The Journal of Nervous & Mental Disease 

Volume 186(1), January 1998, pp 57,58

Early-Onset Dysthymia and Personality Disturbance among Patients in a Primary
Care Setting

[Brief Reports]

Sansone, Randy A. M.D.; Wiederman, Michael W. Ph.D.; Sansone, Lori A. M.D.;
& Touchet, Bryan M.D.

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Several investigators have indicated that dysthymic disorder is often accompanied
by a comorbid personality disorder. Sanderson et al. (1992) reported that 52% of
patients with dysthymic disorder met criteria for at least one personality
disorder, particularly cluster C (32%) and B (16%) personality disorders.
Markowitz et al. (1992) reported that, compared with nondysthymics, subjects
with dysthymia were more likely to meet criteria for self-defeating, avoidant,
borderline, or dependent personality disorders.

Several authors have indicated that early-onset dysthymia may have a particularly
high frequency of personality disorder (Hirschfeld, 1990; Pepper et al., 1995;
Schrader, 1994). Compared with individuals with episodic major depression,Pepper
et al. (1995) reported that subjects with early-onset dysthymia had significantly
greater axis II comorbidity, the strongest associations being with cluster C
(37%) and B (32%) disorders. The preceding studies explored the comorbidity of
dysthymic disorder and personality disorders among patients seen in mental
health settings. The current study was undertaken to determine whether the
association between early-onset dysthymia and personality psychopathology occurs
among patients being treated for mood disorders in primary care settings.

Methods

Subjects were 39 primary care patients (33 women, 6 men) who were being treated
with SSRI-type antidepressants prescribed by a primary care physician, not a
psychiatrist, for more than 12 months (range = 12-96 months, mean = 36.10, SD =
20.75). All participants were between the ages of 18 and 51 (mean= 39.05 years,
SD = 8.12). The majority were married (84.6%), and all had completed high
school. Twenty (51.3%) had attended some college or postsecondary school
training, and an additional 9 (23.1%) had completed a bachelor's degree or
greater.

The study was undertaken in an HMO setting located in a relatively affluent
section of a city of 400,000 people. Potential candidates (N = 73) for the
project were solicited directly by the primary-care investigator at the time of
medical service or through a posted advertisement in the pharmacy. Patients who
were seriously ill or cognitively impaired were not invited to participate.
Those who had received psychiatric treatment during the current course of SSRI
treatment were excluded (N = 8) as were eight other individuals who did not meet
selection criteria (e.g., age). Of the remaining 57 individuals who were asked
to participate, 56 agreed to do so(response rate = 98.2%). Of these 56
individuals, 4 failed research appointments and 13 could not be contacted.
Ultimately, 39 individuals were successfully contacted and completed all
measures. Patient-candidate reasons for not participating were not explored.
Each participant underwent a general psychiatric interview by a 4th-year
psychiatric resident who used DSM-IV criteria, printed on an interview form, to
confirm several psychiatric diagnoses including dysthymia. In addition, each
participant completed the Millon Clinical Multiaxial Inventory-III (MCMI-III;
Millon, 1984) as a measure of personality psychopathology. Individuals were
paid$20 for their participation.

Results

Among the 39 subjects, 14 met criteria for early-onset dysthymia (i.e., onset of
dysthymia prior to age 21). Remaining diagnoses within the sample were major
depression (N = 8), late-onset dysthymia (N = 4), and bipolar (N = 1), panic (N
= 11), and premenstrual dysphoric (N = 1) disorders. The large majority of
participants(69.2%) had primary care diagnoses of "depression" in their medical
records.

With regard to personality disturbance, we took a conservative approach and
considered base-rate scores of 85 or greater on the MCMI-III as indicative of
clinically significant levels of personality psychopathology. The proportions of
participants who had at least one elevated MCMI-III personality scale score were
92.9% of early-onset dysthymics versus 52.0% of the remaining sample([chi]2 =
6.74, p 2 = 5.57, p N = 3, or 21.4%), avoidant (N = 4, or 28%), depressive (N =
9, or 64.3%), dependent (N = 6, or 42.9%), narcissistic (N = 2, or 14.3%),
passive-aggressive (N = 1, or 7.1%), and self-defeating(N = 4, or 28.6%)
personality psychopathology.

Discussion

These data suggest that, compared with a peer group having significant axis I
psychopathology, there is a significant and greater prevalence of personality
disturbance among primary care patients with early-onset dysthymia. These
findings appear to reflect the comorbidity patterns observed among dysthymic
individuals in psychiatric settings. Given the high incidence of comorbidity, it
is not surprising that these individuals have continued on antidepressant
therapy for longer than 12 months, which appears to be an appropriate intervention.

There are several possible implications of these findings. First, there are
overlapping criteria between dysthymic disorder and particular personality
disorders (e.g., borderline personality), and this overlap might result in the
illusion of two distinct clinical disorders rather than a single psychiatric
phenomenon. Second, the apparent association between personality disturbance and
early-onset dysthymia may be that personality disturbance sets the early stage
for chronic affective difficulties. Likewise, it may be that early-onset mood
disorders have profound and lasting effects on personality development and
subsequent expression.

The most predominant personality disturbances seen among participants in this
study were depressive, dependent, avoidant, and self-defeating personality
disorders. Our findings mirror previous studies examining dysthymia in mental
health populations with regard to an association with cluster B and C disorders.

One interesting aspect of this study is the presence of an exclusion criterion
relating to current psychiatric care. Despite the apparent complexity of their
clinical depressions (i.e., significant comorbid personality disturbance), it
appears that some patients with early-onset dysthymia are utilizing primary care
physicians, rather than mental health professionals, as their exclusive source
of psychiatric care. Perhaps among well-educated individuals, there are concerns
about the potential stigmatization from psychiatric illness or treatment. In
addition, functional individuals may not perceive their disorders as truly
psychiatric in nature. Finally, cost may play a meaningful role resulting in
care from primary care physicians rather than from psychiatrists, as health
insurance coverage may be more consistent for the former compared with the
latter.

The current study is the first to our knowledge to explore personality
comorbidity among primary care patients with early-onset dysthymia. Our findings
indicate that primary care patients, like patients in mental health settings,
with early-onset dysthymia tend to have frequent personality comorbidity.
Whether there are differences between these populations in treatment responsivity
and outcome is yet to be determined.

Randy A. Sansone, M.D.

Michael W. Wiederman, Ph.D.,

Lori A. Sansone, M.D., &

Bryan Touchet, M.D.



References

Hirschfeld R (1990) Personality and dysthymia. In: SW Burton, HS Akiskal (Eds),
Dysthymic disorder (pp 69-77). London: Gaskell. 

Markowitz JC, Moran ME, Kocsis JH, Frances AJ (1992) Prevalence and comorbidity
of dysthymic disorder among psychiatric outpatients. J Affect Disord 24:63-71.
Full Text Bibliographic Links Document Delivery 

Millon T (1994) MCMI-III manual. Minneapolis: National Computer Systems. 

Pepper CM, Klein DN, Anderson RL, Riso LP, Ouimette PC, Lizardi H (1995)
DSM-III-R axis II comorbidity in dysthymia and major depression. Am J Psychiatry
152:239-247. Ovid Full Text Bibliographic Links Document Delivery 

Sanderson WC, Wetzler S, Beck AT, Betz F (1992) Prevalence of personality
disorders in patients with major depression and dysthymia.Psychiatry Res
42:93-99. Full Text Bibliographic Links Document Delivery 

Schrader G (1994) Chronic depression: state or trait?J Nerv Ment Dis 182:552-555.