Response to Cognitive Therapy in Depression The Role of Maladaptive Beliefs and Personality Disorders Willem Kuyken School of Psychology University of Exeter Nicole Kurzer Department of Psychology University of Pennsylvania Robert J. DeRubeis Department of Psychology University of Pennsylvania Aaron T. Beck Department of Psychiatry University of Pennsylvania Gregory K. Brown Department of Psychiatry University of Pennsylvania ABSTRACT This study examined whether personality disorder status and beliefs that characterize personality disorders affect response to cognitive therapy. In a naturalistic study, 162 depressed outpatients with and without a personality disorder were followed over the course of cognitive therapy. As would be hypothesized by cognitive theory ( A. T. Beck & A. Freeman, 1990 ), it was not personality disorder status but rather maladaptive avoidant and paranoid beliefs that predicted variance in outcome. However, pre- to posttherapy comparisons suggested that although patients with or without comorbidity respond comparably to "real-world" cognitive therapy, they report more severe depressive symptomatology at intake and more residual symptoms at termination. There have been numerous randomized clinical trials that support the efficacy and effectiveness of cognitive therapy for depression ( A. T. Beck, Rush, Shaw, & Emery, 1979 ) across a variety of clinical settings (for a review, see Clark, Beck, & Alford, 1999 ; DeRubeis & Crits-Christoph, 1998 ). However, rates of dropout, treatment nonresponse, and relapse are considerable (e.g., Elkin et al., 1989 ; Evans et al., 1992 ) and demand better understanding of the factors associated with treatment response ( Scott, 1996 ). One factor that may account for some depressed patients' having a limited response to cognitive therapy is the presence of a comorbid personality disorder ( Pretzer & Beck, 1996 ). Several studies involving other treatment modalities have indicated that when depression is comorbid with a personality disorder it is associated with a poorer response to psychotherapy ( Perry, Banon, & Ianni, 1999 ), pharmacotherapy ( Sato, Sakado, Sato, & Morikawa, 1994 ), and combined treatment ( Pilkonis & Frank, 1988 ). Other studies, however, have not supported this association (e.g., Black, Bell, Hulbert, & Nasrallah, 1988 ). In an effort to improve the treatment response for depressed patients with comorbid personality disorders, cognitive therapy has been adapted for these populations (e.g., A. T. Beck & Freeman, 1990 ; Young, 1994 ). Cognitive theory of personality disorders proposes that personality disorders comprise a relatively stable organization of cognitive, affective, behavioral, motivational, and physiological Journal of Consulting and Clinical Psychology © 2001 by the American Psychological Association June 2001 Vol. 69, No. 3, 560-566 For personal use only--not for distribution. Page 1 of 119/5/2001http://spider.apa.org/ftdocs/ccp/2001/june/ccp693560.htmlschemas for representing responses to external and internal demands ( Pretzer & Beck, 1996 ). These schemas are rigid, typically include avoidant strategies, and fail to process disconfirming inputs into the cognitive system. Pretzer and Beck have suggested that individuals with personality disorders have developed maladaptive cognitive processes and maladaptive behavioral strategies that render them more vulnerable to recurrent depression. Furthermore, each personality disorder is characterized by specific clusters of maladaptive beliefs. For example, individuals with an avoidant personality disorder might believe strong feelings are intolerable and thus should be avoided ( A. T. Beck & Freeman, 1990 ). For these patients, this belief affects how they process information, subsequently feel, and behave. Consistent with this theory, several researchers have reported that individuals with personality disorders have dysfunctional cognitions that are rigid and persistent even after a depressive episode remits ( Ilardi & Craighead, 1999 ; Zuroff, Blatt, Sanislow, Bondi, & Pilkonis, 1999 ). It follows that in cognitive therapy, patients with comorbidity may find it difficult to change their maladaptive beliefs. Therefore, researchers hypothesized that the rates of comorbidity would be higher among nonresponders and partial responders than among responders. Initial findings addressing this hypothesis have yielded conflicting results. The National Institute of Mental Health Treatment of Depression Collaborative Research Program involved 239 outpatients with major depressive disorder, 74% of whom also had a personality disorder ( Elkin et al., 1989 ). The presence of a personality disorder predicted a worse outcome in terms of socialfunctioning and self-report depressive symptoms at the end of treatment, but not in terms of work functioning or clinician-rated depressive symptoms ( Shea et al., 1990 ). In contrast, in a further randomized controlled trial and a naturalistic outpatient study, the presence of a personality disorder was not a significant factor in cognitive therapy outcome ( Hardy et al., 1995 ; Persons, Burns, & Perloff, 1988 ). Given these inconsistent findings, the present study examined whether personality disorders, and the specific maladaptive beliefs that characterize particular personality disorders ( A. T. Beck, Butler, Brown, & Dahlsgaard, 2000 ), are associated with a poorer treatment response to cognitive therapy. Specifically, we hypothesized that greater levels of maladaptive beliefs would be associated with the worse treatment outcome. We included both established categorical systems for diagnosing personality disorders and more recently developed theory-driven measures of maladaptive beliefs in personality disorders ( A. T. Beck & Beck, 1991 ). Method Sample The study participants were 162 outpatients who received cognitive therapy at the Center for Cognitive Therapy (CCT), University of Pennsylvania. The sample comprised 93 (57%) women and 69 (43%) men. The mean age of the sample was 33.61 ( SD = 11.91), ranging from 18—73 years old. Fifty-one (32%) participants were married, 4 (2.5%) were widowed, 16 (10%) were divorced or separated, and 91 (56%) were single (never married). Three (2%) patients indicated a range of 7th—11th grade as the highest level of education obtained, 17 (11%) had a high school diploma or its equivalent, 44 (27%) completed some college, 47 (29%) had a college degree, and 48
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