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[Anxious (avoidant) personality disorder].

The anxious (avoidant or fearful) type of personality disorder has a lifetime prevalence of 5%, which makes it the most common form of personality disorder. Although it is one of the leading risk factors for severe depressive illnesses, anxiety disorders, substance dependence, eating disorders and chronic pain, its importance is frequently underestimated. Ambulatory treatment comprises psychoeducation, self-management and training in social competence.

Anxiety Disorders↗

The relationship between panic disorder/agoraphobia and personality disorders.

This selective review of the relationship between panic disorder/agoraphobia and DSM-III personality disorders points to a preponderance of dependent, avoidant, and histrionic features and reveals a certain degree of covariation between severity of Axis I disorder and personality functioning. However, the link between panic/agoraphobia and Axis II disorders does not appear to be specific because (1) general features such as neuroticism, stress, dysphoric mood, and interpersonal sensitivity, rather than duration and severity of panic attacks and phobias, emerge as unique predictors or determinants of personality disorder; and (2) similar personality profiles are obtained in a heterogenous population of psychiatric outpatients or patients with social phobia, obsessive-compulsive disorder, and major depression.

Adult↗

The DSM-III personality disorders section: a commentary.

The author reviews the DSM-III section on personality disorders, discusses several of its more controversial diagnoses, and suggests some possible alternatives. He attributes the continued low reliability of personality diagnoses, compared with the other major sections of DSM-III, to two inherent obstacles: the lack of clear boundaries demarcating the personality disorders from normality and from one another, and the confounding influence of state and role factors. Nonetheless, the DSM-III multiaxial system highlights the importance of personality diagnosis and, together with the provision of clearly specified diagnostic criteria, achieves a considerably improved reliability compared with previous nomenclatures.

Antisocial Personality Disorder↗

Genetic and environmental contributions to depressive personality disorder in a population-based sample of Norwegian twins.

BACKGROUND: Depressive personality disorder (DPD) was introduced in DSM-IV as a new category requiring further study. The aim of this study was to estimate genetic and environmental contributions to DPD in a population-based twin sample, and include data on criteria performance, prevalence and diagnostic overlap. METHODS: Axis I and Axis II diagnoses were obtained by structured interviews in a population-based sample of 2794 young adult twins. Statistical analyses included correlation and factor analysis based on polychoric correlation coefficients, and diagnostic overlap applying adjusted odds ratios. Contributions from additive genetic and common and unique environmental influences to the liability to DPD were computed using structural equation modelling, applying a multiple threshold variable. RESULTS: Liability to DPD could best be explained by additive genetic and unique environmental factors, with heritability estimates of 49% (95% CI 0.41-0.57) in females and 25% (95% CI 0.12-0.40) in males. The best-fitting model indicated that some of the genes contributing to DPD differ between men and women. Chronbach's alpha was 0.87. 2.0% of participants fulfilled the criteria for DPD, and overlap was most pronounced for dysthymic disorder and avoidant personality disorder. LIMITATIONS: Low prevalence rates and subsequent inclusion of subthreshold criteria could have influenced parameter estimates, especially in males. CONCLUSIONS: DPD was almost twice as heritable in females as in males, comparable to previous studies on major depression. The proposed criteria showed good measurement properties, and DPD was not completely subsumed within any other disorder.

Adult↗

Psychopathology in the families of children and adolescents with borderline personality disorder.

OBJECTIVE: The purpose of this study was to determine whether rates of psychopathology differed between the families of a group of children and adolescents with borderline personality disorder and the families of a psychiatric comparison group. METHOD: The rates of psychiatric disorders in the families of 44 child and adolescent outpatients with borderline personality disorder were compared with the rates in the families of a psychiatric comparison group of 100 children and adolescents, none of whom had a diagnosis of borderline personality disorder. Psychopathology in family members was ascertained by the family history method with the use of information from semistructured interviews with the subjects in the two study groups and with their parents or guardians. The adults were systematically interviewed regarding specific DSM-III-R disorders in their families. RESULTS: The families of the patients with borderline personality disorder had significantly greater rates of psychopathology, particularly in the areas of depressive, substance abuse, and antisocial disorders. CONCLUSIONS: The finding of higher rates of psychopathology among the family members of the group with borderline personality disorder supports the hypothesis that a history of significant family psychopathology is associated with the disorder.

Adolescent↗

The effect of personality disorder on clinical outcome, social networks and adjustment: a controlled clinical trial of psychiatric emergencies.

One hundred psychiatric emergencies presenting to an inner London teaching hospital had formal assessments of psychopathology, personality disorder (using both ICD-10 and the Personality Assessment Schedule), social networks and social functioning before being randomly assigned to a multidisciplinary community-based team (Early Intervention Service (N = 48) or conventional hospital-based psychiatric services (N = 52) and treated for a period of 12 weeks. The ICD-10 classification yielded a higher proportion (50%) of personality disordered patients than the Personality Assessment Schedule (34%) and those from ethnic minorities (mainly Afro-Caribbean) and upper social classes had a lower incidence of personality disorder. Social networks were smaller in personality disordered patients and there were fewer attachment figures. Improvement in social function, and to a lesser extent with depressive symptomatology, was better in patients with no differences were found between the numbers and duration of social contacts in the two services and it is concluded that the better outcome in the community-treated patients was independent of changes in social networks.

Community Mental Health Services↗

Sex bias in the diagnosis of histrionic and antisocial personality disorders.

The differential prevalence of the histrionic and antisocial personality disorders among men and women has been attributed both to sex biases and to actual variation in disorder base rates. The present study assessed the bias and base rate explanations and examined whether sex biases are minimized by the relatively explicit diagnostic criteria in the DSM-III. Psychologists (N = 354) either diagnosed 9 DSM-III disorders from case histories that varied in the ambiguity of the antisocial and histrionic personality disorder diagnoses or rated the degree to which specific features extracted from the case histories met 10 histrionic and antisocial diagnostic criteria. The sex of the patient was either male, female, or unspecified. Sex biases were evident for the diagnoses but not for the diagnostic criteria. The results are discussed with respect to base rate effects, sex biases, and the construction of diagnostic criteria.

Adult↗

Cassel Personality Disorder Study. Methodology and treatment effects.

BACKGROUND: The effectiveness of hospital-based treatment models for personality disorder is still uncertain. AIMS: To compare effectiveness of two models of psychosocial intervention for personality disorder. METHOD: Two samples of people with personality disorder allocated to a one-stage treatment model (in-patient treatment with no after care) and to a two-stage model (shorter in-patient admission followed by outreach therapy) are prospectively compared. RESULTS: Subjects in the two-stage sample did significantly better on global assessment of mental health (according to the Global Assessment Score (GAS)) at 6 and 12 months and on social adjustment (according to the Social Adjustment Scale (SAS)) at 12 months. Significant differences in rates of reliable improvement on the GAS (43% v. 17%) and SAS (39% v. 15%) in favour of the two-stage condition were found at 12 months. Subjects with borderline personality disorder (BPD) allocated to the two-stage model improved significantly more than such patients in the one-stage model. CONCLUSIONS: A long-term phased model which combines hospital-based and community-based strategies has advantages over a purely in-patient model for the treatment of BPD.

Adult↗

Personality disorders and romantic adult attachment: a comparison of secure and insecure attached child molesters.

This study analyzed personality disorders in a group of 33 securely and 51 insecurely attached child molesters. A total of 51 child molesters were selected from a community based educational training program, and the other group was selected from a Belgian prison (n = 33). Research shows that adult attachment styles and personality disorders share a common underlying structure. It is remarkable that very little is known about differences between securely and insecurely attached child molesters. In this study, the authors found that the schizoid personality disorder differed between securely and insecurely attached child molesters. These findings have implications for the aetiology and treatment of child molesters. Future research is necessary to determine patterns of attachment in relationship to personality disorders.

Adult↗

Temperament, character, and personality disorder in bulimia nervosa.

In a sample of 76 women participating in a clinical treatment trial for bulimia nervosa, we examined the clinical differences between subjects with and without concurrent personality disorders and the ability of "self-directedness" (a character scale of Cloninger's Temperament and Character Inventory) to predict the presence of personality disorder. Sixty-three percent of the sample had at least one personality disorder diagnosis. Fifty-one percent of personality disorders were in cluster C, 41% were in cluster B, and 33% were in cluster A. The presence of personality disorder was associated with greater depressive symptoms, worse global functioning, laxative use, greater body dissatisfaction, higher harm avoidance, and lower self-directedness. As hypothesized, low self-directedness scores were associated with a markedly increased probability of a personality disorder.

Adult↗

Child maltreatment, attention networks, and potential precursors to borderline personality disorder.

Potential precursors to borderline personality disorder (BPD) were investigated in a sample of 185 maltreated and 175 nonmaltreated school-aged children attending a summer camp research program. Self-report, peer-report, and counselor-report measures were utilized to assess developmental constructs conceptualized to constitute vulnerability for later emerging BPD. These areas, including personality features, representational models of self, parent, and peers, interpersonal relationship difficulties with peers and adults, and suicidal/self-harm behavior, were used to develop a BPD precursors composite. Additionally, the efficiency of three attention networks was assessed with a computerized task. Maltreated children had higher mean scores on the BPD precursors composite, and children classified as having high levels of these precursors were more prevalent in the maltreatment group. No maltreatment group differences were found for the efficiency of the three attention networks; however, children with high levels of BPD precursors evinced less efficient processing of the conflict attention network, comparable to findings observed among adult patients with BPD. Child maltreatment and efficiency of the conflict attention network independently predicted scores on the BPD precursors composite. Experiential and biological contributions to risk for BPD and recommendations for prevention and intervention are discussed.

Attention↗

Psychotherapist personality characteristics and the perception of self and patients in the treatment of borderline personality disorder.

The influence of certain personality characteristics (tendency to depressive experiences, personal boundary preferences) on psychotherapist reaction to patients with borderline personality disorder was assessed by semantic differential ratings in an analogue study. Vignettes presented one of two patients enacting the Rewarding and Withdrawing object relations unit in two separate therapy sessions. Therapists higher on anaclitic depressive and fusion tendencies evaluated themselves less positively than other therapists (p less than .01) in the Withdrawing condition. They evaluated the patient less positively regardless of condition (p less than .05). High boundary therapists evaluated patients more positively (p less than .05) in the Withdrawing condition. They evaluated themselves more positively regardless of condition (p less than .05) and showed less tendency to devalue self and patient with the lower functioning borderline patient.

Adult↗

Neurobiological correlates of borderline personality disorder.

Although patients with borderline personality disorder (BPD) are commonly seen in psychiatric practice, there has been far less biological research in BPD than in other psychiatric disorders. This article reviews the neurobiological research that has been performed to date in BPD and integrates the biological, psychological, and clinical findings in this disorder. BPD is best thought of in terms of dimensions rather than as a specific disorder. Each dimension has a biological profile and may be expressed differently in different patients. Four core elements are suggested to play a major role in the development of BPD: interpersonal stress, affective instability, impulsivity, and dissociation and self-injurious behavior. Genetic and environmental factors lead to brain alterations that are the basis for specific presentations of the disorder, such as self-injurious and impulsive aggressive behavior.

Borderline Personality Disorder↗

Is electroconvulsive therapy effective for the depressed patient with comorbid borderline personality disorder?

Among the more common current indications for electroconvulsive therapy (ECT) is treatment-resistant depression. Treatment resistance is correlated with a number of factors, including the presence of comorbid personality disorders, such as borderline personality disorder (BPD). A detailed review of the literature was undertaken and very few reports or studies have dealt specifically with ECT in borderline patients. Thirteen original reports on ECT outcome in personality disordered patients were identified. Depressed patients with a personality disorder, particularly BPD, may have a poorer outcome on some measures. However, the available data suggests that depression in these patients can be effectively treated with ECT. The depressed, borderline patient appears to have two distinct disorders, one which is responsive to ECT and the other which is not. Unfortunately, the literature is limited by lack of rigorous randomized treatment studies, lack of long-term follow-up, and other methodological weaknesses. Clinical guidelines are suggested.

Borderline Personality Disorder↗

Standardized approaches to individual psychotherapy of patients with borderline personality disorder.

Recent developments in individual psychotherapy for patients with borderline personality disorder include psychodynamic, interpersonal, behavioral, and cognitive treatments. The author provides an overview of standardized treatment approaches--that is, modes of treatment that have a clear theoretical rationale and specific strategies and techniques--for borderline personality disorder. Evaluations of the efficacy of these approaches are discussed. Although there is little empirically based knowledge about the effectiveness of these treatments, their adaptation for the specific treatment of borderline personality disorder represents an important step for treatment and research in this area.

Behavior Therapy↗

DSM-III personality disorders in obsessive-compulsive disorder: changes with treatment.

Twenty-seven patients meeting DSM-III diagnostic criteria for obsessive-compulsive disorder (OCD) completed the Personality Diagnostic Questionnaire (PDQ; a self-rating scale designed to assess the axis II personality disorders [PDs] from the DSM-III) before and after 12 weeks of treatment with clomipramine. Treatment was accompanied with reduction on several personality variables, including the number of personality diagnoses assigned, the distribution of traits in the sample, and the number of items endorsed in each personality category. The data also showed that improvement in personality functioning was significantly greater in responders compared with nonresponders or partial responders. Further investigation of the relationship between personality and treatment outcome did not provide strong support for the notion that personality factors may have prognostic significance in the treatment of OCD. These findings suggest similarities and differences with panic/agoraphobia which are briefly discussed.

Adult↗

Psychopharmacology of borderline personality disorder.

Psychopharmacology is widely used in the treatment of borderline personality disorder. However, support for this form of treatment has been largely based on case reports, case series, and open-label clinical trials. This evidence-based review examines the most recent randomized controlled trials of psychopharmacology in the treatment of borderline personality disorder, with a goal of highlighting the most promising pharmacotherapy for use in current clinical practice, as well as for future large-scale research testing. The results and limitations of the randomized controlled trial data are presented along with case vignettes illustrating the complexity of the disorder and the heterogeneity of its treatment. To date, there is at least some evidence-based support for the use of antipsychotics (conventional and atypical), monoamine oxidase inhibitors, serotonin reuptake inhibitors, and omega-3 fatty acids in the treatment of borderline personality disorder.

Aggression↗

The frequency of multiple personality disorder among psychiatric inpatients.

OBJECTIVE: A 2-year study was undertaken to determine the frequency of multiple personality disorder among general adult psychiatric inpatients. METHOD: All individuals admitted to two 23-bed acute care wards in a teaching hospital in Winnipeg, Man., were screened with the Dissociative Experiences Scale. Individuals with prior diagnoses of multiple personality disorder were excluded. All subjects scoring 20 or higher on the Dissociative Experiences Scale were interviewed with the Dissociative Disorders Interview Schedule. Then subjects with a diagnosis of multiple personality disorder and comparison subjects were interviewed by a clinician who was blind to all research data. RESULTS: A total of 299 subjects completed the Dissociative Experiences Scale and 80 received a structured diagnostic interview. Ten subjects (3.3%) had clinically confirmed multiple personality disorder. CONCLUSIONS: If these results are replicated and accepted, multiple personality disorder will become a serious consideration in the differential diagnosis of many psychiatric patients.

Adult↗