Patterns of personality pathology in patients with generalized anxiety disorder, panic disorder with and without agoraphobia, and social phobia

Interpersonal Subtypes of Anxiety Disorder Patients: Relationship to Assessment and Treatment Variables

We attempted to replicate earlier findings of interpersonal subtypes in patients with anxiety disorder (Psychotherapy. 2011;48:304-310) and examine whether these subtypes are characterized by different types of pathology and respond differently to treatment. Interpersonal problems were measured by the Inventory of Interpersonal Problems (Inventory of Interpersonal Problems Manual. San Antonio, TX: Psychological Cooperation; 2000) in a sample of 31 patients with anxiety disorder. Results demonstrated the existence of 4 interpersonal subtypes. The subtypes did not differ in severity of anxiety and global levels of symptoms at pretreatment or in Reliable Change Index of anxiety symptoms over the course of treatment. However, they were significantly different in terms of overall interpersonal problems (p = 0.004). Regarding treatment variables, half of the patients in the nonassertive cluster discontinued treatment prematurely. The number of psychotherapy sessions attended was significantly different across the 4 clusters (p = 0.04), with socially avoidant patients attending significantly greater number of sessions.

The nosologic relationship between generalized anxiety disorder and major depression

Generalized anxiety disorder (GAD) has undergone a series of revisions in its diagnostic criteria that has moved it, nosologically, away from its original affiliation with panic disorder (PD) and closer to major depressive disorder (MDD). This, together with its high comorbidity and putative shared genetic risk with MDD, has brought into question its place in future psychiatric nosology, prompting the planners of Diagnostic and Statistical Manual-V (DSM-V) and International Classification of Diseases-11 (ICD-11) to set up a workgroup tasked to better understand the relationship between GAD and MDD. This review attempts to summarize the extant data to compare GAD and MDD on a series of research validators to explore this relationship. Although insufficient data currently exist for GAD in several key validator classes, tentative conclusions can be drawn on the diagnostic status of GAD in relation to MDD. Although GAD possesses substantial overlap with MDD in the areas of genetics, childhood environment, demographics, and personality traits, this tends to hold true for other anxiety disorders (ADs) as well, with the strongest evidence for PD. Data from life events, personality disorders, biology, comorbidity, and pharmacology are mixed, showing some areas of similarity between GAD and MDD but some clear differences, again with a moderate degree of nonspecificity. Thus, although the bulk of evidence supports a close underlying relationship between them, the relatively nonspecific nature of these findings provides little more reason to question the nosologic validity of GAD in relation to MDD than that of some other anxiety disorders.

Screening results correlating to personality disorder traits in a new employee population of People's Republic of China

BACKGROUND

Adaptation to a new environment may have an uncertain influence on young employees, whose values are still being formed during early adulthood. To understand the current mental status and further improve the mental health level of the new employee population of People's Republic of China, we conducted a cross-sectional study to screen the prevalence and correlates of personality disorder (PD) traits in this population.

METHODS

This study included all male participants who were new employees (those who had started working in approximately the last three months) from 12 machinery factories in People's Republic of China. The Personality Diagnostic Questionnaire-4+ was used to evaluate the mental status of all participants. The Connor-Davidson Resilience Scale was used to assess the resilience of the study participants.

RESULTS

A total of 3,960 male participants were included in the analysis. The mean age of the study participants was 18.7±1.5 years. The mean values of all PD subtypes were scored from 0.74 to 2.90, with a total of 16.85. Of all 10 PD traits, obsessive-compulsive, histrionic, and narcissistic scored the highest. PD traits scored significantly higher among participants who had higher education levels, came from a single-parent (divorced or separated) family, were raised in a neglectful parental rearing pattern, were the only child of the family, were living in city areas, or had a lower family income. All subtype PD traits were significantly and negatively correlated with resilience.

CONCLUSION

Education level, single-parent family, parental rearing pattern, only-child status, living place, and family income may influence the development of PD traits. Additional high-quality studies are needed to learn more about the mental health status of new employees. Optimal interventions are warranted to avoid potential adverse events in this population.

Social phobia and avoidant personality disorder: similar but different?

Avoidant personality disorder (AvPD) is regarded as a severe variant of social phobia (SP), consistent with a dimensional model. However, these conclusions are largely drawn from studies based on individuals with SP, with or without comorbid AvPD. The present study hypothesized that there are qualitative differences between AvPD and SP that are undermined by limiting research to participants with SP. The authors sought to test this hypothesis by comparing three groups-SP only, AvPD only, and SP+AvPD-using data extracted from an epidemiological sample of 10,641 adults aged 18 years and over. Screening questions were used in the epidemiological survey to identify ICD-10 personality disorders; from this the author developed a proxy measure for DSM-IV AvPD. Axis I diagnoses, including DSM-IV SP, were identified using the Composite International Diagnostic Interview (CIDI). In this sample, the majority of those with AvPD did not also have SP: The authors found 116 persons with AvPD only, 196 with SP only, and 69 with SP+AvPD. There was little difference between any of the groups on sex, marital status, employment, education, or impairment variables. The SP+AvPD group reported more distress and comorbidity than the SP only and AvPD only groups, which did not differentiate from each other. More feared social situations were endorsed in the SP only group compared to the AvPD only group. Although the finding of few differences between SP only and AvPD only groups among the variables measured in this epidemiological survey fails to provide support for the hypothesis of qualitative differences, the finding that the AvPD only group appears more similar to the SP only group than to the SP+AvPD group also fails to provide support for the alternative continuity hypothesis. The greater distress and additional comorbidity with depression associated with SP+AvPD may be due to the additional symptom load of a second disorder rather than simply representing a more severe variant of social phobia. The use of a proxy for AvPD is a limitation of the study. Future studies should focus on broader clinical variables that have been proposed as qualitatively different between these disorders, and on the possible genetic and environmental factors that might help explain such differences.

Emotional Intelligence and Personality in Anxiety Disorders

Anxiety disorders (AD) are by far the most frequent psychiatric disorders, and according to epidemiologic data their chronicity, comorbidities, and negative prognostic constitute a public health problem. This is why it is necessary to continue exploring the factors which contribute to the incidence, appearance, and maintenance of this set of disorders. The goal of this study has been to analyze the possible relationship between Emotional Intelligence (EI) and personality disorders (PersD) in outpatients suffering from AD. The sample was made up of 146 patients with AD from the Mental Health Center at the Health Consortium of Maresme, who were evaluated with the STAI, MSCEIT, and MCMI-II questionnaires. The main findings indicate that 89,4% of the patients in the sample met the criteria for the diagnosis of some PersD. The findings also confirm that patients with AD present a low EI, especially because of difficulties in the skills of emotional comprehension and regulation, and the lack of these skills is related to a higher level of anxiety and the presence of PersD. These findings suggest the need to consider emotional skills of EI and personality as central elements for the diagnosis and treatment of AD.

Cluster A personality pathology in social anxiety disorder: a comparison with panic disorder

BACKGROUND

Social anxiety disorder (SAD) has been associated with cluster A personality disorder (PD) traits, mainly paranoid and schizoid traits.

AIM

The aim of the study was to further investigate cluster A personality pathology in patients with SAD.

METHODS

Self-reported PD traits were investigated in a clinical sample of 161 participants with SAD and in a clinical comparison group of 145 participants with panic disorder with or without agoraphobia (PAD).

RESULTS

A diagnosis of SAD was associated with more paranoid and schizotypal PD traits, and an association between depression and personality pathology could indicate a state-effect of depression on PD traits.

CONCLUSIONS

Patients with SAD had more cluster A personality pathology than patients with PAD, with the most solid indication for paranoid personality pathology.

Worry and generalized anxiety disorder: a review and theoretical synthesis of evidence on nature, etiology, mechanisms, and treatment

Generalized anxiety disorder (GAD) is associated with substantial personal and societal cost yet is the least successfully treated of the anxiety disorders. In this review, research on clinical features, boundary issues, and naturalistic course, as well as risk factors and maintaining mechanisms (cognitive, biological, neural, interpersonal, and developmental), are presented. A synthesis of these data points to a central role of emotional hyperreactivity, sensitivity to contrasting emotions, and dysfunctional attempts to cope with strong emotional shifts via worry. Consistent with the Contrast Avoidance model, evidence shows that worry evokes and sustains negative affect, thereby precluding sharp increases in negative emotion. We also review current treatment paradigms and suggest how the Contrast Avoidance model may help to target key fears and avoidance tendencies that serve to maintain pathology in GAD.

Alexithymia and personality in relation to social anxiety among university students

The aims of the present study were to investigate the relationship of social anxiety symptoms with alexithymia and personality dimensions in university students and to control the effects of depression and anxiety on this relationship. A total of 319 university students (85 males and 234 females) from two different universities in Ankara were investigated with the Liebowitz Social Anxiety Scale (LSAS), the Beck Depression Inventory (BDI), the Beck Anxiety Inventory (BAI), the Toronto Alexithymia Scale (TAS-20) and the Temperament and Character Inventory (TCI). We found that subscales of the LSAS (fear or anxiety and avoidance) were positively correlated with depression and alexithymia and "difficulty in identifying feelings" (DIF) and "difficulty in describing feelings" (DDF) subscales of the TAS-20. Harm avoidance (HA) showed positive correlations with subscales of the LSAS, whereas self-directedness (SD) showed negative correlations with these subscales. High TAS-20 DDFand HA and low SD predicted fear or anxiety LSAS subscale scores, whereas high TAS-20 DDF, HA and depression scores were predictors for LSAS avoidance subscale scores. Although our sample is not representative of the whole Turkish university student population, we conclude that both fear or anxiety and avoidance were mainly interrelated with DDF and HA, although the causal relationship is not clear.

Personality disorder types proposed for DSM-5

The Personality and Personality Disorders Work Group has proposed five specific personality disorder (PD) types for DSM-5, to be rated on a dimension of fit: antisocial/psychopathic, avoidant, borderline, obsessive-compulsive, and schizotypal. Each type is identified by core impairments in personality functioning, pathological personality traits, and common symptomatic behaviors. The other DSM-IV-TR PDs and the large residual category of personality disorder not otherwise specified (PDNOS) will be represented solely by the core impairments combined with specification by individuals' unique sets of personality traits. This proposal has three main features: (1) a reduction in the number of specified types from 10 to 5; (2) description of the types in a narrative format that combines typical deficits in self and interpersonal functioning and particular configurations of traits and behaviors; and (3) a dimensional rating of the degree to which a patient matches each type. An explanation of these modifications in approach to diagnosing PD types and their justifications--including excessive co-morbidity among DSM-IV-TR PDs, limited validity for some existing types, lack of specificity in the definition of PD, instability of current PD criteria sets, and arbitrary diagnostic thresholds--are the subjects of this review.

Does avoidant personality disorder impact on the outcome of treatment for bulimia nervosa?

OBJECTIVE

To examine the impact of avoidant personality disorder (AVPD) on bulimia nervosa (BN) treatment outcome over 3 years.

METHOD

Women with BN were participating in a randomized treatment trial. The sample was split into: AVPD (n = 37), other PD (n = 37), and no PD (n = 60). Eating disorder symptomatology, depressive symptoms and psychosocial functioning were examined at pretreatment and follow-up. Multiple regression was conducted to control for high axis I comorbidity.

RESULTS

There were no significant differences across the groups at pretreatment or follow-up on eating disorder symptoms. AVPD had worse depressive symptoms and psychosocial functioning at pretreatment which continued 3 years post-treatment. Multiple regression analyses revealed that the presence of any lifetime mood disorder contributed to these significant results.

DISCUSSION

These findings suggest AVPD is not a significant predictor of BN outcome. However, AVPD is associated with poorer psychiatric symptoms although much of this variance appears to be attributable to the lifetime presence of any mood disorder.

Social anxiety disorder: questions and answers for the DSM-V

BACKGROUND

This review evaluates the DSM-IV criteria of social anxiety disorder (SAD), with a focus on the generalized specifier and alternative specifiers, the considerable overlap between the DSM-IV diagnostic criteria for SAD and avoidant personality disorder, and developmental issues.

METHOD

A literature review was conducted, using the validators provided by the DSM-V Spectrum Study Group. This review presents a number of options and preliminary recommendations to be considered for DSM-V.

RESULTS/CONCLUSIONS

Little supporting evidence was found for the current specifier, generalized SAD. Rather, the symptoms of individuals with SAD appear to fall along a continuum of severity based on the number of fears. Available evidence suggested the utility of a specifier indicating a "predominantly performance" variety of SAD. A specifier based on "fear of showing anxiety symptoms" (e.g., blushing) was considered. However, a tendency to show anxiety symptoms is a core fear in SAD, similar to acting or appearing in a certain way. More research is needed before considering subtyping SAD based on core fears. SAD was found to be a valid diagnosis in children and adolescents. Selective mutism could be considered in part as a young child's avoidance response to social fears. Pervasive test anxiety may belong not only to SAD, but also to generalized anxiety disorder. The data are equivocal regarding whether to consider avoidant personality disorder simply a severe form of SAD. Secondary data analyses, field trials, and validity tests are needed to investigate the recommendations and options.

The relationship of treatment preferences and experiences to outcome in generalized anxiety disorder (GAD)

OBJECTIVES

The relationship of treatment preferences and experiences to outcome was explored in patients with generalized anxiety disorder (GAD).

DESIGN

Patients were randomly allocated to either affect-focused body psychotherapy (ABP) (N=26) or standard psychiatric out-patient treatment (N=17).

METHOD

Initial preferences and subsequent experiences of treatment interventions were measured using a questionnaire focusing on support, inward reflection, concrete and directive problem solving, and affective expression. Outcome was assessed after 1 and 2 years in relation to symptom change.

RESULTS

ABP patients reported being helped by supportive and reflective treatment interventions to a greater extent than controls. ABP patients also had more positive experiences of supportive and emotionally expressive interventions than they had expected at initial assessment. When patients were divided into two groups on the basis of patterns of preferences and experiences using cluster analysis, it was found that differences in outcome were considerably more marked for clusters than treatment groups.

CONCLUSIONS

It is concluded that treatment preferences may have considerable interpersonal potential in therapy; how therapists utilize this potential may be important for improving outcome.

Prevalence, correlates, disability, and comorbidity of DSM-IV narcissistic personality disorder: results from the wave 2 national epidemiologic survey on alcohol and related conditions

OBJECTIVES

To present nationally representative findings on prevalence, sociodemographic correlates, disability, and comorbidity of narcissistic personality disorder (NPD) among men and women.

METHOD

Face-to-face interviews with 34,653 adults participating in the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions conducted between 2004 and 2005 in the United States.

RESULTS

Prevalence of lifetime NPD was 6.2%, with rates greater for men (7.7%) than for women (4.8%). NPD was significantly more prevalent among black men and women and Hispanic women, younger adults, and separated/divorced/widowed and never married adults. NPD was associated with mental disability among men but not women. High co-occurrence rates of substance use, mood, and anxiety disorders and other personality disorders were observed. With additional comorbidity controlled for, associations with bipolar I disorder, post-traumatic stress disorder, and schizotypal and borderline personality disorders remained significant, but weakened, among men and women. Similar associations were observed between NPD and specific phobia, generalized anxiety disorder, and bipolar II disorder among women and between NPD and alcohol abuse, alcohol dependence, drug dependence, and histrionic and obsessive-compulsive personality disorders among men. Dysthymic disorder was significantly and negatively associated with NPD.

CONCLUSIONS

NPD is a prevalent personality disorder in the general U.S. population and is associated with considerable disability among men, whose rates exceed those of women. NPD may not be as stable as previously recognized or described in the DSM-IV. The results highlight the need for further research from numerous perspectives to identify the unique and common genetic and environmental factors underlying the disorder-specific associations with NPD observed in this study.

Agoraphobia between panic and phobias: clinical epidemiology from the Sesto Fiorentino Study

In the last few decades, there has been a long debate on the existence of agoraphobia (AG) without a history of panic attacks (PAs). In the present study, the problem of the relationships between AG and PAs is addressed trough a reevaluation of the cases who had been diagnosed with AG in the community survey of Sesto Fiorentino. Forty-one of the 75 subjects who met the criterion of AG in the Sesto Fiorentino Study were reinterviewed by experienced clinical psychiatrists. The Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and the Composite International Diagnostic Interview were used to make the diagnoses. The Mobility Inventory for Agoraphobia (MIA) and a specific adjunctive question, "why do/did you avoid?", were used to compare AG subjects with or without PD. Of the 41 subjects with a lifetime history of AG, 12 cases had original diagnosis of AG without PAs and the remaining 29 had PD with AG. After the reassessment, in 10 cases, the criteria for the diagnosis of AG without PAs were confirmed, totaling a lifetime prevalence of 0.4% (confidence interval, 0.2-0.8). Agoraphobia subjects with and without PAs were comparable as regard to sex, age, age of onset, duration of illness, family history for anxiety or mood disorders, MIA scores, number, and type of situations avoided. Thus, AG seems to exist also in absence of a history of PAs, and the one-way relationship between the occurrence of PAs and a following development of AG, postulated by DSM-IV, should be reconsidered for the future classifications.

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.

The relationship between avoidant personality disorder and social phobia

The main explanatory hypothesis for the distinction between social phobia (SP) and avoidant personality disorder (APD) has been the severity continuum hypothesis, stating that APD only differs from SP in terms of severity of dysfunction and symptomatic distress, that is, social anxiety and depressive symptoms. This study aimed at a comprehensive evaluation of this hypothesis in a large sample (n = 2192) of thoroughly assessed patients, most of whom had a diagnosis of personality disorder. Social phobia was stronger associated with APD than with other personality disorders, and APD was stronger associated with SP than with other symptom disorders. Social phobia-pure patients had a higher level of global functioning and lower levels of general symptom distress and interpersonal problems than APD-pure patients. The 2 groups were similar on domains that pertain to social anxiety and introversion, but APD was associated with a broader array of symptoms and interpersonal problems and was substantially lower on the personality domain of conscientiousness. Avoidant personality disorder was stronger associated with eating disorders, and SP was stronger associated with panic disorder. The APD diagnosis seems to capture a broader constellation of symptoms and personality features pointing toward more severe personality dysfunction. Our findings suggest that the severity continuum hypothesis lacks specificity and exploratory power to account for both similarities and differences between SP and APD.

Emptiness in agoraphobia patients

In light of new research findings about the efficacy of psychodynamic treatment for panic disorder and agoraphobia, it seems a prudent time to carefully address psychoanalytic thinking about the treatment of agoraphobia. The literature has highlighted oedipal contributions to its genesis and clinical unraveling in psychoanalysis. While those contributions are indeed central to the disorder, structural deficits in the self-representation often become a central focus of treatment once symptomatic remission has been achieved in psychoanalytic treatment. This aspect of the clinical presentation of agoraphobia has not yet been specifically addressed in the psychiatric literature. Some aspects of the phenomenon have been described by psychoanalysts. It is more difficult to treat this "emptiness" than the overt symptoms of agoraphobia, as described in DSM-IV. Nonetheless, this phenomenon may be one of the contributors to the chronicity of the disorder. Two clinical cases illustrate these points.

Personality disorders evident by early adulthood and risk for anxiety disorders during middle adulthood

Data from the Children in the Community Study, a prospective longitudinal investigation, were used to investigate the association of personality disorder (PD) traits, evident by early adulthood, with risk for development of anxiety disorders by middle adulthood. Individuals without a history of anxiety disorders who met diagnostic criteria for >or=1 PD by early adulthood were at markedly elevated risk for agoraphobia, generalized anxiety disorder, obsessive-compulsive disorder, and panic disorder by middle adulthood. Antisocial, avoidant, borderline, dependent, depressive, histrionic, obsessive-compulsive, passive-aggressive, and schizotypal PD traits, evident by early adulthood, were associated with elevated risk for >or=1 anxiety disorder during middle adulthood. These associations remained significant after a history of anxiety disorder and co-occurring Axis I psychiatric disorder was controlled statistically. Findings of this study suggest that some types of PD traits that become evident by early adulthood may contribute to increased risk for the development of anxiety disorders by middle adulthood.

The effect of temperament and character on response to selective serotonin reuptake inhibitors in panic disorder

OBJECTIVE

In this prospective study, temperament and character were evaluated in patients with panic disorder (PD), before 1 year of medication therapy, to verify whether these factors influenced the outcome of treatment.

METHOD

Seventy-one PD patients 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 pharmacotherapy and were evaluated monthly over 1 year.

RESULTS

Before treatment, non-remitted patients showed higher levels of harm avoidance (HA) and lower levels of persistence (P), self-directedness (SD) and cooperativeness (C), whereas remitted patients showed only higher levels of HA. After controlling the effect of the confounding variables, the likelihood to achieve remission was positively related to SD score (OR = 1.12; P = 0.002), particularly 'self-acceptance' SD dimension (OR = 1.30; P = 0.02).

CONCLUSIONS

Our data suggest that in PD: i) the evaluation of personality, using the Cloninger's model, confirms the presence of personality pathology as one predictor of non-response to treatment; ii) in patients with low SD a combination of medication and cognitive-behaviour therapy should be the most effective treatment.

The effect of pharmacotherapy on personality disorders in panic disorder: a one year naturalistic study

BACKGROUND

In this prospective study, Personality Disorders (PersD) were evaluated in patients with Panic Disorder (PD), before and after one year of pharmacotherapy to verify whether personality characteristics changed after treatment.

METHOD

Sixty PD patients and 60 sex and age-matched normal controls participated in the study. All subjects were evaluated with the SCID-IV, the Structured Interview for DSM-IV Personality Disorders (SIDP), the SCL-90, the Ham-A and the Ham-D. Patients were treated with paroxetine or citalopram and were evaluated monthly for one year to assess the remission of symptoms. The SIDP was re-administered to the patients at the end of the study.

RESULTS

Before treatment, PD patients showed a higher prevalence (60%) of PersD than normal subjects (8%). After treatment, PersD rate decreased (43%) due to the reduction of the rate of paranoid, avoidant and dependent PersD. When the effect of the treatment on personality traits was evaluated, we found that avoidant traits decreased only in remitted patients, paranoid traits decreased both in remitted and in non-remitted patients, and dependent traits decreased only in patients with major depression comorbidity.

LIMITATIONS

The small sample size and the short length of the follow-up period of our study suggest caution in the generalization of our results.

CONCLUSIONS

In our PD patients, an improvement of symptoms was associated with a reduction of paranoid, avoidant and dependent traits, with a normalization of paranoid traits and a persistence of avoidant and dependent characteristics. Therefore, our data suggest that in PD patients not only paranoid traits but also avoidant and dependent traits show, at least in part, a state phenomenon.

Personality disorder traits associated with risk for unipolar depression during middle adulthood

Data from the Children in the Community Study, a prospective longitudinal investigation, were used to investigate the association of personality disorder (PD) traits, evident by early adulthood, with risk for the development of unipolar depressive disorders by middle adulthood. Antisocial, borderline, dependent, depressive, histrionic, and schizotypal PD traits, identified between ages 14 and 22, were significantly associated with risk for dysthymic disorder (DD) or major depressive disorder (MDD) by a mean age of 33 after a history of unipolar depression and other psychiatric disorder was controlled statistically. Individuals without a history of unipolar depression who met diagnostic criteria for > or =1 PD by a mean age of 22 were at elevated risk for DD or MDD by a mean age of 33 years. Individuals identified as having a DSM-IV Cluster A (paranoid, schizoid, or schizotypal) or Cluster C (avoidant, dependent, obsessive-compulsive) PD by a mean age of 22 years were at elevated risk for recurrent or chronic unipolar depression. The findings of this study suggest that some types of PD traits that become evident by early adulthood may contribute to an increased risk for the development or recurrence of unipolar depressive disorders by middle adulthood.

Avoidant personality disorder and social phobia: distinct enough to be separate disorders?

OBJECTIVE

Existing evidence from anxiety disorder research indicates that social phobics (SP) with avoidant personality disorder (AVPD) experience more anxiety and show more impairment than patients with SP alone. The purpose of this study was to examine whether in patients diagnosed with AVPD, the co-occurrence of SP adds to its severity. We hypothesized that the addition of SP will not add to the severity of AVPD alone.

METHOD

Two groups of patients (AVPD=224; AVPD/SP=101) were compared at baseline and 2 years later on multiple demographic and clinical variables.

RESULTS

Patients with AVPD and an additional diagnosis of SP differed little from patients with AVPD alone.

CONCLUSION

These findings suggest that AVPD and SP may be alternative conceptualizations of the same disorder.

Relationships between major depressive disorder and comorbid anxiety and personality disorders

OBJECTIVE

The aim of the study was to examine whether comorbid anxiety disorders influence depressed patients' likelihood of meeting criteria for a personality disorder (PD) and whether comorbid anxiety disorders influence the stability of the PDs in patients with remitted depression.

METHODS

The initial sample consisted of 373 outpatients who met criteria for major depressive disorder (MDD) (by Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition-Patient Edition) and who were enrolled in the 8-week acute treatment phase of a study of fluoxetine for MDD. Sixty-four subjects who responded to fluoxetine treatment in the acute phase met criteria for remission throughout a 26-week continuation phase during which they remained on fluoxetine with or without cognitive behavioral therapy. Stability of PDs was defined as meeting criteria for a PD at both beginning and end point of the continuation treatment phase.

RESULTS

Before fluoxetine treatment, anxious depressed patients (defined as meeting criteria for MDD as well as at least one comorbid anxiety disorder) were significantly more likely to meet criteria for any comorbid PD diagnosis compared with depressed patients without comorbid anxiety disorders. In particular, there was a significant relationship between the presence of Cluster A and C PDs and the presence of anxious depression at baseline before antidepressant treatment. After successful treatment of MDD, we found a significant relationship between anxious depression diagnosed at baseline and the stability of a Cluster C PD diagnosis.

CONCLUSION

Anxious depression may place patients at greater risk of having a PD diagnosis, especially one from Cluster A or C. Once the depression remits, patients who initially met criteria for anxious depression may be more likely to maintain a Cluster C PD diagnosis compared with patients initially diagnosed with MDD alone.

Efficacy of cognitive behaviour therapy in generalized anxiety disorders. Results of a controlled clinical trial (Berlin CBT-GAD Study)

BACKGROUND

Generalized anxiety disorders (GAD) are amongst the most prevalent mental disorders. Recent studies have suggested that cognitive behaviour therapy (CBT) is an effective treatment for GAD. A controlled clinical trial was done to evaluate the efficacy of CBT treatment in outpatients with pure GAD who were treated by a therapist working in routine care.

METHODS

Seventy-two outpatients, fulfilling GAD criteria according to DSM-IV, were included in the study. From this group, 36 patients (CBT-A) were randomly assigned to 25 sessions of CBT and the other 36 formed a contact control group (CCG). After the contact control period (CC period), these patients were also treated with CBT (CBT-B), allowing not only a parallel group comparison but also an A-B comparison. Therapists were licensed full-time psychologists who worked routinely in outpatient care and had a professional training in CBT. Treatment was done in accordance with a manual, and treatment conformity was controlled by several methods.

RESULTS

The reduction in the score on the Hamilton Anxiety Observer Rating Scale was 6.4% (1.5 points) in the CCG, 35.4% (9.5 points) in the CBT-A and 47.3% (10.3 points) in the CBT-B. In the self-rating Spielberger State-Trait Anxiety Inventory, a reduction of 2.7% was seen in CCG, 14.6% in CBT-A, and 11.6% in CBT-B. According to the Clinical Global Impression Rating, 65.6% of patients were still at least moderately ill at the end of the CC period, while this rate was 33.4% at the end of CBT-A, or 15.7% at the end of CBT-B. All these differences between treatment and control group are statistically highly significant. The clinical improvement remained stable over a follow-up period of 8 months.

CONCLUSIONS

CBT is an effective method of treatment for GAD. Differences between control and treatment group are comparable to or larger than those reported in studies on antidepressant drugs.

Is SCL-90R helpful for the clinician in assessing DSM-IV symptom disorders?

OBJECTIVE

To investigate associations between six of the Symptom Check-List 90R (SCL-90R) subscales and specific DSM-IV symptom disorders in a sample of patients with high comorbidity of axis I and axis II disorders.

METHOD

SCL-90R questionnaires from 1202 patients admitted for treatment in the Norwegian Network of Psychotherapeutic Day Hospitals. Mean score differences on subscales among diagnostic categories were investigated. With diagnoses as external criteria, cut-off scores for different diagnostic groups were used to calculate diagnostic efficacy. Multiple regressions were conducted in order to disentangle variance of the subscales accounted for by symptom disorders. Frequency distributions of subscales for patients with and without symptom disorders were compared.

RESULTS

Poor diagnostic efficacy was found for most of the subscales, except for the phobic anxiety subscale. The strongest association with each subscale was with its associated symptom disorder, except for dysthymia.

CONCLUSION

Diagnostic inferences about DSM-IV symptom disorders based on SCL-90R should be conducted with care.

DSM-IV obsessive-compulsive personality disorder: prevalence in patients with anxiety disorders and in healthy comparison subjects

The relationship between obsessive-compulsive disorder (OCD) and obsessive-compulsive personality disorder (OCPD) has not yet been fully clarified. The aim of the present study was to analyze DSM-IV OCPD prevalence rates in OCD and panic disorder (PD) patients to test for the specificity of the OCPD-OCD link, and to compare them to OCPD prevalence in a control group of subjects without any psychiatric disorder. A total of 109 patients with a principal diagnosis of DSM-IV (SCID-I) OCD and 82 with PD were interviewed using the Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II) in order to assess the prevalence of OCPD. All patients with a coexisting axis I diagnosis were excluded from the study to eliminate confounding factors when evaluating the association between prevalence rates of OCPD and anxiety disorder diagnoses. An exclusion criteria was also a Hamilton Depression Rating Scale (HAM-D) score >/=16. A sample of comparison subjects (age 18 to 65 years) without any psychiatric disorder was recruited from people registered with two general practitioners (GPs), whether or not they consulted the doctor, in order to evaluate OCPD prevalence rate in the community. A significant difference was found between the prevalence of OCPD in OCD (22.9%) and in PD (17.1%) on one hand, and that in the comparison sample (3.0%) on the other. No differences were found between the two psychiatric groups, even when splitting the samples according to gender. Our study failed to support the hypothesis of a specific relationship between OCPD and OCD; we confirmed the higher prevalence rate of this personality disorder in OCD subjects with regard to the general population, but we also confirmed the higher rate of OCPD in another anxiety disorder which is phenomenologically well characterized and different from OCD, such as PD.

Mood patterns and variations associated with personality disorder pathology

This study examined mood and mood variation in relation to varying forms and degrees of personality disorder (PD) pathology. Mood experiences of 98 psychotropic medication-free individuals were repeatedly assessed over a 4-day period. Persons with PDs (n = 57) generally displayed neutral to moderately positive moods; however, overall mood valence was less positive when compared to those without PDs (n = 41). Mood ratings demonstrated moderate covariations with anxious-fearful (A-F) PD traits but little or no association with erratic-emotional-dramatic (E-D) and odd-eccentric (O-E) PD traits once common variance among PD dimensions was removed. For PD diagnostic categories, the presence of avoidant and/or depressive PDs was most strongly associated with negative mood. When dimensional scores based on specific PD trait features were considered, avoidant, depressive, borderline, passive-aggressive, obsessive-compulsive, dependent, paranoid, and schizoid PD traits demonstrated the most reliable associations with negative mood. Apart from borderline PD features, traits associated with other E-D cluster PDs displayed little or no associations with mood quality. Consistent with previous research, mood variability emerged as an internally consistent and stable individual difference variable. Mood variability, however, was not generally associated with PD diagnostic categories or traits. Implications of this study's findings are considered in relation to the conceptual modeling of PDs.

The lifelong course of social anxiety disorder: a clinical perspective

Social anxiety disorder (SAD) is among the most frequently observed psychiatric disorders, with estimates of approximately 10% of people likely to suffer from the disorder during their lifetime. However, despite causing significant impairment of normal functioning, this disorder is often mistaken as shyness and remains under-recognized and under-treated. Following onset in adolescence, patients with generalized SAD often experience a lifelong and unremitting mental disorder characterized by severe anxiety and disability. Typical duration of the illness is far in excess of that seen in panic disorder, and prospective, long-term, naturalistic studies have indicated that only one-third of individuals attain remission from SAD within 8 years, compared with over two-thirds of those with panic disorder. Comorbidity of other anxiety disorders, depression and personality disorders are common in SAD and associated with more pronounced impairment and a poorer long-term outcome. Effective treatment for SAD is available but use is low and may remain suboptimal, despite the development of pharmacotherapeutic agents with anxiolytic and antidepressant properties and the efficacy of psychotherapeutic approaches. Increased knowledge of the course of SAD highlights the need to examine the role of available treatments, administered individually or in combination, as acute, continuation or maintenance therapy to maximize the chances of remission and long-term benefit for patients.

Stability as a distinction between Axis I and Axis II disorders

Temporal stability has served as a conceptual basis for the distinction between the clinical syndromes of Axis I disorders and the Axis II personality disorders, the latter being viewed as lifelong enduring patterns. However, comparisons of the stability of Axis I and II disorders have been limited. The present review examines findings from three naturalistic longitudinal studies that utilize similar methodology: the Collaborative Longitudinal Personality Disorders Study (CLPS; Gunderson et al., 2000), the Collaborative Depression Study (CDS; Katz & Klerman, 1979), and the Harvard/Brown Anxiety Research Program (HARP; Keller et al., 1994). Using a definition of remission/recovery as having no or minimal symptoms for 8 consecutive weeks, the courses of personality, depressive, and anxiety disorders were compared. Though remission/recovery rate at the 2-year follow-up was highest for mood disorders, the probability of recurrence was also particularly high. Personality disorders, with remission rates higher than the anxiety disorders, appear to be less stable than conceptualized. The anxiety disorders had remarkably low recovery rates even beyond 5 years of prospective follow-up. Factors that may explain these findings, as well as implications for future conceptualization of DSM, are discussed.

Predictors of response in anxiety disorders

Anxiety disorder variables such as duration, severity of illness, and comorbidity with other anxiety or mood disorders appear to identify individuals who are at the greatest risk of treatment nonresponse. Conversely, in accord with clinical experience, shorter periods of illness, less severe illness, being treatment naive, and the absence of comorbidity tend to identify patients who are likely to respond robustly to medication management. Symptom clusters in OCD and PTSD are promising as a means of stratifying those more likely to respond to standard pharmacologic treatment. The presence of hoarding or sexual obsessions seems to presage poorer response in OCD, while the presence of dissociative symptoms in PTSD has been linked to high nonspecific treatment response rates to placebo. Genotyping individuals with respect to genes that are thought to have an important role in the underlying disease process, such as the work with the 5HTTL-PR allele, is exciting and is perhaps the first glimmer of using genotyping to identify treatment strategies or to predict the likelihood or speed of response. The use of neuroimaging as a means of identifying individuals who may respond favorably to pharmacologic or neurosurgical intervention is still in its infancy. As a strategy, it may help combine symptom severity and response variables into a clear neurobiologic vulnerability model of illness. In the future, it may be possible to identify specific treatment interventions for specific patterns of abnormal metabolic rates in certain areas of the brain. However, it should be emphasized that such an approach has not been empirically demonstrated in a rigorous experimental context at this time.

Personality and anxiety disorders: a review

In this article, we summarize research on how normal personality and personality disorder traits may relate to anxiety disorders as predisposing factors, complications, and results of common underlying etiologies. We outline important questions and how these may be addressed through future research using genetically informative longitudinal and other designs, including: Are high neuroticism/cluster C personality traits causally related to the development of anxiety disorders? To what extent does the state of having an anxiety disorder influence the assessment of personality traits? Do high neuroticism/personality disorder traits and anxiety disorders co-occur because of shared genetic and environmental determinants? And, do personality disorder traits add to the prediction of anxiety disorders when normal personality traits are taken into account?