Background: The nosological status of dysthymia has generated considerable controversy. The major... more Background: The nosological status of dysthymia has generated considerable controversy. The major issues include whether dysthymia should be classified as a form of mood or personality disorder and, if dysthymia is classified as a mood disorder, whether it is sufficiently distinct from major depression to warrant a separate category. Methods: We conducted a family study of 97 outpatients with early-onset dysthymia, 45 outpatients with episodic major depression, and 45 normal controls, and their 882 first-degree relatives. Axis I and II disorders were assessed in relatives using direct and informant interviews and all available medical records. Results: The rate of major depression in the relatives of early-onset dysthymic probands was significantly greater than in the relatives of normal controls and nonsignificantly greater than in the relatives of episodic major depressive probands. The rate of dysthymia was significantly greater in the relatives of dysthymic probands than in rela...
Depression is distinguished from ordinary sadness by its greater duration, severity, and impact o... more Depression is distinguished from ordinary sadness by its greater duration, severity, and impact on functioning. It is a highly prevalent condition, often with an early onset. Nearly a quarter of all individuals will experience a diagnosable depression at some point in their lifetimes. The early onset and recurrent nature of depression contribute to making it the most burdensome illness in the entire world, according to the World Health Organization. Over the last thirty years, the diagnosis of depression has changed little. Since 1980, every edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) has included a category for severe acute depression (i.e., “major depression” or “major depressive disorder”) and a category for chronic depression (i.e., “dysthymia,” “dysthymic disorder,” or “persistent depressive disorder”). The current edition of the DSM (DSM-5) includes two main categories, “major depressive disorder” and “persistent depressive disorder.” Owing, perh...
The present study examined the test-retest reliability of team consensus best-estimate diagnoses ... more The present study examined the test-retest reliability of team consensus best-estimate diagnoses of axis I and II disorders. As part of a series of family studies of outpatients with depressive and personality disorders, best-estimate diagnoses of relatives were derived in team diagnostic conferences held regularly over 4 years. Diagnoses were based on all available information, including direct interviews, family history data, and treatment records, and explicit guidelines were developed to resolve discrepancies between data sources. To evaluate the reliability of the team best-estimate diagnoses, 92 relatives were independently rediagnosed after a 2-year interval. The reliability of both axis I and II disorders was good to excellent. The results were similar for cases in which diagnoses were based on direct interviews plus informant data and cases in which diagnoses were based on informant data alone. These data indicate that the team consensus best-estimate diagnostic method can ...
The International journal of eating disorders, 2005
We provided a selective review of the relationship between anorexia nervosa (AN) and personality.... more We provided a selective review of the relationship between anorexia nervosa (AN) and personality. They reviewed the existing empirical literature examining the relationship between AN and personality. In spite of continued methodologic challenges related to personality assessment, there appears to be a relatively common phenotype in restricting-type AN characterized by high degrees of obsessionality, restraint, and perfectionism. However, there is also evidence of variability within the AN diagnostic category that is related to personality variables. Importantly, personality variables may significantly predict the course and outcome of AN. Personality variables may be risk factors for AN, consequences of AN, share a common cause with AN, or affect the course and outcome of AN. This literature would be enhanced by the articulation of conceptual models of these relationships that can be empirically tested.
Journal of Consulting and Clinical Psychology, 2003
This study examined whether reactance would negatively influence treatment outcome in 347 patient... more This study examined whether reactance would negatively influence treatment outcome in 347 patients diagnosed with chronic forms of depression and treated at 9 sites with either Nefazodone, cognitivebehavioral analysis system of psychotherapy (CBASP), or combination therapy. Contrary to our hypotheses, reactance positively predicted treatment outcome in CBASP on 2 of 4 scales. These effects were independent of the therapeutic alliance, which also positively predicted outcome. Reactance did not predict outcome in the groups receiving medication alone or in combination with CBASP. The findings suggest that reactance may be an asset in psychotherapy among chronically depressed individuals and that reactant patients can benefit from directive psychotherapy when therapists flexibly respond to perturbations in the therapeutic relationship. Results support the importance of Aptitude ϫ Treatment interactions in psychotherapy outcome. The direction and significance of such interactions may vary with different forms of psychopathology. Despite considerable progress in developing effective psychosocial treatments for specific behavioral and psychiatric disorders (for reviews,
Journal of Consulting and Clinical Psychology, 2003
Although many studies report that the therapeutic alliance predicts psychotherapy outcome, few ex... more Although many studies report that the therapeutic alliance predicts psychotherapy outcome, few exclude the possibility that this association is accounted for by 3rd variables, such as prior improvement and prognostically relevant patient characteristics. The authors treated 367 chronically depressed patients with the cognitive-behavioral analysis system of psychotherapy (CBASP), alone or with medication. Using mixed effects growth-curve analyses, they found the early alliance significantly predicted subsequent improvement in depressive symptoms after controlling for prior improvement and 8 prognostically relevant patient characteristics. In contrast, neither early level nor change in symptoms predicted the subsequent level or course of the alliance. Patients receiving combination treatment reported stronger alliances with their psychotherapists than patients receiving CBASP alone. However, the impact of the alliance on outcome was similar for both treatment conditions. Numerous studies have demonstrated that the therapeutic alliance has a modest, but consistent, relationship with outcome in psychotherapy . In a recent meta-analytic review of 68 studies, reported that the overall weighted alliance-outcome correlation was .22. The effect was consistent
The definitions that are commonly employed to describe the outcome of the depressive disorders ar... more The definitions that are commonly employed to describe the outcome of the depressive disorders are often used in inconsistent ways and remain largely untested. The lack of a standard and valid set of outcome definitions hinders the study of the naturalistic course and treatment of depressive disorders. In the present study, we operationalized definitions for response, remission, relapse, recovery, and recurrence and examined their validity in a sample of depressed patients treated with cognitive behavior therapy. Validity was evaluated by the ability of the definitions to predict subsequent outcome in acute treatment and during a 3 year follow-up period. All five definitions demonstrated moderate to excellent validity. Moreover, we were able to empirically distinguish response from remission, and relapse from recurrence, despite the frequent confusion of these terms in the literature. Several of the findings suggest that continued refinement of the outcome definitions may enhance validity even further.
In 1983, Akiskal proposed that primary early-onset dysthymia should be divided into two subtypes:... more In 1983, Akiskal proposed that primary early-onset dysthymia should be divided into two subtypes: subaffective dysthymia, which is a subsyndromal form of major mood disorder; and character spectrum disorder, which is a form of personality disorder with secondary dysphoria. The present study attempted to validate this distinction. criteria were applied to a sample of 97 early-onset dysthymic outpatients, yielding groups of 41 subaffective and 56 character spectrum patients. Patients were evaluated using structured interviews for Axis I and II disorders, family history of psychopathology, and the early home environment, and a comprehensive battery of questionnaires. In addition, direct and family history interviews were conducted with their first-degree relatives. There was mixed support for Akiskal's typology. Consistent with the model, subaffectives exhibited higher rates of major depression, depressive symptoms, and a number of depressive personality and cognitive features. In addition, there was a higher rate of alcoholism among the relatives of character spectrum patients. However, contrary to Akiskal's model, the groups did not differ on gender, unstable personality disorders, family history of mood disorders, or the early home environment.
While strides have been made in the classification, assessment and identification of chronic depr... more While strides have been made in the classification, assessment and identification of chronic depression, there remains a limited understanding of the factors underlying chronicity. This review focuses on six putative determinants of chronic depression: developmental factors, personality and personality disorders, psychosocial stressors, comorbid disorders, biological factors and cognitive factors. The strongest support was found for the role of developmental factors in the chronicity of depression. Some support was found for the role of chronic stressors and certain personality features such as stress reactivity. Few other factors found support. The determinants of chronic depression do not differ qualitatively from acute depression. Rather, the development of chronic depression may involve increased levels of childhood adversity, protracted environmental stress and heightened stress reactivity. However, it is difficult to determine to what extent these putative determinants might reflect retrospective bias in data collection, or even parental reaction to children with subthreshold depressive traits. Detailed etiological models await further research attention to understudied areas and improved research designs. Suggestions for future research include greater specification of criteria for chronicity, use of more appropriate comparison groups and longer term prospective follow-up studies.
Background: Individuals with chronic depression respond poorly to both medication and psychothera... more Background: Individuals with chronic depression respond poorly to both medication and psychotherapy. The reasons for the poorer response, however, remain unclear. One potential factor is the presence of comorbid Axis II personality disorders (PDs), which occur at high rates among these patients. Methods: This study examines the moderating influence of co-occurring PDs, primarily in cluster C, among 681 chronically depressed adult outpatients who were randomly assigned to 12 weeks of treatment with nefazodone, a specialized psychotherapy for chronic depression, or their combination. Results: At baseline, 50.4% (n = 343) of patients met criteria for one or more Axis II disorders. Following 12 weeks of treatment, patients with comorbid PDs had statistically lower depression scores (M = 12.2, SD = + 9.2) than patients without comorbid PDs (M = 13.5, SD = + 8.7). There was no differential impact of a comorbid PD on responsiveness to medication versus psychotherapy. The results did not change when the data were analyzed using an intent-to-treat sample or when individual personality disorders were examined separately. Limitations: Patients with severe borderline, antisocial, and schizotypal PDs were excluded from study entry; therefore, these data primarily apply to patients with cluster C PDs and may not generalize to other Axis II conditions. Conclusions: Comorbid Axis II disorders did not negatively affect treatment outcome and did not differentially affect response to psychotherapy versus medication. Treatment formulations for chronically depressed patients with certain PDs may not need to differ from treatment formulations of chronically depressed patients without co-occurring PDs.
Background: The nosological status of dysthymia has generated considerable controversy. The major... more Background: The nosological status of dysthymia has generated considerable controversy. The major issues include whether dysthymia should be classified as a form of mood or personality disorder and, if dysthymia is classified as a mood disorder, whether it is sufficiently distinct from major depression to warrant a separate category. Methods: We conducted a family study of 97 outpatients with early-onset dysthymia, 45 outpatients with episodic major depression, and 45 normal controls, and their 882 first-degree relatives. Axis I and II disorders were assessed in relatives using direct and informant interviews and all available medical records. Results: The rate of major depression in the relatives of early-onset dysthymic probands was significantly greater than in the relatives of normal controls and nonsignificantly greater than in the relatives of episodic major depressive probands. The rate of dysthymia was significantly greater in the relatives of dysthymic probands than in rela...
Depression is distinguished from ordinary sadness by its greater duration, severity, and impact o... more Depression is distinguished from ordinary sadness by its greater duration, severity, and impact on functioning. It is a highly prevalent condition, often with an early onset. Nearly a quarter of all individuals will experience a diagnosable depression at some point in their lifetimes. The early onset and recurrent nature of depression contribute to making it the most burdensome illness in the entire world, according to the World Health Organization. Over the last thirty years, the diagnosis of depression has changed little. Since 1980, every edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) has included a category for severe acute depression (i.e., “major depression” or “major depressive disorder”) and a category for chronic depression (i.e., “dysthymia,” “dysthymic disorder,” or “persistent depressive disorder”). The current edition of the DSM (DSM-5) includes two main categories, “major depressive disorder” and “persistent depressive disorder.” Owing, perh...
The present study examined the test-retest reliability of team consensus best-estimate diagnoses ... more The present study examined the test-retest reliability of team consensus best-estimate diagnoses of axis I and II disorders. As part of a series of family studies of outpatients with depressive and personality disorders, best-estimate diagnoses of relatives were derived in team diagnostic conferences held regularly over 4 years. Diagnoses were based on all available information, including direct interviews, family history data, and treatment records, and explicit guidelines were developed to resolve discrepancies between data sources. To evaluate the reliability of the team best-estimate diagnoses, 92 relatives were independently rediagnosed after a 2-year interval. The reliability of both axis I and II disorders was good to excellent. The results were similar for cases in which diagnoses were based on direct interviews plus informant data and cases in which diagnoses were based on informant data alone. These data indicate that the team consensus best-estimate diagnostic method can ...
The International journal of eating disorders, 2005
We provided a selective review of the relationship between anorexia nervosa (AN) and personality.... more We provided a selective review of the relationship between anorexia nervosa (AN) and personality. They reviewed the existing empirical literature examining the relationship between AN and personality. In spite of continued methodologic challenges related to personality assessment, there appears to be a relatively common phenotype in restricting-type AN characterized by high degrees of obsessionality, restraint, and perfectionism. However, there is also evidence of variability within the AN diagnostic category that is related to personality variables. Importantly, personality variables may significantly predict the course and outcome of AN. Personality variables may be risk factors for AN, consequences of AN, share a common cause with AN, or affect the course and outcome of AN. This literature would be enhanced by the articulation of conceptual models of these relationships that can be empirically tested.
Journal of Consulting and Clinical Psychology, 2003
This study examined whether reactance would negatively influence treatment outcome in 347 patient... more This study examined whether reactance would negatively influence treatment outcome in 347 patients diagnosed with chronic forms of depression and treated at 9 sites with either Nefazodone, cognitivebehavioral analysis system of psychotherapy (CBASP), or combination therapy. Contrary to our hypotheses, reactance positively predicted treatment outcome in CBASP on 2 of 4 scales. These effects were independent of the therapeutic alliance, which also positively predicted outcome. Reactance did not predict outcome in the groups receiving medication alone or in combination with CBASP. The findings suggest that reactance may be an asset in psychotherapy among chronically depressed individuals and that reactant patients can benefit from directive psychotherapy when therapists flexibly respond to perturbations in the therapeutic relationship. Results support the importance of Aptitude ϫ Treatment interactions in psychotherapy outcome. The direction and significance of such interactions may vary with different forms of psychopathology. Despite considerable progress in developing effective psychosocial treatments for specific behavioral and psychiatric disorders (for reviews,
Journal of Consulting and Clinical Psychology, 2003
Although many studies report that the therapeutic alliance predicts psychotherapy outcome, few ex... more Although many studies report that the therapeutic alliance predicts psychotherapy outcome, few exclude the possibility that this association is accounted for by 3rd variables, such as prior improvement and prognostically relevant patient characteristics. The authors treated 367 chronically depressed patients with the cognitive-behavioral analysis system of psychotherapy (CBASP), alone or with medication. Using mixed effects growth-curve analyses, they found the early alliance significantly predicted subsequent improvement in depressive symptoms after controlling for prior improvement and 8 prognostically relevant patient characteristics. In contrast, neither early level nor change in symptoms predicted the subsequent level or course of the alliance. Patients receiving combination treatment reported stronger alliances with their psychotherapists than patients receiving CBASP alone. However, the impact of the alliance on outcome was similar for both treatment conditions. Numerous studies have demonstrated that the therapeutic alliance has a modest, but consistent, relationship with outcome in psychotherapy . In a recent meta-analytic review of 68 studies, reported that the overall weighted alliance-outcome correlation was .22. The effect was consistent
The definitions that are commonly employed to describe the outcome of the depressive disorders ar... more The definitions that are commonly employed to describe the outcome of the depressive disorders are often used in inconsistent ways and remain largely untested. The lack of a standard and valid set of outcome definitions hinders the study of the naturalistic course and treatment of depressive disorders. In the present study, we operationalized definitions for response, remission, relapse, recovery, and recurrence and examined their validity in a sample of depressed patients treated with cognitive behavior therapy. Validity was evaluated by the ability of the definitions to predict subsequent outcome in acute treatment and during a 3 year follow-up period. All five definitions demonstrated moderate to excellent validity. Moreover, we were able to empirically distinguish response from remission, and relapse from recurrence, despite the frequent confusion of these terms in the literature. Several of the findings suggest that continued refinement of the outcome definitions may enhance validity even further.
In 1983, Akiskal proposed that primary early-onset dysthymia should be divided into two subtypes:... more In 1983, Akiskal proposed that primary early-onset dysthymia should be divided into two subtypes: subaffective dysthymia, which is a subsyndromal form of major mood disorder; and character spectrum disorder, which is a form of personality disorder with secondary dysphoria. The present study attempted to validate this distinction. criteria were applied to a sample of 97 early-onset dysthymic outpatients, yielding groups of 41 subaffective and 56 character spectrum patients. Patients were evaluated using structured interviews for Axis I and II disorders, family history of psychopathology, and the early home environment, and a comprehensive battery of questionnaires. In addition, direct and family history interviews were conducted with their first-degree relatives. There was mixed support for Akiskal's typology. Consistent with the model, subaffectives exhibited higher rates of major depression, depressive symptoms, and a number of depressive personality and cognitive features. In addition, there was a higher rate of alcoholism among the relatives of character spectrum patients. However, contrary to Akiskal's model, the groups did not differ on gender, unstable personality disorders, family history of mood disorders, or the early home environment.
While strides have been made in the classification, assessment and identification of chronic depr... more While strides have been made in the classification, assessment and identification of chronic depression, there remains a limited understanding of the factors underlying chronicity. This review focuses on six putative determinants of chronic depression: developmental factors, personality and personality disorders, psychosocial stressors, comorbid disorders, biological factors and cognitive factors. The strongest support was found for the role of developmental factors in the chronicity of depression. Some support was found for the role of chronic stressors and certain personality features such as stress reactivity. Few other factors found support. The determinants of chronic depression do not differ qualitatively from acute depression. Rather, the development of chronic depression may involve increased levels of childhood adversity, protracted environmental stress and heightened stress reactivity. However, it is difficult to determine to what extent these putative determinants might reflect retrospective bias in data collection, or even parental reaction to children with subthreshold depressive traits. Detailed etiological models await further research attention to understudied areas and improved research designs. Suggestions for future research include greater specification of criteria for chronicity, use of more appropriate comparison groups and longer term prospective follow-up studies.
Background: Individuals with chronic depression respond poorly to both medication and psychothera... more Background: Individuals with chronic depression respond poorly to both medication and psychotherapy. The reasons for the poorer response, however, remain unclear. One potential factor is the presence of comorbid Axis II personality disorders (PDs), which occur at high rates among these patients. Methods: This study examines the moderating influence of co-occurring PDs, primarily in cluster C, among 681 chronically depressed adult outpatients who were randomly assigned to 12 weeks of treatment with nefazodone, a specialized psychotherapy for chronic depression, or their combination. Results: At baseline, 50.4% (n = 343) of patients met criteria for one or more Axis II disorders. Following 12 weeks of treatment, patients with comorbid PDs had statistically lower depression scores (M = 12.2, SD = + 9.2) than patients without comorbid PDs (M = 13.5, SD = + 8.7). There was no differential impact of a comorbid PD on responsiveness to medication versus psychotherapy. The results did not change when the data were analyzed using an intent-to-treat sample or when individual personality disorders were examined separately. Limitations: Patients with severe borderline, antisocial, and schizotypal PDs were excluded from study entry; therefore, these data primarily apply to patients with cluster C PDs and may not generalize to other Axis II conditions. Conclusions: Comorbid Axis II disorders did not negatively affect treatment outcome and did not differentially affect response to psychotherapy versus medication. Treatment formulations for chronically depressed patients with certain PDs may not need to differ from treatment formulations of chronically depressed patients without co-occurring PDs.
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Papers by Lawrence Riso