Some therapists don’t talk much about diagnosis, but it is essential they think about diagnosis. Proper treatment depends on the correct classification.
In the case of longstanding depression, here’s why:
- Effective therapy for Persistent Depressive Disorder (PDD) differs from approaches to other types.
- Persistent Depressive Disorder consists of a distinct set of symptoms not typical of the broad range of mood problems.
How is PDD different from other periods of unusual sorrow? Duration is emphasized.*
The syndrome lasts longer (at least two years) and often starts early. Symptom-free periods, if they happen, last no more than two months. More comorbidities are present: that is, other diagnosable conditions.
Among additional distinguishing characteristics, traumatic and abusive childhood experiences are frequently a part of the individual’s back story. In general, the younger the patient was at onset, the more limited his problem-solving skills are today.
Though the above list may be daunting, the evidence supporting the effectiveness of the Cognitive Behavioral Analysis System of Psychotherapy (CBASP) is impressive. Indeed, an extensive review of the scientific literature endorsed by the European Psychiatric Association recommended it as a top-line psychotherapeutic procedure for people with PDD.**
Perhaps not surprisingly, significant improvement tends to demand an extended therapeutic regime. More than a year would not be uncommon, with an indefinite but lengthy course of less frequent follow-up sessions to maintain gains.
The prescription of psychotropic medication in combination with the “talking cure” is customary, as well.
One of the most notable features of CBASP is its focus on fragile self-esteem. The client views himself as unable to produce satisfying encounters with acquaintances, coworkers, and friends. Nor does he realize the degree to which his words and deeds (or their absence) cause some of his unhappiness.
While his pain is acknowledged as genuine, CBASP views the new client as someone with chronic and pessimistic expectations of the world: self-fulfilling prophecies.
History informs him of how his life has worked out and, he believes, will work out. The evaluation of the patient, therefore, seeks to uncover the ways he contributes (without intention) to the repetition of disappointments characteristic of his past.
Moreover, the practitioner expects such counterproductive social interactions not to be restricted to life outside the consulting room. Comparable events are predicted in-session. The provider of treatment discusses this prospect with the sufferer.
Together they analyze what the depressed individual forecasts will happen between them, along with the actual effects of his behavioral choices. The atmosphere of the conversation must ensure a feeling of safety, not judgement.
An enlargement of the patient’s self-awareness develops as his anticipation of the psychotherapist’s behavior is explored. The Socratic dialogue with the healer should lead him to conclusions he comes to on his own.
This enlightenment is also fostered when the therapist tells him of his own internal reactions to what the client is doing: the feelings or thoughts emerging inside himself (the analyst) in-the-moment. In this way, the patient begins to become aware of his impact on others.
When the process works as designed, the outpatient starts to try out what are novel efforts to accomplish the kind of responses he desires. This begins in the office and extends to people he encounters elsewhere.
Thus, the transference relationship with the counselor is key. The system builds toward recognition of the healer as somebody who responds differently from those in his pretreatment life who caused harm or neglect.
Just as he comes to grasp he was mistaken in many of his beliefs about the adviser, so he begins to recognize routine errors in expecting the worst from much of the rest of the human world.
Progress relies, in part, on the subject’s growing ability to sense his own power to affect how people react to him. Another marker of improvement is his expanding understanding of how failed actions and inactions have added to his fixed sense of helplessness and hopelessness. Increased flexibility in both cognitive and emotional domains is a goal.
The therapeutic conversation includes a step-wise analysis of how troublesome situations in the client’s life developed – what happened at the start, in the middle, and at the end of them. Questions include, for example, “How did you interpret what occurred?” “What did you do?” “What did you want” and “Did you get what you wanted?”
A successful course of CBASP empowers the patient to gain insight through the emotions and thoughts evoked by inquiries like this. The ease of performing similar analyses on his own expands. He reaches the point of engaging the interpersonal world with an enhanced belief in what is possible.
Hopefulness comes to occupy an enlarged place in the client’s vision of what lies ahead. As a result, he risks letting go of passive-aggressive, hostile, submissive, and avoidant strategies. Friendly and assertive advances toward society increase.
Put simply, while there are no guarantees, the news is encouraging for those long-depressed souls who have yet to find a satisfying route to the alleviation of their unhappiness.
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*The complete diagnostic criteria for Persistent Depressive Disorder can be found here: https://images.pearsonclinical.com/images/assets/basc-3/basc3resources/DSM5_DiagnosticCriteria_PersistentDepressiveDisorder.pdf
**Jobst, A., Brakemeier, E. L.., Buchheim, A., Caspar, F., Cuijpers, P., Ebmeier, K. P., … Padberg, F. (2016). European Psychiatric Association guidance on psychotherapy in chronic depression across Europe. European Psychiatry, 33, 18-36. http://doi.org/10.1016/j.eurpsy.2015.12.003
The bottom photo is Central Utah in Late Summer at Sunset by Laura Hedien, with her kind permission: https://laura-hedien.pixels.com/
Dr. Gerald Stein 
Is persistent depressive disorder the same as major depressive disorder? If not, what are the differences?
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They are not identical. It is possible to have both, a condition sometimes called “double depression.” Note that one of the differences between the sets of criteria is the minimum two-year duration of Persistent Depressive Disorder. Here are the diagnostic criteria for Major Depression: https://medicaidmentalhealth.fmhi.usf.edu/_assets/file/Guidelines/2017-2018%20Treatment%20of%20Adult%20Major%20Depressive%20Disorder.pdf
You can compare these criteria against those in the pdf link for Persistent Depressive Disorder I listed above in the footnotes.
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I see the differences. I had been dxd w/MDD in the past, which only requires a 2-week period. Not many clinicians or mental health professionals assess PDD though. They will screen for depression in general. Many will also label clients “treatment resistant,” instead of looking at potential misdiagnoses and alternative diagnoses such as what you suggested with double depression, comorbidity, and potential PDD as a diagnosis by itself or comorbid with other diagnoses, like the criteria for PDD mentions. PDD would require asking about the past 2 years, but screeners may not ask that at all. I can also see some other differences as well, such as what you describe with self-esteem issues. I tried asking about the treatments for self-esteem a while back. I never received an answer. Many believe it is a PD issue, so they assign DBT as the standard treatment for PD issues.
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The idea of treatment resistance is addressed by practitioners of CBASP. There is not such diagnostic category as “treatment resistance depression,” though practitioners do refer to it. In any case, the practitioners of CBASP have good luck with long-term depressed patients, some of who have been characterized in that way. Also, please note that In a blog it is not possible to cover all the details of what such a therapy includes.
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My last mentor worked on analyzing fragile self-esteem as the inverse differences depicted between implicit and explicit self-esteem subtypes. Those who were high explicit but low in implicit self-esteem were deemed as fragile self-esteem. I think the reverse, those who were high in implicit but low in explicit self-esteem, were called something else. Then there were those with overall low self-esteem (both implicit and explicit) and overall high self-esteem (both implicit and explicit). All were tested to see if there was a significant relationship between the groupings of self-esteem and the various types of personality disorders. In that study, I think there was no significant findings. Some researchers and theorists hypothesize that narcissistic personality disorder is linked to fragile self-esteem. I am not sure what the other types of self-esteem would be linked to, in terms of personality disorders. It was an interesting study that never made publication. I am wondering if it is the same fragile self-esteem you are speaking of.
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Since the work of your mentor seems to have been both recent and unpublished, I can’t say. In any case, I would encourage anyone seeking treatment to search for a therapist who has experience with an empirically validated therapy. Not all counselors do.
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Thank you, Dr. Stein. I mentioned my former mentor who is no longer a mentor of mine. His work was done with other people, but there have been other researchers who have published similar studies that he was trying to replicate. Testing hypotheses and testing treatment efficacy appear to be two very different studies, but I am guessing here. You make great points about different treatment needs for different kinds of depression. Being diagnosed correctly makes all the difference, since treatments are based on diagnoses. Not all patients are diagnosed properly.
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I was never dxd w/PDD, but I feel that I would be if I were screened and assessed for it. I may be of the latent type, however. I really love this paragraph you wrote: “The therapeutic conversation includes a step-wise analysis of how troublesome situations in the client’s life developed – what happened at the start, in the middle, and at the end of them. Questions include, for example, ‘How did you interpret what occurred?’ ‘What did you do?’ ‘What did you want” and “Did you get what you wanted?'”
I have a ton of answers and scenarios to these questions. I have DID and my parts hold many of these thoughts, memories, and feelings for me as well. Overall, I never got what I wanted, the world in general feels unsafe, people seem to have hidden agendas for me all the time, my implicit reactions that are often pessimistic and guarded probably interfere with my relationships, my inability to focus when I start entertaining details in my verbose speech is a cover up for protecting myself when I sense someone else taking my dignity away, in addition to the self-fulfilling prophecies related to self-sabotaging my own career and future with pessimistic attitudes. My past experiences with racism, discrimination, military sexual trauma, and subsequent traumas in the civilian world that added to sexual trauma, domestic violence victimization and blame on me, etc., had undone all the resilience I had years prior with my childhood maltreatment experiences. Whereas I was once resilient as a child, I no longer became resilient to cumulative traumas as an adult. Nothing I did mattered anymore. The harder I tried to succeed in life, the more people were out to challenge me harmfully. These, I know, are cognitive distortions of mine. But it is hard to break when such distortions are actually believed in a similar way by perpetrators, when using psychology to investigate criminal and unlawful behaviors. Perpetrators do harm via discrimination or hate crimes or rape or sexual harassment, and they are out to knock growing successful minorities. Perpetrators’ own cognitive distortions about themselves and different others become similar cognitive distortions internalized by victims. Victims learn from their perpetrators, and both fallaciously generalize. Victims’ cognitive distortions are reinforced whenever victims lack capable guardianship, which typically includes protective factors against victimization such as going with one or more trusted people to a bar, having security systems put in your home, etc. But one key area that lacks in the discussion of victimization prevention is assertiveness training and self-esteem healing as forms of capable guardianship for victims with PDD. If the cycle of self-fulfilling prophesies via cognitive distortions could end, that may protect against future victimization and thus be considered as a form of capable guardianship since mental illness serves as a risk factor for being vulnerable to criminal and unlawful victimizations. Medications and treatments that empower victims may help in this regard, which can help with not feeling so anxious, panicked, defeated, hopeless, lost, and picked on in this wicked world.
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Since DSM V was not published until 2013, if you were diagnosed previous to that time you could not have been given the PDD label.
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Thank you, Dr. S. I forgot what I wrote, so I re-read what I wrote. Sometimes I think I have all the problems in the DSM, lol. I was diagnosed prior to 2013. Sometimes I do not know what I write until later. I must have been in a weird place when I wrote the above response.
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No problem, gb. Sometimes a prior diagnosis can follow someone around and unconsciously narrow the choices of a new therapist. From time to time, a counselor should try to wipe the blackboard clean and try to take a fresh look. Be well, gb.
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I have a great therapist now. I think she is always open to assessing me , though my focus now is less about the diagnosis and more about my actual relationship with the therapist.
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Glad to hear it.
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