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Tackling the conundrum of whether medication changes a personality or simply treats symptoms often generates more questions than it answers. At a symposium at APA's 1998 annual meeting, however, one conclusion emerged: Concepts of "symptom," "personality," and "personality disorder" should be reevaluated.
Several psychiatrists presented data from research on the relationship between Axis I disorders treated with medication and changes in aspects of personality. Robert Hirschfeld, M.D., the Titus H. Harris Distinguished Professor and chair of the department of psychiatry at the University of Texas, discussed several studies designed to determine whether patients' personality features and personality disorders change when they are treated for depression. Citing research he has done, he said that patients with abnormal personality features (neurotic, introverted, emotionally reliant on other people) did improve with treatment. They still had abnormal features, but were closer to normal, said Hirschfeld. Likewise, patients with personality disorders treated for depression improved. Two-thirds of patients who had personality disorders at the time of entrance recovered and no longer had disorders.
"I think this addresses the question about whether or not personality disorder improves as depression improves-in an empirical way the answer is yes. My conclusion from this is that the distinction we have made between personality features, personality disorders, and depressive symptoms is perhaps more of a habit, or a tradition, and not something that is really relevant," said Hirschfeld.
"The fact that symptoms can be improved makes the distinction between what we in the past have called symptoms and what we called personality features or aspects of personality, start to blur."
Discussant Robert Michels, M.D., the Walsh McDermott University Professor of Medicine and University Professor of Psychiatry at Cornell University Medical College, critiqued three studies Hirschfeld had outlined and said that there were method-ologic problems to consider. One of his concerns was contamination of data. Personality disorder criteria get contaminated by health-sickness issues because personality disorder is a maladaptive scale, he said. Another study may also have faulty data because doing assessment at the acute stage of depression contaminates assessment. Finally, Michels suggested that weaknesses in assessment tools may have distorted research data.
"The most probable explanation of any tool that seems to suggest that personality changes as a result of treating an acute syndrome is that the tool isn't very good and is picking up information from the state change because it isn't designed to screen out all state-related factors and measure only personality factors," he said.
"Any real data about the effect of treating depression on comorbid personality type or pathology would require a pre-depressed state personality evaluation in order to be confident that we're not dealing with contamination of the evaluation method or strategy because of the state."
Hirschfeld replied that he agrees personality assessment should not be made during periods of depression, but noted that this perspective was not well accepted a few years ago. "I'm pleased that we're moving in the same direction," he said to Michels.
Three other presenters discussed their own research. Carlos Blanco, M.D., a resident in the department of psychiatry at Columbia University, presented a study in which patients with Axis I affective and anxiety disorders completed the Inventory of Personality Organization self-report measure at baseline and completion of a randomized clinical trial of medication. Linda Mullen, M.D., also a resident in the department of psychiatry at Columbia University, presented a study that attempted to determine whether a pattern of defense mechanisms was stable regardless of treatment of an Axis I disorder. Emil F. Coccaro, M.D., director of the Clinical Neuroscience Research Unit and professor at MCP Hahnemann School of Medicine, reviewed the biological correlates of personality as they relate to personality disorder as well as data about the efficacy of psychopharmacologic intervention.
Michels raised questions about the presentations of the two Columbia researchers. "We're troubled by having too few words," he said. "I think one of the reasons for that is that we're working within the DSM-IV framework rather than seeing that as a diagnostic tool. DSM-IV gives us two axes for talking about psychopathology. That was an arbitrary decision by a committee sitting around a table-it is not ingrained in stone. Values of the concept of temperament could be another possible axis. My own model is based on traits and states."
States don't last that long-they change frequently, said Michels, while traits last a long time and change slowly. "Axis 1 mostly talks about states or at least predisposition to recurring states. Axis II talks about traits, but because psychiatry is heavily focused on Axis I issues, we have clumsily merged everything else into traits, ignoring important distinctions among different types of traits."
One type of trait, he said, is the biological constitutional predisposition often called temperament. The second type of trait is character. "Character is seen as an epigenetic conclusion of a developmental process," which interacts with constitutional, temperamental, and environmental factors that become permanently ingrained in the person's repertoire. Character is related to temperament, he said, but it changes slowly, while temperament is permanent. Both can be hard to measure.
Personality has to do with observable phenomena rather than ingrained predisposition patterns. It is the most objective of the classifications and has the highest interrater reliability in scoring, Michels said, but it is also the most likely to be contaminated by state phenomena, context, or social situation. Personality is highly relevant to the situation or state the individual is in, and it can be reliably measured.
Michels again urged psychiatrists to rethink concepts of personality and disorder. "Our conceptual system has been hung up on a diagnostic system that worships interrater reliability and therefore has abandoned theoretical value in guiding our thinking," he observed. "I think we have to bring it back."