REVIEW PAPERS

Personality Dimensions and Depression:

Review and Commentary
Murray W Enns, MD I , Brian J Cox, PhD 2

Objectives: The relationship between dimensionally assessed personality and the onset, features, and course of
depressive illness will be critically examined and considered in relation to 4 hypothesized models: predisposition
or vulnerability: pathoplasty; complication or scar: and spectrum or continuity.
Method: Studies that have used clinically depressed adult patients to explore the relationship between personality
dimensions and depression will he reviewed.
Results: Higher-order personality factors that have shown a significant and consistent association with major
depressive illness include neuroticism, extraversion (negative relationship), and the factors of Cloninger '.I'
Tridimensional Personality Model. Neuroticism appears to be the most powerful predictor of depression.
Lower-orderfactors showing a significant and consistent relationship with depressive illness include dependency,
self-criticism, obsessionality, and perfectionism. The links between depression and dependency and self-criticism
have the strongest empirical support.
Conclusions: Several personality dimensions are significantly associated with depressive illness, hut the evidence
that unequivocally demonstrates a true personality predisposition for depression is modest. Measures ofperson-
ality may prove to he clinically useful for treatment selection.

(Can J Psychiatry 1997;42:274-284)

Key Words: depression, personality, personality factors, dimensions ofpersonality

P ersonality functioning and depressive illness are com-

plexly interrelated. There is an extensive psychiatric lit-
erature on the relationship between personality disorders and
depression, and this body of work has been reviewed else-
where (1,2). Psychiatrists may be less familiar, however, with
personality dimensions or factors that emerging research has
identified as important in the etiology and maintenance of
major depression.
In contrast to categorical approaches, dimensional assess-
ment seems theoretically more applicable in describing
Manuscript received August 1996,revised December 1996.
I Associate Professor, Department of Psychiatry, University of Manitoba,
Winnipeg, Manitoba.
~As,sistant Professor, Departmentsof Psychology and Psychiatry, University
of Manitoba, Winnipeg, Manitoba.
Address forcorrespondence: Dr MW Enns, PsycHealthCentre, PZ-430771
BannatyneAvenue, Winnipeg, MB R3E 3N4
Can) PsycWatry, Vol 42, Aprll1997
normally distributed traits. such as the continuum of normal
and pathological personality traits, and has advantages in its
precision and its ability to describe "border" cases reliably
(3,4). The relative advantages and drawbacks of categorical
and dimensional personality assessment are described in
more detail by Frances (5), The present review will focus on
studies that have used adult patients with rigorously defined
major depression (for example, Feighner, Research Diagnos-
tic Criteria [ROC], DSM-I11 and its successors) to examine
the relationship between personality or temperament and the
occurrence, course, prognosis, and associated features of
depressive illness. The review will begin by examining broad,
empirically derived (higher-order) factors and then review
several specific lower-order factors that have been associated
with depression.
Conceptually, 4 kinds of relationship may exist between
personality and depression. These include a vulnerability
model (personality factors predispose to the development of
depression), a pathoplasty model (personality factors affect
the expression ofdepression), a complication or "scar" model

274
April 1997 Personality Dimensions and Depression
(depression leads to changes in personality function), and a
continuity or spectrum model (an underlying process is re-
sponsible for the occurrence ofboth personality problems and
d~pression) (6). As studies are described, their consistency
with one or more of these models will be presented.
Neuroticism
. ~euroticism is a major higher-order personality dimension
ongmally derived by factor analysis from large and diverse
samples. (Streiner [7] provides a concise review of factor
analysis.) Neuroticism is a broad, general personality trait, the
c~re of which is a temperamental sensitivity to negative
stimuli. High-neuroticism patients tend to experience a vari-
ety of negative affective states (8). Studies ofthe relationship
between neuroticism and depression have used a number of
different personality measures, including the Maudsley Per-
sonality Inventory (MPI) (9), the Eysenck Personality Inven-
tory (EPI) (10), the Neuroticism, Extraversion, Openness
Personality Inventory (NEO-PI) (I I), and the Munich Per-
sonality Test (MPT) (12). Because neuroticism measures
have been available for many years, a wealth of data on their
relationship to depression is available. Only an overview of
the major findings, therefore, will be presented.
Eight longitudinal follow-up studies of depressed patients
Used the MPI to measure neuroticism, and thus their findings
can be compared easily across studies (I 3-21). Overall, the
stUdies show that depressive patients have higher neuroticism
scores than controls and that chronic or persistent depression
is associated with continued elevation ofneuroticism (consis-
tent with the continuity model or state effects). Recovery from
depression is associated with very gradually declining
neuroticism (consistent with the scar model). Highly elevated
neuroticism scores during depression are predictive of poor
prognosis; "reactive" depression patients exhibit more
neuroticism than endogenous depressives (both observations
Consistent with the pathoplasty model). Finally, premorbid
testing shows greater neuroticism in those who later develop
depression than in those who do not (vulnerability model).
Several other prernorbid assessment studies found that high
neuroticism scores predicted later depression (vulnerability
model) (2 I).
A number of studies of neuroticism and depression have
noted a remarkably powerful relationship between neuroti-
cism and the prognosis of depression (pathoplasty model)
(22-27). One of the most interesting of these studies was
reported by Taylor and McLean (26). They studied 155
depressed patients who were assigned to 4 different treat-
ments (psychotherapy, relaxation. behaviour therapy, or
amitriptyline); high neuroticism predicted worse outcome
regardless of treatment modality.
Several studies have examined the familial relationship
between neuroticism and depression, and collectively, these
studies provide evidence for all 4 of the hypothesized
275
relationships between neuroticism and depression (28-3 I). A
major study by Kendler and others examined the genetics of
neuroticism and depression in a longitudinal study of 1733
female twin pairs using the Virginia Twin Registry (31). The
twins completed neuroticism ratings (EPI) and were compre-
hensively interviewed on 2 occasions, 14 months apart. In
summary, the study demonstrated the following: neuroticism
was strongly predictive of both lifetime and one-year preva-
lence of depression (vulnerability model); an episode of de-
pression occurring between assessments increased
neuroticism (scar model); a current new episode ofdepression
at the second assessment increased neuroticism (continuity
model or state effect); and the relationship between neuroti-
cism and depression was found to be 70% attributable to
shared genetic risk factors for both (continuity) and 10% to
depression increasing neuroticism (state effect).
The broad literature on neuroticism and depression spans
o.ver3 deca?es m~d provides support for each of the hypothe-
.slzed relationships between personality and depression.
~here_ an~, how.:ver, significant limitations to these impres-
sive findings. First, the neuroticism measure has been dem-
onstrated in a .number of studies to be significantly
s~ate-depend~nt; It appears to reflect strongly current depres-
sion ~nd anxiety symptoms in addition to long-standing per-
sonality (31,32). Second, neuroticism is a broad construct that
appears to convey vulnerability in a rather nonspecific man-
ner f~r.a range of"distress disorders" (anxiety and depressive
conditions) .(~,33). C~inicians and researchers alike may
therefore be interested 111 personality traits or factors that have
greater speci ficity.
Extraversion
Extraversion is another major personality dimension that
was derived by factor analysis (9, I0). Extraversion is a stable
heritable, and highly general temperamental dimension char~
acterized by positive emotionality, energy, and dominance
(8,33,34). The same personality tests described earlier lor
neuroticism also contain a measure of extraversion (9-12).
Eight studies of personality and depression that used the
MPI-N (neuroticism) measure also used the MPI-E (extra-
version) scale (13-2 I). Overall, the effects ofextraversion are
less robust than the comparable findings for neuroticism. Like
neuroticism, extraversion appears to be subject to significant
state effects (14,15,18, I9), with depressed subjects showing
a significant increase in extraversion with recovery from
depression. Low extraversion was also shown to be associ-
ated with poorer prognosis in some (13, I 5,18), but not all of
these reports (17,20,21) (pathoplasty model). The one
premorbid assessment study that used MPI-E did not find low
.extraversion scores to be predictive of new onset of depres-
sion (17). The finding of higher prernorbid extraversion
scores (18) compared with postmorbid extraversion scores
( 13-20) provides evidence of a scar effect.
276 The Canadian Journal of Psychiatry
Several other studies have evaluated the pathoplastic ef-
fects of extraversion. While neuroticism has been fairly
consistently associated with depression subtype, reported
studies ofextraversion have been less remarkable. Two recent
studies failed to find a relationship between extraversion and
situational versus reactive types of depression (30,35). Some
studies have found lower extraversion in nonmelancholic or
nonendogenous versus melancholic or endogenous depres-
sion (36), but others have not (37). Extraversion scores have
also been evaluated in relation to the prognosis of depression.
Again, the findings have been mixed, with some studies
finding that higher extraversion is associated with recovery
(26,37) and others failing to find the relationship (24,25).
In a large sample offemale twins in the general population
(N = 1733), no evidence ofa significant relationship between
extraversion and major depression was found; extraversion
did not predict new onset, one-year prevalence, or lifetime
prevalence of depression, and neither the depressed state nor
postdepressive state influenced the level of extraversion (31).
The reported findings regarding the relationship between
extraversion and depression are less robust and consistent
than the data for neuroticism. Continuity, pathoplasty, and
scar models are most strongly supported.
Recently, Clark and Watson have integrated the data on
neuroticism, extraversion, and depression in a tripartite model
of the relationship between temperament or personality and
the "distress disorders" (33). This model groups anxiety and
depressive symptoms into 3 subtypes: nonspecific symptoms
of general distress (related to neuroticism), depression-spe-
cific symptoms of anhedonia, low energy, and low positive
affect (related to low extraversion), and relatively anxiety-
specific symptoms of somatic or autonomic arousal (33,38).
This empirically supported model has proven to be valuable
in organizing research on the relationships among neuroti-
cism, extraversion, depression and the comorbidity ofdepres-
sion and anxiety disorders.
Cloninger Tridimensional Personality Model
Based on a general biosocial theory of personality (39),
Cloninger has developed a novel system of describing and
studying temperament and personality. Cloninger proposed a
system ofpersonality description based on 3 independent and
heritable higher-order personality dimensions that reflect ba-
sic stimulus-response characteristics (40). These 3 major
personality dimensions are termed harm avoidance (HA),
reward dependence (RD), and novelty seeking (NS) and are
measured by the Tridimensional Personality Questionnaire
('fPQ) (41). The TPQ has more recently been expanded and
revised to create the Temperament and Character Inventory
(TCI) (42,43), but the majority ofpublished studies evaluat-
ing the relationship of personality to depression have used the
earlier instrument (TPQ). Cloninger's system of personality
description and classification differs from traditional factor
Vol 42, No 3
analysis-based systems in that the personality variables were
deduced from a synthesis ofinformation from family and twin
studies, neuropharmacologic and neurobehavioural studies in
humans and animals, and studies oflongitudinal development
(40,42). The personality dimensions so derived are hypotheti-
cally related to underlying neurotransmitter systems (HA
relates to serotonergic function, RD to noradrenergic func-
tion, and NS to dopaminergic function) (40).
The depressed state has been demonstrated to affect TPQ
scores. Joffe and others conducted a longitudinal study of
patients with major depression who completed the TPQ while
depressed and at follow-up (44). Patients who had recovered
from depression after 3 months showed a decrease in HA
scores, while those who did not recover had no change in HA
scores. NS and RD did not show significant state effects. In
support of the continuity and vulnerabi lity models, the
authors noted that the HA scores of their depressed patients
were substantially higher than published normative values
regardless of response status (responder versus nonrespon-
der) or clinical state (depressed versus remitted). The scar
model was supported by the observation that HA scores in
remitted depressives are lower than in the acutely depressed
state but still remain substantially higher than norms.
Pathoplastic effects ofTPQpersonalityvariables have also
been demonstrated in a number of studies. The previously
cited study by Joffe and others found that high HA scores
were indicative of poorer prognosis (44). Joyce and others
explored predictors of response to 6 weeks of treatment with
a tricyclic antidepressant in 84 patients with major depression
(45). The authors used combinations of "high" versus "low"
scores on the NS, HA, and RD scales to define 8 temperamen-
tal types (40) that were strongly predictive of treatment out-
come (individually, NS, HA, and RD were not strongly
predictive of outcome). In general, patients with low levels
of NS, HA, and RD and patients with high HA and RD
(regardless ofNS) had a favourable outcome. A later report
partially replicated these results in a group of major depres-
sion subjects treated in an 8-week trial of nefazodone (46).
These reports are impressive in the amount of predictive
power they demonstrate for temperament, but the results are
difficult to reconcile with other studies and require
replication.
Studies of the relationship ofTPQ-assessed temperament
to biological markers of depression have also been published.
Joyce and others studied morning and afternoon cortisol
levels of patients with major depression and controls (47). RD
and NS were significantly predictive of morning hypercorti-
solemia in the depressed subjects. It was interesting that
temperament was a more powerful predictor than the severity
of depression or the number of melancholic symptoms.
The foregoing sections of this review have dealt with
broad, general personality factors that have origins in a larger
framework of personality theory. These broad personality
dimensions can be described as higher-order factors. Such
 April 1997 Personality Dimensions and Depression
personality factors have strong empirical foundations, and as
indicated above, some have shown significant relationships
with depressive illness. These personality factors were not
developed specifically for the study of depression, however.
In their review of the relationship of personality to affec-
tive disorders, Akiskal and others identified a number of
personality associations with depression, including lack of
self-confidence (self-criticism), dependency, obsessionality,
and pessimism, that are strongly connected to clinical obser-
vations and explorations (6). To this list we would add the
cognitively based constructs of sociotropy and autonomy
proposed by Beck and others (48) and perfectionism. (These
clinically grounded constructs can be described as lower-or-
der traits or factors.) Instruments have been derived to meas-
ure each of these personality factors, and over the last 20
years, a significant literature on their relationship to depres-
sive illness has accumulated. The remainder of this review
will focus on these lower-order traits and depression.
Dependency
The role of interpersonal dependency in psychogenetic
predisposition to depressive illness has been recognized for
much of the last century, but systematic study ofthis relation-
ship by operationalizing "dependency" and formally testing
hypotheses has been a more recent development (49). The
basic model of the relationship between dependency and
depression has been that dependency acts as a vulnerability
factor; the dependent individual is vulnerable to depression
When affection, love, or caring from a valued other person is
withheld or lost.
Hirschfeld and others developed the Interpersonal De-
pendency Inventory (101) based on the understanding of
interpersonal dependency as a "complex of thoughts, beliefs,
feelings and behaviours which revolve around the need to
associate, interact with, and rely upon valued other people"
(49, p 374). The 101 has 3 subscales including emotional
reliance on another person (ERA), lack of social self-confi-
dence (LSC), and assertion of autonomy (AA) (50).
The effect of the depressed state on the 101 measure is
robust, with depressed individuals showing a significant de-
cline in both ERA and LSC with recovery (15). Symptomati-
cally remitted depressive subjects, however, continue to have
ERA and LSC scores above expected baseline levels (consis-
tent with scar, continuity. and predisposition models) (16,51).
A comparison of depressed subjects who eventually remitted
against a matched group who remained ill after a 2-year
follow-up did not demonstrate pathoplastic effects of
interpersonal dependency; ERA, LSC. and AA were not
different between groups (52).
In a prospective. premorbid assessment study, a group of
390 never-ill high-risk patients (relatives of depressed sub-
jects) were assessed using the 101 at baseline and followed
for 6 years (17). Among younger subjects. dependency did
277
not predict new onset of depression, but in "older" subjects
(31 to 41 years of age), increased dependency (ERA. LSC)
was associated with the onset of depression (vulnerability
model). Dependency scores in symptomatically recovered
depression patients were higher than the premorbid scores of
new-onset subjects (scar effect). Another study that tested the
scar hypothesis in older subjects obtained results which were
more consistent with dependency as a trait marker (orvulner-
ability factor) and not consistent with scar effects (53).
The specificity of interpersonal dependency to depression
has been questioned. Reich and others conducted a compari-
son of depression, anxiety. and control subjects (54). They
found no difference in the state effects of depression and
anxiety on ERA and LSC and no differences in interpersonal
dependency in panic and depression patients.
Several other authors have noted pathoplastic effects of
101 dependency, though the findings have not always been in
.agreement. Frank and others found that slow responders to
antidepressant treatment were significantly more dependent
(ERA and LSC) than normal responders (13). Boyce and
others found that nonmelancholic patients were more depend-
ent (ERA and LSC) than melancholic patients, but not signifi-
cantly so (55). Another group of investigators conducted a
large study (N = 569) to characterize a "nuclear depressive
syndrome" (consisting of patients who commonly meet cri-
teria lor multiple definitions of the endogenous/melancholic
subtype of depression). They found that "nuclear" depressed
patients were significantly more dependent (ERA only) than
nonnuclear depressed patients (56).
Several important observations have been made about the
relationship of 101 dependency to depression. The ERA and
LSC subscales have been most fruitful. while the AA subscale
has not yielded meaningful positive findings. For this reason,
it has been suggested that this subscale be abandoned (57).
The Interpersonal Sensitivity Measure (IPSM) was spe-
cifically developed as a measure of disposition to depression
(58). The authors defined interpersonal sensitivity as "undue
and excessive awareness of. and sensitivity, to the behaviour
and feelings of others" (58. p 34 I) . Inspection of the item
content of the IPSM reveals a striking similarity between the
constructs of "dependency" and "interpersonal sensitivity"
(57). A prospective. premorbid assessment study showed that
high IPSM scores predicted the onset ofdepressive symptoms
following the stressor of childbirth (59.60) (vulnerability
model). The IPSM has also been shown to distinguish be-
tween remitted melancholic and nonmelancholic depressed
patients; nonmelancholic patients showed higher interper-
sonal sensitivity than melancholic patients (55), and the IPSM
scores of melancholic patients were not different from those
of control subjects (61) (pathoplasty model). High IPSM
score has also been associated with poor outcome in de-
pressed patients (62) (pathoplasty model).
278 The Canadian journal of Psychiatry
Table \. Predisposition to depression: psychoanalytic
and cognitive models
Psychoanalytic construct Cognitive construct
(measured with Blatt's (measured with Beck's
Personality trait DEQ) SAS)
Dependency Anaclitic type Sociotropy dimension
_ Selt:':~~:ism ._L~:oje~~ve ~_e ~:onomy dimension __
The data reviewed suggest that there may be a bidirec-
tional relationship between depression and dependency. Ele-
vated dependency appears to act as a vulnerability factor that
increases the risk of depression, and the experience of having
a depressive episode may increase the individual's interper-
sonal dependency.
Dependency and Self-Criticism
Several authors have conceptualized the vulnerability to
depression as consisting of2 lower-order personality factors:
dependency and self-criticism. Blatt integrated psychoana-
lytic and ego psychological theories to propose 2 personality
structures influencing vulnerability, namely anaclitic and
introjective types (63). In the more primitive anaclitic (de-
pendent) form, the primary concern is interpersonal relation-
ships, and the features of depression predicted are
helplessness, tearfulness, mood reactivity, substance abuse,
and "borderline features." In the introjective (self-critical)
form, the primary concerns are self-worth and identity issues,
and the features of depression predicted are anhedonia, lack
of mood reactivity, social withdrawal, and feelings of guilt
and worthlessness. Personality vulnerability to depression
has also been considered from a cognitive perspective, Beck
offered a formulation using the dual constructs ofsociotropy
(dependency) and autonomy (self-criticism) (64). Cognitive
theorists have also extended these constructs in the Dysfunc-
tional Attitudes Scale (DAS), which is intended to measure
the negative attitudes that organize negative cognitions (65).
The latter instrument is not clearly intended to measure "per-
sonality," per se. It may, however, be quite difficult to sepa-
rate "personality" from "cognition" (Table I).
Blatt's anaclitic and introjective types were reconstructed
into dependent and self-critical personality dimensions in the
Depressive Experiences Questionnaire (DEQ) (66). Several
notable findings on the relationship between DEQ scores and
depression have been reported. There are 3 reports on corn-
parisons of depressed subjects (while acutely depressed and
remitted) versus controls (67-69). The findings can be sum-
marized as follows. First, depressed patients consistently
show greater dependency and self-criticism than controls.
Second, dependency and, to a lesser extent, self-criticism are
affected by the clinical state; both are more pronounced
during depression (continuity). Third, shortly after recovery,
depressed individuals still score higher than controls on both
dependency and self-criticism scales (scar hypothesis), but
Vol 42, No 3
after 6 or more months, these scores move toward normal,
Fourth, self-criticism scores are associated with depression
severity (pathoplasty). Finally, higher baseline DEQ depend-
ency and self-criticism scores are associated with nome-
covery (pathoplasty).
One of the key predictions of Blatt's model of depressive
vulnerability is a difference in the symptom structure of
anaclitic versus introjective depressed patients (63,66,70).
The most methodologically sophisticated study to test this
prediction in these subjects was able to find only limited
support for this distinction (67). The specificity of dependent
and self-critical personality dimensions was assessed in a
comparative study of patients with panic disorder with ago-
raphobia versus major depression (71). No difference in
DEQ-measured dependency scores was observed in the 2
groups; self-criticism, however, was significantly higher in
the depressed subjects, even after controlling for depressed
mood. (One might also expect to find that self-criticism is
nonspecific if social phobia patients were examined, because
self-criticism is a typical clinical feature in socially phobic
patients.)
A conceptually similar model and line of research comes
from Beck and colleagues. Beck's constructs of sociotropy
and autonomy have been studied as personality dimensions
that differentiate "depressions" according to cognitive
vulnerability. Sociotropy refers to a person's need for positive
interchange with other people; highly sociotropic people are
very concerned about disapproval from others, and their
behaviour is often intended to please others and secure their
attachments. Autonomy refers to an individual's need for
independence and the attainment of meaningful goals; highly
autonomous people are preoccupied with potential personal
failure (48). Beck has also postulated that these personality
dimensions may be related to differing clinical presentations
of depression. The highly sociotropic individual is hypothe-
sized to develop depression around a theme of deprivation
and display symptoms typically associated with "neurotic/re-
active" depression (72). The highly autonomous individual is
hypothesized to develop depression around a theme of defeat
and to show symptoms typically associated with "endogene-
morphic depression" (73). These postulated symptom pat-
terns have been subjected to empirical study.
Robins, Block, and Peselow (74) examined the relations
between levels of sociotropic and autonomous personality
characteristics and depressive symptom clusters using Beck's
Sociotropy-Autonomy Scale (SAS) in 80 patients with major
depression. They found a strong relationship between socio-
tropy and proposed sociotropic symptoms, but no relationship
was observed between autonomy and the proposed
autonomous symptom cluster. The authors speculated that the
autonomy measure (rather than the construct) may require
revision. Similar findings were reported by Moore and Black-
burn (75). Observations such as these have led to refinements
in the psychometric assessment of autonomy (76,77). Using
April 1997 Personality Dimensions and Depression
a newer measure of sociotropy and autonomy in a group of
50 depressed inpatients, Robins and Luten (77) were able to
demonstrate a selective relationship between sociotropy, as
well as autonomy, and the predicted sets ofclinical symptoms
(pathoplasty model).
The constructs ofsociotropy and autonomy have also been
demonstrated to predict vulnerability to depression in relation
to speci fie kinds of stressful or negative life events. One study
found that the onset or exacerbation of depressive symptoms,
as well as the total number of symptoms, was more strongly
associated with negative interpersonal events in sociotropic
patients and more strongly associated with negative achieve-
ment events in autonomous patients (78). Another study of
highly sociotropic versus highly autonomous depressed pa-
tients found support for the "personality-event congruence
hypothesis" in the sociotropic patients only (79)
(predisposition).
Important pathoplastic effects (relating to treatment re-
sponse) have also been reported for the personality constructs
of sociotropy and autonomy. In one study of SAS-defined
sociotropy and autonomy and response to pharmacotherapy,
a regression analysis showed that the sociotropy-autonomy
distinction but not the endogenous-nonendogenous distinc-
tion predicted drug treatment response (80). Subjects with
high autonomy plus low sociotropy scores showed greater
response to antidepressants and greater drug-placebo differ-
ences. This striking and somewhat surprising finding clearly
requires replication. Two studies by the same research group
evaluated the response to individual or group cognitive psy-
chothcrapy in relation to SAS scores (8 I,82). In the first
study, the authors observed that sociotropic subjects showed
greater improvement in the more interpersonal context of
group therapy, whereas autonomous patients improved more
in individual therapy. In the second study, matching oftrcat-
ment modality (sociotropic subjects in groups, autonomous
subjects in individual therapy) was not associated with better
treatment outcome but was associated with more sustained
improvement at 2-month follow-up. These findings are con-
sistent with Beck's predictions (48).
There is mixed support for the dependency and self-
criticism constructs, but the results to date are encouraging.
Overall, there appears to be greater support for the depend-
ency dimensions. A variety of methodo logic weaknesses that
may account for the lack ofclear and consistent findings have
recently been identified and reviewed (83). These weaknesses
include the use of arbitrary cut-off points to classify partici-
pants into types and the tendency to exclude those patients
who have both high sociotropy and high autonomy scores (a
group of important subjects who may be at particularly high
risk). Other significant shortcomings in this research area
include the lack of prospective studies and the practice of
assessing symptom change, when in fact the models are
intended to predict the onset of major depressive episodes.
279
In our opinion, there is also a conceptual problem in the
diathesis-event-eonsequence models. Researchers have typi-
cally classified interpersonal events solely in the dependency
domain. Could relationship difficulties not provoke depres-
sion in a highly self-critical individual? Such an individual
may blame himself or herself for the relationship problems
and attribute these difficulties to personal inadequacy.
Obsessionality
A relationship between obsessionality and depression has
been documented in a very large body of literature covering
a period of several decades (84). In contemporary
(psychometric) literature, a critical assessment issue for ob-
sessionality is the distinction between obsessive-compulsive
symptoms (typical of obsessive-eompulsive disorder), such
as genuine obsessive ruminations, rituals, and checking be-
haviours, and obsessional personality traits. such as preoccu-
pation with orderliness, perfectionism, control, and
. conscientiousness. Two of the most commonly used dimen-
sional assessment instruments for obsessional personality
traits are the Leyton Inventory (85) and the obsessional pat-
tern of the Lazare-Klerman-Armor inventory (LKA-O) (86).
The MPT (12) also measures "rigidity," which is very similar
to the construct ofobsessionality.
A series of papers from the National Institutes of Mental
Health (NIMH) examining the relationship between a variety
ofpersonality dimensions and depression was cited earlier in
this review (14-17,52). This series of investigations also used
the LKA inventory to measure obsessionality, with entirely
negative results, Another study that characterized nuclear
(endogenous) and nonnuclear (nonendogenous) types of de-
pression in a large number of subjects with major depression
failed to demonstrate differences between these groups in
LKA-O scores (56). Also, a study comparing ROC-defined
depressed patients with panic patients found no difference in
LKA obsessionality between groups (54). Finally, a study of
LKA obsessionality in normal versus slow responders to
antidepressant treatment found no difference between
groups (13).
In contrast to the collection of negative studies summa-
rized above, studies using other instruments to measure ob-
sessionality have shown positive results. Hirschfeld and
Klerman (14) compared patients with an ROC diagnosis of
depression with manic patients and controls using the Leyton
Obsessional Inventory (LO\). They found higher levels of
trait obsessionality (obsessional personality traits) in de-
pressed than in control subjects and higher levels of state
obsessionality (obsessive-compulsive symptoms) in de-
pressed than in either manic or control subjects. Another very
long-term (18-year) follow-up study of89 inpatients meeting
ROC criteria for depression found that high obsessional in-
terference scores on the LOI predicted poor long-term out-
come, impaired social adjustment, and more time spent in
hospital (pathoplasty) (22). Maier and others (28) studied
280 The Canadian Journal of Psychiatry
MPT -defined rigidity in the relatives of depressed subjects
and normal controls. They found higher levels of rigidity in
both previously depressed and never-depressed relatives of
depressed patients compared with control relatives (most
consistent with vulnerability and continuity models).
Rumination may be a particularly important aspect of
obsessionality. Researchers such as Morrow and Nolen-
Hoeksema (87) have suggested that individuals differ in their
duration of depressive episode in part because of their ten-
dency to engage in rumination in reaction to their depressed
mood. Preliminary evidence from dysphoric subjects and
bereaved adults have supported this contention (88,89). Un-
fortunately, studies of this intriguing hypothesis using clini-
cally depressed subjects have not been reported.
Overall, it appears that the studies reviewed support a
relationship between obsessionality and depression, but they
indicate that the LKA-O measure is problematic. Premorbid
assessment studies using an instrument other than the LKA
measure of obsessionality have not been reported.
Perfectionism
Perfectionism is also thought to confer vulnerability to
depression. The theoretical relationship between perfection-
ism and depression has been described from both cognitive
(90) and psychodynamic (91) perspectives. The basic hy-
pothesis is that perfectionistic standards increase the fre-
quency and magnitude of the perceived failures which can
provoke depression. Two multidimensional instruments have
been developed to quantify perfectionism and its personal and
social aspects (92,93). Only the Multidimensional Perfection-
ism Scale (MPS) of Hewitt and Flett has been studied in
clinically depressed patients. The components of
perfectionism that are identified and measured by the MPS
include self-oriented perfectionism (setting and striving for
unrealistic standards and focusing on flaws), other-oriented
perfectionism (behaviourally similar, but directed toward
others rather than the self), and socially prescribed perfection-
ism (the belief that others hold perfectionistic expectations
for oneself) (93). A recent study compared the Hewitt and
Flett MPS with the Frost perfectionism scale in depressed
patients and found that socially prescribed perfectionism was
the strongest predictor of depressed mood (94).
The specificity of these dimensions of perfectionism to
depression was explored in a study of depressed patients,
matched controls, and anxiety-disordered subjects (95). The
authors reported that self-oriented perfectionism was ele-
vated in depressed subjects compared with both controts and
anxiety patients, whereas socially prescribed perfectionism
was elevated in both depressed and anxious patients relative
to controls. These results suggest that higher levels of self-
oriented perfectionism may be specific to clinical depression,
while socially prescribed perfectionism may be related to
various kinds of maladjustment.
Vol 42, No 3
A significant relationship between self-oriented and par-
ticularly socially prescribed perfectionism and suicidal idea-
tion or intent has also been reported in mixed psychiatric
samples (96,97). Unfortunately, these interesting findings
have not been replicated in a more homogenous clinical
depression group.
The relationship between perfectionism and major depres-
sion has also been explored from the perspective ofa "specific
vulnerability hypothesis." Hewitt and Flett found that
self-oriented perfectionism interacted specifically with
achievement-related stresses to predict severity of depres-
sion, and socially prescribed perfectionism interacted specifi-
cally with interpersonal stresses to predict severity of
depression (the former finding was replicated in a diagnosti-
cally heterogeneous sample, while the latter was not) (98).
These observations are most consistent with a pathoplasty
model (since onset of depression was not considered in this
study). In a recent report from the NIMH Treatment of
Depression Collaborative Research Program, perfectionism
was observed to predict poor outcome consistently, regard-
less of treatment modality (the treatments included interper-
sonal therapy, cognitive-behavioural therapy, imipramine,
and placebo) (99).
The dimensional measures of perfectionism have only
relatively recently been developed, so the literature on per-
fectionism and depression is limited. The relationship be-
tween perfectionism and depression appears to be a promising
area for further research. Clarification is needed regarding the
conceptual and/or measurement overlap between perfection-
ism and other lower-order constructs related to depression.
The most obvious case is self-oriented perfectionism and
self-criticism. Another possibility is a relationship between
socially prescribed perfectionism and interpersonal depend-
ency. Finally, the evidence reviewed indicates that like
neuroticism, perfectionism may be linked to a number of
different clinical disorders in addition to depression. It there-
fore becomes important to demonstrate that perfectionism has
incremental predictive power over higher-order factors
(neuroticism, extraversion) in major depression.
Summary and Conclusions
There are substantial limitations to the intriguing results
reviewed in this paper, and these limitations present signifi-
cant research challenges. As noted in our review, a major
shortcoming in many areas of study is the absence of longi-
tudinal studies in which personality is assessed prior to the
onset ofthe first episode of depression. Such studies provide
the greatest assurance that personality is being assessed with-
out undue influence of the potentially distorting effects of
current or past depression. This is particularly important in
attempting to establish a personality factor or trait as a genu-
ine predisposing factor for depression.
Aprll1997 Personality Dimensions and Depression 281

Table 2. Summary of major findings on the relationship between personality and major depression
Personality/depression models
Pathoplasty:
_Personality factors VUlnerability/predisposition Pathoplasty: outcome symptomatology Scar/compiication Continuity/spectrum
Higher order
Neuroticism ++ ++ ++ ++ ++
Extraversion 0 +/- +/- + +
TPQ factors + ++ + + +
Lower order
Dependency (sociotropy) + ++ +/- ++ ++
Self-criticism (autonomy) + ++ +/- + +
Obsessionality +/- + 0 0 +
Perfectionism + + + 0 +

++ =strongly supported (premorbid assessment is required for strong support of the vulnerability model).
+ =moderately supported (studies are smaller. methodologically weaker. or fewer in number).
+/- =mixed positive and negative findings.
()= not yet demonstrated.

The great majority of research studies examining person-
ality dimensions and depression have relied on self-report
inventories for the measurement ofpersonality. This presents
a substantial methodologic issue because comparisons of
interview and self-report assessments have shown that self-
reports provide more elevated assessments of maladaptive
personality traits, in part because of the effects of depressed
mood (100). In contrast, self-report inventories probably
show an advantage over interviews in long-term test-retest
reliability (10 1).
The frequent observation ofstrong effects ofthe depressed
state on personality "trait" measurement also presents a chal-
lenge. The constructs of personality and mood overlap, and
the distinction between personality and depression is not an
absolute trait-state distinction (101). This is most evident in
the neuroticism factor, which has been described as a "dimen-
sion of stable and pervasive individual differences in mood
and self concept" (102, P 465). A significant association
between a personality factor and a measure of depressive
symptoms suggests that the factor could reflect a predisposi-
tion for depression (103). Excessive overlap between a per-
sonality measure and depression symptom measure,
however, indicates that the personality measure does not
evaluate personality independently of current symptomatol-
ogy (104). For clinicians, the most important implication is
that personality evaluations which are conducted during an
acute depressive episode should be considered with caution.
Another substantial limitation to the research literature on
personality and depression has been emphasized by Coyne
and Whiffen (83). These authors argue that the measured
personality dimensions may reflect current difficult life cir-
cumstances in addition to the trait-like dispositions that they
are intended to tap. For example, involvement in a deteriorat-
ing intimate relationship might result in endorsement of items
reflecting dependency and recent events such as failures in
career or finances may result in endorsement of items reflect-
ing self-criticism. Thus the importance of carefully assessing
the social context in which depression and "personality" are
assessed is clear.
Finally, few studies of the relationships between person-
ality and depression have used measures of several higher-
and lower-order personality factors simultaneously in at-
tempting to explain the onset, features, or course of depres-
sion. Thus opportunities for comparing the validity of
competing th,eories and/or demonstrating the additional pre-
dictive value oflower-order factors (over and above neuroti-
cism) have been limited.
Numerous personality factors that show a substantial
relationship with depressive illness have been identified.
These relationships are summarized (in a simplified manner)
in Table 2. The strongest research evidence pertaining to the
relationship between personality and depression is available
for neuroticism. Several lower-order personality factors are
directly connected with clinical formulations ofdepression in
the form of "specific vulnerability hypotheses." These in-
clude the hypothesized specific association between socio-
tropy or socially prescribed perfectionism and interpersonal
stresses or between autonomy or self-oriented perfectionism
and achievement stresses and the onset or exacerbation of
depressive symptoms. These personality factors may be use-
ful to unify the understanding of depression occurring in
patients with a wide variety or combination of personality
disorders as conceptualized in the DSM-IV.
Evidence is accumulating that measured personality vari-
ables may be useful to guide clinicians in selecting treatment
approaches. For example, highly sociotropic (dependent) in-
dividuals may be treated most effectively in group settings,
whereas highly autonomous (self-critical) patients may do
282 The Canadian Journal of Psychiatry
better in individual therapy (81). Also, because of the asso-
ciations of self-criticism with depression severity (67) and
perfectionism with suicidality (105), cognitive or other psy-
chotherapeutic approaches that can effectively deal with
self-critical and perfectionistic cognitions and personality
styles may be particularly helpful. These examples serve to
highlight the importance of these avenues of research for the
clinical practice of treating depressive disorders.
Clinical Implications
• There is a complex interaction between dimensionsof person-
ality and depression.
• Several personalitydimensions have shown a substanti.al rela-
tionship to the features, course, and treatment responsiveness
of major depression.
• Researchfindingsthat support"specific vulnerability hypothe-
ses" are congruentwith some traditional dynamicformulations
of depression.
Limitations
• Personalityassessment in patients with depression is problem-
atic because of the significant effects that current (or past)
episodes of depressionand current difficult life circumstances
may have on personalitymeasures.
• The numberof prospectivestudies that have assessed personal-
ity prior to the onset of major. depressionis limited.
• The majority of research in this area has been based on self-
report measures of personality.
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Resume
Objectifs : La relation entre la personnalite, dont on a evalue les dimensions. et le debut, les caracteristiques et
l'evolution de la depression fera l'objet d'un examen critique. et elle sera etudiee l 'egard de 4 modeles a
hypothetiques " predisposition ou vulnerabilite. pathophysiologie, complication ou cicatrice et spectre ou con-
tinuite.
Methode: On examinera des etudes portant sur des patients adultes deprimes cliniquement et visant explorer a
la relation entre les dimensions de la personnalite et la depression.
Resultats : Les facteurs de personnalite d 'ordre superieur. qui ont revele un lien significatifet constant avec les
depressions majeures, comprennent les traits nevrotiques, I 'extroversion (relation negative) et les facteurs du
modele de personnalite tridimensionnelle de Cloninger. Les traits nevrotiques semblent constituer Ie predicteur
Ie plus puissant de la depression. Les facteurs d'ordre inferieur, revelant un relation significative et constante
avec la depression, comprennent la dependance, l'autocritique. l'obsessionnalite et le perfectionnisme. Les liens
entre la depression, la dependance et l'autocritique comportent le fondement empirique Ie plus solide.
Conclusions: Plusieurs dimensions de la personnalite sont liees de facon significative a la depression, mais il y
a peu de donnees revelant sans equivoque une veritable predisposition de la personnalite la depression. Les a
mesures de la personnalite pourraient devenir cliniquement utiles dans Ie choix du traitement.In translation