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TitleDepression And Personality: Conceptual And Clinical Challenges
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LanguageEnglish
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Table of Contents
                            CONTENTS
CONTRIBUTORS
PREFACE
INTRODUCTION
PART I: CONCEPTUAL ISSUES
	1 PERSONALITY AND TEMPERAMENT: HISTORICAL PERSPECTIVES
	2 THE PSYCHOBIOLOGY OF PERSONALITY DISORDERS
	3 PERSONALITY TRAITS/DISORDERS AND DEPRESSION: A SUMMARY OF CONCEPTUAL AND EMPIRICAL FINDINGS
	4 THE DEPRESSIVE PERSONALITY: PSYCHOPATHOLOGY, ASSESSMENT, AND TREATMENT
PART II: TREATMENT IMPLICATIONS
	5 THE IMPACT OF PERSONALITY ON THE PHARMACOLOGICAL TREATMENT OF DEPRESSION
	6 CLINICAL STRATEGIES FOR EFFICIENT TREATMENT OF MAJOR DEPRESSIVE DISORDER COMPLICATED BY PERSONALITY DISORDER
	7 REFRACTORY AND CHRONIC DEPRESSION: THE ROLE OF AXIS II DISORDERS IN ASSESSMENT AND TREATMENT
	8 BIPOLAR DISORDER AND PERSONALITY: CONSTRUCTS, FINDINGS, AND CHALLENGES
	9 EVALUATING THE CONTRIBUTION OF PERSONALITY FACTORS TO DEPRESSED MOOD IN ADOLESCENTS: CONCEPTUAL AND CLINICAL ISSUES
	10 THE IMPACT OF PERSONALITY DISORDERS ON LATE-LIFE DEPRESSION
INDEX
	A
	B
	C
	D
	E
	F
	G
	H
	I
	J
	K
	L
	M
	N
	O
	P
	Q
	R
	S
	T
	V
	W
                        
Document Text Contents
Page 2

DEPRESSION AND
PERSONALITY

Conceptual and Clinical Challenges

Page 169

142 DEPRESSION AND PERSONALITY

ity disorders typically see a psychopharmacologist for medication and
a psychologist or a social worker for psychotherapy. This approach has
advantages and disadvantages. It may be cost-effective if the psychia-
trist is much more skilled in medication treatment than in the delivery
of empirically supported psychotherapeutic approaches (which many
but not all psychologists practice today). Split treatment may also be ap-
propriate if the psychiatrist has concerns that a combination treatment
may dilute the rigor of either the delivery of the psychotherapy or the
pharmacotherapy. Nonetheless, a split-treatment approach is also asso-
ciated with limitations. It requires close communication and mutual re-
spect between the different clinicians in order to provide the patient
with clear and consistent information. This need for close communica-
tion may be a problem for very busy psychopharmacologists, who treat
a large number of patients. The allocation of regular time for communi-
cation is crucial for patients with personality disorders, who are prone
to cognitive distortions such as dichotomous thinking. In situations
where clinician communication and mutual respect are not present, it is
not uncommon to observe splitting as well as devaluation of one of the
therapies undermining the overall treatment. Our strong opinion,
based on personal experience, is that psychiatrists who provide medi-
cation treatment combined with an active, skills-oriented, empirically
supported psychotherapeutic approach offer the depressed Axis II pa-
tient the most satisfactory treatment. Future research should delineate
whether this combined treatment is actually feasible and cost-effective.

Once a patient has responded to medication, it is very important to
empower him or her by emphasizing that the patient gets the credit for
the changes that have occurred, not the medications. It is critical for the
clinician to emphasize that the medication allowed the patient to han-
dle a specific stressful situation and to function in spite of the difficul-
ties that were encountered. It is also important that patients see
themselves as active participants who have the opportunity to become
their own pharmacotherapists:

Ms. C: Last night when I felt alone and discouraged, I felt like cutting
again but didn’t.

Psychiatrist: Do you know why you didn’t?
Ms. C: I think the medications are making a big difference.
Psychiatrist: Let’s look at that. I’m glad that although you felt like cut-

ting, you didn’t. I agree that the medications may be helping. But
I think that perhaps you’re not taking enough credit for yourself.
I think the work you’ve been doing, becoming more aware of the
triggers that overwhelm you, is very important. The meds may be
helping, but you’re the one doing the work.

Page 170

Major Depression With Personality Disorder: Clinical Strategies 143

With regard to medication and major depression and personality
disorder patients, it is important to target Axis I disorders primarily.
However, if the patients do not meet the full criteria of Axis I, it is rea-
sonable to target symptom clusters and treat appropriately. Augmenta-
tion strategies are worth considering as well. In some depressive
patients who have personality disorder and micropsychotic episodes,
atypical neuroleptics are worth considering. Atypical neuroleptics help
as a third-line augmentation strategy for major depression (Kennedy et
al. 2001), but they also may help with micropsychotic episodes, with
mood stabilization, and as “ego glue” (a term loosely used clinically).
Given the relationship between major depression and borderline per-
sonality disorder and the possibility that some such patients are bipolar
spectrum disorder patients, atypical neuroleptics may have a mood-
stabilizing function. Traditional mood stabilizers such as lithium and
divalproex can be considered, although one is more hesitant using lith-
ium because of its lower therapeutic index.

Thus, with regard to medication issues and depressed patients with
personality disorder, it is important not to be blinded by conceptual
frameworks that could cause clinicians to overlook Axis I or Axis II is-
sues. Seeing only the Axis I issue deprives clinicians of considering the
Axis II issues that need psychotherapeutic intervention. Seeing only
Axis II issues deprives clinicians of using pharmacotherapy to help
with negative affective states as well as with affective dysregulation.

In Ms. C’s case, her psychiatrist was guided by the fact that Ms. C’s
sister had a history of bipolar II disorder, and Ms. C herself had many
symptoms consistent with a bipolar spectrum disorder. Other impor-
tant considerations were Ms. C’s history of erratic medication adher-
ence and her potential for impulsive self-destructive behavior. Ms. C’s
sister had a positive response to fluoxetine combined with lamotrigine,
and this regimen was initiated with Ms. C. Unfortunately, despite very
slow dosage titration, she developed a severe rash on lamotrigine and
this was discontinued. A trial of fluoxetine combined with olanzapine
was then initiated and after 12 weeks was successful in relieving much
of the patient’s depressive and anxiety symptoms.

Principles of Psychotherapy for Patients With
Depression and Personality Disorder

As noted earlier, patients with depression and personality disorder gen-
erally require longer term treatment than patients with depression un-
complicated by severe personality dysfunction. One of the special

Page 338

Index 311

Sociotropy/dependency (SOC-DEP)
personality dimension, 47–49,
52, 54, 61

Spectrum models, of personality-
depression relationship, 45–46,
53, 57, 217, 219. See also Bipolar
spectrum disorder

Split treatment, for major depression
complicated by personality
disorders, 142

Spontaneous mania, and bipolar
disorder, 206

Spurzheim, Johann Gaspar, 4
Stability

diagnosis of depressive
personality disorder and, 69

of personality over time, 231
of personality in young adults,

234–235
Staged therapy, for major depression

with personality disorders,
127

Stanley Foundation Bipolar
Network, 215, 219

State dependence model, of
personality-depression
relationship, 238

Strategic approach, to treatment of
major depression with
personality disorders, 126–127

Stress. See also Life events
genetics and response to, 165
relationship between depression

and personality disorders
and, 160, 165

Stroke, and depression, 274–275
Structured Clinical Interview for

DSM-III Personality Disorders
(SCID), 108, 191

Structured Clinical Interview for
DSM-IV Axis II Personality
Disorders (SCID-II), 83, 192, 213,
214, 215, 253

Structured Interview for DSM
Personality (SIDP), 188–189

Structured Interview for DSM-IV
Personality (SIDP-IV), 83–84

Structured Interview for the Five
Factor Model (SIFFM), 85

Subclinical model. See Spectrum
models

Substance abuse. See also Alcohol
abuse

in adolescents with personality
disorder and depression,
255

borderline personality disorder
and, 205

Suicide and suicidal ideation
antidepressant use in adolescents

and, 255–256
bipolar disorder and, 168, 215
elderly patients and, 275
impulsivity in depression and

risk of, 28
major depressive disorder with

comorbid personality
disorder and, 103, 137–138,
271

Supportive psychotherapy, for
depression in elderly, 280

Symptom presentation, and
personality factors in major
depressive disorder, 103,
104

Systematic Treatment Enhancement
Program for Bipolar Disorder
(STEP-BD), 219

Temperament. See also Personality
bipolar disorder and, 209–213
classification of personality and,

158–161
definition and concepts of, 3–4, 8–

13
depression in adolescents and,

243–244
seven-factor model of, 101–102
theoretical and referential

meanings of, 15–17

Page 339

312 DEPRESSION AND PERSONALITY

Temperament and Character
Inventory (TCI), 101–102, 103,
109, 269

Tendencies, and definition of
personality, 230

Therapeutic alliance, and major
depression complicated by
personality disorders, 139, 147

Therapy-interfering behaviors, and
major depression complicated
by personality disorders, 135–
140

Thiothixene
borderline personality disorder

and, 30
schizotypal personality disorder

and, 34
Thomas, Alexander, 9–10
Trait markers, of bipolar disorder,

209–213. See also Personality
traits

Tranylcypromine, 22
Treatment. See also Combination

treatment; Compliance;
Countertransference;
Electroconvulsive therapy;
Integrative treatment;
Pharmacotherapy;
Psychotherapy; Relapse
prevention; Split treatment;
Therapeutic alliance

chronic depression comorbid
with personality disorders
and integrative, 165–175

of depression in adolescents, 247–
257

of depression in elderly,
276–283

of depressive personality
disorder, 72–73, 85–88

of major depressive disorder with
comorbid personality
disorder, 102–107, 121–151

personality factors in bipolar
disorder and, 213–217, 218

Tricylic antidepressants (TCAs). See
also Antidepressants

chronic depression comorbid
with personality disorders
and, 167

major depressive disorder and,
108, 109

psychobiology of affective
instability and, 21,
22

Tridimensional Personality
Questionnaire (TPQ), 101, 106,
109, 110, 210–211, 269

Tripartite model, of personality-
depression relationship,
49–53

Tryptophan hydroxylase (TPH), and
aggression, 27

Twin studies. See also Genetics;
Family studies

of borderline personality
disorder, 24

of personality and major
depression in women,
53

Venlafaxine, 167
von Zerssen, D., 194, 201
Vulnerabilities, to psychiatric

disorders
assessment of depression in

adolescents and, 241–246,
248–252

definition of personality and,
230–234

major depressive disorder and,
97–98

personality in adolescents and,
234–241

Vulnerability models, of personality-
depression relationship, 46, 47–
49, 57, 58, 217

Wisconsin Card Sorting Test
(WCST), 33, 34

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