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<a href=Journal of Affective Disorders 168 (2014) 322 330 Contents lists available at S c i e n c e D i r e c t Journal of Affective Disorders journal homepage: w w w . e l s e v i e r . c o m / l o c a t e / j a d Research report A comparative analysis of personality pathology pro fi les among patients with pure depressive-, pure anxiety-, and pure somatoform disorders Ingrid V.E. Carlier , Sjoerd Colijn , Yanda R. van Rood , Marion F. Streevelaar , Irene M. van Vliet , Tineke van Veen Leiden University Medical Centre, Department of Psychiatry, Albinusdreef 2, Post zone B1-P, 2300 RC Leiden, The Netherlands GGZ Del fl and, Lindberghlaan 113, 2497 EB Den Haag, The Netherlands article info Article history: Received 26 May 2014 Received in revised form 9 July 2014 Accepted 9 July 2014 Available online 18 July 2014 Keywords: C omorbid personality pathology Personality traits Depressive disorders Anxiety disorders Somatoform disorders Routine outcome monitoring abstract Background: Depressive-, anxiety-, and somatoform disorders are among the most common psychiatric disorders. The assessment of comorbid personality pathology or traits in these disorders is relevant, because it can lead to the exacerbation of them or to poorer remission rates. To date, no research fi ndings have been published on the comparison of these three prevalent patient groups with regard to comorbid dimensional personality pathology. Methods: Data of participants (18 – 60 years) came from a web-based Routine Outcome Monitoring (ROM) programme. The present study used baseline data and was designed to compare personality pathology pro fi les between three separate outpatient groups: pure anxiety disorders ( n ¼ 1633), pure depressive disorders ( n ¼ 1794), and pure somatoform disorders ( n ¼ 479). Personality pathology was measured with the Dimensional Assessment of Personality Pathology-Short Form (DAPP-SF). Results: The pure depressive disorder group, in comparison to the other two disorder groups, exhibited 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 speci fi c 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 re fl ects 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 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). http://dx.doi.org/10.1016/j.jad.2014.07.012 0165-0327/ & 2014 Elsevier B.V. All rights reserved. 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 de fi ni- 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 classi fi cation of personality disorders which is re fl ected in " id="pdf-obj-0-7" src="pdf-obj-0-7.jpg">

Contents lists available at ScienceDirect

Journal of Affective Disorders

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

<a href=Journal of Affective Disorders 168 (2014) 322 330 Contents lists available at S c i e n c e D i r e c t Journal of Affective Disorders journal homepage: w w w . e l s e v i e r . c o m / l o c a t e / j a d Research report A comparative analysis of personality pathology pro fi les among patients with pure depressive-, pure anxiety-, and pure somatoform disorders Ingrid V.E. Carlier , Sjoerd Colijn , Yanda R. van Rood , Marion F. Streevelaar , Irene M. van Vliet , Tineke van Veen Leiden University Medical Centre, Department of Psychiatry, Albinusdreef 2, Post zone B1-P, 2300 RC Leiden, The Netherlands GGZ Del fl and, Lindberghlaan 113, 2497 EB Den Haag, The Netherlands article info Article history: Received 26 May 2014 Received in revised form 9 July 2014 Accepted 9 July 2014 Available online 18 July 2014 Keywords: C omorbid personality pathology Personality traits Depressive disorders Anxiety disorders Somatoform disorders Routine outcome monitoring abstract Background: Depressive-, anxiety-, and somatoform disorders are among the most common psychiatric disorders. The assessment of comorbid personality pathology or traits in these disorders is relevant, because it can lead to the exacerbation of them or to poorer remission rates. To date, no research fi ndings have been published on the comparison of these three prevalent patient groups with regard to comorbid dimensional personality pathology. Methods: Data of participants (18 – 60 years) came from a web-based Routine Outcome Monitoring (ROM) programme. The present study used baseline data and was designed to compare personality pathology pro fi les between three separate outpatient groups: pure anxiety disorders ( n ¼ 1633), pure depressive disorders ( n ¼ 1794), and pure somatoform disorders ( n ¼ 479). Personality pathology was measured with the Dimensional Assessment of Personality Pathology-Short Form (DAPP-SF). Results: The pure depressive disorder group, in comparison to the other two disorder groups, exhibited 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 speci fi c 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 re fl ects 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 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). http://dx.doi.org/10.1016/j.jad.2014.07.012 0165-0327/ & 2014 Elsevier B.V. All rights reserved. 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 de fi ni- 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 classi fi cation of personality disorders which is re fl ected in " id="pdf-obj-0-56" src="pdf-obj-0-56.jpg">

Research report

A comparative analysis of personality pathology pro les among patients with pure depressive-, pure anxiety-, and pure somatoform disorders

<a href=Journal of Affective Disorders 168 (2014) 322 330 Contents lists available at S c i e n c e D i r e c t Journal of Affective Disorders journal homepage: w w w . e l s e v i e r . c o m / l o c a t e / j a d Research report A comparative analysis of personality pathology pro fi les among patients with pure depressive-, pure anxiety-, and pure somatoform disorders Ingrid V.E. Carlier , Sjoerd Colijn , Yanda R. van Rood , Marion F. Streevelaar , Irene M. van Vliet , Tineke van Veen Leiden University Medical Centre, Department of Psychiatry, Albinusdreef 2, Post zone B1-P, 2300 RC Leiden, The Netherlands GGZ Del fl and, Lindberghlaan 113, 2497 EB Den Haag, The Netherlands article info Article history: Received 26 May 2014 Received in revised form 9 July 2014 Accepted 9 July 2014 Available online 18 July 2014 Keywords: C omorbid personality pathology Personality traits Depressive disorders Anxiety disorders Somatoform disorders Routine outcome monitoring abstract Background: Depressive-, anxiety-, and somatoform disorders are among the most common psychiatric disorders. The assessment of comorbid personality pathology or traits in these disorders is relevant, because it can lead to the exacerbation of them or to poorer remission rates. To date, no research fi ndings have been published on the comparison of these three prevalent patient groups with regard to comorbid dimensional personality pathology. Methods: Data of participants (18 – 60 years) came from a web-based Routine Outcome Monitoring (ROM) programme. The present study used baseline data and was designed to compare personality pathology pro fi les between three separate outpatient groups: pure anxiety disorders ( n ¼ 1633), pure depressive disorders ( n ¼ 1794), and pure somatoform disorders ( n ¼ 479). Personality pathology was measured with the Dimensional Assessment of Personality Pathology-Short Form (DAPP-SF). Results: The pure depressive disorder group, in comparison to the other two disorder groups, exhibited 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 speci fi c 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 re fl ects 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 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). http://dx.doi.org/10.1016/j.jad.2014.07.012 0165-0327/ & 2014 Elsevier B.V. All rights reserved. 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 de fi ni- 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 classi fi cation of personality disorders which is re fl ected in " id="pdf-obj-0-65" src="pdf-obj-0-65.jpg">

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 Deland, Lindberghlaan 113, 2497 EB Den Haag, The Netherlands

article info

Article history:

Received 26 May 2014 Received in revised form 9 July 2014 Accepted 9 July 2014 Available online 18 July 2014

Keywords:

Comorbid personality pathology Personality traits Depressive disorders Anxiety disorders

Somatoform disorders Routine outcome monitoring

abstract

Background: Depressive-, anxiety-, and somatoform disorders are among the most common psychiatric

disorders. The assessment of comorbid personality pathology or traits in these disorders is relevant, because it can lead to the exacerbation of them or to poorer remission rates. To date, no research ndings have been published on the comparison of these three prevalent patient groups with regard to comorbid dimensional personality pathology.

Methods: Data of participants (1860 years) came from a web-based Routine Outcome Monitoring (ROM) programme. The present study used baseline data and was designed to compare personality pathology proles between three separate outpatient groups: pure anxiety disorders (n ¼ 1633), pure depressive

disorders (n ¼ 1794), and pure somatoform disorders

(n ¼ 479). Personality pathology was measured with

the Dimensional Assessment of Personality Pathology-Short Form (DAPP-SF). Results: The pure depressive disorder group, in comparison to the other two disorder groups, exhibited 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 specic 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 reects 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).

0165-0327/& 2014 Elsevier B.V. All rights reserved.

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 deni- 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 classication of personality disorders which is reected in

I.V.E. Carlier et al. / Journal of Affective Disorders 168 (2014) 322 330

323

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 proles 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 Braseld, 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

psychiatric disorders and the assessment of comorbid personality pathology in these disorders is clinically highly relevant. So far, no research ndings 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 proles 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 age ¼ 36.1 years; SD ¼ 11.7), 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 (1860 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 12 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- decit/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 MontgomeryǺ sberg 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 testretest 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, obsessivecompulsive, 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 ve 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 ve-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 Dysregulationincludes 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. Inhibitednessincludes the sub- scales: Intimacy Problems and Restricted Expression. Compulsivityincludes 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 3040, 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 proles 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. Signicance level was set at p o 0.01.

  • 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 scientic purposes.

I.V.E. Carlier et al. / Journal of Affective Disorders 168 (2014) 322 330

Table 1

325

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 ¼ 1794

disorder N ¼ 479

N ¼ 2016

Gender Female (n, %)

Employment status (n, %)

1085 (66.4)

1066 (59.4)

353 (73.7)

1336 (66.3)

o 0.001

Age (yr) (mean, SD) Ethnicity

33.8 (11.1) a

38.9 (11.8) b

39.4 (11.4) b

37.6

(11.3) c

o 0.001

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 Educational status (n, %)

478 (29.3)

464 (25.9)

107 (22.3)

524 (26.0)

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)

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 specic disorder group (n, %)

o 0.001

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)

4 3

9 (0.6)

171 (8.5)

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

3. Results

  • 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

Disorder: 16.0%; Generalized Anxiety Disorder: 15.8%; Obsessive Compulsive Disorder: 13.6%; Panic Disorder without Agoraphobia:

8.0%; and Specic 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: rst, 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 proles of the patient groups

Table 3 shows the dimensional personality pathology scores (DAPP-SF) for the research groups. It appears from Table 3, that rst 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

2

N ¼ 1633

 

N ¼ 1794

N ¼ 479

 

N ¼ 2016

adjusted *

size η p

CPRS (mean, 99% CI) BAS score

13.41

(13.0313.78) a 14.62

(14.2714.98) b

11.26

(10.5811.95) c

 

17.59

(17.2617.92) d

o 0.001

o 0.001

0.11

MADRS score

12.50 (12.0212.99) a 22.55 (22.0923.00) b

10.78 (9.9011.66) c

22.74

(22.3123.17) b

o 0.001

o 0.001

0.31

BSI subscale (geometric mean, 99% CI) Somatisation

0.72 (0.680.76) a

 

0.86 (0.820.91) b

0.71 (0.630.79) a

 

1.17 (1.121.21) c

o 0.001

o 0.001

0.064

Obsession compulsion

1.15 (1.101.20) a

1.73

(1.671.78)

b

0.92

(0.841.01) c

1.91

(1.851.96)

d

o 0.001

o 0.001

0.15

Interpersonal sensitivity

1.11 (1.051.16) a

1.49 (1.431.55) b

0.62 (0.540.71) c

1.76

(1.701.82)

d

o 0.001

o 0.001

0.12

Depression

0.97

(0.921.01) a

1.91

(1.861.97)

b

0.67

(0.600.75)

c

1.99

(1.932.04) d

o 0.001

o 0.001

0.27

Anxiety

1.34 (1.281.40) a

 

1.20 (1.151.25) b

0.63 (0.550.71) c

 

1.70

(1.651.75) d

o 0.001

o 0.001

0.12

Hostility

0.52 (0.490.56) a

0.87 (0.830.91) b

0.42 (0.360.49) c

0.95 (0.910.99) d o 0.001 o 0.001

0.095

Phobic anxiety

1.05 (1.001.10) a

0.82 (0.770.86) b

0.34 (0.270.42) c

1.32

(1.271.37) d

o 0.001

o 0.001

0.12

Paranoid ideation

0.75

(0.700.80)

a

1.07

(1.021.12) b

0.45

(0.370.53)

c

1.24

(1.191.29) d

o 0.001

o 0.001

0.090

Psychoticism

0.81 (0.770.85) a

1.26 (1.211.30) b

0.46 (0.390.52) c

 

1.39

(1.341.43)

d

o 0.001

o 0.001

0.17

Total score

0.98

(0.941.01) a

1.31

(1.271.34)

b

0.64

(0.580.69)

c

1.56

(1.521.59)

d

o 0.001

o 0.001

0.19

MASQ subscale (mean, 99% CI)

 

General

distress

mixed

33.80

(33.1834.43) a 43.55

(42.8844.24)

(34.7036.07)

(25.4226.38)

b

31.69

(30.5832.81)

c

45.13

(44.4845.78) d

o 0.001

o 0.001

0.21

General

distress

depression 25.34

(24.7325.96) a 35.39

b

21.51 (20.4822.56) c

36.26

(35.6236.92)

b

o 0.001

o 0.001

0.22

General

distress

anxiety

24.16

(23.6724.64) a 25.90

b

20.59

(19.7821.43)

c

29.47

(29.0029.95)

d

o 0.001

o 0.001

0.11

Anhedonic depression

68.11 (67.2368.98) a 84.19 (83.3785.02) b

66.00 (64.4167.60) a

84.60

(83.8285.37)

b

o 0.001

o 0.001

0.26

Anxious arousal n SF-36 subscale (mean, 99% CI)

28.65 (28.0229.28) a 30.63 (29.9931.28) b

26.98 (25.8928.11) c

34.92

(34.2335.59)

d

o 0.001

o 0.001

0.064

Physical functioning

 

83.35

(81.9384.77) a 75.57

(74.2276.91)

b

61.61

(59.0164.21)

c

69.96

(68.7071.23)

d

o 0.001

o 0.001

0.079

Social functioning

56.41

(54.8158.00) a 41.76 (40.2443.27) b 49.74

(46.8252.67) c

36.22

(34.8037.64)

d

o 0.001

o 0.001

0.097

Mental health

51.32

(50.3052.35) a 36.41

(35.4437.39)

(27.8229.77)

b

63.43

(61.5665.31) c

34.63

(33.7235.54)

d

o 0.001

o 0.001

0.26

Vitality

45.39

(44.3646.42) a 28.80

b

38.48

(36.6040.36) c

27.59

(26.6828.51) 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% condence intervals (CI) are presented. Values in the same row with different superscript letters are signicantly different (Post-hoc comparisons by Bonferroni test, P-value o 0.01).

For effect

2

size (η ) small ¼ 0.01, medium ¼ 0.06 and large ¼ 0.14.

p

 

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 ¼ 479

 

N ¼ 2016 Mean

 

adjusted n

size η

2

disorder N ¼ 1633 Mean (99% CI)

disorder N ¼ 1794 Mean (99% CI)

Mean (99% CI)

(99% CI)

 

p

Emotional Dysregulation

 

Submissiveness

2.80 (2.742.86) a 41.2

 

2.94 (2.883.00) b 45.9

2.30 (2.202.41) c 22.8

3.04

(2.993.10) d 51.3

o 0.001 o 0.001

0.045

Cognitive distortion

1.89

(1.841.94) a 13.6

2.17 (2.122.23) b 22.4

1.53 (1.451.60) c

 

5.2

2.30

(2.252.35) d 28.1

o 0.001 o 0.001

0.078

Identity problems

2.67

(2.612.73) a 36.1

3.31

(3.253.36) b 62.4

2.23

(2.132.34) c 18.4

3.40

(3.343.45) b 66.8

o 0.001 o 0.001

0.15

Affective lability

2.96 (2.913.02) a 48.1

3.28

(3.233.33) b 62.0

2.55

(2.452.65) c 29.6

3.40

(3.353.44) d 68.0

o 0.001 o 0.001

0.085

Oppositionality

2.49

(2.432.54) a 27.0

2.93

(2.882.98) b 44.3

2.31

(2.212.41) c 16.3

2.95

(2.913.00) b 45.6

o 0.001 o 0.001

0.077

Anxiousness

3.17 (3.113.23) a 57.5

3.38

(3.333.44) b 64.2

2.59

(2.482.69) c 31.5

3.55

(3.503.60) d 72.1

o 0.001 o 0.001

0.078

Suspiciousness

1.76

(1.711.81) a 14.9

1.96

(1.912.01) b 17.8 1.44

(1.371.52) c

4.6

2.12 (2.072.17) d 24.8

 

o 0.001 o 0.001

0.061

Social avoidance

2.81 (2.742.87) a 43.1

2.94

(2.883.00) b 46.2

2.16

(2.042.28) c 18.4

3.20

(3.143.26) d 56.7

o 0.001 o 0.001

0.068

Narcissism

2.30

(2.252.34) a 20.3

2.41

(2.362.45) b 20.7

2.07

(1.982.16) c 10.6

2.36

(2.322.41) ab 19.6

o 0.001 o 0.001

0.013

Insecure attachment 2.75 (2.682.82) a 38.4

2.84

(2.772.90) a 40.6

2.09

(1.962.21) b 15.9

3.05

(2.983.11) c 49.8

o 0.001 o 0.001

0.051

Self-harm

1.25

(1.211.28) a 4.5

1.74 (1.691.79) b 16.6

1.20

(1.131.26) a 2.7 1.67

(1.631.72) b 15.2

o 0.001 o 0.001

0.11

Dissocial behavior

Stimulus seeking

1.84

(1.801.89) a 8.6

 

2.13

(2.082.17) b 16.1

1.87

(1.791.95)

a

8.1

2.02

(1.982.06) c 10.4

o 0.001 o 0.001

0.025

Callousness

1.63

(1.591.66) a 2.6

1.70

(1.671.73) b 3.5

1.60

(1.541.66) a 1.7

 

1.68

(1.651.71) b 2.8

o 0.001 o 0.001

0.005

Rejection 2.23 (2.182.28) a 17.0 2.38 (2.342.43) b 21.6

2.28

(2.192.37) ab 16.5

2.29

(2.252.34) a 17.9

o 0.001 o 0.001

0.006

Conduct problems

1.20

(1.191.22) a

1.0

 

1.28

(1.261.30) b

1.8

1.18 (1.151.21) a

 

0.0

1.27

(1.261.29) b

1.2

o 0.001 o 0.001

0.017

Inhibitedness

Intimacy problems

2.29 (2.242.34) a 17.4 2.40 (2.352.45) bc 23.3

2.30

(2.212.40) ab 21.5

2.44

(2.392.48) c 25.8

o 0.001 o 0.001

0.006

Restricted expression 3.02

(2.973.07) a 48.2

 

3.29

(3.233.34) b 61.5

2.72

(2.622.82) c 34.9

3.40

(3.353.44) d 66.0

o 0.001 o 0.001

0.058

Compulsivity

Compulsivity

2.88

(2.822.94) a 41.9 2.83

(2.772.88) a 39.4

2.66

(2.552.77) b 33.8

2.99

(2.933.04) 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 signicantly different (Post-hoc comparisons by Bonferroni test, P-value o 0.01) By some dimensions because of their skewed distributions, back-transformed geometric mean and 99% condence intervals (CI) are presented. Cut-off (CO) Z 3.1 (Schulte-van Maaren et al., 2012).

For effect size

2

(η ) small ¼ 0.01, medium ¼ 0.06 and large ¼ 0.14.

p

n Adjusted for age, gender and education level.

I.V.E. Carlier et al. / Journal of Affective Disorders 168 (2014) 322 330

Table 4

327

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

DAPP-SF

Pure depressive disorder N ¼ 1794 mean (99% CI)

CO (%) Depressivewith anxiety CO (%) Depressivewith

disorder N ¼ 1358 mean (99% CI)

somatoform disorder N ¼ 251 mean (99% CI)

CO (%) P-value

P-value adjusted n Effect size η

2

p

Emotional Dysregulation

Submissiveness

Cognitive distortion

Identity problems

Affective lability

Oppositionality

Anxiousness

Suspiciousness

Social avoidance

Narcissism

Insecure attachment

Self-harm

Dissocial behavior

Stimulus seeking

Callousness

Rejection

Conduct problems

Inhibitedness

2.93 (2.872.98) a 45.9

2.17 (2.122.22) a

22.4

3.30 (3.243.35) a 62.4

3.27 (3.223.32) a 62.0 2.93 (2.882.98) a 44.3 3.36 (3.313.42) a 64.2

1.95

(1.902.00) a

17.8

2.93 (2.872.99) a 46.2

2.38 (2.332.43) a 20.7

2.83 (2.762.89) a 40.6

1.74 (1.691.79) a

2.12 (2.072.16) a

16.6

16.1

3.12

(3.063.18) b

2.38 (2.312.44) b

3.48 (3.423.54) b 3.44 (3.383.49) b

3.00 (2.943.06) a

3.62

2.19

3.29

(3.563.68)

b

(2.132.26) b

(3.223.36)

b

2.35 (2.302.41) a 3.13 (3.053.20) b 1.71 (1.651.77) a

2.04 (1.992.09) b

56.0

30.5

70.5

70.5

48.3

75.9

27.5

61.0

20.1

53.5

17.1

11.0

2.86 (2.713.00) a 44.2

2.11 (1.982.25) a

21.9

3.32

(3.183.46) ab 64.9

3.26

(3.133.38) a 60.2

2.87 (2.733.00) a 38.6

3.29

1.89

2.89

(3.153.43) a 61.4 (1.772.03) a 15.5 (2.733.05) a 43.4

2.30 (2.172.42) a 17.9

2.71

(2.532.89) a 34.7

1.74 (1.611.89) a 13.5

2.01 (1.892.13) ab 11.2

o 0.001

o 0.001

o 0.001

o 0.001

0.001

o 0.001

o 0.001

o 0.001

0.093

o 0.001

0.90

o 0.001

o 0.001

o 0.001

o 0.001

0.010

o 0.001

o 0.001

o 0.001

0.23

o 0.001

0.68

0.001

0.002

1.70 (1.671.73) a 3.5 1.68 (1.641.71) a 2.5 1.67 (1.591.76) a 4.4 0.25 0.43

2.38 (2.332.43) a 21.6

1.28 (1.261.30) a

1.8

2.26

(2.212.32) b

1.29 (1.271.31) a

17.5

1.2

2.37

(2.242.50) ab 17.9

1.23 (1.191.28) a

0.8

o 0.001

0.010

o 0.001

0.025

Intimacy problems

2.41 (2.352.46) a 23.3

Restricted expression 3.29 (3.243.34) a 61.5

Compulsivity

Compulsivity

2.83 (2.772.88) a 39.4

2.46 (2.402.52) a

3.46

(3.403.52)

b

3.02

(2.953.08)

b

27.3

68.7

47.5

2.49 (2.352.63) a 26.7

3.25

(3.113.38) a

58.6

2.89

(2.743.04) ab 43.0

0.026

o 0.001

0.11

o 0.001

o 0.001

o 0.001

0.012

0.013

0.010

0.011

0.003

0.023

0.019

0.032

0.001

0.020

0.00

0.004

0.00

0.005

0.002

0.001

0.012

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 signicantly different (Post-hoc comparisons by Bonferroni test, P-value o 0.01) By some dimensions because of their skewed distributions, back-transformed geometric mean and 99% condence intervals (CI) are presented. Cut-off (CO) Z 3.1 (Schulte-van Maaren et al., 2012). For effect size (η ) small ¼ 0.01, medium ¼ 0.06 and large ¼ 0.14.

2

p

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: rst, 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 specically 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 signicant correlations between DAPP-SF dimensions and MASQ symptom dimensions were rather low (below r ¼ 0.50). Exceptions with signicant moderate correlations (r ¼ 0.50 to r ¼ 0.70) 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 (r ¼ 0.576), General distress depression (r ¼ 0.640), General distress mixed (r ¼ 0.507); and Anxiousness (DAPP-SF) with the MASQ

dimension of General distress depression

(r ¼ 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

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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 signicantly more frequently married and higher educated, which may reect 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 sufce to diagnose personality disorders (Wakeeld, 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 dening 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 signicant 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 specic 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 specic 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 ndings are available on the compar- ison of dimensional personality pathology proles (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. Signicant 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 Braseld (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-lifepsychiatric 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 conrmed 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 inuenced 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 efciently, 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 specic 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 specically, the assessment of comorbid personality pathology before the start of the treatment is useful, because in this way treatment can partly be focused on specic maladaptive personality traits. Closer clinical monitoring of such patients is warranted. Also, the treat- ment plan could include specic 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 specic 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; Löfer-Stastka et al., 2010; Clark and Ro, 2014).

Role of funding source

Nothing declared.

Conict of interest No conict declared.

I.V.E. Carlier et al. / Journal of Affective Disorders 168 (2014) 322 330

329

Acknowledgments

The essential contributions made by the participants of this study as well as the

mental healthcare provider Rivierduinen are very gratefully acknowledged.

References

Berghuis, H., Kamphuis, J.H.,Verheul, R., 2014. Specic personality traits and general personality dysfunction as predictors of the presence and severity of person- ality disorders in a clinical sample. J. Pers. Assess. 96, (4), 410-416, /http://dx.

Brezo, J., Paris, J., Tremblay, R., Vitaro, F., Turecki, G., 2008. DAPP-BQ: factor structure in French Canadians. J. Pers. Disord. 22 (5), 538545. Carlier, I.V.E., Meuldijk, D., van Vliet, I.M., van Fenema, E., N.J., van der Wee, Zitman, F.G., 2012a. Routine outcome monitoring and feedback on physical or mental health status: evidence and theory. J. Eval. Clin. Pract. 18 (1), 104 110. Carlier, I.V.E., Schulte-Van Maaren, Y., Wardenaar, K., Giltay, E., Van Noorden, M., Vergeer, P., Zitman, F.G., 2012b. Development and validation of the 48-item Symptom Questionnaire (SQ-48) in patients with depressive, anxiety and somatoform disorders. Psychiatry Res. 200 (23), 904 910. Claes, L., Müller, A., Norré, J., Assche, L., Wonderlich, S., Mitchell, J.E., 2012. The relationship among compulsive buying, compulsive internet use and tempera- ment in a sample of female patients with eating disorders. Eur. Eat. Disord. Rev 20 (2), 126131. Clark, L.A., Watson, D., 1991. Tripartite model of anxiety and depression: psycho- metric evidence and taxonomic implications. J. Abnorm. Psychol. 100, 316336. Clark, L.A., Vittengl, J., Kraft, D., Jarrett, R.B., 2003. Separate personality traits from states to predict depression. J. Pers. Disord. 17 (2), 152172. Clark, L.A., Ro, E., 2014. Three-pronged assessment and diagnosis of personality disorder and its consequences: personality functioning, pathological traits, and its psychosocial disability. Personal. Disord. 5 (1), 5569. Cohen, J., 1988. Statistical Power Analysis for the Behavioral Sciences, 2nd ed. Lawrence Erlbaum Associates, Hillsdale NJ. Cuijpers, P., van Straten, A., Donker, M., 2005. Personality traits of patients with mood and anxiety disorders. Psychiatry Res. 133 (23), 229237. de Beurs, E., 2005. De Brief Symptom Inventory; Handleiding ([The Brief Symptom Inventory; Manual]). Pits Publishers, Leiden. de Beurs, E., Rinne, T., Kampen, van D., Verheul, R., Andrea, H., 2009. Reliability and validity of the Dutch Dimensional Assessment of Personality Pathology-Short Form (DAPP-SF), a shortened version of the DAPP-basic Questionnaire. J. Pers. Disord. 23 (3), 308326. de Beurs, E., Hollander, Gijsman, den, M.E., van Rood, Y.R., van der Wee, N.J.A., Giltay, E.J., van Noorden, M.S., van der Lem, R., van Fenema, E., Zitman, F.G, 2011. Routine outcome monitoring in the Netherlands: practical experiences with a web-based strategy for the assessment of treatment outcome in the clinical practice. Clin. Psychol. Psychother. 18, 112. de Clercq, .B., de Fruyt, F., Leeuwen, van K., Mervielde, I., 2006. The structure of maladaptive personality traits in childhood: a step toward an integrative developmental perspective for DSM-V. J. Abnorm. Psychol. 115 (4), 639657. de Klerk, S., van Noorden, M.S., van Giezen, A.E., Spinhoven, P., Hollander, Gijsman, den, M.E., Giltay, E.J., Speckens, A.E., Zitman, F.G., 2011. Prevalence and correlates of lifetime deliberate self-harm and suicidal ideation in naturalistic outpatients: the Leiden routine outcome monitoring study. J. Affect. Disord. 183, 257264 . Derogatis, L.R., Lipman, R.S., Covi, L., 1973. SCL-90: an outpatient psychiatric rating scale-preliminary report. Psychopharmacol. Bull. 9 (1), 1328. Derogatis, L.R., Melisaratos, N., 1983. The Brief Symptom Inventory: an introductory report. Psychol. Med. 13 (3), 595605.

de Reus, R.J.M., van den Berg, J.F., Emmelkamp, P.M.G., 2013. Personality Diagnostic Questionnaire 4 þ is not useful as a screener in clinical practice. Clin. Psychol. Psychother. 20 (1), 4954. de Waal, M.W.M., Arnold, I.A., van Hemert, A.M, 2004. Somatoform disorders in general practice: prevalence, functional impairment and comorbidity with anxiety and depressive disorders. Br. J. Psychiatry 184, 470476. First, M.B., Gibbon, M., Spitzer, R.L., Williams, J.B., Benjamin, L.S., 1997. Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II). American Psychiatric Publishing, Washington, DC. Frank, E., Cassano, G.B., Rucci, P., Thompson, W.K., Kraemer, H.C., Fagioloni, A., Maggi, L., Kupfer, D.J., Shear, M.K., Houck, P.R., Calguci, S., Grochocinski, V.J., Scocco, P., 2011. Predictors and moderators of time to remission of major depression with interpersonal psychotherapy and SSRI pharmacotherapy. Psychol. Med. 41, 151162. Friborg, O., Martinsen, E.W., Martinussen, M., Kaiser, S., Overgård, K.T., Rosenvinge, J.H., 2014. Comorbidity of personality disorders in mood disorders: a meta- analytic review of 122 studies from 1988 to 2010. J. Affect. Disord. 152154, 111. http://dx.doi.org/10.1016/j.jad.2013.08.023 (Epub 2013 Sep 2). Garcia-Campayo, J., Alda, M., Sobradiel, N., Olivan, B., Pascual, A., 2007. Personality disorders in somatization disorder patients: a controlled study in Spain. J. Psychosom. Res. 62 (6), 675680 . Goekoop, J.G., van der Knoppert-Klein, E.A., Hoeksema, T., Klinkhamer, R.A., van Gaalen, H.A., van der Velde, E.A., 1991. The interrater reliability of a Dutch Version of the Comprehensive Psychopathological Rating Scale. Acta Psychiat. Scand. 83 (3), 202205. Goldner, E.M., Srikameswaran, S., Schroeder, M.L., Livesley, W.J., Birmingham, C.L.,

categories in primary care? Results from a large cross-sectional study. J. Psychosom. Res. 67, 189197. Harned, M.S., Valenstein, H.R., 2013. Treatment of borderline personality disorder and co-occurring anxiety disorders. F1000 Prime Rep 2013, 5 15 (http://dx.doi.

personality traits in posttraumatic stress disorder. Psychiatr. Danub. 24 (3), 256266 . Judd, L.L., Schettler, P.J., Coryell, W., Akiskal, H.S., Fiedorowicz, J.G., 2013. Overt irritability/anger in unipolar major depressive episodes: past and current characteristics and implications for long-term course. JAMA Psychiatry 70 (11), 11711780. Jylhä, P., Isometsä, E., 2006. The relationship of neuroticism and extraversion to symptoms of anxiety and depression in the general population. Depress. Anxiety 23 (5), 281289. Karlsen, T.I., Tveitå, E.K., Natvig, G.K., Tonstad, S., Hjelmesæth, J., 2011. Validity of the SF-36 in patients with morbid obesity. Obes. Facts 4 (5), 346351. Krischer, M.K., Sevecke, K., Lehmkuhl, G., Pukrop, R., 2007. Dimensional assessment of personality pathology in female and male juvenile delinquents. J. Pers. Disord. 21 (6), 675689 . Krueger, R.F., Eaton, N.R., Clark, L.A., Watson, D., Markon, K.E., Derringer, J., Skodol, A., Livesly, W.J., 2011. Deriving an empirical structure of personality pathology for DSM-5. J. Pers. Disord. 25 (2), 170191. Kushner, S.C., Quilty, L.C., Tackett, J.L., Bagby, R.M., 2011. The hierarchical structure of the dimensional assessment of personality pathology (DAPP-BQ). J. Pers. Disord. 25 (4), 504 516. Lecrubier, Y., Sheehan, D.V., Weiller, E., Amorim, P., Bonora, I., Sheehan, K.H., Amorim, P., Bonora, I., Sheehan, K., Janavs, J., Dunbar, G., 1997. The Mini International Neuropsychiatric Interview (MINI). A short diagnostic structured interview: reliability and validity according to the CIDI. Eur. Psychiatry 12 (5),

  • 330 I.V.E. Carlier et al. / Journal of Affective Disorders 168 (2014) 322 330

Reuber, M., Pukrop, R., Bauer, J., Derfuss, R., Elger, C.E., 2004. Multidimensional assessment of personality in patients with psychogenic non-epileptic seizures. J. Neurol. Neurosurg. Psychiatry 75 (5), 743748. Rø, O., Martinsen, E.W., Hoffart, A., Rosenvinge, J., 2005. Two-year prospective study of personality disorders in adults with longstanding eating disorders. Int. J. Eat. Disord. 37 (2), 112118. Rose, M., Wahl, I., Crusius, J., Löwe, B., 2011. Psychological comorbidity. A challenge in acute care. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 54 (1), 8389. Samaniego, M.L., Oyarzábal, V.J., Gómez, G.A.M., Frenández, H.A., Gutiérrez-Zotes, J.A., Alquézar, L.A., 2011. Schizotypy and pathological prole in siblings of patients with psychosis. Psicothema 23 (1), 8086. Samuel, D.B., Simms, L.J., Clark, L.A., Livesley, W.J., Widiger, T.A., 2010. An item response theory integration of normal and abnormal personality scales. Personal. Disord. 1 (1), 521. Saper, Z., Braseld, C.R., 1998. Two-phase treatment of panic disorder and post- traumatic stress disorder with associated personality features resulting from childhood abuse: case study. J. Behav. Ther. Exp. Psychiatry 29 (2), 171178. Schulte-van Maaren, Y.W., Carlier, I.V., Zitman, F.G., van Hemert, A.M., de Waal, M.W., Noorden, v.a.n., M.S., Giltay, E.J., 2012. Reference values for generic instruments used in routine outcome monitoring: the Leiden routine outcome monitoring study. BMC Psychiatry 12, 203. http://dx.doi.org/10.1186/1471-244X-12203. Sheehan, D.V., Lecrubier, Y., Sheehan, K.H., Amorim, P., Janavs, J., Weiller, E., Hergueta, T., Baker, R., Dunbar, G.C., 1998. The Mini-International Neuropsy- chiatric Interview (MINI): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J. Clin. Psychiatry 59 (20), 2233. Simonsen, S., Simonsen, E., 2009. The Danish DAPP-BQ: reliability, factor structure, and convergence with SCID-II and IIP-C. J. Pers. Disord. 23 (6), 629646 .

Skodol, A.E., 2011. Scientic Issues in the Revision of Personality Disorders for DSM- 5, 5. American Psychiatric Association, Washington, DC, pp. 97111. http://dx.