German Journal of Psychiatry
From the Dept. of Psychiatry and Psychotherapy, University of Hamburg, Germany. Corresponding author: Dr. H. Peter, Department of Psychiatry and Psychotherapy, University of Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany, Tel.: 040 - 47174249, Fax: 040 - 47175025, E-mail: Peter@uke.uni-hamburg.de
The course of illness and treatment of a 27-year-old female
patient suffering from chronic depression and a dependent and
borderline personality disorder is presented. Various psycho-
and pharmacotherapeutic treatment methods proved unsuccessful
over a period of several years. Finally, a combined treatment
with behaviour therapy (BT) and fluoxetine was successful. In
addition to a complete remission of symptoms, the treatment led
in turn to an improvement in the underlying personality disorder.
Of particular interest are the possible synergistic effects and
the temporal course of BT and fluoxetine treatment. Aspects of
combined treatment involving psycho- and pharmacotherapy are discussed
on the basis of a literature review on the topic of SSRIs in the
case of personality disorders and treatment-resistant depression
(German J Psychiatry 1998;1:15-30).
Keywords: fluoxetine - behaviour therapy - treatment-resistent
depression - personality disorder
Received: April 14, 1998
Published: April 24, 1998
Treatment-resistant depression occurs in 10-30% of all depressive
episodes which lack somatic causes (Phillips & Niernberg,
1994). However, it must be considered that there are no clear
and generally valid criteria for treatment failure (Nierenberg,
1990), and that frequently used success criteria (e.g. 50% reduction
of symptoms) can lead to an overly optimistic view of therapy
success. This is because some patients continue to suffer from
substantial depressive symptoms even after the attainment of operational
criteria. In the case of inadequate treatment success, it must
naturally be guaranteed that this is not due to an insufficient
therapy. Psychiatric co-morbidity - especially substance dependence,
eating disorders and personality disorders - is, in the case of
depression, connected with a resistance in particular to antidepressant
treatment (Phillips & Nierenberg, 1994).
While pharmacological studies on numerous substances have been
able to demonstrate efficacy in the treatment of depression, systematic
efficacy studies of psychotherapeutic procedures have, up to now,
only been carried out for behaviour therapy (BT) and interpersonal
psychotherapy (IPT). In a review of the efficacy of psychotherapeutic
procedures for the treatment of depression, Hand (1994) suggests
that it is not possible to make a final judgement on the basis
of the existing data. The results of a multi-centre study by the
NIMH (Elkin et al., 1989) suggest that both BT as well as IPT
represent successful intervention strategies. In a comparison
of both procedures, IPT was more successful than BT at the end
of therapy; however, this advantage could no longer be maintained
by the time of an 18 month follow-up. In fact, BT exhibited the
most convincing results 18 months after the conclusion of therapy.
All studies before and after the NIMH study pointed to equivalent
therapy effects of BT and IPT in the short-term. In the long-term,
BT was - according to Hand - clearly superior. For severe, endogenous
depression, the data situation is not yet convincing for a psychotherapy
In meta-analytical efficacy comparisons of various psycho- and
pharmacotherapeutic procedures, two studies (Dobson, 1989; Hautzinger,
1993) found no different effects for the individual intervention
strategies - neither for single nor for combined applications.
This picture nevertheless changes as soon as a distinction is
made between light or moderately severe depression, and severe
disorders. In the case of severe depression, antidepressants,
best studied in the case of imipramine, are the therapy of choice
with the quickest and most extensive prospects of improvement.
Long-term successes are presumably best attainable with - as early
as possible - a combination with BT. In the case of severely disturbed
depressive patients, the issue is, according to the present state
of knowledge, not so much a case of "either-or, but rather
the optimal combination of pharmaco- and behaviour therapy"
There are only a few controlled studies on the treatment of therapy-refractory
depression. Some studies indicate that a differentiated drug treatment
can lead to better therapy results. Thus, there are indications
that depression with anxiety and agitation symptoms (Partiot et
al., 1997) or an impairment of autoaggressive impulse control
(Amin et al., 1984; Montgomery et al., 1981) responds better to
selective serotonin-reuptake inhibitors (SSRI) than to tricyclic
antidepressants (TCA). Lithium augmentation led to therapy success
in 30-65% of therapy resistant depressions (Phillips and Nierenberg,
1994). An antidepressant combination treatment, e.g. with fluoxetine
and a TCA, can lead to an increase in the success rate to 87%
(Weilburg et al., 1989). That the combination with psychotherapy
can result in additional positive effects can only be presumed
at the present time. Evidence from controlled studies is still
The case of a 27-year-old female patient, who suffered almost
continuously over a 5½ year period from a severe, therapy
refractory depressive disorder with chronic suicidality, is presented
here. The disorder had developed against the background of a mixed
personality disorder with dependent, anxious-avoiding, and borderline
elements. Treatment took place during this time completely under
in-patient or day clinic conditions.
From as early as the age of nine, the patient felt unhappy and
had lasting anxious changes to her basic mood. The first depressive
episode occurred during preparations for her school-leaving examination,
accompanied by apathy and suicidality. She did not seek professional
help at this time, however. At the age of 21, during the leaving
examination for her apprenticeship, there was a recurrence of
clinically relevant depressive symptoms with severe inner tension
and fears of failure. During this time, she attempted suicide
for the first time, taking an undetermined quantity of propanolole.
With the psychopathological clinical picture of a severe depressive
disorder, with feelings of guilt, fear and failure, she was admitted
as a psychiatric in-patient following further persistence of suicidality.
She was in an anorexic condition (44 kg, with a height of 162
The father's brother suffered from a depressive disorder and committed
suicide when the patient was 16 years old. The father had an alcohol
addiction which may have masked a depressive disorder. Impairment
of his aggressive impulse control occurred under the influence
of alcohol. No psychic abnormalities are known in the mother's
The patient is the youngest of three children (sister +2 years,
half-brother +5 years). The mother, widowed in her first marriage,
is described as being strict and at the same time anxious. She
had the role of the family breadwinner because the father, as
an alcoholic, did not pursue a regular occupation. When in an
alcoholised state, he would insult and threaten the entire family
and was especially violent towards the mother and the half-brother.
The mother was frequently chased out of the house with the children
and locked out for days on end. As a child, the patient was spared
the father's violent outbursts; however, he frequently sought
a close, and possibly abusive contact with her when he was drunk.
Because of the special relationship with her father, she was entrusted
by the remaining family members with the role of mediator at an
early stage, whereby the hazardous proximity to the alcoholised
father took on a central significance in the maintenance of the
family structure. The remaining family members tolerated and sanctioned
the risk to the patient for the sake of protection from the father's
violence. The patient developed a chronic anxious tension in this
constellation, which persisted over many years. She received no
emotional support from her mother. Instead, the satisfaction of
her natural childhood needs for motherly attachment and attention
was denied, because this was forbidden by the father, while not
being permitted by the emotionally distanced and strict mother.
The patient grew up in a village community in which she was subject
to constant social control. As a member of an alcoholic's family
despised in the village, she experienced early stigmatisation
and social isolation. A deep-seated impairment of self-esteem
and marked social anxieties developed early on, inhibiting normal
social integration outside of the family. She attempted to compensate
her feelings of inferiority by outstanding academic achievements
at school. Despite academic success, she could not fulfil her
own achievement expectations, and was tortured by fears of failure
during her entire time at school. Following school lessons, she
preferred to remain alone in a boiler-room and did her homework
there. At the onset of puberty, the few activities with her peers
were largely reduced to formal school contacts, so that any form
of psychosexual development was lacking.
During this time, the mother filed for divorce and there was a
separation from the father. Years later, the latter emigrated
to South America without taking any further interest in the family.
Following the school-leaving examination, with the second-best
marks of her year, the patient left home and took up training
as a child nurse after a voluntary social year. It was her express
wish "to concern herself completely with the care of small
children." The new domestic situation in a sisters' home
contributed to further isolation, because here also she was unsuccessful
at integrating into her social surroundings. Anxious-depressive
decompensation and a clinical manifestation of the psychiatric
disorder ultimately developed under the pressure of the leaving
After the first suicide attempt, a 1.5-year in-patient treatment
followed, with a focus on a psychoanalytic approach. According
to the patient, a drug treatment with 75 mg amitriptyline took
place over the entire period. These measures failed to have a
lasting positive effect on the depressive syndrome or the chronic
suicidality. Because documentation from this treatment period
is largely lacking, the reasons for the unsuccessful adherence
to the drug regime are unknown. During the long period of residence
as an in-patient, she lost her few social contacts. The chronic
suicidality prevented discharge and return to her own home, so
that a therapeutic home was planned in the course of further treatment.
The course of treatment, including that of the suicidal decompensation,
was largely dominated by dependent, anxious-avoiding and borderline
personality traits which fulfilled the criteria for corresponding
personality disorders (ICD 10 F61.0). An extreme dependent relationship
with the attending female therapist developed, to the exclusion
of other persons. Imminent or anticipated separation (e.g. discharge)
led in every case to a reactivation of the latent suicidal impulse.
Shortly before one of the planned transfers, there was a second
serious suicide attempt (attempt at strangulation and suffocation
with a belt and plastic bag). After 1.5 years of unsuccessful
treatment, there was a change of therapist, in view of the irresolvable
emotional complications in the patient-therapist interaction,
which led to a third suicide attempt. The patient threw herself
in front of an underground train and suffered a fracture dislocation
with incomplete paraparesis on the level of the lumbar vertebrae
After a six-month neurological rehabilitation treatment as an
in-patient in another clinic, exclusively in-patient psychiatric
treatment was resumed. The paraparesis and the resulting additional
problems for coping with everyday life led to a worsening of the
depressive syndrome, so that the psychiatric admission, originally
planned as a transitional measure, lasted for a further 1.5 years.
An interim attempt at discharge into a therapeutic home failed
after only three months.
Therapeutic efforts now focused on a stabilising psychiatric treatment.
Behaviour therapy sessions took place once a week, concentrating
on coping with daily life problems. Attempted drug treatment played
a more significant role. Various psychotropic drugs were employed
during this time, partly administered in a combination treatment
of three different substances. Antidepressant medication: trimipramine
up to a maximum of 75 mg, viloxazine up to a maximum of 600 mg.
Benzodiazepines: nitrazepam up to a maximum of 5 mg, lorazepam
up to a maximum of 8 mg. Neuroleptics: melperone up to a maximum
of 100 mg.
After 3.5 years of treatment as an in-patient and several frustrated
attempts at transferring the patient to a complementary therapeutic
institution, further treatment was planned in a day clinic setting.
To this end, the patient was transferred to the psychiatric department
of the University Hospital. Curative treatment goals had meanwhile
given way to a supportive approach. The therapeutic goal in the
day clinic was the gradual severance of the dependence on an in-patient
setting, which in an extreme fashion had become a substitute for
lacking social contacts and family connections.
The first impression in the admission interview was that of an
alert, reflective, in spontaneous rapport fluent, communicative,
almost logorrhoeic patient who hardly seemed depressed. In view
of the outlined pre-history and course of illness, the patient's
self-portrayal seemed oddly parathymous, or at least dissimulating.
An agitated-anxious depressive mood with latent to open aggressiveness
only became perceptible in later interviews. The patient denied
having acute suicidal impulses; however, chronic latent suicidality
had to be assumed on the basis of the case history. There were
no signs of paranoid symptoms. Her thought processes were, however,
dominated by depressive content. Her depressive, self-deprecating
cognitions were accompanied by considerable feelings of guilt
and insufficiency. Signs of apathy, a psychomotor retardation
or an affective vacancy were not determined.
The day clinic treatment, lasting 19 months in total, was marked
by various crises. The patient had to be transferred to in-patient
treatment seven times, sometimes also under closed ward conditions,
because of suicidal or parasuicidal decompensation (on four occasions,
there were actual suicide attempts or parasuicidal actions). Conditions
of existential anxiety occurred repeatedly, accompanied by menacing
fantasies and nightmares, including recollections of physical
and sexual threats by her father during early childhood. The patient
herself described a deep-seated disturbance of self-esteem associated
with a strong yearning for death.
In the day clinic treatment, her relationships with the therapists
were characterised by marked ambivalence. Her intense wish for
emotional attachment was eclipsed by a deep-seated mistrust in
the stability of the relationship and by her deep conviction regarding
her own worthlessness in relationships. She often provoked crises
in the therapeutic relationship through rejection, sometimes hostile,
deprecating and self-deprecating behaviour, which for the patient
involved a threatening and anxiously anticipated instability in
the relationship. The therapist's absence at weekends, during
holidays and due to illness triggered deep despair and reactivated
her yearning for death.
The severe clinical picture made systematic therapy planning and
treatment impossible. Therapeutic sessions concerning biographical
events often led to crisis-like worsening which made further exploration
difficult, often impossible. The exploration sessions either were
broken off by the patient or immediately led to therapeutic treatment.
The stages of therapy below in part overlapped with shifting focus.
The chronological sequence implied by the numbering is intended
exclusively as a rough orientation:
The patient's need for attachment, with simultaneous mistrustful
rejection, at first impeded content-related therapeutic work,
so that the stability of the therapeutic relationship became the
centre of attention in the treatment. In the case of every necessary
crisis-related transfer to the ward, the patient was reassured
of the continuity of both the treatment offered as well as of
the female therapist to whom she related most closely. The constant
experience of continuity, in spite of repeated separation provoked
by the patient (e.g. admission to a closed ward), made possible
a gradual building up of trust in the therapeutic relationship
which, thanks to the special efforts of the therapist, developed
into a sound treatment alliance.
Traumatising childhood experiences were made a central theme in
individual sessions, on the one hand to promote further hypothesis
development and, on the other hand, because recurring memories
of these experiences increasingly revealed themselves to be an
intrapsychic condition for the origin and maintenance of the depressive
syndrome. This was because they essentially contributed to chronic
affective labilisation as well as to the development of the autodestructive
self-image, due to culpable processing. The patient's attempts
to avoid examination of these memories were unsuccessful, because
they intruded intensively into her everyday life, despite her
efforts. The dysfunctional avoidance behaviour meant that an adequate
processing and emotional distancing failed to occur. In therapy,
confrontation with the upsurge of emotions had to take place in
cautious steps which were bearable for the patient. Through graduated
emotional exposure, an initiation of the necessary grief could
be permitted, as well as an open experience of her suppressed
anger. The fact that she could cope with the released emotions
and was not, as she had feared, overwhelmed and destroyed by them,
led to a reduction in her anxiety. The repeated experience that
the anticipated condemnation by the therapist did not occur promoted
trust in the therapeutic relationship and at the same time led
to a correction of the depressive self-image. An examination of
the disturbance model presented in the therapy enabled a distanced
reflection on her past and a new evaluation of her childhood memories.
Depression-specific automatic thoughts and basic assumptions were
identified during biographical analysis. An indirect and cautious
procedure in Socratic dialogue proved to be the most successful
in the treatment of these cognitions. Again, the experience that
she was not condemned by the therapist, despite the exposure of
supposed weaknesses and mistakes, was helpful in this situation.
This enabled reflection on the deep-seated attributions of guilt.
As therapy progressed, a direct treatment of the depressive attitudes
and a corresponding correction was increasingly possible in the
dialogue. Far-reaching changes of dysfunctional depressive cognitions
could be attained in this phase, and there was a change from a
self-destructive behavioural pattern to an active coping style
in crisis situations.
In the course of treatment, social anxieties and deficits were
integrated into the therapy plan and treated both in an individual
as well as in a group setting. After step-wise analysis of problem
and alternative behaviour, considerable difficulties arose in
the implementation of exercise units. These could only be mastered
under certain conditions through role plays. An exceptionally
high level of anxiety and the persistence of depressive symptoms,
but also motivation problems - especially the activation of fears
of separation in the case of steps taken outside of the day clinic
- were the main reasons for this. The first exercise steps in
a real situation were finally enabled by constant encouragement
from the therapist. Initially for the therapist's sake, and later
because of an understanding of their necessity, the patient carried
them out and thus reduced her anxiety by means of repeated exposure.
As a result, it was possible to develop or to improve social skills
in diverse social contexts (making contact, holding a conversation,
group activities, dealing with public authorities) with therapeutic
guidance (behaviour analysis, role plays, exercises). This also
involved changes in her sometimes brusque, rejecting interaction
behaviour. In this way, she was finally able to achieve the building
up of social activities and contacts which she consistently maintained,
despite the continued persistence of depressive mood. She regularly
participated in activities outside of the day clinic (sports for
the disabled, a self-help group for physically disabled women,
adult college choir, concerts, weekend seminars), which she nevertheless
often found strenuous and, in part, an ordeal. Her understanding
of the necessity of these measures, as well as regular motivation
by the therapist, helped her to persevere with these behaviour
changes despite insufficient improvement of mood.
In particular it was the last focal point of therapy, inherently
associated with release from dependence on hospital, which led
to an activation of her fears of separation, and thus to the occurrence
of crises. Nevertheless, an examination of these themes took place,
because a change in behaviour pattern and in the cognitive evaluation
of such crises had developed during therapy. Suicidal thoughts
and actions were substituted by admittedly still inadequate, but
not life-threatening retreat behaviour in overload situations
(overdoses with the medication, in order to sleep through the
Despite the therapy successes described above, the persistent
depressive mood, with marked feelings of hopelessness and fears
of failure which could not adequately be influenced cognitively,
remained a decisive barrier to further positive development.
At the commencement of day clinic treatment, the patient took
viloxazine 600 mg, lorazepam 2.5 mg, and chloral hydrate 500 mg.
The long-term goal of the pharmacological treatment was the adjustment
to an effective antidepressant medication and, given the high
dependence potential of the patient, the gradual reduction of
the lorazepam dosage. However, changes in medication during the
first half of treatment were in particular influenced by the crisis-like
worsening of the symptoms on a number of occasions. During this
time, psychotropic drugs such as perazine and buspirone were employed
because of the repeated agitated-anxious and depressive-suicidal
decompensations. The psychopathological picture and the hitherto
unsuccessful treatment with a TCA, as well as with two atypical
antidepressants, suggested the employment of an SSRI. A systematic
change of the antidepressant medication was not attempted, because
even the smallest changes in well-being, e.g. caused by changes
in medication, provoked acute suicidality and thus endangered
the treatment setting in the day clinic. A renewed, longer-term
admission as an in-patient was inconsistent with the original
therapeutic goal, namely to achieve independence from such a setting.
This would have reactivated all the problems of separation, and
was furthermore rejected by the patient. There were further reservations
against using SSRIs, since suicidality is still listed as one
of their relative contra-indications.
Only once the acute risk of suicide had abated was an SSRI therapy
carried out under day clinic conditions. With 20 mg fluoxetine,
there was a clear improvement in mood after around 14 days, accompanied
by further behaviour changes already planned before the change
in medication, but not implemented. In the following four months,
the patient was able to achieve further changes in lifestyle,
e.g. taking up various social contacts and activities. These were
also increasingly accompanied by a sense of pleasure and joie
de vivre. Her body weight returned to normal during this time.
It was now possible in psychotherapeutic work to concentrate on
the central theme of relationship continuity and to plan and carry
out a staged release from dependence on a therapeutic setting,
so that a discharge from hospital was possible six months after
the commencement of fluoxetine therapy.
Some months later, the patient took a further step towards autonomy.
She left the therapeutic flat-sharing community, and shared an
independent flat with a female friend whom she had met in the
course of her social activities. Here, it was possible for her
to build up a sound bond and, for the first time since her early
childhood, to overcome her social isolation and loneliness. Furthermore,
for the first time in her life she was able to develop her first
sexual relationship with a man. She took on a course of study
and was able, accompanied by many kinds of uncertainty, but without
the familiar fears of failure and achievement, to cope with the
initial demands. These changes in the patient's lifestyle can,
in view of the intrapsychic problems reaching far back into childhood,
be considered far more than a mere abatement of a depressive syndrome.
Rather, changes were exhibited in the premorbid personality traits
that predisposed towards the depressive disorder. The patient
has now been in a stable mental state for a total of two years
under fluoxetine. For the past year, she has been treated exclusively
as an out-patient.
The case report presented above describes the course of illness
of a 27-year-old female patient who suffered for 5½ years
from a severe depressive disorder with chronic suicidality against
the background of dependent, anxious-avoiding, and emotionally
unstable personality traits. The severe, therapy-refractory suffering
of the patient made in-patient (or day clinic) and pharmacological
treatment necessary over the entire period. Given the unsuccessful
therapy over many years, the surprising and rapid remission following
commencement of SSRI therapy poses a series of questions and aspects
worthy of discussion, in particular related to the sequentially
interacting affects of psycho- and pharmacotherapy.
From a pathogenic point of view - despite the peculiarities in
the course of illness related to intensity and chronicity of the
symptoms - a very typical constellation existed, suggesting a
multi-factor, biopsychosocial origin of the disorder. The family
history points to a significant biological-genetic component,
with an accumulation of psychiatric illnesses in the father's
family. By contrast, given the biographical and anamnestic data,
the disorder can be understood both for the psychoanalytically
orientated as well as for the behaviour therapy orientated therapist
as a psychogenic disorder. This constellation contains the danger
of a one-sided dichotomisation of the presumed causes of illness
and of the resulting treatment concepts. In the case of the patient
described above, the focus of treatment during the first 1.5 years
was psychoanalytically orientated in-patient therapy which, given
the ominous biography and the self-image of the patient, appeared
to be justified. This attempt at treatment failed tragically.
A marked dependence on the attending female therapist developed.
At the same time, there was a complete loss of the rudimentary
social network with a consecutive chronicity of the problems.
Pharmacological measures were employed during this treatment phase
primarily in the sense of accompanying medication. Antidepressant
medication was administered over the entire period which, in spite
of insufficient effects on the target symptoms, did not entail
a change in dosage (too low) or substance.
In contrast to the above, the procedure during the second in-patient
treatment phase was characterised by the process of progressive
chronicity, and was lastingly influenced by a severe suicide attempt
with resulting paraparesis. The psychotherapeutic curative treatment
approach largely gave way to a general psychiatric procedure with
stabilising and structuring interview contacts and the minimal
goal of re-establishing the patient's independence of hospital
psychiatry with the aid of complementary treatment facilities.
During this in-patient treatment phase, which lasted barely two
years, various antidepressants were administered, sometimes at
the maximum dosage. At the same time, tranquillisers and neuroleptics
were administered, similarly without much success.
Transfer to the university's psychiatric department was followed
by a third treatment period in a day clinic. The focus of the
first treatment phase was the overcoming of problems in patient-therapist
interaction. These had developed against the background of a personality-related
relationship disorder on the patient's part. Building on this,
content-related therapeutic goals were striven for, in particular
related to the depressive cognition as well as the social deficits
and the deep-seated fears of failure against the background of
the traumatising childhood experiences. This represented the basis
for changes in attitude and behaviour with respect to current
lifestyle and life planning. There was a change of pre-existing
behavioural patterns in crisis situations as well as in passive,
avoiding, and autodestructive conflict behaviour. Nevertheless,
the psychotherapeutic measures did not have sufficient impact
on the depressive symptoms. The commencement of fluoxetine treatment
at this point led to a rapid abatement of the depressive mood
and, as a result, to a far-reaching psychosocial adaptation with
positive changes extending into the personality.
The surprising turning-point in the chronic course of the illness,
which far exceeded an abatement of the depressive syndrome, is
a relatively rare phenomenon in everyday clinical terms. Given
the drastic changes immediately after use of the SSRI, the question
must be raised as to whether the observed effect can be attributed
exclusively to the medication, or rather to a synergistic effect
between psycho- and pharmacotherapy. In order to review the first
possibility, it is necessary to clarify the matter of how fluoxetine
differs positively in its effect on the symptoms of the patient
compared with that of other antidepressants and, if need be, whether
its use at an earlier stage, despite existing suicidality, would
have been possible or should even have been carried out. The second
possibility, namely the assumption of a synergistic effect between
psycho- and pharmacotherapy, would appear to be justified in the
light of the course of illness and therapy. With respect to the
potential clinical implications, it represents an exciting alternative.
In studies on SSRIs, there are indications that in the case of
symptom constellations such as in the case presented - with chronic
suicidality, disturbed aggressive impulse control, and agitated-anxious
mood - a serotonin deficiency can be of decisive pathogenic significance:
A serotonin disorder first became associated with depression at
the end of the 1960s. 5-hydroxyindole acetic acid (5-HIAA), a
breakdown-product of serotonin metabolism, is reduced in the cerebrospinal
fluid of some, but not all depressive patients (Åsberg et
al., 1976). An explanation for this non-uniform finding was first
found in later studies; in particular, it was suicidal patients
who were affected. Subsequent studies confirmed these results
and showed that this involved an extremely stable and culture-independent
context. The suicidality hypothesis was further specified in the
course of time. A metabolic disorder of the serotonin balance
is associated less with depression or some other diagnostic category;
rather, it is associated with an impairment of aggressive behaviour
Therapeutic studies indicate that fluoxetine can be particularly
effective in the case of agitated-anxious depressions (Partiot
et al., 1997) and borderline personalities (Coccaro et al., 1990;
Cornelius et al., 1990; Coccato and Kavoussi, 1997; Norden 1989).
A positive effect on the depressive mood and impulsive aggressiveness
could be demonstrated, in the case of borderline patients, with
a dosage of 5-80 mg fluoxetine. In a comprehensive meta-analysis
(Montgomery, 1989), fluoxetine was found to be superior in comparison
with reference antidepressants (TCA) and a placebo in patients
with agitated depression. A positive effect on the agitated-anxious
syndrome could also be demonstrated for other SSRIs. In a comparison
between paroxetine, placebo and active control (mostly TCA) on
about 3,000 patients, Sheehan et al. (1992 ) found that paroxetine
significantly reduced anxiety symptoms, while the active control
condition showed no effect on anxieties. In two comprehensive
meta-analyses, a superiority of fluvoxamine in the treatment of
anxiety symptoms in the case of depression could be demonstrated
compared to imipramine (Montgomery, 1991). These results are in
accordance with the known positive effects of serotonin reuptake
inhibitors in the treatment of anxiety disorders. Paroxetine also
seems to have a favourable effect on personality-related characteristics
of affectivity. In an initial double-blind, placebo-controlled
study (Knutson et al., 1996), a significant reduction of the "negative
affects" and hostility in the case of healthy test persons
could be attained one and four weeks after commencement of treatment,
in comparison with a placebo group.
In the case of the treatment of our patient, an SSRI medication
would thus not only be indicated, but would even come into question
as the therapy of first choice. In contrast to this, there are
case reports which indicate that an increase in suicidal actions
can occur with SSRIs, so that suicidality is still listed today
as a relative contraindication in the directions for use for fluoxetine
treatment. Although more recent studies (Beasley et al., 1991;
Judge, 1997) show that a reinforcement of suicidal actions is
improbable on fluoxetine and fluvoxamine (Wagner et al., 1993),
suicidality is still seen as a relative contraindication for SSRI
treatment in a German standard textbook on psychiatric pharmacotherapy
(Benkert et al., 1996) and has restrictions such as a temporary
combination with benzodiazepines. There is hence, despite current
study results, uncertainty over the possibilities and limits of
treatment of suicidal patients with SSRIs, which can lead to therapeutic
reservations especially under out-patient or day clinic conditions.
The far-reaching psychopathological changes following the use
of fluoxetine are in many details similar to Kramer's descriptions
of personality changes with fluoxetine (1993). In the case presented,
partial therapeutic successes had, however, already occurred before
SSRI therapy, whereby the alternative assumption of a synergistic
interaction of psycho- and pharmacotherapy becomes more plausible.
The sequential therapy successes alone, with changes in various
psychic functional areas as a result of different therapeutic
measures, supports this hypothesis. During psychotherapy, there
were far-reaching changes in the central cognitions and behaviour
patterns for the depressive disorder prior to fluoxetine treatment.
According to an understanding of behaviour therapy, the symptom
complex, consisting of self-deprecating cognition, social isolation,
lack of perspective in lifestyle and destructive coping strategies,
represents a fundamental maintaining condition for the depression.
Successful treatment of depression thus requires positive changes
in these areas, so that a reduction of the depressive mood with
retention of the pathological attitudes and behaviour patterns
would only have been of limited stability and without far-reaching
consequences. The therapeutic successes prior to the pharmacologically
induced improvement of mood are, according to this theory, a fundamental
requirement for the exceptional efficacy of the SSRI medication.
Despite the stable cognitive and behavioural changes which were
achieved in the BT, the desired reduction in depressive mood did
not occur. The insufficient impact on mood became a decisive barrier
to further therapeutic success, and could only be overcome by
pharmacological influence on the serotonin metabolism. According
to BT concepts, it must be assumed that genetic or acquired biological
conditions, e.g. a pathological alteration of the central serotonin
balance, became a decisive maintaining condition of the disorder
at this point in the therapy process, and required a specific
biological therapy. The biologically induced improvement of mood,
the emotional support in the therapeutic relationship and the
cognitive and behavioural changes through the therapeutic work
could have resulted in a constellation which was hitherto lacking
in the biography of the patient, enabling the subsequent changes
in the premorbid personality traits.
The presumption, that interactions between psycho- and pharmacotherapy
can occur which have a greater effect than the sum of the individual
effects, can only be speculative at the present time. A systematic
study of this assumed phenomenon has yet to be conducted. Because
of the possible therapeutic implications, however, such a study
would be of great clinical relevance. For the behaviour therapist,
a series of questions is posed in this context: Can the prospects
for success of behaviour therapy be improved by prior pharmacotherapy
and, if so, is it possible to develop specific indication criteria
for these? Can behaviour therapy successes lead to a potentiation
of the effect of subsequent pharmacotherapy and, if so, under
what circumstances can such effects arise? Possible consequences
must also be considered with respect to pharmacotherapy. Thus,
in addition to psychopathological aspects in the choice of medication,
the question of the optimal time of commencement of treatment
can play a role in therapeutic decisions. Given the considerations
presented here, it would in individual cases be possible that
a medication employed unsuccessfully could later in the treatment
process - after removal of the symptom-maintaining conditions
- demonstrate a hitherto unseen therapeutic effect.
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