Personality disorders over time: precursors, course and outcome

Personality disorders cause dysfunction over the course of adult life. A chronic course of disorder tends to be associated with an early onset, and personality disorders are preceded by precursor symptoms in childhood. Long-term outcome varies by personality disorder category: antisocial and borderline personality tend to remit with age, an improvement that is not seen in other diagnoses. The chronicity of personality disorders can usefully guide treatment planning, and psychotherapy for personality disorders can focus on rehabilitation.     

Personality,life events and the course of anxiety and depression

Using data from the Netherlands Study of Depression and Anxiety, we examined among 1322 participants with a DSM‐IV diagnosis of depression or anxiety: (i) whether positive and negative life events influence 1‐year course of anxiety and depressive symptoms; (ii) whether personality traits (neuroticism and extraversion) predict symptom course and moderate the impact of life events on symptom course; and (iii) whether life events mediate relationships of neuroticism and extraversion with symptom course. Negative life events were predictive of both anxiety and depressive symptoms, while positive life events predicted the course of depressive symptoms only. Personality traits had significant predictive and moderating effects on symptom course, though these effects were rather small. Copyright © 2011 John Wiley & Sons, Ltd.     

A comparison of depressed patients with and without borderline personality disorder: implications for interpreting studies of the validity of the bipolar spectrum

The nosological status of borderline personality disorder as it relates to the bipolar disorder spectrum has been controversial. Studies have supported, in part, the validity of the bipolar spectrum by demonstrating that these patients, compared to patients with nonbipolar depression, are characterized by earlier age of onset of depression, recurrent depressive episodes, comorbid anxiety and substance use disorders and increased suicidality. However, all of these factors have likewise been found to distinguish depressed patients with and without borderline personality disorder. A family history of bipolar disorder is one of the few disorder specific validators. In the present study from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we compared the demographic and clinical characteristics of depressed patients with and without borderline personality disorder. We hypothesized that many of the factors used to validate the bipolar spectrum will also distinguish depressed patients with and without borderline personality disorder except, however, a family history of bipolar disorder. Two thousand nine hundred psychiatric outpatients at Rhode Island Hospital were evaluated with the Structured Clinical Interview for DSM-IV (SCID) and Structured Interview for DSM-IV Personality Disorders (SIDP-IV). Family history information regarding first-degree relatives was obtained from the patient using the Family History Research Diagnostic Criteria. One hundred and one patients with borderline personality disorder plus major depressive disorder were compared to 947 patients with major depressive disorder alone on the prevalence of bipolar disorder validators. Compared to depressed patients without borderline personality disorder, depressed patients with borderline personality disorder had a younger age of onset, more depressive episodes, a greater likelihood of experiencing atypical symptoms and had a higher prevalence of comorbid anxiety disorders, substance use disorders, and number of previous suicide attempts. The depressed patients with borderline personality disorder did not significantly differ from the patients without borderline personality disorder on morbid risk for bipolar disorder in first degree relatives. In addition, patients with a diagnosis of bipolar disorder had a significantly higher morbid risk of bipolar disorder in first degree relatives than the borderline personality disorder group. The findings indicate that many factors used to validate the bipolar spectrum are not disorder specific. These results raise questions about studies of the validity of the broad bipolar spectrum that do not assess borderline personality disorder. Our results do not support inclusion of borderline personality disorder as part of the bipolar spectrum.     

Suicidality as a function of impulsivity, callous-unemotional traits, and depressive symptoms in youth

Suicidality represents one of the most important areas of risk for adolescents, with both internalizing (e.g., depression, anxiety) and externalizing-antisocial (e.g., substance use, conduct) disorders conferring risk for suicidal ideation and attempts (e.g., Bridge, Goldstein, & Brent, 2006). However, no study has attended to gender differences in relationships between suicidality and different facets of psychopathic tendencies in youth. Further, very little research has focused on disentangling the multiple manifestations of suicide risk in the same study, including behaviors (suicide attempts with intent to die, self-injurious behavior) and general suicide risk marked by suicidal ideation and plans. To better understand these relationships, we recruited 184 adolescents from the community and in treatment. As predicted, psychopathic traits and depressive symptoms in youth showed differential associations with components of suicidality. Specifically, impulsive traits uniquely contributed to suicide attempts and self-injurious behaviors, above the influence of depression. Indeed, once psychopathic tendencies were entered in the model, depressive symptoms only explained general suicide risk marked by ideation or plans but not behaviors. Further, callous-unemotional traits conferred protection from suicide attempts selectively in girls. These findings have important implications for developing integrative models that incorporate differential relationships between (a) depressed mood and (b) personality risk factors (i.e., impulsivity and callous-unemotional traits) for suicidality in youth.     

Heightened subjective experience of depression in borderline personality disorder

Despite the frequent comorbidity of major depression and borderline personality disorder (BPD), limited research has examined what effect this comorbidity has on the severity, course, and presentation of depression. The purpose of this study was to examine whether the severity of major depressive disorder (MDD) in the context of comorbid borderline personality disorder (BPD) differs from MDD when comorbid BPD is not present and to determine whether different measures of depression yield convergent findings. Sixty patients diagnosed with DSM-IV MDD participated in this study. Twenty-nine were diagnosed with DSM-IV BPD, while the remaining 31 had no Axis II diagnosis. Depression was evaluated with both clinician (Hamilton Rating Scale for Depression) and self-report (Beck Depression Inventory) ratings. While the two groups were rated as similarly depressed by clinicians on the overall rating and the factor scores, the MDD/BPD group reported more severe depressive symptoms on the self-report measure. This difference was significant even after controlling for clinician-rated severity. Gender interacted with diagnosis, males in the BPD group showed the largest discrepancies between clinician ratings and self-reports. Posthoc analyses of HDRS factors with the BDI showed that the clinicianrated cognitive disturbance and retardation factors were correlated with self-rated severity overall. Within subgroups, only the retardation factor was correlated with the BDI. Our results suggest that while depressed individuals with and without BPD may be rated as similarly depressed when assessed with objective rating methods, the subjective experience of the depression may be rated as more intense or severe by patients with comorbid BPD. The mechanism underlying this effect remains unknown, and requires further research.     

Coping-related expectancies and dispositions as prospective predictors of coping responses and symptoms

We used Rotter's (1954, 1982) social learning theory and Kirsch's (1985, 1999) response expectancy extension thereof to clarify distinctions between coping-related expectancies (beliefs about the outcomes of coping efforts) and coping dispositions (tendencies to use particular coping responses), specifically focusing on the role of generalized expectancies for negative mood regulation (NMR) as a predictor of individual differences in coping and well-being. Two studies using structural equation modeling provided support for direct and indirect associations between NMR expectancies and symptoms of depression. In Study 1 NMR expectancies predicted situational avoidance coping responses and symptoms of depression and anxiety, independent of dispositional avoidance coping tendencies. In Study 2, NMR expectancies were associated with depressive symptoms, concurrently and prospectively, independent of dispositional optimism and pessimism. Both studies indicated that NMR expectancies are more strongly associated with depressive symptoms than with symptoms of anxiety and physical illness. Results underscore the importance of distinguishing between expectancies and other personality variables related to coping.     

Overgeneral autobiographical memory predicts higher prospective levels of depressive symptoms and intrusions in borderline patients

Overgeneral memory (OGM), the tendency to retrieve categories of events from autobiographical memory instead of single events, is found to be a reliable predictor for future mood disturbances and post-traumatic symptom severity. Patients with borderline personality disorder (BPD) often report co-morbid episodes of major depressive disorder (MDD) and post-traumatic stress disorder (PTSD). Therefore, we investigated whether OGM would predict depression severity and (post-traumatic) stress symptoms in BPD patients. At admission (N?=?54) and at six-month follow-up (N?≥?31), BPD patients completed the Structured Clinical Interview for DSM-IV Disorders, the Assessment of DSM-IV Personality Disorders, the Autobiographical Memory Test, the Beck Depression Inventory—2nd edition (BDI-II), and the Impact of Event Scale. OGM at baseline predicted (a) higher levels of depressive symptoms at follow-up and (b) more intrusions related to a stressful event over and above baseline levels of borderline symptoms, depressive symptoms, and intrusions, respectively. No association was found between memory specificity and event-related avoidance at follow-up. Despite previous findings suggesting that OGM in BPD is less robust than in MDD and PTSD, our results suggest that memory specificity in BPD patients may have some relevance for the course of depressive and stress symptomatology in BPD.     

Comorbid social anxiety disorder in clients with depressive disorders: predicting changes in depressive symptoms, therapeutic relationships, and focus of attention in group treatment

The current study examined whether depressed outpatients with comorbid SAD respond differently to a cognitive-behavioral group intervention and if so, how and why. Using growth curve modeling, we found evidence that depressed clients with comorbid SAD had rapid improvement in depressive symptoms over the course of treatment and generally did not differ from those without comorbidity in developing close therapeutic relationships and modifying the direction of attentional focus away from the self. Non-linear effects demonstrated that rates of change in depressive symptoms, relationship variables, and focus of attention, were most rapid early in treatment. In contrast to hypotheses, trajectories of change in therapeutic relationships and attentional focus did not mediate the effect of SAD on treatment improvement in depressive symptoms. These findings suggest that comorbid SAD does not have a detrimental effect on the course of depression treatment and group-based treatments can be as beneficial for depressed individuals with comorbid SAD. It may be that group-based treatments for depression provide explicit opportunity for emotional processing in social situations (i.e., exposure) and hence mimic efficacious therapies for SAD.     

Attachment styles and personality disorders as predictors of symptom course.

Adult attachment styles and personality disorders (PDs) show some conceptual and empirical overlap and both may complicate the course of symptoms among psychiatric patients. In this naturalistic prospective study, 149 patients with affective, anxiety, substance use, and other disorders were interviewed shortly after entering treatment, which included psychotherapy, pharmacotherapy, or both. Follow-up interviews were conducted 6 and 12 months later. Attachment styles, DSM-III-R PDs, and symptoms were assessed using structured interviews and consensus ratings. At intake, borderline, avoidant, and dependent PD features correlated consistently with symptom severity and secure attachment correlated inversely with two of four symptom scales. Secure attachment was linked with greater relative improvement in global functioning and a more benign course of anxiety symptoms over 6 months. Borderline PD features predicted less relative improvement of depressive symptoms over 6 months. These findings clarify the relations between attachment styles and PD features and they point to potential mediators of treatment response.     

A preliminary report on defenses and conflicts associated with borderline personality disorder

The authors present preliminary psychodynamic findings from a naturalistic study of borderline personality disorder compared to antisocial personality disorder and bipolar type II (depression with hypomania) affective disorder. An independent psychodynamic interview of each subject was videotaped from which ratings were made of the presence of 22 defense mechanisms and 11 psychodynamic conflicts. A factor analysis of ratings from 81 subjects supported the separation of borderline (splitting, projective identification) from narcissistic defenses (devaluation, omnipotence, idealization, mood-incongruent denial). While certain groups of defenses were associated with each diagnosis, defense ratings did not significantly discriminate the three diagnostic groups, suggesting a limit to their diagnostic value. Among 27 subjects rated, borderline personality was strongly associated with two conflicts: separation-abandonment, and a global conflict over the experience and expression of emotional needs and anger. Antisocial personality was psychodynamically distinct and more heterogeneous. Bipolar type II was associated with two hypothesized depressive conflicts: dominant other and dominant goal. Chronic depression, which was more common in both personality disorder groups than in bipolar type II, was associated with a third depressive conflict, overall gratification inhibition. Overall, conflicts were powerful discriminators of the three diagnostic groups. The heuristic value of these findings is discussed.     

Self-compassion mediates the link between dependency and depressive symptomatology in college students

Depression is highly prevalent among college students and is associated with significant morbidity and mortality. Dependency is among the known personality traits that predict an elevated risk for depression. Prior research has focused on the depressogenic role of self-critical thoughts among destructive overdependent (DO) individuals but has not considered other internal processes (such as self-compassion) that might influence mental health. The current report examined whether self-compassion had either moderating or mediating effects on the links between dependency and depression in college students. In a cross-sectional study, 85 college students completed measures of dependency, self-compassion, and depressive symptoms. Analyses suggested that self-compassion mediated both the effect of DO on depressive symptoms and the effect of healthy dependency (HD) on lower depressive symptoms; self-compassion did not moderate links between dependency and depressive symptoms. Our exploratory findings suggest that positive self-schema (in the form of self-compassion) may contribute to the downstream mental health effects of both adaptive HD and maladaptive DO.     

Age-related differences in individual DSM criteria for borderline personality disorder

This study examined age-related effects of individual DSM criteria for borderline personality disorder (BPD) and symptoms of depression and anxiety in three groups: patients diagnosed with BPD, another personality disorder, or no personality disorder. The goal was to determine if distinctive age effects emerged within the BPD group. This mixed clinical and community sample (N = 380) ranged from 20-50 years old. Each participant was assessed for symptoms of axis I and II psychopathology. We found significant interactions for personality disorder group x age for the suicidal behavior and impulsivity criteria that reflected distinctive changes in the BPD group. The BPD group reported significantly more anxious and depressive symptoms. However, no main effect for age or personality disorder x age interaction emerged with symptoms. These results demonstrate that older individuals with BPD report less impulsivity and fewer suicidal behaviors, although symptoms of distress persist.     

Self-mutilation and symptoms of depression, anxiety, and borderline personality disorder

The goal of this study was to examine the relationship between self-mutilation and symptoms of depression and anxiety in a nonclinical population. Self-mutilators reported significantly more symptoms of depression and anxiety than did the control group. When the group of self-mutilators was divided into individuals who cut themselves and individuals who harm themselves in other ways, we found that the between-group differences were primarily due to individuals with a history of cutting. Yet when symptoms of borderline personality disorder (BPD) were statistically controlled, all significant between-group differences in depressive and anxious symptoms were reduced to nonsignificant. These findings highlight the importance of assessing symptoms of BPD in self-mutilators, regardless of diagnosis.     

Clinical implications of "subthreshold" depressive symptoms

There is active debate regarding whether diagnosable depression exists on a continuum with subthreshold depressive symptoms or represents a categorically distinct phenomenon. To address this question, multiple indexes of dysfunction (psychosocial difficulties, mental health treatment history, and future incidence of major depression and substance abuse/dependence) were examined as a function of the extent of depressive symptoms in 3 large community samples (adolescent, adult, and older adult; N = 3,003). Increasing levels of depressive symptoms were associated with increasing levels of psychosocial dysfunction and incidence of major depression and substance use disorders. These findings suggest that (a) the clinical significance of depressive symptoms does not depend on crossing the major depressive diagnostic threshold and (b) depression may best be conceptualized as a continuum. Limitations of the present study are discussed.     

Borderline personality disorder level predicts change in depressiveness after short‐term group psychotherapy: A study in a daily psychiatric clinic

The project examined the comorbidity between depression symptoms and the level of borderline personality organisation among patients admitted for group psychotherapy (Study 1). It also aimed to analyse how the level of borderline personality organisation relates to the reduction in depression symptoms after short‐term psychotherapy (Study 2). The study was conducted in a day clinic where patients were receiving psychotherapy for emotional problems affecting their functioning (N = 57). The study used the Borderline Personality Inventory (BPI) and the Patient Health Questionnaire. The analysis showed that BPI was positively related to depression symptoms. The higher borderline personality organisation patients presented when entering group psychotherapy, the greater was the decrease in depression symptoms after 3 months of psychotherapy. We discuss the results in relation to the notion that the presence of depression could be a positive prognostic indicator for patients with borderline personality.     

Borderline personality disorder symptoms as predictors of 4-year romantic relationship dysfunction in young women: addressing issues of specificity

The relationships between romantic relationship dysfunction and symptoms of borderline personality disorder (BPD), other personality disorders, and depression were examined prospectively in a community sample of 142 late adolescent women. Although BPD symptoms predicted 4-year romantic dysfunction (romantic chronic stress, conflicts, partner satisfaction, abuse, and unwanted pregnancy), the associations were not unique to BPD. Instead, relationship dysfunction was better predicted by a cumulative index of non-BPD Axis II pathology. Depression did not predict outcomes uniquely when Axis II symptoms were included, except in the case of unplanned pregnancy. The results suggest that although BPD is associated with relationship dysfunction, the effect is a more general phenomenon applying rather broadly to Axis II pathology. The results also highlight the importance of subclinical psychopathology in the construction of early intimate relationships.     

Does who you marry matter for your health? Influence of patients' and spouses' personality on their partners' psychological well-being following coronary artery bypass surgery

Research suggests that presurgical personality attributes influence postsurgical well-being in both patients and their spouses in the context of coronary artery bypass grafting (CABG) surgery. The authors hypothesized that a spouse's characteristics would influence a partner's psychological well-being, regardless of whether he or she was the patient or the caregiver. In this study, 111 male patients and their caregiver spouses completed measures of neuroticism, optimism, perceived marital satisfaction, and depression prior to elective CABG. Follow-up was conducted at 18 months. As expected, higher caregiver presurgical neuroticism predicted higher patient depressive symptoms at follow-up, with caregiver's concurrent 18-month affect controlled for. Likewise, higher patient presurgical neuroticism predicted higher caregiver depressive symptoms at follow-up. Additionally, higher patient presurgical depressive symptoms and lower presurgical optimism contributed to greater caregiving burden. Relationship satisfaction moderated these effects. These results suggest that partners' personality traits are important determinants of both patients' and their caregiving spouses' well-being.     

Associations between prenatal maternal mental health indices and mother–infant relationship quality 6 to 18 months’ postpartum: A systematic review

Maternal mental disorders can significantly impact on children's psychosocial and psychological development, incurring substantial ongoing economic and personal costs. A key mediating mechanism is mother–infant relationship quality (MIRQ). Research studies and perinatal mental health screening initiatives have predominantly focused on depressive symptoms and perinatal depression as predictors of MIRQ. While maternal depression is associated with suboptimal MIRQ, the findings have not been consistent. Personality characteristics are associated with parenting and proneness to depression, presenting a potential addition to prenatal mental health assessment. We conducted a systematic review of studies that have examined the link between prenatal depressive symptoms and/or personality characteristics with postnatal MIRQ. Our findings suggest that both maternal personality traits and depressive symptoms measured in early pregnancy are associated with postnatal MIRQ. A measure of personality characteristics may enhance prenatal mental health assessment, affording opportunities for targeted intervention commencing in pregnancy to improve MIRQ, parenting, maternal mental health outcomes, and infant psychosocial and psychological development, and thereby contributing to the reduction of human and economic cost burdens.     

Stop Thinking and Start Doing: Switching From Cognitive Therapy to Behavioral Activation in a Case of Chronic Treatment-Resistant Depression

Several recent investigations have demonstrated that Cognitive Therapy (CT) and Behavioral Activation (BA) are both efficacious treatments for depression (Butler, Chapman, Forman, & Beck, 2006; Dimidjian et al., 2006; Dobson, 1989; Gloaguen, Cottraux, Cucherat, & Blackburn, 1998; Hollon, Thase, & Markowitz, 2002; Jacobson et al., 1996). This investigation focuses on the treatment of Mr. X, a 62-year-old man with chronic treatment-resistant depression and comorbid personality pathology. After a course of 21 sessions of CT, treatment was switched to BA. We present daily mood data from 147 days of each treatment. Generalized least squares analyses of these time series data demonstrated that BA was associated with improved mood and these results were supported by clinical observation of improved functioning during the course of BA. We hypothesize that efforts at cognitive restructuring had an iatrogenic effect on this client and paradoxically triggered depressive rumination; these failed efforts provided further evidence in support of his underlying defectiveness schema. We also speculate that this client's dependent personality ran counter to CT's emphasis on autonomous homework assignments. Future randomized clinical trials are needed to investigate if nonresponders to CT benefit by switching to BA.