Depressive personality disorder

Depressive Personality Disorder (also known as melancholic personality disorder) is a controversial psychiatric diagnosis that denotes a personality disorder with depressive features.

Originally included in the American Psychiatric Association's DSM-II, depressive personality disorder was removed from the DSM-III and DSM-III-R.^[1] Recently, it has been reconsidered for reinstatement as a diagnosis. Depressive personality disorder is currently described in Appendix B in the DSM-IV-TR as worthy of further study. Although no longer listed in the manual's personality disorder category, the diagnosis is included under the section “personality disorder not otherwise specified”.

While depressive personality disorder shares some similarities with mood disorders such as dysthymic disorder, it also shares many similarities with personality disorders including avoidant personality disorder. Some researchers argue that depressive personality disorder is sufficiently distinct from these other conditions so as to warrant a separate diagnosis.

Characteristics

The DSM-IV defines depressive personality disorder as "a pervasive pattern of depressive cognitions and behaviors beginning by early adulthood and occurring in a variety of contexts."^[2] Depressive personality disorder occurs before, during, and after major depressive episodes, making it a distinct diagnosis not included in the definition of either major depressive episodes or dysthymic disorder. Specifically, five or more of the following must be present most days for at least two years in order for a diagnosis of depressive personality disorder to be made:

• Usual mood is dominated by dejection, gloominess, cheerlessness, joylessness, and unhappiness
• Self-concept centers around beliefs of inadequacy, worthlessness, and low self-esteem
• Is critical, blaming, and derogatory towards the self
• Is brooding and given to worry
• Is negativistic, critical, and judgmental toward others
• Is pessimistic
• Is prone to feeling guilty or remorseful^[2]

People with depressive personality disorder have a generally gloomy outlook on life, themselves, the past and the future. They are plagued by issues developing and maintaining relationships. In addition, studies have found that people with depressive personality disorder are more likely to seek psychotherapy than people with Axis I depression spectrums diagnoses.

Recent studies have concluded that people with depressive personality disorder are at a greater risk of developing dysthymic disorder than a comparable group of people without depressive personality disorder.^[3] These findings lead to the fact that depressive personality disorder is a potential precursor to dysthymia or other depression spectrum diagnoses. If included in the DSM-V, depressive personality disorder would be included as a warning sign for potential development of more severe depressive episodes.

Researchers at McLean Hospital in Massachusetts looked at the comorbidity of depressive personality disorder and a variety of other disorders. It was found that subjects with depressive personality disorder were more likely than the subjects without depressive personality disorder to currently have major depression and an eating disorder. Subjects with and without depressive personality disorder were statistically equally likely to have any of the other disorders examined.

Axis I Disorders in Subjects With and Without Depressive Personality Disorder

	Present (N=30)		Absent (N=24)
Disorder	N	%	N	%	pa
Major Depression
Current	12	40	7	29	0.57
Lifetime	25	83	17	71	0.33
Bipolar Disorder
Current	2	7	2	8	1.00
Lifetime	2	7	4	17	0.39
Dysthymia
All Types	11	37	8	33	1.00
Primary early onset	5	17	5	21	0.74
Any mood disorder
Current	20	67	14	58	0.58
Lifetime	28	93	22	92	1.00
Substance use disorders (lifetime)	11	37	7	29	0.77
Anxiety disorders (lifetime)	15	50	11	46	0.79
Somatoform disorders (lifetime)	2	7	1	4	1.00
Eating disorders (lifetime)	7	23	1	4	0.06

Millon’s subtypes

Theodore Millon, a former professor of Harvard Medical School and University of Miami and a respected psychiatrist, identified five subtypes of depression.^[4][5] Any individual depressive may exhibit none, or one or more of the following:

• Ill-humored depressive, including negativistic (passive-aggressive) features. Patients in this subtype are often hypochondriacal, cantankerous and irritable, and guilt-ridden and self-condemning. In general, ill-humored depressives are down on themselves and think the worst of everything.
• Voguish depressive, including histrionic, narcissistic features. Voguish depressives see unhappiness as a popular and stylish mode of social disenchantment, personal depression as self-glorifying, and suffering as ennobling. The attention from friends, family, and doctors is seen as a positive aspect of the voguish depressive’s condition.
• Self-derogating depressive, including dependent features. Patients who fall under this subtype are self-deriding, discrediting, odious, dishonorable, and disparage themselves for weaknesses and shortcomings. These patients blame themselves for not being good enough.
• Morbid depressive, including masochistic features. Morbid depressives experience profound dejection and gloom, are highly lugubrious, and often feel drained and oppressed.
• Restive depressive, including avoidant features. Patients who fall under this subtype are consistently unsettled, agitated, wrought in despair, and perturbed. This is the subtype most likely to commit suicide in order to avoid all the despair in life. ^[6]

Not all patients with a depressive disorder fall into a subtype. These subtypes are multidimensional in that patients usually experience multiple subtypes, instead of being limited to fitting into one subtype category. Currently, this set of subtypes is associated with melancholic personality disorders. All depression spectrum personality disorders are melancholic and can be looked at in terms of these subtypes.

Criticisms of the Inclusion of Depressive Personality Disorder in the DSM-V

Similarities to Dysthymic Disorder

Much of the controversy surrounding the potential inclusion of depressive personality disorder in the DSM-V stems from its apparent similarities to dysthymic disorder, a diagnosis already included in the DSM-IV. Dysthymic disorder is characterized by a variety of depressive symptoms, such as hypersomnia or fatigue, low self esteem, poor appetite, or difficulty making decisions, for over two years, with symptoms never numerous or severe enough to qualify as major depressive disorder. Patients with dysthymic disorder may experience social withdrawal, pessimism, and feelings of inadequacy at higher rates than other depression spectrum patients. Early-onset dysthymia is the diagnosis most closely related to depressive personality disorder.^[7]

The key difference between dysthymic disorder and depressive personality disorder is the focus of the symptoms used to diagnose. Dysthymic disorder is diagnosed by looking at the somatic senses, the more tangible senses. Depressive personality disorder is diagnosed by looking at the cognitive and intrapsychic symptoms. The symptoms of dysthymic disorder and depressive personality disorder may look similar at first glance, but the way these symptoms are considered distinguish the two diagnoses.

Comorbidity with Other Disorders

Many researchers believe that depressive personality disorder is so highly comorbid with other depressive disorders, manic-depressive episodes and dysthymic disorder, that it is redundant to include it as a distinct diagnosis. Recent studies however, have found that dysthymic disorder and depressive personality disorder are not as comorbid as previously thought. It was found that almost two thirds of the test subjects with depressive personality disorder did not have dysthymic disorder, and 83% did not have early-onset dysthymia.^[8] The comorbidity with Axis I depressive disorders is not as high as had been assumed. An experiment conducted by American psychologists showed that depressive personality disorder shows a high comorbidity rate with major depression experienced at some point in a lifetime and with any mood disorders experienced at any point in a lifetime. A high comorbidity rate with these disorders is expected of many diagnoses. As for the extremely high comorbidity rate with mood disorders, it has been found that essentially all mood disorders are comorbid with at least one other, especially when looking at a lifetime sample size.^[9]

Changes to Cluster C

If depressive personality disorder were added to the DSM-V, it would be included in the Cluster C personality disorders, anxious and fearful personality disorders. At this time, those include avoidant, obsessive-compulsive, and dependent personality disorders. The make-up of Cluster C would have to be rethought, as the figure shown below could no longer represent all of the disorders if depressive personality disorder were to be included. The relation shown in the Venn diagram has been accepted for years and would have to be rethought and redesigned if depressive personality disorder were to be added. Further studies are in progress looking into the comorbidity of Cluster C disorders and depressive personality disorder, as well as how these disorders interact with each other in patients diagnosed with multiple Cluster C disorders.

References

1. ^ Millon, T. (2006). Personality subtypes. Retrieved from http://millon.net/taxonomy/summary.htm
2. ^ ^{a b} Millon, T. (2006). Personality subtypes. Retrieved from http://millon.net/taxonomy/summary.htm
3. ^ Kwom, JS, Kim, YM, Chang , CG, Park, BK, & Yoon, DJ. (2000). Three-year follow-up of women with the sole diagnosis of depressive personality disorder: subsequent development of dysthymia and major depression.. American Journal of Psychiatry, 157(12), Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/11097962
4. ^ Millon, Theodore, Personality Disorders in Modern Life, 2004
5. ^ Millon, T. (2006). Personality subtypes. Retrieved from http://millon.net/taxonomy/summary.htm
6. ^ Millon, T. (2006). Personality subtypes. Retrieved from http://millon.net/taxonomy/summary.htm
7. ^ University of Michigan Psychology Department, . (2006, January 20). Dysthymic disorder. Retrieved from http://www.med.umich.edu/depression/dysthymia.htm
8. ^ Millon, T. (2006). Personality subtypes. Retrieved from http://millon.net/taxonomy/summary.htm
9. ^ Nemeroff, C.B. (2002). Comorbidity of mood and anxiety disorders: the rule, not the expception?. American Journal of Psychiatry, 159(1), Retrieved from http://ajp.psychiatryonline.org/cgi/reprint/159/1/3

Further reading

• Finnerty, Todd (2009). Depressive Personality Disorder: Understanding Current Trends in Research and Practice. Columbus, OH: WorldWideMentalHealth.com.

• Huprich, Steven K. (2009). What Should Become of Depressive Personality Disorder in DSM-V? Harvard Review of Psychiatry, 17:1,41-59.

• Millon, Theodore; Davis; Roger; Millon, Carrie (1997). MCMI-III Manual, 2nd edition. Minneapolis, MN: National Computer Systems.