Daniel F. Becker

Psychiatric Comorbidity in Adolescent Inpatients with Substance Use Disorders

OBJECTIVE To assess DSM-III-R Axis I and Axis II co-occurrence and comorbidity in adolescent inpatients with substance use disorders (SUD). METHOD A consecutive series of 138 adolescent inpatients were reliably assessed with structured diagnostic interviews for Axis I disorders and Axis II personality disorders. To determine significant co-occurrence of diagnoses, comparisons were between 69 patients with SUD and 69 patients without SUD. RESULTS Disruptive behavior disorders were diagnosed significantly more frequently in patients with SUD than in those without SUD. Conduct disorder was diagnosed more frequently and oppositional defiant disorder was diagnosed less frequently in the SUD patients than in the non-SUD patients. Anxiety disorders were diagnosed less frequently in the SUD group. Cluster B personality disorders and borderline personality disorder were diagnosed more frequently in the SUD group. CONCLUSIONS The findings replicate previous research showing high rates of co-occurrence of other psychiatric disorders in adolescent inpatients with SUD. The use of a relevant psychiatric comparison group allows for finer distinctions regarding significant comorbidity and the psychopathological implications thereof.

Gender differences in personality disorders in psychiatrically hospitalized young adults

We examined gender differences in DSM-III-R personality disorders in psychiatrically hospitalized young adults. Structured diagnostic interviews were reliably performed on a consecutive series of 118 inpatients. Men were significantly more likely to meet criteria for cluster A, schizotypal, and antisocial personality disorders. To reduce variability due to axis I heterogeneity, we retested for gender differences in a subgroup of patients with major depression. Depressed men were more likely to meet criteria for cluster A, schizotypal, and cluster C personality disorders. Women were not observed to have a higher frequency of any personality disorder than men in either study group.

EATING DISORDERS IN FEMALE INPATIENTS WITH VERSUS WITHOUT SUBSTANCE USE DISORDERS

This study assessed the relationship between substance use disorders and eating disorders in female psychiatric inpatients. Structured diagnostic interviews were reliably administered to a series of inpatients with substance use disorders (n = 67) and a comparison sample without substance use disorders (n = 69). Eating disorder diagnoses as a whole, including eating disorder not otherwise specified, were distributed significantly more frequently among subjects with substance use disorders than among psychiatric controls. Frequencies of the specific diagnoses of bulimia nervosa and anorexia nervosa, however, did not differ significantly between groups. The results suggest that eating disorder features may be overrepresented among female inpatients with substance use disorders.

Diagnostic Efficiency of DSM-IV Criteria for Borderline Personality Disorder: An Evaluation in Hispanic Men and Women with Substance Use Disorders.

This study examined diagnostic efficiency of Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), criteria for borderline personality disorder (BPD). One hundred thirty monolingual Hispanic adults (90 men, 40 women) at an outpatient psychiatric and substance abuse clinic were assessed with the Spanish-Language Version of the Diagnostic Interview for DSM-IV Personality Disorders (C. M. Grilo, L. M. Anez, & T. H. McGlashan, 2003). The BPD diagnosis was determined by the best-estimate method. Diagnostic efficiency indices were calculated for all BPD criteria, for the entire study group, and separately by gender. Overall, the best exclusion criterion was affective instability, whereas suicidality or self-injury was the best inclusion criterion and the best predictor overall. These findings did not differ by gender, are similar to those reported elsewhere in the literature, and have implications for the refinement of diagnostic systems.

Eating disorders with and without substance use disorders: A comparative study of inpatients

We assessed the co-occurrence of DSM-III-R axis I and II disorders and self-reported psychologic distress in inpatients with eating disorders with and without substance use disorders (ED-SUD and ED groups, respectively) and in a matched comparison sample with substance use disorders but no eating disorder (SUD group). The three groups showed similar distributions of axis I disorders but differed in the distribution of axis II disorders. Cluster B personality disorders were diagnosed more frequently in SUD and ED-SUD groups than in the ED group. In contrast, cluster C personality disorders were diagnosed more frequently in the ED group than in SUD and ED-SUD groups. The SUD group reported greater psychologic distress than ED and ED-SUD groups. Possible implications of the observed group differences for psychologic models of why these disorders may be associated are considered.

Prediction of suicidality and violence in hospitalized adolescents: comparisons by sex

Objective: To examine psychological correlates of suicidality and violent behaviour in hospitalized adolescents and the extent to which these associations may be affected by their sex. Method: A sample of 487 psychiatric inpatients (207 male, 280 female), aged 12 to 19 years, completed a battery of psychometrically sound self-report measures of psychological functioning, substance abuse, suicidality, and violent behaviour. We conducted multiple regression analyses to determine the joint and independent predictors of suicide risk and violence risk. In subsequent analyses, we examined these associations separately by sex. Results: Multiple regression analysis revealed that 9 variables (sex, age, hopelessness, self-esteem, depression, impulsivity, alcohol abuse, drug abuse, and violence risk) jointly predicted suicide risk and that an analogous model predicted violence risk. However, we found several differences with respect to which variables made significant independent contributions to these 2 predictive models. Female sex, low self-esteem, depression, drug abuse, and violence risk made independent contributions to suicide risk. Male sex, younger age, hopelessness, impulsivity, drug abuse, and suicide risk made independent contributions to violence risk. We observed a few additional differences when we considered male and female subjects separately. Conclusions: We found overlapping but distinctive patterns of prediction for suicide risk and violence risk, as well as some differences between male and female subjects. These results may reflect distinct psychological and behavioural pathways for suicidality and violence in adolescent psychiatric patients and differing risk factors for each sex. Such differences have potential implications for prevention and treatment programs.

The prevalence and structure of obsessive-compulsive personality disorder in Hispanic psychiatric outpatients

This study sought to confirm a multi-factor model of Obsessive-compulsive personality disorder (OCPD) in a Hispanic outpatient sample and to explore associations of the OCPD factors with aggression, depression, and suicidal thoughts. One hundred and thirty monolingual, Spanish-speaking participants were recruited from a community mental health center and were assessed by bilingual doctoral-level clinicians. OCPD was highly prevalent (26%) in this sample. Multi-factor models of OCPD were tested and the two factors - perfectionism and interpersonal rigidity - provided the best model fit. Interpersonal rigidity was associated with aggression and anger while perfectionism was associated with depression and suicidal thoughts.

Comorbidity of mood and substance use disorders in patients with binge-eating disorder: Associations with personality disorder and eating disorder pathology.

OBJECTIVE Binge-eating disorder (BED) is associated with elevated rates of mood and substance use disorders, but the significance of such comorbidity is ambiguous. We compared personality disorder and eating disorder psychopathology in four subgroups of BED patients: those with mood disorders, those with substance use disorders, those with both, and those with neither. METHOD Subjects were 347 patients who met DSM-IV research criteria for BED. Semistructured interviews evaluated lifetime DSM-IV axis I disorders, DSM-IV personality disorder features, and eating disorder psychopathology. RESULTS Among these patients, 129 had co-occurring mood disorder, 34 had substance use disorder, 60 had both, and 124 had neither. Groups differed on personality disorder features, with those having mood disorder and both mood and substance use disorders showing the highest frequencies. Although groups did not differ in body mass index or binge eating frequency, they did differ on eating disorder psychopathology-with the groups having mood disorder and both comorbidities demonstrating higher eating, weight, and shape concerns. No differences were observed between groups with respect to ages of onset for specific eating behaviors, but some differences were observed for ages of disorder onset. CONCLUSION Mood and substance use disorders co-occur frequently among patients with BED. Compared with a previous work, the additional comparison group (those with both mood and substance use disorders) and the control group (those with neither) afforded better discrimination regarding the significance of these comorbidities. Our findings suggest approaches to subtyping BED based on psychiatric comorbidity, and may also have implications for treatment.

Childhood trauma histories in adolescent inpatients

The authors describe the prevalence of childhood traumatic experiences among adolescent inpatients. A Childhood Trauma Chart Review Scale (CTCRS) was developed to assess traumatic experiences during childhood and adolescence. The CTCRS was reliably applied to the medical records of 75 adolescent inpatients who had been given structured clinical interviews for DSM-III-R diagnoses at the time of admission. Most subjects (81%) had experienced at least one traumatic event during childhood, with loss of caregiver being the most frequent type of traumatic experience. Many subjects had multiple types of traumatic experiences, during both early and late childhood. A history of childhood trauma was associated with greater functional impairment and higher likelihood of having a personality disorder, but with no difference in Axis I diagnoses.

Effects of Emotion on Perceptual Asymmetry in Adolescent Inpatients with Attention-deficit Hyperactivity Disorder

OBJECTIVE The authors studied the hemispheric functioning of adolescents with attention-deficit hyperactivity disorder (ADHD) in relation to this groups response to positively toned emotional stimuli. METHOD Dichotic word tests were used to measure perceptual asymmetry in 21 adolescent inpatients and 24 control subjects. Ten patients had ADHD; 11 did not. Subjects were tested under four emotional conditions by using combinations of neutral, positive, and negative words. RESULTS the ADHD group had lower right ear advantage (REA) scores when presented with stimulus pairs containing positive words than when presented with pairs not containing positive words. By comparison, the non-ADHD patient group and the control group had higher REA scores under positive emotional conditions than under non-positive conditions. CONCLUSIONS The abnormal response to positive emotional tone supports the reward system dysfunction hypothesis of ADHD and may also have implications for learning problems, behavioral difficulties, and disturbed interpersonal relationships in this population.