Depression and stress: a biopsychosocial exploration of evolved functions and mechanisms

Expanding the notion of mechanism to further understanding of biopsychosocial disorders? Depression and medically-unexplained pain as cases in point

Evidence-Based Medicine has little consideration for mechanisms and philosophers of science and medicine have recently made pleas to increase the place of mechanisms in the medical evidence hierarchy. However, in this debate the notions of mechanisms seem to be limited to 'mechanistic processes' and 'complex-systems mechanisms,' understood as 'componential causal systems'. I believe that this will not do full justice to how mechanisms are used in biological, psychological and social sciences and, consequently, in a more biopsychosocial approach to medicine. Here, I propose, following (Kuorikoski, 2009), to pay more attention to 'abstract forms of interaction' mechanisms. The present work scrutinized review articles on depression and medically unexplained pain, which are considered to be of multifactorial pathogenesis, for their use of mechanisms. In review articles on these disorders there seemed to be a range of uses between more 'abstract forms of interaction' and 'componential causal system' mechanisms. I therefore propose to expand the notions of mechanisms considered in medicine to include that of more 'abstract forms of interaction' to better explain and manage biopsychosocial disorders.

CBT for difficult-to-treat depression: self-regulation model

BACKGROUND

Cognitive behavioural therapy (CBT) is an effective treatment for depression but a significant minority of clients do not complete therapy, do not respond to it, or subsequently relapse. Non-responders, and those at risk of relapse, are more likely to have adverse childhood experiences, early-onset depression, co-morbidities, interpersonal problems and heightened risk. This is a heterogeneous group of clients who are currently difficult to treat.

AIM

The aim was to develop a CBT model of depression that will be effective for difficult-to-treat clients who have not responded to standard CBT.

METHOD

The method was to unify theory, evidence and clinical strategies within the field of CBT to develop an integrated CBT model. Single case methods were used to develop the treatment components.

RESULTS

A self-regulation model of depression has been developed. It proposes that depression is maintained by repeated interactions of self-identity disruption, impaired motivation, disengagement, rumination, intrusive memories and passive life goals. Depression is more difficult to treat when these processes become interlocked. Treatment based on the model builds self-regulation skills and restructures self-identity, rather than target negative beliefs. A bespoke therapy plan is formed out of ten treatment components, based on an individual case formulation.

CONCLUSIONS

A self-regulation model of depression is proposed that integrates theory, evidence and practice within the field of CBT. It has been developed with difficult-to-treat cases as its primary purpose. A case example is described in a concurrent article (Barton et al., 2022) and further empirical tests are on-going.

Relationships of work stress and interpersonal needs with industrial workers' mental health: a moderated mediation model

OBJECTIVES

This study explores whether feelings of defeat (i.e., a sense of failed struggle and losing rank; referred to as defeat for simplicity) mediated the effect of work stress on depression/anxiety, the effect of interpersonal needs on depression/anxiety for Chinese industrial workers, and the possible moderating role of social support.

METHOD

A cross-sectional study was conducted in Shenzhen, China in 2019, in total, 2023 industrial workers (of 2700 invited; response rate = 75%) completed a self-administered survey consisted of Job Stress Scale, Interpersonal Needs Questionnaire, Defeat Scale, Centre for Epidemiological Studies Depression Scale, Generalized Anxiety Disorder Scale, two face-valid questions for social support, as well as sociodemographic information. Moderated mediation model was tested and loop plots were applied to probe into the conditional effects of work and interpersonal stress on depression and anxiety symptoms.

RESULT

Both the direct and indirect effect of work stress on depression and anxiety through defeat were significant (Work stress→ Depression: B = 0.035, p < .001, Work stress→ Defeat→ Depression: B = 0.034, p < .001; Work stress→ Anxiety: B = 0.038, p < .001, Work stress→ Defeat→ Anxiety: B = 0.045, p < .001). Meanwhile, defeat mediated the relationship of interpersonal needs with depression partially and the relationship of interpersonal needs with anxiety totally (Interpersonal needs→ Anxiety: B = 0.133, p < .001, Interpersonal needs→ Defeat→ Anxiety: B = 0.010, p = .537). Social support moderated the indirect path between interpersonal needs and depression/anxiety and buffered the effect.

CONCLUSION

The mediating role of defeat and the moderator role of social support in the relationship between stress and depression/anxiety were confirmed in industrial workers. Workers who reported more work and interpersonal stress would report more defeat feelings, and then exhibited more depression and anxiety symptoms; this mediation effect was stronger for those who had lower social support, respectively.

Entrapment, Hopelessness, and Cognitive Control: A Moderated Mediation Model of Depression

The present study aimed to examine the roles that hopelessness and cognitive control play in the relationship between entrapment and depression. Data were collected from 367 college students in South Korea. The participants completed a questionnaire that consisted of the Entrapment Scale, the Center for Epidemiologic Studies Depression Scale, the Beck Hopelessness Inventory, and the Cognitive Flexibility Inventory. Results showed that hopelessness partially mediated the relationship between entrapment and depression. In addition, cognitive control moderated the relationship between entrapment and hopelessness: greater cognitive control weakened the positive association between entrapment and hopelessness. Finally, the mediating effect of hopelessness was moderated by cognitive control. The findings of this study expand the understanding of the protective role of cognitive control, especially when an increased sense of entrapment and hopelessness intensifies depression.

Social Stigma and Depression among Asymptomatic COVID-19 Carriers in Shanghai, China: The Mediating Role of Entrapment and Decadence

INTRODUCTION

Since the advent of 2019 novel coronavirus (COVID-19), the coexistence between social stigma and depression symptoms (depression hereafter) in COVID-19 patients has been mentioned, but the mechanisms involved remains unclear. This study aimed to explore how the stigma affects depression during the mid-pandemic period.

METHODS

A cross-sectional survey using non-probability sampling was conducted among asymptomatic COVID-19 carriers in Shanghai, China (April 2022). An online questionnaire was used to obtain information on demographic characteristics and psychological traits. Logistic regression and path analysis were performed to analyze the depression risk factors and examine the mediation model, respectively.

RESULTS

A total of 1283 participants (59.6% men) were involved in this study, in which 44.7% of carriers reported having depression. Univariate analyses found that education level (OR 0.575; 95% CI 0.448-0.737) and doses of vaccine (OR 1.693; 95% CI 1.042-2.750), were significantly associated with depression among asymptomatic carriers. The association between social stigma and depression was fully mediated by their feelings of entrapment and decadence (indirect effect = 0.204, p < 0.001; direct effect = -0.059, p = 0.058). The mediating role of entrapment between stigma and depression was moderated by age group (estimate = 0.116, p = 0.008).

CONCLUSION

Mental health issues resulting from the COVID-19 pandemic are increasingly apparent in China and require urgent attention and responses. These findings provide new perspectives for the early prevention of depression in asymptomatic carriers.

The association between entrapment and depression among migrant workers in China: a social rank theory based study

BACKGROUND

Migrant workers are a group susceptible for depression evolution due to occupational maladaptive triggers. The social rank theory illustrates the pathology process from defensive adaptation to depression, pointing out the early prevention of depression by discovering entrapment. This study aims to reveal the relationship between migrant workers' entrapment and depressive symptoms.

METHODS

A total of 1805 migrant workers in Shenzhen were recruited by stratified multi-stage sampling. Sample's demographic, behavioral and psychosocial characteristics were described and analyzed to reveal the relationship between entrapment and depressive symptoms. The Receiver Operator Characteristic was performed to find the optimal cut-off point of Entrapment Scale for predicting depressive symptoms.

RESULTS

In the binary logistic regression of sociodemographic variables, migrant workers who were married (univariate odds ratio (ORu) = 0.69, 95% Confidence Interval (CI) = 0.56-0.84), owned 1 or 2 children (ORu = 0.71, 95% CI = 0.58-0.86), had been working over 10 years (ORu = 0.71, 95% CI = 0.54-0.95), earned > 4999 yuan per month (ORu = 0.68, 95% CI = 0.47-0.99; multivariate odds ratio (ORm) = 0.57, 95% CI = 0.38-0.87) or with low risks of alcohol use disorders (ORu = 0.51, 95% CI = 0.34-0.75) had lower risks of depressive symptoms. After adjusted the aforementioned significant sociodemographic variables, migrant workers with severer entrapment were more likely to have depressive symptoms (adjusted odds ratio (ORa) = 1.13, 95% CI = 1.12-1.15). Besides, the study proved the reliability and validity of the Chinese version Entrapment Scale, preferring a two-dimensional structure, and 11 was the optimal cut-off value of this scale for predicting depressive symptoms among migrant workers.

CONCLUSIONS

This result indicates the potential value of entrapment according to the social rank theory on facilitating early prevention of migrant works' depression and the application value of Entrapment Scale for effectively measuring mental status among migrant workers.

Relationship of Resilience Factors With Biopsychosocial Markers Using a Comprehensive Home Evaluation Kit for Depression and Suicide Risk: A Real-World Data Analysis

OBJECTIVES

Adverse childhood experiences (ACEs) are fundamental factors in developing depression with increased suicide risk. Resilience is considered an important protective factor that can prevent trauma survivors from developing depression. We developed a home evaluation kit for a comprehensive assessment of bio-psycho-social factors related to depression and suicide. This kit contained a psycho-social evaluation battery, named the Protective and Vulnerable factors battery questionnaire (PROVE) comprising depressive symptoms and suicide risk, as well as various depression-related psychosocial factors, such as ACE, resilience, mentalization capacity, and attachment, via online survey tools. Furthermore, salivary cortisol levels were used as biological indicators to assess the hypothalamus-pituitary-adrenal axis function.

METHODS

Real-world data analysis was made out of data collected from participants who visited CHEEU Counseling center or Gangnam Severance hospital for mental health check-ups. The participants were put into three mental state groups (green-normal, yellow-borderline, and red-risk) depending on the result of PROVE battery. The difference between psychosocial factors and salivary cortisol indicators by the group was identified by analysis of covariance with sex and age as covariates. Linear regression analysis was conducted to find a significant association of resilience score with other bio-psycho-social variables, such as ACE, attachment, mentalization, or post-awakening cortisol concentrations (area under the curve with respect to ground, AUCg). A partial correlation analysis was performed to evaluate the relationship of AUCg with psychosocial factors.

RESULTS

Depression-related psycho-social indicators were significantly different among groups. Insecure attachment and the mentalization problem are negatively influencing factors to resilience. Furthermore, the severity of depression in participants with ACE was also influenced by mentalization problems. AUCg was different according to the PROVE group, presence of ACE, or resilience level. In addition, AUCg showed a positive correlation with resilience score but negative correlations with depressive symptoms, ACE, mentalization problems, and anxiety or avoidance attachment.

CONCLUSION

This study suggests that there are some key factors negatively affecting resilience: insecure attachment and mentalization problems. In groups with ACE, a mentalization problem was suggested as a factor that can increase depressive symptoms. AUCg was associated with resilience as well as several other vulnerable factors of depression, showing its potential as a promising biomarker.

Remission of symptoms is not equal to functional recovery: Psychosocial functioning impairment in major depression

The ultimate goal of depression treatment is to achieve functional recovery. Psychosocial functioning is the main component of functional impairment in depressed patients. The concept of psychosocial functioning has an early origin; however, its concept and connotation are still ambiguous, which is the basic and key problem faced by the relevant research and clinical application. In this study, we start from the paradox of symptoms remission and functional recovery, describe the concept, connotation, and characteristics of psychosocial functioning impairment in depressed patients, and re-emphasize its importance in depression treatment to promote research and clinical applications related to psychosocial functioning impairment in depressed patients to achieve functional recovery.

Predictors of poor 6-week outcome in a cohort of major depressive disorder patients treated with antidepressant medication: the role of entrapment

BACKGROUND

Only a small number of consistent processes predict which depressed patients will achieve remission with antidepressant medication. One set of processes is that of social ranking strategies/variables that are related to life events and severe difficulties. Particularly, defeat and entrapment predict poorer response to antidepressants. However, results are inconsistent.

AIM

The current study aimed to evaluate evolutionary strategies, childhood maltreatment, neglect and life events and difficulties (LEDs) as predictors of remission in depressed patients undergoing pharmacological treatment in a psychiatric outpatient sample.

METHODS

A cohort of 139 depressed outpatients undergoing pharmacological treatment was followed prospectively in a naturalistic study for 6 weeks. Two major evaluations were considered at baseline and 6 weeks. We allocated patients to a pharmacological treatment algorithm for depression - the Texas Medication Algorithm Project. Variables evaluated at baseline and tested as predictors of remission included demographic and clinical data, severity of depression, social ranking, evolution informed variables, LEDs and childhood maltreatment.

RESULTS

Of the 139 patients, only 24.5% were remitted at week 6. In univariate analyses, non-remitted patients scored significantly higher in all psychopathology and vulnerability scales except for submissive behaviour and internal entrapment. For the logistic regression, a higher load of LEDs of the entrapment and humiliation dimension in the year before the index episode (OR = 6.62), and higher levels external entrapment in the Entrapment Scale (OR = 1.10) predicted non-remission. These variables accounted for 28.7% of the variance.

CONCLUSIONS

Multivariate analysis revealed that external entrapment was the only predictor of non-remission.

Instructed Partnership Appreciation in Depression: Effects on Mood, Momentary Relationship Satisfaction, and Psychobiological Arousal

BACKGROUND

Depressive disorders are associated with attentional bias and social anhedonia. There is evidence supporting the hypothesis that depressed individuals participate less in potentially rewarding social situations and exhibit alterations in stress reactivity. With the present study, we aimed at investigating the affective and psychobiological response of couples with a depressed (female) partner in an instructed partnership appreciation task (PAT) that included positive and appreciative communication.

METHODS

In a quasi-experimental repeated-measures design, depressive couples (DCs)-i.e., the female partner being diagnosed with a depressive disorder-were compared to non-depressive couples (NDCs). Study outcomes were the PAT-induced changes in state mood, momentary relationship satisfaction, salivary cortisol, and salivary alpha-amylase. Additionally, we assessed psychometric baseline data on depression, relationship quality, social support, and chronic stress. Data was analyzed using multilevel modeling.

RESULTS

A total of 184 individuals from N = 47 DCs and N = 45 NDCs were included. DCs were characterized by higher depressiveness, lower relationship quality, less actually received social support from the partner, and higher chronic stress than NDCs. Manipulation checks led to the additional exclusion of two couples. Regarding mood, depressed women showed lower baseline scores and no significant differences in mood increase compared to non-depressed women (p = 0.107). Increases in relationship satisfaction were significantly stronger in the depressed group (p = 0.035). In addition, we found a significantly stronger cortisol increase in depressed women, but only if relationship duration was taken into account as a moderating factor (p = 0.022). No significant group differences were found for women's amylase trajectories or for sex-dependent interaction effects on the couple level (all p > 0.05).

CONCLUSIONS

Instructed engagement in positive couple interaction may require high effort and increased psychobiological arousal, but may finally result in emotional and social benefits in depressed women. While these findings encourage speculations about the therapeutic application of instructed partnership appreciation, more research is needed on the effectiveness of such interventions and on the moderating role of relationship duration in depression and couple functioning.

Social rank theory of depression: A systematic review of self-perceptions of social rank and their relationship with depressive symptoms and suicide risk

BACKGROUND

Depression can be debilitating, as well as a risk factor for self-harm and suicide. Social rank theory (SRT) suggests depression stems from feelings of defeat and entrapment that ensue from experiencing oneself to be of lower rank than others. This study aims to review the literature investigating the relationship between self-perceptions of social rank and depressive symptoms or suicidal ideation/behaviour.

METHODS

A keyword search of three psychological and medical databases was completed (Psychinfo, Medline, Web of Knowledge). Studies were quality assessed using established criteria.

RESULTS

An initial 1290 records were identified. After application of inclusion and exclusion criteria, 70 remained measuring depressive symptoms (n = 68), self-harm (n = 3) and suicidal ideation (n = 3). The main measures assessing social rank were the social comparison scale (SCS; n = 32) and subjective social status (SSS, n = 32), with six additional papers including another measure of social rank. In univariate analyses, as perceptions of social rank decreased, depressive symptoms (and suicidal ideation/self-harm) increased. Multivariate analyses indicated that social rank may act as a psychosocial mechanism to explain the relationship between social factors (in particular socio-economic status) and depressive symptoms. Additionally, psychological variables, such as rumination or self-esteem, may mediate or moderate the relationship between social rank and depressive or suicidal symptoms.

LIMITATIONS

Study quality was variable and 89% of studies were cross-sectional.

CONCLUSIONS

Although more prospective research is required, this review highlights the importance of understanding an individual's perception of their social position compared to others as it may lead to an enhanced understanding of the aetiology of depressive disorders.

An Examination of Social Comparison and Suicide Ideation Through the Lens of the Integrated Motivational-Volitional Model of Suicidal Behavior

We aimed to investigate whether negative social comparisons are associated with key components of the integrated motivational-volitional (IMV) model of suicidal behavior. Specifically, we investigated the relationship between negative social comparisons, suicide ideation, defeat, entrapment, socially prescribed perfectionism, and resilience. Adult participants (N = 422) completed an online survey comprised of a range of psychological measures. An initial regression analysis indicated that negative social comparisons were associated with suicide ideation. Three mediation models were tested based on the IMV model, all controlling for depressive symptoms. In the first, social comparison partially mediated the relationship between socially prescribed perfectionism and defeat. In the second, defeat mediated the relationship between negative social comparisons and entrapment, and resilience moderated the relationship when defeat was high. In the final model, entrapment mediated the relationship between defeat and suicide ideation, with resilience moderating this relationship when entrapment was high. These findings are novel and lend support to the IMV model. The clinical implications include highlighting the importance of targeting resilience given its potential association with defeat and entrapment.

Plasma cortisol and oxytocin levels predict help-seeking intentions for depressive symptoms

BACKGROUND

Depressed individuals often refuse or withdraw from help, a phenomenon termed help-negation, which is a risk factor for poor outcomes. Most previous research has investigated psychosocial factors including stigma as causes of low help-seeking intentions for depression, however these do not adequately explain the problem. We hypothesised that because help-negation worsens with symptom severity, it might be linked to important biological changes associated with depression itself. We investigated the relative contributions of cortisol, a stress hormone linked to depression, and oxytocin, a hormone which mediates social behaviours, alongside psychosocial factors, to help-seeking intentions among depressed and non-depressed individuals.

METHODS

Morning plasma cortisol and oxytocin levels, psychopathology, suicidal ideation, help-seeking intentions from informal sources including family and friends, and formal sources including health professionals, and perceived social support were quantified in 63 adults meeting DSM-5 criteria for major depressive disorder (MDD) who were not receiving any treatment, and 60 healthy controls. Between-group analyses of variance, correlations, and hierarchical multiple regressions were employed.

RESULTS

Help-seeking intentions were lower in depressed than healthy participants, negatively correlated to cortisol and positively correlated to oxytocin. Cortisol negatively, and oxytocin positively, predicted help-seeking intentions from informal but not formal sources, after controlling for psychopathology and psychosocial factors.

CONCLUSIONS

Neuroendocrine changes associated with depression may contribute to low help-seeking from friends and family, which may have implications for interpersonal support and outcomes. Research and clinical approaches which incorporate biological as well as psychosocial factors may allow for more targeted and effective early interventions to address lack of help-seeking and depression progression.

A Descriptive Study of Feelings of Arrested Escape (Entrapment) and Arrested Anger in People Presenting to an Emergency Department Following an Episode of Self-Harm

BACKGROUND AND OBJECTIVES

To explore the role of elevated feelings of anger and desires to escape (fight/flight), which are experienced as inhibited, blocked, and arrested (i.e., arrested anger and arrested flight/escape leading to feelings of entrapment). This descriptive study developed measures of arrested anger and arrested flight and explored these in the context of a recent self-harm event in people presenting to a Hospital's Emergency Department (ED).

METHODS

Fifty-eight individuals presenting to an ED following an act of self-harm were recruited. Participants completed newly developed measures of arrested flight, arrested anger and anger with self in regard to self-harm, and suicide intent and depression.

RESULTS

Ninety-three percent of participants presented after self-poisoning. The majority (95%) reported having experienced high escape motivation that felt blocked (arrested flight) with 69% reporting feeling angry with someone but unable to express it (arrested anger). For many participants (53.7%), strong desires to escape from current situations and/or to express anger did not diminish immediately after the act.

LIMITATIONS

As with many studies, a select group of participants agreed to take part and we did not keep records of how many refused. There are no other validated measures of arrested escape and arrested anger and so for this study, our short item-focused measures rely on face validity.

CONCLUSION

Arrested defenses of fight and flight, and self-criticism are common in those who have self-harmed and may continue after acts of self-harm. Many participants revealed that talking about their experiences of escape motivation and blocked anger (using our measures) was helpful to them.

PRACTICE POINTS

Feelings of entrapment and arrested anger are common in people who self-harmClinicians could benefit from increased awareness and measures of arrested flight and arrested angerDiscussing these concepts and experiences appears to be useful to people who have self-harmedFurther research is needed on how best to help people with such experiences.

The distinctive sequelae of children's coping with interparental conflict: Testing the reformulated emotional security theory

Two studies tested hypotheses about the distinctive psychological consequences of children's patterns of responding to interparental conflict. In Study 1, 174 preschool children (M = 4.0 years) and their mothers participated in a cross-sectional design. In Study 2, 243 preschool children (M = 4.6 years) and their parents participated in 2 annual measurement occasions. Across both studies, multiple informants assessed children's psychological functioning. Guided by the reformulated version of emotional security theory, behavioral observations of children's coping with interparental conflict assessed their tendencies to exhibit 4 patterns based on their function in defusing threat: secure (i.e., efficiently address direct instances of threat), mobilizing (i.e., react to potential threat and social opportunities), dominant (i.e., directly defeat threat), and demobilizing (i.e., reduce salience as a target of hostility). As hypothesized, each profile predicted unique patterns of adjustment. Greater security was associated with lower levels of internalizing and externalizing symptoms and greater social competence, whereas higher dominance was associated with externalizing problems and extraversion. In contrast, mobilizing patterns of reactivity predicted more problems with self-regulation, internalizing symptoms, externalizing difficulties, but also greater extraversion. Finally, higher levels of demobilizing reactivity were linked with greater internalizing problems and lower extraversion but also better self-regulation. (PsycINFO Database Record

The temporal dynamics of cortisol and affective states in depressed and non-depressed individuals

OBJECTIVES

Cortisol levels have been related to mood disorders at the group level, but not much is known about how cortisol relates to affective states within individuals over time. We examined the temporal dynamics of cortisol and affective states in depressed and non-depressed individuals in daily life. Specifically, we addressed the direction and timing of the effects, as well as individual differences.

METHODS

Thirty depressed and non-depressed participants (aged 20-50 years) filled out questionnaires regarding their affect and sampled saliva three times a day for 30 days in their natural environment. They were pair-matched on age, gender, smoking behavior and body mass index. The multivariate time series (T=90) of every participant were analyzed using vector autoregressive (VAR) modeling to assess lagged effects of cortisol on affect, and vice versa. Contemporaneous effects were assessed using the residuals of the VAR models. Impulse response function analysis was used to examine the timing of effects.

RESULTS

For 29 out of 30 participants, a VAR model could be constructed. A significant relationship between cortisol and positive or negative affect was found for the majority of the participants, but the direction, sign, and timing of the relationship varied among individuals.

CONCLUSION

This approach proves to be a valuable addition to traditional group designs, because our results showed that daily life fluctuations in cortisol can influence affective states, and vice versa, but not in all individuals and in varying ways. Future studies may examine whether these individual differences relate to susceptibility for or progression of mood disorders.

The multiple faces of interparental conflict: Implications for cascades of children's insecurity and externalizing problems

This multistudy article examined the relative strength of mediational pathways involving hostile, disengaged, and uncooperative forms of interparental conflict, children's emotional insecurity, and their externalizing problems across 2 longitudinal studies. Participants in Study 1 consisted of 243 preschool children (M age = 4.60 years) and their parents, whereas Study 2 consisted of 263 adolescents (M age = 12.62 years) and their parents. Both studies utilized multimethod, multi-informant assessment batteries within a longitudinal design with 3 measurement occasions. Across both studies, lagged, autoregressive tests of the mediational paths revealed that interparental hostility was a significantly stronger predictor of the prospective cascade of children's insecurity and externalizing problems than interparental disengagement and low levels of interparental cooperation. Findings further indicated that interparental disengagement was a stronger predictor of the insecurity pathway than was low interparental cooperation for the sample of adolescents in Study 2. Results are discussed in relation to how they inform and advance developmental models of family risk. (PsycINFO Database Record

A meta-analysis of perceptions of defeat and entrapment in depression, anxiety problems, posttraumatic stress disorder, and suicidality

BACKGROUND

There is a burgeoning literature examining perceptions of being defeated or trapped in different psychiatric disorders. The disorders most frequently examined to date are depression, anxiety problems, posttraumatic stress disorder (PTSD), and suicidality.

AIMS

To quantify the size and consistency of perceptions of defeat and entrapment in depression, anxiety problems, PTSD and suicidality, test for differences across psychiatric disorders, and examine potential moderators and publication bias.

METHOD

Random-effects meta-analyses based on Pearson's correlation coefficient r.

RESULTS

Forty studies were included in the meta-analysis (n = 10,072). Perceptions of defeat and entrapment were strong (around r = 0.60) and similar in size across all four psychiatric disorders. Perceptions of defeat were particularly strong in depression (r = 0.73). There was no between-study heterogeneity; therefore moderator analyses were conducted in an exploratory fashion. There was no evidence of publication bias.

LIMITATIONS

Analyses were cross-sectional, which precludes establishing temporal precedence or causality. Some of the meta-analyses were based on relatively small numbers of effect sizes, which may limit their generalisability.

CONCLUSIONS

Perceptions of defeat and entrapment are clinically important in depression, anxiety problems, PTSD, and suicidality. Similar-sized, strong relationships across four different psychiatric disorders could suggest that perceptions of defeat and entrapment are transdiagnostic constructs. The results suggest that clinicians and researchers need to become more aware of perceptions of defeat and entrapment.

A prospective study of suicidal ideation in posttraumatic stress disorder: the role of perceptions of defeat and entrapment

OBJECTIVES

This study aimed to provide the first prospective test of the ability of defeat and entrapment to predict suicidal ideation in posttraumatic stress disorder (PTSD) after controlling for the effects of PTSD severity, comorbid depressive symptoms, and hopelessness on suicidal ideation.

METHODS

Participants were 52 individuals diagnosed with PTSD. Baseline and follow-up assessments were 13 to 15 months apart. Defeat and entrapment were conceptualized and analyzed as a unique construct (defeat/entrapment) in this study. Multiple regression analysis was applied to examine the predictive effects of defeat/entrapment on suicidal ideation.

RESULTS

Defeat/entrapment scores predicted changes in the levels of suicidal ideation at follow-up while controlling for baseline suicidal ideation, PTSD severity, comorbid depressive symptoms, and hopelessness.

CONCLUSIONS

These outcomes provide support to contemporary models of suicidality that suggest that defeat/entrapment is a strong predictor of suicidality in PTSD.

The prospective role of defeat and entrapment in depression and anxiety: a 12-month longitudinal study

The concepts of "defeat" (representing failed social struggle) and "entrapment" (representing an inability to escape from a situation) have emerged from the animal literature, providing insight into the health consequences of low social rank. Evolutionary models suggest that these constructs co-occur and can lead to the development of mental disorders, although there is limited empirical evidence supporting these predictions. Participants (N=172) were recruited from economically deprived areas in North England. Over half of participants (58%) met clinical cut-offs for depression and anxiety, therefore we conducted analyses to establish whether participant outcomes were dependent on baseline defeat and entrapment levels. Participants completed measures of defeat, entrapment, depression and anxiety at two time-points twelve months apart. Factor analysis demonstrated that defeat and entrapment were best defined as one factor, suggesting that the experiences co-occurred. Regression analyses demonstrated that changes in depression and anxiety between T1 and T2 were predicted from baseline levels of defeat and entrapment; however, changes in defeat and entrapment were also predicted from baseline depression and anxiety. There are implications for targeting perceptions of defeat and entrapment within psychological interventions for people experiencing anxiety and depression and screening individuals to identify those at risk of developing psychopathology.

The reformulation of emotional security theory: the role of children's social defense in developmental psychopathology

Although children's security in the context of the interparental relationship has been identified as a key explanatory mechanism in pathways between family discord and child psychopathology, little is known about the inner workings of emotional security as a goal system. Thus, the objective of this paper is to describe how our reformulation of emotional security theory within an ethological and evolutionary framework may advance the characterization of the architecture and operation of emotional security and, in the process, cultivate sustainable growing points in developmental psychopathology. The first section of the paper describes how children's security in the interparental relationship is organized around a distinctive behavioral system designed to defend against interpersonal threat. Building on this evolutionary foundation for emotional security, the paper offers an innovative taxonomy for identifying qualitatively different ways children try to preserve their security and its innovative implications for more precisely informing understanding of the mechanisms in pathways between family and developmental precursors and children's trajectories of mental health. In the final section, the paper highlights the potential of the reformulation of emotional security theory to stimulate new generations of research on understanding how children defend against social threats in ecologies beyond the interparental dyad, including both familial and extrafamilial settings.

Entrapment and defeat perceptions in depressive symptomatology: through an evolutionary approach

The social rank and arrested defenses model for mood disorders bridges between animal and human models of psychopathology. There is increasing evidence that depression is associated with subordinated and loss of social rank, feeling inferior, shame, submissive behavior, and feeling defeated. These stressful states activate threat coping responses of fight and flight. If these are aroused but blocked, feelings of entrapment emerge with a negative impact on mood. The current study builds on previous studies and explores the association between depressive symptoms, social rank variables (of social comparison and submissive behavior), entrapment, and defeat in a sample of patients (n = 106) with major depression and in a sample of healthy controls (n = 116). Results showed that social rank variables, entrapment, and defeat were strongly associated with depressive symptoms in both samples. Entrapment and defeat showed significant association with other social rank variables. Logistic regression analysis revealed that defeat and internal entrapment were significant predictors of the belonging to the clinical or control groups. The present study extends previous research and supports the importance of defeat and external entrapment in clinical depression.

Prospective predictors of suicidality: defeat and entrapment lead to changes in suicidal ideation over time

Theoretical perspectives into suicidality have suggested that heightened perceptions of defeat and entrapment lead to suicidality. However, all previous empirical work has been cross-sectional. We provide the first longitudinal test of the theoretical predictions, in a sample of 79 students who reported suicidality. Participants completed self-report measures of suicidal ideation, depression, defeat, and entrapment at two time points, approximately 12 months apart. People higher in defeat became more suicidal over time (β= .45), with baseline levels of suicidality and depressive symptoms controlled. The current results support the posited role of perceived defeat in driving suicidal ideation.

Interpersonal sensitivities: their links to mood, anger and gender

This paper explores two interpersonal sensitivities (to rejection and to social put-down) in a group of 54 depressed men and 50 depressed women. Measures of anhedonia, anxiety, anger, social comparison, and submissive behaviour were also obtained. We found no differences in rejection sensitivity, anger, anhedonia, or anxiety between the sample of depressed men and women. Depressed women rated themselves as more submissive and more inferior than depressed men, and blamed themselves more for being criticized and put-down by other people. Principal components analysis (PCA) revealed three underlying factors: mood (including anxiety and depression), internalization (related to self-blame and feelings of low rank), and externalization (related to anger and blaming others for criticism). For both men and women internalization was significantly correlated with depression. However, externalization was negatively related to depression in women, but positively related to depression in men.

The relation of entrapment, shame and guilt to depression, in carers of people with dementia

There is increasing research exploring depression in carers of people with dementia. This study explored the relation of entrapment, shame and guilt to depression in a group of 70 carers of those with dementia. As in other studies the experience of entrapment in the role was highly related to depression. Moreover, experiences of shame relating to self-criticism, other people's expectations and the fear of their criticism were significantly related to depression, entrapment and guilt. Guilt however, as focused on the fears of harming others, letting others down and sense of responsibility, was not associated with depression or entrapment. Depression in carers may relate in part to feeling trapped in a role but also being vulnerable to criticism and feelings of inadequacy in that role. In this study, degree of behavioural disturbance/dependence was not found to be significantly associated with any of the research variables.

Susceptibility to subchronic unpredictable stress is related to individual reactivity to threat stimuli in mice

As in many complex behavioral responses, inter-individual variability can be observed in the responses to a chronic mild stress. While some subjects exhibit more resilient behaviours, others appear more susceptible to stress. This study hypothesizes that this variability relies on the individual appraisal of the stressful event. To study this assumption, mice were first subjected to a conditioned task occurring in a circular arena. In this task, a mild air-puff (i.e. stressor) in a given quadrant of the arena was coupled with the presence or the absence of a light in the same quadrant. Half of mice were then submitted to a 15-day subchronic stress consisting in various environmental and social mild stressors randomly applied two or three times a day. At the end of this procedure, the occurrence of depressive-like behaviours in stressed mice was assessed using measures of the stress regime (i.e. physical state, choice test, grooming test). The physical state assessed the physical appearance of mice. The grooming test consisted in measuring the time spent in grooming after mice were sprayed upon with a viscous solution. The choice test consisted in measuring the time spent in an uncomfortable place (i.e. whose floor was covered with damp sawdust) versus a more comfortable one (i.e. with dry sawdust) to evaluate the reactivity to a negative stimulus previously encountered during the subchronic stress. Multiple regression analyses revealed a relationship between attention toward salient stressful stimuli in the conditioned task and susceptibility to the subchronic stress procedure. These results are discussed regarding their relevance for the understanding of aetiologies of depressive illnesses.

Life events, entrapments and arrested anger in depression

OBJECTIVES

A recent, evolution derived theory of depression has suggested that aroused but arrested defences of fight (arrested anger) and flight (entrapments) may be important components of depression. This study therefore set out to explore unexpressed anger and entrapment in depression. The focus was on the nature of severe life events and difficulties, the time course of arrested defences, fantasies of escaping, fantasies of expressing anger, and reasons for not acting on emotions/behaviours.

METHODS

Fifty diagnosed depressed people, being treated for depression, were interviewed using the Life Event and Difficulties Schedule (LEDS). They then completed five further questionnaires: the escape inhibition questionnaire; the reasons for not escaping questionnaire; the anger inhibition questionnaire; the reasons for not expressing anger questionnaire, and the Beck Depression Inventory.

RESULTS

In regard to arrested flight, 88% of the group acknowledged strong desires to escape difficulties in their life but many felt unable to. Transcript analysis from the LEDS also indicated strong themes of entrapment. 38.7% felt trapped before becoming depressed. Fantasies of escaping were common, but making actual plans to get away less common. A variety of reasons were given for not escaping: In regard to arrested anger, 82% felt they suppressed their anger and 56% felt this problem predated their depression. A number of different reasons were given for not expressing anger. Despite self-blame often being seen as important to depression, we found that for many severe life events and difficulties patients did not blame themselves. Rather they blamed external circumstances or other people and saw these as the source of their entrapment.

CONCLUSIONS

Disturbances in fight/flight mechanisms are common in depression. For some these may predate a depression and may play a causal role, whilst for others these experiences emerge with the depression. Depression is related to chronic stress states and clinical attention to disturbances in flight/flight may throw light on these states and offer novel approaches to intervention.

Evolutionary aspects of anxiety disorders

Danger and harm are avoided by strategic decisions made at all three levels of the triune forebrain: rational (neomammalian), emotional (paleomammalian), and instinctive (reptilian). This applies also to potential harm from conspecifics, which leads to a choice between escalating and de-escalating strategies. Anxiety is a component of de-escalating strategies mediated by the paleomammalian and reptilian forebrains. When the neomammalian (rational) brain fails to deal with the threat of conspecific danger, these more primitive de-escalating strategies may be activated and may present as anxiety disorders. The capacity for concealment of anxiety and other forms of negative affect has also evolved, and excessive concealment may lead to psychopaihology by breaking the negative feedback loop of excessive motivation, leading to impaired performance, leading to signals of distress, and leading to reduced exhortation to succeed on the part of parents and teachers; this situation is illustrated by a model based on the Yerkes-Dodson law.

The Social Risk Hypothesis of Depressed Mood: Evolutionary, Psychosocial, and Neurobiological Perspectives

The authors hypothesize that depressed states evolved to minimize risk in social interactions in which individuals perceive that the ratio of their social value to others, and their social burden on others, is at a critically low level. When this ratio reaches a point where social value and social burden are approaching equivalence, the individual is in danger of exclusion from social contexts that, over the course of evolution, have been critical to fitness. Many features of depressed states can be understood in relation to mechanisms that reduce social risk in such circumstances, including (a) hyper-sensitivity to signals of social threat from others, (b) sending signals to others that reduce social risks, and (c) inhibiting risk-seeking (e.g., confident, acquisitive) behaviors. These features are discussed in terms of psychosocial and neurobiological research on depressive phenomena.

Pessimism and the Evolution of Negativity

The universal and nonrandom distribution of anxiety, fears, and depression suggests that there may have been underlying evolutionary pressures leading to adaptations for pessimistic thinking. Symptoms and processes that today we may label as psychopathology may have solved problems in an evolutionarily relevant environment, providing variations in individual behavior as a response to variations in availability of resources and vulnerability to threats and danger from predation. For example, investment strategies, the focus of this article, change with seasonal variation. Hibernation is marked by reduction of demand by limiting metabolic rates, activity, and arousal during winter months when resources are reduced, and conservation is salient, whereas manic enthusiasm focuses on short windows of opportunity, emphasizing overvaluation of pleasure, exploration, breeding, and diversification. A general theoretical model of investment strategies is proposed that accounts for sex differences in parental investments. Cognitive schemata focused on pessimistic strategies are viewed as operating through evolved algorithms that attempt to assure that behavioral and genetic investments are protected. These cognitive biases may account for male strategies of diversification and female strategies of consolidation and protection, and suggest possible determinants of a greater likelihood of females to be characterized by inhibition and depression.

Evolutionary Approaches to Psychopathology and Cognitive Therapy

This opening article outlines some key themes of an evolutionary approach to psychopathology, and explores possible implications for cognitive therapy. Evolutionary psychology suggests that many of our mental mechanisms are designed to promote survival and reproduction, not happiness, or even mental health, as such. This article focuses on the concept of evolved strategies and their phenotypic expressions, to fit specific niches. It suggests that evolved strategies and their phenotypic expressions partly operate through two psychobiological systems, called the defense and safeness systems, which detect and respond to threats and punishments, and safeness and potential rewards, respectively. Various cognitive schemas, rules and automatic thoughts, especially those linked to psychopathology, are often products of the linkages in strategies as coded in defense and safeness systems. The latter part of the article gives a brief exploration of the view that self-to-self relationships (self-evaluations and “self-talk”) evolved from social cognitions and behavior. Negative self-evaluations, self-criticism, and self-attacking are viewed as internalized interactions between a hostile, dominant part of self, and an appeasing, subordinate part of self. One way of undermining this interaction is to introduce the notion of compassion for the self. A brief consideration is given to the development of “compassionate mind” in work with shame-prone people as expressed in high self-criticalness and/or self-hating. Throughout the text the main problems addressed are those of the more chronic, emotional difficulties often associated with some degree of what is called personality disorder.

Evolution and social anxiety. The role of attraction, social competition, and social hierarchies

If human social anxiety is not predominately about the fear of physical injury or attack, as it is in other animals, then, to understand human social anxiety (i.e., fear of evaluation), it is necessary to consider why certain types of relationships are so important. Why do humans need to court the good feelings of others and fear not doing so? And why, when people wish to appear attractive to others (e.g., to make friends, date a desired sexual partner, or give a good presentation), do some people become so overwhelmed with anxiety that they behave submissively and fearfully (which can be seen as unattractive) or are avoidant? This article has suggested that humans have evolved to compete for attractiveness to make good impressions because these are related to eliciting important social resources and investments from others. These, in turn, have been linked to inclusive fitness and have physiological regulating effects. Being allocated a low social rank or ostracized carries many negative consequences for controlling social resources and physiological regulation. Social anxiety, like shame, can be adaptive to the extent that it helps people to "stay on track" with what is socially acceptable and what is not and could result in social sanction and exclusion. However, dysfunctional social anxiety is the result of activation of basic defensive mechanisms (and modules for) for threat detection and response (e.g., inhibition, eye-gaze avoidance, flight, or submission) that can be recruited rapidly for dealing with immediate threats, override conscious wishes, and interfere with being seen as a "useful associate." Second, this article has suggested that socially anxious people are highly attuned to the competitive dynamics of trying to elicit approval and investment from others but that they perceive themselves to start from an inferior (i.e., low-rank) position and, because of this, activate submissive defensives when attempting to present themselves as confident, able, and attractive to others. These submissive defenses (which evolved to inhibit animals in low-rank positions from making claims on resources or up-rank bids) interfere with confident performance, leading to a failure cycle. While psychological therapies may target specific modules, cognitions, and behaviors (e.g., damage limitation behaviors, eyes gaze avoidance, theory of mind beliefs) that underpin social anxiety, drugs may work by having a more generalized effect on the threat-safety balance such that there is a different "weighting" given to various social threats and opportunities. If social anxiety (and disorders associated with it) are increasing in the modern age, one reason may be invigorated competition for social prestige, attractiveness, and resources.