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Neuroticism and personality disorder in depression
Journul ofA//ectrrw Elsevier
Dtsorders, 8 (1985) 177-182
177
JAD 00276
Neuroticism Jonathan
and Personality
Davidson’.3,
Disorder in Depression
Robert Miller 2 and Rosemary
Strickland
’ Depurtment of Psychiatry, Duke Unioersrty Medrcul Center, Durham, NC. ’ Veterum Adrmmstration Medicul Center, Durhum, NC; and -’MendotuMental He&h Center, Mudison.
’ WI (U.S.A.)
(Received 18 June, 1984) (Accepted 23 August. 19X4)
Summary
Neuroticism and DSM-III personality disorder were studied in 39 depressed inpatients. Interrelationships between these variables and their relationship to depressive typology were compared. The relationship of neuroticism, DSM-III personality type and adequacy of personality to MAOI treatment are also examined. Neuroticism scores were unaffected by short-term treatment, and no differences in neuroticism were observed between melancholies and nonmelancholics, or between endogenous and nonendogenous depressives. Higher neuroticism scores were associated with DSM-III personality disorder. Personality disorder occurred significantly more often in nonmelancholia; borderline, antisocial and histrionic personality disorders occurred exclusively in nonmelancholia, while passive-aggressive, dependent and avoidant disorders occurred in both kinds of depression. Response to MAO inhibitor treatment was similar in patients with high and low neuroticism, adequate and inadequate personality, DSM-III personality disorder and no DSM-III personality disorder. Ambiguities of Eysenck’s neuroticism scale are discussed in relationship to depression.
Key words:
Depression
- DSM-III
personality
disorder - Eysenck ‘.Yneuroticism
Introduction
The relationship between depressive illness and personality has long been of interest in psychiatry. In their review, Akiskal et al. (1983) indicate that introversion is a premorbid trait of nonbipolar depression, while extraversion, obsessoid and cyclothymic features may be premorbid traits for Address correspondence to: Jonathan Davidson. M.D., Mental Hygiene Clinic. V.A. Medical Center. Durham. NC 27705. U.S.A. 0165-0327/X5/$03.30
‘i; 1985 Elsevier Science Publishers
scale-
Neuroticism
bipolar patients. The authors propose various interactive models to account for the association between depression and character pathology. Many aspects of personality have been examined in relation to depression, including the constructs of neuroticism and adequacy of personality, both of which are judged to have diagnostic and prognostic significance. As described by Eysenck and Eysenck (1968) the concept of neuroticism encompasses vulnerability to breakdown under stress, proneness to anxiety and emotional instability; it is sometimes regarded as an aspect of
B.V. (Biomedical
Division)
17x
emotional like reflect
strength
any
measure
trait
relationship
(Hirschfield
et al. 19X3). and
of personality.
rather
than
between
state
is supposed characteristics.
neuroticism
and
to The
depressive
illness has been examined in many studies, most of which suggest that depressive and anxiety symptoms can produce higher neuroticism scores. i.e. indicating a strong state-dependent component to this measure (Kendell and DiScipio 1968; Kerr et al. 1970; Garside et al. 1970; Wretmark et al. 1970; Paykel et al. 1976; Weissman et al. 197X: Hirschfield and Klerman 1979: Benjaminsen 19X1; Hirschfield et al. 19X3). One reason could be that depressed patients do not rate themselves with reference to their nondepressed state unless specifically instructed to do so. Indeed, some chronic depressives may find it very difficult to rate themselves in anything other than the depressed state. Furthermore. many of the neuroticism items in the Eysenck Personality Inventory (EPI) are indistinguishable from symptoms of depression and anxiety. Some studies have shown that
lower
neuroticism
scores
are associated
19X1) we are struck by the which are described between
endogenous depression and stability. or adequacy of personality. In using the terms endogenous depression or melancholia, we should remember that definitions vary, and it is therefore possible that the observed relationships between neuroticism and depressive type
may
vary
as a result.
Two
common
during antidepressive suggested inadequate
treatment. personality
that the prespoor outcome
Several reports (West and Da114
1959; Tyrer and Steinberg 1975; Da114 and Connolly 1981). passive-dependent and anankastic personality (Tyrer et al. 19X3). borderline personality disorder
(Carroll
and high neuroticism all associated with
et al. 1982; Pope et al. 19X3) (Weissman et al. 197X) are poor outcome in depressive
illness. In this report we will examine the relationship between neuroticism and (1) the Newcastle and DSM-III definitions of endogenous depression and melancholia respectively, and (2) presence or absence of DSM-III personality disorder. We will also examine the relationship between the DSM-III diagnosis of melancholia and personality disorder. Finally, we will assess the relevance of neuroticism, personality disorder and adequacy of personality to the response to MAO inhibitor treatment.
with
endogenous depression (Paykel et al. 1976). depression characterLed by marked vegetative symptoms and non-reactivity of mood (Benjaminsen 19X1), and psychomotor retardation (Garside et al. 1970). Moreover. in reviewing the literature (Rosenthal and Gudeman 1967; Paykel et al. 1976: Nelson and Charney repeated associations
A number of authors have found ence of personality disorder predicts
defini-
tions of endogenous depression and melancholia are those of the Newcastle Index (Carney et al. 1965) and of DSM-III. The Newcastle Scale is the only scale of its kind which includes adequate personality as a defining criterion of endogenous depression (Davidson et al. 19x4~). DSM-III intentionally excludes personality characteristics from the list of diagnostic criteria for melancholia, yet there does appear to be an association between melancholia and absence of personality disorder (Nelson and Charney 19X1).
Material
and Methods
The patient sample comprised 39 inpatients who fulfilled RDC for major depression of nondelusional type (Spitzer et al. 1975). All patients entered a 4-week treatment study of isocarboxazid which has been described elsewhere (Davidson et al. 19X4a). Patients were assessed before treatment for the presence of endogenoua depression and melancholia by two observers (JD and KS). who had achieved good inter-rater reliability as described elsewhere (Davidson et al. 19X4b; 19x4~). Assessment of adequate personality has been described by us elsewhere (Davidson et al. 19X4b). Good inter-rater reliability was shown for this item. We would point out here that the concept of adequate personality may be seen ah a convenient global assessment of a patient’s ability to cope with life: put simply, one is assessing the capacity to love. work and play. The EPI. form A, was completed by each patient before treatment, and again at the end of 4 weeks’ treatment. At each time, patients were asked to complete the questions with reference to how they would feel in the nondepressed state. The investigators did not have access to EPI scores
179
until after the patient had been discharged. Diagnoses of DSM-I I I personality disorder were made about the time of discharge. after it had been possible to assess patients once depressive symptoms had disappeared or been substantially reduced. Two raters (JD, RS) independently made judgments about DSM-III personality disorder, and discussed their observations before reaching a conclusion. Ratings of depressive symptoms before and during treatment were made by a third independent rater (RM) who was not part of the pre-treatment or post-treatment assessments of personality and diagnostic type. The symptom ratings were made according to the Hamilton Depression Scale. Use of this third rater reduced halo effects that would occur if personality assessment and symptom ratings had been made by the same raters. Statistical methods involved the use of 2-tailed Student’s r-test and x2 comparisons, as appropriate.
Hamilton Score (r = 0.14). We have, therefore, in most subsequent analyses of neuroticism combined the 31 post-treatment results with the pretreatment results obtained in 8 patients in whom it was not possible to obtain post-treatment scores. Adequate personality was present in 21 (54%) patients, whereas the personality was considered to be inadequate in 15 patients (38%). Agreement as to adequacy could not be reached in 3 cases (8%). Eighteen out of 29 (46%) patients with major depression had a concomitant axis 11 diagnosis of personality disorder, while 21 (54%) had no personality disorder. The following disorders occurred, sometimes being present simultaneously: dependent (7) borderline (6) histrionic (5) antisocial (3), passive-aggressive (2). mixed (2), avoidant (1). Neuroticism (u) Neuroticism und type of depression
Results Thirty-nine patients entered the study, and 35 completed treatment. Assessments of personality disorder, personality adequacy and neuroticism were made in all patients, although post-treatment neuroticism measures were obtained in only 31 of the 39 patients, because 8 patients either dropped out of treatment early (n = 4) or failed to complete the EPI following treatment (n = 4). The analyses to follow are either of the 31 treatment completers or of the combination of these 31 completers and the remaining 8 pretreatment assessments (henceforth referred to as the combined group). The mean pre-treatment N score for all 39 patients was 12.3 f 5.0 (SD). Initially we assessed whether, as has been reported by others. the N score changed during treatment in the 31 patients in whom post-treatment scores were available. Despite a significant decline in the Hamilton Depression Score from 26.0 f 3.9 to 12.9 f 7.7, the N scores did not decrease significantly. The mean pre-treatment N score was 12.0 f 4.6 (n = 31) compared to a post-treatment score of 11.2 f 4.5 (n = 31). Moreover, there was no correlation between the post-treatment N score and the final
Post-treatment N scores for Newcastle endogenous (n = 13) and nonendogenous (n = 18) depressives were compared. Data showed no significant difference in that the mean N scores were 10.0 & 4.3 SD and 11.5 _t 4.5 SD respectively (t = 1.67, df 29, ns). For DSM-III melancholic and nonmelancholic patients, the mean post-treatment N scores were 10.5 f 4.6 SD (n = 12) and 11.3 i4.3 (n = 19), respectively. These are not significant differences (t = 0.88, dj 29, ns). When the results are based on the combined group of 39, findings are similar. The N scores for all endogenous (n = 18) and nonendogenous (n = 21) patients were 10.5 _t 4.8 and 12.5 + 5.1 (t = 1.30, df 37, ns); for melancholic (n = 15) and nonmelancholic (n = 24) patients’ scores were 11 .l k 5.5 and 12.9 f 4.4 (1 = 1.07, ~“37, ns). Although there was a tendency for endogenous/melancholic patients to be less neurotic, this did not reach statistical significance in our series. (h) Neuroticism and DSM-III personulit_v disorder N scores for the combined group of 39 were studied in relationship to DSM-III personality disorder. The mean f SD N scores were 14.3 f 5.0 for patients with personality disorder and 10.5 f
3.6 for patients without (t = 2.55, dJ 37. P < 0.05), indicating significantly less neuroticism in the absence of personality disorder. DSM-III
personality
TABLE
1
WEEK 4 HAMILTON SCORE TION TO PERSONALITY
(MEANkSD)
I
disorder Neuroticism swrr
((I) Relutionship to diugnostic t>spe A diagnosis of personality disorder was significantly more common in nonmelancholia than in melancholia (62% vs 20%: xZ 5.1, df 1, P < 0.02). Although a similar pattern was found in Newcastle endogenous depression, there were no significant differences between nonendogenous and endogenous patients in respect of personality disorder (59% vs 29%: x2 = 3.39, crf 1. P < 0.1). There was also a relationship between the type of personality disorder and type of depression. We formed three retrospective groups of personality disorder according to whether or not there was a tendency to act out and show “instability”. The defined groups were (1) antisocial-histrionicborderline disorders (n = 7). (2) avoidant-dependent-passive aggressive disorders (n = 9). and (3) disorders of mixed type (n = 2). None of the antisocial-borderline-histrionic patients had melancholia/endogenous depression, and all had nonmelancholia/nonendogenous depression. The group of avoidant-dependent-passive aggressive personality disorders was equally distributed among the two depressive types. i.e. 5 had melancholia and 7 had nonmelancholia: 7 had Newcastle endogenous depression and 5 had nonendogenous depression. Mixed personality disorder was diagnosed in two patients who had borderline, narcissistic, antisocial. avoidant. or histrionic traits. which did not in themselves occur in sufficient number to merit a diagnosis of the particular disorder, but together or with other features amounted to a diagnosis of personality disorder. mixed type. Both patients with this personality disorder had nonmelancholia/nonendogenous depression. Personulit~~ fuc~t0r.s mid treutment resporwe We examined whether there was any relationship between response to isocarboxazid and neuroticism. adequate personality or a diagnosis of personality disorder. The results are shown in Table 1. As mentioned earlier. no correlation was observed between post-treatment neuroticism and the
IN RELA-
Personality
4
‘I
Prr\onal~ty disorder (DSM-III) (’ Determination
Io(n
= 15)
-5 11 (n=16) Adequate (n = 19) Inadequate (n = 14) Aixent (n = 20) Present (n = 15)
11.6*7.X
c;LIue
l.O?(fl\)
14.1 r 5.4 12.7*7.x 0.75 (ns) 10.X+6.7 12.7*9.1 0.11 (ns) 12.4*6.1
could not he made in 2 case\.
Hamilton Depression Score at week 4. We also grouped the 31 patients according to whether their post-treatment neuroticism score was in excess of 10, the median score in our population, which is close to the mean N score of 9 in the normal population. We found that the final Hamilton Depression Score for patients with a neuroticism score of < 10 was 11.6 f 7.X. compared to a score of 14.1 i 5.4 for patients with a neuroticism score of 2 11. This difference is not significant ( t = 1.03. d/ 29). There was no relationship between adequacy of personality and treatment outcome. In patients with adequate personality (n = 19). the mean final Hamilton Score was 12.7 + 7.8 SD. compared to a score of 10.8 & 6.7 in patients with no adequate personality (n = 14) (t = 0.75. df 31. ns). The presence of a DSM-III Personality disorder similarly had no bearing upon treatment outcome. At 4 weeks, the mean + SD Hamilton Score for patients with no personality disorder (n = 20) was 12.7 f 9.1. compared to patients with personality disorder (n = 15) whose Hamilton Score was 12.4 + 6.1 (r = 0.11. Q.33, ns). Discussion
Personality disorder occurred in approximately two-thirds of nonmelancholic patients. as compared to one-third of melancholies, figures which are remarkably similar to those of Charney et al. (I 981). Surprisingly. the difference was nonsignificant. and less marked. when Newcastle endogenous and nonendogenous depressions were com-
IX1
pared; one might have expected to find a greater difference with this scheme. since adequate personality is one of the scale’s defining criteria. One limiting factor in our findings is failure to use independent raters for assessing DSM-III personality type. We also used a consensus method for reaching a diagnosis rather than basing the assessments upon proved inter-rater reliability. Acknowledging these limitations, however, we found that when personality disorder was present in melancholia, it was of the avoidant-dependentpassive aggressive type, in contrast to the borderline-antisocial-histrionic disorders which were found exclusively in nonmelancholia and nonendogenous depression, a finding similar to that of Charney et al. (1981). The basis for this interesting association between personality cluster and depressive type bears further study. It might perhaps relate to possible biological differences within personality disorders in which regulation of impulse control could be an important determinant. A clustering of borderline-histrionic-antisocial personality types has been noted elsewhere by Pope et al. (1983). These “unstable” personality types do not appear to respond to tricyclic antidepressants as well as patients with “stable” personality disorders such as dependent and depressive personality (Akiskal et al. 1980). The MAO inhibitors probably offer certain advantages to patients with unstable personality features such as borderline and histrionic disorder (Liebowitz and Klein 1981). Our data are consistent with this possibility. since the lowest mean final Hamilton Scores were found in patients with inadequate personality, and were generally similar in all diagnostic groups. Precaution should be exercised, however. when MAO inhibitors are administered to sociopaths (Dally 1967). In a similar study to our own, Tyrer et al. (1983) found that the worse responses to phenelzine occurred in patients with personality disorder. However, these personality disorders comprised chiefly passive-dependent and anankastic types. and borderline, histrionic and narcissistic disorders were not described, so it is hard to compare their findings with ours. Although neuroticism was greater in patients with personality disorder, and personality disorder occurred more often in nonmelancholia, neuroticism scores in melancholia and nonmelancholia
did not differ. This calls for comment. since other studies referred to have shown greater neuroticism in nonmelancholia. Sample selection could be one possible reason for our findings, since all patients were nondelusional and had been selected for antidepressant drug therapy on the basis of nonresponse to the environmental changes of being hospitalized. Baseline Hamilton Scores between endogenous and nonendogenous patients were similar, and it is quite likely, therefore, that any differences between the groups may have been outweighed by similarities. We also found that the N score remained stable throughout an acute illness, and suggested that pretreatment measures are unlikely to change with symptom reduction over 4 weeks. It is possible, however, that the N score would diminish further following prolonged symptom remission, or after total elimination of symptoms. The N scores were in fact much less in 4 patients whose final Hamilton Score was below 6, which raises the possibility that almost any level of symptomatology influences the N score, and that it makes little difference whether symptoms are mild, moderate or severe. Overall. we do have some reservations about whether the N scale measures personality traits in depressed patients. since 19 of the 24 scale items appear in the Hamilton Depression Scale, and 12 appear in the Hamilton Anxiety Scale. These items cover guilt, poor self-esteem, irritability, sleeplessness. nervousness. worry and hypochondriasis. Bianchi and Fergusson (1977) found it impossible to identify enough items that were independent of the Hamilton Anxiety Score: they could not, therefore, conduct a modified scale which was independent of symptoms. Our study has examined a number of important, and in some cases, little studied aspects of the relationship between personality and depression. In future assessments of the phenomenology, classification and response to treatment. greater attention needs to be given to the influence of personality, preferably by the use of standardized rating techniques. We (Krishnan et al. 1984) and others (Carroll et al. 1982) have also shown that important relationships may exist between biological alterations (e.g. abnormal DST response), presence of personality disorder and depression.
1x2
References Akiskal. H.S., Rosenthal, T.L.. Haykal, R.F.. et al., Characterological depressions Clinical and sleep EEG findings separating subaffective dysthymias from character spectrum disorders. Arch. Gen. Psychiat.. 126 (1980) 973-983. Akiskal, H.S., Hirschfield. R.M.S. and Yerevanian, B.I.. The relationship of personality to affective disorders. Arch. Gen. Psychiat.. 40 (1983) XOll810. Benjaminsen. S.. Primary nonendogenous depression and features attributed to reactive depression. J. Affect. Dis.. 3 (1981) 2455259. Bianchi. G.N. and Fergusson. D.M., The effect of mental states on EPI scores. Brit. J. Psychiat., 31 (1977) 3066309. Carney, M.W.P., Garside, R.F. and Roth. M., The diagnosis of depressive syndromes and prediction of ECT response, Brit. J. Psychiat., 111 (1965) 6599674. Carroll, B.J.. Greden. J.F.. Feinberg. M.. et al., Neuroendocrine evaluation of depression in borderline patients, Psychiat. Clin. N. Amer.. 4 (1982) 89-99. Charney. D.S., Nelson, J.C. and Quinlan, D.S., Personality trait and disorder in depression. Amer. J. Psychiat.. 138 (1981) 1601l1604. Dally, P.J.. Chemotherapy of Psychiatric Disorders, Plenum Press, New York. 1967. p. 44. Dally. P.J. and Connolly, J.. An Introduction to Physical Methods of Treatment in Psychiatry. 6th edition. Churchill Livingstone, New York, 1981, p. 20. Davidson, J.R.T.. Miller, R.D. and Turnbull. C.D., An evaluation of two doses of isocarboxazid in depression. J. Affect. Dis.. 65 (1984a) 201-207. Davidson. J.R.T., Strickland. R., Turnbull. C.D.. et al., The Newcastle Endogenous Depression Diagnostic Index ~ Validity and reliability. Acta Psychiat. Stand.. 69 (1984b) 220-230. Davidson. J.R.T., Turnbull. C.D.. Strickland. R., et al. Cornparative diagnostic criteria for melancholia and endogenous depression. Arch. Gen. Psychiat., 41 (1984~) 506 -511. Eysenck, H.J. and Eysenck, S.B.G., Eysenck Personality Inventory Educational and Industrial Testing Service. San Diego, CA. 196X. Garaide, R.F., Kay. D.W.K.. Roy, J.R., et al.. M.P.I. scores and symptoms of depression, Brit. J. Psychiat.. 116 (1970) 4299432. Hirschfield. R.M.A. and Klerman. G.S., Personality attributes and affective disorders. Amer. J. Psychiat.. 136 (1979) 67-70. Hirschfield. R.M.A.. Klerman. G.L., Clayton. P.J.. et al.. Per-
sonality and depression. Arch. Gen. Psychiat.. 40 (19X3) 9933998. Kendell. R.E. and DiScipio. W.J., Eyjenck Personality Inventory scores of patients with depressive illnesses. Brit. J. Paychiat.. 114 (1968) 767-770. Kerr, T.A.. Schapira, K.. Roth. M.. et al.. The relationship between the Maudsley Personality Inventory and the course of affective disorders. 116 (1970) 11-20. Krishnan. R.R.K.. Davidson. J.R.T., Rayaaam. R.. et al.. The dexamethasone suppression test in borderline personality disorder, Biol. Psychiat.. 19 (1984) 1155-1198. Liebowitz., M. and Klein. D.F.. Interrelationship of hysteroid dysphoria and borderline personality disorder, Psychiat. Clin. N. Amer., 4 (1981) 67787. Lunghi, M. and Ryle, A., The stability of scores on the Eysenck Personality Inventory in a university population. Brit. J. Psychiat., 113 (1969) 1201~1202. Nelson, J.C. and Charney. D.S.. The symptoms of major depressive illness. Amer. J. Psychiat.. 138 (1981) 1-13. Paykel. E.S.. Klerman, G.L. and Prusoff. B.A.. Personality and symptom pattern m depression. Brit. J. Psychiat.. 129 (1976) 2377244. Pope, H.G.. Jonas. J.M., Hudson. J.I.. et al., The validity of DSM-III borderline personality disorder, Arch. Gen. Psychiat., 40 (1983) 23-30. Rosenthal. S.H. and Gudeman, J.E:.. The erdogenous depre\sive pattern, Arch. Gen. Psychiat.. 16 (1967) 241-249. Rosenthal. S.H. and Klerman, G.L.. Content and consistency in the endogenous depressive pattern, Brit. J. Paychiat.. 112 ( 1966) 47 1-4X4. Spitrer. R.L.. Endicott, J. and Robins. E., Research Diagnostic Criteria for a Selected Group of Functional Disorders, 3rd edition. New York, New York Psychiatric Institute. 1979. Tyrer. P.J. and Steinburg. D., Symptomatic treatment of agoraphobia and social phobias, Brit. J. Psychiat., 127 (1975) 1633168. Tyrer, P.J.. Casey. P. and Gau, J., Relationship between neuro sis and personality disorder. Brit. J. Paychiat.. 142 (1983) 404-408. Weissman. M.M., Prusoff, B.A. and Klerman. G.S.. Personality and the prediction of long-term outcome of depression. Amer. J. Psychiat.. 135 (197X) 797-802. West. ED. and Dally, P.J., Effect of iproniazid in depressive syndromes, Brit. Med. J., I (1959) 1491-1494. Wretmark, G.. Astrom. J. and Erikason, M.. The Maudsley Personality Inventory as a prognostic instrument. Brit. J. Psychiat.. 116 (1970) 21-36.
Dtsorders, 8 (1985) 177-182
177
JAD 00276
Neuroticism Jonathan
and Personality
Davidson’.3,
Disorder in Depression
Robert Miller 2 and Rosemary
Strickland
’ Depurtment of Psychiatry, Duke Unioersrty Medrcul Center, Durham, NC. ’ Veterum Adrmmstration Medicul Center, Durhum, NC; and -’MendotuMental He&h Center, Mudison.
’ WI (U.S.A.)
(Received 18 June, 1984) (Accepted 23 August. 19X4)
Summary
Neuroticism and DSM-III personality disorder were studied in 39 depressed inpatients. Interrelationships between these variables and their relationship to depressive typology were compared. The relationship of neuroticism, DSM-III personality type and adequacy of personality to MAOI treatment are also examined. Neuroticism scores were unaffected by short-term treatment, and no differences in neuroticism were observed between melancholies and nonmelancholics, or between endogenous and nonendogenous depressives. Higher neuroticism scores were associated with DSM-III personality disorder. Personality disorder occurred significantly more often in nonmelancholia; borderline, antisocial and histrionic personality disorders occurred exclusively in nonmelancholia, while passive-aggressive, dependent and avoidant disorders occurred in both kinds of depression. Response to MAO inhibitor treatment was similar in patients with high and low neuroticism, adequate and inadequate personality, DSM-III personality disorder and no DSM-III personality disorder. Ambiguities of Eysenck’s neuroticism scale are discussed in relationship to depression.
Key words:
Depression
- DSM-III
personality
disorder - Eysenck ‘.Yneuroticism
Introduction
The relationship between depressive illness and personality has long been of interest in psychiatry. In their review, Akiskal et al. (1983) indicate that introversion is a premorbid trait of nonbipolar depression, while extraversion, obsessoid and cyclothymic features may be premorbid traits for Address correspondence to: Jonathan Davidson. M.D., Mental Hygiene Clinic. V.A. Medical Center. Durham. NC 27705. U.S.A. 0165-0327/X5/$03.30
‘i; 1985 Elsevier Science Publishers
scale-
Neuroticism
bipolar patients. The authors propose various interactive models to account for the association between depression and character pathology. Many aspects of personality have been examined in relation to depression, including the constructs of neuroticism and adequacy of personality, both of which are judged to have diagnostic and prognostic significance. As described by Eysenck and Eysenck (1968) the concept of neuroticism encompasses vulnerability to breakdown under stress, proneness to anxiety and emotional instability; it is sometimes regarded as an aspect of
B.V. (Biomedical
Division)
17x
emotional like reflect
strength
any
measure
trait
relationship
(Hirschfield
et al. 19X3). and
of personality.
rather
than
between
state
is supposed characteristics.
neuroticism
and
to The
depressive
illness has been examined in many studies, most of which suggest that depressive and anxiety symptoms can produce higher neuroticism scores. i.e. indicating a strong state-dependent component to this measure (Kendell and DiScipio 1968; Kerr et al. 1970; Garside et al. 1970; Wretmark et al. 1970; Paykel et al. 1976; Weissman et al. 197X: Hirschfield and Klerman 1979: Benjaminsen 19X1; Hirschfield et al. 19X3). One reason could be that depressed patients do not rate themselves with reference to their nondepressed state unless specifically instructed to do so. Indeed, some chronic depressives may find it very difficult to rate themselves in anything other than the depressed state. Furthermore. many of the neuroticism items in the Eysenck Personality Inventory (EPI) are indistinguishable from symptoms of depression and anxiety. Some studies have shown that
lower
neuroticism
scores
are associated
19X1) we are struck by the which are described between
endogenous depression and stability. or adequacy of personality. In using the terms endogenous depression or melancholia, we should remember that definitions vary, and it is therefore possible that the observed relationships between neuroticism and depressive type
may
vary
as a result.
Two
common
during antidepressive suggested inadequate
treatment. personality
that the prespoor outcome
Several reports (West and Da114
1959; Tyrer and Steinberg 1975; Da114 and Connolly 1981). passive-dependent and anankastic personality (Tyrer et al. 19X3). borderline personality disorder
(Carroll
and high neuroticism all associated with
et al. 1982; Pope et al. 19X3) (Weissman et al. 197X) are poor outcome in depressive
illness. In this report we will examine the relationship between neuroticism and (1) the Newcastle and DSM-III definitions of endogenous depression and melancholia respectively, and (2) presence or absence of DSM-III personality disorder. We will also examine the relationship between the DSM-III diagnosis of melancholia and personality disorder. Finally, we will assess the relevance of neuroticism, personality disorder and adequacy of personality to the response to MAO inhibitor treatment.
with
endogenous depression (Paykel et al. 1976). depression characterLed by marked vegetative symptoms and non-reactivity of mood (Benjaminsen 19X1), and psychomotor retardation (Garside et al. 1970). Moreover. in reviewing the literature (Rosenthal and Gudeman 1967; Paykel et al. 1976: Nelson and Charney repeated associations
A number of authors have found ence of personality disorder predicts
defini-
tions of endogenous depression and melancholia are those of the Newcastle Index (Carney et al. 1965) and of DSM-III. The Newcastle Scale is the only scale of its kind which includes adequate personality as a defining criterion of endogenous depression (Davidson et al. 19x4~). DSM-III intentionally excludes personality characteristics from the list of diagnostic criteria for melancholia, yet there does appear to be an association between melancholia and absence of personality disorder (Nelson and Charney 19X1).
Material
and Methods
The patient sample comprised 39 inpatients who fulfilled RDC for major depression of nondelusional type (Spitzer et al. 1975). All patients entered a 4-week treatment study of isocarboxazid which has been described elsewhere (Davidson et al. 19X4a). Patients were assessed before treatment for the presence of endogenoua depression and melancholia by two observers (JD and KS). who had achieved good inter-rater reliability as described elsewhere (Davidson et al. 19X4b; 19x4~). Assessment of adequate personality has been described by us elsewhere (Davidson et al. 19X4b). Good inter-rater reliability was shown for this item. We would point out here that the concept of adequate personality may be seen ah a convenient global assessment of a patient’s ability to cope with life: put simply, one is assessing the capacity to love. work and play. The EPI. form A, was completed by each patient before treatment, and again at the end of 4 weeks’ treatment. At each time, patients were asked to complete the questions with reference to how they would feel in the nondepressed state. The investigators did not have access to EPI scores
179
until after the patient had been discharged. Diagnoses of DSM-I I I personality disorder were made about the time of discharge. after it had been possible to assess patients once depressive symptoms had disappeared or been substantially reduced. Two raters (JD, RS) independently made judgments about DSM-III personality disorder, and discussed their observations before reaching a conclusion. Ratings of depressive symptoms before and during treatment were made by a third independent rater (RM) who was not part of the pre-treatment or post-treatment assessments of personality and diagnostic type. The symptom ratings were made according to the Hamilton Depression Scale. Use of this third rater reduced halo effects that would occur if personality assessment and symptom ratings had been made by the same raters. Statistical methods involved the use of 2-tailed Student’s r-test and x2 comparisons, as appropriate.
Hamilton Score (r = 0.14). We have, therefore, in most subsequent analyses of neuroticism combined the 31 post-treatment results with the pretreatment results obtained in 8 patients in whom it was not possible to obtain post-treatment scores. Adequate personality was present in 21 (54%) patients, whereas the personality was considered to be inadequate in 15 patients (38%). Agreement as to adequacy could not be reached in 3 cases (8%). Eighteen out of 29 (46%) patients with major depression had a concomitant axis 11 diagnosis of personality disorder, while 21 (54%) had no personality disorder. The following disorders occurred, sometimes being present simultaneously: dependent (7) borderline (6) histrionic (5) antisocial (3), passive-aggressive (2). mixed (2), avoidant (1). Neuroticism (u) Neuroticism und type of depression
Results Thirty-nine patients entered the study, and 35 completed treatment. Assessments of personality disorder, personality adequacy and neuroticism were made in all patients, although post-treatment neuroticism measures were obtained in only 31 of the 39 patients, because 8 patients either dropped out of treatment early (n = 4) or failed to complete the EPI following treatment (n = 4). The analyses to follow are either of the 31 treatment completers or of the combination of these 31 completers and the remaining 8 pretreatment assessments (henceforth referred to as the combined group). The mean pre-treatment N score for all 39 patients was 12.3 f 5.0 (SD). Initially we assessed whether, as has been reported by others. the N score changed during treatment in the 31 patients in whom post-treatment scores were available. Despite a significant decline in the Hamilton Depression Score from 26.0 f 3.9 to 12.9 f 7.7, the N scores did not decrease significantly. The mean pre-treatment N score was 12.0 f 4.6 (n = 31) compared to a post-treatment score of 11.2 f 4.5 (n = 31). Moreover, there was no correlation between the post-treatment N score and the final
Post-treatment N scores for Newcastle endogenous (n = 13) and nonendogenous (n = 18) depressives were compared. Data showed no significant difference in that the mean N scores were 10.0 & 4.3 SD and 11.5 _t 4.5 SD respectively (t = 1.67, df 29, ns). For DSM-III melancholic and nonmelancholic patients, the mean post-treatment N scores were 10.5 f 4.6 SD (n = 12) and 11.3 i4.3 (n = 19), respectively. These are not significant differences (t = 0.88, dj 29, ns). When the results are based on the combined group of 39, findings are similar. The N scores for all endogenous (n = 18) and nonendogenous (n = 21) patients were 10.5 _t 4.8 and 12.5 + 5.1 (t = 1.30, df 37, ns); for melancholic (n = 15) and nonmelancholic (n = 24) patients’ scores were 11 .l k 5.5 and 12.9 f 4.4 (1 = 1.07, ~“37, ns). Although there was a tendency for endogenous/melancholic patients to be less neurotic, this did not reach statistical significance in our series. (h) Neuroticism and DSM-III personulit_v disorder N scores for the combined group of 39 were studied in relationship to DSM-III personality disorder. The mean f SD N scores were 14.3 f 5.0 for patients with personality disorder and 10.5 f
3.6 for patients without (t = 2.55, dJ 37. P < 0.05), indicating significantly less neuroticism in the absence of personality disorder. DSM-III
personality
TABLE
1
WEEK 4 HAMILTON SCORE TION TO PERSONALITY
(MEANkSD)
I
disorder Neuroticism swrr
((I) Relutionship to diugnostic t>spe A diagnosis of personality disorder was significantly more common in nonmelancholia than in melancholia (62% vs 20%: xZ 5.1, df 1, P < 0.02). Although a similar pattern was found in Newcastle endogenous depression, there were no significant differences between nonendogenous and endogenous patients in respect of personality disorder (59% vs 29%: x2 = 3.39, crf 1. P < 0.1). There was also a relationship between the type of personality disorder and type of depression. We formed three retrospective groups of personality disorder according to whether or not there was a tendency to act out and show “instability”. The defined groups were (1) antisocial-histrionicborderline disorders (n = 7). (2) avoidant-dependent-passive aggressive disorders (n = 9). and (3) disorders of mixed type (n = 2). None of the antisocial-borderline-histrionic patients had melancholia/endogenous depression, and all had nonmelancholia/nonendogenous depression. The group of avoidant-dependent-passive aggressive personality disorders was equally distributed among the two depressive types. i.e. 5 had melancholia and 7 had nonmelancholia: 7 had Newcastle endogenous depression and 5 had nonendogenous depression. Mixed personality disorder was diagnosed in two patients who had borderline, narcissistic, antisocial. avoidant. or histrionic traits. which did not in themselves occur in sufficient number to merit a diagnosis of the particular disorder, but together or with other features amounted to a diagnosis of personality disorder. mixed type. Both patients with this personality disorder had nonmelancholia/nonendogenous depression. Personulit~~ fuc~t0r.s mid treutment resporwe We examined whether there was any relationship between response to isocarboxazid and neuroticism. adequate personality or a diagnosis of personality disorder. The results are shown in Table 1. As mentioned earlier. no correlation was observed between post-treatment neuroticism and the
IN RELA-
Personality
4
‘I
Prr\onal~ty disorder (DSM-III) (’ Determination
Io(n
= 15)
-5 11 (n=16) Adequate (n = 19) Inadequate (n = 14) Aixent (n = 20) Present (n = 15)
11.6*7.X
c;LIue
l.O?(fl\)
14.1 r 5.4 12.7*7.x 0.75 (ns) 10.X+6.7 12.7*9.1 0.11 (ns) 12.4*6.1
could not he made in 2 case\.
Hamilton Depression Score at week 4. We also grouped the 31 patients according to whether their post-treatment neuroticism score was in excess of 10, the median score in our population, which is close to the mean N score of 9 in the normal population. We found that the final Hamilton Depression Score for patients with a neuroticism score of < 10 was 11.6 f 7.X. compared to a score of 14.1 i 5.4 for patients with a neuroticism score of 2 11. This difference is not significant ( t = 1.03. d/ 29). There was no relationship between adequacy of personality and treatment outcome. In patients with adequate personality (n = 19). the mean final Hamilton Score was 12.7 + 7.8 SD. compared to a score of 10.8 & 6.7 in patients with no adequate personality (n = 14) (t = 0.75. df 31. ns). The presence of a DSM-III Personality disorder similarly had no bearing upon treatment outcome. At 4 weeks, the mean + SD Hamilton Score for patients with no personality disorder (n = 20) was 12.7 f 9.1. compared to patients with personality disorder (n = 15) whose Hamilton Score was 12.4 + 6.1 (r = 0.11. Q.33, ns). Discussion
Personality disorder occurred in approximately two-thirds of nonmelancholic patients. as compared to one-third of melancholies, figures which are remarkably similar to those of Charney et al. (I 981). Surprisingly. the difference was nonsignificant. and less marked. when Newcastle endogenous and nonendogenous depressions were com-
IX1
pared; one might have expected to find a greater difference with this scheme. since adequate personality is one of the scale’s defining criteria. One limiting factor in our findings is failure to use independent raters for assessing DSM-III personality type. We also used a consensus method for reaching a diagnosis rather than basing the assessments upon proved inter-rater reliability. Acknowledging these limitations, however, we found that when personality disorder was present in melancholia, it was of the avoidant-dependentpassive aggressive type, in contrast to the borderline-antisocial-histrionic disorders which were found exclusively in nonmelancholia and nonendogenous depression, a finding similar to that of Charney et al. (1981). The basis for this interesting association between personality cluster and depressive type bears further study. It might perhaps relate to possible biological differences within personality disorders in which regulation of impulse control could be an important determinant. A clustering of borderline-histrionic-antisocial personality types has been noted elsewhere by Pope et al. (1983). These “unstable” personality types do not appear to respond to tricyclic antidepressants as well as patients with “stable” personality disorders such as dependent and depressive personality (Akiskal et al. 1980). The MAO inhibitors probably offer certain advantages to patients with unstable personality features such as borderline and histrionic disorder (Liebowitz and Klein 1981). Our data are consistent with this possibility. since the lowest mean final Hamilton Scores were found in patients with inadequate personality, and were generally similar in all diagnostic groups. Precaution should be exercised, however. when MAO inhibitors are administered to sociopaths (Dally 1967). In a similar study to our own, Tyrer et al. (1983) found that the worse responses to phenelzine occurred in patients with personality disorder. However, these personality disorders comprised chiefly passive-dependent and anankastic types. and borderline, histrionic and narcissistic disorders were not described, so it is hard to compare their findings with ours. Although neuroticism was greater in patients with personality disorder, and personality disorder occurred more often in nonmelancholia, neuroticism scores in melancholia and nonmelancholia
did not differ. This calls for comment. since other studies referred to have shown greater neuroticism in nonmelancholia. Sample selection could be one possible reason for our findings, since all patients were nondelusional and had been selected for antidepressant drug therapy on the basis of nonresponse to the environmental changes of being hospitalized. Baseline Hamilton Scores between endogenous and nonendogenous patients were similar, and it is quite likely, therefore, that any differences between the groups may have been outweighed by similarities. We also found that the N score remained stable throughout an acute illness, and suggested that pretreatment measures are unlikely to change with symptom reduction over 4 weeks. It is possible, however, that the N score would diminish further following prolonged symptom remission, or after total elimination of symptoms. The N scores were in fact much less in 4 patients whose final Hamilton Score was below 6, which raises the possibility that almost any level of symptomatology influences the N score, and that it makes little difference whether symptoms are mild, moderate or severe. Overall. we do have some reservations about whether the N scale measures personality traits in depressed patients. since 19 of the 24 scale items appear in the Hamilton Depression Scale, and 12 appear in the Hamilton Anxiety Scale. These items cover guilt, poor self-esteem, irritability, sleeplessness. nervousness. worry and hypochondriasis. Bianchi and Fergusson (1977) found it impossible to identify enough items that were independent of the Hamilton Anxiety Score: they could not, therefore, conduct a modified scale which was independent of symptoms. Our study has examined a number of important, and in some cases, little studied aspects of the relationship between personality and depression. In future assessments of the phenomenology, classification and response to treatment. greater attention needs to be given to the influence of personality, preferably by the use of standardized rating techniques. We (Krishnan et al. 1984) and others (Carroll et al. 1982) have also shown that important relationships may exist between biological alterations (e.g. abnormal DST response), presence of personality disorder and depression.
1x2
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