Co-occurrence of 12-month mood and anxiety disorders and personality disorders in the US: results from the national epidemiologic survey on alcohol and related conditions

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Abstract

The objective of this study was to determine the prevalence and co-occurrence of DSM-IV personality disorders (PDs) among individuals with current DSM-IV mood and anxiety disorders in the US population and among individuals who sought treatment for such mood or anxiety disorders. Face-to-face interviews were conducted with 43,093 individuals, 18 years and older, in the National Institute on alcohol abuse and alcoholism's 2001–2002 National epidemiologic survey on alcohol and related conditions (NESARC). Odds ratios (ORs) were calculated to determine the prevalence and associations between current DSM-IV axis I and axis II disorders. Associations between mood, anxiety and PDs were all positive and statistically significant. Avoidant and dependent PDs were more strongly related to mood and anxiety disorders than other PDs. Associations between obsessive–compulsive PD and mood and anxiety disorders were significant, but much weaker. Paranoid and schizoid PDs were most strongly related to dysthymia, mania, panic disorder with agoraphobia, social phobia and generalized anxiety disorder, while histrionic and antisocial PDs were most strongly related to mania and panic disorder with agoraphobia. Results of this study highlight the need for further research on overlapping symptomatology, factors giving rise to the associations and the treatment implications of these disorders when comorbid.

Introduction

Numerous studies have addressed the prevalence of personality disorders (PDs) among patients with axis I anxiety disorders or mood disorders. The rates of these disorders in these patients have varied across studies, but are consistently quite high (Corruble et al., 1996; Iketani et al., 2002; Moran, 1999; Oldham et al., 1995; Pepper et al., 1995; Sanderson et al., 1994; Skodal et al., 1995). Further, PDs have consistently been shown to adversely affect treatment compliance and outcome for axis I mood and anxiety disorders (Alnaes and Torgersen, 1997; Baer et al., 1992; Pfohl et al., 1987; Sato et al., 1993; Turner, 1987; Zimmerman et al., 1986).

Despite the considerable clinical interest in personality disorders, empirical knowledge in this area has been limited by a number of factors. First, many of the samples studied were small. Second, the focus of many of the studies was on the comorbidity of personality disorders with major depression, with few studies (Oldham et al., 1995; Skodal et al., 1995; Zimmerman and Coryell, 1989) addressing a broader range of PDs and Axis I disorders in the same sample. Third, relatively few studies are available that used the most current nomenclature of the American psychiatric association, the diagnostic and statistical manual of mental disorders-fourth edition (DSM-IV) (American Psychiatric Association, 1994). Fourth, large epidemiologic surveys conducted in the US over the past two decades have addressed only a single personality disorder, antisocial PD (Kessler and Walters, 2002; Robins and Reigier, 1991). As a result, accurate data on the prevalence and comorbidity of a broad range of PDs and mood and anxiety disorders in the general population reflects a major gap in our understanding of these disorders. This gap limits the development and testing of hypotheses that can be applied to uncovering fundamental etiologic factors and developmental pathways underlying these disorders.

The present study was designed, in part, to address this gap. We present the first nationally representative data on the prevalence and co-occurrence of seven of the 10 PDs defined in DSM-IV among individuals with current DSM-IV mood and anxiety disorders. These disorders were assessed in the National Institute on alcohol abuse and alcoholism's (NIAAA) 2001–2002 National epidemiologic survey on alcohol and related conditions (NESARC) (Grant et al., 2003b). Because of the NESARC sample size (n=43,093), accurate estimation was possible of current or recent (past year) co-occurrence of DSM-IV Axis I disorders (major depression, dysthymia, mania, hypomania panic disorder with and without agoraphobia, social phobia, specific phobia, and generalized anxiety disorder) with Axis II disorders, including avoidant, dependent, obsessive–compulsive, histrionic, paranoid, schizoid and antisocial PDs. This study also provides comorbidity rates for the subset of respondents who sought treatment for mood and anxiety disorders to determine if the treated and total rates differed and because such patterns of comorbidity are of considerable interest to practicing clinicians.

Section snippets

NESARC Sample

The 2001–2002 NESARC is a representative sample of the US sponsored by the NIAAA, as described in detail elsewhere (Grant et al., 2003b, Grant et al., 2004). The target population of the NESARC was the civilian noninstitutionalized population, including group quarters, 18 years and older, residing in the continental United States, the District of Columbia, and Alaska and Hawaii. The sample included persons living in households, the military living off base and the following group quarters:

Prevalence of mood and anxiety disorders and PDs

The 12-month prevalence of any mood or anxiety disorder was 9.2% and 11.1% in the total sample. The most prevalent mood and anxiety disorders were major depression (7.1%) and specific phobia (7.1%), followed by social phobia (2.8%), generalized anxiety disorder (2.1%), dysthymia (1.8%), mania (1.7%), panic disorder without agoraphobia (1.6%), hypomania (1.2%) and panic disorder with agoraphobia (0.6%). The most prevalent PD in the general population was obsessive–compulsive personality disorder

Discussion

The co-occurrence of DSM-IV PDs and DSM-IV current mood and anxiety disorders is pervasive in the US population. Among individuals with a current mood or anxiety disorder, nearly half had at least one PD. Personality disorders were no less prevalent among individuals with anxiety disorders than among individuals with mood disorders as some research has suggested (Sanderson et al., 1994; Siever and Davis, 1991; Widiger and Hyler, 1987). Further, the associations between PDs and current mood and

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