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42nd.

International Meeting of the Society for Psychotherapy Research June 29 July 2, 2011 Bern, Switzerland

Personal dilemmas as cognitive vulnerability factors in unipolar depression


Guillem Feixas (UB), Victoria Compa (UB), Adrin Montesano (UB), Luis Angel Sal (UNED)
This work has been supported by the Spanish Ministry of Science and Innovation, grant ref. PSI2008-00406.

Cognitive factors affecting depression


Early models (Beck et al in the seventies)
negative views of self, the world and the future cognitive errors and other attribution biases

Recent contributions
processing of self-referential stimuli memory (both implicit and explicit) biases deficits in the control of attention (rumination) need for assessing self-relevant stimuli and depth of processing (Wisco, 2009)

no traces of cognitive or internal conflicts.

The notion of internal conflict


Conflicts and personal dilemmas have been credited for their importance in psychology Psychoanalysis was founded on the notion of conflict, in terms of the internal dynamics of the psyche Piaget used the term cognitive conflict to refer to contradictions the child encounters when trying to explain events Also in Gestalt Therapy, Bernes Transactional Analysis, and other approaches.

In Cognitive Analytic Therapy


Coming from and object relations and personal construct background, Ryle (1979) underlined the importance of dilemmas. They were one of the seeds for his cognitive analytic approach which was developed later:
"Dilemmas can be expressed in the form of "either/or" (false dichotomies that restrict the range of choice), or of "if/then" (false assumptions of association that similarly inhibit change). Two common dilemmas could be expressed as follows: 1) "in relationships I am either close to someone and feel smothered, or I am cut off and feel lonely"; () 2) "I feel that if I am masculine then I have to be insensitive" (italics in the original).

Social cognitive theorists (Festinger, Heider) where also focused on conflicts and efforts human do to balance them HOWEVER, little has been done in terms of defining conflicts in an operational way, and thus, little research has been done Even less is known about the role of conflicts for both physical and psychological health, development, and change (psychotherapy)

Personal Construct Theory


Kelly (1955) sees the human being very much as a scientist who creates hypotheses in order to make it easier to interpret and understand events. These hypotheses are personal constructs which are basically bipolar in nature. Constructs are the grasping of differences, discriminations we make in our experience.

PCT: core vs. peripheral constructs


A person is obviously not guided by one only construct but by an entire network of meanings. This system consists of hierarchically arranged personal constructs. The most central or "core" constructs are those that define the person's identity. In addition, there are more peripheral constructs that, although subordinate to these core constructs, are actively involved in construing events and further actions.

PCT: Identity, fragmentation


In the core of the construct system lies the sense of identity, represented by a set of core constructs whose invalidation produces great distress, and is strongly resisted. This portion of the system is mainly non-verbal or implicit but governs decisions taken at lower, more peripheral levels. It also might produce plans and personal goals that in certain situations become incompatible. IT IS NOT A LOGICAL SYSTEM The person is not aware of all its components, neither of the conflicts created by the fragmentation of the system.

Repertory Grid Technique (RGT)


The RGT is a structured procedure designed to elicit a repertoire of constructs and to explore their structure and interrelations. Its aim is to describe the ways in which people give meaning to their experience in their own terms. It is not so much a test in the conventional sense of the word as a structured interview designed to make those constructs with which persons organise their world more explicit.

A Repertory Grid consists of:


a series of elements that are representative of the content area under study, a set of personal constructs that the subject uses to compare and contrast these elements, a rating system (e.g., from 1 to 7) that evaluates the elements based on the bipolar arrangement of each construct.

Teresas grid

Self-congruency and self-discrepancy in the RGT


To study the construction of the self, the RGT includes these two elements: SELF NOW (How I see myself now?) IDEAL SELF (How I would like to be?) Constructs in which SN and IS are close are termed congruent and those in which they are set apart discrepant

Types of cognitive conflict identified with the Repertory Grid


Implicative dilemmas based on the association between a congruent and a discrepant construct Dilemmatic constructs based on the central position of the IDEAL SELF in a given construct

An example of Implicative Dilemma

Congruent Construct

Concerned about others

Selfish

r = 0,41

Discrepant Construct

Gets depressed easily

Does not get Depressed easily

Cognitive conflict
A type of cognitive structure Related to identity (core constructs), implicit or tacit, resistant to change A particular form of organization that links specific cognitive contents (e.g., I wish to overcome my shyness) to core values (e.g., I am modest) in a conflictive way (e.g., If I become social I might also end up being arrogant BUT If I want to keep my modesty I have to remain timid)

Cognitive conflict: Clinical Implications


Leaving the symptom pole of a construct, while desirable, may carry negative implications Having a symptom is associated with other traits central to the clients sense of identity Abandoning the symptom would involve a major change in the system being a different, undesirable, type of person

EMPIRICAL STUDY
work in progress, (data collected until April, 2011)

MAIN HYPOTHESIS
Cognitive conflicts are especially prevalent in unipolar depression, and may therefore play a role in its etiopathogenesis and/or its maintenance. Thus, cognitive conflicts may help to explain the difficulty of these patients to overcome their disphoric mood. The role of these conflicts varies depending on the type of depression (dysthimic vs. major depressive disorder) A higher presence of conflicts is associated with symptom severity and chronicity.

Participants: clinical sample


Group A: Major Depression (n = 69, 55 women and 14 men). Inclusion criteria: Meet diagnostic criteria for major depressive disorder according to DSM-IV-TR (APA, 2002) and a score above 19 in the BDI-II questionnaire. Group B: Dysthymia (n = 12, 9 women and 3 men): Criteria for inclusion: Meet diagnostic criteria for dysthymic disorder according to DSM-IV-TR and score above 19 in the BDI-II questionnaire. Exclusion criteria: are excluded from groups A and B persons having bipolar disorder, psychotic symptoms, substance abuse, organic brain dysfunction or mental retardation. The presence of other comorbidities (anxiety disorders, eating, personality, etc.) will not be a reason for exclusion but will be evaluated for statistical control. Depending on the number of participants who met criteria for both diagnoses (called "double depression") assess its treatment as a distinct group or their exclusion from the study.

Participants: non-clinical samples


65 psychology students (graduate and undergraduate):
50 women (77%) 15 hombres (23%)

80 participants from a community sample


45 women (56%) 35 men (44%)

Instruments
SCID-I (First, Spitzer, Gibbon and Williams, 1999) for the diagnosis of mental disorders and the collection of socio-demographic data and consumption of psychotropic drugs. BDI-II (Sanz, shot and Vazquez, 2003) for assessing depressive symptoms. Repertory Grid Technique (Fransella, Bell & Bannister, 2004; Feixas and Cornejo, 1996) for evaluating the presence, number and intensity of cognitive conflicts, construction of the self and cognitive structure.

Results: Presence of Implicative Dilemma(s)


Percentage of participants with Implicative Dilemma(s)
80
80

Percentage of participants with Implicative Dilemma(s)


70 60 50 40 30 20 10 0

70 60 50 40 30 20 10 0 Depression Control

MajorDep

Dysthimya

Students

Community

p = 0.02

Number of Implicative Dilemmas (I)


Proportion of Implicative Dilemmas
3,5
3,5

Proportion of Implicative Dilemmas


3

3 2,5 2 1,5 1 0,5 0 Depression Control

2,5 2 1,5 1 0,5 0 MajorDep Dysthymia Students Community

p < 0.000 in all comparisons (dysthimia was not compared)

Number of Implicative Dilemmas (II)


Major Depression N = 69 X = 3,08 (SD = 3,89) Comparing with Dysthymia N =12 X = 2,58 (SD = 4,43) Major Depression Students N = 65 X = 1,22 (SD = 1,95) p = 0,000 Community N = 80 X = 0,85 (SD =1,73) p = 0,000

Presence of ID(s) and depressive symptoms


40 35 30 25 20 BDI-II 15 10 5 0 Depression ID(s) Absence Presence p Depression group N = 23; X = 37,13 (DT = 11,40) N = 58; X = 33,53 (DT = 9,35) 0,147 Control Control group N = 74; X = 4,43 (DT = 3,88) N = 71; X = 7,90 (DT = 6,70) 0,000 Absence of IDs Presence of ID(s)

Presence of ID(s) and depressive symptoms (II)

ID(s) Abasence

Major Depression N = 19 X = 37,47 (SD = 11,34) N = 50 X = 34,16 (SD = 9,48) 0,224

Students N = 26 X = 4,12 (SD = 3,83) N = 39 X = 8,64 (SD = 7,57) 0,007

Community N = 48 X = 4,60 (SD = 3,94) N = 32 X = 7,00 (SD = 5,45) 0,025

Presence

Presence of ID(s) and cronicity


MDD (single e.) N = 32 Presence of Implicative Dilemma(s) 68,8% (22) MDD (recurrent) N = 37 75,7% (28) Dysthymia N = 12 66,7% (8)

Presence of Dilemmatic Construct(s) (DC)


Depression 60,5% (49) Control 73,1 % (106)

Major Depression 60,87 % (42)

Dysthymia 58,3 % (7)

Students 75,4 % (49)

Community 71,3 % (57)

About 90% of the clinical sample presented either ID(s) or DC(s)

Conclusions
Cognitive conflicts might explain the blockage and the difficult progress of patients with depression Need for specific interventions focused in the resolution of these internal conflicts.

New project
An intervention focused on the cognitive conflict(s) specifically detected for each patient will contribute to enhance the efficacy of psychotherapy for depression. A therapy manual is being developed and tested using a randomized clinical trial by comparing the outcome of two treatment conditions:
1. A cognitive-behavioral treatment package (8 group + 8 individual sessions) 2. A package combining CBT (8 group sessions) and a dilemma-focused intervention (8 individual sessions)

We expect that this combined package will increase the efficacy in the treatment of depression

Many thanks for your attention!! gfeixas@ub.edu http://www.usal.es/tcp

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