Jean-Pierre Schuster

Personality Disorders in Older Adults: Findings From the National Epidemiologic Survey on Alcohol and Related Conditions

OBJECTIVES To examine the prevalence, sociodemographic correlates, psychiatric and medical comorbidities, and the disability of personality disorders among adults age 65 years and older. METHODS Data were drawn from the National Epidemiologic Survey on Alcohol and Related Conditions, focusing on a subsample of 8,205 adults age 65 years and older. RESULTS A total of 8.07% (SE: 0.37) of American adults age 65 years and older presented at least one personality disorder. The most prevalent personality disorder was the obsessive-compulsive personality disorder. The overall pattern of associations between each personality disorder and lifetime psychiatric comorbidity correlates was statistically significant. Participants with a personality disorder show a lower quality of life than their counterparts. CONCLUSIONS Personality disorders in older adults are highly associated with disability, medical, and psychiatric disorders. These findings highlight the need to develop more effective prevention and intervention programs in this specific population.

Gender differences in firesetting: Results from the national epidemiologic survey on alcohol and related conditions (NESARC)

This study presents gender differences in sociodemographics and in psychiatric correlates of firesetting in the United States. Data were derived from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a representative sample of U.S. adults. Face-to-face interviews of more than 43,000 adults were conducted in the 2001-2002 period. This study focused on the 407 subjects with a lifetime history of firesetting. The prevalence of lifetime firesetting in the U.S. was 1.7% in men and 0.4% in women. Firesetting was significantly associated with a wide range of antisocial behaviors that differed by gender. Multivariate logistic regression analyses indicated associations in both genders with psychiatric and addictive disorders. Men with a lifetime history of firesetting were significantly more likely than men without such history to have lifetime generalized anxiety disorder as well as a diagnosis of conduct disorder, antisocial personality disorder, alcohol or cannabis use disorder, and obsessive-compulsive personality disorder. Women with a lifetime history of firesetting were significantly more likely than women without such history to have lifetime alcohol or cannabis use disorder, conduct disorder, and antisocial or obsessive compulsive personality disorder, as well as psychotic disorder, bipolar disorder or schizoid personality disorder. Women with a lifetime history of firesetting were significantly more likely than men with such history to have a lifetime diagnosis of alcohol abuse and antisocial personality disorder as well as a diagnosis of schizoid personality disorder. Our findings indicate that firesetting in women could represent a behavioral manifestation of a broader spectrum than firesetting in men.

Why does the lifetime prevalence of major depressive disorder in the elderly appear to be lower than in younger adults? Results from a national representative sample

BACKGROUND The explanation of the lower lifetime prevalence rate of major depressive disorder (MDD) in older adults compared to younger people in community surveys is debated. This study examines the hypothesis that the decrease of the lifetime prevalence of MDD in older adults may be due to an age-related difference in the lifetime prevalence of subthreshold hypomania and, to a lesser extent, to the increased rate of medical induced-depression. METHODS Data were derived from the National Epidemiological Survey on Alcohol and Related Conditions (NESARC), a national representative sample of 43,093 adults of the United States population. We examined lifetime prevalence rates of pure MDD and MDD plus subthreshold hypomania (D(m)) by age, assuming that the lifetime prevalence of pure MDD in older adults would be similar to that in the youngest cohort, consequent to an inverse age-D(m) relationship. We further considered non-hierarchical MDD (i.e., general medical condition depressive disorders were not ruled out) with the same method. RESULTS The lifetime prevalence of D(m) among depressed adults aged 65 years and over was substantially lower compared to the youngest group. When considering non-hierarchical MDD, the odds ratio of the lifetime prevalence estimates of non-hierarchical pure MDD in older adults compared to the youngest group appeared not significantly different from 1. CONCLUSIONS Findings indicate that the decrease of lifetime prevalence of MDD in older adults may be due to an age-related difference in the lifetime prevalence of subthreshold hypomania and, to a lesser extent, to the increased rate of medical induced-depression.

Association Between Peptic Ulcer and Personality Disorders in a Nationally Representative US Sample

Objective: To assess the association between peptic ulcer and a wide range of personality disorders in a large sample representative of the general population in the United States. Methods: Data were drawn from the National Epidemiologic Survey on Alcohol and Related Conditions, on the basis of a face-to-face interview of more than 43,000 adults. Univariate and multivariate logistic regression were used to examine the relationship between self-reported “stomach ulcer” and personality disorders. Results: All seven personality disorders assessed in the National Epidemiologic Survey on Alcohol and Related Conditions (i.e., avoidant, dependent, obsessive-compulsive, paranoid, schizoid, histrionic, and antisocial personality disorders) were associated with stomach ulcer, with odds ratio ranging from 2.26 (obsessive compulsive personality disorder) to 5.54 (dependent personality disorder). Participants with ulcer were five times more likely to have more than three personality disorders than participants without ulcer. The relationship between ulcer and personality disorders was only slightly attenuated after adjusting for sociodemographic conditions, physical and psychiatric disorders, and addictions. Conclusions: Self-reported peptic ulcer is associated with increased rates of personality disorders, beyond the influence of psychiatric disorders or addictions. NESARC = National Epidemiologic Survey on Alcohol and Related Conditions; AUDADIS-IV = Alcohol Use Disorders and Associated Disabilities Interview Schedule DSM-IV version; PDs = personality disorders; DSM-IV = Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition; PUD = peptic ulcer disease.

Sex differences in shoplifting: results from a national sample.

Abstract This study presents the sex differences in sociodemographics and in psychiatric correlates of shoplifting in the United States. Data were drawn from the National Epidemiologic Survey on Alcohol and Related Conditions, a nationally representative sample of US adults. Shoplifting was associated with numerous psychiatric and addictive disorders with significant sex effects. Women with a lifetime history of shoplifting were significantly more likely than men with a lifetime history of shoplifting to have a lifetime diagnosis of alcohol abuse or dependence, nicotine dependence, cannabis, amphetamine, cocaine, or inhalant use disorder, and antisocial personality disorder, whereas men were significantly more likely than women to have a lifetime diagnosis of generalized anxiety disorder. The findings suggest that shoplifting could be better understood as a behavioral manifestation of a broader impaired impulse control spectrum in women. Shoplifting could be more a part of the externalizing spectrum disorders rather than the internalizing spectrum disorders in women compared to men.

Hostility and the risk of peptic ulcer in the GAZEL cohort.

OBJECTIVE Evidence for an association between hostility and peptic ulcer mainly relies on cross-sectional studies. Prospective studies are rare and have not used a validated measure of hostility. This prospective study aimed to examine the association between hostility and peptic ulcer in the large-scale French GAZEL cohort. METHOD In 1993, 14,674 participants completed the Buss and Durkee Hostility Inventory. Participants were annually followed-up from 1994 to 2011. Diagnosis of peptic ulcer was self-reported. The association between hostility scores and ulcer incidence was measured by hazard ratios (HR) and 95% confidence intervals computed through Cox regression. RESULTS Among 13,539 participants free of peptic ulcer history at baseline, 816 reported a peptic ulcer during a mean follow-up of 16.8 years. Adjusting for potential confounders, including smoking, occupational grade, and a proxy for nonsteroidal anti-inflammatory drug exposure, ulcer incidence was positively associated with total hostility (HR per SD: 1.23, confidence interval: 1.14-1.31), behavioral hostility (HR per SD: 1.13, confidence interval: 1.05-1.21), cognitive hostility (HR per SD: 1.26, confidence interval: 1.18-1.35), and irritability (HR per SD: 1.20, confidence interval: 1.12-1.29). The risk of peptic ulcer increased from the lowest to the highest quartile for all hostility measures (p for linear trend < .05). CONCLUSIONS Hostility might be associated with an increased risk of peptic ulcer. Should these results be replicated, further studies would be needed to explore the underlying mechanisms.

Impact of switching or initiating antipsychotic treatment on body weight during a 6-month follow-up in a cohort of patients with schizophrenia.

Objective Although weight gain is one of the most widely studied adverse effects of second-generation antipsychotics, only relatively few studies have specifically evaluated the long-term effect of switching antipsychotic medication on body weight. We aimed to evaluate the impact of switching antipsychotics on body mass index (BMI) during a 6-month follow-up period in a large cohort of patients with schizophrenia. Method Data came from a 6-month prospective naturalistic survey in 6007 patients with schizophrenia. Results We prospectively studied the effect on BMI of initiating or switching antipsychotic medication after 6 months of treatment among 3801 patients with schizophrenia in a real-life setting. Patients who were being treated with clozapine or olanzapine at baseline were more likely to experience a decrease in BMI during the follow-up period than the patients who were being treated with a conventional antipsychotic (odds ratio, 2.25 and 1.68, respectively). Patients treated with aripiprazole and, to a lesser extent, those treated with risperidone were more likely to experience a decrease in BMI during follow-up than patients treated with conventional antipsychotics (odds ratio, 2.96 and 2.06, respectively). Conclusions Our findings suggest that switching antipsychotics could be an effective strategy for reducing or preventing weight gain.

Le mutisme hystérique

BACKGROUND Conversion disorders comprise many clinical pictures, including hysterical mutism. Hysterical mutism has emerged as a clinical entity that remains difficult to diagnose, and whose treatment is poorly codified. Hysterical mutism is a disorder of the vocal function without changing the integrity of the body, resulting in loss of voice. Identified at all times, hysterical mutism entered the medical field in the late nineteenth century, under the direction of Jean-Martin Charcot (Salpêtrière School). Since then, although the disorder has emerged as a clinical entity, it remains little known. METHOD A systematic review of the literature. We performed electronic literatures search of relevant studies using Medline, SUDOC, and BIUM. Search terms used were mutism, functional aphonia, conversion disorder, hysteria. RESULTS The epidemiology of hysterical mutism is difficult to assess. The first limitation is the lack of consensensual diagnostic criteria. An estimate of its frequency may be advanced through registries consultation of otolaryngology-head and neck surgery. Through a literature review, emerges a rare disorder, about 5% of functional dysphonia. The sex-ratio is in favour of women. Regarding age of onset of disorder, functional aphonia mainly concerns adults with an average around the age of 30-40 years. The onset of the disorder typically involves a sudden onset and a recent stressful event. The duration of the disorder is difficult to specify. It appears that this dysfunction is rapidly reversible and that the majority of patients are in remission of this disorder within three months. The recurrence of dysfunction seems to be frequent. The existence of psychiatric comorbidity did not appear to be the rule. The natural history of this disorder is not known making it tricky to evaluate the efficiency of therapeutic approaches. CONCLUSION Today the term hysterical mutism does not appear as an entity in either international classification. It belongs to the category of conversion disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). Identified as a medical entity described by the school of the Salpêtrière, this disorder has raised little interest. The medicalization of the condition remains difficult because of the importance of stigma associated with it, which contributes to the rejection rather than support of patients with mutism. To better understand this disorder and improve the care of patients who suffer, renewed interest is warranted.

Benedict Augustin Morel (1809–1873)

For scientists worldwide, 2009 was marked by celebrations of Charles Robert Darwin’s bicentenary. Born in the same year as the originator of modern evolutionary theory, Benedict Augustin Morel has also made a significant contribution to scientific thought. Indeed, Morel is the father of ‘dementia praecox’ and ‘the theory of degeneration’, two concepts that contributed to the understanding of mental illness at the turning point of the nineteenth and twentieth centuries. Morel, born in 1809 in Vienna, Austria, of French parents earned his medical doctorate in 1839 and 2 years later became secretary to the renowned Jean-Pierre Falret at the Salpêtrière hospital in Paris, France. He died of diabetes in 1873, having worked as director of the mental asylum at Saint-Yon after appointment in 1856 (1). Morel is the author of ‘Traité des dégénérescences physiques, intellectuelles et morales de l’espèce humaine’ published in 1857 (2). Inspired by the thinking of Saint Augustin and Rousseau, he formed the theory of degeneration, and as a devout Catholic conceived his hypothesis of degeneracy with a religious tinge. According to Morel’s theory, madness is the consequence of physical damage and/or moral injury, which are ultimately embodied in the nervous system. The nervous disorder is transmitted to one’s descendants, not in the specific form it took in the parent but as a morbid nervous pre-disposition. This pre-disposition is the causative matrix common to all mental disorders. Morel posits the notion of heredity as a biological determinant of madness. Through this theory, Morel offers a comprehensive global a etiological model that anchors psychiatric medicine to general medicine without assimilation, thereby explaining its success at the time (3). The theory of degeneration has since been adopted in many areas of medicine and beyond that has contributed to its outreach and dissemination, thus inspiring criminological (Lombroso’s theory of anthropological criminology), aesthetic (Max Nordau) and political doctrines with racist theories. Finally, it is worth noting that the theory of degeneration is captured within the description of French writer Emile Zola’s main work Les Rougon-Macquart. Although the theory of degeneration is regarded as outdated today, it is arguably this work that has placed Morel as a progenitor of the current biological approach to psychiatric illnesses.

Effects of Psychiatric Disorders on Suicide Attempt: Similarities and Differences Between Older and Younger Adults in a National Cohort Study

OBJECTIVE Several common psychiatric disorders are associated with increased risk of suicide attempts, and the strength of these associations may vary between younger and older adults, which may explain age differences in suicide risk. Because psychiatric disorders often co-occur, it remains unclear whether (1) the risk of suicide attempt in older and younger adults is due to specific psychiatric disorders or underlying psychopathology dimensions (ie, internalizing and externalizing dimensions) and (2) the extent to which individual psychiatric disorders make distinct contributions to suicide attempt risk varies by age. METHODS In a large nationally representative longitudinal survey, the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC; Wave 1, 2001-2002; Wave 2, 2004-2005), multiple-group structural equation modeling was used to examine shared and specific effects of DSM-IV-TR Axis I and Axis II disorders on the 3-year occurrence of suicide attempts in 4 different age groups (18-30 years, 31-40 years, 41-49 years, and ≥ 50 years). RESULTS The study population included 34,653 individuals. In each age group, effect of psychiatric disorders on risk of attempting suicide was almost exclusively mediated through a general psychopathology factor representing the shared effect across all disorders (P < .01). The magnitude of this effect was significantly lower in older than in younger adults (P < .05). No individual disorder had significant additional effects on attempt risk. CONCLUSIONS These findings underscore the importance of assessing suicide attempt risk in patients at all ages who present with common psychiatric disorders and the need for prevention strategies focused on the general psychopathology dimension.