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Attributional style and perceived stress in endogenous and reactive depression
Journal of Affective Elsevier
Disorders, 18 (1990) 281-287
281
JAD 00691
Attributional
style and perceived stress in endogenous and reactive depression
Paul Willner ‘, Margaret Wilkes 132and Arnold Orwin 2 ’ Psychology Department, City of London Polytechnic, London El 7NT, U.K. and ’ The Woodbourne Cbnic, Edgbaston, Birmingham
BI 7 SBZ, U.K.
(Received 21 April 1989) (Revision received 22 August 1989) (Accepted 30 August 1989)
The depressive Attributional Style Questionnaire (Peterson et al., 1982) and the Hassles and Uplifts Questionnaire (Kanner et al., 1981) were administered to melancholic and non-melancholic depressed patients (matched for severity according to a doctors/nurses rating scale), and to non-depressed volunteers. Compared to the other two groups, melancholic patients had higher internality and stability scores for negative attributions, and reported a greater intensity of ‘hassles’ and a lower frequency of ‘uplifts’. The intensity of ‘uplifts’ was reduced in both depressed groups. On all other cognitive measures, the reactive patients were indistinguishable from non-depressed volunteers. The results suggest that the ‘depressive attributional style’ may be specific to melancholic patients, and underline the importance of studying well-defined diagnostic subgroups. Key words: Depression; Attributional
style; Perceived stress; Hassles; Melancholia
Introduction The learned helplessness hypothesis of depression suggested that certain depressions resulted from learning that one’s attempts to control the occurrence of aversive events were ineffective (Seligman, 1975). In the subsequent reformulation of this hypothesis, the consequences of perceived
Address for correspondence: Department, City of London London El 7NT, U.K. 0165-0327/90/$03.50
Dr. P. Willner, Psychology Polytechnic, Old Castle St,
0 1990 Elsevier Science Publishers
uncontrollability were assumed to be mediated by attributions of the causes of aversive events. The ‘depressive attributional style’ postulated by Seligman and colleagues (Abramson et al., 1978) is a tendency to attribute aversive events to causes that are internally located, stable in time, and global in scope. This hypothesis has been examined in numerous studies; many of them have supported the concept of a depressive attributional style, but a significant minority have not (reviewed by Coyne and Gotlib, 1983; Peterson and Seligman, 1984; Peterson et al., 1985; Sweeney et al., 1986). While the learned helplessness hypothesis was intended to explain only a subset of depressions
B.V. (Biomedical
Division)
282
(Seligman, 1975) it has never been clear to which diagnostic group, if any, the hypothesis properly refers (Depue and Monroe, 1978). The hypothesis was originally based on experiments in animals subjected to uncontrollable stressors (Seligman, 1975; Maier and Seligman, 1976). These animals display a wide range of pathological symptoms, including, in addition to a performance deficit in aversively motivated tasks, locomotor hypoactivity, reductions in food intake and body weight, decreased aggression, and significantly, a decreased response to rewards (reviewed by Weiss et al., 1982; Willner, 1986). Although Seligman (1975) originally suggested that learned helplessness provided a model of reactive depression, the symptom picture displayed by animals subjected to uncontrollable stress is more suggestive of an endogenous depression; in particular, the decrease in responsiveness to rewards appears to model the anhedonia that defines melancholia in DSM-III (American Psychiatric Association, 1980). Following its reformulation in attributional terms, the learned helplessness hypothesis of depression was no longer applicable to the animal literature on which it was originally based, and as a result, animal and human helplessness research have proceeded independently since 1978. However, the potential parallels between melancholia and ‘helplessness’ in animals remain intriguing. We have therefore examined attributional style in melancholic and non-melancholic patients. The etiological significance for depression of aversive experiences has usually been studied in the context of life event research, which has demonstrated a significant increase in the onset of depressive episodes in the months following particular kinds of life events (Lloyd, 1980; Brown and Harris, 1988). However, evidence has also been presented implicating chronic stress in the etiology of depression (e.g., Aneshensel and Stone, 1982; Billings et al., 1983; Feather and Barber, 1983). In animal studies, chronic stress has also been found to decrease sensitivity to rewards, and this effect is observed not only with severe chronic stress (Katz, 1982), but also using chronic mild stress (Willner et al., 1987). An instrument (the Hassles and Uplifts Questionnaire) has been developed for the measurement of low-grade stressors (Kanner et al., 1981). While numerous studies
have demonstrated a relationship between ‘hassles’ and general health (e.g. Zarski, 1984; Weinberger et al., 1987; De Longis et al., 1988) their involvement in depression is at best weakly supported (Kanner et al., 1981; Holahan and Holahan, 1987; De Longis et al., 1988). In view of the evidence from animal experiments that exposure to chronic mild stress may decrease sensitivity to rewards (Willner et al.. 1987) we thought it of interest to examine also whether the reporting of ‘hassles’ differs between melancholic and nonmelancholic depressives. Methods Subjects The subjects for this study were 20 depressed patients undergoing inpatient treatment at a private clinic, and 10 non-depressed volunteers. The patients were diagnosed by the admitting and attending psychiatrists as DSM-III major depression (American Psychiatric Association, 1980), and included 10 melancholic patients and 10 nonmelancholic patients. Only patients between 18 and 72 years of age and in social class 2 of the Registrar General’s classification (professional/administrative) were admitted to the study. Obsessive-compulsive and tension state patients, patients showing schizoaffective or manic features, and patients suffering underlying organic diseases were excluded, as were severely agitated or suicidal patients, and those undergoing treatment with neuroleptics, electroconvulsive therapy, abreaction therapy and monoamine oxidase inhibitors. Patients who were too severely depressed to undertake the questionnaires and patients whose diagnosis changed between admission and the commencement of the study were also excluded. Volunteers were included in the control group only if they, their parents, and their siblings had no psychiatric history, and they had not recently been taking any psychotropic medication. The melancholic group consisted of six men and four women, mean age (k standard error) 45 (+ 3.6) years, range 30-72. The non-melancholic group also contained six men and four women, mean age 42 (+ 3.9), range 23-62. The volunteers were five men and five women, mean age 36
283
( f 3.0) range
19-68. The age differences between the groups were not statistically significant, and no correlations were apparent between age and any of the variables reported in this study. Procedure Beginning 7 days following inpatient admission to the clinic, the patients were regularly assessed by the nursing staff, using doctors/nurses observer rating scales for depression (Costain et al., 1964). Scores on these scales range from 0 (severely depressed) through 5 (normal) to 9 (severely manic). Patients were rated by the ‘nursing staff on each of the scales (activity, mood, talk) at hourly intervals between 07.00 h and 20.00 h, for 7 days. This method of rating the severity of depression was used in preference to an interview-based scale in order to avoid imposing on the patients more than absolutely necessary. When these ratings were complete, and after final selection of the patients according to the above criteria, the Attributional Style Questionnaire (ASQ) was administered, followed by the Hassles and Uplifts questionnaire; these tests were also administered to the normal volunteer group. Testing of the patients took place in the early evening; the volunteers were assessed at various times throughout the day. The ASQ asks subjects to generate a possible cause for each of 12 hypothetical events, six good and six bad, and then to rate the cause on 7-point scales corresponding to the dimensions of internality, stability and globality; this instrument was administered in its original form (Peterson et al., 1983). The Hassles and Uplifts questionnaire asks whether each of 120 bad and 120 good events has occurred in the past month, and asks for ratings of the events that did occur on a 3-point scale of severity (Kanner et al., 1981). In order to make this task more manageable for the depressed patients, both parts of the questionnaire were reduced to half the original length. Items deleted were largely those that were irrelevant to subjects of higher social class, inappropriate in a British context, or felt to have the potential to cause unwarranted distress. A copy of the reduced questionnaire is available on request. Analysis The results
were analyzed
by analysis
of vari-
”
C
E R POSITIVE
C
E
R
NEGATIVE
Fig 1. Composite scores (sum of the three subscales) for positive and negative attributions, in melancholic (endogenous: E) and non-melancholic (reactive: R) depressed patients, and in normal controls (C). Values are means ( + standard error). * * * P < 0.001.
ante, supplemented by tests of simple main effects and planned comparisons. Results The two groups of depressed patients did not differ significantly in severity, as assessed by the doctors/nurses rating scales. The mean score (_t standard error) in both groups, averaged across all ratings, was 1.5 (+ 0.5). On the ASQ (Fig. l), the three groups of subjects did not differ in their attributions for positive events (F (2,54) = 0.7, NS), but melancholic patients had higher scores for negative events than
6
0
C
E
R
INTERNAL
C
E
STABLE
R
C
E
R
GLOBAL
Fig. 2. Negative attribution scores on the internality, and globality subscales of the ASQ, in melancholic nous: E) and non-melancholic (reactive: R) depressed and in normal controls (C). Values are means (+ error).*P~0.05;**P~0.01;***P~0.001.
stability, (endogepatients, standard
284
HASSLES
UPLIFTS
C z
3.0
v, 5
2.0
2 1.0
E
R
***
***
E
R
l--k&s% C
E
R
C
Fig. 3. Frequency (above) and severity (below) of reported hassles and uplifts in melancholic (endogenous: E) and nonmelancholic (reactive: R) depressed patients, and in normal controls (C). Values are means (+ standard error). * * * P < 0.001. relative to controls.
the other two groups (F (2.54) = 11.4, P < O.OOl), whose scores were almost identical. These differences in negative attributions were also apparent on the three subscales (Fig. 2) though only the effects on the internality and stability scales were significant (F (2,81) = 15.1, P < 0.001; 3.9, P -c0.025, respectively). The three groups did not differ significantly in the number of ‘hassles’ they reported (F (254) = 0.8, NS). However, the ‘hassles’ that did occur were rated as very much more intense by the melancholic patients (Fig. 3) compared both to the non-depressed subjects (F (1,54) = 18.7, P < 0.001) and to the non-melancholic patients (F (1,54) = 8.7, P < 0.01) who did not differ significantly from the controls (F (1,54) = 1.9, NS). Melancholic patients reported very few ‘ uplifts’, compared to the other two groups (F (2,54) = 19.4, P -cO.OOl), which again did not differ significantly (F (1,54) = 0.3, NS). However, the reported intensity of ‘uplifts’ was lower in both patient groups (F (2,54) = 16.9, P < 0.001). Although the melancholic patients had somewhat lower scores than the non-melancholic patients, this difference was not significant (F (1,54) = 3.3,0.05 < P < 0.1). Discussion
The extensive literature examining attributional style in depression has been the subject of several
reviews. While most studies have supported the concept of a ‘depressive attributional style’, as postulated by Seligman and colleagues as part of the reformulation of the learned helplessness hypothesis of depression (Abramson et al., 1978). a significant minority have not (Coyne and Gotlib, 1983; Peterson and Seligman, 1984; Peterson et al., 1985). Positive studies have tended to involve large samples, attributions concerning hypothetical events, and large numbers of events (Coyne and Gotlib, 1983; Peterson and Seligman, 1984; Peterson et al., 1985). However, these reviews did not examine the possibility that diagnostic subgroups might differ in their attributional style. In the present study, the depressive attributional style was strongly confirmed in melancholic patients. but was absent in non-melancholic patients. An earlier study reported no difference between melancholic and non-melancholic groups, through the data did tend non-significantly in the same direction (Zimmerman et al., 1984). The reasons for this discrepancy are unclear. The earlier study did not include a control group of normal volunteers; it should also be pointed out that the patients in the present study were relatively homogenous socioeconomically, and were somewhat atypical in not being predominantly female. Although in the present study the increase in composite negative attribution score in melancholic patients was substantial, the changes were not uniform across the three subscales. The effect arose largely from an increase in internal attributions, with a lesser contribution from stable attributions, the effect on global attributions being in the same direction, but non-significant. Although Abramson et al. (1978) originally postulated that the severity of depressed mood is determined largely by the propensity for making internal attributions (p. 65) some studies have found the tendency to make global and stable attributions to be more significant determinants (Alloy et al., 1984; Metalsky et al., 1987). It is possible that the substantial increase in internal attributions in melancholic patients may to some extent reflect feelings of excessive guilt, which contribute in DSM-III to the diagnosis of melancholia, rather than helplessness. While helplessness and guilt occur together in a substantial proportion of depressed patients (Beck, 1967; Abramson and Sackheim, 1977; Blatt
285
et al., 1982) there is some evidence that they may be relatively independent phenomena (Blatt et al., 1976, 1982). Thus, the interpretation of an increase in internality is somewhat problematic. While the increase in stability of negative attributions in melancholic patients provides less ambiguous evidence for helplessness, this effect was considerably smaller. Melancholic patients also reported a substantial increase in the severity of the hassles they experienced; indeed, their scores on this measure were close to the maximum possible. However, the fact that they did not report an increase in the number of hassles experienced suggests caution in the interpretation of this finding. While it is possible that the hassles encountered by the melancholic patients really were more severe it seems more probable that this reflects the tendency of depressives to interpret events unfavorably (Beck, 1967, 1974). Indeed, depressed patients have been found to rate specific stressful life events as more unpleasant than did non-depressed subjects (Schless et al., 1974; Lewinsohn and Tarkington, 1979; Hammen and Cochran, 1981). It is easier to take at face value the virtual absence of uplifts in melancholic patients. The decreased frequency of uplifts together with an increased severity of hassles is reminiscent of an earlier study which also reported that a decrease in the frequency of pleasant events in depressed patients was associated with an increase in the unpleasantness of unpleasant events (Grosscup and Lewinsohn, 1980). The fact that both increased severity of hassles and a depressive attributional style were found in the melancholic group, but not among the nonmelancholic patients, suggests that there could be a causal relationship between attributional style and the perceived severity of minor stressors. Either direction of causality is possible: a depressive attributional style might increase the perceived severity of hassles, for instance by attributing self-blame. Alternatively, an increase in the level of subjective exposure to stress might influence the development of the depressive attributional style. Although originally postulated to be a characteristic trait (Abramson et al., 1978) recent studies have established that attributional style is rather labile. While some prospective studies have confirmed that a depressive attributional style pre-
cedes the onset of depression (Peterson et al., 1983; Nolen-Hoeksema et al., 1986), the majority have not (Golin et al., 1981; Lewinsohn et al., 1981; Manly et al., 1982; Hammen et al., 1988); this stands in sharp contrast to the high proportion (75%) of studies reporting depressive attributions during a depressive episode (Peterson et al., 1985). Conversely, there is also evidence that the depressive style normalizes during recovery from depression (Hamilton and Abramson, 1983; Persons and Rao, 1985; Seligman et al., 1988). The possibility must also be considered that the increase in the perceived severity of hassles and the changes in depressive attributional style are both secondary reflections of a depressed mood. Two avenues are open to explain the presence of these phenomena in melancholic but not nonmelancholic patients. Firstly, although the two groups of patients were rated equal in severity of depression, it is possible that the nurses rating scale was insufficiently sensitive to reveal a difference between the groups. In fact, the presence of melancholia does usually betoken a more severe depression (Nelson and Charney, 1981). However, this need not necessarily be the case (Beth, 1981; Feinberg and Carroll, 1982). Secondly, as noted above, the presence of excessive guilt in melancholic patients could contribute to their increase in internal attributions. However, this factor would not explain either their increase in global attributions, or the increase in their perceived severity of minor stressors. Whatever the direction of causality, the major finding of the present study is the pronounced difference between melancholic and non-melancholic patients. In contrast to the major abnormalities of the melancholic patients in the reporting of hassles and uplifts and in attributional style, the only significant difference between the nonmelancholic patients and normal volunteers was a small reduction in the intensity of uplifts (see also Lewinsohn and MacPhillamy, 1974; Grosscup and Lewinsohn, 1980) which did not approach in its severity the pervasive absence of pleasure reported by the melancholic group. It remains to be established which psychological tests would reveal abnormalities specific to severely depressed but non-melancholic patients. However, it would appear important that future research on cognitive
286
functioning erogeneity
in depression of the disorder
take the diagnostic fully into account.
het-
Acknowledgements We are grateful to the nursing staff at the Woodbourne Clinic for their invaluable assistance, and to Dr. M.E.P. Seligman for permission to use the ASQ. References Abramson, L.Y. and Sackheim, H.A. (1977) A paradox in depression: uncontrollability and self-blame. Psychol. Bull. 84, 838-851. Abramson. L.Y., Seligman, M.E.P. and Teasdale, J.D. (1978) Learned helplessness in humans: critique and reformulation. J. Abnorm. Psychol. 87, 49-74. Alloy, L.B., Peterson. C., Abramson, L.Y. and Seligman, M.E.P. (1984) Attributional style and the generality of learned helplessness. J. Pers. Sot. Psychol. 46, 681-687. American Psychiatric Association (1980) Diagnostic and Statistical Manual of Psychiatric Disorders, 3rd edn. American Psychiatric Association, Washington, DC. Aneshensel, C.S. and Stone, J.D. (1982) Stress and depression: a test of the buffering model of social support. Arch. Gen Psychiatry 39, 1392-1396. Beth, P. (1981) Rating scales for depression: their validity and consistency. Acta Psychiatr. Stand. 65 (Suppl. 295). Beck, A.T. (1967) Depression: Clinical, Experimental and Therapeutic Aspects. Harper and Row, New York, NY. Beck, A.T. (1974) The development of depression: a cognitive model. In: R.J. Friedman and M.M. Katz (Eds.), The Psychology of Depression: Contemporary Theory and Research. Wiley, New York, NY, pp. 3-20. Billings, A.G., Cronkite, R.C. and Moos, R.H. (1983) Socialenvironmental factors in unipolar depression: comparisons of depressed patients and non-depressed controls. J. Abnorm. Psychol. 82, 119-133. Blatt, S.J., D’Affliti, J.P. and Quinlan, D.M. (1976) Experiences of depression in normal young adults. J. Abnorm. Psychol. 85, 383-389. Blatt, S.J., Quinlan, D.M., Chevron, ES. and McDonald, C. (1982) Dependency and self-criticism: psychological dimensions of depression. J. Consult. Clin. Psychol. 50, 113-124. Brown, G.W. and Harris, T. (Eds.) (1988) Life Events and Illness. Guilford Press, London. Costain, R., Redfearn, J.W.T. and Lippold, O.C.J. (1964) A controlled trial of the therapeutic effects of polarization of the brain in depressive illness. Br. J. Psychiatry 110. 786799. Coyne, J.C. and Gotlib, I.H. (1983) The role of cognition in depression: a critical appraisal. Psychol. Bull. 94, 472-505. De Longis, A., Folkman, S. and Lazarus, R. (1988) The impact of daily stress on health and mood: psychological and social resources as mediators. J. Pers. Sot. Psychol. 54, 486-495.
Depue, R.A. and Monroe, S.M. (1978) Learned helplessness in the perspective of the depressive disorders: conceptual and definitional issues. J. Abnorm. Psychol. 87. 3-20. Feather, N.T. and Barber, J.G. (1983) Depressive reactions and unemployment. J. Abnorm. Psychol. 92, 185-195. Feinberg, M. and Carroll, B.J. (1982) Separation of subtypes of depression using discriminant analysis. I. Separation of unipolar endogenous depression from non-endogenous depression. Br. J. Psychiatry 140. 384-391. Golin, S., Sweeney, P.D. and Schaeffer, D.E. (1981) The causality of causal attributions in depression: a cross-lagged panel correlational analysis. J. Abnorm. Psychol. 90. 14-22. Grosscup. S.J. and Lewinsohn, P.M. (1980) Unpleasant and pleasant events and mood. J. Clin. Consult. Psychol. 36, 252-259. Hamilton, E.W. and Abramson. L.Y. (1983) Cognitive patterns and major depressive disorder: a longitudinal study in a hospital setting. J. Abnorm. Psychol. 92, 173-184. Hammen, C.L. and Cochrane, SD. (1981) Cognitive correlates of life stress and depression in college students. J. Abnorm. Psychol. 90. 23-27. Hammen, H., Adrian, C. and Hiroto, D. (1988) A longitudinal test of the attributional vulnerability model in children at risk for depression. Br. J. Clin. Psychol. 27, 37-46. Holahan, C.K. and Holahan, C.J. (1987) Life stress. hassles, and self-efficacy in aging: a replication and extension. J. Appl. Sot. Psychol. 17, 574-592. Kanner, A.D., Coyne, J.C., Schaefer, C. and Lazarus. R.S. (1981) A comparison of two modes of stress measurement: daily hassles and uplifts versus major life events. J. Behav. Med. 4, l-39. Katz, R.J. (1982) Animal model of depression: pharmacological sensitivity of a hedonic deficit. Pharmacol. Biochem. Behav. 16, 965-968. Lewinsohn, P.M. and MacPhillamy, D.J. (1974) The relationship between age and engagement in pleasant activities. J. Gerontol. 29, 290-294. Lewinsohn, P.M. and Tarkington. J. (1979) Studies on the measurement of unpleasant events and relations with depression. Appl. Psychol. Meas. 3, 83-101. Lewinsohn, P.M., Steinmetz, J.L., Larson, D.W. and Franklin. J. (1981) Depression-related cognitions: antecedent or consequence? J. Abnorm. Psycho]. 90, 213-219. Lloyd, C. (1980) Life events and depressive disorders reviewed. II. Life events as precipitating factors. Arch. Gem Psychiatry 37, 541-548. Maier, S.F. and Seligman, M.E.P. (1976) Learned helplessness: theory and evidence. J. Exp. Psychol. Gen. 1, 3--46. Manly, P.C., McMahon, R.J., Bradley, CF. and Davidson, P.O. (1982) Depressive attributional style and depression following childbirth. J. Abnorm. Psychol. 91, 245-254. Metalsky, G.I., Halberstadt. L.J. and Abramson, L.Y. (1987) Vulnerability to depressive mood reaction: toward a more powerful test of the diathesis-stress and causal mediation components of the reformulated theory of depression. J. Pers. Sot. Psychol. 52, 386-393. Nelson, J.C. and Charney, D.S. (1981) The symptoms of major depression. Am. J. Psychiatry 138, l-13.
287 Nolen-Hoeksema, S., Girgus, J.S. and Seligman, M.E. (1986) Learned helplessness in children: a longitudinal study of depression, achievement, and explanatory style. J. Pers. Sot. Psychol. 51, 435-442. Persons, J.B. and Rao, P.A. (1985) Longitudinal study of cognitions, life events, and depression in psychiatric inpatients. J. Abnorm. Psychol. 94, 51-63. Peterson, C. and Seligman, M.E.P. (1984) Causal explanations as a risk factor for depression: theory and evidence. Psychol. Rev. 91, 347-374. Peterson, C., Luborsky, L. and Seligman, M.E.P. (1983) Attributions and depressive mood shifts: a case study using the symptom-context method. J. Abnorm. Psychol. 92, 96-103. Peterson, C., Villanova. P. and Raps, C. (1985) Depression and attributions: factors responsible for inconsistent results in the published literature. J. Abnorm. Psychol. 94, 165-168. Schless, A.P., Schwartz, L., Goetz, C. and Mendels, J. (1974) How depressives view the significance of life events. Br. J. Psychiatry 125, 406-410. Seligman. M.E.P. (1975) Helplessness: On Development, Depression and Death. Freeman, San Francisco, CA. Seligman, M.E.P., Castellon, C., Cacciola, J. and Schulman, P. (1988) Explanatory style change during cognitive therapy for unipolar depression. J. Abnorm. Psychol. 97, 13-18. Sweeney. P.D., Anderson, K. and Bailey, S. (1986) Attribu-
tional style in depression: a meta-analytic review. J. Pers. Sot. Psychol. 50, 974-991. Weinberger, M., Hiner, S.L. and Tierney, W. (1987) In support of hassles as a measure of stress in predicting health outcomes. J. Behav. Med. 10, 19-31. Weiss, J.M., Bailey, W.H., Goodman, P.A., Hoffman, L.J., Ambrose, M.J., Salman, S. and Chart-y, J.M. (1982) A model for neurochemical study of depression. In: M.Y. Spiegelstein and A. Levy (Eds.), Behavioural Models and the Analysis of Drug Action. Elsevier, Amsterdam, pp. 195-223. Willner, P. (1986) Validating criteria for animal models of human mental disorders: learned helplessness as a paradigm case. Prog. Neuropsychopharmacol. Biol. Psychiatry 10, 677-690. Willner, P., Towell, A., Sampson, D., Sophokleous, S. and Muscat, R. (1987) Reduction of sucrose preference by chronic mild unpredictable stress, and its restoration by a tricyclic antidepressant. Psychopharmacology 93, 3588364. Zarski, J.J. (1984) Hassles and health: a replication. Health Psychol. 3, 243-251. Zimmerman, M., Coryell, W. and Corenthal, C. (1984) Attribution style, the dexamethasone suppression test, and the diagnosis of melancholia in depressed inpatients. J. Abnorm. Psychol. 93. 373-377.
Disorders, 18 (1990) 281-287
281
JAD 00691
Attributional
style and perceived stress in endogenous and reactive depression
Paul Willner ‘, Margaret Wilkes 132and Arnold Orwin 2 ’ Psychology Department, City of London Polytechnic, London El 7NT, U.K. and ’ The Woodbourne Cbnic, Edgbaston, Birmingham
BI 7 SBZ, U.K.
(Received 21 April 1989) (Revision received 22 August 1989) (Accepted 30 August 1989)
The depressive Attributional Style Questionnaire (Peterson et al., 1982) and the Hassles and Uplifts Questionnaire (Kanner et al., 1981) were administered to melancholic and non-melancholic depressed patients (matched for severity according to a doctors/nurses rating scale), and to non-depressed volunteers. Compared to the other two groups, melancholic patients had higher internality and stability scores for negative attributions, and reported a greater intensity of ‘hassles’ and a lower frequency of ‘uplifts’. The intensity of ‘uplifts’ was reduced in both depressed groups. On all other cognitive measures, the reactive patients were indistinguishable from non-depressed volunteers. The results suggest that the ‘depressive attributional style’ may be specific to melancholic patients, and underline the importance of studying well-defined diagnostic subgroups. Key words: Depression; Attributional
style; Perceived stress; Hassles; Melancholia
Introduction The learned helplessness hypothesis of depression suggested that certain depressions resulted from learning that one’s attempts to control the occurrence of aversive events were ineffective (Seligman, 1975). In the subsequent reformulation of this hypothesis, the consequences of perceived
Address for correspondence: Department, City of London London El 7NT, U.K. 0165-0327/90/$03.50
Dr. P. Willner, Psychology Polytechnic, Old Castle St,
0 1990 Elsevier Science Publishers
uncontrollability were assumed to be mediated by attributions of the causes of aversive events. The ‘depressive attributional style’ postulated by Seligman and colleagues (Abramson et al., 1978) is a tendency to attribute aversive events to causes that are internally located, stable in time, and global in scope. This hypothesis has been examined in numerous studies; many of them have supported the concept of a depressive attributional style, but a significant minority have not (reviewed by Coyne and Gotlib, 1983; Peterson and Seligman, 1984; Peterson et al., 1985; Sweeney et al., 1986). While the learned helplessness hypothesis was intended to explain only a subset of depressions
B.V. (Biomedical
Division)
282
(Seligman, 1975) it has never been clear to which diagnostic group, if any, the hypothesis properly refers (Depue and Monroe, 1978). The hypothesis was originally based on experiments in animals subjected to uncontrollable stressors (Seligman, 1975; Maier and Seligman, 1976). These animals display a wide range of pathological symptoms, including, in addition to a performance deficit in aversively motivated tasks, locomotor hypoactivity, reductions in food intake and body weight, decreased aggression, and significantly, a decreased response to rewards (reviewed by Weiss et al., 1982; Willner, 1986). Although Seligman (1975) originally suggested that learned helplessness provided a model of reactive depression, the symptom picture displayed by animals subjected to uncontrollable stress is more suggestive of an endogenous depression; in particular, the decrease in responsiveness to rewards appears to model the anhedonia that defines melancholia in DSM-III (American Psychiatric Association, 1980). Following its reformulation in attributional terms, the learned helplessness hypothesis of depression was no longer applicable to the animal literature on which it was originally based, and as a result, animal and human helplessness research have proceeded independently since 1978. However, the potential parallels between melancholia and ‘helplessness’ in animals remain intriguing. We have therefore examined attributional style in melancholic and non-melancholic patients. The etiological significance for depression of aversive experiences has usually been studied in the context of life event research, which has demonstrated a significant increase in the onset of depressive episodes in the months following particular kinds of life events (Lloyd, 1980; Brown and Harris, 1988). However, evidence has also been presented implicating chronic stress in the etiology of depression (e.g., Aneshensel and Stone, 1982; Billings et al., 1983; Feather and Barber, 1983). In animal studies, chronic stress has also been found to decrease sensitivity to rewards, and this effect is observed not only with severe chronic stress (Katz, 1982), but also using chronic mild stress (Willner et al., 1987). An instrument (the Hassles and Uplifts Questionnaire) has been developed for the measurement of low-grade stressors (Kanner et al., 1981). While numerous studies
have demonstrated a relationship between ‘hassles’ and general health (e.g. Zarski, 1984; Weinberger et al., 1987; De Longis et al., 1988) their involvement in depression is at best weakly supported (Kanner et al., 1981; Holahan and Holahan, 1987; De Longis et al., 1988). In view of the evidence from animal experiments that exposure to chronic mild stress may decrease sensitivity to rewards (Willner et al.. 1987) we thought it of interest to examine also whether the reporting of ‘hassles’ differs between melancholic and nonmelancholic depressives. Methods Subjects The subjects for this study were 20 depressed patients undergoing inpatient treatment at a private clinic, and 10 non-depressed volunteers. The patients were diagnosed by the admitting and attending psychiatrists as DSM-III major depression (American Psychiatric Association, 1980), and included 10 melancholic patients and 10 nonmelancholic patients. Only patients between 18 and 72 years of age and in social class 2 of the Registrar General’s classification (professional/administrative) were admitted to the study. Obsessive-compulsive and tension state patients, patients showing schizoaffective or manic features, and patients suffering underlying organic diseases were excluded, as were severely agitated or suicidal patients, and those undergoing treatment with neuroleptics, electroconvulsive therapy, abreaction therapy and monoamine oxidase inhibitors. Patients who were too severely depressed to undertake the questionnaires and patients whose diagnosis changed between admission and the commencement of the study were also excluded. Volunteers were included in the control group only if they, their parents, and their siblings had no psychiatric history, and they had not recently been taking any psychotropic medication. The melancholic group consisted of six men and four women, mean age (k standard error) 45 (+ 3.6) years, range 30-72. The non-melancholic group also contained six men and four women, mean age 42 (+ 3.9), range 23-62. The volunteers were five men and five women, mean age 36
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( f 3.0) range
19-68. The age differences between the groups were not statistically significant, and no correlations were apparent between age and any of the variables reported in this study. Procedure Beginning 7 days following inpatient admission to the clinic, the patients were regularly assessed by the nursing staff, using doctors/nurses observer rating scales for depression (Costain et al., 1964). Scores on these scales range from 0 (severely depressed) through 5 (normal) to 9 (severely manic). Patients were rated by the ‘nursing staff on each of the scales (activity, mood, talk) at hourly intervals between 07.00 h and 20.00 h, for 7 days. This method of rating the severity of depression was used in preference to an interview-based scale in order to avoid imposing on the patients more than absolutely necessary. When these ratings were complete, and after final selection of the patients according to the above criteria, the Attributional Style Questionnaire (ASQ) was administered, followed by the Hassles and Uplifts questionnaire; these tests were also administered to the normal volunteer group. Testing of the patients took place in the early evening; the volunteers were assessed at various times throughout the day. The ASQ asks subjects to generate a possible cause for each of 12 hypothetical events, six good and six bad, and then to rate the cause on 7-point scales corresponding to the dimensions of internality, stability and globality; this instrument was administered in its original form (Peterson et al., 1983). The Hassles and Uplifts questionnaire asks whether each of 120 bad and 120 good events has occurred in the past month, and asks for ratings of the events that did occur on a 3-point scale of severity (Kanner et al., 1981). In order to make this task more manageable for the depressed patients, both parts of the questionnaire were reduced to half the original length. Items deleted were largely those that were irrelevant to subjects of higher social class, inappropriate in a British context, or felt to have the potential to cause unwarranted distress. A copy of the reduced questionnaire is available on request. Analysis The results
were analyzed
by analysis
of vari-
”
C
E R POSITIVE
C
E
R
NEGATIVE
Fig 1. Composite scores (sum of the three subscales) for positive and negative attributions, in melancholic (endogenous: E) and non-melancholic (reactive: R) depressed patients, and in normal controls (C). Values are means ( + standard error). * * * P < 0.001.
ante, supplemented by tests of simple main effects and planned comparisons. Results The two groups of depressed patients did not differ significantly in severity, as assessed by the doctors/nurses rating scales. The mean score (_t standard error) in both groups, averaged across all ratings, was 1.5 (+ 0.5). On the ASQ (Fig. l), the three groups of subjects did not differ in their attributions for positive events (F (2,54) = 0.7, NS), but melancholic patients had higher scores for negative events than
6
0
C
E
R
INTERNAL
C
E
STABLE
R
C
E
R
GLOBAL
Fig. 2. Negative attribution scores on the internality, and globality subscales of the ASQ, in melancholic nous: E) and non-melancholic (reactive: R) depressed and in normal controls (C). Values are means (+ error).*P~0.05;**P~0.01;***P~0.001.
stability, (endogepatients, standard
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HASSLES
UPLIFTS
C z
3.0
v, 5
2.0
2 1.0
E
R
***
***
E
R
l--k&s% C
E
R
C
Fig. 3. Frequency (above) and severity (below) of reported hassles and uplifts in melancholic (endogenous: E) and nonmelancholic (reactive: R) depressed patients, and in normal controls (C). Values are means (+ standard error). * * * P < 0.001. relative to controls.
the other two groups (F (2.54) = 11.4, P < O.OOl), whose scores were almost identical. These differences in negative attributions were also apparent on the three subscales (Fig. 2) though only the effects on the internality and stability scales were significant (F (2,81) = 15.1, P < 0.001; 3.9, P -c0.025, respectively). The three groups did not differ significantly in the number of ‘hassles’ they reported (F (254) = 0.8, NS). However, the ‘hassles’ that did occur were rated as very much more intense by the melancholic patients (Fig. 3) compared both to the non-depressed subjects (F (1,54) = 18.7, P < 0.001) and to the non-melancholic patients (F (1,54) = 8.7, P < 0.01) who did not differ significantly from the controls (F (1,54) = 1.9, NS). Melancholic patients reported very few ‘ uplifts’, compared to the other two groups (F (2,54) = 19.4, P -cO.OOl), which again did not differ significantly (F (1,54) = 0.3, NS). However, the reported intensity of ‘uplifts’ was lower in both patient groups (F (2,54) = 16.9, P < 0.001). Although the melancholic patients had somewhat lower scores than the non-melancholic patients, this difference was not significant (F (1,54) = 3.3,0.05 < P < 0.1). Discussion
The extensive literature examining attributional style in depression has been the subject of several
reviews. While most studies have supported the concept of a ‘depressive attributional style’, as postulated by Seligman and colleagues as part of the reformulation of the learned helplessness hypothesis of depression (Abramson et al., 1978). a significant minority have not (Coyne and Gotlib, 1983; Peterson and Seligman, 1984; Peterson et al., 1985). Positive studies have tended to involve large samples, attributions concerning hypothetical events, and large numbers of events (Coyne and Gotlib, 1983; Peterson and Seligman, 1984; Peterson et al., 1985). However, these reviews did not examine the possibility that diagnostic subgroups might differ in their attributional style. In the present study, the depressive attributional style was strongly confirmed in melancholic patients. but was absent in non-melancholic patients. An earlier study reported no difference between melancholic and non-melancholic groups, through the data did tend non-significantly in the same direction (Zimmerman et al., 1984). The reasons for this discrepancy are unclear. The earlier study did not include a control group of normal volunteers; it should also be pointed out that the patients in the present study were relatively homogenous socioeconomically, and were somewhat atypical in not being predominantly female. Although in the present study the increase in composite negative attribution score in melancholic patients was substantial, the changes were not uniform across the three subscales. The effect arose largely from an increase in internal attributions, with a lesser contribution from stable attributions, the effect on global attributions being in the same direction, but non-significant. Although Abramson et al. (1978) originally postulated that the severity of depressed mood is determined largely by the propensity for making internal attributions (p. 65) some studies have found the tendency to make global and stable attributions to be more significant determinants (Alloy et al., 1984; Metalsky et al., 1987). It is possible that the substantial increase in internal attributions in melancholic patients may to some extent reflect feelings of excessive guilt, which contribute in DSM-III to the diagnosis of melancholia, rather than helplessness. While helplessness and guilt occur together in a substantial proportion of depressed patients (Beck, 1967; Abramson and Sackheim, 1977; Blatt
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et al., 1982) there is some evidence that they may be relatively independent phenomena (Blatt et al., 1976, 1982). Thus, the interpretation of an increase in internality is somewhat problematic. While the increase in stability of negative attributions in melancholic patients provides less ambiguous evidence for helplessness, this effect was considerably smaller. Melancholic patients also reported a substantial increase in the severity of the hassles they experienced; indeed, their scores on this measure were close to the maximum possible. However, the fact that they did not report an increase in the number of hassles experienced suggests caution in the interpretation of this finding. While it is possible that the hassles encountered by the melancholic patients really were more severe it seems more probable that this reflects the tendency of depressives to interpret events unfavorably (Beck, 1967, 1974). Indeed, depressed patients have been found to rate specific stressful life events as more unpleasant than did non-depressed subjects (Schless et al., 1974; Lewinsohn and Tarkington, 1979; Hammen and Cochran, 1981). It is easier to take at face value the virtual absence of uplifts in melancholic patients. The decreased frequency of uplifts together with an increased severity of hassles is reminiscent of an earlier study which also reported that a decrease in the frequency of pleasant events in depressed patients was associated with an increase in the unpleasantness of unpleasant events (Grosscup and Lewinsohn, 1980). The fact that both increased severity of hassles and a depressive attributional style were found in the melancholic group, but not among the nonmelancholic patients, suggests that there could be a causal relationship between attributional style and the perceived severity of minor stressors. Either direction of causality is possible: a depressive attributional style might increase the perceived severity of hassles, for instance by attributing self-blame. Alternatively, an increase in the level of subjective exposure to stress might influence the development of the depressive attributional style. Although originally postulated to be a characteristic trait (Abramson et al., 1978) recent studies have established that attributional style is rather labile. While some prospective studies have confirmed that a depressive attributional style pre-
cedes the onset of depression (Peterson et al., 1983; Nolen-Hoeksema et al., 1986), the majority have not (Golin et al., 1981; Lewinsohn et al., 1981; Manly et al., 1982; Hammen et al., 1988); this stands in sharp contrast to the high proportion (75%) of studies reporting depressive attributions during a depressive episode (Peterson et al., 1985). Conversely, there is also evidence that the depressive style normalizes during recovery from depression (Hamilton and Abramson, 1983; Persons and Rao, 1985; Seligman et al., 1988). The possibility must also be considered that the increase in the perceived severity of hassles and the changes in depressive attributional style are both secondary reflections of a depressed mood. Two avenues are open to explain the presence of these phenomena in melancholic but not nonmelancholic patients. Firstly, although the two groups of patients were rated equal in severity of depression, it is possible that the nurses rating scale was insufficiently sensitive to reveal a difference between the groups. In fact, the presence of melancholia does usually betoken a more severe depression (Nelson and Charney, 1981). However, this need not necessarily be the case (Beth, 1981; Feinberg and Carroll, 1982). Secondly, as noted above, the presence of excessive guilt in melancholic patients could contribute to their increase in internal attributions. However, this factor would not explain either their increase in global attributions, or the increase in their perceived severity of minor stressors. Whatever the direction of causality, the major finding of the present study is the pronounced difference between melancholic and non-melancholic patients. In contrast to the major abnormalities of the melancholic patients in the reporting of hassles and uplifts and in attributional style, the only significant difference between the nonmelancholic patients and normal volunteers was a small reduction in the intensity of uplifts (see also Lewinsohn and MacPhillamy, 1974; Grosscup and Lewinsohn, 1980) which did not approach in its severity the pervasive absence of pleasure reported by the melancholic group. It remains to be established which psychological tests would reveal abnormalities specific to severely depressed but non-melancholic patients. However, it would appear important that future research on cognitive
286
functioning erogeneity
in depression of the disorder
take the diagnostic fully into account.
het-
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