dePReSSiVe SYMPTOMATOLOGY in
SMOkeRS wiTH PeRSOnALiTY diSORdeRS
wHO PARTiciPATed in A PSYcHOLOGicAL
TReATMenT PROGRAMMe FOR SMOkinG
ceSSATiOn
Elena Fe nández del Río, Ana López y Elisa do Becoña
Smoking.Addic ion.Uni ,.Uni e si y.o .San iago.de.Compos ela
(Recei ed/Recibido: 06/05/2010 - Accep ed/Acep ado: 02/06/2010)
RESUMEN
El p esen e es udio analiza la p esencia de sin oma ología dep esi a
en una mues a de 202 umado es con y sin as o nos de pe sona-
lidad que acuden a un a amien o psicológico pa a deja de uma .
Los esul ados encon ados indican que el g upo de umado es con
as o nos de pe sonalidad p esen ó más sín omas dep esi os que el
g upo de umado es sin as o nos de pe sonalidad, an o al inicio del
a amien o como al inaliza el mismo. Es e hallazgo con i ma ía la
ecuen e asociación en e as o nos del Eje II y males a emocional,
p oduc o del de e io o del uncionamien o gene al del suje o po causa
de los pa ones de compo amien o in lexibles ca ac e ís icos de los
as o nos de pe sonalidad.
Palab as cla e: dep esión, as o nos de pe sonalidad, deja de uma ,
BDI-II
97
Heal h and Addic ions © Heal h and Addic ions / Salud y D ogas
www.haaj.o g ISSN edición imp esa: 1578-5319
ISSN edición elec ónica: 1988-205X
Co espondencia
Elena Fe nández del Río, Ph.D.
Smoking Cessa ion Uni , Uni e si y o San iago de Compos ela, Facul y o Psychology,
Depa men o Clinical Psychology and Psychobiology, Campus Su , 15782 San iago de
Compos ela, Galicia, Spain o mail ([email p o ec ed]).
Heal h and Addic ions / Salud y D ogas 2010, Vol. 10, nº 1, pp. 97-109
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FeRnándeZ, LÓPeZ Y becOñA
Heal h and Addic ions / Salud y D ogas 2010, Vol. 10, nº 1, pp. 97-109
ABS RAC
The p esen s udy analyzes he p esence o dep essi e symp oma ol-
ogy in a sample o 202 smoke s wi h and wi hou pe sonali y diso de s
who pa icipa e in a psychological ea men p og amme o gi ing up
smoking. The esul s indica e ha he g oup o smoke s wi h pe sonal-
i y diso de s p esen ed mo e dep essi e symp oms han he g oup o
smoke s wi hou pe sonali y diso de s, bo h a he s a and a he end
o he ea men . This inding would con i m he widely ound associa-
ion be ween Axis II diso de s and emo ional dis ess, esul ing om he
de e io a ion o he indi idual’s gene al unc ioning due o he in lexible
beha iou pa e ns cha ac e is ic o pe sonali y diso de s.
Key wo ds: dep ession, pe sonali y diso de s, smoking cessa ion, BDI-II
iN RoDUC ioN
Ciga e e smoking is he main cause o mo bi-mo ali y wo ldwide,
causing some 5 million dea hs a yea (Wo ld Heal h O ganiza ion,
2008). Apa om i s close associa ion wi h physical illnesses, smoking is
ela ed o a ious psychopa hological diso de s. The majo i y o esea ch
has ocused on he ela ionship be ween smoking and his o y o majo
dep ession, indings in clinical samples showing ha be ween 25% and
61% o smoke s ha e su e ed om a dep essi e diso de a some ime
in hei li e (Becoña, 2003; Becoña & Míguez, 2004; Wilhelm, Wedgwood,
Ni en & Kay-Lambkin, 2006). Such s udies ha e led obacco smoking
o be conside ed as a isk ac o o dep ession (Pasco, Williams, Jacka,
Ng, Hen y, Nicholson e al., 2008). People wi h a his o y o dep essi e
diso de a e mo e likely o be smoke s and o be nico ine-dependen ,
ha e g ea e di icul y gi ing up smoking and a e a g ea e isk o
su e ing mood al e a ions when hey do gi e up he habi (B eslau,
Kilbey & And eski, 1992; Die ke & Donny, 2008; Gu ea & Pine , 2004;
Hughes, 2007; Le en hal, Kahle , Ray & Zimme man, 2009; Schmi z,
K use & Kugle , 2003; Vázquez, Becoña & Míguez, 2002). Mo eo e ,
bo h his o y o majo dep ession and dep essi e symp oms a e associ-
a ed wi h highe ailu e a es in a emp s o gi e up smoking (Anda,
Williamson, Escobedo, Mas , Esco ino & Reming on, 1990; Glassman,
Helze , Co ey, Co le , S e ne , Tipp & Johnson, 1990), highe le els o
nega i e a ec du ing abs inence synd ome (Co ey, Glassman & S e ne ,
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1997) and highe elapse a es (Kinnunen, Dohe y, Mili ello & Ga ey,
1996). P e ious esea ch has shown ha e en low le els o dep essi e
symp oma ology may be associa ed wi h di icul ies o gi ing up smok-
ing and g ea e pe sis ence o nico ine dependence (Hi sman, Bo elli,
McCha gue, Sp ing & Niau a, 2003; Niau a, B i , Shadel, Golds ein,
Ab ams & B own, 2001).
Smoking has also been associa ed wi h Axis II pe sonali y diso de s.
Howe e , he esul s a e inconsis en as ega ds he p e alence o hese
diso de s in smoke s, wi h pe cen ages anging om 9% (Black, Zim-
me man & Co yell, 1999) o 45% (Lasse , Wesley, Woolhandle , Him-
mels ein, McCo mick & Bo , 2000). This g ea a ia ion is due in pa
o he me hodology used, o sample he e ogenei y and o he de ini ion
o smoke s a us used in each s udy (Fe nández del Río & Becoña, in
p ess). No is he e consensus in he li e a u e abou he in luence o
pe sonali y diso de s on he e icacy o he apeu ic in e en ion. Thus,
while some s udies conclude ha ha ing an associa ed pe sonali y dis-
o de is a p edic o a iable o ea men ailu e in addic i e beha iou
(Ve heul, an den B ink & Ha ge s, 1998), o he s ha e shown ha Axis
II psychopa hology, despi e being associa ed wi h p e- and pos - ea -
men p oblems, does no cons i u e a obus p edic o o he esul o
in e en ion in subs ance use s, and ha hese indi iduals may bene i
om clinical in e en ion a leas as much as people wi hou an associ-
a ed pe sonali y diso de (Al e man, Ru he o d, Cacciola, McKay &
Boa dman, 1998; Cacciola, Al e man, Ru he o d, Al e man, McKay
& Snide , 1996; C i s-C is oph, Siqueland, Blaine, F ank, Lubo sky,
Onken, e al., 1999).
Fu he mo e, i is known ha he majo i y o indi iduals wi h a pe -
sonali y diso de also ha e Axis I men al diso de s (Skodol, 2007). This
como bidi y o Axis I and Axis II diso de s anges om 66% o 100%
(Dolan-Sewell, K uege & Shea, 2001), and o en complica es he apeu ic
in e en ion (To ens, 2008). Indeed, people wi h pe sonali y diso de s
commonly seek specialis help owing o he de elopmen o exace ba-
ion o an Axis I diso de . Such indi iduals o en expe ience conside able
amily, employmen and in e pe sonal p oblems, esul ing om hei
sca ce lexibili y and adap abili y (Caballo, 2004). People wi h pe son-
ali y diso de s possess ha dly any al e na i e s a egies o ela ing o
o he s, using he s a egies hey ha e in a igid ashion, and ind i ha d
o adap o change, ending o c ea e icious ci cles and o modi y hei
en i onmen so ha i does no make demands on hem ha a e ou side
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hei usual epe oi e (Millon & E e ly, 1994). The e o e, i is common o
such indi iduals o su e dep essi e symp oms esul ing om he de e-
io a ion o hei gene al unc ioning (Eu elings-Bon ekoe, an de Slikke
& Ve schuu , 1997). Ne e heless, some s udies ha e epo ed ha he
p esence o dep essi e symp oms, a leas in some indi iduals wi h pe -
sonali y diso de s, is associa ed wi h be e ea men esul s, inso a as
he dis ess caused by such symp oms se es as mo i a ion o seek ea -
men , which would acili a e he modi ica ion o maladap i e beha iou s
cha ac e is ic o Axis II diso de s (Shea, Widige & Klein, 1992).
I we add o he equen como bidi y be ween dep essi e diso de s
and pe sonali y diso de s he an idep essan e ec s o nico ine (Salín-
Pascual, Rosas, Jiménez-Genchi, Ri e a-Meza & Delgado-Pa a, 1996),
i is o be expec ed ha smoke s wi h Axis II diso de s will expe ience
g ea e dep essi e symp oma ology a he beginning o a psychological
ea men p og amme o gi ing up smoking, a he end o he p o-
g amme and a he 12-mon h ollow-up.
The aim o he p esen s udy is o assess he p esence o dep essi e
symp oma ology in smoke s wi h and wi hou pe sonali y diso de s
who pa icipa e in a psychological ea men p og amme o gi ing up
smoking.
ME HoD
Pa iciPan s
The sample was made up o smoke s who eques ed smoking cessa-
ion ea men a he Smoking Addic ion Uni in he Psychology Facul y
o he Uni e si y o San iago de Compos ela (Spain) be ween Oc obe
2006 and Feb ua y 2008. Inclusion c i e ia o he s udy we e: age 18 o
o e ; eely wishing o ake pa in he ea men ; smoking a leas 10
ciga e es pe day p io o s a ing he ea men ; and p ope ly illing
ou all he ques ionnai es in he p e- ea men assessmen . Exclusion
c i e ia we e: diagnosed se e e men al diso de (bipola diso de and/
o psycho ic diso de ); concu en dependence on o he subs ances
(cocaine and/o he oin); ha ing pa icipa ed in he same psychological
ea men p og amme o in a simila one du ing he p e ious yea ; ha -
ing ecei ed some o he ype o e ec i e ea men o gi ing up smok-
ing (nico ine eplacemen he apy, bup opion, a enicline) in he p e i-
ous yea ; p esence o some physical pa hology in ol ing high li e- isk
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o he indi idual, which would equi e immedia e in e en ion on an
indi idual o ma (e.g., ecen hea a ack, pneumo ho ax); and ailu e
o a end he i s g oup session o ea men . O an ini ial sample o 243
indi iduals, 41 we e excluded on he basis o he p e iously-men ioned
exclusion c i e ia, so ha he inal sample was composed o 202 ciga e e
smoke s (43.1% men and 56.9% women). Mean age was 43.99 yea s (S.
D. = 10.70). A he s a o he ea men p og amme hey smoked a
mean o 24.32 ciga e es pe day (S. D. = 10.22).
ins umEn s
All he smoke s we e assessed by means o he Cues iona io sob e el
hábi o de uma [Ques ionnai e on he smoking habi ] (Becoña, 1994),
which ga he s in o ma ion on sociodemog aphic a iables and smoking-
ela ed da a.
Fo he assessmen o he pe sonali y diso de s we used he sc eening
ques ionnai e o he IPDE (In e na ional Pe sonali y Diso de Examina-
ion, Lo ange , 1995), DSM-IV Module. Lo ange , Janca and Sa o ius
(1997) se he cu -o poin a h ee posi i e i ems o mo e, o conside -
ing each ca ego y as signi ican , bu his a he low cu -o poin , while
imp o ing he sensi i i y o he ins umen , ma kedly inc eases he
numbe o alse posi i es. Au ho s such as Lewin, Slade, And ews, Ca
and Ho nabock (2005) p oposed using he ICD-10 diagnos ic c i e ia o
each pe sonali y diso de as a solu ion o inc easing he speci ici y o
he sc eening ques ionnai e. In he p esen s udy, and basing ou sel es
on he s udy by Lewin e al. (2005), we adop ed as cu -o poin s o
he sc eening ques ionnai e o he IPDE, DSM-IV Module, he DSM-IV
diagnos ic c i e ia (Ame ican Psychia ic Associa ion, 1994) o each pe -
sonali y diso de .
Dep essi e symp oma ology was assessed by means o he BDI-II
(Beck Dep ession In en o y, second e sion; Beck, S ee & B own, 1996;
in i s Spanish e sion by Sanz, Pe digón & Vázquez, 2003), which assess
he p esence o dep essi e symp oms in he wo weeks p io o he p e-
ea men assessmen . In he p esen s udy we used a sco e o 19 as a
cu -o poin o speak o mode a e o se e e dep essi e symp oma ology
(Beck e al., 1996).
Dep essi e symp oma ology was assessed p io o he s a o he
psychological smoking cessa ion ea men , a he end o i and a he
12-mon h ollow-up. Al hough all pa icipan s ook pa in he p e-
ea men assessmen , he assessmen a he end o he ea men p o-
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Heal h and Addic ions / Salud y D ogas 2010, Vol. 10, nº 1, pp. 97-109
g amme was ob ained om 165 indi iduals (37 ailed o a end he inal
session), and ha o he 12-mon h ollow-up om 188 indi iduals (14
could no be loca ed).
P ocEdu E
The ini ial assessmen o all he smoke s was ca ied ou in a single
session, which in ol ed he applica ion o all he ins umen s desc ibed
abo e. All he smoke s signed he in o med consen o ake pa in he
s udy. The Bioe hics Commi ee o he Uni e si y o San iago de Com-
pos ela ga e i s au ho iza ion o he s udy o be ca ied ou .
Du a ion o he ea men p og amme was 6 weeks (one session pe
week las ing a ound 1 hou ), and pa icipan s we e ea ed in g oups o
be ween 2 and 8. The ea men was applied by wo psychologis s wi h
se e al yea s o expe ience in he ea men o smoke s.
The psychological ea men ca ied ou was he P og ama pa a deja
de uma [Smoking Cessa ion P og amme] (Becoña, 1993, 2007). This is
a cogni i e-beha iou al ea men consis ing o six sessions in g oup o -
ma . This ea men in ol es he ollowing elemen s: ea men con ac ,
sel - epo and g aphic ep esen a ion o ciga e e consump ion, gene al
in o ma ion on obacco, s imulus con ol, ac i i ies o a oiding nico ine
wi hd awal synd ome, physiological eedback on ciga e e consump-
ion (measu emen o ca bon monoxide in expi ed ai in each session),
g adual educ ion o nico ine and a inges ion (nico ine ading), and
elapse-p e en ion s a egies ( aining in asse i eness, p oblem-sol ing,
change o mis aken belie s, anxie y and ange managemen , physical
exe cise, weigh con ol and sel - ein o cemen ).
A he end o he ea men we once again adminis e ed he BDI-II,
wi h he aim o assessing he p esence o dep essi e symp oma ology
associa ed wi h gi ing up smoking (n = 165). A he 12-mon h ollow-
up we applied a ollow-up ques ionnai e acco ding o he s a us o he
pa icipan a ha momen (smoke /nonsmoke ), in addi ion o he
BDI-II (n = 188).
RESUl S
On analyzing he ela ionship be ween dep essi e symp oma ology
a he s a o he ea men and he p esence o a leas one pe sonal-
i y diso de , we ound s a is ically signi ican di e ences on he BDI-II
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(χ2 (1) = 13.623, p ≤ .001). The smoke s wi h pe sonali y diso de s ha e
mo e dep essi e symp oma ology p io o s a ing he smoking ces-
sa ion ea men han hose wi hou pe sonali y diso de s (21.4% and
2.6%, espec i ely) (Table 1).
A he end o he smoking cessa ion ea men , he sco es o hose wi h
pe sonali y diso de s a e also highe on he BDI-II (χ2 (1) = 4.885, p ≤
.05). A ha poin , 10.8% o smoke s wi h pe sonali y diso de s p esen
suspec ed dep ession, compa ed o 1.6% o he ini ial g oup o smoke s
wi hou pe sonali y diso de s.
A he 12-mon h ollow-up, no s a is ically signi ican di e ences we e
ound on he BDI-II be ween pa icipan s wi h and wi hou pe sonali y
diso de s.
As ega ds s a us o he indi idual a he 12-mon h ollow-up (smok-
e , nonsmoke ) acco ding o he p esence o pe sonali y diso de s and
BDI-II, we ound signi ican di e ences in he p e- ea men assessmen
(F (4,201) = 11.001, p ≤ .001), whe e he smoke s wi h pe sonali y diso de s
sco e highe (12.87) han he o he g oups. The Sche é pos . hoc es
e ealed signi ican di e ences be ween smoke s wi h pe sonali y dis-
o de s and smoke s wi hou pe sonali y diso de s (p ≤ .001) (Table 2).
Wi h ega d o he BDI-II a he end o he ea men , we also ound
signi ican di e ences (F (4,164) = 6.169, p ≤ .001), inso a as he smok-
e s wi h pe sonali y diso de s sco ed highe (9.04) han he es o he
g oups. The Sche é pos .hoc es e ealed di e ences be ween he smok-
Table 1. Pe cen age o indi iduals wi h suspec ed dep ession (BDI-II) acco ding o he p esence o
a pe sonali y diso de (sc eening IPDE p e- ea men )
Suspec ed dep ession (BDI-II ≥ 19)
Wi h PD
(n = 126)
Wi hou PD
(n = 76)
n%n%χ2
P e- ea men assessmen (n = 202)
27
27 21.4 2 2.6 13.623***
Assessmen a end o ea men (n = 165) 11 10.8 1 1.6 4.885*
12-mon h ollow-up assessmen (n = 188) 22 18.8 7 9.9 2.710
*p < .05; ***p < .001
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e s wi h and wi hou pe sonali y diso de s (p ≤ .001), and be ween he
smoke s wi h pe sonali y diso de s and he nonsmoke s wi hou pe -
sonali y diso de s (p ≤ .01).
Finally, we ound s a is ically signi ican di e ences in dep essi e
symp oma ology a he 12-mon h ollow-up (F (4,187) = 5.342, p ≤ .001).
No able once mo e a his assessmen poin a e he smoke s wi h pe -
sonali y diso de s (mean sco e on he BDI-II = 1.62). The Sche é pos .
hoc es e ealed signi ican di e ences be ween he smoke s wi h and
wi hou pe sonali y diso de s (p ≤ .01), and be ween he smoke s wi h
pe sonali y diso de s and he nonsmoke s wi hou pe sonali y diso -
de s (p ≤ .05).
Al hough he equi ed s a is ical signi icance was no a ained, indi-
iduals wi h pe sonali y diso de s who we e abs inen a 12 mon hs
sco ed highe on he BDI-II, a all ime poin s, han abs inen indi iduals
wi hou pe sonali y diso de s (e.g., 10.31 e sus 6.69, mean sco es on he
BDI-II o pa icipan s abs inen a 12 mon hs, wi h and wi hou pe sonal-
i y diso de s, espec i ely).
DiSCUSSioN
The esul s ob ained in he p esen s udy suppo he hypo hesis ha
smoke s wi h pe sonali y diso de s p esen g ea e dep essi e symp-
oma ology p io o s a ing a psychological ea men o gi ing up
Table 2. Mean sco es on he BDI-II a he di e en ea men poin s, acco ding o he p esence o
absence o a pe sonali y diso de (PD) and smoke s a us a 12 mon hs
Smoke s
12m ollow-up
(n = 163)
Nonsmoke s
12m ollow-up
(n = 39)
Wi hou PD Wi h PD Wi hou PD Wi h
PD F
P e- ea men assessmen (n = 202) 5.29 12.87 6.69 10.31 11.001***
Assessmen a end o ea men (n = 165) 4.98 9.04 2.33 7.88 6.169***
12-mon h ollow-up assessmen (n = 188) 7.02 11.62 4.69 7.92 5.342***
***p < .001
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smoking. This may be ela ed o he dis ess associa ed wi h he in lex-
ible beha iou pa e ns cha ac e is ic o pe sonali y diso de s, which
cause de e io a ion o in e pe sonal and employmen ela ionships
(Caballo, 2004; Millon & Da is, 1998).
On he o he hand, indi iduals wi h pe sonali y diso de s expe ienced
g ea e dep essi e symp oma ology a he end o he smoking cessa ion
ea men han hose wi hou Axis II psychopa hology. Al hough nico-
ine has an an idep essan unc ion (Mu phy, Ho on, Monson, Lai d,
Sobol & Leigh on, 2003), i s ch onic use leads o neu oadap a ion, wi h
inc eased dep essi e symp oms i consump ion is in e up ed (Gu ea
& Pine , 2004). Va ious s udies ha e indica ed ha be ween 3% and
20% o smoke s de elop clinical dep ession be ween he i s 3 and 26
weeks o abs inence (Hughes, 2006). In he p esen s udy, he pe cen -
age o pa icipan s wi h pe sonali y diso de s p esen ing dep essi e
symp oma ology was lowe han a he p e- ea men assessmen . A e
six sessions o he psychological ea men , hese smoke s expe ienced a
sligh imp o emen in hei mood. Howe e , a he 12-mon h ollow-up
hey had a ained le els o dep essi e symp oma ology simila o hose
o he p e- ea men assessmen (Figu e 1).
The esul s o he p esen s udy would indica e ha smoke s wi h
some associa ed pe sonali y diso de expe ience mo e dep essi e symp-
oms be o e ying o gi e up smoking and a e ha ing done so, e en
hough hey may emain abs inen 12 mon hs la e ; his would sup-
po he idea ha Axis II psychopa hology ends o be accompanied by
Figu e 1. Pe cen age o indi iduals wi h suspec ed dep ession acco ding o he BDI-II a he
di e en poin s o he ea men , acco ding o p esence o absence o a pe sonali y diso de (PD).
