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Course and clinical correlates of obsessive-compulsive disorder with or without comorbid personality disorder
... In a clinical trial of clomipramine in OCD, comorbid borderline personality disorder was associated with worse outcomes [20]. In a longitudinal study of OCD (n = 263 participants), researchers found that those with a personality disorder reported worse OCD and depression symptom chronicity over 5 years [21]. It is important to note, however, that OCD is not the same as trichotillomania and skin picking disorder, but a possible comorbidity with borderline personality disorder may provide clues as to why treatments for trichotillomania and skin picking disorder have produced inconsistent results. ...
Background
Comorbidity studies in trichotillomania and skin picking disorder (known as Body-Focused Repetitive Behaviors, BFRBs) have traditionally not examined rates of borderline personality disorder. When it co-occurs, borderline personality disorder may necessitate different treatment approaches and if untreated may interfere with the response to the treatment for trichotillomania or skin picking disorder. The objectives of this study were to (1) examine the rate of co-occurring borderline personality disorder in BFRBs; and (2) explore associations between co-occurring borderline personality disorder and relevant clinical characteristics (such as demographic features, BFRB symptom severity, lifetime history of suicide attempt[s], levels of dissociation, and other comorbidities including impulsive conditions that are often unmeasured in studies).
Methods
Adults with skin picking disorder, trichotillomania, or both completed an online survey. The survey was comprised of demographic and clinical questions, plus instruments to measure for probable borderline personality disorder, as well as BFRB severity, dissociation, impulse control conditions (including BFRBs), and alcohol use disorder. Each participant also completed questions about previous formal mental health diagnoses.
Results
Of the 281 adults with BFRBs (n = 105 with skin picking disorder; 93 with trichotillomania, and 82 with both disorders), 105 (37.4%) screened positive for a probable diagnosis of borderline personality disorder. Participants screening positive for probable borderline personality disorder reported significantly worse pulling and picking symptoms (p < .001), higher rates of dissociation (p < .001), and were significantly more likely to report lifetime suicide attempts (p < .001) and to endorse co-occurring alcohol problems (p < .001), compulsive buying disorder (p < .001), gambling disorder (p < .001), compulsive sexual behavior (p < 001), and kleptomania (p = .005).
Conclusions
These data suggest relatively high rates of borderline personality disorder in people with BFRBs, in turn linked to more severe psychopathology and elevated lifetime suicide attempt risk. Perhaps the comorbidity with borderline personality disorder reflects a possible subtype of these behaviors that is more impulsive and may necessitate different treatment approaches.
Objectives: The study aimed to identify the level of the degree of relative contribution of each of the symptoms of obsessive-compulsive disorder and health anxiety to cyberchondria. The study sample consisted of 816 nursing students (178 males, 638 females) at Jordanian universities who were selected using the available method. To achieve the objectives of the study, the researcher used the McElroy et al. (2019) scale for cyberchondria, the Salkovskis et al. (2002) scale for health anxiety, and the Goodman et al. (1989) scale for obsessive-compulsive disorder. Methodology: Predictive descriptive approach. Results: This was after ensuring the validity and reliability of the instruments. The results of the study indicated that the overall symptoms of obsessive-compulsive disorder were low on all dimensions. The level of the overall health anxiety was also low on all dimensions, and that the overall level of cyberchondria was moderate. The level of the "Excessiveness" dimension was high, while the level of the two dimensions (Distress and Reassurance) was medium level, and the "Compulsion" dimension obtained low level. The results of the study showed the ability of both obsessive-compulsive disorder symptoms and health anxiety to predict cyberchondria. They explained an amount of (8.90%) of the cyberchondria, and the predictive variables explained an amount of (4.70%) of the "Excessiveness" dimension. The predictive variables explained an amount of (9.30%) of the "Distress" dimension. The predictive variables explained an amount of (1.70%) of the "Reassurance" dimension. The predictive variables explained an amount of (10.70%) of the "Compulsion" dimension. Conclusion: The study concluded with a set of recommendations. The most prominent of which was working on future studies with other groups, such as medical students or hospital workers. This is to expand the results further.
The purpose of this study was to describe the onset age distribution for first episodes of unipolar depression for men and women. From a total of 6,742 participants ranging in age from 18 to 88 years, 2,046 were selected for a diagnostic interview on the basis of elevated scores on a self-report depression inventory and were diagnosed as per the Schedule for Affective Disorders and Schizophrenia and Research Diagnostic Criteria procedures. Of those interviewed, 1,012 were diagnosed as having suffered from a previous episode of depression. The Life Table method was used to describe the risks associated with different ages for developing an initial episode of depression. The results indicate that the hazard rates are very low through age 14 years, increase during adolescence (15–19 years) and young adulthood (20–24 years), peak between 45 and 55 years, and then decrease with increasing age, becoming zero at 80 years or older. The hazard rates for men and women differed, with women between the ages of 9 and 69 years having higher hazard rates than men between the same ages. The average age at onset for first episodes of depression for men and women did not differ.
Comorbidities are seen with obsessive-compulsive disorder (OCD) across the lifespan. Neurodevelopmental comorbidities are common in young children, followed by mood, anxiety, and obsessive-compulsive related disorders (OCRDs) in children, adolescents and adults, and neurological and degenerative disorders in the elderly. Understanding comorbidity prevalence and patterns has clinical and research implications. We conducted a systematic review and meta-analysis on comorbidities in OCD across the lifespan, with the objective to, first, estimate age-wise pattern and prevalence of comorbidities with OCD and, second, to examine associations of demographic (age at assessment, gender distribution) and clinical characteristics (age of onset, illness severity) with comorbidities. Four electronic databases (PubMed, EMBASE, SCOPUS, and PsycINFO) were searched using predefined search terms for articles published between 1979 and 2020. Eligible studies, across age, reported original findings on comorbidities and had an OCD sample size of ≥100. We excluded studies that did not use standardised diagnostic assessments, or that excluded patients on the basis of comorbidity. We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The review protocol has been registered on the International Prospective Register of Systematic Reviews. A comorbidity rate of 69% was found in a pooled sample of more than 15,000 individuals. Mood disorders (major depressive disorder), anxiety disorders (generalised anxiety disorder), neurodevelopmental disorders (NDDs) and OCRDs were the commonest comorbidities. Anxiety disorders prevailed in children, mood disorders in adults, whereas NDDs were similarly prevalent. Higher comorbidity with any psychiatric illness, NDDs, and severe mental disorders was seen in males, vs. females. Illness severity was inversely associated with rates for panic disorder, tic disorders, OCRDs, obsessive compulsive personality disorder, and anorexia nervosa. This systematic review and meta-analysis provides base rates for comorbidities in OCD across the lifespan. This has implications for comprehensive clinical evaluation and management planning. The high variability in comorbidity rates suggests the need for quality, multi-centric, large studies, using prospective designs.
Systematic Review Registration: Unique Identifier: CRD42020215904.
Objective: The comorbidity of obsessive-compulsive disorder (OCD) and personality disorders (PDs) is frequent but there are conflicting findings about which PDs are the most common. This study aimed to investigate the personality beliefs that exist on a more pathological level among OCD patients, to explore the association between personality beliefs and OCD severity, and to clarify the mediator effect of depression in this relationship.
Methods: 202 OCD patients and 76 healthy controls with similar sociodemographic features were included in the study. The Personality Belief Questionnaire-Short Form was administered to both groups. The Yale-Brown Obsessions and Compulsions Scale, Beck Depression Inventory, and the Beck Anxiety Inventory were administered only to the clinical sample.
Results: The dependent, histrionic, paranoid, borderline, and avoidant personality subscale scores were significantly higher in the
OCD group than in the control group. There was an association only between OCD severity and narcissistic personality beliefs, also depression mediated the relationship between narcissistic personality and OCD severity.
Conclusion Some personality beliefs at a pathological level are more common among OCD patients. Personality beliefs, as well as depression, should be routinely assessed, as they may affect OCD severity, help-seeking behavior, and response to treatment.
Obsessive-compulsive personality disorder (OCPD) remains understudied despite its high community prevalence and substantial societal burden. Elucidating the factors involved in OCPD traits and behaviors could improve conceptual models of OCPD and guide treatment development. Intolerance of uncertainty (IU) has been investigated as a transdiagnostic factor linked to many conditions, including anxiety disorders and obsessive-compulsive disorder (OCD). Despite OCPD's links to OCD, very little research has investigated whether IU may also be a relevant factor in OCPD. The present study administered measures of IU and OCPD to a large community sample of adults (n = 534) as well as a group of individuals with self-identified OCPD (n = 76). The OCPD measure assessed five OCPD trait dimensions as well as overall OCPD severity. We also included measures of other symptoms (OCD, depression, anxiety, and stress) as well as quality of life. Results revealed that the OCPD group reported heightened IU compared with the community sample, even when controlling for group differences in anxiety, depression, stress, and OCD symptoms. IU was significantly correlated with OCPD trait severity, and regression analyses demonstrated that IU predicted severity of OCPD traits controlling for distress symptoms. Moreover, IU significantly mediated the relationship between OCPD traits and reduced quality of life. These results highlight the importance of considering IU in the context of OCPD, with possible implications for improving treatment. Limitations and future directions for research are discussed. (PsycINFO Database Record (c) 2020 APA, all rights reserved).
Personality disorders are a common comorbidity in obsessive-compulsive disorder (OCD). The effect of comorbidity on the symptom presentation, course, and treatment outcome of OCD is being discussed here. OCD and obsessive-compulsive personality disorder (OCPD) though similar in their symptom presentation, are distinct constructs. Schizotypal disorder, OCPD, and two or more comorbid personality disorders have been found to be consistently associated with a poor course of illness and treatment response. Further research is needed to determine treatment strategies to handle the personality pathology in OCD.
The current paper was aimed at: (1) investigating the comorbidity between obsessive-compulsive disorder (OCD) and personality disorders (PDs) using an OCD sample and clinician-administered structured interviews; (2) exploring the associations of different cluster comorbid PDs with the specific symptom dimensions of OCD; (3) analyzing the variables which could play a significant role in the probability of having at least one comorbid PD, controlling for confounding variables. The SCID-II and Y-BOCS, together with a series of self-report measures of OCD, depression and anxiety symptoms were administered to a clinical sample of 159 patients with a primary diagnosis of OCD. 20.8 % of the participants suffered from at least one comorbid PD; the most common was obsessive-compulsive PD (9.4 %), followed by narcissistic PD (6.3 %). In OCD patients with comorbid cluster C PDs, the percentage of responsibility for harm, injury, or bad luck symptoms was significantly greater than other OCD symptom dimensions (p < .005). Logistic regression found some evidence supporting the association between severity of OCD symptoms and comorbid PDs. PDs are prevalent among Italian people with OCD and should be routinely assessed, as comorbidity may affect help-seeking behaviour and response to treatment.
The core symptoms of obsessive-compulsive personality disorder (OCPD) often lead to interpersonal difficulties. However, little research has explored interpersonal functioning in OCPD. This study examined interpersonal problems, interpersonal sensitivities, empathy, and systemizing, the drive to analyze and derive underlying rules for systems, in a sample of 25 OCPD individuals, 25 individuals with comorbid OCPD and obsessive-compulsive disorder (OCD), and 25 healthy controls. We found that OCPD individuals reported hostile-dominant interpersonal problems and sensitivities with warm-dominant behavior by others, whereas OCPD+OCD individuals reported submissive interpersonal problems and sensitivities with warm-submissive behavior by others. Individuals with OCPD, with and without OCD, reported less empathic perspective taking relative to healthy controls. Finally, we found that OCPD males reported a higher drive to analyze and derive rules for systems than OCPD females. Overall, results suggest that there are interpersonal deficits associated with OCPD and the clinical implications of these deficits are discussed.
Objective:
This study assesses the long-term course of treatment-seeking youth with a primary diagnosis of DSM-IV OCD.
Method:
Sixty youth and their parents completed intake interviews and annual follow-up interviews for 3 years using the youth version of the Longitudinal Interval Follow-up Evaluation (Y-LIFE) and Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS). Remission was defined as no longer meeting DSM-IV criteria for OCD for 8 weeks or more, and recurrence was defined as meeting full criteria for OCD for 4 consecutive weeks after having achieved symptom remission. Remission rates for youth were compared to rates of adults participating in the same study.
Results:
The probability of achieving partial remission of OCD was 0.53 and the probability of achieving full remission was 0.27. Among the 24 youth participants who achieved remission, 79% stayed in remission throughout the study (mean of 88 weeks of follow-up) and 21% experienced a recurrence of symptoms. Better functioning at intake and a shorter latency to initial OCD treatment were associated with faster onset of remission (P<.001).
Conclusions:
Remission is more likely among youth versus adults with OCD. Treatment early in the course of illness and before substantial impact on functioning predicted a better course.
Although the relationship between obsessive-compulsive disorder (OCD) and obsessive-compulsive personality disorder (OCPD) has long been debated, clinical samples of OCD (without OCPD) and OCPD (without OCD) have never been systematically compared. We studied whether individuals with OCD, OCPD, or both conditions differ on symptomatology, functioning, and a measure of self-control: the capacity to delay reward.
Twenty-five OCD, 25 OCPD, 25 comorbid OCD + OCPD, and 25 healthy control subjects completed clinical assessments and a validated intertemporal choice task that measures capacity to forego small immediate rewards for larger delayed rewards.
OCD and OCPD subjects both showed impairment in psychosocial functioning and quality of life, as well as compulsive behavior, but only subjects with OCD reported obsessions. Individuals with OCPD, with or without comorbid OCD, discounted the value of delayed monetary rewards significantly less than OCD and healthy control subjects. This excessive capacity to delay reward discriminates OCPD from OCD and is associated with perfectionism and rigidity.
OCD and OCPD are both impairing disorders marked by compulsive behaviors, but they can be differentiated by the presence of obsessions in OCD and by excessive capacity to delay reward in OCPD. That individuals with OCPD show less temporal discounting (suggestive of excessive self-control), whereas prior studies have shown that individuals with substance use disorders show greater discounting (suggestive of impulsivity), supports the premise that this component of self-control lies on a continuum in which both extremes (impulsivity and overcontrol) contribute to psychopathology.
The effect of comorbid personality disorders (PD) on treatment outcomes in obsessive-compulsive disorder (OCD) is unclear. The authors systematically review results from investigations of therapy outcomes in adult patients with OCD and a comorbid PD. PsycINFO and MEDLINE were searched for original articles. Twenty-three studies assessing PDs through interviews were selected. Cluster A PDs, particularly schizotypal PD, narcissistic PD, and the presence of two or more comorbid PDs, were associated with poorer treatment outcomes in patients with OCD. With regard to other PDs and clusters, the results are inconsistent or the sample sizes are too small to reach a conclusion. OCD patients with different comorbid PDs differ in their therapeutic response to treatment. To optimize the treatment of OCD, the predictive value of PDs on the treatment outcome should be further investigated, and treatment of Axis I and II comorbidity requires more attention.
Although obsessive-compulsive disorder (OCD) is typically described as a chronic condition, relatively little is known about the naturalistic, longitudinal course of the disorder. The purpose of the current study was to examine the probability of OCD remission and recurrence as well as to explore demographic and clinical predictors of remission.
This study uses data from the Harvard/Brown Anxiety Disorders Research Program, which is a prospective, naturalistic, longitudinal study of anxiety disorders. Diagnoses were established by means of a clinical interview at study intake. One hundred thirteen Harvard/Brown Anxiety Disorders Research Program participants with OCD were included in the study; all had a history of at least 1 other anxiety disorder. Assessments were conducted at 6-month and/or annual intervals during 15 years of follow-up.
Survival analyses showed that the probability of OCD remission was .16 at year 1, .25 at year 5, .31 at year 10, and .42 at year 15. For those who remitted from OCD, the probability of recurrence was .07 at year 1, .15 by year 3, and by year 5, it reached .25 and remained at .25 through year 15. In predictors of course, those who were married and those without comorbid major depressive disorder (MDD) were more likely to remit from OCD. By year 15, 51% of those without MDD remitted from OCD compared to only 20% of those with MDD.
In the short term, OCD appears to have a chronic course with low rates of remission. However, in the long term, a fair number of people recover from the disorder, and, for those who experience remission from OCD, the probability of recurrence is fairly low.
The purpose of this study was to examine the effects of specific personality disorder comorbidity on the course of major depressive disorder in a nationally representative sample.
Data were drawn from 1,996 participants in a national survey. Participants who met criteria for major depressive disorder at baseline in face-to-face interviews (in 2001-2002) were reinterviewed 3 years later (in 2004-2005) to determine persistence and recurrence. Predictors included all DSM-IV personality disorders. Control variables included demographic characteristics, other axis I disorders, family and treatment histories, and previously established predictors of the course of major depressive disorder.
A total of 15.1% of participants had persistent major depressive disorder, and 7.3% of those who remitted had a recurrence. Univariate analyses indicated that avoidant, borderline, histrionic, paranoid, schizoid, and schizotypal personality disorders all elevated the risk for persistence. With axis I comorbidity controlled, all personality disorders except histrionic personality disorder remained significant. With all other personality disorders controlled, borderline and schizotypal disorders remained significant predictors. In final, multivariate analyses that controlled for age at onset of major depressive disorder, the number of previous episodes, duration of the current episode, family history, and treatment, borderline personality disorder remained a robust predictor of major depressive disorder persistence. Neither personality disorders nor other clinical variables predicted recurrence.
In this nationally representative sample of adults with major depressive disorder, borderline personality disorder robustly predicted persistence, a finding that converges with recent clinical studies. Personality psychopathology, particularly borderline personality disorder, should be assessed in all patients with major depressive disorder, considered in prognosis, and addressed in treatment.
This study prospectively examined the natural clinical course of six anxiety disorders over 7 years of follow-up in individuals with personality disorders (PDs) and/or major depressive disorder. Rates of remission, relapse, new episode onset and chronicity of anxiety disorders were examined for specific associations with PDs.
Participants were 499 patients with anxiety disorders in the Collaborative Longitudinal Personality Disorders Study, who were assessed with structured interviews for psychiatric disorders at yearly intervals throughout 7 years of follow-up. These data were used to determine probabilities of changes in disorder status for social phobia (SP), generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), panic disorder and panic disorder with agoraphobia.
Estimated remission rates for anxiety disorders in this study group ranged from 73% to 94%. For those patients who remitted from an anxiety disorder, relapse rates ranged from 34% to 67%. Rates for new episode onsets of anxiety disorders ranged from 3% to 17%. Specific PDs demonstrated associations with remission, relapse, new episode onsets and chronicity of anxiety disorders. Associations were identified between schizotypal PD with course of SP, PTSD and GAD; avoidant PD with course of SP and OCD; obsessive-compulsive PD with course of GAD, OCD, and agoraphobia; and borderline PD with course of OCD, GAD and panic with agoraphobia.
Findings suggest that specific PD diagnoses have negative prognostic significance for the course of anxiety disorders underscoring the importance of assessing and considering PD diagnoses in patients with anxiety disorders.
Surprisingly little is known about the long-term course of obsessive-compulsive disorder (OCD). This prospective study presents 2-year course findings, as well as predictors of course, from the Brown Longitudinal Obsessive Compulsive Study, the first comprehensive prospective investigation of the observational course of OCD in a large clinical sample.
The sample included 214 treatment-seeking adults with DSM-IV OCD at intake who identified OCD as the most problematic disorder over their lifetime. Subjects were enrolled from 2001-2004. At annual interviews, data on weekly OCD symptom status were obtained using the Longitudinal Interval Follow-Up Evaluation. Probabilities of full remission and partial remission over the first 2 years of collected data and potential predictors of remission were examined.
The probability of full remission from OCD was 0.06, and the probability of partial remission was 0.24. Of the 48 subjects whose OCD symptoms partially or fully remitted, only 1 relapsed within the first 2 years. Earlier age at onset of OCD, greater severity of symptoms at intake, older age at intake, and being male were associated with a decreased likelihood of remission. Insight, diagnostic comorbidity, and treatment were not found to be associated with the likelihood of achieving full or partial remission.
Though one-quarter of the sample had periods of subclinical OCD symptoms during the prospective period, full remission was rare, consistent with the view of OCD as a chronic and persistent illness. Age at onset, OCD symptom severity, current age, and sex emerged as potent predictors of course.
Despite significant advances in the study of obsessive-compulsive disorder (OCD), important questions remain about the disorder's public health significance, appropriate diagnostic classification, and clinical heterogeneity. These issues were explored using data from the National Comorbidity Survey Replication, a nationally representative survey of US adults. A subsample of 2073 respondents was assessed for lifetime Diagnostic and Statistical Manual of Mental Disorders, 4th edn (DSM-IV) OCD. More than one quarter of respondents reported experiencing obsessions or compulsions at some time in their lives. While conditional probability of OCD was strongly associated with the number of obsessions and compulsions reported, only small proportions of respondents met full DSM-IV criteria for lifetime (2.3%) or 12-month (1.2%) OCD. OCD is associated with substantial comorbidity, not only with anxiety and mood disorders but also with impulse-control and substance use disorders. Severity of OCD, assessed by an adapted version of the Yale-Brown Obsessive Compulsive Scale, is associated with poor insight, high comorbidity, high role impairment, and high probability of seeking treatment. The high prevalence of subthreshold OCD symptoms may help explain past inconsistencies in prevalence estimates across surveys and suggests that the public health burden of OCD may be greater than its low prevalence implies. Evidence of a preponderance of early onset cases in men, high comorbidity with a wide range of disorders, and reliable associations between disorder severity and key outcomes may have implications for how OCD is classified in DSM-V.
The aims of the present study were to examine the frequency of personality disorders in 36 patients with obsessive-compulsive disorder (OCD), and to investigate whether patients with a coexisting personality disorder could be characterized by certain personality traits assessed by means of the Karolinska Scales of Personality (KSP). In total, 27 (75%) of the OCD patients fulfilled the DSM-III-R criteria for a personality disorder, and 13 patients (36%) had an obsessive-compulsive personality disorder. Subjects with a comorbid personality disorder had significantly higher scores on most of the KSP scales, including all anxiety scales, as well as scales measuring indirect aggression, irritability, guilt and detachment, whereas subjects without personality disorders did not differ significantly from healthy controls with regard to personality traits.
Background:
This study had two main objectives. The first was to detail the prevalence of major depressive disorder over 24 years of follow-up for both patients with borderline personality disorder (BPD) and comparison subjects with other personality disorders (OPD). The second was to determine time-to-remission, recurrence, and new onset of major depression among these two groups of patients.
Methods:
The SCID-I was administered to 290 borderline inpatients and 72 personality-disordered comparison subjects during their index admission. It was also re-administered at 12 contiguous two-year follow-up periods.
Results:
The prevalence of major depression was significantly higher for borderline patients over time but declined significantly over time for those in both study groups. In terms of time to events, 93% of borderline patients meeting criteria for major depression at baseline experienced a two-year remission by the time of the 24-year follow-up. Recurrences were about as common (90% for those with remitted major depression). New onsets of major depression were also very common (86% for those without major depression during their index admission).
Limitations:
Results may not pertain to less severely ill patients with BPD and those in less treatment.
Conclusions:
Taken together, the results of this study suggest that the remitting-recurring course of major depression in borderline patients is very similar to the course of major depression in those with other types of personality disorder and those for whom major depression is their primary disorder.
Obsessive-Compulsive Disorder (OCD) is characterized by maladaptive patterns of repetitive, inflexible cognition and behavior that suggest a lack of cognitive flexibility. Consistent with this clinical observation, many neurocognitive studies suggest behavioral and neurobiological abnormalities in cognitive flexibility in individuals with OCD. Meta-analytic reviews support a pattern of cognitive inflexibility, with effect sizes generally in the medium range. Heterogeneity in assessments and the way underlying constructs have been operationalized point to the need for better standardization across studies, as well as more refined overarching models of cognitive flexibility and executive function. Neuropsychological assessments of cognitive flexibility include measures of attentional set shifting, reversal and alternation, cued task switching paradigms, cognitive control measures such as the Trail-Making and Stroop tasks, and several measures of motor inhibition. Differences in the cognitive constructs and neural substrates associated with these measures suggest that performance within these different domains should be examined separately. Additional factors, such as the number of consistent trials prior to a shift and whether a shift is explicitly signaled or must be inferred from a change in reward contingencies, may influence performance, and thus mask or accentuate deficits. Several studies have described abnormalities in neural activation in the absence of differences in behavioral performance, suggesting that our behavioral probes may not be adequately sensitive, but also offering important insights into potential compensatory processes. The fact that deficits of moderate effect size are seen across a broad range of classic neuropsychological tests in OCD presents a conceptual challenge, as clinical symptomatology suggests greater specificity. Traditional cognitive probes may not be sufficient to delineate specific domains of deficit in this and other neuropsychiatric disorders; a new generation of behavioral tasks that test more specific underlying constructs, supplemented by neuroimaging to provide greater insight into the underlying processes, may be needed.
Objective:
This report examines the relationship of DSM-IV borderline personality disorder (BPD) to anxiety disorders using data on the reciprocal effects of improvement or worsening of BPD and anxiety disorders over the course of 10 years.
Method:
We reliably and prospectively assessed borderline patients (n = 164) with DSM-IV-defined co-occurring generalized anxiety disorder (GAD; n = 42), panic disorder with agoraphobia (n = 39), panic disorder without agoraphobia (n = 36), social phobia (n = 48), obsessive-compulsive disorder (OCD; n = 36), and posttraumatic stress disorder (PTSD; n = 88) annually over a period of 10 years between 1997 and 2009. We used proportional hazards regression analyses to assess the effects of monthly improvement or worsening of BPD and anxiety disorders on each other's remission and relapse the following month.
Results:
BPD improvement significantly predicted remission of GAD (hazard ratio [HR] = 0.65, P < .05) and PTSD (HR = 0.57, P < .05), whereas BPD worsening significantly predicted social phobia relapse (HR = 1.87, P < .05). The course of anxiety disorders did not predict BPD remission or relapse, except that worsening PTSD significantly predicted BPD relapse (HR = 1.90, P < .05).
Conclusions:
BPD negatively affects the course of GAD, social phobia, and PTSD. In contrast, the anxiety disorders, aside from PTSD, had little effect on BPD course. For GAD and social phobia, whose course BPD unidirectionally influences, we suggest prioritizing treatment for BPD, whereas BPD should be treated concurrently with panic disorders, OCD, or PTSD. We discuss state/trait issues in the context of our findings.
We assessed correlates of obsessive-compulsive (OCPD), schizotypal (SPD) and borderline (BPD) personality disorders in 110 obsessive-compulsive disorder (OCD) patients. We found OCD patients with OCPD (20.9%) to exhibit higher rates of hoarding and bipolar disorders, increased severity of hoarding and symmetry, lower prevalence of unacceptable thoughts involving sex and religion and less non-planning impulsivity. Conversely, OCD patients with SPD (13.6%) displayed more frequently bipolar disorder, increased severity of depression and OCD neutralization, greater prevalence of "low-order" behaviors (i.e., touching), lower low-planning impulsivity and greater "behavioral" compulsivity. Finally, in exploratory analyses, OCD patients with BPD (21.8%) exhibited lower education, higher rates of several comorbid psychiatric disorders, greater frequency of compulsions involving interpersonal domains (e.g. reassurance seeking), increased severity of depression, anxiety and OCD dimensions other than symmetry and hoarding, more motor and non-planning impulsivity, and greater "cognitive" compulsivity. These findings highlight the importance of assessing personality disorders in OCD samples.
Copyright © 2015. Published by Elsevier Ltd.
This study examines the relationship of DSM-III-R personality disorders to functional impairment as measured by the Global Assessment of Functioning (GAF) scale. The results include: (1) Patients with any personality disorder were more impaired than those without. (2) The greater the total number of Axis II criteria met, the more severe the functional impairment (r = .60, p < .01). (3) Using a categorical classification model (i.e., threshold), schizotypal and schizoid personality disorders were associated with the greatest functional impairment, whereas use of a dimensional model (i.e., continuum) found that patients with schizotypal, paranoid, and borderline personality disorders were most severely impaired. (4) Disorders associated with the least functional impairment were histrionic and obsessive- compulsive.
• The development design and reliability of the Yale-Brown Obsessive Compulsive Scale have been described elsewhere. We focused on the validity of the Yale-Brown Scale and its sensitivity to change. Convergent and discriminant validity were examined in baseline ratings from three cohorts of patients with obsessive-compulsive disorder (N = 81). The total Yale-Brown Scale score was significantly correlated with two of three independent measures of obsessive-compulsive disorder and weakly correlated with measures of depression and of anxiety in patients with obsessive-compulsive disorder with minimal secondary depressive symptoms. Results from a previously reported placebo-controlled trial of fluvoxamine in 42 patients with obsessive-compulsive disorder showed that the Yale-Brown Scale was sensitive to drug-induced changes and that reductions in Yale-Brown Scale scores specifically reflected improvement in obsessive-compulsive disorder symptoms. Together, these studies indicate that the 10-item Yale-Brown Scale is a reliable and valid instrument for assessing obsessive-compulsive disorder symptom severity and that it is suitable as an outcome measure in drug trials of obsessive-compulsive disorder.
Objective:
To study the long-term rate and predictors of remission in adults with obsessive-compulsive disorder (OCD), using meta-analysis.
Data sources:
The MEDLINE database was searched to May 2013 using the search terms obsessive-compulsive disorder, prospective, outcome study, clinical course, remission, prognosis, follow-up, and long-term and limits for language (English), species (humans), and age (adults). This was supplemented by manual bibliographic cross-referencing.
Study selection:
English-language studies from peer-reviewed journals on adults with DSM-III-R, DSM-IV, DSM-IV-TR, ICD-9, or ICD-10 diagnosis of OCD followed up for ≥ 1 year and treated with serotonin reuptake inhibitors and/or cognitive-behavioral therapy that reported rate of remission (Yale-Brown Obsessive Compulsive Scale [YBOCS] score < 16 at longest follow-up) were included.
Data extraction:
Data were gathered as numbers/means/percentages/categories on sample size, study design, follow-up duration, age at assessment, illness duration, age at illness onset, gender, marital status, inpatient/outpatient status, family history, baseline YBOCS score, comorbidities, and remission.
Results:
Seventeen studies (pooled N = 1,265) fit the selection criteria and were used for the meta-analysis. The pooled sample had a mean follow-up duration 4.91 years and was predominantly male and outpatient and had onset of illness in the second decade, illness duration more than 10 years, and moderate-to-severe OCD. Pooled remission rate was 53% (95% CI, 42%-65%). Prospective studies showed higher pooled remission rate than retrospective studies (55% [95% CI, 45%-65%] vs 50% [95% CI, 27%-73%], P < .001). Indian studies showed higher pooled remission rate than others (71% [95% CI, 59%-83%] vs 48% [95% CI, 37%-59%], P < .001). Age at onset (t = -7.08, P = .019), illness duration (t = -8.13, P = .015), baseline YBOCS score (t = -6.81,P = .021), and male gender (t = -5.92, P = .027) had significant negative association with remission on meta-regression.
Conclusion:
A high long-term remission rate found in this meta-analysis is contrary to generally held beliefs about poor outcome of individuals with OCD. Multicenter, prospective, long-term studies should systematically examine course and outcome in larger samples, emphasizing symptomatic and functional recovery.
Objective:
To examine the relationship of borderline personality disorder (BPD) to mood disorders by using data from the Collaborative Longitudinal Personality Disorders Study on the reciprocal interactions of BPD with both depressive and bipolar disorders over the course of 10 years.
Method:
The study included 223 BPD patients with DSM-IV-defined co-occurring major depressive disorder (MDD) (n = 161), bipolar I disorder (n = 34), and bipolar II disorder (n = 28) who were reliably and prospectively assessed over a period of 10 years between 1997 and 2009. Proportional hazards regression analyses were used to assess the effects of improvement or worsening of BPD and mood disorders on each disorder's time to remission and time to relapse.
Results:
Borderline personality disorder and MDD had strong and statistically significant reciprocal effects, delaying each disorder's time to remission (BPD's effect on MDD, P = .0004; MDD's effect on BPD, P = .0002) and accelerating time to relapse (BPD's effect on MDD, P = .0410; MDD's effect on BPD, P = .0011), whereas BPD and the bipolar disorders were largely independent disorders except that bipolar II lengthened BPD's time to remission (P = .0085).
Conclusions:
Borderline personality disorder and MDD interactions suggest overlap in their psychopathologies and argue for prioritizing the treatment of BPD. Borderline personality disorder and bipolar disorders appear to be independent disorders, underscoring the need to provide appropriate treatment for each.
The present chapter will critically review the available research on the role of Comorbid Personality Disorders (CPDs) in Obsessive-Compulsive Disorder (OCD).
The first section will cover evidence on the prevalence of concurrent axis II conditions in OCD. There is a variety among studies in the reported findings on this topic, with some studies indicating such prevalence as high as 88% and other as low as 9% (Black et al., 1993; Pigott et al., 1994). Such inconsistency may be attributed to both theoretical and methodological variations across studies. Many studies differ in terms of theoretical definition of personality psychopathology (focus on personality dimensions vs. CPD diagnoses), instruments for CPD assessment (semi-structured interviews vs. self-report measures), research designs (cross-sectional vs. longitudinal), sample selection (inpatient vs. outpatient samples), focus on specific CPDs rather than number of CPDs.
This section will also systematically review research on demographic and clinical features related to OCD with CPDs. For example, consistent findings suggested that OCD patients with CPDs tend to be to a higher extent impaired in overall functioning (Denys et al., 2004). Conversely, contradictory results have been found on the association between OCD severity and CPDs, with some studies showing a significant association (Aubuchon & Malatesta, 1994) and other not (Matsunaga et al., 1998).
This section will also focus on moderators of the association between OCD and specific CPDs. For example, a greater rigidity was found to mediate the relation between OCD severity and Obsessive-Compulsive Personality Disorder (OCPD) (Wetterneck et al., 2011).
The second section of the chapter will cover research on the prognostic role of CPDs in the outcome of cognitive-behavioural therapy (CBT) for OCD. The role of CPDs in OCD outcome raises questions on the necessity to adapt treatment planning to the comorbid status.
A noticeable body of research indicated that the presence of CPDs may be associated with a poorer prognosis for CBT (Keeley et al., 2008). However, not all studies consistently found such association. Variations across studies could explain such inconsistency (Dreessen & Arntz, 1998). Some studies assessed personality psychopathology as traits and other as categorical CPD diagnoses. Moreover, the role of CPDs will be critically reviewed in relation to differences across trials in terms of treatment formats (for example low vs. high intensity treatments) or therapeutic components. Consistently, some evidence showed that OCD patients with CPDs may benefit from augmentation treatments, like a time-intensive CBT format (Dèttore et al., 2013).
Personality factors that negatively impact treatment could also be specific to some CPDs. Recent trials focused on specific CPDs or personality traits, with some results indicating OCPD and schizotypal traits as predictors of non-response (Moritz et al., 2004; Pinto et al., 2011). A greater perfectionism and a poorer insight could account for such negative outcome of OCPD and schizotypal personality respectively. These findings may underline symptom patterns that could be targeted by tailored interventions.
In conclusion, starting from all the available evidence on CPDs in OCD, implications for clinical practice and directions for future research will be highlighted.
Accessible summary
Borderline Personality Disorder (BPD) is a complex disorder that is difficult to treat. Five psychotherapeutic approaches are used in the management of BPD. These include cognitive behavioural therapy, mentalization‐based therapy, schema‐focused therapy, transference‐focused therapy and dialectical behaviour therapy (DBT). Of the five approaches used to manage BPD, DBT has been studied the most extensively.
Dialectical behaviour therapy (DBT) is a multi‐pronged approach comprising of skills‐based training, individual psychotherapy, telephone calls and consultation team meetings.
DBT can have a positive effect on therapists, shifting therapeutic pessimism towards one of optimism with DBT therapists also describing personal changes resulting from their work with clients.
A considerable number of trials have been conducted as DBT was developed in the early 1990s, and most support the usefulness of BPD in the treatment of BPD. However, two Cochrane reviews conclude that more research is needed to provide stronger evidence in support of DBT for the management of BPD.
Abstract
Borderline personality disorder ( BPD ) is a complex disorder that is difficult to treat. However, dialectical behaviour therapy ( DBT ), developed by D r. M arsha L inehan in the early 1990s, has emerged as a promising treatment option for those diagnosed with BPD . DBT is a multi‐pronged treatment approach delivered normally in outpatient settings over 12 months and requires highly skilled and trained therapists. Many trials have provided evidence to support the use of DBT in the treatment of BPD . However, outcome measures vary and are mostly limited to measurable behavioural outcomes such as incidences of deliberate self‐harm or suicidal thoughts. Two recent C ochrane reviews conclude that DBT does benefit those with BPD , but more robust evidence is needed. DBT training for health care professionals also has the potential to shift health care professionals' attitudes from one of therapeutic pessimism to one of optimism.
Obsessive-compulsive disorder (OCD) is a heterogeneous and disabling condition; however, no studies have examined symptom categories or subtypes as predictors of long-term clinical course in adults with primary OCD.
A total of 213 adults with DSM-IV OCD were recruited from several mental health treatment sites between July 2001 and February 2006 as part of the Brown Longitudinal Obsessive Compulsive Study, a prospective, naturalistic study of treatment-seeking adults with primary OCD. OCD symptoms were assessed annually over the 5-year follow-up period using the Longitudinal Interval Follow-Up Evaluation.
Thirty-nine percent of participants experienced either a partial (22.1%) or a full (16.9%) remission. Two OCD symptom dimensions impacted remission. Participants with primary obsessions regarding overresponsibility for harm were nearly twice as likely to experience a remission (P < .05), whereas only 2 of 21 participants (9.5%) with primary hoarding achieved remission. Other predictors of increased remission were lower OCD severity (P < .0001) and shorter duration of illness (P < .0001). Fifty-nine percent of participants who remitted subsequently relapsed. Participants with obsessive-compulsive personality disorder were more than twice as likely to relapse (P < .005). Participants were also particularly vulnerable to relapse if they experienced partial remission versus full remission (70% vs 45%; P < .05).
The contributions of OCD symptom categories and comorbid obsessive-compulsive personality disorder are critically important to advancing our understanding of the prognosis and ultimately the successful treatment of OCD. Longer duration of illness was also found to be a significant predictor of course, highlighting the critical importance of early detection and treatment of OCD. Furthermore, having full remission as a treatment target is an important consideration for the prevention of relapse in this disorder.
Presents a review of the literature on patterns of intelligence, rigidity and age, tolerance of ambiguity, creativity, extremity ratings, and inductive vs deductive reasoning in obsessional neurosis or obsessional personality. A theory of obsessional thinking based on G. H. Kelly's theory of personality constructs is presented, and suggestions for therapy are noted. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Avoidant personality disorder (AvPD) has a high level of symptom overlap and comorbidity with generalized social anxiety disorder (GSAD). We examined whether the presence of comorbid AvPD adds significant clinically relevant information for individuals seeking treatment for GSAD. Results suggested that AvPD was significantly associated with poorer quality of life and greater disability in univariate, but not multivariate analyses. Endorsement of more AvPD symptoms was associated with increased disability, increased risk of intimacy, and lower social support, even after covariate adjustment. Specifically, AvPD item 3, hard to be "open" even with people you are close to, was most strongly correlated with quality of life and disability. A binary diagnosis of AvPD alone adds little beyond a marker of greater GSAD severity and depression among patients with GSAD, while a specific feature of AvPD not captured by the GSAD diagnosis, namely emotional guardedness, may be associated with greater impairment.
Objectives:
There are ongoing uncertainties in the relationship between obsessive-compulsive disorder (OCD) and obsessive-compulsive personality disorder (OCPD). This study aimed to test the proposition that OCPD may be a marker of severity of OCD by comparing groups of OCD individuals with and without OCPD on a number of variables.
Method:
A total of 148 adults with a principal diagnosis of OCD were administered the Mini International Neuropsychiatric Interview, Yale-Brown Obsessive-Compulsive Scale, Sheehan Disability Scale, Vancouver Obsessional Compulsive Inventory and Symptom Checklist 90-Revised. Participants with a DSM-IV diagnosis of OCPD were compared with those without OCPD.
Results:
Some 70 (47.3%) participants were diagnosed with OCPD. The groups of participants with and without OCPD did not differ significantly with respect to any of the demographic variables, clinician-rated severity of OCD, levels of disability and mean age of onset of OCD. All self-rated OCD symptom dimensions except for contamination and checking were significantly more prominent in participants with OCPD, as were all self-rated dimensions of psychopathology. Participants with OCPD had significantly more frequent hoarding compulsions and obsessions involving a need to collect and keep objects. Of Axis I disorders, only panic disorder was significantly more frequent in participants with OCPD than in those without OCPD.
Conclusions:
A high frequency of OCPD among individuals with OCD suggests a strong, although not necessarily a unique, relationship between the two conditions. This finding may also be a consequence of the blurring of the boundary between OCD and OCPD by postulating that hoarding and hoarding-like behaviours characterise both disorders. Results of this study do not support the notion that OCD with OCPD is a marker of clinician-rated severity of OCD. However, individuals with OCPD had more prominent OCD symptoms, they were more distressed and exhibited various other psychopathological phenomena more intensely, which is likely to complicate their treatment.
Comorbid obsessive-compulsive personality disorder (OCPD) is well-described in obsessive-compulsive disorder (OCD). It remains unclear, however, whether OCPD in OCD represents a distinct subtype of OCD or whether it is simply a marker of severity in OCD.
The aim of this study was to compare a large sample of OCD subjects (n=403) with and without OCPD on a range of demographic, clinical and genetic characteristics to evaluate whether comorbid OCPD in OCD represents a distinct subtype of OCD, or is a marker of severity.
Our findings suggest that OCD with and without OCPD are similar in terms of gender distribution and age at onset of OC symptoms. Compared to OCD-OCPD (n=267, 66%), those with OCD+OCPD (n=136, 34%) are more likely to present with the OC symptom dimensions which reflect the diagnostic criteria for OCPD (e.g., hoarding), and have significantly greater OCD severity, comorbidity, functional impairment, and poorer insight. Furthermore there are no differences in distribution of gene variants, or response to treatment in the two groups.
The majority of our findings suggest that in OCD, patients with OCPD do not have a highly distinctive phenomenological or genetic profile, but rather that OCPD represents a marker of severity.
Although psychiatric comorbidity is common among patients with anxiety disorders, its impact on treatment outcome remains unclear. The present study used meta-analytic techniques to examine the relationship between diagnostic comorbidity and treatment outcome for patients with anxiety disorders. One hundred forty-eight anxiety-disordered treatment samples (combined N=3534) were examined for post-treatment effects from the PsychINFO database. Samples consisted of those exposed to both active (CBT, dynamic therapy, drug treatment, CBT+drug treatment, mindfulness) and inactive treatments (placebo/attention control, wait-list). All treatments were associated with significant improvement at post-treatment, and active treatments were associated with greater effects than were inactive treatments. However, overall comorbidity was generally unrelated to effect size at post-treatment or at follow-up. A significant negative relationship between overall comorbidity and treatment outcome was found for mixed or "neurotic" anxiety samples when examining associations between comorbidity and specific diagnoses. Conversely, there was a significant positive relationship between overall comorbidity and treatment outcome for panic disorder and/or agoraphobia and PTSD or sexual abuse survivors. These findings suggest that while diagnostic comorbidity may not impact the effects of specific anxiety disorder treatments, it appears to differentially impact outcome for specific anxiety disorder diagnoses.
The present study examined whether the comorbidity of obsessive-compulsive personality disorder (OCPD) and obsessive-compulsive disorder (OCD) constitute a specific subtype of OCD. The study sample consisted of 146 consecutive outpatients with a DSM-IV diagnosis of OCD. Diagnoses were established using MINI, IPDE, YBOCS and YBOCS-SC. OCD patients with comorbid OCPD were compared with OCD patients without OCPD on various sociodemographic and clinical variables. Almost one third of the OCD subjects met criteria for comorbid OCPD. OCD+OCPD patients had a significantly earlier age at onset of initial OC symptoms, earlier age at onset of OCD and more obsessions and compulsions than pure obsessions compared to the patients with OCDOCPD. OCD+OCPD patients also had a higher rate of comorbidity with avoidant personality disorder and showed more impairment in global functioning. There were not differences between the two sub-groups on severity of OCD symptoms and also on type of OCD onset. Our results indicate that the comorbidity of OCD with OCPD is associated with a number of specific clinical characteristics of OCD. These findings in conjunction with of current clinical, family and genetic studies provide some initial evidence that OCD comorbid with OCPD constitute a specific subtype of OCD.
Available evidence about the relationship between poor insight and other clinical characteristics in patients with obsessive-compulsive disorder (OCD) is inconclusive and conflicting. There is also a paucity of data on the long-term course and treatment outcome of OCD patients with poor insight. The present study reports the findings of a relatively large sample (n=106) of outpatients fulfilling DSM-IV criteria for OCD, treated with serotonin reuptake inhibitors (SRIs) and prospectively followed up for 3 years. Baseline information was collected on demographic and clinical characteristics, using standardized instruments. Insight was assessed by means of the Brown Assessment of Beliefs Scale (BABS). Eighty-three patients were followed prospectively and evaluated systematically by validated measures of psychopathology. Compared to their good insight counterparts, the OCD patients with poor insight (22%) showed a greater severity of obsessive-compulsive and depressive symptomatology; an earlier age at onset; a higher rate of schizophrenia spectrum disorder in their first-degree relatives; a higher comorbidity with schizotypal personality disorder. During the follow-up period, poor insight OCD patients were less likely to achieve at least a partial remission of obsessive-compulsive symptoms; required a significantly greater number of therapeutic trials; received more frequently augmentation with antipsychotics. The results suggest that the specifier "poor insight" helps to identify a subgroup of patients at the more severe end of OCD spectrum, characterized by a more complex clinical presentation, a diminished response to standard pharmacological interventions, and a poorer prognosis. Further research is needed to identify alternative strategies for the management of these patients.
The Yale-Brown Obsessive Compulsive Scale was designed to remedy the problems of existing rating scales by providing a specific measure of the severity of symptoms of obsessive-compulsive disorder that is not influenced by the type of obsessions or compulsions present. The scale is a clinician-rated, 10-item scale, each item rated from 0 (no symptoms) to 4 (extreme symptoms) (total range, 0 to 40), with separate subtotals for severity of obsessions and compulsions. In a study involving four raters and 40 patients with obsessive-compulsive disorder at various stages of treatment, interrater reliability for the total Yale-Brown Scale score and each of the 10 individual items was excellent, with a high degree of internal consistency among all item scores demonstrated with Cronbach's alpha coefficient. Based on pretreatment assessment of 42 patients with obsessive-compulsive disorder, each item was frequently endorsed and measured across a range of severity. These findings suggest that the Yale-Brown Scale is a reliable instrument for measuring the severity of illness in patients with obsessive-compulsive disorder with a range of severity and types of obsessive-compulsive symptoms.
The Longitudinal Interval Follow-up Evaluation (LIFE) is an integrated system for assessing the longitudinal course of psychiatric disorders. It consists of a semistructured interview, an Instruction booklet, a coding sheet, and a set of training materials. An interviewer uses the LIFE to collect detailed psychosocial, psychopathologic, and treatment information for a six-month follow-up interval. The weekly psychopathology measures ("psychiatric status ratings") are ordinal symptom-based scales with categories defined to match the levels of symptoms used in the Research Diagnostic Criteria. The ratings provide a separate, concurrent record of the course of each disorder initially diagnosed in patients or developing during the follow-up. Any DSM-III or Research Diagnostic Criteria disorder can be rated with the LIFE, and any length or number of follow-up intervals can be accommodated. The psychosocial and treatment information is recorded so that these data can be linked temporally to the psychiatric status ratings.
Examined the onset age distribution for first episodes of unipolar depression for men and women using 2,046 Ss (aged 18–88 yrs) selected for a diagnostic interview on the basis of elevated scores on the Center for Epidemiological Studies Depression Scale. Of those Ss interviewed, 1,012 were diagnosed as having suffered from a previous episode of depression. The Life Table method (S. Anderson et al [1980]; J. D. Kalbfeisch and R. L. Prentice [1980]) was used to describe the risks associated with different ages for developing an initial episode of depression. The results indicate that the hazard rates are very low through age 14 yrs, increase during adolescence (15–29 yrs) and young adulthood (20–24 yrs), peak between 45 and 55 yrs, and then decrease with increasing age, becoming zero at 80 yrs or older. The hazard rates for men and women differed, with women between the ages of 9 and 69 yrs having higher hazard rates than men between the same ages. The average age at onset for first episodes of depression for men and women did not differ. (53 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
While the Hamilton Rating Scale for Depression (HRSD) has been the standard instrument for the assessment of the severity of depression for many years, this scale has a number of limitations. We developed the Modified Hamilton Rating Scale for Depression (MHRSD) to overcome some of these limitations and to enable paraprofessional research assistants to make reliable and valid assessments of depressive symptoms. The present study investigates the reliability and validity of the MHRSD. Interrater reliability among paraprofessional research assistants was excellent. The relationship between the MHRSD and expert clinician ratings on the MHRSD and the original HRSD was also high. Thus, the MHRSD appears to be a useful addition to the clinical researcher's assessment battery.
The LIFE-UP, an instrument for prospectively following course for psychiatric disorders, has been extended to include Psychiatric Status Ratings (PSRs) for the DSM-III-R anxiety disorders panic (with and without agoraphobia), agoraphobia without panic, generalized anxiety disorder, social phobia, and simple phobia. This paper reports data on the reliability and validity of the LIFE-UP as used in the Harvard/Brown Anxiety Disorders Research Program. We found generally good reliability for the PSRs, both inter-rater and long-term test-retest. The reliability coefficients for the rater-administered instruments were very similar to those for the self-reports, suggesting that a large proportion of the variance was due to subject variability rather than rater variability. Reliability for the beginning of the year of follow-up was very similar to that for the time just before the interview. In addition, correlations with other measures of psychosocial function or anxiety symptomatology provided evidence for the external validity of the PSRs as measures of psychiatric morbidity.
The present study examined a group of patients who have obsessive compulsive disorder (OCD) and certain comorbid personality disorders to provide data on types of clinical problems that complicate treatment. Data are presented on patient response to a comprehensive behavior therapy.
Forty-one consecutively referred, adult, nonpsychotic patients with OCD were evaluated independently by their attending psychiatrist and a consulting psychologist for presence of DSM-III-R personality disorder. Thirty-one of these patients, for whom there was 100% agreement on presence or absence of a comorbid personality disorder, participated in a course of comprehensive behavior therapy. OCD patients with comorbid personality disorder (OCD+PD) were compared with a group of OCD patients without comorbid personality disorder (nonPD OCD) on pretreatment and treatment-related variables.
There was significantly high interrater reliability between psychiatrist and psychologist on diagnosis of personality disorder (p < .001). OCD+PD patients demonstrated poorer response to prior psychiatric treatments and greater psychosocial and psychiatric impairment at pretreatment than did nonPD OCD patients. The OCD+PD patients demonstrated a moderate response to comprehensive behavior therapy, but below that of nonPD OCD patients. OCD+PD patients were also rated as more difficult to treat, required more psychiatric hospitalizations during treatment, and were more likely to terminate behavior therapy prematurely than were nonPD OCD patients.
In modest samples of OCD+PD patients (N = 26), and nonPD OCD patients (N = 5), this study found that OCD patients with personality disorder had greater psychopathology, fewer coping and living skills, and were more resistant to psychiatric treatment than the nonPD OCD patients. In addition, when treated with a comprehensive behavior therapy that focuses on other clinical problems in addition to the OCD symptoms, the OCD+PD patients had an enhanced response to treatment.
The Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q) is a self-report measure designed to enable investigators to easily obtain sensitive measures of the degree of enjoyment and satisfaction experienced by subjects in various areas of daily functioning. The summary scores were found to be reliable and valid measures of these dimensions in a group of depressed outpatients. The Q-LES-Q measures were related to, but not redundant with, measures of overall severity of illness or severity of depression within this sample. These findings suggest that the Q-LES-Q measures may be sensitive to important differences among depressed patients that are not detected by the measures usually employed.
This study examined whether categorical or dimensional personality disorder variables affected treatment outcome in a sample of 52 patients with obsessive compulsive disorder who followed a standardized cognitive behavior therapy program. Treatment consisted of 12 weekly sessions and was completed by 43 patients. The Structured Clinical Interview for DSM-III-R personality disorders (SCID-II) was taken before the start of treatment by an independent rater. The treatment outcome measures included questionnaires and a Behavioral Assessment Test. Measurements were taken before and after treatment, and at 1 and 6 month follow-up tests. After the first follow-up test, further treatment was provided if clinically indicated. Neither categorical, nor dimensional personality disorder variables affected treatment outcome significantly. The inclusion of drop-outs in the analyses, did not change these results. Therefore, patients with obsessive compulsive disorder and concomitant personality disorder pathology should not be excluded from cognitive or behavior therapy for their obsessive compulsive complaints. Attributing therapy failure to concomitant Axis II pathology should be approached with caution.
A total of 75 patients with obsessive-compulsive disorder (OCD) were studied in order to investigate the characteristics of OCD symptoms and the comorbidity of personality disorders (PD). Contamination obsessions and checking compulsions were most commonly found in patients, of whom 53% met the criteria for at least one PD. Among comorbid PD, the anxious-fearful (cluster C) PDs, such as avoidant, obsessive-compulsive and dependent PD, were most prevalent, followed by the odd-eccentric (cluster A) PDs, such as paranoid and schizotypal PD. The patients with PD had more severe social maladaptation and concurrent depressive and anxious symptoms than the patients without any PD, despite the similar severity of OCD symptoms. These results are consistent with those reported in the Western world, and are considered to be relatively stable cross-culturally.
The recurrence of an affective disorder in people who initially recover from major depressive disorder was characterized by using the unique longitudinal prospective follow-up data from the National Institute of Mental Health Collaborative Program on the Psychobiology of Depression-Clinical Studies.
Up to 15 years of prospective follow-up data on the course of major depressive disorder were available for 380 subjects who recovered from an index episode of major depressive disorder and for 105 subjects who subsequently remained well for at least 5 years after recovery. Baseline demographic and clinical characteristics were examined as predictors of recurrence of an affective disorder. The authors also examined naturalistically applied antidepressant therapy.
A cumulative proportion of 85% (Kaplan-Meier estimate) of the 380 recovered subjects experienced a recurrence, as did 58% (Kaplan-Meier estimate) of those who remained well for at least 5 years. Female sex, a longer depressive episode before intake, more prior episodes, and never marrying were significant predictors of a recurrence. None of these or any other characteristic persisted as a predictor of recurrence in subjects who recovered and were subsequently well for at least 5 years. Subjects reported receiving low levels of antidepressant treatment during the index episode, which further decreased in amount and extent during the well interval.
Few baseline demographic or clinical characteristics predict who will or will not experience a recurrence of an affective disorder after recovery from an index episode of major depressive disorder, even in persons with lengthy well intervals. Naturalistically applied levels of antidepressant treatment are well below those shown effective in maintenance pharmacotherapy studies.
Systematic studies of course of illness in obsessive-compulsive disorder (OCD) using standardized diagnostic criteria are relatively rare. In the present study, 100 patients diagnosed with OCD were prospectively followed for up to 5 years. Other comorbid conditions included anxiety disorders (76%), major depressive disorder (33%), and at least one personality disorder (33%), mainly in the anxious cluster. Approximately 20% of patients had full remission and 50% had partial remission during follow-up. Significant predictors of partial remission included being married and having lower global severity scores at intake; the presence of major depression was marginally predictive of poorer course. Adequate serotonergic medication was associated with worse course, but findings are likely spurious. Only marital status and global severity were retained as predictors in a final regression model. Findings are discussed with regard to sample characteristics and similarity to other reports on predictors of course and of treatment outcome.