اختلالات شخصیتی در بیماران مبتلا به اختلال جسمانی سازی: یک مطالعه کنترل شده در اسپانیا

Abstract Objective The aim of this paper is to assess personality disorder (PD) comorbidity in somatization disorder (SD) patients compared with psychiatric controls in a Spanish sample. Methods This is a case–control study. Selection of 70 consecutive SD patients was made, and an age-, sex-, and ethnic-group-matched control group of 70 mood and/or anxiety disorder patients recruited in psychiatric outpatient clinics was selected. PDs were measured using the International Personality Disorder Examination, and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Axis I morbidity was measured by means of the Standardized Polyvalent Psychiatric Interview. Results PD comorbidity in SD patients was 62.9%, compared to 28.2% in controls [odds ratio (OR)=3.7; 95% confidence interval (95% CI)=1.8–7.6]. The highest ORs of PD in SD patients, compared with controls, were for paranoid (OR=9.2; 95% CI=1.9–43), obsessive–compulsive (OR=6.2; 95% CI=1.2–53.6), and histrionic (OR=3.6; 95% CI=0.9–13.9) PDs. Conclusions This is a controlled study with the largest sample of SD patients. The prevalence of PD comorbidity is similar to that of a previously published controlled study but is different from those of the most frequent PD subtypes.

Introduction Somatization disorder (SD) is considered the most valid, reliable, and stable-over-time disorder from the whole group of somatoform disorders [1]. From the few published studies on personalities in SDs [2], [3] and [4], it is widely accepted that the association between personality disorders (PDs) and SDs is frequent and intense, and appears early in the history of the patient. In fact, several authors consider somatoform disorders as a form of PD and believe that they should not be included in the Diagnostic and Statistical Manual (DSM) Axis I, but in Axis II disorders instead [5]. Unfortunately, there is only one controlled study on this subject [4], which is in need of replication. Moreover, despite the acceptance of the great influence of transcultural factors on the prevalence and expression of both SD and PD [6], all prior studies on PD and SD have been developed in Western English-speaking countries. Presently, when the very validity of somatoform disorders is being questioned to the extent that this category could disappear in the next Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [7] and [8], research on this subject may shed some light on this discussion. The aim of this article is to compare a group of Spanish SD outpatients to an age-, sex-, and ethnic-group-matched control group of psychiatric outpatients diagnosed with depressive and anxiety disorders, in order to determine the differences in the prevalence of Axis II disorders.

Results All patients in the study were White and Spanish speaking. The majority of the sample were middle-aged married women with a low education level. There were no significant differences in sociodemographic characteristics, as expected, given the matching selection of controls (Table 1). The only exception was disability, which was more frequent in SD patients than in controls. Table 1. Demographics of the sample SD (n=70) Controls (n=70) Difference Sex [n (% female)] 62 (88.5) 62 (88.5) nsa Age in years [mean (S.D.)] 47.6 (7.1) 48.7 (7.3) nsb Length of education in years [mean (S.D.)] 8.1 (1.5) 8.3 (1.6) nsb Married [n (%)] 55 (78.6%) 52 (73.2%) nsa Disability [n (%)] a 37 (52.8%) 17 (23.9%) P<.05 ⁎ a McNemar test. b Wilcoxon matched-pairs signed-rank test. ⁎ P=.033, binomial test computed. Table options Many SD patients showed associated Axis I comorbidity. Table 2 summarizes this comorbidity and the psychiatric diagnoses of controls. Only 38.6% of SD patients did not present Axis I comorbidity. The remaining SD patients mainly suffered from depressive disorders (major depressive disorder, 12.8%; dysthymia, 11.4%), anxiety disorders (panic disorder with or without agoraphobia, 12.8%; generalized anxiety disorder, 10%; agoraphobia, 4.2%), and other depressive and anxiety disorders (5.6%), giving a total of 56.8%. Table 2. Associated Axis I comorbidity of SD patients (n=70) and Axis I psychopathology of controls (n=70) DSM-IV diagnosis SD [n (%)] a Controls [n (%)] b Major depressive disorder (296.00) 9 (12.8) 34 (48.5) Panic disorder with or without agoraphobia (300.01 and 300.21) 9 (12.8) 20 (28.5) Dysthymia (300.40) 8 (11.4) 13 (25.7) Generalized anxiety disorder (300.02) 7 (10) 15 (21.4) Alcohol abuse/dependence (303.90) 5 (7.1) 2 (2.8) Agoraphobia (300.22) 3 (4.2) 6 (8.5) Obsessive–compulsive disorder (300.03) 2 (2.8) 0 (0) Drug abuse/dependence (305.50) 2 (2.8) 3 (4.2) Other depressive and anxiety disorders (311.00 and 30023) 4 (5.6) 9 (12.6) No additional Axis I disorder 27 (38.6) 0 (0) a Six SD patients presented two additional psychiatric diagnoses in Axis I. b Thirty-two control patients presented two Axis I psychiatric diagnoses. Table options In the control group, there was a predominance of depressive disorders (major depressive disorder, 48.5%; dysthymia, 25.7%), followed by anxiety disorders (panic disorder with or without agoraphobia, 28.5%; generalized anxiety disorder, 21.4%; agoraphobia, 8.5%). Alcohol/drug dependence/abuse was 9.9% in SD patients and 7% in the control group. Table 3 summarizes PDs in SD patients and controls. As can be seen, Axis II comorbidity in SD patients was 63.9%, while it was 28.2% in the control group. The OR of suffering from a PD in the SD group was 3.7 [95% confidence interval (95% CI)=1.8–7.6], compared to the control group. The most frequent PDs in the SD group were paranoid (15.7%), histrionic (14.2%), and avoidant (12.8%) PDs; meanwhile, in the control group, they were borderline (7.1%), avoidant (5.6%), and antisocial, histrionic, and dependent (4.2% each) PDs. However, when we observed the OR, the PDs with higher OR in the SD group, compared with the control group, were paranoid (OR=9.2; 95% CI=1.9–43), obsessive–compulsive (OR=6.2; 95% CI=1.2–53.6), and histrionic (OR=3.6; 95% CI=0.9–13.9) PDs. Table 3. PDs in SD patients (n=70) and controls (n=70) Personality disorder SD [n (%)] a Control [n (%)] b OR (95% CI) Cluster A Paranoid (301.0) 11 (15.7) 2 (2.8) 9.2 (1.9–43.0) Schizoid (301.20) 2 (2.8) 1 (1.4) 2.0 (0.1–22.9) Schizotypal (301.22) 1 (1.4) 0 (0) NAc Cluster B Antisocial (301.7) 7 (10) 3 (4.2) 2.5 (0.6–10.3) Borderline (301.83) 7 (10) 5 (7.1) 1.5 (0.4–5.0) Histrionic (301.50) 10 (14.2) 3 (4.2) 3.6 (0.9–13.9) Narcissistic (301.81) 1 (1.4) 0 (0) NAc Cluster C Avoidant (301.82) 9 (12.8) 4 (5.6) 2.5 (0.7–8.5) Dependent (301.60) 8 (11.4) 3 (4.2) 3.0 (0.7–11.8) Obsessive–compulsive (301.40) 6 (8.5) 1 (1.4) 6.2 (1.2–53.6) No PDs 26 (37.1) 51 (71.8) One or more PDs 44 (63.9) 20 (28.2) 3.7 (1.8–7.6) a Seventeen patients present two Axis II disorders. b Two patients present no Axis II disorder. c Not available (denominator=0).