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Pseudoseizures: an overview.

Pseudoseizures, formerly called hysterical seizures, have become an acknowledged clinical entity in their own right. Diagnosis of pseudoseizures is a complex process, depending primarily on clinical neurologic observation of the spell pattern and negative response to anticonvulsant therapy. Diagnosis is aided by psychiatric evidence of psychopathology, and in difficult cases, by video/EEG observation of actual spells, either spontaneous or induced by saline infusion or hypnosis. Exposure to some model of spell behavior is considered important in the development of most cases of pseudoseizures. Pseudoseizures are difficult to treat successfully, and exploratory attempts at treatment have included hypnosis and behavior therapy. Pseudoseizures may represent either conversion disorder or dissociative disorder.

Anticonvulsants↗

The relationship between five-factor personality measurements and ICD-10 personality disorder dimensions: results from a sample of 229 subjects.

This article examines the relationship between the five-factor model (FFM) and dimensional ICD-10 personality disorders. In a follow-up study of a child and adolescent psychiatric cohort, former patients and controls were assessed with NEO-FFI and the IPDE interview (CD-10 personality disorder). Full data were available for 229 subjects (149 former patients, 80 controls). Multiple regression analysis showed that the five factors of the FFM as independent variables explained between 5% (schizoid personality disorder) and 32% (anxious personality disorder) of the variance of ICD-10 dimensional personality disorder scores. For the two types of emotionally unstable personality disorder dimension (impulsive and borderline), for anxious (avoidant) personality disorder dimension and for the total score of any personality disorder dimension, FFM explained between 17% and 32% of the variance with almost identical results for the former patient group and the control group. High neuroticism was a feature of paranoid, emotionally unstable, histrionic, anankastic, anxious (avoidant), and dependent personality disorder dimensions, whereas low agreeableness was found in dissocial, emotionally unstable and histrionic personality disorder dimensions. Low extraversion was found in schizoid, anxious (avoidant) and dependent personality disorder dimensions, whereas histrionic PD dimension correlated with high extraversion. We find that the FFM is valuable for the further understanding not only of DSM-IV but also of ICD-10 personality disorder dimensions. The differences between ICD-10 and DSM-IV in this respect seem to be small.

Adult↗

[Diagnostic structured interviews in child and adolescent's psychiatry].

Structured diagnostic interviews, which evolved along the development of classification's systems, are now widely used in adult psychiatry, in the fields of clinical trials, epidemiological studies, academic research as well as, more recently, clinical practice. These instruments improved the reliability of the data collection and interrater reliability allowing greater homogenisation of the subjects taking part in clinical research, essential factor to ensure the reproducibility of the results. The diagnostic instruments, conversely to the clinical traditional diagnostic processes allow a systematic and exhaustive exploration of disorders, diagnostic criteria but also severity levels, and duration. The format of the data collection, including the order of exploration of the symptoms, is fixed. The formulation of the questions is tested to be univocal, in order to avoid confusions. In child and adolescent, researches in pharmacology and epidemiology increased a lot in the last decade and the standardisation of diagnostic procedures is becoming a key feature. This Article aims to make an assessment, a selection, and a description of the standardized instruments helping psychiatric diagnosis currently available in the field of child and adolescent's psychiatry. Medline and PsycINFO databases were exhaustively checked and the selection of the instruments was based on the review of four main criteria: i) compatibility with international diagnostic systems (DSM IV and/or ICD-10); ii) number of disorders explored; iii) peer reviewed Journals and iv) richness of psychometric data. After the analysis of the instruments described or mentioned in the literature, 2 structured interviews [the Diagnostic Interview Schedule for Children (DISC) and the Children's Interview for Psychiatric Syndromes (ChIPS)] and 4 diagnostic semi-structured interviews [the Schedule for Affective Disorders and Schizophrenia for School-Age Children (Kiddie-SADS), the Diagnostic Interview for Children and Adolescent (DICA), the Child and Adolescent Psychiatric Assessment (CAPA) and the Interview Schedule for Children and Adolescents ISCA)] were retained according to the 3 first criteria. All can be administered by clinicians, and x out of 6 can also be administered by lay-interviewers. All include a child/adolescent version and a parent version. Two instruments evaluate the presence of DSM IV axe II disorders: The ISCA explores the criteria of the Antisocial Personality Disorder. The CAPA evaluates Borderline, Obsessional-compulsive, Histrionic and Schizotypic Personality Disorders. Regarding the psychometric quality criterion, the selection was much more difficult because of the lack of data and the weakness of the samples studied in reliability studies. Interrater reliability appeared to be good for the 6 instruments, with kappas ranging from 0.5 to 1. This is usual in such instruments. The test-retest reliability was found to vary from bad to excellent depending on the instruments, the "informant" status (child/adolescent or parent), and the disorder explored, kappas ranging from 0.32 to 1. The worst results concerned face-to-face reliability studies which showed weak concordances for the diagnoses, whatever the procedure implemented: Diagnostic interview vs. i) Another diagnostic interview, vs. ii) An expert diagnosis or vs. iii) Scales and questionnaires. Overall, the K-SADS-PL appeared to be the instrument that has the best test-retest reliability for Anxious Disorders and Affective Disorders (the value kappa showing good to excellent reliabilities). Several important methodological observations emerged from this review. Firstly, the metrological data corresponding to the diagnoses according to DSM IV or ICD-10 criteria's were lacking. The face validity was globally satisfactory, but the data concerning their face-to-face validities and their test-retest reliability, although better than in the former versions, were limited because they were tested on small sample. In fact, it appeared that the agreements depend on the informant, the sample studied, the various diagnostic categories and the instrument used. Since the studies carried out by Cohen et al., with now obsolete versions of the DISC and K-SADS, no other study establishing a comparison between two EDS have been conducted. Consequently, the clinicians must be very careful before comparing DSM or ICD diagnoses generated by different instruments. The second point was the length of the interviews that appeared sometimes longer than instruments used in adults, considering the fact that diagnostic procedure implies two independent interviews, one with the child/adolescent and one with the adult referent. The minimum duration was found to be 1 h 30 for the Chips in clinical setting, while it could reach 4 h or more for the DISC IV or the ISCA. The interviews had to be often carried out in several sessions, so the assessment became very difficult in easily tired and/or distractible subjects. The third point referred to the necessity to consider multiple data sources in young patients during the diagnostic procedure, and the weakness of the levels of agreement generally reported between sources. Empirically, it was observed that the investigator granted more weight to the report of the children than to the parent's one, when the clinical judgement was necessary to synthesize the data. On another level, studies showed a high agreement on the factual contents or on the specific events (ex: hospitalization), like on the obvious symptoms (ex: enuresis). The parents report more problems of behaviour, school and relational difficulties, whereas the children report more fear, anxiety, obsessions and compulsions, or delusional ideas. In other words, it appeared that children were better informants in describing their mental states (internalised disorders), and that adults would bring more reliable information in describing externalised disorders. Like McClellan and Werry, we think that further researches are needed to clarify if and when this is the case. The last major point concerned the problem of language. These instruments must be used in the maternal language of the interviewees and they were developed for most of them into English only. For example, there is only one instrument available into French (the Kiddie SADS). Nowadays, it remains difficult to conduct international studies in child and adolescent psychiatry and/or to compare data is this domain. To conclude, the use of the EDS and EDSS brings many benefits, in academic researches as well as in clinical practice, but a more systematic use is limited by a certain number of parameters. The instruments currently available in child and adolescent are far from being optimal in terms of quality and quantity. It seems necessary and useful to contribute to their development and their improvement. In particular, the following points should be considered: drastic reduction of the length of the interviews; simplification in the use of these instruments, during the interviews, but also in the treatment of the data collected during the final phase of diagnosis generation, the clinician having to carry out ceaseless returns to check the presence or not of each diagnostic criterion; reduction of the duration of the highly necessary training, which can be easily solved by the global simplification of the instruments; quantitative and qualitative improvements of psychometric properties, in particular in terms of sensitivity, specificity and face-to-face validity. Finally, it is highly necessary to continue to develop structured diagnostic interviews adapted to the assessment of child and adolescent psychiatric diagnoses keeping in mind simplicity, feasibility and reliability. Developing this kind of instruments is hard, expensive, and sometimes tiresome but it remains the inescapable stage to produce high quality data in the future.

Adolescent↗

Psychological features of women with idiopathic detrusor instability.

Psychological tests were completed by 57 incontinent women with idiopathic detrusor instability, and compared with those of 22 women with genuine stress incontinence (an anatomical disorder) and published norms. The previously reported findings of hysterical personality traits, situational stresses and sexual dysfunction in patients with detrusor instability were not confirmed. Higher scores for anxiety, neuroticism, hostility, and depression were found in patients with detrusor instability than in controls. These findings, known associations of psychosomatic disorders, lend further support to the view that idiopathic detrusor instability is a psychosomatic disorder.

Adult↗

Hysterical personality disorder. The process of diagnosis in clinical and experimental settings.

A study of the case notes of 52 patients with a diagnosis of hysterical personality disorder showed that 27 had no recorded features of that condition, but were frequently described as aggressive, uncooperative, or attention-seeking. Although 60% were recorded as depressed, only 17% received antidepressant treatment. In an experimental study, the core traits of the disorder were found to have a low inter-rater reliability. Two patients, who had received hospital diagnoses of hysterical personality disorder, were shown to display behaviour that caused psychiatrists to make a diagnosis on wholly inadequate information.

Adult↗

The "A-B-C's" of the cluster B's: identifying, understanding, and treating cluster B personality disorders.

This article is a summary of some of the more recent research on the diagnosis, etiology, and treatment of Cluster B personality disorders (antisocial, histrionic, borderline, and narcissistic). Research on psychological, psychosocial, and biological perspectives of these disorders is presented. Individual psychotherapy, group psychotherapy, and other forms of multi-person therapies are also discussed. Finally, perspectives on issues of countertransference when treating these personality-disordered patients are addressed.

Countertransference↗

Raising doubts about claims of malingering: implications of relationships between MCMI-II and MMPI-2 performances.

Test results from 90 personal injury claimants were used to explore the relationship between personality disorders (Dependent, Histrionic, Compulsive, Schizoid, Schizotypal, Paranoid, Narcissistic, Borderline, Antisocial, Avoidant, and Passive-Aggressive) as assessed by the MCMI-II and response style measured by MMPI-2 validity scales (F, K, L, F-K, O-S, Es, and FBS). With the exception of the Dependent and Narcissistic scales, all personality disorder scales were found to have a significant relationship with validity indicators in the direction of faking bad. These results suggest that the presence of characterological factors (i.e., a personality disorder), rather than malingering, contributes to exaggerated results in a forensic setting. Implications for future research are addressed.

Adult↗

Personality disorders in dysthymia and major depression.

OBJECTIVE: The purpose of the present study was to investigate the comorbidity of personality disorders in patients with primary dysthymia compared to those with episodic major depression. METHOD: A total of 177 out-patients with primary dysthymia and 187 outpatients with episodic major depression were administered a structured diagnostic interview for DSM-III-R Axis II disorders. In addition, all of these patients completed the BDI, and those with the appropriate level of education also completed the Minnesota Multiphasic Personality Inventory (MMPI). RESULTS: A significantly higher proportion of dysthymic patients than patients with major depression met the criteria for a personality disorder, for borderline, histrionic, avoidant, dependent, self-defeating types and for personality disorders of clusters B and C. Further analysis revealed that the above differences were mainly due to the subgroup of patients with 'early-onset dysthymia'. Finally, patients with a personality disorder, both dysthymics and those with major depression, had significantly higher scores on the BDI and on the majority of the MMPI scales compared to those without a personality disorder. CONCLUSION: The data indicated that (i) dysthymia--mainly that of early onset--is associated with significantly higher personality disorder comorbidity than episodic major depression, and (ii) the presence of a personality disorder is related to more severe overall psychopathology.

Adult↗

Substance use disorders in a sample of Canadian patients with chronic mental illness.

In a study designed to investigate the pattern of substance use disorders among a group of chronic mentally ill patients in Toronto, 102 patients completed the Structured Clinical Interview for DSM-III-R and a modified substance-use-disorder module of the Diagnostic Interview Schedule. Forty percent of the sample met criteria for substance use disorders, and 49 percent for personality disorder. Among patients with personality disorder, all those with a personality disorder in cluster B (that is, with antisocial, borderline, histrionic, or narcissistic personality disorder) had a substance use disorder, while the majority of patients in cluster A and cluster C were not substance abusers. In the overall sample, the group with substance use disorders was significantly younger than the group without. In contrast to findings of previous studies, women met criteria for substance use disorders as often as men did.

Adult↗

The hysterical personality disorder: a proposed clarification of a diagnostic dilemma.

This paper reviews the marked confusion surrounding the diagnosis of the hysterical personality disorder, which has resulted from the use of vague and at times contradictory criteria in making this diagnosis. It is recommended that the diagnosis be based exclusively on psychodynamic characteristics, and a specific psychodynamic formulation is offered for this disorder. The formulation is examined from the perspectives of genetic development, drive organization, and ego and superego organization.

Diagnosis, Differential↗