- Email: [email protected]
Are personality disorders more frequent in early onset geriatric depression?
Journal of Affective Disorders 46 (1997) 297–302
Preliminary communication
Are personality disorders more frequent in early onset geriatric depression? Vincent Camus*, Carlos Augusto de Mendonc¸a Lima, Michel Gaillard, Italo Simeone, Jean Wertheimer Geriatric Psychiatry Department, University of Lausanne, 1011 -CHUV Lausanne, Switzerland
Abstract This preliminary study evaluates the prevalence of personality disorders (PD) in a sample of 37 elderly recovered depressed and non-demented patients, using the French version of the Vragenlijst voor Kenmezken van de Persoonlijkheid (VKP) or Questionnaire on Personality Traits (QPT). The prevalence of definite personality disorder was 65% with predominance of Cluster C and particularly dependent and avoidant PD. The rate of PDs was higher in early onset (73%) than in late onset (45%) geriatric depression, even though there is only a trend towards statistical significance (Chi square 5 2.588, p 5 0.107). These results are consistent with those of previous reports using different PD assessment methods, supporting evidence that the QPT could be useful in PD assessment of elderly French speaking patients. 1997 Elsevier Science B.V. Keywords: Personality disorders; Depression; Elderly; Ageing; Psychodiagnostic interview
1. Introduction As defined by current classification systems, personality disorders describe enduring, inflexible and maladaptive patterns of perceiving, relating to, and thinking about, the environment and the self. Persisting throughout adulthood, they interfere with interpersonal relationships and social competencies. Their comorbidity with Axis I DSM diagnosis and particularly with affective illness, is well known in adulthood (Flick et al., 1993; Pilkonis and Frank, 1988). Moreover they have been shown to impair treatment response to Axis I conditions (Reich and *Corresponding author. E-mail: [email protected]
Vasile, 1993; Shea et al., 1990). It is still unclear whether personality disorders remain stable during the ageing process, and data on personality disorders in the elderly remain sparse. A mean prevalence of 10% of personality disorders in elderly patients has been established by a meta-analysis of 11 recent studies (Abrams and Horowitz, 1996). The results of these studies remain heterogeneous because of methodological issues: recruitment of patients may be from community, outpatient or inpatient facilities, some of the studies are retrospective, others prospective. In addition, the diagnostic assessment of personality disorders varies from clinical to structured interviews or self-report tools (Table 1). Over the past 20 years, great efforts have been
0165-0327 / 97 / $17.00 1997 Elsevier Science B.V. All rights reserved. PII S0165-0327( 97 )00152-3
298
V. Camus et al. / Journal of Affective Disorders 46 (1997) 297 – 302
Table 1 Recent epidemiological studies on prevalence of personality disorders in the elderly Author
n5
Setting
Axis I diagnoses
Prevalence of personality disorders
Personality disorders assessment
(%) (Mezzich et al., 1987) (Abrams et al., 1987)
(Thompson et al., 1988) (Fogel and Westlake, 1990)
494 .60 yrs 4357 ,60 yrs 36
120
Community mental health service Inpatient community (controls) Outpatient
2322
Inpatient
(Speer and Bates, 1992) (Schneider et al., 1992)
128 50
Inpatient Oupatient
(Kunik et al., 1993)
154
Inpatient
(Kunik et al., 1994)
547
Inpatient
(Devanand et al., 1994) (Abrams et al., 1994)
40 30
(Ames and Molinari, 1994) (Molinari et al., 1994) (Molinari and Marmion, 1995)
200 200 76
(Golomb et al., 1995)
316 180 ,41 yrs 136 42–65 yrs 208 89 elderly 119 young
(Agbayewa, 1996)
Outpatient Inpatient n517 Outpatient n513 Community Inpatient Inpatient n524 Outpatient n552 Outpatient
Inpatient
made to increase inter-rater reliability of standardised assessment methods for diagnosis of personality disorders (Fergusson and Tyrer, 1989). The most frequently structured interviews used are the Structured Clinical Interview (SCID II) (Spitzer et al., 1987) which includes the Personality Disorder Questionnaire (PDQ), SIDP (Pfohl et al., 1986), Personality Disorder Examination (PDE) (Loranger et al., 1987) and Zutezuotional Personality Disorder Examination (IPDE) (Loranger et al., 1994) whose reliability and validity have been considered as acceptable (Pilkonis et al., 1995). The Questionnaire on Personality Traits (QPT) has been recently proposed (Duijsens et al., 1996b). It consists in a
All diagnoses 21 Recovered depressed 15 Healthy controls Major depressive episode Major depressive episode All diagnoses 20 Recovered depressed 30 Healthy subjects Major depressive episode All diagnoses (including 154 depressed patients) Dysthymia Early and late onset depressive episodes – All diagnoses Depressed and bipolar Major depressive episode Major depressive episode
6 22 9.5 –
Clinical
33
SIDP
15.8
Clinical
30 40 10 24
Clinical SCID II Clinical
13
Clinical
10 5.5
SCID PDE
13 51 61.5 67 Young 92 57
SIDP-R SIDP-R SIDP-R
PDE
Aged 91 62
PDQ-R SCID II Clinical
27 43
standardised self-report questionnaire for diagnosis of DSM-III-R personality disorders. Its concurrent validity has been established against IPDE (Duijsens et al., 1996a). Its sensitivity is 100% for three of the DSM-III-R personality disorders, but less than 50% for antisocial, histrionic, obsessive compulsive and narcissistic personality disorder. Specificity is 80% or greater for ten of 13 of the disorders. Its temporal stability has shown to be sufficient (Duijsens et al., 1996b). A French version of the QPT is now available and was tested in adult patients (Marchiori et al., in press). This version was used for the present study. The main aim of this preliminary study was to test
V. Camus et al. / Journal of Affective Disorders 46 (1997) 297 – 302
the use of the French version of the QPT in elderly patients. Secondarily, it was to evaluate the prevalence of personality disorders in recovered depressed elderly patients, as assessed by QPT, and to test the hypothesis that an early onset of first depressive episode or past history of depressive episodes in adulthood (before 60 years old) could be strongly associated to high frequency of personality disorders in geriatric depression.
2. Methods The sample consisted of 37 non-demented elderly patients admitted to a geriatric psychiatry day-hospital for rehabilitation after acute treatment of a depressive episode which was previously conducted in a geriatric psychiatry inpatient unit. Each patient had a diagnosis of major depressive episode as established by an experienced geriatric psychiatrist according to DSM-III-R criteria, and none met diagnostic criteria for dementia (Min: Mental State Examination was 25.26 2.5). They were assessed for marital status, age, gender, educational level. The sample was divided into two categories: early onset / late onset depressive disorder, on the basis of the presence / absence of a past history of depressive episode before the age of 60 years. Because self-
299
report measures of personality assessment can be affected by residual symptoms of affective disorders (Abrams, 1996), patients were administered the QPT during the remission phase of a depressive episode, and scores on the 17 items of the Hamilton Depression Rating Scale (HDRS) were noted at the time of the personality disorders clinical investigation. The time needed to complete the QPT was 45 to 60 min. The QPT self-report is a 152 question instrument covering all criteria for DSM-III-R personality disorders diagnoses. All questions are structured such that they can be answered as ‘‘definitely yes’’ ‘‘definitely no’’, ‘‘cannot decide’’, and ‘‘not applicable’’. Patients were instructed to answer each questions on the basis of their entire life experience, and a trained nurse assisted them during questionnaire completion. A cover sheet gives algorithms to allow the presence or absence of each subtype of personality disorder to be determined according to the number of present / absent criteria. Patients who scored positively on 15 or more questionnaire items without fulfilling criteria for a specific personality disorder, was assessed as Not Otherwise Specified (NOS) personality disorder. In order to assess the severity of the disorder, a dimensional score was defined for each subtype as the ratio ‘‘number of criteria present / total number of criteria’’. For example meeting ]58 criteria for borderline personality disorders, dimensional score50.625.
Table 2 Clinical characteristics of the sample Full sample Age (yrs) 73.767 Educational level (yrs) 11.161.8 MMS 25.262.5 HDRS 11.864.5 Gender (n5) Male 10 Female 27 Marital status (n5) Married 15 Divorced 7 Widowed 8 Single 1 Age of first depressive episode (n5) Early (,60 yrs) 26 Late (.60 yrs) 11
Absence of personality disorder
Presence of personality disorder
Significance
7562 11.160.5 25.360.7 1061.26
7263 1160.4 25.160.5 1361.04
t5 1.172, p50.24 t5 0.053, p50.95 t5 0.205, p50.83 t5 21.833, p50.076
4 9
6 18
Chi square50.142 p50.7
5 0 5 1
10 7 3 0
Chi square510.644 p50.041
7 6
19 5
Chi square52.588 p50.107
V. Camus et al. / Journal of Affective Disorders 46 (1997) 297 – 302
300
3. Results Demographic variables of the sample are reported in Table 2. Patients ranged from 64 to 86 years old (mean age573.765.8). Among this patients, 70% (n526) had a past history of depressive disorder before the age of 60 (early onset depressive disorder), and 65% (n524) fulfilled criteria of at least one personality disorder, according to the results of the QPT. Seventy-three percent of the early onset depressed patients had personality disorder, compared to only 45% in those with late onset depression (Chi square52.588, p50.107). On the 24 patients who had personality disorder, only 37.5% (n59) had a single personality disorder, whereas 25% (n56) had criteria for two, and 37.5% (n59) had criteria for three or more diagnoses. Cluster C was the most frequently reported Cluster (44%), before Cluster B (25%), Cluster A (20%), and NOS personality disorder (8%). The most frequent personality disorder diagnoses were, respectively: dependent, avoidant, NOS, histrionic and borderline (Table 3). To assess the severity of personality disorders, the
dimensional score was established as described before. Higher dimensional scores were reported for avoidant (0.3660.23), dependant (0.3360.25), selfdefeating 0.3360.26), borderline (0.2860.24), schizoid (0.2360.22) and paranoid (0.2260.23) personality disorder subtypes. The dimensional score of avoidant personality disorder was significantly higher in early onset depressed patients than in late onset ( p50.013).
4. Discussion The major finding of this preliminary study is to confirm a higher rate of personality disorders in early onset than in late onset geriatric depression, even though there is only a trend toward significance. This needs to be confirmed in a larger sample, but it adds to the body of evidence for considering age of onset of depressive disorder as a clinical subtype of geriatric depression. Late onset geriatric depression has been shown to be associated with a lower incidence of family history of depressive disorders,
Table 3 Effect of age of onset of depressive disorders on dimensional score of personality disorders Personality disorders subtype
Cluster A Paranoid Schizoid Schizotypical Cluster B Antisocial Borderline Histrionic Narcissistic Cluster C Avoidant Dependant Compulsive Passive agressive NOS Sadistic Self-defeating NOS Total
Total number of criteria
Number of requested criteria for definitive diagnostic
7 7 9
4 4 5
12 8 8 9
3 5 4 5
7 9 9 9
5 5 5 5
8 8
4 5 15
Number of patients who fulfilled criteria for definite diagnostic (n5)
Mean dimensional score (number of criteria present / total number of criteria)
Early onset
Late onset
Full sample
Early onset
Late onset
Significance
10 4 4 2 16 0 6 7 3 24 9 10 2 3 6 0 6 0 56
4 1 2 1 2 0 1 1 0 7 2 3 1 1 2 1 1 1 15
14 (20%) 5 6 3 18 (25%) 0 7 8 3 31 (44%) 11 13 3 4 9 (11%) 1 7 1 72 (100%)
0.2360.23 0.2460.22 0.1960.21
0.2060.25 0.2060.24 0.1560.25
t50.276, p50.78 t50.421, p50.67 t50.600, p50.55
0.0460.07 0.3160.24 0.2660.21 0.2060.20
0.0460.07 0.2060.25 0.1760.25 0.1160.15
t50.111, t51.286, t51.086, t51.400,
p50.91 p50.20 p50.28 p50.17
0.4260.20 0.3660.25 0.2660.16 0.2360.18
0.2260.24 0.2760.27 0.2660.17 0.1860.19
t52.614, t50.971, t50.107, t50.786,
p50.013 * p50.33 p50.91 p50.43
0.0760.11 0.3660.26
0.0660.15 0.2460.24
t50.201, p50.84 t51.354, p50.18
V. Camus et al. / Journal of Affective Disorders 46 (1997) 297 – 302
poorer outcome, as well as having a strong association with dementia, all of which suggest that brain deterioration is an important etiological factor (Conwell et al., 1989; Alexopoulos et al., 1993). In contrast, personality and psychological patterns may be more important determinants of early onset geriatric depression. Compared to previous data obtained by similar design but using PDE (Abrams et al., 1994), the rate of 65% of patients fulfilling criteria for definite personality disorder seems to be rather high, but it is comparable to a prevalence of 71% reported in adult Swiss outpatients (Marchiori et al., in press), or of 67% (Molinari and Marmion, 1995) and 65% (Golomb et al., 1995) reported in US elderly depressed outpatients. The predominance of Cluster C personality disorders and particularly dependent personality disorder is consistent with other reports (Kunik et al., 1993; Thompson et al., 1988). The higher mean dimensional score of avoidant personality disorder in early onset geriatric depression was previously established by Abrams et al. (1994). The reproducibility of such a result in the present study gives an additional argument to consider Cluster C and particularly avoidant personality disorder as more related to early onset geriatric depression. Multiple diagnosis has been previously reported in one third of elderly depressed patients with personality disorders (Molinari and Marmion, 1995). The rate of two third of multiple diagnoses in the current study is nonetheless surprising. It could suggest that the DSM-III-R formulation of diagnostic criteria for personality disorders is not very specific in old age. More probably, it could be considered to result from methodological bias, particularly as an effect of the characteristics of the diagnostic assessment tool itself. Indeed, as a self-report questionnaire, the QPT has appeared to overestimate the number of personality disorders when compared to the IPDE (Duijsens et al., 1996a). This could explain why such a high rate (73%) of multiple diagnosis has been obtained in a depressed adult Swiss outpatients study which uses the same instrument. An other possible explanation is that instruments such as the QPT tend to diagnose several disorders because its diagnostic algorithm cannot prioritise diagnoses. This is, indeed, one of the main ways in which
301
clinical and research methods of assessing personality disorder diverge (Westen, 1997). Despite this latter methodological restriction, and because personality disorders are often underestimated and misdiagnosed, the use of reliable assessment methods to support clinical diagnosis should be valuable. This preliminary work is a first step in exploring self-report assessment tools for French speaking elderly patients. Though their reliability may be low compared to semistructured interview, with risks of overestimation of disorder frequency and of dimensional scores, self-report assessment of personality disorders seems at least to be feasible in elderly non-demented patients.
Acknowledgements We are grateful to M. Bianchi, A. Delgado, N. Lharras, M. Rubeli, M. Samitca and all the team of the Day-Hospital for their active contribution to this work.
References Abrams, R.C., Alexopoulos, G.S., Young, R.C., 1987. Geriatric depression and DSM-III-R personality disorder criteria. J. Am. Geriatr. Soc. 35, 383–386. Abrams, R.C., Rosendahl, E., Card, C., Alexopoulos, G.S., 1994. Personality disorder correlates of late and early onset depression. J. Am. Geriatr. Soc. 42, 727–731. Abrams, R.C., 1996. Personality disorders in the elderly. Int. J. Geriatr. Psychiatry 11, 759–763. Abrams, R.C., Horowitz, S.V., 1996. Personality disorders after age 50—a meta-analysis. J. Pers. Disord. 10, 271–281. Agbayewa, M.O., 1996. Occurrence and effects of personality disorders in depression: are they the same in the old and young?. Can. J. Psychiatry 41, 223–226. Alexopoulos, G.S., Young, R.C., Meyers, B.S., 1993. Geriatric depression: age of onset and dementia. Biol. Psychiatry 34, 141–145. Ames, A., Molinari, V., 1994. Prevalence of personality disorders in community-living elderly. J. Geriatr. Psychiatry Neurol. 7, 189–194. Conwell, Y., Nelson, J.C., Kim, K.M., Mazure, C.M., 1989. Depression in late life: age of onset as marker of a subtype. J. Affect. Disord. 17, 189–195. Devanand, D.P., Nobler, M.S., Singer, T., Kiersky, J.E., Turret, N., Roose, S.P., Sackeim, H.A., 1994. Is dysthymia a different disorder in the elderly?. Am. J. Psychiatry 151, 1592–1599. Duijsens, I.J., Bruinsma, M., Jansen, S.J.T., Eurelings-Bontekoe,
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E.H.M., 1996. Agreement between self-report and semi-structured interviewing in the assessment of personality disorders. Person. Individ. Diff. 21, 261–270. Duijsens, I.J., Eurelings-Bontekoe, E.H.M., Diekstra, R.F., 1996. The VKP, a self-report instrument for DSM-III-R and ICD-10 personality disorders: Construction and psychometric properties. Person. Individ. Diff. 20, 171–182. Ferguson, B., Tyrer, P., 1989. Personality disorders. In: C. Thompson (Ed.), The Instruments of Psychiatry Research. John Wiley, Chichester, New York, 239–251. Flick, S.N., Roy-Byrne, P.P., Cowley, D.S., Shores, M.M., Dunner, D.L., 1993. DSM-III-R personality disorders in a mood and anxiety disorders clinic: prevalence, comorbidity, and clinical correlates. J. Affect. Disord. 27, 71–79. Fogel, B.S., Westlake, R., 1990. Personality disorder diagnoses and age in inpatients with major depression [see comments]. J. Clin. Psychiatry 51, 232–235. Golomb, M., Fava, M., Abraham, M., Rosenbaum, J.F., 1995. The relationship between age and personality disorders in depressed outpatients. J. Nerv. Ment. Dis. 183, 43–44. Kunik, M.E., Mulsant, B.H., Rifai, A.H., Sweet, R.A., Pasternak, R., Rosen, J., Zubenko, G.S., 1993. Personality disorders in elderly inpatients with major depression. Am. J. Geriatr. Psychiatry 1, 38–45. Kunik, M.E., Mulsant, B.H., Rifai, A.H., Sweet, R.A., Pasternak, R., Zubenko, G.S., 1994. Diagnostic rate of comorbid personality disorder in elderly psychiatric inpatients. Am. J. Psychiatry 151, 603–605. Loranger, A.W., Susman, V.L., Oldham, J.M., Russakoff, 1987. The Personality Disorder Examination: A preliminary report. J. Pers. Disord. 1, 1–13. Loranger, A.W., Sartorius, N., Andreoli, A., Berger, P., Buchheim, P., Channabasavanna, S.M., Coid, B., Dahl, A., Diekstra, R.F., Ferguson, B., Jacobsberg, L.B., Mombour, W., 1994. The International Personality Disorder Examination. The World Health Organization /Alcohol, Drug Abuse, and Mental Health Administration international pilot study of personality disorders. Arch. Gen. Psychiatry 51, 215–224. Marchiori, E., Andreoli, A.V., Brandt, A., Reich, J., Diekstra, R.F., Duijsens, I.J. Assessing personality disorders in outpatient community services. J. Pers. Disord. Mezzich, J.E., Fabrega, Jr. H., Coffman, G.A., Glavin, Y.F., 1987. Comprehensively diagnosing geriatric patients. Compr. Psychiatry 28, 68–76.
Molinari, V., Ames, A., Essa, M., 1994. Prevalence of personality disorders in two geropsychiatric inpatients units. J. Geriatr. Psychiatry Neurol. 7, 209–215. Molinari, V., Marmion, J., 1995. Relationship between affective disorders and Axis II diagnoses in geropsychiatric patients. J. Geriatr. Psychiatry Neurol. 8, 61–64. Pfohl, B., Coryell, W., Zimmerman, M., Stangl, D., 1986. DSM-III personality disorders: Diagnostic overlap and internal consistency of individual DSM-III criteria. Compr. Psychiatry 27, 21–34. Pilkonis, P.A., Heape, C.L., Proietti, J.M., Clark, S.W., McDavid, J.D., Pitts, T.E., 1995. The reliability and validity of two structured diagnostic interviews for personality disorders. Arch. Gen. Psychiatry 52, 1025–1033. Pilkonis, P.A., Frank, E., 1988. Personality pathology in recurrent depression: nature, prevalence, and relationship to treatment response. Am. J. Psychiatry 145, 435–441. Reich, J.H., Vasile, R.G., 1993. Effect of personality disorders on the treatment outcome of axis I conditions: an update. J. Nerv. Ment. Dis. 181, 475–484. Schneider, L.S., Zemansky, M.F., Bender, M., Sloane, R.B., 1992. Personality in recovered depressed elderly. Int. Psychogeriatr. 4, 177–185. Shea, M.T., Pilkonis, P.A., Beckham, E., Collins, J.F., Elkin, I., Sotsky, S.M., Docherty, J.P., 1990. Personality disorders and treatment outcome in the NIMH Treatment of Depression Collaborative Research Program. Am. J. Psychiatry 147, 711– 718. Speer, D.C., Bates, K., 1992. Comorbid mental and substance disorders among older psychiatric patients. J. Am. Geriatr. Soc. 40, 886–890. Spitzer, R.L., William, J., Gibbon, M., 1987. Structured Clinical Interview for DSM-III-R (SCID-II). Biometric Research, New York. Thompson, L.W., Gallagher, D., Czirr, R., 1988. Personality disorder and outcome in the treatment of late-life depression. J. Geriatr. Psychiatry 21, 133–146. Westen, D., 1997. Divergences between clinical and research methods for assessing personality disorders: implications for research and the evolution of Axis II. Am. J. Psychiatry 154, 895–903.
Preliminary communication
Are personality disorders more frequent in early onset geriatric depression? Vincent Camus*, Carlos Augusto de Mendonc¸a Lima, Michel Gaillard, Italo Simeone, Jean Wertheimer Geriatric Psychiatry Department, University of Lausanne, 1011 -CHUV Lausanne, Switzerland
Abstract This preliminary study evaluates the prevalence of personality disorders (PD) in a sample of 37 elderly recovered depressed and non-demented patients, using the French version of the Vragenlijst voor Kenmezken van de Persoonlijkheid (VKP) or Questionnaire on Personality Traits (QPT). The prevalence of definite personality disorder was 65% with predominance of Cluster C and particularly dependent and avoidant PD. The rate of PDs was higher in early onset (73%) than in late onset (45%) geriatric depression, even though there is only a trend towards statistical significance (Chi square 5 2.588, p 5 0.107). These results are consistent with those of previous reports using different PD assessment methods, supporting evidence that the QPT could be useful in PD assessment of elderly French speaking patients. 1997 Elsevier Science B.V. Keywords: Personality disorders; Depression; Elderly; Ageing; Psychodiagnostic interview
1. Introduction As defined by current classification systems, personality disorders describe enduring, inflexible and maladaptive patterns of perceiving, relating to, and thinking about, the environment and the self. Persisting throughout adulthood, they interfere with interpersonal relationships and social competencies. Their comorbidity with Axis I DSM diagnosis and particularly with affective illness, is well known in adulthood (Flick et al., 1993; Pilkonis and Frank, 1988). Moreover they have been shown to impair treatment response to Axis I conditions (Reich and *Corresponding author. E-mail: [email protected]
Vasile, 1993; Shea et al., 1990). It is still unclear whether personality disorders remain stable during the ageing process, and data on personality disorders in the elderly remain sparse. A mean prevalence of 10% of personality disorders in elderly patients has been established by a meta-analysis of 11 recent studies (Abrams and Horowitz, 1996). The results of these studies remain heterogeneous because of methodological issues: recruitment of patients may be from community, outpatient or inpatient facilities, some of the studies are retrospective, others prospective. In addition, the diagnostic assessment of personality disorders varies from clinical to structured interviews or self-report tools (Table 1). Over the past 20 years, great efforts have been
0165-0327 / 97 / $17.00 1997 Elsevier Science B.V. All rights reserved. PII S0165-0327( 97 )00152-3
298
V. Camus et al. / Journal of Affective Disorders 46 (1997) 297 – 302
Table 1 Recent epidemiological studies on prevalence of personality disorders in the elderly Author
n5
Setting
Axis I diagnoses
Prevalence of personality disorders
Personality disorders assessment
(%) (Mezzich et al., 1987) (Abrams et al., 1987)
(Thompson et al., 1988) (Fogel and Westlake, 1990)
494 .60 yrs 4357 ,60 yrs 36
120
Community mental health service Inpatient community (controls) Outpatient
2322
Inpatient
(Speer and Bates, 1992) (Schneider et al., 1992)
128 50
Inpatient Oupatient
(Kunik et al., 1993)
154
Inpatient
(Kunik et al., 1994)
547
Inpatient
(Devanand et al., 1994) (Abrams et al., 1994)
40 30
(Ames and Molinari, 1994) (Molinari et al., 1994) (Molinari and Marmion, 1995)
200 200 76
(Golomb et al., 1995)
316 180 ,41 yrs 136 42–65 yrs 208 89 elderly 119 young
(Agbayewa, 1996)
Outpatient Inpatient n517 Outpatient n513 Community Inpatient Inpatient n524 Outpatient n552 Outpatient
Inpatient
made to increase inter-rater reliability of standardised assessment methods for diagnosis of personality disorders (Fergusson and Tyrer, 1989). The most frequently structured interviews used are the Structured Clinical Interview (SCID II) (Spitzer et al., 1987) which includes the Personality Disorder Questionnaire (PDQ), SIDP (Pfohl et al., 1986), Personality Disorder Examination (PDE) (Loranger et al., 1987) and Zutezuotional Personality Disorder Examination (IPDE) (Loranger et al., 1994) whose reliability and validity have been considered as acceptable (Pilkonis et al., 1995). The Questionnaire on Personality Traits (QPT) has been recently proposed (Duijsens et al., 1996b). It consists in a
All diagnoses 21 Recovered depressed 15 Healthy controls Major depressive episode Major depressive episode All diagnoses 20 Recovered depressed 30 Healthy subjects Major depressive episode All diagnoses (including 154 depressed patients) Dysthymia Early and late onset depressive episodes – All diagnoses Depressed and bipolar Major depressive episode Major depressive episode
6 22 9.5 –
Clinical
33
SIDP
15.8
Clinical
30 40 10 24
Clinical SCID II Clinical
13
Clinical
10 5.5
SCID PDE
13 51 61.5 67 Young 92 57
SIDP-R SIDP-R SIDP-R
PDE
Aged 91 62
PDQ-R SCID II Clinical
27 43
standardised self-report questionnaire for diagnosis of DSM-III-R personality disorders. Its concurrent validity has been established against IPDE (Duijsens et al., 1996a). Its sensitivity is 100% for three of the DSM-III-R personality disorders, but less than 50% for antisocial, histrionic, obsessive compulsive and narcissistic personality disorder. Specificity is 80% or greater for ten of 13 of the disorders. Its temporal stability has shown to be sufficient (Duijsens et al., 1996b). A French version of the QPT is now available and was tested in adult patients (Marchiori et al., in press). This version was used for the present study. The main aim of this preliminary study was to test
V. Camus et al. / Journal of Affective Disorders 46 (1997) 297 – 302
the use of the French version of the QPT in elderly patients. Secondarily, it was to evaluate the prevalence of personality disorders in recovered depressed elderly patients, as assessed by QPT, and to test the hypothesis that an early onset of first depressive episode or past history of depressive episodes in adulthood (before 60 years old) could be strongly associated to high frequency of personality disorders in geriatric depression.
2. Methods The sample consisted of 37 non-demented elderly patients admitted to a geriatric psychiatry day-hospital for rehabilitation after acute treatment of a depressive episode which was previously conducted in a geriatric psychiatry inpatient unit. Each patient had a diagnosis of major depressive episode as established by an experienced geriatric psychiatrist according to DSM-III-R criteria, and none met diagnostic criteria for dementia (Min: Mental State Examination was 25.26 2.5). They were assessed for marital status, age, gender, educational level. The sample was divided into two categories: early onset / late onset depressive disorder, on the basis of the presence / absence of a past history of depressive episode before the age of 60 years. Because self-
299
report measures of personality assessment can be affected by residual symptoms of affective disorders (Abrams, 1996), patients were administered the QPT during the remission phase of a depressive episode, and scores on the 17 items of the Hamilton Depression Rating Scale (HDRS) were noted at the time of the personality disorders clinical investigation. The time needed to complete the QPT was 45 to 60 min. The QPT self-report is a 152 question instrument covering all criteria for DSM-III-R personality disorders diagnoses. All questions are structured such that they can be answered as ‘‘definitely yes’’ ‘‘definitely no’’, ‘‘cannot decide’’, and ‘‘not applicable’’. Patients were instructed to answer each questions on the basis of their entire life experience, and a trained nurse assisted them during questionnaire completion. A cover sheet gives algorithms to allow the presence or absence of each subtype of personality disorder to be determined according to the number of present / absent criteria. Patients who scored positively on 15 or more questionnaire items without fulfilling criteria for a specific personality disorder, was assessed as Not Otherwise Specified (NOS) personality disorder. In order to assess the severity of the disorder, a dimensional score was defined for each subtype as the ratio ‘‘number of criteria present / total number of criteria’’. For example meeting ]58 criteria for borderline personality disorders, dimensional score50.625.
Table 2 Clinical characteristics of the sample Full sample Age (yrs) 73.767 Educational level (yrs) 11.161.8 MMS 25.262.5 HDRS 11.864.5 Gender (n5) Male 10 Female 27 Marital status (n5) Married 15 Divorced 7 Widowed 8 Single 1 Age of first depressive episode (n5) Early (,60 yrs) 26 Late (.60 yrs) 11
Absence of personality disorder
Presence of personality disorder
Significance
7562 11.160.5 25.360.7 1061.26
7263 1160.4 25.160.5 1361.04
t5 1.172, p50.24 t5 0.053, p50.95 t5 0.205, p50.83 t5 21.833, p50.076
4 9
6 18
Chi square50.142 p50.7
5 0 5 1
10 7 3 0
Chi square510.644 p50.041
7 6
19 5
Chi square52.588 p50.107
V. Camus et al. / Journal of Affective Disorders 46 (1997) 297 – 302
300
3. Results Demographic variables of the sample are reported in Table 2. Patients ranged from 64 to 86 years old (mean age573.765.8). Among this patients, 70% (n526) had a past history of depressive disorder before the age of 60 (early onset depressive disorder), and 65% (n524) fulfilled criteria of at least one personality disorder, according to the results of the QPT. Seventy-three percent of the early onset depressed patients had personality disorder, compared to only 45% in those with late onset depression (Chi square52.588, p50.107). On the 24 patients who had personality disorder, only 37.5% (n59) had a single personality disorder, whereas 25% (n56) had criteria for two, and 37.5% (n59) had criteria for three or more diagnoses. Cluster C was the most frequently reported Cluster (44%), before Cluster B (25%), Cluster A (20%), and NOS personality disorder (8%). The most frequent personality disorder diagnoses were, respectively: dependent, avoidant, NOS, histrionic and borderline (Table 3). To assess the severity of personality disorders, the
dimensional score was established as described before. Higher dimensional scores were reported for avoidant (0.3660.23), dependant (0.3360.25), selfdefeating 0.3360.26), borderline (0.2860.24), schizoid (0.2360.22) and paranoid (0.2260.23) personality disorder subtypes. The dimensional score of avoidant personality disorder was significantly higher in early onset depressed patients than in late onset ( p50.013).
4. Discussion The major finding of this preliminary study is to confirm a higher rate of personality disorders in early onset than in late onset geriatric depression, even though there is only a trend toward significance. This needs to be confirmed in a larger sample, but it adds to the body of evidence for considering age of onset of depressive disorder as a clinical subtype of geriatric depression. Late onset geriatric depression has been shown to be associated with a lower incidence of family history of depressive disorders,
Table 3 Effect of age of onset of depressive disorders on dimensional score of personality disorders Personality disorders subtype
Cluster A Paranoid Schizoid Schizotypical Cluster B Antisocial Borderline Histrionic Narcissistic Cluster C Avoidant Dependant Compulsive Passive agressive NOS Sadistic Self-defeating NOS Total
Total number of criteria
Number of requested criteria for definitive diagnostic
7 7 9
4 4 5
12 8 8 9
3 5 4 5
7 9 9 9
5 5 5 5
8 8
4 5 15
Number of patients who fulfilled criteria for definite diagnostic (n5)
Mean dimensional score (number of criteria present / total number of criteria)
Early onset
Late onset
Full sample
Early onset
Late onset
Significance
10 4 4 2 16 0 6 7 3 24 9 10 2 3 6 0 6 0 56
4 1 2 1 2 0 1 1 0 7 2 3 1 1 2 1 1 1 15
14 (20%) 5 6 3 18 (25%) 0 7 8 3 31 (44%) 11 13 3 4 9 (11%) 1 7 1 72 (100%)
0.2360.23 0.2460.22 0.1960.21
0.2060.25 0.2060.24 0.1560.25
t50.276, p50.78 t50.421, p50.67 t50.600, p50.55
0.0460.07 0.3160.24 0.2660.21 0.2060.20
0.0460.07 0.2060.25 0.1760.25 0.1160.15
t50.111, t51.286, t51.086, t51.400,
p50.91 p50.20 p50.28 p50.17
0.4260.20 0.3660.25 0.2660.16 0.2360.18
0.2260.24 0.2760.27 0.2660.17 0.1860.19
t52.614, t50.971, t50.107, t50.786,
p50.013 * p50.33 p50.91 p50.43
0.0760.11 0.3660.26
0.0660.15 0.2460.24
t50.201, p50.84 t51.354, p50.18
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poorer outcome, as well as having a strong association with dementia, all of which suggest that brain deterioration is an important etiological factor (Conwell et al., 1989; Alexopoulos et al., 1993). In contrast, personality and psychological patterns may be more important determinants of early onset geriatric depression. Compared to previous data obtained by similar design but using PDE (Abrams et al., 1994), the rate of 65% of patients fulfilling criteria for definite personality disorder seems to be rather high, but it is comparable to a prevalence of 71% reported in adult Swiss outpatients (Marchiori et al., in press), or of 67% (Molinari and Marmion, 1995) and 65% (Golomb et al., 1995) reported in US elderly depressed outpatients. The predominance of Cluster C personality disorders and particularly dependent personality disorder is consistent with other reports (Kunik et al., 1993; Thompson et al., 1988). The higher mean dimensional score of avoidant personality disorder in early onset geriatric depression was previously established by Abrams et al. (1994). The reproducibility of such a result in the present study gives an additional argument to consider Cluster C and particularly avoidant personality disorder as more related to early onset geriatric depression. Multiple diagnosis has been previously reported in one third of elderly depressed patients with personality disorders (Molinari and Marmion, 1995). The rate of two third of multiple diagnoses in the current study is nonetheless surprising. It could suggest that the DSM-III-R formulation of diagnostic criteria for personality disorders is not very specific in old age. More probably, it could be considered to result from methodological bias, particularly as an effect of the characteristics of the diagnostic assessment tool itself. Indeed, as a self-report questionnaire, the QPT has appeared to overestimate the number of personality disorders when compared to the IPDE (Duijsens et al., 1996a). This could explain why such a high rate (73%) of multiple diagnosis has been obtained in a depressed adult Swiss outpatients study which uses the same instrument. An other possible explanation is that instruments such as the QPT tend to diagnose several disorders because its diagnostic algorithm cannot prioritise diagnoses. This is, indeed, one of the main ways in which
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clinical and research methods of assessing personality disorder diverge (Westen, 1997). Despite this latter methodological restriction, and because personality disorders are often underestimated and misdiagnosed, the use of reliable assessment methods to support clinical diagnosis should be valuable. This preliminary work is a first step in exploring self-report assessment tools for French speaking elderly patients. Though their reliability may be low compared to semistructured interview, with risks of overestimation of disorder frequency and of dimensional scores, self-report assessment of personality disorders seems at least to be feasible in elderly non-demented patients.
Acknowledgements We are grateful to M. Bianchi, A. Delgado, N. Lharras, M. Rubeli, M. Samitca and all the team of the Day-Hospital for their active contribution to this work.
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