Conceptualization Of Chronic Depression

Chronic depression is not a homogenous problem, and patient history, course of current episode, and presentation can vary widely. As in the standard CT model for acute depression (Beck, Rush, Shaw, & Emery, 1979), the theme of loss (actual and perceived) and the negative cognitive triad (negative view of self, world, and future) are helpful as an initial starting point for formulating the patient's problems. However, in the model of chronic depression, the losses are often more enduring and may arise as a consequence of the depression itself. Similarly, the negative thoughts that characterize a chronic presentation are more enduring in nature and have over time become interwoven with associated behavioral strategies, and their social and environmental consequences. On the basis of this observation we propose a chronic cognitive triad as follows: low self-esteem (negative view of self), helplessness (negative view of the world), and hopelessness (negative view of the future).

Furthermore, we propose that the chronicity of negative thinking in each domain is a direct product of three factors. First, extreme and rigidly held conditional and unconditional beliefs provide an enduring vulnerability to negative automatic thoughts in each domain. Second, cognitive, affective, and behavioral avoidance are used to manage distress that would otherwise be constantly present when these belief are activated. Finally, the implementation of avoidant coping strategies leads to the recurrence of negative situations and events, which then provides the individual with confirmatory evidence to support his/her conditional and unconditional beliefs. This in turn further entrenches those beliefs and provides fuel for further negative automatic thoughts. Thus, an especially pernicious maintenance cycle is established.

A further aspect of the proposed model is that, over time, the person with chronic depression integrates the illness into his/her sense of self. The resulting emergence of beliefs about depression itself forms an important aspect of the maintenance of the disorder.

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