Impact of transient and persistent personality disturbance on the
outcome of anxiety and depressive disorders
Professor Peter Tyrer (Imperial College, London)Dr Boliang Guo (University of Nottingham)
Professor Min Yang (University of Sichuan, Chengdu, China)
Aims To summarise the hypotheses of the Nottingham
Study of Neurotic Disorder (NSND) To summarise previous opinions on the course
of personality disorder and its influence on the outcome of anxiety and depression
To compare the outcome of patients in NSND by transient and persistent personality disorder status over a 12 year period
To explain why the results are important
Nottingham study of Neurotic Disorder (1983-2019)
Hypotheses: (1) outcome of common anxiety and depressive disorders is dependent on personality status, not on treatment
(2) Personality and clinical status in the form of the general neurotic syndrome (mixed anxiety and depression and dependent/anankastic personality) would have the worst outcome
(3) These differences would become greater over time
Brief summary of design Brief summary of design
Patients seen between 1983 and 1987 in Patients seen between 1983 and 1987 in general practice clinics in Nottingham if they (i) general practice clinics in Nottingham if they (i) were on no treatment, (ii) had a diagnosis of were on no treatment, (ii) had a diagnosis of dysthymia (chronic depression), generalised dysthymia (chronic depression), generalised anxiety, or panic disorder (DSM-III), (iii) agreed anxiety, or panic disorder (DSM-III), (iii) agreed to randomisation to diazepam, dothiepin, to randomisation to diazepam, dothiepin, placebo, CBT or self-help for 6 weeks with all placebo, CBT or self-help for 6 weeks with all treatment tailed off by 10 weeks.treatment tailed off by 10 weeks.
210 recruited 210 recruited
Assessments at baseline and Assessments at baseline and subsequentlysubsequently
Baseline, 2, 12 and 30 years – Personality assessment using Baseline, 2, 12 and 30 years – Personality assessment using Personality Assessment Schedule (Tyrer & Alexander, Br J Personality Assessment Schedule (Tyrer & Alexander, Br J Psychiatry (1979), Psychiatry (1979), 135135, 163-67., 163-67.
At baseline, 2, 4, 6, 10, 16, 32 and 52 weeks, and at 2, 12, and 30 At baseline, 2, 4, 6, 10, 16, 32 and 52 weeks, and at 2, 12, and 30 years – Comprehensive Psychopathological Rating Scale (CPRS), years – Comprehensive Psychopathological Rating Scale (CPRS), Montgomery & Asberg Depression Rating Scale (MADRS), Brief Montgomery & Asberg Depression Rating Scale (MADRS), Brief Anxiety Scale (BAS), Hospital Anxiety and Depression Rating Anxiety Scale (BAS), Hospital Anxiety and Depression Rating Scale (HADS-A and HADS-D) Scale (HADS-A and HADS-D)
All psychotropic medication recorded (0-30 years)All psychotropic medication recorded (0-30 years) Social function (SFQ) recorded at 12 and 30 yearsSocial function (SFQ) recorded at 12 and 30 years Neurotic Disorder Outcome Scale (NDOS)(12 and 30 years, plus Neurotic Disorder Outcome Scale (NDOS)(12 and 30 years, plus
self-harm history, GP and hospital contactsself-harm history, GP and hospital contacts SCID (DSM diagnosis) at baseline, 10, 16, 32, 52 wks and at 2, 12 SCID (DSM diagnosis) at baseline, 10, 16, 32, 52 wks and at 2, 12
and 30 years and 30 years
Summary of findings Summary of findings
Diazepam inferior to other treatments, including placebo Diazepam inferior to other treatments, including placebo after 10 weeks (Tyrer et al, Lancet (1988), after 10 weeks (Tyrer et al, Lancet (1988), 332332, 235-40), 235-40)
After 2 years patients with the general neurotic After 2 years patients with the general neurotic syndrome had a significantly worse outcome than other syndrome had a significantly worse outcome than other groups (Tyrer et al, Acta Psychiat Scand (1992), groups (Tyrer et al, Acta Psychiat Scand (1992), 85, 201-06.
Personality status had no influence on outcome at 10 Personality status had no influence on outcome at 10 weeks (Tyrer et al, Psychol Med, 1990, 20, 423-31.weeks (Tyrer et al, Psychol Med, 1990, 20, 423-31.
but had a negative effect at 5 and 12 years (Tyrer et al, but had a negative effect at 5 and 12 years (Tyrer et al, Psychol Med, (2004) Psychol Med, (2004) 34: 1385-1394.
Personality disorder at baseline had no effect on 10 week outcome
Reasons for recording personality status Reasons for recording personality status both at baseline and two years both at baseline and two years
To determine whether any of the treatments had a To determine whether any of the treatments had a positive effect on personality status positive effect on personality status
To assess the long-term temporal reliability of To assess the long-term temporal reliability of personality disorder using the PAS, as short-term personality disorder using the PAS, as short-term reliability had been shown to be good (Tyrer et al, reliability had been shown to be good (Tyrer et al, Psychol Med, (1983) Psychol Med, (1983) 13, 393-98.
To determine whether the diagnostic criteria for the To determine whether the diagnostic criteria for the general neurotic syndrome were still met at 2 yearsgeneral neurotic syndrome were still met at 2 years
(None of these hypotheses has been tested as the second (None of these hypotheses has been tested as the second personality assessment fell by the wayside) personality assessment fell by the wayside)
Reason why the analysis of personality Reason why the analysis of personality data at 2 years has become importantdata at 2 years has become important
We now know that personality shifts greatly over time and is We now know that personality shifts greatly over time and is not nearly as persistent as first thoughtnot nearly as persistent as first thought
The reasons for this include The reasons for this include
(i) difficulty in distinguishing personality from mental state (so (i) difficulty in distinguishing personality from mental state (so that when mental state improved personality may also), that when mental state improved personality may also),
(ii) environmental changes may reduce or increase impact of (ii) environmental changes may reduce or increase impact of personality abnormalitypersonality abnormality
(iii) social functioning tends to remain poor even if symptoms (iii) social functioning tends to remain poor even if symptoms improve in personality disorder (Shea et al,2004)improve in personality disorder (Shea et al,2004)
(iv) developing general view that a single assessment of (iv) developing general view that a single assessment of personality is not enough to confirm diagnosis of personality personality is not enough to confirm diagnosis of personality disorderdisorder
Why are these hypotheses important?
They are important scientifically as if personality, independently of mental state, does show evidence of increasing increasing
(2) Personality and clinical status in the form of the general neurotic syndrome (mixed anxiety and depression and dependent/anankastic personality) would have the worst outcome
(3) These differences would become greater over time
Hypotheses in present investigation
1. Those who have personality disorder at both baseline and two years (ie persistent disorder) have true personality disorder and would have a worse long term outcome than those who had personality disorder only at baseline (transient personality disorder)
2. Those who had personality disorder at 2 years only would have the same outcome as those with personality disorder at baseline only
3. Social function would be more impaired in personality disorders than psychiatric symptoms
BIGSPD Leeds 2015
01
02
03
04
0M
ean
0 5 10 15time
0PD at 0&2year PD both 0&2yearPDbase 02year 0 base pd 2year
mean_CPRS_for_PD_types
This is the persistent pd group
BIGSPD Leeds 2015
01
02
03
0M
ean
0 5 10 15time
0PD at 0&2year PD both 0&2yearPDbase 02year 0 base pd 2year
mean_MADRS_for_PD_types
-----------------------------------------------------
Threshold forpathology
Message – Long-term outcome of depression is good unless personality disorder is persistent
Persistent pd
BIGSPD Leeds 2015
CPRS
0 PD at both 0 &2yr 21.54 7.44 13.40 8.88 8.71 10.28
0.2084
PD both 0 &2year 25.64 8.18 21.80 11.18 4.02 10.44
PDbase 0 2year 20.39 8.99 13.66 11.54 7.28 12.80
0 base pd 2year 19.32 6.52 12.18 8.22 7.05 9.49
HADSA 0PD at 0
&2year 13.93 3.74 8.05 5.10 6.14 4.83
0.0232*
PD both 0 &2year 14.67 3.53 11.80 5.22 3.24 4.96
PDbase 0 2year 13.12 4.01 7.35 5.00 6.06 5.31
0 base pd 2year 13.93 3.83 8.91 5.14 5.18 4.99
BIGSPD Leeds 2015
outcome group
Mean (bsl)
Sd (base)
Means
(12 yr)
Sds (12 year
change
Sd (chg)
P Value of change
comparison
HADS-D No pd
ever 9.56 4.47 6.02 5.12 3.90 5.10
0.2390
persistent
PD both 0 &2year 11.62 4.09 9.46 5.31 2.12 5.17
transient
PD base 0 2year 9.55 4.12 6.10 6.06 3.52 5.97
transient
0 base pd 2year 9.36 4.31 4.45 3.83 4.36 3.17
MADRS No pd
ever 19.15 8.14 11.33 9.59 8.40 12.58
0.0702
persistent
PD both bsl & 2yr 20.89 7.87 18.96 11.57 1.80 12.65
transient
PD bsl 0 2year 17.18 8.06 11.63 12.70 6.09 13.64
transient
0 base pd 2year 16.32 7.34 9.64 8.49 7.05 8.81
Additional Findings Additional Findings with social with social
functioning (SFQ) functioning (SFQ) SFQ*
none
No PD at 0 or at 2 yr
6.05 4.42
pers
PD both 0 &2year
10.88 5.23
trans
PDbase 0 2year
7.75 5.90
trans
0 base pd 2year
6.91 4.80
0.0001
BIGSPD Leeds 2015
12 yr mean Sd
P value of
comparison
SFQ – higher scores indicate worse social function. Population mean is 4.6, a score of 10 or more indicates poor social function
ConclusionsConclusions
Persistent personality disorder impairs the Persistent personality disorder impairs the outcome of anxiety and depressive disorders to outcome of anxiety and depressive disorders to the extent that no significant symptomatic the extent that no significant symptomatic improvement is shown over 12 yearsimprovement is shown over 12 years
Transient personality disorder is associated with Transient personality disorder is associated with the same outcomes as those with no personality the same outcomes as those with no personality disorder at baseline and two yearsdisorder at baseline and two years
