روابط بین اختلال افسردگی اساسی و اضطراب و اختلالات شخصیتی

Abstract Objective The aim of the study was to examine whether comorbid anxiety disorders influence depressed patients' likelihood of meeting criteria for a personality disorder (PD) and whether comorbid anxiety disorders influence the stability of the PDs in patients with remitted depression. Methods The initial sample consisted of 373 outpatients who met criteria for major depressive disorder (MDD) (by Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition—Patient Edition) and who were enrolled in the 8-week acute treatment phase of a study of fluoxetine for MDD. Sixty-four subjects who responded to fluoxetine treatment in the acute phase met criteria for remission throughout a 26-week continuation phase during which they remained on fluoxetine with or without cognitive behavioral therapy. Stability of PDs was defined as meeting criteria for a PD at both beginning and end point of the continuation treatment phase. Results Before fluoxetine treatment, anxious depressed patients (defined as meeting criteria for MDD as well as at least one comorbid anxiety disorder) were significantly more likely to meet criteria for any comorbid PD diagnosis compared with depressed patients without comorbid anxiety disorders. In particular, there was a significant relationship between the presence of Cluster A and C PDs and the presence of anxious depression at baseline before antidepressant treatment. After successful treatment of MDD, we found a significant relationship between anxious depression diagnosed at baseline and the stability of a Cluster C PD diagnosis. Conclusion Anxious depression may place patients at greater risk of having a PD diagnosis, especially one from Cluster A or C. Once the depression remits, patients who initially met criteria for anxious depression may be more likely to maintain a Cluster C PD diagnosis compared with patients initially diagnosed with MDD alone.

Introduction Research suggests a complex relationship between major depressive disorder (MDD), anxiety disorders, and personality disorders (PDs). In some cases, meeting criteria for MDD as well as at least one comorbid anxiety disorder is referred to as anxious depression [1], which appears quite prevalent. For example, Fava and colleagues [2] found that 44.7% of 255 outpatients with MDD met criteria for a comorbid anxiety disorder, whereas Melartin and colleagues [3] found that 57% of 269 patients with MDD met criteria for a comorbid anxiety disorder. Some investigators have examined the impact of anxious depression on the treatment of MDD, with varied results. Most studies report a decreased likelihood of response to antidepressant treatment if a patient meets criteria for anxious depression [4], [5] and [6], although not all studies support this view [7]. As part of the Harvard/Brown Anxiety Research Project, Dyck and colleagues [8] found that whereas generalized anxiety disorder, social phobia, and MDD were positively associated with the presence of one or more PDs, panic disorder with agoraphobia was not positively associated with the presence of PDs. Zlotnick and colleagues [9] examined the relationship between borderline personality disorder (BPD) and posttraumatic stress disorder. They found that women having both disorders were likely to have more general dysfunction and increased risk of hospitalization. There is limited research on the impact of anxious depression on personality pathology. Reich [10] proposed that personality pathology might emerge in part from stress related to comorbid anxiety and depression. By reviewing previously published studies, Reich [10] found an association between comorbid anxiety, depression, and PDs. A few studies [11] and [12] have shown that different profiles of the Tri-dimensional Personality Questionnaire [13] emerged between patients with MDD alone compared with patients with anxious depression. For example, 2 studies showed that anxious depressed patients exhibit higher harm avoidance (HA) scores compared with those that have MDD alone [11] and [12]. In addition, Ongur and colleagues [14] found that patients who have MDD with comorbid social anxiety disorder or generalized anxiety disorder reported higher HA scores, whereas patients who have MDD with comorbid social anxiety, obsessive compulsive disorder, or panic disorder reported lower scores in novelty seeking. Melartin and colleagues [3] have also suggested that anxious depression is associated with specific personality clusters. These reports suggest that specific patterns of personality pathology may be significantly related to anxious depression. On a related note, Joyce and colleagues [15] suggested that a combination of risk factors (temperament, childhood experiences, and childhood/adolescent psychopathology) contributes to the presence of personality pathology, especially BPD and avoidant personality disorder. The authors suggested that although BPD may arise from a combination of childhood abuse and/or neglect, borderline temperament, and childhood/adolescent depression, avoidant personality disorder is more likely to arise from a combination of high HA, parental neglect, and childhood and adolescent anxiety disorders [15]. In regard to stability of PD diagnoses, we have previously shown that although a number of PD diagnoses are no longer present among depressed outpatients successfully treated with antidepressants [16], PD diagnoses are generally more stable among outpatients with remitted MDD [17]. Based on our literature review, no studies have examined the impact of anxious depression on the stability of PDs in remitted depressed outpatients. Given the above findings, and the frequent co-occurrence of comorbid anxiety and comorbid personality pathology in MDD, we wanted to further clarify the relationship between comorbid anxiety disorders and the occurrence of PDs in patients with MDD and the relationship between anxious depression and the stability of PDs in patients with remitted MDD.

Results Three hundred seventy-three subjects completed the SCID-II baseline assessment and were deemed eligible for further analysis. The demographic and clinical characteristics of the 373 outpatients with MDD are summarized in Table 1. Our sample was composed of the following: 55% women; 48% of all patients were never married; 49% were college graduates; and 63% were employed at the time of the study. The mean age for our sample was 39.9 ± 10.5 years. The mean HAMD-17 score was 19.6 ± 3.4 at baseline, and the mean age of onset of first MDD was 26.0 ± 13.4 years. The mean duration of the current depressive episode was 3.5 ± 7.4 years, with the following frequency of episodes: 48% reported 1 depressive episode, 14% reported 2 episodes, and 38% reported 3 or more depressive episodes. Sixty-four percent of the sample met criteria for any PD disorder, 26% for Cluster A, 26% for Cluster B, and 57% for Cluster C. Forty-two percent met criteria for anxious depression at baseline. See Table 1, Table 2 and Table 3 for characteristics of MDD, rates of PDs, and rates of anxious depression. Table 1. Demographic and clinical characteristics of enrolled subjects Demographic and clinical factors Acute phase (n = 373) Continuation phase (n = 64) n % n % Females 204 55 33 52 Marital status Never married 178 48 28 44 Married once 86 23 19 30 Divorced 60 16 12 19 Divorced/widowed and remarried 49 13 5 8 Employed 236 63 48 75 Education Some high school 12 3 1 2 High school/GED 52 14 11 17 Some college 94 25 15 23 2-y College 33 9 1 2 4-y College and more 182 49 36 56 No. of lifetime episodes of MDD 1 Episode 180 48 17 27 2 Episodes 53 14 7 11 ≥3 Episodes 140 38 40 63 GED indicates General Educational Development Diploma. Table options Table 3. Prevalence rates of anxious depression and PDs Acute phase (n = 373) Continuation phase (n = 64) n % n % Any PD diagnosis 238 64 32 50 Cluster A 97 26 8 13 Cluster B 96 26 8 13 Cluster C 214 57 27 42 Anxious depression 155 42 27 42 Table options Table 2. Age and characteristics of depression for enrolled subjects Acute phase (n = 373) Continuation phase (n = 64) Mean SD Mean SD Age (y) 39.9 10.5 42.5 8.9 HAMD-17 beginning 19.6 3.4 4.50 2.22 Age of onset of first MDD (y) 26.0 13.4 24.9 13.3 Duration of current episode of MDD (y) 3.5 7.4 2.5 4.5 Table options In the continuation phase, 64 patients met criteria for remitted MDD. The number of subjects in each category (any PD, Cluster A, Cluster B, and Cluster C) changed based on the number of subjects who meet criteria for a stable PD in that category. See Table 1, Table 2 and Table 3 for characteristics of MDD, rates of PDs, and rates of anxious depression. In the preliminary analysis of the acute phase, meeting criteria for any PD at baseline was significantly related to sex (P = .0005) and to severity of depression (P = .0062) at baseline, but not to age (P = .2357). Meeting criteria for a Cluster A diagnosis was related to severity of depression (P = .0301) and to sex (P = 0004), but not to age (P = .1697). Meeting criteria for a Cluster B diagnosis was related to severity of depression (P = .0052), to sex (P = .0029), and to age (P = .0035). Meeting criteria for Cluster C was related to severity of depression (P = .0003) and to sex (P = .0347), but not to age (P = .2668). After controlling for these relationships in our multiple logistic regressions, there was a significant relationship at baseline between meeting criteria for any PD diagnosis and meeting criteria for anxious depression (R2 = 0.099; P ≤ .0001). Likewise, there was a significant relationship between meeting criteria for a Cluster A diagnosis (R2 = 0.072; P = .0003) and for a Cluster C diagnosis (R2 = 0.076; P ≤ .0001) and meeting criteria for anxious depression (see Table 4). Table 4. Relationship between anxious depression and meeting criteria for a PD diagnosis or clusters at baseline Acute phase Anxious depression Yes No R2 P n % n % Any diagnosis 124 (155) 80 114 (218) 52 0.099 <.0001* Cluster A 57 (155) 37 40 (218) 18 0.072 .0003* Cluster B 48 (155) 31 48 (218) 22 0.066 .2175 Cluster C 112 (155) 72 102 (218) 47 0.076 <.0001* * Significant at P ≤ .05. Table options In the preliminary analysis of the continuation phase, age was not related to having any stable PD diagnosis or to having a stable Cluster A, B, or C PD. Sex was related to having a stable Cluster A diagnosis (P = .0340) as well as to having a stable Cluster B diagnosis (P = .0258). As summarized in Table 5, there was no significant relationship between anxious depression and the stability of any PD diagnosis, Cluster A, or Cluster B PD diagnosis. However, there was a significant relationship between anxious depression and the stability of a Cluster C diagnosis (R2 = 0.079; P = .0437). Table 5. Relationship between anxious depression at baseline and meeting criteria for a stable PD diagnosis during remission of MDD Continuation phase Anxious depression Remitted MDD Yes No R2 P n % n % Any stable PD diagnosis 10(17) 59 10(27) 37 0.033 .1615 Stable Cluster A 3 (24) 13 3 (32) 9 0.132 .5468 Stable Cluster B 0 (22) 0 4 (34) 12 0.338 .9823 Stable Cluster C 9 (18) 50 5 (25) 20 0.079 .0437* * Significant at P ≤ .05.