Depressive personality disorder: rates of comorbidity with personality disorders and relations to the five-factor model of personality

Sleep loss suicidal ideation: the role of trait extraversion

Background: It is known that sleep disturbance is associated with increased suicidal thinking. Moreover, completed suicides, when adjusted for the proportion of the populace that is awake at a given time, are more probable during the late night/early morning hours. Despite these concerns, no studies have examined the role of trait-like individual differences in vulnerability to suicidal ideation during sleep deprivation or insomnia. In two separate studies, we examined whether the trait of extraversion is predictive of changes in suicidal thinking following two nights of sleep deprivation and among individuals meeting the criteria for insomnia.

Methods:Study 1: Twenty-five healthy military personnel (20 males), ages 20–35 completed the NEO-PI-R Extraversion scale and the Suicidal Ideation (SUI) scale of the Personality Assessment Inventory (PAI). Participants completed 77 h of continuous sleep deprivation. After 56 h of sleep deprivation, participants completed the SUI scale a second time. We predicted a change in SUI scores from baseline extraversion. Study 2: 2,061 adults aged 18–79 (900 males) were divided into two groups based on the clinical threshold (≥ 10) on the Insomnia Severity Index (ISI) and completed measures of extraversion and depression, including the suicide item of the Patient Health Questionnaire-9 (PHQ9).

Results:Study 1: After controlling for the caffeine group and changes in PAI Depression, Extraversion scores were used to predict changes in SUI scores using stepwise multiple linear regression. Higher Extraversion was significantly associated with increased non-clinical suicidal ideation following sleep loss, β = 0.463, partial r = 0.512, p = 0.013. Study 2: After controlling for depression, the effect of insomnia on suicidal ideation was moderated by trait extraversion (p < 0.0001). Overall, the presence or absence of insomnia had little effect on individuals low in trait extraversion (i.e., introverts), but insomnia was associated with significantly higher suicidal ideation among high trait extraverted individuals.

Conclusions: Higher trait extraversion was associated with increased vulnerability to suicidal ideation between rested baseline and total sleep deprivation and was associated with greater suicidal ideation among those meeting criteria for clinically severe insomnia. These findings point to a potential trait-like vulnerability factor that may further our understanding of sleep disruption in the phenomenology of suicide.

DSM‐IV personality disorders and the Five‐Factor Model of personality: a multi‐method examination of domain‐ and facet‐level predictions

The personality disorder classification system (Axis II) in the various versions of the Diagnostic and Statistical Manuals of Mental Disorders (DSM) has been the target of repeated criticism, with conceptual analysis and empirical evidence documenting its flaws. In response, many have proposed alternative approaches for the assessment of personality psychopathology, including the application of the Five‐Factor Model of personality (FFM). Many remain sceptical, however, as to whether domain and facet traits from a model of general personality functioning can be successfully applied to clinical patients with personality disorders (PDs). In this study, with a sample of psychiatric patients (n = 115), personality disorder symptoms corresponding to each of the 10 PDs were successfully predicted by the facet and domain traits of the FFM, as measured by a semi‐structured interview, the Structured Interview for the Five Factor Model (SIFFM; Trull & Widiger, 1997) and a self‐report questionnaire, the Revised NEO Personality Inventory (NEO PI‐R; Costa and McCrae, 1992). These results provide support for the perspective that personality psychopathology can be captured by general personality dimensions. The FFM has the potential to provide a valid and scientifically sound framework from which to assess personality psychopathology, in a way that covers most of the domains conceptualized in DSM while transcending the limitations of the current categorical approach to these disorders. Copyright © 2005 John Wiley & Sons, Ltd.

Personality and personality disorders: introduction to the special issue

The study of extreme variants of phenomena has always been a challenge for science. While the science of personality has roots in several traditions, historically numerous personality theories and constructs for the assessment and explanation of individual differences have strongly been influenced by the progress made in conceptualizing extreme states of psychological functioning. Yet, division of labour resulted in psychiatry and clinical psychology focusing on deviant or maladaptive and personality psychology specializing on the normal range of individual differences. This special issue of the European Journal of Personality is driven by the idea that linking the study of personality and psychopathology offers insights that neither discipline can achieve on its own. Copyright © 2005 John Wiley & Sons, Ltd.

Neediness and connectedness and the five‐factor model of personality

This study examined maladaptive and relatively more adaptive forms of dependency, as measured by the neediness and connectedness factors of the Depressive Experiences Questionnaire (DEQ; Blatt, D'Afflitti, & Quinlan, 1976), within a comprehensive scheme of personality provided by the revised NEO Personality Inventory (NEO‐PI‐R; Costa & McCrae, 1992). University students (n = 475) completed the DEQ, NEO‐PI‐R, and a measure of depressive symptoms. Results indicated that neediness reflected anxiety, self‐consciousness, vulnerability, unassertiveness, and inactivity, whereas connectedness reflected anxiety, warmth, agreeableness, and valuing of relationships. Neediness demonstrated stronger relations than connectedness with depressive symptoms. These results support the validity of DEQ neediness and connectedness as measures of maladaptive and relatively more adaptive forms of dependency. Copyright © 2006 John Wiley & Sons, Ltd.

Temperament and character influence on depression treatment outcome

BACKGROUND

personality features have been repeatedly associated with depression treatment outcome in Major Depressive Disorder (MDD), however conclusive results are still lacking. Moreover, as for Bipolar Disorder (BD), results are only few and preliminary.

AIM

the aim of the present study was to perform an exploratory investigation of the influence of personality traits as assessed by the Temperament and Character Inventory (TCI), on principal depression treatment outcomes (non remission, non response and resistance).

METHODS

743 mood disorders patients (455 MDD (61.24%) and 288 BD (38.76%)) were recruited in the context of 6 European studies. Generalized logit models were performed to test the effects of TCI dimensions on treatment outcomes, considering possible confounders such as age, gender and education. Positive results were controlled for comorbidities (anxiety and substance use disorders) as well.

RESULTS

MDD Non-Remitters showed high Harm Avoidance (HA) and Self Transcendence (ST) (p = 0.0004, d = 0.40; p = 0.007, d = 0.36 respectively) and low Persistence (P) and Self Directedness (SD) (p = 0.05; d = 0.18; p = 0.002, d = 0.40, respectively); MDD Non-Responders showed a slightly different profile with high HA and low Reward Dependence (RD) and SD; finally, MDD Resistants showed low RD, P and Cooperativeness (C). In BD patients, only higher HA in non response was observed.

LIMITATIONS

the retrospective cross-sectional design, the TCI assessment regardless of the mood state and the small number of bipolar patients represent the main limitations.

CONCLUSION

specific TCI personality traits are associated with depression treatment outcome in MDD patients. The inclusion of such personality traits, together with other socio-demographic and clinical predictors, could ameliorate the accuracy of the prediction models available to date.

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.

Combining self-defeating and depressive personality symptoms into one construct

In the history of the DSM, two disorders have been proposed for consideration that shared much in common - self-defeating personality disorder (SDPD) and depressive personality disorder (DPD). In a previous paper, it was reported that SDPD (n = 34) and DPD (n = 240) shared a diagnostic overlap of 70%. It was concluded that SDPD could not be empirically supported as a diagnostic category. In this paper, the overlap of the two disorders was explored further in this same sample (n = 1,200) of psychiatric outpatients. We found that symptoms of the two disorders were positively correlated. Confirmatory factor analysis (CFA) provided strong support for a model with two distinct, but very highly correlated constructs. Based on the hypothesis that SDPD and DPD are separate but related, a second-order CFA factor was fit to the data to further examine the strong association between the two disorders. Taken collectively, it is concluded that DPD and SDPD are components of the same construct, and that the current DPD and SDPD diagnoses as proposed in the DSM are actually subtypes of a common personality pathology (i.e. a second-order factor).

Depressive Personality Disorder: A Comparison of Three Self-Report Measures

Depressive personality disorder (DPD) was included in the appendix of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition ( DSM-IV) for further study. Questions abound regarding this disorder in terms of its distinctiveness from extant diagnostic constructs and clinical significance.This study examines the interrelations between three assessments of DPD and their relations to pathological personality traits and disorders in a sample of undergraduates ( N = 182). The DPD indices evinced adequate convergence with each other (mean r = .60) and similar pathological personality profiles. The authors also tested the incremental validity of the DPD scores in relation to psychological functioning, after controlling for depressive symptoms and the DSM-IV personality disorders (PDs). The DPD scores manifested limited incremental validity, mainly in the form of predicting lower levels of positive affectivity. Our results suggest that this is not specific to DPD, however, as the official PDs also manifested limited incremental validity.

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.

A study of patients with personality disorder not otherwise specified

BACKGROUND

Personality disorder not otherwise specified (PD NOS) is a frequently applied diagnosis, but we lack knowledge of the clinical appearance of patients receiving the diagnosis. This study applied a large clinical sample (N = 1516) to investigate (1) the prevalence and diagnostic and clinical characteristics of patients with PD NOS defined according to Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and (2) the prevalence and psychosocial impairment associated with different definitions of PD NOS.

METHOD

Patients from the Norwegian Network of Psychotherapeutic Day Hospitals diagnosed in accordance with the LEAD standard (Longitudinal, Expert, All Data) were evaluated on several clinical measures at admission and discharge from short-term treatment.

RESULTS

The DSM-IV PD NOS category was the third most frequent PD diagnosis. Seventeen percent of the total sample and 22% of those with PDs had a PD NOS diagnosis, with an average of 9 PD criteria. Patients with PD NOS were heterogeneous with respect to types of PD criteria, 41% were not subthreshold on any specific PD. The PD NOS patients were intermediate between patients with specific PDs and those with no PD regarding number of fulfilled PD criteria and several social and clinical variables. Alternative operationalizations of PD NOS, that is, subthreshold on at least 2 specific PDs or meeting a minimum of 10 PD criteria, resulted in lower prevalence rates and defined clinically more impaired patients.

CONCLUSION

The PD NOS defined according to DSM-IV has a high prevalence and seems to capture a group of patients with fewer PD criteria and less severe psychosocial impairment compared to patients with specific PDs. The findings indicate that the operational definition of PD NOS may have a strong impact on the prevalence and clinical appearance of patient receiving this diagnosis.

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.

The trait of Introversion-Extraversion predicts vulnerability to sleep deprivation

According to Eysenck's theory of Introversion-Extroversion (I-E), introverts demonstrate higher levels of basal activity within the reticular-thalamic-cortical loop, yielding higher tonic cortical arousal than Extraverts, who are described conversely as chronically under-aroused and easily bored. We hypothesized that higher scores on the trait of Extraversion would be associated with greater declines in psychomotor vigilance performance during prolonged wakefulness. We evaluated the relationship between I-E and overnight psychomotor vigilance performance during 77 h of continuous sleep deprivation in a sample of 23 healthy adult military personnel (19 men; four women), ranging in age from 20 to 35 years. At baseline, volunteers completed the Revised NEO Personality Inventory (NEO PI-R) and completed psychomotor vigilance testing at approximately 10-min intervals from 00:15 to 08:50 hours over three nights of continuous sleep deprivation. In addition, 12 participants received four repeated administrations of caffeine (200 mg) every 2 h each night. Analysis of covariance and stepwise multiple regression analyses showed that, above and beyond the effects of caffeine, higher Extraversion was significantly related to more extensive declines in speed of responding and more frequent attentional lapses, but only for the first overnight testing session. Sub-factors of Extraversion, including Gregariousness and higher Activity level were most predictive of these changes following sleep loss. These findings are consistent with Eysenck's cortico-reticular activation theory of I-E and suggest that individual differences in the trait of Extraversion confer some vulnerability/resistance to the adverse effects of sleep loss on attention and vigilance.

Dependent Personality Disorder

Assessment of the Diagnostic and Statistical Manual of Mental Disorders (4th Ed.; DSM-IV ) personality disorders (PDs) using five-factor model (FFM) prototypes and counts has shown substantial promise, with a few exceptions. Miller, Reynolds, and Pilkonis suggested that the expert-generated FFM dependent prototype might be misspecified in relation to the DSM-IV because of the overemphasis of high Agreeableness and underemphasis of low Conscientiousness in the experts' conception. A meta-analytic review of the relations between the FFM facets and Dependent PD (DPD) was conducted and used to create a revised, empirically based FFM DPD profile and count. The revised profile and count were more strongly correlated with DSM and non-DSM conceptualizations of maladaptive dependency. In addition, the revised FFM DPD profile was able to recreate the patterns of comorbidity typically found when using DSM-IV measures of DPD. Possible explanations for the discrepancy between the expert ratings and the meta-analytic results are offered.

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.

Five-Factor Model Assessment of Personality Disorder

The Five-factor model (FFM) provides a viable dimensional model of personality disorder assessment. Advantages of the FFM include the provision of a precise yet comprehensive description of both normal and abnormal personality functioning, the avoidance of the many limitations and problems inherent to the categorical diagnostic system, and the incorporation of basic science research on general personality structure and functioning into clinicians' description and understanding of personality disorders. We discuss three alternative instruments for the assessment of personality disorder from the perspective of the FFM. We also provide a method for diagnosing personality disorders and illustrate its application through a case study.

Assessment and diagnosis of personality disorder: perennial issues and an emerging reconceptualization

This chapter reviews recent (2000-2005) personality disorder (PD) research, focusing on three major domains: assessment, comorbidity, and stability. (a) Substantial evidence has accrued favoring dimensional over categorical conceptualization of PD, and the five-factor model of personality is prominent as an integrating framework. Future directions include assessing dysfunction separately from traits and learning to utilize collateral information. (b) To address the pervasiveness and extent of comorbidity, researchers have begun to move beyond studying overlapping pairs or small sets of disorders and are developing broader, more integrated common-factor models that cross the Axis I-Axis II boundary. (c) Studies of PD stability have converged on the finding that PD features include both more acute, dysfunctional behaviors that resolve in relatively short periods, and maladaptive temperamental traits that are relatively more stable-similar to normal-range personality traits-with increasing stability until after 50 years of age. A new model for assessing PD-and perhaps all psychopathology-emerges from integrating these interrelated reconceptualizations.

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.

A simplified technique for scoring DSM-IV personality disorders with the Five-Factor Model

The current study compares the use of two alternative methodologies for using the Five-Factor Model (FFM) to assess personality disorders (PDs). Across two clinical samples, a technique using the simple sum of selected FFM facets is compared with a previously used prototype matching technique. The results demonstrate that the more easily calculated counts perform as well as the similarity scores that are generated by the prototype matching technique. Optimal diagnostic thresholds for the FFM PD counts are computed for identifying patients who meet diagnostic criteria for a specific PD. These threshold scores demonstrate good sensitivity in receiver operating characteristics analyses, suggesting their usefulness for screening purposes. Given the ease of this scoring procedure, the FFM count technique has obvious clinical utility.