The psychotherapy of depression overview 2016

Depression

1. The Psychotherapy of Depression Overview; May 2016 Demetrios Peratsakis, LPC

2. “To suffer, is a privilege….”

3. Overview of Depression The Center for Disease Control (CDC) and the National Institute of Mental Health (NIMH) estimate that in any given year almost 25% of the adult public suffers from a serious, debilitating mental health condition, 26% of whom suffer from chronic depression. Annual World Health Organization estimates: 350 million suffer from depression, 800,000 of who commit suicide. US: 15 million depressed, 30,000 suicides, at an annual cost of $210 Billion (MDD) Depressed Mood (Irritability and anger in adolescents) Anger Markedly diminished interest or pleasure Significant change in appetite and/or weight Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or loss of energy; diminished concentration Becoming withdrawn or isolated Feelings of worthlessness or excessive guilt Recurrent thoughts of death or suicide

4. Anxiety and Depression: the Yin and Yang O ne study found that 85% of those with major depression were also diagnosed with generalized anxiety disorder and 35% had symptoms of panic disorder.

5. 1. Kessler et al. Arch Gen Psychiatry, 1995 2. DSM-IV 3. Rasmussen. Psychopharmacol Bull, 1988 4. Van Ameringen et al. J Affect Disord, 1991 5. Brawman-Mintzer, Lydiard RB. J Clin Psychiatry, 1996 6. Stein et al, Am J Psychiatry, 2000 Major Depression Posttraumatic Stress Disorder Social Phobia (Social Anxiety Disorder) OCD Panic Disorder GAD 8%-39% of Patients with GAD 5 67% of Patients with OCD 3 34-70% of Patients with Social Phobia 4,6 48% of Patients with PTSD 1 50% to 65% of Patients with Panic Disorder 2 Comorbid Mood and Anxiety Disorders Lifetime Comorbidity

6. Merriam-Webster defines emotions as “the affective aspect of consciousness”; a nd, as “a conscious mental reaction (as anger or fear) subjectively experienced as strong feeling usually directed toward a specific object and typically accompanied by physiological and behavioral changes in the body”. . Prevailing thoughts and models that add to our understanding of Depression Depression is a medical disease caused by neurochemical or hormonal imbalances (Neurobiology) Depression is the result of unfortunate experiences (Psychosocial ) Depression is caused by certain styles of thinking (Cognitive-Behavioral) Depression as e volutionary advantage Depression as existential dread Depression as power and unexpressed r age: Purposive Emotion and Behavior Etiology and Pathophysiology of Depression

7. Chemical Imbalance/Faulty Brain Wiring Electro-chemical disruption to monoamine neurotransmitters (serotonin, dopamine, norepinephrine, neuropeptides) or neural communication receptors of the limbic system, a part of the brain associated with the regulation of sleep, appetite, memory and emotional processes; low levels, particularly of norepinephrine and serotonin, appear to result in depression, whereas excess or imbalanced levels, particularly of dopamine, appear associated with mania. Neuro -imagery shows lower activity levels in the frontal lobes during depression, the part of the brain associated with higher cognitive processes, and high levels of activity in the amygdala, the part of the brain associated with fear, a possible correlation. Research suggests that with each subsequent period of mood disturbance 1) the period of time between each episode decreases, 2) the episodes occur more readily, and that 3) the experience is more debilitating. 3. Brain Atrophy CT and MRI scans have found atrophy or deterioration in the cerebral cortex and cerebellum in severe cases of unipolar depression and bipolar depression. Patients with left frontal stroke often manifest depressive symptomatology, whereas, patients with right frontal stroke often manifest manic symptomatology. Loss of brain volume (atrophy) in the frontal lobe, prefrontal cortex, and hippocampus, areas associated with emotions and important in the consolidation of information from short-term memory to long-term memory, has been implicated in the development of depression through suppression of the the BDNF (brain-derived neurotrophic factor) protein essential to neurogenesis and cell survival. BDNF modification of synaptic transmission, especially in the hippocampus and neo-cortex, may contribute to conditions such as epilepsy, chronic pain sensitization, and all mood related neuropsychiatric disorders. 4. Hormonal Imbalances Chronic activation (endocrinal default) in the hypothalamic-pituitary-adrenal (HPA) axis, the region that manages the body’s response to stress, has been associated with depression. When stressed, the hypothalamus produces corticotropin -releasing factor (CRF) and other substances that stimulate the pituitary gland to release stress hormones that send a flight-or-fight response. PET scans have also shown decreased metabolic activity in the frontal area of the cortex of people with severe depression. 5. Genetics Genetics are believed to predispose individuals toward or away (vulnerabilities/resiliencies) the development of depression or other mood disorders. Twin studies suggest 46 percent matching for identical twins, compared with 20 percent of fraternal twins. Brain Inflammation Activation or inflammation of Microglia, endogenous immune cells of the brain, by pathogens such as peripheral immune cells or toxins, leeched through the blood vessel walls, has been implicated in depression. Major stimulators of inflammation in our diet are gluten and sugar; depression is found in as many as 52 percent of gluten-sensitive individuals. Disease Model of Depression (neurobiology)

8. Genetic and biomedical factors predispose individuals to vulnerabilities that may trigger anxiety and depression when major changes and life events result in psychosocial distress. Trauma, loss and other extremely disruptive events overwhelm an individual and override their resiliency. Anxiety, phobia and compulsions are different manifestations of depression, caused by harm Loss of loved one, treasured possession, body part, status or prestige, goal, or familiar way of being Natural catastrophe, war or disaster Betrayal Incest Rejection, isolation, ostracism or shunning Domestic violence; physical and emotional abuse and neglect Rape or sexual violence Bullying Chronic childhood discouragement Sadness complicated by event(s) that further reduce resiliency or increase vulnerability resulting in downward spiral characterized by excessive rumination and self-deprecation (Blame/Shame) Psychosocial Model of Depression

9. Events do not trigger depression; how we respond to the things that happen to us in life does Depression relies how we explain things to ourselves; how we interpret reality Depressive thinking styles form a pattern of thinking, a cycle of depression, creates a downward spiral that fuels the depression Behavioral Theories Depression results from negative life events that represent a reduction in positive reinforcement; sympathetic responses to depressive behavior then serve as positive reinforcement for the depression itself. Learned Helplessness Theory Uncontrollable negative event(s) lead to stress and belief that one is helpless to control important outcomes. In turn, hopelessness leads to loss of motivation, to reduced actions that might control the environment, and to an inability to learn how to control situations that are controllable. Cognitive Distortion Theory (A. Beck) Depression results from errors in thinking leading to a gloomy view of one’s self, the world, and the future: All or nothing thinking (seeing things in black or white); Overgeneralization (seeing a single negative event as part of a large pattern of negative events); Disqualifying the positive (rejecting positive experiences by discounting them), Jumping to conclusions (concluding that something negative will happen or is happening with no evidence), Emotional reasoning (assuming that negative emotions necessarily reflect reality), “Should” statements (putting constant demands on oneself), and Labeling (overgeneralizing by attaching a negative, global label to a person or situation) Thinking Style Model of Depression

10. Analytical (or adaptive) rumination hypothesis ( ARH) by Andrews PW , and Thomson JA Jr. D epression as a suite of body responses designed to promote rumination, reportedly a form of intensive problem-solving. Specifically, “… that depression is a stress response mechanism (a) that is triggered by analytically difficult problems that influence important fitness-related goals; (b) that coordinates changes in body systems to promote sustained analysis of the triggering problem, otherwise known as depressive rumination; (c) that helps people generate and evaluate potential solutions to the triggering problem; and (d) that makes trade-offs with other goals to promote analysis of the triggering problem, including reduced accuracy on laboratory tasks. Collectively, we refer to this suite of claims as the analytical rumination hypothesis .” Psychological Review, 2009 1. Depression as a form of healing and self-compassion Body language and emotional tone are universal communications One withdraws in self-protection to reconsider and recharge, potentially to improve Others form a protective ring of support, reaffirming pairing, familial and social bonds Anxiety acts as a fear response furthering self-protection and healing 2. Rumination: an intense , analytic thinking process examining problems and concerns Persistent analysis and contemplation provides solution-oriented action Rumination can continue uninterrupted with minimal neuronal damage due to 5HT1A receptor activity Evolutionary Psychology Depression as an adaptive response to hurt and stress.

11. Depression and anxiety are the result of one’s recognition of the meaninglessness of life, our intrinsic isolation, the agonizing responsibility of being free to choose and become, and the utter finality of our death and non- beingness ( Yalom ) Death Anxiety : Conflict between awareness of death and desire to live a ) What comes after death? b) the act of Dying; c) Ceasing to be To cope we erect defenses against death awareness. Psychopathology in part is due to failure to deal with the inevitability of death Freedom : Conflict is between groundlessness and desire for ground/structure we are responsible for our own choices Implications for therapy: Responsibility, Willing, Impulsivity, Compulsivity, Decision Isolation: Angst that each of us enters and departs the world alone Meaninglessness: Conflict stems from “How does a being who requires meaning find meaning in a universe that has no meaning?” Depression as Existential Dread

12. Alfred Adler considered all behavior and emotion to be purposive; that action was a means by which we communicate intent within social interactions that is meaningful and consistent with our world-view. “In this regard, depression that results from loss or trauma could be viewed as more than a condition or syndrome that merely happens to someone, but rather as a dynamic expression of the individual’s beliefs about how to reconcile power struggles in their relationship with others. Depression acquires functional value within relationship systems around which interaction becomes ritualized. The ensuing dysfunctional interactional pattern becomes a stylized method of belonging with others and negotiating issues of power: Depression as an act of punishment or revenge Depression as a means of winning or mitigating loss in a power-struggle Depression as a means of cutting off and avoiding conflict with others Depression as a means of blaming and “ guilting ” others Depression as a means of avoiding responsibility and placing others in one’s service Depression as a means of contrition for shame and wrong-doing (self-blame/shame; guilt) Depression as a means of protecting one’s self from fear or additional harm Depression as a socially acceptable alternative to expressing rage or the shame from failing to do so” --- Demetrios Peratsakis Depression as a form of physical and psychological fatigue that results from psychological pain and the expenditure of energy required to contain unexpressed rage. It acquires functional value in relationships, becoming purposive for healing as well as for retaliation. Depression as Revenge & Unexpressed Rage

13. Medications   including antidepressants, mood stabilizers and antipsychotic medications Tricyclic Antidepressants ie . (imipramine ( Tofranil ), amitriptylene (Elavil), desipramine ( Norpramin ). Prevent reuptake of monoamines in the synapse while changing the sensitivity and number of monoamine receptors; 60-85% response rate; can take 4-8 weeks to show an effect. Selective Serotonin Reuptake Inhibitors ie . fluoxetine (Prozac), paroxetine (Paxil). Inhibit reuptake of serotonin increasing the amount in the synapse; quick acting (first couple of weeks), less severe side effects. Monamine Oxidase Inhibitors (MAOIs) ie . phenelzine ( Nardil ), tranyclpromine ( Parnate ). Inhibit monoamine oxidase, an enzyme that breaks down monoamines in the synapse, resulting in more monoamines; studies show MAOIs as less effective than the tricyclic antidepressants Lithium Reduces levels of certain neurotransmitters and decreases the strength of neuronal firing; 30-50% response rate. More effective in reducing the symptoms of mania than of depression. Used as a prophylactic to avoid relapse. Anticonvulsants, Antipsychotics, and Calcium Channel Blockers Alternatives to lithium and its side effects: anticonvulsant drugs reduce mania with less volatile side effects; antipsychotic drugs reduce levels of dopamine but neurological side effects such as tics Psychotherapy  including cognitive behavioral therapy, family-focused therapy and interpersonal therapy Behavioral Theories Depression results from negative life events that represent a reduction in positive reinforcement; sympathetic responses to depressive behavior then serve as positive reinforcement for the depression itself. Learned Helplessness Theory Uncontrollable negative event(s) lead to stress and belief that one is helpless to control important outcomes. In turn, hopelessness leads to loss of motivation, to reduced actions that might control the environment, and to an inability to learn how to control situations that are controllable. Cognitive Distortion Theory (A. Beck) Depression results from errors in thinking leading to a gloomy view of one’s self, the world, and the future: All or nothing thinking (seeing things in black or white); Overgeneralization (seeing a single negative event as part of a large pattern of negative events); Disqualifying the positive (rejecting positive experiences by discounting them), Jumping to conclusions (concluding that something negative will happen or is happening with no evidence), Emotional reasoning (assuming that negative emotions necessarily reflect reality), “Should” statements (putting constant demands on oneself), and Labeling (overgeneralizing by attaching a negative, global label to a person or situation ) Brain stimulation therapies   including electroconvulsive therapy (ECT) or repetitive transcranial magnetic stimulation ( rTMS ). Induction of a brain seizure by electrical current (ECT) relieves depression in 50-60 percent of patients. Increases permeability of the blood-brain barrier, allowing antidepressant medications more fully into the brain, stimulates the hypothalamus and increases the number and sensitivity of the serotonin receptors. Relapse rate can be as high as 85 %. Light therapy Treatment for seasonal affective disorder that involves exposure to bright lights during the winter months. May impact circadian rhythms (natural cycles of biological activities that occur every 24hrs .), regulate the hormone melatonin and increase serotonin levels . Self-Management: Exercise, Nutrition, Sleep, Stress Reduction, Social Support Alternative therapies  and Mind/body/spirit approaches including acupuncture, nutrition, meditation, faith and prayer Treatment Options

14. 15 Psychotherapy for Depression and Anxiety

15. Treatment of choice: psychotherapy, augmented with medication for the management of more disturbing symptoms . Double-blind, controlled trials for outpatient treatment with mild-to-moderate depression have reported remission rates of 46 % for medication alone, 46% for psychotherapy and 24% for control conditions ( Casacalenda et al., 2002), leaving up to 50% of patients with some degree of persistent symptoms. General Purpose of Therapy Understand the behaviors, emotions, and ideas that contribute to one’s depression Understand and identify the life problems or events—like a major illness, death, a loss of a job or a divorce—that contribute or result in depression and discover which aspects of those one may be able to solve or improve Express underlying feelings of shame, blame, guilt and anger Regain a sense of control and pleasure in life Learn coping techniques and problem-solving skills Over 800 distinct psychotherapies; no preeminent form Some advantage noted in treatment of depression with Cognitive Behavioral Therapy (CBT) and Interpersonal Therapy (IPT) Brief therapy (up to 6 months) helpful for mild to moderate or simple depression, longer-term therapy (1-3 years) beneficial for complicated depression and treatment of chronic, unresolved trauma   Psychotherapy There is no single cause of depression. It can develop for different reasons and has many different triggers. Treatment, therefore, must consider all options and methodologies.

16. The National Institute of Mental Health (2011) highlighted CBT and IPT as primary psychotherapeutic treatments for depression . (Higher clinical benefits have been suggested by interpersonal psychotherapy (IPT), cognitive behavior therapy (CBT), and two types of behavior therapy (BT) (Hollon & Ponniah, 2010, p. 917). Hollon and Ponniah (2010) summarized that these treatments showed evidence of being as effective as medication and also appeared to “enhance the effectiveness of medications when added in combination” (p. 926). Interpersonal Therapy (IPT) Designed for symptom reduction and improved interpersonal relationships The goal is to change feelings, thoughts and actions and improve communication skills and increase self-esteem during a short period of time (three to four months). Works well for depression caused by loss, major life events, role transitions, social isolation, and unresolved conflict in relationships such as disputes, frustrations and anxieties that impact mood and self-esteem. Focus on interpersonal experience; challenges negative, irrational and distorted thinking in relation to significant others, although the intent is to change the relationship pattern rather than depressive cognitions Focus on affect Explores avoidances and resistance behavior Attention to past experience Emphasis on the therapeutic relationship Exploration of client’s wishes, dreams and fantasies Blagys & Hilsenroth, 2000 Interpersonal Therapy (IPT)

17. Believes that cognitions affect behavior and emotion and that a change in cognitive and behavioral strategies can change mood The goal is to establish new ways of thinking by directing attention to both the "wrong" and "right" assumptions one make about themselves and others Rumination triggers and perpetuates depression Focus on negative self-talk and thoughts that shape beliefs about the hopelessness of one’s condition and their relative lack of self-worth; use of action plan to identify and reshape negative or inaccurate thinking: Identifying and modifying automatic thoughts and core beliefs Regulating routine, and Minimizing avoidance Cognitive Behavior Therapy (CBT)

18. As with its predecessors, DSM 5 neatly categorizes disorders of mood by type and severity of symptom. While ideal for assessment purposes, many clinicians prefer a working format that views the anxieties, depressions and compulsive disorders as related, if different, manifestations of the same underlying processes associated with unresolved trauma or conflict. One such consideration is to view all disorders related to mood (including affective disorders, anxiety neurosis, compulsive disorders, hysteria and phobic disorders) as by-products of depression which can be further considered as falling into one of three categories: Simple Depression, Complex Depression, and Depressive Life-style. Simple Depression: Depression mixed with anger. A normative response to harm, loss, disappointment or rejection. The mood and thoughts draw others near and foster nurturing and the opportunity to self-heal, a pulling into one’s self for self–reflection and perspective. Guilt and rumination may benefit self-activation. Social pairing and intimacy bonds are often re-affirmed.   Degree of worthlessness (sense of helplessness and despair) and discouragement is low or non-existent The depression or sadness is used for healing of the self Improvement and healing occur with or without the help and support of others May occur at any time or age. The cause of the depression may or may not be associated with others and revenge may or may not be needed or beneficial Others feel sympathetic and find joy in helping The number one reason for depression is loss, which may take several forms Loss of a loved one Loss of a valued possession Loss of familiar way of being Loss of prestige, job, status or lifestyle Loss of a body part, function or ability Loss of a goal, even through its attainment   Simple and Complex Depression and Depressives

19. Complicated Depression: Depression and anxiety as a consequence of trauma or unresolved conflict; mixed with anger, shame, guilt and blame. Rage often develops as a consequence of unresolved power-struggles   Depending on how pervasive or prolonged the trauma, one’s thoughts of themselves and the world can be changed, creating complication in identity and function. It may result in guilt, shame, anger and/or rage, which can result in despair, either through a sense of helplessness or worthlessness or both . Degree of worthlessness and discouragement is high, yet it likely does not create irreparable damage to the self. It is not a life-long image of the self in relation to others, although it can have life-long residual fall-out The depression is used to protect the self from additional or further harm (safe-guarding) and typically develops in concert with sustained anxiety or tension.  Improvement and healing occur better and faster when supported by others, especially when empathy by other survivors is present May occur at any time or age as a single trauma or prolonged episode of harm. It often occurs in a social context or its aftermath has close social implications. Revenge can be an important and needed method of healing Others feel empathetic, although may also experience anger, disgust or rejection The number one reason for complicated d epression is unresolved trauma or conflict that results in a sense of extreme power- lessness and loss of hope, often associated with suicidality . Rumination recycles feelings of shame, guilt, anger and blame resulting in anger and rage. Depression may acquire functional value and become a means of organizing family functions, avoiding responsibility, dominating a power-play or seeking revenge Complicated Depression

20. Depressive Life-style : Depression as a means of socializing and interacting with others   Depressives are depression-prone individuals who effect social power and place others into their service through the use of their helplessness. They reaffirm their feelings of worthlessness through self-recrimination and guilt. Self-blame can be both noble and a good strategy to defemd oneself from blame by others. Despite professing good intentions, depressives are nonetheless very resistant to change, typically evidencing life-long themes related to a sense of hopelessness and despair, failure, and feelings of guilt and shame. They are passive-aggressive and elicit feelings of anger and resentment in others. This interpersonal style is extremely intractable, conveying great dominance over others. Self-harming behavior, including suicidality , may be used as a threat or manipulative ploy. Psychotherapists find Depressives highly oppositional to any attempt to lift them from their depression (therapist-slayers)   Degree of Worthlessness (sense of helplessness and despair) and discouragement is pervasive and an integral part of the identity of self in relation to others Depression is used to control others and place them in one’s service. There is a nobility to the struggle of reaching for superiority from feelings of worthlessness Improvement requires considerable re-socialization. Personal discouragement is high and ingrained to the point that efforts to improve threaten the identity of worthlessness. Hopelessness, despair, good intention (guilt) and continual failure reaffirm the sense of worthlessness. Depressives recoil from attempts to uplift the depression and improve the individual’s self-esteem and image of self. Depression occurs as means of coping during an early history of prolonged or severe discouragement or repeated trauma. Depressives develop their life-style from childhood, typically in a neglectful, abusive or over-controlling home environment. Adult victims of early, pervasive childhood abuse often develop depressive life-styles.  Depression develops as a means of controlling others. Others feel placed upon and resentful The number one reason for the development of a Depressive Life-style is a pervasive, prolonged early life development with caretakers whose parenting style was exceedingly over-protective/over-pampering (Adler), neglectful or abusive.     Depression as a Life-style

21. Behavior and Emotion are purposive; we interpret events, then feel and behave in a manner consistent with our beliefs about ourselves and how to interact and belong with others. Depression is psychological pain and anger at interpersonal trauma: shame, fear, guilt, blame and rage. These drive neuro-biologic changes and the symptoms we call anxiety and depression. Hopelessness and worthlessness fuel Depression, which always involves issues of Power & Intimacy. a) Loss: leads to sadness and anger, sense of vulnerability, can imperil trust and desire to connect; practical re-arrangements. Psychological issues dissipate without complications. b) Domestic Violence/Abuse (rape, incest, bullying, ostracism): results in shame, sense of vulnerability and mistrust, PTSD, fear/anxiety, disassociation, & depression. Trust/Intimacy, Control/Anger, Shame. c) Betrayal: results in hurt and shame; becomes depression and anxiety or rage. Revenge; Trust issues Therapy is, in essence, for healing unresolved conflicts and trauma: Challenge world-view and magical thinking; match thought and behavior and both with intent Disengage and re- dircet power-play(s) Negotiate decisions and remedies for resolving problems Challenge thoughts that drive shame, guilt and blame Tap into underlying anger and desire for revenge Move toward forgiveness and redemption Enlist supports and remedy emotional cut-offs; rebuild intimacy Move toward meaningful activity and relations Button-up relapse and recovery practice a) Permission to grieve; tap anger; fill void; address cut-offs, as added loss (“ghosts”); enlist support from others b) Address self-blame and “ shoulds ”/feelings of guilt; manage anxiety and depersonalization; tap anger c) Express rage; obtain revenge, which can take many, legal and ethical forms; move to forgiveness and redemption. Risk betrayal to trust and love again Synthesis for Working with Depression

22. Love Hurts, --- and Heals “Love is the only way to grasp another human being in the innermost core of his personality. No one can become fully aware of the very essence of another human being unless he loves him. By his love he is enabled to see the essential traits and features in the beloved person; and even more, he sees that which is potential in him, which is not yet actualized but yet ought to be actualized. Furthermore, by his love, the loving person enables the beloved person to actualize these potentialities. By making him aware of what he can be and of what he should become, he makes these potentialities come true.” ― Viktor E. Frankl, Man's Search for Meaning