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Comorbidity of DSM-III-R personality disorders in schizophrenic and unipolar mood disorders: A comparative study
Abstract
We investigated the overall prevalence and the differential comorbidity of Diagnostic and Statistical Manual (DSM)-III-R personality disorders in 166 remitted or recovered patients with schizophrenic (n = 102) or unipolar mood disorder (n = 64). Over 60% of both patient groups met the DSM-III-R criteria of at least one DSM-III-R personality disorder as assessed by means of the Structured Clinical Interview for DSM-III-R (SCID-II-R), receiving on average 3.1 personality diagnoses. Neither DSM-III-R categories of personality disorders, nor scores on its three clusters A, B and C, nor total score on SCID-II-R differed significantly across the two groups. In conclusion, DSM-III-R personality disorders, although highly prevalent in schizophrenic and unipolar mood disorders, lack any specificity with respect to these categories of mental disorders.
... Our results also showed differences between the groups in terms of premorbid PD types. In schizophrenic patients without comorbidity, the most common premorbid PDs were avoidant (35%), paranoid (17.5%), and obsessive-compulsive (15%), which supports previous reports about premorbid PDs in schizophrenic patients (32,34). Avoidant PD was more frequently seen in patients with schizophrenia, which shows that this disorder can be part of the same pathological spectrum of schizotypal and schizoid PDs (35,36,37). ...
... Avoidant PD-the most frequently determined premorbid PD in our study's group without comorbidity-was also proposed for inclusion in the spectrum (40). Unlike some other studies, the number of patients with premorbid schizoid and schizotypal PDs were less common in our study (32,34). ...
... Our results also showed differences between the groups in terms of premorbid PD types. In schizophrenic patients without comorbidity, the most common premorbid PDs were avoidant (35%), paranoid (17.5%) and obsessive-compulsive (15%), which supports previous reports about premorbid PDs in schizophrenic patients (32,34). Avoidant PD was more frequently seen in patients with schizophrenia, which shows that this disorder can be a part of the same pathological spectrum of schizotypal and schizoid PDs (35,36,37). ...
... Avoidant PD, the most frequently determined premorbid PD in our study group without comorbidity, was also proposed for inclusion in the spectrum (40). In contrast to some other studies, the number of patients with premorbid schizoid and schizotypal PDs were less common in our study (32,34). ...
Introduction:
Although substance abuse is an important clinical problem in schizophrenic patients, very little evidence explains why these patients use drugs and alcohol. This study therefore aimed to examine whether premorbid personality disorders affect substance abuse.
Methods:
The sample included 40 male schizophrenic patients with and 40 male schizophrenic patients without substance use disorder comorbidity who had applied to Ankara Numune Research and Training Hospital. Each participant and a family member were interviewed in a structured clinical interview that addressed premorbid personality disorders.
Results:
Altogether, 32 patients (80%) in the group with comorbidity and 28 (70%) in the group without comorbidity had a premorbid personality disorder. Antisocial (35% vs. 0%; p<.001) and borderline (37.5% vs. 5%; p=.001) personality disorders were more often detected in the group with comorbidity, while avoidant (10% vs. 35%; p=.014) and obsessive-compulsive (0% vs. 15%; p=.026) personality disorders were less frequently found in this group. Comparing the group with comorbidity with premorbid personality types, schizophrenic patients with premorbid antisocial personality disorder were more frequently unemployed and hospitalized as well as had an earlier onset age of schizophrenia (p=.034, p=.038 and p=.035, respectively). Schizophrenic patients with premorbid borderline personality disorder had a significantly earlier onset age of substance use (19±5; p=.028).
Conclusion:
Schizophrenic patients with substance use comorbidity variously differ from those without comorbidity and some of these differences may be associated with premorbid personality disorders.
... These findings are consistent with clinical samples of NPD that cite the most frequent comorbid diagnoses as major depression or dysthymia (41% to 50%), substance abuse (24% to 50%), and bipolar disorder (5% to 18%) (Clemence, Perry, & Plakun, 2009;Ronningstam, 1996). Oulis, Lykouras, Hatzimanolis and Tomaras (1997) found that among 102 recovered schizophrenic patients, 15% met criteria for NPD, and a clinical epidemiological study of 32 first-episode psychotic patients revealed 16% met criteria for NPD (Simonsen et al., 2008). ...
Now in its fourth edition, the acclaimed Oxford Textbook of Psychopathology aims for both depth and breadth, with a focus on adult disorders and special attention given to personality disorders. It provides an unparalleled guide for professionals and students alike. Esteemed editors Robert F. Krueger and Paul H. Blaney selected the most eminent researchers in abnormal psychology to provide thorough coverage and to discuss notable issues in the various pathologies which are their expertise. This fourth edition of the Oxford Textbook of Psychopathology is fully updated and also reflects alternative, emerging perspectives in the field (e.g., the National Institute of Mental Health’s Research Domain Criteria Initiative [RDoC, the Hierarchical Taxonomy of Psychopathology [HiTOP]). The Textbook exposes readers to exceptional scholarship, the history and philosophy of psychopathology, the logic of the best approaches to current disorders, and an expert outlook on what researchers and mental health professionals will be facing in the years to come. This volume will be useful for all mental health workers, including clinical psychologists, psychiatrists, and social workers, and as a textbook focused on understanding psychopathology in depth for anyone wishing to be up to date on the latest developments in the field.
... Consequently, opportunities of a focused approach to treatment using psychotherapy are lost. The prevalence of PD was 24.0 % in this Chinese clinical population with SZ, and was within the range of estimates (22 -28 %) found in some previous epidemiologic surveys [35][36][37], but not in others [7,[38][39][40]. Newton-Howes and colleagues (2008) used the multilevel modeling method and found that there was great variation in the reported prevalence of PD in SZ. ...
Background:
The reported rates of personality disorder (PD) in subjects with schizophrenia (SZ) are quite varied across different countries, and less is known about the heterogeneity of PD among subjects with SZ. We examined the co-morbidity of PD among patients who are in the stable phase of SZ.
Method:
850 subjects were randomly sampled from patients diagnosed with SZ in psychiatric and psycho-counseling clinics at Shanghai Mental Health Center. Co-morbidity of PDs was assessed through preliminary screening and patients were administered several modules of the SCID-II. Evidence of heterogeneity was evaluated by comparing patients diagnosed with SZ with those who presented with either affective disorder or neurosis (ADN).
Results:
204 outpatients (24.0 %) in the stable phase of SZ met criteria for at least one type of DSM-IV PD. There was a higher prevalence of Cluster-A (odd and eccentric PD) and C (anxious and panic PD) PDs in SZ (around 12.0 %). The most prevalent PD was the paranoid subtype (7.65 %). Subjects with SZ were significantly more likely to have schizotypal PD (4.4 % vs. 2.1 %, p = 0.003) and paranoid PD (7.6 % vs. 5.4 %, p = 0.034), but much less likely to have borderline, obsessive-compulsive, depressive, narcissistic and histrionic PD.
Conclusions:
These findings suggest that DSM-IV PD is common in patients with SZ than in the general population. Patterns of co-morbidity with PDs in SZ are different from ADN.
... In a study of 102 recovered schizophrenic outpatients, Oulis et al. found that 15 percent met criteria for DSM-III-R NPD (Oulis, Lykouras, Hatzimanolis, & Tomaras, 1997), whereas Solano and De Chavez (2000) found a five percent prevalence of NPD in 40 schizophrenic patients. ...
This chapter reviews the comorbidity between narcissistic personality disorder (NPD) and Axis I disorders. NPD prevalence is elevated in many samples of individuals with Axis I diagnosis, but the effects are highly sample dependent. A suggestion is made for more research on this topic.
... This is not surprising, however, since axis one of the DSM system is built up of course of illness and symptoms, deliberately excluding personality organization [47], which is considered in axis two [23]. The finding is also consistent with earlier findings of difficulties in demonstrating personality differences even between different main diagnoses [48,49], but it differs from some previous studies using a five-factor model of personality, which have demonstrated differences between people with schizophrenia and healthy controls [1] and between schizophrenia patients and other diagnoses [50]. ...
Research findings that link personality factors to functioning and symptoms in schizophrenia are inconsistent, and further studies are needed within the area. The purpose of this study was to investigate how personality, as measured by the Temperament and Character Inventory (TCI), was related to demographic factors, subtypes of diagnoses, level of functioning, and aspects of psychological health, including sense of coherence, perceived control, and self-esteem, among people with schizophrenia. Subjects were 104 individuals, aged 20-55 years, in psychiatric outpatient care. The results indicated that personality was not related to subtypes of diagnoses or demographic characteristics of the respondents, but to level of functioning and all aspects of psychological health. Especially self-directedness distinguished three groups of functioning and was highly correlated with the different aspects of psychological health. The article discusses how knowledge of schizophrenic patients' personality structure might be used for tailoring psychiatric treatments.
... Some of them have analyzed or reviewed personality traits in patients with defined schizophrenia [2][3][4][5][6][7][8] or the axis II comorbidity of schizophrenia. 9 From a different approach, others have tried to analyze the premorbid personality of patients affected by this illness. [10][11][12] Another area of theoretical interest has been the study of personality in families of patients with schizophrenia. ...
Psychotic features have been considered the main determinant of psychosocial function in schizophrenia. However, other variables are likely to affect dysfunction in these patients. The authors' hypothesis is that personality traits in outpatients with chronic schizophrenia differ from traits found in the healthy population and may be associated with disability in this disorder. A total of 62 patients with schizophrenia were evaluated with the Eysenck Personality Questionnaire (EPQ) and the Tridimensional Personality Questionnaire (TPQ). Psychotic features were measured with the help of the Positive and Negative Syndrome Scale (PANSS). Disability was assessed with the Disability Assessment Schedule (DAS). A total of 43 healthy subjects were used as controls for personality measurements. Normative data for the study population was also used to evaluate results in patients. Patients with schizophrenia had higher levels of neuroticism (median in percentile 65) and lower levels of extraversion (median in percentile 25) than the healthy population. Results of the TPQ showed higher harm avoidance and lower reward dependence levels compared to the healthy population. After multiple regression tests, negative symptoms were the strongest predictor of disability in patients with schizophrenia. Neuroticism contributed independently to the DAS overall behavior and global judgement subscales scores (more negative symptoms and higher neuroticism resulted in worse functioning), but not to the social role subscale. Outpatients with chronic schizophrenia showed high levels of neuroticism, harm avoidance, and introversion. Neuroticism significantly contributes to the long-term deficits found in patients with schizophrenia.
Resumen
Los hallazgos de investigación que vinculan factores de personalidad con el funcionamiento y los síntomas en la esquizofrenia no son coherentes, y se necesitan más estudios dentro del área. El propósito de este estudio era investigar cómo la personalidad, medida por el Inventario del Temperamento y el Carácter (TCI), se relacionaba con factores demográficos, subtipos de diagnósticos, nivel de funcionamiento y aspectos de la salud psicológica, incluido el sentido de coherencia, el control percibido y la autoestima entre personas con esquizofrenia. Los sujetos eran 104 individuos de 20-55 años en atención ambulatoria psiquiátrica. Los resultados indicaron que la personalidad no estaba relacionada con subtipos de diagnósticos o características demográficas de los respondientes, sino con el nivel de funcionamiento y todos los aspectos de la salud psicológica. Especialmente, la autodirección distinguía tres grupos de funcionamiento y estaba muy correlacionada con los diferentes aspectos de la salud psicológica. El artículo analiza cómo el conocimiento de la estructura de la personalidad de los pacientes esquizofrénicos se podría utilizar para adaptar tratamientos psiquiátricos.
Resumen
Investigamos la prevalencia global y la comorbilidad diferencial de los trastornos de la personalidad del Manual Diagnóstico y Estadístico (DSM) III-R en 166 pacientes con trastorno esquizofrénico (n = 102) o trastorno unipolar del estado de ánimo (n = 64) en remisión o recuperados de la enfermedad. Más del 60% de ambos grupos de pacientes cumplían los criterios del DSM III-R al menos de un trastorno de la personalidad evaluado por medio de la Entrevista Clínica Estructurada para el DSM III-R (SCID II-R), recibiendo como media 3,1 diagnósticos de personalidad. Ni las categorías de los trastornos de personalidad del DSM III-R, ni las puntuaciones en sus tres grupos A, B y C, ni la puntución total en la SCID II-R difirieron significativamente a través de los dos grupos. En conclusión, los trastornos de personalidad del DSM III-R, aunque muy prevalentes en los trastornos esquizofrénico y unipolar del estado de ánimo, carecen de toda especificidad con respecto a estas categorías de trastornos mentales.
Antisocial personality disorder (ASPD) affects 3% to 5% of adults in the general population of the United States and Canada. It is associated with substantial burden on affected individuals, their families, and society, both in its own right and because of its high comorbidity with medical illnesses and injuries as well as a broad range of other psychiatric disorders, notably including substance use disorders. Diagnostic criteria for ASPD under the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III), the Diagnostic and Statistical Manual of Mental Disorders, Third Edition-Revised (DSM-III-R), and the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) require both conduct disorder (CD) with onset before age 15 years, and a persistent pattern of aggressive, irresponsible, impulsive, and remorseless behaviors thereafter. However, many individuals with syndromal antisocial behavior in adulthood do not report enough symptoms to meet criteria for CD before age 15 (adult antisocial behavioral syndrome, or AABS). AABS is not a codable DSM-IV diagnosis. Nevertheless, while individuals with AABS display fewer antisocial symptoms, and in particular fewer violent symptoms, in adulthood than those with ASPD, these 2 groups differ little on antisocial symptom profiles in adulthood, many forms of psychiatric and general medical comorbidity, and, among addiction treatment clients, substance use histories. This chapter reviews what is known about the comorbidity of antisocial behavioral syndromes in adulthood with other psychiatric disorders and general medical conditions, including similarities and differences between individuals with ASPD and those with AABS and the relationships of comorbid antisociality to the clinical presentation of co-occurring conditions. Gaps in current knowledge, including mechanisms underlying comorbidity and its associations with clinical presentation, implications for clinical care of comorbid individuals, and burdens on persons besides antisocial adults that are specifically attributable to antisocial syndromes, will be highlighted and directions for future research will be suggested. Implications for the development and prioritization of preventive and therapeutic interventions targeting antisociality across the lifespan will be discussed.
Personality disorders accompanying schizophrenia: analysis of a series consisting of 75 patients Introduction: Accompanying personality disorders can frequently be encountered in schizophrenic patients and they may change the expressions of symptoms and the course of the disease. Objective: We aimed to investigate the frequency and distribution of personality disorders and their relationship with some sociodemographic and clinical variables in a group of schizophrenic patients. Possible effects of the personality disorders on the diagnosis, course, follow-up, and treatment planning of the schizophrenia are also discussed. Method: The study group was composed of 37 female and 38 male (total 75) patients who were followed up by the diagnosis of schizophrenia. A data set including some demographic - social variables and the status of symptoms evaluated by some clinical tests, as well as accompanying personality pathologies were obtained. Results: In our sample approximately 70% of schizophrenic patients have had one or more types of accompanying personality disorders, The most frequently seen types were avoidant, paranoid, and obsessive-compulsive personality disorders. The types and frequencies of the personality disorders showed differences among the patient groups formed by various criteria. Discussion: Knowing the distribution and frequency of personality disorders in schizophrenic patients may provide useful data to the clinicians in both the diagnosis / follow up and the planning of the pharmacological treatment of the disease. Possibly the personality disorders may negatively affect the course of the disease either by interfering with the adherence of the patients or by some pathogenetical mechanisms, which are not fully understood yet.
Personality disorder (PD) in psychosis is poorly studied. As PD can affect outcome in mental disorders, it is important to understand its prevalence in order to plan services, understand prognosis more fully and maximize management options. Method
Literature searching revealed 3972 potential papers. Twenty papers including 6345 patients were included in the final analysis. There was great variation in prevalence and multilevel modelling was used to identify possible reasons for this heterogeneity.
The prevalence of PD varied from 4.5% to 100%. Multilevel analysis suggested country of study, study type, the instruments used to diagnose PD and patient care correlated with the prevalence data explaining the study level heterogeneity, with 34.2, 33.4, 17.0 and 4.5% by each variable respectively. Personality studies in Canada and Sweden reported lower PD prevalence, whereas in Spain it was higher than the multinational study. Compared with randomized controlled trials, case-control studies reported lower prevalence [odds ratio (OR)=0.35, 95% confidence interval (CI) 0.15-0.79] and observational studies higher prevalence (OR 70.5, 95% CI 8.5-583). Primary-care patients were less likely to be diagnosed (OR 0.02, 95% CI 0-0.19) than hospital patients, and out-patients had higher prevalence (OR 12.5, 95% CI 1.77-88.6).
The reported prevalence of PD in schizophrenia varies significantly. Statistical modelling suggests care, country, study type and diagnostic tools for PD all bias prevalence rates. The number of papers reaching the inclusion criteria, the relative paucity of information and the difficulties in developing an accurate statistical model limited interpretation from the study.
• We reanalyzed the Copenhagen schizophrenia high-risk project data set to test recently developed models of the antecedents of predominantly negative and predominantly positive forms of schizophrenia. Among a group of 138 high-risk individuals, those at elevated genetic risk who suffered severe delivery complications and who were autonomic nonresponders during adolescence were significantly more likely than those without this pattern to evidence outcomes of schizophrenia with predominantly negative symptoms (86% vs 0.8%, respectively). Among a group of 160 high-risk subjects, those who escaped delivery complications, who evidenced a high degree of autonomic responsiveness in adolescence, and who experienced severe disruption of the early family rearing environment were significantly more likely than those without this pattern to evidence outcomes of schizophrenia with predominantly positive symptoms (40% vs 1.2%, respectively). In late childhood and early adolescence, predominantly negative-symptom schizophrenics were rated by their teachers as passive, socially isolated, and unresponsive to praise; predominantly positive-symptom schizophrenics were rated as overactive, irritable, distractible, and aggressive. The study is limited by the fact that the hypotheses were based in part on previous analyses of the same data set, by the small number of schizophrenic subjects of each subtype, and by the use of simplified theoretical and statistical models that do not address the multidetermination of negative and positive symptoms.
We reanalyzed the Copenhagen schizophrenia high-risk project data set to test recently developed models of the antecedents of predominantly negative and predominantly positive forms of schizophrenia. Among a group of 138 high-risk individuals, those at elevated genetic risk who suffered severe delivery complications and who were autonomic nonresponders during adolescence were significantly more likely than those without this pattern to evidence outcomes of schizophrenia with predominantly negative symptoms (86% vs 0.8%, respectively). Among a group of 160 high-risk subjects, those who escaped delivery complications, who evidenced a high degree of autonomic responsiveness in adolescence, and who experienced severe disruption of the early family rearing environment were significantly more likely than those without this pattern to evidence outcomes of schizophrenia with predominantly positive symptoms (40% vs 1.2%, respectively). In late childhood and early adolescence, predominantly negative-symptom schizophrenics were rated by their teachers as passive, socially isolated, and unresponsive to praise; predominantly positive-symptom schizophrenics were rated as overactive, irritable, distractible, and aggressive. The study is limited by the fact that the hypotheses were based in part on previous analyses of the same data set, by the small number of schizophrenic subjects of each subtype, and by the use of simplified theoretical and statistical models that do not address the multidetermination of negative and positive symptoms.
The personalities of 6,315 Swiss conscripts of the army were assessed in 1971 by the Freiburg Personality Inventory (FPI), together with social attributes and consumption of tobacco, alcohol, and drugs. Up to 1983, 185 psychiatric patients were identified who were treated as inpatients or outpatients in the same geographic area. A subsample of 87 patients were chosen for a blind diagnostic study applying Feighner criteria to the records. Their premorbid personalities are compared to controls from the same group. The results are preliminary, the diagnostic groups are small. The schizophrenics scored high in autonomic lability. The bipolar patients did not deviate significantly in any personality dimension from the controls. They differed significantly from the unipolar depressives by a lower aggression score. Unipolar depressives scored high in aggression and in autonomic lability. The same was true for the sociopaths. Aggression scores were also high in those who committed suicide or died by accidents. Independent of the diagnostic classification, subjects with suicidal attempts scored high in aggression, whereas subjects with suicidal ideation scored low in aggression.
The Standardized Assessment of Personality, a semistructured interview for use with an informant, was used with a relative or a close friend to determine the premorbid personality of 100 consecutive patients admitted with major psychiatric disorders - major affective disorders (18 manics, 35 depressives), schizophrenia (28) and other functional psychoses (19). Forty-four per cent of the entire sample had an abnormal personality as defined by the presence of one of 10 prominent traits to a marked degree. A further 6% had the same traits to a lesser degree. The proportion of patients with an abnormal personality (all types) was comparable across the four diagnostic groups (manics 39%, depressives 54%, schizophrenics 39%, other functional psychotics 37%). However, if one included all traits (marked and mild), patients with an affective disorder had more between them than did the non-affective groups. This difference was largely accounted for by cyclothymic, anxious and obsessional traits. The schizophrenics and other functional psychotics had surprisingly few prominent traits and, in particular, a schizoid personality rarely preceded a schizophrenic illness.
The authors studied the relationship between DSM-III axis I and axis II diagnoses in 2,462 medical center patients. Personality disorders were most commonly associated with substance use disorders and with the anxiety and somatoform disorders traditionally classified as neuroses. There was a particularly strong connection between antisocial personality disorder and substance abuse. The psychotic and major affective illnesses were significantly less often associated with personality disorders. The results of this study suggest a need for refining the criteria for several DSM-III categories. Overall, the separate personality disorder axis in the DSM-III system provides information not contained with the syndromal classification alone.
All hospital records, interviews, and notes are reviewed on a group of 52 chronic hebephrenic/catatonic schizophrenics who were institutionalized before the era of antipsychotic medications. The authors catalog the presence or absence of individual symptoms of schizophrenia on a year by year basis over a span of 25 years and present this data in a series of bar graphs. Symptoms such as avolition, impaired social interaction, and flat affect become more frequent over the 25 years of follow-up. Hallucinations and delusions become less frequent. Eighteen of the patients are noted to have had a DSM-III personality disorder premorbidly and eight of these are characterized as schizoid personality disorder. Level of insight is found to be poor at the onset of schizophrenia and deteriorates further over the next 5 years. Although the study design contains a sampling bias in favor of chronically institutionalized cases, several lines of evidence suggest that the trends reported here are not artifacts of institutionalization but are due to schizophrenia.
Three hundred fifty-three psychiatric inpatients and their 192 living spouses and 98 control subjects and their 54 living spouses were examined and interviewed for affective, schizoaffective, schizophrenic (Research Diagnostic Criteria [RDC]), and personality disorders (DSM-III-R) using the Lifetime Version of the Schedule for Affective Disorders and Schizophrenia (SADS-L) and the Structured Clinical Interview for DSM-III-Personality Disorders (SCID). The morbid risks of spouses for unipolar depression were between .15 and .25, and those for other major disorders were below .03. The morbid risks of spouses of bipolar patients for unipolar depression exceeded those of other spouses by 50% without reaching statistical significance. Personality disorders were found in 44.6% of patients, in 8.4% of patients' spouses, and in 9.8% of healthy controls. There was only one couple in which the husband and wife had each had a major disorder before marriage. Only four husband-wife pairs suffered the same personality disorder. Spouses of patients do not have significantly more psychiatric disorders than healthy controls; therefore, assortative mating can only be of minor relevance in family studies.