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.     

Association between childhood trauma and dissociation among patients with borderline personality disorder

OBJECTIVE: To examine the relationship between childhood trauma and dissociative experience in adulthood in patients with borderline personality disorder. METHOD: Dissociative experiences scale scores and subscale scores for the Childhood Trauma Questionnaire were correlated in 139 patients. Patients were dichotomized into high or low dissociators using the Median Dissociative Experiences Scale score as the cut-off. RESULTS: Childhood Trauma Questionnaire Subscale scores for emotional and physical abuse and emotional neglect but not sexual abuse correlated significantly with Dissociative Experiences Scale scores. High dissociators reported significantly greater levels of emotional abuse, physical abuse, emotional neglect and physical neglect but not sexual abuse than low dissociators. CONCLUSION: Patients with borderline personality disorder therefore demonstrated levels of dissociation that increased with levels of childhood trauma, supporting the hypothesis that traumatic childhood experiences engender dissociative symptoms later in life. Emotional abuse and neglect may be at least as important as physical and sexual abuse in the development of dissociative symptoms.     

Predictors of trait aggression in bipolar disorder

OBJECTIVES: Although aggressive behavior has been associated with bipolar disorder (BD), it has also been linked with developmental factors and disorders frequently found to be comorbid with BD, making it unclear whether or not it represents an underlying biological disturbance intrinsic to bipolar illness. We therefore sought to identify predictors of trait aggression in a sample of adults with BD. METHODS: Subjects were 100 bipolar I (n = 73) or II (n = 27) patients consecutively evaluated in the Bipolar Disorders Research Program of the New York Presbyterian Hospital-Payne Whitney Clinic. Diagnoses were established using the Structured Clinical Interview for the DSM-IV (SCID-I) and Cluster B sections of the SCID-II. Mood severity was rated by the Hamilton Depression Rating Scale (HDRS) and Young Mania Rating Scale (YMRS). Histories of childhood maltreatment were assessed via the Childhood Trauma Questionnaire (CTQ), while trait aggression was measured by the Brown-Goodwin Aggression Scale (BGA). RESULTS: In univariate analyses, significant relationships were observed between total BGA scores and CTQ total (r = 0.326, p = 0.001), childhood emotional abuse (r = 0.417, p < 0.001), childhood physical abuse (r = 0.231, p = 0.024), childhood emotional neglect (r = 0.293, p = 0.004), post-traumatic stress disorder (t = -2.843, p = 0.005), substance abuse/dependence (t = -2.914, p = 0.004), antisocial personality disorder (t = -2.722, p = 0.008) and borderline personality disorder (t = -5.680, p < 0.001) as well as current HDRS (r = 0.397, p < 0.001) and YMRS scores (r = 0.371, p < 0.001). Stepwise multiple regression revealed that trait aggression was significantly associated with: (i) diagnoses of comorbid borderline personality disorder (p < 0.001); (ii) depressive symptoms (p = 0.001); and (iii) manic symptoms (p < 0.001). CONCLUSIONS: Comorbid borderline personality disorder and current manic and depressive symptoms each significantly predicted trait aggression in BD, while controlling for confounding factors. The findings have implications for nosologic distinctions between bipolar and borderline personality disorders, and the developmental pathogenesis of comorbid personality disorders as predisposing to aggression in patients with BD.     

Physical and sexual abuse in adolescent girls with borderline personality disorder

Recent investigations suggest that a history of childhood sexual abuse may be associated with borderline personality disorder. This study compares a group of female adolescents diagnosed as borderline with a control group for history of physical and sexual abuse. History of both forms of abuse, particularly sexual, distinguishes the two groups. Results point to the impact of repeated trauma on character structure, cognitive functioning, and Axis II symptomatology.     

Co-occurrence of Axis I and Axis II disorders in female and male patients with panic disorder with agoraphobia

Objective

The aim of this study is to compare female and male patients with panic disorder with agoraphobia (PDA) for the co-occurring Axis I and Axis II (personality) disorders, to better understand sex differences in PDA.

Methods

The Structured Clinical Interview for Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV) Axis I Disorders, Clinician Version and the Structured Clinical Interview for DSM-IV Axis II Personality Disorders were administered to 157 consecutive outpatients (112 females and 45 males) with principal diagnosis of PDA, who sought treatment at the 2 anxiety disorders clinics. Women and men with PDA were then compared with regard to the type and frequency of the co-occurring Axis I and Axis II disorders.

Results

Women with PDA had a statistically greater tendency to receive co-occurring Axis I diagnoses and a greater number of Axis I diagnoses than men. Such a difference was not found for personality disorders. However, no sex difference was found for the mean number of co-occurring Axis I and Axis II diagnoses per patient. There were significantly more women with at least one co-occurring anxiety disorder. Women had a significantly higher frequency of specific phobia, whereas men were diagnosed with hypochondriasis and past alcohol abuse or dependence significantly more often. With regard to Axis II disorders, the only significant sex difference pertained to the higher frequency of dependent personality disorder among women.

Conclusions

The results of this study suggest that there are more similarities than differences between sexes in the co-occurring Axis I and Axis II disorders. Still, the relatively specific relationships between PDA and excessive alcohol use in men and between PDA and dependent personality traits and personality disorder in women seem important and have implications for clinical practice and treatment.     

Gender Patterns in Borderline Personality Disorder

Gender differences in patients with borderline personality disorder are potentially relevant because they may guide clinicians in assessment and treatment. To date, a number of clinical features in borderline personality disorder have been examined for gender differences. As for prevalence, earlier research concluded that a higher proportion of women than men suffer from borderline personality disorder, although more recent research has determined no differences in prevalence by gender. In addition, there may not be gender differences in borderline personality disorder with respect to specific types of self-harm behavior, such as self-cutting or levels of psychological distress at clinical presentation. However, current evidence indicates that there are notable gender differences in borderline personality disorder with regard to personality traits, Axis I and II comorbidity, and treatment utilization. With regard to personality traits, men with borderline personality disorder are more likely to demonstrate an explosive temperament and higher levels of novelty seeking than women with borderline personality disorder. As for Axis I comorbidity, men with borderline personality disorder are more likely to evidence substance use disorders whereas women with borderline personality disorder are more likely to evidence eating, mood, anxiety, and posttraumatic stress disorders. With regard to Axis II comorbidity, men with borderline personality disorder are more likely than women to evidence antisocial personality disorder. Finally, in terms of treatment utilization, men with borderline personality disorder are more likely to have treatment histories relating to substance abuse whereas women are more likely to have treatment histories characterized by more pharmacotherapy and psychotherapy.     

Comorbid personality disorders in subjects with panic disorder: do personality disorders increase clinical severity?

Personality disorders are common in subjects with panic disorder. Personality disorders have been shown to affect the course of panic disorder. The purpose of this study was to examine which personality disorders affect clinical severity in subjects with panic disorder. This study included 122 adults (71 women, 41 men) who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition ( DSM-IV ) criteria for panic disorder (with or without agoraphobia). Clinical assessment was conducted by using the Structured Clinical Interview for DSM-IV Axis I Disorders, the Structured Clinical Interview for DSM-IV Axis II Personality Disorders, and the Panic and Agoraphobia Scale, Global Assessment Functioning Scale, Beck Depression Inventory, and State-Trait Anxiety Inventory. Patients who had a history of sexual abuse were assessed with Sexual Abuse Severity Scale. Logistic regressions were used to identify predictors of suicide attempts, suicidal ideation, sexual abuse, and early onset of disorder. The rates of comorbid Axes I and II psychiatric disorders were 80.3% and 33.9%, respectively, in patients with panic disorder. Patients with panic disorder with comorbid personality disorders had more severe anxiety, depression, and agoraphobia symptoms, had earlier ages at onset, and had lower levels of functioning. The rates of suicidal ideation and suicide attempts were 34.8% and 9.8%, respectively, in subjects with panic disorder. The rate of patients with panic disorder and a history of childhood sexual abuse was 12.5%. The predictor of sexual abuse was borderline personality disorder. The predictors of suicide attempt were comorbid paranoid and borderline personality disorders, and the predictors of suicidal ideation were comorbid major depression and avoidant personality disorder in subjects with panic disorder. In conclusion, this study documents that comorbid personality disorders increase the clinical severity of panic disorder. Borderline personality disorder may be the predictor of a history of sexual abuse and early onset in patients with panic disorder. Paranoid and borderline personality disorders may be associated with a high frequency of suicide attempts in patients with panic disorder.     

Are there differential relationships between different types of childhood maltreatment and different types of adult personality pathology?

While considerable data support the relationship between childhood trauma and adult personality pathology in general, there is little research investigating the specific relationships between different types of childhood maltreatment and adult personality disorders. The present study tested a model incorporating five a priori hypotheses regarding the association between distinct forms of childhood maltreatment and personality pathology in 231 psychiatric patients using multiple self-report measures (Personality Diagnostic Questionnaire-4th Edition, Child Trauma Questionnaire, Conflict in Tactics Scale Parent-Child Child-Adult, and Multidimensional Neglectful Behavior Scale). Step-wise linear regressions supported three out of five hypotheses, suggesting independent relationships between: physical abuse and antisocial personality disorder traits; emotional abuse and Cluster C personality disorder traits; and maternal neglect and Cluster A personality disorder traits after controlling for co-occurring maltreatment types and personality disorder traits. Results did not support an independent relationship between sexual abuse and borderline personality traits nor between emotional abuse and narcissistic personality disorder traits. Additionally, there were three unexpected findings: physical abuse was independently and positively associated with narcissistic and paranoid traits and negatively associated with Cluster C traits. These findings can help refine our understanding of adult personality pathology and support the future development of clinical tools for survivors of childhood maltreatment.     

Adult experiences of abuse reported by borderline patients and Axis II comparison subjects over six years of prospective follow-up

The main objective of this study was to assess the rates of adult experiences of verbal, emotional, physical, and sexual abuse reported by borderline patients and Axis II comparison subjects during 6 years of prospective follow-up. A semistructured interview was administered to 290 borderline patients and 72 Axis II comparison subjects during their index admission. A follow-up analogue to this interview was administered at three contiguous 2-year follow-up periods. Over 94% of surviving patients were re-interviewed at all three follow-up waves. The rates of all four forms of reported abuse declined significantly over time for all subjects considered together. However, each of these types of abuse was reported by a significantly higher percentage of borderline patients than Axis II comparison subjects. When the presence of these forms of abuse was used to predict time to remission, all but sexual abuse were strongly associated with the failure to achieve symptomatic remission from borderline personality disorder. Taken together, the results of this study suggest that the rates of adult abuse reported by borderline patients decline significantly with time but remain relatively high. They also suggest that adult experiences of abuse are strongly associated with a failure to remit from borderline personality disorder.     

Child and adolescent psychiatric disorders predicting adult personality disorder: a follow-up study

The objective of this study was to examine associations between childhood and adolescent psychiatric disorders and adult personality disorders in a group of former child psychiatric inpatients. One hundred and fifty-eight former inpatients with a mean age of 30.5 +/- 7.1 years at investigation had their childhood and adolescent Axis I disorders, obtained from their medical records, coded into DSM-IV diagnoses. Personality disorders in adulthood were assessed by means of the DSM-IV and ICD-10 Personality Questionnaire (DIP-Q). The predictive effects of child and adolescent Axis I disorders on adult personality disorders were examined with logistic regression analyses. The odds of adult schizoid, avoidant, dependent,borderline and schizotypal personality disorders increased by almost 10, five, four, three and three times, respectively, given a prior major depressive disorder. Those effects were independent of age, sex and other Axis I disorders. In addition, the odds of adult narcissistic and antisocial personality disorders increased by more than six and five times, respectively, given a prior disruptive disorder, and the odds of adult borderline, schizotypal, avoidant and paranoid personality disorders increased between two and three times given a prior sub-stance-related disorder. The results illustrate an association between mental disorders in childhood and adolescence and adult personality disorders. Identification and successful treatment of childhood psychiatric disorders may help to reduce the risk for subsequent development of an adult personality disorder.     

Relationship between borderline personality disorder and Axis I diagnosis in severity of depression and anxiety

BACKGROUND: This study tested the hypothesis that subjects with borderline personality disorder irrespective of the presence or absence of an Axis I mood or anxiety disorder would exhibit greater severity of depression and anxiety than subjects with either a personality disorder other than borderline personality disorder or no personality disorder. METHOD: Two hundred eighty-three subjects from an outpatient psychiatry clinic were administered the following assessments: the Structured Clinical Interview for DSM-III-R (SCID) for Axes I and II, the Hamilton Rating Scales for Depression and Anxiety, the Beck Depression Inventory, and the Spielberger State-Trait Anxiety Inventory. Subjects were categorized into borderline personality disorder, other personality disorder, and no personality disorder categories and into present versus absent categories on Axis I diagnosis of depression and of anxiety. A 2-factor multiple analysis of variance compared personality disorder status and Axis I diagnosis on severity of depression by observer rating and self-report. The analysis was repeated for anxiety. RESULTS: As hypothesized, significant main effects were found for borderline personality disorder and for both depression and anxiety. Subjects with borderline personality disorder showed greater severity on both depression and anxiety rating scales than did patients with another personality disorder, who showed greater severity than did patients with no personality disorder. Axis I diagnosis was also associated with greater severity on depression or anxiety rating scales. These differences were found for both observer ratings and self-report. An interaction was also found for depression: Subjects with borderline personality disorder but without an Axis I diagnosis of depression rated themselves as more severely depressed on the Beck Depression Inventory than did subjects with another or no personality disorder who also had an Axis I diagnosis of depression. CONCLUSION: Implications from the study are discussed including the need to assess for borderline personality disorder in research studies of depression and anxiety and to integrate treatments for borderline personality disorder into depression and anxiety treatment to maximize clinical outcomes.     

Characteristics of depressed patients who report childhood sexual abuse

OBJECTIVE: Depressed patients who had and had not been exposed to childhood sexual abuse were studied to determine differences in severity of depressed mood, lifetime histories of anxiety and depression, childhood environment, and disordered personality function. METHOD: Data were obtained from 269 inpatients and outpatients with major depression (171 women and 98 men) by means of structured clinical interviews and self-report questionnaires. RESULTS: Forty-six of the 269 patients reported childhood sexual abuse; 40 of these were women. These 40 women were compared with the 131 who did not report childhood sexual abuse. The patients who experienced abuse did not differ from those who had not on psychiatrist-rated mood severity estimates, but they did have higher self-report depression scores. They also evidenced more self-destructive behavior, more personality dysfunction, and more overall adversity in their childhood environment. Childhood sexual abuse status was associated with more borderline personality characteristics independently of other negative aspects of the patients' earlier parenting. Childhood sexual abuse status was linked strongly to adult self-destructiveness, as was early exposure to maternal indifference. CONCLUSIONS: Multivariate analyses suggest that depression is unlikely to be a direct consequence of childhood sexual abuse. Childhood sexual abuse appears to be associated with a greater chance of having experienced a broadly dysfunctional childhood home environment, a greater chance of having a borderline personality style, and, in turn, a greater chance of experiencing depression in adulthood.     

Predictors of comorbid personality disorders in patients with panic disorder with agoraphobia

The aim of this study was to ascertain predictors of comorbid personality disorders in patients with panic disorder with agoraphobia (PDAG). Sixty consecutive outpatients with PDAG were administered the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II) for the purpose of diagnosing personality disorders. Logistic regressions were used to identify predictors of any comorbid personality disorder, any DSM-IV cluster A, cluster B, and cluster C personality disorder. Independent variables in these regressions were gender, age, duration of panic disorder (PD), severity of PDAG, and scores on self-report instruments that assess the patient's perception of their parents, childhood separation anxiety, and traumatic experiences. High levels of parental protection on the Parental Bonding Instrument (PBI), indicating a perception of the parents as overprotective and controlling, emerged as the only statistically significant predictor of any comorbid personality disorder. This finding was attributed to the association between parental overprotection and cluster B personality disorders, particularly borderline personality disorder. The duration of PD was a significant predictor of any cluster B and any cluster C personality disorder, suggesting that some of the cluster B and cluster C personality disorders may be a consequence of the long-lasting PDAG. Any cluster B personality disorder was also associated with younger age. In conclusion, despite a generally nonspecific nature of the relationship between parental overprotection in childhood and adult psychopathology, the findings of this study suggest some specificity for the association between parental overprotection in childhood and personality disturbance in PDAG patients, particularly cluster B personality disorders.     

Patterns and predictors of attention-deficit/hyperactivity disorder persistence into adulthood: results from the national comorbidity survey replication.

BACKGROUND: Despite growing interest in adult attention-deficit/hyperactivity disorder (ADHD), little is known about predictors of persistence of childhood cases into adulthood. METHODS: A retrospective assessment of childhood ADHD, childhood risk factors, and a screen for adult ADHD were included in a sample of 3197 18-44 year old respondents in the National Comorbidity Survey Replication (NCS-R). Blinded adult ADHD clinical reappraisal interviews were administered to a sub-sample of respondents. Multiple imputation (MI) was used to estimate adult persistence of childhood ADHD. Logistic regression was used to study retrospectively reported childhood predictors of persistence. Potential predictors included socio-demographics, childhood ADHD severity, childhood adversity, traumatic life experiences, and comorbid DSM-IV child-adolescent disorders (anxiety, mood, impulse-control, and substance disorders). RESULTS: Blinded clinical interviews classified 36.3% of respondents with retrospectively assessed childhood ADHD as meeting DSM-IV criteria for current ADHD. Childhood ADHD severity and childhood treatment significantly predicted persistence. Controlling for severity and excluding treatment, none of the other variables significantly predicted persistence even though they were significantly associated with childhood ADHD. CONCLUSIONS: No modifiable risk factors were found for adult persistence of ADHD. Further research, ideally based on prospective general population samples, is needed to search for modifiable determinants of adult persistence of ADHD.     

Manic symptoms in young males with ADHD predict functioning but not diagnosis after 6 years

OBJECTIVE: To compare the outcome in early adulthood of males who met criteria for attention-deficit/hyperactivity disorder (ADHD) and mania, ADHD alone, or no psychiatric disorder when aged 9-13 years. METHOD: Males who met criteria at baseline assessment conducted in the period 1992-1994 for mania+ADHD (n = 15), ADHD without mania (n = 65), or no psychiatric diagnosis (n = 17) were reevaluated after 6 years using computer-assisted structured interviews for Axis I and Axis II disorders, questionnaires about functioning and service utilization, and a clinician-rated assessment of global functioning. RESULTS: There were no group differences in the prevalence of Axis I or Axis II disorders, with the exception of alcohol abuse, which was higher in controls. Manic symptoms persisted in only one mania+ADHD subject, while three (5%) of the ADHD subjects had new-onset manic symptoms. There were no clear cases of bipolar disorder. The groups were not distinguished on levels of service utilization or criminal behavior, but global functioning was significantly lower at follow-up in the mania+ADHD group compared with controls. CONCLUSIONS: Although a pilot study in scope, the findings cast doubt on a link between mania symptoms associated with ADHD in childhood and later bipolar disorder.     

Differential diagnosis and comorbidity of attention-deficit/hyperactivity disorder (ADHD) and borderline personality disorder (BPD) in adults

Attention-deficit/hyperactivity disorder (ADHD) in adults and borderline personality Disorder (BPD) share some similar clinical features (e. g. impulsivity, emotional dysregulation, cognitive impairment). ADHD in childhood has been reported to be highly associated with the diagnosis of BPD in adulthood and adult ADHD often co-occurs with BPD. Treatment studies revealed an efficacy of dialectical behavioral therapy (DBT) and DBT-based psychotherapy, respectively, in BPD and adult ADHD as well as neuroimaging and psychopharmacological studies showed some evidence for a potential common neurobiological dysfunction suggesting the hypothesis that ADHD and BPD may not be two distinct disorders, but represent at least in a subgroup of patients two dimensions of one disorder.     

Childhood antecedents of avoidant personality disorder: a retrospective study

OBJECTIVE: To explore potential risk factors and early manifestations of avoidant personality disorder (AVPD) by examining retrospective reports of social functioning and adverse childhood experiences. METHOD: Early social functioning and pathological childhood experiences were assessed using the Childhood Experiences Questionnaire-Revised. The responses of 146 adults diagnosed with primary AVPD were compared with a group of 371 patients with other personality disorders as a primary diagnosis and a group of 83 patients with current major depression disorder and no personality disorders, using chi2 analyses. Diagnoses were based on semistructured interviews by trained reliable clinicians. RESULTS: Adults with AVPD reported poorer child and adolescent athletic performance, less involvement in hobbies during adolescence, and less adolescent popularity than the depressed comparison group and the other personality disorder group. Reported rates of physical and emotional abuse were higher than the depressed group, but this result was influenced by comorbid diagnoses. CONCLUSIONS: These results suggest that early manifestations of AVPD are present in childhood but that various forms of abuse are not specific to the disorder.     

Anatomical MRI study of borderline personality disorder patients

Hippocampal volume reduction has been reported in patients with borderline personality disorder (BPD), and is hypothesized to be associated with traumatic childhood experiences. We extended this investigation to explore additional brain regions and other potential clinical correlates of structural brain changes in BPD. Ten unmedicated BPD subjects and 20 healthy controls were assessed for current and past Axis I and II comorbidities and histories of childhood abuse. All had magnetic resonance imaging (MRI) studies with a 1.5 T GE Signa Imaging System, performing three-dimensional-gradient echo imaging (SPGR) with the following parameters: TR=25 ms, TE=5 ms, and slice-thickness=1.5 mm. Compared with healthy controls, BPD subjects had significantly smaller right and left hippocampal volumes, most marked in subjects with childhood abuse, and significantly increased right and left putamen volumes, especially in subjects with substance use disorders. No significant differences between groups were found for caudate, amygdala, temporal lobes, dorsolateral prefrontal cortex and total brain volumes. This study replicated prior findings of diminished hippocampal volumes in subjects with BPD. Also, increased putamen volumes were found in BPD, a finding that has not been previously reported. Early traumatic experiences may play a role in hippocampal atrophy, whereas substance use disorders may contribute to putamen enlargement.     

Antecedents of opioid dependence and personality disorder: attention-deficit/hyperactivity disorder and conduct disorder

Both attention-deficit/hyperactivity disorder (ADHD) and conduct disorder (CD) were explored as possible antecedents of opioid dependence and personality disorder. One hundred adult opioid-dependent, treatment-seeking male inpatients were explored; an extended clinical semistructured interview to collect sociodemographic, drug use related, and clinical data and the Structural Clinical Interview for DSM-IV personality disorders SCID-II were carried out. Four groups of patients, namely ADHD alone (4 patients). ADHD + CD (7 patients), CD alone (47 patients) and no ADHD/no CD (42 patients) were identified and compared with each other. The results indicate that ADHD alone does not predispose to the development of opioid dependence in male inpatients. Childhood ADHD may nevertheless be found more frequently in male opioid addicts due to its comorbidity with CD, which was identified in more than half of our sample. Patients with ADHD history seemed to go through the drug abuse career earlier and to develop more frequently histrionic and obsessive-compulsive personality disorder. Over half of the CD patients developed borderline and/or antisocial personality disorder; both ADHD and CD predispose significantly to the PD development. Early substance use preventive measures are necessary in children and adolescents suffering from CD and from ADHD comorbid with CD. Received: 27 September 2000 / Accepted: 30 January 2001