Category: Borderline Personality Disorder

A new study suggests that the way in which professional care workers respond emotionally to substance abuse patients with personality disorders depends on the type of disorder.

Birgitte Thylstrup and Morten Hesse of Aarhus University, Centre for Alcohol and Drug Research, in Copenhagen, Denmark, explain that while previous research has shown that antisocial and aggressive behavior in patients can affect how professionals manage them, no previous studies have investigated the distinction between the full range of different personality disorders and their effects on professional health care workers.

The idea that the emotional reactions of a professional to his or her patient may play an important part in psychotherapeutic treatment dates back to the work of Sigmund Freud. He coined the term 'countertransferance' to describe the observation that a patient's influence on the analyst's unconscious feelings may interfere with the patient's treatment.

In order to test whether this hypothesis holds for the interaction between health professionals and substance abuse patients, the researchers asked staff members to complete an inventory of emotional reactions to their patients. Concomitantly, the patients, most commonly men in their thirties, were asked to complete a personality disorder questionnaire.

The researchers then sought to determine if there were any correlations between the emotional reactions reported by staff and the type of personality disorder in the patient.

Not unexpectedly, they found that patients with features of antisocial personality disorder induced feelings of distance in their carers. Interestingly, feelings of helpfulness were induced by those with features of avoidant personality disorder.

"The patient with antisocial personality disorder tends to be manipulative and aggressive. It is natural for staff members to react to such behavior with some negative reactions, and this is not a sign of unprofessional conduct", says Morten Hesse. "On the other hand, the patient with avoidant personality disorder is often cautious and appears vulnerable and needy. In that context, many clinicians feel that they can be useful to the patient, and feel secure in their role as treatment providers."

The researchers point out that by using self-reporting, rather than disorders assessed by the staff, they have, for the first time, avoided the problem of a confounding diagnosis. "Staff reactions should be considered in supervision of staff, and in treatment models for substance abuse patients with personality disorders," the researchers conclude.

Journal reference: Substance abusers' personality disorders and staff members' emotional reactions. Birgitte Thylstrup and Morten Hesse. BMC Psychiatry 

Using new approaches, an interdisciplinary team of scientists at NewYork-Presbyterian Hospital/Weill Cornell Medical Center in New York City has gained a view of activity in key brain areas associated with a core difficulty in patients with borderline personality disorder—shedding new light on this serious psychiatric condition.

"It's early days yet, but the work is pinpointing functional differences in the neurobiology of healthy people versus individuals with the disorder as they attempt to control their behavior in a negative emotional context. Such initial insights can help provide a foundation for better, more targeted therapies down the line," explains lead researcher Dr. David A. Silbersweig, the Stephen P. Tobin and Dr. Arnold M. Cooper Professor of Psychiatry and Professor of Neurology at Weill Cornell Medical College, and attending psychiatrist and neurologist at NewYork-Presbyterian Hospital/Weill Cornell Medical Center.

Borderline personality disorder is a devastating mental illness that affects between 1 to 2 percent of Americans, causing untold disruption of patients' lives and relationships. Nevertheless, its underlying biology is not very well understood. Hallmarks of the illness include impulsivity, emotional instability, interpersonal difficulties, and a preponderance of negative emotions such as anger—all of which may encourage or be associated with substance abuse, self-destructive behaviors and even suicide.

"In this study, our collaborative team looked specifically at the nexus between negative emotions and impulsivity—the tendency of people with borderline personality disorder to 'act out' destructively in the presence of anger," Dr. Silbersweig explains. "Other studies have looked at either negative emotional states or this type of behavioral disinhibition. The two are closely connected, and we wanted to find out why. We therefore focused our experiments on the interaction between negative emotional states and behavioral inhibition."

Advanced brain-scanning technologies developed by the research team made it possible to detect the brain areas of interest with greater sensitivity.

"Previous work by our group and others had suggested that an area at the base of the brain within the ventromedial prefrontal cortex was key to people's ability to restrain behaviors in the presence of emotion," Dr. Silbersweig explains.

Unfortunately, tracking activity in this brain region has been extremely difficult using functional MRI (fMRI). "Due to its particular location, you get a lot of signal loss," the researcher explains.

However, the Weill Cornell team used a special fMRI activation probe that they developed to eliminate much of that interference. This paved the way for the study, which included 16 patients with borderline personality disorder and 14 healthy controls.

The team also used a tailored fMRI neuropsychological approach to observe activity in the subjects' ventromedial prefrontal cortex as they performed what behavioral neuroscience researchers call "go/no go" tests.

These rapid-fire tests require participants to press or withhold from pressing a button whenever they receive particular visual cues. In a twist from the usual approach, the performance of the task with negative words (related to borderline psychology) was contrasted with the performance of the task when using neutral words, to reveal how negative emotions affect the participants' ability to perform the task.

As expected, negative emotional words caused participants with borderline personality disorder to have more difficulty with the task at hand and act more impulsively—ignoring visual cues to stop as they repeatedly pressed the button.

But what was really interesting was what showed up on fMRI.

"We confirmed that discrete parts of the ventromedial prefrontal cortex—the subgenual anterior cingulate cortex and the medial orbitofrontal cortex areas—were relatively less active in patients versus controls," Dr. Silbersweig says. "These areas are thought to be key to facilitating behavioral inhibition under emotional circumstances, so if they are underperforming that could contribute to the disinhibition one so often sees with borderline personality disorder."

At the same time, the research team observed heightened levels of activation during the tests in other areas of the patients' brains, including the amygdala, a locus for emotions such as anger and fear, and some of the brain's other limbic regions, which are linked to emotional processing.

"In the frontal region and the amygdala, the degree to which the brain aberrations occurred was closely correlated to the degree with which patients with borderline personality disorder had clinical difficulty controlling their behavior, or had difficulty with negative emotion, respectively," Dr. Silbersweig notes.

The study sheds light not only on borderline personality disorder, but on the mechanisms healthy individuals rely on to curb their tempers in the face of strong emotion.

Still, patients struggling with borderline personality disorder stand to benefit most from this groundbreaking research. An accompanying journal commentary labels the study "rigorous" and "systematic," and one of the first to validate with neuroimaging what scientists had only been able to guess at before.

"The more that this type of work gets done, the more people will understand that mental illness is not the patient's fault—that there are circuits in the brain that control these functions in humans and that these disorders are tied to fundamental disruptions in these circuits," Dr. Silbersweig says. "Our hope is that such insights will help erode the stigma surrounding psychiatric illness."

The research could even help lead to better treatment.

As pointed out in the commentary, the research may help explain how specific biological or psychological therapies could ease symptoms of borderline personality disorder for some patients, by addressing the underlying biology of impulsivity in the context of overwhelming negative emotion. The more scientists understand the neurological aberrations that give rise to the disorder, the greater the hope for new, highly targeted drugs or other therapeutic interventions.

"Going forward, we plan to test hypotheses about changes in these brain regions associated with various types of treatment," Dr. Silberswieg says. "Such work by ourselves and others could help confirm these initial findings and point the way to better therapies."

The findings are featured in this month's issue of the American Journal of Psychiatry.

This work was funded by the Borderline Personality Disorder Research Foundation and the DeWitt Wallace Fund of the New York Community Trust.

Co-researchers include senior author Dr. Emily Stern, as well as Dr. John F. Clarkin, Dr. Martin Goldstein, Dr. Otto F. Kernberg, Dr. Oliver Tuescher, Dr. Kenneth N. Levy, Dr. Gary Brendel, Dr. Hong Pan, Dr. Manfred Beutel, Dr. Jane Epstein, Dr. Mark F. Lenzenweger, Dr. Kathleen M. Thomas, Dr. Michael I. Posner, and Michelle T. Pavony—all of NewYork-Presbyterian Hospital/Weill Cornell Medical Center.

— Impulsivity is a problem common to many different personality and psychiatric disorders, including alcoholism. A new study that looked at impulsivity among alcoholic subpopulations has found that, one, the inability to delay gratification may be a vulnerability marker for alcoholism, and two, certain inhibitory-control issues may be specific to antisocial and borderline personality disorders.

"Around 50 percent of alcoholic patients have psychiatric disorders that include pathological impulsivity," said Gabriel Rubio, associate professor at Complutense University of Madrid, Spain. Yet few studies have explored behavioral measures of impulsivity within different alcoholic subpopulations, which could have important treatment and relapse implications.

Cluster B personality disorders involve dramatic or erratic behaviour. "The two most frequent cluster B personality disorders found in alcoholic samples are borderline personality and antisocial personality disorders," said Rubio. "We did not know if impulsivity found in alcoholics is due to a specific trait typical of alcoholism or is due to comorbidity with cluster B personality disorders."

Accordingly, they designed their study to assess if alcoholic patients with borderline personality disorder exhibited the same pattern of behavioral impulsivity as alcoholic patients with antisocial personality disorder.

Rubio and his colleagues examined two groups: 247alcoholic men recruited from two alcohol-treatment centers, and 96 non-substance-abusing men from the community that were matched on age and education. The researchers measured inhibitory control, and assessed sustained attention, rapid-response impulsivity, and ability to delay reward, for all participants.

"Our results indicated that alcoholics without cluster B personality disorders displayed a greater inability to delay gratification than control healthy subjects," said Rubio. "This means that a subject prefers a smaller but sooner expected value, such as a drink right now, over a later but larger expected value, such as increases in health or psychological condition. We can hypothesize that this subject will relapse very quickly."

The second finding involved alcoholics with cluster B personality disorders, who displayed more impairment on inhibitory control. "This means that a subject has problems with appropriately inhibiting thoughts or actions," said Rubio. "In other words, when an action has begun, such as drinking that first drink, he or she will have difficulties stopping, meaning he or she cannot stop drinking."

Rubio said these finding suggest that the traditional perception of alcoholism and impulsive behaviour may need to be reconsidered. "High levels of behavioural impulsivity may be related to other disorders, such as borderline personality or antisocial personality disorders, which are frequently present in subsets of alcoholics," he said. "We may also need to rethink treatment options. Programs that emphasize immediate rewards for abstinence may have a better chance of succeeding with antisocial personality disorder. Conversely, psychotherapeutic and pharmacological interventions that focus on 'behavioral control' may work better with subjects with borderline personality disorders."

Results are published in the November issue of Alcoholism: Clinical & Experimental Research.

Eighty per cent of psychiatric nurses believe that people with Borderline Personality Disorder (BPD) receive inadequate care, despite the fact that one in fifty adults suffer from the condition, according to the October issue of the Journal of Psychiatric and Mental Health Nursing.

Ninety-eight per cent of nurses said service shortages played a role in inadequate care and 83 per cent said that disagreements between staff on how to care for people with BPD was a factor.

Researchers from the Republic of Ireland – Professor Seamus Cowman, from the Royal College of Surgeons and Philip James, a Clinical Nurse Specialist from the Health Service Executive – found that more than a quarter of the nurses surveyed (27 per cent) had daily contact with patients with BPD.

Despite this, only three per cent had received post-graduate training in BPD and, when training was provided, it tended to be a single workshop or lecture.

BPD is a serious mental illness characterised by persistent instability in moods, personal relationships, self-image and behaviour. This instability can affect aspects of the individual's life and their sense of identity, resulting in self-harm and a significant rate of suicide attempts. It is more common in young women and sufferers often need extensive mental health services.

A hundred and fifty seven ward and community-based nurses working for a health service providing mental health inpatient and outpatient services were surveyed, with 67 (41 per cent) completing the detailed questionnaire.

"A worrying finding of this study is that the majority of staff believe that multi-disciplinary team disagreements lead to inadequate care," says Professor Seamus Cowman.

"This points to the need for greater guidance to avoid different approaches being taken to managing clients with the same disorder. The need for all services to develop policies on handling BPD was also highlighted by the Expert Group on Mental Health Policy in its 2006 report."

Lack of specialist training was also a concern.

"The majority of nurses strongly agreed that they had a key role to play in the assessment and management of people with BPD and 90 per cent said they would be keen to receive further training in dealing with BPD" says Professor Cowman.

"We were concerned to note that only three per cent had received post-graduate training. In contrast, Australian nurses receive 11 times as much post-graduate training in BPD as their colleagues in the Republic of Ireland.

"This lack of training needs to be addressed as other studies have shown that it can improve both knowledge of BPD and attitudes towards it."

88 per cent of the nurses who took part in the survey said that people with BPD were difficult to treat. 75 per cent said they were very or moderately difficult to look after and 80 per cent believed that they were more difficult to look after than other clients.

62 per cent felt that lack of staff training or expertise contributed to inadequate care for people with BPD and 65 per cent said that not telling people they had BPD was another factor.

Nurses were also asked how much they knew about the condition. The number of questions answered correctly ranged from two to nine and averaged 5.8.

When it came to how services could be improved, providing specialist services for people with BPD was the most favoured option (65 per cent), followed by standard protocols for managing people with BPD (60 per cent) and skills training workshops for staff (51 per cent).

Improving undergraduate training (48 per cent), improving in-service training (48 per cent) and providing psychiatric staff who liaise with accident and emergency departments (42 per cent) were also popular responses.

"This study shows that psychiatric nurses come into regular contact with patients with BPD and believe they have a role to play in caring for them" says Professor Cowman.

"But the majority see people with BPD as a difficult group to care for and feel that the overall care that is being provided is inadequate.

"It does however highlight a willingness for nurses to work with people with BPD and a desire to improve the services that they receive.

"We hope that this research will help to drive service improvements for people with BPD and provide staff with the education and guidance they need to make best use of their skills."

Reference: Psychiatric nurses' knowledge, experience and attitudes towards clients with borderline personality disorder. James et al. Journal of Psychiatric and Mental Health Nursing. 14, 670-678. (October 2007)

 An intensive form of talk therapy, known as transference-focused psychotherapy (TFP), can help individuals affected with borderline personality disorder (BPD) by reducing symptoms and improving their social functioning, according to an article in the June issue of the American Journal of Psychiatry, a premier psychiatry journal.

BPD, a chronic and disabling condition affecting about 1% of the United States population, has long defied psychologists and psychiatrists seeking to treat the illness. Affecting day-to-day functions, symptoms of the illness include unstable relations with others, pervasive mood instability, chaotic variation in self-image, self-destructive behavior, impulsive behaviors (such as sexual promiscuity, substance abuse, or gambling), and intense, uncontrolled rages.

In the new study, Mark F. Lenzenweger, distinguished professor of psychology at Binghamton University, State University of New York, and colleagues at the Weill College of Medicine, Cornell University, examined three treatments applied to carefully diagnosed BPD patients for a period of one year.

The treatments included dialectical behavior therapy, supportive psychotherapy, and TFP, a specialized psychodynamic form of talk therapy, pioneered by Otto F. Kernberg, a study co-author and professor of psychiatry at Weill-Cornell, that focuses on dominant emotionally charged themes that emerge in the relationship between patient and therapist.

As the patients moved through the yearlong treatments, they were carefully assessed on a wide range of psychiatric symptom and functioning domains, such as depression, anger, social functioning, suicidal behaviors, impulsivity, social adjustment, and various forms of irritability and aggression.

At the end of the year of treatment, a detailed examination of the change revealed that the BPD patients in the TFP treatment showed improvement in ten out of the twelve domains studied.

“The improvements for the TFP patients were not merely statistically reliable, but they represented fairly impressive scientific effects, not just trivial changes,” said Lenzenweger. “TFP not only helped reduced suicidal behaviors, but also seemed particularly helpful in reducing irritability and angry behaviors.”

Kernberg noted, “We are pleased about the progress in the empirical development of a psychoanalytic treatment for borderline patients that focuses on the personality, rather than simply on symptoms, yet also shows improvements in symptoms.”

The study also included dialectical behavior therapy (or DBT), which is a cognitively based therapy. Supportive therapy also has its roots in psychoanalytic methods, but differs substantially from TFP.     

“This is the first study to compare DBT, considered by many to be the standard, with two psychodynamic treatments,” said John F. Clarkin, the lead author on the study and professor of clinical psychology at Weill-Cornell.

A major implication of the study is that all three treatments show some effect in alleviating the impact of BPD. The weight of the evidence in the study importantly suggests that TFP and supportive psychotherapy are both viable alternatives to DBT for the treatment of BPD.

“We hope to explore the results of the study further to determine what factors predicted the best outcomes,” said Lenzenweger. “And of course, we hope to use these results to further guide our development of basic studies in the neuroscience and genomics of BPD.”

The study was supported, in part, by the Borderline Personality Disorder Research Foundation and the Personality Disorders Institute at the Department of Psychiatry, Weill College of Medicine, Cornell University.

Abused children may have a difficult time developing adult relationships with new people who reminded them of their abusive parent, even if only implicitly, according to a recent study published in the November issue of Personality and Social Psychology Bulletin, an official publication of the Society for Personality and Social Psychology, published by SAGE Publications.

Kathy R. Berenson and Susan M. Andersen, of New York University's Department of Psychology, used groundbreaking methods to study how two groups of adult women, those with a history of childhood abuse and those without, reacted to a stranger whose characteristics were similar to their own parent (or were not). The researchers found that for both groups, the participants' feelings about the abusive parent tended to "transfer" to the new person — presumably without the participants realizing it. Both groups of participants reacted to the new person with facial expressions of positive emotion (presumably deriving from love for the parent). Among participants who had been abused, however, this was accompanied by negative reactions as well, such as expectations for rejection, mistrust, dislike, and emotional distancing. Notably, no such pattern occurred among abused participants when the new person bore no resemblance to the parent (a control condition).

Researchers additionally found that the abused participants reported a decrease in negative mood when the new person resembling the parent was also described as explicitly threatening (as compared to when there was no explicit threat). They showed no such response in the absence of parental resemblance. "A possible interpretation of this," write the authors, is that this may have evoked, for abused individuals, their "well-practiced affective responses to threat. These individuals may have self-protective strategies that are set into motion when a person acting in threatening ways reminds them of their abusive parent."

Berenson and Andersen conclude that the process of transference can lead previously abused individuals to use behavioral patterns from their relationship with the abusive parent in later interpersonal relationships, even when such patterns may be inappropriate or ineffective for the current interpersonal situation. "The study demonstrated the differences between abused and non-abused participants in their responses to a new person and highlights the pains and pleasures that past significant relationships can bring when experienced in the present." This work truly has practical applications for understanding those who live with or treat formerly abused adults.

"Childhood Physical and Emotional Abuse by a Parent: Transference Effects in Adult Interpersonal Relations" is published in the November issue of Personality and Social Psychology Bulletin and can be accessed for a limited time at no charge at http://pspb.sagepub.com/cgi/reprint/32/11/1509.

 Specific personality variables, such as anger or irritability predict the tendency to either engage in aggressive behavior willingly or to engage in aggressive behavior when provoked, according to a recent meta-analysis in the September issue of Psychological Bulletin, published by the American Psychological Association (APA).

In a review of 63 studies, psychologist Ann Bettencourt, PhD and coauthors Amelia Talley, MA, University of Missouri – Columbia, Arlin James Benjamin, PhD, Panhandle State University, and Jeffery Valentine, PhD,  Duke University, examined the association between personality variables and aggressive behavior, under provoking and relatively neutral conditions. The following personality variables were identified: trait aggressiveness, trait irritability, trait anger, Type A personality, dissipation-rumination, emotional susceptibility (tendency to feel inadequate or vulnerable), narcissism, and impulsivity.  Study participants ranging from 7 years old to 48 years old were subjected to different types of provoking situations such as verbal insults, frustration in the form of difficult puzzles, physical aggression, loud noises and disparaging comments. Neutral comparison conditions were similar to those in the provoking conditions but lacked insulting, irritating, and frustrating situations.

Persons identified as having an aggressive and irritable personality were more likely to engage in aggressive behavior regardless of whether situations were provoking.  “This may suggest that these persons have the capacity to engage in cold-blooded style of aggressive behavior, reacting harshly as a result to little or no agitation” said lead author B. Ann Bettencourt.

The review also found that personality variables, and the level of provocation, interact to influence aggressive behavior. For instance, people who are Type A personalities, have a tendency to express anger (trait anger), have self-destructive tendencies and mull-over upsetting situations, are emotional susceptible, narcissistic and for the most part impulsive were more likely to behave aggressively only under provoking conditions. This type of reaction is considered “hot-blooded” because a person is usually upset by the provoking situation, which induces the aggressive behavior. Bettencourt and her colleagues labeled the two different patterns of associations between personality and aggressive behavior as aggression-prone and provocation-sensitive.

“Problems with aggression and violence continue to plague people’s interpersonal life, their intergroup interactions, and society in general. Social scientists need to develop a better understanding of the complex dynamics among personality variables, situational variables, and aggressive behavior to gain a better understanding of human aggression. The knowledge gained from further research will refine therapeutic and policy interventions aimed at reducing aggression and violence,” stated Bettencourt.

Article: “Personality and Aggressive Behavior Under Provoking and Neutral Conditions: A Meta- Analytic Review,” B. Ann Bettencourt, PhD, Amelia Talley, MA, University of Missouri – Columbia; Arlin James Benjamin, PhD, Panhandle State University; Jeffery Valentine, PhD,  Duke University; Psychological Bulletin, Vol.132 No.5.

Non-fatal, self-inflicted injuries by adolescent and young adult females are major public health problems and researchers have found physiological evidence that this behavior may lead to a more serious psychological condition called borderline personality disorder.

University of Washington psychologists have discovered that adolescent girls who engage in behaviors such as cutting themselves have lower levels of serotonin, a hormone and brain chemical, in their blood. They also have reduced levels in the parasympathetic nervous system of what is called respiratory sinus arrhythmia, a measure of the ebb and flow of heart rate along with breathing.

"A low level of this measure of the parasympathetic nervous system is characteristic of people who are anxious and depressed and among boys who are delinquent. But this is the first study to show it among adolescent girls who engage in self-harming behavior," said Theodore Beauchaine, UW associate professor of psychology.

The findings come from a study that also uncovered sharp disparities in the number of self-harming events and suicide attempts reported by the girls and their parents.

The research, headed by Sheila Crowell, a UW psychology doctoral student, focused on girls because self-harming behavior affects females far more often than it does males. The study included 23 girls, ages 14 to 18, who engaged in what psychologists call parasuicidal behavior. Participants were included if they had engaged in three or more self-harming behaviors in the previous six months or five or more such behaviors in their lifetime. An equal number of girls of the same ages who did not engage this behavior were enrolled as a comparison group.

The adolescents in the parasuicide group reported far more incidents of self-harming behavior than did their parents. Individuals engaged in this kind of behavior between 11 and 839 times. Their parents, however, reported a range of 0 to 205 incidents. Similarly, the girls reported more than three times the number self-harming behaviors with intent to die, 310 events versus 90, than their parents did. However, the girls and their parents were very close on the number of times an adolescent required medical attention.

Twenty of the girls, or 87 percent, reported at least one attempted suicide, but Crowell said this number is not that surprising in this population.

"You need to understand a person's intent and the lethality of their attempts," she said. "Did they take a small number of Tylenol or were they holding a loaded gun to their head?"

She noted cutting was the most common self-harming behavior in which the girls engaged. Eight-two percent of girls used instruments ranging from paper clips to kitchen knives and razors with the intent of hurting themselves.

"These attempts have to be taken seriously," said Beauchaine. "These girls may be really at risk for later suicide, and in the long term there needs to be studies of the progression of self-harm attempts."

To find physiological markers of self-harming behavior, the UW researchers showed both groups of adolescents a three-minute film clip from the movie "The Champ" depicting a boy with his dying father. Previous studies have shown the film can induce sadness. A number of different psychophysiological measures were collected from each of the girls before, while and after viewing the film clip. Following the viewing a small blood sample was taken to measure whole-blood serotonin.

The girls who engaged in self-harming behavior had lower levels of respiratory sinus arrhythmia in their parasympathetic nervous system while watching the film clip. These measures, the researchers argue, support the idea that the inability to regulate emotions and impulsivity can trigger self-harming behavior.

"This research supports the primary theory that borderline personality disorder is caused by an inability to manage emotions. These girls have an excessively strong emotional reactions and they have extreme difficulty in controlling those emotions," said Beauchaine. "Their self-harming behavior serves to distract them from these emotions."

Borderline Personality Disorder is far more serious than self-harming behavior and people with the condition have a very high suicide rate. An estimated 5.8 million to 8.7 million Americans, mostly women, suffer from borderline personality disorder. People with the condition have a multiple spectrum of disorders that are marked by emotional instability, difficulty in maintaining close relationships, eating disorders, impulsivity, chronic uncertainty about life goals and addictive behaviors such as using drugs and alcohol. They also have major impact on the medical system by being among the highest users of emergency and in-patient medical services.

Co-authors of the study are Elizabeth McCauley, UW professor of psychiatry and behavioral science; Cindy Smith a former psychiatrist at Children's Hospital who is now in private practice; Adrianne Stevens, an incoming UW psychology graduate student, and Patrick Sylvers, a former UW student who is now a graduate student at Emory University. The study, published in the journal Development and Psychopathology, was funded by Seattle Children's Hospital, the National Foundation for Suicide Prevention and the National Institute of Mental Health.

A little-known mental disorder marked by episodes of unwarranted anger is more common than previously thought, a study funded by the National Institutes of Health's (NIH) National Institute of Mental Health (NIMH) has found. Depending upon how broadly it's defined, intermittent explosive disorder (IED) affects as many as 7.3 percent of adults — 11.5-16 million Americans — in their lifetimes. The study is based on data from the National Comorbidity Survey Replication, a nationally representative, face-to-face household survey of 9,282 U.S. adults, conducted in 2001-2003.

People with IED may attack others and their possessions, causing bodily injury and property damage. Typically beginning in the early teens, the disorder often precedes — and may predispose for — later depression, anxiety and substance abuse disorders. Nearly 82 percent of those with IED also had one of these other disorders, yet only 28.8 percent ever received treatment for their anger, report Ronald Kessler, Ph.D., Harvard Medical School, and colleagues. In the June, 2006 Archives of General Psychiatry, they suggest that treating anger early might prevent some of these co-occurring disorders from developing.

To be diagnosed with IED, an individual must have had three episodes of impulsive aggressiveness "grossly out of proportion to any precipitating psychosocial stressor," at any time in their life, according to the standard psychiatric diagnostic manual. The person must have "all of a sudden lost control and broke or smashed something worth more than a few dollars … hit or tried to hurt someone … or threatened to hit or hurt someone."

People who had three such episodes within the space of one year — a more narrowly defined subgroup — were found to have a much more persistent and severe disorder, particularly if they attacked both people and property. The latter group caused 3.5 times more property damage than other violent IED sub-groups. Affecting nearly 4 percent of adults within any given year — 5.9-8.5 million Americans — the disorder leads to a mean of 43 attacks over the course of a lifetime and is associated with substantial functional impairment.

Evidence suggests that IED might predispose toward depression, anxiety, alcohol and drug abuse disorders by increasing stressful life experiences, such as financial difficulties and divorce.

Given its earlier age-of-onset, identifying IED early — perhaps in school-based violence prevention programs — and providing early treatment might prevent some of the associated psychopathology, propose the researchers. Although most study respondents with IED had seen a professional for emotional problems at some time in their lives, only 11.7 percent had been treated for their anger in the 12 months prior to the study interview.

Although the new prevalence estimates for IED are somewhat higher than previous studies have found, the researchers consider them conservative. For example, anger outbursts in people with bipolar disorder, which often overlaps with IED, were excluded. Previous studies have found little overlap between IED and other mental illnesses associated with impulsive violence, such as antisocial and borderline personality disorders.

Also participating in the study were Dr. Emil Coccaro, University of Chicago, Dr. Maurizio Fava, Massachusetts General Hospital, and Dr. Savina Jaeger, Robert Jin, and Ellen Walters, Harvard University.

In addition to primary funding from the NIMH, the National Comorbidity Survey Replication received supplemental funding from a number of sources, including National Institute on Drug Abuse (NIDA) and the Substance Abuse and Mental Health Services Administration (SAMHSA).

Children with personalities marked by aggressiveness, mood swings, a sense of alienation and a need for excitement may be at greater risk for attention deficit hyperactivity disorder or conduct disorder, according to a new Florida State University study.

FSU psychology professors Jeanette Taylor and Chris Schatschneider, FSU doctoral student Kelly Cukrowicz and University of Minnesota Professor William Iacono found that children with ADHD or conduct disorder had more negative emotions – aggressiveness, tension and feelings of being exploited, unlucky or poorly treated – and lower constraints – a tendency to break rules and engage in thrill-seeking behavior – than children with neither of the disorders. Not surprisingly, those children who have both ADHD and conduct disorder had the most extreme personality profiles.

"This helps us to understand that personality is part of the bigger picture of these disorders," Taylor said. "That could help with initial assessments or lead to unexpected discoveries or potential interventions. We're saying to researchers and clinicians, 'Think about personality when you look at these issues.' "

The study, published in the Journal of Child Psychology and Psychiatry, is the first to investigate personality trait patterns among children who have ADHD, conduct disorder or a combination of both. It is important to learn more about the co-occurrence of ADHD and conduct disorder because the consequences are so severe, Taylor said.

"It's more than the sum of its parts," she said, explaining that children and adolescents with a combination of the two disorders are at much higher risk of school failure, criminal activity, substance abuse and depression. Previous studies have indicated that between 15 to 35 percent of children with ADHD also have conduct disorder.

Between 3 percent and 5 percent of U.S. school age children are estimated to have ADHD, a disorder that encompasses symptoms of hyperactivity, inattention or impulsivity. Conduct disorder affects about 13 percent of children and adolescents and is characterized by severe misbehavior including chronic lying, setting fires, destroying property or hurting animals.

The researchers analyzed personality data from 1,438 sets of same-sex, reared-together 11-year-old and 17-year-old male and female twins who participated in the Minnesota Twin Family Study. The rate of ADHD, conduct disorder and the co-occurrence of both was about the same as is found in the general population, Taylor said. Those who did not have symptoms of the disorders served as the control group.

The connection between personality and the disorders is clear, but more research will have to be done to determine whether the personality traits are shaped by the psychological disorders or vice versa.

"Developmentally, it makes sense that the personality comes first," she said. "But to say that one causes the other is too simplistic. I think they become intertwined."