The prevalence, age distribution and comorbidity of personality disorders in Australian women

OBJECTIVE: We aimed to describe the prevalence and age distribution of personality disorders and their comorbidity with other psychiatric disorders in an age-stratified sample of Australian women aged ⩾25 years. METHODS: Individual personality disorders (paranoid, schizoid, schizotypal, histrionic, narcissistic, borderline, antisocial, avoidant, dependent, obsessive-compulsive), lifetime mood, anxiety, eating and substance misuse disorders were diagnosed utilising validated semi-structured clinical interviews (Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Research Version, Non-patient Edition and Structured Clinical Interview for DSM-IV Axis II Personality Disorders). The prevalence of personality disorders and Clusters were determined from the study population (n = 768), and standardised to the Australian population using the 2011 Australian Bureau of Statistics census data. Prevalence by age and the association with mood, anxiety, eating and substance misuse disorders was also examined. RESULTS: The overall prevalence of personality disorders in women was 21.8% (95% confidence interval [CI]: 18.7, 24.9). Cluster C personality disorders (17.5%, 95% CI: 16.0, 18.9) were more common than Cluster A (5.3%, 95% CI: 3.5, 7.0) and Cluster B personality disorders (3.2%, 95% CI: 1.8, 4.6). Of the individual personality disorders, obsessive-compulsive (10.3%, 95% CI: 8.0, 12.6), avoidant (9.3%, 95% CI: 7.1, 11.5), paranoid (3.9%, 95% CI: 3.1, 4.7) and borderline (2.7%, 95% CI: 1.4, 4.0) were among the most prevalent. The prevalence of other personality disorders was low (⩽1.7%). Being younger (25-34 years) was predictive of having any personality disorder (odds ratio: 2.36, 95% CI: 1.18, 4.74), as was being middle-aged (odds ratio: 2.41, 95% CI: 1.23, 4.72). Among the strongest predictors of having any personality disorder was having a lifetime history of psychiatric disorders (odds ratio: 4.29, 95% CI: 2.90, 6.33). Mood and anxiety disorders were the most common comorbid lifetime psychiatric disorders. CONCLUSIONS: Approximately one in five women was identified with a personality disorder, emphasising that personality disorders are relatively common in the population. A more thorough understanding of the distribution of personality disorders and psychiatric comorbidity in the general population is crucial to assist allocation of health care resources to individuals living with these disorders.

Should personality traits be considered when refining substance misuse treatment programs?

The interplay between stable personality characteristics and environmental factors is emphasised in most contemporary approaches to individual differences. This interaction appears to be important in understanding the development of substance use and misuse. Impulsivity related personality traits such as sensation-seeking, novelty seeking, reward-sensitivity and behavioural disinhibition, are strongly linked to adolescent and adult substance use and misuse. The role of anxiety-related traits, in the development of substance misuse is less clear. Nonetheless, anxiety disorders are very common amongst adult substance misusers and almost certainly play a critical role in the maintenance of a substance use disorder and influence treatment effectiveness. The data suggest that personality influences treatment outcomes and yet these individual differences are generally not addressed in treatment. We argue in this review that interventions which are matched to these relevant personality traits may improve treatment outcomes for substance misusers. [Staiger PK, Kambouropoulos N, Dawe S. Should personality traits be considered when refining substance misuse treatment programs?

Readiness for treatment in high risk offenders with personality disorders

Low engagement and non-completion of therapeutic interventions are important issues in the treatment and rehabilitation of offenders and mentally disordered offenders. Such factors influence a range of outcomes, including the reduction of clinical and criminogenic needs. In this paper it is proposed that low engagement and non-completion are usefully viewed as a consequence of low readiness for treatment. The dimensions of readiness are summarized (from the Multifactor Offender Readiness Model) and applied to high risk offenders with severe personality disorders. A readiness analysis has implications for the assessment and treatment of this patient/offender population and is useful in identifying future research and clinical priorities.

Vulnerable dark triad personality facets are associated with religious fundamentalist tendencies

BACKGROUND: This study explores the possibility that religious fundamentalism (RF) may be linked to deficits in personality structure, which is in contrast to the general assumption that religiosity and spirituality are positively related to mature personality development. SAMPLING AND METHODS: To test this hypothesis, 327 (232 female) college students completed the Multidimensional Inventory for Religious/Spiritual Well-Being together with the Innsbrucker Religious Fundamentalism Scale. In addition, the 'vulnerable dark triad' of personality ('vulnerable narcissism', subscale of the Pathological Narcissism Inventory; 'secondary psychopathy', subscale of Levenson's Self-Report Psychopathy Scale; 'borderline personality', of the Borderline Personality Inventory) was assessed. RESULTS: In general, the relation between spirituality and healthy personality functioning was confirmed. In addition to greatly overlapping with 'general religiosity' (p < 0.001), RF was also relevantly predicted by narcissistic ('hiding the self') and borderline ('primitive defenses') personality facets (p < 0.05 for both). CONCLUSIONS: Based on these preliminary data, we conclude that specific structural deficits in personality might lead to more rigorous variants of religious/spiritual beliefs such as RF. Further research in clinical surroundings as well as in religious extremist groups is recommended.

Persistence and subtype stability of ADHD among substance use disorder treatment seekers

OBJECTIVE: To examine ADHD symptom persistence and subtype stability among substance use disorder (SUD) treatment seekers. METHOD: In all, 1,276 adult SUD treatment seekers were assessed for childhood and adult ADHD using Conners' Adult ADHD Diagnostic Interview for Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; CAADID). A total of 290 (22.7%) participants met CAADID criteria for childhood ADHD and comprise the current study sample. RESULTS: Childhood ADHD persisted into adulthood in 72.8% (n = 211) of cases. ADHD persistence was significantly associated with a family history of ADHD, and the presence of conduct disorder and antisocial personality disorder. The combined subtype was the most stable into adulthood (78.6%) and this stability was significantly associated with conduct disorder and past treatment of ADHD. CONCLUSION: ADHD is highly prevalent and persistent among SUD treatment seekers and is associated with the more severe phenotype that is also less likely to remit. Routine screening and follow-up assessment for ADHD is indicated to enhance treatment management and outcomes.

The effect of Shamanic-like stimulus conditions and the cognitive-perceptual factor of schizotypy on phenomenology

Shamanism has remained an integral part of indigenous healing rituals since ancient times and is currently attracting interest as a complementary therapeutic technique in psychology. Recently, shamanic-like techniques have been used to facilitate changes in the phenomenology of nonshamans. However, such research has largely been delimited to a single shamanic-like technique (i.e., drumming), and the role of personality traits with regards to receptivity to this technique has been neglected. The purpose of the present study was to investigate experimentally the effect of different shamanic-like techniques and the cognitive-perceptual factor of the schizotypy construct on phenomenology. One hundred and four non-shamans were randomly assigned to one of three conditions: Drumming, Ganzfeld, or Sitting Quietly with Eyes Open. Participants' phenomenology was assessed using the Phenomenology of Consciousness Inventory, Phenomenology associated with shamanic-like techniques appeared to be statistically significantly different from phenomenology associated with sitting quietly with eyes open. Furthermore, high cognitive-perceptual participants reported significant alterations in phenomenology compared to their low cognitive-perceptual counterparts. Methodological shortcomings of the present study are discussed and suggestions for future research are advanced.

Implications for the prevention of aggressive behavior within psychiatric hospitals drawn from interpersonal communication theory

Although interpersonal style is a defining feature of personality and personality disorder and is commonly identified as an important influence on aggressive behavior, treatment completion, and the development of an effective therapeutic alliance, it is rarely considered in practice guidelines for preventing, engaging, and managing patients at risk of aggression. In this article, the authors consider three potential applications of interpersonal theory to the care and management of patients at risk of aggression during hospitalization: (a) preventing aggression through theoretically grounded limit setting and de-escalation techniques, (b) developing and using interventions to alter problematic interpersonal styles, and (c) understanding therapeutic ruptures and difficulties establishing a therapeutic alliance. Interpersonal theory is proposed to offer a unifying framework that may assist development of intervention and management strategies that can help to reduce the occurrence of aggression in institutional settings.

The relationship between suicide and violence in schizophrenia: analysis of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) dataset

Background

Suicide and violence often co-occur in the general population as well as in mentally ill individuals. Few studies, however, have assessed whether these suicidal behaviors are predictive of violence risk in mental illness.

Aims

The aim of this study is to investigate whether suicidal behaviors, including suicidal ideation, threats, and attempts, are significantly associated with increased violence risk in individuals with schizophrenia.

Method

Data for these analyses were obtained from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) trial, a randomized controlled trial of antipsychotic medication in 1460 adults with schizophrenia. Univariate Cox regression analyses were used to calculate hazard ratios (HRs) for suicidal ideation, threats, and attempts. Multivariate analyses were conducted to adjust for common confounding factors, including: age, alcohol or drug misuse, major depression, antisocial personality disorder, depression, hostility, positive symptom, and poor impulse control scores. Tests of discrimination, calibration, and reclassification assessed the incremental predictive validity of suicidal behaviors for the prediction of violence risk.

Results

Suicidal threats and attempts were significantly associated with violence in both males and females with schizophrenia with little change following adjustment for common confounders. Only suicidal threats, however, were associated with a significant increase in incremental validity beyond age, diagnosis with a comorbid substance use disorder, and recent violent behavior.

Conclusions

Suicidal threats are independently associated with violence risk in both males and females with schizophrenia, and may improve violence risk prediction.

Predictors of outcomes of psychological treatments for disordered gambling : a systematic review

This systematic review aimed to synthesise the evidence relating to pre-treatment predictors of gambling outcomes following psychological treatment for disordered gambling across multiple time-points (i.e., post-treatment, short-term, medium-term, and long-term). A systematic search from 1990 to 2016 identified 50 articles, from which 11 socio-demographic, 16 gambling-related, 21 psychological/psychosocial, 12 treatment, and no therapist-related variables, were identified. Male gender and low depression levels were the most consistent predictors of successful treatment outcomes across multiple time-points. Likely predictors of successful treatment outcomes also included older age, lower gambling symptom severity, lower levels of gambling behaviours and alcohol use, and higher treatment session attendance. Significant associations, at a minimum of one time-point, were identified between successful treatment outcomes and being employed, ethnicity, no gambling debt, personality traits and being in the action stage of change. Mixed results were identified for treatment goal, while education, income, preferred gambling activity, problem gambling duration, anxiety, any psychiatric comorbidity, psychological distress, substance use, prior gambling treatment and medication use were not significantly associated with treatment outcomes at any time-point. Further research involving consistent treatment outcome frameworks, examination of treatment and therapist predictor variables, and evaluation of predictors across long-term follow-ups is warranted to advance this developing field of research.

Benzodiazepine use of community-based violent offenders : a preliminary investigation

Objective: To explore the relationship between benzodiazepine use and violent crime in a sample of community-based offenders. Methods: Participants were recruited via drug diversion and treatment programs in Melbourne, Australia. Data regarding benzodiazepine and other substance use, mental health, personality characteristics, and crime involvement were collected through semistructured interviews conducted in 2011. Participants (n = 82, 79.3% male) were 21–56 years old, predominantly Australian-born (89%), with 14.6% identifying as Aboriginal or Torres Strait Islanders. Eligibility criteria were having been charged with a criminal offence in the previous six months and at least monthly benzodiazepine use. Group differences between violent (n = 11) and nonviolent offenders were assessed via independent samples t-tests (two-tailed) and nonparametric tests. Results: Individuals charged with violent index offences were significantly more likely to use higher average doses of alprazolam (p = 0.040) and exhibit benzodiazepine dependence (p = 0.037) as well as report high levels of sensation seeking, prior violence, and the diagnoses of depression and personality disorder than individuals charged with nonviolent index offences. Conclusions: The findings suggest the existence of a complex dynamic between mental health and violent offending that may be influenced by benzodiazepine use, in particular alprazolam. A core implication of these preliminary findings includes attending to the interpersonal skills and adaptive coping resources of violent offenders.

The association between parental personality patterns and internalising and externalising behaviour problems in children and adolescents

Background:  This study investigated the relationship between parental personality patterns and internalising and externalising behaviour problems in a clinically referred sample of children (aged 4–8) and adolescents (aged 12–18).

Methods:  Data from families involved in two clinical trials in Victoria, Australia were analysed (n = 59). Families were administered the Millons Clinical Multiaxial Inventory—III (MCMI-III) which reports personality patterns consistent with Axis II disorder and an Achenbach measure of mental health as appropriate to child's age (Child Behavior Checklist (CBCL), Youth Self-Report (YSR), or Adult Self-Report (ASR)). Relationships between internalising and externalising behaviour problems, and parental personality patterns were examined via correlation and regression analyses.

Results:  The study found a positive correlation between parental borderline, paranoid, and avoidant personality patterns, and child and adolescent externalising behaviour problems. The relationships were generally stronger for adolescents than for children. However, no relationship was observed between parental personality patterns and internalising behaviour problems.

Conclusions:  These findings underline the importance of clinical assessment of the family ecology as a whole—including the interaction between parental personality patterns and child and adolescent behaviour and emotional problems. These findings contribute to the understanding of developmental risk factors for child and adolescent mental health and the transmission of psychopathology across generations.

Origins of inflated responsibility in obsessive compulsive disorder

The pivotal role of inflated responsibility beliefs in the maintenance and treatment of obsessive-compulsive disorder (OCD) has been clearly demonstrated (Rachman, 1993; Salkovskis, 1998; Shafran, 1997; van Oppen & Arntz, 1994). Yet little is known about the origins of these beliefs, their contribution to a sense of inflated responsibility or the symptoms of OCD, or the contribution of personality to inflated responsibility and to OCD, The aims of this thesis were to investigate a model of the inter-relationships among the personality dimensions of neuroticism and psychoticism, inflated responsibility and OCD, and the origins of inflated responsibility to inflated responsibility and to OCD. In order to achieve these aims, a scale was developed to assess the origins of inflated responsibility based upon the five pathways proposed by Salkovskis, Shafran, Rachman, and Freeston (1999) and the additional domains of guilt, vigilance and thought-action fusion (Shafran, Thordarson, & Rachman, 1996; Shafran, Watkins & Charman, 1996; Tallis, 1994). Eighty-four participants with OCD (age M = 43.36) and 74 control participants (age M =37.14) volunteered to participate in the two studies of this thesis. The aim of Study 1 was to develop and validate a measure of the Origins of Inflated Responsibility (OIR). The results of the first study yielded a 25-ttem scale, the Origins of Inflated Responsibility Questionnaire (OIRQ) with five independent factors: responsibility, strictness, protection from responsibility, critical incidents, and peer blame which demonstrated both internal reliability and temporal stability over a 2-week period. In Study 2, participants also completed the Responsibility Attitudes Scale (Salkovskis, Wroe, Gledhill, Morrison, Forrester, Richards, ct al. (2000) (a measure of inflated responsibility), the Padua Inventory (Sanavio, 1988) (to measure of the symptoms of OCD)y and the Eysenck Personality Inventory-Revised (Eysenck & Eysenck, 1991). Multivariatc Analysis of Variance revealed that the OCD group scored higher on all variables than the control group except for strictness where the groups were not different, and psychoticism where the OCD group scored lower. A series of Multiple Regression analyses revealed that both group and the OIR contributed to inflated responsibility (R2 = .56). When all variables, OIR, inflated responsibility and neuroticism were entered as predictors of OCD, 60% of the variance in OCD was explained however, 49% of the variance was shared by the independent variables suggesting the presence of some underlying construct. Structural Equation Modelling, where all the constructs in the model were examined simultaneously, revealed that neuroticism contributed to the OIR, inflated responsibility and OCD. The OIR were also significant predictors of inflated responsibility and indirectly through inflated responsibility predictive of OCD. The OIR also directly predicted OCD and when the total effects are considered, their contribution was greater than the total effect for inflated responsibility alone. The results of these studies provide good support for the origins of inflated responsibility proposed by Salkovskis et al. (1999), as measured by the OIRQ developed for use in the current thesis. The results also support the contribution of inflated responsibility and neuroticism, as well as the OIR, to OCD, The large amount of variance shared by the OIR, inflated responsibility and neuroticism suggest that there might be some underlying construct, perhaps of a biopsychosocial nature, that requires further investigation for its role in the onset and maintenance of OCD. The clinical relevance of these findings is discussed in terms of early prevention strategies and interventions.

Subtypes of psychopathy : proposed differences between narcissistic, borderline, sadistic and antisocial psychopaths

Atascadero State Hospital (ASH) is a maximum-security forensic hospital that houses male patients with a wide range of psychiatric diagnoses. Psychopaths at this institution appear to be a heterogeneous group of individuals who, while sharing core personality characteristics, manifest substantial variability in their behavior. Identifying subtypes within this clinical classification can have implications for patient treatment and management, as well as for the safety of the staff who work with them and for the communities to which they will eventually return. Several means of identifying subtypes have been proposed in the literature, and potential subgroups have been identified. Clinical observations at ASH have suggested 4 possible subtypes of psychopathy: narcissistic, borderline, sadistic, and antisocial. Issues related to the conceptualization of psychopathy are addressed, recognizing that additional data are needed to understand the observed variations in cases of psychopathy.

Sensitivity to motivational cues in attention-deficit / hyperactivity disorder

This thesis examined a prediction of Reinforcement Sensitivity Theory regarding the association between personality traits and motivated behaviour and, whether reward-and-punishment sensitivity is associated with Attention-deficit / Hyperactivity disorder (ADHD). Results supported the predicted association between personality and motivated behaviour, but not the predicted association between reward-and-punishment sensitivity and ADHD.