority patients attending primary care clinics, high rates of exposure to interpersonal trauma, and elevated risk for psychiatric comorbidity in this population may enhance physicians' understanding, treatment, and referral of BPD patients.

Screening for personality disorders

A brief but valid self-report measure to screen for personality disorders (PDs) would be a valuable tool in making decisions about further assessment and in planning optimal treatments. In psychiatric and nonpsychiatric samples, we compared the validity of three screening measures: the PD scales from the Inventory of Interpersonal Problems, a self-report version of the Iowa Personality Disorder Screen, and the selfdirectedness scale of the Temperament and Character Inventory. Despite their different theoretical origins, the screeners were highly correlated in a range from .71 to .77. As a result, the use of multiple screeners was not a significant improvement over any individual screener, and no single screener stood out as clearly superior to the others. Each performed modestly in predicting the presence of any PD diagnosis in both the psychiatric and nonpsychiatric groups. Performance was best when predicting a more severe PD diagnosis in the psychiatric sample. The results also highlight the potential value of multiple assessments when relying on self-reports.

Persons with depressive symptoms and the treatments they receive: a comparison of primary care physicians and psychiatrists

OBJECTIVE

To determine if demographic differences exist in patients with depressive symptoms as the principal reason for visits to primary care physicians (PCP) versus psychiatrists. To estimate the likelihood of these patients receiving a range of mental health services from each provider group.

METHODS

Review and analysis of all outpatient visits made by patients with depressive symptoms using the National Ambulatory Medical Care Surveys (NAMCS) conducted in 1995 and 1996.

RESULTS

A significantly greater proportion of visits by persons with depressive symptoms as the principal reason for visit were made to psychiatrists than to primary care physicians (T = -3.56, p = .000). However, men, African-Americans, other Non-White persons, and persons aged 65 to 74 and 75 years and over were proportionately more likely to visit a PCP than a psychiatrist. Women, whites, and persons aged 45 to 64 were proportionately more likely to make a visit to a psychiatrist than to a PCP. The overall intensity of care delivered by PCPs for patients with depressive symptoms was significantly lower than that provided by psychiatrists (t = -2.03, p = .02). Analysis of individual services also revealed significant differences in service provision.

CONCLUSIONS

Demographic differences among the patient caseloads of these physician groups have implications for mental health service delivery because of known distinctions in prevalence rates, symptom presentation, and functionality among depressed patient subgroups.

The aetiology, presentation and treatment of personality disorders

Personality disorders are a heterogeneous collection of conditions with common features, which may include an exaggerated self-centred nature, little regard for the feelings of others, or the regular fabrication of stories to explain the behaviour of self or others. Whilst such features might be recognized as being present in many people at different times of their lives, it is the persisting nature and extremes of personality traits that distinguishes those who have personality disorders from those who do not. Apart from the problems that personality disorders bring on their own (such as dysfunctional relationships), when they coexist with mental disorders it makes the latter more difficult to treat. People with personality disorders are often depicted as being dangerous, yet only a few are and it is this minority group that attract public attention. Personality disorders are recognized as belonging to the group known as the serious mental illnesses, a group that mental health nurses are being encouraged to focus their attentions on, but it is accepted that there is a paucity of education and training in appropriate interventions for this group of people. This article provides an overview of the aetiology and presentation of personality disorders together with an examination of evidence-based therapeutic interventions.

Epidemiology of personality disorders

Epidemiology is concerned with the occurrence of disease in populations. Epidemiologic studies measure the prevalence and distribution of disorders, investigate questions of case definition, determine risk factors, and evaluate the natural history and consequences of disorders. This paper reviews and discusses empiric advances made over the past 2 years in the epidemiologic study of personality disorders.