Self-harm behavior among individuals with intermittent explosive disorder and personality disorders

Self-harm behaviors are a major public health concern across the lifespan, particularly among individuals with psychiatric disorders. Little research, however, has examined these behaviors among individuals with a diagnosis characterized by recurrent acts of impulsive aggression, Intermittent Explosive Disorder (IED). Furthermore, extant research has not examined variables that might mediate the relationship between IED and self-harm. The current study examined the rates of non-suicidal self-injury (NSSI) and suicide attempts among individuals with IED as compared to healthy controls, individuals with personality disorders (PDs; which are highly comorbid with IED), and individuals with comorbid IED and PD. The study also examined the indirect effects of aggression, impulsivity, and affective lability in the relationship between diagnosis and self-harm. Participants were 1079 community individuals and prevalence rates among the total sample were 18% for NSSI and 13.2% for suicide attempts. Scores on measures aggression, impulsivity, and affect lability showed significant indirect effects on the relationships between IED + PD and NSSI; scores on aggression showed a significant indirect effect on the relationship between PD and NSSI; scores on impulsivity showed a significant indirect effect on the relationship between IED + PD and suicide attempt. These results suggest that individuals with PDs, and particularly those with comorbid IED and PD, are at increased risk for engagement in self-harm behaviors. Furthermore, traits of aggression, impulsivity, and affect lability significantly accounted for the relationship between diagnostic status and self-harm, particularly in regards to NSSI.     

Frequency of comorbid personality disorders in bipolar and unipolar affective disorders

One expression of the complex relationship between personality and affective disorder is the comorbidity of personality disorders (PDs) with affective disorders. In a sample of 117 patients with unipolar and 60 with bipolar affective disorders, we assessed DSM-III-R PDs with the Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II) and compared them with personality factors as obtained by the five-factor model (FFM-NEO Five-Factor Inventory). Fifty-one percent of the unipolar and 38% of the bipolar disorders fulfilled criteria for a comorbid PD. The three most frequent PDs were obsessive-compulsive PD, borderline PD, and narcissistic (bipolar) or avoidant (unipolar) PD. Cluster C PDs and especially avoidant PD occurred significantly more frequently in unipolar than in bipolar patients, while narcissistic PD occurred significantly more often in bipolar than in unipolar patients. The FFM results supported the validity of our PD diagnoses. In a logistic regression analysis, higher depression score at the time of the SCID-II interview and shorter duration of the illness were weakly related to a higher frequency of PDs. Our results indicate that PDs are frequent in affective disorders and that there are subtle differences between unipolar and bipolar patients concerning such comorbid disorders.     

Personality disorders among patients accessing alcohol detoxification treatment: prevalence and gender differences

BackgroundAlcohol abuse and dependence are frequently associated with psychiatric disorders and personality disorders (PDs) with differences among gender. However, only few studies investigated gender differences in PDs among alcoholics. The aim of this study was to investigate PDs in a sample of patients accessing inpatient alcohol detoxification treatment and to describe gender differences in prevalence and comorbidity of PDs.MethodsThe study population consisted of 206 patients entering alcohol detoxification treatment in a specialized clinic in Italy. At enrollment, patients filled in the Millon Clinical Multiaxial Inventory-III for the assessment of PDs.ResultsThe sample consisted of 150 males and 56 females. Twenty-five percent of males vs 12.5% of females had 1 PD; 16% vs 23%, 2 PDs; and 46% vs 48%, more than 3 PDs. A statistically significant higher proportion of females got high scores on avoidant (21.4% vs 9.3%), self-defeating (50.0% vs 24.0%), and borderline scales (42.9% vs 25.3%). Depressive, self-defeating, and borderline PDs were frequently associated both to other PDs and among each other, particularly among females.ConclusionsBorderline PD is confirmed to be more frequent among females than among males accessing alcohol detoxification treatment. More studies are needed to clarify prevalence and associations of PDs, prognosis, and gender differences in alcoholics patients.     

Personality disorders in a total population twin cohort with eating disorders

Findings regarding the occurrence of personality disorders (PDs) in eating disorders (EDs) have been contradictory. Most previous studies have been clinic-based. The aims of the current study were to assess the prevalence of PD in ED in a population-based twin group and to establish the distribution of PD in three subgroups of ED. A two-step screening and diagnostic study of ED was performed in a large Danish twin population. Axis I and axis II DSM-III-R and DSM-IV ED diagnoses were made on the basis of results obtained at clinical investigations and interviews. Forty-nine percent of the participants with ED had at least one PD, compared to 26% in those with no ED (P <.001). Cluster C PD was the most common type of PD in all subgroups of ED, and cluster B PD was found only in participants with bulimic symptoms. Genetic factors appeared to contribute significantly to the variance of cluster C PD in ED, which was evaluated as a possibly important background factor in ED.     

The impact of avoidant personality disorder on psychosocial impairment is substantial

Few studies have compared the psychosocial problems associated with different types of personality disorders (PDs). The aim of this study was to investigate the functional impairment and symptomatic distress associated with six PD diagnoses coded in DSM-IV: paranoid, borderline, avoidant, dependent, obsessive–compulsive PD and PD not otherwise specified, as well as a condition of non-psychotic symptom disorders with no PD. The study included 1023 patients from eight day treatment units specialized in the treatment of PDs. Eighty-one per cent had one or more PD diagnoses. At admission to day treatment, the patients were evaluated with respect to global functioning, symptomatic and interpersonal distress, education, quality of life, social support, legal problems and previous psychotic episodes and psychiatric hospitalizations. There were few differences in global functioning or symptomatic and interpersonal distress between patients with a single PD diagnosis. Avoidant PD and borderline PD was the diagnoses that contributed most to dysfunction in most variables when taking into account the presences of several co-occurrent PD diagnoses and axis I disorders. The psychosocial problems associated with avoidant and borderline PD were partly domain specific. The study indicates that avoidant PD is associated with severe dysfunction and subjective distress, at a level comparable to that of borderline PD. Avoidant PD deserves more attention, both with respect to the specific psychopathology and dynamics underlying the disorder and the development of treatment approaches.     

Co-occurrence of Axis I and Axis II disorders in substance abusers

OBJECTIVE: This study examined the co-occurrence of anxiety/mood and personality disorders (PDs) in substance abusers, the impact of anxiety/ mood disorders on the symptom profiles of PDs, and the impact of anxiety/mood disorders and PDs on pre-treatment status. METHOD: Current anxiety/mood disorders and PDs and pre-treatment status were assessed using semi-structured interviews in 370 treated substance abusers. RESULTS: Anxiety/mood disorders and PDs frequently co-occurred, with the overall pattern of associations being non-specific. The strongest associations were of social phobia with avoidant and schizotypal PD, and of major depression with borderline PD. However, symptom profiles of PDs were not associated with anxiety/mood disorders. Finally, anxiety/mood disorders and PDs were both independently and differentially associated with poor pre-treatment characteristics. CONCLUSION: The findings suggest the clinical importance of obtaining both Axis I and Axis II diagnoses in treated substance abusers, and highlight the distinctiveness of the Axis I and Axis II disorders.     

Personality disorders and quality of life. A population study

The purpose of the study was to investigate the relationship between specific personality disorders (PDs) and specific aspects of quality of life in the common population. The sample consisted of 2053 individuals between 18 and 65 years old. Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition (DSM-III-R), axis I was studied by means of a structured interview (Composite International Diagnostic Interview) and axis II by means of a Structured Interview for DSM-III-R Personality Disorders; sociodemographic variables were taken into account, and broad aspects of quality of life were included. Personality disorders appeared to be more important statistical predictors of quality of life than sociodemographic variables, somatic health, and axis I disorder. Those with avoidant, schizotypal, paranoid, schizoid, and borderline PDs had the strongest and broadest reduction in quality of life, whereas those with histrionic, obsessive-compulsive, passive-aggressive, and sadistic PDs did not show any reduction. A number of specific relationships occurred. Furthermore, the more PDs that existed and the more personality criteria fulfilled, the poorer the quality of life, pointing to the importance of comorbidity and continuity.     

Patterns of axis II comorbidity in early-onset versus late-onset panic disorder in Japan

Early onset of psychiatric disorders has been reported to be associated with increased familial risk or more severe clinical symptoms. In this study, we specifically examine the association between clinical severity and early versus late onset in panic disorder. We hypothesize the existence of differences in rates of axis II disorders in these two groups that will relate to clinical severity. Subjects were a consecutive clinical case series of 105 panic disorder patients (age, 18.3 to 70.9 years). Thirty-one panic disorder patients were classified as early onset (age of onset < or = 25 years) and 74 as late onset (age of onset >25). We compared symptomatology and rates of comorbid axis II disorders (diagnosed by structured clinical interview) between the early- and the late-onset groups. We found a statistically significant increase in the number of suicide attempts and likelihood of comorbid axis II disorders in the early-onset group compared to the late-onset group. In logistic regression analyses, cluster B personality disorders (PDs), especially borderline and histrionic, were statistically significantly associated with the presence of suicide attempts. The following limitations are present: first, we have not taken into consideration comorbidity of other axis I disorders, especially major depression. Second, there is imprecision associated with efforts to date the onset of panic disorder retrospectively. We conclude that comorbid axis II disorders are more likely to occur in early-onset panic disorder patients. Cluster B PDs, especially borderline or histrionic, may be associated with a high frequency of suicide attempts in this group. In clinical practice, efforts to aggressively detect and treat axis II disorders in early-onset panic disorder patients are warranted.     

The impact of comorbid dysthymic disorder on outcome in personality disorders

Objective

The goal of our study was to investigate the impact of dysthymic disorder (DD), a form of chronic depression, on naturalistic outcome in individuals with personality disorders (PDs).

Method

The Collaborative Longitudinal Personality Disorders Study is a cohort initially including 573 subjects with 4 targeted PDs (borderline, avoidant, schizotypal, and obsessive-compulsive) and 95 subjects with major depression but no PD. At baseline, 115 subjects were diagnosed with coexisting DD, of whom 109 (94.8%) were PD subjects. Regression analyses were performed to predict 3 classes of broad clinical outcome after 2 years of prospective follow-up. We hypothesized that DD diagnosis at baseline would be associated with worse outcome on (1) persistence of a PD diagnosis, (2) impairment in psychosocial functioning (as measured by the Longitudinal Interval Follow-up Evaluation), and (3) crisis-related treatment utilization.

Results

Baseline DD diagnosis was associated with persistence of PD diagnosis at 2 years, particularly for borderline and avoidant PDs. It was associated with worse outcome on global social adjustment, life satisfaction, recreation, and friendships, but not employment or relationship with spouse. Contrary to expectation, DD did not increase suicide attempts, emergency room visits, or psychiatric hospitalizations.

Conclusions

Comorbidity of DD is associated with persistence of PD diagnosis and with worse outcome on many, but not all, measures of psychosocial functioning.     

DSM-III personality disorder dimensions

Dimensional scores were computed for the 11 DSM-III personality disorders (PDs) in 797 relatives of psychiatric patients and never ill control subjects interviewed with the Structured Interview for DSM-III Personality Disorders. The distribution of scores for all 11 PD dimensions was skewed to the right. A principal components analysis with varimax rotation produced three factors that closely corresponded to DSM-III's suggested clustering of the PDs into eccentric, dramatic, and anxious types. Men scored significantly higher on the paranoid, schizoid, compulsive, antisocial, and narcissistic dimensions, whereas women had significantly higher histrionic, dependent, and avoidant scores. Age was negatively correlated with most of the PD dimensions, and the correlations were strongest with the four PDs in cluster 2 (histrionic, antisocial, narcissistic, and borderline). Each of the eight axis I disorders examined was associated with increased axis II pathology.     

Gender differences in social and interpersonal features and personality disorders among Japanese patients with obsessive-compulsive disorder

This study sought to elucidate the differential effect of gender on clinical features in 40 males and 54 females who met both DSM-III-R and DSM-IV criteria for obsessive-compulsive disorder (OCD). Males had a lower rate of marriage, and a higher rate of major impairment in social or occupational functioning, whereas females were significantly more likely to involve others in their OCD symptoms, such as reassurance-seeking. Although no significant differences were detected in the distribution of OCD symptoms, cluster A personality disorders (PDs), especially schizotypal PD, were more frequently diagnosed in males, and borderline and dependent PDs tended to be more prevalent in females. Thus, gender differences in OCD subjects were prominently observed in social or interpersonal features, which might be consistent with the differential PD pathology between males and females.     

A twin study of personality disorders

No twin study has previously investigated the whole range of personality disorders (PDs) recorded by interviews. Based on twin and patient registries, 92 monozygotic (MZ) and 129 dizygotic (DZ) twin pairs were interviewed with the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II). Observed prevalence rates from a normal population study of more than 2,000 individuals were used in combination with data from the present study to generate statistics assumed to be valid for a normal twin population, and these statistics were used for structural equation modeling. The best-fitting models had a heritability of .60 for PDs generally, .37 for the eccentric (A) cluster, .60 for the emotional (B) cluster, and .62 for the fearful (C) cluster. Among the specific PDs, the heritability appeared to be .79 for narcissistic, .78 for obsessive-compulsive, .69 for borderline, .67 for histrionic, .61 for schizotypal, .57 for dependent, .54 for self-defeating, .29 for schizoid, .28 for paranoid, and .28 for avoidant PDs. The best-fitting models never included shared-in-families environmental effects. However, a model with only shared familial and unique environmental effects could not be ruled out for dependent PD. Shared familial environmental effects may also influence the development of any PD and borderline PD. Passive-aggressive PD did not seem to be affected by genes or family environment at all. The low occurrence of antisocial PD in the twin sample precluded any model for this disorder. PDs seem to be more strongly influenced by genetic effects than almost any axis I disorder, and more than most broad personality dimensions. However, we observed a large variation in heritability among the different PDs, probably partly because of a moderate sample size and low prevalence of the specific disorders.     

Stressful life events as predictors of functioning: findings from the collaborative longitudinal personality disorders study

OBJECTIVE: Although much attention has been given to the effects of adverse childhood experiences on the development of personality disorders (PDs), we know far less about how recent life events influence the ongoing course of functioning. We examined the extent to which PD subjects differ in rates of life events and the extent to which life events impact psychosocial functioning. METHOD: A total of 633 subjects were drawn from the Collaborative Longitudinal Personality Disorders Study (CLPS), a multi-site study of four personality disorders--schizotypal (STPD), borderline (BPD), avoidant (AVPD), obsessive-compulsive (OCPD)--and a comparison group of major depressive disorders (MDD) without PD. RESULTS: Borderline personality disorder subjects reported significantly more total negative life events than other PDs or subjects with MDD. Negative events, especially interpersonal events, predicted decreased psychosocial functioning over time. CONCLUSION: Our findings indicate higher rates of negative events in subjects with more severe PDs and suggest that negative life events adversely impact multiple areas of psychosocial functioning.     

Treatment implications of Axis-II comorbidity in eating disorders

In this article, we review the clinical research on the implications of comorbid personality disorders (PDs), pathological personality traits, and the expression and response to treatment of those with eating disorders (EDs) (i.e., anorexia and bulimia nervosa, and binge eating disorder). Obsessive-compulsive PDs and related traits, such as perfectionism and rigidity, appear to be clear-cut risk and maintenance factors for anorexia nervosa. In bulimia nervosa, trait impulsivity seems to be related to early termination from therapy and, according to at least some indices, poorer responses to treatment. Dramatic-Erratic PD features, generally more characteristic of binge-purge ED variants, clearly predict a protracted course for general psychiatric symptoms, but may have less prognostic value for eating symptoms. Recent guidelines from two influential bodies--the American Psychiatric Association (APA, 2000) and the United Kingdom's National Institute for Clinical Excellence (NICE, 2004)--both include the concept that "trait-oriented" interventions, targeting personality-linked components like perfectionism, affective instability, impulsivity, and interpersonal disturbances, may optimize treatment effects. In general, the literature supports the recommendation that clinicians should apply well-validated, symptom-focused therapies for the EDs; in addition, clinicians may wish to incorporate trait-focused interventions in patients in whom personality pathology contributes to suboptimal response.     

DSM-IV personality disorders in the National Comorbidity Survey Replication.

BACKGROUND: The population prevalence of DSM-IV personality disorders (PDs) remains largely unknown. Data are reported here on the prevalence and correlates of clinician-diagnosed Clusters A, B, and C DSM-IV PDs in the general population of the United States. METHODS: Personality disorder screening questions from the International Personality Disorder Examination (IPDE) were administered in Part II (n = 5692) of the National Comorbidity Survey Replication (NCS-R). A probability sub-sample was then interviewed with the IPDE and used to link screening question responses with IPDE clinical diagnoses. The method of Multiple Imputation (MI) was then implemented to estimate prevalence and correlates of PDs in the full sample. RESULTS: The MI prevalence estimates were 5.7% Cluster A, 1.5% Cluster B, 6.0% Cluster C, and 9.1% any PD. All three PD clusters were significantly comorbid with a wide range of DSM-IV Axis I disorders. Significant associations of PDs with functional impairment were largely accounted for by Axis I comorbidity. CONCLUSIONS: Strong Axis I comorbidity raises questions about the somewhat arbitrary separation of PDs from Axis I disorders in the DSM nomenclature. The impairment findings suggest that the main public health significance of PDs lies in their effects on Axis I disorders rather than in their effects on functioning.     

Disentangling depressive personality disorder from avoidant, borderline, and obsessive-compulsive personality disorders

Several studies have found that 3 personality disorders (PDs) tend to share moderate rates of comorbidity with depressive PD: avoidant, borderline, and obsessive-compulsive. This study sought to evaluate the diagnostic criteria of each disorder in an effort to understand where areas of overlap may occur and to modify criteria sets where reasonable to reduce any degree of overlap. One thousand two hundred psychiatric outpatients were interviewed with the Structured Interview for DSM-IV Personality Disorders. The highest degree of comorbidity was observed between avoidant PD and depressive PD. Logistic regression analyses indicated that 2 criteria-avoidant criterion 5 and depressive criterion 2-could be removed from the diagnostic criteria sets and reduce the rates of overlap by as much as 15%. A factor analysis of the criteria of all 4 PDs indicated that there is a common clustering of many of the symptoms of avoidant, borderline, depressive, and obsessive-compulsive PDs and that borderline symptoms tend to cluster together most consistently. Avoidant and obsessive-compulsive personality symptoms clustered in ways that may reflect a problem of how to engage with others, suggestive of an approach-avoidance conflict. Depressive PD symptoms clustered in a way suggestive of problems with anger that is directed toward oneself and others. The factor analysis results suggest that an organization of symptoms around themes of conflict may provide useful ways of understanding the personality patterns of these 4 disorders.     

海洛因依赖与人格障碍共病调查

目的：调查海洛因依赖者的人格障碍共病状况。方法：采用美国精神障碍诊断与统计手册第4版（DSM-Ⅳ）系统轴Ⅱ人格障碍访谈问卷（SCID-II）（第2版）对90例海洛因依赖者进行评定及相关统计分析。结果：79例（87.8%）符合至少一种人格障碍,常见的为偏执型、强迫型、反社会型、未加标明组（被动攻击型及抑郁型）、边缘型、回避型、自恋型等,人均患2.5种人格障碍。以戏剧化-情绪组人格障碍最常见。结论：在海洛因依赖者中人格障碍共病现象相当普遍。     

Personality disorders in a clinical sample of Cannabis dependent young adults

INTRODUCTION: Cannabis addiction with comorbid personality disorders (PDs) is associated with a heavier individual burden of disease. Most previous studies focussed on singular disorders like borderline or antisocial PD, there is little data available on the full range of PD. Even less is known about the prevalence of PD with cannabis addiction in inpatient settings. The aim of this study is to investigate the frequency of PD and their relevance in treatment of young adult Cannabis-dependent inpatients. METHODS: 99 adolescents and young adults diagnosed with Cannabis dependence according to DSM I, were investigated during their detoxification treatment in an addiction treatment ward. Personality disorders were assessed using the SCID II questionnaire. RESULTS: The intensity of personality disorder traits was high in this inpatient sample. The probands showed a higher burden of disease from PDs other than the antisocial and Borderline PDs previously reported. Almost 90% of the subjects received the diagnosis of an antisocial PD, more than half had a paranoid and more than a third suffers from a Borderline PD. More than 35% of the sample had more than three PDs. There were no consistent relationships between PDs and concurrent consumption of other drugs, severity of drug addiction or delinquency. CONCLUSION: There is evidence of PDs in almost all inpatient Cannabis-dependent adolescents and young adults. Diagnosis and treatment of these subjects has to provide not only addiction-specific approaches but also strategies to improve dysfunctional behaviour caused by personality disorder characteristics.     

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.     

Co-occurrence of 12-month mood and anxiety disorders and personality disorders in the US: results from the national epidemiologic survey on alcohol and related conditions

The objective of this study was to determine the prevalence and co-occurrence of DSM-IV personality disorders (PDs) among individuals with current DSM-IV mood and anxiety disorders in the US population and among individuals who sought treatment for such mood or anxiety disorders. Face-to-face interviews were conducted with 43,093 individuals, 18 years and older, in the National Institute on alcohol abuse and alcoholism's 2001-2002 National epidemiologic survey on alcohol and related conditions (NESARC). Odds ratios (ORs) were calculated to determine the prevalence and associations between current DSM-IV axis I and axis II disorders. Associations between mood, anxiety and PDs were all positive and statistically significant. Avoidant and dependent PDs were more strongly related to mood and anxiety disorders than other PDs. Associations between obsessive-compulsive PD and mood and anxiety disorders were significant, but much weaker. Paranoid and schizoid PDs were most strongly related to dysthymia, mania, panic disorder with agoraphobia, social phobia and generalized anxiety disorder, while histrionic and antisocial PDs were most strongly related to mania and panic disorder with agoraphobia. Results of this study highlight the need for further research on overlapping symptomatology, factors giving rise to the associations and the treatment implications of these disorders when comorbid.