Depression or Depressive Personality?

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Readers familiar with the TV series House are familiar with a little-talked about personality disorder. Dr. Gregory House, the prickly genius star of the show, is often brooding, ill-humored, and pessimistic, leading to interpersonal discord; core features of a depressive personality (DP). Interestingly, House also exhibits some narcissistic components, what Millon called a "voguish" tendency in some DP cases.

Depression has, for centuries, been recognized as both a trait (inborn) and characteristic (learned/influenced by environment). Regardless of etiology, it has also been noted to be episodic in some, chronic in others, and so ingrained in yet others that it's "just who they've always been," indicative of personality pathology.

You may be asking, "Where is this Depressive Personality Disorder?" This has a rocky history in terms of acceptance as a condition. Given it may be difficult to differentiate long-term, chronic depression (the generally-accepted definition being at least two years' duration for adults) from personality, which is constant by nature, is the overarching reason why the American Psychiatric Association (APA) ultimately erased this from the Diagnostic and Statistical Manual of Mental Disorders (DSM). Its last mention was in the DSM-IV TR appendix "Conditions for Further Study."

Despite APA's stance, some personality disorder aficionados feel it has validity. Psychologists Todd Finnerty (2009) and Theodore Millon (1996, 2021) are two experts who have advocated for modern-day acceptance of the condition, Millon referring to it as the Pessimistic or Melancholic Personality. Research interest has fallen by the wayside, previous advocates generally accepting defeat, but even some of my undergraduate students have offered that the diagnosis holds water.

These students argued DP presents a different "flavor" than depression per se, and has much more of an interpersonal characteristic. Not that "Axis 1" depression can't affect relationships, but DP brings a global sense of inflexible, maladaptive schema/world view inherent in personality issues, not simply the low self-esteem and hopelessness schematics that occur in episodic depression. Given global core schema are in place by latency (Shannon, 2019), and tend to be learned, it is likely DP evolves from an upbringing where pessimistic and helpless thinking is the norm, perhaps coupled with a genetic predisposition for depression.

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It is easy to see how, for example, a child growing up in a house where a parent with untreated depression models hopelessness and helplessness from the start, could shape the child's tendency to evolve a pessimistic worldview which is, well, depressing. With this mind frame, they never bother trying because "what's the point?" and become bitter and discontented with life, and towards others who do well. People with DP may turn their suffering into a badge, an attempt to capture some self-esteem. It's as if to say, "I've suffered more than you. I'm more resilient." Think of a person who one-ups your hardships, or keeps a running tally of their woes, always ready to share, unsolicited.

The above considered, it is perhaps best to think of DP as similar to the relationship between Schizotypal Personality and Schizophrenia-spectrum conditions. They occupy different points on a continuum but the long-standing, pervasive, baseline pattern that engenders significant interpersonal complications renders it a matter of personality.

This may seem again like splitting hairs, as in Schizophrenia or Schizotypal Personality, but it holds treatment implications. First, let's examine signs the depressive presentation may be DP.

Differential diagnosis tips

1. The person has presented a depressive demeanor for a long as anyone can recall and is troubling to spend time with because of:
2. Brooding, caustic pessimism, frequent criticism of others, and complaints of how everyone else has it better.
3. The person is permeated by thoughts like, "the grass is always greener," "I'll never get it right" and "what a crummy existence I lead."
4. They feel they can’t do anything right, and view themselves as helpless, giving up, and often summons others to take care of them. As Millon noted, this may be a mechanism designed to receive recognition from others and thus feel they do matter, despite their feelings towards themselves.
5. The person is not entirely incapacitated, remaining functioning, albeit not optimally. They appear depressing but are not necessarily depressed per se.
6. Sleep, appetite, and energy disturbances may be present but tend to be secondary complaints.
7. Despite trials of various therapies and anti-depressants, the depressive picture remains "treatment-resistant."

If items in 6 become a primary focus of clinical attention and are coupled with anhedonia, suicidal thinking/complete hopelessness, agitation, psychosis or catatonic symptoms, a superimposed Major Depression episode (MDE) or Dysthymia episode is likely emerging. Superimposed depressive episodes are likely to occur, given the nature of the person's self and worldview.

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Conversely, should such symptoms remit in a patient presenting for MDE or Dysthymia, but they maintain a baseline of 2, 3, 4, and 5, DPD is a likely culprit. As noted by Laptook et al. (2006), DP has prognostic implications for treatment of Axis 1 depressive conditions. Focus on improving DP characteristics will then likely help keep future MDE at bay.

Lastly, individuals I've worked with who meet criteria for DP, like some other personality disorders, tend to elicit a "button-pushing effect." For example, one woman frequently offered that she was positive I could do nothing for her. On one occasion, I gave her a card with a quote relevant to recent topics: "Life isn't about waiting for the storm to pass. It's about learning how to dance in the rain." She impulsively responded, "Well I sure as hell ain't dancing in any rain!"

Treatment implications

1. Focus will not be on categorically improving various symptoms like in depression. Rather, it will be much more relational, because chances are the person is having significant interpersonal relational issues in their life. For example, my patient's snippy reply spurred my reflection, "I went out of my way to show I thought of you, someone who complains of loneliness, by getting you a card I thought you'd find helpful, and that's the response? I'm starting to understand why it's difficult for you to keep peaceful family relationships or make friends." She had nowhere to look but the mirror for why she was unfulfilled, and a more productive course began to unfold as she realized she repelled that which she desired.
2. A large focus must be on challenging core schema about futility and that any search for enjoyment will end in disappointment. Psychologist Jeffrey Young's Schema Questionnaires can be helpful.
3. Therapists will need to be very careful in collaborating with DP clients. Being heavy on the homework, for example, may produce little results for lack of initiative and beliefs they are incapable. Failing to do the work, in turn, reinforces their sense of being a failure, placing therapy in a rut.