Diagnosis of Depression - Essay Example

Diagnosis of Depression Introduction I recently read an article in Huffington Post that discussed how several celebrities like Nicole Kidman became victims of depression after their divorce, and had to struggle hard to get over it to continue excelling in their carriers; “In spite of all their fame and fortune, celebrities struggle in the wake of a break up just like the rest of us do” (Borresen, 2012). It came as a surprise to me because I thought celebrities lived too fanciful a life to suffer from depression since breakups in relationships don’t matter as much to them as they do to common people since there are always so many hands available to knock at the doors of their hearts. But as I pondered over the matter, I realized that celebrities are also human beings like us and are affected by things despite all sorts of distractions that exist in their lives. This spurred a desire in me to write about depression. It was a big challenge for me because I was always afraid of talking to people in depression because I thought their condition could affect my own psyche in a bad way, so this project was no less than a challenge to me in which I had to remain composed while listening to the sad stories and seeing their mental scars getting unveiled. I was aware that I might have to modify the classical psychoanalytic techniques in order to retrieve optimal amount of information from the interviewees. My essay commences with a brief discussion of some of the main psychoanalytic and psychiatric theories of depression, and then applies these concepts to a clinical example. The paper further discusses the psychoanalytical strategies to deal with the patients of depression. Etiology of Depression There are numerous causes of depression some of which are discussed as follows: Genetics Despite lack of a definitive cause of depression, one of the etiologies of depression is genetics. Depression in some cases is inherited since it is seen in more than one members of the same family. A worldwide chromosomal research is being conducted to find more objective evidence of relationship between genetics and depression. Biochemical Causes Certain chemicals called neurotransmitters occur in the brain naturally. High-tech imaging of brain shows that physical changes in neurotransmitters causes depression in people, though certain factors like weight loss and lack of sleep might also be the causes of depression. Although it is not a main cause, yet depleted monoamine levels are commonly observed in the chronically depressed patients. Hormonal imbalances also cause depression. Likewise, there are some medicines that have an adverse impact on mood and need proper monitoring, else they can cause depression. Environmental Factors The environment is also a possible causal factor of depression. In everyday life, people are exposed to numerous stressful situations that include but are not limited to loss of job, divorce, death of a friend or a family member, financial problems, and diseases. In addition to these factors, several unfortunate or traumatic events experienced in the past like child sexual abuse, violence, and bullying and any kind of maltreatment may affect the emotional and psychological health in a negative way. Diagnostic Criteria for Depression Before getting into the details of psychoanalytic theories of depression, it is customary to discuss the psychiatric criteria of diagnosis of depression as outlined by DSM-IV. According to DSM-IV, the patient needs to have at least five symptoms from the list of nine symptoms given below sustained over a period of two weeks and the symptoms bring a transition from the previous functioning where at least one symptom is loss of pleasure or interest, or depressed mood (American Psychiatric Association, 2000). The list containing some of the nine symptoms mentioned by DSM-IV is as follows: 1. Depressed mood for a major part of the day on daily basis indicated either by others or by feelings of sadness. 2. Experiencing hypersomnia or insomnia almost daily 3. Experiencing fatigue almost daily 4. Feelings of guilt or worthlessness almost daily 5. A change of over 5 per cent in the total weight of the body in one month either through overweight or underweight without dieting, or change in appetite almost daily 6. Loss of pleasure or interest in almost every activity that makes part of the daily life almost every day Diagnosis of depression in two individuals may be based on no more than just one common symptom since DSM-IV necessitates the presence of only five of the nine symptoms it lists for an individual to be diagnosed with depression. This speaks of the width of terrain covered by depression and the presence of a variety of symptoms for the same psychological condition in different people. Psychoanalytic Theories of Depression Since the psychiatric definition of depression focuses upon poor self-esteem and poor interpersonal relationships, there is little surprise in the attempt of the psychoanalysts to engage with depression; ideas about the relationship of self to the objects are the focus of the psychoanalytic thinking. Nevertheless, psychoanalysis emphasizes upon the role of childhood experiences of the patients of depression more than psychiatry as it considers past experiences a guiding force behind the present behavior. Attachment theory has been jointly proposed by Mary Ainsworth and John Bowlby. John Bowlby proposed the fundamental theoretical tenets drawing on the concepts from information processing, cybernetics, psychoanalysts, etiology, and developmental psychology. John Bowlby brought a revolution in the thinking regarding the bond between a child and a mother as well as its disruption by means of bereavement, separation, and deprivation. The innovative methodology proposed by Mary Ainsworth enabled the test of John Bowlby’s ideas empirically and also played a role in the expansion of the theory. Mary Ainsworth projected the attachment figure’s concept as a secure base using which an infant may study the world. The ideas that now control the attachment theory contain a long history of development. In spite of their independent working during their initial careers, both John Bowlby and Mary Ainsworth were greatly influenced by psychoanalytic thinkers like Freud; in Mary Ainsworth’s case, indirectly whereas in John Bowlby’s case, directly. John Bowlby got training at the British Psychoanalytic Institute along with his studies in psychiatry and medicine. At that time, there were three groups in the institute, one of which sided with Klein, the other sided with Freud, whereas the third one sided with neither of the two. Melanie Klein was a main influence for John Bowlby since he was exposed to her ideas through Joan Riviere who was the training analyst. “Although he acknowledges Riviere and Klein for grounding him in the object-relations approach to psychoanalysis, with its emphasis on early relationships and the pathogenic potential of loss…he had grave reservations about aspects of the Kleinian approach to child psychoanalysis” (Bretherton, 1992). Melanie Klein holds a strategic position in the history of psychoanalysis as well as in the formation of the psychoanalytic theory. Melanie Kein has played the role of a dialectical fulcrum between the object relations theories and the drive (Kavaler-Adler, 1993). Melanie Klein has a personal history as a patient of depression which allowed her a more objective insight into its various aspects. Born as the youngest and fourth child to her parents on 30 March, 1882 (Segal, 1979), Melanie was greatly inspired by her father and was much attached to her elder sister who used to help her with her studies. Melanie’s depression started with the death of her sister when she was only five years old. Melanie Klein decided to pursue her career in medicine at the age of 14 years. At that time, she was close to her brother and met Arthur Stephen Klein, her future husband through her brother. Arthur and Melanie got engaged when she was 19 years old which came in the way of her plans of studying medicine. Around then, her brother died, thus contributing to a long-lasting streak of depression that made an integral part of Melanie’s personality. Melanie got married to Arthur at the age of 21 years and moved to different towns. Melanie remained very unhappy till the time she had her two children. According to Melanie Klein, the emotional problems in children can entirely be attributed to the fantasies that yield from the conflicts between the libidinal and aggressive drives instead of events that happen in the external world. Melanie Klein forbade John Bowlby to a 3-year-old child’s mother that he was analyzing. John Bowlby was an English psychologist in the mid 20th century and is popular for having named the motherly love scientifically. John Bowlby referred to his premises as the Attachment Thoery. The main thesis of John Bowlby is that “the success of all relationships or “attachments” in life is dependent of the success of the first one, namely, of the bond between the infant or small child and his mother or primary caregiver” (Bordie, 2012). It came as an anathema to John Bowlby who believed in the importance of actual family experiences in the development of emotional disturbance. John Bowlby refuted the ideas of Melanie Klein in a theoretical paper he wrote in the year 1940 wherein he proposed that psychoanalysts need to explore the organisms’ nature, soil properties, and their interaction. According to John Bowlby, for the mothers who experience difficulties in parenting, “a weekly interview in which their problems are approached analytically and traced back to childhood has sometimes been remarkably effective. Having once been helped to recognize and recapture the feelings which she herself had as a child and to find that they are accepted tolerantly and understandingly, a mother will become increasingly sympathetic and tolerant toward the same things in her child” (Bowlby, 1940, p. 23). This shows John Bowlby’s early clinical and theoretical interest in the attachment relations’ intergenerational transmission as well as in the tendency to assist parents to help the children. The object-relations theories of psychoanalysis subsequently proposed by Fairbain in the year 1952 and Winnicott in the year 1965 were affable to the theory of John Bowlby, though he had developed his thinking independently. After Freud focused upon other areas, his colleague and close friend Karl Abraham resolved to carry out further investigation in child sexual trauma. In his two initial articles about the sexual molestation of children, Abraham asserted that the psychotic and neurotic patients commonly experienced sexual abuse as a consequence of a repetition compulsion’s conceptual precursor related to trauma, which is termed as traumatophilic diathesis. Abraham and Freud corresponded with each other, and Freud offered criticism on several areas covered in the topics of sexual trauma in Abraham’s papers, though Freud did endorse Abraham’s writings on sexual trauma publicly. “For largely transferential reasons...Abraham did not encourage dialogue regarding persistent questions on the seduction issue, ceased publishing on that topic, and for some time controlled his apparently deep rankle over Freud's criticisms and failure to acknowledge Abraham's contribution to the concept of the repetition compulsion” (Good, 1995). Abraham’s death after conflicts with Freud had an inhibiting impact on the seduction theory’s earlier reconsideration by the theorists. The concept of traumatophilia given by Abraham that was previously unheralded is related to the contemporary clinical controversy about sexual trauma and constitution. The general picture of melancholia and mourning justifies the correlation between the two. “I look at the way Freud made use of this seemingly focal exploration of these two psychological states [mourning and melancholia] as a vehicle for introducing – as much implicitly as explicitly – the foundation of his theory of internal object relations” (Person, 2009, p. 3). The environmental influences that serve as the exciting causes are the same for both melancholia and mourning. Mourning is defined as the reaction shown upon the loss of a beloved individual, or some abstraction’s loss that has taken one’s place like an ideal or a country etcetera. Some people experience melancholia rather than mourning because of the same influences and so they can be suspected of a pathological disposition. Mourning encapsulates departures from an individual’s normal behavior towards life but it never happens in such a way that medical treatment can be taken for it. A vast majority of people tend to give it time to recede thinking that any intervention could be harmful and useless. Reflective Critique After conducting a thorough review of the psychoanalytical theories above, now I would like to share my thoughts on them. The field of psychopathology in a way confuses me because of the comforting structure it provides. I had assumed that the truths encapsulated by the psychoanalytic pathologising are universal and can be generalized for all situations related to a particular condition, which reflects my psychodynamic bias. It is an established fact that the nuances of individual experience are captured by no psychoanalytical theory because the personality is abstract and the range of psychoanalytical theories related to depression and that explain its various aspects is very vast, thus making it impossible to devise a diagnostic model that can be applied in all cases. A Psychoanalytical Sketch of Depression: Case Study An objective and in-depth theoretical knowledge is compulsory while working with the patients of depression because the doctors and professionals need to know the strategies using which they can diagnose a patient with different kinds of psychological disorders like depression. This is a case study of a patient of depression named Antonio taken from the book The Mystery of Things by Bollas (1999). Antonio had left the job of an engineer with a construction company, but left it without an objective reason. Bollas (1999) describes how she noticed Antonio when he shared his experiences with her. Randomly, Antonio would suddenly become quiet and the interviewer had to reiterate what he had been saying to make him resume the conversation from where he had ended it. Antonio’s narrative suggested the interviewer that he was self-conscious and thought that people thought bad of him. Antonio considered himself mutant, and he related this self-identification to an incident that happened in his childhood when his mother resolved against the suggestion of his father and sibling to go to museum rather than the park because it had started raining. “Antonio broke off relationships in order to pass on to the other a part of the mother’s dead soul, a picture-fetish of the dead mother that becomes the love object” (Bollas, 1999, p. 118). An in-depth analysis of Antonio’s case suggests that John Bowlby’s attachment theory is justified since all relations in Antonio’s life are affected because of his relationship with his mother in his early childhood. From the case studies touched upon in this paper including that of Melanie Klein and Antonio, it becomes obvious that the unfortunate and traumatic experiences of the childhood play a decisive role in determining an individual’s susceptibility to depression in the adolescence and at later points in time. Experiences of the childhood leave a bad mark on the individual’s psychology that stays with the individual for a life-time. Working Psychoanalytically with Depression Writing this essay was undoubtedly a challenging task. It required a lot of detailed research to study and understand the underlying features of the various theories pertaining to depression, and learning about and interpreting the experience of the patient was an equally demanding task emotionally. Talking to a patient of depression and learning about the underlying causes of depression is as daunting for the listener as it is for the patient. Dealing with the patients of depression is a strategic task and requires a great deal of emotional intelligence on the part of the therapist. As a starting point, the approach of keeping alive, well, and awake as proposed by Winnicott (2007, p. 166) while working psychoanalytically with the patients of depression seems a good idea, but there is a limit to which the therapist can sustain such an attitude because such attitude if carried over a long time might make the patient feel like the therapist is not taking him/her as seriously as he/she should given the patient is discussing the most sensitive incidents of his/her life that need to be listened to with more care and seriousness. On the other hand, maintaining too much seriousness throughout the session makes the therapist feel overwhelmed and there may approach a time, when the therapist might be so shocked that he/she cannot work out a way to proceed further. This calls for an optimal emotional balance between liveliness and seriousness while working psychoanalytically with the patients of depression. Owing to the fact that such therapeutic sessions are emotionally charging, therapist’s mental agility and presence is a driver of the therapy’s effectiveness. Most importantly, the therapist needs to be there physically as well as mentally to develop that coalition with the patient that leads the two to a favorable result for both. DSM-IV suggests different methods of treatment for depression depending upon the level of severity of the condition (American Psychiatric Association, 2000). Pharmacotheraphy is suggested for the mild to moderate condition, and for the severe depression without psychotic traits, whereas for the severe form of depression accompanied with the psychotic features, DSM-IV prescribes antidepressant as well as antipsychotic medication. Depression-focused psychotherapy is prescribed only for the mild to moderate depression and not for the severe depression with or without psychotic features. DSM-IV recommends providing the patients of depression with pharmacotherapy in addition to the depression-focused psychotherapy for the mild to moderate condition particularly when the patients have interpersonal problems or psychosocial problems, and also for the severe depression without the psychotic features whereas for the patients that have severe depression along with psychotic features, DSM-IV suggests antipsychotic medication along with antidepressant. Electroconvulsive therapy is recommended for some patients with mild to moderate depression, and for all patients with severe depression with or without psychotic features. References: American Psychiatric Association 2000, Diagnosis of Depression - DSM-IV-TR Criteria for Major Depressive Episode and Major Depressive Disorder, [Online] Available at http://alerecares.com/pl/MultiSiteIncludes/PDF/pdfs/Depression%20Guideline%20Summary%2003-11.pdf [accessed: 10 November 2012]. Bollas, C 1999, Chapter 9: Dead Mother, Dead Child in The Mystery of Things, London & New York: Routledge. Borresen, K 2012, Depression And 4 Other Celebs Who Struggled Post-Split, Huffington Post, [Online] Available at http://www.huffingtonpost.com/2012/10/05/nicole-kidman-divorce-and_n_1941261.html [accessed: 11 November 2012]. Brodie, R 2012, John Bowlby: The Father of Attachment Theory, Child Development Media, [Online] Available at http://www.childdevelopmentmedia.com/john-bowlby-the-father-of-attachment-theory.html [accessed: 10 November 2012]. Bowlby, J 1940, The influence of early environment in the development of neurosis and neurotic character, International Journal of Psycho-Analysis, Vol. 21, pp. 1-25. Bretherton, I 1992, The Origins of Attachment Theory: John Bowlby and Mary Ainsworth, Developmental Psychology, Vol. 28, pp. 759-775. 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