抑郁障碍与人格障碍的共病研究

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

A Comparative Study on Alexithymia in Depressive,Somatoform, Anxiety,and Psychotic Disorders among Koreans

Objective

Little is known about the characteristic differences in alexithymic construct in various psychiatric disorders because of a paucity of direct comparisons between psychiatric disorders. Therefore, this study explored disorder-related differences in alexithymic characteristics among Korean patients diagnosed with four major psychiatric disorders (n=388).

Methods

Alexithymic tendencies, as measured by the Korean version of the 20-item Toronto Alexithymia Scale (TAS-20K), of patients classified into four groups according to major psychiatric diagnosis were compared. The groups consisted of patients with depressive disorders (DP; n=125), somatoform disorders (SM; n=78), anxiety disorders (AX; n=117), and psychotic disorders (PS; n=68).

Results

We found that substantial portions of patients in all groups were classified as having alexithymia and no statistical intergroup differences emerged (42.4%, 35.9%, 35.3%, and 33.3% for DP, SM, PS, and AX). However, patients with DP obtained higher scores in factor 2 (difficulties describing feelings) than those with SM or AX, after adjusting for demographic variables.

Conclusion

These findings suggest that alexithymia might be associated with a higher vulnerability to depressive disorders and factor 2 of TAS-20K could be a discriminating feature of depressive disorders.     

Delusional versus nondelusional body dysmorphic disorder: clinical features and course of illness

DSM-IV's classification of body dysmorphic disorder (BDD) is controversial. Whereas BDD is classified as a somatoform disorder, its delusional variant is classified as a psychotic disorder. However, the relationship between these BDD variants has received little investigation. In this study, we compared BDD's delusional and nondelusional variants in 191 subjects using reliable and valid measures that assessed a variety of domains. Subjects with delusional BDD were similar to those with nondelusional BDD in terms of most variables, including most demographic features, BDD characteristics, most measures of functional impairment and quality of life, comorbidity, and family history. Delusional and nondelusional subjects also had a similar probability of remitting from BDD over 1 year of prospective follow-up. However, delusional subjects had significantly lower educational attainment, were more likely to have attempted suicide, had poorer social functioning on several measures, were more likely to have drug abuse or dependence, were less likely to currently be receiving mental health treatment, and had more severe BDD symptoms. However, when controlling for BDD symptom severity, the two groups differed only in terms of educational attainment. These findings indicate that BDD's delusional and nondelusional forms have many more similarities than differences, although on several measures delusional subjects evidenced greater morbidity, which appeared accounted for by their more severe BDD symptoms. Thus, these findings offer some support for the hypothesis that these two BDD variants may constitute the same disorder. Additional studies are needed to examine this issue, which may have relevance for other disorders with both delusional and nondelusional variants in DSM.     

Clinical characteristics of unipolar disorder and bipolar disorder according to the lifetime presence of recurrent panic attacks

Objectives:  The frequent comorbidity of panic and affective disorders has been described in previous studies. However, it is not clear how panic disorder comorbidity in unipolar disorder and bipolar disorder is related to illness course.
Methods:  We compared lifetime clinical characteristics of illness and items of symptomatology in samples of individuals with bipolar I disorder (n = 290) and unipolar disorder (n = 335) according to the lifetime presence of recurrent panic attacks.
Results:  We found significant differences in clinical course of illness characteristics that were shared across the unipolar and bipolar samples according to the lifetime presence of panic attacks. We also found a number of differences according to the presence of panic attacks that may be specific to the diagnostic group.
Conclusions:  Distinguishing patients who have mood disorder diagnoses, especially bipolar I disorder, according to the lifetime presence of panic attacks may not only be of use in clinical practice, but may also be informative for aetiological research, such as molecular genetic studies.     

Posttraumatic stress disorder and substance use disorder in adolescent bipolar disorder

Objective: Anxiety disorders such as posttraumatic stress disorder (PTSD) and substance use disorders (SUD) are increasingly recognized as comorbid disorders in children with bipolar disorder (BPD). This study explores the relationship between BPD, PTSD, and SUD in a cohort of BPD and non‐BPD adolescents. Methods: We studied 105 adolescents with BPD and 98 non‐mood‐disordered adolescent controls. Psychiatric assessments were made using the Kiddie Schedule for Affective Disorders and Schizophrenia–Epidemiologic Version (KSADS‐E), or Structured Clinical Interview for DSM‐IV (SCID) if 18 years or older. SUD was assessed by KSADS Substance Use module for subjects under 18 years, or SCID module for SUD if age 18 or older. Results: Nine (8%) BPD subjects endorsed PTSD and nine (8%) BPD subjects endorsed subthreshold PTSD compared to one (1%) control subject endorsing full PTSD and two (2%) controls endorsing subthreshold PTSD. Within BPD subjects endorsing PTSD, seven (39%) met criteria for SUD. Significantly more SUD was reported with full PTSD than with subthreshold PTSD (χ² = 5.58, p = 0.02) or no PTSD (χ² = 6.45, p = 0.01). Within SUD, the order of onset was BPD, PTSD, and SUD in three cases, while in two cases the order was PTSD, BPD, SUD. The remaining two cases experienced coincident onset of BPD and SUD, which then led to trauma, after which they developed PTSD and worsening SUD. Conclusion: An increased rate of PTSD was found in adolescents with BPD. Subjects with both PTSD and BPD developed significantly more subsequent SUD, with BPD, PTSD, then SUD being the most common order of onset. Follow‐up studies need to be conducted to elucidate the course and causal relationship of BPD, PTSD and SUD.     

Prevalence of Axis II Comorbidity in Bipolar Patients with and Without Alcohol Use Disorders

Objective: This study sought to determine the prevalence of comorbid personality disorder in euthymic bipolar I patients. Method: Sixty-one outpatients were assessed using the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID II) and/or the Personality Diagnostic Questionnaire-Revised (PDQ-R). Results: Thirty-eight percent of bipolar patients met criteria for an Axis II diagnosis based on the SCID II. Bipolar subjects with a history of comorbid alcohol use disorder were significantly more likely to have a SCID II diagnosis (52%) compared to those bipolar subjects without an alcohol use disorder history (24%). Cluster A diagnoses were significantly more common in the bipolar/alcohol use disorder group. The PDQ-R consistently overdiagnosed Axis II disorders, finding 62% of the overall bipolar group to have an Axis II diagnosis. Conclusions: Euthymic bipolar patients may have an increased rate of personality disorders, but much less so than previously reported in studies that did not take into account (1) current mood state, (2) comorbidity for an alcohol use disorder, and (3) instrument used for assessment of Axis II psychopathology.     

Oppositional Defiant and Conduct Disorder Behaviors in Boys With Autism Spectrum Disorder With and Without Attention-Deficit Hyperactivity Disorder Versus Several Comparison Samples

We compared disruptive behaviors in boys with either autism spectrum disorder (ASD) plus ADHD (n = 74), chronic multiple tic disorder plus ADHD (n = 47), ADHD Only (n = 59), or ASD Only (n = 107). Children were evaluated with parent and teacher versions of the Child Symptom Inventory-4 including parent- (n = 168) and teacher-rated (n = 173) community controls. Parents rated children in the three ADHD groups comparably for each symptom of oppositional defiant disorder (ODD) and conduct disorder. Teacher ratings indicated that the ASD + ADHD group evidenced a unique pattern of ODD symptom severity, differentiating them from the other ADHD groups, and from the ASD Only group. The clinical features of ASD appear to influence co-morbid, DSM-IV-defined ODD, with implications for nosology.     

双相障碍共病强迫症的临床特征与治疗

本文目的是对双相障碍共病强迫症的临床特征与治疗进行综述,以期为临床早期识别和干预提供参考.双相障碍共病强迫症的临床现象并不少见,但两者的治疗原则存在差异甚至互斥,导致治疗困境.本文就双相障碍共病强迫症的流行病学特征、临床特征及治疗进行探讨.     

Personality and personality disorders among patients with major depression in combination with dysthymic or cyclothymic disorders

Personality traits and personality disorders in 298 consecutive outpatients with pure major depression, major depression with dysthymic or cyclothymic disorder, pure dysthymic or cyclothymic disorder and other disorders were investigated. Patients with dysthymic or cyclothymic disorders alone or in combination with major depression showed more self-doubt, insecurity, sensitivity, compliance, rigidity and emotional instability. They were more schizoid, schizotypal, borderline and avoidant according to MCMI and had a higher prevalence of DSM-III Axis II diagnoses, and more borderline, avoidant, and passive-aggressive personality disorders, as measured by SIDP. All in all, dramatic and anxious clusters of personality disorders were more frequent among patients with dysthymic-cyclothymic disorders in addition to major depression than among patients with major depression only. The findings elucidated the close connection between the more chronic affective disorders and the personality disorders, irrespective of any concomitant diagnosis of major depression.     

Childhood and current autistic features in adolescents with schizotypal personality disorder

The diagnostic boundaries between autistic- and schizophrenia-spectrum disorders have varied over the years, and some overlap in diagnostic criteria persists. The present study examined childhood and current signs of autistic disorder (AD) in adolescents with schizotypal personality disorder (SPD) or other personality disorders, as well as healthy controls. A structured interview was administered to rate participants' current symptoms. Participants' guardians were interviewed with the Autism Diagnostic Inventory-Revised (ADI-R), a clinical assessment of childhood and current autistic signs. Compared to both the other personality-disordered and healthy groups, adolescents with SPD were rated as having significantly more impairment on childhood and current social functioning, and having more unusual interests and behaviors. For the entire sample, impaired childhood social functioning and unusual interests and behaviors were associated with higher negative symptom scores. Current impairments in social functioning, unusual interests and behaviors, and communication were also linked with greater negative symptoms. However, neither childhood nor current autistic features significantly predicted later conversion to an Axis I psychotic disorder over the course of three years of follow-up. The findings indicate that past and current autistic signs are more common in adolescents with SPD, but neither current nor childhood autistic features are linked with conversion to psychosis.     

Bipolar disorder in young people: Description,assessment and evidence-based treatment

Objective: The literature on bipolar in children and adolescents was reviewed to provide an update for clinicians.

Review process: Literature of particular relevance to evidence-based practice was selected for critical review.

Outcomes: An up-to-date overview of clinical features, epidemiology, prognosis, aetiology, assessment and intervention was provided.

Conclusions: Bipolar disorder in children and adolescence is a relatively common, multifactorially determined and recurring problem which persists into adulthood. Psychometrically robust screening questionnaires and structured interviews facilitate reliable assessment. Multimodal chronic care programmes involving medication (notably lithium) and family-oriented psychotherapy are currently the treatment of choice.     

Differential contextual factors of comorbid conduct and depressive disorders in Spanish children

AbstractObjective The aim of this study was to clarify the validity of the mixed conduct/depressive disorder in young people to justify its place in ICD-10 by examining a wide range of risk factors, school performance and other contextual variables.Method Data on risk factors and other school and family variables were compared between 66 referred children with depressive disorders without conduct disorder, 135 with conduct or oppositional defiant disorder without depressive disorders, and 90 with both. Data were obtained through structured diagnostic interviews with parents and children and questionnaires.Results Marked differences emerged between depressive and comorbid groups in rearing style, school and friends. Comorbid conduct-depression and pure conduct disorders share similar contextual factors; the differences are larger in school, where the pure conduct group has more difficulties.Conclusions Based on contextual factors, pure depression is different from conduct-depressive disorder, but pure conduct disorder is similar to the comorbid condition. The results have implications for nosology and treatment of these disorders.     

双相障碍与强迫症的共病

概述

在双相障碍患者中强迫症状是常见的。因为双相障碍和强迫症的共病状态会令这两种障碍的临床治疗复杂化，所以确定这些共病的患者是很重要的。我们讨论了强迫症和双相障碍的共病，介绍了可能导致这种常见共病状态的发病机制，也讨论了该领域最新的研究进展，并提出一些管理这些患者的临床原则。

中文全文

本文全文中文版从2015年10月26日起在http://dx.doi.org/10.11919/j.issn.1002-0829.215009可供免费阅览下载 Previous studies have documented high rates of comorbidity of other psychiatric conditions among individuals with bipolar disorders (BD).[1] One study estimated that obsessive-compulsive disorders (OCD) accounted for 21% of all comorbidities in BD.[2] There is continuing debate about whether (a) these are two independent conditions that can co-occur or (b) OCD is a specific subtype of BD. Regardless of the interrelationship of the two conditions, the comorbid occurrence of these two types of symptoms can cause a clinical dilemma because selective serotonin reuptake inhibitors (SSRIs)-which are quite commonly used to treat OCD-increases the risk of precipitating manic symptoms.[3,4,5,6] The OCD symptoms that occur in individuals with BD often occur during the depressive episodes or during the intervals between episodes of depressive or manic symptoms.[7,8] This timing of OCD symptoms during BD is consistent with the cyclic nature of BD and suggests shared biological mechanisms between the two disorders. In support of this hypothesis, a study using Positron Emission Tomography (PET) found that in untreated persons with BD the serotonin-transporter binding potential in the insular and dorsal cingulate cortex was higher among BD patients with pathological obsessions and compulsions than among BD patients without such symptoms.[9] Moreover, a linkage study found that compared to OCD patients without comorbid BD, patients with comorbid OCD and BD were more likely to have a family history of mood disorders but less likely to have a family history of OCD.[10] However, another study found no significant difference in the rates of a positive family history of OCD between patients with OCD alone and those with comorbid OCD and BD.[11] Further support for the hypothesized common etiology comes from a preliminary molecular genetic study which found that hyperpolarization activated cyclic nucleotide-gated channel 4 (HCN4) is a common susceptible locus for both mood disorders and OCD, but further studies with larger sample sizes are needed to replicate this finding.[12] The presence of OCD in BD complicates the clinical presentation. Compared to patients with BD without comorbid OCD, those that have comorbid BD and OCD often have a more severe form of BD, have more prolonged episodes, are less adherent to medication, and are less responsive to medication. Recent studies about comorbid BD and OCD have reported the following: (a) Temporal relationship. Some studies suggest that OCD is an antecedent of BD,[10] but others report concurrent onset of OCD and BD.[13,14] (b) Course of disease. In 44% of patients with comorbid BD and OCD the episodes are cyclic.[15] The course of disease is more chronic among BD patients with OCD compared to those without comorbid OCD.[16,17] OCD is more commonly observed in patients with Type II BD, among whom the prevalence of OCD has been reported to be as high as 75%.[18] (c) Compulsive behaviors. The most commonly reported compulsions among patients with comorbid OCD and BD are compulsive sorting,[14,19,20,21] controlling or checking, [20] repeating behaviors,[13,22] excessive washing,[20] and counting.[19] Obsessive reassurance-seeking is also commonly reported in these patients.[23] In children and adolescents with BD, compulsive hoarding, impulsiveness,[24] and sorting[25] are more common. (d) Substance and alcohol abuse. A study found a higher prevalence of sedative, nicotine, alcohol, and caffeine use among individuals with comorbid OCD and BD compared to those with BD without OCD.[14] Similarly, compared to OCD patients without comorbid mood disorders, those with a comorbid mood disorder were more likely to have a substance abuse diagnosis (OR=3.18, 95%CI=1.81-5.58) or alcohol abuse diagnosis (OR=2.21, 95%CI=1.34-3.65).[11,13,26,27,28] (e) Suicidal behaviors. Compared to BD patients without OCD, a greater proportion of patients with both disorders had a lifetime history of suicidal ideation and suicide attempts.[2,11,13,29,30] The clinical management of comorbid OCD and BD requires first focusing on stabilizing the patient’s mood, which requires the combined use of multiple medications such as the use of lithium with anticonvulsants or atypical antipsychotic medications such as quetiapine;[31,32,33] adjunctive treatment with aripiprazole may be effective for the comorbid OCD symptoms.[4] In the case of OCD comorbid with type II BD, after full treatment of the mood symptoms with mood stabilizers the clinician can, while monitoring for potential drug interactions, cautiously try adjunctive treatment with antidepressants that are effective for both depressive symptoms and OCD symptoms and that have a low risk of inducing a full manic episode, including the selective serotonin reuptake inhibitors (SSRIs): fluoxetine, fluvoxamine, paroxetine, and sertraline.[32,35] In summary, BD comorbid with OCD may be etiologically distinct from either of the disorders. Clinicians should pay attention to its complex clinical manifestations and carefully consider the treatment principles outlined above.     

重性抑郁障碍或双相障碍患者抑郁发作伴随躁狂症状的临床特征

目的:了解重性抑郁障碍(MDD)或双相障碍抑郁发作患者出现躁狂症状的频率和程度。方法:对52例经简明国际神经精神访谈(MINI)、符合《美国精神障碍诊断与统计手册》第4版(DSMIV)重性抑郁障碍或双相障碍抑郁发作的患者,采用情感障碍评估量表(ADE)评估患者本次抑郁发作中出现的躁狂症状。结果:52例患者中有36例重性抑郁障碍,16例为双相障碍抑郁发作。至少有1条躁狂症状的患者达86.5%(n=45),至少有3条躁狂症状的患者占32.7%(n=17),而没有任何躁狂症状的患者仅占13.5%(n=7)。结论:抑郁发作患者大多存在不同程度的躁狂症状,及时识别这些症状,对诊断与治疗有指导意义。情感障碍评估量表是一个值得应用的评估情感发作的工具。     

Dissociative disorders among adults in the community, impaired functioning, and axis I and II comorbidity

OBJECTIVE: To investigate the association of dissociative disorder (DD) with impaired functioning and co-occurring Axis I and personality disorders among adults in the community. METHOD: Psychiatric interviews were administered to a sample of 658 adult participants in the Children in the Community Study, a community-based longitudinal study. RESULTS: Depersonalization disorder (prevalence: 0.8%), dissociative amnesia (prevalence: 1.8%), dissociative identity disorder (prevalence: 1.5%), and dissociative disorder not otherwise specified (prevalence: 4.4%), evident within the past year, were each associated with impaired functioning, as assessed by the clinician-administered Global Assessment of Functioning Scale. These associations remained significant after controlling for age, sex, and co-occurring disorders. Individuals with anxiety, mood, and personality disorders were significantly more likely than individuals without these disorders were to have DD, after the covariates were controlled. Individuals with Cluster A (DD prevalence: 58%), B (DD prevalence: 68%), and C (DD prevalence: 37%) personality disorders were substantially more likely than those without personality disorders were to have DD. CONCLUSIONS: DD is associated with clinically significant impairment among adults in the community. DD may be particularly prevalent among individuals with personality disorders.     

Comorbid Anxiety in Bipolar Disorder Alters Treatment and Prognosis

Mood disorders in general, and bipolar disorder in particular, are unique among the psychiatric conditions in that they are associated with extraordinarily high rates of comorbidity with a multitude of psychiatric and medical conditions. Among all the potential comorbidities, co-occurring anxiety disorders stand out due to their very high prevalence. Outcome in bipolar illness is worse in the presence of a comorbid anxiety disorder. The coexistence of an anxiety disorder presents a particularly difficult challenge in the treatment of bipolar illness since antidepressants, the mainstay of pharmacologic treatments for anxiety, may adversely alter the course of manic-depression. Identification of anxiety disorders in bipolar patients is important. The treatment plan needs to balance the potential benefit and harm of antidepressant administration.     

Psychogenic nonepileptic seizures: answers and questions

Psychogenic nonepileptic seizures (PNES) superficially resemble epileptic seizures, but are not associated with ictal electrical discharges in the brain. PNES constitute one of the most important differential diagnoses of epilepsy. However, despite the fact they have been recognized as a distinctive clinical phenomenon for centuries and that access to video/EEG monitoring has allowed clinicians to make near-certain diagnoses for several decades, our understanding of the etiology, underlying mental processes, and, subsequently, subdifferentiation, nosology, and treatment remains seriously deficient. Emphasizing the clinical picture throughout, the first part of this article is intended to "look and look again" at what we know about the epidemiology, semiology, clinical context, treatment, and prognosis of PNES. The second part is dedicated to the questions that remain to be answered. It argues that the most important reason our understanding of PNES remains limited is the focus on the visible manifestations of PNES or the seizures themselves. In contrast, subjective seizure manifestations and the biographic or clinical context in which they occur have been relatively neglected.     

The Netherlands Mental Health Survey and Incidence Study‐2 (NEMESIS‐2): design and methods

The psychiatric epidemiological population study NEMESIS‐2 (Netherlands Mental Health Survey and Incidence Study‐2) replicates and expands the first Netherlands Mental Health Survey and Incidence Study (NEMESIS‐1) conducted from 1996 to 1999. The main objectives of the new study are to provide up‐to‐date figures on the prevalence, incidence, course and consequences of mental disorders, and to study trends in mental disorders and service use, with the use of a new sample. New topics not included in NEMESIS‐1 were added, e.g. impulse‐control disorders, and genetic correlates of mental disorders through gathering DNA from saliva samples. This paper gives an overview of the design of NEMESIS‐2, especially of its recently completed first wave. NEMESIS‐2 is a prospective study among Dutch‐speaking subjects aged 18–64 years from the general Dutch population. Its baseline wave included 6646 subjects. Three waves are planned with three year‐intervals between the waves. A multistage, stratified random sampling procedure was applied. The baseline wave of NEMESIS‐2 was performed between November 2007 and July 2009. Face‐to‐face interviews were administered with the Composite International Diagnostic Interview (CIDI) 3.0. The response rate was 65.1%, and 76.4% of the respondents donated saliva. The sample was reasonably nationally representative, but younger subjects were somewhat underrepresented. In conclusion, we were able to build a comprehensive dataset of good quality, permitting several topics to be studied in the future. Copyright © 2010 John Wiley & Sons, Ltd.     

Affective and schizoaffective mixed states

Abstract. Although both DSM-IV and ICD-10 define schizoaffective mixed states, they have not received much attention—neither in the clinical nor in research context. We present preliminary results of a prospective study of bipolar affective (n = 100) and bipolar schizoaffective (n = 177) patients. 25% of the bipolar affective and 32% of the bipolar schizoaffective patients had at least one (schizo)mixed episode during the illness course. Nevertheless, (schizo)mixed episodes were rare—only 5.6% of all episodes. There was a trend that patients with (schizo)mixed episodes were more often women and exhibited more disability (reflected by higher rates of disability payments). Nevertheless, these differences failed to reach significance. Overall, schizo-mixed episodes are as frequent as pure affective mixed episodes. They might be linked to a less favourable course. Nevertheless, while their diagnostic criteria are problematic, they are systematically underdiagnosed.     

Comparisons of insight in schizophrenia,bipolar I disorder,and depressive disorders with and without comorbid alcohol use disorder

Aims: To compare the level of insight among six groups of patients with psychiatric disorders, including those with schizophrenia (SZ), bipolar I disorder (BP), or depressive disorders (DD) who had or did not have comorbid alcohol use disorder (AUD). Methods: A total of 285 outpatients meeting the aforementioned criteria were recruited into the study. The Schedule of Assessment of Insight–Expanded version (SAI‐E) was used to measure subjects' insight. Analysis of covariance (ancova ) was used to compare the levels of insight among the six groups of subjects. Results: Regardless of whether patients had comorbid AUD or not, patients with DD had higher levels of insight than did patients with SZ. Comorbid AUD had independent effects on the differences in the level of insight between patients with DD and BP and between patients with BP and SZ. No statistically significant difference in insight was found between patients with the same psychiatric diagnosis with and without comorbid AUD. Conclusions: In addition to psychotic features and clinical states, comorbid AUD should be taken into consideration when comparing the level of insight among patients with different psychiatric diagnoses.