اختلال شخصیتی همراه در افراد مبتلا به اختلال وحشت: آیا اختلال شخصیتی باعث افزایش شدت بالینی است؟

Abstract Personality disorders are common in subjects with panic disorder. Personality disorders have been shown to affect the course of panic disorder. The purpose of this study was to examine which personality disorders affect clinical severity in subjects with panic disorder. This study included 122 adults (71 women, 41 men) who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for panic disorder (with or without agoraphobia). Clinical assessment was conducted by using the Structured Clinical Interview for DSM-IV Axis I Disorders, the Structured Clinical Interview for DSM-IV Axis II Personality Disorders, and the Panic and Agoraphobia Scale, Global Assessment Functioning Scale, Beck Depression Inventory, and State-Trait Anxiety Inventory. Patients who had a history of sexual abuse were assessed with Sexual Abuse Severity Scale. Logistic regressions were used to identify predictors of suicide attempts, suicidal ideation, sexual abuse, and early onset of disorder. The rates of comorbid Axes I and II psychiatric disorders were 80.3% and 33.9%, respectively, in patients with panic disorder. Patients with panic disorder with comorbid personality disorders had more severe anxiety, depression, and agoraphobia symptoms, had earlier ages at onset, and had lower levels of functioning. The rates of suicidal ideation and suicide attempts were 34.8% and 9.8%, respectively, in subjects with panic disorder. The rate of patients with panic disorder and a history of childhood sexual abuse was 12.5%. The predictor of sexual abuse was borderline personality disorder. The predictors of suicide attempt were comorbid paranoid and borderline personality disorders, and the predictors of suicidal ideation were comorbid major depression and avoidant personality disorder in subjects with panic disorder. In conclusion, this study documents that comorbid personality disorders increase the clinical severity of panic disorder. Borderline personality disorder may be the predictor of a history of sexual abuse and early onset in patients with panic disorder. Paranoid and borderline personality disorders may be associated with a high frequency of suicide attempts in patients with panic disorder.

. Introduction In psychiatry, about one half of all patients have personality disorder, which are frequently comorbid with Axis I conditions. Personality factors interfere with the response to treatment of all Axis I syndromes and increase personal incapacitation, morbidity, and mortality of these patients. Moreover, personality disorders are a predisposing factor for many other psychiatric disorders, including substance use disorders, suicide, mood disorders, impulse-control disorders, eating disorders, and anxiety disorders [1]. Personality disorders are common in subjects with panic disorder. The comorbidity rates of panic disorder and personality disorders are reported to be between 35% and 95% [2], [3], [4], [5], [6], [7] and [8]. Starcevic et al [9] found high rates of Axes I and II psychiatric disorders in subjects with panic disorder (88.6% and 48.6%, respectively). These rates were higher in subjects with suicidal thoughts (92% and 76.7%, respectively). Borderline and dependent personality disorders were the most prevalent personality disorders (22.7%). Borderline personality disorder was the most prevalent personality disorder in subjects with suicidal thoughts (48%). Reich [10] reported high rates of cluster B (antisocial, borderline, histrionic, and narcissistic) and cluster C (avoidant, dependent, and obsessive-compulsive) personality disorders in patients with panic disorder. It has been found a strong negative association between the outcome of treated panic disorder and the presence of antisocial, borderline, histrionic, and narcissistic personality disorders. Skodol et al [11] found that panic disorder, either current or lifetime, is associated with borderline, avoidant, and dependent personality disorders. Their results indicated that anxiety disorders with personality disorders are characterized by chronicity and lower levels of functioning compared with anxiety disorders without personality disorders. Dammen et al [12] found that borderline and avoidant personality disorders were significantly more often in patients with panic disorder than in patients without panic disorder. In patients with panic disorder, the presence of any personality disorder was significantly associated with higher scores of self-reported anxiety-agoraphobia symptoms, neuroticism, and the presence of suicidal thoughts. Mavissakalian et al [13] found that the major personality disorders identified in panic/agoraphobic patients were avoidant, dependent, histrionic, and borderline personality disorders. Personality disorders have been shown to affect the course of panic disorder. Individuals with comorbid panic disorder and personality disorder were twice as likely as patients with panic disorder but without personality disorder to have a history of depression, a history of childhood anxiety disorder, and a chronic unremitting course [14]. Langs et al [3] found a rate of 41.7% comorbid major depressive disorder in subjects with panic disorder. The rate of comorbid personality disorder in subjects with pure panic disorder (40.8%) is lower than subjects with panic disorder and comorbid depressive disorder (68.6%). A significant statistical association was found between personality disorder and depression in subjects with panic disorder. Starcevic et al [9] reported that suicidal thoughts, comorbid personality disorders (especially clusters C and B), and depression affect the severity of panic disorder. The effects of personality disorders on the short-term treatment of panic disorder were examined in a study by Black et al [15]. These investigators examined 66 patients who had completed 3 weeks of treatment with fluvoxamine (n = 23), cognitive therapy (n = 20), or placebo (n = 23). Treatment response was weakened by the presence of comorbid personality disorders. A similar response was displayed in a study by Fava et al [16]. One hundred ten patients with panic disorder and agoraphobia were treated with behavioral exposure at an outpatient clinic. Sixteen of these patients (19.8%) met the criteria for a personality disorder (dependent, avoidant, histrionic, or narcissistic). As in the study of Black et al [15], poorer outcome was associated with the presence of a personality disorder. Personality disorders are prevalent in subjects with panic disorder. The presence of personality disorders affects the prevalence of depression and other Axis I psychiatric disorders, the risk of suicide, the severity of illness, and the outcome of treatment in patients with panic disorder. It is important to diagnose comorbid personality disorders in patients with panic disorder to plan treatment and to predict prognosis. The purpose of this study was to examine which personality disorders affect clinical severity in subjects with panic disorder.

5. Conclusions In conclusion, this study documents that comorbid personality disorders increase the clinical severity of panic disorder. Patients with comorbid Axis I psychiatric disorders, especially major depression, had higher rate of comorbid personality disorders. Borderline personality disorder may be the predictor of a history of sexual abuse and early onset in patients with panic disorder. Paranoid and borderline personality disorders may be associated with a high frequency of suicide attempts in patients with panic disorder.