1. SEMINAR
Depression.
Date: 14 June 2013
By : Syeda Shahnaz
2nd Year M.Phil, M&SP
Dept. Clinical Psychology
LGBRIMH, Tezpur.

2. • Psychotherapy is a general term referring to
therapeutic interaction or treatment contracted
between a trained professional and a client,
patient, family, couple, or group. The problems
addressed are psychological in nature and can
vary in terms of their causes, influences, triggers,
and potential resolutions.
• “The principle aim of psychotherapy is not to
transport one to an impossible state of
happiness, but to help (the client) acquire
steadfastness and patience in the face of
suffering. ” -C.G. Jung

3. •
•
•
•
•
•
•
Interpersonal Psychotherapy:
Behavioural Activation:
Cognitive Behavioural Therapy:
Problem Solving Therapy:
Psychodynamic Therapy:
Social Skills Therapy:
Supportive Counselling:

4. • Interpersonal Psychotherapy: This short-term model (6-20
sessions) focuses on the client’s interpersonal issues,
patterns of interaction with family and friends, and has the
goal of reducing specific symptoms, improving
interpersonal skills, and helping increase social support for
the client.
• Behavioral Activation: This approach focuses on helping
the client increase positive interactions between
themselves and the environment, bringing increased
awareness of positive activities and interactions.
• Cognitive Behavioral Therapy: This kind of treatment
uncovers the patient’s negative beliefs about self and
others, then teaches how these beliefs impact on behavior
in order to facilitate symptom resolution.
• Problem Solving Therapy: This model explores the nature
of the client’s problems that contribute to the depression.
The client examines multiple solutions for each problem,
and then selects, implements, and evaluates the best
solution.

5. • Psychodynamic Therapy: This paradigm focuses on
how unresolved conflicts and issues from the past have
a negative impact on the patient’s current situation.
Through insight and exploration of old patterns, the
client develops new healthier ways of relating.
• Social Skills Therapy: This highly educational process
teaches people the skills needed to build and maintain
healthy relationships.
• Supportive Counseling: This less directive model
encourages the client to talk about their life
experiences and emotions. The therapist then offers
active listening and empathy without suggesting
solutions or teaching new skills.

6. Brief Introduction
to
Depression

7. • Depression is a common mental disorder that
presents with depressed mood, loss of interest or
pleasure, decreased energy, feelings of guilt or low
self-worth, disturbed sleep or appetite, and poor
concentration. Moreover, depression often comes
with symptoms of anxiety. These problems can
become chronic or recurrent and lead to substantial
impairments in an individual’s ability to take care
of his or her everyday responsibilities. At its worst,
depression can lead to suicide.

8. • The 2012 Depression package is intended to
provide information about depression as a
treatable illness, and to spread the message
that recovery is possible and achievable.

11. Clinical Features of Depression
•
Mood disturbances
• Psychomotor disturbances
• Cognitive disturbances
• Vegetative disturbances
• Relationships

12. Mood disturbances• Painful arousal- negative affective arousal is described as
depressed, anxious, irritable, mournful. It is qualitatively different from
neurotic counterparts.
• Hypersensitivity to unpleasant events
• Insensitivity to pleasant events
• Insensitivity to unpleasant events
• Reduced anticipatory pleasure
• Anhedonia or reduced pleasure- inability to experience emotions both
pleasurable and depressive. May lose capacity to cry, lose their feelings
for family members. Gives up pleasurable acts. Patient suffers from
inability to experience emotions (differentiating flat affect)
• Affective blunting
• Apathy
• Masked depression- depression sine depression one is commonly
observed in older patients and presents with bodily symptoms and to be
diagnosed by physician by appearance, vocal inflection and expression

13. • Psychomotor disturbances
– Agitation
– Retardation
– Stupor
– Pseudodementia
• Cognitive disturbances
– Mood congruent psychotic features
– Mood incongruent psychotic features
– Negative view of self, world and future
– Excessive guilt
– Poor concentration, indecision
– Suicide
• Vegetative disturbances
– Appetite
• Anorexia and weight loss, Weight gain
– Sleep
• Insomnia, Hypersomnia
– Sexual function
• Relationships
- Family , peer, educational, work.

14. Etiologies of Depression
1. Biological Theories
• Genetics
• Limbic system and dorsolateral prefrontal
cortex
• Neurotransmitters
• Neuroendocrine and immune system 1 Presentation
neuro.flv
• Sleep architecture and circadian rhythms
(around day)

16. 2. Stress Theories
• i. Stress Diathesis Model
• Depression only follows exposure to stress in people
who have specific biological or psychological attributes
that render them vulnerable to stressful life events and
most vulnerable require least stress to for dep. To occur (
Joiner & Timmons 2009; Joormann 2009; Levinson 2009)
• ii. Stress generation theory
• People with cetain personal attributes inadveretently
generate excessive stress, which inturn lead to dep. (Lie
& Alloy 2010)
• iii. Early life stress Childhood – Adulthood dep. with min
stress (Goodman & Brand 2009; Hammen 2009;
harkness & Lumley 2008)

17. • iv. As number of episodes of dep. increases,
the amount of stress required to precipitate a
relapse decreases. (Boland & Keller 2009)
• This may be due to the neurobiological
process of kindling (Neuro sys vulnerable) (Monroe &
Harkness 2005) and cognitive process of
rumination (McLaughlin & Nolen- Hoeksema
2011)

18. Temperament, Traits, Cognitive Biases,
Coping strategies and
Interpersonal Styles.
i. Temperament Character Inventory
(Cloninger et al 1993) Four dimensions :
• Harm Avoidance – serotonin system
• Reward dependence – noradrenaline
• Novelty seeking – dopamine .
• Persistence

19. ii. Traits: Big 5 personality traits N E C O A
Neuroticism – major depression (Kotov et al
2010)
• Dependence/ Sociotropy ~ loss of
relationships
• Self critical/ autonomy (self define) ~ failure in
achieving
=
Depression

20. • iii. Cognitive biases: Dep. show a range of
information processing biases, during and
between depressive episodes at the levels of
attention, memory and reasoning that render
them vulnerable to depression and maintain low
mood during depressive episodes. (Joorman
2009)
• Selectively attend to & remember, negative
information about the self & world (Peckham
Phillips 2010)
• Tendency to remember generalities but not
specific details of past events (Summer et al
2010)

21. • iv. Coping strategies : Rumination as a coping
style (Aldao et al 2010)
• Negative co relation between depression &
adaptive coping – problem solving,
acceptance, reappraisal.
• V. Interpersonal Style: Insecure attachment
style , parental rejection, neglect, social skill
deficit. (Joiner & Timmons 2009)
• Expressed emotions – relapse (Hooley 2007)

22. Psychoanalytic Theories
• Freud’s classical psychoanalytic theory
- Self directed anger in response to loss of valued
person or attribute
- Major loss in adult life – regression to oral stage
- Superego directs anger on ego (children)
- Self directed anger (guilt and shame) (Kim et al
2011)
- Early life experiences.

23. • Bibring’s ego psychology theory
• Low self esteem -> from gap between self as it is and
ideal self.
• Ideal self = superego
• Important correlates and precursor
• Blatt’s psychoanalytic theory of two types of
depression
• Early exp of punitive parenting ->vulnerability to stress
involving loss autonomy and control = dep [projection
& reaction formation]
• Neglectful parenting / loss of parents -> vulnerability to
stress involving loss of present attachment relationship
= dep [denial & repression DM]

24. Cognitive and Behavioural Theories
• 1. Lewinsohn’s Behavioural Theory :
• Maintained by a lack of response-contingent
positive reinforcement (RCPR)
• Includes relaxation and coping skills training to
deal with negative emotions arising out of
stressful events
• More activity + more pleasant events =more
opportunities for using social skills to obtain
RCPR

25. Beck’s cognitive theory
• Depression occurs when life events involving loss
occur and re-activate negative cognitive schemas
formed early in childhood as a result of early loss
experiences. These negative schema entail negative
assumptions such as,
“ I am only worthwhile if everybody likes me”
[Dysfunctional attitude scale, Weissman & Beck 1978]
• When a depressed person experiences a drop in
mood in a particular situation, this mood change is
due NOT to the situation but the Negative Automatic
Thoughts that the situation elicited.

26. • The low mood and related depressive
behaviour that occur in such situations makes
it more likely that similar situations will recur
• These episodes also reinforce depressive
schemas.
• Negative schemas have their roots in loss
experience in early childhood : loss of
parents, positive parental care, personal
health, loss of positive peer relations by
bulling or exclusion from peer
groups, expectation of loss.
• CBT model of depression

27. Early life stress
(Long separation from parent in early
childhood)
•
Recent life
event
(Bereavement
activates latent
schema)
A.
Activating
Agent (he
did’nt say hello)
SWL
Confirm
core belief
SCHEMA
Core Belief
(I am worthless)
Assumptions
(If people don’t like
me, I am worthless)
B.
Automatic
thoughts (I am
not good he
doesn’t like
me)
Emotional
(sad)
Behavioural
(withdrawl)
Physiological
(lethargy)
C.
Consequences
S W L Confirm set up more activating agent

30. • Two latent schema importance particularly in
case of Dep.
IPR [sociotropy]
Personal achievement [ autonomy]
• The various logical errors that people suffering
from depression usually make are referred to
as cognitive distortions:

31. 1. ALL-OR-NOTHING THINKING: You see things in black and
white categories. If your performance falls short of
perfect, you see yourself as a total failure.
2. OVERGENERALIZATION: You see a single negative event
as a never-ending pattern of defeat.
3. MENTAL FILTER: You pick out a single negative detail and
dwell on it exclusively so that your vision of all reality
becomes darkened, like the drop of ink that discolors
the entire beaker of water.
4. DISQUALIFYING THE POSITIVE: You reject positive
experiences by insisting they “don’t count” for some
reason or other. In this way you can maintain a negative
belief that is contradicted by your everyday experiences.

32. 5. JUMPING TO CONCLUSIONS: You make a
negative interpretation even though
there are no definite facts that convincingly
support your conclusions.
a. Mind Reading. You arbitrarily conclude that
someone is reacting negatively
to you, and you don’t bother to check this out.
b. The FortuneTeller Error. You anticipate that
things will turn out badly, and you feel
convinced that your prediction is an already
established fact.

33. 6. MAGNIFICATION (CATASTROPHIZING) OR
MINIMIZATION: You exaggerate the importance of
things (such as your goof-up or someone else’s
achievement). Or you inappropriately shrink things
until they appear tiny (your own desirable qualities
or the other fellow’s imperfections). This is also called
the “binocular trick.”
7. EMOTIONAL REASONING: You assume that your
negative emotions necessarily reflect the way things
really are: "I feel it, therefore it must be true."

34. 8. SHOULD STATEMENTS: You try to motivate yourself with
shoulds and shouldn’ts, as if you had to be whipped and
punished before you could be expected to do anything.
“Musts” and “oughts” are also offenders. The emotional
consequence is guilt. When you direct should statements
toward others, you feel anger, frustration,
and resentment.
9. LABELING AND MISLABELING: This is an extreme form of
over-generalization. Instead of describing your error, you
attach a negative label to yourself: “I’m a loser.” When
someone else’s behavior rubs you the wrong way, you attach
a negative label to him: “He’s a damn louse.” Mislabeling
involves describing an event with language that is highly
colored and emotionally loaded.
10. PERSONALIZATION: You see yourself as the cause of some
negative event which in fact you were not primarily
responsible for.

35. Cognitive Therapy
• Clients learn to monitor situations where negative
mood changes occur – to identify negative
automatic thoughts- to generate positive
interpretation of situations in which negative mood
changes occur and to evaluate the validity of these
positive and negative views mood altering
situations.
• Cognitive Therapy is a system of psychotherapy
that attempts to reduce excessive emotional
reactions and self-defeating behaviour, by
modifying the faulty or erroneous thinking and
maladaptive beliefs that underlie these reactions
•
Beck et al 1976, 1979, 1993
1 Cognitive Behavioral Therapy-CBT - YouTube.flv

36. Learned Helplessness theory
• When a person repeatedly fails to control the
occurrence of negative stimuli or has repeated
experiences of failure at valued tasks and
adopts a cognitive style that involves making
internal , global, stable attribution for failure
• And
• External, specific, unstable attributions for
success

37. Family system theory
•
•
•
•
Family based stress
Support
Belief system
Interaction pattern

38. What Is the Case Formulation Approach to
Cognitive-Behavior Therapy?
The core idea of any therapy calling itself cognitive is that
people’s emotional reaction and behaviour are strongly
influenced by cognition (in other words, their
thoughts, beliefs and interpretation about themselves or the
situations in which the find themselves- fundamentally the
meaning they give to the events of their life.)
The case formulation approach to cognitive-behavior therapy is
a framework for providing cognitive-behavior therapy (CBT)
that flexibly meets the unique needs of the patient at
hand, guides the therapist’s decision making, and is evidence
based.

39. Case formulation-driven CBT is not a new therapy. It
is a method for applying empirically supported
CBTs and theories in routine clinical practice.
The elements of the case formulation
approach to CBT are depicted in

40. • Elements of a Case Formulation
A complete case formulation ties all of the following
parts together into a logically coherent whole:
1. It describes all of the patient’s
symptoms, disorders, and problems.
2. It proposes hypotheses about the mechanisms
causing the disorders and problems.
3. It proposes the recent precipitants of the current
disorders and problems, and
4. The origins of the mechanisms.

41. Elements of the Case Formulation Approach to
CBT
• Assessment to Obtain a Diagnosis and Initial
Case Formulation
• Developing a Mechanism Hypothesis
• Levels of Formulation
• Treatment Planning
• Monitoring and Hypothesis Testing
• The Therapeutic Relationship

42. • General formulation model of depression
PREDISPOSING FACTORS
Any developmental factors that sensitize a person to loss of significant relationship or
esteem. PERSONAL FACTOR – Genetic vulnerability to depression, loss & failure
experiences,
depressive
temperament,
neuroticism,
introversion,
low
conscientiousness,
cognitive
schemas
&
styles,
low
self
esteem, perfectionism, attachment insecurity, socials skills deficit, depressive IPR style.
FAMILY FACTORS , COMMUNITY FACTORS
MAINTAINING FACTORS
Depressive cognitive
styles, self defeating
behaviour, ruminative &
avoidant coping.
Lack of family support
Lack of school /work
place support
Lack of peer support
Treatment refusal, non
adherence or faliure
PROTECTIVE FACTOR
PRECIPITATION
FACTORS
Stresses involving loss
and failure
DEPRESSION
Good pre-mormid
adjustment, personal
strengths &
achievement
Family support
School or workplace
support
Peer group support
Engagement in
treatment

43. • 1. case Depression.docx