The relationship between comorbid personality disorders and treatment received in patients with anxiety disorders

Few studies have addressed the relationship between the presence of a comorbid personality disorder and the amount of psychiatric treatment received by patients with an Axis I disorder. This issue has not been studied in patients with anxiety disorders. In a prospective, naturalistic, longitudinal study of anxiety disorders, 526 subjects were assessed with the Personality Disorder Examination, and types of treatment received in 1991 and 1996 were identified. In 1991, compared to subjects without a personality disorder, subjects with a personality disorder were as likely to receive medication and they received a greater number of medications. Subjects with borderline personality disorder were more likely to receive heterocyclic antidepressants and interventions characteristic of psychodynamic psychotherapy and cognitive therapy; they also reported receiving a greater number of medications and types of psychosocial treatment than other subjects. In 1996, subjects with borderline personality disorder were more likely to receive psychodynamic interventions. These findings suggest that in patients with an anxiety disorder, the presence of a comorbid personality disorder is associated with receiving a greater number of medications but not with a greater likelihood of receiving pharmacologic or psychosocial treatment. However, the presence of borderline personality disorder is associated with a greater likelihood of receiving, and receiving a greater number of, certain types of somatic and psychosocial treatments.     

Childhood-onset multiple sclerosis and mood disorders: a case study.

Multiple Sclerosis (MS) is rare in children. Little research exists regarding emotional and behavioral disorders in childhood-onset MS, despite the occurrence of such problems in adults with MS. This paper describes the cognitive and behavioral characteristics of a boy diagnosed with MS at age 9 and mood disorder at age 10. He displayed no cognitive or behavioral problems prior to the onset of physical symptoms of MS. Three years after diagnosis, this child showed persistent problems with speed of processing, visual-motor skills, and parent and teacher-reported executive functioning. In addition, he had difficulties with emotional lability, behavioral disinhibition, depression, and social interaction. As with adults, children with MS may be at increased risk for mood disorder compared to their peers. Mood disorders in children with MS are likely to be multiply determined, although the specific causal mechanisms are unknown.     

PTSD,comorbid depression,and the cortisol waking response in victims of intimate partner violence: preliminary evidence

Posttraumatic Stress Disorder (PTSD) and Major Depressive Disorder (MDD) are two highly comorbid and debilitating disorders experienced by more than half of intimate partner violence victims (IPV). Hypothalamic–pituitary–adrenal (HPA) abnormalities are common in both disorders, though the direction of abnormalities often differs. The present study examined the relationship between comorbid PTSD and MDD, and the (salivary) cortisol waking response in 104 recently abused IPV victims. Waking cortisol levels, area under the waking curve with respect to ground (AUCg), and AUC with respect to increase (AUCi) were examined to determine the relation of HPA dynamics to comorbidity for basal versus more dynamic measures. Prior to accounting for comorbidity, women with PTSD or MDD showed significantly greater AUCi than women without the respective disorder. Accounting for comorbidity, PTSD only did not differ from other groups, while MDD only and PTSD + MDD showed greater AUCi than women with neither disorder. Results were nonsignificant for waking cortisol levels or AUCg. Results suggest that MDD drives elevated waking cortisol response, but not basal cortisol activity in recently abused IPV victims. Results demonstrate the importance of examining comorbid diagnoses and HPA activity from a dynamic perspective. Therapeutic implications are discussed.     

Clinically useful assessments: substance use and comorbid psychiatric disorders

This review addresses the assessment of substance use and related constructs with persons having severe and persistent mental illness. The review contains two major sections. The first section focuses on issues particular to the assessment of substance use and abuse in the context of major mental illness; these include the social and motivational context of assessment, the impact of mental status and acute symptoms, limitations associated with acute and chronic cognitive impairment, and the psychosocial relevance of assessment items. The second section highlights a selected set of substance assessment tools for use with this population; evidence for the reliability, validity, and/or feasibility of these tools is summarized. Each instrument meets the criteria of being: (a). relatively brief; (b). easy to administer and interpret; and (c). useful for treatment planning, motivational feedback, and/or monitoring change.     

Testing hypotheses regarding the causes of comorbidity: examining the underlying deficits of comorbid disorders

The authors examined the validity of a method commonly used to test alternative hypotheses regarding the causes of comorbidity: the examination of underlying deficits of comorbid disorders. The authors simulated data in which the true causes of comorbidity were known, then compared the patterns of underlying deficits of the comorbid disorders found in the simulated data with the predicted results. The method of examining the underlying deficits of comorbid disorders could distinguish between several comorbidity models, including those that could not be distinguished well using other methods. The ability to distinguish the correct model decreased as the sample size and the correlation between the underlying deficits and the symptom scores decreased, suggesting that the issue of power should be considered carefully.     

Individual Therapy via the Phenomenon of Hope for Treating Chronic and Complex PTSD

Evidence-based treatment (EBT) supports different types of cognitive-behavioral therapy (CBT) for treating post-traumatic stress disorder (PTSD). Yet, a growing body of evidence shows a high therapy dropout rate and non-response rate among PTSD patients, especially patients with complex PTSD. A different, short-term therapeutic approach is therefore needed which combines CBT and psychodynamic therapy (PDT) because it is better for patients with chronic and/or complex PTSD to work with clarified stages and an end of treatment in mind. The patient's mental structure is conceptualized as a continuum, and functional problems are regarded as stemming from cognitive structures and unresolved developmental conflict. The five phases of the phenomenon of hope model proposed in an earlier article—a connection phase; an agency and pathway phase (developing a goal-oriented decision-making pattern and learning to plan toward goal achievement); a reconstruction phase; a phase of processing the conflict characteristic of PTSD by utilizing the natural power of hope; and a summary and separation phase—advance a short-term therapy that combines CBT and PDT techniques. This integrated therapy is based on notes that were kept relating to the case study of a chronic PTSD patient.     

Assessing ADHD and comorbid disorders in children: the Child Behavior Checklist and the Devereux Scales of Mental Disorders

Evaluated discriminant validity and clinical utility of selected subscales of the Devereux Scales of Mental Disorders (DSMD; Naglieri, LeBuffe, & Pfeiffer, 1994) and the Child Behavior Checklist (CBCL; Achenbach, 1991a) in 228 children referred to a clinic for the evaluation and treatment of attention deficit hyperactivity disorder (ADHD). The DSMD is a multiaxial behavior rating scale that measures symptomatology for a broad range of child psychopathology as described in the Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev. [DSM-R-III] and 4th ed. [DSM-IV]; American Psychiatric Association, 1987, 1994). Discriminant function analyses as well as sensitivity, specificity, and predictive power analyses were computed to evaluate the discriminant validity and clinical utility of selected DSMD and CBCL subscales for assessing ADHD, oppositional defiant disorder (ODD), and anxiety disorders. Results indicated that the DSMD compared very favorably with the CBCL in the ability to discriminate between children with ADHD and those without ADHD and between children with comorbid ODD and anxiety disorders and children who did not meet criteria for these disorders. The DSMD Attention subscale may be somewhat better at ruling in ADHD combined subtype (ADHD-C) and ADHD inattentive subtype (ADHD-I) than the CBCL Attention Problems subscale, but the CBCL Attention Problems subscale may have slightly better utility than the DSMD Attention subscale in ruling out these subtypes. Both the CBCL and DSMD were more useful for ruling out than for ruling in ODD and anxiety disorders.     

Co-occurrence of developmental disorders: The case of Developmental Dyscalculia

Five to seven percent of children experience severe difficulties in learning mathematics and/or reading. Current trials that are focused on identifying biological markers suggest that these learning disabilities, known as Developmental Dyscalculia (DD) and Dyslexia (for reading), are due to underlying brain dysfunctions. One ongoing controversy concerns the extent to which arithmetic impairments are specific to DD or shared with other developmental disorders such as Dyslexia. This review explores and develops a hypothesis for cases of DD + Dyslexia. Three factors warrant consideration: (a) the behavioral factor, including definitions of the disabilities and assessment tools; (b) the cognitive factor, including whether co-occurrence of DD and other developmental disorders such as Dyslexia derive from similar or different cognitive risk factors; (c) the biological factor, including consideration of static vs. developmental neuropsychology. Better understanding of the causes of co-occurrence of DD and Dyslexia, or other developmental disorder such as Attention Deficit Hyperactivity Disorder (ADHD), can have an important influence on research that examine the two disorders, including research on therapy and etiology.     

The validity of the PTSD checklist as a measure of symptomatic change in combat-related PTSD

Little research to date has examined the ability of self-report measures to assess changes in symptom severity and diagnostic status as a function of treatment. This study investigated the validity of the posttraumatic stress disorder (PTSD) checklist (PCL) as a measure of symptomatic change following programmatic treatment. A sample of 97 Vietnam veterans with combat-related PTSD was assessed using the clinician-administered PTSD scale (CAPS) and the PCL prior to, and 9 months following, participation in a PTSD treatment program. Using the CAPS as the "gold standard" measure of PTSD symptomatology, the PCL demonstrated high diagnostic accuracy pre- and posttreatment. However, significant variations in accuracy were evident in the ability of the PCL to determine the presence and severity of individual symptoms at each time point. In addition, as symptoms improved from pre- to posttreatment, and approached the threshold criteria, the PCL demonstrated reductions in diagnostic accuracy. As a measure of overall symptomatic change, the PCL underrated improvement in comparison to the CAPS. The results supported the use of an overall cut-off score of 50 on the PCL for a diagnosis, and an item score of 3 for symptom criterion, in this population.     

Comorbidity in youth with specific phobias: Impact of comorbidity on treatment outcome and the impact of treatment on comorbid disorders

The purpose of the present study was twofold. In an analysis of data from an existing randomized control trial of brief cognitive behavioral treatment on specific phobias (One-Session Treatment, OST; Ollendick et al., 2009), we examined 1) the effect of comorbid specific phobias and other anxiety disorders on treatment outcomes, and 2) the effect of treatment of the specific phobia on these co-occurring disorders. These relations were explored in 100 youth presenting with animal, natural environment, situational, and “other” types of phobia. Youth were reliably diagnosed with the Anxiety Disorders Interview Schedule for DSM-IV: Child and Parent versions (Silverman & Albano, 1996). Clinician severity ratings at post-treatment and 6-month follow-up were examined as were parent and child treatment outcome satisfaction measures. Results indicated that the presence of comorbid phobias or anxiety disorders did not affect treatment outcomes; moreover, treatment of the targeted specific phobias led to significant reductions in the clinical severity of other co-occurring specific phobias and related anxiety disorders. These findings speak to the generalization of the effects of this time-limited treatment approach. Implications for treatment of principal and comorbid disorders are discussed, and possible mechanisms for these effects are commented upon.     

Optimal test length for multiple prediction: The general case

The concepts of differential prediction and multiple absolute prediction were developed in earlier papers [2, 3]. Methods for determining optimal distribution of testing time for each type of prediction are available [4, 5] and are appropriate for use provided that no altered time allotment approaches zero. In this article the methods developed in [4, 5] are extended to include cases where the altered time allotment for one or more tests may approach zero. The procedures developed are illustrated by numerical examples, after which the mathematical rationales are provided.