This Update outlines how to identify an individual’s personality style and tailor their treatment. It is by Professor Gordon Parker, AO, MBBS, MD, PhD, DSc, FRANZCP, FASSA and Associate Professor Vijaya Manicavasagar, PhD.

Professor Gordon Parker, AO, MBBS, MD, PhD, DSc, FRANZCP, FASSA
Professor Parker is Executive Director of the Black Dog Institute and Scientia Professor, School of Psychiatry, University of New South Wales.

Associate Professor Vijaya Manicavasagar, PhD
Professor Manicavasagar is Director of Psychological Services at the Black Dog Institute, Sydney, NSW.

INTRODUCTION
TEMPERAMENT and personality styles have long been associated with various psychopathologies, such as high levels of perfectionism with anorexia and other eating disorders, or introversion with pathological shyness and social phobia.

The presence of recurrent depressive episodes or chronic depression can also reflect an underlying personality style influencing onset and persistence of the depressive disorder.

The Black Dog Institute aetiological model for mood disorders asserts that there are three subtypes of depression: psychotic melancholia, melancholic depression and non-melancholic depression.

Both psychotic melancholia and melancholic depression are thought to be primarily driven by neurobiological perturbations that disrupt neural pathways.

Non-melancholic depression, on the other hand, is thought to be primarily driven by stress, personality styles and dysfunctional coping repertoires – so that we view personality styles as particularly salient to the non-melancholic depressive conditions.

A corollary of this aetiological model is that treatments need to be tailored to the subtype of depression, with medication being the primary intervention in psychotic melancholia and melancholic depression, while psychological interventions become the mainstay of non-melancholic depression treatment.

Depression, when it occurs in the context of bipolar disorder, is almost always melancholic in nature and, given the biological basis for this type of illness, is necessarily treated with medication as a first step.

Psychological interventions are recommended in the treatment and management of the more biologically based mood disorders, but only after the acute symptoms have been addressed by medication.

PERSONALITY TYPE AND DEPRESSION
Further research conducted at the former Mood Disorders Unit and, later, at the Black Dog Institute in Sydney has identified at least eight personality styles of salience to non-melancholic depression, which is one of the most frequently occurring categories of mood disorders and accounts for about 90% of depressions seen in clinical practice.

Personality styles, which usually manifest in the cognitive and behavioural domains, are affected by psychosocial stressors, which, in turn, can compromise an individual’s self-esteem and ability to cope, thus exacerbating the impact of the original stressor and causing depression onset.

In addition, particular personality styles can sometimes increase the likelihood of stressful events.

For example, an individual with a rejection-sensitive personality style, who is prone to interpreting events with a bias towards rejection and abandonment by others, is more likely to manifest clingy, dependent behaviours, which make them more likely to actually be rejected by others.

Although, and as noted, this cycle is particularly relevant for the development and maintenance of non-melancholic depressions, dysfunctional personality characteristics can also play a significant role in the maintenance of other types of mood disorders, including melancholic depression and bipolar disorder. While the primary drivers for these types of mood disorders are considered to be neurobiological, maladaptive cognitions and behaviours can still impact on the course of recovery.

For example, individuals with melancholic depression and a perfectionist personality style may initially respond well to antidepressant medication, but continue to criticise themselves about suffering from depression and worry about the process of recovery. This level of self-criticism and worry may be sufficient to retard their rate of improvement from the depression and/or increase their likelihood of relapse.

DIFFERENT PERSONALITY STYLES
The personality styles identified in the subtyping model for depression are perfectionistic, socially avoidant, anxious worrier, irritable, socially reserved, rejection sensitive, self-focused, and self-critical.

These personality styles are thought to be subsumed by the neurobiological underpinnings of temperament, such that those with the more ‘externalising’ constructs of personality styles, for example, irritable or self-focused, are more likely to ‘blow up’ when upset or engage in reckless or impulsive behaviours when depressed.

While individuals with these types of personality styles are more likely to experience transient depressive episodes, the people around them may experience ‘collateral damage’ as a consequence of their eternalising response style.

In contrast to ‘externalisers’, personality styles that reflect an ‘internalising’ construct, such as the anxious worrier or rejection sensitive, are more likely to stew over specific events, worry and seek reassurance from others.

As noted earlier, personality styles can influence vulnerability to depressive episodes, exposure to environmental stressors, symptom patterns in non-melancholic depression and response to treatment. These points can be best illustrated with the two most common personality styles seen by clinicians, that of the anxious worrier and the perfectionist.

TREATING THE ANXIOUS WORRIER
Individuals with an anxious-worrying personality style are characterised by high levels of autonomic arousal, a tendency to worry, and increased vulnerability to non-melancholic depression.

When depressed, they typically present with significant physical and cognitive symptoms of anxiety, including ruminations, catastrophic thoughts and self-doubt.

Their chronic worry may result in repeated reassurance-seeking from family members, friends and health professionals.

In addition, a range of avoidance behaviours may complicate their clinical presentation and result in lifestyle restrictions, such as avoiding social situations or taking on new challenges and responsibilities at work.

Treating an individual with an anxious-worrying personality can include medications such as SSRIs to reduce anxiety and curb worry, together with a range of psychological interventions to address their concerns and negative thinking styles.

These psychological strategies can include relaxation and meditation exercises, problem-solving strategies, goal-setting and time-management skills, and cognitive behavioural therapy in order to learn how to challenge and change maladaptive catastrophic thoughts.

TREATING THE PERFECTIONIST
The anxiety often observed in individuals with a perfectionistic personality is somewhat different in aetiology to that for the anxiety worrier. While the anxious worrier may stew over current events, experience catastrophic thoughts about events and seek reassurance from others, perfectionists typically are prone to self-criticism, fear of failure and making the ‘wrong’ decisions, ruminations over past behaviours and feeling overwhelmed.

Perfectionists are also less likely to solicit others for help or to seek professional advice when depressed.

‘Behavioural paralysis’ and procrastination are usually related to anxieties over making a wrong decision or not being able to complete a task as well as expected.

Unlike anxious worrying, perfectionism as a personality characteristic is usually somewhat protective against depression onset. Their self-imposed high standards, self-discipline and control not only ensure high productivity and achievement, but also lessen the likelihood of being exposed to, and becoming overwhelmed by, unexpected stressors. However, once they are overwhelmed by uncontrollable stressors, perfectionist individuals are slower to recover and return to their previous level of functioning.

In treatment for a depressive illness, perfectionists do not usually benefit from antidepressant medications as they prefer to be ‘in control’ rather than surrendering such control to medication.

In addition, their depression is generally underpinned by a sense of failing to meet goals or standards rather than being due to emotional dysregulation (which is prevalent in anxious worrying).

Finally, the need for control acts against any likelihood for spontaneous remission and improvement, thus weakening a possible springboard for a therapeutic response.

Psychological therapies also face significant challenges when used with the perfectionist patient, who may experience difficulty in trusting their GP or therapist and forming any, let alone a strong, treatment alliance. Hence the widespread perception among clinicians that, once depressed, perfectionists are difficult to treat and that their depressions do not quickly remit.

TREATING BIOLOGICAL DEPRESSION
For the more biologically based mood disorders, personality styles can also influence the ways in which individuals cope with their depression and the types of psychological interventions that may be helpful once the acute symptoms have begun to remit.

For example, an individual with a melancholic depression together with a socially avoidant personality style may become more avoidant while depressed, but is unlikely to be the life and soul of a party even when their depression improves.

Although their therapist may refer them for group social skills training or other group-based programs, an individual with a socially avoidant personality style is unlikely to comply with such a treatment approach despite the obvious benefits.

Psychological strategies will firstly need to harness their motivation to address their anxieties about social situations and, secondly, apply skills training or cognitive restructuring on an individual basis, at least until they feel comfortable attending any group-based interventions.

Recurrent depressive episodes or chronic depression can reflect an underlying personality style influencing persistence of the depressive disorder.

PERSONALITY STYLES VS PERSONALITY DISORDERS
One important point to remember is that personality styles are not synonymous with personality disorders. Personality styles are enduring characteristics that affect the way in which individuals perceive themselves, understand life events, cope with stress and interact with others. In this way, personality styles may be adaptive for an individual’s lifestyle or social and cultural niche, or maladaptive if they lead to ongoing psychosocial difficulties.

Personality styles are shaped by social and cultural influences, early life experiences such as quality of parental care or experiences of abuse, as well as ‘temperament’ (i.e. the neuronal ‘hardwiring’ that underpins the expression of certain behavioural characteristics such as shyness).

In contrast, personality disorders are highly dysfunctional ways of thinking, behaving, coping with stressful life events and interacting with others. Individuals with clearly defined personality disorders exhibit significant impairments in their lives.

While personality styles themselves are considered to be unchangeable, the ways in which they are expressed may be open to modification. For example, an individual with a socially reserved personality style may find it difficult to confide in or trust others. They may have a number of superficial friends, but find interactions with them neither rewarding nor uplifting. They may yearn for emotional closeness, but not possess the necessary skills to develop closer friendships or deeper relationships.

If sufficiently motivated, an individual with a socially reserved personality style may be instructed in skills to challenge their dysfunctional thoughts about trusting other people, express their feelings to others, and organise social occasions in which to practise these skills.

For clinicians, helping patients shift their maladaptive thoughts and behaviours to more adaptive expressions can be helpful in reducing distress and promoting recovery from mood disorders (e.g. various maladaptive thoughts are associated with perfectionism, such as harsh self-criticism and loss of self-esteem when facing failure).

Perfectionist individuals tend to invest their identity and sense of self in the successful completion of tasks, and thus tend to ‘beat themselves up’ over perceived failure. Helping perfectionist individuals to develop a strong self-identity that is independent of task completion can help to break the vicious cycle comprising fears of failure, harsh self-criticism and loss of self-esteem.

ASSESSMENT AND MANAGEMENT
Personality styles can be reliably (and anonymously) assessed using the Black Dog Institute’s Temperament and Personality Questionnaire (T&P questionnaire), which is available on the website (www.black­doginstitute.org.au).

The T&P is a validated self-report measure that assesses all eight personality styles found in depressive disorders. It provides a score for each of the styles, so it is possible for individuals to load highly on more than one (e.g. social avoidance and rejection sensitivity).

Information about high scores on each of the personality subscales can be used to inform psychological approaches to managing mood disorders and preventing relapse.

Another tool developed by the institute for GPs is the Mood Assessment Program (MAP), which is aimed at improving diagnostic accuracy in depression subtypes and in diagnosing bipolar disorder. Apart from incorporating the T&P questionnaire, the MAP also inquires about current and past stresses, thus providing clinicians with a clearer picture of how these personality styles may have impacted on the development and maintenance of a mood disorder.

In addition, the Black Dog Institute runs training workshops for GPs and other health professionals overviewing the diagnosis and management of mood disorders. These courses detail the issues involved in assessing and treating patients whose personality styles have significantly impacted on the development and maintenance of a mood disorder. This is especially relevant for those patients whose depressions do not easily remit and where recurrent episodes are ongoing features.          

KEY POINTS

• There are three subtypes of depression: psychotic melancholia, melancholic depression and non-melancholic depression.
• Non-melancholic depression is driven by stress, personality styles and dysfunctional coping repertoires.
• Psychotic melancholia and melancholic depression are thought to be primarily driven by neurobiological pathways.