Personality and symptom profiles of the angry hostile depressed patient

Interpersonal styles in major and chronic depression: A systematic review and meta-analysis

BACKGROUND

McCullough's (2000) theory of chronic depression posits that a hostile-submissive interpersonal style distinguishes chronically depressed individuals from those with Major Depressive Disorder (MDD). This study sought to determine to what extent hostility and submissiveness feature in MDD, and whether there is evidence for a stronger effect in chronic depression.

METHODS

A systematic literature search was conducted for research measuring the relationship between depression and hostility and/or submissiveness. A meta-analysis was carried out to determine the strength of the relationship. Separate analyses were conducted for the effects of hostility, submissiveness, and hostile-submissiveness. Subgroup analyses were performed comparing the effect sizes of chronic depression and MDD.

RESULTS

Twelve studies met criteria for inclusion. Subgroup analyses revealed large effect sizes for submissiveness (d = 0.86) and hostile-submissiveness (d = 0.93) in chronic depression, and a medium effect for hostility (d = 0.72). MDD was associated with medium effects for hostility (d = 0.58) and hostile-submissiveness (d = 0.63), and a small effect for submissiveness (d = 0.40).

LIMITATIONS

The review yielded a small number of papers, particularly in relation to chronic depression. The majority reported secondary analyses using baseline samples of intervention trials, with normative data as controls. Quality scores were generally low, and analyses revealed high heterogeneity, which may indicate differences between clinical populations studied.

CONCLUSIONS

The review provides preliminary evidence that individuals with chronic depression are more hostile-submissive than those with MDD. Results highlight the limited research into interpersonal correlates of chronic depression.

Personality and emotional processing: A relationship between extraversion and the late positive potential in adolescence

Neuroticism and extraversion are multifaceted affective-laden personality traits that have been associated with major depressive disorder (MDD). Research and theory have argued that extraversion, and particularly its facet positive emotionality, is specific to MDD, while neuroticism is common across internalizing disorders. Converging evidence has suggested that MDD is associated with reduced engagement with emotional stimuli, but it remains unclear whether either extraversion, neuroticism, or both modulate reactivity to emotional cues. The late positive potential (LPP) is an event-related brain potential that is uniquely suited to assess engagement with emotional stimuli because it reflects sustained attention toward emotional content. The current study examined the LPP in relation to personality traits that may confer risk for depression by examining the relationship between the LPP and both neuroticism and extraversion in never-depressed adolescent girls. Specifically, 550 girls aged 13.5-15.5 with no lifetime history of depression completed an emotional picture-viewing task, and the LPP was measured in response to neutral, pleasant, and unpleasant pictures. Personality traits were gathered via self- and informant report. Results indicated that high extraversion was associated with a potentiated LPP to emotional pictures-and this effect was accounted for by positive emotionality in particular. In contrast, there was no association between the LPP and neuroticism or its facets. The present study is one of the first to demonstrate that extraversion is associated with variation in neural indices of emotional picture processing, similar to what has been observed among individuals with depression and at high risk for depression.

Neuropsychological correlates of symptom dimensions in inpatients with major depressive disorder

Symptoms of major depressive disorder (MDD) manifest variably across individuals. Accordingly, recent models of the disorder imply that MDD may be characterized according to independent symptom dimensions. In particular, several studies reveal that depression may be characterized along dimensions of negative affect, agitation and hostility, and lassitude and malaise. No research has examined the relationship between these dimensions and neuropsychological function. Towards this end, 133 in patients with unipolar MDD and 17 people without psychiatric illness were administered a brief battery of neuropsychological tests and the MMPI-2. Paralleling earlier research, principal component analysis of the MMPI-2 revealed symptom dimensions of negative affect, agitation, and lassitude and malaise. Multiple regression analyses showed that the negative affect and agitation dimensions accounted for significant variance on measures of executive function, speed of information processing, new learning, dexterity, and overall impairment. Lassitude and malaise failed to correspond with neuropsychological performance. Implications of these data for clinical practice and neural models of MDD are discussed.

Personality self-reports are concurrently reliable and valid during acute depressive episodes

BACKGROUND

It is alleged that depression distorts the assessment of general personality traits. To test that hypothesis, we examined scores on the Revised NEO Personality Inventory (NEO-PI-R) administered to acutely depressed patients at baseline and 14 to 26 weeks after treatment with antidepressant medication.

METHOD

Two hundred and fifty patients completed the NEO-PI-R at baseline, 109 patients after 14 to 26 weeks of antidepressant pharmacotherapy. 48 patients (49.5%) were identified as responders while 49 (50.5%) were identified as non-responders. The remaining 12 patients were excluded because they met HRSD response criteria but not the SCID-I MDD criteria at treatment completion.

RESULTS

At baseline, NEO-PI-R scales showed high internal consistency and replicated the normative factor structure, suggesting that psychometric properties were preserved. Among non-responders, retest correlations were uniformly high (rs=.50 to .88) and mean levels showed little change, providing evidence for the consistency of personality self-reports during an acute depressive episode. NEO-PI-R scales showed construct validity in the concurrent prediction of a number of clinical criteria. Effective treatment had significant effects on the mean levels of neuroticism, which decreased, and extraversion, openness, and conscientiousness, which increased.

LIMITATIONS

The participants were from a clinical database and were not randomly assigned for the treatment.

CONCLUSIONS

The results suggest that the effect of acute depression is to amplify somewhat the personality profile of people prone to depression. Rather than regard these depression-caused changes in assessed personality trait levels as a distortion, we interpret them as accurate reflections of the current condition of the individual. Personality traits have biological bases, and when they are changed (by disease or therapeutic interventions) trait levels change.

Relationship of anger and anger attacks with depression: a brief review

Anger is a common and potentially destructive emotion that has considerable social and public health importance. The occurrence of anger, irritability and hostility in depression have been known for many years, but the prevalence, significance for treatment and prognosis and the mechanisms involved remain poorly understood. More recently, anger attacks have been proposed as a specific form of anger in depression. They are characterized by a rapid onset of intense anger and a crescendo of autonomic arousal occurring in response to trivial provocations. Though the presence or absence of hostility, anger and aggression in depression has been a matter of controversy, anger attacks have been found to occur more often in depressed patients in comparison to healthy controls. Some studies have reported that depressed patients with anger attacks differ from those without such attacks in terms of clinical profile, comorbid personality disorders and certain biological variables. Serotonergic dysfunction may characterize this distinct subtype of depression - depression with anger attacks.

Dimensional psychopathology of depression: detection of an 'activation' dimension in unipolar depressed outpatients

BACKGROUND

Despite the high prevalence of bipolar spectrum disorders, most instruments currently available for the assessment of depression do not explore symptoms of 'activation' such as anger, irritability, aggressiveness, hostility, and psychomotor activation.

METHODS

Two samples of adults with unipolar depression were studied. They had no comorbid DSM-IV disorder, and they were free from antidepressant drugs. The first sample (n = 380) was assessed with the SVARAD, a validated scale for the rapid assessment of the main psychopathological dimensions. The second sample (n = 143) was assessed with the MMPI-2. Factor analysis was performed on SVARAD items and MMPI-2 clinical scales.

RESULTS

In both samples, we obtained a three-factor solution with factors interpreted as a depressive dimension, an anxious dimension, and an activation dimension. The latter dimension appeared to be clinically relevant in 20-27% of patients.

LIMITATIONS

The presence of a comorbid disorder may have been missed in some cases. Also, some bipolar II patients might have been misdiagnosed as unipolar and included in the study. Further, our findings apply only to a selected psychiatric population, and it should be tested whether they generalize to other settings of care and other countries.

CONCLUSIONS

Our results suggest that depressive mixed states are not rare even in patients diagnosed as unipolar, and that some unipolar patients might actually be 'pseudounipolar' and belong to the bipolar spectrum. More in general, our findings suggest that some depressed patients have prominent symptoms of activation that can easily go unnoticed using instruments that do not explore such symptoms. Detecting these symptoms has important treatment implications.

Relevance of anger and irritability in outpatients with major depressive disorder

INTRODUCTION

Current psychiatric classification systems underestimate the part played by anger and aggressiveness in unipolar depression. This study was designed to assess the relevance of anger, irritability, aggressiveness, hostility, and psychomotor activation in major depressive disorder.

METHODS

A total of 222 newly admitted consecutive outpatients with major depressive disorder (mean age 48.9 years, 64.4% females) were enrolled in the study. They had no comorbid axis I or II DSM-IV disorder, and they received no treatment with antidepressants in the preceding 2 months. They were assessed with the SVARAD, a validated scale for the rapid assessment of the main psychopathological dimensions. Principal component analysis was performed on SVARAD items.

RESULTS

We obtained a three-factor solution accounting for 47.4% of total variance. The factors were interpreted as 'anger/irritability', 'depression', and 'anxiety', respectively. The anger/irritability dimension was clinically relevant in 23% of patients. Anger/aggressiveness was especially frequent (21.6%), whereas psychomotor activation was infrequent (0.9%).

DISCUSSION

In depressive disorders, there are psychopathological dimensions other than depressed mood and anxiety that deserve greater clinical recognition and research. Our study suggests that one of these symptom clusters includes anger, irritability, aggressiveness, and hostility. The relevance of this dimension was not related to concurrent pharmacological treatment. Misdiagnosis of bipolar II disorder is also unlikely to explain our findings. Possibly, personality factors might at least partly explain the occurrence of anger and aggressiveness in several depressed patients. Attachment theory suggests that anger might also be conceived as part of the protest-despair-detachment reaction to a loss, either actual or symbolic.

NEO-FFI factor scores as predictors of clinical response to fluoxetine in depressed outpatients

Research in unipolar depression suggests that neuroticism is associated with poor long-term outcome and greater chronicity. The objective of this study was to determine whether baseline neuroticism scores predict response to treatment with fluoxetine in depressed outpatients. Seventy-six depressed outpatients participating in a clinical trial of fluoxetine (fixed/flexible dosing) completed the NEO-FFI (five factor inventory short form) at baseline. Clinical response was defined as a 50% or greater decrease in the 17-item Hamilton Depression Rating Scale (HAM-D-17) total score (final visit--baseline). Logistic regression evaluated NEO-FFI factor scores as predictors of treatment outcome within an intent-to-treat model. Scores on the neuroticism scale were not found to significantly predict treatment response as measured by the HAM-D-17. Strengths of this study include a standardized treatment protocol and use of structured interview instruments, while limitations include a modest sample size, lack of continuation data, state/trait effects, and lack of generalizability to other antidepressant treatments.

Differential pharmacological treatment response in high angry hostile and low angry hostile depressed patients: a retrospective analysis

Fava et al., Am. J. Psychiatry 150 (1993)1158-1163, have recently proposed the existence of a sub-type of depressed patients who experience anger attacks. These investigators hypothesized that patients who experience anger attacks will respond better to a specific selective serotonin reuptake inhibitor (SSRI) medication than will depressed patients who do not experience anger attacks. Using a non-randomized, archival treatment methodology, 158 patients were classified as either high angry hostile (n = 83) or low angry hostile (n = 75). These patients had been treated with either a primarily noradrenergic reuptake inhibitor (desipramine) a SSRI (sertraline or paroxetine), or the combined serotonin and norepinephrine reuptake inhibitor (SNRI), venlafaxine. A 2 (high angry hostile/low angry hostile) x 3 (medication type) analysis of variance (ANOVA) was non-significant, indicating no differential treatment effects.