Schizophrenia spectrum disorders in Denmark between 2000 and 2018: Incidence and early diagnostic transition

Background

Schizophrenia spectrum disorders (SSD) comprise a group of related mental disorders, which share clinical features and common genetic disposition, but it is unknown if there is a diagnostic transition between these disorders over time. We aimed to study the incidence at the first SSD diagnosis between 2000 and 2018, defined as schizophrenia, schizotypal or schizoaffective disorder, and the early diagnostic transition between these disorders.

Methods

Using Danish nationwide healthcare registers, we identified all individuals aged 15–64 years during the period from 2000 to 2018 in Denmark and calculated the yearly incidence rates for the specific SSDs. We studied the diagnostic pathways from the first ever diagnosis of an SSD across the subsequent two treatment courses with an SSD diagnosis to evaluate early diagnostic stability, and explore potential changes over time.

Results

Among 21,538 patients, yearly incidence rates per 10,000 individuals were similar during the observation period for schizophrenia (2000: 1.8; 2018: 1.6), lower for schizoaffective disorder (2000: 0.3; 2018: 0.1) and increasing for schizotypal disorder (2000: 0.7; 2018: 1.3). Among the subgroup of 13,417 individuals with three separate treatment courses, early diagnostic stability was present among 89.9% which differed between the disorders (schizophrenia: 95.4%; schizotypal disorder: 78.0%; schizoaffective disorder: 80.5%). Among 1352 (10.1%) experiencing an early diagnostic transition, 398 (3.0%) were diagnosed with schizotypal disorder after a schizophrenia or schizoaffective disorder diagnosis.

Conclusion

This study provides comprehensive incidence rates for SSDs. The majority of patients experienced early diagnostic stability, but sizable proportions of people with initial schizophrenia or schizoaffective disorder are subsequently diagnosed with schizotypal disorder.     

Acute polymorphic psychosis in adults with mild intellectual deficits

Abstract This paper describes two representative cases of acute polymorphic psychotic disorder (APPD) defined in the International Classification of Diseases (ICD)-10 in adults with mild intellectual deficits. The patients showed mild intellectual impairment but had worked diligently for many years without their impairment being noticed by others. Some displayed maladjustments in their childhood and were classified as having intellectual disabilities. With their low self-esteem, precipitating events forced the patients to act inappropriately and, as a result, they became psychotic. Although APPD is supposed to occur without causative stress, an intellectual limitation combined with a certain personality can precipitate such a psychosis. It is noted that APPD might mask intellectual deficit and their precipitating factors and that a relapse could be prevented by advising a member of the patient's family.     

Diagnostic stability in adolescent onset psychotic disorders

The purpose was to examine the long-term stability of a diagnosis of psychotic disorder in adolescence and to focus on diagnostic change over time. A total of 88 patients with a first episode of early onset psychosis (before 19 years) were followed up an average of 10.5 years (range 5.1-18.2) after admission. This report includes the 68 patients who could be traced and interviewed with the Positive and Negative Symptom Scale and lifetime Structured Clinical Interview for DSM-IV diagnosis. An initial diagnostic split between schizophrenia spectrum and affective disorder had a good (> 80 %) Positive Predictive Validity and Sensitivity. The main diagnostic shift was an influx to schizophrenia spectrum disorder (n = 6). These patients resembled the stable affective group (n = 27) in premorbid and prodromal aspects but changed over time to resemble the poor outcome of the stable schizophrenia spectrum group (n = 28) albeit with fewer negative symptoms and a better social function. Family history of nonaffective psychosis in first or second degree relatives was often found in the "change to schizophrenia group". A diagnosis in adolescence of schizophrenia spectrum or affective psychotic disorder is usually stable over time. A subgroup of non-schizophrenia patients go on to develop a schizophrenia spectrum disorder.     

Ten-year stability of depressive personality disorder in depressed outpatients

OBJECTIVE: The purpose of this study was to examine the long-term stability of depressive personality disorder. METHOD: The subjects included 142 outpatients with axis I depressive disorders at study entry; 73 had depressive personality disorder. The patients were assessed by using semistructured diagnostic interviews at baseline and in four follow-up evaluations at 2.5-year intervals over 10.0 years. Follow-up data were available for 127 (89.4%) of the patients. RESULTS: The 10.0-year stability of the diagnoses of depressive personality disorder was fair, and the rate of depressive personality disorder declined over time. The dimensional score was moderately stable over 10.0 years. Growth curve analyses revealed a sharp decline in the level of depressive personality disorder traits between the baseline and 2.5-year assessments, followed by a gradual linear decrease. Reductions in depressive personality disorder traits were associated with remission of the axis I depressive disorders. Finally, depressive personality disorder at baseline predicted the trajectory of depressive symptoms over time in patients with dysthymic disorder. CONCLUSIONS: Depressive personality disorder is moderately stable, particularly when assessed with a dimensional approach. However, the diagnosis rate and traits of depressive personality disorder tend to decline over time. The degree of stability for depressive personality disorder is comparable to that for the axis II disorders in the main text of DSM-IV. Finally, depressive personality disorder has prognostic implications for the course of axis I mood disorders, such as dysthymic disorder.     

Diagnostic stability in depressive disorder as according to ICD-10 in clinical practice

BACKGROUND: The diagnostic stability of the ICD-10 diagnosis of depressive disorder has not been investigated in clinical practice. SAMPLING AND METHODS: All patients who were diagnosed with depressive disorder at least once in a period from 1994 to 2002 in psychiatric out- or inpatient settings in Denmark were identified in a nationwide register. RESULTS: A total of 39,741 patients were diagnosed with depressive disorder at least once; among these, 81% were diagnosed at the first contact. In approximately 56% of patients, the initial diagnosis of depressive disorder eventually changed during follow-up mainly to the schizophrenic spectrum (16%), but also to personality disorders (9%), neurotic, stress-related and somatoform disorders (8%) and to bipolar disorder (8%). Among the 18% of patients who were later diagnosed with depressive disorder, 23% initially had a diagnosis of adjustment disorder. CONCLUSIONS: When the ICD-10 diagnoses are used in clinical practice, the diagnosis of depressive disorder has a low stability over time. These findings emphasize the need for a longitudinally based diagnostic process in the diagnostic systems.     

Diagnostic Instability Over Time in the Late-Onset Frontal Lobe Syndrome: When Can We Say it's FTD?

ObjectivesDistinguishing sporadic behavioral variant of frontotemporal dementia (bvFTD) from late-onset primary psychiatric disorders (PPD) remains challenging with the lack of robust biomarkers. An early bvFTD misdiagnosis in PPD cases and vice-versa is common. Little is known about diagnostic (in)stability over longer period of time. We investigated diagnostic instability in a neuropsychiatric cohort up to 8 years after baseline visit and identified which clinical hallmarks contribute to diagnostic instability.DesignDiagnoses of participants of the late-onset frontal lobe (LOF) study were collected from the baseline visit (T0) and the 2-year follow-up visit (T2). Clinical outcomes were retrieved 5–8 years after baseline visit (T_final). Endpoint diagnoses were categorized into bvFTD, PPD and other neurological disorders (OND). We calculated the total amount of participants that switched diagnosis between T0-T2 and T2-T_final. Clinical records of participants that switched diagnosis were assessed.ResultsOf the 137 patients that were included in the study, the final diagnoses at T_final were bvFTD 24.1% (n = 33), PPD 39.4% (n = 54), OND 33.6% (n = 46) and unknown 2.9% (n = 4). Between T0 and T2, a total of 29 (21.2%) patients switched diagnosis. Between T2 and T_final, 8 (5.8%) patients switched diagnosis. Prolonged follow-up identified few cases with diagnostic instability. Major contributors to diagnostic instability where a nonconverting diagnosis of possible bvFTD and a probable bvFTD diagnosis based on informant-based history and an abnormal FDG-PET scan whilst having a normal MRI.ConclusionConsidering these lessons, a FTD diagnosis remains stable enough to conclude that 2 years is sufficient to say if a patient with late-life behavioral disorder has FTD.     

Increasing incidence of medically recognized migraine headache in a United States population.

OBJECTIVE: To investigate trends in the incidence of medically recognized migraine in Olmsted County, Minnesota over approximately a decade. METHODS: The authors used the records-linkage system of the Rochester Epidemiology Project to identify individuals whose records included any diagnostic rubric related to headache for the 3-year period 1979 through 1981 and the 2-year period 1989 through 1990. A nurse abstracter and a neurologist (J.W.S.) reviewed the complete history of each potential case and assigned a diagnosis using the International Headache Society classification (IHS, modified). Only patients who consulted a doctor for their headache and had their initial visit for migraine within the study years were considered as incident cases. RESULTS: The incidence of medically recognized migraine increased in female subjects between the 1979-through-1981 period and the 1989-through-1990 period for all ages, but particularly among those who were aged 10 to 49 years. The peak incidence rate at age 20 to 29 years increased from 634.5 new cases per 100,000 person-years in 1979 through 1981 to 986.4 in the 1989-through-1990 period (absolute increase 351.9; relative increase 56%). The rise in incidence in female subjects was most sizable for migrainous disorder (IHS code 1.7); smaller increases were noted for migraine without aura and with typical aura. Only a slight absolute increase in migraine incidence rates was observed in male subjects, restricted to those 10 to 19 years of age (absolute increase 174.7; relative increase 89%). CONCLUSIONS: Although the incidence rates reported here are restricted to patients who consulted a doctor for their headache, the authors suggest that the incidence of migraine has increased over time in female subjects, especially those of reproductive age. The increase was most pronounced for migrainous disorder. Incidence rates were more stable in male subjects over time.     

Delusional Disorders—Are They Simply Paranoid Schizophrenia?

Objectives:

This article tries to give an answer to the question of whether International Classification of Diseases (ICD-10) persistent delusional disorder (PDD) or Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) delusional disorder (DD) is simply paranoid schizophrenia (PS). Because ICD-10 PDD and DSM-IV DD are identical, we use DD as a synonym. Methods: A prospective and longitudinal study compared all inpatients with DD treated at the Halle-Wittenberg university hospital during a 14-year period with a previously investigated selected cohort of patients with PS. Sociodemographic data, symptomatology, course, and outcome parameters were examined using standardized instruments. The duration of the follow-up period in patients with DD was 10.8 years and for the PS patients 12.9 years.

Results:

Significant differences between DD and PS were found: DD patients are, in comparison to patients with PS, significantly older at onset. Less of their first-degree relatives have mental disorders. They less frequently come from a broken home situation. First-rank symptoms, relevant negative symptoms, and primary hallucinations did not occur in patients with DD. Patients with DD were less frequently hospitalized, and the duration of their hospitalization was shorter. Their outcome is much better regarding employment, early retirement due to the disorder, and psychopharmacological medication. They more often had stable heterosexual partnerships and were autarkic. They had lower scores in the Disability Assessment Scale and in Positive and Negative Syndrome Scale. The diagnosis of DD is very stable over time.

Conclusions:

The findings of this study support the assumption that DDs are a separate entity and only exceptionally can be a prodrome of schizophrenia.     

Ten-year diagnostic consistency of bipolar disorder in a first-admission sample

Ruggero CJ, Carlson GA, Kotov R, Bromet EJ. Ten-year diagnostic consistency of bipolar disorder in a first-admission sample.
Bipolar Disord 2010: 12: 21–31. © 2010 The Authors.
Journal compilation © 2010 John Wiley & Sons A/S.
Objectives:  A number of reports have examined the stability of the diagnosis of schizophrenia, but fewer studies have considered the long-term consistency of a bipolar diagnosis or factors that influence the likelihood of a diagnostic change. The present study sought to estimate how consistently a bipolar diagnosis was made across a 10-year period and factors associated with consistency, particularly demographic and clinical characteristics, childhood-related factors, and illness course.
Methods:  The sample included 195 first-admission patients presenting with psychosis who were assessed soon after hospitalization and at 6-month, 2-year, and 10-year follow-up and diagnosed with bipolar disorder on at least one of these assessments. Diagnoses were made using best-estimate procedures and were blind to all previous consensus diagnoses. Respondents who were consistently diagnosed with bipolar disorder were compared to those whose diagnosis shifted across assessments.
Results:  Overall, 50.3% (n = 98) of the 195 respondents were diagnosed with bipolar disorder at every available assessment, but 49.7% (n = 97) had a diagnostic shift to a non-bipolar disorder at least once over the course of the 10-year study. Childhood psychopathology and poorer illness course were among the few variables associated with increased odds of a change in diagnosis.
Conclusions:  Even with optimal assessment practices, misdiagnosis of bipolar disorder is common, with complex clinical presentations often making it difficult to consistently diagnose the disorder over the long term.     

Current status of multiple personality disorder in India

Three consecutive cases of multiple personality disorder seen over a period of 3 years at a psychiatric clinic in India are reported. The prevalence of this disorder at the clinic is about 0.15/1,000 patients per year. The authors discuss the infrequency of this diagnosis in India in contrast to the frequent diagnosis of possession syndrome for patients who have many of the same symptoms. Transcultural differences in diagnostic practices are also discussed.     

Early onset psychotic disorders: Diagnostic stability and clinical characteristics

Objectives: To examine the clinical features and diagnostic stability of early-onset psychotic disorders. Methods: These data are from a two-year longitudinal prospective study of youth with psychotic disorders. Standardized diagnostic assessments are administered at baseline and at one and two-year's follow-up. Results: Fifty-one subjects have been recruited to date; 18 with schizophrenia, 14 with bipolar disorder, 7 with schizoaffective disorder, 1 with an organic psychosis, and 11 subjects whose symptoms where either questionable and/or did not meet diagnostic criteria for another disorder (classified as psychosis nos). Thirty-nine subjects were reassessed at year one, twenty-four at year two. Three subjects have been lost to follow-up. The study diagnosis was the same as the first onset diagnosis (prior to entering the study) in 50 % of subjects. Over the two-year period of the study, the diagnosis remained unchanged in over 90 % of subjects. Subjects with schizophrenia had higher ratings of premorbid impairment, including social withdrawal and dysfunctional peer relationships, than those with bipolar disorder. At the one-year follow-up, subjects with schizophrenia and schizoaffective disorder had significantly higher rates of delusions, bizarre behavior, and negative symptoms than those with bipolar disorder. Subjects with bipolar disorder tended to have cyclical courses, whereas those with schizophrenia and schizoaffective disorder were often chronically impaired. Subjects with psychosis nos had higher rates of dissociative symptoms and histories of child maltreatment. Conclusions: Early-onset psychotic disorders can be reliably diagnosed using standardized assessments and are stable over a two-year period. Compared to bipolar disorder, schizophrenia is associated with a poorer premorbid history, and persistent positive and negative symptoms.     

Diagnostic subtypes of bipolar disorder in older versus younger adults

OBJECTIVE: To investigate differences in diagnostic subtypes of bipolar disorder as according to ICD-10 between patients whose first contact with psychiatric health care occurs late in life (over 50 years of age) and patients who have first contact earlier in life (50 years of age or below). METHODS: From 1994 to 2002 all patients who received a diagnosis of a manic episode or bipolar disorder at initial contact with the mental healthcare system, whether outpatient or inpatient, were identified in Denmark's nationwide register. RESULTS: A total of 852 (49.6%) patients, who were over age 50, and 867 patients, who were 50 or below, received a diagnosis of a manic episode or bipolar disorder at the first contact ever. Older inpatients presented with psychotic symptoms (35.4%) significantly less than younger inpatients (42.6%) due specifically to a lower prevalence of manic episodes with psychotic symptoms. Conversely, older inpatients more often presented with severe depressive episodes with psychotic symptoms than younger inpatients (32.0% versus 17.0%). Among outpatients, no significant differences were found between patients older than 50 years and patients 50 years of age or younger. However, a bimodal distribution of age at first outpatient contact was found with an intermode of 65 years and outpatients older than 65 years more often presented with severe depressive episodes with psychosis. CONCLUSIONS: Bipolar patients who are older at first psychiatric hospitalization (>50 years) present less with psychotic manic episodes and more with severe depressive episodes with psychosis than younger patients. The distribution of age at first outpatient contact is bimodal with an intermode of 65 years and outpatients older than 65 years more often present with severe depressive episodes with psychosis.     

Acute and transient psychotic disorders: An overview of studies in Asia

Abstract

Acute and transient psychotic disorders (ATPD), introduced in the International Classification of Diseases (ICD-10) diagnostic system, have not received much attention in Asia. As the World Health Organization (WHO) is in the process of revising the ICD-10 and ICD-11 is expected to be published in the near future, it seems appropriate to review the status of ATPD in this region. A PubMed search using appropriate keywords was conducted to identify literature describing samples from Asian countries with the diagnosis of ATPD for evidence of ATPD as a distinct diagnostic group. A total of 103 papers were found, but only nine publications were specifically related to ATPD and the ICD-10 criteria. The total number of patients receiving a diagnosis of ATPD in these studies was 390. Immigrants appear prone to ATPD, especially foreign domestic workers. When compared to schizophrenia, ATPD as a group had a different family history, course and outcome. However, ATPD was diagnostically unstable over time. A range of 35.5% to 73.3% in Asian patients with baseline ATPD retained their diagnoses over 3–12 years. Most individuals with polymorphic subtypes of ATPD in India and Hong Kong were rediagnosed with bipolar disorder after 3–5 years. In Japan, 31.2% of polymorphic cases were diagnosed as schizophrenia after 12 years of follow-up. This review supports the ICD-10 concept of separating ATPD into its own group; however, polymorphic subtypes may need revision in ICD-11. Before firm suggestions are submitted to the WHO, further research and data review from other regions is necessary.     

Psychiatric diagnoses made by the agecat system in residents of local authority homes for the elderly: Outcome and diagnostic stability after four years

Eighty-six residents of 12 local authority homes for the elderly were interviewed with the Geriatric Mental State (GMS) in 1985/6 after having been classed as depressed by a screening interview. The data so gathered were analysed by the computerized diagnostic program AGECAT in order to derive psychiatric diagnoses for these residents. All were traced after four years; 61 were dead. The 25 survivors were reinterviewed and given a second AGECAT diagnosis. In 1985/6 70 of the 86 examined were ‘diagnostic cases’ of psychiatric disorder. After four years 22 of the 25 survivors were classed as diagnostic cases. AGECAT diagnoses of organic psychosis were stable over four years within this population though the majority of subjects so diagnosed died within four years. Cases of depression had a more varied prognosis, with death, continunce as cases of depression or progression to organic psychosis being the most common outcomes. Recovery from any class of AGECAT disorder was an uncommon event.     

Case series of diagnostic shift from bipolar disorder to schizoaffective disorder

Objective: To describe three cases of diagnostic shift from bipolar I disorder (BD) to schizoaffective disorder (SAD).

Methods: BD patients were clinically assessed and followed up in a mood disorder program. A questionnaire was applied to assess clinical and socio-demographic characteristics, and a Structured Clinical Interview (SCID-I) was conducted.

Results: We identified three patients with diagnosis conversion to SAD from 2005 to 2016. The mean time between BD diagnosis and the diagnostic shift to SAD was 9 years.

Conclusions: Psychotic symptoms may become persistent, chronic and unrelated to the presence of mood episodes many years after the beginning of BD. Psychiatrists should be aware of this and reassess the diagnosis during the longitudinal course of BD, especially in those patients who present psychotic symptoms     

Organic syndromes diagnosed as conversion disorder: identification and frequency in a study of 85 patients

BACKGROUND: The percentage of patients initially diagnosed with a conversion disorder and later identified as having an organic disorder has been decreasing in recent studies. METHOD: Consecutive patients with a diagnosis of conversion disorder were referred for psychiatric diagnosis and treatment. Research questions were: (1) What incidence of neurological disorder is revealed by neurological reassessment and by which diagnostic technique is the final diagnosis established? (2) What differences can be observed between true-positive and the false-positive results? RESULTS: Ten (11.8%) of the 85 patients examined appeared to suffer from a neurological disorder. In this sample, variables discriminating between the true positives and false positives were: (1) prior suspicion of neurological disorder; (2) older age at referral; (3) older age at onset of symptoms; (4) longer duration of symptoms; and (5) use of medication. Three variables contributed significantly to the prediction of organic disorder: prior suspicion of neurological disorder; age at onset of symptoms; and duration of symptoms. CONCLUSIONS: Although our results are in line with those of other recent studies, the percentage of false positives was still high. The data further emphasize the dangers of making a diagnosis of conversion disorder in the absence of positive evidence. It is important to continue to provide follow up for patients with a diagnosis of conversion disorder. Unfortunately, unreliable psychiatric indications, like certain behavioral characteristics, are still used in the diagnostic process. The results show that a general neurological examination is still a valuable diagnostic instrument in addition to modern diagnostic techniques.     

河南省某地区初中生情绪和行为相关障碍的诊断变化——1年随访

目的研究青少年情绪和行为相关障碍在1年内出现的诊断变化情况。方法于2015年4月采用整群随机抽样方法,从河南省唐河县城郊乡和舞阳县文烽乡的两所中学的初一、初二年级抽取34个班共1 500名学生,采用长处和困难筛查问卷(学生版)(SDQ)进行筛查,对334例筛查阳性者依据《精神障碍诊断与统计手册(第5版)》(DSM-5)进行诊断,符合入组标准共75例,共64例完成随访,并于半年后和1年后进行两次随访,再次依据DSM-5进行诊断。结果 9例注意缺陷/多动障碍患者中的3例、12例抑郁障碍患者中的5例、34例焦虑障碍患者中的4例、3例创伤及应激相关障碍中的2例出现诊断变化;其中抑郁障碍比焦虑障碍诊断变化更明显(P=0. 039),多转变为强迫障碍、环性心境障碍、破坏性心境失调等。结论青少年抑郁障碍诊断易出现变化,注意缺陷/多动障碍、抑郁障碍的诊断分别预示其以后更易患上焦虑障碍、双相情感障碍。     

Older patients referred to a consultation-liaison psychiatry clinic

BACKGROUND: Little is known about the psychiatric disorders which are associated with somatic presentations of psychological distress in older people. METHOD: A study of patients aged 65 years and over referred to an adult consultation-liaison psychiatry clinic in a general hospital. RESULTS: Of 900 patients referred over a 7-year period, 45 (5%) were aged 65 years and over. The most frequent ICD-10 diagnostic category was somatoform disorder (N=30) followed by depressive disorder (N=6). The age of onset of the physical symptoms was significantly earlier in those with somatoform disorders (mean 49 years; SD 3.1 years) compared with patients with depressive disorders (mean 74 years; SD 3.1 years) (p<0.05). All diagnoses were equally associated with moderate functional impairment. CONCLUSION: Medically unexplained physical symptoms may occur as part of a range of psychiatric disorders in older people and diagnostic groups are distinct in a number of ways. The usefulness of the ICD-10 classification of disorders in relation to these patients is considered. Implications for the delivery of old age psychiatry services are discussed.     

Longitudinal study of the influence of life events and personality status on diagnostic change in three neurotic disorders

It has been known for many years that diagnosis within the neurotic spectrum of disorders is temporally unstable and also that life events can be major precipitants of change in symptoms. Reasons for this instability could include inherent inadequacy of current diagnostic practice, the influence of life events as an agent of diagnostic shift, and an innate course of disorder with features dependent on the stage at which disorder presents (e.g., development of panic to agoraphobia). These possibilities were examined in a prospective study that was initially a randomised controlled trial. Two hundred ten patients recruited from primary care psychiatric clinics with DSM-III diagnosed dysthymic, generalised anxiety, and panic disorders were randomly allocated to either drug treatment (mainly antidepressants), cognitive-behaviour therapy, or self-help therapy over a 2 year period, irrespective of original diagnosis. Life events were recorded by using a standard procedure over the period 6 months before starting treatment and at five occasions over 2 years; 181 (86%) of the patients had follow-up data and 76% maintained compliance with the original treatment allocated over the 2 years; and 155 of the 181 patients (86%) had at least one diagnostic change in this period. There was no difference in the number of diagnostic changes between the three original diagnostic groups, but dysthymic disorder changed more frequently to major depressive episode than did GAD or panic disorder (20; 11; 12) (%) and panic disorder changed more frequently to agoraphobia (with or without panic) than did dysthymia or GAD (18; 8; 6) (%). There was no relationship between loss events and depressive diagnoses or between addition events and anxiety diagnoses, but greater numbers of conflict events were associated with diagnostic change. More life events were associated with the flamboyant and dependent personality disorders, reinforcing other evidence that many life events are internally generated by personality characteristics and cannot be regarded as truly independent.     

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

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