Journal of Affective Disorders 168 (2014) 322–330

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Journal of Affective Disorders

journal homepage: www.elsevier.com/locate/jad

Research report

A comparative analysis of personality pathology profiles

among patients with pure depressive-, pure anxiety-, and pure
somatoform disorders
Ingrid V.E. Carlier a,n, Sjoerd Colijn b, Yanda R. van Rood a, Marion F. Streevelaar a,
Irene M. van Vliet a, Tineke van Veen a
a
Leiden University Medical Centre, Department of Psychiatry, Albinusdreef 2, Post zone B1-P, 2300 RC Leiden, The Netherlands
b
GGZ Delfland, Lindberghlaan 113, 2497 EB Den Haag, The Netherlands

art ic l e i nf o a b s t r a c t

Article history: Background: Depressive-, anxiety-, and somatoform disorders are among the most common psychiatric
Received 26 May 2014 disorders. The assessment of comorbid personality pathology or traits in these disorders is relevant,
Received in revised form because it can lead to the exacerbation of them or to poorer remission rates. To date, no research findings
9 July 2014
have been published on the comparison of these three prevalent patient groups with regard to comorbid
Accepted 9 July 2014
Available online 18 July 2014
dimensional personality pathology.
Methods: Data of participants (18–60 years) came from a web-based Routine Outcome Monitoring (ROM)
Keywords: programme. The present study used baseline data and was designed to compare personality pathology
Comorbid personality pathology profiles between three separate outpatient groups: pure anxiety disorders (n ¼1633), pure depressive
Personality traits
disorders (n ¼ 1794), and pure somatoform disorders (n ¼ 479). Personality pathology was measured with
Depressive disorders
the Dimensional Assessment of Personality Pathology-Short Form (DAPP-SF).
Anxiety disorders
Somatoform disorders Results: The pure depressive disorder group, in comparison to the other two disorder groups, exhibited
Routine outcome monitoring the worst psychopathological and functional health image and most personality pathology. In the pure
anxiety disorder group, the highest mean was found for the personality trait Anxiousness; and in the
pure depressive disorder group for the traits Identity problems, Affective lability, Anxiousness, and
Restricted expression.
Limitations: The cross-sectional nature of the study limits the conclusions that can be drawn.
Conclusions: The assessment of comorbid personality pathology in depressive-, anxiety-, somatoform
disorders is clinically relevant, whether a patient has a personality disorder or not. This way, treatment
could partly be focused on specific personality traits that may be counterproductive for treatment
outcome, especially in depressive disorders.
& 2014 Elsevier B.V. All rights reserved.

1. Introduction
Depressive-, anxiety-, and somatoform disorders are common
psychiatric disorders which also show an excess co-morbidity (de
Waal et al., 2004; Lieb et al., 2007; Means-Christensen et al., 2008;
Löwe et al., 2008; Hanel et al., 2009). The clinical relevance of this
comorbidity is considerable as it reflects more psychosocial dis-
ability and functional impairment, elevated risk for suicidality,
more drop-out, and increased medical care utilization (Maier and
Falkai, 1999; Ansseau et al., 2004; Barsky et al., 2005; Beesdo et al.,
2010; Rose et al., 2011; de Reus et al., 2013). The assessment of
comorbid personality pathology in these three disorder groups is
n
Corresponding author. Tel.: þ 31 71 5265237; fax: þ 31 71 5248156.
E-mail address: I.V.E.Carlier@lumc.nl (I.V.E. Carlier).
also clinically relevant, because it can possibly lead to the exacer-
bation of the disorders or to poorer remission rates (Massion et al.,
2002; Phillips et al., 2005; Frank et al., 2011; van Noorden et al.,
2012). To date, research in these three disorder groups mainly
focused on comorbid personality disorders and not on comorbid
personality pathology or pathological personality traits (Garcia-
Campayo et al., 2007; Harned and Valenstein, 2013; Friborg et al.,
2014). Personality traits cover a continuum of adaptive to mala-
daptive, whereas personality disorders are maladaptive by defini-
tion (Clark et al., 2003).
The DSM-IV-TR (American Psychiatric Association, APA., 2000)
and also the DSM-5 (American Psychiatric Association, APA., 2013)
conceptualize personality disorders as categorical syndromes
that are distinct from normal personality (Samuel et al., 2010).
Currently, there is a general movement towards a dimensional
classification of personality disorders which is reflected in

http://dx.doi.org/10.1016/j.jad.2014.07.012
0165-0327/& 2014 Elsevier B.V. All rights reserved.
 I.V.E. Carlier et al. / Journal of Affective Disorders 168 (2014) 322–330
dimensional assessment instruments. This dimensional movement
is not restricted to personality disorders, but also applies to the
assessment of disorders such as depression and anxiety disorders
(Clark and Watson, 1991; Wardenaar et al., 2010). In the DSM-5,
the dimensional approach in the diagnosis of personality disorders
is intended for further study and can be found in Section 3
(“Alternative DSM-5 Model for Personality Disorders”; American
Psychiatric Association, APA., 2013). According to the dimensional
viewpoint, personality disorders are maladaptive expressions of
general personality traits and personality pathology exists at a
more extreme level of the latent trait than does general person-
ality traits (Samuel et al., 2010). A representation of this viewpoint
is Livesley's dimensional model of personality pathology (Livesley
et al., 2005). This model was associated with important person-
ality paradigms and it had good predictive power for personality
disorders (Hernández et al., 2009).
Livesley's model inspired the development of a self-report
questionnaire called the ‘Dimensional Assessment of Personality
Pathology-Basic Questionnaire’ (DAPP-BQ; Livesley et al., 1991;
Livesley et al., 1998). This instrument is widely used for the
assessment of dimensional personality pathology or traits. The
DAPP-BQ provides a systematic representation of the overall
domain of personality disorders, and adequately represents the
dimensional structure of personality disorder itself. Several studies
have provided support for the validity of the DAPP-BQ (Pukrop et
al., 2001; Bagge and Trull, 2003; Gutiérrez-Zotes et al., 2008;
Kushner et al., 2011). Also, the value of the DAPP-BQ for the
assessment of personality pathology in adults has been replicated
in adolescents (Tromp and Koot, 2008, 2009, 2010). This is in line
with an integrative developmental perspective, that similar per-
sonality pathology dimensions are relevant for adolescents and
adults (de Clercq et al., 2006; Krischer et al., 2007).
Research with the DAPP-BQ has demonstrated that the person-
ality dimensions could adequately distinguish between samples
with and without personality disorders (Gutiérrez-Zotes et al.,
2008; Pukrop et al., 2009) and between samples with different
personality disorders (Bagge and Trull, 2003; Kushner et al., 2011).
In addition, the DAPP-BQ was useful for identifying pathological
personality profiles in psychosis (Samaniego et al., 2011); eating
disorders (Goldner et al., 1999; Livesley et al., 2005; Holliday et al.,
2006; Claes et al. 2012); (non)seasonal depression (Michalak et al.,
2004); psychogenic non-epileptic seizures (Reuber et al., 2004);
trauma related anxiety disorders (Saper and Brasfield, 1998).
Moreover, there is evidence for the structural stability of the
DAPP-BQ personality traits across different cultural contexts:
French Canadians (Brezo et al., 2008); Spanish (Gutiérrez-Zotes
et al., 2008); Japanese (Maruta et al., 2006); Chinese (Zheng et al.,
2002); German (Pukrop et al., 2001, 2009); Danish (Simonsen and
Simonsen, 2009); and Dutch (van Kampen, 2002, 2006).
A major drawback of the DAPP-BQ is its length (290 items).
Therefore, a 136-item version of the DAPP-BQ was developed,
called the ‘Dimensional Assessment of Personality Pathology-Short
Form’ (DAPP-SF; van Kampen et al., 2008; de Beurs et al., 2009).
Research has shown that the good psychometric properties of the
original DAPP-BQ were preserved in the DAPP-SF (de Beurs et al.,
2009). Related to the relatively recent construction of the DAPP-SF
(van Kampen et al., 2008), less research is done with it compared
to the DAPP-BQ. So far, the DAPP-SF was used with community
samples and the following patient samples: personality disorders;
a mixed sample of mood-, anxiety-, somatoform disorders; acro-
megaly and Cushing's disease (van Kampen et al., 2008; de Beurs
et al., 2009; Tiemensma et al., 2010a,2010b; van der Lem et al.,
2011; de Klerk et al., 2011; Schulte-van Maaren et al., 2012; van
den Broeck et al., 2013).
The present study contributes to further research with the
DAPP-SF. Depressive-, anxiety-, somatoform disorders are prevalent
323
psychiatric disorders and the assessment of comorbid personality
pathology in these disorders is clinically highly relevant. So far, no
research findings have been published on the three separate patient
groups with regard to dimensional personality pathology as mea-
sured by a self-report questionnaire such as the DAPP-SF. Therefore,
the present study was designed to compare the personality pathol-
ogy profiles of the following three patient groups: pure depressive
disorders (excluding bipolar disorders), pure anxiety disorders (one
or more anxiety disorders), and pure somatoform disorders (one or
more somatoform disorders).
2. Method
2.1. Design
A cross-sectional comparison of personality pathology in three
separate groups of psychiatric outpatients: patients with pure
anxiety disorders, patients with pure depressive disorders, and
patients with somatoform disorders. Related to the mutual comor-
bidity between the three pure disorder groups, we also included a
fourth comparison group: a mixed group of mood-, anxiety-, and/
or somatoform disorders (MAS).
2.2. Participants and procedure
A total of 5922 psychiatric outpatients were included (3840
females; mean age¼36.1 years; SD ¼11.7), referred to the Depart-
ment of Psychiatry of the Leiden University Medical Centre (LUMC)
or to Rivierduinen Psychiatric Institute (service area with 1.1 mil-
lion inhabitants). There were 1633 patients with pure anxiety
disorder (current diagnosis, no co-morbid other disorder than
anxiety disorder); 1794 patients with pure depressive disorder
(current diagnosis, no comorbid other disorder than depressive
disorder, excluding Bipolar Disorders); 479 patients with pure
somatoform disorder (current diagnosis, no comorbid other dis-
order than somatoform disorder); and 2016 patients with comor-
bidity of mood-, anxiety-, somatoform disorders (MAS). With
regard to percentage disorders within each of the three pure
disorder groups: see Section 3.1.
Data of participants (18–60 years) came from a web-based
Routine Outcome Monitoring (ROM) programme, in which they
were routinely assessed as part of the usual diagnostic procedure.
ROM measurements (duration 1–2 h) occurred before (baseline),
during, and after treatment. For the present study, only the
baseline data (before the start of treatment) were used. ROM
consisted of a battery of instruments, both self-report and
interviewer-based. All interviewer-based measurements were
administered by an independent assessor (trained psychiatric
research nurses or psychologists). Self-report questionnaires were
completed by the patient using a touch screen computer. The main
objective of ROM is to improve clinical practice by interim
monitoring and evaluation of the effectiveness of treatment for
the individual patient. The ROM test results after each measure-
ment are given by the assessor to the practitioner, who also
discusses these results with the patient. For more detailed
information on ROM: see de Beurs et al., (2011); de Klerk et al.
(2011); Carlier et al. (2012a),(2012b); www.lumc.nl/psychiatry/
ROM-instruments.
2.3. Measures
2.3.1. Psychiatric diagnoses
Clinical diagnoses on Axis I and Axis II were assigned by a staff
psychiatrist. In addition, the presence of DSM-IV diagnoses was
assessed by an independent and trained assessor (psychiatric
324 I.V.E. Carlier et al. / Journal of Affective Disorders 168 (2014) 322–330
research nurse or psychologist) using the Mini-International
Neuropsychiatric Interview Plus (MINI-Plus; Sheehan et al.,
1998). The MINI-Plus is an extended version of the original MINI.
It is a fully structured diagnostic interview that assesses suicide
risk as well as the presence or absence of DSM criteria for the main
psychiatric disorders (current/life-time) such as mood disorders,
anxiety disorders, somatoform disorders, substance use disorders,
psychotic disorders, eating disorders, conduct disorders, attention-
deficit/hyperactivity disorder, adjustment disorder, and also anti-
social personality disorder. The MINI is organized in diagnostic
modules. Positive answers to screening questions are explored by
further investigation of other diagnostic criteria. Excellent inter-
rater and test-retest reliabilities of the English version of MINI, and
moderate validity of MINI versus CIDI and SCID-P were reported
(Lecrubier et al., 1997; Sheehan et al., 1998). In the present study,
the Dutch translation of the MINI-Plus was used with likewise
demonstrated good psychometric properties (van Vliet and Beurs,
2007; de Beurs et al., 2009).
2.3.2. General psychopathology and functional health status
General psychopathology was measured with the CPRS, BSI,
MASQ and the functional health status was measured with the
SF-36.
The abbreviated Comprehensive Psychopathological Rating Scale
(CPRS) consists of the Montgomery–Ǻsberg Depression Rating
Scale (MADRS; Montgomery and Asberg, 1979), the Brief Anxiety
Scale (BAS; Tyrer et al., 1984), and a scale for psychomotor
inhibition (INH; Asberg et al., 1978; Goekoop et al., 1991). The
CPRS is an interviewer-based instrument, administered in this
study by an independent and trained assessor (psychiatric
research nurse or psychologist). The CPRS was used in Dutch
translation. Its interrater reliability has appeared at least as good
as that of the Present State Examination (Goekoop et al., 1991).
Higher scores correspond to a worse state.
The Brief Symptom Inventory (BSI) is an instrument that assesses
general psychopathological complaints or symptoms in several
domains. The BSI has 53 items and is an abbreviated version of the
Symptom Checklist-90, designed for use in adults in the outpatient
medical setting (Derogatis et al., 1973). The BSI demonstrates high
concordance with clinician symptom assessment and strong test–
retest and internal consistency reliabilities (Derogatis and
Melisaratos, 1983; de Beurs, 2005). It is administered through
self-report and includes the following nine symptom domains:
somatization, obsessive–compulsive, interpersonal sensitivity,
depression, anxiety, hostility, phobic anxiety, paranoid ideation,
psychoticism, and the BSI total score. Higher scores correspond to
a worse state.
The Mood and Anxiety Symptom Questionnaire (MASQ) (Watson
and Clark, 1991) consists of 90 items, which assess depressive,
anxious, and mixed symptomatology (Watson and Clark, 1991;
Watson et al., 1995). The MASQ has five subscales or symptom
dimensions: 1) anhedonic depression; 2) anxious arousal; 3) general
distress depression; 4) general distress anxiety; and 5) general
distress mixed. All items are presented with a five-point rating scale
ranging from 1 (not at all) to 5 (very much). The questionnaire
measures the dimensions of the tripartite model of anxiety and
depression (Watson et al., 1995). It has good psychometric properties
(Watson et al., 1995). Higher scores correspond to a worse state.
The Short Form Health Survey 36 (SF-36), derived from the Rand
Medical Outcome Study (Aaronson et al., 1998; Ware et al., 1993),
has demonstrated high levels of reliability and validity (Karlsen et
al., 2011). It measures functional health status and well-being, and
can be used as a population-based assessment of quality of life.
The SF-36 consists of 36 items divided into eight subscales:
Physical Functioning, Role limitations due to Physical health
problems (Role-Physical), Bodily Pain, Social Functioning, General
Mental Health (Mental Health), Role limitations due to Emotional
problems (Role-Emotional), Vitality, General Health Perceptions
(General Health) and a question about perceived change of health
during the last year (Health Transition). Subscale scores are
calculated as the sum of the relevant items, ranging from 0 to
100. The present study only reports on the most relevant subscales
of Physical Functioning, Social Functioning, General Mental Health,
and Vitality. Lower scores correspond to a worse state.
2.3.3. Personality pathology
The Dimensional Assessment of Personality Pathology-Short
Form (DAPP-SF) consists of 136 items to assess personality
pathology, subdivided into 18 subscales or dimensions/traits and
4 broad higher-order constructs/factors (de Beurs et al., 2009).
“Emotional Dysregulation” includes the following subscales: Sub-
missiveness, Cognitive Distortion, Identity Problems, Affective
Lability, Oppositionality, Anxiousness, Suspiciousness, Social Avoi-
dance, Narcissism, Insecure Attachment, and Self-harm. “Dissocial
behavior” includes the subscales: Stimulus Seeking, Callousness,
Rejection, and Conduct Problems. “Inhibitedness” includes the sub-
scales: Intimacy Problems and Restricted Expression. “Compulsivity”
includes the subscale Compulsivity.
The items are rated on a 5-point Likert scale, with scores
ranging from 1 (very unlike me) to 5 (very like me). The score for
each subscale differs with maxima of 30–40, and higher scores
indicate more pronounced maladaptive personality traits. The
selection of the 136 items of the DAPP-SF is described by van
Kampen (2006). In general, the Dutch version of the DAPP-SF has
good psychometric properties (van Kampen et al., 2008; de Beurs
et al., 2009; Tiemensma et al., 2010a,2010b). In this context,
Schulte-van Maaren et al. (2012) calculated cut-off scores, as part
of a larger study with other generic ROM instruments (mean cut-
off value for DAPP-SF dimensions: 3.1).
2.4. Statistical analyses
For the socio-demographic characteristics, chi-squared tests
were used to compare categorical variables and analysis of
variance (ANOVA) to compare continuous variables. Where neces-
sary, data were transformed to obtain normal distributions.
Bonferroni correction was performed in post-hoc test. Symptom
profiles and dimensions of personality pathology were com-
pared between the patient groups using analysis of covariance
(ANCOVA). These analyses were adjusted for age, gender and
education.
For effect size, partial eta squared was used (interpretation:
small .01% or 1%, medium .06% 0r 6%, large .138% or 13.8%; Cohen,
1988). Data were analyzed using SPSS version 20.0 statistical
software. Significance level was set at p o0.01.
2.5. Ethics approval
The Medical Ethical Committee of the LUMC approved the
general study protocol regarding ROM, in which ROM is consid-
ered integral to the treatment process (no written informed
consent is institutionally required). A comprehensive protocol
(titled “Psychiatric Academic Registration Leiden database”) was
used, which safeguarded the anonymity of participants and
ensured proper handling of the data. All participants gave permis-
sion for the (anonymized) use of their data for scientific purposes.
 I.V.E. Carlier et al. / Journal of Affective Disorders 168 (2014) 322–330 325

Table 1
Sociodemographic and clinical characteristics of patient groups with pure anxiety-. pure depressive-. pure somatoform disorders and MAS comorbidity

Pure anxiety disorder Pure depressive Pure somatoform MAS-comorbidity P-value

N ¼ 1633 disorder N ¼1794 disorder N ¼ 479 N ¼2016

Gender
Female (n, %) 1085 (66.4) 1066 (59.4) 353 (73.7) 1336 (66.3) o 0.001
Age (yr) – (mean, SD) 33.8 (11.1)a 38.9 (11.8)b 39.4 (11.4)b 37.6 (11.3)c o 0.001
Ethnicity
Not Dutch (n, %) 260 (15.9) 374 (20.8) 73 (15.2) 484 (24.0) o 0.001
Married or living together (n, %) 821 (50.3) 904 (50.4) 277 (57.8) 1034 (51.3) o 0.001
Housing situation (n, %) 0.001
Living independently and alone 316 (19.4) 418 (23.3) 88 (18.4) 433 (21.5)
Living independently with partner and/or children 839 (51.4) 912 (50.8) 284 (59.3) 1059 (52.5)
Residing with family 478 (29.3) 464 (25.9) 107 (22.3) 524 (26.0)
Educational status (n, %)
Lower education 89 (5.5) 148 (8.2) 41 (8.6) 195 (9.7) o 0.001
Middle education 1201(73.5) 1307 (72.9) 334 (69.7) 1453 (72.1)
Higher education 343 (21.0) 339 (18.9) 104 (21.7) 368 (18.3)
Employment status (n, %)
Working full-time 446 (27.3) 406 (22.6) 82 (17.1) 346 (17.2) o 0.001
Working part time 504 (30.9) 398 (22.2) 105 (21.9) 384 (19.0)
Retired/unemployed 432 (26.5) 470 (26.2) 131 (27.3) 565 (28.0)
On sick leave 251(15.4) 520 (29.0) 161 (33.6) 721 (35.8)
Number of diagnoses according to MINI-plus, within the o 0.001
specific disorder group (n, %)
1 1309 (80.2) 1759 (98.0) 470 (98.1) –
2 270 (16.5) 35 (2.0) 9 (1.9) 1393 (69.1)
3 45 (2.8) – – 452 (22.4)
43 9 (0.6) – – 171 (8.5)

Note: Values in the same row with different superscript letters are significantly different (Post-hoc comparisons by Bonferroni test, P-value o 0.01).
MAS denotes mood, anxiety and somatoform.

3. Results Disorder: 16.0%; Generalized Anxiety Disorder: 15.8%; Obsessive

3.1. Sociodemographic and clinical characteristics of the patient
groups
The socio-demographic characteristics of the research groups
are presented in Table 1. The sample consisted of 1633 patients
with pure anxiety disorders, 1794 patients with pure depressive
disorders, 479 patients with pure somatoform disorders, and 2016
patients with MAS-comorbidity. None of the patients of these
groups had any personality disorder (clinical diagnoses assigned
by staff psychiatrist, antisocial personality disorder also by MINI).
The pure somatoform disorder group, compared to the other
groups, had a higher proportion of women (73.7%), the oldest
participants (39.4 years), more married participants (57.8%), higher
educated participants (21.7%) and, together with the MAS group,
more participants on sick leave (respectively 35.8% and 33.6%).
The pure depressive disorder, compared to the other groups,
had fewer female participants (59.4%), more participants living
alone (23.3%) and, together with the MAS group, more non-Dutch
participants (respectively 24% and 20.8%).
The pure anxiety disorder group, compared to the other groups,
had the youngest participants (33.8 years), more participants
residing with family (29.3%), more middle educated participants
(73.5%), and more working participants (full-time 27.3%; part-time
30.9%).
In clinical terms, most patients in the pure disorder groups had
only one diagnosis: 98.1% in the pure somatoform disorder group,
98% in the pure depressive group, and 80.2% in the pure anxiety
disorder group. In case a patient had more than 1 diagnosis in the
pure disorder groups, the clinical picture was as follows (not
shown in table, total rates not always 100% if patients had multiple
disorders within that group).
The group “pure anxiety disorder” (current diagnosis, all
possible anxiety disorders) consisted of: Social Anxiety Disorder:
25.2%; Panic Disorder with Agoraphobia: 18.2%; Posttraumatic
Stress Disorder: 16.5%; Agoraphobia without History of Panic
Compulsive Disorder: 13.6%; Panic Disorder without Agoraphobia:
8.0%; and Specific Phobia: 7.2%.
The group “pure depressive disorder” (current diagnosis, with-
out bipolar disorders/cyclothymia/psychotic features) consisted of:
Major Depressive Disorder, Recurrent: 57.5%; Major Depression
Disorder, Single Episode: 35.1%; and Dysthymic Disorder: 9.4%.
The group “pure somatoform disorder” (current diagnosis, all
possible somatoform disorders) consisted of: Undifferentiated
Somatoform Disorder: 64.1%; Pain Disorder: 19.2%; Hypochondria-
sis: 9.8%; Body Dysmorphic Disorder: 5.6%; Conversion Disorder:
2.3%; and Somatization Disorder: 0.8%.
3.2. Psychopathological and functional health characteristics of the
patient groups
Table 2 shows the general psychopathological (CPRS, BSI,
MASQ) and functional health (SF-36) characteristics of the
research groups. Overall, it appears from Table 2 that the MAS
group shows the worst clinical picture, which was to be expected
given their comorbidity. Of the three pure disorder groups, the
pure depressive disorder group exhibits the worst psychopatho-
logical and functional health image (CPRS, BSI, MASQ, SF-36) that
also closely resembles that of the MAS group. With the following
two exceptions: first, the SF-36 subscale scores on Physical
functioning were the worst (lowest) for the pure somatoform
disorder and MAS groups (respectively 61.61 and 69.96). Second,
the BSI subscale scores on Anxiety and Phobic Anxiety were the
worst (highest) for the MAS and pure anxiety groups (Anxiety
respectively 1.70 and 1.34, Phobic Anxiety respectively 1.32 and
1.05). Effect sizes shown in Table 2 are medium to large.
3.3. Dimensional personality pathology profiles of the patient groups
Table 3 shows the dimensional personality pathology scores
(DAPP-SF) for the research groups. It appears from Table 3, that
first the MAS group and then the pure depressive disorder group
326 I.V.E. Carlier et al. / Journal of Affective Disorders 168 (2014) 322–330

Table 2
Psychosocial and symptom scores of patients groups with pure anxiety-. pure depressive-. pure somatoform disorders and MAS comorbidity.

Pure anxiety disorder Pure depressive disorder Pure somatoform disorder MAS-comorbidity P-value P-value Effect
N¼ 1633 N ¼1794 N ¼ 479 N¼ 2016 adjusted* size η2p

CPRS (mean, 99% CI)

BAS score 13.41 (13.03–13.78)a 14.62 (14.27–14.98)b 11.26 (10.58–11.95)c 17.59 (17.26–17.92)d o 0.001 o 0.001 0.11
MADRS score 12.50 (12.02–12.99)a 22.55 (22.09–23.00)b 10.78 (9.90–11.66)c 22.74 (22.31–23.17)b o 0.001 o 0.001 0.31
BSI subscale
(geometric mean, 99% CI)
Somatisation 0.72 (0.68–0.76)a 0.86 (0.82–0.91)b 0.71 (0.63–0.79)a 1.17 (1.12–1.21)c o 0.001 o 0.001 0.064
Obsession compulsion 1.15 (1.10–1.20)a 1.73 (1.67–1.78)b 0.92 (0.84–1.01)c 1.91 (1.85–1.96)d o 0.001 o 0.001 0.15
Interpersonal sensitivity 1.11 (1.05–1.16)a 1.49 (1.43–1.55)b 0.62 (0.54–0.71)c 1.76 (1.70–1.82)d o 0.001 o 0.001 0.12
Depression 0.97 (0.92–1.01)a 1.91 (1.86–1.97)b 0.67 (0.60–0.75)c 1.99 (1.93–2.04)d o 0.001 o 0.001 0.27
Anxiety 1.34 (1.28–1.40)a 1.20 (1.15–1.25)b 0.63 (0.55–0.71)c 1.70 (1.65–1.75)d o 0.001 o 0.001 0.12
Hostility 0.52 (0.49–0.56)a 0.87 (0.83–0.91)b 0.42 (0.36–0.49)c 0.95 (0.91–0.99)d o 0.001 o 0.001 0.095
Phobic anxiety 1.05 (1.00–1.10)a 0.82 (0.77–0.86)b 0.34 (0.27–0.42)c 1.32 (1.27–1.37)d o 0.001 o 0.001 0.12
Paranoid ideation 0.75 (0.70–0.80)a 1.07 (1.02–1.12)b 0.45 (0.37–0.53)c 1.24 (1.19–1.29)d o 0.001 o 0.001 0.090
Psychoticism 0.81 (0.77–0.85)a 1.26 (1.21–1.30)b 0.46 (0.39–0.52)c 1.39 (1.34–1.43)d o 0.001 o 0.001 0.17
Total score 0.98 (0.94–1.01)a 1.31 (1.27–1.34)b 0.64 (0.58–0.69)c 1.56 (1.52–1.59)d o 0.001 o 0.001 0.19
MASQ subscale (mean, 99% CI)
General distress mixed 33.80 (33.18–34.43)a 43.55 (42.88–44.24)b 31.69 (30.58–32.81)c 45.13 (44.48–45.78)d o 0.001 o 0.001 0.21
General distress depression 25.34 (24.73–25.96)a 35.39 (34.70–36.07)b 21.51 (20.48–22.56)c 36.26 (35.62–36.92)b o 0.001 o 0.001 0.22
General distress anxiety 24.16 (23.67–24.64)a 25.90 (25.42–26.38)b 20.59 (19.78–21.43)c 29.47 (29.00–29.95)d o 0.001 o 0.001 0.11
Anhedonic depression 68.11 (67.23–68.98)a 84.19 (83.37–85.02)b 66.00 (64.41–67.60)a 84.60 (83.82–85.37)b o 0.001 o 0.001 0.26
Anxious arousaln 28.65 (28.02–29.28)a 30.63 (29.99–31.28)b 26.98 (25.89–28.11)c 34.92 (34.23–35.59)d o 0.001 o 0.001 0.064
SF-36 subscale (mean, 99% CI)
Physical functioning 83.35 (81.93–84.77)a 75.57 (74.22–76.91)b 61.61 (59.01–64.21)c 69.96 (68.70–71.23)d o 0.001 o 0.001 0.079
Social functioning 56.41 (54.81–58.00)a 41.76 (40.24–43.27)b 49.74 (46.82–52.67)c 36.22 (34.80–37.64)d o 0.001 o 0.001 0.097
Mental health 51.32 (50.30–52.35)a 36.41 (35.44–37.39)b 63.43 (61.56–65.31)c 34.63 (33.72–35.54)d o 0.001 o 0.001 0.26
Vitality 45.39 (44.36–46.42)a 28.80 (27.82–29.77)b 38.48 (36.60–40.36)c 27.59 (26.68–28.51)b o 0.001 o 0.001 0.19

Note: BSI denotes Brief Symptom Inventory; SF-36 denotes Short Form-36; MASQ denotes Mood and Anxiety Symptom Questionnaire. CPRS denotes abbreviated
Comprehensive Psychopathological Rating Scale; BAS denotes Brief Anxiety Scale; MADRS denotes Montgomery-Äsberg Depression Rating Scale. Higher scores imply worse
functioning except for the SF-36 (lower scores implying worse functioning). MAS denotes mood, anxiety and somatoform.
By some dimensions because of their skewed distributions, back-transformed geometric mean and 99% confidence intervals (CI) are presented.
Values in the same row with different superscript letters are significantly different (Post-hoc comparisons by Bonferroni test, P-value o0.01).
For effect size (η2p) small ¼0.01, medium ¼0.06 and large¼ 0.14.
n
Adjusted for age, gender and education level.

Table 3
Dimensional personality pathology of patient groups with pure anxiety-. pure depressive-. pure somatoform disorders and MAS comorbidity.

DAPP-SF Pure anxiety CO (%) Pure depressive CO (%) Pure somatoform CO (%) MAS-comorbidity CO (%) P-value P-value Effect
disorder N ¼1633 disorder N ¼ 1794 disorder N ¼479 N ¼ 2016 Mean adjustedn size ηp2
Mean (99% CI) Mean (99% CI) Mean (99% CI) (99% CI)

Emotional Dysregulation
Submissiveness 2.80 (2.74–2.86)a 41.2 2.94 (2.88–3.00)b 45.9 2.30 (2.20–2.41)c 22.8 3.04 (2.99–3.10)d 51.3 o 0.001 o 0.001 0.045
Cognitive distortion 1.89 (1.84–1.94)a 13.6 2.17 (2.12–2.23)b 22.4 1.53 (1.45–1.60)c 5.2 2.30 (2.25–2.35)d 28.1 o 0.001 o 0.001 0.078
Identity problems 2.67 (2.61–2.73)a 36.1 3.31 (3.25–3.36)b 62.4 2.23 (2.13–2.34)c 18.4 3.40 (3.34–3.45)b 66.8 o 0.001 o 0.001 0.15
Affective lability 2.96 (2.91–3.02)a 48.1 3.28 (3.23–3.33)b 62.0 2.55 (2.45–2.65)c 29.6 3.40 (3.35–3.44)d 68.0 o 0.001 o 0.001 0.085
Oppositionality 2.49 (2.43–2.54)a 27.0 2.93 (2.88–2.98)b 44.3 2.31 (2.21–2.41)c 16.3 2.95 (2.91–3.00)b 45.6 o 0.001 o 0.001 0.077
Anxiousness 3.17 (3.11–3.23)a 57.5 3.38 (3.33–3.44)b 64.2 2.59 (2.48–2.69)c 31.5 3.55 (3.50–3.60)d 72.1 o 0.001 o 0.001 0.078
Suspiciousness 1.76 (1.71–1.81)a 14.9 1.96 (1.91–2.01)b 17.8 1.44 (1.37–1.52)c 4.6 2.12 (2.07–2.17)d 24.8 o 0.001 o 0.001 0.061
Social avoidance 2.81 (2.74–2.87)a 43.1 2.94 (2.88–3.00)b 46.2 2.16 (2.04–2.28)c 18.4 3.20 (3.14–3.26)d 56.7 o 0.001 o 0.001 0.068
Narcissism 2.30 (2.25–2.34)a 20.3 2.41 (2.36–2.45)b 20.7 2.07 (1.98–2.16)c 10.6 2.36 (2.32–2.41)ab 19.6 o 0.001 o 0.001 0.013
Insecure attachment 2.75 (2.68–2.82)a 38.4 2.84 (2.77–2.90)a 40.6 2.09 (1.96–2.21)b 15.9 3.05 (2.98–3.11)c 49.8 o 0.001 o 0.001 0.051
Self-harm 1.25 (1.21–1.28)a 4.5 1.74 (1.69–1.79)b 16.6 1.20 (1.13–1.26)a 2.7 1.67 (1.63–1.72)b 15.2 o 0.001 o 0.001 0.11
Dissocial behavior
Stimulus seeking 1.84 (1.80–1.89)a 8.6 2.13 (2.08–2.17)b 16.1 1.87 (1.79–1.95)a 8.1 2.02 (1.98–2.06)c 10.4 o 0.001 o 0.001 0.025
Callousness 1.63 (1.59–1.66)a 2.6 1.70 (1.67–1.73)b 3.5 1.60 (1.54–1.66)a 1.7 1.68 (1.65–1.71)b 2.8 o 0.001 o 0.001 0.005
Rejection 2.23 (2.18–2.28)a 17.0 2.38 (2.34–2.43)b 21.6 2.28 (2.19–2.37)ab 16.5 2.29 (2.25–2.34)a 17.9 o 0.001 o 0.001 0.006
Conduct problems 1.20 (1.19–1.22)a 1.0 1.28 (1.26–1.30)b 1.8 1.18 (1.15–1.21)a 0.0 1.27 (1.26–1.29)b 1.2 o 0.001 o 0.001 0.017
Inhibitedness
Intimacy problems 2.29 (2.24–2.34)a 17.4 2.40 (2.35–2.45)bc 23.3 2.30 (2.21–2.40)ab 21.5 2.44 (2.39–2.48)c 25.8 o 0.001 o 0.001 0.006
Restricted expression 3.02 (2.97–3.07)a 48.2 3.29 (3.23–3.34)b 61.5 2.72 (2.62–2.82)c 34.9 3.40 (3.35–3.44)d 66.0 o 0.001 o 0.001 0.058
Compulsivity
Compulsivity 2.88 (2.82–2.94)a 41.9 2.83 (2.77–2.88)a 39.4 2.66 (2.55–2.77)b 33.8 2.99 (2.93–3.04)c 46.8 o 0.001 o 0.001 0.010

Note: DAPP-SF denotes Dimensional Assessment of Personality Pathology-Short Form. MAS denotes mood, anxiety and somatoform.
Values in the same row with different superscript letters are significantly different (Post-hoc comparisons by Bonferroni test, P-value o0.01)
By some dimensions because of their skewed distributions, back-transformed geometric mean and 99% confidence intervals (CI) are presented.
Cut-off (CO)Z 3.1 (Schulte-van Maaren et al., 2012).
For effect size (η2p) small ¼0.01, medium ¼0.06 and large¼0.14.
n
Adjusted for age, gender and education level.
 I.V.E. Carlier et al. / Journal of Affective Disorders 168 (2014) 322–330 327

Table 4
Dimensional personality pathology of patient groups with pure depressive- and depressive with anxiety- and depressive with somatoform disorders.

DAPP-SF Pure depressive CO (%) Depressive– with anxiety CO (%) Depressive– with CO (%) P-value P-value adjustedn Effect size η2p
disorder N ¼ 1794 disorder N ¼ 1358 somatoform
mean (99% CI) mean (99% CI) disorder N¼ 251
mean (99% CI)

Emotional Dysregulation
Submissiveness 2.93 (2.87–2.98) a 45.9 3.12 (3.06–3.18)b 56.0 2.86 (2.71–3.00)a 44.2 o0.001 o 0.001 0.012
Cognitive distortion 2.17 (2.12–2.22)a 22.4 2.38 (2.31–2.44)b 30.5 2.11 (1.98–2.25)a 21.9 o0.001 o 0.001 0.013
Identity problems 3.30 (3.24–3.35)a 62.4 3.48 (3.42–3.54)b 70.5 3.32 (3.18–3.46)ab 64.9 o0.001 o 0.001 0.010
Affective lability 3.27 (3.22–3.32)a 62.0 3.44 (3.38–3.49)b 70.5 3.26 (3.13–3.38)a 60.2 o0.001 o 0.001 0.011
Oppositionality 2.93 (2.88–2.98)a 44.3 3.00 (2.94–3.06)a 48.3 2.87 (2.73–3.00)a 38.6 0.001 0.010 0.003
Anxiousness 3.36 (3.31–3.42)a 64.2 3.62 (3.56–3.68)b 75.9 3.29 (3.15–3.43)a 61.4 o0.001 o 0.001 0.023
Suspiciousness 1.95 (1.90–2.00)a 17.8 2.19 (2.13–2.26)b 27.5 1.89 (1.77–2.03)a 15.5 o0.001 o 0.001 0.019
Social avoidance 2.93 (2.87–2.99)a 46.2 3.29 (3.22–3.36)b 61.0 2.89 (2.73–3.05)a 43.4 o0.001 o 0.001 0.032
Narcissism 2.38 (2.33–2.43)a 20.7 2.35 (2.30–2.41)a 20.1 2.30 (2.17–2.42)a 17.9 0.093 0.23 0.001
Insecure attachment 2.83 (2.76–2.89)a 40.6 3.13 (3.05–3.20)b 53.5 2.71 (2.53–2.89)a 34.7 o0.001 o 0.001 0.020
Self-harm 1.74 (1.69–1.79)a 16.6 1.71 (1.65–1.77)a 17.1 1.74 (1.61–1.89)a 13.5 0.90 0.68 0.00
Dissocial behavior
Stimulus seeking 2.12 (2.07–2.16)a 16.1 2.04 (1.99–2.09)b 11.0 2.01 (1.89–2.13)ab 11.2 0.001 0.002 0.004
Callousness 1.70 (1.67–1.73)a 3.5 1.68 (1.64–1.71)a 2.5 1.67 (1.59–1.76)a 4.4 0.25 0.43 0.00
Rejection 2.38 (2.33–2.43)a 21.6 2.26 (2.21–2.32)b 17.5 2.37 (2.24–2.50)ab 17.9 o0.001 o 0.001 0.005
Conduct problems 1.28 (1.26–1.30)a 1.8 1.29 (1.27–1.31)a 1.2 1.23 (1.19–1.28)a 0.8 0.010 0.025 0.002
Inhibitedness
Intimacy problems 2.41 (2.35–2.46)a 23.3 2.46 (2.40–2.52)a 27.3 2.49 (2.35–2.63)a 26.7 0.026 0.11 0.001
Restricted expression 3.29 (3.24–3.34)a 61.5 3.46 (3.40–3.52)b 68.7 3.25 (3.11–3.38)a 58.6 o0.001 o 0.001 0.012
Compulsivity
Compulsivity 2.83 (2.77–2.88)a 39.4 3.02 (2.95–3.08)b 47.5 2.89 (2.74–3.04)ab 43.0 o0.001 o 0.001 0.009

Note: DAPP-SF denotes Dimensional Assessment of Personality Pathology-Short Form. MAS denotes mood, anxiety and somatoform.
Values in the same row with different superscript letters are significantly different (Post-hoc comparisons by Bonferroni test, P-value o0.01)
By some dimensions because of their skewed distributions, back-transformed geometric mean and 99% confidence intervals (CI) are presented.
Cut-off (CO)Z 3.1 (Schulte-van Maaren et al., 2012).
For effect size (η2p) small ¼ 0.01, medium ¼0.06 and large¼0.14.
n
Adjusted for age, gender and education level.

had the worst clinical picture for most DAPP-SF subscales regard-
ing Emotional Dysregulation, Inhibitedness, and Compulsiveness.
This entailed both the highest scores and the highest rate of
patients that reached the cut-off value of 3.1 (Schulte-van Maaren
et al., 2012). With the following two exceptions: first, for Emo-
tional Dysregulation, scores on the subscales Narcissism and Self-
harm were the highest in the pure depressive disorder group
(2.41 and 1.74). Second, for Dissocial behavior, scores on all
subscales were the highest in the pure depressive disorder group
(Stimulus seeking 2.13, Callousness 1.70, Rejection 2.38, Conduct
problems 1.20).
Finally, when we focus on the cut-off score of 3.1 within the
three pure disorder groups, we see the following. In the pure
anxiety disorder group, the highest mean was found for the
subscale Anxiousness (3.17). In the pure depressive disorder group,
the highest mean was found for the subscales Identity problems
(3.31), Affective lability (3.28), Anxiousness (3.38), and Restricted
expression (3.29). In the pure somatoform disorder group, none of
the general means reached the cut-off value. Overall, effect sizes
shown in Table 3 are medium for the subscales of Emotional
regulation, with the exception of Identity problems (large). Effect
sizes for other subscales were small.
Since Tables 2 and 3 show that the pure depressive disorder
group exhibits the most unfavorable clinical picture of all pure
disorder groups, we have studied this further. In Table 4, the DAPP-
SF scores of the pure depressive disorder group are compared to
the following two newly formed comorbidity groups: depressive
with anxiety disorder (N ¼ 1358) and depressive with somatoform
disorder (N ¼ 251).
In general, Table 4 shows that the Depressive Anxiety Disorder
group exhibits most personality pathology and the Depressive
with somatoform disorder group least personality pathology.
However, there are some exceptions. First, the highest means for
the DAPP-SF subscales Self-harm and Intimacy problems are found
in the Depressive with somatoform disorder group (respectively
1.74 and 2.49). Second, the highest means for the DAPP-SF
subscales Narcissism, Self-harm, Stimulus seeking, Callousness,
and Rejection are found in the pure depressive disorder group
(respectively 2.38, 1.74, 2.12, 1.70, and 2.38). Overall, effect sizes
shown in Table 4 are small.
Finally, the DAPP-SF dimensions were correlated with the other
dimensional instrument in this study, the MASQ. Since the MASQ
specifically relates to mood and anxiety, correlations were calcu-
lated separately for the pure depressive disorder group and for the
pure anxiety group. The results were as follows (not shown in
table). On the whole, the significant correlations between DAPP-SF
dimensions and MASQ symptom dimensions were rather low
(below r¼0.50). Exceptions with significant moderate correlations
(r¼0.50 to r¼0.70) were solely found for the pure anxiety disorder
group and not for the pure depression group: Identity problems
(DAPP-SF) with the MASQ dimensions of Anhedonic depression
(r¼0.576), General distress depression (r¼0.640), General distress
mixed (r¼0.507); and Anxiousness (DAPP-SF) with the MASQ
dimension of General distress depression (r¼ 0.526).
4. Discussion
Our results generally showed that the pure depressive disorder
group, in comparison to the pure anxiety and pure somatoform
disorder groups, exhibited the worst psychopathological and func-
tional health image. Exceptions were the subscales Physical func-
tioning (SF-36, worst for pure somatoform disorder group), and
Anxiety and Phobic Anxiety (BSI, worst for pure anxiety group).
The pure depressive disorder group, compared to the other two
pure disorder groups, also scored most personality pathology
concerning all four higher-order factors (Emotional Dysregulation,
Dissocial behavior, Inhibitedness, and Compulsiveness). In the pure
328 I.V.E. Carlier et al. / Journal of Affective Disorders 168 (2014) 322–330
anxiety disorder group, the highest mean was found for the
subscale Anxiousness (3.17); in the pure depressive disorder group
for the subscales Identity problems (3.31), Affective lability (3.28),
Anxiousness (3.38), and Restricted expression (3.29).
In the pure somatoform disorder group, none of the general
means reached the cut-off value of 3.1 (Schulte-van Maaren et al.,
2012). This is perhaps somewhat unexpected, since it has been
described that many patients with somatoform disorder also meet
criteria for a personality disorder, or that certain personality
disorders and traits contribute to somatization (Bass and
Murphy, 1995; Noyes et al., 2001; Garcia-Campayo et al., 2007).
Participants in the Only somatoform disorder group, compared to
those in the other two groups, were significantly more frequently
married and higher educated, which may reflect some personal
stability.
The relevance of dimensional trait models for the conceptua-
lization and assessment of personality disorders is widely
acknowledged. However, the same holds for the notion that
personality traits alone do not suffice to diagnose personality
disorders (Wakefield, 2008; Widiger and Costa, 2012; Berghuis et
al., 2014). Simply having extreme traits is not necessarily patho-
logical, since personality functioning and psychosocial disability
are also important (Clark and Ro, 2014). This is in line with the
alternative DSM-5 Model for personality Disorder (American
Psychiatric Association, APA., 2013), proposing that the combina-
tion of severity levels of dysfunction of core features of personality
disorder and elevated personality traits leads to a diagnosis of
personality disorder (Berghuis et al., 2014).
Durability (trait notion) has been considered to be a defining
feature of personality disorders (Gutiérrez, 2014). Recent studies
have challenged this with a state notion, because maladaptive
personality traits steadily decrease with age, at times personality
pathology can be quite variable, and patients eventually develop
more mature dispositions (Reich, 2007; Gutiérrez, 2014). Espe-
cially for the pure anxiety group our results seem to point toward
the state notion, because some significant moderate correlations
were found between personality pathology dimensions and symp-
tom dimensions. Also, the pure anxiety disorder group had the
highest mean for the DAPP-SF subscale Anxiousness. Because of
their current mood, the possibility exists that patients may
evaluate their personality dimensions in a biased way. Also,
patients may have personality pathology that appears to be
mediated by anxiety or depression (Reich, 2007).
With regard to the comparison of our results with those from
other studies, the following can be said. Jylhä and Isometsä. (2006)
found a relationship of personality dimensions (such as neuroti-
cism and extraversion, Eysenck Personality Inventory) to symp-
toms of depression and anxiety in the general population. Cuijpers
et al. (2005) showed that personality traits (NEO Five factor
Inventory) in outpatients with mood and anxiety disorders were
associated with comorbidity and less so with any specific disorder.
This is somewhat in line with our results, which showed that the
Depressive Anxiety Disorder group exhibits most personality
pathology (table 4). On the other hand, we also found the highest
means for some specific personality pathology subscales in the
pure depressive disorder group (DAPP-SF subscales Narcissism,
Self-harm, Stimulus seeking, Callousness, and Rejection; see
Table 4). So far, no research findings are available on the compar-
ison of dimensional personality pathology profiles (DAPP-SF or
DAPP-BQ) between patients with pure depressive-, pure anxiety-,
and pure somatoform disorders. Concerning depression, Michalak
et al. (2004) used the DAPP-BQ for a comparison among patients
with seasonal depression, nonseasonal depression, and nonclinical
participants. Significant differences between the groups were
detected on all DAPP-BQ dimensions. The results demonstrated
that the personality traits associated with seasonal and
nonseasonal depression differ in degree, not in kind. Concerning
anxiety disorders, Saper and Brasfield (1998) used the DAPP-BQ as
an outcome measure for treatment in a case study of a patient
with panic disorder with agoraphobia and posttraumatic stress
disorder (PTSD). They found decreased scores after treatment on
several of the DAPP-BQ dimensions. These results are important,
because they suggest the possibility of improving certain comor-
bid personality pathology in anxiety disorders by treatment.
Concerning pure somatoform disorders, no studies were con-
ducted with the DAPP-BQ or the DAPP-SF.
Strengths of the present study are the large samples which
were part of a naturalistic patient population, generalizable to
“real-life” psychiatric practice. This study also has limitations. The
cross-sectional nature of the study limits the conclusions that can
be drawn. Effect sizes regarding personality pathology
(Tables 3 and 4) were small. Also, our results need to be confirmed
in psychiatric inpatients. This study focused on the comparison of
personality pathology among three pure disorder groups. How-
ever, having for example multiple anxiety disorders may be
considered as co-morbidity and it is unclear to what extent this
might have influenced our results. Finally, our results regarding
personality pathology are based on a self-report instrument.
Assessment of personality disorders was exclusively based on
clinical diagnosis, with the exception of antisocial personality
disorder (also measured by the MINI Plus). To assess personality
disorders efficiently, the administration of a semi-structured inter-
view such as the SCID II (Structured Clinical Interview for DSM IV
Axis II Personality Disorders; First et al., 1997) is recommended
(Widiger and Samuel, 2005; van Kampen et al., 2008).
The implications of our results for clinical practice and future
research are as follows: individual differences in personality traits
may play an important role in the development and formation of
specific symptoms, for instance of Posttraumatic Stress Disorder
(Jaksic et al., 2012). Personality traits can lead to the exacerbation
of mood-, anxiety-, somatoform disorders and to poorer remission
rates (Massion et al., 2002; Phillips et al., 2005; Frank et al., 2011;
van Noorden et al., 2012). Certain personality characteristics may
also interact with treatment approaches or they can alter the
course of treatment of a mental disorder, for example by a longer
treatment duration. Therefore, the assessment of dimensional
personality pathology or personality traits is clinically relevant,
whether a patient has a personality disorder or not (Skodol, 2011,
Krueger et al., 2011; Gutiérrez, 2014). More specifically, the
assessment of comorbid personality pathology before the start of
the treatment is useful, because in this way treatment can partly
be focused on specific maladaptive personality traits. Closer
clinical monitoring of such patients is warranted. Also, the treat-
ment plan could include specific strategies for the management of
maladaptive personality symptoms (e.g. self-harm and compul-
siveness) (Judd et al., 2013; Reich, 2007). This is consistent with
research suggesting some normalization of specific deviant per-
sonality scores following treatment of axis 1 disorders (Rø et al.,
2005; Holliday et al., 2006). It is recommended to conduct further
research in these patient groups with regard to the stability of
traits but also the predictive impact of comorbid personality
pathology on outcome, therapy utilization, and rejecting or drop-
ping out of therapy (Thormählen et al., 2003; Löffler-Stastka et al.,
2010; Clark and Ro, 2014).
Role of funding source
Nothing declared.
Conflict of interest
No conflict declared.
 I.V.E. Carlier et al. / Journal of Affective Disorders 168 (2014) 322–330
Acknowledgments
The essential contributions made by the participants of this study as well as the
mental healthcare provider Rivierduinen are very gratefully acknowledged.
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