The influence of personality on melancholic depression and psychotic melancholia is, at best, slight and may even be non-existent. Personality and temperament appear to be of relevance only to the non-melancholic disorders. (Temperament can be best defined as ‘hard-wired’ and largely genetically driven. Personality, on the other hand, can be defined as temperament modified by life situations generally experienced in our early years.)
There are a number of temperament and personality ‘styles’ that are commonly represented in non-melancholic depression. Those suffering from this disorder could:
- be anxious, or anxious worriers;
- see themselves as shy;
- have a low self-esteem or sense of self-worth;
- be controlling and perfectionist (and become vulnerable when they lose control or have it taken away);
- be sensitive to, or expect rejection in, social and close relationships;
- be volatile and both frustrated and impatient when their needs are not met.
It is important to remember that not all clinically observed personality styles actually increase the individual’s chance of developing depression. Indeed, some actually decrease the chance of depression. For example, while some people who develop a non-melancholic depression have an ‘obsessional’ personality, ‘obsessionality’ is actually somewhat protective, so that ‘obsessional’ people are less likely to become depressed.
A second example involves those with a volatile, impulsive and reckless personality style that may dispose them to depression, but also lead to rapid resolution because they ‘externalise’ their distress.
Thus, here, we are not considering ‘at-risk’ personality styles (that is, ones that necessarily increase the chance of clinical depressive episodes), but more ones that trigger and shape the non-melancholic depressive disorder and which need to be factored into any treatment or management plan.
Models of so-called ‘normal temperament’ emphasise four principal underpinning dimensions. First, we all range along a dimension of being ‘anxious worriers’ through to demonstrating immense resilience to stressful events. Second, we range across an introversion versus extroversion dimension, from being shy and preferring our own company to being party animals seeking novelty, stimulation and excitement. Third, in the dimension of task-orientation, we may function from highly reliable, conscientious, work-focused and even perfectionistic through to easygoing, unreliable and even feckless.
The fourth dimension is simply described as ‘agreeableness’, where we range across a gradient of being pleasant and caring to viewing others as being there principally to meet our needs.
Some personality styles observed clinically appear to reflect basic temperaments (for example, anxious worrying), while others (such as self-blaming) may be acquired.
As each of these personality and temperament ‘styles’ is dimensional, it is rare for individuals to be placed at risk of depression in relation to only one. Nevertheless, each of the four dimensions has some relevance. These are some of the personality ‘faces’ of people who develop non-melancholic depression, with each ‘face’ not only defining the individual’s vulnerability to depressive disorders, but also informing us about how the individual is likely to handle their depression.
The personality style may therefore help shape the therapeutic intervention. At highest risk of developing non-melancholic depression are those with an ‘anxious worrying’ personality style. People with this personality type tend to have family members with a similar temperament style (arguing for a genetic contribution). They are at high risk of developing both anxiety and depressive disorders, which frequently appear in adolescence or early adulthood. Why are they so at risk? Simply because worry drives and perpetuates depression. The next at-risk group is those who have an ongoing low self-worth and who blame themselves when things go wrong. They often turn early criticism into self-criticism and depression.
The third at-risk group is those who are shy and introverted. This group tends to remember themselves in their younger years as being reserved, with few or no friends, and generally avoiding social interaction and being inhibited in their behaviours toward others. As might be predicted, there is an overlap between anxious worriers and the shy and introverted, with anxious worriers likely to remember themselves as being shy in childhood.
The fourth group comprises those who rate high on reliability and conscientiousness, and who are highly self-controlled. They control their environment in direct and indirect ways so as to reduce the chance of being exposed to stressful events. This group is also less likely to seek clinical attention as doing so would involve a risk of surrendering control—a central issue of concern. They are, however, most likely to develop depression when they have lost ‘control’ of an issue that they see as their responsibility (such as their child not taking up an expected career choice or getting into a relationship judged to be unsatisfactory). This group are highly valued as community members, and we seek them out to be our doctors, lawyers or financial advisers. Their vulnerability is the flip-side to their personality style—they lack flexibility and are less adroit in situations when they are required to move from an entrenched view. Their sense of pride—not only in their work but in many other matters—also leaves them particularly vulnerable to depression (and even to suicide) when their reputation or judgment is challenged or impugned.
These four groups can all be described as having ‘internalising’ personality styles. When stressed, they tend to go quiet, muse and worry and retreat from others. Their stress and depression is experienced at the emotional and cognitive level.
This is in sharp contrast to those who have a more ‘externalising’ personality style, of which there are two common types. With the first type, the individual externalises anxiety as irritability when stressed and often becomes irritated by little things, is rattled easily, is quick-tempered and quite ‘snappy’. With the second type, the individual tends to be dramatic, emotional, volatile and often erratic in their general functioning. As the psychiatrist Kay Jamison puts it: ‘For those with a short wick . . . and impulse-laden wiring, life’s setbacks and illness are more dangerous.’
While both personality styles are frequent in those who develop depression, individuals in the second group are less likely to develop persisting clinical non-melancholic depression.
They are more likely to externalise their depression by raising their voice, arguing, throwing things or by being reckless. By releasing their frustration and distress in these ways, they often recover rapidly from their depressed mood. Those around them, however, may end up distressed from the fallout. As Jamison notes, for those who are impetuous and volatile, ‘their. . . risk taking will make them generators and throwers of sparks as well [as] . . . high-wire acts and dealers in discord’.
While there are many personality styles, most can be considered in reference to the six dimensions just described. For example, ‘interpersonal sensitivity’ has been held to be a key risk factor in non-melancholic depression. Here individuals tend to avoid others for fear that they will be rejected, disapproved of, ridiculed or criticised. Thus they feel socially inept and inferior to others. Predictably, they rate high on shyness and introversion, the third dimension.
Interestingly, when depressed, a percentage of people with interpersonal sensitivity develop a clinical pattern of features that contrast with the usual profile, often describing appetite increase rather than appetite loss, and excessive sleep rather than insomnia.
As noted in an earlier chapter, excessive sleeping may restore slow-wave sleep during stressful periods, while food cravings may increase L-tryptophan levels and thus serotonergic transmission. Our research suggests that individuals with interpersonal sensitivity are highly likely to have a primary anxiety disorder. The term atypical depression was developed to describe this clinical constellation of depressive and personality features.
A key cognitive theory of depression argues that those who develop depression view themselves, their future and the world in a negative way, and that this view is ongoing. A number of recent research studies, however, have suggested that such views are generally held only when an individual is depressed.
Their role in causing depression, therefore, has been down-graded in recent times.
Cognitive theorists quite reasonably argue that it is the way in which we see the world, rather than the way the world actually is, that influences our judgments and may or may not lead to depression. Thus, those who do not believe themselves to be particularly influential or masterful are more likely to develop depression. A related ‘locus of control’ theory similarly suggests that those who have an ‘external locus of control’ (that is, they see themselves as a cork on the ocean, prone to being moved around at the whim of others) are highly likely to develop depression. This is in sharp contrast with those who have a strong ‘internal locus of control’; that is, they view themselves as masters of their own destiny and have their hand on the tiller.
✰ Clinical presentation of personality styles
Under stress, personality styles can be magnified. Clinicians see three common patterns in individuals who present with a non-melancholic depression—in addition to many rare and even unique ones. Most common are patterns of (i) anxious worrying, (ii) declared irritability, or manifest volatility, anger and even hostility, and (iii) evident long-standing low self-confidence and high self-blame.
Anxious worriers are highly likely to have had a clinical anxiety disorder (such as panic disorder, social phobia or obsessive compulsive disorder) before developing their initial depressive episode. Where an individual is both depressed and irritable or hostile, two sub-groups appear to exist. Those in the first sub-group are intrinsically anxious (and generally do not have a volatile personality). They become more anxious with their depressive episode, and then externalise their anxiety via irritability. The second sub-group is made up of those who have an ongoing volatile personality style and who generally become angered when their needs are not met.
The third pattern has been defined as a ‘depressive personality’ style by some writers. It describes those whose usual mood is gloomy and unhappy, whose self-concept is dominated by beliefs of inadequacy and low self-esteem, and who are often self-critical and negative. Such people often report life-long depression. ‘Depression’ may be little more than an extension of these long-standing characteristics, so that people in the third group often have difficulty in determining when episodes start and finish.
How can we make better sense of these differing clinical profiles which reflect a mixture of personality styles and depressive features? What are the processes that lie behind the different classes? While personality and temperament styles contribute to non-melancholic depression in many ways, a key factor is their influence on emotional equilibrium.
✰ Emotional equilibrium
Emotional equilibrium is a state of stable balance, such that any disturbance from outside tends to be corrected.
Let’s assume that everyone has an internal ‘regulating machine’ that requires ‘resetting’ after an upsetting event. Most people will develop a depressed mood after an upsetting event, but the great majority return to emotional equilibrium within days (that is, they have a ‘normal’ depressed mood state). Some people, however, are unable to reset their mechanism easily, thus losing their ‘emotional equilibrium’. They remain essentially ‘stuck’. Their personality styles and ways of dealing with events ‘sustain’ the depression, rather than enabling them to ‘get over it’.
So how can equilibrium be lost? There are two main ways:
1. The machinery can fail; for example, if the keel on a yacht breaks off, the yacht will capsize.
2. A ‘positive feedback loop’ can develop. This means that two or more factors can influence each other to such a degree that a small disturbance leads to a further disturbance. This loop is sometimes also called a ‘vicious circle’.
An example of feedback occurs when a microphone is put too close to a speaker. A small noise from the speaker is amplified into the mike, and further amplified by the speaker. While the feedback loop can be of use to create musical effects, such reverberation (mulling over and rumination) is not useful for humans.
Non-melancholic depressions represent what happens when an upsetting event occurs to people with personality styles that ‘sustain’ depression. Those with internalising personalities may create internal feedback. They stew on and worry about the upsetting event, become increasingly self-critical, and keep the mental image of the problem humming round their circuits.
They operate like a feedback loop. Those with externalising personalities may ‘sustain’ their depression by over-reacting to a disturbance and generating new incoming drama, a bit like a guitarist standing close to a loud amplifier.
In addition to treating the depression, the management of non-melancholic depression requires consideration to be given as to how the predisposing and sustaining personality characteristics (such as worrying, irritability, self-critical talk, volatility) can be modified to achieve greater emotional equilibrium. If non-melancholic depression is to be effectively treated, the personality contribution that can both dispose to, and maintain, depressive episodes needs to be identified and modified.
(extracted from) Dealing with Depression: A Commonsense Approach to Mood Disorders by Gordon Parker, published by Allen & Unwin