Psychiatry & Psychotherapy Podcast - The Big Five: Neuroticism Part 2

Episode Date: September 26, 2020

In part 2 if the Big Five series we talk about how medications, such as Selective Serotonin Reuptake Inhibitors (SSRIs), psychotherapy, and exercise can make an impact. Trial studies of mindfulness-based cognitive therapy and cognitive behavioral therapy (CBT) have shown promise in the treatment of neuroticism. We also discuss the possible benefits of neuroticism. Studies have shown that neurotic people may outperform their stable counterparts in a work context. This "healthy neuroticism" may exist when the effects of neuroticism and conscientiousness interact.  By listening to this episode, you can earn 0.5 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Hello and welcome to the Psychiatry and Psychotherapy Podcast. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. One thing that created a lot of burnout and angst for me was trying to get continued medical education right at the last minute. So why not join the CME membership and do CMEE while listening to this podcast? Go to Psychiatrypodcast.com, sign up, sign in, take the test, and the certification is email to you in seconds. All right, welcome back to the podcast. This is Neuroticism Part 2. I am joined with Alec Zane, fourth year soon to be psychiatry resident, fourth year medical student.

And we are going to be going through neuroticism. We're going to be talking about the psychopharmacology of neuroticism. What do medications do? Do medications treat neuroticism? And then we're going to be talking about psychotherapy. We're going to be talking about exercise. So welcome back to the podcast. Hey, guys.

Good to be back. Yeah. So tell me a little bit about this one study, Quilty 2008. It's a randomized controlled trial examining whether neuroticism acts as a mediator of treatment in response to SSRIs and major depression. Yeah. So basically what they sought out to look at was whether neuroticism played a role in the effect that SSRIs have in MDD. So they proposed two different models, actually, in which neuroticism could mediate this treatment. The first one is the mediation model. This model says that all changes in depressive symptoms in response to SSRI treatment were preceded by changes in neuroticism. Basically, there's just saying that depressive symptoms were only fixed due to changes in neuroticism. And their second model that they pointed out was complication model.

What this model says is that changes in neuroticism are a byproduct of S-SRI improved depression. So this model basically, it doesn't say that neuroticism acts as a mediator, but it's rather just a side effect, basically, of treating depression with S-S-R-I's. Okay, that's cool. So they go in there with different models. want to see which model is more accurate. Right. And they studied 62 men and 89 females, and they treated them with SSRIs.

What were the other options that they gave? Yeah, so the other options included NDMs and RIMAs. Yeah, so this was a really interesting study because they looked at comparing SSRIs with dopamine reuptake blockers and monoamine, reversible monoamine oxidase inhibitors. So they compared the two groups, SSRIs versus, they kind of grouped the reversible monomine oxidase inhibitors and the dopamine reuptake blockers together.

And they found there was not much difference in the two groups. So that means that they could actually look at these and compare the results. and they looked at a Hamilton depression score, a Beck Depression inventory, and they looked at the Neo, the large Neo, so they looked at the full Big Five characteristics before and after treatment, and that's why it's really interesting to me. You know, does neuroticism decrease, right? That's one of my questions with proper treatment.

and what they found was that in fact the SSRIs worked better at decreasing the neuroticism. And so before the score was like 120 pre-treatment and after it dropped to 100 and about a standard deviation was about 20. So that's a one standard deviation shift in the neuroticism score. And that was with the SSRIs. With the other two medications, it was only a drop in five points. So that's a quarter of a standard deviation. So the effect size for treatment of neuroticism was one, which is really nice with SSRIs. Further, the HAMD, you know, the BDI also decreased.

So drops from like the Hamd6, which is part of the Hamdi was 10.5 before and then it dropped to 3.2. And then the BDI with SSRI dropped from 29 to 13. And there was less of a drop with the other two medications. So in regards to the model, they thought that the neuroticism change was more linked to the depression change. and with a bigger neuroticism shift, you'll have a bigger depression shift. So that potentially is a little bit of a new way of thinking about treating depression.

So, Alec, what's the big sort of takeaway that you had from this study? So the big takeaway that I got is that when we treat depression with esteris, it often co-occurts with decreases in neuroticism. Yeah. Okay, so with that first study in mind, we looked at a second study. This was a more recent study done by Hayward 2013. And it suggested that outcomes and treatment of depression may be worsened by higher levels of neuroticism. But in looking at the study, because we have this mindset now from this prior study,

that you can change your neuroticism, 20 points by treatment. That's one standard deviation. One of the big mistakes this study made was that they looked at the timing of when they took the neo, and it was between zero and 62 months after starting treatment, meaning for some people they did it before they started treatment. For some people, they did it after they started treatment. And so because of that, when I look at this study, it's almost like I can't even really wrap my head around the details of the study

because what if you had someone at 62 months after they started treatment and they're still very depressed and they're also very high neuroticism and you test the neuroticism and it's high? and you're like, oh, well, I guess the person who was highly neurotic had more difficult to treat depression. But it seems that in the prior study, both the depression and the neuroticism were both treated. Actually, in this paper they said in their introduction, that neuroticism was very stable across the life course.

I think that's fundamentally not true, mild to moderate at most, right? So I'm going to skip, we're going to skip this study. Not going to too many details of it. We'll put it up on the website if you want to take a closer look at it yourself. All right. So now we're going to move into psychotherapy. So tell me about this first study by, oh gosh, I'm going to butcher this name. Rognikzuk, 2003.

Yeah, that's pretty much as good as I would have gotten it. So, yeah, so this was a study that looked, and they were looking to see if personality traits had an effect on therapy treatment outcomes. So they theorized that neuroticism would have a negative effect, actually. So this study was done on psychiatric outpatients who had complicated grief. these patients either completed interpretive or supportive short-term group therapy. Group therapy. I think that's important to mention. Yeah, and we'll definitely touch upon that again later. But prior to therapy, their personalities were measured with the Neo-FFI. And treatment outcomes were operationalized as outcome were grief symptoms, interpersonal distress and psychiatric symptoms measured by several different questionnaires.

And what they found was that neuroticism was actually associated with less favorable outcomes, meaning that the patients still had greater grief symptoms, more in personal distress, psychiatric symptoms, etc., as compared to other personality traits. And on the other hand, extroversion, conscientiousness, and openness actually were directly associated with more favorable treatment outcomes. Yeah, it's hard, it's hard from this study to tell exactly how strong those links are. Then my other thought was they did this, they did the, the Neo at the beginning of the treatment, but not at the end. I wish they would have done it at the end so we could see before and after how much the, how much the neuroticism and the different

things changed with treatment. I would have also liked to I've seen, it's possible that the people who were higher in neuroticism just had worse symptoms. Because in that prior study we looked at with SSRIs, it seems like there was a close tie between neuroticism and depression. So, like, were the people with less favorable outcomes really just more severely ill? Which, of course, people who are more severely ill, they're going to take more treatment. It's going to require much more treatment to get them better. So those are some of my thoughts. The next study we looked at was mindfulness-based cognitive therapy, which showed reductions in neuroticism. This was Armstrong and Rhymes 2016. So a pretty recent study. And they defined

mindfulness as awareness and acceptance of ongoing emotional experience. And they thought it was a potential protective factor against neuroticism. So, yeah, tell me a little bit about this study. Yeah, so the idea was that they thought practicing mindfulness would help prevent neuroticism by treating, you know, sort of that perceptive negative thinking, resulting in decreased emotional sensitivity in neurotic patients. So this was a pilot randomized control trial that helped. It basically placed mindfulness-based cognitive therapy, MBCT, against online self-help intervention,

which served as the control group for highly neurotic patients. So neuroticism was measured with the Isnick personality questionnaire, and this was administered throughout treatment, actually. And participants, in order to be in the study, they actually had to have a level of six or higher in neuroticism in order to be qualified. And what they found was that the MBCT group actually had lower levels of neuroticism versus the control group at four weeks post-treatment. Yeah, and just to give you an idea on the numbers, which don't mean a lot to me because I'm not familiar with this exact inventory, but the pre-treatment was 8.5, post-treatment was 4.5 for the

mindfulness-based CBT, whereas in the other group, pre-treatment 10.2, post-treatment 9.2. So a much lower decrease. Okay, so we looked at the number of, you know, the change from the before and after. And, you know, we had this group that went through the mindfulness-based cognitive therapy, and they went from 8.5 to 4.5 through the treatment. And so I was thinking like, what does that really mean? Okay? And it's kind of hard to understand until you look at the actual thing that we're looking at.

So this is a neuroticism scale score. And in this normal group of people, the mean was 3.6. And the standard deviation was 1.9 for men. and 3.7 with a standard deviation of 1.7 for females. So that is very helpful. So basically think about the normal being 3.6 and 2 being the standard deviation. So if your score goes from 3.6 to 5.6, you just became one standard deviation more neurotic than the general population. Okay. That's a rough estimate, right? So think about the study where you had a group of people who started out pre-treatment at 8.5 and then post-treatment, they went all the way down to

4.5. That is two standard deviation shift. That's kind of what we saw actually in the SSRI study, right? So that's cool. That's really cool. So that's what I took away from this study. Is there anything else from this study that you thought was important? Yeah, so it was a very interesting pilot study. And then they definitely suggested that there will be a number of studies like this in the future just to see if it was as promising as it seemed. Yeah. The other thing that I think is helpful talking about from this study is what they actually did.

Right. So were they only teaching mindfulness? No, because it's mindfulness-based cognitive therapy. So they defined what they did pretty well, actually, in this study. So in this training, they did two-hour sessions. It was an eight-week program with weekly two-hour sessions, so 16 hours total, which is actually not that much if you think about it. It's like eight weeks and you get that big of a change.

They worked on stress reactivity, and they worked on interpreting biases, you know, thoughts and feelings. So that's probably more like something like a mood log. They looked at cognitive distortions, catastrophizing, all or nothing thinking, overgeneralization, jumping conclusions, they looked at that. They looked at stress sensitivity in the third session. And they looked at how mindfulness might help that. They looked at avoidance and safety seeking behavior in the fourth.

fourth session. In the fifth session, they added suffering, which let's see what it meant. They looked at specific, there was a more specific focus on the ways in which our interpretations, avoidance behaviors, and attempts to avoid sensations and emotions can add to our stress. So kind of that avoidance of, you know, maybe negative things. And participants were invited to complete a home practice diary where they noted their direct sensations, emotions, and added suffering in relation to situations during the week. In the sixth session, they looked at overthinking, like thoughts are not facts, and it was expanded to include further discussion of forms of overthinking such as rumination and worry.

methods for increasing awareness of overthinking and ways of addressing it were covered. In the seventh session, they looked at self-acceptance, self-compassion, kindness. They were encouraged to undertake a loving kindness practice at home on alternative days of the week. That's a type of meditation, I think, where you look at yourself with more compassion. And then the eighth one was stress vulnerability. relapse prevention. They focused on bringing together what they had learned

about stress management rather than depressive relapse. So they did some guided meditation practice, group discussion, and they also were given meditation tracks and had homework each week. So that's pretty cool.

It's a cool study. It's something to look at. as one of the many things that will likely reduce neuroticism. Is there anything else you'd like to add about the study? Yeah, so one interesting thing is that they also measured each component that they were working on during the study for each of the weeks. And they also measured that the NBCT group, they actually had reductions in rumination

and increases in self-compassion and decentering as well. So in addition to reduction of overall neuroticism. Very cool. And there was a more recent study on mindfulness skills and long-term reduction of neuroticism with mindfulness-based cognitive therapy. Anything you want to mention on that one? Yeah, so this one was more recent done in 2017. So in this study, they took data from two randomized control trials, actually. They looked at patients with recurrent depression in remission. And similar to the other study, they were treated with MBCT. It was measured after treatment as well and at a 15-month follow-up.

So what they found was promising as well. They found significantly lower levels of neuroticism overall, and they actually found higher levels of conscientiousness at a 15-month follow-up. Yeah, so the mean for this was 151. And then at 15-month follow-up, it dropped to 145. Interestingly, this effect size is quite a bit smaller. It's 0.54. But sometimes we see that with bigger studies.

You see a lower effect size. Because there were 282 participants. That's quite a bit. Okay, let's keep moving. I want to touch on exercise a little bit before we move on. and it's really hard, it was really hard for us to find studies where they look specifically at neuroticism before and after starting exercise. But what we do know is we do know that major depression, anxiety, you know, is highly linked with neuroticism. So there's a couple studies that are pretty

recent actually, and I'd like to discuss them a little bit and show how there might be a connection between, you know, improving anxiety, depression, and therefore neuroticism. So in a large population study of 17,839 adults, the combination of aerobic and muscle strengthening exercise was associated with the lowest likelihood of reporting depressive symptoms, followed by aerobic and muscle strengthening only. That was Bernie 2019. And further, a 12-week prospective study in elderly patients with MDD found that having both aerobic and strength training contributed to improved treatment responses compared to low-intensity exercise.

Further, a meta-analysis of 17 studies revealed that strength training and combined aerobic strength training increased peripheral blood BDNF concentrations in older adults. However, low and moderate aerobic exercise alone did not. So you really need to get that sort of either more intense aerobic exercise or the combined aerobic strength training to get that brain-derived neurotrophic factor, which is like miracle growth for the brain, to get pushed out and activate. Finally, a cross-sectional study of 5,180 Australian women found that the combination of resistance training and aerobic exercises yielded lower probabilities of depression, 0.61, compared to aerobic exercise alone, but there was no association found between resistance training alone and depression, which surprises me because I've seen a number of studies that show that. resistance training does help. This study showed that there seems to be a synergistic influence

between aerobic and resistance training. So all of that put together, I think that best practices for someone with higher neuroticism is to do consistent exercises, both aerobic and strength training. And you can refer to my other episodes on strength training for best practices and other benefits. Okay. So finally, I wanted to sort of see if there was any possible benefits of neuroticism. So, you know, we know that good wartime leaders like Winston Churchill probably were a little bit neurotic if you read his life history. People who are a little bit more close to the truth actually are a little bit less optimistic. So people who live in reality have slight sort of skew in that direction, right? Were there any studies that you could find that showed that highly neurotic individuals could outperform counterparts?

Yeah, so there's actually a few studies out there that support neuroticism actually in the work context. So there was a field study done by Smiley in 2006 that suggested. said that highly neurotic individuals actually outperform their stable counterparts in a busy work environment or if they were expending a high level of effort. So this was a field study that looked at office busyness and the Eisenig personality neuroticism. They looked to see if that could predict telesale performance actually. In this study, office busyness was operationalized as the total number of issued within the whole office during a time period, and job performance was operationalized as the number of individual sales made by a participant.

And what they found was that increases in office busyness were associated with greater performance improvements, actually, for highly neurotic individuals as compared to less neurotic individuals. They found overall that neuroticism was a significant moderator in the relationship between office sales and individual sales. And overall, yeah, highly neurotic individuals outpermed their stable counterparts in a busy environment if they expended a high level of effort. Yeah, so, you know, we did look at a prior study on work and work productivity earlier

in the beginning of this episode. Yes. That looked at like actually maybe neuroticism might hurt people at work. but actually in this, there are some contexts where neuroticism might actually be beneficial. There was another study that showed a curvilinear effect of state neuroticism and task performance when high performing professionals were asked to complete a complex cognitive task. Tell me about that one. Yeah, so that can explain some sort of the variable effect that neuroticism may have on people's work performance.

So this study done by Beckman in 2013, it examined the relationship of neuroticism and performance when undertaking cognitive tests. So this study was based on the Yerkes-Dotson law, a fundamental psychology law that states that performance is an inverted u-function of arousal. Basically what that means is that we tend to function best when we are at more moderate levels of arousal versus high or low levels of arousal.

So they wanted to see if neuroticism actually was related to cognitive performance in the same way, where as in if there was a moderate level of neuroticism, participants would perform better rather than when it was too high. That's really interesting. I like this kind of study because it looks, at the non-linear relationship. Most correlations are just like a linear relationship between two things, but this is really looking at a nice curve, like a mountain, right?

So there's this place in the middle, somewhere in the middle, where you can get peak performance. And you can think about that with different activities, right? So there would be some activities that would be highly stimulating or high fear-inducing for some people. And so maybe the type of person that would be better at that is someone who's lower in neuroticism. Yeah, interestingly, I'm looking at my neuroticism scores

to kind of compare it to what I see here. There's some parts of my score scored really, really low in neuroticism. My N2, which is the anger hostility, was like very, very low. It was two and a half standard deviations below the mean. whereas impulsiveness was maybe a little bit higher that probably is due to all the food questions I enjoy food quite a bit anxiety I had one standard deviation below the mean and depression I was about middle self-consciousness about middle vulnerability about middle yeah interesting

so yeah it seems to me that there's different jobs and there's different amounts of neuroticism might actually play into certain jobs being more beneficial for someone higher or lower neuroticism. Yeah, and then the study actually gave a good example of air traffic controllers. Yeah. Sort of direct where planes go. So in that situation, you know, higher level neuroticism may definitely be beneficial. Kind of on the edge at all time for danger, right?

And then most of the time, things are pretty peaceful. But then there's some times where it's like really, really bad. And they have to be ready. Exactly. Okay, well, that was pretty much the end of part two of neuroticism. And I wanted to go over some big takeaways. Neuroticism has been shown to have a mediator effect on treatment of depression with SSRIs. So it's possible that the SSRIs are more true.

treating the neuroticism than the depression. When compared to other big five personality types, neuroticism has been associated with less favorable outcomes in group psychotherapy. There have been several studies that have shown that mindfulness-based cognitive therapy show promise in decreasing neurotic symptoms. So this kind of plays into my idea that neuroticism isn't completely. static that there's things that we can actually do to help people. Exercise has been shown to help people with depression and anxiety and I imagine would help

people who are more neurotic. I would recommend vigorous exercise and strength training and a combination of both of those things for pretty much every mental health issue. And then it's potential, there's a potential that there are some situations where neurotic patients would outperform stable counterparts. And we showed that study, hopefully reducing some of the stigma if you do feel more neurotic. And there could be a curvilinear effect for state neuroticism on task performance, meaning too little neuroticism or too much could be a bad thing. And you could think about certain jobs where you would want to be either high or low. And finally, I, hope that you enjoy this. I hope this was helpful. You know, I occasionally have people that I'm

coaching that I take through the big five. I do a test on them. And so if that's something you would like, reach out to me. Obviously, this is a something that's a cash payment type of thing. It's not free. It costs me money actually to run this thing. So I want to thank Alexane. Thank you so much for helping me out with this. It's been great working with you. And he's co-authoring a couple other articles with me on The Big Five. Please check out the notes on this. They're really nice.

Check out the research library. Check out the notes. I think it will really help kind of cement it. If you take a look at the notes, if you read it a couple times, you'll get it. And you'll start seeing this. And I think it'll be functional for you in your practice. All right. Have a good day.