Jill I. Mattia

Axis I diagnostic comorbidity and borderline personality disorder

Borderline personality disorder (PD) has been the most studied PD. Research has examined the relationship between borderline PD and most axis I diagnostic classes such as eating disorders, mood disorders, and substance use disorders. However, there is little information regarding the relationship of borderline PD and overall comorbidity with all classes of axis I disorders assessed simultaneously. In the present study, 409 patients were evaluated with semistructured diagnostic interviews for axis I and axis II disorders. Patients with a diagnosis of borderline PD versus those who did not receive the diagnosis were assigned significantly more current axis I diagnoses (3.4 v 2.0). Borderline PD patients were twice as likely to receive a diagnosis of three or more current axis I disorders (69.5% v 31.1%) and nearly four times as likely to have a diagnosis of four or more disorders 147.5% v 13.7%). In comparison to nonborderline PD patients, borderline PD patients more frequently received a diagnosis of current major depressive disorder (MDD), bipolar I and II disorder, panic disorder with agoraphobia, social and specific phobia, posttraumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), eating disorder NOS, and any somatoform disorder. Similar results were observed for lifetime diagnoses. Overall, borderline PD patients were more likely to have multiple axis I disorders than nonborderline PD patients, and the differences between the two groups were present across mood, anxiety, substance use, eating, and somatoform disorder categories. These findings highlight the importance of performing thorough evaluations of axis I pathology in patients with borderline PD in order not to overlook syndromes that are potentially treatment-responsive.

Psychiatric diagnosis in clinical practice: is comorbidity being missed?

The recognition of comorbidity has important clinical significance. Comorbidity predicts a poorer outcome for patients with depressive and anxiety disorders, and the presence of multiple psychiatric disorders is associated with greater psychosocial impairment. In routine clinical settings, an unstructured interview is typically used to assess patients. However, unstructured interviews may result in missed diagnoses, with potential negative clinical consequences. The goal of the present study was to examine whether diagnostic comorbidity is less frequently identified during a routine clinical evaluation versus a semistructured diagnostic interview. Axis I diagnoses derived from structured and unstructured clinical interviews were compared in two groups of psychiatric outpatients in the same practice setting. Five hundred individuals presenting for an intake appointment to a general adult psychiatric practice underwent a routine unstructured clinical interview. Subsequent to completion of the first study, the method of conducting diagnostic evaluations was changed and 500 individuals were interviewed with the Structural Clinical Interview for DSM-IV Axis I Disorders (SCID). The two groups had similar demographic characteristics and scored similarly on symptom questionnaires. Individuals interviewed with the SCID were assigned significantly more axis I diagnoses than individuals assessed with an unstructured interview. More than one third of the patients interviewed with the SCID were diagnosed with three or more disorders, in contrast to fewer than 10% of the patients assessed with an unstructured interview. Fifteen disorders were more frequently diagnosed in the SCID sample, and these differences occurred across mood, anxiety, eating, somatoform, and impulse-control disorder categories. The results suggest that in routine clinical practice, clinicians underrecognize diagnostic comorbidity. Anxiety, somatoform, and not otherwise specified (NOS) disorders were the most frequently underdetected disorders. The implications of underdiagnosis for the treatment outcome are discussed.

Clinical correlates of self-mutilation in a sample of general psychiatric patients.

The aims of this study were to examine whether certain axis I disorders characterized by impulsive aggression were associated with self-mutilative behavior and to evaluate the clinical correlates of self-mutilation in a sample of general psychiatric outpatients. Two hundred fifty-six outpatients were administered diagnostic interviews for axis I and axis II disorders. In addition, questionnaires that measured self-mutilative acts within the last 3 months, dissociation, and childhood abuse were completed. This study found that axis I disorders of substance abuse, posttraumatic stress disorder, and intermittent explosive disorder were significantly related to self-mutilative behavior, independent of borderline personality disorder and antisocial personality disorder. Also, a higher level of dissociation was related to self-mutilation, controlling for borderline personality disorder and childhood abuse. Outpatients with certain axis I disorders and those who dissociate may represent a sizable group of patients who are at risk for self-mutilative behavior.

The relationship between posttraumatic stress disorder, childhood trauma and alexithymia in an outpatient sample

One aim of this study was to examine the strength of association between posttraumatic stress disorder (PTSD) and alexithymia relative to other psychiatric disorders in a sample of 252 treatment-seeking psychiatric patients. The other aim of this study was to explore which type of childhood trauma was associated with a greater level of adult alexithymia. The study found that PTSD and borderline personality disorder (BPD) were the two disorders among selected psychiatric disorders to contribute independently to a higher degree of alexithymia. Another finding was that a greater severity of emotional neglect and physical neglect, rather than abuse, was significantly related to higher levels of alexithymia. In addition, the study found that among these variables, BPD had the strongest relationship to alexithymia.

Body dysmorphic disorder in psychiatric outpatients: Recognition, prevalence, comorbidity, demographic, and clinical correlates

The prevalence of Body Dysmorphic Disorder (BDD), based on structured and unstructured clinical interviews, was compared in two samples of psychiatric outpatients drawn from the same practice setting. In the first sample, 500 patients were diagnosed according to a routine, unstructured clinical interview. In the second sample, 500 subjects were diagnosed according to information obtained by the Structured Clinical Interview for DSM-IV (SCID). No patient was diagnosed with BDD in the clinical sample, whereas 16 (3.2%) patients were diagnosed with BDD in the SCID sample. Compared with patients without BDD, patients with BDD received significantly more current axis I diagnoses, and were more likely to be diagnosed with current obsessive-compulsive disorder (OCD) and social phobia. Both groups were diagnosed with major depression at similar rates. Patients with BDD, versus those without, tended to be sicker and more functionally impaired. It appears that BDD is an infrequent disorder in an outpatient setting, which is rarely recognized when clinicians conduct their routine diagnostic interview. Although it was not usually a patients principal reason for seeking treatment, the majority of patients with BDD in this sample wanted their treatment to address these symptoms.

Is posttraumatic stress disorder underdiagnosed in routine clinical settings

The goal of the present study was to examine whether posttraumatic stress disorder (PTSD) is underrecognized in routine clinical practice. One thousand patients were evaluated at the Rhode Island Hospital Department of Psychiatry outpatient practice. The first 500 patients completed a psychiatric diagnostic screening questionnaire that included a PTSD subscale. The next 500 individuals were interviewed with the Structured Clinical Interview for DSM-IV (SCID). In the first 500 patients, 36 (7.2%) patients were diagnosed by their clinicians with PTSD and an additional 18.6% of the sample screened positive on the questionnaire but were not diagnosed with PTSD. The patients who were diagnosed with PTSD and the patients who screened positive but were not given the diagnosis were significantly younger, had lower GAF scores, and less frequently graduated from college than the non-PTSD group. The frequency of suicidal thoughts was identical in the two PTSD groups and twice as high as the frequency in the non-PTSD group. Scores on 9 of the other 12 psychopathology dimensions assessed by the screening questionnaire were significantly higher in the two PTSD groups than the non-PTSD group. In the 500 patients interviewed with the SCID the prevalence of PTSD was two times higher than in the 500 patients diagnosed with an unstructured clinical interview (14.4% vs. 7.2%). The difference in prevalence rates of PTSD between the SCID and clinical samples was significant when considering PTSD as an additional diagnosis; there was no difference in prevalence rates when restricting the analysis to principal diagnoses. The results of this study suggest that PTSD is frequently overlooked in routine clinical practice when symptoms of PTSD are not the presenting complaint.

Clinical features of survivors of sexual abuse with major depression

OBJECTIVE This study examined differences in rates of trauma-related disorders between patients with histories of childhood sexual abuse and those without such histories in a sample of depressed outpatients. Another aim of this study was to determine whether childhood sexual abuse is associated with recent suicidal attempts, affect dysregulation and duration of index depressive episode, independent of posttraumatic stress disorder and borderline personality disorder. METHOD Subjects were 235 treatment-seeking outpatients with major depression. Structured interviews were administered to assess for Axis I and Axis II disorders, childhood sexual abuse, and various clinical features. RESULTS Patients with sexual abuse compared to those without sexual abuse histories had higher rates of comorbidity, primarily borderline personality disorder, posttraumatic stress disorder and multiple Axis I diagnoses. Childhood sexual abuse status was linked to a longer duration of the index depressive episode, independent of borderline personality disorder and/or posttraumatic stress disorder. However, childhood sexual abuse status was not independently related to affect dysregulation and suicidal attempts. CONCLUSION The findings suggest that patients with histories of sexual abuse represent a subgroup of depressed patients who are at especially high risk for psychiatric morbidity and a prolonged episode of depression.

Comorbidity burden and its impact on psychosocial morbidity in depressed outpatients.

BACKGROUND Many studies have examined the co-occurrence of depression and one or two nondepressive disorders; however, little research has looked at broad spectrum comorbidity (i.e., comorbidity across several diagnostic categories) in depressed patients. Research on diagnostic practices in routine clinical settings--in which unstructured interviewing is the norm--suggests that comorbid conditions are often not detected [Zimmerman, M., Mattia, J. 1999. Psychiatric diagnosis in clinical practice: Is comorbidity being missed? Compr. Psychiatry, 40, 182-191]. In this study we examined the independent impact of different comorbid diagnostic categories on psychosocial morbidity in psychiatric outpatients with Major Depressive Disorder (MDD). METHODS Participants were drawn from a pool of 1000 psychiatric outpatients interviewed with the Structured Clinical Interview for DSM-IV diagnoses (SCID-IV; [First, M.B., Spitzer, R.L., Williams, J.B.W., Gibbon, M., 1995. Structured Clinical Interview for DSM-IV (SCID). American Psychiatric Association, Washington, D.C.]). We compared the demographics, clinical characteristics, and psychosocial functioning of depressed outpatients with and without different axis I comorbidities, then conducted multivariate analyses to determine the respective impact of comorbid axis I disorders. RESULTS Three hundred and seventy-three patients had a principal diagnosis of unipolar MDD. One hundred twenty-nine (34.6%) were diagnosed with MDD only, and 244 (65.4%) had MDD and at least one other axis I disorder. Comorbidity was associated with longer duration of index episode, more psychiatric morbidity, and more social and occupational impairment. There was also a significant relationship between increasing number of comorbid axis I disorders and greater psychiatric and psychosocial impairment. In regression analyses, comorbidity burden (i.e., the number of comorbid axis I disorders) showed the strongest relation to psychiatric and psychosocial impairment. LIMITATIONS This is not a random sample of depressed outpatients and, thus, may not be generalizable to all outpatients with depression. Second, Axes II and III comorbidity were not assessed. CONCLUSIONS Comorbidity burden showed the strongest relation to impairment over and above the presence of any particular class of disorders.