Saturday, January 23, 2010

Illness or Personality - What's in YOUR Depression?

Both here at Knowledge is Necessity and over at HealthCentral’s BipolarConnect, I have been investigating the issue of illness vs personality (or temperament). Say you are dealing with depression. In all likelihood, you are thinking that your depression is an alien invader that is robbing you of your personality. But what if miserable is your true baseline?

Why this is important is that medications are designed to treat an illness, not change a personality. An article by some prominent academics on the blog site of author Todd Finnerty PsyD makes a case for the diagnosis of Depressive Personality Disorder (DPD). I had occasion to hear one of the authors, Michael Bagby MD of the University of Toronto, at the 2006 American Psychiatric Association annual meeting in Toronto.

Historically, according to Dr Bagby, minor depression was thought to exist on a spectrum with personality, and "may define a group who are pessimistic, disaffected, and frustrated, perhaps because they see their illness as an intractable and enduring part of their selves."

According to the authors of the blog article: “Depressive personality disorder is not simply a variation of normal psychological functioning.” It is an illness, distinct from major depression and dysthymia.

Appendix B to the DSM-IV lists DPD as “worthy of further study,” but is not included in the main text. The appendix defines DPD as “a pervasive pattern of depressive cognitions and behaviors.” By contrast, classic Axis I DSM major depression is described as an “episode,” with symptoms lasting at least two weeks, while minor depression (dysthymia) is regarded as “chronic” (two years or more).

In other words, if you are undergoing major or minor clinical depression right now, all those around you - including your psychiatrist - assume your brain will eventually boot back up to “normal.” But with DPD, you may already be imprisoned in your own version of “normal.”

According to the authors of the article, a number of studies validate DPD, but the obvious overlap with clinical depression, in particular dysthymia, poses major problems. The authors argue that it is dysthymia that suffers from redundancy, not DPD. DSM dysthymia, they contend, comes across as major depression lite, with nearly the same symptoms but with an arbitrarily-added two-year requirement.

DPD, by contrast, serves up a different symptom list, namely:
  1. Usual mood is dominated by dejection, gloominess, cheerlessness, joylessness, unhappiness
  2. Self-concept centers around beliefs of inadequacy, worthlessness, and low self-esteem
  3. Is critical, blaming, and derogatory toward self
  4. Is brooding and given to worry
  5. Is negativistic (passive-aggressive), critical, and judgmental towards others
  6. Is pessimistic
  7. Is prone to feeling guilty or remorseful
But the real turf DPD may be encroaching on may involve the personality disorders (such as avoidant personality disorder). In particular, there are issues regarding the Five Factor Model (FFM), which is to personality testing what Simon is to American Idol.

The FFM has a good chance of influencing the next DSM as part of a “hybrid” system of classifying Axis II personality disorders. The current DSM is structured according to the type of “categorical” schema that works (to a point) for Axis I disorders. In other words, depression is different from schizophrenia. (Never mind that depressed people can have psychosis and those with schizophrenia can be depressed - that is for another piece.)

This separation is even more problematic with personality disorders, where there is considerably greater overlap amongst symptoms (such as where borderline meets antisocial meets narcissism). A “dimensional” schema not only acknowledges the overlap, but takes into account degrees of severity. As a speaker explained at a conference I attended a few years back: We all have blood pressure. But we have reliable tests to ascertain when our blood pressure is too high.

Think of the FFM as a blood pressure test. The “big five” traits it measures include openness, conscientiousness, extraversion, agreeableness, and neuroticism. A person who passes with flying colors is one who is not likely cave into fear, has his or her shit together, lights up a room, cares about others, and doesn’t readily fly off the handle.

If you were to see these qualities in someone on eHarmony, you would immediately propose marriage to this individual, sight unseen. If for some reason, you failed to initiate contact, you are probably emotionally tied up in knots.

The FFM may crack your case, but here’s the rub. Suppose the results revealed a “neurotic” temperament. According to the authors of the blog article, neuroticism is a pretty airy-fairy term that also embraces other emotions such as anger and anxiety.

It could be you fail to pursue an eHarmony lead because your inner critic is working overtime. You consider yourself worthless. You’re beating yourself up. And now you’re alone and socially isolated. How does that make you feel? Well, depressed.

Okay, suppose you do have a depressive temperament. Does that mean you have DPD? Absolutely not. The authors of the article point out that DPD has a dimensional component, which means we are asking “how much?” So, if you’re the type who prefers staying home alone with a book to going out dancing, you can relax. You may be a lot happier and better adjusted than Joe Cool and Miss Congeniality.

But even if you have been thinking that black is the new pink your entire life, the experts remind us that although our traits are inherited they are not necessarily deterministic. Turning our lives around may not be easy, but we can change, or at least come up with adaptive responses.

The authors contend that DPD should be included in the DSM-V, under personality disorders. We will leave that debate for another time. The point is, in the unending quest for the true me we alone are our own judges. Illness or personality? Perhaps a bit of both? We can’t afford to wait for someone else to ask these questions.

Further reading:

From Knowledge is Necessity

Is There Anything At All Possibly Good About Depression?
Depressed or Thinking Deep?
Breaking Down Personality

From BipolarConnect

Wearing the Mask, Acting "Normal"
Peace of Mind
Personality vs Illness - The Conversation Continues
Personality or Illness


Willa Goodfellow said...

You cover yourself with the appropriate caveats. But do those who want to expand the definistions of disorders? "The big five traits [the FFM] measures are openness, conscientiousness, extroversion, agreeableness and neuroticism." Presumably extroversion is the preferred option over introversion. The extent to which this culture values extroversion gets us into a lot of trouble. A president who is a "decider," not a thinker, comes to mind. See "The Institute for the Study of the Neorologicallyy Typical" [ for further reference.

I can understand the insurance companies' apprehension of this direction,the pathologizing of personality, even if these traits do show up in brain scans.

A former therapist once suggested that the DSM section on personality disorders could be used for an examination of conscience. It's too bad that our society has lost any depth to our examination of conscience. I don't doubt that there are real illnesses there. But not only can we turn our lives around, we can turn them the wrong way. Just because we don't feel guilty doesn't mean we shouldn't. Habitual bad behavior can form personality.

John McManamy said...

Hey, Willa. Great insights, and as an introvert I totally agree. Extraverts are in the majority in the general population and so their values are valued over ours. Which often translates to obnoxious and shallow and bullying over sensitive and thoughtful.

Years ago I polled my Newsletter readers and discovered about 80 percent were introverts. The depression (and bipolar)-introvert connection has been borne out in research.

The catch is we introverts tend to isolate, which is often the last thing we need to be doing, especially when sliding into depression. Also, we could use a little extraversion to make us more at ease around people.

I've had to do considerable work on this. By nature I'm a hermit who could easily live in a cave. I'm more comfortable alone, but this isn't good for me. Fortunately, I do perk up around people. And these days - of all the crazy things - people mistake me for some kind of exuberant extravert. I call this a success story, but trust me, I'm still true to my introvert nature, which is a good thing.

Re George Bush - another good internet friend made very similar observations to me, which I agree with whole-heartedly. I'm amazed the American public swallowed his bullshit. Then again, they're the crazy ones, not me. :)

Re pathologizing personality: Yes, a very big concern. For reasons above, we don't want to cure introversion, but we do need to give people like me tools to survive in an often hostile extraverted world.

Check out my mcman web article, which I will probably post here sometime soon:

Further: In past blogs I noted I do not want my depressive temperament cured. That's the deep and thoughtful and brooding and somewhat twisted part of me that I highly value. The illness part of me that reduces me to nothing, saps my energy, makes me and living totally miserable, and takes my frontal lobes off line - that's the illness I want no part of.

Let's keep the conversation going.

Anonymous said...

I so like variety in people. If we were all "deciders" wow, what a world it would be!
You put it well, the part that zaps a person, causes them pain and misery---that part needs to be relieved. Not the part that is just variety.