Benzodiazepine use by women prisoners: Association with personality disorder and behavioural dyscontrol

Benzodiazepine use is common in women prisoners and causes considerable concern to prison authorities. This article outlines some of the factors involved in benzodiazepine use and dependence, and presents results from a pilot study on benzodiazepine use/abuse in women prisoners. The doses used and the frequency of paradoxical effects are highlighted. The results suggest that particular personality types may be more at risk of such effects. Further study is needed to determine whether benzodiazepine use plays a role in offending behaviour. It is suggested that the medical profession should pay greater attention to prescribing practice in this area.     

A behavioral comparison of female adolescent inpatients with and without borderline personality disorder

Patients with borderline personality disorder (BPD) are thought to have problematic hospitalizations. This study seeks to examine this phenomenon in adolescence by documenting the specific problem behaviors exhibited by patients, and the staff interventions in response to these behaviors in patients with and without BPD. Data were collected from the charts of 81 hospitalized adolescent girls regarding restraints, seclusions, incidents of self-abuse and aggression, incidents of signing the intent-to-leave form, nonroutine drug and/or alcohol screens, and discharges against medical advice. The two groups were compared using the analysis of variance (ANOVA) statistic for continuous variables and the chi-square statistic for the categorical variable. A follow-up multivariate ANOVA (MANOVA) was performed using the length of stay as a covariate. The BPD group displayed significantly higher rates of certain behaviors per day, but not of others. The length of stay was significantly higher in the BPD group. Further analysis indicated that some of the behavioral differences between the two groups may be due to the effect of the difference in length of stay. The data also suggest that while most BPD patients behave similarly to other patients, there may be a subset of BPD patients who behave in an extreme manner while hospitalized. BPD patients may display more of certain problematic behaviors than non-BPD patients in the hospital. However, it is hypothesized that these differences in hospital behavior may be largely due to the different lengths of stay between the two groups or to an acting-out subgroup of BPD patients.     

The psychological treatment of personality disorder.

The author presents three case reports of individuals with personality disorder, none of whom demonstrated significant ability for transitional relatedness before therapy. In therapy, he conceptualized for the two adult patients the importance of their inability to experience in the transitional mode; he offered concrete potential transitional objects to the one child patient. The therapeutic results were good.     

Characteristics of offenders referred to a medium secure NHS personality disorder service: the first five years

Background As new services for offenders with personality disorder emerge in the UK, there is interest in the methods of assessments and characteristics of patients admitted. Aim To evaluate use of selection criteria for admission to a dedicated personality disorder service within medium secure hospital provision in the UK, and to test for features that discriminate between those admitted and those rejected. Method A structured multidisciplinary assessment was administered to offenders referred to a new personality disorder service in a medium secure psychiatric unit. The evaluation included self‐report and observer ratings across a range of domains including categorical axis I disorders and axis II disorders, dimensional assessment of personality and ratings of intellect and risk. Results Sixty‐eight male offenders were assessed, of whom 47 were offered admission. No differences were found between those accepted or rejected on demographic, offence and most clinical characteristics. Axis I comorbidity was high in both groups (over 90%). There was no indication of staff overriding exclusion criteria but men who were accepted had greater extraversion and conscientiousness on the NEO‐FFI. Conclusion Staff screening men for suitability for admission to this new specialist medium security hospital unit stayed true to given exclusion criteria in their decision not to offer a bed. Characteristics with face value as qualities necessary for engagement in treatments appeared to influence positive choices. Next steps will be to test the validity of choice with outcome studies. Copyright © 2007 John Wiley & Sons, Ltd.     

A comparison of male and female adolescents referred to an eating disorder program.

OBJECTIVE: To compare gender-related psychopathology and psychiatric diagnoses in male and female adolescents referred to an adolescent eating disorder program. METHOD: All adolescents presenting at the Eating Disorder Program at our hospital completed the semistructured Diagnostic Interview for Children and Adolescents-Revised (DICA-R) and self-report scales, including the Children's Depression Inventory (CDI), the Brief Symptom Inventory (BSI), the Eating Disorder Inventory (EDI-2), and the Family Assessment Measure (FAM-III), during their initial assessment. The 157 subjects (21 male, 136 female) were classified into Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) eating disorder (ED) subtypes and then recombined into male and female restricters (R) and ED-related groups: showing eating-related concerns but not having a DSM-IV diagnosis. We compared the male and female restricter groups and ED-related group on 5 specific psychological dimensions to examine comorbid psychiatric diagnosis, ED-specific and nonspecific psychopathology, EDI clinical and provisional subscales, and family functioning using multivariate analyses of covariance (MANCOVAs). RESULTS: Males endorsed statistically significant lower drive for thinness and body dissatisfaction than did females. However, there are no representative norms for adolescent males on these variables. The ED-related group also endorsed statistically significant lower drive for thinness and body dissatisfaction (specific ED psychopathology) than did the ED-restricter groups. The males in both groups endorsed fewer EDI items than did their female counterparts, but the differences were not statistically significant. Comorbid psychiatric diagnoses of depression and anxiety in male and female restricters were common but did not distinguish the groups. CONCLUSIONS: Our results suggest that male and female adolescents with EDs are clinically similar to each other and therefore resemble adults for lack of gender-specific effects on self-reported psychopathology, family functioning, and comorbid psychiatric disorders.     

SSRI treatment of borderline personality disorder: a randomized,placebo-controlled clinical trial for female patients with borderline personality disorder

OBJECTIVE: Selective serotonin reuptake inhibitors (SSRIs) are recommended for treatment of affect lability, impulsivity, and aggression in patients with borderline personality disorder. This recommendation is based on positive findings in at least 10 open studies and one small double-blind study of SSRIs for patients with borderline personality disorder and one study of impulsive aggressive patients with different personality disorders. A randomized, placebo-controlled SSRI study with borderline personality disorder patients, however, provided inconclusive results because of a large response to placebo. It was, therefore, decided to conduct a new randomized trial with a larger study group. METHOD: A double-blind, placebo-controlled, randomized trial using the SSRI fluvoxamine for 6 weeks followed by a blind half-crossover for 6 weeks and an open follow-up for another 12 weeks was conducted with 38 nonschizophrenic, nonbipolar female patients with borderline personality disorder. The outcome measures were the rapid mood shift, impulsivity, and aggression subscales from the Borderline Personality Disorder Severity Index. RESULTS: Fluvoxamine but not placebo produced a robust and long-lasting reduction in the scores on the subscale for rapid mood shifts. In contrast, no difference between the fluvoxamine and placebo groups was observed in the effect on the impulsivity and aggression scores. CONCLUSIONS: In this study, fluvoxamine significantly improved rapid mood shifts in female borderline patients, but not impulsivity and aggression. This latter finding may be due to gender-specific differences in impulsivity and aggression.     

Pilot study of treatment for major depression among women prisoners with substance use disorder

This study, the largest randomized controlled trial of treatment for major depressive disorder (MDD) in an incarcerated population to date, wave-randomized 38 incarcerated women (6 waves) with MDD who were attending prison substance use treatment to adjunctive group interpersonal psychotherapy (IPT) for MDD or to an attention-matched control condition. Intent-to-treat analyses found that IPT participants had significantly lower depressive symptoms at the end of 8 weeks of in-prison treatment than did control participants. Control participants improved later, after prison release. IPT's rapid effect on MDD within prison may reduce serious in-prison consequences of MDD.     

Cluster A personality pathology in social anxiety disorder: A comparison with panic disorder

Abstract

Background: Social anxiety disorder (SAD) has been associated with cluster A personality disorder (PD) traits, mainly paranoid and schizoid traits. Aim: The aim of the study was to further investigate cluster A personality pathology in patients with SAD. Methods: Self-reported PD traits were investigated in a clinical sample of 161 participants with SAD and in a clinical comparison group of 145 participants with panic disorder with or without agoraphobia (PAD). Results: A diagnosis of SAD was associated with more paranoid and schizotypal PD traits, and an association between depression and personality pathology could indicate a state-effect of depression on PD traits. Conclusions: Patients with SAD had more cluster A personality pathology than patients with PAD, with the most solid indication for paranoid personality pathology.     

Screening for personality disorder: a comparison of personality disorder assessment by patient and informants

The Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II Version 2.0) is becoming the most favoured instrument to measure personality disorder but takes up to an hour to complete. The Standardized Assessment of Personality (SAP), an informant-based measure, takes 10 to 15 minutes to complete. Both instruments have been validated independently. This study aimed to determine whether the SAP is a suitable screening instrument for personality disorder as measured by the SCID-II. Fifty-seven psychiatric patients were assessed for personality disorder using both the SAP and the SCID-II. The SAP assessments were conducted blind to the results of the SCID-II assessments. Agreement between the two instruments in this population was low (kappa = 0.3). The level of agreement differed between personality disorder categories, ranging from kappa = 0.4 (antisocial) to 0.1 (narcissistic). In this population of patients, the SAP proved to be a poor screen for the SCID-II. The study highlights the discrepancy between informant and self-report assessments for personality disorder.     

A comparison of UK and US guidelines for drug treatment in borderline personality disorder

The UK and USA differ considerably in their guidance regarding the use of drug treatment for borderline personality disorder, but generally agree over the use of psychological treatment. The 2009 UK guidelines from the National Institute for Health and Clinical Excellence (NICE) do not recommend any form of drug treatment except in a crisis with the intention of ceasing such treatment shortly afterwards. The US guidelines from the American Psychiatric Association (APA), published in 2001, are much more positive and suggest that there is a place for selective serotonin reuptake inhibitors (SSRIs), mood stabilizers and antipsychotic drugs as adjunctive treatments in borderline personality disorder. The guidelines are summarized and two main reasons for the differences identified. First, the separation of the borderline personality group into those with 'affective dysregulation', 'impulsive behaviour dyscontrol' and 'cognitive-perceptual' symptoms in the US guidelines was felt by the guideline development group for the NICE guideline to be a post hoc classification not supported by any other evidence. Second, the threshold of evidence necessary for making recommendations was much higher for the UK than the US guideline. Both guidelines recognize that we need more substantial trials, preferably independent of the pharmaceutical industry, before we can have any real confidence in our recommendations.     

A comparison of UK and US guidelines for drug treatment in borderline personality disorder

Abstract

The UK and USA differ considerably in their guidance regarding the use of drug treatment for borderline personality disorder, but generally agree over the use of psychological treatment. The 2009 UK guidelines from the National Institute for Health and Clinical Excellence (NICE) do not recommend any form of drug treatment except in a crisis with the intention of ceasing such treatment shortly afterwards. The US guidelines from the American Psychiatric Association (APA), published in 2001, are much more positive and suggest that there is a place for selective serotonin reuptake inhibitors (SSRIs), mood stabilizers and antipsychotic drugs as adjunctive treatments in borderline personality disorder. The guidelines are summarized and two main reasons for the differences identified. First, the separation of the borderline personality group into those with ‘affective dysregulation’, ‘impulsive behaviour dyscontrol’ and ‘cognitive–perceptual’ symptoms in the US guidelines was felt by the guideline development group for the NICE guideline to be a post hoc classification not supported by any other evidence. Second, the threshold of evidence necessary for making recommendations was much higher for the UK than the US guideline. Both guidelines recognize that we need more substantial trials, preferably independent of the pharmaceutical industry, before we can have any real confidence in our recommendations.     

Narcissistic personality disorder. A validity study and comparison to borderline personality disorder

Seventeen former inpatients with NPD were retrospectively compared to 19 patients with schizophrenia, 26 with MAD and 33 patients with BPD in terms of longitudinal course and outcome, exploring the validity of the NPD diagnosis. Two illustrative cases were presented. Results suggest that NPD is a valid diagnostic entity, more distinct from schizophrenia than MAD. NPD probably differs from BPD in terms of equal sex distribution in NPD; poor social functioning, especially in the low level of satisfaction with heterosexual relationships in NPD at follow-up; more rehospitalization in NPD; probably poorer global functioning in NPD at admission; and probably poorer overall follow-up functioning in NPD.     

A comparison of self-concept and personality disorders in women with pain accounted for by psychological factors, women with major depression, and healthy controls

OBJECTIVE: Do patients with pain accounted for by psychological factors (P) differ in their self-concept and personality disorders from patients with major depression (D) and healthy controls (C)? METHOD: Thirty hospitalized P-patients (DSM-IV, 307.80) and 30 hospitalized D-Patients (DSM-III-R) were given the Beck Depression Inventory on admission (BDI-1) and at discharge (BDI-2). Together with BDI-2, patients filled out the Personality Disorder Questionnaire for DSM-III-R (PDQR) and the Frankfurt Self-Concept Scales (FSKN). Thirty-two healthy comparisons (C) completed the same questionnaires. RESULTS: BDI-2 showed no significant differences between groups P and D, a prerequisite for the comparison of psychological traits. PDQR differed in the three groups. D showed more dependent, obsessive-compulsive, and histrionic personality features than group P. The three groups differed in FSKN total score and all 10 subscales (C (healthiest self-concept) > P > D). Groups P and D were different (P > D) in total score and subscales: performance, problem coping, confidence in behavior and decision taking, and self-esteem. Ten P-patients with pathological BDI-2 (P(D)) had significantly more disturbed PDQR and FSKN scores than the non-depressed (P(ND)), and closely resembled the D-patients. CONCLUSIONS: Personality disorders and self-concept are not homogenous in female patients with P. Subgroup P(ND) differs from patients with depression (fewer personality disorders, better self-concept), whereas subgroup P(D) closely resembles them.     

A comparison of posttraumatic stress disorder with and without borderline personality disorder among women with a history of childhood sexual abuse: etiological and clinical characteristics

The overlap in definition and presentation between posttraumatic stress disorder (PTSD) and borderline personality disorder (BPD) has raised questions about the relationship of these disorders. Are they separate disorders, variants of the same disorder, or comorbid conditions? The present study examined etiological variables and current functioning among two groups of outpatient women with a history of childhood sexual abuse: those with PTSD only (N = 45) and those with PTSD and BPD (N = 26). The groups did not differ in severity, frequency, or number of perpetrators of their childhood sexual abuse, or whether the perpetrator was a family member or not. The additional diagnosis of BPD was associated with earlier age of abuse onset and significantly higher rates of physical and verbal abuse by mother. Severity and frequency of PTSD symptoms were not affected by BPD diagnosis, suggesting that the personality disorder and PTSD are independent symptom constructs. The PTSD+BPD group scored higher on several other clinical measures including anger, dissociation, anxiety, and interpersonal problems. They did not differ in their frequency of use of mental health services but tended to be less compliant in their treatment. These and other findings are discussed, and implications for treatment are considered.     

Divalproex sodium treatment of women with borderline personality disorder and bipolar II disorder: a double-blind placebo-controlled pilot study

BACKGROUND: The intent of this study was to compare the efficacy and safety of divalproex sodium and placebo in the treatment of women with borderline personality disorder and comorbid bipolar II disorder. METHOD: We conducted a placebo-controlled double-blind study of divalproex sodium in 30 female subjects aged 18 to 40 years who met Revised Diagnostic Interview for Borderlines and DSM-IV criteria for borderline personality disorder and DSM-IV criteria for bipolar II disorder. Subjects were randomly assigned to divalproex sodium or placebo in a 2:1 manner. Treatment duration was 6 months. Primary outcome measures were changes on the interpersonal sensitivity, anger/hostility, and depression scales of the Symptom Checklist 90 (SCL-90) as well as the total score of the modified Overt Aggression Scale (MOAS). RESULTS: Twenty subjects were randomly assigned to divalproex sodium; 10 subjects to placebo. Using a last-observation-carried-forward paradigm and controlling for baseline severity, divalproex sodium proved to be superior to placebo in diminishing interpersonal sensitivity and anger/hostility as measured by the SCL-90 as well as overall aggression as measured by the MOAS. Adverse effects were infrequent. CONCLUSION: The results of this study suggest that divalproex sodium may be a safe and effective agent in the treatment of women with criteria-defined borderline personality disorder and comorbid bipolar II disorder, significantly decreasing their irritability and anger, the tempestuousness of their relationships, and their impulsive aggressiveness.     

Self-stigma in women with borderline personality disorder and women with social phobia

Little is known about how women with borderline personality disorder (BPD) and women with social phobia react to mental illness stigma. The goal of this study was to assess empirically self-stigma and its correlates in these groups. Self-stigma and related constructs were measured by self-report questionnaires among 60 women with BPD and 30 women with social phobia. Self-stigma was inversely related to self-esteem, self-efficacy, and quality of life and predicted low self-esteem after controlling for depression and shame-proneness. Stereotype awareness was not significantly correlated with self-esteem or quality of life. While there was no difference in stereotype awareness between women with BPD and women with social phobia, women with BPD showed higher self-stigma than women with social phobia. Self-stigma is associated with low self-esteem and other indices of poor psychological well-being. In comparison to women with social phobia, women with BPD suffer from more self-stigma. This may reflect intense labeling processes as being mentally ill due to repeated hospitalizations, frequent interpersonal difficulties, and visible scars.     

Motives for nonsuicidal self-injury among women with borderline personality disorder

Patients with borderline personality disorder (BPD) are known to use nonsuicidal self-injury (NSSI) as a dysfunctional strategy to regulate intense emotions. The primary purpose of this study was to clarify the motives for NSSI along with their interrelations. We further investigated the variety of emotions preceding NSSI and possible effects of NSSI on these emotions. To this end, a structured self-rating questionnaire on NSSI was administered to 101 female BPD-patients exhibiting NSSI. Most patients reported multiple motives for NSSI. The motives were more likely to compound than to exclude one another. Negative reinforcement was almost always involved in NSSI, whereas positive reinforcement (e.g., "getting a kick") played an additional role among about half of the patients. NSSI was usually preceded by a large variety of negative feelings that were reported to clearly improve with NSSI. In conclusion, therapists should anticipate a multidimensional functional spectrum when exploring motives of NSSI.