Clinical presentation

Borderline personality disorder (BPD) is a serious mental illness characterized by “a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity that begins by early adulthood and is present in a variety of contexts” ( , p. 663). Individuals with BPD frequently experience extreme fear of abandonment and make frantic and often self-sabotaging efforts to avoid real or perceived rejection, such as responding with inappropriate anger, suicidal threats, or parasuicidal gestures. This dynamic is produced by an intense fear of being alone and an overreliance on others for a sense of personal identity and worth. BPD patients struggle with individuation and often experience their identity as “fused” with that of other people. At the same time, their interpersonal relationships are marked by instability and intensity, often resulting in significant fluctuations from idealization to debasement or derision, depending on their perception of the other individual’s readiness to meet their needs or prove their loyalty. Their descriptions of other people may lack complexity and are often extreme: for example, “the best human being ever” or “a total loser.” These individuals’ self-image and sense of self are also highly unstable, and they are prone to intense shame, guilt and self-condemnation. They experience these feelings as so intolerable, that they often resort to radical and ultimately counterproductive mitigating measures, such as self-mutilation and suicidal behaviors. Individuals with BPD also display significant impulsivity, including behaviors that prove to be self-damaging (e.g., unprotected sex, excessive spending, substance abuse, unsafe driving, etc.). Finally, BPD is characterized by affective volatility, frequently resulting in depressive states marked by intense albeit transitory dysphoria, several hours to a few days in duration, anger and hostility. These fluctuations stem from BPD-associated mood reactivity, which, in turn, is triggered by a real or imagined abandonment or anticipated rejection. In some cases, the affective dysregulation can be accompanied by transient paranoid ideation or dissociative experiences.

Due to its characteristic instability of emotions and predominance of negative affect, BPD can often mimic a depressive disorder. Both BPD and MDD are marked by dysphoric affect and increased risk for suicidal behavior, which makes the task of determining whether the depressive symptoms should be attributed to the cooccurring depression or to the personality disorder itself, more complicated. Furthermore, individuals with this type of personality pathology appear to have a heightened subjective experience of depression, so much so that patients with BPD without MDD often score as highly on standardized self-rated depression measures as BPD patients with MDD and as highly as patients with MDD without BPD ( ). In addition, patients with comorbid MDD and BPD tend to endorse greater severity of symptoms on self-report measures as compared to clinician-rated severity ( ). Finally, the experience of depression in individuals with MDD is often qualitatively different from that in BPD patients, with the former being marked by melancholy, anhedonia, and apathy, accompanied by neurovegetative symptoms, and the latter by a sense of boredom, alienation, emptiness and inner “badness,” as well as anger and hostility ( ; ; ).

BPD comorbidity and its impact on the course and treatment outcome in MDD

BPD is a relatively common mental illness, with prevalence rates of approximately 1.7% in the general population and 15%–28% in patients receiving psychiatric care in inpatient and outpatient settings ( ). BPD is also by far the most-studied personality disorder, and its interface with depression has received a great deal of attention in professional literature. The lifetime prevalence of cooccurrence of depression with this type of personality pathology is extremely high, with recent studies suggesting that 61%–85% of individuals with BPD eventually meet the criteria for MDD ( ; ).

In light of the frequent comorbidity encountered in both research and clinical practice, a number of studies have explored the possibility that the two conditions have shared causes, with some authors going as far as conceptualizing BPD as a variant of a mood disorder ( ; ). A recent review by has in fact revealed an overlap in neurobiology of BPD and MDD, including reduced serotonin neurotransmission, amygdala hyperreactivity to emotional stimuli, and volume abnormalities in the anterior cingulate cortex and hippocampus. At the same time, the review also identified significant differences in brain region involvement, neurohormonal activation, heritability, symptomatology, prognosis, and pharmacotherapy response. The above similarities notwithstanding, the consensus of expert opinion remains that BPD and MDD are separate and distinct disorders ( ; ; ; ; ; ; ) that may share certain biological, temperamental, and early environmental risk factors ( ; ).

There has been a long-standing consensus of expert opinion that antidepressant medication is not as effective in ameliorating the symptoms of major depression cooccurring with BPD as in MDD without personality pathology ( ; ). In a recent systematic literature review synthesizing the findings of three longitudinal studies ( ; ; ) with a total sample of nearly 2400 patients, reported that the presence of comorbid BPD in fact slightly worsens the outcome of MDD. Cooccurring BPD is also associated with earlier onset of depression, longer duration of Major Depressive Episodes (MDE), increased rate of persistence of depressive symptoms, and lower rate of remission ( ; ). These findings are consistent with the results of an earlier review of the impact of personality pathology on treatment outcome in major depression ( ) that reported that high neuroticism scores, which are characteristic of BPD ( ), were associated with poor prognosis, particularly in long-term outcomes. Furthermore, in a 6-year prospective study, found that high neuroticism scores also predicted earlier relapse and shorter remission of major depression, suggesting that that depressed patients with cooccurring BPD respond more poorly to pharmacological treatment. In addition, in a prospective epidemiological study using a large nationally-representative sample from the National Epidemiologic Survey on Alcoholism and Related Conditions, observed that BPD accounted for over half of cases of persistent depression at the 3-year follow-up. BPD robustly predicted persistence of MDD, even after controlling for age at onset of depression, the number of previous episodes, duration of the current episode, family history, treatment, and other personality disorders. Finally, in another longitudinal study from CLPS that followed a sample of BPD patients with and without cooccurring MDD for 3 years, found that the rate of remission of BPD was not affected by the presence of comorbid MDD; however, the remission rate of MDD was significantly reduced by the presence of coexisting BPD. When considered together, the above evidence identifies BPD as a key risk factor for TRD.

It should be noted here that the prognostic significance of comorbid BPD extends to somatic treatments for major depression, although the available evidence is more limited. A narrative review by suggested that depressed patients receiving ECT had poorer outcomes on some measures in the presence of coexisting BPD. This finding was supported by more recent original studies ( ; ). For example, in a prospective longitudinal study, compared the outcome of ECT in three different groups of depressed patients: (a) those with BPD, (b) those with PDs other than BPD, and (c) those without a PD and found that the BPD group showed the least amount of symptomatic improvement following treatment completion. In addition, in a recent retrospective chart review of patients with MDD receiving ECT and transcranial magnetic stimulation (TMS), found that the presence of coexisting borderline personality traits modestly predicted poorer response to ECT. Interestingly, the authors also found that borderline personality traits had no impact on the outcome of TMS. The available data does indicate that MDD could be successfully treated with ECT in patients with cooccurring BPD, leading some researchers to speculate that “the depressed patient appears to have two distinct disorders, one with is responsive to ECT and the other which is not” ( , p. 91).

Treatment

In light of the negative prognostic impact of BPD on cooccurring major depression, a proper initial treatment of BPD can improve the chances of achieving remission in MDD. In fact, found that improvements in BPD were followed by improvements in MDD, but not vice versa. This section will provide an overview of treatments for BPD and review the available limited data on treatments for the combination of MDD and BPD.

Clinical illustration ^a

a A composite case.

Sharon is a 29-year-old recently divorced heterosexual Caucasian female who was referred to a TRD specialty clinic by her outpatient treatment team for a one-time consultation due to chronic depression with suicidal ideation, extreme anxiety, relationship problems, and limited response to treatment. She has been psychiatrically hospitalized five times in the past 3 years as a result of suicide attempts. She acknowledged having attempted suicide at least 10 other times. All of the suicide attempts involved intentional overdosing on prescription medications. She also acknowledged some past nonsuicidal self-injurious behavior. She indicated that common triggers for these behaviors were relationship difficulties, including marital separation and divorce.

Sharon has been under the care of a psychiatrist and a Masters-level therapist for the last 3 years, with a working diagnosis of Major Depressive Disorder, Recurrent, Severe and Panic Disorder. Within this time period, she completed several unsuccessful antidepressant medication trials of adequate duration and intensity. There are some indications that she did not always remember to take her medications regularly and at times refused to take medication stating that they did not work. She is currently prescribed bupropion extended-release 300 mg qam and fluvoxamine 200 mg qam. She also completed a series of 12 acute and 6 maintenance ECT treatments in the past year. She indicates that these treatments were ineffective in addressing her depression and believes that they have had a lasting negative effect on her memory. Sharon has also been in weekly psychotherapy for the last 3 years. The progress notes indicate the use of cognitive-behavioral, interpersonal, and acceptance and commitment therapy modalities. In regards to her psychotherapy, Sharon states that she is “sick of talking about herself.” Despite the ongoing treatment, she reports experiencing unremitting severe depressive symptoms that significantly interfere with her daily functioning.

Sharon’s parents divorced when she was 10 years old. She has an older brother to whom she never felt close and from whom she is currently estranged. She was very close with her mother who died of ALS 3 years ago. Outside of her parents’ divorce, she describes growing up in a “typical American household” and denies experiencing significant trauma, abuse, or neglect. Socially, she reports that she always had friends growing up, but also that she could be “hot or cold” with friends. She lost a group of close friends following a break-up in a romantic relationship in high school, which precipitated her first depressive episode. Sharon acknowledges that she currently has very few friends and is largely isolated socially. Since separating from her husband, she has had a string of unsuccessful romantic relationships and has been uncharacteristically promiscuous. She feels that she needs “constant attention” from men. Currently, her social network is limited to her father and two friends, both of whom live out of state. She lives in a rented townhouse and sublets one room to a graduate student. She shares custody of her 2-year-old daughter with her ex-husband, from whom she has been divorced for 1 year. Sharon works part-time as a cashier at a local hardware store, and, despite having a college degree, believes that she will never make more than the minimum wage. She reports having no hobbies or interests and states that she “doesn’t do anything.” When she is not taking care of her daughter, she spends much of her free time sleeping and browsing social media on her phone. She used to enjoy literature, art, and music, but says that she “cannot remember the last time she read a book.”

Sharon’s comprehensive consultation at the specialty clinic included a thorough review of history, an interview with a clinical psychologist, who also administered a battery of psychological tests geared for TRD, and a reevaluation by a psychiatrist. The results of the diagnostic interviews and psychological testing indicated the presence of major depression, anxiety, and personality pathology marked by borderline and depressive traits. She appears to experience intense irritable and depressed affects with few outlets for them. Her daily experience is marked by guilt and shame. Her relational style is marked by an approach-avoidance conflict and she vacillates between an intense desire for closeness and withdrawal. She exhibits extreme fear of rejection and reacts strongly to real or perceived abandonment. She often finds herself acting in ways that ultimately bring about the very thing she fears. She has a generally pessimistic, negative outlook on life. Cognitively, she is prone to all-or-nothing thinking, which appears to drive some of her distress. She has strong negative affectivity punctuated by lability, disinhibited behaviors, and significant instability in her sense of self and interpersonal functioning. These traits have become more pronounced in recent years, although they have been present throughout her life to a greater or lesser extent. This constellation of personality and emotional features is best captured by the diagnosis of Borderline Personality Disorder.

Clinical presentation

Narcissistic Personality Disorder (NPD) is characterized by an exaggerated sense of self-importance and expectations that others appreciate and recognize one’s uniqueness and specialness ( ). Individuals with NPD often present as entitled and struggle to see the perspectives of others, often using others mainly to meet their own needs without appreciating the needs of others. On the surface, NPD individuals may not seem likely to present for treatment for depression; however, they actually do make their way to psychotherapy and/or pharmacotherapy quite often, due to the high level of fluctuation in their self-esteem ( ; ). Narcissistic patients often find themselves negatively impacted by the criticism or disappointment of others. And while they are likely to externalize these problems to others, NPD patients may become depressed and suicidal ( ; ), with NPD being uniquely associated with an increasing risk of suicide attempts over a 10-year period ( ) and an increased risk for suicide completion ( ). Depression in NPD patients often presents with fluctuations in the depressive state, ruminations about the hostility of others, fluctuation in suicidal ideation triggered by external events, which is accompanied by parasuicidal behavior, and a lack of neurovegetative symptoms ( ). Their chronic depressive episodes subsequently make them a particularly challenging group of patients to treat.

Individuals with NPD are prone to prolonged depressive episodes due to repeated work and relational failures, perceived social humiliation, and defeat. Chronic experiences like these predispose the patient toward feelings of shame and aggression, with acting out one’s aggressive feelings on others as a consequence. For instance, a patient might be passed up for a job promotion, invoking feelings of depression, humiliation, and shame. However, in order to avoid feeling this level of rejection, the patient verbally lashes out at colleagues, disparaging the individual who was selected for the promotion and invoking concerns about the unfairness and poor judgment of those making the decisions. While such reactions might be short-lived, the NPD patient might continue to act out in some aggressive ways but may also become self-destructive, for example, by drinking too much alcohol, or even driving an automobile while intoxicated. In fact, high rates of substance abuse disorders are commonly reported in NPD patients ( ). Given their proclivity to deny their vulnerability ( ), NPD patients may appear angry or frustrated, yet their underlying depression can often be detected within the first few sessions of psychotherapy.

Prevalence of comorbidity of NPD and depression

found that in a sample of patients diagnosed with narcissistic PD, 47% met criteria for Major Depressive Disorder, and 42% for Dysthymia. Similar comorbidity rates were reported by and . In addition, in a study of Narcissistic PD subtypes, found that the vulnerable subtype showed particular proneness to depression. However, more recently, suggested that the rates of Dysthymia were much higher in NPD than the rates of MDD. There is a dearth of research on the effects of Narcissistic PD on the treatment of depression. However, reviewed six longitudinal studies with a combined total of 2717 subjects and found that individuals with high self-esteem have a lower risk for developing depression, regardless of whether or not they were narcissistic.

Treatment

It is not uncommon for NPD patients who present with depression to be treated with an SSRI, as it is not uncommon for most patients with personality disorders to be provided with a medication upon consultation with a primary care physician or psychiatrist. In fact, it has been observed that both pharmacotherapy and psychotherapy may be utilized to treat depressed patients with personality pathology ( ; ). However, recent reviews of literature have failed to provide any empirical support for the efficacy of pharmacotherapy for NPD ( ). There are likely many reasons for these failures, such as the difficulty in detecting and subsequently treating NPD, the poor adherence that many NPD patients have in pharmacotherapy or psychotherapy, and the possible premature discontinuation of medication in patients with NPD who often resist acknowledging their need for medication. Furthermore, many NPD patients are unlikely to seek psychiatric treatment for depression. Consequently, pharmacotherapy for NPD currently lacks empirical support.

A frequently discussed treatment for NPD in the literature is a psychoanalytically-informed treatment known as transference-focused psychotherapy (TFP; ). First applied to the treatment of Borderline Personality Disorder (BPD), TFP is designed to elicit the maladaptive representations of self and other that exist in the therapeutic relationship, and elucidate the process by which these representations lead to affective and behavioral dysregulation ( ). Past research on TFP with BPD patients has demonstrated that these patients recover from their chronic depressivity ( ) and develop more adaptive and realistic representations of self and other. report that TFP is associated with a lower dropout rate in NPD patients than other types of psychotherapy, and that its efficacy may be attributed to challenging and changing the grandiose and vulnerable aspects of the self-representations. For example, NPD patients may feel the therapist is being overly critical of judgmental toward them and begin to feel depressed or ashamed. In TFP, the therapist identifies these depressive and shameful feelings and thus interprets how and why they developed and how they are being applied inappropriately to the current situation between the patient and therapist.

Another treatment recently described in the literature is mentalization-based treatment ( ). In this theoretical framework, NPD is understood to develop from noncontingent mirroring of the child by the parents, such that the mirroring reflects the parents’ experiences of the child and not their experiences directly. For instance, the parent might be overly effusive about the child’s accomplishments while not recognizing or attending to his or her vulnerable affective states, such as depression. Consequently, the child (and adult) adapts a more grandiose representation known as the narcissistic alien self , which overvalues the parent’s effusive praise but pays little to no attention to the more vulnerable states. This leads the child to a disconnection from his or her primary affective experience. MBT seeks to bring these experiences into conscious awareness, so that the NPD patient can learn to evaluate his or her experiences more accurately and within the context in which they occur. Thus, depressive or shameful feelings can be experienced more immediately and with appropriate context to make sense of why they are there and how they might be managed. While there is no empirical evidence yet for MBT applied to NPD patients, treatment successes have been reported in case studies and clinical experience ( ).

Many authors have articulated that NPD is marked by both feelings of grandiosity and vulnerability, with some suggesting that there are two distinct phenotypes of NPD ( ). Those who are more grandiose are typically socially charming and outgoing, desire admiration, and have fantasies about success, yet are often seen as self-absorbed, struggle to recognize others’ feelings and motives, and tend to have shallow relationships. Those who are more vulnerable tend to struggle with self-doubt and feelings of inferiority, have difficulty depending on and trusting others, often feel depressed and easily hurt, and regularly experience shame and embarrassment. While these phenotypes, or subtypes, have been described in the literature, there is a growing consensus that patients with NPD tend to have both grandiose and vulnerable aspects to their personalities, with one being more dominant than the other. Indeed, what has been described above are the reactions of NPD patients who experience both grandiose and vulnerable self-representations. However, a sizable body of literature describes the very different expressions of these subtypes based upon the type of traits they exhibit ( ), response to treatment ( ), and response to ego threat ( ). To account for these differences, Pincus and colleagues (e.g., ; ) recommend the use of the term pathological narcissism to encompass the wide range of emotional, social, and behavior expressions that are part and parcel of NPD. While this concept has been a useful addition to the literature, this conceptualization of narcissism has some challenges, particularly as it is related to the chronic nature of depressivity that is experienced by patients with NPD.

Clinical illustration

Ethan is a 26-year-old Caucasian male who is seeking treatment over difficulty with a relationship break-up 3 years ago. He reported prior treatment with both an SSRI medication and psychotherapy but discontinued the medication after 4 months when he began using marijuana periodically. Although he had previously been in psychotherapy for about 2 months, he discontinued after the therapist reportedly “shamed” him for how he treated his previous girlfriend. Ethan also devalued the therapist because she was about his age and, in his perception, did not have enough experience to help him. He sought out the current therapist for his expertise and maturity.

Ethan indicated that he has been depressed “on and off for years,” thinking he would never get better. He reported some suicidal ideation, but no plan or intent. He believed his former girlfriend was “perfect” for him, and, when she broke up with him (although later he indicated that the break-up was mutual), he became very depressed. Since then, he dated intermittently, getting sexually involved with a woman early in their relationship, only later to decide she was not good enough for him or did not measure up to his previous girlfriend. The therapist began to identify the patient’s relational pattern as that marked by an idealized sense of self and devaluation of women, which helped relieve any depressive affect he might have about the relationship ending badly. When the therapist would offer an observation on this pattern, Ethan would say, “that is really insightful” or “that’s a really good comment.” Yet, as the therapy relationship unfolded, Ethan wondered if there might be anything he would learn about psychotherapy that might allow him to undermine the work he was doing with the therapist.

Though the therapy utilized a transference-focused approach (discussed earlier) toward integrating the disparate and split-off aspects of the self and others, it also addressed depressive episodes as they arose. For instance, one time, after a brief romantic relationship did not end well, the patient smoked marijuana and contacted his former, idealized girlfriend. This led him to become very depressed, feeling suicidal, and then smoking too much marijuana and drinking too much alcohol. He missed work, and the therapist explored the extent to which his actions could be detrimental to both his physical health and work vitality. Ethan avoided discussion of his depressive affect; yet, the therapist persisted and addressed his resistance. This led the patient to eventually talk about his hopelessness in ever being able to get over the breakup, which evoked sadness and depression in session. Subsequent sessions found Ethan returning to consider these feelings, though often another problem would arise centering around a relational template of grandiosity and vulnerability, which would be explored and interpreted. The identification and explanation of these templates offered a new perspective to the patient about how his mood state was linked to his ideas about himself and others. He began to find himself feeling more stable and resilient to events that would otherwise be distressing. Over time, he moved more toward a stance of greater curiosity about himself and began feeling less depressed.

The DSM-5 alternative model of personality disorder diagnosis and assessment (AMPD)

As noted earlier, the AMPD was included in the DSM-5 for ongoing empirical and clinical evaluation. This model makes explicit that depressivity and anhedonia are personality trait facets and within the Negative Affectivity and Detachment trait domains. Individuals with high levels of depressivity are described as regularly feeling down, miserable, and/or hopeless. They have difficulty recovering from these moods and are often pessimistic about the future. They also have frequent feelings of shame and/or guilt, low self-worth, and thoughts of suicide or suicidal behavior. Individuals with high levels of anhedonia lack enjoyment in life’s experiences and avoid engaging in them. Thus, the AMPD explicitly emphasizes that these problems in mood are actually problems in personality. These traits are described as being relatively stable across time, having their onset in adolescence or early adulthood, and persisting across different situations. Furthermore, the AMPD discusses problems with levels of personality functioning. Patients with TRD would be anticipated to have problems in their personality functioning. Specifically, their sense of self is likely to be negatively affected by low self-esteem or self-esteem instability, as well as difficulties with engaging in personally meaningful goals. Their interpersonal functioning also is likely to be negatively affected, as they struggle to relate to the experiences of others when their own experience is so pervasively negative, and their ability to develop deep relationships might be severely hampered by their limited emotional “bandwidth” and psychological “unattractiveness” to others. An expanded discussion of TRD features through the lens of the AMPD could be found in .

It is critical to note that the concept of personality is central to the understanding of TRD in modern psychiatry. This idea is not new, having been discussed for decades and reviewed by . Unfortunately, personality has received little attention in treatment outcome studies (e.g., STAR*D) seeking to understand why some depressed patients do not recover from brief psychotherapies and pharmacotherapy. As discussed later, insights from personality theory might prove to be very useful in the conceptualization and treatment of some patients with TRD.

Depressive personality disorder

In DSM-IV ( ), the diagnosis of Depressive Personality Disorder (DPD) was introduced. Drawing upon a long history in the clinical literature (see ), DPD was meant to fill the gap in the literature by describing those patients whose chronic depressive affect was embedded more within their personality structure and less in symptoms. Features of DPD included depressed affect, pessimism, self-criticism, negative feelings toward others, proneness to feeling guilty, and feelings of inadequacy. In fact, DPD was differentiated from DSM-IV Dysthymic Disorder, whose symptoms were associated with somatic abnormalities, such as low energy and motivation, difficulty concentrating, and disruptions in eating or sleeping patterns. DPD was proposed for inclusion in future editions of the DSM given the wealth of clinical experience that documents that certain patients’ distress seems rooted in their personality organization and developmental history, making them poor candidates for pharmacotherapy and potentially good candidates for psychotherapy.

Research on DPD led to many interesting findings. First, studies indicated that the overlap between DPD and Dysthymia in clinical and nonclinical samples ranged between 18% and 95% (reviewed in ), with an average rate of comorbidity being approximately 50%. Second, despite efforts to develop psychometrically sound measures for assessing and differentiating DPD and Dysthymia, most instruments failed to effectively differentiate patients with these conditions, thus limiting their clinical utility. Third, no randomized control trial of treatment for DPD was ever conducted, though a few studies evaluated how DPD traits affected outcome of treatment of Major Depressive Disorder. One study found DPD to interfere with successful treatment ( ), while others found no adverse effects of DPD on treatment outcome ( ; ). However, in one study, DPD traits had a negative effect on outcome of interpersonal psychotherapy of 16–20 weeks’ duration ( ). In that same study, antidepressant medication from multiple pharmacological classes was found to be effective in treating MDD without a negative effect of DPD traits.

Other studies have documented that DPD patients are commonly seen in outpatient clinical settings ( ; ), are more prone to major depressive and dysthymic disorders and suicide attempts (e.g., ; ), and spend more time in psychotherapy than those with other mood disorders, often with less improvement ( ). In short, DPD patients may be the prototype of what it means to have treatment-resistant depression. However, studies on treatment-resistant depression often rule out personality disorders and have not included assessment for DPD. In fact, it could be because of the underlying personality structure that a number of treatments for MDD fail, resulting in TRD.

Unfortunately, the Personality and Personality Disorders Workgroup of DSM-5 failed to recommend DPD as a diagnostic category in DSM-5. It might have been that the issues of comorbidity with other mood disorders led to its exclusion from the manual ( ); however, no formal justification was provided for this decision ( ). In fact, the workgroup appeared to violate its own rules for the inclusion of DPD as reliable and valid diagnostic category ( ). Nonetheless, ideas were proposed for what might become of DPD ( ; ), including the need to consider underlying psychological and personality processes when reformulating the construct, which has demonstrated decades of interest clinically. Out of this concern, a new construct was derived.

Malignant self-regard

In a comprehensive review of the DPD literature, identified a number of personality patterns that were common in several personality disorders and related conditions, which included not only DPD, but also masochistic or self-defeating personalities, and vulnerable expressions of narcissistic personality. Among the shared qualities are depression proneness; feelings of guilt, shame, and inadequacy; self-criticism; hypersensitive self-focus; pessimism; perfectionism in the context of “grandiose” or idealized fantasies; desire for approval from others; masochism; and poor anger management. described this constellation of features as malignant self-regard (MSR), which identifies a condition of the underlying self-structure. Based in personality theory, MSR captures many features that are commonly shared among patients who have, among other things, persistent depression that is often resistant to treatment. Several studies have validated the MSR construct in university students, nonclinical adult population, psychiatric outpatients, and medical outpatients in different parts of the world. Similarly, factor analytic studies have confirmed that the MSR construct is composed of a single factor of features of DPD, Self-Defeating PD, vulnerable narcissism, and depressive symptoms ( ; ; ; ; ). Even when controlling for depressive symptoms, the same personality variables continue to load on a single factor, thus supporting the coherence of these personality patterns independent of depressive symptoms. Also of note, MSR and vulnerable narcissism have been further considered in light of their connection with chronic depression. Guidelines for the differentiation of the two constructs, particularly with regard to the manifestation of and clinical attention needed for chronic depression, are provided in the Appendix for the interested reader.