- Email: [email protected]
Psychodynamic and Characterological Heterogeneity among Adolescents with Major Depressive Disorders
Psychodynamic and Characterological Heterogeneity among Adolescents with Major Depressive Disorders DOUGLAS R. ROBBINS, M.D., NORMAN E. ALESSI, M.D., GORDON W. YANCHYSHYN, M.D., AND MARIT COLFER, M.D. This examination of six adolescents who were hospitalized for an Endogenous Major Depressive Disorder suggests wide heterogeneity in several personality dimensions. These personality dimensions may be critical in the determination of prognosis and require careful assessment and individualized treatment. It appears that a diagnosis of the major affective disorder allows no simple generalizations about the need for treatment of other personality disturbances. Further study of these factors should enhance both our clinical interventions with children and adolescents and our understanding ofthe processes involved in personality and affective development. Journal of the American Academy of Child Psychiatry, 22,5:487-491, 1983.
Basic clinical and developmental questions require that we investigate the relationships between affect and other dimensions of personality. The clinician must be aware that neurotic or characterological features may greatly influence the appearance and course of a depressive episode, and that they may continue to incapacitate many patients following resolution of the affective symptoms. The clinician must understand the different indications for medication, psychotherapy (individual, family, group), and other interventions. The student of development must consider both the effects of affective experience on personality development and the contribution of personality factors to the etiology, onset, or specific form of an affective disorder. While much work has been done on these issues (cf. Chodoff, 1972), answers have been elusive in part because of the absence of a meaningful system of classification of affective disorders. While we do not yet have such a complete nosology, we do understand some important distinctions. For instance, there is evidence that endogenous or melancholic depression is qualitatively different from neurotic or characterological depressions, rather than differing only in degree (Carroll et al., 1980; Klein, 1974). Melancholic depressions are more clearly associated with disturbances of biological parameters and response to biological treatment. Studies which have not made distincDr. Robbins is Assistant Professor of Psychiatry, Dr. Alessi is Research Fellow in Child Psychiatry, Dr. Yanchyshyn is a Lecturer in the Department of Psychiatry, Sunnybrook Hospital, Toronto, Ontario, and Dr. Colfer is an Instructor in Psychiatry, all at the Department of Psychiatry, University of Michigan, School of Medicine (Ann Arbor, MI48109), where reprints may be requested from Dr. Robbins}. 0002-7138/83/2205-0487 $02.00/0 © 1983 by the American Academy of Child Psychiatry.
tions between normal sad affect and clinical depression, between minor and major depressions, and between melancholic and nonmelancholic depressions are likely to be misleading. An etiological factor relevant to one type of depression is likely to appear insignificant if assessed in all depressions. Such phenomenological distinctions now allow us to reconsider the relationship between depressive symptoms and other personality dimensions. Clarification of these issues should help us to be more precise in our prescriptions of clinical treatment as well as to refine basic etiological concepts. This paper discusses certain clinical observations regarding personality and interpersonal functioning in a group of depressed adolescent psychiatric inpatients. The adolescents discussed met the Research Diagnostic Criteria (RDC) for Endogenous Major Depressive Disorder (Spitzer et al., 1978) and thus were relatively homogenous in the type and severity of their affective disorder. This discussion does not address issues regarding the adolescents with other forms of depression.
488
ROBBINS ET AL.
et ai., 1982b). This paper will confine itself to an examination of this RDC Major Depressive Disorder Endogenous subgroup. The psychological features are clinical judgments by the authors based on therapists' impressions, psychological testing and hospital observations. The authors were not blind to the RDC diagnoses at the time these judgments were made. The intent here was to generate rather than to test hypotheses.
Observations Reasons for referral of those with Endogenous Major Depressive Disorder included suicidal behavior (2 patients), school refusal (3 patients), substance abuse (all predominantly alcohol) (3 patients), irritability (1 patient), and somatic symptoms (1 patient). Depression was recognized prior to referral in 5 patients but in none was it the primary reason for their being brought for help. The raters' judgments of stresses or life changes preceding the referral ranged from "minimal" (4 patients) (e.g., increasing pressure from impending high school graduation), to "moderate" (1 patient) (e.g., suicides of acquaintances), to "moderate-severe" (1 patient) (e.g., recurrent abandonment by parents). All 6 had a chronic history of sad affect. In 4 of
these, there was a distinct episodic exacerbation, and of these 3 had had at least one previous episode. The "predominant affect," on RDC categorization, varied from "depressed" (3 patients) to "hostile" (1 patient), to "apathetic" (2 patients). Axis II DMS-III diagnoses were based primarily on the adolescents' function during their least depressed periods, either by observation, by history, or both (table 1). One was considered to show no personality disorder when euthymic. One had an Oppositional Personality Disorder, 1 Avoidant Personality Disorder, 1 Avoidant and Oppositional, and 2 had Borderline Personality Disorder. Impressions of predominant defenses, level of object relations, and predominant psychodynamic conflicts are outlined in Table 1. As with Axis II diagnoses, these reflect function when least depressed. They range from an essentially healthy-neurotic level to severe deficits and conflicts. The level of character pathology and neurotic conflict appeared to be a crucial variable in the adolescents' function after discharge-perhaps of more prognostic significance than the severity of affective symptomatology. We will describe two of these patients who were alike not only in that both were admitted in an episode of Endogenous Major Depression, but that both had abnormal Dexamethasone Suppression Tests. We will
TABLE 1 Presenting Symptoms and Personality Characteristics PaAge Sex tient
Presenting Symptoms
Predominant Affect (from RDC)
17
M
Suicidal behavior, Depression, Substance abuse
Depressed
2
13
M
School refusal, Depression, Substance abuse
Depressed
3
17
M
Suicidal behavior, Depression, Irritability
4
16
M
5
13
6
16
Personality Disorder (DSMIII Axis II)
Predominant Defenses
Object Relations
Predominant Conflicts
Sublimation, Intellectualization
Ambivalent, Integrated, Empathic
Separation Oedipal
Oppositional
Somatization, Intellectualization Undoing
Ambivalent, Empathic
Undoing of success Assertiveness
Hostile
Borderline
Denial, Projection, Narcissism, Omnipotence
Split, Projecting, Devaluing
Rage at parental intrusions and loss of omnipotence
School refusal, Depression, Headache, Abdominal pain
Depressed
Avoidant
Somatization, Reaction formation
Ambivalent, Empathic
Delayed Separation
F
School withdrawal, Psychomotor retardation
Apathetic
Avoidant, Oppositional
Obsessivecompulsive, Somatization Denial
Part-object needgratifying
Obstinate struggle against separation
F
Social withdrawal, Psychomotor retardation, Substance abuse
Apathetic
Borderline
Denial, Somatization
Split Need-gratifying
Object-hunger neediness
PSYCHODYNAMIC CHARACTEROLOGICAL HETEROGENEITY
then compare their levels of object relations, predominant defenses, and psychodynamic conflicts.
Patient 1 John was a 17-year-old white male patient who was brought to the Emergency Room after a suicide attempt. He had ingested a bottle of sleeping pills and a bottle of wine and gone to sleep under circumstances such that he was unlikely to be discovered until the next day. He had awakened vomiting and then sought help from his parents. Over the preceding 3 months, he had become increasingly withdrawn from friends and had given up virtually all activities he had previously enjoyed. He was distressed by his inability to concentrate in school and he had become increasingly preoccupied with death as the only way to stop feeling miserable. His RDC diagnosis was Major Depressive Disorder, Endogenous, Recurrent, Unipolar. The family minimized his symptoms and were reluctant to hospitalize him. In the Emergency Room they alluded to a relative with a psychiatric disturbance but later insisted that there was no family history of psychiatric illness. The mother alternated between denying John's symptoms and identifying with his depression, blaming the father's inadequacies and emotionally distant style for the depression. John improved moderately within the first week of hospitalization without medication. He beame superficially sociable and involved in activities although he remained passive and subdued. His concentration improved gradually and he began to be able to do gradelevel schoolwork. He was quite open in individual psychotherapy and he talked about feeling understood for the first time in months. He was quite anxious about graduating high school, seeing this as having to face demands he was not ready for, and comparing himself to more assertive, successful siblings and to his father. He was discharged after 6 weeks to outpatient individual and family psychotherapy. He maintained his improvement for about 2 months before becoming increasingly depressed, nearly to the previous severity. Desipramine was begun (to 200 mg/day), and within 2 weeks he began to improve. His energy, interest, social interests, and concentration improved. His grades improved and he began planning for college. He stopped his medication after 4 months and individual psychotherapy 2 months later and continued to do well for several months. He voluntarily returned to his psychiatrist 1 year after discharge complaining of increasing depression and requesting weekly psychotherapy and medication. He improved and continued to do well with school, separation from his family, and with peers.
489
Patient 3 Chuck was a 17-year-old white male patient who attempted suicide by carbon monoxide inhalation. He was hospitalized for 1 month with moderate improvement. His parents withdrew him against advice and did not follow-up with the recommendations of continued treatment. He remained moderately depressed and became increasingly agitated and angry and had difficulty sleeping. The parents requested rehospitalization when he became increasingly hostile with his mother. He had appeared to become increasingly depressed after the suicides of three peers, none of whom he had known well. He described one 2-week period in which he had had excessive energy and grandiose plans, talked incessantly, and had had a markedly decreased need for sleep. The family denied a family history of psychiatric illness but seemed very guarded during the inquiry. Prior to this episode he had beeen active on the swim team and had maintained average grades, but had few peer friendships and a turbulent relationship with his intrusive mother. His RDC diagnosis was Bipolar II Affective Disorder (Major Depressive Disorder with periods of hypomania), currently in an episode of Major Depressive Disorder. In the hospital, Chuck was most overtly depressed in the morning and hostile during much of the day. He showed considerable affective reactivity to peer relationships but after brief periods (minutes to hours) of feeling good, he again became depressed and anhedonic. He became less depressed within 1 week of starting lithium carbonate (1500 mg/day, blood levels of 1.1 meq/L). Despite his affective improvement, he continued to demean and devalue his female therapist. He showed marked splitting in his perceptions of hospital staff, seeing some as empathic and supportive and others as abusive and humiliating. He had difficulty developing close peer relationships with either sex, forming relatively superficial relationships largely based on his perception of the group's status hierarchy. Without showing other symptoms of hypomania, he exaggerated his mental and athletic abilities and was enraged when confronted with his limitations. As he became more angry with his therapist, he began to get along comfortably with his parents. A split began to develop in the staff between whether to discharge him because his affective symptoms had improved or to continue inpatient treatment because of his personality disordeT. He and the family insisted on discharge against medical advice and did not follow recommendations for continued outpatient treatment. Five months after discharge he was rehos-
490
ROBBINS ET AL.
pitalized for depression, and 5 months later committed suicide by carbon monoxide inhalation. We would now like to briefly discuss these boys' levels of object relationships, their predominant defenses, and their most prominent psychodynamic issues.
Object Relations John was capable of relatively empathic relationships in which he perceived others in an integrated, fairly realistic way as having both positive and negative characteristics. Similarly, he could perceive himself in a healthy ambivalent way, when not depressed, as having both strengths and limitations. These capacities were reflected in his relatively good premorbid peer and adult relationships and in his capacity to move relatively readily into a therapeutic alliance with a therapist. Chuck was quite egocentric, tending to maintain relationships with those who admired him or to idealize those he perceived as powerful. Perceptions of others were characterized by positive or negative idealization. Differing perceptions of others and of himself could not be integrated, and he showed little ambivalence. Predominant Defenses John used sublimation, intellectualization, and some reaction formation. He showed some capacity for resiliency when threatened. Chuck relied on projection to deal with negative self-perceptions. He used denial, distortion and splitting. He seemed rigid and brittle, showing considerable affective lability when his self-esteem was threatened. Psychodynamic Issues John appeared engaged in a difficult oedipal triangle. When his mother attended to his difficulties, she appeared to be using them to express her frustration with his father. Mother's anger and the father's vulnerability appeared to play a role in his difficulty in becoming competent and successful. Separation from high school and the family appeared to be difficult for John because of his conflicts about being assertive, competent and perhaps more successful than his father. Chuck appeared to defend against his mother's intrusiveness by adopting a phallic-narcissistic stance, insisting that he was invulnerable and omnipotent. He reacted with rage or denial when forced to deal with parts of reality which did not fit with this selfperception. Discussion These two adolescents are alike in that both have experienced severe affective disturbances with "endog-
enous" clinical features-including significant suicidal behavior-and abnormal hypothalamic-pituitary-adrenal activity as assessed by the Dexamethasone Suppression Test. They are quite different, however, in other dimensions of personality, ranging from a fairly healthy level to serious character pathology. Similarly, the rest of the Endogenous Major Depressive Disorder group showed heterogeneity in all of the observations described. One implication is that there appears to be no obvious specific personality or psychodynamic profile which is specific to Major Affective Disorder, either as an etiologic factor or as an inevitable sequel. The impression that prognosis in school and interpersonal functioning was affected less by the severity of symptoms of the acute episode than by longitudinal characterological factors is similar to findings in adults with affective disorders (Bothwell and Weissman, 1977) and with schizophrenia (Strauss and Carpenter, 1978). A clinical implication is that there may be wide variation in such patients' needs for treatment of neurotic behavior or symptoms of personality disturbances in conjunction with treatment of the affective disorder itself. Furthermore, it appears that while an episode of Major Depression exaggerates certain personality features, possibly leading to an overestimation of conflicts and ego deficits and the need for continuing treatment, it does appear possible to initiate an assessment of these issues during the episode. These observations can help us return to our original clinical and developmental questions with a greater awareness of the issues and distinctions needed to get meaningful results.
Questions for Further Study 1. Do reactive, neurotic, and characterological factors play a role in the precipitation of episodes of Major Depression? While there may be no simple universal patterns, such issues may be important. For instance, it has long been suggested that while the role of actual losses and separations is uncertain, perceived loss or narcissisic injury may be a common precipitating factor. This may be an artifact of depressive cognitive style, or it may be a significant contributing factor. An assessment of narcissistic injury requires a comprehensive assessment of personality, because the meaning of a particular life event may be very different in different individuals (e.g., a separation may be much more of a narcissistic injury to a person with poor object constancy than to one with stable object representations) . 2. Does a Major Depressive Disorder have deleterious effects on personality development? Again, there appears to be no simple, universal answer, but there
PSYCHODYNAMIC CHARACTEROLOGICAL HETEROGENEITY
may be important relationships. Through various means, a major affective disturbance in a child may distort the relationship with parents significantly. Parents' responses to a depressed child may vary from nurturance to neglect to attacking. The depressed child's attitude toward the parents may vary from dependent clinging to rage at their inability to change how he feels. The depressed child may devalue the parents as a function of his depressive cognitive style. If these factors are important, we would expect more personality disturbance with patients with earlier onset and more chronic courses of their affective disorder. 3. Do personality variables beginning in childhood and adolescence influence the form of affective disturbance manifested (pathoplastic effects, as opposed to pathogenic effects)? Do such variables account for the appearance within what may be one genotype of a range of phenotypic expression including unipolar, bipolar, schizoaffective, minor depressive, and alcoholic phenotypes? Work with Akiskal et al. (1980) and Winokur (1979) has suggested that this is the case. 4. Do personality variables influence prognosis? As noted above, there is considerable evidence that this is so with adults. If so, it highlights the importance of assessing such features early and including them in planning interventions. Methodological Issues 1. Clearly, as discussed, phenomenological (e.g., RDC or DSM-III) diagnoses must be made since a factor relevant to one type of depression may be unimportant to another. 2. One must distinguish between personality disturbances present during an affective episode and those persisting in the euthymic or baseline state. This is complex in a chronic or labile affective disorder. 3. Assessment of personality or psychosocial factors must be independent of the Axis I diagnosis and of the current affective state. For instance, ratings of peer relationship patterns by chart review, ward observation or psychological testing could be made by a clinician blind to the DSM-III diagnosis. Such assessments must be reliable and valid.
491
4. While there may be no simple, direct associations between personality dimensions and affective disorder, there may be important relationships between these phenomena via intervening variables. One group of such variables might involve the child's interactions with his caregivers. Depression in the child may be one of many factors influencing the quality of his critical relationships, which in turn may influence personality development. It has been observed in infants and toddlers, for instance, that deviant affective communication interfered with engagement with caretakers or elicited negative responses (Gaensbauer and Sands, 1979). Such indirect relationships may be multifactorial and nonlinear. It may be erroneous, however, to assume that the absence of clear, simple correlations between Major Affective Disorder and personality factors indicate that they are not interrelated.
References AKISKAL, H. S., ROSENTHAL, T. L., HAYKAL, R F., LEMMI, H., ROSENTHAL, R H. & SCOTT-STRAUSS, A. (1980), Characterological depressions: clinical and sleep EEG findings separating subaffective dysthymias from character spectrum disorders. Arch. Gen. Psychiat., 37:777-783. BOTHWELL, S. & WEISSMAN, M. M. (1977), Social impairments four years after an acute depressive episode. Amer. M. Orthopsychiat., 47:231-237. CARROLL, B. J., FEINBERG, M., GREDEN, J. F., HASKETT, R F., JAMES, N. McL, STEINER, M. & TARIKA, J. (1980), Diagnosis of endogenous depression: comparison of clinical research and neuroendocrine criteria. J. Affect. Dis., 2:177-194. CHODOFF, P. (1972), The depressive personality: a critical review. Arch. Gen. Psychiat., 27:666-673. GAENSBAUER, T. J. & SANDS, K. (1979), Distorted affective communications in abused/neglected infants and their potential impact on caretakers. This Journal, 18:236-250. KLEIN, D. F. (1974), Endogenomorphic depression: a conceptual and terminological revision. Arch. Gen. Psychiat., 31:447-454. ROBBINS, D. R, ALESSI, N. E., COOK, S. C., POZNANSKI, E. O. & YANCHYSHYN, G. W. (1982a), The use of the Research Diagnostic Criteria (RDC) for depression in adolescent psychiatric inpatients. This Journal, 21:251-255. - - YANCHYSHYN, G. W. & COLFER, M. V. (1982b), Preliminary report of the dexamethasone suppression test in adolescents. Am. J. Psychiat., 139:942-943. SPITZER, R L., ENDICOTT, J. & ROBINS, E. (1978), Research diagnostic critera. Arch. Gen. Psychiat., 35:773-782. STRAUSS, J. S. & CARPENTER, W. J. (1978), The prognosis of schizophrenia: rationale for a multidimensional concept. Schizophrenia Bulletin, 4:56-67. WINOKUR, G. (1979), Unipolar depression: is it divisible into autonomous subtypes? Arch. Gen. Psychiat., 36:47-52.
Basic clinical and developmental questions require that we investigate the relationships between affect and other dimensions of personality. The clinician must be aware that neurotic or characterological features may greatly influence the appearance and course of a depressive episode, and that they may continue to incapacitate many patients following resolution of the affective symptoms. The clinician must understand the different indications for medication, psychotherapy (individual, family, group), and other interventions. The student of development must consider both the effects of affective experience on personality development and the contribution of personality factors to the etiology, onset, or specific form of an affective disorder. While much work has been done on these issues (cf. Chodoff, 1972), answers have been elusive in part because of the absence of a meaningful system of classification of affective disorders. While we do not yet have such a complete nosology, we do understand some important distinctions. For instance, there is evidence that endogenous or melancholic depression is qualitatively different from neurotic or characterological depressions, rather than differing only in degree (Carroll et al., 1980; Klein, 1974). Melancholic depressions are more clearly associated with disturbances of biological parameters and response to biological treatment. Studies which have not made distincDr. Robbins is Assistant Professor of Psychiatry, Dr. Alessi is Research Fellow in Child Psychiatry, Dr. Yanchyshyn is a Lecturer in the Department of Psychiatry, Sunnybrook Hospital, Toronto, Ontario, and Dr. Colfer is an Instructor in Psychiatry, all at the Department of Psychiatry, University of Michigan, School of Medicine (Ann Arbor, MI48109), where reprints may be requested from Dr. Robbins}. 0002-7138/83/2205-0487 $02.00/0 © 1983 by the American Academy of Child Psychiatry.
tions between normal sad affect and clinical depression, between minor and major depressions, and between melancholic and nonmelancholic depressions are likely to be misleading. An etiological factor relevant to one type of depression is likely to appear insignificant if assessed in all depressions. Such phenomenological distinctions now allow us to reconsider the relationship between depressive symptoms and other personality dimensions. Clarification of these issues should help us to be more precise in our prescriptions of clinical treatment as well as to refine basic etiological concepts. This paper discusses certain clinical observations regarding personality and interpersonal functioning in a group of depressed adolescent psychiatric inpatients. The adolescents discussed met the Research Diagnostic Criteria (RDC) for Endogenous Major Depressive Disorder (Spitzer et al., 1978) and thus were relatively homogenous in the type and severity of their affective disorder. This discussion does not address issues regarding the adolescents with other forms of depression.
488
ROBBINS ET AL.
et ai., 1982b). This paper will confine itself to an examination of this RDC Major Depressive Disorder Endogenous subgroup. The psychological features are clinical judgments by the authors based on therapists' impressions, psychological testing and hospital observations. The authors were not blind to the RDC diagnoses at the time these judgments were made. The intent here was to generate rather than to test hypotheses.
Observations Reasons for referral of those with Endogenous Major Depressive Disorder included suicidal behavior (2 patients), school refusal (3 patients), substance abuse (all predominantly alcohol) (3 patients), irritability (1 patient), and somatic symptoms (1 patient). Depression was recognized prior to referral in 5 patients but in none was it the primary reason for their being brought for help. The raters' judgments of stresses or life changes preceding the referral ranged from "minimal" (4 patients) (e.g., increasing pressure from impending high school graduation), to "moderate" (1 patient) (e.g., suicides of acquaintances), to "moderate-severe" (1 patient) (e.g., recurrent abandonment by parents). All 6 had a chronic history of sad affect. In 4 of
these, there was a distinct episodic exacerbation, and of these 3 had had at least one previous episode. The "predominant affect," on RDC categorization, varied from "depressed" (3 patients) to "hostile" (1 patient), to "apathetic" (2 patients). Axis II DMS-III diagnoses were based primarily on the adolescents' function during their least depressed periods, either by observation, by history, or both (table 1). One was considered to show no personality disorder when euthymic. One had an Oppositional Personality Disorder, 1 Avoidant Personality Disorder, 1 Avoidant and Oppositional, and 2 had Borderline Personality Disorder. Impressions of predominant defenses, level of object relations, and predominant psychodynamic conflicts are outlined in Table 1. As with Axis II diagnoses, these reflect function when least depressed. They range from an essentially healthy-neurotic level to severe deficits and conflicts. The level of character pathology and neurotic conflict appeared to be a crucial variable in the adolescents' function after discharge-perhaps of more prognostic significance than the severity of affective symptomatology. We will describe two of these patients who were alike not only in that both were admitted in an episode of Endogenous Major Depression, but that both had abnormal Dexamethasone Suppression Tests. We will
TABLE 1 Presenting Symptoms and Personality Characteristics PaAge Sex tient
Presenting Symptoms
Predominant Affect (from RDC)
17
M
Suicidal behavior, Depression, Substance abuse
Depressed
2
13
M
School refusal, Depression, Substance abuse
Depressed
3
17
M
Suicidal behavior, Depression, Irritability
4
16
M
5
13
6
16
Personality Disorder (DSMIII Axis II)
Predominant Defenses
Object Relations
Predominant Conflicts
Sublimation, Intellectualization
Ambivalent, Integrated, Empathic
Separation Oedipal
Oppositional
Somatization, Intellectualization Undoing
Ambivalent, Empathic
Undoing of success Assertiveness
Hostile
Borderline
Denial, Projection, Narcissism, Omnipotence
Split, Projecting, Devaluing
Rage at parental intrusions and loss of omnipotence
School refusal, Depression, Headache, Abdominal pain
Depressed
Avoidant
Somatization, Reaction formation
Ambivalent, Empathic
Delayed Separation
F
School withdrawal, Psychomotor retardation
Apathetic
Avoidant, Oppositional
Obsessivecompulsive, Somatization Denial
Part-object needgratifying
Obstinate struggle against separation
F
Social withdrawal, Psychomotor retardation, Substance abuse
Apathetic
Borderline
Denial, Somatization
Split Need-gratifying
Object-hunger neediness
PSYCHODYNAMIC CHARACTEROLOGICAL HETEROGENEITY
then compare their levels of object relations, predominant defenses, and psychodynamic conflicts.
Patient 1 John was a 17-year-old white male patient who was brought to the Emergency Room after a suicide attempt. He had ingested a bottle of sleeping pills and a bottle of wine and gone to sleep under circumstances such that he was unlikely to be discovered until the next day. He had awakened vomiting and then sought help from his parents. Over the preceding 3 months, he had become increasingly withdrawn from friends and had given up virtually all activities he had previously enjoyed. He was distressed by his inability to concentrate in school and he had become increasingly preoccupied with death as the only way to stop feeling miserable. His RDC diagnosis was Major Depressive Disorder, Endogenous, Recurrent, Unipolar. The family minimized his symptoms and were reluctant to hospitalize him. In the Emergency Room they alluded to a relative with a psychiatric disturbance but later insisted that there was no family history of psychiatric illness. The mother alternated between denying John's symptoms and identifying with his depression, blaming the father's inadequacies and emotionally distant style for the depression. John improved moderately within the first week of hospitalization without medication. He beame superficially sociable and involved in activities although he remained passive and subdued. His concentration improved gradually and he began to be able to do gradelevel schoolwork. He was quite open in individual psychotherapy and he talked about feeling understood for the first time in months. He was quite anxious about graduating high school, seeing this as having to face demands he was not ready for, and comparing himself to more assertive, successful siblings and to his father. He was discharged after 6 weeks to outpatient individual and family psychotherapy. He maintained his improvement for about 2 months before becoming increasingly depressed, nearly to the previous severity. Desipramine was begun (to 200 mg/day), and within 2 weeks he began to improve. His energy, interest, social interests, and concentration improved. His grades improved and he began planning for college. He stopped his medication after 4 months and individual psychotherapy 2 months later and continued to do well for several months. He voluntarily returned to his psychiatrist 1 year after discharge complaining of increasing depression and requesting weekly psychotherapy and medication. He improved and continued to do well with school, separation from his family, and with peers.
489
Patient 3 Chuck was a 17-year-old white male patient who attempted suicide by carbon monoxide inhalation. He was hospitalized for 1 month with moderate improvement. His parents withdrew him against advice and did not follow-up with the recommendations of continued treatment. He remained moderately depressed and became increasingly agitated and angry and had difficulty sleeping. The parents requested rehospitalization when he became increasingly hostile with his mother. He had appeared to become increasingly depressed after the suicides of three peers, none of whom he had known well. He described one 2-week period in which he had had excessive energy and grandiose plans, talked incessantly, and had had a markedly decreased need for sleep. The family denied a family history of psychiatric illness but seemed very guarded during the inquiry. Prior to this episode he had beeen active on the swim team and had maintained average grades, but had few peer friendships and a turbulent relationship with his intrusive mother. His RDC diagnosis was Bipolar II Affective Disorder (Major Depressive Disorder with periods of hypomania), currently in an episode of Major Depressive Disorder. In the hospital, Chuck was most overtly depressed in the morning and hostile during much of the day. He showed considerable affective reactivity to peer relationships but after brief periods (minutes to hours) of feeling good, he again became depressed and anhedonic. He became less depressed within 1 week of starting lithium carbonate (1500 mg/day, blood levels of 1.1 meq/L). Despite his affective improvement, he continued to demean and devalue his female therapist. He showed marked splitting in his perceptions of hospital staff, seeing some as empathic and supportive and others as abusive and humiliating. He had difficulty developing close peer relationships with either sex, forming relatively superficial relationships largely based on his perception of the group's status hierarchy. Without showing other symptoms of hypomania, he exaggerated his mental and athletic abilities and was enraged when confronted with his limitations. As he became more angry with his therapist, he began to get along comfortably with his parents. A split began to develop in the staff between whether to discharge him because his affective symptoms had improved or to continue inpatient treatment because of his personality disordeT. He and the family insisted on discharge against medical advice and did not follow recommendations for continued outpatient treatment. Five months after discharge he was rehos-
490
ROBBINS ET AL.
pitalized for depression, and 5 months later committed suicide by carbon monoxide inhalation. We would now like to briefly discuss these boys' levels of object relationships, their predominant defenses, and their most prominent psychodynamic issues.
Object Relations John was capable of relatively empathic relationships in which he perceived others in an integrated, fairly realistic way as having both positive and negative characteristics. Similarly, he could perceive himself in a healthy ambivalent way, when not depressed, as having both strengths and limitations. These capacities were reflected in his relatively good premorbid peer and adult relationships and in his capacity to move relatively readily into a therapeutic alliance with a therapist. Chuck was quite egocentric, tending to maintain relationships with those who admired him or to idealize those he perceived as powerful. Perceptions of others were characterized by positive or negative idealization. Differing perceptions of others and of himself could not be integrated, and he showed little ambivalence. Predominant Defenses John used sublimation, intellectualization, and some reaction formation. He showed some capacity for resiliency when threatened. Chuck relied on projection to deal with negative self-perceptions. He used denial, distortion and splitting. He seemed rigid and brittle, showing considerable affective lability when his self-esteem was threatened. Psychodynamic Issues John appeared engaged in a difficult oedipal triangle. When his mother attended to his difficulties, she appeared to be using them to express her frustration with his father. Mother's anger and the father's vulnerability appeared to play a role in his difficulty in becoming competent and successful. Separation from high school and the family appeared to be difficult for John because of his conflicts about being assertive, competent and perhaps more successful than his father. Chuck appeared to defend against his mother's intrusiveness by adopting a phallic-narcissistic stance, insisting that he was invulnerable and omnipotent. He reacted with rage or denial when forced to deal with parts of reality which did not fit with this selfperception. Discussion These two adolescents are alike in that both have experienced severe affective disturbances with "endog-
enous" clinical features-including significant suicidal behavior-and abnormal hypothalamic-pituitary-adrenal activity as assessed by the Dexamethasone Suppression Test. They are quite different, however, in other dimensions of personality, ranging from a fairly healthy level to serious character pathology. Similarly, the rest of the Endogenous Major Depressive Disorder group showed heterogeneity in all of the observations described. One implication is that there appears to be no obvious specific personality or psychodynamic profile which is specific to Major Affective Disorder, either as an etiologic factor or as an inevitable sequel. The impression that prognosis in school and interpersonal functioning was affected less by the severity of symptoms of the acute episode than by longitudinal characterological factors is similar to findings in adults with affective disorders (Bothwell and Weissman, 1977) and with schizophrenia (Strauss and Carpenter, 1978). A clinical implication is that there may be wide variation in such patients' needs for treatment of neurotic behavior or symptoms of personality disturbances in conjunction with treatment of the affective disorder itself. Furthermore, it appears that while an episode of Major Depression exaggerates certain personality features, possibly leading to an overestimation of conflicts and ego deficits and the need for continuing treatment, it does appear possible to initiate an assessment of these issues during the episode. These observations can help us return to our original clinical and developmental questions with a greater awareness of the issues and distinctions needed to get meaningful results.
Questions for Further Study 1. Do reactive, neurotic, and characterological factors play a role in the precipitation of episodes of Major Depression? While there may be no simple universal patterns, such issues may be important. For instance, it has long been suggested that while the role of actual losses and separations is uncertain, perceived loss or narcissisic injury may be a common precipitating factor. This may be an artifact of depressive cognitive style, or it may be a significant contributing factor. An assessment of narcissistic injury requires a comprehensive assessment of personality, because the meaning of a particular life event may be very different in different individuals (e.g., a separation may be much more of a narcissistic injury to a person with poor object constancy than to one with stable object representations) . 2. Does a Major Depressive Disorder have deleterious effects on personality development? Again, there appears to be no simple, universal answer, but there
PSYCHODYNAMIC CHARACTEROLOGICAL HETEROGENEITY
may be important relationships. Through various means, a major affective disturbance in a child may distort the relationship with parents significantly. Parents' responses to a depressed child may vary from nurturance to neglect to attacking. The depressed child's attitude toward the parents may vary from dependent clinging to rage at their inability to change how he feels. The depressed child may devalue the parents as a function of his depressive cognitive style. If these factors are important, we would expect more personality disturbance with patients with earlier onset and more chronic courses of their affective disorder. 3. Do personality variables beginning in childhood and adolescence influence the form of affective disturbance manifested (pathoplastic effects, as opposed to pathogenic effects)? Do such variables account for the appearance within what may be one genotype of a range of phenotypic expression including unipolar, bipolar, schizoaffective, minor depressive, and alcoholic phenotypes? Work with Akiskal et al. (1980) and Winokur (1979) has suggested that this is the case. 4. Do personality variables influence prognosis? As noted above, there is considerable evidence that this is so with adults. If so, it highlights the importance of assessing such features early and including them in planning interventions. Methodological Issues 1. Clearly, as discussed, phenomenological (e.g., RDC or DSM-III) diagnoses must be made since a factor relevant to one type of depression may be unimportant to another. 2. One must distinguish between personality disturbances present during an affective episode and those persisting in the euthymic or baseline state. This is complex in a chronic or labile affective disorder. 3. Assessment of personality or psychosocial factors must be independent of the Axis I diagnosis and of the current affective state. For instance, ratings of peer relationship patterns by chart review, ward observation or psychological testing could be made by a clinician blind to the DSM-III diagnosis. Such assessments must be reliable and valid.
491
4. While there may be no simple, direct associations between personality dimensions and affective disorder, there may be important relationships between these phenomena via intervening variables. One group of such variables might involve the child's interactions with his caregivers. Depression in the child may be one of many factors influencing the quality of his critical relationships, which in turn may influence personality development. It has been observed in infants and toddlers, for instance, that deviant affective communication interfered with engagement with caretakers or elicited negative responses (Gaensbauer and Sands, 1979). Such indirect relationships may be multifactorial and nonlinear. It may be erroneous, however, to assume that the absence of clear, simple correlations between Major Affective Disorder and personality factors indicate that they are not interrelated.
References AKISKAL, H. S., ROSENTHAL, T. L., HAYKAL, R F., LEMMI, H., ROSENTHAL, R H. & SCOTT-STRAUSS, A. (1980), Characterological depressions: clinical and sleep EEG findings separating subaffective dysthymias from character spectrum disorders. Arch. Gen. Psychiat., 37:777-783. BOTHWELL, S. & WEISSMAN, M. M. (1977), Social impairments four years after an acute depressive episode. Amer. M. Orthopsychiat., 47:231-237. CARROLL, B. J., FEINBERG, M., GREDEN, J. F., HASKETT, R F., JAMES, N. McL, STEINER, M. & TARIKA, J. (1980), Diagnosis of endogenous depression: comparison of clinical research and neuroendocrine criteria. J. Affect. Dis., 2:177-194. CHODOFF, P. (1972), The depressive personality: a critical review. Arch. Gen. Psychiat., 27:666-673. GAENSBAUER, T. J. & SANDS, K. (1979), Distorted affective communications in abused/neglected infants and their potential impact on caretakers. This Journal, 18:236-250. KLEIN, D. F. (1974), Endogenomorphic depression: a conceptual and terminological revision. Arch. Gen. Psychiat., 31:447-454. ROBBINS, D. R, ALESSI, N. E., COOK, S. C., POZNANSKI, E. O. & YANCHYSHYN, G. W. (1982a), The use of the Research Diagnostic Criteria (RDC) for depression in adolescent psychiatric inpatients. This Journal, 21:251-255. - - YANCHYSHYN, G. W. & COLFER, M. V. (1982b), Preliminary report of the dexamethasone suppression test in adolescents. Am. J. Psychiat., 139:942-943. SPITZER, R L., ENDICOTT, J. & ROBINS, E. (1978), Research diagnostic critera. Arch. Gen. Psychiat., 35:773-782. STRAUSS, J. S. & CARPENTER, W. J. (1978), The prognosis of schizophrenia: rationale for a multidimensional concept. Schizophrenia Bulletin, 4:56-67. WINOKUR, G. (1979), Unipolar depression: is it divisible into autonomous subtypes? Arch. Gen. Psychiat., 36:47-52.