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PERSONALITY DISORDERS and the PERSISTENCE of ANXIETY DISORDERS in a NATIONALLY REPRESENTATIVE SAMPLE ∗ Andrew E

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PERSONALITY DISORDERS and the PERSISTENCE of ANXIETY DISORDERS in a NATIONALLY REPRESENTATIVE SAMPLE ∗ Andrew E DEPRESSION AND ANXIETY 00:1–8 (2014) Research Article PERSONALITY DISORDERS AND THE PERSISTENCE OF ANXIETY DISORDERS IN A NATIONALLY REPRESENTATIVE SAMPLE ∗ Andrew E. Skodol, M.D.,1,2,3 Timothy Geier, M.S.,2,4 Bridget F. Grant, Ph.D.,5 and Deborah S. Hasin, Ph.D.1,2,6 Background: Among individuals with anxiety disorders, comorbid personality disorders (PDs) increase cross-sectional symptom severity and decrease function- ing. Little is known, however, about how PDs influence the course of anxiety disorders over time. The purpose of this study was to examine the effect of PDs on the persistence of four anxiety disorders in a nationally representative sample in the United States. Methods: Two waves of data were collected on 34,653 participants, 3 years apart. At both waves, participants were evaluated for gen- eralized anxiety disorder (GAD), social and specific phobias, and panic disorder. Predictors of persistence included all DSM-IV PDs. Control variables included demographics, comorbid PDs, age at onset of the anxiety disorder, number of prior episodes, duration of the current episode, treatment history, and cardinal symptoms of exclusionary diagnoses for each anxiety disorder. Results: Any PD, two or more PDs, borderline PD, schizotypal PD, mean number of PD criteria met, and mean number of PDs diagnosed predicted the persistence of all four anx- iety disorders. Narcissistic PD predicted persistence of GAD and panic disorder. Schizoid and avoidant PDs also predicted persistence of GAD. Finally, avoidant PD predicted persistence of social phobia. Particular patterns of cross-cluster PD comorbidity were strong predictors of the persistence of individual anxiety dis- orders as well. Conclusions: In this national sample, a variety of PDs robustly predicted the persistence of anxiety disorders over 3 years, consistent with the results of recent prospective clinical studies. Personality psychopathology should be assessed and addressed in treatment for all patients with anxiety disorders. Depression and Anxiety 00:1–8, 2014. C 2014 Wiley Periodicals, Inc. Key words: personality disorder; anxiety disorder; comorbidity; epidemiology; clinical course INTRODUCTION able psychosocial impairment,[4, 5] and have surprisingly low rates of remission,[2,6,7] suggesting a chronic bur- Anxiety disorders are prevalent in the clinic and [1–3] den. Among individuals with anxiety disorders, comor- in the community, are associated with consider- bid personality disorders (PDs) increase cross-sectional Contract grant sponsor: NIAAA; Contract grant numbers: 1Department of Psychiatry, College of Physicians and Sur- U01AA01811 and K05 AA014223; Institutional support: New York geons, Columbia University, New York, New York State Psychiatric Institute. 2New York State Psychiatric Institute, New York, New York 3Department of Psychiatry, University of Arizona College of ∗ Correspondence to: Andrew E. Skodol, 2626 E. Arizona Biltmore Medicine, Tucson, Arizona Circle, #29, Phoenix, AZ 85016. E-mail: [email protected] 4Department of Psychology, University of Wisconsin, Milwau- kee, Wisconsin Received for publication 28 August 2013; Revised 20 May 2014; 5Laboratory of Epidemiology and Biometry, National Institute Accepted 27 May 2014 on Alcohol Abuse and Alcoholism, Bethesda, Maryland DOI 10.1002/da.22287 6 Department of Epidemiology, Mailman School of Public Published online in Wiley Online Library Health, Columbia University, New York, New York (wileyonlinelibrary.com). C 2014 Wiley Periodicals, Inc. 2 Skodol et al. symptom severity and decrease functioning.[8–10] Identi- representative sample in the United States: GAD, social fying factors that contribute to a chronic course in anx- phobia, specific phobia, and panic disorder. The 3-year iety disorders is important for prognosis and treatment follow-up provides a unique opportunity to determine planning. Little is known about how PDs influence the rates of persistence of the four anxiety disorders and the course of anxiety disorders over time.[1] specific effects of all DSM-IV PDs, and representations Three prospective studies examined associations be- of PD severity, while controlling for other potentially tween PDs and the course of anxiety disorders in pa- prognostic factors. These data allow examination of the tients. In a 6-year follow-up of Norwegian outpatients, hypothesis generated in clinical populations that PDs ex- borderline PD predicted the presence of any anxiety ert strong, independent, adverse effects on the course of disorder, obsessive–compulsive PD predicted panic dis- common anxiety disorders. order, and avoidant PD predicted social phobia.[11] In the Harvard/Brown Anxiety Research Program (HARP) 5-year study, DSM-III-R dependent and avoidant PDs MATERIALS AND METHODS decreased the likelihood of remission from generalized PARTICIPANTS anxiety disorder (GAD) and avoidant PD decreased the Participants were respondents in Waves 1 and 2 of the Na- [12] likelihood of remission from social phobia. No PD tional Epidemiologic Survey on Alcohol and Related Conditions affected the course of panic disorder, while borderline, (NESARC).[19,20] The target population was the civilian noninsti- schizotypal, and obsessive–compulsive PDs were too in- tutionalized population 18 years and older in households and group frequent to analyze. The Collaborative Longitudinal quarters (e.g., college quarters, group homes, boarding houses) in the Study of Personality Disorders Study (CLPS) prospec- United States. Blacks, Hispanics, and adults ages 18–24 were over- tively examined the effects of DSM-IV PDs on the sampled, with data adjusted via sample weights for oversampling and course of several anxiety disorders over 7 years,[13] find- household- and person-level nonresponse, in order to make standard ing that a number of PDs adversely impacted the clini- errors of estimates accurate, and to make the findings representative of the general population.[20] Of the 43,093 respondents interviewed at cal course of anxiety disorders. Specifically, schizotypal Wave 1, census-defined eligible respondents for Wave 2 re-interviews PD influenced the course of social phobia, PTSD, and included those not deceased (N = 1,403); deported, mentally or phys- GAD; avoidant PD influenced social phobia and OCD; ically impaired (i.e., too impaired to participate in an interview) (N = obsessive–compulsive PD influenced GAD, OCD, and 781); or on active military duty (N = 950). In Wave 2, 34,653 of 39,959 agoraphobia; and borderline PD impacted the course of eligible respondents were re-interviewed, for a response rate of 86.7%. OCD, GAD, and panic disorder with agoraphobia. Sample weights further adjusted for Wave 2 nonresponse.[20] Overall, In addition, interest is growing in PD severity as a crit- 4,755 had GAD, social phobia, specific phobia, and/or panic disorder ical variable in PD psychopathology, stimulating efforts at Wave 1. Of these, 4,010 participated in Wave 2 and constitute the to revise the PD sections of both DSM-5[14] and ICD- present sample: 746 respondents meeting criteria for Wave 1 current 11.[15] Reviews of levels of personality functioning[16] and GAD, 989 for social phobia, 2,579 for specific phobia, and 775 for panic [17] disorder, with or without agoraphobia. Demographic characteristics of of other representations of PD severity suggest that the entire Wave 2 sample and of those with each anxiety disorder are severity might be the key PD factor in predicting con- shown in Table 1. In general, most respondents with anxiety disorders current and prospective functioning. Thus, associations were female, White, over age 40, married or cohabiting, and college of disorder chronicity with various representations of educated. PD severity, including PD cluster, number of PD cri- [17] teria, number of PDs, and “complex PD” may be PROCEDURES significant. In-person interviews were conducted at both waves by experienced Prospective studies of patient samples provide im- lay interviewers with extensive training and supervision.[19,20] All pro- portant information, but may be biased by numerous cedures, including informed consent, received full ethical review and confounds and selection factors differentiating those re- approval from the U.S. Census Bureau and U.S. Office of Management ceiving or not receiving treatment. Thus, generalization and Budget. from clinical samples may be difficult and prognostic fac- tors obscured or distorted. One prospective community ASSESSMENT AND VARIABLES [18] study showed that having any PD by early adulthood Interviewers administered the NIAAA Alcohol Use Disorder elevated the risk of any anxiety disorder by middle adult- and Associated Disabilities Interview Schedule-DSM-IV Version hood. However, the sample size precluded examination (AUDADIS-IV),[21] a structured diagnostic interview developed to as- of specific PDs and specific anxiety disorders. Larger sess substance use and other mental disorders in large-scale surveys. prospective studies of general population samples are Computer algorithms produced diagnoses of DSM-IV Axis I disorders needed to better understand the relationship of PDs to and all DSM-IV PDs. persistent anxiety disorders. Anxiety Disorders. GAD, social phobia, specific phobia, and panic disorder (with or without agoraphobia) were defined accord- ing to DSM-IV inclusion criteria, including all symptom, duration, AIMS OF THE STUDY and clinical significance (i.e., distress or impairment) criteria. Diag- noses additionally required that the disorders be “primary,” that is, The present
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