Personality Traits Associated With Panic Disorder: Change Associated With Treatment Russell Noyes, Jr., James H. Reich, Michael Suelzer, and Jody Christiansen Eighty-two subjects with panic disorder completed the Personality Diagnostic Questionnaire (PDQ) before treatment and again after a period of relatively stable improvement 3 years later. At baseline, panic subjects scored higher than normal control subjects, who had been matched for age and sex, on avoidant, dependent, histrionic, and paranoid personality subscales. Improvement in panic symptoms after 3 years was associated with reductions in these same subscale scores. Examination of individual items that distinguished panic from normal subjects showed themes of dependency, lack of self-confidence, emotional instability, and sensitivity to criticism that reflected demoralization in the panic disorder subjects. To a large extent, the findings reveal nonspecific, state-dependent effects of panic and agoraphobic symptoms on the personality functioning and morale of patients with panic disorder. Copyright 0 199 1 by W. B. Saunders Company

R

ECENT STUDIES examining the occurrence of personality disorders among patients with panic disorder and/or agoraphobia have supported earlier work showing a close relationship between anxiety states and personality disturbances.’ Using categorical measures, recent investigators have identified personality disorders in 27% to 76% of panic disorder patients, which is higher than the 11% to 18% estimate for the general population.z~i” The variation in these estimates is probably due to differences in populations studied and methods used to assign diagnoses. With respect to type, anxious personality disorders (cluster C) have been observed most consistently, especially the dependent and avoidant varieties.4~73’1.‘2 For example, Reich et al., who found dependent personality disorder common among panic patients, reported that this disorder was most frequent in the subgroup with extensive phobic avoidance.6 However, unstable personality disorders (cluster B) have also been identified among panic disorder patients, especially histrionic and borderline disorders.4.5.7.“,1’Mavissakalian and Hamann, for instance, found traits of these personalities prominent on the composite profile of agoraphobic patients they studied.4 These findings of frequent and varied personality disturbances among panic and agoraphobic patients force us to look closely at the meaning of this association between axis I and II disorders. The importance of coexisting personality disturbances may be seen in their influence on treatment response and outcome.‘3 The studies examining this issue have found that anxious patients with personahty disorders have done less well with treatment. For example, Tyrer et al. found a strong relationship between personality and response to phenelzine in patients with anxiety and other neuroses.’ Similarly, Mavissakalian and Hamann, who treated agoraphobics with

From the Department of Psychiatry, University of Iowa College of Medicine, Iowa City, IA; and the Massachusetts Mental Health Center, Harvard Medical School, Boston, MA. Supported in part by a grant from The Upjohn Company. Address reprint requests to Russell Noyes, Jr., M.D., 500 Newton Rd, Iowa City, IA 52242. Copyright 0 I991 by W.B. Saunders Company OOIO-440X/91/3204-OOI2$03.00/0 Comprehensive

Psychiatry, Vol. 32, No. 4 (July/August),

1991: pp 283-294

283

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combined drug and behavior therapy, found that the majority of nonresponders had personality disorders.” Also, among panic patients treated with benzodiazepines, Reich and Green found that patients with unstable (cluster B) personality disorders responded less we11.‘4In two studies, personality measures predicted the outcome of panic and agoraphobic patients treated naturalistically. Farvelli and Albanesi reported that scales from the Minnesota Multiphasic Personality Inventory and Maudsley Personality Inventory accounted for most of the variance in outcome after 1 year.” Similarly, Noyes et al. found personality disturbance the strongest predictor of social maladjustment after 3 years.16 The research just cited suggests that personality disturbances contribute to the overall psychopathology of panic disorder, but does not tell us whether these disturbances are unique to panic patients or whether they are trait- or statedependent phenomena. One way to approach these issues is to compare the personality profiles of patients with panic disorder with those of other patient and nonpatient groups. Such an approach was taken by Mavissakalian and Hamann, who found dependent, avoidant, and histrionic traits more frequent than the traits of other personality disorders in patients with agoraphobiaP Because the investigators found these traits just as frequently in obsessive-compulsive disorder patients, they questioned their specificity. I7Also, after 16 weeks of combined drug and behavioral treatment, they observed a substantial reduction in abnormal traits in agoraphobic patients, as measured by the Personality Diagnostic Questionnaire (PDQ), and concluded that at least some of these traits are responsive to treatment.” We sought to replicate and extend the findings of Mavissakalian and Hamann by administering the PDQ to approximately 90 patients with panic disorder before they participated in a pharmacologic treatment study and again, when they were followed up, 3 years later.4s” METHOD This study involved 97 subjects with panic disorder who were recruited via the news media and screened using the Structured Clinical Interview for DSM-III (SCID) developed by Spitzer and Williams.‘” All subjects met DSM-III-R criteria for panic disorder and had had at least one panic attack in the week before being enrolled in a drug treatment study.” Subjects were excluded who had a history of psychosis, dementia, bipolar disorder, melancholia, or alcohol abuse (within the past 6 months). Subjects with major depression were included, providing depressive symptoms began after the onset of anxiety. Subjects with distinctly abnormal laboratory values or uncontrolled physical disease were also excluded. At baseline the level of anxiety symptoms was measured using the Hamilton Anxiety Rating Scale (HAS) and the Self-Rated Anxiety Scale (SRAS) developed by Sheehan.““2’ Agoraphobic symptoms were rated using a phobia scale on which fear (0, not at all, to 10, extremely) and avoidance (0, never, to 4, always) were rated separately for each item. This scale included seven agoraphobic symptoms that were summed separately.‘” The overall severity of phobic symptoms was rated on an 11-point scale (0, no phobias present, to 10, extremely distressing or restricting). Personality was assessed by means of the Structured Interview for DSM-III Personality (SIDP) and the PDQ,‘3,2”the latter being a 163-item, self-administered questionnaire designed to assess DSM-III personality disorders. The PDQ has adequate test-retest reliability for many disorders and good internal consistency.Z,26 When compared with structured interviews for assessing personality, it showed high sensitivity, but only moderate specificity for most disorders.*’ From the PDQ, scores for individual personality disorders and for clusters may be calculated; also, a total score, representing the sum of items answered in the pathological direction, may be obtained. In addition, a series of personality dimensions were recently identified through factor analysis of the PDQF8

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The subjects of this investigation had been off all psychotropic medication for at least 1 week before baseline assessment. At that point, each was randomly assigned to alprazolam (1-mg capsules), diazepam (lo-mg capsules), or placebo, which was administered in a flexible dose for 8 weeks. If, at the end of this period, subjects were doing well, they could elect to receive study medication (double-blind) for 6 additional months. At that point, study medication was gradually discontinued and subjects were treated naturalistically. Approximately half of the subjects responded well to study medication and chose to continue beyond 8 weeks. The results of this study will be reported elsewhere. Those participants in the treatment study who received at least one dose of study medication were followed up between 2 and 4 years after their initial enrollment. At this time they were personally interviewed by a trained research assistant familiar with anxiety disorder patients (J.C.). Subjects were interviewed in their homes or, if they lived more than 150 miles from the University of Iowa Hospitals, by telephone. Each was given a structured interview and questionnaires including the PDQ and a repeat of the Self-Rated Anxiety Scale (SRAS) and other scales administered at the initiation of the treatment study. Control subjects consisted of 48 relatives of patients with major depression who participated in the National Institute of Mental Health Collaborative Depression Study at the University of Iowa.” These relatives had been screened for psychiatric illness using the Schedule for Atfective Disorders and Schizophrenia, Lifetime Version, and had provided demographic information 3 years earlier.“’ Controls were selected who had no psychiatric illness (lifetime), unless that illness would not have excluded them from the panic disorder treatment study, and were matched as a group for age and sex with panic subjects. Three controls had minor depressive disorder. two had generalized anxiety disorder, and one had an unspecified psychiatric illness. Control subjects were asked to complete the PDQ on one occasion. Eighty-two of the panic subjects who had completed the PDQ at baseline completed it again at follow-up. The follow-up interval ranged from 25 to 49 months, and the mean interval was 36.5 months (initiation of treatment study to follow-up). A total of 46 control subjects completed the PDQ. Panic and control subjects were closely matched: 57.3% and 54.3%, respectively, were women, and the median ages were 38.7 + 10.6 and 38.0 * 9.6, respectively. Also, they were similar with respect to social class: the mean Hollingshead, Two-Factor Index of Social Position scores were 37.5 ? 14.1 and 38.3 ~fr 15.2, respectively. The analyses reported in this study were limited to the PDQ, which was administered at baseline and again at follow-up. Data from the SIDP, given only at baseline, have been reported elsewhere.‘” Summary scores from the PDQ and SIDP were highly correlated (Pearson correlation coefficient for sums of abnormal traits was +.76 at baseline) and the overall results using these measures were similar. For the purpose of comparison, PDQ scores for individual personalities, clusters, factors, and a total score were calculated for each subject. These scores represented the sum of items making up each category. Comparisons of means were carried out using unpaired f tests or paired t tests for comparison of baseline and follow-up scores. Although a multivariate T’ statistic would have taken the intercorrelation of PDQ scales into account more adequately, we felt that the use of standard r tests was simpler and more consistent with our purposes. The categorical frequencies of individual PDQ items were examined for independence using chi-square tests and for change from baseline to follow-up using the sign test. Correlations between the level of anxiety and phobic symptoms and personality subscales were examined using Pearson correlation coefficients.

RESULTS

The influence of age, sex, and social class on PDQ scores was examined for both panic and control subjects at baseline. This was done by separating them into men versus women, young versus old, and low versus high social class, the last two separations being made at the median. Among panic subjects, the PDQ total was 34.8 for men and 31.9 for women (P = .48); also, among individual disorders and clusters, there were no statistically significant gender differences. There were no statistically significant differences between young and old subjects on individual disorders, clusters, or total PDQ scores, except that young panic subjects scored higher than old subjects with respect to histrionic personality (3.5 v 2.3, P < .02). Similarly, young control subjects scored higher on the unstable personality cluster

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(B) than old subjects (7.5 v 4.1, P = .05). Also, panic subjects belonging to lower social class scored higher on schizoid personality than did higher social class subjects (0.9 v 0.5, P < .05). At baseline, 26.8% of the panic disorder subjects had total scores of 40 or more on the PDQ, compared with 10.9% of the control subjects. A score of 40 or more is indicative of significant personality disturbance.24 Also, 40.2% of the panic subjects had scores of 2 or more on the PDQ, impairment/distress scale, compared with 17.4% of the control subjects. Such a score, according to the authors of the PDQ, indicates the presence of significant social impairment related to personality dysfunction. A comparison of mean subscale and total PDQ scores at baseline for panic disorder and control subjects is shown in Table 1. As may be seen, the greatest differences were found on the avoidant, dependent, histrionic, and paranoid scores. Because several subscales contain more than 10 items (antisocial, 22; borderline, 20; schizotypal, 15; paranoid, 15) differences between panic and normal subjects on these scales may have appeared greater than they were. All the remaining scales were made up of 10 items or less. Table 1 also shows mean PDQ scores for panic disorder subjects who at baseline scored above and below the median on the SRAS. The high-anxiety group had higher mean scores for most individual personality disorders, clusters and total PDQ. However, the high- and low-anxiety groups showed greatest differences on the avoidant, dependent, histrionic, paranoid, and compulsive subscales. Statistically significant (P < .Ol) correlations between the SRAS and PDQ subscales at baseline were as follows: schizotypal, .53; dependent, .47; avoidant, .44; compulsive, .42; paranoid, .40; histrionic, .39; and borderline, .37. Panic patients who scored above and below the median on the global phobia rating scale at baseline were also compared with respect to their scores on the PDQ. Statistically significant differences were found between the high and low groups (N of 38 and 44, respectively) for dependent personality (3.9 v 2.0, P < .OOl), avoidant personality (5.1 v 4.0, P < .05), schizotypal personality (3.2 v 2.0, P < .02), and the anxious personality cluster (C) (14.4 v 10.8, P < .02). To examine the influence of stable improvement on personality traits, we identified patients who had had a 50% reduction in anxiety symptoms from baseline to follow-up as measured by the SRAS. The 44 patients who had improved to this extent had a mean SRAS of 54.8 at baseline and 16.5 at follow-up. PDQ scores for these patients at baseline and follow-up are shown on Table 1. Statistically significant reductions were observed on the dependent, avoidant, histrionic, paranoid, and compulsive personality subscales. Table 2 shows the 23 (of 137) PDQ items on which panic disorder subjects and controls differed to a statistically significant degree (P < .Ol) at baseline. Most of the items from the schizoid cluster (A) belonged to the paranoid (five) and schizotypal (two) personality disorders. Those from the unstable cluster (B) came mostly from the histrionic (three) and borderline (three) personalities and those from the anxious cluster (C) belonged to the dependent (five) and avoidant (three) personality disorders. With respect to content, the items that were more frequently affirmed by panic than by normal subjects appeared to focus on themes of interpersonal dependency, lack of self-confidence, emotional instability, and

2.9 4.5 2.8 2.2 12.5 33.1

(2.5) (2.2) (1.9) (1.6) (6.6) (17.6)

(3.0) (2.2) (1.6) (7.7) 1.1 3.0 1.8 1.5 7.4 19.7

1.9 1.5 1.5 5.8 (1.6) (2.0) (1.8) (1.1) (5.5) (13.6)

(2.8) (1.2) (1.2) (5.9)

1 .o (2.1)

1.8 (3.1)

3.6 2.9 2.0 10.3

4.1 (3.6)

1.9 (1.8) 0.7 (0.9) 1.5 (1.6)

7.4 (5.2)

4.2 (2.9) 0.7 (0.9) 2.5 (2.2)

Control Subjects (N = 46)

.OOOl ,001 .Ol .Ol .OOOl .OOOl

.Ol .OOOl .05 .OOl

NS

,001

.OOOl NS .Ol

P

3.8 5.4 3.4 2.6 15.2 40.3

4.5 3.6 2.4 12.8 (2.5) (2.1) (1.9) (1.7) (6.4) (17.6)

(3.1) (2.4) (1.8) (8.6)

2.3 (3.4)

9.1 (5.2)

5.0 (3.0) 0.8 (0.9) 3.3 (2.3)

HighAnxiety (N = 41)

2.0 3.6 2.2 1.9 9.7 25.9

2.7 2.2 1.7 7.9 (2.2) (2.0) (1.7) (1.3) (5.7) (14.4)

(2.6) (I .8) (1.4) (5.6)

1.2 (2.5)

5.7 (4.7)

3.3 (2.6) 0.6 (1.0) 1.8 (1.7)

LowAnxiety (N = 41)

.OOl .OOOl .Ol .05 .OOOl .OOOl

.Ol .Ol NS .Ol

NS

.Ol

.Ol NS .Ol

P

2.5 4.3 2.4 2.0 11.2 29.8

3.2 3.0 1.8 9.5

(2.7) (2.3) (1.6) (1.5) (6.5) (16.4)

(2.9) (2.3) (1.5) (7.3)

1.6 (2.9)

6.2 (4.4)

3.6 (2.5) 0.5 (0.7) 2.3 (2.1)

Panic Baseline (N = 44)

1.6 3.3 1.9 1.7 8.5 24.6

3.0 2.3 1.7 8.6

(2.1) (2.1) (1.4) (1.4) (5.8) (15.7)

(2.9) (2.1) (1.4) (7.3)

1.6 (3.0)

5.0 (4.2)

2.8 (2.5) 0.4 (0.7) 1.8 (1.8)

Panic Follow-Up (N = 44)

.Ol .OOOl .05 NS NS .Ol

NS .05 NS NS

NS

.05

.Ol NS NS

P

NOTE. The table also shows PDQ scores for panic subjects falling above and below the median on the SRAS, as well as PDQ scores at baseline and follow-up for panic subjects showing at least a 50% reduction in SRAS scores from baseline to follow-up.

Anxious cluster (C) Dependent Avoidant Compulsive Passive-aggressive Total Total PDQ

Borderline Histrionic Narcissistic Total

Total Unstable cluster (B) Antisocial

Schizoid cluster (A) Paranoid Schizoid Schizotypal

Panic Subjects (N = 82)

Table 1. Mean PDQ Scores for Panic Disorder and Control Subjects

?J z

g

: is n

z

z

3 6

B

ZTJ

2

;;1 D

2

1

:

_.

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Table 2. Percent of Panic and Control Subjects Affirming Individual Items From the PDCI Panic Disorder (N = 82) %

Control Subjects (N = 46) %

P

PAR PAR STP PAR PAR STP PAR

68 54 52 45 40 34 16

24 17 26 09 15 11 00

.OOOl .OOOl .Ol .OOOl .Ol .Ol .Ol

NAR HIS BOR BOR HIS BOR HIS

50 46 39 37 33 32 28

17 17 13 13 02 09 04

.OOOl .OOl .Ol .Ol .OOOl .Ol .OOOl

AVD DEP COM AVD/DEP AVD DEP DEP PAA DEP

66 54 44 40 39 38 32 29 23

35 20 13 11 15 09 04 07 04

.OOl .OOOl .OOOl .OOOl .Ol .OOOl .OOOl .Ol .Ol

Personality Subscale Schizoid cluster (A) I find it easy to relax.* I am easily offended. I am overly sensitive to criticism. People say I exaggerate my difficulties. I wonder if people I know can be trusted. I am usually at ease with others.* People think I’m open-minded.* Unstable cluster (6) Criticism often makes me feel ashamed... I often act very emotionally... My feelings toward others often change... I feel empty and bored much of the time. If I don’t get my way I get angry... I rarely get so angry that I lose control.* I usually handle my own problems...* Anxious cluster (C) I am overly critical of myself. I am often unsure of myself. It takes me too long to make decisions. I haven’t made much of my life. I often feel rejected. I am usually self-confident.* I am a self-reliant person.* I often feel that people push me around. I am very dependent on others...

NOTE. The table includes items on which panic and control subjects differed (P < .Ol using a chi-square test). *Items scored positively if answered “no.”

sensitivity to criticism. Most of the interpersonal dependency and lack of self-confidence items belonged to the dependent and avoidant personality disorders. Items having to do with emotional instability came from the histrionic and borderline personality disorders, while those dealing with sensitivity to criticism came from the paranoid and schizotypal personality disorders. Table 3 shows 20 items that changed to a statistically significant degree (P 5 .05) or showed a trend toward significant change from baseline to follow-up among patients showing at least a 50% reduction in anxiety symptoms as measured by the SRAS. With two exceptions, the proportion of subjects affirming these items fell from baseline to follow-up by 11% to 37%. Two items, “My friends, goals or beliefs are always changing” and “I was always breaking the rules at home or at school,” were affirmed by more subjects at follow-up than at baseline. Nine of the 20 items were among those that had originally distinguished panic disorder subjects from control subjects. Six of the items belonged to the avoidant personality subscale. In addition, three each belonged to the dependent, histrionic, borderline, and paranoid personality subscales. Table 4 shows a comparison of scores on a series of PDQ dimensions that had been identified by factor analysis?* Panic disorder subjects differed from control subjects at baseline on four factors at a level of P < .Ol, including social dysphoria,

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289

Table 3. Percent of Panic Subjects Affirming Individual Items From the PDQ Baseline Panic (N = 44) %

Follow-Up Panic (N = 44) %

P

PAR PAR PAR

73 55 48

36 32 27

.Ol .05 .05

BOR HIS

50 39

25 18

.05 .Ol

HIS BOR HIS

30 27 18

18 09 07

.lO .05 .lO

BOR ASP

02 02

18 16

.05 .05

AVD AVD DEP DEP AVD COM COM AVD/DEP

61 43 41 41 34 34 34 32

48 27 27 21 18 18 16 14

.05 .05 .lO .05 .05 .lO .05 .05

AVD AVD

30 30

16 14

.lO .05

Personality Subscale Schizoid cluster (A) I find it easy to re1ax.t I am easily offended. People say I exaggerate my difficulties. Unstable cluster (B) I am a moody person. If I don’t get my way I get angry... I am much more concerned about my looks...* Being alone doesn’t usually bother me.t Many people find me charming but... My friends, goals or beliefs are always changing. I was always breaking the rules... Anxious cluster (C) I am overly critical of myself.* I worry a lot that people won’t like me. I am often unsure of myself.* If I depend upon someone... I often feel rejected.* It takes me too long to make decisions.* I often get lost in the details... I haven’t made much of my life.* Even when I am around people, I keep to myself. I make friends with people only when... NOTE. (P < .I0 *Items 2). tltems

The table includes items on which panic subjects changed from baseline to follow-up using a sign test). from the PDQ that had distinguished panic disorder from normal subjects (see Table scored positively if answered “no.”

controlling/paranoid, dependency, and passive aggressive. High-anxiety subjects differed from low-anxiety subjects on two of the same factors, namely social dysphoria and dependency. In addition, panic subjects who improved showed a significant reduction in social dysphoria at follow-up. DISCUSSION

Using the PDQ, we were able to show that patients with panic disorder more frequently have personality disturbances than do normal subjects, thus confirming the findings of previous investigators. In terms of a composite profile, panic patients scored highest on the avoidant, dependent, histrionic, and paranoid traits. A similar profile was reported by Mavissakalian and Hamann, who administered the PDQ to 60 patients with agoraphobia.4 When we compared our patients with normal subjects, the greatest differences were observed in most of the same personality traits, namely, avoidant, dependent, histrionic, and paranoid. With the possible exception of paranoid traits, these differences correspond to clinical description of the personality disturbance found in panic and agoraphobic patients.

(2.8) (1.2) (0.9) (0.6) (0.5) (0.2) (0.2) (0.2) (0.7) (0.5) (0.5)

2.7 0.4 0.5 0.4 0.4 0.1 0.1 0.1 0.6 0.3 0.4

(3.5) (1.6) (1 .O) (0.6) (0.9) (0.5) (0.6) (0.4) (0.9) (0.6) (0.5)

5.6 0.8 0.9 0.5 0.9 0.2 0.5 0.2 1.1 0.4 0.3 NS .05 NS .OOl .05 .OOOl NS ,001 NS NS

.OOOl

P 7.1 0.0 1.1 0.7 1.1 0.3 0.7 0.3 1.3 0.5 0.4

(3.5) (0.0) (1.0) (0.7) (0.9) (0.6) (0.6) (0.5) (0.9) (0.7) (0.5)

HighAnxiety (N = 41) 4.3 0.0 0.7 0.4 0.7 0.2 0.2 0.1 0.8 0.2 0.2

(3.1) (0.0) (1 .O) (0.5) (0.8) (0.3) (0.5) (0.2) (0.9) (0.4) (0.4)

LowAnxiety (N=41)

NS NS .05 .05 NS .OOl .05 .05 .05 NS

.OOl

P 5.1 0.7 0.8 0.5 0.8 0.2 0.4 0.1 0.9 0.2 0.3

(4.2) (1.4) (1.1) (0.7) (0.9) (0.6) (0.6) (0.4) (0.9) (0.7) (0.5)

Panic Baseline (N = 44)

3.6 0.8 0.9 0.3 0.8 0.0 0.3 0.1 0.7 0.2 0.3

(3.4) (1.2) (0.9) (0.6) (0.7) (0.2) (0.5) (0.3) (0.8) (0.5) (0.5)

Panic Follow-Up (N = 44)

NS NS NS NS .05 NS NS .05 NS NS

.OOl

P

NOTE. Table also shows PDQ scores for panic subjects falling above and below the median on the SRAS, as well as PDQ scores at baseline and follow-up for panic subjects showing at least a 50% reduction in SRAS scores from baseline to follow-up.

Social dysphoria Juvenile delinquency Impulsive/dangerous Lacks feelings/isolated Controlling/paranoid Illusions/identity disturbance Dependency Unstable relations/exploitative Passive aggressive Cold/aloof Magical thinking/illusions

Factors

Control Subjects (N = 46)

Panic Subjects (N = 82)

Table 4. Mean PDQ Factor Scores for Panic Disorder and Control Subjects

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291

We also observed a substantial reduction in PDQ scores at follow-up, after our patients had received treatment and had experienced a period of sustained improvement. This improvement was documented by the readministration of anxiety and phobia scales that had been given at baseline, the results of which are reported elsewhere.16 When we examined a subset of the most improved patients, we found significant reductions in traits belonging to the avoidant, dependent, histrionic, and paranoid traits. Thus, traits of the same personality disorders that distinguished between panic and normal subjects diminished in association with improvement of panic disorder. In fact, many items, that belonged to the avoidant and dependent personality subscales and that had distinguished panic from normal subjects, were the same ones that showed reduction with improvement. These findings raise two questions, the first having to do with what the PDQ measures and the second with what the relationship between PDQ abnormalities and panic disorder may be. Neither question has an obvious answer, but our findings suggest that some items from the PDQ do not measure the personality disturbances they were intended to measure. For example, even though panic disorder patients score high on the paranoid personality subscale, they do not appear paranoid in the usual clinical sense. However, examination of the individual items from the paranoid subscale, on which panic patients scored high, suggests that some of these items deal with aspects of the illness experience. For example, “I find it easy to relax,” appears to be an anxiety symptom. Also, “People say I exaggerate my difficulties,” refers to the problem patients with panic disorder often have in getting others to accept their illness.” The statement, “I am easily offended,” may refer to the heightened interpersonal sensitivity that patients with panic disorder often report. A lack of specificity in what the PDQ measures may also be seen in the factor scores comparing panic disorder subjects and normals. One of the four factors on which panic subjects differed from normals was the first or social dysphoria factor. This largest factor comprises 29 highly intercorrelated items from the PDQ that reflect hypersensitivity to criticism, social anxiety, and low self-esteem.” Thirteen of the individual items belonging to this factor were among those that distinguished panic from normal subjects and the themes making up this factor were prominent among the items distinguishing panic from normal subjects. As the authors of the PDQ noted, this factor includes items from nine different personality disorders; consequently, it is not related to any single disorder. Social dysphoria in our panic patients appears to be a nonspecific disturbance of social interaction that is akin to demoralization. According to Frank, demoralization is a distressed state of mind that results from persistent failure to cope with stressors that a person expects himself to handle. It is characterized by feelings of impotence, isolation, and despair.3’,33 The demoralized person’s self-esteem is damaged and he feels rejected by others because of his failure to meet their expectations. His alienation from family and community may give rise to a sense of meaninglessness. Although no precise definition of demoralization has been proposed, this emotional state has been called on in panic patients to account for the development of depression on the one hand and response to nonspecific therapy on the other.34,35 The term demoralization has been applied to the nonspecific distress measured on a variety of symptom rating scales and a series of

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highly correlated items from one such scale has been used to measure demoralization.36-38 If we look at the individual PDQ items that distinguish panic disorder from normal subjects, as well as those items that change with improvement, we can identify themes that appear to fit the concept of demoralization. These include interpersonal dependency, lack of self-confidence, emotional instability, and sensitivity to criticism. Such themes reflect not only the subjective distress experienced by panic patients (e.g., discouragement, sadness, anger, etc.), but also the perceived social incompetence and alienation associated with their illness. Patients with panic disorder frequently comment on these aspects of the illness experience and, not infrequently, offer them as presenting complaints. According to Frank, most forms of psychotherapy serve to reverse demoralization and, by restoring a patient’s sense of mastery and hope, reduces his symptoms and improves his functioning.33 Our data suggest that drug therapy, which most of our patients received, has a similar effect. Findings such as ours, while of interest to clinicians, may be troubling to the developers of personality tests. The creators of such instruments seek scales that are diagnostically distinct and, therefore, free of nonspecific distress. The measurement of such distress contributes little to the identification or assessment of specific personality traits. When Mavissakalian et al. compared panic and obsessive-compulsive patients using the PDQ, they found similar personality profiles and concluded that the abnormalities in these patients may have been nonspecific in character.” However, it may have been that patients with these disorders shared demoralization and that the measurement of this distress by the PDQ obscured real differences in personality traits. This possibility is supported by a factor analysis of the PDQ showing that a single nonspecific factor explains most of the variance accounted for by the test.‘* In fairness to the PDQ, it should be noted that the DSM-III-R criteria include many items that are not distinctive; the problem exists for personality tests generally, not just the PDQ. Nevertheless, our findings suggest that caution should be used in interpreting results of self-report measures. As a group, panic and agoraphobic patients have been described as dependent and avoidant and as lacking in assertiveness and self-confidence.4’39’40We found confirmation of these clinical impressions in the personality scores of our panic disorder subjects. Substantial differences in the frequency of dependent and avoidant personality traits were observed between panic and normal subjects and between high- and low-anxiety subjects. Also, traits of these same personality disorders appeared to be especially responsive to treatment. Dependent and avoidant traits reflect, to some extent, the direct influence of panic disorder on personality functioning. If, as is commonly the case, an agoraphobic patient has a fear of being alone and is comforted by the presence of a trusted companion, this is apt to influence that patient’s response to the PDQ. Of course, we are talking here about a composite picture. Individual patients may have a variety of personality disorders, which because of their infrequent occurrence and/or because of their heterogeneity, do not show up in the overall results. Avoidant personality, a new axis II disorder in DSM-III, has been shown to have a close association with social phobia.4’ In fact, a majority of social phobics qualify for avoidant personality disorder causing some investigators to suggest

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that the personality disturbance is a feature of social phobia and not a separate axis II disorder (F.R. Schneier, personal communication, December 5, 1990). That avoidant personality traits respond to pharmacologic treatment, supports this view.42 Our finding in panic patients of high avoidant personality scores that came down with treatment also suggests that avoidant personality is not a true axis II disorder. Instead, it appears to represent the influence of state anxiety on personality functioning and, in that case, it should, perhaps, not be retained as a separate personality disorder category.4’ The question of whether the personality disturbance that distinguishes panic disorder patients from normal subjects is entirely a state-dependent manifestation of the illness or a preexisting vulnerability cannot be answered by this study. Indeed, prospective study of high-risk populations (e.g., children of persons with panic disorder), many members of which subsequently develop the disorder, is needed to accomplish this. Work of this kind is underway and one wonders whether behavioral inhibition identified in the children of agoraphobics may not be a forerunner of the disturbance we observed in panic disorder adults.44 Although much improved at follow-up, 90% of the patients in our study were still symptomatic 3 years after participation in a treatment study.” Consequently, we were not able to assess them in a recovered or symptom-free state. And, although improved as far as personality functioning was concerned, they still differed substantially from normal subjects. Clearly, certain traits are highly correlated with anxiety symptoms and appear state-dependent. Many other traits showed little change with improvement and, therefore, appear to be more enduring.” REFERENCES 1. Roth M. Gurney C, Garside RF, et al: Studies in classification of affective disorders. The relationship between anxiety states and depressive illnesses. Br J Psychiatry 121:147-161, 1972 2. Tyrer P, Casey P, Gall J: Relationship between neurosis and personality disorder. Br J Psychiatry 142:404-408, 1983 3. 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 4. Mavissakalian M, Hamann MS: DSM-III personality disorder in agoraphobic. Compr Psychiatry 27:471-479, 1986 5. Friedman CJ, Shear MK, Frances A: DSM-III personality disorders in panic patients. J Pers Disord 1:132-135,1987 6. Riech JH, Noyes R, Troughton E: Dependent personality disorder associated with phobic avoidance in patients with panic disorder. Am J Psychiatry 144:323-326, 1987 7. Green MA, Curtis GC: Personality disorders in panic patients: Response to termination of antipanic medication. J Pers Disord 2:303-314, 1988 8. Alnaes R, Torgersen S: The relationship between DSM-IV symptom disorders (axis I) and personality disorders (axis II) in an outpatient population. Acta Psychiatr Stand 8:485-491, 198X 9. Reich J, Yates W, Nduaguba M: Prevalence of DSM-III personality disorders in the community. Sot Psychiatry Psychiatr Epidemiol24:12-16, 1989 10. Zimmerman M, Coryell W: DSM-III personality disorder diagnoses in a nonpatient sample. Arch Gen Psychiatry 46:682-689, 1989 11. Mavissakalian M, Hamann MS: DSM-III personality disorder in agoraphobia. II. Changes with treatment. Compr Psychiatry 28:356-361, 1987 12. American PsychiatricAssociation: Diagnostic and Statistical Manual of Mental Disorders (ed 3, revised) (DSM-III-R). Washington, DC, APA, 1987 13. Reich JH, Green AI: Effect of personality disorders on outcome of treatment. J Nerv Ment Dis 179:74-82, 1991 14. Reich JH: DSM-III personality disorders and the outcome of treated panic disorder. Am J Psychiatry 1988; 145:1149-1152

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