Lack of remorse in antisocial personality disorder: sociodemographic correlates, symptomatic presentation, and comorbidity with Axis I and Axis II disorders in the National Epidemiologic Survey on Alcohol and Related Conditions

OBJECTIVE: The purpose of this study was to compare sociodemographic and family history correlates, symptomatic presentation, and comorbidity with Axis I and Axis II disorders, in an epidemiologic sample of adults with DSM-IV antisocial personality disorder (ASPD) who lacked, vs those who did not lack, remorse. METHODS: This study is based on a nationally representative sample of adults. Lifetime prevalences of each ASPD diagnostic criterion and each comorbid mood, anxiety, substance use, and personality disorder were estimated. Logistic regression was used to examine associations of lack of remorse with ASPD symptom patterns and comorbid disorders. Diagnoses were made using the National Institute on Alcohol Abuse and Alcoholism Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV Version. RESULTS: Among the 1422 respondents with ASPD, 728 (51%) lacked remorse. Respondents who lacked remorse were younger and more often reported a family history of drug problems than those who did not. More often than remorse-positive respondents, those who were remorse-negative met diagnostic criteria involving violence against persons and less often met criteria involving offenses against property. Remorse was not associated with cruelty to animals, nor with most nonviolent antisocial behaviors. Remorse-negative respondents endorsed more total lifetime violent behaviors than those who were remorse-positive. Lack of remorse was not associated with any lifetime comorbid Axis I or Axis II disorder. Patterns of findings were generally similar between men and women. CONCLUSIONS: Lack of remorse appears to identify at best a modestly more symptomatically severe and violent form of ASPD in nonclinical populations.     

Lifetime comorbidity of antisocial personality disorder and anxiety disorders among adults in the community

The association between lifetime anxiety disorders, conduct disorder (CD), and antisocial personality disorder (ASPD) among adults in the community was explored. Data were drawn from the National Comorbidity Survey (n = 5,877), a representative community sample of adults aged 15-54 in the 48 contiguous US states. Multiple logistic regression analyses were used to determine the association between anxiety disorders, CD and ASPD, and between the co-occurrence of anxiety disorders and ASPD in the likelihood of comorbid substance use and affective disorders, suicidal ideation (SI) and suicide attempt (SA). Out of the 3.3% of adults with ASPD, over half (54.33%) had a comorbid anxiety disorder (lifetime). Similarly, 42.31% of adults with a history of CD (9.4%) who did not meet criteria for ASPD had a lifetime anxiety disorder. Social phobia [OR = 1.65 (1.01, 2.7)] and post-traumatic stress disorder [OR = 2.28 (1.3, 4.0)] were associated with significantly increased odds of ASPD, after adjusting for differences in sociodemographic characteristics and other psychiatric comorbidity. Major depression was no longer significantly associated with ASPD after adjusting for anxiety disorders. The comorbidity of anxiety disorders and ASPD was associated with significantly higher odds of major depression, substance use disorders, and SI and SA compared with odds among those without both disorders. These data provide initial evidence of an association between PTSD and social phobia and an increased likelihood of ASPD among adults in the community, after adjustment for comorbid affective and substance use disorders. Adults with ASPD and comorbid anxiety had significantly higher levels of comorbid major depression, alcohol dependence, and substance dependence and substantially higher rates of lifetime suicidal ideation and suicide attempts compared to adults with ASPD or anxiety disorders alone or with neither disorder. Future studies are needed to replicate this finding using longitudinal data and to investigate the possible mechanisms of the observed links between anxiety disorders and ASPD.     

Adult psychopathic personality with childhood-onset hyperactivity and conduct disorder: a central problem constellation in forensic psychiatry

To describe lifetime mental disorders among perpetrators of severe inter-personal crimes and to identify the problem domains most closely associated with aggression and a history of repeated violent criminality, we used structured interviews, clinical assessments, analyses of intellectual functioning, medical and social files, and collateral interviews in 100 consecutive subjects of pretrial forensic psychiatric investigations. Childhood-onset neuropsychiatric disorders [attention-deficit/hyperactivity disorder (AD/HD), learning disability, tics and autism spectrum disorders] affected 55% of the subjects and formed complex comorbidity patterns with adult personality disorders [including psychopathic traits according to the Psychopathy Checklist (PCL-R)], mood disorders and substance abuse. The closest psychiatric covariates to high Lifetime History of Aggression (LHA) scores and violent recidivism were the PCL-R scores and childhood conduct disorder (CD). Behavioral and affective PCL-R factors were closely associated with childhood AD/HD, CD, and autistic traits. The results support the notion that childhood-onset social and behavioral problems form the most relevant psychiatric symptom cluster in relation to pervasive adult violent behavior, while late-onset mental disorders are more often associated with single acts of violent or sexual aggression.     

Bipolar disorder with comorbid cluster B personality disorder features: impact on suicidality

BACKGROUND: Because of their overlapping phenomenology and mutually chronic, persistent nature, distinctions between bipolar disorder and cluster B personality disorders remain a source of unresolved clinical controversy. The extent to which comorbid personality disorders impact course and outcome for bipolar patients also has received little systematic study. METHOD: One hundred DSM-IV bipolar I (N = 73) or II (N = 27) patients consecutively underwent diagnostic evaluations with structured clinical interviews for DSM-IV Axis I and cluster B Axis II disorders, along with assessments of histories of childhood trauma or abuse. Cluster B diagnostic comorbidity was examined relative to lifetime substance abuse, suicide attempt histories, and other clinical features. RESULTS: Thirty percent of subjects met DSM-IV criteria for a cluster B personality disorder (17% borderline, 6% antisocial, 5% histrionic, 8% narcissistic). Cluster B diagnoses were significantly linked with histories of childhood emotional abuse (p = .009), physical abuse (p = .014), and emotional neglect (p = .022), but not sexual abuse or physical neglect. Cluster B comorbidity was associated with significantly more lifetime suicide attempts and current depression. Lifetime suicide attempts were significantly associated with cluster B comorbidity (OR = 3.195, 95% CI = 1.124 to 9.088), controlling for current depression severity, lifetime substance abuse, and past sexual or emotional abuse. CONCLUSIONS: Cluster B personality disorders are prevalent comorbid conditions identifiable in a substantial number of individuals with bipolar disorder, making an independent contribution to increased lifetime suicide risk.     

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.     

Current comorbidity of psychiatric disorders among DSM-IV major depressive disorder patients in psychiatric care in the Vantaa Depression Study

BACKGROUND: While numerous studies have documented the high comorbidity of major depressive disorder (MDD) with individual mental disorders, no published study has reported overall current comorbidity with all Axis I and II disorders among psychiatric patients with MDD, nor systematically investigated variations in current comorbidity by sociodemographic factors, inpatient versus outpatient status, and number of lifetime depressive episodes. METHOD: Psychiatric outpatients and inpatients in Vantaa, Finland, were prospectively screened for an episode of DSM-IV MDD, and 269 patients with a new episode of MDD were enrolled in the Vantaa Depression MDD Cohort Study. Axis I and II comorbidity was assessed via semistructured Schedules for Clinical Assessment in Neuropsychiatry, version 2.0, and Structured Clinical Interview for DSM-II-R personality disorders interviews. RESULTS: The great majority (79%) of patients with MDD suffered from 1 or more current comorbid mental disorders, including anxiety disorder (57%), alcohol use disorder (25%), and personality disorder (44%). Several anxiety disorders were associated with specific Axis II clusters, and panic disorder with agoraphobia was associated with inpatient status. The prevalence of personality disorders varied with inpatient versus outpatient status, number of lifetime depressive episodes, and type of residential area, and the prevalence of substance use disorders varied with gender and inpatient versus outpatient status. CONCLUSION: Most psychiatric patients with MDD have at least 1 current comorbid disorder. Comorbid disorders are associated not only with other comorbid disorders, but also with sociodemographic factors, inpatient versus outpatient status, and lifetime number of depressive episodes. The influence of these variations on current comorbidity patterns among MDD patients needs to be taken account of in treatment facilities.     

Antisocial personality disorder is on a continuum with psychopathy

Background

Antisocial personality disorder (ASPD) and psychopathy are different diagnostic constructs. It is unclear whether they are separate clinical syndromes or whether psychopathy is a severe form of ASPD.

Methods

A representative sample of 496 prisoners in England and Wales was interviewed in the second phase of a survey carried out in 1997 using the Schedules for Clinical Assessment in Neuropsychiatry, the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Axis II personality disorders, and the Psychopathy Checklist-Revised.

Results

Among those 18 years and older (n = 470), 211 (44.9%) received a diagnosis of ASPD, of whom 67 (31.8%) were classified as psychopaths, indicated by Psychopathy Checklist-Revised scores of 25 and above. Symptoms of ASPD and psychopathy both demonstrated low diagnostic contrast when comparing subgroups of ASPD above and below the cutoff for psychopathy. There were no differences in demography, Axis I comorbidity, and treatment-seeking behavior. Psychopathic individuals with ASPD demonstrated comorbid schizoid and narcissistic personality disorder, more severe conduct disorder and adult antisocial symptoms, and more violent convictions.

Conclusions

Psychopathy and ASPD are not separate diagnostic entities, but psychopathic ASPD is a more severe form than ASPD alone with greater risk of violence. Dimensional scores of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition personality disorders (other than ASPD) may be helpful in identifying this specific subgroup.     

Comorbidity of borderline personality disorder and posttraumatic stress disorder in the U.S. population

While placed on different axes of the DSM classification system, borderline personality disorder (BPD) and posttraumatic stress disorder (PTSD) have important relationships with trauma, and overlap between these disorders has long been recognized. The current study is the first to examine comorbidity of PTSD and BPD in a large nationally representative sample using a reliable and valid method of assessing Axis I and II mental disorders. Data came from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) Wave II (N = 34,653; response rate 70.2%). Multiple regression models were used to examine differences in psychopathology, traumatic events and health-related quality of life across individuals with PTSD alone (n = 1820), BPD alone (n = 1290) and those with comorbid PTSD–BPD (n = 643). The lifetime prevalence of PTSD and BPD were 6.6% and 5.9%, respectively. Of individuals with BPD, 30.2% were also diagnosed with PTSD, whereas 24.2% of individuals with PTSD were also diagnosed with BPD. Individuals with comorbid PTSD–BPD had a poorer quality of life, more comorbidity with other Axis I conditions, increased odds of a lifetime suicide attempt, and a higher prevalence of repeated childhood traumatic events than individuals with either condition alone. These results show that PTSD and BPD have a high degree of lifetime co-occurrence but are not entirely overlapping. Their concurrence is associated with poorer functioning compared to either diagnosis alone, emphasizing the clinical utility of diagnosing both conditions. Future research should explore the determinants of having either or both diagnoses with an aim toward improved identification, prevention, and intervention.     

Patterns of axis I comorbidity in early-onset versus late-onset major depressive disorder.

BACKGROUND: This study of a large clinical sample of depressed patients examined whether childhood onset as compared with adult onset Major Depressive Disorder (MDD) would confer a greater risk for Axis I comorbidity and whether childhood onset MDD would also differ from adult onset MDD in the pattern of comorbid disorders. METHODS: We examined lifetime co-occurrence of Axis I disorders among 381 adult outpatients with MDD by Structured Clinical Interview for DSM-III-R-Patient Edition (SCID-P). Subjects were divided into childhood onset (n = 47), adolescent onset (n = 101) and adult onset (n = 233) MDD groups. RESULTS: We found that the two early-onset groups exhibited significantly increased rates of Axis I comorbidity. The childhood onset group accounted for a disproportionately high percentage of depressed adults with two or more comorbid Axis I disorders. Social and simple phobias and alcohol abuse/dependence were significantly more prevalent among individuals with childhood onset MDD than among individuals with adult onset MDD. Alcohol abuse/dependence, but not anxiety disorders, was significantly more prevalent among adolescent onset than adult onset MDD groups. Panic, generalized anxiety, obsessive-compulsive and somatoform disorders were equally distributed across MDD onset groups. Comorbid disorders were much more likely to have followed onset of MDD among individuals with childhood compared with adult onset, except for social phobia which more frequently preceded the depression. The relative ordering among the comorbid conditions with respect to whether they followed or preceded MDD did not vary notably across the three age of onset groups. CONCLUSIONS: We conclude that early-onset MDD is associated with an increased density of Axis I comorbidity that seems to be limited to specific disorders.     

Differences in Axis I and II comorbidity between bipolar I and II disorders and major depressive disorder

OBJECTIVE: To obtain a comprehensive view of differences in current comorbidity between bipolar I and II disorders (BD) and (unipolar) major depressive disorder (MDD), and Axis I and II comorbidity in BD in secondary-care psychiatric settings. METHOD: The psychiatric comorbidity of 90 bipolar I and 101 bipolar II patients from the Jorvi Bipolar Study and 269 MDD patients from the Vantaa Depression Study were compared. We used DSM-IV criteria assessed by semistructured interviews. Patients were inpatients and outpatients from secondary-care psychiatric units. Comparable information was collected on clinical history, index episode, symptom status, and patient characteristics. RESULTS: Bipolar disorder and MDD differed in prevalences of current comorbid disorders, MDD patients having significantly more Axis I comorbidity (69.1% vs. 57.1%), specifically anxiety disorders (56.5% vs. 44.5%) and cluster A (19.0% vs. 9.9%) and C (31.6% vs. 23.0%) personality disorders. In contrast, BD had more single cluster B personality disorders (30.9% vs. 24.6%). Bipolar I and bipolar II were similar in current overall comorbidity, but the prevalence of comorbidity was strongly associated with the current illness phase. CONCLUSIONS: Major depressive disorder and BD have somewhat different patterns in the prevalences of comorbid disorders at the time of an illness episode, with differences particularly in the prevalences of anxiety and personality disorders. Current illness phase explains differences in psychiatric comorbidity of BD patients better than type of disorder.     

Age at onset of bipolar disorder and risk for comorbid borderline personality disorder

Objectives: The relationship between bipolar disorder and cluster B personality disorders remains phenomenologically complex and controversial. We sought to examine the relationship between early age at onset of bipolar disorder and development of comorbid borderline personality disorder. Methods: A total of 100 adults in an academic specialty clinic for bipolar disorder underwent structured diagnostic interviews and clinical assessments to determine lifetime presence of comorbid borderline personality disorder, histories of childhood trauma, and clinical illness characteristics. Results: Logistic regression indicated that increasing age at onset of bipolar disorder was associated with a lower probability of developing comorbid borderline personality disorder (odds ratio = 0.91, 95% confidence interval: 0.83–0.99) while controlling for potential confounding factors, including a history of severe child trauma/abuse. Conclusion: Early onset of bipolar disorder increases the probability of developing comorbid borderline personality disorder, independent of the effects of severe childhood trauma/abuse. In patients with borderline personality disorder, prospective studies of new‐onset bipolar disorder may underestimate the prevalence of true comorbidity unless they capture the primary risk window for first‐episode mania arising before the end of adolescence.     

Conduct disorder and adult psychiatric diagnoses: associations and gender differences in the U.S. adult population

The authors' objective was to examine the presence of Axis I and II psychiatric disorders among adult males and females with a history in childhood and/or adolescence of conduct disorder (CD). Data were derived from a large national sample of the U.S. population. Face-to-face interviews of more than 34,000 adults ages 18 years and older were conducted during 2004-2005 using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV Version. After adjusting for sociodemographic characteristics and psychiatric comorbidity, CD was associated with all Axis I and II disorders, particularly substance use disorders (SUD), bipolar disorder, and histrionic personality disorders. After adjusting for gender differences in the general population, men had significantly greater odds of social anxiety disorder and paranoid personality disorder, whereas women were more likely to have SUD. Furthermore, there was dose-response relationship between number of CD symptoms and risk for most psychiatric disorders. From a clinical standpoint, knowledge of the gender differences in associations of CD with other psychiatric disorders in adulthood may be informative of developmental pathways of the disorder, and of possible gender-specific risk factors. Early recognition and treatment of CD may help prevent the development of adult-onset disorders.     

Personality disorders in elderly patients with dysthymic disorder.

The authors evaluated personality disorders in elderly patients with DSM-IV dysthymic disorder (DD) to identify prevalent personality disorders and their clinical correlates. Outpatients (>/=60 years; N=76) with DD were evaluated; most were male (65.8%) and had late age at onset (>50 years: 60.5%). Axis II disorders were present in 31.2% of patients, with obsessive-compulsive personality disorder (OCD; 17.1%) and avoidant personality disorder (11.8%) being the most common. Personality disorders were associated with an earlier age at onset of depressive illness, greater lifetime history of comorbid Axis I disorders, greater severity of depressive symptoms, and lower socioeconomic status. Personality disorders occurred in a minority of elderly patients with DD and mainly comprised the obsessive-compulsive and avoidant subtypes, similar to reports of personality disorders in elderly patients with major depression. In contrast, young adults with DD have been shown consistently to have personality disorders at high frequency. Together with the predominance of late onset and the lack of psychiatric comorbidity, the current findings on personality disorders reinforce our view that DD in elderly patients is typically a different disorder from DD in young adults.     

Conduct disorder subtype and comorbidity.

BACKGROUND: Conduct disorder is considered difficult to treat, but comorbid psychiatric disorders may be a basis for treating some youths with conduct disorder. We sought to identify patterns of comorbid psychiatric diagnoses and psychopathology associated with conduct disorder by reported age-of-onset. METHODS: Referred children and adolescents, aged 4-17 years old, were clinically evaluated. Ages of onset of CD symptoms (N=53) were ascertained and divided according to DSM-IV criteria as childhood onset (<10 years old) or adolescent onset (>or=10 years old). RESULTS: Childhood-onset conduct disorder was associated with higher rates of ADHD and anxiety disorders, male gender, and perceived and total hostility scores than adolescent-onset conduct disorder. Adolescent-onset was associated with higher rates of PTSD, alcohol and substance use disorders, complex comorbidity (i.e., 6+ diagnoses lifetime), and female gender. CONCLUSIONS: Understanding age-of-onset-related patterns of comorbidity may facilitate psychiatric treatment planning in children and adolescents with conduct disorder.     

Bipolar II disorder and comorbidity

The validity and reliability of the diagnosis of bipolar II disorder has been questioned by means of comorbidity with nonaffective disorders, including substance abuse, personality disorders, and anxiety disorders. This study examined the comorbid diagnosis of a sample of bipolar II patients, comparing patients with comorbidity and those with "pure" bipolar II disorder. Forty Research Diagnostic Criteria (RDC) bipolar II patients were assessed by means of the Schedule for Affective Disorders and Schizophrenia, Lifetime Version (SADS-L) and Structured Clinical Interview for DSM-III-R axis I (SCID-II) for personality disorders. Patients fulfilling RDC criteria for any psychiatric disorder (except personality disorders) or DSM-IV criteria for any personality disorder were compared with patients without comorbidity. For practical reasons, cyclothymia was not considered as a comorbid diagnosis. Half of the sample had lifetime comorbidity with other psychiatric disorders, mainly personality disorders (33%), substance abuse or dependence (21%), and anxiety disorders (8%). However, only the rates of suicidal ideation (74% v 24%, chi square [chi2] = 9.03, P = .003) and suicide attempts (45% v 5%, chi2 = 8.53, P = .003) were significantly different between patients with and without comorbidity. In summary, although the rates of comorbidity are relatively high in bipolar II disorder, most clinical and course variables are strikingly similar in patients with and without comorbidity except for suicidal behavior, suggesting that comorbidity does not reduce the validity of the diagnosis of bipolar II disorder.     

Considering comorbidity in social phobia

BACKGROUND: Considering comorbidity in social phobia contributes to our understanding of causal pathways and improved classifications for psychiatric disorders. Comorbidity also has important clinical implications. While a number of studies have investigated comorbidity in social phobia, only one other study has used the Composite International Diagnostic Interview (CIDI) and considered comorbidity in subtypes of social phobia. This study evaluated lifetime social phobia comorbidity with other common mental disorders as well as comorbidity in subtypes of social phobia. We also considered whether social fears, reported by respondents with social phobia, had an earlier or later age of onset than other disorders. METHODS: Data came from the Mental Health Supplement to the Ontario Health Survey, a survey of 8,116 Canadian respondents, ages 15-64. Psychiatric diagnoses were determined using the CIDI. This instrument is considered more sensitive than earlier instruments for diagnosing social phobia. RESULTS: Fifty-two percent of respondents with lifetime social phobia reported at least one other lifetime mental disorder and 27% reported three or more lifetime mental disorders. Social phobia, in this sample, is strongly comorbid with anxiety and affective disorders, and moderately comorbid with substance abuse disorders. When two social phobia subgroups were considered, the largest odds ratios were found among the not-exclusively-speaking social phobia group. This subgroup would include most of the respondents with a generalized form of social phobia. Age of onset of social fears, in respondents with social phobia, preceded age of onset of the comorbid disorder in 32% of cases with comorbid anxiety disorder, 71% of cases with comorbid affective disorder and 80% of cases with comorbid substance dependence/abuse disorder. CONCLUSIONS: Comorbidity and relative age of onset among respondents with social phobia in this study are generally consistent with previous epidemiologic studies. Clinicians should be vigilant for comorbidity in social phobia and should select treatments that target the full range of comorbid disorders. Early intervention or prevention of social fears or social phobia has the potential to reduce the risk of comorbid disorders.     

Criminal conviction, impulsivity, and course of illness in bipolar disorder

Swann AC, Lijffijt M, Lane SD, Kjome KL, Steinberg JL, Moeller FG. Criminal conviction, impulsivity, and course of illness in bipolar disorder.
Bipolar Disord 2011: 13: 173–181. © 2011 The Authors.
Journal compilation © 2011 John Wiley & Sons A/S. Objective: Criminal behavior in bipolar disorder may be related to substance use disorders, personality disorders, or other comorbidities potentially related to impulsivity. We investigated relationships among impulsivity, antisocial personality disorder (ASPD) or borderline personality disorder symptoms, substance use disorder, course of illness, and history of criminal behavior in bipolar disorder. Methods: A total of 112 subjects with bipolar disorder were recruited from the community. Diagnosis was by Structured Clinical Interview for DSM‐IV (SCID‐I and SCID‐II); psychiatric symptom assessment by the Change version of the Schedule for Affective Disorders and Schizophrenia (SADS‐C); severity of Axis II symptoms by ASPD and borderline personality disorder SCID‐II symptoms; and impulsivity by questionnaire and response inhibition measures. Results: A total of 29 subjects self‐reported histories of criminal conviction. Compared to other subjects, those with convictions had more ASPD symptoms, less education, more substance use disorder, more suicide attempt history, and a more recurrent course with propensity toward mania. They had increased impulsivity as reflected by impaired response inhibition, but did not differ in questionnaire‐measured impulsivity. On logit analysis, impaired response inhibition and ASPD symptoms, but not substance use disorder, were significantly associated with criminal history. Subjects convicted for violent crimes were not more impulsive than those convicted for nonviolent crimes. Conclusions: In this community sample, a self‐reported history of criminal behavior is related to ASPD symptoms, a recurrent and predominately manic course of illness, and impaired response inhibition in bipolar disorder, independent of current clinical state.     

The prevalence of psychiatric disorder among a community sample of crack cocaine users: an exploratory study with practical implications

The Diagnostic Interview Schedule for DSM-IV was used to assess the lifetime prevalence of psychiatric disorder among not-in-treatment crack cocaine users (N = 313). The most common dependencies involved cocaine (59.7%), alcohol (37.7%), and cannabis (12.1%). The most common nondependency disorders were antisocial personality disorder (ASPD; 24%), depression (17.8%), and posttraumatic stress disorder (PTSD; 11.8%). Comorbidity was present in 36.4% of the sample. Proportionately more white than black users were dependent on cocaine, alcohol, amphetamine, and sedative-hypnotics. More white than black users experienced ASPD, depression, PTSD, and attention deficit disorder. Proportionately fewer black users suffered comorbid disorders. Proportionately more men had ASPD, whereas more women had PTSD and phobias. Multinominal modeling revealed that black users and users with a high school education were less likely to have comorbid disorders; married users were less likely to have nondependency disorders. White crack users were more likely to have comorbidity, complicating their treatment.     

Chronic depression and comorbid personality disorders: response to sertraline versus imipramine

BACKGROUND: Chronic subtypes of depression appear to be associated with high rates of Axis II personality disorder comorbidity. Few studies, though, have systematically examined the clinical correlates of Axis II personality disorder comorbidity or its effect on treatment response or time to response. METHOD: 635 patients diagnosed with DSM-III-R chronic major depression or "double depression" (dysthymia with concurrent major depression) were randomized to 12 weeks of double-blind treatment with either sertraline or imipramine between February 1993 and December 1994. Axis II diagnoses were made using the personality disorders version of the DSM-III-R Structured Clinical Interview. The effect of study treatment was measured utilizing the Hamilton Rating Scale for Depression and the Clinical Global Impressions scale. RESULTS: Forty-six percent of patients met criteria for at least 1 comorbid Axis II personality disorder, with cluster C diagnoses being the most frequent at 39%; 21% met criteria for at least 2 Axis II personality disorders. A cluster C diagnosis was associated with significantly higher rates of early-onset depression (before age 21; 47% vs. 32% for no cluster C; p =.005) and comorbid anxiety disorder (34% vs. 18% for no cluster C; p <.001). Overall, the presence of Axis II personality disorder comorbidity had minimal-to-no effect on the ability to achieve either an antidepressant response or remission and had inconsistent effects on time to response. The presence of Axis II personality disorder comorbidity did not appear to reduce functional and quality-of-life improvements among patients responding to acute treatment with sertraline or imipramine. CONCLUSION: In this treatment sample, rates of Axis II personality disorder comorbidity were substantial in patients suffering from chronic forms of depression. Axis II personality disorder comorbidity did not appear to diminish symptomatic response to acute treatment or associated improvement in functioning and quality of life.     

Axis I and axis II comorbidity in panic/agoraphobic patients with and without suicidal ideation

In view of the controversial relationship between certain aspects of panic disorder with agoraphobia (PDA), suicidal ideation and comorbidity, the purposes of this study were to compare severity of PDA and Axis I and Axis II comorbidity in PDA patients with and without suicidal ideation, and to examine predictors of suicidal ideation in these patients. Eighty-eight consecutive outpatients with PDA were administered structured diagnostic interviews for the DSM-IV Axis I and Axis II disorders (SCID-I and SCID-II), while the severity of PDA was assessed by means of the Panic Disorder Severity Scale. Of the patients, 25 (28.4%) reported suicidal ideation in past years ('ideators'). The severity of PDA was greater among ideators, and they were significantly more likely to have a personality disorder and more than one comorbid Axis I and Axis II disorder. There were no ideators without either Axis I or Axis II comorbidity. Univariate logistic regression identified several predictors of suicidal ideation: any DSM-IV Cluster C personality disorder, any DSM-IV Cluster B personality disorder, any comorbid mood disorder, and severity of PDA. With multivariate logistic regression, a combination of any Cluster C personality disorder and severity of PDA emerged as the most significant predictor of suicidal ideation. These findings have implications for clinical practice in that PDA patients should be carefully assessed for the severity of their illness and presence of certain personality disorders and comorbid mood disorders, because they may all increase the risk for suicidal ideation.