The Nottingham Study of Neurotic Disorder: predictors of 12-year outcome of dysthymic, panic and generalized anxiety disorder
Abstract
Background. Controlled prospective studies of the simultaneous long-term outcome of several mental disorders are rare. This study sought to determine if there were important differences between the outcome of anxiety and depressive disorders after 12 years and to examine their main predictors. Method. A cohort of 210 people seen in general practice psychiatric clinics with a DSM-III diagnosis of generalized anxiety disorder (71), panic disorder (74), or dysthymic disorder (65), including combined anxiety-depressive disorder (cothymia) (67) was followed up after 12 years. Interview assessments of symptoms, social functioning and outcome were made, the latter using a new scale, the Neurotic Disorder Outcome Scale. Seventeen baseline predictors were also examined. Results. Data were obtained from 201 (96%) patients, 17 of whom had died. Only 73 (36%) had no DSM diagnosis at the time of follow-up. Using univariate and stepwise multiple linear regression those with cothymia, personality disorder, recurrent episodes and greater baseline self-rated anxiety and depression ratings had a worse outcome than others; initial diagnosis did not contribute significantly to outcome and instability of diagnosis over time was much more common than consistency. Conclusion. Only two out of five people with the common neurotic disorders have a good outcome despite alleged advances in treatment. Those with greater mood symptoms and pre-morbid personality disorder have the least favourable outcome. It is suggested that greater attention be paid to the concurrent treatment of personality disorder and environmental factors rather than symptoms as these may be the real cause of apparent treatment resistance.
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Other naturalistic long-term follow-up investigations show high rates of persistent illness and recurrences in dysthymia and panic disorder with agoraphobia.
“These findings are in accordance with other naturalistic long-term follow-up investigations showing high rates of persistent illness and recurrences in dysthymia and panic disorder with agoraphobia [2,3,8].”
From Helpful and hindering factors for remission in dysthymia and panic disorder at 9-year follow-up: A mixed methods study (2008) · cites this paper as [2]
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“…higher baseline self-reported anxiety/depression, plus premorbid PD predicted the least favorable outcome, whereas initial Axis I diagnosis per se did not predict outcome, and “instability of [Axis I] diagnosis over time was much more common than consistency” (Tyrer et al. 2004, p. 1385).”
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“Patients with ‘co-morbid’ depression and generalised anxiety disorder have a more severe and prolonged course of illness and greater functional impairment (Tyrer et al., 2004).”
BackgroundClassification, assessment, prevalence, and effect of personality disorder
Tyrer, P., Reed, G. M., & Crawford, M. J. (2015) · The Lancet · doi:10.1016/s0140-6736(14)61995-4 · Cited by 656 · see citing works
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“…about 55% of patients with personality disorder had a poor outcome compared with about 45% of those without, demonstrating that many of those with depression and personality disorder remain unwell, a feature that is particularly noticeable in the long term (Kennedy et al, 2004; Tyrer et al, 2004).”
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“Obesity, mood disorders, and anxiety disorders are associated with a variety of negative outcomes [42–47].”
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“indicates increased severity, functional impairment and economic costs (Andrews et al., 2002; Moffitt et al., 2007; Tyrer et al., 2004; Zhu et al., 2009).”
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“Patients with comorbid major depression and GAD tend to have a more severe and prolonged course of illness and greater functional impairment (Judd et al. 1998 ; Tyrer et al. 2004).”
BackgroundPersonality pathology recorded by severity: national survey
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“GAD and major depression have a similar degree of functional impairment(8,9) but patients with comorbid major depression and GAD have a more severe and prolonged course of illness and greater impairment.(10) GAD is also common among patients with “medically unexplained” chronic pain,(11) chronic physical ill-health,(1…”
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“, 2004), and even between depressive disorders and anxiety disorders (Fichter et al., 2010; Merikangas et al., 2003; Rhebergen et al., 2011; Scholten et al., 2013a; Tyrer et al., 2004; Wittchen et al., 2000).”
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The 7-year course of depression and anxiety in the general population
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“(26) found that 36% of 210 outpatients with a neurotic disorder (dysthymia, panic disorder, or generalized anxiety disorder) was free of a DSM diagnosis after 12 years of follow-up.”
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Self-citationWomen, anxiety and mood: a review of nomenclature, comorbidity and epidemiology
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Comorbid depression, but not comorbid anxiety disorders, predicts poor outcome in anxiety disorders.
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“This finding has led to criticism of the present diagnostic system by European and Australian clinicians [Andrews, 1996; Tyrer et al., 2004; May, 2005] who contend that the so-called ‘‘comorbidity’’ is actually a consequence of the splitting of the neurosis concept into several anxiety and mood…”
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“…in panic disorder with or without agoraphobia [PD(A)], just as it is in late‐life anxiety and depression (Basoglu et al., 1994; Seivewright et al., 1998; Slaap and den Boer, 2001; Ramnero and Ost, 2004; Tyrer et al., 2004; Mitchell and Subramaniam, 2005; Dow et al., 2007a; Dow et al., 2007b).”
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PERSONALITY DISORDERS AND THE PERSISTENCE OF ANXIETY DISORDERS IN A NATIONALLY REPRESENTATIVE SAMPLE
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“In addition to borderline PD, schizotypal, narcissistic, and avoidant PDs all had significant effects on the persistence of multiple anxiety disorders.”
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Bokma, W. A., Wetzer, G. A. A. M., Gehrels, J. B., Penninx, B. W. J. H., Batelaan, N. M., & Balkom, A. L. J. M. (2019) · Depression and Anxiety · doi:10.1002/da.22895 · Cited by 58 · see citing works
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“…for example, it is more likely for those with greater impulsiveness and dramatic behaviour to develop substance misuse disorder and for those with greater anxiousness to develop phobic and other anxiety disorders (Tyrer et al. 1992, 2004; Khan et al. 2005; Krueger, 2005; Moran et al. 2006).”
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“In a similar cohort of 68 people with generalised anxiety disorder alone (as defined by DSM-III criteria) at initial assessment and followed over 12 years, two had the disorder alone after 12 years, 28 no longer had a diagnosis, 12 had developed dysthymic disorder, and 10 had developed depression; the rest had been lo…”
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“However, inmates with undetected personality pathology (Tyrer et al., 2004) may develop severe functional impairment and behavior management problems.”
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Pharmacological Treatment of Generalized Anxiety Disorder
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“32,33 It appears that, for the majority of those with MADD this can be considered a self-limiting condition, with improvements expected for most in the short and longer term.”
The General Neurotic Syndrome: A Re-Evaluation
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“In fact, a poor response to treatment was related to any PersD, regardless of cluster or specific diagnosis (1, 18, 20), to PersD of the anxious-fearful cluster (21), particularly avoidant PersD (16, 18), to PersD of the dramatic cluster (22).”
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BackgroundResultWhat can be learnt from the natural history of anxiety disorders?
Rubio, G., & López-Ibor, J. J. (2006) · European Psychiatry · doi:10.1016/j.eurpsy.2006.09.007 · Cited by 29 · see citing works
“Long-term studies with more than 10 years of follow-up of PD are rare, and have been carried out with small numbers of patients [2,7,8,49,52].”
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“Patients were subsequently followed-up over a 12-year period (8).”
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Rhebergen, D., & Graham, R. (2013) · Current Opinion in Psychiatry · doi:10.1097/yco.0000000000000022 · Cited by 23 · see citing works
“[9] demonstrated the diagnostic instability of these psychiatric conditions, once collectively described as neurotic disorders (dysthymic disorder, MDD, GAD and panic disorder) – and these findings have been supported in data-based studies.”
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Premature mortality of people with personality disorder in the Nottingham Study of Neurotic Disorder
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Impact of severity of personality disorder on the outcome of depression
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“This study was undertaken in the context of conflicting findings regarding the relationship between personality disorder and outcome of treatment for Axis 1 psychiatric disorders: for example, while there is strong evidence that personality disorder is associated with poor prognosis in neurotic disorders [17,23], the…”
BackgroundSelf-citationAnxiety states: a review of conceptual and treatment issues
Starčević, V. (2005) · Current Opinion in Psychiatry · doi:10.1097/01.yco.0000194146.81024.5a · Cited by 20 · see citing works
Personality change in the Nottingham Study of Neurotic Disorder: 30-Year cohort study
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“At 12 years follow-up, some participants were assessed who did not have measures at 2 years (Tyrer et al., 2004).”
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Self-citationHengartner, M. P., Tyrer, P. J., Ajdacic‐Gross, V., Angst, J., & Wulf Rössler, A. (2017) · European Archives of Psychiatry and Clinical Neuroscience · doi:10.1007/s00406-017-0796-8 · Cited by 17 · see citing works
Self-citationSvanborg, C., Bäärnhielm, S., Åberg Wistedt, A., & Lützen, K. (2008) · BMC Psychiatry · doi:10.1186/1471-244x-8-52 · Cited by 14 · see citing works
“These findings are in accordance with other naturalistic longterm follow-up investigations showing high rates of persistent illness and recurrences in dysthymia and panic disorder with agoraphobia [2,3,8].”
BackgroundResultYang, M., Tyrer, P. J., & Tyrer, H. (2022) · Personality and Mental Health · doi:10.1002/pmh.1548 · Cited by 15 · see citing works
“…on continuous clinical measures including the Social Function Questionnaire (SFQ) (Tyrer et al., 2005), the Neurotic Disorders Outcome Scale (NDOS) (Tyrer et al., 2004) and clinical symptomatology, Pearson's correlation coefficient was used to study the association at 12 and 30 years, respectively.”
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Pharmacological interventions for anxiety in Parkinson’s disease sufferers
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An examination of generalized anxiety disorder and dysthymic disorder by latent class analysis
Rhebergen, D., van der Steenstraten, I. M., Sunderland, M., de Graaf, R., ten Have, M., Lamers, F., Penninx, B. W. J. H., & Andrews, G. (2013) · Psychological Medicine · doi:10.1017/s0033291713002225 · Cited by 14 · see citing works
“They concluded that the outcomes give some support to the notion of the general neurotic syndrome – a coaxial diagnosis of mixed anxiety and depression and personality pathology (Tyrer et al. 2003, 2004).”
BackgroundTreatment of panic disorder: recent developments and current status
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“However, approximately 30%–60% of the patients remain symptomatic after treatment.(6,7) Many studies focused on sociodemographic factors that may positively influence treatment response.”
Stein, D. J. (2013) · South African Journal of Psychiatry · doi:10.4102/sajpsychiatry.v19i3.950 · Cited by 12 · see citing works
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“A 12‐year follow‐up study of patients with GAD and/or dysthymic disorder and/or panic disorder found that patients with greater levels of mood symptoms and pre‐morbid personality disorder symptoms had the worst outcomes (Tyrer et al., 2004).”
BackgroundComplex personality disorder in bulimia nervosa
Rowe, S. L., Jordan, J., McIntosh, V. V. W., Carter, F. A., Frampton, C. M., Bulik, C. M., & Joyce, P. R. (2010) · Comprehensive Psychiatry · doi:10.1016/j.comppsych.2010.02.012 · Cited by 10 · see citing works
“Unlike those studies that reported poorer treatment response, worse outcome, and greater disability associated with complex PD [9,10,32], we found that significant pretreatment differences in eating disorder attitudes (drive for thinness, body dissatisfaction), general psychosocial functioning, and…”
Dependent personality, separation anxiety disorder and other anxiety disorders in OCD
Mroczkowski, M. M., Goes, F. S., Riddle, M. A., Grados, M. A., Bienvenu, O. J., Greenberg, B. D., Fyer, A. J., McCracken, J. T., Rauch, S. L., Murphy, D. L., et al. (2015) · Personality and Mental Health · doi:10.1002/pmh.1321 · Cited by 10 · see citing works
Domschke, K., Kapfhammer, H., & Deckert, J. (2017) · Springer eBooks · doi:10.1007/978-3-662-49295-6_69 · Cited by 8 · see citing works
Evidence-based pharmacotherapy of generalized anxiety disorder
Baldwin, D. S., Waldman, S., & Allgulander, C. (2012) · Cambridge University Press eBooks · doi:10.1017/cbo9780511910395.008 · Cited by 8 · see citing works
Tyrer, P. J., Wang, D., Tyrer, H., Crawford, M., Loebenberg, G., Cooper, S., Barrett, B. M., & Sanatinia, R. (2020) · Personality and Mental Health · doi:10.1002/pmh.1496 · Cited by 8 · see citing works
Self-citationHengartner, M. P., & Yamanaka, M. (2017) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2017.00009 · Cited by 7 · see citing works
Kişilik bozukluklarının tanısı: yeni bulgular ile tanıda kullanılan anket ve ölçekler
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Personality disorder 1 Classifi cation, assessment, prevalence, and eff ect of personality disorder
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“Other broader items included were social function and scores on the Neurotic Disorder Outcome Scale (NDOS) [30], a 10 point measure of longitudinal outcome.”
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Neurotic, stress-related and somatoform disorders
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Relationship between personality traits and panic disorder.
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Tyrer, P. J. (2008) · Cambridge University Press eBooks · doi:10.1017/cbo9780511544125.008 · Cited by 3 · see citing works
Self-citationInfluencia de los trastornos de la personalidad en el pronóstico de la depresión
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ten Have, M., Tuithof, M., van Dorsselaer, S., Batelaan, N. M., Penninx, B. W. J. H., Luik, A. I., & Vermunt, J. K. (2024) · Psychological Medicine · doi:10.1017/s0033291724001740 · Cited by 2 · see citing works
“Additionally, a growing body of research has found evidence for quite high transition rates over time between depressive and anxiety disorders (Fichter, Quadflieg, Fischer, & Kohlboeck, 2010; Merikangas et al., 2003; Tyrer, Seivewright, & Johnson, 2004).”
- Authors
- TYRER, P., SEIVEWRIGHT, H., & JOHNSON, T.
- Affiliations
- MRC Biostatistics Unit (GB)
- Venue
- Psychological Medicine
- Publisher
- Cambridge University Press (CUP)
- Published
- 2004-11
- Volume
- 34
- Issue
- 8
- Pages
- 1385-1394
- ISSN
- 0033-2917 (ISSN-L)
- 1469-8978
- OpenAlex
- W2167393079
- Cited by
- 119
- References
- 0
- Citations by year
- 2026: 1 · 2025: 1 · 2024: 1 · 2023: 3 · 2022: 4 · 2021: 7 · 2020: 4 · 2019: 4 · 2018: 4 · 2017: 7 · 2016: 9 · 2015: 7 · 2014: 5 · 2013: 9 · 2012: 3
- FWCI
- 9.45
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Psychological Medicine (publishedVersion)
- PubMed (publishedVersion)
- Spiral (Imperial College London) (submittedVersion)
- Topics
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
- Social Sciences › Psychology › Clinical Psychology › Personality Disorders and Psychopathology
- Keywords
- neurosis, long-term outcomes, dysthymia, panic disorder, generalized anxiety disorder, personality disorders, prognostic factors, treatment resistance, social functioning
- MeSH terms
- Adult, Female, Follow-Up Studies, Humans, Male, Middle Aged, Prognosis, Recurrence, Cohort Studies, Panic Disorder, Treatment Outcome, Dysthymic Disorder
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