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PubMed2003

Early identification of individuals at risk for antisocial personality disorder.

BACKGROUND: Antisocial personality disorder is usually preceded by serious and persistent conduct problems starting in early childhood, and so there is little difficulty in identifying an at-risk group. AIMS: To address six key areas concerning the relationship between early conduct problems and antisocial personality disorder. METHOD: Review of recent research into early identification of and intervention in child conduct problems, following up to possible adult antisocial behaviour. RESULTS: Conduct problems are predictive of antisocial personality disorder independently of the associated adverse family and social factors. Prediction could be aided through identification of subtypes of conduct problems. There is limited evidence on which children have problems that are likely to persist and which will improve; children who desist from early conduct problems and those with onset in adolescence are also vulnerable as adults. CONCLUSIONS: The predictive power of the childhood precursors of antisocial personality disorder provides ample justification for early intervention. Greater understanding of subgroups within the broad category of antisocial children and adults should assist with devising and targeting interventions.

Adolescent↗
PubMed1989

Suicide and parasuicide in multiple personality disorder.

Multiple personality disorder (MPD) has been diagnosed with increasing frequency in the 1980s: according to one estimate 6,000 cases have now been diagnosed in North America (Coons 1986). The diagnosis of MPD can be difficult because patients usually present in a polysymptomatic fashion, and the specific features of their dissociative disorder may be difficult to elicit (Kluft 1985a, 1987). One of the most common presenting features consists of suicidal ideation and suicide attempts. Putnam et al. (1986), for instance, noted suicidality as a presenting symptom in nearly 70% of 100 cases of MPD reported to them by 92 clinicians throughout North America. We have collected a series of 236 cases of MPD reported to us by 203 clinicians throughout North America. Our results show that 72% of the patients attempted suicide. The purpose of this report is to compare 48 cases of MPD from this series with no previous suicide attempts to 167 cases that have attempted suicide to determine features that differentiate the patients who attempt suicide from those who do not.

Adult↗
PubMed1993

An occupational therapy perspective in the treatment of multiple personality disorder.

Adult persons with multiple personality disorder have survived a traumatic past. After diagnosis and the initiation of psychotherapy, they frequently face a long and arduous treatment process. During this time, intense emotions and memories are retrieved that can disrupt functional life skills in an already disjointed life. The stresses of life combine with therapeutic issues to perpetuate the dissociation that interrupts functional performance. The original traumas occurred when the child was functioning primarily at a sensorimotor level. Occupational therapy can identify sensorimotor activities that provide a focal point of control to reduce stress during the therapeutic process and to develop new life skills.

Activities of Daily Living↗
PubMed2000

A comparison of posttraumatic stress disorder with and without borderline personality disorder among women with a history of childhood sexual abuse: etiological and clinical characteristics.

The overlap in definition and presentation between posttraumatic stress disorder (PTSD) and borderline personality disorder (BPD) has raised questions about the relationship of these disorders. Are they separate disorders, variants of the same disorder, or comorbid conditions? The present study examined etiological variables and current functioning among two groups of outpatient women with a history of childhood sexual abuse: those with PTSD only (N = 45) and those with PTSD and BPD (N = 26). The groups did not differ in severity, frequency, or number of perpetrators of their childhood sexual abuse, or whether the perpetrator was a family member or not. The additional diagnosis of BPD was associated with earlier age of abuse onset and significantly higher rates of physical and verbal abuse by mother. Severity and frequency of PTSD symptoms were not affected by BPD diagnosis, suggesting that the personality disorder and PTSD are independent symptom constructs. The PTSD+BPD group scored higher on several other clinical measures including anger, dissociation, anxiety, and interpersonal problems. They did not differ in their frequency of use of mental health services but tended to be less compliant in their treatment. These and other findings are discussed, and implications for treatment are considered.

Adult↗
PubMed2005

Cortisol, the cortisol-dehydroepiandrosterone ratio, and pro-inflammatory cytokines in patients with current major depressive disorder comorbid with borderline personality disorder.

BACKGROUND: Major depression in young women is often comorbid with borderline personality disorder (BPD); however, adrenal steroids and pro-inflammatory cytokines in patients with comorbid current major depressive disorder and BPD (MDD/BPD) have not been systematically examined. Therefore, our study aimed at examining serum profiles of cortisol, cytokines, and the cortisol/dehydroepiandrosterone (cortisol/DHEA) ratio in MDD/BPD patients and a healthy comparison group. METHODS: Twelve medication-free female patients with MDD/BPD and 12 healthy women were included. Serum profiles of cortisol, DHEA, tumor necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6), and interleukin-1beta were sampled, and the molar cortisol/DHEA ratio was determined. RESULTS: Concentrations of serum cortisol, TNF-alpha, and IL-6, as well as the cortisol/DHEA ratios were significantly increased in MDD/BPD patients as compared with the healthy comparison group. CONCLUSIONS: Depressed patients with comorbid BPD display endocrine and immune alterations similar to those observed in cases of melancholic MDD without BPD. Elevated concentrations of serum cortisol, cortisol/DHEA ratios, and pro-inflammatory cytokines might indicate a state marker in these patients and might contribute to long-term metabolic alterations that have also been associated with MDD.

Adult↗
PubMed1990

Platelet MAO activity in personality disorders and normal controls.

Platelet monoamine oxidase (MAO) activity has been related to several psychiatric disorders and personality dimensions. The purpose of this study was to measure platelet MAO activity in personality disorders and determine its relationship to symptoms analogous to sensation seeking. Twenty-eight males admitted to a psychiatric unit with a DSM-III-R diagnosis of personality disorder were compared to normal controls. Patients with Axis I diagnoses other than adjustment disorder were excluded. There was no difference in MAO activity between patients and normals, although it was lower in borderline patients. MAO activity was inversely correlated with sensation seeking, especially in the patient group, as predicted. The results are consistent with the view that platelet MAO activity is a marker of general psychopathology.

Adjustment Disorders↗
PubMed1998

The cooccurrence of DSM-III-R personality disorders.

The distinction between personality disorder diagnoses is often unclear because of the frequent cooccurrence of one or more of the diagnoses. To date, studies using sample sizes large enough to evaluate the rates of cooccurrence in the less prevalent personality disorders have not been conducted. The Structured Interview for Diagnosis of Personality-Revised, a semistructured instrument designed to yield reliable personality disorder diagnoses, was used to evaluate 1116 subjects for the presence of DSM-III-R personality disorder diagnoses. Cooccurrence rates and odds ratios were calculated for each pair of diagnoses. There was a high degree of cooccurrence between the cluster A personality disorders, between the cluster C personality disorders, and between narcissistic, borderline, and histrionic disorders. In addition, there was also a high frequency of avoidant personality disorders within the cluster A personality disorder diagnoses. Possible explanations for the high degree of cooccurrence and the potential implications for the DSM-IV personality disorder diagnoses are discussed.

Adult↗
PubMed2003

Risperidone in the treatment of schizotypal personality disorder.

OBJECTIVE: Schizotypal personality disorder (SPD) has many phenomenological, genetic, physiologic, and neuroanatomical commonalities with schizophrenia. Patients with the disorder often suffer from marked social and occupational impairment, yet they have been difficult to treat with medications because of their unusual sensitivity to side effects. This study was designed to determine whether low-dose risperidone treatment is acceptable to SPD patients and can reduce characteristic schizotypal symptoms. In addition, if SPD patients respond to an antipsychotic medication, this will provide support for the notion of a commonality in treatment response between SPD and schizophrenia. METHOD: Twenty-five patients with DSM-IV-defined SPD were entered into a 9-week randomized, double-blind, placebo-controlled study of low-dose risperidone (starting dose of 0.25 mg/day, titrated upward to 2 mg/day) in the treatment of SPD. Patients were rated with the Positive and Negative Syndrome Scale (PANSS), the Schizotypal Personality Disorder Questionnaire, the Hamilton Rating Scale for Depression, and the Clinical Global Impressions scale. Data were collected from 1995 to 2001. RESULTS: The subjects had a low incidence of depression and of comorbid borderline personality disorder. Patients receiving active medication had significantly (p <.05) lower scores on the PANSS negative and general symptom scales by week 3 and on the PANSS positive symptom scale by week 7 compared with patients receiving placebo. Side effects were generally well tolerated, and there was no group difference in dropout rate for side effects. CONCLUSION: Low-dose risperidone appears to be effective in reducing symptom severity in SPD and is generally well tolerated.

Adolescent↗
PubMed1998

Personality traits and personality disorders.

The structure of personality disorder traits was examined in a sample of 400 undergraduates who completed the personality disorder questionnaire from the Structured Clinical Interview for DSM-III-R (SCID-II). The relations between personality disorder and normal personality traits indexed by the Eysenck Personality Questionnaire-Revised (EPQ-R) were examined. The three-cluster model of personality traits--as described in the DSM scheme--found equivocal support. Exploratory principal components analysis and confirmatory factor analysis found four broad factors of personality disorder that overlapped with normal personality traits: an asthenic factor related to neuroticism; an antisocial factor associated with psychoticism; an asocial factor linked to introversion-extraversion; and an anankastic (obsessive-compulsive) factor. There is growing agreement about the number and type of broad personality disorder dimensions; similar dimensions may be found in clinical and non-clinical samples, suggesting that those people with personality disorders differ quantitatively rather than qualitatively from others; and there is substantial overlap between normal and abnormal personality dimensions.

Adult↗
PubMed1989

Screening for Axis II personality disorders in women with bulimic eating disorders.

The Personality Diagnostic Questionnaire (PDQ) was completed by 628 eating-disordered women: 300 with normal-weight bulimia, 15 with anorexia nervosa with bulimic features, and 313 with subdiagnostic eating disorders. Three-quarters (75%) of subjects with normal-weight bulimia had personality disorder diagnoses, compared with 50% of those with subdiagnostic eating disorders. The average number of separate PDQ diagnoses was 2.7 for the normal-weight bulimia group, 2.5 for the group with anorexia nervosa with bulimic traits, and 1.5 for the subdiagnostic group. The most common PDQ diagnoses were schizotypal, histrionic, and borderline disorders, but avoidant and dependent personality features also occurred. Personality disturbances may be common in patients with eating disorders.

Anorexia Nervosa↗
PubMed2002

Personality disorders and depression.

BACKGROUND: Personality disorders (PDs) were assessed among depressed out-patients by clinical interview before and after antidepressant treatment with fluoxetine to assess the degree of stability of PD diagnoses and determine whether changes in PD diagnoses across treatment are related to the degree of improvement in depressive symptoms. METHOD: Three hundred and eighty-four out-patients (55% women; mean age = 39.9 +/- 10.5) with major depressive disorder (MDD) diagnosed with the SCID-P were enrolled into an 8 week trial of open treatment with fluoxetine 20 mg/day. The SCID-II was administered to diagnose PDs at baseline and endpoint. RESULTS: A significant proportion (64%) of our depressed out-patients met criteria for at least one co-morbid personality disorder. Following 8 weeks of fluoxetine treatment, there was a significant reduction in the proportion of patients meeting criteria for avoidant, dependent, passive-aggressive, paranoid and narcissistic PDs. From baseline to endpoint, there was also a significant reduction in the mean number of criteria met for paranoid, schizotypal, narcissistic, borderline, avoidant, dependent, obsessive-compulsive, passive aggressive and self-defeating personality disorders. While changes in cluster diagnoses were not significantly related to improvement in depressive symptoms, there were significant relationships between degree of reduction in depressive symptoms (percentage change in HAM-D-17 scores) and degree of change in the number of criteria met for paranoid, narcissistic, borderline and dependent personality disorders. CONCLUSIONS: Personality disorder diagnoses were found to be common among untreated out-patients with major depressive disorder. A significant proportion of these patients no longer met criteria for personality disorders following antidepressant treatment, and changes in personality disorder traits were significantly related to degree of improvement in depressive symptoms in some but not all personality disorders. These findings suggest that the lack of stability of PD diagnoses among patients with current MDD may be attributable in part to a direct effect of antidepressant treatment on behaviours and attitudes that comprise PDs.

Adolescent↗
PubMed2002

Anorexia nervosa: obsessive-compulsive disorder, obsessive-compulsive personality disorder, or neither?

Anorexia nervosa (AN) is a severe and often chronic disorder with uncertain aetiology and poor prognosis. New approaches to the understanding of the disorder are needed in order to aid the development of more effective treatments. Several authors have suggested that AN has a considerable overlap with obsessive-compulsive disorder (OCD) and that this may reflect common neurobiological, genetic, or psychological elements. However, more recent studies have suggested that AN may have a closer relationship with obsessive-compulsive personality traits such as those found in obsessive-compulsive personality disorder (OCPD). In this paper, evidence for links between the three conditions is reviewed, suggestions for further research are outlined and possible implications for the treatment of AN are presented.

Anorexia Nervosa↗
PubMed1991

Personality disorder in perspective.

Personality disorders have for many years been on the fringe of psychiatry, with considerable doubts expressed about the usefulness, implications and validity of the concept. It is argued here that developments in the past few years have brought personality disorders into the mainstream of psychiatric practice. In particular, the recognition that personality function can be separated usefully from clinical symptoms, and that both mental state and personality can be disordered simultaneously, has led to better assessment and understanding. Advances in the classification, epidemiology, treatment and prognosis of personality disorders show that these conditions are common, extensive in their pathology, and cause much suffering. They cannot be ignored or dismissed as peripheral to psychiatry for they are an essential part of good psychiatric practice.

Humans↗
PubMed2005

Positron emission tomography of regional brain metabolic responses to a serotonergic challenge in major depressive disorder with and without borderline personality disorder.

Previous neuroimaging studies of major depression have not controlled for the presence of personality disorders characterized by impulsive aggressive behavior, such as borderline personality disorder (BPD). Using positron emission tomography (PET), we studied regional glucose uptake in response to fenfluramine (FEN) in depressed subjects with BPD (n=11) and depressed patients without Cluster B Axis II disorders (n=8). Subjects were scanned while medication-free after a single blind placebo administration and after FEN on a second day. Brain responses were measured by PET imaging of [18F]fluorodeoxyglucose (FDG) and serial prolactin levels. Scans were compared at a voxel level using statistical parametric mapping. Correlations of changes in relative regional cerebral uptake (rCMRglu) with clinical measures were assessed. Depressed borderline patients had greater relative activity in parietotemporal cortical regions (BA 40, BA 22, and BA 42) before and after FEN activation compared to those without BPD. They also had less relative uptake in the anterior cingulate cortex (BA 32) at baseline compared to depressed patients without BPD and FEN abolished this difference. Impulsivity was positively correlated with rCMRglu in superior and middle frontal cortex (BA 6 and 44). Hostility was positively correlated with rCMRglu in temporal cortical regions (BA 21 and 22). In conclusions, borderline pathology in the context of a Major Depressive Disorder is associated with altered activity in parietotemporal and anterior cingulate cortical regions. Controlling for the presence of BPD in future imaging studies of mood disorders may elucidate similarities and differences in regional serotonergic function in these two often comorbid disorders.

Adult↗
PubMed1995

Multiple personality disorder among female inpatients in a state hospital.

OBJECTIVE: Professional skepticism and concerns regarding diagnostic reliability hinder research in dissociative disorders and multiple personality disorder. The reported frequency of multiple personality disorder in different psychiatric settings ranges from 2.4% to 35%. The authors conducted a replication study of multiple personality disorder ascertainment in women admitted to a state hospital over a 5.5-month period. METHOD: Responses to the Dissociative Experiences Scale and to the Dissociative Disorders Interview Schedule were obtained, along with data on length of stay, county of admission referral, admission commitment status, and discharge diagnoses, for 176 female inpatients in a state hospital. Of 421 women representing 483 consecutive admissions, 121 were discharged before they could be assessed for study, 64 were excluded, 60 declined to participate, 176 enrolled in the study, and 175 completed the research procedures. RESULTS: Twenty-one women (12%) met criteria for multiple personality disorder based on the Dissociative Disorders Interview Schedule; these women were significantly younger than the women without multiple personality disorder. Scores on the Dissociative Experiences Scale of the women with multiple personality disorder (mean = 59.5, SD = 19.6) were significantly higher than the scores of women without multiple personality disorder (mean = 22.5, SD = 20.1), but considerable overlap occurred. There was no significant difference between groups in length of stay or admission status. CONCLUSIONS: The authors conclude that 1) the wide variability in multiple personality disorder detection is partially due to site-specific ascertainment biases and 2) despite its apparent usefulness for screening purposes, the Dissociative Experiences Scale requires more comprehensive evaluation before it can be applied broadly.

Adolescent↗
PubMed2006

Pharmacological interventions for people with borderline personality disorder.

BACKGROUND: Borderline Personality Disorder (BPD) is prevalent (2% in the general population, 20% among psychiatry in-patients) and has a major impact on health facilities as those affected often present in crisis but then make poor use of further attempts to help them. OBJECTIVES: To evaluate the effects of pharmacological interventions for people with borderline personality disorder. SEARCH STRATEGY: We conducted a systematic search of 26 specialist and general bibliographic databases (October 2002) and searched relevant reference lists for further trials. SELECTION CRITERIA: We included all randomised clinical trials comparing any psychoactive drugs with any other treatment for people with borderline personality disorder. DATA COLLECTION AND ANALYSIS: We independently selected, quality assessed and data extracted studies. For binary outcomes we calculated a standard estimation of the risk ratio (RR), its 95% confidence interval (CI), and where possible the number need to help/harm (NNT/H). For continuous outcomes, endpoint data were preferred to change data. Non-skewed data from valid scales were synthesised using a weighted mean difference (WMD). MAIN RESULTS: We found ten small (total n=554), short, randomised studies involving eight comparisons from which we could extract usable data. Studies comparing antidepressants with placebo were small (total n=79, 2 RCTs) but for ratings of anger fluoxetine may offer some improvement for those on antidepressant therapy over placebo (n=22, 1 RCT, RR anger not improved 0.30 CI 0.10 to 0.85, NNT 2 CI 2 to 9). The one small study investigating the important outcome of attempted suicide found no difference between mianserin and placebo (n=38, 1 RCT, RR 0.82 CI 0.44 to 1.54). Haloperidol may be better than antidepressants for symptoms of hostility and psychotism. There were few differences between MAOIs and placebo except that people given MAOIs were less hostile (n=62, 1 RCT, MD -9.19 CI -16.12 to -2.26). Although some ratings were statistically significant the comparison of MAOIs with antipsychotics did not show convincing differences. Antipsychotics may effect some mental state symptoms more effectively than placebo but results are difficult to interpret clinically and there is little evidence of advantage of one antipsychotic over another. Finally mood stabilisers such as divalporex may help mental state (n=16, 1 RCT, RR no improvement in mental state 0.58 CI 0.36 to 0.94, NNT 3 CI 2 to 17) but data are far from conclusive. AUTHORS' CONCLUSIONS: Pharmacological treatment of people with BPD is not based on good evidence from trials and it is arguable that future use of medication should be from within randomised trials. Current trials suggest that the positive effect of antidepressants, in particular, could be considerable. Well designed, conducted and reported clinically meaningful trials are possible and needed with, perhaps, the question of antidepressant versus placebo being addressed first.

Antidepressive Agents↗
PubMed2006

Hierarchical relationships between borderline, schizotypal, avoidant and obsessive-compulsive personality disorders.

OBJECTIVE: Comorbidity among personality disorders is widely considered problematic. The validity of one proposed solution, diagnostic hierarchies, was investigated in the current study with respect to borderline, schizotypal, avoidant, and obsessive-compulsive personality disorders. METHOD: One approach used discriminant functions, derived from multiple psycho-social domains, that were used to classify comorbid individuals from the Collaborative Longitudinal Personality Disorder study (CLPS) to explore the possibility of hierarchical precedence of one personality disorder over another. A second approach examined the incremental increase in R(2)-value in predicting functioning and personality provided by each diagnosis over each other diagnosis. RESULTS: Obsessive-compulsive personality disorder was consistently subordinate to other diagnoses, whereas other indications of hierarchical relationships were domain-specific. CONCLUSION: Results indicate minimal support for an over-arching hierarchical pattern among studied personality disorders, and suggest the inclusion of all relevant diagnoses in clinical practice.

Adolescent↗
PubMed1992

The outcome of childhood conduct disorder: implications for defining adult personality disorder and conduct disorder.

The effect of conduct disorder on adult social functioning in the areas of work, sexual/love relationships, social relationships and criminality was studied in a sample of young adults who spent much of their childhoods in group-cottage children's homes and an inner-city comparison group. Most subjects with conduct disorder had pervasive (but not necessarily severe) social difficulties compared to peers without conduct disorder. Less than half of this group met DSM-III adult criteria for antisocial personality disorder and just over half were given a diagnosis of personality disorder on interviewer clinical ratings. A latent class model that used both the retrospective and contemporaneous indicators of conduct disorder confirmed the very high continuity with adult social difficulties. Current diagnoses did not adequately describe this group and conduct disorder appeared to be an almost necessary condition for multiple social disability in adults in these samples.

Adolescent↗