Comorbidity of axis I and axis II disorders.

OBJECTIVE: In light of continuing controversies concerning the DSM-III-R system for diagnosing personality disorders, their construct validity, and the assignment of disorders to a particular axis, the authors studied patterns of axis I-axis II comorbidity. METHOD: Semistructured interviews were used to assess axis I and axis II disorders in 200 inpatients and outpatients. Odds ratios were calculated to determine significant comorbidity between classes of current axis I disorders and axis II personality disorders diagnosed according to two methods and defined at two diagnostic thresholds. Distributions of personality disorder traits were also compared in patients with and without axis I disorders. RESULTS: Significantly elevated odds ratios were found for co-occurrence of current mood disorders with avoidant and dependent personality disorders; anxiety disorders with borderline, avoidant, and dependent personality disorders; psychotic disorders with schizotypal, borderline, and dependent personality disorders; psychoactive substance use disorders with borderline and histrionic personality disorders; and eating disorders with schizotypal, borderline, and avoidant personality disorders. These results held when conservative and liberal definitions of personality disorders were used. Non-specific axis I and axis II associations were confirmed for distributions of personality disorder traits. CONCLUSIONS: Significant associations occurred between most axis I classes of disorders and axis II disorders and traits in more than one cluster. All axis I classes of disorders except mood disorders co-occurred with borderline personality disorder; however, patients with mood disorders had elevated levels of borderline traits. When any personality disorder was present, there were significant odds that a mood, anxiety, psychotic, or eating disorder would also be present; psychoactive substance use disorders, in contrast, significantly co-occurred with borderline and histrionic personality disorders.

Serotonergic sensitivity in borderline personality disorder: preliminary findings.

Twelve patients with borderline personality disorder and 15 healthy comparison subjects were challenged with single doses of oral m-chlorophenylpiperazine (m-CPP) and placebo. Following m-CPP, the patients experienced decreased anger and fear. Seven of the 12 patients reported a "spacy," "high," depersonalized/derealized experience following m-CPP, which was confirmed by clinicians' ratings. Compared with the normal male subjects, the male patients with borderline personality disorder had higher cortisol levels and marginally blunted prolactin responses after receiving m-CPP. These results suggest serotonergic dysfunction in borderline personality disorder.

Diagnosis of DSM-III-R personality disorders by two structured interviews: patterns of comorbidity.

OBJECTIVE: The purpose of this study was to examine patterns of co-occurrence of axis II disorders in a group of consecutive patients evaluated with two contrasting structured interviews. METHOD: One hundred of 106 consecutive applicants for long-term, inpatient treatment of severe personality psychopathology were assessed, face-to-face, by psychiatrists using the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) and the Personality Disorder Examination (PDE). The percent of co-occurrence of pairs of disorders diagnosed by each structured interview separately was calculated, and significance levels were determined by using chi-square tests of independence. Finally, odds ratios were computed for the odds of each pair of disorders occurring together compared with the odds for the occurrence of each disorder alone. RESULTS: The two interview methods revealed different comorbidity patterns. Significant covariation was found for 29 pairs of disorders diagnosed with the PDE, compared with 12 pairs diagnosed with the SCID-II. Six pairs of disorders covaried significantly and were associated with odds ratios greater than 4: histrionic with borderline, histrionic with narcissistic, narcissistic with antisocial, narcissistic with passive-aggressive, avoidant with schizotypal, and avoidant with dependent. CONCLUSIONS: Substantial overlap occurred among personality disorders. In this group of patients, consistent patterns of comorbidity involving narcissistic, avoidant, and histrionic personality disorders suggest that categorical distinctions between them and certain other DSM-III-R personality disorders may be illusory. The question of which of two overlapping disorders is more valid, however, is left unanswered. For clinical purposes, a two-level diagnostic convention is proposed.

Validity of the Personality Diagnostic Questionnaire--revised: comparison with two structured interviews.

The authors gave the self-report Personality Diagnostic Questionnaire--Revised (PDQ-R) to 87 applicants for inpatient treatment of severe personality psychopathology and, blind to these results, diagnosed personality disorders in the applicants by using the Personality Disorder Examination and the Structured Clinical Interview for DSM-III-R Personality Disorders. The PDQ-R was not a substitute for a structured interview assessment of axis II disorders because many of its diagnoses were false positives. Its high sensitivity and moderate specificity for most of the axis II disorders suggest, however, that it is an efficient instrument for screening patients with DSM-III-R personality disorders.

Validating structured DSM-III-R personality disorder assessments with longitudinal data.

The authors observed 20 patients over time for mal-adaptive personality traits during hospitalization and made longitudinal diagnoses to validate Structured Clinical Interview for DSM-III-R (SCID) assessments of personality disorders. The SCID assessments identified certain personality disorders better than others.

Use of a long-term inpatient unit as a site for learning psychotherapy.

Little has been written about the benefits of a long-term inpatient unit as a site for training psychiatric residents to do psychoanalytically-oriented psychotherapy. An account is provided of the General Clinical Research Service at the New York State Psychiatric Institute, a unit that is structured to provide residents with this type of learning experience, which is described at length. Emphasis is placed on how the rotation is designed to ensure that residents learn affectively and experientially as well as intellectually.

Efficacy of desipramine in endogenomorphically depressed patients.

This study was designed to test the hypothesis that there are 2 biochemical subgroups of 'endogenously' depressed patients--serotonin-deficient and noradrenalin-deficient groups--which respond differently to antidepressants depending on relative blockade of serotonin vs. norepinephrine (NE) reuptake. Patients with pervasive anhedonia and autonomy of depressed mood (endogenomorphic depressives) were treated first with the noradrenergic agent desipramine (DMI), then, if still depressed, such patients were randomized double-blind to continued DMI or clomipramine (CMI), a primarily serotonergic agent. Of 34 such endogenomorphically depressed patients 2 responded during a placebo period and 5 dropped out. Of 27 patients completing at least 4 weeks of DMI (mean maximum daily dose 283 mg, range 100-400 mg/d), 23 (85.2%) responded. With only 4 nonresponders, the second, or CMI, part of the study had to be abandoned. Since DMI strongly blocks neuronal reuptake of catecholamines with little effect on serotonin reuptake, these results suggest that endogenomorphic depressives may have a relatively homogeneous catecholamine deficiency. Alternatively, DMI may exert its effect by a mechanism other than blockade of EN reuptake. Eleven of the endogenomorphically depressed patients also met Research Diagnostic Criteria for situational depression (reactive). Ten of these 11 responded to DMI suggesting that presence or absence of a precipitant may be irrelevant in predicting response to tricyclic antidepressants in endogenomorphic depressions. Mean blood levels drawn at equivalent DMI dose were 238 ng/ml (range, 48-712) for responders, and 352 ng/ml (range, 160-877) for non-responders, indicating that patients appear to respond to DMI across a wide range of blood levels and suggesting the absence of a narrow therapeutic window.