Depression

SEMINAR Depression.

Date: 14 June 2013

By : Syeda Shahnaz 2nd Year M.Phil, M&SP

Dept. Clinical PsychologyLGBRIMH, Tezpur.

• Psychotherapy is a general term referring to therapeutic interaction or treatment contracted between a trained professional and a client, patient, family, couple, or group. The problems addressed are psychological in nature and can vary in terms of their causes, influences, triggers, and potential resolutions.

• “The principle aim of psychotherapy is not to transport one to an impossible state of happiness, but to help (the client) acquire steadfastness and patience in the face of suffering. ” -C.G. Jung

• Interpersonal Psychotherapy:• Behavioural Activation:• Cognitive Behavioural Therapy:• Problem Solving Therapy:• Psychodynamic Therapy:• Social Skills Therapy:• Supportive Counselling:

• Interpersonal Psychotherapy: This short-term model (6-20 sessions) focuses on the client’s interpersonal issues, patterns of interaction with family and friends, and has the goal of reducing specific symptoms, improving interpersonal skills, and helping increase social support for the client.

• Behavioral Activation: This approach focuses on helping the client increase positive interactions between themselves and the environment, bringing increased awareness of positive activities and interactions.

• Cognitive Behavioral Therapy: This kind of treatment uncovers the patient’s negative beliefs about self and others, then teaches how these beliefs impact on behavior in order to facilitate symptom resolution.

• Problem Solving Therapy: This model explores the nature of the client’s problems that contribute to the depression. The client examines multiple solutions for each problem, and then selects, implements, and evaluates the best solution.

• Psychodynamic Therapy: This paradigm focuses on how unresolved conflicts and issues from the past have a negative impact on the patient’s current situation. Through insight and exploration of old patterns, the client develops new healthier ways of relating.

• Social Skills Therapy: This highly educational process teaches people the skills needed to build and maintain healthy relationships.

• Supportive Counseling: This less directive model encourages the client to talk about their life experiences and emotions. The therapist then offers active listening and empathy without suggesting solutions or teaching new skills.

Brief Introduction to

Depression

• Depression is a common mental disorder that presents with depressed mood, loss of interest or pleasure, decreased energy, feelings of guilt or low self-worth, disturbed sleep or appetite, and poor concentration. Moreover, depression often comes with symptoms of anxiety. These problems can become chronic or recurrent and lead to substantial impairments in an individual’s ability to take care of his or her everyday responsibilities. At its worst, depression can lead to suicide.

• The 2012 Depression package is intended to provide information about depression as a treatable illness, and to spread the message that recovery is possible and achievable.

Clinical Features of Depression

• Mood disturbances• Psychomotor disturbances• Cognitive disturbances• Vegetative disturbances• Relationships

• Painful arousal- negative affective arousal is described as depressed, anxious, irritable, mournful. It is qualitatively different from neurotic counterparts.

• Hypersensitivity to unpleasant events• Insensitivity to pleasant events• Insensitivity to unpleasant events• Reduced anticipatory pleasure• Anhedonia or reduced pleasure- inability to experience emotions both

pleasurable and depressive. May lose capacity to cry, lose their feelings for family members. Gives up pleasurable acts. Patient suffers from inability to experience emotions (differentiating flat affect)

• Affective blunting• Apathy• Masked depression- depression sine depression one is commonly

observed in older patients and presents with bodily symptoms and to be diagnosed by physician by appearance, vocal inflection and expression

Mood disturbances-

• Psychomotor disturbances – Agitation– Retardation– Stupor– Pseudodementia

• Cognitive disturbances– Mood congruent psychotic features– Mood incongruent psychotic features– Negative view of self, world and future– Excessive guilt– Poor concentration, indecision – Suicide

• Vegetative disturbances– Appetite

• Anorexia and weight loss, Weight gain– Sleep

• Insomnia, Hypersomnia– Sexual function• Relationships - Family , peer, educational, work.

Etiologies of Depression

1. Biological Theories• Genetics• Limbic system and dorsolateral prefrontal

cortex • Neurotransmitters • Neuroendocrine and immune system

1 Presentation neuro.flv

• Sleep architecture and circadian rhythms (around day)

2. Stress Theories• i. Stress Diathesis Model• Depression only follows exposure to stress in people who have

specific biological or psychological attributes that render them vulnerable to stressful life events and most vulnerable require least stress to for dep. To occur ( Joiner & Timmons 2009; Joormann 2009; Levinson 2009)

• ii. Stress generation theory • People with cetain personal attributes inadveretently generate

excessive stress, which inturn lead to dep. (Lie & Alloy 2010)

• iii. Early life stress Childhood – Adulthood dep. with min stress (Goodman & Brand 2009; Hammen 2009; harkness & Lumley 2008)

• iv. As number of episodes of dep. increases, the amount of stress required to precipitate a relapse decreases. (Boland & Keller 2009)

• This may be due to the neurobiological process of kindling (Neuro sys vulnerable) (Monroe & Harkness 2005) and cognitive process of rumination (McLaughlin & Nolen- Hoeksema 2011)

Temperament, Traits, Cognitive Biases, Coping strategies and Interpersonal Styles.

i. Temperament Character Inventory (Cloninger et al 1993) Four dimensions :

• Harm Avoidance – serotonin system• Reward dependence – noradrenaline • Novelty seeking – dopamine .• Persistence

ii. Traits: Big 5 personality traits N E C O A Neuroticism – major depression (Kotov et al

2010)

• Dependence/ Sociotropy ~ loss of relationships

• Self critical/ autonomy (self define) ~ failure in achieving

= Depression

• iii. Cognitive biases: Dep. show a range of information processing biases, during and between depressive episodes at the levels of attention, memory and reasoning that render them vulnerable to depression and maintain low mood during depressive episodes. (Joorman 2009)

• Selectively attend to & remember, negative information about the self & world (Peckham Phillips 2010)

• Tendency to remember generalities but not specific details of past events (Summer et al 2010)

• iv. Coping strategies : Rumination as a coping style (Aldao et al 2010)

• Negative co relation between depression & adaptive coping – problem solving, acceptance, reappraisal.

• V. Interpersonal Style: Insecure attachment style , parental rejection, neglect, social skill deficit. (Joiner & Timmons 2009)

• Expressed emotions – relapse (Hooley 2007)

Psychoanalytic Theories

• Freud’s classical psychoanalytic theory - Self directed anger in response to loss of

valued person or attribute- Major loss in adult life – regression to oral stage- Superego directs anger on ego (children)- Self directed anger (guilt and shame) (Kim et al

2011)- Early life experiences.

• Bibring’s ego psychology theory• Low self esteem -> from gap between self as it is and

ideal self.• Ideal self = superego• Important correlates and precursor • Blatt’s psychoanalytic theory of two types of

depression• Early exp of punitive parenting ->vulnerability to stress

involving loss autonomy and control = dep [projection & reaction formation]

• Neglectful parenting / loss of parents -> vulnerability to stress involving loss of present attachment relationship = dep [denial & repression DM]

Cognitive and Behavioural Theories

• 1. Lewinsohn’s Behavioural Theory :• Maintained by a lack of response-contingent

positive reinforcement (RCPR)• Includes relaxation and coping skills training to

deal with negative emotions arising out of stressful events

• More activity + more pleasant events =more opportunities for using social skills to obtain RCPR

Beck’s cognitive theory• Depression occurs when life events involving loss

occur and re-activate negative cognitive schemas formed early in childhood as a result of early loss experiences. These negative schema entail negative assumptions such as,

“ I am only worthwhile if everybody likes me”[Dysfunctional attitude scale, Weissman & Beck 1978]

• When a depressed person experiences a drop in mood in a particular situation, this mood change is due NOT to the situation but the Negative Automatic Thoughts that the situation elicited.

• The low mood and related depressive behaviour that occur in such situations makes it more likely that similar situations will recur

• These episodes also reinforce depressive schemas.

• Negative schemas have their roots in loss experience in early childhood : loss of parents, positive parental care, personal health, loss of positive peer relations by bulling or exclusion from peer groups, expectation of loss.

• CBT model of depression

Early life stress(Long separation from parent in early

childhood)

SCHEMACore Belief

(I am worthless)Assumptions

(If people don’t like me, I am worthless)

• Recent life event

(Bereavement activates latent

schema)

Emotional (sad)

Behavioural(withdrawl)

Physiological(lethargy)

A. Activating Agent (he

did’nt say hello)

B. Automatic

thoughts (I am not good he doesn’t like

me)

C.Consequences

S W LConfirm core belief

S W L Confirm set up more activating agent

• Two latent schema importance particularly in case of Dep.

- IPR [sociotropy]- Personal achievement [ autonomy]

• The various logical errors that people suffering from depression usually make are referred to as cognitive distortions:

1. ALL-OR-NOTHING THINKING: You see things in black and white categories. If your performance falls short of perfect, you see yourself as a total failure.

2. OVERGENERALIZATION: You see a single negative event as a never-ending pattern of defeat.

3. MENTAL FILTER: You pick out a single negative detail and dwell on it exclusively so that your vision of all reality becomes darkened, like the drop of ink that discolors

the entire beaker of water.

4. DISQUALIFYING THE POSITIVE: You reject positive experiences by insisting they “don’t count” for some reason or other. In this way you can maintain a negative

belief that is contradicted by your everyday experiences.

5. JUMPING TO CONCLUSIONS: You make a negative interpretation even though

there are no definite facts that convincingly support your conclusions.

a. Mind Reading. You arbitrarily conclude that someone is reacting negatively

to you, and you don’t bother to check this out.b. The FortuneTeller Error. You anticipate that

things will turn out badly, and you feel convinced that your prediction is an already established fact.

6. MAGNIFICATION (CATASTROPHIZING) OR MINIMIZATION: You exaggerate the importance of things (such as your goof-up or someone else’s achievement). Or you inappropriately shrink things until they appear tiny (your own desirable qualities

or the other fellow’s imperfections). This is also called the “binocular trick.”

7. EMOTIONAL REASONING: You assume that your negative emotions necessarily reflect the way things really are: "I feel it, therefore it must be true."

8. SHOULD STATEMENTS: You try to motivate yourself with shoulds and shouldn’ts, as if you had to be whipped and punished before you could be expected to do anything. “Musts” and “oughts” are also offenders. The emotional consequence is guilt. When you direct should statements toward others, you feel anger, frustration,

and resentment.

9. LABELING AND MISLABELING: This is an extreme form of over-generalization. Instead of describing your error, you attach a negative label to yourself: “I’m a loser.” When someone else’s behavior rubs you the wrong way, you attach a negative label to him: “He’s a damn louse.” Mislabeling involves describing an event with language that is highly colored and emotionally loaded.

10. PERSONALIZATION: You see yourself as the cause of some negative event which in fact you were not primarily responsible for.

Cognitive Therapy• Clients learn to monitor situations where negative mood

changes occur – to identify negative automatic thoughts- to generate positive interpretation of situations in which negative mood changes occur and to evaluate the validity of these positive and negative views mood altering situations.

• Cognitive Therapy is a system of psychotherapy that attempts to reduce excessive emotional reactions and self-defeating behaviour, by modifying the faulty or erroneous thinking and maladaptive beliefs that underlie these reactions

• Beck et al 1976, 1979, 1993 1 Cognitive Behavioral Therapy-CBT - YouTube.flv

Learned Helplessness theory

• When a person repeatedly fails to control the occurrence of negative stimuli or has repeated experiences of failure at valued tasks and adopts a cognitive style that involves making internal , global, stable attribution for failure

• And• External, specific, unstable attributions for

success

Family system theory

• Family based stress• Support• Belief system• Interaction pattern

What Is the Case Formulation Approach to Cognitive-Behavior Therapy?

The core idea of any therapy calling itself cognitive is that people’s emotional reaction and behaviour are strongly influenced by cognition (in other words, their thoughts, beliefs and interpretation about themselves or the situations in which the find themselves- fundamentally the meaning they give to the events of their life.)

The case formulation approach to cognitive-behavior therapy is a framework for providing cognitive-behavior therapy (CBT) that flexibly meets the unique needs of the patient at hand, guides the therapist’s decision making, and is evidence based.

Case formulation-driven CBT is not a new therapy. It is a method for applying empirically supported CBTs and theories in routine clinical practice.

The elements of the case formulationapproach to CBT are depicted in

• Elements of a Case FormulationA complete case formulation ties all of the

following parts together into a logically coherent whole:

1. It describes all of the patient’s symptoms, disorders, and problems.

2. It proposes hypotheses about the mechanisms causing the disorders and problems.

3. It proposes the recent precipitants of the current disorders and problems, and

4. The origins of the mechanisms.

Elements of the Case Formulation Approach to CBT

• Assessment to Obtain a Diagnosis and Initial Case Formulation

• Developing a Mechanism Hypothesis• Levels of Formulation• Treatment Planning• Monitoring and Hypothesis Testing• The Therapeutic Relationship

• General formulation model of depressionPREDISPOSING FACTORS

Any developmental factors that sensitize a person to loss of significant relationship or esteem. PERSONAL FACTOR – Genetic vulnerability to depression, loss & failure experiences, depressive temperament, neuroticism, introversion, low conscientiousness, cognitive schemas & styles, low self esteem, perfectionism, attachment insecurity, socials skills deficit, depressive IPR style. FAMILY FACTORS , COMMUNITY FACTORS

PRECIPITATION FACTORS

Stresses involving loss and failure

PROTECTIVE FACTOR

Good pre-mormid adjustment, personal

strengths & achievement

Family supportSchool or workplace

supportPeer group support

Engagement in treatment

MAINTAINING FACTORS

Depressive cognitive styles, self defeating

behaviour, ruminative & avoidant coping.

Lack of family supportLack of school /work

place supportLack of peer support

Treatment refusal, non adherence or faliure

DEPRESSION

• 1. case Depression.docx