Recovery from dysthymia and panic disorder : Options and obstacles

Dysthymia, a depressive disorder with usually an insidious, early onset (before age 21), and panic disorder are psychiatric disorders with a major impact on public health due to their high frequency of recurrence, persistent course and superimposed major depressions. This thesis aimed to improve knowledge of factors that help or hinder recovery from such disorders in ordinary outpatient psychiatric settings. A focus was how various understandings of illness may affect recognition, treatment and outcome. The thesis consists of a study that examined the validity of a self-report instrument for DSM-IV personality disorders, the DIP-Q, in different clinical samples (Paper I), and a prospective 9-year longitudinal study of patients with dysthymia and panic disorder that combined quantitative and qualitative methods (Papers II & III). Paper II presented the long-term outcome, stability of change and impact of comorbid personality disorders. For the investigation of lifetime course and treatments, a modification of the NIMH Life-Charting Methodology was used. Paper III examined the phenomenon of recovery by analysing in-depth interviews with qualitative content analysis. A theory-testing and explorative multiple-case study used developmental cognitive theory as a framework to examine barriers to recognition and treatment for patients with early-onset dysthymia (Paper IV). Personality disorders (PD) evaluated by DIP-Q discriminated between different clinical samples and healthy controls, and the self-assessed PD had independent strong associations to depression and belonging to a sample of psychotherapy applicants. In Paper II, low recovery rates were observed; about 50% had improved, of whom 25% had recovered. Life-charting and case records indicated that undertreatment contributed to poor outcome. Comorbid PD was a negative prognostic factor and patients with panic disorder had deteriorated compared to the 2year outcome. Based on the qualitative analysis in Paper III, a general model for recovery from dysthymia and panic disorder is suggested, involving: (1) understanding self and mechanisms of illness, (2) enhanced flexibility of thinking, (3) change from avoidance coping to approach coping, and that a helpful relationship to the health care provider is a vehicle for this change. Patients with dysthymia and panic disorder described specific helpful relationships to therapists (‘as a parent’ vs. ‘as a coach’) and central areas for change (self-acceptance and resolution of relational problems vs. identifying and handling feelings), indicating necessity of distinguishing early onset (before age 21) dysthymia from secondary depressions. The common main obstacle was difficulty in negotiating treatments. Non-remitted patients with PD had problems expressing needs, which may explain why comorbid PD is a negative prognostic factor. Paper IV showed that barriers to treatment of dysthymia could be explained by misunderstandings as patients mainly expressed illness with a complexity of concrete, perceptually bound language structures and providers focused mainly on a single aspect. Other barriers were patients’ core pattern of concealing due to fear of rejection and distrust, providers’ attitudes, access problems and providers’ lack of follow-up. To achieve higher recovery rates and reduce inequalities in attaining care, comorbid PD need to be assessed and addressed in ordinary psychiatric practice. Early-onset dysthymia needs to be recognised and distinguished from secondary depressions, e.g. by noting cognitive core symptoms and examining age of onset. To enhance collaboration, means of shared understanding and treatment planning are suggested, such as combining diagnostic assessments with attention to patients’ perceptually bound understanding of illness, goals and treatment preferences, as well as systematic follow-up including re-evaluations. Life-charting may be a tool. Key-words: dysthymic disorder, panic disorder, personality disorder, remission, recovery, mixed methods design, long-term follow-up, therapeutic relationship, patient preferences and experiences LIST OF PUBLICATIONS The thesis is based on the following papers, which will be referred to in the text by their Roman numerals. I. Bodlund, O., Grann, M., Ottosson, H., & Svanborg, C. (1998). Validation of the self-report questionnaire DIP-Q in diagnosing DSM-IV personality disorders: A comparison of three psychiatric samples. Acta Psychiatrica Scandinavica, 97, 433-439. II. Svanborg, C., Aberg Wistedt, A. & Svanborg, P. Long-term outcome of patients with dysthymia and panic disorder: A naturalistic 9-year follow-up study. Nordic Journal of Psychiatry. In Press 2008 III. Svanborg, C., Baarnhielm, S., Aberg Wistedt, A. & Lutzen, K. Helpful and hindering factors to remission in dysthymia and panic disorder at 9-year follow-up: A mixed methods study. Manuscript IV. Svanborg, C., Scarpinati Rosso, M., Lutzen, K., Aberg Wistedt, A. & Baarnhielm, S. Barriers in the help-seeking process: A multiple-case study of early-onset dysthymia in Sweden. Nordic Journal of Psychiatry.