Elsevier

Psychiatry Research

Volume 160, Issue 2, 15 August 2008, Pages 184-191
Psychiatry Research

Personality disorders and perceived stress in major depressive disorder

https://doi.org/10.1016/j.psychres.2007.06.014Get rights and content

Abstract

The investigation of comorbidity between major depressive disorder (MDD) and personality disorders (PDs) has attracted considerable interest. Whereas some studies found that the presence of PDs has adverse effects on the course and treatment of MDD, others have failed to demonstrate this link. These inconsistent findings suggest that specific PD comorbidity might affect the course of MDD by modulating factors that increase the overall risk of depression, including an elevated tendency to perceive stress. To investigate whether the presence of a specific PD cluster was associated with elevated levels of stress appraisal, we administered the Perceived Stress Scale (PSS) before and after treatment to 227 MDD outpatients enrolled in an 8-week open-label treatment with fluoxetine. Following treatment, multiple linear regression analyses revealed that the presence of Cluster A, but not Cluster B or C, was associated with higher levels of perceived stress, even after adjusting for baseline depression severity and PSS scores, as well as various sociodemographic variables. The presence of Cluster A PD comorbidity was uniquely associated with elevated stress appraisal after antidepressant treatment, raising the possibility that stress exacerbation might be an important factor linked to poor treatment outcome in MDD subjects with Cluster A pathology.

Introduction

Over the years, increasing attention has been devoted to investigating the comorbidity between major depressive disorder (MDD) and personality disorders (PDs). In general, the presence of PDs is assumed to have adverse effects on the course and treatment of MDD (for a recent review, see Newton-Howes et al., 2006). Consistent with this hypothesis, co-occurrence of MDD and PD has been associated with poorer response to treatment in most (Peselow et al., 1992, Sato et al., 1993) but not all (Fava et al., 1994, Fava et al., 1997) studies, and with higher risk of depressive recurrence (Ilardi et al., 1997, Hart et al., 2001). Moreover, compared with MDD subjects without PD, those with comorbid PD reported significantly greater impairments in social and emotional functioning and lower well-being (Skodol et al., 2005); higher levels of residual symptoms (Shea et al., 1990); slower recovery (Patience et al., 1995); higher levels of psychotropic utilization at a 1-year follow-up (Casey et al., 2004); and more frequent referral to psychiatric services (Moran et al., 2001).

On the other hand, others have failed to find a link between comorbid PD and poor treatment response (Fava et al., 1994, Fava et al., 1997, Fava et al., 2002, Russell et al., 2003, Mulder et al., 2003). Echoing these negative findings, a recent meta-analysis including findings from six randomized controlled trials with strict methodological criteria found that MDD subjects with comorbid PD had only a 3% lower remission rate compared to MDD subjects without PD, a difference that was not statistically significant (Kool et al., 2005). Taken together, these findings raise the possibility that comorbid personality pathology is not necessarily associated with poor treatment response, and that other intervening variables might be involved.

One possibility is that the three PD clusters based on the Diagnostic and Statistical Manual (DSM; American Psychiatric Association, 1987, American Psychiatric Association, 2000), Cluster A (paranoid, schizoid, schizotypal), Cluster B (borderline, histrionic, narcissistic, antisocial), and Cluster C (avoidant, dependent, obsessive–compulsive) may be differentially related to the course and outcome of depression. Sato et al. (1994), for example, found that only the presence of a Cluster A PD had a significant negative effect on short-term outcome in depression, while Fava et al. (1994) showed that the presence of Cluster B (but not Cluster A or C) PD in MDD was associated with a more favorable outcome following treatment with fluoxetine. Similarly, in a cohort of depressed patients undergoing a 6-month treatment, the presence of symptoms of avoidant, schizotypal, and schizoid, but no other, PD was associated with poorer outcome (Mulder et al., 2006).

A second, not mutually exclusive, possibility is that the presence of comorbid PD among MDD subjects is associated with higher occurrence of factors that increase the risk of depression, such as life stressors and poor social support (Pfohl et al., 1984). Consistent with this hypothesis, in a community sample, symptoms of Cluster A and B, but not Cluster C, disorders predicted interpersonal chronic stress and self-generated episodic stress over 2 years, which in turn increased the vulnerability for depressive symptoms (Daley et al., 1998). Thus, in the study of Daley et al., life stress mediated the relationship between personality pathology and later depression, even when controlling for initial depressive severity.

Findings of a possible mediating role of stress on the relationships between PD and depression are intriguing, particularly since stress has been implicated in the etiology and maintenance of depression (Kendler et al., 1999, Brown and Harris, 1989, Hammen, 2005), and has been associated with poorer treatment outcome and more frequent relapse (Tennant, 2002). Of note, research has suggested that risk for depression increases when individuals perceive stress as uncontrollable, unpredictable, and severe, and deem coping resources as insufficient (Cohen and Williamson, 1988, Hammen, 2005, Lazarus and Folkman, 1984). In addition, compared to pre-treatment levels, perceived stress markedly diminishes following antidepressant treatment, and the degree of stress reduction tends to be highly related to the degree of depressive symptom reduction (Fava et al., 1992).

In the present study, we evaluated 384 MDD outpatients enrolled in an 8-week open-label treatment with fluoxetine for the presence of Cluster A, B, or C PD, as defined by the DSM-III-R (American Psychiatric Association, 1987). To investigate whether PD was associated with elevated stress perception, a subgroup of these participants (n = 227) filled out before and after treatment the Perceived Stress Scale (PSS; Cohen et al., 1983), which assessed the degree to which participants appraised their daily life as unpredictable, uncontrollable, and overwhelming. Specifically, our goal was to test whether the presence of a given DSM-III-R-based PD cluster predicted levels of stress after 8-week antidepressant treatment with fluoxetine. We hypothesized that the presence of Cluster A or Cluster B PD comorbidity would predict elevated levels of perceived stress in MDD outpatients.

Section snippets

Participants

Data from the current study were derived from a larger study conducted at the Depression Clinical and Research Program (DCRP) at Massachusetts General Hospital (Fava et al., 2002, Farabaugh et al., 2002). The main goal of the parent study, which included 384 outpatients between the ages of 18 and 65, was to evaluate the efficacy of fluoxetine in the treatment of MDD. In order to be enrolled in an 8-week open treatment of fluoxetine 20 mg/day, subjects were required to meet criteria for MDD, as

Results

Three hundred eighty-four subjects were enrolled in the 8-week open treatment of fluoxetine 20 mg/day (Fava et al., 2002). In this sample, 54.7% of the subjects were female (n = 210), 33.6% were married (n = 129), 56.5% completed at least a college degree (n = 217), and 62.5% were currently employed (n = 240). The mean age of this sample was 39.8 (S.D.: 10.5), and the mean baseline HAMD-17 score was 19.7 (S.D.: 3.5). The mean age of onset of the first MDD and the mean duration of the current MDD

Discussion

Stress and major life events have been implicated in the etiology and maintenance of depression (Kendler et al., 1999, Brown and Harris, 1989, Hammen, 2005). Consistent with this hypothesis, prior studies have found that higher daily life stressors and perceived stress were associated with poorer outcome in major depressive disorder (Tennant, 2002). The main goal of this study was to investigate whether the presence of a stable PD comorbidity, specifically a DSM-III-R-based Cluster A, B or C

Acknowledgments

This work was supported by NIMH grant R01-MH-48-483-05. Dr. Fava has received research support from Abbott Laboratories, Lichtwer Pharma GmbH, Lorex Pharmaceuticals; as well as honoraria from EPIX Pharmaceuticals, Bayer AG, Compellis, Janssen Pharmaceutica, Knoll Pharmaceutical Company, Lundbeck, Dov Pharmaceuticals, Biovail Pharmaceuticals, Inc., BrainCells, Inc., Cypress Pharmaceuticals, Fabre-Kramer Pharmaceuticals, Inc., Grunenthal GmBH, MedAvante, Inc., Sepracor, and Somerset

References (51)

  • PfohlB. et al.

    The implications of DSM-III personality disorders for patients with major depression

    Journal of Affective Disorders

    (1984)
  • SatoT. et al.

    Cluster A personality disorder: a marker of worse treatment outcome of major depression?

    Psychiatry Research

    (1994)
  • American Psychiatric Association

    Diagnostic and Statistical Manual of Mental Disorders (DSM III-R)

    (1987)
  • American Psychiatric Association

    Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision

    (2000)
  • BlaisM.A.

    Clinician ratings of the five-factor model of personality and the DSM-IV personality disorders

    The Journal of Nervous and Mental Disease

    (1997)
  • BrownG. et al.

    Life Events and Illness

    (1989)
  • CohenS. et al.

    Perceived stress in a probability sample of the United States

  • CohenS. et al.

    A global measure of perceived stress

    Journal of Health and Social Behavior

    (1983)
  • CostaP.T. et al.

    Personality disorders and the five-factor model of personality

    Journal of Personality Disorders

    (1990)
  • DaleyS.E. et al.

    Axis II symptomatology, depression, and life stress during the transition from adolescence to adulthood

    Journal of Consulting and Clinical Psychology

    (1998)
  • FarabaughA. et al.

    Predictors of stable personality disorder diagnoses in outpatients with remitted depression

    The Journal of Nervous and Mental Disease

    (2002)
  • FavaM. et al.

    Correlations between perceived stress and depressive symptoms among depressive outpatients

    Stress Medicine

    (1992)
  • FavaM. et al.

    Personality disorder comorbidity with major depression and response to fluoxetine treatment

    Psychotherapy and Psychosomatics

    (1994)
  • FavaM. et al.

    Personality disorders and depression

    Psychological Medicine

    (2002)
  • FirstM.B. et al.

    Structured Clinical Interview for DSM-IV Personality Disorders, (SCID-II)

    (1997)
  • Cited by (29)

    • Pathogenic beliefs among patients with schizotypal personality disorder

      2020, Heliyon
      Citation Excerpt :

      Personality disorders (PDs) occur in approximately 9% of the general population (Gawda and Czubak, 2017) and are comorbid with a wide range of clinical psychiatric disorders (Lenzenweger et al., 2007). Individuals with PDs typically suffer from interpersonal problems, insecure attachment, perceived stress, depression, anxiety, and somatization (Berry et al., 2006; Candrian et al., 2008; Neelapaijit, T Wongpakaran, Wongpakaran and Thongpibul, 2017). Schizotypal PD is diagnosed on the basis of irregularities in a patient's thinking, behaviour, and appearance.

    • Polyunsaturated fatty acids moderate the effect of poor sleep on depression risk

      2016, Prostaglandins Leukotrienes and Essential Fatty Acids
      Citation Excerpt :

      PSS scores were strongly correlated with BDI scores (R=0.7), and only somewhat correlated with stressful life events. This is consistent with observations that the subjective perception of stress is likely related to mood state and can improve with antidepressant treatment [66]. PSS lost the power to predict IFN-MDD when AA/EPA+DHA was used to split the population into subgroups; and LES had no predictive power.

    • A study of prevalence of depression, anxiety, and stress among malaysian female inmates

      2023, Handbook of Research on Dissecting and Dismantling Occupational Stress in Modern Organizations
    View all citing articles on Scopus
    View full text