Affective disorders history of studying the main theoretical models. Etiology of affective disorders

4. Multifactorial model of affective disorders

A.B. Kholmogorova and N.G. Garanyan

In domestic clinical psychology, A.B. Kholmogorova and N.G. Garanyan proposed a hypothetical multifactorial model of depressive disorders (1998). This model considers psychological factors at different levels - macrosocial, family, interpersonal, personal, cognitive and behavioral. This approach is based on the idea that biological vulnerability results in disease only when exposed to unfavorable social and psychological factors.

From the point of view of A.B. Kholmogorova and N.G. Garanyan, in modern culture there are quite specific psychological factors that contribute to the growth of the total number of experienced negative emotions in the form of melancholy, fear, aggression and at the same time complicate their psychological processing. These are special values ​​and attitudes that are encouraged in society and cultivated in many families, as a reflection of the wider society. These attitudes then become the property of the individual consciousness, creating a psychological predisposition or vulnerability to emotional disorders.

Emotional disturbances are closely related to the cult of success and achievement, the cult of strength and competitiveness, the cult of rationality and restraint that characterize our culture. Table 2 shows how these values ​​are then refracted in family and interpersonal relationships, in individual consciousness, determining the style of thinking, and, finally, in painful symptoms. In the table, one or another type of values ​​and attitudes is rather conventionally associated with certain syndromes - depressive, anxious, somatoform. This division is quite arbitrary, and all the identified attitudes may be present in each of the three analyzed disorders. We are talking only about the relative weight of certain attitudes, about trends, but not about the strict cause-and-effect relationships of a certain attitude with a certain syndrome.

Table 2. Multivariate model of emotional disorders.

Conclusion

In order to achieve these goals, in my work I compiled an overview of the main psychological approaches (models) to the study of depression. As you can see, each of the considered models (psychoanalytic, behaviorist, cognitive) of depression expresses an original approach to explaining the causes and factors of the occurrence of depressive symptoms.

The psychoanalytic approach to the study of depression is based on the primacy of the affective radical in the formation of the depressive symptom complex and develops from Freud’s ideas about the loss of an object, loss in the sphere of one’s own Self.

With the development of Ego psychology and the theory of object relations, the focus of attention of psychoanalysts shifted to object relations in depression, the characteristics of the Ego and the Self, in particular to the problems of self-esteem and its determinants. Representatives of the theory of object relations assign a large role to the success of the baby overcoming successive phases of development and the harmony of relationships with the object.

In the cognitive-behaviourist approach, the main role is given to the cognitive components of the self-concept. Depression is understood as the result of irrational and unrealistic thinking.

A modern multifactorial model of affective disorders developed by A.B. Kholmogorova and N.G. Garanyan presents a special scheme that explains the connection between specific psychological factors of the cultural level and the occurrence of emotional disorders and shows how the values ​​characteristic of modern culture are refracted in family and interpersonal relationships, in the individual consciousness, determining the style of thinking, and, finally, in painful symptoms . In this approach, the authors pay attention not to individual factors, but consider the interaction of various factors - cognitive, behavioral, social, interpersonal, family, biomedical and others.

The difficulty of studying affective disorders lies in the “difficulty” of the object of study, since emotions and affects represent a specific coloring of the content of consciousness, a special experience of phenomena that are not emotions in themselves, and the possibility of emotional “switching”, interaction and “layering”, so that one an emotion can become a subject for the emergence of a subsequent one.
In essence, each of the presented models quite adequately describes a separate class of depressive disorders, and these models should not be considered as mutually exclusive, but as complementary to each other.

Speaking about the prospects in the study of depression, we can list the areas that are already available at the moment. For example, one of the important areas of psychoanalytic research is the identification of different types of depression (or types of depressive personality).

Much attention is paid to the study of personal factors influencing the onset and course of depression, but the interaction of various factors - cognitive, behavioral, social, interpersonal, family, biomedical and others - is also studied.

The topic of depression is very interesting and relevant in our time. Therefore, I also plan to connect the topic of my next course work with the study or research of depression, but in a more specific form.

References

1. Beck A., Rush A., Shaw B., Emery G. Cognitive therapy for depression. St. Petersburg, 2003.

2. Vinogradov M.V. Toward the diagnosis and treatment of masked depression. Soviet medicine. 1979, no. 7.

3. Klein Melanie. Envy and gratitude. St. Petersburg, 1997.

4. Mosolov S.N. Clinical use of modern antidepressants. St. Petersburg: "Medical Information Agency", 1995. - 568 p.

5. Obukhov Ya.L. The significance of the first year of life for the subsequent development of the child (review of Winnicott's concept). - Russian Med. Academy of Postgraduate Education. - M., 1997

6. Sokolova E.T. Research and applied tasks in psychotherapy of personality disorders. Social and clinical psychiatry, - Volume 8/No. 2/1998.

7. Tkhostov A.Sh. Psychological concepts of depression. // RMJ. - St. Petersburg, Volume 1/No. 6/1998.

8. Freud 3. Sadness and melancholy. Psychology of emotions. Texts. M., 1984.

9. Kholmogorova A.B., Garanyan N.G. Multifactorial model of depressive, anxiety and somatoform disorders as the basis of their integrative psychotherapy.

10. Kholmogorova A. B. Theoretical and empirical foundations of integrative psychotherapy for affective spectrum disorders (Author's abstract), - Moscow, 2006.

11. Kholmogorova A.B., Garanyan N.G. Integrative psychotherapy for anxiety and depressive disorders based on the cognitive model.

12. Psychological counseling: Problems, methods, techniques. - // Concepts of Beck and Seligman, - 2000, pp. 278-187.

13. Ellis A. The unfairly neglected cognitive element of depression. MRP, - No. 1/1994.

14. Horney K. Neurotic personality of our time. Introspection. M., 1993.

15. Kupfer D. Depression: a major contributor to world-wide disease burden // International Medical News.- 1999.- Vol.99, No. 2.- P.1-2.

16. E.S.Paykel, T.Brugha, T.Fryers. The scale and burden of depressive disorders in Europe (extended abstract of the review). - // Psychiatry and psychoform therapy. - Volume 08/No. 3/2006.

TOPIC: PSYCHOLOGICAL APPROACHES TO STUDYING THE THEORY OF PERSONALITY AND INTERPERSONAL RELATIONS. MOTTO “PSYCHOLOGY” OMSK 1997 CONTENTS Page INTRODUCTION........................................................ ....................................... 3 - 4 CHAPTER 1. Psychological theory of S. Freud . 1.1. Personality structure........................................................ ...... 5 - 9 1.2. ...

When performing research. Whatever aspect of depression (or anxiety disorder) is studied, the question always arises whether the findings are due to the depression (anxiety disorder) or to comorbid Axis I and II illness. The rules of hierarchical exclusion do not solve the problem, but take it beyond the scope of discussion. Two combined diagnoses also do not solve the problem. Besides, ...

Education, i.e. Having arisen once as a result of a frustrating influence and persisting throughout life, it is etiologically defined as reactive. Behaviorist theories of depression, like psychoanalytic ones, are etiological, however, unlike psychoanalysis, which concentrates on intrapsychic phenomena, in behaviorist approaches attention is paid to behavior, and...

Suicidogenic factors include: psychological, environmental, economic, social, cultural. 2. Psychological aspects of preventive assistance to people “at risk of developing suicidal behavior” 2.1. Psychological diagnosis of suicidal behavior Despite the variety of methods for diagnosing suicidal behavior, accurate registration of suicidal...

Garanyan N.G. (Moscow)

Garanyan Natalya Georgievna

- member of the editorial board of the journal “Medical Psychology in Russia”;

Candidate of Psychological Sciences, leading researcher at the Laboratory of Clinical Psychology and Psychotherapy of the Moscow Research Institute of Psychiatry of the Ministry of Social Health Development, Professor of the Department of Clinical Psychology and Psychotherapy of the Faculty of Psychological Counseling of the Moscow State University of Psychology and Education.

Email: [email protected]

Annotation. The analysis is based on theoretical models that consider hostility as an important personality factor in depressive and anxiety disorders - the psychoanalytic model, the serotonin hypothesis of “angry” depression, the psychosocial model of hostility and depression, the cognitive model of hostility and depression, the multifactorial psychosocial model of affective spectrum disorders. The results of empirical studies of hostility and aggression in depressive and anxiety disorders obtained using self-report methods, video observation and projective techniques are analyzed. Contradictions and limitations of the obtained data are identified; prospects for future developments are outlined.

Key words: hostility, aggression, depressive and anxiety disorders.

The authors of analytical reviews unanimously note that research hostility have become an independent direction in general somatic medicine, psychiatry and clinical psychology. Its high status is associated with the significant role of hostility in the origin and course of a number of somatic, psychosomatic and mental disorders. It has been proven that hostility is a predictor of cardiovascular diseases and early mortality, as well as a prognostic criterion for the unfavorable course of allergic, oncological, viral diseases and personality disorders.

An additional incentive for its study is the data from intervention studies assessing the effectiveness of treatment for depression (psychopharmacotherapy and psychotherapy). High levels of patient hostility predict a poor working alliance in both treatments, which in turn is a major predictor of good outcome. One recent study showed that high levels of hostility in marital communications predict poor outcome in cognitive-behavioural therapy for generalized anxiety disorder. However, treatment resistance is not the only consequence of hostility for patients with depressive and anxiety disorders. Patients with intense hostility have worse indicators of somatic health and a greater tendency to alcoholism compared to more friendly patients. When studying the factors of student health, it was found that depression, combined with high levels of hostility, has a more destructive effect on indicators of the somatic well-being of young people than such harmful factors as increased body weight, smoking, consumption of large amounts of salt, caffeine and physical inactivity. Modern pharmacological approaches to the treatment of depression take into account indicators of the patient's aggressiveness and hostility.

Despite the obvious relevance of the problem, studies of hostility, anger and aggression in clinical psychology have long been hampered by the lack of generally accepted definitions of the terms, as well as the use of too different diagnostic tools: “... for many years the concept of “aggression” in psychology and psychiatry was interpreted very broadly, in in particular, it included both feelings of anger and hostility. Intensive study of hostility as such became possible after methodological elaboration and differentiation of closely related concepts - aggression, aggressiveness, anger, hostility."

An illustration of this conceptual “confusion” is the variability in definitions of anger and hostility. For example, according to the concept of C. Spielberger, anger is a multidimensional construct, the structure of which includes internalized anger(tendency to suppress the emotion of anger and thoughts of angry content), externalized anger(tendency to engage in aggressive behavior towards surrounding people or inanimate objects) and anger control(the ability to manage the experience of anger and its expression, as well as prevent them). It is easy to see that such an understanding equates the concepts of “externalized anger” and “aggression.”

This too broad interpretation of the concept of “anger” is opposed by a more modern one, which assigns this term exclusively to emotional phenomena: “Anger is the internal experiences of a person, varying in frequency, duration and intensity.”

Another example of a confusion of concepts can be broad interpretations of the term “hostility”, which mean “an oppositional attitude towards people, including cognitive, affective and behavioral components.” In this understanding, anger and aggression act as emotional and behavioral components of hostility. In recent years, many foreign and domestic authors have begun to adhere to a narrow understanding of the term as “a complex of cognitive attitudes (images, ideas, beliefs, assessments) in relation to other people.” Domestic experts have done significant methodological work to clarify the boundaries of each of the concepts (anger, hostility, aggressiveness and aggression), describe the psychological forms of each of the constructs, and establish phenomenological connections between them. The works of the cited authors created a theoretical foundation on the basis of which it became possible to differentiate the study of various forms of hostility, aggression and aggressiveness in various mental disorders and unlawful behavior.

This review is primarily focused on foreign theories that emphasize the role of hostility as a personality factor in depressive and anxiety disorders. The article presents the results of their empirical testing in recent decades. It should be noted that it does not claim to be a complete reflection of all data on this problem, but only records the most important information from sources available to domestic specialists.

1. Psychoanalytic models linking anger, aggression and hostility to depressive and anxiety disorders.

1.1. Psychoanalytic models of aggression and depression

The classical psychoanalytic models of K. Abraham and S. Freud assigned aggression and the experience of anger a central role in the origin of depression. These early theories identified the depressive reaction with ideas of self-blame, guilt, and self-destruction. Almost every depressive reaction was seen as the result of a self-referral initially addressed to an external object, and then internalized aggression against an incorporated loved and hated object. The tendency to express aggression towards others in such depressed patients was regarded as denied and repressed. It was assumed that hostile feelings towards significant others are not allowed into consciousness, where they are replaced by painful feelings of guilt. Some followers regarded aggression as the main psychodynamic factor of all types of depression (for example, M. Klein).

However, in the middle of the 20th century, four authors opposed this view. Thus, M. Balint interpreted depressive experiences of bitterness and resentment as a reaction to an illness, and not a persistent characteristic of a depressive personality. E. Bibring considered aggression in depression as a secondary phenomenon that arises as a result of a “breakdown” of self-esteem. M. Cohen and her research group described a complex cycle of interpersonal interactions: depressed patients greatly irritate and bore others, who naturally respond to them with indignation. Expressions of hostility become a secondary reaction to the anger of others and never stem from a primary impulse to harm them. These authors also objected to the assertion that the self-devaluation characteristic of depressed people can be considered as “self-directed” aggression. Thus, psychoanalyst S. Mendelson argued that the classics of psychoanalysis created theoretical models that had little relation to clinical reality, and their followers gave them the status of universal concepts and uncritically applied them to all depressive phenomena [cit. according to 26].

At the same time, clinical experience allows modern psychoanalysts to assert that aggression is “one of the important paths leading to depression.” According to the author, the mechanisms of the relationship between aggression and depression can be different:

1. If the “objects” of one’s own life are subject to aggressive devaluation (people, groups and organizations close to the individual, the types of activities in which he is involved, objects of property that he possesses), a special inner world arises in which there is nothing valuable that can maintain self-esteem personality. When such a devalued world is compared with a fantasy world full of idealized objects, depression becomes inevitable.

2. If aggression openly reacts to external objects (other people), destroying friendly, family and collegial relationships, the likelihood of satisfying love desires, achieving success, and recognition from the outside world decreases.

3. Finally, aggression directed against one’s own personality also serves as a mechanism for depression. Constant self-criticism damages the self-representation and has a negative impact on its functioning, blocking the development of abilities, the satisfaction of desires and the maintenance of self-esteem.

Thus, modern analysts are moving away from the original interpretation of depression as “introjection of aggression onto one’s own “I” as a result of the loss of an object.” They show that depression can be associated with various forms of aggression - the so-called. “internalized” (directed at one’s own “I”) and “externalized” (directed at living and non-living objects of the external world).

However, the idea that overt aggressive behavior is difficult in depressive disorders has been revived in concept of “deficit aggression” G. Ammon. The concept describes a special form of behavior with a characteristic deficit in the skills of constructive expression of aggression, which leads to a blockade of the corresponding impulses and, as a result, their insufficient response. The poverty of the arsenal of behavioral skills is combined with an intense internal experience of aggression, which finds other, painful for others, indirect, passive manifestations, for example, “when they provoke you with silence or pretend not to notice you.” According to the creator of dynamic psychiatry, individuals with deficient aggression are characterized by blockade of activity in general, including social activity, loss of the desire for personal autonomy, blocking of self-actualization processes, refusal of the desire to leave the “primary maternal symbiosis,” and difficulties in self-regulation. According to a number of authors, deficient aggression is a risk factor for the development of emotional disorders (primarily depressive, obsessive-compulsive and somatoform), as well as psychosomatic diseases. G. Ammon contrasts deficit aggression with its constructive version, which is characterized by the open manifestation of aggressive impulses in a socially acceptable form, which is ensured by appropriate behavioral skills and stereotypes of emotional response.

In our opinion, an accurate generalization of the state of affairs in the area under study can be the long-standing, but still relevant, statement of A. Beck: “It is quite obvious that the differences in points of view on the role of aggression in the origin of depression are associated with the inaccuracy of the definitions of both concepts, which leads to semantic confusion. There is no consensus on the relationship between aggression and depression. The question of whether the pathology of aggression is a persistent predispositional characteristic of individuals with depressive disorders or a secondary problem that arises in response to the disease and its attendant interpersonal difficulties remains open.”

1.2. Psychoanalytic models of hostility, anger and anxiety disorders

In psychoanalytic research on anxiety disorders, there is a well-known paradox: having created several models of anxiety at an early stage in the development of the theory, psychoanalysts only in the last two decades have approached the development of models of individual anxiety disorders and the development of specialized therapeutic interventions. Systematic placebo-controlled studies of the effectiveness of this type of treatment for anxiety disorders have not been conducted until very recently. By 2007, special treatment guidelines had been created by psychoanalysts only for panic disorder. Nevertheless, psychodynamic theory contains powerful potential to explain the development of anxiety disorders. It is based on several key ideas. The initial idea is that the unconscious of the future patient contains fantasies, desires or impulses, the implementation of which would seem dangerous to the conscious Ego. As a rule, they are of a sexual or aggressive nature. “Signal” anxiety alerts the Ego to this threat and triggers psychological defense mechanisms - displacement, projection and avoidance, whose role is to contain or mask dangerous desires and impulses. When the patient's ego is overwhelmed with anxiety and stimuli that cannot be effectively contained, "traumatic anxiety" may develop in the form of persistent anxiety or episodic panic. An alternative option is represented by the development of symptoms that “link” anxiety - phobias or obsessions. According to the psychodynamic model, anxiety “tied” to specific symptoms becomes more controllable, and frightening aggressive impulses or feelings of anger become well disguised. For example, with object phobias, fear of one's own internal motivations is converted into a signal of external danger that can be avoided. Symptoms of anxiety disorders are considered to be “compromise formations” that establish a balance between dangerous aggressive impulses and psychological protection against them. Unconscious impulses find symbolic expression in these symptoms. According to the pleasure principle, symptoms of anxiety disorders cause less discomfort than awareness of the underlying conflict.

One of the aspects of S. Freud's teachings - the connection between anxiety and repressed hostile-aggressive impulses - was developed in social psychoanalysis K. Horney. The isolation and development of this particular aspect was not accidental, but is associated with the conflicting tendencies of modern culture: orientation towards success and fierce competition coexist with the value of partnership, decent and friendly behavior. According to K. Horney, “hostile impulses of various kinds form the main source from which neurotic anxiety arises.” Why does the repression of hostility turn into fear for a person? Because to repress hostility means for a person to pretend that “everything is fine” and, thus, to withdraw from the fight when this was strongly wanted or necessary. As K. Horney believes, repression of hostility occurs if its awareness is unbearable for a person for a number of reasons: 1) due to inconsistency of feelings - deep emotional attachment to the object of hostility; 2) due to fear of the sides of one’s personality that give rise to hostility (envy, competitiveness, etc.), and reluctance to see them; 3) due to high ethical standards and a rigid “super-ego”. The repression of hostility has a number of consequences for a person: the constant experience of vague anxiety due to the presence of a dangerous, explosive affect inside, the projection of one’s own hostile impulses onto the outside world (a person believes that destructive impulses come not from him, but from someone outside), a feeling helplessness and powerlessness in the face of an “insurmountable” danger from the outside. Of the many forms of anxiety that can arise as a result of the process of repressing hostility, Horney identifies four main types:

1. Danger is felt to arise from one's own motives and threaten the Self. For example, a phobia associated with the urge to jump from a height.

2. Danger is perceived as coming from one's own motives and threatening others. For example, fear of hurting someone.

3. Danger is felt as coming from outside and threatening the Self. For example, fear of thunderstorms.

4. Danger is perceived as coming from outside and threatening others. An example is the anxiety of overprotective mothers about the dangers surrounding their children.

As K. Horney notes, not only does hostility cause anxiety, but anxiety can also cause hostility. Anxiety based on a sense of threat easily provokes defensive hostility in response. Reactive hostility can also, if repressed, give rise to anxiety, and thus "vicious circles of anxiety and hatred" arise.

Currently, these classical ideas are complemented by the concepts object relations theories. Patients with anxiety disorders have negative object representations: others are represented in their mental apparatus as “demanding,” “controlling,” “threatening,” “fear-inducing.” Object representations of this kind serve as an additional source of subjective feelings of danger, since they are charged with intense aggression. The anger inevitably generated by such images of loved ones is experienced as a threat to attachment; attachment loses its secure character.

The ideas of classical analysis and object relations theory formed the basis of modern models of individual anxiety disorders. Psychodynamic model of panic disorder (PD), proposed by F. Busch and M. Shear, integrates neurophysiological factors with psychodynamic ones. According to the model, the constitutional fearfulness of a child who experiences fears in unfamiliar situations forms an anxious attachment to close people with the expectation that they will provide safety and emotional comfort. Such dependence inevitably stimulates the child to experience narcissistic humiliation and anger towards loved ones when they are unable to provide sufficient comfort and alleviate the anxious state. Dependence on loved ones, “colored” in alarming tones, is also formed in an environment where parents behave in a critical, rude, threatening or rejecting manner. Thus, the child develops object representations of loved ones as “abandoning,” “rejecting,” and “strictly controlling.” These perceptions serve as “fuel” for anger, however, the child is afraid of this feeling, because it can alienate or harm the much-needed adult.

Anxious dependence can become actualized in adulthood against the background of life events that subjectively represent in the patient’s mind the threat of loss or separation from a significant other. Angry affect, often unconscious, is experienced at these moments as a danger to relationships of enormous vital importance. It is this circumstance, the authors believe, that triggers the alarm. Psychological defense mechanisms come into play: “reaction formation” converts anger into positive feelings or a desire to help, and “cancellation” moves any aggressive feeling that arises in consciousness back to the unconscious. As a result of the inevitable breakdown of these defenses, the patient experiences a manifestation of “traumatic anxiety” in the form of a panic attack. Panic attacks represent a compromise formation in which the patient can express anger in the form of persistent demands for help from loved ones, and also desperately seek support that can prevent terrifying events - loss or separation. Finally, this education allows the patient to "melt" dangerous experiences of anger into intense anxiety, which, according to the "pleasure principle", is less painful for the patient than the risk of losing an important attachment figure or awareness of the symbolic meaning that this state carries.

Psychodynamic studies of obsessive-compulsive disorder (OCD) were actively carried out in the early stages of the development of psychoanalysis. However, they were subsequently stopped, which is also recorded by psychoanalysts themselves. As in the case of PD, the central condition for the occurrence of OCD is considered to be a conflict associated with the experience of anger and competitive relationships. The idea is put forward that OCD represents a regression to an ontogenetically early stage of development, the characteristic experience of which is the fear of one’s own thoughts, feelings and fantasies as capable of causing harm to other people. The harsh, punitive superego present in these patients increases the potential danger of unconscious experiences. The patient's perceived fear in this disorder focuses on the theme of loss of control. Defenses in the form of “invalidation” and attempts to symbolically or magically replace hostile experiences with compulsive behavior are typical of OCD. Patients also resort to “intellectualization,” which hides hostile emotions. As in the case of PD, OCD symptoms serve as a compromise formation. L. Salzman described this psychodynamic process as follows: “Obsessive-compulsive dynamism is a device for preventing any thought or feeling that can generate shame, infringe on pride, reduce status, cause feelings of weakness or inferiority, whether these feelings are of an aggressive or any other nature.” . Some modern psychoanalysts emphasize the importance of ontogenetic events and the family context - the breakdown of emotional contact between the infant and the caregiver. From this point of view, aggression and guilt, with which S. Freud associated the phenomenon of obsession, are natural reactions to powerful traumas received in the family from emotionally unresponsive, cruel guardians. Thus, obsessive symptoms mask both experiences of unsafe relationships with parents and attempts to control the fear of losing an attachment figure.

Psychodynamic model of social phobia (SF) emphasizes a number of factors: neurophysiological predisposition, the presence of ontogenetic stressors, negative object representations. In the early stages of life, individuals who subsequently suffer from SF develop a negative perception of parents, other caregivers, and siblings as “blaming,” “criticizing,” “ridiculing,” “humiliating,” “embarrassing.” Subsequently, these images are projected onto the people around them; as a result, the patient begins to avoid social contacts due to fear of criticism and rejection, which increases his difficulties. As with PD, experiences of anger are fraught with danger due to the possibility of being rejected by an important attachment figure. With social phobia, the emotions of anger and contempt are usually projected onto others, which avoids opening these experiences in one's own soul. However, as a result of this projection, the patient sees other people as aggressive, critical and rejecting, which triggers intense social anxiety. In addition, the patient feels guilty for experiencing anger at other people and being offensively critical towards them. Social anxiety becomes a tangible punishment for aggressive impulses, albeit denied.

Along with these conflicts, patients with SF are also characterized by other contradictions: in parallel with reduced self-esteem, they may develop compensatory grandiosity, accompanied by fantasies of universal admiration. They are characterized by exhibitionistic sexual impulses, which, however, are subject to denial. Aspirations of this kind also increase distress and disappointment in current social situations, which again increases pain and anger. Like other symptoms, social phobia is a compromise formation. These patients are characterized by a conflict between the desire for exhibitionism and social anxiety; the latter acts both as a manifestation of conflict and as punishment.

The main psychoanalytic ideas about the functioning of aggression in depressive and anxiety disorders can be summarized as follows: 1) both types of emotional disorders are associated with unconscious experiences of anger and hostility; 2) awareness of aggression and anger, as well as their open expression in behavior, are blocked; 3) the main obstacles to the awareness of anger and aggression and their discharge are low autonomy and dependence on the object of hostile feelings.

In conclusion of this section, it should be noted that in the considered models of depressive and anxiety disorders, the concepts of “anger,” “aggression,” and “hostility” are used virtually synonymously; We were unable to detect any attempt to define or differentiate these terms in any of the theoretical works cited.

1.3. Alternative models linking anger, aggression, and hostility to depressive and anxiety disorders

In the late 1980s - early 1990s. Several new theories have been created describing the links between hostility, aggression and depressive and anxiety disorders.

Serotonin hypothesis of "angry" depression was formulated by M. Fava and co-authors in the early 90s. . The hypothesis was based on observations of several patients who experienced sudden, not always explainable, clearly disproportionate attacks of anger. The physical sensations that arose were very reminiscent of the symptoms of a panic attack. However, there were no indications of any manifestations of fear in the patients' self-reports. Their daily existence was colored by experiences of “unhappiness.” A thorough analysis of anamnestic information, assessment of the mental status of patients, as well as their reactions to pharmacotherapeutic interventions allowed the researchers to formulate a hypothesis that these attacks may be variants of panic attacks or an atypical form of depressive disorder. They believe that there is a common biological mechanism between mood disorders and aggression pathology related to serotonin metabolism.

In the descriptions of M. Fava and his colleagues, “angry depression” is phenomenologically close to the subaffective cyclothymic disorders identified by X. Akiskal. The frequency of occurrence of this variant of the disorder, the accompanying organic disorders and personality dysfunctions remain poorly studied. Data obtained within the framework of the “serotonin theory of aggression, anxiety and depression” completely contradict psychoanalytic models.

"A Predispositional Psychosocial Model of Hostility and Depression" argues that individuals high in this personality trait are more prone to interpersonal conflict, have low levels of social support, and experience a greater number of stressful life events. Numerous studies have shown that a high frequency of stressful life events increases the risk of developing depressive disorders. According to the diathesis-stress model, social support may act as a buffer against the negative effects of stress. Thus, the combination of these two factors (high frequency of stressful events and low social support) makes hostile individuals particularly vulnerable to depression. This model is based on the modern definition of hostility as oppositional attitudes towards other people, particular variants of which are cynicism and persistent distrust.

"A Predispositional Cognitive Model of Hostility and Depression" relies on several concepts:

1. The concept of hostility as a “negative cognitive scheme” in the perception of other people, which is based on the fragility of self-esteem, numerous cognitive distortions (overgeneralization, personalization, dichotomous thinking, distorted ideas about causality), as well as overly rigid “shoulds” addressed to others people As A. Beck suggests, hostility forms the “cognitive basis” of anger, hatred and violence, regardless of where they arise - in marital relationships or racial, ethnic and interstate conflicts.

2. The concept of “stress generation”, according to which depressed patients can not only become “passive victims of the blows of fate”, but also actively generate at least part of the stressful circumstances in which they find themselves.

3. The concept of DSM-IV, according to which, at an early stage, many forms of depressive disorders are characterized not so much by the affect of melancholy, but by signs of irritability and irascibility.

The cognitive model linking anger, hostility and depression describes the following chain of events. Elevated levels of anger and high rates of hostility can create serious problems in an individual's interpersonal relationships, which creates stress. The response to this stress is an influx of negative automatic thoughts, especially intense when it comes to relationships with the closest people. Cognitive factors combined with counterproductive coping strategies (eg, blaming others, avoidance, and greedy seeking of social support) may maintain unfavorable interpersonal dynamics in which desired support is unlikely and stress is persistent. The likelihood of depression in such a stressful environment is very high.

Domestic "Multifactorial psychosocial model of affective spectrum disorders" A.B. Kholmogorova also considers hostility as an important personality variable included in the “psychological equation” of depressive and anxiety disorders. The author of the model traces the cause-and-effect path from family dysfunctions in the form of “inducing distrust of strangers”, the practice of “abuse in the family”, the high frequency of cases of alcoholism in parental families with brutal behavior of drinkers to the formation of hostility as an individual characteristic, which becomes impoverished in adulthood social support resources for the patient.

Thus, current models integrate several risk factors for depressive disorders: high levels of anger and hostility, negative automatic thoughts, negative social interactions, stressful events in daily life, and counterproductive ways of coping with stress. Let us note that the ideas about anger and hostility in depression, developed in these models, are completely opposite to the psychoanalytic ones: we are talking about well-recognized and openly manifested psychological properties.

Let us consider the main results of empirical studies verifying various models of the relationship between aggression and emotional disorders.

2. Empirical studies of the relationship between anger, aggression and hostility in patients with depressive and anxiety disorders

Two methodological approaches have been widely used: 1) the study of anger and aggression using self-report scales; 2) study of natural communications of patients using the observation method.

2.1. Research on the directionality of anger and aggression using self-report scales

An empirical test of theories linking anger, hostility, and aggression to depressive disorders was started only in the 60s. last century and continues to this day, facilitated by progress in the development of diagnostic tools. According to the classical point of view, one would expect that, as a result of the action of the defense mechanism, the self-reports of patients with depressive and anxiety disorders would not contain indicators of experienced anger, hostility and overt aggression. However, even the first attempts to verify the psychodynamic model of depression yielded unexpected results.

Thus, when interviewing depressed elderly patients, E. Busse found virtually no experiences of guilt, internalization or suppression of aggressive and hostile impulses. Moreover, his patients readily expressed outrage and resentment.

A. Weissman and co-authors studied in a group of female college students the relationship between mood fluctuations (from depressive to elated) and the direction of their aggressive or punitive reactions (Ronzweig's frustration tolerance test). Contrary to analytical ideas, the frequency of extrapunitive reactions was significantly higher in this group on days when they felt depressed compared to periods when they did not feel depressed. Intropunitive reactions were significantly less frequent in this group during depression. Clearly puzzled by these data, A. Weissman and her co-authors concluded that relatively healthy individuals with a depressed mood can become more extrapunitive - more openly express aggression and hostility. Internalization, suppression, or self-directed aggression is more likely to occur in individuals with severe (and even psychotic) forms of depression.

A. Friedman and S. Granick obtained only one result that confirmed the classical hypothesis. In response to the question “Is it always right to feel angry?” the unconditional answer “YES” was significantly less common in the group of depressed patients than in the control group of healthy people. Of course, these data did not reveal anything about the intensity of the experience and expression of anger/aggression. They only showed that open expression of anger was less acceptable for depressed patients. However, this result also became questionable taking into account the age factor: older patients were significantly less likely to give an unconditional answer “YES” in comparison with young subjects, regardless of their group affiliation.

In 1971, in order to achieve greater clarity in the issue under study, A. Friedman undertook an intervention study, which to this day has a high citation index. According to his hypothesis, changes in indicators of aggression and hostility should correlate with positive clinical dynamics in depressed patients. At study baseline, 534 moderately to severely depressed inpatients (mean age 42 years) completed the Bass-Darkey Hostility Questionnaire and a patient self-report of clinical improvement. 213 patients completed both instruments 6 times over 7 weeks of treatment.

At the beginning of the study, the indicators of “Verbal hostility” in patients were significantly lower than those of healthy people, the indicators of “Resentment” were significantly higher, and the indicators of “Suspicion” at the level of asymptotic significance exceeded the norm results. According to the author, high levels of resentment were more likely to indicate a projection of hostility onto the world in depressed patients rather than its denial or repression. The combination of results made clear the unfavorable situation of the patients: “If an individual experiences feelings of resentment of above average intensity, perceives the attitude of other people towards him as unfair, but is not inclined or unable to openly verbalize his feelings, his internal state becomes uncomfortable and unhealthy.”

Another result was the discovery of positive significant correlations between two forms of hostility-aggression - externalization (in the form of resentment) and internalization. He refuted the idea that there is a certain static amount of aggression in the body; The fewer hostile-aggressive tendencies are expressed externally, the greater the need for internalization of these tendencies. The data suggested that with a large number of hostile-aggressive impulses, there is a tendency for their simultaneous externalization and internalization.

By the end of the seventh week of treatment, a clear pattern became clear: the more pronounced the improvement, the less hostility-aggression of any type the patient experienced. The most obvious and simple explanation of these results did not require psychoanalytic formulations, consideration of the unconscious and repression mechanisms. When patients are depressed and experience suffering, pain and frustration, they are more likely to experience hostility towards the world and complain about it, they also have greater irritability and somatic manifestations of hostility. When you feel better, the tendency to such negative reactions decreases along with irritability. In this explanation, depression is primary and can be seen as the cause of hostility, but not vice versa.

Unexpected were the findings that depressed patients in a state of remission move even further away from the norm in terms of open expression of verbal hostility. It was concluded that low verbal expression of hostility is a persistent character trait of these patients. As the authors suggest, “at the point of breakdown of defense mechanisms, when a depressive episode develops and hospitalization occurs, they may express slightly more verbal hostility than usual. It is possible that their inability to openly, spontaneously and at the appropriate moment verbalize hostility towards the person towards whom he feels it is an element of predisposition to depression. Their tendency to “deny” the badness of significant others and to selectively perceive them so that they do not experience conscious anger and depression may be more pronounced during remission, a period free of symptoms.”

In the last two decades, there has been an increase in interest in this issue in domestic clinical psychology. Several authors have examined the relationship between aggression, hostility, and depression using self-report methods.

Testing G. Ammon’s concept using the Russian version of the “I-structural test” showed that the deficit version of aggression is accompanied by the presence of “neurotic traits” that are very close to depressive and anxious symptoms - experiences of joylessness and hopelessness, increased lability of emotional processes, fixation on bodily sensations with exaggerated anxiety about health and excessive self-control.

Another domestic study recorded a number of results that are in good agreement with the above data from A. Friedman. A.A. Abramova examined 87 patients suffering from depressive disorders within the framework of mood disorders, schizophrenia and personality disorders. According to the results of the Bass-Darki method, this heterogeneous group was characterized by significantly higher rates of suspicion, resentment, and hostility compared to healthy subjects. In terms of the total indicator of aggression, no significant differences were established between sick and healthy subjects. A connection was recorded between the indicators of the Bassa-Darka technique and the severity of the depressive state: in patients with severe depression, suspicion, resentment and hostility were significantly higher than in the group with minimal depression. Finally, patients with personality disorders showed higher rates of physical aggression compared to the other two groups included in the study.

In general, many studies using self-report scales have found similar results: compared to healthy subjects, depressed patients are characterized by more intense feelings of anger. At the same time, they are characterized by a pronounced desire to suppress anger. Open manifestations of anger and aggression are observed in this group of people less often than normal, or with the same frequency. This trend was documented in a fundamental review by L. Feldman and H. Gotlib.

However, in very recent years, data have been obtained that do not fit into this picture. The main source of these data were studies aimed at studying hostility in various forms of depressive disorders.

An example of this type of work is the clinical study of A.V. Waksman, in which, based on a cluster analysis of the results of 100 middle-aged patients with depressive disorders who filled out the aggression scale of the Social Dysfunction and Aggression Scale and the Bass and Darkey questionnaire, a group of patients with a high level of aggressive and hostile manifestations. Patients in this group were characterized by a number of features: young people with secondary education predominated among them, they had a high level of organic and endocrine burden, their personality profile was clearly dominated by features of histrionic and borderline disorders, the leading affect was represented by anxiety. The author established connections between indicators of aggression and hostility and disorders of socio-psychological functioning in the sphere of interpersonal responsibilities, communication, and the sexual sphere. A number of patients in this group and in the premorbid period showed both active, extrapunitive forms of aggression and hostility (in the form of suspicion), and intrapunitive forms in the form of suicidal tendencies and self-harming actions. Effective treatment of these patients required a combination of antidepressants with sedative antipsychotics.

The undoubted value of this work lies in clarifying the sociodemographic, clinical and personal characteristics of patients with “angry depression” described within the framework of the “serotonin hypothesis”. However, in our opinion, this work lacks a statistical procedure that would allow us to assess the contribution of each factor (depression itself, organic burden, endocrine burden, borderline personality disorder traits) to the dispersion of indicators of aggression and hostility. The lack of these data, as well as comparisons with a group of healthy individuals, does not allow us to definitively clarify the relationships between depression, aggression and hostility. The question of whether high rates of overtly displayed aggression and hostility are characteristic of depression as such remains open.

Finally, in recent years, research has emerged hostility in depressive disorders, based on the modern understanding of the term.

Thus, within the framework of the “Predispositional Psychosocial Model of Hostility and Depression,” a 19-year longitudinal study was conducted. At its initial stage, 6484 subjects were examined, at the end point - 3639 subjects, 15% of whom showed signs of depressive mood. The results showed that cynical hostility and distrust of people, assessed in midlife using the Cook-Medley scale, may be predictors of depression in early aging. High levels of hostility have been associated with a number of sociodemographic (lower socioeconomic classes and non-European race), clinical (greater severity of general psychopathology) and psychosocial (narrow social network size, social isolation and more stressful life events) variables.

The “predispositional cognitive model of hostility and depression” also found empirical support in a population-based study of university students. Two groups of subjects were compared - those who had a history of depressive episodes (the “high-risk” group) and those who did not. High levels of hostility and anger turned out to be informative signs that reliably predict whether a subject belongs to the group of “increased risk of developing depression.” Risk group subjects also demonstrated special coping strategies in the form of a tendency to “blame oneself for negative incidents,” “blame others,” and “seek social support.” The combination of these factors - intense anger, high hostility, a tendency to blame oneself and others, and influxes of negative thoughts - creates “interpersonal storms”, interferes with receiving the desired support and sharply increases the likelihood of depression in the risk group.

However, the modelers point out a number of important limitations of their research: 1) both models have so far been tested only in population samples; 2) they did not involve subjects with clinical forms of depressive disorders. The validity of transferring these conclusions to clinical samples requires further confirmation.

Exploring the relationships between anger, hostility, aggression and anxiety disorders was started in the last two decades, which is due to their relatively recent appearance of the corresponding headings in diagnostic classifications.

The first and most significant work of this kind was a comparative study by M. Dadds and his colleagues, which assessed hostility in four groups of patients - with panic disorder, agoraphobia and panic disorder, generalized anxiety disorder and social phobia. The groups did not differ in the level of extrapunitive hostility, however, significant differences were found in the intropunitive form of this trait: patients with social phobia showed the maximum amount of self-criticism, followed by patients with agoraphobia and generalized anxiety disorder. Minimal levels of intropunitive hostility were found to be characteristic of patients with panic disorder. The concept of hostility was used in this work synonymously with the term "aggression".

Several studies have found opposite results. For example, according to M. Fava and his colleagues, rates of hostility are significantly higher in anxiety-phobic disorders compared to the norm. These authors showed that high hostility and irritability are characteristic symptoms of panic disorder with agoraphobia and can be addressed through psychotherapy.

A very recent study assessed differences in the experience and expression of anger in five groups of subjects - patients with anxiety disorders (panic disorder, obsessive-compulsive disorder, social phobia, simple phobias) and healthy controls. Patients with panic, obsessive-compulsive disorder, as well as patients with social phobia demonstrated a significantly greater tendency to experience anger than healthy subjects. Patients with panic disorder had significantly higher rates of angry aggression compared to healthy subjects and patients with OCD. Patients with social phobia were characterized by significantly reduced verbal aggression compared to healthy individuals. However, the differences found disappeared when the contribution of depressive symptoms was controlled.

The results presented in this paragraph clearly indicate that the results of research on anger, hostility and aggression in anxiety disorders are clearly contradictory.

At the end of this section, it should be noted that the number studies comparing measures of anger, hostility, and aggression in depressive and anxiety disorders very limited. In one of the rare studies of this kind, it was found that indicators of internalized (self-directed) anger, as well as difficulties in controlling anger, serve as predictors of both depression and anxiety. However, externalized anger also turned out to be a specific predictor of depression, which was not recorded for anxiety. The study authors believe that diagnosing anger and hostility, particularly the tendency to turn anger on the self, should become an important target in the diagnosis and treatment of both depressive and anxiety disorders.

At the moment, there is clear research evidence that could serve as arguments in the dispute between supporters “unitary” and “pluralistic” models There are no correlations between depression and anxiety.

2.2. Assessment of hostility and aggressiveness in natural communications of patients with depressive disorders using observational methods

The uncertainty in the issue being studied is enhanced by another circumstance: there is a sharp discrepancy between the data obtained by self-report methods and observation methods.

Thus, a multidimensional diagnosis of hostility in a group of 40 patients with depressive disorders revealed discrepancies in the manifestations of hostility in different situations. Depressed patients were cooperative during the initial interview and did not appear hostile at all. During this interview, they did acknowledge moderate hostility towards other people. Comparison of their psychometric indicators with those of healthy individuals revealed that depressed patients practice much more hostile behavior with other people. This hostility became even more intense towards those with whom the patients had close relationships, in particular their husbands and children.

A British study examined the natural communication of inpatients suffering from depressive disorders. A 20-minute video recording of the patients' conversations with their partners during the visit was made. Similar video surveillance was carried out in one of the hospital's surgical departments. A careful analysis of video recordings of communications between patients and their spouses shows: depressed patients show significantly more open aggression towards their partner than patients experiencing such powerful stress as surgery, and than healthy subjects.

In our opinion, video observation data cannot be considered as unambiguous evidence of increased verbal aggression or aggressiveness in depressed patients. They allow for several alternative interpretations: 1) there is a shift of aggression to a relatively safe object (it is known that partners of patients with affective disorders are significantly less likely to initiate divorce than persons from the general population); 2) increased aggression towards a partner may be not so much an individual characteristic of patients, but a reflection of the style of emotional communication in a couple, thus being a systemic phenomenon. The principle of “circularity of communications” allows us to interpret the results of British observers as signs of general marital distress. It also requires studying the communicative maneuvers by which men provoke overt aggressive behavior in partners who are potentially averse to such behavior.

However, attempts have been made to explain the above discrepancy in the results of empirical studies of aggression in depressed patients. L. Goldman and D. Haaga conducted a study to test whether this discrepancy was the result of: a) differences in the methods used (self-report/video recording); b) differences in the target of aggression (people “in general”/spouse). Married patients diagnosed with “major depression” and “dysthymia” filled out two versions of a questionnaire testing the intensity of the subjective experience of anger, the tendency to suppress anger, and the open expression of anger. The first version of the questionnaire was focused on marital relationships, the second - on interpersonal contacts in general. The subjects also filled out two similar versions of a questionnaire testing fears of various consequences of angry expression. The results of the study showed that depressed patients experience significantly more intense anger towards their partner than healthy subjects. At the same time, they are characterized by a significantly more pronounced tendency to suppress anger, both in family life and in communication with other people. In the group of patients, there is also a more intense fear of the consequences of aggression (both in communication with the spouse and with other people). However, their indicator of “anger expression in marital relationships” is significantly higher than that of healthy individuals. The authors find the following explanation for the data obtained: in marital relationships, the level of experience of anger in depressed patients is so high that even with powerful suppression, its expression will be significant.

This study cannot be considered as fully explaining the discrepancies in the experimental data, since it used only one method of collecting information - self-report scales.

2.3. Assessment of hostility and aggressiveness in patients with depressive and anxiety disorders using projective methods

Projective methods have great advantages in diagnosing such unpleasant personality traits as hostility and aggressiveness. Domestic researchers, using the projective “Hand” test by A. Wagner, the drawing test of frustration tolerance by A. Rosenzweig, and the Rorschach test, have established a number of phenomena.

According to the Hand test, patients with depression are characterized by significantly higher proactive aggressiveness aimed at objects than healthy subjects. The compared groups do not differ in the level of proactive aggressiveness directed at people. The author interprets data on a high level of potential aggression towards objects (inanimate objects) in depressed patients from the perspective of the frustration theory of aggression - fear of punishment from others, fear of disapproval from others give rise to the phenomenon of “displacement of aggression” to a potentially safe object. There is a correlation between the obtained data and indicators of the severity of depression: in patients with severe forms of depression, proactive aggressiveness directed at people is significantly higher than in mildly ill patients. When comparing two groups of depressed patients, distinguished by the indicator “duration of illness,” data were obtained indicating a decrease in proactive and reactive aggressiveness as depressive disorders progress. The author explains the discovered pattern by the effects of psychopharmacotherapy, as well as hypothetical personal and emotional changes caused by affective illness.

E.T. Sokolova and Y.A. Kochetkov examined 24 patients with panic disorder and agoraphobia using the Rorschach test. The level of hostility in patients was significantly higher than normal. The patients' object relations were closer to the pole of immaturity and dependence, with the theme of the evil power of one image over another being expressed. The patients' object relations were focused on the so-called. “conflict of dependence”: the desire for dependence on others and the simultaneous desire for independence and freedom from power and control.

The study authors conclude that in symbiotic relationships, primitive dependence is the cause of high levels of anxiety and hostility. It should be noted that the data obtained by the authors, as well as the interpretations they made, are fully consistent with the psychodynamic model of panic disorder.

Finally, another group of domestic researchers, using an original hostility test, obtained data in representative samples of patients with depressive and anxiety disorders. The indicators of the studied trait in the patient groups turned out to be significantly higher than similar indicators of healthy individuals. No significant differences were established between the patient groups. These results suggest that patients hold a deeply negative view of the moral qualities of other people: they perceive them as dominant and envious, inclined to rejoice in the misfortunes of others (thus strengthening self-esteem), despising “weakness,” disrespecting those who seek help, indifferent and cold, not inclined to compassion for people and helping them. At the same time, the level of severity of aggressiveness in these patients did not exceed that of healthy subjects (data from the “Hand” test). Interpersonal dependence with an intense need for contact acted as a mechanism for containing aggression. Patients with depressive and anxiety disorders use different strategies to maintain dependency relationships: in depressed patients, the pattern of compliance and subordination is more present, in patients with anxiety disorders, demonstrativeness is more developed . A fixed combination of characteristics (intense irritation, hostility towards other people with normative indicators of open forms of aggression and blockade of aggressiveness due to interpersonal dependence) can cause constant tension, uncomfortable mental and somatic well-being, increased passive (indirect) forms of aggressive behavior, and psychosomatic disorders.

In general, the results of the cited studies are quite close: patients with depressive and anxiety disorders are characterized by high hostility, however, the open implementation of aggressive impulses is difficult due to dependence on other people. In depressed patients, aggression is discharged in the form of less dangerous aggression towards objects; in patients with panic disorder, it is transformed into physical sensations during panic attacks.

Conclusion

Considering the history of studying the issue of the specifics of anger, aggression and hostility in emotional disorders, it is necessary to note a certain deformation, which arose in this research direction. This deformation consists, in our opinion, in the following. The powerful influence of psychodynamic concepts has led to research predominantly focusing on the directionality of anger and aggression in emotional disorders. The question “ANGER IN or ANGER OUT???” could be the title of many monotonous foreign publications that have regularly appeared in special editions for the last 50 years. Paradoxically, the concentration on this issue, bordering on mania, has not yet led to any more or less consistent conclusions.

On the one hand, this suggests the conclusion that that both depressed and anxious patients are characterized by an intense and well-conscious experience of anger, combined with a tendency to suppress its overt expression and a deficit in the skills of constructive aggression. On the other hand, this conclusion cannot be considered final:

a) certain forms of depressive and anxiety disorders have been established, in which there is a tendency to open, frequent and intense expression of anger, as well as physical and verbal aggression. Sociodemographic, clinical and personal characteristics of patients with angry depression need further clarification. There are indications of the predominance of young people in this category, pronounced signs of organic and endocrine burden, a connection with bipolarity, and a clear predominance of histrionic and borderline traits in the personal profile of patients.

b) there is a discrepancy between the data recorded by different methods. The results of the self-report scales confirm the stated conclusion; observational data on natural communications of depressed patients (for example, with marriage partners) indicate a high level of aggression openly displayed in communication. In our opinion, using a systematic approach could eliminate this contradiction.

The most unfavorable thing for the constructive development of this field of knowledge was the disappearance from the field of view of researchers of several fundamentally important issues.

There is a dearth of research on hostility in the modern definition of the term, which narrows the term to “negative cognitive attitudes towards other people.” Studies focused on studying this subjective picture of the social world in patients with depressive and anxiety disorders have begun recently and are therefore few in number. At the same time, data on the negative impact of hostility on the effectiveness of treatment of depressive and anxiety disorders, as well as on indicators of somatic health in people with symptoms of depression, make this research direction particularly relevant.

It remains unclear whether high hostility is a stable personality characteristic of patients with depressive and anxiety disorders? Many authors have documented a relationship between indicators of hostility and anger and the severity of depression. In light of these data, the point of view of M. Balint and other authors may prevail, considering hostility as a secondary reaction to severe emotional illness and not playing any causal role in its occurrence. According to A. Beck’s theory, a depressive state is characterized by a “negative cognitive triad” - a negative view of one’s own personality, the future and the world as a whole. From these positions, “the tendency to endow objects of the social world with negative qualities” (the so-called “hostile picture of the world”) may turn out to be a component of the affective state, and not a persistent personal characteristic. There is also a strong opinion that hostility is a universal factor in mental pathology, nonspecific for emotional disorders.

There is a shortage of comparative studies of anger, hostility and aggression in depressive and anxiety disorders, which could provide new arguments in the debate between representatives of the “unitary” and “pluralistic” models of the relationship between depression and anxiety.

One of the least studied, and at the same time very important, aspects of the problem are the mechanisms that inhibit the manifestations of anger and aggression in patients with depressive and anxiety disorders. The importance of this aspect of the functioning of aggression is defended by domestic experts. For a long time, authors of the psychodynamic direction considered dependence on the object of aggression as such mechanisms. However, concepts from more recent years have offered additional interpretations containing powerful explanatory potential. For example, A.B. Kholmogorova showed that these patients are characterized by special value systems that prohibit the experience and open expression of anger. The author explains the origin of these attitudes by a complex of factors in the macrosocial (cultural stereotypes) and microsocial (family norms and communications) environment. Within the framework of the “metacognitive direction,” the doctrine of the so-called “emotional cognitive schemas” (subjective theories of emotions), which may include beliefs about the inadmissibility and harmfulness of a number of emotions, including anger; It has been hypothesized that patients with depressive and anxiety disorders adhere to special “emotional schemas.” These phenomena have clearly not been studied enough.

The least studied aspect of the problem is the connection between hostility and aggression with stress and ways of coping with it, while the phenomenology of these psychological qualities itself can serve as a basis for the corresponding hypotheses.

However, it would be biased not to note the emergence in the last decade of a number of pre-dispositional models that consider hostility in the context of a wide range of characteristics - stressful events, social support, coping strategies, thinking patterns, family functioning.

At the end of the article, it is appropriate to cite the statement of G. Pohlmeier: “The discussion regarding aggression, and at the same time depression, today is still or - let’s say - again very relevant.”

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As a manuscript

Kholmogorova Alla Borisovna

THEORETICAL AND EMPIRICAL BASES

INTEGRATIVE PSYCHOTHERAPY

AFFECTIVE SPECTRUM DISORDERS

19.00.04 – Medical psychology

dissertations for an academic degree

Doctor of Psychology

Moscow – 2006

The work was carried out at the Federal State Institution “Moscow Research Institute of Psychiatry of the Federal Agency for Health and Social Development”

Scientific consultant– Doctor of Medical Sciences,

Professor Krasnov V.N.

Official opponents– Doctor of Psychology,

Professor Nikolaeva V.V.

Doctor of Psychology

Dozortseva E.G.

Doctor of Medical Sciences,

Professor Eidemiller E.G.

Lead institution- St. Petersburg psychoneurological

Institute named after V.M. Bekhtereva

The defense will take place on December 27, 2006 at 14:00 at a meeting of the Dissertation Academic Council D 208.044.01 at the Moscow Research Institute of Psychiatry of the Federal Agency for Health and Social Development at the address: 107076, Moscow, st. Poteshnaya, 3

The dissertation can be found at the Moscow Research Institute of Psychiatry of the Federal Agency for Health and Social Development

Scientific secretary

Dissertation Council

Candidate of Medical Sciences Dovzhenko T.V.

GENERAL CHARACTERISTICS OF WORK

Relevance. The relevance of the topic is associated with a significant increase in the number of affective spectrum disorders in the general population, among which depressive, anxiety and somatoform disorders are the most epidemiologically significant. In terms of prevalence, they are the undisputed leaders among other mental disorders. According to various sources, they affect up to 30% of people visiting clinics and from 10 to 20% of people in the general population (J.M.Chignon, 1991, W.Rief, W.Hiller, 1998; P.S.Kessler, 1994; B.T.Ustun, N. Sartorius, 1995; H.W. Wittchen, 2005; A.B. Smulevich, 2003). The economic burden associated with their treatment and disability constitutes a significant part of the budget in the health care system of different countries (R. Carson, J. Butcher, S. Mineka, 2000; E.B. Lyubov, G.B. Sargsyan, 2006; H.W. Wittchen, 2005). Depressive, anxiety and somatoform disorders are important risk factors for the emergence of various forms of chemical dependence (H.W. Wittchen, 1988; A.G. Goffman, 2003) and, to a large extent, complicate the course of concomitant somatic diseases (O.P. Vertogradova, 1988; Yu.A. Vasyuk, T.V. Dovzhenko, E.N. Yushchuk, E.L. Shkolnik, 2004; V.N. Krasnov, 2000; E.T. Sokolova, V.V. Nikolaeva, 1995)

Finally, depressive and anxiety disorders are the main risk factor for suicide, in terms of the number of which our country ranks among the first (V.V. Voitsekh, 2006; Starshenbaum, 2005). Against the backdrop of socio-economic instability in recent decades in Russia, there has been a significant increase in the number of affective disorders and suicides among young people, elderly people, and able-bodied males (V.V. Voitsekh, 2006; Yu.I. Polishchuk, 2006). There is also an increase in subclinical emotional disorders, which are included within the boundaries of affective spectrum disorders (H.S. Akiskal et al., 1980, 1983; J. Angst et al, 1988, 1997) and have a pronounced negative impact on quality of life and social adaptation.

The criteria for identifying different variants of affective spectrum disorders, the boundaries between them, the factors of their occurrence and chronicity, targets and methods of assistance are still debatable (G. Winokur, 1973; W. Rief, W. Hiller, 1998; A. E. Bobrov, 1990; O.P.Vertogradova, 1980, 1985; V.N.Krasnov, 2003; G.P.Panteleeva, 1998; 2003). Most researchers point to the importance of an integrated approach and the effectiveness of a combination of drug therapy and psychotherapy in the treatment of these disorders (O.P. Vertogradova, 1985; A.E. Bobrov, 1998; A.Sh. Tkhostov, 1997; M. Perrez, U. Baumann , 2005; W. Senf, M. Broda, 1996, etc.). At the same time, in different areas of psychotherapy and clinical psychology, various factors of the mentioned disorders are analyzed and specific targets and tasks of psychotherapeutic work are identified (B.D. Karvasarsky, 2000; M. Perret, U. Bauman, 2002; F.E. Vasilyuk, 2003, etc. .).

Within the framework of attachment theory, system-oriented family and dynamic psychotherapy, disruption of family relationships is indicated as an important factor in the emergence and course of affective spectrum disorders (S. Arietti, J. Bemporad, 1983; D. Bowlby, 1980, 1980; M. Bowen, 2005 ; E.G.Eidemiller, Yustitskis, 2000; E.T.Sokolova, 2002, etc.). The cognitive-behavioral approach emphasizes skill deficits, disturbances in information processing processes and dysfunctional personal attitudes (A.T.Beck, 1976; N.G. Garanyan, 1996; A.B. Kholmogorova, 2001). Within the framework of social psychoanalysis and dynamically oriented interpersonal psychotherapy, the importance of disrupting interpersonal contacts is emphasized (K. Horney, 1993; G. Klerman et al., 1997). Representatives of the existential-humanistic tradition highlight the violation of contact with one’s internal emotional experience, the difficulties of its awareness and expression (K. Rogers, 1997).

All the mentioned factors of occurrence and the resulting targets of psychotherapy for affective spectrum disorders do not exclude, but complement each other, which necessitates the integration of various approaches when solving practical problems of providing psychological assistance. Although the task of integration is increasingly coming to the fore in modern psychotherapy, its solution is hampered by significant differences in theoretical approaches (M. Perrez, U. Baumann, 2005; B. A. Alford, A. T. Beck, 1997; K. Crave, 1998; A. J. Rush, M. Thase, 2001; W. Senf, M. Broda, 1996; A. Lazarus, 2001; E. T. Sokolova, 2002), which makes it relevant to develop theoretical foundations for the synthesis of accumulated knowledge. It should also be noted that there is a lack of comprehensive objective empirical research confirming the importance of various factors and the resulting targets of assistance (S.J.Blatt, 1995; K.S.Kendler, R.S.Kessler, 1995; R.Kellner, 1990; T.S.Brugha, 1995, etc.). Finding ways to overcome these obstacles is an important independent scientific task, the solution of which involves the development of methodological means of integration, conducting comprehensive empirical studies of the psychological factors of affective spectrum disorders and the development of scientifically based integrative methods of psychotherapy for these disorders.

Purpose of the study. Development of theoretical and methodological foundations for the synthesis of knowledge accumulated in different traditions of clinical psychology and psychotherapy, a comprehensive empirical study of the system of psychological factors of affective spectrum disorders with the identification of targets and the development of principles of integrative psychotherapy and psychoprevention of depressive, anxiety and somatoform disorders.

Research objectives.

1. Theoretical and methodological analysis of models of occurrence and methods of treatment of affective spectrum disorders in the main psychological traditions; justification of the need and possibility of their integration.
2. Development of methodological foundations for the synthesis of knowledge and integration of methods of psychotherapy for affective spectrum disorders.
3. Analysis and systematization of existing empirical studies of psychological factors of depressive, anxiety and somatoform disorders based on the multifactorial psycho-social model of affective spectrum disorders and the four-aspect model of the family system.
4. Development of a methodological complex aimed at the systematic study of macrosocial, family, personal and interpersonal factors of emotional disorders and affective spectrum disorders.
5. Conducting an empirical study of patients with depressive, anxiety and somatoform disorders and a control group of healthy subjects based on a multifactorial psycho-social model of affective spectrum disorders.
6. Conducting a population-based empirical study aimed at studying macrosocial factors of emotional disorders and identifying high-risk groups among children and youth.
7. Comparative analysis of the results of studies of various population and clinical groups, as well as healthy subjects, analysis of connections between macrosocial, family, personal and interpersonal factors.
8. Identification and description of the system of targets for psychotherapy for affective spectrum disorders, based on data from theoretical and methodological analysis and empirical research.
9. Formulation of the basic principles, objectives and stages of integrative psychotherapy for affective spectrum disorders.
10. Determination of the main tasks of psychoprophylaxis of emotional disorders in children at risk.

Theoretical and methodological foundations of the work. The methodological basis of the study is the systemic and activity-based approaches in psychology (B.F. Lomov, A.N. Leontiev, A.V. Petrovsky, M.G. Yaroshevsky), the bio-psycho-social model of mental disorders, according to which the emergence and in the course of mental disorders, biological, psychological and social factors are involved (G. Engel, H. S. Akiskal, G. Gabbard, Z. Lipowsky, M. Perrez, Yu. A. Aleksandrovsky, I. Ya. Gurovich, B. D. Karvasarsky, V. N. Krasnov), ideas about non-classical science as focused on solving practical problems and integrating knowledge from the perspective of these problems (L.S. Vygotsky, V.G. Gorokhov, V.S. Stepin, E.G. Yudin, N. L.G. Alekseev, V.K. Zaretsky), cultural and historical concept of mental development by L.S. Vygotsky, concept of mediation by B.V. Zeigarnik, ideas about the mechanisms of reflexive regulation in normal and pathological conditions (N.G. Alekseev, V. K. Zaretsky, B.V. Zeigarnik, V.V. Nikolaeva, A.B. Kholmogorova), a two-level model of cognitive processes developed in cognitive psychotherapy by A. Beck.

Object of study. Models and factors of mental norm and pathology and methods of psychological assistance for affective spectrum disorders.

Subject of research. Theoretical and empirical foundations for the integration of various models of the occurrence and methods of psychotherapy for affective spectrum disorders.

Research hypotheses.

1. Different models of the emergence and methods of psychotherapy for affective spectrum disorders focus on different factors; the importance of their comprehensive consideration in psychotherapeutic practice necessitates the development of integrative models of psychotherapy.
2. The developed multifactorial psycho-social model of affective spectrum disorders and the four-aspect family system model allow us to consider and study macrosocial, family, personal and interpersonal factors as a system and can serve as a means of integrating various theoretical models and empirical studies of affective spectrum disorders.
3. Macrosocial factors such as social norms and values ​​(the cult of restraint, success and perfection, gender role stereotypes) affect the emotional well-being of people and can contribute to the occurrence of emotional disorders.
4. There are general and specific psychological factors of depressive, anxiety and somatoform disorders associated with different levels (family, personal, interpersonal).
5. The developed model of integrative psychotherapy for affective spectrum disorders is an effective means of psychological assistance for these disorders.

Research methods.

1. Theoretical and methodological analysis – reconstruction of conceptual schemes for studying affective spectrum disorders in various psychological traditions.

2. Clinical-psychological – study of clinical groups using psychological techniques.

3. Population - study of groups from the general population using psychological techniques.

4. Hermeneutic - qualitative analysis of interview data and essays.

5. Statistical - the use of mathematical statistics methods (when comparing groups, the Mann-Whitney test was used for independent samples and the Wilcoxon T-test for dependent samples; to establish correlations, the Spearman correlation coefficient was used; to validate methods - factor analysis, test-retest, coefficient - Cronbach's, Guttman Split-half coefficient; multiple regression analysis was used to analyze the influence of variables). For statistical analysis, the software package SPSS for Windows, Standard Version 11.5, Copyright © SPSS Inc., 2002, was used.

6. Method of expert assessments – independent expert assessments of interview data and essays; expert assessments of the characteristics of the family system by psychotherapists.

7. Follow-up method - collecting information about patients after treatment.

The developed methodological complex includes the following blocks of methods in accordance with the levels of research:

1) family level – family emotional communications questionnaire (FEC, developed by A.B. Kholmogorova together with S.V. Volikova); structured interviews “Scale of stressful events in family history” (developed by A.B. Kholmogorova together with N.G. Garanyan) and “Parental criticism and expectations” (RKO, developed by A.B. Kholmogorova together with S.V. Volikova), test family system (FAST, developed by T.M. Gehring); essay for parents “My Child”;

2) personal level – questionnaire of prohibition of expressing feelings (ZVCh, developed by V.K. Zaretsky together with A.B. Kholmogorova and N.G. Garanyan), Toronto Alexithymia Scale (TAS, developed by G.J. Taylor, adaptation by D.B. Eresko , G.L. Isurina et al.), emotional vocabulary test for children (developed by J.H. Krystal), emotion recognition test (developed by A.I. Toom, modified by N.S. Kurek), emotional vocabulary test for adults ( developed by N.G. Garanyan), perfectionism questionnaire (developed by N.G. Garanyan together with A.B. Kholmogorova and T.Yu. Yudeeva); physical perfectionism scale (developed by A.B. Kholmogorova together with A.A. Dadeko); hostility questionnaire (developed by N.G. Garanyan together with A.B. Kholmogorova);

1. interpersonal level – social support questionnaire (F-SOZU-22, developed by G.Sommer, T.Fydrich); structured interview “Moscow Integrative Social Network Questionnaire” (developed by A.B. Kholmogorova together with N.G. Garanyan and G.A. Petrova); test for the type of attachment in interpersonal relationships (developed by C. Hazan, P. Shaver).

To study psychopathological symptoms, we used the severity of psychopathological symptoms questionnaire SCL-90-R (developed by L.R. Derogatis, adapted by N.V. Tarabrina), the depression questionnaire (BDI, developed by A.T. Beck et al., adapted by N.V. Tarabrina), the anxiety questionnaire ( BAI, developed by A.T.Beck and R.A.Steer), Childhood Depression Inventory (CDI, developed by M.Kovacs), Personal Anxiety Scale (developed by A.M. Prikhozhan). To analyze factors at the macrosocial level when studying risk groups from the general population, the above methods were selectively used. Some of the methods were developed specifically for this study and were validated in the laboratory of clinical psychology and psychotherapy of the Moscow Research Institute of Psychiatry of the Russian Health Service.

Characteristics of the examined groups.

The clinical sample consisted of three experimental groups of patients: 97 patients with depressive disorders , 90 patients with anxiety disorders, 52 patients with somatoform disorders; two control groups of healthy subjects included 90 people; groups of parents of patients with affective spectrum disorders and healthy subjects included 85 people; samples of subjects from the general population included 684 school-age children, 66 parents of schoolchildren and 650 adult subjects; The additional groups included in the study to validate the questionnaires included 115 people. A total of 1929 subjects were examined.

The study involved employees of the laboratory of clinical psychology and psychotherapy of the Moscow Research Institute of Psychiatry of the Russian Health Service: Ph.D. leading researcher N.G. Garanyan, researchers S.V. Volikova, G.A. Petrova, T.Yu. Yudeeva, as well as students of the department of the same name of the Faculty of Psychological Counseling of the Moscow City Psychological and Pedagogical University A.M. Galkina, A. A. Dadeko, D. Yu. Kuznetsova. A clinical assessment of the patients’ condition in accordance with ICD-10 criteria was carried out by a leading researcher at the Moscow Research Institute of Psychiatry of the Russian Health Service, Ph.D. T.V. Dovzhenko. A course of psychotherapy was prescribed to patients according to indications in combination with drug treatment. Statistical processing of the data was carried out with the participation of Doctor of Pedagogical Sciences, Ph.D. M.G. Sorokova and Candidate of Chemical Sciences O.G. Kalina.

Reliability of results is ensured by a large volume of survey samples; using a set of methods, including questionnaires, interviews and tests, which made it possible to verify the results obtained using individual methods; using methods that have undergone validation and standardization procedures; processing the obtained data using methods of mathematical statistics.

Main provisions submitted for defense

1. In existing areas of psychotherapy and clinical psychology, different factors are emphasized and different targets for working with affective spectrum disorders are identified. The current stage of development of psychotherapy is characterized by trends towards more complex models of mental pathology and the integration of accumulated knowledge based on a systematic approach. The theoretical basis for integrating existing approaches and research and identifying on this basis a system of targets and principles of psychotherapy are the multifactorial psycho-social model of affective spectrum disorders and the four-aspect model of family system analysis.

1.1. The multifactorial model of affective spectrum disorders includes macrosocial, family, personal and interpersonal levels. At the macrosocial level, factors such as pathogenic cultural values ​​and social stress are highlighted; at the family level - dysfunction of the structure, microdynamics, macrodynamics and ideology of the family system; at the personal level - disorders of the affective-cognitive sphere, dysfunctional beliefs and behavioral strategies; at the interpersonal level - the size of the social network, the presence of close trusting relationships, the degree of social integration, emotional and instrumental support.