نتیجه طولانی مدت اختلال شخصیت مالیخولیایی

Abstract Hypochondriacal personality disorder diagnosed according to the Personality Assessment Schedule, a structured clinical interview, was related to outcome after 2 years and 5 years in a randomized, controlled trial of treatment of generalized anxiety, panic, and dysthymic disorders. Seventeen individuals (9%) from a population of 181 patients had hypochondriacal personality disorder and they experienced a significantly worse outcome than other patients, including those with other personality disorders, in terms of symptomatic change and health service utilization. This lack of improvement was associated with persistent somatization in hypochondriacal personality disorder. The results give further support to the belief that hypochondriacal personality disorder is a valid clinical diagnosis that has important clinical correlates, but further work is needed to establish the extent of its overlap with hypochondriasis as a mental state disorder.

Introduction Although personality characteristics have been recognized as important in the evaluation of hypochondriacal personality disorders for over 400 years [1], they are not currently acknowledged in either of the main classification systems (DSM and ICD) in psychiatry. The possibility that at least some forms hypochondriasis primarily encompass personality rather than mental state was not mentioned in authoritative reviews [2] until recently 3 and 4. We feel this is an error, and in defining a better classification of hypochondriacal disorders it is essential to take into account personality factors. In previous work, we have described the main characteristics of hypochondriacal personality disorder, a condition developing early in adult life and associated with persistent preoccupation with health and avoidance of disease, the magnification of minor ailments into major disease in personal perception, repeated medical consultations for this imagined disease, and adoption of self-help and alternative treatment strategies [5]. This work suggests that hypochondriacal personality disorder is a condition within the anxious–fearful cluster of personality disorders with associations with both anankastic and anxious personality features [6]. However, this work has only identified the disorder in cross-sectional form and its relevance in longitudinal studies is the subject of this article. The main distinctions between hypochondriacal personality disorder and hypochondriasis as a mental state disorder within the somatoform group are the persistent features of the personality disorder, the constant preoccupation with health seeking behavior as a desirable goal, and a lifestyle designed to perpetuate these ends that is defended strongly at all times. Hypochondriasis as a mental disorder is different, with recognition that it is not habitual behavior (i.e., is ego-dystonic), is associated with the “persistent belief of the presence of a maximum of two serious specific diseases” [7] and which, because of the degree of personal distress created by the symptoms, is associated with more determined attempts to find the alleged disease, including frequent changes of doctor and direct consultations with a large number of professionals. The condition is also commonly associated with high levels of anxiety. In hypochondriasis as a somatoform disorder, improvement in anxiety and associated symptoms also leads to improvement in hypochondriasis pari passu 8 and 9. Nevertheless, there is a certain amount of overlap between these conditions and health anxiety is common to both. Our previous work has suggested that hypochondriacal personality disorder seldom exists in pure form and is usually associated with other psychiatric disorders, particularly affective and neurotic disorders. We therefore examined the outcome of hypochondriacal disorder in a population of patients with defined neurotic disorders who also had hypochondriacal personality disorder. A comparison of those with and without the disorder in terms of outcome was therefore possible.

Results One hundred eighty-one (91%) of the 198 patients who had original PAS assessments were assessed after 2 and 5 years. Of these, 17 (9%) had hypochondriacal personality disorder, and 47 (26%) had other personality disorders. Two-year outcome The outcome after 2 years showed the patients with hypochondriacal personality disorder improved to a significantly lesser extent with respect to global psychopathology (CPRS) than the other patients, including those with other personality disorders (Fig. 2). The same general findings were shown with the other ratings, but only depression rating scores with MADRS showed a significantly worse outcome than the other groups (Table II). After 2 years, only 3 of 16 patients with hypochondriacal personality disorder (19%) had no psychiatric diagnosis according to the SCID compared with 18 of 42 (43%) with other personality disorders and 58 of 106 patients (55%) with no personality disorder (χ2=8.0, df 2, p<0.02). Somatization scores were higher in the hypochondriacal group with greater persistence at 2 years, but these were not significantly different (Fig. 3). Comparison of global outcome scores of the Comprehensive Psychopathological ... Fig. 2. Comparison of global outcome scores of the Comprehensive Psychopathological Rating Scale (CPRS) in 181 patients separated by personality status into those with no personality disorder (no pd) (n=117), personality disorder other than hypochondriacal personality disorder (n=47), and hypochondriacal personality disorder (n=17). F-ratio (groups)=2.42; df 2, 178; p=0.09; F-ratio (groups×time)=6.46; df 2, 178; p=0.002 Figure options Table II. Mean scores and standard deviations of 181 patients with neurotic disorder separated into those with no personality disorder (n = 117), personality disorder other than hypochondriacal personality disorder (n = 47) and hypochondriacal personality disorder (n = 17) on anxiety and depression rating scales Mean scores (sd) Rating Personality group Initial Two years F-ratio (type) Degrees of freedom p MADRS No PD 18.1 (8.1) 8.7 (8.7) 7.5 2,178 <0.001 PD other 20.3 (7.8) 15.0 (15.9) (personality groups) Hypochondriacal PD 21.6 (7.2) 17.2 (8.7) 3.2 (groups × time) 2,178 0.04 BAS No PD 19.6 12.0 3.0 2,178 0.05 PD other 19.5 13.2 (personality groups) Hypochondriacal PD 22.2 18.1 1.7 (groups × time) 2,178 ns HAD-D No PD 9.6 (4.3) 4.6 (4.7) 7.3 2,178 <0.001 (depression) PD other 11.2 (4.3) 6.8 (5.6) (personality groups) Hypochondriacal PD 12.1 (4.2) 8.4 (4.0) 0.8 (groups × time) 2,178 ns HAD-A No PD 13.9 (3.7) 8.0 (4.9) 1.6 2,178 ns (anxiety) PD other 14.2 (3.0) 9.2 (4.8) (personality groups) Hypochondriacal PD 13.8 (5.1) 10.8 (5.4) 2.8 (groups × time) 2,178 ns Table options Distribution of somatization scores in 181 patients with neurotic disorder ... Fig. 3. Distribution of somatization scores in 181 patients with neurotic disorder separated by personality status. F-ratio (groups)=2.5; df 2, 178 (NS); F-ratio (groups×times)=2.8; df 2, 178; p=0.065 Figure options In the original study, a specific hypothesis investigated was that patients with a coaxial diagnosis of mixed anxiety and depression together with inhibited (anxious, dependent, or anankastic) personality disorder (the general neurotic syndrome), were particularly likely to have a persistent course and this was, to some extent, confirmed at 2 years [23]. A significantly greater proportion of the patients with hypochondriacal personality disorder (13 of 17) (76%) had the general neurotic syndrome compared with only 53 of 164 (32%) in other patients, with the odds on a patient with hypochondriacal personality disorder also having the general neurotic syndrome was nearly seven times greater than for patients not having the syndrome (OR=6.8; 95% confidence interval 2.12–28.2; p<0.001). Five-year outcome The difference in outcome was still present after 5 years when outcome was determined to a greater extent by utilization of health services. A total of 164 of the 181 patients (91%) seen at 2 years were assessed. Only 4 of the 15 patients (27%) with hypochondriacal personality disorder had good outcome compared with 27 of 44 (61%) patients with other personality disorders and 67 of 109 (62%) with no personality disorder (Fig. 4). Five-year outcome in 168 patients separated by personality status on entry to ... Fig. 4. Five-year outcome in 168 patients separated by personality status on entry to the study. χ2=6.8; df 2; p<0.05