Complex Personality Disorder Research Articles

Treatment of borderline personality disorder and co-occurring anxiety disorders

Anxiety disorders are highly prevalent among individuals with borderline personality disorder, with comorbidity rates of up to 90%. Anxiety disorders have been found to reduce the likelihood of achieving remission from borderline personality disorder over time and to increase the risk of suicide and self-injury in this population. Evidence-based treatments for borderline personality disorder have not sufficiently focused on targeting anxiety disorders, and their effects on these disorders are either limited or unknown. Conversely, evidence-based treatments for anxiety disorders typically exclude suicidal, self-injuring, and seriously comorbid patients, thereby limiting their generalizability to individuals with borderline personality disorder. To address these limitations, recent research has begun to emerge focused on developing and evaluating treatments for individuals with co-occurring borderline personality disorder and anxiety disorders, specifically posttraumatic stress disorder (PTSD), with promising initial results. However, there is a need for additional research in this area, particularly studies evaluating the treatment of anxiety disorders among high-risk and complex borderline personality disorder patients.

Age of Onset of Mood Disorders and Complexity of Personality Traits

Objective. The aim of the present study is to evaluate the link between the age of onset of mood disorders and the complexity of the personality traits. Methods. 209 patients with major depressive or manic/hypomanic episodes were assessed using the Structured Clinical Interview for DSM Axis I diagnoses and the Millon Clinical Multiaxial Inventory-III (MCMI-III). Results. 17.2% of the patients had no elevated MCMI-III scores, 45.9% had one peak, and 36.9% had a complex personality disorder with two or more elevated scores. Mood disorders onset of 29 years or less was the variable most related to the complexity of personality disorders as indicated from a recursive partitioning analysis. Conclusions. The relationship between mood disorders and personality traits differ in reference to age of onset of the mood disorder. In younger patients, maladaptive personality traits can evolve both in a mood disorder onset and in a complex personality disorder, while the later development of a severe mood disorder can increase the personality symptomatology. Our results suggest a threshold of mood disorder onset higher compared to previous studies. Maladaptive personality traits should be assessed not only during adolescence but also in young adults to identify and treat potential severe mood disorders.

Commentary on ‘treating complex personality disorder’: What is a complex personality disorder and how do we treat them?

Commentary on ‘treating complex personality disorder’: What is a complex personality disorder and how do we treat them?

Personality disorders with over-regulation of emotions and poor self-reflectivity-The case of a man with avoidant and not-otherwise specified personality disorder and social phobia treated with Metacognitive Interpersonal Therapy

Treating patients with personality disorders (PD) with significant over-regulation of affects, poor metacognition and a restricted interpersonal schema repertoire requires specialized procedures. We present here the case of a man in his 30s suffering from Avoidant PD and overall 21 PD criteria met, with co-occurring axis I disorders. Metacognitive Interpersonal Therapy was used, and after 1 year of therapy, outcome was good, although therapy is still continuing. First, a more nuanced understanding of mental states and then attempts at change began, which led to a modification of the patient's negative self-image and a reduction of social avoidance. The possible relevance and generalization of formalized procedures, applied with a careful case formulation, is discussed to successfully treat persons with this type of complex PD. Copyright © 2012 John Wiley & Sons, Ltd.

The effect of age on prevalence, type and diagnosis of personality disorder in psychiatric inpatients

To examine age-related differences in personality disorder (PD) comorbidity and in their diagnosis in psychiatric inpatients. Two hundred thirty-one consenting adults consecutively admitted to inpatient psychiatry units and aged between the age of 18 and 100 were assessed using the Structured Clinical Interview for DSM IV Axis I and II (SCID-I and -II), after excluding cognitively impaired, non-English speaking, short stay and respite patients. Hospital files were audited for clinical diagnoses, in particular for recorded PDs. Rates of PD prevalence and clinician diagnosis were compared for young (n = 76), middle-age (n = 57) and older (n = 98) patients. Significant personality comorbidity was evident at all ages, but rates were lowest in the older group. PD was present in 73.7% of young, 71.9% of middle-age and 58.8% of older patients. Complex PD was more common in young patients. Only 19.8% of PDs were noted by their clinicians to have PD. Comorbid PD is common in psychiatric inpatient groups regardless of age but seldom diagnosed clinically.

Complex personality disorder in bulimia nervosa

Objective Recent research has suggested a move toward a dimensional system for the classification of personality disorders (PDs). Tyrer's dimensional model using severity as a form of categorizing PDs was used to compare eating disorder outcome in women with bulimia nervosa (BN) over 3 years. Method One hundred thirty-four women with BN were divided into 4 groups based on PD severity: no PD (n = 32), personality difficulty (n = 27), simple PD (n = 29), and complex PD (n = 46). Eating disorder symptoms and attitudes, general psychosocial functioning, and depressive symptoms were examined at pretreatment and at 1-year and 3-year follow-up (posttreatment). Results The complex PD group had greater Axis I comorbidity and psychopathology than the remaining 3 groups at pretreatment. At 1-year and 3-year follow-up, there were no differences in eating disorder outcome, general psychosocial functioning, and depressive symptoms across the 4 groups. Conclusion These results suggest that having an increased number of PDs comorbid with BN does not influence eating disorder outcome up to 3 years after treatment.

P01-225 - Hospital admissions and personality pathology in adolescents with psychiatric disorders

The use of psychiatric services has been associated with a wide range of clinical variables. However, information about the impact of adolescent personality pathology related to hospital admissions is limited.ObjectiveTo analyze the different combination of personality pathology associated to variables of psychiatric hospital admissions (number of admissions, total of days spent as psychiatric inpatient, average of days for admission, and number of admissions in a day care hospital).MethodThe ICD-10 and DSM-IV modules of the semi-structured interview IPDE (International Personality Disorders Examination) were administered, in a sample of 107 adolescent psychiatric patients (M=15.8, SD=0.8 years old; age rank 15-17; 79% female).ResultsPersonality pathology group identified by the IPDE showed significantly higher number (p< .001) of psychiatric admissions (M=1.48) than no personality pathology group (M=0.57), but not significant higher number of admissions in a day care hospital. Psychotic patients showed the highest rate of admissions (M=2.88). In present sample, between 30% and 38% of all hospital admitted patients showed a Cluster B personality disorder (PD).The users of psychiatric inpatient services with a complex PD (two o more PD from different clusters) presents in average: 2-2.5 admissions, 34-53 total days spent as psychiatric inpatient, and 11-16 days on each admission.ConclusionPatients with psychotic disorders or complex PD were the highest users of inpatients services, but not of day care hospital admissions.

Complex personality disorder in bulimia nervosa

Complex personality disorder in bulimia nervosa

A comparison of women who continue and discontinue treatment for borderline personality disorder

AbstractBackground Treatment non‐completion is a significant problem for personality disorder treatment services.Aims We investigated differences between treatment continuers and treatment discontinuers of a tertiary specialist service for people with borderline personality disorder. The two groups were compared on: (1) personality disorder severity; (2) motivation for therapy; (3) mood; and (4) social problem solving.Method Patients' personality disorders were examined using the International Personality Disorder Examination. Three self‐report questionnaires were administered at the start of treatment: the Treatment Motivation Questionnaire, the Hospital Anxiety and Depression Scale (HADS), and the Social Problem Solving Inventory‐Revised.Results Of 14 outpatients recruited to the service during 2005 to 2007, seven continued and seven discontinued treatment. Those who did not continue with therapy had more complex personality disorder profiles, were more externally motivated for treatment and were less internally motivated for treatment. All patients scored high on the HADS. Problem‐solving abilities were apparently intact, but adversely affected by a negative problem orientation. Treatment discontinuers spent, on average, three times longer in hospital than continuers.Conclusion Engaging people with complex personality disorders, low internal motivation for therapy and negative problem orientation is a challenge for services. Non‐completion of treatment is associated with more days in hospital and higher service costs. Copyright © 2009 John Wiley & Sons, Ltd.

Impact of severity of personality disorder on the outcome of depression

The influence of severity of personality disorder on outcome of depression is unclear. Four hundred and ten patients with depression in 9 urban and rural communities in Finland, Ireland, Norway, Spain and the United Kingdom, were randomised to individual problem-solving treatment ( n = 121), group sessions on depression prevention ( n = 106) or treatment as usual ( n = 183). Depressive symptoms were recorded at baseline, 6 and 12 months. Personality assessment was performed using the Personality Assessment Schedule and analysed by severity (no personality disorder, personality difficulty, simple personality disorder, complex personality disorder). Complete personality assessments were performed on 301 individuals of whom 49.8% had no personality disorder; 19.3% had personality difficulties; 13.0% had simple personality disorder; and 17.9% had complex personality disorder. Severity of personality disorder was correlated with Beck Depression Inventory (BDI) scores at baseline (Spearman's r = 0.21; p < 0.001), 6 months ( r = 0.14; p = 0.02) and 12 months ( r = 0.21; p = 0.001). On multi-variable analysis, BDI at baseline ( p < 0.001) and type of treatment offered (individual therapy, group therapy, treatment as usual) ( p = 0.01) were significant independent predictors of BDI at 6 months. BDI at baseline was the sole significant independent predictor of BDI at 12 months ( p < 0.001). There was no interaction between personality disorder and treatment type for depression. While multi-variable analyses indicate that depressive symptoms at baseline are the strongest predictor of depressive symptoms at 6 and 12 months, the strong correlations between severity of personality disorder and depressive symptoms make it difficult to establish the independent effect of personality disorder on outcome of depression.

The Relationship of Impairment to Personality Disorder Severity Among Individuals with Specific Axis I Disorders: Results from the National Epidemiologic Survey on Alcohol and Related Conditions

The present study examined one dimensional approach to personality disorders (PDs) in a large (n = 43,093), nationally representative sample of the U.S. population. Respondents were classified in four personality severity categories (no PD, subthreshold PD, simple PD, complex PD). Linear regression analyses were conducted to examine mental disability by PD severity for major DSM-IV substance use, mood and anxiety disorders. Significant increases in disability were observed between no PD and simple PD and between simple PD and complex PD for each Axis I disorder except drug dependence, but few differences in disability were found between no PD and subthreshold PD. This study found support for the clinical utility of the dimensional classification of PD severity with regard to the distinction between simple and complex PD and for a combined no PD-subthreshold PD level of severity. Future planned analyses will address the clinical utility of the classification prospectively, with a full battery of all Axis II PDs.

Management of complex and severe personality disorders in community mental health services

To describe the prevalence and specific management of severe and complex personality disorders in community mental health services and similar settings. Conflicting reports exist in the literature but the consensus of evidence suggests that more complex personality disorder (more so than simple personality disorder) impairs response to treatment of most psychiatric disorders and complicates their management. Poor adherence to treatment may be one of the mechanisms underlying this. Increasing evidence now suggests that more complex and severe personality disorders have a negative impact on the outcome of most psychiatric disorders. Some indications, however, are there to show that pharmacological treatments may not handicap the outcome of pharmacological treatment as much as other types of intervention and may be selectively chosen in this group. Severe personality disorder needs to be identified early in community services as by anticipating and adjusting to its effects it is likely to improve treatment plans and prognosis.

Assessment of the Burden of Disease Among Inpatients in Specialized Units That Provide Psychotherapy

The burden of disease of 1,651 inpatients in the Netherlands who had complex personality problems and personality disorders and who were treated in specialized units that provide psychotherapy was compared with the burden of disease of patients with other mental and physical conditions. Patients completed the EuroQol EQ-5D, a generic quality-of-life questionnaire. The mean EQ-5D index score was .54 (possible scores range from -.59 to 1.00, with higher scores indicating fewer problems). This score reflects a burden of disease comparable with the burden in severe illnesses, such as Parkinson's disease (.58) or rheumatic disease (.53).

Schema modes and childhood abuse in borderline and antisocial personality disorders

Complex personality disorders (PDs) have been hypothesized to be characterized by alternating states of thinking, feeling and behavior, the so-called schema modes (Young, Klosko, & Weishaar (2003). Schema therapy: A practioner's guide. New York: Guilford). The present study tested the applicability of this model to borderline personality disorders (BPD) and antisocial personality disorders (APD), and related it to a presumed common etiological factor, childhood trauma. Sixteen patients with BPD, 16 patients with APD and 16 nonpatient controls (all 50% of both sexes) completed a Schema Mode Questionnaire assessing cognitions, feelings and behaviors characteristic of six schema modes. Participants were interviewed to retrace abusive sexual, physical and emotional events before the age of 18. BPD as well as APD participants were characterized by four maladaptive modes (Detached Protector, Punitive Parent, Abandoned/Abused Child and Angry Child). APD displayed most characteristics of the Bully/Attack mode, though not significantly different from BPD. The Healthy Adult mode was of low presence in BPD and of high presence in APD and the nonpatients. Frequency and severity of the three kinds of abuse were equally high in both PD groups, and significantly higher than in nonpatients.

Limbic abnormalities in affective processing by criminal psychopaths as revealed by functional magnetic resonance imaging

Background: Psychopathy is a complex personality disorder of unknown etiology. Central to the disorder are anomalies or difficulties in affective processing. Methods: Functional magnetic resonance imaging was used to elucidate the neurobiological correlates of these anomalies in criminal psychopaths during performance of an affective memory task. Results: Compared with criminal nonpsychopaths and noncriminal control participants, criminal psychopaths showed significantly less affect-related activity in the amygdala/hippocampal formation, parahippocampal gyrus, ventral striatum, and in the anterior and posterior cingulate gyri. Psychopathic criminals also showed evidence of overactivation in the bilateral fronto-temporal cortex for processing affective stimuli. Conclusions: These data suggest that the affective abnormalities so often observed in psychopathic offenders may be linked to deficient or weakened input from limbic structures.

Casos Clínicos Hamartoma hipotalámico, una causa de pubertad precoz: Caso clínico

Hypothalamic hamartomas are non neoplastic lesions that may cause precocious puberty with or without complex seizures, personality disorders and mental retardation. We report a 14 years old male that had a precocious puberty at the age of 11 and a prolonged episode of altered sensorium with automatism, that was diagnosed as a complex seizure. Physical examination showed a sexual development classified as Tanner stage III-IV, a height of 168 cm and a weight of 61 kg. Neurological examination was normal. A CAT scan showed a 13 x 13 x 9 mm mass in the suprasellar cistern, between the infundibulum and the brain stem, without exerting a mass effect over adjacent structures. It was diagnosed as an hypothalamic hamartoma.

Potential Contributions of Hypnosis to Ego-Strengthening Procedures in EMDR

This paper explores how hypnotic principles can be systematically incorporated into the standard EMDR protocol to enhance various ego strength capacities during EMDR treatment. Expanding these skill areas can widen the therapeutic window of possibility for clients with a variety of complex clinical issues, including posttraumatic, dissociative or personality disorders, anxiety symptoms, and depressive difficulties. Clinical case examples are used to illustrate ways of integrating hypnotic principles within a proposed EMDR protocol to promote ego strengthening and facilitate therapeutic change.

Dissociation, development, and the psychobiology of trauma.

Dissociation, development, and the psychobiology of trauma.

Behaviour therapy for the neuroses: some conceptual and practical problems.

Some problems in reconciling behaviourism as pure science with clinical behaviour therapy for complex neurotic and personality disorders are examined. A major problem is the inability of scientific behaviourism to permit motivation, will and choice to be considered from an intrapsychic perspective. Cognitive behaviour therapy and its derivatives have been developed in an attempt to overcome this problem. Although such therapies have retained a paradigmatic attachment to behaviourism, they have more in common with psychodynamic psychotherapy. Conflict among contemporary behaviourists about the relevance of cognitive theory to behaviourism has obscured more fundamental issues such as the role of the patients-therapist relationship. Both classical and cognitive behaviour therapists view a direct examination of the patient-therapist relationship as therapeutically irrelevant, although there is evidence that such a viewpoint may be anti-therapeutic in some severe neurotic disorders. Behaviourists must acknowledge the central importance of examining the patient-therapist relationship in such disorders if they are to continue their successful dialectic with psychodynamic therapists.

Personality traits and disorder in depression.

The authors examined the relationship of personality traits and personality disorder to depressive subtype, descriptive characteristics, and outcome in 160 depressed inpatients. Personality disorder was significantly more common in unipolar nonmelancholic depressed patients (61%) than in unipolar melancholic (14%) or bipolar depressed patients (23%). Personality disorder did not affect symptom manifestation but was related to earlier onset of depressive illness and worse outcome within the unipolar nonmelancholic group. Obsessive traits were most common in the unipolar melancholic patients, while histrionic, hostile, and borderline traits predominated in the nonmelancholic patients. The authors discuss the usefulness of a multiaxial diagnostic system and the importance of separating trait and disorder in personality assessment.