The Sad Type: Personality Disorders and Depression

Cases of comorbid depression and additional conditions and circumstances are abundant. The interaction between major depressive disorder with other, debilitating mental health issues, in particular, has been shown to be especially prevalent. And when it comes to some of the most pervasive mental health disorders—personality disorders—the comorbid existence of depression can further burden an already challenged mental health setting. Read on to learn how these two types of conditions most commonly relate to one another, and the result of their coexistence.

Comorbid depression

Major Depression: A Void Existence

A mood disorder that has received substantial attention both in research and in the field, depression is primarily defined through a significant decrease in mood, or the inability to feel joy. Its overall symptomatology tends to shut down the individual experiencing it, so they feel depleted of energy, neglect key relationships, struggle to function, feel a demoralizing lack of self-worth, and are hopeless that things will ever improve.

Depression has been recognized to severely affect one’s well-being since the time of the Ancient Greeks, and since then it has garnered a great deal of interest. This is primarily due to its relative prevalence among the general population, and the empirically proven efficacy of certain depressive treatments.

Depression is one of the most common mental health disorders in the world and across cultures. The American Psychiatric Association (APA) states that 7% of the adult population contends with depression, with women facing it 1.5-3 times more than men.

Depression has also been shown to have a significant reaction to both psychotherapeutic intervention (specifically psychodynamics) and psychopharmacology (specifically selective serotonin reuptake inhibitors), while usually causing a tolerable level of side effects. This allows patients facing this condition to be able to choose between either one of these routes, combine the two together, or add another type of treatment they might find beneficial.

One such treatment is Deep Transcranial Magnetic Stimulation (Deep TMS), a noninvasive medical device treatment that is FDA-cleared to treat depression and a number of other conditions. Deep TMS utilizes electromagnetic fields to regulate the neural activity of brain structures found to play a role in the appearance of depressive symptoms.

Comorbid personality disorder

Personality Disorders: A Slanted Worldview

According to the APA, personality disorders are defined as a significant deviation from social norms, so much so that the individual’s worldview, behavior, and their expectations of others are all vastly different from their local culture.

Not all uniqueness is considered a mental health disorder. Rather, it is when an individual’s perspective is strikingly dissimilar to that of those around them, the source of significant distress or impairment, and so rigid that it does not allow them to accommodate others, that a personality disorder diagnosis may be considered.

The APA continues to state that 15% of the population contends with at least one type of personality disorder. Unlike psychosis, individuals with a personality disorder usually have an accurate perception of external reality. The main focus of this family of disorders lies within the interpersonal, as its destabilizing and erratic symptoms tend to harm the individual’s relationship with others, often causing them to feel maligned, attacked or misunderstood. As a result, they are prone to conflict, emotionality, while finding it difficult to de-escalate a social situation they find triggering.

Variations on a Theme: The Ten Personality Disorders

The APA currently cites ten distinct personality disorders, listing them into three clusters:

  • Cluster A: The “odd” cluster, includes three personality disorders that evoke strikingly or eccentric behavior:
    • Paranoid Personality Disorder: Distrustful of others and tends to believe those around them want to take advantage of them.
    • Schizoid Personality Disorder: Limited emotional expression and social interaction.
    • Schizotypal Personality Disorder: Extremely eccentric and struggles to navigate relationships. At times also experiences reality distortions.
  • Cluster B: The “dramatic” cluster, includes four personality disorders that induce unpleasant emotionality and erratic behavior:
    • Antisocial Personality Disorder: Tends to disregard rules and others’ safety, while feeling comfortable carrying out deceitful behavior.
    • Borderline Personality Disorder: Defined by impulsivity, unstable relationships, and significant insecurity. Women compose 75% of those with this condition.
    • Histrionic Personality Disorder: Defined by extreme attention-seeking, emotionality, and being impressionable.
    • Narcissistic Personality Disorder: Marked by a great deal of loneliness. a lack of empathy, and self-involvement, with a constant need for admiration.
  • Cluster C: The “anxious” cluster, includes three personality disorders defined by induce fear:
    • Avoidant Personality Disorder: Induces feelings of extreme social inadequacy, with a tendency toward inhibited behavior, and a great sensitivity to criticism.
    • Dependent Personality Disorder: Submissive behavior with a lack of independence, and a desire to be taken care of.
    • Obsessive-compulsive personality disorder: Marked by perfectionism and working toward complete orderliness and control.

When Depression and Personality Disorders Interact

The main difficulty defining the personality disorders family resides in the social sphere, while the anguish and persistent lack of energy that define depression occupy a more intrapsychic and emotional sphere. Yet the two aspects of mental health often exist together, influencing and sustaining one another. Research has found a 50% comorbidity rate between major depression and personality disorders, noting that borderline personality disorder is found at consistently high rates across different cultures, among those facing depression.

Studies suggest that in certain cases, being fundamentally entwined with the individual’s personality from a young age can cause personality disorders to introduce the erratic circumstances and cycles of difficult interactions with others into the individual’s life, essentially laying the groundwork for depressive symptoms such as hopelessness and despair to appear.

Borderline Personality Disorder and Depression

With a comorbidity rate ranging from 20% to half of recorded cases, borderline personality disorder is the most common personality disorder to appear with major depression, and the only one specifically mentioned by the APA in the DSM-V as tending to co-appear with depression.

Borderline personality disorder and major depression share a number of symptoms, including:

  • Anguish.
  • Helplessness and hopelessness.
  • Unhappiness and generally negative affect.

However, while cases of depression may exhibit these symptoms in relation to a sense of lacking, or a difficulty accessing the full emotional spectrum, with borderline personality disorder these symptoms tend to be more transient and relate more to interpersonal stressors.

Individuals with both of these disorders usually exhibit a less favorable prognosis, compared to those with major depression alone. Specifically, those with both disorders:

  • Do not respond as well to antidepressant medication.
  • Go through a longer remission process.
  • Are more likely to experience additional major depressive episodes in the future.

Like all personality disorders, borderline personality disorder is quite persistent, and hard to uproot. It can take years of psychotherapy to bring about moderate change, with the personality disorder often acting as a dynamo that preserves the conditions leading to depression.

Depression and borderline personality disorder also appear to share a biological background, with neural hyperreactivity in the amygdala, anterior cingulate cortex, and a consistent deficit of serotonin facilitating both conditions. Experiencing late childhood trauma and having an anxious temperament additionally act as risk factors for the two disorders.

The Case of the Depressive Personality Disorder Category

The APA’s 1968 edition of its mental health guidebook, the DSM-II, included a diagnosis of depressive personality disorder. The disorder has gone through a rather volatile recognition process of its own: after being removed from the DSM-III in 1980, it was included in 2000 in one of the DSM-IV’s appendixes, which stated its validity should be further discussed. The current DSM-V (published in 2013) has once again removed the depressive personality disorder from its pages, demonstrating the fluctuating dynamics that shape each generation’s perception of mental health. Rather than discard the diagnosis completely, it can contribute to a richer understanding of cases where the individual’s mental health status seems to be built around a deep moroseness that defines their very character.

Depressive personality disorder was defined through its pervasiveness. For the diagnosis to had been considered, feelings of gloom, guilt, and worry, as well as beliefs of inadequacy and worthlessness, had to have appeared at different periods of the individual’s life, starting from early adulthood.

The persistence of such depressive features had caused mental health professionals to state that in essence, the definition of depressive personality disorder is not significantly different than that of persistent depressive disorder, otherwise known as dysthymia. Over time, this claim gained a good amount of traction, until in 2013, the diagnosis was indeed removed from the APA’s manual.

Approaching Depression in a Personality Disorder Context

Treating depression is often a complex matter that necessitates addressing the biological, genetic, environmental and psychodynamic issues at play. An individual’s personality can also play a decisive role in the appearance of depression, and even more so when a comorbid personality disorder is involved.

Since a key feature in all personality disorders is their rigidity, contending with both a personality disorder and depression commonly hinders the individual’s ability to approach their treatment with an open mind. Those with a personality disorder will likely find it harder to accept a new perspective on their depression, and on their ability to respond differently to aspects of their past and present that preserve this condition.

As a result of the persistence of their effects, personality disorders may respond well to long-term psychodynamic therapy. It takes time to unpack issues stemming from formative relationships and acknowledging the experiences that have created and sustained their depression. But it is through continuously approaching such issues that deep, long-lasting change may occur, and one’s personality may become flexible enough to allow the burden of depression to be lifted.