Treating the Toughest Cases of Depression and Brain Illness

Resilience and how to Strengthen Resilience

The complexity of personality functions is another unexamined aspect to the process of refining an individualized treatment plan. As Clonninger told us in 1992:

In order to overcome arbitrariness inherent in categorical diagnoses of affective, personality and anxiety disorders, we use a dimensional approach to personality, mood and anxiety. According to our results, mood and anxiety states affect personality domains differentially. Namely, relatively large portions of personality and behavior, such as higher-order traits of novelty seeking and reward dependence, seem independent from mood and anxiety states. In contrast, the higher-order dimension of harm avoidance and its corresponding lower-order traits reflect changes in mood and anxiety to a much greater extent. Both the likelihood that large portions of personality may be independent from current mood and the likelihood that some precisely delineated personality domains tend to change simultaneously with current mood may improve our understanding of the relationship of personality to emotionality and affective disorders.

Of particular interest is how to facilitate the patient to become his own agent in the maintenance of well-being. Hirschfeld described the complex interplay of personality, mood disorder, and resilience:

Thirty-one female patients with primary nonbipolar major depressive disorder were assessed diagnostically using the Schedule for Affective Disorders and Schizophrenia and completed a battery of standard self-report personality inventories when they were completely symptom free. Their personality scale scores were compared with those of female relatives who had recovered from the same type of disorder, those of female relatives with no history of psychiatric illness, and published scale norms. Compared with the normal population, both groups of recovered depressives were introverted, submissive, and passive, with increased interpersonal dependency but normal emotional strength. Comparison to never-ill relatives yielded similar results except that the never-ill relatives had scores reflecting extraordinary emotional strength.

In this regard we can might direct attention towards Dweck’s work on malleability. She states:

My research shows that acquired beliefs play a critical role in how well people function. These are people’s self-theories. Some people have a fixed (or ‘‘entity’’) theory, believing that their qualities, such as their intelligence, are simply fixed traits. Others have a malleable (or incremental) theory, believing that their most basic qualities can be developed through their efforts and education. Research shows that people with a malleable theory are more open to learning, willing to confront challenges, able to stick to difficult tasks, and capable of bouncing back from failures. These qualities lead to better performance in the face of challenges such as difficult school transitions, demanding business tasks (e.g., negotiations), and difficulties in relationships (e.g., dealing with conflict). All of us would agree that these are a key part of how people function.

Dweck then continues with the next paragraph:

However, a malleable theory can be taught. When it is, people show increased motivation to learn and they perform better on challenging tasks. How is the malleable theory taught? In a study by Aronson, Fried, and Good (2002) with college students at a rigorous university, students in the experimental group were shown a film that highlighted how the brain is capable of making new connections throughout life and how it grows in response to intellectual challenge. They also wrote a letter to a struggling younger student emphasizing that the brain is malleable and that intelligence expands with hard work. At the end of that semester, the college students who had learned about malleable intelligence (compared to two control groups that did not) showed greater valuing of academics, enhanced enjoyment of their academic work, and higher grade-point averages.

At the level of mobilizing a person to control and selectively engage awareness, a variety of techniques have promise: medical hypnosis, mindfulness training, meditation, purposeful cognitive- emotional reactivation of positive experience, and neurofeedback. This is not the same as asking a person to simply ignore a problem – nor as directive as the “work-hardening” done in order to assist a person in re-entry to everyday life. The techniques hold the promise of actually removing active awareness of a symptom from moment-to-moment function. They require a healthy nervous system as a backdrop for this rather taxing expression of selective attention. They rely upon intact thalamocortical networks and cannot be easily accessed once a thalamocortical dysrhythmia has been established. But these strategies can be taught, and learned in a routine way by those with a relatively intact nervous system.

The effect of “state” upon so-called “behavioral trait” is clear, and can be permanently debilitating. Akiskal found that severe mood disorders altered interpersonal function in a remarkable way:

As contrasted to Comparison Group and published norms, the postmorbid self-described “usual” personality is 1) sanguine among many, but not all, BP-I; 2) labile or cyclothymic among BP-II; and 3) subanxious and subdepressive among Unipolar Depression patients. It is further noteworthy that with the exception of BP-II, the temperament scores of BP-I and MDD were within one SD from published norms. Rather than being pathological, these attributes are best conceived as subclinical temperamental variants of the normal, thereby supporting the notion of continuity between interepisodic and episodic phases of affective disorders. These findings overall are in line with Kraepelin’s views and contrary to the DSM-IV formulation of axis-II constructs as being pathological and sharply demarcated from affective episodes.