Personality disorder traits as predictors of subsequent first-onset panic disorder or agoraphobia
Introduction
Determining how personality disorder traits and panic disorder and/or agoraphobia relate longitudinally is an important step in developing a comprehensive understanding of the etiology of panic/agoraphobia. Cluster C (anxious cluster) personality traits, especially avoidant and dependent traits, are strongly related to anxiety disorders, including panic disorder and agoraphobia, cross-sectionally [1], [2], [3].
Some have argued that avoidant and dependent traits are predisposing factors for (or prodromal factors in) panic/agoraphobia, based on retrospective reports of anxious patients' premorbid personalities [4]. However, relying on retrospective reports introduces potential recall bias, that is, patients with current panic/agoraphobia may have biased memories of their premorbid personality traits.
Others have argued that early panic symptoms probably shape personality, for example, enhancing avoidant and dependent tendencies [5], [6]. Indeed, personality abnormalities can be diminished somewhat by effective treatment of panic disorder and agoraphobia [7], [8], and this may indicate some degree of state-trait confounding in the context of acute psychopathology [9]. Of course, a state-trait confounding explanation presumes that treatment of panic/agoraphobia has no influence on personality traits themselves; this may not be correct [10], [11].
The most informative method for determining whether or not personality disorder traits are risk factors for panic/agoraphobia is to longitudinally relate the former to later first onset of the latter; we know of only one prior study that used this method [12]. [Note that we are using the term risk factor in a broad sense here: that is, a risk factor is an attribute or exposure that is associated with an increased probability of a specified outcome [13], not necessarily a causal factor.] The current study uses general population cohort data to determine whether baseline personality disorder characteristics predict subsequent first onset of panic disorder or agoraphobia over a 13-year period, excluding participants with baseline spontaneous panic attacks or subthreshold panic-like spells from the risk groups. If personality abnormalities are merely epiphenomena of panic/agoraphobia, baseline personality disorder traits should be unrelated to subsequent onset. Because avoidant and dependent traits are strongly related to panic and agoraphobia cross-sectionally, these were the strongest a priori candidates as personality disorder trait risk factors.
Section snippets
Methods
The current study, which was approved by the Johns Hopkins Institutional Review Board, involves the longitudinally assessed Baltimore Epidemiologic Catchment Area cohort. In 1981, trained nonclinician interviewers administered a Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III) version of the National Institute of Mental Health Diagnostic Interview Schedule (DIS-III) [14] to a probabilistic sample of the adult population of eastern Baltimore (n = 3481).
Results
Baseline (1981) demographic characteristics of the 432 participants were as follows: 36% were 18 to 29 years old, 30% were 30 to 44 years old, 22% were 45 to 64 years old, and 12% were 65 years or older; 32% were male and 68% were female; 58% were white, 38% were African American, and 4% were of another race; 15% had 8 years or less of education, 29% had 9 to 11 years, 29% had 12 years, and 27% had more than 12 years; 38% were married, 12% were widowed, 11% were separated, 12% were divorced,
Discussion
We found that avoidant, dependent, and related traits (timidity) predicted onset of panic disorder, agoraphobia, or both conditions over the follow-up period. These findings fit conceptions of avoidant and dependent traits as risk factors, as opposed to consequences of panic attacks or panic-like spells (recall that we excluded participants with baseline panic attacks or panic-like spells from the risk groups).
These findings support the contention of Roth [29, p 36] that panic and agoraphobia
Acknowledgment
National Institute of Mental Health grants R01-MH47447, R01-MH50616, and K23-MH64543 supported this study. The authors report no competing interests.
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