A Bifactor Model of Personality Organization.

The aim of this study was to explore the viability of a bifactor model for the Inventory of Personality Organization (IPO), which is a self-report measure of personality functioning based on Kernberg's model of personality organization. A heterogeneous, predominantly clinical sample (N = 616) completed the German 83-item version of the IPO. Confirmatory and Exploratory Factor Analyses were applied to explore the factor structure of the IPO. We were able to establish a bifactor model with a general factor of personality functioning and three specific factors (Aggression, Reality Testing, Moral Values), which represent additional dimensions of personality organization. Virtually all items showed substantial positive loadings on the general factor, explaining roughly 66% of the common variance. Furthermore, we found support for convergent and discriminant validity of general and specific factors with regard to interview-based assessments of personality disorders and personality organization. The results lend support to a bifactor approach to Kernberg's model of personality organization. We also present a 30-item brief form of the IPO that efficiently implements the bifactor approach and may be further validated in future studies.

Changes in the level of personality functioning in inpatient psychotherapy.

Background: The model of Operationalized Psychodynamic Diagnosis and the model of Personality Organization influenced the concept of the Level of Personality Functioning (LPF) in DSM-V. The LPF is becoming a key variable for diagnostics, treatment and outcome measurement, but there are few studies which integrate the LPF in the study design. This study pursues to expand this body of knowledge by investigating the research question: would an inpatient psychotherapy lead to significant improvements in the LPF? Methods: The study included 156 inpatients at the Psychiatric Hospital Münsterlingen, Switzerland. Exclusion criteria were aggression, psychosis, mental retardation, and participation in another study. The LPF was measured with the Operationalized Psychodynamic Diagnosis-Structure Questionnaire (OPD-SQ) and the short version of the Inventory of Personality Organization (IPO-16) at admission and termination of treatment about eleven weeks later. A repeated-measures ANOVA controlled for age, symptom load, treatment duration and gender was conducted. Results: Data revealed significant, medium improvements for OPD-SQ (F(2,88) = 8.24, p < .01, ηp2 = 0.09) and IPO-16 (F(2,91) = 6.09, p < .05, ηp2 = 0.06) between admission and termination of psychotherapy and a different change pattern for OPD-SQ and IPO-16. Conclusion: Inpatient psychotherapy is associated with improvements in LPF.

The Effects of Co-prescription of Pantoprazole on the Clozapine Metabolism.

BACKGROUND: Polypharmacy including somatic medications such as proton pump inhibitors is a common phenomenon in psychiatric care. The aim of this study was to evaluate the pantoprazole effects on clozapine metabolism. METHODS: A large therapeutic drug-monitoring database containing plasma concentrations of CLZ was analyzed. The results were stratified into four groups: a non-smoking (n=250) and a smoking group (n=326), and two groups co-medicated with pantoprazole: non-smokers (n=26) and smokers (n=29). The analysis was based on the non-parametrical Mann-Whitney U test (M-W-U) with a significance level of 0.05. RESULTS: Differences reached statistical significance for pharmacokinetic parameters between CLZ monotherapy and co-medication with pantoprazole neither in smokers nor in non-smokers (p>0.05 for M-W-U in pairwise comparisons). In patients with clozapine monotherapy, smokers had a higher daily dosage of CLZ compared to non-smokers (mean dosage 363±181 vs. 291±145 mg/day, p<0.001 for M-W-U). CONCLUSIONS: Adding pantoprazole to an ongoing treatment with clozapine does not alter the metabolism of clozapine to a significant extent.

Disclosure of Diagnosis in Early Recognition of Psychosis.

There is a debate concerning risks and benefits of early intervention in psychosis, especially concerning diagnosis disclosure. The present study reports preliminary findings on self-reported locus of control and psychological distress after the disclosure of diagnosis in an early recognition center. We compared the ratings of the locus of control and psychological distress before and after communication of diagnosis. The study included individuals with an at-risk mental state (ARMS) (n = 10), schizophrenia (n = 9), and other psychiatric disorders (n = 11). Results indicate greater endorsement of the internal locus of control in individuals with ARMS after communication of diagnosis in contrast to the other groups. Our results suggest that disclosure of diagnosis in an early recognition center leads to a reduction of psychological distress and increased feelings of control over one's health. Persons with ARMS seem to particularly benefit from disclosure of diagnosis as part of early intervention.

Impact of Interpersonal Problems in Borderline Personality Disorder Inpatients on Treatment Outcome and Psychopathology.

BACKGROUND: Borderline personality disorder (BPD) is a very common illness; interpersonal problems are one of the core features. The purpose of this study was to investigate the changes in interpersonal problems after transference-focused psychotherapy (TFP)-based disorder-specific treatment and to explore whether the severity of interpersonal problems could serve as a predictor for other variables. SAMPLING AND METHODS: A sample of 37 inpatients with BPD was assessed with the Structured Clinical Interviews for DSM-IV Axis I and II Disorders (SCID I and II) and had to complete a questionnaire including the Inventory of Interpersonal Problems (IIP-C), Inventory of Personality Organization (IPO), Beck Depression Inventory (BDI), Spielberger State and Trait Inventory (STAI), Spielberger State and Trait Anger Inventory (STAXI), and Symptom Checklist-90 (SCL-90-R). After 12 weeks of TFP-based disorder-specific treatment, the patients repeated the same questionnaire; 7 patients had to be excluded from the study, and thus calculations were conducted with 30 patients. RESULTS: After treatment, the patients showed a significant decrease in the IIP total item score and all 8 subscales except the domineering, intrusive, and cold scales. The IIP total item baseline score was correlated with borderline symptomatic and psychopathology [e.g. anxiety, Global Severity Index (GSI)] after 12 weeks as well as with most IIP postsubscales. CONCLUSIONS: Although interpersonal problems are considered one of the more stable features of BPD, our results showed a significant improvement after 12 weeks of TFP-based disorder-specific inpatient treatment, especially in the total score and the subscales on the friendly submissive level. The severity of interpersonal problems at baseline was connected to outcome values of other borderline features as well as general psychiatric complaints. It therefore seems important to consider the treatment of interpersonal problems in therapy to be of greater significance.

Aberrant DNA Methylation of rDNA and PRIMA1 in Borderline Personality Disorder.

Borderline personality disorder (BPD) is a serious psychic disease with a high risk for suicide. DNA methylation is a hallmark for aberrant epigenetic regulation and could be involved in the etiology of BPD. Previously, it has been reported that increased DNA methylation of neuropsychiatric genes is found in the blood of patients with BPD compared to healthy controls. Here, we analyzed DNA methylation patterns of the ribosomal RNA gene (rDNA promoter region and 5'-external transcribed spacer/5'ETS) and the promoter of the proline rich membrane anchor 1 gene (PRIMA1) in peripheral blood samples of 24 female patients (mean age (33 ± 11) years) diagnosed with DSM-IV BPD and in 11 female controls (mean age (32 ± 7) years). A significant aberrant methylation of rDNA and PRIMA1 was revealed for BPD patients using pyrosequencing. For the promoter of PRIMA1, the average methylation of six CpG sites was 1.6-fold higher in BPD patients compared to controls. In contrast, the methylation levels of the rDNA promoter region and the 5'ETS were significantly lower (0.9-fold) in patients with BPD compared to controls. Thus, for nine CpGs located in the rDNA promoter region and for four CpGs at the 5'ETS decreased methylation was found in peripheral blood of patients compared to controls. Our results suggest that aberrant methylation of rDNA and PRIMA1 is associated with the pathogenesis of BPD.

Neuropsychological profile of a male psychiatric patient with a Morgagni-Stewart-Morel syndrome.

In 1765 Giovanni Morgagni described a syndrome consisting of hyperostosis frontalis interna (HFI), obesity and hirsutism. In 1928 Stewart and in 1930 Morel added neuropsychiatric symptoms, e.g. depression and dementia, which led to the definition of the Morgagni-Stewart-Morel Syndrome (MSM). Although mostly women were characterized in literature no gender specifity is demanded. This case report presents the rare case of a 66 year old male psychiatric patient with Morgagni-Stewart-Morel Syndrome. The patient complained of loss of concentration and difficulties with activities of daily living. Admission diagnosis was an opioid misuse on the basis of a chronic pain syndrome. In this case report we are describing clinical features, the patient history and technical (MRI) and neuropsychological tests. Although severe psychiatric symptoms and neuropsychological deficits are commonly seen in these patients, our patient showed only mild symptoms. This case reports shows the possibility of a male patient with MSM. If MSM is a separate entity or just an epiphenomena of hormone dysregulation should be investigated in further studies.

Change in Identity Diffusion and Psychopathology in a Specialized Inpatient Treatment for Borderline Personality Disorder.

OBJECTIVES: Patients with borderline personality disorder (BPD) show various psychopathological symptoms and suffer especially from disturbance in their identity. The purpose of the study was to investigate changes-particularly in affective BPD symptoms and identity diffusion-during a structured, disorder-specific inpatient treatment (DST) that combined a psychodynamic transference-focused psychotherapy approach with modules of dialectical behavioural skills training. METHOD: In a prospective, two-group comparison trial, 44 patients with BPD were assessed with questionnaires addressing identity diffusion and state, as well as trait affective psychopathology, before and after 12 weeks of inpatient treatment. Thirty-two patients received DST, whereas 12 patients were given inpatient treatment-as-usual (TAU). The patients were allocated in a non-random procedure for two groups, in order of admission and availability of treatment options in the DST unit. RESULTS: In the pre-post-comparison, the DST group showed a significant decrease in identity diffusion (p < 0.001) and improvements in instability of the image of self and others (p < 0.008), as well as in pathological (trait and state) symptoms. However, there was no significant improvement in the TAU group. CONCLUSIONS: After a 12-week inpatient treatment, the findings indicate significant improvements in the DST group in typical affective borderline symptomatology and in the personality structure feature of identity diffusion. This highlights the significance of a short-term specific inpatient therapy for BPD. KEY PRACTITIONER MESSAGE: A structured, disorder-specific inpatient treatment of patients diagnosed with borderline personality disorder (BPD) combined a psychodynamic transference-focused psychotherapy treatment approach (focusing on pathological features in personality organization, particularly on non-integrated images of self and others) with modules of dialectical behavioural skills training. This treatment is associated with a decrease in identity diffusion of these patients after 12 weeks of treatment. The treatment is also related to a significant decrease in borderline typical psychopathological symptoms such as depressive symptoms, as well as an improvement in state anger. The outcomes of this structured, disorder-specific inpatient treatment of severely ill BPD patients indicated the relevance of intensive short-term inpatient psychotherapy in terms of psychopathological improvements as well as initial changes in structural personality organization.

[Standardization of the German 16-item short version of the Inventory of Personality Organization (IPO-16)]. / Normierung der deutschsprachigen 16-Item-Version des Inventars der Persönlichkeitsorganisation (IPO-16).

UNLABELLED: Standardization of the German 16-item short version of the Inventory of Personality Organization (IPO-16). OBJECTIVES: The 16-item short version of the Inventory of Personality Organization (IPO-16) is a self-report measure assessing the severity of personality dysfunction. This study provides representative norms and determines the smallest real difference value for the IPO-16. METHODS: Standardization of the IPO-16 was based on a representative survey among the German general population (N = 2502). Retest reliability and the smallest real difference were assessed in a separate longitudinal online survey, whereby participants completed the IPO-16 three times at time intervals of 2 months (N = 495). RESULTS: The average IPO-16-mean score in the general population was 1.87. The influence of age and sex was small, albeit statistically significant.We therefore developed sex- and age-specific norms. The average retest reliability across 2 months was .85, and the smallest real difference was 0.66. CONCLUSIONS: The IPO-16 is a well-validated, and now standardized, screening instrument for the assessment of severity of personality dysfunction. It can be recommended for use in research and practice.

Comorbid atypical depression in borderline personality disorder is common and correlated with anxiety-related psychopathology.

BACKGROUND: The core features of borderline personality disorder (BPD) are affective instability, unstable relationships and identity disturbance. Axis I comorbidities are frequent, in particular affective disorders. The concept of atypical depression is complex and often underestimated. The purpose of the study was to investigate the comorbidity of atypical depression in borderline patients regarding anxiety-related psychopathology and interpersonal problems. METHODS: Sixty patients with BPD were assessed with the Structured Clinical Interviews for DSM-IV Axis I and II Disorders (SCID I, SCID II) as well as the Atypical Depression Diagnostic Scale (ADDS). Additionally, patients completed a questionnaire (SCL-90-R, BDI, STAI, STAXI, IIP-C). RESULTS: Forty-five BPD patients (81.8%) had a comorbid affective disorder of which 15 (27.3%) were diagnosed with an atypical depression. In comparison to patients with major depressive disorder or no comorbid depression, patients with atypical depression showed significant higher scores in psychopathological symptoms regarding anxiety and global severity as well as interpersonal problems. CONCLUSIONS: The presence of atypical depression in borderline patients is correlated with psychopathology, anxiety, and interpersonal problems and seems to be of clinical importance for personalized treatment decisions.

Cannabis use among a sample of 16 to 18 year-old students in Switzerland.

BACKGROUND: The aim of this study was to estimate the prevalence of cannabis use among Swiss students and to assess their attitudes regarding health and safety issues associated with drug use. SUBJECTS AND METHODS: After a workshop, 173 students (23.1% male, 75.7% female; 44.4% age 16, 43.8% age 17 and 11.8% age 18) from a Swiss school were surveyed by questionnaire. RESULTS: 59.3% (n=103) of all participants had tried cannabis, and 30.1% of those who reported cannabis use had consumed more than 100 joints. Of those 103 students with cannabis experience, 6.8% rated the risk of cannabis-related psychic effects as low, and 9.8% were not concerned about driving under the influence of cannabis. In cases of heavy cannabis use, the chance of increased tobacco, alcohol or other drug use is higher than for those with less or no cannabis use at all (odds ratios of 4.33-10.86). CONCLUSIONS: This paper deals primarily with cannabis prevalence data in adolescents from previous studies and sources, and shows that our findings deviate significantly - and surprisingly - from past research. Our data from a school survey indicates higher cannabis use than data from official drug policy studies. Additionally, our data shows that the students' self-reported attitudes towards health and safety issues were mostly realistic. The examination of methodological issues that might impact prevalence estimates should be added to the cannabis literature.

"By the foolish Paynter Bayer"--characteristics of the psychopathology of expression in a previously unknown work of the early 18th century by a very probably schizophrenic heraldic painter and his identification.

BACKGROUND: Whether schizophrenia existed before the 19th century is an important issue within the history of psychiatry. Written records or other documents that could identify this psychopathology are extremely rare and must therefore be subjected to meticulous historical and psychopathologic analysis. METHODS: A previously unknown heraldic sheet, with accompanying text, was subjected to historical, heraldic, and psychopathologic analysis. The contemporary inscription "by the mad paynter Bayer" was found on the back of the painting. The phenomenologic analysis emphasized the phenomenology of Jaspers for the formal criteria of a psychosis. RESULTS: Many of the characteristics as seen typical psychopathologic of presumably schizophrenic psychoses by some authors can be found in the formal features of the work. Moreover, a precise historic and heraldic investigation (blazon) allowed us to assign this previously anonymous work to an artist of the period around 1720 to 1740, Abraham Beurer, and to find his contemporary portrait. CONCLUSIONS: This is one of the earliest works that can be unambiguously assigned to the psychopathology of expression (art brut). The formal features of schizophrenia appear to be remarkably typical, timeless, and stable, although the objective features are strictly historical. The work provides further evidence that there were individual cases of schizophrenia even before the 18th century. The external designation as "mad" provides important additional support for this view.

Association between leptin levels and doses of clomethiazole during alcohol withdrawal: a pilot study.

AIMS: The issue of leptin as a putative state marker of alcohol use and its role in craving has been raised in the last few years. Recently, a strong GABA-ergic modulation of leptin was postulated. The aim of the pilot study was to examine leptin levels in correlation with the strongly GABA-mimetic active substance clomethiazole. The main hypothesis was that higher doses of the strong GABA-mimetic clomethiazole are positively correlated with higher leptin levels. METHODS: Twenty-eight alcohol-dependent patients (3 females, median age 36 years) undergoing alcohol withdrawal were included. In 18 patients with and 10 without clomethiazole, serum leptin was analyzed at day 1 and day 7 of alcohol withdrawal. Both groups did not differ by age, BMI, or alcohol use characteristics. RESULTS: In the clomethiazole group, significant correlations were found between leptin levels at day 1 and clomethiazole dose (p = 0.004), clomethiazole and leptin at day 1/BMI (p = 0.009) and leptin at day 1 and clomethiazole/body surface (p = 0.006). Furthermore, patients with higher clomethiazole doses demonstrated significant higher leptin levels at day 1 (p = 0.044) and day 7 (p = 0.046). CONCLUSIONS: Our pilot data show a strong association between leptin levels and clomethiazole doses, thus supporting further research.

Associations between identity diffusion, Axis II disorder, and psychopathology in inpatients with borderline personality disorder.

BACKGROUND: Patients with borderline personality disorder (BPD) suffer from instability in their relationships, their affectivity, and their identity. However, the associations between these dimensions are not clear. The purpose of the present study was to investigate the relation between identity diffusion and psychopathology in BPD. METHODS: In the second week of inpatient treatment, 52 patients with BPD were assessed with the Inventory of Personality Organization (IPO) and questionnaires measuring general psychiatric symptoms, mood states, and negative affects (SCL-90-R, BDI, STAI, and STAXI). A median split was examined to differentiate BPD patients with high identity diffusion from those with low identity diffusion. RESULTS: BPD patients with high identity diffusion did not differ in their social data from BPD patients with low identity diffusion. However, BPD patients with high identity diffusion showed significantly higher levels of psychiatric symptoms, as well as higher anxiety, anger, and depression scores (p < 0.01). Moreover, they suffered more frequently from concurrent personality disorders (p < 0.05). CONCLUSIONS: These findings indicate an association of identity diffusion with psychopathological symptoms and features of personality disorder and emphasize the clinical significance of identity diffusion for patients with BPD.

[Multisystemic Therapy (MST) for adolescents with severe conduct disorders in German-speaking Switzerland - implementation and first results]. / Multisystemische Therapie (MST) für Jugendliche mit schweren Störungen des Sozialverhaltens.

OBJECTIVE: To determine the extent to which MST can be applied in German-speaking Switzerland, and the extent to which respectable international treatment outcomes can be replicated. METHOD: A sample of 70 adolescents was treated for an average of 155 days. Of these adolescents, 60 (85.5 %) remained in the study until the conclusion of treatment. The results of the parent version of the Strengths and Difficulties Questionnaire (SDQ) are available for 38 (63.3 %) of the completers. For 52 patients (86.7 %), the therapist ratings for Values for Clinical Global Impression (CGI) and for Global Assessment of Functioning (GAF) are available. RESULTS: The overall problem score of the parent version of the SDQ was reduced from 20 at the beginning of treatment to 14.6 at the conclusion of treatment. The overall score of the GAF improved from 55.4 to 70.3, and the CGI improved from 3.6 to 2.7 points. These results are statistically highly significant. The 6-month follow-up interview revealed treatment success rates of 91 % for «adolescent remains in his family of origin,¼ 94 % for «adolescent remains in school or vocational training,¼ and 91 % for «adolescent does not commit chargeable offences.¼ The 18-month follow-up interviews show success rates of 80 %, 86 %, and 86 %, respectively. CONCLUSIONS: Multisystemic Therapy is a complex treatment program that is clearly applicable in the cultural environment of Switzerland. Respectable international results were replicated in this sample.

Facial Affective Behavior in Borderline Personality Disorder Indicating Two Different Clusters and Their Influence on Inpatient Treatment Outcome: A Preliminary Study.

BACKGROUND: The purpose of the present study was threefold: first, to investigate the facial affective behavior in patients with a borderline personality disorder (BPD); second, to examine whether these patients could be divided into clusters according to facial affective behavior; and third, to test whether these clusters would influence the inpatient treatment outcome. METHODS: Thirty inpatients with BPD were assessed with the Structured Clinical Interviews for DSM-IV Axis I and II Disorders (SCID I, SCID II) and had to complete a series of questionnaires before and directly after the 12-week long inpatient treatment. Facial affective behavior was recorded during the structured interview for personality organization (STIPO) and afterward coded with the emotional facial action coding system (EMFACS). Measures on psychopathology [beck depression inventory (BDI), Spielberger state and trait anxiety inventory (STAI), Spielberger state and trait anger inventory (STAXI), and symptom cheklist-90-revised (SCL-90-R)], interpersonal problems [Inventory of Interpersonal Problems (IIP)], and personality organization [inventory of personality organization (IPO)] were administered. RESULTS: Cluster analysis before the treatment yielded two groups that differed in general facial expressivity, and regarding the display of anger, contempt, and disgust. The effect sizes of the repeated measures ANOVAs showed that persons with higher scores on the affective facial expressions benefitted more from the treatment in terms of STAI state anxiety, STAXI state and trait anger, IIP total, and the two scales primitive defenses and identity diffusion of the IPO, whereas persons with lower scores benefitted more on the scale IPO reality testing. CONCLUSION: Our results indicated some initial trends for the importance of facial affective behavior in patients with BPD and their treatment outcome.

The lack of negative affects as an indicator for identity disturbance in borderline personality disorder: a preliminary report.

BACKGROUND: Patients with borderline personality disorder (BPD) suffer from instability of their relationships, their affectivity and their identity. The purpose of the study was to investigate negative affects and identity disturbance in patients with BPD and in patients without personality disorder using questionnaire data and interview data. SAMPLING AND METHODS: Twelve patients with BPD and 12 patients with major depressive disorder without any personality disorder were assessed with the Structured Interview of Personality Organization (STIPO) and questionnaires (Inventory of Personality Organization, Beck Depression Inventory, State-Trait Anxiety Inventory). They were compared with respect to the frequency of negative affective verbal expressions using computerized content analysis methods. RESULTS: BPD patients showed higher levels of anxiety, depression and identity diffusion in the questionnaires than major depressive disorder patients without personality disorder. However, they did not report more negative affective expressions in the interview. Patients with identity disturbance of both groups showed higher values of negative mood in the questionnaires, but less anger, less anxiety and less affective intensity in the interview. CONCLUSION: The preliminary findings indicate that patients with identity disturbance show high levels of negative affects in questionnaires but only few negative affects in the interview situation. More studies are needed to enhance the understanding of negative affects and identity disturbance in BPD.

Alcoholism, craving, and hormones: the role of leptin, ghrelin, prolactin, and the pro-opiomelanocortin system in modulating ethanol intake.

Evidence is growing that appetite regulating peptides such as leptin and ghrelin, but also other hormones including prolactin are altered in alcoholism. The brain pro-opiomelanocortin (POMC) system which has important mediating roles in alcohol intake also has important functions in prolactin regulation and energy homeostasis. Furthermore, it has been demonstrated to be functionally integrated with leptin regulation. The satiety factor leptin seems to be counteracted by the gut-derived peptide ghrelin which increases hunger and food intake. Consequently, the POMC system may have a role in integrating regulation of alcohol effects and these seemingly disparate regulatory systems. The goal of this mini-review is to discuss the results of some recent investigations of the potential interactions of these systems with acute and chronic alcohol responses.