A comparison of DSM-III personality disorders in panic/agoraphobia and obsessive-compulsive disorder

One hundred eighty-seven patients meeting DSM-III criteria for panic disorder (161 with agoraphobia) and 51 patients meeting DSM-III criteria for obsessive-compulsive disorder (OCD) were assessed with the Personality Diagnostic Questionnaire (PDQ), a self-rating scale designed to assess axis II personality disorders and traits. The results showed that the personality profiles were similar between the two diagnostic groups and that the major personality characteristics identified in panic/agoraphobic patients, e.g., avoidant, dependent, histrionic, and borderline, were more pronounced in patients with OCD. These findings support our earlier suggestion of a nonspecific link between panic disorder/agoraphobia and personality disorder (PD)/traits.     

Personality disorder traits as predictors of subsequent first-onset panic disorder or agoraphobia

Determining how personality disorder traits and panic disorder and/or agoraphobia relate longitudinally is an important step in developing a comprehensive understanding of the etiology of panic/agoraphobia. In 1981, a probabilistic sample of adult (≥18 years old) residents of east Baltimore were assessed for Axis I symptoms and disorders using the Diagnostic Interview Schedule (DIS); psychiatrists reevaluated a subsample of these participants and made Axis I diagnoses, as well as ratings of individual Diagnostic and Statistical Manual of Mental Disorders, Third Edition personality disorder traits. Of the participants psychiatrists examined in 1981, 432 were assessed again in 1993 to 1996 using the DIS. Excluding participants who had baseline panic attacks or panic-like spells from the risk groups, baseline timidity (avoidant, dependent, and related traits) predicted first-onset DIS panic disorder or agoraphobia over the follow-up period. These results suggest that avoidant and dependent personality traits are predisposing factors, or at least markers of risk, for panic disorder and agoraphobia—not simply epiphenomena.     

Personality traits in early phases of panic disorder: implications on the presence of agoraphobia, clinical severity and short-term outcome

OBJECTIVE: To explore the relations between personality traits using the Big Five model and presence of agoraphobia, clinical severity and short-term outcome in an unbiased clinical sample of never-treated panic disorder patients. METHOD: Panic disorder (PD) patients (n = 103) in the first stages of their illness were evaluated using the Neuroticism-Extraversion-Openness Five Factor Inventory of Personality (NEO-FFI) and were compared with a sample of healthy subjects. Severity was assessed by the Panic Disorder Severity Scale and the Clinical Global Impression Scales. Patients were evaluated after 8 weeks of naturalistic pharmacologic treatment with Selective Serotonin Reuptake Inhibitors. RESULTS: Panic disorder patients show more neuroticism than healthy subjects. Patients suffering from agoraphobia are more introverted than controls. Extraversion, in addition to gender and distress, during panic attacks allows to correctly classifying 72% of the cases of agoraphobia. CONCLUSION: Low scores in extraversion contribute to explain the presence of agoraphobia in panic disorder. Personality traits are neither related to clinical severity nor to short-term response to pharmacological treatment.     

Relationship between panic disorder and agoraphobia. A family study

A family study of patients with agoraphobia (n = 40), panic disorder (n = 40), and nonanxious controls (n = 20) showed that the morbidity risk for panic disorder was increased among the relatives of agoraphobics (8.3%) and the relatives of patients with panic disorder (17.3%). The morbidity risk for agoraphobia was also increased among the relatives of agoraphobics (11.6%) but not the relatives of panic disorder patients (1.9%). Male relatives of agoraphobics were shown to be at higher risk for alcohol disorders (30.8%). No greater risk for primary affective disorders was found among the relatives of agoraphobic or panic disorder patients or among the relatives of probands with secondary depression compared with relatives of probands without secondary depression. Probands and relatives with agoraphobia reported an earlier onset of illness, more persistent and disabling symptoms, more frequent complications, and a less favorable outcome than probands and relatives with panic disorder. The findings suggest that agoraphobia is a more severe variant of panic disorder. They also lend support to the separation between anxiety disorders and affective disorders.     

DSM-III personality disorders in obsessive-compulsive disorder: changes with treatment

Twenty-seven patients meeting DSM-III diagnostic criteria for obsessive-compulsive disorder (OCD) completed the Personality Diagnostic Questionnaire (PDQ; a self-rating scale designed to assess the axis II personality disorders [PDs] from the DSM-III) before and after 12 weeks of treatment with clomipramine. Treatment was accompanied with reduction on several personality variables, including the number of personality diagnoses assigned, the distribution of traits in the sample, and the number of items endorsed in each personality category. The data also showed that improvement in personality functioning was significantly greater in responders compared with nonresponders or partial responders. Further investigation of the relationship between personality and treatment outcome did not provide strong support for the notion that personality factors may have prognostic significance in the treatment of OCD. These findings suggest similarities and differences with panic/agoraphobia which are briefly discussed.     

Relationship between perfectionism,personality disorders and agoraphobia in patients with panic disorder

OBJECTIVE: In earlier reports, we found that perfectionism might be involved in the development and/or maintenance of agoraphobia in panic disorder. The present report extends this work by examining the relationship between perfectionism and comorbidity with personality disorders in panic disorder patients with agoraphobia (PDA) and those without agoraphobia (PD). METHOD: We examined comorbidity of personality disorders by Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) and assessed perfectionism using multidimensional perfectionism scale in 56 PDA and 42 PD patients. RESULTS: The PDA group met criteria for at least one personality disorder significantly more often than the PD group. With stepwise regression analyses, avoidant and obsessive-compulsive personality disorders emerged as significant indicators of perfectionism in patients with panic disorder. CONCLUSION: These findings suggest that perfectionism in panic disorder patients may be more common in those with comorbid personality disorders, and may be an important target for preventive and therapeutic efforts.     

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

Abstract

Background: Social anxiety disorder (SAD) has been associated with cluster A personality disorder (PD) traits, mainly paranoid and schizoid traits. Aim: The aim of the study was to further investigate cluster A personality pathology in patients with SAD. Methods: Self-reported PD traits were investigated in a clinical sample of 161 participants with SAD and in a clinical comparison group of 145 participants with panic disorder with or without agoraphobia (PAD). Results: A diagnosis of SAD was associated with more paranoid and schizotypal PD traits, and an association between depression and personality pathology could indicate a state-effect of depression on PD traits. Conclusions: Patients with SAD had more cluster A personality pathology than patients with PAD, with the most solid indication for paranoid personality pathology.     

Clinical characteristics and treatment outcomes of patients with major depressive disorder and comorbid anxiety disorders - results from a European multicenter study

This naturalistic European multicenter study aimed to elucidate the association between major depressive disorder (MDD) and comorbid anxiety disorders. Demographic and clinical information of 1346 MDD patients were compared between those with and without concurrent anxiety disorders. The association between explanatory variables and the presence of comorbid anxiety disorders was examined using binary logistic regression analyses. 286 (21.2%) of the participants exhibited comorbid anxiety disorders, 10.8% generalized anxiety disorder (GAD), 8.3% panic disorder, 8.1% agoraphobia, and 3.3% social phobia. MDD patients with comorbid anxiety disorders were characterized by younger age (social phobia), outpatient status (agoraphobia), suicide risk (any anxiety disorder, panic disorder, agoraphobia, social phobia), higher depressive symptom severity (GAD), polypsychopharmacy (panic disorder, agoraphobia), and a higher proportion receiving augmentation treatment with benzodiazepines (any anxiety disorder, GAD, panic disorder, agoraphobia, social phobia) and pregabalin (any anxiety disorder, GAD, panic disorder). The results in terms of treatment response were conflicting (better response for panic disorder and poorer for GAD). The logistic regression analyses revealed younger age (any anxiety disorder, social phobia), outpatient status (agoraphobia), suicide risk (agoraphobia), severe depressive symptoms (any anxiety disorder, GAD, social phobia), poorer treatment response (GAD), and increased administration of benzodiazepines (any anxiety disorder, agoraphobia, social phobia) and pregabalin (any anxiety disorder, GAD, panic disorder) to be associated with comorbid anxiety disorders. Our findings suggest that the various anxiety disorders subtypes display divergent clinical characteristics and are associated with different variables. Especially comorbid GAD appears to be characterized by high symptom severity and poor treatment response.     

Sertraline treatment of panic disorder: response in patients at risk for poor outcome

BACKGROUND: More than one third of panic disorder patients have a chronic and/or recurrent form of the disorder, accounting for much of the individual and societal cost associated with the illness. Six clinical variables have been most consistently identified as high-risk predictors of poor outcome: (1) panic severity, (2) presence of agoraphobia, (3) comorbid depression, (4) comorbid personality disorder, (5) duration of illness, and (6) female sex. No published research has systematically examined the differential antipanic efficacy of selective serotonin reuptake inhibitors in patients at high risk for poor outcome. METHOD: Data were pooled (N = 664) from 4 double-blind, placebo-controlled studies of the efficacy of sertraline for the treatment of DSM-III-R panic disorder. Two of the studies were 12-week fixed-dose studies with starting daily doses of sertraline, 50 mg, and 2 were 10-week flexible-dose studies with starting daily doses of sertraline, 25 mg. All other study design features were the same, except for the exclusion of women of childbearing potential in the 2 fixed-dose studies. Exclusion of patients with marked personality disorders and depression meant that only 4 of the poor-outcome variables could be evaluated. RESULTS: Clinical improvement was similar for patients treated with sertraline whether or not they carried an agoraphobia diagnosis, had a duration of illness > 2 years, or were female. Patients with high baseline panic severity had significantly (p = .01) less improvement on the endpoint Clinical Global Impressions-Improvement (CGI-I) scale than patients with moderate severity, although the Clinical Global Impressions-Severity of Illness scale change score was higher in the patients with high severity (-2.00 vs. -1.31). For patients with 3 or more high-risk variables, there was a modest, but statistically significant, tendency for reduced global improvement (endpoint CGI-I score of 2.7 for the high-risk vs. 2.4 for the non-high-risk group; p = .017), although the high-risk group actually had a similar endpoint reduction in frequency of panic attacks (82%) compared with the non-high-risk group (78%). CONCLUSION: Treatment of panic disorder with sertraline was generally effective, even in the presence of baseline clinical variables that have been associated with poor treatment response. The main limitations of the analysis were the reliance on pooled data from 4 studies (even if the designs were similar) and our inability to examine the impact of depression and personality disorders on response to treatment because of the exclusion criteria of the clinical trials.     

DSM-III-R Axis I and II disorders in agoraphobic patients with and without panic disorder

Patients attending an inpatient phobia treatment program were diagnosed for DSM-III-R Axis I and II disorders, using the Structured Clinical Interview for DSM-III-R Disorders, and completed a set of self-report instruments. They were divided into 3 groups: (a) those who met the criteria for panic disorder with agoraphobia (n= 57), (b) those who met the criteria for agoraphobia without a history of panic disorder (n= 21), and (c) those who met criteria for other anxiety disorders, but not for panic/agoraphobia (n= 14). On Axis I, more of the panic with agoraphobia than of the agoraphobia without panic patients had obsessive-compulsive disorder. On Axis II, no significant differences between the agoraphobic patients with and without panic occurred. However, the number of hysterical traits was related to the presence of panic disorder among the agoraphobic patients. Avoidant and dependent traits were related to symptom severity.     

DSM-II personality characteristics of panic disorder with agoraphobia patients in stable remission.

The Personality Diagnostic Questionnaire (PDQ), a self-rating scale designed to assess DSM-III axis II personality disorders (PD), was administered to 12 panic disorder with agoraphobia patients during a 6-month stable and virtually symptom-free remission period with the aim of assessing the personality characteristics of these patients in the best possible approximation of the not-ill condition in clinical reality. The personality profile of the sample remained unchanged during remission and was predominated by avoidant PD traits. In a finer grain analysis, the stable and commonly endorsed individual PDQ items were compared with previously reported panic disorder and normal control subjects, which showed that the present sample was more like the panic patients in their tendency to see themselves as rather unassertive, indecisive, self-critical, and emotional individuals who are easily frustrated and feel rejected when criticized by others. These results suggest that avoidant behavioral and attitudinal patterns may be enduring personality characteristics of panic disorder with agoraphobia patients.     

Heightened embarrassability discriminates between panic disorder patients with and without agoraphobia

Embarrassability refers to an individual's general susceptibility to becoming embarrassed and is closely linked to another personality characteristic known as fear of negative evaluation. To find out if panic disorder patients with and without agoraphobia differ in terms of embarrassability and fear of negative evaluation 100 patients with a DSM-III-R diagnosis of panic disorder with agoraphobia, 30 patients with a DSM-III-R diagnosis of uncomplicated panic disorder and 80 controls were administered the Embarrassability Scale and the 12-item version of the Fear of Negative Evaluation Scale. Depressive mood in the clinical group was assessed with the help of the Beck Depression Inventory. Comparisons between these three groups, between patients with mild, moderate, and severe phobic avoidance and between male and female subjects were carried out. Patients with agoraphobic avoidance showed significantly higher scores on both scales than patients with uncomplicated panic disorder and controls and women generally showed higher embarrassability scores than men. We conclude that heightened embarrassability is an important characteristic of patients suffering from panic disorder with agoraphobia.     

Comparing panic disorder uncomplicated and panic disorder with agoraphobia in cardiology patients with atypical or nonanginal chest pain

Thirty-eight cardiology patients with either atypical or nonanginal chest pain and current panic disorder were divided into two groups, those with agoraphobia (N = 8) and those without agoraphobia (N = 30). The agoraphobia group reported marginally longer duration of panic disorder (17.0 ± 21.1 years vs. 3.0 ± 3.2 years) and significantly more panic symptoms (10.6 ± 3 vs. 7.3 ± 2.2) during the last major attack. The agoraphobia group also scored significantly higher on measures of anxiety, depression, phobic avoidance, somatization, interpersonal sensitivity, and psychoticism and also scored higher on three of three global measures of distress. This agoraphobia group differed from previously reported agoraphobics with panic attacks in that they all had current panic disorder, while previously reported groups were categorized according to DSM-III, which required only a history of panic attacks. These findings suggest that patients who have current panic disorder and agoraphobia are more symptomatic. Of interest is the low proportion of agoraphobics compared to nonagoraphobics found in this panic disorder population.     

The relationship between panic disorder/agoraphobia and personality disorders

This selective review of the relationship between panic disorder/agoraphobia and DSM-III personality disorders points to a preponderance of dependent, avoidant, and histrionic features and reveals a certain degree of covariation between severity of Axis I disorder and personality functioning. However, the link between panic/agoraphobia and Axis II disorders does not appear to be specific because (1) general features such as neuroticism, stress, dysphoric mood, and interpersonal sensitivity, rather than duration and severity of panic attacks and phobias, emerge as unique predictors or determinants of personality disorder; and (2) similar personality profiles are obtained in a heterogenous population of psychiatric outpatients or patients with social phobia, obsessive-compulsive disorder, and major depression.     

Major depression and agoraphobia in patients with angiographically normal coronary arteries and panic disorder

Patients with panic disorder and/or agoraphobia appearing in psychiatric settings report rates for lifetime major depression between 24% and 91%. Between 40% and 90% of patients with panic disorder in psychiatric populations report concomitant agoraphobia. A recent study of panic disorder subjects appearing in an outpatient cardiology clinic confirmed the strong link between panic and depression but found only a weak association between panic disorder and agoraphobia. In order to test the reliability of these outpatient cardiology findings, the authors studied major depression and agoraphobia in patients with angiographically normal coronary arteries and panic disorder. Twelve of the 32 (37.5%) panic disorder subjects reported a lifetime history of major depression (nine current, three past only). Only two of the 32 (six percent) reported any phobic avoidance. This study confirms the previous findings which suggest that major depression is common in cardiology populations with panic disorder and that phobic avoidance is uncommon in this group.     

Thyroid hormones in panic disorder, panic disorder with agoraphobia, and generalized anxiety disorder

Fifty-two patients with generalized anxiety disorder who had symptoms persisting for at least 6 months, 41 patients suffering from either panic disorder (32 patients) or panic disorder with agoraphobia (9 patients), and 14 control subjects were screened for thyroid disease. Total serum thyroxine (TT4), serum-free thyroxine index (FT4I), and triiodothyronine resin uptake (T3RU), were examined for the entire sample, using a one-way analysis of variance (ANOVA). No significant differences were found in TT4 (p = .24), FT4I (p = .24), and T3RU (p = .19). Thyroid-stimulating hormone (TSH) was examined in a subsample of 10 patients with generalized anxiety disorder, 11 with panic disorder or panic disorder with agoraphobia, and 10 controls. One-way ANOVA again showed no significant differences, although there was a trend (p = .07). This is the first report that compares generalized anxiety disorder patients, panic disorder patients, and patients with panic disorder and agoraphobia with controls on measures of thyroid function. It is also the first to report normal values in the thyroid indices of generalized anxiety disorder patients.     

The relationship of panic disorder to agoraphobia

Twenty patients with agoraphobia or panic disorder were compared to each other using multiple variables of clinical illness. No differences were found. Only one of thirteen agoraphobic patients did not experience panic attacks. The agoraphobia symptoms never preceded the panic attacks in those twelve patients experiencing both agoraphobia and panic attacks. This study data and that of others is most consistent with the hypothesis that agoraphobia is a secondary manifestation of panic disorder.     

DSM-III-R personality disorders in panic and obsessive-compulsive disorder: a comparison study.

Forty-eight patients with panic disorder/agoraphobia (PAD) and 30 with obsessive-compulsive disorder (OCD) were assessed for DSM-III-R axis II personality disorders (PD) and the presence of the same anxiety disorder in the relatives of probands (homotypic disorders). No specific personality disorder was present significantly more often in either of the two groups. Agoraphobia was not associated with higher rates of axis II disorders in PAD patients. Duration of illness did not influence the presence of a PD in patients of both groups. Secondary cases of the same anxiety disorder were significantly more common among first-degree relatives of PAD patients. A discriminant analysis performed on the most frequent personality traits of both groups provided a correct classification of cases of 97.4%. Our results do not support the hypothesis of PD as secondary to anxiety disorders and confirm previous findings of a lack of specificity between DSM-III-R axis II categories and OCD and PAD.     

惊恐障碍的临床变量比较

目的；了解伴和不伴广场恐怖的惊恐障碍患者的临床变量有无差异。方法；对连续门诊的４６例伴广场恐怖的惊恐障碍患者，和５４例不伴广场恐怖的惊恐障碍患者的临床谱量进行对照比较。结果；在离婚、确诊前内科门诊，发作频率主诉等变量上存在显著差异，在有无早搏变量上存在非常显著差异。