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Personal Dilemmas as Cognitive Vulnerability Factors in Depression


This is a summary of our ongoing research on the relevance of congitive conflicts in unipolar depression (paper presented at the Bern conference of Society of Psychotherapy Research (2011). – PowerPoint PPT presentation

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Title: Personal Dilemmas as Cognitive Vulnerability Factors in Depression

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.

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
  • 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.
  • 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
  • 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
Self / Ideal Self
Congruent Construct
Concerned about others
r 0,41
Ideal Self
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

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

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

  • 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

Participants non-clinical samples
  • 65 psychology students (graduate and
  • 50 women (77) 15 hombres (23)
  • 80 participants from a community sample
  • 45 women (56) 35 men (44)

  • 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)
p 0.02
Number of Implicative Dilemmas (I)
p lt 0.000 in all comparisons (dysthimia was not
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
Presence of ID(s) and depressive symptoms
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
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
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)
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)
  • Cognitive conflicts might explain the blockage
    and the difficult progress of patients with
  • 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
  • A cognitive-behavioral treatment package (8
    group 8 individual sessions)
  • A package combining CBT (8 group sessions) and a
    dilemma-focused intervention (8 individual
  • We expect that this combined package will
    increase the efficacy in the treatment of

  • Many thanks for your attention!!
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