صفات اختلال شخصیت در بزرگسالی میانه با خطر ابتلا به افسردگی تک قطبی

Abstract Data from the Children in the Community Study, a prospective longitudinal investigation, were used to investigate the association of personality disorder (PD) traits, evident by early adulthood, with risk for the development of unipolar depressive disorders by middle adulthood. Antisocial, borderline, dependent, depressive, histrionic, and schizotypal PD traits, identified between ages 14 and 22, were significantly associated with risk for dysthymic disorder (DD) or major depressive disorder (MDD) by a mean age of 33 after a history of unipolar depression and other psychiatric disorder was controlled statistically. Individuals without a history of unipolar depression who met diagnostic criteria for ≥ 1 PD by a mean age of 22 were at elevated risk for DD or MDD by a mean age of 33 years. Individuals identified as having a DSM-IV Cluster A (paranoid, schizoid, or schizotypal) or Cluster C (avoidant, dependent, obsessive–compulsive) PD by a mean age of 22 years were at elevated risk for recurrent or chronic unipolar depression. The findings of this study suggest that some types of PD traits that become evident by early adulthood may contribute to an increased risk for the development or recurrence of unipolar depressive disorders by middle adulthood.

Introduction The association of personality disorder (PD) with risk for unipolar depression is of considerable interest to researchers, and it has important clinical and theoretical implications. Clinicians are interested in this association because they recognize the importance of being well informed about the outcomes that may be associated with PD and other mental disorders. A variety of conceptual and theoretical models have been advanced regarding the associations of specific types of PDs with depressive and other Axis I disorders (e.g., Klein et al., 1993 and Lyons et al., 1997). Some PDs may contribute to increased vulnerability for depressive disorders and other Axis I disorders (Gunderson and Phillips, 1991). Common etiological factors have been hypothesized to underlie the development of certain PDs and depressive disorders (Daley et al., 1999). Another hypothesis is that some PDs and mood disorders (e.g., borderline PD and mood disorders; depressive PD and unipolar depression) may occupy different points along a common affective or depressive spectrum (Siever and Davis, 1991 and Klein and Shih, 1998). Some associations between PDs and Axis I disorders could also be attributable, in part, to overlapping diagnostic criteria (Widiger and Shea, 1991). Although research has demonstrated that PDs often co-occur with depressive disorders and other Axis I disorders (e.g., Zanarini et al., 1998, McGlashan et al., 2000 and Dyck et al., 2001), there are significant gaps in the scientific literature. Much of the information that is currently available regarding the association between PD and depressive disorders has been obtained from cross-sectional studies of Axis I–Axis II comorbidity (e.g., Zimmerman and Coryell, 1989, Nestadt et al., 1992 and Oldham et al., 1995). These studies have not been able to investigate hypotheses about the direction of the associations between PDs and depressive disorders. A number of studies, conducted with samples of depressed patients, have investigated PD sequelae, such as the association of PD with treatment outcomes. These investigations have established that depressed patients with PDs tend to have poor outcomes, including dysthymic disorder (DD), recurrent major depressive disorder (MDD), and suicidal behavior (Pilkonis and Frank, 1988, Raczek et al., 1989, Reich, 1990, Shea et al., 1990, Shea et al., 1992, Perry et al., 1992, Ilardi and Craighead, 1995 and Klein, 2003). However, most of these studies had samples of modest size, had relatively brief follow-up intervals (typically 1 year or less), or focused on a limited range of PDs. While many studies have investigated outcomes associated with antisocial and borderline PDs, few have investigated other PDs in a systematic way. Moreover, the findings of studies that have investigated the sequelae of PDs among patients in clinical settings may not apply to the general population. Patients with PDs differ from individuals with PDs in the remainder of the population, insofar as their symptoms tend to be more severe, and treatment may tend to have a systematic and indeterminate impact on the course and outcomes of the disorder. For these reasons, it is important for researchers to obtain data from prospective longitudinal studies of representative, community-based samples. To date, however, few community-based studies have investigated the long-term mental health consequences of PDs. The studies that have investigated the associations of PD with subsequent depressive symptoms have focused on overall PD symptoms (Johnson and Bornstein, 1991 and Johnson et al., 1996), PD clusters (Daley et al., 1999), a limited range of PDs (e.g., Kwon et al., 2000), or included bipolar disorder (Johnson et al., 1999). In all but one of these studies (Johnson et al., 1996), PDs were assessed among adolescents or college students. There have not yet been any comprehensive population-based investigations of specific types of PD symptoms, evident by early adulthood, and risk for subsequent unipolar depressive disorders. It is important to fill this gap in the scientific literature by investigating the long-term sequelae of PDs, which may not become evident until early adulthood, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychiatric Association, 2000). We report findings from the Children in the Community Study, a community-based prospective longitudinal study, regarding the association of PD by early adulthood with risk for unipolar depression by middle adulthood

Results Mean antisocial, borderline, dependent, depressive, histrionic, and schizotypal PD trait levels between ages 14 and 22 were associated with a significantly elevated risk for DD or MDD by mean age 33 when the covariates were controlled (Table 1). There were not enough individuals with specific DSM-IV PD diagnoses to permit multivariate analyses regarding associations of specific PD diagnoses with risk for DD or MDD by mean age 33. Bivariate analyses indicated that individuals with avoidant, borderline, dependent, histrionic, or schizotypal PD by mean age 22 were at greater risk for DD or MDD by mean age 33 than individuals without any PD by mean age 22 (Table 2). Table 1. Association of mean personality disorder (PD) trait level at mean ages 14–22 with risk for dysthymic (DD) or major depressive disorder (MDD) at mean age 33a Personality disorder (PD) Aggregate PD trait level (ages 14–22) Mean (SD) Adjusted odds ratiob,c 95% confidence interval Paranoid PD traits 1.02 (0.90) 1.11 0.84–1.45 Schizoid PD traits 1.03 (0.82) 1.24 0.92–1.68 Schizotypal PD traits 1.83 (0.98) 1.91 1.48–2.46 Antisocial PD traits 1.36 (1.00) 1.32 1.02–1.71 Borderline PD traits 1.32 (1.09) 1.58 1.26–1.97 Histrionic PD traits 1.67 (1.08) 1.43 1.12–1.80 Narcissistic PD traits 1.61 (1.21) 1.15 0.92–1.43 Avoidant PD traits 0.95 (0.85) 1.31 0.99–1.72 Dependent PD traits 1.25 (0.99) 1.32 1.03–1.68 Obsessive–compulsive PD traits 0.86 (0.67) 1.36 0.96–1.92 Depressive PD traits 0.77 (0.83) 1.36 1.05–1.76 Passive-–aggressive PD traits 0.97 (0.94) 1.14 0.89–1.48 a Significant associations (P < 0.05) are indicated in bold print. b Controlling for age, sex, and unipolar depressive disorder, any Axis I anxiety, disruptive, or substance use disorder, and any co-occurring PD between mean ages 14 and 22. c Odds ratio indicates the increase in risk for DD or MDD that would be associated with an elevation of 0.33 PD traits. Thus, for example, an increase from one to two depressive PD traits would be associated with a 108% increase in risk for subsequent DD or MDD. Table options Table 2. Bivariate associations of specific personality disorder (PD) diagnoses at mean ages 14–22 with risk for dysthymic (DD) or major depressive disorder (MDD) at mean age 33a Personality disorder (PD) Prevalence of DD or MDD at mean age 33 among individuals with Odds ratiob 95% confidence interval Fisher's exact test (2-tailed) No PD by mean age 22 Specific PD present by mean age 22 % (n / N) % (n / N) Paranoid PD 9.8 (50 / 509) 22.2 (4 / 18) 2.62 0.83–8.27 P = 0.10 Schizoid PD 9.8 (50 / 509) 27.3 (3 / 11) 3.44 0.88–13.39 P = 0.09 Schizotypal PD 9.8 (50 / 509) 50.0 (6 / 12) 9.18 2.85–29.54 P < 0.001 Antisocial PD 9.8 (50 / 509) 11.1 (2 / 18) 1.15 0.26–5.14 P = 0.70 Borderline PD 9.8 (50 / 509) 36.8 (7 / 19) 5.36 2.02–14.22 P = 0.002 Histrionic PD 9.8 (50 / 509) 27.8 (5 / 18) 3.53 1.21–10.31 P = 0.03 Narcissistic PD 9.8 (50 / 509) 20.0 (4 / 20) 2.62 0.83–8.27 P = 0.14 Avoidant PD 9.8 (50 / 509) 36.8 (7 / 19) 5.36 2.02–14.22 P = 0.002 Dependent PD 9.8 (50 / 509) 33.3 (5 / 15) 4.59 1.51–13.96 P = 0.01 Obsessive–compulsive PD 9.8 (50 / 509) 20.0 (1 / 5) 2.30 0.25–20.93 P = 0.41 Depressive PD 9.8 (50 / 509) 16.7 (2 / 12) 1.84 0.39–8.62 P = 0.34 Passive–aggressive PD 9.8 (50 / 509) 20.0 (5 / 25) 2.30 0.83–6.38 P = 0.16 a Significant associations (P < 0.05) are indicated in bold print. b Odds ratio indicates the increase in risk for DD or MDD that would be associated with the presence of a specific PD, compared with no PD by mean age 22. Table options DSM-IV Cluster A, B, and C PD trait levels and overall PD trait levels by mean age 22 were associated with significantly elevated risk for DD or MDD by mean age 33 (Table 3). Individuals with DSM-IV Cluster A (i.e., paranoid, schizoid, or schizotypal PDs) or Cluster C PDs (i.e., avoidant, dependent, and obsessive–compulsive PDs) by mean age 22 were at significantly elevated risk for DD or MDD by mean age 33 when the covariates were controlled. Table 3. Association of DSM-IV Cluster A, B, and C personality disorders (PDs) at mean ages 14–22 with risk for dysthymic (DD) or major depressive disorder (MDD) at mean age 33a Personality disorder (PD) Aggregate PD trait level (ages 14–22) Mean (SD) Adjusted odds ratio: PD traits (95% CI)b,c Prevalence of DD or MDD at mean age 33 among individuals Adjusted odds ratio: PD diagnosis (95% CI)b,d Without PD diagnosis by mean age 22 With PD diagnosis by mean age 22 % (n / N) % (n / N) DSM-IV Cluster A PDs 3.88 (2.07) 1.21 (1.08–1.36) 11.5 (71 of 620) 31.6 (12 of 38) 2.26 (1.01–5.08) • Paranoid PD • Schizoid PD • Schizotypal PD DSM-IV Cluster B PDs 4.81 (2.95) 1.16 (1.06–1.27) 11.5 (69 of 602) 25.0 (14 of 56) 1.12 (0.54–2.36) • Antisocial PD • Borderline PD • Histrionic PD • Narcissistic PD DSM-IV Cluster C PDs 3.06 (1.98) 1.19 (1.05–1.35) 11.3 (70 of 620) 34.2 (13 of 38) 2.43 (1.11–5.30) • Avoidant PD • Dependent PD • Obsessive–compulsive PD Any DSM-IV PD 13.28 (6.98) 1.07 (1.04–1.11) 9.8 (50 of 509) 22.1 (33 of 149) 1.48 (0.85–2.58) a Significant associations (P < 0.05) are indicated in bold print. b Controlling for age, sex, and unipolar depressive disorder, any Axis I anxiety, disruptive, or substance use disorder, and any co-occurring PD between mean ages 14 and 22. c Odds ratio indicates the increase in risk for DD or MDD that would be associated with a mean elevation of 0.33 PD traits. Thus, an increase in the overall PD trait level from 1 to 2 PD traits would be associated with a 21% increase in risk for subsequent DD or MDD. d Odds ratio indicates the increase in risk for DD or MDD that would be associated with the presence of a PD diagnosis by mean age 22. Table options Individuals who met the diagnostic criteria for one or more PDs by mean age 22 but did not have a unipolar depressive disorder by mean age 22 were at significantly elevated risk for DD or MDD at mean age 33 [bivariate odds ratio (OR) = 2.49, 95% confidence interval (CI) = 1.36–4.58] (Fig. 1). However, the presence of one or more PDs by mean age 22 was not significantly associated with risk for DD or MDD among individuals with a history of unipolar depression. In addition, the overall association of PD status with subsequent unipolar depressive disorders was not significant when the covariates were controlled (Table 3). Association of personality disorders (PDs), evident by mean age 22, with risk ... Fig. 1. Association of personality disorders (PDs), evident by mean age 22, with risk for unipolar depressive disorders at mean age 33 among individuals with and without a history of unipolar depressive disorder by mean age 22. Figure options Bivariate analyses indicated that individuals with Cluster C PDs by mean age 22 who had a history of unipolar depressive disorder were at particularly elevated risk for DD or MDD by mean age 33 (OR = 3.88, CI = 1.40–10.75) (Fig. 2). A similar pattern of findings was obtained with regard to Cluster A PDs that were evident by mean age 22, though the effect size for Cluster A PDs was somewhat smaller than the Cluster C effect size (OR = 3.38, CI = 1.20–9.53). Association of DSM-IV Cluster C personality disorders (PDs), evident by mean age ... Fig. 2. Association of DSM-IV Cluster C personality disorders (PDs), evident by mean age 22, with risk for unipolar depressive disorders at mean age 33 among individuals with and without a history of unipolar depressive disorder by mean age 22.