Transcript Document

Models of Development
and Mental Health
Lecture 6:
Object Relations Model:
Depression
Depression
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Low Mood Vs Clinical Depression
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Major Depressive Disorder; Manic Depression (primary mood
disorders) Vs depressive symptomatology as secondary feature
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Unipolar (Depression) – Bipolar (Manic Depression)
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Reactive Vs Endogenous
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Co-morbidity: highest rates between Anxiety Disorders and
Major Depressive Disorders; also high rates between
Depression and Conduct Disorder, Oppositional Defiant
Disorder, ADHD, Substance Abuse Disorders and Eating
Disorders
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Prevalence
Prevalence
For MDD range from .4% to
2-5% for children, and from
.4% to 8.3% for adolescents
Lifetime: 15%-20%
age
Adults > Adolescents >
children
gender
Before puberty equal rates;
after puberty girls > boys
(adults 2-3:1)
Socio-economic status
No clear cut patterns
Race/ethnicity
Possibility of higher rates in
African-American boys
Adapted from Phares, 2003
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Developmental Course
Preschoolers and younger children:
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irritability and somatic complaints rather than dysphoric mood or hopelessness
less likely to have sleep disturbances, compared with adolescents
Developmental constraints, such as language, cognition, memory and selfunderstanding may compromise the accuracy of assessment of MDD in children
(Cicchetti & Toth, 1998)
Assessment tool: Childhood Depression Inventory
Adolescents:
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more likely to report depressed mood, feelings of hopelessness, and low self esteem.
The older the individual, the lower self esteem tends to be in clinical samples.
Adults:
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Sleep, eating, mood, activity levels, suicidal ideation and behaviour
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Risk of suicidal behaviour
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Approx one third of children with MDD and/or dysthymia at risk for a first
suicide attempt by age 17 years (Kovacs et al., 1993)
25%-34% of depressed children and adolescents had attempted suicide Ryan et
al. (1987); Approx 50% of those who make one suicide attempt make further
attempts (Kovacs et al., 1993; Pfeffer et al., 1991)
Fatal suicide in young people linked with MDD. Chance of having MDD 27 times
higher among those who committed suicide than among case controls (Brent et
al., 1993; Shaffer et al., 1996)
‘Developmental Costs’ (Kovacs, 1997)
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during depressive episode children are removed from normal social experiences
that serve developmental function of building social-cognitive and interpersonal
skills.
Attachment may be disrupted. Depressed children show lack of reciprocity (or
negative reciprocity) in interpersonal interactions. May elicit negative parental
responses and undermine affective bonds.
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Aetiology
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Genetics
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Approx 50% of variance due to genetic influences. Children of depressed
parents are more likely to develop depression even if children are raised by
non-depressed adoptive parents (Rutter et al., 1999)
Monozygotic twins, even when raised apart, have higher concordance for
major depression than dyzygotic twins or siblings (Hammen, 1991)
Environmental
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Children’s outcomes depend on presence or absence of parental conflict
(Downey and Coyne, 1990)
high inter-parental conflict associated with externalising problems (CD,
ODD)
low levels of parental conflict associated with internalising problems, e.g.
depression and anxiety
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Assessment Tool
Houghton, S., McConnell, M. O’Flaherty,
A. (1998), The use of the Children’s
Depression Inventory in an Irish
context, Irish Journal of Psychology,
19, 2-3, pp313-331.
Compared Irish sample to norms,
differences in age and gender
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Assessment Tool 2
• Houghton, F.Cowley, H., Meehan,
F. & Houghton, S., Kelleher, K.
(2006). The short 4-item Center
for Epidemiological Studies
Depression Scale for Children
(CES-DC) in Ireland, Irish Journal
of Psychology, 27, 3-4, pp183-190
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National Institute for
Health and Clinical
Excellence
• NICE Guidelines – Depression in children
and adolescents (September, 2005)
• http://www.nice.org.uk
• See quick reference guide (word & pdf)
• Depression (December, 2004)
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Object Relations Model
• Freud
– Importance of the unconscious & Defense mechanisms
– Depression - Object loss:
• Those with depressive personality can be identified by their
object loss & distinctive object relations (Huprich, 2001)
• Melanie Klein
– Paranoid-Schizoid phase
– Depressive phase
– Defenses of introjection, splitting and projective
identification in both normal and abnormal development
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Donald Winnicott
• The facilitating environment
• The transitional object
• Illusions of omnipotence to gradual
disillusionment
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Therapeutic
Intervention
• Emphasis on relationships
– Change occurs within the context of the
therapeutic relationship
• The meaning of symptoms
– Karon, B.P. (2005) Recurrent psychotic
depression is treatable by psychoanalytic
therapy without medication, Ethical Human
Psychology and Psychiatry, 7,1.
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Object Relations &
Attachment
• Murray, L. (1991).
Intersubjectivity, object relations
theory and empirical evidence from
mother-infant interactions, Infant
Mental Health Journal, 12,3
• Study of postnatal depression –
linking attachment theory with OR
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Effectiveness
• The outcome measures used to
determine treatment effectiveness
generally reflect changes in
behaviour or perceived mental
health as opposed to more basic
enduring changes in personality
structure. (Peleikis & Dahl, 2005)
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OR & Outcomes
• Van, Henricus et al. (2008).
Predictive value of object relations
for therapeutic alliance and
outcome in psychotherapy for
depression: An exploratory study.
Journal of Mental and Nervous
Diseases, 196,9,pp655-662
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OR & Research
• When is transference work useful in
dynamic psychotherapy? Gabbard, G.
(2006). American Journal of Psychiatry,
163, 10, pp1667-1669 (commentary on
below article)
• Hoglend et al., (2006) Analysis of the
patient–therapist relationship in dynamic
psychotherapy: An experimental study of
transference interpretations (Rct study)
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OR & Research
• Cramer, P. (2002). Defense
mechanisms behavior and affect in
young adulthood, Journal of
Personality, 70, 1.
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Cramer’s study
• “The findings show that men and women who rely
on the immature defense of denial at age 23
showmultiple signs of behavioral immaturity, as
well as anxiety. In contrast, extensive use of
projection was related to a suspicious, hyperalert
personality style, including anxiety and
depression, in men, but to a sociable, nonwary,
nondepressed style in women. The use of the
mature defense ofidentification, by women, was
related to behavior characterized by maturity,
social competence, and the absence of depressive
symptoms.” (Cramer, 2002 – abstract)
Rosaleen McElvaney, Phd