edited by Michael Rosenbluth, M.D., Sidney H. Kennedy, M.D., and R. Michael Bagby, M.D.; Arlington, Virginia, American Psychiatric Publishing, Inc., 2005, 343 pages softcover, $39.95
Dr. Gans is a licensed psychologist at Forensic Services, Arlington, Massachusetts.
The editors of this volume, who are much published in this field, have collected articles that address the relationship between personality disorders, axis II diagnoses, and depression. The book addresses the diagnostic and methodological issues that affect the study of this relationship. These issues include, but are not limited to, terminology and definitions, data collection, gaps in the research, and treatment implications. The book will be valuable to prescribers, treating clinicians, and researchers.
The book is divided into two sections: Conceptual Issues and Treatment Implications. First, we get a history of the idea of personality, starting with the medieval conception of humors. The rest of the book reminds us that personality is a historical construct and does not have one definition, and neither does depression. For instance, some models of personality are "categorical"; that is, they postulate a fixed personality made up of more or less consistent features and traits. In this model, a personality disorder represents a categorical deviation from a healthy personality. Other models suggest a dimensional approach, that is, personality disorders exist along a spectrum of personality types and exaggerate traits that constitute all of our personalities.
Depression also appears in a variety of forms: dysthymia, major depressive disorder, bipolar I and II, and the possibility—though not formalized in DSM IV-TR—of a depressive personality disorder. Depression ranges from mild to severe, from transient to chronic or recurrent. Not all researchers are studying the same things.
Data collection is complicated. For example, it is difficult to differentiate sometimes among the symptoms of depression, the consequences of being depressed, and a personality disorder. The patient may not be a reliable reporter. How does a researcher know what the patient was like before depression and who is a reliable source of information? We don't know yet whether mood disorders and depression are independent of one another or whether they interact, reinforce, and permanently influence one another.
The section on treatment likewise raises important questions. Personality disorders seem to exacerbate depression and negatively influence treatment outcomes. Yet the book demonstrates how this generalization is open to interpretation and analysis. If we know how different personality disorders interact with depression and whether they affect treatment seeking, compliance, or the therapeutic alliance, we may be able to intervene. The authors encourage therapeutic optimism.
The book does a good job of presenting the provisional quality of what we know and asking salient questions. The chapters on adolescents and elderly patients especially highlight areas for further research. Psychopharmacology at times eclipses the role of other treatment modalities, but cognitive-behavioral treatments and some illuminating case studies are also given attention. A chapter that addressed the situational and cultural influences and biases that color our notions of personality, personality disorder, and depression would have offered a wider context in which to consider the issues. These are minor complaints, and the references are numerous so any reader can find further resources. The questions raised are as interesting as the results found.