BEHAVIORAL ATTITUDES AND DEPRESSION: CAUSE AND EFFECT RELATIONSHIPS
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February 28, 2013
Activitas Nervosa Superior 2007;49:3-4
V. Rotenberg, A. Cholostoy, P. Gurwitz, E. Shamir & Y. Baruch Abarbanel Mental Health Center, Tel-Aviv University
Correspondence to: V. S. Rotenberg, MD, Ph.D., D.Sc.email@example.com
Abstract :It was shown previously that depression is characterized by the decrease of the active search behavior and by the increase of renunciation of search. The goal of this investigation was to check the relationships between the severity of depression and the structure of behavioral attitudes: search activity, stereotyped, chaotic and passive behavior. Subjects were 44 patients with major depression.
Key words: major depression; behavioral attitudes; BASE test
Methods: BASE test for the evaluation of behavioral attitudes and the 21-item Hamilton Rating Scale for depression. Results:
Conclusion: the level of depression does not determine the configuration of behavioral attitudes but rather is the outcome of this configuration.
In our pilot investigation performed on 20 patients with major depression (Rotenberg, Cholostoy, 2004) we found that depressed patients in comparison to control group of healthy subjects are characterized by prominent decrease of search activity and by increase of passive behavior (renunciation of search). These data confirmed the prediction of the search activity concept (Rotenberg, 1984; 2003). According to this psychobiological concept, the subject's resistance to stress and to psychosomatic disorders is determined by the subject's predominating behavior in indefinite situations with unpredictable outcome. Four types of behavior are distinguished:
1. Search activity (SA) which is designed to change the situation or the subject's attitudes to it, with uncertainty regarding the results of this activity, but with constant monitoring of the results at all stages of activity. Active estimation of the situation in order to choose a relevant strategy of behavior also relates to search activity.
2. Stereotyped behavior (St), which uses habitual skills and algorithms with the predictable outcome of behavior. This behavior is adaptive and relevant in definite conditions that does not require search for new ways.
3. Chaotic (Ch) or panicky behavior, which does not include monitoring of the results of activity, is not flexible and is usually accompanied by maladaptive anxiety.
4. Renunciation of search (passive behavior, Pa) is opposite to search activity and manifests itself in giving up and helplessness. According to the concept, it is a background of depression and is often a final outcome of chaotic behavior (Rotenberg, Boucsein, 1993).
Both search activity and stereotyped behavior are goal-oriented and adaptive forms of behavior while chaotic and passive behavior is maladaptive.
In order to estimate quantitatively the different forms of behavior we have developed a special test BASE (Behavioral Attitudes and Search Evaluation, Venger et al., 1996). This test combines principles of both projective technique and a personality questionnaire (for details see Methods). We have used BASE for the investigation of healthy Russian-speaking new immigrants in Israel, both adolescents and adults (Rotenberg et al., 1998; 2001). Recently we have investigated also 37 healthy native citizens of Israel. We found that in healthy adult subjects SA and St scores have usually positive meanings (>0) while Ch and Pa scores have usually negative meanings. In depressed patients, according to
the pilot investigation mentioned above the configuration of BASE was different: SA had a negative meaning and Pa had a positive meaning. These data correspond to the data of the investigation performed under the supervision of Professor Viviola Gomez (Umana et al., submitted for publication). They found in healthy subjects a significant although not high correlation between Pa score of BASE and the depression subscale of the General Health Questionnaire (GHQ-28) in healthy subjects. It corresponds also to the data of Hossain et al. (1999) who have shown that SA scores was significantly less in depressed patients than in patients with night apnea.
However, our pilot investigation was performed on a restricted number of only Russian speaking depressed patients, thus the number of the investigated patients has to be enlarged and include the representatives of the native citizens of Israel. In addition, one important question remained open: do the alterations of behavioral attitudes in depressed patients reflect the state of depression and depend on the severity of depression, or are they trait variables and characterize personal predisposition towards depression. If behavioral attitudes correlate with the severity of depression (measured by use of the Hamilton Rating Scale) and if the values of behavioral attitudes are significantly different in patients with the prominently high vs. low indexes of Hamilton Rating Scale, then it is worth to suggest that the alterations of behavioral attitudes reflect the severity of depression. On the other hand, if the behavioral attitudes are similar in patients that differ in the severity of depression and do not correlate with the Hamilton Rating Scale, it seems reasonable to suggest that the alteration of the structure of behavioral attitudes probably displays a predisposition to depression rather than its outcome.
The well known "monoamine concept" (Schildkraut, 1965) which emphasized the role of the deficit of monoamines, particularly norepinephrine and serotonin at relevant synapses in the pathogenesis of depression (Delgado, 2000; Moreno et al., 2000) makes the discussion of the relationships between behavior and brain monoamines relevant. According to the modified "monoamine concept" (Rotenberg, 2006), search activity in wakefulness requires a certain critical level of the brain monoamines to start, and at the same time search behavior stimulates by itself the synthesis of the brain monoamines and ensures their availability. This concept proposes that search activity in wakefulness decreases the sensitivity of the inhibitory presynaptic alpha2-adrenoreceptors thus preventing the inhibition of monoamines neurons for maintaining a stable high level of monoamines in synapses used as an "oil" for the active behavior. Thus, the more pronounced search activity is, the sooner the turnover and synthesis of monoamines will be, in its turn maintaining search behavior (positive feedback system). In a passive state of renunciation of search this positive feedback system does not function and monoamines display a tendency to drop, especially by taking into consideration that renunciation of search is usually accompanied by distress. This theory helps to solve some paradoxes related to the effect of different antidepressants (see Rotenberg, 2006).
According to this proposition, search activity concept postulates the vicious circle between behavior and depression: search activity is required to prevent or overcome depression while depression by itself blocks active behavior. Renunciation of search may be the outcome of depression; however it may be also a predisposition to depression. It may be caused by traumatic life events like in reactive depression or in the posttraumatic syndrome (as an outcome of the state of helplessness), while in major depression it may be a personal feature that predisposes subject to the development of depression. In such cases behavioral attitudes will not depend directly on the level of depression.
The goal of the present investigation was to check the propositions mentioned above and to investigate the relationships between the level of depression and the structure of behavioral attitudes.
44 patients with major depression (21 men and 23 women, mean age 44, 8, SD=14.5 years) hospitalized in Abarbanel Mental Health center. The study was approved by the Institutional Review Board and the Israeli Ministry of Health Committee for Studies in Human Subjects. Written informed consent was obtained from all participants following an explanation of the nature of the study. Diagnosis was established according to DSM-IV criteria on the basis of the structured clinical interview. There were no non-psychiatric medical conditions responsible for depression. All patients were treated with SSRI partly combined with mood stabilizers and benzodiazepines. The mean duration of illness was 14.2, SD= 11.6
years. The mean number of previous hospitalizations was 2.4, SD=2.2.
Patients were asked to complete the Behavioral attitudes and Search Evaluation test (BASE). This test combines principles of both projective technique and a personality questionnaire (Venger et al., 1996) and was validated in our previous investigations (Rotenberg et al., 1998; 2001). It includes descriptions of 16 open situations with four possible reactions on each of them. The tested subject has to choose two reactions (two types of behavior) in each situation: the most appropriate from his/her point of view (scored by a sign +) and the least appropriate (scored by a sign --). The preferences of the subject provide an opportunity for quantitative measurement of each of the behavioral attitudes mentioned above: SA, St, Ch, and Pa. The total score of the four scales can range from -16 to + 16.
All reactions on test situations seem equally acceptable both ethically and pragmatically. Here is an example to illustrate the general principle: "A group of hikers went to a cavern unfamiliar to them. Just as they arrived inside the cavern, a landslide buried the exit. While discussing the situation, the following suggestions arose:
A. I suggest searching for another exit. We'll mark our way with small mounds of stones so that we might recognize the place we would once pass even by touch when our flashes are out."
B. Of course, we must search for another exit! But we cannot waste our time for excessive precautions. Remember that we do not have food."
C. "Let us wait till our friends find us. If we economize our strength, so our poor provisions will be enough to maintain our lives while waiting".
D. I suggest trying to dig a passage through the landscape. This can take a lot of time, but at least we know that the exit is here and don't know whether there is another exit elsewhere.
In this situation, the answer "A" corresponds to search orientation because it suggests activity with unpredictable outcome, and fixation of all intermediate results (marking the way with stones). The answer "B" indicates chaotic tendency because it denies fixation of the intermediate results. The answer "C" reflects passive attitudes because it does not suggest any types of activity. The answer "D" shows a
tendency to stereotyped behavior: high level of activity in the same direction without considering possible obstacles.
As we have already stressed in the introduction, the normal configuration of BASE in healthy subjects is usually characterized by positive meanings of SA and St and negative meanings of Ch and Pa. The level of depression was measured using the 21-item Hamilton Rating Scale for depression (Hamilton, 1960). This test was applied on the same day as BASE. Statistic: We have used t-Test: Two-Sample Assuming Unequal Variances.
Hamilton Rating Scale values do not correlate with any particular behavioral attitudes (scales of BASE).
Two subgroups of patients have been selected: Group 1(8 patients) with the maximal (for our patients) level of the Hamilton Rating Scale >31, 14 (mean data + SD), and Group 2 (7 patients) with the minimal level of the Hamilton Rating Scale < 22.76 (mean data - SD). No significant differences have been found between the mean values of BASE scales in Group 1 and Group 2. In Group 1: SA=0.875, SD= 2.68; St = 1.125, SD= 3.56; Ch = -2.75, SD= 3.69; Pa = 0.75, SD=3.10. In Group 2: SA = -1.14, SD= 4.09; St = 1.85, SD= 4.4; Ch = -1.14, SD=3.57; Pa = 0.42, SD=5.05.
In order to find out whether the configuration of the BASE test is related to the level of depression we have compared two following subgroups of patients: Group A contains 11 patients with the normal configuration of BASE scales (SA and St scales have positive meaning, while Ch and Pa scales have negative meanings) and Group B with the inverted configuration of BASE that contained all other 33 patients. The BASE structure of patients in Group B is not obligate to be straight opposite to the BASE structure of patients in Group A because Group B contains patients with at least one scale being different from normal position (either SA or St with negative meanings or either Ch or Pa with positive meanings). In the process of selection of these two groups we were interested only in the direction of scales (whether they have positive or negative meaning) while their absolute values were not taken into consideration. These two groups displayed a difference in the level of the Hamilton Rating Scale that was higher in Group B: 27.78, SD= 4.08 vs. 24.6, SD= 3.34, p=0.009. However it is worth to emphasize, that most patients of
the Group 1 and Group 2 (with the opposite level of the depression's value) are characterized by the inverted configuration of BASE. It means that in some particular cases the inverted structure of behavioral attitudes may correspond to the relatively low level of depression, although in general the level of depression is lower in patients with the normal configuration of behavioral attitudes.
According to the results of the present study it is possible to suggest that the level of depression does not determine the alteration of behavioral attitudes. Hamilton Rating Scale does not correlate with any single scales of BASE, they do not differ significantly in subjects with high and low Hamilton Rating Scale data. Moreover, it is a non-significant tendency in patients with a low level of depression to display a lower SA and higher Ch values in comparison to patients with a high level of depression. At the same time patients with inverted configuration of the BASE scales display a higher level of depression than patients with a normal configuration of BASE scales. Thus it is possible to suggest that the configuration of behavioral attitudes determines the level of depression. The inversion of the BASE scales configuration by itself is also more important for the variables of the concrete behavioral attitudes than the level of depression.
These data correspond to the theories considering the role of helplessness and hopelessness as etiological factors for explanation the onset and maintenance of depression (Henkel et al., 2002). According to the search activity concept, helplessness is one of the models of renunciation of search (low SA and high Pa, Rotenberg, 1984). It was recently shown that helplessness and hopelessness belong to the strongest factors characterizing major depression (McGlinchey et al., 2006).
The peculiarity of behavioral attitudes in depression (the inverted, in comparison to healthy subjects, interrelationships between active goal-oriented adaptive behavioral strategies and maladaptive passive and chaotic behavior) corresponds also to the data of modern psychobiological investigations in depression. As was published recently ( Rotenberg, 2004; Figelkarts et al., 2006 a, b) depressed patients are characterized by the functional deficiency of both right and left frontal lobe. The physiological alterations in depression (like increased physiological activity in the right frontal lobe, unusual increase in the number and strength of short-range functional connections of brain processes in distributed neuronal networks in the left hemisphere as well as the analogous increase in long-range connections in the right hemisphere) are estimated as signs of the unsuccessful attempts for compensating this functional insufficiency. Such approach is supported by the whole cortex (including frontal lobes) hypometabolism in patients with major depression (Martinot et al., 1990). At the same time frontal cortex is responsible for all range of executive functions (that include active goal-oriented behavior - search activity). The functional insufficiency of this structure can severely affect the patients' ability to be effective at work and in every-day life (Stahl et al., 2003) and display itself particularly in the lack of search activity. The present study shows that in 25% of depressed patients the structure of behavioral attitudes (the configuration of BASE scales) was normal and behavioral attitudes are very similar to those in healthy subjects although mean level of depression is still high enough or at least moderate. Thus it is reasonable to suggest that the formation of the normal configuration of behavioral attitudes (with the positive meaning of active goal-oriented forms of behavior - SA and St) may be a sign of the possible positive dynamics of the disease and may predict the further restoration of mental health. At the same time the inverted BASE configuration may probably predict the stability and resistance of depression even if the level of the Hamilton Rating Scale is not extremely high. This proposition corresponds to the modern approach to the treatment of depression through the stimulation of the patient's active behavior.
It was shown recently (Hopko et al., 2003) that the brief behavioral activation treatment for depression (BATD) increases exposure to positive activities and help to alleviate depressive affect. This investigation demonstrated the effectiveness and superiority of BADT as compared with the standard supportive treatment. Progress in the clinical improvement was achieved by moving from the easiest behavior (that requires only stereotyped activity) to the more difficult behavior like reading and writing complicated texts (that requires search activity). Increased activity preceded reduced depression and further lead to the increase of positive thoughts and feelings. In this context it is worth to take into consideration the positive feedback between search activity and self-esteem based on the pride that subject does not give up in front of problems and obstacles and is trying to overcome it. High self-esteem by itself supports activity with an unpredictable outcome. This positive feedback proposed by Rotenberg et al. ( 1996 )
is confirmed in the recent investigation of Umana et al. who have found a positive association between search activity and self-efficacy. On the other hand, a regular self-accusation for failures (even when subject is not guilty for them) and decreased self-respect finally causes even in healthy subjects stable renunciation of search (Rotenberg, Korosteleva, 1990).
Among more severely depressed patients behavioral activation according to its treatment effect was comparable to antidepressant medication and both outperformed cognitive therapy (Dimidjian et al., 2006). The abovementioned authors have shown that behavioral activation targets the reduction of avoidance behavior related to both intra-personal and interpersonal difficulties. Avoidance minimizes any interactions with the environment and thus corresponds to renunciation of search (Pa) in our terminology. According to Dimidjian et al., 2006, behavioral activation specifies attention-to-experience that also contributes to search activity.
In our study (Rotenberg, Zusman, 2002) we have checked the effect of the psychotherapeutic group oriented on the increase of motivation of achievement and of the subject's self-esteem on the BASE variables in subjects who were searching for a professional job. We have found that in men after few group sessions attitudes toward SA increased and attitudes toward Ch and Pa decreased. Women also displayed a tendency toward an increase of SA although it was less prominent. Thus, it is possible to conclude that the special stimulating psychotherapy can improve the structure of behavioral attitudes.
Burns and Spangler (2000) have shown that psychotherapeutic homework compliance had a causal effect on the reduction of depression. Patients who did the most of homework (that included reading, performing self-assessment tests, listening to audiotapes, challenging automatic negative thoughts, scheduling productive and rewarding activities all forms of behavioral activation) improved much more than patients who did little or no homework. At the same time (and it is especially interesting in context of the present investigation) depressive severity did not appear to influence homework compliance: patients with severe level of depression were able to complete homework assignments as well as patients with mild mood problems. This asymmetry resembles the present data: the configuration of behavioral attitudes has a causal effect on the level of depression while the level of depression by itself does not determine the BASE variables. Authors (Burns and Spangler, 2000) emphasized that the size of correlation is not the same as the size of causal effect, and our present data are leading to the same conclusion.
According to our data and in the context of the abovementioned outcome of behavioral activation it is possible to propose that the configuration of BASE (and especially the positive vs. negative meaning of SA and Pa) may be used for the prediction of the dynamics of depression and can be more relevant than the Hamilton Rating Scale values for this prediction. It has to be an important topic of the further investigation. The main limitation of the present study is the absence of data of the alterations of behavioral attitudes in parallel of the Hamilton Rating Scale in the process of treatment of the same patients. It is also a task to be investigated further.
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