Evaluating the Co-morbidity of Major Depression Disorder and Personality Disorder in Year Old Women Referring to Outpatient Clinics

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1 Evaluating the Co-morbidity of Major Depression Disorder and Personality Disorder in Year Old Women Referring to Outpatient Clinics Farrokh Lagha Alhooei 1, Omid Rezaei* 2, Behrooz Dolatshahi 3 1. Department of Psychology, Science and Research Branch, Islamic Azad University, Tehran, Iran. 2. Associate Professor of Psychiatry, University of Social Welfare & Rehabilitation Sciences, Tehran, IRAN. 3. Assistant Professor, University of Social Welfare & Rehabilitation Sciences, Tehran, IRAN *Corresponding author: Omid Rezaei Abstract Considering the importance of co morbid surveys for personality disorders in patients with major depression disorder, the objective of this study is to evaluate the co morbidity and relationship of major depression severity and personality disorders. In this descriptive-analytic study the sample included 98 subjects chosen though convenience sampling. The degree of severity for depression was determined with the Beck Depression Inventory (BDI) and personality traits were evaluated using Millon Clinical Multiaxial Inventory. Data was analyzed using descriptive statistics, Pearson correlation test, Chi-square test and T test. Results showed that personality disorder and major depression are 61% co morbid and the highest rate of co morbidity is for depressive, negativistic, dependent, histrionic and borderline personality disorders. Also the correlation between severity of depression and schizoid, depressive, dependent, antisocial, negativistic, schizotypal personality traits and anxiety, somatoform, manic, posttraumatic stress and thought disorder clinical syndromes is significant at Key words: Co morbidity, major depression, personality disorders Introduction Major depression disorder (MDD) is a disabling psychiatric disorder and the costs for the person, family and society are known to be substantial since the high prevalence of the chronic condition imposes sever economic and human burden. This mental condition also interferes with the job and school performance and makes its way to disturb interpersonal relationships. It s noteworthy that half of this depressed people experience it at the active age of Depression is one of the most prevalent disorders taking many people to the offices of psychiatrics and psychologists each year (Kaplan & Sadock, 2005). Depression is one of the disorders highly comorbid with other disorders. The term comorbidity describes two or more disorders occurring in the same person. In many studies major depression disorder and personality disorders are said to be commonly comorbid disorders (Marneros, 2009; Wittchen, 1996; Rennebergm, Rennebergm, Heyn, Gebhard, & Achmann, 2005; Mulder, Joyce, & Cloninger, 2004). Personality disorder is a class of perception, thinking mental disorder and generally a kind of inflexible and incompliance attitude towards the environment, others and self and they are conditions with heavy burden on the person experiencing the disorder and the society (Mac-Manus, & Fahy, 2008; Joyce et al., 2003; Zimmerman, M., Chelminski, I., & Young, 2008). Many studies suggest that there is a common pathologic ground between personality disorder and major depression (Gunderson, Stout, & Sanislow, 2008; Agosti, Hellerstein, & Stewart, 2009; Kool et al., 2005; Corruble, Ginestet, & Guelfi, 1999). The prevalence of depression among women is twofold and there is evidence that gender differences are in part the reason why women face risk factors. For example, hormones and neurotransmitters can influence emotion regulation process so that they are more vulnerable to stressors in events (David, Dozois, & Dobson, 2004). Accordingly to what been said, the present study aims at evaluating the

2 16 Turkish Journal of Psychology Vol 31, No 77 (2016), October 2016, PP comorbidity of major depression and personality disorders among women and examine the personality patterns of patients with major depression. Also, the relationship between the degrees of severity in depression with personality disorders was examined to determine the factors in etiology and treat major depression in relation with personality patterns. There been numerous studies related to personality disorders comorbid with major depression. Kelly, Nur, Tyrer, & Casey (2009) studied the effect of personality disorder severity and depression treatment on 410 patients. Three hundred of them answered complete personality assessment questions. The results showed that 49.8 percent were not experiencing any personality problems, 19.3 percent were experiencing personality problems, 13 percent were experiencing a simple personality problem (one disorder) and 17.9 percent were experiencing complex personality disorder (at least two disorders). Severity of personality disorder was correlated to the severity of depression onset (Beck test scores) (mean Beck score: 22.76) (Kelly et al., 2009). Bukh Bock, Vinberg (2010) surveyed 394 patients in psychiatric centers (inpatient and outpatient). They classified major depression period to different degrees of severity: minor (16.2), medium (51.1), severe (22.1) and unknown (10.4). Results showed that 33 percent of the patients met personality disorder criteria. Goodarzi (2003) examined personality patterns of patients with major depression disorder and results suggested a correlation between schizoid, avoidant, dependent and passive-aggressive personality disorder with major depression disorder. It is worth mentioning that the effect of changes in depression treatment related to personality disorder continues for two months after the intervention ends. Eftekhar, Dadfar, & Karimi (2004) suggested a 9.1 percent comorbidity of major depression disorder and personality disorder after examining the comorbidity of psychiatric disorders on 648 patients of which 218 (33.6 percent) were experiencing major depression disorder (Eftekhar, Dadfar, & Karimi, 2004). Results by clusters derivation and disorder categorized A, B, C classes are as follows: Cluster A (0.9%): paranoid (0.9%). Cluster B (4.3%): histrionic (1.7%), borderline (0.9%), anti-social (0.4%), and personality disorder B without certain type (1/3%).Cluster C (3.9%): obsessive compulsive (2.6%), avoidant (0.9%), dependent (0.4%) (Gunderson, Stout, & Sanislow, 2008). Methodology The present study is a descriptive-analytical and etymology type study and we used inferential statistics to evaluate the relationship. The statistical population of present study consists of women age with major depression disorder that referred to outpatient clinics. Among them 98 patients with major depression disorder who referred to psychiatric center were chosen using Convenience sampling. Measuring instruments included: 1. Clinical interview by psychiatric based on DSM-V 2. Demographic questionnaire 3. The Beck Depression Inventory in order to evaluate depression among psychiatric patients and normal people. The validity of the content and wide use by many experts validates the questionnaire. 4. Millon Clinical Multi-axial Inventory-III ( MCMI-III) to evaluate personality disorder. The questionnaire is very well validated through the Diagnostic Validity for all of the MCMI-III measures. The original MCMI-III scales demonstrated good predictive power (indexes ranging from 0.30 to 0.81) and excellent sensitivity (values from 0.54 to 0.92; Millon, Davis, & Millon,

3 17 Turkish Journal of Psychology 1997). Convergent validity between the MCMI-III and the Minnesota Multiphasic Personality Inventory-2 resulted well (Millon, Davis, & Millon, 1997). In order to analyze and interpret the data, descriptive statistical methods (Frequency distribution, Percentage Distribution, mean and standard deviation) and Inferential Statistics (Pearson Correlation, Chi-squared test and T test) were used. Data was analyzed using SPSS software. Before completing the questionnaires, the written informed consent was obtained and the participants were told about the objectives of the study. Results The results of the study listed as follows. Table 1 depicts the mean of major depression disorder in the subject sample. It also depicts the greater frequency of depression disorder in medium and sever clusters. Table 1. Sample distribution of subject sample based on major depression disorder Variable Frequency Percentage Mean mode SD Major depression disorder (Total) None or the least Minor Medium Table 2. Correlation between severity of depression and personality traits (Personality disorder and clinical syndrome) Personality traits Correlation coefficient 0.261(**) (**) 0.320(**) Antisocial@6A 0.277(**) (**) 0.245(*) Schizotypal S 0.266(**) Borderline C 0.223(*) Paranoid P Anxious A 0.352(**) Somatoform H 0.302(**) Manic N 0.281(**) Dysthymic D 0.249(*) Alcohol dependency Drug dependency Posttraumatic stress disorder 0.373(**) Thought disorder SS 0.328(**) Delusional disorder PP *Level of significance: 0.01 and significant at 0.05

4 18 Turkish Journal of Psychology As can be seen from the table 35 individuals identified with medium as well as severe depression. While 19 (19.4%) of the individuals diagnosed with minor depression. Table 2 shows the relationship between severity of depression and feminine personality traits in year old women. In order to evaluate the relationship, the Pearson correlation test was used. The above table shows that the correlation between depression and personality traits (schizoid, depressed, dependent, antisocial, negativistic, schizotypal) and clinical syndrome (anxiety, somatoform, manic, posttraumatic stress, thought disorder and major depression) is significance at Meanwhile the greatest correlation between severity of depression with personality disorder and clinical patterns is with depressive personality disorder (r=0.46) and the least correlation is with sadistic personality disorder (r=0.1). The correlation order is: depressive personality (r=0.46), negativistic (r =0.32), schizotypal (r=0.27), antisocial (r=0.28) schizoid (r=0.26). Moreover the greatest correlation is between severity of depression and clinical syndrome with anxiety disorder (r =0.35) and the least correlation is with drug dependency (r =0.16). Correlation order with clinical syndrome is: posttraumatic stress disorder (r =0.37), anxiety disorder (r =0.35), though disorder (r =0.33), somatoform (r =0.3), manic (r =0.28) and dysthymic disorder (r =0.25). Table3. Correlation between severity of depression and personality traits (Personality disorder and clinical syndrome) Personality traits Correlation coefficient 0.261(**) (**) 0.320(**) Antisocial@6A 0.277(**) (**) 0.245(*) Schizotypal S 0.266(**) Borderline C 0.223(*) Paranoid P Anxious A 0.352(**) Somatoform H 0.302(**) Manic N 0.281(**) Dysthymic D 0.249(*) Alcohol dependency Drug dependency Posttraumatic stress disorder 0.373(**) Thought disorder SS 0.328(**) Delusional disorder PP *Level of significance: 0.01 and significant at 0.05

5 19 Turkish Journal of Psychology Table 3 shows that that the relationship between major depression disorder with personality disorders (cluster A) is weak and statistically insignificant (P>0.05). Table 4. Relationship between severity of major depression disorder with the frequency of personality disorder in year old women (Cluster B). Personality Disorder Disorder Frequency and Percentage Severe depression x 2 d.f Sig Ø Antisocial Borderline Histrionic Narcissistic Doesn t Has Doesn t Frequency percentage has Frequency - - Percentage - - Doesn t Frequency Percentage has Frequency 5 4 Percentage Doesn t Frequency Percentage has Frequency 5 7 Percentage Doesn t Frequency Percentage has Frequency 1 3 Percentage Table 5. Relationship between severity of major depression disorder with the frequency of personality disorder in year old women (Cluster C). Personality Disorder Frequency Severe depression x 2 d.f Sig Ø disorder and percentage Has Doesn t Avoidant Doesn t Frequency Percentage has Frequency 1 0 Percentage 1 0 Dependent Doesn t Frequency Percentage has Frequency 6 8 Percentage Obsessive- Compulsive Doesn t Frequency Percentage has Frequency 4 0 Percentage 4.1 0

6 20 Turkish Journal of Psychology Table 4 shows that the relationship between major depression disorder with personality disorders (cluster B for borderline personality disorder is weak and statistically insignificant (P<0.05) but for histrionic and narcissistic personality disorder is close to significance and are in an almost sever degree relationship. Table 5 shows that only the relationship between major depression disorder with dependent personality disorder is statistically significant (P<0.05). The severity of relationship of major depression disorder and dependent personality is Table 6. Relationship between major depression disorder and other personality disorder in year old women. Personality Disorder Frequency and Severe depression x 2 d.f Sig Ø Disorder Percentage Has Doesn t Depressive self-destructive Negativistic Sadistic Doesn t Frequency Percentage has Frequency Percentage /4 Doesn t Frequency Percentage has Frequency 1 1 Percentage 1 1 Doesn t Frequency Percentage has Frequency 9 6 Percentage Doesn t Frequency Percentage has Frequency 0 1 Percentage 0 1 Table 6 shows that only the relationship between major depression disorder and Depressive personality disorder is statistically significant (P<0.05). The severity of major depressive disorder and depressive disorder is Discussion Depression is a disabling psychiatric disorder and the costs for the person, family and society are known to be substantial since the high prevalence in active ages leads to rather chronic trend. This mental condition also interferes with the job and school performance and makes its way to disturb relationships (Paykel, 1992). It seems that with evaluating personality patterns and disorders and by exploring the relationship of disorders such as depression which a rather known biological source, basic data can be obtained related to genetic and biologic factors in personality disorders and abnormalities. Thus, appropriate interventions can be provided for treatment. In fact, if the personality disorders comorbidity is evaluated and determined in a systematic way, the patients recover and also relapse is less probable (Maier, Lichterman, & Minges, 1992).

7 21 Turkish Journal of Psychology The present study achieved valuable results and conclusions. It showed that 61 percent of sample patients with major depressive disorder experience personality disorders. Five more comorbid personality traits with major depression disorder include: depressive personality disorder (44%), negativistic disorder (15%), dependent personality (14%), histrionic personality disorder (12%) and borderline personality disorder (9%) and the least comorbid depression disorder and personality traits is: antisocial personality disorder, avoidant personality disorder, sadistic personality disorder, paranoid personality disorder and schizoid personality disorder. comorbidity of major depression and personality disorders in the sample was 61 percent 31.6 percent of which belongs to one disorder, 14.3 belongs to two disorders and 15.3 percent belongs to three personality disorders or more at the same time. The greatest comorbidity of personality disorders relates to depressive-negativistic, depressive-dependent and depressive-borderline disorders respectively. Also 37.7 percent of depressed patients were comorbid in at least one of the personality and clinical measures of Millon Inventory and the greatest comorbidity relates to depressive anxiety, thought, depressive-somatoform and negativistic-dysthymic-thought disorders respectively. This is in compliance with Fava et al., (2002). In their work they showed that 384 outpatient with major depression meet 64 percent of a type of personality disorder criteria. Another finding is that considering the frequency and comorbidity percentage of major depression disorder and cluster a personality disorder, comorbidity of major depression disorder and cluster A personality disorder is 7.1 percent and the greatest comorbidity is with schizotypal disorder. Individuals in cluster A form a homogeneous group and weird traits like social relation split, limited emotional states, specific way of thinking, lack of trust, type of relationship, lack of intimacy, play a part. This is in compliance with the results of Eftekhar, Dadfar and Karimi (2004) findings. They surveyed 648 outpatient people 218 of which (33.6%) consisted of people with major depression disorder and suggested the comorbidity of 9.1 percent between major depression and personality disorders. Meanwhile this study suggested that the comorbidity of major depression disorder and cluster B personality disorder is 25.5 percent and the greatest comorbidity is with histrionic personality disorder and borderline personality disorder. Cluster B is more comorbid with major depression. These people are emotional, histrionic and unbalanced and traits like lack of deep attachment sever dependency demands, lack of emotional balance, and interpersonal relationships, inability in acquiring new skills to regulate emotions, interpersonal relationships and facing emotions such as anger and sadness can well explain the existing comorbidity. This is in compliance with the findings of Abrams et al., (1998). They surveyed 47 patients in different depression stages and showed that patients with interpersonal problems and patients with Cluster A and B personality disorders has less social reaction and weaker relationships after recovery. Another finding of the present study was that the comorbidity of major depression disorder and cluster C personality disorder is 19.4 percent and the greatest comorbidity is with dependent personality. The basic traits of cluster care; anxiety, phobia, liability in different studies. Being highly sensitive to rejection, inhabitation, lacking trust to judgments or personal abilities, obsession and anxiety can explain why the comorbidity is so high. This is in compliance with results of Bukh et al., (2010) findings. Thy surveyed 394 patients and they met 33 percent of personality disorder criteria and the remaining diagnoses were split among cluster A, B and C which had a share of 3.8, 12.9 and 17.8 percent respectively.

8 22 Turkish Journal of Psychology Eventually, they came to this conclusion that the relationship between severity of depression with clinical syndrome (Schizoid, depressive, dependent, antisocial, negativistic and Schizotypal) and also the relationship of depression with clinical syndrome (anxiety, somatoform, manic, posttraumatic stress disorder) are at 0.01 level of significance. The correlation between masochism, borderline and dysthymic personality traits is at 0.05 level of significance. This research showed that the greatest correlation is between severity of depression and depressive personality disorder and the least correlation is with masochism personality disorder. This is in compliance with the findings of study conducted by Goodarzi (2003). In his work he found a correlation between schizoid, avoidant, dependent, passive-aggressive personality disorders with major depression disorder. Evaluating the relationship between the frequency of personality disorder with severity of depression, we led to this finding that the relationship between major depression disorder and Cluster A personality disorder is weak and statistically insignificant.the relationship between major depression disorder and Cluster B personality disorder is weak for borderline personality disorder and statistically insignificant but for histrionic and narcissistic personality disorder is close to significance and are in an almost sever degree of relationship. The relationship between major depression disorder and Cluster C personality disorder is only statistically significant for dependent personality disorder. The severity of relationship between major depression disorder and dependent personality is The relationship between major depression disorder and other personality disorders is only statistically significant for depressive personality disorder. The severity of relationship between major depression disorder and depressive personality disorder is This is in compliance with Kelly et al., findings (2009). They assessed the personality of a population of 300 people and found that 49.8 percent of them are not experiencing any personality disorders while 19.3 percent were experiencing personality disorders, 13 percent were experiencing a simple personality disorder (one disorder) and 17.9 percent of them were experiencing complex personality disorder (at least two disorders). And this is also in compliance with Bukh et al., (2010) work. As is the case with any research, readers need to consider the presented results within the context of limitations including excessive number of items in Millon Inventory which caused fatigue and mitigated incentives for respondents. Also in this search only the personality traits among MDD women were surveyed so it can t be generalized for the whole population. Thus, it may be worth doing further researches on wider sample of MDD patients (of both genders) in private, public and inpatient centers with periodical and chronic trends. With respect to the current research, cultural factors can influence different personality aspects thus; it is suggested to prepare clinical tests tailored for Iranian culture and society to provide better conditions for respondents in order to gather more and at the same time more precise data. Finally, we can conclude that since depression and personality disorders take their roots in a social background, if in a research important social variables are used for explaining comorbidity of depression and personality disorders and determine the effect of the whole on prevalence of depression and personality disorders, a psychological and social treatment can be generated to fight against this issue in the society. It s ideal to consider comorbid personality disorder in early stages (patients experiencing the early signs of depression). Perceiving the reason of simultaneous disorders creates important opportunities for prevention and makes it possible to intervene before the symptoms expand to later stages.

9 23 Turkish Journal of Psychology Acknowledgement Authors would like to express their gratitude to the "DaneshAban" Educational, Research and Treatment Institute which has been instrumental in executive stages, preparation and the successful completion of this project. Compliance with Ethical Standards Funding: None This research received no specific grant from any funding agency, commercial or not-for-profit sectors. Ethical approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent Informed consent was obtained from all individual participants included in the study. References Abrams, R. C., Spielman, L. A., Alexopoulos, G.S., & Klausner, E. (1998). Personality disorder symptoms and functioning in elderly depressed patients. American Journal Geriatr Psychiatry, Winter; 6(1), Agosti, V., Hellerstein, D. J., & Stewart, J. W. (2009). Does Personality disorder decrease the likelihood of remission in early onset chronic depression? Comprehensive psychiatry 2009, 60, Bukh, J. D., Bock, C., Vinberg, M. (2010). Clinical utility of Standardized Assessment of personality Abbreviated Scale(SAPAS) among patient with first episode depression. Journal of effective disorder, 127, Corruble, E., Ginestet, D., & Guelfi, J. D. (1999). Comorbidity of personality disorders and major depression: A review. Service de psychiatric, Hospital Paul. David, J. A., Dozois, D. G. A., & Dobson, K. S. (2004). The prevention of anxiety and depression: theory, research. Eftekhar, M., Dadfar, M., & Karimi, E. (2004). Comorbidity of psychiatric disorders in a Psychiatric outpatient clinic, Andeesheh va Raftar Journal, 10(1&2), 1. Fava, M., Farabaugh, A. H., Sickinger, A. H., Wright, E., Alpert, J. E., Sonawallas, A., Neirenberg, A. A., & Wothington, J. J. (2002). Personality disorders and depression Psychology Medicine, 6, Goodarzi, J. (2003). Efficacy of cognitive-behavioral Therapy (includes stop thinking, problem solving and assertiveness) in the treatment of depression [Master's thesis], Iran university Psychiatric Institute. Gunderson, J. G., Stout, R. L., Sanislow, C. A. (2008). New episodes and new onsets of major depression in borderline and other personality disorders. Journal of Affective Disorders, 111, Joyce, P. R., Mulder, R. T., Luty, S. E., McKenzie, J. M., Sullivan, P. F., & Cloninger, R. C. (2003). Borderline personality disorder in major depression: symptomatology, temperament, character, deferential drug response, and 6_month outcome. Comprehensive Psychiatry, 1,

10 24 Turkish Journal of Psychology Kaplan H. L., Sadock, B. J. (2005) "Comprehensive Textbook of Psychiatry", 18 th Edition. Lippincott, Williams and Wilkins. Kelly, B. D., Nur, U. A., Tyrer, P., & Casey, P. (2009). Impact of severity of personality disorder on the outcome of depression. European psychiatry, 24, Kool S, Shoevers R, Maat SD, Van R, Molenaar Vink A, & Dekker J. (2005). Efficacy of pharmacotherapy in depressed patients with and without personality disorders: A systematic review and meta_analysis. Journal of affective disorder, 88, Mac-Manus, D., & Fahy, T. (2008). Personality disorders. Medicine, 8, Maier, W., Lichterman, D., & Minges, J. (1992). The Familial relation of personality disorder (DSM-III-R) to unipolar major depression. Journal of Affective Disorder, 26, Marneros A. (2009). Mood disorder: epidemiology and natural history. Psychiatry Journal, 2, Millon, T., Davis, R.D., and Millon, C. (1997). Manual for the Millon Clinical Multiaxial Inventory-III (MCMI-III), Second Edition. Minneapolis, MN: National Computer Systems. Mulder, R. T., Joyce, P.R., & Cloninger, C. R. (2004). Temperament and early environment influence comorbidity and personality disorders in major depression. Comprehensive Psychiatry, 35, Paykel, E. S. (1992). Hand book of affective disorders (2 nd ed., pp ) New York: Guilford press. Rennebergm, B., Heyn, K., Gebhard, R. B., Achmann, S. (2005). Facial expression of emotions in borderline personality disorder and depression. Journal of behavior therapy and experimental psychiatry, 36, 3, Wittchen H. U. (1996). Critical issues in the evaluation of comorbidity of psychiatric disorders. British Journal of psychiatry, 168, (30), Zimmerman, M., Chelminski, I., & Young, D. (2008). The Frequency of personality disorder in psychiatric patients. Psychiatric Clinics of North America; 3,