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* Panic Disorder
Psychosomatics 41:269-276, June 2000
© 2000 The Academy of Psychosomatic Medicine

Personality Profiles in Patients Referred for Chest Pain

Investigation With Emphasis on Panic Disorder Patients

Toril Dammen, M.D., Øivind Ekeberg, M.D., Ph.D., Harald Arnesen, M.D., Ph.D., and Svein Friis, M.D., Ph.D.

Received February 3, 1999; revised July 12, 1999; accepted July 28, 1999. From the Departments of Psychiatry, Acute Medicine, and Cardiology, Ullevål University Hospital, Oslo, Norway. Address reprint requests to Dr. Dammen, Department of Psychiatry, Ullevål University Hospital, 0407 Oslo, Norway; email: toril.dammen{at}psykiatri.uio.no


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Patients (N=199) referred to cardiac outpatient investigation because of chest pain were assessed with the Personality Diagnostic Questionnaire (PDQ-4). Thirty-nine percent scored positive for any personality disorder. Borderline and avoidant personality disorders were found significantly more often in patients with panic disorder (PD) (n=72) than in patients without PD (12.5% vs. 2.5%, 23.7% vs. 7.7%, respectively). In PD patients, the presence of any personality disorder was significantly associated with higher scores of self-reported anxiety-agoraphobia symptoms, neuroticism, and the presence of suicidal thoughts. These results suggest that personality pathology is important in a subgroup of patients presenting with chest pain and that these patients may require more extensive treatment.

Key Words: Panic Disorder • Other Personality Disorder • Chest Pain

  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
In studies of panic disorder (PD) patients with or without agoraphobia, the prevalence of personality disorders ranges from 27% to 58%, with avoidant, dependent, histrionic, and borderline disorders as the most common.1–3 The variability in prevalence may be due to differences in diagnostic criteria, diagnostic procedures, and sample characteristics. Reich and Braginsky4 argue that in PD patients, patient selection may influence the results of personality assessments, as they found paranoid personality disorder in 54% of PD patients recruited from a tertiary outpatient care system. The empirical findings of a high frequency of personality disorders in PD patients have practical clinical implications because PD patients with comorbid personality disorder have been reported to have poorer treatment outcome,5 to be more likely to relapse after termination of antipanic medication,6 and to exhibit increased distress and poorer functioning.7

To date, most studies on personality disorder in panic patients have been conducted in samples presenting for psychiatric treatment. The results of these studies may not be generalizable to other clinical settings where PD has been reported to be prevalent, such as in cardiology settings. There is a high rate (20%–57%) of PD among patients seeking help for cardiac complaints such as chest pain.8 Two recent studies compare panic patients presenting in medical settings because of chest pain with those who presented for psychiatric treatment. Both studies found that the psychiatric patients had more severe panic-agoraphobic symptoms.9,10 It has been hypothesized that the presence of personality disorder may increase the probability that the patient will seek psychiatric treatment.11 All together, these findings may indicate that personality disorders are less frequent among PD patients in a chest pain setting compared to psychiatric settings.

The Personality Diagnostic Questionnaire (PDQ) is a self-report instrument that was developed with questions to match each DSM-III personality disorder criterion. PDQ and the revised version keyed to DSM-III-R (PDQ-R) have been used in several studies of personality pathology in PD patients.4–7,12–14 PDQ was later updated and renamed PDQ-4, to match the DSM-IV criteria.15 PDQ has been reported to have adequate test-retest reliability, concurrent validity, construct validity with respect to personality disorder clusters, and the ability to predict poor outcome of Axis I disorders.14,16–19 Compared with structured interviews, the PDQ-R has been found to have high sensitivity and moderate specificity.20,21 Consequently, the PDQ is considered an effective screening instrument for personality disorders and a valid measure of personality pathology.4,20,21 Its main advantages include easy administration and scoring.

Fleet et al.22 reported a 25% rate of suicidal ideation in PD patients presenting with chest pain to an emergency department. We found in a recent study of chest pain patients referred for cardiac outpatient investigation a higher prevalence of self-destructive behavior among PD patients compared to non-PD patients.23 The presence of personality disorders, such as borderline personality disorder, has been associated with an increased risk of suicidal ideation and suicidal attempts in PD patients in psychiatric settings.24 Such associations need to be explored in cardiac settings.

Chest pain is a common symptom, and 74% of chest pain patients have been reported to suffer from chest pain up to 11 years after negative coronary angiography.25,26 Continuing chest pain is associated with considerable social and occupational disability.8 Despite this, we have found no previous study that has investigated personality disorders and traits in chest pain patients. In other pain patient samples, the presence of personality disorders has been associated with poor outcome regarding disability and symptom improvement.27,28 Thus, there is a need to characterize personality traits in chest pain patients as these patients require more intensive treatment.

The aims of the present study are the following: 1) to assess the prevalence of PDQ-personality disorders in patients referred for cardiac investigation because of chest pain; 2) to describe PDQ personality traits; 3) to compare patients with and without PD with respect to PDQ-personality disorder frequency and traits; 4) to compare the various subgroups with and without PD and any personality disorder in terms of demographic variables, comorbidity of psychiatric state disorders (Axis I), psychological distress, and pain variables; and 5) to explore the relationship between co-occurring PDQ-personality disorders, experienced treatment needs, and suicidal ideation in PD patients.


  METHODS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
The research protocol was accepted by the Regional Ethics Committee, Oslo, Norway, November 1994.

Subjects
The sample comprised 199 of 264 (75.4%) consecutive eligible cardiac outpatients who met the following inclusion criteria: 1) referred for investigation of a main complaint of chest pain, 2) no prior documented organic heart disease, 3) age 18–65 years, 4) no psychosis, 5) being able to understand and write the Norwegian language, and 6) signed informed consent. The main reasons for nonparticipation were the following: unknown (54%), lack of time (15%), transportation problems (12%), the study felt irrelevant (9%), and others (10%). Participants and nonparticipants did not differ significantly in any variables, such as age, sex, prevalence of coronary artery risk factors, or medical diseases/conditions. Significantly more participants were diagnosed as having coronary artery disease, compared with nonparticipants (16.1% [32/199] vs. 3.2% [2/63]; P=0.005). Demographically, 49.2% of the included patients were women; mean age was 50.4 years (SD=9.4). Thirty-two patients (16%) suffered from coronary artery disease. Because there were neither statistically nor clinically significant differences between patients with and without coronary artery disease regarding PDQ variables, the two groups were merged for data analysis. Patient characteristics and procedure have previously been described in more detail.23

Assessments
Psychiatric disorders were assessed by a trained rater and psychiatrist (T.D.) using the Structured Clinical Interview for DSM-IV (SCID).29 The PD group comprised 76 patients (38%) who met the DSM-IV criteria for current PD. The interrater reliability score (kappa) for PD was 0.88.

The Personality Diagnostic Questionnaire for DSM-IV (PDQ-4)15 was administered as part of a large battery of self-rating questionnaires.23 The PDQ-4 is designed to assess the 10 personality disorders (paranoid, schizoid, schizotypal, histrionic, narcissistic, antisocial, borderline, avoidant, dependent, and obsessive-compulsive) included in the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV). Furthermore, the PDQ-4 comprises a two-item suspect questionnaire scale. A true response to either of the two items indicates suspect response, and subjects with such responses (five in all, of whom four suffered from current PD) were excluded from further analysis. In the present study, the items assessing antisocial personality disorders were omitted because, in a pilot study, some chest pain patients found the questions offensive. Thus, the PDQ version that was used comprised 97 true/false items. The following variables were derived: a diagnosis for each of the disorders, the number of positive responses within each diagnostic category, and a total PDQ sumscore as an index of overall personality disturbance. The diagnostic scores were also classified as follows: Cluster A comprises diagnoses from the paranoid, schizoid, and schizotypal categories; Cluster B includes borderline, histrionic, and narcissistic diagnoses; and Cluster C comprises avoidant, dependent, and obsessive-compulsive diagnoses.

For the purpose of the present study, each participant was also asked to fill out the following questionnaires: 1) Demographic questionnaire, 2) Symptom Checklist-90-Revised (SCL-90-R),30 3) Eysenck Personality Questionnaire-Neuroticism (EPQ-N),31 4) Short-Form McGill Pain Questionnaire (SF-MPQ),32 5) Agoraphobia Cognitions Questionnaire (ACQ),33 6) Body Sensations Questionnaire (BSQ),33 and 7) Mobility Inventory for Agoraphobia (MIA).34 The patients' experienced treatment need was assessed by asking open-ended questions about whether they wanted treatment for PD symptoms (0=no and 1=yes). Fifty-six percent of the included PD patients wanted treatment, whereas 44% did not. Suicidal ideation was assessed with the following: 1) Question 15 in SCL-90-R, "During the last 7 days, including today, how much were you distressed by thoughts of killing yourself?" Ninety percent of the PD patients reported not to have been distressed by suicidal thoughts, whereas 10% reported that they had been "a little bit" to "extremely" distressed; and 2) PDQ-4 Question 39: "During the last years I have tried to hurt or kill myself." Sixteen percent responded positively to this question.

For the purpose of the present study, four groups were compared on demographic variables, comorbidity of psychiatric state disorders (Axis I), psychological distress, and pain variables: 1) patients with both PD and positive score for any personality disorder (PD-Pers dis+), 2) patients with PD and without any personality disorder (PD-Pers dis-), 3) patients without PD and with positive score of any personality disorder (Non-PD-Pers dis+),and 4) patients with neither PD nor personality disorder (Non-PD-Pers dis-).

Data Analysis
Comparisons between PD patients and non-panic disorder patients (Non-PD) were performed by using independent Student t-test for normally distributed continuous variables and Mann-Whitney U test for continuous variables without normal distribution. The latter variables were also analyzed by Student t-test. Because both tests yielded basically the same results, data are presented as mean±SD. All tests were two-tailed. Bonferroni's correction was applied for repeated tests. Chi-square test or Fisher's exact test was applied for dichotomous variables. Differences between the four patient groups were analyzed by using two-way analyses of variance (ANOVAs). Agreement between interviewers on psychiatric diagnosis was assessed using the kappa coefficient (kappa). The statistical package SPSS/PC 7.5 was used for all data analysis.


  RESULTS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
PDQ-Personality Disorders and PDQ Personality Traits
The frequencies of PDQ-4 diagnoses and clusters are shown in Table 1. Thirty-nine percent of the patients scored positive for at least one personality diagnosis. Of those who scored positive, 59% met the criteria for one diagnosis, 18% for two, 11% for three, 6% for four, and 7% for five or more. Diagnoses from the Anxious Cluster were most commonly reported.


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TABLE 1. Frequencies of DSM-IV personality disorders diagnosed by PDQ-4 in a sample of chest pain patients with panic disorder (PD) and without panic disorder (non-PD) referred to cardiac outpatient investigation



Table 2 shows the mean number of PDQ diagnostic criteria endorsed in the patient sample. The highest scores were obtained for obsessive-compulsive, paranoid, and histrionic traits.


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TABLE 2. Mean scores of PDQ diagnostic criteria in a sample of chest pain patients with panic disorder (PD) and without panic disorder (non-PD) referred to outpatient investigation



Patients With Panic Disorder vs. Patients Without Panic Disorder
As shown in Table 1, avoidant personality disorder and borderline personality disorder occurred significantly more often in PD than in non-PD patients. The PD patients scored significantly higher on all personality disorder criteria except schizoid, narcissistic, and obsessive-compulsive disorders (Table 2).

Comparisons Between the Four Patient Groups Regarding Demographic Variables, Comorbidity of Psychiatric State Disorders (Axis I), Psychological Distress, and Pain Variables
Patients in the four groups did not differ significantly in terms of age, sex, marital status, and mean years of education when Bonferroni's correction was applied.

Table 3 shows that there were significant differences among the four groups in occurrence of hypochondriasis and agoraphobia. These disorders were most common in the PD-Pers dis+ group, but the difference between the two PD groups was statistically significant for agoraphobia only (P=0.008, Fisher's exact test). Concerning psychological distress and pain, PD proved to have a significant main effect on the level of all variables, irrespective of the presence of a personality disorder, even after controlling for the effects of sex, age, education, and presence of coronary disease (Table 4). The presence of any personality disorder had an additional significant effect (irrespective of the presence of PD) for anxiety, neuroticism, body sensation, agoraphobic cognition, and avoidance behavior, whereas there were statistically significant interactions between the presence of PD and any personality disorder for agoraphobic cognition and avoidance behavior only. For these variables the co-occurrence of the two groups of diagnoses gave a potentiation of the effect of each of them, and this potentiation was of real importance.


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TABLE 3. Psychiatric comorbidity




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TABLE 4. Mean scores on psychological self-assessment scales among four patient groups with negative (Pers dis-) vs. positive (Pers dis+) scores for any personality disorder and negative panic disorder (Non-PD) vs. positive panic disorder (PD)



Experienced Treatment Needs and Suicidal Ideation in PD Patients
No statistically or clinically significant associations were found between personality variables and reported need for treatment.

There were significant associations between a positive report of distress by suicidal thoughts and positive scores for any personality disorder, Cluster A, and Cluster B (all Ps<0.01), whereas a positive trend for such an association was found between Cluster C and the presence of suicidal thoughts (P=0.095). There was a significant association between positive score on any Cluster A disorder and positive response on the PDQ Item 39 on self-destruction/suicidal attempts, whereas a nonsignificant trend occurred for the association between positive score on any personality disorder, Cluster B, Cluster C, and positive response on the PDQ Item 39 (0.55<P<0.085). In these analyses, the PDQ Item 39 was omitted when diagnostic variables and clusters were computed.


  DISCUSSION

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
One of the main findings of this study was that 39% of the total sample scored positively for a PDQ-4 personality diagnosis. The most common PDQ diagnoses in the total sample were obsessive-compulsive (23.3%), avoidant (13.8%), and paranoid (13.2%) disorders. Borderline and avoidant personality disorders occurred significantly more often in PD patients than in non-PD patients. Regardless of the exact prevalence, the results suggest that a subgroup of the total patient sample may suffer from clinically significant personality pathology. Considering PD patients, the prevalence of 46% for personality disorders is similar to that reported in other PDQ studies (27%–46%).4,7,12,13 The rates of avoidant, obsessive-compulsive, and borderline personality disorders are within the range of rates reported in other studies.4,5,7,12–14 The frequency of dependent personality disorder was lower in this sample than that reported in most other studies using PDQ (15%–36%)4,5,14 but was more similar to what was found (7%) in a sample of patients referred to a general hospital.12 These results may indicate that PD patients referred to medical settings may exhibit fewer dependent personality traits compared with patients who seek or are referred to psychiatric treatment. Future studies that directly compare psychiatric samples and medical samples may clarify this issue.

PD patients with any personality disorder reported higher scores on psychological distress/panic-agoraphobia variables compared with PD patients without any personality disorder. However, no such differences were found for pain variables and somatization. One explanation of this finding may be that patients with high scores on psychological distress tended to score positively on the PDQ, whereas the somatization/pain scores did not affect the PDQ scores in a similar way. Another explanation may be that personality pathology has a different impact on psychological and somatization/pain variables. Such associations should be further explored.

The presence of any personality disorder was not associated with dysthymia and social phobia, as has previously been reported.35 One explanation may be the low comorbidity of these disorders in the present sample. The presence of any personality disorder was associated with more anxiety and panic-agoraphobia symptomatology, as expected. No associations were found between personality variables and reported need for treatment. The presence of any personality disorder, Cluster A, and Cluster B disorders, was associated with suicidal thoughts/self-destructive behavior. This is in line with previous findings connecting suicidal thoughts in PD to personality disorders such as borderline personality disorder.24

With regard to the effect of comorbid personality disorders on the treatment outcome of PD, the personality disorders most commonly reported in the present study have been reported to have implications for treatment. Avoidant personality disorder has been reported to be significantly associated with relapse after pharmacological treatment and a less favorable 1-year follow-up outcome after combined behavior and psychodynamic group therapy.36 Some evidence has been reported for a negative impact of the dramatic cluster on treatment outcome, and the presence of any personality disorder has been reported to predict a more negative long-term outcome.37,38 Because PD patients with a comorbid personality disorder present higher levels of symptoms before treatment, it has been suggested that longer treatment should be applied.38 Regarding treatment of panic symptoms in the medical setting, it has been suggested that brief and early interventions should be tested.9 Because the results of our study indicate more disabling cognitive and behavioral (agoraphobic avoidance) characteristics in patients with any personality disorder, we suggest that this subgroup of PD patients will require more intensive treatment. These results underscore the importance of personality assessment and evaluation in the treatment of PD in medical settings.

Some caution must be exercised in interpreting the results of the present study. First, even if PDQ has been claimed to measure important personality variables,4 the self-report diagnoses in the present study are not necessarily identical to those that would have been obtained by using structured clinical interviews. We did not apply other instruments for assessment of PDQ validity. Although previous studies have suggested the PDQ to be effective as a screening instrument, Fossati et al.39 recently compared PDQ-4 with a structured clinical interview (SCID) and found low agreement between the two instruments. However, a review of personality disorder assessment concluded that personality disorder instruments often do not agree with each other, and there is no current "gold standard" in the assessment of personality disorders.40 More studies comparing PDQ-4 with other personality assessment methods are required. Second, compared with structured interviews, PDQ has been reported to yield false positive results.20 However, there is no reason to suspect that the over-endorsements necessarily would differ among settings. Thus the comparisons of our results with those reported in psychiatric settings may be considered valid. Methodological studies on PDQ have been conducted in psychiatric samples and nonclinical samples, but the generalizability to medical settings may be questioned. Third, panic-state symptomatology may affect personality disorder assessment because subjects with more symptoms may tend to score positively on more personality items than persons with fewer symptoms. One way to approach the issue of whether or not state anxiety symptoms are confounders in personality assessment could be to assess personality characteristics in current and remitted panic states. The results of such studies suggest a combined predisposition-state model.40

In conclusion, the present study suggests personality pathology to be important in chest pain patients. In the PD patients, the prevalence of PDQ-personality disorders and personality profiles was largely similar to that previously reported in psychiatric samples. In the PD patients, the presence of any personality disorder was associated with higher scores for anxiety and panic-agoraphobia symptoms and the presence of suicidal thoughts. These findings indicate a need for specific treatment and emphasize the importance of assessing personality disorders in PD patients referred for investigation of chest pain. The prevalence and impact of personality pathology should be addressed in future studies using structured clinical interviews for assessments of personality disorders in chest pain patients with or without PD. The relative prognostic importance of such personality pathology should be addressed.


  REFERENCES

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

  1. Noyes R Jr, Hoehn-Saric R: The Anxiety Disorders. New York, Cambridge University Press, 1998
  2. Brooks RB, Baltazar PL, McDowell DE, et al: Personality disorders co-occurring with panic disorder with agoraphobia. J Person Disord 1991; 53:28–36
  3. Mavissakalian M: The relationship between panic disorder/agoraphobia and personality disorders. Psychiatr Clin North Am 1990; 13:661–684[Medline]
  4. Reich J, Braginsky Y: Paranoid personality traits in a panic disorder population: a pilot study. Compr Psychiatry 1994; 35:260–264[Medline]
  5. Reich JH: DSM-III personality disorders and the outcome of treated panic disorder. Am J Psychiatry 1988; 145:1149–1152
  6. Green MA, Curtis GC: Personality disorders in panic patients: response to termination of antipanic medication. J Person Disord 1988; 2303–2314
  7. Mavissakalian MR, Hamann MS, Abou Haidar S, et al: DSM-III personality disorders in generalized anxiety, panic/agoraphobia, and obsessive-compulsive disorders. Compr Psychiatry 1993; 34:243–248[Medline]
  8. Fleet RP, Marchand A, Dupuis G, et al: Comparing emergency department and psychiatric setting patients with panic disorder. Psychosomatics 1998; 39:512–518[Abstract/Free Full Text]
  9. Fleet RP, Beitman BD: Unexplained chest pain: when is it panic disorder? Clin Cardiol 1997; 20:187–194
  10. Beck JG, Berisford MA, Taegtmeyer H, et al: Panic symptoms in chest pain without coronary artery disease: a comparison with panic disorder. Behav Ther 1990; 21:241–252[CrossRef]
  11. Ayuso Mateos JL, Bayon Perez C, Santo-Domingo Carrasco J, et al: Atypical chest pain and panic disorder. Psychother Psychosom 1989; 52:92–95[CrossRef][Medline]
  12. Pollack MH, Otto MW, Rosenbaum JF, et al: Personality disorders in patients with panic disorder: association with childhood anxiety disorders, early trauma, comorbidity, and chronicity. Compr Psychiatry 1992; 33:78–83[CrossRef][Medline]
  13. Reich J, Troughton E: Frequency of DSM-III personality disorders in patients with panic disorder: comparison with psychiatric and normal control subjects. Psychiatry Res 1988; 26:89–100[Medline]
  14. Mavissakalian M, Hamann MS: DSM-III personality disorder in agoraphobia. Compr Psychiatry 1986; 27:471–479[Medline]
  15. Hyler S: Personality Diagnostic Questionnaire for DSM-IV (PDQ-4). New York, New York State Psychiatric Institute, 1994
  16. Uehara T, Sakado K, Sato AT: Test-retest reliability of the Personality Diagnostic Questionnaire: Revised. Psychiatry Clin Neurosci 1997; 51:369–372[Medline]
  17. Dowson JH, Berrios GE: Factor structure of DSM-III-R personality disorders shown by self-report questionnaire: implications for classifying and assessing personality disorders. Acta Psychiatr Scand 1991; 84:555–560[Medline]
  18. Johnson JG, Bornstein RF: Utility of the Personality Diagnostic Questionnaire-Revised in a nonclinical population. J Person Disord 1992; 6:450–457
  19. Pfohl B, Coryell W, Zimmermann M, et al: Prognostic validity of self report and interview measures of personality disorders in depressed patients. J Clin Psychiatry 1987; 48:468–472[Medline]
  20. Hyler SE, Skodol AE, Oldham JM, et al: Validity of the Personality Diagnostic Questionnaire Revised: a replication in an outpatient sample. Compr Psychiatry 1992; 33:73–77[CrossRef][Medline]
  21. Dubro AF, Wetzler S, Kahn MW: A comparison of three self-report questionnaires for the diagnosis of DSM-III Personality disorders. J Person Disord 1998; 2:256–266
  22. Fleet RP, Dupuis G, Marchand A, et al: Panic disorder in emergency department chest pain patients: prevalence, comorbidity, suicidal ideation, and physician recognition. Am J Med 1996; 101:371–380[CrossRef][Medline]
  23. Dammen T, Arnesen H, Ekeberg , et al: Panic disorder in chest pain patients referred to cardiological out-patient investigation. J Intern Med 1999; 245:497–507[CrossRef][Medline]
  24. Friedman S, Jones JC, Chernen L, et al: Suicidal ideation and suicide attempts among patients with panic disorder: a survey of two outpatient clinics. Am J Psychiatry 1992; 149:680–685[Abstract/Free Full Text]
  25. Kroenke K, Mangelsdorff AD: Common symptoms in ambulatory care: incidence, evaluation, therapy, and outcome. Am J Med 1989; 86:262–266[CrossRef][Medline]
  26. Potts SG, Bass CM: Psychological morbidity in patients with chest pain and normal or near-normal coronary arteries: a long term follow-up study. Psychol Med 1995; 25:339–347[Medline]
  27. Elkayam O, Ben Itzhak S, Avrahami E, et al: Multidisciplinary approach to chronic back pain: prognostic elements of the outcome. Clin & Exp Rheumatol 1996; 14:281–288[Medline]
  28. Gatchel RJ, Polatin PB, Kinney RK: Predicting outcome of chronic back pain using clinical predictors of psychopathology: a prospective analysis. Health Psychol 1995; 14:415–420[CrossRef][Medline]
  29. First MB, Spitzer RL, Gibbon M, et al: Structured Clinical Interview for DSM-IV Axis I Disorders-Patient Edition (SCID I/P, version 2.0). New York, New York State Psychiatric Institute, 1995
  30. Derogatis LR: The SCL-90-R: administration, scoring and procedures manual. Baltimore, Clinical Psychometric Research, 1977
  31. Eysenck HJ, Eysenck SBG: The manual for the Eysenck Personality Questionnaire. London, Hodder and Stoughton, 1975
  32. Melzack R: The short-form McGill Pain Questionnaire. Pain 1987; 30:191–197[CrossRef][Medline]
  33. Chambless DL, Caputo GC, Bright P, et al: Assessment of fear of fear in agoraphobics: the body sensations questionnaire and the agoraphobic cognitions questionnaire. J Consult Clin Psychol 1984; 52:1090–1097
  34. Chambless DL, Caputo GC, Jasin SE, et al: The Mobility Inventory for Agoraphobia. Behav Res Ther 1985; 23:35–44[CrossRef][Medline]
  35. Renneberg B, Chambless DL, Gracely EJ: Prevalence of SCID-diagnosed personality disorders in agoraphobic outpatients. J Anxiety Disord 1992; 6:111–118
  36. Hoffart A, Marthinsen EW: The effect of personality disorder and anxious-depressive comorbidity on outcome in patients with unipolar depression and with panic disorder and agoraphobia. J Person Disord 1993; 7:304–311
  37. Dreessen L, Arntz A: The impact of personality disorders on treatment outcome of anxiety disorders: best evidence synthesis. Behav Res Ther 1998; 36:483–504[Medline]
  38. Fava G, Zielezny M, Savron G, et al: Long term effects of behavioural treatment for panic disorder with agoraphobia. Br J Psychiatry 1995; 166:87–92[Abstract/Free Full Text]
  39. Fossati A, Maffei C, Bagnato M, et al: Brief communication: criterion validity of the Personality Diagnostic Questionnaire-4+ (PDQ-4+) in a mixed psychiatric sample. J Person Disord 1998; 12:172–178[Medline]
  40. Perry JC: Problems and considerations in the valid assessments of personality disorders. Am J Psychiatry 1992; 149:1645–1653
  41. Hoffart A, Thornes K, Hedley LM: DSM-III-R Axis I and II disorders in agoraphobic inpatients with and without panic disorder before and after psychosocial treatment. Psychiatry Res 1995; 56:1–9[Medline]



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