Journal of Affective Disorders, 20 (1990) 151-157 Elsevier

151

JAD 00751

Major depression with and without a coexisting anxiety disorder: social dysfunction, social integration, and personality features Thomas

Bronisch

and Heidemarie

Hecht

Max Planck Institute of Psychiatry, Munich, F.R.G. (Received 28 February 1990) (Revision received 11 June 1990) (Accepted 19 June 1990)

Twenty-two inpatients with an acute major depression without an additional lifetime DSM-III axis I diagnosis were compared with 20 inpatients suffering from an acute major depression with a coexistent anxiety disorder. The comparisons focused on social dysfunction, social support, and premorbid personality features. Characteristics of provoking life events and chronic conditions of life during the year before the index admission were analyzed exploratively. Major depressives with an anxiety disorder reported a higher number of abnormal premorbid personality traits such as neuroticism and a tendency towards social isolation; they had fewer confidants and lived alone more frequently than pure major depressives. Furthermore, pure major depressives reported more non-illness-related chronic burdening conditions during the year before the onset of depression than did major depressives with an anxiety disorder. However, there were no differences between the patient groups as to social dysfunction. The results point to fewer personal and social resources of the comorbidity group.

Key words:

Major depression; Comorbidity; morbid personality features

Anxiety disorders;

Introduction A considerable overlap exists between depression and anxiety at the symptom level as well as at the diagnostic level (Boyd et al., 1984; VanValkenburg et al., 1984; Angst and Dobler-Mikola, 1985; Hecht et al., 1989, 1990; Hiller et al., 1989). Possi-

Address for correspondence: Planck Institute of Psychiatry, Munich 40, F.R.G. 0165-0327/90/$03.50

Dr. Thomas Bronisch, Max Kraepelinstrasse 10, D-8000

0 1990 Elsevier Science Publishers

Social dysfunction;

Social support; Pre-

ble boundaries between anxiety and depressive disorders have been discussed elsewhere (see, e.g., Stavrakaki and Vargo, 1986; Klerman, 1988). Empirical research dealing with the comparison of depressive disorders with and without a coexisting anxiety disorder indicate, with one exception (Murphy et al., 1986), that comorbid major depressives are more severely impaired in terms of symptomatology and/or social functioning (VanValkenburg et al., 1984; Angst and Dobler-Mikola, 1985; Coryell et al., 1988; Hecht et al., 1990) have a worse short-term outcome and treatment re-

B.V. (Biomedical

Division)

152

sponse (VanValkenburg et al., 1984; Coryell et al., 1988) and report more stressful childhood experiences (Alnaes and Torgersen, 1988) than those suffering from a depressive disorder alone; likewise, oral personality features are more pronounced, whereas obsessive personality features are less pronounced (Alnaes and Torgersen, 1989). Using a statistical approach for defining an anxious depressive subtype of depression, Paykel (1971) found the highest scores on neuroticism for this combination. The aim of the present study was to examine the relationship between social dysfunctions and personality features in pure major depressives (PMD) and major depressives with a coexistent anxiety disorder (MDA). In contrast to our other study based on a different sample (Hecht et al., 1990) most subjects of the mixed group were suffering exclusively from anxiety and depression without further psychiatric complications such as drug abuse or alcoholism, which are often associated with severe anxiety states (Wittchen et al., 1988; Benos, 1990). Furthermore, in contrast to the studies cited above, both patient groups included only subjects without a chronic course of the depressive disorder (according to ICD-9 all patients were diagnosed as adjustment disorders by clinicians). Based upon the findings outlined above, we hypothesized that (1) MDAs report more neuroticism, less frustration tolerance and less rigidity than PMDs (Paykel, 1971; Alnaes and Torgersen, 1989) and are more introverted. The evaluation of other personality features such as ‘isolation tendency’ and ‘esoteric tendencies’ is only performed at a descriptive level; (2) MDAs are socially more handicapped in terms of social support, social functioning, and satisfaction with social life than PMDs (VanValkenburg et al., 1984; Hecht et al., 1990). Characteristics of life events and life conditions antedating the onset of depression are analyzed only exploratively. Methods Subjects

The patients were selected from a sample inpatients who had consecutively been admitted

of to

the crisis intervention ward of the Max Planck Institute of Psychiatry (MPIP) during the period from 1983 to 1984. All adult subjects (2 20 years) with a diagnosis of brief or prolonged depressive reaction according to ICD-9 (309.0 and 309.1) lasting not longer than 3 months and with an inpatient stay of at least 5 days were included in the original sample (n = 76). For this study, we have chosen from this sample only subjects who cross-sectionally fulfilled the DSM-III criteria for a major depression (but not for dysthymia) without an additional lifetime DSM-III/axis I diagnosis, i.e., pure major depression (PMD; n = 22). or those with a cross-sectional (during the last 2 weeks) diagnosis of a major depression and suffering simultaneously from an anxiety disorder according to DSM-III (MDA; n = 20). Of the 20 MDAs three patients had a panic disorder, 12 an agoraphobia, nine a simple phobia, four an obsessive compulsive disorder. and five an additional somatization disorder as a cross-sectional diagnosis. Half of the 20 patients suffering from anxiety and depression fulfilled the DSM-III criteria for at least two anxiety disorders. Both groups were comparable with regard to age at onset (PMD: X = 29.0, SD = 9.3; MDA: X = 25.7, SD = 8.5) duration of the longest depressive episode (PMD: X = 26.1 weeks, SD = 38.0; MDA: X = 41.0, SD = 60.1) as well as frequency of depressive episodes before the index manifestation (PMD: X = 3.0. SD = 2.7; MDA: ;3 = 3.6, SD = 3.9) but ~ as the higher standard deviations indicate - the MDA group seemed to be even more heterogenous regarding the course of depression. Table 1 shows the sociodemographic characteristics of PMDs and MDAs. Whereas occupational status and social class distribution were very similar in both groups, there were differences in age and sex distribution and marital status. Significantly more subjects of the MDA group were younger than 40 years (P < 0.05, Fisher’s exact test). MDAs had a higher proportion of females than PMDs, but in both groups women prevailed. Probably due to the difference in age between the groups, the proportion of persons never married was higher in MDAs than in PMDs. However, due to the small sample size, the latter differences were

153 TABLE

1

SOCIODEMOGRAPHIC MAJOR DEPRESSIVES SIVES WITH ANXIETY

CHARACTERISTICS (PMD) AND MAJOR DISORDERS (MDA)

OF PURE DEPRES-

PMD (n = 22)

MDA (n=20)

n

%

n

%

9 2 9 2 36.7 10.8

41 9 41 9

7 10 3 32.5 7.1

35 50 15 -

Male Female

I 15.

32 68

2 18

10 90

Marikzl slams Never married Married Divorced Separated

5 12 1 4

23 55 5 18

10 7 2 1

50 35 10 5

Occupational sIa1u.s Employed (full-time/part-time) Prematurely retired In training Housewife Unemployed

15 1 1 3 2

68 5 5 14 9

14 2 4 -

70 10 20 -

4 9 9

18 41 41

5 8 7

25 40 35

Age 20-29 years 30-39 years 40-49 years 50-59 years x SD SPX

Social Upper Middle Lower

class a class class class

a According

to Moore and Kleining

statistically act test).

not

significant

(1960).

(P z 0.05, Fisher’s

ex-

Control groups The patients were additionally compared with (mentally healthy) matched control subjects when analyzing the social variables. Sex and age were controlled in the analysis of social functioning. Sex, age, marital and professional status were taken into account in the life event analyses. The control groups were drawn from a representative general population sample (the Munich Follow-up Study, MFS; see Wittchen and von Zerssen, 1988).

Instruments DSM-III diagnoses were assessed on the third day (or fourth day in case of a weekend) after admission with the Diagnostic Interview Schedule (DIS, Version II, Robins et al., 1981; German version, Wittchen and Rupp, unpublished). The test-retest and the interrater reliability of the DIS can be regarded as sufficiently high (Semler and Wittchen, 1983; Wittchen, 1983). Personality. features were measured with the Munich Personality Test (MPT) (von Zerssen et al., 1988). This self-rating test consists of 42 items representing six factor analytic defined dimensions. The scales are labelled: Extraversion, Neuroticism, Frustration tolerance, Rigidity, Isolation tendency, and Esoteric tendencies. In addition, an orientation towards social norms in a subject’s attitude to self-evaluation and/or possibly also to real life is measured with a six-item ‘lie’ scale; the motivation for adequate performance on the test is represented by three items. The scores of patients with a major depression at index admission but without a major depression at the 4-6-year followup are highly correlated, with the exception of the neuroticism factor (extraversion 0.83, rigidity 0.67, frustration tolerance 0.61, esoteric tendencies 0.60, isolation tendency 0.55, neuroticism 0.37). The Social Interview Schedule (SIS; Clare and Cairns, 1978; modified German version, Hecht et al., 1987; Hecht and Wittchen, 1988) was applied to evaluate the kind and degree of social dysfunction. The SIS assesses the subject’s social situation, covering 13 social role areas (e.g., work, child-rearing) in three ‘dimensions’, viz., objective social conditions (0), management of social difficulties (M), and satisfaction with social roles (S). In contrast to the first two dimensions, the third dimension (S) is rated by the patient himself. Each rating is based on a 4-point scale (1 = no restrictions/no difficulties/very satisfied, 4 = severe restrictions/ severe difficulties/very dissatisfied). Additional items allow the construction of two social support indices which are comparable to the indices defined by Surtees (1980). ‘Close social support’ comprises the quality and number of close ties and ‘diffuse social support’ covers the quality and number of superficial contacts. High global scores indicate a lack of social support. The SIS is a cross-sectional instrument (reference

period: the last 4 weeks). The interrater reliability of the SIS can be judged as sufficiently high (Faltermaier et al., 1985). Life events during the 12 months prior to admission were assessed with the Munich Event List (MEL) (Maier-Diewald et al., unpublished). It consists of 74 items which cover 11 different social areas. Forty-seven items represent life events, 27 deal with life conditions lasting for at least 3 months. An additional 11 items are open questions. As a first step, the patients are given a list of events which helps them to remember the events and conditions experienced. As the second step, an interview is conducted about the exact definition and evaluation of the events concerned. In addition, the 74 life events and life conditions were a priori evaluated by experts as to whether the specific event/life condition could be illnessrelated or not. Not illness-related means there is no influence of a psychiatric disorder to trigger a life event or life condition (example: the death or an illness of a close relative). The MEL has been examined with regard to test-retest reliability and ‘fall-off’ rates (Wittchen et al., 1989). Both interviewers (T.B. and H.H.) had been trained in the diagnostic and social interviews (DIS, SIS, MEL) and participated in the pertinent reliability studies cited above. Statistical procedures

For statistical analysis, the &i-square technique, Fisher’s exact test, and the Mann-Whitney U-test with a correction for ties (if necessary) were used. The distribution of data on personality features is shown by boxplots (Emerson and Strenio, 1983). Sample effect sizes are expressed as biserial

TABLE

Fig. 1. Personality features of both patient groups, measured with the Munich Personality Test (MPT). E = Extraversion; N = Neuroticism; F = Frustration tolerance; R = Rigidity; Is = Isolation tendency; Es = Esoteric tendencies.

rank correlation coefficients ( rblsR) using Spearman’s formula (tests of significance are based on the rank sum test of Mann-Whitney). rbirR expresses the association between group membership and the rank values of the other variable under consideration (Bortz, 1985). A significance level of 5% was chosen for the (Y error. Taking Cohen’s (1977) conventional frame for effect sizes, a medium effect size of rbia = 0.24 becomes apparent for the given (Yand sample sizes with a probability of 1 - /3= 0.46 and a large effect size of rbis = 0.37 with a probability of 0.80. Since the non-central distribution of the U-test is not known, the a posteriori estimation of statistical power is based on the analogous parametric

2

OBJECTIVE SOCIAL CONDITIONS, SOCIAL DYSFUNCTION. SATISFACTION, INDEX ADMISSION OF BOTH PATIENTS GROUPS AND MATCHED CONTROL

Objective conditions Social dysfunction Satisfaction Close social support Diffuse social support * P s 0.05 (u-test,

AND SOCIAL SUBJECTS (C)

SUPPORT

PMD median

C median

rbd

MDA median

C median

f-b,SR

‘blSR

1.57 2.12 * 2.42 * 2.50 2.00

1.44 1.38 1.90 4.00 2.00

0.24 0.75 0.17 0.04 0.00

1.55 2.25 * 2.67 * 5.00 * 1.50

1.48 1.42 1.90 3.50 1.00

0.02 0.75 0.74 0.38 0.22

0.12 0.12 0.15 0.38 * 0.01

one-tailed).

PRIOR

PMD vs. MDA

TO

155

procedure (t-test) as suggested Westermann (1983).

by

Hager

and

Results Personality features As to the MPT profile (see Fig. 1) of both groups, MDAs showed significantly higher values for neuroticism, whereas - contrary to our expectations - the scores for frustration tolerance, extraversion, and rigidity were very similar in both groups. Furthermore, our exploratory analysis revealed (significantly) higher values for MDAs regarding isolation tendency. Social dysfunction and social support Comparing each patient group to its corresponding control group, social dysfunction and dissatisfaction with social life were strongly related to patient status, while differences between the patient groups did not emerge (Table 2). MDAs had significantly less close social support than PMDs, which was primarily due to the smaller number of confidants of the MDAs. Life events and life conditions As can be seen in Table 3, the two patient groups had experienced an almost equal number of life events and chronic life conditions during the 12 months before the index admission. Regarding chronic life conditions, long-standing marital friction dominated in both patient groups (PMD 64%; MDA 65%), whereas the control groups reported only few such conditions (C-PMD 5%, C-MDA 0%). With reference to acute life events, the end of a relationship dominated in

MDAs (MDA 55%, C-MDA 5%), whereas restrictions in leisure activities dominated in PMDs (PMD 46%, C-PMD 0%). However, when looking exclusively at the definitely non-illness-related life events and chronic conditions, we found that only PMDs reported more conditions of that kind than the control group. Most of the non-illness-related chronic conditions reported by the PMDs were related to the severe illness of a close relative (PMD 46%, C-PMD 0%). Discussion The aim of the study was to compare definitely pure depressives with depressives with a coexistent anxiety disorder which should be similar regarding the course of the depressive disorder. Due to this selection the sample sizes were small. As a consequence, the statistical power of our analyses is low which should be kept in mind when interpreting the data. Our results indicate that social dysfunction of subjects with anxiety and depression is mainly related to depression and not to anxiety or the interaction between the two, as discussed in one of our earlier papers (Hecht et al., 1989). This finding is in line with the epidemiological study by Murphy et al. (1986) but contrasts with the results of a clinical study conducted by VanValkenburg et al. (1984). In our own epidemiological study, the results were ambiguous. At the diagnostic level, we found no differences regarding social dysfunction between pure depressives and those with a coexistent anxiety disorder. However, using a dimensional approach to operationalize anxiety and depression, cases with severe depressive and at the

TABLE 3 LIFE EVENTS AND LIFE CONDITIONS Category

Overall Life events Life conditions Nor illness-related Life events Life conditions

OF BOTH PATIENT GROUPS AND MATCHED

PMD (n = 22) median

C (n = 22) median

7.0 * 15.5 * 1.0 * 1.5 *

* P 5 0.05 (U-test, two-tailed)

CONTROL

SUBJECTS

(C)

PMD vs. MDA

rb,sR

MDA (n = 20) median

C (n = 20) median

rb,sR

rb,sR

1.0 0.0

0.76 0.79

5.0 * 13.0 *

1.0 4.0

0.75 0.62

0.14 0.15

0.0 0.0

0.29 0.46

0.0 0.0

0.0 0.0

0.12 0.18

0.11 0.21

same time severe anxious symptoms were more impaired in their social functioning (Hecht et al., 1990). The contradictory results are possibly due to differences in the samples studied. In contrast to community samples or the sample studied by us, clinical samples usually include a high percentage of chronically disordered subjects. The corresponding findings that the coexistence of the two disorders is more often associated with further complications, such as the development of disorders not belonging to the affective spectrum (Hecht et al., 1990) a more chronic course of symptoms (VanValkenburg et al., 1984; Hecht et al., 1990) poorer treatment response (VanValkenburg et al., 1984) or a higher treatment rate as well as a higher rate of lifetime suicide attempts (Vollrath and Angst, 1989), indicate that the social adjustment of pure depressives improves - at least partially - with remission of symptoms, whereas social dysfunction of mixed cases and especially those suffering from panic disorder tends to persist and may get worse. Despite the fact that our study was exclusively based on non-chronic depressives, we also found some evidence for more long-standing social dysfunction associated with a mixed psychopathology: MDAs had fewer confidants, more often showed neurotic personality features, and the depressive episode of mixed cases was often precipitated by social stress brought about by the patients themselves. MDAs possibly initiate distressing life events and life conditions as a result of their more ‘neurotic life style’ and they experience less crisis support due to their more problematic interpersonal behavior. Paykel reported more neurotic features in anxious depressives, and Alnaes and Torgersen (1989) found more oral and fewer obsessive personality features of mixed subjects compared to those suffering solely from depression. These results correspond with ours concerning neuroticism. (The concepts of orality and neuroticism overlap because both include items measuring pessimism, dependence, aggression, interpersonal hypersensitivity). However, our results concerning rigidity are divergent from those reported by Alnaes and Torgersen. In the light of findings which indicate that rigidity seems to be more pronounced in patients with severer types of depression (von Zerssen et al., 1988; Bronisch and

Hecht, 1989) this finding is reasonable as our patient groups were comparable regarding the severity of depression (Hecht and Bronisch, in preparation). When interpreting comorbidity data, we should be aware of the numerous methodological problems affecting the findings, such as the use of different classification systems, the extent of coverage (diagnostic criteria included) characterizing the diagnostic instruments applied, the influence of base rates, and the severity of illness experienced by the study subjects (Frances et al., 1987). Furthermore, more information, especially about course and pathogenesis, is necessary in order to explain the frequent association between anxiety and depression References Alnaes, R. and Torgersen, S. (1988) Major depression, anxiety disorders and mixed conditions: childhood and precipitating events. Acta Psychiatr. Stand. 78, 632-638. Alnaes, R. and Torgersen, A. (1989) Clinical differentiation between major depression only, major depression with panic disorder and panic disorder only. Childhood. personality and personality disorder. Acta Psychiatr. Stand. 79. 370311. Angst, J. and Dobler-Mikola, A. (1985) The Zurich Study: VI. A continuum from depression to anxiety disorders? Eur. Arch. Psychiatry Neurol. Sci. 235. 179-186. Benos. J. (1990) Fiihrt Alkohol zu Angstsyndromen? Psycho 16. 13-19. Bortz. J. (1989) Lehrbuch der Statistik, 2nd edn. Springer. Berlin. Boyd, J.H., Burke. J.D. Jr.. Gruenberg, E., Holzer. C.E.. Rae. D.S., George, L.K., Karno, M.. Stoltzman, R., McEvoy, L. and Nestadt, G. (1984) Exclusion criteria of DSM-III: a study of co-occurrence of hierarchy-free syndromes. Arch. Gen. Psychiatry 41, 983-989. Bronisch. T. and Hecht, H. (1989) Validity of adjustment disorder, comparison with major depression. J. Affect. Disord. II, 229-236. Clare. A.W. and Cairns. V.E. (1978) Design, development and use of a standardized interview to assess social maladjustment and dysfunction in community studies. Psychol. Med. 8. 589-604. Cohen. J. (1977) Statistical Power Analysis for the Behavioral Sciences. rev. edn. Academic Press, New York, NY. Coryell, W., Endicott, J.. Andreasen, N.C., Keller, M.B., Clayton, P.J., Hirschfeld, R.M.A., Scheftner, W.A. and Winokur. G. (198X) Depression and panic attacks: the significance of overlap as reflected in follow-up and family study data. Am. J. Psychiatry 145. 293-300. Emerson, J.D. and Strenio, J. (1983) Boxplots and batch comparison. In: D.C. Hoaglin. F. Mosteller and J.W. Tukey

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Moore, H. and Kleining, G. (1960) Das soziale Selbstbild der Gesellschaftsschichten in Deutschland. KGlner Z. Soziol. Sozialpsychol. 12, 86-119. Murphy, J.M., Olivier, D.C., Sobol, A.M., Monson, R.R. and Leighton, A.H. (1986) Diagnosis and outcome: depression and anxiety in a general population,. Psychol. Med. 16, 117-126. Paykel, E.S. (1971) Classification of depressed patients: a cluster analysis derived grouping. Br. J. Psychiatry 118, 275-288. Robins, L.N., Helzer, J.E., Croughan, J. and Ratcliff, K.S. (1981) National Institute of Mental Health. Diagnostic Interview Schedule: its history, characteristics and validity. Arch. Gen. Psychiatry 38, 381-389. Semler, G. and Wittchen, H.-U. (1983) Das Diagnostic Interview Schedule: erste Ergebnisse zur Reliabilitlt und differentiellen Validit& der deutschen Fassung. In: D. Kommer and B. Rijhrle (Eds.), Gemeindepsychologische Perspektiven (3). dgvt, Tiibingen; GwG, Kiiln, pp. 109-117. Stavrakaki, C. and Vargo, B. (1986) The relationship of anxiety and depression: a review of the literature. Br. J. Psychiatry 149,7-l& Surtees, P.G. (1980) Social support, residual adversity and depressive outcome. Sot. Psychiatry 15, 71-80. VanValkenburg, C., Akiskal, H.S., Puzantian, V. and Rosenthal, T. (1984) Anxious depressions: clinical, family history, and naturalistic outcome - comparisons with panic and major depressive disorders. J. Affect. Disord. 6. 67-82. Vollrath, M. and Angst, J. (1989) Outcome of panic and depression in a seven-year follow-up: results of the Zurich study. Acta Psychiatr. Stand. 80, 591-596. Wittchen, H.-U. (1983) DIS Final Report. The German Version of the Diagnostic Interview Schedule (DIS, Version II): Reliability and Results from a General Population Survey. Report to the Division of Biometry and Epidemiology, NIMH. Wittchen, H.-U. and Rupp, H.-U. (1981) Diagnostic Interview Schedule: Deutsche Version II. Max-Planck-Institut fir Psychiatric, Munich (unpublished). Wittchen, H.-U. and von Zerssen, D. (1988) Verllufe behandelter und unbehandelter Depressionen und AngststGrungen. Springer, Berlin. Wittchen, H.-U., Essau, CA., Hecht, H., Teder, W. and Pfister, H. (1989) Reliability of life event assessments: test-retest reliability and fall-off effects of the Munich Interview for the Assessment of Life Events and Conditions. J. Affect. Disord. 16, 77-91. Zerssen, D. van, Pfister, H. and Koeller, D.-M. (1988) The Munich Personality Test (MPT): a short questionnaire for self-rating and relatives’ rating of personality traits: formal properties and clinical potential. Eur. Arch. Psychiatry Neural. Sci. 238, 73-93.