StayOnTop: Depression

Most of us will be aware that the idea that there is one main cause of depression is overly simplistic. In some corners of the internet you’ll still find websites where this primitive idea lingers on, probably based on the hope that by just pinpointing the one essential cause, we can also indicate the one and only universal cure. But today, this is mainly the position of quacks who try to make a fast buck by selling false hope to the gullible.

    Still, even in professional psychiatry and psychology, researchers and therapists sometimes tend to keep searching for causes in one specific direction: brain functions, chemical or hormonal balances, genetic inheritance, environmental factors, food or sleep or daily-behavior patterns, or some other part of the puzzle (see for example my post on “Steampunk Psychiatry”).

    In an interesting research article (footnote at bottom) Denny Borsboom and four of his colleagues, psychologists at the University of Amsterdam, have now tried to outline a different and more nuanced approach – one that also leaves room for acknowledging more individual variation in the ways mental health problems can develop and grow worse over time.

    Basically, they view depression (and other forms of psychiatric illness) not as one single problem but as a cluster of interconnected problems: as a complex, dynamic network of symptoms.

    Put even more basically, we can say that their approach starts from something that resembles the well-known metaphor of the domino effect: the chain of reactions where in a row of standing domino stones, each falling one causes the next one to fall.

In the context of depression a typical “domino” sequence can be, for example, that you experienced a loss, consequently start brooding about it, consequently loose sleep, consequently function less well socially, consequently start feeling guilty: all these consequential symptoms re-triggering and reinforcing each other.

    Two things are notable here. In the first place, the Amsterdam researchers tried to identify possible domino stones and their relations. They collected all kinds of recognized symptoms from the authoritative DSM-IV handbook and grouped them by diagnosis. In that way they were able to construct various (but partially overlapping) clusters of interconnected symptoms.

    Secondly, the researchers did not assume one fixed, standard domino sequence. They also did not just suppose that the tendency-to-fall of any domino stone can differ for individual people (which they think might have to do with complex genetic connections). In their view, for different people, different domino stones can play a role, and can fall in a different sequence: even if the overall end result (what we call “depression”, the name for a cluster of those symptoms) looks more or less the same.

They visualized this schematically for two different cases:

The picture shows how within the “network” of one’s personal depression, for two people the actual connections may be very different. Each dot stands for a specific depression-related symptom: for an explanation, I must refer you to page 2 of the actual paper. The red dot at the top stands for some external life event that triggers the whole (the first domino stone, we might say).

    This, in my own view, is a shortcoming here: it looks like the researchers assume, without much discussion, that there usually is some external event that initially triggers the whole cascade of symptomatic effects. I wonder if that can always said to be true. Couldn’t the process begin just as well with one random symptom, all by itself, internally, so to speak?

    But I must say I find the approach of these researchers very refreshing and interesting. They also come up with original suggestions I cannot go into here in detail, such as the option of trying to define not just symptoms but also anti-symptoms in a kind of reverse-DSM list – in the domino metaphor perspective, that would be domino stones that are sturdy and stable enough to keep standing and to prevent other elements from falling.

    I must warn you that their paper is, as was to be expected, a rather technical read. Sometimes it is abstract to the point of becoming hard to comprehend for ordinary mortals like you and me. The researchers clearly aim at first building some kind of theoretical framework here, some kind of basis for discussion and further research. So you should not expect much in the line of concrete, directly applicable suggestions. Still I found it original and thought-inspiring. Try taking a look!

    And at least one clear lesson can be drawn. Do I need to remember you how not to fight a cascade of falling domino stones?

No, what you see here is not the wisest strategy. Many of us may futilely keep trying to resist in such a way: keep trying to change everything for the better again, all at once. But in the middle of a deep depression, this simply may mean you’re asking too much from yourself.

    Instead, a much better strategy to counteract such a chain reaction is to just remove some links from the chain: to quickly pull one or two domino stones out of the row. Then even if the first ones begin to fall, all the rest – past the gap – will remain standing.

Which leaves us with a strategy tip that is in fact not new at all.

• tip: If you have many symptoms of depression (suicidal thoughts, sleep problems, feelings of guilt, eating problems, and so on) then maybe it’s a good idea to concentrate on one specific, small, single thing for a while: why not try to pull that one little domino stone out of the row?
    For example, if one of the problems is you don’t have the energy to take a daily walk anymore, focus on that one thing only and try forcing yourself to take that walk anyway. It may help to interrupt the ongoing cascade.

• note: This post was about The Small World of Psychopathology by Denny Borsboom, Angélique Cramer, Verena Schmittmann, Sacha Epskamp and Lourens Waldorp from the University of Amsterdam, published November 2011 in the online peer-reviewed journal PloS ONE.
    Full text of the article: PloS ONE: The Small World of Psychopathology. Next to the text you’ll also find a link for downloading the 11-page PDF version (I recommend that one, because of the diagrams and graphs).

• update: In a reaction to this post, author Denny Borsboom emphasized that they did not intend to suggest one-sidedly that a depression “cascade” usually needs some external event (such as the loss of a loved one) to be triggered. They also assume the possibility of internal physical triggers (such as chronic pain). And in line with general system theory, they also assume that in some cases one’s internal “network” can just be inherently unstable.

 
Author: Henk van Setten