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Correlates of DMS-III personality disorder in Generalized Anxiety Disorder
Journal of
Anxiety Disorders,Vol. 9,
Pergamon
No. 2, pp. 103-115.1995 Copyright 0 1995 Ekvier Science Ltd Printed in the USA. All rights reserved 0887-6185195 $9.50 + .@I
0887-6185(94)ooo34-4
Correlates of DSM-I I I Personality Disorder in Generalized Anxiety Disorder MAIIG R. MAVISSAKALIAN, M.D., MARY SUE HAMANN, MS., SAID ABOU HAIDAR, M.D., AND CHRISTOPHER M. DE GROOT,M.D. Department
of Psychiatry,
The Ohio State University,
College
of Medicine
Abstract - Eighty-one patients with primary Generalized Anxiety Disorder (GAD) completed the Personality Diagnostic Questionnaire (PDQ), a self-rating scale designed to assess Axis II personality disorders (PD) from DSM-III. Results showed that 37% of the patients received at least one PD diagnosis. The most frequent diagnosis was avoidant (26%). followed by paranoid (10%). schizotypal (10%). and histrionic (9%). Consideration of the personality traits irrespective of diagnostic category showed that patients exhibiting a greater number of personality traits were also significantly mom symptomatic. However, anxiety symptoms were not selected as unique predictors of any personality variables in the regression analyses. Rather, the most important correlate of traits in general and of specific PD diagnoses was interpersonal sensitivity, as measured by the Hopkins Symptom Checklist. Less consistently related, but also important, was the Beck Depression Inventory, notably for Cluster C diagnoses. Further analysis led to the tentative suggestion that personality disorder in the sense of serious interpersonal dysfunction and unhappiness is most likely to occur when undue social anxiety, low self-confidence, and chronic feelings of emptiness or boredom accompany an avoidant lifestyle.
There are very few published studies of Axis II disorders in patients with Generalized Anxiety Disorder (GAD). Sanderson and Wetzler (1991) reported that 16 (50%) of 32 patients with primary GAD were diagnosed with a comorbid personality disorder (PD), most commonly avoidant (16%). dependent (13%), and not otherwise specified (13%) PDs. In a study of the relationship between DSM-III Axis I and Axis II disorders of a large sample of psychiatric outpatients in Oslo, Norway, Alnaes and Torgersen (1988) reported that 8 (73%) of 11 patients with GAD assessed with the use of the Structured Supported in part by Grant MH42730 from the National Institute of Mental Health. Correspondence and requests for mprints should he.addressed to Matig R. Mav&kahan, M.D., The Ohio State University, Department of Psychiatry, 473 West 12th Avenue, Columbus, OH 43210. 103
104
M. R. MAVISSAKALJAN
ET AL.
Interview for DSM-III Personality Disorders (SIDP) met criteria for an Axis II disorder. Interestingly, they estimated that the observed frequency of dependent PD (Yll, 18%) in GAD was less than half expected according to base rates, whereas avoidant PD (5/11, 45%) was neither overrepresented nor under-represented in GAD patients compared to the total sample. On the other hand, an Italian study that has compared Axis II SIDP diagnoses in 46 patients with primary GAD and 50 volunteers from a general population survey sample who were free of Axis I diagnosis has found no significant differences on any PD between the GAD and control groups (Gasperini, Battaglia, Diaferia, & Bellodi, 1990). The most frequent Axis II diagnoses assigned in the GAD group were mixed PD (39%), histrionic PD (17%), compulsive PD (15%). schizotypal PD (6.5%), dependent PD (6.5%). and avoidant PD (4%). Further analysis identified four personality traits that were significantly more frequent in the GAD sample: “hypervigilance” and “tendency to be easily slighted and quick to take offence,” both from paranoid PD, “suspiciousness or paranoid ideation” from schizotypal PD, and “dependent, helpless, seeking reassurance” from histrionic PD. In a previous paper (Mavissakalian, Hamann, Haidar, & deGroot, 1993), we compared the responses to the Personality Diagnostic Questionnaire (PDQ) of 36 GAD, 187 Panic Disorder (Panic), and 51 Obsessive-Compulsive Disorder (OCD) patients. We found that the personality profiles were similar in the three diagnostic groups, but that the major personality features identified, namely, avoidant, dependent, and histrionic features, were more pronounced in patients with OCD than in the other two anxiety disorders. We also reported that the Panic and GAD groups were identical in terms of a generic PDQ trait score, as well as on the Eysenck measures of neuroticism and extraversion. Because GAD lacks prominent panic, phobic, and obsessive-compulsive symptoms, the overwhelming similarities among these anxiety disorders on the personality measures supported earlier suggestions of a nonspecific link between DSM-III personality PD/traits and Panic Disorder (Mavissakalian & Hamann, 1988) or OCD (Mavissakalian, Hamann, & Jones, 1990). Indeed, the more pronounced personality profile in OCD was generalized and not limited to one specific PD, such as compulsive PD, and this may have been largely related to the severely disruptive interference of OCD symptoms with coping and interpersonal functioning. In this respect, dependent PD/traits reflected more closely the functional impairment caused by Axis I symptoms, which is highest in OCD, lowest in GAD, and intermediate in panic/agoraphobia, whereas avoidant PD measures varied less and were equally represented in the Panic and GAD groups. These findings, coupled with observations made during stable remission of Panic Disorder patients (Mavissakalian & Hamann, 1992), suggested that DSM-III avoidant PD may essentially capture the common and enduring personality, perhaps even temperamental, characteristics in anxiety disorders. The aim of the present paper is to describe the DSM-III personality PDs/traits in 81 GAD patients, as well as to assessthe correlates of personality in this anxiety disorder, a disorder that some authors believe may more closely resemble a personality disorder than an Axis I syndrome (Sanderson & Wetzler, 1991).
PERSONALKY
DISORDER
IN GAD
105
METHOD Sdjects Subjects were 81 patients meeting DSM-III-R diagnostic criteria for GAD; they comprised two consecutive samples of subjects referred to our specialty clinic for evaluation for pharmacological treatment studies. Data from the first sample, II = 39, have been previously reported (Mavissakalian et al., 1993). Comparison of the two samples yielded no significant differences on patientrated or clinician-rated Axis I measures; thus, the two samples were combined for all analyses reported herein. Demographically, the patients had an average age of 38.7 + 10.0 years and an age range from 19 to 61, were 52% female, 56% married, 86% employed, and had an average of 14.4 + 2.1 years of education. Clinically, all met criteria for Generalized Anxiety Disorder, one person met criteria for concurrent major depression, and no patients met criteria for concurrent panic disorder, agoraphobia, or substance abuse. Thirty-five percent of the sample (28 patients) had a past history of major depression, and this was primary in eight cases. Twenty-three percent (19 patients) had a past diagnosis of substance abuse. The mean age of onset of the anxiety symptoms was 3 1.0 & 11.O years, with a mean duration of illness of 8.1 + 7.8 years. Assessments The same clinical psychologist administered all assessments, which took place during the subjects’ initial evaluation. This took typically three hours to complete and began with the Structured Clinical Interview for DSM-III-R Patient Version (Spitzer, Williams, Gibbon, 8z First, 1988), and was followed by the administration of clinician-rated scales and then the self-rating scales. All subjects presented in this study also had a clinical, diagnostically focused interview with the first author, either on the same day or at their next visit 7 to 10 days later, that corroborated the diagnosis of GAD. The Personality Diagnostic Questionnaire (PDQ) (Hyler, Reider, Spitzer, & Williams, 1983; Reich, 1989), as well as a battery of tests assessing anxiety, depression, and clinical severity were administered. We have described in detail the procedure for administering and scoring the PDQ in an earlier report (Mavissakalian 8z Hamann, 1986). Briefly, the PDQ is a self-rating questionnaire of 163 true or false items, designed to assessthe 11 personality disorders from Axis II of the DSM-III (paranoid, schizoid, schizotypal, histrionic, narcissistic, antisocial, borderline, avoidant, dependent, compulsive, passiveaggressive). Four variables may be derived: a diagnosis for each of the disorders; the presence or absence of each personality trait, irrespective of diagnostic category; a total PDQ score (Noyes, Reich, Suelzer, 8z Christiansen, 1991); and a personality profile, which is obtained by tallying the number of endorsements of the items in each diagnostic category. Moreover, the diagnostic scoring may be further classified: Cluster A indicates odd or eccentric behavior, as evidenced by a diagnosis from the paranoid, schizoid, or schizotypal categories; Cluster B indicates dramatic, emotional, or erratic behavior and comprises the antisocial, borderline, histrionic, or narcissistic diagnoses; and
106
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ET AL.
Cluster C, anxious or fearful behavior, from avoidant, dependent, compulsive, or passive-aggressive categories. The patient-rated measures of anxiety, depression, and general psychiatric symptomatology were the Zung Anxiety Scale (Zung, 1971); the Beck Depression Inventory (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961); and the Hopkins Symptom Checklist (Derogatis, Lipman, Rickels et al., 1974), the 68-item version that has factors of somatization, obsessions-compulsions, interpersonal sensitivity, depression, anxiety, and agoraphobia. The Hopkins Symptom Checklist was available for only 61 of the patients. The clinician-rated scales included the Hamilton scales for anxiety (Hamilton, 1959) and depression (Hamilton, 1960), as well as a seven-point clinician rating of global severity, where 1 = normal, not at all ill ,4 = moderately ill, and 7 = extremely ill. RESULTS Diagnoses Fifty-one PD diagnoses were assigned, distributed among thirty patients; thus, 37% of this GAD sample received at least one diagnosis. By far the most common diagnosis was avoidant personality disorder (26% of the patients), followed by paranoid, schizotypal, and histrionic (about 10% of the patients, see Table 1). In terms of the cluster categories, 15(19%) of the patients had a diagnosis from Cluster A, 7(9%) from Cluster B, and 23(28%) from Cluster C. Fifteen patients received only one PD diagnosis: eight were avoidant, three were histrionic, two were paranoid, one was schizotypal, and one was schizoid. Nine patients received two diagnoses from the set of avoidant, dependent, paranoid, schizotypal, histrionic, and passive-aggressive. Six patients were diagnosed with three personality disorders each: all were avoidant and had two other diagnoses from the set of schizotypal, histrionic, paranoid, and compulsive. Traits In Table 1, we also present the number and percentage of patients who met the criteria for the DSM-III traits. Fifteen traits were endorsed by at least 30% of the sample: desire for affection, low self-esteem, hypersensitivity to rejection, unwillingness to enter relationships, and social withdrawal, from the avoidant category; hypersensitivity and suspiciousness and mistrust, from paranoid (and the latter is also duplicated in the schizotypal category); affective instability, feeling empty or bored, and intense, uncontrolled anger, from borderline; social and occupational ineffectiveness and indirect resistance from passive-aggressive; lacks self-confidence, from dependent; undue social anxiety, from schizotypal; and indecisiveness, from compulsive. We have not included results for Antisocial Personality Disorder in Table 1 because the DSM-III description of the traits is qualitatively different for this category than for all others; however, we note that 18(22%) of the sample reported manifestations of antisocial personality before age 18, and
PERSONALITY
DJSORDER
107
IN GAD
TABLE 1 NUMBERANTIPERCENTAGE OF81 GBNWAL~ZEOANXIER DISORDERPATENTS MEermo DSM-III DIAGNOSTIC
Disorder
No. (%) of Patients Meeting Diagnostic Criteria
Paranoid
8 (10)
Schizoid
1 (1)
schizotypal
8 (10)
Histrionic
7 (9)
Narcissistic
0
Borderline
0
Avoidant
21 (26)
Dependent
4 (5)
Compulsive
1 (1)
Passive-agressive
1 (1)
AND TWIT
AXIS II (I~TEFU
DSM-Ill Traits A. Suspiciousness and mistrust B. Hypersensitivity C. Restricted affectivity A. Emotional coldness B. Indifference to praise or criticism C. Few close friendships Al. Magical thinking A2. Ideas of reference A3. Social isolation A4. Recurrent illusions A5. odd speech A6. Inadequate rapport Al. Suspiciousness A8. Undue social anxiety A. Dramatic behavior B. Disturbed relationships A. Self-importance B. Preoccupation with fantasies C. Exhibitionism D. Indifferent or angry responses E. Disturbed relationship Al. Impulsivity or unpredictability A2. Unstable and intense relations A3. Intcnsc or uncontrolled anger A4. Identity disturbance A5. Afktive instability A6. Intolerance of being alone A7. Physically self-damaging acts A8. feeling empty or bored A. Hypersensitivity to rejection B. Unwillingness to enter relationships C. Social withdrawal D. Desire for affection E. Low self-esteem A. Allows others responsibility B. Subordinates own needs C. Lacks self-confidence 1. Restricted emotional expression 2. Perfectionism 3. Insistence on own way 4. Excessive devotion to work 5. Indeciiiveness A. Resistance to demands B. Indirect resistance C. Social and occupational ineffectiveness D. Persistence of behavior
No. (76) of Patients Meeting Trait Criteria 45 55 11 5 3 15 0
(56) (68) (14) (6) (4) (19)
8 (10) 13 0 21 18 45 32 22 22 14 12 12 1 8 20 0 24 1 54 19 0 29 57 39 38 79 72 12 18 40 13 23 3 19 31
(16) (26) (22) (56) (40) (27) (27) (17) (15) (15) (1) (10) (25) (30) (1) (67) (23) (36) (70) (48) (47) (98) (89) (15) (22) (49) (16) (28) (4) (23) (38)
2 (2)
51 (63) 53 (65) 3 (4)
108
M. R. MAVISSAKALIAN
ET AL.
3(4%) after age 18. There were no diagnoses of antisocial personality present in the sample. PDQ Total Score To obtain a total PDQ score, the response bias questions that are not required for trait and diagnostic determination, the questions relevant to masochistic PD. and the items that appear in more than one category are eliminated, leaving a range for the total score from 0 to 141. For the current sample, the mean total score was 37.8 + 14.7, ranging from 10 to 65. Using the suggested cut-off of 40 or more on the total score to determine the presence of serious personality disturbance, we found that 32 (49%) of the patients could be so classified. Profile Figure 1 presents the personality profile for the sample, derived by calculating the percentage of positive endorsements (from the total number of questions) within each PD category. Apparent from the graph is the pronounced elevation of avoidant features and the clearly secondary importance of other Cluster C PDs, which were similar in prominence to paranoid PD and only slightly more prominent than histrionic or schizotypal features in the personality profile of the sample. Regression analysis - correlates of personality. To examine the relationships between the personality variables and the demographic, clinical, and symptom measures in greater detail, a series of stepwise regression analyses were performed (Table 2). The trait score was first regressed against the demographic variables, and we found a higher score for women than men. Next, the trait score was regressed against the clinical variables, and we found that past depression was positively correlated with trait score. When the group of patient-rated measures was tested, the Beck Depression Inventory and the interpersonal sensitivity scale of the Hopkins Symptom Checklist were significant predictors, such that greater severity on one predicted greater severity on the other. Finally, none of the clinician-rated scales predicted the trait score. To compare the relative importance of the factors that emerged in the separate regressions, an overall model was sought, using all the previously selected variables, again in stepwise fashion. For this overall model, only two factors, the interpersonal sensitivity scale frost and the Beck depression second, were selected: F(2,57) = 33.10,~ < 0.01, Rz = 0.54. Similar analyses were conducted for the number of endorsements within the three personality clusters, and these are also presented in Table 2. The overall model for Cluster A included the Hopkins measure of interpersonal sensitivity and the clinician’s global rating of severity. A history of past substance abuse, being male, and having a higher score on interpersonal sensitivity predicted the Cluster B score. The factors for the overall model for Cluster C were identical to those for the trait score, namely, Beck depression and Hopkins interpersonal sensitivity. The same linear, stepwise method was
PERSONALITY
DISORDER
IN GAD
109
1 70 8s 60 i?i 50 P H 40
6 j 3o 5 20 h g 10 E
0
Personality Disorders FK3.1. PIZlCSONALITY PROPILE IN 81 GENERALIZED AN~IB~DISOBDERPATIENTS. PAR,PARANOID; SW), scmzom; STP, sc HIZOPIPAL;HIS,HI~oNIc;NAR,NARCISSISTIC; AS, ANTISCCIAL;BOR, BOBDEBLINE; AVD,AVOIDANT,DEP, DBPBNDENT;COM,COMPULSIVE; PA, PASSIVE-ACGFWMVE.
applied to each of the 11 diagnostic categories separately; results for the categories prominent in the present sample are shown in Table 2. These regressions reflect the primary importance of patient ratings of interpersonal sensitivity and depression. Regression analysis - significance of personality features. A personality trait score (ranging from 0 to 14) was calculated for each patient based on the number of endorsed traits out of the 14 of the 15 traits endorsed by at least 30% of the patients (see Table 1); the trait of desire for affection was not included in the trait score because 98% of the patients endorsed it. Patients were grouped by trait score, and differences between high trait and low trait groups were examined (Table 3). The average personality trait score for the sample was 7.7 + 3.5, with a median score of 8 and a modal score of 10. The low trait group included 40 patients with trait scores of 7 or less, and the remaining patients formed the high trait group. As shown in the table, significant trait group differences or trends toward significance were found for age, onset age, past depression, the Beck Depression Inventory, the Zung Anxiety Scale, the factors of interpersonal sensitivity, depression, and anxiety from the Hopkins Symptom Checklist, and the Hamilton scales for anxiety and depression. We used stepwise regression (multiple linear regression in all cases except for past depression, for which we used logistic) to examine these observed differences; the variable that reflected the trait group difference was the dependent variable and the 15 frequent traits were independent variables in all cases. As shown in Table 4, significant regression models were found for all variables, as expected, but the best regression models, those that accounted for the largest percentage of variance, were for the interpersonal sensitivity scale of the Hopkins Symptom Checklist (explained by undue social anxiety, feeling empty or bored, and indirect resistance) and the Beck Depression Inventory
Demographic variables Age Sex (Female) Married Employed Clinical variables Age of onset Duration of illness Past depression Past substance abuse Patient-rated symptom scales Beck Depression Inventory Zung Anxiety Scale
.62b
.30
-
.26
Trait Score
.31
-
AWJL SzD,STP)
.53b
-
-.39b -
B(HIS,NAR, BOR,AS)
Cluster Scorea
.69b
.31 -
-
C(AVD,DEP, COM,PA)
.63b
.27
-
.35b -
AVD
SELFXTED M REGRESSION MODE=
TABLE 2 VARIABLES (AND CORRELATIONS)
.55b -
-
DEP
.35 .50b
-
.26b
-
PA
-
-
-
COM
Category Scorea
-
.38
-
PAR
Lr
F(2,571 =33.10 R==O.54
-b .68
-
.39
.55b
-b .37 F(2.571 =16.31 R= =0.36
aScote = Mean number of endorsements. bVariable was selected in the overall regerssion model. ‘p < .Ol for all models.
Hopkins Symptom Checklist Somatization Obsessions-compulsions Interpersonal sensitivity Depression Anxiety Agoraphobia Clinician-rated symptom scales Hamilton Anxiety Scale Hamilton Depression Scale Global Rating Overall regression modelc F(3,561 =12.72 R= = 0.41
.33b
F(2,57) =40.63 R= =0.59
-
-b .68
-
F(3.561 =27.78 R==O.60
-
-b .69 F(2.571 =18.80 R==OAO
.58b
F(L 58) =16.68 R==0.23
-
-
.47b
F(2.57) =14.15 R2=0.33
-
.48 -
-
-b .36 F(2.57) =10.89 R= =0.28
-
-b .45
112
M.R.MAVISSAKALJANETAL. TABLE COMPARISONOFLOWTMTAND
3
Cell Means
Demographic variables Age (Years) Sex (female) Married Employed Clinical variables Age of onset (years) Duration of illness (years) Past depression Past sub&&e abuse Patient-rated symptom scales Beck Depression Inventory (O-63) Ztmg Anxiety Scale (20-80) Hopkins Symptom C&Mist Somatization (12-48) Obsessions-aunpolsions (8-32) Intexpersonal sensitivity (7-28) Depression (1 l-44) Anxiety (6-24) Agoraphobia (6-24) Clinician-rate4i symptom scales Hamilton Anxiety Scale (O-56) Hamilton Depression Scale (O-50) Global Rating (l-7)
HIGHTRAIT
GROUPS
(SD)
Low Trait n=40 XtSO
High Trait n=41
41.0 (9.8) 48% 52% 85%
36.5 (9.7) 56% 59% 88%
2.08 (79) 0.60 0.30 0.14
.04 NS NS NS
33.4 (10.3) 8.1 (9.1) 18% 18%
28.6 (11.4) 8.0 (6.3) 51% 29%
1.99 (79) 0.04 (79) 10.18 1.56
.05 NS < .Ol NS
10.1 39.1
(4.0) (5.7)
18.9 43.4
(7.6) (6.0)
6.48 (79) 3.29 (79)
c .Ol c .Ol
19.4 16.1 11.0 17.8 9.9 7.3
(4.2) (4.1) (2.4) (4.3) (3.0) (1.4)
19.6 17.3 16.0 22.3 11.5 7.8
(4.7) (5.5) (4.0) (5.9) (3.3) (2.1)
0.24 0.92 5.74 3.40 1.95 1.03
(59) (59) (59) (59) (59) (59)
NS NS c .Ol <.Ol .06 NS
22.6 11.7 3.8
(3.2) (2.7) (0.8)
24.7 14.5 4.1
(3.8) (3.0) (0.7)
2.76 4.40 1.43
(79) (79) (74)
.Ol c .Ol NS
WO
-
(explained by lacks self-confidence, social withdrawal, and feeling empty or bored). Further, it is interesting that there was much better agreement among the models for depression than for anxiety; significant models for the three measures of current depression all contained the traits of social withdrawal and feeling empty or bored. In contrast, the models for the three measures of current anxiety, which also explained much less of the variance than the depression models, had no traits in common. Finally, examination of the table as a whole reveals that more than half of the 24 inclusions of a trait in a model were accounted for by just four traits: feeling empty or bored (BOR), lacks self-confidence (DEP), social withdrawal (AVD), and undue social anxiety (SIT).
DISCUSSION By far the most common of the Axis II diagnoses and traits in this sample of GAD patients was from the avoidant category. This finding supports
PERSONW
DISORDER
TABLE
4
STEFVJISE REGRESSION MODELS TO EXPLAIN TFMT
Variable
Traits
Age Onset age Past depression
Beck Depression Inventory Zung Anxiety
Scale
HopkinsInterpersonal Sensitivity Hopkins-Depression Hopkins-
Anxiety
Hamilton
Anxiety
Hamilton
Depression
*All
hear
regression
Selected
Lacks self-confidence (DEP) Affective instability (BOR) AiTective instability (BOR) Indecisiveness (COM) Undue social anxiety (STP) Desire for affection (AVD) Social and occupational ineffectiveness (PA) Lacks self-confidence (DEP) Social withdrawal (AVD) Feeling empty or bored (BOR) Lacks self-confidence (DEP) Intense or uncontrolled anger @ORI Undue social anxiety (SIT’) Feeling empty or bored (BOR) Indirect resistance (PA) Social withdrawal (AVD) Feeling empty or bored (BOR) Hypersensitivity to rejection (AVE) Undue social anxiety (STP) Social and occupational ineffectiveness (PA) Desire for affection (AVD) Social withdrawal (AVD) Feeling empty or bored (BOR) models
significant
113
IN GAD
Single -.29 -.29 -.33 -.32 .32 -.22 .31
GROUP DEFERIBCES
R
statistics F(2,78) = 6.26* R*=O.l4 F(2.78) = 8.90 R*=O.l9 Improvement *(l)
= 4.22,
p=O.O4 Goodness
of fit *(75)
= 83.16,
p=O.24 SO
F(3,77)
.45 .36 .36 .23
R*=O.38 F(2.78) R*=O.l9
= 9.10
.55 40
F(3,57)
= 16.03
= 16.04
R*=O.46
.31 .45 .40
F(2.58)
23
R* = 0.08
.35
F&79) R*=O.l2 F(4.76)
.35 34 .28 .35
R* =0.32
= 11.77
R* =0.29 F(1.59)
= 5.14 = 10.70 = 8.76
at p < .Ol.
previous suggestions of a particularly close relationship between avoidant PD and the anxiety disorders in general, and between avoidant PD and GAD in particular (Mavissakalian et al., 1993; Sanderson 8z Wetzler, 1991). Other Cluster C diagnoses, most notably dependent PD, were much less frequent than avoidant, but also were less frequent than paranoid, schizotypal, and histrionic PDs, and remained clearly of secondary importance in the personality profile of this sample. The most important correlate of traits in general and of specific PD diagnoses was interpersonal sensitivity, as measured by the Hopkins Symptom Checklist. Less consistently related, but also important, was the Beck Depression Inventory, notably for the Cluster C diagnoses. These, findings present an interesting parallel to PanicAgoraphobia and Obsessive-Compulsive patients because interpersonal sensitivity and depression, rather than duration or severity of panic, phobic, and obsessive-compulsive symptoms, also emerged as the salient correlates
114
M. R. MAVISSAKALIAN
ET AL.
of personality functioning in these disorders (Mavissakalian & Hamann, 1988; Mavissakalian et al., 1990). In addition to demonstrating the nonspecific link between Axis I anxiety disorders and Axis II traits or personality profile, the consistent depiction of dysphoria and interpersonal sensitivity as the most important determinants of Axis II features is consistent with the suggestion that personality dysfunction is primarily determined by maladaptive coping skills in an interpersonal context independent of the Axis I vs Axis II categories involved. In this respect, it is interesting that four personality traits, each from a separate Axis II diagnostic category, were most consistently associated with greater dysphoria and interpersonal sensitivity. This leads to the tentative suggestion that, even if avoidant PD is a temperamental characteristic of Generalized Anxiety and other anxiety disorder patients, personality disorder in the sense of serious interpersonal dysfunction and unhappiness is most likely to occur when undue social anxiety, low self-confidence, and chronic feelings of emptiness or boredom accompany an avoidant personality style. Patients exhibiting a greater number of personality traits were also significantly more symptomatic, replicating the oft-noted covariation between Axis I symptom severity and Axis II PDsAraits in other disorders (Mavissakalian & Hamann, 1988; Mavissakalian et al., 1990). It is, however, noteworthy that the regression models for the three measures of current anxiety had no personality traits in common, and that these were either different or explained much less of the variance than the traits selected as predictors of interpersonal sensitivity and depression. This raises the intriguing possibility that specific personality traits impact differently on personality functioning and Axis I symptoms. If this is true, then the data seem to suggest that “intense and uncontrolled anger” and “hypersensitivity to rejection” may contribute uniquely or preferentially to symptom severity, whereas “lacks self-confidence” and “undue social anxiety” may contribute both to symptom severity and personality dysfunction. Ten percent of the present sample met criteria for paranoid and schizoid PDs, respectively, and the traits of “suspiciousness and mistrust” and “hypersensitivity” were present in 56% and 68% of the patients, respectively, which supports Gasperini et al’s (1990) characterization of GAD patients’ distinctive personality features as hypervigilance, suspiciousness, and a tendency to be easily slighted. However, in the present study, suspiciousness did not emerge as a correlate or predictor of anxiety severity or personality disorder in the sense of interpersonal dysfunction and unhappiness. This appears inconsistent with suggestions that the apprehensive expectation and vigilance that are central to GAD may be inherently paranoid (Gasperini et al., 1990, Sanderson & Wetzler, 1991). Future research comparing patients selected primarily on the basis of paranoid PD to GAD patients may help clarify the phenomenological similarities and differences of anxiety experienced by these patient groups. Clearly, the absence of a control group, in particular of normal controls, and the large number of statistical analyses preformed in this exploratory study recommend caution in the interpretation of results before large-scale studies replicate, extend, and test the suggestions based on the present descriptive and primarily hypothesis-generating findings.
PERSONALITY
DISORDERIN GAD
115
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Mavissakalian, M., Hamann, M. S., & Jones, B. (1990). Correlates of DSM-III personality disorder in obsessive-compulsive disorder. Comprehensive Psychiatry. 31,481-489. Noyes, R., Jr., Reich, J. H.. Suelxer, M., and Cbristiansen, J. (1991). Personality traits associated with panic disorders: Change associated with treatment. Comprehensive Psychiatry, 32, 283-294. Reich, J. (1989). Update on instruments to measure DSM-III and DSM-IIIR personality disorders. Journal of Nervous and Mental Disease, 177.366-370. Sanderson, W. C.. & Wet&r, S. (1991). Chronic anxiety and generalized anxiety disorder: issues in comorbidity. In R. M. Rapee & D. H. Barlow @is.), Chronic an&y, generalized anxiety disorder; und mixed anxiety-depression. New York: Guilford Press. Spitxer, R. I, Williams, J. B. W.. Gibbon, M., First, M. B. (1988). Structured Clinical Interview for D&W-III-R Patient Version (SCID-P). New York, New York State Psychiatric Institute, Biometrics Research. Zung, W. W. K. (1971). A Rating instrument for anxiety disorders. Psychosomatics, 12.371-379.
Anxiety Disorders,Vol. 9,
Pergamon
No. 2, pp. 103-115.1995 Copyright 0 1995 Ekvier Science Ltd Printed in the USA. All rights reserved 0887-6185195 $9.50 + .@I
0887-6185(94)ooo34-4
Correlates of DSM-I I I Personality Disorder in Generalized Anxiety Disorder MAIIG R. MAVISSAKALIAN, M.D., MARY SUE HAMANN, MS., SAID ABOU HAIDAR, M.D., AND CHRISTOPHER M. DE GROOT,M.D. Department
of Psychiatry,
The Ohio State University,
College
of Medicine
Abstract - Eighty-one patients with primary Generalized Anxiety Disorder (GAD) completed the Personality Diagnostic Questionnaire (PDQ), a self-rating scale designed to assess Axis II personality disorders (PD) from DSM-III. Results showed that 37% of the patients received at least one PD diagnosis. The most frequent diagnosis was avoidant (26%). followed by paranoid (10%). schizotypal (10%). and histrionic (9%). Consideration of the personality traits irrespective of diagnostic category showed that patients exhibiting a greater number of personality traits were also significantly mom symptomatic. However, anxiety symptoms were not selected as unique predictors of any personality variables in the regression analyses. Rather, the most important correlate of traits in general and of specific PD diagnoses was interpersonal sensitivity, as measured by the Hopkins Symptom Checklist. Less consistently related, but also important, was the Beck Depression Inventory, notably for Cluster C diagnoses. Further analysis led to the tentative suggestion that personality disorder in the sense of serious interpersonal dysfunction and unhappiness is most likely to occur when undue social anxiety, low self-confidence, and chronic feelings of emptiness or boredom accompany an avoidant lifestyle.
There are very few published studies of Axis II disorders in patients with Generalized Anxiety Disorder (GAD). Sanderson and Wetzler (1991) reported that 16 (50%) of 32 patients with primary GAD were diagnosed with a comorbid personality disorder (PD), most commonly avoidant (16%). dependent (13%), and not otherwise specified (13%) PDs. In a study of the relationship between DSM-III Axis I and Axis II disorders of a large sample of psychiatric outpatients in Oslo, Norway, Alnaes and Torgersen (1988) reported that 8 (73%) of 11 patients with GAD assessed with the use of the Structured Supported in part by Grant MH42730 from the National Institute of Mental Health. Correspondence and requests for mprints should he.addressed to Matig R. Mav&kahan, M.D., The Ohio State University, Department of Psychiatry, 473 West 12th Avenue, Columbus, OH 43210. 103
104
M. R. MAVISSAKALJAN
ET AL.
Interview for DSM-III Personality Disorders (SIDP) met criteria for an Axis II disorder. Interestingly, they estimated that the observed frequency of dependent PD (Yll, 18%) in GAD was less than half expected according to base rates, whereas avoidant PD (5/11, 45%) was neither overrepresented nor under-represented in GAD patients compared to the total sample. On the other hand, an Italian study that has compared Axis II SIDP diagnoses in 46 patients with primary GAD and 50 volunteers from a general population survey sample who were free of Axis I diagnosis has found no significant differences on any PD between the GAD and control groups (Gasperini, Battaglia, Diaferia, & Bellodi, 1990). The most frequent Axis II diagnoses assigned in the GAD group were mixed PD (39%), histrionic PD (17%), compulsive PD (15%). schizotypal PD (6.5%), dependent PD (6.5%). and avoidant PD (4%). Further analysis identified four personality traits that were significantly more frequent in the GAD sample: “hypervigilance” and “tendency to be easily slighted and quick to take offence,” both from paranoid PD, “suspiciousness or paranoid ideation” from schizotypal PD, and “dependent, helpless, seeking reassurance” from histrionic PD. In a previous paper (Mavissakalian, Hamann, Haidar, & deGroot, 1993), we compared the responses to the Personality Diagnostic Questionnaire (PDQ) of 36 GAD, 187 Panic Disorder (Panic), and 51 Obsessive-Compulsive Disorder (OCD) patients. We found that the personality profiles were similar in the three diagnostic groups, but that the major personality features identified, namely, avoidant, dependent, and histrionic features, were more pronounced in patients with OCD than in the other two anxiety disorders. We also reported that the Panic and GAD groups were identical in terms of a generic PDQ trait score, as well as on the Eysenck measures of neuroticism and extraversion. Because GAD lacks prominent panic, phobic, and obsessive-compulsive symptoms, the overwhelming similarities among these anxiety disorders on the personality measures supported earlier suggestions of a nonspecific link between DSM-III personality PD/traits and Panic Disorder (Mavissakalian & Hamann, 1988) or OCD (Mavissakalian, Hamann, & Jones, 1990). Indeed, the more pronounced personality profile in OCD was generalized and not limited to one specific PD, such as compulsive PD, and this may have been largely related to the severely disruptive interference of OCD symptoms with coping and interpersonal functioning. In this respect, dependent PD/traits reflected more closely the functional impairment caused by Axis I symptoms, which is highest in OCD, lowest in GAD, and intermediate in panic/agoraphobia, whereas avoidant PD measures varied less and were equally represented in the Panic and GAD groups. These findings, coupled with observations made during stable remission of Panic Disorder patients (Mavissakalian & Hamann, 1992), suggested that DSM-III avoidant PD may essentially capture the common and enduring personality, perhaps even temperamental, characteristics in anxiety disorders. The aim of the present paper is to describe the DSM-III personality PDs/traits in 81 GAD patients, as well as to assessthe correlates of personality in this anxiety disorder, a disorder that some authors believe may more closely resemble a personality disorder than an Axis I syndrome (Sanderson & Wetzler, 1991).
PERSONALKY
DISORDER
IN GAD
105
METHOD Sdjects Subjects were 81 patients meeting DSM-III-R diagnostic criteria for GAD; they comprised two consecutive samples of subjects referred to our specialty clinic for evaluation for pharmacological treatment studies. Data from the first sample, II = 39, have been previously reported (Mavissakalian et al., 1993). Comparison of the two samples yielded no significant differences on patientrated or clinician-rated Axis I measures; thus, the two samples were combined for all analyses reported herein. Demographically, the patients had an average age of 38.7 + 10.0 years and an age range from 19 to 61, were 52% female, 56% married, 86% employed, and had an average of 14.4 + 2.1 years of education. Clinically, all met criteria for Generalized Anxiety Disorder, one person met criteria for concurrent major depression, and no patients met criteria for concurrent panic disorder, agoraphobia, or substance abuse. Thirty-five percent of the sample (28 patients) had a past history of major depression, and this was primary in eight cases. Twenty-three percent (19 patients) had a past diagnosis of substance abuse. The mean age of onset of the anxiety symptoms was 3 1.0 & 11.O years, with a mean duration of illness of 8.1 + 7.8 years. Assessments The same clinical psychologist administered all assessments, which took place during the subjects’ initial evaluation. This took typically three hours to complete and began with the Structured Clinical Interview for DSM-III-R Patient Version (Spitzer, Williams, Gibbon, 8z First, 1988), and was followed by the administration of clinician-rated scales and then the self-rating scales. All subjects presented in this study also had a clinical, diagnostically focused interview with the first author, either on the same day or at their next visit 7 to 10 days later, that corroborated the diagnosis of GAD. The Personality Diagnostic Questionnaire (PDQ) (Hyler, Reider, Spitzer, & Williams, 1983; Reich, 1989), as well as a battery of tests assessing anxiety, depression, and clinical severity were administered. We have described in detail the procedure for administering and scoring the PDQ in an earlier report (Mavissakalian 8z Hamann, 1986). Briefly, the PDQ is a self-rating questionnaire of 163 true or false items, designed to assessthe 11 personality disorders from Axis II of the DSM-III (paranoid, schizoid, schizotypal, histrionic, narcissistic, antisocial, borderline, avoidant, dependent, compulsive, passiveaggressive). Four variables may be derived: a diagnosis for each of the disorders; the presence or absence of each personality trait, irrespective of diagnostic category; a total PDQ score (Noyes, Reich, Suelzer, 8z Christiansen, 1991); and a personality profile, which is obtained by tallying the number of endorsements of the items in each diagnostic category. Moreover, the diagnostic scoring may be further classified: Cluster A indicates odd or eccentric behavior, as evidenced by a diagnosis from the paranoid, schizoid, or schizotypal categories; Cluster B indicates dramatic, emotional, or erratic behavior and comprises the antisocial, borderline, histrionic, or narcissistic diagnoses; and
106
M. R. MAVISSAKALIAN
ET AL.
Cluster C, anxious or fearful behavior, from avoidant, dependent, compulsive, or passive-aggressive categories. The patient-rated measures of anxiety, depression, and general psychiatric symptomatology were the Zung Anxiety Scale (Zung, 1971); the Beck Depression Inventory (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961); and the Hopkins Symptom Checklist (Derogatis, Lipman, Rickels et al., 1974), the 68-item version that has factors of somatization, obsessions-compulsions, interpersonal sensitivity, depression, anxiety, and agoraphobia. The Hopkins Symptom Checklist was available for only 61 of the patients. The clinician-rated scales included the Hamilton scales for anxiety (Hamilton, 1959) and depression (Hamilton, 1960), as well as a seven-point clinician rating of global severity, where 1 = normal, not at all ill ,4 = moderately ill, and 7 = extremely ill. RESULTS Diagnoses Fifty-one PD diagnoses were assigned, distributed among thirty patients; thus, 37% of this GAD sample received at least one diagnosis. By far the most common diagnosis was avoidant personality disorder (26% of the patients), followed by paranoid, schizotypal, and histrionic (about 10% of the patients, see Table 1). In terms of the cluster categories, 15(19%) of the patients had a diagnosis from Cluster A, 7(9%) from Cluster B, and 23(28%) from Cluster C. Fifteen patients received only one PD diagnosis: eight were avoidant, three were histrionic, two were paranoid, one was schizotypal, and one was schizoid. Nine patients received two diagnoses from the set of avoidant, dependent, paranoid, schizotypal, histrionic, and passive-aggressive. Six patients were diagnosed with three personality disorders each: all were avoidant and had two other diagnoses from the set of schizotypal, histrionic, paranoid, and compulsive. Traits In Table 1, we also present the number and percentage of patients who met the criteria for the DSM-III traits. Fifteen traits were endorsed by at least 30% of the sample: desire for affection, low self-esteem, hypersensitivity to rejection, unwillingness to enter relationships, and social withdrawal, from the avoidant category; hypersensitivity and suspiciousness and mistrust, from paranoid (and the latter is also duplicated in the schizotypal category); affective instability, feeling empty or bored, and intense, uncontrolled anger, from borderline; social and occupational ineffectiveness and indirect resistance from passive-aggressive; lacks self-confidence, from dependent; undue social anxiety, from schizotypal; and indecisiveness, from compulsive. We have not included results for Antisocial Personality Disorder in Table 1 because the DSM-III description of the traits is qualitatively different for this category than for all others; however, we note that 18(22%) of the sample reported manifestations of antisocial personality before age 18, and
PERSONALITY
DJSORDER
107
IN GAD
TABLE 1 NUMBERANTIPERCENTAGE OF81 GBNWAL~ZEOANXIER DISORDERPATENTS MEermo DSM-III DIAGNOSTIC
Disorder
No. (%) of Patients Meeting Diagnostic Criteria
Paranoid
8 (10)
Schizoid
1 (1)
schizotypal
8 (10)
Histrionic
7 (9)
Narcissistic
0
Borderline
0
Avoidant
21 (26)
Dependent
4 (5)
Compulsive
1 (1)
Passive-agressive
1 (1)
AND TWIT
AXIS II (I~TEFU
DSM-Ill Traits A. Suspiciousness and mistrust B. Hypersensitivity C. Restricted affectivity A. Emotional coldness B. Indifference to praise or criticism C. Few close friendships Al. Magical thinking A2. Ideas of reference A3. Social isolation A4. Recurrent illusions A5. odd speech A6. Inadequate rapport Al. Suspiciousness A8. Undue social anxiety A. Dramatic behavior B. Disturbed relationships A. Self-importance B. Preoccupation with fantasies C. Exhibitionism D. Indifferent or angry responses E. Disturbed relationship Al. Impulsivity or unpredictability A2. Unstable and intense relations A3. Intcnsc or uncontrolled anger A4. Identity disturbance A5. Afktive instability A6. Intolerance of being alone A7. Physically self-damaging acts A8. feeling empty or bored A. Hypersensitivity to rejection B. Unwillingness to enter relationships C. Social withdrawal D. Desire for affection E. Low self-esteem A. Allows others responsibility B. Subordinates own needs C. Lacks self-confidence 1. Restricted emotional expression 2. Perfectionism 3. Insistence on own way 4. Excessive devotion to work 5. Indeciiiveness A. Resistance to demands B. Indirect resistance C. Social and occupational ineffectiveness D. Persistence of behavior
No. (76) of Patients Meeting Trait Criteria 45 55 11 5 3 15 0
(56) (68) (14) (6) (4) (19)
8 (10) 13 0 21 18 45 32 22 22 14 12 12 1 8 20 0 24 1 54 19 0 29 57 39 38 79 72 12 18 40 13 23 3 19 31
(16) (26) (22) (56) (40) (27) (27) (17) (15) (15) (1) (10) (25) (30) (1) (67) (23) (36) (70) (48) (47) (98) (89) (15) (22) (49) (16) (28) (4) (23) (38)
2 (2)
51 (63) 53 (65) 3 (4)
108
M. R. MAVISSAKALIAN
ET AL.
3(4%) after age 18. There were no diagnoses of antisocial personality present in the sample. PDQ Total Score To obtain a total PDQ score, the response bias questions that are not required for trait and diagnostic determination, the questions relevant to masochistic PD. and the items that appear in more than one category are eliminated, leaving a range for the total score from 0 to 141. For the current sample, the mean total score was 37.8 + 14.7, ranging from 10 to 65. Using the suggested cut-off of 40 or more on the total score to determine the presence of serious personality disturbance, we found that 32 (49%) of the patients could be so classified. Profile Figure 1 presents the personality profile for the sample, derived by calculating the percentage of positive endorsements (from the total number of questions) within each PD category. Apparent from the graph is the pronounced elevation of avoidant features and the clearly secondary importance of other Cluster C PDs, which were similar in prominence to paranoid PD and only slightly more prominent than histrionic or schizotypal features in the personality profile of the sample. Regression analysis - correlates of personality. To examine the relationships between the personality variables and the demographic, clinical, and symptom measures in greater detail, a series of stepwise regression analyses were performed (Table 2). The trait score was first regressed against the demographic variables, and we found a higher score for women than men. Next, the trait score was regressed against the clinical variables, and we found that past depression was positively correlated with trait score. When the group of patient-rated measures was tested, the Beck Depression Inventory and the interpersonal sensitivity scale of the Hopkins Symptom Checklist were significant predictors, such that greater severity on one predicted greater severity on the other. Finally, none of the clinician-rated scales predicted the trait score. To compare the relative importance of the factors that emerged in the separate regressions, an overall model was sought, using all the previously selected variables, again in stepwise fashion. For this overall model, only two factors, the interpersonal sensitivity scale frost and the Beck depression second, were selected: F(2,57) = 33.10,~ < 0.01, Rz = 0.54. Similar analyses were conducted for the number of endorsements within the three personality clusters, and these are also presented in Table 2. The overall model for Cluster A included the Hopkins measure of interpersonal sensitivity and the clinician’s global rating of severity. A history of past substance abuse, being male, and having a higher score on interpersonal sensitivity predicted the Cluster B score. The factors for the overall model for Cluster C were identical to those for the trait score, namely, Beck depression and Hopkins interpersonal sensitivity. The same linear, stepwise method was
PERSONALITY
DISORDER
IN GAD
109
1 70 8s 60 i?i 50 P H 40
6 j 3o 5 20 h g 10 E
0
Personality Disorders FK3.1. PIZlCSONALITY PROPILE IN 81 GENERALIZED AN~IB~DISOBDERPATIENTS. PAR,PARANOID; SW), scmzom; STP, sc HIZOPIPAL;HIS,HI~oNIc;NAR,NARCISSISTIC; AS, ANTISCCIAL;BOR, BOBDEBLINE; AVD,AVOIDANT,DEP, DBPBNDENT;COM,COMPULSIVE; PA, PASSIVE-ACGFWMVE.
applied to each of the 11 diagnostic categories separately; results for the categories prominent in the present sample are shown in Table 2. These regressions reflect the primary importance of patient ratings of interpersonal sensitivity and depression. Regression analysis - significance of personality features. A personality trait score (ranging from 0 to 14) was calculated for each patient based on the number of endorsed traits out of the 14 of the 15 traits endorsed by at least 30% of the patients (see Table 1); the trait of desire for affection was not included in the trait score because 98% of the patients endorsed it. Patients were grouped by trait score, and differences between high trait and low trait groups were examined (Table 3). The average personality trait score for the sample was 7.7 + 3.5, with a median score of 8 and a modal score of 10. The low trait group included 40 patients with trait scores of 7 or less, and the remaining patients formed the high trait group. As shown in the table, significant trait group differences or trends toward significance were found for age, onset age, past depression, the Beck Depression Inventory, the Zung Anxiety Scale, the factors of interpersonal sensitivity, depression, and anxiety from the Hopkins Symptom Checklist, and the Hamilton scales for anxiety and depression. We used stepwise regression (multiple linear regression in all cases except for past depression, for which we used logistic) to examine these observed differences; the variable that reflected the trait group difference was the dependent variable and the 15 frequent traits were independent variables in all cases. As shown in Table 4, significant regression models were found for all variables, as expected, but the best regression models, those that accounted for the largest percentage of variance, were for the interpersonal sensitivity scale of the Hopkins Symptom Checklist (explained by undue social anxiety, feeling empty or bored, and indirect resistance) and the Beck Depression Inventory
Demographic variables Age Sex (Female) Married Employed Clinical variables Age of onset Duration of illness Past depression Past substance abuse Patient-rated symptom scales Beck Depression Inventory Zung Anxiety Scale
.62b
.30
-
.26
Trait Score
.31
-
AWJL SzD,STP)
.53b
-
-.39b -
B(HIS,NAR, BOR,AS)
Cluster Scorea
.69b
.31 -
-
C(AVD,DEP, COM,PA)
.63b
.27
-
.35b -
AVD
SELFXTED M REGRESSION MODE=
TABLE 2 VARIABLES (AND CORRELATIONS)
.55b -
-
DEP
.35 .50b
-
.26b
-
PA
-
-
-
COM
Category Scorea
-
.38
-
PAR
Lr
F(2,571 =33.10 R==O.54
-b .68
-
.39
.55b
-b .37 F(2.571 =16.31 R= =0.36
aScote = Mean number of endorsements. bVariable was selected in the overall regerssion model. ‘p < .Ol for all models.
Hopkins Symptom Checklist Somatization Obsessions-compulsions Interpersonal sensitivity Depression Anxiety Agoraphobia Clinician-rated symptom scales Hamilton Anxiety Scale Hamilton Depression Scale Global Rating Overall regression modelc F(3,561 =12.72 R= = 0.41
.33b
F(2,57) =40.63 R= =0.59
-
-b .68
-
F(3.561 =27.78 R==O.60
-
-b .69 F(2.571 =18.80 R==OAO
.58b
F(L 58) =16.68 R==0.23
-
-
.47b
F(2.57) =14.15 R2=0.33
-
.48 -
-
-b .36 F(2.57) =10.89 R= =0.28
-
-b .45
112
M.R.MAVISSAKALJANETAL. TABLE COMPARISONOFLOWTMTAND
3
Cell Means
Demographic variables Age (Years) Sex (female) Married Employed Clinical variables Age of onset (years) Duration of illness (years) Past depression Past sub&&e abuse Patient-rated symptom scales Beck Depression Inventory (O-63) Ztmg Anxiety Scale (20-80) Hopkins Symptom C&Mist Somatization (12-48) Obsessions-aunpolsions (8-32) Intexpersonal sensitivity (7-28) Depression (1 l-44) Anxiety (6-24) Agoraphobia (6-24) Clinician-rate4i symptom scales Hamilton Anxiety Scale (O-56) Hamilton Depression Scale (O-50) Global Rating (l-7)
HIGHTRAIT
GROUPS
(SD)
Low Trait n=40 XtSO
High Trait n=41
41.0 (9.8) 48% 52% 85%
36.5 (9.7) 56% 59% 88%
2.08 (79) 0.60 0.30 0.14
.04 NS NS NS
33.4 (10.3) 8.1 (9.1) 18% 18%
28.6 (11.4) 8.0 (6.3) 51% 29%
1.99 (79) 0.04 (79) 10.18 1.56
.05 NS < .Ol NS
10.1 39.1
(4.0) (5.7)
18.9 43.4
(7.6) (6.0)
6.48 (79) 3.29 (79)
c .Ol c .Ol
19.4 16.1 11.0 17.8 9.9 7.3
(4.2) (4.1) (2.4) (4.3) (3.0) (1.4)
19.6 17.3 16.0 22.3 11.5 7.8
(4.7) (5.5) (4.0) (5.9) (3.3) (2.1)
0.24 0.92 5.74 3.40 1.95 1.03
(59) (59) (59) (59) (59) (59)
NS NS c .Ol <.Ol .06 NS
22.6 11.7 3.8
(3.2) (2.7) (0.8)
24.7 14.5 4.1
(3.8) (3.0) (0.7)
2.76 4.40 1.43
(79) (79) (74)
.Ol c .Ol NS
WO
-
(explained by lacks self-confidence, social withdrawal, and feeling empty or bored). Further, it is interesting that there was much better agreement among the models for depression than for anxiety; significant models for the three measures of current depression all contained the traits of social withdrawal and feeling empty or bored. In contrast, the models for the three measures of current anxiety, which also explained much less of the variance than the depression models, had no traits in common. Finally, examination of the table as a whole reveals that more than half of the 24 inclusions of a trait in a model were accounted for by just four traits: feeling empty or bored (BOR), lacks self-confidence (DEP), social withdrawal (AVD), and undue social anxiety (SIT).
DISCUSSION By far the most common of the Axis II diagnoses and traits in this sample of GAD patients was from the avoidant category. This finding supports
PERSONW
DISORDER
TABLE
4
STEFVJISE REGRESSION MODELS TO EXPLAIN TFMT
Variable
Traits
Age Onset age Past depression
Beck Depression Inventory Zung Anxiety
Scale
HopkinsInterpersonal Sensitivity Hopkins-Depression Hopkins-
Anxiety
Hamilton
Anxiety
Hamilton
Depression
*All
hear
regression
Selected
Lacks self-confidence (DEP) Affective instability (BOR) AiTective instability (BOR) Indecisiveness (COM) Undue social anxiety (STP) Desire for affection (AVD) Social and occupational ineffectiveness (PA) Lacks self-confidence (DEP) Social withdrawal (AVD) Feeling empty or bored (BOR) Lacks self-confidence (DEP) Intense or uncontrolled anger @ORI Undue social anxiety (SIT’) Feeling empty or bored (BOR) Indirect resistance (PA) Social withdrawal (AVD) Feeling empty or bored (BOR) Hypersensitivity to rejection (AVE) Undue social anxiety (STP) Social and occupational ineffectiveness (PA) Desire for affection (AVD) Social withdrawal (AVD) Feeling empty or bored (BOR) models
significant
113
IN GAD
Single -.29 -.29 -.33 -.32 .32 -.22 .31
GROUP DEFERIBCES
R
statistics F(2,78) = 6.26* R*=O.l4 F(2.78) = 8.90 R*=O.l9 Improvement *(l)
= 4.22,
p=O.O4 Goodness
of fit *(75)
= 83.16,
p=O.24 SO
F(3,77)
.45 .36 .36 .23
R*=O.38 F(2.78) R*=O.l9
= 9.10
.55 40
F(3,57)
= 16.03
= 16.04
R*=O.46
.31 .45 .40
F(2.58)
23
R* = 0.08
.35
F&79) R*=O.l2 F(4.76)
.35 34 .28 .35
R* =0.32
= 11.77
R* =0.29 F(1.59)
= 5.14 = 10.70 = 8.76
at p < .Ol.
previous suggestions of a particularly close relationship between avoidant PD and the anxiety disorders in general, and between avoidant PD and GAD in particular (Mavissakalian et al., 1993; Sanderson 8z Wetzler, 1991). Other Cluster C diagnoses, most notably dependent PD, were much less frequent than avoidant, but also were less frequent than paranoid, schizotypal, and histrionic PDs, and remained clearly of secondary importance in the personality profile of this sample. The most important correlate of traits in general and of specific PD diagnoses was interpersonal sensitivity, as measured by the Hopkins Symptom Checklist. Less consistently related, but also important, was the Beck Depression Inventory, notably for the Cluster C diagnoses. These, findings present an interesting parallel to PanicAgoraphobia and Obsessive-Compulsive patients because interpersonal sensitivity and depression, rather than duration or severity of panic, phobic, and obsessive-compulsive symptoms, also emerged as the salient correlates
114
M. R. MAVISSAKALIAN
ET AL.
of personality functioning in these disorders (Mavissakalian & Hamann, 1988; Mavissakalian et al., 1990). In addition to demonstrating the nonspecific link between Axis I anxiety disorders and Axis II traits or personality profile, the consistent depiction of dysphoria and interpersonal sensitivity as the most important determinants of Axis II features is consistent with the suggestion that personality dysfunction is primarily determined by maladaptive coping skills in an interpersonal context independent of the Axis I vs Axis II categories involved. In this respect, it is interesting that four personality traits, each from a separate Axis II diagnostic category, were most consistently associated with greater dysphoria and interpersonal sensitivity. This leads to the tentative suggestion that, even if avoidant PD is a temperamental characteristic of Generalized Anxiety and other anxiety disorder patients, personality disorder in the sense of serious interpersonal dysfunction and unhappiness is most likely to occur when undue social anxiety, low self-confidence, and chronic feelings of emptiness or boredom accompany an avoidant personality style. Patients exhibiting a greater number of personality traits were also significantly more symptomatic, replicating the oft-noted covariation between Axis I symptom severity and Axis II PDsAraits in other disorders (Mavissakalian & Hamann, 1988; Mavissakalian et al., 1990). It is, however, noteworthy that the regression models for the three measures of current anxiety had no personality traits in common, and that these were either different or explained much less of the variance than the traits selected as predictors of interpersonal sensitivity and depression. This raises the intriguing possibility that specific personality traits impact differently on personality functioning and Axis I symptoms. If this is true, then the data seem to suggest that “intense and uncontrolled anger” and “hypersensitivity to rejection” may contribute uniquely or preferentially to symptom severity, whereas “lacks self-confidence” and “undue social anxiety” may contribute both to symptom severity and personality dysfunction. Ten percent of the present sample met criteria for paranoid and schizoid PDs, respectively, and the traits of “suspiciousness and mistrust” and “hypersensitivity” were present in 56% and 68% of the patients, respectively, which supports Gasperini et al’s (1990) characterization of GAD patients’ distinctive personality features as hypervigilance, suspiciousness, and a tendency to be easily slighted. However, in the present study, suspiciousness did not emerge as a correlate or predictor of anxiety severity or personality disorder in the sense of interpersonal dysfunction and unhappiness. This appears inconsistent with suggestions that the apprehensive expectation and vigilance that are central to GAD may be inherently paranoid (Gasperini et al., 1990, Sanderson & Wetzler, 1991). Future research comparing patients selected primarily on the basis of paranoid PD to GAD patients may help clarify the phenomenological similarities and differences of anxiety experienced by these patient groups. Clearly, the absence of a control group, in particular of normal controls, and the large number of statistical analyses preformed in this exploratory study recommend caution in the interpretation of results before large-scale studies replicate, extend, and test the suggestions based on the present descriptive and primarily hypothesis-generating findings.
PERSONALITY
DISORDERIN GAD
115
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