Comparison of personality beliefs between depressed patients and healthy controls

    Comparison of Personality Beliefs between Depressed Patients and Healthy Controls Bengu Yucens, Erkan Kuru, Yasir Safak, Mehmet Emrah Karadere, Mehmet Hakan Turkcapar PII: DOI: Reference:

S0010-440X(14)00189-8 doi: 10.1016/j.comppsych.2014.07.020 YCOMP 51363

To appear in:

Comprehensive Psychiatry

Received date: Revised date: Accepted date:

24 June 2014 25 July 2014 28 July 2014

Please cite this article as: Yucens Bengu, Kuru Erkan, Safak Yasir, Karadere Mehmet Emrah, Turkcapar Mehmet Hakan, Comparison of Personality Beliefs between Depressed Patients and Healthy Controls, Comprehensive Psychiatry (2014), doi: 10.1016/j.comppsych.2014.07.020

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ACCEPTED MANUSCRIPT Comparison of Personality Beliefs between Depressed Patients and Healthy Controls

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Hakan Turkcapard

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Bengu Yucensa*, Erkan Kurub, Yasir Safak b, Mehmet Emrah Karaderec, Mehmet

Ankara Numune Training and Research Hospital, Psychiatry Clinic, Ankara, Turkey

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Ankara Diskapi YB Training and Research Hospital, Psychiatry Clinic, Ankara, Turkey

Hitit University Corum Training and Research Hospital, Psychiatry Clinic, Corum, Turkey d

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Gazikent Hasan Kalyoncu University, Department of Psychology, Gaziantep, Turkey

Abstract

Introduction: According to the cognitive model, the common mechanism underlying all psychological disorders is distorted or dysfunctional thoughts that affect mood and behaviors.

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Dysfunctional thoughts predispose an individual to depression and are among the processes

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that form the basis of personality traits. Elucidating the personality beliefs associated with depression and dysfunctional thoughts is important to understanding and treating depression.

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The aim of the present study is to determine whether depressed patients exhibited pathological

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personality beliefs compared with healthy controls. Furthermore, we investigated which personality beliefs were more common among such depressed patients. Methods: A total of 70 patients who were admitted to the Department of Psychiatry at Ankara Diskapi Yildirim Beyazit Training and Research Hospital (Ankara, Turkey) and diagnosed with major depressive disorder according to The Diagnostic and Statistical Manual of Mental Disorders- IV (DSM-IV) diagnostic criteria were included in the study. Additionally, 70 healthy controls matched for age, marital status, and education were included in the study. The Sociodemographic Data Form and Personality Belief Questionnaire-Short form (PBQ-SF) were administered to the participants.

ACCEPTED MANUSCRIPT Results: A comparison of the depression group with the healthy controls revealed higher scores in dependent, passive-aggressive, obsessive-compulsive, antisocial, histrionic,

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paranoid, borderline, and avoidant personality subscales in the depressive group.

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Conclusions: These results suggest that personality beliefs at the pathological level are more common in depressive patients and that the detection of these beliefs would be useful for

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predicting the prognosis of the disease and determining appropriate treatment methods. Keywords: personality disorders, depression, cognition

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* Corresponding author. Ankara Numune Training and Research Hospital, Psychiatry

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Clinic, (06100), Ankara, Turkey. Tel.: +905052633138 E-mail address: [email protected]

ACCEPTED MANUSCRIPT 1. Introduction The cognitive theory of depression is a bio-psycho-social model in which biological,

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environmental, cognitive, and behavioral factors can play a role in the occurrence and

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persistence of depression [1]. According to Beck's theory, cognitive errors were important in depression, but deeper cognitive structures are also believed to make a contribute to triggering

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depression [2]. Beck proposed that three different cognitive levels interact with each other and

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lead to depression. Negative automatic thoughts are at the surface level of cognition. Beliefs, dysfunctional attitudes, and personal rules are deeper cognitive structures. Core beliefs conceptualized as thoughts, attitudes, and negative information processing are at the deepest levels of cognition [3] [4].

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A basic characteristic of the cognitive theory of personality disorders is the emphasis placed on the role of dysfunctional beliefs. According to this theory, each personality disorder

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has a characteristic group of dysfunctional beliefs. The behavioral pattern in different

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personality disorders appears as overt symptoms of underlying cognitive structures [5]. Dysfunctional beliefs are the central component of cognitive case formulation in the therapy

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and the main target of the intervention [6]. If dysfunctional beliefs are identified correctly, these beliefs reflect cognitive themes indicating the developmental history of the patient, compensatory strategies, and dysfunctional reactions toward existing conditions [7]. With the therapist and patient working together to identify and modify these beliefs, improvements can be observed in many areas of functionality. These cognitive features seem to be primary focus and mechanism of change in cognitive interventions in personality disorders [8]. Elucidating personality traits associated with depression and possible consequences of this association has been the focus of numerous empirical studies to better understand and treat depression. Depressed patients have been found to have higher rates of personality disorders compared with non-depressed individuals. Studies have reported different rates of

ACCEPTED MANUSCRIPT comorbidities ranging from 15-95%, depending on methodological differences between the studies in terms of sample size, follow-up period, and evaluation methods [9].

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Many studies have shown that patients with personality disorders and comorbid

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depression respond poorly to psychotherapy and drug therapies compared with depressed patients without personality disorders [10]. Psychiatrists must prepare appropriate treatment

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plans for depressed patients with personality disorders. As per American Psychological Association (APA) guidelines about the treatment of depression, the treatment must primarily

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focus on depression; psychotherapeutic and combined pharmacotherapeutic approaches may be attempted with success if the symptoms of a personality disorder persist after the symptoms of depression are relieved. Indeed, the response of patients with a personality disorder to antidepressant therapy has been found to be lower compared with patients without

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personality disorders, in terms of social functioning and residual depressive symptoms [11].

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The presence of a personality disorder impairs compliance with treatment and the establishment of psychotherapeutic relationships and also increases the risk of depressive

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episodes and prolongs the time necessary to achieve remission [12].

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In light of these studies, personality traits or disorders comorbid with depression are considered to play an important role in the evaluation and selection of treatment approaches [13]. Cognitive therapy is a commonly used treatment approach that has been shown to efficiently treat depression. The determination of personality beliefs and personality disorders in a depressed patient during the course of cognitive therapy could contribute to the selection and efficiency of cognitive interventions. The aim of the present study is to determine the personality beliefs of patients diagnosed with major depressive disorder and the differences exhibited by various personality beliefs. To this end, the personality beliefs of patients diagnosed with major depressive disorders according to Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV)

ACCEPTED MANUSCRIPT criteria and age-matched healthy controls showing similar features were compared using the scales that measure personality traits in different cognitive domains. We hypothesize that

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patients with major depressive disorders would more frequently exhibit dysfunctional beliefs.

2. Method

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2.1. Sample

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A total of 70 patients, who were admitted to the Department of Psychiatry at Ankara Diskapi Yildirim Beyazit Training and Research Hospital (Ankara,Turkey) and who were diagnosed with major depressive disorder according to DSM-IV diagnostic criteria were included in the study. Additionally, 70 healthy controls with similar sociodemographic

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features were included in the study. The subjects in the study and the control groups were informed of the study objectives and methods, and consent was obtained from all participants

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for the study. The study was approved by the Ethics Committee of Ankara Diskapi Yildirim

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Beyazit Training and Research Hospital. The study inclusion criteria were as follows: an age between 18-65 years, a diagnosis

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of major depressive disorder according to DSM-IV diagnostic criteria, a minimum education level above primary school, and consent to participate in the study. Patients with comorbid psychotic disorders, any anxiety disorders, mental retardation, or severe neurological impairment and other conditions related to general medical conditions were excluded from the study. A face-to-face interview was conducted with all patients and healthy volunteers. The Structured Clinical Interview for DSM-IV Diagnosis (SCID-I) clinical interview form, structured according to the DSM-IV, was used to diagnose or rule out Axis-I psychiatric disorders. The two groups of patients and healthy controls were administered the Sociodemographic Data Form to determine demographic features and other data related to the

ACCEPTED MANUSCRIPT subjects, and the Personality Belief Questionnaire-Short Form (PBQ-SF) was administered to determine belief levels related to personality.

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2.2. Instruments of Assessment

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2.2.1. Sociodemographic Data Form: This form developed by the researchers contains questions about demographic features including age, gender, marital status, educational level,

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and monthly income.

2.2.2. Structured Clinical Interview for DSM-IV Diagnosis (Clinical Version): A structured

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clinical interview form developed by APA for DSM-IV Axis-I disorders in 1994 and a semistructured clinical interview scale developed to diagnose major DSM-IV Axis-I disorders. This form can be administered to both psychiatric patients and general patients. The form, suitable primarily for adults in terms of readability and diagnostic coverage, is composed of

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six modules. The form has been adapted and the validity studies for Turkey were performed

MD, in 1999 [14].

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by Aytul Ozkurkcugil, MD, Omer Aydemir, MD, Mustafa Yildiz, MD, and Ertugrul Koroglu,

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2.2.3. Personality Belief Questionnaire-Short Form : The Personality Belief Questionnaire

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(PBQ), developed by Beck [15] based on cognitive theory and clinical observations for AxisII disorders, contains schemas composed of specific beliefs and assumptions. These schemas correspond to nine personality disorders (avoidant, dependent, passive-agressive, obsessivecompulsive, antisocial, narcissistic, histrionic, paranoid and schizoid) in the DSM-IV. The scale contains 14 questions for each disorder (for a total of 126 items). In clinical practice, the PBQ can be used to construct a profile of cognition and to identify dysfunctional beliefs that could be used in treatment. Since its development in 1991, the PBQ has been used both for normal population and psychiatric patients. The Turkish version of the original PBQ was evaluated for its validity and reliability by Turkcapar in 2007 [16], and the scale achieved an internal consistency between 0.67 and 0.90. The researchers that developed the original

ACCEPTED MANUSCRIPT version of this form subsequently developed a PBQ-SF containing 65 distinctive items selected from the original PBQ form in order to create a short and more practical version with

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a similar evaluation power [17]. In total, 10 scales assess 10 personality disorders: paranoid,

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schizoid, antisocial, borderline, histrionic, narcissistic, avoidant, dependent, obsessivecompulsive, and passive-agressive. PBQ-SF is a self-reported Likert-type questionnaire that is

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scored from 0 ("I don't believe it at all.") to 4 ("I believe it totally."). Example items from the PBQ-SF include "I am not influenced by others in what I decide to do." (schizoid), "I can not

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tolerate unpleasant feelings." (avoidant), "If I am not loved, I will always be unhappy." (dependent), and "The only way I can preserve my self-respect is by asserting myself indirectly." (passive-aggressive). The Turkish version of the original PBQ short form was evaluated for its validity and reliability by Taymur et al. (2011) [18].

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2.3. Statistical analysis

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The Statistical Package for the Social Sciences (SPSS) for Windows 11.5 (SPSS Inc; Chicago, IL) was used to analyze the data. After calculating descriptive statistics (frequency,

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percentage distribution, and mean ± standard deviation), the Shapiro-Wilk test was used to

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check if the variables’ distribution was close to normal. In order to evaluate the difference between the two groups in terms of continuous variables, the Student’s t-test was used when parametric assumptions were satisfied, and the Mann-Whitney U-test was used when parametric assumptions were not satisfied. The differences in the distribution of discontinuous variables across the groups were evaluated using Fisher’s exact test, Yates chi squared test, and Pearson’s chi squared test. In all analyses, p values less than 0.05 were considered statistically significant.

3. Results

ACCEPTED MANUSCRIPT The mean age of the patients in the depression group was 35.68±10.52 years and 41.65±17.20 years in the control group. There was no statistically significant difference

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between the groups in terms of mean age. There were 14 males (20%) and 56 females (80%)

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in the depression group and 14 males (20%) and 56 (80%) females in the control group. The distribution of gender was equal between the two groups. The demographic features of the

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groups are comparatively presented in Table 1.

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A comparison of the groups in terms of their scores in the PBQ-SF subscales revealed that the patients in the depression group achieved higher scores in the dependent, passiveaggressive, obsessive-compulsive, antisocial, histrionic, paranoid, borderline, and avoidant personality subscales compared with the control group. Furthermore, there was no statistically

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significant difference between the groups in terms of their scores in the narcissistic and

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schizoid personality subscales (Table 2; Figure 1).

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4. Discussion

The relationship between depression and personality disorders is important from a

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clinical, therapeutic, and prognostic perspective. The aim of the present study is to show that patients diagnosed with depression more commonly exhibit personality beliefs at the pathological level compared with healthy controls and to identify these personality beliefs using the PBQ. In clinical practice, the PBQ-SF, which reveals the clusters of specific beliefs corresponding to specific personality diagnosis separated into relevant factors, can be used to construct a cognitive profile and identify dysfunctional beliefs that can be used in treatments [19]. The evaluation of the beliefs also allows for the examination of the personality prototypes theory considered to have reduced empirical validity. If one can demonstrate that each prototype defined on the basis of behavioral criteria is shown to have certain beliefs,

ACCEPTED MANUSCRIPT such findings may provide the required support for the validity of the prototypes. Furthermore, evaluation of the beliefs would be also sufficient for the trait-based model of

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personality proposed in The Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-

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5) [20]. In the DSM-5, a hybrid categorical-dimensional approach model is suggested for diagnosing personality disorders. According to this model, core impairments in personality

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functions, pathological personality traits and significant pathological personality types compose the definition of personality pathology. If the patient is not appropriate for a single

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and specific DSM-IV personality disorder type (e.g., antisocial personality disorder ), the clinician records personality disorder-trait specified and details the patient's important personality features. For example, consider a patient have features of antisocial, narcissistic, and borderline personality disorder. Instead of recording all three diagnoses, the clinician can

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record personality disorder-trait specified and note the mix of antagonistic, grandiose,

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attention-seeking, and emotionally labile. These evaluations would also allow the quantification of dysfunctional beliefs that are taken into consideration in the characterization

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of pathological personality types [21]. Additionally, incorporating beliefs as disorder-specific

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criteria should improve the accuracy of diagnoses and therefore improve their reliability [19]. There are differences between studies evaluating the relationship between depression and personality disorders. These differences are due to methodological factors such as different concepts and validity of diagnosis in personality disorders, effects of mood on diagnosis, and overlapping mood symptoms and signs of personality disorder. Many personality traits and disorders can be a part of the psychopathology of depression or may share a common origin [22]. Comorbid personality pathology is a common finding and constitutes a potentially important situation in depressed patients. The most commonly reported personality disorders are avoidant and borderline personality, and more variable paranoid and obsessive personality traits [22].

ACCEPTED MANUSCRIPT According to a review by Corruble, it was estimated that 20–50% of inpatients and 50–85% of outpatients with depression had personality disorder [23]. Cluster B personality

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disorders, particularly borderline (1–30%), histrionic (2–20%), and antisocial (0–10%)

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personality traits were more common, and the narcissistic (less than 5%) personality trait was rarely reported. The major feature of Cluster C personality disorders is the great variability in

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their prevalence, except for obsessive compulsive personality disorder (the prevalence of which is consistent and between 0 and 20%). The results of Cluster A personality disorders

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are heterogeneous. The prevalence of schizotypal personality disorder was marginally high (0–20%), the prevalence of paranoid personality disorder was low (less than 5%), and the prevalence of schizoid personality disorder was variable [23]. In the present study, Cluster B borderline, histrionic, and anti-social personality traits were more prominent in patients with

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depression; however, unlike the findings of the review conducted by Corruble [23] all Cluster

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C personality disorders (avoidant, dependent, and obsessive-compulsive traits) and Cluster A paranoid personality traits were significantly more prominent in the depressed patient group.

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The finding that there was no statistically significant difference between depressed patients

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and the control group in terms of narcissistic and schizoid personality traits is consistent with the findings of Corruble. Skodol [24] calculated the co-occurrence of existing and life-long mood disorders and personality disorders; compared with other DSM-IV personality disorders, borderline, avoidant, and dependent personality disorders were more common in patients with depression. In a study by Rossi [25], 117 patients with depression and 71 bipolar patients were evaluated for personality disorder using the SCID-II [25]. Among patients with depression, avoidant and borderline personality disorder were found to be the most common personality disorders with prevalence rates of 31.6% and 30.8%, respectively. In the bipolar group, the rates of obsessive-compulsive, borderline, and avoidant personality disorders were 32.4%,

ACCEPTED MANUSCRIPT 29.6%, and 19.7%, respectively. Similar to the current study, this finding also supports a strong relationship between avoidant and borderline personality traits and depression.

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In a multicenter study [26], the rate of personality disorders was found to be 51% in

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patients with chronic major depression and double depression. In another study that excluded patients with severe borderline personality disorder, antisocial personality disorder, and

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schizotypal personality disorder, avoidant personality disorder was the most common personality disorder reported to accompany chronic depression (25%). This disorder was

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followed by obsessive-compulsive (18%) and self-defeating (16%) personality disorder In a more recent study – the ‘National Epidemiologic Survey on Alcohol and Related Conditions’ (NESARC, N = 43.093) [27] – obsessive-compulsive personality disorder was found to be the most common personality disorder in the general population of the United

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States, with a prevalence of 7.88%. Obsessive-compulsive personality disorder was also the

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most common comorbid personality disorder in patients diagnosed with depression in the last year, with a rate of 22.5%.

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In a study by Grant [28], all personality disorders were found to be more common in

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depressed patients; paranoid and obsessive-compulsive personality disorders showed the highest prevalence rates. Unlike these studies, paranoid, borderline, avoidant, passive-aggressive, and antisocial personality beliefs are significantly more common in patients with depression. Although studies in the literature repetitively suggest that obsessive-compulsive personality disorder is the most common personality disorder in depressed patients, this personality disorder was significantly common in depressed patients in the current study; however, the level of this significance was lower compared with that of other personality disorders. In the present study, there was no significant difference between depressed patients and normal control patients in terms of the prevalence of schizoid and narcissistic personality

ACCEPTED MANUSCRIPT disorder. The diagnosis of narcissistic personality disorder is empirically the least prominent personality disorder and has not been sufficiently studied in relation to comorbid conditions

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for many years. In a study by Stinson [29] that evaluated the results of the second-wave

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National Epidemiological Survey in 2009, the rate of narcissistic personality disorder among patients with any psychiatric disorder was found to be higher compared with the rate of

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psychiatric disorders in patients with narcissistic personality disorder. The males with narcissistic personality disorder were mostly found to have bipolar I disorder and substance

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abuse disorder; females with narcissistic disorder were mostly found to have anxiety disorder. These findings support a weak relationship between depression and narcissistic personality disorder. From a clinical perspective, dysfunctional beliefs in depressed patients qualitatively differ from self-admiration as in narcissistic personality traits and disregarding appraisal by

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others as in schizoid personality disorder. The fact that beliefs consistent with narcissistic and

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schizoid personality traits are less commonly encountered in depressed patients may suggest

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that such beliefs are not associated with a tendency toward depression.

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5. Conclusions and recommendations We found that the patients in the depressed group had higher scores in the dependent, passive-aggressive, obsessive-compulsive, antisocial, histrionic, paranoid, borderline, and avoidant personality subscales compared with the control group; there was no significant difference between the groups in terms of their score in the narcissistic and schizoid personality subscales. It would not be appropriate to diagnose personality disorder in patients with depression and then state that it is improper to diagnose personality disorder in depressed patients considering their existing condition. The symptoms of personality disorder are affected by changes in the symptoms of mood disorder due to overlapping symptoms of mood

ACCEPTED MANUSCRIPT and personality disorders, and the symptoms of personality disorder may have been masked in a depressed patient; anti-depressants are also effective in the treatment of personality disorder

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[30].

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The present study was limited by a lack of comparison between the subjects in terms of personality traits using other evaluation methods. Furthermore, the patients were already

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receiving psychiatric therapy. The identification of other personality traits accompanying depression using other evaluation methods may have provide clinical benefits to demonstrate

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the consistency between the methods; however, the principal motivation underlying the efforts to detect personality traits accompanying depression was a better understanding of the patient and an ensuring complementary treatment approach instead of diagnosing a comorbidity. Also, another limitation of the research was excluding the depressive patients

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with comorbid any anxiety disorders. These individuals were excluded because the anxiety

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levels of these patients might have affected the results, but this exclusion resulted in an atypical patient population and limited the generalizability of the results.

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Acknowledgements

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We thank the anonymous reviewers for their valuable comments. We express our deepest gratitude to all of the patients and the healthy subjects for being part of this study. References:

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ACCEPTED MANUSCRIPT [4] Beck AT. Depression: clinical, experimental, and theoretical aspects. New York: Hoeber; 1967.

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ACCEPTED MANUSCRIPT [14] Ozkurkcugil A, Aydemir O, Yıldız M. DSM-IV eksen I bozuklukları için yapılandırılmış klinik görüşmenin Türkçe’ye uyarlanması ve güvenilirlik calışması. İlaç ve Tedavi Derg

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Figure 1. Bar graph of mean scores of the patients in the two groups in subscales of the PBQ

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Table 1. The comparison of the two groups in terms of demographic features GROUPS

Marital status

Monthly income

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*Student t Test ** Yate’s Ki-kare Test ▼ Pearson Ki-kare Test sd: standart deviation

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Level of education

male female single married Primary school graduate Secondary school graduate High school graduate University graduate 0-500 TL 501-1000 TL 1001 TL and higher

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Gender

35.68±10.52 n %n 14 20 56 80 50 71.4 20 28.6 23 32.9

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Age,years (mean)

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Control(n=70) mean± sd

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Depression(n=70) mean±sd

p

41.65±17.20 N % N 14 20 56 80 46 65.7 24 34.3 29 41.4

17

24.3

7

10.0

18

25.7

24

34.3

12

17.1

10

14.3

19 35 16

27.1 50 22.9

22 29 19

31.4 41.4 25.7

0.095* 1.000** 0.466▼ 0.117▼

0.656▼

ACCEPTED MANUSCRIPT Table 2. The comparison of the cases in the two groups in terms of mean scores in all subscales of the PBQ Groups Control (n=70)

t

p <0.001

sd

Mean

sd

15.16

6.64

7.15

-8.50

14.76

5.08

11.17

16.24

5.80

12.57

Antisocial

12.31

6.48

8.57

4.86

-3.86

0.001

Narcissistic

10.13

6.03

8.60

5.33

-1.59

0.180

Histrionic

10.07

6.77

7.04

5.30

-2.94

0.008

Schizoid

13.89

5.60

12.40

6.08

-1.50

0.168

Paranoid

13.01

6.73

8.60

5.93

-4.11

<0.001

Borderline

14.87

6.63

6.44

4.41

-8.85

<0.001

Avoidant

16.71

5.52

12.74

5.05

-4.44

<0.001

Passiveaggressive Obsessivecompulsive

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Student t Test sd: standart deviation

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Dependent

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mean

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Depression (n=70)

PBQ

4.42 5.43 5.97

-4.03 -3.68

<0.001 0.001