Adrián Montesano

Cognitive conflicts in major depression: Between desired change and personal coherence

Objectives The notion of intrapsychic conflict has been present in psychopathology for more than a century within different theoretical orientations. However, internal conflicts have not received enough empirical attention, nor has their importance in depression been fully elaborated. This study is based on the notion of cognitive conflict, understood as implicative dilemma (ID), and on a new way of identifying these conflicts by means of the Repertory Grid Technique. Our aim was to explore the relevance of cognitive conflicts among depressive patients. Design Comparison between persons with a diagnosis of major depressive disorder and community controls. Methods A total of 161 patients with major depression and 110 non-depressed participants were assessed for presence of IDs and level of symptom severity. The content of these cognitive conflicts was also analysed. Results Repertory grid analysis indicated conflict (presence of ID/s) in a greater proportion of depressive patients than in controls. Taking only those grids with conflict, the average number of IDs per person was higher in the depression group. In addition, participants with cognitive conflicts displayed higher symptom severity. Within the clinical sample, patients with IDs presented lower levels of global functioning and a more frequent history of suicide attempts. Conclusions Cognitive conflicts were more prevalent in depressive patients and were associated with clinical severity. Conflict assessment at pre-therapy could aid in treatment planning to fit patient characteristics. Practitioner points Internal conflicts have been postulated in clinical psychology for a long time but there is little evidence about its relevance due to the lack of methods to measure them. We developed a method for identifying conflicts using the Repertory Grid Technique. Depressive patients have higher presence and number of conflicts than controls. Conflicts (implicative dilemmas) can be a new target for intervention in depression. Cautions/Limitations A cross-sectional design precluded causal conclusions. The role of implicative dilemmas in the causation or maintenance of depression cannot be ascertained from this study.

Implicative Dilemmas and Symptom Severity in Depression: A Preliminary and Content Analysis Study

An implicative dilemma, a type of cognitive conflict, is found in a subjects repertory grid whenever a personal construct on which change is desired is associated with another construct on which change is undesirable. We studied dilemmas in 57 participants who met criteria for depressive spectrum disorders and compared them to 496 nonclinical controls. Almost 60% of the clinical sample presented with at least one implicative dilemma in their grids, as compared to 39% of controls. Participants with dilemma(s) showed higher levels of depressive symptoms and general distress (SCL-90-R) than those without any implicative dilemma in their grids. Also, the number of implicative dilemmas was associated with symptom severity. An analysis of the specific content of the personal constructs forming such dilemmas revealed that congruent constructs were mostly of moral nature, whereas discrepant constructs were related to emotional balance. Further studies may investigate whether an intervention targeted to the resolution of such dilemmas could be incorporated into existing treatments for depression to enhance their efficacy.

Efficacy of a dilemma-focused intervention for unipolar depression: study protocol for a multicenter randomized controlled trial

BackgroundDepression is one of the more severe and serious health problems because of its morbidity, disabling effects and for its societal and economic burden. Despite the variety of existing pharmacological and psychological treatments, most of the cases evolve with only partial remission, relapse and recurrence.Cognitive models have contributed significantly to the understanding of unipolar depression and its psychological treatment. However, success is only partial and many authors affirm the need to improve those models and also the treatment programs derived from them. One of the issues that requires further elaboration is the difficulty these patients experience in responding to treatment and in maintaining therapeutic gains across time without relapse or recurrence. Our research group has been working on the notion of cognitive conflict viewed as personal dilemmas according to personal construct theory. We use a novel method for identifying those conflicts using the repertory grid technique (RGT). Preliminary results with depressive patients show that about 90% of them have one or more of those conflicts. This fact might explain the blockage and the difficult progress of these patients, especially the more severe and/or chronic. These results justify the need for specific interventions focused on the resolution of these internal conflicts. This study aims to empirically test the hypothesis that an intervention focused on the dilemma(s) specifically detected for each patient will enhance the efficacy of cognitive behavioral therapy (CBT) for depression.DesignA therapy manual for a dilemma-focused intervention will be tested using a randomized clinical trial by comparing the outcome of two treatment conditions: combined group CBT (eight, 2-hour weekly sessions) plus individual dilemma-focused therapy (eight, 1-hour weekly sessions) and CBT alone (eight, 2-hour group weekly sessions plus eight, 1-hour individual weekly sessions).MethodParticipants are patients aged over 18 years meeting diagnostic criteria for major depressive disorder or dysthymic disorder, with a score of 19 or above on the Beck depression inventory, second edition (BDI-II) and presenting at least one cognitive conflict (implicative dilemma or dilemmatic construct) as assessed using the RGT. The BDI-II is the primary outcome measure, collected at baseline, at the end of therapy, and at 3- and 12-month follow-up; other secondary measures are also used.DiscussionWe expect that adding a dilemma-focused intervention to CBT will increase the efficacy of one of the more prestigious therapies for depression, thus resulting in a significant contribution to the psychological treatment of depression.Trial registrationISRCTN92443999; ClinicalTrials.gov Identifier: NCT01542957.

Cognitive conflicts and symptom severity in dysthymia: "I'd rather be good than happy"

SUMMARY A method for studying cognitive conflicts using the repertory grid technique is presented. By means of this technique, implicative dilemmas can be identified, cognitive structures in which a personal construct for which change is wished for implies undesirable change on another construct. We assessed the presence of dilemmas and the severity of symptoms in 46 participants who met criteria for dysthymia and compared then to a non-clinical group composed of 496 participants. Finally, an analysis of the specific content of the personal constructs forming such dilemmas was also performed. Implicative dilemmas were found in almost 70% of the dysthymic participants in contrast to 39% of controls and in greater quantity. In addition, participants in both groups with this type of conflict showed more depressive symptoms and general distress than those without dilemmas. Furthermore, a greater number of implicative dilemmas was associated with higher levels of symptom severity. Finally, content analysis results showed that implicative dilemmas are frequently composed of a constellation of moral values and emotion, indicating that symptoms are often related to moral aspects of the self and so change processes may be hindered. Clinical implications of targeting implicative dilemmas in the therapy context are discussed.

A review of cognitive conflicts research: a meta-analytic study of prevalence and relation to symptoms

Recent research has highlighted the role of implicative dilemmas in a variety of clinical conditions. These dilemmas are a type of cognitive conflict, in which different aspects of the self are countered in such a way that a desired change in a personal dimension (eg, symptom improvement) may be hindered by the need of personal coherence in another dimension. The aim of this study was to summarize, using a meta-analytical approach, the evidence relating to the presence and the level of this conflict, as well as its relationship with well-being, in various clinical samples. A systematic review using multiple electronic databases found that out of 37 articles assessed for eligibility, nine fulfilled the inclusion criteria for meta-analysis. Random effects model was applied when computing mean effect sizes and testing for heterogeneity level. Statistically significant associations were observed between the clinical status and the presence of dilemmas, as well as level of conflict across several clinical conditions. Likewise, the level of conflict was associated with symptom severity. Results highlighted the clinical relevance and the transdiagnostic nature of implicative dilemmas.

Systemic Couple Therapy for dysthymia.

We examined the effect of Systemic Couple Therapy on a patient diagnosed with dysthymic disorder and her partner. Marge and Peter, a middle-aged married couple, showed significant and meaningful changes in their pattern of interaction over the course of the therapy and, by the end of it, Marge no longer met the diagnostic criteria for dysthymic disorder. Her scores on the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) and Beck Depression Inventory, Second Edition (BDI-II) were in the clinical range before treatment and in the nonclinical one at the end of therapy. Although scores on Dyadic Adjustment Scale showed different patterns, both members reported significant improvement. The analysis of change in the alliance-related behaviors throughout the process concurred with change in couples pattern of interaction. Treatment effects were maintained at 12-month follow-up. Highlights in the therapy process showed the importance of relational mechanisms of change, such as broadening the therapeutic focus into the couples pattern of interaction, reducing expressed emotion and resentment, as well as increasing positive exchanges. The results of this evidence-based case study should prompt further investigation of couple therapy for dysthymia disorder. Randomized clinical trial design is needed to reach an evidence-based treatment status.

Self-Construction, Cognitive Conflicts, and Disordered Eating Attitudes in Young Women

The aim of this study is to identify cognitive variables that predict disordered eating attitudes in a nonclinical sample composed of 50 female university students. Repertory grid technique was used to assess cognitive features of self-construing and cognitive conflicts. Drive for Thinness and Body Dissatisfaction scales from the Eating Disorder Inventory–2 were used as dependent variables, as previous studies suggested that high scores on these scales are associated with the risk of developing or aggravating eating syndromes. Results suggest that drive for thinness can be associated with cognitive conflicts, whereas body dissatisfaction may be higher for those who construct themselves as inadequate and similar to others. In addition, both dependent variables were predicted by being younger and having a higher body mass index.

Psychometric properties of the Spanish version of the Clinical Outcomes in Routine Evaluation - Outcome Measure.

Objective The objective of this paper is to assess the reliability and validity of the Spanish translation of the Clinical Outcomes in Routine Evaluation – Outcome Measure, a 34-item self-report questionnaire that measures the client’s status in the domains of Subjective well-being, Problems/Symptoms, Life functioning, and Risk. Method Six hundred and forty-four adult participants were included in two samples: the clinical sample (n=192) from different mental health and primary care centers; and the nonclinical sample (n=452), which included a student and a community sample. Results The questionnaire showed good acceptability and internal consistency, appropriate test–retest reliability, and acceptable convergent validity. Strong differentiation between clinical and nonclinical samples was found. As expected, the Risk domain had different characteristics than other domains, but all findings were comparable with the UK referential data. Cutoff scores were calculated for clinical significant change assessment. Conclusion The Spanish version of the Clinical Outcomes in Routine Evaluation – Outcome Measure showed acceptable psychometric properties, providing support for using the questionnaire for monitoring the progress of Spanish-speaking psychotherapy clients.

A DILEMMA-FOCUSED INTERVENTION FOR DEPRESSION: A MULTICENTER, RANDOMIZED CONTROLLED TRIAL WITH A 3-MONTH FOLLOW-UP.

Since long ago it has been asserted that internal conflicts are relevant to the understanding and treatment of mental disorders, but little research has been conducted to support the claim. The aim of this study was to test the differential efficacy of group cognitive behavioral therapy (CBT) plus an intervention focused on the dilemma(s) detected for each patient versus group individual CBT plus individual CBT for treating depression. A comparative controlled trial with a 3‐month follow‐up was conducted.

Depression and Identity: Are Self-Constructions Negative or Conflictual?

Negative self-views have proved to be a consistent marker of vulnerability for depression. However, recent research has shown that a particular kind of cognitive conflict, implicative dilemma, is highly prevalent in depression. In this study, the relevance of these conflicts is assessed as compared to the cognitive model of depression of a negative view of the self. In so doing, 161 patients with major depression and 110 controls were assessed to explore negative self-construing (self-ideal discrepancy) and conflicts (implicative dilemmas), as well as severity of symptoms. Results showed specificity for the clinical group indicating a pattern of mixed positive and negative self-descriptions with a high rate of conflict. Regression analysis lent support to the conflict hypothesis in relation to clinically relevant indicators such as symptom severity, global functioning. However, self-ideal discrepancy was a stronger predictor of group membership. The findings showed the relevance of cognitive conflicts to compliment the well-consolidated theory of negative self-views. Clinical implications for designing interventions are discussed.