89
Psychiatry Research, 39:89-98 Elsevier
Avoidant and Dependent Personality Traits in Relatives of Patients With Panic Disorder, Patients With Dependent Personality Disorder, and Normal Controls James Received
Reich May 25, 1990; revised version received December 27, 1990; accepled March 9, 1991.
Abstract. Psychiatric researchers have long wondered whether personality traits might predispose toward or be integral to Axis I illnesses. The question is difficult to address because acute illness can either create personality traits or distort their measurement. The present study bypassed that problem by examining personality traits in relatives of patients. Panic disorder, dependent personality disorder, and control subjects were the proband groups. A cluster of traits that appeared to reflect low social self-confidence combined with a desire for social interaction occurred significantly more often in relatives of patients in both groups. Key Words. Diagnosis,
family studies,
anxiety
disorders.
Psychiatric researchers have long been interested in the relationship between Axis I and Axis II disorders. Axis I and Axis II disorders tend to be comorbid, and research suggests that the presence of a personality disorder bodes poorly for the successful treatment of an Axis I disorder (Pilkonis and Frank, 1988; Reich, 1988, 1990). However, there are difficult methodologic problems in studying this phenomenon. The cross-sectional co-occurrence of Axis I and Axis 11 pathology could have many possible explanations: (1) The measurement of personality disorders in acutely ill patients could be an artifact created by state depression or state anxiety (cf. Hirschfeld et al., 1983; Reich et al., 1987~). (2) An illness episode might create personality traits. (3) The association might be coincidental (i.e., there is a high frequency of personality disorder in psychiatric populations and, by chance, it overlaps with various Axis I disorders). (4) Personality traits could be an integral part of the illness state. (5) The presence of certain personality disorders or traits might predispose toward the development of an Axis I disorder. The ideal approach would be to study these issues prospectively, but such studies are so expensive and time consuming that few have been performed. An alternative approach would be to study families of psychiatric patients, thereby eliminating the first three of the confounding variables listed above. The empirical literature in the area of the anxiety disorders does not provide definitive answers to the question of a relationship between Axis I and Axis II disorders, although there are suggestive findings. Cross-sectional studies show an
An earlier Association
version of this report was presented at the Annual
Meeting of the American Psychiatric in New York City on May 16, 1990. James Reich, M.D., M.P.H., M.R.C.P.. is Assistant Professor of Psychiatry. Massachusetts Mental Health Center, Harvard Medical School, Boston, MA. (Reprint requests to Dr. Reich at 138 Fuller St.,#4, Brookline, MA 02146, USA.)
0165-1781/91/$03.50
@ 1991 Elsevier Scientific
Publishers
Ireland
Ltd.
90 association between panic disorder and avoidant and dependent personality disorders (Koenigsberg et al., 1985; Mavissakalian and Harmann, 1986; Reich et al., 1987~; Reich and Troughton, 1988). There are also two reports indicating that DSM-III dependent and anxious personality disorders cluster in families (Reich, 1989~; Torgersen, 1990). Two prospective studies have looked at the effect of personality traits on the subsequent development of Axis I disorders. The first was carried out in Iceland by Nystriim and Lindegard (1975), who found that certain personality traits predisposed to the development of either anxiety or depressive disorders. In a later study, Hirschfeld et al. (1989) prospectively examined relatives at risk for depression. They found that certain personality traits predicted the development of depression in certain age groups. These two studies indicate a high likelihood of a true relationship between personality traits and the development of anxiety and depressive disorders. They do not determine, however, whether personality traits predispose toward Axis 1 disorder or whether they are merely a prodromal sign of the disorder. This article examines the relationship of DSM-III (American Psychiatric Association, 1980) avoidant and dependent personality traits and panic disorder by measuring personality traits in relatives. Two comparison groups are used to help define the outcome. The first is a group of relatives of probands with dependent personality disorder, but not panic disorder. The second is a group of relatives of probands screened to have no Axis 1 or Axis II disorders. DSM-III avoidant and dependent personality traits were chosen for study because the anxious personality cluster seems to include the “neurotic” symptoms that are prominent in many clinical conceptions and have been empirically studied by Eysenck (1947). Compulsive personality traits were excluded because factor-analytic studies indicate that compulsive traits do not cluster with anxious personality or neurotic traits (cf. van den Brink, 1989). Passiveaggressive traits were not studied because it was unclear how central they were to the anxious personality cluster and whether they could be measured reliably by the diagnostic instrument used in this study. Methods Subjects. Six groups were used in this study: three proband and three relative groups. Proband group 1 comprised patients with DSM-III-R (American Psychiatric Association, 1987) panic disorder who were recruited by advertisements for participants in a pharmacological treatment trial of panic disorder. Respondents were diagnosed using the Structured Clinical Interview for DSM-III-R Disorders (SCID; Spitzer and Williams, 1980). Patients were only accepted into that study if they met current criteria for panic disorder and were having at least three panic attacks a week. Patients were excluded for organic brain syndrome, mental disorder, current drug or alcohol retardation, any psychotic illness, obsessive-compulsive abuse, and major depression preceding the development of panic disorder or whose clinical picture dominated the symptoms of panic disorder. Subjects with current major depressive disorder were excluded from the substudy. The many exclusion criteria made this a highly homogeneous group. Proband group 2 comprised 83 randomly selected intakes to a university psychiatric outpatient clinic. The group excluded those with organic brain syndrome, mental retardation, and any psychotic illness. From this group were selected those who met the diagnosis of DSM-III dependent personality disorder on the Personality Diagnostic Questionnaire (PDQ;
91 Hyler et al., 1983) and who did not have a diagnosis of panic disorder. This group had to score at least 2 on the PDQ impairment-distress scale. Axis I diagnoses were made using the Schedule for Affective Disorders and Schizophrenia (SADS; Endicott and Spitzer, 1978). Proband group 3 was recruited from the community through advertisements for normal volunteers. Respondents were then screened with the Diagnostic Interview Schedule (DIS; Robins et al., 1981) and those with Axis 1disorders were excluded. Any who had a personality disorder on the PDQ or a score > 15on the PDQ total summary score were excluded. (A score > 50 is considered by the test developers to be highly indicative of a personality disorder.) Relatives of subjects in the three proband groups were contacted first by letter and then by telephone, and asked to participate in the study. All available first degree relatives were used. Relatives were given the SADS and were also administered the PDQ. Since state anxiety and depression have sometimes been shown to affect personality measures (Hirschfeld et al., 1983; Reich et al., 1987a), the Brief Symptom Inventory (BSI; Derogatis and Spencer, 1982) selfreport scale for anxiety and depression was given to all relative groups. All Axis I interviews and the PDQ were administered by Master’s level research assistants. Although the three proband groups were diagnosed using different Axis I measures, there are several reasons why this is not crucial. The main reason is that the Axis I diagnoses were largely restricted to panic disorder and major depression (proband groups I and 2) and absence ofany diagnosis (proband group 3). Given these restrictions, the three instruments agree with each other fairly well. Instruments. Personality disorders in patients were determined by the PDQ, a selfadministered 152-item true/false instrument that measures all I I L>SM-II/ personality disorders (and includes some self-defeating personality disorder criteria also). Test-retest reliability (kappa) for psychiatric outpatients at I month is 2 0.56 for paranoid, schizotypal, antisocial, borderline, avoidant, and compulsive personality disorder (Hurt et al., 1984). Preliminary work with 2-month test-retest on the PDQ gave kappas of 0.80 for the anxious personality disorder cluster, 0.75 for dependent personality, and 0.50 for avoidant personality (Reich, 1989b). The specific personality criteria of interest were those items in the DSM-III criteria for avoidant and dependent personality. (See Table I for definitions of criteria and l-week test-retest kappas for 20 stable psychiatric outpatients.) The choice of a self-report instrument could be criticized on the grounds of lesser reliability or validity than an interview instrument. There are several indications of the PDQ’s usefulness. Test-retest reliabilities were performed on panic disorder patients before and after effective treatment-a fairly stringent test of reliability. The PDQ has been used in a number of studies that reported results in line with previous studies or concurrently used personality measures (Mavissakalian and Harmann, 1986; Pfohl et al., 1987; Reich, and Troughton, 1988; Reich, 19896; Reich et al., 1989). (These studies were performed by various investigators on at least five different study populations.) Although there is evidence that the PDQ does not agree highly with unstructured clinical ratings (Hyler et al., 1989), many structured measures do not show such agreement. In fact, most structured measures of psychopathology were designed to serve as remedies for low levels of agreement between clinicians. However, data are now available indicating that the PDQ may agree as well with interview Axis II measures as they agree with each other. Kappas of agreement for dependent personality disorder between the PDQ and the SCID-II, PDQ and PDE (Personality Disorder Examination), and SCID-II and PDE were 0.62, 0.56, and 0.60, respectively. Corresponding scores for avoidant personality disorder were 0.70,0.56, and 0.56 (Skodal et al., 1988). (The SCID-II and the PDEare standardized DSM-III Axis II interview instruments.) When the PDQ diagnosis for dependent personality disorder was compared to a “L.E.A.D. standard,” predictive power positive was 0.57 and predictive power negative was 0.97. For avoidant personality, corresponding scores were 0.64 and 0.93 (Skodal et al., 1988). The L.E.A.D. standard refers to “longitudinal, expert opinion, all-data” and was developed by R. Spitzer, M.D. Although these values are not perfect, they are as high as those for other accepted standardized Axis II measures.
92 Table 1. Individual criteria for DSM-III avoidant and dependent personality disorders and their l-week test-retest kappas in 20 stable nonpsychotic psychiatric outpatients Code symbol
DSM-III criteria
Definition
Kappa
A
Avoidant
A
Hypersensitivity to rejection; apprehensively alert to signs of social derogation, interprets mnocuous events as ridicule.
0.75
B
Avoidant
B
Unwillrng to enter into relationships unless given unusually strong guarantees of uncritical acceptance.
0.85
C
Avoidant
C
Social withdrawal; distances self from close personal attachments, engages in penpheral social & vocational roles.
0.75
D
Avordant
D
Desire for affectron
0.85
& acceptance.
E
Avoidant E Dependent C
Low self-esteem
F
Dependent
A
Passively allows others to assume responsibility for major areas of life because of inability to function independently.
0.65
G
Dependent
B
Subordinates own needs to those of person on whom he or she depends In order to avoid possibility of having to rely on self.
0.80
Note. The l-week crlterlon.
0.70
kappas refer to the specific
Personality
Diagnostic
Questionnaire
questions
relevant to each
Procedures. Subject recruitment was as follows: For the random outpatient sample. patients were asked to participate after their intake interviews if they appeared to meet criteria. They would then be interviewed and asked to fill out questionnaires in the next 7 days. (Usually they were not on medications or on them only a few days.) Panic patients were recruited predominantly by newspaper advertising. They responded to a telephone number given in the newspaper and, if they passed a preliminary telephone screening, were brought in for a SCID interview to determine their eligibility for the study. Those eligible received the PDQ within I week of study entry (before they were on medication). Controls were recruited by advertising. They were screened initially over the telephone to eliminate those with histories of psychiatric Illness. Those who passed this screening were brought in for testing to see if they met criteria for the normal control group. Relatives were first contacted by mail and then followed up by telephone. Approximately 7OYcof relatives contacted agreed to take part in the study. First degree relatives who agreed to participate were administered the interviews and questionnaires. The study groups were drawn from three different studies, but certain training procedures remained constant throughout. All interviewers were Master’s level and were trained by didactic sessions, training tapes, and joint interviews until adequate reliability on interviews was achieved. Since the PDQ is a self-report measure, its administration only required that interviewers know how to answer questions from subjects appropriately. Care was taken to ensure that interviews with relatives were carried out without knowledge of the diagnostic status of the proband groups. Analysis.
avoidant
The major goal was to examine the differences (if any) in the prevalence of DSM-III and dependent personality traits in relatives of different proband groups. The age, sex
93 ratio, and BSl anxiety scores of the relatives of normal and dependent personality disorder probands did not differ significantly, so results for these two groups of relatives were compared directly using Fisher’s exact test. Since personality traits in the anxious cluster can be familial (Reich, 1989~; Torgersen, 1990) as can normal personality traits (Bouchard et al., 1990) analyses comparing relatives of panic patients with relatives of controls were adjusted for the presence of personality traits in panic probands by using the Mantel-Hazel technique. The Mantel-Hazel technique controls for an undesired variable effect by stratifying the analysis. For example. a researcher might wish to compare a population that drank alcohol with one that did not on the outcome of a certain type of cancer. Unfortunately, members of both groups smoke, and it is known that smoking influences the outcome of this type of cancer. The Mantel-Hazel technique could stratify the analysis by degree of smoking and produce a statistical result reflecting only the effect of alcohol and not that of smoking. In the present analysis, the results are free of the effect of panic probands having avoidant or dependent personality traits. There were many different analyses that varied only in adjustment for a specific variable (e.g., state anxiety, state depression, and presence or absence of acute illness in relatives). Since these adjustments did not alter the results, the simplest appropriate analyses are reported here for the sake of clarity. Differences between combinations of avoidant and dependent personality traits were not examined because the samples were too small. To prevent spurious results due to excessive testing, a significance level of 0.02 was chosen (one spurious result would be expected
at the 0.02 level out of 50 tests).
Results Tables 2 and 3 provide demographic and diagnostic information for the proband groups. Their composition is what would be expected on the basis of the inclusion and exclusion criteria used. Table 4 gives the sex, age, state anxiety scores, and state depression scores for the three relative groups, which are not significantly different. The state anxiety and depression scores are within the normal range. Table 5 gives the Axis I psychiatric diagnoses of the relative groups-again no major surprises.
Table 2. Demographic
description
of proband
groups Grows
Panic
Variables Sample size
71
Mean age (SD), in years % Female
36.4 57.7
Dependent PD 17
(10.21
35.9 64.7
Controls 11
(11.0)
37.6 54.5
(4.31
Nofe. PD = personality disorder.
Table 6 compares the relatives of the control group with the relatives of the dependent personality and panic patients. (Findings for the relatives of the panic group were analyzed using the Mantel-Hazel statistic to adjust for the presence of avoidant and dependent personality traits in probands.) Here there are significant increases in traits D (“desire for affection and acceptance”) and G (“subordinates own needs to those of another person”; see Table 1 for exact wording) when relatives of both patient groups are compared with relatives of controls. A significantly higher level of trait B (“unwilling to enter into relationships unless given unusually strong guarantees of uncritical acceptance”) is also seen in relatives of panic patients compared with relatives of controls. (Although the numbers are in a similar direction for the relatives of dependent personality disorder patients VS. relatives of controls, the
94
difference does not reach significance.) There were no differences in frequency of avoidant and dependent personality traits between relatives of panic patients and relatives of dependent personality disorder patients. Table 3. Current
Axis I and Axis II diagnoses
of proband
groups
(O/O)
Groups Panic (n = 71)
Dependent PD (n = 17)
Controls (n = 11)
I (current)1
Axis
0
0
64.7
0
5.9
0
4.2
17.6
0
0
11.8
0
Drug abuse
0
11.8
0
Social
1.4
11.8
0
Paranoid
4.2
5.8
0
Schizoid
0
5.8
0
33.8
11.8
0
0
0
Panic disorder
100
Major depression
03
Bipolar1
0
Generalized Alcohol
anxiety
abuse phobia
Axis 112
Schizotypal Narcissistic
1.4
Histrionic
16.9
58.8
0
Borderline
16.9
47.1
0
1.4
5.8
0
Avoidant
Antisocial
14.1
36.3
0
Dependent
26.7
100
0
Passive-aggressive
1.4
5.9
0
Obsessive-compulsive
8.4
5.9
0
Note.
PD
=
personalfty disorder
1. Diagnoses for dependent group were made usfng the Schedule for Affectives Disorders and Schizophrenia; dtagnoses for the panic and control groups were made using the Diagnostic Interview Schedule. Master’s level mtervtewers were used. 2 Personality diagnoses were performed using the Personality Diagnostic Questionnaire, rncluding its impairment cnteria as part of the dragnosis. 3. Although not current, 28% had a past hrstory of major depresston.
Table 4. Age, sex, and state anxiety and depression
scores for relative groups
Groups Variables Sample
Panic
size
158
Mean age (SD), in years
40.5
% Female
55
BSI anxiety
(SOI
BSI depression
(SDI
Note. PD = personality
disorder.
Dependent PD 45
115.4)
42.5
Controls 51
(16.3)
51
38.9
117.71
49.0
3.4
(2.61
3.4
(2.55)
1.9
12.1 I
3.6
13.61
3.5
12.49)
1.8
12.4~
BSI = Brief Symptom
Inventory
95 Table
5. Current
Axis I diagnoses
in relative groups Groups
Panic
(n = 158)
Dependent PD (n = 45)
Controls (n = 51)
Major depression
2.5
11.1
0
Panic
7.6
0
0
5.1
6.6
0
Alcoholism
5.1
4.4
7.8
Drug abuse
3.8
4.4
7.8
Obsessive-comoulsive
0.6
0
0
Axis I
Generalized
anxiety
Note. PD = personality disorder
Table 6. DSM-III groups (O/O)
Criteria
avoidant Panic disorder (n = 158)
and dependent
personality
MantelHazel statistic
traits
in relative
Dependent personality ln = 45)
Control group (n = 51) 15.7
A
38.0
3.6
28.9
B
25.31
5.5
17.8
9.8
C
26.5
4.2
26.7
13.7
D
88.02
84.43
25.5
E
21.5
1.3
22.2
7.8
F
32.3
1.4
28.9
21.6
G
47.54
a.8
46.75
21.6
75.5
Note. Since age and sax ratios did not differ, relatives of patients with dependent personality disorder and relatives of control subjects were compared directly using Fisher’s exact test. Adjustments for proband personality traits were made in the panic disorder vs. control comparisons by using the Mantel-Hazel technique. A probability level of p < 0.02 was used as a cutoff to prevent spurious findings secondary to excessive testrng. All percentages are presented in their uncorrected form for ease of reader understanding. Levels of anxiety and depression were measured dimensronally and did not differ significantly between relative groups. When they were adjusted for (data not showni. there was no change m the results. The numbers in column 3 are the Mantel-Hazel statistic values for the panic disorder analyses. They are neither percentages of the population wrth these traits nor corrected percentages of the population with these traits. 1. 2. 3. 4. 5.
p p p p p
< < < c
. 145435 441,
1988.
Reich, J. DSM-III can Journal
personality
disorders
of Psychiatry,
145:1149-l Reich, J. Familiality of DSM-III Mental Disease, 177:96-101, 1989a.
Reich, J. Update on instruments Journal
of Nervous
and Mental
and the outcome
of treated panic disorder.
Ameri-
153, 1988.
personality
clusters.
DSM-III and DSM-III1771366-37 1, 19896.
to measure Disease,
disorder
Journal
of Nervous
R personality
and
disorders.
Reich, J. The effect of personality on the outcome of panic disorder patients treated with placebo. Journal of Nervous and Mental Disease, 178:699-703, 1990. Reich, J.; Noyes, R.; Hirschfeld, R.; Coryell, W.; and O’Gorman, T. State effects on personality measures in depressed and panic patients. American JournaiofPsychiatry, 144: 18 l187, 1987a. Reich, J.; Noyes, R.; and Troughton, E. Comparison of instruments to measure DSM-III, Axis Il. In: Millon, T., ed. Conference on the Millon ClinicaI Inventories. March 8, 1986. Minnetonka, MN: National Computer Systems, 19876. pp. 223-234. Reich, J.; Noyes, R.; and Troughton, E. Dependent personality in panic patients with phobic avoidance. American Journal of Psychiatry, 144:323-327, 1987~. Reich, J., and Troughton, E. Frequency of personality disorders in panic, outpatient, and normal populations. Journal of Psychiatric Research, 26:89-100, 1988. Reich, J.; Yates, W.; and Nduaguba, M. Prevalence of DSM-III personality disorders in the community. Social Psychiatry, 24: 12-16, 1989. Robins, L.N.; Helzer, J.E.; Croughan, J.; and Ratcliff, K.L. National Institute of Mental Health Diagnostic Interview Schedule: Its history, characteristics and validity. Archives of General
Psychiatry,
38:38 l-389,
198
I.
Skodol, A.W.; Rosnick, L.; Kellman, D.; Oldham, J.M.; and Hyler, S.E. The validity of structured assessments of Axis II. Presented at Symposium 57, “Axis 11-New Perspectives on Association, Montreal, Validity,” at the 141st Annual Meeting of the American Psychiatric Que., Canada, May 11, 1988. Spitzer, R.L., and Williams, J.B. Structured Clinical Interviewfor DSM-Ill Disorders. New York: N.Y. State Psychiatric Institute, 1980. Torgersen, S. Etiologic factors in personality disorders. Presented at the Regional Symposium of the World Psychiatric Association, Oslo, Norway, August 25, 1990. van den Brink, W. Categorical versus dimensional approaches to DSM-III personality disorders. In: Stefanis, C.N.; Solidatos, C.R.; and Rabavilas, A.D., eds. Abstracts From the VIIIth International World Congress of Psychiatry. International Congress Series 899. Amsterdam: Excerpta Medica, 1989. p. 337. Widiger, T.A., and Freeman, K.G. Personality lnterview Questionnaire: 11. Reliability and methodologic issues. Presented at the National Institute of Mental Health Workshop on Assessment of Personality Disorders, Bethesda, MD, November 14, 1988.
Psychiatry Research, 39:89-98 Elsevier
Avoidant and Dependent Personality Traits in Relatives of Patients With Panic Disorder, Patients With Dependent Personality Disorder, and Normal Controls James Received
Reich May 25, 1990; revised version received December 27, 1990; accepled March 9, 1991.
Abstract. Psychiatric researchers have long wondered whether personality traits might predispose toward or be integral to Axis I illnesses. The question is difficult to address because acute illness can either create personality traits or distort their measurement. The present study bypassed that problem by examining personality traits in relatives of patients. Panic disorder, dependent personality disorder, and control subjects were the proband groups. A cluster of traits that appeared to reflect low social self-confidence combined with a desire for social interaction occurred significantly more often in relatives of patients in both groups. Key Words. Diagnosis,
family studies,
anxiety
disorders.
Psychiatric researchers have long been interested in the relationship between Axis I and Axis II disorders. Axis I and Axis II disorders tend to be comorbid, and research suggests that the presence of a personality disorder bodes poorly for the successful treatment of an Axis I disorder (Pilkonis and Frank, 1988; Reich, 1988, 1990). However, there are difficult methodologic problems in studying this phenomenon. The cross-sectional co-occurrence of Axis I and Axis 11 pathology could have many possible explanations: (1) The measurement of personality disorders in acutely ill patients could be an artifact created by state depression or state anxiety (cf. Hirschfeld et al., 1983; Reich et al., 1987~). (2) An illness episode might create personality traits. (3) The association might be coincidental (i.e., there is a high frequency of personality disorder in psychiatric populations and, by chance, it overlaps with various Axis I disorders). (4) Personality traits could be an integral part of the illness state. (5) The presence of certain personality disorders or traits might predispose toward the development of an Axis I disorder. The ideal approach would be to study these issues prospectively, but such studies are so expensive and time consuming that few have been performed. An alternative approach would be to study families of psychiatric patients, thereby eliminating the first three of the confounding variables listed above. The empirical literature in the area of the anxiety disorders does not provide definitive answers to the question of a relationship between Axis I and Axis II disorders, although there are suggestive findings. Cross-sectional studies show an
An earlier Association
version of this report was presented at the Annual
Meeting of the American Psychiatric in New York City on May 16, 1990. James Reich, M.D., M.P.H., M.R.C.P.. is Assistant Professor of Psychiatry. Massachusetts Mental Health Center, Harvard Medical School, Boston, MA. (Reprint requests to Dr. Reich at 138 Fuller St.,#4, Brookline, MA 02146, USA.)
0165-1781/91/$03.50
@ 1991 Elsevier Scientific
Publishers
Ireland
Ltd.
90 association between panic disorder and avoidant and dependent personality disorders (Koenigsberg et al., 1985; Mavissakalian and Harmann, 1986; Reich et al., 1987~; Reich and Troughton, 1988). There are also two reports indicating that DSM-III dependent and anxious personality disorders cluster in families (Reich, 1989~; Torgersen, 1990). Two prospective studies have looked at the effect of personality traits on the subsequent development of Axis I disorders. The first was carried out in Iceland by Nystriim and Lindegard (1975), who found that certain personality traits predisposed to the development of either anxiety or depressive disorders. In a later study, Hirschfeld et al. (1989) prospectively examined relatives at risk for depression. They found that certain personality traits predicted the development of depression in certain age groups. These two studies indicate a high likelihood of a true relationship between personality traits and the development of anxiety and depressive disorders. They do not determine, however, whether personality traits predispose toward Axis 1 disorder or whether they are merely a prodromal sign of the disorder. This article examines the relationship of DSM-III (American Psychiatric Association, 1980) avoidant and dependent personality traits and panic disorder by measuring personality traits in relatives. Two comparison groups are used to help define the outcome. The first is a group of relatives of probands with dependent personality disorder, but not panic disorder. The second is a group of relatives of probands screened to have no Axis 1 or Axis II disorders. DSM-III avoidant and dependent personality traits were chosen for study because the anxious personality cluster seems to include the “neurotic” symptoms that are prominent in many clinical conceptions and have been empirically studied by Eysenck (1947). Compulsive personality traits were excluded because factor-analytic studies indicate that compulsive traits do not cluster with anxious personality or neurotic traits (cf. van den Brink, 1989). Passiveaggressive traits were not studied because it was unclear how central they were to the anxious personality cluster and whether they could be measured reliably by the diagnostic instrument used in this study. Methods Subjects. Six groups were used in this study: three proband and three relative groups. Proband group 1 comprised patients with DSM-III-R (American Psychiatric Association, 1987) panic disorder who were recruited by advertisements for participants in a pharmacological treatment trial of panic disorder. Respondents were diagnosed using the Structured Clinical Interview for DSM-III-R Disorders (SCID; Spitzer and Williams, 1980). Patients were only accepted into that study if they met current criteria for panic disorder and were having at least three panic attacks a week. Patients were excluded for organic brain syndrome, mental disorder, current drug or alcohol retardation, any psychotic illness, obsessive-compulsive abuse, and major depression preceding the development of panic disorder or whose clinical picture dominated the symptoms of panic disorder. Subjects with current major depressive disorder were excluded from the substudy. The many exclusion criteria made this a highly homogeneous group. Proband group 2 comprised 83 randomly selected intakes to a university psychiatric outpatient clinic. The group excluded those with organic brain syndrome, mental retardation, and any psychotic illness. From this group were selected those who met the diagnosis of DSM-III dependent personality disorder on the Personality Diagnostic Questionnaire (PDQ;
91 Hyler et al., 1983) and who did not have a diagnosis of panic disorder. This group had to score at least 2 on the PDQ impairment-distress scale. Axis I diagnoses were made using the Schedule for Affective Disorders and Schizophrenia (SADS; Endicott and Spitzer, 1978). Proband group 3 was recruited from the community through advertisements for normal volunteers. Respondents were then screened with the Diagnostic Interview Schedule (DIS; Robins et al., 1981) and those with Axis 1disorders were excluded. Any who had a personality disorder on the PDQ or a score > 15on the PDQ total summary score were excluded. (A score > 50 is considered by the test developers to be highly indicative of a personality disorder.) Relatives of subjects in the three proband groups were contacted first by letter and then by telephone, and asked to participate in the study. All available first degree relatives were used. Relatives were given the SADS and were also administered the PDQ. Since state anxiety and depression have sometimes been shown to affect personality measures (Hirschfeld et al., 1983; Reich et al., 1987a), the Brief Symptom Inventory (BSI; Derogatis and Spencer, 1982) selfreport scale for anxiety and depression was given to all relative groups. All Axis I interviews and the PDQ were administered by Master’s level research assistants. Although the three proband groups were diagnosed using different Axis I measures, there are several reasons why this is not crucial. The main reason is that the Axis I diagnoses were largely restricted to panic disorder and major depression (proband groups I and 2) and absence ofany diagnosis (proband group 3). Given these restrictions, the three instruments agree with each other fairly well. Instruments. Personality disorders in patients were determined by the PDQ, a selfadministered 152-item true/false instrument that measures all I I L>SM-II/ personality disorders (and includes some self-defeating personality disorder criteria also). Test-retest reliability (kappa) for psychiatric outpatients at I month is 2 0.56 for paranoid, schizotypal, antisocial, borderline, avoidant, and compulsive personality disorder (Hurt et al., 1984). Preliminary work with 2-month test-retest on the PDQ gave kappas of 0.80 for the anxious personality disorder cluster, 0.75 for dependent personality, and 0.50 for avoidant personality (Reich, 1989b). The specific personality criteria of interest were those items in the DSM-III criteria for avoidant and dependent personality. (See Table I for definitions of criteria and l-week test-retest kappas for 20 stable psychiatric outpatients.) The choice of a self-report instrument could be criticized on the grounds of lesser reliability or validity than an interview instrument. There are several indications of the PDQ’s usefulness. Test-retest reliabilities were performed on panic disorder patients before and after effective treatment-a fairly stringent test of reliability. The PDQ has been used in a number of studies that reported results in line with previous studies or concurrently used personality measures (Mavissakalian and Harmann, 1986; Pfohl et al., 1987; Reich, and Troughton, 1988; Reich, 19896; Reich et al., 1989). (These studies were performed by various investigators on at least five different study populations.) Although there is evidence that the PDQ does not agree highly with unstructured clinical ratings (Hyler et al., 1989), many structured measures do not show such agreement. In fact, most structured measures of psychopathology were designed to serve as remedies for low levels of agreement between clinicians. However, data are now available indicating that the PDQ may agree as well with interview Axis II measures as they agree with each other. Kappas of agreement for dependent personality disorder between the PDQ and the SCID-II, PDQ and PDE (Personality Disorder Examination), and SCID-II and PDE were 0.62, 0.56, and 0.60, respectively. Corresponding scores for avoidant personality disorder were 0.70,0.56, and 0.56 (Skodal et al., 1988). (The SCID-II and the PDEare standardized DSM-III Axis II interview instruments.) When the PDQ diagnosis for dependent personality disorder was compared to a “L.E.A.D. standard,” predictive power positive was 0.57 and predictive power negative was 0.97. For avoidant personality, corresponding scores were 0.64 and 0.93 (Skodal et al., 1988). The L.E.A.D. standard refers to “longitudinal, expert opinion, all-data” and was developed by R. Spitzer, M.D. Although these values are not perfect, they are as high as those for other accepted standardized Axis II measures.
92 Table 1. Individual criteria for DSM-III avoidant and dependent personality disorders and their l-week test-retest kappas in 20 stable nonpsychotic psychiatric outpatients Code symbol
DSM-III criteria
Definition
Kappa
A
Avoidant
A
Hypersensitivity to rejection; apprehensively alert to signs of social derogation, interprets mnocuous events as ridicule.
0.75
B
Avoidant
B
Unwillrng to enter into relationships unless given unusually strong guarantees of uncritical acceptance.
0.85
C
Avoidant
C
Social withdrawal; distances self from close personal attachments, engages in penpheral social & vocational roles.
0.75
D
Avordant
D
Desire for affectron
0.85
& acceptance.
E
Avoidant E Dependent C
Low self-esteem
F
Dependent
A
Passively allows others to assume responsibility for major areas of life because of inability to function independently.
0.65
G
Dependent
B
Subordinates own needs to those of person on whom he or she depends In order to avoid possibility of having to rely on self.
0.80
Note. The l-week crlterlon.
0.70
kappas refer to the specific
Personality
Diagnostic
Questionnaire
questions
relevant to each
Procedures. Subject recruitment was as follows: For the random outpatient sample. patients were asked to participate after their intake interviews if they appeared to meet criteria. They would then be interviewed and asked to fill out questionnaires in the next 7 days. (Usually they were not on medications or on them only a few days.) Panic patients were recruited predominantly by newspaper advertising. They responded to a telephone number given in the newspaper and, if they passed a preliminary telephone screening, were brought in for a SCID interview to determine their eligibility for the study. Those eligible received the PDQ within I week of study entry (before they were on medication). Controls were recruited by advertising. They were screened initially over the telephone to eliminate those with histories of psychiatric Illness. Those who passed this screening were brought in for testing to see if they met criteria for the normal control group. Relatives were first contacted by mail and then followed up by telephone. Approximately 7OYcof relatives contacted agreed to take part in the study. First degree relatives who agreed to participate were administered the interviews and questionnaires. The study groups were drawn from three different studies, but certain training procedures remained constant throughout. All interviewers were Master’s level and were trained by didactic sessions, training tapes, and joint interviews until adequate reliability on interviews was achieved. Since the PDQ is a self-report measure, its administration only required that interviewers know how to answer questions from subjects appropriately. Care was taken to ensure that interviews with relatives were carried out without knowledge of the diagnostic status of the proband groups. Analysis.
avoidant
The major goal was to examine the differences (if any) in the prevalence of DSM-III and dependent personality traits in relatives of different proband groups. The age, sex
93 ratio, and BSl anxiety scores of the relatives of normal and dependent personality disorder probands did not differ significantly, so results for these two groups of relatives were compared directly using Fisher’s exact test. Since personality traits in the anxious cluster can be familial (Reich, 1989~; Torgersen, 1990) as can normal personality traits (Bouchard et al., 1990) analyses comparing relatives of panic patients with relatives of controls were adjusted for the presence of personality traits in panic probands by using the Mantel-Hazel technique. The Mantel-Hazel technique controls for an undesired variable effect by stratifying the analysis. For example. a researcher might wish to compare a population that drank alcohol with one that did not on the outcome of a certain type of cancer. Unfortunately, members of both groups smoke, and it is known that smoking influences the outcome of this type of cancer. The Mantel-Hazel technique could stratify the analysis by degree of smoking and produce a statistical result reflecting only the effect of alcohol and not that of smoking. In the present analysis, the results are free of the effect of panic probands having avoidant or dependent personality traits. There were many different analyses that varied only in adjustment for a specific variable (e.g., state anxiety, state depression, and presence or absence of acute illness in relatives). Since these adjustments did not alter the results, the simplest appropriate analyses are reported here for the sake of clarity. Differences between combinations of avoidant and dependent personality traits were not examined because the samples were too small. To prevent spurious results due to excessive testing, a significance level of 0.02 was chosen (one spurious result would be expected
at the 0.02 level out of 50 tests).
Results Tables 2 and 3 provide demographic and diagnostic information for the proband groups. Their composition is what would be expected on the basis of the inclusion and exclusion criteria used. Table 4 gives the sex, age, state anxiety scores, and state depression scores for the three relative groups, which are not significantly different. The state anxiety and depression scores are within the normal range. Table 5 gives the Axis I psychiatric diagnoses of the relative groups-again no major surprises.
Table 2. Demographic
description
of proband
groups Grows
Panic
Variables Sample size
71
Mean age (SD), in years % Female
36.4 57.7
Dependent PD 17
(10.21
35.9 64.7
Controls 11
(11.0)
37.6 54.5
(4.31
Nofe. PD = personality disorder.
Table 6 compares the relatives of the control group with the relatives of the dependent personality and panic patients. (Findings for the relatives of the panic group were analyzed using the Mantel-Hazel statistic to adjust for the presence of avoidant and dependent personality traits in probands.) Here there are significant increases in traits D (“desire for affection and acceptance”) and G (“subordinates own needs to those of another person”; see Table 1 for exact wording) when relatives of both patient groups are compared with relatives of controls. A significantly higher level of trait B (“unwilling to enter into relationships unless given unusually strong guarantees of uncritical acceptance”) is also seen in relatives of panic patients compared with relatives of controls. (Although the numbers are in a similar direction for the relatives of dependent personality disorder patients VS. relatives of controls, the
94
difference does not reach significance.) There were no differences in frequency of avoidant and dependent personality traits between relatives of panic patients and relatives of dependent personality disorder patients. Table 3. Current
Axis I and Axis II diagnoses
of proband
groups
(O/O)
Groups Panic (n = 71)
Dependent PD (n = 17)
Controls (n = 11)
I (current)1
Axis
0
0
64.7
0
5.9
0
4.2
17.6
0
0
11.8
0
Drug abuse
0
11.8
0
Social
1.4
11.8
0
Paranoid
4.2
5.8
0
Schizoid
0
5.8
0
33.8
11.8
0
0
0
Panic disorder
100
Major depression
03
Bipolar1
0
Generalized Alcohol
anxiety
abuse phobia
Axis 112
Schizotypal Narcissistic
1.4
Histrionic
16.9
58.8
0
Borderline
16.9
47.1
0
1.4
5.8
0
Avoidant
Antisocial
14.1
36.3
0
Dependent
26.7
100
0
Passive-aggressive
1.4
5.9
0
Obsessive-compulsive
8.4
5.9
0
Note.
PD
=
personalfty disorder
1. Diagnoses for dependent group were made usfng the Schedule for Affectives Disorders and Schizophrenia; dtagnoses for the panic and control groups were made using the Diagnostic Interview Schedule. Master’s level mtervtewers were used. 2 Personality diagnoses were performed using the Personality Diagnostic Questionnaire, rncluding its impairment cnteria as part of the dragnosis. 3. Although not current, 28% had a past hrstory of major depresston.
Table 4. Age, sex, and state anxiety and depression
scores for relative groups
Groups Variables Sample
Panic
size
158
Mean age (SD), in years
40.5
% Female
55
BSI anxiety
(SOI
BSI depression
(SDI
Note. PD = personality
disorder.
Dependent PD 45
115.4)
42.5
Controls 51
(16.3)
51
38.9
117.71
49.0
3.4
(2.61
3.4
(2.55)
1.9
12.1 I
3.6
13.61
3.5
12.49)
1.8
12.4~
BSI = Brief Symptom
Inventory
95 Table
5. Current
Axis I diagnoses
in relative groups Groups
Panic
(n = 158)
Dependent PD (n = 45)
Controls (n = 51)
Major depression
2.5
11.1
0
Panic
7.6
0
0
5.1
6.6
0
Alcoholism
5.1
4.4
7.8
Drug abuse
3.8
4.4
7.8
Obsessive-comoulsive
0.6
0
0
Axis I
Generalized
anxiety
Note. PD = personality disorder
Table 6. DSM-III groups (O/O)
Criteria
avoidant Panic disorder (n = 158)
and dependent
personality
MantelHazel statistic
traits
in relative
Dependent personality ln = 45)
Control group (n = 51) 15.7
A
38.0
3.6
28.9
B
25.31
5.5
17.8
9.8
C
26.5
4.2
26.7
13.7
D
88.02
84.43
25.5
E
21.5
1.3
22.2
7.8
F
32.3
1.4
28.9
21.6
G
47.54
a.8
46.75
21.6
75.5
Note. Since age and sax ratios did not differ, relatives of patients with dependent personality disorder and relatives of control subjects were compared directly using Fisher’s exact test. Adjustments for proband personality traits were made in the panic disorder vs. control comparisons by using the Mantel-Hazel technique. A probability level of p < 0.02 was used as a cutoff to prevent spurious findings secondary to excessive testrng. All percentages are presented in their uncorrected form for ease of reader understanding. Levels of anxiety and depression were measured dimensronally and did not differ significantly between relative groups. When they were adjusted for (data not showni. there was no change m the results. The numbers in column 3 are the Mantel-Hazel statistic values for the panic disorder analyses. They are neither percentages of the population wrth these traits nor corrected percentages of the population with these traits. 1. 2. 3. 4. 5.
p p p p p
< < < c
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