Does personality disorder decrease the likelihood of remission in early-onset chronic depression?

Exploring the Utility of Neurostimulation Therapies in the Treatment of Borderline Personality Disorder: A Systematic Literature Review

ABSTRACT

The use of electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS) in the treatment of people diagnosed with borderline personality disorder (BPD) highlights the need for systematic review of the evidence supporting this practice. A comprehensive literature search identified seven original clinical research studies investigating the use of brain stimulation therapies in people diagnosed with BPD. The lack of consistent study design, diagnostic methodology, treatment parameters, and outcome measures precluded analysis of aggregated study results. There were no ECT studies evaluating BPD symptom outcomes; however, studies of ECT in patients with comorbid BPD and depression suggested that depressive symptoms were less responsive to ECT compared with depression-only patients. The few studies available suggest that TMS may lead to clinically and statistically significant improvements in BPD symptoms and depressive symptoms. Similar overall improvements were reported despite the use of heterogeneous TMS treatment protocols, highlighting the importance of including a sham condition to investigate the contribution of the placebo effect to overall improvement. There is still no clear evidence supporting the use of ECT for treating people with BPD (with or without depression); therefore, the use of ECT in this population should be approached with caution. Although TMS shows early promise, the low numbers of participants in the few available studies suggest the urgent need for larger randomized controlled trials to provide an evidence base for this increasingly popular treatment.

Effectiveness of Electroconvulsive Therapy in Patients With Major Depressive Disorder and Comorbid Borderline Personality Disorder

OBJECTIVE

Previous research suggests that electroconvulsive therapy (ECT)-the criterion standard for the treatment of severe depression-is not as effective when the patient has comorbid borderline personality disorder (BPD). The ECT outcomes of patients with and without BPD were compared in a retrospective chart review to test this claim.

METHODS

We enrolled 137 patients with a diagnosis of major depressive disorder who completed the McLean Screening Instrument for Borderline Personality Disorder. Twenty-nine patients had positive screening scores for BPD. The difference in Patient Health Questionnaire (PHQ-9) scores before and after ECT was compared between patients with and without BPD. Follow-up PHQ-9 scores determined after treatment were collected and analyzed.

RESULTS

Electroconvulsive therapy equally improved symptoms of depression as measured by PHQ-9 score in both patients who screened positive and patients who screened negative for BPD. No difference in the increase in PHQ-9 scores between these 2 groups was noted 1 month after treatment (P = 0.19).

CONCLUSIONS

These data showed that a positive BPD screen does not necessarily predict a poorer response to ECT, nor does it predict greater symptom recurrence after ECT. This does not suggest that ECT is necessarily an appropriate treatment for major depressive disorder in patients with a comorbid BPD, given the limitations of screening instruments.

The impact of personality disorder pathology on the effectiveness of Cognitive Therapy and Interpersonal Psychotherapy for Major Depressive Disorder

BACKGROUND

Despite extensive research, there is no consensus how Personality Disorders (PD) and PD features affect outcome for Major Depressive Disorder (MDD). The present study evaluated the effects of PD (features) on treatment continuation and effectiveness in Cognitive Therapy (CT) and Interpersonal Psychotherapy (IPT) for MDD.

METHODS

Depressed outpatients were randomized to CT (n=72) and IPT (n=74). Primary outcome was depression severity measured repeatedly with the Beck Depression Inventory-II (BDI-II) at baseline, three months, at the start of each therapy session, at post-treatment and monthly during five months follow-up.

RESULTS

Comorbid PD and PD features did not affect dropout. Multilevel and Cox regression models indicated no negative effect of PD on BDI-II change and remission rates during treatment and follow-up, irrespective of the treatment received. For both therapies, higher dependent PD features predicted overall lower BDI-II scores during treatment, however this effect did not sustain through follow-up. Cluster A PD features moderated treatment outcome during treatment and follow-up: individuals with high cluster A PD features had greater BDI-II reductions over time in CT as compared to IPT.

LIMITATIONS

Not all therapists and participants were blind to the assessment of PD (features), and assessments were performed by one rater. Further research must investigate the state and trait dependent changes of PD and MDD over time.

CONCLUSIONS

We found no negative impact of PD on the effectiveness and treatment retention of CT and IPT for MDD during treatment and follow-up. If replicated, cluster A PD features can be used to optimize treatment selection.

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

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

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

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

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

Predictors of remission from chronic depression: a prospective study in a nationally representative sample

PURPOSE

The aims of this study were to identify predictors of remission from chronic depression in a prospective longitudinal general population survey; second, to determine the relative level functioning and well-being of those in remission.

METHODS

The sample included respondents who met the criteria for major depressive disorder from Wave 1 (2001-2002) and through Wave 2 (2004-2005) of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC).

RESULTS

Panic Disorder, Generalized Anxiety Disorder, Cluster B personality disorders and a history of Physical Abuse were correlated with reduced likelihood of chronic depression remission. The functioning and well-being of the remitted group was below the norm.

CONCLUSIONS

These prognostic factors are similar to those found in clinical samples. Despite remission from chronic depression, a significant proportion have impairments in functioning.

The effect of personality disorders on treatment outcomes in patients with obsessive-compulsive disorders

The effect of comorbid personality disorders (PD) on treatment outcomes in obsessive-compulsive disorder (OCD) is unclear. The authors systematically review results from investigations of therapy outcomes in adult patients with OCD and a comorbid PD. PsycINFO and MEDLINE were searched for original articles. Twenty-three studies assessing PDs through interviews were selected. Cluster A PDs, particularly schizotypal PD, narcissistic PD, and the presence of two or more comorbid PDs, were associated with poorer treatment outcomes in patients with OCD. With regard to other PDs and clusters, the results are inconsistent or the sample sizes are too small to reach a conclusion. OCD patients with different comorbid PDs differ in their therapeutic response to treatment. To optimize the treatment of OCD, the predictive value of PDs on the treatment outcome should be further investigated, and treatment of Axis I and II comorbidity requires more attention.

The dopamine transporter gene possibly affects personality traits in patients with early-onset major depressive disorder

OBJECTIVE

Comorbid personality pathologies may affect the outcome of patients with major depression (MD). The dopamine transporter gene DAT1 (SLC6A3) has been suggested to play a role in both depression and specific personality traits. The aim of this study was to assess five polymorphisms of the DAT1 gene (rs2550948, rs2975226, rs6347, rs27072, and 3'-VNTR) to determine whether this gene influences personality traits in patients with MD or its subgroups.

METHODS

The DAT1 polymorphisms were analysed in 463 unrelated Han Chinese MD patients. The personality traits, novelty seeking (NS), and harm avoidance (HA), were examined using the Tridimensional Personality Questionnaire. The patients were also divided into four clinical subgroups on the basis of differences in their sex (male or female) and age at disease onset (early or late).

RESULTS

There was no association between the DAT1 gene and either NS or HA in the total MD sample or in the sex-based subgroups. However, early-onset MD patients with the G/G genotype of rs2550948 and the T/T genotype of rs2975226 had lower NS scores than did patients with the other genotypes (p corrected = 0.05 for rs2550948 and p corrected = 0.005 for rs2975226).

CONCLUSION

Our study suggests that DAT1 promoter variants possibly influence specific personality traits in the early-onset subgroup of depressed patients in the Han Chinese population. Further prospective cohort studies are required to verify our preliminary finding and to confirm the effects of personality susceptibility on long-term disease outcomes.

Obsessive compulsive personality disorder as a predictor of exposure and ritual prevention outcome for obsessive compulsive disorder

Despite elevated rates of obsessive compulsive personality disorder (OCPD) in patients with obsessive compulsive disorder (OCD), no study has specifically examined comorbid OCPD as a predictor of exposure and ritual prevention (EX/RP) outcome. Participants were adult outpatients (n = 49) with primary OCD and a Yale-Brown Obsessive Compulsive Scale (YBOCS) total score ≥ 16 despite a therapeutic serotonin reuptake inhibitor dose for at least 12 weeks prior to entry. Participants received 17 sessions of EX/RP over 8 weeks. OCD severity was assessed with the YBOCS pre- and post-treatment by independent evaluators. At baseline, 34.7% of the OCD sample met criteria for comorbid DSM-IV OCPD, assessed by structured interview. OCPD was tested as a predictor of outcome both as a diagnostic category and as a dimensional score (severity) based on the total number of OCPD symptoms coded as present and clinically significant at baseline. Both OCPD diagnosis and greater OCPD severity predicted worse EX/RP outcome, controlling for baseline OCD severity, Axis I and II comorbidity, prior treatment, quality of life, and gender. When the individual OCPD criteria were tested separately, only perfectionism predicted worse treatment outcome, over and above the previously mentioned covariates. These findings highlight the importance of assessing OCPD and suggest a need to directly address OCPD-related traits, especially perfectionism, in the context of EX/RP to minimize their interference in outcome.