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Homogamous and heterogamous marriages.

This paper explores two marital constructs set forth by Peter Giovacchini. The first is based on a symbiotic reenactment in which the investment of both partners is tenacious and reciprocal, an attachment which Giovacchini refers to as a "character object" relationship. It represents intrapsychic homogramy. In the second construct, this deep form of attraction is absent and the dyadic bond is superficial, frequently transitory. The latter couples do not require an elementary, intrapsychic bond but do share particular defensive traits or symptoms. Thus these unions are termed "symptom object" relationships and are characterologically heterogamous. By means of a group case study approach, this distinction was statistically supported. Furthermore, it was found that homogamous marriages stay in treatment longer, maintain a lower divorce rate, and respond best to individual psychoanalytic psychotherapy. Heterogamous marriages, by contrast, show a higher divorce rate and tend to leave therapy prior to termination. The research also suggests that the initial treatment of choice for this type of marriage may well be conjoint or group psychotherapy.

Compulsive Personality Disorder↗

Prolonged LSD flashbacks as conversion reactions.

This paper presents a case study of the background and treatment of a patient with prolonged LSD flashbacks. The hypothesis that flashbacks can be psychologically determined symptoms is supported by the dynamics of the case and the course of treatment. A second focus is a partial explanation for the often made observation that obessive-compulsive personalities are at increased risk for LSD flashbacks.

Adult↗

[Self-assessment questionnaire of alcoholic craving (ECCA Questionnaire: Behavior and Cognition in Relation to Alcohol: French translation and validation of the Obsessive-Compulsive Drinking Scale].

Clinical, neurobiological and neuropsychological hypotheses suggest that the dimension of alcohol craving includes the concept of both obsessive thoughts about alcohol use and compulsive behaviors toward drinking. Anton et al. (1995) developed a 14 items self-rating scale, the Obsessive Compulsive Drinking Scale (OCDS) which includes items for assessing three dimensions: global, and the obsessive and the compulsive subdimensions. In this study, we included 156 patients, 105 men and 51 women, who met DSM IV diagnostic criteria for alcohol dependence. The mean age of our population was 39.1 +/- 11.2 years without difference between sexes. We did not found any correlation between the CAGE score and the OCDS total score or the obsessive and compulsive subscores (respectively, r = .15, r = .10 et r = .18). Moreover, we did not found any correlation between OCDS scores and mean daily alcohol consumption (r = .18, r = .16, r = .19). This could indicate that the dimension measured by the scale was somewhat independent of actual drinking. As such, it might act as an independent measure of the "state of illness" for alcohol-dependent patients. The test-retest correlation for the OCDS total score was .95 and the obsessive and compulsive subscales test-retest correlations were .93 and .89 respectively. The internal consistency of the items of the OCDS was high (alpha = .89). Principal component analysis had identified in the french version of the OCDS, three factors accounting for 63.5% of the total variance. These results indicate that the french version of the OCDS seems to validly measure a dimension of alcohol dependence. The ease of administration, reliability, and concurrent validity of the OCDS makes it particularly useful as an outcome measurement tool for various clinical therapeutic protocols in alcoholism.

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↗

Psychiatric manifestations of homocystinuria due to cystathionine beta-synthase deficiency: prevalence, natural history, and relationship to neurologic impairment and vitamin B6-responsiveness.

Homocystinuria commonly affects the central nervous system (CNS), primarily as mental retardation, seizures, and stroke. Case reports have long suggested a predisposition to schizophrenia, but no careful study of predisposition to psychiatric illness has been performed. Accordingly, we evaluated 63 persons with homocystinuria due to cystathionine beta-synthase deficiency for psychiatric disturbance, intelligence, evidence of other CNS problems, and responsiveness to vitamin B6. The overall rate of clinically significant psychiatric disorders was 51%, predominated by four diagnostic categories: episodic depression (10%), chronic disorders of behavior (17%), chronic obsessive-compulsive disorder (5%), and personality disorders (19%). The average IQ was 80 +/- 27 (1 SD); and an IQ of less than or equal to 79 was two-thirds more common among vitamin B6-nonresponsive patients compared to vitamin B6-responsive patients. Aggressive behavior and other disorders of conduct were particularly common among patients with mental retardation and among vitamin B6-nonresponsive patients.

Cystathionine beta-Synthase↗

Diogenes syndrome and hoarding in the elderly: case reports.

Presented here are two case reports of elderly persons with Diogenes syndrome (variously known as senile breakdown, social breakdown and senile squalor syndrome). Diogenes syndrome is often (but not always) characterized by a tendency to hoard excessively (syllogomania). The first patient was diagnosed as having both a schizotypal personality disorder and obessive-compulsive disorders (OCD) while the second was diagnosed as having a schizoid personality disorder. Only the former demonstrated the tendency to hoard rubbish. The Diogenes syndrome in both cases can be hypothesized to be a reaction to stress in elderly people with certain personality characteristics or as the end stage of a personality disorder. The hoarding behavior that was manifested only in the first case can probably be the result of the presence of an OCD. The authors raise the possibility that OCD may be the cause of hoarding rubbish in those cases of Diogenes syndrome in which hoarding exists and cannot be explained by psychotic disorders, dementia or any other mental disorders due to a general medical condition (GMC) or substance-related disorders.

Aged↗

[Trichotillomania].

Trichotillomania is the recurrent pulling out of one's own hair, which results in noticeable hair loss, classified in DSM IV and ICD 10 as an impulse control disorder. Trichotillomania can occur as an isolated symptom or may be associated with affective disorders, schizophrenia, substance abuse, borderline personality, obsessive-compulsive disorder. Its onset is usually in childhood and females are more affected than males.

Child↗

Anorexia nervosa with excessive exercise: a phenotype with close links to obsessive-compulsive disorder.

Anorexia nervosa (AN) and obsessive-compulsive disorder (OCD) are highly comorbid, and appear to share a common neurophysiological dysfunction that contributes to the obsessional thoughts and compulsive behaviours seen in both disorders. Obsessive-compulsive personality (OCP) traits are also important risk factors for AN. Since excessive exercise has also been associated with greater obsessionality, we hypothesised that AN patients with a hyperactive behavioural profile represent a phenotype more closely linked to OCD than their non-exercising counterparts. We examined prospectively 50 female AN-Restrictor patients whom we classified as "excessive" or "non-excessive" based on their exercise status i) at admission and ii) over the lifetime of their illness. Validated measures of OCD symptoms and OCP traits were obtained at admission and after refeeding at discharge. On both classification methods, excessive exercisers had greater OCD symptoms and OCP traits than the non-excessive group, but did not differ on body mass index. OCD symptoms, but not OCP traits, decreased between admission and discharge. Findings support our prediction that AN patients with excessive physical activity constitute a subtype of the disorder with strong links to OCD. Indeed, this phenotype may be a culture-bound variant of OCD.

Adolescent↗

Changes in DSM-III-R axis II diagnoses following treatment of obsessive-compulsive disorder.

Seventeen patients with obsessive-compulsive disorder and concomitant personality disorders were treated with pharmacologic and/or behavioral therapy and reassessed after 4 months. Nine of the 10 patients who responded to treatment for obsessive-compulsive disorder no longer met criteria for a personality disorder. Of the seven nonresponders, five continued to meet criteria for a personality disorder.

Adult↗

[Liaison between body dysmorphic disorder and eating disorders].

This study presents the cases of anorexia nervosa which began with a body dysmorphic disorder lasting for at least 6 months. In some subjects (25%) there was comorbidity of 3 mental disorders: anancastic personality or obsessive-compulsive disorder + dysmorphophobia + anorexia nervosa or dysmorphophobia + anorexia nervosa + depressive disorder (dysthymia or major depression). The author considers the conception that in some cases dysmorphophobia and anorexia nervosa are a spectre of obsessive-compulsive disorder or affective disorders in adolescents.

Adolescent↗

Diagnosing personality disorders in the community. A comparison of self-report and interview measures.

The rapidly expanding empirical study of personality disorders is the result of the publication of operational diagnostic criteria in DSM-III and the development of instruments to assess these criteria. Few researchers have examined the comparability of measures of personality disorders, and to our knowledge there are no studies of the factors associated with discordance between measures. In the present study, 697 relatives of psychiatric patients and healthy controls were interviewed with the Structured Interview for Personality Disorders (SIDP) and completed the Personality Disorders Questionnaire (PDQ). Significantly more individuals had a personality disorder according to the SIDP; however, multiple personality disorders were more frequently diagnosed on the PDQ. Schizotypal, compulsive, dependent, and borderline personality disorders were significantly more frequently diagnosed by the PDQ, whereas the SIDP more frequently diagnosed antisocial and passive-aggressive personality disorder. The corresponding dimensional scores of the two measures were all significantly correlated; however, the concordance for categorical diagnoses was poor. Discrepancies between the PDQ and the SIPD dimensional scores were significantly associated with current level of depressive symptoms and PDQ lie scale scores.

Adult↗

Excessive dependency and depression: is the relationship specific?

Excessive dependency has been hypothesized to be both a risk factor and a complication of depression. The purpose of this study was to test the specificity of the relationship between DSM-III-R dependent personality disorder (DPD) and depressive disorders. Two hundred subjects were independently administered the Structured Clinical Interview for DSM-III-R (SCID) and the Personality Disorder Examination (PDE) face-to-face by two experienced clinicians. Comorbidity of DPD and axis I disorders of five different types was examined. Dependent personality disorder was associated with mood disorders, both bipolar disorder and major depression, but was also associated with several anxiety disorders, bulimia, and nonaffective psychotic disorders. Dependent-personality disorder was associated with borderline, avoidant, schizotypal, obsessive-compulsive, narcissistic, and paranoid personality disorder made no significant additional contribution to the association between personality disorder and axis I disorder. These results suggest the DPD represents maladaptive traits and behaviors that cut across a range of personality psychopathology and are related to a variety of types of psychological distress. Thus, a specific++ relationship od DPD to depression was not supported.

Adolescent↗

Beliefs in personality disorders: a test with the personality disorder belief questionnaire.

The hypothesis that each personality disorder (PD) is characterized by a specific set of beliefs was tested in a sample of 643 subjects, including non-patient controls, axis-I and axis-II patients, diagnosed with SCID-I and -II interviews. Beliefs of six PDs (avoidant, dependent, obsessive-compulsive, paranoid, histrionic, borderline) were assessed with the Personality Disorder Belief Questionnaire (PDBQ). Factor analyses supported the existence of six hypothesized sets of beliefs. Structural equation modeling (SEM) supported the hypothesis that each PD is characterized by a specific set of beliefs. Path coefficients were however in the medium range, suggesting that PDs are not solely determined by beliefs. Nevertheless, empirically derived cutoff scores of the six belief subscales were reasonably successful in classifying subjects, percentages ranging form 51% to 83%. It appeared that there was a monotonical increase in scores on each belief subscale from non-patient controls, to patients without any PD, to patients with PDs (other than the pertinent PD), to patients with the pertinent PD. This suggests that PD-related beliefs are at least partly associated with (personality) psychopathology in general. Another explanation is that many patients' position on the underlying dimensions is not high enough to lead to a DSM PD diagnosis, but high enough to lead to an elevated belief score.

Adult↗

Personality changes in adult subjects with major depressive disorder or obsessive-compulsive disorder treated with paroxetine.

BACKGROUND: Human and animal studies point to 3 dimensions of personality that change during pharmacotherapy with a selective serotonin reuptake inhibitor (SSRI). Specifically, harm avoidance has been found to decrease, social dominance has been found to increase, and hostility in social situations has been found to decrease with SSRI treatment. We sought to determine personality changes in subjects with either major depressive disorder (MDD) or obsessive-compulsive disorder (OCD) treated with paroxetine. We also sought to determine whether or not these personality changes were associated with disease state (MDD vs. OCD) or treatment response (responders vs. nonresponders). METHOD: Thirty-seven subjects diagnosed with either MDD or OCD (according to DSM-IV criteria) completed the Cattell 16 Personality Factor Inventory (16-PF) before and after treatment with paroxetine. Treatment response was defined as a Clinical Global Impressions-Improvement rating of "much" or "very much" improved and a drop in Hamilton Rating Scale for Depression score of at least 50% for MDD or Yale-Brown Obsessive Compulsive Scale score of at least 30% for OCD. RESULTS: No significant differences were found between subjects with MDD and OCD in personality change with treatment. In the whole group, treatment responders had a greater decrease than nonresponders in 16-PF factors relating to harm avoidance. An increase in social dominance factors and a decrease in factors relating to hostility in social situations were found, but these changes were not significantly different between responders and nonresponders. CONCLUSION: These findings indicate that certain personality dimensions change with SSRI treatment and that some of these changes are independent of clinical treatment response.

Adult↗

Personality dysfunction among somatizing patients.

To examine the nature and extent of personality dysfunction related to somatization, the authors administered the Structured Interview for DSM-IV Personality and the NEO Five-Factor Inventory to a series of somatizing and nonsomatizing patients in a general medicine clinic. A greater percentage of somatizers met criteria for one or more DSM-IV personality disorders, especially obsessive-compulsive disorder, than did control patients. Somatizers also differed from control patients with respect to self-defeating, depressive, and negativistic personality traits and scored higher on the dimension of neuroticism and lower on the dimension of agreeableness. In addition, initial and facultative somatizers showed more personality pathology than true somatizers. These findings suggest that certain personality disorders and traits contribute to somatization by way of increased symptom reporting and care-seeking behavior.

Adult↗