Diagnosing personality disorders in psychiatric inpatients

This study investigated assumptions made by DSM-III and DSM-III-R regarding Axis I-Axis II associations and sex differences for the 11 personality disorders (PD). A total of 112 patients formed 4 Axis I diagnostic groups: recent-onset schizophrenia (n = 35); recent-onset mania (n = 26); unipolar affective disorder (n = 30); and a mixed diagnostic group (n = 21). The prevalence of PD was determined using the Structured Interview for DSM-III Personality Disorders (SIDP). Schizophrenia was associated with antisocial PD and schizotypal PD; manic disorder was associated with histrionic PD; and unipolar affective disorder was associated with borderline, dependent and avoidant PD. Some of these results were consistent with DSM-III/DSM-III-R postulates. However, there was little support for the DSM-III/DSM-III-R statements on sex differences in the prevalence of PD, except for antisocial PD. The implications of the results for DSM-III/DSM-III-R assumptions are discussed.     

Familial aggregation of psychiatric disorders and the consequences for the psychiatric diagnosis

Schizophrenic and affective disorders, anxiety disorders, and alcoholism show familial aggregation; the impact of familial aggregation on the classification and etiology of psychiatric disorders is discussed. Ideal diagnostic schedules should a) identify conditions with a substantially increased familial risk and b) reach diagnostic homogeneity in multiplex families. A review of the literature shows a) that age at onset, long-term course and comorbidity modify familial risks and should therefore be given more attention in diagnostic schedules and b) that the heterogeneity of disorders in multiplex families draws the validity of currently used diagnostic schedules into question. Against this background the hypothesis of "unitary psychosis" is discussed.     

Effects induced by cannabinoids on monoaminergic systems in the brain and their implications for psychiatric disorders

The endocannabinoid system and CB(1) receptors participate in the control of emotional behavior and mood through a functional coupling with the classic monoaminergic systems. In general, the acute stimulation of CB(1) receptors increases the activity (spontaneous firing rate) of noradrenergic (NE), serotonergic (5-HT) and dopaminergic (DA) neurons as well as the synthesis and/or release of the corresponding neurotransmitter in specific brain regions. Notably, the antagonist/inverse agonist rimonabant (SR141617A) can decrease the basal activity of NE and 5-HT neurons, suggesting a tonic/constitutive regulation of these neuronal systems by endocannabinoids acting at CB(1) receptors. Monoaminergic systems are modulated via CB(1) receptors by direct or indirect effects depending on the localization of this inhibitory receptor, which can be present on monoaminergic neurons themselves and/or inhibitory (GABAergic) and/or excitatory (glutamatergic) regulatory neurons. The repeated stimulation of CB(1) receptors is not associated with the induction of tolerance (receptor desensitization) on the activity of NE, 5-HT and DA neurons, in contrast to chronic agonist effects on neurotransmitter synthesis and/or release in some brain regions. CB(1) receptor desensitization may alter the direct and/or indirect effects of cannabinoid drugs modulating the functionality of monoaminergic systems. The sustained activation of monoaminergic neurons by cannabinoid drugs can also be related to changes in the function of presynaptic inhibitory α(2)-adrenoceptors or 5-HT(1A) receptors (autoreceptors and heteroreceptors), whose sensitivity is downregulated or upregulated upon chronic CB(1) agonist exposure. The functional interactions between endocannabinoids and monoaminergic systems in the brain indicate a potential role for CB(1) receptor signaling in the neurobiology of various psychiatric disorders, including major depression and schizophrenia as the major syndromes.     

Treatment of patients with personality disorders in specialized units for psychotherapy in Bavarian psychiatric hospitals

Data about patients with personality disorders treated in specialized psychotherapy units in bavarian psychiatric hospitals during the second half-year 2001 (n = 256) were collected by a questionnaire. Diagnostic, therapeutic and social characteristics were registered. Treatment possibilities of the psychotherapeutic units und special qualifications of the staff were investigated as well. - RESULTS: The investigated population of personality disorders is mentally seriously handicapped has high rates of suicide-attempts and co-morbidity with other mental disorders. The units for psychotherapy offer a wide range of different psychotherapeutic treatments. The staff is well trained in psychotherapeutic qualifications. These results show, that bavarian psychiatric hospitals play an important role in psychotherapeutic treatment of severely ill in-patients.     

对精神病学教科书中双重人格定义的再认识

1 起因 近日"啃书"间偶然发现,我国精神卫生界两本权威的书--<精神病学>(江开达主编,8年制全国高等学校教材)与<精神病学>(沈渔邨主编,第四版)对精神科术语"双重人格"的解释有较大的分歧.     

Cost of care of patients with personality disorders in forensic psychiatric hospitals in the Netherlands

Background Ter beschikking stelling (TBS) clinics form the mainstay of forensic psychiatric services in the Netherlands. Their costs are rising, but little is known about how these costs are distributed. Aim To determine the distribution of service costs for patients with personality disorders in TBS medium security units in the Netherlands. Method Data on service use were extracted retrospectively from the case files of 55 people with personality disorder who are residents in six medium security units within two TBS centres during 2006 (De Rooyse Wissel and Pompestichting). Standard unit costs were obtained for each service, and multiplied by frequency of service use to obtain the total cost of service per patient. A modified version of the Secure Facilities Service Use Schedule was completed. Results The average daily cost of a bed in a TBS hospital in 2006 was 388 Euros (402 (SD 37) Euros in De Rooyse Wissel; 375 (SD 48) Euros in the Pompestichting). Over half of this was spent on non‐treatment fixed costs (overheads). There was considerable difference between patients and between unit variations in the other costs, but about one‐third went on costs of staying in department (sociotherapists), and less than 10% each on specific therapeutic interventions or daily activities. About 3% of the budget overall was spent on other costs, but, as these included escorted leaves, at times these costs accounted for a much higher proportion of the per patient expenditure. Conclusion Our results may provide a baseline measurement, with which future costs of TBS treatment can be compared as the services expand and develop. More attention to costs in this way may help to contain budget increases. New studies could examine more specific aspects of treatment or other specific patient groups. Copyright © 2009 John Wiley & Sons, Ltd.     

Sex distribution of DSM-III personality disorders in psychiatric outpatients

The author determined the sex distribution of 170 outpatients with a DSM-III diagnosis of personality disorder measured by standardized instruments and compared his findings with DSM-III predictions. They confirmed the prediction of more women diagnosed as having histrionic personality disorder and more men diagnosed as having paranoid, compulsive, and antisocial personality disorders. The predicted excess of women diagnosed as having borderline and dependent personality disorders was not confirmed.     

The prevalence of DSM-IV personality disorders in psychiatric outpatients

OBJECTIVE: The largest clinical epidemiological surveys of personality disorders have been based on unstructured clinical evaluations. However, several recent studies have questioned the accuracy and thoroughness of clinical diagnostic interviews; consequently, clinical epidemiological studies, like community-based studies, should be based on standardized evaluations. The Rhode Island Methods to Improve Diagnostic Assessment and Services project is one of the largest clinical epidemiological studies to use semistructured interviews to assess a wide range of psychiatric disorders conducted in general clinical outpatient practice. In the present report, the authors examined the frequency of DSM-IV personality disorders in a patient group and the comorbidity among them. METHOD: Eight hundred fifty-nine psychiatric outpatients were interviewed with the Structured Interview for DSM-IV Personality upon presentation for treatment. RESULTS: Slightly less than one-third of the patients were diagnosed with one of the 10 official DSM-IV personality disorders (N=270, 31.4%). When the patients with personality disorder not otherwise specified were included, the rate of any personality disorder increased to almost half of the group (N=391, 45.5%). The majority of patients meeting criteria for one of the specific personality disorders were diagnosed with more than one. Avoidant, borderline, and obsessive-compulsive personality disorder were the most frequent specific diagnoses. CONCLUSIONS: Personality disorders, as a group, are among the most frequent disorders treated by psychiatrists. They should be evaluated in all psychiatric patients because their presence can influence the course and treatment of the axis I disorder that patients typically identify as their chief complaint.     

Trait-state artifacts and the diagnosis of personality disorders

The multiaxial nature of DSM-III has stimulated interest in the personality disorders. There are also indications that it has produced an increase in their diagnosis. However, there is clinical and psychometric evidence that a personality evaluation undertaken while a patient is in a dysphoric mental state may distort or misrepresent traits, the so-called trait-state problem in personality assessment. The present study appears to be the first to investigate this phenomenon with a clinical interview rather than with personality tests. It examined the effect of anxiety, depression, and level of global impairment on the diagnosis of personality disorder and the assessment of the criteria for the individual Axis II disorders. Eighty-four patients, most of whom had current Axis I diagnoses, were evaluated by seven experienced clinicians with a new semistructured interview, the Personality Disorder Examination. The sample evidenced a trend toward acknowledging fewer maladaptive personality traits at follow-up than at entry. There was no evidence, however, that anxiety or depression had affected either the diagnosis of a personality disorder or the criteria associated with most of the individual personality disorders.     

Structured interviews and the diagnosis of personality disorders

Structured interviews were developed to improve the reliability of the diagnosis of personality disorders, as it has occurred in other areas of psychopathology. Several such interviews are described in this review, which draws together reports scattered across a wide literature. The appearance of structured interviews in Britain reflected the early interest there in the special problems associated with diagnosing personality disorders, whereas in America their development had to await publication of the DSM-III. Studies using these techniques have illustrated important aspects of clinical diagnosis and can be expected to assign value to the diagnosis of personality disorders in the future.     

Kleptomania: comorbid psychiatric diagnosis in patients and their families

OBJECTIVES: Kleptomania, defined by DSM-IV as the inability to resist the impulse to steal objects which are not needed for personal use or for their monetary value, may reflect a form of obsessive-compulsive spectrum disorder and/or affective spectrum disorder. METHODS: Twenty-one kleptomanic patients and 57 first-degree relatives completed a semistructured DSM-IV-based interview and questionnaires. Questionnaires are: the HDRS-17 (the Hamilton Rating Scale for Depression), the HARS (Hamilton Rating Scale for Anxiety), the Y-BOCS (Yale-Brown Obsessive Compulsive Scale), the YMRS (Young Mania Rating Scale). The two groups were compared to demographically matched normal controls (n = 64). RESULTS: We found a high prevalence of affective and anxiety disorders in our sample of kleptomanic patients and their first-degree relatives. In addition, the scores on the HDRS, HARS, and Y-BOCS were significantly higher in the study group than in the control group. CONCLUSIONS: Our finding of a high prevalence of psychiatric comorbidity in kleptomanic patients could lead to the development of new treatment strategies for this disorder. Furthermore, the pattern of psychiatric disorders seen in the first-degree relatives can lead to new insights about the nosology and etiopathology of kleptomania.     

Review of the american psychiatric publishing textbook of personality disorders

Reviews the book, The American Psychiatric Publishing Textbook of Personality Disorders edited by John M. Oldham, Andrew E. Skodol, and Donna S. Bender (see record 2005-05013-000). Definitive, encyclopedic, and somewhat daunting, The American Psychiatric Publishing Textbook of Personality Disorders is a monument to the progress of contemporary psychiatry and related disciplines in understanding and treating the Axis II disorders--as well as to its limitations. One may properly ask, how well does this volume succeed in providing guidance for professionals who work with individuals diagnosed with personality disorders? To a large degree, I believe it succeeds. With all its exciting insights into the impact of trauma, the interaction between genes, serotonin and impulsive behavior, and so forth, and with its occasional frustrations, the Textbook of Personality Disorders provides an accurate, in-depth depiction of a true frontier of psychiatry. (PsycINFO Database Record (c) 2010 APA, all rights reserved).     

Dimensions of personality structure among patients with substance use disorders and co-occurring personality disorders: A comparison with psychiatric outpatients and healthy controls

Background

Although dual diagnosis has been a topic of great scientific interest for a long time, few studies have investigated the personality traits that characterize patients suffering from substance use disorders and co-occurring personality disorders through a dimensional approach. The present study aimed to evaluate structural personality profiles among dual-diagnosis inpatients to identify specific personality impairments associated with dual diagnosis.

Methods

The present study involved 97 participants divided into three groups: 37 dual-diagnosis inpatients, 30 psychiatric outpatients and 30 nonclinical controls. Dimensions of personality functioning were assessed and differences between groups were tested using Kernberg's dimensional model of personality.

Results

Results showed that dual diagnosis was associated with the presence of difficulties in three main dimensions of personality functioning. Dual-diagnosis inpatients reported a poorly integrated identity with difficulties in the capacity to invest, poorly integrated moral values, and high levels of self-direct and other-direct aggression.

Conclusions

The present study highlighted that a dimensional approach to the study of dual diagnosis may clarify the personality functioning of patients suffering from this pathological condition. The use of the dimensional approach could help to advance research on dual diagnosis, and it could have important implications on clinical treatment programs for dual-diagnosis inpatients.     

Debate: Stigma implications for diagnosing personality disorders in adolescents

Diagnosing personality disorders (PDs) in adolescence is a complex and often controversial decision. While early diagnosis provides a pathway to treatment, stigmatizing labels might unintentionally increase prejudice and discrimination for youth and their families, resulting in harm and treatment avoidance. In this paper, we outline stigma-related considerations for diagnosing PDs in adolescence, including types of stigma (public stigma, self-stigma, associative stigma) and moderators of stigma (continuum beliefs, biogenetic attributions, PD sub-diagnosis). Research indicates that PDs are among the most stigmatizing diagnoses in adults, particularly among healthcare providers. Experiences with stigma may differentially impact adolescents, who are undergoing rapid changes in identity development and profound influences from educational systems, peers, and social media. Youth who receive mental health services (especially those embedded in schools) worry about whether and how to talk about a diagnosis. However, adolescents with significant behavioral symptoms are often seen as different from their peers even prior to a formal diagnosis. Systematic efforts are needed to anticipate and mitigate stigma-related impacts on adolescents who might be diagnosed with PDs.     

Subtyping of psychiatric disorders: implications for drug development

Psychiatric diagnosis suffers from being based on phenomenology and not on pathophysiology. Data are presented showing that psychiatric patients reveal consistent quantitative electroencephalographic abnormalities, such that they can be separated from normals and from each other. Clustering these pathophysiological groupings reveals an underlying variability, which permits useful subtyping. Data are presented relating subtyping to pharmacological treatment.     

Sleep disorders in patients with personality disorders

63 patients with personality disorders have been hospitalized in a Sleep Disorder Clinic. Sleep disorders usually started during childhood, disappeared ant the reappeared around the age of 25. The polysomnographic data do not show a specific profile. Most of the patients were of the schizotypal or the borderline type. Therapeutic guidelines are presented.     

Neurogenetic and experiential processes underlying major personality traits: implications for modelling personality disorders

Abstract The association of personality traits to personality disorders (PDs) is assumed by many to fit a dimensional model, where PDs emerge at the extremes of personality dimensions. Nevertheless, attempts to demonstrate such an association have been empirically disappointing and conceptually unilluminating. In this article we attempt to extend such models by outlining the neurobehavioural systems that underlie major personality traits, and highlight the evidence that they are subject to experience-dependent modification that can be enduring through effects on genetic expression, mainly through processes known as epigenetics. It is through such processes that risk for personality disorder may be modified by experience at any point in development, but perhaps especially during early critical periods of development. We conclude by presenting a novel multidimensional model of PDs that relies on the concepts developed earlier in the article. Our goal is to provide a guide for research on the psychobiological nature and pharmacological treatment of PDs.