DA 99021

DEPRESSION AND ANXIETY 10:175–182 (1999)

CO-OCCURRENCE OF MOOD AND PERSONALITY

DISORDERS: A REPORT FROM THE
COLLABORATIVE LONGITUDINAL PERSONALITY
DISORDERS STUDY (CLPS)
Andrew E. Skodol, M.D.,2* Robert L. Stout, Ph.D.,1 Thomas H. McGlashan, M.D.,5 Carlos M. Grilo, Ph.D.,5
John G. Gunderson, M.D.,3 M. Tracie Shea, Ph.D.,1 Leslie C. Morey, Ph.D.,4 Mary C. Zanarini, Ed.D.,3
Ingrid R. Dyck, M.P.H.,1 and John M. Oldham, M.D.2

The purpose of this study was to examine the relationship of subtypes and par-
ticular clinical features of mood disorders to co-occurrence with specific person-
ality disorders. Five hundred and seventy-one subjects recruited for the
Collaborative Longitudinal Personality Disorders Study (CLPS) were assessed
with the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I)
and the Diagnostic Interview for DSM-IV Personality Disorders (DIPD-IV).
Percent co-occurrence rates for current and lifetime mood disorders with per-
sonality disorders were calculated. Logistic regression analyses examined the
effects of clinical characteristics of depressive disorders (e.g., age at onset, re-
currence, symptom severity, double depression, and atypical features) on per-
sonality disorder co-occurrence. In comparison with other DSM-IV personality
disorders, avoidant, borderline, and dependent personality disorders (PDs)
were most specifically associated with mood disorders, particularly depressive
disorders. Severity and recurrence of major depressive disorder and comorbid
dysthymic disorder predicted co-occurrence with borderline and to a lesser ex-
tent research criteria depressive personality disorders. The results are consis-
tent with the view that a mood disorder with an insidious onset and
recurrence, chronicity, and progression in severity leads to a personality disor-
der diagnosis in young adults. Depression and Anxiety 10:175–182, 1999.
© 1999 Wiley-Liss, Inc.

Key words: comorbidity; bipolar disorder; depressive disorder; mood disorders;

personality disorders

INTRODUCTION occurrence of Axis I and Axis II disorders. So-called

The advent of DSM-III’s multiaxial diagnostic sys- “comorbidity” is viewed as a significant aspect of psy-
tem, which placed personality disorders on a separate chopathology with potential to shed light on funda-
axis (Axis II) from the majority of other mental disor- mental etiological factors [Siever and Davis, 1991],
ders, has spawned numerous studies documenting co- developmental pathways [Akiskal et al., 1983], and the

1
Department of Psychiatry and Human Behavior, Brown Uni- This publication has been reviewed and approved by the Publi-
versity, Providence, Rhode Island cations Committee of the Collaborative Longitudinal Personality
2 Disorders Study.
Columbia University College of Physicians and Sur-
geons and New York State Psychiatric Institute, New Contract grant sponsor: National Institute of Mental Health; Contract
York, New York grant numbers: R10 MH 50837, 50838, 50839, 50840, 50850.
3
Harvard Medical School and McLean Hospital, Boston,
*Correspondence to: Andrew E. Skodol, M.D., New York State
Massachusetts
4 Psychiatric Institute, 1051 Riverside Drive, Box 129, New York,
Vanderbilt University, Nashville, Tennessee
5 NY 10032.
Yale Psychiatric Institute and Department of Psychiatry,
Yale University School of Medicine, New Haven, Con- Received for publication 21 September 1999; Accepted 21 Sep-
necticut tember 1999

© 1999 WILEY-LISS, INC.

176 Skodol et al.
outcome of treatment [Reich and Green, 1991; Reich
and Vasile, 1993; Ruegg and Frances, 1995] for a vari-
ety of mental disorders.
Because of their prevalence in clinical settings,
mood disorders have been the Axis I focus of the larg-
est number of studies of comorbidity with personality
disorders. Nevertheless, there continues to be no con-
sensus about overall rates of mood disorder/personal-
ity disorder comorbidity, specific personality disorders
most often found in conjunction with mood disorders,
types or characteristics of mood disorders most often
associated with personality disorders, or the signifi-
cance of co-occurrence, i.e., whether it reflects a clini-
cally or etiologically significant relationship between
certain disorders (i.e., true comorbidity) or simply
chance co-occurrence.
Methodologic differences between studies account
in part for the variability in existing mood disorder/
personality disorder comorbidity studies. Only 15
studies have employed recognized structured or semi-
structured interviews to assess a range of Axis I and
Axis II disorders [Dahl, 1986; Reich and Noyes, 1987;
Alnaes and Torgersen, 1988; Zanarini et al., 1989,
1998; Zimmerman and Coryell, 1989; Jackson et al.,
1991; Markowitz et al., 1992; Sanderson et al., 1992;
Coid, 1993; Golomb et al., 1995; Oldham et al., 1995;
Pepper et al., 1995; Fava et al., 1996; Alpert et al.,
1997]. Differences in sample composition (i.e., inpa-
tients, outpatients, criminals, and nonpatients) and fo-
cus on current or lifetime disorders account for
additional variation. Some studies report frequencies
of personality disorders in subjects with mood disor-
ders; other studies report frequencies of mood disor-
ders in subjects with personality disorders. Only a
handful of studies have examined mood disorders
other than major depressive disorder, included com-
parison groups by which clinically significant comor-
bidity could be discerned, or examined the effects of
factors such as age at onset, recurrence, chronicity, or
symptom type or severity of mood disorders on
comorbidity.
Of those studies employing structured interviews
and reporting on the proportion of subjects with a
mood disorder who also have a personality disorder
[Reich and Noyes, 1987; Alnaes and Torgersen, 1988;
Zimmerman and Coryell, 1989; Jackson et al., 1991;
Markowitz et al., 1992; Sanderson et al., 1992; Go-
lomb et al., 1995; Pepper et al., 1995; Fava et al.,
1996; Alpert et al., 1997], estimates range from 18%
to 95%, with patients with dysthymic disorder having
somewhat higher rates of personality disorder (PD)
comorbidity than patients with major depressive disor-
der (MDD). Avoidant, dependent, and borderline per-
sonality disorders have been most common, but not
necessarily most discriminating with respect to a com-
parison group. A study by Fava et al. [1996] found that
early onset major depressive disorder had somewhat
higher rates of PDs than later onset MDD, and an-
other study by Alpert et al. [1997] found that major
depressive disorder with atypical features had higher
PD rates than MDD without atypical features.
Of those interview-based studies reporting on the
proportion of subjects with a personality disorder who
also have a mood disorder [Dahl, 1986; Zanarini et al.,
1989, 1998; Coid, 1993; Oldham et al., 1995], esti-
mates range from 4% to 100%. Borderline personality
disorder has been most commonly studied, and both
major depressive disorder and dysthymic disorder
have been found to co-occur with it.
This report describes a study of patterns of mood
disorder/personality disorder comorbidity using the
large and diverse sample of the Collaborative Longi-
tudinal Personality Disorders Study (CLPS). It re-
ports co-occurrence rates between a range of DSM-IV
mood disorders and all DSM-IV personality disorders,
including the research criteria for depressive personal-
ity disorder. It examines the relationship of mood dis-
order subtypes and particular clinical features (e.g.,
age at onset, recurrence, symptom severity, and atypi-
cal features) to co-occurrence with personality disor-
ders. We hypothesized that mood disorder/personality
disorder co-occurrence would be most significant for
severe, atypical, chronic, or recurrent mood disorders,
which had an early onset.
MATERIALS AND METHODS
SUBJECTS
Subjects 18 to 45 years of age were recruited prima-
rily at clinical services affiliated with each of the four
recruitment sites of the Collaborative Longitudinal
Personality Disorders Study: Brown, Columbia, Har-
vard, and Yale Universities. The sample was supple-
mented by subjects responding to postings or media
advertising for an interview study of personality, who
had previously or were currently receiving psychiatric
treatment or psychological counseling. In all, 668 sub-
jects with at least one of four targeted personality dis-
orders (schizotypal, n = 86; borderline, n = 175;
avoidant, n = 157; or obsessive-compulsive, n = 153)
or with MDD and no PD were recruited; the MDD
no PD group is excluded from these analyses, leaving
a total sample of 571. Forty-five percent were re-
cruited while outpatients in mental health settings,
11% were psychiatric inpatients, 5% were from other
mental health or medical settings, and 39% were self-
referred.
Subjects were prescreened to determine age eligibil-
ity and treatment status or history and to exclude pa-
tients with active psychosis, substance intoxication or
withdrawal or other confusional states, and history of
schizophrenia or schizoaffective disorder. All subjects
signed written informed consent after the research
procedures had been fully explained.
Table 1 shows the demographic characteristics of
the subjects. The majority were women, white, and
from the higher Hollingshead and Redlich social
classes. Due to the large sample size, however, sub-
 Research Article: Co-Occurrence of Mood and Personality Disorders 177

stantial numbers of subjects of the minority statuses Interviewers were trained in the administration of
(males, n = 204; nonwhites, n = 141; SES classes III–V, the SCID-I/P and DIPD-IV at a 5-day workshop at
n = 225) are included. The subjects were roughly McLean Hospital conducted by one of the authors
evenly distributed across the age range selected for (MZ). Quality of interviews was monitored via ongo-
the study. ing supervision of the interviewers by the Principal
Investigators at each of the four data collection sites
ASSESSMENT (TS, AS, JG, TMcG) and monthly conference calls
between the head trainer (MZ), the project coordina-
Subjects meeting basic inclusion and exclusion cri- tors, and the clinical interviewers.
teria for study participation were screened for possible
personality disorder using a self-report Personality ANALYSES
Screening Questionnaire (PSQ) consisting of items Percent co-occurrence rates were calculated for cur-
from the PDQ-4 Personality Questionnaire pertaining rent and lifetime (includes current) mood disorders
to the four targeted personality disorders. Earlier ver- sufficiently represented in the sample and each indi-
sions of the PDQ-4 have been shown to be highly vidual personality disorder diagnosed by the DIPD-
sensitive in screening for personality disorders in both IV. Percent co-occurrence is defined as the proportion
inpatients and outpatients [Hyler et al., 1990, 1992]. of subjects receiving both a given mood disorder and a
Subjects who were positive on the PSQ were inter- given personality disorder (+/+ cell) divided by the
viewed face-to face by trained and experienced inter- proportion of subjects receiving either diagnosis (+/+,
viewers with master’s or doctoral degrees. To establish +/–, and –/+ cells combined). Percent co-occurrence is
Axis I diagnoses, the interviewers administered the a single number simultaneously representing the pro-
Structured Clinical Interview for DSM-IV Axis I Dis- portion of subjects with a mood disorder who have a
orders-Patient Version (SCID-I/P) [First et al., 1996]. personality disorder and the proportion with the per-
Inter-rater reliabilities for major mood disorders were sonality disorder who have the mood disorder. As
as follows: major depressive disorder, kappa (k) = 0.80; such, it represents a convenient summary statistic.
dysthymic disorder, k = 0.76; any bipolar disorder, k = Odds ratios are the preferred statistic in studies of epi-
0.76. Interviewers also administered the Diagnostic demiologic comorbidity [Kraemer, 1995], but the spe-
Interview for DSM-IV Personality Disorders (DIPD- cific recruitment strategy of the CLPS (i.e., focused
IV) [Zanarini et al, 1996]. Inter-rater reliabilities for per- on recruiting adequate samples of four representative
sonality disorders diagnosed with the DIPD-IV ranged personality disorders) makes the subjects receiving
from k = 0.58 to 1.0. A more extended report detailing neither of a pair of diagnoses (the –/– cell) under-
the inter-rater and test-retest reliability studies for Axis I represented. Chi-square analyses of 2 × 2 contingency
disorders and for categorical and dimensional measures tables of each mood disorder and personality disorder
of PDs is in preparation. with Yates’ correction were conducted to determine
the significance above chance of the associations.
Table 1. Demographic characteristics (N=571) A series of logistic regression analyses was con-
ducted to examine the effects of clinical characteristics
Characteristic N (%) of depressive disorders on personality disorder co-oc-
Gender
currence. For major depressive disorder, the predictor
Male 205 35.9 variables were age at onset, severity of the current epi-
Female 366 64.1 sode, number of lifetime episodes, presence vs. ab-
Age (in years) sence of co-occurring dysthymic disorder (i.e., double
18–25 138 24.2 depression) and presence vs. absence of atypical fea-
26–30 97 17.0 tures. Age at onset was dichotomized at <18 years vs. >
31–35 92 16.1 18 years. Severity was rated as mild, moderate, or se-
36–40 115 20.1 vere (with or without psychotic features) as specified
41–45 129 22.6 in DSM-IV. Number of episodes was stipulated as 1
Ethnicity
(i.e., first or single episode), 2–10, or 10 or more life-
White 430 75.3
Black 62 10.9
time episodes. The predictor variables for dysthymic
Hispanic 56 9.8 disorder were early vs. late age at onset, presence vs.
Asian 11 1.9 absence of co-occurring current major depressive dis-
Other 12 2.1 order, and presence vs. absence of atypical features.
Socioeconomic Statusa Dysthymic disorder is a chronic disorder not charac-
Class I 173 30.3 terized by episodes, and severity ratings are not made
Class II 173 30.3 in the SCID-I/P. Atypical features include mood reac-
Class III 103 18.0 tivity plus two or more of the following features: in-
Class IV 121 21.2 creased appetite or weight gain, hypersomnia, leaden
Class V 1 0.2
paralysis, and pattern of interpersonal rejection sensi-
a
Hollingshead and Redlich, 1958. tivity. The dependent variables in the regression
178 Skodol et al.

analyses were those personality disorders that com-
monly, consistently, and significantly co-occurred with
depressive disorders in this sample (see below under
Results).
RESULTS
Of the 571 subjects with personality disorders,
61.3% were diagnosed according to the SCID-I/P
with a current mood disorder; 92.6% had a mood dis-
order on a lifetime basis. The proportion of the
sample with specific mood disorders, current or life-
time, respectively, were as follows: major depressive
disorder, 38.7%, 74.4%; dysthymia (lifetime diagnosis
only), 18.9%; bipolar I disorder, 7.9%, 7.9%; and bi-
polar II disorder 2.6%, 4.0%.
Table 2 presents co-occurrence percentages for cur-
rent mood disorders and DSM-IV personality disorders
diagnosed with the DIPD-IV. As can be seen in Table 2,
major depressive disorder most commonly co-occurred
with avoidant (35.2%), borderline (31.3%), and research
criteria depressive (29.4%) personality disorders, at rates
that significantly exceeded chance. For dysthymic dis-
order, significant rates of co-occurrence were found
for avoidant (21.0%), depressive (20.9%), dependent
(10.6%), and schizoid (6.8%) personality disorders.
Bipolar disorders significantly co-occurred only with
antisocial (both bipolar I and II disorders) and histri-
onic (bipolar I disorder only) PDs. Mood disorders, in
general, were found at significantly elevated rates in
avoidant, borderline, depressive, dependent, and anti-
social personality disorders, in comparison with all
other PDs.
On a lifetime basis (Table 3), results for mood disorder
and personality disorder co-occurrence were similar to
those for current disorders, with a few exceptions. On a
lifetime basis, major depressive disorder co-occurred sig-
nificantly with schizotypal PD (13.5%) and with antiso-
cial PD (6.3%), but not with borderline or depressive
PDs, although the latter lifetime co-occurrence rates
were relatively large. Dysthymic disorder is made in
DSM-IV only on a lifetime basis and no cases of bipolar
I disorder were rated as in remission. Therefore, these
co-occurrence results are identical to those for current
disorders. Bipolar II disorder was found to be signifi-
cantly associated with borderline and passive-aggres-
sive (research criteria) PDs when diagnosed on a
lifetime basis, although no such relationships were
found for current bipolar II disorder. Mood disorders,
in general, were not significantly associated with anti-
social or dependent PDs on a lifetime basis, although
these relationships were found for current mood dis-
orders. Lifetime mood disorders, in general, were
found to be highly associated with obsessive-compul-
sive personality disorder; current mood disorders had
not shown a relationship. Avoidant, borderline, and
depressive PDs continued to show high rates of co-
occurrence with mood disorders on a lifetime basis, as
they had when diagnosed as present at intake.
Tables 4 and 5 present the results of logistic regres-
sion analyses predicting the personality disorders most
commonly and significantly associated with current
major depressive disorder and with dysthymic disorder
on the basis of clinical characteristics of the mood dis-
orders. The four PDs are borderline, avoidant, depen-
dent, and depressive.
The overall model of clinical characteristics of ma-
jor depressive disorder predicting borderline personal-
ity disorder was highly significant (log likelihood test
chi-square = 37.26, df = 5, P = 0.0001). As can be seen
in Table 4, three of the five characteristics of MDD
significantly predicted co-occurring borderline per-
sonality disorder (BPD). Increasing episode severity
was 2.5 times more likely to be associated with BPD,
co-occurring dysthymic disorder 2.1 times more
likely, and increasing number of episodes 1.9 times
more likely. The overall model for avoidant person-
ality disorder was not significant (log likelihood test
chi-square = 8.34, df = 5, P = 0.1386). For dependent
personality disorder, the model was again highly sig-

Table 2. Percent co-occurrence of current mood disorders and personality disorders

Current Mood Disorders

Personality disorder (N) MDDa (n = 221) DYS (n = 108) BPI (n = 45) BPII (n = 15) Any mood disorder (n = 350)

Paranoid 81 13.6 11.2 5.0 3.3 15.0

Schizoid 18 4.4 6.8* 1.6 0 4.0
Schizotypal 96 13.2 10.3 8.5 2.8 17.4
Antisocial 49 19.5 6.8 9.3* 10.3*** 10.3*
Borderline 240 31.3** 16.0 9.2 4.1 39.2***
Histrionic 13 1.3 2.6 7.4** 3.7 2.8
Narcissistic 36 14.9 5.9 3.8 4.1 6.4
Avoidant 324 35.2** 21.0** 7.0 3.1 47.5**
Dependent 49 9.4 10.6* 4.4 5.0 10.6*
Obsessive-compulsive 261 24.2 18.3 5.5 3.0 33.4
Passive-aggressive 54 8.4 7.3 5.3 6.2 10.0
Depressive 177 29.4*** 20.9*** 6.7 4.4 34.6***
a
MDD, major depressive disorder; DYS, dysthymic disorder; BPI, bipolar I disorder; BPII, bipolar II disorder.
Chi-square tests wtih Yate’s correction for continuity: *P<.05; **P<01; ***P<.001.
 Research Article: Co-Occurrence of Mood and Personality Disorders 179

Table 3. Percent co-occurrence of lifetime mood disorders and personality disorders

Lifetime Mood Disorders

Personality disorder (N) MDDa (n = 425) DYS (n = 108) BPI (n = 45) BPII (n = 23) Any mood disorder (n = 529)
Paranoid 81 13.5 11.2 5.0 5.1 14.7
Schizoid 18 3.5 6.8* 1.6 0 3.2
Schizotypal 96 13.5* 10.3 8.5 3.5 16.6
Antisocial 49 6.3** 6.8 9.3* 12.5*** 9.3
Borderline 240 37.4 16.0 9.2 6.9** 43.9***
Histrionic 13 1.6 2.6 7.4** 2.9 2.5
Narcissistic 36 5.8 5.9 3.8 5.4 6.4
Avoidant 324 51.3* 21.0** 7.0 4.4 57.9***
Dependent 49 8.3 10.6* 4.4 6.0 8.9
Obsessive-compulsive 261 38.6 18.3 5.5 2.9 41.3***
Passive-aggressive 54 9.2 7.3 5.3 8.5* 10.2
Depressive 177 29.9 20.9*** 6.7 5.3 32.2*
a
MDD, major depressive disorder; DYS, dysthymic disorder; BPI, bipolar I disorder; BPII, bipolar II disorder.
Chi-square tests wtih Yate’s correction for continuity: *P<.05; **P<01; ***P<.001.

nificant (log likelihood test chi-square = 25.67, df = 5,
P = 0.0001). In this model, increasing severity was 5
times and presence of atypical features 3.7 times
more likely to be associated with dependent person-
ality disorder, but decreasing number of episodes was
a significant predictor. Finally, the overall model
predicting depressive personality disorder was also
significant (log likelihood test chi-square = 22.24, df
= 5, P = 0.0005). Among the predictors, greater epi-
sode severity and presence of dysthymic disorder
were significant.
The overall models of clinical characteristics of dys-
thymic disorder predicting borderline (log likelihood
test chi-square = 19.31, df = 3, P = 0.0002) and depres-
sive (log likelihood test chi-square = 15.30, df = 3, P =
0.0016) personality disorders were significant, but not
for avoidant (log likelihood test chi-square = 7.42, df =
3, P = 0.0597) or dependent (log likelihood test chi-
square = 0.33, df = 3, P = 0.9534) personality disor-
ders. Co-occurring major depressive disorder and
early age at onset were significant predictors of both
borderline and depressive personality disorders.
DISCUSSION
In comparison with other DSM-IV personality dis-
orders, avoidant, borderline, and obsessive-compulsive
PDs most commonly occurred with mood disorders in
general and with depressive disorders in particular in
this study. Avoidant, borderline, and dependent PDs
were most discriminating for mood disorders. Bipolar
disorders were more likely to be associated with anti-
social and histrionic PDs. In addition, the new re-
search criteria depressive PD, included in DSM-IV

Table 4. Logistic regression analysis of clinical characteristics of current major depressive disorder predicting
specific personality disorder types

Personality disorder

Clinical characteristic Borderline Avoidant Dependent Depressive

a b
of major depressive disorder OR (95% CI ) OR (95% CI) OR (95% CI) OR (95% CI)
Age at onset 0.6 (0.3–1.0) 1.6 (0.8–2.9) 1.2 (0.4–3.6) 0.8 (0.4–1.5)
Severity of current episode 2.5 (1.5–4.2)c 1.1 (0.7–1.8) 5.0 (2.1–12.1)f 2.4 (1.4–3.9)i
Number of episodes 1.9 (1.2–3.2)d 1.1 (0.7–1.8) 0.4 (0.2–0.8)g 1.0 (0.6–1.7)
Co-occurring dysthymic disorder 2.1 (1.1–4.2)e 2.1 (1.0–4.2) 1.6 (0.6–4.4) 2.3 (1.2–4.4)j
Atypical features 0.7 (0.3–1.4) 0.7 (0.3–1.4) 0.3 (0.1–0.8)h 0.6 (0.3–1.1)
a
OR, Odds ratio.
b
CI, Confidence interval.
c
Wald chi-square = 12.34, df = 1, P < .001.
d
Wald chi-square = 6.24, df = 1, P < .05.
e
Wald chi-square = 4.47, df = 1, P < .05.
f
Wald chi-square = 12.60, df = 1, P < .001.
g
Wald chi-square = 7.05, df = 1, P < .01.
h
Wald chi-square = 5.74, df = 1, P < .05.
i
Wald chi-square = 11.56, df = 1, P < .001.
j
Wald chi-square = 5.73, df = 1, P < .05.
180
Table 5. Logistic regression analysis of clinical characteristics of dysthymic disorder predicting specific personality
disorder types
Clinical characteristic Borderline
of dysthymic disorder ORa (95% CIb)
c
Age at onset 0.3 (0.1–0.7)
Co-occurring major depressive 4.5 (1.9–10.4)d
disorder
Atypical features 1.0 (0.4–2.5)
a
OR, Odds ratio.
b
CI, Confidence interval.
c
Wald chi-square = 6.45, df = 1, P < .05.
d
Wald chi-square = 11.91, df = 1, P < .001.
e
Wald chi-square = 6.20, df = 1, P < .05.
f
Wald chi-square = 4.85, df = 1, P < .05.
Appendix B, was strongly associated with depressive
disorders. These results generally held true, whether
the mood disorder was diagnosed on a current or a
lifetime basis.
Furthermore, we found that certain clinical character-
istics of major depressive disorder and of dysthymic dis-
order predicted common, significant PD co-occurrences.
In particular, the more severe the current episode of ma-
jor depression, the more likely it was associated with bor-
derline, dependent, or depressive PDs. The greater the
number of prior episodes, the more likely an associated
borderline PD diagnosis would be made, but dependent
PD was more likely when the number of previous epi-
sodes was fewer. Co-occurring dysthymic disorder and
major depressive disorder predicted a borderline or de-
pressive personality disorder diagnosis, in addition. Early
onset dysthymic disorder also signified a greater likeli-
hood of either a borderline or depressive personality dis-
order diagnosis.
We found no evidence of early onset major depres-
sive disorder increasing the risk of a co-occurring per-
sonality disorder, and atypical features of depressive
disorders did not seem to be associated with PDs ex-
cept for dependent. No characteristics of depressive
disorders predicted avoidant PD.
Our co-occurrence results are consistent with much
of the existing literature on mood disorder and per-
sonality disorder co-occurrence, in which semistruc-
tured instruments were used to assess Axis I and Axis
II disorders. In an early study by Reich and Noyes
[1987] of 24 outpatients with current major depressive
disorder, dependent, avoidant, and obsessive-compul-
sive PDs were three of the four most common (histri-
onic was the other), although schizotypal PD was the
only PD (though much rarer) that discriminated the
depressed sample from a comparison group with panic
disorder. In Alnaes and Torgerson’s [1988] sample of
97 outpatients with major depression and 18 with dys-
thymic disorder, the majority received Axis II diagnoses
of avoidant or dependent PDs. Percent co-occurrence of
avoidant personality disorder (AVPD) and major depres-
Skodol et al.
Personality disorder
Avoidant Dependent Depressive
OR (95% CI) OR (95% CI) OR (95% CI)
3.0 (1.0–8.9) 0.9 (0.3–3.1) 0.3 (0.1–0.8)e
2.1 (0.9–4.9) 1.3 (0.4–3.9) 2.5 (1.1–5.8)f
0.9 (0.3–2.3) 1.2 (0.3–4.0) 2.1 (0.9–5.4)
sion calculated from their data was 29.7%, compared to
the 35.2% found for AVPD and current MDD in our
study. More recent studies of outpatients with major
depressive disorder have consistently found significant
rates of PD co-occurrence for avoidant and borderline
PDs, and to a lesser extent for obsessive-compulsive
and dependent PDs [Sanderson et al., 1992; Golomb
et al., 1995; Fava et al., 1996; Alpert et al., 1997]. Re-
sults for outpatients with dysthymic disorder [Marko-
witz et al., 1992; Sanderson et al., 1992; Pepper et al.,
1995] and for inpatients [Jackson et al., 1991] and
nonpatients [Zimmerman and Coryell, 1989] with de-
pressive disorders are comparable. In a mixed sample
of inpatients and outpatients, Oldham et al. [1995] re-
ported increased rates of borderline, avoidant, and de-
pendent PDs (the latter two most significantly) in
association with mood disorders. In a large sample of
inpatients who had borderline personality disorder,
Zanarini et al. [1998] found that 83% had a lifetime
major depression, 39% had dysthymia, and fully 96%
had some lifetime mood disorder.
Depressive personality disorder was placed in DSM-
IV’s Appendix B for Criteria Sets and Axes Provided for
Further Study, despite a long clinical history, because of
controversy over whether it could be differentiated con-
ceptually and empirically from mood disorders such as
dysthymic and major depressive disorders [Phillips et al.,
1993]. Like the recent study by Phillips et al. [1998],
we found substantial but incomplete overlap between
major depressive disorder and dysthymic disorder and
depressive personality disorder. Forty-nine percent of
our subjects with depressive personality disorder did
not have a current major depressive disorder, 22% did
not have a lifetime major depressive disorder, and
72% did not have dysthymic disorder. These figures
compare with 60%, 17%, and 63%, respectively, in
the Phillips et al. [1998] sample.
There are far fewer studies of the comorbidity of
personality disorders with bipolar mood disorders
than there are for unipolar mood disorders. Alnaes
and Torgerson [1988] reported that nearly half of a
 Research Article: Co-Occurrence of Mood and Personality Disorders
small sample of bipolar outpatients had dependent
personality disorder. Zimmerman and Coryell [1989]
found that only 7% of nonpatients with mania could
be diagnosed with a co-occurring PD. Zanarini et al.
[1989] found no cases of bipolar II disorder in an early
sample of 50 borderline outpatients; in her more re-
cent sample of inpatients with BPD, only 10% were
diagnosed with lifetime bipolar II disorder, although
this rate was significantly greater than the rate in inpa-
tients with other PDs [Zanarini et al., 1998]. Peselow
et al. [1995] found that 27% of bipolar patients with
current hypomania met criteria for borderline person-
ality disorder on direct interview at intake. Only Jack-
son et al. [1992] have previously reported substantial
rates of histrionic PD (and borderline) in patients with
mania. None of the previously cited studies of mood
disorder/personality disorder co-occurrence have re-
ported elevated or significant rates of antisocial PD
among bipolar patients, as we have found.
We attempted, but failed, to replicate the findings
of Fava et al. [1996] that early onset major depression
would be associated with increased rates of personality
disorder co-occurrence. We also failed to replicate
Alpert et al.’s [1997] finding that atypical features in
major depression would be more likely to be associ-
ated with PD co-occurrence. Early onset of dysthymic
disorder was, however, associated with greater chance
of PD co-occurrence. Furthermore, we found evi-
dence that a more severe and chronic (as indicated by
recurrent episodes of major depressive disorder and
co-occurring dysthymic disorder) mood disorder was
indeed more likely to be accompanied by a personality
disorder diagnosis.
The findings of our study are consistent with the
view that a mood disorder with an insidious onset and
recurrence, chronicity, and progression in severity
leads to a personality disorder diagnosis, particularly
borderline personality disorder, in young adults. The
mean age at onset of dysthymic disorder in our sample
of subjects with double depression was approximately
14 years, an onset that preceded the first episode of
major depressive disorder by almost 5 1/2 years. This
pattern of chronic depression increasing in severity
over time and associated with the development of per-
sonality psychopathology echoes results recently re-
ported by Lewinsohn et al. [1997]. They found greater
personality psychopathology in young adults who as
adolescents had suffered from major depressive disor-
der with a debilitating course characterized by longer
episode duration, greater likelihood of recurrence,
greater severity, more mental health treatment utiliza-
tion, and greater likelihood of suicide attempts. To-
gether with the findings of other investigators [Rey et
al., 1995; Bernstein et al., 1996; Kasen et al., 1999],
these results suggest that adolescent onset mood dis-
order psychopathology is an important risk factor,
alone or in conjunction with other (e.g., behavioral)
problems, for personality disorders in young adults.
Since the onset of PD symptomatology was not dated in
181
our study, it is also possible that early signs of personality
dysfunction exacerbated the course of adolescent onset
mood disorders. Regardless, greater attention needs to
be paid to the relationship and evolution of mood distur-
bance during adolescence and the development of per-
sonality disorder in young adulthood.
The co-occurrence of BPD and MDD in our sample
deserves further comment, given that this association has
had the most extensive, and often controversial, exposi-
tion in the literature. Gunderson and Phillips’[1991] ex-
tensive review concluded that while many studies have
found increased rates of depression in BPD, close inspec-
tion of the literature did not support any specific rela-
tionship. DSM-IV MDD is a broadly defined disorder
that is common and ubiquitous in treatment seeking
populations. Therefore, it frequently co-occurs with
many other disorders, both Axis I and Axis II, but its
association with singular PDs is often marginal and
not specific, i.e., not definitively exceeding already
high base rates in the sample.
We found an association of BPD and MDD that
was significant for current MDD but not for lifetime
MDD. Distinctive features of MDD such as increased
severity or number of lifetime episodes and the co-oc-
currence of dysthymia increased the association be-
tween BPD and MDD in a statistically and clinically
meaningful fashion. Thus, our data suggest that BPD
is associated with a particular subtype of MDD: earlier
onset, chronic, mild depression leading to a more dis-
tinctive type of MDD that is also chronic, recurrent,
and progressive. This is consistent with current etio-
pathologic thinking about BPD as a disorder that is
determined early in life, either as a product of experi-
ential trauma, or the early expression of mood disor-
der vulnerability, or both. In short, BPD may have a
robust relationship with specific forms of mood dis-
turbance, but this relationship may become mar-
ginalized and obscured by a definition of MDD that is
too broad and nonspecific. BPD may also have signifi-
cant relationships with other Axis I disorders that are
even stronger and of equal or greater clinical signifi-
cance than its relationships to mood disorders.
A limitation of this study for co-occurrence analyses
is its focus on four specific personality disorders in
subject recruitment. Also, its goal was explicitly to
chart the course of personality disorders diagnosed in
clinical settings from adulthood on; thus, it is less
suited than a study beginning in childhood or adoles-
cence to elucidate the interplay between personality
traits and behaviors and Axis I symptoms and disor-
ders. Nonetheless, it adds new data based on rigorous
assessments of Axis I and II disorders on types and fea-
tures of mood disorders likely to be associated with
specific personality disorder types.
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