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Changes in thought content following sleep deprivation in depression
Changes in Thought Content Following Sleep Deprivation in Depression Alan M. Kraft, Paul Willner,
C.G. Gillin, David Janowsky, Neborsky
and Robert
ABSTRACT Thisarticle examines the relationship between elements of the self-concepts of depressed Persons and changes in mood which are stimulated by a biologica\ intervention (Sleep deprivafion). In a pilot study, seven depressed patients were tested before and after sleep deprivation to rate therr thinking about their personal life issues or themes. The changes in thought content were then compared and contrasted with changes noted on the Beck, Hamilton, and POMS. AS in previous studies, we found that sleep deprivation in the short-term alleviates depressed mood. While there is overall change in the direction of alleviation of depressive thought content, patients showed very individualized patterns of change in the ways they thought about their problems. These are differences in the way individual thought content changes which are not addressed by standardized tests.
T
he differential effects of psychotherapy and psychopharmacology on depression have been addressed by a number of investigators’m4 but the issue has not yet been adequately resolved. Psychotherapy appears to improve social functioning, insight, mood, work interests, and problem-solving abilities, while antidepressant drugs improve mood, vegetative symptoms such as appetite, sleep, and psychomotor dysfunction, as well as the “pseudo-dementia” of depression. One might expect that psychotherapy would change thought content since psychotherapy directly addresses thinking (as well as behavior and feelings). What is less certain is the kind of changes biological interventions produce upon thought content in depression. This is a report of a study which begins to address this issue. There have been numerous reports of the beneficial effects of sleep deprivation in depression.sm7 Though the reasons for this phenomenon are not well understood, it has been often replicated; a recent review of the published literature calculated that 58% of depressed patients benefitted.’ The reported changes tend to be more regularly noted in endogenous depressions but are not related to age, gender, or polarity of the affective disorder. The effect usually lasts for hours, sometimes for days, and there have been reports of “cures”.’ It is not yet clear to what extent psychological factors and biological factors interact with each other in the etiology and maintenance of depression. However, changes in patients’ thinking about their psychological conflicts, which are often
From .41’unM. Kraji. M. D.. Pro/esor Albany.
IV l’.: Puul
C. G. Gilliu.
Willner.
M.D.,
Projkssor,
Department
Sun Diego. LaJolla.
Calijomia;
Medicine.
oj Cafij&nia
Clinical
University
ProJ~.x~or. Department
LaJolla. Addrccr
end Chairmun.
Ph.D.. Proj&sor
oj’ P.sychiatry.
David Janow.sky. at &II
Depurtmort
oj.Puychology. M.D..
Po(vtechnic.
College of Medicine. Prof~vsor.
Diego. LuJofia.
of‘ Puvchiatry,
oj’t?c~vchiutry. .ANiany Mcdieui
Cit.v o/London
Robert
Univwcity
Cuiic~~c Euglutld:
Univer.sit.v of’ Culi/oruiu
Departmertl
Culifornia;
College) of’ kfedicin(~.
London.
ut
of’ Psych~or~v. Collc~gc o]’ XcborrX_v, M.D..
:lrwciutc
oj’ Cal~&ttiu
at Surl Diciro.
.dlbat~_v. Yew
York
Calijbrnia. repritlt
requests to Alan M
IC; 1984 hv Grune & Stratton.
KraJi,
M.D..
Albany
Medico1
College
1X)X
ltrc. 0010.44llX/R4/_‘503-~~OS~Ol. OO/O
Comprehensive Psychiatry, Vol. 25, No. 3, (May/June)
1984
283
284
KRAFT ET AL
expressed in their daily functioning, are a critical issue to patients and clinicians, and are quite probably relevant to investigations into the etiology and mechanisms of depression. Research in biological psychiatry has not typically explored these kinds of psychological changes, usually focusing on the important descriptive elements of depression. Despite the fact that depression involves changes in thinking,9 which may take a variety of forms,‘O,” research designs have almost invariably ignored the experience of the individual patient by using standardized rating scales. There is, therefore, a paucity of knowledge about the subtle, difficult to measure but significant, subjective changes that occur in depression, particularly in their relationship to biological variables. While it has been reasonably demonstrated that mood and behavior change in depressed patients following sleep deprivation, we could find no assessments of possible changes in thought content, with the single exception of a study of effects of sleep deprivation on memory function. I2 Our investigation was directed toward understanding what changes took place in the way patients thought about their own idiosyncratic problems and conflicts following sleep deprivation, as a part of a larger study of changes in the psychological themes of patients who were participating in a variety of neuroendocrine and psychopharmacologic investigations on a university-affiliated Veterans Administration inpatient clinical research unit. The purpose of this particular study was to address the question of the relationship between the changes in mood produced by sleep deprivation and the way individuals regard themselves and their lives’ salient issues and conflicts. To put it another way, we seek understanding of the following question: if as a result of sleep deprivation patients feel and act less depressed, do any changes also occur in the way they think about themselves and the important psychological problems in their lives. MATERIALS AND METHODS The methodology for this research was modified from that developed by Luborsky”.14 for assessment of change in psychotherapy. It attempts to identify the core conflictual problem of each patient. This core problem, or theme, is persistent and manifests itself in many of the patient’s significant relationships in problematic ways. From the patient’s history it becomes apparent in the patient’s reports of current and past interpersonal relationships. All patients in this study were men. A psychiatric interview was conducted with each patient during which key conflictual issues were identified. The formulation of the theme took the form of statements about (1) the patient’s most critical wish, hope, or goal; (2) the paradigmatic person (object) toward whom the patient directed this wish; and (3) the consequences he encountered, feared, or expected in his attempt to satisfy the wish. A written version in lay language was discussed with the patient who, with the psychiatrist, worked out a formulation which both agreed reflected the patients’ perceptions about himself. This written statement was then used as a referent for subsequent ratings by the patient about how he thought about his problems. The patient could modify, or if he wished, reject the theme or elements of it. Thus, the patient was the judge of the theme’s validity. In addition, a second formulation of the theme was written in technical language. A second psychiatrist, using an audio tape recording of the initial diagnostic interview, independently formulated a technical theme statement. These two theme versions were then rated for consensus by a third psychiatrist, who found a high level of consensus (Table 1). Examples of the two versions follow. The p&em’s version. “I wanted very much for my mother to love me, to support me, to care about me, but I never felt she did. This has carried over now into relationships in which I keep seeking love
SELF-CONCEPT
285
AND SLEEP DEPRIVATION
and approval from women. When I’m disappointed 1 feel worthless. and sometimes even guilty like I’ve done something wrong, and I feel sad and depressed.” The technical vmion. 1. The wish: nurturant love. 2. The object: maternal figure. 3. The consrquruceh’ negative external rejection; negative internal feelings of loss. guilt. failure. sadness. Having defined and agreed upon the patient’s theme, he u’as asked to rate his thoughts about II on nine scales selected to tap key issues commonly encountered in depression. Though each patient’s theme was unique to him. each patient responded to the same nine scale<. in relationship to his own personal life’s issues. This enabled us to quantify and compare responses by an individual over time and between patients. Prior to use of the scales the patient read the theme statement and was instructed to rr\prlnd to the rating scales as they specifically related to his theme, and not in a general or global way. Responses were scored using visual analogue scales. The pat&! was instructed to mark along a IOOmm line his reaction
to the question
along a high/low
or he\tiuor\l
continuum.
These were scored IO
the nearest digit from 0 to IO. The scales were I. Overall emotional feeling about the theme. 2. 3. 4. 5. 6. 7. 8.
Perceived Intensity of the theme at that moment in the patlenr’b thoughts Optlmicm or pessimism about hi< ability to deal with the conflicts in the theme. Personal \ense of responsibility for the issue\ described in the theme. Sense of Inner mastery of the theme issues. Sense of power to deal effectively with theme-related reality sltuationb Loneliness as related to the theme. Theme-related self-esteem.
9. Theme-related guilt. A tenth scale, “general feeling of physical health”. was also included, but since this scale is not theme related, results were not included in the calculation of the total ‘theme scale‘ score. Stability of the scale5 was assessed by examining the response\ of the first nine patients admitted to the larger study (of whom five were included in the sleep deprivation study) at the time of their Initial Interview (TO) and prior to the experimental interview (Tl). the day before the sleep deprivatioo No scale showed a Tignificant change m mean score from TO to Tl. and all test re-test correlations were significanl. (range: Y = .75 to r = .97: P < .02 to P < ,001.) Seven patients participated in the sleep deprivation study. Table 2 shows their age. diagnose,, and Hamilton Depression Scale and Beck Inventory scores on admission. Although all the patient\ were \ignificantly depressed on admission, some improved prior to the sleep deprivation study. In order to assure that the patient did not sleep he was accompamed by a \taff member during the time of sleep deprivation. Theme rallngs
were done at three different
fimer during
the study.
Since the literature
report\
case\
in which a nap caused the reversal of the beneficial effect. the ratlngq were done at ~.AM on the morning prior to 4eep deprivation (TI), at HAM on the morning after rhe night of sleep deprivation CT?). and again aftt.r a lO-minute nap at 3l’M of the same day (T3). At these Same times the patient %a\ aI50 rated by the POMS. Beck and Hamilton depression scales. Scores at Tl. T2 and T3 were huhjectcd to analysis of variance qupplemented by post-hoc /-tests (I-tailed). and Pearson product-moment iorrclatlons between the various measures were calculated.
Table 1. Consensus Psychiatrist with Psychiatrist II (RN) Mean Standard deviation with Psychiatrist Ill (CG) Mean Standard deviation Shows consensus
I (AMK)
Between Wish
9.2 .84
8.6 .55
Theme Formulations Object
IO 0
9.4 .55
(on a scale of 1 to 10) between formulations
Consequences
Overall
8.3
1.35
9.1 65
7.2 .45
8.6 .55
of the theme of ten patients.
286
KRAFT ET AL
Table 2. Admission
Pt. 1 2 3 4 5 6 7
RDC Diagnosis Bipolar affective disorder Major depression Bipolar 2 depression Major depression Major depression Major depression Major depression
‘Tricyclic
antidepressant,
Data for Seven Depressed
Patients
Admission Hamilton
Admission Beck
Age
Medication
21 29 21 36 22 33 23
23 24 37 39 29 30 16
38 34 31 57 35 60 35
TCA’ TCA’ TCA* TCA’ TCA* None None
started after admission,
-
from 2 to 15 days before this study
RESULTS The validity of the present method may be addressed by examining the relationship of the Theme scores to scores on the three standard depression scales. At all three assessments, total Theme scores were significantly correlated with scores on each of the three standard instruments (range: r = 0.76 to r = 0.96; P < 0.05 to P < 0.001). The total Theme score does, therefore, correlate with standard research measures of depression. Examination of the individual Theme scales revealed significant correlations with the standard instruments for the “overall feeling” and “self-esteem” scales (range: r = 0.76 to r = 0.92). Similar but weaker relationships were also shown by the “optimism”, “mastery”, and “guilt” scales. Scores on the other sclaes-“intensity”, “responsibility”, “power”, and “loneliness” were not significantly correlated with scores in the POMS, Beck, or Hamilton. Total scores on all four instruments are shown in Table 3. Sleep deprivation (Tl to T2) did not significantly improve depression as measured by the Beck Inventory. There were, however, significant decreases in the Hamilton and POMS scores and large changes in the way the patients thought about their theme. These improvements on POMS, Hamilton and Theme scores were maintained through the afternoon nap (Tl to T3). After the nap a small improvement on the Beck also became apparent. Changes in the subject’s Theme scores are shown in Table 4. Five of nine Theme scales changed significantly following sleep deprivation (Tl to T2).
Table 3. Mean Scores on POMS, Beck, and Hamilton Tl, T2, and T3
POMS Hamilton Beck Themes (9 scales) Tl T2 T3 ‘P +P
= = = < <
Tl 28.3 15.0 19.6 56.6
T2 21.6’ 10.3* 17.7 44.7t
day before sleepless night. morning after sleepless night. after IO-minute nap on day after sleepless .05 .oi
T3 19.9’ 10.0’ 14.4’ 47.6’
night.
at
SELF-CONCEPT
287
AND SLEEP DEPRIVATION
Changes in individual Theme scale scores were not closely tied to changes in the POMS, Beck, or Hamilton scores. Two of the scales, “loneliness” and “intensity”. showed significant changes with sleep deprivation. while “mastery” and “selfesteem” were unchanged. The most striking feature of Table 4 is the variability of response; for those patients who showed an overall improvement, the scales on which they improved varied from patient to patient. We tested the possibility that patients who improved most as measured by the total Theme score or the POMS, Beck, or Hamilton, improved on the Theme scales which were initially most problematic or, alternatively, least problematic in their theme; this proved not to be the case. These data suggest that for persons with major depressions, the theme scores illuminate an aspect of the patient’s experience to which investigators would not attend if they depend entirely on the usual depression scales. Subject 3, for example, had very httle or no response to sleep deprivation as measured on the POMS. Beck, and Hamilton. Yet on the theme scales his response was more robust. In talking to him after sleep deprivation, he reported that he was bothered less with his guilty thoughts. He was not preoccupied with these and was able to think of ways to act which he would find more satisfying and effective. In his theme guilt was a significant issue. Patient 1, on the other hand, for whom guilt was also R key issue in his theme, did not have a decrease in guilty thought with sleep deprivation, but he did show improvement in the intensity of the troublesome thoughts about the theme and in his overall thinking and feeling about it. Subject 6 was delusional and clinically the most profoundly depressed patient in the study. He was the only patient who reported feeling somewhat worse after sleep deprivation, and showed only minor improvements on the theme scales. The nap was adverse in its effects only on patient 5, whose scale scores and verbal reports indicate a relapse after the 31% nap. The other subjects sustained their improved mood after the nap.
Table 4. Changes
in Scores Following
Sleep Deprivation Patient Number
Scale Overall feelrng Optimrsm Intensity Responsibility Sense of Mastery Sense of Power Loneliness Self esteem Guilt General Health Total change 9 scales (excluding general health) Changes response. in column + :y P c
1
2
2313303 1 2 0342300 0 -3 0 0 0 -1 -1 4 -1 1 -1 2 1 0 0 11
3
4
5
6
7
2
0
4
0
0
3 2 0 2 3 5
0 1 1 4 0 0 1 6
0 0 0 0
Pl l
P2
.
* -7 4 3 2 5 0 25
A 1 1 2 0 3 10
-2 25
’
1 1 --5 6
on scores on Theme scales from Tl to T2. Negatrve numbers reflect a more depressive Probability values for those scales which changed significantly from Tl to T2 are shown p 1; similarly significant changes from Tl to T3 are shown in column p 2. 0.01; + = /= < 0.025; : = P < 0.05
288
KRAFT ET AL
DISCUSSION Although the number of patients in the present study is small, the results suggest that at least in response to sleep deprivation the Theme method may be more sensitive to change than some standard measuring instruments. The study also suggests that the method may indeed be appropriate for investigating subjective issues not considered in standard instruments. For example, the theme scales showed significant improvement on the “loneliness” and “intensity” subscales. Perhaps surprising, measures of “self-esteem” and “mastery” did not show significant change, even though these subscales were significantly correlated with standard measures of depression prior to sleep deprivation. These preliminary findings suggest that further inquiry along these lines is warranted. The scales used here were derived de novo out of a clinical sense of what issues might be relevant in depression. Thus, guilt, mastery, power, loneliness, and selfesteem are the theme issues which were chosen for the scales. For a group of anxious, phobic, or schizophrenic patients other scales would have to be defined,i5 though the patient’s theme would still be the referent. The method requires a skilled interviewer, probably an experienced clinician, to give three to four hours to interview the patient, to formulate the theme, and to arrive at a consensus with the patient. This puts a limitation on how the scales may be realistically used in other research protocols. On the other hand, the methodology may be facilitated in a therapeutic context in which such psychological explorations are done routinely. In spite of its limitations, this study does suggest that sleep deprivation induces changes in the content of thought regarding important life issues in patients with major depressions. There is no apparent pattern to which all patients conform in terms of which issues change as a result of sleep deprivation. Rather, each patient changed in his own way, sometimes dramatically. Although the Theme method appears to be a reliable and valid way of assessing depression, we do not believe that the themes are diagnostically specific, though the study suggests that the changes in the way the patients think and feel about their theme are a useful measure of response to sleep deprivation and possibly to other therapeutic or experimental interventions. The core conflict or theme seems to be a persistent psychological constellation for each individual. Sleep deprivation, and quite probably other variables, may change the way patients think about their constellation, or possibly act in relation to it, but the theme itself continues as a central issue. The method of studying thought content described here offers the possibility for examining and comparing changes in thought content, for example, changes in individual scales under the influence of different conditions. It would be feasible to study the different effects of psychotherapy and tricyclic drugs on a single individual, or between cohorts of bipolar and unipolar depressions. There are also implications of this investigation for research concerning the linkage between subjective experience and observable behavior in depression. Clearly, there is a need for tools like the methodology we have described which offer a means for observing, measuring, correlating, and ultimately understanding the transitions between physiologic, cognitive, and experiential phenomena.16
SELF-CONCEPT
AND SLEEP DEPRIVATION
289
REFERENCES 1. Kovacs M, Rush AJ, Beck AT, et al: Depressed outpatients treated with cognitive therapy or pharmacotherapy. Arch Gen Psychiatry 30:33-39, 1981 2. Hollon SD, Beck AT: Psychotherapy and drug therapy: comparison and combinations. in Garfield SL, Bergin AE teds): Handbook of Psychotherapy and Behavioral Change: An Empirical Analysis. New York, John Wiley Sons, 1978 3. Weissman MM, Klerman GL, Prusoff BA, et al: Depressed outpatients. Arch Gen Psychiatry 30:51-55, 1981 4. Klerman GL, Schechter G: Drugs and psychotherapy, in Paykel ES fed): Handbook of Affective Disorders. New York, Guilford Press, 1982 5. Gerner RH, Post RM, Gillin JC, et al: Biological and behavioral effects. of one night’s sleep deprivation in depressed patients and normals. J Psychiat Res 15:2140, 1979 6. Pflug B, Tolle R: Disturbance of 24-hour rhythm, endogenous depression, and the treatment of endogenous depression by sleep deprivation. Int Pharmnacopsychiatr 6: 187196, 1971 7. Gillin JC: The sleep therapies of depression. Prog Neuropsychopharmacol 1983 (in press) 8. Kvist J, Kirkegard C: Effect of repeated sleep deprivation on clinical symptoms and the TRH test in endogenous depression. ACTA Psychiatr Stand 62(5):494-502, 1980 9. Beck AT: Cognition, affect and psychopathology. Arch Gen Psychiatr 24:495--500. 1971 10. Biatt SJ, Wein SJ, Chevron E, et al: Parental representations and depression in normal young adults. J Abnorm Psycho1 88:4,388-397, 1979 11. Blatt SJ, Quinlan DM, Chevron ES, et al: Dependency and self-criticism: psychological dimensions of depression. J Consult Clin Psycho1 20:1,113-124. 1982 12. Greenberg R, Schwartz WR, Pearlman C, et al: Memory, emotion, and REM sleep. J Abnorm Psycho1 19:92,3, 378-381, 1983 13. Luborsky L: Measuring a pervasive psychic structure in psychotherapy: The core conflictual relationship theme, in Freidman N, Grand S teds): Communicative Structures and Psychic Structures. New York, Plenum Press, 1976 14. Levine FJ, Luborsky L: The core conflictual relationship theme, in Tuttman S, Carol K, Zimmerman M teds): Object and Self. New York, International University Press, 1981 15. Parrott AC, Kentridge R: Personal constructs of anxiety under the 1,5-Benzodiazepine derivative clobazam related to trait-anxiety levels of the personality. Psychopharmacology 78:353--357, 1982 16. Willner P: A conceptual framework for psychobiological synthesis. Biol Psychiatr (in press)
C.G. Gillin, David Janowsky, Neborsky
and Robert
ABSTRACT Thisarticle examines the relationship between elements of the self-concepts of depressed Persons and changes in mood which are stimulated by a biologica\ intervention (Sleep deprivafion). In a pilot study, seven depressed patients were tested before and after sleep deprivation to rate therr thinking about their personal life issues or themes. The changes in thought content were then compared and contrasted with changes noted on the Beck, Hamilton, and POMS. AS in previous studies, we found that sleep deprivation in the short-term alleviates depressed mood. While there is overall change in the direction of alleviation of depressive thought content, patients showed very individualized patterns of change in the ways they thought about their problems. These are differences in the way individual thought content changes which are not addressed by standardized tests.
T
he differential effects of psychotherapy and psychopharmacology on depression have been addressed by a number of investigators’m4 but the issue has not yet been adequately resolved. Psychotherapy appears to improve social functioning, insight, mood, work interests, and problem-solving abilities, while antidepressant drugs improve mood, vegetative symptoms such as appetite, sleep, and psychomotor dysfunction, as well as the “pseudo-dementia” of depression. One might expect that psychotherapy would change thought content since psychotherapy directly addresses thinking (as well as behavior and feelings). What is less certain is the kind of changes biological interventions produce upon thought content in depression. This is a report of a study which begins to address this issue. There have been numerous reports of the beneficial effects of sleep deprivation in depression.sm7 Though the reasons for this phenomenon are not well understood, it has been often replicated; a recent review of the published literature calculated that 58% of depressed patients benefitted.’ The reported changes tend to be more regularly noted in endogenous depressions but are not related to age, gender, or polarity of the affective disorder. The effect usually lasts for hours, sometimes for days, and there have been reports of “cures”.’ It is not yet clear to what extent psychological factors and biological factors interact with each other in the etiology and maintenance of depression. However, changes in patients’ thinking about their psychological conflicts, which are often
From .41’unM. Kraji. M. D.. Pro/esor Albany.
IV l’.: Puul
C. G. Gilliu.
Willner.
M.D.,
Projkssor,
Department
Sun Diego. LaJolla.
Calijomia;
Medicine.
oj Cafij&nia
Clinical
University
ProJ~.x~or. Department
LaJolla. Addrccr
end Chairmun.
Ph.D.. Proj&sor
oj’ P.sychiatry.
David Janow.sky. at &II
Depurtmort
oj.Puychology. M.D..
Po(vtechnic.
College of Medicine. Prof~vsor.
Diego. LuJofia.
of‘ Puvchiatry,
oj’t?c~vchiutry. .ANiany Mcdieui
Cit.v o/London
Robert
Univwcity
Cuiic~~c Euglutld:
Univer.sit.v of’ Culi/oruiu
Departmertl
Culifornia;
College) of’ kfedicin(~.
London.
ut
of’ Psych~or~v. Collc~gc o]’ XcborrX_v, M.D..
:lrwciutc
oj’ Cal~&ttiu
at Surl Diciro.
.dlbat~_v. Yew
York
Calijbrnia. repritlt
requests to Alan M
IC; 1984 hv Grune & Stratton.
KraJi,
M.D..
Albany
Medico1
College
1X)X
ltrc. 0010.44llX/R4/_‘503-~~OS~Ol. OO/O
Comprehensive Psychiatry, Vol. 25, No. 3, (May/June)
1984
283
284
KRAFT ET AL
expressed in their daily functioning, are a critical issue to patients and clinicians, and are quite probably relevant to investigations into the etiology and mechanisms of depression. Research in biological psychiatry has not typically explored these kinds of psychological changes, usually focusing on the important descriptive elements of depression. Despite the fact that depression involves changes in thinking,9 which may take a variety of forms,‘O,” research designs have almost invariably ignored the experience of the individual patient by using standardized rating scales. There is, therefore, a paucity of knowledge about the subtle, difficult to measure but significant, subjective changes that occur in depression, particularly in their relationship to biological variables. While it has been reasonably demonstrated that mood and behavior change in depressed patients following sleep deprivation, we could find no assessments of possible changes in thought content, with the single exception of a study of effects of sleep deprivation on memory function. I2 Our investigation was directed toward understanding what changes took place in the way patients thought about their own idiosyncratic problems and conflicts following sleep deprivation, as a part of a larger study of changes in the psychological themes of patients who were participating in a variety of neuroendocrine and psychopharmacologic investigations on a university-affiliated Veterans Administration inpatient clinical research unit. The purpose of this particular study was to address the question of the relationship between the changes in mood produced by sleep deprivation and the way individuals regard themselves and their lives’ salient issues and conflicts. To put it another way, we seek understanding of the following question: if as a result of sleep deprivation patients feel and act less depressed, do any changes also occur in the way they think about themselves and the important psychological problems in their lives. MATERIALS AND METHODS The methodology for this research was modified from that developed by Luborsky”.14 for assessment of change in psychotherapy. It attempts to identify the core conflictual problem of each patient. This core problem, or theme, is persistent and manifests itself in many of the patient’s significant relationships in problematic ways. From the patient’s history it becomes apparent in the patient’s reports of current and past interpersonal relationships. All patients in this study were men. A psychiatric interview was conducted with each patient during which key conflictual issues were identified. The formulation of the theme took the form of statements about (1) the patient’s most critical wish, hope, or goal; (2) the paradigmatic person (object) toward whom the patient directed this wish; and (3) the consequences he encountered, feared, or expected in his attempt to satisfy the wish. A written version in lay language was discussed with the patient who, with the psychiatrist, worked out a formulation which both agreed reflected the patients’ perceptions about himself. This written statement was then used as a referent for subsequent ratings by the patient about how he thought about his problems. The patient could modify, or if he wished, reject the theme or elements of it. Thus, the patient was the judge of the theme’s validity. In addition, a second formulation of the theme was written in technical language. A second psychiatrist, using an audio tape recording of the initial diagnostic interview, independently formulated a technical theme statement. These two theme versions were then rated for consensus by a third psychiatrist, who found a high level of consensus (Table 1). Examples of the two versions follow. The p&em’s version. “I wanted very much for my mother to love me, to support me, to care about me, but I never felt she did. This has carried over now into relationships in which I keep seeking love
SELF-CONCEPT
285
AND SLEEP DEPRIVATION
and approval from women. When I’m disappointed 1 feel worthless. and sometimes even guilty like I’ve done something wrong, and I feel sad and depressed.” The technical vmion. 1. The wish: nurturant love. 2. The object: maternal figure. 3. The consrquruceh’ negative external rejection; negative internal feelings of loss. guilt. failure. sadness. Having defined and agreed upon the patient’s theme, he u’as asked to rate his thoughts about II on nine scales selected to tap key issues commonly encountered in depression. Though each patient’s theme was unique to him. each patient responded to the same nine scale<. in relationship to his own personal life’s issues. This enabled us to quantify and compare responses by an individual over time and between patients. Prior to use of the scales the patient read the theme statement and was instructed to rr\prlnd to the rating scales as they specifically related to his theme, and not in a general or global way. Responses were scored using visual analogue scales. The pat&! was instructed to mark along a IOOmm line his reaction
to the question
along a high/low
or he\tiuor\l
continuum.
These were scored IO
the nearest digit from 0 to IO. The scales were I. Overall emotional feeling about the theme. 2. 3. 4. 5. 6. 7. 8.
Perceived Intensity of the theme at that moment in the patlenr’b thoughts Optlmicm or pessimism about hi< ability to deal with the conflicts in the theme. Personal \ense of responsibility for the issue\ described in the theme. Sense of Inner mastery of the theme issues. Sense of power to deal effectively with theme-related reality sltuationb Loneliness as related to the theme. Theme-related self-esteem.
9. Theme-related guilt. A tenth scale, “general feeling of physical health”. was also included, but since this scale is not theme related, results were not included in the calculation of the total ‘theme scale‘ score. Stability of the scale5 was assessed by examining the response\ of the first nine patients admitted to the larger study (of whom five were included in the sleep deprivation study) at the time of their Initial Interview (TO) and prior to the experimental interview (Tl). the day before the sleep deprivatioo No scale showed a Tignificant change m mean score from TO to Tl. and all test re-test correlations were significanl. (range: Y = .75 to r = .97: P < .02 to P < ,001.) Seven patients participated in the sleep deprivation study. Table 2 shows their age. diagnose,, and Hamilton Depression Scale and Beck Inventory scores on admission. Although all the patient\ were \ignificantly depressed on admission, some improved prior to the sleep deprivation study. In order to assure that the patient did not sleep he was accompamed by a \taff member during the time of sleep deprivation. Theme rallngs
were done at three different
fimer during
the study.
Since the literature
report\
case\
in which a nap caused the reversal of the beneficial effect. the ratlngq were done at ~.AM on the morning prior to 4eep deprivation (TI), at HAM on the morning after rhe night of sleep deprivation CT?). and again aftt.r a lO-minute nap at 3l’M of the same day (T3). At these Same times the patient %a\ aI50 rated by the POMS. Beck and Hamilton depression scales. Scores at Tl. T2 and T3 were huhjectcd to analysis of variance qupplemented by post-hoc /-tests (I-tailed). and Pearson product-moment iorrclatlons between the various measures were calculated.
Table 1. Consensus Psychiatrist with Psychiatrist II (RN) Mean Standard deviation with Psychiatrist Ill (CG) Mean Standard deviation Shows consensus
I (AMK)
Between Wish
9.2 .84
8.6 .55
Theme Formulations Object
IO 0
9.4 .55
(on a scale of 1 to 10) between formulations
Consequences
Overall
8.3
1.35
9.1 65
7.2 .45
8.6 .55
of the theme of ten patients.
286
KRAFT ET AL
Table 2. Admission
Pt. 1 2 3 4 5 6 7
RDC Diagnosis Bipolar affective disorder Major depression Bipolar 2 depression Major depression Major depression Major depression Major depression
‘Tricyclic
antidepressant,
Data for Seven Depressed
Patients
Admission Hamilton
Admission Beck
Age
Medication
21 29 21 36 22 33 23
23 24 37 39 29 30 16
38 34 31 57 35 60 35
TCA’ TCA’ TCA* TCA’ TCA* None None
started after admission,
-
from 2 to 15 days before this study
RESULTS The validity of the present method may be addressed by examining the relationship of the Theme scores to scores on the three standard depression scales. At all three assessments, total Theme scores were significantly correlated with scores on each of the three standard instruments (range: r = 0.76 to r = 0.96; P < 0.05 to P < 0.001). The total Theme score does, therefore, correlate with standard research measures of depression. Examination of the individual Theme scales revealed significant correlations with the standard instruments for the “overall feeling” and “self-esteem” scales (range: r = 0.76 to r = 0.92). Similar but weaker relationships were also shown by the “optimism”, “mastery”, and “guilt” scales. Scores on the other sclaes-“intensity”, “responsibility”, “power”, and “loneliness” were not significantly correlated with scores in the POMS, Beck, or Hamilton. Total scores on all four instruments are shown in Table 3. Sleep deprivation (Tl to T2) did not significantly improve depression as measured by the Beck Inventory. There were, however, significant decreases in the Hamilton and POMS scores and large changes in the way the patients thought about their theme. These improvements on POMS, Hamilton and Theme scores were maintained through the afternoon nap (Tl to T3). After the nap a small improvement on the Beck also became apparent. Changes in the subject’s Theme scores are shown in Table 4. Five of nine Theme scales changed significantly following sleep deprivation (Tl to T2).
Table 3. Mean Scores on POMS, Beck, and Hamilton Tl, T2, and T3
POMS Hamilton Beck Themes (9 scales) Tl T2 T3 ‘P +P
= = = < <
Tl 28.3 15.0 19.6 56.6
T2 21.6’ 10.3* 17.7 44.7t
day before sleepless night. morning after sleepless night. after IO-minute nap on day after sleepless .05 .oi
T3 19.9’ 10.0’ 14.4’ 47.6’
night.
at
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AND SLEEP DEPRIVATION
Changes in individual Theme scale scores were not closely tied to changes in the POMS, Beck, or Hamilton scores. Two of the scales, “loneliness” and “intensity”. showed significant changes with sleep deprivation. while “mastery” and “selfesteem” were unchanged. The most striking feature of Table 4 is the variability of response; for those patients who showed an overall improvement, the scales on which they improved varied from patient to patient. We tested the possibility that patients who improved most as measured by the total Theme score or the POMS, Beck, or Hamilton, improved on the Theme scales which were initially most problematic or, alternatively, least problematic in their theme; this proved not to be the case. These data suggest that for persons with major depressions, the theme scores illuminate an aspect of the patient’s experience to which investigators would not attend if they depend entirely on the usual depression scales. Subject 3, for example, had very httle or no response to sleep deprivation as measured on the POMS. Beck, and Hamilton. Yet on the theme scales his response was more robust. In talking to him after sleep deprivation, he reported that he was bothered less with his guilty thoughts. He was not preoccupied with these and was able to think of ways to act which he would find more satisfying and effective. In his theme guilt was a significant issue. Patient 1, on the other hand, for whom guilt was also R key issue in his theme, did not have a decrease in guilty thought with sleep deprivation, but he did show improvement in the intensity of the troublesome thoughts about the theme and in his overall thinking and feeling about it. Subject 6 was delusional and clinically the most profoundly depressed patient in the study. He was the only patient who reported feeling somewhat worse after sleep deprivation, and showed only minor improvements on the theme scales. The nap was adverse in its effects only on patient 5, whose scale scores and verbal reports indicate a relapse after the 31% nap. The other subjects sustained their improved mood after the nap.
Table 4. Changes
in Scores Following
Sleep Deprivation Patient Number
Scale Overall feelrng Optimrsm Intensity Responsibility Sense of Mastery Sense of Power Loneliness Self esteem Guilt General Health Total change 9 scales (excluding general health) Changes response. in column + :y P c
1
2
2313303 1 2 0342300 0 -3 0 0 0 -1 -1 4 -1 1 -1 2 1 0 0 11
3
4
5
6
7
2
0
4
0
0
3 2 0 2 3 5
0 1 1 4 0 0 1 6
0 0 0 0
Pl l
P2
.
* -7 4 3 2 5 0 25
A 1 1 2 0 3 10
-2 25
’
1 1 --5 6
on scores on Theme scales from Tl to T2. Negatrve numbers reflect a more depressive Probability values for those scales which changed significantly from Tl to T2 are shown p 1; similarly significant changes from Tl to T3 are shown in column p 2. 0.01; + = /= < 0.025; : = P < 0.05
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KRAFT ET AL
DISCUSSION Although the number of patients in the present study is small, the results suggest that at least in response to sleep deprivation the Theme method may be more sensitive to change than some standard measuring instruments. The study also suggests that the method may indeed be appropriate for investigating subjective issues not considered in standard instruments. For example, the theme scales showed significant improvement on the “loneliness” and “intensity” subscales. Perhaps surprising, measures of “self-esteem” and “mastery” did not show significant change, even though these subscales were significantly correlated with standard measures of depression prior to sleep deprivation. These preliminary findings suggest that further inquiry along these lines is warranted. The scales used here were derived de novo out of a clinical sense of what issues might be relevant in depression. Thus, guilt, mastery, power, loneliness, and selfesteem are the theme issues which were chosen for the scales. For a group of anxious, phobic, or schizophrenic patients other scales would have to be defined,i5 though the patient’s theme would still be the referent. The method requires a skilled interviewer, probably an experienced clinician, to give three to four hours to interview the patient, to formulate the theme, and to arrive at a consensus with the patient. This puts a limitation on how the scales may be realistically used in other research protocols. On the other hand, the methodology may be facilitated in a therapeutic context in which such psychological explorations are done routinely. In spite of its limitations, this study does suggest that sleep deprivation induces changes in the content of thought regarding important life issues in patients with major depressions. There is no apparent pattern to which all patients conform in terms of which issues change as a result of sleep deprivation. Rather, each patient changed in his own way, sometimes dramatically. Although the Theme method appears to be a reliable and valid way of assessing depression, we do not believe that the themes are diagnostically specific, though the study suggests that the changes in the way the patients think and feel about their theme are a useful measure of response to sleep deprivation and possibly to other therapeutic or experimental interventions. The core conflict or theme seems to be a persistent psychological constellation for each individual. Sleep deprivation, and quite probably other variables, may change the way patients think about their constellation, or possibly act in relation to it, but the theme itself continues as a central issue. The method of studying thought content described here offers the possibility for examining and comparing changes in thought content, for example, changes in individual scales under the influence of different conditions. It would be feasible to study the different effects of psychotherapy and tricyclic drugs on a single individual, or between cohorts of bipolar and unipolar depressions. There are also implications of this investigation for research concerning the linkage between subjective experience and observable behavior in depression. Clearly, there is a need for tools like the methodology we have described which offer a means for observing, measuring, correlating, and ultimately understanding the transitions between physiologic, cognitive, and experiential phenomena.16
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