Tre a t m e n t - R e s i s t a n t

D e p re s s i o n
The Importance of Identifying and Treating
Co-occurring Personality Disorders

Michael Young, MD, MS

KEYWORDS
 Depression  Treatment-resistant depression  Personality traits
 Personality disorder  Borderline personality disorder

KEY POINTS
 Treatment-resistant depression (TRD) is common and produces significant burden to in-
dividuals and society. Comprehensive and individualized approaches are needed to
address this complex clinical situation.
 Diagnostic reevaluation is indicated in cases of TRD to determine the numerous factors
that could be playing a role in the treatment resistance.
 Diagnostic reevaluation in the setting of TRD should include assessment for personality
disorders, because these are common contributors to treatment resistance and are often
not adequately addressed.
 There are validated psychotherapeutic interventions that have proved effective in treating
personality disorders to help patients improve both self-functioning and interpersonal
functioning.

INTRODUCTION

Treatment-resistant depression (TRD) is a significant burden to individual patients and

society because many individuals with depression do not achieve or sustain remis-
sion, despite multiple pharmacologic interventions and treatment settings. Review
of the literature reveals many approaches to addressing TRD, including augmentation
of antidepressants with atypical antipsychotics and other medications, aerobic exer-
cise, manual-based psychotherapies, and a variety of neurostimulation strategies.1
Despite this variety of treatment approaches, TRD remains a common and burden-
some condition, and each case of TRD requires a thoughtful and individualized treat-
ment approach with attention to the biological, psychological, medical, social, cultural,
and spiritual factors involved.

Disclosure: The author has no disclosures.

Sheppard Pratt Health System, 6501 North Charles Street, Towson, MD 21204, USA
E-mail address: [email protected]

Psychiatr Clin N Am - (2018) -–-

https://doi.org/10.1016/j.psc.2018.01.003 psych.theclinics.com
0193-953X/18/ª 2018 Elsevier Inc. All rights reserved.
2 Young

Reevaluating the Diagnosis in Treatment-Resistant Depression

TRD often has multiple contributing factors that need to be identified so that they
can be addressed with a comprehensive and individualized treatment plan.
Reevaluating the clinical diagnoses to help clarify the contributing causes of treat-
ment resistance is an essential component in the assessment of patients with
TRD. Common causes of treatment resistance can include misdiagnosis of
bipolar depression as unipolar depression, co-occurring substance use disorders,
untreated medical conditions, cognitive impairments, trauma disorders, and
co-occurring personality disorders. Considering all of these factors in a method-
ical and thoughtful way is essential in the diagnostic assessment of patients with
TRD (Fig. 1).
Many psychiatrists have observed treatment resistance resulting from cases in
which bipolar depression or mixed states of bipolar disorder have not been recognized
and the symptoms have been treated as a unipolar depression. In these cases, the
medication regimen often has included antidepressants indicated to treat major
depressive disorder but not bipolar disorder. Antidepressants in the setting of bipolar
disorder are often ineffective and can potentially exacerbate the symptoms of the
bipolar illness and lead to agitation, restlessness, and increased anxiety. Considering
the possibility of an underlying bipolar disorder in these cases is often the key to
achieving a more effective pharmacologic approach.
In other cases of TRD, there is an underlying substance use disorder (eg,
alcohol abuse), untreated or undertreated medical condition (eg, hypothyroidism,
cardiovascular disease), underlying cognitive impairment (eg, mild cognitive
impairment, dementia), or underlying trauma disorder (eg, posttraumatic stress
disorder) complicating or confounding the successful treatment of the depressive
episode. Careful history taking, physical examination, urine drug screens, basic
medical screening laboratory tests, neurocognitive testing, and brain imaging
can often be useful in identifying these contributors of treatment resistance
so that appropriate interventions for these complicating factors can be
recommended.
In addition to the aforementioned contributors to TRD, co-occurring personality dis-
orders, including a poorly integrated or disrupted sense of self, can contribute signif-
icantly to treatment resistance and enduring depressive symptoms. For example, in an
avoidant personality disorder there can be low self-esteem, feelings of inferiority,
excessive feelings of shame or inadequacy, preoccupation with and sensitivity to crit-
icism or rejection, avoidance of social activity, lack of energy for engaging in life, and a
deficit in the capacity to feel pleasure. As another example, in borderline personality
disorder (BPD) there can be a poorly developed or unstable self-image; excessive
self-criticism; chronic feelings of emptiness; mood instability; frequent feelings of be-
ing down and hopeless; feelings of low self-worth; and thoughts of suicide, including

Fig. 1. Diagnostic assessment in TRD. D/O, disorder.

 Treatment-Resistant Depression 3

suicidal behavior.2 It is evident when reviewing the criteria for personality disorders
that it can be challenging to distinguish symptoms related to TRD from enduring traits
associated with the personality disorder that are fairly stable across time and consis-
tent across different situations. In these cases, the underlying personality structure
needs to be addressed specifically as a part of the comprehensive treatment plan if
the patient’s symptoms are going to be adequately resolved.

Differences in the Quality of Depression with and Without Personality Disorders

Patients with depression and comorbid personality disorders have been shown to
differ from patients with depression alone on various measures, including those
with personality disorders showing earlier onset, higher severity scores, less social
support, more psychosocial stressors, and poorer response to antidepressant
medication.3
Previous investigators have also examined the relationship of personality traits and
disorder to depressive subtype and outcomes in depressed inpatients. It has been re-
ported that personality disorders are more common in unipolar nonmelancholic
depressed patients compared with unipolar melancholic or bipolar depressed
patients. Furthermore, personality disorder has been related to earlier onset of depres-
sive illness and worse outcome within the unipolar nonmelancholic group of patients.
Obsessive traits have been found to be most common in unipolar melancholic pa-
tients, whereas histrionic, hostile, and borderline traits have been found to be predom-
inant in nonmelancholic depressed patients.4 The outcomes described in this study
provide additional support for the idea that assessment of personality disorders is
an important part of the evaluation in patients with depression, and particularly for pa-
tients with a unipolar nonmelancholic subtype of depression.

Further Exploration of Depression Co-occurring with Personality Disorders

The frequent phenomenon of co-occurring depression and personality disorders can
be understood from a psychological standpoint by assessing factors that contribute to
both depression and personality structure. For example, it has been reported that
among types of childhood maltreatment, emotional and physical neglect were the
strongest predictors of depression.5 Because neglectful and inconsistent caregivers
during childhood can also contribute to a poorly integrated sense of self that is a hall-
mark of certain personality disorders, it is sensible that depression and personality dis-
orders can often co-occur in cases in which there is a history of childhood neglect.
As an example of underlying personality disorder complicating the treatment of
depression, it has been reported that patients with BPD have a poorer acute response
to electroconvulsive therapy.6 Therefore, one of the gold standards for treating severe
and persistent major depressive episodes can be rendered less effective in patients
with BPD. In addition, it has been suggested that a diagnosis of BPD has a significant
impact on the course of symptoms in self-harming adolescents. Specifically, adoles-
cents with BPD have been shown to have poorer treatment outcomes, including
significantly higher levels of clinician-rated and self-reported depressive symptoms
and lower levels of global functioning than those without BPD.7
TRD can occur in the setting of a biological depression without an underlying per-
sonality disorder, in the setting of a biological depression comorbid with a personality
disorder, or in the setting of a personality disorder in which the TRD is primarily a mani-
festation of the enduring traits of the personality disorder (Fig. 2).
In some cases, the biological depression can lead to symptoms that appear to
others as a personality disorder. This situation can occur when the biological depres-
sion, caused by a unipolar or bipolar affective disorder, leads to symptoms such as
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Fig. 2. TRD caused by personality disorder (PD), biological depression (Bio), or a

combination.

avoidance, self-criticism, feelings of emptiness, and suicidal behavior, which are com-
mon in personality disorders. In these cases, the treatment of the depression and the
pseudo–personality disorder is often a biological intervention (eg, medication, neuro-
stimulation) with adjunctive psychotherapeutic intervention (Fig. 3). The ability for bio-
logical treatment of depression to seemingly alter personality characteristics, such as
self-confidence, has also been well described.8
In contrast, in some cases, the personality disorder can be the primary cause of
persistent depressive symptoms and impairment in social and occupational func-
tioning. In these cases, the primary treatment needed is psychotherapy to address
the personality disorder, with the possibility of adding an adjunctive biological inter-
vention (Fig. 4). Given the inadequacy of biological interventions alone in treating
the persistent depressive symptoms caused by a personality disorder, specific treat-
ment of the personality disorder is indicated. Therefore, it is important for an assess-
ment of personality functioning to take place during the initial assessment and during
ongoing follow-up assessments.
Multiple investigators have described the interplay between affective disorders and
personality disorders, with a large body of research dealing specifically with connec-
tions between affective disorders and BPD. In generally considering the effects of per-
sonality disorders on functioning and well-being in the setting of major depressive

Fig. 3. TRD resulting in PD diagnosis.

 Treatment-Resistant Depression 5

Fig. 4. PD resulting in presentation of TRD.

disorder (MDD), it has been shown that co-occurring personality disorders contribute
to impairments in both social and emotional functioning and also decreased sense of
well-being.9 Furthermore, personality disorders at baseline have been shown to pre-
dict accelerated relapse after an episode of major depression.10
Gunderson and colleagues11 have done extensive research on the longitudinal
course in personality disorders. It has been reported that the course of BPD is char-
acterized by high rates of remission, low rates of relapse, and also severe and persis-
tent impairments in social functioning. This finding points to the importance of
identifying and treating co-occurring personality disorders when they occur, so as
to improve the social and occupational functioning for patients recovering from
depression. This improvement in social and occupational functioning can also be an
important factor leading to the patients’ recovery from depression.
Gunderson and colleagues12 also evaluated the interactions of BPD and mood dis-
orders over a 10-year period showing that BPD and MDD showed strong reciprocal
effects, delaying each disorder’s time to remission and accelerating time to relapse.
Galione and Zimmerman13 compared depressed patients with and without person-
ality disorder. Depressed patients with personality disorder had a younger age of
onset; more depressive episodes; greater likelihood of atypical symptoms; and a
higher prevalence of comorbid anxiety disorders, substance use disorders, and num-
ber of previous suicide attempts.
Zimmerman and colleagues14 set out to distinguish bipolar II depression from MDD
with comorbid BPD. It was shown that patients with MDD comorbid with BPD were
more often diagnosed with posttraumatic stress disorder, current substance use dis-
order, somatoform disorder, and other nonborderline personality disorders, whereas
clinical ratings of anger, anxiety, paranoid ideation, and somatization were signifi-
cantly higher. It was also reported that the patients with MDD comorbid with BPD
were rated lower on the Global Assessment of Functioning scale, had poorer current
social functioning, and made significantly more suicide attempts.

Additional Factors in the Diagnostic Assessment for Personality Disorders

To determine the possible contribution of a personality disorder to TRD, a careful diag-
nostic interview needs to be conducted, with particular focus on the quality of the pa-
tient’s relationships and on the amount of integration present in the patient’s sense of
self and others. By including a focus on underlying personality structure and interper-
sonal functioning during the assessment, clinicians are more likely to identify cases in
6 Young

which personality disorders are a prominent factor in perpetuating the depression. For
example, when the patient’s depressed mood and comorbid symptoms are highly var-
iable depending on the specific circumstances of the moment or in response to an
interpersonal conflict, then the clinician should further assess whether the depressive
symptoms are primarily related to a personality disorder. This affective instability
based on the external circumstances is often seen in patients with a borderline per-
sonality structure, who lack a stable and integrated sense of self and others.
It has been shown that patients with BPD show more self-criticism than depressed
patients without BPD.15 It has also been shown that the psychological constructs of
emptiness and abandonment fears are highly associated with borderline disorders.16
Therefore, the occurrence of these psychological constructs should trigger a more in-
depth assessment for BPD as a factor complicating the clinical picture.
A history of self-harm is another important area of assessment in patients being
assessed for depression, because self-harm is related to lower levels of global func-
tioning, higher severity of depressive symptoms, and higher levels of self-reported
emotional dysregulation.17 Because self-harm is a common symptom in BPD,
this history being present indicates a clear need to assess the personality structure
of patients who have self-harmed so that an appropriate intervention can be
recommended.
Previous investigators have proposed that a comprehensive clinical assessment
combines both an assessment of symptoms and also an assessment of identity, level
of defense mechanisms, and global reality testing with a focus on internal representa-
tions of self, others, and relationship patterns. The diagnosis of a borderline personal-
ity organization and moderate to severe symptoms has been reported to indicate the
need for a validated treatment of BPD.18

Consideration of Treatment Options for Personality Disorders

An examination of 3 treatments for BPD (dialectical behavioral therapy [DBT],
transference-focused psychotherapy, and dynamic supportive treatment) showed
that patients in all 3 treatment groups showed significant positive change in depres-
sion, anxiety, global functioning, and social adjustment across 1 year of treatment.19
DBT has been shown to be useful in addressing high suicide risk in individuals with
BPD.20 General psychiatric management (GPM) for patients with BPD is another para-
digm developed as an outpatient intervention that can be delivered by independent
community health professionals.21 GPM can be particularly useful if more resource-
intensive services such as DBT programs are not available. Mentalization-based ther-
apy (MBT) provides another empirically supported approach to BPD that could be
considered.22

Case Studies
To show how TRD can be approached by addressing the underlying personality struc-
ture of the patient, selected aspects of 2 cases are briefly described here. Character-
istics that could identify specific patients have been changed so that confidentiality is
maintained.

Mr G: finding a voice
Mr G, a 50-year-old, separated manager of a transportation company, presented to
the psychiatric clinic reporting a chronically depressed mood throughout his adult-
hood and a persistent inability to discuss his emotions and needs with other people.
Biological intervention in other settings had not been effective at relieving his depres-
sion or in providing relief to his constant feelings of guilt, self-criticism, and passivity.
 Treatment-Resistant Depression 7

When asked what he would like help with he replied, “I want to be able to tell other
people how I feel without becoming emotional.”
Mr G was financially supporting his girlfriend, several of her family members, his
adult children, and his ex-wife, despite her having another significant other and a
separate life. He was working more than 80 h/wk as a manager of a transportation
company to make enough money to support these multiple households financially.
He stated that he frequently berates himself for sleeping in on the weekends and
feels guilty about not getting more done around the house when he was off from
work over the weekend. He described that he has not had the desire to ride his
motorcycle like he used to and he becomes guilty when he sees it. He reported
that he feels “used” and does not tell people what he wants. He added that he would
like to be divorced from his wife and free from paying her mortgage, but he is unable
to ask for a divorce, stating, “It’s easier to not deal with it.everybody is in control of
everything but me.I don’t think I’ll ever achieve happiness unless I can tell people
what I want.” He frequently returned to the theme that he is a “doormat.” It was
evident that at both work and home there was a consistent pattern of him seeing
himself as a doormat across multiple domains in his life and with many different peo-
ple. He described feeling “stuck” in his current circumstances.
When asked about this pattern of being a doormat for others and not being able to
assert himself, he was able to describe that his passive nature may be an effort to be
“the opposite” of his father. It was noted that his desire to not be like his father was
serving to keep him emotionally connected with his father nonetheless.
Mr G’s parents divorced when he was 11 years old. His father was harsh, exces-
sively punitive, and frequently told him, “You can do nothing right.” After the divorce
of his parents, Mr G and his 2 younger siblings were moved around to various apart-
ments in dangerous neighborhoods because of the financial strain of his father’s
absence. Mr G acknowledged that his inability to ask for a divorce after 9 years could
be a demonstration of trying to be the opposite of his father.
Mr G arrived to one session upset about a work meeting earlier in the day; however,
he was passive during the meeting and did not advocate for himself. He described,
“My feelings won’t be perceived well.they’ll say I’m negative.they’ll say I have to
go.the person running the meeting doesn’t like me.I get belittled all the time by peo-
ple who don’t know what they are talking about.I feel dismissed and belittled.I
checked out.I can’t debate it, because I’m never going to win.” When asked to ima-
gine how the situation would have played out if he had responded more assertively he
replied, “They’d be angry.” It was evident that he was experiencing his boss at work as
unfairly dismissive and belittling, similar to the way he experienced his father as a
child, when self-advocacy or expression of anger was not an option for him.
The inability for Mr G to express anger, even when appropriate, and his inability to
advocate for his own needs were identified as central themes that were keeping Mr G
in a constant state of despair and feeling put on by others. It was clear that his anger
was defended against by his becoming passive and, in his words, a doormat. By iden-
tifying this pattern and consistently commenting on this defense to Mr G during ses-
sions, his ability to express anger in the sessions slowly increased.
There were several instances during his therapy during which Mr G developed a sig-
nificant amount of anger showing up in the transference. One such example was on
display during a discussion around a missed appointment, which he initially explained
by his statement, “Sometimes I forget things.” At the suggestion that his missed
appointment could be an unconscious response to the challenge of being in therapy,
he became visibly angry during the session and then missed the next session. The
following session began with Mr G discussing his irritation that his girlfriend was
8 Young

frequently forgetting things. When asked if this comment could be a masked expres-
sion of his irritation at himself for forgetting his last appointment, he became angry and
stated, “I never forget anything. I didn’t forget my last appointment. I went home and
fell asleep and didn’t wake up.”
Several more months of providing a holding environment for Mr G to become more
comfortable expressing his anger enabled Mr G to see that it is possible to express
anger and other emotions without destroying himself or others in the process. The
shame and guilt associated with his anger lessened, and he came to realize that
appropriate expression of anger was an expected and appropriate human behavior.
This progress was demonstrated in session when he described his “mini-break-
through,” during which he was able to advocate for himself in a situation with a
coworker in which he previously would have remained silent, resented the situation,
and directed his anger inward.
Once free to express his wishes and advocate more readily for himself, Mr G no
longer was bound to be a doormat for others, which had been leading to a negative
view of himself and frequent resentment toward others. He was no longer as burdened
by the weight of the world, and he was freer to pursue happiness in his life.

Ms S: finding the self-compassion within

Ms S, a 55-year-old, twice divorced customer service representative, presented to the
clinic to undergo treatment of her chronic depression, obsessive compulsive behav-
iors, attentional difficulties, and anxiety. Ms S described that her chronic depression
was frequently severe and caused significant impairment in her social and occupa-
tional functioning. Her chronic symptoms included depressed mood, anhedonia,
hypersomnia, decreased interest in the world, excessive guilt, low energy, poor con-
centration, poor appetite, and feeling “disconnected” from her family and friends. On
initial presentation she reported various current stressors, including a job she disliked
and found unfulfilling, significant financial difficulties, and fear of foreclosure on her
home, which was in disrepair and almost uninhabitable because of her hoarding.
She described feeling like, “My very presence is an embarrassment,” and that she
has felt this way for years.
Ms S described enduring many medication trials in the past to help manage her
depression; however, she had been exquisitely sensitive to side effects with most
medications that were tried. She had been treated with an array of selective serotonin
reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, mood stabilizers,
and antipsychotic medications to no avail. She described a particularly bad experi-
ence with lithium when she ended up hospitalized because of adverse effects of the
medication.
Early in the course of therapy, Ms S’s notable masochistic traits became evident.
One example of this was seen in her compliant acceptance of a job that she found
humiliating and painful coupled with an unwillingness to seek another position. She
would frequently describe the horrible work conditions, lack of training opportunities,
and unsupportive management that she contended with. Despite having a college de-
gree in education and a history of competent performance working in the insurance
industry, she resigned herself to a customer service job in which she felt constantly
guilty over not being able to satisfy her customers in addition to receiving poor treat-
ment from her employers. When queried whether changing jobs was a possibility, she
was dismissive, stated that no new jobs are listed in the county, and remained deter-
mined to suffer through the day-to-day painful experience of her current job.
Ms S also demonstrated her masochism in her inability to allow herself
any modicum of joy. During the period surrounding her daughter’s wedding, Ms S
 Treatment-Resistant Depression 9

expressed significant depressed feelings, disconnection, and guilt, stating, “I feel like
[my daughter] is leaving me and it is not fair to feel that way.she’s entitled to her own
life.I feel bad that I’m not happy about her wedding.I can’t shake the feeling of
sadness.I feel empty inside.I feel very sad and alone.I feel a huge sense of
loss.her getting married is the beginning of me having to face the mess I’ve created
for myself.”
Another example of Ms S’s inability to allow herself to experience positive emotion
showed up when she received positive feedback at work, noting her development of
an effective working relationship with staff at another location, which was improving
customer service. After relating this positive feedback she continued, “Nothing is dif-
ferent.I’m tired, discouraged, disappointed at myself.discouraged at life in gener-
al.work isn’t any better.I feel like I’m not pulling my weight just like I feel in the
rest of my life.it’s another environment where I haven’t lived up to my capabili-
ties.every second the rug can be pulled from under me and it would be my fault.I’m
just so disappointed in myself.my life wasn’t supposed to be like this.I expected
more of myself.I feel like a major failure.”
Because of the notable and extreme sense of guilt, shame, and self-criticism that
Ms S displayed across many different scenarios, this was formulated as an area of
central importance. Previous investigators have described that identifying the sources
of the masochism, be it parents, culture, religion, or otherwise, is an essential part of
treating masochism in that it can help patients gain insight into the motives behind the
masochistic thoughts and behaviors.23
In this vein, Ms S was encouraged to explore the invalidating and sometimes hos-
tile home environment she experienced as a child. She described, “Growing up, Dad
was always mad, and Mom was always sad.” She stated that she was the middle
child in the household and “tried to please everybody.” Although she tried to please
her parents, she would frequently feel inadequate in her ability to make things right in
her household and this caused her significant distress and guilt. In one session she
stated, “With my mom’s mental illness and my dad’s sternness, I always felt like I had
done something to make them unhappy.the thought of disappointing my father
scared me to death.I spent my life so my dad wouldn’t be mad and my mom
wouldn’t be unhappy.I feel like I’ve let everybody down.my mom, my dad, and
my daughter.” When she lamented in a subsequent session, “I don’t have a right
to expect to feel good or a right to feel happy because my house is in disarray
and my finances are a mess,” it was evident that she was continuing to experience
the unrelenting guilt over not being able to make things right, similar to what she
experienced in childhood.
In another session, Ms S provided another illustrative example of the guilt that she
experienced as a young child. She related a story dating to when she was 10 years old
when she went for a ride in the car with her father. During the trip her father asked both
her and her sister which way he should turn, because both ways led to their destina-
tion. She said turn right and her sister said turn left. After her father turned right, the car
hit a nail in the road and caused a flat tire that needed to be fixed. Ms S responded at
the time with a tremendous amount of guilt and personal responsibility. She described,
“I felt responsible.I still feel that sense of responsibility.I feel personally responsible
that my life hasn’t turned out well.due to my financial indiscretions I have no right to
have fun.I walk around my whole life feeling bad because I feel responsible for every-
thing bad that’s happened.I should have been able to make it better and to do some-
thing so that everybody wouldn’t be hurting.” Ms S carried with her a strong sense of
responsibility for her family’s dysfunction growing up, which continued to undermine
her sense of worthiness throughout her adulthood.
10 Young

From the point of identifying the origin of Ms S’s harsh and critical inner voice, the
therapeutic task included lessening the power that this voice held over her. Over the
next several sessions, Ms S was able to explore feelings toward her mother for being
unavailable at times because of her mental illness and hospitalizations and at other
times becoming angry and yelling at the children. Ms S was able to acknowledge
the anger she harbored toward her mother and how her mother’s critical voice contrib-
uted to her poor self-esteem. In becoming more comfortable with acknowledging her
anger toward her mother, Ms S was able to direct less of her anger toward herself
through self-criticism, which had been perpetuating her depression and contributing
to treatment resistance.
The goal for the therapeutic holding environment for Ms S was to provide the space
for her to develop self-compassion as a replacement to her self-criticism. This goal
was addressed in therapy by helping Ms S gain insight into her suffering so that she
could treat herself with more patience and understanding. Working through many ses-
sions in therapy, Ms S slowly started replacing her self-critical internal voice with an
internal voice more nurturing and accepting of imperfection. After several months of
working on a more self-compassionate inner voice, Ms S discussed what her daughter
wanted for her, stating, “She wants to see me happy and feel successful.to be in a
relationship.because she knows I have a lot to give.” Ms S was starting to give her-
self the permission to get well.

Further Discussion of Case Studies

In the case of Mr G, participation in psychotherapy enabled him to achieve significant
relief from his depressive symptoms and improvement in both social and occupational
functioning. Although the biological intervention of medication management had not
been effective, the psychotherapeutic intervention ultimately allowed for relief from
the feelings of guilt, self-criticism, and passivity that had limited his capacity to advo-
cate for himself and make decisions in support of his well-being and happiness. During
the course of treatment, he developed the capacity to advocate for a more manage-
able work schedule and request more shared responsibility from those he had been
financially supporting so he could achieve a better work-life balance. He also devel-
oped a greater capacity to advocate for his own needs in his interpersonal relation-
ships, which he could readily notice and appreciate. This psychological growth in
Mr G occurred over approximately 2 years of weekly psychodynamically informed
supportive psychotherapy. This type of psychotherapy both reinforces the patient’s
adaptive coping mechanisms and strengths and provides a safe space to explore
the maladaptive defense mechanisms that are present, underlying motivations influ-
encing behavior, and patterns that have developed in interpersonal relationships
over time. Focus on the transference, and particularly the anger that presented in
the room during sessions, was a very useful technique that allowed Mr G to gain better
insight into his own psychological functioning.
Ms S was also able to achieve significant relief from her depressive symptoms and
an improvement in functioning as a result of her participation in psychotherapy.
Although several medication trials were not adequate to achieve remission of her
depression, the psychotherapeutic intervention provided her a framework to allow
herself to heal. Similar to the case of Mr G, the personal growth in Ms S occurred
over approximately 2 years of weekly psychodynamically informed supportive psy-
chotherapy. Because of a fragile sense of self that often left her feeling dejected
and self-critical, a supportive and encouraging therapeutic relationship helped to build
a trustworthy foundation for some of the deeper insight-oriented work that occurred
later in the course of treatment. Early in the treatment, cognitive behavioral techniques
 Treatment-Resistant Depression 11

were also used to help Ms S achieve more immediate control of her hoarding behavior,
which was contributing to a significant amount of daily stress. Ultimately, a psychody-
namic psychotherapy approach, with a focus on how her experiences in childhood
have significantly affected her thought patterns, emotions, and behavior throughout
her adulthood, proved to be a key element of Ms S’s ability to free herself from her
compulsive masochism. During the latter part of the treatment, her improvement in so-
cial functioning was evident in her positive descriptions of her new role as grand-
mother and in her reengagement as a positive presence in her daughter’s life.

SUMMARY

Although the dual-diagnosis approach of treating 2 disorders simultaneously is

frequently discussed in the setting of substance use disorders co-occurring with af-
fective disorders, this dual-diagnosis terminology is not often applied in the setting
of personality disorders co-occurring with depression. However, similar to how
depression often cannot be effectively treated in the setting of active substance
abuse, depression often cannot be effectively treated in the setting of an active per-
sonality disorder, unless the personality disorder is addressed in an effective way.
Therefore, it would be sensible to adopt the dual-diagnosis approach when a patient
is experiencing TRD and a personality disorder is diagnosed or suspected.
Psychotherapy can be particularly useful in managing symptoms of depression and
also comorbid symptoms that contribute to treatment resistance, including personal-
ity disorders. Acceptance and commitment treatment, cognitive behavioral analysis
system of psychotherapy, DBT, and mindfulness-based cognitive therapy have all
shown evidence for treatment of TRD.24 Current evidence also supports the efficacy
of psychodynamic psychotherapy. A review of the effectiveness of psychodynamic
psychotherapy has shown a trend toward larger effect sizes at follow-up, indicating
continued improvement in symptoms after the course of therapy has ended.25
Given that there are now multiple validated methods for treating various personality
disorders, psychotherapy to address underlying personality disorders should be
considered as a first-line, standard-of-care approach in the setting of TRD when there
is a personality disorder diagnosed or suspected.
Reasons that have been given to explain the difficulty in treating comorbid person-
ality disorders include the significant time commitment that treatment requires, a
shortage of clinicians trained in treating personality disorders, and the presumed
high cost of effective treatment. However, given the exceedingly high costs of TRD
to both individuals and society, it is essential for clinicians to recognize the significant
role that personality disorders can play in TRD and recommend a treatment plan to
address the personality disorders when present. Given the long-recognized observa-
tion by clinical psychotherapists and the emerging research evidence that personality
disorders can be effectively treated, a strong case can be made that investing re-
sources into treatment of personality disorders must be a priority in modern psychiatry.
In the case examples described earlier, it was the psychotherapeutic intervention of
providing a safe and supportive holding environment to foster the development of
greater insight and self-compassion that enabled Mr G and Ms S to gain traction in
their journeys of recovery.

ACKNOWLEDGMENTS

The author would like to thank Dr Don Ross, MD, a psychiatrist in the Sheppard Pratt
Health System and faculty at the University of Maryland/Sheppard Pratt Psychiatry
Residency Program, for his assistance with this article.
12 Young

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