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Byline: Uzma Masroor, Mussarat Jabeen Khan and Nazia Iqbal


Objective: The present research aimed at exploring if outcomes show difference when psychotherapeutic intervention is practiced on patients who are diagnosed with a single clinical disorder (anxiety or depressive disorder) and who have an additional diagnosis of personality disorder. It was hypothesized that patients diagnosed with anxiety and depressive disorder (Axis I) alone will show better progress in treatment through psychotherapy, as compared to those having an additional diagnosis of some personality disorders(on axis II).

Place of Study: Karachi and Islamabad, Pakistan.

Sample and Method: The sample selected consisted of diagnosed 60 patients (36 males /24 females) diagnosed with either anxiety or depressive disorders as per DSM criteria, and pursued psychological treatment from different professionally qualified clinical psychologists (N=9), age ranged between 18 to 55, from psychiatric units of different hospitals and psychological clinics of Karachi and Islamabad. The sample was further divided into two groups, one with single axis I diagnosis (n=30) and the second group (n=30) having an additional diagnosis of personality disorders (Axis II). After controlling principal and additional diagnoses, the subjects' GAF scale (DSM-IV-TR) before the treatment started was noted from data files. All the patients were asked to fill in "Questionnaire of personal change (Q-PC)" by Krampen before and after completion of initial 30 sessions, and GAF scale was rerated to assess the improvement in global functioning.

Results: The results revealed momentous improvement in patients who suffered from single Axis I diagnosis as compared to those who also had an additional diagnosis of personality disorders on Axis II.

Conclusion: It was concluded that psychotherapeutic outcomes are influenced negatively by co-occurrence of personality disorder.

Key words: Psychotherapeutic outcomes; comorbidity; personality disorder


The term psychotherapy was referred as the informed and intentional application of clinical methods and interpersonal stances derived from established psychological principles for the purpose of assisting people to modify their behaviors, cognitions, emotions, and other personal characteristics in directions that the participants deem desirable . Psychotherapy has been found an effective strategy for managing psychiatric disorders.

There are numerous psychiatric disorders as categorized by DSM IV -TR, and each one manifests itself in variety of symptoms and conditions, which are of primary concern to a clinician. After addressing them with medicine initially (if required), the emphasis is placed on psychotherapy for long term remediation. Principle diagnosis (based on reason for referral or predominant symptoms) is stated on Axis I as per Multi-axial system of diagnosis by DSM-IV-TR, while personality disorders are placed on Axis II. They can be characterized by distinguishable personality types with enduring patterns of behaviors usually associated with significant distress or disability. The patients of personality disorder are identified as deviating from social expectations as well. This category of disorders is found to be usually diagnosed in 40-60 percent of psychiatric patients, hence can be referred as the most frequent of all psychiatric diagnoses.

Mood and anxiety disorders are noted to be mostly co morbid with Personality Disorders. Psychiatric disorders cause considerable life suffering as symptoms and features become hindrance in normal functioning of individuals, usually witnessed by person himself or family members. The situation becomes worse in case of presence of either one or more personality disorders. Though many studies remained limited to the examination of single Axis I diagnostic groups or explicit personality disorders types , yet the co-occurrence between Axis I disorders (clinical disorders) and Axis II personality disorders (PDs) has been widely studied with Psychiatric inpatient or outpatient samples . In other words patients with Personality Disorders (PDs) are liable to have substantial impairment as evident by poor treatment outcomes when show recurrence of Axis I disorders.

There is also existing evidence that anxiety disorders, mood disorders, and substance use disorders are associated with Personality disorders in general population . Personality psychopathology is suggested to be ruled out in all patients with major depressive disorder specifically and addressed in treatment as there is established evidence of prevalence of personality disorders as borderline personality disorder among patients with Mood disorders. It has been evident that clinical disorders which usually without psychotic content show better progress then PDs, due to endurable and inflexible pattern. Several researches compared the two in terms of outcomes after psychotherapy. According to a study the patients with anxiety and depression show better improvement than personality disorders . Though the nature of Personality type affects the outcomes in terms of time ration taken, like borderline Personality disorder may take longer than others.

Depression has shown positive outcome in psychotherapy but that the presence of personality disorder does impede the process . Cognitive Behavior Therapy (CBT) is typically limited to episodes of 6-20 weeks, once weekly, while in the case of personality disorders, episodes of therapy are mostly repeated often over the course of years to become aware of and understand their emotions which may be more beneficial in facilitating change. Interpretive or expressive therapy, with its focus on painful emotions and intra-psychic conflicts, is more likely to provide opportunity to male patients with new overcoming methods for dealing with their problems. The present research was designed to explore the interfering role of an additional Axis II diagnosis in Pakistani population once the anxiety or depressive disorder has already been diagnosed.

The availability and effective practice of psychotherapeutic intervention appears to be limited as the awareness and training in this type of consultation is in its infancy. The co-occurrence of Axis I and II diagnosis has an established background throughout the world as literature suggests, and the current research intends to observe the same phenomenon in the Pakistani culture. The pervasive pattern of personality disorder is usually overlooked and people rarely seek treatment for this specifically. Another objective of the present research is to explore the effectiveness of psychotherapy in general, with respect to gender and age in Pakistani population.



Questionnaire of Personal Changes (Q-PC)

Questionnaire of Personal Changes" (Q-PC) was developed by Krampen1. It is based on the foundations and theory of change in integrative and differential psychotherapy 45. It is consisting of 12 items with 7-point rating scale ranging from +3 to -3. +3 = strong positive change, +2 = medium positive change, +1 = weak positive change, 0 = no change, -1 = weak negative change, -2 = medium negative change, -3 = strong negative change". The Cronbach's alpha reliability of Questionnaire of Personal Changes (Q-PC) is 0.94.

The Global Assessment of Functioning (GAF)

It is a numeric scale (0 through 100) used by mental health clinicians and physicians to subjectively rate the social, occupational, and psychological functioning of adults, e.g., how well or adaptively one is meeting various problems-in-living.GAF also considered important as segment of multi-axial system of diagnosis as it indicates the level of current functioning of individual on the average. For paper and pencil administration of GAF the Cronbach's alpha reliability is 0.98.

Sample and Procedure

The selected sample consisted of diagnosed 60 psychiatric patients (36 males /24 females) on the basis of convenience sampling , already under psychological treatments from different professionally qualified clinical psychologists (n=9), age ranged from 18 to 55 from psychiatric units of four different hospitals and two psychological clinics of Karachi and Islamabad. The sample was further divided in two groups, one with single axis I diagnosis (anxiety or depressive disorder) (n=30), 12 males and 18 females, second group having an additional diagnosis of personality disorders (Axis II), (n=30) 13 males and 17 females. Permission was taken from the concerned authorities of the psychiatric departments of the hospitals. All subjects were registered patients of respective hospitals and were taking medicine for at least last six months.

As a pre-assessment, the GAF Scale rating was taken after a detailed psycho diagnostic assessment conducted by a certified psychologist, also the Q-PC, was filled by the patient him/herself. The same procedure was repeated as post assessment on completion of 30 sessions by their psychologists using eclectic approach in providing psychotherapy.


Table 1 Alpha Reliability Coefficient of Questionnaire of Personal Changes (Q-PC)

Scale###Number of items###Reliability

Questionnaire of Personal Changes (Q-PC)###12###.94

Table 1 show that the reliability of Questionnaire of Personal Changes (Q-PC) is highly satisfactory.

Table 2 Mean Difference between patients with clinical disorders only and patients having an additional diagnosis of personality disorder on Questionnaire of Personal Changes and Global Assessment of Functioning (N = 60)

###PCI###PCI and PD

###(n=30)###(n=30)###95% CI

###M (SD)###M (SD)###T###p###LL###UL

Q-PC###74.53( 1.99)###57.67(1.09)###40.60###.000###16.04###17.69

GAF###85.20( 2.81)###70.33( 1.97)###23.73###.000###13.61###16.12

df= 78; Note. PCI= Patients with Clinical Disorder; PCI and PD= Patients with clinical disorder + personality disorder; CI= Confidence Interval; LL= Lower Limit; UL= Upper Limit.

Table 2 shows the mean differences between patients with clinical disorders and patients with clinical disorders having an additional diagnosis of personality disorder. Patients with clinical disorders have better outcomes as indicated by rating on Q-PC (M=74.53, SD= 1.99) and GAF (M=85.20, SD= 2.81) compared to patients with clinical disorders having an additional diagnosis of personality disorder as showed by rating on Q-PC (M=57.67, SD= 1.09) and GAF (M=70.33, SD= 1.97).

Table 3 Mean difference between Male and Female patients on Questionnaire of Personal Changes and Global Assessment of Functioning (N = 60)


###(n=36)###(n=24)###95% CI

###M (SD)###M (SD)###T###P###LL###UL

Q-PC###71.78(6.52)###57.58 (1.10)###10.54###.000###11.49###16.89

GAF###82.72 (6.20)###70.33(2.07)###9.414###.000###9.76###15.02

df= 78 Note. Q-PC=Questionnaire of Personal Changes; GAF=Global Assessment of Functioning CI= Confidence Interval; LL= Lower Limit; UL= Upper Limit.

Table 3 shows the mean differences between male and female patients on Q-PC and GAF. Male patients have better outcomes as indicated by rating on Q-PC (M=71.78, SD=6.52) and GAF (M=82.72, SD= 6.20) compared to female patients as showed by rating on Q-PC (M=57.58, SD= 1.10) and GAF (M=70.33, SD= 2.07).

Table 4 Frequencies of Personality Disorders among Psychiatric Patients

Personality Disorders###Diagnosis

###Anxiety Disorder###Depression




Obsessive Compulsive###4###1


Without Personality Disorders###17###13


There has been an evidence of efficacy of different types of psychotherapies with general psychiatric patients as Seligman reported, regardless of specific modality preferred. However its efficacy depends upon several factors that include therapists' personality variables, severity and duration of disorder, patients' own support system and insight etc. . One of them has been identified as an additional diagnosis at Axis II that sometimes interferes with the psychotherapy outcomes. Patients who suffer from a single clinical disorder that can be distinctively diagnosed on Axis I, while an, additional co-occurring disorder on the same axis or on Axis II usually assume to be impeding the treatment outcomes. As it was hypothesized that patients who have been diagnosed with clinical disorder (either anxiety or depressive) will show better progress with psychotherapy as compared to those who have an additional diagnosis of personality disorder (Table 2), has been complimented by results on both measures used.

The findings remain consistent with literature reviewed, many other in the field have found out the same results like Skodol, et al. ; Steketee, Chambless and Tran . A study comparing therapeutic outcomes of patients with agoraphobia and Obsessive Compulsive disorder with the interfering effects of a co-existing diagnosis of personality disorder concluded the same. The Pakistani population taken for the present study is already in dilemma of suffering while the treatment, as sixty eight percent populations is rural , not sought and is considered the last option when the normal functioning is almost diminished. People usually prefer medicine and rarely show compliance to psychotherapy as the previous is of instant relief. It is a challenging task for a psychologist to make sure about the persistent availability of client until the results are obvious.

In such scenario the diagnosis of personality disorder demands more time and effort to work with, addressing the dominant and apparent presenting symptoms is a priority, hence is ignored mostly.

As far as the prevalence of co morbidity with two major disorders is concerned, the present research identified anxiety relatively more with co-existing personality disorder, usually with cluster C (fearful/anxious) that also has been observed in several studies. In Pakistani population the depressive and anxiety disorders are most frequently diagnosed disorders, however the personality disorders are overlooked due to time, availability and patient's compliance. The present research intended to provide traditional psychotherapy to address the chief symptoms of either anxiety or depressive disorder, though the specific strategies for treatment of enduring patterns of co-existing personality disorder were also incorporated in the treatment plan.

The gender differences have been observed as per predicted in the light of previous body of researches, i.e. males show better outcomes in psychotherapeutic intervention as compared to females. The mean differences between male and female patients on Questionnaire of Personal Change (Q-PC) and Global Assessment of Functioning (GAF) is indicated by rating by significant difference as shown in table 3. For the present research the gender was taken as to be displaying different results depending in general. As the results indicated that male have shown better progress then females on measures of outcomes.The results obtained can be explained in terms of Pakistani culture and society that women suffer from anxiety and depression more as compared to males ,that already has been studied before in the very same culture by Creed .

There are several factors to attribute to high prevalence of occurrence and lower improvement through psychotherapy, like marital issues, gender role expectations, living with an extended family, inter-personal conflicts, and lack of social interaction as also endorsed by a study conducted by Hussain .

These factors are common in almost all situations for females and support to deal with them effectively is very low. Pursuing for permission or approval from the husband and sometimes in-laws family members for seeking psychological help and considering the view points of others in family before making any decision are also potential obstacles for showing better outcomes in therapy in the same culture. It becomes an issue of great controversy to reveal the inner matters to a stranger (therapist) and discussing about the relational and personal problems for the purpose of treatment is also taken offensive and is observed as a cultural taboo as also observed by Randhawa and Stein and Tabassum while studying the mental health of South Asian women. Instead of proving something beneficial it is seen as damage to the family's reputation.

The purpose of discussing the multifaceted issues encountered by females in this society is that either an extensive effort is required on the part of therapist to initially address the immediate concerns or relatively longer period of time is to be ensured for engaging the women in psychotherapy for better outcomes. Males in contrast can manage the availability, time and autonomy for the psychological treatment.

Another assumption related to age factor and therapeutic revealed better side of patients below 30 years of age. Although age is an important factor regarding the outcomes in psychological treatment and youngers show better improvement as concluded by Haddock, Lewis, Bentall, Dunn and Tarrier . As it has been mentioned already that the information gathered through researches is very limited concerning the psychological treatment outcome as very less consideration has been given to this mode of treatment

The individuals aware of this modality i.e. psychological treatment in the form of psychotherapy, are expected to show better understanding and insight into taking it as a matter of changing thought patterns and psychological developments as compared to middle aged or older. Secondly the development of some disorder during early years of life are relatively thought to be curable as compared to later age rigidity, when problem is rooted deeper as the change in personality is less likely to occur as established by Mroczek and Spiro .

The overall findings of present research supported the assumptions drawn from preexisting body of knowledge. In brief it was concluded that the patients suffering from clinical disorders (anxiety and depression), when treat with psychotherapy in addition to medicine ,they show better progress in reduction of symptoms. While patients who, though suffer from either of these disorders in addition to at least one personality disorder. Male patients show better progress as compared to females.

Limitations and suggestions

The study was limited to the subjects and regions; hence the results obtained cannot be fully generalized over the population widely. Additionally the type of therapy used, the therapists' variables, and severity level of disorder should also be taken into account for more accurate findings. The present research can be helpful to emphasize the ruling out of any pre-existing disorder for the clinician so the possible hindrance could be removed by adopting specific therapeutic strategies addressing personality disorders.

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Publication:Pakistan Journal of Clinical Psychology
Article Type:Report
Geographic Code:9PAKI
Date:Dec 31, 2013

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