Irish study on high-density schizophrenia families:field methods and power to detect linkage

Large samples of multiplex pedigrees will probably be needed to detect susceptibility loci for schizophrenia by linkage analysis. Standardized ascertainment of such pedigrees from culturally and ethnically homogeneous populations may improve the probability of detection and replication of linkage. The Irish Study of High-Density Schizophrenia Families (ISHDSF) was formed from standardized ascertainment of multiplex schizophrenia families in 39 psychiatric facilities covering over 90% of the population in Ireland and Northern Ireland. We here describe a phenotypic sample and a subset thereof, the linkage sample. Individuals were included in the phenotypic sample if adequate diagnostic information, based on personal interview and/or hospital record, was available. Only individuals with available DNA were included in the linkage sample. Inclusion of a pedigree into the phenotypic sample required at least two first, second, or third degree relatives with non-affective psychosis (NAP), one whom had schizophrenia (S) or poor-outcome schizo-affective disorder (PO-SAD). Entry into the linkage sample required DNA samples on at least two individuals with NAP, of whom at least one had S or PO-SAD. Affection was defined by narrow, intermediate, and broad criteria. The phenotypic sample contained 277 pedigrees and 1,770 individuals and the linkage sample 265 pedigrees and 1,408 individuals. Using the intermediate definition of affection, the phenotypic sample contained 837 affected individuals and 526 affected sibling pairs. Parallel figures for the linkage sample were 700 and 420. Individuals with schizophrenia from these multiplex pedigrees resembled epidemiologically sampled cases with respect to age at onset, gender distribution, and most clinical symptoms, although they were more thought-disordered and had a poorer outcome. Power analyses based on the model of linkage heterogeneity indicated that the ISHDSF should be able to detect a major locus that influences susceptibility to schizophrenia in as few as 20% of families. Compared to first-degree relatives of epidemiologically sampled schizophrenic probands, first-degree relatives of schizophrenic members from the ISHDSF had a similar risk for schizotypal personality disorder, affective illness, alcoholism, and anxiety disorder. With sufficient resources, large-scale ascertainment of multiplex schizophrenia pedigrees is feasible, especially in countries with catchmented psychiatric care and stable populations. Although somewhat more severely ill, schizophrenic members of such pedigrees appear to clinically resemble typical schizophrenic patients. Our ascertainment process for multiplex schizophrenia families did not select for excess familial risk for affective illness or alcoholism. With its large sample ascertained in a standardized manner from a relatively homogeneous population, the ISHDSF provides considerable power to detect susceptibility loci for schizophrenia.

A interface entre distúrbio obsessivo-compulsivo e esquizofrenia: Desafios da prática clínica

The article discusses the relationship between obsessive-compulsive disorder (OCD) and schizophrenia, based on the report of eight clinical cases. It describes and discusses cases of OCD with poor insight, obsessions that seem paranoid delusions or auditive hallucinations, OCD with transient psychotic reactions, OCD with schizotypal personality disorder and schizophrenia with obsessive-compulsive symptoms.

The significance of at-risk symptoms for psychosis in children and adolescents

The early detection and treatment of people at risk for psychosis is currently regarded as a promising strategy in fighting the devastating consequences of psychotic disorders. Currently, the 2 most broadly used sets of at-risk criteria, that is, ultra-high risk (UHR) and basic symptom criteria, were developed mainly in adult samples. We review the data regarding the presence and relevance of at-risk symptoms for psychosis in children and adolescents. The few existing studies suggest that attenuated psychotic symptoms (APS) and brief limited intermittent psychotic symptoms (BLIPS) do have some clinical relevance in young adolescents from the general population. Nevertheless, their differentiation from atypical psychotic symptoms or an emerging schizotypal personality disorder, as well as their stability and predictive accuracy for psychosis, are still unclear. Further, standard interviews for UHR criteria do not define a minimum age for the assessment of APS and BLIPS or guidelines as to when and how to include information from parents. APS and basic symptoms may be predictive of conversion to psychosis in help-seeking young adolescents. Nevertheless, the rate and timing, and thus the required observation time, need further study. Moreover, no study has yet addressed the issue of how to treat children and adolescents presenting with at-risk symptoms and criteria. Further research is urgently needed to examine if current at-risk criteria and approaches have to be tailored to the special needs of children and adolescents. A preliminary rationale for how to deal with at-risk symptoms for psychosis in clinical practice is provided.

Developing Psychosis and Its Risk States Through the Lens of Schizotypy

Starting from the early descriptions of Kraepelin and Bleuler, the construct of schizotypy was developed from observations of aberrations in nonpsychotic family members of schizophrenia patients. In contemporary diagnostic manuals, the positive symptoms of schizotypal personality disorder were included in the ultra high-risk (UHR) criteria 20 years ago, and nowadays are broadly employed in clinical early detection of psychosis. The schizotypy construct, now dissociated from strict familial risk, also informed research on the liability to develop any psychotic disorder, and in particular schizophrenia-spectrum disorders, even outside clinical settings. Against the historical background of schizotypy it is surprising that evidence from longitudinal studies linking schizotypy, UHR, and conversion to psychosis has only recently emerged; and it still remains unclear how schizotypy may be positioned in high-risk research. Following a comprehensive literature search, we review 18 prospective studies on 15 samples examining the evidence for a link between trait schizotypy and conversion to psychosis in 4 different types of samples: general population, clinical risk samples according to UHR and/or basic symptom criteria, genetic (familial) risk, and clinical samples at-risk for a nonpsychotic schizophrenia-spectrum diagnosis. These prospective studies underline the value of schizotypy in high-risk research, but also point to the lack of evidence needed to better define the position of the construct of schizotypy within a developmental psychopathology perspective of emerging psychosis and schizophrenia-spectrum disorders

Comorbidity of obsessive-compulsive disorder and personality disorders. A Brazilian controlled study

The aim of this study was to evaluate the presence of personality disorders (PDs) in 40 patients with obsessive-compulsive disorder (DSM-III-R criteria) from the Medical School of Botucatu (UNESP), Sao Paulo, Brazil. It is a case-control study. Patients were 24 women and 16 men, 16-68 years old, referred to our outpatient psychiatric service for treatment. Controls were 40 nonpsychiatric outpatients matched to the cases by sex, age and marital status. The instrument used was the Portuguese version of the Structured Interview for DSM-III-R Personality Disorders (SIDP-R). All interviews (n = 80) were made simultaneously by 2 raters, with independent scoring, so that the interrater reliability of the instrument could also be assessed (kappa statistics). The consensual axis II diagnoses in the OCD group were: avoidant (52.5%, κ = 0.80), dependent (40%, κ = 0.84), histrionic (20%, κ = 0.83), paranoid (20%, κ = 0.74), obsessive-compulsive (17.5%, κ = 0.86), narcissistic (7.5%, κ = 1.00), schizotypal (5%, κ = 0.65), passive-aggressive (5%, κ = 0.79) and self-defeating (5%, κ 0.55). At least one PD diagnosis was made in 70% of the patients, while only 6 controls had a PD diagnosis (p < 0.01). A great deal of diagnostic overlap was found in the OCD group (57.5% had two or more PDs), especially between avoidant and dependent PDs. The features of these two PDs may be secondary to the OCD. The study also suggests that there is not a close relationship between OCD and obsessive-compulsive personality disorder (OCPD). Patients with OCPD or even 3 or 4 O-C traits had significantly less insight into their obsessions and compulsions (p < 0.01).

Personality disorders and adult attachment dimensions in a mixed psychiatric sample: A multivariate study

The associations between personality disorders and adult attachment dimensions were assessed in a sample of 487 consecutively admitted psychiatric subjects. Canonical correlation analysis showed that two sets of moderately correlated canonical variates explained the correlations between personality disorders and adult attachment patterns. The first and second attachment variates closely resembled the avoidance and anxiety attachment dimensions, respectively. The first personality disorder variate was mainly characterized by avoidant, depressive, paranoid, and schizotypal personality disorders, whereas dependent, histrionic, and borderline personality disorders loaded on the second canonical variate. However, these linear combinations of personality disorders were different from those obtained from principal component analysis. The results extend previous studies linking personality disorders and attachment patterns and suggest the importance of focusing on specific constellations of symptoms associated with dimensions of insecurity.

The Influence of Borderline Personality Traits on the Course of Bipolar Disorder

Background and Aims: Bipolar disorder and borderline personality disorder are commonly comorbid. Borderline personality disorder is diagnosed categorically, but personality pathology may be better characterised dimensionally. The impact of borderline personality traits (not diagnosis) on the course of bipolar disorder is unknown. We examined the presence and severity of borderline personality traits in a large UK sample of bipolar disorder, and the impact of these traits on illness course. Methods: Borderline Evaluation of Severity over Time (BEST) was used to measure presence and severity of borderline traits in 1447 individuals with DSM-IV bipolar I disorder (n = 1008) and bipolar II disorder (n = 439) recruited into the Bipolar Disorder Research Network (www.bdrn.org). Clinical course was measured via semi-structured interview (Schedules for Clinical Assessment in Neuropsychiatry) and case-notes. Results: BEST score was higher in bipolar II than bipolar I (36 v 27, p < 0.001) and 9/12 individual BEST traits were significantly more common in bipolar II than bipolar I. Within both bipolar I and bipolar II higher BEST score was associated with younger age of bipolar onset (p < 0.001), history of alcohol misuse (p < 0.010), and history of suicide attempt (p < 0.001). Conclusions: Borderline personality traits are common in bipolar disorder, and more severe in bipolar II than bipolar I disorder. Borderline trait severity was associated with more severe bipolar illness course; younger age of onset, alcohol misuse and suicidal behaviour. Clinicians should be vigilant for borderline personality traits irrespective of whether criteria for diagnosis are met, particularly in those with bipolar II disorder and younger age of bipolar onset.

Pathologising difference, governing personality

Recent research has stressed the integral part played by teachers in both preliminary diagnosis and ongoing treatment of a range of conduct and personality disorders. Teachers are not only required to be aware of a variety of new categories of difference (Attention Deficit Disorder, Selective Mutism, Borderline Personality Disorder, Antisocial Personality Disorder, to name but a few), but are also now lauded for extending the role of education into new areas of social management. This paper will take issue with this understanding on two counts: first, teachers have always sought to mould the personalities of students, and the pathologisation of specific forms of conduct is simply a new tactic within a very old and familiar strategy. Second, schools do not simply discover disorders such as ADD as objective facts of nature. Rather, they are part of the process through which such differences are created, and by which individuals can be more effectively governed.

Personality, health and lifestyle in a questionnaire family study: A comparison between highly cooperative and less cooperative families

The effect of nonresponse on health and lifestyle measures has received extensive study, showing at most relatively modest effects. Nonresponse bias with respect to personality has been less thoroughly investigated. The present study uses data from responding individuals as a proxy for the missing data of their nonresponding family members to examine the presence of nonresponse bias for personality traits and disorders as well as health and lifestyle traits. We looked at the Big Five personality traits, borderline personality disorder (BPD) features, attention-deficit/hyperactivity disorder, Anger, and several measures of health (Body Mass Index, migraine) and lifestyle (smoking, alcohol use). In general, outcomes tend to be slightly more favorable for individuals from highly cooperative families compared to individuals from less cooperative families. The only significant difference was found for BPD features (p = .001). However, the absolute difference in mean scores is very small, less than 1 point for a scale ranging from 0 to 72. In conclusion, survey data on personality, health and lifestyle are relatively unbiased with respect to nonresponse.

Long-term Outcome of DSM-IV Major Depressive Disorder in Psychiatric Care

Much of what we know regarding the long-term course and outcome of major depressive disorder (MDD) is based on studies of mostly inpatient tertiary level cohorts and samples predating the era of the current antidepressants and the use of maintenance therapies. In addition, there is a lack of studies investigating the comprehensive significance of comorbid axis I and II disorders on the outcome of MDD. The present study forms a part of the Vantaa Depression Study (VDS), a regionally representative prospective and naturalistic cohort study of 269 secondary-level care psychiatric out- and inpatients (aged 20-59) with a new episode of DSM-IV MDD, and followed-up up to five years (n=182) with a life-chart and semistructured interviews. The aim was to investigate the long-term outcome of MDD and risk factors for poor recovery, recurrences, suicidal attempts and diagnostic switch to bipolar disorder, and the association of a family history of different psychiatric disorders on the outcome. The effects of comorbid disorders together with various other predictors from different domains on the outcome were comprehensively investigated. According to this study, the long-term outcome of MDD appears to be more variable when its outcome is investigated among modern, community-treated, secondary-care outpatients compared to previous mostly inpatient studies. MDD was also highly recurrent in these settings, but the recurrent episodes seemed shorter, and the outcome was unlikely to be uniformly chronic. Higher severity of MDD predicted significantly the number of recurrences and longer time spent ill. In addition, longer episode duration, comorbid dysthymic disorder, cluster C personality disorders and social phobia predicted a worse outcome. The incidence rate of suicide attempts varied robustly de¬pending on the level of depression, being 21-fold during major depressive episodes (MDEs), and 4-fold during partial remission compared to periods of full remission. Although a history of previous attempts and poor social support also indicated risk, time spent depressed was the central factor determining overall long-term risk. Switch to bipolar disorder occurred mainly to type II, earlier to type I, and more gradually over time to type II. Higher severity of MDD, comorbid social phobia, obsessive compulsive disorder, and cluster B personality disorder features predicted the diagnostic switch. The majority of patients were also likely to have positive family histories not exclusively of mood, but also of other mental disorders. Having a positive family history of severe mental disorders was likely to be clinically associated with a significantly more adverse outcome.

Suicidal behaviour in bipolar disorder

The Jorvi Bipolar Study (JoBS) is a collaborative ongoing bipolar research project between the Department of Mental Health and Alcohol Research of the National Public Health Institute, Helsinki, and the Department of Psychiatry, Jorvi Hospital, Helsinki University Central Hospital (HUCH), Espoo, Finland. The JoBS is a prospective, naturalistic cohort study of secondary level care psychiatric out-and inpatients with a new episode of Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) bipolar disorder (BD). Altogether, 1630 patients (aged 18-59) years were screened using the Mood Disorder Questionnaire (MDQ) for a possible new episode of DSM-IV BD. 490 patients were interviewed with semi-structured interview [the Structured Clinical Interview for DSM-IV Disorders, research version with Psychotic Screen (SCID-I/P)]. 191 patients with new episode of DSM-IV BD were included in the bipolar cohort study. Psychiatric comorbidity was evaluated using semi-structured interviews. At 6- and 18-month follow-up, the interviews were repeated and life-chart methodology was used to integrate all available information about nature and duration of all different phases. Suicidal behaviour was examined both at intake and follow-up by psychometric scale [Scale for Suicidal Ideation (SSI)], interviewer s questions and medical and psychiatric records. The aim of this thesis was to evaluate prevalence of suicidal behaviour and incidence of suicide attempts, and examine the wide range of risk factors for attempted suicide both, at intake and follow-up, in representative secondary-level sample of psychiatric in- and outpatients with BD. In this study suicidal behaviour was common among psychiatric patients with BD. During the episode when patients were included into cohort study (index episode), 20% of the patients had attempted suicide and 61% had suicidal ideation. Severity of depressive episode and hopelessness were independent risk factors for suicidal ideation, whereas hopelessness, comorbid personality disorder and previous suicide attempt predicted suicide attempts during the index episode. There were no differences in prevalence of suicidal behaviour between bipolar I and II disorder; the risk factors were overlapping but not identical. During the index episode, suicide attempts took place during depressive, mixed and depressive mixed phases. Furthermore, there were marked differences regarding level of suicidal ideation during different phases, with the highest levels during the mixed phases of the illness. Hopelessness was independently associated with suicidal behaviour during the depressive phase. A subjective rating of severity of depression (Beck Depression Inventory) and younger age predicted suicide attempts during mixed phases. During the 18-month follow-up 20% of patients attempted suicide. Previous suicide attempts, hopelessness, depressive phase at index episode and younger age at intake were independent risk factors for suicide attempts during follow-up. Taken altogether, 55% patients attempted suicide before index episode, during index episode or during follow-up. The incidence of suicide attempts was 37-fold during combined mixed and depressive mixed states and 18-fold during major depressive phase as compared with other phases. Prior suicide attempt and time spent in combined mixed phases - mixed and depressive mixed - and depressive phases independently predicted the suicide attempt during follow-up. More than half of the patients have attempted suicide during their lifetime, a finding which highlights the public health importance of suicidal behaviour in bipolar disorder. Clinically, it is crucial to recognize BD and manage the mixed and depressive phases of bipolar patients fast and effectively, as time spent in depressive and mixed phases involves a remarkably high risk of suicide attempts.

Self and identity in women with symptoms of borderline personality: A qualitative study

Identity disturbance has been suggested to be a core feature of borderline personality disorder (BPD). However, there is little known about the identity of individuals with symptoms of BPD from the participant’s perspective. This study availed of in-depth lightly structured life story interviews with five female participants. Thematic analysis was utilized to derive three themes of identity: connection, distance between us, and hurt and healing. Results provided support for multiple and flexible conceptualizations of identity in comparison to the idea of a unitary self/identity. Results also suggested that participants were able to establish differing connections to others ranging from disconnection to intimacy and care. Participants reported that their identities were impacted upon by historical and current family/relationship dysfunction, but life stories also illustrated the positive impact of healing relationship experiences. Findings provide support for psychological theories that consider a multiple and relational self/identity and the empowerment of healthy aspects of the self in BPD recovery. Studies that assess the association between insight and change may further our knowledge into this complex population.

The comorbidity of psychopathy, anxiety, and depression disorder

La psychopathie est un désordre de la personnalité caractérisé par des traits de comportement, tels qu’un manque d’empathie, du narcissisme, une estime de soi élevée, etc. Souvent, ces traits sont considérés comme indésirables. Ces caractéristiques se manifestent chez l’homme et la femme, autant dans la population criminelle que non-criminelle. L’étude de la psychopathie et la relation entre celle-ci et d’autres désordres mentaux représente un domaine relativement novateur de la psychologie. Des études démontrent une forte corrélation négative entre la psychopathie et l'anxiété, et entre la psychopathie et la dépression. Au total, 92 étudiants actuels ou ayant récemment graduées, au niveau du baccalauréat, de la maîtrise, et du doctorat ont été recrutés pour participer à cette étude. Ces participants ont complété quatre questionnaires standardisées qui évaluent leur niveau de psychopathie, d’anxiété et de dépression. Les évaluations utilisées sont le « Levenson’s Self-Report Psychopathy scale », le « Childhood and Adolescent Taxon Self-Report », le « Beck Depression Inventory », et le « Beck Anxiety Inventory ». Les résultats suggèrent l'existence d'une forte corrélation positive entre la dépression et la psychopathie, entre l'anxiété et la psychopathie, et entre l'anxiété et la dépression. Des variables additionnelles, tels que le sexe et l’éducation antérieure, contribuent aussi de façon significatives à ce modèle. Les résultats sont analysés tout en considérant des études antérieures et l’importance de la comorbidité psychopathique dans la recherche à venir.

The Experience of Treatment of Persons Presenting with Concomitant Psychotic and Borderline Personality Disorders

Essai doctoral présenté à la Faculté des arts et des sciences en vue de l'obtention du grade de doctorat en psychologie (D.Psy.) option psychologie clinique

Housing trajectories of individuals found not criminally responsible on account of mental disorder.

Au Canada, les Commissions d'Examen des Troubles Mentaux de chaque province ont la responsabilité de déterminer les conditions de prise en charge des personnes déclarées Non Criminellement Responsables pour cause de Troubles Mentaux (NCRTM) et de rendre, sur une base annuelle une des trois décisions suivantes: a) détention dans un hôpital, b) libération conditionnelle, ou c) libération absolue. Pour favoriser la réinsertion sociale, la libération conditionnelle peut être ordonnée avec la condition de vivre dans une ressource d’hébergement dans la communauté. Parmi les personnes vivant avec une maladie mentale, l’accès aux ressources d’hébergement a été associé à une plus grande stabilité résidentielle, une réduction de nombre et de la durée de séjours d'hospitalisation ainsi qu’une réduction des contacts avec le système judiciaire. Toutefois, l’accès aux ressources d’hébergement pour les personnes trouvées NCRTM est limité, en partie lié à la stigmatisation qui entoure cette population. Il existe peu d’études qui traitent du placement en ressources d’hébergement en psychiatrie légale. Pour répondre à cette question, cette thèse comporte trois volets qui seront présentés dans le cadre de deux manuscrits: 1) évaluer le rôle du placement en ressources d’hébergement sur la réhospitalisation et la récidive chez les personnes trouvées NCRTM; 2) décrire les trajectoires de disposition et de placement en ressources d’hébergement, et 3) mieux comprendre les facteurs associés à ces trajectoires. Les données de la province du Québec du Projet National de Trajectoires d’individus trouvés NCRTM ont été utilisées. Un total de 934 personnes trouvées NCRTM entre le 1er mai 2000 et le 30 avril 2005 compose cet échantillon. Dans le premier manuscrit, l’analyse de survie démontre que les individus placés dans un logement indépendant suite à une libération conditionnelle de la Commission d’Examen sont plus susceptibles de commettre une nouvelle infraction et d’être ré-hospitalisés que les personnes en ressources d’hébergement. Dans le deuxième article, l'analyse de données séquentielle a généré quatre modèles statistiquement stables de trajectoires de disposition et de placement résidentiel pour les 36 mois suivant un verdict de NCRTM: 1) libération conditionnelle dans une ressource d’hébergement (11%), 2) libération conditionnelle dans un logement autonome (32%), 3) détention (43%), et 4) libération absolue (14%). Une régression logistique multinomiale révèle que la probabilité d'un placement en ressource supervisée comparé au maintien en détention est significativement réduite pour les personnes traitées dans un hôpital spécialisé en psychiatrie légale, ainsi que pour ceux ayant commis un délit sévère. D'autre part, la probabilité d’être soumis à des dispositions moins restrictives (soit le logement indépendant et la libération absolue) est fortement associée à des facteurs cliniques tels qu’un nombre réduit d'hospitalisations psychiatriques antérieures, un diagnostic de trouble de l'humeur et une absence de diagnostic de trouble de la personnalité. Les résultats de ce projet doctoral soulignent la valeur protectrice des ressources en hébergement pour les personnes trouvées NCRTM, en plus d’apporter des arguments solides pour une gestion de risque chez les personnes trouvées NCRTM qui incorpore des éléments contextuels de prévention du risque, tel que l’accès à des ressources d’hébergement.