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Name _______________________ Major Depressive Disorder: Janet Adapted from Case Studies in Abnormal Psychology by Olrmanns, Neale and Davison. Janet called the mental health center to ask if someone could help her year-old son, Adam. He had been having trouble sleeping for the past several weeks, and Janet was becoming concerned about his health. Adam refused to go to sleep at his regular bedtime and also woke up at irregular intervals throughout the night. Whenever he woke up, Adam would come downstairs to be with Janet. Her initial reaction had been sympathetic; she would give him some water, talk to him, and rock him back to sleep. As the cycle came to repeat itself night after night, Janet's tolerance grew thin and she became more argumentative. She found herself engaged in repeated battles that usually ended when she agreed to let him sleep in her room. Janet felt guilt about giving in to a 5-year-old's demands, but it seemed like the only way they would ever get any sleep. The family physician was unable to identify a physical explanation for Adam's problem; he suggested that Janet contact a psychologist. The therapist began by asking several questions about Janet and her family. Janet was 30 years old and had been divorced from her husband, David, for a little more than one year. Adam was the youngest of Janet's three children; Jennifer was 10 and Claire was 8. Janet had resumed her college education on a part-time basis when Adam was 2 years old. She had hoped to finish her bachelor's degree at the end of the next semester and enter law school in the fall. Unfortunately, she had withdrawn from classes about a month ago. Her current plans were indefinite. She spent almost all of her time at home with Adam. Janet and the children lived in a large, comfortable house that she had received as part of her divorce settlement. Finances were a major concern to Janet, but she managed to make ends meet through the combination of student loans, a grant-in-aid from the university, and child-support payments from David. David lived in a nearby town with a younger woman whom he had married shortly after the divorce. He visited Janet and the children once or twice every month and took the children to spend weekends with him once a month. Having collected the necessary background information, the therapist asked for a description of the circumstances surrounding the development of Adam's sleep difficulties and the factors that currently affected the problem. This discussion covered the sequence of a typical evening's events, beginning with dinner and progressing through the following morning. It was clear during this discussion that Janet felt completely overwhelmed by the situation. She was exasperated and felt that she was completely unable to control her son. At several points during the interview, Janet seemed to be on the verge tears. Her eyes were watery, and her voice broke as they discussed her response to David's occasional visits. The therapist, therefore, suggested that they put off a further analysis of Adam's problems and spend some time discussing Janet's situation in a broader perspective. In the subsequent conversation it became clear that Janet's mood had been depressed since her husband had asked for a divorce. She felt sad, discouraged, and lonely. This feeling seemed to become even more severe just prior to her withdrawal from classes
at the university (one year after David's departure and two months before her first clinic appointment). When David left, she remembered feeling "down in the dumps," but she could usually cheer herself up by playing with the children or going for a walk. Now she was nearing desperation. She cried frequently and for long periods of time. Nothing seemed to cheer her up. She had lost interest in her friends, and the children seemed to be more of a burden than ever. Her depression was somewhat worse in the morning, when it seemed that she would never be able to make it through the day. Janet was preoccupied by her divorce from David and admitted that she spent hours each day brooding about the events that led to their separation. These worries interfered considerably with her ability to concentrate and seemed directly related to her withdrawal from the university. She had found that she was totally unable to study the assigned reading or concentrate on a 45-minute lecture. Withdrawing from school had precipitated further problems. She was no longer eligible for student aid and would have to begin paying back her loans within a few months. In short, one worry led to another, and her attitude became increasingly pessimistic. Janet blamed herself for the divorce, although she also harbored considerable resentment toward David and his new wife. Among other things, she believed that her return to school had placed additional strain on an already problematic relationship. She wondered whether she had acted selfishly. The therapist noted that Janet's reasoning about her marriage often seemed vague and illogical. She argued that she had been a poor marital partner and cited several examples of her own misconduct. These included events and circumstances that struck the therapist as being very common and perhaps expected differences between men and women. She spent more money than he did on clothes, did not share his enthusiasm for sports, and frequently tried to engage David in discussions about his personal habits that annoyed her and the imperfections of their relationship. Of course, one could easily argue that David had not been sufficiently concerned about his own appearance (spending too little effort on his own wardrobe), that he had been too preoccupied with sports, and that he had avoided her sincere efforts to work on their marital difficulties. But Janet blamed herself. Rather than viewing these things as simple differences in their interests and personalities, Janet saw them as evidence of her own failures. She blew these matters totally out of proportion until they appeared to her to be terrible sins. Janet also generalized from her marriage to other relationships in her life. If her first marriage had failed, how could she ever expect to develop a satisfactory relationship with another man? Furthermore, Janet had begun to question her value as a friend and parent. The collapse of her marriage seemed to affect the manner in which she viewed all of her social relationships. The future looked bleak from her current perspective, but she had not given up all hope. Her interest in solving Adam's problem, for example, was an encouraging sign. Although she was not optimistic about the chances of success, she was willing to try to develop new skills that would help her become a more effective parent. Social History Janet's early childhood had been uneventful. Not having any siblings, she spent most of her time with adults, particularly her mother. She remembered her parents'
sudden exit. Whatever her motivation might have been, her marriage was followed shortly by her first pregnancy, which precipitated her withdrawal from the university during her sophomore year. For the next seven years, Janet was occupied as a full- time mother and housekeeper. When Adam was two years old and able to attend a day-care center, Janet decided to resume her college education. She and David had discussed her desire to complete her degree and pursue a profession on several occasions. He was less than excited about this prospect and preferred that Janet continue in her present role. She disagreed but admitted that the children were too young and they could not afford both tuition and day care. Now that Adam was older, the circumstances were finally in Janet's favor, and David agreed to take a more active role in various responsibilities that had previously been assumed by Janet alone. Adam was enrolled at a daycare center on a half-time basis, and Janet began taking two courses each semester. Following Janet's return to school, her relationship with David became increasingly strained. They had even less time than usual to spend with each other. David resented his increased household responsibilities. Janet was no longer able to prepare meals for the family every night of the week, so David had to learn to cook. He also had to share the cleaning and drive the children to many of their lessons and social activities. A more balanced and stable relationship would have been able to withstand the stress associated with these changes, but Janet and David were unable to adjust. Instead of working to improve their communications, they bickered continuously. They found it impossible to negotiate a mutually acceptable exchange of responsibilities. The final blow came when David met another woman to whom he was attracted and who offered him an alternative to the escalating hostility with Janet. He asked for a divorce and moved to an apartment. Janet was shaken by David's departure, in spite of the fact that they had not been happy together. Fortunately, she did have a few friends to whom she could turn for support. The most important one was a neighbor who had children of approximately the same ages as Janet's daughters. There were also two couples with whom she and David had socialized. They were all helpful for the first few weeks, but she quickly lost contact with the couples. It was awkward to get together as a threesome, and Janet had never been close enough with the women to preserve their relationships on an individual basis. That left the neighbor, Susan, as her sole adviser and confidante. Susan was the only person with whom Janet felt she could discuss her feelings openly. They spent hours talking about the recent events in Janet's life and her plans for the coming months. For the next few months, Janet was able to continue her studies. With the children's help she managed the household chores and kept up with her work. She even found time for some brief social activities. She agreed to go out on two blind dates arranged by people with whom she and David had been friends. These were generally unpleasant encounters; one of her dates was boring and unattractive, and the other was obnoxiously aggressive. After the latter experience, she discontinued the minimal efforts she had made to develop new friendships. The process seemed too difficult and threatening. Janet referred to single-parent clubs as "meat markets" where people paired off for casual sexual encounters. She might have become acquainted with other
people in her classes at the university, but she was uncomfortable initiating conversations with her classmates. As time wore on, Janet found herself brooding more and more about the divorce. She was gaining weight at the rate of three or four pounds a month. The first few pounds had been easy to ignore and were more a nuisance than anything else. But soon her clothes no longer fit, and the children began to comment on her appearance. To make matters worse, Claire developed a serious ear infection just prior to Janet's midterm exams. The added worry of Claire's health and her concern about missed classes and lost studying time contributed substantially to a decline in Janet's mood. She finally realized that she would have to withdraw from her classes to avoid receiving failing grades. By this point, one month prior to her appointment at the mental health center, she had lost interest in most of her previous activities. Even casual reading had come to be a tedious chore. She did not have any hobbies because she never had enough time. She also found that her friend Susan was becoming markedly aloof. When Janet called, Susan seldom talked for more than a few minutes before finding an excuse to hang up. Their contacts gradually diminished to an occasional wave across the street or a quick, polite conversation when they picked up their children from school. It seemed that Susan had grown tired of Janet's company. This was Janet's situation when she contacted the mental health center. Her mood was depressed and anxious. She was preoccupied with financial concerns and her lack of social relationships. Adam's sleeping problem, which had begun about one week after she withdrew from her classes, was the last straw. She felt that she could no longer control her difficult situation and recognized that she needed help.
She learned of the opening when she called to ask about the campus riding club. They were looking for someone who would feed and exercise the horses every morning. The wages were low, but she was allowed to ride as long as she wanted each day without charge. Furthermore, the schedule allowed her to finish before the girls returned from school. The money also helped her return Adam to the day-care center on a part-time basis. Janet still felt depressed when she was at home, but she loved to ride and it helped to know that she would go to work in the morning. An unfortunate sequence of events led to a serious setback shortly after it seemed that Janet's mood was beginning to improve. Her financial aid had been discontinued, and she could no longer cover her monthly mortgage payments. Within several weeks, she received a notice from the bank threatening to foreclose her mortgage and sell her house. Her appearance was noticeably changed when she arrived for her next appointment. She was apathetic and lethargic. She cried through most of the session, and her outlook had grown distinctly more pessimistic. The therapist was particularly alarmed by an incident that Janet described as happening the previous day. She had been filling her car with gas when a mechanic at the service station mentioned that her muffler sounded like it was cracked. He told her that she should get it fixed right away because of the dangerous exhaust fumes. In his words, "that's a good way to kill yourself." The thought of suicide had not occurred to Janet prior to this comment, but she found that she could not get it out of her mind. She was frightened by the idea and tried to distract herself by watching television. The thoughts continued to intrude despite these efforts. The therapist immediately discussed several changes in the treatment plan with Janet. He arranged for her to consult a psychiatrist, who prescribed fluoxetine (Prozac), an antidepressant drug. She also agreed to increase the frequency of her appointments at the clinic to three times a week. These changes were primarily motivated by the onset of suicidal ideation. More drastic action, such as hospitalization or calling relatives for additional support, did not seem to be necessary because her thoughts were not particularly lethal. For example, she said that she did not want to die, even though she was thinking quite a lot about death. The idea frightened her, and she did not have a specific plan arranged by which she would accomplish her own death. Nevertheless, the obvious deterioration in her condition warranted a more intense treatment program. The next month proved to be a difficult one for Janet, but she was able to persevere. Three weeks after she began taking the medication, her mood seemed to brighten. The suicidal ideation disappeared, she became more talkative, and she resumed most of her normal activities. The people who owned the riding stable were understanding and held Janet's new job for her until she was able to return. The financial crisis was solved, at least temporarily, when her father agreed to provide her with substantial assistance. In fact, he expressed surprise and some dismay that she had never asked him for help in the past or even told him that she was in financial trouble. The problem-solving and social skills program progressed well after Janet began taking medication. Within several weeks, she was able to reestablish her friendship with Susan. She was able to meet a few people at the riding stable, and her social network seemed to be widening.
After Janet's mood had improved, the issue of Adam's sleeping problem was addressed. The therapist explained that Janet needed to set firm limits on Adam's manipulative behavior. Her inconsistency in dealing with his demands, coupled with the attention that he received during the bedtime scene, could be thought of as leading to intermittent reinforcement of his inappropriate behavior. Janet and the therapist worked out a simple set of responses that she would follow whenever he got up and came downstairs. She would offer him a drink, take him back to his room, tuck him in bed, and leave immediately. Ten days after the procedure was implemented, Adam began sleeping through the night without interruption. This rapid success enhanced Janet's sense of control over her situation. Her enthusiasm led her to enroll in the parent-training program for which she had originally applied. She continued to improve her relationship with her children. Janet's individual therapy sessions were discontinued nine months after her first appointment. At that point, she was planning to return to school, was still working part-time at the riding stable, and had started to date one of the men she met at work. Her children were all healthy, and she had managed to keep their house. The antidepressant medication was discontinued one year after it was initiated.
study and her loss of interest in almost everything. Excessive and inappropriate guilt was clearly a prominent feature of her constant brooding about the divorce. Although she did not actually attempt to harm herself, she experienced a distressing period of ruminative suicidal ideation. Sleep impairment may also have been a problem, but it was difficult to evaluate in the context of Adam's behavior. Prior to her first visit at the clinic, Janet had been sleeping less than her usual number of hours per night, and she reported considerable fatigue. It was difficult to know whether she would have been able to sleep if Adam had not been so demanding of her attention throughout the night. Etiological Considerations Several psychological models have been proposed to account for the development of major depression. Each model focuses on somewhat different features of depressive disorders (e.g., interpersonal relations, inactivity, or self-deprecating thoughts), but most share an interest in the role of negative or stressful events in the precipitation of major depression. Freud's explanation for the development of depression began with a comparison between depression and bereavement. The two conditions are similar. Both involve a dejected mood, a loss of interest in the outside world, and an inhibition of activity. One principal feature distinguishes between the person who is depressed and the person who is mourning: a disturbance of self-regard. Depressed people chastise themselves, saying that they are worthless, morally depraved, and worthy of punishment. Freud noted the disparity between such extreme negative views and the more benign opinions of other people who do not hold the depressed person in such contempt. In other words, the depressed person's view does not seem to be an accurate self-perception. Freud went on to argue that depressed people are not really complaining about themselves but are, in fact, expressing hostile feelings that pertain to someone else. Depression is therefore the manifestation of a process in which anger is turned inward and directed against the self instead of against its original object. Why would some people direct hostility against themselves? Freud argued that the foundation for this problem is laid in early childhood. For various reasons, people who are prone to depression have formed dependent interpersonal relationships. This dependency fosters frustration and hostility. Because these negative feelings might threaten the relationship if they are expressed openly, they are denied awareness. Problems then arise when the relationship is ended, for whatever reason. The depressed person's ego presumably identifies with the lost loved one. The intense hostility that had been felt for that person is now turned against the self, or introjected. Following this model, treatment would consist of an attempt to make the client aware of these unconscious, hostile impulses. Their more direct expression would presumably eliminate the depression. At least one aspect of this model seems consistent with Janet's situation. She had, in fact, formed a series of intense, dependent relationships with men, beginning in high school. One might argue that her depression was precipitated by the loss incurred during her separation and divorce from David. She resented the separation deeply. Her guilt might be seen as a criticism of David's behavior. Other aspects of Janet's behavior, however, are inconsistent with Freud's model. Although Janet was critical
of herself, she was also quite vocal in David's presence. They fought openly several times, both before and after the divorce, and he was fully aware of Janet's anger and resentment. It therefore seems unlikely that Janet's depression was a simple manifestation of misdirected hostility. It is also unlikely that her depression would be relieved by simply encouraging her to express her feelings more openly. More recent attempts to explain the development of depression in psychological terms have borrowed and extended various aspects of Freud's psychoanalytic model. One important consideration involves his observation that the onset of depression is often preceded by a dependent personality style and then precipitated by the loss of an important relationship. Personality factors and relational distress may help to explain the fact that women are twice as likely as men to develop major depression. Dependent people base their self-esteem on acceptance and approval by others. Some authors have suggested that, throughout their social development, women are frequently taught to think this way about themselves (Gilligan, 1982). An extension of this hypothesis holds that women are more likely than men to define themselves in terms of their relationships with other people. Women would then presumably be more distressed by marital difficulties and divorce. In Janet's case, the loss of her relationship with David was certainly an important consideration in the onset of her depression. Her sense of self-worth was severely threatened by the divorce, in spite of the fact that her marriage had been far from ideal. Stressful life events undoubtedly play a causal role in the etiology of depression. One classic study has received considerable attention because it led to the development of a model that begins to explain the relationship between environmental conditions and the onset of depression. Brown and Harris (1978) found an increased incidence of stressful events in the lives of depressed women, but only with regard to a particular subset of such events - those that were severe and involved long-term consequences for the woman's well-being. Divorce and marital separation were prominent among these events, which also included events such as illness, loss of a job, and many other types of personal adversity. Brown and Harris referred to these events as "provoking agents." They also found other events or social circumstances that they called "vulnerability factors." These were not capable of precipitating depression on their own, but they did lead to a substantial increase in risk given the experience of a stressful life event. The vulnerability factors were (1) lack of an intimate, confiding relationship (generally with a spouse or boyfriend); (2) presence in the home of three or more children under the age of 14; (3) lack of full-or part-time employment; and (4) loss of the woman's mother before the age of 11. Consider, for example, the intimacy factor. The social support afforded by such a relationship is a powerful mediator between stress and the onset of depression, even if the absence of intimacy does not provoke depression by itself. Subsequent investigations have extended these findings and identified additional factors that help to explain the relation between stressful life events and depression. The impact of a stressful event apparently depends on the meaning that the event has for the person. Severe events that occur in the context of ongoing difficulties (such as a chronically distressed marriage) and events that occur in areas of a woman's life to which she is particularly committed (such as a child's health or the development of a career) are most likely to lead to the onset of depression.
friends, she seemed lost. The few attempts that she had made, such as her blind dates, had gone badly, and she did not know where else to begin. Several studies have demonstrated that depressed people do indeed have a negative impact on other people's moods and nonverbal behavior (Hammen, 1997). Their social networks are smaller and less supportive than those of people who are not depressed. They know fewer people, interact with them less often, and consider them to be less supportive. Family interactions are generally more negative and argumentative for people who are clinically depressed. Perhaps most important, these maladaptive patterns of interpersonal relationships are not uniquely associated with episodes of major depression. The problems persist into periods of symptomatic remission. These results are consistent with the hypothesis that depressed people may, perhaps unintentionally, turn away sources of social support that could otherwise help them cope with stressful events. This kind of phenomenon seemed to be operating in Janet's relationship with Susan. Another consideration in social learning views of depression involves the way in which people respond to the onset of a depressed mood. Some people try to distract themselves from negative emotions by becoming involved in some activity. Others respond in a more passive fashion and tend to ruminate about the sources of their distress. Nolen-Hoeksema (1990) proposed that people who respond in a passive, ruminative way will experience longer and more severe periods of depression. She also suggested that this factor may account for gender differences in the prevalence of depression because women are more likely than men to employ this response style. Janet's behavior following her divorce fits nicely with Nolen-Hoeksema's conceptual framework. Although Janet initially tried to cope actively with her various problems, she soon relinquished most of her efforts to find new friends or to keep up with her studies. She frequently found herself brooding about the divorce and the hopeless nature of her circumstances. Her therapist encouraged Janet to engage more frequently in pleasant activities in an effort to break this cycle of passive, ruminative behavior. In addition to the social and behavioral aspects of depression, it is also important to consider the way in which depressed people perceive or interpret events in their environment. Beck (1987) has proposed that certain negative cognitive patterns play a prominent role in people who are prone to the development of depression. The way in which depressed people process information about themselves and their environment is presumably distorted by the activation of self-defeating schemas that prevent the recognition or assimilation of positive events. The hopelessness theory of depression presents a similar view (Abramson, 1989). According to this theory, the perceived occurrence of negative life events may lead to the development of hopelessness, which in turn causes the onset of symptoms of depression. Two cognitive elements define the state of hopelessness: (1) the expectation that highly desired outcomes will not occur or that highly aversive outcomes will occur, and (2) the belief that the person cannot do anything (is helpless) to change the likelihood that these events will occur. The crucial link in this causal chain occurs between the perception of negative life events and the appearance of hopelessness. Why do some people become hopeless
after such experiences while others do not? The theory holds that the likelihood of developing hopelessness will depend on the person's inferences regarding three factors: the cause of the event, the consequences of the event, and the implications of the event with regard to the self. For example, hopeless depression is likely to occur if the person views a negative event as being important and also attributes the event to factors that are enduring (stable) and likely to affect many outcomes (global). The theory also recognizes that the perceived consequences of the negative event may be as important as inferred causes. If the person views the negative consequences of the event as important, persistent, and wide-ranging, depression will be more likely to develop than if the consequences are viewed as unimportant, short-lived, or limited in scope. The third and final consideration involves negative inferences about the self. Depression is a more likely outcome if the person interprets a negative event to mean that she or he is a less able, worthy, or desirable person. Depressed people do express an inordinately high proportion of negative self- statements. Janet's verbal behavior provided several clear examples of the negative schemas that Beck has described, and her interpretation of the events leading up to and surrounding her divorce fit nicely with the hopelessness theory. She believed that the disintegration of her marriage was her own fault rather than David's; she argued that her failure in that relationship was characteristic of her interactions with all other men rather than specific to one person; and she maintained that she would never be able to change this pattern of behavior. No one doubts that depressed people express negative thoughts. The difficult question, and one that is currently a matter of considerable controversy, is whether cognitive events play a central, formative role in the development of depression. Are they antecedents or consequences of emotional changes? Cognitive theorists have reported a considerable amount of empirical evidence in support of their position (e.g., Peterson & Seligman, 1984). On the other hand, critics have pointed to a number of problems with studies purporting to implicate cognitive events in the etiology of depression. Longitudinal analyses have indicated that dysfunctional attitudes and tendencies toward cognitive distortion do not precede the onset of depression but seem to appear and recede in synchrony with dysphoric mood states (Lewinsohn, Hoberman, & Rosenbaum, 1988).
cognitive and interpersonal therapy with antidepressant medication over 16 weeks of treatment ( Elkin , 1994; Shea & Elkin, 1996). Unipolar depressed outpatients were randomly assigned to one of four treatment groups: interpersonal therapy, cognitive therapy, medication (a tricyclic antidepressant), or placebo plus "clinical management" (extensive support and encouragement). The results of this study were generally quite positive over the short run. All three types of active treatment were superior to the placebo plus clinical management condition in terms of their ability to reduce depression and improve overall levels of functioning. Patients improved somewhat more rapidly if they were receiving medication, but the rate of improvement in both psychotherapy groups caught up to the drug condition by the end of treatment. Cognitive and interpersonal therapy were equivalent to antidepressant medication in terms of their ability to treat less severely disturbed patients. People who were more severely depressed responded best to medication. Furthermore, within the severely depressed patients, interpersonal therapy was more effective than cognitive therapy (Klein & Ross, 1993). Follow-up evaluations conducted 18 months after the completion of treatment were less encouraging than the original outcome data, however. By that point, patients in the three active treatment groups were no longer functioning at a higher level than those who received only the placebo and clinical management. Less than 30 percent of the patients who were considered markedly improved at the end of treatment were still non-depressed at follow-up. This aspect of the study's results points to the need for continued efforts to improve currently available treatment methods. Several years after the initial treatment program was conducted, results from the TDCRP are still being debated, particularly as they apply to the value of cognitive-behavior therapy in the treatment of depression.
