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Distinguishing Between Adjustment Disorder and Depressive Episode in Clinical Practice: The Role of Personality Disorder Dr Anne M Doherty MD MRCPsych University College Dublin, King’s College Hospital London BIGSPD, Leeds 5th March 2015 Background on Adjustment Disorder Adjustment disorder is a state of “subjective distress and emotional disturbance, usually interfering with social functioning and performance, and arising in the period of adaptation to a significant life change or to the consequences of a stressful life event” ICD-10 & DSM-V criteria 1. Symptoms must arise in response to stressful event 2. Short time frame: 3m DSM-5; 1m ICD-10 3. Symptoms must be clinically significant 4. Symptoms must NOT be due to another Axis I disorder 5. Resolution within 6m of end of stressor DSM I: “transient situational personality disorder” DSM-5 • under the heading of “trauma-and stressor-related disorders” • “some personality features may be associated with a vulnerability to situational distress that may resemble an adjustment disorder” • “stressors may also exacerbate personality disorder symptoms” but a diagnosis of adjustment disorder should not be made unless the “stress-related disturbance exceeds what may be attributable to maladaptive personality disorder symptoms” (APA, 2013; p. 288). The spectrum Adjustment disorder Mild distress Depressive illness AD epidemiology – general v. liaison • Not included in the major epidemiological studies e.g. Epidemiological Catchment Area Study (Myers 1984), National Comorbidity Survey Replication (Kessler 2005), National Psychiatric Morbidity Study (Jenkins 1997). • In acutely ill medical inpatients AD 3 times as common as depression (Silverstone 1996) • At ED following self-harm 19.5% diagnosed with depression; 31.8% with AD (Taggart 2006) AD and Personality Disorders • Strain (1998) found that personality disorder was frequently co-morbid with AD (15%) • No difference in prevalence of personality disorder between AD and DE (ODIN – Casey 2004) AD & Suicidal Behaviour • Rates of suicidal behaviour 25%/60% in AD (Pelkonen 2005, Kryzhananovskaya 2001) • 1/3 of completed suicides (Lonquist 1995); most common diagnosis in developing world (Manoranjitham 2010) • Suggested that there may be differences between the 2 diagnoses in risk variables and socio-demographic profile (Polyakova 1998) Suicidality and Personality Disorders At 6 year follow up of personality disorder • Risk of repeated suicide attempt was increased by: • • • • • low socioeconomic status, poor psychosocial adjustment, family history of suicide, previous psychiatric hospitalisation, absence of any outpatient treatment previously • Reduced by: • higher global functioning scores at baseline (Solotoff 2012) Our hypothesis 1. Adjustment disorder is associated with a high level of personality disorder 2. Personality disorder has a stronger association with adjustment disorder than with depressive episode. Aims • To examine the relationship between AD and personality disorder • To examine the association of personality disorder with suicidal ideation and self-harm in patients diagnosed with AD or DE METHODS Our study • Part of a larger study examining AD and DE in liaison psychiatry • Patients – referred to the liaison psychiatry service at 3 Dublin hospitals – diagnosed by the liaison psychiatrists with either DE or AD – Exclusion criteria: – – – – – Substance abuse disorder Cognitive impairment/ incapable of giving informed consent Under 18 Psychotic symptoms Lack of fluency in English • 2 interview points • Recruitment • After 6 months (not in this presentation) Instruments: • • • • • • • • • • SCAN – Schedules for Clinical Assessment in Neuropsychiatry (Wing 1990) BDI – Beck Depression Inventory (Beck et al 1969) IDS-C30 – Inventory of Depressive Symptoms – Clinician Rated (Trivedi et al 2004)(Q. 18) The List of Threatening Experiences (Brugha et al 1985) SAPAS Standardised Assessment of Personality- Abbreviated Scale (Moran et al 2003) Oslo Social Support Scale, (Nosikov & Gudex 2003) SFS – Social Functioning Schedule (Remington and Tyrer 1979) DUREL – Duke University Religion Scale (Koenig 1997) SIS – Suicide Intent Scale (Beck, Schuyler &Herman 1974) SSI - Scale of Suicidal Ideation (Beck, Morris & Beck 1974) Diagnosis • Structured interviews not helpful •Do not include AD •In Inferences and Attributions Section (SCAN) • SCAN Diagnosis looks at symptom numbers and duration only, without taking account of context • Clinical diagnosis looks at both symptoms and their context = GOLD STANDARD. SAPAS • 8-item screening instrument 1. 2. 3. 4. 5. 6. 7. 8. In general, do you have difficulty making and keeping friends? Would you normally describe yourself as a loner? In general, do you trust other people? Do you normally lose your temper easily? Are you normally an impulsive sort of person? Are you normally a worrier? In general, do you depend on others a lot? In general, are you a perfectionist? • 0-2 unlikely personality disorder • 3-8 probable personality disorder Power Calculation & Statistics • Power calculations were based on methodology of Smith and Morrow (1996). To have 95% confidence of detecting a difference in depressive symptomatology of similar magnitude to that detected in Casey et al (2006), at a significance level of p<0.05, we would need 185 individuals with adjustment disorder and 185 individuals with depressive disorder. • Statistics were calculated using SPSS: • Univariate analysis: •Independent Samples T-test •Mann-Whitney U Test •Chi-Square Test •Cohen’s kappa •Multivariate analysis •Logistic regression RESULTS Clinical Diagnosis • 370 patients identified • 185 diagnosed with an adjustment disorder • 185 diagnosed with a depressive episode • Only 26.6% with AD clinically we diagnosed with AD on SCAN (Cohen’s kappa 0.232 ; p<0.001) • Sensitivity 91.8% • Specificity 57.2% Socio-demographics and diagnosis AD & DE Clinical Variables n AD (n=185) Median (Range) DE (n=185) Median (Range P-value Depressive symptoms (BDI) 346 25 (0 - 55) 32 (4 - 60) 0.000a Personality (SAPAS) 346 3 (0 – 8) 4 (0 – 8) 0.030a Social Support (Oslo) 347 10.75 (3 - 14) 10 (3 - 14) 0.024a Life Events 347 2(0 – 9) 1 (0 – 9) 0.000a Social Functioning (SFS) 336 2.3 ( 0- 7.7) 2.8 (0 - 9.6) 0.005a 287 N (%) 128 (74) 45 (26) N (%) 120 (68.5) 55 (31.5) nsb Suicidality ( Q18 ofIDSC-30) Suicidal Not Suicidal There were no significant differences between the 2 diagnostic groups in the sociodemographic variables- -age, gender, marital status, religiousness a = Mann Whitney U Test; b = Chi-square Test Personality traits and diagnosis Life events and diagnosis DE AD Logistic regression Suicidal behaviours No significant difference in suicidality between those with and without PD No significant difference in suicidality between AD & DE We then split the file by personality – above or below the cut-off for PD; and analysed the 2 groups separately. Multivariate Analysis of Suicidality in patients with and without PD Logistic regression with Suicidality as the dependent variable in cases with out personality disorder as indicated by a score of 2 or less on SAPAS (Pseudo-R2 = 23.0 – 33.6%) B P-value Odds Ratio Marital Status -1.268 0.023 3.56 Age -0.039 0.006 1.09 Clinical Diagnosis 0.014 0.001 1.02 Logistic regression with Suicidality as the dependent variable in cases with likely personality disorder as indicated by a score of 3 or greater on SAPAS (Pseudo-R2 = 16.7 – 22.9%) B P-value Odds Ratio Marital Status -0.9 0.010 2.46 Gender -0.802 0.024 2.23 Depressive symptoms (BDI) -0.042 0.015 1.043 Age -0.037 0.037 1.04 Strengths and Limitations • Strengths • Large number of patients with AD • Variables not previously examined • Controlled for multiple confounders • Limitations • Clinical diagnosis Conclusions (1) AIM 1: • To examine the relationship between AD and personality disorder • Finding: • • • • • AD is associated with PD Higher overall scores in DE v AD Worrier, temper traits common in AD (but more common in DE) Certain traits more common in AD: impulsivity; dependence Only significant difference in perfectionism Conclusions (2) AIM 2: • To examine the association of personality disorder with suicidal ideation and self-harm in patients diagnosed with AD or DE • Findings: • In patients without PD younger age, single marital status and a diagnosis of depression predicted suicidal behaviour • In patients with PD younger age, male gender, single marital status and higher number of depressive symptoms were associated with suicidal behaviour • In this population, suicidal ideation and behaviours were not significantly higher in patients who have a personality disorder Conclusions (3) Hypothesis 1: Adjustment disorder is associated with a high level of personality disorder • Finding: • Yes -56% screened positive (65% in DE) Conclusions (4) Hypothesis 2 Personality disorder would have a stronger association with adjustment disorder than with depressive episode. • Finding: This is not the case: Frequency of diagnosis: DE 65% v AD 56% Significant traits in DE Personality may have a greater role in shaping symptoms in DE Implications • Assumption that patients with AD more vulnerable • “transient situational personality disorder” • ICD-10 refers to personality as important in AD • No evidence base for this assumption • Change in ICD-11? • Clinically, focussing on personality disorder in AD may be unhelpful Acknowledgements A special thanks to: • Professor Patricia Casey, UCD/MMUH - PI • Dr Faraz Jabbar, UCD/MMUH • Prof Brendan Kelly UCD/MMUH • Dr John Sheehan, UCD/MMUH/Rotunda Hospital • Dr John Cooney, TCD/St James’ Hospital • Dr Anne Marie O’Dwyer, TCD/St James’ Hospital • All participating patients • The Ethics Committees of the hospitals involved Thank you