Personality traits during depression and after clinical recovery

A quantitative analysis of the relationship between affective state and personality ratings in inpatient depression (RAPID)

BACKGROUND

The relationship between major depressive disorder (MDD) and personality disorders is complex, with implications for diagnosis and treatment. We sought to explore the relationship between these disorders quantitatively in an inpatient setting.

METHODS

We conducted a structured observational study exploring symptoms of depression and selected neurocognitive functions over the span of an inpatient admission in those with depression and personality disorders. Sixty inpatients presenting with symptoms of depression completed ratings of mood and neurocognitive function. Diagnosis was confirmed by structured clinical interview (SCID-5-RV) at discharge and used to allocate patients to one of the two groups for analysis: those with MDD-only and those with a personality disorder (with or without MDD).

RESULTS

On admission, observer-based ratings of depression were significantly higher in the MDD-only group while subjective ratings were higher in the personality disorder group. Depression rating scores lessened in both groups during the admission, but at discharge, the personality disorder group continued to report higher subjective ratings. The personality disorder group also rated themselves as more cognitively impaired than the MDD-only group and unlike the MDD-only group, they did not report subjective improvements in cognitive function over the course of admission. Objective assessment of cognitive function demonstrated improvements in both groups.

CONCLUSIONS

In this study, the presence of a personality disorder was associated with greater subjective severity of depressive symptomatology and selected neurocognitive functioning, despite similar or lower objective severity in comparison with those with MDD. This finding has implications for understanding the patient journey through health care settings.

Personality Factors and Depressive Configurations. An Exploratory Study in an Italian Clinical Sample

Introduction: This study focuses on the relationship between personality configurations and depressive experiences. More specifically, the aim of this study is to investigate the relationship between self-criticism and dependency and personality styles or disorders, exploring the association between personality features and depressive symptoms. The two-configurations model of personality developed by Blatt (2004, 2008) is adopted as a reference point in sharing a valid framework and in understanding the results.

Methods: Five instruments are administered to 51 participants with a diagnosis of depressive disorder, in accordance with DSM-IV-TR (American Psychiatric Association, 2000): Self-criticism and dependency dimensions of depression are measured with the Depressive Experiences Questionnaire (DEQ); self-reported depression is assessed with the Beck Depression Inventory-II (BDI-II); observer-rated depression is assessed with the Hamilton Depression Rating Scale (HDRS); personality is assessed with the Clinical Diagnostic Interview (CDI) and the Shedler Westen Assessment Procedure-200 (SWAP-200).

Results: Only self-criticism, and not dependency, is associated with depressive symptoms. In addition, the SWAP Borderline PD Scale and the Dysphoric: Emotionally dysregulated Q-factor emerge as significant in predicting depression.

Conclusions: Findings support the assumption that depressive personality configurations can enhance the vulnerability to developing depression. Theoretical and clinical implications of these results are discussed.

Neural Implications of Psychotherapy, Pharmacotherapy, and Combined Treatment in Major Depressive Disorder

Numerous clinical trials have been conducted to determine the utility of antidepressant treatment (ADT), psychotherapy, and combined psycho-pharmaco-psychotherapy (PPPT) in treating major depressive disorder (MDD). While all approaches have shown benefit over placebo to varying degrees, the parallel neurophysiological mechanisms that underlie their efficacy have received little attention. The authors will review and discuss a growing body of literature that relates the factors of treatment selection and response to the principles of neuromodulation, with emphasis regarding how neuroimaging and other experimental data reinforce the need for personalized MDD treatment. This manuscript and its theoretical approaches were supported by conducting relevant literature searches of MEDLINE and PubMed electronic databases, prioritizing systemic reviews, and randomized clinical trials using selected MeSH terms. The authors conclude that ADT, psychotherapy, and PPPT all create potentially observable neurofunctional changes and argue that additive and synergistic potentiation of these effects in PPPT may produce more sustained symptom relief than with monotherapy alone.

Influence of personality on the outcome of treatment in depression: systematic review and meta-analysis

There continues to be debate about the influence of personality disorder on the outcome of depressive disorders and is relative interactions with treatment. To determine whether personality disorder, both generically and in terms of individual clusters, leads to a worse outcome in patients with depressive disorders and whether this is influenced by type of treatment, a systematic electronic search of MEDLINE, CINAHL, and PsycINFO from 1966, 1982, and 1882, respectively, until February 2007 was undertaken. The keyword terms depression, mental illness, and personality disorder were used. All references were reviewed and personal correspondence was undertaken. Only English language papers were considered. Any English language paper studying a depressed adult population was considered for inclusion. Studies needed to clearly define depression and personality disorder using peer-reviewed instruments or International Classification of Disease/Diagnostic Statistical Manual criteria. Outcome assessment at greater than 3 weeks was necessary. Final inclusion papers were agreed on by consensus by at least two reviewers. All data were extracted using predetermined criteria for depression by at least two reviewers in parallel. Disagreement was settled by consensus. Complex data extraction was confirmed within the study group. Data were synthesized using log odds ratios in the Cochrane RevMan 5 program. The finding of comorbid personality disorder and depression was associated with a more than double the odds of a poor outcome for depression compared with those with no personality disorder (OR 2.16, CI 1.83-2.56). This effect was not ameliorated by the treatment modality used for the depressive disorder. This finding led to the conclusion that personality disorder has a negative impact on the outcome of depression. This finding is important in considering prognosis in depressive disorders.

Association between genetic polymorphisms in the serotonergic system and comorbid personality disorders among patients with first-episode depression

Studies on the association between genetic polymorphisms and personality disorders have provided inconsistent results. Using the "enriched sample method," the authors of the present study aimed to assess the association between polymorphisms in the serotonergic transmitter system and comorbid personality disorders in patients recently diagnosed with first-episode depression. A total of 290 participants were systematically recruited via the Danish Psychiatric Central Research Register. Diagnoses of personality disorders were assessed by a SCID-II interview, and polymorphisms in the genes encoding the serotonin transporter, serotonin receptors 1A, 2A, 2C, and tryptophan hydroxylase 1 were genotyped. The authors found a significant effect of the length polymorphism in the serotonin transporter gene (5-HTTLPR) on cluster B personality disorder (mainly borderline disorder), but no influence on cluster C personality disorder, and no associations between other polymorphisms and personality disorders. The study adds evidence to the effect of the serotonin transporter gene specifically on cluster B personality disorders.

Differences between early and late onset adult depression

BACKGROUND

It is unclear, whether age-of-onset identifies subgroups of depression.

AIM

To assess the clinical presentation of depression with onset in the early adult age (18-30 years) as compared to depression with later onset (31-70 years).

METHOD

A total number of 301 patients with first episode depression were systematically recruited. Characteristics including psychiatric co-morbidity, personality disorders and traits, stressful life events prior to onset, family history, and treatment outcome were assessed by structured interviews and compared by chi-square tests for categorical data, t-tests for continuous parametric data and Mann-Whitney U-test for continuous nonparametric data. Logistic and multiple regression analyses were used to adjust the analyses for potentially confounding variables.

RESULTS

Patients with early onset of depression were characterised by a higher prevalence of co-morbid personality disorders, higher levels of neuroticism, and a lower prevalence of stressful life events preceding onset compared to patients with later age-of-onset. There were no differences in severity of the depressive episode, treatment outcome or family loading of psychiatric illness.

CONCLUSION

Early adult onset of depression is associated with co-morbid personality deviances, whereas late onset is associated with environmental risk factors.

Impulsivity is an independent predictor of 15-year mortality risk among individuals seeking help for alcohol-related problems

BACKGROUND

Although past research has found impulsivity to be a significant predictor of mortality, no studies have tested this association in samples of individuals with alcohol-related problems or examined moderation of this effect via socio-contextual processes. The current study addressed these issues in a mixed-gender sample of individuals seeking help for alcohol-related problems.

METHODS

Using Cox proportional hazard models, variables measured at baseline and Year 1 of a 16-year prospective study were used to predict the probability of death from Years 1 to 16 (i.e., 15-year mortality risk). There were 628 participants at baseline (47.1% women); 515 and 405 participated in the follow-up assessments at Years 1 and 16, respectively. Among Year 1 participants, 93 individuals were known to have died between Years 1 and 16.

RESULTS

After controlling for age, gender, and marital status, higher impulsivity at baseline was associated with an increased risk of mortality from Years 1 to 16; however, this association was accounted for by the severity of alcohol use at baseline. In contrast, higher impulsivity at Year 1 was associated with an increased risk of mortality from Years 1 to 16, and remained significant when accounting for the severity of alcohol use, as well as physical health problems, emotional discharge coping, and interpersonal stress and support at Year 1. In addition, the association between Year 1 impulsivity and 15-year mortality risk was moderated by interpersonal support at Year 1, such that individuals high on impulsivity had a lower mortality risk when peer/friend support was high than when it was low.

CONCLUSIONS

The findings highlight impulsivity as a robust and independent predictor of mortality and suggest the need to consider interactions between personality traits and socio-contextual processes in the prediction of health-related outcomes for individuals with alcohol use disorders.

Biased emotional recognition in depression: perception of emotions in music by depressed patients

BACKGROUND

Depression is a highly prevalent mood disorder, that impairs a person's social skills and also their quality of life. Populations affected with depression also suffer from a higher mortality rate. Depression affects person's ability to recognize emotions. We designed a novel experiment to test the hypothesis that depressed patients show a judgment bias towards negative emotions.

METHODS

To investigate how depressed patients differ in their perception of emotions conveyed by musical examples, both healthy (n=30) and depressed (n=79) participants were presented with a set of 30 musical excerpts, representing one of five basic target emotions, and asked to rate each excerpt using five Likert scales that represented the amount of each one of those same emotions perceived in the example.

RESULTS

Depressed patients showed moderate but consistent negative self-report biases both in the overall use of the scales and their particular application to certain target emotions, when compared to healthy controls. Also, the severity of the clinical state (depression, anxiety and alexithymia) had an effect on the self-report biases for both positive and negative emotion ratings, particularly depression and alexithymia.

LIMITATIONS

Only musical stimuli were used, and they were all clear examples of one of the basic emotions of happiness, sadness, fear, anger and tenderness. No neutral or ambiguous excerpts were included.

CONCLUSIONS

Depressed patients' negative emotional bias was demonstrated using musical stimuli. This suggests that the evaluation of emotional qualities in music could become a means to discriminate between depressed and non-depressed subjects. The practical implications of the present study relate both to diagnostic uses of such perceptual evaluations, as well as a better understanding of the emotional regulation strategies of the patients.

Clinical utility of Standardised Assessment of Personality - Abbreviated Scale (SAPAS) among patients with first episode depression

BACKGROUND

Personality disorder frequently co-occurs with depression and seems to be associated with a poorer outcome of treatment and increased risk for recurrences. However, the diagnosing of personality disorder can be lengthy and requires some training. Therefore, a brief screening interview for comorbid personality disorder among patients suffering from depression would be of clinical use.

METHOD

The present study aimed to assess the utility of the Standardised Assessment of Personality - Abbreviated Scale (SAPAS) as a screen for personality disorder in a population of patients recently diagnosed with first episode depression. A total number of 394 patients with an ICD-10 diagnosis of a single depressive episode were sampled consecutively via the Danish Psychiatric Central Research Register during a 2years inclusion period and assessed by the screening interview and, subsequently, by the Structured Clinical Interview for DSM-IV Personality Disorders.

RESULTS

We found, that a cut-off of 3 on the screen correctly identified the presence of comorbid personality disorder in 73.1% of the patients. The sensitivity and specificity were 0.80 and 0.70, respectively.

LIMITATIONS

The findings cannot be generalized to patients outside hospital settings.

CONCLUSION

The study provides evidence for the clinical utility of SAPAS as a screening interview for comorbid personality disorder in a population of patients with a primary diagnosis of depression.

The Impact of Residual Symptoms in Major Depression

The current definition of remission from major depressive disorder does not fully take into account all aspects of patient recovery. Residual symptoms of depression are very common in patients who are classified as being in remission. Patients with residual symptoms are at increased risk of functional and interpersonal impairments, and are at high risk for recurrence of depression. This article discusses the incidence of residual symptoms of depression, as well as the risks and consequences of these symptoms, and will review the state of current treatment.

Interaction between genetic polymorphisms and stressful life events in first episode depression

BACKGROUND

A polymorphism in the serotonin transporter (5-HTT) gene seems to moderate the influence of stressful life events on depression. However, the results from previous studies of gene-environment interactions in depression are inconsistent and might be confounded by the history of depression among participants.

METHOD

We applied a case-only design, including 290 ethnically homogeneous patients suffering exclusively from first episode depression. Psychiatric mo-morbidity, personality traits and disorders and stressful life events in a six months period preceding onset of depression were evaluated by means of interviews and questionnaires. Additionally, we genotyped nine polymorphisms in the genes encoding the serotonin transporter, brain derived neurotrophic factor, catechol-O-methyltransferase, angiotensin converting enzyme, tryptophane hydroxylase, and the serotonin receptors 1A, 2A, and 2C.

RESULTS

The low activity variants of the 5-HTT-linked polymorphic region in the serotonin transporter gene and the Met-allele of a single nucleotide polymorphism (Val66Met) in the gene encoding brain derived neurotrophic factor were independently associated with the presence of stressful life events prior to onset of depression, also when corrected for the effect of age, gender, marital status, personality disorder, neuroticism, and severity of depressive symptoms at the time of interview.

CONCLUSION

Polymorphisms in the genes encoding the serotonin transporter and the brain derived neurotrophic factor interact with recent stressful life events on depression among patients with no history of previous depressive episodes.

Childhood maltreatment and adult personality disorder symptoms: influence of maltreatment type

The present study examines the effects of different types of childhood maltreatment on personality disorder symptoms in a sample of adults with no Axis I psychopathology. Participants reporting a history of moderate to severe maltreatment on the Childhood Trauma Questionnaire (n = 70) were grouped by type of abuse and compared with a non-abused group (n = 35) with regard to the number of personality disorder symptoms endorsed. Physical/sexual abuse and emotional abuse/neglect each were associated with elevated symptoms of all three personality disorder clusters. Elevated symptoms of several specific personality disorders were also seen, including paranoid, borderline, avoidant, dependent, obsessive-compulsive, and depressive personality disorder. There were no significant differences between the maltreatment groups. These findings indicate that emotional abuse/neglect and physical/sexual abuse are risk factors for a broad array of personality outcomes in a non-clinical sample.

Psychosocial determinants of recovery in depression

There is a growing body of literature on residual symptoms after apparently successful treatment. The strong prognostic value of subthreshold symptomatology upon remission and the relationship between residual and prodromal symptomatology (the rollback phenomenon) have been outlined. Most residual symptoms also occur in the prodromal phase of depression and may progress to become prodromes of relapse. These findings entail important implications. It is necessary to closely monitor the patient throughout the different phases of illness and to assess the quality and extent of residual symptoms. A more stringent definition of recovery, which is not limited to symptomatic assessment, but includes psychological well-being, seems to be necessary. New therapeutic strategies for improving the level of remission, such as treatment of residual symptoms that progress to become prodromes of relapse and/or increasing psychological well-being, appear to yield more lasting benefits. The sequential model may provide room for innovative treatment approaches, including the use of drugs for specifically addressing residual symptoms. As occurs in other medical disorders (such as diabetes and hypertension), the active role of the patient in achieving recovery (self-therapy homework) should be pursued.

Comorbid anxiety in bipolar disorder: does it have an independent effect on suicidality?

OBJECTIVE

Comorbid anxiety disorder is reported to increase suicidality in bipolar disorder. However, studies of the impact of anxiety disorders on suicidal behavior in mood disorders have shown mixed results. The presence of personality disorders, often comorbid with anxiety and bipolar disorders, may explain these inconsistencies. This study examined the impact of comorbid Cluster B personality disorder and anxiety disorder on suicidality in bipolar disorder.

METHODS

A total of 116 depressed bipolar patients with and without lifetime anxiety disorder were compared. Multiple regression analysis tested the association of comorbid anxiety disorder with past suicide attempts and severity of suicidal ideation, adjusting for the effect of Cluster B personality disorder. The specific effect of panic disorder was also explored.

RESULTS

Bipolar patients with and without anxiety disorders did not differ in the rate of past suicide attempt. Suicidal ideation was less severe in those with anxiety disorders. In multiple regression analysis, anxiety disorder was not associated with past suicide attempts or with the severity of suicidal ideation, whereas Cluster B personality disorder was associated with both. The results were comparable when comorbid panic disorder was examined.

CONCLUSIONS

Comorbid Cluster B personality disorder appears to exert a stronger influence on suicidality than comorbid anxiety disorder in persons with bipolar disorder. Assessment of suicide risk in patients with bipolar disorder should include evaluation and treatment of Cluster B psychopathology.

Reliability of personality disorder diagnosis during depression: the contribution of collateral informant reports

OBJECTIVE

Research has found low concordance of personality disorder diagnoses made during depression versus after remission and made using patient versus collateral informants, but little is known about the reliability of personality disorder (PD) diagnoses made during depression using patient and collateral reports.

METHOD

A total of 168 patients were evaluated for PDs during depression and following response using patient and close informant reports. kappa coefficients of inter-informant and test-retest reliability were calculated.

RESULTS

After depression response, the proportion diagnosed with cluster A and C PDs fell by both patient and close informant report, and overall inter-informant reliability declined. Overall test-retest reliability did not differ between patients and informants.

CONCLUSION

Collateral informants do not improve the reliability of PD diagnoses made during depressive episodes.

Prodromal stage of major depression

AIM

The aim of this review was to survey the available literature on prodromal symptoms of unipolar major depression.

METHODS

Both a computerized (Medline) and a manual search of the literature were performed.

RESULTS

In a substantial proportion of patients with depression a prodromal phase can be identified. There is a relationship between residual and prodromal symptomatology (the rollback phenomenon).

CONCLUSIONS

Appraisal of prodromal phase of major depression has important implications as to pathophysiological models of disease and relapse prevention. It may allow a staging system of depressive illness that may yield more enduring results in the therapeutic efforts.

Tridimensional personality questionnaire factors in major depressive disorder: relationship to anxiety disorder comorbidity and age of onset

OBJECTIVE

We used the Tridimensional Personality Questionnaire (TPQ) to study the relationship between temperamental traits and comorbid anxiety disorders as well as age of onset of major depressive disorder (MDD) in 263 patients with MDD.

METHODS

Patients recruited for a large clinical study on MDD underwent a Structured Clinical Interview for DSM-III-R assessment and were administered the self-rated TPQ [mean age = 39.5 +/- 10.5 years, women = 138 (53%), initial 17-item Hamilton Rating Scale for Depression (HAM-D-17) score = 19.6 +/- 3.4]. The TPQ was scored for three previously identified factors -- harm avoidance (HA), novelty seeking (NS), and reward dependence (RD). Multiple linear regression methods were used to evaluate the relationship between TPQ factors and each comorbid anxiety disorder as well as between early-- vs. late-onset MDD, after controlling for age, gender and initial HAM-D-17 score (when these were related to the dependent variable in simple regressions).

RESULTS

Social anxiety disorder in MDD was strongly associated with higher scores on HA and lower scores on NS and RD (t = 5.4, p < 0.0001; t = 2.6, p = 0.009; t = 2.2, p = 0.028, respectively). A diagnosis of generalized anxiety disorder in MDD was significantly related to higher HA scores (t = 2.8, p = 0.006). The presence of comorbid obsessive-compulsive disorder was associated with lower NS scores (t = 2.3, p = 0.023) as was that of comorbid panic disorder (t = 2.0, p = 0.051). Finally, the presence of simple phobias was associated with lower scores on RD (t = 2.4, p = 0.016). HA scores were higher in patients with early onset of MDD (adjusted p = 0.05). Early versus late onset of MDD was not significantly related to NS or RD scores.

LIMITATIONS

Since our sample consisted of moderately depressed outpatients, our ability to generalize our findings to other populations is limited.

CONCLUSIONS

Features of temperament are related to patterns of anxiety disorder comorbidity and age of onset among patients with MDD. Higher levels of HA and lower levels of RD and NS were associated with an increased risk of anxiety disorder comorbidity in our sample. HA may also be related to early onset of depression.

Cluster C personality disorder and recovery from major depression: 24-month prospective follow-up

We investigated whether Cluster C personality disorder (CPD) is associated with recovery from depression. Changes in symptom scales in 30 patients with MD and CPD were compared with changes in 60 patients with MD alone over a 24-month follow-up period. Recovery of patients with MD and comorbid CPD was inferior to recovery of those with MD alone based on the Hamilton and Beck Depression Inventory (BDI) scales, and the SCL-90 total score. Only 18% of those with MD alone but 47% of those with CPD and MD met the criteria for major depression at the end of the 24-month follow-up. Multiple logistic regression analyses revealed an independent association between the lack of recovery (BDI score > 9 at 24 months) and the presence of CPD (OR 4.9, 95% CI 1.5-16.0). Moreover, the presence of CPD associated with the presence of major depression at 24 months (OR 4.2, 95% CI 1.4-12.2). The presence of CPD hinders the alleviation of depressive symptoms in major depression.

Changes in personality pathology after pharmacotherapy and combined therapy for depressed patients

The central question addressed by this article is whether courses of treatment consisting of pharmacotherapy or pharmacotherapy combined with psychotherapy (combined therapy) produce different changes in personality pathology at follow-up after 40 weeks. We also examined whether recovery from depression has an influence on outcome. The study population consisted of 128 outpatients in whom personality pathology and severity of depression were determined at the start of the study. For 72 patients, personality pathology and severity of depression were determined again after 40 weeks. Of the group of 72 patients, 25 patients received only pharmacotherapy for 6 months, and 47 patients received combined treatment (pharmacotherapy and psychodynamic supportive psychotherapy). The antidepressant protocol provides for three successive steps in case of intolerance or inefficacy: fluoxetine, amitriptyline, and moclobemide. The combined therapy condition consisted of 16 sessions of Short Psychodynamic Supportive Psychotherapy in addition to pharmacotherapy. In the combined therapy condition there was a significant reduction in personality pathology in patients who recovered from depression but also in patients who had not. In the pharmacotherapy condition the significant decrease was restricted to patients who recovered from depression. The results were most striking for Cluster C psychopatology. Patients with cluster B pathology changed the least. Depressed patients with comorbid personality pathology appear to benefit most from a combination of pharmacotherapy and a form of short, psychodynamic, supportive psychotherapy.

Residual symptoms in depression: an emerging therapeutic target

Residual symptoms, despite successful response to therapy, appear to be the rule in unipolar depression. Most of the residual symptoms occur in the prodromal phase of illness. Residual symptoms are associated with biological correlates, mainly involving the hypothalamic-pituitary-adrenal (HPA) axis and the sleep architecture. They are powerful predictors of relapse. These findings have led to the hypothesis that residual symptoms upon recovery may progress to become prodromal symptoms of relapse. A sequential strategy (encompassing pharmacotherapy in the acute phase of illness and cognitive behavioral therapy in its residual phase) has been developed and was found to be effective in decreasing relapse rate in controlled studies. A largely untested assumption in unipolar depression is that pharmacological strategies that are effective in the short term are the most suitable for postacute and residual phases or maintenance. The literature on subclinical symptomatology calls for specific, stage-oriented, therapeutic approaches. The efficacy of antidepressant drugs may be assessed not only on differential remission rates, but also on differential amount of residual symptomatology after response.

Consequences of comorbid personality disorders in major depression

To describe consequences of the presence of a comorbid personality disorder (PD) in inpatients with a major depressive disorder (MDD) on variables connected to course and outcome of the unipolar affective illness, 117 inpatients with a major depressive episode were assessed at various times during inpatient treatment. Trait markers (including personality and PDs) were obtained toward the end of the treatment, when acute psychopathology had largely remitted. Fifty-one percent of all patients fulfilled the criteria for a DSM-III-R PD, 15% met the criteria for two or more PDs, and 18% fulfilled the criteria for at least one cluster A or B PD. Except for age of onset, number of suicide attempts and quality of life all other outcome and course variables were unrelated to the presence or absence of a comorbid PD. In this sample, one comorbid PD in patients with MDD was of limited relevance to the course of the affective illness, especially if it was a cluster C PD. Two or more comorbid PDs in patients with unipolar depression tended to reduce quality of life and have an earlier age of onset. Patients with cluster A or B PD and MDD had attempted suicide more often than patients with a cluster C PD and MDD. Although comorbid cluster C PDs were seen in all age groups of patients with an MDD, cluster A or B PDs and the presence of more than one PD were mainly seen in younger patients with an MDD.

Alexithymia in patients with major depressive disorder and comorbid cluster C personality disorders: a 6-month follow-up study

The authors examined the association between alexithymia, cluster C personality disorders (CPD), and severity of depression among 121 outpatients with major depressive disorder (MDD) in a 6-month, follow-up study. Diagnosis of depression and CPD was confirmed by means of the Structured Clinical Interviews for DSM-III-R (SCID I and SCID II). Alexithymia was screened using the 20-item version of the Toronto Alexithymia Scale and severity of depression was assessed using the 21-item Beck Depression Inventory. Results indicated that alexithymic features are common in patients with MDD but often alleviated during recovery from depression. Moreover, comorbid CPD and severity of depression seemed to be associated with poorer recovery from alexithymia. The implications of these findings are discussed.

Assessment of subclinical symptoms and psychological well-being in depression

A substantial body of research suggests that subclinical symptoms characterize the longitudinal course of major depression and have important pathophysiological and treatment implications. Specific treatment of residual symptoms may in fact improve longterm outcome, by acting on those residual symptoms that progress to become prodromes of relapse. The assessment of psychological well-being is also important, since its absence may create conditions of vulnerability to possible adversities. The route of recovery, thus, lies not exclusively in alleviating the negative, but in engendering the positive.

Stability and predictive value of self-report personality traits pre- and post-electroconvulsive therapy: a preliminary study

The accuracy and value of personality assessment for depressed patients receiving electroconvulsive therapy (ECT) is an underexplored and controversial area. However, there are data suggesting that personality traits and personality disorders affect the ultimate outcome of depressed patients receiving a variety of somatic treatments including ECT. Despite these data, controversy continues regarding the advisability of evaluating personality functioning in patients with severe depression. This study sought to explore the stability and predictive value of self-reported personality traits in depressed patients undergoing ECT. Sixteen subjects completed a self-report test of personality functioning and the Beck Depression Inventory (BDI) before and after ECT treatment. The results showed that the majority of self-report personality traits were stable pre- and post-ECT treatment. However, major depressive disorder did significantly affect the report of avoidant, histrionic, aggressive-sadistic, and schizotypal personality traits. Treatment did not change the overall personality profile of these subjects. Furthermore, regression analysis controlling for pretreatment depression showed pretreatment borderline personality traits to be significantly related to the posttreatment depression scores (response to treatment). These findings suggest that routine administration of a standard self-report measure of personality may aid in the evaluation of and treatment planning for patients receiving ECT.

Personality disorder scores improve with effective pharmacotherapy of depression

INTRODUCTION

We hypothesized that the probability of personality disorder ('PROB') predicted by the Temperament and Character Inventory ('TCI') would decline after successful pharmacotherapy of depression.

METHODS

We administered a computerized version of the TCI to 15 patients with DSM-III-R major depression, before and after treatment with serotonergic antidepressants.

RESULTS

PROB declined from 58.9% +/- 18.0% to 42.4% +/- 22.8% (P < 0.003), due to a significant increase in the Self-Directedness scale. This change in PROB correlated with improvement in self-rated severity of depression (P < 0.02).

CONCLUSION

TCI prediction of personality disorder is susceptible to state effects of depression.

Psychosocial factors and completed suicide in personality disorders

The aim of the present study was to investigate the relationships between personality disorders (PD) and various psychosocial factors in a random sample (n = 229) of suicides with psychological autopsy-based DSM-III-R diagnoses representing the total 1-year suicide population in Finland. Background social factors and social interaction factors for 56 suicide victims with a PD diagnosis were compared with those of 56 age- and sex-matched non-PD diagnosis victims. The groups were similar with regard to marital status, socio-economic status, parental divorce, broken home before the age of 16 years, parental suicide attempts, and proportion of subjects living with parents. The PD suicide victims had more commonly had a companion of the opposite sex, lived alone, and resided in an urban area, but had less often experienced parental psychiatric hospitalization during their childhood. Although the groups did not differ with regard to complaints of loneliness before suicide, the lonely PD suicide victims had experienced more interpersonal loss and/or conflict than the lonely non-PD suicide victims. The PD suicide victims were very similar with regard to psychosocial factors, irrespective of sex, age, Axis-I comorbidity, or the cluster type of the PD. Only living alone was more common in young PD suicide victims, and male PD subjects had less often had confidants or friends with whom they shared common interests.

DSM-III-R personality disorders in seasonal affective disorder: change associated with depression

Forty-five patients with winter Seasonal Affective Disorder (SAD) completed the Personality Diagnostic Questionnaire-Revised (PDQ-R) in a depressed state before starting therapy (light or medication), and again 14 weeks later when the scores on the Montgomery Asberg Depression Rating Scale (MADRS) had been reduced by an average of 74%. Prevalence and pattern of personality disorders (PDs) before treatment were similar to that found in patients with nonseasonal major depressive disorder (MDD) during a depressive episode. Number of categorical diagnoses were lower at follow-up for most PDs, but differences were not statistically significant. However, for dimensional scores (number of positive DSM-III-R criteria) significant changes were found for schizotypal, histrionic, narcissistic, and obsessive-compulsive PD, and for total dimensional score in cluster B and total score for all PDs. These changes differ from findings in similar studies of outpatients with nonseasonal MDD. Whether this indicates a specific pattern of change for patients with SAD is discussed. Multiple regression analysis showed a significant association between changes in positive PD criteria between the depressed and nondepressed state and change in depression score. No significant relationship was found between changes in PD criteria and Global Seasonality Score (GSS), a measure reflecting the sum of ratings of seasonal variation in sleep length, social activity, mood, weight, appetite, and energy level.

Comorbidity of personality disorders and unipolar major depression: a review

The association of major depressive disorders with personality disorders is relevant in terms of clinical, therapeutic and prognostic aspects. However, the prevalence of this association remains unclear. This may be due to methodological considerations. Nonetheless, it could be estimated from this review that 20% to 50% of inpatients and 50% to 85% of out-patients with a current major depressive disorder have an associated personality disorder. Cluster B personality disorders, in particular borderline (10-30%), histrionic (2-20%) and antisocial (0-10%), seem to be overrepresented, even if the narcissistic one is rare (less than 5%). The main characteristic of Cluster C personality disorders is the great variability of results across studies, except for the obsessive compulsive personality disorder, whose prevalence is consistent and rather high (0-20%). Cluster A personality disorders are an heterogeneous group, since the prevalence of schizotypal personality disorder is rather high (0-20%), the prevalence of paranoid personality disorder is low (less than 5%) and the prevalence of schizoid personality disorder is quite variable from one study to another. The prevalence of personality disorders among patients with a lifetime major depression has been insufficiently studied, although it may concern half of these patients. The prevalence of current of lifetime major depression among patients with a personality disorder has not been sufficiently studied and results are very scattered. Also, the coexistence of personality disorder and major depression is frequent, and this review emphasizes the heterogeneity of the personality styles associated with major depression. Finally, an optimization of methods and the adjunction of a dimensional point of view to the categorical approach may help to study the comorbidity of major depression and personality disorders and its consequences.

Multiple axis-II diagnoses of personality disorder

BACKGROUND

Simultaneous diagnosis of more than one personality disorder (PD) has been termed 'comorbidity' or 'co-occurrence' implying that single diagnoses are the norm and multiple diagnoses interesting exceptions. Surveys of PD subjects in fact show 1.5-5.6 diagnoses per subject. Our study explores the hypothesis that multiple PD diagnosis is common and increases with increasingly personality disordered populations.

METHOD

The PDQ-R questionnaire was administered to three UK samples: referrals for specialist PD in-patient treatment (n = 275); high tariff offenders attending a probation centre (n = 57); and undergraduate students (n = 274).

RESULTS

Means of 6.0 (95% CI 5.7-6.3), 4.0 (3.1-5.0) and 3.4 (3.0-3.8) PDQ-R diagnoses per subject were found respectively. High rates of PD diagnosis in individual subjects suggest that multiple diagnosis is the norm rather than the exception.

CONCLUSIONS

Multiple diagnosis of PD is better construed as 'breadth' of psychopathology rather than comorbidity and is a function of sampling frame. High rates of multiple diagnoses question the interpretation of studies of any single PD. The graded construct of 'breadth' of axis-II pathology may further our understanding of PD.

Personality disorders in patients with winter depression

Sixty-six patients satisfying the criteria for seasonal affective disorder (SAD) winter depression type (n = 57) or subsyndromal SAD (n = 9), were interviewed in a nondepressed state with the Structured Interview for DSM-III-R Personality Disorders (SIDP-R). Twenty-three percent of the patients in the SAD sample met DSM-III-R criteria for one or more categorical diagnosis of personality disorder (PD). Disorders in cluster C occurred in 18% of the sample, while 12% had cluster B PDs and 5% a cluster A disorder. The relative number of positive criteria, as a dimensional measure of PD, were higher for all cluster C disorders than for any PD in the other clusters. Our data indicate that the pattern of personality disorders in patients with winter SAD are similar to that previously reported for outpatients with non-SAD major depression. We explored the relationship between lifetime severity and clinical manifestation of SAD and dimensional measures of PD with multiple regression analyses. No significant association was found. This is in accordance with the hypothesis that the two disorders are distinct conditions with independent causes.