The Depression Conundrum and the Advantages of Uncertainty.

According to the WHO (2012), the prevalence of unipolar depressive disorders is rising, even in those places where mental health treatments are widely available. The WHO predicts that these disorders will be the leading contributor to the global burden of disease by 2030. This sobering projection fits poorly with how psychological treatments for depression are presented in the mainstream scientific literature: as highly effective therapies, based upon a sound understanding of the causes of distress. There is a clear discrepancy between the rising prevalence figures on the one hand, and the confident claims of this effectiveness research on the other. This discrepancy prompts a set of complex interlinked questions, which we have called 'The Depression Conundrum.' In search of a partial answer, the aim of our study was to critically analyze five meta-analytic studies investigating the effectiveness of psychological EBTs for depression, all of which had been published in high impact factor journals. Our examination established a number of methodological and statistical shortcomings in every study. Furthermore, we argue that the meta-analytic technique is founded upon problematic assumptions. The implications of our analysis are clear: decades of quantitative research might not allow us to conclude that psychological EBTs for depression are effective. The uncertainty and questions raised by our findings might act as a catalyst to broaden the way in which depression and associated therapies are researched. In addition, it might contribute toward a more vigorous and interdisciplinary debate about how to tackle this soon-to-be global public health priority number one.

Psychopathy and internalizing psychopathology.

There is general consensus in clinical and research literature that the core feature of psychopathy consists of an affective deficit. However, previous studies tend to find weak and inconsistent associations between psychopathy and measures of internalizing psychopathology. In this study we test whether the predominant practice of using questionnaires to assess internalizing psychopathology has influenced the results of previous research. We argue that questionnaires measure general distress rather than specific symptoms of internalizing psychopathology, and that the validity of questionnaires might be impaired by psychopathic traits, such as impression management and lack of affective experience. Combining a questionnaire (Depression Anxiety Stress Scales-21; DASS-21) and a semi-structured interview (Structured Clinical Interview for DSM-IV-R Axis 1 Disorders; SCID-I) for internalizing psychopathology, we test the differential association of both measures with the Psychopathy Checklist-Revised (PCL-R) in a sample of 89 male detainees. In accordance with our prediction, we found moderate negative associations between the Interpersonal and Affective facets of the PCL-R and SCID-I, but no significant associations with the DASS-21. We found no evidence that psychopathic traits decrease the validity of the responses on a questionnaire. We conclude that the interpersonal and affective features of psychopathy are negatively related to specific symptoms of internalizing psychopathology, but not with general distress.

Psychopathy, traumatic exposure, and lifetime posttraumatic stress.

This study examined two theoretical models on the interaction between psychopathy, traumatic exposure, and lifetime posttraumatic stress in a sample of 81 male detainees. In Model 1, the interpersonal and affective features of psychopathy were assumed to protect against posttraumatic stress. In Model 2, the lifestyle and antisocial traits of psychopathy were assumed to lead to a lifestyle that increases the risk of traumatic exposure and subsequent posttraumatic stress. The authors found significant negative bivariate associations between Psychopathy Checklist-Revised (PCL-R) total, Interpersonal and Affective facet scores, and posttraumatic stress. Model 1 was confirmed, as they found the interaction between the Affective facet and traumatic exposure had a significant negative effect on posttraumatic stress. Model 2 was rejected. The authors' findings confirm that the interpersonal and affective features of psychopathy are associated with an emotional deficit and that the affective features of psychopathy are crucial for understanding the relationship between psychopathy and anxiety.

Psychopathy and lifetime experiences of depression.

BACKGROUND: Previous studies have investigated an association between psychopathy and depression as part of the broader study of co-morbidity between psychopathy and Axis I psychopathology or as part of validity tests for psychopathy. These study methods have, however, been limited, for example, by exclusive use of questionnaires, or categorical measures of depression, and by low base rates of psychopathology. AIMS: Our aims were to extend previous research on psychopathy and depression and to test the hypothesis that total Psychopathy Checklist - Revised (PCL-R) scores, and the four facets of interpersonal, affective, lifestyle and anti-social behaviour, would be negatively associated with depressive symptom scores. METHODS: Dimensional measures of psychopathy and lifetime major depression were derived from structured interviews (the PCL-R and the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised) with adult male prisoners. The emotional experience of depression was also studied through analysis of the narratives used by the men to describe their depressive symptoms. RESULTS: The PCL-R scores, and in particular the interpersonal, affective and lifestyle facets of the PCL-R, were inversely associated with depression scores. CONCLUSION: Our findings suggest that psychopathy does influence the way depression is experienced.

In search of a framework for the treatment of alexithymia.

PURPOSE: Clinical observations and controlled studies indicate that the treatment of alexithymic patients is most difficult. Moreover, stronger degrees of alexithymia predict worse therapy outcome. We argue that in order to make therapy for alexithymia-related disorders fruitful, a conceptualization of alexithymia in terms of interpersonally imbedded affect regulation is needed. METHODS AND RESULTS: Based on a re-interpretation of Freud's actual neurosis via Lacan's theory and contemporary attachment theory, we present a theoretical framework that incorporates these points. This framework helps us to explain why classic psychotherapeutic approaches fail, and to formulate principles for an alternative psychoanalytic therapeutic approach that addresses the theoretically discerned difficulties. A clinical vignette is used to examine how these principles can be implemented in clinical practice. CONCLUSION: Therapy with actual-neurotic alexithymic patients should focus on distressing situations, starting from which a three-step logic can be deployed. During therapy, mental representations on difficult situations in patients' lives need to be constructed by (1) putting into words the chain of events that makes up the distressing situation; (2) making the patient's appraisal of the difficult situation explicit; and (3) addressing affective responses and discussing the patient's way of dealing with the difficult situation.

Reconstruction and validation of the Personal Style Inventory in a Flemish clinical and student sample.

The Personal Style Inventory-II (Robins, Ladd, Welkowitz, Blaney, Diaz, & Kutcher, 1994) was constructed to assess sociotropy and autonomy; two personality dimensions associated with increased susceptibility to depression. In the present study, the authors used a confirmatory factor analysis to evaluate the fit of the theoretical model of the Personal Style Inventory-II in a heterogeneous clinical sample (N=266) and in a student sample (N=799); construct validity was evaluated by correlating the Personal Style Inventory-II scales with the scales of the Inventory of Interpersonal Problems-64 and the Symptom Checklist-90-R. Poor fit of the original Personal Style Inventory-II model was observed in both samples. Yet, after progressive elimination of 18 items, a good fit was obtained in the clinical sample and replicated in the student sample. This brief version demonstrated better construct validity than the long version, especially in a depressed clinical sample: sociotropy was associated with nonassertive, overly accommodating, and self-sacrificing interpersonal behaviour, depressive symptoms, phobic complaints, and anxiety and somatic symptoms; autonomy was associated with cold and vindictive interpersonal behaviour, obsessive-compulsive symptoms, and aggressive urges. In contrast to the long version, scores on the shortened version showed the predicted sex differences.

Interpersonal problems in alexithymia: A study in three primary care groups.

OBJECTIVES: The present study investigated the relation between alexithymia and interpersonal problems in a sample of primary care patients with either chronic fatigue syndrome (CFS); a chronic cardiovascular or auto-immune disease; or a minor medical condition. It was hypothesized that the relation between cold interpersonal functioning would account for the differences in alexithymia scores between the patient groups. DESIGN AND METHODS: Participants were 155 primary care patients that were recruited through 52 general practitioners: 52 CFS patients; 52 patients with a chronic cardiovascular or auto-immune disease; 51 patients with a minor medical condition. Interpersonal problems were assessed by means of the Inventory of Interpersonal Problems and alexithymia was assessed by means of the Toronto Alexithymia Scale. RESULTS: CFS patients and patients with a chronic cardiovascular or auto-immune disease have substantially higher alexithymia scores than patients with a minor medical condition. Alexithymia is positively related to cold and distant interpersonal functioning; negatively related to self-sacrificing and overly accommodating in relation to others; and positively related to vindictiveness and self-centredness. The relation between alexithymia and these interpersonal problems accounts for the differences in alexithymia scores between the patient groups. CONCLUSIONS: Alexithymia and interpersonal problems should be considered together, in terms of one deficient affect regulatory system, and the relation between alexithymia and specific illness conditions is secondary to this. Clinical assessment of patients with problems in naming and discussing affective states should never be isolated from an examination of their interpersonal problems, and vice versa. Mentalization-based therapy is recommended for patients with problems in naming affective states, interpersonal problems, and concomitant CFS or other alexithymia-related diseases.

Unexplained chronic fatigue and interpersonal problems: a study in a primary care population.

OBJECTIVE: Unexplained fatigue syndromes are multidimensional phenomena that involve a constellation of symptoms. This article explores whether typical interpersonal problems are associated with self-reported and clinically-rated fatigue symptoms in chronically fatigued patients. We hypothesize that the severity of fatigue symptoms will be associated with a pattern of withdrawal from social interaction. METHOD: Interpersonal problems were assessed by means of a self-report questionnaire. Chronic fatigue was assessed with a self-report questionnaire (both self-rated and clinically-rated) in a primary care Chronic Fatigue Syndrome (CFS) group (N = 52) and compared with two other clinical populations (minor medical condition: N = 51; chronic organic disease: N = 52). RESULTS: Compared to patients with a minor medical condition, CFS patients are substantially more fatigued and more socially withdrawn. Compared to patients with a chronic organic disease, somewhat more fatigue-related disability was observed in CFS patients, but no distinct interpersonal problems came to the fore. CFS patients and physicians proved to differ in their opinion on the patient's motivation. In line with the hypothesis, self-rated and clinically-scored fatigue problems proved to be related to a pattern of withdrawal from social interaction. CONCLUSION: Differences between physicians' and patients in how symptoms are interpreted might be related to patients feeling misunderstood and result in social withdrawal.

Alcohol addiction and the attachment system: an empirical study of attachment style, alexithymia, and psychiatric disorders in alcoholic inpatients.

This study aims at investigating alcoholic inpatients' attachment system by combining a measurement of adult attachment style (AAQ, Hazan and Shaver, 1987. Journal of Personality and Social Psychology, 52(3): 511-524) and the degree of alexithymia (BVAQ, Bermond and Vorst, 1998. Bermond-Vorst Alexithymia Questionnaire, Unpublished data). Data were collected from 101 patients (71 men, 30 women) admitted to a psychiatric hospital in Belgium for alcohol use-related problems, between September 2003 and December 2004. To investigate the research question, cluster analyses and regression analyses are performed. We found that it makes sense to distinguish three subgroups of alcoholic inpatients with different degrees of impairment of the attachment system. Our results also reveal a pattern of correspondence between the severity of psychiatric symptoms-personality disorder traits (ADP-IV), anxiety (STAI), and depression (BDI-II-Nl)-and the severity of the attachment system's impairment. Limitations of the study and suggestions for further research are highlighted and implications for diagnosis and treatment are discussed.

The Depressive Experiences Questionnaire as a measure of psychoanalytic constructs reported to be measured.

This study presents an empirical test of Coyne, Thompson, and Whiffen's statement that the Depressive Experiences Questionnaire does not measure the psychoanalytic constructs it is supposed to measure. Convergence was evaluated between the Depressive Experiences Questionnaire's Dependency and Self-criticism scales and clinicians' ratings on hysterical/anaclitic and obsessional/ introjective personality styles in a sex-balanced sample of 56 Flemish outpatients. In line with expectations from Blatt's research paradigm, convergence was observed between the Dependency scale and ratings on hysterical/anaclitic style in the full sample as well as female and male samples separately; convergence between the Self-criticism scale and ratings on obsessional/introjective style was only observed for men. This study yielded no evidence for divergence of the Depressive Experiences Questionnaire and Blatt's psychoanalytic theory. Research is needed to evaluate the sex-specific validity of these subscales.

Unexplained chronic fatigue and core conflictual relationship themes: A study in a chronically fatigued population.

OBJECTIVE: Unexplained fatigue syndromes are multidimensional phenomena that involve a constellation of symptoms. This paper explores whether typical relationship patterns are associated with self-reported and clinically rated fatigue symptoms in chronically fatigued patients. METHOD: Relationship patterns were assessed by means of the core conflictual relationship theme (CCRT) method. This method examines transference patterns, and was applied to interview data collected from chronically fatigued patients (N=30). Chronic fatigue was assessed by means of a self-report questionnaire and was also rated clinically. RESULTS: Both self-reported and clinically rated fatigue correlated with relationship themes. The intensity of fatigue related to the perception of others as not respecting and as negatively interfering. The typical reaction of the self to relationships consists of feeling disrespected, anger, passivity, and reduced feelings of self-consistency. CONCLUSION: Patients' perception of interpersonal relationships as distressing may be pivotal in understanding these results. Implications for clinical intervention and future research are indicated.

The Dula Dangerous Driving Index: an investigation of reliability and validity across cultures.

The aim of this study is to further establish the validity and reliability of the Dula Dangerous Driving Index (DDDI). The reliability and validity of the instrument was investigated by comparing data from a US university sample, a US community sample, and a sample of Belgian traffic offenders. Exploratory and confirmatory factor analysis supported the presence of a four-factor structure with items for Drunk Driving forming a separate scale apart from items for Risky Driving, Negative Cognitive/Emotional Driving and Aggressive Driving. A multi-group confirmatory factor analysis with model constraints supported the validity of the DDDI. Inter-correlations revealed that the DDDI subscales are closely interrelated and uni-dimensionality of the measure was found in all three samples. This suggests the DDDI Total score can be used as a composite measure for dangerous driving. However, the validity of the subscales was demonstrated in the Belgian sample, as specific traffic offender groups (convicted for drunk driving, aggressive driving, speeding) scored higher on corresponding scales (Drunk Driving, Aggressive Driving, and Risky Driving, respectively), indicating that it is clinically meaningful to differentiate the subscales.

Actual neurosis as the underlying psychic structure of panic disorder, somatization, and somatoform disorder: an integration of Freudian and attachment perspectives.

Starting from a contemporary critique of the DSM-IV, this paper argues that the diagnostic categories of panic disorder somatization, and undifferentiated somatoform disorders can be understood as belonging to a common type of psychopathology--i.e., the Freudian actual neuroses. In addition to their strong clinical similarity, these disorders share an etiological similarity; and the authors propose a combination of Freud's focus on this type of patient's inability to represent an endogenous drive arousal with the post-Freudian focus on separation anxiety. An etiological hypothesis is put forward based on contemporary psychoanalytic attachment theory, highlighting mentalization. Concrete implications for a psychoanalytically based treatment are proposed.

Relationship patterns in alexithymia: a study using the core conflictual relationship theme method.

BACKGROUND: Alexithymia is a disturbance in regulating affective states. Clinical observations suggest that alexithymic patients relate to others in a specific way. This paper explores whether specific relationship or transference patterns are typical of alexithymia. SAMPLING AND METHODS: Relationship patterns were assessed by means of the Core Conflictual Relationship Theme method, standard categories version. This method examines transference patterns and was applied to clinical interview data collected from a sample (n = 31) of mental health outpatients. Alexithymia was assessed by means of a score on the 20-item Toronto Alexithymia Scale corrected for the degree of depression (measured by the Beck Depression Inventory-II). Data were analysed by means of the leaps and bounds regression algorithm for selecting optimal subsets of indicators and by bootstrapping to determine 95% confidence intervals. RESULTS: First, we observed that alexithymia can be meaningfully explained by typical wishes, typical subjective perceptions of how others respond and one's own typical responses to others. This result indicates that the more marked a patient's alexithymic traits are, the more probable it is that specific transference themes come to the fore. Second, a set of three core indicators of trait alexithymia was mapped: little concern about being good to others, a strong perception of others as cooperative, and weak levels of reacting to others and to conflict by means of somatic symptoms. CONCLUSION: Alexithymia is related to a double interpersonal indifference: not much is expected from others, nor is there a personal urge to fulfill the expectations of others. Moreover, in alexithymia somatic symptoms proved to be non-reactive to interpersonal situations. Implications for diagnosis and treatment are highlighted. Limitations of our study are that alexithymia was only assessed with a self-report measure and that conclusions are based only upon data from a heterogeneous mental health sample.

The Depressive Experiences Questionnaire: on using a student-based scoring program for a clinical sample.

In both clinical and nonclinical samples, the Depressive Experiences Questionnaire is scored with a program that computes factor scores by using means, standard deviations, and item-loadings of a student sample. The underlying assumption of the use of this program in clinical samples is that factor scores computed on the basis of the student factor solution are similar to factor scores computed on the basis of a clinical factor solution. Consequently, both series of scores should lead up to the same conclusions when studying associations with theoretically related variables. This assumption has not been tested although the questionnaire has been used in research for almost 30 years. In the present paper an alternative scoring program was constructed, based on the factor solution of a clinical sample (N = 400) to assess whether scores of this clinical scoring program are associated in the same way with different types of depressive symptoms and interpersonal problems as the scores of the original (student-based) program. Analysis gave results inconsistent with the assumption and did not support the use of the student-based scoring program in the clinical sample. Further, results suggest that standards for assessing factorial similarity used in confirmatory factor analysis might be too lenient.