ANALIZA DIJAGNOZE POREMECAJA LICNOSTI KODPACIJENATA SA PANICNIM POREMECAJEM I

AGORAFOBIJOM

Milan Latas, Vladan Starcevic , Goran Bogojevic, GoranT'r aj kovic

Cilj studije je da se utvrditi postqja'?Je, ueestalost i tip poremeeq!aIzlnosti kod pacijmata sa agorajobijoJJJ i paniini»:poremeeq!em, kao ida se uporedi klinieka slika pacijenata sa porellJeeq!em lienosti ipacijenclta bezporemeeq!a lienosti. Rezultati ukazuju dapostoii visokaupIta uiestalost poremefqja liinosti (45%), pri eemu su najeefCiporemeeqji lienosti iZ klastera anksioznih poremeeqja lienosti (45%)}odnosno, cgranielli (20%), opsesivno-kompul'{jt'1li (18'10)} zavislli(15%), paranoidnt (15%) i izjJegat1ajuci (12%) poremeeq! Izlnosti.Pored toga} stud!/a .Ie ukazala i na znaeqjne implikac!ie prisustvaporeme/aja lict/osti na klinicku prezentacijtt pacijenata sa agoraJobijomi pallienim poremeeajem - u smislu teze klinieke slike kod ovihpacijimata.

Kljucne reci: agorafobij'a, panicniporemeeq!, poremeeaj licnosti.

UVODKl in icarim a jc dobro poznato da postojanjc poremeca)a licn o sri kodpacijenata sa agorafobijom i p ani c n im p orerne cajern ima v az an uticajna etiologiju, kli n icku sliku, psihijatrijski trctman i ishod samogporcmecaja.

U rcvijalnom radu, koji obuhvata vise raz lic itih studija,Brooks i sar.! zakljucuju da je uc estalo s t po ternecaj a licno s ti kodpacijenata sa agorafobijom i p ani cnirn porernecajern u rangu izmcdju40°1c) i 65(%. U ovim studijama n ajv ise su bili zastupljcni p o rcmccajilic n o sti iz klastera "C" DSM klasifikacije, odnosno, zavisni iizbegavajuCi porcrnccaji l ic no s ti. Slicni rezultati dobijeni su i unarednim studijama koje su ispitivale prisustvo p ore m ecaja Iicn o s tikod pacijenata sa agorafobijom i p an i cn im p orcm ecajcrn. 27

Pored toga, do sadas nja is traz ivanj a uglavnom ukazuju daagorafobicni pacijcnti sa p o rem ecaj im a licn o s ti imaju iz raz.e nije

ENGRAMI 22 (2000) 2----------------- 71

Milan Latas, Vladan Starcevt«, Goran Bognjevie, Goran 'I'r ajkovlc _

klinicke simptome od pacijenata bez poremecaja licnosti. 8,9 Sa druge

strane - sto je iz razeniji stepen fobije - vise pacijenata ispunjavakriterijume za dijagnozu po remecaja Iicno sti. 10

Op sez nijih ispitvanja koja su ispitivala odnos agorafobije sap anicriirn po reme cajern i porernecaja Iicno s ti (uccstalo s t

komorbiditeta, etio lo sk a veza, kl in ic ka slika kod osoba sakomorbidnim po remecajima itd.) u nasoj populaciji jos nije bilo.Zbog toga, cilj is traz ivanja je bio da se utvrditi postojanje, uces tal o s t

i tip po rernecaja Iicno sti kod pacijenata sa agorafobijom i pani cnirnpo re mecajcm. Pored toga cilj is traz ivanja je bio i da se analizirakli nicka slika kod pacijenata sa agorafobijom i p ani cnirnpo rernecajern i po remecajima licrio sti.

METOD RADA

Is traz.ivanje je sprovedeno kao kli nicka studija, u direktnomradu sa pacijentima, a obavljeno je u Dnevnoj bolnici Instituta zamentalno zdravlje u Beogradu.

Uzorak istraz ivanja obuhvatao je 60 ispitanika, koji su

veCinom bili srednjih godina (34 ± 8 god.) od kojih je 75°!<) biloz.en skog pola. Ispitanici su vccino m bili u braku (63%) i u velikojve ci ni imali su zavrseriu bar srednju skolu (98%).

Svi ispitanici su bili sa osnovnom dijagnozom agorafobije sapani cnirn poremccajem, koja je postavljena na osnovu Strukturisanogkl iriickog intrvjua za DSM-IV klasifikaciju - SCID. 11

Dijagnoza po rcmccaja Iicn o sti postavljena je na osnovumodifikovanog Strukturisanog kliriickog intrvjua za p oremecaj elicnosti prema DSM-IV klasifikaciji - SCID-II, koji je primenjen kao"skrining" upitnik. 12

Pored toga, svi pacijenti su pro sli potpuno kli nickoispitivanje, koje je sprovedeno neposredno pri prijemu na Iece nje, auz upotrebu sl ede cih instrumenata:1. The Hopkins Symptom Checklist - 90 - Hopkinsova li s ta simptoma

upotrebljena je radi procene sp eci fi cnih dimenzijapsihijatrijske simptomatologije. 13

2. Fear Questionnaire - Upitnik za strah upotrebljen je radi proccnestepena izbegavanja spe cificnih fobicnih si tuacija.J"

3. Beck Anxiety Inventory - Bckov upitnik za anksioznost upotrcbljcnje radi ocene stepena op ste anksio znos ti.l '

4. Beck Depression Inventory Bckov upitnik za depresivnostupotrebljen je radi procene stepena aktuelne d cp rc sivno sti.I"

72 ENGRAMI 22 (2000) 2

POREMECAJI LICNOSTI KOD PACIJENATA SA ...--------

5. Panic .Appraisa! Lnuetory - Panic Consequences - Upitnik za procenupredvidjanja posledica p ani cn ih napada upotrebljen jc radiprocene speci ficn ih dimenzija anticipatorne anksioznos ti koja

dno si ·v d 1718se 0 n o s i na panlcne napa e. '6. I//neJJ .Attitudes Scales - Upitnik za odnos prcma bolcstije

upotrebljen radi procene hipohondrijskih tendcncija, kao vrloce s te sckundarnc pojave kod pacijenata sa agorafobijom i

• v • ,. 19panlcnlm poremeca)em.

REZULTATI

Od 60 ispitanika koji su uce s tvovali u i s traz iv anju njih

dvadeset sedam (45 0ft)) ispunjavalo je kri terijume za dijagnozu bar

jcdnog po r e m e c aj a Iicno sti.

Tabela prikazuje uce stalo s t dijagnoza specificnih

po rem ecaja Iicno s ti kod 27 ispitanika koji su imali bar jednu

dijagnozu po rcmecaja licno s ti:

Tabela 1

Broj

dijagnoza Broj%

po remccaj a ispi tanika

Iicno s ti

0 33 55.0

1 11 18.3

2 4 6.7

3 8 13.3

4 3 5

5 1 1.7

ukupno 60 100

Min 0

Max 5

Ve ci broj pacijenata imao je v i se s tru ke dijagnoze poremeca)a

licno s ti, pa se zbog toga u rezultatima pojavljuje veci broj dijagnoza

ENGRAMI 22 (2000) 2 73

Milan Latas, Vladan Starcevtc, Goran Bogujevlc, Goran Trajkovic'---__

po reme caja licnosti (60) od broja ispitanika koji imaju dijagnozu

poremccaja Iicno sti (27).

Tabela 2 prikazuje ucestalo st spccificnih poremecaja li cno s ti

(N=27):

Tabela 2

Po reme caj licrio s ti Klas te r Uce s tal o s t %

Paranoidni A 9 15.0

Shizoidni (ekscen trici) 2 3.3

Shizotipni 0 0.0

His trio nicni 6 10.0

Narci s tic ki B (dramatici) 4 6.7

Granicni 12 20.0

Antisocijni 0 0.0

1z begavajuci C 7 11.7

Zavisni (s tra slj ivci) 9 15.0

Opsesivno-kompulzivni (Anksiozni11 18.3

PL)

UKUPNO 60 100

Tabela 3 prikazuje uce stalo s t komorbidnih dijagnoza

sp ecifi cnih p o rcmecaja Iicn o s ti po klasterima (N=27).Tabcla 3

Klas te r Uce s ta lo s t %)

A (ekscentrici) 11 18.3

B (dramatici) 22 36.7

C (s tras lj ivci) 27 45.0

Ukupno 60 100

U nastavku is trazivanj a multivarijantnim testom uporedjenesu varijable iz upitnika koji se odnose na klini cku simptomatologijuispitanika sa dijagnozom p o rcmecaja li cn o s ti i ispitanika bezdijagnoze p oremecaja Iicno sti.

/ 74 ------------------ENGRAMI 22 (2000) 2

POREMECAJI LICNOSTI KOD PACIJENATA SA ...--------

Multivarijantni test ukazuje da globalna razlika izmedjunavedene dye grupe ne d o s tiz e nivo s ta tis ticke z n ac aj n o s ti ali postojijasno iz r a z e n trend ka s ta.ti s ti ck oj z nacajno s ti (F=1.69, SS=25/34,p=O.078).

Zatim su analizirane sve subskale sa upitnika za kl ini ckusimptomatologiju. Zbog velikog broja ispitivanih varijabli (25)s ti s ti s ti ck i z n a c aj n e razlike su na varijablarria gde je p<O.002. Tako,s ta tis tick i z.an a c aj n a razlika postoji na Bekovom upitniku z adepresivnost (p=O.OOO) i subskalama se nzrtrvno s t (p=O.001) iparanoidnost (p=O.OOO) Hopkinsovc liste simptoma. Na o s talirnsubskalama koje se odnose na speci ficn e psihijatrijske simptome,postoji razlika (i ako n e stas tis tick i z n acajn a) izmcdju grupcispitanika sa po rern ec.ajim a licn o s ti i grupe ispitanika bez p ore m e c aj aIicn o s ti. Pri tome, pima vrcdnosti od 0.004 do 0.074. To se odnosin a simp tome o pste anksioznosti, fobicno sti , depresivnosti,anticipatornc anksioznosti, hipohondrijc. Razlika izmedju ispitanikane postoji samo na varijablama koje se odnose na socijalnuanksioznost (p=0.250) i kategorijalno odredjenjc hipohondrijc(p=0.130).

DISKUSIJA

Uc e s talo s t po re m e caj a l i cnos ti

Rezultat i s traz ivanj a ukazuje da je n e sto manje od polovine(45%) .pacijenata sa agorafobijom i panlcnlm poremecaJemispunjavalo kriterijume za dijagnozu bar jednog poremecaja Iicrio s ti ,s to je u saglasnosti sa ranije navedenim staudijama. 1 Pored toga, usaglasnosti sa ranijim stujama je i podatak da su najzastupljcnijiporem e caji licno s ti iz klastera C i klastera B 1, odnosno granicni,opscsivno-kompulzivni, zavisni, paranoidni i izbegavajuCi p o r e m ccajl icno s ti J i da ih je vecina irn al a vi s e s truke dijagnoze porem e cajaIicn o s ti. 20

Po kus ali smo da objasnimo visoku ucestalo st poremecapli cn o s ti kod pacijcnata sa agorefobijom i pa ni cnirn po r cmccajem.

Manje - vise sve studije (pa i ova) ukazuju na visokuuce s ta lo s t anksioznih p o re m e caj a licn o s ti , o dn o sn o , opscsivno­kompulzivnog, zavisnog i izb egavajuceg po rern ecaja Iicn o s ti kod

ENGRAMI 22 (2000) 2 75

Milan Latas, Vladan Starcevic, Goran Bogujevlc, Goran Trajkovic'--__

pacijenata sa agorafobijom i pani cnim poremecajern. Kao objasnjenjcza ovu pojavu moze posluz iti "model prcdispozieijc", 8,21 kojiukazuje da navedeni po rernecaji licno s ti, u spccificnirn okolnostima,predisponiraju pojavu agorafobije.

Nasuprot tome, moguce je da navedeni po rem ecaji licno s tipredstavljaju izraz klinicke slike agorafobije i p anicn og po rem ecaja.Kao dokaz za ovakvu pretpostavku navode se studije koje ukazujuda se p ato lo ske erte licnosti povla ce nakon uspdnog tretmanaagorafobije. 22

Kao medjuvarijatnta navedenih pretpostavki, m oguce je da seagorafobija sa panicnirn po remecajem i pojedini po rernecaji li cno sti(pre svega zavisni i izbegavajuCi) nalaze na "kontinuumu", odnosnoda su navedeni porcrnccaji Iicno sti hronicne , subsindromske formeagorafobije i panicriog porernecaja. 23,24

I na kraju, moguce je i da su agorafobija s p anicnirnporemecajem i pojedini porernecaji Iicrio sti uzrokovani z.aje dnickim"trecim" faktorom, i da predstavljaju razliCite klinicke prezentaeijeistog etio lo skog Fakrora."

Za postojanje svake od navedenih m ogucno sti postoje pro etcontra argumenti. Medjutim, u posmatranju odnosa komorbiditctaagorafobijc sa panicnirn porcrnecajcrn i razliCitih po rcmccaja licn o s tineopravdano je prihvatanje sarno jedne, uz is kljuciv anj e ostalihmogucnosti. Smatra sc da se tek uklj ucivanjcrn ne1incarnog,multifaktorijalnog modela posmatranja mogu' se doneti validnizakljucci 0 odnosu izmedju ovih porernccaja.i"

Klinicka slika

Rezultati studije ukazuju da su paeijenti sa porernccajimalicnosti imali tezu klinicku sliku u odnosu na paeijente bezporernecaja licno s ti. Rezultati do sadasnjih studija daju razliCitepodatke 0 odnosu postojanja dijagnoze po rernecaja Iicno s ti i tez iriekli nicke slike. Renneberg i sar. 20 i Sanderson i sar." ukazuju dapacijenti sa porerriecajima licnosti nisu imali visi stepen simptomapanike, anksioznosti i agorafobije od paeijenata bez p oremecajalicno sti , ali su paeijenti sa porernecajima licno sti imali ve ci stependepresivnosti.

S druge strane, Mavissakalian & Hamann 27 ukazuju dapaeijenti sa agorafobijom i panicnim poremccajem, koji imaju visepatalo skih erta karaktera, imaju iz razeriiju psihijatrijsku

,76 ------------------ENGRAMI 22 (2000) 2

POREMECAJI LICNOSTI KOD PACIJENATA SA ..--------

simptomatologiju. Sl icno tome, Reich i Chaudry 9 zakljucuju da jedijagnoza po rernecaja licno sti uce stalija kod anksioznih pacijenata saiz raz.enijorn simptomatologijom. Ovakve nalaze potvrdili su i drugiautori. 7, 10

Uz im ajuci sve ovo u obzir, m o ze se reci da su sp ec ifi cnipsihijatrijski simptomi i zraz en ij i (i ako ne uvek na sta ti sti ckizn acajno m nivou) kod pacijenata sa agorafobijom i panlCnlmpo rernec ejern i dijagnozom po rerne caj a li cn o sti u odnosu na istepacijente be z dijagnoze po rernecaja licno s ti..

Objasnjcnjc za iz raz cniju kli n ic ku sliku kod pacijcnata sadijagnozom p o remcc aja licno sti, m oz e biti u pretpostavki da supacijcnti sa maladaptivnim obrazcima p o n asanj a vulnerabilniji zarazvoj psihijatrijskih p orcme caj a (pa tako i agorafobije sa pariicnirnporcm ccajcm). S drugc stranc, njihovo hro ni cno lose funkcionisanjei primarna simptomatologija jo s vise se pogorasav aju u slucajupojave psihijarijskih po rcmccaj a (agorafobijc sa p ani cni mporernecajern). a time kli n icka slika postaje sl ozenija u odnosu sarnona po rcm ccaje li cn o sti ili u odnosu sarno na psihijatrijskcpo rem ecaje (agorafo bij a sa p anicnirn porernecajern).

ZAKLJUCAK

Rezultati studije ukazuju da postoji znacaj no prisustvo

p o r eme caj a licno sti kod pacijenata sa agorafobijom i panlCnlm

porcmccajcrn. Pored toga, studija je ukazala i n a znacajnc implikacije

prisustva po rern ecaja licno sti n a klinicku prezentaciju pacijenata sa

agorafobijom i p anicnirn po remecajern - u smislu tez e kli ni cke slike

kod ovih pacijenata. Medjutim, pored ovog ep idernio lo skog i

klinickog zn acaja, porcmccaji licn os ti ponekad presudno uticu n a

tok, prognozu i ishod le ce nja osnovnog po rernecaja. Zbog toga se

n ajvaz nija implikacija ispitivanja poremecaja licno sti u svakodncvnoj

klin ickoj praksi odnosi na domen planiranja ciljanog terapijskog

pristupa kod pacijenata sa pato lo skorn strukturom licno sti. Is tice se

da je vrlo cesto potrebno modifikofati i prilagoditi terapiju u smislu

intanzivnijeg i duzeg Iecenja agorafobije sa panicnirn p o remecaje m u

zavis no sti od tipa po remecaja licno sti.

ENGRAMI 22 (2000) 2 77

Milan Latas, Vladan Starcevlc, Goran Bogujevic, Goran Trajkovle _

Dr Milan La tas , psihijatar, mr. sci m ed., Institut za psihijatriju KCS,Centar za parcijalnu hospitalizaciju

Dr Vladan Starccvic, psihijatar, docent Medicinskog fakulteta uBeogradu, Institut za mentalno zdravlje

Dr Goran Bogojevic, psihijatar, KPD Bolnica, Beograd

Dr Goran Trajkovic, psihijatar, asistent Medicinskog fakultetaUniverziteta u PriStini

78 -------------------ENGRAMI 22 (2000) 2

ANALYSIS OF DIAGNOSES OF PERSONALITY DISORDERSIN PATIENTS WITH PANIC DISORDER AND

AGORAPHOBIA

Latas, M., St a rcevi c, V., Bogojevi c, G., T'rajkovic, G.

The aim ofthis stt/c!y is to examine presence, Jreqt/enry and !ype ifper.ronaliry disorders in patients }})ith agoraphobia IJJith panic disorderand to compare clinical presentation of patients IJJith and Ivithout anyper.rollaliry disorder. The results suggests that there is a highoverall rate0/comarbldpersonali!)' disorders (45%)and, specijical!y, a high rates 0/anxiety personality disorders (45%), especiallY borderline (201%),

obsessive-compulsive (18%), dependent (15%), paranoid (151%) andavoidant (12%) penonaliry disorder. The results also suggests thatpatients Ivitli personaliry disorders exhibit more severe [Ymptoms incomparison IJJith patientsIvithoutpersonaliry disorder.

Key words: agoraphobia, panic disorder, personaluy disorder.

INTRODUCTION

Clinicians well know that the presence of personality disorders inpatients with agoraphobia and panic disorder have great impact onetiology, clinical picture, psychiatric treatment, and outcome of thedisorder.

In the review from Brooks and al .", that explore a lot ofprevious studies, authors indicated that the prevalence of personalitydisorders in patients with agoraphobia and panic disorder is in rangefrom 40(/'{1 to 65 0ft). In those studies, the most frequent werepersonali ty disorders from cluster C from DSM classi fication, i.e.dependent and avoidant personality disorders. Similar results weregiven in the following studies that examined presence of personalitydisorder in agoraphobic and panic paticnts.f"

Also, previous studies indicate that agoraphobic patients withpersonality disorders have more severe clinical symptoms thenagoraphobic patients without personality dis o rders.":" Furthermore,the most severe phobic symptoms are in samples of patients withmore comorbid personality disorders.!"

ENGRAMI 22 (2000)2------------------ 79

Latas, M., Starcevtc, V., Boguj evlc, G., Trajkovie, G. _

Until now, there was no comprehensive studies in Yugoslavpopulation that examined relationship between agoraphobia withpanic disorder and personality disorders (prevalence of comorbidity,etiological relationship, clinical picture in patients with suchcomorbidity etc.). Since that, the aim of this study was to observepresence, prevalence and kind of personality disorders in patientswith agoraphobia and panic disorder. Also, the aim of the study wasto analyze the clinical presentation of patients with agoraphobia andpanic disorder and comorbid personality disorders.

METHOD

The study was designed as clinical examination and it wasconducted in the Day hospital of Institute of Mental Health inBelgrade.

The sample was consisted of 60 patients, which was middle-

aged (34±8 years old), mostly women (75%), mostly married (63(10)and with at least secondary education (98%).

All patients were with principal diagnosis of agoraphobia withpanic disorder, which was estimated on the basis of StructuralClinical Interview for DSM IV classification - SCID. 1 1

The diagnoses of personality disorders were estimated on thebasis of modified Structural Clinical Interview for PersonalityDisorders for DSM-IV classification - SCID-II which was used as a

•. 12screening Instrument.

All patient were examined at the beginning of the treatmentwith following instruments:

1. The Hopkins Symptom Checklist - 90 - which was used toexamine the specific dimensions of psychiatric

I 13symptomato ogy.

2. Fear Questionnaire - which was used to assess symptoms ofphobic avoidance b eh avio rv'"

3. Beck Anxiety Inventory - which was used to assess symptoms of1 ' 15genera anx re ty .':

4. Bec.kDepres sio n Inventory - which was used to assess symptomsf d

. 16o epresslOn.

5. Panic Appraisal Inventory - Panic Consequences - which was used

80 ------------------ENGRAMI 22 (2000) 2

PERSONALITY DISORDERS IN PATIENTS . . .

to assess specific dimensions of anticipatory anxiety that wereI d . k 1718re ate to panlC attac s. '

6. Illness Attitudes Scales - which was used to assess symptoms ofh h dri 19ypoc on rra.

RESULTS

From the 60 patients that participated the study 27 (45%)patients had the at least one diagnosis of personality disorder.

Table 1 shows number of diagnoses of personality disordersin 27 patients with at least one diagnosis of personality disorder:Table 1

Number of

diagnoses of Number of%

personality patients

disorders

0 33 55.0

1 11 18.3

2 4 6.7

3 8 13.3

4 3 5

5 1 1.7

Total 60 100

Min 0

Max 5

Some of patients had multiple diagnoses of personality disorders

and that was reason for higher number of diagnoses of personality

disorders (60) than number of patients with at least one diagnosis of

personality disorder (27).

ENGRAMI 22 (2000)2------------------ 81

Latas, M., Starcevlc, V., Bogojevle, G., 'I'r ajkovlc, G. _

Table 2 shows frequency of specific personality disorders(N=27):

Table 2

Personality disorder Cluster Frequency %

Paranoid 9 15.0Schizoid A 2 3.3

(eccentrics)Schizotip 0 0.0

Histrionic 6 10.0Narcissistic B 4 6.7

(dramatics)Borderline 12 20.0Antisocial 0 0.0

Dependent C (anxious 7 11. 7Avoidant personali ty 9 15.0Obsessive - disorders)

11 18.3compulsive

Total 60 100

Table 3 shows frequencies of specific comorbid diagnoses ofpersonality disorders by clusters (N=27).

Table 3

Cluster Frequency 0/0

A (Eccentrics) 11 18.3

B (Dramatics) 22 36.7

C (Anxious) 27 45.0

Total 60 100

In addition of the study, variables from the variousquestionnaires that examined clinical symptomatology of patientswith and without diagnosis of personality disorders were comparedby multivariate test.

82 ENGRAMI 22 (2000) 2

PERSONALITY DISORDERS IN PATIENTS ...

Multivariate test shows that global difference is notsta tis ticall y signi fi can t bat tha t there is tendency to sta ticallysignificant difference (F=1.69, SS=25/34, p=0.078).

After that, we have analyzed subscales from thosequestionnaires that examined clinical symptomatology. Statisticalsignificant difference was on p<0.002. There were statisticallysignificant differences on Beck Depression Inventory (p=O.OOO) andon subscales of sensitivity (p=O.OOl) and paranoidity (p=O.OOO) fromThe Hopkins Symptom Checklist. On the others subscales thatexamined clinical symptomatology there is difference (but notstatistically significant) between patients with and without comorbidpersonality disorders. P values were from 0.004 to 0.074. That isrelated on symptoms of general anxiety, phobia, depression,anticipatory anxiety, and hypochondria. There were not differencebetween patients on variables related to social anxiety (p=0.250) andcategorical determination of hypochondria (p=0.130).

DISCUSSION

Prevalence of personality disorders

The result from this study shows that slightly less then half (45°;(l)patients with principal diagnosis of agoraphobia with panic disorderhave at least one comorbid diagnosis of personality disorder. Thisfinding is in similarly to the previous studies. 1 Besides that, similarlyto the other studies, most frequent personality disorders were fromclusters C and B 1, i.e. borderline, obsessive-compulsive, dependent,paranoid and avoidant personality disorder! and that most ofpatients had more then one comorbid diagnosis of personalitydisorder. 20 We have tried to explain this high prevalence ofpersonality disorders in patients with agoraphobia and panicdisorder. More or less, all studies (including this) indicate on highprevalence of anxious personality disorders, i.e. obsessive­compulsive, dependent and avoidant personality disorders inpatients with agoraphobia and panic disorder. That phenomenacould be explain by predisposition model 8,2! that hypothesized thatthose personality disorders could, in specific occasions, predisposedevelopment of agoraphobia. In contrast, those personalitydisorders could only be specific clinical presentation of agoraphobia

ENGRAMI 22 (2000)2------------------ 83

Latas, M., Starcevlc, V., Bogojevlc, G., Traj ko vlc, G. _

and panic disorder. As a support for this hypothesis there arestudies that shows that pathological personality traits disappear afterthe successful treatment of ago rap ho bi a.V Also, it could be thatagoraphobia with panic disorder and some personality disorders(avoidant and dependent) are on continuum, i.e. those personalitydisorders could be chronic, subsyndromal forms of agoraphobia

, h ic di d 2324wit panlc rso r er.. ,At the end, it could be that agoraphobia with panic disorder and

some personality disorders could be predisposed by third commonfactor and that there are different clinical presentations of the sameetiological factor. 24

All of these hypotheses have pro and contra arguments. But, indiscussion on relationship between agoraphobia with panic disorderand personality disorder it is not comprehensive to analyze only oneof those possibilities. Only nonlinear, multifactorial model couldgive satisfied conclusion on this rela tio n ship.f '

Clinical Picture

The results of this study show that patients with personalitydisorders had more severe clinical picture then patients withoutpersonality disorders. Previous studies display controversial resultsabout presence of personality disorder and clinical picture.Renneberg and al. 20 and Sanderson and al. (, indicate that patientswith personality disorders don't have more severe symptoms ofpanic, anxiety and agoraphobia but they have more severe symptomsof depression than patient without personality disorders does.

In opposite, Mavissakalian and Hamann 27 indicate thatpatient with agoraphobia and panic disorder with more pathologicalpersonality traits have more severe psychiatric symptomatology.Reich and Chaudry 9 concluded that diagnosis of personalitydisorder is more frequent in anxious patients with intensivepsychiatric symptoms. Those results were confirmed by others tud ics.f!''

All of this indicate that specific psychiatric symptoms aremore prominent (but not always on statistically significantdifference) in patients with comorbid personality disorder.Explanation for this finding could be postulate that patients withpathological personality traits are more vulnerable for thedevelopment of psychiatric disorders (i.e. agoraphobia and panicdisorder). In addition, their chronically maladaptive functionalityand primary symptoms could be worse after the occurrence of84 ENGRAMI 22 (2000) 2

PERSONALITY DISORDERS IN PATIENTS . . .

psychiatric disorders (agoraphobia with panic disorder) when clinicalpicture could be more severe.

CONCLUSION

The results of this study shows on high prevalence of

comorbid personality disorders in patients with agoraphobia and

panic disorder. Also, the study indicated on significant implicationsof personality disorders to clinical presentation of patients with

agoraphobia and panic disorder in terms of severe clinical picture ofthis patients. But, besides those epidemiological and clinicalfindings, personality disorders sometimes could have significant

influence on prognosis and treatment outcome of principal disorder.

Since that, most important implication of assessment of personality

disorder in clinical practice is related on treatment planning of

patients with pathological personality nraits. Clinician could modify

and adj us t speci fie therapy in terms to intense and prolong

treatment of agoraphobia and panic disorder, which depend, ofspecific type of personality disorder.

Milan Latas, MD, MA, psychiatrist, Ins ti tute of psychiatry ClinicalCentra of Serbia, Center for partial hospitalization

Vladan Starccvic, MD, psychistrist, associated professor, Belgrade,University School of Medicine, Institute of mental health

Goran Bogojcvic , MD, psychaitrsit, KPD hospital, Belgrade

Goran T'rajkovi c , MD, psychaitrsit, assistent lecturer Pri st inaUniversity School of Medicine

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ENGRAMI 22 (2000) 2 85

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