Do young people with comorbid mental and alcohol disorders experience worse behavioural problems?

This article examines whether young individuals in the general population with comorbid alcohol use and mental health disorders experience worse internalizing and externalizing behaviour problems than those with single disorders. A large cohort of women at the Mater Misericordiae Hospital in Brisbane, Australia, was enroled during pregnancy in a longitudinal study. Mother/offspring dyads were followed over 21 years. At age 21, offspring behaviour problems were examined using the Young Adult Self Report, alcohol and mental health disorders with the Composite International Diagnostic Interview. Associations between comorbidity and behaviour problems were assessed using multinomial logistic regression, accounting for life-course factors. Twelve per cent of young adults had alcohol/mental health DSM-IV disorders with significant temporal overlap. A further 16% had alcohol disorders only and 23% mental health disorders only. The comorbid group scored significantly higher on total and externalizing behaviour problems but not internalizing behaviour problems. Stronger associations of aggression/delinquency with comorbidity were not fully accounted for by factors known to influence separate development of mental health and alcohol disorders. Young adults with comorbid alcohol/mental health disorders experience more, and more severe, behavioural problems than those with single disorder types, indicating an increased burden from comorbidity, with implications for treatment and public order.     

Personality and trajectories of posttraumatic psychopathology: A latent change modelling approach

BackgroundSurvivors of traumatic events may develop a range of psychopathology, across the internalizing and externalizing dimensions of disorder and associated personality traits. However, research into personality-based internalizing and externalizing trauma responses has been limited to cross-sectional investigations of PTSD comorbidity. Personality typologies may present an opportunity to identify and selectively intervene with survivors at risk of posttraumatic disorder. Therefore this study examined whether personality prospectively influences the trajectory of disorder in a broader trauma-exposed sample.MethodsDuring hospitalization for a physical injury, 323 Australian adults completed the Multidimensional Personality Questionnaire—Brief Form and Structured Clinical Interview for DSM-IV, with the latter readministered 3 and 12 months later. Latent profile analysis conducted on baseline personality scores identified subgroups of participants, while latent change modelling examined differences in disorder trajectories.ResultsThree classes (internalizing, externalizing, and normal personality) were identified. The internalizing class showed a high risk of developing all disorders. Unexpectedly, however, the normal personality class was not always at lowest risk of disorder. Rather, the externalizing class, while more likely than the normal personality class to develop substance use disorders, were less likely to develop PTSD and depression.ConclusionsResults suggest that personality is an important mechanism in influencing the development and form of psychopathology after trauma, with internalizing and externalizing subtypes identifiable in the early aftermath of injury. These findings suggest that early intervention using a personality-based transdiagnostic approach may be an effective method of predicting and ultimately preventing much of the burden of posttraumatic disorder.     

Beyond treatment effects: comorbid psychopathologies and long-term outcomes among substance-abusing delinquents

Secondary analyses of a randomized clinical trial controlled for treatment condition effects and examined the impact of comorbid psychopathologies on the mental health, physical health, and criminal behavior of 80 substance abusing delinquents approximately 5 years later in emerging adulthood. Overall, emerging adults with a comorbid disorder during adolescence scored higher on psychopathology, criminal behavior, and health problems. Participants with both internalizing and externalizing disorders exhibited more negative outcomes than those with a comorbid externalizing disorder. For the entire sample, more internalizing diagnoses forecasted higher internalizing and aggression scores, more criminality, and poorer physical health. More externalizing disorders predicted higher internalizing, delinquency, and criminality scores, but was unrelated to physical health. More internalizing diagnoses for females but not males predicted greater criminality, and especially more aggressive crimes in emerging adulthood.     

Self-reported mental health in children ages 6–12 years across eight European countries

Worldwide, approximately one in eight children or adolescents suffers from a mental disorder. The present study was designed to determine the self-reported prevalence of mental health problems in children aged 6–11 years across eight European countries including Italy, France, Germany, the Netherlands, Lithuania, Bulgaria, Romania, and Turkey. Data were drawn from 6245 children participating in the School Children Mental Health in Europe (SCHME) study and a large cross-sectional survey in France. Self-reported child mental health was assessed using the Dominique Interactive (DI). Overall, 22.0% of children were identified per their own evaluation as having at least one mental disorder, ranging from 16.4% in the Netherlands to 27.9% in Bulgaria. The prevalence of internalizing disorders was 18.4% across countries and ranged from 11.8% in the Netherlands to 24.3% in Turkey. The prevalence of externalizing disorders was lower with an average of 7.8%, ranging from 3.5% in Turkey to 10.5% in Bulgaria. Combining samples across European countries, 1 in 5 children reported internalizing problems and 1 in 12 children externalizing problems. The net completion rates of 4.1–74.3% preclude conclusions about national differences in prevalence rates.     

Examination of the structure of psychopathology using latent class analysis

Several recent studies using factor analytic methods find that the structure of psychopathology reflects broad internalizing and externalizing dimensions, with the internalizing dimension being further divided into fear and distress disorders. Although these variable-centered studies have provided important insights into the structure of psychopathology, they provide limited information about the classification of individual cases. The present study examines patterns of lifetime internalizing and externalizing psychopathology in participants from the Oregon Adolescent Depression Project using latent class analysis that classifies individuals rather than variables. A 4-class solution best fits the data. The largest class (62.5%) included individuals with relatively little psychopathology; 1 class (16.4%) was largely characterized by internalizing disorders, 1 class (16.9%), largely characterized by externalizing disorders; and the final class (4.2%), characterized by both internalizing and externalizing disorders. The validity of the classes was further examined using data on psychiatric morbidity, temperament, and family aggregation of psychopathology. Classes differed on indices of positive, negative, and disinhibited temperament in ways that were consistent with theoretical predictions. Patterns of familial aggregation of psychopathology demonstrated relative specificity of transmission of different disorders. Overall, the findings support conclusions from studies of dimensional models of internalizing and externalizing disorders, and extend them to person-centered approaches to classification.     

Suicide attempts associated with externalizing psychopathology in an epidemiological sample

OBJECTIVE: Borrowing from recent dimensional models of psychopathology, the authors conducted analyses that optimized the common variance shared by internalizing (depression, anxiety) and externalizing (antisocial personality, substance dependence) disorders in statistically predicting suicidal behaviors. These relationships were analyzed in a large epidemiological sample, thus allowing for the examination of gender differences in risk for suicide attempts associated with psychopathology. METHOD: The data were obtained from the Colorado Social Health Survey. Participants (N=4,745) were a community sample recruited by household address. Structured clinical interviews were used to obtain lifetime diagnostic and symptom count information. Symptom counts were included in a factor analysis that yielded two main dimensions of psychopathology: internalizing and externalizing. These factors were used in hierarchical logistic regression analyses to predict history of suicide attempts associated with the presence of internalizing symptoms, externalizing symptoms, and comorbid internalizing and externalizing symptoms. RESULTS: After the investigators controlled for the presence of internalizing symptoms and the comorbidity of internalizing and externalizing symptoms, externalizing symptoms were related to suicidal behavior in both men and women, although comorbidity was most predictive of suicide attempts among women, compared to men. CONCLUSIONS: Suicidal behavior among individuals with externalizing symptoms is not necessarily a result of comorbid depressive or other internalizing disorder. Thus, persons exhibiting antisocial behaviors should receive rigorous assessment for suicidal ideation and behavior.     

The effects of latent variables in the development of comorbidity among common mental disorders

Background: Although numerous studies have examined the role of latent predispositions to internalizing and externalizing disorders in the structure of comorbidity among common mental disorders, none examined latent predispositions in predicting development of comorbidity. Methods: A novel method was used to study the role of latent variables in the development of comorbidity among lifetime DSM‐IV disorders in the National Comorbidity Surveys. Broad preliminary findings are briefly presented to describe the method. The method used survival analysis to estimate time‐lagged associations among 18 lifetime DSM‐IV anxiety, mood, behavior, and substance disorders. A novel estimation approach examined the extent to which these predictive associations could be explained by latent canonical variables representing internalizing and externalizing disorders. Results: Consistently significant positive associations were found between temporally primary and secondary disorders. Within‐domain time‐lagged associations were generally stronger than between‐domain associations. The vast majority of associations were explained by a model that assumed mediating effects of latent internalizing and externalizing variables, although the complexity of this model differed across samples. A number of intriguing residual associations emerged that warrant further investigation. Conclusions: The good fit of the canonical model suggests that common causal pathways account for most comorbidity among the disorders considered. These common pathways should be the focus of future research on the development of comorbidity. However, the existence of several important residual associations shows that more is involved than simple mediation. The method developed to carry out these analyses provides a unique way to pinpoint these significant residual associations for subsequent focused study. Depression and Anxiety, 2011. © 2011 Wiley‐Liss, Inc.     

DSM-IV personality disorders and associations with externalizing and internalizing disorders: Results from the National Epidemiologic Survey on Alcohol and Related Conditions

Background

Although associations between personality disorders and psychiatric disorders are well established in general population studies, their association with liability dimensions for externalizing and internalizing disorders has not been fully assessed. The purpose of this study is to examine associations between personality disorders (PDs) and lifetime externalizing and internalizing Axis I disorders.

Methods

Data were obtained from the total sample of 34,653 respondents from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Drawing on the literature, a 3-factor exploratory structural equation model was selected to simultaneously assess the measurement relations among DSM-IV Axis I substance use and mood and anxiety disorders and the structural relations between the latent internalizing–externalizing dimensions and DSM-IV PDs, adjusting for gender, age, race/ethnicity, and marital status.

Results

Antisocial, histrionic, and borderline PDs were strong predictors for the externalizing factor, while schizotypal, borderline, avoidant, and obsessive-compulsive PDs had significantly larger effects on the internalizing fear factor when compared to the internalizing misery factor. Paranoid, schizoid, narcissistic, and dependent PDs provided limited discrimination between and among the three factors. An overarching latent factor representing general personality dysfunction was significantly greater on the internalizing fear factor followed by the externalizing factor, and weakest for the internalizing misery factor.

Conclusion

Personality disorders offer important opportunities for studies on the externalizing–internalizing spectrum of common psychiatric disorders. Future studies based on panic, anxiety, and depressive symptoms may elucidate PD associations with the internalizing spectrum of disorders.     

Reliability and validity of the Child Behavior Checklist Obsessive-Compulsive Scale

This study examined the psychometric properties of the Obsessive-Compulsive Scale (OCS) of the Child Behavior Checklist (CBCL). Participants included 48 youth with obsessive-compulsive disorder (OCD), 41 with a non-OCD internalizing disorder, and 101 with an externalizing disorder. Confirmatory factor analysis of the 8-item OCS did not result in an adequate fit. Exploratory factor analysis identified a 1-factor model consisting of 6 items. Adequate internal consistency for the revised OCS (OCS-R) was obtained, and convergent validity was supported by moderate relationships with other OCD indices. The OCS-R had stronger associations with measures of OCD symptoms than with measures of depression and externalizing behaviors. Youth with OCD had significantly higher OCS-R scores than those with internalizing and externalizing disorders. Suggestions for cutoff scores are provided using results from ROC analyses. Overall, these findings suggest that the OCS-R is a reliable and valid instrument for the assessment of pediatric OCD.     

Neurological Soft Signs and Disruptive Behavior Among Children of Opiate Dependent Parents

The present study investigates the relationship between neurological soft signs and psychiatric symptoms among children of opiate dependent parents. A consecutive series of 102 children of opiate dependent parents received standardized psychiatric and neurological assessments. Symptoms of externalizing but not internalizing disorders associated with poor performance on the soft sign exam, controlling for age, intelligence, and socioeconomic status. Given the importance of externalizing disorders in the development of substance use disorders, studies of children at high risk for substance use disorder should also consider screening and assessment of children for soft neurological signs.     

Familial and neighborhood effects on psychiatric disorders in childhood and adolescence

BackgroundMore knowledge is needed on potential associations between individual-, family-, and neighborhood-level factors and psychiatric disorders in children and adolescents.AimsTo examine associations between, individual-, family-, and neighborhood-level factors and incident internalizing (anxiety and mood) disorders and externalizing (ADHD and conduct) disorders in children and adolescents, and to estimate the relative contributions of family and neighborhood to individual variation in these disorders.MethodWe performed a three-level logistic regression on all 542,195 children born in Sweden in 1992–1996, nested in 427,954 families, which in turn were nested in 8475 neighborhoods. The children were followed from 2000 to 2010 for incident internalizing and externalizing psychiatric disorders, assessed from medical records.Results26,514 children (4.8%) were diagnosed with internalizing or externalizing psychiatric disorders. Approximately 29% of the total individual variance in internalizing disorders could be attributed to the family level, which includes both genetic and family environmental effects, and 5% to the neighborhood level. The corresponding figures for externalizing disorders were 43.5% and 5.5%, respectively. After adjustment for individual-level sociodemographic factors, high neighborhood deprivation was associated with increased risks of externalizing and internalizing psychiatric disorders (odds ratio [OR] = 1.37, 95% credible interval [CI] = 1.25–1.50 and OR = 1.34, 95% CI = 1.25–1.45, respectively), including conduct disorder (OR = 2.01, 95% CI = 1.58–2.55), anxiety disorders (OR = 1.40, 95% CI = 1.29–1.52), and mood disorders (OR = 1.21, 95% CI, 1.09–1.35). The strongest association between neighborhood deprivation and ADHD was observed in moderately deprived neighborhoods (OR = 1.31, 95% CI = 1.19–1.44).ConclusionsThese findings call for policies to promote mental health that consider potential influences from children's family and neighborhood environments.conclusionTrial registrationNot applicable.     

Categorical versus dimensional models of mental disorder: the taxometric evidence

OBJECTIVE: To review studies of the categorical versus dimensional status of mental disorders that employ taxometric methodology. METHOD: A comprehensive qualitative review of all published taxometric studies of psychopathology. RESULTS: Categorical and dimensional models each receive well-replicated support for some groups of mental disorders. Studies favour categorical models for melancholia, eating disorders, pathological dissociation, and schizotypal and antisocial personality disorders. Dimensional models tend to be favoured for the broad neurotic spectrum--general depression, generalized anxiety, posttraumatic stress disorder--and for borderline personality disorder. CONCLUSIONS: Taxometric research clarifies the latent structure of psychopathology in ways that have implications for the classification, assessment, explanation and conceptualization of mental disorder.     

Patterns of agreement among parent, teacher and youth ratings in a referred sample

ObjectiveThe purpose of this study was to investigate the degree of agreement among parents, teachers and adolescents with respect to the Child Behavior Checklist (CBCL), the Teacher's Report Form (TRF), and the Youth Self Report (YSR). In addition we evaluated the suitability of these three forms (CBCL, TRF and YSR) in terms of their contribution to understanding internalizing and externalizing disorders in youths being referred to a child and adolescent unit of a psychiatric care facility.MethodsA total of 611 patients aged 11–18 years (mean age 13.0, SD 1.6) were assessed using the CBCL, the TRF and the YSR.ResultsIntraclass coefficients (ICC) showed low to moderate agreement among informants. Furthermore, the level of agreement was generally less among patients suffering from internalizing disorders than for young patients who displayed externalizing disorders. Logistic regression revealed that the TRF internalizing syndrome scale, the CBCL internalizing syndrome scale and gender were relevant prognostic factors for the occurrence of internalizing disorders in youth. The YSR internalizing syndrome scale, on the other hand, was not a relevant factor among adolescents of a clinical target population. Likewise, only the TRF externalizing syndrome scale, the CBCL externalizing syndrome scale and gender were relevant prognostic factors for the occurrence of externalizing disorders in youth.ConclusionsParticularly the CBCL and TRF are useful instruments in assessing internalizing and externalizing disorders in adolescents referred to a mental health setting.     

Ethnicity and Clinical Psychiatric Diagnosis in Childhood

This paper focuses on whether a consistent difference by ethnicity existed in the clinical diagnosis of children and adolescents in two behavioral health service environments and reviews plausible explanations for such a difference. Key measures were clinical diagnosis and ethnicity, abstracted from the administrative dataset of a New Jersey behavioral health care organization during 2000–2002, and a data collection conducted for the State of Indiana during 1991–1992. Sample sizes were 5,394 and 10,437, respectively. Only primary diagnoses were used in this study, classified into externalizing versus internalizing disorders. Logistic regression was performed for the dependent variable of presence/absence of an externalizing disorder or internalizing disorder. A main effect for ethnicity was found; African American youth received more externalizing diagnoses than did European American youth (odds ratio 2.01 (CI: 1.73–2.33) in one sample and 1.67 (CI: 1.44–1.94) in the other); African American youth also received fewer internalizing diagnoses than European American youth (odds ratio 0.55 (CI: .48–.63) in one sample and 0.75 (CI:.64–.88) in the other. Potential explanations for these findings include: 1. Biopsychosocial origin; 2. Clinician bias; 3. Discordant normative behavioral expectations between parents and service providers; and 4. Interaction between differential expression of underlying pathology and tolerance for such expressions.     

The structure of genetic and environmental risk factors for common psychiatric and substance use disorders in men and women

BACKGROUND: Patterns of comorbidity suggest that the common psychiatric and substance use syndromes may be divisible into 2 broad groups of internalizing and externalizing disorders. We do not know how genetic and environmental risk factors contribute to this pattern of comorbidity or whether the etiologic structure of these groups differ in men and women. METHODS: Lifetime diagnoses for 10 psychiatric syndromes were obtained at a personal interview in more than 5600 members of male-male and female-female twin pairs ascertained from a population-based registry. Multivariate twin modeling was performed using the program Mx. RESULTS: We first fit models to the following 7 syndromes: major depression, generalized anxiety disorder, phobia, alcohol dependence, drug abuse/dependence, adult antisocial behavior, and conduct disorder. The full model, which could be constrained to equality in male and female subjects, identified 2 genetic factors. The first had strongest loadings on alcohol dependence, drug abuse/dependence, adult antisocial behavior, and conduct disorder; the second, on major depression, generalized anxiety disorder, and phobia. Alcohol dependence and drug abuse/dependence had substantial disorder-specific genetic risk factors. Shared environmental factors were most pronounced for conduct disorder and adult antisocial behavior. No clear internalizing/externalizing structure was seen for the unique environmental common factors. We then fit models to 5 internalizing syndromes. The full model, which could also be constrained to equality in men and women, revealed one genetic factor loading most heavily on major depression and generalized anxiety disorder and another loading most strongly on animal and situational phobia. CONCLUSIONS: The underlying structure of the genetic and environmental risk factors for the common psychiatric and drug abuse disorders in men and women is very similar. Genetic risk factors predispose to 2 broad groups of internalizing and externalizing disorders. Within the internalizing disorders, 2 genetic factors are seen that predispose to disorders dominated by anxious-misery and fear. Substance use disorders have disorder-specific genetic risks. The externalizing disorders of conduct disorder and adult antisocial behavior are significantly influenced by the shared environment. The pattern of lifetime comorbidity of common psychiatric and substance use disorders results largely from the effects of genetic risk factors.     

Pathological gambling and the structure of common mental disorders

This study investigated a proposed three-factor model of common mental disorders in the National Epidemiologic Survey of Alcohol and Related Conditions (NESARC; N = 43,093). It also evaluated the inclusion of pathological gambling (PG) in the three-factor model to determine whether PG loaded more strongly on a higher-order externalizing factor comprised of alcohol and drug dependence and antisocial personality disorder. The results indicated the three-factor model showed good fit to the NESARC data. PG loaded onto the externalizing factor for men and women, but in women, PG showed the best fit when it was allowed to load on the externalizing factor as well as a lower-order internalizing factor of anxious-misery composed primarily of mood disorders. Findings emphasize the need to investigate the differences in the nature of PG behavior between men and women.     

Mental disorder comorbidity and treatment utilization

ObjectiveEffective interventions have been developed for myriad common psychological and substance use disorders, though they remain highly underutilized. Previous research has shown that the likelihood of treatment utilization varies across disorder diagnosis. However, studies that focus on individual disorders have resulted in a large, piecemeal literature that neglects the high rates of multivariate comorbidity. The current study investigated the association between treatment utilization and transdiagnostic comorbidity factors.MethodsIn a nationally representative sample of the United States adult population (N = 34,653), we applied the internalizing–externalizing latent comorbidity model to examine its association with lifetime utilization of various treatments for mood, anxiety, and substance use disorders.ResultsBoth internalizing and externalizing transdiagnostic factors were positively associated with all forms of treatment utilization. Stronger within-domain domain (e.g., internalizing's association with mood or anxiety treatment) than between-domain (e.g., internalizing's association with substance use disorder treatment) associations were found. Significant antagonistic internalizing-by-externalizing interactions were also observed.ConclusionsThese results underscore the importance of applying a nuanced approach to modeling comorbidity when predicting treatment utilization. Clinical implications are discussed.     

Is it always the same? Variability of depressive symptoms across six European countries

Using common diagnostic systems together with structured interviews to assess mental disorders has made it possible to compare diagnostic groups of mental disorders across countries. The implicit assumption is that the symptomatology of a particular disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) will not vary between different countries. However, it is conceivable that there will be some variability in the symptom patterns. The present study examines if differences in depressive symptom patterns across European countries can be found and if there are different associations between symptoms and the latent construct depression. Data from 4025 individuals of the European Study of the Epidemiology of Mental Disorders (ESEMeD) project were analysed. Individuals were interviewed using the Composite International Diagnostic Interview (CIDI 3.0). Confirmatory factor analysis was used to examine the associations between depressive symptoms and the latent construct of depression in each country. The proportions of endorsed symptoms of depression showed only slight variation across European countries and only minor to moderate differences in the associations between depressive symptoms and the latent construct depression. The results demonstrated that in European countries using a fully structured and standardized interview based on European-American diagnostic concepts leads to similar results with regard to depressive symptom patterns.     

The temporal stability of the bifactor model of comorbidity: An examination of moderated continuity pathways

BackgroundStructural models of psychopathology indicate that common mental disorder comorbidity reflects latent transdiagnostic factors. Multiple studies have replicated transdiagnostic internalizing (mood and anxiety disorders) and externalizing (substance use, antisociality-, and impulsivity-related disorders) factors; other studies support distress and fear sub-factors of internalizing. These factors show a high degree of temporal stability. Recently, a bifactor conceptualization of multivariate comorbidity has emerged, positing the existence of an orthogonal general psychopathology factor that saturates all diagnoses in addition to internalizing/distress/fear and externalizing, although no studies have examined the temporal stability of the factors in this competing model over time among adults.MethodIn a large, two-wave nationally representative sample (N = 43,093), we investigated the structure of the bifactor model and examined all potential within- and between-factor stability pathways in a structural equation modeling framework.ResultsIn general, within-domain stability (e.g., Wave 1 general factor predicting Wave 2 general factor) was high, while between-domain pathways (e.g., Wave 1 general factor predicting the Wave 2 externalizing factor) did not differ significantly from zero. We then tested possible age and gender moderation of factor stability, finding that the stability for all factors, except fear, significantly differed across demographic sub-groups. However, these differences were not clinically meaningful.ConclusionsResults indicated that bifactor model factors show varying degrees of temporal stability, with lowest comorbidity continuity over time reflecting distress stability. Findings are discussed with regard to recent evidence that the general factor may, to some extent, represent the negative emotionality captured by internalizing/distress in correlated two- and three-factor solutions.     

Intermittent explosive disorder: Associations with PTSD and other Axis I disorders in a US military veteran sample

This study examined the prevalence of intermittent explosive disorder (IED) and its associations with trauma exposure, posttraumatic stress disorder (PTSD), and other psychiatric diagnoses in a sample of trauma-exposed veterans (n = 232) with a high prevalence of PTSD. Structural associations between IED and latent dimensions of internalizing and externalizing psychopathology were also modeled to examine the location of IED within this influential structure. Twenty-four percent of the sample met criteria for a lifetime IED diagnosis and those with the diagnosis were more likely to meet criteria for lifetime PTSD than those without (30.3% vs. 14.3% respectively). Furthermore, regression analyses revealed lifetime PTSD severity to be a significant predictor of IED severity after controlling for combat, trauma exposure, and age. Finally, confirmatory factor analysis revealed significant cross-loadings of IED on both the externalizing and distress dimensions of psychopathology, suggesting that the association between IED and other psychiatric disorders may reflect underlying tendencies toward impulsivity and aggression and generalized distress and negative emotionality, respectively.