Impact of dissociation on treatment of depressive and anxiety spectrum disorders with and without personality disorders

Figures & data

Table 1 Inclusion and exclusion criteria

Inclusion criteria

1. Depressive disorder, panic disorder, generalized anxiety disorder, mixed anxiety–depressive disorder, agoraphobia, social phobia, OCD, PTSD, adjustment disorders, dissociative/conversion disorders, somatoform disorder, or other anxiety/neurotic spectrum disorder (WHO 1996)

2. Both sexes

3. Age between 18 and 70 years

4. Informed consent

Exclusion criteria

1. Severe somatic illness

2. Organic psychiatric disorder

3. Bipolar affective disorder lifetime

4. Alcohol or substance dependency

5. Schizophrenia lifetime

6. Mental retardation

7. Acute suicidal behavior or plan

8. Patients using no prescribed medication

9. Dissocial personality disorder

Abbreviations: OCD, obsessive compulsive disorder; PTSD, posttraumatic stress disorder; WHO, World Health Organization.

Table 2 Demographic and clinical data – comparison of all enrolled patients and the patients who completed the study

Variable	Enrolled patients (n=840)	Patients who completed the study (n=606)	Statistics: enrolled patients versus patients completing the study
Age	38.7±12.3	38.6±12.3	Mann–Whitney test: MW U=246,800; ns
Sex (M/F)	278/562	192/414	Fisher’s exact test: ns
Age at onset of the disorder	30.3±13.9	30.3±13.8	Mann–Whitney test: MW U=247,000; ns
Duration of the disorder	8.3±8.8	8.3±8.8	Mann–Whitney test: MW U=247,000; ns
Heredity no/yes	438/402	324/282	Fisher’s exact test: ns
Education basic/vocational training/secondary school/university	118/251/333/115	83/187/251/84	Chi-square test: ns
No information	23	1
Employed/unemployed	484/356	244/362	Fisher’s exact test: ns
No pension/pension	657/183	474/132	Fisher’s exact test: ns
Marital status: single/married/divorced/widowed	355/267/165/31	259/201/120/26	Chi-square test: ns
No information	22	0
Personality disorder no/yes	614/226	442/164	Fisher’s exact test: ns
CGI-S-1	4.1±1.7	4.3±1.4	Mann–Whitney test: MW U=238,700; ns
BAI-1	23.1±14.0	24.1±12.5	Mann–Whitney test: MW U=235,100; ns
BDI-II-1	24.0±11.6	25.0±10.4	Unpaired t-test: t=1.585, df=1,401; ns
SPRAS-1	60.1±33.6	59.9±35.5	Mann–Whitney test: MW U=213,500; ns
DES-1	14.5±15.4	14.3±15.4	Mann–Whitney test: MW U=202,600; ns
Antidepressant index	41.26±24.10 (n=502)	41.29±23.88 (n=532)	Mann–Whitney test: MW U=202,600; ns
Anxiolytic index	17.63±18.09 (n=231)	15.93±15.83 (n=164)	Mann–Whitney test: MW U=17,760; ns
Antipsychotic index	1.739±1.985 (n=212)	1.602±2.055 (n=157)	Mann–Whitney test: MW U=15,560; ns

Abbreviations: BAI, Beck Anxiety Inventory; BDI-II, Beck Depressive Inventory, second edition; CGI-S, Clinical Global Impression-Severity of the disorder; DES, Dissocative Experience Scale; df, degrees of freedom; F, females; M, males; ns, not significant; SPRAS, Sheehan Patient-Related Anxiety Scale.

Table 3 Scores in rating scales at the beginning of the treatment according to the diagnostic groups

Main diagnosis	Measurements
	BDI-II	BAI	SPRAS	CGI-S	DES	DES-T
Depressive disorder (n=108)	26.82±9.46	22.19±11.56	55.74±23.89	4.26±1.40	13.38±13.45	7.97±13.53
Panic disorder/agoraphobia (n=68)	21.14±10.00	29.34±10.56	68.20±22.43	4.16±1.27	10.58±12.01	6.50±11.76
Social phobia (n=45)	22.48±9.30	23.19±10.88	55.70±20.40	3.96±1.28	10.19±9.32	5.76±8.33
GAD/MAD (n=134)	25.59±9.37	25.50±12.88	66.46±59.22	4.18±1.23	13.10±14.53	6.52±9.42
OCD (n=53)	22.66±10.87	20.47±12.72	55.02±25.87	4.87±1.21	15.02±16.27	12.05±17.17
PTSD (n=16)	31.80±11.10	25.93±11.18	66.79±15.42	4.38±1.82	21.56±12.46	11.46±15.57
Adjustment disorders (n=108)	27.32±10.81	22.50±12.40	55.04±22.96	3.94±1.57	16.46±15.54	10.57±17.08
Dissociative/conversion disorders (n=39)	24.48±12.55	28.96±15.74	63.60±33.42	4.39±1.97	22.06±22.86	13.31±20.27
Somatoform disorders (n=23)	21.49±10.96	22.79±12.31	57.00±29.30	4.84±1.41	16.48±21.57	6.97±13.03
Others (n=12)	24.55±13.37	21.50±18.31	57.50±33.51	4.33±1.56	17.22±22.60	12.00±19.27
Statistics	One-way ANOVA: F=3.935, df=588*** Bonferroni’s multiple comparison test: DEP versus PAN* PTSD versus PAN* AD versus PAN**	One-way ANOVA: 3.082, df=593** Bonferroni’s multiple comparison test: DEP versus PAN* OCD versus PAN** AD versus PAN*	Kruskal–Wallis test: KW U=22.92** Dunn’s multiple comparison test: DEP versus PAN* AD versus PAN*	Kruskal–Wallis test: KW U=27.47** Dunn’s multiple comparison test: SF versus OCD* AD versus OCD** AD versus SoD*	Kruskal–Wallis test: KW U=22.69** Dunn’s multiple comparison test: PD versus PTSD* SF versus PTSD*	Kruskal–Wallis test: KW U=8.722; ns

Notes:

* P<0.05;

** P<0.01;

*** P<0.001.

Abbreviations: AD, adjustment disorders; ANOVA, analysis of variance; BAI, Beck Anxiety Inventory; BDI-II, Beck Depressive Inventory, second edition; CGI-S, Clinical Global Impression-Severity of the disorder; DEP, depressive disorders; DES, Dissocative Experience Scale; DES-T, Dissociative Experiences Scale-Taxon; GAD, generalized anxiety disorder; ns, not significant; OCD, obsessive compulsive disorder; PAD, panic disorder and agoraphobia; PD, personality disorder; PTSD, posttraumatic stress disorder; SF, social phobia; SoD, somatoform disorders; SPRAS, Sheehan Patient-Related Anxiety Scale; PAN, panic disorder.

Figure 1 Mean BDI-II and BAI scores each week during the treatment.

Notes: (A) Statistics: Kruskal–Wallis test, P<0.0001; Dunn’s multiple comparison test: BDI-1 versus BDI-2, P<0.001; BDI-2 versus BDI-3, P<0.001; BDI-3 versus BDI-4, P<0.001; BDI-4 versus BDI-5, ns; BDI-5 versus BDI-6, P<0.001. (B) Statistics: Kruskal–Wallis test, P<0.0001; Dunn’s multiple comparison test: BAI-1 versus BAI-2, P<0.001; BAI-2 versus BAI-3, P<0.001; BAI-3 versus BAI-4, P<0.001; BAI-4 versus BAI-5, P<0.001; BAI-5 versus BAI-6, P<0.001.
Abbreviations: BAI, Beck Anxiety Inventory; BDI, Beck Depressive Inventory, second edition; ns, not significant.

Table 4 Mean scores on the rating scales at the beginning and end of the treatment

Measurements	BDI-II	BAI	SPRAS	CGI-S	DES	DES-T
Beginning of the treatment	24.95±10.44	24.07±12.54	59.93±35.46	4.251±1.418	14.30±15.39	8.48±13.93
End of the treatment	18.60±11.99	19.93±14.26	52.28±28.56	3.059±1.334	13.98±16.03	9.35±15.10
Statistics	Paired t-test: t=16.43, df=573; P<0.0001	Paired t-test: t=8.122 df=585; P<0.0001	Paired t-test: t=5.404 df=546; P<0.0001	Paired t-test: t=16.40 df=605; P<0.0001	Paired t-test: t=1.103 df=519; ns	Paired t-test: t=1.134 df=515; ns

Abbreviations: BAI, Beck Anxiety Inventory; BDI-II, Beck Depressive Inventory, second edition; CGI-S, Clinical Global Impression-Severity of the disorder, patient evaluation; DES, Dissocative Experience Scale; DES-T, Dissociative Experiences Scale-Taxon; df, degrees of freedom; ns, not significant; SPRAS, Sheehan Patient-Related Anxiety Scale.

Table 5 Changes in the rating scales and the level of dissociation during the treatment according to the qualitative demographic parameters, comorbidity, and psychotherapeutic approach

Parameters	Measurements
	BDI-II relative change	BAI relative change	SPRAS relative change	CGI-S absolute change	DES relative change
Males (n=193)	0.28±0.55	0.13±0.65	0.08±0.66	1.28±1.78	−0.32±2.04
Females (n=413)	0.27±0.45	0.08±0.70	0.07±0.44	1.15±1.79	−0.18±1.88
Statistics	Mann–Whitney: MW U=38,600; ns	Mann–Whitney: MW U=37,310; ns	Mann–Whitney: MW U=30,850; ns	Mann–Whitney: MW U=38,760; ns	Mann–Whitney: MW U=29,490; ns
Unemployed (n=243)	0.27±0.42	0.10±0.54	0.07±0.38	1.34±1.80	−0.24±2.13
Employed (n=363)	0.27±0.53	0.09±0.77	0.07±0.60	1.09±1.77	−0.23±1.66
Statistics	Mann–Whitney: MW U=42,380; ns	Mann–Whitney: MW U=39,900; ns	Mann–Whitney: MW U=33,680; ns	Mann–Whitney: MW U=41,250; ns	Mann–Whitney: MW U=31,380; ns
Single (n=259)	0.27±0.46	0.13±0.63	0.06±0.60	1.04±1.82	−0.15±1.77
Married (n=201)	0.29±0.57	0.11±0.76	0.09±0.47	1.32±1.69	−0.22±1.25
Divorced (n=120)	0.27±0.42	0.03±0.60	0.09±0.43	1.29±1.90	−0.43±2.78
Widow (n=26)	0.17±0.32	−0.16±0.96	0.02±0.41	1.31±1.62	−0.37±1.57
Statistics	Kruskal–Wallis test: KW S=5.02; ns	Kruskal–Wallis test: KW S=8.51; P<0.05 Dunn’s multiple comparison test: ns in all comparisons	Kruskal–Wallis test: KW S=1.22; ns	Kruskal–Wallis test: KW S=2.59; ns	Kruskal–Wallis test: KW S=1.50; ns
No heredity (n=324)	0.26±0.43	0.07±0.72	0.09±0.55	1.05±1.81	−1.08±8.11
Heredity (n=282)	0.28±0.55	0.12±0.65	0.05±0.48	1.35±1.75	−0.45±2.93
Statistics	Mann–Whitney: MW U=42,820; ns	Mann–Whitney: MW U=42,770; ns	Mann–Whitney: MW U=35,790; ns	Mann–Whitney: MW U=40,350; P<0.05	Mann–Whitney: MW U=27,910; ns
Without personality disorder (n=442)	0.29±0.51	0.09±0.74	0.09±0.50	1.25±1.72	0.09±0.74
Comorbid personality disorder (n=164)	0.22±0.42	0.10±0.52	0.03±0.57	1.03±1.96	0.10±0.52
Statistics	Mann–Whitney: MW U=31,620; P<0.05	Mann–Whitney: MW U=33,280; ns	Mann–Whitney: MW U=28,090; ns	Mann–Whitney: MW U=34,430; ns	Mann–Whitney: MW U=33,280; ns

Abbreviations: BAI, Beck Anxiety Inventory; BDI-II, Beck Depressive Inventory, second edition; CGI-S, Clinical Global Impression-Severity of the disorder; DES, Dissocative Experience Scale; ns, not significant; SPRAS, Sheehan Patient-Related Anxiety Scale.

Table 6 Changes in the rating scales and the level of dissociation during the treatment according to the diagnostic groups

Main diagnosis	Measurements
	BDI-II relative change	BAI relative change	SPRAS relative change	CGI-S absolute change	DES relative change
Depressive disorder	0.32±0.36	0.14±0.61	0.09±0.42	1.35±1.69	−0.19±1.29
Panic disorder/agoraphobia	0.43±0.41	0.30±0.62	0.11±0.76	1.43±1.88	−0.07±0.96
Social phobia	0.33±0.45	2.24±0.42	0.23±0.41	1.04±1.33	0.15±0.68
GAD/MAD	0.26±0.39	0.09±0.65	0.03±0.51	1.25±1.57	−0.35±1.45
OCD	0.17±0.49	0.03±0.76	0.05±0.41	1.70±1.32	−0.52±3.00
PTSD	0.08±0.44	−0.15±0.72	−0.02±0.28	0.94±2.54	0.11±0.61
Adjustment disorders	0.31±0.42	−0.002±0.79	0.07±0.63	0.90±2.02	−0.44±3.03
Dissociative/conversion disorders	0.01±0.61	0.03±0.38	−0.12±0.41	0.65±2.42	−0.44±1.37
Somatoform disorders	0.12±0.98	0.08±0.70	0.09±0.45	0.85±2.06	0.09±0.81
Others	0.14±0.50	−0.32±1.51	0.12±0.33	1.17±1.64	0.12±0.51
Statistics	Kruskal–Wallis test: KW U=26.40** Dunn’s multiple comparison test: PAD versus OCD* PAD versus DiD**	Kruskal–Wallis test: KW U=24.26** Dunn’s multiple comparison test: PAD versus AD*	Kruskal–Wallis test: KW U=16.54; ns (P=0.057)	Kruskal–Wallis test: KW U=13.03; ns	Kruskal–Wallis test: KW U=8.98; ns

Notes:

* P<0.05;

** P<0.01.

Abbreviations: AD, adjustment disorders; BAI, Beck Anxiety Inventory; BDI-II, Beck Depressive Inventory, second edition; CGI-S, Clinical Global Impression-Severity of the disorder; DES, Dissocative Experience Scale; DiD, dissociative and conversion disorders; GAD, generalized anxiety disorder; ns, not significant; OCD, obsessive compulsive disorder; PAD, panic disorder and agoraphobia; PTSD, posttraumatic stress disorder; SPRAS, Sheehan Patient-Related Anxiety Scale; MAD, mixed anxiety and depressive disorder; KW, Kruskal–Wallis.

Table 7 Correlations of the relative change in BDI-II and BAI and the absolute change in CGI-S with demographic and clinical data

Measurement	Outcome criteria
	BDI-II relative change	BAI relative change	CGI-S absolute change
Age	−0.04	−0.07	0.03
Onset of the disorder	−0.04	−0.07	−0.02
Duration of the disorder	−0.03	−0.01	0.09S**
BDI-II-1	−0.08S*	−0.11S**	0.09S**
BAI-1	−0.12S**	0.11S**	0.13S**
CGI-S-1	−0.13S**	−0.04	0.70S***
SPRAS-1	−0.17S***	−0.11S**	0.16S***
DES-1	−0.19S***	−0.15S***	−0.01
DES-T-1	−0.18S***	−0.12S**	−0.003
Relative DES change	0.27S***	0.22S***	0.15S***
Relative DES-T change	0.18S***	0.14S**	0.10S*
Antidepressant paroxetine index	−0.04	0.01	0.10S*
Anxiolytic diazepam index	0.004	0.02	0.08
Antipsychotic risperidon index	−0.07	−0.04	0.12

Notes: S, Spearman r.

* P<0.05;

** P<0.01;

*** P<0.001.

Abbreviations: BAI, Beck Anxiety Inventory; BDI-II, Beck Depressive Inventory, second edition; CGI-S, Clinical Global Impression-Severity of the disorder; DES, Dissocative Experience Scale; DES-T, Dissociative Experiences Scale-Taxon; SPRAS, Sheehan Patient-Related Anxiety Scale.

Table 8 Comparison of the patients with and without comorbid personality disorder

Variable	Without personality disorder (n=442)	With personality disorder (n=164)	Statistics
Age	40.63±12.38	33.13±10.07	Mann–Whitney test: MW U=23,460; P<0.0001
Age at onset of the disorder	32.22±14.00	25.05±11.60	Mann–Whitney test: MW U=25,270; P<0.0001
Duration of the disorder	8.42±9.21	7.82±7.47	Mann–Whitney: MW U=35,600; ns
BDI-II-1	23.68±10.07	28.36±10.69	Mann–Whitney: MW U=25,640; P<0.0001
BAI-1	23.32±12.55	26.07±12.31	Mann–Whitney: MW U=30,420; P<0.05
SPRAS-1	59.12±39.16	61.74±23.45	Mann–Whitney: MW U=29,180; ns (P=0.06)
CGI-S-1	4.258±1.418	4.232±1.421	Mann–Whitney: MW U=35,940; ns
DES-1	13.01±15.55	17.52±14.51	Mann–Whitney: MW U=20,720; P<0.0001
DES-T-1	7.115±12.71	11.91±16.14	Mann–Whitney: MW U=24,100; P<0.0001
Antidepressant index	40.52±23.54 (n=374)	42.65±24.28 (n=128)	Mann–Whitney: MW U=22,750; ns
Anxiolytic index	15.75±15.87 (n=100)	16.36±15.90 (n=49)	Mann–Whitney: MW U=2,731; ns
Antipsychotic index	1.577±2.248 (n=107)	1.655±1.585 (n=50)	Mann–Whitney: MW U=2,482; ns
BDI-II relative change	0.29±0.51	0.22±0.42	Mann–Whitney: MW U=31,620, P<0.05
BAI relative change	0.09±0.74	0.10±0.52	Mann–Whitney: MW U=33,280; ns
SPRAS relative change	0.09±0.50	0.03±0.57	Mann–Whitney: MW U=28,090; ns
CGI-S absolute change	1.25±1.72	1.03±1.96	Mann–Whitney: MW U=33,280; ns
DES relative change	−0.1757±1.609	−0.3764±2.349	Mann–Whitney: MW U=24,630; ns
DES-T relative change	−0.7948±7.088	−0.7461±3.552	Mann–Whitney: MW U=21,910; ns

Abbreviations: BAI, Beck Anxiety Inventory; BDI-II, Beck Depressive Inventory, second edition; CGI-S, Clinical Global Impression-Severity of the disorder; DES, Dissocative Experience Scale; DES-T, Dissociative Experiences Scale-Taxon; ns, not significant; SPRAS, Sheehan Patient-Related Anxiety Scale.

Table 9 Backward stepwise regression with BDI-II relative change as the dependent variable

Model	Regressors	B	SE	β	t	Significance
8	Comorbid PD	−0.122	0.047	−0.128	−2.610	0.009
	BAI-1	−0.003	0.002	−0.091	−1.745	0.082
	DES-T-1	−0.006	0.002	−0.182	−3.463	0.001
	Relative	0.027	0.008	0.159	3.277	0.001
	DES-T change

Notes: ANOVA: F=10.33, df=391; P<0.000. Adjusted r²=0.087.

Abbreviations: ANOVA, analysis of variance; BAI, Beck Anxiety Inventory; BDI-II, Beck Depressive Inventory, second edition; DES-T, Dissociative Experiences Scale-Taxon; PD, personality disorder; SE, standard error.

Table 10 Backward stepwise regression with the BAI relative change as the dependent variable

Model	Regressors	B	SE	β	t	Significance
7	BAI-1	0.017	0.003	0.308	5.540	0.000
	BDI-II-1	−0.007	0.004	−0.104	−1.872	0.062
	DES-T-1	−0.009	0.002	−0.192	−3.718	0.000
	Relative	0.046	0.016	0.134	2.819	0.005
	DES change

Notes: ANOVA: F=11.26, df=407; P<0.000. Adjusted r²=0.092.

Abbreviations: ANOVA, analysis of variance; BAI, Beck Anxiety Inventory; BDI-II, Beck Depressive Inventory, second edition; DES, Dissocative Experience Scale; DES-T, Dissociative Experiences Scale-Taxon; df, degrees of freedom; SE, standard error.

Table 11 Backward stepwise regression with CGI-S absolute change as the dependent variable

Model	Regressors	B	SE	β	t	Significance
9	CGI-S-1	0.889	0.054	0.696	16.461	0.000
	BDI-II-1	−0.023	0.007	−0.133	−3.171	0.002
	Relative	0.052	0.022	0.093	2.326	0.021
	DES-T change

Notes: ANOVA: F=97.34, df=341; P<0.000. Adjusted r²=0.459.

Abbreviations: ANOVA, analysis of variance; BDI-II, Beck Depressive Inventory, second edition; CGI-S, Clinical Global Impression-Severity of the disorder; DES-T, Dissociative Experiences Scale-Taxon; df, degrees of freedom; SE, standard error.

Table 12 Logistic regression – predictors for achieving remission (CGI-S last 1 or 2)

Variables in the equation
Step	Variable	B	SE	Wald	df	Significance	Exp (B)
16	Diagnosis			19.396	9	0.022
	Depression	−1.426	0.912	2.443	1	0.118	0.240
	Panic/agoraphobia	−1.241	0.940	1.742	1	0.187	0.289
	Social phobia	−1.993	0.983	4.107	1	0.043	0.136
	GAD/MAD	−1.782	0.913	3.806	1	0.051	0.168
	OCD	−2.226	0.969	5.280	1	0.022	0.108
	PTSD	−3.079	1.379	4.984	1	0.026	0.046
	Adjustment disorders	−1.169	0.933	1.569	1	0.210	0.311
	Dissociative/conversion disorders	−2.043	1.138	3.220	1	0.073	0.130
	Somatoform disorders	−3.509	1.150	9.313	1	0.002	0.030
	Occupation	−0.397	0.262	2.301	1	0.129	0.672
	DES-1	−0.031	0.016	3.836	1	0.050	1.032
	DES-T-1	−0.066	0.020	10.302	1	0.001	0.936
	BDI-II-1	−0.039	0.014	8.070	1	0.005	0.962

Notes: Chi-square test: P<0.000. Nagelkerke’s R²=0.207.

Abbreviations: BDI-II, Beck Depressive Inventory, second edition; CGI-S, Clinical Global Impression-Severity of the disorder; DES, Dissocative Experience Scale; DES-T, Dissociative Experiences Scale-Taxon; df, degrees of freedom; GAD, generalized anxiety disorder; OCD, obsessive compulsive disorder; PTSD, posttraumatic stress disorder; SE, standard error.