0
Get Alert
Please Wait... Processing your request... Please Wait.
You must sign in to sign-up for alerts.

Please confirm that your email address is correct, so you can successfully receive this alert.

1
Editorial   |    
Personality Disorders in the Depressed: Seeing Clearly Through Blue Lenses
Robert Michels, M.D.
Am J Psychiatry 2010;167:487-488. doi:10.1176/appi.ajp.2010.10020172
View Author and Article Information

Disclosures of Editors of The American Journal of Psychiatry are published each year in the January issue.

Address correspondence and reprint requests to Dr. Michels, Department of Psychiatry, Cornell University Medical College, 418 East 71st St., Suite 41, New York, NY 10021; rmichels@med.cornell.edu (e-mail). Editorial accepted for publication February 2010.

Accepted February , 2010.

Copyright © American Psychiatric Association

One of the oldest distinctions in psychiatry is that between state and trait—between a transient or time-limited event, such as a panic attack or a depressive episode, and an enduring, even lifelong, condition such as schizophrenia, mental retardation, or a personality disorder. This distinction is further complicated in that some states may recur, as is common with depression, so that the predisposition to the state becomes a trait, while some traits may be found on closer examination to have variable and unpredictable courses, with the stability and outcome less predictable than the pure notion of trait would suggest, as has been reported in recent studies of personality disorders.

An individual may have a state and trait at the same time—that is, state and trait can be comorbid. The organization of DSM-III, DSM-III-R, and DSM-IV into axis I and axis II was in great part intended to highlight such comorbidities and call clinical attention to them. One of the commonest comorbidities in psychiatry is between a depressive episode and a personality disorder (1). In this issue, Morey et al. (2) report that about two-thirds of their patients with personality disorders had comorbid depressive episodes, consistent with the findings of others. However, this raises a state-trait dilemma in the methodology of diagnosis and assessment that runs through the personality disorder-depression literature. Does a coexisting depressive episode influence the validity of a simultaneous personality disorder diagnosis? In other words, does the depressed patient's depressed view of self and world lead to false positive diagnoses of personality disorders, diagnoses that will disappear after the depression has ended?

This potential problem was recognized many years ago, and there has been a series of attempts to address it. Self-report questionnaires have been reported to be more valid when patients are given clear instructions to describe their usual or premorbid characteristics rather than their current ones (3). Some personality trait assessments have been reported to be affected by depressive episodes at the time of evaluation while others were not (4). Collateral informants can supplement information provided by the patient (5). Interviews by experienced clinicians seem superior to self-reports, and training of interviewers improves the results further (6, 7). The Morey et al. study represents a major addition to this literature by examining the long-term outcome and diagnostic stability of patients with depression, personality disorder, or both. They studied 433 patients from four sites over a 6-year period: 73 with depression alone, 119 with personality disorder alone (and no history of previous depression), and 241 with both depression and personality disorder. The patients with personality disorders had one of four disorders—schizoid (cluster A), borderline (cluster B), avoidant, or obsessive-compulsive (both cluster C). These disorders had comparable stability over a 6-year period and had comparably high rates of comorbidity with depression (67%). Personality disorders were evaluated by both questionnaires and interviews.

Morey et al. found that depressive states did not alter the validity of personality disorder diagnoses. Personality pathology diagnosed during a depressive episode persisted over time and endured after the depressive episode had ended; it seemed in every regard similar to personality pathology diagnosed in the absence of a depressive episode. Clinicians who know how to diagnose personality pathology should be able to do so whether or not the patient is simultaneously depressed.

The clinical importance of the question is underlined by Morey and colleagues' finding that while only 8% of the depressed patients without personality disorders remained depressed at 6-year follow-up, 29% of the depression-plus-personality disorder group did so, suggesting either that the persistent symptoms were a manifestation of the personality disorder or that the personality disorder interfered with recovery from depression. The latter interpretation is a recurrent theme in the literature (811).

The assessment of personality is an important part of the assessment of any depressed patient. It can be made during the depressed state and is relevant to the prediction of prognosis and treatment response.

Oldham  JM;  Skodol  AE;  Kellman  HD;  Hyler  SE;  Doidge  N;  Rosnick  L;  Gallaher  PE:  Comorbidity of axis I and axis II disorders.  Am J Psychiatry 1995; 152:571—578
[PubMed]
 
Morey  LC;  Shea  MT;  Markowitz  JC;  Stout  RL;  Hopwood  CJ;  Gunderson  JG;  Grilo  CM;  McGlashan  TH;  Yen  S;  Sanislow  CA;  Skodol  AE:  State effects of major depression on the assessment of personality and personality disorder.  Am J Psychiatry 2010; 167:528—535
[CrossRef] | [PubMed]
 
Kendell  RE;  DiScipio  WJ:  Eysenck Personality Inventory scores of patients with depressive illnesses.  Br J Psychiatry 1968; 114:767—770
[CrossRef] | [PubMed]
 
Hirschfeld  RM;  Klerman  GL;  Clayton  PJ;  Keller  MB;  McDonald-Scott  P;  Larkin  BH:  Assessing personality: effects of the depressive state on trait measurement.  Am J Psychiatry 1983; 140:695—699
[PubMed]
 
Bagby  RM;  Rector  NA;  Bindseil  K;  Dickens  SE;  Levitan  RD;  Kennedy  SH:  Self-report ratings and informants' ratings of personalities of depressed outpatients.  Am J Psychiatry 1998; 155:437—438
[PubMed]
 
Loranger  AW;  Lenzenweger  MF;  Gartner  AF;  Susman  VL;  Herzig  J;  Zammit  GK;  Gartner  JD;  Abrams  RC;  Young  RC:  Trait-state artifacts and the diagnosis of personality disorders.  Arch Gen Psychiatry 1991; 48:720—727
[PubMed]
[CrossRef]
 
Zimmerman  M:  Diagnosing personality disorders: a review of issues and research methods.  Arch Gen Psychiatry 1994; 51:225—245
[PubMed]
[CrossRef]
 
Shea  MT;  Pilkonis  PA;  Beckham  E;  Collins  JF;  Elkin  I;  Sotsky  SM;  Docherty  JP:  Personality disorders and treatment outcome in the NIMH Treatment of Depression Collaborative Research Program.  Am J Psychiatry 1990; 176:711—718
 
Reich  J;  Noyes  R  Jr;  Coryell  W;  O'Gorman  TW:  The effect of state anxiety on personality measurement.  Am J Psychiatry 1986; 143:760—763
[PubMed]
 
Gunderson  JG;  Morey  LC;  Stout  RL;  Skodol  AE;  Shea  MT;  McGlashan  TH;  Zanarini  MC;  Grilo  CM;  Sanislow  CA;  Yen  S;  Daversa  MT;  Bender  DS:  Major depressive disorder and borderline personality disorder revisited: longitudinal interactions.  J Clin Psychiatry 2004; 65:1049—1056
[CrossRef] | [PubMed]
 
Newton-Howes  G;  Tyrer  P;  Johnson  T:  Personality disorder and the outcome of depression: meta-analysis of published studies.  Br J Psychiatry 2006; 188:13—20
[CrossRef] | [PubMed]
 
References Container
+

References

Oldham  JM;  Skodol  AE;  Kellman  HD;  Hyler  SE;  Doidge  N;  Rosnick  L;  Gallaher  PE:  Comorbidity of axis I and axis II disorders.  Am J Psychiatry 1995; 152:571—578
[PubMed]
 
Morey  LC;  Shea  MT;  Markowitz  JC;  Stout  RL;  Hopwood  CJ;  Gunderson  JG;  Grilo  CM;  McGlashan  TH;  Yen  S;  Sanislow  CA;  Skodol  AE:  State effects of major depression on the assessment of personality and personality disorder.  Am J Psychiatry 2010; 167:528—535
[CrossRef] | [PubMed]
 
Kendell  RE;  DiScipio  WJ:  Eysenck Personality Inventory scores of patients with depressive illnesses.  Br J Psychiatry 1968; 114:767—770
[CrossRef] | [PubMed]
 
Hirschfeld  RM;  Klerman  GL;  Clayton  PJ;  Keller  MB;  McDonald-Scott  P;  Larkin  BH:  Assessing personality: effects of the depressive state on trait measurement.  Am J Psychiatry 1983; 140:695—699
[PubMed]
 
Bagby  RM;  Rector  NA;  Bindseil  K;  Dickens  SE;  Levitan  RD;  Kennedy  SH:  Self-report ratings and informants' ratings of personalities of depressed outpatients.  Am J Psychiatry 1998; 155:437—438
[PubMed]
 
Loranger  AW;  Lenzenweger  MF;  Gartner  AF;  Susman  VL;  Herzig  J;  Zammit  GK;  Gartner  JD;  Abrams  RC;  Young  RC:  Trait-state artifacts and the diagnosis of personality disorders.  Arch Gen Psychiatry 1991; 48:720—727
[PubMed]
[CrossRef]
 
Zimmerman  M:  Diagnosing personality disorders: a review of issues and research methods.  Arch Gen Psychiatry 1994; 51:225—245
[PubMed]
[CrossRef]
 
Shea  MT;  Pilkonis  PA;  Beckham  E;  Collins  JF;  Elkin  I;  Sotsky  SM;  Docherty  JP:  Personality disorders and treatment outcome in the NIMH Treatment of Depression Collaborative Research Program.  Am J Psychiatry 1990; 176:711—718
 
Reich  J;  Noyes  R  Jr;  Coryell  W;  O'Gorman  TW:  The effect of state anxiety on personality measurement.  Am J Psychiatry 1986; 143:760—763
[PubMed]
 
Gunderson  JG;  Morey  LC;  Stout  RL;  Skodol  AE;  Shea  MT;  McGlashan  TH;  Zanarini  MC;  Grilo  CM;  Sanislow  CA;  Yen  S;  Daversa  MT;  Bender  DS:  Major depressive disorder and borderline personality disorder revisited: longitudinal interactions.  J Clin Psychiatry 2004; 65:1049—1056
[CrossRef] | [PubMed]
 
Newton-Howes  G;  Tyrer  P;  Johnson  T:  Personality disorder and the outcome of depression: meta-analysis of published studies.  Br J Psychiatry 2006; 188:13—20
[CrossRef] | [PubMed]
 
References Container
+
+

CME Activity

There is currently no quiz available for this resource. Please click here to go to the CME page to find another.
Submit a Comments
Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
Comments are moderated and will appear on the site at the discertion of APA editorial staff.

* = Required Field
(if multiple authors, separate names by comma)
Example: John Doe



Web of Science® Times Cited: 3

Related Content
Books
Gabbard's Treatments of Psychiatric Disorders, 4th Edition > Chapter 55.  >
Textbook of Psychotherapeutic Treatments > Chapter 16.  >
Textbook of Psychotherapeutic Treatments > Chapter 16.  >
The American Psychiatric Publishing Textbook of Substance Abuse Treatment, 4th Edition > Chapter 38.  >
The American Psychiatric Publishing Textbook of Substance Abuse Treatment, 4th Edition > Chapter 38.  >
Topic Collections
Psychiatric News
APA Guidelines