Understanding and Treating Anxiety Disor PDF

Chapter 12
Understanding and Treating Anxiety Disorders in

Presence of Personality Disorder Diagnosis
Véronique Palardy, Ghassan El-Baalbaki,

Claude Bélanger and Catherine Fredette
Additional information is available at the end of the chapter
http://dx.doi.org/10.5772/53554
1. Introduction
The prevalence of personality disorders varies between 0.5% and 2.5% in the general popu‐
lation and it increases drastically in the clinical population [1, 2]. In a psychiatric population,
about one half of all patients have pathological personality [3]. Following the multiaxial
classification of the Diagnostic Manual of the American Psychiatric Association (DSM-IV-
TR; [1]), Axis II personality disorders are defined as being stable, inflexible, and pervasive
patterns of psychological experiences and behaviors that differ prominently from cultural
expectations, and that lead to clinically significant distress or impairment in important areas
of functioning. In the DSM-IV-TR, there are 10 distinct personality disorders organized into
three clusters. Cluster ″A″ includes three personality disorders considered as odd or eccen‐
tric: paranoid, schizoid and schizotypal. Antisocial, borderline, narcissistic and histrionic
personality disorders are grouped under Cluster ″B″, which is considered as the dramatic,
emotional or erratic cluster. Finally, Cluster ″C″ comprises three anxious or fearful person‐
ality disorders: the avoidant personality disorder, the dependent personality disorder and
the obsessive-compulsive personality disorder. In the next version of the DSM (DSM-V), the
task force is proposing some major changes for Axis II and as per the may 1st 2012 online
revision[4], the DSM-V will retain six personality disorder types : schizotypal, antisocial,
borderline, narcissistic, avoidant and obsessive-compulsive.
The comorbidity between Axis I and Axis II disorders is much documented, and there are
some voices in the scientific community that would even question whether or not the dis‐
tinction between those two axis should be revisited [5-8]. Specifically, Axis II disorders have
been found to be strongly associated with anxiety disorders [9, 10] and an increased preva‐
lence of personality disorders has been found in patients with anxiety disorders [11, 12]. Per‐
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288 New Insights into Anxiety Disorders
sonality disorders are associated to high social cost and mortality, such as crime, disability,
underachievement, underemployment, increased need for medical care, institutionalization,
suicide attempts, self-injurious behavior, family disruption, child abuse and neglect, pover‐
ty, and homelessness [12]. This underlies the importance of finding optimal treatment for
this population, and understanding the mechanisms by which personality pathology inter‐
feres with other psychiatric disorders, such as anxiety disorders.
This chapter presents a comprehensive review of the literature on the co-occurrence of person‐
ality and anxiety disorders, and the treatment of the latter when comorbidity occurs. First, the
influence of personality pathology on anxiety disorders in general is discussed, with no regard
to specific anxiety disorders. Afterwards, the clinical features of each of the major anxiety dis‐
orders that are comorbid with personality disorders are examined separately. The influence of
personality disorders on anxiety disorder symptomatology and on the course of illness is also
discussed in terms of treatment. Emphasis will be on the outcome of cognitive and/or behavio‐
ral therapy, since its efficacy has been repeatedly established in the treatment of anxiety disor‐
ders. The influence of Axis II diagnosis on the outcome of pharmacological treatment of anxiety
disorders is also briefly discussed. Major characteristics of the studies that are reviewed in the
present chapter are presented in a table. Finally, future research questions on comorbidity of
anxiety disorders in the presence of personality disorders are proposed.
2. Co-occurrence of personality disorders and anxiety disorders
From 36% to 76% of patients with anxiety disorders have been found to have a comorbid
personality disorder diagnosis, with avoidant, dependent, obsessive-compulsive and para‐
noid being the most frequent [12]. Thus, anxiety disorders seem to be particularly associated
with Cluster C personality disorders [13]. Personality disorders are known to be strongly as‐
sociated with functional impairment [14], more severe psychopathology, and a decreased re‐
sponse to treatment [15]. When they coexist with anxiety disorders, the latter are
characterized by chronicity and more functional impairment that when compared to anxiety
disorders without Axis II comorbidity [11]. For example, in a study by Klass and colleagues
[16], anxiety patients with comorbid personality disorders were three to four times more
likely to have current dysthymia. Furthermore, patients with a personality disorder diagno‐
sis were significantly more likely to present a past major depressive episode, and they re‐
ceived lower scores for current level of functioning, compared with a control group matched
on primary anxiety diagnosis, sex, and age [16]. Moreover, the co-occurrence of personality
disorders and anxiety disorders has been found to be associated with suicide. In one study,
individuals with an anxiety disorder and antisocial personality disorder had more suicidal
ideation and suicide attempts, in comparison to individuals with either disorder alone [17].
Finally, personality disorders were reported to have a negative prognostic impact on the
naturalistic course of anxiety disorders. Ansell and colleagues [18] found that groups with
higher rates of personality disorders generally showed a more complex and variable course
of illness, which was characterized by frequent remissions and relapses, and the occurrence
of new onsets of anxiety disorders over a 7-year period. Although, their sample was recruit‐
Understanding and Treating Anxiety Disorders in Presence of Personality Disorder Diagnosis 289
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ed among a treatment-seeking population, the purpose of this study was to investigate the
naturalistic course of anxiety disorders. Thus, the treatment received was not controlled,
and it was not considered in the analysis.
2.1. Etiology of comorbidity
It is likely that multiple mechanisms contribute to the co-occurrence of anxiety and personality
disorders. One possible explanation is that Axis I and II disorders are etiologically independ‐
ent and that apparent high rates of co-occurrence are simply due to high rates of each disor‐
der[19]. However, Ruegg and Frances [12] argued that the high rates of co-occurrence found in
several studies are due to sampling bias, since most studies have been made among treatment
seeking populations. Given that treatment seeking generally correlates with higher sympto‐
matology severity and with the presence of multiple comorbid disorders, it is likely that these
samples overestimate the relationship between anxiety and personality disorders [12]. High
rates of co-occurrence have also been explained by issues in assessing personality disorders
among individuals with anxiety disorders. This refers to the ″state versus trait″ issue in comor‐
bidity research [20]. Because mood state tend to color the perceptions, going through an epi‐
sode of anxiety disorder may affect the patients’ perception of their personality, which would
result in a distorted report of the latter [19]. Thus, the presence of an Axis I disorder may result
in a false positive diagnosis of personality disorder [12], which would lead to an overestima‐
tion of the prevalence of personality disorders among individuals with anxiety disorders. Sev‐
eral models have been proposed to explain the high rates of coexisting personality and anxiety
disorders, and these are described in the following section.
First, it has been suggested that individuals with personality disorders are more vulnerable to
develop comorbid disorders. Vulnerability models assume that the disorders are distinct but
are causally related, such that the presence of one disorder increases the risk to develop the
other [19]. For example, because of their interpersonal difficulties, individuals with personali‐
ty disorders would be more prone to experience repeated, chronic and acute negative life
events, such as failures and losses, which would then increase the risk to develop and/or
maintain anxiety disorders [19]. Second, some studies have supported the hypothesis that
personality disorder traits are risk factors for anxiety disorders. For example, schizotypal, an‐
tisocial, borderline, histrionic and dependent personality traits present in adolescence and
early adulthood have been associated with higher risk of having an anxiety disorder by mid‐
dle adulthood [21]. In one study [22], high narcissistic personality traits, measured one week
after trauma, have been associated with an increased risk of developing posttraumatic stress
disorder (PTSD) one month and four months after trauma, even when controlling for baseline
anxiety disorders. However, Brandes and Bienvenu [23] mentioned that these findings do not
consider possible causal mechanisms involved. For instance, personality disorder traits and
anxiety disorders could share a common etiology, and personality disorder traits would only
be earlier manifestations of these common causal influences [23]. Third, another model of co‐
morbidity refers to overlapping criteria [24] and shared etiology [23]. Thus, characteristics of
each disorder are viewed as manifestations of a common dimension of psychopathology,
which would suggest that these disorders are not entirely distinct [19]. If they do share etio‐
logical factors, a shared genetic influence could be expected. Indeed, some results have sup‐
ported the hypothesis of a common genetic base to anxiety and personality disorders. For
instance, avoidant and dependent personality traits have been found to be more common in
first-degree relatives of patients with panic disorder (PD) compared with relatives of control
participants [25]. In another study, obsessive-compulsive traits were higher in first-degree rel‐
atives of patients with obsessive-compulsive disorder (OCD), compared with relatives of con‐
trols [26]. However, these findings could also be explained by environmental influences [23],
since patients and their relatives could have lived in a similar environment. Fourth, the patho‐
plasty conceptualization emphasizes the influence of one condition on the presentation or
course of the other, but does not assume a shared etiology [19]. Thus, one condition may have
an additive effect on the other condition, or exacerbate the latter [27]. For example, avoidant
personality disorder (AVPD) and panic disorder with agoraphobia (PDA) may have a patho‐
plastic relationship such that the presence of personality traits and anxious predispositions
interact to promote the development of personality or anxiety disorders [18]. Finally, it has
been suggested that personality disorder traits could be shaped by the experience of having
an anxiety disorder in childhood or adolescence [23]. For example, current anxiety disorders
among adolescents have been found to predict schizotypal, schizoid, borderline, avoidant,
and dependent personality traits in early adulthood, even when controlling for other Axis I
disorders during adolescence [28]. However, in this study, personality disorder traits have
not been assessed during adolescence, so it cannot be concluded that they were subsequent to
the development of anxiety disorders [23]. Results from Kasen and colleagues [29] gave addi‐
tional support to this model. Indeed, the presence of an anxiety disorder in adolescence was
found to predict an increased likelihood of having a paranoid personality disorder in young
adulthood, when controlling for personality disorders in adolescence. Also, adolescents who
reported anxiety symptoms that were increasing over time were more likely to have a para‐
noid personality disorder, or an OCPD in young adulthood [29]. The authors suggested that
behaviors and thoughts associated with perfectionism and rigidity, which characterized
OCPD, may develop to help control anxiety symptoms [29]. Yet, these findings still do not ex‐
clude the possibility that personality and anxiety disorders share a common etiology, al‐
though in this case, personality disorders would be the later manifestations [23]. Though all
these models give interesting explanations to comorbidity of anxiety and personality disor‐
ders, they are not mutually exclusive and it is likely that more complex bio-psycho-social
models are needed to explain the co-occurrence of these psychopathologies.
3. Influence of personality disorders on the outcome of treatment for

anxiety disorders
Since patients with multiple psychopathologies are often excluded from treatment trials, co‐
morbidity is often disregarded [30]. Thus, few controlled prospective studies have specifical‐
ly examined the effect of comorbid personality disorders on the outcome of cognitive and
behavioral treatment (CBT) for anxiety disorders. However, some studies have investigated
this area of research, with interesting results.
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The Reich and Green [31] review, based on studies of depressive and anxiety disorders, con‐
cluded that the presence of a personality disorder had a negative influence on the outcome
of treatment for Axis I disorders. In fact, personality pathology was found to predict a nega‐
tive outcome of treatment in practically all studies [31]. Another review [20], which covered
empirical studies published between 1991 and 1993, yielded similar conclusions. However,
with regard to anxiety disorders, only studies that investigated the outcome of treatment for
PD or OCD were included in the two previous reviews. Although Reich confirmed the gen‐
eral conclusion that dysfunctional personality traits have a negative effect on the outcome of
treatment for Axis I disorders in his latest review [32], he also reported that individuals with
comorbid personality disorders show improvement of their anxiety disorder symptoms
when treated for their anxiety disorder. However, in the Dreessen and Arntz [33] selective
review, personality disorders were not found to predict negatively the outcome of psycho‐
logical treatment for anxiety disorders. It was concluded that no specific personality disor‐
der was consistently found to affect negatively treatment outcome of anxiety disorders, and
that patients with a comorbid personality disorder were not more likely to select themselves
out of treatment [33]. Finally, the authors reported that patients with a personality disorder
generally do not respond less to cognitive and/or behavioral treatment for their anxiety dis‐
order, compared to patients without a personality disorder. However, these authors also re‐
port in their review that personality disorders are found to have a negative effect on the
outcome of pharmacological treatment for anxiety disorders.
4. Panic disorder with and without agoraphobia (PD/A)
Among panic patients, prevalence rates of comorbid personality disorders (mostly in the
Cluster C) range from 37% to 60% [3, 34-42]. No study has yet established a clear link be‐
tween a specific type of personality disorder and the diagnosis of PDA [43]. Some have re‐
ported a strong association of panic disorder with AVPD [35, 38], whereas others have
found higher rates of obsessive-compulsive personality disorder (OCPD; [36, 44]). This be‐
ing said, Mavissakalian, Hamann, and Jones [45] reported that personality disorders cannot
be presumed to have specific etiological significance for PD, given that the personality disor‐
der traits that are generally identified in PD patients are also present, and they are even
more pronounced, in OCD patients.
4.1. Initial symptomatology and course of illness

Individuals with comorbid PD and personality disorders tend to present a higher clinical se‐
verity [3, 38, 44, 46] and a more chronic course of illness [41] than PD patients without a per‐
sonality disorder. For instance, the presence of borderline personality disorder (BPD; [18]) or
OCPD [47] was found to predict new onsets of PD, when no treatment is considered. In a
study by Ozkan and Altindag [3], patients with comorbid PD and personality disorders had
more severe anxiety, depression, and agoraphobic symptoms, onset was at younger age, and
they had lower levels of functioning. On the other hand, Mellman and colleagues [37] found
no significant differences in baseline clinical ratings, and on most measures of chronicity, se‐
verity and duration of PD in the presence of a personality disorder. In Ansell et al. study
[18], the presence of an AVPD at baseline was even associated with a decreased likelihood of
relapsing in their PDA.
In addition, comorbid personality disorders in PD patients have been associated with an in‐
creased risk of suicidal thoughts [44, 48] and suicide attempts [48]. In one study [49], all PD
patients who had made serious suicide attempts had a comorbid personality disorder. A sig‐
nificant correlation between suicide attempts and comorbid Cluster B personality disorders
was reported, particularly with BPD and histrionic personality disorder [49]. Other studies
found a similar association of BPD with suicidal ideation [50] or suicide attempts [3] among
PD patients. Also, paranoid personality disorder has been reported to predict suicide at‐
tempts, and AVPD to predict suicidal ideation among this population [3]. Moreover, it ap‐
pears that personality disorder criteria do not necessarily need to be met to aggravate the
severity of PD. Indeed, studies have found personality disorder traits to be associated with
more baseline clinical disturbance among this population. For instance, PD patients with a
greater number of personality disorder traits have been found to be more symptomatic on
almost all measures of psychopathology [51].
4.2. Influence of personality pathology on the outcome of cognitive and/or behavioral

treatment for panic disorder with and without agoraphobia
Studies examining the effect of personality disorders on the outcome of cognitive and/or be‐
havioral therapy for PD have obtained conflicting results. However, as can be expected, many
studies have found a negative impact of personality disorders on the outcome of treatment.
Tyrer and colleagues [52] randomly assigned 181 patients with generalized anxiety disorder
(GAD), PD, or dysthymia to three modalities of treatment: pharmacological treatment, cogni‐
tive therapy, or self–help. Their results indicated that the presence of a personality disorder did
negatively influence the outcome of cognitive therapy and self–help at the 2-year follow-up
test. Using the same sample to measure the effect of time on treatment outcome, Seivewright,
Tyrer, and Johnson [53] found that the presence of a personality disorder was still associated
with a negative prognostic indicator five years after cognitive therapy. Other studies also
found a negative influence of personality disorders on the outcome of CBT [38] or behavioral
treatment [54] for PD. Keijsers, Schaap, and Hoogduin [55] found that higher personality psy‐
chopathology, as measured by the revised version of the personality diagnostic questionnaire
((PDQ-R; [56]) scores, was related to higher levels of agoraphobic avoidance and higher fre‐
quency of panic attacks after behavioral treatment. Yet, the relationship was no longer signifi‐
cant after statistical adjustment for multiple tests [55]. Chambless and colleagues [57]
examined the effects of secondary major depression, dysthymia, GAD, and AVPD on the out‐
come of a behavioral treatment, which mostly consisted of an exposure-based individual treat‐
ment, and a group psychotherapy that focused on interpersonal and intrapsychic problems
that were believed to maintain their PDA. Their results indicated that AVPD predicted less im‐
provement in the frequency of panic attacks at the 6-month follow-up. Finally, the influence of
specific clusters of personality disorders on treatment outcome has been found to vary depend‐
ing on whether personality pathology was assessed dimensionally or categorically. For exam‐
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ple, the presence of a Cluster A diagnosis was the strongest predictor of CBT outcome when
assessed categorically, whereas these Cluster A disorders were not associated with CBT out‐
come when assessed dimensionally [38].
In other studies, comorbid personality disorders have been found to have little or no impact on
the outcome of cognitive and/or behavioral treatment for PD. Dreessen, Arntz, Luttels, and Sal‐
laerts [58] results suggest that PD patients with and without personality disorders profit equal‐
ly from CBT for their PD, although certain personality disorder traits were found to have some
impact on treatment outcome. Indeed, OCPD traits were negatively related to treatment out‐
come, and borderline traits predicted better outcome, but this latter finding was only observed
at the 6-month follow-up test. However, given that personality disorders were lumped togeth‐
er to obtain adequate sample sizes, the influence of individual personality disorders on the out‐
come of CBT for PD was not measured [58]. Black and colleagues [59] studied treatment
response in 66 PD patients who had completed three weeks of treatment with cognitive thera‐
py, pharmacotherapy, or placebo pharmacotherapy. Surprisingly, this study yielded different
conclusions depending on the measurement method used to assess personality functioning.
The presence of a personality disorder assessed by the Structured Interview for DSM-III-R Per‐
sonality disorders (SIDP; Stangl et al., 1987] was not a predictor of treatment outcome at week
four whereas the presence of a personality disorder assessed by a self-report questionnaire was
a negative predictor of outcome in the groups receiving cognitive therapy or placebo [59]. In
their selective review, Dreessen and Arntz [33] also examined the two previous studies, and the
Chambless et al. [57] study. They concluded that personality disorders do not seem to signifi‐
cantly affect the outcome of cognitive and/or behavioral treatment for PD, but when personali‐
ty disorders are examined separately, AVPD appears to be associated with a less favorable
outcome in the long term, although it has no effect on immediate outcome [33]. To our knowl‐
edge, two other studies also concluded that patients with and without personality disorders
seem to profit equally from CBT for their PDA [60, 61]. Hofmann and colleagues [62] found
similar results. Indeed, personality disorder characteristics, as measured by the Wisconsin Per‐
sonality Disorders Inventory (WISPI; [63]) were not found to predict outcome of CBT for PD.
Finally, Kampman, Keijsers, Hoogduin, and Hendriks [64] examined whether Cluster C per‐
sonality disorders predicted treatment response in a sample of 161 PD patients treated with
CBT. Their results indicated that the presence of Cluster C personality disorders did not affect
treatment outcome. These researchers [64] suggested that their results may be explained by the
use of a self-report questionnaire to assess personality (PDQ-R), which is known to have high
sensitivity, and moderate specificity [65].
4.3. Pharmacological treatment
The presence of a comorbid personality disorder has been found to be one of the most ro‐
bust predictors of nonresponse to pharmacological treatment for PD [66]. For example, Mar‐
chesi and colleagues [67], in a study with 71 PD patients, found a negative effect of
borderline personality traits on the outcome of selective serotonin reuptake inhibitor (SSRI)
pharmacological treatment. In their study, Green and Curtis [35] measured the effect of per‐
sonality disorders on the outcome of a pharmacological treatment (participants were treated
with a tricyclic antidepressant or an anxiolytic) among 25 PD patients. There was a signifi‐

cant relationship between the presence of at least one personality disorder and relapse, and
with regard to specific personality disorders, AVPD was associated with an increased likeli‐
hood of relapse. Reich [42] found a negative association between the outcome of pharmaco‐
logical treatment (benzodiazepine molecules) and the presence of borderline, antisocial,
histrionic, and narcissistic personality disorders. However, other studies [62, 68] did not find
an influence of personality disorders on the outcome of pharmacological treatment for PD.
The Tyrer et al. study [52] mentioned previously also found no influence of personality dis‐
orders on the outcome of pharmacological treatment for PD, which is inconsistent with con‐
clusions drawn from Dreessen and Arntz review [33]. This is explained by the fact that the
Tyrer et al. study [52] has not been reviewed by Dreessen and Arntz [33], given that it did
not meet the “best-evidence criteria” needed to be included in the review. Indeed, the au‐
thors only reviewed the studies that met the two criteria that they believed would meet the
best designed studies, which are a prospective design, and the use of a structured, or semi-
structured, interview.
In some studies, treatment consisted of combined CBT and pharmacotherapy. In one study
[69], comorbid personality disorders were associated with a delayed response to pharmaco‐
therapy and behavioral treatment for PD, and the association was stronger for AVPD. In an‐
other study [70], 60 PD patients were treated with SSRIs and CBT, or with CBT only. Results
indicated that treatment for patients without a personality disorder was significantly more
effective with regard to general psychopathology, PD symptoms, and depression. However,
there were no differences between groups on overall symptoms of anxiety, as measured by
Hamilton Anxiety Scale and Beck Anxiety Inventory [70-72].
5. Obsessive-Compulsive Disorder (OCD)
Studies have found prevalence rates of comorbid personality disorders of 49% to 75% in pa‐
tients with OCD, and personality disorders from Cluster C were found to be the most diag‐
nosed [45, 73-77]. As can be expected, many studies have reported OCPD to be the most
diagnosed among clinical samples of OCD patients [26, 73, 75, 78-82], with prevalence rates
of 18% to 55% [75, 78, 80]. However, other studies have found much lower rates of OCPD
among OCD patients (6% for Baer et al. [83]; 4% for Joffee, Swinson, & Regan [84]; 4% for
Steketee [77]).
OCD patients with comorbid personality disorders do not seem to have more severe OCD
symptoms compared to those without personality disorders [76, 77, 80]. Cavedini and col‐
leagues [78] found no differences in the severity of OCD symptoms at baseline between
OCD patients with and without OCPD. However, studies indicate more depressive and anx‐
ious symptoms, and more impairment in functioning before treatment in OCD patients with
comorbid Axis II diagnosis [76, 81]. Bejerot and colleagues [73] found similar results. In their
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study, higher scores on all anxiety scales, and more functional impairment were reported for
OCD individuals with comorbid personality disorders. In the Fricke et al. [80] study, the
presence of a personality disorder was associated with more depressive symptoms and
higher levels of functional impairment. In addition, the presence of an OCPD [18, 85] or an
AVPD was found to predict new onsets of OCD, and the presence of a BPD diagnosis at
baseline was associated with an increased likelihood of relapsing in OCD, when no treat‐
ment was considered [18].

treatment for OCD
Baer and Jenike [86] reviewed the presence of comorbid personality disorders in OCD pa‐
tients and their influence on treatment outcome. They concluded that schizotypal personali‐
ty disorder was the only one that predicted poorer outcome of treatment (behavioral or
pharmacological) for OCD. Although this Axis II disorder is not particularly common
among patients with OCD [26], schizotypal personality disorder and traits have been repeat‐
edly related to poor response to behavioral treatment for OCD [87, 88]. Moritz and collea‐
gues [89] suggest that it may be the positive schizotypal symptoms (e.g. unusual perceptual
experiences, paranoid ideation, sensory irritation, magical beliefs) that predict poor treat‐
ment outcome. Impairment of learning [88] and difficulties to comply with treatment [90]
have also been suggested to explain nonresponse to OCD treatment among individuals with
a schizotypal personality disorder. Moreover, OCD patients with a schizotypal personality
disorder may respond better to low-dose atypical neuroleptics and specialized CBT for
schizotypal symptoms [89]. Other personality disorders have been associated with a less fa‐
vorable outcome of CBT among OCD patients. In one study [91], OCD patients with any
Cluster A or Cluster B personality disorder showed a poorer response to behavioral treat‐
ment or CBT at 12-month follow-up, compared with patients without these diagnoses.
Some studies have found no effect of personality disorders on the outcome of CBT for OCD.
Dreessen and colleagues [79] studied 43 OCD patients who completed a behavioral or cogni‐
tive treatment, or a CBT. The presence of one or more personality disorders had no impact
on the outcome of treatment. Indeed, patients with personality disorders did not differ in
their improvement from patients without a personality disorder, and they dit not differ on
their end-state functioning. Moreover, those who abandoned treatment did not differ from
completers with regard to personality disorder characteristics. In another study [80], influ‐
ence of personality disorders on the outcome of CBT has been compared for 24 OCD pa‐
tients with comorbid personality disorders, and 31 without a personality disorder. Results
indicated that both groups benefited equally from treatment, and were able to maintain
their improvement at follow-up. Steketee [77] also found no association between personality
disorders and the outcome of a behavioral treatment for OCD. However, the author suggest‐
ed that an unsufficient statistical power might have explained that no differences in out‐
come were found between patients with and without a personality disorder [77].
Surprisingly, a positive impact of personality disorder traits on treatment outcome was
found: patients with dependent or avoidant personality traits had improved significantly
more on target symptoms at posttest. Yet, the improvement was not maintained during the
follow-up period. No explanation was proposed for this unusual finding, and it should be
carefully interpreted given the small sample size in this study (n=26).
The presence of a comorbid schizotypal personality disorder has also been associated with
poorer outcome of pharmacological treatment [87, 90, 92], and of combined behavioral and
pharmacological treatment [88] for OCD. In one study [93], the presence of schizotypal per‐
sonality disorder, AVPD, or BPD, and the presence of any Cluster A diagnosis were associ‐
ated with poorer outcome of a tricyclic antidepressant treatment (TCA) for OCD. Cavedini
and colleagues [78] found a negative influence of OCPD on the outcome of a pharmacologi‐
cal treatment. Thus, poorer response to TCA or SSRI treatment was reported in OCD pa‐
tients with OCPD than those without the comorbid Axis II diagnosis. However, one study
[94] found no effect of personality disorders on the outcome of an SSRI medication for OCD.
An association with outcome was only found for AVPD, which was associated with greater
improvement on OCD symptoms.
6. Generalized Anxiety Disorder (GAD)
Studies have reported prevalence rates of personality disorders of 35% to 50% among pa‐
tients with GAD [13, 95-98]. Compared with PD patients, GAD patients have been found to
be more likely to have at least one personality disorder [13]. Similar to personality disorders,
GAD seems to be more trait-like than state-like, since its symptoms are fairly continuous
and lasting in time [13]. Thus, it has been suggested that personality disorders may be a
more important factor in the development of GAD than they are for other anxiety disorders
[13, 99]. Although GAD does not seem to have a strong association with a particular type of
personality disorder [100], Dyck and colleagues [13] found AVPD to be the most prevalent
(22%) in their sample of 122 GAD patients. Some correlations have also been found with ob‐
sessive-compulsive traits [101], OCPD [102], and dependent personality disorder [96].
6.1. Initial symtomatology and course of illness
There is an association between low social functioning and the presence of personality disor‐
ders among GAD population, although the relation seems to be specific to certain areas of
functioning [103]. Indeed, results indicated no significant association between the presence
of a personality disorder and functioning with mates, siblings, or functioning as a student.
In addition, personality disorders were found to influence the naturalistic course of GAD.
For instance, Ansell and colleagues [18] found that GAD patients with OCPD or BPD at
baseline were more likely to have a GAD relapse, and those with OCPD were also more like‐
ly to have a new episode onset of GAD, compared with patients without these personality
disorders. Also, schizotypal personality disorder was found to be the strongest predictor of
chronicity, which was measured by the proportion of weeks spent in episode of GAD [18].
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In another study [95], the presence of AVPD or dependent personality disorder explained
the lower probability of remission from GAD.

treatment for GAD
Very few studies have examined the effect of personality disorders on the outcome of CBT
for GAD. The lack of treatment studies with GAD patients may be partly explained by the
fact that this anxiety disorder was not officially recognized as a primary diagnostic category
until the appearance of the DSM-III-R [104]. However, Sanderson, Beck, and McGinn [97]
examined the effect of personality disorders on the immediate outcome of a cognitive thera‐
py for 22 patients with GAD. Although there were no significant differences in improve‐
ment and end-state functioning in patients with and without personality disorders, patients
with a comorbid personality disorder were more likely to drop out of treatment [97]. In ad‐
dition, the Tyrer et al. study [52] mentioned previously found a negative influence of per‐
sonality disorders on the outcome of CBT for GAD.
To our knowledge, very few controlled prospective studies have examined the link between
the presence of a personality disorder and the outcome of pharmacological treatment for
GAD. Although they did find an influence of personality disorders on the outcome of CBT,
Tyrer and colleagues [52] found no effect of personality disorders on the outcome of phar‐
macotherapy for GAD. One retrospective study [102] examined the effect of personality dis‐
orders on the outcome of a benzodiazepine drug treatment for GAD. The results indicated
that chronic GAD patients were more likely to have Cluster B or C disorders than were re‐
mitted GAD patients. However, it is impossible to assume that outcome is due to the origi‐
nal drug treatment because participants had not been assessed immediately after treatment.
In fact, participants were only interviewed 16 months after treatment, and during the fol‐
low-up period, they have had different types of treatment, pharmacological or psychologi‐
cal. Also, personality disorders were not assessed before treatment [102]. Thus, based on
these results only, it cannot be concluded that personality disorders have a negative effect
on the outcome of pharmacological treatment for GAD.
7. Social phobia
The rate of personality disorder diagnoses has been reported to be generally higher among
social phobic patients than among patients with other Axis I conditions [13, 15]. Among
anxiety disorder patients, some studies have also found the highest rates of personality dis‐
orders to be among patients with social phobia [16, 98]. The prevalence of personality disor‐
ders among social phobic patients ranges from 24% to 56% [105-107]. A strong association
has been found between social phobia and AVPD [107-110]. Indeed, Dyck and colleagues
[13] results indicated that individuals with social phobia were more than two times more
likely to have an AVPD, compared with patients with PD or GAD. Overall, studies have re‐
ported 36% to 89% of comorbidity between AVPD and the generalized subtype of social
phobia [13, 111-114]. In fact, questions have been raised about the validity of the existing cat‐
egorical distinction between these two disorders [15, 23, 105]. Indeed, DSM-IV-TR criterion
A for social phobia (“a marked and persistent fear of one or more social or performance sit‐
uations in which the person is exposed to unfamiliar people or to possible scrutiny by oth‐
ers; the individual fears that he or she will act in a way (or show anxiety symptoms) that
will be humiliating or embarrassing”) overlaps with criterion four of AVPD (“the individual
is preoccupied with being criticized or rejected in social situations”). In addition, DSM-IV-
TR criterion D for social phobia (“the feared social or performance situations are avoided or
else are endured with intense anxiety or distress”) overlaps with criteria one (“avoids occu‐
pational activities that involve significant interpersonal contact, because of fears of criticism,
disapproval, or rejection”) and seven (“is unusually reluctant to take personal risks or to en‐
gage in any new activities because they may prove embarrassing”) for AVPD. Furthermore,
given that studies have found few cases of AVPD without generalized social phobia [115,
116], it has been suggested that AVPD could represent a subtype of more severe social pho‐
bia [15, 39]. In a review of literature on this subject, Widiger [116] concluded that there is no
evidence indicating a clear demarcation between the two disorders, and that they appear to
be a single disorder. Moreover, a recent twin study [117] found a common genetic vulnera‐
bility to women with AVPD and women with social phobia, which gives support to the hy‐
pothesis of a shared etiology. Even though the literature has focused on the association of
social phobia with AVPD, other personality disorders have been found to be prevalent
among social phobics. In their review, Johnson and Lydiard [15] reported OCPD and de‐
pendent personality disorder to be the second most prevalent among social phobics. Thus,
social phobia seems to be particularly associated with Cluster C personality disorders.
In most studies, social phobic patients with comorbid personality disorders are reported to be
more severely impaired before treatment. Mersch and colleagues [106] showed that social pho‐
bic patients with a comorbid personality disorder presented a more severe symptom pattern at
baseline, with more irrational and negative thinking patterns, compared to those without a
personality disorder. Moreover, two studies found more depressive symptoms for social pho‐
bic patients with personality disorders compared to those without an Axis II diagnosis [15,
107]. Herbert and colleagues [112] compared patients with generalized social phobia with and
without AVPD, and found that patients with AVPD had more comorbid pathology, impair‐
ment in functioning, and reported higher levels of severity on all measures, including fear of
negative evaluation, social avoidance and distress, depression and general psychopathology.
Other studies have reported social phobic patients with a comorbid AVPD to have a more se‐
vere baseline symptomatology compared to those without an AVPD [111, 113]. In addition, the
presence of a personality disorder, and more specifically an AVPD, has been associated with a
decreased likelihood of remission from social phobia, when no treatment is considered [18, 95].
Patients with this comorbidity are also more likely to have a new episode onset of social pho‐
bia, in comparison to social phobics without an AVPD [18]. A comorbid AVPD was also found
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to be the strongest predictor of chronicity of social phobia [18]. Finally, the presence of a schizo‐
typal personality disorder has been associated with an increased likelihood of social phobia re‐
lapse [18]. Given that it may be difficult to distinguish between long-standing social fears and
Cluster A personality disorder symptoms, the latter finding could be explained by an errone‐
ous assessment [115]. Thus, the social isolation would not be the result of a social anxiety, but
rather a consequence of the paranoid thinking that generally characterizes an individual with a
schizotypal personality disorder.

treatment for social phobia
Outcome studies have shown that there is no effect of personality disorders on the outcome
of cognitive and/or behavioral treatment for social anxiety. For instance, a study [106] exam‐
ining the outcome of two forms of treatment for social phobia, an exposure-based treatment
or CBT, showed that patients with a comorbid personality disorder have been found to im‐
prove as much as those without a personality disorder. Another study [110] also indicated
no differences on the outcome of a behavioral therapy with regard to the presence or ab‐
sence of a comorbid personality disorder. Indeed, results indicated that patients with and
without personality disorders improved at the same rate on social phobic avoidance, cogni‐
tions, and target situations that needed to be changed.
Because of its strong association with social phobia, many studies examined the specific effect
of AVPD on the outcome of treatment. Feske and colleagues [111] examined its effect on the
outcome of an exposure-based therapy for 48 patients with social phobia. Those with an
AVPD improved less with regard to trait anxiety and self-esteem at posttest, but no differen‐
ces in improvement rates were found with regard to depression, social adjustment and social
phobic complaints. Although patients with an AVPD continued to have more severe sympto‐
matology than those without AVPD at posttest and 3-month follow-up, both groups im‐
proved at the same rate during the follow-up period. However, the authors mentioned that
interpretation of the follow-up data is difficult because of the additional uncontrolled treat‐
ments received during this period [111]. Other studies also reported no effect of AVPD on the
outcome of cognitive and/or behavioral treatment for social phobia [110, 113, 118, 119]. Thus,
evidence suggests no influence of AVPD on the outcome of CBT for social phobia.
To our knowledge, only one study [120] found a negative impact of personality disorders on
the outcome of a cognitive and behavioral group treatment for social phobic patients. After
treatment, patients without a personality disorder had improved significantly more on all
outcome measures, except for the State-Trait Anxiety Inventory (STAI) and on the rating of
avoidance of worst fear, for which there were no significant differences [120]. However,
these results should be carefully interpreted, given that the effect sizes are very small for all
of these outcome measures.

Very few studies have examined the impact of Axis II diagnosis on the outcome of phar‐
macological treatment for social phobia. To our knowledge, one study [121] has found a
negative influence of personality disorders on the outcome of a pharmacological treat‐

ment for social phobia. In this study [121], long-term treatment with moclobemide (mono‐
amine oxidase inhibitor; MAOI) was investigated among 101 social phobic patients.
Treatment consisted of four years of moclobemide, with a drug-free period of at least one
month, after the first two years. Dependent personality disorder and AVPD were diag‐
nosed in 16% and 72% of patients, respectively. Results indicated that Axis II diagnosis
predicted non-response to moclobemide.
8. Posttraumatic Stress Disorder (PTSD)
High rates of personality disorders have been found among individuals with PTSD
[122-124]. Studies have reported comorbid Axis II diagnosis in 39% to 45% of PTSD patients
[125, 126]. A strong association has been found between PTSD and BPD [127, 128]. For ex‐
ample, Zanarini and colleagues [129] results indicated that PTSD was significantly more di‐
agnosed among BPD patients than among patients with other personality disorders. Also, in
a sample of 34 male combat veterans with PTSD, BPD was the most common Axis II diagno‐
sis, with a prevalence rate of 76% [123]. Shea and colleagues [124] also reported high rates of
BPD [68%) among PTSD patients.
Given that past events of traumatic exposure are commonly reported by individuals with
BPD [130], a history of trauma has been proposed to have a formative role in the develop‐
ment of BPD [131-133]. However, a strong association between the two disorders has not
been found consistently across studies. In two other studies [126, 134], only 10% of PTSD pa‐
tients had a comorbid BPD. Hembree and colleagues [126] suggested that these low rates
might be explained by the exclusion of patients with current suicidal plans or intentions,
and those with self-injurious behaviors from both studies. Since these characteristics are
commonly present among individuals with BPD, this could have possibly led to the exclu‐
sion of a significant amount of BPD patients in those studies.
PTSD patients with comorbid personality disorders may experience a more severe course of
illness than PTSD patients without personality disorders [135]. More specifically, Ansell and
colleagues [18] found that PTSD patients with a schizotypal personality disorder at baseline
were less likely to remit from PTSD than patients without a schizotypal diagnosis [18]. Sur‐
prisingly, their results also suggest that the presence of an OCPD is associated with a posi‐
tive course of illness for PTSD. Indeed, patients with an OCPD at intake were less likely to
have a PTSD relapse [18]. This could be explained by the fact that OCPD is characterized by
perfectionism, meticulosity, rigidity, and extreme devotion to work and efficiency (DSM-IV-
TR), which may lead to a good compliance with treatment. As mentioned previously, al‐
though Ansell and colleagues [18] investigated the naturalistic course of anxiety disorders,
they recruited their sample among a treatment-seeking population. Even though no treat‐
ment was controlled in this study, the patients still received some form of treatment during
http://dx.doi.org/10.5772/53554
the 7-year period of the study. Thus, OCPD patients, because of their possibly good compli‐
ance with treatment, might have respond better to treatment for their PTSD, which might
have led to a decreased likelihood of relapse.
However, most studies have specifically measured the impact of BPD on pretreatment
symptomatology of PTSD patients. For instance, Axis I diagnoses were found to be more
prevalent among individuals with coexisting PTSD and BPD, in comparison to individuals
with PTSD alone [128]. A comorbid BPD diagnosis has also been associated with greater
psychosocial impairment [128], and higher general distress [127, 136]. Moreover, studies
have reported greater suicide proneness [128] among PTSD individuals with comorbid BPD,
compared with PTSD individuals without BPD. Also, PTSD patients with comorbid BPD
were reported to be more severely disturbed with regard to PTSD symptoms [127], although
other studies did not find such differences between PTSD patients with and without comor‐
bid BPD [136, 137]. Feeny and colleagues [134] also found no group differences on measures
of anxiety, depression, and social functioning with regard to the presence or absence of par‐
tial, or complete BPD diagnosis.

treatment for posttraumatic stress disorder
As for other anxiety disorders, studies have yielded conflicting findings with regard to the
effect of Axis II diagnosis on the outcome of CBT for PTSD. In the Hembree et al. [126]
study, there were no significant differences between women with and without personality
disorders on the prevalence of PTSD at the end of CBT or prolonged exposure. However,
significantly more participants without a personality disorder (76%) achieved good end-
state functioning status than participants with a personality disorder (41%). However, the
group with personality disorders had higher scores on measures of PTSD symptoms, anxi‐
ety, and depression at pretreatment compared to the group without personality disorders,
which could explain that this group was less likely to achieve a good end-state functioning
[126]. In their retrospective study, Feeny and colleagues [134] examined the effect of border‐
line personality characteristics on the outcome of cognitive and/or behavioral therapy
among 72 women with PTSD. Their results indicated that the group without borderline per‐
sonality characteristics (described as having no significant BPD symptoms) had achieved a
better end-state functioning at posttest, although this result was not obtained at the 3-month
follow-up. However, there were no differences between groups on PTSD status, and out‐
come measures at posttest and follow-up [134].
In one study [138] examining predictors of outcome for PTSD patients treated with an expo‐
sure-based treatment, personality disorders were not found to predict treatment outcome, or
premature dropout. In their retrospective study, Clarke and colleagues [127] found similar
results with regard to borderline personality characteristics. Their results indicated that
PTSD women with higher rates of borderline personality characteristics benefited as much
from CBT, and that they were not more likely to drop out of treatment. To our knowledge,
no study has examined the influence of personality disorders on the outcome of pharmaco‐
logical treatment for PTSD.
Authors Year Participants Treatment Influence of Other results

personality disorders
on outcome
Tyrer, Seivewright, 1993 181 patients with Pharmacotherapy, cognitive The presence of a
Ferguson, Murphy, GAD, PD, or therapy, or self-help. personality disorder was
and Johnson dysthymia associated with a poorer
outcome of CBT and self–
help at 2-year follow-up.
Seivewright, Tyrer, 1998 181 patients with Pharmacotherapy, cognitive The presence of a
and Johnson GAD, PD, or therapy, or self-help. personality disorder
dysthymia predicted poorer outcome
of CBT and self-help at 5-
year follow-up.
Panic disorder with and/or without agoraphobia
Green and Curtis 1988 25 patients with Pharmacological treatment The presence of one or
PD/A (13 had at (alprazolam, imipramine, or more personality disorder,
least one placebo) and the presence of AVPD
personality were associated wih
disorder) relapse.
Reich 1988 52 patients with Pharmacological treatment The presence of antisocial,
PD/A (19 had at (alprazolam or diazepam) borderline, narcissistic,
least one and histrionic personality
personality disorders was associated
disorder) with poorer outcomes on
all measures, except for
spontaneous panic
attacks.
Marchand and 1993 41 patients with CBT No differences were found
Wapler PDA on outcome with regard
to the presence or
absence of a personality
disorder.
Keijsers, Schaap, and 1994 60 patients with Behavioral treatment As measured by PDQ-R The relationship was
Hoogduin PD/A scores, higher personality no longer significant
psychopathology was after adjusting for
associated with higher multiple tests.
levels of agoraphobic
avoidance and higher
frequency of panic attacks
at posttest.
Dreessen, Arntz, 1994 (1st 31 patients with CBT No influence on outcome OCPD traits predicted
Luttels, and Sallaerts study) PD/A (14 had at was found with regard to worse outcome at
least one the presence of a posttest, 1-month, and
personality personality disorder. 6-month follow-up.
disorder) Borderline personality
traits predicted better
outcome at 6-month
follow-up.
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on outcome
Black et al. 1994 66 patients with Cognitive therapy, The presence of a The presence of a
PD/A (23 had at pharmacotherapy, or personality disorder was personality disorder
least one placebo. not a predictor of was a negative
personality treatment outcome at predictor of outcome
disorder when week 4, when personality at week 4 in groups
measured by SIDP- was assessed by the SIDP- receiving cognitive
R, and 22 had at R. therapy or placebo,
least one when personality was
personality assessed by a self-
disorder when report questionnaire
measured by PDQ) (PDQ).
Fava et al. 1995 110 patients with Behavioral treatment The presence of a
PDA personality disorder was
associated with a
decreased likelihood of
remission for 7 years after
treatment.
Rathus, Sanderson, 1995 18 patients with CBT No differences were found
Miller, and Wetzler PDA (10 had at on outcome measures
least one with regard to the
personality presence or absence of a
disorder) personality disorder.
Hofmann et al. 1998 93 patients with CBT or pharmacotherapy Personality disorder traits
PD/A did not predict outcome
of treatments.
Chambless et al. 2000 49 patients with Behavioral treatment AVPD predicted less
PDA (27% had improvement in the
AVPD) frequency of panic attacks
at the 6-month follow-up.
Toni et al. 2000 326 patients with Pharmacological treatment Personality disorders were
PD/A (antidepressants, mainly not associated with
imipramine, clomipramine, outcome of treatment.
and paroxetine)
Berger et al. 2004 73 patients with Pharmacological treatment The presence of a
PD/A (23 had at (paroxetine) or personality disorder,
least one pharmacological treatment particularly AVPD, was
personality + cognitive therapy associated with poorer
disorder) response to treatment.
Prasko et al. 2005 60 patients with Pharmacological treatment The presence of a There were no
PD/A (29 had at (SSRI) + CBT (15 patients personality disorder was differences on overall
least one received CBT only) associated with poorer symptoms of anxiety,
personality outcomes on most with regard to the
disorder) measures. presence or absence of
a personality disorder.

on outcome
Marchesi et al. 2006 71 patients with Pharmacological treatment BPD traits were negatively
PD/A (38 had at (paroxetine or citalopram) associated with remission
least one of panic attacks
personality
disorder)
Kampman, Keijsers, 2008 161 patients with CBT The presence of Cluster C
Hoogduin, and PD/A (of the 129 personality disorders was
Hendriks completers, 60 had not associated with
at least one Cluster outcome of treatment.
C personality
disorder, and 47
had AVPD)
Telch, Kamphuis, and 2011 173 patients with CBT The presence of one or When baseline severity
Schmidt PD/A (54 had at more personality disorders was controlled, Cluster
least one was associated with a A and C personality
personality poorer outcome of CBT at disorders were
disorder) posttest, when baseline associated with poorer
severity of panic disorder outcome. When
was not controlled. assessed
dimensionally, only
Cluster C traits were
associated with poorer
outcome.
Obsessive-compulsive disorder
Jenike, Baer, 1986 43 patients with Pharmacotherapy, Behavior The presence of a
Minichiello, OCD (14 with a therapy, or a combination schizotypal personality
Schwartz, and Carey schizotypal of both disorder predicted poorer
personality response to both types of
disorder and 29 treatment.
without a
schizotypal
personality
disorder)
Minichiello, Baer, 1987 29 patients with Behavioral treatment or The presence of a The number of
and Jenike OCD (10 with a Behavioral treatment + schizotypal personality schizotypal traits was
schizotypal Pharmacological treatment disorder was negatively also negatively
personality associated with outcome. associated with
disorder and 19 outcome.
without a
schizotypal
personality
disorder)
Steketee 1990 26 patients with Behavioral treatment Personality disorders were Dependent and
OCD (13 had at not associated with avoidant traits were
least one treatment outcome.
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on outcome
personality associated with better
disorder) outcomes.
Baer and Jenike 1990 67 patients with Pharmacological treatment The presence of an AVPD
OCD (fluoxetine) was associated with more
improvement on OCD
symptoms.
Baer et al. 1992 55 patients with Pharmacological treatment The presence of The presence of any
OCD (33 had at (clomipramine) schizotypal personality Cluster A diagnosis,
least one disorder, AVPD, and BPD and the number of
personality was associated with personality disorders
disorder) poorer outcomes. diagnosed were
associated with poorer
outcomes.
Maina, Bellino, and 1993 48 patients with Pharmacological treatment Number of personality
Bogetto OCD (44 had at disorders diagnosed, and
least one the presence of a
personality schizotypal personality
disorder) disorder were associated
with chronicity of OCD
Ravizza, Barzega, 1995 53 patients with Pharmacological treatment The presence of a
Bellino, Bogetto, and OCD (28% (n=15) (clomipramine or schizotypal personality
Maina had a schizotypal fluoxetine) disorder was associated
personality with nonresponse to
disorder) treatment.
Cavedini, Erzegovesi, 1997 30 patients with Pharmacological treatment The presence of an OCPD
Ronchi, and Bellodi OCD (9 with an (clomipramine or predicted poorer
OCPD and 21 fluvoxamine) treatment outcome.
without an OCPD)
Dreessen, Hoekstra, 1997 52 patients with Behavior therapy, Cognitive Personality disorders were
and Arntz OCD (of the 43 therapy, or CBT not associated with
completers, 22 had outcome of treatment.
at least one
personality
disorder)
Fricke et al. 2005 55 patients with CBT The presence of a
OCD (24 had at personality disorder was
least one not associated with
personality treatment outcome.
disorder)
Hansen, Vogel, Stiles, 2007 35 patients with CBT or Behavior therapy + The presence of Cluster A
and Götestam OCD (24 had at relaxation training or B personality disorders
least one was associated with
personality poorer outcomes at 12-
disorder) month follow-up, in both
treatment conditions.

on outcome
Generalized anxiety disorder
Mancuso, Townsend, 1993 44 patients with Pharmacological treatment The presence of a
and Mercante GAD (adinazolam or placebo) personality disorder,
particularly in Cluster B or
C, was negatively
associated with remission
16 months after
treatment.
Sanderson, Beck, and 1994 22 patients with Cognitive therapy Personality disorders were Patients with
McGinn GAD (9 had at least not associated with personality disorders
one personality treatment outcome. were more likely to
disorder) drop out of treatment.
Social phobia
Turner 1987 13 patients with CBT Patients with personality
social phobia (7 disorders improved less on
had at least one most outcome measures
personality during treatment.
disorder)
Mersch, Jansen, and 1995 34 patients with Behavioral treatment or CBT Personality disorders did
Arntz social phobia (8 not influence the outcome
had at least one of treatment.
personality
disorder)
Hofmann, Newman, 1995 16 patients with Behavioral treatment Patients with and without
Becker, Taylor, and social phobia (8 an AVPD improved as
Roth with an AVPD and much with treatment.
8 without an
AVPD)
Brown, Heimberg, 1995 102 patients with CBT The presence of an AVPD
and Juster social phobia (28 did not predict treatment
with an AVPD and outcome.
74 without an
AVPD)
Hope, Herbert, and 1995 23 patients with CBT The presence of an AVPD
White social phobia (14 did not predict treatment
with an AVPD and outcome.
9 without an
AVPD)
Feske, Perry, 1996 48 patients with Behavioral treatment The presence of an AVPD However, patients with
Chambless, generalized social was associated with less an AVPD continued to
Renneberg, and phobia (35 with an improvement on trait be more severely
Goldstein AVPD and 13 anxiety and self-esteem impaired at posttest
without an AVPD) during treatment, but no and follow-up.
differences were found When baseline
with regard to depression, depression was
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on outcome
social adjustment and controlled, AVPD no
social phobic complaints. longer predicted
Patients with and without improvement during
an AVPD improved at the treatment.
same rate during the
follow-up period.
Versiani et al. 1996 101 patients with Pharmacological treatment Personality disorders
social phobia (moclobemide) predicted nonresponse to
treatment.
Van Velzen, 1997 61 patients with Behavioral treatment Personality disorders did
Emmelkamp, and social phobia (30 not influence the outcome
Scholing without any of treatment.
personality
disorder, 18 with
an AVPD, and 13
with multiple
personality
disorders)
Posttraumatic stress disorder
Feeny, Zoellner, and 2002 72 women with Cognitive therapy, behavior There were no differences The presence of BPD
Foa PTSD (7 with therapy, or CBT between patients with characteristics was
complete BPD and without BPD associated with a
diagnosis, 5 with characteristics with regard decreased likelihood of
partial BPD to PTSD status, and achieving good end-
diagnosis, and 60 measures of PTSD state functioning at
without a BPD) symptoms, anxiety and posttest.
depression after
treatment.
van Minnen, Arntz, 2002 122 patients with Behavioral treatment Personality disorder traits
and Keijsers PTSD were not associated with
treatment outcome, or
premature termination of
treatment.
Hembree, Cahill, and 2004 75 women with Behavioral treatment or CBT Personality disorders did Patients with a
Foa PTSD (29 had at not influence the personality disorder
least one prevalence of PTSD were less likely to
personality diagnosis at posttest. achieve a good end-
disorder) sate functioning after
treatment.
Clarke, Rizvi, and 2008 131 women with Cognitive therapy or Patients with higher BPD
Resick PTSD behavior therapy characteristics benefited
as much from treatment.
Table 1. Studies examining the influence of personality disorders on the outcome of CBT and/or pharmacological
treatment for anxiety disorders
9. Mechanisms underlying the influence of personality disorders on

treatment for anxiety disorders
Many arguments have been reported to explain the negative impact of personality disorders
on the outcome of treatment for anxiety disorders. For instance, adverse life events have
been found to be related to symptoms of anxiety and depression, and in many of those
events, the individual is actively involved in both the onset and termination of the event
[139]. Thus, personality disordered patients may create more negative life events for them‐
selves, which contribute to chronic psychosocial dysfunction and increased stress [139],
which in turn can negatively affect treatment outcome [32]. In addition, it has been argued
that part of the differences in outcome between patients with and without personality disor‐
ders may be explained by higher drop-out rates among patients with comorbid personality
disorders [32, 140]. Indeed, patients with personality disorders may experience less emo‐
tional improvement during cognitive therapy than patients without personality disorders
[141]. Thus, these patients may drop out of treatment because they perceive therapy sessions
as being less effective [142]. Given that compliance with treatment regimens as rated by the
therapist has been associated with positive outcome of CBT for anxiety disorders [143], anxi‐
ety patients with personality pathology might comply less with treatment, which would
negatively affect the outcome of intervention or lead to premature drop-out. Finally, as men‐
tioned previously, patients with coexisting anxiety and personality disorders have been re‐
ported to have higher initial levels of symptomatology compared with anxiety patients
without a personality disorder, which could account for the difference in results when base‐
line severity is not controlled in the analysis. When a person reports more severe symptoms
at baseline, we could expect that this person would still remain more symptomatic after
treatment, even though she might have improved at the same rate. In fact, the severity of
symptoms before treatment has been found to predict the outcome of treatment for anxiety
disorders. In one study, this baseline symptomatology has been found to be a strong predic‐
tor of end-state functioning at the 3-year follow-up test [46]. In the Telch et al. [38] study,
initial levels of PD severity accounted for 27% of the explained variance in clinically signifi‐
cant change at posttreatment. Yet, after controlling for baseline severity of PD, results indi‐
cated that the presence of a Cluster A personality disorder still had a significant negative
effect on treatment outcome, although the relationship was very modest [38].
10. Effect of treatment for anxiety disorders on personality functioning
There is evidence suggesting that treatment for Axis I disorders reduces Axis II disorders and
traits. For example, Ricciardi and colleagues [144] reported that 90% of responders to OCD phar‐
macological and/or behavioral treatment no longer met criteria for a personality disorder, most‐
ly avoidant, dependent, or obsessive-compulsive personality disorder. Some authors have
argued that improvement of personality functioning with treatment for anxiety disorders is ex‐
plained by the instruments used to assess personality, which may confound Axis I and Axis II
disorders [145] or be unable to distinguish between abnormal personality traits and personality
http://dx.doi.org/10.5772/53554
disorder symptoms [146]. Also, as mentioned previously, assessment of personality may be af‐
fected by the presence of Axis I disorders, which would explain improvement in personality
functioning with improvement of OCD symptoms [144]. In addition, three studies [147-149]
have found a reduction of avoidant personality traits after pharmacological treatment for social
phobia. However, most of the studies that examined changes in personality functioning with
anxiety disorder treatment were conducted among patients with PD. Thus, improvement in
personality functioning with cognitive and/or behavioral treatment for PD has been demon‐
strated more than once [61, 62, 146, 150, 151]. For instance, PD patients treated with CBT have
been reported to show significant decline in all personality disorder subscales, with the excep‐
tion of schizoide personality traits, from pretreatment to the second assessment (after the 11th
session; [62]). However, the decline from the second to the third assessment (six months after the
second assessment) was not significant for any of the subscales, except for the Schizoid Personal‐
ity Disorder Scale, even though patients had received six additional monthly maintenance ses‐
sions during this period. Although these results were obtained when responders and
nonresponders were combined, responders to CBT were found to have greater improvement in
personality disorder characteristics than nonresponders to CBT [62]. In another study [150], an
82% decrease of personality disorder traits has been found among PD patients treated with cog‐
nitive therapy. Pharmacological treatment for PD has also been demonstrated to improve per‐
sonality disorder characteristics [36, 62]. For example, in Marchesi et al. study [36], the rate of
personality disorders has been found to decrease from 60% before treatment to 43% after treat‐
ment, and these results were mainly due to the reduction in the rate of paranoid, avoidant and
dependent traits. The results obtained in these studies do not necessarily indicate that personali‐
ty changes that occur after successful treatment for anxiety disorders result in a return to pre‐
morbid function [23]. Indeed, there is some evidence suggesting that these patients’
personalities still remain differentiable from normal controls [152]. Many suggestions have
been made to explain the possible influence of anxiety disorder treatment on personality pathol‐
ogy. First, abnormal personality traits may be a consequence of living with an anxiety disorder
[36, 61]. Thus, the personality dysfunction may decrease with the improvement of anxiety disor‐
der symptoms. Second, an interaction or overlap of Axis I and Axis II symptoms may explain the
improvement of personality dysfunction with successive treatment for Axis I disorders [20].
Third, CBT for anxiety disorders could provide general problem-solving skills to the patients,
which could decrease pathological personality dysfunction [62]. In addition to the confounding
assessment of personality in the presence of Axis I disorders that was reported earlier, methodo‐
logical limitations may have led to these results. For example, in the Ricciardi et al. study [144],
the very small sample size (n=10) may have increased the risk of type I error. Thus, we cannot ex‐
clude the possibility that their findings are only due to chance fluctuations.
11. Issues to consider in therapy
Studies have yielded conflicting conclusions regarding the influence of Axis II diagnosis on
the outcome of treatment for anxiety disorders. However, anxiety patients with comorbid
personality disorders were consistently reported to improve on their anxiety disorder symp‐
toms with treatment for their anxiety disorder, even though they did not always improve as
much as patients without Axis II comorbidity. Therefore, these patients should not be ex‐
cluded from treatment for their anxiety disorder, because of their comorbid diagnosis [33].
Also, clinicians should be aware of their own attitude towards patients with personality dis‐
orders, given that the therapist's belief that patients with a comorbid personality disorder
will not benefit from any therapy, might initiate a self fulfilling prophecy [33]. In addition,
to reduce the probability of early termination of treatment among patients with comorbid
personality disorders, clinicians should identify these patients early in therapy, and fre‐
quently give feedback about the therapeutic process [142]. Since most individuals with per‐
sonality disorders have major issues in their interpersonal relationships, it may be difficult
to establish a solid therapeutic alliance. Thus, when working with patients with dysfunc‐
tional personality, it is often necessary to monitor patients’ expectation with regard to the
therapeutic relationship, to be flexible in using various relationship-building techniques, to
identify the inevitable ″ruptures″ that occur in any therapeutic context, and to work to re‐
pair such ruptures when they occur [153]. Also, the dysfunctional attitudes1 that are central
to specific personality disorders should be discussed as a first step in therapy, given that
they have a functional relation to anxiety, and that the development of some ego-dystony
concerning attitudes is necessary for a specific anxiety treatment to be useful [155]. Finally,
when working with patients with severe personality disorders, it is recommended to use a
team-based treatment approach, since it may become emotionally too difficult for an indi‐
vidual therapist alone to treat patients with socially disruptive behaviors, such as parasui‐
cide, and verbal and physical aggressions [153]. Moreover, patients’ interactions with
several professionals could enhance the acquisition of the adaptative skills taught in thera‐
py. Special considerations in therapy should extend to individuals who consult for their per‐
sonality disorder. Indeed, when patients present a history of anxiety disorders, treatment for
personality disorders should be adapted to prevent the recurrence of anxiety disorder symp‐
toms [18].
12. Plausible explanations for conflicting results
Some of the conflicting results that were presented in this chapter may be explained by
methodological flaws in the existing studies, such as low statistical power (given the small
sample sizes in many studies), failure to control for baseline severity of Axis I pathology,
and the use of questionnaires to assess personality dysfunction [33]. Indeed, the use of a self-
report questionnaire to assess personality pathology has been criticized. Compared to inter‐
views, self-report questionnaires would be more sensitive to state factors, such as anxiety
and depression, which would lead to a higher number of personality disorder diagnosis,
particularly among individuals with Axis I disorders [33]. However, results from Black and
colleagues [59] are not consistent with this, given that one more patient (23 vs 22) was diag‐
1 Negatively biased assumptions and beliefs regarding oneself, the world, and the future. [154]
http://dx.doi.org/10.5772/53554
nosed with at least one personality disorder when an interview was used to assess personal‐
ity instead of a self-report questionnaire.
Furthermore, two of the studies [79, 97] reported in the Dreessen and Arntz review [33] as
having yielded negative findings showed a strong trend for a higher level of personality
pathology in drop-outs than in completers [32]. This may indicate that there was a negative
effect of personality pathology in these studies, which was manifested in the drop-out rates
[32]. Finally, the general conclusions drawn from the Dreessen and Arntz review [33] should
be carefully interpreted. Indeed, some studies were reported as having no effect of personal‐
ity on outcome, although when examined separately, there was at least a moderate effect
[32]. As mentioned by Reich [32], it was reported in the review that Dreessen and colleagues
[58] obtained negative results, although obsessive-compulsive personality traits were related
negatively to treatment outcome, and they reported negative findings for the Black et al. [59]
study when it was actually concluded that the presence of a personality disorder was a pre‐
dictor of poor outcome in the non SSRI-treated group when the self-report questionnaire
was used to assess personality pathology.
13. Future area of research
Even though studies have yielded conflicting conclusions regarding the influence of Axis II
diagnosis on the outcome of treatment for anxiety disorders, most studies examining the
outcome of treatment for PD and OCD have found at least some influence of personality
disorders on CBT or pharmacotherapy outcome. However, personality disorders were gen‐
erally found to have no influence on the outcome of CBT for social phobia and PTSD. Yet,
most studies on social phobia and PTSD exclusively examined the influence of specific per‐
sonality disorders, AVPD and BPD, respectively, and little is known about the influence of
personality disorders in general on treatment outcome for these anxiety disorders. No con‐
clusions can be yielded from GAD studies, given that, to our knowledge, only three studies
have examined the influence of personality disorders on treatment outcome for GAD, and
that one of these had serious methodological limitations. Furthermore, the mechanisms that
underlie the effect of Axis II disorders on the outcome of treatment for anxiety disorders are
not strongly established. Future studies should concentrate on studying well reasoned hy‐
potheses concerning these mechanisms [33] so that responsible personality variables could
be understood, and intervention adapted for the needs of this specific population. For in‐
stance, the associations in course between anxiety and personality disorders may be ex‐
plained by personality traits, which underlie both disorders [18], and examining these
maladaptive personality traits could help us understand better the underlying mechanisms
that explain the influence of personality on anxiety disorders. Although some studies have
examined the influence of personality disorder traits on treatment outcome of anxiety disor‐
ders, different results have been obtained when personality was assessed dimensionally in‐
stead of categorically. In addition, improvement in the evaluation of personality is needed,
to eliminate, or at least decrease, the overlap of Axis I and Axis II criteria. There is also a
need for more consistency in the methods used to assess personality disorders, given that
different results were obtained when personality was assessed by a self-report questionnaire
instead of an interview. Further research is needed to determine whether patients with co‐
morbid personality disorders could attain levels of posttreatment functioning equal to anxi‐
ety patients without personality dysfunction by varying duration and/or intensity of
treatment sessions [38, 106], or by combining different treatment modalities [80]. Finally,
more controlled prospective studies with larger sample sizes are needed to better under‐
stand the influence of personality disorders on anxiety disorders, particularly for GAD, giv‐
en the small number of studies conducted among individuals with this anxiety disorder.
Author details
Véronique Palardy1, Ghassan El-Baalbaki1,2, Claude Bélanger1,2 and Catherine Fredette1
1 University of Quebec at Montreal, Quebec, Canada
2 McGill University, Quebec, Canada
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Chapter 12

Understanding and Treating Anxiety Disorders in

Véronique Palardy, Ghassan El-Baalbaki,

Additional information is available at the end of the chapter

2. Co-occurrence of personality disorders and anxiety disorders

2.1. Etiology of comorbidity

3. Influence of personality disorders on the outcome of treatment for

4. Panic disorder with and without agoraphobia (PD/A)

4.1. Initial symptomatology and course of illness

4.2. Influence of personality pathology on the outcome of cognitive and/or behavioral

4.3. Pharmacological treatment

with a tricyclic antidepressant or an anxiolytic) among 25 PD patients. There was a signifi‐

5. Obsessive-Compulsive Disorder (OCD)

5.1. Initial symptomatology and course of illness

5.2. Influence of personality pathology on the outcome of cognitive and/or behavioral

5.3. Pharmacological treatment

6. Generalized Anxiety Disorder (GAD)

6.1. Initial symtomatology and course of illness

6.2. Influence of personality pathology on the outcome of cognitive and/or behavioral

6.3. Pharmacological treatment

7.1. Initial symptomatology and course of illness

7.2. Influence of personality pathology on the outcome of cognitive and/or behavioral

7.3. Pharmacological treatment

negative influence of personality disorders on the outcome of a pharmacological treat‐

8. Posttraumatic Stress Disorder (PTSD)

8.1. Initial symptomatology and course of illness

8.2. Influence of personality pathology on the outcome of cognitive and/or behavioral

Authors Year Participants Treatment Influence of Other results

Authors Year Participants Treatment Influence of Other results

Authors Year Participants Treatment Influence of Other results

Authors Year Participants Treatment Influence of Other results

Authors Year Participants Treatment Influence of Other results

Authors Year Participants Treatment Influence of Other results

9. Mechanisms underlying the influence of personality disorders on

10. Effect of treatment for anxiety disorders on personality functioning

11. Issues to consider in therapy

12. Plausible explanations for conflicting results

13. Future area of research

Véronique Palardy1, Ghassan El-Baalbaki1,2, Claude Bélanger1,2 and Catherine Fredette1

1 University of Quebec at Montreal, Quebec, Canada

2 McGill University, Quebec, Canada

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