Personality disorders do not influence the results of cognitive behavior therapies for anxiety disorders

doi:10.1016/0010-440X(94)90018-3

Comprehensive Psychiatry

Volume 35, Issue 4, July–August 1994, Pages 265-274

https://doi.org/10.1016/0010-440X(94)90018-3 Get rights and content

Abstract

Two studies are presented in which the presence of personality disorders (PDs) was assessed using a structured clinical interview (Structured Clinical Interview for DSM-III-R Personality Disorders [SCID-II]) by an independent rater before the start of treatment. The therapy effect was measured by change scores. In the first study, patients (N = 31) with panic disorder (with or without agoraphobia) received standardized cognitive behavioral treatment protocols. The effect of treatment as assessed by questionnaires and panic frequency was comparable in the groups with and without PD. In a second study, patients (N = 57) with various anxiety disorders were assessed before and after an individually tailored cognitive behavioral treatment. In general, results showed that anxiety patients with PDs have more severe axis I pathology, but show a change parallel to the patients without PD. Thus, if the effect of therapy is measured by change scores, PD is not related to therapeutic failure of cognitive behavioral treatment of anxiety disorders in general and panic disorder in particular.

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Cited by (70)

Empirical evidence of the effect of personality pathology on the outcome of panic disorder
2018, Journal of Psychiatric Research
Treatment resistant disorders are a significant clinical problem. Impediments to good outcome need to be identified and addressed. Personality pathology has been hypothesized to be one such factor in panic disorder. There is no consensus as to the effects of personality pathology on the outcome of panic disorder. This study examined empirical evidence. The hypothesis was that personality pathology would cause poorer outcome of panic disorder.
A literature search was conducted that winnowed 2627 articles down to 27 based on 1) longitudinal design; 2) validated measures of personality; 3) validated outcome measures; and 4) the presence of effect size or data to calculate effect size. All effect sizes were translated into odds ratios (ORs) for ease of comparison.
An overall median OR of 2.7 was found, indicating personality pathology negatively affected outcome. This finding persisted even when adjusted for baseline severity of illness. The effects were found for both clinical outcomes (OR = 2.7) and for social adjustment (OR = 2.9). There was a tendency for more dropouts in the personality pathology group. More highly structured drug therapy regimens and highly structured psychotherapy seemed to partially mitigate this outcome.
The negative effect of personality pathology was confirmed in well-designed longitudinal studies. This was not related to initial clinical severity. Clinical implications are that patients with personality pathology require the therapist to stick more closely to treatment protocols and to mitigate the tendency of these patients to drop out of treatment.
Treatment outcomes for inpatients with obsessive-compulsive personality disorder: An open comparison trial
2017, Journal of Affective Disorders
Citation Excerpt :
To understand this phenomenon, it is necessary to parse degree of pre-post improvement (such as RCI scores) from remission rates. Several studies report minimal negative impact of PD on pre-post improvement (Dreessen et al., 1994, 1997; Steketee et al., 2001; Gordon et al., 2016); however, most studies also note that baseline and end-point functioning were more impaired for the PD groups (with the exception of Gordon et al. (2016) which found higher admission severity but equivalent end-point severity for OCPD patients with co-morbid OCD). By contrast, the studies cited in meta-analysis with more stringent criteria for remission rates (Newton-Howes et al., 2006) indicate significant negative impact of co-morbid PD.
The current case-control study compared rates of clinically significant and reliable change in psychopathology and global functioning, prevalence of clinical deterioration, and rates of symptom remission among adult patients with obsessive compulsive personality disorder OCPD (n=52) and well-matched inpatients with any other personality disorder (n=56) and no personality disorder (n=53).
Propensity score matching (PSM) was utilized to select patients matched on specific criteria present in the OCPD group. Multivariate analysis of variance models measured differences in admission functioning and RCI change across depression and anxiety severity, emotion dysregulation and suicidal ideation.
Patients diagnosed with OCPD admit to treatment with higher rates of depression, anxiety, difficulty with emotion regulation and non-acceptance of emotional experience than inpatient controls. Furthermore, OCPD patients respond to treatment at a similar rate to inpatient controls, but experience lower rates of anxiety remission upon discharge. Post-hoc analyses indicate individuals meeting stubbornness and rigidity (OCPD Criteria 8) were nine times more likely to report moderate to severe anxiety at point of discharge.
Limitations include a predominantly Caucasian, inpatient sample, use of self-report measures and a non-manualized treatment approach.
Overall, OCPD inpatients benefit from an intensive multimodal psychiatric treatment, but experience more anxiety than non-PD patients upon discharge.
Impact of personality psychopathology on outcome in short-term cognitive-behavioral therapy for Axis I disorders
2015, Psychiatry Research
Citation Excerpt :
Some investigators have found that Axis II comorbidity predicts poorer response to CBT (AuBuchon and Malatesta, 1994; Chambless et al., 1997; Mennin and Heimberg, 2000; Prasko et al., 2005; Vyskocilova et al., 2011), at least for certain personality types or certain Axis I diagnoses (Van Velzen et al., 1997; Fricke et al., 2006; Bagby et al., 2008). Others have found that comorbid personality disorder did not affect CBT outcomes, even if the affected patients exhibit more severe symptoms before and after treatment (Dreessen et al., 1994; Dreessen et al., 1997; Muszer and Bailer, 2011). For example, in one inpatient sample where 68% of patients had one or more personality disorders, the presence of an Axis II disorder did not reduce the effect of CBT targeting an Axis I diagnosis (Van den Hout et al., 2006).
Cognitive behavioral therapy (CBT) is efficacious for many Axis I disorders, though its effectiveness in the real world, for patients with Axis II comorbidity is less well known. This study examines the effectiveness of CBT for Axis I disorders in three groups of patients: those with personality disorders, those with personality disorder traits and those with no Axis II pathology. Consecutive referrals of patients with non-psychotic Axis I disorders were assessed for short-term CBT in a University Teaching Unit. While the acceptance rate was lower for individuals with personality disorders, there were no group differences in dropout rates. Of those who completed therapy (mean number of sessions=17.8, SD=11.2), those in the Personality Disorders group (n=45) had 4 sessions more on average than the Personality Disorder Traits group (n=42) or the No Axis II Group (n=266). All 3 groups were equally successful, whether the outcome was therapist opinion of success, the clinical global impression, or the reliable change index based on patient-reported symptom change. Intent to treat analysis results paralleled those of the completer analysis. Our findings indicate that the presence of a personality disorder does not negatively impact therapy adherence or success in short-term CBT for an Axis I disorder.
The impact of comorbid personality difficulties on response to IAPT treatment for depression and anxiety
2015, Behaviour Research and Therapy
Citation Excerpt :
Our results are also consistent with literature on the impact of personality disorder on treatment for anxiety disorders (e.g. Black et al., 1994; Hansen et al., 2007; Latas & Milovanovic, 2014; Steketee et al., 2001; Telch et al., 2011). In contrast, Dreessen, Arntz, Luttels, and Sallaerts (1994) argue that individuals with personality disorders show a similar amount of change after treatment for anxiety disorders, although their higher initial symptom severity is associated with higher symptom scores at end of treatment. Importantly, our study showed an effect of high risk of personality disorder on both end of treatment scores and raw change over the course of treatment even after controlling for the confounding effects of initial symptom scores.
The UK's Improving Access to Psychological Therapies (IAPT) initiative provides evidence-based psychological interventions for mild to moderate common mental health problems in a primary care setting. Predictors of treatment response are unclear. This study examined the impact of personality disorder status on outcome in a large IAPT service. We hypothesised that the presence of probable personality disorder would adversely affect treatment response.
We used a prospective cohort design to study a consecutive sample of individuals (n = 1249).
Higher scores on a screening measure for personality disorder were associated with poorer outcome on measures of depression, anxiety and social functioning, and reduced recovery rates at the end of treatment. These associations were not confounded by demographic status, initial symptom severity nor number of treatment sessions. The presence of personality difficulties independently predicted reduced absolute change on all outcome measures.
The presence of co-morbid personality difficulties adversely affects treatment outcome among individuals attending for treatment in an IAPT service. There is a need to routinely assess for the presence of personality difficulties on all individuals referred to IAPT services. This information will provide important prognostic data and could lead to the provision of more effective, personalised treatment in IAPT.
Comorbidity of personality disorders in anxiety disorders: A meta-analysis of 30 years of research
2013, Journal of Affective Disorders
Citation Excerpt :
One distinction between axis I and II comorbid disorders seems to be in terms of severity and complexity. First, the degree of fear and phobic avoidance (Dreessen et al., 1994; Kose et al., 2009) is usually more pronounced in patients with axis II compared with axis I comorbidity, as well as the level of general psychopathology (Dreessen et al., 1994; Ozkan and Altindag, 2005). This is also reflected in analyses of health care costs showing that axis II PD patients represent a markedly higher economic burden to the health care system than for example depression and anxiety patients (Soeteman et al., 2008).
A comprehensive meta-analysis to identify the proportions of comorbid personality disorders (PD) across the major subtypes of anxiety disorders (AD) has not previously been published.
A literature search identified 125 empirical papers from the period 1980–2010 on patients with panic disorders, social phobia, generalised anxiety, obsessive-compulsive (OCD) and post-traumatic stress disorder (PTSD). Several moderators were coded.
The rate of any comorbid PD was high across all ADs, ranging from .35 for PTSD to .52 for OCD. Cluster C PDs occurred more than twice as often as cluster A or B PDs. Within cluster C the avoidant PD occurred most frequently, followed by the obsessive-compulsive and the dependent PD. PTSD showed the most heterogeneous clinical picture and social phobia was highly comorbid with avoidant PD. A range of moderators were examined, but most were non-significant or of small effects, except an early age of onset, which in social phobia increased the risk of an avoidant PD considerably. Gender or duration of an AD was not related to variation in PD comorbidity.
Blind rating of diagnoses was recorded from the papers as an indication of diagnostic validity. However, as too few studies reported it the validity of the comorbid estimates of PD was less strong.
The findings provided support to several of the proposed changes in the forthcoming DSM-5. Further comorbidity studies are needed in view of the substantial changes in how PDs will be diagnosed in the DSM-5.
The effects of comorbid personality disorders on cognitive behavioral treatment for panic disorder
2011, Journal of Psychiatric Research
Citation Excerpt :
This is due to the small number of prospective studies and the significant methodological limitations of the existing studies i.e., small sample size, use of questionnaires to assess personality dysfunction, and failure to control for baseline severity of Axis I pathology (Dreessen and Arntz, 1998; Shear et al., 1994). Of the prospective studies investigating the linkage between Pers-D comorbidity and treatment response in panic disorder, three published studies have investigated the effects of Pers-D pathology (as assessed by structured clinical interview) on panic patients’ response to cognitive-behavioral therapy (Black et al., 1994; Dreessen et al., 1994; Kampman et al., 2008). Several additional studies have examined response to naturalistic treatment e.g. (Mellman et al., 1992; Noyes et al., 1990), which may have involved some cognitive-behavioral treatment.
The present study investigated the influence of personality pathology assessed both dimensionally and categorically on acute clinical response to group cognitive-behavioral treatment in a large sample of panic disorder patients (N = 173) meeting DSMIII-R criteria for panic disorder with or without agoraphobia. Nearly one-third of the sample met for one or more personality disorders, with the majority meeting for a Cluster C diagnosis. Patients with one or more comorbid personality disorders displayed higher baseline and higher post treatment scores across multiple indices of panic disorder severity compared to those without personality disorders. After controlling for panic disorder severity at baseline, the presence of both Cluster C and Cluster A Pers-Ds predicted a poorer outcome, whereas when assessed dimensionally, only Cluster C symptoms predicted a poorer treatment response. However, the influence of personality pathology was modest relative to that of baseline panic disorder severity.

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: Supported by the Community Mental Health Care Centre, Maastricht, The Netherlands.

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Personality disorders do not influence the results of cognitive behavior therapies for anxiety disorders

Abstract

Compr Psychiatry

Compr Psychiatry

J Anxiety Disord

J Anxiety Disord

Behav Res Ther

Compr Psychiatry

J Psychiatr Res

Compr Psychiatry

Compr Psychiatry

Clin Psychol Rev

Behav Res Ther

Compr Psychiatry

J Anxiety Disord

Schema-focused CT: comments and questions

Int Cogn Ther Newslett

Obsessional neurotics

Br J Psychiatry

Relationship between neurosis and personality disorder

Br J Psychiatry

Obsessive-compulsive disorder and borderline personality disorder

Am J Psychiatry

The effects of personality disorder diagnoses on the outcome of social anxiety symptom reduction

J Pers Disord

Personality disorders in panic patients: response to termination of antipanic medication

J Pers Disord

DSM-III personality disorders and the outcome of treated panic disorder

Am J Psychiatry

Borderline personality disorder as a negative prognostic factor in anxiety disorders

J Pers Disord

The effect of personality on placebo response in panic patients

J Nerv Ment Dis