Diagnosing comorbid psychiatric disorders in substance abusers: validity of the Spanish versions of the Psychiatric Research Interview for Substance and Mental Disorders and the Structured Clinical Interview for DSM-IV

OBJECTIVE: The authors' goal was to assess the validity of DSM-IV diagnoses obtained with the Spanish versions of the Psychiatric Research Interview for Substance and Mental Disorders (PRISM) and the Structured Clinical Interview for DSM-IV (SCID) compared with the longitudinal, expert, all data (LEAD) procedure in a group of substance abusers. METHOD: A total of 105 substance abusers recruited at a drug abuse treatment center in Barcelona, Spain, were assessed. The PRISM and SCID were administered blindly by independent research interviewers. LEAD diagnoses were made by two senior psychiatrists who were blind to PRISM and SCID diagnoses. The kappa statistic was used to measure concordance between the LEAD procedure and the PRISM and SCID. RESULTS: Affective and anxiety disorders were diagnosed more frequently by the PRISM and SCID than by the LEAD procedure. Use of the PRISM resulted in more diagnoses of substance-induced depression, and use of the SCID resulted in more diagnoses of primary major depression than the LEAD procedure. Kappas between the LEAD procedure and the PRISM in current major depression, past substance-induced depression, and borderline personality disorder were better than those obtained between the LEAD procedure and the SCID. The concordance among the three methods for diagnoses of current dependence disorders was good or excellent for alcohol, anxiolytic, cocaine, and heroin dependence and fair for cannabis dependence. Abuse diagnoses showed poor concordance. CONCLUSIONS: Using the LEAD procedure as a "gold standard," the authors conclude that the Spanish version of the PRISM seems to be a better instrument than the Spanish version of the SCID for diagnosing major depression and borderline personality disorders in substance abusers.     

Test-retest reliability of anxiety symptoms and diagnoses with the Anxiety Disorders Interview Schedule for DSM-IV: child and parent versions

OBJECTIVE: To examine the test-retest reliability of the DSM-IV anxiety symptoms and disorders in children with the Anxiety Disorders Interview Schedule for DSM-IV: Child and Parent Versions (ADIS for DSM-IV:C/P). METHOD: Sixty-two children (aged 7-16 years) and their parents underwent two administrations of the ADIS for DSM-IV:C/P with a test-retest interval of 7 to 14 days. RESULTS AND CONCLUSIONS: Results revealed that the ADIS for DSM-IV:C/P is a reliable instrument for deriving DSM-IV anxiety disorder symptoms and diagnoses in children. The ADIS for DSM-IV:C/P was found to have excellent reliability in symptom scale scores for separation anxiety disorder, social phobia, specific phobia, and generalized anxiety disorder and good to excellent reliability for deriving combined diagnoses of these disorders, as well as using child-only and parent-only interview information. Reliability coefficients were generally similar and, in most instances, superior to those found in previous ADIS-C/P reliability studies. Limitations and directions for future research are discussed.     

Differences between early-phase primary psychotic disorders with concurrent substance use and substance-induced psychoses

CONTEXT: The distinction between a substance-induced psychosis and a primary psychotic disorder that co-occurs with the use of alcohol or other drugs is critical for understanding illness course and planning appropriate treatment, yet there has been little study and evaluation of the differences between these 2 diagnostic groups. OBJECTIVE: To identify key demographic, family, and clinical differences in substance-induced psychosis and primary psychotic disorders diagnosed according to DSM-IV criteria using a research diagnostic instrument for psychiatric and substance use comorbidity. DESIGN: Data on demographic, family, and clinical factors were gathered at baseline as part of a 3-year longitudinal study of early-phase psychosis and substance use comorbidity in New York, NY. SETTING: Psychiatric emergency department admissions. PARTICIPANTS: The study is based on a referred sample of 400 subjects interviewed at baseline. Participants had at least 1 psychotic symptom assessed during administration of the research protocol, had used alcohol and/or other drugs within the past 30 days, and had no psychiatric inpatient history before the past 6 months. Subject race included 43.5% black, 42.0% Hispanic, and 14.5% white or other. MAIN OUTCOME MEASURE: Psychotic disorders defined by the DSM-IV. RESULTS: Overall, 169 (44%) were diagnosed as having substance-induced psychosis and 217 (56%), as having primary psychosis. Significant differences were observed in all 3 domains. Multivariate analysis using logistic regression identified the following 3 key predictors as being greater in the substance-induced group: parental substance abuse (odds ratio [OR], 1.69; 95% confidence interval [CI], 1.00-2.85), a diagnosis of dependence on any drug (OR, 9.41; 95% CI, 5.26-16.85), and visual hallucinations (OR, 2.13; 95% CI, 1.10-4.13). The key predictor of total positive and negative symptom score was greater in the primary psychosis group (OR, 0.96; 95% CI, 0.94-0.97). CONCLUSIONS: Differences in demographic, family, and clinical domains confirm substance-induced and primary psychotic disorders as distinct entities. Key predictors could help emergency clinicians to correctly classify early-phase psychotic disorders that co-occur with substance use.     

Use of health services by men with and without antisocial personality disorder who are alcohol dependent

In a sample of 104 medically stable male veterans with alcohol dependence, rates of health service utilization were compared for 48 patients with a primary diagnosis of antisocial personality disorder and 56 patients without this diagnosis. Patients were diagnosed using DSM-IV lifetime criteria; previous utilization of health services was based on self-reports. Although a similar proportion of both groups reported previous service use, patients with antisocial personality disorder reported using more substance abuse treatment services than those with a primary diagnosis of alcohol dependence. Between-group multiple regression analysis showed that an earlier age at onset of alcoholism and a history of a comorbid substance-induced mental disorder best predicted higher rates of use of substance abuse treatment.     

Importance of clinical diagnoses for comorbidity studies in substance use disorders

Many clinical and epidemiologic studies have shown a high frequency of co-occurrence of substance abuse and psychiatric disorders, with important consequences from health and social perspective. However, the identification of reliable and valid diagnosis of psychiatric comorbidity in substance abusers is problematic, mainly because the acute or chronic effects of substance abuse can mimic symptoms of many other mental disorders, making difficult to differentiate psychiatric symptoms that represent effects of acute or chronic substance use or withdrawal, of those that represent an independent disorder. While DSM-IIII-R and earlier nomenclatures were unclear in differentiating independent from other psychiatric disorders, DSM-IV and DSM-IV-TR provided clearer guidelines in diagnosing psychiatric disorders in heavy users of alcohol and drugs, providing three categories: "primary" psychiatric disorders, "substance-induced" disorders, and "expected effects" of the substances, meaning expected intoxication and/or withdrawal symptoms that should not be diagnosed as symptoms of a psychiatric disorder. The use of the "Psychiatric Research Interview for Substance and Mental Disorders (PRISM)", a structured interview developed to improve the diagnosis of co morbidity in drug abusers according DSM-IV, supplies new opportunities in the clinical research in this field.     

Screening for mental health: validity of the MHI-5 using DSM-IV Axis I psychiatric disorders as gold standard

Short screening questionnaires for mental health are useful tools for research and clinical practice, e.g. they could play a major role in detecting patients with psychiatric disorders in primary care. The present study tests the validity of the five-item Mental Health Inventory (MHI-5) screening test using DSM-IV Axis I diagnoses as a gold standard and analyzes its performance in different diagnostic groups. A random sample was drawn from the resident registration office files in northern Germany. Personal interviews with a response rate of 70% were conducted. Of the sample, 4036 respondents filled in the MHI-5. DSM-IV diagnoses were assessed using the Munich Composite International Diagnostic Interview (M-CIDI). The area under the receiver operating characteristics curve (AUC) of 0.72 in identifying any DSM-IV Axis I disorder (except substance use) is not satisfying. The MHI-5 revealed best performance for mood (AUC: 0.88) followed by anxiety disorders (AUC: 0.71). Sensitivity and specificity were poor for somatoform and substance use disorders, especially in cases without comorbid mood or anxiety disorder. The power to detect mood and anxiety disorders of the MHI-5 was better for the 4-week compared with the 12-month diagnoses. The MHI-5 can be recommended to screen for mood disorders. Data have to be confirmed for primary care settings.     

Reliability of anxiety assessment. I. Diagnostic agreement

Test-retest reliability of lifetime anxiety disorder diagnoses was determined using the Schedule for Affective Disorders and Schizophrenia-Lifetime Anxiety version. The subjects were 104 patients at an anxiety research clinic. Reliability ranged from good to excellent (kappa = +.60 to +.90) for generalized anxiety, social phobic, panic, agoraphobic, and obsessive-compulsive disorders. Simple phobia showed poor agreement. Current episodes showed better agreement than past episodes, particularly for social phobia and obsessive-compulsive disorder. Major sources of disagreement (variance in subject report, rate error, criterion ambiguity) were reviewed for each diagnosis and implications for DSM-IV are proposed.     

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.     

Axis II comorbidity of substance use disorders among patients referred for treatment of personality disorders.

OBJECTIVE: The purpose of this study was to determine the extent of comorbid substance use disorders in patients referred for treatment of personality disorders. METHOD: Two hundred inpatients and outpatients were assessed by semistructured interviews for substance use and personality disorders. Univariate odds ratios were calculated for groups of substance use disorders and each DSM-III-R axis II disorder; comorbidity among axis II disorders was controlled in multivariate models predicting current or lifetime substance use disorder groups. The impact of personality disorder on chronicity and overall impairment associated with substance use disorders was evaluated. RESULTS: Close to 60% of subjects with substance use disorders had personality disorders. Borderline personality disorder was significantly associated with current substance use disorders, excluding alcohol and cannabis, and with lifetime alcohol, stimulant, and other substance use disorders, excluding cannabis. Antisocial personality disorder was associated with lifetime substance use disorders other than alcohol, cannabis, and stimulants. These relationships remained significant after controlling for the presence of all other personality disorders. There was no evidence that personality disorders increased the chronicity of substance use disorders, but comorbid personality disorders were associated with greater global impairment. CONCLUSIONS: Borderline personality disorder may be associated with a wide variety of substance use disorders, especially among patients seeking treatment for personality problems.     

Psychopathy and Axis I and Axis II psychiatric disorders in a forensic psychiatric population in Sweden

The relationship between psychopathy and mental disorders was investigated in 61 male subjects during a forensic psychiatric examination. The Psychopathy Checklist Revised (PCL-R) and the Structured Clinical Interview for DSM-III-R (SCID) were used for the assessments. Although psychotic subjects were excluded, the overall psychiatric morbidity in the study population was high. Comorbidity was common, irrespective of the degree of psychopathy. Psychopathy was strongly positively correlated with substance abuse/dependence but negatively correlated with depression. Almost all of the subjects with high PCL-R scores had DSM-III-R antisocial and/or borderline personality disorders. However, some subjects with antisocial personality disorders had medium or low PCL-R scores. When the subjects were reassessed with diagnoses of DSM-IV and ICD-10 personality disorders, the difference between psychopathy and antisocial personality disorder was reduced.     

Differences in DSM-III-R and DSM-IV diagnoses in eating disorder patients

Two hundred eighty-eight eating disorder patients were administered the DSM-III-R Structured Clinical Interview (SCID) and the DSM-IV SCID for axis I and II. Concordance between DSM-III-R and DSM-IV was excellent for the axis I affective and anxiety disorders, bulimia nervosa, and substance abuse/dependence. It was also excellent for axis II paranoid, schizoid, borderline, and antisocial personality disorders. Agreement between the two nosological systems was lower for alcohol abuse/dependence with a kappa of.63. Kappas were also poor for the following personality disorders: schizotypal (.44), histrionic (.29), dependent (.54), obsessive-compulsive (.62) and not otherwise specified (.63). There was a substantial difference in the diagnosis of anorexia nervosa between DSM-III-R and DSM-IV. Fourteen patients were diagnosed with anorexia nervosa, binge/purge type, using DSM-IV criteria, while only six received the diagnoses of anorexia nervosa and bulimia nervosa using DSM-III-R criteria. Kappa was.49 and the percent agreement was 79%. While there are considerable areas of overlap in DSM-IV and DSM-III-R, there are also areas of substantial differences. Clinicians and researchers must be very cautious when attempting to compare data from the different nosologies.     

Confirmatory factor analysis of DSM-IV criteria for borderline personality disorder: findings from the collaborative longitudinal personality disorders study

OBJECTIVE: This study tested the factor structure of the DSM-IV criteria for borderline personality disorder by using confirmatory methods for the analysis of covariance structures in a large group from a multisite study. METHOD: A total of 668 primarily treatment-seeking subjects were reliably assessed for personality disorders by using the Diagnostic Interview for DSM-IV Personality Disorders. Associations among criteria for borderline personality disorder were examined. A confirmatory factor analysis was performed to test diagnosis as a unitary construct and to test an earlier-reported three-factor model comprising disturbed relatedness, behavioral dysregulation, and affective dysregulation. The three-factor model was subsequently tested by using a subset (N=498) of the study group that was reassessed 2 years later by independent evaluators who were blind to original diagnoses. RESULTS: Internal consistency of the borderline personality disorder diagnosis was adequate for both baseline and follow-up assessments. A confirmatory factor analysis model testing the borderline personality disorder diagnosis as a unitary construct provided good fit, and the three-factor model offered a significantly better fit for the baseline assessment. The three-factor model was replicated with the 2-year follow-up data. CONCLUSIONS: The diagnostic criteria for borderline personality disorder appear to reflect a statistically coherent construct. Three homogeneous components were supported empirically, lending conceptual clarity to different classes of the criteria for borderline personality disorder.     

The impact of ADHD and autism spectrum disorders on temperament, character, and personality development

OBJECTIVE: The authors describe personality development and disorders in relation to symptoms of attention deficit hyperactivity disorder (ADHD) and autism spectrum disorders. METHOD: Consecutive adults referred for neuropsychiatric investigation (N=240) were assessed for current and lifetime ADHD and autism spectrum disorders and completed the Temperament and Character Inventory. In a subgroup of subjects (N=174), presence of axis II personality disorders was also assessed with the Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II). RESULTS: Patients with ADHD reported high novelty seeking and high harm avoidance. Patients with autism spectrum disorders reported low novelty seeking, low reward dependence, and high harm avoidance. Character scores (self-directedness and cooperativeness) were extremely low among subjects with neuropsychiatric disorders, indicating a high overall prevalence of personality disorders, which was confirmed with the SCID-II. Cluster B personality disorders were more common in subjects with ADHD, while cluster A and C disorders were more common in those with autism spectrum disorders. The overlap between DSM-IV personality disorder categories was high, and they seem less clinically useful in this context. CONCLUSIONS: ADHD and autism spectrum disorders are associated with specific temperament configurations and an increased risk of personality disorders and deficits in character maturation.     

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.     

Dysmorphic concern symptoms and personality disorders: a clinical investigation in patients seeking cosmetic surgery

Body dysmorphic disorder (BDD) is a somatoform disorder characterized by an excessive concern with an imagined or slight defect in appearance. BDD has been particularly studied in cosmetic surgery settings. The object of the present study is to investigate the relationship between personality disorders and dysmorphic symptoms in a group of 66 patients seeking cosmetic surgery. Assessment instruments included the following: a semistructured interview for demographic and clinical characteristics; the Structured Clinical Interview for DSM-IV, the Hamilton Depression and Anxiety Rating Scales, and the Body Dysmorphic Disorder Yale - Brown Obsessive--Compulsive Scale (BDD - YBOCS). A multiple regression analysis was performed using the BDD - YBOCS score as a continuous dependent variable. The severity of dysmorphic symptoms (BDD - YBOCS score) was significantly related to two factors: the number of diagnostic criteria for schizotypal and paranoid personality disorders. The results suggest that the presence of a psychopathological reaction to imagined defects in appearance in subjects pursuing a surgical correction is associated with the severity of schizotypal and paranoid personality disorders. Preoperative assessment could help to define the clinical profile of patients in cosmetic surgery settings.     

Co-occurrence of mood and personality disorders: a report from the Collaborative Longitudinal Personality Disorders Study (CLPS)

The purpose of this study was to examine the relationship of subtypes and particular clinical features of mood disorders to co-occurrence with specific personality disorders. Five hundred and seventy-one subjects recruited for the Collaborative Longitudinal Personality Disorders Study (CLPS) were assessed with the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) and the Diagnostic Interview for DSM-IV Personality Disorders (DIPD-IV). Percent co-occurrence rates for current and lifetime mood disorders with personality disorders were calculated. Logistic regression analyses examined the effects of clinical characteristics of depressive disorders (e.g., age at onset, recurrence, symptom severity, double depression, and atypical features) on personality disorder co-occurrence. In comparison with other DSM-IV personality disorders, avoidant, borderline, and dependent personality disorders (PDs) were most specifically associated with mood disorders, particularly depressive disorders. Severity and recurrence of major depressive disorder and comorbid dysthymic disorder predicted co-occurrence with borderline and to a lesser extent research criteria depressive personality disorders. The results are consistent with the view that a mood disorder with an insidious onset and recurrence, chronicity, and progression in severity leads to a personality disorder diagnosis in young adults.     

Early-onset obsessive-compulsive disorder and personality disorders in adulthood

Obsessive-compulsive disorder (OCD) often emerges in childhood or adolescence. The aim of the present study was to evaluate whether adult patients with prepuberal onset differ from subjects with later onset in terms of personality disorder comorbidity. The Structured Clinical Interview for DSM-IV Axis II Disorders was used to assess 148 patients with a principal diagnosis of OCD according to the Structured Clinical Interview for DSM-IV Axis I Disorders. The following two subgroups of subjects were selected according to the age at onset of symptomatology: patients with an early-onset (< or =10 years), and patients with a later onset (> or =17 years). Of the 148 patients screened for the present study, 33 (22.3%) had an early onset and 1369 (46.6%) had a later onset. With regard to personality disorders, early-onset patients showed more OC personality disorders (OCPD) than later onset patients. Our finding suggests that OCD in childhood increases the risk for developing OCPD in adulthood, or that early-onset OCD and OCPD share a common pathogenesis.     

Validity, reliability and objectivity of the family history method in psychiatry: a meta analysis.

BACKGROUND: The family history is a widely used method in psychiatry; but data on the method's objectivity, reliability and validity shows partly diverging results. METHOD: In October 2005, a Medline search was conducted that yielded 7 studies regarding objectivity/reliability and 13 studies regarding validity. Results for six main groups of psychiatric diagnoses and any mental disorder were combined qualitatively for objectivity/reliability, and quantitatively for validity. RESULTS: Objectivity was generally high (kappa in the 0.80 range). Reliability was high for any mental disorder, schizophrenia, substance abuse and depression (kappa in the 0.70 range), and low or medium for anxiety (kappa between 0.30 and 0.50). Results on validity displayed an OR=148 for the family history for schizophrenia; OR=64 for mania/bipolar disorder; and OR's between 8 and 194 for substance abuse, between 3 and 37 for depression, between 5 and 350 for personality disorders, between 2.5 and 49 for anxiety, and between 2.4 and 9 for any mental disorder. CONCLUSION: There is clear evidence that the family history provides results that are better than chance for all disorders examined. But variance among diagnostic groups and among studies is considerable.     

Confirmatory factor analysis of DSM-IV borderline,schizotypal, avoidant and obsessive-compulsive personality disorders: findings from the Collaborative Longitudinal Personality Disorders Study

OBJECTIVE: To test the diagnostic constructs implied by DSM-IV Axis-II personality disorders by examining relationships between different combinations of DSM-IV criteria. METHOD: Confirmatory factor analysis was used to test the borderline, schizotypal, avoidant and obsessive-compulsive personality disorder constructs in a large treatment-seeking sample (N= 668) from a multisite study. A model based on the three DSM-IV Axis II clusters was also tested. Both models were tested against a unitary 'generic' model constructed from four criteria sets combined. RESULTS: Goodness-of-fit for both the three-cluster and four disorder models was significantly better than the unidimensional model, and the four-disorder model was significantly better than the three-cluster model. Results were replicated using data from 2-year follow-up obtained by interviewers blind to original Axis II diagnoses at baseline. CONCLUSION: Support is provided for the DSM-IV disorder-level classification for schizotypal, borderline, avoidant and obsessive-compulsive personality disorders in a treatment-seeking sample.