Personality disorders in patients with panic disorder: association with childhood anxiety disorders, early trauma, comorbidity, and chronicity

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of panic disorder, social anxiety disorder and generalised anxiety disorder

Objective:

To provide practical clinical guidance for the treatment of adults with panic disorder, social anxiety disorder and generalised anxiety disorder in Australia and New Zealand.

Method:

Relevant systematic reviews and meta-analyses of clinical trials were identified by searching PsycINFO, Medline, Embase and Cochrane databases. Additional relevant studies were identified from reference lists of identified articles, grey literature and literature known to the working group. Evidence-based and consensus-based recommendations were formulated by synthesising the evidence from efficacy studies, considering effectiveness in routine practice, accessibility and availability of treatment options in Australia and New Zealand, fidelity, acceptability to patients, safety and costs. The draft guidelines were reviewed by expert and clinical advisors, key stakeholders, professional bodies, and specialist groups with interest and expertise in anxiety disorders.

Results:

The guidelines recommend a pragmatic approach beginning with psychoeducation and advice on lifestyle factors, followed by initial treatment selected in collaboration with the patient from evidence-based options, taking into account symptom severity, patient preference, accessibility and cost. Recommended initial treatment options for all three anxiety disorders are cognitive–behavioural therapy (face-to-face or delivered by computer, tablet or smartphone application), pharmacotherapy (a selective serotonin reuptake inhibitor or serotonin and noradrenaline reuptake inhibitor together with advice about graded exposure to anxiety triggers), or the combination of cognitive–behavioural therapy and pharmacotherapy.

Conclusion:

The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of panic disorder, social anxiety disorder and generalised anxiety disorder provide up-to-date guidance and advice on the management of these disorders for use by health professionals in Australia and New Zealand.

Please Don't Leave Me-Separation Anxiety and Related Traits in Borderline Personality Disorder

PURPOSE OF REVIEW

In light of the apparent symptomatic resemblance of separation anxiety disorder (SAD) symptoms on the one hand and abandonment fears, anxiousness, and separation insecurity central to borderline personality disorder (BPD) on the other hand, a comprehensive overview of separation anxiety and related traits in BPD is provided.

RECENT FINDINGS

Epidemiological, environmental, psychological, and neurobiological data connecting BPD to separation events, feelings of loneliness, insecure attachment styles, dimensional separation anxiety as well as SAD per se suggest a partly shared etiological pathway model underlying BPD and SAD. Differential diagnostic aspects and implications for treatment are discussed, highlighting separation anxiety as a promising transdiagnostic target for specific psychotherapeutic and pharmacological treatment approaches in BPD. This innovative angle on cross-disorder symptomatology might carry potential for novel preventive and therapeutic avenues in clinical practice by guiding the development of interventions specifically targeting separation anxiety and attachment-related issues in BPD.

Impact of childhood trauma on course of panic disorder: contribution of clinical and personality characteristics

OBJECTIVE

To investigate the impact of childhood trauma on the clinical course of panic disorder and possible contributing factors.

METHOD

Longitudinal data of 539 participants with a current panic disorder were collected from the Netherlands Study of Depression and Anxiety (NESDA). Childhood trauma was assessed with a structured interview and clinical course after 2 years with a DSM-IV-based diagnostic interview and the Life Chart Interview.

RESULTS

At baseline, 54.5% reported childhood trauma, but this was not predictive of persistence of panic disorder. Emotional neglect and psychological abuse were associated with higher occurrence of anxiety disorders other than panic disorder (social phobia) and with higher chronicity of general anxiety symptoms (anxiety attacks or episodes and avoidance). Baseline clinical features (duration and severity of anxiety and depressive symptoms) and personality traits (neuroticism and extraversion) accounted for roughly 30-60% of the total effect of childhood trauma on chronicity of anxiety symptoms and on occurrence of other anxiety disorders.

CONCLUSION

After two years, childhood trauma is associated with chronicity of anxiety symptoms and occurrence of social phobia, rather than persistence of panic disorder. These relationships are partially accounted for by duration and severity of anxiety and depressive symptoms, and neuroticism and extraversion.

Defense Mechanisms in "Pure" Anxiety and "Pure" Depressive Disorders

Our study was intended to test whether there are any differences in the way defense mechanisms are used by patients suffering from pure anxiety and those with pure depressive disorders. The sample size was as follows: depressive disorders without psychotic symptoms 30, anxiety disorders 30, and the healthy control group 30. The assessment of defense mechanisms was made using the DSQ-40 questionnaire. Our findings show that "pure" anxiety disorders differ from "pure" depressive disorders only in the use of immature defense mechanisms. The group with depressive disorders was significantly more prone to use immature defense mechanisms than the group with anxiety disorders (p = 0.005), primarily projection (p = 0.001) and devaluation (p = 0.003). These defense mechanisms may therefore be used both to differentiate between anxiety and depressive disorders and also to determine which symptoms (anxiety or depressive disorders) are dominant at any given stage of treatment.

Are there associations between early emotional trauma and anxiety disorders? Evidence from a systematic literature review and meta-analysis

BACKGROUND

Previous studies indicate a possible association between early emotional trauma (EET) and the development of anxiety disorders (ADs) in adult life. However, no previous studies have compiled the findings of such studies and analyzed their statistical significance. Therefore, the objective of this study was to conduct a systematic literature review and meta-analysis to determine possible associations between EET and three ADs (panic, generalized anxiety, and social anxiety disorders).

METHODS

A systematic search was conducted in PubMed, PsycInfo, and Scielo with no publication date limitations. A total of 2127 studies were found, 32 studies of which were selected for the systematic review and 13 studies of which were selected for the meta-analysis.

RESULTS

High prevalence rates of different EETs were observed among the individuals with ADs (median: 18%-45%). The results of the meta-analysis indicated that individuals with EETs were 1.9- to 3.6-fold more likely to develop ADs compared with a control group of healthy individuals. Emotional traumas were the main risk factor for social anxiety disorder. However, no specific associations were found for the other ADs.

CONCLUSIONS

EET is a risk factor for ADs, underscoring the importance of preventive measures to combat the development of these disorders. Moreover, the identification of EETs among patients with ADs is essential for implementing remedial measures to minimize the impact and damage arising from this association by decreasing the risk and severity of symptoms and to improve the response rate to treatment of ADs.

The efficacy of psychotherapy: focus on psychodynamic psychotherapy as an example

The growing number of individuals seeking treatment for mental disorders calls for intelligent and responsible decisions in health care politics. However, the current relative decrease in reimbursement of effective psychotherapy approaches occurring in the context of an increase in prescription of psychotropic medication lacks a scientific base. Using psychodynamic psychotherapy as an example, we review the literature on meta-analyses and recent outcome studies of effective treatment approaches. Psychodynamic psychotherapy is an effective treatment for a wide variety of mental disorders. Adding to the known effectiveness of other shorter treatments, the results indicate lasting change in many cases, especially for complex and difficult to treat patients, ultimately reducing health-care utilization. Research-informed health care decisions that take into account the solid evidence for the effectiveness of psychotherapy, including psychodynamic psychotherapy, have the potential to promote choice, increase mental health, and reduce society's burden of disease in the long run.

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.

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.

The effect of temperament and character on response to selective serotonin reuptake inhibitors in panic disorder

OBJECTIVE

In this prospective study, temperament and character were evaluated in patients with panic disorder (PD), before 1 year of medication therapy, to verify whether these factors influenced the outcome of treatment.

METHOD

Seventy-one PD patients were evaluated with the SCID-IV, the Temperament and Character Inventory (TCI), the SCL-90, the Ham-A and the Ham-D. Patients were treated with pharmacotherapy and were evaluated monthly over 1 year.

RESULTS

Before treatment, non-remitted patients showed higher levels of harm avoidance (HA) and lower levels of persistence (P), self-directedness (SD) and cooperativeness (C), whereas remitted patients showed only higher levels of HA. After controlling the effect of the confounding variables, the likelihood to achieve remission was positively related to SD score (OR = 1.12; P = 0.002), particularly 'self-acceptance' SD dimension (OR = 1.30; P = 0.02).

CONCLUSIONS

Our data suggest that in PD: i) the evaluation of personality, using the Cloninger's model, confirms the presence of personality pathology as one predictor of non-response to treatment; ii) in patients with low SD a combination of medication and cognitive-behaviour therapy should be the most effective treatment.

The effect of pharmacotherapy on personality disorders in panic disorder: a one year naturalistic study

BACKGROUND

In this prospective study, Personality Disorders (PersD) were evaluated in patients with Panic Disorder (PD), before and after one year of pharmacotherapy to verify whether personality characteristics changed after treatment.

METHOD

Sixty PD patients and 60 sex and age-matched normal controls participated in the study. All subjects were evaluated with the SCID-IV, the Structured Interview for DSM-IV Personality Disorders (SIDP), the SCL-90, the Ham-A and the Ham-D. Patients were treated with paroxetine or citalopram and were evaluated monthly for one year to assess the remission of symptoms. The SIDP was re-administered to the patients at the end of the study.

RESULTS

Before treatment, PD patients showed a higher prevalence (60%) of PersD than normal subjects (8%). After treatment, PersD rate decreased (43%) due to the reduction of the rate of paranoid, avoidant and dependent PersD. When the effect of the treatment on personality traits was evaluated, we found that avoidant traits decreased only in remitted patients, paranoid traits decreased both in remitted and in non-remitted patients, and dependent traits decreased only in patients with major depression comorbidity.

LIMITATIONS

The small sample size and the short length of the follow-up period of our study suggest caution in the generalization of our results.

CONCLUSIONS

In our PD patients, an improvement of symptoms was associated with a reduction of paranoid, avoidant and dependent traits, with a normalization of paranoid traits and a persistence of avoidant and dependent characteristics. Therefore, our data suggest that in PD patients not only paranoid traits but also avoidant and dependent traits show, at least in part, a state phenomenon.

Comorbid personality disorders in subjects with panic disorder: do personality disorders increase clinical severity?

Personality disorders are common in subjects with panic disorder. Personality disorders have been shown to affect the course of panic disorder. The purpose of this study was to examine which personality disorders affect clinical severity in subjects with panic disorder. This study included 122 adults (71 women, 41 men) who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition ( DSM-IV ) criteria for panic disorder (with or without agoraphobia). Clinical assessment was conducted by using the Structured Clinical Interview for DSM-IV Axis I Disorders, the Structured Clinical Interview for DSM-IV Axis II Personality Disorders, and the Panic and Agoraphobia Scale, Global Assessment Functioning Scale, Beck Depression Inventory, and State-Trait Anxiety Inventory. Patients who had a history of sexual abuse were assessed with Sexual Abuse Severity Scale. Logistic regressions were used to identify predictors of suicide attempts, suicidal ideation, sexual abuse, and early onset of disorder. The rates of comorbid Axes I and II psychiatric disorders were 80.3% and 33.9%, respectively, in patients with panic disorder. Patients with panic disorder with comorbid personality disorders had more severe anxiety, depression, and agoraphobia symptoms, had earlier ages at onset, and had lower levels of functioning. The rates of suicidal ideation and suicide attempts were 34.8% and 9.8%, respectively, in subjects with panic disorder. The rate of patients with panic disorder and a history of childhood sexual abuse was 12.5%. The predictor of sexual abuse was borderline personality disorder. The predictors of suicide attempt were comorbid paranoid and borderline personality disorders, and the predictors of suicidal ideation were comorbid major depression and avoidant personality disorder in subjects with panic disorder. In conclusion, this study documents that comorbid personality disorders increase the clinical severity of panic disorder. Borderline personality disorder may be the predictor of a history of sexual abuse and early onset in patients with panic disorder. Paranoid and borderline personality disorders may be associated with a high frequency of suicide attempts in patients with panic disorder.

Lung disease and internalizing disorders. Is childhood abuse a shared etiologic factor?

OBJECTIVE

To investigate the role of childhood abuse in the relationship between panic attack, depression and lung disease among adults in the population.

METHODS

Data were drawn from the National Comorbidity Survey (n=5877), a representative sample of adults age 15-54 in the United States. Multiple logistic regression analyses were used to determine the association between childhood abuse and lung disease, and to determine whether childhood abuse is an independent predictor of the co-occurrence of lung disease, panic attack and depression.

RESULTS

Childhood abuse was associated with significantly increased odds of panic attacks (OR=2.2 (1.5, 3.1)) and depression (OR=1.6 (1.1, 2.3)). Childhood abuse increased likelihood of lung disease (OR=1.5 (1.1, 2.2)). Childhood abuse independently predicted the co-occurrence of lung disease, panic attack and depression (OR=10.7 (2.2, 51.5)).

CONCLUSION

These data are preliminary, but if replicated, suggest that childhood abuse may be associated with increased risk of lung disease during adulthood, and further may reflect a shared vulnerability for the co-occurrence of lung disease, panic attack and depression in the community. Future studies are needed to further explore the mechanism of this association.

Personality disorders and posttraumatic stress disorder in motor vehicle accident survivors

This study examined the impact of a co-occurring personality disorder on the development and remission of posttraumatic stress disorder (PTSD) in 158 motor vehicle accident (MVA) survivors followed prospectively for 1 year. Participants were assessed 1 to 4 months after trauma and at 6-month and 1-year follow-up evaluations during 1991 through 1993. These archival data were analyzed in the present study. The prevalence of at least one personality disorder was 13.3%, with the majority (52.4%) presenting with obsessive-compulsive personality disorder. Persons with a personality disorder were significantly more likely to be diagnosed with PTSD at 1-year follow-up evaluation. For persons diagnosed with PTSD at the initial assessment, those with a personality disorder were significantly less likely to remit by 1 year. The presence of a preexisting personality disorder may increase the risk of chronic PTSD and impede remission.

Personality disorder comorbidity in panic disorder patients with or without current major depression

To investigate the relationship between current or past major depressive disorder (MDD) on comorbid personality disorders in patients with panic disorder, we compared the comorbidity of personality disorders using the Structured Clinical Interview for DSM-III-R personality disorders (SCID-II) in 34 panic disorder patients with current MDD (current-MD group), 21 with a history of MDD but not current MDD (past-MD group), and 32 without lifetime MDD comorbidity (non-MD group). With regard to personality disorders, patients in the current-MD group met criteria for at least one personality disorder significantly more often than patients in the past-MD group or the non-MD group (82.4% vs. 52.4% and 56.3%, respectively). The current-MD group showed statistically significantly more borderline, dependent, and obsessive-compulsive personality disorders than the past-MD group or non-MD group. With stepwise regression analyses, number of MDD episodes emerged as an indicator of the comorbidity of cluster C personality disorder and any personality disorders. Future studies should determine whether aggressive treatment of comorbid personality disorders improves the outcome (e.g., lowers the likelihood of comorbid MDD) of patients with panic disorder.

Defense styles and Personality dimensions of research subjects with anxiety and depressive disorders

We used the Bond Defense Style and Cloninger Tridimensional Personality questionnaires to assess defense styles and personality dimensions in subjects with anxiety and depressive disorders. When measured against a comparison group, maladaptive defense style scores were significantly higher in those with major depression, panic disorder, generalized anxiety disorder, and social phobia, and higher at a trend level in the subjects with obsessive-compulsive disorder and mixed anxiety and depression. However, there were no differences in adaptive defense style scores between the subjects and the comparison group. The harm avoidance personality dimension scores were significantly higher in subjects with both anxiety and depressive disorders than in the comparison group. The harm avoidance scores correlated positively with the maladaptive defense scores, but negatively with the adaptive defense scores. These findings are discussed in terms of severity of illness, level of functioning, and relationships between Axis I and II disorders.

Treating traumatized patients and victims of violence

This chapter presents a thorough exposition of treating traumatized patients and victims of violence, addressing many aspects of trauma and victimization critical to a vast proportion of the work that mental health professionals find themselves doing.

Personality profiles in patients referred for chest pain. Investigation with emphasis on panic disorder patients

Patients (N = 199) referred to cardiac outpatient investigation because of chest pain were assessed with the Personality Diagnostic Questionnaire (PDQ-4). Thirty-nine percent scored positive for any personality disorder. Borderline and avoidant personality disorders were found significantly more often in patients with panic disorder (PD) (n = 72) than in patients without PD (12.5% vs. 2.5%, 23.7% vs. 7.7%, respectively). In PD patients, the presence of any personality disorder was significantly associated with higher scores of self-reported anxiety-agoraphobia symptoms, neuroticism, and the presence of suicidal thoughts. These results suggest that personality pathology is important in a subgroup of patients presenting with chest pain and that these patients may require more extensive treatment.

The impact of comorbid mood and personality disorders in the cognitive-behavioral treatment of panic disorder

The present review examined the effect of comorbid major depressive disorder and personality disorder on the outcome of cognitive-behavioral interventions for panic disorder. Panic disorder patients often present with these comorbid conditions, but for the most part, treatment studies have paid little attention to them. Most studies on the effects of comorbidity on treatment outcome address pharmacological treatment. However, there is a growing literature on the effect of additional disorders on the outcome of cognitive-behavioral interventions for panic disorder. Findings from the studies of comorbidity with depression are equivocal, possibly reflecting inconsistencies in measurement methodology across studies. However, personality psychopathology was found to exert a detrimental effect on the outcome of cognitive-behavioral treatment for panic disorder. Further research is necessary to elucidate the impact of these concurrent conditions on cognitive-behavioral treatment for panic disorder. It is suggested that studies utilizing cognitive-behavioral treatment routinely examine the influence of comorbid conditions on treatment outcome.

Predictors of comorbid personality disorders in patients with panic disorder with agoraphobia

The aim of this study was to ascertain predictors of comorbid personality disorders in patients with panic disorder with agoraphobia (PDAG). Sixty consecutive outpatients with PDAG were administered the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II) for the purpose of diagnosing personality disorders. Logistic regressions were used to identify predictors of any comorbid personality disorder, any DSM-IV cluster A, cluster B, and cluster C personality disorder. Independent variables in these regressions were gender, age, duration of panic disorder (PD), severity of PDAG, and scores on self-report instruments that assess the patient's perception of their parents, childhood separation anxiety, and traumatic experiences. High levels of parental protection on the Parental Bonding Instrument (PBI), indicating a perception of the parents as overprotective and controlling, emerged as the only statistically significant predictor of any comorbid personality disorder. This finding was attributed to the association between parental overprotection and cluster B personality disorders, particularly borderline personality disorder. The duration of PD was a significant predictor of any cluster B and any cluster C personality disorder, suggesting that some of the cluster B and cluster C personality disorders may be a consequence of the long-lasting PDAG. Any cluster B personality disorder was also associated with younger age. In conclusion, despite a generally nonspecific nature of the relationship between parental overprotection in childhood and adult psychopathology, the findings of this study suggest some specificity for the association between parental overprotection in childhood and personality disturbance in PDAG patients, particularly cluster B personality disorders.

Prevalence, patterns and role of personality disorders in panic disorder patients with and without comorbid (lifetime) major depression

A total of 84 consecutive out-patients from the Anxiety Disorders Clinic of the Psychiatric University Hospital in Graz with a current panic disorder were diagnosed for Axis I and II disorders using the Structured Clinical Interviews for DSM-III-R. The subjects were divided into two groups: (i) 49 patients who met the criteria for panic disorder with or without agoraphobia and had no history of an affective disorder and (ii) 35 patients who had a (lifetime) comorbidity of a major depressive disorder. There was a statistically significant difference in the prevalence of personality disorders between the two groups, which was due to the higher frequency of narcissistic personality disorder in the comorbid sample. Logistic regression analysis revealed that agoraphobia and/or major depression were associated with personality disorders, thus indicating that the relationship between panic disorder, agoraphobia and major depression is not straightforward, but is strongly influenced by the presence of Axis II disorders. Furthermore, the results of this study provide support for the 'unitary position' concerning the relationship between panic disorder and depression.

Delineating a putative phobic-anxious temperament in 126 panic-agoraphobic patients: toward a rapprochement of European and US views

BACKGROUND

The current US official position, since DSM-III, is that panic attacks represent the hallmark of panic disorder and play a major role in the development of the agoraphobic syndrome. The more favoured view in the European tradition is that neurotic personality and/or prodromal features such as mild depression and excessive worries precede the illness.

METHOD

We studied 126 consecutive cases of panic disorder with or without agoraphobia by DSM-III-R criteria, evaluated by relevant structured and semi-structured interviews.

RESULTS

We provide evidence that characterological and prodromal antecedents represent a putative phobic-anxious temperamental substrate occurring in at least 30% of our sample. This temperament consists of three or more of the following traits: (1) increased sympathetic activity with repeated sporadic and isolated autonomic manifestations; (2) marked fear of illness; (3) hypersensitivity to separation; (4) difficulty to leave familiar surroundings; (5) marked need for reassurance; (6) oversensitivity to drugs and substances. Our data further suggest that these attributes are of familial origin, as a result of which the illness tends to declare itself earlier.

LIMITATION

The present investigation is largely correlational without a prospective component; however, the key validating familial data were obtained blindly.

CONCLUSION

Our data support a pathogenetic model whereby genetic diathesis unfolds from subclinical to clinical manifestations along temperamental, panic, phobic and avoidant patterns. We submit that the delineation of the phobic-anxious temperament will be useful in more completely charting the life course of the panic-agoraphobic spectrum; avoidant and dependent (Axis II) patterns appear more distal in the pathogenetic chain and, in many cases, can be conceptualized to be epiphenomenal to the disease process.

Patterns of anxiety and personality disorder comorbidity

The purpose of this study was to examine patterns of comorbidity of DSM-III-R anxiety disorders and personality disorders (PD). Two-hundred subjects were independently interviewed with the Structured Clinical Interview for DSM-III-R (SCID) and the Personality Disorder Examination (PDE) face-to-face by two experienced clinicians. One-hundred and forty-six also completed the Personality Diagnositc Questionnaire-Revised (PDQ-R). Rates of personality disorder among patients with and without anxiety disorders were determined by each of the three instruments. Comorbidity between panic disorder social phobia, obsessive-compulsive disorder and simple phobia and a conservative estimate of individual Axis II disorders was examined. Results indicate that panic disorder, either current or lifetime, is associated with borderline, avoidant, and dependent personality disorders: social phobia is associated with avoidant personality disorder, and obsessive-compulsive disorder is associated with obsessive-compulsive and avoidant personality disorders. Anxiety disorders with personality disorders are characterized by chronicity and lower levels of functioning compared with anxiety disorders without personality disorders.

Childhood trauma and personality disorder in 43 women with panic disorder

Among 43 women with panic disorder (38 with agoraphobia), 23 reported histories of childhood sexual abuse associated with high incidence of other early adverse experiences. The finding that subjects reporting childhood sexual and physical abuse were more likely to receive an Axis II diagnosis than those who did not confirms prior work.

Multiple axis-II diagnoses of personality disorder

BACKGROUND

Simultaneous diagnosis of more than one personality disorder (PD) has been termed 'comorbidity' or 'co-occurrence' implying that single diagnoses are the norm and multiple diagnoses interesting exceptions. Surveys of PD subjects in fact show 1.5-5.6 diagnoses per subject. Our study explores the hypothesis that multiple PD diagnosis is common and increases with increasingly personality disordered populations.

METHOD

The PDQ-R questionnaire was administered to three UK samples: referrals for specialist PD in-patient treatment (n = 275); high tariff offenders attending a probation centre (n = 57); and undergraduate students (n = 274).

RESULTS

Means of 6.0 (95% CI 5.7-6.3), 4.0 (3.1-5.0) and 3.4 (3.0-3.8) PDQ-R diagnoses per subject were found respectively. High rates of PD diagnosis in individual subjects suggest that multiple diagnosis is the norm rather than the exception.

CONCLUSIONS

Multiple diagnosis of PD is better construed as 'breadth' of psychopathology rather than comorbidity and is a function of sampling frame. High rates of multiple diagnoses question the interpretation of studies of any single PD. The graded construct of 'breadth' of axis-II pathology may further our understanding of PD.

Panic attacks and panic disorder in Japanese non-patient population: epidemiology and psychosocial correlates

To investigate the prevalence rates of panic disorder and panic attacks in the general population of Japan, a set of questionnaires were administered to 207 people aged 18 or over, who were then interviewed. Seven (3.4%) had experienced one or more unexpected panic attacks in their lifetime. Two subjects (1.0%) had had panic disorder (DSM-III-R), and five (2.4%) had had panic attacks not meeting the criteria for panic disorder. Seventy percent of the persons with panic disorder or panic attacks had sought medical care. There was comorbidity with agoraphobia in two cases, and with major depression in five. Harsh discipline, frequent quarrel, between parents, and serious illness before the age of 16 were more frequent in individuals suffering from panic attacks, compared to those without.