اختلالات شخصیتی پیش مرضی در اسکیزوفرنی

Abstract Premorbid personality disorders (PD) were studied retrospectively in 40 schizophrenic patients by interviewing the parents and patients who were reliable with the SCID-II. 85% of the patients had premorbid PDs. The most frequent premorbid PDs were: avoidant PD (32.5%), schizoid PD (27.5%), paranoid PD (20%), dependent PD (20%) and schizotypal PD (12.5%). In most of the patients, two or more PDs could be diagnosed simultaneously (47.5%), comorbilidity of the premorbid PDs in schizophrenia being the most common one. The most frequent combination was avoidant-schizoid-schizotypal PD.

Introduction For many years, psychiatrists have attempted to understand mental illness and its relationship to the characteristics of the patients suffering from it. The relationship between premorbid personality and schizophrenia was first studied in the early years of this century. Some authors proposed that a worsening of previously present schizoid features produced schizophrenia (Bleuler, 1924, Kraepelin, 1913 and Kretschmer, 1925). Others suggested that schizophrenia was independent of the previous personality and that schizophrenic patients could have previously had normal personalities or any PD (Jaspers, 1948 and Schneider, 1974). It has been suggested that PDs can be considered as intermediate points on a spectrum having mild traits at one extreme and serious symptomatic disorders at the other (Claridge, 1987, Kretschmer, 1925, Meehl, 1962, Siever and Davis, 1991 and Stone, 1993). Schizophrenic disorders seem to exist on a spectrum with group A PDs (Baron et al., 1983, Gunderson and Siever, 1985, Kendler and Gruenberg, 1982, Kendler and Gruenberg, 1984, Kendler and Walsh, 1995, Kendler et al., 1981, Kety et al., 1968, Nestadt et al., 1994, Rosenthal et al., 1971 and Torgersen, 1985). Thus schizoid, schizotypal and paranoid disorders are made up by what are called ‘schizophrenia spectrum PDs’. On the other hand, other authors, in agreement with the ideas of Jaspers and Schneider, have found premorbid PDs which do not form a part of the spectrum and which are also associated with schizophrenia. (Arieti, 1974, Bleuler, 1978 and Hogg et al., 1990). The existence of premorbid PDs in schizophrenia is compatible with the neurodevelopment hypothesis of schizophrenia (Lewis, 1989, Murray and Lewis, 1987 and Weinberger, 1987). This hypothesis proposes that schizophrenia arises as a consequence of an early and non-progressive brain lesion. This lesion would be manifested as schizophrenia in adolescence or later, but up to that point the manifestations would be much subtler, appearing either as disorders of premorbid adjustment or as PDs. The existence of premorbid PDs could be the expression of these psychosocial functioning difficulties which would arise from a non-progressive lesion of the CNS. The available evidence suggests that PDs are highly prevalent in both the general population (2–28%) (Casey and Tyrer, 1986 and Casey and Tyrer, 1990) and the general psychiatric population (36–67%) (Dahl, 1986, Jackson et al., 1991, Kass et al., 1985 and Koenigsberg et al., 1985). The high prevalence of PDs in psychiatric patients demands a significant consumption of mental health resources. Consequently, these PDs cannot be overlooked by the psychiatric field. In summary, in the present report we attempt to determine the prevalence of specific PDs in a group of schizophrenic patients.

3. Results 3.1. Number of PDs and associations Of the 40 patients included in this study, 34 of them (85%) have one or more PDs. 15 (37.5%) have only one PD, 13 (32.5%) have two PDs, and 6 of the patients (15%) have more than two PDs. Thus, associated PDs are most frequently found. The 18 patients having two or more disorders constitute 47.5% of the total. The mean number of PDs found in the study was of 1.6±1.3 with a range from 0 to 6. Five associated disorders were found in one patient and six in another. Among those subjects with only one PD, the most frequent was the dependent PD (26.7%), followed by the paranoid PD (20%). In individuals with two or more PDs, the most common association was avoidant-schizoid PD (21% of the total associations). Avoidant-schizotypal PD (12%) and avoidant-dependent PD (12%) coalitions were next in frequency. After these, with a percentage of 9% in each, schizotypal-schizoid, avoidant-paranoid and obsessive-compulsive-paranoid associations were found. 3.2. Correlation among premorbid PDs The correlation between the different PDs was studied using the dimensional measure. The association data coincide with the correlations found (Table 2). The avoidant PD significantly and acceptably correlated with schizotypal and schizoid PD. The schizoid and schizotypal PD also correlated among themselves in a significant and acceptable way, but the fact that no important correlation of these disorders with the paranoid PD was found stands out. Table 2. Correlation among the different types of premorbid personality PD Avoidant Dependent Obsessive-compulsive Passive-aggressive Self-defeating Paranoid Schizotypal Schizoid Histrionic Narcissistic Borderline Antisocial B Antisocial C Avoidant - 0.27 0.35a −0.10 0.02 0.34a 0.57a 0.51a −0.26 −0.04 0.03 −0.30 −0.32a Dependent - −0.07 0.16 −0.14 −0.17 −0.24 −0.30 0.27 0.40a 0.27 −0.16 −0.12 Obsessive-compulsive - −0.18 0.19 0.54a 0.11 0.10 0.01 0.18 −0.06 −0.32a −0.21 Passive-aggressive - −0.06 0.09 0.05 −0.23 0.37a 0.48a 0.48a 0.30 0.40a Self-defeating - 0.36a 0.09 −0.09 −0.21 −0.22 −0.05 −0.17 0.02 Paranoid - 0.29 0.02 −0.21 0.10 0.11 −0.05 −0.02 Schizotypal - 0.65a −0.42a −0.02 −0.13 0.16 −0.02 Schizoid - −0.37a −0.24 −0.21 −0.11 −0.23 Histrionic - 0.51a 0.34a 0.01 0.01 Narcissistic - 0.45a 0.28 0.19 Borderline - 0.13 0.42a Antisoc. B - 0.60a Antisoc. C - a Correlation of Pearson significant p<0.05 Table options The dependent PD, which most frequently appears alone, does not correlate with any PDs, except in a very mild way with the narcissistic one. Other important correlations are the obsessive–compulsive–paranoid, histrionic–narcissistic and narcissistic–borderline ones. The correlation between the ‘B’ and ‘C’ criteria of the antisocial disorder is also acceptable. The passive-aggressive PD correlates with almost all PDs of the ‘dramatic’ group. The correlations described up to now have been positive. Regarding the negative correlations, only the schizotypal and schizoid PD with the histrionic PD, and the antisocial PD with avoidant and obsessive-compulsive PD, in a mild way, can be mentioned. 3.3. Frequency of PDs When the criteria in DSM-III-R for the diagnosis of PDs are used, the results in our schizophrenics sample are shown in Table 3. Avoidant PD is the most frequent, appearing in 32.5% of schizophrenics. Schizoid PD (27.5%) is the next in frequency, followed by paranoid and dependent PD with 20% each. Next in frequency is schizotypal PD which appears in only 12.5% of the cases. It should also be mentioned that 10% of the patients have an obsessive-compulsive PD and another 10% had a childhood behavior disorder (Antisocial B criterion). Table 3. Prevalence of premorbid PDs in schizophrenia PDs DSM-III-R N % Avoidant 13 32.5 Dependent 8 20.0 Obsessive-compulsive 4 10.0 Passive-aggressive 2 5.0 Self-defeating 2 5.0 Paranoid 8 20.0 Schizotypal 5 12.5 Schizoid 11 27.5 Histrionic 2 5.0 Narcissistic 2 5.0 Borderline 1 2.5 Antisocial B 4 10.0 Antisocial C 3 7.5 Table options 3.4. Clinical characteristics of the patients with PDs Table 4 shows the clinical characteristics of the patients with different types of PDs. We can verify how patients with avoidant PD are more frequently single than the other patients in the complete sample. Patients with a dependent PD also present paranoid schizophrenias, lack a family history of schizophrenia and condition development, so that their development always occurs in attacks without any deterioration. They also tend to be single less frequently and to have a somewhat greater functioning during the disease. Patients with schizoid or schizotypal PD are more frequently single and have a clear preponderance towards process evolutions with more tendency towards deterioration. Table 4. Clinical characteristics of patients with PDs Variable Total sample Avoidant PD Dependent PD Paranoid PD Schizoid and schizotypal PD N 40 13 8 8 12 Male sex 55% 62% N.S. 50% N.S. 63% N.S. 67% N.S. Single 70% 92% p<.05 38% p< .1 63% N.S. 92% p<.05 Age of disease onset 24±4.5 24±5 N.S. 24±4 N.S. 28±4 N.S. 23±5 N.S. No. of hospi-talizations 1.4±1.6 0.8±1.1 N.S. 1.3±2.5 N.S. 1.3±1 N.S. 1±1 N.S. Paranoid type 75% 62% N.S 100% p<.001 88% N.S. 58% N.S. Process evolution 28% 46% N.S. 0% p<.001 14% N.S. 67% p<.05 Family background 15% 8% N.S. 0% p<.01 13% N.S. 33% N.S. GAF in the disease 26±7 25±8 N.S. 31±5 p<.1 24±4 N.S. 23±8 N.S.