Research findings on Greek forensic patients found not guilty by reason of insanity. A juxtaposition of patients who committed a criminal offense during their first psychotic episode with those who did so later in the course of their illness.

The aim of this study was to compare the baseline characteristics (demographic, psychiatric-psychopathological and legal) among Greek forensic patients found not guilty by reason of insanity. The first step of this approach being differentiating patients who committed a criminal offense during their first psychotic episode from the ones who did so later in the course of their illness. All patients were hospitalized in the Department of Forensic Psychiatry (DFP) of the Psychiatric Hospital of Thessaloniki (PHT) from January 2015 to January 2020 and were examined in order to be included in the study. The final research sample consisted of 78 patients (70 identifying themselves as males and 8 identifying themselves as females) aged 18 and older, 21 of whom committed a criminal offense during their first psychotic episode (FEP, N = 21) and 57 did so later on in the course of their illness (Course, N = 57). Data were collected from multiple sources and several psychometric tools were used (Mini International Neuropsychiatric Interview-M.I.N·I, Positive And Negative Syndrome Scale-PANSS, Addiction Severity Index-ASI, CAGE Questionnaire, Hostility and Direction of Hostility Questionnaire-HDHQ, Global Assessment of Functioning-GAF and Aggression Questionnaire). Comparing the two groups (FEP vs. Course) we found that patients in FEP were younger, had experienced stressful life events in the last 24 months, committed more serious violent crimes, and more frequently attempted suicide after the crime. Their victims were usually members of their family. The main psychometric disparities between the two groups were found in the "Hostility" score of the Aggression questionnaire, and the items "Criticism of Others" and "Paranoid Hostility" of the HDHQ questionnaire, where patients in FEP scored lower. Patients in FEP scored significantly higher in items P1 (delusions), P4 (excitement), P6 (suspiciousness/persecution) and P7 (hostility) of the PANSS scale. No statistically significant differences were found between the two groups regarding their evaluation with the CAGE, ASI or GAF questionnaires. When comparing the patients' present scores in PANSS scale, the patients in FEP had lower total scores in the Positive and the General Psychopathology subscales. Both groups showed significant improvement during hospitalization in all scales (PANSS & GAF), except for the Negative Subscale of the PANSS scale. Through logistic regression analysis, we found that patients in FEP were younger, more likely to have recently experienced stressful life events and more likely to have assaulted a member of their family. Patients with higher scores in the "Hostility" subscale of the Aggression questionnaire were found to remain at risk for committing a crime during the course of their illness. These findings underline the need to design and develop specialized mental health services in order to identify and treat patients involved in violent crime in a timely and effective manner addressing their multiple needs.

Early intervention services in Greece: Time to focus on people at high risk.

Over the last twenty years, a lot of early intervention services operate worldwide with the aim of offering assistance and promoting the early diagnosis and management, not only of people who experience a first episode of psychosis but also of individuals that are at high risk of developing psychosis. The early intervention services that operate in other countries have been reviewed in correlation with the current status of early intervention services for psychosis in Greece. Early intervention services were first established in Australia, and now hundreds of similar programs exist in Europe, North America and Asia. Furthermore, early intervention services incorporate teams that engage people who have an at risk mental state (ARMS), and are at high risk of developing psychosis. The first clinical service for individuals at high risk for psychosis was established in Melbourne in 1995, and an increasing number of similar services have since emerged worldwide. One of the largest of these is OASIS (Outreach and Support in South London). The first early intervention service was developed during the December 2007, in a rural catchment region of north-western Greece, in Ioannina. After the establishment of Ioannina Early Intervention Service, there was a growing interest of the Greek psychiatric community in the issues of early detection and prevention of psychotic disorders which led to the development of early psychosis units in other regions of Greece, like Athens, Thessaloniki and Patras. However, this field remains neglected in Greece, since in the absence of funding for such early detection services, there are only a few programs that operate mainly on a voluntary basis. Moreover, specialized mental health services for people at high risk for psychosis that have significant clinical benefits and are also cost effective, do not exist in the majority of Greek services. Greece and other countries in a similar condition need to understand the significance of untreated or poorly treated psychotic disorders that affect a lot of young people in late adolescence and early adult life. Focusing on people at high risk of developing psychosis will promote public health and will help not only to prevent the onset of psychotic disorders but to enhance their prognosis as well.

[The psychiatric comorbidity of anorexia nervosa: A comparative study in a population of French and Greek anorexic patients]. / La comorbidité psychiatrique de l'anorexie mentale : une étude comparative chez une population de patients anorexiques français et grecs.

OBJECTIVE: The current study had two objectives: (1) to access the psychiatric comorbidity in axis I and axis II (according to DSM-IV) of anorexia nervosa in a sample of 60 anorexic patients; (2) to compare the features of the psychiatric comorbidity between the two groups of French and Greek anorexic patients who participated in the study, as well as to compare some psychological and behavioral aspects of their anorectic psychopathology. METHOD: Sixty anorexic patients, thirty French and thirty Greek, aged between 18 and 60 years, referred for evaluation and therapy at the unit of eating disorders at the "Institut national Marcel-Rivière of the MGEN" (hôpital de La Verrière, France) and at the unit of eating disorders of the First Department of Psychiatry of EGINITIO University Psychiatric Hospital in Athens (Greece), were accessed with the Eating Attitudes Test-26 (EAT26), Eating Disorder Inventory (EDI), Symptom Checklist-90-Revised (SCL90R), Mini International Neuropsychiatric Interview, Version 5.0.0 and the International Personality Disorder Examination. RESULTS: The comparison between the Greek and French patient populations did not show significant differences in age, socio-educational status, family status and BMI. French patients were hospitalized more regularly than Greek patients (χ2 (1)=6.65, P=0.01) and psychotropic drug therapy was more common in French anorexic patients (χ2 (1)=4.59, P=0.06). The results of the EAT 26 questionnaire in Greek and French patients show an average of 34.93 (±18.54) in total, with no statistically significant difference between the two groups. The results of EDI show a statistically significant difference between the two groups in the subscale 3 (body dissatisfaction) in which the Greeks scored on average at 9.40 and the French at 14.90 (t (58)=3.09, P<0.01). According to the results of the MINI scale, 47% of the patients in our total sample had a restrictive anorexia nervosa and 47% had anorexia nervosa of binge-eating/purging type. The most frequent comorbid disorder was the major depressive episode (40%) and the obsessive compulsive disorder (18.3%). The only statistically significant difference between the two groups was the frequency of the major depressive episode, which appeared statistically higher among the French (χ2 (1)=6.94, P=0.01). According to the results of IPDE, 73.3% of patients in total (76.6% of the French and 70% of the Greeks) showed a personality disorder. The most common personality disorder was borderline personality disorder (40%), followed by obsessive-compulsive personality disorder (26.6%) and avoidant personality disorder (21.7%), with no statistically significant differences between the two groups. DISCUSSION: The profile of anorexic patients who are addressed to the specialized units of eating disorders in both cities (Paris, Athens) had many points in common (demographic parameters, BMI, subtype of anorexia). The results of the EAT-26 and EDI questionnaires did not differ between the two groups, except for the EDI questionnaire subscale 3, which showed body dissatisfaction, where the French had higher scores; this fact underlines the influence of cultural factors on some psychological and behavioral aspects of the psychopathology of the anorexia nervosa. The rates of comorbidity of anorexia nervosa in axis I and axis II found in our study are in agreement with data from various literature reviews and studies in the recent years. The most interesting point of the comorbidity comparison on axis I between the two groups of patients concerns the difference in the frequency of the major depressive episode, for which the results show higher rates in French patients. We can consider that this finding follows the general trend of mood disorder rates in Western countries and we can assume an explanation based on cultural influences. Finally, we can consider that the differences concerning the hospitalization of French patients in a more regular way than Greek patients and the higher rates of psychotropic treatment in French patients reflect the differences in the health systems between the two countries. CONCLUSION: Our study has shown high rates of major depressive episode, as well as personality disorders. There were statistically significant differences in four parameters between our two patient groups, explained by the influence of cultural factors.

[Manic episode in a patient with Beçhet's disease].

Beçhet's disease (BD) is a chronic, heterogeneous, multisystem disease that affects young males and females around the Mediterranean region, as well as from Far and Middle East. Its etiology is vague with vasculitis being its main pathological feature. International diagnostic criteria have been established and they require the presence of recurrent oral ulcerations plus two of the following: Recurrent genital ulceration, eye lesions, skin lesions and positive pathergy test. A significant number of patients with Beçhet's disease suffers from symptoms from the central nervous system (CNS), while the most common clinical symptoms are pyramidal signs, mental-behavioral changes, hemiparesis and brain stem syndrome. The existence of mental-behavioral changes seems to be one of the most common findings in patients with Neuro-Beçhet (N-BD). These changes seem to be related with memory and attention deficits, and the process of deterioration continues even in attack-free periods, suggesting a continuously active disease process in the CNS. The prevalence of anxiety, depression and general psychiatric symptoms is higher among patients with BD compared to healthy individuals. However, the association between psychiatric symptoms and BD is not clearly understood. On the other hand, syndromes like psychosis or bipolar disorder appear to be less frequent, especially in attack-free periods. We describe the case of a 52-year old woman with Beçhet's disease who developed a single manic episode 13 years after the onset of Beçhet's disease. A 52-year old woman, suffering from Beçhet's disease since the age of 39, developed manic symptoms, namely elevated mood, pressured speech, flight of ideas, distractibility and decreased need for sleep. The above symptoms developed during a period that no other symptoms of Beçhet's disease were present. Moreover there was no other manifestation from the nervous system. A brain MRI was unremarkable, while a brain SPECT study revealed severe hypoperfusion of the left prefrontal cortex. Neuropsychological examination revealed severe disturbance in attention, working memory and learning ability, while her visuaspatial ability and executive functions were well spared. Her symptoms were well controlled after treated with quetiapine 800 mg. The manic episode developed in the absence of any neurological manifestation (Neuro-Beçhet), or other symptom of Beçhet's disease, and was clearly distinguishable from euphoria, disinhibition or irritability that are common in patients with Beçhet's disease. It looks probable that CNS damage caused by the disease constitutes a biological substrate for the development of manic episodes in patients suffering from Beçhet's disease.

The Validity of the Distress Thermometer in Greek Colon Cancer Patients.

BACKGROUND: Although screening for distress is a crucial part of psycho-social care for cancer patients, there has not been a validation study for this purpose in Greece. The purpose of this study was to evaluate for the first time the psychometric properties of the Greek translation of the Distress Thermometer (DT) and Problem List (PL) in Greek colorectal cancer patients (CRC). METHODS: Participants were 84 CRC inpatients of the 1st Surgical Propedeutic Department of the Aristotle University of Thessaloniki with a mean age of 70.8±9.5 years. Participants completed the DT, PL and the Hospital Anxiety and -Depression Scale (HADS). RESULTS: The Cronbach's alpha coefficient in the DT was 0.795. Patients' mean score in the DT was 5.7±2.74, while the mean number of the reported problems in the PL was 18.85±5.50 and the mean total score of the HADS was 15.61±6.95. ROC-analysis supported that a cut-off score of 7 gives the optimal sensitivity and specificity for the DT. CONCLUSION: The index sample has manifested high levels of distress, which correspond to high need for support and improvement of the patient-provider relationship. This is probably a difficult task, since the Greek healthcare system has minimal experience of providing psycho-oncology care. The present study has indicated that the DT can be reliably used in the Greek clinical setting. Future studies, along with state provision, are essential in order to offer Greek cancer patients state-of-the-art and comprehensive care.

Controlled shifting of attention in schizophrenia and bipolar disorder through a dichotic listening paradigm.

The dichotic listening (DL) task was developed originally to examine bottom-up or "automatic" information processing. More recently, however, it has been used as a tool in the study of top-down or "controlled" information processing. This has been done by including forced-choice conditions, wherein the examinee is required to focus attention on one or the other ear. It has been widely utilized with patients with schizophrenia, who exhibit rather severe deficits in managing their attention, but not with other patient groups, such as patients with bipolar disorder. In the present study, we examined potential performance similarities in the DL listening task. In total, the sample consisted of 38 patients with schizophrenia, 20 patients with psychotic bipolar disorder and 35 healthy individuals, who performed a DL task with verbal stimuli once at the beginning of their hospitalization and again on the last day before discharge. Our findings indicated that both patient groups showed similarly diminished performance when compared to healthy participants at both times of administration. Symptom improvement between the two evaluations did not significantly influence performance in the DL task. In conclusion, impaired automated and controlled information processing appears to be a common deficit in both schizophrenia and bipolar disorder.

Psychotic symptoms in normal pressure hydrocephalus.

Normal Pressure Hydrocephalus due to idiopathic aqueductal stenosis is a chronic abnormal accumulation of cerebrospinal fluid in the cerebral ventricles caused by an obstruction in the Sylvian aqueduct. This leads to a dilatation of the ventricular system and to subsequent damage of the adjacent parenchyma. Although NPH typically presents with the progressive 'triad' of cognitive impairment, gait disturbance and urinary incontinence, it has been described that it rarely manifests in the form of predominant psychotic symptoms. It has been suggested that thought and perceptual disorders could develop secondary to the damage caused by NPH. Although precise anatomical correlates have not yet been established, certain cerebral regions -primarily the frontal cortex, mesencephalic and diencephalic structures of the brain- have been implicated in the pathogenesis of hydrocephalic psychosis. Because frontal lobe lesions are traditionally known to facilitate one's inability to integrate and correct perceptual distortions in the face of contradictory evidence, frontal lobe dysfunction may be integral in delineating the etiology of delusions in NPH. We present the case of a 30-year-old female, admitted involuntarily to our acute psychiatric department because she exhibited aggressive behavior while being in an agitated state with delusions of persecution. Her neurological examination disclosed subtle bradykinesia. Neuropsychological batteries and intelligence testing revealed mild cognitive impairment and a CT scan showed considerable dilatation of the ventricular system due to idiopathic aqueductal stenosis. While a conservative approach was chosen for the treatment of NPH, our patient was initiated on 2nd generation antipsychotics showing marked improvement of her psychiatric symptomatology. The atypical presentation of hydrocephalus in the aforementioned case underlines the necessity to thoroughly investigate the possible presence of an underlying organic factor in those patients who present with predominant psychotic symptoms in association with soft non-localising neurological signs and mild cognitive deficits. Furthermore, our patient's marked improvement indicates that, in cases where the primary cause is treated conservatively, hydrocephalic psychosis could respond to 2nd generation antipsychotics. In light of this case report, we reviewed past and present literature on the matter.

Assessing personality traits by questionnaire: psychometric properties of the Greek version of the Zuckerman-Kuhlman personality questionnaire and correlations with psychopathology and hostility.

BACKGROUND: The Zuckerman-Kuhlman Personality Questionnaire (ZKPQ) was developed in an attempt to define the basic factors of personality or temperament. We aimed to assess the factor structure and the psychometric properties of its Greek version and to explore its relation to psychopathological symptoms and hostility features. METHODS: ZKPQ was translated into Greek using back-translation and was administered to 1,462 participants (475 healthy participants, 619 medical patients, 177 psychiatric patients and 191 opiate addicts). Confirmatory and exploratory factor analyses were performed. Symptoms Distress Check-List (SCL-90R) and Hostility and Direction of Hostility Questionnaire (HDHQ) were administered to test criterion validity. RESULTS: Five factors were identified, largely corresponding to the original version's respective factors. Retest reliabilities were acceptable (rli's: 0.79-0.89) and internal consistency was adequate for Neuroticism-Anxiety (0.87), Impulsive Sensation Seeking (0.80), Aggression-Hostility (0.77) and Activity (0.72), and lower for Sociability (0.64). Most components were able to discriminate psychiatric patients and opiate addicts from healthy participants. Opiate addicts exhibited higher rates on Impulsive Sensation Seeking compared to healthy participants. Neuroticism-Anxiety (p<0.001) and Impulsive Sensation Seeking (p<0.001) were significantly associated with psychological distress and Aggression-Hostility was the most powerful correlate of Total Hostility (p<0.001), and Neuroticism-Anxiety was the stronger correlate of introverted hostility (p<0.001), further supporting the instrument's concurrent validity. CONCLUSIONS: Present findings support the applicability of the Greek version of ZKPQ within the Greek population. Future studies could improve its psychometric properties by finding new items, especially for the Sociability scale.

Insights into theory of mind in schizophrenia: the impact of cognitive impairment.

The ability to mentalize and attribute beliefs, intentions and desires to others has been found by the vast majority of studies to be impaired in patients with schizophrenia. However, it is not yet clear if this deficit in Theory of Mind (ToM) is independent of their also well established deficits in basic cognitive functioning. In the present study, we sought to clarify the above relationship by exploring patients' ToM impairment after controlling for their putative cognitive deficits. We examined 36 patients with schizophrenia and 30 healthy matched controls on first and second order tasks of ToM and on commonly used neuropsychological tests. Patients performed poorly on ToM tasks even after controlling for their cognitive deficits, particularly on second order ToM. The present findings contribute to the understanding of the mechanism of ToM, suggesting that ToM deficits are core characteristics in schizophrenia and relatively independent of patients' cognitive impairment.

Evaluation of cognitive-analytic therapy (CAT) outcome in patients with panic disorder.

Two categories of treatment have been shown to be effective in treating panic disorder with or without agoraphobia. One is pharmacotherapy using antidepressants and benzodiazepinesand the other is psychotherapy. The present study aims at the assessment of the outcome of Cognitive-Analytic Therapy (CAT), a type of brief psychotherapy, in a sample of 128 psychiatricoutpatients with DSM-IV diagnosis of panic disorder, who attended the Mental Health Center of Northwestern District of Thessaloniki. For this purpose, validated instruments for the evaluation,such as the Minnesota Multiphasic Personality Inventory (MMPI), the Beck Depression Inventory (BDI), the State-Trait Anxiety Inventory (STAI) and the Post-therapy Questionnaire (PtQ), were used.The patients were evaluated in two follow ups, 2 months and 1 year after therapy termination. The results showed that on the 2 month follow up 78 patients showed a statistically significant improvementin comparison to the intake time, in all but two (Mf, Ma) clinical scales of the MMPI, on their sum and on some research scales of the MMPI, on the BDI and on the STAI scores. On the 1-yearfollow-up, according to the results of the MMPI, BDI, STAI and PtQ, the patients maintained the achieved improvement. The above results indicate that CAT is an effective brief psychotherapeuticapproach for patients with panic disorder.

[Schizoaffective disorder: An arguable diagnostic entity].

Seventy-five years ago, J. Kasanin introduced the term "schizoaffective disorder" to refer to a disorder with symptoms of both schizophrenia and affective disorders. Since then, schizoaffective disorder has raised a considerable amount of discussion about its definition and position as a variant of schizophrenia, a variant of mood disorder or as an entity in between. This ambiguity is reflected on the definition of diagnostic criteria of the disorder in the taxonomic systems, which are practically too complex. Furthermore, there are essential differences between DSM-IV and ICD-10 regarding schizoaffective definition. Finally, the disorder has a very low inter-rater reliability and a very low longitudinal diagnostic stability. All the above have even led to proposals of elimination of schizoaffective disorder as a separate diagnostic entity. The prevalence of the disorder varies between 0.3% and 0.8%. Schizoaf fective disorder is more common in women than in men, a dif ference that is mostly attributed to increased incidence among women of the depressive type. The bipolar type of the disorder is more often found in young adults, whereas the depressive type is commoner in older adults. With regards to other variables such as educational level, marital status, prognosis, occupational level and social adjustment, schizoaffective disorder has more favourable characteristics than schizophrenia and less favourable than mood disorders. Age at onset is earlier than mood disorders and later than schizophrenia. The above epidemiologic and clinical data, as well as data from family, twin, genetic and neuroimaging studies, indicate that schizoaffective disorder can be best viewed as a mid-point on a continuum between schizophrenia and mood disorders and represents the most prominent paradigm challenging the so-called "Kraepelinian dichotomy" of major psychiatric disorders. Though schizoaffective disorder is a nosological nuisance, it is also a clinical reality and it is not advisable to abandon it as a separate diagnosis.

[First-episode schizophrenia: Pharmacotherapy and psychosocial interventions].

The first episode of schizophrenia is a field of great interest from both clinical and research perspectives. Most clinical and psychosocial deterioration in schizophrenia occurs within the first 5 years of the onset of the illness, suggesting that this is a critical period for treatment initiation. Therefore, early detection and subsequent effective therapeutic intervention are vital for the patient, as they significantly determine the course and the long term outcome of the disease. Pharmacotherapy is the cornerstone of the whole therapeutic approach. Patients with first-episode psychosis are comparatively more treatment responsive than patients with multiple episodes. They need lower doses of antipsychotic medication but at the same time are quite sensitive to side effects mainly to extrapyramidal symptoms and signs. All current guidelines consider second generation antipsychotics as first choice drug for first episode schizophrenics. Data from few double blind randomized clinical trials indicate that the newer agents show equal or even better efficacy than the neuroleptics and to a certain extend fewer side effects, mainly extrapyramidal symptoms. Despite initial symptom reduction, achievement of full remission -particularly if it is defined according to strict criteria- and even more, achievement of full recovery remains unsatisfactory. Predictors of poor short term and long term outcome include male gender, low educational level, "soft" neurological signs, severe positive symptoms at baseline, cognitive deficits at intake, poor premorbid functioning especially during adolescence, prefrontal neuronal dysfunction, extrapyramidal symptoms and tardive dyskinesia early in treatment, long duration of untreated psychosis or untreated illness. Although published guidelines do not make definitive recommendations about the duration of maintenance treatment after the first episode, recent data suggest that 1 or 2 years might not be adequate. Medication adherence is problematic in first episode schizophrenics even within the first six months. Poor adherence is predicted by male gender, younger age, poor insight after discharge, severe positive symptoms at baseline, alcohol and drug abuse, inadequate family involvement, lower occupational status, not positive relationship with the psychiatrist, bad admission experience and medication side effects. Adjunctive psychosocial interventions may be beneficial across a variety of domains and can assist with symptomatic and functional recovery. Cognitive-behavior therapy has shown modest efficacy in reducing symptoms and assisting patients in adjusting to their illness but has shown minimal efficacy in reducing relapse. Some reports support the benefits of family interventions, while there is a paucity of data evaluating group inter ventions. Comprehensive (i.e. multi element) treatment approaches show promise in reducing symptoms and hospital readmissions as well as improving functional outcomes. More randomized controlled trials are needed to evaluate the ef fectiveness of psychosocial interventions, in general, in first-episode psychosis patients.

[Chronic renal insufficiency after long term lithium treatment].

Lithium is, in the era of evidence-based psychiatry, an efficacious and, simultaneously, cost-effective treatment for bipolar disorder, despite the existence of alternative mood-stabilizers (antiepileptics, atypical antipsychotics). A prerequisite for lithium administration in patients with bipolar disorder is the patient 's cooperation, in order to ensure monitoring of drug plasma levels as well as thyroid and renal function. Lithium-related renal complications include impairment in renal concentrating ability resulting in polyuria, increase of plasma creatinine levels and, more rarely, renal insufficiency. In this paper we present the case of a patient with bipolar disorder, who developed chronic renal insufficiency after 25 years of treatment with lithium.

[Neuroleptic malignant syndrome and atypical antipsychotics: two case reports].

Neuroleptic malignant syndrome (NMS) constitutes the most serious adverse effect of antipsychotic medications. Although it was initially described as a complication of conventional neuroleptics, atypical antipsychotic agents are also capable of inducing the syndrome. It has been suggested that atypical antipsychotic-induced NMS may be qualitatively and quantitatively different from the NMS caused by conventional neuroleptics; however, atypical antipsychotics can also be associated with severe forms of NMS. We report two patients who manifested severe NMS in association with atypical antipsychotic agents. Both patients were receiving low antipsychotic doses; moreover, one of the patients had not undergone any recent changes in his antipsychotic regimen. Thus, it is pointed out that vigilance for signs of NMS should not be influenced by antipsychotic type and dose.

Psychiatric comorbidity in Greek patients with generalized anxiety disorder.

From a total sample of 1,448 psychiatric outpatients, 81 (5.6%) received a diagnosis of generalized anxiety disorder (GAD) according to DSM-III-R criteria. Fifty-three (65%) of them had another Axis I diagnosis, while this percentage increased to 78% (63/81) when lifetime psychiatric diagnoses were recorded. The most frequent comorbid diagnoses were panic disorder, dysthymia, major depression and social phobia. Forty-three (53%) of the GAD patients met the criteria for personality disorder. They manifested obsessive-compulsive, avoidant personality and personalities of cluster C in general significantly more frequently than the rest of the total sample. The presence of a personality disorder was related to a significantly higher score on almost all the Minnesota Multiphasic Personality Inventory clinical and research scales, to a worse level of functioning and to an earlier age of onset of GAD. The results of the present study (1) support previous findings of high rates of comorbidity of clinical syndromes in GAD, (2) indicate that GAD co-occurs frequently with cluster C personality disorders, mainly avoidant and obsessive-compulsive, and (3) that the presence of a concomitant personality disorder is related to severer psychopathology and to a worse level of functioning.

Somatoform disorders: comorbidity with other DSM-III-R psychiatric diagnoses in Greece.

From a total sample of 1,448 psychiatric outpatients, 175 (12.1%) received a diagnosis of a somatoform disorder according to DSM-III-R criteria. One hundred twenty-two (70%) of these patients had another current axis I diagnosis, and this rate increased to 79% (139 of 175) when lifetime psychiatric diagnoses were recorded. The most frequent comorbid diagnoses were depressive disorders, i.e., dysthymia and major depression, and then anxiety disorders, mainly panic disorder. One hundred ten (63%) of the somatoform patients met the criteria for a personality disorder, significantly higher than the rate (52%) for the rest of the total sample (n = 1,273), who were used as a control group. The most frequent comorbid personality disorders were histrionic, dependent, and personalities of cluster B in general. Hypochondriasis was the only somatoform disorder that was additionally significantly related to obsessive-compulsive personality disorder. Somatoform patients with a concomitant personality disorder manifested more severe overall psychopathology as measured by the Minnesota Multiphasic Personality Inventory (MMPI) and a worse level of functioning than those without. The results of the present study show that (1) patients with somatoform disorders have a high rate of comorbidity with other clinical syndromes and personality disorders, and (2) the presence of a personality disorder is related to more severe overall psychopathology and a worse level of functioning. All of the above indicate that special attention must be paid to the interaction between somatoform disorders, other clinical syndromes, and personality structure at the level of both clinical and research practice.