Comorbidity of Personality Disorders and Depression Implications for Treatment M. Tracie Shea Department of Psychiatry and Human Behavior Brown University Thomas A. Widiger University of Kentucky Marjorie H. Klein Department of Psychiatry University of Wisconsin–Madison ABSTRACT This article reviews naturalistic and controlled studies of the impact of comorbidity of personality disorders and depression on response to various forms of treatment. The findings support the common belief that personality disorders are associated with a poorer response to treatment for depression. In contrast, the limited data available suggest that the presence of depression may be a positive prognostic indicator for patients with borderline and antisocial personality disorder. There are insufficient data to draw conclusions regarding the influence of specific types of personality disorders on outcome with specific forms of treatment for depression. More specific assessment of personality disorders, particularly of possible underlying dimensions, is likely to be a more fruitful approach than the currently used categorical approach in identifying effective treatments for patients with personality disorders and depression. Correspondence may be addressed to M. Tracie Shea, Department of Psychiatry and Human Behavior, Brown University, Duncan Building, 700 Butler Drive, Providence, Rhode Island, 02906. Received: May 30, 1991 Revised: June 1, 1992 Accepted: June 29, 1992 The introduction of a separate axis for the diagnosis of personality disorders in the Diagnostic and Statistical Manual of Mental Disorders (3rd ed.; DSM—III; American Psychiatric Association, 1980 ), and the encouragement to make simultaneous diagnoses for syndromal (Axis I) and personality (Axis II) disorders, suggest a conceptualization of these conditions as distinct disorders. This conceptualization is reflected in the frequent use of the term comorbidity in reference to personality disorders and depression. As a result, there has been an increasing focus in recent years on the impact of the personality disorders on the treatment response and general course of Axis I disorders and, to a lesser extent, on the influence of Axis I disorders on the outcome of personality disorders. The goal of this article is to review and consider the implications of comorbidity of personality disorders and depression for treatment. The definition and criteria for depression and personality disorder, and current forms of treatment for each, are briefly outlined. We then consider the meaning of the term comorbidity, as applied to personality disorders and depression, in the context of various hypothesized relations between personality disorders and depression. Next we review the empirical findings on rates of comorbidity of personality disorders and depression and the impact of personality disorders on Journal of Consulting and Clinical Psychology © 1992 by the American Psychological Association December 1992 Vol. 60, No. 6, 857-868 For personal use only--not for distribution. Page 1 of 1911/27/2001http://spider.apa.org/ftdocs/ccp/1992/december/ccp606857.htmltreatment outcome for depression. The few studies that deal with the reverse effect (i.e., the impact of depression on course and treatment outcome of personality disorders) are also considered. Limitations of existing knowledge and research strategies are examined, and suggestions for future research directions are presented. Definitions The terms personality disorder and depression, as used in this article refer primarily to the disorders defined in the standard classification schemes, including the DSM , Research Diagnostic Criteria ( RDC; Spitzer, Endicott, & Robins, 1978 ), and International Classification of Diseases ( ICD; World Health Organization, 1978 ) systems. In the Diagnostic and Statistic Manual of Mental Disorders (3rd ed., rev.; DSM—III—R; American Psychiatric Association, 1987 ), depression is included among the mood disorders, which are divided into bipolar disorders and depressive disorders by the presence or absence of one or more episodes of mania or hypomania. Depressive disorders are further divided into major depression (one or more major depressive episodes) and dysthymia (a history of chronic depressed mood not meeting criteria for a major depressive episode; American Psychiatric Association, 1987 ). Most of the existing research on comorbidity of personality disorders and depression involves major depression (nonbipolar) or dysthymia. Unless otherwise noted, the use of the term depression in this article refers to nonbipolar depression. The few studies covered here that focus on patients with bipolar disorder are identified as such. In contrast to the depressive disorders, which can be (although are not necessarily) episodic and can onset at any age, personality disorders by definition are enduring, inflexible, and maladaptive patterns of traits and behaviors that are typically manifested by adolescence or early adulthood. The maladaptive behaviors and traits occur across abroad range of situations and cause significant and persistent functional impairment or personal distress. Disturbances are manifested in cognition (i.e., perception and interpretation of others, oneself, and events), affect (i.e., frequency, intensity, and appropriateness of emotional arousal and expression), control over impulses, and interpersonal functioning (i.e., relating to others and the ability to handle interpersonal situations). The personality disorders have been grouped conceptually by DSM—III and DSM—III—R according to three clusters, by similarity in features: (a) paranoid, schizoid, and schizotypal personality disorders, characterized by odd or eccentric behavior; (b) histrionic, narcissistic, antisocial, and borderline personality disorders, characterized by dramatic, erratic, or emotional behavior; and (c) avoidant, dependent, compulsive, and passive—aggressive personality disorders, characterized by anxious or fearful behavior. Each of the individual disorders are defined by a set of explicit criteria, and diagnosis requires manifestation of a minimum number of the criteria by early adulthood, manifestation of the maladaptive behaviors and traits in a variety of contexts, and significant impairment in social or occupational functioning or subjective distress. Consistent with the medical model approach to psychopathology, the DSM system has
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