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Personality traits of Japanese patients in remission from an episode of primary unipolar depression
Journal of Affective Disorders 44 (1997) 145–152
Research report
Personality traits of Japanese patients in remission from an episode of primary unipolar depression a, b c d e Detlev von Zerssen *, Nozomu Asukai , Hitoshi Tsuda , Yutaka Ono , Yasuo Kizaki , Yoshinori Cho f a Max Planck Institute of Psychiatry, Clinical Institute, Munich, Germany Department of Social Psychiatry, Tokyo Institute of Psychiatry, Tokyo, Japan c Department of Psychiatry, Branch Hospital of Tokyo University, Tokyo, Japan d Department of Neuropsychiatry, Keio University, School of Medicine, Tokyo, Japan e Central Health Institute of East JR, Tokyo, Japan f Department of Psychiatry, Teikyo University, School of Medicine, Tokyo, Japan b
Received 2 January 1997; accepted 17 March 1997
Abstract Personality traits were assessed by means of the Munich Personality Test (MPT) in 75 Japanese subjects, 27 patients in remission from an episode of moderate to severe primary unipolar depression, with melancholic features during one episode or more of the disorder, in 24 patients in remission from other non-organic mental disorders and in 24 healthy controls. Compared with healthy controls, unipolar depressives displayed decreased Frustration Tolerance and elevated Rigidity as well as a stronger Orientation towards Social Norms. No significant difference was found between patients in remission from either unipolar depression or other mental disorders. However, the increase in Rigidity in comparison with healthy subjects was significant in the depressives only whereas the other patients, in contrast to the depressives, had significantly lower scores in Extraversion than the healthy subjects. Our results in Japanese patients are similar to findings of previous German studies, including two high risk studies, in which the same assessment instrument was used. This suggests that, beyond cultural differences, Rigidity, possibly in combination with a strong Orientation towards Social Norms and a reduced Frustration Tolerance, is a stable vulnerability marker for at least the more severe forms of primary unipolar depression. 1997 Elsevier Science B.V. Keywords: Personality traits; Unipolar depression; Neuroticism; Frustration Tolerance; Rigidity; Orientation towards Social Norms
*Corresponding author. Prof. Dr. Detlev von Zerssen, Ottostr. 11, D-82319 Starnberg, Germany, fax: 1 49 8151 4116. 0165-0327 / 97 / $17.00 1997 Elsevier Science B.V. All rights reserved PII S0165-0327( 97 )00038-4
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1. Introduction Certain pre-morbid personality traits have been described in the literature as vulnerability factors of depression (see reviews by Chodoff, 1972; Mendelson, 1976; von Zerssen, 1982, 1996; Akiskal et al., 1983; Hirschfeld and Shea, 1992). Even in a remitted state, unipolar patients show less normal profiles in personality questionnaires than bipolar patients who exhibit no or only marginal and inconsistent differences from mentally healthy individuals (von Zerssen, 1982; Goodwin and Jamison, 1990). In high risk (Hirschfeld et al., 1989; Boyce et al., 1991; Maier et al., 1992; Lauer et al., 1997) as well as in prospective cohort studies of subjects unaffected by a mental disorder at or before index investigation ¨ and Lindegard, ˚ (Nystrom 1975; Angst and Clayton, 1986; Hirschfeld et al., 1989; Kendler et al., 1993; Clayton et al., 1994), Neuroticism was consistently identified as a risk factor for unipolar, but not for bipolar depression (Angst and Clayton, 1986; Hirschfeld et al., 1989; Clayton et al., 1994). In addition, Interpersonal Sensitivity (Boyce et al., 1991), Dependency and a lack of Stress Tolerance (Hirschfeld et al., 1989) / Resiliency (Clayton et al., 1994) were also found pre-morbidly in subjects who later developed unipolar depression. An exception to the rule of increased Neuroticism was a study (Boyce et al., 1993) in which unipolar depressives with melancholia, in contrast to non-melancholic depressives, did not deviate from healthy controls in Interpersonal Sensitivity which is composed mainly of elements of Neuroticism such as need for approval, separation anxiety, timidity etc.. Furthermore, a set of obsessional personality features such as over-conscientiousness, scrupulousness, orderliness, conventionality and rigid moral standards have been observed in melancholic patients by psychoanalysts (e.g. Abraham, 1954; Cohen et al., 1954; see Mendelson, 1976) and clinical psychiatrists (e.g. Tellenbach, 1980) independently in several Western countries (see von Zerssen, 1982, 1996). This trait pattern, which can be summarized under the heading of Rigidity, was also discovered in Japanese patients (e.g. Shimoda, 1950; Hirasawa, 1962; Sato et al., 1994). In case control studies using the Munich Personality Test (MPT: von Zerssen et al., 1988), a self-rating questionnaire, an elevated
level of Rigidity, in addition to increased Neuroticism-scores, was demonstrated among unipolar major depressives (Bronisch and Hecht, 1989; ¨ Schafer, 1991, 1994) or relatives of such patients (Maier et al., 1992; Lauer et al., 1997). In an investigation of biographical case notes, the ‘melancholic type’ of pre-morbid personality, described by Tellenbach (1980) as showing high degrees of orderliness and dependency, was predominant mainly in unipolar ‘endogenous’ depressives (von Zerssen et al., 1994). This is in agreement with the majority of psychometric studies performed in Anglosaxon countries (Nietzel and Harris, 1990). However, some investigations did not support the high prevalence of pre-morbid obsessional traits in unipolar depressives (e.g. Hirschfeld et al., 1989; Roy, 1990). The inconsistency of results regarding obsessional features might be due to differences in the diagnostic composition of patient samples (unipolar depressives only or unipolar as well as bipolar depressives, patients with or without melancholic features etc.) or to differences in the sensitivity of personality inventories to detect the particular traits that characterise the pre-morbid personality in certain types of depression. Furthermore, patients with either primary unipolar or bipolar depression achieved higher scores on a conventional ‘Lie’ scale than patients with depression secondary to a neurotic disorder (Benjaminsen, 1981); in another study (Bech et al., 1980), unipolar depressives scored higher on such a scale than bipolar patients, both groups scoring higher than the normative test samples of males and females. Similar findings were reported by Abou-Saleh and Coppen (1984), however, not by some other authors who applied similar measures of social desirability (e.g. Perris et al., 1984). Nonetheless, a trend to social desirability of self-ratings of primary unipolar depressives can probably be assumed. This ‘‘may well reflect serious concern with social norms and rigid moral standards and not a tendency towards lying or denial of illness’’ (von Zerssen, 1982). According to clinical observations, such a concern with social norms appears typical of (recovered) melancholics (Kraus, 1977; Tellenbach, 1980). In order to clarify the inconsistencies of findings reported so far, it is necessary to study diagnostically well-defined homogeneous groups by means of
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reliable and valid multidimensional personality inventories that contain scales for the assessment of the traits in question, i.e. Neuroticism, Resiliency (or Stress Tolerance / Frustration Tolerance), Rigidity (in this context probably the central aspect of the obsessional trait pattern in depressives: von Zerssen, 1982), and an Orientation towards Social Norms. On this methodological basis, it may also be possible to determine whether specific pre-morbid personality traits of depressives are culture-bound or common to quite different cultures. Only in the latter case, deviations of personality traits from cultural norms can be considered with some confidence as stable vulnerability markers for depression. The purpose of this study was to investigate retrospectively personality traits of Japanese patients in remission from an episode of primary unipolar major depression and control subjects in a similar way as in a preceding study of German subjects (von Zerssen, unpublished report to the Deutsche Forschungsgemeinschaft, 1994). The data could later be used to perform direct cross-cultural comparisons.
2. Subjects and methods
2.1. Subjects The total sample (n 5 75) of the present study consists of Japanese subjects, namely 53 patients and 24 healthy probands. They form three subsamples: The index group (Idx) comprises 27 patients in remission from a moderate to severe episode of primary unipolar major depression. With one questionable exception, all of them had fulfilled the criteria of the melancholic subtype according to DSM-III-R (American Psychiatric Association, 1987) during one episode or more of their disorder. Control group I (CI) consists of 24 patients in remission from other non-organic mental disorders (see below). Control group II (CII) is composed of 24 subjects without any mental or physical disorder. Idx and CI were selected from outpatients or inpatients who had entered treatment at one of the following six facilities in Tokyo: three university hospitals, a metropolitan general hospital, a private mental hospital, and a health institute of the Metropolitan Railway Company of Tokyo, respectively.
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The heterogeneity of institutions decreases the probability of a selection bias. CII was recruited from the personnel of three company offices and from participants of a community college course on psychology for citizens of Tokyo. The aim and the design of the study were explained to all subjects and informed consent was obtained. Patients with organic mental disorders or subnormal intelligence were excluded from the study. All subjects but two had completed high school or had achieved a higher educational level. A female patient of Idx and another female patient of CI had completed middle school only, but they had an average verbal IQ according to the subtest ‘Information’ of the Wechsler Adult Intelligence Scale (WAIS-R: Wechsler, 1981). The Structured Clinical Interview for DSM-III-R (SCID: Spitzer et al., 1990) was applied to all subjects for an operational diagnosis of DSM-III-R Axis I disorders. Patients who had suffered from any Axis I disorder before the age of 20 were excluded from the study in order to ensure optimal comparability with the German sample (see Section 1). In assessing personality traits typical of subjects suffering from a depressive disorder, heterogeneity of samples might cause problems (see above). The DSM-III-R diagnosis of a major depressive episode requires at least five criteria out of a total of nine. However, patients with various kinds of mental disorders may experience a mild episode of major depression according to the criteria of DSM-III-R so that studies including cases of mild depression may be contaminated with psychopathology other than typical pure depression. In our study, subjects of Idx had to fulfil at least seven criteria during the severest lifetime episode with no lifetime co-morbidity of other Axis I disorders. Therefore, Idx consists exclusively of patients who had previously suffered from moderate to severe primary unipolar major depression, except for one questionable case, with melancholic features. CI consists of 14 psychotic patients (mainly schizophrenics) and 10 patients with various disorders of the ‘neurotic’ type (mainly anxiety disorders). All these patients had never fulfilled the criteria of other Axis I disorders. Patients were excluded from CI if they had experienced past episodes fulfilling the criteria of major depression, bipolar disorder or schizoaffective disorder. Subjects
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of CII (with no mental disorders) had never undergone an Axis I disorder according to DSM-III-R criteria. In order to confirm that the subjects in the three groups were not in a depressed state at the time of the study, all of them were investigated by means of the 21 item Hamilton Depression Scale (Hamilton, 1960) and those with a score of 10 or above were excluded from further inquiry. The age ranges within the three groups varied from 28–59 years of age (Idx), 28–58 years (CI) and 36–57 years (CII). The male / female ratio, age distribution, marital as well as employment status of subjects in the three groups were similar (Table 1).
2.2. Assessment of personality traits Personality traits were assessed by means of a Japanese version of the MPT (von Zerssen et al., 1988). This instrument is a multidimensional selfrating personality inventory composed of 51 items. These form eight homogeneous scales which were derived from a series of principle component analyses of a set of well over 450 items. Six of the scales represent the personality dimensions of Extraversion (E), Neuroticism (N), Frustration Tolerance (F), Rigidity (R), Isolation Tendency (Is), and Esoteric Tendencies (Es); the two other scales refer to an Orientation towards Social Norms (No; an equivalent of conventional ‘Lie’ scales) and the Motivation for adequate responses to the test items (Mo). According
to the test instruction, subjects have to rate their behaviour in a state of physical and mental health. This is required with the intention to diminish the influence of (residual) psychopathology on the selfratings of patients (see Kendell and DiScipio, 1968). The original version of the MPT was evaluated in German subjects according to the usual test criteria and provided quite satisfactory results regarding internal consistency, re-test reliability and various aspects of validity (von Zerssen et al., 1988). In the present study, 67 subjects (out of the 75 in all three groups) were re-investigated after one month to seven months (M 5 96 days, S.D. 5 39 days). The test–retest reliability of the Japanese version was similar to that of the original German version for five of the six personality scales proper, varying between 0.64 for N (German version: 0.73 after approximately one year) and 0.78 for E (German version: 0.76). Only for Is it was but 0.49 (German version: 0.62).
2.3. Statistical data analysis Because of ordinal scaling and the limited sample sizes, non-parametric statistical tests (Siegel and Castellan Jr., 1988) were used to determine significant differences between the groups, namely the Kruskal–Wallis H test in the case of three groups and the Mann–Whitney U test for pairwise comparisons among the three groups. Likewise in view of the n per group, the a-level of 5% was accepted as indicating significance. For the same reason, it
Table 1 Socio-demographic characteristics of the subsamples
Male (m) / female (f) ratio Mean age (S.D.) Marital status Married Single Divorced / widowed Employment Employed / housewife Unemployed
Index group (Idx) Unipolar depression n 5 27
Control group I (CI) Other mental disorders n 5 24
Control group II (CII) No mental disorders n 5 24
16 / 11 m 44.1 (8.9) f 49.2 (6.9)
12 / 12 m 42.2 (9.8) f 47.0 (7.4)
13 / 11 m 42.8 (6.2) f 46.6 (6.7)
24 3 0
18 4 2
20 2 2
23 4
22 2
24 0
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was not adjusted for multiple testing, which would have increased the danger of type 2 errors. Instead, the number of differences reaching the (unadjusted) 5% level was compared with the respective number to be expected by chance.
3. Results The overall test for three groups revealed significant differences in E, F, R and No (Table 2). In pairwise comparisons, Idx had significantly lower values in F; it reached higher values in R and No than CII. CI deviated from CII in a somewhat different way by showing lower values in E in addition to lower values in F and higher values in No. The R values of this group were, on an average, intermediate between those of Idx and CII. There were no significant differences in any of the scales between Idx and CI. Thus, out of the 32 statistical tests in an eight times four contingency table, ten (four H and six U tests) reached the 5%
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level of significance instead of only one or two to be expected by chance.
4. Discussion We investigated personality traits of Japanese patients in remission from an episode of moderate to severe primary unipolar major depression and two control samples (composed of either patients recovered from another non-organic mental disorder or healthy probands) with the aid of a multidimensional personality inventory (MPT). The results partially replicated the findings of previous studies in Germany in which the same instrument had been applied: Unipolar major depressives displayed an elevated level of Rigidity (Bronisch and Hecht, ¨ 1989; Schafer, 1991) and decreased Frustration ¨ Tolerance (Schafer, 1991). However, an increase in Neuroticism was not found. This is different from other studies in which Neuroticism was elevated in the whole group of patients with major depression ¨ (Schafer, 1991) and in (still) healthy relatives of
Table 2 Comparison of MPT scores among the subsamples MPT scales
Extraversion (E) Neuroticism (N) Frustration Tolerance (F) Rigidity (R) Isolation Tendency (Is) Esoteric tendencies (Es) Orientation towards social norms (No) Motivation (Mo) a
Index group (Idx)
Control group I (CI)
Control group II (CII)
Significance among
Significance of pairwise comparisons b
Unipolar depression n 5 27 Mean (S.D.)
Other mental disorders n 5 24 Mean (S.D.)
No mental disorders
3 groups a
Idx / CI
Idx / CII
CI / CII
n 5 24 Mean (S.D.)
9.1 (6.5) 9.0 (4.9) 5.3 (3.0)
7.5 (4.0) 8.8 (5.1) 6.1 (2.9)
11.5 (5.5) 8.0 (4.2) 8.1 (2.3)
* ns **
ns
ns
**
ns
**
*
11.0 (5.1) 4.0 (1.5)
9.6 (3.2) 3.5 (1.7)
7.5 (4.0) 3.8 (1.8)
* ns
ns
*
ns
2.5 (1.8)
2.2 (1.5)
2.4 (2.2)
ns
14.0 (3.0)
13.8 (3.9)
12.6 (2.4)
*
ns
*
*
8.0 (1.4)
7.9 (1.3)
7.8 (1.2)
ns
Kruskal–Wallis H test. b Mann–Whitney U test. * P , 0.05. ** P , 0.01.
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such patients (Lauer et al., 1997; in a study by Maier et al. (1992) in male relatives only). The increase of an Orientation towards Social Norms in our depressives has not been described in former MPT studies, but it was found in other studies using equivalent scales (see Section 1). The concordance of results regarding elevated MPT scores for Rigidity in unipolar major depression in previous German studies of patients ¨ (Bronisch and Hecht, 1989; Schafer, 1991) and high risk subjects (Maier et al., 1992; Lauer et al., 1997) and in this study of Japanese patients suggests that a certain set of obsessional personality features may be a vulnerability factor for primary unipolar major depression beyond cultural differences. The respective trait pattern can be labelled as ‘strength of superego functions’ (devotion to work, perfectionism, submissiveness to authorities and cultural norms, scrupulousness etc.). It resembles descriptions of the character structure of melancholics in the psychoanalytic and clinical psychiatric literature (see Section 1). The Rigidity scale of the MPT may thus be a powerful tool for detecting this particularly relevant aspect of pre-morbid personality features in subjects with primary unipolar major depression. The two high risk studies in which the MPT was used (Maier et al., 1992; Lauer et al., 1997) did not reveal a significant reduction of Frustration Tolerance in (still healthy) relatives of patients suffering from major depression. On the other hand, two prospective studies found a tendency to reduced Resilience in subjects who later on developed a depressive disorder (Hirschfeld et al., 1989; Clayton et al., 1994). It cannot be determined yet, whether decreased Frustration Tolerance of the unipolar depressives in our study reflects a pre-morbid personality trait or a post-morbid change of personality or both. This is also true for an increased Orientation towards Social Norms. Conversely, a pre-morbid elevation of neurotic traits in unipolar depressives is a relatively consistent finding of prospective studies. These traits were ¨ and Lindegard, ˚ described as Subvalidity (Nystrom 1975), Autonomic Lability (Angst and Clayton, 1986; Clayton et al., 1994), Neuroticism (Boyce et al., 1991; Kendler et al., 1993), decreased Emotional Strength (Hirschfeld et al., 1989) etc. However, as mentioned in Section 1, Boyce et al. (1993), in a
study of patients in remission from an episode of major depression and healthy controls, found increased Interpersonal Sensitivity, which is closely related to Neuroticism, in non-melancholic and not in (formerly) melancholic depressives. As almost all depressives in our study had fulfilled the criteria of the melancholic subtype during one episode or more of their illness, it seems possible that Neuroticism is a vulnerability factor for non-melancholic rather than for melancholic depression. The control subjects with mental disorders other than depression (mainly neurotics or psychotics in a remitted state) had lower Extraversion scores than the healthy subjects. However, like the depressives, they had decreased scores on Frustration Tolerance and increased scores on an Orientation towards Social Norms and they, too, did not show a significant increase in Neuroticism. Furthermore, they scored intermediate between unipolar depressives and healthy subjects on Rigidity. One possible explanation is that remitted neurotics and / or schizophrenics may differ from unremitted cases by a lower pre-morbid level of Neuroticism and higher levels of Rigidity and an Orientation towards Social Norms. These features may facilitate their clinical improvement and social adaptation. However, it cannot be excluded that the tendency to Social Desirability in our Japanese patients indicates a response set rather than a behavioural trait. This set may have reduced self-rated Neuroticism and thus obscured a difference in personality traits between the patients and their healthy controls. In only a few prospective studies, personality traits of depressives and other psychiatric patients were investigated simultaneously. Angst and Clayton (1986) found pre-morbid neurotic traits not only in unipolar depressives but also in schizophrenics and anxiety neurotics; but nothing is known about the further course of their disorders. It is, however, well-documented in other investigations that Neuroticism is a predictor of an unfavorable course, at least in depression (e.g. Weissman et al., 1978; ¨ Moller et al., 1987). In view of this complex situation, a definite explanation of the lack of increased Neuroticism in our patients is not yet possible. Our study has some limitations. Firstly, it is retrospective in nature. Secondly, we did not select
D. von Zerssen et al. / Journal of Affective Disorders 44 (1997) 145 – 152
the subjects randomly or by consecutive sampling. However, with the exception of the second author of this paper, the Japanese members of our team who recruited patients in each facility were not informed about the composition of the MPT scales and the results of previous studies. Therefore, an effect of a selection bias on the data, if there is any, can be considered as minimal. Thirdly, we investigated patients in clinical settings only. It is questionable whether pre-morbid personality traits are common to unipolar depressives of clinical and non-clinical populations. Despite the similarity with findings of two independent German studies of subjects at high risk for major depression (Maier et al., 1992; Lauer et al., 1997), our results need to be replicated in Japanese high risk studies and / or prospective cohort studies of healthy subjects. Finally, we did not include bipolar patients in our study so that we cannot decide whether in Japanese samples Rigidity is more prominent among unipolar depressives than among bipolars.
5. Conclusions Although pre-morbid personality traits have been described as vulnerability factors of depressive disorders in different countries, it has not been studied psychometrically by means of the same assessment instruments whether such variables are, indeed, common to basically different cultures. We therefore assessed retrospectively personality traits of Japanese patients in remission from moderate to severe primary unipolar major depression and control subjects with the aid of a multidimensional self-rating personality inventory, the MPT, which had already been used in several case control and high risk studies in a Western country (Germany). On this basis, we found elevated scores for Rigidity and an Orientation towards Social Norms as well as decreased scores for Frustration Tolerance (Resiliency) in the formerly depressed patients. Although these findings are not very specific of unipolar depressives compared with other psychiatric patients, they are rather similar to those of previous studies in Germany and to related findings in other Western countries; the only exception refers to Neuroticism which, in contrast to most studies in
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Western countries, was not elevated in our patients. It has to be clarified in further investigations whether this is due to cultural differences, to clinical features of our patient samples (e.g. the high prevalence of melancholic features in our depressives and the degree of remission in our psychiatric controls) or to a response set in the self-ratings. However, Rigidity as assessed by the MPT, possibly in combination with a strong Orientation towards Social Norms and a decreased Frustration Tolerance, seems to represent a common vulnerability factor, at least for the more severe forms of primary unipolar major depression, beyond cultural differences.
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Research report
Personality traits of Japanese patients in remission from an episode of primary unipolar depression a, b c d e Detlev von Zerssen *, Nozomu Asukai , Hitoshi Tsuda , Yutaka Ono , Yasuo Kizaki , Yoshinori Cho f a Max Planck Institute of Psychiatry, Clinical Institute, Munich, Germany Department of Social Psychiatry, Tokyo Institute of Psychiatry, Tokyo, Japan c Department of Psychiatry, Branch Hospital of Tokyo University, Tokyo, Japan d Department of Neuropsychiatry, Keio University, School of Medicine, Tokyo, Japan e Central Health Institute of East JR, Tokyo, Japan f Department of Psychiatry, Teikyo University, School of Medicine, Tokyo, Japan b
Received 2 January 1997; accepted 17 March 1997
Abstract Personality traits were assessed by means of the Munich Personality Test (MPT) in 75 Japanese subjects, 27 patients in remission from an episode of moderate to severe primary unipolar depression, with melancholic features during one episode or more of the disorder, in 24 patients in remission from other non-organic mental disorders and in 24 healthy controls. Compared with healthy controls, unipolar depressives displayed decreased Frustration Tolerance and elevated Rigidity as well as a stronger Orientation towards Social Norms. No significant difference was found between patients in remission from either unipolar depression or other mental disorders. However, the increase in Rigidity in comparison with healthy subjects was significant in the depressives only whereas the other patients, in contrast to the depressives, had significantly lower scores in Extraversion than the healthy subjects. Our results in Japanese patients are similar to findings of previous German studies, including two high risk studies, in which the same assessment instrument was used. This suggests that, beyond cultural differences, Rigidity, possibly in combination with a strong Orientation towards Social Norms and a reduced Frustration Tolerance, is a stable vulnerability marker for at least the more severe forms of primary unipolar depression. 1997 Elsevier Science B.V. Keywords: Personality traits; Unipolar depression; Neuroticism; Frustration Tolerance; Rigidity; Orientation towards Social Norms
*Corresponding author. Prof. Dr. Detlev von Zerssen, Ottostr. 11, D-82319 Starnberg, Germany, fax: 1 49 8151 4116. 0165-0327 / 97 / $17.00 1997 Elsevier Science B.V. All rights reserved PII S0165-0327( 97 )00038-4
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1. Introduction Certain pre-morbid personality traits have been described in the literature as vulnerability factors of depression (see reviews by Chodoff, 1972; Mendelson, 1976; von Zerssen, 1982, 1996; Akiskal et al., 1983; Hirschfeld and Shea, 1992). Even in a remitted state, unipolar patients show less normal profiles in personality questionnaires than bipolar patients who exhibit no or only marginal and inconsistent differences from mentally healthy individuals (von Zerssen, 1982; Goodwin and Jamison, 1990). In high risk (Hirschfeld et al., 1989; Boyce et al., 1991; Maier et al., 1992; Lauer et al., 1997) as well as in prospective cohort studies of subjects unaffected by a mental disorder at or before index investigation ¨ and Lindegard, ˚ (Nystrom 1975; Angst and Clayton, 1986; Hirschfeld et al., 1989; Kendler et al., 1993; Clayton et al., 1994), Neuroticism was consistently identified as a risk factor for unipolar, but not for bipolar depression (Angst and Clayton, 1986; Hirschfeld et al., 1989; Clayton et al., 1994). In addition, Interpersonal Sensitivity (Boyce et al., 1991), Dependency and a lack of Stress Tolerance (Hirschfeld et al., 1989) / Resiliency (Clayton et al., 1994) were also found pre-morbidly in subjects who later developed unipolar depression. An exception to the rule of increased Neuroticism was a study (Boyce et al., 1993) in which unipolar depressives with melancholia, in contrast to non-melancholic depressives, did not deviate from healthy controls in Interpersonal Sensitivity which is composed mainly of elements of Neuroticism such as need for approval, separation anxiety, timidity etc.. Furthermore, a set of obsessional personality features such as over-conscientiousness, scrupulousness, orderliness, conventionality and rigid moral standards have been observed in melancholic patients by psychoanalysts (e.g. Abraham, 1954; Cohen et al., 1954; see Mendelson, 1976) and clinical psychiatrists (e.g. Tellenbach, 1980) independently in several Western countries (see von Zerssen, 1982, 1996). This trait pattern, which can be summarized under the heading of Rigidity, was also discovered in Japanese patients (e.g. Shimoda, 1950; Hirasawa, 1962; Sato et al., 1994). In case control studies using the Munich Personality Test (MPT: von Zerssen et al., 1988), a self-rating questionnaire, an elevated
level of Rigidity, in addition to increased Neuroticism-scores, was demonstrated among unipolar major depressives (Bronisch and Hecht, 1989; ¨ Schafer, 1991, 1994) or relatives of such patients (Maier et al., 1992; Lauer et al., 1997). In an investigation of biographical case notes, the ‘melancholic type’ of pre-morbid personality, described by Tellenbach (1980) as showing high degrees of orderliness and dependency, was predominant mainly in unipolar ‘endogenous’ depressives (von Zerssen et al., 1994). This is in agreement with the majority of psychometric studies performed in Anglosaxon countries (Nietzel and Harris, 1990). However, some investigations did not support the high prevalence of pre-morbid obsessional traits in unipolar depressives (e.g. Hirschfeld et al., 1989; Roy, 1990). The inconsistency of results regarding obsessional features might be due to differences in the diagnostic composition of patient samples (unipolar depressives only or unipolar as well as bipolar depressives, patients with or without melancholic features etc.) or to differences in the sensitivity of personality inventories to detect the particular traits that characterise the pre-morbid personality in certain types of depression. Furthermore, patients with either primary unipolar or bipolar depression achieved higher scores on a conventional ‘Lie’ scale than patients with depression secondary to a neurotic disorder (Benjaminsen, 1981); in another study (Bech et al., 1980), unipolar depressives scored higher on such a scale than bipolar patients, both groups scoring higher than the normative test samples of males and females. Similar findings were reported by Abou-Saleh and Coppen (1984), however, not by some other authors who applied similar measures of social desirability (e.g. Perris et al., 1984). Nonetheless, a trend to social desirability of self-ratings of primary unipolar depressives can probably be assumed. This ‘‘may well reflect serious concern with social norms and rigid moral standards and not a tendency towards lying or denial of illness’’ (von Zerssen, 1982). According to clinical observations, such a concern with social norms appears typical of (recovered) melancholics (Kraus, 1977; Tellenbach, 1980). In order to clarify the inconsistencies of findings reported so far, it is necessary to study diagnostically well-defined homogeneous groups by means of
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reliable and valid multidimensional personality inventories that contain scales for the assessment of the traits in question, i.e. Neuroticism, Resiliency (or Stress Tolerance / Frustration Tolerance), Rigidity (in this context probably the central aspect of the obsessional trait pattern in depressives: von Zerssen, 1982), and an Orientation towards Social Norms. On this methodological basis, it may also be possible to determine whether specific pre-morbid personality traits of depressives are culture-bound or common to quite different cultures. Only in the latter case, deviations of personality traits from cultural norms can be considered with some confidence as stable vulnerability markers for depression. The purpose of this study was to investigate retrospectively personality traits of Japanese patients in remission from an episode of primary unipolar major depression and control subjects in a similar way as in a preceding study of German subjects (von Zerssen, unpublished report to the Deutsche Forschungsgemeinschaft, 1994). The data could later be used to perform direct cross-cultural comparisons.
2. Subjects and methods
2.1. Subjects The total sample (n 5 75) of the present study consists of Japanese subjects, namely 53 patients and 24 healthy probands. They form three subsamples: The index group (Idx) comprises 27 patients in remission from a moderate to severe episode of primary unipolar major depression. With one questionable exception, all of them had fulfilled the criteria of the melancholic subtype according to DSM-III-R (American Psychiatric Association, 1987) during one episode or more of their disorder. Control group I (CI) consists of 24 patients in remission from other non-organic mental disorders (see below). Control group II (CII) is composed of 24 subjects without any mental or physical disorder. Idx and CI were selected from outpatients or inpatients who had entered treatment at one of the following six facilities in Tokyo: three university hospitals, a metropolitan general hospital, a private mental hospital, and a health institute of the Metropolitan Railway Company of Tokyo, respectively.
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The heterogeneity of institutions decreases the probability of a selection bias. CII was recruited from the personnel of three company offices and from participants of a community college course on psychology for citizens of Tokyo. The aim and the design of the study were explained to all subjects and informed consent was obtained. Patients with organic mental disorders or subnormal intelligence were excluded from the study. All subjects but two had completed high school or had achieved a higher educational level. A female patient of Idx and another female patient of CI had completed middle school only, but they had an average verbal IQ according to the subtest ‘Information’ of the Wechsler Adult Intelligence Scale (WAIS-R: Wechsler, 1981). The Structured Clinical Interview for DSM-III-R (SCID: Spitzer et al., 1990) was applied to all subjects for an operational diagnosis of DSM-III-R Axis I disorders. Patients who had suffered from any Axis I disorder before the age of 20 were excluded from the study in order to ensure optimal comparability with the German sample (see Section 1). In assessing personality traits typical of subjects suffering from a depressive disorder, heterogeneity of samples might cause problems (see above). The DSM-III-R diagnosis of a major depressive episode requires at least five criteria out of a total of nine. However, patients with various kinds of mental disorders may experience a mild episode of major depression according to the criteria of DSM-III-R so that studies including cases of mild depression may be contaminated with psychopathology other than typical pure depression. In our study, subjects of Idx had to fulfil at least seven criteria during the severest lifetime episode with no lifetime co-morbidity of other Axis I disorders. Therefore, Idx consists exclusively of patients who had previously suffered from moderate to severe primary unipolar major depression, except for one questionable case, with melancholic features. CI consists of 14 psychotic patients (mainly schizophrenics) and 10 patients with various disorders of the ‘neurotic’ type (mainly anxiety disorders). All these patients had never fulfilled the criteria of other Axis I disorders. Patients were excluded from CI if they had experienced past episodes fulfilling the criteria of major depression, bipolar disorder or schizoaffective disorder. Subjects
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of CII (with no mental disorders) had never undergone an Axis I disorder according to DSM-III-R criteria. In order to confirm that the subjects in the three groups were not in a depressed state at the time of the study, all of them were investigated by means of the 21 item Hamilton Depression Scale (Hamilton, 1960) and those with a score of 10 or above were excluded from further inquiry. The age ranges within the three groups varied from 28–59 years of age (Idx), 28–58 years (CI) and 36–57 years (CII). The male / female ratio, age distribution, marital as well as employment status of subjects in the three groups were similar (Table 1).
2.2. Assessment of personality traits Personality traits were assessed by means of a Japanese version of the MPT (von Zerssen et al., 1988). This instrument is a multidimensional selfrating personality inventory composed of 51 items. These form eight homogeneous scales which were derived from a series of principle component analyses of a set of well over 450 items. Six of the scales represent the personality dimensions of Extraversion (E), Neuroticism (N), Frustration Tolerance (F), Rigidity (R), Isolation Tendency (Is), and Esoteric Tendencies (Es); the two other scales refer to an Orientation towards Social Norms (No; an equivalent of conventional ‘Lie’ scales) and the Motivation for adequate responses to the test items (Mo). According
to the test instruction, subjects have to rate their behaviour in a state of physical and mental health. This is required with the intention to diminish the influence of (residual) psychopathology on the selfratings of patients (see Kendell and DiScipio, 1968). The original version of the MPT was evaluated in German subjects according to the usual test criteria and provided quite satisfactory results regarding internal consistency, re-test reliability and various aspects of validity (von Zerssen et al., 1988). In the present study, 67 subjects (out of the 75 in all three groups) were re-investigated after one month to seven months (M 5 96 days, S.D. 5 39 days). The test–retest reliability of the Japanese version was similar to that of the original German version for five of the six personality scales proper, varying between 0.64 for N (German version: 0.73 after approximately one year) and 0.78 for E (German version: 0.76). Only for Is it was but 0.49 (German version: 0.62).
2.3. Statistical data analysis Because of ordinal scaling and the limited sample sizes, non-parametric statistical tests (Siegel and Castellan Jr., 1988) were used to determine significant differences between the groups, namely the Kruskal–Wallis H test in the case of three groups and the Mann–Whitney U test for pairwise comparisons among the three groups. Likewise in view of the n per group, the a-level of 5% was accepted as indicating significance. For the same reason, it
Table 1 Socio-demographic characteristics of the subsamples
Male (m) / female (f) ratio Mean age (S.D.) Marital status Married Single Divorced / widowed Employment Employed / housewife Unemployed
Index group (Idx) Unipolar depression n 5 27
Control group I (CI) Other mental disorders n 5 24
Control group II (CII) No mental disorders n 5 24
16 / 11 m 44.1 (8.9) f 49.2 (6.9)
12 / 12 m 42.2 (9.8) f 47.0 (7.4)
13 / 11 m 42.8 (6.2) f 46.6 (6.7)
24 3 0
18 4 2
20 2 2
23 4
22 2
24 0
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was not adjusted for multiple testing, which would have increased the danger of type 2 errors. Instead, the number of differences reaching the (unadjusted) 5% level was compared with the respective number to be expected by chance.
3. Results The overall test for three groups revealed significant differences in E, F, R and No (Table 2). In pairwise comparisons, Idx had significantly lower values in F; it reached higher values in R and No than CII. CI deviated from CII in a somewhat different way by showing lower values in E in addition to lower values in F and higher values in No. The R values of this group were, on an average, intermediate between those of Idx and CII. There were no significant differences in any of the scales between Idx and CI. Thus, out of the 32 statistical tests in an eight times four contingency table, ten (four H and six U tests) reached the 5%
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level of significance instead of only one or two to be expected by chance.
4. Discussion We investigated personality traits of Japanese patients in remission from an episode of moderate to severe primary unipolar major depression and two control samples (composed of either patients recovered from another non-organic mental disorder or healthy probands) with the aid of a multidimensional personality inventory (MPT). The results partially replicated the findings of previous studies in Germany in which the same instrument had been applied: Unipolar major depressives displayed an elevated level of Rigidity (Bronisch and Hecht, ¨ 1989; Schafer, 1991) and decreased Frustration ¨ Tolerance (Schafer, 1991). However, an increase in Neuroticism was not found. This is different from other studies in which Neuroticism was elevated in the whole group of patients with major depression ¨ (Schafer, 1991) and in (still) healthy relatives of
Table 2 Comparison of MPT scores among the subsamples MPT scales
Extraversion (E) Neuroticism (N) Frustration Tolerance (F) Rigidity (R) Isolation Tendency (Is) Esoteric tendencies (Es) Orientation towards social norms (No) Motivation (Mo) a
Index group (Idx)
Control group I (CI)
Control group II (CII)
Significance among
Significance of pairwise comparisons b
Unipolar depression n 5 27 Mean (S.D.)
Other mental disorders n 5 24 Mean (S.D.)
No mental disorders
3 groups a
Idx / CI
Idx / CII
CI / CII
n 5 24 Mean (S.D.)
9.1 (6.5) 9.0 (4.9) 5.3 (3.0)
7.5 (4.0) 8.8 (5.1) 6.1 (2.9)
11.5 (5.5) 8.0 (4.2) 8.1 (2.3)
* ns **
ns
ns
**
ns
**
*
11.0 (5.1) 4.0 (1.5)
9.6 (3.2) 3.5 (1.7)
7.5 (4.0) 3.8 (1.8)
* ns
ns
*
ns
2.5 (1.8)
2.2 (1.5)
2.4 (2.2)
ns
14.0 (3.0)
13.8 (3.9)
12.6 (2.4)
*
ns
*
*
8.0 (1.4)
7.9 (1.3)
7.8 (1.2)
ns
Kruskal–Wallis H test. b Mann–Whitney U test. * P , 0.05. ** P , 0.01.
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such patients (Lauer et al., 1997; in a study by Maier et al. (1992) in male relatives only). The increase of an Orientation towards Social Norms in our depressives has not been described in former MPT studies, but it was found in other studies using equivalent scales (see Section 1). The concordance of results regarding elevated MPT scores for Rigidity in unipolar major depression in previous German studies of patients ¨ (Bronisch and Hecht, 1989; Schafer, 1991) and high risk subjects (Maier et al., 1992; Lauer et al., 1997) and in this study of Japanese patients suggests that a certain set of obsessional personality features may be a vulnerability factor for primary unipolar major depression beyond cultural differences. The respective trait pattern can be labelled as ‘strength of superego functions’ (devotion to work, perfectionism, submissiveness to authorities and cultural norms, scrupulousness etc.). It resembles descriptions of the character structure of melancholics in the psychoanalytic and clinical psychiatric literature (see Section 1). The Rigidity scale of the MPT may thus be a powerful tool for detecting this particularly relevant aspect of pre-morbid personality features in subjects with primary unipolar major depression. The two high risk studies in which the MPT was used (Maier et al., 1992; Lauer et al., 1997) did not reveal a significant reduction of Frustration Tolerance in (still healthy) relatives of patients suffering from major depression. On the other hand, two prospective studies found a tendency to reduced Resilience in subjects who later on developed a depressive disorder (Hirschfeld et al., 1989; Clayton et al., 1994). It cannot be determined yet, whether decreased Frustration Tolerance of the unipolar depressives in our study reflects a pre-morbid personality trait or a post-morbid change of personality or both. This is also true for an increased Orientation towards Social Norms. Conversely, a pre-morbid elevation of neurotic traits in unipolar depressives is a relatively consistent finding of prospective studies. These traits were ¨ and Lindegard, ˚ described as Subvalidity (Nystrom 1975), Autonomic Lability (Angst and Clayton, 1986; Clayton et al., 1994), Neuroticism (Boyce et al., 1991; Kendler et al., 1993), decreased Emotional Strength (Hirschfeld et al., 1989) etc. However, as mentioned in Section 1, Boyce et al. (1993), in a
study of patients in remission from an episode of major depression and healthy controls, found increased Interpersonal Sensitivity, which is closely related to Neuroticism, in non-melancholic and not in (formerly) melancholic depressives. As almost all depressives in our study had fulfilled the criteria of the melancholic subtype during one episode or more of their illness, it seems possible that Neuroticism is a vulnerability factor for non-melancholic rather than for melancholic depression. The control subjects with mental disorders other than depression (mainly neurotics or psychotics in a remitted state) had lower Extraversion scores than the healthy subjects. However, like the depressives, they had decreased scores on Frustration Tolerance and increased scores on an Orientation towards Social Norms and they, too, did not show a significant increase in Neuroticism. Furthermore, they scored intermediate between unipolar depressives and healthy subjects on Rigidity. One possible explanation is that remitted neurotics and / or schizophrenics may differ from unremitted cases by a lower pre-morbid level of Neuroticism and higher levels of Rigidity and an Orientation towards Social Norms. These features may facilitate their clinical improvement and social adaptation. However, it cannot be excluded that the tendency to Social Desirability in our Japanese patients indicates a response set rather than a behavioural trait. This set may have reduced self-rated Neuroticism and thus obscured a difference in personality traits between the patients and their healthy controls. In only a few prospective studies, personality traits of depressives and other psychiatric patients were investigated simultaneously. Angst and Clayton (1986) found pre-morbid neurotic traits not only in unipolar depressives but also in schizophrenics and anxiety neurotics; but nothing is known about the further course of their disorders. It is, however, well-documented in other investigations that Neuroticism is a predictor of an unfavorable course, at least in depression (e.g. Weissman et al., 1978; ¨ Moller et al., 1987). In view of this complex situation, a definite explanation of the lack of increased Neuroticism in our patients is not yet possible. Our study has some limitations. Firstly, it is retrospective in nature. Secondly, we did not select
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the subjects randomly or by consecutive sampling. However, with the exception of the second author of this paper, the Japanese members of our team who recruited patients in each facility were not informed about the composition of the MPT scales and the results of previous studies. Therefore, an effect of a selection bias on the data, if there is any, can be considered as minimal. Thirdly, we investigated patients in clinical settings only. It is questionable whether pre-morbid personality traits are common to unipolar depressives of clinical and non-clinical populations. Despite the similarity with findings of two independent German studies of subjects at high risk for major depression (Maier et al., 1992; Lauer et al., 1997), our results need to be replicated in Japanese high risk studies and / or prospective cohort studies of healthy subjects. Finally, we did not include bipolar patients in our study so that we cannot decide whether in Japanese samples Rigidity is more prominent among unipolar depressives than among bipolars.
5. Conclusions Although pre-morbid personality traits have been described as vulnerability factors of depressive disorders in different countries, it has not been studied psychometrically by means of the same assessment instruments whether such variables are, indeed, common to basically different cultures. We therefore assessed retrospectively personality traits of Japanese patients in remission from moderate to severe primary unipolar major depression and control subjects with the aid of a multidimensional self-rating personality inventory, the MPT, which had already been used in several case control and high risk studies in a Western country (Germany). On this basis, we found elevated scores for Rigidity and an Orientation towards Social Norms as well as decreased scores for Frustration Tolerance (Resiliency) in the formerly depressed patients. Although these findings are not very specific of unipolar depressives compared with other psychiatric patients, they are rather similar to those of previous studies in Germany and to related findings in other Western countries; the only exception refers to Neuroticism which, in contrast to most studies in
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Western countries, was not elevated in our patients. It has to be clarified in further investigations whether this is due to cultural differences, to clinical features of our patient samples (e.g. the high prevalence of melancholic features in our depressives and the degree of remission in our psychiatric controls) or to a response set in the self-ratings. However, Rigidity as assessed by the MPT, possibly in combination with a strong Orientation towards Social Norms and a decreased Frustration Tolerance, seems to represent a common vulnerability factor, at least for the more severe forms of primary unipolar major depression, beyond cultural differences.
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