Transcript Doherty A Distinguishing between adjustment disorder

Distinguishing Between Adjustment
Disorder and Depressive Episode in
Clinical Practice: The Role of
Personality Disorder
Dr Anne M Doherty MD MRCPsych
University College Dublin, King’s College Hospital London
BIGSPD, Leeds
5th March 2015
Background on Adjustment Disorder
 Adjustment disorder is a state of “subjective distress and
emotional disturbance, usually interfering with social
functioning and performance, and arising in the period of
adaptation to a significant life change or to the
consequences of a stressful life event”
 ICD-10 & DSM-V criteria
1. Symptoms must arise in response to stressful event
2. Short time frame: 3m DSM-5; 1m ICD-10
3. Symptoms must be clinically significant
4. Symptoms must NOT be due to another Axis I
disorder
5. Resolution within 6m of end of stressor
DSM I: “transient situational personality disorder”
DSM-5
• under the heading of “trauma-and stressor-related
disorders”
• “some personality features may be associated with
a vulnerability to situational distress that may
resemble an adjustment disorder”
• “stressors may also exacerbate personality disorder
symptoms” but a diagnosis of adjustment disorder
should not be made unless the “stress-related
disturbance exceeds what may be attributable to
maladaptive personality disorder symptoms” (APA,
2013; p. 288).
The spectrum
Adjustment
disorder
Mild distress
Depressive
illness
AD epidemiology – general v. liaison
• Not included in the major epidemiological studies e.g.
Epidemiological Catchment Area Study (Myers 1984),
National Comorbidity Survey Replication (Kessler 2005),
National Psychiatric Morbidity Study (Jenkins 1997).
• In acutely ill medical inpatients AD 3 times as common
as depression (Silverstone 1996)
• At ED following self-harm 19.5% diagnosed with
depression; 31.8% with AD (Taggart 2006)
AD and Personality Disorders
• Strain (1998) found that personality disorder was
frequently co-morbid with AD (15%)
• No difference in prevalence of personality
disorder between AD and DE (ODIN – Casey 2004)
AD & Suicidal Behaviour
• Rates of suicidal behaviour 25%/60% in AD (Pelkonen
2005, Kryzhananovskaya 2001)
• 1/3 of completed suicides (Lonquist 1995); most common
diagnosis in developing world (Manoranjitham 2010)
• Suggested that there may be differences between the 2
diagnoses in risk variables and socio-demographic profile
(Polyakova 1998)
Suicidality and Personality Disorders
At 6 year follow up of personality disorder
• Risk of repeated suicide attempt was increased by:
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low socioeconomic status,
poor psychosocial adjustment,
family history of suicide,
previous psychiatric hospitalisation,
absence of any outpatient treatment previously
• Reduced by:
• higher global functioning scores at baseline
(Solotoff 2012)
Our hypothesis
1. Adjustment disorder is associated with a high level of
personality disorder
2. Personality disorder has a stronger association with
adjustment disorder than with depressive episode.
Aims
• To examine the relationship between AD and personality
disorder
• To examine the association of personality disorder with
suicidal ideation and self-harm in patients diagnosed with
AD or DE
METHODS
Our study
• Part of a larger study examining AD and DE in liaison
psychiatry
• Patients
– referred to the liaison psychiatry service at 3 Dublin hospitals
– diagnosed by the liaison psychiatrists with either DE or AD
– Exclusion criteria:
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Substance abuse disorder
Cognitive impairment/ incapable of giving informed consent
Under 18
Psychotic symptoms
Lack of fluency in English
• 2 interview points
• Recruitment
• After 6 months (not in this presentation)
Instruments:
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SCAN – Schedules for Clinical Assessment in Neuropsychiatry
(Wing 1990)
BDI – Beck Depression Inventory (Beck et al 1969)
IDS-C30 – Inventory of Depressive Symptoms – Clinician Rated
(Trivedi et al 2004)(Q. 18)
The List of Threatening Experiences (Brugha et al 1985)
SAPAS Standardised Assessment of Personality- Abbreviated
Scale (Moran et al 2003)
Oslo Social Support Scale, (Nosikov & Gudex 2003)
SFS – Social Functioning Schedule (Remington and Tyrer 1979)
DUREL – Duke University Religion Scale (Koenig 1997)
SIS – Suicide Intent Scale (Beck, Schuyler &Herman 1974)
SSI - Scale of Suicidal Ideation (Beck, Morris & Beck 1974)
Diagnosis
• Structured interviews not helpful
•Do not include AD
•In Inferences and Attributions Section (SCAN)
• SCAN Diagnosis looks at symptom numbers and
duration only, without taking account of context
• Clinical diagnosis looks at both symptoms and their
context = GOLD STANDARD.
SAPAS
• 8-item screening instrument
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In general, do you have difficulty making and keeping friends?
Would you normally describe yourself as a loner?
In general, do you trust other people?
Do you normally lose your temper easily?
Are you normally an impulsive sort of person?
Are you normally a worrier?
In general, do you depend on others a lot?
In general, are you a perfectionist?
• 0-2 unlikely personality disorder
• 3-8 probable personality disorder
Power Calculation & Statistics
• Power calculations were based on methodology of Smith and
Morrow (1996). To have 95% confidence of detecting a difference
in depressive symptomatology of similar magnitude to that
detected in Casey et al (2006), at a significance level of p<0.05, we
would need 185 individuals with adjustment disorder and 185
individuals with depressive disorder.
• Statistics were calculated using SPSS:
• Univariate analysis:
•Independent Samples T-test
•Mann-Whitney U Test
•Chi-Square Test
•Cohen’s kappa
•Multivariate analysis
•Logistic regression
RESULTS
Clinical Diagnosis
• 370 patients identified
• 185 diagnosed with an adjustment disorder
• 185 diagnosed with a depressive episode
• Only 26.6% with AD clinically we diagnosed with
AD on SCAN (Cohen’s kappa 0.232 ; p<0.001)
• Sensitivity 91.8%
• Specificity 57.2%
Socio-demographics and
diagnosis
AD & DE Clinical Variables
n
AD (n=185)
Median (Range)
DE (n=185)
Median (Range
P-value
Depressive symptoms (BDI)
346
25 (0 - 55)
32 (4 - 60)
0.000a
Personality (SAPAS)
346
3 (0 – 8)
4 (0 – 8)
0.030a
Social Support (Oslo)
347
10.75 (3 - 14)
10 (3 - 14)
0.024a
Life Events
347
2(0 – 9)
1 (0 – 9)
0.000a
Social Functioning (SFS)
336
2.3 ( 0- 7.7)
2.8 (0 - 9.6)
0.005a
287
N (%)
128 (74)
45 (26)
N (%)
120 (68.5)
55 (31.5)
nsb
Suicidality ( Q18 ofIDSC-30)
Suicidal
Not Suicidal
There were no significant differences between the 2 diagnostic groups in the sociodemographic variables- -age, gender, marital status, religiousness
a = Mann Whitney U Test; b = Chi-square Test
Personality traits and diagnosis
Life events and diagnosis
DE
AD
Logistic regression
Suicidal behaviours
No significant difference in suicidality between those
with and without PD
No significant difference in suicidality between AD &
DE
We then split the file by personality – above or
below the cut-off for PD; and analysed the 2 groups
separately.
Multivariate Analysis of Suicidality in
patients with and without PD
Logistic regression with Suicidality as the dependent variable in cases with out personality disorder as
indicated by a score of 2 or less on SAPAS (Pseudo-R2 = 23.0 – 33.6%)
B
P-value
Odds Ratio
Marital Status
-1.268
0.023
3.56
Age
-0.039
0.006
1.09
Clinical Diagnosis
0.014
0.001
1.02
Logistic regression with Suicidality as the dependent variable in cases with likely personality disorder
as indicated by a score of 3 or greater on SAPAS (Pseudo-R2 = 16.7 – 22.9%)
B
P-value
Odds Ratio
Marital Status
-0.9
0.010
2.46
Gender
-0.802
0.024
2.23
Depressive symptoms (BDI)
-0.042
0.015
1.043
Age
-0.037
0.037
1.04
Strengths and Limitations
• Strengths
• Large number of patients with AD
• Variables not previously examined
• Controlled for multiple confounders
• Limitations
• Clinical diagnosis
Conclusions (1)
AIM 1:
• To examine the relationship between AD and personality
disorder
• Finding:
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AD is associated with PD
Higher overall scores in DE v AD
Worrier, temper traits common in AD (but more common in DE)
Certain traits more common in AD: impulsivity; dependence
Only significant difference in perfectionism
Conclusions (2)
AIM 2:
• To examine the association of personality disorder with suicidal
ideation and self-harm in patients diagnosed with AD or DE
• Findings:
• In patients without PD younger age, single marital status and a
diagnosis of depression predicted suicidal behaviour
• In patients with PD younger age, male gender, single marital status
and higher number of depressive symptoms were associated with
suicidal behaviour
• In this population, suicidal ideation and behaviours were not
significantly higher in patients who have a personality disorder
Conclusions (3)
Hypothesis 1:
Adjustment disorder is associated with a high level of
personality disorder
• Finding:
• Yes -56% screened positive (65% in DE)
Conclusions (4)
Hypothesis 2
Personality disorder would have a stronger association
with adjustment disorder than with depressive episode.
• Finding:
This is not the case:
Frequency of diagnosis: DE 65% v AD 56%
Significant traits in DE
Personality may have a greater role in shaping symptoms
in DE
Implications
• Assumption that patients with AD more
vulnerable
• “transient situational personality disorder”
• ICD-10 refers to personality as important in AD
• No evidence base for this assumption
• Change in ICD-11?
• Clinically, focussing on personality disorder in
AD may be unhelpful
Acknowledgements
A special thanks to:
• Professor Patricia Casey, UCD/MMUH - PI
• Dr Faraz Jabbar, UCD/MMUH
• Prof Brendan Kelly UCD/MMUH
• Dr John Sheehan, UCD/MMUH/Rotunda Hospital
• Dr John Cooney, TCD/St James’ Hospital
• Dr Anne Marie O’Dwyer, TCD/St James’ Hospital
• All participating patients
• The Ethics Committees of the hospitals involved
Thank you