DSM-III-R personality diagnoses in anxiety disorder patients

DSM-III-R

Personality Diagnoses Disorder Patients

in Anxiety

Ellen Tobey Klass, Peter A. DiNardo, and David H. Barlow This study compared clinical characteristics of anxiety disorder patients with and without a co-occurring diagnosis of personality disorder. A structured diagnostic interview for anxiety disorders was used to make DSM-III-R diagnoses and to derive clinical ratings. The personality diagnosis group (n = 27) was compared with a large clinical series of anxiety disorder patients (n = 288) and with a group of patients without personality diagnoses who were matched on primary anxiety diagnosis, sex, and age (n = 25). The personality diagnosis group received significantly more diagnoses of current dysthymia and past major depression. The personality diagnosis group also had a significantly higher rate of rare anxiety disorders than the clinical series and significantly lower ratings of current adaptive functioning than the matched controls. These findings, suggesting the presence of a group of anxiety disorder patients with significant personality and affective symptomatology, are discussed in terms of models of syndrome-personality comorbidity and treatment response. @ 1989 by W.B. Saunders Company.

W

ITH THE ADVENT OF THE DSM-III multiaxial system for psychiatric diagnosis,’ researchers have begun to examine relationships between the specific symptomatic disorders of Axis I and the more generalized personality disorders of Axis II. The occurrence of difficulties at both levels in the same patients, or syndrome-personality comorbidity, has been of particular interest. Most empirical research on syndrome-personality comorbidity has investigated Axis I affective disorders and Axis II borderline personality disorder,* but such comorbidity questions are also pertinent to the study and treatment of anxiety disorders. The Axis I symptomatology of anxiety patients with syndrome-personality comorbidity may differ from that of patients with the same Axis I disorder, but no personality disorder.3 In addition, research on the treatment of anxiety disorders has begun to consider the prediction of nonresponders and relapsers.4 The presence of a longstanding maladaptive interpersonal style, i.e., personality disorder, seems to hold promise as a predictor of treatment response.5 Several empirical studies6-lo have used DSM-III diagnostic criteria to examine rates of personality disorder in anxiety disorder patients. These studies have reported widely varying rates of personality disorder, from 27%” to 58%.6 Findings have been divided on whether there is an excess of DSM-III cluster C anxious personality disorders. Three studies reported such an excess,7,9*‘oone’ reported a high rate of the cluster-B “dramatic” disorders, and another6 reported equally high rates of cluster-B and -C disorders. It should also be noted that with one exception8 studies have examined panic disorder patients with and without agoraphobia, but not patients with other anxiety disorders. It has recently been demonstrated that anxiety disorder patients often meet the

From the Department of Psychology, Hunter College, City University of New York: the Department of Psychology, State University of New York, College at Oneonta; and the Department of Psychology, State University of New York at Albany. Address reprint requests to Ellen Tobey Klass, Ph.D., 7 Cornelia St., New York, NY 10014. 0 1989 by W.B. Saunders Company. 0010-440X/89/3003-0009$03.00/0 ComprehensivePsychiatry,

Vol. 30, No. 3 (May/June),

1989: pp 251-258

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criteria for multiple anxiety diagnoses. In two studies,“*12 patients were assessed using the Anxiety Disorders Interview Schedule (ADIS), a structured diagnostic interview for anxiety disorders.13 Using nonhierarchical diagnoses, patients were assigned all Axis I diagnoses for which they met criteria, and one diagnosis was assigned primary status based on severity and interference with functioning. Findings indicated that =50% of anxiety disorder cases were assigned additional anxiety diagnoses, and =25% received an additional affective disorder diagnosis.“*12 The question thus arises whether patterns of co-occurring diagnoses and symptomatology differ between anxiety disorder patients with and without personality disorder diagnoses. The purpose of our study was to examine a sample of patients with a variety of anxiety diagnoses in order to consider differences in co-occurring Axis I diagnoses and dimensions of psychopathology as a function of the presence of a personality diagnosis. Specifically, we identified an index group of patients who received both a primary Axis I anxiety disorder diagnosis and also an Axis II personality disorder diagnosis. We compared the index group with a series of 288 anxiety disorder patients previously described by DiNardo and Barlow12 (base-rate study) and with a sample of patients without personality diagnoses who were matched for primary anxiety diagnosis, sex, and age (matched-control study). Comparisons between the groups were made on the following variables: current primary and additional diagnoses; past diagnoses; scores on the Hamilton Rating Scale for Anxiety (HRSA)14 and the 21-item Hamilton Rating Scale for Depression (HRSD)“; and Global Assessment of Functioning scores.16 METHOD All subjects were outpatients who presented at the Phobia and Anxiety Disorders Clinic of the Center for Stress and Anxiety Disorders, State University of New York at Albany. Patients were routinely assessed with the ADIS-R”, a version of the ADIS updated to conform to DSM-III-R.‘6 All data were drawn from the interview records. The index cases in the personality-diagnosis group consisted of all patients who presented in 1987 and who received both a primary Axis I diagnosis of anxiety disorder and a probable or definite diagnosis of personality disorder on Axis II.

Base-Rate

Study

The base-rate sample consisted 1985 to 1986 and who received a tics of the base-rate sample were tics of the personality diagnosis compared.

Matched-Control

of a consecutive series of 288 patients who presented at the Clinic from primary anxiety diagnosis. The demographic and clinical characterisrecently described by DiNardo and Barlow.” The clinical characterisand base-rate samples, as determined from the ADIS record, were

Study

A matched-control group was drawn from the series of primary anxiety patients who presented in 1987 and who did not receive a personality diagnosis. Patients were randomly selected from those who matched index patients on primary anxiety diagnosis, sex, and age within 5 years. In four cases, the index cases had two co-primary diagnoses, which the clinician judged to be independent and to interfere equally with functioning. For these cases, control subjects were randomly selected from the demographically-matched patients who had either of the primary anxiety diagnoses of the index patient. Two personality diagnosis patients could not be matched on demographics and were excluded from the matched-control study. The clinical characteristics of the personality diagnosis and matched-control groups, as determined from the ADIS record, were compared.

PERSONALITY

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253

PATIENTS

ADIS The ADIS is a structured interview protocol designed to permit differential diagnosis of anxiety and affective disorders as well as to screen for substance abuse and psychosis; it includes the HRSA14 and HRSD.” Consistent with DSM-III-R, Axis I diagnoses are assigned without a priori exclusions. When multiple diagnoses are made, the determination of primary v additional status is based on which diagnosis interferes with functioning. Severity is rated on a scale of 0 to 8, with 2 indicating mildest interference and 8 indicating the most severe interference. A rating of 4 corresponds to definite clinical severity and 3 to probable clinical severity. In research on the interrater reliability of primary ADIS diagnoses,‘8*‘9each of 125 consecutive admissions was administered the ADIS by two clinicians, who arrived independently at a primary diagnosis blind to each other’s conclusions. Kappa coefficients for primary anxiety disorder diagnoses ranged from .56 (simple phobia) to .91 (social phobia). Although the ADIS does not include structured questions for Axes II through V, a variety of questions does allow determination of the patient’s status on these axes. All interviewers received training and supervision in making these diagnoses. Patients were included in the present study if they had received a definite primary diagnosis of anxiety disorder. Consistent with the practices in previous comorbidity studies from our clinic,“,” additional Axis I diagnoses were required to be of probable severity to be included in the data.

RESULTS Personality Diagnosis Group

The personality diagnosis group consisted of 27 patients, representing 12% of the series from which the index group was drawn. There were 11 men and 16 women, with a mean age of 34.6 years. The personality diagnosis group received a total of 3 1 personality diagnoses; four patients were each given two personality diagnoses. Table 1 presents the distribution of specific personality disorders and diagnoses according to DSM-III-R clusters A (odd), B (dramatic), and C (anxious). Nine of 11 DSM-III-R personality diagnoses were made; only schizoid and narcissistic personality disorder were not found. The most frequent personality diagnosis was not otherwise specified (NOS), and the most frequent specific diagnoses were histrionic and dependent personality disorder. Although cluster C diagnoses were somewhat more frequent (40%), there was not a significant excess of diagnoses in any cluster. Table 1. Distribution

of Personality

Diagnoses

in a Sample of Anxiety

Disorder

No. (96)’ Diagnosis Cluster A Paranoid Schizoid Schizotypal Cluster B Antisocial Borderline Histrionic Narcissistic Cluster C Avoidant Dependent Obsessive-compulsive Passive-aggressive NOS *Due

to multiple responses,

entries exceed sample size.

(N = 27) 6 3 0 3 7 1 1 5 0 11 5 4 1 1 7

(22) (11) (0) (11) (26) (4) (4) (18) (0) (40) (18) (13) (4) (4) (26)

Patients

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Table 2. Primary Axis

I Diagnoses of Anxiety Disorder Patients Diagnoses Versus Base-Rate Sample

With Personality

Group

Diagnosis Panic disorder with agoraphobia Agoraphobia without panic Social phobia Simple phobia Panic disorder Generalized anxiety disorder Obsessive-compulsive disorder Posttraumatic stress disorder Anxiety disorder, NOS Major depression Dysthymia Co-primary diagnoses Low-frequency anxiety diagnoses

Personality Diagnosis (%I (n = 2713 2 1 9 1 5 5 2 3 3 1 1 4 7

Base-Rate (%I* (n = 288) 91 1 55 28 73 33 15 0 0 6 16

(7) (4) (33) (4) (18) (18) (7) (11) (111 (4) (4) (15) (28)

P Value

(32) (0) (19) (IO) (25) (I I) (5) (0) (0) (21 (6)

16 (6) 16 (6)

<.06t <.OOl

*Data from DeNardo and Barlow.13 TStatistical comparisons were made only for co-primary and low-frequency diagnoses. *Due to multiple responses, entries exceeded sample size.

Base-Rate Study

Table 2 presents the distribution of primary anxiety disorder diagnoses found in the personality diagnosis and base-rate samples. The results suggest that the personality diagnosis group had a lower rate of agoraphobia and higher rates of social phobia, posttraumatic stress disorder, and anxiety disorder, NOS. Due to the small sample size of the personality diagnosis group, significance tests were not conducted on specific diagnoses. We compared statistically the rates of co-primary diagnoses and low-frequency diagnoses in the personality diagnosis and the baserate samples. Co-primary diagnoses refer to two independent disorders judged to be equal with regard to severity and interference with functioning. In the base-rate group, co-primary diagnoses were rare, occurring in 6% of patients, while 15% of personality diagnosis patients received Axis I co-primary diagnoses. A test for the difference between proportions 2o demonstrated a strong trend toward significance (P c.06). Low-frequency primary diagnoses were operationalized as those made for Table 3. Characteristic of Anxiety Disorder Patients With Personality Diagnoses Versus Base-Rate Sample Group

Variable

Personality Diagnosis (%I (n = 27)

Base-Rate (%I (n = 288)

Female Any additional Axis I diagnoses Current major depression Current dysthymia Past major depression HRSA, M (SD) HRSD, M (SD)

16 (59) 19 (70) 3(11) 15 (56) 10 (37) 19.4 (7.3) 18.4 (5.7)

190 (66) 114(40) 20 (7) 35 (12) 86 (30) 19.0 (7.61 15.4 (7.7)

P Value <.Ol <.Ol -

PERSONALITY

Table 4.

DIAGNOSES

Demographic

IN ANXIETY

255

PATIENTS

Characteristics of Anxiety Disorder Patients Diagnoses Versus Matched Controls

With Personality

Group

Variable Female Age (yr) M (SD) Marital Status Single Married Divorced/separated

Personality Diagnosis (%) In = 25)T

MatchedControl* (%) (n = 25)

16 (64)

16 (64)

33.9 (8.4)

32.8 (7.4)

15 (60) 7 (28) 3 (12)

10 (40) 13 (52) 2 (8)

*Controls matched on primary anxiety diagnosis, sex, and age within 5 years. tTwo personality diagnosis patients could not be matched and were excluded.

~10% of the base-rate sample-specifically, agoraphobia without panic; anxiety disorder, NOS; obsessive-compulsive disorder; and posttraumatic stress disorder. The personality diagnosis group received significantly more low-frequency primary diagnoses than the base-rate group (P ~001). Table 3 presents characteristics of the personality diagnosis and base-rate samples. Demographically, the two groups did not differ significantly in sex, age, and marital status. In terms of clinical characteristics, the personality diagnosis patients were almost twice as likely to receive additional Axis I diagnoses (x2 = 8.37; P ~01). The excess of additional diagnoses was accounted for primarily by dysthymia, which occurred more than four times as often in the personality diagnosis group (x2 = 10.5; P ~01). Rates of current and past major depression in the two groups did not significantly differ, nor did scores on the HRSA. Although HRSD scores were higher for the personality diagnosis group, the difference was not statistically significant (t = 1.52). Matched-Control

Study

Table 4 shows that demographic matching was successfully accomplished, with exactly the same sex distribution and no significant age difference. In addition, the distribution of marital status in the two groups did not differ significantly. Table 5 presents the comparisons on clinical characteristics between the personalTable 5. Clinical Characteristics of Anxiety Disorder Patients Personality Diagnoses Versus Matched Controls

With

Group

Variable Severity of primary Axis I diagnoses, M (SD) Any additional Axis I diagnoses Current major depression Current dysthymia Past major depression HRSA, M (SD) HRSD, M (SD)

Personality Diagnosis (%I (n = 25)

MatchedControl (%) (n = 25)

6.0 i.9) 19 (76)

5.6 (1.2) 16 (64)

2 12 9 19.4 17.9

(8) (48) (36) (5.9) (7.0)

4 (16) 4 (16) 3 (12) 19.1 (5.5) 14.1 (7.0)

P Value

<.03 <.05 <.06

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AND BARLOW

ity diagnosis and matched-control groups. Interestingly, the two groups did not differ significantly in the rated severity of their primary anxiety diagnoses, although they were not intentionally matched on severity. The HRSA scores of the two groups also did not differ significantly. Four personality diagnosis patients had co-primary diagnoses, while none of the matched controls received co-primary diagnoses, reflecting a nonsignificant trend (P c.07). Turning to the pattern of additional Axis I diagnoses, personality diagnosis and matched-control groups did not differ significantly in the proportion that received additional Axis I diagnoses, which were frequent in both groups. (This suggests that comorbidity for additional Axis I diagnoses may be a function of particular anxiety disorders rather than of comorbidity with personality disorder per se.) However, there were significant differences in the patterning of additional diagnoses and symptoms. The personality diagnosis group received three times as many diagnoses of dysthymia, while conversely the matched-control group received three times as many diagnoses of simple phobia (in both cases, x2 = 4.67; P c.03). Although current major depression was rare and equally common in both groups, diagnoses of past major depression were three times as frequent among personality diagnosis patients (x’ = 3.95; P < .05). Consistent with their current dysthymia, personality diagnosis patients showed higher scores on the HRSD, a difference that demonstrated a strong trend toward significance (t [48] = 1.94; P < .06). Finally, the personality diagnosis group received significantly lower scores for current functioning on the Global Assessment of Functioning scale (t [29] = 2.46; P -c.02). Scores for highest functioning in the past year did not differ significantly. DISCUSSION

To our knowledge, this is the first study to systematically compare the diagnostic and clinical characteristics of anxiety disorder patients with and without concurrent personality disorder diagnoses. In comparison with both a base-rate series of anxiety patients and with matched controls, anxiety patients with personality diagnoses were three to four times more likely to receive diagnoses of dysthymia. Compared with the matched controls, the personality diagnosis group was also significantly more likely to receive a diagnosis of past major depression. These findings are particularly striking in light of the similar severity of the primary anxiety diagnoses in the two groups. Moreover, personality diagnoses were associated with different presentation of anxiety disorders, as evidenced by the significantly higher rates of anxiety disorders and of co-primary diagnoses in the personality diagnosis group. The personality diagnosis group also received significantly lower ratings for current level of adaptive functioning than the matched controls. The observation of excesses in current dysthymia and in past major depression among the personality diagnosis group suggests that there may be a phenomenologitally distinct group of anxiety patients with personality disorder and low-level depression. A pattern in which some patients with a specific Axis I syndrome exhibit comorbidity with other Axis I and Axis II disorders might have a variety of causal explanations.’ The low-level depressive symptoms suggested by the affective diagnoses may be a complication of, or intrinsic to, personality disorder. Indeed, Akiska12’ suggested that dysthymia is itself a form of personality disorder. It is also possible that affective symptoms alter the clinical picture and/or self-report, so that the patient presents as personality disordered.’ Whether the presence of anxiety

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disorder affects the relationship between dysthymia and personality disorder is an open question. The lower level of current functioning among the personality diagnosis group is also of interest. It suggests that the general clinical picture may be more negative in personality cases at the time that they seek treatment for anxiety disorders. Counter to the view that personality disorder involves more long-term impairment, the highest level of functioning in the last year did not differ between groups. Our findings converge interestingly with recent research on the treatment of anxiety disorders. Depressive symptoms have been linked to poor response to behavioral treatment of obsessive-compulsive disorder*’ and social phobia,23 although not of agoraphobia. 24 By the same token, some evidence suggests that personality disorder predicts poor response to behavioral treatment of social phobia23 and to pharmacological treatment of panic disorder.‘,*’ The depression and personality disorder variables may individually predict treatment outcome in some anxiety disorders. In view of the current findings of a close relationship between dysthymia and personality disorder in anxiety patients, the prognostic significance of this joint diagnostic pattern should be examined. The ADIS gathers information beyond basic Axis I diagnostic criteria and thus permits the clinician to assess aspects of interpersonal functioning that are relevant to making personality diagnoses. However, it does not specifically survey the diagnostic criteria for Axis II disorders. This could account for both the high frequency of personality diagnoses of NOS and for the overall rate of personality diagnoses, which was substantially below that found in prior studies applying DSM-III criteria. With one exception,* these studies have employed structured The ADIS diagnostic procedure may be less measures of personality disorder.6~7~9~‘0 sensitive to personality disorder, such that the association with dysthymia may be found only for severe personality disorders. Nonetheless, the present findings support the concurrent validity of our personality diagnoses. The significant differences in current dysthymia and functional impairment, and in past major depression, found between the personality diagnosis patients and carefully matched anxiety patients without Axis II diagnoses, are especially pertinent. In addition, in the base-rate study, anxiety patients who received Axis II diagnoses showed a more unusual presentation on Axis I, with higher rates of co-primary and low-frequency diagnoses and more frequent additional diagnoses, largely dysthymia. Clearly, the next step is to systematically examine the clinical characteristics of anxiety patients for whom personality disorder diagnosis is based on structured interview. In the present study, specific personality diagnoses were equally distributed among the three clusters of odd, dramatic, and anxious personality disorders. In contrast, Green and Curtis,’ Mavissakalian and Hamann,’ and Reich et al.” reported a significant excess of cluster C, anxious disorders. It should be noted that these studies involved only panic disorder and agoraphobic patients, although Friedman et al.6 found equally high rates of cluster B (dramatic) and cluster C disorders in their panic disorder patients. Koenigsberg et a1.,8 found their highest rate in cluster B disorders in heterogeneous anxiety patients. In our study examining the full range of anxiety disorders did not reveal a differential association with one particular personality disorder cluster, although the possibility of differences in sample characteristics due to the different nature of the treatment facilities should be considered.

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