Chronic depression (I)
“This book develops a new explanatory framework for chronic depression […]. The framework rests on the premise that depression appears to include self-sustaining processes, that these processes may be, at least in part, interpersonal, and that understanding of these processes from an interpersonal standpoint may be useful in applied settings.”
I read this book a couple of days ago – here’s my short goodreads review. As mentioned in the review, the book includes quite a bit of rather old research and a lot of theorizing, which would probably be my two main points of criticism. I gave the book two stars on goodreads, but I should emphasize that this two star rating doesn’t really mean I think it’s a bad book; sometimes two star books are ‘borderline’, but this one isn’t and I found some of the coverage quite interesting. Given that the book explores how depression relates to interpersonal factors, I’ve of course read at least some stuff about many of the topics touched upon in the book before, e.g. here, here, here, here, and here. There was quite a bit of new stuff as well, though – in particular previous works dealing with depression which I’ve read have not had that much to say about how depression impacts people’s behaviours towards others and others’ behaviours towards the person who is depressed; the ‘interpersonal factors’ part of the coverage of previous works I’ve read on these topics has usually been limited to observations to the effect that lonely people are more likely to be depressed and similar, though the effects of social anxiety, often observed in depressed individuals (“the co-occurrence of depression and anxiety is very common. As many as 50% of people with major depression also experience an anxiety disorder” – a quote from the book), have admittedly also been pointed out to me before. This book however goes into more detail about these things and cover effects I do not recall having seen mentioned before.
Below I have added some observations from the book.
“There is good reason to emphasize the chronic nature of depression. First, some forms of depression, such as dysthymia, are chronic by definition (at least 2 years’ persistence in the case of dysthymia). Second, depression appears to be persistent within an episode, and, once it finally lets up, it tends to come back. Depression is both persistent within episodes and recurrent across episodes. […] Recurrence is defined as the reestablishment of clinical depression following a diagnosis-free period. […] Relapse is the resumption of symptoms in the vulnerable timeframe just following remission of a depressive episode. […] Several theorists have argued that depressive symptoms have a way of sustaining themselves. In this view, it is as if depression “feeds off itself,” “maintains its own momentum,” and “self-amplifies.” A key argument of this book is that these self-sustaining processes in depression may be interpersonal in nature. […] interpersonal factors are among the strongest predictors of depression chronicity. […] People with more interpersonal problems experience longer duration of depressive episodes”.
“Dysregulations of serotonin neurotransmitter systems, as well as of the hypothalamic-pituitary-adrenal axis (which regulates cortisol levels), have […] been proposed as a stable depression risk. There is little question that serotonin and cortisol levels are altered during depressive episodes (and related phenomena such as suicide). It is interesting to note that animals defeated in social skirmishes display behavioral and neurochemical similarities to depressed people […]. However, there is little persuasive evidence that dysregulation of these systems provides a full account of depression’s causes. [You can find some recent discussion of these topics, which also touches upon the observations included below, here] […] Regarding psychological explanations […], these theories can be grouped into those emphasizing cognitive vulnerability factors (e.g., pessimism), those emphasizing interpersonal vulnerability factors (e.g., excessive dependency), and those emphasizing personality-based vulnerability factors (e.g., high neuroticism, low extroversion). As with genetic—neurobiological explanations, psychological approaches have made some progress but cannot claim to provide a complete account of depression’s causes. […] shyness represents a stable vulnerability for depression. […] Although the notion that stable vulnerabilities like shyness only lead to depression in the context of some stressor is a reasonable view, it does not account for the finding that some shy (or otherwise vulnerable) people experience depression independent of negative life events. Partly in response to this quandary, a main purpose of this book is to explore interpersonal mechanisms whereby depression prolongs itself, even in the absence of external causes like negative life events.”
“there is some reason to suspect that depression’s properties may differ in certain subsets of people. Regarding late-life populations — for example, depressions that first occur in later life, as compared with those that first occur in early adulthood — occurrences may be about equally common in men and women (whereas “early” depressions are more common in women […]). In addition, late-life first occurrences are less associated with first-degree relatives’ depression risk […]; more related to neurological or medical disease […]; less severe […]; less associated with suicidal and anxious symptoms […]; and less related to personality problems, such as excessive dependency and avoidance […] Definitional problems plague depression research.”
“The incidence of clinical depression and depressive symptoms is two to three times higher among women than men. […] Although the gender differential in depression is consistent and well documented, little is known about the processes that underlie these differences.”
“In studies with follow-ups of 10 years or more, Coryell and Winokur (1992) found that 70% of people with one depressive episode subsequently experienced at least one more.”
“The link between life stress and depression is well-known — in general, the occurrence of life stressors appears to contribute to the development of depression […] Haramen (1991) theorized that depressed people are particularly stress-prone, in the sense that they actively generate negative life events. (It is important to distinguish active from intentional here — we do not believe that depressed people intentionally create problems for themselves, but that some of their behaviors have the unintended consequence of making life more stressful). If so, a self-sustaining process would be implicated in which formerly depressed people actively generate future life events that, in turn, sow the seeds of future depression. This would explain, at least in part, why depression persists and recurs. In a series of empirical studies, Hammen, Davila, Brown, Ellicott, and Gitlin, (1992) have documented the phenomenon of “stress generation.” […] In a 1-year study of women with depression, bipolar disorder, medical illness, or no disorder, Hammen (1991) showed that depressed women experienced more interpersonal stress to which the women themselves contributed (e.g., disputes with teachers or bosses; conflicts with children or partners), even compared with the women with bipolar disorder and medical illness. The finding was specific to interpersonal events — depressed women did not differ from others with regard to “fateful” events (i.e., those that really are randomly foisted on people). This result highlights the importance of interpersonal events, as well as the idea that nonrandom, self-produced negative events are characteristic of depressed people. Notably, the depressed women in Hammen’s (1991) study all experienced chronic forms of depression. This finding has been replicated in samples of men and women […] marital couples […] adolescent women […] children […] as well as by other research groups […] This line of research implicates the important possibility that, although depression may occur in the wake of stress, so may stress occur in depression’s wake.”
“Evidence suggests that people who are depressed demonstrate average problem-solving skills in impersonal settings (e.g., solving a puzzle), yet display specific problem-solving deficits in interpersonal settings […]. Examples of lapses in interpersonal problem solving may include the misperception of an offhand, trivial comment as an insulting attack; persistently avoiding someone who represents a key source of social support because of a minor misunderstanding; and angry, accusing confrontation of someone who was sincerely trying to help.”
“Many stress generation studies examine the links between self-reported depression and self-reported negative life stress. Because self-report is the source for assessment of both depression and stress, it is possible that increases in reported negative life events may merely reflect an increasingly hopeless outlook, rather than actual stress increases. A depressed person may thus perceive and report stress, even when stress is not actually present. […] the possible influence of increasing hopelessness in stress generation deserves attention […], especially insofar as hopelessness is a hallmark of major descriptive and etiological accounts of depression […] hopelessness, because of its embittering and stultifying effects on other people, may be particularly likely to disaffect others (i.e., to generate the stress of interpersonal rejection).”
“depression chronicity itself may be involved in stress generation. As depression persists, those who experience it may become more and more hopeless, and their significant others may become more and more burdened and disaffected. […] A second possibility is that hopelessness, because it has embittering and stultifying effects, may lead to cognitive representations of depressed people in the minds of significant others that are negative and change resistant. Sacco (1999) argued that once these representations are developed, they selectively guide attention and expectancies to confirm the representation. These social-cognitive processes may occur spontaneously and outside of awareness […] Once crystallized, cognitive representations of negative behaviors are more change resistant than representations of positive behaviors […]. Moreover, such representations gain momentum with use, in that they come to disproportionately influence social cognition relative to actual subsequent behaviors of the represented person […] With regard to others’ perceptions, the hopeless and potentially depressed person may face a very difficult problem: Continued hopelessness may only serve to maintain others’ negative views and thus generate stress in the form of criticism; positive changes, because they do not match others’ schemata, may be unnoticed or misattributed, leaving others’ negative representations unchanged.”
“there is accumulating evidence that depressed people actively generate their own stress, especially interpersonal stress […] For example, negative feedback-seeking (defined as the tendency to directly or indirectly invite criticism from other people and viewed as motivated by self-verification strivings […] represents a specific mechanism by which depression-prone people contribute to such stressors as relationship dissatisfaction and dissolution. Similarly, excessive reassurance-seeking (defined as the tendency to repeatedly and persistently demand assurance from others as to one’s lovability and worth, even after such is provided; […] also directly contributes to interpersonal stress. Interpersonal conflict avoidance ([…] defined as the anxious avoidance of self-assertion situations), also sows the seeds of stress generation. […] Research on self-handicapping and inoculation indicates that depressed people may gain self-protective and other rewards for depressive cognition and behavior. These rewards serve to maintain depressive cognition and behavior, and thereby [also] increase depression chronicity”.
[S]elf-verification theory […] proposes that people strive to attain and preserve predictable, certain, and familiar self-concepts. Further, the theory indicates that people accomplish this by actively seeking self-confirming interpersonal responses from those in their social environment. A key and perhaps counterintuitive implication of the theory is that there is no difference in the self-verification needs between people with positive self-concepts and people with negative self-concepts. […] In Study 1 [of Katz and Joiner (2002)], people in stable dating relationships were most intimate with and somewhat more committed to partners when they perceived that partners evaluated them as they evaluated themselves (even if negative). In Study 2, men reported the greatest esteem for same-sex roommates who evaluated them in a self-verifying manner (even if negative). Results from Study 2 were replicated and extended to both male and female roommate dyads in Study 3. […] In related research, it has been demonstrated that feedback that matches one’s self-concept is more “attention-grabbing,” more memorable, more rewarding, and more believable […]. In addition, a growing body of research suggests that people are more satisfied with and intimate in self-verifying relationships”.
“neither we nor self-verification theory imply that people enjoy the pain of abusive relationships and therefore seek them out. That is, self-verification theory is not talking about masochism. Rather, the theory points out the intractable dilemma of people with low self-esteem. If they choose (by whatever means, conscious or not) affirming relationships, relationship dysfunction, including abuse, may be in the cards. If they choose healthier relationships, they may have to grapple with the feeling that these relationships, despite their healthy qualities, do not provide them with self-confirmation. This represents a very difficult problem that has obvious effects on people’s well-being. […] there is growing evidence that people with depressive symptoms actively seek self-verification (i.e., negative feedback), often receive it, and may become depressed as a result. […] Depression may [also] perpetuate itself as a function of encouraging negative feedback-seeking. That is, people with depressive symptoms may solicit negative appraisals (and get them), and the receipt of negative feedback may serve to maintain or amplify their depression.”
“Coyne’s interpersonal theory of depression (1976b) proposed that in response to doubts as to their own worth or as to whether others truly care about them, initially nondepressed individuals may seek reassurance from others. Others may provide reassurance, but with little effect, because potentially depressed people doubt the reassurance, attributing it instead to others’ sense of pity or obligation. Potentially depressed people thus face a very difficult problem: They both need and doubt others’ reassurance. The need is emotionally powerful and thus may win out (at least temporarily), compelling the potentially depressed individuals to again “go back to the well” for reassurance from others; even if received, however, the reassurance is again doubted, and the pattern is repeated. Because the pattern is repetitive and resistant to change, the increasingly depressed persons’ significant others become confused, frustrated, and irritated and thus increasingly likely to reject the depressed persons and to become depressed themselves. […] We suggest that there is a considerable difference between the routine and adaptive solicitation of social support across distinct situations, and the repeated and persistent seeking of reassurance within the same situation, even when reassurance has already been provided.”
“Joiner and Katz (1999) reviewed the literature on contagious depression, and concluded that 40 findings from 36 separate studies provided substantial overall support for the proposition that depressed mood, and particularly, depressive symptoms, are contagious. […] excessive reassurance-seeking may explain, in part, when depression will be interpersonally transmitted. Taken together with research on interpersonal rejection, the work on contagious depression suggests that the joint operation of depressive symptoms and excessive reassurance-seeking disaffects significant others, by distancing them actually (e.g., ending the relationship) or functionally (e.g., emotional unavailability due to frustration or to contagious depression). […] In the interpersonal arena, excessive reassurance-seeking and negative feedback-seeking compound one another by creating a particularly confusing and frustrating experience for relationship partners of depressed people. […] It is interesting to note that this process has been confirmed empirically: Joiner and Metalsky (1995) found that relationship partners of depressed people are particularly likely to evaluate them negatively if they engaged in both excessive reassurance-seeking and negative feedback-seeking.”
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