Chronic, low-grade depression in a nonclinical sample: depressive personality or dysthymia?

Comorbidity of personality disorders in mood disorders: a meta-analytic review of 122 studies from 1988 to 2010

BACKGROUND

A meta-analysis was conducted to identify the proportions of comorbid personality disorders (PD) in mood disorders.

METHODS

We found 122 empirical papers published in the period 1980-2010 on participants having mood disorders in addition to a comorbid PD. Mood disorders were classified as bipolar disorders (BD), major depressive disorders (MDD) and dysthymic disorders (DYS). Several moderators were coded as well.

RESULTS

The risk of having at least one comorbid PD (any PD) was high across all three mood disorders (BD=.42, MDD=.45), but highest in DYS (.60). Cluster B and C PDs were most frequent in BD, while cluster C PDs dominated in MDD and DYS. Among the specific PDs, the paranoid (.11 versus .07/.05), borderline (.16 versus .14/.13), histrionic (.10 versus .06/.06) and obsessive-compulsive (.18 versus .09/.12) PDs occurred more frequently in BD versus MDD/DYS, whereas the avoidant PD (.22 versus .12/.16) was most frequent in DYS versus BD/MDD. Moderator analyses showed higher comorbidity when diagnoses were based on questionnaires versus clinical interviews, DSM-III-R versus DSM-IV, more women were included or the duration of the disorder was longer. Age of onset yielded mixed results.

LIMITATIONS

Blind rating of diagnoses was recorded, but was employed in too few studies to be usable as an indication of diagnostic validity.

CONCLUSIONS

Personality disorders are common in mood disorders. Implications of the identified moderators as well as the new DSM-5 diagnostic system are considered.

Psychometric properties of the Spanish version of the diagnostic interview for depressive personality

The aim of this study was to evaluate the reliability and validity of the Spanish-language version of the diagnostic interview for depressive personality (DIDP). The DIDP was administered to 328 consecutive outpatients and the test-retest and inter-rater reliability were assessed. Factor analysis was used in search of factors capable of explaining the scale and a cutoff point was established. The DIDP scales showed adequate Cronbach's α values and acceptable test-retest and inter-rater reliability coefficients. Convergent and discriminant validity were explored, the latter with respect to avoidant and borderline personality disorders. The results of the factor analysis were consistent with the four-factor structure of the DIDP scales. The receiver operating characteristic (ROC) analysis revealed the area under the curve to be 0.848. We found 30 to be a good cutoff point, with a sensitivity of 74.5% and a specificity of 78.5%. The DIDP proved to be a reliable and valid instrument for assessing depressive personality disorder, at least among our outpatients. The psychometric properties of the DIDP support its clinical usefulness in assessing depressive personality.

Genetic and environmental contributions to the co-occurrence of depressive personality disorder and DSM-IV personality disorders

One of the main controversies with regard to depressive personality disorder (DPD) concerns the co-occurrence with the established DSM-IV personality disorders (PDs). The main aim of this study was to examine to what extent DPD and the DSM-IV PDs share genetic and environmental risk factors, using multivariate twin modeling. The DSM-IV Structured Interview for Personality was applied to 2,794 young adult twins. Paranoid PD from Cluster A, borderline PD from Cluster B, and all three PDs from Cluster C were independently and significantly associated with DPD in multiple regression analysis. The genetic correlations between DPD and the other PDs were strong (.53-.83), while the environmental correlations were moderate (.36-.40). Close to 50% of the total variance in DPD was disorder specific. However, only 5% was due to disorder-specific genetic factors, indicating that a substantial part of the genetic vulnerability to DPD also increases the vulnerability to other PDs.

The Swedish Depressive Personality Disorder Inventory: psychometrics and clinical correlates from a DSM-IV and proposed DSM-5 perspective

BACKGROUND

Depressive personality is commonly seen in clinical practice, and today only one exclusive self-report instrument-the Depressive Personality Disorder Inventory (DPDI)-is available for its assessment based on the DSM-IV description of the construct.

AIMS

The purpose of this research was to evaluate a Swedish version of this measure (DPDI-Swe) in terms of its reliability, internal structure, and convergent validity using related variables from the DSM-IV criteria for depressive personality disorder (DPD) and the proposed DPD trait set for DSM-5.

METHODS

A non-clinical sample of 255 adults in southern Sweden completed a self-report package, which, in addition to DPD, included the assessment of self-esteem, optimism, hope, rumination, worry, depression, and anxiety. Quality of life was also measured.

RESULTS

Results indicated that the DPDI-Swe was internally consistent (α = 0.96). Exploratory factor analysis with oblique rotation yielded three components, together accounting for 48.21% of the variance in DPDI-Swe scores. There were strong positive associations between the DPDI-Swe and measures of depression, anxiety, rumination, and worry, and strong negative associations between the DPDI-Swe and measures of self-esteem, optimism, hope, and quality of life. These significant relationships remained, albeit slightly diminished, after statistically controlling for current depressed mood.

CONCLUSIONS AND CLINICAL IMPLICATIONS

The DPDI-Swe appears to be a reliable and valid measure of DPD, and it is available for clinical and research use.

Mood and Global Symptom Changes among Psychotherapy Clients with Depressive Personality

The present study assessed the rate of depressive personality (DP), as measured by the self-report instrument depressive personality disorder inventory (DPDI), among 159 clients entering psychotherapy at an outpatient university clinic. The presenting clinical profile was evaluated for those with and without DP, including levels of depressed mood, other psychological symptoms, and global severity of psychopathology. Clients were followed naturalistically over the course of therapy, up to 40 weeks, and reassessed on these variables again after treatment. Results indicated that 44 percent of the sample qualified for DP prior to treatment, and these individuals had a comparatively more severe and complex presenting disposition than those without DP. Mixed-model repeated-measures analysis of variance was used to examine between-groups changes on mood and global severity over time, with those with DP demonstrating larger reductions on both outcome variables, although still showing more symptoms after treatment, than those without DP. Only eleven percent of the sample continued to endorse DP following treatment. These findings suggest that in routine clinical situations, psychotherapy may benefit individuals with DP.

Affect regulation and Depressive Personality Disorder

Depressive Personality Disorder (DPD) has been under consideration for inclusion in the Diagnostic and Statistical Manual of Mental Disorders since 1994; yet, few studies have been published that test whether those with DPD have affective experiences that are characterized exclusively by depression and negative affect. One hundred ninety-seven undergraduate students were interviewed for DPD and Borderline Personality Disorder with the Personality Disorder Interview for DSM-IV (Widiger, Mangine, Corbitt, Ellis, & Thomas, 1995), in order to control for frequently co-occurring BPD which is characterized by affective lability. Participants also were administered measures of affective lability, affective intensity, anxious and depressive states, and more trait-like manifestations of depression, anxiety, and anger. Results indicate that those with DPD may be described as having a mood state characterized by transitions from a baseline neutral mood to one of anxiety, with their experiences being more prominently depressed and dysphoric. They also have tendencies toward angry hostility, though they may not report frequent shifts from a baseline neutral mood to anger. Those with DPD also report intense, frequent experiences of depression and dysphoria, with many shifts between depression and anxiety.

What should become of depressive personality disorder in DSM-V?

Depressive personality disorder (DPD) has been under consideration for inclusion in the Diagnostic and Statistical Manual of Mental Disorders for many years. The wealth of empirical studies on the validity of DPD has raised many questions about the validity of the DPD construct and its measures. This article specifically reviews studies on the validity of that construct and how it is measured. Although the evidence supports the idea that DPD is a viable diagnostic category, there remain significant challenges to its assessment. These findings are discussed in the context of some potential changes that may occur in the classification and diagnosis of personality disorders in DSM-V.

Comparison of prototypic cases of depressive personality disorder and dysthymic disorder

Although depressive personality disorder (DPD) was included in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; American Psychiatric Association, 1994) appendix as a proposed category needing further research, there are concerns that it overlaps excessively with dysthymic disorder (DD). The purpose of this investigation was to identify the characteristic features of representative patients with DPD and patients with DD, and to determine whether they could be distinguished by their symptoms. Two matched samples of psychologists (n=57, n=48) identified a prototypic patient with DPD or DD, provided demographic and treatment information about the patient, and rated the patient's symptoms on a series of mood and personality disorder symptoms taken from the DSM-IV and the literature. When composite descriptions were constructed using the highest rated symptoms, there was considerable overlap in symptoms of identified DPD and DD patients. The DSM-IV research criteria for DPD provided the best description of the DPD patients; however, there was a high degree of correlation between DPD and DD criteria sets. There was also considerable comorbidity, with the majority of the patients in both groups meeting criteria for DPD and DD. However, there was a significant difference in comorbid diagnoses (and other differences in family history, outcome, and treatment history that failed to reach the more stringent level of statistical significance, i.e., p<.001) suggesting that there may be some important differences between DPD and DD. Nevertheless, the symptom ratings imply blurred boundaries between DPD and DD, suggesting the need for clearer differentiation between the two disorders or the need to adopt an alternative model of classification.

Depressive personality disorder, dysthymia, and their relationship to perfectionism

This paper reports the results of two studies in a nonclinical (n=105) and primary care outpatient sample (n=110), in which Depressive Personality Disorder (DPD), Dysthymia, and depression were assessed for their distinctive relationship with perfectionism. Results from both studies found that self-reported DPD, Dysthymia, and depressive symptoms were all intercorrelated, and that DPD, Dysthymia, and depressive symptoms were correlated with three dimensions of perfectionism-Concern over Mistakes, Doubts about Actions, and Parental Criticism. In the nonclinical sample, variance in measures of DPD was predicted by measures of perfectionism after controlling for depression and Dysthymia symptoms. A similar pattern of findings was observed in the primary care sample. This relationship with perfectionism did not occur when Dysthymia or depressive symptoms were predicted. Nevertheless, much of the variance in measures of DPD, Dysthymia, and depressive symptoms is associated with each other and not perfectionism. It is concluded that a common factor or set of factors underlies these disorders, but that DPD may be more strongly related to perfectionism than Dysthymia and depression. As a common factor(s) is identified, measures of DPD and Dysthymia may be refined, thereby increasing the discriminant validity of their measures.

Personality and depression

OBJECTIVE

To examine the implications of the association between personality and depression for the understanding, assessment, and treatment of major depression.

METHOD

A broad range of peer-reviewed manuscripts relevant to personality and depression was reviewed. Particular emphasis was placed on etiology, stability, diagnosis, and treatment implications.

RESULTS

Personality features in depressed samples reliably differ from those of healthy samples. The associations between personality and depression are consistent with a variety of causal models; these models can best be compared through longitudinal research. Research demonstrates that attention to personality features can be useful in diagnosis and treatment. Indeed, personality information has been on the forefront of recent efforts to advance the current diagnostic classification system. Moreover, personality dimensions have shown recent promise in the prediction of differential treatment outcome. For example, neuroticism is associated with preferential response to pharmacotherapy rather than psychotherapy.

CONCLUSIONS

Consideration of personality features is crucial to the understanding and management of major depression.

Genetic and environmental contributions to depressive personality disorder in a population-based sample of Norwegian twins

BACKGROUND

Depressive personality disorder (DPD) was introduced in DSM-IV as a new category requiring further study. The aim of this study was to estimate genetic and environmental contributions to DPD in a population-based twin sample, and include data on criteria performance, prevalence and diagnostic overlap.

METHODS

Axis I and Axis II diagnoses were obtained by structured interviews in a population-based sample of 2794 young adult twins. Statistical analyses included correlation and factor analysis based on polychoric correlation coefficients, and diagnostic overlap applying adjusted odds ratios. Contributions from additive genetic and common and unique environmental influences to the liability to DPD were computed using structural equation modelling, applying a multiple threshold variable.

RESULTS

Liability to DPD could best be explained by additive genetic and unique environmental factors, with heritability estimates of 49% (95% CI 0.41-0.57) in females and 25% (95% CI 0.12-0.40) in males. The best-fitting model indicated that some of the genes contributing to DPD differ between men and women. Chronbach's alpha was 0.87. 2.0% of participants fulfilled the criteria for DPD, and overlap was most pronounced for dysthymic disorder and avoidant personality disorder.

LIMITATIONS

Low prevalence rates and subsequent inclusion of subthreshold criteria could have influenced parameter estimates, especially in males.

CONCLUSIONS

DPD was almost twice as heritable in females as in males, comparable to previous studies on major depression. The proposed criteria showed good measurement properties, and DPD was not completely subsumed within any other disorder.

Depressive personality and dysthymia: evaluating symptom and syndrome overlap

BACKGROUND

Depressive Personality (DP) is being evaluated for future inclusion in DSM. One recurring issue has been conceptual and empirical redundancy with Dysthymia (i.e., Dysthymic Disorder; DD).

METHODS

The symptom and syndrome overlap of DP and DD were tested in a clinical sample (N = 125) using both self-report and clinician ratings.

RESULTS

Confirmatory factor analyses of the DP and DD symptoms indicated that models which separate these two syndromes had a better fit than a model in which all symptoms were classified together, particularly for the clinician-rated data. At the same time, the syndromes were highly correlated. Binary diagnostic analysis showed that over 80% of the individuals meeting criteria for DP also met criteria for DD. As predicted, the best fit was obtained when the 'psychological' symptoms of DD-- low self-esteem and feelings of hopelessness-- were allowed to be part of both syndromes, and 82% of patients who met criteria for both DP and DD endorsed these two symptoms.

LIMITATIONS

Clinical ratings rather than structured diagnostic interviews were used. As well, some models required modification to improve fit.

CONCLUSIONS

Depressive personality traits can be empirically separated from DD symptoms, but including DP as a categorical diagnosis would lead to a high degree of diagnostic overlap. Much of this overlap is due to sharing psychological features in common. Revisions in the diagnostic system should find a way to incorporate depressive personality traits without insisting that they be diagnosed in a categorical manner.

Functional health status and its relationship to depressive personality disorder, dysthymia, and major depression: preliminary findings

Controversy continues on the extent to which depressive personality disorder (DPD) and dysthymic disorder (DYST) may be differentiated. Although affective disorders often are accompanied by changes in functional health status, to date no study has examined how functional health associated with affective disorders may assist in differentiating the two disorders. In this study, we hypothesized that measures of DPD would have fewer correlations with functional health status than would measures of DYST and major depressive disorder (MDD). African American women (n=110) completed questionnaires that assessed for depressive disorders, somatic concerns, and physical health. Measures of DPD, DYST, and MDD were all significantly correlated with functional health status. When symptoms of MDD were controlled, DYST was more associated with functional health status than was a DSM-IV measure of DPD, although a self-report measure of DPD--the Depressive Personality Disorder Inventory [DPDI; Huprich et al., 1996: J Clin Psychol 52:152-159]--remained significantly correlated with functional health status. When symptoms of DYST were controlled, DSM-IV symptoms of DPD were not strongly associated with functional health status, although measures of MDD and the DPDI were correlated with functional health status. We concluded that despite the overlap in depressive symptoms and functional health status, DPD may be less associated with functional health status in a primary care population than DYST and MDD. Implications for the assessment of DPD are provided.

Role of perfectionism and personality disorder features in response to brief treatment for depression

Using data from the Treatment of Depression Collaborative Research Program (TDCRP), the authors compared the role of patients' perfectionism and features of personality disorder (PD) in the outcome of brief treatment for depression. Data were extracted as to patients' intake levels of symptoms; perfectionism; and PD features, measured as continuous variables, as well as their symptoms at termination; their contribution to the therapeutic alliance; and their satisfaction with social relations. Poorer therapeutic outcome was demonstrated for patients with elevated levels of perfectionism and odd-eccentric and depressive PD features. Patients' contribution to therapeutic alliance and satisfaction with social relations were predicted by perfectionism but not by PD features. Results highlight the central role played by patients' personality in the course of brief treatment for depression.

Depressive personality disorder: a critical overview

Depressive personality disorder (DPD), which has a long tradition in psychiatry, currently resides in Appendix B ("Disorders for Further Study") of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. After a brief outline of this history, the authors review empirical research on DPD using the Robins and Guze criteria (discussed later) for diagnostic and clinical validity as a framework. Although DPD has unique features, the authors argue that this diagnosis can largely be subsumed under dysthymic disorder. As a result of diagnostic confusion, and of the small amount of research conducted in this area, recommendations for the assessment and treatment of DPD are necessarily speculative. The authors conclude that if personality disorders are maintained as categoric constructs, DPD may best be understood as a subtype of dysthymic disorder. A more radical solution would be to conceptualize DPD, along with the other personality disorders, as extreme positions along dimensional continua.

Depressive personality and its relationship to depressed mood, interpersonal loss, negative parental perceptions, and perfectionism

Eighty veteran psychiatric outpatients were evaluated for depressive personality disorder on the Depressive Personality Disorder Inventory (DPDI). It was predicted that those classified with depressive personality would report higher levels of interpersonal loss, negative perceptions of their parents, and higher levels of perfectionism than psychiatric control subjects. Nine of the 12 measures of these variables were significantly greater in those with depressive personality compared with psychiatric control subjects. When statelike depression was controlled for, seven of the nine variables still significantly differed between the two groups. Hierarchical regression analysis and discriminant function analysis found that these variables predicted 9% of the variance in the DPDI above and beyond statelike depression, and that a combination of these variables correctly classified 91% of the depressive personalities and 88% of the psychiatric control subjects. It is concluded that, as hypothesized, depressive personality disorder is associated with loss, negative parental perceptions, and perfectionism, and that these relationships are not accounted for exclusively by a depressed mood.

Decrease in genu of the corpus callosum in medication-naïve, early-onset dysthymia and depressive personality disorder

BACKGROUND

The purpose of this study was to detect differences in regional areas of the corpus callosum (CC) in subjects with early-onset minor depression (dysthymia or depressive personality disorder) and healthy comparison subjects. Based on previous reports that have suggested reduced frontal lobe volume and reduced hemispheric lateralization in the frontal regions of the brain in depression, we hypothesized that the area of the CC that interconnects the frontal regions of the brain, i.e., the genu, will be smaller compared to that of healthy comparison subjects.

METHODS

Forty female subjects with early-onset dysthymia or depressive personality disorder, as defined by the Structured Clinical Interview for DSM-III-R and the Diagnostic Interview for Depressive Personality, respectively, and age- and gender-matched healthy comparison subjects (n = 42) were recruited (age: 21.4 +/- 2.1 and 20.9 +/- 2.8 years, respectively). All subjects were psychotropic medications-naïve and right-handed. A 1.5T GE Sigma scanner was used to acquire 124 1.5-mm-thick contiguous coronal images. Midsagittal slice images were carefully selected from reconstructed magnetic resonance images both from native and stereotaxic space to measure seven regional areas of the CC.

RESULTS

There were significant diagnosis by CC region interactions [F(6,480) = 4.06, p <.001; F(6,480) = 3.30, p =.003, native and stereotaxic space, respectively]. Early-onset minor depression subjects had a 9.9% (native space) and 6.9% (stereotaxic space) smaller genu of the CC compared to the healthy comparison subjects (the Newman-Keuls post hoc test, p =.005 and.019, native and stereotaxic space, respectively). Early-onset minor depression subjects also had a 7.8% smaller posterior midbody relative to the comparison subjects (the Newman-Keuls post hoc test, p =.033) only in the native space. Severity of current depressive symptoms or duration of illness did not correlate with the size of the genu or the posterior midbody parts of the CC.

CONCLUSIONS

These results suggest frontal lobe structural, and possibly functional, abnormalities in the brain in young female adults with a milder spectrum of depression, i.e., DSM-IV early-onset dysthymia or depressive personality disorder. The present findings point out the possible role of frontal lobe abnormality in pathophysiology of early-onset minor depression.

Personality disorders at the crossroads

Personality disorders are now at a crossroads with respect to theory, research, and conceptualization. In this article, we review relevant and current issues within the personality disorder field. After reviewing changes in the conception of personality disorders across the past half century (1952 to 2002), we focus on the issue of continuity versus discontinuity methodologies for assessing personality, interactionism, treatments, resolved and unresolved issues, and future directions. The issue of continuity versus discontinuity is a theme in this article. We conclude that the evidence is in favor of a reapprochment between a categorical classification system and a dimensional system and we also outline the difficulties in achieving this change.

Spectrum and nosology: implications for DSM-V

The authors attempt to show similarities and differences between a spectrum and the DSM-IV perspective in how psychopathology is best represented to clinicians and clinical researchers. Subthreshold symptoms are given little or no attention in DSM; noncriterion symptoms are given none at all. Not otherwise specified disorders may be a widely used category in DSM-IV, but in a spectrum diagnosis there is no similar designation, because use of the whole spectrum of symptoms is possible. Although a DSM-IV categorical disorder may not be the best representation of psychopathology, it is clearly defined and is efficient for the purposes of communication and labeling. Both systems of nosology are essentially atheoretical; comorbidity exists in both, although to a lesser degree in some spectrum models. Data are summarized that clearly demonstrate the need for designers of DSM-V to create a nosology that is, at least in part, dimensional.