Depressive Personality Disorder Dsmivtr Appendix B

Clinical Description

The appearance of the Depressive Personality Disorder in DSM-IV was not unheralded (Coolidge & Segal, 1998). The DSM-II, published in 1968, had at least two personality disorders with many of the features of Depressive Personality Disorder. Whereas the cyclothymic personality included many of the same depressive symptoms as the current depressive personality, the symptoms alternated with periods of elation in the cyclothymic type. But the worry, pessimism, and general sense of futility are nearly identical to current criteria. The DSM-II also included the asthenic personality, with such symptoms as lack of enthusiasm and marked incapacity for enjoyment. The latter symptom is nearly identical to a feature listed in DSM-IV-TR for the Depressive Personality Disorder, and the lack of enthusiasm symptom is similar to other currently listed features.

The central feature of Depressive Personality Disorder is a pervasive pattern of depressive, pessimistic cognitions and behaviors beginning by early adulthood. The negativism of the individual is thought to be a chronic and unremitting trait and not limited to transient states, nor are the symptoms thought to be elicited only in response to depressing news or events in the individual's life. The person's mood is characterized by a general sense of gloom and joylessness. There is not necessarily a sense of apprehension, as that would connote the person anticipates dread or catastrophe in the near future. With the depressive personality type, it is as if they know dread and catastrophe are certain, so there is no need for apprehension. Their gloominess pervades their sense of self and extends to others. They have a very low self-esteem and a pervasive sense of worthlessness. This describes the individual who experiences life through a gray filter.

People with Depressive Personality Disorder seek out others who would reinforce their lowly self-image and avoid those who argue with them and try to bolster their negative perceptions. This choice of others might also maintain and perpetuate the person's negative self-image and would do little to counter

Table 5.3 Research Criteria for Depressive Personality Disorder (DSM-IV-TR, Appendix B)

A. A pervasive pattern of depressive cognitions and behaviors beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

(1) usual mood is dominated by dejection, gloominess, cheerlessness, joylessness, unhappiness

(2) self-concept centers around beliefs or inadequacy, worthlessness, and low self-esteem

(3) is critical, blaming, and derogatory toward self

(4) is brooding and given to worry

(5) is negativistic, critical, and judgmental toward others

(6) is pessimistic

(7) is prone to feeling guilty or remorseful

B. Does not occur exclusively during Major Depressive Episodes and is not better accounted for by Dysthymic Disorder.

Source: From Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision, American Psychiatric Association, 2000, Washington, DC: Author. Copyright 2000 by American Psychiatric Association. Reprinted with permission.

or ameliorate their overly negativistic worldview. These people might even join groups of other individuals who share their pessimistic views, such as end-of-the-world cults, although many depressive people are prone to isolation. Their cheerless-ness and unhappiness tend to drive others away. When interviewed, patients with Depressive Personality Disorder are often critical of their own behavior and self-derogatory. They freely admit their feelings of guilt and remorse for their current state of affairs. As noted, these negative feelings would also extend to others, so no one would escape their negativistic and critical evaluations and judgmental scrutiny. Some evidence suggests that these chronic depressive traits are heritable and begin before early adulthood (e.g., Coolidge, Thede, & Jang, 2001). Table 5.3 lists the DSM-IV-TR diagnostic criteria for Depressive Personality Disorder.

Potential Age-Bias of Criteria

Because most of the symptoms of the depressive type center around negative mood states and pessimistic, critical attitudes

(and not behaviors that require high energy or stamina), there is little reason to think that older adults would not manifest the symptoms as they are delineated in the manual. One possible diagnostic bias may occur in cases when others incorrectly view the older person's gloominess and negativity as a normal part of aging and not recognize it as part of a lifelong pathological pattern of pessimism and unhappiness.

Theorized Pattern in Later Life and Possible Impact of Aging The aging process is challenging enough, so one can imagine the outcome of a characteristically dour and self-flagellating person. Little is definitively known about the depressive personality type in general, and even less knowledge is available about the effects of aging. Nonetheless, we see two possibilities for the depressive type. The counterintuitive hypothesis might be that people with Depressive Personality Disorder are likely to do as well as anyone else as they age because any of the negative effects of aging might be seen as confirming their lifelong held suspicions that life is a gloomy and cheerless place and continues to be so: "You work hard and then you die." The negative events that have been created by older depressive patients as a consequence of their self- and other-critical behaviors appear to them as a constant, which in contrast to psychologically healthier older adults does not necessarily suddenly upset or surprise the depressive patients. Poor treatment, neglectful care, deteriorating health, and ageism may be seen as something the aging depressive patient expected and anticipated. In contrast, the other hypothesis is that many of the symptoms of the Depressive Personality Disorder might exacerbate as a reaction to some of the "slings and arrows" that physical and mental declines bring with advanced age. Thus, it is possible for features of Depressive Personality Disorder to be more prominent in the elderly when they have not been blatantly characteristic earlier in life.

To some extent, people prone to Depressive Personality Disorder features may have their full-blown symptoms kept at subclinical levels by their spouses or occupations. Because mentally healthy adults are able to keep a balanced perspective about the benefits and vagaries of life, people with depressive tendencies may be propped up by those in their lives with healthier attitudes and perspectives. These situations may be the opposite of folie a deux. The depressive spouse shares the positive illusions of the healthy spouse, a pattern we label as joie a deux. In the situation where the healthy spouse dies first, the depressive person may then revert to more natural depressive traits and symptoms. Although it may appear that the depressive symptoms arose only as a function of the death of the spouse, in reality they have been suspended in a subclinical state by the healthier attitudes of the other spouse. Clinicians may wish to probe depressive patients carefully in such circumstances and interview other family members should these suspicions arise.

Retirement may also exacerbate Depressive Personality Disorder traits, as there are often many naturally positive aspects to one's job or occupation. Those fortunate to have had rewarding job positions and occupations may have had their depressive traits kept at bay by raises, attitudes of healthy coworkers, and other benefits from jobs with self-actualizing potential. With the free time and loss of prestige that often accompany retirement, depressive tendencies may intensify.

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