There’s a load of research, and common sense, to suggest a strong relationship between anxiety disorders and underlying personality disorders, although the nature of this relationship can vary.
Comorbidity: Several studies have found high rates of comorbidity between anxiety disorders and personality disorders. For example, a study published in the Journal of Anxiety Disorders in 2011 found that among individuals with generalized anxiety disorder (GAD), nearly 60% had at least one personality disorder, with avoidant and obsessive-compulsive personality disorders being most common.
Shared Features: Both anxiety disorders and personality disorders share certain features, such as excessive worry, fearfulness, and difficulties in social interactions. This overlap in symptoms may contribute to the co-occurrence of these disorders.
Vulnerability Factors: Some research suggests that certain personality traits, such as neuroticism or high levels of trait anxiety, may predispose individuals to both anxiety disorders and personality disorders. Longitudinal studies have shown that these traits can precede the onset of anxiety disorders and may also increase the risk of developing certain personality disorders.
Underlying Mechanisms: There is ongoing research into the underlying mechanisms that may link anxiety disorders and personality disorders. For example, abnormalities in neurotransmitter systems (such as serotonin and dopamine) and dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis have been implicated in both types of disorders.
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A large body of research has explored the comorbidity between anxiety disorders and personality disorders. Skodol et al. found associations between certain types of anxiety disorders and specific personality disorders. For instance, panic disorder was linked with borderline, avoidant, and dependent personality disorders while social phobia was associated with avoidant personality disorder. Obsessive-compulsive disorder was connected to obsessive-compulsive and avoidant personality disorders ([Skodol et al., 1995](https://dx.doi.org/10.1016/0022-3956(95)00015-W)). Additionally, the presence of major depressive disorder in patients with panic disorder resulted in higher rates of comorbid personality disorders, particularly borderline, dependent, and obsessive-compulsive personality disorders ([Iketani et al.](https://dx.doi.org/10.1002/da.10050)).
Another study by Tomko et al. reported an 84.8% comorbidity rate of anxiety disorders in individuals with borderline personality disorder (BPD) in the community ([Tomko et al., 2013](https://dx.doi.org/10.1521/pedi_2012_26_093)). Moreover, recent research indicated that while social anxiety disorder (SAD) and antisocial personality disorder (ASPD) are separate conditions, there is a subtype of SAD that exhibits characteristics common to ASPD ([Galbraith et al., 2013](https://dx.doi.org/10.1016/j.janxdis.2013.11.009)).
The complexities of comorbidity were also highlighted in studies investigating the interplay between temperamental traits, dysfunctional attitudes, and the onset of comorbid anxiety disorders in patients with major depressive disorder (MDD) ([Öngür et al., 2005](https://dx.doi.org/10.1159/000084002); [Farabaugh et al., 2005](https://dx.doi.org/10.1002/da.20174)). The high prevalence of BPD comorbidity with anxiety disorders, bipolar disorder, and other personality disorders has been consistently supported by research ([Grant et al., 2008](https://dx.doi.org/10.4088/JCP.V69N0701); [Carpenter et al., 2016](https://dx.doi.org/10.1521/pedi_2015_29_197)).
Furthermore, the study by Carpenter et al. demonstrated that alcohol, cocaine, and opiate use disorders uniquely associated with BPD ([Carpenter et al., 2016](https://dx.doi.org/10.1521/pedi_2015_29_197)). Additionally, Ford and Courtois discussed the continuum of conceptualization between PTSD, complex PTSD (cPTSD), and BPD, suggesting a potential overlap that includes elements of dissociation in each disorder ([Ford & Courtois, 2021](https://dx.doi.org/10.1186/s40479-021-00155-9)).
Comorbidity studies in adolescents and adults further expand on the intricate relationship between these disorders. They illustrate the presence of complex comorbidity involving mood or anxiety disorders combined with a disorder of impulsivity as a distinguishing feature ([Ha et al., 2014](https://dx.doi.org/10.4088/JCP.13m08696)). Other studies have examined the familial aggregation of disorders such as generalized anxiety disorder and antisocial personality disorder, indicating potential hereditary aspects of comorbidity ([Kendler et al., 1997](https://dx.doi.org/10.1192/bjp.170.6.541)).
Considering impulsivity levels, Tóth et al. found that increased impulsivity could decrease the likelihood of comorbid anxiety disorders in individuals diagnosed with both borderline personality disorder and adult Attention Deficit Hyperactivity Disorder (aADHD) ([Tóth et al., 2022](https://dx.doi.org/10.1192/j.eurpsy.2022.1167)). These studies offer a nuanced view of the potentially symbiotic relationship between anxiety and personality disorders, with evidence pointing to a high degree of comorbidity and suggesting shared underlying psychological mechanisms.
In conclusion, the amassed research underscores a compelling likelihood of a bidirectional relationship between anxiety disorders and underlying personality disorders. The substantial rates of comorbidity observed in various studies, alongside the shared features and vulnerability factors implicated in both types of disorders, suggest a complex interplay between them. Moreover, the identification of specific associations between different anxiety disorders and personality disorders, as well as the recognition of unique subtypes and overlapping symptomatology, further accentuate the intricate nature of this relationship.
The findings elucidating the role of temperament, dysfunctional attitudes, and substance use disorders in the context of comorbidity provide additional layers of understanding, while studies examining the continuum of conceptualization between PTSD, complex PTSD, and BPD highlight potential overlaps and shared mechanisms.
Furthermore, insights from adolescent and adult populations, familial aggregation studies, and investigations into impulsivity levels contribute to a nuanced perspective on the symbiotic relationship between anxiety and personality disorders. Collectively, these findings offer robust evidence supporting the proposition that anxiety disorder sufferers may have an underlying personality disorder, and vice versa. Understanding this relationship is vital for more effective diagnosis, treatment planning, and interventions aimed at addressing the complex needs of individuals experiencing these co-occurring conditions.
As the P.D’s are grouped under the “Cluster types” A, B & C, and to help illustrate this point, they are also known as Weird, Wild and Worried. It is fairly obvious that Anxiety Disorders fall squarely under Cluster Type “C” of the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition), disorders characterized by anxious or fearful thinking and behavior. AKA Worried.
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