Transcript Nottingham Back & Pain Team

Impact of transient and persistent
personality disturbance on the
outcome of anxiety and depressive
disorders
Professor Peter Tyrer (Imperial College, London)
Dr Boliang Guo (University of Nottingham)
Professor Min Yang (University of Sichuan, Chengdu, China)
Aims
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To summarise the hypotheses of the Nottingham
Study of Neurotic Disorder (NSND)
To summarise previous opinions on the course
of personality disorder and its influence on the
outcome of anxiety and depression
To compare the outcome of patients in NSND by
transient and persistent personality disorder
status over a 12 year period
To explain why the results are important
Nottingham study of Neurotic Disorder
(1983-2019)
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Hypotheses: (1) outcome of common anxiety
and depressive disorders is dependent on
personality status, not on treatment
(2) Personality and clinical status in the form of
the general neurotic syndrome (mixed anxiety
and depression and dependent/anankastic
personality) would have the worst outcome
(3) These differences would become greater
over time
Brief summary of design
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Patients seen between 1983 and 1987 in
general practice clinics in Nottingham if they (i)
were on no treatment, (ii) had a diagnosis of
dysthymia (chronic depression), generalised
anxiety, or panic disorder (DSM-III), (iii) agreed
to randomisation to diazepam, dothiepin,
placebo, CBT or self-help for 6 weeks with all
treatment tailed off by 10 weeks.
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210 recruited
Assessments at baseline and
subsequently
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Baseline, 2, 12 and 30 years – Personality assessment using
Personality Assessment Schedule (Tyrer & Alexander, Br J
Psychiatry (1979), 135, 163-67.
At baseline, 2, 4, 6, 10, 16, 32 and 52 weeks, and at 2, 12,
and 30 years – Comprehensive Psychopathological Rating
Scale (CPRS), Montgomery & Asberg Depression Rating
Scale (MADRS), Brief Anxiety Scale (BAS), Hospital Anxiety
and Depression Rating Scale (HADS-A and HADS-D)
All psychotropic medication recorded (0-30 years)
Social function (SFQ) recorded at 12 and 30 years
Neurotic Disorder Outcome Scale (NDOS)(12 and 30 years,
plus self-harm history, GP and hospital contacts
SCID (DSM diagnosis) at baseline, 10, 16, 32, 52 wks and at
2, 12 and 30 years
Summary of findings
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Diazepam inferior to other treatments, including placebo
after 10 weeks (Tyrer et al, Lancet (1988), 332, 235-40)
After 2 years patients with the general neurotic
syndrome had a significantly worse outcome than other
groups (Tyrer et al, Acta Psychiat Scand (1992), 85,
201-06.
Personality status had no influence on outcome at 10
weeks (Tyrer et al, Psychol Med, 1990, 20, 423-31.
but had a negative effect at 5 and 12 years (Tyrer et al,
Psychol Med, (2004) 34: 1385-1394.
Personality disorder at baseline had no effect on 10 week outcome
Reasons for recording personality status
both at baseline and two years
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To determine whether any of the treatments had a
positive effect on personality status
To assess the long-term temporal reliability of
personality disorder using the PAS, as short-term
reliability had been shown to be good (Tyrer et al,
Psychol Med, (1983) 13, 393-98.
To determine whether the diagnostic criteria for the
general neurotic syndrome were still met at 2 years
(None of these hypotheses has been tested as the second
personality assessment fell by the wayside)
Reason why the analysis of personality
data at 2 years has become important
We now know that personality shifts greatly over time and is
not nearly as persistent as first thought
The reasons for this include
(i) difficulty in distinguishing personality from mental state (so
that when mental state improved personality may also),
(ii) environmental changes may reduce or increase impact
of personality abnormality
(iii) social functioning tends to remain poor even if symptoms
improve in personality disorder (Shea et al,2004)
(iv) developing general view that a single assessment of
personality is not enough to confirm diagnosis of personality
disorder
Why are these hypotheses important?
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They are important scientifically as if personality,
independently of mental state, does show
evidence of increasing increasing
(2) Personality and clinical status in the form of
the general neurotic syndrome (mixed anxiety
and depression and dependent/anankastic
personality) would have the worst outcome
(3) These differences would become greater
over time
Hypotheses in present investigation
1.
2.
3.
Those who have personality disorder at both
baseline and two years (ie persistent disorder)
have true personality disorder and would have
a worse long term outcome than those who had
personality disorder only at baseline (transient
personality disorder)
Those who had personality disorder at 2 years
only would have the same outcome as those
with personality disorder at baseline only
Social function would be more impaired in
personality disorders than psychiatric
symptoms
This is the persistent pd group
20
0
10
Mean
30
40
mean_CPRS_for_PD_types
0
5
10
15
time
0PD at 0&2year
PDbase 02year
PD both 0&2year
0 base pd 2year
BIGSPD Leeds 2015
30
mean_MADRS_for_PD_types
-----------------------------------------------------
0
10
Mean
20
Persistent pd
0
5
10
15
time
Threshold for
pathology
0PD at 0&2year
PDbase 02year
PD both 0&2year
0 base pd 2year
Message – Long-term outcome of depression is good unless personality disorder is
BIGSPD Leeds 2015
persistent
CPRS
0.2084
0 PD at
both 0 &2yr
21.54
7.44
13.40
8.88
8.71
10.28
PD both 0
&2year
25.64
8.18
21.80
11.18
4.02
10.44
PDbase 0
2year
20.39
8.99
13.66
11.54
7.28
12.80
0 base pd
2year
19.32
6.52
12.18
8.22
7.05
9.49
0PD at 0
HADSA
&2year
0.0232*
13.93
3.74
8.05
5.10
6.14
4.83
PD both 0
&2year
14.67
3.53
11.80
5.22
3.24
4.96
PDbase 0
2year
13.12
4.01
7.35
5.00
6.06
5.31
0 base pd
2year
13.93
3.83
8.91
5.14
5.18
4.99
BIGSPD Leeds 2015
outcome
HADS-D
persistent
transient
transient
group
Mean
(bsl)
Sd
(base)
Means
(12 yr)
P Value of change
comparison
Sds
(12 year
change
Sd
(chg)
0.2390
No pd ever
PD both 0
&2year
PD base 0
2year
0 base pd
2year
9.56
4.47
6.02
5.12
3.90
5.10
11.62
4.09
9.46
5.31
2.12
5.17
9.55
4.12
6.10
6.06
3.52
5.97
9.36
4.31
4.45
3.83
4.36
3.17
MADRS
0.0702
No pd ever
19.15
8.14
11.33
9.59
8.40
12.58
persistent
PD both bsl
& 2yr
20.89
7.87
18.96
11.57
1.80
12.65
transient
PD bsl 0
2year
17.18
8.06
11.63
12.70
6.09
13.64
transient
0 base pd
2year
16.32
7.34
9.64
8.49
7.05
8.81
BIGSPD Leeds 2015
Additional Findings with
social functioning (SFQ)
SFQ
*
none
12 yr
mean
No PD at 0
or at 2 yr
trans
PD both 0
&2year
PDbase 0
2year
trans
0 base pd
2year
pers
Sd
6.05
4.42
10.88
5.23
7.75
5.90
P value of
compariso
n
0.0001
6.91
4.80
SFQ – higher scores indicate worse social function. Population mean
is 4.6, a score of 10 or more indicates poor social function
BIGSPD Leeds 2015
Conclusions
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Persistent personality disorder impairs the
outcome of anxiety and depressive disorders to
the extent that no significant symptomatic
improvement is shown over 12 years
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Transient personality disorder is associated with
the same outcomes as those with no personality
disorder at baseline and two years