Enhancing the capacity for optimal social and personality function through the mediational intervention for sensitizing caregivers: A case illustration.

OBJECTIVE: Based on the well-known principle that the ability to meaningfully relate to others starts in the context of early attachment relationships, the current case illustration uses a recent extension of mentalization-based theory and practice to demonstrate how caregivers can enhance the capacity for optimal social and personality function through the mediational intervention for sensitizing caregivers (MISC). METHODS: Case material is presented to demonstrate the implementation of the MISC affective and cognitive components with a mother of an adopted 10-year-old girl who shows signs of affect avoidance, social isolation within and outside the family, and maladaptive personality development. RESULTS: The case illustration shows how video feedback sessions facilitate the gradual use of affective and cognitive components in the daily interactions between mother and daughter, thereby scaffolding optimal social and personality development. CONCLUSIONS: Affective and cognitive components of the Mediational Intervention for Sensitizing Caregiving can be effectively integrated to enhance mentalizing capacity in caregiver-child interactions.

Five failures and five challenges for prevention and early intervention for personality disorder.

Despite global consensus regarding the early detection of personality disorder, current approaches to early intervention have failed to deliver for the majority of young people. This only serves to reinforce the enduring effects of personality disorder on functioning, mental and physical health, resulting in a reduction of quality of life and life expectancy. Here, we describe five significant challenges facing prevention and early intervention for personality disorder: identification, access to treatment, research translation, innovation and functional recovery. These challenges highlight the need for early intervention to shift from niche programmes in specialist services for a select few young people to become established in mainstream primary care and specialist youth mental health services.

Clozapine Reduces Self-Injurious Behavior in a State Prison Population.

Self-injurious behavior (SIB) is a common, disruptive, and costly occurrence in U.S. prisons. In this study, we describe the use of clozapine to treat 10 offenders with chronic, repetitive self-injury refractory to other medications and behavioral therapies. The primary diagnosis for all 10 offenders was a personality disorder. Eight of the 10 inmates allowed weekly blood draws and took medication regularly (approximately 95% adherence), whereas two inmates discontinued treatment within the first two weeks. For these eight patients, we compared the number of in-house urgent care visits and outside emergency room visits related to SIB for the six-month periods before and after treatment with clozapine. After initiation of clozapine treatment, there were 66 fewer urgent care visits (94 versus 28) and 26 fewer emergency room visits (37 versus 11), a 70 percent reduction in each. As a secondary outcome, we assessed disciplinary infractions. There were 132 fewer infractions (197 versus 65), a 67 percent reduction. The median dose of clozapine used was 125 mg/day, substantially lower than doses typically used to treat schizophrenia. Clozapine appears to be a feasible and effective treatment for some patients with chronic, repetitive SIB for whom other treatments have failed.

Are suicide risk factors gender specific? / Czy czynniki zwiazane z ryzykiem samobójstwa sa specyficzne dla plci?

OBJECTIVES: Suicide is an important clinical problem in psychiatric patients. The highest risk of suicide attempts is noted in affective disorders. In this study we tested 20 factors described in the literature (sociodemographic and clinical factors as well as family burden) in association with suicidal behavior and we analyzed whether the significance of those factors differs between males and females. METHODS: In the study we included patients with major depressive disorder (MDD; n = 249) and bipolar affective disorder (BP; n = 582). The Structured Clinical Interview for DSM-IV Axis I (SCID I), the Operational Criteria Diagnostic Checklist (OPCRIT) and a questionnaire of family history were used. RESULTS: In the study population we observed an association between suicidal attempts and the following factors: family history of psychiatric disorders, affective disorders and psychoactive substance abuse/dependence; family history of attempted/completed suicide; occurrence of specific symptoms in the course of depressive episode (inappropriate guilt, sense of worthlessness, early morning awakening); and psychotic symptoms. Having children was also associated with suicide attempts. The risk factors of suicide attempt differ between males and females. The age of onset of MDD and coexistence of substance abuse/dependence with affective disorder were significant for lifetime risk of attempted suicide only in female group. Having children was associated with suicide attempts in the whole group and in the male subgroup, but not in the female subgroup. CONCLUSIONS: Suicide attempts are significantly associated with 10 out of 20 analyzed clinical factors in our group of affective patients, however, the significance (or lack of it) of these factors differed in female and male groups in half the cases.

Time for a new zeitgeist in perinatal mental health.

Perinatal depression, and to a lesser extent anxiety, has been the focus of interest for perinatal psychiatrists for several decades. Policy and substantial funding has supported this. We argue that it is now time to change this focus and to invest greater funding to support clinical and research effort in 'high-risk' caregivers and their infants. We define high-risk caregivers as those who are likely to have attachment and relationship difficulties with their infant as a result of their own developmental experiences, personality difficulties and/or trauma-related mental disorders, often complicated by substance abuse, depression and anxiety. We propose that early intervention with such caregivers, focussing on both maternal mental health and on the needs of the infant for responsive and sensitive interaction and emotional care, would contribute to prevention of infant developmental disorders, with real gains to be made in breaking the transgenerational cycle of development of severe personality disorder.

Big Five personality traits may inform public health policy and preventive medicine: Evidence from a cross-sectional and a prospective longitudinal epidemiologic study in a Swiss community.

BACKGROUND: Some evidence documents the importance of personality assessments for health research and practise. However, no study has opted to test whether a short self-report personality inventory may comprehensively inform health policy. METHODS: Data were taken from a population-based epidemiologic survey in Zurich, Switzerland, conducted from 2010-2012. A short form of the Big Five Inventory was completed by n=1155 participants (54.4% women; mean age=29.6 years), while health-related outcomes were taken from a comprehensive semi-structured clinical interview. A convenience subsample averaging n=171 participants additionally provided laboratory measures and n=133 were subsequently followed-up at least once over a maximal period of 6 months. RESULTS: Personality traits, in particular high neuroticism and low conscientiousness, related significantly to poor environmental resources such as low social support (R(2)=0.071), health-impairing behaviours such as cannabis use (R(2)=0.071), and psychopathology, including negative affect (R(2)=0.269) and various mental disorders (R(2)=0.060-0.195). The proportion of total variance explained was R(2)=0.339 in persons with three or more mental disorders. Personality significantly related to some laboratory measures including total cholesterol (R(2)=0.095) and C-Reactive Protein (R(2)=0.062). Finally, personality prospectively predicted global psychopathological distress and vegetative symptoms over a 6-month observation period. CONCLUSIONS: Personality relates consistently to poor socio-environmental resources, health-impairing behaviours and psychopathology. We also found some evidence for an association with metabolic and immune functions that are assumed to influence health. A short personality inventory could provide valuable information for preventive medicine when used as a means to screen entire populations for distinct risk exposure, in particular with respect to psychopathology.

Maternal personality traits associated with patterns of prenatal smoking and exposure: Implications for etiologic and prevention research.

BACKGROUND: Little is known about the characteristics of women who smoke during pregnancy beyond demographic factors. We examined the relationship between novelty seeking, harm avoidance, and self-directedness and (a) abstinence from smoking during pregnancy and (b) average daily cigarette consumption during pregnancy. METHODS: Participants were 826 birth mothers who made adoption placements in the Early Growth and Development Study and completed the Temperament and Character Inventory - Short Form, and interview-based smoking assessments 3-6 months postpartum. Never smokers (n=199), pregnancy abstainers (n=277), pregnancy light smokers (n=184), and pregnancy heavy smokers (n=166) were compared on personality dimensions and smoking-related processes. Using regression analyses we examined relationships between personality and (a) abstinence versus smoking during pregnancy; and (b) average daily cigarette consumption among lifetime smokers, controlling for nicotine dependence, birth father substance dependence, maternal antisocial behavior, and depressive symptoms during pregnancy. RESULTS: Smokers with higher self-directedness and lower harm avoidance were more likely to abstain during pregnancy [O.R. 1.380; 95% C.I. (1.065-1.787); B(SE)=.322(.132); p=.015] and [O.R. .713; 95% C.I. (.543-.935); B(SE)=-.339(.138); p=.014], respectively. Novelty seeking differentiated never smokers from lifetime smokers (t=-3.487; p=.001), but was not significant in multivariate models. Lifetime smokers who abstained during pregnancy reported fewer depressive symptoms relative to never smokers. CONCLUSIONS: Personality dimensions associated with abstinence from smoking and cigarettes per day during pregnancy may be important to consider in etiologic and intervention research.

Evaluating a selective prevention program for substance use and comorbid behavioral problems in adolescents with mild to borderline intellectual disabilities: Study protocol of a randomized controlled trial.

BACKGROUND: Substance use and abuse is a growing problem among adolescents with mild to borderline intellectual disabilities (ID). Substance use patterns in general population are similar to patterns among non-disabled peers, but substance use has more negative consequences for adolescents with mild to borderline ID, and they are at an increased risk for developing a substance use disorder. Nevertheless, effective and evidence based prevention programs for this groups are lacking. The study described in this protocol tested the effectiveness of a selective intervention aimed at reducing substance use in adolescents with mild to borderline ID and behavioral problems. In the intervention, participants acquire competences to deal with their high-risk personality traits. METHODS: A randomized controlled trial will be conducted among 14-21-year old adolescents with mild to borderline ID and behavioral problems admitted to treatment facilities in the Netherlands. Inclusion criteria are previous substance use and personality risk for substance use. Participants will be individually randomized to the intervention (n = 70) or control (n = 70) groups. The intervention group will be exposed to six individual sessions and five group sessions carried out by two qualified trainers over six-week period. Primary outcomes will be the percentage reduction in substance use (for alcohol: percentage decrease of binge drinking, weekly use and problematic use, for cannabis: the percentage decrease of lifetime cannabis use and weekly use and for hard drug: the percentage decrease of lifetime use). Secondary outcomes will be motives for substance use, intention to use, and internalizing and externalizing behavioral problems. All outcome measures will be assessed after two, six, and twelve months after the intervention. DISCUSSION: This study protocol describes the design of an effectiveness study of a selective prevention program for substance use in adolescents with mild to borderline ID and behavioral problems. We expect a significant reduction in alcohol, cannabis and hard drug use among adolescents in the intervention group compared with the control group. TRIAL REGISTRATION: This trial is registered in the Dutch Trial Register (Cochrane Collaboration) as NTR5037 registered at 15 April 2015.

[A 43-year-old patient with character changes, recurrent impaired consciousness and retrograde amnesia]. / 43-jähriger Patient mit Wesensveränderung, rezidivierenden Bewusstseinsstörungen und retrograder Amnesie.

A 43-year-old male patient with recurring impaired consciousness and retrograde amnesia was admitted to the department of neurology. During the neurological evaluation no pathological findings could initially be revealed but one day the patient was confused again and presented with inadequate behavior: at this time a blood glucose value of 40 mg/dl was measured. For further evaluation the patient was transferred to our department. As the reason for the impaired consciousness was suspected to be of neuroglucopenic origin a rapid adrenocorticotropic hormone (ACTH) stimulation test was first performed to rule out adrenal insufficiency. For further evaluation a fasting test was conducted: after 48 h an episode with neuroglucopenic symptoms occurred again which disappeared after intravenous administration of glucose. The laboratory results of glucose, insulin and c-peptide determined at this point in time led to the diagnosis of an insulinoma. By ultrasound examination a hypoechogenic lesion 1.5 cm in size could be shown in the head of the pancreas and was confirmed by magnetic resonance imaging (MRI). After duodenum-preserving partial pancreatic head resection with enucleation of the insulinoma no further neuroglucopenic symptoms occurred.

Personality pathology factors predict recurrent major depressive disorder in emerging adults.

OBJECTIVE: Prior investigations consistently indicate that personality pathology is a risk factor for recurrence of major depressive disorder (MDD). Lack of emipircal support, however, for the Diagnostic and Statistical Manual of Mental Disorders (DSM) Fourth Edition organization of Axis II disorders supports the investigation of empirically derived factors of personality pathology as predictors of recurrence. METHOD: A sample of 130 previously depressed emerging adults (80% female; aged 18 to 21 years) were assessed for personality disorder symptoms at baseline. Participants were then followed for 18 months to identify MDD recurrence during the first 2 years of college. RESULTS: Based on a previous factor analysis of DSM personality disorder criteria, eight personality pathology factors were examined as predictors of MDD recurrence. Survival analysis indicated that factors of interpersonal hypersensitivity, antisocial conduct, and social anxiety were associated with increased risk of MDD recurrence. CONCLUSIONS: These findings suggest that an empirically based approach to personality pathology organization may yield useful predictors of MDD recurrence during emerging adulthood.

Implicit theories of personality and attributions of hostile intent: a meta-analysis, an experiment, and a longitudinal intervention.

Past research has shown that hostile schemas and adverse experiences predict the hostile attributional bias. This research proposes that seemingly nonhostile beliefs (implicit theories about the malleability of personality) may also play a role in shaping it. Study 1 meta-analytically summarized 11 original tests of this hypothesis (N = 1,659), and showed that among diverse adolescents aged 13-16 a fixed or entity theory about personality traits predicted greater hostile attributional biases, which mediated an effect on aggressive desires. Study 2 experimentally changed adolescents' implicit theories toward a malleable or incremental view and showed a reduction in hostile intent attributions. Study 3 delivered an incremental theory intervention that reduced hostile intent attributions and aggressive desires over an 8-month period.

[Personality disorders and working capacity]. / Persoonallisuushäiriöt ja työkyky.

Personality disorders are common: some personality disorder is present in 6 to 10% of the populations. These disorders appear mostly together with some other psychiatric disorder which often has a larger impact on the working ability than the personality disorder. Because personality disorders appear particularly in interactive relationships, the patients may impose strain on their work community and jeopardize the working capacity of their workmates. Work itself is likely to improve the prognosis of personality disorders. Thus, for a person with personality disorder after losing his/her working capacity, primary objectives are active therapeutic approach, as short sick leave as possible and support for returning to work.

Quarrelsomeness in daily life.

It is common in studies of interpersonal characteristics to examine personality variables as static predictors. Yet in recent years it has also become possible to examine personality and related interpersonal processes as they unfold over time in association with event specific cues. The present article reviews research that (1) identifies behaviors that reflect the occurrence of hostile-irritable-quarrelsome traits in daily life, (2) demonstrates both the stability and within-person variability of these behaviors over time, (3) documents event-level interpersonal cues that are systematically associated with within-person variation in quarrelsome behavior, and (4) describes how dispositional level agreeableness and irritability moderate the associations of event-level cues with quarrelsome behavior. The influence of the neurotransmitter serotonin on quarrelsome behavior is also considered. The studies indicate that quarrelsome individuals have reduced affective reactivity to engaging in quarrelsome behavior, increased behavioral reactivity to perceptions of quarrelsomeness in others, and greater responsiveness to change in serotonin levels.

Predictors of withdrawal: possible precursors of avoidant personality disorder.

Relations of avoidant personality disorder (AvPD) with shyness and inhibition suggest that a precursor of AvPD is withdrawal. Using a sample of 4.5- to 7-year-olds studied four times, 2 years apart, four and three classes of children differing in trajectories of mother- and teacher-reported withdrawal, respectively, were identified. Mothers and teachers generally did not agree on children's trajectories but the pattern of findings in the two contexts did not differ markedly. The mother-identified high and declining withdrawal class, in comparison with less withdrawn classes, and the teacher-identified high and declining class compared with low withdrawal classes, were associated with relatively high levels of anger and low levels of attentional control and resiliency. The mother-identified moderate and increasing withdrawal class was distinguished from less problematic withdrawal classes by higher anger, lower resiliency, and sometimes, lower attentional control. The teacher-identified low and increasing withdrawal class was distinguished from less problematic withdrawal classes by lower resiliency and lower attentional control. Findings are discussed in terms of the developmental precursors to social withdrawal and avoidant behavior.

Treatment with a C5aR antagonist decreases pathology and enhances behavioral performance in murine models of Alzheimer's disease.

Alzheimer's disease (AD) is an age-related dementia, characterized by amyloid plaques, neurofibrillary tangles, neuroinflammation, and neuronal loss in the brain. Components of the complement system, known to produce a local inflammatory reaction, are associated with the plaques and tangles in AD brain, and thus a role for complement-mediated inflammation in the acceleration or progression of disease has been proposed. A complement activation product, C5a, is known to recruit and activate microglia and astrocytes in vitro by activation of a G protein-coupled cell-surface C5aR. Here, oral delivery of a cyclic hexapeptide C5a receptor antagonist (PMX205) for 2-3 mo resulted in substantial reduction of pathological markers such as fibrillar amyloid deposits (49-62%) and activated glia (42-68%) in two mouse models of AD. The reduction in pathology was correlated with improvements in a passive avoidance behavioral task in Tg2576 mice. In 3xTg mice, PMX205 also significantly reduced hyperphosphorylated tau (69%). These data provide the first evidence that inhibition of a proinflammatory receptor-mediated function of the complement cascade (i.e., C5aR) can interfere with neuroinflammation and neurodegeneration in AD rodent models, suggesting a novel therapeutic target for reducing pathology and improving cognitive function in human AD patients.

Effect of pharmacological treatment on temperament and character in panic disorder.

Temperament and character were evaluated in patients with panic disorder (PD) before and after 1 year of pharmacological therapy to verify whether personality characteristics change after treatment. Therefore, 65 PD patients and 71 healthy subjects participated in the study. All subjects were evaluated with the SCID-IV, the Temperament and Character Inventory (TCI), the SCL-90, the Ham-A and the Ham-D. Patients were treated with paroxetine or citalopram. The TCI was re-administered to the patients at the end of the study. At the end of the study, complete remission was achieved by 31 patients (R), whereas symptoms did not disappear in the remaining 34 patients (NR). Before treatment, NR patients showed higher levels of harm avoidance (HA) and lower levels of persistence (P), self-directedness (SD) and cooperativeness (C) than healthy controls. Only HA levels were higher than normal in R, although they were significantly lower in R than in NR patients. These differences persisted after treatment. However, in NR patients the levels of SD and C worsened, whereas the difference between R patients and controls in HA levels (higher in R patients than in controls) disappeared after controlling the effect of residual phobic anxiety (higher than normal in R patients). Our data suggest that the high levels of HA found after remission may depend on the subsyndromal residual phobic symptoms, observed in R patients. Moreover, the persistence of anxious symptoms may have worsened the low levels of SD and C observed before treatment in patients who did not achieve remission.

Dangerous and severe personality disorder: an ethical concept?

Most clinicians and mental health practitioners are reluctant to work with people with dangerous and severe personality disorders because they believe there is nothing that mental health services can offer. Dangerous and severe personality disorder also signals a diagnosis which is problematic morally. Moral philosophy has not found an adequate way of dealing with personality disorders. This paper explores the question: What makes a person morally responsible for his actions and what is a legitimate mitigating factor? How do psychiatric nurses working with this client group understand the awful things some clients do? What concepts do they need, if they are to know how to explain and how to react? It is suggested that dangerous and severe personality disorder is best regarded as a moral category, framed in terms of goodness, badness, obligation and other ethical concepts. It seems plausible that in important ways the dangerous and severe personality disordered client does not understand morality or understands it differently. The peculiar position of the dangerous and severe personality disordered individual in our system of moral responsibility stems from his apparent inability to see the importance of the interests of others. It might be more helpful to regard personality disordered clients as we do children: partially but not fully reasonable for their actions. We might regard the dangerous and severe personality disordered client responsible for those actions which he most clearly understands, such as causing others physical pain, but not for those with which he is only superficially engaged, such as causing emotional pain. The paper concludes by suggesting that the dangerous and severe personality disordered individual does not fit easily into any conventional moral category, be it criminal, patient, animal or child, and thus an assessment of his moral accountability must take into consideration his special circumstances.

The importance of parenting in the development of disorganized attachment: evidence from a preventive intervention study in adoptive families.

BACKGROUND: As infant disorganized attachment is a serious risk factor for later child psychopathology, it is important to examine whether attachment disorganization can be prevented or reduced. METHOD: In a randomized intervention study involving 130 families with 6-month-old adopted infants, two attachment-based intervention programs were tested. In the first program, mothers were provided a personal book, and in the second program mothers received the same personal book and three home-based sessions of video feedback. The third group did not receive intervention (control group). RESULTS: The intervention with video feedback and the personal book resulted in enhanced maternal sensitive responsiveness (d=.65). Children of mothers who received this intervention were less likely to be classified as disorganized attached at the age of 12 months (d=.46), and received lower scores on the rating scale for disorganization than children in the control group (d=.62). In the book-only intervention group children showed lower disorganization ratings compared to the control group, but no effect on the number of infants with disorganized attachment classifications was found. CONCLUSION: Our short-term preventive intervention program with video feedback and a book lowered the rate of disorganized attachment. The effectiveness of our intervention documents the importance of parenting in the development of infant attachment disorganization.