Social phobia, avoidant personality disorder and atypical depression: co-occurrence and clinical implications

BACKGROUND: Increasing attention has been directed in recent years to the detection and treatment of psychiatric co-morbidity among depressed individuals. The overlap of social phobia (SP) and avoidant personality disorder (APD) has been well recognized and a relationship between these disorders and depression has been suggested. METHODS: The pattern and clinical implications of co-morbidity of SP and APD with major depressive disorder (MDD), diagnosed by DSM-III-R criteria, were studied among 243 out-patients presenting with depression. RESULTS: Overall, 26.7% of adults in our sample with MDD met criteria for SP and 28.4% for APD. Almost two-thirds of depressed adults meeting criteria for social phobia or avoidant personality disorder met criteria for both (SP+APD). Depressed adults who met criteria for both SP+APD exhibited a significantly higher proportion of atypical depression (54.8%) compared with those with neither SP nor APD (31.1%). Among depressed patients, the co-occurrence of SP with APD was also associated with an earlier age of onset of MDD, a greater number of comorbid Axis I diagnoses, and greater impairment of social adjustment and assertiveness. CONCLUSIONS: Results confirm the overlap of SP and APD in a depressed population and the high prevalence of these disorders in MDD. They suggest that depressed individuals with both SP and APD but not SP alone are at particularly high risk for atypical depression and for social dysfunction in excess of that caused by a current major depression.     

Antisocial personality disorder, conduct disorder, and substance abuse in schizophrenia.

The validity of subtypes based on antisocial personality disorder (APD) or childhood conduct disorder without adult APD (CD only) in patients with schizophrenia (or schizoaffective disorder) and a substance use disorder (abuse or dependence) was examined. APD patients scored lower on personality measures related to socialization and higher on antisocial bebavior, psychopathy, and aggression. APD patients also reported higher rates of aggression and legal problems. APD, and to a lesser extent CD only, was associated with more severe psychiatric symptoms, an earlier age of onset of substance abuse, more severe symptoms of substance abuse, and a stronger family history of substance abuse and psychiatric hospitalization. The findings suggest that schizophrenia patients with APD represent a high-risk subgroup vulnerable to more severe substance abuse, psychiatric impairment, aggression, and legal problems. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Development of antisocial personality disorder in detained youths: The predictive value of mental disorders.

Antisocial personality disorder (APD) is a serious public and mental health concern. Understanding how well conduct disorder (CD) and other mental disorders predict the development of APD among youths involved in the juvenile justice system is critical for prevention. The authors used a stratified random sample of 1,112 detained youths to examine the development of APD at a 3-year follow-up interview. Nearly one fifth of male juvenile detainees later developed APD; approximately one quarter of male juvenile detainees with CD at baseline later developed APD. Significantly more males than females developed APD; no differences were found by race/ethnicity. Having 5 or more symptoms of CD, dysthymia, alcohol use disorder, or generalized anxiety disorder was significantly associated with developing modified APD (M-APD; APD without the CD requirement). Some disorders were strong predictors of APD; however, none were adequate screeners for identifying which detainees would later develop M-APD. The findings of this study have implications for interventions and further research in developmental psychopathology. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Response to methadone maintenance and counseling in antisocial patients with and without major depression

This study compared the treatment response of four groups of psychiatrically diverse opiate-dependent, methadone maintenance patients receiving drug counseling. The four groups were patients with no other nonsubstance abuse axis I psychiatric diagnoses (OP only; N = 65), patients with lifetime major depression (DEP; N = 60), patients with both antisocial personality disorder and lifetime major depression (APD + DEP; N = 35), and patients with only APD (APD only; N = 24). Patients were assessed at intake, during treatment, and 7 months after treatment admission. No statistically significant differences were found among the groups in treatment retention/attendance. Few significant group differences were revealed during-treatment urine screens, except that barbiturate use was more common for the APD only group. The APD only group also had significantly more positive urine screens for benzodiazepines than the other three groups at 7-month follow-up. All groups reported considerable improvement in problem level at 7 months compared with admission status. The APD only group reported fewer gains in legal and employment problems than the other groups but reported greater improvement in the drug area. Thus, there was some limited support for a prior finding, based on individual psychotherapy, that the treatment response of APD only patients was inferior to that of APD + DEP patients or non-APD patients.     

The comorbidity of alcoholism and personality disorders in a clinical population: Prevalence and relation to alcohol typology variables.

This study assessed prevalence rates and overlap among Diagnostic and Statistical Manual of Mental Disorders ( 3rd ed., revised; DSM-III—R; American Psychiatric Association, 1987) personality disorders in a multisite sample of 366 substance abusers in treatment. In addition, the relation of antisocial personality disorder (APD), borderline personality disorder (BPD), and paranoid personality disorder (PPD) to alcohol typology variables was examined. Structured diagnostic interviews and other measures were administered to participants at least 14 days after entry into treatment. Results indicated high prevalence rates for APD and non-APD disorders. There was extensive overlap between Axis I disorders and personality disorders, and among personality disorders themselves. APD, BPD, and PPD were linked to more severe symptomatology of alcoholism and other clinical problems. However, only APD and BPD satisfied subtyping criteria, after controlling for other comorbidity. Implications for classifying alcoholics by comorbid disorders are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Familial risk factors to oppositional defiant disorder and conduct disorder: Parental psychopathology and maternal parenting.

In a sample of 177 clinic-referred children (aged 7–13 yrs), an association was found between a diagnosis of conduct disorder (CD) and several aspects of family functioning: maternal parenting (supervision and persistence in discipline) and parental adjustment (paternal antisocial personality disorder and paternal substance abuse). Children with oppositional defiant disorder were intermediate to families of children with CD and clinic control children on all variables, but differed from control children only in having a higher rate of paternal substance abuse and paternal antisocial personality disorder (APD). When both parental APD and deviant maternal parenting were entered into 2?×?2 logit-model analyses predicting CD, only parental APD was significantly associated with CD, and no interactions between parental adjustment and maternal parenting were found. The importance of these findings for understanding the etiology of CD and for disentangling correlated risk factors in future studies is discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Speed and accuracy of facial expression classification in avoidant personality disorder: A preliminary study.

The aim of this preliminary study was to examine whether individuals with avoidant personality disorder (APD) could be characterized by deficits in the classification of dynamically presented facial emotional expressions. Using a community sample of adults with APD (n = 17) and non-APD controls (n = 16), speed and accuracy of facial emotional expression recognition was investigated in a task that morphs facial expressions from neutral to prototypical expressions (Multi-Morph Facial Affect Recognition Task; Blair, Colledge, Murray, & Mitchell, 2001). Results indicated that individuals with APD were significantly more likely than controls to make errors when classifying fully expressed fear. However, no differences were found between groups in the speed to correctly classify facial emotional expressions. The findings are some of the first to investigate facial emotional processing in a sample of individuals with APD and point to an underlying deficit in processing social cues that may be involved in the maintenance of APD. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Personality disorders and the outcome of cognitive–behavioural treatment of panic disorder with agoraphobia.

In recent years, cognitive–behavioural interventions have proven to be effective in the treatment of Panic Disorder with Agoraphobia (PDA). However, there is controversy concerning treatment efficacy of PDA for patients with a comorbid diagnosis of Personality Disorder (PD). This study evaluates the impact of a PD on PDA treatment response. 81 patients suffering from PDA were recruited from a cognitive–behavioural group treatment program. Diagnoses on Axis I (N?=?81) and Axis II (N?=?36) were made at treatment onset according to Diagnostic and Statistical Manual of Mental Disorders-III-Revised (DSM-III-R) criteria. Validated questionnaires were used to assess agoraphobia at treatment onset, following treatment, and at the 3 mo follow-up. All patients improved markedly from pretest to posttest and at the 3 mo follow-up. Grouping of patients according to the presence or absence of a personality disorder revealed significant differences between the groups on pre- and posttreatment scores on agoraphobia. Results also reveal that patients with a personality disorder improve more slowly than patients without a personality disorder. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Conduct disorder: Parsing the confounded relation to parental divorce and antisocial personality.

Previous research has shown an association between parental divorce and child conduct problems. This relation is confounded, however, because antisocial personality disorder (APD) is common among the parents of children with conduct disorder (CD) and divorce is very frequent for adults with this disorder. Twenty-eight clinic-referred boys who received a Diagnostic and Statistical Manual of Mental Disorders (DSM-III; American Psychiatric Association, 1980) diagnosis of conduct disorder and 34 who received any other diagnosis served as subjects. A 2 (APD vs. not APD)?×? 2 (divorced vs. not divorced) log-linear analysis revealed a significant main effect for APD with the number of sons given the diagnosis of conduct disorder as the dependent variable, but the main effect for divorce and the interaction were not significant. Among boys with divorced parents, more than twice as many boys with a parent with APD received a diagnosis of CD than boys without a parent with APD, but there was no significant association between divorce and CD in the absence of parental APD. A similar 2?×?2 analysis of variance of the number of 13 specific DSM-III symptoms of conduct disorder resulted in essentially identical findings. These results suggest the hypothesis that parental APD is directly linked to both parental divorce and child CD, but the divorce and CD are not directly related. Methodological limitations of the present dataset are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

DSM-III-R personality disorders in a mood and anxiety disorders clinic: prevalence, comorbidity, and clinical correlates

This study examined the prevalence, comorbidity, and clinical correlates of personality disorders in an outpatient sample (N = 352) with anxiety and depression. Subjects were diagnosed using the Structured Clinical Interview for DSM-III-R (SCID) on Axes I and II, and they also completed interview and self-report measures of symptoms. Subjects with a personality disorder were less likely to be married, more likely to be single or divorced, had lower family incomes, had more severe symptoms of both anxiety and depression, and had a greater number of lifetime Axis I diagnoses. Subjects with dysthymic and bipolar disorders were more likely, and subjects with panic disorder uncomplicated by agoraphobia were less likely to have a personality disorder compared to the rest of the sample. The most prevalent personality disorders were Avoidant, Obsessive-Compulsive, Paranoid, and Borderline. Paranoid co-occurred with Narcissistic, and Borderline co-occurred with Histrionic personality disorder significantly more often than chance and base rates would predict.     

Avoidant personality disorder and the generalized subtype of social phobia.

Social phobia and avoidant personality disorder (APD) may be given as comorbid diagnoses. However, it is not known if the labels provide independent, useful diagnostic information. The authors classified social phobics by social phobia subtype and presence of APD. Generalized social phobics with and without APD (ns?=?10 and 10) and nongeneralized social phobics without APD (n?=?10) were distinguished on measures of phobic severity. The generalized groups also showed earlier age at onset and higher scores on measures of depression, fear of negative evaluation, and social anxiety and avoidance than did the nongeneralized group. APD criteria of general timidity and risk aversion were more frequently endorsed by social phobics with AD. The data suggest that both the generalized subtype of social phobia and the presence of APD do provide useful diagnostic information, but the additional diagnosis of APD may simply identify a severe subgroup of social phobics. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Impact of Cluster C personality disorders on outcomes of contrasting brief psychotherapies for depression.

Twenty-seven of 114 depressed clients, stratified for severity of depression, obtained a Diagnostic and Statistical Manual of Mental Disorders (3rd ed.; DSM-III; American Psychiatric Association, 1980) diagnosis of Cluster C personality disorder, that is, avoidant, obsessive-compulsive or dependent personality disorder (PD clients), whereas the remaining 87 did not (non-personality-disorder [NPD] clients). All clients completed either 8 or 16 sessions of cognitive-behavioral (CB) or psychodynamic-interpersonal (PI) psychotherapy. On most measures, PD clients began with more severe symptomatology than NPD clients. Among those who received PI therapy, PD clients maintained this difference posttreatment and at 1-year follow-up. Among those who received CB therapy, posttreatment differences between PD and NPD groups were not significant. Treatment length did not influence outcome for PD clients. PD clients whose depression was also relatively severe showed significantly less improvement after treatment than either PD clients with less severe depression or NPD clients. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Personality disorders in patients with eating disorders: a controlled study

A group of 24 eating-disordered female subjects (10 anorexia nervosa--AN--and 14 bulimia nervosa--BN--patients) were interviewed, using a semistructured interview for DSM-III-R Axis-II Personality Disorders (SCID-II). A group of 54 subjects without eating disorder acted as a control group. A high rate of personality disorder (PD) diagnoses occurred in eating disordered subjects (AN and BN patients), with a high prevalence of borderline, dependent, and self-defeating PD. Avoidant and obsessive-compulsive PD were more common in AN patients, whereas BN was associated with histrionic PD. Findings have implications for the assessment and diagnosis of eating-disordered patients and for treatment planning.     

Psychopathy and the DSM-IV criteria for antisocial personality disorder.

The Axis II Work Group of the Task Force on Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) has expressed concern that antisocial personality disorder (APD) criteria are too long and cumbersome and that they focus on antisocial behaviors rather than personality traits central to traditional conceptions of psychopathy and to international criteria. R. D. Hare et al describe an alternative to the approach taken in the DSM-III—Revised (DSM-III—R; American Psychiatric Association, 1987), namely, the revised Psychopathy Checklist. The authors also discuss the multisite APD field trials designed to evaluate and compare 4 criteria sets: the DSM-III—R criteria, a shortened list of these criteria, the criteria for dyssocial personality disorder from the 10th edition of the International Classification of Diseases (World Health Organization, 1990), and a 10-item criteria set for psychopathic personality disorder derived from the revised Psychopathy Checklist. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychophysiological differences between subgroups of social phobia.

Individuals meeting criteria of the revised third edition of Diagnostic and Statistical Manual for Mental Disorders (American Psychiatric Association, 1987) for social phobia with a fear of speaking in front of people were subdivided into those with (n?=?16) and without (n?=?14) avoidant personality disorder (APD). These individuals and nonanxious controls (n?=?22) spoke in front of a small audience while speaking time, subjective anxiety, fearful thoughts, and electrocardiographic and respiratory measures were recorded. Controls spoke for longer than either social phobia group. Those with social phobia and APD reported more subjective anxiety and more fear cognitions than the other two groups; phobic individuals without APD showed greater heart rates in the phobic situation than either social phobics with APD or controls. The latter two groups did not differ in heart rate. These results indicate incongruent subjective and heart rate responses to the feared situation. A similar pattern of results was found when participants were divided into generalized and specific social phobia groups. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Eye movement impairment and schizotypal psychopathology

OBJECTIVE: Eye movement dysfunction in relation to a smooth pursuit task has been documented in schizophrenic patients and in patients with the related personality disorder, schizotypal personality disorder. To investigate which quantitative measures are associated with the eye movement dysfunction and whether the dysfunction is more related to the psychotic-like or the deficit-like symptoms of schizotypal personality disorder, ratings of eye movements in several groups of subjects were compared. METHOD: The study groups consisted of 26 patients with schizotypal personality disorder, 42 patients with other personality disorders (22 who also had two or more schizotypal personality traits and 20 who had fewer than two), and 37 normal comparison subjects. Smooth pursuit eye tracking of sinusoidal and constant velocity targets was recorded by an infrared eye tracking system. Two raters evaluated pursuit gain and large and small saccades in the direction of the target and in the direction opposite to that of the target (quantitative ratings) and constant velocity (qualitative rating). RESULTS: Patients with schizotypal personality disorder and patients with other personality disorders and two or more schizotypal traits, but not those with fewer than two schizotypal traits, had significantly poorer qualitative ratings of tracking than the normal comparison subjects. Neither gain nor any of the saccadic measures significantly differed between groups. The number of large saccades in the direction of the target was the only quantitative variable that predicted low qualitative ratings. Qualitatively poor tracking was associated with the deficit-like, but not the psychotic-like, symptoms of schizotypal personality disorder. CONCLUSIONS: Patients with schizotypal personality disorder demonstrate qualitatively poorer tracking than comparison groups, and the impaired tracking is associated with deficit-like symptoms.     

Predicting Future Antisocial Personality Disorder in Males From a Clinical Assessment in Childhood.

It is essential to identify childhood predictors of adult antisocial personality disorder (APD) to target early prevention. It has variously been hypothesized that APD is predicted by childhood conduct disorder (CD), attention-deficit/hyperactivity disorder (ADHD), or both disorders. To test these competing hypotheses, the authors used data from a single childhood diagnostic assessment of 163 clinic-referred boys to predict future APD during early adulthood. Childhood Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev.; American Psychiatric Association, 1987) CD, but not ADHD, significantly predicted the boys' subsequent APD. An interaction between socioeconomic status (SES) and CD indicated that CD predicted APD only in lower SES families, however. Among children who met criteria for CD, their number of covert but not overt CD symptoms improved prediction of future APD, controlling for SES. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Change in obsessive-compulsive and avoidant personality disorders following time-limited supportive-expressive therapy.

24 patients with avoidant personality disorder (AVPD) and 14 patients with obsessive-compulsive personality disorder (OCPD; all Ss 20–65 yrs old) were assigned to 52 sessions of time-limited Supportive-Expressive dynamic psychotherapy. At intake, most Ss had least 1 concurrent depressive and/or anxiety disorder. OCPD Ss lost their personality disorder diagnoses significantly faster than did AVPD Ss. By the end of treatment, 39% of AVPD Ss still retained their diagnosis while only 15% of OCPD did so. Using hierarchical linear modeling, both patient groups improved significantly across time on measures of personality disorders, depression, anxiety, general functioning, and interpersonal problems. OCPD Ss remained in treatment significantly longer and tended to improve more than did AVPD Ss. Alliance ratings from both Ss and therapists increased significantly over time, expect for those OCPD Ss who remained constant. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Reliability and validity of depressive personality disorder

OBJECTIVE: Depressive personality disorder was introduced into DSM-IV's appendix amid controversy. While that disorder appears to be a reliable and valid one, the authors offer new data about its relationship to major depression, dysthymic disorder, and other personality disorders. METHOD: The authors assessed 54 subjects with early-onset, long-standing mild depressive features for depressive personality disorder, axis I and axis II disorders, family history, and treatment history; they conducted follow-up interviews 1 year after the baseline assessment. Subjects with (N=30) and without (N=24) depressive personality disorder were characterized and compared in terms of those variables. RESULTS: Although depressive personality disorder and dysthymia co-occurred in some subjects, 63% of subjects with depressive personality disorder did not have dysthymia, and 60% did not have current major depression. Although subjects with depressive personality disorder were more likely than the mood disorder comparison group to have another personality disorder, 40% had no such disorder. Contrary to study hypotheses, mood disorder was not more common in first-degree relatives of subjects with depressive personality disorder than in relatives of the comparison group. Subjects with and without depressive personality disorder had similar rates of past treatment with medication and psychotherapy; however, the duration of psychotherapy was significantly longer for subjects with than for those without depressive personality. The depressive personality diagnosis was relatively stable over the 1-year follow-up period. CONCLUSIONS: Depressive personality disorder appears to be a relatively stable condition with incomplete overlap with axis I mood disorders and personality disorders. Further studies are needed to better characterize its treatment response and relationship to axis I mood disorders.