Research report
Exploring preoperational features in chronic depression

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Abstract

Background

The Cognitive Behavioral Analysis System of Psychotherapy (CBASP) by James McCullough is the first psychotherapeutical approach specifically designed for chronic depression. Whereas its efficacy has recently been studied, empirical investigations on the underlying etiopathological hypotheses are missing. McCullough postulates that chronically depressed patients — particularly those with early onset — think preoperationally. This term was coined by J. Piaget and includes egocentrism in the views of self and others and incapacity for authentic interpersonal empathy. In accordance, empirical studies indicate a deficit in theory of mind (ToM) in depressed individuals.

Methods

Sixteen patients with early onset chronic depression were compared to sixteen matched healthy controls using three measurements: 1) the Movie for the Assessment of Social Cognition (MASC) as a new video-based theory of mind test, 2) self-rated questionnaires on empathy (Interpersonal Reactivity Index (IRI), and a scale assessing individual competence in relationships), and 3) a structured evaluation by the patients' therapists.

Results

The groups did not differ in their theory of mind performance on any aspect assessed by the used test. However, patients rated their empathy in daily life as significantly inferior to healthy controls. In addition, the therapists assigned a considerable amount of preoperational behavior to their patients. No meaningful correlations between these three types of measurements were found. Limitations: Small sample size, no structural assessment of possible psychopathology in the control group, control group was not rated by clinicians concerning preoperational behaviors.

Conclusions

Lack of empathy exists in the daily life of early onset chronically depressed patients according to their own and their therapists' evaluation. However, a video-based test failed to pick up deficits in their theory of mind capacities. Further research is needed to investigate theory of mind deficits using real life interpersonal interactions demanding the patient's personal involvement.

Introduction

During the last two decades chronic depression has been recognized as a distinct and significant diagnostic subgroup (Eaton et al., 2008, Keller et al., 1995, Torpey & Klein, 2008). Based on his rich clinical experience, McCullough designed the Cognitive Behavioral Analysis System of Psychotherapy (CBASP; McCullough, 2000) which specifically addresses the challenges typically posed by chronically depressed patients in psychotherapy (such as approaching hostile-detached behavior). Clinical trials have found this treatment to be efficacious (Keller et al., 2000, Klein et al., 2004, Schramm, 2009). The goals of CBASP include perceiving the consequences of one's own behavior, recognizing one's stimulus value for others, learning how to interact empathically with others, developing social problem-solving abilities and coping strategies, as well as healing interpersonal trauma. CBASP techniques include situational analysis, an interpersonal discrimination exercise based on a transference hypothesis, and behavioral skill training. Despite its increasing utilization, empirical investigations on the underlying assumptions of the CBASP-model remain scarce.

CBASP is based on the observation that chronically depressed adults think and operate on a preoperational level. The term preoperational is taken from Jean Piaget's developmental theory (Piaget, 1926) and implies that fully matured reasoning (in the sense of highly flexible operation on any object) is not (yet) available. In particular, both preschool children and chronically depressed adults (1) use global and prelogical thinking; (2) have thought processes uninfluenced by the reasoning and logic of others; (3) are pervasively egocentric in their views of self and others; (4) communicate verbally in largely monologue form; (5) are unable to express authentic interpersonal empathy; and (6) exhibit poor affective control under stress (McCullough, 2000, p. 35). McCullough's theory also contains assumptions about the origin of these structural deficits. In early onset patients, they stem from inadequate (aversive or deprivating) conditions in early childhood that interrupt the normal development. In later-onset patients, deficits are rooted in intense emotionality during a depressive episode that disturbs previously developed mature patterns of reasoning. The postulated preoperational characteristics were examined prior to testing the pathogenic hypotheses.

Whereas Piaget observed typical errors in the physical reasoning of preschool children, chronically depressed patients are supposed to show preoperational patterns only in the social domain (McCullough, 2000). Hence, traditional Piagetian tasks (like assembled in the scale for logical thinking; Longeot, 1974) are not suitable for testing the CBASP hypotheses. Lack of empathy and egocentrism rather refer to paradigms of perspective taking and theory of mind.

Theory of Mind (ToM) is considered an evolutionary emerged ability to understand other peoples' minds by imputing mental states in order to optimize social interactions (Premack and Woodruff, 1978). First studied in primates, today there are various tasks for children and adults to test different aspects of ToM (Adolphs, 2003, Sprong et al., 2007). Empirical evidence asserts that patients with depressive disorders perform considerably poorly on the Reading the Mind in the Eyes Test (Eyes Test; Baron-Cohen et al., 2001) — a test for emotional face decoding (Harkness et al., 2005, Lee et al., 2005, Wang et al., 2008) — and in understanding false beliefs in cartoon tasks (Inoue et al., 2004, Uekermann et al., 2008, Zobel et al., submitted for publication). However, results from these studies are not clear-cut as confounding effects might have affected ToM performance. In addition, the applied paradigms have been of low ecological validity since only a very limited range of stimuli have been implemented to describe social situations.

Further studies are required using more adequate instruments (i.e., in terms of ecological validity and differentiation of subcomponents of ToM) on more homogenous samples. With its multiple subscales, the MASC test (Movie for the Assessment of Social Cognition; Dziobek et al., 2006) seems suitable to the current debate on the heterogeneity of the ToM concept (Hynes et al., 2006, Pineda & Hecht, 2009, Sabbagh, 2004). In this test, the participant faces a complex social situation presented in short segments of a movie. It is designed to assess the patient's ability to detect emotions of others, interpret their actions, and infer the thoughts of the depicted characters. Furthermore it demands the ability to switch in a flexible way between different social perspectives. According to the theoretical concept of CBASP, restriction to an egocentric perspective is one of the core deficits in chronic depressive disorder. It leads to insufficient interactional behavior as well as ignorance of social feedback, which contributes to problems in multiple areas of the patient's life. Thus, we expected chronically depressed patients to demonstrate poor performance in this advanced ToM test, in analogy to preoperational children who are restricted to an egocentric perspective (Piaget, 1926).

Adding neuropsychological tests for the measurement of concentration and executive functioning addresses the issue of domain specificity in ToM test performance (Apperly et al., 2005, Stone & Gerrans, 2006) by ruling out possible differences (other than ToM) between patients and healthy controls.

The sample of the present study includes patients with chronic depression of any severity. As McCullough refers to a developmental theory, he postulates severe structural deficits in chronically depressed patients, rather than merely functional impairment due to current illness. Therefore, we specified that all included patients had an early onset. Early aversive experiences and trauma were assessed retrospectively since a subgroup analysis of the Keller et al. (2000) study indicates that patients with early trauma respond better to CBASP than to medication (Nemeroff et al., 2003).

The primary aim of this study was to explore McCullough's hypothesis of preoperational characteristics in chronic depression and to search for adequate assessment methods. We focused on the aspects of egocentrism and lack of empathy. Both constructs were operationalized by the MASC test for multiple components of ToM as well as by self-perception of empathy assessed by questionnaires and the therapists' opinion. Assuming these operationalizations to be adequate, the CBASP theory would predict lower ToM performance and empathy ratings in patients than in healthy subjects. Furthermore, global, precausal, and prelogical thinking may refer to the well established concept of hopelessness particularly in chronic depression (Joiner et al., 2007). Significant correlations between hopelessness, ToM, and empathy may confirm the existence of a symptom cluster which is termed preoperational. Finally, this investigation served as a replication of ToM studies using a new assessment tool in a subpopulation of depressed patients exhibiting high risk for social deficits.

Section snippets

Subjects

We compared 16 early onset chronically depressed patients with 16 healthy controls. The clinical sample was recruited from the local University Medical Center, Department of Psychiatry and Psychotherapy in Freiburg, Germany. Including inpatients, outpatients, and former patients, inclusion criteria were (a) chronic depression (i.e. with a duration of least 2 years), (b) early onset, (c) a minimum BDI score of 12, (d) no other primary diagnosis on DSM-IV (American Psychiatric Association, 1994)

Theory of mind performance

Control-questions (non-ToM items) were solved correctly in 74.4% (multiple choice) and 73.4% (open answers) of cases overall. This did not differ between groups (multiple choice: patients 73.96 ± 18.23, controls 75.0 ± 16.10, t(30) =  0.17, p = .865, d = .06, open answers: patients 77.08 ± 17.08, controls 69.79 ± 15.18, t(30) = 1.28, p = .212, d = .45).

Regardless of the answering modus, groups did not differ in the main outcome variable of the MASC test (multiple choice: t(30) = 0.01, p = .924, d = .03, open answers: t

Discussion

The present study had two goals: 1) to explore the assumption that McCullough's treatment model of preoperational characteristics is prevalent in chronically depressives, and 2) to search for adequate methods to operationalize this hypothesis. Furthermore, this study served as a replication of empirical ToM results of other trials with depressed patients. Three special features of our study stand out: first, the MASC test has high ecological validity since emotions, thoughts, and intentions of

Role of funding source

There was no financial support and no competing interest.

Conflict of interest

All authors declare that they have no conflicts of interest.

Acknowledgements

We would like to thank R. Schneibel, Dr. S. Kech, and D. Werden for their kind help and assistance. A special thanks goes to Dr. S. Fleck for providing us with the MASC test.

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