Personality type and depression - Black Dog Institute

28 mo update clinical reviewPersonality type and depressionFurther research conducted at the formerMood Disorders Unit and, later, at theBlack Dog Institute in Sydney has identifiedat least eight personality stylesof salience to non-melancholic depression,which is one of the most frequentlyoccurring categories of mood disordersand accounts for about 90% of depressionsseen in clinical practice.Personality styles, which usually manifestin the cognitive and behaviouraldomains, are affected by psychosocialstressors, which, in turn, can compromisean individual’s self-esteem andability to cope, thus exacerbating theimpact of the original stressor and causingdepression onset.In addition, particular personalitystyles can sometimes increase the likelihoodof stressful events.For example, an individual with arejection-sensitive personality style, whois prone to interpreting events with a biastowards rejection and abandonment byothers, is more likely to manifest clingy,dependent behaviours, which make themmore likely to actually be rejected byothers.Although, and as noted, this cycle isparticularly relevant for the developmentand maintenance of non-melancholicdepressions, dysfunctional personalitycharacteristics can also play a significantrole in the maintenance of othertypes of mood disorders, including melancholicdepression and bipolar disorder.While the primary drivers for these typesof mood disorders are considered to beneurobiological, maladaptive cognitionsand behaviours can still impact on thecourse of recovery.For example, individuals with melancholicdepression and a perfectionist personalitystyle may initially respond wellto antidepressant medication, but continueto criticise themselves about sufferingfrom depression and worry aboutthe process of recovery. This level of selfcriticismand worry may be sufficient toretard their rate of improvement fromthe depression and/or increase their likelihoodof relapse.Different personality stylesThe personality styles identified in thesubtyping model for depression are perfectionistic,socially avoidant, anxious worrier,irritable, socially reserved, rejectionsensitive, self-focused, and self-critical.These personality styles are thoughtto be subsumed by the neurobiologicalunderpinnings of temperament, such thatthose with the more ‘externalising’ constructsof personality styles, for example,irritable or self-focused, are more likely to‘blow up’ when upset or engage in recklessor impulsive behaviours when depressed.While individuals with these types ofpersonality styles are more likely to experiencetransient depressive episodes, thepeople around them may experience ‘collateraldamage’ as a consequence of theireternalising response style.In contrast to ‘externalisers’, personalitystyles that reflect an ‘internalising’construct, such as the anxious worrier orrejection sensitive, are more likely to stewover specific events, worry and seek reassurancefrom others.As noted earlier, personality stylescan influence vulnerability to depressiveepisodes, exposure to environmentalstressors, symptom patterns in non-melancholicdepression and response to treatment.These points can be best illustratedwith the two most common personalitystyles seen by clinicians, that of the anxiousworrier and the perfectionist.Treating the anxious worrierIndividuals with an anxious-worryingpersonality style are characterised by highlevels of autonomic arousal, a tendency toworry, and increased vulnerability to nonmelancholicdepression.When depressed, they typically presentwith significant physical and cognitivesymptoms of anxiety, including ruminations,catastrophic thoughts and self-doubt.Their chronic worry may result inrepeated reassurance-seeking from familymembers, friends and health professionals.In addition, a range of avoidancebehaviours may complicate their clinicalpresentation and result in lifestyle restrictions,such as avoiding social situationsor taking on new challenges and responsibilitiesat work.Treating an individual with an anxious-worryingpersonality can includemedications such as SSRIs to reduce anxietyand curb worry, together with a rangeof psychological interventions to addresstheir concerns and negative thinkingstyles.These psychological strategies caninclude relaxation and meditation exercises,problem-solving strategies, goalsettingand time-management skills, andcognitive behavioural therapy in order tolearn how to challenge and change maladaptivecatastrophic thoughts.Perfectionists donot usually benefitfrom antidepressantmedication.iStockphoto.comTreating the perfectionistThe anxiety often observed in individualswith a perfectionistic personalityis somewhat different in aetiology tothat for the anxiety worrier. While theanxious worrier may stew over currentevents, experience catastrophic thoughtsabout events and seek reassurance fromothers, perfectionists typically are proneto self-criticism, fear of failure and makingthe ‘wrong’ decisions, ruminationsover past behaviours and feeling overwhelmed.Perfectionists are also less likely tosolicit others for help or to seek professionaladvice when depressed.‘Behavioural paralysis’ and procrastinationare usually related to anxietiesover making a wrong decision or notbeing able to complete a task as well asexpected.Unlike anxious worrying, perfectionismas a personality characteristicis usually somewhat protective againstdepression onset. Their self-imposedhigh standards, self-discipline and controlnot only ensure high productivityand achievement, but also lessen thelikelihood of being exposed to, andbecoming overwhelmed by, unexpectedstressors. However, once they are overwhelmedby uncontrollable stressors,perfectionist individuals are slower torecover and return to their previous levelof functioning.In treatment for a depressive illness,perfectionists do not usually benefitfrom antidepressant medications asthey prefer to be ‘in control’ rather thansurrendering such control to medication.In addition, their depression is generallyunderpinned by a sense of failingto meet goals or standards ratherthan being due to emotional dysregulation(which is prevalent in anxiousworrying).Finally, the need for control actsagainst any likelihood for spontaneousremission and improvement, thus weakeninga possible springboard for a therapeuticresponse.Psychological therapies also face significantchallenges when used with theperfectionist patient, who may experiencedifficulty in trusting their GP ortherapist and forming any, let alone astrong, treatment alliance. Hence thewidespread perception among cliniciansthat, once depressed, perfectionists aredifficult to treat and that their depressionsdo not quickly remit.13 APRil 2012

clinical review update mo29Treating biological depressionFor the more biologically based mooddisorders, personality styles can alsoinfluence the ways in which individualscope with their depression and the typesof psychological interventions that maybe helpful once the acute symptoms havebegun to remit.For example, an individual with amelancholic depression together with asocially avoidant personality style maybecome more avoidant while depressed,but is unlikely to be the life and soulof a party even when their depressionimproves.Although their therapist may referthem for group social skills training orother group-based programs, an individualwith a socially avoidant personalitystyle is unlikely to comply with such atreatment approach despite the obviousbenefits.Psychological strategies will firstlyneed to harness their motivation toaddress their anxieties about social situationsand, secondly, apply skills trainingor cognitive restructuring on anindividual basis, at least until they feelcomfortable attending any group-basedinterventions.Recurrent depressive episodes orchronic depression can reflect an underlyingpersonality style influencing persistenceof the depressive disorder.KEY POinTSn There are three subtypes ofdepression: psychotic melancholia,melancholic depression and nonmelancholicdepression.n Non-melancholic depression is drivenby stress, personality styles anddysfunctional coping repertoires.n Psychotic melancholia andmelancholic depression are thoughtto be primarily driven byneurobiological pathways.Personality styles vs personality disordersOne important point to remember is thatpersonality styles are not synonymous withpersonality disorders. Personality styles areenduring characteristics that affect the wayin which individuals perceive themselves,understand life events, cope with stress andinteract with others. In this way, personalitystyles may be adaptive for an individual’slifestyle or social and cultural niche, ormaladaptive if they lead to ongoing psychosocialdifficulties.Personality styles are shaped by socialand cultural influences, early life experiencessuch as quality of parental care orexperiences of abuse, as well as ‘temperament’(i.e. the neuronal ‘hardwiring’ thatunderpins the expression of certain behaviouralcharacteristics such as shyness).In contrast, personality disorders arehighly dysfunctional ways of thinking,behaving, coping with stressful life eventsand interacting with others. Individualswith clearly defined personality disordersexhibit significant impairments in their lives.While personality styles themselves areconsidered to be unchangeable, the ways inwhich they are expressed may be open tomodification. For example, an individualwith a socially reserved personality stylemay find it difficult to confide in or trustothers. They may have a number of superficialfriends, but find interactions with themneither rewarding nor uplifting. They mayyearn for emotional closeness, but not possessthe necessary skills to develop closerfriendships or deeper relationships.If sufficiently motivated, an individualwith a socially reserved personality stylemay be instructed in skills to challenge theirdysfunctional thoughts about trusting otherpeople, express their feelings to others, andorganise social occasions in which to practisethese skills.For clinicians, helping patients shift theirmaladaptive thoughts and behaviours tomore adaptive expressions can be helpful inreducing distress and promoting recoveryfrom mood disorders (e.g. various maladaptivethoughts are associated with perfectionism,such as harsh self-criticism and loss ofself-esteem when facing failure).Perfectionist individuals tend to investtheir identity and sense of self in the successfulcompletion of tasks, and thus tend to‘beat themselves up’ over perceived failure.Helping perfectionist individuals to developa strong self-identity that is independentof task completion can help to break thevicious cycle comprising fears of failure,harsh self-criticism and loss of self-esteem.Assessment and managementPersonality styles can be reliably (andanonymously) assessed using the BlackDog Institute’s Temperament and PersonalityQuestionnaire (T&P questionnaire),which is available on the website (www.black doginstitute.org.au).The T&P is a validated self-reportmeasure that assesses all eight personalitystyles found in depressive disorders. It providesa score for each of the styles, so it ispossible for individuals to load highly onmore than one (e.g. social avoidance andrejection sensitivity).Information about high scores on eachof the personality subscales can be usedto inform psychological approaches tomanaging mood disorders and preventingrelapse.Another tool developed by the institutefor GPs is the Mood Assessment Program(MAP), which is aimed at improving diagnosticaccuracy in depression subtypes andin diagnosing bipolar disorder. Apart fromincorporating the T&P questionnaire, theMAP also inquires about current and paststresses, thus providing clinicians with aclearer picture of how these personalitystyles may have impacted on the developmentand maintenance of a mood disorder.In addition, the Black Dog Institute runstraining workshops for GPs and otherhealth professionals overviewing the diagnosisand management of mood disorders.These courses detail the issues involved inassessing and treating patients whose personalitystyles have significantly impactedon the development and maintenance of amood disorder. This is especially relevantfor those patients whose depressions do noteasily remit and where recurrent episodesare ongoing features. For the references and patient handout,‘Depression’, go to medobs.com.au