همبودی اختلالات شخصیت ضد اجتماعی و اضطراب در بزرگسالان در جامعه

Abstract The association between lifetime anxiety disorders, conduct disorder (CD), and antisocial personality disorder (ASPD) among adults in the community was explored. Data were drawn from the National Comorbidity Survey (n=5,877), a representative community sample of adults aged 15–54 in the 48 contiguous US states. Multiple logistic regression analyses were used to determine the association between anxiety disorders, CD and ASPD, and between the co-occurrence of anxiety disorders and ASPD in the likelihood of comorbid substance use and affective disorders, suicidal ideation (SI) and suicide attempt (SA). Out of the 3.3% of adults with ASPD, over half (54.33%) had a comorbid anxiety disorder (lifetime). Similarly, 42.31% of adults with a history of CD (9.4%) who did not meet criteria for ASPD had a lifetime anxiety disorder. Social phobia [OR=1.65 (1.01, 2.7)] and post-traumatic stress disorder [OR=2.28 (1.3, 4.0)] were associated with significantly increased odds of ASPD, after adjusting for differences in sociodemographic characteristics and other psychiatric comorbidity. Major depression was no longer significantly associated with ASPD after adjusting for anxiety disorders. The comorbidity of anxiety disorders and ASPD was associated with significantly higher odds of major depression, substance use disorders, and SI and SA compared with odds among those without both disorders. These data provide initial evidence of an association between PTSD and social phobia and an increased likelihood of ASPD among adults in the community, after adjustment for comorbid affective and substance use disorders. Adults with ASPD and comorbid anxiety had significantly higher levels of comorbid major depression, alcohol dependence, and substance dependence and substantially higher rates of lifetime suicidal ideation and suicide attempts compared to adults with ASPD or anxiety disorders alone or with neither disorder. Future studies are needed to replicate this finding using longitudinal data and to investigate the possible mechanisms of the observed links between anxiety disorders and ASPD.

Introduction Previous studies have found that comorbidity of anxiety disorders with affective, psychotic, and substance use disorders is common and associated with increased impairment, suicidality and psychiatric symptoms among adults in the general population (Wittchen et al., 2000, Klerman et al., 1991, Kasen et al., 2001, Kessler et al., 1998 and Regier et al., 1998). For instance, epidemiologic data suggest that up to half of adults with a lifetime history of depression have also met diagnostic criteria for an anxiety disorder, and that alcohol and substance use disorders are associated with significantly higher than expected rates of comorbid anxiety disorders (Regier et al., 1998). Moreover, previous evidence suggests that the co-occurrence of depression and anxiety is associated with a significantly increased risk of additional psychiatric comorbidity, suicidal ideation and suicidal behavior, compared with the risk in those with either or neither disorder (Roy-Byrne et al., 2000 and Cottler et al., 1998). Information about patterns of comorbidity can help to reveal shared and specific risk and protective factors for mental disorders both in terms of primary prevention and secondary prevention of comorbid disorders. As epidemiologic studies consistently find that the onset of anxiety disorders occurs relatively early in life, frequently temporally primary to affective and substance use disorders, there are some data to suggest that anxiety disorders are risk factors for comorbid affective and substance use disorders and may be modifiable risk factors, though evidence to date remains inconclusive. While the mechanism of the association between anxiety disorders and substance use disorders remains unclear, there are some data and theory to suggest that substance use disorders follow the onset and are associated with anxiety disorders due to the self-medication anxiolytic effects of alcohol. There is also evidence to suggest that the comorbidity of alcohol use disorders and anxiety disorders may be due to a common genetic or environmental factor. It is our hypothesis that anxiety disorders may also be related to antisocial personality disorder (ASPD) by similar mechanisms. It is possible that some antisocial behavior develops as a means of coping with anxiety among persons without the emotional resources to solve problems and manage frustration in more effective and productive ways. It is also conceivable that a third common factor, which could be environmental or genetic, underlies the linkage between anxiety disorders and ASPD. In contrast to the above-described literature on the prevalence and correlates of the co-occurrence of anxiety disorders with affective, psychotic, and substance use disorders, there has been little available data on the relationship between anxiety disorders and ASPD. Furthermore, relatively few epidemiologic studies have reported on ASPD in a representative population sample (Jackson and Burgess, 2002 and Wells et al., 1989), and to our knowledge no previous studies have investigated the relationship between all anxiety disorders and ASPD. Some clinical data and theory have suggested that conduct disorder (CD) with comorbid anxiety is associated with less psychosocial impairment, compared with CD without anxiety (Walker et al., 1991 and Pine et al., 2000). Previous findings suggest there may be subtypes of CD, for instance, which are related to the presence of anxiety symptoms and temperamental differences (Frick et al., 1999b and Weissenberger et al., 2001). More recent information, however, has indicated that there may be higher than expected rates of anxiety associated with ASPD in clinical settings. Specifically, two studies have provided evidence of an association between ASPD and an increased likelihood of obsessive-compulsive disorder (Hollander et al., 1996 and Kolada et al., 1994) and another recent study showed that anxiety disorders were common among a majority (61%) of patients with ASPD and alcohol use disorders, with 43% having panic/agoraphobia (Tomasson and Vaglum, 2000). Interestingly, the prevalence of comorbid anxiety disorders was higher than that of comorbid affective disorders in this sample (39%). Given the strong association between ASPD and increased likelihood of depression and substance use disorders (Corruble et al., 1996 and Rounsaville et al., 1991), both of which are highly comorbid with anxiety (Wittchen et al., 2000, Klerman et al., 1991, Kasen et al., 2001, Kessler et al., 1998, Regier et al., 1998, Roy-Byrne et al., 2000 and Cottler et al., 1998), it is of interest to determine the relationship between anxiety disorders and ASPD among adults for at least two reasons. First, if anxiety disorders are a causal risk factor for ASPD, as evidence suggests may be the case for other personality disorders and major depression, then strategies aimed early identification and prevention can be developed. Second, it is important to determine the potential risks and outcomes associated with the co-occurrence of ASPD and anxiety disorders as a better understanding of this pattern of comorbidity will allow for the development of more effective treatment strategies, which is especially challenging in ASPD. The goal of the current study is to at least partially fill this gap by answering three main questions. First, are anxiety disorders associated with a significantly increased likelihood of ASPD among adults in the community? Second, is the association specific to some anxiety disorders but not others, and is it independent of other psychiatric comorbidity? Third, is the co-occurrence of ASPD and anxiety disorders associated with increased burden of psychopathology, such as comorbid affective and substance use disorders and suicidal ideation and behavior? Based on previous clinical findings, we hypothesized that anxiety disorders would be associated with a significantly increased likelihood of ASPD. As anxiety disorders and ASPD are each independently associated with increased risk of depression, substance use disorders, and suicidal ideation and suicide attempt, we also predicted that the co-occurrence of anxiety disorders and ASPD would be associated with significantly increased odds of depression and substance dependence compared with the odds among those with either or neither of these disorders

3. Results 3.1. Lifetime prevalence Overall, 3.3% of the population had ASPD (lifetime), 9.4% had CD without ASPD, and 23.9% had an anxiety disorder without ASPD. Over half (54.3%) of adults with ASPD met criteria for an anxiety disorder during their lifetime, and 42.31% of those with CD without ASPD had at least one lifetime anxiety disorder. 3.2. Sociodemographic characteristics associated with ASPD with comorbid anxiety disorders Compared with ASPD without anxiety disorders, the co-occurrence of ASPD and anxiety disorders was significantly more common among females and among those who were separated or divorced, and less common among married individuals (data not shown). There were no other significant differences in sociodemographic characteristics between those with ASPD with and without anxiety disorders. 3.3. Association between anxiety disorders and CD and ASPD Almost half (42.31%) of adults with a history of CD who did not meet criteria for ASPD had a lifetime anxiety disorder (see Table 1). After adjusting for differences in demographic characteristics, any anxiety disorder (OR=2.33), agoraphobia (OR=1.68), post-traumatic stress disorder (PTSD) (OR=1.9), specific phobia (OR=1.72), and social phobia (OR=1.83) were associated with an increased likelihood of CD. Similarly, slightly over half (54.33%) of those with ASPD had a lifetime anxiety disorder. Any anxiety disorder (OR=2.93), panic attack (OR=2.26), agoraphobia (OR=2.44), specific phobia (OR=3.0), social phobia (OR=1.8), PTSD (OR=3.61) and generalized anxiety disorder (OR=3.49) were all associated with increased likelihood of ASPD, after adjusting for differences in demographic characteristics. After additionally adjusting for all anxiety disorders, depression, and alcohol and substance dependence simultaneously, only social phobia [OR=1.64 (1.06, 2.54)], PTSD [OR=2.3 (1.38, 3.82)], alcohol dependence [OR=4.21 (2.7, 6.6)], and substance dependence [OR=5.24 (3.36, 8.18)] were associated with increased likelihood of ASPD. Of note, depression was no longer significantly associated with ASPD after adjusting simultaneously for all anxiety disorders and other comorbidity. Alcohol dependence [OR=3.1 (2.57, 3.75)], drug dependence [OR=2.4 (0.176, 3.27)], depression [OR=1.58 (1.2, 2.08)], social phobia [OR=1.43 (1.05, 1.94)], and PTSD [OR=1.78 (1.32, 2.41)] were associated with increased likelihood of CD. Table 1. Association between conduct disorder, antisocial personality disorder and comorbid anxiety disorders among adults in the community No CD or ASPD CD, no ASPD ASPD n=7094 OR n=783 OR AOR n=261 OR AOR (ref. group) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Any anxiety disorder 27.41% 1.0 42.31% 1.94 2.33 53.33% 3.51 2.93 (1.63, 2.32) (1.96, 2.76) (2.56, 4.82) (2.19, 3.94) Panic attack 6.76% 1.0 8.55% 1.66 1.29 14.41% 3.26 2.26 (1.38, 2.41) (0.9, 1.84) (2.03, 5.14) (1.44, 3.54) Agoraphobia 5.96% 1.0 9.62% 1.87 1.68 14.11% 2.8 2.44 (1.33, 2.62) (1.19, 2.37) (1.8, 3.96) (1.76, 3.39) Generalized anxiety disorder 4.52% 1.0 6.21% 1.80 OR=1.4 14.63% 4.56 3.49 (1.22, 2.67) (0.96, 2.05) (3.19, 6.54) (2.37, 5.13) Post-traumatic stress disorder 6.34% 1.0 11.41% 2.54 1.9 20.94% 5.04 3.61 (1.93, 3.34) (1.47, 2.46) (3.23, 7.86) (2.45, 5.33) Specific phobia 10.29% 1.0 16.51% 2.16 1.72 18.03% 2.2 3 (1.63, 2.87) (1.32, 2.25) (1.48, 3.28) (2.17, 4.17) Social phobia 12.14% 1.0 20.20% 1.92 1.83 30.88% 3.11 1.8 (1.51, 2.44) (1.42, 2.35) (2.12, 4.55) (1.22, 2.56) Bold=P<0.05. AOR=adjusted for differences in demographic characteristics. Table options 3.4. Association between comorbid anxiety disorders and ASPD and the likelihood of psychiatric comorbidity and SI and SA ASPD, without comorbid anxiety disorders was associated with a significantly increased likelihood of comorbid depressive and substance use disorders compared with that among adults without ASPD or anxiety disorders (see Table 2). The comorbidity of ASPD and anxiety disorders was associated with a significantly increased likelihood of comorbid depressive and substance use disorders. Those with anxiety disorders without ASPD also had higher rates of major depression and substance use disorders. All of these associations persisted after adjusting for differences in sociodemographic characteristics. Similarly, suicidal ideation and suicide attempts were both significantly elevated among those with both an anxiety disorder and ASPD, compared with those with either disorder alone or with neither disorder. Table 2. Psychopathological correlates of comorbid anxiety disorders and ASPD among adults in the community No ASPD ASPD, no Anxiety disorder, ASPD+ or anxiety anxiety disorder no ASPD anxiety disorder n=5637 n=114 n=2200 n=147 % AOR % AOR % AOR % AOR (95% CI) (95% CI) (95% CI) (95% CI) Major depression 8.54% 1 19.18% 4.05 36.00% 5.73 39.57% 9.31 (2.32, 7.09) (4.59, 7.16) (5.65, 15.33) Alcohol dependence 10.80% 1 54.13% 7.52 18.40% 2.38 70.01% 18.16 (4.32, 13.09) (1.97, 2.87) (10.52, 31.35) Substance dependence 3.94% 1 40.79% 12.91 11.35% 3.29 53.54% 24.42 (7.28, 22.88) (2.61, 4.14) (14.05, 42.43) Suicidal ideation 7.30% 1 28.02% 6.66 23.51% 3.55 46.85% 12.41 (3.33, 13.35) (2.76, 4.57) (8.73, 17.63) Suicide attempt 1.87% 1 11.26% 8.96 9.49% 4.45 28.97% 20.32 (3.81, 21.09) (2.93, 6.78) (11.82, 34.93) Bold=P<0.05. AOR=adjusted for age, gender, race, marital status, income and education. Table options 3.5. Independent correlates of ASPD (no anxiety disorder), and comorbid ASPD and anxiety disorder among adults in the community After simultaneously entering demographic characteristics, lifetime alcohol dependence, substance dependence, depression, dysthymia, and bipolar disorder in a logistic regression model, lower formal education [OR=0.52 (0.38, 0.73)], being unmarried [OR=0.63 (0.33, 0.9)], being male [OR=0.14 (0.06, 0.31)], alcohol dependence [OR=3.38 (1.84, 6.2)] and substance dependence [OR=6.16 (3.17, 11.97)] were associated with increased likelihood of ASPD (no anxiety). Again, it is interesting to note that in the absence of anxiety disorders, major depression is no longer significantly associated with ASPD, suggesting that comorbid anxiety disorders are integral to the previously observed link between ASPD and depression. Using the same analytic strategy, we found that lower formal education [OR=0.44 (0.33, 0.59)], alcohol dependence [OR=6.64 (3.41, 12.94)], substance dependence [OR=7.65 (3.7, 15.46)], depression [OR=3.18 (1.52, 6.63)], and dysthymia [OR=5.41 (2.48, 11.83)] were associated with increased odds of comorbid ASPD and anxiety disorders.