May 2010

Vol. 22. No. 2


Giving personality disorders their due

“All is caprice, they love without measure those whom they will soon hate without reason.”
Thomas Sydenham
     This issue of Annals of Clinical Psychiatry presents a series of articles exploring personality disorders, which clinicians often underappreciate. With DSM-III in 1980, personality disorders were accorded new status on a separate axis (Axis II), which I believe had the unintentional effect of devaluing personality disorders’ importance by suggesting they are lesser disorders. Many of our patients’ primary problem is a personality disorder, not dysthymia, panic disorder, or adjustment disorder coded on Axis I. 

     The current system for diagnosing personality disorders is imperfect, yet the DSM-5 draft represents a major change that involves creating 5 personality “types”— rather than the currently recognized 10—and dimensionally coding up to 37 “trait facets.” I have argued that psychiatrists think categorically and, although psychologists and researchers favor dimensional systems, such systems are cumbersome for busy clinicians. In addition, clinicians worry about reimbursement, which generally is tied to a diagnostic code. I encourage readers to see for themselves and submit their comments at

     In this issue, we begin with a review of methodological considerations for treatment trials in persons with borderline personality disorder (BPD) by Mary C. Zanarini, EdD, and colleagues. This article describes the problems of conducting research with BPD patients and makes useful recommendations. Frederick W. Reimherr, MD, and colleagues, including Reid J. Robison, MD, and Erika D. Williams, MSW, contribute 3 articles describing personality disorders in persons with attention-deficit/hyperactivity disorder, including prevalence, social adjustment, and the effect of personality disorder symptoms on antidepressant response. My colleagues and I describe the impact of antisocial personality disorder on incarcerated offenders. Zoltán Rihmer, MD, PhD, DSc, and the late Franco Benazzi, MD, PhD, DTMH, explore the effect of specific BPD traits (impulsivity and affective instability) on suicidality and confirm that impulsivity is a strong independent predictor. Patrick J. Marsh, MD, in collaboration with Jon E. Grant, JD, MD, MPH, and his team, presents data on the prevalence of paraphilia and shows its alarming frequency in adult psychiatric inpatients. 

     I was saddened to learn that Dr. Benazzi passed away on August 22, 2009, at age 52. He was a remarkably productive researcher and writer, committed to gaining a better understanding of mood disorders. Few know that he was a solo practitioner in a small Italian community who systematically reported clinical observations from his own patients. 

     It was great to see many friends and colleagues at the recent American Academy of Clinical Psychiatrists (AACP)/Current Psychiatry meeting April 8 to 10, 2010. Chicago is a great place in the spring, and the meeting, “Mood and anxiety disorders: Solving clinical challenges, improving patient care,” was our best attended ever. The quality of the speakers and topics attracted clinicians from around the country. I hope that attending our annual meeting will become a habit for our friends and new AACP members.



Personality disorder in ADHD Part 1: Assessment of personality disorder in adult ADHD using data from a clinical trial of OROS methylphenidate

Erika D. Williams, MSW | Frederick W. Reimherr, MD | Barrie K. Marchant, MS | Robert E. Strong, DO | Corinne Halls, MS | Poonam Soni, MD | Philip D. Gale, MD | Reid J. Robison, MD

BACKGROUND: Comorbidity of personality disorder (PD) and attention deficit/hyperactivity disorder (ADHD) has been suggested in several reports. However, assessment of PD is problematic, and studies have over relied on baseline evaluations.

METHODS: Forty-seven patients entered a double-blind trial of osmotic release oral system (OROS) methylphenidate (MPH). Patients were assessed at baseline with the Wisconsin Personality Inventory IV (WISPIIV) and the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II). Following the study, all information—including tests, family reports, and extended clinical observations—produced a final PD diagnosis. Three post hoc categories were created: PD-negative (no PD), PD-positive (1 PD), and PD-plus (2 or more PDs).

RESULTS: Twenty-one (45%) patients had a PD on the final assessment vs 62% using SCID-II and 33% using WISPI-IV; final PD diagnosis revealed 9% cluster A, 17% cluster B, and 28% cluster C. Twenty-one percent of patients experienced multiple disorders. Using a weighted kappa, the number of PDs on the final assessment correlated with the WISPI-IV (κ =.53; P > .001) and the SCID-II (κ =.70; P < .001). However the SCID-II overidentified and the WISPI-IV underidentified PD.

CONCLUSION: Almost all PDs were represented in this sample, and past emphasis on cluster B appears unwarranted. Although the SCID-II and WISPI-IV had limited success in identifying specific PDs, they were more successful in identifying the number of PDs present in each patient. The small sample makes these findings preliminary.


Personality disorders in ADHD Part 2: The effect of symptoms of personality disorder on response to treatment with OROS methylphenidate in adults with ADHD

Reid J. Robison, MD | Frederick W. Reimherr, MD | Philip D. Gale, MD | Barrie K. Marchant, MS | Erika D. Williams, MSW | Poonam Soni, MD | Corinne Halls, MS | Robert E. Strong, DO

BACKGROUND: This study explored the relationship between personality disorder (PD) and treatment response in a randomized, double-blind, clinical trial of osmotic release oral system (OROS) methylphenidate (MPH).

METHODS: Forty-seven patients entered a crossover trial using the Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADDS) to assess outcome. A final personality diagnosis was made using staff consensus and information from the Wisconsin Personality Inventory IV (WISPI-IV) and the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II). Three post hoc categories were created: PD-negative (no PD; n = 26), PD-positive (patients with 1 PD; n = 11), and PD-plus (patients with 2 or more PDs; n = 10). Improvement in attention-deficit/hyperactivity disorder (ADHD) symptoms was assessed using a mixed-model analysis with treatment and personality categories as fixed variables. Average z scores on the WISPI-IV and items endorsed on SCID-II provided dimensional measures of PD severity.

RESULTS: Different treatment effects were observed for the PD subgroups (P < .001). PD-negative patients improved 40% on OROS MPH vs 7% on placebo, and PD-positive patients improved 66% on OROS MPH vs 9% on placebo. In contrast, PD-plus patients improved 26% on OROS MPH vs 23% on placebo.

CONCLUSION: Most patients experienced significantly reduced ADHD symptoms on OROS MPH; however, patients with 2 or more PDs did not. The 2 alternate measures of PD supported this observation in this small exploratory study.


Personality disorders in ADHD Part 3: Personality disorder, social adjustment, and their relation to dimensions of adult ADHD

Frederick W. Reimherr, MD | Barrie K. Marchant, MS | Erika D. Williams, MSW | Robert E. Strong, DO | Corinne Halls, MS | Poonam Soni, MD

BACKGROUND: This study explored the relationship between the dimensions of adult attention-deficit/hyperactivity disorder (ADHD), personality disorder (PD), and adverse social adjustment.

METHODS: In a controlled trial of osmotic release oral system methylphenidate, PD was assessed using the Wisconsin Personality Disorders Inventory IV (WISPI-IV), the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II), and a final consensus diagnosis. Participants were categorized 2 ways: (1) ADHD alone, ADHD with emotional dysregulation (ADHD + ED), and ADHD plus emotional dysregulation plus oppositional symptoms (ADHD + ED + ODD); and (2) those with no PD (PD-negative), 1 (PD-positive), and 2 or more (PD-plus) PDs.

RESULTS: None of the ADHD-alone patients had a PD compared with 33% of ADHD + ED patients and 68% of ADHD + ED + ODD patients. The level of ADHD-related emotional and oppositional symptoms correlated significantly with the severity of PD dimensions as assessed by WISPI-IV z scores and the number of items endorsed on the SCID-II screening questionnaire. Complex presentations (define by both ADHD and personality categories) were associated with high childhood ADHD ratings and problems in work, extended family, and economic functioning.

CONCLUSION: The ADHD symptoms of emotional dysregulation and oppositional symptoms were associated with increased Axis II disorders. Adverse outcomes were concentrated in patients with ADHD combined with emotional and oppositional symptoms, and in those with comorbid PDs.


Antisocial personality disorder in incarcerated offenders: Psychiatric comorbidity and quality of life

Tracy Gunter, MD | Peggy Loveless, PhD | Jeff Allen, PhD | Bruce Sieleni, MD

BACKGROUND: We determined the frequency of antisocial personality disorder (ASPD) in offenders. We examined demographic characteristics, psychiatric comorbidity, and quality of life in those with and without ASPD. We also looked at the subset with attention-deficit/hyperactivity disorder (ADHD).

METHODS: A random sample of 320 newly incarcerated offenders was assessed using the Mini International Neuropsychiatric Interview (MINI), the 36-item Short Form Health Survey (SF-36), and the Level of Service Inventory–Revised (LSI-R).

RESULTS: ASPD was present in 113 subjects (35.3%). There was no gender-based prevalence difference. Offenders with ASPD were younger, had a higher suicide risk, and had higher rates of mood, anxiety, substance use, psychotic, somatoform disorders, borderline personality disorder, and ADHD. Quality of life was worse, and their LSI-R scores were higher, indicating a greater risk for recidivism. A subanalysis showed that offenders with ASPD who also had ADHD had a higher suicide risk, higher rates of comorbid disorders, and worse mental health functioning.

CONCLUSION: ASPD is relatively common among both male and female inmates and is associated with comorbid disorders, high suicide risk, and impaired quality of life. Those with comorbid ADHD were more impaired than those without ADHD. ASPD occurs frequently in prison populations and is nearly as common in women as in men. These study findings should contribute to discussions of appropriate and innovative treatment of ASPD in correctional settings.