Pre-morbid personality and depression following stroke

BACKGROUND: The role of individual differences, including pre-morbid personality, in the development of post-stroke depression, has received relatively little attention. We undertook a cross-sectional study to investigate the relationship between pre-morbid personality and other individual differences, and depression following acute stroke. METHOD: We studied 61 consecutive patients admitted to a dedicated stroke inpatient unit. DSM-IV depressive diagnoses were ascertained using the Composite International Diagnostic Interview and depressive symptoms were ascertained on the Hamilton Depression Rating Scale and the Center for Epidemiologic Studies Depression Scale. Informant-rated personality scores were obtained on the full 240-item Neuroticism, Extraversion and Openness Personality Inventory--Revised. Adaptive function was measured on the Modified Barthel Index and the Instrumental Activities of Daily Living scale. Cognitive function was assessed on the Mini-mental State Examination. RESULTS: An increased risk of post-stroke depression was conferred by both pre-morbid neuroticism [odds ratio (OR) 3.69; 95% confidence interval (95% CI) 1.25-10.92] and a past history of mental disorder (OR 10.26; 95% CI 3.02-34.86). There was no significant relationship demonstrated between lesion location and post-stroke depression. CONCLUSIONS: Informant-rated pre-morbid neuroticism and a past history of mental disorder were important predictors of depression following stroke. Stroke side was not significantly related to risk of depressive symptoms following stroke.     

The stalemate position

The psychosurgical operation of stereotactic subcaudate tractotomy can be a highly effective treatment for chronic and intractable affective disorders. We have lately given increasing attention to cases where the depressed mood appears to lift although there is little improvement in social function. In these cases there has been a failure of rehabilitation and the complexities of this process post-operatively are discussed. In addition, relatives report in some 10% of cases "personality changes" after the operation which are not perceived in this way by an independent medical assessor and these observations seem to depend upon relatives mis-interpreting the resumption of pre-morbid personality function after long illnesses as undesirable side-effects. Case histories illustrating the problems are described. Treatment and rehabilitation strategies are outlined.     

Normalization of personality characteristics in patients with incapacitating anxiety disorders after capsulotomy

The personality characteristics of 24 consecutive patients undergoing psycho-surgery for incapacitating anxiety disorders were assessed prospectively using a self-report personality inventory. The main findings were: absence of negative personality changes after surgery, significant postoperative changes towards normalization on the majority of the scales, and significant symptomatic relief in 80% of the cases. The changes on scales reflecting anxiety proneness were conspicuous in patients suffering from "pure" anxiety disorders, as compared with those suffering from obsessive-compulsive disorder (OCD). In OCD patients, correlations were obtained between changes in brain metabolism studied with positron emission tomography and changes in personality scores. It is concluded that negative personality changes are not likely to occur after capsulotomy.     

A psychosocial model of parent fixation in people with dementia: the role of personality and attachment

This study replicates and extends research into the occurrence of parent fixation in people with dementia by exploring the relationship between demographic, cognitive and psychological factors. Fifty-one people with dementia, living both in the community and in residential/nursing home settings, were interviewed about their parents and a relative of each completed measures assessing the person with dementia's demographic details, level of cognitive impairment/executive functioning, behavioural consequences of parent fixation and pre-morbid personality and attachment style. Results indicated that parent fixation can be viewed as a psychosocial phenomenon arising from the environment, pre-morbid personality and attachment style and that the behavioural consequences of parent fixation are maintained by the individual's level of executive functioning and gender. Findings and clinical implications are discussed in relation to Miesen's (1992, 1993, 1999) theoretical assumption that dementia is a loss process that activates the experience of feeling unsafe and the emotional need for the security of an attachment figure.     

Dominant psychiatric manifestations in Wilson's disease: a diagnostic and therapeutic challenge!

INTRODUCTION: Recognition of psychiatric manifestations of Wilson's disease (WD) has diagnostic and therapeutic implications. OBJECTIVE: To describe the clinical features and psychopathology of patients with WD who had initial or predominant psychiatric manifestations. PATIENT AND METHODS: Records of 15 patients with WD (M:F: 11:4), from a large cohort of 350 patients, with predominant psychiatric manifestations at onset were reviewed. Their initial diagnosis, demographic profile, family history, pre-morbid personality, clinical manifestations, treatment and outcome were recorded. RESULTS: Their mean age at diagnosis was 19.8+/-5.8 years. Six patients were born to consanguineous parentage and two patients each had family history of WD and past history of psychiatric illness. Diagnosis of WD was suspected by detection of KF rings (all), observing sensitivity to neuroleptics (n=2), history of jaundice (n=2) and family history suggestive of WD (n=9). Psychiatric manifestations could be classified as affective disorder spectrum (n=11) and schizophreniform-illness (n=3). While the psychiatric symptoms improved in five patients with de-coppering therapy, seven patients needed symptomatic treatment as well. Three of the four patients who responded to de-coppering therapy were sensitive to neuroleptics. Long-term follow up of 10 patients revealed variable recovery. CONCLUSIONS: Young patient with psychiatric manifestations with clues like history of jaundice, family history of neuropsychiatric manifestations and sensitivity to neuroleptics should be evaluated for WD to avoid delay in diagnosis and associated morbidity. SIGNIFICANT OUTCOMES: The study reemphasizes the importance of behavioral manifestations in Wilson disease in terms of diagnosis and management difficulties. LIMITATIONS: Retrospective nature of the study.     

Avoidant personality disorder and taijin kyoufu: Sociocultural implications of the WHO/ADAMHA International Study of Personality Disorders in Japan

Ono Y, Yoshimura K, Sueoka R, Yamauchi K, Mizushima H, Momose T, Nakamura K, Okonogi K, Asai M. Avoidant personality disorder and taijin kvoufu: Sociocultural implications of the WHO/ ADAMHA International Study of Personality Disorders in Japan. Acta Psychiatr Scand 1996: 93: 172–176. © Munksgaard 1996. This paper discusses the characteristics of avoidant personality disorder in a cultural context based on the Japanese concept of taijin kyoufu as well as that of DSM-III-R and DSM-IV Social phobia. Sixty-six patients were given the International Personality Disorder Examination and questionnaires including the Beck Anxiety Inventory. Among the 23 DSM-III-R personality disorder patients, 8 patients were diagnosed as having avoidant personality disorder. Six of them were suffering from taijin kyoufu symptoms. Among 27 ICD personality disorder patients, 22 patients were diagnosed as having ICD anxious personality disorder. All DSM avoidant patients were included in the ICD anxious group. These findings suggest that patients with avoidant personality disorder have had a long history of difficulties and share common personality problems with a milder form of taijin kyoufu, which is conceptually different from Social phobia.     

Gender differences in premorbid cognitive performance in a national cohort of schizophrenic patients

Despite significant research, there are still inconsistent findings regarding gender differences in cognitive performance in individuals already diagnosed with schizophrenia; studies have found that males suffering from schizophrenia are more, less or equally impaired compared with females. Gender differences in cognitive performance in individuals suffering from schizophrenia may be influenced by gender differences in premorbid cognitive performance; the very few and very small N studies published indicated that males have a poorer pre-morbid cognitive performance than females. This study examined the gender differences in premorbid cognition, utilizing cognitive assessments performed on female and male adolescents before induction into military service. The Israeli Draft Board Registry, which contains cognitive assessments equivalent to IQ scores on 16-18 year old Israeli adolescents, was linked with the Israeli National Psychiatric Hospitalization Case Registry, which records all psychiatric hospitalizations in the country. Scores on premorbid cognitive performance in schizophrenia were examined in 90 female-male case pairs matched for school attended as a proxy for socio-economic status. The mean age of first hospitalization was 20. 1+/-1.8 years of age for males and 19.6+/-1.8 years of age for females. A repeated-measures ANCOVA with age of first hospitalization and years of formal education as covariates, and controlling for gender differences in cognitive performance in healthy adolescents, revealed a significant difference in pre-morbid cognitive performance between males and females on all four cognitive measures [F(1,87)=8.07, P=0.006] with females scoring lower (worse) than males. In this national cohort, pre-morbid cognition was poorer in female, compared with male, adolescents who will suffer from schizophrenia in the future, a result consistent with some, but not all, similar studies. These results may be valid only for patients with first hospitalization around age 20. Hence, gender differences in premorbid cognition should be taken into account when assessing gender differences in cognition in schizophrenia.     

A study of premorbid personality and behavioural and psychological symptoms of dementia in nursing home residents

OBJECTIVE: to investigate the relationship between pre-morbid personality and behavioural and psychological symptoms of dementia (BPSD). METHODS: we studied 58 subjects with dementia and depression and/or psychosis residing in 11 Sydney nursing homes cross-sectionally. Informal caregivers completed ratings of residents' pre-morbid personality on the NEP Five-Factor Inventory (NEO-FFI). Information on BPSD was obtained using the BEHAVE-AD. RESULTS: higher neuroticism was predictive of delusions; higher agreeableness of hallucinations, aggressiveness, affective disturbance and overall behavioural disturbance; and higher openness of affective disorder. CONCLUSION: our findings are inconsistent with previous research and clinical experience. Prospective studies are needed to clarify the association between personality and behavioural disturbance in dementia.     

PERSONALITY IN EPILEPSY

Three groups of epileptic out-patients (juvenile myoclonie epilepsy, psychomotor epilepsy, and cryptogenic grand mal) were studied. the groups were matched as closely as possible with each other with regard to sex, age, and treatment. Out-patients suffering from Menière's disease served as a control group; these patients were treated with placebo and matched with the epilepsy groups with regard to sex, duration of disease and social level. the Marke-Nyman inventory was used as a quantitative assessment of personality traits. This inventory is an operative definition of Sjöbring's neurophysiological model of personality, including the three dimensions: validity, stability and solidity. Our results showed that epileptic patients irrespective of the type of seizures were substable. Low validity was found in patients with juvenile myoclonic epilepsy and in patients with psychomotor epilepsy with temporal EEG focus. In those latter epilepsy groups a tendency to subsolidity was also observed. In Sjöbring's frame of reference these substable patients of low validity have a psychological vulnerability since they are unable to overcome the small concrete adversities of life. They adhere to problems, and being unable to solve them they tend to react in a mood of discontent or of maladjustment. In the usual psychiatric frame of reference substable patients of low validity are classified as psychoastenic patients with emotional instability.     

Changes of hand preference in Parkinson’s disease

This study focused on the difference between pre-morbid and current hand preference of patients with Parkinson's disease (PD). A survey instrument comprised items measuring pre-morbid and current hand preference and question related to the side of occurrence of initial symptoms. These questions were administered to 471 PD patients. The results show a significant change of pre-morbid right hand preference toward using the left when the side of PD onset was on the right hand and vice versa. Disease duration does not predict the amount of hand preference shift.     

Course of schizoaffective psychosis: a retrospective study

This study investigated the clinical course and outcome of 72 patients diagnosed as suffering from schizoaffective psychosis according to ICD-9 criteria who also satisfied RDC criteria for schizoaffective disorder. The results show a clear relationship between patients' overall functioning and premorbid personality: a better premorbid social adjustment indicates a better current state. Those who met DSM-III criteria for schizophrenic or schizophreniform disorder had an earlier age of onset and a higher frequency of relapse, followed by schizoaffective and affective patients. Patients who presented interepisodic psychotic symptoms differed from those who did not in that they showed more recurrences, an earlier age of onset and a premorbid personality with poorer social adjustment. The age of onset of the disease was significantly earlier in patients who had hyperthymic episodes. Schizoaffective disorders therefore are a heterogeneous group as regards premorbid personality, DSM-III diagnosis, and the presence or absence of interepisodic psychotic symptoms and hyperthymic episodes.     

Comorbidity of Personality Disorders and Adult Attention Deficit Hyperactivity Disorder (ADHD)—Review of Recent Findings

Children suffering from attention deficit hyperactivity disorder (ADHD) may remit until adulthood. But, more than 60–80 % have persisting ADHD symptoms. ADHD as an early manifesting neurodevelopmental disorder is considered a major risk factor for the development of comorbid psychiatric disorders in later life. Particularly, personality disorders are oftentimes observed in adult patients suffering from ADHD. If ADHD and personality disorders share common etiological mechanisms and/or if ADHD as a severely impairing condition influences psychological functioning and learning and leads to unfavorable learning histories is unclear. The development of inflexible and dysfunctional beliefs on the basis of real and perceived impairments or otherness due to the core symptoms of ADHD is intuitively plausible. Such beliefs are a known cause for the development of personality disorders. But, why some personality disorders are more frequently found in ADHD patients as for example antisocial and borderline personality disorder remains subject of debate. Because of the high prevalence of ADHD and the high impact of personality disorders on daily functioning, it is important to take them into account when treating patients with ADHD. Research on the developmental trajectories leading to personality disorders in adult ADHD patients might open the door for targeted interventions to prevent impairing comorbid clinical pictures.     

Suicide in borderline personality disorder: a meta-analysis

Suicide is the major cause of death among patients with borderline personality disorder; however, the literature on completed suicides in such disorder is inconclusive, as suicide rates vary greatly among cohorts of patients. We searched MedLine, Excerpta Medica and PsycLit from 1980 to 2005 to identify papers dealing with suicide in borderline personality disorder. We also searched the World Health Statistics Annual to ascertain the suicide rate in the age groups for specific years and country. We selected eight studies comprising 1179 patients with a diagnosis of borderline personality disorder. Of these patients, 94 committed suicide. Results obtained for each study were processed together to calculate the mean figure for each year of suicides for 100,000 individuals suffering from borderline personality disorder. Our meta-analysis shows that suicide among patients with borderline personality disorder is more frequent when compared with the general population. All study analyses reported that patients with borderline personality disorder committed suicide more often than their counterparts in the general population. Suicide seems more alarming in the first phases of follow-up than during chronic phases of illness.     

Psychopathological study of parents who abuse their children]

After recalling the studies of French authors, especially those of P. Parisot and L. Caussade at the Congress of Legal Medicine in Nancy (1929), and more recent, those of the Nancy school, and, in Paris, those of P. Straus and A. Wolf, of L. Kreisler and P. Straus, the author studies Anglo-Saxon research on subject, particularly that undertaken in the U.S.A. The study by Steele and Pollock on the psychology of parents of battered children has shown anomalies with an infantile characteristic in the psychology of some parents (apparently having no problems and living in easy circumstances, but demanding of their children a constant reassurance which the latter are unable to give, hence a permanent frustration leading to agressivity and actual tormenting. Eight observations are presented, covering the whole range of clinical forms observed with parents of battered children: psychopathic personality with perverse sado-masochism, affective immaturation with decompensation during pregnancy, lack of psycho-affective balance with aggression upon some of the children (target-children), a need for domination in the form of tyrannical matriarchate, nevropathy with aggressive perfectionism, and finally subnormal personality with nevropathy, the latter categories leaving a hop for a possibility of attaining transformation through analytical psychotherapy, such as practised by the author in one of his cases.     

Transformation from a neuroprotective to a neurotoxic microglial phenotype in a mouse model of ALS

Neuroinflammation is a prominent pathological feature in the spinal cords of patients with amyotrophic lateral sclerosis (ALS), as well as in transgenic mouse models of inherited ALS, and is characterized by activated microglia. Earlier studies showed that activated microglia play important roles in both motoneuron protection and injury. More recent studies investigating the pathoprogression of disease in ALS mice have demonstrated that the in vivo activation states of microglia, including their anti- versus pro-inflammatory responses, are best characterized as a continuum between two extreme activation states which are represented as a neuroprotective M2 (alternatively-activated) phenotypic state or an injurious/toxic M1 (classically-activated) state; a more complete understanding and determination the temporal transformation of microglia activation states in the ALS disease pathoprogression is therefore warranted. In the current study, we demonstrated a phenotypic and functional transformation of adult ALS mice microglia that overexpress mutant superoxide dismutase (mSOD1). mSOD1 microglia isolated from ALS mice at disease onset expressed higher levels of Ym1, CD163 and BDNF (markers of M2) mRNA and lower levels of Nox2 (a marker of M1) mRNA compared with mSOD1 microglia isolated from ALS mice at end-stage disease. More importantly, when co-cultured with motoneurons, these mSOD1 M2 microglia were neuroprotective and enhanced motoneuron survival than similarly co-cultured mSOD1 M1 microglia; end-stage mSOD1 M1 microglia were toxic to motoneurons. Our study documents that adult microglia isolated from ALS mice at disease onset have an M2 phenotype and protect motoneurons whereas microglia isolated from end-stage disease ALS mice have adopted an M1 phenotype and are neurotoxic supporting the dual phenotypes of microglia and their transformation during disease pathoprogression in these mice. Thus, harnessing the neuroprotective potential of microglia may provide novel avenues for ALS therapies.     

Personality traits in migraine and tension-type headaches: a five-factor model study

Although abnormal personality traits have been frequently reported in patients with primary headaches, the overlaps between these domains need a clear standard definition, for example, by a five-factor personality model. Moreover, personality abnormalities in patients with episodic tension-type headache (ETH) and migraine with aura (MA) are less well studied. Therefore, we administered Zuckerman-Kuhlman's Personality Questionnaire to 72 patients suffering from chronic tension-type headaches (CTH), 33 with ETH, 15 with MA and 57 with migraine without aura (MO), as well as 58 healthy subjects. Depressive trends were measured with Plutchik-van Praag's Depression Inventory. Compared to healthy controls, the CTH, ETH and MO groups showed significantly greater neuroticism-anxiety and depression. In addition, the MO group scored significantly higher on aggression-hostility than healthy controls. No abnormal personality traits were found in patients with MA. This study, from the perspective of a five-factor model, confirms most previous reports about personality in patients with primary headaches and establishes elevated aggression-hostility only in MO sufferers.     

The relationship between pre-morbid personality and challenging behaviour in people with dementia: A systematic review

It has been suggested that challenging behaviour in people with dementia reflects a person's pre-morbid personality traits and a number of studies have explored this hypothesis. However, inconsistencies in outcome between studies suggest a need to review the available evidence systematically. As a result, major bibliographic databases were searched for studies examining the relationship between pre-morbid personality and challenging behaviour in order to conduct a systematic review. We included all English language studies published in referenced journals that assessed pre-morbid personality via a valid comprehensive personality measure, and also explored a relationship with challenging behaviour in people with dementia. A total of 18 studies were identified that covered a wide range of challenging behaviours including ‘wandering’, affective states, aggression, anxiety and delusions/hallucinations. Studies were assessed for their methodological quality and statistical findings. Studies lacked representative samples, were affected by confounding variables and suffered from small sample sizes. However, 72% of the studies reported significant relationships between pre-morbid personality and behaviour. In terms of specific relationships, the strongest evidence was found for a positive relationship between pre-morbid neuroticism and mood, and aggression and overall behavioural acts, thus supporting the inclusion of personality as one factor in the formulation of behaviour (Ballard, C., O’Brien, J., James, I., & Swann, A. (2001). Dementia: Management of Behavioural and Psychological Symptoms. Oxford: Oxford University Press; Kitwood, T. (1993 Kitwood, T. 1993. Person and process in dementia: Editorial. International Journal of Geriatric Psychiatry, 1: 541–545. [Crossref] [Google Scholar]). Person and process in dementia: Editorial. International Journal of Geriatric Psychiatry, 1, 541–545).     

Psychopharmacologic treatment of personality disorders

There is only a paucity of studies concerning the pharmacological treatment of personality disorders per se. On the other hand the clinical use of medication in these conditions is quite high, although there is no effective psychopharmacological treatment of distinct personality disorders. The psychopharmacological treatment of patients suffering from a personality disorder focuses on distinct symptoms and its comorbidity. Some symptoms could also be associated with other disorders like depression or psychosis, which often makes an exact differentiation of these disorders and a personality disorder difficult. Since symptoms of personality disorders are ego-syntonic, chronic and very often dependent on psychosocial factors, it is unlikely that a solely psychopharmacological treatment will be successful in most patients with a personality disorder. However, severe syndromes like depressive, impulsive, aggressive, dissociative, anxious or psychotic features may render a pharmacotherapy necessary. For the treatment of depressive syndromes or impulsivity a medical therapy with serotonin reuptake inhibitors, for the treatment of psychotic syndromes a medication with atypical antipsychotics is recommended. Impulsive or aggressive behaviour could be treated with mood stabilizers as well. Furthermore, there are indications for the use of alpha2-agonists, micro-opiate-antagonists and omega-3 fatty acid. The general use of benzodiazepines should be avoided as well as polypragmasy. Advantages versus potential damage of a high dose pharmacotherapy should be carefully weighed against each other. This article gives an overview over the today's most common psychopharmacological treatment possibilities in patients with a personality disorder.     

Outcome two months after myocardial infarction

A hundred patients suffering a first myocardial infarct were interviewed in hospital and at home two months after the infarct using a semi-structured interview. Spouses were interviewed separately. There was a wide variation in disability, unrelated to cardiac state, and we describe effects on mental state, physical activity, return to work and compliance. Patterns of outcome and associations between pre-morbid and two-month measures are discussed.