Ingrid R. Dyck

Predictors of course in obsessive compulsive disorder

Systematic studies of course of illness in obsessive-compulsive disorder (OCD) using standardized diagnostic criteria are relatively rare. In the present study, 100 patients diagnosed with OCD were prospectively followed for up to 5 years. Other comorbid conditions included anxiety disorders (76%), major depressive disorder (33%), and at least one personality disorder (33%), mainly in the anxious cluster. Approximately 20% of patients had full remission and 50% had partial remission during follow-up. Significant predictors of partial remission included being married and having lower global severity scores at intake; the presence of major depression was marginally predictive of poorer course. Adequate serotonergic medication was associated with worse course, but findings are likely spurious. Only marital status and global severity were retained as predictors in a final regression model. Findings are discussed with regard to sample characteristics and similarity to other reports on predictors of course and of treatment outcome.

Co-occurrence of mood and personality disorders: A report from the collaborative longitudinal personality disorders study (CLPS)†

The purpose of this study was to examine the relationship of subtypes and particular clinical features of mood disorders to co‐occurrence with specific personality disorders. Five hundred and seventy‐one subjects recruited for the Collaborative Longitudinal Personality Disorders Study (CLPS) were assessed with the Structured Clinical Interview for DSM‐IV Axis I Disorders (SCID‐I) and the Diagnostic Interview for DSM‐IV Personality Disorders (DIPD‐IV). Percent co‐occurrence rates for current and lifetime mood disorders with personality disorders were calculated. Logistic regression analyses examined the effects of clinical characteristics of depressive disorders (e.g., age at onset, recurrence, symptom severity, double depression, and atypical features) on personality disorder co‐occurrence. In comparison with other DSM‐IV personality disorders, avoidant, borderline, and dependent personality disorders (PDs) were most specifically associated with mood disorders, particularly depressive disorders. Severity and recurrence of major depressive disorder and comorbid dysthymic disorder predicted co‐occurrence with borderline and to a lesser extent research criteria depressive personality disorders. The results are consistent with the view that a mood disorder with an insidious onset and recurrence, chronicity, and progression in severity leads to a personality disorder diagnosis in young adults. Depression and Anxiety 10:175–182, 1999.© 1999 Wiley‐Liss, Inc.

Internal consistency, intercriterion overlap and diagnostic efficiency of criteria sets for DSM-IV schizotypal, borderline, avoidant and obsessive-compulsive personality disorders

Objective: To evaluate performance characteristics of DSM‐IV Personality Disorders (PDs) criteria.

Plausibility and possible determinants of sudden 'remissions' in borderline patients

Abstract This study documents dramatic improvements in patients with borderline personality disorder (BPD) and explores their possible determinants. From a sample of the 160 carefully diagnosed borderline patients on whom prospective follow-along data was collected, a subsample of 18 was identified whose DSM-IV criteria count fell to two or fewer during the course of the first 6 months of the study and retained that improvement for the next 6 months. Follow-along data including month-by-month ratings of BPD criteria; week-by-week ratings of Axis I disorders, medication changes, and life events were then used to establish concensus ratings on four hypothesized causes: Axis I remissions, situational change, misdiagnosis, and treatment effects. Follow-up data collected at 2 years was examined to see whether the improvements persisted. The results were that 18 BPD patients underwent dramatic improvements in the first 6 months. Only one had relapsed by 2 years. Though one was judged to have been misdiagnosed at baseline, the most important determinants were judged to be situational changes (n = 10) and remissions of co-occurring Axis I disorders (n = 7). In 10 patients treatment appeared to have facilitated these situational or Axis I resolutions. In conclusion, patients with BPD can make significant improvements that are rapid and of sufficient duration to be considered remissions. Determinants were identified that warrant further prospective evaluation.

A 2-year prospective follow-up study of the course of obsessive-compulsive disorder.

BACKGROUND Surprisingly little is known about the long-term course of obsessive-compulsive disorder (OCD). This prospective study presents 2-year course findings, as well as predictors of course, from the Brown Longitudinal Obsessive Compulsive Study, the first comprehensive prospective investigation of the observational course of OCD in a large clinical sample. METHOD The sample included 214 treatment-seeking adults with DSM-IV OCD at intake who identified OCD as the most problematic disorder over their lifetime. Subjects were enrolled from 2001-2004. At annual interviews, data on weekly OCD symptom status were obtained using the Longitudinal Interval Follow-Up Evaluation. Probabilities of full remission and partial remission over the first 2 years of collected data and potential predictors of remission were examined. RESULTS The probability of full remission from OCD was 0.06, and the probability of partial remission was 0.24. Of the 48 subjects whose OCD symptoms partially or fully remitted, only 1 relapsed within the first 2 years. Earlier age at onset of OCD, greater severity of symptoms at intake, older age at intake, and being male were associated with a decreased likelihood of remission. Insight, diagnostic comorbidity, and treatment were not found to be associated with the likelihood of achieving full or partial remission. CONCLUSIONS Though one-quarter of the sample had periods of subclinical OCD symptoms during the prospective period, full remission was rare, consistent with the view of OCD as a chronic and persistent illness. Age at onset, OCD symptom severity, current age, and sex emerged as potent predictors of course.

Age of onset, clinical characteristics, and 15-year course of anxiety disorders in a prospective, longitudinal, observational study.

BACKGROUND Age of onset is rarely studied in the anxiety disorders literature. The current study examined age of onset as it relates to clinical characteristics and course of anxiety disorders using a prospective, longitudinal, observational design. METHODS Fifteen-year follow-up data were examined for participants with panic disorder with (PDA) or without (PD) agoraphobia, social phobia (SP), and/or generalized anxiety disorder (GAD) at baseline. Logistic regression analyses were conducted to determine whether age of onset was associated with demographic or clinical variables at baseline. Cox regression analyses were conducted to examine longitudinal course (time to recurrence and recovery, respectively) for each diagnostic group. RESULTS At baseline, PD participants with early onset (i.e., < age 20) were more likely to have comorbid MDD, GAD, and SP relative to late-onset participants (≥ age 20). For PDA, early-onset participants were less likely to be married, and more likely to have both GAD and SP at baseline. With respect to longitudinal course, earlier onset was associated with an increased likelihood of recurrence in participants with PDA. No other models reached significance. LIMITATIONS The sample sizes for some disorders were comparatively small in relation to PDA, and all participants were treatment-seeking, which may limit generalizability. CONCLUSIONS For some anxiety disorders, earlier age of onset appears to be associated with greater severity and worse course, as evidenced by increased risk of recurrence over 15years of follow-up. Early interventions focused on children and adolescents may alleviate some of the public health burden associated with anxiety disorders.

Anxiety sensitivity as a predictor of the clinical course of panic disorder: a 1‐year follow‐up study

Background: There is evidence that negative affect (NA) and anxiety sensitivity (AS) predict the development of anxiety disorders, particularly panic disorder (PD). The main purpose of this study was to examine whether NA and AS will also predict the clinical course of PD. Methods: Participants were 136 individuals with a DSM‐III‐R diagnosis of PD (with or without agoraphobia) enrolled in a naturalistic and longitudinal study of anxiety disorders, the Harvard/Brown Anxiety Research Project (HARP). Participants were administered the Anxiety Sensitivity Index and the Negative Affect Scales of the Positive and Negative Affect Schedule‐Expanded Form (PANAS‐X‐NA) and their percentage of time in PD episode was followed for 1 year after the administration of the measures. Results: Multiple regression analyses indicated that AS, but not NA, was a significant predictor of percentage of time in PD episode after controlling for previous time in PD episodes, comorbid depression, other anxiety disorders, and exposure to psychopharmacological and behavioral treatments. As expected, the Physical Concerns subscale of the Anxiety Sensitivity Index had a significant independent contribution in predicting the course of the disorder. Conclusions: Overall, these findings suggest that AS, as a unique construct, may be predictive of the amount of time patients are in episode of PD. Depression and Anxiety, 2009. Published 2009 Wiley‐Liss, Inc.

Longitudinal course of obsessive-compulsive disorder in patients with anxiety disorders: a 15-year prospective follow-up study

BACKGROUND Although obsessive-compulsive disorder (OCD) is typically described as a chronic condition, relatively little is known about the naturalistic, longitudinal course of the disorder. The purpose of the current study was to examine the probability of OCD remission and recurrence as well as to explore demographic and clinical predictors of remission. METHODS This study uses data from the Harvard/Brown Anxiety Disorders Research Program, which is a prospective, naturalistic, longitudinal study of anxiety disorders. Diagnoses were established by means of a clinical interview at study intake. One hundred thirteen Harvard/Brown Anxiety Disorders Research Program participants with OCD were included in the study; all had a history of at least 1 other anxiety disorder. Assessments were conducted at 6-month and/or annual intervals during 15 years of follow-up. RESULTS Survival analyses showed that the probability of OCD remission was .16 at year 1, .25 at year 5, .31 at year 10, and .42 at year 15. For those who remitted from OCD, the probability of recurrence was .07 at year 1, .15 by year 3, and by year 5, it reached .25 and remained at .25 through year 15. In predictors of course, those who were married and those without comorbid major depressive disorder (MDD) were more likely to remit from OCD. By year 15, 51% of those without MDD remitted from OCD compared to only 20% of those with MDD. CONCLUSIONS In the short term, OCD appears to have a chronic course with low rates of remission. However, in the long term, a fair number of people recover from the disorder, and, for those who experience remission from OCD, the probability of recurrence is fairly low.

Comparison of Personality Disorders in Different Anxiety Disorder Diagnoses: Panic, Agoraphobia, Generalized Anxiety, and Social Phobia

Recently there has been increasing interest in the relationship of the personality and the anxiety disorders. This paper presents comorbidity findings between DSM-III-R personality pathology and several DSM-III-R anxiety disorders and makes direct comparisons between anxiety groups. This is the most extensive comparison of this kind reported thus far. This report is on the first 475 anxiety patients who were recruited from multiple sites to take part in a naturalistic study of anxiety. All had a DSM-III-R diagnosis of panic, agoraphobia, social phobia, or generalized anxiety disorder (GAD). Previous studies which found a high comorbidity between the anxiety and the personality pathology were confirmed, with a significantly higher prevalence of personality pathology occurring with social phobia and GAD. Among our patients, all of whom had anxiety disorders, the presence of comorbid major depression is associated with an increase in the levels of comorbid personality pathology--as previously described in the literature. The relationship between low social functioning and the presence of personality pathology was confirmed, however, the relationship appears to be specific to certain areas of functioning, a new finding. There is a clinically important relationship between Personality Diagnostic Questionnaire--Revised personality pathology and the anxiety disorders characterized by different prevalences of personality disorders in different anxiety disorders and specific areas of social dysfunction.

Ethnicity and mental health treatment utilization by patients with personality disorders

The authors examined the relationship between ethnicity and treatment utilization by individuals with personality disorders (PDs). Lifetime and prospectively determined rates and amounts of mental health treatments received were compared in over 500 White, African American, and Hispanic participants with PDs in a naturalistic longitudinal study. Minority, especially Hispanic, participants were significantly less likely than White participants to receive a range of outpatient and inpatient psychosocial treatments and psychotropic medications. This pattern was especially pronounced for minority participants with more severe PDs. A positive support alliance factor significantly predicted the amount of individual psychotherapy used by African American and Hispanic but not White participants, underscoring the importance of special attention to the treatment relationship with minority patients. These treatment use differences raise complex questions about treatment assessment and delivery, cultural biases of the current diagnostic system, and possible variation in PD manifestation across racial/ethnic groups. Future studies need to assess specific barriers to adequate and appropriate treatments for minority individuals with PDs.