Clinically diagnosed axis II co-morbidity and the short term outcome of CBT for axis I disorders

Personality Pathology in Winter Depression: Prevalence and Treatment Trajectories in Cognitive-Behavioral Therapy and Light Therapy

Personality disorders are highly comorbid with major depression; however, findings are mixed regarding their impact on depression treatment outcomes and trajectories. Limited research has studied personality pathology in winter depression, specifically. This study (1) explored the prevalence of personality pathology in winter depression and (2) examined its effects on winter depression treatment trajectories. Participants were 174 adults with Major Depression, Recurrent with Seasonal Pattern from a randomized clinical trial comparing group cognitive-behavioral therapy for seasonal affective disorder (CBT-SAD) and light therapy. Participants completed the Millon Clinical Multiaxial Inventory-III (MCMI-III; Millon et al., 1994) at baseline. The prevalence of MCMI-III-defined pathological personality traits and personality disorders in this sample was 98/174 (56.3%) with any trait and 65/174 (37.4%) with any disorder. Dependent was the most common elevation (65/174, 37.4%), trait (43/174, 24.7%), and disorder (22/174, 12.6%). Most participants with pathological personality elevations had only one personality disorder (58/174, 33.3%) and one pathological personality trait (82/174, 47.1%). Growth curve analysis revealed personality pathology predicted higher baseline depression scores, but the number of MCMI-III pathological personality elevations (i.e., traits and disorders) and personality disorders did not predict change in depression over the timeframe of pretreatment, weekly during treatment, posttreatment, and follow-ups one and two winters later in CBT-SAD or light therapy. Results suggest that personality pathology is not a negative prognostic indicator or prescriptive factor for winter depression treatment with CBT-SAD or light therapy, which may inform treatment algorithms and decision-making in practice.

Prognostic Value of Pathological Personality Traits for Treatment Outcome in Anxiety and Depressive Disorders: The Leiden Routine Outcome Monitoring Study

ABSTRACT

Previous studies have failed to take baseline severity into account when assessing the effects of pathological personality traits (PPT) on treatment outcome. This study assessed the prognostic value of PPT (Dimensional Assessment of Personality Pathology-Short Form) on treatment outcome (Brief Symptom Inventory [BSI-posttreatment]) among patients with depressive and/or anxiety disorders ( N = 5689). Baseline symptom level (BSI-pretreatment) was taken into account as a mediator or moderator variable. Results showed significant effects of PPT on outcome, of which Emotional Dysregulation demonstrated the largest association ( β = 0.43, p < 0.001). When including baseline BSI score as a mediator variable, a direct effect ( β = 0.11, p < 0.001) remained approximately one-third of the total effect. The effects of Emotional Dysregulation (interaction effect β = 0.061, p < 0.001) and Inhibition (interaction effect β = 0.062, p < 0.001), but not Compulsivity or Dissocial Behavior, were moderated by the baseline symptom level. PPT predicts higher symptom levels, both before and after treatment, but yields relatively small direct effects on symptom decline when the effect of pretreatment severity is taken into account.

Impact of Comorbid Personality Disorders on Depression Treatment in Routine Outpatient Care

OBJECTIVE

The impact of personality disorder on treatment effectiveness for depression has been debated, and study results have been inconsistent. However, studies that report a negative impact of personality disorders on depression treatment outcomes are often characterized by uncontrolled treatment designs. Within such contexts, individuals with depression and personality disorders are at risk to receive suboptimal treatment. The aim of this retrospective observational study was to investigate whether and to what extent comorbid personality disorders were associated with the type and amount of depression treatment received in routine outpatient care.

METHODS

Retrospectively extracted data from electronic records of 1,455 outpatients treated for depression at several sites of a nationwide mental health provider in the Netherlands were included. The type and number of treatment sessions and visits were analyzed by using regression models.

RESULTS

Individuals with depression and comorbid personality disorders received more psychotherapy sessions than individuals without personality disorders, irrespective of depression severity. The number of pharmacotherapy sessions and supportive and crisis visits did not differ between individuals with and without comorbid personality disorders.

CONCLUSIONS

Individuals with depression and personality disorders received more intensive treatment than individuals without comorbid personality disorders. These results conflict with treatment guidelines and recommendations from high-quality studies and may be indicative of overtreatment among this large group of patients.

Impact of Comorbid Personality Disorders on Depression Treatment in Routine Outpatient Care

OBJECTIVE

The impact of personality disorder on treatment effectiveness for depression has been debated, and study results have been inconsistent. However, studies that report a negative impact of personality disorders on depression treatment outcomes are often characterized by uncontrolled treatment designs. Within such contexts, individuals with depression and personality disorders are at risk to receive suboptimal treatment. The aim of this retrospective observational study was to investigate whether and to what extent comorbid personality disorders were associated with the type and amount of depression treatment received in routine outpatient care.

METHODS

Retrospectively extracted data from electronic records of 1,455 outpatients treated for depression at several sites of a nationwide mental health provider in the Netherlands were included. The type and number of treatment sessions and visits were analyzed by using regression models.

RESULTS

Individuals with depression and comorbid personality disorders received more psychotherapy sessions than individuals without personality disorders, irrespective of depression severity. The number of pharmacotherapy sessions and supportive and crisis visits did not differ between individuals with and without comorbid personality disorders.

CONCLUSIONS

Individuals with depression and personality disorders received more intensive treatment than individuals without comorbid personality disorders. These results conflict with treatment guidelines and recommendations from high-quality studies and may be indicative of overtreatment among this large group of patients.

Impact of Personality Disorder on the Treatment of Psychiatric Disorders in People Receiving Methadone-Assisted Treatment

This study evaluates personality disorder as a moderator of psychiatric treatment response in people receiving methadone-assisted treatment. Participants (N = 125) were enrolled in a 12-week parent study that evaluated the impact of incentives on attendance to psychiatric care. All participants had a current DSM IV-R Axis I disorder and were classified based on presence of an Axis II disorder: Axis I-only (n = 46) versus Axis I + II (n = 79). All participants received an identical protocol of psychiatric and substance use disorder care. Although Axis I + II participants endorsed more psychiatric distress (on the Hopkins Symptom Checklist-Revised) throughout treatment, they reported significant reductions in distress that paralleled reductions reported by Axis I-only participants. Rates of substance use were low and similar across groups. Results support the benefits of integrated psychiatric and substance use care for people with opioid use disorder, with or without a co-occurring personality disorder.

Personality Disorders and Their Relation to Treatment Outcomes in Cognitive Behavioural Therapy for Depression: A Systematic Review and Meta-analysis

Background

Previous reviews indicate that depressed patients with a comorbid personality disorder (PD) tend to benefit less from psychotherapies for depression and thus personality pathology needs to be the primary focus of treatment. This review specifically focused on studies of Cognitive Behavioural Therapy (CBT) for depression examining the influence of comorbid PD on post-treatment depression outcomes.

Methods

This was a systematic review and meta-analysis of studies identified through PubMed, PsychINFO, Web of Science, and Scopus. A review protocol was pre-registered in the PROSPERO database (CRD42019128590).

Results

Eleven eligible studies (N = 769) were included in a narrative synthesis, and ten (N = 690) provided sufficient data for inclusion in random effects meta-analysis. All studies were rated as having “low” or “moderate” risk of bias and there was no significant evidence of publication bias. A small pooled effect size indicated that patients with PD had marginally higher depression severity after CBT compared to patients without PD (g = 0.26, [95% CI: 0.10, 0.43], p = .002), but the effect was not significant in controlled trials (p = .075), studies with low risk of bias (p = .107) and studies that adjusted for intake severity (p = .827). Furthermore, PD cases showed symptomatic improvements across studies, particularly those with longer treatment durations (16–20 sessions).

Conclusions

The apparent effect of PD on depression outcomes is likely explained by higher intake severity rather than treatment resistance. Excluding these patients from evidence-based care for depression is unjustified, and adequately lengthy CBT should be routinely offered.

The Impact of Obsessive Compulsive Personality Disorder on Cognitive Behaviour Therapy for Obsessive Compulsive Disorder

BACKGROUND

It is often suggested that, in general, co-morbid personality disorders are likely to interfere with CBT based treatment of Axis I disorders, given that personality disorders are regarded as dispositional and are therefore considered less amenable to change than axis I psychiatric disorders.

AIMS

The present study aimed to investigate the impact of co-occurring obsessive-compulsive disorder (OCD) and obsessive-compulsive personality disorder (OCPD) on cognitive-behavioural treatment for OCD.

METHOD

92 individuals with a diagnosis of OCD participated in this study. Data were drawn from measures taken at initial assessment and following cognitive-behavioural treatment at a specialist treatment centre for anxiety disorders.

RESULTS

At assessment, participants with OCD and OCPD had greater overall OCD symptom severity, as well as doubting, ordering and hoarding symptoms relative to those without OCPD; however, participants with co-morbid OCD and OCPD demonstrated greater treatment gains in terms of OCD severity, checking and ordering than those without OCPD. Individuals with OCD and OCPD had higher levels of checking, ordering and overall OCD severity at initial assessment; however, at post-treatment they had similar scores to those without OCPD.

CONCLUSION

The implications of these findings are discussed in the light of research on axis I and II co-morbidity and the impact of axis II disorders on treatment for axis I disorders.

Impact of personality psychopathology on outcome in short-term cognitive-behavioral therapy for Axis I disorders

Cognitive behavioral therapy (CBT) is efficacious for many Axis I disorders, though its effectiveness in the real world, for patients with Axis II comorbidity is less well known. This study examines the effectiveness of CBT for Axis I disorders in three groups of patients: those with personality disorders, those with personality disorder traits and those with no Axis II pathology. Consecutive referrals of patients with non-psychotic Axis I disorders were assessed for short-term CBT in a University Teaching Unit. While the acceptance rate was lower for individuals with personality disorders, there were no group differences in dropout rates. Of those who completed therapy (mean number of sessions=17.8, SD=11.2), those in the Personality Disorders group (n=45) had 4 sessions more on average than the Personality Disorder Traits group (n=42) or the No Axis II Group (n=266). All 3 groups were equally successful, whether the outcome was therapist opinion of success, the clinical global impression, or the reliable change index based on patient-reported symptom change. Intent to treat analysis results paralleled those of the completer analysis. Our findings indicate that the presence of a personality disorder does not negatively impact therapy adherence or success in short-term CBT for an Axis I disorder.

Influence of personality on the outcome of treatment in depression: systematic review and meta-analysis

There continues to be debate about the influence of personality disorder on the outcome of depressive disorders and is relative interactions with treatment. To determine whether personality disorder, both generically and in terms of individual clusters, leads to a worse outcome in patients with depressive disorders and whether this is influenced by type of treatment, a systematic electronic search of MEDLINE, CINAHL, and PsycINFO from 1966, 1982, and 1882, respectively, until February 2007 was undertaken. The keyword terms depression, mental illness, and personality disorder were used. All references were reviewed and personal correspondence was undertaken. Only English language papers were considered. Any English language paper studying a depressed adult population was considered for inclusion. Studies needed to clearly define depression and personality disorder using peer-reviewed instruments or International Classification of Disease/Diagnostic Statistical Manual criteria. Outcome assessment at greater than 3 weeks was necessary. Final inclusion papers were agreed on by consensus by at least two reviewers. All data were extracted using predetermined criteria for depression by at least two reviewers in parallel. Disagreement was settled by consensus. Complex data extraction was confirmed within the study group. Data were synthesized using log odds ratios in the Cochrane RevMan 5 program. The finding of comorbid personality disorder and depression was associated with a more than double the odds of a poor outcome for depression compared with those with no personality disorder (OR 2.16, CI 1.83-2.56). This effect was not ameliorated by the treatment modality used for the depressive disorder. This finding led to the conclusion that personality disorder has a negative impact on the outcome of depression. This finding is important in considering prognosis in depressive disorders.

The effect of personality disorders on treatment outcomes in patients with obsessive-compulsive disorders

The effect of comorbid personality disorders (PD) on treatment outcomes in obsessive-compulsive disorder (OCD) is unclear. The authors systematically review results from investigations of therapy outcomes in adult patients with OCD and a comorbid PD. PsycINFO and MEDLINE were searched for original articles. Twenty-three studies assessing PDs through interviews were selected. Cluster A PDs, particularly schizotypal PD, narcissistic PD, and the presence of two or more comorbid PDs, were associated with poorer treatment outcomes in patients with OCD. With regard to other PDs and clusters, the results are inconsistent or the sample sizes are too small to reach a conclusion. OCD patients with different comorbid PDs differ in their therapeutic response to treatment. To optimize the treatment of OCD, the predictive value of PDs on the treatment outcome should be further investigated, and treatment of Axis I and II comorbidity requires more attention.

Psychotherapy for depression: a randomized clinical trial comparing schema therapy and cognitive behavior therapy

BACKGROUND

The efficacy of Cognitive Behavior Therapy (CBT) for depression has been robustly supported, however, up to fifty percent of individuals do not respond fully. A growing body of research indicates Schema Therapy (ST) is an effective treatment for difficult and entrenched problems, and as such, may be an effective therapy for depression.

METHODS

In this randomized clinical trial the comparative efficacy of CBT and ST for depression was examined. 100 participants with major depression received weekly cognitive behavioral therapy or schema therapy sessions for 6 months, followed by monthly therapy sessions for 6 months. Key outcomes were comparisons over the weekly and monthly sessions of therapy along with remission and recovery rates. Additional analyses examined outcome for those with chronic depression and comorbid personality disorders.

RESULTS

ST was not significantly better (nor worse) than CBT for the treatment of depression. The therapies were of comparable efficacy on all key outcomes. There were no differential treatment effects for those with chronic depression or comorbid personality disorders.

LIMITATIONS

This study needs replication.

CONCLUSIONS

This preliminary research indicates that ST may provide an effective alternative therapy for depression.

Comorbidity of personality disorders in anxiety disorders: a meta-analysis of 30 years of research

BACKGROUND

A comprehensive meta-analysis to identify the proportions of comorbid personality disorders (PD) across the major subtypes of anxiety disorders (AD) has not previously been published.

METHODS

A literature search identified 125 empirical papers from the period 1980-2010 on patients with panic disorders, social phobia, generalised anxiety, obsessive-compulsive (OCD) and post-traumatic stress disorder (PTSD). Several moderators were coded.

RESULTS

The rate of any comorbid PD was high across all ADs, ranging from .35 for PTSD to .52 for OCD. Cluster C PDs occurred more than twice as often as cluster A or B PDs. Within cluster C the avoidant PD occurred most frequently, followed by the obsessive-compulsive and the dependent PD. PTSD showed the most heterogeneous clinical picture and social phobia was highly comorbid with avoidant PD. A range of moderators were examined, but most were non-significant or of small effects, except an early age of onset, which in social phobia increased the risk of an avoidant PD considerably. Gender or duration of an AD was not related to variation in PD comorbidity.

LIMITATIONS

Blind rating of diagnoses was recorded from the papers as an indication of diagnostic validity. However, as too few studies reported it the validity of the comorbid estimates of PD was less strong.

CONCLUSIONS

The findings provided support to several of the proposed changes in the forthcoming DSM-5. Further comorbidity studies are needed in view of the substantial changes in how PDs will be diagnosed in the DSM-5.

Specific and nonspecific comorbidity in anorexia nervosa

OBJECTIVE

This article reports lifetime Axis I and II comorbidity in women with anorexia nervosa (AN), and ascertains specific and nonspecific comorbidity in AN compared to clinical samples of women with bulimia nervosa (BN) or major depression (DEP).

METHOD

Outpatient AN (n = 56), BN (n = 132), and DEP (n = 100) samples were assessed using Structured Clinical Interviews I and II for DSM-III-R. Baseline data were compared using univariate statistics and logistic regression.

RESULTS

In the AN sample as a whole, specific elevations were found for prevalences of obsessive compulsive disorder. The AN-binge eating purging subtype (AN-BP) and the BN sample had elevated prevalences of Cluster B personality disorders. Cluster C prevalences were elevated across samples.

CONCLUSION

Evidence of AN-specific, eating disorder-specific, and nonspecific comorbidity illustrates the heterogeneity in AN. Further research is need to examine the relative impact of specific and nonspecific comorbidity in AN subtypes and AN as a whole.