Health system changes needed to support people consulting general practice out of hours services in Ireland.

BACKGROUND: Mental illness acts as a barrier to accessing and obtaining effective medical care. It has been shown that out of hours services are an important first stop for emergency care for people experiencing mental health difficulties. However, little is in fact known about the use of out of hours general practice services by people experiencing mental health difficulties. AIM: To establish the number and range of consultations that have a primary or related mental health issue attending general practitioner (GP) out of hours and to document adherence to their follow-up care referral. DESIGN AND SETTING: Descriptive study in one large out of hours primary care service in the South East of Ireland (Caredoc). METHODS: An anonymous extraction of retrospective data from 1 year of the out of hours' electronic database was undertaken. Patients who attended the out of hours with a possible mental health issue and were referred to the psychiatric services or back to their own GP, were tracked via phone follow-up with hospitals and GPs over 6 months to establish if they attended for the recommend follow-up care. RESULTS: Over a 1 year period, there were 3844 out of hours presentations with a mental health component. Overall, 9.3% were referred by the out of hours GP for follow-up to a hospital emergency department (ED) or were advised to attend their own GP. A total of 104 patients who were advised to attend their GP or ED following their consultation with the out of hours GP were tracked. Twenty-seven patients were referred back to their GP of which the follow-up call to the GP revealed that 44.5% did not attend. Seventy-seven patients were referred to the hospital services, of whom 37.7% did not attend. CONCLUSIONS: There are significant challenges at the interface of primary care and secondary mental health services in Ireland. As expounded by the WHO and WONCA, in order to be effective and efficient, care for mental health must be coordinated with services at different levels of care complemented by the broader health system.

Comparison of alternative models for personality disorders, II: 6-, 8- and 10-year follow-up.

BACKGROUND: Several conceptual models have been considered for the assessment of personality pathology in DSM-5. This study sought to extend our previous findings to compare the long-term predictive validity of three such models: the five-factor model (FFM), the schedule for nonadaptive and adaptive personality (SNAP), and DSM-IV personality disorders (PDs). METHOD: An inception cohort from the Collaborative Longitudinal Personality Disorder Study (CLPS) was followed for 10 years. Baseline data were used to predict long-term outcomes, including functioning, Axis I psychopathology, and medication use. RESULTS: Each model was significantly valid, predicting a host of important clinical outcomes. Lower-order elements of the FFM system were not more valid than higher-order factors, and DSM-IV diagnostic categories were less valid than dimensional symptom counts. Approaches that integrate normative traits and personality pathology proved to be most predictive, as the SNAP, a system that integrates normal and pathological traits, generally showed the largest validity coefficients overall, and the DSM-IV PD syndromes and FFM traits tended to provide substantial incremental information relative to one another. CONCLUSIONS: DSM-5 PD assessment should involve an integration of personality traits with characteristic features of PDs.

The association of personality disorders with the prospective 7-year course of anxiety disorders.

BACKGROUND: This study prospectively examined the natural clinical course of six anxiety disorders over 7 years of follow-up in individuals with personality disorders (PDs) and/or major depressive disorder. Rates of remission, relapse, new episode onset and chronicity of anxiety disorders were examined for specific associations with PDs. METHOD: Participants were 499 patients with anxiety disorders in the Collaborative Longitudinal Personality Disorders Study, who were assessed with structured interviews for psychiatric disorders at yearly intervals throughout 7 years of follow-up. These data were used to determine probabilities of changes in disorder status for social phobia (SP), generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), panic disorder and panic disorder with agoraphobia. RESULTS: Estimated remission rates for anxiety disorders in this study group ranged from 73% to 94%. For those patients who remitted from an anxiety disorder, relapse rates ranged from 34% to 67%. Rates for new episode onsets of anxiety disorders ranged from 3% to 17%. Specific PDs demonstrated associations with remission, relapse, new episode onsets and chronicity of anxiety disorders. Associations were identified between schizotypal PD with course of SP, PTSD and GAD; avoidant PD with course of SP and OCD; obsessive-compulsive PD with course of GAD, OCD, and agoraphobia; and borderline PD with course of OCD, GAD and panic with agoraphobia. CONCLUSIONS: Findings suggest that specific PD diagnoses have negative prognostic significance for the course of anxiety disorders underscoring the importance of assessing and considering PD diagnoses in patients with anxiety disorders.

Personality traits as prospective predictors of suicide attempts.

OBJECTIVE: To examine higher order personality factors of negative affectivity (NA) and disinhibition (DIS), as well as lower order facets of impulsivity, as prospective predictors of suicide attempts in a predominantly personality disordered sample. METHOD: Data were analyzed from 701 participants of the Collaborative Longitudinal Personality Disorders Study with available follow-up data for up to 7 years. Cox proportional hazards regression analyses was used to examine NA and DIS, and facets of impulsivity (e.g. urgency, lack of perseverance, lack of premeditation and sensation seeking), as prospective predictors of suicide attempts. RESULTS: NA, DIS and all facets of impulsivity except for sensation seeking were significant in univariate analyses. In multivariate models which included sex, childhood sexual abuse, course of major depressive disorder and substance use disorders, only NA and lack of premeditation remained significant in predicting suicide attempts. DIS and the remaining impulsivity facets were not significant. CONCLUSION: NA emerged as a stronger and more robust predictor of suicide attempts than DIS and impulsivity, and warrants greater attention in suicide risk assessment. Distinguishing between facets of impulsivity is important for clinical risk assessment.

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.

Longitudinal diagnostic efficiency of DSM-IV criteria for obsessive-compulsive personality disorder: a 2-year prospective study.

OBJECTIVE: To examine the longitudinal diagnostic efficiency of the DSM-IV criteria for obsessive-compulsive personality disorder (OCPD). METHOD: At baseline, criteria and diagnoses were determined using diagnostic interviews, and blinded assessments were performed 24 months later with 550 participants. Diagnostic efficiency indices (conditional probabilities, total predictive power, and kappa) were calculated for each criterion determined at baseline, using the independent OCPD diagnosis at follow-up as the standard. RESULTS: Longitudinal diagnostic efficiencies for the OCPD criteria varied; findings suggested the overall predictive utility of 'preoccupied with details', 'rigid and stubborn', and 'reluctant to delegate'. CONCLUSION: These findings suggest the predictive validity of three cognitive-interpersonal OCPD criteria.

Internal consistency, intercriterion overlap and diagnostic efficiency of criteria sets for DSM-IV schizotypal, borderline, avoidant and obsessive-compulsive personality disorders.

OBJECTIVE: To evaluate performance characteristics of DSM-IV Personality Disorders (PDs) criteria. METHOD: Six hundred and sixty-eight adults recruited for the Collaborative Longitudinal Personality Disorders Study (CLPS) were assessed with diagnostic interviews. RESULTS: Within-category inter-relatedness was evaluated by Cronbach's alpha and median intercriterion correlations (MIC). Cronbach's alpha ranged from 0.47 to 0.87 (median=0.71); seven of the 10 PDs had alphas greater than 0.70. Between-category criterion overlap was evaluated by "inter-category" intercriterion correlations between all PD pairs (ICMIC). ICMIC values (median=0.08) were lower than MIC values (median=0.23). Diagnostic efficiency statistics (sensitivity, specificity, positive predictive power and negative predictive power were calculated for schizotypal, borderline, avoidant and obsessive-compulsive PDs. CONCLUSION: DSM-IV PD criteria sets have some convergent validity and discriminant validity: criteria for individual PDs correlate better with each other than with criteria for other PDs. Diagnostic efficiency statistics provide guidance regarding usefulness of criteria for inclusion or exclusion.

The relationship between comorbid personality disorders and treatment received in patients with anxiety disorders.

Few studies have addressed the relationship between the presence of a comorbid personality disorder and the amount of psychiatric treatment received by patients with an Axis I disorder. This issue has not been studied in patients with anxiety disorders. In a prospective, naturalistic, longitudinal study of anxiety disorders, 526 subjects were assessed with the Personality Disorder Examination, and types of treatment received in 1991 and 1996 were identified. In 1991, compared to subjects without a personality disorder, subjects with a personality disorder were as likely to receive medication and they received a greater number of medications. Subjects with borderline personality disorder were more likely to receive heterocyclic antidepressants and interventions characteristic of psychodynamic psychotherapy and cognitive therapy; they also reported receiving a greater number of medications and types of psychosocial treatment than other subjects. In 1996, subjects with borderline personality disorder were more likely to receive psychodynamic interventions. These findings suggest that in patients with an anxiety disorder, the presence of a comorbid personality disorder is associated with receiving a greater number of medications but not with a greater likelihood of receiving pharmacologic or psychosocial treatment. However, the presence of borderline personality disorder is associated with a greater likelihood of receiving, and receiving a greater number of, certain types of somatic and psychosocial treatments.

Recent developments in research of trauma and personality disorders.

Although the association between trauma and personality disorders, particularly borderline personality disorder (BPD), has been well established, the etiologic role of trauma in the development of personality disorders has been a topic of debate. Numerous mediation models have been put forth to explain how trauma can serve as a risk factor for the subsequent development of BPD. The symptomatic overlap between the proposed complex post-traumatic stress disorder diagnosis and BPD has fueled research efforts aimed at determining whether these are distinct disorders or should both be considered as trauma spectrum disorders. Treatment implications of this diagnostic differentiation are discussed.

Patterns of personality pathology in patients with generalized anxiety disorder, panic disorder with and without agoraphobia, and social phobia.

The relationship between co-occurring personality disorders and anxiety disorders (panic disorder with or without agoraphobia, social phobia, and generalized anxiety disorder) was examined, taking into account the effect of major depression. This article describes findings for 622 participants in the Harvard/Brown Anxiety Research Project, a longitudinal follow-up study of DSM-III-R-defined anxiety disorders. A total of 24% of participants had at least one personality disorder, with avoidant, obsessive compulsive, dependent, and borderline most common. Generalized anxiety disorder, social phobia, and major depression were positively associated with the occurrence of one or more personality disorders, whereas panic disorder with agoraphobia was not associated. Major depression was associated in particular with dependent, borderline, histrionic, and obsessive compulsive personality disorders and social phobia was associated with avoidant personality disorder. Whereas some of our findings confirm results from earlier studies, others are somewhat inconsistent with previous results and indicate the need for further investigation.

Treatment utilization by patients with personality disorders.

OBJECTIVE: Utilization of mental health treatment was compared in patients with personality disorders and patients with major depressive disorder without personality disorder. METHOD: Semistructured interviews were used to assess diagnosis and treatment history of 664 patients in four representative personality disorder groups-schizotypal, borderline, avoidant, and obsessive-compulsive-and in a comparison group of patients with major depressive disorder. RESULTS: Patients with personality disorders had more extensive histories of psychiatric outpatient, inpatient, and psychopharmacologic treatment than patients with major depressive disorder. Compared to the depression group, patients with borderline personality disorder were significantly more likely to have received every type of psychosocial treatment except self-help groups, and patients with obsessive-compulsive personality disorder reported greater utilization of individual psychotherapy. Patients with borderline personality disorder were also more likely to have used antianxiety, antidepressant, and mood stabilizer medications, and those with borderline or schizotypal personality disorder had a greater likelihood of having received antipsychotic medications. Patients with borderline personality disorder had received greater amounts of treatment, except for family/couples therapy and self-help, than the depressed patients and patients with other personality disorders. CONCLUSIONS: These results underscore the importance of considering personality disorders in diagnosis and treatment of psychiatric patients. Borderline and schizotypal personality disorder are associated with extensive use of mental health resources, and other, less severe personality disorders may not be addressed sufficiently in treatment planning. More work is needed to determine whether patients with personality disorders are receiving adequate and appropriate mental health treatments.

The Collaborative Longitudinal Personality Disorders Study: baseline Axis I/II and II/II diagnostic co-occurrence.

OBJECTIVE: To describe baseline diagnostic co-occurrence in the Collaborative Longitudinal Personality Disorders Study. METHOD: Six hundred and sixty-eight patients were reliably assessed with diagnostic interviews for DSM-IV Axis I and II disorders to create five groups: Schizotypal (STPD), Borderline (BPD), Avoidant (AVPD), Obsessive-Compulsive (OCPD) and Major Depressive Disorder (MDD) without personality disorder (PD). RESULTS: Mean number of Axis I lifetime diagnoses was 3.4; STPD and BPD groups had more diagnoses than AVPD, OCPD, and MDD groups. Significant Axis I co-occurrences emerged for Social Phobia/ AVPD, PTSD/BPD and Substance Use/BPD. Mean number of co-occurring PDs was 1.4; STPD had more than BPD group which had more than AVPD and OCPD groups. Significant PD co-occurrence emerged for: STPD/ Paranoid and Schizoid PDs, BPD with Antisocial and Dependent PDs, and lower frequency for OCPD/Antisocial PD. CONCLUSION: Diagnostic co-occurrences generally followed base rates, while significant departures resemble those of controlled literature.

Personality disorders, history of trauma, and posttraumatic stress disorder in subjects with anxiety disorders.

The purpose of the study was to examine the association of personality disorders, history of trauma, and posttraumatic stress disorder (PTSD) in a large sample of subjects with anxiety disorders. Categorical and continuous indices of personality disorders were compared in three groups from the Harvard/Brown Anxiety Disorders Research Project (HARP): subjects with no history of trauma (n = 403), subjects with a history of trauma but no history of PTSD (n = 151), and subjects with a current or past diagnosis of PTSD (n = 68). Subjects with PTSD were more likely to meet criteria for borderline or self-defeating personality disorder than subjects in the other two groups. PTSD subjects also had higher scores on the continuous measures (total number of criteria met) for borderline and self-defeating personality disorder than the other two groups. The findings suggest that a diagnosis of PTSD rather than a history of trauma is associated with borderline and self-defeating personality disorder features. Alternative conceptualizations of axis II features in individuals with PTSD are discussed.

Multiple recurrences of major depressive disorder.

OBJECTIVE: The authors of this study examined multiple recurrences of unipolar major depressive disorder. METHOD: A total of 318 subjects with unipolar major depressive disorder were prospectively followed for 10 years within a multicenter naturalistic study. Survival analytic techniques were used to examine the probability of recurrence after recovery from the index episode. RESULTS: The mean number of episodes of major depression per year of follow-up was 0. 21, and nearly two-thirds of the subjects suffered at least one recurrence. The number of lifetime episodes of major depression was significantly associated with the probability of recurrence, such that the risk of recurrence increased by 16% with each successive recurrence. The risk of recurrence progressively decreased as the duration of recovery increased. Within subjects, there was very little consistency in the time to recurrence. CONCLUSIONS: Major depressive disorder is a highly recurrent illness. The risk of the recurrence of major depressive disorder progressively increases with each successive episode and decreases as the duration of recovery increases.

The Collaborative Longitudinal Personality Disorders Study: reliability of axis I and II diagnoses.

Both the interrater and test-retest-retest reliability of axis I and axis II disorders were assessed using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) and the Diagnostic Interview for DSM-IV Personality Disorders (DIPD-IV). Fair-good median interrater kappa (.40-.75) were found for all axis II disorders diagnosed five times or more, except antisocial personality disorder (1.0). All of the test-retest kappa for axis II disorders, except for narcissistic personality disorder (1.0) and paranoid personality disorder (.39), were also found to be fair-good. Interrater and test-retest dimensional reliability figures for axis II were generally higher than those for their categorical counterparts; most were in the excellent range (> .75). In terms of axis I, excellent median interrater kappa were found for six of the 10 disorders diagnosed five times or more, whereas fair-good median interrater kappa were found for the other four axis I disorders. In general, test-retest reliability figures for axis I disorders were somewhat lower than the interrater reliability figures. Three test-retest kappa were in the excellent range, six were in the fair-good range, and one (for dysthymia) was in the poor range (.35). Taken together, the results of this study suggest that both axis I and axis II disorders can be diagnosed reliably when using appropriate semistructured interviews. They also suggest that the reliability of axis II disorders is roughly equivalent to that reliability found for most axis I disorders.

The Collaborative Longitudinal Personality Disorders Study: development, aims, design, and sample characteristics.

This paper describes the aims, background, design, and methods used in a collaborative longitudinal study of Axis II personality disorders (PDs). This study examines the putative stability of selected PD diagnoses and criteria, what factors affect their course, and whether their stability and course distinguishes them from a representative Axis I disorder. This article also describes the acquisition and demographics of the sample on whom the study is being done. A prospective, repeated measures investigation of the stability of PDs is now underway at multiple clinical settings in four collaborating urban sites in Boston. New Haven, New York, and Providence. Diagnostic assignments are based on semistructured interview assessments (by clinically trained raters) and confirmed by at least one additional contrasting diagnostic method. The sample consists of 668 treatment seeking and reliably diagnosed adults recruited from a broad range of clinical sites. By design, patients in the sample met standards for one of five diagnostic subgroups: (a) schizotypal (N = 86); (b) borderline (N = 175); (c) avoidant (N = 157); (d) obsessive-compulsive (N = 153) personality disorders or a control group having (e) major depressive disorder without personality disorder (N = 97).

Personality disorders: a discussion of current status and future directions for research, practice, and policy.

This article is the result of a panel discussion on future directions in personality disorders held at the 1998 Meeting of the Society for Psychotherapy Research in Snowbird Utah. Three experts in the field of personality disorders were invited to participate in a dialogue on priorities and directions for research, practice, and policy in this area. Topics discussed amongst the panelists included the following: 1) relevance of psychotherapy process research for treatments of personality disorders, and potential fruitful directions for such research; 2) what has been learned from outcome research in treatment of personality disorders, and directions for such research that are likely to be most productive in improving treatments; 3) the extent to which research has influenced clinical practice and how existing gaps might be addressed; 4) policy questions related to payment for treatment of personality disorders.

Commonality and specificity of personality disorder profiles in subjects with trauma histories.

Recently, attention has been drawn to a range of disturbances in personality functioning that commonly characterize individuals with a history of severe or prolonged trauma. Many of these features overlap with criteria for some of the Axis II personality disorders. The current study investigated the similarity of personality disorder features in different samples of patients with trauma histories, and specificity of such features compared to other psychiatric samples. Profiles of Axis II features, based on relative frequencies of individual disorder "diagnoses" derived from a common measure (Personality Diagnostic Questionnaire-Revised), were compared in three trauma samples: male Vietnam combat veterans with PTSD, female inpatients with a history of childhood sexual abuse, and female outpatients with a history of childhood sexual abuse. The PDQ-R derived profiles in each of the three trauma samples were then compared with similar PDQ-R derived profiles in published reports of psychiatric samples selected for other diagnoses. Each of the three Spearman rank correlations among the three trauma samples were significant, ranging from .72 to .94. There was a clear pattern of higher correlations within the trauma samples (average correlation of .81) than between the trauma and nontrauma samples (average correlations of .11, .36, and .25 between the nontrauma samples and the combat sample, inpatient sexual abuse sample, and outpatient sexual abuse sample, respectively). The findings suggest that a pattern of personality disorder features may be distinctly associated with individuals with trauma histories, at least of the type examined here. Future studies using more clinically valid measures of personality features and including other types of trauma samples are needed to determine the generalizability of the current findings. Also needed are studies with longitudinal designs to address questions of causal pathways that may underlie such associations.