- Top of page
Although many clinical studies have been conducted to determine the etiological role and clinical implications of typus melancholicus for unipolar depression, maladaptive personality features in depressive patients have not been well described. This study explores typus melancholicus, as measured by the rigidity subscale of the Munich Personality Test, and maladaptive personality features, as measured by the Temperament and Character Inventory (TCI), in 131 remitted patients with DSM-IV major depression and 154 normal controls. The patients reported significantly higher scores on rigidity and harm avoidance and significantly lower scores on self-directedness and cooperativeness. Only 23.6% of the variance of the rigidity scale was explained by the variance of the seven TCI scales, in which only persistence was significantly correlated positively to rigidity. Cluster analysis identified four subgroups, two of which were characterized by a high rigidity score. One of these two subgroups showed no maladaptive personality features, as measured by the TCI, while the other showed high harm avoidance and low self-directedness. These results indicate that the personality of depressive patients is characterized not only by typus melancholicus but also by maladaptive personality features, that typus melancholicus is not well represented by any TCI scale, and that typus melancholicus and maladaptive personality features can coexist in some depressive patients.
- Top of page
Typus melancholicus is a type of personality that was originally hypothesized by Tellenbach, 1 a German theorist, to have a specific etiological relationship to unipolar depression. This hypothesis is widely accepted by Japanese psychiatrists. 2–4 According to Tellenbach and other Japanese theorists, 2–4 this type of personality is essentially characterized by a kind of obsessionality that is directed to the pursuit of identification with social norms and much consideration for other people around the individual. Some authors 3,5,6 emphasize that the obsessionality of typus melancholicus should be differentiated from the obsessio-nal personality in the psychoanalytical literature; 7 the latter is typically directed to the domination and manipulation of other people around the individual. Many empirical studies 5,6,8–13 using personality inventories for assessing typus melancholicus have shown that this type of personality may be specifically related to unipolar depression, although some studies have failed to obtain similar results. 14,15 Several studies with family study designs 16–18 have found that first-degree relatives of probands with affective disorders are also characterized by this type of personality; these results suggest that this personality may be a mediator between the genetic factor and the onset of affective disorders.
The relationship between typus melancholicus and unipolar depression has long fascinated Japanese psychiatrists. A number of psychopathological studies in Japan have emphasized a possible etiological role and clinical implications of typus melancholicus in unipolar depression. These studies seem to have not paid sufficient attention to systematic evaluations of personality features other than typus melancholicus in depressive patients. However, is the personality of depressive patients characterized only by typus melancholicus? Contrary to Japanese psychiatry, many studies from Western countries appear to be interested in describing maladaptive personality features as defined by personality disorders. 19–24 These studies have found that at least 50% of depressive patients are diagnosed as having a comorbid personality disorder. Furthermore, some studies 25–33 have suggested that such maladaptive personality features as seen in depressive patients may be of clinical importance in predicting the response to biological treatments and the long-term prognosis, although these maladaptive personality features have been shown to be less important for the etiology of depression. 34 Admittedly, typus melancholicus is an interesting personality feature that is possibly related to the etiology of unipolar depression, but maladaptive personality features may also be important in developing and understanding the complex relationship between personality and depression.
Why have maladaptive personality features in depressive patients been almost ignored in Japanese psychiatry? One possible reason is that in Japanese psychiatry it appears to have been believed that subjects with typus melancholicus are less likely to have significant inner conflicts or daily problems surrounding social adjustments that may induce clinicians to make a diagnosis of a comorbid personality disorders (namely, typus melancholicus might be negatively correlated to maladaptive personality features). However, such a belief has not been tested in empirical investigations. In our own clinical experiences, this belief in the Japanese psychiatry does not seem to be applicable to all depressive patients. Although some depressive patients with typus melancholicus appear to suffer from no daily problems surrounding social adjustments and no significant inner conflicts, other patients appear to be characterized by high levels of inner conflicts surrounding their social adjustments, even though they clearly show personality features of typus melancholicus.
The present study has attempted to investigate the relationship between typus melancholicus and maladaptive personality features in depressive patients (who had been remitted from DSM-IV major depressive episodes). This study explores typus melancholicus, as measured by a self-rating questionnaire, and maladaptive personality features, as measured by the Temperament and Character Inventory (TCI) 35,36 personality dimensions, in 131 remitted patients with major depression and 154 normal controls. The TCI 35,37 is a self-rating personality questionnaire developed by Cloninger’s biosocial theory of personality. This theory is becoming very popular in the psychiatric field because it refers to proposed biological bases for the development of personality, and its personality questionnaires have a strong capability to describe maladaptive personality features. The TCI produces seven personality dimensions, some of which have been shown to be related to maladaptive personality features.
The present study focused on three issues: (i) whether typus melancholicus and the TCI dimensions are related to the diagnosis of major depression (DSM-IV); (ii) to what extent typus melancholicus is explained by the TCI dimensions; and (iii) whether depressive patients with a high typus melancholicus score show maladaptive personality functions.
- Top of page
Table 2 shows the results of comparisons of the rigidity scores and TCI scores between the two groups. To minimize the chance of type I error, the significance level for each analysis was set at P < 0.006 (0.05/8) by using Bonferroni’s adjustments. A significant effect of sex was found on reward dependence; across the groups, women reported a significantly higher score on this scale than did men. Significant effects of diagnosis were found in harm avoidance, self-directedness, cooperativeness, and rigidity; the patients reported significantly higher scores on harm avoidance and rigidity and significantly lower scores on self-directedness and cooperativeness than did the normal controls.
Table 2. Observed mean scores (SD) on the Temperament and Character Inventory dimensions and typus melancholicus
| ||Major depression||Normal controls||Post-hoc univariate analysis of covariance |
|Personality dimensions||Male||Female||Male||Female||Effect of sex†||Effect of diagnosis†|
|Harm avoidance||25.9 (5.3)||25.5 (6.4)||16.8 (6.1)||18.7 (5.7)||0.40||53.24**|
|Novelty-seeking||18.8 (5.2)||18.9 (4.7)||19.8 (4.5)||19.7 (4.6)||0.94||1.51|
|Reward dependence||13.7 (3.0)||15.5 (2.9)||14.5 (3.0)||15.4 (2.8)||11.38**||0.00|
|Persistence||3.9 (1.7)||4.1 (2.1)||4.5 (1.9)||4.3 (1.8)||0.99||0.75|
|Self-directedness||22.6 (7.1)||22.6 (7.3)||29.4 (6.0)||25.6 (6.3)||3.81||11.82**|
|Cooperativeness||26.7 (5.9)||27.9 (5.9)||29.9 (5.8)||30.9 (4.6)||2.65|| 8.41*|
|Self-transcendence||10.3 (5.4)||9.8 (4.9)||10.0 (6.3)||10.9 (5.8)||0.46||1.01|
|Rigidity||11.3 (4.7)||10.5 (4.9)||8.1 (4.3)||8.0 (4.1)||1.38|| 9.23*|
Table 3 demonstrates the relationship of the rigidity scale to the TCI scales in depressive patients. In order to eliminate the effects of age and depression severity, a hierarchical multiple linear regression analysis was used with age and depression severity being entered at the first step and all TCI scores being entered at the second step. The dependent variable was the rigidity score in the analysis. As shown in Table 3, the model improvement from step 1 to step 2 was highly significant (F change = 5.56, d.f. = 9,121, P < 0.001). R2 change at the second step was 0.236; this indicates that the variance of all TCI scores explains 23.6% of the variance of the rigidity score. In the model at step 2, persistence was positively correlated to rigidity (P < 0.01), while novelty-seeking tended to be negatively correlated to rigidity (P < 0.1).
Table 3. Relationship of TCI dimensions to rigidity after eliminating out the effects of age and depression severity (results of hierarchical linear multiple regression analysis)
|Steps||Independent Variables entered ||Beta||S.E.||Partial correlation||t||P|
|Step 1: R2 = 0.037|
| F(2, 128) = 1.74, P < 0.10|| || || ||(d.f. = 128)|
| ||BDI score||0.001||0.046||0.002||0.02||0.984|
|Step 2: R2 = 0.273 (R2 change = 0.236)|
| F(9, 121) = 3.55, P = 0.001|
| (F change (7, 120) = 5.56, P < 0.001)|| || || ||(d.f. = 121)|
| ||Harm avoidance||− 0.043||0.117||− 0.053||−0.37||0.713|
| ||Novelty seeking||− 0.234||0.120||− 0.240||−1.95*||0.055|
| ||Reward dependence||− 0.115||0.171||− 0.072||−0.67||0.504|
| ||Self-directedness||− 0.038||0.090||− 0.056||−0.42||0.676|
Table 4 outlines the results of cluster analysis. The four personality scores (rigidity, harm avoidance, self-directedness and cooperativeness) were used in the analysis, since these personality scores significantly differed between the patients and normal controls in Table 2 and were therefore thought to mainly characterize the depressive patients. The cluster analysis procedure in SPSS showed that a four-group solution maximized the differences among the groups. Table 4 summarizes the differences among the four subgroups. The overall group differences in the personality dimensions were estimated by using ANOVA, and thereafter multiple comparison procedures with Bonferroni’s adjusted confidence intervals were performed. Of the four subgroups, two (subgroups II and III) were characterized by high rigidity. These two subgroups reported similarly high cooperativeness scores but were distinguishable from one another based on harm avoidance and self-directedness. While the subjects classified in subgroup II reported scores similar to the normal controls on harm avoidance and self-directedness, the subjects classified in subtype III reported a higher score on harm avoidance and a lower score on self-directedness. In other words, two different subgroups were recognized in depressive patients with high rigidity; one subgroup (III) was, in addition to high rigidity, characterized by significant personality deviations from normal controls on the harm avoidance and self-directedness dimensions; and the other subgroup (II) showed no such additional deviations on the TCI dimensions. The personality of the latter subgroup was characterized mainly by high rigidity.
Table 4. Personality features characterizing four subgroups of depressive patients produced by cluster analysis
| ||Four subgroups generated by cluster analysis||Group differences|
| ||I (n = 28)||II (n = 29)||III (n = 32)||IV (n = 42)||Overall group differences||Contrast|
|Age, mean (SD)||44.6 (11.8)||48.9 (12.2)||50.3 (15.7)||47.7 (13.5)||F (d.f. = 3, 127) = 0.72†|
|Sex, female, n (%) ||14 (50.0)||15 (53.6)||20 (62.5)||29 (69.0)||χ2 (d.f. = 3) = 2.60§|
|Harm avoidance||29.4 (4.2)||18.7 (5.2)||29.6 (4.1)||24.9 (4.0)||F (d.f. = 3, 127) = 31.6†,*||I = III > IV > II|
|Self-directedness||16.5 (4.2)||29.0 (4.7)||16.5 (4.6)||27.5 (3.7)||F (d.f. = 3, 127) = 18.9†,*||II = IV > I = III|
|Cooperativeness||19.3 (3.7)||32.6 (4.1)||29.6 (3.1)||27.6 (3.8)||F (d.f. = 3, 127) = 51.8†,*||II = III = IV > I|
|Rigidity||9.1 (4.3)||14.6 (4.7)||13.4 (3.7)||7.6 (3.0)||F (d.f. = 3, 127) = 58.7†,*||II = III > I = IV|
The other two subgroups (I and IV) identified by cluster analysis were characterized by low rigidity and high harm avoidance. While subgroup IV reported scores similar to the normal controls on self-directedness and cooperativeness, subgroup I was also characterized by low self-directedness and low cooperativeness. There was no significant difference in age and sex ratio among the four subgroups identified by cluster analysis, indicating that the four subgroups were distributed independently of age and sex.
- Top of page
The results of the present study indicate that the self-rated personality of depressive patients is, compared with the self-rated personality of normal controls, characterized on the whole by a higher score on typus melancholicus, as measured by the rigidity subscale of the MPT. Although this study did not explore control subjects with mental disorders other than major depression, the results are consistent with the view in Japanese psychiatry that typus melancholicus may be a premorbid personality feature of depression.
It appears, however, that the personality of depressive patients is characterized not only by a higher score on the typus melancholicus scale but also by deviated scores on some TCI personality dimensions. As shown in Table 2, depressive patients reported a higher score on harm avoidance and lower scores on self-directedness and cooperativeness. Several studies 43,48 have consistently found that low self-directedness and low cooperativeness are significantly related to maladaptive personality functions (i.e. personality disorders as defined by DSM-III and its revised versions), and high harm avoidance is significantly related to symptoms of cluster C personality disorders. Based on these significant relationships between the three TCI dimensions and personality disorders, the results of this study can be interpreted as indicating that the self-rated personality of depressive patients is, on the whole, characterized by both typus melancholicus and some deviated personality features suggestive of the presence of personality disorders.
The concepts that depressive patients are characterized by maladaptive personality features does not seem to have been well accepted in Japanese psychiatry, although many studies including those conducted in Japan have shown at least 50% of depressive patients are diagnosed as having one comorbid personality disorder. 19–25,49 Furthermore, there is some evidence that comorbid personality disorders in depressive patients are predictive of the response to biological treatments, 25–32 although typus melancholicus has not been shown by several studies to be related to antidepressant responses in major depression. 6 Maladaptive personality features, as measured by the TCI, have also been reported to be related to a poorer response to antidepressant treatments. 50 Some studies have found that comorbid personality disorders or maladaptive personality features in depressive patients predict long-term outcome including converts into bipolar disorders. 33 Given the evidence of these previous studies, the results of the present study suggest that much more attention should be paid to maladaptive personality features in order to describe the various aspects of personality in depressive patients and to more thoroughly understand the relationship between personality and the outcome in depression.
It is interesting to determine whether typus melancholicus is related with the TCI scales, and to what extent typus melancholicus is explained by the TCI scales. The multiple linear regression analysis in the present study indicated that only 23.6% of the variance of typus melancholicus, as measured by the rigidity scale of the MPT, was explained by the variance of TCI scores. This means that typus melancholicus is relatively independent of any TCI scale. The highest partial correlation to the rigidity scale was seen for persistence (r = 0.318, P < 0.01); but this TCI dimension did not differentiate depressive patients from normal controls. These results suggest that typus melancholicus is moderately correlated to persistence but is largely different from persistence in the diagnostic performance. Typus melancholicus may be a special personality feature, the constructs of which cannot be represented by any TCI scale.
The finding that typus melancholicus is relatively independent of any TCI scale suggests that in some depressive patients, typus melancholicus and maladaptive personality features, as measured by the TCI, can coexist. This was confirmed by the cluster analysis conducted in the present study. Among the four subgroups identified by the analysis, two subgroups with a high typus melancholicus score were found: one (subgroup II) was characterized only by a high typus melancholicus score, but the other (subgroup III) was characterized not only by a high typus melancholicus score but also by maladaptive personality features such as high harm avoidance and low self-directedness. High harm avoidance and low self-directedness suggest that maladaptive personality features, as seen in subgroup III, are mainly characterized by features of cluster C personality disorders. The results of the cluster analysis suggest that although typus melancholicus can be seen in some patients without maladaptive personality features, it is also seen in other patients together with maladaptive personality features related to cluster C personality disorders.
The results of the cluster analysis are inconsistent with what has generally been believed in Japanese psychiatry, but are consistent with our clinical experiences described in the introduction. A systematic study by one of the authors (TS) 51 has also shown that in another sample of unipolar depression, some depressive patients with a high typus melancholicus score have severe personality disorders. It should be noted that two empirical studies favor the view that typus melancholicus can, in some depressive patients, coexist with maladaptive personality features, indicating that the belief in Japanese psychiatry is not underpinned by scientific evidence.
Some studies 51–53 have suggested the possibility that depressive patients who show both typus melancholicus and maladaptive personality features may be classified into ‘atypical’ subtype of major depression; this subtype has been newly adopted by DSM-IV. It is unknown, however, whether depressive patients who show both typus melancholicus and maladaptive personality features differ from other depressive patients in terms of other variables such as clinical features, treatment responses, long-term prognosis, and family history. These issues need to be clarified by further study; such a study may make a large contribution to identifying the possible importance of typus melancholicus for DSM-IV subtypes of major depression.
The cluster analysis in this study found two subgroups with a low typus melancholicus score. The number of patients classified into these subgroups was not small. One of the two subgroups (subgroup I: n = 28) was characterized by high harm avoidance, low self-directedness, and low cooperativeness, while the other (subgroup IV: n = 42) was characterized only by high harm avoidance. These results indicate that more than a small number of patients with major depression may not show typus melancholicus, and that the TCI scales may have a strong capability of describing the personality of depressive patients who lack the personality features of typus melancholicus.
Because our exclusion of the nine depressive patients who were not remitted at the 26-week outcome assessment may have selection-biased our results, we replicated our analyses using the entire sample with the nine patients included. Both sets of results were similar, indicating that our findings were not significantly distorted by selection bias. It is interesting to speculate that the personality features that were related to major depression reflect premorbid personality function. The personality assessments in the present study were performed when the patients were remitted, assuring us that the results in the present study have not been distorted by the state effects of depression. In addition, recent longitudinal studies 54–56 have indicated that self-rated personality features, such as neuroticism and similar other personality dimensions, are not significantly affected by prior experience of depressive episodes, as based on both epidemiological and clinical samples. These studies favor the view that personality deviations related to major depression strongly reflect the premorbid personality function. However, prospective studies will be necessary in the future in order to replicate the results of this present study.