Personality Mariangela

Features Related to Generalized Disorder

Anxiety

Gasperini, Marco Battaglia, Giuseppina Diaferia, and Laura Bellodi

Forty-six patients with generalized anxiety disorder (GAD) without any other coexisting axis I diagnoses were compared with 50 control subjects for assessment on axis II. No specific personality disorder (PD) was found to be significantly associated with chronic anxiety, although the majority of anxious patients showed significantly more maladaptative traits than controls. Discriminant analysis selected a list of items able to provide a correct classification rate of 9 1% based on personality features selected in canonical function. Factor analysis indicated that personality characteristics of expectation of damage were more closely related to GAD in our sample. 0 1990 by W. B. Saunders Company.

I

n recent times, panic disorder and generalized anxiety disorder (GAD) have been outlined as two separate main categories of anxiety disorders.’ Such diagnostic categorization was mainly influenced by the conceptualization of Klein’s studies, based on pharmacological evidence.* Panic disorder was extensively studied in the last decade, and several indications, from both the pharmacological and genetic point of view,374have been collected for its validation as a separate diagnostic entity. However, GAD still appears as a less validated diagnosis. Some attempts to better characterize it, for instance genetically, have been of limited success. Twin studies failed to provide higher concordance for GAD in monozygotic than in dizygotic pairs.’ Therefore, patients with this disorder are hypothetically accepted as a heterogeneous group, since unequivocal data supporting the validity of this diagnosis are lacking, even for outcome on pharmacologic treatment.6 In order to improve the reliability of the diagnosis of GAD, and to facilitate validation studies, the revised version of DSM-III’ also introduced the more restrictive criterion of 6 months for the duration of anxious symptoms. However, a clear differentiation between GAD and, for instance, “adjustment disorder with anxious mood” is controversial.8*9 A correct assessment of the severity of stressors conditioning the development of anxious symptoms cannot always be unequivocally attempted, and therefore, the fixed limit of 6 months for the resolution of an adjustment reaction appears forced. Dealing with features associated with GAD, such as personality traits, the first studies employing assessment instruments, including the Eysenck Personality Inventory, failed to single out differences between patients with panic disorder and GAD, both appearing frequently “quiet, shy, worrisome, emotional, and highly strung.“‘O,” More recently, personality disorders were studied in patients with panic disorder,12,13 also in the light of outcome on pharmacological treatment. A high

From the Department of Sciences and Biomedical Technologies, Istituto Scientifico S. Raffaele, University of Milan School of Medicine, Milan, Italy. Address reprint requests to Laura Bellodi. M.D., Chair of Psychopathology, Ospedale S. Rafaele. 29 via Prinetti. 20127 Milano. Italy. 0 1990 by W.B. Saunders Company. 0010-440x/90/3104-0001$03.00/0 Comprehensive

Psychiatry,

Vol. 3 1, No. 4 (July/August),

1990: pp 363-368

363

364

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frequency of avoidant and dependent personality traits or disorders were found. The same evaluation applied to patients with GAD,14 indicating that roughly one third of them had a definite personality disorder (PD), and an additional one third showed some maladaptative traits, suggesting a personality predisposition to GAD. Our aim was to evaluate the relationship between personality and chronic anxiety. We compared a group of patients with a diagnosis of GAD according to DSM-III-R (without other coexisting axis I psychiatric diagnosis) with a control group. We assessed all the subjects for axis I and II disorders and single personality traits, looking for possible personality characteristics specifically linked to GAD. METHODS Our sampleincluded46 patients(36 women,20 men)withGAD who had been referred to our clinic’s outpatient service over a period of 2 years, and 50 controls (27 women, 23 men) recruited as volunteers from a sample of a general population survey ongoing at our department. This control group included employees, medical students, nurses, and relatives of medical patients from S. Raffaele Hospital. The mean age (*SD) for patients was 38 r 13.3 and 34 k 15.2 years for controls. Diagnoses on axis I were made according to DSM-III-R using the Schedule for Affective Disorders and Schizophrenia-Lifetime Version, modified for the study of Anxiety Disorders (SADS-LA). In order to have a homogeneous sample, this study included only those patients who met the criteria for GAD, without any present or past evidence for other coexisting psychiatric disorders (eg, panic disorder or mood disorders). Control subjects never met a psychiatric diagnosis in their life course. Patients and controls were assessed for axis II disorders using the Structured Interview for DSM-III Personality Disorders (SIDP),‘5 a 160-item semistructured interview. The interviews were conducted by two senior psychiatrists (M.G. and M.B.) trained in the use of this diagnostic instrument.16 Their diagnostic agreement for the presence or absence of any PD evaluated on 40 joint SIDP interviews to psychiatric outpatients showed a K coefficient of .80. The patients with GAD, all in treatment with benzodiazepines, underwent this assessment after a period of at least moderate relief from anxiety symptoms, in order to minimize the possible influence of state anxiety on personality evaluation.” During the interview, patients and controls were reminded to describe their usual and stable behavior. We analyzed the distribution of PD and the single subcriteria (or criteria for monothetic PD) identified by SIDP in patients compared with controls using the chi-square test. All 23 subcriteria of the antisocial personality disorder were excluded from the analysis, because they were not represented in our sample. In order to identify a possible cluster of traits significantly related to axis I diagnosis (GAD v control) considered as “group variable,” all 74 remaining traits from the other 10 DSM-III personality disorders were thus included in a discriminant analysis. I8We used the stepwise method and Wilk’s Lambda as the criteria for variable selection. The variables “sex” and “axis I diagnosis” and all 29 traits included in the discriminant function were successively processed by factor analysis” in order to clarify their mutual relationships.

RESULTS

Table 1 shows the distribution of personality disorder diagnoses in GAD patients and controls. All DSM-III PD were represented in both groups, with the exception of antisocial PD. Multiple PD diagnoses were present in 10.9% of patients and 10% of controls. Mixed PD was the most common diagnosis in both groups, accounting for 40% in controls and 39% in GAD patients. The low rate of subjects without any PD (26% in controls and 15% in GAD patients) appears to be an effect of the inclusiveness of the criteria applied for diagnosing mixed PD, which is to say, coming within one criterion of meeting two or more PD. All the differences in the distribution of axis II diagnoses were not statistically significant. The mean number of criteria for mixed PD in GAD subjects was 9.2 + 3.2 and in controls 7 + 2.9. This difference was significant (two-tailed Student’s t test = 2.14 P 5 ,039, df = 36).

PERSONALITY

FEATURES IN GAD

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Table 1, Distribution

of Personality

Disorders

in the Sample GAD N = 46

Controls

N = 50 Axis II Diagnosis

(23 Men, 27 Women)

Paranoid Schizoid Schizotypal Histrionic Narcissistic Borderline Antisocial Dependent Avoidant Compulsive Passive-aggressive Mixed No PD

(20 Men, 26 Women) 1 1 3 8 2 2

3 (6%) 1 (2%)

3 8 5 3

(6%) (16%) (10%) (6%) -

3 (6%) 1 (2%) 2 (4%) 2 (4%) 20 (40%) 13 (26%)

(2.2%) (2.2%) (6.5%) (17.4%) (4.3%) (4.3%)

3 (6;%) 2 (4.3%) 7 (15.2%) 1 (2.2%) 18 (39.1%) 7 (15.2%)

NOTE. Percentage values exceed 100% because of multiple diagnoses. in the two groups were not statistically significant.

The differences

for all PD

These findings indicate that none of the DSM-III PD diagnoses were specifically associated with GAD in our sample. However, we hypothesized that if any meaningful differences were able to characterize GAD patients compared with controls, they would be found in their personality traits. Results from the discriminant analysis, performed with the 74 personality traits as variables, appeared to support this hypothesis. A high degree of separation as indicated by the final Wilk’s Lambda (.33) and by canonical correlation (.81) for the first and only discriminant function was provided by the analysis. The discriminant analysis provided a satisfactory proportion (90.6%) of correct classification of subjects, according to axis I diagnosis assumed as group variable (Table 2). According to the size of correlation within the canonical function, the discriminant analysis selected 29 items (listed in Table 3) representative of personality traits that best discriminated the two groups in the study. However, only four of the 29 items were distributed with significantly higher concentration among GAD patients. They were (1) hypervigilance (23.91% GAD v 4% controls; x2 = 6.5, P 5 .01), (2) tendency to be easily slighted and quick to take offence (47.83% GAD v 26% controls; x3 = 5.50, P 5 .03) (both traits from paranoid PD), (3) suspiciousness or paranoid ideation (19.57% GAD v 2% controls; x2 = 6.15, P 5 .Ol) (from schizotypal PD), and (4) dependent, helpless, seeking reassurance (41.3% GAD v 20% controls; x2 = 4.20, P 5 .04) (from histrionic PD).

Table 2. Classification

of Cases According

to Discriminant

Analysis

Predicted Group Membership

Controls GAD

Group

No. of Cases

0 1

50 46

NOTE. Percent of grouped cases correctly

classified:

Group 0

Group 1

48 (96%) 7 (15.2%)

2 (4%) 39 (84.8%)

90.63%.

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Table 3. List of Personality Traits Included in Canonical Function Personality Disorder Passive-aggressive Borderline Paranoid Avoidant Histrionic Passive-aggressive Paranoid Dependent Borderline Compulsive Histrionic Narcissistic Passive-aggressive Paranoid Passive-aggressive Borderline Schizoid Schizotypal Histrionic Schizoid Paranoid Compulsive Histrionic Histrionic Narcissistic Narcissistic Histrionic Passive-aggressive Paranoid

A A3 A6 D 84 Bl 83 B Al A3 B3 B C A2 0 A6 B A7 Al C A8 A5 A5 A3 El E4 Bl 83 Bl

Trait

Score

Resistance to adequate performances Inappropriate, intense anger Search for confirmation of bias Desire for acceptance Helpless, dependent Procrastination Readiness to counterattack Lack of self-confidence lmpulsivity Insistence Vain and demanding Preoccupation with fantasies of success Occupational ineffectiveness Hypervigilance Persistence of passive methods Intolerance of being alone Indifference to praise/criticism Suspiciousness Self-dramatization No close friendships Pathologic jealousy Indecisiveness Irrational, angry outbursts Craving for activity and excitement Entitlement Lack of empathy Shallow, lacking genuineness Stubborness Tendency to be easily slighted

1.52 1.1 .B9 .7B .77 .72 .65 .63 .62 .60 .60 .60 .59 .55 .54 .50 .49 .44 .41 .40 .40 .3B .36 .34 .33 .33 .31 .30 .2B

With the aim of clustering the different discriminant variables into more concise and informative units, we analyzed them by the factor analysis, which also included the “diagnosis on axis I” and “sex” as variables. Table 4 shows the structure of the four factors extracted by the analysis. The axis I diagnosis is associated to the components of factor III, which included hypervigilance, suspiciousness, and tendency to be easily slighted. DISCUSSION

Definite PD were diagnosed in 46% of patients with GAD (mainly represented by cluster C disorders) and 34% of controls. This difference was not statistically significant. The distribution of definite PD among our controls is quite high. Two recent studies on nonpatient samples reported a prevalence of definite PD varying from 21%*’ to 3O%.*l The excess of PD distribution we found might be interpreted in terms of sample bias; on the other hand, the use of DSM-III criteria, standardized in the American population, may elicit some axis II diagnoses more frequently when applied to different cultural milieux. Clarification on this issue should be provided by the results from our ongoing study on an Italian population. In this study, the distribution of PD in both patients and controls selected from the general population indicates a small proportion of subjects without any PD. The most frequent axis II diagnosis is mixed PD, accounting for 40% and 39% in the two

PERSONALITY

FEATURES IN GAD

Table 4. Principal Component F 1 Coefficient .50 N8 .86 CAA .64 A8 1 .83 AC .83 AD F2 Coefficient .7 1 H82 .62 H83 .76 NH1 F3 Coefficient .64 PA2 .62 P8 1 .70 527 .56 F4 Coefficient .53 HA1 .7 1 HA5 .56 H84 .68 8A3 .51

367

From Factor Analysis

score Preoccupation with fantasies of unlimited success Resistence to demands for adequate performance Resistence expressed indirectly by procrastination Pervasive and long-standing social and occupational ineffectiveness Persistence of using passive methods score Egocentric self-indulgent Vain and demanding Entitlement score Hypervigilance Tendency to be easily slighted and quick to take offence Suspiciousness or paranoid ideation Diagnosis score Self-dramatization Irrational, angry outbursts, or tantrums Dependent, helpless, constantly seeking reassurances Inappropriate, intense anger or lack of control of anger Sex

groups. It is likely that only a portion of these subjects would receive a similar diagnosis in a usual clinical setting, where not all the personality traits are currently evaluated. The procedure of assessing all the personality traits with a structured interview thus seems to elicit a diagnosis of mixed PD more easily. No specific PD, including mixed PD, proved to be significantly associated with GAD in our sample. Nevertheless, the significantly higher number of criteria met for mixed PD in anxious patients compared with controls indicates that meeting such diagnosis with the minimum of required criteria has little meaning, while a high number of evenly scattered maladaptative traits may reflect a more severe condition. We did not find any specific axis II disorder or cluster associated to chronic anxiety. This is in disagreement with data from the literature, where avoidant and dependent PD are often reported in patients with panic disorder and GAD.13S22On the other hand, the high prevalence of avoidant and dependent PD among GAD patients has not been confirmed from large clinical population surveys.14 Moreover, it is possible that a personality assessment on patients remitting or relatively free from anxious symptoms, like those in our study, can show a dramatically reduced level of intraversion and interpersonal dependency compared with the active state of illness.‘7q23A recent study performed on subjects with social phobia suggested that some avoidant traits improved after pharmacological treatment with alprazolam, even if the traits returned to baseline levels posttreatmentS2’ Therefore, it is possible that the pharmacological treatment with benzodiazepines, including alprazolam, decreased the evidence of avoidant traits at the moment of the personality assessment in our patients. Further investigations are required to clarify the reliability in diagnosing Axis II disorders in subjects under treatment. The analyses based on PD criteria and traits, and their reciprocal relationships, were useful in identifying some personality features related to chronic anxiety, as shown by the discriminant and factor analyses. Our group of patients with GAD

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appears to be characterized by a pattern of personality including features of hypervigilance, suspiciousness, and tendency to be easily slighted, clustered in factor III. This finding is in accordance with the nature of anxiety as a state elicited by potentially threatening and conflictual conditions, and suggests a paranoid characterization for the apprehensive expectation and vigilance that are central in the psychopathology of GAD.24 REFERENCES 1. American Psychiatric Association: Diagnostic and Statistic Manual of Mental Disorders (ed 3). Washington DC, APA, 1978 2. Klein DF: Delineation of two drug responsive anxiety syndromes. Psychopharmacologia 5:397-408, 1964 3. Uhde TV, Stein MB: Biology and pharmacological treatment of panic disorder, in Hand I, Wittchen HU (eds): Panic and Phobias (~012). Berlin, FRG, Springer Verlag, 1988, pp 18-35 4. Crowe RR The genetics of panic disorder and agoraphobia, Psychiar Dev 2:171-186, 1985 5. Torgersen S: Genetic factors in anxiety disorders. Arch Gen Psychiatry 40:1085-1089, 1983 6. Kahn RJ, McNair DM, Lipman RS, et al: Imipramine and chlordiazeposside in depressive and anxiety disorders. Arch Gen Psychiatry 43:79-85, 1986 7. American Psychiatric Association: Diagnostic and Statistic Manual of Mental Disorders (ed 3, revised). Washington DC, APA, 1987 8. Andreasen NC, Hoeuk PR: The predictive value of adjustment disorders: A follow up study. Am J Psychiatry 139:584-590, 1982 9. Noyes R, Clarkson C, Crowe RR, et al: A family study of generalized anxiety disorder. Am J Psychiatry 144:1019-1024, 1987 10. Hoehn-Saric R: Comparison of generalized anxiety disorder with panic disorder patients. Psychopharmacol Bull 18:104-108, 1982 11. Anderson DJ, Noyes R, Crowe RR: A comparison of panic disorder and generalized anxiety disorder. Am J Psychiatry 141:572-575, 1981 12. Reich JH: DSM-III personality disorders and the outcome of treated panic disorder. Am J Psychiatry 145:1149-1152, 1988 13. Mavissakalian M, Hamann MS: Correlates of DSM-III personality disorders and agoraphobia. Compr Psychiatry 9:536-544, 1988 14. Koenigsberg HW, Kaplan RD, Gilmore MM, et al: The relationship between syndrome and personality disorder in DSM-III: Experience with 2,462 patients. Am J Psychiatry 142:207-212, 1985 15. Stangl D, Pfohl B, Zimmerman M, et al: A structured interview for DSM-III personality disorders. Arch Gen Psychiatry 42:591-596, 1985 16. Gasperini M, Provenza M, Ronchi P, et al: Cognitive processes and personality disorders in affective patients. J Pers Disord 3:63-71, 1989 17. Reich J, Noyes R Jr, Coryell W, et al: The effect of state anxiety on personality measurement. Am J Psychiatry 143:760-763, 1986 18. Klecka WR: Discriminant Analysis. Beverly Hills, CA, Sage Publications, 1980 19. Jae-on Kim: Factor analysis, in Nie NH, Hadlui Hull C (eds): Statistical Package for the Social Sciences. New York, NY, McGraw Hill, 1975, pp 468-516 20. Zimmerman M, Coryell W: The reliability of personality disorders diagnosis in a nonpatient sample. J Pers Disord 3:53-57, 1989 21. Reich J, Noyes R, Yates W: Alprazolam treatment of avoidant personality traits in social phobic patients. J Clin Psychiatry 50:91-95, 1989 22. Tyrer P, Casey P, Gall J: Relationship between neurosis and personality disorder. Br J Psychiatry 142:404-408, 1983 23. Reich J, Noyes R Jr, Troughton E: Dependent personality disorder associated with phobic avoidance in patients with panic disorder. Am J Psychiatry 144:323-326, 1987 24. Barlow D, Blanchard E, Vermilyea JA, et al: Generalized anxiety disorder: Description and reconceptualization. Am J Psychiatry 143:40-44, 1986

Personality features related to generalized anxiety disorder.

Forty-six patients with generalized anxiety disorder (GAD) without any other coexisting axis I diagnoses were compared with 50 control subjects for as...
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