Download Managing mood disorders and comorbid personality disorders

Managing mood disorders and comorbid personality
disorders
Priya Bajaj and Peter Tyrer
Purpose of review
To examine the influence of personality disorder
comorbidity on the general treatment of mood disorders.
Recent findings
Personality disorders generally have a negative influence on
outcome of mood disorders, both unipolar and bipolar.
When the personality features are addressed, however, the
outcome is less negative. Recent studies suggest a special
role for psychological and educational therapies in the
treatment of these comorbid disorders.
Summary
The assessment of, and attention to, the management of
personality disorder as well as concurrent mood disorder
may improve outcome.
Keywords
bipolar disorder, depression, mood disorder, outcome,
personality disorder
Curr Opin Psychiatry 18:27–31 # 2005 Lippincott Williams & Wilkins.
Department of Psychological Medicine, Imperial College, London
Correspondence to Professor Peter Tyrer, Department of Psychological Medicine,
Imperial College (Charing Cross Campus), St Dunstan’s Road, London W6 8RP,
UK
Tel: +44 207 386 1233; fax: +44 207 386 1216; e-mail: [email protected]
Current Opinion in Psychiatry 2005, 18:27–31
# 2005 Lippincott Williams & Wilkins
0951-7367
Introduction
The relationship between mood disorders and pathological personality features or disorders is an important
clinical issue and has been relatively neglected until just
recently. Mood disorders are frequently recurrent and
refractory to treatment and the presence of maladaptive
personality features is often seen as a poor prognostic
indicator. The presence of a comorbid personality disorder has been related to increased suicide risk, more
frequency of residual symptoms, greater frequency of
mixed and depressive features, worse therapeutic
response and more adherence problems [1–3]. One of
the most vexing questions has been the implications of
personality features and disorders for treatment outcome
in mood disorders. This question has been studied frequently in major depressive disorder but remains almost
unstudied in bipolar disorder [4].
Most of the studies conducted in the past have recorded
personality disorder, but did not make any allowance for
it in planning treatment. Now that specific treatment, or
in some cases, more specific approaches to management
rather than treatment, have been developed for personality disorder, it is important to know when patients are
comorbid for axis I and II conditions, as this could
influence the delivery and type of treatment and be
crucial in successful response [5].
Depression and outcome in personality
disorder
Many studies have been carried out on the outcome of
major depressive disorder and it is not surprising that
personality has been included as an important outcome
variable. The published studies show an important separation depending on the theoretical orientation of the personality measurement. One perspective is based on
research that examines the influence of personality traits
covering the full range of personality variation. The dominant current model of normal personality is commonly
known as the ‘Big Five’ [6] (the five are extraversion,
neuroticism, openness, conscientiousness and agreeableness) and one of these, neuroticism, has been investigated
frequently in major depressive disorder. Others have used
Cloninger’s Temperament and Character Inventory [7] in
the same way. The second approach has been to define
personality disorder as a separate entity and record the
outcome of those with and without personality disorder,
even though it is now accepted that personality abnormality does not lend itself to simple dichotomy.
27
28 Mood disorders
The methodology of recording outcome is also not
without controversy. Some researchers define outcome
in a bimodal fashion, others use a continuum. Whether
or not personality pathology significantly worsens outcome in patients with major depression varies by study
design and there is also a suspicion that depressed
patients with personality pathology are less likely to
receive adequate treatment in uncontrolled studies.
Finally, studies rarely control for depression characteristics (e.g. chronicity, severity) that may influence outcome and be related to personality pathology. Two
recent major reviews on the subject have yielded contrasting findings. One, using the dimensional approach
to personality, suggests no benefit of personality pathology but that ‘comorbid personality pathology should not
be seen as an impediment to good treatment response’
[8] (p. 359); the other, using a metaanalysis of studies in
which patients were separated into those with and
without personality disorder, concluded that the odds
on having a poor outcome with personality disorder were
2.3 times greater than if no personality disorder were
present (Newton-Howes G, Tyrer P, Johnson T, unpublished data).
Patients with major depression and concurrent personality disorder typically have more severe symptoms,
longer duration of symptoms and earlier age at illness
onset, and if these differences are not taken into account
it may unfairly imply a poor outcome in this group [3,5,9].
The nonmelancholic aspect of depression and comorbid
personality disorder has been found to be associated with
an increased suicidal vulnerability [10], and when allowance is made for baseline differences, personality disorder emerges as an important predictor of continuing
pathology in the long term [11].
Personality disorder in bipolar patients
Despite the suggestion that personality features are poor
prognostic indicators in general depression, less research
has addressed these questions in bipolar disorder. Conceptual models linking personality and bipolar disorder
are relatively underdeveloped compared with models for
major depressive disorder. The limited findings that are
available from small studies are supportive of the notion
that personality pathology influences outcome negatively [12]. Personality disorder traits predict poorer
medication compliance among bipolar adults [13,14],
and the social support that buffers against relapse is
lacking [15]. Bipolar patients with personality disorders
also spend more days in the hospital in a given year [16],
are less likely to achieve symptomatic recovery [17],
have more severe mood disorder symptoms, and function at a lower level than those without personality
disorders. Comorbid bipolar patients are more likely
to have suicidal ideation [18] than single diagnosis
patients.
Personality disorders are often overdiagnosed in bipolar
patients, as some clinical features of bipolar acute episodes may overlap with criteria for personality disorders,
particularly borderline, leading to diagnostic confusion
and sometimes to inadequate treatment [19,20].
Symptoms such as affective instability, impulsivity, disinhibition on antidepressants and genetic loading with
bipolarity are shared by both bipolar II and borderline
personality disorders [21], which inevitably leads to
confusion. The incidence of comorbid personality disorder ranges from 45 to 65%, with borderline personality
as the most prevalent, followed by histrionic personality
disorder [22]. To avoid misdiagnosis and overlap, the
presence of a personality disorder in a bipolar patient
should be assessed only during the euthymic phase.
Surprisingly, the literature on the efficacy of combined
approaches for this common condition is almost nonexistent, with only psychoeducation being tested formally.
Group psychoeducation improves the clinical outcome of
bipolar illness by preventing recurrence of any polarity. A
subanalysis was conducted from a single-blind, randomized, prospective clinical trial on the efficacy of group
psychoeducation in bipolar I patients over 2 years. All
bipolar patients recruited fulfilled criteria for any personality disorder as per the DSM-IV. The most striking
result was the poor outcome of comorbid bipolar patients,
as all patients in the control group relapsed within the
2-year follow-up. One-third of this difficult-to-treat population seemed to have some clear benefit from their
inclusion in a psychoeducation program for bipolar disorders. The authors concluded that an intervention
focused on the special needs of this subgroup would
perhaps be more efficacious [20].
Trials of various psychotropic medications have been
shown to be of inconsistent benefit in borderline personality disorder, including atypical antipsychotics, typical
antipsychotics, anticonvulsants and antidepressants. The
treatment response of noncomorbid bipolar and comorbid
bipolar patients to lamotrigine was studied retrospectively in a sample of 37 patients. The exclusion criteria
included rapid cycling; recent alcohol abuse or dependency and personality disorder severe enough to interfere
with the protocol. The results highlighted a 40% reduction in the dimensions of borderline personality disorder
during lamotrigine treatment, without significant differences between affective and nonaffective dimensions
[21].
Treatment of depression and comorbid
personality disorder
Most of the studies conducted to date focus on the impact
of personality disorder on short-term, acute treatment for
depression. The methodological problems which occur in
these studies include controversies centred on validity of
Managing mood disorders Bajaj and Tyrer 29
assessing axis II psychopathology while patients are in an
acute axis I episode. Depressive mood states are known to
transiently affect the appearance, expression and assessment of personality pathology. Most published studies do
not control for depression characteristics that may both be
related to personality disorder and influence outcome.
Pharmacotherapy in depressed patients with personality
disorders was found to produce significantly poorer
results in comparison with patients without personality
disorders [22]. However, personality disorders respond to
treatments for depression even, in some cases, when the
depression itself has not improved. Some personality
disorders improve more than others, suggesting that there
may be variable relationships between depression and
types of personality pathology. Large controlled treatment studies continue to show no overall effect of
comorbid personality disorders on treatment outcome
for depression, although smaller uncontrolled studies
reported a modest negative effect. Treatment-specific
effects are seen such as patients with cluster B personality
disorders responding less well to tricyclic antidepressants
[23]. Some studies have found that patients with cluster
A or cluster B pathology show less satisfactory results in
comparison with cluster C symptoms [24–26].
A large double-blind study was conducted to compare the
efficacy of sertraline and imipramine in the treatment of
chronic major and double depression and the differential
effect of axis II comorbidity on clinical outcome. The
latter was found to have minimal or no effect on antidepressant response for both the drugs. Also, the presence of comorbidity with personality disorder did not
reduce the improvement in perceived quality of life or in
measures of functional status. This was one of the most
surprising findings, since one might have hypothesized
that the maladaptive coping that is central to an axis II
disorder might have had a deleterious effect on the
normalization of psychosocial or quality-of-life measure.
Even the presence of two or more disorders on axis II had
no effect on medication tolerability or premature study
discontinuation due to adverse effects. In fact, the reverse
was found to be true. Lastly, axis II comorbidity was
associated with a somewhat slower time to response. The
authors concluded that the current results apply only to
pharamacological treatment and they could not be generalized to cognitive–behavioural or other psychotherapies. An important limitation of the study was that there
was a lack of an independent assessment of personality
status by a reliable informant [27].
The effects of personality pathology on maintenance
treatment outcome for depression were studied in a
sample of 233 women over a period of 2 years. Levels
of personality pathology obtained at the pre-maintenance
assessment were found to significantly predict both the
likelihood of depression recurrence and time to recurrence over a 2-year course of maintenance therapy. Fortyone percent of personality disorder patients experienced
a major depressive disorder recurrence, with nearly all
patients recurring within the first year of maintenance
treatment, in comparison to the 20% recurrence rate
among the nonpersonality disorder group. The only
clinical feature related both to personality disorder status
and maintenance treatment outcome during the acute
treatment phase was the use of an adjunctive selective
serotonin reuptake inhibitor to achieve remission of the
acute depressive episode [19].
The effects of specific comorbid personality disorder on
the outcome in major depression were investigated in a
24-month prospective follow-up study among patients
with or without cluster C personality disorder. The poor
recovery of those with personality disorder was apparent
throughout the 24 months of follow up. One of the
limitations of this study was the small sample size of
90 patients. Overall, cluster C patients did not respond as
completely or as quickly as patients with pure major
depressive disorder [28].
Much less is known about the results of psychotherapy in
depressed patients with personality pathology. Poorer
results have been obtained in patients with personality
disorder among depressed older patients using cognitive–
behavioural or psychodynamic therapy [29].
The effects of personality pathology on the efficacy of
pharmacotherapy and combined therapy were explored
in a study in Amsterdam. Combined therapy was found to
be more effective in patients with personality pathology
and this important finding needs to be confirmed as it
could lead to the formal recommendation that comorbid
depressed and personality disordered patients should
be treated preferentially with combined treatment
approaches that include psychotherapy. The methodology of the study was not specific enough to make unambiguous interpretations regarding the mechanisms of
effectiveness. The possible explanation given by the
authors for improved results with combined therapy
was the characteristics of the form of psychotherapy
offered. Some of the important goals of short psychodynamic supportive psychotherapy were to hold out hope of
improvement, to enhance motivation, and to further a
positive working relationship. Presumably, the shortterm, structured nature of the therapy counteracts the
tendency towards regression that often characterizes
patients with personality pathology [30]. A similar
finding of an improvement in personality pathology
was found in patients treated for depression after
40 weeks. Combined therapy had produced significantly
better results than pharmacotherapy alone, especially for
cluster C disorders [31].
30 Mood disorders
Conclusion
Research on personality factors in major depressive disorder and results from emerging studies on these issues in
bipolar disorder point to important methodological concerns that must be addressed for studies in this area to be
useful. First, it is important that bipolar disorder is better
separated from borderline personality disorder. Second,
given the chronic nature of both bipolar disorder and
personality features, studies in this area are likely to be
more meaningful when carried out over the longer term,
and too many studies at present are short term. Third,
determination of outcome needs to be evaluated rigorously, consistently and with reliable and valid measures
with allowance for baseline values. It would help greatly
if the decision rules for choosing and classifying were
more consistent.
The merits of semi-structured personality interviews and
self-report measures are often debated in this context.
The arguments for semi-structured interviews are that
they have greater accuracy and agreement with each
other. Studies that are based on self-report inventories
may be reasonably reliable, but are based on the unproven notion that if you want to know why a person acts in a
particular way, you only need to ask and the person will
tell you [32].
The ongoing debate about the effect of mood on assessment of personality disorder has led some authors to
encourage clinicians to wait until the depression remits
to make a diagnosis of personality disorder. However, a
clinician is interested in making predictions and plans,
which usually means studying patients during an acute
illness. If measures of personality consistently predict
something about outcome or choice of treatment then
they are useful. Whether they are actually measuring
personality, chronic depression symptoms, or current
mood is of interest to a researcher rather than a clinician
[23]. In all this work it is useful to note that it is not
only symptoms that change over time; personality does
also [33].
References and recommended reading
Papers of particular interest, published within the annual period of review, have
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of special interest
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A randomized trial conducted over 40 weeks with a large sample size. This study
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