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PubMed2005

The therapeutic alliance in the treatment of personality disorders.

Because personality disorders are associated with significant impairment in interpersonal relationships, special issues and problems arise in the formation of a therapeutic alliance in the treatment of patients with these disorders. In particular, patients with narcissistic, borderline, and paranoid personality traits are likely to have troubled interpersonal attitudes and behaviors that will complicate the patient's engagement with the therapist. While a strong positive therapeutic alliance is predictive of more successful treatment outcomes, strains and ruptures in the alliance may lead to premature termination of treatment. Therefore, clinicians need to consider the patient's characteristic way of relating in order to select appropriate interventions to effectively retain and involve the patient in treatment. Research has shown not only the importance of building an alliance but also that this alliance is vital in the earliest phase of treatment. The author first reviews several definitions of the therapeutic alliance with reference to how they apply to the treatment of patients with personality disorders. Issues relevant to forming a therapeutic alliance with patients with personality disorders are then discussed in terms of the three DSM-IV-TR personality disorder clusters. However, the author notes that these categories do not adequately capture the complexity of character pathology and that clinicians also need to consider which aspects of a patient's personality pathology are dominant at the moment in considering salient elements of the therapeutic alliance. In dealing with Cluster A personality disorders (schizotypal, schizoid, and paranoid personality disorders), what is most relevant for alliance building is the profound impairment in interpersonal relationships. The Cluster B "dramatic" personality disorders (antisocial, borderline, histrionic, and narcissistic) are all associated with pushing the limits. Consequently, clinicians need to exercise great care to avoid crossing inappropriate lines in a quest to build an alliance with patients with one of these disorders. Patients with Cluster C "anxious/fearful" personality disorders (avoidant, dependent, and obsessive-compulsive personality disorders) are emotionally inhibited and averse to interpersonal conflict. These patients frequently feel guilty and internalize blame for situations even when there is none, a tendency that may facilitate alliance building because the patients are willing to take some responsibility for their dilemma and may engage somewhat more readily with the therapist to sort it out, compared with patients with more severe Cluster A or B diagnoses. The author then reviews considerations relevant to treatment alliance that arise in the different treatment approaches that may be used with patients with personality disorders, including psychodynamic psychotherapy/psychoanalysis, cognitive-behavioral therapies, and psychopharmacology. The author also discusses issues, especially splitting, that arise in the alliance when patients with personality disorders are treated in inpatient psychiatric hospital settings.

Adult↗
PubMed2005

Alcoholism and personality disorders: an exploratory study.

AIMS: To define the most frequent personality disorders related to alcohol dependence. METHODS: Using the International Personality Disorder Examination and the Millon Clinical Multiaxial Inventory-II for personality disorders, 30 consecutively recruited alcohol-dependent patients attending an outpatient clinic were compared with 30 consecutively recruited psychiatric patients with non-addictive disorders and 31 subjects from the general population chosen to match the patient samples for age, gender and socio-economic level. RESULTS: Forty percent of the alcohol-dependent patients and 16.6% of the general clinical sample (vs 6.4% of the normative sample) showed at least one personality disorder. Dependent personality disorders were most prevalent (13.3%), followed by paranoid and obsessive-compulsive personality disorders (10% each).

Adult↗
PubMedDate not supplied

Patterns of anxiety and personality disorder comorbidity.

The purpose of this study was to examine patterns of comorbidity of DSM-III-R anxiety disorders and personality disorders (PD). Two-hundred subjects were independently interviewed with the Structured Clinical Interview for DSM-III-R (SCID) and the Personality Disorder Examination (PDE) face-to-face by two experienced clinicians. One-hundred and forty-six also completed the Personality Diagnositc Questionnaire-Revised (PDQ-R). Rates of personality disorder among patients with and without anxiety disorders were determined by each of the three instruments. Comorbidity between panic disorder social phobia, obsessive-compulsive disorder and simple phobia and a conservative estimate of individual Axis II disorders was examined. Results indicate that panic disorder, either current or lifetime, is associated with borderline, avoidant, and dependent personality disorders: social phobia is associated with avoidant personality disorder, and obsessive-compulsive disorder is associated with obsessive-compulsive and avoidant personality disorders. Anxiety disorders with personality disorders are characterized by chronicity and lower levels of functioning compared with anxiety disorders without personality disorders.

Adolescent↗
PubMed2004

The longitudinal relationship of personality traits and disorders.

Personality disorders are presumed to be stable because of underlying stable and maladaptive personality traits, but while previous research has demonstrated a link between personality traits and personality disorders cross-sectionally, personality disorders and personality traits have not been linked longitudinally. This study explores the extent to which relevant personality traits are stable in individuals diagnosed with 4 personality disorders (schizotypal, borderline, avoidant, and obsessive-compulsive personality disorders) and examines the assumption that these personality disorders are stable by virtue of stable personality traits. This assumption was tested via the estimation of a series of latent longitudinal models that evaluated whether changes in relevant personality traits lead to subsequent changes in personality disorders. In addition to offering large consistency estimates for personality traits and personality disorders, the results demonstrate significant cross-lagged relationships between trait change and later disorder change for 3 of the 4 personality disorders studied.

Adult↗
PubMed2003

Evaluating NEO Personality Inventory-Revised profiles in veterans with personality disorders.

Fifty-one psychiatric, veteran outpatients were assessed for personality disorders on the Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II; First, Gibbon, Spitzer, Williams, & Benjamin, 1997a) and were also administered the NEO Personality Inventory-Revised (NEO-PI-R; Costa & McCrae, 1992). Results were compared to Trull and Widiger's (1997) hypotheses about the profiles of such patients and similar past studies. Correlations between NEO-PI-R facets and SCID-II personality disorder symptom clusters generally occurred in the expected direction. Facets hypothesized to be associated with a given personality disorder were able to predict variance in their respective SCID-II personality disorder scores for seven of ten personality disorders. In general, results support the facet-level conceptualizations of these disorders, except for Obsessive-Compulsive Personality Disorder.

Diagnostic and Statistical Manual of Mental Disord↗
PubMed2002

The representation of borderline, avoidant, obsessive-compulsive, and schizotypal personality disorders by the five-factor model.

This study evaluated the accuracy of hypothesized relationships of the five-factor model of personality to four targeted personality disorders in a large multisite sample of patients. Data were gathered from 668 patients, who were assigned to one of five study cells: Borderline, Schizotypal, Avoidant, and Obsessive-Compulsive Personality Disorder, and a Major Depression without personality disorder comparison group. Patients were administered a questionnaire designed to assess the domains and facets of the five-factor model and results were compared among diagnostic groups and between patients and community norms. Although many relationships between personality traits and disorders were obtained, the magnitude of the relationships varied greatly as a function of the comparison group involved. In general, the differences between the personality disorder patients and community norms were far larger than the differences between the specific personality disorder groups. Also, for avoidant personality, it appeared that statistical interactions between personality factors are needed to better differentiate it from other personality disorder groups. The four personality disorder groups studied could each be distinguished from community norms on the personality dimensions of the five-factor model. However, differentiating among the four groups proved more difficult, as each shared the configuration of high Neuroticism, low Agreeableness, and low Conscientiousness. It does not appear that these disorders represent extremes of different personality dimensions, but rather each appears to be a variant of the same extreme configuration. Differences between personality disorders may reflect diverse interactions among the dimensions, rather than differences on single dimensions.

Adult↗
PubMed2000

Psychiatric comorbidity associated with eating disorder symptomatology among adolescents in the community.

OBJECTIVE: This study investigates psychiatric comorbidity associated with eating disorder symptomatology among adolescents in the community. METHOD: Four hundred three adolescents in the community were administered structured clinical interviews to assess mood, anxiety, eating, substance use, and personality disorders. RESULTS: Adolescents with dysthymia, panic and major depressive disorder were significantly more likely than those without these disorders to have an eating disorder. After controlling for the effects of other Axis I disorders and personality disorders, only dysthymia independently predicted the presence of an eating disorder. Several personality disorders were also associated with eating disorder symptoms. However, only obsessive-compulsive personality disorder predicted eating disorder symptoms after controlling for other personality disorders. CONCLUSION: Although previous research on adults has focused on the association between major depressive disorder and eating disorders, dysthymia may be more strongly associated with eating disorders among adolescents in the community. This association is not accounted for by psychiatric comorbidity.

Adolescent↗
PubMed1991

Gender stereotypes for paranoid, antisocial, compulsive, dependent, and histrionic personality disorders.

To assess similarity between gender-role stereotypes and the personality disorder prototypes, university students (31 women and 13 men) were asked to assign gender to six descriptions of DSM-III--R personality disorders. Significant agreement was found in gender assignment for five of the six descriptions. Descriptions of the paranoid, antisocial, and compulsive personality disorders were viewed as male, and descriptions of the dependent and histrionic personality disorders were viewed as female. The description of schizoid personality disorder was not significantly gender-typed.

Adult↗
PubMed1983

Personality disorders.

Personality disorders are characterized by inflexible maladaptive traits that cause significant impairment in social and occupational functioning. Categories of personality disorders include paranoid, schizoid, histrionic, narcissistic, antisocial, borderline, avoidant, dependent, compulsive and passive-aggressive. The inflexible nature of these disorders and the lack of an alternative behavioral repertoire result in an inability to cope with environmental pressure. The goal of management is the development of healthier behavioral responses to stress. A personality change in older patients suggests organic disease.

Adolescent↗
PubMed1999

Ten-year follow-up of adolescent-onset anorexia nervosa: personality disorders.

OBJECTIVE: To study the development of personality disorders, especially those involving obsessions, compulsions, and social interaction problems, in a representative group of anorexia nervosa (AN) cases. METHOD: The prevalence of personality disorders, obsessive-compulsive disorder, and autism spectrum disorders at mean age 24 years (10 years after reported onset) was examined in 51 adolescent-onset AN cases recruited after community screening and 51 comparison cases matched for age, sex, and school. All 102 cases had originally been examined at age 16 years and followed up at 21 years. At 24 years, structured and validated psychiatric diagnostic interviews were performed by a psychiatrist who was blind to original diagnosis. The majority of AN cases (94%) were weight-restored. RESULTS: Personality disorders, particularly cluster C, and autism spectrum disorders were overrepresented in the AN group. Obsessive-compulsive personality disorder and/or autism spectrum disorder was diagnosed in a subgroup of AN cases in all 3 studies. This subgroup had a very poor psychosocial outcome. CONCLUSIONS: Persistent problems with obsessions, compulsions, and social interaction characterized a substantial minority of weight-restored AN cases at 10-year follow-up. These problems appear to be constitutional rather than a result of AN, and they may warrant a different treatment approach.

Adolescent↗
PubMed1985

Obsessive-compulsive behavior, DSM-III, and a psychodynamic classification of psychopathology.

This paper reviews obsessive-compulsive behavior, both neurosis and character, and relates these to DSM-III, as well as to a psychodynamic classification of psychopathology. The DSM-III obsessive-compulsive disorder and the classical obsessive-compulsive neurosis are found to be very similar descriptively. In contrast, the DSM-III compulsive-personality disorder is found to be a much more psychopathological entity than the classical obsessive-compulsive character.

Borderline Personality Disorder↗
PubMed2003

Outcome of teenage-onset anorexia nervosa in a Swedish community-based sample.

In a prospective long-term outcome study of a representative sample of teenage-onset anorexia nervosa (AN), 51 individuals with AN, recruited after community screening, were contrasted with 51 matched comparison cases at a mean age of 24 years (10 years after AN onset). All 102 cases had been examined at age 16 and 21 years. At 24 years all probands were interviewed regarding mental and physical health, and overall outcome was assessed. Ten-year outcome of teenage-onset AN seemed to be relatively favourable in that half of all cases were free from eating disorder (ED) and other axis I disorder. There were no deaths. However, one in four in the AN group had a persisting ED, 3 of whom still had AN. Lifetime diagnoses of affective disorders and obsessive-compulsive disorder (OCD) were overrepresented in the AN group. Affective disorders coincided with the ED, and were not a problem after recovery from the ED. On the other hand, OCD, OCPD (obsessive-compulsive personality disorder), and/or autism spectrum disorder continued to characterise more than one-third of the AN cases. One in six of the AN group had persistent problems with social interaction and obsessive compulsive behaviours from childhood into early adult years. Half the AN group had a poor overall outcome. These were subjects with either persisting ED or lifelong problems with social interaction and obsessive compulsive behaviour.

Adolescent↗
PubMed1999

Clinical characteristics in patients with anorexia nervosa and obsessive-compulsive disorder.

BACKGROUND: The purpose of this study was to assess clinical characteristics, including co-morbid personality disorders in patients with both anorexia nervosa (AN) and obsessive-compulsive disorder (OCD) in comparison with age- and sex-matched patients with OCD. METHODS: Fifty-three female patients with AN were divided into two groups based on the presence or absence of a current diagnosis of OCD, as assessed by the Structured Clinical Interview for DSM-III-R Patient version (SCID-P). Twenty-one women (40 %) who met the DSM-III-R criteria for both AN and OCD were compared with 23 female patients with OCD, using the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and the SCID Axis II disorders. RESULTS: There were no significant differences on the mean Y-BOCS severity scores between these groups. However, AN patients with OCD were significantly more likely than OCD patients to have obsessions with need for symmetry or exactness and ordering/arranging compulsions, whereas both aggressive obsessions and checking compulsions tended to be more frequently identified in OCD patients compared with AN patients with OCD. AN patients with OCD were significantly more likely than OCD patients to meet the criteria for obsessive-compulsive personality disorder (OCPD). CONCLUSIONS: These results suggest that there are some differential characteristics of the OCD symptomatology between these disorders, although many patients with AN manifest significant impairment from primary OCD symptoms with similar magnitude in severity to that found in OCD patients.

Adult↗
PubMed2002

Positive and negative schizotypy in a student sample: neurocognitive and clinical correlates.

Positive and negative schizotypy may represent discrete factors or dimensions. To determine if distinct neurocognitive profiles are associated with these dimensions or factors, we classified university students on the basis of positive and negative schizotypal symptoms and conducted separate analyses. Following prior work in the neuropsychiatric literature, we predicted that subtle prefrontal deficits would be selectively associated with negative schizotypal personality features in a nonclinical student sample. We also investigated the relationship between positive/negative schizotypy and associated clinical states or personality dimensions including antisocial personality disorder, obsessive-compulsive personality traits, generalized and social anxiety, empathy, and impulsivity. Classification of subjects into positive and negative schizotypy groups revealed distinct neurocognitive and clinical profiles. We observed a positive relation between measures of temporolimbic dysfunction, impulsivity, antisocial behavior, and positive schizotypal phenomena. Negative schizotypy was associated with subtle performance deficits on measures of frontal executive function, increased social anxiety, and obsessive-compulsive phenomena. Findings are consistent with the contention that positive and negative schizotypy represent discrete factors.

Adolescent↗
PubMed2002

Hoarding in obsessive-compulsive disorder and related disorders: a preliminary report of 15 cases.

Hoarding, the repetitive collection of excessive quantities of poorly useable items of little or no value with failure to discard these items over time, is characterized in DSM-IV as a symptom of obsessive-compulsive disorder (OCD) and obsessive-compulsive personality disorder (OCPD) but has, until recently, received scant empirical investigation. We describe the demographics, phenomenology, associated psychopathology and family history in 15 subjects presenting with hoarding behavior. Fifteen subjects were recruited from an OCD clinic and newspaper advertisement and assessed with the comprehensive Structured Clinical Interview for DSM-IV (SCID I and II), the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), and a hoarding questionnaire (devised by the authors). The sample comprised 11 women and four men who hoarded a mean of seven item types, with a mean duration of 13.2 +/- 3.9 years (range 2-15 years). Their mean age was 41.8 +/- 14.3 years (range 20-65 years). The most common motive for hoarding was the fear of discarding items of practical value. Nine subjects met DSM-IV criteria for OCD, 9 met criteria for OCPD, for symptoms and behaviors other than hoarding, while six subjects met criteria for a putative OCD spectrum disorder (Tourette's, body dysmorphic disorder, trichotillomania). Six subjects reported little or no control over their hoarding, but only one subject saw her symptoms as an 'illness' warranting treatment. Pathological hoarding is usually a covert and chronic behavior causing distress and/or impairment, and may be related to OCD and OCPD. Hoarding may meet the criterion for a compulsion in DSM-IV, yet there is evidence to suggest that hoarding may manifest in a variety of other psychiatric conditions. While a range of pharmacologic and behavioral treatments have been tried, their effectiveness in managing hoarding behaviors requires additional research.

Adult↗
PubMed2003

The relationship among binge severity, personality psychopathology, and body mass index.

OBJECTIVE: To determine the relationship among binge severity, personality psychopathology, and body mass index (BMI) among individuals with binge eating disorder (BED). METHOD: Participants were 50 individuals from the community who responded to advertisements for a medication treatment study of compulsive overeating and met BED criteria. Participants completed the Eating Disorder Examination and the Structured Clinical Interview for DSM-IV Personality Disorders. RESULTS: Binge eating severity was significantly and positively correlated with BMI and personality disorder symptomatology. The frequency of binge eating episodes, but not binge size, was associated with greater levels of personality psychopathology. BMI and personality psychopathology were unrelated. Twelve percent of the participants met full criteria for avoidant personality disorder (APD) and 10% met full criteria for obsessive-compulsive personality disorder (OCPD). DISCUSSION: Findings suggest that eating pathology, rather than weight, is related to personality psychopathology. APD and OCPD traits may be of particular relevance when considering treatment interventions for individuals with BED.

Adult↗