Premorbid Personality Disorder Research Articles

The Nottingham Study of Neurotic Disorder: predictors of 12-year outcome of dysthymic, panic and generalized anxiety disorder

Controlled prospective studies of the simultaneous long-term outcome of several mental disorders are rare. This study sought to determine if there were important differences between the outcome of anxiety and depressive disorders after 12 years and to examine their main predictors. A cohort of 210 people seen in general practice psychiatric clinics with a DSM-III diagnosis of generalized anxiety disorder (71), panic disorder (74), or dysthymic disorder (65), including combined anxiety-depressive disorder (cothymia) (67) was followed up after 12 years. Interview assessments of symptoms, social functioning and outcome were made, the latter using a new scale, the Neurotic Disorder Outcome Scale. Seventeen baseline predictors were also examined. Data were obtained from 201 (96 %) patients, 17 of whom had died. Only 73 (36 %) had no DSM diagnosis at the time of follow-up. Using univariate and stepwise multiple linear regression those with cothymia, personality disorder, recurrent episodes and greater baseline self-rated anxiety and depression ratings had a worse outcome than others; initial diagnosis did not contribute significantly to outcome and instability of diagnosis over time was much more common than consistency. Only two out of five people with the common neurotic disorders have a good outcome despite alleged advances in treatment. Those with greater mood symptoms and pre-morbid personality disorder have the least favourable outcome. It is suggested that greater attention be paid to the concurrent treatment of personality disorder and environmental factors rather than symptoms as these may be the real cause of apparent treatment resistance.

Personnalité, tempérament et anorexie mentale

The multidimensional approach could be the most accurate to analyze eating disorders. It, this perspective anorexia nervosa could be triggered by a non-specific dieting and become a full-blown eating disorder syndrome because of different risk factors. Biological, familial and social influences and premorbid personality disorder could constitute some of these core vulnerability traits. In this review, the relationship between personality features and anorexia nervosa (and its different subtypes) is described. Perfectionism and psychorigidity are major personality traits of patients with anorexia nervosa. The prevalence of personality disorders is higher among anorectic patients than in controls. The anxious-cluster personality disorder is detected in excess in anorexia nervosa, mainly of the restrictive type, including the obsessive-compulsive personality disorder and, to a less extent, the avoidant personality. This cluster was reported to be in excess in patients with anorexia nervosa according to retrospective assessment of premorbide personality disorder, in patient after recovery of comorbid mood or anxiety disorder, and even in weight-restored patients. Patients with anorexia nervosa and a personality disorder have a poorer prognosis and a higher frequency of comorbid psychiatric disorders than those without such comorbidity. The dimensional approach conceptualizes personality disorder as an extreme of normally distributed personality traits. Cloninger distinguished four core dimensions of temperament (novelty seeking, harm avoidance, reward dependence, persistence) and three dimensions of character (self-directedness, cooperativeness, self-transcendance). The use of such quantitative approach of personality profiles allowed to find personality specificities in 8 to 68% of patients with anorexia nervosa who do not have a syndromic personality disorder. High harm avoidance and low novelty seeking characterize patients with anorexia nervosa. Previous descriptions from the literature are in accordance with this description. The association of these two temperament dimensions, specifically distinguishes anorectic patients with the restrictive type. This profile is also stable, as being observed even after recovery. Personality and temperament of patients with anorexia nervosa and comorbid bulimia nervosa, entitled bulimarexia (“boulimarexie”) in french, is less clear-cut, sharing many traits of each personality profile. Detecting a personality disorder and assessing the temperament profile of eating disorder may help to predict outcome, treatment sensitivity, the potential onset of a different eating disorder or also another psychiatric disorder. Assessing personality disorder and temperament profile in patients with anorexia nervosa may thus be a way to further understand the risk factors involved in eating disorder, and could be taken into account when selecting the most appropriate therapeutic strategy.

A polydiagnostic and dimensional comparison of epileptic psychoses and schizophrenia spectrum disorders

After establishing the validity of the Japanese version of the Operational Criteria Checklist for Psychotic Illness (OPCRIT), we applied it to 58 consecutive patients with epileptic psychoses (index group) and to age- and sex-matched controls with schizophrenia spectrum disorders (control group). Compared with the control group, the index group had a low family history of schizophrenia, high premorbid personality disorder and unemployment, abrupt or acute onset of psychosis, good recovery with single or multiple episodes, and low deterioration from a premorbid level of function. From 9% to 52% of the index group and 38% to 84% of the control group were diagnosed with schizophrenia according to the operational criteria used. The percentages of patients diagnosed with schizophrenia based on various diagnostic criteria in the two groups were similar. In the index group, a diagnosis of schizophrenia was more commonly made among patients with inter-ictal psychosis than among those with post-ictal psychosis. An exploratory factor analysis identified five factor solutions of manic, negative, depressive, vegetative, and positive symptoms. Although positive and negative factor values were lower in the index group than in the control group, the two groups shared a similar factor profile. These results indicate that the difference in symptomatology between the two groups was quantitative rather than qualitative.

Variants of premorbid personality and personality disorder: a taxonomic model of their relationships.

From a biographical analysis of approximately 500 case records of patients with various kinds of mental state (in particular mood, anxiety and schizophrenic) disorders, a typology of premorbid personality variants was derived. It comprises three "affective types" dominating in patients with major affective disorders and three "neurotoid types" prevailing in other, above all anxiety and schizophrenic, disorders. These types were operationalized so that they could be assessed by means of a diagnostically "blind" rating of biographical case reports or of interview protocols concerning the premorbid development of clinically remitted patients. The material for the present analysis consisted of ratings regarding 120 subjects (100 patients and 20 healthy controls) who had been interviewed within a project primarily aiming at the development of a novel assessment tool, the Biographical Personality Interview (BPI). This data was used for constructing a comprehensive taxonomic model of premorbid personality variants and their relationships to personality disorders. The intercorrelation of type-scores representing the six premorbid personality types suggests a circular order of these types, opposing the "neurotoid types" on one side to the "affective types" on the other side of the circle (circumplex) along a dimension of mental abnormality vs. normality. Two types, the ("neurotoid") nervous, tense type, and the ("affective") manic type are contrasted with the ("affective") melancholic and the ("neurotoid") anxious, insecure types along an orthogonal dimension of rather changeable vs. rather constant habitual behaviour. This order is confirmed by the correlation of type-scores with factor scores of the two main dimensions of BPI-item scores. It is also concordant with the correlation of type-scores and scores on questionnaire scales of personality. Personality disorders as maladapted extreme variants of personality can be located outside the circle according to their similarity or dissimilarity with the six premorbid personality types. They are necessarily distributed almost exclusively along the "neurotoid" side of the circumplex. This two-dimensional model of variants of premorbid personality and personality disorders is in basic agreement with models derived from dimensions of personality in mentally healthy subjects and with findings concerning the comorbidity among personality disorders. Further empirical studies are required for choosing or developing the most appropriate model of the relationships between personality variants and personality disorders.

Social Anxiety and Premorbid Personality Disorders in Paranoid Schizophrenic Patients Treated With Clozapine

The concept of anxiety as a distinct comorbid disorder in schizophrenia has recently been rediscovered after having been neglected for a long period of time due to both theoretical and clinical approaches adopted from the appearance of the first edition of the Diagnostic and Statistical Manual of Mental Disorders in 1950. This rediscovery was accentuated by the fact that the concept of comorbidity in various psychiatric disorders has recently won widespread favor within the scientific community, and that the use of atypical neuroleptic medication to treat patients with schizophrenia has been reported to lead to the emergence of anxiety symptoms. Of the atypical neuroleptic medications used to treat schizophrenia, clozapine has most frequently been reported to induce anxiety symptoms. In this paper, 12 cases of patients with paranoid schizophrenia who developed social phobia during clozapine treatment are reported, and their response to fluoxetine augmentation is assessed. Premorbid personality disorders were also investigated; patients were assessed using the Structured Clinical Interview for DSM-III-R-Patient Version and the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (DSM-III-R=Diagnostic and Statistical Manual of Mental Disorders, Third Edition Revised; DSM-IV=Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition). In addition, the Scale for the Assessment of Negative Symptoms, the Scale for the Assessment of Positive Symptoms, the Liebowitz Social Anxiety Scale (LSAS), the Frankfurt Beschwerde Fragebogen (Frankfurt Questionnaire of Complaints), and the Brief Psychiatric Rating Scale were used to rate clinical symptomatology. All patients were reevaluated after 12 weeks of cotreatment with clozapine and fluoxetine. In 8 (66.6%) of the 12 cases, symptoms responded (>/=35% LSAS score reduction) to an adjunctive regimen of fluoxetine. Furthermore, in 7 (58.3%) of the 12 cases, an anxious personality disorder (avoidant=33.3%; dependent=25%) was identified, but no significant differences in the prevalence of comorbid personality disorders emerged in comparison with a group of 16 patients with paranoid schizophrenia treated with clozapine who did not show symptoms of social phobia. The clinical relevance of the assessment and treatment of anxiety disorders is discussed in light of a clinical therapeutic approach that overcomes the implicit hierarchy of classification. Considering that the onset of anxiety-spectrum disorders (such as social phobia) can occur during the remission of psychotic symptoms in clozapine-treated patients with schizophrenia, a comprehensive approach to pharmacological therapy for patients with schizophrenia (or, at least for those treated with clozapine) should be adopted.

Premorbid personality disorders in schizophrenia

Premorbid personality disorders (PD) were studied retrospectively in 40 schizophrenic patients by interviewing the parents and patients who were reliable with the SCID-II. 85% of the patients had premorbid PDs. The most frequent premorbid PDs were: avoidant PD (32.5%), schizoid PD (27.5%), paranoid PD (20%), dependent PD (20%) and schizotypal PD (12.5%). In most of the patients, two or more PDs could be diagnosed simultaneously (47.5%), comorbilidity of the premorbid PDs in schizophrenia being the most common one. The most frequent combination was avoidant-schizoid-schizotypal PD.

Patterns of Relation and Premorbid Personality in Late Paraphrenia and Depression

38 patients with late paraphrenia and 38 with endogenous depression of late onset were compared regarding interpersonal relations and personality traits by means of semistructured interviews. The prevalence of premorbid personality disorder was determined by the Structured Clinical Interview for DSM-III-R Personality Disorders. The main objective of the study was to look for lifetime relation patterns and personality traits distinguishing the two groups and pointing to a specific premorbid vulnerability of paranoid and depressive patients. A high rate of personality disorder comorbidity was found in both groups, with mainly paranoid and schizoid disorder in late paraphrenic patients (39%) and avoidant, dependent or compulsive personality in depressives (35%). As a rule, this corresponded to a lifelong pattern of seclusion and self-sufficiency in the paranoid, and of close intimacy and heteronomy in the depressive patients. On the basis of the results, a polar typology of personality and interpersonal relations in both patient groups is developed.

HIV-1 associated cognitive/motor complex in an injecting drug user

The clinical and social consequences of AIDS dementia complex/HIV-1 associated cognitive/motor complex (ADC/HACC) in drug users have not been well documented. The value of prospective serial neuropsychological, neuroradiological and neurophysiological measurements to assist diagnosis of ADC/HACC in patients with premorbid personality disorder and intercurrent drug use is demonstrated. The psychosocial problems resulting from ADC/HACC with respect to community care and the location of hospitalization is considered. The relevance of the 1984 Mental Health Act (Scotland) with regard to drug users with ADC/HACC is discussed.

Genital Self-Amputation and the Klingsor Syndrome

Two psychotic individuals, who performed acts of genital self-amputation, are presented. One of the patients had self-mutilated with the intention of suicide and had also in the past amputated his hand. Psychotic patients with delusions (often religious), sexual conflict associated with guilt, past suicide attempts or other self-destructive behaviour and depression, severe childhood deprivation, and major premorbid personality disorder, are the group at risk for genital self-amputation. It has been proposed that the eponym, the "Klingsor" syndrome, be applied only to acts of genital self-mutation, involving religious delusions. The author suggests that this syndrome should be expanded to include all cases of genital self-mutation resulting from a psychotic illness.

Treatment of behavioral problems with pindolol

A study was conducted on a group of chronically hospitalized, brain-damaged male patients to assess the effectiveness of treatment with pindolol on behavioral problems. The study was conducted in two parts. The first was a double-blind, placebo-controlled analysis of the effect of pindolol on assaultive behavior, both verbal and physical. The second part was open and sought to determine whether pindolol would diminish such behaviors as resistance to care, sexual preoccupation, or provocation of others, which were sufficient to preclude placement at a lower level of care. These target behaviors and nursing interventions were monitored and clinical global assessments of improvement in behavior and of suitability for lower levels of care were developed. Eight of 13 patients were considered improved. Those with significant premorbid personality disorders showed little benefit. Pindolol appears to ameliorate some management problems and, by inference, improve the quality of life in many patients with behavioral pathology due to organic brain disease.

The research diagnostic criteria for endogenous depression and the dexamethasone suppression test: a discriminant function analysis

Most studies examining the validity of the Research Diagnostic Criteria (RDC) for endogenous depression have been negative. RDC endogenous sub-typing is not associated with short- or long-term treatment outcome, family history of affective disorder, or premorbid personality disorder. Studies examining its relationship to the dexamethasone suppression test (DST) are mixed; half report a significant association, and half do not. The RDC endogenous diagnosis may lack validity either because the criteria do not represent, or are not specific to, the endogenous subtype, or the diagnostic algorithm is inappropriate. In the present study, we conduct a discriminant function analysis on the 10 criteria for the endogenous subtype using DST results as the independent variable. We constructed a new diagnostic algorithm and cross-validated it on a second patient sample. In both samples the discriminant function classification was significantly associated with DST results, whereas the RDC algorithm was not.

Subtypes of drug abuse with psychosis. Demographic characteristics, clinical features, and family history.

Hospital records of 72 drug abusers with psychoses (DAP) were analyzed to clarify the relationship between drug abuse and psychosis. Comparison groups included schizophrenics and atypical schizophrenics without drug abuse and drug abusers without psychoses (DA). Compared with DAP in whom psychoses lasted less than six months before admission (DAP-short), drug abusers with psychoses of a longer duration (DAP-long) had more symptoms, more premorbid personality disorders, and greater familial risks of schizophrenia and affective disorder. The DAP-long group resembled atypical schizophrenia for clinical features and family history, whereas the DAP-short group resembled DA for some clinical features and family history. The results indicate that there are several subgroups of DAP. The importance of clinical features and family history in identifying subgroups of DAP was stressed.