Personality disorders in veterans with posttraumatic stress disorder and depression

Journal of Traumatic Stress, Vol. 17, No. I, February 2004, pp. 75-82 (0 2004)

Personality Disorders in Veterans With Posttraumatic Stress Disorder and Depression

Nancy Jo Dunn,192?3,4y7 Elisia Yanasak: Jeanne Schillaci,1,2 Sofia Sirnotas,' Lynn P. Rehm: Julianne Souchek,17235 Terri M~?nke,'?~9~ Carol Asht0n,'9~3~ and Joseph D. Hamilt0nl3~9~

Little is known about the frequency of the full-range of personality disorders in outpatients with concurrent posttraumatic stress disorder (PTSD) and depression, a common and oftentimes treatment- resistant combination in clinical practice. In a group therapy outcome study, Axis I and I1 diagnoses were assessed with the Structured Clinical Interview for DSM-IV and the Clinician-Administered PTSD Scale to select 115 male combat veterans with PTSD and depressive disorder. Within this sample, 52 (45.2%) had one or more personality disorders-most commonly paranoid (17.4%), obsessive-compulsive (16.5%), avoidant (12.2%), and borderline (8.7%)-and 19 (16.5%) had two or more. Documenting a substantial frequency of personality disorders is a first step in devising appropriate interventions for this treatment-resistant combination of disorders.

~

KEY WORDS: trauma; PTSD; personality disorders; depression; assessment.

Despite the clinical interest in chronic posttraumatic stress disorder (PTSD) and comorbid conditions, little is known about the frequency of the full range of personality disorders in outpatients with concurrent PTSD and depression, a common and oftentimes treatment-resistant combination in clinical practice. This topic is of consid- erable importance to clinicians and researchers alike in delineating the most appropriate treatment regimens for specific subgroups of patients with chronic PTSD. Clini- cal experience and available research concur that person-

' Houston Veterans Affairs Medical Center, Houston, Texas. 2Houston Center for Quality of Care and Utilization Studies, Health Services Research and Development Service, Department of Veterans Affairs Medical Center, Houston, Texas.

3Veterans Affairs South Central Mental Illness Research, Education, and Clinical Center, Houston, Texas.

4Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas.

5J%partment of Medicine, Baylor College of Medicine, Houston, Texas. %niversity of Houston, Houston, Texas. 'To whom correspondence should be addressed at Mental Health Care Line ( 1 16MHCL). Houston VA Medical Center, 2002 Holcombe Boulevard, Houston, Texas 77030 e-mail: [email protected].

ality disorders can complicate the therapeutic process in individuals with PTSD and other primary psychiatric disorders (Crits-Christoph, 1998; Reich, 1990; Southwick, Yehuda, & Giller, 1993). Thus the addition of a personality disorder to the commonly seen co-occurrence of PTSD and depression is likely to present clinicians with an even greater challenge in assessment and treatment.

To date, however, research on PTSD comorbidity has usually been retrospective and focused mainly on the prevalence of other primary psychiatric (Axis I) diagnoses. Several studies have examined the presence of comorbid Axis I diagnoses in combat veterans diagnosed with PTSD (e.g., Kulka et al., 1990; Orsillo et al., 1996; Roszell, McFall, & Malas, 1991). Overall, findings in- dicate high comorbidity between combat-related PTSD and other Axis I disorders; notably, prevalence estimates of mood disorders in Vietnam veterans with PTSD have ranged from 25 to 85% with differing ascertainment methods (e.g., Dunn et al., 1993; Roszell et al., 1991). A few studies have assessed the comorbidity between PTSD and certain personality (Axis 11) disorders-mainly antisocial and borderline (e.g., Bailey, 1985; Reich, 1990; Resnick,

75 0894-9867/04/0200W75/1 0 2004 International Society for Traumatic Stress Studies

76 Dunn, Yanasak, Schillaci, Simotas, Rehm, Souchek, Menke, Ashton, and Hamilton

Foy, Donahoe, & Miller, 1989; Sherwood, Funari, & Pickarski, 1990), probably because these are the most commonly present and socially problematic behaviors leading to treatment (Bollinger, Riggs, Blake, & Ruzek, 2000). Studies examining the full range of comorbid Axis I1 disorders in PTSD patients are scarce. Rates in the few available reports have been high but vary substantially because of the population studied, the treatment setting (inpatient vs. outpatient), and the diagnostic tool used (self- report, clinician-administered, or chart review).

In the earliest such study, Faustman and White (1989) examined DSM-I11 discharge summary diagnoses of 536 male veteran inpatients with definite or provisional PTSD (mainly combat-related) treated in a specialized PTSD program and general psychiatry units at a VA Medical Center. Besides the primary diagnosis of PTSD, 31% of their chart sample included a DSM-I11 personality disorder diagnosis, most commonly mixed personality disorder (1 log%), borderline (5.8%), and antisocial (2.4%). The authors provided no information on the specific personality disorders found in the 19% of the total sample who also had major depressive disorder or dysthymia. Despite the large sample size, the study suffered from the uncertain reliability and validity of retrospectively obtained chart diagnoses.

In a more structured diagnostic study of 18 inpatient and 16 outpatient veterans with PTSD, Southwick et al. ( 1993) used the Personality Disorder Examination, a standardized, clinician-rated diagnostic instrument based on DSM-III-R Axis I1 diagnostic criteria. The authors found high rates of personality disorders, most commonly borderline (76%), obsessive-compulsive (a%), avoidant (41%), and paranoid (38%). They did not report the pro- portion of the sample meeting criteria for any personality disorder, but the frequency for the most common personality disorder (borderline) indicates a minimum of 76%. A third of the sample met criteria for at least two personality disorders: inpatients received personality disorder diagnoses more often than outpatients. This study had the strength of clinician-rated structured diagnoses, but the drawback of a small sample size.

In the most recent and comprehensive study of personality disorders comorbid with PTSD in a combat veteran population, Bollinger et al. (2000) examined 107 veteran inpatients with PTSD, using the Structured Clin- ical Interview for DSM-III-R (SCID-11) to diagnose personality disorders and the Clinician-Administered PTSD Scale (CAPS- 1) to diagnose PTSD. The results indicated a very high frequency of personality disorders in this inpatient population, with over 79% of the patients diagnosed with at least one personality disorder. Most common were avoidant (47.2%), paranoid (46.2%), obsessive-

compulsive (28.3%), and antisocial (15.1%). This study had a careful design and a relatively large sample size, but was limited to an inpatient sample.

Why are personality disorder diagnoses apparently so frequent in individuals with PTSD? Several possible explanations exist:

Pseudo-Comorbidity From Overlapping Diagnostic Criteria. Consider, for example, the commonalities between extreme hypervigilance in PTSD and suspicious- ness in paranoid personality disorder; between avoidance of others from emotional numbing in PTSD and fear of re- jection in avoidant personality disorder; and between the anger and dyscontrol common to PTSD and the hostile impulsivity of antisocial or borderline personality disorder. Although the “double-counting” of such relatively few overlapping behaviors does not appear sufficient to account for the high co-occurrence of personality disorders with PTSD in the studies described above, it may be that over time in these chronic patients the overlapping symptoms develop into the full personality disorder. In any case, because no validated objective criteria indepen- dent of clinical symptoms (e.g., laboratory abnormalities) currently exist to distinguish PTSD from these comorbid disorders (Friedman & Yehuda, 1995), researchers and clinicians must continue to confront these diagnostic uncertainties by administering comprehensive, well- validated, clinician-administered diagnostic interviews (Brady, Killeen, Brewerton, & Lucerini, 2000; Schillaci et al., 2000).

Selection Bias From Using Hospitalized Sample. Co- morbidity within the mainly inpatient samples of the previously cited studies may be inflated because of the well- known epidemiologic bias that patients with two disorders (e.g., PTSD and a personality disorder) are more likely to be hospitalized than those with only one of the disorders (e.g., PTSD alone). In particular, personality disorder may also increase the likelihood of engaging in specific prob- lem behaviors (e.g., suicide attempts) that lead to hospi- talization. One way to assess the possible contribution of this selection bias is to assess comorbidity in an outpatient sample, as the present study does.

Personality Disorder as a Psychological Risk Factor for PTSD, or Vice Versa. Limited research suggests that pretraumatic personality traits (e.g., neuroticism or neg- ativism) may increase vulnerability to PTSD via uncertain mechanisms (Bramsen, Dirkzwager, & van der Ploeg, 2000; Schnurr, Friedman, & Rosenberg, 1993), but studies of whether pretraumatic personality disorders do so are virtually nonexistent. Conversely, one might speculate that PTSD symptoms cause a fundamental, persis- tent shift in the way a person views the world and inter- acts with others-amounting to a new-onset personality

Personality Disorders With PTSD and Depression 77

disorder-but systematic study of this possibility remains in its infancy. Furthermore, exact determination of the relative onset of PTSD versus other disorders is extremely difficult with chronic cases of PTSD, particularly for many combat veterans in whom trauma occurred during young adulthood when many personality characteristics were also solidifying.

Common Biological Vulnerability for Personality Disorder and PTSD. Twin studies of combat-related and noncombat PTSD suggest moderate genetic influence on both exposure to assaultive trauma and development of PTSD after such exposure, though the specific genes remain unknown (Stein, Jang, Taylor, Vernon, & Livesley, 2002). The investigators speculate that the posited genes may produce specific personality traits (again, not necessarily disorders) mediating traumatic exposure, as well as the emotional arousal likely to produce PTSD after such exposure. However, studies have yet to be done to test this speculation or others that might be raised: Are there different pathways by which individuals with PTSD develop personality disorders? Do these pathways differ with additional comorbidities, such as depression? Are there protec- tive factors, such as coping mechanisms that might moderate the development and maintenance of these disorders?

Given the current trend of outpatient treatment for PTSD in most hospital and community health care set- tings, more information on personality disorder frequency in outpatient PTSD populations would be useful to help evaluate the models described above. The present study examined the frequency of the full range of DSM-IV personality disorders, diagnosed with a well-validated structured instrument, in a sample of male combat veteran outpatients with the common dual diagnosis of PTSD and depressive disorder.

Method

Participants

Participants were 115 male combat veterans who were enrolled in a randomized controlled trial com- paring the clinical efficacy and cost-effectiveness of Self-Management Therapy (Rehm, 1995) versus Psychoe- ducational Group Therapy (Dunn et al., 2000) for concurrent PTSD and depression. (The results of the treatment comparison will be reported elsewhere.) Although only I01 participants actually entered treatment, the baseline diagnostic information in the present report was available for all 115 enrollees.

We recruited participants from patients in the Houston VA Medical Center’s Trauma Recovery Program

(a specialized PTSD treatment program) and in two local veteran outreach centers. Participants were outpatients at the time of enrollment. All met DSM-IV criteria (Amer- ican Psychiatric Association, 1995) for PTSD and major depressive disorder or dysthymic disorder (via structured instruments described below) and scored 24 or higher on cognitive testing with the Mini-Mental State Examination (MMSE; Folstein, Folstein, & McHugh, 1975). Exclusion criteria were (1) an MMSE score below 24, (2) a current or past diagnosis of a psychotic disorder by DSM-IV criteria, or (3) active suicidal ideation and intent. Of note is that the study did not exclude patients with suicidal ideation but no intent, or those with substance abuse or dependence, although the clinical program’s policy was to refer patients with serious current abuse to the substance dependence treatment program first. All participants provided written informed consent, and the study was approved by the In- stitutional Review Board of Baylor College of Medicine and the Committee on Human Subjects of the University of Houston.

Measures

To diagnose PTSD and rate its severity, we used the Clinician-Administered PTSD Scale (CAPS- 1 ; Blake et al., 1990), a widely used clinician-administered instrument with excellent reliability and validity (Blake et al., 1995; Weathers & Litz, 1994). For the diagnosis of PTSD, we considered a symptom present if its frequency was at least 1 (at least once during the past month) and its severity was at least 2 (moderately distressing) on the CAPS- 1.

We diagnosed other mental disorders with the Struc- tured Clinical Interview for DSM-IV Axis I (SCID-I; First, Spitzer, Gibbon, & Williams, 1996) and Axis I1 Disorders (SCID-II; First, Gibbon, Spitzer, Williams, & Benjamin, 1997), a standard, well-validated, semistructured diagnostic interview. We used the SCID-I (research patient version with psychotic screen) to diagnose depressive disorders, exclusion diagnoses, and comorbid Axis I psychopathology. We used the SCID-I1 to diagnosis the 11 DSM-IV personality disorders.

For measuring the severity of depression, we used the 18-item version of the Hamilton Depression Rating Scale (HDRS; Hamilton, 1960). The HDRS was embedded in the depression section of the SCID-I by the study team in order to ascertain responses to similar depression items in a streamlined manner.

Procedures

A full description of the study procedures will be presented in a separate report of the main study outcomes.


We describe here only those study procedures most relevant to the currently reported results. Referrals to the study came from the previously described VA programs, based on clinician impressions that the referred patients had probable diagnoses of PTSD and a depressive disorder. We explicitly asked clinicians to consider only the specified inclusion and exclusion criteria listed, and not to exclude difficult or problematic patients (e.g., those with a personality disorder) from referral to the study.

As part of this treatment outcome study, interviewers assessed participants with an extensive battery of clinician- administered and self-report instruments, including the diagnostic and symptom severity measures described above, to determine eligibility for the study and to provide baseline data prior to therapy sessions. All interviewers had graduate-level qualifications in clinical psychology or clinical social work and received an 80-hr training program by a licensed clinical psychologist (N.J.D., J.Sch.) on the assessment procedures. The training regimen con- sisted of reviewing didactic training tapes on the SCID-I, SCID-11, and CAPS- 1, reviewing interviews already con- ducted as part of the study, observing ongoing interviews, conducting interviews initially under the direction of a se- nior interviewer, and then independently conducting the interviews.

We videotaped all study interviews and selected ap- proximately 20% (n = 23) of these videotapes for scoring by a second interviewer on an ongoing basis to determine interrater reliability and check observer drift. (The PTSD reliability was based on 20 interviews rather than 23, because of technical difficulties.) For interrater reliability of each diagnosis, we calculated both the percent agreement and Cohen’s kappa, using the Fleiss (197 1) algorithm for different pairs of raters evaluating each participant.

A weekly clinical conference, chaired by an experienced board-certified psychiatrist (J.D.H.) and attended by all interviewers and clinician investigators of the study, made final decisions on diagnoses and acceptance into the study. In resolving any diagnostic uncertainties, the conference used all available clinical information on participants, made decisions symptom by symptom, and de- veloped guidelines for deciding frequent diagnostic chal- lenges (Schillaci et al., 2000).

A particular diagnostic challenge was to disentangle personality disorders from PTSD, because most of our participants’ combat traumas occurred during their late adolescence or early 20s. Because these are critical pen- ods for personality development, investigating pretrauma behavior was of little help in diagnosis (with the excep- tion of inquiring about early adolescent antisocial behavior). Consequently, our guidelines generally called for di- agnosing a personality disorder whenever the DSM-IV

criteria were met, without trying to assess whether personality traits predated the trauma. However, we did not count symptoms as personality disorder criteria if the veteran’s explanation for the behavior clearly related it to the trauma. Examples included (1) difficulty in being “open” in intimate relationships was ascribed to PTSD if due to a mistrust of others or emotional numbing, but ascribed to avoidant personality disorder if due to a fear of being shamed or ridiculed. (2) Reluctance to try new activities was attributed to PTSD (or depression) if due to a loss of interest in activities or a tendency to isolate, but attributed to avoidant personality disorder if due to a fear of embarrassment. (3) Reluctance to confide in others was ascribed to PTSD when reflecting difficulties in feeling close to others because of emotional numbing, but ascribed to paranoid personality disorder when more strongly related to a fear that others would use information maliciously against the individual.

Results

The mean age of the patients was 54.8 years (SD = 7.1 years) with a mean educational level of 13.9 years (SD = 2.6 years). The ethnicity of the sample was as fol- lows: Caucasian (n = 68,59.1%), African American (n = 30,26.1%), Hispanic Mexican and Other Hispanic (n = 14, 12.2%), and Native American (n = 3,2.6%). Most of the patients were married or remarried (n = 78,67.8%), 9 (7.8%) were separated, 19 (16.5%) were divorced, 7 (6.1%) had never married, and 2 (1.7%) were widowed. The majority of the patients were Vietnam veterans (n = 105,91.3%), although 5.2% (n = 6) served in World War II,4.3% (n = 5) in the Korean War, and one served in the Persian Gulf War. Some patients served in more than one war zone. Most participants (n = 76, 66%) were retired or disabled, 14% (n = 16) worked full-time, 13% (n = 15) were unemployed, and 7% (n = 8) worked part- time. Eighty-six percent (n = 99) indicated that chronic medical problems interfered with their functioning.

The mean CAPS-1 total score was 74.6 (SD = 16.Q indicating severe PTSD (Weathers, Keane, & Davidson, 2001), and the mean HDRS score was 22.1 (SD = 5.4), indicating moderate depression. Although the exact dura- tion of PTSD symptoms is unknown in this sample, participants were typically being treated for chronic PTSD and had experienced their combat-related trauma at a young age. Mean age of enlistment was 19.6 years (SD = 2.2 years), and mean length of service was 4.2 years (SD = 4.2 years). Depressive disorders, though also longstand- ing, began somewhat later, with mean age of onset being 28.4 years (SD = 13.6 years) as assessed by the SCID.


For the study’s qualifying diagnoses, percent agreement between raters was 96% for major depressive disorder (with kappa “paradoxically” low because of the very high frequency; Byrt, Bishop, & Carlin, 1993) and 100% (with kappa equal to 1 .O) for dysthymic disorder and PTSD. Other current and lifetime comorbid Axis I conditions respectively included alcohol abuse or dependence (n = 1,0.9%;n = 84,73%), drug abuse or dependence (n = 1,0.9%; n = 37,32.2%), an anxiety disorder other than PTSD (n = 46,40%;n = 60,52.2%), and other AxisIdisorders(n = 9,7.8%;n = 12, 10.4%).0fthetwo individuals with current substance use diagnoses, one had alcohol abuse and another had cannabis abuse. The modal number of current and lifetime Axis I diagnoses in this sample was two and four, respectively. Thus the recruited sample appeared at least as psychiatrically impaired as in other studies of veteran populations with chronic PTSD (e.g., Keane & Wolfe, 1990; Kulka et al., 1990).

Table 1 shows the frequency of personality disorders, along with the interrater reliability for each. Reliabilities ranged from good to excellent and were comparable to those reported by Bollinger et al. (2000). In our sample, 45.2% (n = 52) of the patients were diagnosed with one or more personality disorders: 28.7% (n = 33) had one, 8.7% (n = 10) had two, 7.0% (n = 8) had three, and 0.9% (n = 1) had four. Among the DSM-IV conceptual “clus- ters’’ of personality disorders, we found Cluster C (anx- ious) personality disorders to be most frequent (n = 35 or 43.2% of the 81 diagnosed in total), followed by Cluster A (odd) with 30.9% (n = 25), and Cluster B (dramatic) with 25.9% (n = 21).

Overall, the most common Axis I1 diagnoses were paranoid (n = 20,17.4%), obsessive-compulsive (n = 19, 16.5%), avoidant (n = 14, 12.2%), and borderline (n = 10, 8.7%) personality disorders, representing 77.8% of all of the diagnosed personality disorders. These rankings remain consistent when the 95% confidence intervals of the percentages (see Table 1) are taken into account. Of the 19 participants who had more than one personality disorder, multiple diagnoses within the same personality cluster occurred only 16.7% (n = 3) of the time. Paranoid personality disorder was not only the most frequently diagnosed personality disorder in the overall sample (n = 20, 17.4%), but of those participants who had two or more personality disorders, paranoid personality disorder was diagnosed 84.2% of the time. For those with two personality disorders, the most frequent combinations were paranoid and obsessive-compulsive, and paranoid and borderline. For those with three personality disorders, the most frequent combination was paranoid, obsessive-compulsive, and avoidant.

Within the total sample we also examined the relationship between the number of personality disorder symptoms (summed across all the personality disorders) and the level of clinician-rated PTSD and depressive symptoms. The correlation between the number of personality disorder symptoms and the PTSD seventy, as measured by the CAPS-1 total score, was nonsignificant (r = . 1 1). However, there was a positive and statistically significant relationship between the number of personality disorders and the seventy of depression as measured by the HDRS (r = .39, p < .001).

Table 1. Freauency of Personality Disorders (N = 115) and Interrater Reliability

Frequency“ Reliabilityb

Axis I1 diagnosis n % 95%CI %Agreement K‘

Cluster A Paranoid 20 17.4 10.5-24.3 96 0.83

100 - Schizoid 3 2.6 0.0-5.5 Schizotypal 2 1.7 0.0-4.1 100 -

Antisocial 8 7.0 2.3-11.6 96 0.64 Borderline 10 8.7 3.5-13.8 96 0.64 Histrionic 1 0.9 0.0-2.6 100 1 .oo Narcissistic 2 1.7 0.0-4.1 96 0.64

Avoidant 14 12.2 6.2-18.2 100 1 .oo

Obsessive-compulsive 19 16.5 9.7-23.3 96 0.64

Cluster B

Cluster C

Dependent 0 0.0 0.0-0.0 100 -

Personality disorder NOS 2 1.7 0.0-4.1 100 - ~~ ~ ~~

aSome participants had more than one personality disorder. bBased on 23 participants. ‘ K is undefined when none (or all) of the 23 individuals in the reliability sample have the disorder, because in such cases the expected percent of agreement would be 100%.

80 Dunn, Yanasak, Schillaci, Sirnotas, Rehm, Souchek, Menke, Ashton, and Hamilton

Discussion

The major findings to consider from this study are that (1) veteran patients with concurrent chronic PTSD and depression in our treatment-seeking sample tend to suffer from one or more personality disorders; (2) despite this substantial frequency, rates of personality disorder in our study are lower than in other major studies of personality disorder in combat veterans with PTSD; (3) in our study and these other major studies, paranoid, obsessive- compulsive, and avoidant personality disorders consis- tently rank among the four most frequent; and (4) the number of personality disorder symptoms in our sample of patients with concurrent chronic PTSD and depression was significantly related to the severity of depression but not to the severity of PTSD.

Despite different ascertainment methods and patient populations, findings from this study and three previous studies (Bollinger et al., 2000; Faustman & White, 1989; Southwick et al., 1993) agree that personality disorders are very frequent in treatment-seeking veterans with chronic PTSD. Let us consider this finding in relation to the possible explanations of comorbidity noted earlier:

First, the frequency of personality disorders appears too high to be explained solely by the small number of diagnostic criteria shared by PTSD and certain personality disorders, particularly because the number of personality disorder symptoms did not correlate with PTSD severity and the second most common personality disorder (obsessive-compulsive) in our sample shares no diagnostic criteria with PTSD. It is possible that our detailed, explicit guidelines for distinguishing among PTSD, other Axis I diagnoses, and personality disorders (Schillaci et al., 2000) may have biased our diagnoses toward PTSD and away from personality disorders when symptoms over- lapped, if the behaviors appeared clearly linked to PTSD in time and in theme. However, we were willing to “double- count” enduring symptoms (i.e., toward both PTSD and a personality disorder) if they fit both sets of diagnostic criteria. Again, we must also consider the possibility that the initially overlapping symptoms may have initiated the development of the full-blown personality disorder in the adult, as opposed to the usually assumed development in childhood and adolescence.

Second, the 45% frequency of personality disorders in our exclusively outpatient population was significantly less than the 76% or more in Southwick et al. (1993) and the 79% in Bollinger et al. (2000), the two major studies that used a structured examination to diagnose personality disorders in populations composed substantially or exclusively of inpatients with combat-related PTSD. This is consistent with a general selection bias toward person-

ality disorders in these previous inpatient studies. Further- more, in our own study, clinicians may have failed to refer patients they were confident would decline participation in a lengthy group therapy research project (e.g., those with paranoid, avoidant, or schizoid personality disorders) and patients they predicted would be especially “difficult” in group therapy (e.g., antisocial personality disorder patients), despite our specific encouragement to avoid such exclusions. Even if referred, some patients with these types of personality disorders may indeed have behaved just as predicted by refusing to participate in the study, although the relatively high frequency of individuals with paranoid and avoidant personality disorders in our study runs counter to this hypothesis. Differences in frequen- cies of particular personality disorders might also have resulted from using the behaviorally focused SCID-11 as a diagnostic instrument in our study and that of Bollinger et al. (2000), versus the Southwick et al. (1993) study’s use of the Personality Disorder Examination, which relies more on subjective patient accounts.

Third, our findng that the number of personality disorder symptoms did not correlate with the symptom severity of PTSD argues against (but cannot refute) the explanation that personality disorder is a psychological risk factor for PTSD or vice versa. A threshold effect remains possible, such that PTSD of a certain level of severity at onset increases susceptibility to developing a personality disorder in general, but without any further increase in risk with progressively worsening PTSD.

Finally, although not inconsistent with the possibility of a genetic or other common biological vulnerability for both personality disorder and PTSD, our findings are not strong evidence in either direction for this possibility.

The particularly frequent personality disorders in our own and previous studies of this population-paranoid, obsessive-compulsive, and avoidantdeserve a closer look. The co-occurrence of paranoid and obsessive- compulsive personality disorders is perhaps most under- standable in light of the nature of a person’s combat experiences and subsequent adaptation to civilian life (Bollinger et al., 2000; Southwick et al., 1993). Paranoid personality disorder is characterized by a pervasive distrust of others’ motives and intentions, and hypervigilance for perceived danger. Obsessive-compulsive personality disorder is characterized by rigidity, adherence to rules, and extreme attention to detail. These character traits are very adaptive in a combat situation in which survival is dependent upon attention to details, following orders, and re- maining extremely vigilant for danger. The same traits are clearly evident in a significant number of veterans years after military discharge, as documented in these three studies. Treatment-seeking veterans with PTSD who are seen


within the VA system are often described as being distrust- ful of others (including the government), being “on guard,” “checking their perimeterhome” in recurring, detailed, rigid fashion for potential threats, and avoiding situations of perceived danger. These characteristics, if set in stone by traumatic combat exposure, can outlive their adaptive functions in a combat situation, and now isolate combat veterans and impair significant current relationships.

The co-occurrence of paranoid and obsessive- compulsive personality disorders in this population also recalls Shapiro’s argument that paranoid personality disorder is an extreme manifestation of an obsessive- compulsive personality disorder in many of its cognitive and behavioral dimensions (Shapiro, 1965). For example, the thought processes of an individual with obsessive- compulsive personality disorder are focused on extreme attention to details that is oftentimes viewed by others as indicative of rigidity. The person with paranoid personality disorder also focuses on details, but as an at- tempt to seek confirmation of a perceived threat or hidden meanings in behavior. Behaviorally, an individual with obsessive-compulsive personality disorder appears to have goal-directed activity, usually to accomplish specific work objectives, whereas the goal-directed behavior of an individual with paranoid personality disorder is viewed as antagonistic and designed to thwart perceived threats.

The relative frequency of avoidant personality disorder would seem to require a different explanation. One of the major differences between the current study and previous work is that participants were required to have a current diagnosis of both PTSD and a depressive disorder, thereby representing a diagnostic subset of the PTSD patients typically studied. Our sample also had consider- able documented additional Axis I psychopathology, consistent with other studies of veterans with chronic PTSD (Keane & Wolfe, 1990; Kulkaet al., 1990). Unfortunately, most other studies examining the range of personality disorders did not provide a description of the full range of Axis I disorders or the relationship between Axis I and I1 disorders in their sample to enable a comparison to the current sample. Avoidant personality disorder (as well as obsessive-compulsive personality disorder) is known to be more prevalent in patients with depressive diagnoses (e.g., Shea, Glass, Pilkonis, Watkins, & Docherty, 1987). Furthermore, some criterion behaviors of avoidant personality disorder, such as social isolation, overlap with symptoms of PTSD and of depressive disorders (although as described above, we attempted to attribute the symptom to one or the other disorder when the patient’s explanation for the behavior allowed a clear differentiation).

The final result to consider in our study is that in this sample of veterans diagnosed with both PTSD and

depression, the number of personality disorder symptoms was unrelated to clinician-rated PTSD severity, but was significantly related to clinician-rated depressive symp- tomatology, The first finding argues against the notion that personality disorders are simply another manifestation of PTSD symptoms. It is also possible that the range of PTSD severity, as measured in this sample of treatment-seeking veterans with chronic PTSD, was so restricted that a relationship between personality disorder symptoms and PTSD seventy could not emerge. The relation between the personality disorders and depressive severity may be due to several factors. One possible inter- pretation is that personality disorders impair social relationships, leading to social isolation, which contributes to depression. However, because causality cannot be deter- mined from these results, it is also possible that depressive symptoms, especially at an early age, may have predis- posed an individual to a personality disorder, based on negative or nonreinforcing interactions and social feed- back from others. In addition, some previous research has also indicated that patients in an acute depressive episode (as most of our participants were) are biased to describe more negative personality traits, leading to more frequent diagnosis of a comorbid personality disorder as compared to assessments performed during remission of the depression (Ferro, Klein, Schwartz, Kasch, & Leader, 1998).

This study has a number of strengths that contribute to knowledge about the frequency of personality disorders in patients with PTSD. The rigorous diagnostic training and decision-making lends confidence to the validity of the documented diagnoses. This sample of outpatients makes the study relevant to the current health care climate. We believe it is the first study to document the full range of DSM-IV personality (Axis 11) disorders, as well as the full range of Axis I disorders, in patients with concurrent PTSD and depression, a common combination of disorders seen in clinical practice. Potential limitations are that we had a small sample of male veterans who had both PTSD and depression, who sought treatment, and volun- teered to participate in a treatment intervention study. They do not represent the many individuals with these disorders who do not seek treatment or whose other symptoms (e.g., severe substance abuse) may take precedence in treatment. Nonetheless, the complex diagnostic mix of patients in our sample reflects the “real-world setting and patients typically seen in a VA outpatient PTSD clinic.

Documentation of personality disorders, however, is only the first step in devising specific intervention strate- gies for these multiply impaired, treatment-resistant patients. The more difficult task will be to find therapies that work.


Acknowledgments

This project was funded by the VA Health Services Research and Development Service (Project #IIR 95-074, N. J. Dunn). The authors acknowledge the following clinical interviewers on the study: Jennifer Adams, Joanne Bailey, James Bridges, Carrie Dodrill, Susan Hall, Alexis Llewellyn, Rebecca Lundwall, and Alisha Wagner. The views expressed herein are those of the authors and do not necessarily reflect those of the Department of Veterans Affairs.

References

American Psychiatric Association. (1995). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

Bailey, J. E. (1985). Differential diagnosis of posttraumatic stress and antisocial personality disorders. Hospital and Community Psychiatry,

Blake, D., Weathers, F., Nagy, L., Kaloupek, D., Gusman, F., Charney, D., et al. (1995). The development of a Clinician-Administered PTSD Scale. Journal of Traumatic Stress, 8. 75-90.

Blake, D., Weathers, F., Nagy, L., Kaloupek, D., Klauminzer, G., Charney, D., et al. (1990). A clinician rating scale for assessing current and lifetime PTSD: The CAPS-1. Behavior Therapist, 13,

Bollinger, A,, Riggs, D., Blake, D., & Ruzek, J. (2000). Prevalence of personality disorders among combat veterans with posttraumatic stress disorder. Journal of Traumatic Stress, 13, 255-270.

Brady, K., Killeen, T., Brewerton, T., & Lucerini, S. (2000). Comorbidity of psychiatric disorders and posttraumatic stress disorder. Journal of Clinical Psychiatry, 6l(Suppl. 7). 22-32.

Bramsen, I., Dirkzwager, A. J. E., & van der Ploeg, H. M. (2000). Predeployment personality traits and exposure to trauma as predictors of posttraumatic stress symptoms: A prospective study of former peacekeepers. American Journal of Psychiatry, 157, 11 15- 1119.

Byrt, T., Bishop, J., & Carlin, J. (1993). Bias, prevalence and kappa. Journal of Clinical Epidemiology, 46,423429.

Crits-Christoph, P. (1998). Psychosocial treatments for personality disorders. In P. Nathan & J. Gorman (Eds.), A guide to treatments that work (pp. 544-553). New York: Oxford University Press.

Dunn, N. J., Denney, L., Blackbum, A., Garcia, J., Wurth, M., Stulb, V., et al. (1993, October). Stereotypes of the Viet Nam vet: Experiences of the Houston VAMC PTSD specialty clinic. Poster presented at the annual meeting of the International Society for Traumatic Stress Studies, San Antonio, TX.

Dunn, N. J., Schillaci, J., Wagner, A., Rehm. L., Souchek, J., Menke, T., et al. (2000, November). Development of a psychoeducational group therapy protocol. Poster presented at the annual meeting of the International Society for Traumatic Stress Studies, San Antonio, TX.

Faustman, W., &White, P. (1989). Diagnostic and psychopharmacolog- ical treatment characteristics of 536 inpatients with posttraumatic stress disorder. Journal of Nervous and Mental Disease, 177, 154- 159.

Fern, T., Klein, D. N., Schwartz, J. E., Kasch, K. L., & Leader, J. B. (1998). 30-Month stability of personality disorder diagnoses in depressed outpatients. American Journal of Psychiatry, 155,653-659.

First, M. B., Gibbon, M., Spitzer, R. L., Williams, J. B. W., & Benjamin, L. S. (1997). User’s Guide for the Structured Clinical Interview for DSM-NAxis 11 Personality Disorders (SCID-11). Washington, DC: American Psychiatric Press.

36,881-883.

187-188.

First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (1996). User’s Guide for the Structured Clinical Interview for DSM-1VAxis 1 Disorders-Research Version (SCID-I, Version 2.0.296 FINAL Version). Unpublished manual.

Fleiss, J. (1971). Measuring nominal scale agreement among many raters. Psychological Bulletin, 76, 378-382.

Folstein, M. F., Folstein, S. E., & McHugh, P. (1975). Mini-mental state: A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 11, 189-198.

Friedman, M. J., & Yehuda, R. (1995). Post-traumatic stress disorder and comorbidity : Psychobiological approaches to differential diagnosis. In M. J. Friedman, D. S. Chamey, & A. Y. Deutsch (Eds.), Neuro- biological and clinical consequences of stress: From normal adaptation to PTSD (pp. 4 2 9 4 5 ) . Philadelphia: Lippincott-Raven.

Hamilton, M. (1960). A rating scale for depression. JournalofNeurology, Neurosurgery and Psychiatry, 23, 56-61.

Keane, T., & Wolfe, J. (1990). Comorbidity in post-traumatic stress disorder: An analysis of community and clinical studies. Journal of Applied Social Psychology, 20, 17761788.

Kulka, R. A., Schlenger, W. E., Fairbank, J. A., Hough, R. L., Jordan, B. K., Marmar, C. R., et al. (1990). Trauma and the Vietnam War generation: Report offndings from the National Vietnam Veterans Readjustment Study. New York Brunner/Mazel.

Orsillo, S. M., Weathers, F. W., Litz, B. T., Steinberg, H. R., Huska, J. A., & Keane, T. M. (1996). Current and lifetime psychiatric disorders among veterans with war zone-related posttraumatic stress disorder. Journal of Nervous and Mental Disease, 184, 307-313.

Rehm, L. P. (1995). Psychotherapies for depression. In K. S. Dobson & K. D. Craig (Eds.), Anxiety and depression in adults and chiMren (pp. 183-208). Thousand Oaks, CA: Sage.

Reich, J. (1990). Personality disorders and posttraumatic stress disorder. In M. E. Wolf & A. D. Mosnaim (Eds.), Posttraumatic stress disorder: Etiology, phenomenology, and treatment (pp. 65-79). Washington, DC: American Psychiatric Press.

Resnick, H., Foy, D., Donahoe, C., &Miller, E. (1989). Antisocial behavior and post-traumatic stress disorder in Vietnam veterans. Journal of Clinical Psychology, 45, 860-866.

Roszell, D. K., McFall, M. E., & Malas, K. L. (1991). Frequency of symptoms and concurrent psychiatric disorder in Vietnam veterans with chronic F‘TSD. Hospital and Community Psychiatry, 42,293- 296.

Schillaci, J., Dunn, N. J., Rehm, L., Yanasak, E., Adams, J., Simotas, S., et al. (2000, November). Guidelines for Axis 1 and 11 di$erential diagnoses in u PTSD population. Poster presented at the annual meeting of the International Society for Traumatic Stress Studies, San Antonio, TX.

Schnurr, P. P., Friedman, M. J., & Rosenberg, S. D. (1993). Premilitary MMPI scores as predictors of combat-related PTSD symptoms. American Journal of Psychiatry, 150,479-483.

Shapiro, D. (1965). Neurotic styles. New York: Basic Books. Shea, M. T., Glass, D., Pilkonis, P., Watkins, J., & Docherty, J. (1987).

Frequency and implications of personality disorders in a sample of depressed outpatients. Journal of Personality Disorders, 1,2742.

Sherwood, R., Funari, D., & Pickarski, M. (1990). Adapted character styles of Vietnam veterans with posttraumatic stress disorder. Psy- chological Reports, 66, 623-63 1.

Southwick, S., Yehuda, R., & Giller, E. (1993). Personality disorders in treatment-seeking combat veterans with posttraumatic stress disorder. American Journal of Psychiatry, 150, 1020-1023.

Stein, M. B., Jang, K. L., Taylor, S., Vernon, P. A,, & Livesley, W. J. (2002). Genetic and environmental influences on trauma exposure and posttraumatic stress disorder symptoms: A twin study. Ameri- can Journal of Psychiatry, 159, 1675-1681.

Weathers, F. W., Keane, T., & Davidson, J. (2001). Clinician- Administered PTSD Scale: A review of the first ten years of research. Depression and Anxiety, 13, 132-156.

Weathers, F. W., & Litz, B. T. (1994). Psychometric properties of the Clinician-Administered PTSD Scale, CAPS-1. PTSD Research Quarterly, 5(2), 2-6.

Documents

Personality disorders in veterans with posttraumatic stress disorder and depression