Axis I phenomenology of borderline personality disorder

The Axis I phenomenology of 50 outpatients meeting both Diagnostic Interview for Borderlines (DIB) and DSM-III criteria for Borderline Personality Disorder (BPD), 29 outpatients meeting DSM-III criteria for Antisocial Personality Disorder (APD), and 26 outpatients meeting DSM-III criteria for Dsythymic Disorder as well as DSM-III criteria for some other type of Axis II disorder (dysthymic OPD) was assessed blind to clinical diagnosis using the Structured Clinical Interview for DSM-III (SCID). Borderlines were significantly more likely than antisocial controls to have met DSM-III criteria for an affective disorder, particularly Dysthymic Disorder, and an anxiety disorder. They were also significantly more likely than dysthymic OPD controls but significantly less likely than antisocial controls to have met DSM-III criteria for alcohol abuse/dependence and drug abuse/dependence. The authors conclude that: (1) the link between BPD and unipolar affective disorders is less specific than previously suggested, and (2) there is a link between BPD and impulse disorders that may be of equal, if not greater, importance.     

Antisocial personality disorder and psychopathy in cocaine-dependent women.

OBJECTIVE: The goal of this study was to examine the lifetime prevalence of antisocial personality disorder according to five diagnostic systems and the prevalence of psychopathy in a study group of women. The relationship between antisocial personality disorder and psychopathy was also examined. Finally, differences in treatment admission variables based on the presence or absence of antisocial personality disorder and/or psychopathy were evaluated. METHOD: Antisocial personality disorder was diagnosed in 137 treatment-seeking, cocaine-dependent women according to the Feighner criteria, Research Diagnostic Criteria (RDC), and DSM-III, DSM-III-R, and DSM-IV criteria. Psychopathy was assessed by the Revised Psychopathy Checklist. RESULTS: Rates of antisocial personality disorder varied from 76% according to the Feighner criteria to 11% for the RDC. Nineteen percent (N = 26) of the women scored in the moderate to high range on the Revised Psychopathy Checklist. All of these women were diagnosed with antisocial personality disorder according to DSM-III and Feighner criteria, but only 15 of the 26 were diagnosed according to DSM-III-R, 12 according to DSM-IV, and six with the RDC. Moderate levels of psychopathy were associated with a history of illegal activity at treatment admission, whereas antisocial personality disorder was not. CONCLUSIONS: There was relatively little diagnostic agreement between classification systems. This study indicates that antisocial personality disorder and psychopathy are not synonymous terms for the same disorder. Findings support a need to redefine antisocial personality disorder diagnostic criteria to make them gender neutral by including behaviors associated specifically with antisociality in women.     

Comparison of DSM-III and DSM-III-R diagnoses for prepubertal children: changes in prevalence and validity

A structured and reliable diagnostic procedure based on a revised version of the Diagnostic Interview Schedule for Children for children, parents, and teachers was used to assign both DSM-III and DSM-III-R diagnoses to 177 outpatient boys aged 7 to 12 years. Compared to their DSM-III counterparts, DSM-III-R oppositional defiant disorder was 25.5% less prevalent, DSM-III-R dysthymia was 37.8% less prevalent, and DSM-III-R conduct disorder (CD) was 44.3% less prevalent. However, DSM-III-R attention deficit hyperactivity disorder was 14.4% more prevalent than DSM-III attention deficit disorder with hyperactivity. The two definitions of CD were compared to exemplify an empirical approach to diagnostic validation. The DSM-III-R diagnosis of CD appears to be more valid as it is more strongly associated with police contacts, school suspensions, and history of antisocial personality disorder in the biological father, but both CD diagnoses are associated with family histories of criminal convictions.     

Symptom profiles of gender dysphoric patients of transsexual type compared to patients with personality disorders and healthy adults

OBJECTIVE: Gender dysphoric patients of transsexual type (TS) have been considered to have severe psychopathology. However, these notions have a weak empirical documentation. METHOD: TS patients (n = 86), patients with personality disorder (PD, n = 98) and adult healthy controls (HC, n = 1068) were compared by means of the Symptom Checklist 90 (SCL-90). All patients were diagnosed by structured interviews (Axis I, II and V of DSM-III-R/IV). PD patients were further characterized according to the LEAD-standard. RESULTS: TS patients scored significantly lower than PD patients on the Global Symptom Index and all SCL-90 subscales. Although the TS group generally scored slightly higher than the HC group, all scores were within the normal range. CONCLUSION: TS patients selected for sex reassignment showed a relatively low level of self-rated psychopathology before and after treatment. This finding casts doubt on the view that transsexualism is a severe mental disorder.     

Bipolar-panic disorder comorbidity within bipolar disorder families: a study of siblings

Objectives:  Although anxiety disorders often co-occur with bipolar disorder in clinical settings, relatively few studies of bipolar disorder have looked specifically at panic comorbidity. This report examines lifetime panic comorbidity within a sample of families with a history of bipolar disorder.
Methods:  One hundred and nine probands with bipolar disorder and their 226 siblings were interviewed as part of a family-genetic study. Logistic regression was used to model bipolar disorder as a predictor of comorbid panic in those with affective disorder, with age at interview and gender included as covariates.
Results:  The percentage with panic attacks was low in those without affective disorder (3%) compared with those with unipolar depression (22%) or bipolar disorder (32%). Panic disorder was found only in those with affective disorder (6% for unipolar, 16% for bipolar). When bipolar disorder and unipolar disorder were compared, controlling for age and sex, having bipolar disorder was associated with panic disorder (OR = 3.0, 95% CI = 1.1, 7.8) and any panic symptoms (OR = 2.0, CI = 1.0,3.8) and more weakly with the combination of panic disorder and recurrent attacks (OR = 1.8, CI = 0.9, 3.5).
Conclusions:  The absence of panic disorder and the low prevalence of any panic symptoms in those without bipolar or unipolar disorder suggest that panic is associated primarily with affective disorder within families with a history of bipolar disorder. Furthermore, panic disorder and symptoms are more common in bipolar disorder than in unipolar disorder in these families.     

Association analysis of the insertion/deletion polymorphism in serotonin transporter gene in patients with affective disorder.

A polymorphism of serotonin transporter was studied in 226 patients with affective disorders (n = 132 for bipolar, n = 94 for unipolar affective disorder) and in 213 healthy subjects. Consensus diagnosis by at least two psychiatrists, according to the ICD-10 and DSM-IV criteria was made for each patient using SCID (Structured Clinical Interview for DSM-IV Axis I Disorders). A functional polymorphism in the promoter region of serotonin transporter gene, where 44 bp are either inserted (long allele) or deleted (short allele) was analysed. Genotype s/s was significantly more frequent in patients comparing to the control group (P = 0.011 for bipolar and P = 0.003 for unipolar affective disorder)--the most marked association was found in males with bipolar and unipolar illness. The allele frequencies also differ significantly between patients and controls (P = 0.003 for bipolar and P = 0.001 for unipolar affective disorder). The frequency of the low activity (short) allele was higher in patients than in controls (51.1% in bipolar, and 54.3 in unipolar vs 39.4% in controls). We suggest that the presence of allele s may increase the susceptibility to occurrence of affective disorder.     

Schizoaffective psychosis. I. Comparative long-term outcome

Patients from the Chestnut Lodge (Rockville, Md) follow-up study with schizoaffective (SA) psychosis (n = 68) were compared with patients with DSM-III schizophrenia (S, n = 163), bipolar disorder (n = 19), and unipolar disorder (n = 44) on multiple premorbid, morbid, and outcome dimensions. This study required that patients with SA disorder satisfy DSM-III criteria for both S and affective disorder (minus mutual exclusionary criteria). The SA cohort demographic and premorbid profile paralleled that of the cohort with unipolar disorder. At follow-up, however, the profile of SA psychosis paralleled that of S, with no significant differences between these patients on virtually all outcome measures. Results suggest that among samples of long-term inpatient, SA psychosis as defined herein is closer to S than affective disorder.     

PERSONALITY FEATURES AND DISORDER IN THE SUBJECTS IN THE NEW YORK HIGH-RISK PROJECT

One hundred and seventy-five offspring of parents in two psychiatrically ill groups and of normal controls in the New York High-Risk Project (NYHRP) were assessed for Axis II personality traits and disorders as defined by the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R). These offspring include: subjects at high risk for schizophrenia (HRSz, n = 48), all of whom have a parent with schizophrenic disorder; subjects at high risk for affective disorder (HRAff, n = 40), all of whom have a parent with affective disorder; and subjects at no increased risk for psychiatric illness (NC, n = 87), whose parents are psychiatrically normal. The trained interviewers, who administered a standardized direct interview, were blind to parental clinical status and to previous clinical status of the offspring.

The rates for any personality disorder (PD) ranged from 7% to 20%. Comorbidity between Axis I and Axis II disorders was high for all groups.     

Gender differences in affective, schizoaffective, and schizophrenic disorders

This study examines gender differences in the clinical profiles and long-term outcomes of chronic DSM-III Axis I psychotic inpatients from the Chestnut Lodge followup study. Diagnostic groups include schizophrenia, schizoaffective psychosis, and unipolar affective disorder. Sex differences were frequent, especially in schizophrenia. Females with schizophrenia, for example, had superior premorbid social, sexual, and marital adjustments. They presented at index hospitalization with more depression, self-destructive behaviors, and troubled interpersonal relationships. Their long-term outcomes were better than males in terms of social activity, work competence, time symptomatic, substance abuse, and marital and parental status. Baseline gender differences were comparatively sparse for the schizoaffective and unipolar cohorts. Outcome differences were virtually nonexistent among the schizoaffective patients but unipolar females received better ratings than males in work competence and substance abuse. Females had a later onset of illness and males presented with more antisocial behaviors across all three diagnostic groups. Results highlight the importance of analyzing data by gender in studies of the psychotic disorders.     

Psychiatric diagnosis in cocaine abuse

The Structured Clinical Interview for DSM-III, Axis I was administered to a consecutive series of 30 cocaine abusers entering outpatient treatment. Another mental disorder was diagnosed only if its onset occurred before the onset of any substance dependence disorder. Diagnoses were made on a lifetime basis without regard to hierarchy. Most cocaine abusers had one or more additional diagnoses. We propose a model of two subtypes of cocaine abusers: (1) a primary affective disorder group, which may be split into bipolar versus unipolar or into severely versus mildly depressed subgroups; and (2) a group with other drug dependencies. The small n, limited sample, and methodological problems with diagnosis in the setting of substance abuse make these findings tentative. Future research should combine larger diagnostic studies with treatment trials to test whether such diagnostic subtypes have prognostic or treatment implications.     

Hyperthyroxinemia in major affective disorders

Ninety-nine patients fulfilling DSM-III criteria for primary major affective disorder, either bipolar or unipolar, were studied. A 12% prevalence of elevated thyroxine levels was found. Three of the 12 hyperthyroxinemia patients also had elevated free thyroxine index. No statistically significant difference in response to antidepressant treatment was observed between the hyperthyroxinemia group and the normal serum thyroxine group.     

Childhood depression and adult personality disorder: alternative pathways of continuity

BACKGROUND: This study extends previous findings of the risks posed by childhood major depressive disorder and other psychopathological features for later personality disorder (PD) in a random sample of 551 youths. METHODS: Self-reports and mother reports were used to evaluate DSM-III-R (Axes I and II) psychiatric disorders at mean ages of 12.7, 15.2, and 21.1 years. Logistic regression was used to examine the independent effects of major depressive disorder in childhood or adolescence on 10 PDs in young adulthood. RESULTS: Odds of dependent, antisocial, passive-aggressive, and histrionic PDs increased by more than 13, 10, 7, and 3 times, respectively, given prior major depressive disorder. Those effects were independent of age, sex, disadvantaged socioeconomic status, a history of child maltreatment, nonintact family status, parental conflict, preexisting PD in adolescence, and other childhood or adolescent Axis I psychopathological features, including disruptive and anxiety disorders. In addition, odds of schizoid and narcissistic PD increased by almost 6 times and odds of antisocial PD increased by almost 5 times given a prior disruptive disorder, and odds of paranoid PD increased by 4 times given a prior anxiety disorder. CONCLUSION: Personality disorders may represent alternative pathways of continuity for major depressive disorder and other Axis I disorders across the child-adult transition.     

Personality disorders in recent-onset bipolar disorder

The frequency and types of DSM-III personality disorders (PDs) were investigated in a sample of 26 recent-onset bipolar-disordered (BD) patients. Results showed that 62% of BD patients had PDs according to the Structured Interview for DSM-III Personality Disorders (SIDP). The most frequently diagnosed PDs were the histrionic, borderline, passive-aggressive, and antisocial categories. A comparison between the BD patients and a sample of 35 recent-onset schizophrenic patients showed significant differences for two PDs. Schizotypal PD was more frequently diagnosed in the schizophrenic group, while the BD group had a higher frequency of histrionic PD.     

Comparisons of males and females with DSM-III dependent personality disorder

To determine whether DSM-III dependent personality disorder (PD) differed in males and females, 30 females and 11 males with this diagnosis were selected from a psychiatric outpatient population. Standardized measures of Axis I, Axis II, and family history were used. There were no differences in age or in the prevalence of Axis I or Axis II disorders in males and females, indicating that females were probably not misdiagnosed as having dependent PD. However, relatives of males had significantly more major depressive disorder and DSM-III anxious personality disorder cluster, while relatives of females had significantly more panic disorder. This may indicate different predisposing factors to dependent PD in males and females.     

Diagnostic criteria for melancholia. The comparative validity of DSM-III and DSM-III-R

The psychometric properties and validity of the DSM-III and DSM-III-R definitions of melancholia were examined in 60 depressed inpatients. The prevalence of melancholia was significantly higher according to the DSM-III-R criteria, and the kappa-coefficient of agreement between the two definitions was .40. For both criteria sets, the internal consistencies and item-scale correlations were low. Both definitions were associated with overall symptom severity and the melancholia symptom subscale; however, only DSM-III melancholics scored higher on the nonmelancholia symptom subscale. The DSM-III-R criteria were associated with more of the predicted correlates of endogenous subtyping. According to both definitions, melancholics were characterized by less stress, greater symptom severity, and less frequent nonserious suicide attempts prior to admission. The DSM-III-R melancholic subtyping was additionally associated with a family history of antisocial personality and substance abuse, presence of a premorbid personality disorder, age, and a tendency to blame others for the depression.     

Interactions between depression and borderline personality disorder. A pilot study

Although many nosologists advocate the autonomy of borderline personality disorder (BPD), its heterogeneity led to demands that it be absorbed into the affective disorder spectrum. This study attempted to determine if (a) BPD and affective disorders overlapped and (b) if BPD characteristics were differentially associated with specific Axis I, DSM-III diagnoses. Forty-three BPD inpatients were rated retrospectively on 29 variables, including BPD characteristics from Gunderson's diagnostic interview for borderlines (DIB). chi 2 analyses were performed for each of 28 variables in 56 contingency tables whose independent variables were dysthymia/other Axis I diagnoses or depression/no depression. BPD inpatients with dysthymia had more impaired occupational functioning and greater use of splitting. Also, depressed BPDs were in general more dependent, empty and bored, and suicidal.     

Bipolar obsessive-compulsive disorder and personality disorders

OBJECTIVES: Relatively few systematic data exist on the clinical impact of bipolar comorbidity in obsessive-compulsive disorder (OCD) and no studies have investigated the influence of such a comorbidity on the prevalence and pattern of Axis II comorbidity. The aim of the present study was to explore the comorbidity of personality disorders in a group of patients with OCD and comorbid bipolar disorder (BD). METHODS: The sample consisted of 204 subjects with a principal diagnosis of OCD (DSM-IV) and a Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) score>or=16 recruited from all patients consecutively referred to the Anxiety and Mood Disorders Unit, Department of Neuroscience, University of Turin over a period of 5 years (January 1998-December 2002). Diagnostic evaluation and Axis I comorbidities were collected by means of the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I). Personality status was assessed by using the Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II). Socio-demographic and clinical features (including Axis II comorbidities) were compared between OCD patients with and without a lifetime comorbidity of BD. RESULTS: A total of 21 patients with OCD (10.3%) met DSM-IV criteria for a lifetime BD diagnosis: 4 (2.0%) with BD type I and 17 (8.3%) with BD type II. Those without a BD diagnosis showed significantly higher rates of male gender, sexual and hoarding obsessions, repeating compulsions and lifetime comorbid substance use disorders, when compared with patients with BD/OCD. With regard to personality disorders, those with BD/OCD showed higher prevalence rates of Cluster A (42.9% versus 21.3%; p=0.027) and Cluster B (57.1% versus 29.0%; p=0.009) personality disorders. Narcissistic and antisocial personality disorders were more frequent in BD/OCD. CONCLUSIONS: Our results point towards clinically relevant effects of comorbid BD on the personality profiles of OCD patients, with higher rates of narcissistic and antisocial personality disorders in BD/OCD patients.     

Affective disorders in university student psychiatric patients

Two hundred and sixty-four student psychiatric referrals were evaluated by the same interviewer using a detailed, precoded questionnaire based on the diagnostic criteria of Feighner et al. (1972). Female sex was associated with secondary and unipolar primary affective disorders. Greater age (over 23 years) was associated with the unipolar primary affective disorder. Race and marital status were not associated with affective disorders.     

The reliability of psychiatric diagnosis in Israel's Psychiatric Case Register

To determine the reliability of psychiatric diagnoses in the Israel Psychiatric Case Register, DSM-III criteria were applied to case record abstracts of first admissions to a large psychiatric hospital in Jerusalem. The DSM-III diagnoses were compared with ICD-8 records diagnoses. Between 40 and 50% of those originally diagnosed as schizophrenia were re-diagnosed into less severe categories. The proportion diagnosed as affective disorder doubled from 21% for ICD-8 diagnoses to 40% for DSM-III diagnoses. The unreliability concerned the diagnoses of schizophrenia and affective disorder. Findings suggest that the introduction of standardized diagnostic criteria in Israel will lead to a substantial increase in the number of cases diagnosed as affective disorder, although difficulties involved in differentiating schizophrenia from the major affective disorders remain. The DSM-III findings suggest a high prevalence of affective disorders among Jews.     

Psychiatric comorbidity is associated with drug use and HIV risk in syringe exchange participants

The present study evaluated the effects of psychiatric comorbidity on substance use disorder prevalence, HIV risk behavior, and other problem severity in male and female out-of-treatment injection drug users newly registered at a syringe exchange program. Participants (N = 338) were administered the Structured Clinical Interview for the DSM-IV, the Addiction Severity Index, and the Risk Assessment Battery, and classified into one of four diagnostic groups: (1) no antisocial personality disorder (APD) or Axis I psychiatric disorder (N = 162), (2) APD only (N = 74), (3) Axis I psychiatric disorder only (N = 55), or (4) APD plus Axis I psychiatric disorder (N = 47). Psychiatric comorbidity was associated with higher rates of substance use disorder and more HIV risk and other problem severity. In general, participants with both APD and an Axis I disorder exhibited the most problem severity. APD was uniquely associated with higher prevalence for each substance use disorder assessed in this study and with elevated HIV risk. These results support and extend studies conducted with opioid-dependent individuals recruited from treatment and community settings, and reinforce the need to develop interventions to encourage syringe exchange program participants to enroll in treatment.