Characteristics of patients with major depression in combination with dysthymic or cyclothymic disorders. Childhood and precipitating events

The relationship between patients with acute major depression and chronic affective disorders was investigated in 298 nonpsychotic outpatients. The patients were categorized into 4 groups: major depression only, major depression with dysthymic or cyclothymic disorders, dysthymic or cyclothymic disorder without major depression and one group of other psychiatric disorders. The patients were interviewed about childhood losses, relationship to parents and siblings and family atmosphere, their personality characteristics as children, as well as precipitating events. The reports in the various diagnostic groups were compared. Patients in the mixed group reported somewhat more traumatic childhood experiences compared with patients in the pure major depression group and pure dysthymic-cyclothymic group, and much more traumatic childhood experiences compared with patients in the group of other disorders. Precipitating events among patients in the acute major depression group consisted of more acute external stressors compared with the events of the patients in the group of chronic affective disorders. Patients with major depression in combination with pure dysthymic-cyclothymic disorder generally remembered their childhood as having been more traumatic, with a less satisfying relationship to their parents.     

The relationship between DSM-III symptom disorders (Axis I) and personality disorders (Axis II) in an outpatient population

The relationship between symptom disorder and personality disorder according to DSM-III was studied in 289 consecutive outpatients. It was observed that personality disorders occurred frequently among the chronic affective and anxiety disorders. The "dramatic" personality disorders were observed especially frequently among patients with cyclothymic disorder, and the "eccentric" personality disorders among patients with a diagnosis of dysthymic disorder, social phobia and agoraphobia. Dramatic personality disorder was also common among patients with simple phobia. As expected, a close correspondence was observed between social phobia, agoraphobia and avoidant personality disorder, between substance use disorder and borderline personality disorder, and between obsessive-compulsive disorder and compulsive personality disorder. Even if a relationship was observed, it was not strong enough to warrant a combination of chronic symptom disorder diagnoses and personality disorder diagnoses.     

DSM-III personality disorders among patients with major depression, anxiety disorders, and mixed conditions

Of 298 mainly nonpsychotic psychiatric outpatients between 19 and 59 years of age, a group of patients having either pure major depression, major depression in combination with anxiety disorders, or pure anxiety disorders was extracted. The anxiety disorders were further differentiated in panic and nonpanic anxiety disorders. The groups were compared as to differences in frequency of personality disorders assessed by means of the Structured Interview for DSM-III Personality Disorders. The mixed major depression/anxiety disorder group appeared to be the most deviant with more severe personality disorders such as paranoid and borderline in addition to avoidant and dependent personality disorder. The differentiation between panic and nonpanic anxiety showed that it was patients with nonpanic anxiety features in addition to major depression who had this higher frequency of personality disorders. These findings imply that it is important to distinguish between major depression cases with and without anxiety disorders both in forthcoming research and in clinical practice.     

Personality disorders in dysthymia and major depression.

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

The nosologic status of borderline personality: clinical and polysomnographic study

The REM latencies of 24 nonschizotypal borderline outpatients--who were not in the midst of a major depressive episode--were in the range of those of 30 patients with primary major depression but were significantly shorter than those of 16 patients with nonborderline personality disorders and 14 nonpsychiatric controls. Also, more of the borderline subjects had lifetime diagnoses of affective disorder, such as dysthymic, cyclothymic, and bipolar II disorder, and of a spectrum of anxiety and somatization disorders. The authors conclude that contemporary operational criteria for borderline disorder identify a wide net of temperamental disorders with strong affective coloring rather than a unitary nosologic entity.     

Prevalence of personality disorders in patients with major depression and dysthymia.

The authors administered the Structured Clinical Interview for DSM-III-R Axis I (SCID-P) and Axis II (SCID-II) Disorders to 197 patients with major depression, 63 patients with dysthymia, and 32 patients with both major depression and dysthymia ("double depression"). Fifty percent of major depressive patients, 52% of dysthymic patients, and 69% of patients with double depression were diagnosed as having at least one personality disorder. Patients with a personality disorder had higher scores on the Beck Anxiety and Depression Inventories. The most commonly diagnosed personality disorders were from the anxious/fearful cluster, most notably avoidant and dependent personality disorders.     

Treatment utilization by patients with personality disorders

OBJECTIVE: Utilization of mental health treatment was compared in patients with personality disorders and patients with major depressive disorder without personality disorder. METHOD: Semistructured interviews were used to assess diagnosis and treatment history of 664 patients in four representative personality disorder groups-schizotypal, borderline, avoidant, and obsessive-compulsive-and in a comparison group of patients with major depressive disorder. RESULTS: Patients with personality disorders had more extensive histories of psychiatric outpatient, inpatient, and psychopharmacologic treatment than patients with major depressive disorder. Compared to the depression group, patients with borderline personality disorder were significantly more likely to have received every type of psychosocial treatment except self-help groups, and patients with obsessive-compulsive personality disorder reported greater utilization of individual psychotherapy. Patients with borderline personality disorder were also more likely to have used antianxiety, antidepressant, and mood stabilizer medications, and those with borderline or schizotypal personality disorder had a greater likelihood of having received antipsychotic medications. Patients with borderline personality disorder had received greater amounts of treatment, except for family/couples therapy and self-help, than the depressed patients and patients with other personality disorders. CONCLUSIONS: These results underscore the importance of considering personality disorders in diagnosis and treatment of psychiatric patients. Borderline and schizotypal personality disorder are associated with extensive use of mental health resources, and other, less severe personality disorders may not be addressed sufficiently in treatment planning. More work is needed to determine whether patients with personality disorders are receiving adequate and appropriate mental health treatments.     

抑郁障碍与人格障碍的共病研究

目的　了解抑郁障碍患者中人格障碍的发生率,探讨抑郁障碍与人格障碍的共病情况。方法　使用SCID- Ⅱ对102例抑郁障碍患者进行人格障碍的评估,并与102例正常人群对照,对抑郁障碍组进行汉密尔顿抑郁量表(HAMD)评定。结果　抑郁障碍组人格障碍的发生率为51.9%,31.4%的患者被诊断为两种或以上的人格障碍,显著高于对照组的14.7%;女性抑郁障碍患者人格障碍的发生率(63.5%)显著多于男性患者(40.0%);重性抑郁症与心境恶劣患者人格障碍的共病率则无统计学差异(P>0.05);抑郁障碍患者中最常见的人格障碍类型为回避型、强迫型、消极型以及偏执型。结论　抑郁障碍患者中具有较高的人格障碍患病率,对抑郁障碍和人格障碍的共病应引起临床高度重视。     

Comorbid psychiatric disorders in late life depression.

In late life depression, common comorbid psychiatric disorders are alcohol use, anxiety, and personality disorders. Elderly depressed patients are three to four times more likely to have an alcohol use disorder compared with nondepressed elderly subjects, with a prevalence of 15%-30% in patients with late life major depression. While the presence of a comorbid alcohol use disorder may worsen the prognosis for geriatric depression, limited data suggest that successful treatment of depression combined with reducing alcohol use leads to the best possible outcomes. Most studies show that the overall prevalence of anxiety disorders, particularly panic disorder and obsessive-compulsive disorder, is low in geriatric depression, but generalized anxiety disorder may not be uncommon. It remains unclear if the presence of a comorbid anxiety disorder impacts on the treatment and prognosis of late life major depression. Personality disorders occur in 10%-30% of patients with late life major depression or dysthymic disorder, particularly in patients with early onset depressive illness. Cluster C disorders, including the avoidant, dependent, and obsessive-compulsive subtypes predominate, while Cluster B diagnoses, including borderline, narcissistic, histrionic and antisocial, are rare. Overall, the research database on comorbid psychiatric disorders in major and nonmajor late life depression is relatively sparse. Since comorbid psychiatric disorders affect clinical course and prognosis, and may worsen long-term disability in late life depression, considerably more research in this field is needed.     

Prospective assessment of treatment use by patients with personality disorders

OBJECTIVE: This study examined the utilization of mental health treatments over a three-year period among patients with schizotypal, borderline, avoidant, or obsessive-compulsive personality disorders compared with patients with major depressive disorder and no personality disorder. METHODS: A prospective, longitudinal study design was used to measure treatment use for 633 individuals aged 18 to 45 years during a three-year period. RESULTS: Patients with borderline personality disorder were significantly more likely than those with major depressive disorder to use most types of treatment. Furthermore, all patients continued using high-intensity, low-duration treatments throughout the study period, whereas individual psychotherapy attendance declined significantly after one year. CONCLUSIONS: Although our data showed that patients with borderline personality disorder used more mental health services than those with major depressive disorder, many questions remain about the adequacy of the treatment received by all patients with personality disorders.     

Clinical differentiation between major depression only, major depression with panic disorder and panic disorder only. Childhood, personality and personality disorder

A consecutive sample of 298 nonpsychotic psychiatric outpatients was classified according to DSM-III and divided into 4 diagnostic groups: pure major depression, mixed major depression/panic disorder, pure panic disorder and a remaining group of other disorders. The patients' report of childhood relationship to parents and siblings, family atmosphere, their own personality characteristics as children and precipitating events were compared in the various groups. In addition, differences in personality and frequencies of personality disorders were investigated by means of various instruments. Our results show that the type of relationship to parents in childhood differed in the various groups. The mother seems to be the most crucial person for the development of depression, the father for the development of panic disorder. Patients with major depression are more obsessive and patients with panic disorder more infantile and avoidant with less control of their personality. Finally, patients with mixed conditions are more in accordance with the DSM-III anxious personality disorder cluster.     

Development of personality disorders in children and adolescents with obsessive-compulsive disorder A 6- to 22-year follow-up study

Forty-seven people with admissions in childhood for obsessive-compulsive disorder (OCD) and 49 child psychiatric controls were followed up in young adulthood and assessed for DSM-III-R personality disorders with the Structured Clinical Interview for DSM-III-R Personality Disorders. The number of personality disorders in OCD patients did not differ significantly from the number in controls. The most common personality disorder was avoidant personality disorder (significantly more frequent than in controls), whereas obsessive-compulsive personality disorder (OCPD) was not found more often in the OCD group. Subjects with OCD in adulthood seemed to have OCPD more often than childhood OCD patients with no OCD at follow-up. In the whole group, histrionic personality disorders were more common in women than in men and OCPD more common in men than in women, whereas borderline personality disorder was most common among women in the OCD group. The presence of a personality disorder in adulthood could not be correlated with such childhood factors as social background, symptoms or age of onset of OCD.     

Co-occurrence of mood and personality disorders: a report from the Collaborative Longitudinal Personality Disorders Study (CLPS)

The purpose of this study was to examine the relationship of subtypes and particular clinical features of mood disorders to co-occurrence with specific personality disorders. Five hundred and seventy-one subjects recruited for the Collaborative Longitudinal Personality Disorders Study (CLPS) were assessed with the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) and the Diagnostic Interview for DSM-IV Personality Disorders (DIPD-IV). Percent co-occurrence rates for current and lifetime mood disorders with personality disorders were calculated. Logistic regression analyses examined the effects of clinical characteristics of depressive disorders (e.g., age at onset, recurrence, symptom severity, double depression, and atypical features) on personality disorder co-occurrence. In comparison with other DSM-IV personality disorders, avoidant, borderline, and dependent personality disorders (PDs) were most specifically associated with mood disorders, particularly depressive disorders. Severity and recurrence of major depressive disorder and comorbid dysthymic disorder predicted co-occurrence with borderline and to a lesser extent research criteria depressive personality disorders. The results are consistent with the view that a mood disorder with an insidious onset and recurrence, chronicity, and progression in severity leads to a personality disorder diagnosis in young adults.     

Sustained unemployment in psychiatric outpatients with bipolar depression compared to major depressive disorder with comorbid borderline personality disorder

Zimmerman M, Martinez JH, Young D, Chelminski I, Dalrymple K. Sustained unemployment in psychiatric outpatients with bipolar depression compared to major depressive disorder with comorbid borderline personality disorder. Bipolar Disord 2012: 14: 856–862. © 2012 John Wiley & Sons A/S.Published by Blackwell Publishing Ltd. Objectives: The morbidity associated with bipolar disorder is, in part, responsible for repeated calls for improved detection and recognition. No such clinical commentary exists for improved detection of borderline personality disorder in depressed patients. Clinical experience suggests that borderline personality disorder is as disabling as bipolar disorder; however, no studies have directly compared the two disorders. For this reason we undertook the current analysis from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project comparing unemployment and disability rates in patients with bipolar disorder and borderline personality disorder. Methods: Patients were interviewed with semi‐structured interviews. We compared three non‐overlapping groups of depressed patients: (i) 181 patients with DSM–IV major depressive disorder and borderline personality disorder, (ii) 1068 patients with major depressive disorder without borderline personality disorder, and (iii) 84 patients with bipolar depression without borderline personality disorder. Results: Compared to depressed patients without borderline personality disorder, depressed patients with borderline personality disorder were significantly more likely to have been persistently unemployed. A similar difference was found between patients with bipolar depression and major depressive disorder without borderline personality disorder. No differences were found between patients with bipolar depression and depression with borderline personality disorder. Conclusions: Both bipolar disorder and borderline personality disorder were associated with impaired occupational functioning and thus carry a significant public health burden. Efforts to improve detection of borderline personality disorder in depressed patients might be as important as the recognition of bipolar disorder.     

Fluoxetine in borderline personality disorder

1. 1. Twelve patients with borderline personality disorder and not suffering a major depression were treated with fluoxetine, a selective serotonin reuptake inhibitor, in an open label trial. All of the patients improved, and 75% were rated as much or very much improved.

2. 2. Treatment was generally very well tolerated, but careful dosage titration was important in some patients, especially to manage agitation.

3. 3. Improvement has been maintained with continued treatment throughout the follow-up period which ranged up to six months.

4. 4. Incidental findings suggest fluoxetine may also be of use in treating substance abuse, attention deficit hyperactivity disorder, late luteal phase dysphoria disorder, dysthymic and cyclothymic disorders, and seasonal pattern depression.

5. 5. These preliminary results support the hypothesis that borderline personality disorder may be related to a central scrotonergic deficit.

DSM-III personality disorders and the outcome of treated panic disorder

Fifty-two patients with panic disorder who had been receiving active benzodiazepine treatment for 8 weeks were assessed by using the outcome measures of spontaneous and situational panic attacks, scores on the Hamilton scales for anxiety and for depression, and scores on self-rated disability scales. Although spontaneous panic attacks were not affected by the presence of any personality disorder, the remaining outcome measures showed a strong and negative association with DSM-III antisocial, borderline, histrionic, and narcissistic personality disorders. There was also a mild negative association with avoidant personality disorder. A subgroup of patients with both major depression and panic disorder appeared more strongly affected.     

Personality disorders in elderly patients with dysthymic disorder.

The authors evaluated personality disorders in elderly patients with DSM-IV dysthymic disorder (DD) to identify prevalent personality disorders and their clinical correlates. Outpatients (>/=60 years; N=76) with DD were evaluated; most were male (65.8%) and had late age at onset (>50 years: 60.5%). Axis II disorders were present in 31.2% of patients, with obsessive-compulsive personality disorder (OCD; 17.1%) and avoidant personality disorder (11.8%) being the most common. Personality disorders were associated with an earlier age at onset of depressive illness, greater lifetime history of comorbid Axis I disorders, greater severity of depressive symptoms, and lower socioeconomic status. Personality disorders occurred in a minority of elderly patients with DD and mainly comprised the obsessive-compulsive and avoidant subtypes, similar to reports of personality disorders in elderly patients with major depression. In contrast, young adults with DD have been shown consistently to have personality disorders at high frequency. Together with the predominance of late onset and the lack of psychiatric comorbidity, the current findings on personality disorders reinforce our view that DD in elderly patients is typically a different disorder from DD in young adults.     

Association of personality disorders with Type A and Type B alcoholics

Personality disorders frequently occur as comorbid disorder in alcohol–dependent subjects. Antisocial personality was described as an important characteristic in Cloninger's Type 2 and Babor's Type B subjects. The impact of other personality disorders on these alcoholism typologies, their pathogenesis and prognosis is, however, still unclear. The present study investigated the prevalence of personality disorders in 237 (194 males) detoxified alcohol–dependent patients after subtyping this sample according to Babor's Type A/B following the criteria suggested by Schuckit et al. (1995). Personality disorders were assessed with the SCID–II (DSM–IV). In all, 160 patients (68 %) could be classified as Type A, and 77 (32 %) as Type B.Type B subjects were younger, had an earlier onset,more alcohol intake and a more severe course of alcohol dependence. Type B patients had significantly more often any cluster A and B personality disorder, and significantly specifically more often a borderline, antisocial and avoidant personality disorder. There were no statistical differences concerning the other personality disorders. In summary, the Type A/B dichotomy using the criteria of Schuckit et al. (1995) was replicated successfully. Differences concerning cluster B personality disorder prevalence of Type B subjects demonstrated that these subjects are significantly more often affected from borderline and antisocial personality disorder. The impact of other personality disorders does not play a substantial role in subtyping alcoholics.     

Affective instability and impulsivity in borderline personality and bipolar II disorders: similarities and differences

Objectives: many studies have reported a high degree of comorbidity between mood disorders, among which are bipolar disorders, and borderline personality disorder and some studies have suggested that these disorders are co-transmitted in families. However, few studies have compared personality traits between these disorders to determine whether there is a dimensional overlap between the two diagnoses. The aim of this study was to compare impulsivity, affective lability and intensity in patients with borderline personality and bipolar II disorder and in subjects with neither of these diagnoses. Methods: patients with borderline personality but without bipolar disorder (n=29), patients with bipolar II disorder without borderline personality but with other personality disorders (n=14), patients with both borderline personality and bipolar II disorder (n=12), and patients with neither borderline personality nor bipolar disorder but other personality disorders (OPD; n=93) were assessed using the Affective Lability Scale (ALS), the Affect Intensity Measure (AIM), the Buss–Durkee Hostility Inventory (BDHI) and the Barratt Impulsiveness Scale (BIS-7B). Results: borderline personality patients had significantly higher ALS total scores (P<0.05) and bipolar II patients tended to have higher ALS scores than patients with OPD (P<0.06). On one of the ALS subscales, the borderline patients displayed significant higher affective lability between euthymia and anger (P<0.002), whereas patients with bipolar II disorder displayed affective lability between euthymia and depression (P<0.04), or elation (P<0.01) or between depression and elation (P<0.01). A significant interaction between borderline personality and bipolar II disorder was observed for lability between anxiety and depression (P<0.01) with the ALS. High scores for impulsiveness (BISTOT, P<0.001) and hostility (BDHI, P<0.05) were obtained for borderline personality patients only and no significant interactions between diagnoses were observed. Only borderline personality patients tended to have higher affective intensity (AIM, P<0.07). Conclusions: borderline personality disorder and bipolar II disorder appear to involve affective lability, which may account for the efficacy of mood stabilizers treatments in both disorders. However, our results suggest that borderline personality disorder cannot be viewed as an attenuated group of affective disorders.     

Temperament, childhood environment and psychopathology as risk factors for avoidant and borderline personality disorders

OBJECTIVE: To evaluate childhood experiences (neglect and abuse), temperament and childhood and adolescent psychopathology as risk factors for avoidant and borderline personality disorders in depressed outpatients. METHOD: One hundred and eighty depressed outpatients were evaluated for personality disorders. Risk factors of childhood abuse, parental care, temperament, conduct disorder symptoms, childhood and adolescent anxiety disorders, depressive episodes, hypomania and alcohol and drug dependence were obtained by questionnaires and interviews. RESULTS: Avoidant personality disorder can be conceptualized as arising from a combination of high harm avoidance (shy, anxious), childhood and adolescent anxiety disorders and parental neglect. Borderline personality disorder can be formulated as arising from a combination of childhood abuse and/or neglect, a borderline temperament (high novelty seeking and high harm avoidance), and childhood and adolescent depression, hypomania, conduct disorder and alcohol and drug dependence. CONCLUSIONS: Combinations of risk factors from the three domains of temperament, childhood experiences and childhood and adolescent psychopathology make major contributions to the development of avoidant and borderline personality disorders.