Theoretical Perspectives of Depression

Introduction

According to the National Institute of Mental Health (NIMH) (2013), depression continues to be a global epidemic. Surely at one time, the majority of the population has experienced bouts of sadness, loss of energy, and emotions such as worthlessness or guilt. However, if such symptoms last longer than two weeks, it is a possibility that clinical depression is the cause. The World Health Organization (WHO) (2012) found that approximately 350 million people worldwide suffer from depression. Moreover, WHO (2012) expects depression will be the second leading cause of disability and morbidity by 2020.

The DSM-5 divides depressive disorders into “disruptive mood dysregulation disorder, major depressive disorder, dysthymia, premenstrual dysphoric disorder, substance or medication induced depressive disorder, depression due to medical conditions, and other specified or non-specified depressive disorders” (American Psychiatric Association, 2013). Ultimately, depressive disorders may vary, but the most common features are “sad, empty, or irritable mood, accompanied by somatic and cognitive changes that significantly affect the individual’s capacity to function” (APA, 2013, para.1). Depression does not discriminate based on gender and race. While it has been noted females are mostly susceptible, males often suffer from depression too. However, while depression can be debilitating, it is a treatable disorder. Treatment includes antidepressants and psychotherapy. Scientists have found that genetics may increase an individual’s propensity to depression. It has been argued that if an abused or neglected person is genetically vulnerable, he or she is more likely to develop depression (Harvard Health Publication, 2011). Object relations theorists suggest that individuals develop depression when they are unable to develop images of healthy relationships (Herbert, McCormack, & Callahan, 2010). Similarly, psychosocial theorists argue that individuals are influenced by unrecognized assumptions regarding their environment (Harvard Health Publications, 2011). Taking each of these arguments into account, this paper will focus on the application of object relations theory and psychosocial theory and apply neurobiological and diversity factors in order to increase understanding of depression’s etiology.

Object Relations Theory

Object relations theory examines a person’s relationship, how the person processes the relationship, and the role of internalized relations (Flanagan, 2011). Flanagan (2011) has noted relations and relationships are two separate factors. Relationships involve external components, so when two people form a relationship, they each form “fantasies, desires, and fears, which invariably include images or representations” (Flanagan, 2011, p. 119) of each other. Furthermore, a person may have an allegedly healthy relationship with one person, but his or her object relations have caused that person to doubt all others and focus on the one person in the relationship (Flanagan, 2011).Furthermore, the person may not have a relatively good relationship because he or she has merely withdrawn from others. Subsequently, this has led the individual to mistakenly believe that the other person is perfect. Fundamentally, object relations theory proposes one’s internalizations of relationships are often more “powerful” than their external interactions (Flanagan, 2011).

In regards to depression, individuals will vary in their reactions to life events. While one person may brush off negative events, another person will internalize that negative event, so it becomes enmeshed with his or her psyche. Object relations theorists such as Melanie Klein, W. R. D. Fairbairn, D. W. Winnicott, and John Bowlby developed their concepts in order to understand depression and its development.

Melanie Klein

Klein proposed that individuals’ inherent characteristics would influence the way that they responded and related to themselves, to others, and their environments. When children are born, they associate certain objects with love (Likierman, 2001). Subsequently, this association also reminds children that their objects and subsequently their love for the objects can be lost (Likierman, 2001). This “depressive position” (Likierman, 2001, p. 100) begins to develop in a child’s first year, but it is refined throughout his or her life (Likierman, 2001). However, the initial love object was often the caregiver or more explicitly the mother. In this case, children eventually realized that they could love and hate their mothers at one time, and in the case they experienced negative emotions regarding their caregiver, they repressed these sentiments and kept those emotions to themselves (Likierman, 2001).

Klein suggested weaning was a child’s first loss (Likierman, 2001). While breastfeeding offers children sustenance, mothers may equate it to early bonding and nurturing. Consequently, to the child, when the mother begins to wean him or her, the child has come to accept the mother’s breasts as sources of food and comfort (Likierman, 2001). Afterwards, after weaning, children have their first experience with mourning and loss. If children were unable to accept their mothers’ decision to stop breastfeeding, they could harbor negative feelings, but they would feel guilty (Likierman, 2001).

In the case of depressed individuals, excessive or unnecessary guilt is one of the most common symptoms (American Psychiatric Association, 2013). Taking Klein’s theory into consideration, weaned children may experience guilt because while they love and accept their mothers, they may subconsciously dislike them for taking away their comfort and security. As children mature, they began to understand weaning is a necessary event, but if they have subconsciously felt guilty for their negativity towards their mothers, the guilt may have transformed into unreasonable guilt. Specifically, Bedi, Muller, and Thornback (2013) suggested “these internalizations are thought to carry over and directly influence adult relationships, often resulting in dissatisfaction in intimate relationships and difficulty trusting others” (p. 233). The DSM-5 (APA, 2013) reveals depressive symptoms may include a decrease or loss of activities. While people may differ in their socialization, depressed patients may lose interest in spending time with their friends. Essentially, they may isolate themselves. Teo (2013) has found that people who suffer from major depression isolate themselves significantly. Unfortunately, Teo (2013) also reported that social isolation is associated with suicide. The DSM-5 has found some patients who suffer from depression reportedly have reoccurring thoughts of death or suicidal ideations (APA, 2013). When applying Klein’s theory to depression, successive guilt or disappointment in others may cause others to socially withdraw from their family, community, or friends. Nevertheless, if a child had an engaging and reciprocal interaction early on, he or she may fell less disposed to depression or social isolation.

W. R. D. Fairbairn

Fairbairn proposed the self and its internal world is the result of external interactions and experiences (Flanagan, 2011, p. 135). Fairbairn speculated that people are loyal to their objects, or relationships, regardless of their status (Gomez). However, when an internal object is negative, individuals will view the external world in the same way (Gomez). Fairbairn suggested the self and its internal world is derived by outside interactions and experiences (Flanagan, 2011, p. 135). While Freud speculated the ego was separated into the id, ego, and superego, Fairbairn believed the ego was a whole unit, but it consisted of conscious and unconscious parts (Flanagan). With that in mind, Fairbairn believed the ego was divided into the central ego, the libidinal ego, and the anti-libidinal ego (Flanagan, 2011).

The central ego seeks relationships; however, depending on the circumstances, the central ego is forced to split (Flanagan, 2011). Subsequently, evolving children’s antilibidinal egos respond to objects that reject them (Flanagan, 2011). In turn, they develop shame or hate against the rejecting object (Flanagan, 2011). In comparison, the libidinal ego is an indulgent force that expects constant love from their objects (Flanagan, 2011). At one point, the libidinal ego internalizes specific times in which caregivers lavished it with love and attention (Flanagan, 2011). Consequently, this fantasy continues and results in an emotionally unhealthy attachment (Flanagan, 2011). In regards to the depressed patient, Fairbairn reported the therapist should commit to the client because the client would only be able to change if he or she took place of the client’s attachments to “internal bad objects” (Gomez, p. 74).

Therefore, when applying Fairbairn’s concept to the development of depressive disorder, the child’s perception of self depends on his or her environment and attachment to objects. If parents neglect their children, children may become hopeless because the object is a negative attribute. In time, this hopelessness may lead to a pessimistic view of the world and relationships and encourage isolation or disinterest. Ultimately, the antilibidinal ego and the libidinal ego are constantly at odds. The DSM-5 reported depressive symptoms include indecisiveness (APA, 2013). Theoretically, perhaps conflict produces that indecision. As aforementioned, Fairbairn suggested children are loyal to their objects. Objects of attachment that continually force the child to love it one moment and hate it the next may also encourage indecision. On the other hand, object relations theorist Winnicott postulated it was up to the individual to balance attachment and attitude (Flanagan, 2011).

D. W. Winnicott

Winnicott proposed casual relationships with strangers could “gratify one’s impulses or drives” (Flanagan, 2011, p. 121). However, in order to satisfy a need, Winnicott speculated that the person supplying the need had to be meaningful to the receiver (Flanagan, 2011). In this case, the caregiver or mother was the likely source of supply. Winnicott proposed “that a healthy mother must allow herself to lose herself completely in her baby” (Flanagan, 2011, p. 127). It is this closeness that allows the baby to feel whole and secure (Gomez). As the baby developed, he or she would become frustrated with his or her limitations; however, at the same time, the mother would lose her “obsession” (p.87) thus enabling the child to explore and become separate. If the mother did not completely lose herself to her child, Winnicott predicted that the child would grow up distrustful and withdrawn (Flanagan, 2011). Skolnick (2006) emphasized that “The presence of others is essential for the reaffirmation and continuance of our internal and external worlds of meaning” (p.2). Consequently, when applying Winnicott’s theory depression, in order to feel as though one is worthy to live, he or she may have to develop that confidence early on in his or her life. Notably, the DSM-5 noted depressive symptoms may include a loss of hope and emptiness (APA, 2013). Perhaps in this case, the lack of reaffirmation may heighten the propensity for depression. On another note, in the therapeutic sense, the therapist becomes the caretaker while the client is the care receiver (Flanagan, 2011. Consequently, therapists should be aware of their clients’ psychological growth.

Bowlby

Bowlby suggested human beings were meant to develop relationships as part of their survival (Gomez). Moreover, children’s bonds to their caregivers differentiated between life and death. Subsequently, if people do not have secure foundations, they may feel insecure with their attachments. John Bowlby suspected early establishment of affectionate relationships were fundamentally important to future emotional development (Shaffer, 2009). Bowlby observed sickly toddlers who spent time without their parents because they were hospitalized and found that these children went through three initial phases: protest phase, phase of despair, and detachment phase (Shaffer, 2009). Bedi, Muller, and Thornback (2013) have suggested “early separation from caregivers [is] thought to result in the development of negative expectations of others and a sense of self as worthless” (p. 233). Subsequently, when applying Bowlby’s theory to depression, one of the most common symptoms is a sense of worthlessness, so it is likely those who suffer with depression were separated from their parents early on, or they were neglected. Bowlby suspected that children who were separated from their parents for long periods of time reached the detachment phase and were unable to develop secure attachments to temporary objects, such as their nurses or other care providers (Shaffer, 2009).

Psychosocial Theory

In his psychosocial theory, Erik Erikson emphasized that there were life stages that categorized development, and individuals would face eight conflicts throughout their life span. Moreover, in order to move on to the next stage in their lives, individuals had to successfully resolve their crisis. Within children’s first year of life, they would face the crisis of “basic trust versus mistrust” (Shaffer, 2009, p. 42). Erikson asserted children wanted to trust their primary caregivers and know, without a doubt, that they would be fed and, most importantly, their caregivers were responsive to their psychological needs as well (Shaffer, 2009). When children had caring and responsive caregivers, they would successfully determine that they could trust those people. On the other hand, if the child was neglected by an unresponsive caregiver, he or she would learn that there were some people that could not be trusted. Essentially, Erikson argues that this first stage has tremendous impact on future relationships (Shaffer, 2009). Notably, Erikson noted that family plays an important role in the child’s development. For example, when children are one to three years old, they experience the stage “autonomy versus shame and doubt” (Shaffer, 2009). In this stage, the child begins to view him or herself as separate from the parent. In addition, at the time children begin to tentatively look after themselves such as allowing themselves to be toilet trained or brushing their own hair (Shaffer, 2009). If a child is unable to master such tasks, he or she may feel shameful and doubtful of his or her independence. At the same time, Erikson suggested that while children are exerting their independence, parents play a significant role in their success (Shaffer, 2009). The family as a whole is a key component in the child’s next crisis of “initiative versus guilt” (Shaffer, 2009). While children are maturing, they begin to make their own decisions. In the case that their decisions conflict with their family, children experience guilt (Shaffer, 2009). Subsequently, if they do not overcome this crisis, children may internalize that guilt and it may become a part of their psyche. Afterwards, as children leave the dynamics of family, they go on to school and develop peer relationships in the “industry versus inferiority” stage and the “identity versus role confusion” stage (Shaffer, 2009, p. 42). In these crises, peers or teachers are key social agents.

Fundamentally, Erikson proposed children wanted to adapt to their environments so they actively explored it (Shaffer, 2009). Fundamentally, “hope, will, purpose, and competence” are a child’s greatest strengths, and children are able to foster these virtues if their caregiver relations and environments are secure (Capps, 2008). In the event children are not exposed to reciprocal relationships with their caregivers, this lack of bonding may impact children’s later years as they can become socially withdrawn and depressed. Capps (2008) has noted that the mother figure is the most important in a child’s life because mothers are able to give life and withhold life, such as breastfeeding, so the mother and child relationship will often determine the child’s fate. On the other hand, Hoare (2013) has suggested Erikson thought all early relationships prompted a child’s identity; however, the child’s self-image depended on the caregiver. In other words, if a caregiver saw a child as inadequate, the child would subsequently view him or herself the same. Hoare (2013) has noted this experience is similar to viewing oneself in a distorted mirror. The image is distorted, so it is not the way a person actually looks. Instead, it is an internal representation because it relies on the person’s perception of the mirror image.

In the case of depressive disorder, Sperry and Widom (2013) have suggested depressed patients internalize other’s opinions or neglect and that internalization causes depression. For instance, if a mother neglected her child in the first year and withheld love, security, and nourishment, the child would learn to mistrust his or her mother. Consequently, if a baby learned to mistrust, he or she would doubt him or herself. Depression often encounters symptoms such as hopelessness, so subconsciously, perhaps depressed individuals identify with this emotion because they were unable to secure their caregivers’ love, so they felt hopeless at a very young age.

Neurobiology

Depressive symptoms may be similar but when two people suffer from depression, the cause, and, subsequently, depression treatment, may differ. Clinicians may refer to depression as a “chemical imbalance” (Harvard Health Publication, 2011, para. 1) because neurotransmitters send chemical messages between neurons (National Institute of Mental Health, n.d., “Brain basics”). Essentially, researchers have found that the connection and growth of the nerve cell, along with “the functioning of nerve circuits” (NTMH, n.d. “Brain basics”) will influence depression.

Fundamentally, the amygdala is the central processing station for emotions (NTMH, n.d. “Brain basics”). Neurons conduct messages; dendrites, the point of contact, result in impulses; and axons send impulses (NTMH, n.d. “Brain basics”). Synapses are the small gaps between neurons, and they transport messages from neuron to neuron, so the neurons’ communication from one to the next will determine individuals’ reactions and actions. With that in mind, one can picture a row of individuals standing in a straight line, holding hands, and swinging their arms. If individual in the middle could not connect with the person on his or her right, the rhythm would be lost. As a generalization, the brain processes its information similarly. If one aspect is out of rhythm, it cannot communicate.

Penninx et al. (2013) reported that the brain’s cortex perceives stress and transmits it to the hypothalamus. In turn, the hypothalamus releases corticotropin-releasing hormone into the pituitary receptors that results in releasing cortisol in the blood (Pennix et al., 2013). Penninx et al. (2013) noted recurrent and first episode depression cases had revealed a higher cortisol awakening response. Subsequently, this finding suggests “HPA-axis hyperactivity represents more a vulnerability than a state indicator” (Penninx, 2013, p.) Moreover, HPA-axis hyperactivity may contribute to the inclination that depression is hereditary because this hyperactivity has been found in a depressed person’s children (Penninx, 2013).

Harvard Health Publication (2011) has noted that studies have found that people who are prone to depression often have a smaller hippocampus. However, males are equally at risk, and their depressive symptoms include isolation, self-medicating, avoidance, and over-working (Chuick et al., 2009). With that said, depressed patients often seek relief in antidepressants.

Antidepressants such as Prozac and Zoloft prevent brain cells from absorbing too much serotonin, so some patients feel relief. For the last fifty years, most researchers have agreed that insufficient serotonin level is the reason behind depression (Cai et al., 2013). However, this serotonin elevation does not relieve every depressed patient (Cai et al., 2013). Cai et al. (2013) found in their research that serotonin actually can heighten communication between brain cells.

Cai et al. (2013) exposed mice and rats to stressful situations in order to replicate psychological triggers. After the stressors, Cai et al. (2013) noted that the study animals exhibited signs of anhedonia. Incidentally, the study animals’ brain activity did not indicate stress had any effect on serotonin levels; however, Cai et al. (2013) found that serotonin helped the excitatory connections to properly function and restore communication. Cai et al. (2013) equated the communication to an amplified voice. Subsequently, their research prompts science to reconsider depression’s origin.

Diversity

The majority of this paper has been focused on the possible reasons behind the development of depression. Significant research has suggested neglected and abused children are at risk for depression later on in their lives because they were unable to form healthy attachments (Bedi, Muller, & Thornback, 2013; Sperry & Widom, 2013; Teo, 2013; and Wilkinson & Mulcahy, 2010); however, other research reports that depression is an emotional vulnerability (Cai et al., 2013; Penninx, Milaneschi, Lamers, & Vogelzangs, 2013). The National Institute of Mental Health (2013) reports that depression is common in the United States, but women are more likely to experience depressive symptoms. In addition, African Americans are noted to be 40% more likely to develop depression compared to Caucasians (NIMH, 2013). While NIMH’s statistics seem to suggest women are more likely to develop major depressive disorder, Chuick et al. (2009) has found that males are less likely to report depressive symptoms. Consequently, depression may not impact females more than men. Chuick et al. (2009) reported males are four times likely to commit suicide, so based on DSM-5 diagnostic criteria; men succumb to the most fatal depressive symptom.

In addition, child abuse and neglect has been attributed to clinical depression. As aforementioned, in object relations theory, the abused child internalizes negative experiences within the environment. In that case, children are only able to form unstable individual and interpersonal representations. Unfortunately, depression’s origins continue to be a mystery for researchers and scientists, so depressed patients may rely on medication and therapy for relief.

Treatment

Ultimately several factors contribute to the etiology of depression. Subsequently, the treatment for individuals with depressive disorders may include therapy and antidepressants. In regards to treatment, depressed patients have responded to Cognitive Behavioral therapy and Interpersonal Psychotherapy. However, individuals have different responses to medications, so effective therapy should consider the person and his or her background.

Cognitive behavior therapy (CBT) teaches patients to understand the types of thoughts and feelings that ultimately influence their behaviors (Ledley, Marx, & Heimberg, 2005). In fact, Ledley, Marx, and Heimberg (2005) have reported CBT’s “therapeutic relationship is viewed as one between equals” (p. 3). In other words, the client and the therapist are “equals” (Ledley, Marx, & Heimberg, 2005, p. 3) because the client has experience with his or her ailments and the therapist has been trained to treat such ailments. Essentially, the therapist teaches the patient to unlearn negative behaviors.

In regards to the depressed patient, CBT allows them to develop coping skills (Ledley, Marx, & Heimberg, 2005) when faced with dangerous thoughts or uncomfortable situations. As the DSM-5 has indicated, depressive symptoms can affect individuals until they are no longer able to properly function in day to day activities ("Depressive Disorders," 2013). Moreover, depression can also be the culmination of internalized images. According to object theorists, early on in a child’s development, he or she may have had a negative outside experience and internalized that experience onto him or herself. On the other hand, psychosocial theorists may consider that the depressed patient did not successfully master the skill of basic trust versus mistrust.

The DSM-5 has reported depression is a recurring disorder ("Depressive Disorders," 2013). Thus, Ledley, Marx, and Heimberg (2005) suggested therapists assess the amount of episodes clients have had. In addition, after therapists understand how many recurring episodes a patient has had, they should attempt to understand what has happened in between each episode in order to identify patterns (Ledley, Marx, & Heimberg, 2005). Ultimately, “clients should be asked about their emotional, behavioral, and physiological responses (Ledley, Marx, & Heimberg, 2005, p. 44) during a depressive episode. While most patients may be able to identify their emotional and behavioral responses, cognitive-behavioral therapists can teach them to understand the physiological responses that may lead to psychomotor agitation or retardation ("Depressive Disorders," 2013). Essentially, CBT is most affective when patients are engaged in their therapy and they have the strength to adopt new behaviors (Ledley, Marx, & Heimberg, 2005, p. 44).

In the case that the therapist finds the patient suffers from relationship and communication problems, he or she may consider Interpersonal Psychotherapy (IPT). Markowitz and Weissman (2012) reported IPT “defines the patient’s problems as a treatable medical diagnosis, and links the patient’s affective distress to interpersonal situations in order to help the patient better understand and handle them” (p. 4). For example, a patient may attribute his or her depression to the significant other, so IPT allows the patient to identify why and how that person, or idea, is causing depressive symptoms. In regards to objects relations theory, IPT falls in line with objects, such as the significant other, affecting the client’s internal organization. Subsequently, IPT would teach the patient how to express his or her feelings to the significant other. Markowitz and Weissman (2012) have suggested role play helps the patient learn to respond, but he or she does so under the therapist’s guidance.

With object relations theory in mind, IPT is especially effective when patients suffer from “interpersonal deficits” (Markowitz & Weissman, 2012, p. 67). Markowitz & Weissman (2012) have admitted that asking patients to recognize their “interpersonal deficits” (p. 67) is difficult, but it is ideal for those who are isolated and difficulty with forming attachments. However, it is important that the therapist thoroughly recognize if the isolation is due to the client’s depression or if it is based on an earlier relationship or lack thereof (Markowitz & Weissman, 2012). Significantly, object relations involve interpersonal relationships and how the depressed person has used these interactions to form his or her self-image. Consequently, these internalizations are an especially important factor to consider in these types of individuals.

Conclusion

Depression comes in many levels and while its severity will differ, it is a treatable and manageable disorder. It has been noted that males and females are both prone to depression. While statistics show women suffer from depression, males are more likely to commit suicide because of depressive disorder. Essentially, it is a danger for both genders. Moreover, the National Institute of Mental Health reported that it is a global epidemic and WHO solidifies that data as they noted 350 million people worldwide suffer from depression. That number continues to grow.

While early neglect and abuse seems to instill vulnerability in certain patients, heredity also plays a role. While object relations theorists suggest depression was developed at a young age and progressed over the years, it seems that early bonding may foster confidence in others and in turn love for oneself. In addition, when one has self-confidence and a positive self-image, he or she may be able to conquer any crisis that comes with natural development. Moreover, depending on a person’s physiology, antidepressants may alleviate the symptoms so he or she can focus on the treatment.Ultimately, educational programs and community awareness regarding depression may encourage people to seek help. CBT and IPT have shown success in treatment. Negative actions and reactions can bear significant weight on weary shoulders, so changing behavior and negative thoughts would help a depressed person to manage and to relearn healthy habits and behaviors. In addition, neglect and abuse are intolerable, but when depressed patients realize that the image they see in the actual mirror is not an internalization of someone who hurt them, they may possibly learn to love themselves and allow themselves to love others. Depression is a clinical disease and if it is left untreated, its consequences are severe.

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