Results of the search for personality disorder screening tools: clinical implications.

OBJECTIVE: To examine the characteristics, validity, posttest probabilities, and screening capabilities of 8 different instruments used to predict personality disorders. METHOD: Screening instruments were examined in 3 prospective, observational, test-development studies in 3 random samples of Dutch psychiatric outpatients, using the Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II) as the "gold standard." The studies were performed from March 2004 to March 2005 (study 1: N = 195, mean age = 32.7 years), October 2006 to January 2007 (study 2: N = 79, mean age = 34.3 years), and January 2008 to October 2009 (study 3: N = 102, mean age = 33.7 years). The following 8 assessment instruments were examined: 3 short questionnaires (a self-report form of the Standardized Assessment of Personality-Abbreviated Scale [SAPAS-SR], the self-report Iowa Personality Disorder Screen [IPDS], and a short self-report version of the SCID-II [S-SCID-II]); 2 longer questionnaires (the self-report SCID-II Personality Questionnaire [SCID-II-PQ] and the NEO Five-Factor Inventory [NEO-FFI]); 1 short semistructured interview (the Quick Personality Assessment Schedule [PAS-Q]); and 2 informant-based interviews (the Standardized Assessment of Personality [SAP] and the Standardized Assessment of Personality-Abbreviated Scale for Informants [SAPAS-INF]). RESULTS: The SCID-II rate of identification of personality disorders in the 3 studies was between 48.1% and 64.1%. The SAPAS-SR, the IPDS, and the PAS-Q had the best sensitivity (83%, 77%, and 80%, respectively) and specificity (80%, 85%, and 82%, respectively). Moreover, these 3 instruments correctly classified the largest number of patients. Using the SAPAS-SR, the IPDS, or the PAS-Q raises the odds from 50% to between 80% and 84% that a patient in a psychiatric outpatient population will receive a personality disorder diagnosis. CONCLUSIONS: The results provide evidence for the usefulness of the SAPAS-SR, IPDS, and PAS-Q instruments for personality disorder screening. Because the PAS-Q takes a longer time and requires qualified personnel to administer it, we recommend use of the SAPAS-SR or the self-report version of the IPDS.

Quick Personality Assessment Schedule (PAS-Q): validation of a brief screening test for personality disorders in a population of psychiatric outpatients.

OBJECTIVE: The internal consistency, test-retest reliability, and validity of the Quick Personality Assessment Schedule (PAS-Q), as a screening instrument for personality disorders were studied in a random sample of 195 Dutch psychiatric outpatients, using the SCID-II as a gold standard. METHOD: All patients were interviewed with the PAS-Q. With an interval of 1 to 2 weeks, they were interviewed with the SCID-II. Three weeks later the PAS-Q was re-administered. RESULTS: According to the SCID-II, 97 patients (50%) were suffering from a personality disorder. The PAS-Q correctly classified 81% of all participants. Sensitivity and specificity were 0.80 and 0.82, respectively. CONCLUSION: The results provide evidence for the usefulness of the PAS-Q as a screening instrument for personality disorders in clinical populations.

Perceiving emotions from bodily expressions and multisensory integration of emotion cues in schizophrenia.

Most studies investigating emotion recognition in schizophrenia have focused on facial expressions and neglected bodily and vocal expressions. Furthermore, little is known about affective multisensory integration in schizophrenia. In the first experiment, the authors investigated recognition of static, face-blurred, whole-body expressions (instrumental, angry, fearful, and sad) with a two-alternative, forced-choice, simultaneous matching task in a sample of schizophrenia patients, nonschizophrenic psychotic patients, and matched controls. In the second experiment, dynamic, face-blurred, whole-body expressions (fearful and happy) were presented simultaneously with either congruent or incongruent human or animal vocalizations to schizophrenia patients and controls. Participants were instructed to categorize the emotion expressed by the body and to ignore the auditory information. The results of Experiment 1 show an emotion recognition impairment in the schizophrenia group and to a lesser extent in the nonschizophrenic psychosis group, and this for all four expressions. The findings of Experiment 2 show that schizophrenia patients are more influenced by the auditory information than controls, but only when the auditory information consists of human vocalizations. This shows that schizophrenia patients are impaired in recognizing whole-body expressions, and they show abnormal affective multisensory integration of bimodal stimuli originating from the same source.

Diagnostic efficiency among psychiatric outpatients of a self-report version of a subset of screen items of the Structured Clinical Interview for DSM-IV-TR Personality Disorders (SCID-II).

This article describes the identification of a 10-item set of the Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II) items, which proved to be effective as a self-report assessment instrument in screening personality disorders. The item selection was based on the retrospective analyses of 495 SCID-II interviews. The psychometric properties were studied in a prospective validation study in a random sample of Dutch adult psychiatric outpatients, using the SCID-II interview as the gold standard. First, all patients completed the short questionnaire. One week later, they were interviewed with the full SCID-II. After another week, the short questionnaire was readministered. According to the scores obtained with the full SCID-II, 97 patients (50%) had a personality disorder. The set of 10 SCID-II items correctly classified 78% of all participants. The sensitivity, specificity, and positive and negative power were 0.78, 0.78, 0.78, and 0.78, respectively. The results based on the retrospectively obtained data were rather similar to those obtained in the prospective validation study. Therefore, it is concluded that the set of 10 SCID-II items can be useful as a quick self-report personality disorder screen in a population of psychiatric outpatients.

Anxiety and mood disorders in narcolepsy: a case-control study.

INTRODUCTION: Narcolepsy is a primary sleeping disorder with excessive daytime sleepiness and cataplexy as core symptoms. There is increasing interest in the psychiatric phenotype of narcolepsy. Although many authors suggest an overrepresentation of mood disorders, few systematic studies have been performed and conflicting results have been reported. Anxiety disorders in narcolepsy have only received little attention. METHODS: We performed a case-control study in 60 narcolepsy patients and 120 age- and sex-matched controls from a previous population study. The Schedules for Clinical Assessment in Neuropsychiatry were used to assess symptoms and diagnostic classifications of mood and anxiety disorders. RESULTS: Symptoms of mood disorders were reported by about one third of patients. However, the prevalence of formal mood disorder diagnoses - including major depression - was not increased. In contrast, more than half of the narcolepsy patients had anxiety or panic attacks. Thirty-five percent of the patients could be diagnosed with anxiety disorder (odds ratio=15.6), with social phobia being the most important diagnosis. There was no influence of age, sex, duration of illness or medication use on the prevalence of mood or anxiety symptoms and disorders. DISCUSSION: Anxiety disorders, especially panic attacks and social phobias, often affect patients with narcolepsy. Although symptoms of mood disorders are present in many patients, the prevalence of major depression is not increased. Anxiety and mood symptoms could be secondary complications of the chronic symptoms of narcolepsy. Recent studies have shown that narcolepsy is caused by defective hypocretin signaling. As hypocretin neurotransmission is also involved in stress regulation and addiction, this raises the possibility that mood and anxiety symptoms are primary disease phenomena in narcolepsy.

Psychotic symptoms in narcolepsy: phenomenology and a comparison with schizophrenia.

OBJECTIVE: Patients with narcolepsy often experience pervasive hypnagogic hallucinations, sometimes even leading to confusion with schizophrenia. We aimed to provide a detailed qualitative description of hypnagogic hallucinations and other "psychotic" symptoms in patients with narcolepsy and contrast these with schizophrenia patients and healthy controls. We also compared the prevalence of formal psychotic disorders between narcolepsy patients and controls. METHODS: We used SCAN 2.1 interviews to compare psychotic symptoms between 60 patients with narcolepsy, 102 with schizophrenia and 120 matched population controls. In addition, qualitative data was collected to enable a detailed description of hypnagogic hallucinations in narcolepsy. RESULTS: There were clear differences in the pattern of hallucinatory experiences in narcolepsy vs. schizophrenia patients. Narcoleptics reported multisensory "holistic" hallucinations rather than the predominantly verbal-auditory sensory mode of schizophrenia patients. Psychotic symptoms such as delusions were not more frequent in narcolepsy compared to population controls. In addition, the prevalence of formal psychotic disorders was not increased in patients with narcolepsy. Almost half of narcoleptics reported moderate interference with functioning due to hypnagogic hallucinations, mostly due to related anxiety. CONCLUSIONS: Hypnagogic hallucinations in narcolepsy can be differentiated on a phenomenological basis from hallucinations in schizophrenia which is useful in differential diagnostic dilemmas.

High prevalence of eating disorders in narcolepsy with cataplexy: a case-control study.

STUDY OBJECTIVES: To study the prevalence of and symptoms of eating disorders in patients with narcolepsy. DESIGN: We performed a case-control study comparing symptoms of eating disorders in patients with narcolepsy versus healthy population controls, using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN 2.1). To study whether an increased body mass index (BMI) could be responsible for symptoms of an eating disorder, we also compared patients with BMI-matched controls, using the SCAN as well as the Eating Disorder Examination-Questionnaire. SETTING: University hospital. PATIENTS AND PARTICIPANTS: Patients with narcolepsy/cataplexy (n = 60) were recruited from specialized sleep centers. Healthy controls (n = 120) were drawn from a population study previously performed in the Netherlands. Separately, 32 BMI-matched controls were recruited. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: In total, 23.3% of the patients fulfilled the criteria for a clinical eating disorder, as opposed to none of the control subjects. Most of these were classified as Eating Disorder-Not Otherwise Specified, with an incomplete form of binge eating disorder. On the symptom level, half of the patients reported a persistent craving for food, as well as binge eating. Twenty-five percent of patients even reported binging twice a week or more often. When compared with BMI-matched controls, the significant increases persisted in symptoms of eating disorders among patients with narcolepsy. Except for a higher level of interference in daily activities due to eating problems in patients using antidepressants, medication use did not influence our findings. CONCLUSIONS: The majority of patients with narcolepsy experience a number of symptoms of eating disorders, with an irresistible craving for food and binge eating as the most prominent features. Eating disorder symptomatology interfered with daily activities. These findings justify more attention for eating disorders in the treatment of patients with narcolepsy.

The relationship between dimensional personality models and quality of life in psychiatric outpatients.

This study examines the relationship between personality and quality of life (QOL) in psychiatric outpatients (N=495). Personality was conceptualized using two-dimensional models, respectively, the five-factor model (FFM) and Cloninger's seven-factor model. The WHOQOL-100 was used for assessing QOL. Neuroticism and Harm Avoidance had negative correlations with QOL, whereas Extraversion, Conscientiousness and Self-Directedness correlated positively with QOL. A considerable part of the QOL variance was explained by personality; Cloninger's character factors were superior to the FFM domains. Although not fully comparable, in general our findings are in accordance with earlier studies. Therefore, paying attention to personality and temperament is recommended in future diagnostic procedures, treatment policies, and program evaluations.

Predictors of quality of life: a model based study.

In this study, predictors of quality of life (QOL) in psychiatric outpatients (n = 410) were investigated using the psychological stress model developed by Taylor and Aspinwall (Psychosocial Stress. Perspective on Structures, Theory, Life-Course and Methods. San Diego, CA: Academic Press, 1996; pp. 71-110). External resources, personal resources, stressors, appraisal of stressors, social support, coping, and QOL were assessed with several questionnaires. The complete original Taylor and Aspinwall model was tested with SEM analyses. These analyses were not able to explain the data adequately. Therefore, initially a more exploratory data analytic strategy was followed using a series of multiple regression analyses. These analyses only partially supported the Taylor and Aspinwall model. In fact, QOL was not predicted by coping, while all other antecedents affected QOL directly, explaining considerable amounts of QOL variance. As a next step, taking the outcomes of the regression analyses as point of departure, new SEM analyses were carried out, testing a modified model. This model, without coping, had an excellent fit. Consequently, modifications of the model are recommended concerning psychiatric outpatients when QOL is the psychosocial outcome measure.

Relationship between mood related disorders and quality of life in a population of Dutch adult psychiatric outpatients.

Our objective was to investigate explicitly the relationship between mood-related disorders (MRDs) and quality of life (QOL), while trying to overcome the limitations of earlier research. QOL scores of psychiatric outpatients with MRDs were compared with QOL scores of outpatients without MRD and a sample of the general Dutch population (GDP). QOL was assessed with the World Health Organization Quality of Life assessment instrument, long version (WHOQOL-100), and depressive symptoms were assessed with the Symptom Checklist-90 (SCL-90). Outpatients with MRD had lower scores on all aspects of the WHOQOL-100 compared with the GDP. Compared with outpatients without MRD, the outpatients with MRD scored lower on most aspects of the WHOQOL-100. Within the group with MRDs, patients with major depressive disorder (MDD) had lower QOL scores compared with patients with dysthymic disorder or adjustment disorder with depressed mood. Severity of MRD and MDD was negatively related to QOL. Comorbid personality disorders worsened QOL. Within the group with MRDs, common variance between depressive symptoms and QOL did not exceed 25%. MRDs are negatively related with QOL. Severity of MRD and comorbidity of personality disorders decrease QOL further. MRDs affect all domains and facets of QOL. The relationship found between MRDs and QOL was not caused by an overlap between the concepts depressive symptoms and QOL, shown by the relative small common variance between (depressive) symptoms and QOL.

Quality of life and psychopathology: investigations into their relationship.

OBJECTIVE: Quality of life (QOL) has become a topic of growing interest in medical and psychiatric practice in general, and in research in particular. Although the body of knowledge about the complex relationship between QOL and psychiatric disorders is growing, understanding this relationship still remains difficult. Therefore, the aim of the present study was to get more and new insights into this relationship. It was hypothesized that QOL would be negatively related to the presence as well as the severity of psychopathology. METHOD: A random sample of Dutch adult psychiatric outpatients (n=410) completed the World Health Organization Quality of Life assessment instrument, abbreviated version (WHOQOL-Bref). In addition, DSM-IV axis I and II diagnoses were obtained. Comparisons were made between scores of the psychiatric outpatients, diagnostic subgroups within this population, and the scores of a general population. RESULTS: Compared with the general population, psychiatric outpatients scored significantly worse on all aspects of QOL. Within the group of outpatients, participants with DSM-IV diagnoses had worse scores than those without. Participants with comorbidity had the worst QOL. CONCLUSIONS: It is concluded that QOL scores are negatively related to both the presence and the severity of psychopathology, and that the presence of a personality disorder plays a role in subjectively experienced QOL.

Validation of the WHO Quality of Life assessment instrument (WHOQOL-100) in a population of Dutch adult psychiatric outpatients.

BACKGROUND: Research concerning the psychometric properties of the WHO Quality of Life Assessment Instrument (WHOQOL-100) in general populations of psychiatric outpatients has not been performed systematically. AIMS: To examine the content validity, construct validity, and reliability of the WHOQOL-100 in a general population of Dutch adult psychiatric outpatients. METHOD: A total of 533 psychiatric outpatients entered the study (438 randomly selected, 85 internally referred). Participants completed self-administered questionnaires for measuring quality of life (WHOQOL-100), psychopathological symptoms (SCL-90), and perceived social support (PSSS). In addition, they underwent two semi-structured interviews in order to obtain Axis-I and Axis-II diagnoses, according to DSM-IV. RESULTS: The drop-out percentage was low (7.1%). Of the 24 facets of the WHOQOL-100, 22 had a good distribution of scores, leaving out the facets physical environment and transport. Exploratory factor analysis revealed a four-factor structure, which was similar to earlier findings in patients with specific somatic diseases and depressive disorders. Various-a priori expected-positive and negative correlations were found between facets and domains of the WHOQOL-100, and dimensions of the SCL-90 and the PSSS-score, indicating good construct validity of the WHOQOL-100. The internal consistency of all facets and the four domains of the WHOQOL-100 was good (Cronbach's alpha's ranging from 0.62 to 0.93 and 0.64 to 0.84, respectively). Sparse and relatively low correlations were found between demographic characteristics (age and sex) and WHOQOL-100 scores. CONCLUSIONS: Content validity, construct validity, and reliability of the WHOQOL-100 in a population of adult Dutch psychiatric outpatients are good. The WHOQOL-100 appears to be a suitable instrument for measuring quality of life in adult psychiatric outpatients.

Internal and external validity of attention-deficit hyperactivity disorder in a population-based sample of adults.

BACKGROUND: Follow-up studies of childhood ADHD have shown persistence of the disorder into adulthood, but no epidemiological data are yet available. METHOD: ADHD DSM-IV symptoms were obtained by self-report in an adult population-based sample of 1813 adults (aged 18-75 years), that was drawn from an automated general practitioner system used in Nijmegen, The Netherlands. The structure of ADHD symptoms was analysed by means of confirmatory factor analyses. Other data used in this report are the General Health Questionnaire (GHQ-28), information about the presence of three core symptoms of ADHD in childhood, and about current psychosocial impairment. RESULTS: The three-factor model that allowed for cross-loadings provided the best fit in the entire sample. This result was replicated across gender and age subsamples. Inattentive and hyperactivity symptom scores were significantly associated with measures of impairment, even after controlling for the GHQ-28. Subjects with four or more inattentive or hyperactive-impulsive symptoms were significantly more impaired than subjects with two, one and no symptoms. The prevalence of ADHD in adults was 1.0% (95% CI 0.6-1.6) and 2.5% (1.9-3.4) using a cutoff of six and four current symptoms respectively, and requiring the presence of all three core symptoms in childhood. CONCLUSIONS: These results support the internal and external validity of ADHD in adults between 18 and 75 years. ADHD is not merely a child psychiatric disorder that persists into young adulthood, but an important and unique manifestation of psychopathology across the lifespan.

Content validity, construct validity, and reliability of the WHOQOL-Bref in a population of Dutch adult psychiatric outpatients.

In this study, the psychometric properties of a quality of life scale, the WHOQOL-Bref, were examined in a population of 533 Dutch adult psychiatric outpatients. Participants underwent two semistructured interviews in order to obtain Axis-I and II diagnoses, according to DSM-IV. Besides the WHOQOL-Bref they also completed questionnaires for measuring psychopathological symptoms (SCL-90) and perceived social support (PSSS). Scores on 25 of the 26 questions of the WHOQOL-Bref had a good distribution. Similar to previous findings, exploratory factor analysis revealed a four-factor structure. A priori expected associations were found between the domains of the WHOQOL-Bref, on the one hand, and dimensions of the SCL-90 and the PSSS-score, on the other hand, indicating good construct validity. The internal consistency of the four domains of the WHOQOL-Bref ranged from 0.66 to 0.80. Domain scores of the WHOQOL-Bref correlated around 0.92 with the WHOQOL-100 domain scores. Relatively low correlations were found between demographic characteristics (age and sex) and WHOQOL-Bref domain scores. It is concluded that the content validity, construct validity, and the reliability of the WHOQOL-Bref in a population of adult Dutch psychiatric outpatients are good. The WHOQOL-Bref, therefore, is an adequate measure for assessing quality of life at the domain level in a population of adult psychiatric outpatients.

Association between antidepressant drug use and hyponatraemia: a case-control study.

AIMS: To estimate the risk of, and risk factors for, hyponatraemia associated with the use of selective serotonin reuptake inhibitors (SSRIs) compared with the use of other antidepressant drugs. METHODS: A case-control study of psychiatric in- and out-patients on antidepressant drugs performed in the mid-southern part of The Netherlands over a 2 year period. Cases (n=29) were all using antidepressant drugs with a serum sodium concentration of < or = 130 mmol l(-1) while controls (n=78) were patients on antidepressants with a normal sodium concentration (136-144 mmol l(-1)). Information on blood sodium concentrations was obtained from clinical chemistry data while information on drug use was obtained from community and hospital pharmacy databases. Medical records were used to ascertain possible risk and confounding factors. Unconditional multivariate logistic regression was used to estimate odds ratios for hyponatraemia in patients on SSRIs compared with patients on other antidepressant drugs. RESULTS: SSRIs were associated with an increased risk of hyponatraemia (OR 3.3; 95% CI 1.3, 8.6) compared with other classes of antidepressant drugs. Stratified and interaction analyses revealed that elderly patients using diuretics concomitantly with SSRIs were at the highest risk of experiencing hyponatraemia (OR 13.5; 95% CI 1.8, 101). CONCLUSIONS: SSRIs are more frequently associated with hyponatraemia than other classes of antidepressant drugs. This adverse drug reaction was more common in older patients (> or = 65 years) and in those using diuretics.