Assessing axis II disorders by informant interview.

Although much of personality disorder research depends on diagnostic data obtained directly from patients, this approach has rarely been compared to interviews with knowledgeable informants. The purpose of this study was to determine the diagnostic agreement between these two assessment methods, as well as their relative contribution to the formulation of consensus diagnoses. Sixty-two psychiatric patients were assessed directly with the Structured Interview for DSM-III Personality Disorders (SIDP), and were asked to nominate an informant--either a family member or friend--to provide information about the patient in an interview with the same instrument. Informant interviews were conducted blind to patient-based information whenever feasible, and diagnostic consensus was achieved by an independent review of all available data by a senior clinician. Diagnostic agreement between patient-based and informant-based personality disorder interview was poor, confirming the findings of two previous studies. Information obtained from patients tended to be given greater weight in formulating consensus diagnoses than information provided by informants. However, about one quarter of diagnostic disagreements were resolved in favor of informant-based information. In contrast to a previous study, the inclusion of informant information did not appear to reveal greater psychopathology in patients. We conclude that supplementing direct patient interview with data provided by a knowledgeable informant appears to enhance the resolution of some personality disorder diagnoses. The utility of informant interviews may depend on an analysis of the costs and benefits of this additional degree of descriptive refinement.

Familial correlates of reduced central serotonergic system function in patients with personality disorders.

BACKGROUND: To test the hypothesis that evidence of reduced central serotonergic (5-HT) system function in probands with personality disorders is associated with an elevated morbid risk of psychopathological conditions putatively associated with 5-HT dysfunction in first-degree relatives of these probands. METHODS: Data were collected during a study of the 5-HT correlates of behavior in male patients with DSM-III personality disorders conducted at a Veterans Affairs medical center. Probands in this study were selected from those patients who had undergone both a fenfluramine hydrochloride challenge and a family history assessment. Axis II diagnosis were made according to DSM-III criteria after a structured interview of the proband, using the Structured Interview for Diagnosing Personality Disorders, given by two raters and a similar interview with a knowledgeable informant by another rater. RESULTS: Reduced prolactin responses to the 5-HT releasing/uptake inhibiting agent fenfluramine was associated with an elevated morbid risk of impulsive personality disorder traits in the first-degree relatives of patients with a primary DSM-III diagnosis of a personality disorder. Quantitative scores on assessments of impulsive aggression in the probands were not correlated with an increased morbid risk for impulsive personality disorder traits. A trend in the same direction was noted for affective personality disorder traits and alcoholism. CONCLUSIONS: These results suggest that a central 5-HT system abnormality in probands is associated with an increased risk of impulsive aggression in their first-degree relatives, and that assessment of central 5-HT system function in probands may be a more sensitive parameter for identification of this familial trait than the presence of impulsive aggressive behaviors in the proband.

Growth hormone responses to intravenous clonidine challenge correlate with behavioral irritability in psychiatric patients and healthy volunteers.

To explore the relationship between central noradrenergic receptor responsivity and indices of impulsive aggression, growth hormone responses to infusions with the alpha 2-adrenergic receptor agonist clonidine (GH[CLON]) and responses on the Buss-Durkee Hostility Inventory (BDHI) were examined in healthy male volunteers and male patients with major affective or personality disorder. GH[CLON] values were found to correlate significantly with the BDHI "Irritability" subscale in all subjects, but especially in healthy volunteer and personality disorder patients. GH[CLON] values did not correlate with the BDHI "Assault" subscale. These results suggest a role for central alpha 2-adrenergic receptor responsivity in the personality trait characterized by behavioral irritability, but not overt assaultiveness, in humans.

Structured interviews for borderline personality disorder.

The authors compared three instruments used to diagnose borderline personality disorder--the Diagnostic Interview for Borderline Patients (DIB), the Schedule for Interviewing Borderlines, and the Structured Interview for DSM-III Personality Disorders--in 56 patients with personality disorders. A borderline diagnosis was made according to the DIB in 30%, the Structured Interview for DSM-III Personality Disorders in 48%, and the Schedule for Interviewing Borderlines in 55% of the patients. Diagnostic agreement was only 52%, which has implications for the generalizability of results of validation studies of the borderline diagnosis. Improvement in diagnostic agreement requires modification of current criteria sets and/or the use of dimensional models.

Eye tracking impairment in clinically identified patients with schizotypal personality disorder.

Eye tracking accuracy, which has been found to be impaired in schizophrenic patients and their relatives, was assessed in 26 patients with schizotypal personality disorder, 17 control subjects with other non-schizophrenia-related personality disorders, 29 normal control subjects, and 44 schizophrenic patients. Both schizotypal and schizophrenic patients, but not control subjects with other personality disorders, demonstrated significantly more impaired tracking than the normal control subjects. These results suggest that patients with clinically defined schizotypal personality disorder may be biologically related to schizophrenic patients as part of a spectrum of schizophrenia-related disorders.

Serotonergic studies in patients with affective and personality disorders. Correlates with suicidal and impulsive aggressive behavior.

Dysfunction of the central serotonergic system has been variously associated with depression and with suicidal and/or impulsive aggressive behavior. To evaluate central serotonergic function in relation to these variables, prolactin responses to a single-dose challenge with fenfluramine hydrochloride (60 mg orally), a serotonin releasing/uptake-inhibiting agent, were examined in 45 male patients with clearly defined major affective (n = 25) and/or personality disorder (n = 20) and in 18 normal male control patients. Prolactin responses to fenfluramine among all patients were reduced compared with responses of controls. Reduced prolactin responses to fenfluramine were correlated with history of suicide attempt in all patients but with clinician and self-reported ratings of impulsive aggression in patients with personality disorder only; there was no correlation with depression. These results suggest that reduced central serotonergic function is present in a subgroup of patients with major affective and/or personality disorder and is associated with history of suicide attempt in patients with either disorder, but with impulsive aggression in patients with personality disorder only.

Between patient and doctor. Improving the quality of care for serious mental illness.

The quality of care typically rendered to seriously mentally ill patients in this country does not reflect the extraordinary expansion and refinement in recent decades of scientifically based psychiatric diagnostic and therapeutic capacities. In this paper, the authors examine reasons for the disparity between the quality of the scientific base and the quality of care, citing recent historical influences and contemporary obstacles, and then propose strategies for change.

Delusional infestation and dementia: a case report.

The case of an 82-year-old woman with delusional infestation and senile dementia of the Alzheimer type is reported. Her symptoms of infestation ceased dramatically with pimozide given for 5 weeks, and did not recur during follow-up over 9 months. The importance of organic factors in patients with this disorder is emphasised.