To better understand the relationship between panic disorder and paranoid personality, panic disorder patients (N = 28) who were referred to an anxiety disorder clinic in a community mental health center were evaluated for paranoid personality traits on a standardized personality self-report instrument. Paranoid personality disorder was found in 54% of subjects. Paranoid subjects were found to have an earlier age of onset, longer duration of illness, and more psychopathology. Possible etiologies and implications for treatment of these findings are discussed.
Copyright © 1994by W.B. Saunders Company
WHEN RESEARCHERS and clinicians think of panic disorders, they tend not to associate them with DSM-III or DSM-III-R paranoid personality disorder. Paranoia is often associated with schizophrenia or the schizophrenic-spectrum disorders and not with the anxiety disorders. However, there is some empirical data available on this subject. Mavissakalian and Hamann1 used the Personality Diagnostic Questionnaire (PDQ) to measure personality in 161 psychiatric outpatients with panic and agoraphobia. They found that 29% of the paranoid criteria were endorsed by this population.* Thirty-eight subjects of the group endorsed paranoid criteria B “suspiciousness and mistrust.” Although only 3% met the PDQ criteria for paranoid personality disorder, 9% met criteria for the near-neighbor personality disorder, schizotypal. Mauri et al.2 examined a group of 40 panic disorder patients using the Personality Disorder Examination. Five percent of those with panic disorder met the criteria for paranoid personality disorder, and an additional 5% met the criteria for the related disorder, schizotypal personality disorder. Reich and Noyes,3 in a Midwest study of personality in ill panic outpatients using the Structured Interview for DSM-III Personality Disorders and the PDQ, found approximately a 5.7% prevalence of paranoid personality disorder using the Structured Interview for DSM-III Personality Disorders. Using the PDQ resulted in a 4.9% prevalence, although the near-neighbor disorder, schizotypal personality disorder, had a 34.1% prevalence on the PDQ. Reich et al.,4 reporting on a population of 475 anxiety patients drawn from multiple sites, using the PDQ, found DSM-III-R paranoid personality disorder to be panic without agoraphobia in 32% and panic and agoraphobia in 29%. (Due to the multiple sites that subjects were drawn from for this study, it may have high generalizability.) Blashfield et al.5 examined personality traits in panic disorder outpatients (N = 84) using the PDQ. The mean number of paranoid personality items endorsed for panic disorder was 3.8, and this was a higher number of items than for any other personality disorder. There is one report, by Friedman et al.,6 which examined 26 panic patients with the Structured Clinical Interview for DSM-III, that found no paranoid or schizotypal personality disorders.
From this review of the literature, the range of paranoid personality disorder in panic patients is from 0% to approximately 30%, with an average prevalence over the studies of about 11%. If the number with paranoid traits or the near-neighbor personality disorder, schizotypal, are included, the number of pathological personality traits in the schizoid personality cluster goes far higher.† This level of prevalence is of possible clinical and theoretical interest for several reasons. Despite the above-cited literature documenting the presence of some paranoid traits in panic patients, no one has specifically examined what the implications of this finding may be. No one has reported whether these findings are associated with increased symptoms or poorer functioning. It is of possible theoretical interest because if the finding is replicated, it raises the question of how such seemingly different disorders (panic disorder and paranoid personality disorder) come to be associated with each other. It is of clinical interest since it is quite likely that patients with paranoid personality traits may require different approaches to treatment than those without. Since the possibility that panic patients have paranoid personality traits is not among the first considerations a clinician would now entertain , writing about this topic may give clinicians valuable insights.
The goal of this report is to measure the prevalence of paranoid personality disorder in a new panic disorder population and to examine the clinical and demographic associations of the presence of paranoid personality disorder. Due to the scarceness of literature in this area and our relatively small sample size, this is both a pilot and exploratory study.
METHOD
Subjects
The sample consisted of 28 consecutive admissions to a university anxiety clinic situated in a community mental health center who met DSM-III-R criteria for panic disorder. Of these, 23 (82%) were agoraphobic. Nineteen (68% ) had one or more lifetime comorbid diagnoses. Ten (36%) had major depression, six (21%) social phobia, three (11%) obsessive-compulsive disorder, and four (14%) alcohol or drug abuse disorders. (None of the alcohol or drug abuse disorders were current.) The subjects were a mean of 35.5 ± 13 years old, and 19 subjects (68%) of the sample were female.
Assessment
Axis I diagnoses were determined by a semistructured clinical interview used at our clinic to diagnose axis I disorders. Upon entry to the clinic, all patients were administered the Brief Symptom Inventory (BSI)7 to assess symptomatology and the PDQ to assess personality traits and disorders.8
The BSI is a 53-item, self-report symptom inventory. Each question is rated on a five-point scale. Specific scales analogous to those on the Hopkins Symptom Checklist-90 can be calculated from the raw scores. Scales on the BSI correlate at approximately the .80 level with scales on the Hopkins Symptom Checklist-90.7
Personality disorder pathology in this report was measured by the PDQ-R.9-10 The PDQ is a 152-item, selfadministered, true/false self-report instrument measuring all 11 DSM-III-R personality disorders. A preliminary study with 2-month test-retest on the PDQ has calculated kappas of .53 for the schizoid cluster.8
The selection of the PDQ-R as a measure of personality disorder pathology has advantages and disadvantages. Testretest reliability and concurrent validity have been found adequate.8,11-17 The self-report format makes data collection easier, and studies that have used it report some meaningful findings, such as the ability to predict poor outcome of the treatment of axis I disorders.18 The major disadvantage is that as a self-report instrument, it does not yield a clinical diagnosis. This has been noted in a number of studies,9,19,20 and the area has been recently reviewed by Perry,21 who came to the same conclusion. One recent study argues with persuasive data that the PDQ-R is measuring personality traits, not disorders.22 With the limitation that clinical diagnoses cannot be made from the PDQ-R, we view it as a valid measure of personality psychopathology.
Analysis
Since our interest was in paranoid personality disorder, the subjects were separated into those with and those without this disorder. (Further subdivisions were not made due to small sample size.) Comparisons between these groups were made on the variables of current age, age of onset, duration of symptoms, number of other personality disorders, and the BSI scales of general anxiety, phobic anxiety, interpersonal sensitivity, hostility, depression, and overall pathology. Variables were compared using twosample t tests.
RESULTS
Our sample consisted of 28 patients who had a mean age of 35.3 ± 13 years. Their marital status was 28.6% married, 25% divorced or separated, 7.1% widowed, and 39.3% single. Educationally, 17.8% were college graduates, 67.9% were high school graduates, and 14.3% had less than a high school education. Sixty-four percent of the sample had DSM-III-R schizoid cluster personality disorder, 39% a dramatic cluster , and 64% an anxious cluster personality disorder. The five most frequent personality disorders were as follows: paranoid, 54%; avoidant , 46%; dependent, 36%; histrionic, 25%; and compulsive, 25%...
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James H. Reich, MD, MPH, is a board-certified Forensic Psychiatrist with extensive civil psychiatry experience who has done hundreds of evaluations. His services are available for civil and some criminal law cases. Clients are assured of his personal dedication to each case. He does high quality research, expert evaluations, writes a solid report, and will testify well. Dr. Reich has been deposed over 50 times.
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