Personal Dilemmas as Cognitive Vulnerability Factors in Depression

1
Personal dilemmas as cognitive vulnerability
factors in unipolar depression
42nd. International Meeting of the Society for
Psychotherapy Research June 29 July 2,
2011 Bern, Switzerland

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

2
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.

3
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.

4
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).

5

• 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)

6
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.

7
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.

8
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.

9
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.

10
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.

11
Teresas grid
12
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

13
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

14
An example of Implicative Dilemma
Self / Ideal Self
Selfish
Congruent Construct
Concerned about others
r 0,41
Self
Ideal Self
Discrepant Construct
Gets depressed easily
Does not get Depressed easily
15
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)

16
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

17
EMPIRICAL STUDY

• work in progress,
• (data collected until April, 2011)

18
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.

19
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. 

20
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)

21
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.

22
Results Presence of Implicative Dilemma(s)
p 0.02
23
Number of Implicative Dilemmas (I)
p lt 0.000 in all comparisons (dysthimia was not
compared)
24
Number of Implicative Dilemmas (II)
Major Depression Dysthymia Students Community
N 69 X 3,08 (SD 3,89) N 12 X 2,58 (SD 4,43) N 65 X 1,22 (SD 1,95) N 80 X 0,85 (SD 1,73)
Comparing with Major Depression p 0,000 p 0,000
25
Presence of ID(s) and depressive symptoms
BDI-II
ID(s) Depression group Control group
Absence N 23 X 37,13 (DT 11,40) N 74 X 4,43 (DT 3,88)
Presence N 58 X 33,53 (DT 9,35) N 71 X 7,90 (DT 6,70)
p 0,147 0,000
26
Presence of ID(s) and depressive symptoms (II)
ID(s) Major Depression Students Community
Abasence N 19 X 37,47 (SD 11,34) N 26 X 4,12 (SD 3,83) N 48 X 4,60 (SD 3,94)
Presence N 50 X 34,16 (SD 9,48) N 39 X 8,64 (SD 7,57) N 32 X 7,00 (SD 5,45)
p 0,224 0,007 0,025
27
Presence of ID(s) and cronicity
MDD (single e.) N 32 MDD (recurrent) N 37 Dysthymia N 12
Presence of Implicative Dilemma(s) 68,8 (22) 75,7 (28) 66,7 (8)
28
Presence of Dilemmatic Construct(s) (DC)
Depression Control
60,5 (49) 73,1 (106)
Major Depression Dysthymia Students Community
60,87 (42) 58,3 (7) 75,4 (49) 71,3 (57)
About 90 of the clinical sample presented either
ID(s) or DC(s)
29
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.

30
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
• A cognitive-behavioral treatment package (8
  group 8 individual sessions)
• 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

31

• Many thanks for your attention!!
• gfeixas_at_ub.edu
• http//www.usal.es/tcp