The relationship between personality disorders and quality of life in adolescent outpatients

Background: During recent years, there has been an increasing focus on the benefits of the early detection and treatment of personality disorders in adolescents. Previous studies of adults have shown that the number of personality disorder criteria met is negatively correlated with a patient’s quality of life and general functioning. Objective: The aim of the present study was to investigate the prevalence of personality disorders, particularly with regard to the correlation between the number of personality disorder criteria fulfilled and self-perceived quality of life. Distribution according to gender and age in a clinical sample of adolescent outpatients were also considered. Method: This study included 153 adolescents between the ages of 14 and 17 years who were referred to a mental health outpatient clinic. Personality disorders were assessed using the Structured Interview for DSM-IV Personality. Quality of life was assessed using the Youth Quality of Life Instrument - Research Version, which is a 41-item questionnaire that covers broad aspects of quality of life. Axis I disorders were assessed using the Mini International Neuropsychiatric Interview. Results: Results demonstrated that 21.6% of the adolescents met the diagnostic criteria for at least one personality disorder. A relationship between the number of personality disorder criteria met and reduced quality of life was found. No significant gender differences with regard to the prevalence of each of the personality disorders were revealed. Adjustment for the presence of Axis I disorders did not appreciably affect these findings Conclusion: The present study indicates that reduced quality of life as a result of the number of personality disorder criteria met affects adolescents in much the same way that it does adults. This further emphasizes the clinical importance of including quality of life assessment as part of the general diagnostic procedures used with adolescents

Personality Disorders as a Possible Moderator of the Effects of Relational Interventions in Short-Term Psychoanalytic Psychotherapy with Depressed Adolescents

A significant proportion of adolescents suffering from major depressive disorder (MDD) are likely to have a co-morbid personality disorder (PD). Short-term psychoanalytic psychotherapy (STPP) was found to be one treatment of choice for adolescents suffering from MDD. BACKGROUND: The first experimental study of transference work-in teenagers (FEST-IT) demonstrated the efficaciousness of transference work in STPP with adolescents suffering from MDD. The usefulness of STPP may be enhanced by exploring possible moderators. METHODS: Depressed adolescents (N = 69), aged 16-18 years, were diagnosed with the structured interview for DSM-IV PDs and randomized to 28 weeks of STPP with or without transference work. A mixed linear model was applied. The moderator effect was investigated by a three-way interaction including "time", "treatment group" and "number of PD criteria". RESULTS: A small but significant moderator effect was found for cluster B personality pathology. Patients with a higher number of cluster B PD criteria at baseline did better up to one-year post-treatment where therapists encouraged patients to explore the patient-therapist relationship in the here and now. CONCLUSION: When treated with psychoanalytic psychotherapy for MDD, adolescents with cluster B PD symptoms seem to profit more from transference work than adolescents without such pathology

Effect of remote ischaemic conditioning on clinical outcomes in patients with acute myocardial infarction (CONDI-2/ERIC-PPCI): a single-blind randomised controlled trial.

BACKGROUND: Remote ischaemic conditioning with transient ischaemia and reperfusion applied to the arm has been shown to reduce myocardial infarct size in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). We investigated whether remote ischaemic conditioning could reduce the incidence of cardiac death and hospitalisation for heart failure at 12 months. METHODS: We did an international investigator-initiated, prospective, single-blind, randomised controlled trial (CONDI-2/ERIC-PPCI) at 33 centres across the UK, Denmark, Spain, and Serbia. Patients (age >18 years) with suspected STEMI and who were eligible for PPCI were randomly allocated (1:1, stratified by centre with a permuted block method) to receive standard treatment (including a sham simulated remote ischaemic conditioning intervention at UK sites only) or remote ischaemic conditioning treatment (intermittent ischaemia and reperfusion applied to the arm through four cycles of 5-min inflation and 5-min deflation of an automated cuff device) before PPCI. Investigators responsible for data collection and outcome assessment were masked to treatment allocation. The primary combined endpoint was cardiac death or hospitalisation for heart failure at 12 months in the intention-to-treat population. This trial is registered with ClinicalTrials.gov (NCT02342522) and is completed. FINDINGS: Between Nov 6, 2013, and March 31, 2018, 5401 patients were randomly allocated to either the control group (n=2701) or the remote ischaemic conditioning group (n=2700). After exclusion of patients upon hospital arrival or loss to follow-up, 2569 patients in the control group and 2546 in the intervention group were included in the intention-to-treat analysis. At 12 months post-PPCI, the Kaplan-Meier-estimated frequencies of cardiac death or hospitalisation for heart failure (the primary endpoint) were 220 (8·6%) patients in the control group and 239 (9·4%) in the remote ischaemic conditioning group (hazard ratio 1·10 [95% CI 0·91-1·32], p=0·32 for intervention versus control). No important unexpected adverse events or side effects of remote ischaemic conditioning were observed. INTERPRETATION: Remote ischaemic conditioning does not improve clinical outcomes (cardiac death or hospitalisation for heart failure) at 12 months in patients with STEMI undergoing PPCI. FUNDING: British Heart Foundation, University College London Hospitals/University College London Biomedical Research Centre, Danish Innovation Foundation, Novo Nordisk Foundation, TrygFonden

Personality Disorders in Adolescent Outpatients: a Cross-sectional Study of Prevalence, Comorbidity and Quality of Life

Personality disorders are defined as enduring and maladaptive patterns of experiencing, coping, and relating to others. In DSM-IV as well as ICD-10, personality disorders may be diagnosed in adolescents when the individual’s maladaptive personality traits are pervasive, persistent, and unlikely to be limited to a particular developmental state or an episode of an Axis I disorder. Research supports the assumption that pathological personality traits emerge at an early age and are related to health-risk behaviors in adolescence as well as young adulthood. In recent years there has been an increasing focus on the valid existence of personality disorders in adolescents, as well as on the prognostic importance of diagnosing these for the most part long-lasting and agonizing disorders as early as possible. Personality disorders are common conditions, with prevalences of about 13% in the general adult population, up to 40% in adult outpatient samples, and up to 71% in adult inpatient samples. In adolescents, prevalences range from 6% to 17% in community samples, and in inpatient and more severely ill outpatient samples from 41% to 88%. There are few, if any, reports on the prevalence in less severely ill adolescents who have been referred to general service outpatient clinics. Previous studies on adults have shown that the number of personality disorder symptoms is negatively correlated to general functioning and quality of life, and that personality disorders are associated with an extensive Axis I comorbidity, such as mood, anxiety, and substance abuse disorders. Objectives: The main objective of this thesis was to study the prevalence of personality disorders and clinically relevant Axis I comorbidity, in an unselected sample of adolescents who were referred to a non-specialized (general service) child and adolescent outpatient clinic. The more specific aims were: - To investigate the relationship of personality disorder symptoms, i.e. the number of personality disorder diagnostic criteria met by the adolescents, with self-perceived quality of life (paper I). - To investigate the co-occurence of personality disorders and common Axis I disorders in adolescents with ADHD, including possible gender differences (paper II). - To investigate the relationship between alcohol and substance use disorders and personality disorders in the referred adolescents, with special regard to gender differences (paper III). Material and methods: The three studies included in this thesis are based on an outpatient clinical sample, consisting of 153 adolescents (94 girls, 59 boys), aged 14 to 17 years. Personality disorders were assessed using the Structured Interview for DSM-IV Personality. Quality of life was assessed using the Youth Quality of Life Instrument - Research Version, which is a 41-item questionnaire covering broad aspects of quality of life. ADHD, conduct disorder and other Axis I conditions were assessed using the Mini International Neuropsychiatric Interview (MINI). All assessment work was done by the author of this thesis. Results: The girls in our study were overall more severely ill than the boys, with higher prevalences of personality disorders as well as Axis I disorders. We found that 21.6% of the adolescents fully met the diagnostic criteria for at least one personality disorder. No significant gender differences in the prevalence of each of the personality disorders were revealed. Practically all adolescents with a personality disorder had one or more Axis I disorders. Quality of life was negatively related to the number of personality disorder criteria met: this finding was comparable to what has previously been reported in adults. Adjustment for the presence of Axis I disorders did not appreciably affect these findings. More than two thirds of the adolescents met the criteria for at least one Axis I disorder, with significantly more mood and anxiety disorders in girls than in boys. A total of 13.7% of the adolescents met diagnostic criteria for ADHD, with no significant gender difference; 17.6% had conduct disorder, and 4.6% had both ADHD and a personality disorder. There was a significantly elevated number of personality disorder symptoms in adolescents with ADHD diagnosis, and this relationship was not significantly weakened when adjusted for age, gender and other Axis I disorders. Antisocial and borderline personality disorders were significantly more frequent in girls than in boys with ADHD. With regard to substance use disorders, 18.3% of the adolescents had either alcohol or cannabis abuse or dependency, also with no significant gender difference. There was a strong association between number of personality disorder symptoms and having one or more substance use disorders; this relationship was not significantly changed by adjustment for gender, age and presence of Axis I disorders. For boys, no significant associations of substance use disorders and specific personality disorders, conduct disorder, or ADHD were found. For girls, there were significant associations of substance use disorders and borderline personality disorder, negativistic personality disorder, having more than one personality disorder, conduct disorder, and ADHD. Conclusions: As expected, the adolescents in our study had more personality disorders than what has been previously found in studies on community samples and primary care patients, but less than in studies on more severely ill outpatients and inpatients. We found the same association as previously reported from studies on adults between personality disorder symptoms and quality of life. This supports the importance of evaluating quality of life when focusing on early detection and treatment of personality disorders in adolescents. ADHD, conduct disorder, antisocial personality disorder and substance use disorders were equally prevalent in both genders. This suggests that ADHD and possibly conduct disorder may be more prevalent than previously assumed in adolescent girls. In girls with ADHD, antisocial and borderline personality disorders were significantly more frequent than in boys. This highlights the importance of assessing antisocial and borderline personality pathology in adolescent girls presenting with ADHD symptoms. The highly significant association between the number of personality disorder symptoms and substance use disorders, regardless of adjustment for gender and Axis I comorbidity, suggests that having a personality disorder in itself may constitute a risk factor for developing substance use disorders in adolescence

Substance abuse and personality disorder comorbidity in adolescent outpatients: are girls more severely ill than boys?

Background Substance use disorders (SUDs) constitute a major health problem and are associated with an extensive psychiatric comorbidity. Personality disorders (PDs) and SUDs commonly co-occur. Comorbid PD is characterized by more severe addiction problems and by an unfavorable clinical outcome. The present study investigated the prevalence of SUDs, PDs and common Axis I disorders in a sample of adolescent outpatients. We also investigated the association between PDs and SUDs, and how this association was influenced by adjustment for other Axis I disorders, age and gender. Methods The sample consisted of 153 adolescents, aged 14–17 years, who were referred to a non-specialized mental health outpatient clinic with a defined catchment area. SUDs and other Axis I conditions were assessed using the mini international neuropsychiatric interview. PDs were assessed using the structured interview for DSM-IV personality. Results 18.3 % of the adolescents screened positive for a SUD, with no significant gender difference. There was a highly significant association between number of PD symptoms and having one or more SUDs; this relationship was practically unchanged by adjustment for gender, age and presence of Axis I disorders. For boys, no significant associations between SUDs and specific PDs, conduct disorder (CD) or attention deficit hyperactivity disorder (ADHD) were found. For girls, there were significant associations between SUD and BPD, negativistic PD, more than one PD, CD and ADHD. Conclusions We found no significant gender difference in the prevalence of SUD in a sample of adolescents referred to a general mental health outpatient clinic. The association between number of PD symptoms and having one or more SUDs was practically unchanged by adjustment for gender, age and presence of one or more Axis I disorders, which suggested that having an increased number of PD symptoms in itself may constitute a risk factor for developing SUDs in adolescence. The association in girls between SUDs and PDs, CD and ADHD raises the question if adolescent girls suffering from these conditions may be especially at risk for developing SUDs. In clinical settings, they should therefore be monitored with particular diligence with regard to their use of psychoactive substances. Trial registration The regional committee for medical research ethics for eastern Norway approved the study protocol in October 2004 (REK: 11395). Address correspondence and reprint requests to: Hans Ole Korsgaard, The Nic Waal Institute, Lovisenberg Diakonale Hospital, P.O. Box 2970 Nydalen, N-0440 Oslo, Norway; E-mail [email protected]

Personality disorders and Axis I comorbidity in adolescent outpatients with ADHD

Background Attention deficit hyperactivity disorder (ADHD) is a lifelong condition which carries great cost to society and has an extensive comorbidity. It has been assumed that ADHD is 2 to 5 times more frequent in boys than in girls. Several studies have suggested developmental trajectories that link ADHD and certain personality disorders. The present study investigated the prevalence of ADHD, common Axis I disorders, and their gender differences in a sample of adolescent outpatients. We also wanted to investigate the relationship between ADHD and personality disorders (PDs), as well as how this relationship was influenced by adjustment for Axis I disorders, age and gender. Methods We used a sample consisting of 153 adolescents, aged 14 to 17 years, who were referred to a non-specialized mental health outpatient clinic with a defined catchment area. ADHD, conduct disorder (CD) and other Axis I conditions were assessed using the Mini International Neuropsychiatric Interview (MINI). PDs were assessed using the Structured Interview for DSM-IV Personality (SIDP-IV). Results 13.7 % of the adolescents met diagnostic criteria for ADHD, with no significant gender difference. 21.6 % had at least one PD, 17.6 % had CD, and 4.6 % had both ADHD and a PD. There was a significantly elevated number of PD symptoms in adolescents with an ADHD diagnosis (p = 0.001), and this relationship was not significantly weakened when adjusted for age, gender and other Axis I disorders (p = 0.026). Antisocial (χ 2 = 21.18, p = 0.002) and borderline (χ 2 = 6.15, p = 0.042) PDs were significantly more frequent in girls than in boys with ADHD. Conclusions We found no significant gender difference in the prevalence of ADHD in a sample of adolescents referred to a general mental health outpatient clinic. Adolescent girls with ADHD had more PDs than boys, with antisocial and borderline PDs significantly different. The present study suggests that ADHD in girls in a general outpatient population may be more prevalent than previously assumed. It especially highlights the importance of assessing antisocial and borderline personality pathology in adolescent girls presenting with ADHD symptoms

Inter-Rater Reliability of the Structured Interview of DSM-IV Personality (SIDP-IV) in an Adolescent Outpatient Population

Personality disorders (PDs) are a class of mental disorders which are associated with subjective distress, decreased quality of life and broad functional impairment. The presence of one or several PDs may also complicate the course and treatment of symptom disorders such as anxiety and depression. Accurate and reliable means of diagnosing personality disorders are thus crucial to ensuring efficient treatment planning and resource allocation, a fact which is widely acknowledged within the adult mental health field. In adolescents, on the other hand, the consensus view has been that the rapid and discontinuous processes of normal personality development render the construct of PD in adolescents clinically unhelpful and conceptually dubious. However, recent research has established the reliability and validity of the construct, heralding an increased interest in the field, with important conceptual and clinical implications. The present article presents reliability data for the Structured Interview of DSM-IV Personality (SIDP-IV) in an adolescent outpatient population. For this study, 25 interviews conducted by experienced clinicians were blindly re-scored based on sound recordings, which allowed for the calculation of intra-class correlation metrics. The intra-class correlation coefficient for categorical diagnosis of specific personality disorders was found to be 0.876 (95% CI 0.718–0.945); Cohen’s kappa for presence/absence of personality diagnosis was found to be 0.896. The present study found excellent intra-rater reliability for the sample, which suggests that the SIDP-IV is a suitable instrument for assessing personality pathology in adolescent populations