Acute and transient psychotic disorders versus persistent delusional disorders: a comparative longitudinal study

Aim: The aim of this work is to investigate differences between two non‐schizophrenic, non‐organic psychotic disorders, namely persistent delusional disorders (PDD) and acute and transient psychotic disorders (ATPD) according to ICD‐10. Method: In a prospective and longitudinal study, we compared all 43 inpatients with PDD who were treated at Halle‐Wittenberg University Hospital during a 14‐year period to a previously investigated cohort of 41 patients with ATPD in regard to demography, long‐term symptomatic outcome, and social consequences. Sociobiographical data were collected using a semi‐structured interview. Follow‐up investigations were performed at a mean of 10–12 years after the onset of the disorder using standardized instruments. Results: With the exception of the duration of the psychotic symptoms, the PDD patients were significantly different from the ATPD patients on various levels, such as sex ratio (female predominance only in ATPD), age at onset (older in PDD), the number of preceding stressful life‐events in the index hospitalization (more frequent in ATPD), richness and variety of symptoms (higher in ATPD), and persistence of positive psychotic symptoms (in PDD). Patients with PDD had significantly less re‐hospitalizations during the course of their illness. Long‐term outcome was marked by chronicity of delusional symptoms and lower global functioning in PDD than in ATPD, while negative symptoms and loss of independence were infrequent in both conditions. Conclusions: PDD differs from ATPD not only in the duration of the psychotic symptoms, but also in a variety of significant variables. They appear to be two separate entities within a psychotic spectrum.     

Follow-up study on borderline versus nonborderline personality disorders

Using a semi-structured interview, 18 DSM-III borderline personality disorder (BPD) patients and 17 other (nonborderline) personality disorder (OPD) patients were compared blind 4 1/2 years after their index discharge. Although significantly younger and mostly single, BPD patients did not differ from OPD patients in the degree of overall psychopathology or in the level of psychosocial functioning and adjustment. They do not seem to represent a particularly severe personality disorder group. Those characteristics differentiating BPD patients from affective disorders and schizophrenia may be nonspecific regarding other personality disorder types. As such, more attention should be paid to cases of OPD in the future.     

The prevalence of personality disorders in a community sample

BACKGROUND: To our knowledge, no previous studies of personality disorders (PDs) in a large representative sample of the common population have been conducted. METHODS: A representative sample of 2053 individuals between the ages of 18 and 65 years in Oslo, the capital of Norway, was studied from 1994 to 1997. Information about PDs was obtained by means of the Structured Interview for DSM-III-R Personality Disorders, in conjunction with an interview recording demographic data. The subjects were interviewed primarily at home, but in some instances, also at the clinic. RESULTS: The prevalence of PDs was 13.4% (SE, 0.7). The prevalence rates (SEs) for specific PDs, irrespective of whether a person had 1 or more PD, were: paranoid, 2.4% (0.3); schizoid, 1.7% (1.6); schizotypal, 0.6% (0.2); antisocial, 0.7% (0.2); sadistic, 0.2% (0.1); borderline, 0.7% (0.2); histrionic, 2.0% (0.3); narcissistic, 0.8; (0.2); avoidant, 5.0% (0.5); dependent, 1.5% (0.3); obsessive-compulsive: 2.0% (0.3); passive-aggressive, 1.7% (0.3); self-defeating, 0.8%, (0.2). The prevalence of PDs was highest among subjects with only a high school education or less, and living without a partner in the center of the city. CONCLUSIONS: Personality disorders were found to be prevalent, with avoidant, schizoid, and paranoid PDs more common, and borderline PD less common than what is usually reported. Personality disorders tend to be more frequent among single individuals from the lower socioeconomic classes in the center of the city. It is impossible to determine what is cause and what is consequence from a cross-sectional study.     

Residential versus day treatment for children: A long-term follow-up study

Adults and adolescents, who as children, received day or residential treatment were followed up ten years after treatment completion. No differences were found between the two treatment modalities on follow-up ratings of personal and social adjustment. This pattern was not influenced by gender, IQ, or presenting problem. Overall, about two-thirds of the children demonstrated improvement at follow-up. As expected, individuals demonstrating higher levels of personal and social adjustment at initial assessment were functioning better at outcome. However, the magnitude of therapeutic gain was not significantly different for mild versus moderate-to-severe presenting problems. Suggestions for future research are included.     

Predictors of dropout among personality disorders in a specialist outpatients psychosocial treatment: a preliminary study

Aim: The aim of this study was to identify factors that may affect treatment retention in a 1‐year psychosocial program for adult personality disorders. Methods: The sample consists of patients admitted to the Adult Personality Disorder Outpatient Programme of the Bologna Community Mental Health Centre in the period 2003–2008. At the beginning of the program, patients were evaluated through a comprehensive assessment including sociodemographic form, diagnostic interviews and self‐report questionnaires. Patients who dropped out from treatment were retrospectively compared with patients who completed the program. Results: Out of 39 patients enrolled in the program, 20 (51.3%) dropped out and 19 (48.7%) completed the treatment. Out of 20 patients who dropped out, 14 terminated the treatment within the first 2 months. The dropout group and the group which remained showed significant differences in diagnosis (borderline personality disorder [BPD]), demographic data (age, time from first contact with psychiatric services), clinical variable (impulsiveness) and subjective experience (motivation, treatment expectation, therapeutic relation perception and barriers to access). BPD and subjective evaluation were found to be predictors of premature termination in the sample. In detail, BPD patients who experienced a less satisfactory therapeutic relationship and reported many external problems were more likely to drop out of the program. Conclusion: Important factors contributing to dropout were identified, with potential implication for clinical practice. Further efforts need to be made to find ways to retain BPD patients who find the first subjective experience of the service more problematic.     

The community meeting: a comparative study.

In this study of two identical open wards, the author found that in ward 1's highly structured meetings a higher proportion of patients participated, and they distributed their participation in more direct proportion to the relative numbers of each present than in the open meetings on ward 2, where patients directed their participation disproportionately to staff. Staff on both wards disproportionately directed their participation to patients, but less so in the structured meetings. The implications of these observations are discussed in terms of the executive ego deficits of the patients involved and their need for structure in the external milieu in order to compensate for these deficits.     

Psychotherapeutic treatment of personality disorders

Treating patients with personality disorders presents a major challenge due to their maladaptive interpersonal styles which affect the therapeutic relationship. A number of therapeutic approaches using psychodynamic, behavioural, and other origins have been developed to treat patients with personality disorders, most of them dealing with borderline personality disorder. Overall, only a few controlled therapy studies have been carried out to document therapy effectiveness. However, available research indicates that psychotherapy has substantial effects even in personality disorders. From a vast literature based on case reports, therapeutic recommendations are presented for specific personality disorders.     

Pharmacological treatment of personality disorders

Therapists are only now just beginning to clear a way through the jungle of personality disorder and any recommendations about drug treatment have to be tentative and, to some extent, speculative. Nevertheless, it is reasonable to conclude that drug treatment, mainly in the form of antipsychotic agents, should be considered in borderline and antisocial personality disorders and also possibly in the schizotypal group. There is also growing evidence that two drugs used in the treatment of manic-depressive psychosis, lithium and carbamazepine, may have independent effects in controlling aggression and impulsiveness and be of value of borderline and antisocial personality disorders. In histrionic and dependent personality disorders, drug treatment is in general contraindicated and for the remaining group our ignorance of the possible benefit of the drugs is almost total. However, the negative effect of these personality disorders on response to treatment in the presence of depression, anxiety, and other abnormal mental state disorders suggests that drug treatment probably has little part to play in management of these particular personality disorders. A major deficiency in our knowledge, which can only be remedied by long-term studies that are extremely difficult to mount, is the recommended duration of treatment with drugs in personality disorder. No guidelines exist at present but now that some measure of efficacy has been established duration of treatment needs to be addressed.     

Psychopharmacologic treatment of personality disorders

There is only a paucity of studies concerning the pharmacological treatment of personality disorders per se. On the other hand the clinical use of medication in these conditions is quite high, although there is no effective psychopharmacological treatment of distinct personality disorders. The psychopharmacological treatment of patients suffering from a personality disorder focuses on distinct symptoms and its comorbidity. Some symptoms could also be associated with other disorders like depression or psychosis, which often makes an exact differentiation of these disorders and a personality disorder difficult. Since symptoms of personality disorders are ego-syntonic, chronic and very often dependent on psychosocial factors, it is unlikely that a solely psychopharmacological treatment will be successful in most patients with a personality disorder. However, severe syndromes like depressive, impulsive, aggressive, dissociative, anxious or psychotic features may render a pharmacotherapy necessary. For the treatment of depressive syndromes or impulsivity a medical therapy with serotonin reuptake inhibitors, for the treatment of psychotic syndromes a medication with atypical antipsychotics is recommended. Impulsive or aggressive behaviour could be treated with mood stabilizers as well. Furthermore, there are indications for the use of alpha2-agonists, micro-opiate-antagonists and omega-3 fatty acid. The general use of benzodiazepines should be avoided as well as polypragmasy. Advantages versus potential damage of a high dose pharmacotherapy should be carefully weighed against each other. This article gives an overview over the today's most common psychopharmacological treatment possibilities in patients with a personality disorder.     

Prevalence of DSM-III personality disorders in the community

Summary A community sample of adults with a standardized DSM-III, Axis II self-report instrument yielded an age adjusted community prevalence of 11.1% of DSM-111 personality disorders. When those with personality disorders (PDs) (n = 26) were compared to those without personality traits (n = 467) the PD group had less education 14.9 (3.0) years vs 16.5 (3.3) years,p = 0.02) and a greater percentage with difficulty with alcohol (19% vs 0.6%,p = 0.0001). Of those married, more 1 PDs reported marital difficulties (29% vs 3.5%,p = 0.002). There was a trend for the PD group to have longer unemployment (p = 0.07).     

Day treatment for personality disorders: a review of research findings

Day treatment, a form of partial hospitalization, may have unique advantages in the care of patients with personality disorders. It appears to offer a favorable level of intensiveness and containment, thus facilitating treatment of the chronic emotional and behavioral difficulties experienced by these individuals. Although several authors have written about the appropriateness of day treatment for personality disorder patients, empirical support has been slow to accumulate. More recently, greater research attention has been focused on this question. This review examines the current research. The findings suggest that day treatment is effective for this difficult patient population and that it is more effective than standard treatment (i.e., medication and support). Preliminary evidence indicates that day treatment may lead to a reduction in future health-services costs. Some findings also show that day treatment may be particularly beneficial for certain patients-for example, those who are more psychologically minded. Implications of these findings for clinical practice are considered. Limitations in our current approach to research in this area are highlighted, and recommendations for future study are provided.     

Auditory brainstem response: a comparative study of ipsilateral versus contralateral recording in neurological disorders of children

The auditory brain stem response (ABR) was studied in 103 normal and 90 neurologically abnormal children. The ABR was recorded simultaneously in Cz to the mastoid both ipsilateral and contralateral to the stimulated ear. A comparison between the ipsilateral and contralateral recording demonstrated that contralateral recording resulted in a small increase in the latency of peak V, whereas peak III showed a small latency reduction in the large majority of normal and neurologically abnormal children despite relatively large intersubject variability. There were some cases (cerebral palsy, infantile spasms) which demonstrated abnormal ABR only on contralateral recordings. Since most averaging systems have two channels, it is desirable to record the ABR simultaneously on bilateral recordings.     

Parricide: a comparative study of matricide versus patricide

Between 1990 and 2005, 64 parents were killed by their children in the province of Quebec, Canada. The authors reviewed all consecutive coroners' files on these cases and found that 27 mothers and 37 fathers were the victims of parricide. The sample included 56 perpetrators: 52 sons and 4 daughters; 9 cases of double parricide were found. Approximately 15 percent of the perpetrators (8/56) attempted suicide following the parricide. A psychiatric motive (stemming from depression or psychotic illness) was determined for 65.5 percent (36/56) of the perpetrators, and 67 percent of them had a psychotic disorder. Similarities and differences were found between cases of matricide and patricide.     

Alexithymia: a comparative study of three self-report measures

This study evaluates and compares the psychometric properties of the three self-report measures of alexithymia - a hypothetical personality construct thought to be associated with hypochondriasis, somatization disorder and a variety of other medical and psychiatric disorders. Two hundred and nine college students were administered the Schalling-Sifneos Personality Scale (SSPS), MMPI alexithymia scale (MMPI-A), Toronto Alexithymia Scale (TAS), and two measures of functional somatic symptoms. Results indicated that the TAS is internally consistent and sensitive to reports of somatic symptoms. In contrast, the SSPS and MMPI-A were found to have response and/or gender biases, poor internal reliabilities, and no systematic relationship with somatic symptoms. In addition, factor analysis showed the TAS to have a stable, replicable factor structure, while the SSPS demonstrated little factor stability. These findings suggest that the TAS is the most psychometrically sound measure of the alexithymia construct.     

Comorbidity of personality disorders: two for the price of three

Clinicians who treat individuals with personality disorders must remain alert to the presence of concurrent mood disorders, anxiety disorders; or schizophrenia. Comorbid disorders can significantly affect a patient's presentation, treatment, and prognosis.     

Conceptualization and treatment of personality disorders

Abstract

Résumé

There is an emerging consensus that the essence of personality pathology consists of difficulties with self-identity and chronic interpersonal dysfunction. The nature of normal and abnormal attachment to others, attention control, affect regulation, and the autobiographical self are related developmentally to the early caregiving context. Psychotherapeutic intervention for adults with personality disorders across many schools of psychotherapy is focused on changing the individual's dysfunctional internal models of self and others. Future research will examine how cognitive, cognitive–behavioral, interpersonal, and psychodynamic treatments accomplish this task. Advances in neurobiology, laboratory tasks, and interview techniques will assist in the measurement of personality organization and identification of subgroups of patients for more refined treatments. Our future treatment development must be differentiated and multifaceted, respecting subgroups of patients with severe personality disorders.

Zusammenfassung

Die Konzeptualisierung und Behandlung von Persönlichkeitsstörungen

Die Ansicht, dass Persönlichkeitsstörungen i. A. durch Probleme der Selbstidentität und eine chronische interpersonelle Disfunktion geprägt sind, setzt sich immer mehr durch. Die Art der normalen und anormalen Bindung an andere, der Aufmerksamkeitskontrolle, der Affektregulierung und des autobiographischen Selbst sind im Kontext der frühkindlichen Versorgung zu sehen. Psychotherapeutische Interventionen bei Erwachsenen mit Persönlichkeitsstörungen sind über viele Psychotherapieschulen hinweg darauf konzentriert, die disfunktionalen inneren Modelle vom Selbst und von anderen zu verändern. Zukünftige Forschung wird herausfinden, wie kognitive, kognitiv-verhaltensmäßige, interpersonelle und psychodynamische Behandlungen dieses Ziel erreichen. Fortschritte in der Neurobiologie, bei experimentellen Aufgaben und bei Interviewtechniken werden die Messung von Persönlichkeitsorganisation unterstützen und die Identifikation von Untergruppen ermöglichen und so zu einer Verfeinerung der Behandlung führen können. Die zukünftige Entwicklung von Behandlungen muss, vom Tatbestand von Untergruppen bei schweren Persönlichkeitsstörungen ausgehend, darauf ausgerichtet sein, einen differenzierten und multiperspektivischen Zugang anzustreben .

Conceptualisation et traitement des troubles de personnalité

Un consensus émerge sur le fait que l'essence de la pathologie de la personnalité consiste autour de difficulté de l'identité de soi et des dysfonctions interpersonnelles chroniques. la nature de l'attachement normal et anormal aux autres, le contrôle de l'attention , la régulation affective, et le soi autobiographique sot reliés avec le contexte de soin précoce. Les interventions psychothérapeutiques pour les adultes présentant des troubles de la personnalité sont dans de nombreuses écoles de psychothérapies focalisées sur leurs modèles internes dysfonctionnels de soi et de l'autre. Les recherches futures ont à examiner comment les traitements comportementaux, cognitifs-comportementaux, interpersonnels et psychodynamiques accomplissent cette tâche. Les progrès en neurobiologie, dans les tâches de laboratoire ainsi que dans les techniques d'entretien vont assister la mesure de l'organisation de la personnalité et l'identification de sous-groupes de patients pour des traitements plus affinés. Notre développement du traitement doit être à l'avenir différencié et à multiples facettes, respectant des sous-groupes de patients avec des troubles sévères de la personnalité.

Sommario

Concettualizzazione e trattamento dei disturbi di personalità.

Esiste un consenso emergente che l'essenza della patologia di personalità consista in difficoltà con l'identità di sè e la disfunzione interpersonale cronica. La natura di un normale ed anormale attaccamento agli altri, il controllo dell'attenzione, la regolazione affettiva ed il sé auto autobiografico sono relativi all'accrescimento iniziale nel contesto di cure parentali. L'intervento psicoterapeutico per gli adulti con i disturbi di personalità attraverso molte scuole della psicoterapia si focalizza sul cambiare i modelli interni disfunzionali dell'individuo e degli altri. La ricerca futura esaminerà come i trattamenti cognitivi, cognitivo-comportamentale, interpersonale ed i trattamenti psicodinamici compiono questa operazione. Gli avanzamenti nella neurobiologia, nei compiti e tecniche di interviste aiuteranno nel misurare l'organizzazione di personalità e nell'identificazione dei sottogruppi di pazienti per trattamenti più raffinati. Il nostro sviluppo futuro di trattamento deve essere differenziato e sfaccettato, rispettando i sottogruppi di pazienti con gravi disturbi di personalità.

Resumen

Conceptualización y tratamiento de los desórdenes de personalidad

Existe un consenso progresivo acerca de que la esencia de la patología de la personalidad consiste en dificultades con la propia identidad y con disfunciones crónicas en las relaciones interpersonales. La naturaleza del apego tanto normal como anormal, el control de la atención, la regulación del afecto y el self autobiográfico están relacionados con el contexto de cuidados tempranos. La intervención psicoterapéutica de adultos con desórdenes de la personalidad según diversas escuelas de psicoterapia está focalizada en cambiar los modelos internos disfuncionales del self y de los otros. La investigación futura examinará cómo los tratamientos cognitivo, cognitivo-comportamental, interpersonal y psicodinámico pueden lograrlo. Los avances en la neurobiología, los trabajos de laboratorio y las técnicas de entrevista ayudarán en la evaluación de la organización de la personalidad y en la identificación de subgrupos de pacientes asignables a tratamientos más refinados. Nuestro desarrollo terapéutico futuro debe ser diferenciado y multifacético respecto de los subgrupos de pacientes con desórdenes severos de la personalidad.

     

The psychopharmacologic treatment of personality disorders

We have reviewed both the rationale for and approaches to the use of psychotropic medications in the treatment of personality disorders. Despite some studies that may provide the seeding crystals around which significant data bases regarding the drug treatment of personality disorders will develop, the pharmacologic treatment of personality disorder remains a clouded area governed more by opinion than fact. Clinicians must still be guided by basic clinical sense regarding the use of medications with these patients. Some questions to ask are the following: Has the patient responded to medications in the past? What are the risks for abuse or self-destructive acting out? What is the risk-to-benefit ratio for the introduction of a drug into a psychotherapeutic situation at a given time? Is hospitalization necessary to assess the potential benefits of medication to the patient while minimizing the potential to act out? Although these guidelines may seem inadequate, clinicians can take some solace in the fact that ongoing studies will lead to better informed psychopharmacologic choices for patients with personality disorders.     

Diagnosis and treatment of personality disorders

This article touches on four current areas of controversy in the field of the personality disorders — definition, etiology, assessment, and treatment. There is a tremendous amount of disability, personal distress, and public health expense as a result of the personality disorders. We are seeing steady progress in each of these areas. The implications of this progress are enormous, and the interest in this area is widespread, not just among psychiatric health professionals or among patients and their families and friends, but also among the public at large.