The value of CT angiography in patients with acute severe headache.

Patients with acute severe headache may have a secondary form of headache. Standard head computer tomography (CT) and cerebrospinal fluid (CSF) examination are often performed in the absence of neurological deficits to exclude subarachnoid hemorrhage (SAH). Increasingly, patients undergo subsequent CT angiography (CTA) to exclude cerebral venous thrombosis (CVT), dissection or reversible cerebral vasoconstriction syndrome (RCVS). It is unknown whether this additional imaging increases diagnostic yield. We aimed to evaluate the yield of CTA in patients with acute severe headache with normal neurological examination and no abnormalities at standard CT and CSF analysis. We included consecutive patients presenting to the emergency room between January 2008 and May 2011 with acute severe headache and without abnormalities at neurological examination, CT and CSF research, who received a CTA in the diagnostic process in our teaching hospital. All scans were rereviewed by an experienced neuroradiologist. We included 70 patients, 71% were women and average age was 45 years. We found a vascular abnormality in 13 (19%) of our patients. Four had either a prior aneurysm or CVT. Eight patients had an unruptured intracranial aneurysm (UIA) on CTA (11%), two had CVT (3%), two had RCVS (3%) and one had cerebral ischemia (1%). We found a high percentage of vascular abnormalities. A third of these patients had a prior episode of either an aneurysm or CVT. In patients with a history of UIA or CVT performing CTA despite normal CT and LP therefore seems warranted. A prospective study to delineate indications for CTA is needed.

Optimizing blood pigment analysis in cerebrospinal fluid for the diagnosis of subarachnoid haemorrhage--a practical approach.

BACKGROUND: Patients presenting with sudden severe headache may have a subarachnoid haemorrhage (SAH). After a normal head computer tomography (CT), a lumbar puncture is routinely performed to rule out SAH. Photospectrometry is then used to detect bilirubin in cerebrospinal fluid (CSF). Photospectrometric analysis of CSF reaches a high sensitivity, but a low specificity for SAH. This low specificity necessitates extensive additional research to rule out cerebral aneurysm accompanied by high costs and risk of complications. OBJECTIVE: The objective of this study was to retrospectively evaluate two different CSF interpretation methods using photospectrometry in patients presenting with acute headache. The first of these is the Leiden method, an iterative model using a standard calculation. The second is the UK NEQAS guideline, which uses the original spectrum in combination with a decision tree. Our goal was to obtain retrospective data on patients screened with both methods to improve specificity of CSF research. RESULTS: We included 361 patients in this study; 47 of these had a raised bilirubin concentration in the CSF according to the Leiden method. In only nine of these 47 patients was an aneurysm found; in the other patients the Leiden test was positive for other reasons (viral meningitis, hyperbilirubinaemia, etc.). Of the 47 patients with raised bilirubin, 24 could be re-evaluated using the UK NEQAS. Of these 24 patients, five had an aneurysm. No aneurysms were found in patients with a negative result according to the UK NEQAS guideline. CONCLUSION: Our data show that a raised bilirubin calculated using the Leiden method seems to have a lower specificity than the UK NEQAS guideline. For practical reasons, it seems advantageous to use the Leiden method as a screening method and use the UK NEQAS guideline if a positive result is found.

In search of patient characteristics that may guide empirically based treatment selection for personality disorder patients-a concept map approach.

Using the concept map method, this study aimed to summarize and describe patient characteristics pertinent to treatment selection for patients with personality disorders (PDs). Initial patient characteristics were derived from the research literature and a survey among Dutch expert clinicians. Concept mapping is a formalized conceptualization procedure that describes the underlying cognitive structures people use in complex tasks, such as treatment allocation. Based on expert opinions of 29 Dutch clinicians, a concept map was generated that yielded eight domains of patient characteristics, i.e., Severity of symptoms, Severity of personality pathology, Ego-adaptive capacities, Motivation and working alliance, Social context, Social demographic characteristics, Trauma, and Treatment history and medical condition. These domains can be ordered along two bipolar axes, running from internal to external concepts and from vulnerability to strength concepts, respectively. Our findings may serve as input for the delineation of algorithms for patient-treatment matching research in PD.

[Personality disorders in older adults: a Delphi-study conducted among Dutch and Belgian experts concerning specific diagnostic and therapeutic aspects]. / Persoonlijkheidsstoornissen bij ouderen: delphi-onderzoek onder Nederlandse en Vlaamse experts over specifieke diagnostische en therapeutische aspecten.

BACKGROUND: In psychiatry for older adults (> 60 years) personality disorders play an important part in diagnosis and treatment and in the advice given to health professionals and carers on how to deal with this age group. So far, however, research in this area has been inadequate. AIM: To investigate age-related diagnostic and therapeutic aspects of personality disorders occurring in adults over the age of 60. METHOD: A Delphi-study was conducted among 35 Dutch and Belgian experts in the field of personality disorders in older adults. This multidisciplinary panel consisted of psychiatrists, psychologists, psychotherapists, geriatricians and psychiatric nurses. In four rounds 21 gerontological statements to be assessed on a 5-point Likert scale were presented to the panel of experts. Agreement was said to be reached when at least two thirds of the experts agreed or fully agreed with a statement.RESULTS Satisfactory agreement was reached in the case of 20 of the 21 diagnostic and/or therapeutic statements about older adults with personality disorders. CONCLUSION There seem to be various age-specific aspects in the diagnosis and treatment of personality disorders in older adults. Therefore, it is advisable to pay more attention to this highly complex group of older adults when guidelines and protocols are being drawn up and scientific research is being planned or conducted.

[A randomised clinical trial on the effectiveness of a re-integration training after short-term inpatient psychotherapy]. / De effectiviteit van re-integratietraining versus boostersessies na kortdurende klinische psychotherapie: een gerandomiseerd klinisch onderzoek.

BACKGROUND: Standardised evaluation studies performed in the Netherlands in a large number of inpatient and day-treatment hospitals providing psychotherapy have shown significant symptomatic improvements in patients between the date of entry to the studies and follow-up after one year. However, the work situation of ex-patients hardly changed and a large number of patients were still receiving psychotherapy. AIM: To examine the effectiveness of a specifically designed course of re-integration training. METHOD: A group of 128 patients were assigned randomly either to a re-integration training course aimed at improved functioning at work and improved relationships, or to booster sessions. Outcome measures were symptom level, work status, absence from work, and further psychotherapy. results After two years the number of patients in paid employment remained the same (76%) in the re-integration training course and increased from 67 to 87% in the booster sessions. Attendance was significantly higher in the booster sessions than in the re-integration training. There were no differences in the other outcome measures. CONCLUSION: We conclude that re-integration training was no more effective than the booster sessions. Our hypothesis is that continuity of care (therapists plus programme) explains the favourable result of the booster sessions.

Substance abuse in borderline personality disorder: clinical and etiological correlates.

This work examines differences between female borderline patients with and without substance abuse problems and between borderline patients from different treatment settings. A total of 64 female borderline patients were recruited from mental health services (n = 34) and addiction treatment services (n = 20); 35 had a substance abuse problem. Patient groups were compared with regard to both clinical and etiological factors using multivariate analysis of variance for 47 continuous variables and logistic regression for 15 dichotomous variables. Borderline patients with substance abuse problems reported less hostility, suspicion, and anger but more anxiety, insufficiency, and suicide attempts. Patients from addiction treatment services reported less avoidant and more antisocial behavior. The differences between borderline patients with and without substance abuse problems are limited in number and size. Therefore, there is no empirical justification for the exclusion of borderline patients with substance abuse problems from general treatment services or clinical trials.

Co-morbidity of personality disorders in individuals with substance use disorders.

This review summarizes the recent literature about personality disorders among substance abusers. First, it will be shown that personality disorders are highly prevalent co-morbid conditions among addicted individuals. Second, it is argued that this co-morbidity is likely to be accounted for by multiple complex etiological relationships. Finally, the clinical relevance of routine assessment of (maladaptive) personality traits in individuals admitting for substance abuse treatment will be discussed.

Core heritable personality characteristics and relapse in alcoholics.

This article represents the proceedings of a symposium at the 2000 ISBRA Meeting in Yokohama, Japan. The chairs were David S. Janowsky and Jan Fawcett. The presentations were (1) The tridimensional personality questionnaire: Predictor of relapse in detoxified alcoholics, by Kurt Meszaros; (2) Novelty seeking predicts clinical trial attrition in alcoholics, by Jan Fawcett; (3) Personality and alcohol/substance use disorder patient relapse and attendance at self-help group meetings, by David S. Janowsky; and (4) A three-pathway psychobiological model for craving for alcohol, by Roel Verheul.

Predicting self-damaging and suicidal behaviors in female borderline patients: reasons for living, coping, and depressive personality disorder.

The aims of this study are to examine (1) whether reasons for living predict self-damaging and suicidal behaviors, (2) the associations of reasons for living with coping strategies and depressive personality disorder (PD), and (3) the unique predictive validity of reasons for living in a multivariate predictor model. Reasons for living (RFL), coping strategies, and depressive personality disorder were measured at baseline in 38 patients who met DSM-IV criteria for borderline personality disorder (BPD). Frequency of self-damaging and suicidal behaviors in the 6-month period following baseline was measured prospectively at 3- and 6-month follow-ups. The RFL has only one subscale that predicts parasuicidal behaviors (i.e. Survival and Coping Beliefs [SCB]). Participants who scored low on this subscale were 6.8 times more likely to exhibit self-damaging and suicidal behaviors in the follow-up period than their high-scoring counter-parts. However, SCB was substantially correlated with the coping strategies "reassuring thoughts," "active coping," and "palliative reaction pattern," as well as with depressive personality traits. In a multivariate model, the predictive power of SCB appeared to be accounted for by reassuring thoughts and depressive PD. Coping scales might be preferable over the RFL as a predictor of self-damaging and suicidal behaviors in borderline patients.

Co-occurrence of Axis I and Axis II disorders in substance abusers.

OBJECTIVE: This study examined the co-occurrence of anxiety/mood and personality disorders (PDs) in substance abusers, the impact of anxiety/ mood disorders on the symptom profiles of PDs, and the impact of anxiety/mood disorders and PDs on pre-treatment status. METHOD: Current anxiety/mood disorders and PDs and pre-treatment status were assessed using semi-structured interviews in 370 treated substance abusers. RESULTS: Anxiety/mood disorders and PDs frequently co-occurred, with the overall pattern of associations being non-specific. The strongest associations were of social phobia with avoidant and schizotypal PD, and of major depression with borderline PD. However, symptom profiles of PDs were not associated with anxiety/mood disorders. Finally, anxiety/mood disorders and PDs were both independently and differentially associated with poor pre-treatment characteristics. CONCLUSION: The findings suggest the clinical importance of obtaining both Axis I and Axis II diagnoses in treated substance abusers, and highlight the distinctiveness of the Axis I and Axis II disorders.

Axis I and Axis II disorders in alcoholics and drug addicts: fact or artifact?

OBJECTIVE: It has been argued that Axis I and Axis II disorders diagnosed in substance users refer to substance-induced conditions rather than to independent psychiatric conditions; this argument will be referred to as the substance-related artifact hypothesis. Furthermore, Axis II symptoms co-occurring with Axis I disorders have been attributed to the contamination of personality assessment by mood and/or anxiety state effects (the trait-state artifact hypothesis). The present study is the first to prospectively examine the validity of these two hypothesized "artifacts" in substance users. METHOD: In 276 individuals (57.6% female) applying for substance use treatment, current substance use disorders, mood/anxiety disorders and Axis II disorders were diagnosed using semistructured interviews both at baseline and at 1-year follow-up. The substance-related artifact hypothesis is tested by examining the covariation between recovery from substance use disorders on the one hand and recovery from and/or improvement of mood/anxiety and Axis II disorders on the other hand. The trait-state artifact hypothesis is tested by examining the covariation between recovery from mood/anxiety disorders on the one hand and recovery from and/or improvement of Axis II disorders on the other hand. RESULTS: Recovery from substance use disorders covaried with recovery from and improvement of mood/anxiety disorders, but not with recovery from or improvement of Axis II pathology. Furthermore, recovery from mood/anxiety disorders covaried with recovery from and improvement of personality disorders, in particular Cluster C disorders. CONCLUSIONS: Results from this study suggest that mood/anxiety disorders, but not personality disorders, diagnosed among people with substance use disorder may partly reflect substance-related artifacts. Furthermore, this study provides evidence for the contention that semistructured interview assessment of Axis II, at least without inquiry on an item-by-item basis, is susceptible to contamination by mood/anxiety state effects.

A three-pathway psychobiological model of craving for alcohol.

In this article, by reviewing the psychological, psychophysiological, neurobiological, and psychopharmacological literature on craving for alcohol, it is argued that converging evidence from several disciplines suggests a three-pathway psychobiological model of craving. Essential to this model is the appreciation of the role of individual differences in affect regulation strategies or personality styles, conditionability, sensitivity to alcohol's effects, and related dysregulations in distinct neural circuitries or neurotransmitter systems. These factors are of crucial importance to a proper understanding of the nature of craving, its underlying mechanisms and different manifestations. As a first pathway, it is suggested that reward craving or desire for the rewarding, stimulating and/or enhancing effects of alcohol might result from either dopaminergic/opioidergic dysregulation or a personality style characterized by reward seeking or a combination of both. As a second pathway, it is suggested that relief craving or desire for the reduction of tension or arousal might result from either gamma-aminobutyric acid (GABA)ergic/glutamatergic dysregulation or a personality style characterized by stress reactivity or a combination of both. Obsessive craving, the result of the third pathway, can be defined as lack of control over intrusive thoughts about drinking resulting in impaired functioning. This type of craving might result either from a serotonin deficiency or a personality style characterized by low constraint or disinhibition or a combination of both. The putative implications of this three-pathway model for the assessment of alcohol craving, diagnosis and treatment of alcoholism, and future research on craving, are discussed.

Antisocial alcoholic patients show as much improvement at 14-month follow-up as non-antisocial alcoholic patients.

The authors investigated the impact of DSM-III-R adult criteria for antisocial personality disorder (and co-occurrence of childhood conduct or mood disorder) on one-year changes of multi-domain problem severity in 309 alcoholic patients. Adult antisocial traits were associated with more drug, legal, and psychiatric problems at baseline and with more drug problems at follow-up. However, patients with antisocial traits showed at least as much improvement from baseline through follow-up as their non-antisocial counterparts. Furthermore, the co-occurrence of childhood conduct disorder or mood disorder among the antisocial alcoholics did not define prognostically relevant subgroups. These findings suggest that antisocial alcoholics benefit from treatment at least as much as non-antisocial alcoholics.

Personality disorders predict relapse in alcoholic patients.

This prospective study examines the association of DSM-III-R Axis II comorbidity with (time to) relapse since the end of treatment in a sample of 105 outpatient and 82 inpatient alcoholics. Furthermore, this study addresses the role of motivation for change, time in program, and working alliance in the mechanism underlying the association between Axis II and relapse. We found that Axis II comorbidity in alcoholics is a robust predictor of relapse following treatment, while the effect is strongest in outpatients with low motivation for change and/or short time in program. Motivation for change and time in program did not mediate the association of Axis II with relapse. We also found poor working alliance to be related to personality pathology among inpatients, and from our findings it can be hypothesised that poor working alliance is part of the mechanism underlying the observed impact of Axis II on treatment outcome in outpatients. A preliminary model of the role of personality pathology in the mechanism of relapse is proposed.

The effect of sampling, diagnostic criteria and assessment procedures on the observed prevalence of DSM-III-R personality disorders among treated alcoholics.

UNLABELLED: OBJECTIVE. In a recent review of empirical studies on the prevalence of DSM-III-R personality disorders among substance abusers, wide ranges of prevalence rates for overall Axis II, antisocial personality disorder (APD) and borderline personality disorder (BPD) were shown. Utilizing subsamples from within a single study population, the current report explores the effect of sampling, diagnostic criteria and assessment procedures on the observed prevalence of DSM-III-R personality disorders among treated alcoholics. METHOD: Personality disorders were assessed with the Personality Diagnostic Questionnaire Revised (PDQR) at two times of measurement (Time 1 n = 459; Time 2 n = 90). In addition, APD was measured with the Composite International Diagnostic Interview (CIDI; n = 587). Finally, an unselected subgroup (n = 136) was interviewed with the International Personality Disorder Examination (IPDE). RESULTS: There were few differences between inpatients or outpatients or between males and females. Using the IPDE, the exclusion of substance-related pathology did not affect the prevalence estimate. However, the prevalence rates according to the PDQR varied greatly across age groups. In a representative subsample (n = 109), the prevalence rates also varied greatly across assessment methods (PDQR, 52% vs IPDE, 31%). The prevalence estimate of APD according to the CIDI was related to setting, gender, age group and the applied time-frame. CONCLUSIONS: These findings indicate the examined factors to be necessary qualifiers of prevalence estimates and, consequently, support the use of a multiple-criteria/multimethod assessment battery in research as well as in clinical work.

Temporal stability of diagnostic criteria for antisocial personality disorder in male alcohol dependent patients.

We evaluated the temporal stability of diagnostic criteria for antisocial personality disorder in 432 male alcohol dependent patients. Indicators for temporal stability were criterion continuation (i.e., the proportion of current or recent diagnoses among those with a lifetime diagnosis) and criterion duration (i.e., the length of time between the first occurrence and the last occurrence). In addition, the effect of diagnostic status (ASPD- versus ASPD+) on stability was examined. Among the criteria, "no regard for the truth" showed consistently high stability; "recklessness" showed moderate to high stability; "inconsistent work behavior," "failure to meet financial obligations," "failure to plan ahead" and "parental irresponsibility" showed consistently low stability. The continuation and duration parameters diverged with respect to "nonconformism" and "irritability/aggressiveness." Temporal stability for "nonconformism" was consistently greater among those with ASPD than among those without. It was concluded that both continuation and duration rates clearly differentiated among criteria. This new criterion-based approach seems to be useful as a strategy for improving the ASPD criteria set.