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