Depression

Depression-5-Christian-Jonathan-Haverkampf-common-mental-health-conditions

Depression

Christian Jonathan Haverkampf, M.D.

Depression is one of the most common medical conditions, which can interfere significantly with a person’s quality of life, relationships and ability to work. Several effective treatments are available, including psychotherapy and medication. This article contains a brief overview of both areas, while focusing on psychotherapy, particularly Communication-Focused Therapy® (CFT), as developed by the author.

Keywords: depression, treatment, psychotherapy, psychiatry

Contents

Introduction. 5

Adaptation. 6

Genetics. 6

Psychotherapy. 7

The World is Not Enough. 8

Negative Thoughts about Oneself 8

Medication. 9

Major Depression vs Reactive Depression. 10

Stress. 10

Depression and Health. 10

Age. 11

Differential Diagnosis. 11

Computer-Based Treatments. 12

Communication. 13

Inside-Outside Reflection. 14

Connectedness. 14

Social Connectedness. 15

Social Identification. 15

Depression Treatments and Connectedness. 16

Adolescents and Young Adults. 16

Technology and Connectedness. 17

Autonomy and Connectedness. 17

Connectedness and the Elderly. 18

Connectedness and Groups. 18

Causes of Depression. 18

The Monoamine Hypothesis. 18

Communication Factors. 19

Symptoms. 20

Physical Symptoms. 21

Treatment. 21

Medication. 21

Psychotherapy. 22

Separating Thoughts from Emotions. 22

Body Work. 23

Communication-Focused Therapy®. 23

Change. 24

Analysing Communication Patterns. 25

The Process. 26

Communication Patterns and Structures. 27

Transfer. 28

Meaning. 29

From Meaning to Meaningfulness. 29

Motivation. 31

Interacting with the World. 32

Powerlessness. 32

Insight into Communication. 33

Building the Sense of Self 34

Resonance. 35

Relevance. 35

Communication Exchange. 36

Experimentation. 37

Observing. 37

Integration. 38

Values, Needs and Aspirations. 38

Internal Communication. 39

Meaningful Messages as the Instrument of Change. 39

Broader Experience. 40

References. 41

Introduction

Depression affects a good size of the population. Although it is relatively common and the impact of the individual quality of life can be enormous, there is still a stigma attached to it. A common belief is that it is not treatable, which is in the vast majority of cases untrue. Another misconception is that it lowers a person’s intelligence or changes one’s personality, which is equally untrue. While someone suffers from depression, the ability to focus and concentrate may be reduced, it does not lower a person’s cognitive abilities when the person recovers from the depression. However, the most serious misconception must be the one that there are no effective treatments. In truth, there are many effective treatments available, but their effectiveness often depends on matching the correct treatment modality to the right patient.

The proportion of the global population living with depression is estimated to be 322 million people—4.4% of the world’s population—according to a new report, “Depression and Other Common Mental Disorders: Global Health Estimates,” released by the World Health Organization. The report also includes data on anxiety disorders, which affect more than 260 million people—3.6% of the global population. The prevalence of these common mental disorders is increasing, particularly in low- and middle-income countries, with many people experiencing both depression and anxiety disorders simultaneously. Depression is, in short, the leading cause of disability in the world (Friedrich, 2017).

Depression is also one of the most common comorbidities of many chronic medical diseases including cancer and cardiovascular, metabolic, inflammatory and neurological disorders. (Gold et al., 2020)

Some possible pathophysiological mechanisms of depression include altered neurotransmission, HPA axis abnormalities involved in chronic stress, inflammation, reduced neuroplasticity, and network dysfunction. All of these proposed mechanisms are integrally related and interact bidirectionally. In addition, psychological factors have been shown to have a direct effect on neurodevelopment, causing a biological predisposition to depression, while biological factors can lead to psychological pathology as well. The authors suggest that while it is possible that there are several different endophenotypes of depression with distinct pathophysiological mechanisms, it may be helpful to think of depression as one united syndrome, in which these mechanisms interact as nodes in a matrix. Depressive disorders are considered in the context of the RDoC paradigm, identifying the pathological mechanisms at every translational level, with a focus on how these mechanisms interact. Finally, future directions of research are identified. (Dean & Keshavan, 2017)

To accommodate, they learn to censor themselves, to devalue their experience, to repress anger, to be silent. Examining moral themes in depressed women’s narratives, Jack demonstrates how internalized cultural expectations about feminine goodness affect women’s behavior in relationships and precipitate the plunge into depression. In a brilliant synthesis, Jack draws on myth and fairy tale for metaphors to further our understanding of women’s depression. (Jack, 1991)

Depressive disorders are frequently associated with significant and pervasive impairments in social functioning, often substantially worse than those experienced by patients with other chronic medical conditions. The enormous personal, social, and economic impact of depression, due in no small part to the associated impairments in social functioning, is often underappreciated. Both pharmacologic and psychotherapeutic approaches can improve social impairments, although there is a lack of extended, randomized controlled trials in this area using consistent assessment criteria. (Hirschfeld et al., 2000)

Adaptation

Many functions have been suggested for low mood or depression, including communicating a need for help, signalling yielding in a hierarchy conflict, fostering disengagement from commitments to unreachable goals, and regulating patterns of investment. A more comprehensive evolutionary explanation may emerge from attempts to identify how the characteristics of low mood increase an organism’s ability to cope with the adaptive challenges characteristic of unpropitious situations in which effort to pursue a major goal will likely result in danger, loss, bodily damage, or wasted effort. In such situations, pessimism and lack of motivation may give a fitness advantage by inhibiting certain actions, especially futile or dangerous challenges to dominant figures, actions in the absence of a crucial resource or a viable plan, efforts that would damage the body, and actions that would disrupt a currently unsatisfactory major life enterprise when it might recover, or the alternative is likely to be even worse. These hypotheses are consistent with considerable evidence and suggest specific tests. (Nesse, 2000)

Genetics

Data are from 2,302 adolescent sibling pairs (mean age = 16 years) who were part of the National Longitudinal Study of Adolescent Health. Although genetic factors appeared to be important overall, model-fitting analyses revealed that the best-fitting model was a model that allowed for different parameters for male and female adolescents. Genetic contributions to variation in all 3 variables were greater among female adolescents than male adolescents, especially for depressed mood. Genetic factors also contributed to the correlations between family and school environment and adolescent depressed mood, although, again, these factors were stronger for female than for male adolescents. (Jacobson & Rowe, 1999)

Psychotherapy

There are many kinds of psychotherapy, but they all derive from the concept of the ‘talking cure’ developed by Freud and Breuer. Over time, various brands have been developed, but the interaction between the patient and therapist, insight, reflection, and learning are still the basic building blocks of psychotherapy or counselling.[1]

Depression very often does not come ‘out of the blue’, and it is important to understand the factors that contribute to it. While some people have a greater predisposition for depression than others, psychological factors usually play a significant role. The three main schools of therapy are cognitive-behavioural, interpersonal, and psychodynamic therapies. Major differences are that the first one focuses more on learning and the last one more on insight and understanding, but many practitioners combine elements of each of them. I have developed a communication-focused approach, that works with both insight and learning, which is described in more detail below.

Depression comes with negative thoughts and feelings, where one influences the other. It can begin with difficulties and interpersonal problems, such as in a relationship or at the workplace. The more one doubts oneself, s self-critical or blames oneself, the more the spiral of depression reaches down. Communication patterns often change, both on the inside and the outside. Internally, ruminations, negative feelings, despair, hopelessness, and doubts can lead to increasing questioning of oneself to the point where one feels a physical pain or pressure. In severe cases of depression, the communication reaches a point where internal communication, feelings and thoughts flatten out. Depression does not necessarily mean that one feels sad all the time. In the more severe cases, it means that one feels less to the extent that one cannot cry anymore and feels a physical pain of emptiness. Thoughts about ending everything, as in self-harm, can occur quite frequently. They need to be taken seriously, and one should look for immediate help, which can also include a hospitalisation where a more intensive treatment and a secure environment are possible.

The outside communication reflects the internal communication to a large extent. And often it has become impossible on the inside to take a step back from the ruminations and circulating negative thoughts and watch what is happening from the outside. This step back would, however, be very important. Most often people then try even harder to run with their head against the invisible wall. The brain’s job is to think and to solve problems in the world by thinking through them. In a rumination the brain tries to ‘think its way out’. However, this usually just makes it worse. To get the view from the outside of what is happening and to find new strategies through changes in perspective are important steps in therapy.

Psychotherapy should address various factors, such as current stressors, unresolved conflicts, also internal emotional ones, past experiences, and patterns of relating with oneself and the world around. Identifying own needs, values, and aspirations in helpful in finding a life ath that is more aligned with what satisfies and makes happy.

Psychotherapy should be tailored to the individual needs of the patient. The main task of the therapist is understanding. All psychotherapeutic techniques are really a support towards this goal. As every patient is different, one begins in some ways from scratch. Being empathetic, mindful and aware of the other are crucial towards understanding the dynamics, needs, and suffering a patient is experiencing. Understanding can be accomplished in many different ways. Some focus more on the narrative, some on the interaction and communication patterns, others more on behavior patterns, or on past experiences. But all this is just to help the therapist understand in a way, that tools for healing can be applied/

The World is Not Enough

Often in depression there is the sense that nothing is very helpful anymore. One feels alone with a situation where there does not seem to be a way out. One experiences feelings that are unpleasant, as mentioned to the extent of being painful. The internal communication revolves around questions that can lead deeper and deeper into depression. As our mind is programmed to solve problems, it pursues the questions as far as it can. However, if the questions are the wrong ones, this will not lead to a resolution.

Negative Thoughts about Oneself

Depression and risk for depression are characterized by the operation of negative biases, and often by a lack of positive biases, in self-referential processing, interpretation, attention, and memory, as well as the use of maladaptive cognitive emotion regulation strategies. (LeMoult & Gotlib, 2019) Depression is in that sense different from fear or anxiety in that one has negative thoughts about important attributes about oneself, such as personality, resources, strengths and weaknesses. At the same time, it is important to realize that this is I not directly about the innermost core sense of self. It is more about the facilities one has than about the feeling of self. Thus, one approach of the therapy is to connect with oneself on the level of the felling of self, which is below the surface of personality and skills (Haverkampf, 2010b). Straight forward mindfulness exercises in combination with any therapeutic approaches that also pay attention to communication can accomplish this. As the self is one’s perceptions of the internal flows of information (Haverkampf, 2010a, 2018a), the ability to take back a step and observing, while connecting with oneself is a key skill.

Medication

There is little doubt that medication is effective in depression. Increasingly, we also understand why it works, and how. The challenge can sometimes be to select the right antidepressant for a specific patient, but the miss rate usually declines with experience of the therapist. Generally, the side effects are low or non-existent and over a couple of weeks to a few months there is in about seventy percent of cases a marked improved in mood, motivation, focus and the energy to engage in activities. Sleep, appetite and other parameters can improve as well, depending on the medication selected. If a drug does not show an effect, or only an unsatisfactory one, after some time, it is often a good idea to switch the antidepressant, which frequently works.

When it comes to medication, it is important to understand that an antidepressant has usually other effects aside from its effect on mood. This also needs to be fitted to the patient. As mentioned, when psychotherapy was discussed, a depression is not the same for everyone. There are different types and flavours of it, which are unfortunately not capture adequately by the diagnostic systems we have. So, there can be a patient with severe mood lows and paralysis in life with a history of depression in the family, while another patient experiences anxiety and panic attacks with depression in the background after a relationship breakup, and a third one who does not feel that low, but who has severely disturbed sleep, libido and appetite in waves. In all those cases one would diagnose depression, but the treatment could be very different, both on the psychotherapy and the medication side. Understanding the patient, the individual history, the fear, needs, symptoms, aspirations, and more, is important not only to select and plan a course of psychotherapy, but also as regards the medication.

Good communicating is the foundation of good medicating. It not only indispensable in building compliance, but also in selecting the right medication. Too often the profile of a drug does not fit the patient. For example, a patient with insomnia may benefit more from an antidepressant that also has a sleep-inducing effect or another patient with anxiety may find it easier to gradually and slowly titrate up a softer serotonergic antidepressant. Potential or current pregnancy leads to its own unique considerations. Although randomised controlled trials on pregnant women are ethically impossible, we have a lot of data on women who took various antidepressants in pregnancy.

Even with medication one should not lose sight of the overall situation the patient is in, the patient’s past and desired future. The medication needs to fit in. For a patient to whom an active sexual life is a major factor in the level of quality of life, a medication that is very likely to impact libido negatively may be an inferior choice if there are other good alternatives.

Major Depression vs Reactive Depression

A depression, if it is not primarily a reaction to a life event, is called in psychiatry a major depressive disorder (MDD). It is a condition characterized by at least two weeks of low mood that is present across most situations. (APA, 2013) It is often accompanied by low self-esteem, loss of interest in normally enjoyable activities, low energy, and psychological pain without a clear cause. There may also be false beliefs and – in the more severe cases – acoustic or visual hallucinations. Major depression needs to be differentiated from sadness. Depression often actually means the subjective absence of feelings, such as sadness. Patients often cannot feel themselves anymore as before, which can cause additional anxiety.

Another form is the reactive depression, which occurs as part of several conditions, such as post-traumatic stress disorder (PTSD). These forms of depressions are discussed within the articles on these conditions. The following will focus on the depression, which is not primarily a part of these conditions, the major depression.

Some people have periods of depression separated by years in which they feel normal while others nearly always have symptoms present. The first line of treatment is a combination of psychotherapy and medication. Some common antidepressants are mentioned below. This combination has allowed most patients to live normal lives and in the clear majority leads to a significantly higher quality of life.

Stress

There is growing interest in moving away from unidirectional models of the stress-depression association, toward recognition of the effects of contexts and personal characteristics on the occurrence of stressors, and on the likelihood of progressive and dynamic relationships between stress and depression over time—including effects of childhood and lifetime stress exposure on later reactivity to stress. (Hammen, 2005)

Depression and Health

Major depression significantly affects a person’s family and personal relationships, work or school life, sleeping and eating habits, and general health. Major depressive disorder can negatively affect a person’s family, work or school life, sleeping or eating habits, and general health. Between 2-7% of adults with major depression die by suicide (Richards & O’Hara, 2014) and up to 60% of people who die by suicide had depression or another mood disorder (Lynch & Duval, 2010). But depression has also been linked with several physical health conditions, such as cardiovascular and autoimmune illnesses. These conditions make up a large share of the costs society incurs when depression remains untreated. Depression causes the second most years lived with disability after low back pain. (Vos et al., 2015)

Age

Depression can strike at any age, and the main tools we have, psychotherapy and medication as well as supportive therapies, mostly apply to all ages. However, the psychological issues for the different age groups can seem quite different. What may be an identity crisis in college aged adults can be a deeper crisis for meaning and purpose in the middle-age. The reason why I used the word ‘seems’ is because the underlying motives are not really age specific. Self-connectedness and connectedness with the world run like a thread through all these different manifestations. The identity crisis in young adults and the search for meaning in the middle-aged mean that one’s own basic parameters, the needs, values, and aspirations and information about the world feel insufficient. These feelings are a need for greater internal and external connectedness. It is important to keep in mind, however, that these two themes are just gross oversimplifications to cast the spotlight at the core theme of connectedness.

As mentioned, depression is common in older adults. (Kok & Reynolds, 2017) Efficacious psychotherapies for late-life depression exist, but are underutilized in part because of their complexity (Alexopoulos, 2019). Although antidepressants may effectively treat depression in older adults, they tend to pose greater risk for adverse events because of multiple medical comorbidities and drug-drug interactions in case of polypharmacy (Kok & Reynolds, 2017). They are also rather ineffective in treating depression of demented patients, but long-term use of antidepressants may reduce the risk of dementia. However, confirmation studies are needed. (Alexopoulos, 2019)

Differential Diagnosis

A diagnosis is only a tool in working out a treatment that offers a greater likelihood of success. It is important to keep this in mind because in medicine frequently a diagnosis seems to be an end in itself, but it should not be. Depression, a lowering of various feeling and cognitive states, is something that has been around for a very long time. However, increases in complexity and demands in the world quite often lead from stress and burnout to symptoms of depression. These demands can come from professional, personal and social areas of life.

There are many conditions, somatic, psychiatric or iatrogenic, which can induce symptoms similar to that of a depression. A host of other possibilities should thus be considered, and, if appropriate, be actively searched for. In most instances the situation is quite clear, especially in an outpatient setting, but even here it is advisable to explore alternative explanations aside from depression. At the same time, about 85% of patients with depression have significant anxiety, and 90% of patients with anxiety disorder have depression. (Tiller, 2013) In some cases, a patient may also suffer separately from a depression and another condition. In other cases, the full symptoms of depression occur as part of the condition, such as in a schizoaffective disorder, which combines both, the symptoms of a psychosis and a depression.

One should also not forget that medication can also induce depression-like symptoms, even though they do not match those of depression fully, such as the emotional flattening observed sometimes in several antipsychotics (Haverkampf, 2013b) In any case, a full list of the somatic and psychiatric medication the patient takes should always be scanned for anything that could lead to the symptoms the patient is experiencing.

Computer-Based Treatments

Psychotherapy aims at changing how patients communicate and process information, and the important tool are information and communication. Helpful and meaningful information can be provided in many forms. Some people who suffer from depression, anxiety, or OCD work successfully with self-help books. This is essentially a one-way communication, and the hope is that the information presented changes a perspective, a way of thinking or acting, reflection and insight, and internal and external communication in general.

There are also internet-based treatment applications. While a book cannot provide feedback, a computer-based system can do so to some extent. However, a patient cannot assume or hope that the computer will offer real understanding similar to that of another human being. While programs that mimic therapists have been around for a long time, as one only needs to think of ‘Eliza’ from the late 1970s, they can hold the illusion only for a limited time. ‘Eliza’ was a very short program, by today’s standards, running on 8-bit computers with small memory even for the time, but it was ingenious. It would take sentence fragments and ask the user ‘How do you feel about …?’or ‘Tell me more about …’ and the like. The effect was really striking, which also illustrates how easy it can be to convey psychological support in real life.

A computer-based system also cannot replicate the many information channels that are usually available in human interactions. Still, internet-based systems have shown to be of some use in the treatment of depression. Josephine and colleagues conducted a systematic review of randomized controlled trials investigating internet- and mobile-based interventions targeting adults with diagnosed depression. They found that these interventions significantly reduced depression symptoms in adults with diagnosed depression at the end of treatment and at follow-up assessments when compared to waitlist conditions. (Josephine et al., 2017)

One should also not forget media that show human connection. The stereotypical image of the lovelorn on a couch self-soothing with ice cream and watching a film is not so far from the truth. Self-soothing is often underrated in working with depressed patients, and the movie temples of Hollywood’s golden age, where people could experience connectedness with themselves or others, have become the on-demand streaming services of today. My home is my cinema, where I can be distracted and feel connectedness. Good movies are those where one can feel connectedness between the characters of some kind, whether in the positive or in the negative. In the milder and more moderate forms of depression the withdrawal from others is usually accompanied with a greater need for connectedness. A greater need for connectedness, coupled with the negative thought and feelings about oneself, such as self-criticism, self-blame, and guilt, actually lead to greater withdrawal. The auto regulation seems to malfunction, which can be corrected through psychotherapy, for example. However, in some cases, a change in scenery, such as travelling abroad, or a provocative book brought about the needed change.

Doing things for oneself that make one feel better is vital in depression, because it helps regain a sense of control over the own feeling states. What makes depression worse is the sense of helplessness and powerlessness in ending the state. Often this is what prolongs or maintains it. Children self-sooth autonomously by, for example, using a finger, or by asking a caretake for help in the form of a hug, a pacifier, or something else that aligns with the present needs. In both cases, internal and external communication is important. In the former, it is the internal reading and processing of signals and the self-soothing activity, in the latter communication with the outside world is added. As both, internal and external communication are linked, they reflect each other.

Communication

Since communication is the main instrument we have for diagnosis and treatment, words play an important role. Sigmund Freud highlighted the importance of ‘mistakes’ people make in everyday language that reveal something about unconscious content, and the deeper meaning of jokes people make. The rich symbolism in myths and sacred texts often relies on the subtle meaning of words and word constellations. Depression does not create content, but it has an impact on content and on how content is processed. The shift in focus towards negative thoughts and feelings could have the function of pushing the individual towards the positive, but this becomes more difficult because of the disconnectedness one experiences internally and externally in depression. Thus, meaningful communication and connectedness can help to bridge the depression by enabling the move to the positive.

Communication is also important in identifying the type of depression. Communication patterns give away the fingerprint of the condition (Haverkampf, 2010c, 2013a). However, content can be helpful as well. The words individuals use in their communication can give us an insight into depression. Eichstaedt and colleagues showed in their study that the content shared by users on Facebook could predict a future occurrence of depression in their medical records. Language predictive of depression included references to typical symptoms, including sadness, loneliness, hostility, rumination, and increased self-reference. (Eichstaedt et al., 2018) As the world is becoming technologically more connected, more information is available on what and how one communicates. This could be used for good

Again, understanding and empathy are important in identifying where the depression affects the internal communication flows. Through its impact on information flows and processing a mental health condition can be identified. Depression has effects on the flow of cognitive information associated with thoughts, information associated with feelings, information associated with sensation, and so on. Psychosis, for example, also has distinct effects, one of which is the failure in separating whether a source of information is inside or outside the person. Connectedness is usually a good thing, but this really requires that we are all smart enough to make the most and best of it. This smartness in turn requires connectedness.

Inside-Outside Reflection

The communication patterns in the outside world and those on the inside are closely linked. So, the disconnectedness a patient with depression is experiencing can be felt on the outside and on the inside. Helping the patient to achieve greater connectedness in the outside world can so also transfer to better connectedness on the inside, while helping the patient to better connect with himself or herself also improves the connections the patient has with others. In Communication-Focused Therapy®, for example, awareness, reflection, insight, feedback, and experimenting with communication follows similar rules for the internal dialogues as well as for the outside dialogues (Haverkampf, 2010b, 2017b)

Connectedness

The feeling of connectedness with others is a powerful antidote to depression, anxiety and other mental health conditions (Haverkampf, 2020b). Important is that one feels connected in a meaningful way. One could feel lonely in a crowd of people or even when with family and friends. Meaningful connectedness means that one feels understood by others, that communication really works. The human touch is at its most powerful if one is in the presence of people where worlds can connect. A shared history can make connectedness easier in some cases, but by itself it is not enough. Connectedness between individuals requires interest and the effort to try to understand the other. However, it is effort well spent, as connectedness, both internally and externally, can decrease fear and other feelings, that often are at the foundations of the various conditions mentioned.

Why is connectedness so important? When we are connected, we lessen the effect of time and external circumstances. Connectedness happens in the present moment, and the feeling is about the now rather than the past and the future. Also, the more connected we are, the less will be our fears and anxieties. The fear of death is a fear of disconnect, and by feeling connectedness we reduce the sense of disconnect. Depression and anxiety, though in different ways, are also related to the internal sense of connectedness. This does not necessarily require the actual physical proximity of others, but the feeling of being connected into the world. Various mindfulness techniques and approaches that work with feeling at home in the body and in one’s environment can be helpful because they can increase the sense of connectedness.

Social Connectedness

Connectedness is different from mere social support. In a testing model in 272 college students, indirect paths to self–esteem and depression through the mediating variable of social connectedness were more strongly supported than direct pathways from social support or social competence to psychological outcomes. (Williams & Galliher, 2006) However, in a meta-review of fifty-one studies, the strongest and most consistent findings were significant protective effects of perceived emotional support, perceived instrumental support, and large, diverse social networks. Little evidence was found on whether social connectedness is related to depression, as was also the case for negative interactions. (Santini et al., 2015) A secondary analysis of a waitlist-controlled trial with 29 patients was conducted to evaluate treatment response and process of change in social connectedness within a 10-session positive activity intervention protocol—Amplification of Positivity (AMP)—designed to increase positive affect in individuals seeking treatment for anxiety or depression. The AMP group displayed significantly larger improvements in social connectedness from pre- to post-treatment compared to waitlist; improvements were maintained through 6-month follow-up. Within the AMP group, increases in positive affect and decreases in negative affect both uniquely predicted subsequent increases in connectedness throughout treatment. However, experiencing heightened negative affect throughout treatment attenuated the effect of changes in positive affect on connectedness. Improvements in connectedness predicted subsequent increases in positive affect, but not changes in negative affect. (Taylor et al., 2020) A convenience sample of rural residents in a western Colorado county. Self-reported survey data collection with hierarchical multiple regression analyses. The investigators found that the more socially connected a person felt, the better they perceived themselves as physically and mentally healthy. Additionally, the more socially connected the individual felt the less depressive symptoms they reported. Spiritual perspective was not found to correlate significantly with either self-reported depression or perceived health. (Galloway & Henry, 2014)

Social Identification

Cruwys and colleagues ran two studies. In Study 1 (N=52), participants at risk of depression joined a community recreation group; in Study 2 (N=92) adults with diagnosed depression joined a clinical psychotherapy group. In both the studies, social identification predicted recovery from depression after controlling for initial depression severity, frequency of attendance, and group type. In Study 2, benefits of social identification were larger for depression symptoms than for anxiety symptoms or quality of life. (Cruwys et al., 2014)

Depression Treatments and Connectedness

Trials with psylocybin for treatment-resistant depression also support the link between connectedness and depression. It has been argued that connectedness is key in understanding the effectiveness of psychedelic drugs against depression, and there is preliminary evidence to support this. (Carhart-Harris et al., 2018) In a study with twenty patients enrolled in an open-label trial of psilocybin for treatment-resistant depression, it was reported that medications and some short-term talking therapies tended to reinforce their sense of disconnection and avoidance, whereas treatment with psilocybin encouraged connection and acceptance. (Watts et al., 2017)

Adolescents and Young Adults

Much of the data on the association between depression and connectedness comes from school and college settings. Data from Waves I and II of the National Longitudinal Study of Adolescent Health (Add Health)  indicated that higher school connectedness and getting along with teachers were significantly associated with fewer depressive symptoms. (Joyce & Early, 2014) In a study of students at an international university in Japan, a high prevalence of depression was associated with acculturation stress and social connectedness. (Nguyen et al., 2019) In an American study of 248 students aged between 15 and 20 years old showed that family ritual meaning was positively related to social connectedness and negatively related to depression. Social connectedness was negatively associated with anxiety and depression. Family ritual meaning was found to be negatively linked to both depression and anxiety symptoms via social connectedness. (Malaquias et al., 2015) However, recent literature suggests that school connectedness may be a key determinant of adolescent mental health. The relationship between social connectedness and low mood was reduced by the inclusion of self-esteem  and peer attachment style. Peer attachment style was the largest predictor of low mood. (Millings et al., 2012) In a 2001 population-based sample of 4746 students in public schools, adolescents’ perceptions of low parental caring, difficulty talking to their parents about problems, and valuing their friends’ opinions for serious decisions were found to be significantly associated with compromised behavioral and emotional health. Interventions aimed at improving the parent–child relationship may provide an avenue toward preventing health risk behaviors in youth. (Ackard et al., 2006) In a longitudinal study of 142 youth recruited from an emergency department, who screened positive for elevated levels of bullying victimization, prospectively, family and school connectedness were negatively associated with depression and suicidal ideation. Across time points, community connectedness was negatively associated with suicidal ideation. The three subtypes of interpersonal connectedness among victimized youth (family, school, community) were associated with depression and suicidal ideation. (Arango et al., 2019)

Technology and Connectedness

a systematic review of recent research addressing the associations between adolescents’ sense of social connectedness and Internet technology use. Although Internet technology might provide additional opportunities for adolescents to seek emotional connection with friends and school, this study suggests that real-life social skills are still a necessary foundation for them to use technology in a beneficial way. (Wu et al., 2016) Hwang and colleagues investigated whether social connectedness on a support website protects older adults against depressive symptoms over the course of a year, above and beyond the protective effect of offline social connectedness. 197 adults aged 65 years or older. The more messages older adults read on the web-based forum for the first 6 months of the study, the less depressed they felt at the 1-year follow-up, above and beyond the availability of offline support networks at baseline. This pinpoints the substantial potential of web-based communication to combat depressive symptoms in this vulnerable population. (Hwang et al., 2021) Results from a study by Grieve and colleagues suggested that Facebook use may provide the opportunity to develop and maintain social connectedness in the online environment, and that Facebook connectedness is associated with lower depression and anxiety and greater satisfaction with life. Limitations and future directions are considered. It is concluded that Facebook may act as a separate social medium in which to develop and maintain relationships, providing an alternative social outlet associated with a range of positive psychological outcomes. (Grieve et al., 2013) A multidatabase search was performed. Papers published between January 2005 and June 2016 relevant to mental illness (depression and anxiety only) were extracted and reviewed. Results: Positive interactions, social support, and social connectedness on social networking sites (SNSs) were consistently related to lower levels of depression and anxiety, whereas negative interaction and social comparisons on SNSs were related to higher levels of depression and anxiety. SNS use related to less loneliness and greater self-esteem and life satisfaction. Findings were mixed for frequency of SNS use and number of SNS friends. Different patterns in the way individuals with depression and individuals with social anxiety engage with SNSs are beginning to emerge. (Seabrook et al., 2016)

Autonomy and Connectedness

The relationship between autonomy–connectedness, and depression and anxiety was investigated in 94 primary mental health care patients and 95 psychology students. All participants completed the Autonomy–Connectedness Scale–30 (ACS‐30), the Beck Depression Inventory (BDI), and the Symptom Checklist–90 (SCL‐90). Results indicated that the primary mental health care group compared with the control group scored lower in Self‐Awareness and Capacity for Managing New Situations, and higher in Sensitivity to Others. Women compared with men had higher levels of self‐reported Sensitivity to Others. Regression analyses showed that both (low) Self‐Awareness and (high) Sensitivity to Others predicted depression, as well as anxiety; also, (low) educational level had predictive value. These results indicate that low autonomy–connectedness might be a risk factor for depression and anxiety. (Bekker & Belt, 2006)

Connectedness and the Elderly

Relationship of loneliness and social connectedness with depression in elderly: A multicentric study under the aegis of Indian Association for Geriatric Mental Health. The study sample comprised 488 elderly patients (age ≥60 years) with depression recruited across 8 centers. About three-fourth of the elderly patients with depression also have associated loneliness. Loneliness is associated with higher severity of depression, anxiety, and somatic symptoms. Severity of depression is associated with loneliness but not with social connectedness. Lower social connectedness among elderly females with depression is associated with higher loneliness, but this is not true for elderly males with depression. (Grover et al., 2018)

Connectedness and Groups

In a further study, Kaniuka and colleagues examined depression and anxiety as mediators of the linkage between perceived stigma and suicidal behaviour, and the moderating role of LGBTQ community connectedness. Among their sample of 496 LGBTQ persons, psychopathology mediated the association between perceived stigma and suicidal behaviour. Connectedness moderated the relation between perceived stigma and depression, and between perceived stigma and suicidal behaviour in the anxiety model. (Kaniuka et al., 2019)

Causes of Depression

Its impact on functioning and well-being has been compared to that of other chronic medical conditions such as diabetes. The biopsychosocial model proposes that biological, psychological, and social factors all play a role in causing depression. The cause is believed to be a combination of genetic, environmental, and psychological factors. (APA, 2013) Risk factors include a family history of the condition, major life changes, certain medications, chronic health problems, and substance abuse. (APA, 2013) About 40% of the risk appears to be related to genetic variations.

Lifetime rates are higher in the developed world compared to the developing world. Maybe a heightened stress level in a more complex living and working environment contributes to that, but it may also be a lower rate of diagnosing this condition in the developing world.

The Monoamine Hypothesis

The monoamine hypothesis has been partially questioned, but it is still the leading, and also most coherent, hypothesis there is in providing a biological explanation for depression, as well as some anxiety disorders. Over time, its emphasis on particular neurotransmitters has shifted to a limited extent, while the focus on the neurotransmitter serotonin has endured. The monoamines are serotonin, norepinephrine, and dopamine. The antidepressants act on the neurotransmitter levels or on the receptors.

Serotonin is hypothesized to regulate other neurotransmitter systems; decreased serotonin activity may allow these systems to act differently and become less stable. According to this hypothesis, depression arises when low serotonin levels promote low levels of norepinephrine, another monoamine neurotransmitter. Some antidepressants enhance the levels of norepinephrine directly, whereas others raise the levels of dopamine, a third monoamine neurotransmitter. These observations gave rise to the monoamine hypothesis of depression.

In its contemporary formulation, the monoamine hypothesis postulates that a deficiency of certain neurotransmitters is responsible for the corresponding features of depression. The main effect is, however, believed to be due to changes in the receptor densities on the cell membrane rather than the changes in the neurotransmitter levels. This also explains why antidepressants can take a few weeks to work. This may be the time needed by the cell to change the receptor density and patterns in the cell membrane through recycling and protein synthesis.

Communication Factors

Humans are constantly in a web of relations with other people. External communication from birth and even before influences how information is processed in the brain and how an individual communicates and interacts with others. The individual learns certain communication strategies and patterns that are shaped over time in response to the environment, internal communication and the biology underlying the neuronal network.

As children we pick up communication patterns from our parents or other important people in our lives which can then be internalized and also influence how we communicate with ourselves internally. And this process continues throughout or life, practically with every interaction we have with others. Our awareness of the flows of internal information then give rise to the sense of self.

Trauma committed by people can have such a devastating effect on individuals because of the communication it contains. Being exposed to someone who communicates that they negate our worth as a human being, our autonomy and integrity, traumatises and hurts us deeply. There need not be physical scars in a somatic medical sense. Our mind and our body form a union, however, and harm to one also harms the other. The body is the means that we can communicate with ourselves and others, while the mind connects us mentally with others. If that delicate fabric of connectedness between ourselves and others is torn or ruptured, we lose some of the safety and security it gives us. Trauma can be healed when we understand that its nature is in the communication that cause it. Awareness, insight, adapting communication patterns and learning new ones, as well as feedback are helpful in overcoming trauma (Haverkampf, 2016, 2020a) as they are in recuperating from depression.

Symptoms

A person having a major depressive episode usually exhibits a very low mood, which pervades all aspects of life, and anhedonia, the inability to experience pleasure in activities that were formerly enjoyed. Depressed people may be preoccupied with, or ruminate over, thoughts and feelings of worthlessness, inappropriate guilt or regret, helplessness, hopelessness, and self-hatred.

Changes in the communication with oneself and others changes when an individual is depressed. This is a consequence of the symptoms of depression but often works also to deepen and prolong the condition. Loss of interest in things that were once enjoyable, seeing less meaning in activities and events and withdrawal from the world, and to an extent from oneself, are often the result and may worsen the depression, while more communication with oneself and others can help to reverse the depression.

In severe cases, depressed people may have symptoms of psychosis. These symptoms include delusions or, less commonly, hallucinations, usually with negative and unpleasant content. A good indication that a psychotic symptom is maintained by a mood disorder is that the value of the content of any delusions or hallucinations is consistently in the direction of the mood disorders, such as negative content in a depression or alternating positive and negative content in bipolar disorder.

Other symptoms of depression, which are commonly observed, include

  • poor concentration and memory
  • withdrawal from social situations and activities
  • reduced sex drive, irritability,
  • insomnia
  • and thoughts of death or suicide (which requires immediate professional help).

Insomnia is a common symptom. In the typical pattern, a person wakes very early and cannot get back to sleep. Hypersomnia, or oversleeping, can also happen. In an atypical form of depression, it is even possible that a patient experiences primarily insomnia, loss of concentration and poor memory retrieval, without a clear lowering in mood.

Physical Symptoms

The physical symptoms of a depression are often underestimated. A depressed person may report multiple physical symptoms such as

  • fatigue
  • headaches, or
  • digestive problems.

Appetite often decreases, with resulting weight loss, although increased appetite and weight gain occasionally occur. Family and friends may notice that the person’s behaviour is either agitated or lethargic.

Treatment

The two types of treatment, for which there exists broad empirical and conceptual support, are medication and psychotherapy. Generally, the best approach is to use both together. However, in very severe cases of depression only medication may be feasible, while in cases of mild depression psychotherapy may be sufficient.

Medication

There are various groups of antidepressants, often with regards to their function on neurotransmitters and neuroreceptors. The selective serotonin receptor inhibitors (SSRIs) are the ones most commonly used. They can also help against anxiety and panic attacks, as well as various other symptoms and conditions, such as emotional instability and eating disorder. Examples are escitalopram (Lexapro®) and sertraline (Zoloft®). The serotonin and norepinephrine reuptake inhibitors can also help against anxiety, but may be more activating, which can lead to increased nervousness and anxiety in the beginning. The best way to reduce an increase in anxiety in the first days, which can happen with most antidepressants, is to start the medication at a very low level and increase it in small increments in patients with anxiety, especially if there are also panic attacks.

Psychotherapy

As already mentioned, there are various brands of psychotherapy which are designed to help in the long run. Cognitive behavioural therapy (CBT) and interpersonal psychotherapy (IPT), as well as Gestalt therapy and others, are also focused at the short-term, while psychodynamic psychotherapy aims at a more permanent resolution of the depression in the long-run. (Haverkampf, 2017a) Communication-focused therapy (CFT), which was developed by the author to more closely work with the mechanism that underlies many forms of psychotherapy, communication. (Haverkampf, 2017f)

Psychotherapy should be targeted at the long-run. Short fixes for depression often do not work, and only in the short run. The reason is that a patient’s interaction patterns with herself and the environment often need to change, which requires some time. Good communication helps against a depression, but it often requires a change in perspective, as well as awareness and reflection, which ensures an enduring effect but requires time.

There is a significant amount of research which shows that the effect of psychotherapy may to a large extent be due to the personality and communication approach of the therapist, and there is a debate to what extent the specific viewpoint of a school of psychotherapy plays an actual role in the outcome of psychotherapy. This is one reason why communication-focused therapy (CFT) puts an emphasis on the communication patterns and dynamics that unfold, and are induced to unfold, in a psychotherapeutic session.

For any form of psychotherapy to work, it has to lead to some form of change. To achieve a lasting adaptive and helpful change, it has to come from the patient himself or herself, because if the change is not in sync with the patient’s basic parameters, any change will over time revert back, either to the state before the therapy or a state that is somewhere half-way between the pre-existing one and the desired state. If change is lasting nevertheless, it is often due to factors outside a manualized and structured therapy. One explanation could be that even a manualized approach contains elements that may help the patient to develop in a direction that correlates with the patient’s basic needs and aspirations on some level.

Separating Thoughts from Emotions

In many schools of psychotherapy there is unfortunately an almost complete separation between thoughts and emotions. However, from a communication perspective they both are signals, containing information. When a thought triggers and emotion, or an emotion leads to certain thoughts, it is in both cases some meaningful information which leads to new sets of information. This is also useful in the therapy, because communication patterns that apply to one kind of information also apply to the other.

The uncrossable dividing line between thoughts and emotions has largely contributed to a situation where we understand neither. We could arbitrarily categorise information, but it still does not bring us closer to understanding the dynamics in which the information, or the categories of information, flow. For example, a question as one of the most powerful communication tools can elicit an emotional signal in a person without a cognitive thought, because it is information which can under certain circumstances be retrieved directly.

Regarding both, emotions and thoughts, as bundles of information does not reduce their individual qualities, but these qualities are part of the information that makes up the thought or emotion. Whether a message is emotional or cognitive cannot be extrinsic to it. However, where a piece of information flows is in a sense intrinsic to it. Thus, the thought of pain and the feeling of pain can be quite similar in information content, but where the information flows in the neural network, and in what way, may be vastly different.

Body Work

Focusing on the mind often neglects the wider dimensions of the body. In a study with a group of women with major depressive disorder, experiences of yoga were that it served as a self-care technique for the stress and ruminative aspects of depression and that it served as a relational technique, facilitating connectedness and shared experiences in a safe environment. (Kinser et al., 2013)

Communication-Focused Therapy®

Communication-Focused Therapy (CFT) was developed by the author to focus more specifically on the communication process between patient and therapist. (Haverkampf, 2010b, 2017b, 2017f, 2018b) The central piece is that the sending and receiving of meaningful messages is at the heart of any change process. Communication processes are at the same time the instruments of change and their target. Any therapy needs to lead to change in some form. (Haverkampf, 2010b)

register them as emotions; thus, severely depressed patients are as in-capable of experiencing sadness as of feeling joy. Their feelings are diffuse, are not registered as emotions, and are not properly identified. (Bucci & Freedman, 1981)

Change

Change can include changes in acceptance levels, new insights, learning processes and more. All these aspects are determined by communication processes and some are communication processes themselves. For the acceptance of a certain situation or emotion, for example, with the aim of reducing conflicting emotions and anxiety, one needs to learn about the situation or emotions and identify them and then put them into context with information from memory and use internal and external communication flows to reflect on them.

There are various factors that may stand in the way. If fear inhibits the information retrieval from memory this will not fully work. However, this fear is again a signal, information that is transferred from one point to another and triggers certain information processing patterns. If these patterns are not helpful in supporting the larger goals of need fulfilment with respect to the internal and external world, they can lead into such stationary and change inhibiting dynamics as indefinite loops, or vicious cycles, in which a fear signal just leads to another fear signal, rather than inducing change. These dynamics include

  • looping of information
  • disconnects
  • misdirected information

and many others. They are a consequence of inhibited change. To break out of these communication predicaments, changes in communication patterns are needed that compensate, interrupt, reconnect, or act in another positive way.

Michael feels a lump in his throat. His therapist looks at his with an encouraging trace of a benevolent smile. Michael is not helped much by it, he feels under even more pressure. The therapist than finally asks a question, while Michael is about to despair. “Described the lump.” At first Michael does not know what to do with this question. However, he begins describing the lump and develops increasing investigatory spirit in doing so. After he has been talking for a little while, Michael discovers that his narrative has actually shifted to talking about his feelings …

CFT aims, among other things, at reducing the fear of information retained in memory or communicated from others. This requires more meaningful information rather than less which can be communicated more freely as the fears or other inhibiting factors decrease. The freer and more open the communication processes become, the easier it is for autoregulatory processes to counter unhelpful diversions from health affect states. However, this requires insight, reflection and experimentation in therapy.

The goal is thus not to simply provide information, to communicate information from one point to another, but to understand the flows of information, to better use communication patterns and to recognise if something is not working. The objective is really to understand flows of information rather than to get caught in a specific content. Since change comes from the detection, decoding and processing of meaning in a message, a patient suffering from depression, and several other mental health conditions, will see a decline in symptoms over the time, the better he or she becomes in spotting meaning.

Many popular forms of psychotherapy, such as Cognitive-behavioural Therapy (CBT), psychodynamic psychotherapy and Interpersonal Psychotherapy (IPT) define a format in which communication patterns take place that can bring about change. However, they do not address and work with the communication processes directly. In psychodynamic psychotherapy, communication constructs like transference and counter-transference have been formulated, which focuses on the outcome of communication processes. CFT in contrast attempts to focus on the process itself.

CFT attempts to analyse how information is exchanged, the various channels involved and how meaning is generated. Messages do not have to be contained in words, they can also be transmitted by facial gestures or any behaviour of the send. To contain meaning they have to be relevant to the recipient and have the potential to bring about a change in the recipient.

Analysing Communication Patterns

The first important step in therapy is to create awareness for communication in general. Humans are sending and receiving countless of messages every minute, and most of this runs automatically. However, for messages that can be processed by higher brain functions, whether from internal and external sources, there is the option to make these communication processes conscious. Particularly in interactions with other living organisms, particularly humans, communication patterns have evolved that facilitate the exchange of meaningful information between one brain and another. While most of this communication is outside consciousness, there are processes that let some of it pass the filter and bring it into consciousness. Creating greater awareness means putting the focus on these flows of information by observing the observable. For example, if a patient focuses just on her right hand, for example, while she is talking or on the timber in her voice, this creates awareness for a small aspect of the information in her interaction with another. Becoming aware of a thought that is repeatedly coming back and is followed by a feeling of anxiety may lead to the observance of internal communication flows. While the majority of the information exchange in the human body, particularly on a cellular body, is not accessible to conscious awareness, the aggregate result is.

Paul is at home alone. It is close to midnight, he feels low and cannot sleep. He does not really know why. The day has been good overall, but sporadically a melancholic feeling strikes, as if out of nowhere. He looks at the clock in the living room, as the hands seem to stand still. Everything is still. It has been an intense week, and it is maybe the first time when everything seems to quiet down. In this stillness, he notices something new, a tension he cannot put his finger on. It seems as if from nowhere and he cannot identify it.

Rather than thinking about, he just sits there, experiences, is open and curious. The point of tensions takes on more detail, and he feels he can make out some context, bits of emotions and thoughts, faint signals that are becoming more defined. While he is curious about what they may grow into and become, he enjoys the changes that are taking place before his inner eye …

The Process

The emotional signals contained in a message are important because own emotions one becomes aware of can contain a lot of information. The brain uses a lot of information to form an emotion. To yield an emotion of sadness requires not only the information that a relationship has ended, but also the information about the relationship itself and potentially the relationships before, including information from interactions with one’s parents, and so forth. In a therapeutic setting, all this information can be helpful to adapt strategies, or to design new ones, and help the patient to integrate all this information into his or her life.

The communication between therapist and patient gives clues about thought patterns and beliefs, which affect how messages from others are interpreted and how own messages are assembled and communicated. It also helps to get an idea for how a patient constructs meaning. What someone sees as meaningful and relevant is largely determined by own needs and wants, but also past experiences. When the patient begins to form new communication patterns or adapts old ones, it is helpful to help in identifying patterns that have worked well for him or her in the past. Sometimes new ones have to be constructed from scratch, if a patient has been socially isolated for a while, for example. It is then useful to rely more on the therapeutic interaction as a model to train new communication patterns. In some patients who have suffered from depression for a long time with social isolation this may be necessary, but also important to maintain the patient’s motivation for the therapeutic work.

The importance of awareness is that it gives the patient a greater sense of hope and control when the depression causes hopelessness and despair. The journey patient and therapist take together in exploring and experimenting with communication in itself has a major antidepressant effect. It requires openness and insight which cannot be manualized. Communication has, however, universal rules which can be understood and worked with.

Communication Patterns and Structures

Communication patterns are basic units of communication dynamics which make spontaneous communication in everyday situations possible. A certain form of question may be such a communication pattern, which humans use instinctively without further thinking about the pattern they are using. Some basic communication patterns may be hardwired, but many are also learned. Since they all have to adhere to basic laws of information exchange, the patterns themselves adhere to certain rules. The author has focused more specifically on the origin and nature of communication patterns elsewhere. (Haverkampf, 2018c)

An awareness of communication structures and patterns begins with an inventory of what is there. An analysis reveals the constructivist nature of conversation, how the therapist uses rhetorical devices in an interactive manner to pursue his therapeutic agenda and how the dialogue is a systemic process. However, it goes deeper as the same laws of communication do not only apply in the external world but also in the inner realms of a person. This makes communication less constructivist, but as natural processes that follow universal laws.

Humans interact on millions of communication channels at one point in time. Cells have their communication channels, and every information coming into the system and leaving it uses communication patterns. Communication has certain rules, and in a context communication patterns emerge that help the organism survive, evolve and prosper. A language can be seen as sets of symbols and signals that are used within communication patterns. We all communicate in patterns because they make communication more efficient within a given context, However, people spend little time observing and reflecting on their communication patterns on the inside and in the external world.

Two cardinal symptoms of depression are ruminations and selecting negative information. Many therapeutic approaches focus on the negative, for example, and try to unlearn them. This may work in the short-term but often fails in the long-term if the communication patterns with oneself and the world do not change. An external pattern may be how one could ask for information that could dispel the negative thoughts or an internal testing of the information. All these are modifications in external and internal communication patterns because they change which and how information is sent, how it is received and how meaning is extracted from it. All these steps can either be adaptive or maladaptive. Depression comes with maladaptive communication patterns which then cause even more maladaptive communication patterns. The way out is to create awareness for, reflect and experiment with these communication patterns, at first in a therapeutic setting and then in the real world.

Passive social media use (PSMU)—for example, scrolling through social media news feeds—has been associated with depression symptoms. More time spent on PSMU was associated with higher levels of interest loss, concentration problems, fatigue, and loneliness. (b) Fatigue and loneliness predicted PSMU across time, but PSMU predicted neither depression symptoms nor stress. (Aalbers et al., 2019)

Facebook depression is defined as feeling depressed upon too much exposure to Social networking sites (SNS). Researchers have argued that upward social comparisons made on SNS are the key to the Facebook depression phenomenon. Our literature search yielded 33 articles with a sample of 15,881 for time spent on SNS, 12 articles with a sample of 8041 for SNS checking frequency, and 5 articles with a sample of 1715 and 2298 for the general and the upward social comparison analyses, respectively. In both SNS-usage analyses, greater time spent on SNS and frequency of checking SNS were associated with higher levels of depression with a small effect size. Further, higher levels of depression were associated with greater general social comparisons on SNS with a small to medium effect, and greater upward social comparisons on SNS with a medium effect. Both social comparisons on SNS were more strongly related to depression than was time spent on SNS. (Yoon et al., 2019)

A search of PsycINFO, Medline, Embase, CINAHL and SSCI databases reaped 13 eligible studies, of which 12 were cross-sectional. Findings were classified into four domains of social media: time spent, activity, investment and addiction. All domains correlated with depression, anxiety and psychological distress. However, there are considerable caveats due to methodological limitations of cross-sectional design, sampling and measures. Mechanisms of the putative effects of social media on mental health should be explored further through qualitative enquiry and longitudinal cohort studies. (Keles et al., 2020)

There are growing concerns about the impact of digital technologies on children’s emotional well-being, particularly regarding fear, anxiety, and depression. A growing body of research confirms the relationship between digital media and depression. Although there is evidence that greater electronic media use is associated with depressive symptoms, there is also evidence that the social nature of digital communication may be harnessed in some situations to improve mood and to promote health-enhancing strategies. Much more research is needed to explore these possibilities. (Hoge et al., 2017)

Transfer

Considerations of psychopathology and a greater understanding of child and developmental psychology provide a greater insight into the question how depression may be transferred from mother to child, for example. (Goodman, 2020) From a communication perspective this is easily understandable. The child’s first experiences of the world internally and externally is shaped through the communication with others, mainly the primary caretakers. Depressed parents have been found to interact with their children differently, in ways that affect child development. Depressed mothers have been found in some studies to use less emotion and expressivity in their language with their babies. Non-verbal communication is especially important at an early age, and depressed mothers tend to make less eye contact. Through withdrawal, depression can also lead to a wider social disconnect, which can then affect both, the mother and the child.

Meaning

Individuals suffering from depression often see less meaning in the things they do. In therapy an important part is to rediscover meaning and find it in the things that are relevant to the patient. Relevant is anything that is close to his or her values, basic interests, aspirations, wants, wishes and desires.

Information that contains meaning has the potential to bring about a change. This means it that it has to contain something that is not entirely predictable. If we were fully certain of that piece of information, it could not lead to change. Thus, any therapy that does not work with meaning and meaningful information must be quite useless and ineffective. Even a highly manualized and structured therapy contains some novel information, which can be relevant and meaningful to the patient. In fact, practically all interactions with other people contain some elements of novelty, relevance and meaning. If communication is all pervasive, chances are high that there will also be some meaningful communication.

By focusing more specifically on the communication process, it is possible to increase the density of helpful change, and thus to make therapy more effective. A positive effect is also that as the patient experiences the relevance and practical workings of the therapeutic process, motivation and optimism about the positive outcomes of therapy increase. These effects come through connectedness, but also increase connectedness in the future.

Meaning is here used in the sense of understanding the information behind information, its symbolic content. For example, even the simple sentence “How are you?” can have a broad range of meanings from “Hi!” to “Are you feeling better?” Our thoughts and feelings affect how we decode meaning. They affect the questions we ask about another’s comment and the context in which we understand it. This applies to our own internal communications, and external ones. Learning communication in different contexts is like learning foreign languages.

Important is also how we interpret our own thoughts, the meaning we give to them and to our feelings. How we interpret our own thoughts, the internal communication in general, influences how we see ourselves. Thus, by changing our internal communication strategies we can also affect how we feel about ourselves. Primarily cognitive and psychodynamic psychotherapies offer many strategies in this area, while the former tends to be more manualized and the latter organically growing out of the psychotherapeutic work.

From Meaning to Meaningfulness

To be able to help patients with depression it is important to understand the road from meaning to meaningfulness. While meaning is relevant content, meaningfulness is a measure of how much relevant content one sees in something. At the same time, meaningfulness can be a feeling, which imputes relevance to something, a relevance, which, as has been described above, contains hope for some change in emotional, cognitive or other state or process. The importance in getting patients to see more meaningfulness has been borne out in many studies. Carstens and colleagues, for example, administered in their study the Sense of Coherence scale and the Beck Depression Inventory to fifty patients diagnosed with major depressive disorder and to fifty control subjects. Significant negative correlations were found between scores on Depression and total scores on the Sense of Coherence scale as well as all three of its subscales (Comprehensibility, Manageability, and Meaningfulness). A significant positive correlation was found between scores on the Sense of Coherence scale and age. Of the three subscales, a low score on Meaningfulness was the best predictor of scores on Depression. (Carstens & Spangenberg, 1997)

How do we achieve the perception of more meaningfulness? That is linked to the ‘demands’ of our basic parameters, our needs, values, and aspirations. Identifying them through information we already have about ourselves from the past, in terms of situations that were fulfilling or unfulfilling, and through observation and reflection on our communication patterns can make it easier for us to find what is meaningful to us. Once things that are meaningful are identified, one not only gravitates more towards those things, but can also seem more of them in present activities and situations.

As an example, consider a social get together, a party, where people stand around and talk to each other.

Last year, Randy felt uncomfortable at Bob’s birthday party, particularly on a day where he does not feel his best. Bob always invites lots of people Randy does not know. He would stand there and do his best to mingle. Was that not the point of it to mingle? But Randy was not entirely sure what he was doing at the party? Yes, sure, he wanted to have a good time, had to have a good time, but it would be over after a couple of hours anyway, and then he would be by himself again.

Since last year, Randy had looked into Communication-Focused Therapy and several other therapeutic approaches, which seemed to help people. He also worked with a therapist. He found out that he likes being with people and is interested in them at a deeper level, rather than just pleasantries. He probably had learned at home not to look into things too deeply. Don’t scratch the surface. But that did not lead to very fulfilling relationships.

This year, Randy is at Bob’s birthday party again. He walked into the main room. He sees a woman looking at a photograph hanging at the wall. Since last year he has discovered his interest in other people’s lives, their perspectives and insights. He walks over to her and talks about the photograph, and asks what she thinks about it? How she feels about it? An hour later they were talking again about things that were important to them. This was a new experience for Randy.

What this everyday occurrence illustrates, that if one zooms in on the meaningful, such as talking with another human being about what they find important, it is less likely to get caught in the meaningless, small talk for the sake of small talk. While small talk fills an important role in building relationships, one needs to see it only as a transition phase, in which the focus should already be on the next phase in relationship building. Far too many people, particularly those with social anxiety or depression, stay in the small talk for its own purpose state. One reason may be, what we already discussed under the topic of connectedness, the longing for connectedness and, at the same time, the apprehensiveness about it. Ways to see more meaningfulness are powerful antidotes to this dilemma.

Meaningfulness is frequently something that is seen within the context of one’s life story, or part of the life story. However, it should not be dependent on the story, because the story in turn depends again on the individual needs, values, and aspirations, the basic parameters of the person. On the other hand, a story is a frame for communication that takes place within it. At the same time, the communication dynamics that develop within a story are meant to get the person closer to the fulfilment of the individual needs, values, and aspirations. Thus, identifying the latter can help to construct a story, in which more meaningfulness can be found. It is in the story where past present and future can come together and support one in the creation of more meaning and more meaningfulness. Stories, as long as they are flexible and align with oneself, can also speed up the decoding process of messages and facilitate communication.

Motivation

Decreased motivation is a central symptom of depression which often makes therapy more difficult. It is no different in a communication focused approach. Experiencing what is possible in therapy can raise motivation significantly, but this requires at least some motivation to begin a therapy and makes it through the early stages. A communication focused approach may have the advantage here that it has material to work with from the time the therapist opens the door and makes eye contact with the patient. Another advantage on the motivational side is that a communication focused approach places emphasis on the interaction between patient and therapist, and thus the relationship, which helps to motivate the patient to wait and see what the therapy has to offer.

Motivation often comes when one has already started on a task. This is even more true in depression. Once one is engaged in a task, the depression tends to become less of an issue. The thoughts and feelings we build up before engaging in a task can be coloured significantly by mood and other factors, so that depression can influence the motivation and initiative to begin on a task quite directly. Here it is again to zoom in on what is really important to oneself, and also to see the communication aspects when one engages in a task. Any task is an interaction with the environment and with oneself, and as we already discussed, our communication or interaction patterns with the environment shape the enjoyment and satisfaction we derive from it. One valuable task in therapy is to look at, reflect, and experiment with these patterns.

Interacting with the World

At the core of Communication-Focused Therapy® is interaction. Interacting with the world is an important pillar in moving away from depression. Anything that helps to interact with the world in a meaningful way can help to overcome negative thoughts, feelings, and ruminations, as well as to find energy, initiative and motivation again. But how to get back into the world if one cannot find the energy and initiative to do so, and the world seems bleak?

As already mentioned, an important part in reintegrating in the world is just to do things. Action. However, it is not mindless action we are looking for, but mindful action; the kind that gives one the feeling of progressing rather than regressing. The first steps are often the most difficult steps, and anything that helps us to get moving is usually leading one in the right direction. Important from a Communication-Focused Therapy® perspective is to examine the pattern one usually used to interact with the world and to see where changes can be helpful. One often also needs to develop new ones, either in combination with old ones or by themselves. Through experimentation one can then adjust them so that they fit and are effective in getting one’s needs, values, and aspirations met in the world.

Powerlessness

The feeling of powerlessness is one of the hallmark features of depression, which often leads into a vicious cycle, which further paralyses the patient. This powerlessness often goes hand in hand with a sense of disconnectedness. After all, communication is how we can exert power by changing our environment and ourselves. As depression inhibits meaningful communication, the latter can help overcome the sense of powerlessness.

Particularly problematic can also be the feedback a depressed person receives from others, which can maintain the depression. Coyne tested the hypotheses that (a) normal Ss respond differentially to the behavior of depressed patients, (b) this differential response is due to the fact that the target individuals are depressed, and not that they are patients, and (c) this pattern can be related to the symptomatology of depression. Each of 45 normal female undergraduates conversed on the telephone with either a depressed patient ( n = 15), a nondepressed patient ( n = 15), or a normal control ( n = 15). It was found that following the phone conversation, Ss who had spoken to depressed patients were themselves significantly more depressed, anxious, hostile, and rejecting. Measures of activity, approval responses, hope statements, and genuineness did not distinguish between S groups or between target groups, but important differences were found in the Ss’ perception of the patients. It was proposed that environmental response may play an important role in the maintenance of depressed behavior. Furthermore, special skills may be required of the depressed person to cope with the environment his behavior creates. (Coyne, 1976)

Insight into Communication

In many instances, reflecting on one’s communication patterns and strategies with oneself and others in concrete situations leads to insight about them. This is quite practical in nature. Observing communication patterns and trying out new ones is an important part of therapy. Since communication has different components one can focus on its components:

Person A

  • Selecting information for a message (e.g. I am not OK with our weekend plans because I rather stay in the city; I need to communicate this to my partner)
  • Encoding the information in a message (I will say it to him verbally; I want to be clear but cautious because we had a fight yesterday and he is feeling low today)
  • Sending the message through a communication channel (using the speech system to say the words)

Person B

  • Receiving the message through a communication channel (using the auditory system)
  • Decoding the message into information (my partner is unhappy)
  • Processing the information further (is she unhappy with me? I better don’t go there.)

It is obvious from this example that communication has failed, as the feeling “I rather stay in the city” gets converted into “is she unhappy with me?” Some vital information is not transmitted even though both individuals have the capability to communicate anything they want. It is not difficult to imagine that person A could be an anxious person and person B a depressed person. The communication patterns they use may have served some function in the past, as they both seem to be protecting themselves from some negative emotional consequence. However, in the present they do not promote a more optimal outcome, which could take into account both their needs, values and aspirations. On the other hand, it is also easy to see how awareness, reflection and experimentation with new communication patterns can resolve the problem, reduce the anxiety in A and lift the mood of B. That is what a communication-oriented therapy should do.

Maladaptive communication pattern can lead to the perception of more negative consequences and less meaning in the world. The former can be a filtering and interpretation deficit, the second often follows the first in the form of a disconnect or disengagement from the world. Insight does not have to lead to a change of current communication patterns, but in many cases also the development of new ones. In practice, this may also include considering situations which can facilitate better communication patterns, as the communication patterns one uses also depends on the communication patterns of the people one interacts with. This is also the basic dynamic when an individual is constantly exposed to other people who are stressed, anxious or depressed. Especially in infants and children who are still in the process of acquiring and forming communication patterns, an anxious parent, for example, can pass on some of the maladaptive communication patterns to the child. Depending on any helpful communication patterns already in memory and the effectiveness of autoregulatory processes, the child may adopt less of the maladaptive communication patterns than it might otherwise.

Observing and insight into internal and external communication patterns are both important. An individual suffering from depression is less likely to see messages as relevant and meaningful if the communication patterns that make up the feeling of being oneself have been compromised. The feeling of being oneself is itself the own observation of internal flows of information or communication. There is thus a strong link between internal and external communication patterns, which also explains how individuals can spiral into a vicious cycle of depression where engaging with the world can make the internal sense of dread and depression even greater, and vice versa. For example, a depressed person who pushes himself or herself to be more outgoing in a social situation often feels worse in the end.

Building the Sense of Self

Seeing relevance in a message requires knowing what one needs, wants, as well as one’s values and aspirations. In short, it means knowing some basic parameters about oneself. When the self becomes more meaningful, the motivation and desires to learn or try out something new, including therapy, increase. To give the sense of self texture requires awareness and identification of the own needs, values and aspiration, thereby attaching more subjectively perceived value to it.

The sense of self is awareness of certain communication flows in one’s own body. These information flows can be sensory, emotional or other signals from cognitive processes or from memory. This is the reason why internal and external communication patterns play such an important role for the sense of self because they influence these information flows. If a patient uses an external communication pattern which interferes with social exchanges, the information flow from the outside world in this respect will be reduced which has as effect on the sense of self. Thus, exposure to meaningful communication and improvements in communication can be very effective in treating the symptoms of depression. Negative perceptions of oneself are reduced and the interactions with the environment improve, which in itself has an antidepressant effect. As the moods lift concentration, focus and memory problems tend to decrease because things feel more relevant consciously and subconsciously.

Resonance

Resonance is when new information becomes meaningful because of the information the other person possesses, whether consciously or subconsciously. The interaction between therapist and patient is meaningful to the patient if what is happening resonates with the values, basic interests or aspirations of the patient. This also means that the therapist, consciously or subconsciously, needs to have a good sense of the patient’s values, interests and aspirations, of what is relevant to the patient, which can also show in the symptoms and the situations in which the symptoms are triggered.

In therapy, patient and therapist look for resonance because it is necessary for the communication of meaning, which brings about a change in the patient. Often resonance can only be guessed by either patient or therapist, and it takes some amount of communication to find resonance. A good starting point is listening to what the patient is saying and otherwise communicating, since it reflects the information the patient already has, and which represents the foundation for resonance.

Depression makes the own information, particularly the emotional information less accessible, which can also lower resonance. However, while in most depressed patients resonance may become narrower, it does not cease to exist. Reflecting with a patient on everyday activities can help to find spots of resonance. If the therapist then uses an inquisitive and interested communication pattern to get information on what about this activity is valued, needed or aspired to by the patient, the patient’s internalization of this pattern can help to form more adaptive communication patterns which can help against and prevent a depression.

Relevance

Depression makes everything seem less relevant as it reduces the spectrum of information that is available, including emotional signals. Less available information leads to less resonance, and thus less meaning which is extracted from messages form internal and external sources as well as less openness to new messages. Looking at a tree may, for example, not be as enjoyable anymore. The visual information about the tree still arrives in the brain as it always did, but the information stored in memory about the good feelings associated with a tree is tuned down. The actual tress has not changed, but it has become less relevant to the person.

Less relevance also means less focus, which could support an evolutionary explanation of depression. In times of stress, it can be helpful if one sees less relevance in the situation and withdraws. However, this may not feasible in the world we live in today. One cannot just leave one’s job form one day to the next. Rather, a common response to stress is often to work even harder, which can the lead into burnout.

Relevance is a connection one has with things, people and situations. If something is relevant to what one needs, wants, values or aspires to, one is more likely to be open to information associated with it. If one values being in a relationship, for example, one is more likely to be receptive to messages from a partner, if they are seen as relevant to the maintenance of the relationship. Although, one may not have enough information to judge what is relevant, and therefore focus on the wrong messages, or one may not understand a message. All this can be remedied with better communication patterns which lead to better information, and exposure to meaningful communication.

Changing a situation or one’s perception of it requires taking stock of one’s needs, wants, values and aspirations and then to make a change. If one is working in a job which does not seem relevant to oneself, an option, aside from quitting and finding another one, is to assess if a change in the work or one’s perspective of it is possible that could align it more closely with one’s needs and wants. This can be worked out in therapy. But whatever action one takes, just the doing it already helps against depression.

In therapy, rebuilding relevance through new communication patterns which bring a different focus and more useful information changes how the own person and the world are seen. It also puts the focus on better sources of meaningful messages. For example, if a patient gains the insight that he values staying in touch with a particular group of friends because they share his interests, he is more likely not to decline a lunch invitation by someone who is a part of that group. At lunch, this friend may tell him then what the other members of the group have been up to, which may help the patient with his own career choices as he shares their interests. Raising the level of resonance, and thereby the relevance one sees in oneself, others, activities, things and so on, is very effective in the treatment of depression and other mental health conditions because it lets through more and better information to make better decisions and raises the mood as the world as a whole seems more meaningful now.

Communication Exchange

Meaning is built within the communication processes in the therapy. The interaction between two minds can give rise to a dynamic, which carries the flow of meaningful messages and brings the process forward. Motivation for the process is usually maintained if the messages feel relevant and meaningful to the patient in the present. If emotions or thoughts about the past are brought to the centre of attention, they are important to the extent that they are still relevant in the present. This relevance depends on the emotions they can induce in the moment.

The exchange of messages can be influenced by both partners to the interaction. The depression can be felt by both, since it interferes with the construction and free flow of messages. As long as the therapist is open and receptive to the patient’s messages and tries to understand the communication dynamics and the patient sees the process as relevant, it can move forward. Since the patient and therapist have different neuronal networks and past communication (life) experiences they can induce change in each other through the communication of meaningful messages.

Experimentation

Experimenting with communication patterns is a central element of Communication-Focused Therapy®, which is shared by therapist and patient. As a therapist, one has to continually find new ways of doing things, mostly quite spontaneously in the situation. This is where creativity is an important skill of the therapist. At the same time, the patient needs to learn to also experiment with different ways of doing things, particularly in communicating and interacting with themselves and the world around them. Depression, anxiety, OCD, fears, psychosis, and many other conditions, lead to a narrowing of the breadth of communication and interaction patterns. The result is often a rigidity in these patterns also within oneself. Thoughts and feeling become more monotone and lead back to themselves in endless cycles. It seems as if there is no way out of them. A reset often can be helped by several techniques that bring the focus to new and potentially meaningful information, such as in mindfulness practices, for example, where one may focus on an object and investigate it mentally at deeper and deeper levels. One positive outcome is to prevent thoughts spirals triggered by irrelevant questions. Also, new information of any kind is like a ray of sunlight shining into the prison cell of depression. One at least has to grapple with the fact that there is a sun out there, which leads toa greater desire for change. Action for change may be much more difficult to accomplish in more severe cases of depression, but new meaningful information can contain a chance for change.

Core benefits of experimentation also include practice of great flexibility, which can break the rigidity in depression and lead to the openness, which lets through more meaningful information from more sources. This increases the perceived connectedness with oneself and the world, which is a powerful antidote against depression, fear and anxiety. Experimentation also helps to instil the connectedness with more life through constant change.

Observing

Observing is a skill that usually leads to many of the other skills. Important is the ability to observe without asking any specific questions. The communication patterns we use today have their origin in our past interaction and experiences on a bed of biology. Observing our own actions and those of others in various situations help to bring us insight into the underlying dynamics we repeat again and again in interactions with others, as well as the patterns we repeat within ourselves. Some of them work and some less so. An important and very basic question is whether they serve the aim of greater connectedness with ourselves and others, whether they help us to identify more closely our own needs, values, and aspirations, and whether they support us in achieving these basic parameters with others. Communication is how things are create, evolve, and are put into practice in the world, and the more one feels one understands and can make one’s communication patterns work for oneself and others, the less helpless, alone, and powerless one feels. Thus, working with them has a direct effect on the feelings that underlie and come with depression.

Observing one’s internal communication patterns has a similar effect on the feelings of depression from the inside.

Integration

As change in the communication pattern occurs, the information flows within the individual also change. Since the self is a reflection on these communication flows, it can bring about a change in how a person experiences the own self. In the long run, the identified meaning is integrated into the self, which, depending on the meaningful information perceived, can make the self itself more meaningful and valuable. One derives meaning from interacting with oneself and with other people, and this is also how people build their sense of self. Thus, while personality stays largely constant, the sense of self can get a boost from exposing oneself to the right communication environment.

Values, Needs and Aspirations

Depression blurs what feels important to a patient, and the fit between values, needs and aspirations and the current life situation is usually reduced. Whether in professional or personal life, getting what one needs, values and aspires to makes happiness, contentment and satisfaction more likely in the long run. If I value helping people, I know what makes me happy and gives me satisfaction. Communication, whether internal or external, is the instrument, that makes individuals aware of these basic parameters and helps them to pursue them.

The basic parameters, values, needs and aspirations, change little over time. One may alternate between being hungry and not being hungry within hours but eating as a basic need does not change and nor does someone who is happy with being a vegetarian. To some extent these basic parameters seem to be built into our biology, and it is not the therapeutic task to change them but to arrange the world around in such a way as to be able to live one’s values, needs and aspirations. Working with and improving communication with oneself and others usually accomplishes that.

Internal Communication

Exploring interests, values, needs and wants requires becoming sensitive to one’s own thoughts, emotions and physical sensation, to be open and receptive to the information coming in from one’s body and mind. It is about feeling what makes one feel good and what does not. At the same time, it has to make sense and should fit together. If specific values and needs appear to be in conflict with each other, a combination of emotions and rational thinking is often helpful. For a depressed patient, this may not be an easy task, but to bring more structure and sense into a seemingly chaotic and disconnected world, can be helpful.

Internal communication can be practiced in therapy. Since there is a correlation between the communication with others and one’s own internal communication, rehearsing and going through communication patterns in therapy, is often helpful to the patient outside of therapy, not only for the interactions with others, but also for the interaction with oneself. Values and needs can be clarified by talking to someone else and engaging in soul searching on one’s own. An important experience in therapy should be that one can clarify one’s needs and values by reflecting and communicating about them.

Meaningful Messages as the Instrument of Change

Communication in its various forms needs to be the target of therapy because it can be fined tuned and a change here can bring lasting change. The author has described this elsewhere (Haverkampf, 2017b, 2018b) Communication-Focused Therapy has been developed by the author for several psychiatric conditions. (Haverkampf, 2017g, 2017c, 2017e, 2017d, 2017h, 2017i). In depression, the desired change is for a broader emotional experience, seeing more relevance in oneself, one’s thoughts, emotions, and in the world as a whole. Adjusting, discarding and forming new communication patterns can lead to a reduction in symptoms that is more permanent than techniques the focus less on communication.

The actual instrument of change are, however, the meaningful messages which, provided they are encoded, sent and decoded, induce the change. As information in a message resonates and is processed with the already existing information, meaning is created which leads to changes in the future.

Broader Experience

If there is more meaning in oneself and the world, it is easier to focus on aspects of oneself and of the world. This expands one’s experience of oneself and of the world around. Seeing more relevance and more sources of novelty and change in the world, increases one’s experience of the world and makes this experience richer. However, it also requires that one engages with the world, which may be difficult due to anxiety cause by fears and other unresolved emotions. However, working with communication early in the therapeutic process often reduces any anxiety quickly as the patient learns to become aware of and experiment with communication and appreciates and gains insight into the predictability of communication.


Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy and counselling in Dublin, Ireland. He is the author of several books and over a hundred articles. Dr Haverkampf has developed Communication-Focused Therapy® and written extensively about it. He also has advanced degrees in management and law. The author can be reached by email at jonathanhaverkampf@gmail.com or on the websites www.jonathanhaverkampf.ie and www.jonathanhaverkampf.com. He is also a frequent guest on www.askdrjonathan.com.

References

Aalbers, G., McNally, R. J., Heeren, A., De Wit, S., & Fried, E. I. (2019). Social media and depression symptoms: A network perspective. Journal of Experimental Psychology: General, 148(8), 1454.

Ackard, D. M., Neumark-Sztainer, D., Story, M., & Perry, C. (2006). Parent-child connectedness and behavioral and emotional health among adolescents. American Journal of Preventive Medicine, 30(1), 59–66. https://doi.org/10.1016/j.amepre.2005.09.013

Alexopoulos, G. S. (2019). Mechanisms and treatment of late-life depression. In Translational Psychiatry (Vol. 9, Issue 1, pp. 1–16). Nature Publishing Group. https://doi.org/10.1038/s41398-019-0514-6

APA (Ed.). (2013). Diagnostic and statistical manual of mental disorders. Am Psychiatric Assoc.

Arango, A., Cole-Lewis, Y., Lindsay, R., Yeguez, C. E., Clark, M., & King, C. (2019). The Protective Role of Connectedness on Depression and Suicidal Ideation Among Bully Victimized Youth. Journal of Clinical Child and Adolescent Psychology, 48(5), 728–739. https://doi.org/10.1080/15374416.2018.1443456

Bekker, M. H. J., & Belt, U. (2006). The role of autonomy-connectedness in depression and anxiety. Depression and Anxiety, 23(5), 274–280. https://doi.org/10.1002/da.20178

Bucci, W., & Freedman, N. (1981). The language of depression. Bulletin of the Menninger Clinic, 45(4), 334.

Carhart-Harris, R. L., Erritzoe, D., Haijen, E., Kaelen, M., & Watts, R. (2018). Psychedelics and connectedness. In Psychopharmacology (Vol. 235, Issue 2, pp. 547–550). Springer Verlag. https://doi.org/10.1007/s00213-017-4701-y

Carstens, J. A., & Spangenberg, J. J. (1997). Major depression: A breakdown in sense of coherence? Psychological Reports, 80(3 PART 2), 1211–1220. https://doi.org/10.2466/pr0.1997.80.3c.1211

Coyne, J. C. (1976). Depression and the response of others. Journal of Abnormal Psychology, 85(2), 186–193. https://doi.org/10.1037/0021-843X.85.2.186

Cruwys, T., Alexander Haslam, S., Dingle, G. A., Jetten, J., Hornsey, M. J., Desdemona Chong, E. M., & Oei, T. P. S. (2014). Feeling connected again: Interventions that increase social identification reduce depression symptoms in community and clinical settings. Journal of Affective Disorders, 159, 139–146. https://doi.org/10.1016/j.jad.2014.02.019

Dean, J., & Keshavan, M. (2017). The neurobiology of depression: An integrated view. In Asian Journal of Psychiatry (Vol. 27, pp. 101–111). Elsevier B.V. https://doi.org/10.1016/j.ajp.2017.01.025

Eichstaedt, J. C., Smith, R. J., Merchant, R. M., Ungar, L. H., Crutchley, P., Preoţiuc-Pietro, D., Asch, D. A., & Schwartz, H. A. (2018). Facebook language predicts depression in medical records. Proceedings of the National Academy of Sciences of the United States of America, 115(44), 11203–11208. https://doi.org/10.1073/pnas.1802331115

Friedrich, M. J. (2017). Depression Is the Leading Cause of Disability Around the World. JAMA, 317(15), 1517. https://doi.org/10.1001/jama.2017.3826

Galloway, A. P., & Henry, M. (2014). Relationships between Social Connectedness and Spirituality and Depression and Perceived Health Status of Rural Residents. Online Journal of Rural Nursing and Health Care, 14(2), 43–79. https://doi.org/10.14574/ojrnhc.v14i2.325

Gold, S. M., Köhler-Forsberg, O., Moss-Morris, R., Mehnert, A., Miranda, J. J., Bullinger, M., Steptoe, A., Whooley, M. A., & Otte, C. (2020). Comorbid depression in medical diseases. In Nature Reviews Disease Primers (Vol. 6, Issue 1, pp. 1–22). Nature Research. https://doi.org/10.1038/s41572-020-0200-2

Goodman, S. H. (2020). Intergenerational Transmission of Depression. In Annual Review of Clinical Psychology (Vol. 16, pp. 213–238). Annual Reviews Inc. https://doi.org/10.1146/annurev-clinpsy-071519-113915

Grieve, R., Indian, M., Witteveen, K., Anne Tolan, G., & Marrington, J. (2013). Face-to-face or Facebook: Can social connectedness be derived online? Computers in Human Behavior, 29(3), 604–609. https://doi.org/10.1016/j.chb.2012.11.017

Grover, S., Avasthi, A., Sahoo, S., Lakdawala, B., Dan, A., Nebhinani, N., Dutt, A., Tiwari, S., Gania, A., Subramanyam, A., Kedare, J., & Suthar, N. (2018). Relationship of loneliness and social connectedness with depression in elderly: A multicentric study under the aegis of Indian Association for Geriatric Mental Health. Journal of Geriatric Mental Health, 5(2), 99. https://doi.org/10.4103/jgmh.jgmh_26_18

Hammen, C. (2005). Stress and depression. In Annual Review of Clinical Psychology (Vol. 1, pp. 293–319).  Annual Reviews . https://doi.org/10.1146/annurev.clinpsy.1.102803.143938

Haverkampf, C. J. (2010a). A Primer on Interpersonal Communication (3rd ed.). Psychiatry Psychotherapy Communication Publishing Ltd. https://jonathanhaverkampf.com/books/

Haverkampf, C. J. (2010b). Communication and Therapy (3rd ed.). Psychiatry Psychotherapy Communication Publishing Ltd. https://jonathanhaverkampf.com/books/

Haverkampf, C. J. (2010c). Depression Mania and Communication (3rd ed.). Psychiatry Psychotherapy Communication Publishing Ltd.

Haverkampf, C. J. (2013a). A Case of Depression. J Psychiatry Psychotherapy Communication, 2(3), 88–90.

Haverkampf, C. J. (2013b). Antipsychotics: Emotional Flattening vs Apathy. J Psychiatry Psychotherapy Communication. 2(2), 31–32.

Haverkampf, C. J. (2016). Trauma (1). http://www.jonathanhaverkampf.com

Haverkampf, C. J. (2017a). CBT and Psychodynamic Psychotherapy – A Comparison. J Psychiatry Psychotherapy Communication, 6(2), 61–68. https://doi.org/10.5281/zenodo.3529280

Haverkampf, C. J. (2017b). Communication-Focused Therapy (CFT) (2nd ed.). Psychiatry Psychotherapy Communication Publishing Ltd. https://jonathanhaverkampf.com/books/

Haverkampf, C. J. (2017c). Communication-Focused Therapy (CFT) for ADHD. J Psychiatry Psychotherapy Communication, 6(4), 110–115.

Haverkampf, C. J. (2017d). Communication-Focused Therapy (CFT) for Anxiety and Panic Attacks. J Psychiatry Psychotherapy Communication, 6(4), 91–95.

Haverkampf, C. J. (2017e). Communication-Focused Therapy (CFT) for Bipolar Disorder. J Psychiatry Psychotherapy Communication, 6(4), 125–129.

Haverkampf, C. J. (2017f). Communication-Focused Therapy (CFT) for Depression. J Psychiatry Psychotherapy Communication, 6(4), 101–104.

Haverkampf, C. J. (2017g). Communication-Focused Therapy (CFT) for OCD. J Psychiatry Psychotherapy Communication, 6(4), 102–106.

Haverkampf, C. J. (2017h). Communication-Focused Therapy (CFT) for Psychosis. J Psychiatry Psychotherapy Communication, 6(4), 116–119.

Haverkampf, C. J. (2017i). Communication-Focused Therapy (CFT) for Social Anxiety and Shyness. J Psychiatry Psychotherapy Communication, 6(4), 107–109.

Haverkampf, C. J. (2018a). A Primer on Communication Theory. https://jonathanhaverkampf.com/books/

Haverkampf, C. J. (2018b). Communication-Focused Therapy (CFT) – Specific Diagnoses (Vol II) (2nd ed.). Psychiatry Psychotherapy Communication Publishing Ltd. https://jonathanhaverkampf.com/books/

Haverkampf, C. J. (2018c). Communication Patterns and Structures.

Haverkampf, C. J. (2020a). Communication-Focused Therapy® (CFT) and Trauma (1). In C. J. Haverkampf (Ed.), Communication-Focused Therapy® (CFT) Vol IV (pp. 61–80). Psychiatry Psychotherapy Communication Publishing Ltd. https://jonathanhaverkampf.com/communication-focused-therapy-cft-and-trauma-1/

Haverkampf, C. J. (2020b). Connectedness. In C. J. Haverkampf (Ed.), Life Improvement Vol IV (pp. 41–60). https://jonathanhaverkampf.com/connectedness/

Hirschfeld, R. M. A., Montgomery, S. A., Keller, M. B., Kasper, S., Schatzberg, A. F., Moller, H.-J., Healy, D., Baldwin, D., Humble, M., & Versiani, M. (2000). Social Functioning in Depression: A Review. The Journal of Clinical Psychiatry, 61(4), 0–0. https://www.psychiatrist.com/jcp/depression/social-functioning-depression-review

Hoge, E., Bickham, D., & Cantor, J. (2017). Digital media, anxiety, and depression in children. Pediatrics, 140(Supplement 2), S76–S80. https://doi.org/10.1542/peds.2016-1758G

Hwang, J., Toma, C. L., Chen, J., Shah, D. V., Gustafson, D., & Mares, M. L. (2021). Effects of Web-Based Social Connectedness on Older Adults’ Depressive Symptoms:A Two-Wave Cross-Lagged Panel Study. Journal of Medical Internet Research, 23(1), e21275. https://doi.org/10.2196/21275

Jack, D. C. (1991). Silencing the self: Women and depression. Harvard University Press.

Jacobson, K. C., & Rowe, D. C. (1999). Genetic and environmental influences on the relationships between family connectedness, school connectedness, and adolescent depressed mood: sex differences. Developmental Psychology, 35(4), 926–939. https://doi.org/10.1037/0012-1649.35.4.926

Josephine, K., Josefine, L., Philipp, D., David, E., & Harald, B. (2017). Internet- and mobile-based depression interventions for people with diagnosed depression: A systematic review and meta-analysis. In Journal of Affective Disorders (Vol. 223, pp. 28–40). Elsevier B.V. https://doi.org/10.1016/j.jad.2017.07.021

Joyce, H. D., & Early, T. J. (2014). The impact of school connectedness and teacher support on depressive symptoms in adolescents: A multilevel analysis. Children and Youth Services Review, 39, 101–107. https://doi.org/10.1016/j.childyouth.2014.02.005

Kaniuka, A., Pugh, K. C., Jordan, M., Brooks, B., Dodd, J., Mann, A. K., Williams, S. L., & Hirsch, J. K. (2019). Stigma and suicide risk among the LGBTQ population: Are anxiety and depression to blame and can connectedness to the LGBTQ community help? Journal of Gay and Lesbian Mental Health, 23(2), 205–220. https://doi.org/10.1080/19359705.2018.1560385

Keles, B., McCrae, N., & Grealish, A. (2020). A systematic review: the influence of social media on depression, anxiety and psychological distress in adolescents. In International Journal of Adolescence and Youth (Vol. 25, Issue 1, pp. 79–93). Routledge. https://doi.org/10.1080/02673843.2019.1590851

Kok, R. M., & Reynolds, C. F. (2017). Management of depression in older adults: A review. In JAMA – Journal of the American Medical Association (Vol. 317, Issue 20, pp. 2114–2122). American Medical Association. https://doi.org/10.1001/jama.2017.5706

LeMoult, J., & Gotlib, I. H. (2019). Depression: A cognitive perspective. In Clinical Psychology Review (Vol. 69, pp. 51–66). Elsevier Inc. https://doi.org/10.1016/j.cpr.2018.06.008

Lynch, V. A., & Duval, J. B. (2010). Forensic nursing science-e-book. Elsevier Health Sciences.

Malaquias, S., Crespo, C., & Francisco, R. (2015). How do Adolescents Benefit from Family Rituals? Links to Social Connectedness, Depression and Anxiety. Journal of Child and Family Studies, 24(10), 3009–3017. https://doi.org/10.1007/s10826-014-0104-4

Millings, A., Buck, R., Montgomery, A., Spears, M., & Stallard, P. (2012). School connectedness, peer attachment, and self-esteem as predictors of adolescent depression. Journal of Adolescence, 35(4), 1061–1067. https://doi.org/10.1016/j.adolescence.2012.02.015

Nesse, R. M. (2000). Is depression an adaptation? In Archives of General Psychiatry (Vol. 57, Issue 1, pp. 14–20). American Medical Association. https://doi.org/10.1001/archpsyc.57.1.14

Nguyen, M. H., Le, T. T., & Meirmanov, S. (2019). Depression, Acculturative Stress, and Social Connectedness among international university students in Japan: A statistical investigation. Sustainability (Switzerland), 11(3), 878. https://doi.org/10.3390/su11030878

Richards, C. S., & O’Hara, M. W. (2014). The Oxford handbook of depression and comorbidity. Oxford University Press.

Santini, Z. I., Koyanagi, A., Tyrovolas, S., Mason, C., & Haro, J. M. (2015). The association between social relationships and depression: A systematic review. In Journal of Affective Disorders (Vol. 175, pp. 53–65). Elsevier. https://doi.org/10.1016/j.jad.2014.12.049

Seabrook, E. M., Kern, M. L., & Rickard, N. S. (2016). Social Networking Sites, Depression, and Anxiety: A Systematic Review. JMIR Mental Health, 3(4), e50. https://doi.org/10.2196/mental.5842

Taylor, C. T., Pearlstein, S. L., Kakaria, S., Lyubomirsky, S., & Stein, M. B. (2020). Enhancing Social Connectedness in Anxiety and Depression Through Amplification of Positivity: Preliminary Treatment Outcomes and Process of Change. Cognitive Therapy and Research, 44(4), 788–800. https://doi.org/10.1007/s10608-020-10102-7

Tiller, J. W. G. (2013). Depression and anxiety. The Medical Journal of Australia, 199(6), S28–S31. https://doi.org/10.5694/mja12.10628

Vos, T., Barber, R. M., Bell, B., Bertozzi-Villa, A., Biryukov, S., Bolliger, I., Charlson, F., Davis, A., Degenhardt, L., Dicker, D., Duan, L., Erskine, H., Feigin, V. L., Ferrari, A. J., Fitzmaurice, C., Fleming, T., Graetz, N., Guinovart, C., Haagsma, J., … Murray, C. J. L. (2015). Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990-2013: A systematic analysis for the Global Burden of Disease Study 2013. The Lancet, 386(9995), 743–800. https://doi.org/10.1016/S0140-6736(15)60692-4

Watts, R., Day, C., Krzanowski, J., Nutt, D., & Carhart-Harris, R. (2017). Patients’ Accounts of Increased “Connectedness” and “Acceptance” After Psilocybin for Treatment-Resistant Depression. Journal of Humanistic Psychology, 57(5), 520–564. https://doi.org/10.1177/0022167817709585

Williams, K. L., & Galliher, R. V. (2006). Predicting depression and self-esteem from social connectedness, support, and competence. Journal of Social and Clinical Psychology, 25(8), 855–874. https://doi.org/10.1521/jscp.2006.25.8.855

Wu, Y.-J., Outley, C., Matarrita-Cascante, D., & Murphrey, T. P. (2016). A systematic review of recent research on adolescent social connectedness and mental health with internet technology use. Adolescent Research Review, 1(2), 153–162.

Yoon, S., Kleinman, M., Mertz, J., & Brannick, M. (2019). Is social network site usage related to depression? A meta-analysis of Facebook–depression relations. In Journal of Affective Disorders (Vol. 248, pp. 65–72). Elsevier B.V. https://doi.org/10.1016/j.jad.2019.01.026

This article is solely a basis for academic discussion and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition. Neither author nor publisher can assume any responsibility for using the information herein.

Trademarks belong to their respective owners. Communication-Focused Therapy, the CFT logo with waves and leaves, Dr Jonathan Haverkampf, Journal of Psychiatry Psychotherapy and Communication, and Ask Dr Jonathan are registered trademarks.

This article has been registered with the U.S. Copyright Office. Unauthorized reproduction, distribution or publication in any form is prohibited.

© 2012-2021 Christian Jonathan Haverkampf. All Rights Reserved

Unauthorized reproduction and/or publication in any form is prohibited.


[1] Both terms, psychotherapy and counselling, are often used interchangeably. In academia and research ‘psychotherapy’ has been used traditionally more frequently. Many patients, however, find the term ‘counselling’ less stigmatizing and ‘pathological’. I will use the term psychotherapy as a matter of habit and convenience.

Communication-Focused Therapy® (CFT) for Depression

Haverkampf-C.-J.-2020.-Communication-Focused-Therapy®-CFT-for-Depression.-In-CFT-Vol-IV-pp.-320-339

Communication-Focused Therapy® (CFT) for Depression

Christian Jonathan Haverkampf, M.D.

Depression is a mental health condition that affects a large part of the population at least once over their life span, significantly reducing life quality and impairing work and relationships. Psychotherapy and medication are the main treatments for the condition. Communication-Focused Therapy® (CFT) is a therapy developed by the author, focusing on communication processes to treat depression. Improvements in internal and external communication and awareness for a patient’s needs, values and aspirations appear to be effective against several symptoms of depression and increase motivation and compliance for therapy. This article provides an overview of a conceptual framework from a communication perspective and several approaches for treating depression with psychotherapy.

Keywords: depression, communication-focused therapy, CFT, communication, psychotherapy, psychiatry, treatment

Table of Contents

Introduction. 4

Depression. 6

Flattening of Emotions. 6

Negative Interpretations. 7

Communication-Focused Therapy® (CFT®) 9

Communication Patterns. 10

Questions. 11

Timeline. 11

Getting Information. 12

Connecting. 12

Integration. 13

Analyzing Communication Patterns. 13

Emotional Signals. 14

Motivation. 15

Insight into Communication. 15

Building the Sense of Self 17

Meaning. 18

Resonance. 18

Relevance. 19

Communication Exchange. 21

Integration. 21

Values, Needs and Aspirations. 22

Internal Communication. 22

Meaningful Messages as the Instrument of Change. 23

Broader Experience. 23

References. 25

 

Introduction

Depression is a general lowering of emotional experiences, while in the lighter forms, it may just be a reduction of positive emotional experiences. A dialling down of internal and external communication, such as thoughts, feelings and activities, usually accompanies it. Loss of energy, motivation, and initiative, loss of enjoyment and interest in pleasurable activities, and loss of concentration are just some of the possible attributes of depression.

All explanations for depression seem to depend on the framework of the school of thought that produced them. An early answer from ego psychology was that depression is the emotional expression of a state of ego-helplessness and ego-powerlessness to live up to certain strongly maintained narcissistic aspirations. (Bibring, 1953) This explanation is in some ways not so far from what we can observe in depression in every clinical practice, even if we rarely use the terminology anymore. Patients who are depressed indeed mostly feel helpless and powerless, which are practically requirements of the sense of feeling depressed. When we find ourselves in a situation where there seems no escape or where we have to decide quite literally between a rock and a hard place, we are more likely to feel depressed, unless we develop a new alternative and open a door we have not seen before. Unfortunately, depression makes it seem harder to innovate and be creative. One of the techniques of Communication-Focused Therapy® (CFT) is to restore the ability to see a broad range of options and innovate in depression. The path there is through work on communication patterns, as communication is how we all get our needs, values and aspirations satisfied.

Depression usually impairs the emotional communication one has with oneself and with others. (Haverkampf, 2017e) Experimental data has been showing quite consistently that depressive subjects exhibit disrupted emotional processing.  (Delle-Vigne et al., 2014) This emotional disconnect from oneself leads to a less complete sense of self and lower confidence in oneself and the world. (Haverkampf, 2012) The disconnect then leads to significant secondary impairments in everyday life.  It affects the interaction patterns one has with other people and oneself, leading to various relationship and workplace problems, and from here to further depression and anxiety. Thus, a neverending vicious cycle can pull the individual suffering from depression ever further down. Fortunately, in most people, depressive episodes are self-limiting as self-regulatory mechanisms usually kick in once it has reached a level where the quality of life is severely compromised. What then happens is that a shift or change in the internal and external communication happens that pulls the individual out of the depression. This latter process is what Communication-Focused Therapy® aims to bring about in patients where these auto-regulatory processes are absent or maladaptive. (Haverkampf, 2010b)

The symptoms of depression are the result of maladaptive internal and external communication patterns. A disturbance in the flows of meaningful information flows within the nervous system and between the nervous system and the outside world leads to a disconnect, resulting in less perceived meaning in the world and worse decisions because there is less available information. The informational deficit about oneself and the world leads to depression and anxiety, which causes even more withdrawal in a vicious cycle.

The link between communication patterns and mental well-being is an essential insight for its enormous ramifications on understanding and treating depression. However, one needs to view it as a large puzzle, where the pieces all fit in in the end. These puzzle pieces can come from many areas of an individual’s everyday life. In a study on monogamous romantic relationships, for example, mutual constructive communication was associated with decreases in depressive symptoms for males. In contrast, demand-withdraw communication correlated with increases in attachment avoidance and depressive symptoms. (Givertz & Safford, 2011)

An essential step in overcoming depression is becoming curious about how one communicates with oneself and others. Using constructive inquisitive communication patterns can have a healing effect (Haverkampf, 2017i). In therapy, the therapist can encourage observing the communication patterns a client operates and the assumptions made in them about intentions, wishes and needs, values, and other factors that determine the quality, quantity and future of human interactions. Since all psychotherapies to date, use human interaction as the main instrument in the healing process, even if they do not focus on it, most therapies can have a beneficial effect. Unfortunately, the focus is often not on communication patterns, which can, at least from a theoretical perspective, render them less efficient. While it is true that learned behaviour and past experiences influence the severity of the symptoms, they do so via internal and external patterns of communication. In any instance where therapy works, it is a change in information flows and communication behaviours that brings about changes in symptoms and quality of life. (Haverkampf, 2010b, 2017a)

Depression

Depression is a state of low mood and aversion to activity that can affect a person’s thoughts, behaviour, feelings, and sense of well-being. A depressed mood can be a normal temporary reaction to life events such as loss of a loved one, a job loss, but also ‘positive’ ones, such as winning in a lottery or having sudden and spectacular success. All these events represent changes globally, requiring internal modifications to adjust internal and external communication systems to the new reality. A job that is now suddenly more practical requires a different internal dialogue, such as less analysis and more exploration. It may also require different external communication patterns with colleagues rather than work in front of a computer screen. If these changes have only occurred partially or not, the information exchange patterns do not fit the situation. This lack of fit can lead to feelings of being overwhelmed, withdrawal, emptiness and feelings of depression, or in some cases (hypo)manic states.

The sum of the basic patterns of external and internal communication, an individual’s personality, remains relatively stable over time. (Haverkampf, 2010a) This also applies if a mental health condition, such as depression, improves. In a sample of depressed outpatients receiving a 5-week trial of pharmacotherapy, changes in neuroticism and extraversion scores were modestly or not accounted for by changes in depression scores. (Santor et al., 1997) However, how individual communication elements and patterns are used in given situations can be subjected to change, leading to significant changes in personal satisfaction, contentment and happiness.

Flattening of Emotions

Depression leads to a disconnect. A patient is no longer able to access positive emotions to the same extent as before. However, at the same time he or she may also become disconnected to a varying degree from ‘negative’ emotions, such as sadness. In all cases, the individual suffers from missing out on important information about the own person. This then leads to negative feelings, possibly also fears and anxiety, because meaningful information is missing. To some degree it is possible to counteract this with activities that are meaningful to oneself. One may even say that in the best a depression weeds out thoughts and activities that are less meaningful. And in most cases short and especially the reactive depressive episodes are self-limiting. But in the more severe and longer lasting depression the disconnectedness from emotional signals accelerates the downward spiral of decreasing emotional connectedness and increasing ability to correctly send and receive meaningful messages. (Haverkampf, 2010c, 2013)

Reconnecting with emotional signals can be helpful in depression. This should not add to the pressure on the patient ‘to feel better’. In Communication-Focused Therapy®, this is usually done by using the communication patterns in the session or memories of past interactions and experiences in the world to inquire into the feelings that were associated with them. However, the main technique is concerned less with individual emotional episodes, but with enabling a patient to become more aware of and influence communication processes and information, which lead to particular emotional signals. (Haverkampf, 2017a)

Negative Interpretations

Elevated levels of repetitive negative thinking are present across a large range of Axis I disorders and appear to be causally involved in the maintenance of emotional problems. It has also been argued that repetitive negative thinking is characterized by the same process across disorders due to the inherent similarities (Ehring & Watkins, 2008). A depression leads to more negative interpretations of messages from the environment and from within oneself. As one attributes the cause of negative experiences to oneself and engages in self-blame, feelings of guilt, failure and incompetence emerge. At the same time, the own person, others and the world as a whole appear to be less meaningful and less relevant. This loss of meaning can potentially lead to dangerous situations of self-harm or even suicide. To prevent this requires an insightful and caring use of communication between therapist and patient.

It is important to realize that it can be the same information which reaches the patient, but which is associated with more negative emotions and thus more hypotheses of negative consequences. A depressed affect can so lead to an increased selection of information associated with negative emotions, which can then lead to an even more depressed affect. This vicious cycle usually does not pose a problem because positive information becomes more appealing, which pulls the individual out of the negative affective state. In a depression where emotional and other communication is inhibited already, it is more difficult for the autoregulatory mechanisms to work, making a spiralling into an increasingly depressed affect more likely.

Analytical internal communication patterns can be helpful in many areas of life. However, in depression they are often used for the wrong purpose, possibly in the attempt to extricate oneself from the symptoms of depression. In a study by Rimes and Watkins, thirty depressed participants and thirty never-depressed participants were randomly allocated to ‘analytic’ (high analysis) or ‘experiential’ (low analysis) self-focused manipulations. As predicted, in depressed participants, the analytical self-focus condition increased ratings of the self as worthless and incompetent pre- to post-manipulation, whereas the experiential self-focus condition resulted in no significant change in such judgements. (Rimes & Watkins, 2005)

Negative thinking can often be triggered by some internal or external information, frequently an intrusive, which may be easier to shrug off for a non-depressed person. In this instance, it is as if the depressed person tries to preempt any disappoints or possible negative emotions from an adverse outcome, by already realizing them intracranially and fighting them with compensating emotions. However, this only leads to further negative thoughts and downward spiraling ruminations. One solution is to identify thoughts as mere thoughts and not real, another to build a sense of oneself as being able to deal with whatever may be coming one’s way, particularly the own emotions.

Repetitive negative thinking can, on the other hand, be distinguished from other forms of recurrent cognitions, such as obsessions, intrusive memories or functional forms of repeated thinking. (Ehring & Watkins, 2008) This illustrated how certain symptoms of a mental health condition can be grouped along the internal and external communication patterns they are associated with, and that they can be categorized into a moderate number of sets.

Communication-Focused Therapy® (CFT®)

Communication-Focused Therapy® (CFT®) was developed by the author to focus more specifically on the communication process between patient and therapist. The central piece is that the sending and receiving of meaningful messages is at the heart of any change process. Communication processes are at the same time the instruments of change and their target. Any therapy has to lead to change. This can include changes in acceptance levels, new insights, learning processes and more. All these aspects are determined by communication processes and some are communication processes themselves. For the acceptance of a certain situation or emotion, for example, with the aim of reducing conflicting emotions and anxiety, one needs to learn about the situation or emotions and identify them and then put them into context with information from memory and use internal and external communication flows to reflect on them. If fear inhibits the information retrieval from memory this will not fully work. CFT aims, among other things, at reducing the fear of information retained in memory or communicated from others. This requires more meaningful information rather than less which can be communicated more freely as the fears or other inhibiting factors decrease. The freer and more open the communication processes become, the easier it is for autoregulatory processes to counter unhelpful diversions from health affect states. However, this requires insight, reflection and experimentation in therapy.

Many popular forms of psychotherapy, such as Cognitive-behavioral Therapy (CBT), psychodynamic psychotherapy and Interpersonal Psychotherapy (IPT) define a format in which communication patterns take place that can bring about change. However, they do not address and work with the communication processes directly. In psychodynamic psychotherapy, there is the concept of transference and counter-transference which focuses on the result of communication processes. CFT in contrast attempts to focus on the process itself. (Haverkampf, 2017a)

CFT attempts to analyze how information is exchanged, the various channels involved and how meaning is generated. Messages do not have to be contained in words, they can also be transmitted by facial gestures or any behavior of the send. To contain meaning they have to be relevant to the recipient and have the potential to bring about a change in the recipient. Working with and analyzing patterns of internal and external communication helps to make the exchange of meaningful information work more effectively, reducing anxiety, emotional, mood, psychotic and other disorder in the long-run. (Haverkampf, 2018b) This does not mean that medication and other forms of therapy do not have their places in treatment, it does not change that at all. However, CFT provides a theoretical and empirical framework that can enrich these other therapeutic approaches, while also being used on its own.

Communication Patterns

Humans interact on millions of communication channels at one point in time. Cells have their communication channels, and every information coming into the system and leaving it uses communication patterns. The reason why certain patterns have to be used is so that the other person can understand the message. A language can be seen as a form of communication patterns on a more complex level. We all communicate in patterns. However, unlike learning a language, people spend little time observing and reflecting on the other communication patterns they use all the time.

In biology, an emerging picture of interconnected networks has replaced the earlier view of discrete linear pathways that relate extracellular signals to specific genes, raising questions about the specificity of signal-response events (Kholodenko, 2006). In synthetic biology, researchers integrate basic elements and modules to create systems-level circuitry (Purnick & Weiss, 2009). The communication of the cells with each other and with the environment determines how effective they are in, for example, eliminating tumor cells. The important basic material is ‘information’, which is then activated and given influence over other factors through meaning, whether that is meaning in in an intracellular or an interpersonal context. Communication patterns and structures facilitate this process. (Haverkampf, 2018c)

Two cardinal symptoms of depression are ruminations and selecting negative information. Many therapeutic approaches focus on the negative, for example, and try to unlearn them. This may work in the short-term but often fails in the long-term if the internal and external communication patterns do not change. An external pattern may be how one could ask for information that could dispel the negative thoughts or an internal testing of the information. Changes in communication patterns means modifications in which and how information is sent, how it is received and how meaning is extracted from it. All these steps can either be adaptive or maladaptive. Depression comes with maladaptive communication patterns which then cause even more maladaptive communication patterns. The way out is to create awareness for, reflect and experiment with these communication patterns, at first in a therapeutic setting and then in the real world.

Questions

As has been pointed out by the author already elsewhere, questions are powerful communication patterns in effecting change in other communication patterns (Haverkampf, 2017i). In depression, they can mobilize resources and redirect thinking towards a different focus, and they can also help end ruminations and looping thoughts. Over time, the patient should become a personal expert in asking the right questions.

Questions represent a large group of communication patterns with very diverse combinations of communication elements. One needs to fine-tune questions to the present communication dynamics and the aim of the questioning. Using them is to cause a branching off in the communication dynamics, which then brings about change in everyone in the session. One should not forget that a question can also change the one asking it, even if one has used a particular type of question hundreds or thousands of times. Questions are so embedded in the social and interactional everyday life that we mostly are not aware of them more than the microtasks we carry out when driving a car. The author has written elsewhere much more in-depth about the question as a communication pattern that can be a potent therapy tool.

Timeline

Patients with depression often spend a considerable amount of time ruminating about the past. Those who also suffer from anxiety may also ruminate about the future. What frequently gets lost is thinking about the present, even though that is the point-like interval of time which is the only one that is ever real. To avoid the reality of the present can be due to various reasons. The depression can make existence so unbearable that one escapes into a different ‘time zone’, and that it is not real may even be wished for in the hope that this also makes the pain less real.

The use of observations, feedback and questions can help the patient to stay in the patient. Several other communication patterns can also achieve this goal. Whenever a communication pattern leads to greater internal and external connectedness, it helps to anchor the patient more firmly in the now. However, this does not lead to more intense suffering because it is the disconnectedness that usually causes suffering. Patients with severe depression do not feel sadder, but they often feel nothing. Truly experiencing an emotion like sadness, when one feels ready for it and while being connected with others and oneself, can be an essential step in dealing with and overcoming a loss or other saddening event. And nothing can be as connectivity promoting as communication itself.

Getting Information

Questions help the patient in changing communication patterns. Still, they can also produce information, which lowers uncertainty, brings new insight or leads to something new in the world, which is enjoyable and improves the overall mood. Often, patients with depression return to the same thoughts or situations because they do not see alternative actions or ideas, which may be enjoyable and lead to a better mood.  Ruminations result not from too much but too little useful information, yet finding the right information again depends on communication patterns.

When things look at their darkest, and everything around seems empty like a desert, it helps be aware of all the meaningful information that is already easily accessible.  Connecting within oneself and others can lead to insights that help in countering the depressed rumination. A therapist’s task is to help the patient build communication patterns that are more effective towards connecting with oneself and others. Doing so allows a patient to find more meaningful information in places such as the own life experiences, which are a treasure trove of information. If I ask what is important to me and what I value, I just have to look at situations in the past and probe how I felt, what I thought and whether my actions and interactions in these situations benefitted me. One only has to be more open to information that can be helpful, and one aim in therapy is to help patients become better at this without fear.

Connecting

Communication patterns that help the therapist and patient connect in the session can also help the patient connect with others and with themselves. As already pointed out, the internal and external communication is a reflection of the other. The ability to communicate with the outer world also increases the ability to communicate better on the inside. Communication-Focused Therapy® supports patients in becoming more aware of, reflecting on, and experimenting with communication, which leads to the flexibility and openness in communication that is very effective against many forms of depression.

Communication patterns to facilitate connecting may again include questions and other communication patterns that enable the flows of meaningful information. Patterns may be repeating a modified message, providing information about a feeling or thought triggered in response to the patient’s communication, making an observation that offers a new perspective, and so forth. It is more than small talk because the therapeutic communication patterns not only test and build relationships but should also provide greater insight. The latter also includes insight into the communication patterns themselves.

Integration

By talking about the communication between patient and therapist it is possible to help the patient see how communication can be influenced and shaped so as to lead to new insights and to make new connections between pieces of information. This integration of different strands of information flows are important in helping the patient to feel more integrated as a whole. For example, talking about communication can help the patient to associate an image with emotions, which in turn may connect with past memories. This integration, however, requires that it is first possible to talk about these thoughts and feelings, and secondly that it is possible to talk about communication in ways which helps the patient to make associations between the different flows of information.

Analyzing Communication Patterns

The first important step in therapy is to create awareness for the flows of information, and their patterns. (Haverkampf, 2018c) These dynamics happen largely outside of consciousness, but they are not random. Rather, they are a result of biology and the internal and external communication experiences of an individual over time. Complex organisms receive, combine transform and send millions of bits of information in the smallest fraction of a microsecond. To navigate within this sea of information successfully is the primary objective of every organism, humans included. Health conditions in general are a result if these processes no longer work adequately. Mental health conditions often also include a significant impairment in the external communication between a person and the environment.

The human brain is in a particularly good position to work with information, and one objective of therapy should be to help it work better with information, whether this is coming from emotional signals, sensory organs, or retrieved from within the neural network itself. Communication processes and information can be made conscious. We might not be able to identify the information stored in a neuron, which would not anyway, because that information only makes sense within the context of the neural network. However, we can become aware of information stored in the neural network, even if it is a tiny detail or something that does not seem to fit into an existing pattern.

Particularly in interactions with other humans and other living organisms, communication patterns have evolved that facilitate the exchange of meaningful information in an efficient way. They need to be largely automatic, such as a gesture in response or a change of voice, and it may be even more distracting to follow them all, but it is possible to discern and work with some universal patterns. For example, the sequence of a specific type of question and a specific type of answer can be universal, such as the nod of a waiter signaling attention, followed by a guest using the palm of her hand and finger to scribble in mid-air, which indicates that she wants the bill. A complex business negotiation, however, would also use the basic communication element of question and answer and build it into more complex patterns. Spiraling negative thoughts in depression, on the other hand, also use otherwise adaptive communication elements, however, they do so in unhelpful communication patterns. The problem is not the ability to worry and think, but how this is done, the pattern, which is not constructive and unhelpful.

Emotional Signals

The emotional signals contained in a message are important because own emotions one becomes aware of can contain a lot of information. The brain uses a lot of information to form an emotion. To yield an emotion of sadness requires not only the information that a relationship has ended, but also the information about the relationship itself and potentially the relationships before, including information from interactions with one’s parents, and so forth. In a therapeutic setting, all this information can be helpful to adapt strategies, or to design new ones, and help the patient to integrate all this information into his or her life.

The communication between therapist and patient gives clues about thought patterns and beliefs, which affect how messages from others are interpreted and how own messages are assembled and communicated. It also helps to get an idea for how a patient constructs meaning. What someone sees as meaningful and relevant is largely determined by own needs and wants, but also past experiences. When the patient begins to form new communication patterns or adapts old ones, it is helpful to help in identifying patterns that have worked well for him or her in the past. Sometimes new ones have to be constructed from scratch, if a patient has been socially isolated for a while, for example. It is then useful to rely more on the therapeutic interaction as a model to train new communication patterns. In some patients who have suffered from depression for a long time with social isolation this may be necessary, but also important to maintain the patient’s motivation for the therapeutic work.

The importance of awareness is that it gives the patient a greater sense of hope and control when the depression causes hopelessness and despair. The journey patient and therapist take together in exploring and experimenting with communication in itself has a major antidepressant effect. It requires openness and insight which cannot be manualized. Communication has, however, universal rules which can be understood and worked with.

Motivation

Decreased motivation is a central symptom of depression which often makes therapy more difficult. It is no different in a communication focused approach. Experiencing what is possible in therapy can raise motivation significantly, but this requires at least some motivation to begin a therapy and makes it through the early stages. A communication focused approach may have the advantage here that it has material to work with from the time the therapist opens the door and makes eye contact with the patient. Another advantage on the motivational side is that a communication focused approach places emphasis on the interaction between patient and therapist, and thus the relationship, which helps to motivate the patient to wait and see what the therapy has to offer.

Insight into Communication

In many instances, reflecting on one’s communication patterns and strategies with oneself and others in concrete situations leads to insight about them. This is quite practical in nature. Observing communication patterns and trying out new ones is an important part of therapy. Since communication has different components one can focus on its components:

Person A

  • Selecting information for a message
  • Encoding the information in a message
  • Sending the message through a communication channel (using the speech system to say the words)

Person B

  • Receiving the message through a communication channel (using the auditory system)
  • Decoding the message into information
  • Processing the information further

One will observe quite often that a message it not received accurately. For example, one may say “the weather is nice today”, and the other person may interpret this as a signal that one wants to go on a hiking tour. The easiest way, of course, is to ask the other person again if one is in doubt. However, patients with depression or anxiety are less likely to get the full information.

The communication patterns a depressed patient uses may have served some function in the past, as they could have protected from some negative emotional consequence. However, in the present they no longer promote an optimal outcome, one that takes into account both the own needs, values and aspirations. On the other hand, it is also easy to see how awareness, reflection and experimentation with new communication patterns can resolve the problem, reduce the anxiety in A and lift the mood of B. That is what a communication-oriented therapy should do.

Maladaptive communication pattern can lead to the perception of more negative consequences and less meaning in the world. The former can be a filtering and interpretation deficit, the second often follows the first in the form of a disconnect or disengagement from the world. Insight does not have to lead to a change of current communication patterns, but in many cases also the development of new ones. In practice, this may also include considering situations which can facilitate better communication patterns, as the communication patterns one uses also depends on the communication patterns of the people one interacts with. This is also the basic dynamic when an individual is constantly exposed to other people who are stressed, anxious or depressed. Especially in infants and children who are still in the process of acquiring and forming communication patterns, an anxious parent, for example, can pass on some of the maladaptive communication patterns to the child. Depending on any helpful communication patterns already in memory and the effectiveness of autoregulatory processes, the child may adopt less of the maladaptive communication patterns than it might otherwise.

Observing and insight into internal and external communication patterns are both important. An individual suffering from depression is less likely to see messages as relevant and meaningful if the communication patterns that make up the feeling of being oneself have been compromised. The feeling of being oneself is itself the own observation of internal flows of information or communication. There is thus a strong link between internal and external communication patterns, which also explains how individuals can spiral into a vicious cycle of depression where engaging with the world can make the internal sense of dread and depression even greater, and vice versa. For example, a depressed person who pushes himself or herself to be more outgoing in a social situation often feels worse in the end.

Building the Sense of Self

Seeing relevance in a message requires knowing what one needs, wants, as well as one’s values and aspirations. In short, it means knowing some basic parameters about oneself. When the self becomes more meaningful, the motivation and desires to learn or try out something new, including therapy, increase. To give the sense of self texture requires awareness and identification of the own needs, values and aspiration, thereby attaching more subjectively perceived value to it.

The sense of self is awareness of certain communication flows in one’s own body. These information flows can be sensory, emotional or other signals from cognitive processes or from memory. This is the reason why internal and external communication patterns play such an important role for the sense of self because they influence these information flows. If a patient uses an external communication pattern which interferes with social exchanges, the information flow from the outside world in this respect will be reduced which has as effect on the sense of self. Thus, exposure to meaningful communication and improvements in communication can be very effective in treating the symptoms of depression. Negative perceptions of oneself are reduced and the interactions with the environment improve, which in itself has an antidepressant effect. As the moods lift concentration, focus and memory problems tend to decrease because things feel more relevant consciously and subconsciously.

Meaning

Individuals suffering from depression often see less meaning in the things they do. In therapy an important part is to rediscover meaning, and find it in the things that are relevant to the patient. Relevant is anything that is close to his or her values, basic interests, aspirations, wants, wishes and desires.

Meaning requires that one can decode a message and extract some novel information form it which can potentially lead to change within oneself, a new thought, state or emotional signal, for example, which can then also lead to a change in the world. Helping patients to reassess and readjust communication patterns can be particularly helpful in therapy because the resulting change in perceiving and thinking usually also leads to a change in perspective (Haverkampf, 2018d), which then in turn also lead to changes in thinking, feeling, acting and interacting.

Resonance

Resonance is when synchronicity or similarity leads to a potentiation of a signal or piece of information. In a therapeutic setting, resonance can be important because it identifies information that may be important or relevant. A depressed patient who has lost a grasp of what is potentially enjoyable and meaningful can rediscover it when resonance is detected. When the therapist becomes aware of resonance in how a patient is communicating about something, it is often helpful to point that out. If there is true resonance, the patient will usually acknowledge it quite quickly. In other cases, the therapist may also identify it as a projection of something that is important to the therapist only. But if the patient sees a resonance, it can be helpful in getting more insight into the own needs, values and aspirations.

Resonance is when new piece of information becomes more meaningful because of the information that is already present (Haverkampf, 2018a). The interaction between therapist and patient is meaningful to the patient if what is happening resonates with the values, basic interests or aspirations of the patient. In therapy, often the technique of the ‘fishhook’ (Haverkampf, 2010b) may be used. One asks the patient to describe life in general, such as the events of the weekend. The more the patient learns to work with resonance, the easier it will be for her to find insight in these everyday events by using an increasing volume of information effectively, including emotional signals, perceptions, cognitive thoughts and more.

In therapy, patient and therapist look for resonance because it is necessary for the communication of meaning, which brings about a change in the patient. Often resonance can only be guessed by either patient or therapist, and it takes some amount of communication to find resonance. A good starting point is listening to what the patient is communicating, since it reflects the information the patient already has, and which represents the foundation for resonance. The question “how was life yesterday?” or “what did you do yesterday?” can be more powerful than a complex intervention, because it can serve as the starting point to greater insight if one is aware of information resonance.

Depression makes old and new information, particularly emotional information, less accessible, which lowers any potential resonance. However, in many patients suffering from mild or moderate forms of depression accessibility may not be greatly reduced. Rather, it is a question of whether a patient can still believe there is ‘something’ below the unpleasant state. Resonance can help to rebuild a connection with interests, needs, values and aspiration, whose pursuit can be enjoyable, below a surface of depressed feelings. Reflecting with a patient on everyday activities can help to find spots of resonance. If the therapist then uses an inquisitive and interested communication pattern to get information on what about this activity is valued, needed or aspired to by the patient, the patient’s internalization of this pattern can help to form more adaptive communication patterns which can help against and prevent a depression.

Relevance

Depression makes everything seem less relevant as it reduces the spectrum of information that is available, including emotional signals. Less available information leads to less resonance, and thus less meaning which is extracted from messages form internal and external sources as well as less openness to new messages. Looking at a tree may, for example, not be as enjoyable anymore. The visual information about the tree still arrives in the brain as it always did, but the information stored in memory about the good feelings associated with a tree is tuned down. The actual tress has not changed, but it has become less relevant to the person.

Less relevance also means less focus, which could support an evolutionary explanation of depression. In times of stress, it can be helpful if one sees less relevance in the situation and withdraws. However, this may not feasible in the world we live in today. One cannot just leave one’s job form one day to the next. Rather, a common response to stress is often to work even harder, which can the lead into burnout. However, the more one thinks about relevance on a smaller level, the easier it becomes to adjust larger constructs, such as ‘one’s job’. As mentioned before, it is the details which help to identify one’s needs, values and aspirations. On the smaller scale, the brain reorients focus to task-relevant stimulus information. Egner and Hirsch showed that, in response to high conflict, cognitive control mechanisms enhance performance by transiently amplifying cortical responses to task-relevant information rather than by inhibiting responses to task-irrelevant information (Egner & Hirsch, 2005). This also shows that the brain focuses on picking out potentially relevant information rather than by suppressing non-relevant one. Of course, what is relevant is subjective to the individual, but it must be based on existing information about the needs of the individual, one’s internal state and the state of the world.

From a broader and more long-term perspective, relevance is a connection one has with things, people and situations. If something is relevant to what one needs, wants, values or aspires to, one is more likely to be open to information associated with it. If one values being in a relationship, for example, one is more likely to be receptive to messages from a partner, if they are seen as relevant to the maintenance of the relationship. Although, one may not have enough information to judge what is relevant, and therefore focus on the wrong messages, or one may not understand a message. All this can be remedied with better communication patterns which lead to better information, and exposure to meaningful communication.

Changing a situation or one’s perception of it requires taking stock of one’s needs, wants, values and aspirations and then to make a change. If one is working in a job which does not seem relevant to oneself, an option, aside from quitting and finding another one, is to assess if a change in the work or one’s perspective of it is possible that could align it more closely with one’s needs and wants. This can be worked out in therapy. But whatever action one takes, just the doing it already helps against depression.

In therapy, rebuilding relevance through new communication patterns which bring a different focus and more useful information changes how the own person and the world are seen. It also puts the focus on better sources of meaningful messages. For example, if a patient gains the insight that he values staying in touch with a particular group of friends because they share his interests, he is more likely not to decline a lunch invitation by someone who is a part of that group. At lunch, this friend may tell him then what the other members of the group have been up to, which may help the patient with his own career choices as he shares their interests. Raising the level of resonance, and thereby the relevance one sees in oneself, others, activities, things and so on, is very effective in the treatment of depression and other mental health conditions because it lets through more and better information to make better decisions and raises the mood as the world as a whole seems more meaningful now.

Communication Exchange

Meaning is built within the communication processes in the therapy. The interaction between two minds can give rise to a dynamic, which carries the flow of meaningful messages and brings the process forward. Motivation for the process is usually maintained if the messages feel relevant and meaningful to the patient in the present. If emotions or thoughts about the past are brought to the center of attention, they are important to the extent that they are still relevant in the present. This relevance depends on the emotions they can induce in the moment.

The exchange of messages can be influenced by both partners to the interaction. The depression can be felt by both, since it interferes with the construction and free flow of messages. As long as the therapist is open and receptive to the patient’s messages and tries to understand the communication dynamics and the patient sees the process as relevant, it can move forward. Since the patient and therapist have different neuronal networks and past communication (life) experiences they can induce change in each other through the communication of meaningful messages.

Integration

As change in the communication pattern occurs, the information flows within the individual also change. Since the self is a reflection on these communication flows, it can bring about a change in how a person experiences the own self. In the long run, the identified meaning is integrated into the self, which, depending on the meaningful information perceived, can make the self itself more meaningful and valuable. One derives meaning from interacting with oneself and with other people, and this is also how people build their sense of self. Thus, while personality stays largely constant, the sense of self can get a boost form exposing oneself to the right communication environment.

Values, Needs and Aspirations

Depression blurs what feels important to a patient, and the fit between values, needs and aspirations and the current life situation is usually reduced. Whether in professional or personal life, getting what one needs, values and aspires to makes happiness, contentment and satisfaction more likely in the long run. If I value helping people, I know what makes me happy and gives me satisfaction. Communication, whether internal or external, is the instrument, that makes individuals aware of these basic parameters and helps them to pursue them.

The basic parameters, values, needs and aspirations, change little over time. One may alternate between being hungry and not being hungry within hours but eating as a basic need does not change and nor does someone who is happy with being a vegetarian. To some extent these basic parameters seem to be built into our biology, and it is not the therapeutic task to change them but to arrange the world around in such a way as to be able to live one’s values, needs and aspirations. Working with and improving communication with oneself and others usually accomplishes that.

Internal Communication

Exploring interests, values, needs and wants requires becoming sensitive to one’s own thoughts, emotions and physical sensation, to be open and receptive to the information coming in from one’s body and mind. It is about feeling what makes one feel good and what does not. At the same time, it has to make sense and should fit together. If specific values and needs appear to be in conflict with each other, a combination of emotions and rational thinking is often helpful. For a depressed patient, this may not be an easy task, but to bring more structure and sense into a seemingly chaotic and disconnected world, can be helpful.

Internal communication can be practiced in therapy. Since there is a correlation between the communication with others and one’s own internal communication, rehearsing and going through communication patterns in therapy, is often helpful to the patient outside of therapy, not only for the interactions with others, but also for the interaction with oneself. Values and needs can be clarified by talking to someone else and engaging in soul searching on one’s own. An important experience in therapy should be that one can clarify one’s needs and values by reflecting and communicating about them.

Meaningful Messages as the Instrument of Change

Communication in its various forms needs to be the target of therapy because it can be fined tuned and a change here can bring lasting change. The author has described this elsewhere (Haverkampf, 2017a, 2018b) Communication-Focused Therapy has been developed by the author for several psychiatric conditions. (Haverkampf, 2017f, 2017b, 2017d, 2017c, 2017g, 2017h). In depression, the desired change is for a broader emotional experience, seeing more relevance in oneself, one’s thoughts, emotions, and in the world as a whole. Adjusting, discarding and forming new communication patterns can lead to a reduction in symptoms that is more permanent than techniques the focus less on communication.

The actual instrument of change are the meaningful messages which, provided they are encoded, sent and decoded, induce the change. As information in a message resonates and is processed with the already existing information, meaning is created which leads to changes in the future.

Broader Experience

If there is more meaning in oneself and the world, it is easier to focus on aspects of oneself and of the world. This expands one’s experience of oneself and of the world around. Seeing more relevance and more sources of novelty and change in the world, increases one’s experience of the world and makes this experience richer. However, it also requires that one engages with the world, which may be difficult due to anxiety cause by fears and other unresolved emotions. However, working with communication early in the therapeutic process often reduces any anxiety quickly as the patient learns to become aware of and experiment with communication and appreciates and gains insight into the predictability of communication.


Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. You can reach author by email at jonathan@jonathanhaverkampf.com or on the websites www.jonathanhaverkampf.com and www.jonathanhaverkampf.ie.

 

 

References

Bibring, E. (1953). The mechanism of depression.

Delle-Vigne, D., Wang, W., Kornreich, C., Verbanck, P., & Campanella, S. (2014). Emotional facial expression processing in depression: Data from behavioral and event-related potential studies. In Neurophysiologie Clinique (Vol. 44, Issue 2, pp. 169–187). Elsevier Masson SAS. https://doi.org/10.1016/j.neucli.2014.03.003

Egner, T., & Hirsch, J. (2005). Cognitive control mechanisms resolve conflict through cortical amplification of task-relevant information. Nature Neuroscience, 8(12), 1784–1790. https://doi.org/10.1038/nn1594

Ehring, T., & Watkins, E. R. (2008). Repetitive Negative Thinking as a Transdiagnostic Process. International Journal of Cognitive Therapy, 1(3), 192–205. https://doi.org/10.1521/ijct.2008.1.3.192

Givertz, M., & Safford, S. (2011). Longitudinal Impact of Communication Patterns on Romantic Attachment and Symptoms of Depression. Current Psychology, 30(2), 148–172. https://doi.org/10.1007/s12144-011-9106-1

Haverkampf, C. J. (2010a). A Primer on Interpersonal Communication (3rd ed.). Psychiatry Psychotherapy Communication Publishing Ltd. https://jonathanhaverkampf.com/books/

Haverkampf, C. J. (2010b). Communication and Therapy (3rd ed.). Psychiatry Psychotherapy Communication Publishing Ltd. https://jonathanhaverkampf.com/books/

Haverkampf, C. J. (2010c). Depression Mania and Communication (3rd ed.). Psychiatry Psychotherapy Communication Publishing Ltd.

Haverkampf, C. J. (2012). Feel! (1st ed.). Psychiatry Psychotherapy Communication Publishing Ltd. https://jonathanhaverkampf.com/books/

Haverkampf, C. J. (2013). A Case of Depression. J Psychiatry Psychotherapy Communication, 2(3), 88–90.

Haverkampf, C. J. (2017a). Communication-Focused Therapy (CFT) (2nd ed.). Psychiatry Psychotherapy Communication Publishing Ltd. https://jonathanhaverkampf.com/books/

Haverkampf, C. J. (2017b). Communication-Focused Therapy (CFT) for ADHD. J Psychiatry Psychotherapy Communication, 6(4), 110–115.

Haverkampf, C. J. (2017c). Communication-Focused Therapy (CFT) for Anxiety and Panic Attacks. J Psychiatry Psychotherapy Communication, 6(4), 91–95.

Haverkampf, C. J. (2017d). Communication-Focused Therapy (CFT) for Bipolar Disorder. J Psychiatry Psychotherapy Communication, 6(4), 125–129.

Haverkampf, C. J. (2017e). Communication-Focused Therapy (CFT) for Depression. J Psychiatry Psychotherapy Communication, 6(4), 101–104.

Haverkampf, C. J. (2017f). Communication-Focused Therapy (CFT) for OCD. J Psychiatry Psychotherapy Communication, 6(4), 102–106.

Haverkampf, C. J. (2017g). Communication-Focused Therapy (CFT) for Psychosis. J Psychiatry Psychotherapy Communication, 6(4), 116–119.

Haverkampf, C. J. (2017h). Communication-Focused Therapy (CFT) for Social Anxiety and Shyness. J Psychiatry Psychotherapy Communication, 6(4), 107–109.

Haverkampf, C. J. (2017i). Questions in Therapy. J Psychiatry Psychotherapy Communication, 6(1), 80–81.

Haverkampf, C. J. (2018a). A Primer on Communication Theory. https://jonathanhaverkampf.com/books/

Haverkampf, C. J. (2018b). Communication-Focused Therapy (CFT) – Specific Diagnoses (Vol II) (2nd ed.). Psychiatry Psychotherapy Communication Publishing Ltd. https://jonathanhaverkampf.com/books/

Haverkampf, C. J. (2018c). Communication Patterns and Structures.

Haverkampf, C. J. (2018d). Fear, Social Anxiety and Communication (3rd ed.). Psychiatry Psychotherapy Communication Publishing Ltd.

Kholodenko, B. N. (2006). Cell-signalling dynamics in time and space. Nature Reviews Molecular Cell Biology, 7(3), 165–176. https://doi.org/10.1038/nrm1838

Purnick, P. E. M., & Weiss, R. (2009). The second wave of synthetic biology: from modules to systems. Nature Reviews Molecular Cell Biology, 10(6), 410–422. https://doi.org/10.1038/nrm2698

Rimes, K. A., & Watkins, E. (2005). The effects of self-focused rumination on global negative self-judgements in depression. Behaviour Research and Therapy, 43(12), 1673–1681. https://doi.org/10.1016/J.BRAT.2004.12.002

Santor, D. A., Bagby, R. M., & Joffe, R. T. (1997). Evaluating stability and change in personality and depression. Journal of Personality and Social Psychology, 73(6), 1354–1362. https://doi.org/10.1037/0022-3514.73.6.1354

This article is solely a basis for academic discussion, and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition. Neither author nor publisher can assume any responsibility for using the information herein.

Communication-Focused Therapy and CFT are registered trademarks. Other trademarks belong to their respective owners. No checks have been made.

This article has been registered with the U.S. Copyright Office. Unauthorized reproduction, distribution and/or publication in any form is prohibited. Copyright will be enforced.

© 2017-2020 Christian Jonathan Haverkampf. All Rights Reserved

Unauthorized reproduction, distribution and/or publication in any form or medium is prohibited.

Therapy of Social Anxiety Disorder (5)

Therapy-of-Social-Anxiety-Disorder-5-Christian-Jonathan-Haverkampf-psychotherapy-series

Therapy of Social Anxiety Disorder

Christian Jonathan Haverkampf, M.D.

Social anxiety disorder can significantly reduce an individual’s choices in life and the quality of life overall. Since communication is the process by which humans fulfil their needs, values and aspirations, its effectiveness is important for satisfaction, contentment and happiness in life. It is the main autoregulatory instruments, also in the psychotherapeutic process, to promote mental health. If interpersonal communication is interfered with by anxiety, these processes can no longer work effectively. As the individual withdraws further, the capabilities for needs fulfilment and autoregulation decline further.

Focusing on interpersonal and intrapersonal communication patterns can help to reverse the vicious cycle of social anxiety. Communication-Focused Therapy® (CFT®) provides a toolset, methodological and theoretical framework to facilitate the awareness for individual communication patterns and the interventions to improve them in line with the patient’s needs, values and aspirations.

Keywords: social anxiety, communication-focused therapy, CFT, CBT, psychodynamic psychotherapy, treatment, psychotherapy, psychiatry

Contents

Introduction. 4

Self-Image. 4

External Image. 5

Focus. 5

Experiencing the Interaction. 6

Transparency. 6

Habituation. 7

Social Network. 7

Social Exclusion. 7

Hierarchies. 8

Technology. 8

Symptoms. 9

Measurement 9

Neurobiology. 9

The Amygdala. 9

Identity. 10

‘Lost Opportunities’ 11

Judgment 11

Location. 11

Treatment 12

Cognitive-Behavioral Therapy (CBT) 12

Psychodynamic Psychotherapy. 13

Mindfulness-based stress reduction (MBSR) 13

D-Cycloserine. 13

Communication-Focused Therapy® (CFT®) 13

Introduction. 14

Communication as Autoregulation. 14

Communication Patterns. 14

Attention. 15

Communication to Participate in Life. 15

Understanding Social Anxiety and Shyness. 15

Internal Communication. 16

Uncertainty. 16

Communication Deficits. 16

Avoidance. 17

Meaning. 17

Awareness of Thought Patterns. 17

Flow of Information. 18

Emotional Reconnection. 18

Experiencing the World. 18

Communication Techniques. 19

Breaking the Cycle of Anxiety. 19

The Reward of Seeing More. 20

Values, Needs and Aspirations. 20

The Need for Communication. 20

Meaningful Messages as the Instrument of Change. 21

Embracing Change. 22

Living. 23

References. 24

Introduction

A person suffering from social anxiety disorder feels unwell in social situations and begins to avoid them, which can not infrequently lead to significant problems in daily life. Social anxiety is more than just shyness. According to ICD-10 guidelines, the main diagnostic criteria of social anxiety disorder are fear of being the focus of attention, or fear of behaving in a way that will be embarrassing or humiliating, avoidance and anxiety symptoms. (World Health Organization, 1992) The prevalence of 12-month and lifetime prevalence of social anxiety disorder is around 3% and 5%, respectively. (Grant et al., 2005) It is the most common anxiety disorder; it has an early age of onset—by age 11 years in about 50% and by age 20 years in about 80% of individuals—and it is a risk factor for subsequent depressive illness and substance abuse. (Stein & Stein, 2008) In a study by La Greca and Lopez on adolescents, girls reported more social anxiety than boys, and social anxiety was more strongly linked to girls’ social functioning than to that of boys. Girls with higher levels of social anxiety reported fewer friendships, and less intimacy, companionship, and support in their close friendships. (La Greca & Lopez, 1998)   Social anxiety disorder is also sometimes referred to as social phobia.

Functional neuroimaging studies point to increased activity in amygdala and insula in patients with social anxiety disorder, and genetic studies are increasingly focusing on this and other (e.g., personality trait neuroticism) core phenotypes to identify risk loci. (Stein & Stein, 2008) There are several psychological and psychopharmacological treatments (Haverkampf, 2017h) available. Communication-Focused Therapy® (CFT®) as developed by the author is an approach that targets the processes and patterns which are underlying interpersonal interactions. (Haverkampf, 2013, 2017a, 2018f)

Self-Image

The sense of a stable self-image plays an important role in lowering social anxiety. The more confident one is oneself, and thus the more one is connected with oneself in a meaningful way, the lower the anxiety will be in interpersonal or social situations. Having a good and stable self-image requires connection with oneself, the ability to be open and receptive to information that originates within oneself, other than the information that is received from the external world through the sense, for example. Even though the distinction between the internal and the external maybe somewhat artificial, it is important to acknowledge that there are sources of information which are not in the external world. In some psychiatric conditions, such as in psychosis, this distinction between the external and the internal can get lost with potentially severe consequences.

How the internal self-image can affect the communication with others has been demonstrated by Hirsch and colleagues. One group was asked to hold in mind a negative self‐image, while the other held in mind a less negative (control) self‐image. When holding the negative image, the socially anxious volunteers felt more anxious, reported using more safety behaviors, believed that they performed more poorly, and showed greater overestimation of how poorly they came across (relative to ratings by the conversational partner). Conversational partners rated the socially anxious volunteers’ performance as poorer in the negative image condition. Furthermore, both groups of participants rated its quality as poorer in the negative image condition. (Hirsch et al., 2004)

External Image

Social anxiety arises when individuals are motivated to make a preferred impression on real or imagined audiences, such as when one tries to portray an image to others one believes others want to see, or where a person believes there is an external benefit to making oneself appear with certain characteristics. This is inextricably linked to the fear that just being oneself is not good enough, that one will be judged in unpredictable and possibly harsh ways by everyone or a defined group of others.

The cognitive state of the individual can mediate both affective arousal and behavior. (Schlenker & Leary, 1982) At the same time, external factors within the environment can have an effect on how an individual thinks and feels in a given situation, which is also influenced by individual predispositions and traits. In clinical experience, the more an individual tries to adhere to portraying an external image that is believed to be required by external factors and other people, but which does not match with the individual’s communication styles and personality traits, needs, values and aspirations, the less stable the interaction will become, leading to more anxiety and a mutually less satisfying experience. (Haverkampf, 2010a, 2013)

Focus

When it comes to the important role of information dynamics in the epigenesis of social anxiety, focus is an important mediator because it selects the information that becomes available in an interaction. Since all forms of anxiety arise from a deficit of meaningful information or unhelpful ways of processing it, social anxiety can be improved by helping a patient to learn more helpful ways in selecting and focusing on particular types of information.

Socially anxious individuals are excessively concerned about negative evaluation by others. And they often focus more on threat cues or imagined threat cues. In a study by Mansell and colleagues, high socially anxious individuals when compared to low socially anxious individuals showed an attentional bias away from emotional (positive and negative) faces when under conditions of social-evaluative threat. (Mansell et al., 1999) As discussed above, this leads to a situation where less information is available to the socially anxious person, which does not help mitigate the social anxiety.

Socially-anxious individuals also have an increased number of negative cognitions and fewer positive cognitions, while situational factors appear to mediate the absolute level of reactivity. (Beidel et al., 1985) This probably turns the focus even more away from sources of information which could lead to a reduction in the anxiety, resulting in a vicious cycle in which social withdrawal and more negative interpretation of interpersonal interactions and the environment overall leads to even more social withdrawal. In Communication-Focused Therapy® this cycle can be broken by working on the communication patterns the individual uses, which are the structural entities that facilitate the information flow to him or her.

Experiencing the Interaction

Many people who are suffering from social anxiety are familiar with the feeling of continuously asking themselves what other people are thinking about them. In one study, anxious subjects were more likely to attribute more meaning to others’ thoughts. (Hezel & McNally, 2014) The same study interestingly also found that socially anxious individuals performed worse on theory of mind tasks. Theory of mind is the ability to attribute mental states — beliefs, intents, desires, emotions, knowledge, etc. — to oneself and to others. It is necessary to understand that others have beliefs, desires, intentions, and perspectives that are different from one’s own. In other words, to fully appreciate the separate mind of another person with its unique content and information processing requires a theory of mind, which seems impaired in individuals with social anxiety. However, to fully reflect on the information dynamics and communication patterns within an interaction it is important to have a basic working concept of an “I” and a “You”. Communication-Focused Therapy® also includes techniques aimed at strengthening this distinctions. (Haverkampf, 2017a, 2017e)

A person suffering from social anxiety takes great pains to not only try to follow the dynamics of an interaction but at the same time to interpret what the partners to an interaction are thinking and feeling about them. While individuals with social anxiety are often quite perceptive and sensitive to various channels of information, this can lead to an information overload, which as a result makes them turn away from the interaction, which increases the anxiety even to a higher level. Communication-Focused Therapy® attempts to reverse this vicious cycle by developing awareness for communication patterns and information flows and practicing communication in a way that leads to fulfilment of own needs, values and aspirations, which also lowers the anxiety.

Transparency

Being able to give oneself permission to practice greater openness in communicating with others is an important step towards overcoming social anxiety. The feedback and information from others help to lower the anxiety as others’ dreaded thoughts turn out to be untrue. However, many people suffering from social anxiety already believe that they are overly transparent to others, that others can see what they are thinking and feeling, such as the anxiety or negative feelings, such as anger or frustration, which could interfere with the social bond from the interaction. As the distinction between the inside and outside worlds of the mind are weaker, the socially anxious person tries even harder to control themselves. Individuals with social anxiety are often quite sensitive, but their interpretation of information is often more on the negative side. Depression with anxiety can mask as the ‘pure’ social anxiety disorder.

Interesting is that studies suggest that socially anxious individuals remember more negative memories than those less distressed. This may either have a biological explanation or be a learned phenomenon. However, since social anxieties do seem to run in families at least partially, there may be a biological explanation to it.  A 2006 study found that the area of the brain called the amygdala, part of the limbic system, is hyperactive when patients are shown threatening faces or confronted with frightening situations. They found that patients with more severe social phobia showed a correlation with the increased response in the amygdala.

Habituation

Habituation is the process by which through a ‘getting used’ to an anxiety or fear inducing stimulus the psychological and physical reaction to it decreases. One becomes less anxious or fearful in the face of information that otherwise induced anxiety or fear, such as the visual input that one is looking out high up on a tall building, if one exposes oneself repeatedly to the information. Social anxiety involves social cues that can induce anxiety. The latency at which habituation occurs, however, seems to be different in individuals that are suffering from social anxiety. (Beidel et al., 1985)

From the perspective of Communication-Focused Therapy® (CFT), any information that is repetitive and has lost its characteristics of novelty will lead to a lesser response, whether in terms of feelings, emotions, thoughts or otherwise. Thus, the internal and external context matters whether habituation will take place. One may reach habituation in one type of situation and when experiencing a particular family of thoughts and perceptions, but conventional behavioural and cognitive methods in the form of CBT, for example, often lead to improvements that are limited in time and circumstance. However, changing one’s exposure to meaningful information, that is information which brings about a change in the recipient, through changes in communication patterns, can be highly effective. Changes in communication patterns also have a longer-lasting effect because the flow of information is permanently altered. CFT works to adjust the communication patterns in the session through awareness, reflection, experimentation and change. It is not primarily the change in perspective or learning new thought patterns that bring about change but changes in communication patterns that determine them through the information they make available, and how information is processed. (Haverkampf, 2010b, 2017a) Practising new communication patterns in the therapeutic session usually shows a significant over time with respect to anxiety, but also anxiety in general.

Social Network

Various aspects of social relations uniquely contribute to feelings of internal distress. In a study by La Greca and Harrison with adolescents, crowd affiliations (high and low status), positive qualities in best friendships, and the presence of a dating relationship protected adolescents against feelings of social anxiety, whereas relational victimization and negative interactions in best friendships predicted high social anxiety. In contrast, affiliation with a high-status peer crowd afforded some protection against depressive affect; however, relational victimization and negative qualities of best friendships and romantic relationships predicted depressive symptoms. (La Greca & Harrison, 2005)

Social Exclusion

Baumeister and Tice’s social exclusion theory of anxiety proposes that a primary source of anxiety is perceived exclusion from important social groups. The relationship between perceived social exclusion and social anxiety, jealousy, loneliness, and depression. Self-esteem can moderate reactions to perceived exclusion. (Leary, 1990) Relationships are expectations of future communication (Haverkampf, 2018c), and not being part of a web of communication increases anxiety. One of the reasons is that living organisms fulfil their needs, and in the case of humans also their values and aspirations, through communication, the exchange of meaningful information with others (Haverkampf, 2010a). Not just the shared reality, but even only the imagined reality can lead to significant anxiety.

Hierarchies

Social rank theory (Price and Sloman, 1987; Gilbert, 1989, 1992) argues that emotions and moods are significantly influenced by the perceptions of one’s social status or rank; that is the degree to which one feels inferior to others and looked down on. A common outcome of such perceptions is submissive behavior. Gilbert showed in a study that shame, social anxiety and depression (but not guilt) are highly related to feeling inferior and to submissive behavior. (Gilbert, 2000) Since these feelings develop from the workings of communication patterns as they determine the information that will ultimately reach various centers of the brain (Haverkampf, 2018c), an adjustment to these communication patterns changes feelings that can be associated with social anxiety. Especially with feelings that have a strong social context, such as shame, changes in communication patterns with the help of a therapeutic seeting can be very helpful. Shame is a result of internal and external communication patterns that are being used, while communication patterns can be influenced by a feeling of shame. Important is to remember that work with any communication pattern can be used to change the whole vicious cycle. (Haverkampf, 2017d, 2017a)

Technology

Increasing the number of available communication channels, such as adding communication via the Internet, can in theory help reduce the sense of isolation rather than increasing it. However, this has been hotly discussed. A study by Caplan supports the hypothesis that the relationship between loneliness and preference for online social interaction is spurious, and that social anxiety is the confounding variable. (Caplan, 2007) Communication means offered by the Internet are tools to interact with humans or human-designed programs in a meaningful way. It depends on what the individual makes out of them. How much one can use a technology to one’s advantage depends on the use of the right communication patterns and an insight into the own basic parameters, including one’s needs, values and aspirations. (Haverkampf, 2017f)

A ‘reduced channel’ communication offered, for example, by online chats or social networks may make it easier for a person suffering from social anxiety to connect with others, but to do in a less anxiety provoking and non-threatening way. As long as it is seen as steps on the way towards overcoming the social anxiety and adding more channels of communication, according to the individual needs, preferences and aspirations, it can be even helpful. For many people suffering from social anxiety the step from no communication to full interpersonal interaction in subjectively experienced high stakes settings can be too high. Online dating platforms, for example, can make it possible for people to go on dates who would otherwise never been able to do so.

Symptoms

Social anxiety often leads to physical symptoms that can worsen the vicious cycle of trying not to appear nervous and anxious, but by ‘fighting’ to do so the nervousness and anxiety just keep on getting worse. In adults, feelings of social anxiety may be associated with tears, blushing, excessive sweating, nausea, difficulty breathing, shaking, and palpitations. They are somatic manifestations, though often experienced much more intensely subjectively than observed objectively, of the fight-or-flight-response, which is largely hardwired into our brains. Since as we have discussed previously, social success is as much a matter of survival as finding food or warding off an attacker, anything that seems to interfere with it can lead to negative emotional states, such as anxiety.

Research suggests that socially anxious individuals interpret ambiguous social information in a more threatening manner compared to non-anxious individuals. It has even been shown that experimentally modifying interpretation in non-anxious individuals affected their anxiety. (Beard & Amir, 2008) Since how information is interpreted depends on external communication channels and on how the information is communicated internally, the techniques of Communication-Focused Therapy work with communication patterns to affect a change. As external and internal communication patterns reflect each other (Haverkampf, 2010a, 2010b, 2017a), the work on communication patterns in therapy has a direct effect on the internal information processing that leads to and maintains social anxiety.

Measurement

The clinically most commonly used questionnaire to assess social anxiety is the Liebowitz Social Anxiety Scale (LSAS). The LSAS has been empirically shown to be a reliable, valid and treatment sensitive measure of social phobia. (Heimberg et al., 1999) It lists a variety of different situations and asks to rate for anxiety and avoidance. This practical orientation is very helpful because it leads to greater insight into the underlying motives of the anxiety. For example, if the contexts of the anxiety provoking situations have in common that they are more of an interpersonal nature with people that are familiar (or strangers), awareness of it can lead to greater understanding of possible underlying causes. People adapt particular communication patterns as a reaction to the perceived need to manage interpersonal dynamics.

Neurobiology

The Amygdala

The amygdala is often implicated in social anxiety and the processing of social threats. In a quantitative meta-analysis, Etkin and Wager compared functional magnetic resonance imaging and positron emission tomography studies of posttraumatic stress disorder (PTSD), social anxiety disorder, specific phobia, and fear conditioning in healthy individuals. Patients with any of the three disorders consistently showed greater activity than matched comparison subjects in the amygdala and insula, structures linked to negative emotional responses. Hyperactivation in the amygdala and insula were, of interest, more frequently observed in social anxiety disorder and specific phobia than in PTSD. Only patients with PTSD, on the other hand, showed hypoactivation in the dorsal and rostral anterior cingulate cortices and the ventromedial prefrontal cortex—structures linked to the experience and regulation of emotion. (Etkin & Wager, 2007)

Amygdala activation to interpersonal threat has been linked to the severity of social anxiety symptoms. Phan and colleagues examined in a study the association between response to emotionally harsh faces in the amygdala and severity of social anxiety symptoms in patients with generalized social phobia. Relative to happy faces, activation of the amygdala in response to harsh (angry, disgusted, fearful) faces was greater in the patients than in controls, and the extent of amygdala activation was positively correlated with severity of social anxiety symptoms, but not general state or trait anxiety levels. (Phan et al., 2006)

However, it needs to be remembered in this context that information is stored in many areas of the brain which all contribute to the signals that then flow through and are integrated, compared, subtracted and processed in specific areas like the amygdala. (Haverkampf, 2018g) Thus, to understand the complexity, and at the same time simplicity of social anxiety one also needs to look at the actual communication patterns an individual uses, externally and internally, and how information is received, selected for, transported and stored. Meaning

Identity

An important question is why I as a socially anxious person feel as the center of attention if it is not what I want, or is it? Many people with social anxieties actually want to have good relationships and are often fond of people. The problem is how they see themselves or that in many cases they cannot really see who they are. Sometimes there may also be an ambivalence in one’s relationship with people, which might be a result of personal life experiences or some unresolved conflicts from another source.

The search for identity lies at the heart of any form of social anxieties. Often, if some fundamental questions about oneself can be answered the social anxiety decreases. Basic parameters are:

  • Needs
  • Values
  • Aspirations

(Haverkampf, 2018h)

An important method in therapy to have the client imagine a situation and run through it. This helps break down the distinction between reality and the imagined world. Many people suffering from social anxieties are very sensitive, which also contributes to the symptoms. Physical symptoms often include excessive blushing, excess sweating, trembling, palpitations, and nausea. There may even be stammering and rapid speech. Panic attacks can also occur under intense fear and discomfort.

Many people with social anxieties have difficulties imagining the future because it is too painful. Here it helps to identify emotions and feeling that underlie the negative thoughts. Often the tensions and anxieties have underlying processes that need to be identified.

People with social anxiety often set high standards for themselves for social situations. Since they believe they cannot reach these standards they have a lot of negative thoughts about how they do in those situations and the outcomes. The sense of failure can be reinforced in the situation by very minor mishaps, such as a stutter or notices sweating. This leads to even greater self-consciousness and the likelihood actually of sweating or stuttering increases. Anxiety can increase to panic attacks.

‘Lost Opportunities’

It is also important to deal with the losses patients subjectively think they have incurred as a result of their social anxiety. People avoid situations where the social anxieties cause the symptoms. In more severe cases this can mean that the individual has no romantic relationships and does not take up jobs that could be interesting and enjoyable. Here the first step it to acknowledge the problem and realize that while one may not have done the preferred choice in the moment, social anxiety is often a problem of not knowing what one really wants. Finding this out can be a tremendous chance.

Judgment

The sense of being judged is quite common in social anxiety disorder. The judgment by others gets a relatively high significance. People with social anxieties can be very competitive in professional or academic situations. It seems easier to believe the judgment of others. The combination of a greater focus on oneself, being more alert to anything other people may see or perceive, and reduced trust in oneself and others frequently gives rise to the fear of being judged. If there is a greater disconnect from oneself and others, this can cause additional problems and potentially more anxiety.

There is a perceived need for a more complete control of one’s external communication, out of fear that the connection with the world could be lost, but this sought-after control by necessity also has to extend then to the internal communication, which destabilizes further can causes additional anxiety. The ultimate fear in social anxiety is not of social situations per se, but that connections and relationships could be lost forever. Fears of loss of relationships and loss of control is often at the heart of social anxiety. Helping people with social anxiety means exploring new ways of communicating, so that they learn that communication and relationships are in their essence quite predictable and stable.

Location

The setting can also play a problem and may be worthwhile to thematize. Instead of making a new friend at a bar, a person with social anxiety might find this task easier to accomplish via an online friendship or dating site. As patients develop a greater understanding of their wants, needs and aspirations, they also develop a better understanding of how they interact and communicate with their environment in ways that are more helpful, more efficient and better suited to their own needs and personality.

Treatment

he most well-researched psychosocial treatments for social anxiety disorder are cognitive-behavioral therapies (CBTs). However, there are several other therapeutic approaches which have shown promising in the treatment of social anxiety disorder. There are also various psychopharmacological approaches which demonstrate effectiveness.

Medication can help. From clinical experience the selective serotonin reuptake inhibitors (SSRIs), such as be helpful, particularly in the form of selective serotonin reuptake inhibitors (SSRIs) or sometimes serotonin norepinephrine reuptake inhibitors (SNRIs) if needed over a longer interval. Selective Serotonin Inhibitors (SSRIs) are often used in generalized social anxiety disorders, if psychotherapy does not help fast enough or as a support. Historically, paroxetine and fluoxetine have often been used, but newer SSRIs, such as escitalopram, seem also to work. In clinical experience, some people benefit significantly from SSRIs, while others do not. One explanation is that it depends on the presence of other symptoms and psychiatric disorders, as well as how generalized the symptoms are, or how specific they apply to certain situations. Overall, there can be many different reasons, especially psychodynamic ones, that make up this diverse diagnosis, and they need to be carefully explored to increase the chances of therapeutic success.

Cognitive-Behavioral Therapy (CBT)

Meta-analyses indicate that all forms of CBT appear likely to provide some benefit for adults. (Rodebaugh et al., 2004) On the behavioral side, exposure therapy, for example, involves exposing the patient to anxiety invoking interpersonal situations in a gradual fashion, beginning with less anxiety provoking scenarios, and moving up to the ones to which a greater level of potential anxiety is attached. Research suggests that anxious individuals show deficits in the mechanisms believed to underlie exposure therapy, such as inhibitory learning. (Craske et al., 2014) Exposure optimization strategies include the following:

  1. expectancy violation
  2. deepened extinction
  3. occasional reinforced extinction
  4. removal of safety signals
  5. variability
  6. retrieval cues
  7. multiple contexts
  8. affect labeling.

(Craske et al., 2014)

On the cognitive side, other techniques commonly used in CBT are to reflect on the negative thoughts and ruminations in interpersonal situations, identify unhelpful beliefs and biases, make more realistic probability estimates and use other more or less structured thought processes. The cognitive approach focuses mainly on intrapersonal rather than interpersonal processes. (Stangier et al., 2011)

Psychodynamic Psychotherapy

In a large multicenter study Leichsenring and colleagues used a manual-guided form of psychodynamic therapy that was specifically developed for their trial. (Leichsenring et al., 2013) It was based on Luborsky’s model of psychodynamic therapy, including supportive and expressive interventions. A secure helping alliance is an important element of the model. Expressive interventions relate the symptoms of social anxiety disorder to the patient’s underlying core conflictual relationship theme, such as a wish, an anticipated response and a response from the self, in order to reduce the symptoms of social anxiety disorder. (Leichsenring et al., 2013) The response from the self represents the symptoms of social anxiety disorder. The core conflictual relationship theme is worked through in present and past relationships as well as in the relationship to the therapist. (Leichsenring et al., 2013)

Mindfulness-based stress reduction (MBSR)

Mindfulness-based stress reduction (MBSR) has shown in several studies to reduce symptoms of stress, anxiety, and depression. MBSR is believed to alter emotional responding by modifying cognitive–affective processes. Since social anxiety disorder is characterized by emotional and attentional biases as well as distorted negative self-beliefs, this can be a helpful approach. MBSR training in patients with social anxiety disorder may reduce emotional reactivity while enhancing emotion regulation.

Goldin and Gross examined MBSR-related changes in the brain–behavior indices of emotional reactivity and regulation of negative self-beliefs in patients with social anxiety disorder. Compared with baseline, MBSR completers showed improvement in anxiety and depression symptoms and self-esteem. During the breath-focused attention task, they also showed decreased negative emotion experience, reduced amygdala activity, and increased activity in brain regions implicated in attentional deployment. (Goldin & Gross, 2010)

D-Cycloserine

Clinical data with specific phobias has suggested that the treatment effects of exposure therapy for SAD may be enhanced with D-cycloserine, an agonist at the glutamatergic NMDA receptor, and its use has been suggested for social anxiety disorder. In a study by Hofmann and colleagues, patients receiving D-cycloserine in addition to exposure therapy reported significantly less social anxiety compared with patients receiving exposure therapy plus placebo. Controlled effect sizes were in the medium to large range. (Hofmann et al., 2006)

Communication-Focused Therapy® (CFT®)

Communication-Focused Therapy (CFT) was developed by the author to focus more specifically on the communication process between patient and therapist. The central piece is that the sending and receiving of meaningful messages is at the heart of any change process. CBT, psychodynamic psychotherapy and IPT help because they define a format in which communication processes take place that can bring about change. However, thy do not work directly with the communication processes. CFT attempts to do so.

Introduction

We engage constantly in communication. The cells in our bodies do so with each other using electrical current, molecules, vibrations or even electromagnetic waves. People communicate with each other also through a multitude of channels, which may on several technologies and intermediaries. It does not have to be an email. Spoken communication requires multiple signal translations from electrical and chemical transmission in the nervous system to mechanical transmission as the muscles and the air stream determine the motions of the vocal cords and then as sound waves travelling through the air, followed by various translations on the receiving end. At each end, in the sender and in the receiver, there is also a processing of information which relies on the highly complex networks of the nervous system. Communication, in short, happens everywhere all the time. It is an integral part of life.

Communication as Autoregulation

Communication is an autoregulatory mechanism. It ensures that living organisms, including people, can adapt to their environment and live a life according to their interests, desires, values, and aspirations. This does not only require communicating with a salesperson, writing an exam paper or watching a movie, but also finding out more about oneself, psychologically and physically. Whether measuring one’s strength at the gym or engaging in self-talk, this self-exploration requires flows of relevant and meaningful information. Communication allows us to have a sense of self and a grasp of who we are and what we need and want in the world, but it has to be learned similar to our communication with other people.

If one suffers from social anxiety, this autoregulation seems to fail. One reason why it fails is because communication is such an important and basic process that there is nothing that could hierarchically control it and put a problem in it right. Only changes in communication can put a communication failure right. This is why a therapy that focuses on communication by identifying communication patterns and reflecting on them is in a good position to treat social anxiety.

Communication Patterns

Communication patterns are sequences in which meaningful information flows between individuals who are interacting with each other. A question in one person leading to an answer in another person is an example, which also illustrates how one communication pattern gives rise to another one. Communication patterns exist as templates in a social or cultural setting. They are activated and modified by the person using them. In a therapeutic setting one may, for example, look with patients at which communication patterns they use and how. Since meaningful information can only flow if it is transmitted within the dynamics of communication patterns, no matter how simple and rudimentary they may be, improving one’s selection and use of communication patterns also leads to a more efficient transmission of meaningful information. This is particularly useful in anxiety conditions, which are characterized by a subjective lack of meaningful information. Since a socially anxious person may actually be very sensitive and perceptive, and thus have more information about interactional clues and the other person available, the focus in Communication-Focused Therapy®, for example, is not necessarily the quantity of information, but how the patient finds, absorbs and processes the information which is most helpful to further the own needs, values and aspirations. In clinical experience, the more competent a patient feels in this regard, the lower the anxiety usually is. This applies particularly to social anxiety, where the anxiety revolves around external communication.

Attention

Attention is the ability to notice new information within a defined space, but also the capability to attach relevance to it.  Both attention and focus are important in the acquisition of meaningful and relevant information form the environment. If they are interfered with or misdirected, there is less relevant information available, which can increase the experienced anxiety. The attention of highly anxious individuals is more automatically captured by sub-threshold cues.  (Mogg & Bradley, 2002) Attentional bias toward negative social cues is thought to serve an etiological and/or maintaining role in social anxiety disorder. As discussed above, anxiety in general is a result of the subjective perception of missing relevant information. (Haverkampf, 2010a, 2018f)

Schmidt and colleagues tested in their study whether training patients to disengage from negative social cues may ameliorate social anxiety in patients with a primary diagnosis of generalized social anxiety disorder. Patients who underwent attention training exhibited significantly greater reductions in social anxiety and trait anxiety, compared with patients in the control condition. At termination, 72% of patients in the active treatment condition, relative to 11% of patients in the control condition, no longer met the DSM-IV criteria for social anxiety disorder. At 4-month follow-up, patients in the attention training condition continued to maintain their clinical improvement. (Schmidt et al., 2009)

Communication to Participate in Life

Communication is important to be connected into the web of life. The exchange of meaningful messages helps one to get what one needs, wants and aspires to. This applies to communication with oneself and others. Finding out what one needs, wants and aspires to happens through communication with oneself. It requires openness and insight.

The feeling of being a part of ‘the whole thing’ is important to an individual, not jut because the individual is part of a chain of generations. When one exchanges meaningful messages with others, oneself and the world around become meaningful to oneself. Losing a part of oneself or a loss of meaning, however, represents an existential threat, which can induce anxiety. This is how social anxiety and a loss in meaningful connectedness with others can lead to more anxiety. To an extent, this can be compensated for with meaningful communication with oneself, but for most this is not enough.

Understanding Social Anxiety and Shyness

Social anxiety is often present from childhood. The fears already interfere with one’s development early on. Since some of the most experiences in a human life are the interpersonal ones, this can interfere with one’s personal development. As already mentioned, shyness is not a disorder, and a person may be happy about it. However, the potential loss to quality of life of social anxiety and shyness can be similar. Shy people often develop adaptive communication pathways, such as relying more heavily on the Internet and may be content with it. However, interpersonal communication is an important piece of change and of bringing about in the world, and without it some of this dynamic may be missed out on. Given the many possible channels of communicating with the world, it does not matter so much which one is used. The important factor is that it allows the exchange of meaningful messages, which aid the individual in becoming better connected with oneself and the world.

Internal Communication

Often, there are already maladaptive communication patterns before, that cause the problems in the relationship or interpersonal interactions. These patterns can be analyzed and changed. Another important element is that communication can also take place on the inside of the individual. Individuals with social anxiety are often very critical of themselves, and this is what is then projected into others, who then appear critical of oneself. An important, and often helpful, step is to become aware of this.

The internal and external communication go hand in hand. Thought patterns that are used in one’s communication with oneself are usually also used in the communication with others. If there are doubts and fears in the communication with oneself, they often will also be present in one’s communication with others.

Uncertainty

In life, one has to live with uncertainty. Uncertainty just means that there is no manual in the beginning and there are still unknowns which leave room for excitement and exploration. Life is a learning experience. An individual suffering from anxiety may have areas in life where she thrives on excitement, and other areas where images of worst-case scenarios cause her to freeze when she just considers a change in action or any action at all. Uncertainty to someone suffering from anxiety seems to be bearable in some areas and avoided in others. Often, the areas where it is not tolerated feel meaningful only to the person suffering from anxiety.

Studies have shown that the intolerance of uncertainty explains a significant amount of variance in social anxiety severity when controlling for several cognitive correlates of social anxiety, such as the fear of negative evaluation, and for neuroticism. Intolerance of uncertainty also seems to be related with symptom levels of GAD, OCD, and social anxiety, but not depression. (Boelen & Reijntjes, 2009) It seems to play a significant role in performance and interaction social anxiety, but probably a slightly greater role in the former. (Whiting et al., 2014) Intolerance of uncertainty also appears significantly associated with symptom levels of separation anxiety disorder. (Boelen et al., 2014)

Communication Deficits

Areas which people often feel anxious about are where there has been an issue with their interpersonal interactions in the past. Early traumata, like a disappearing or abusive parent, stay unresolved. For example, if a parent feels fearful and angry with himself and this is picked up by a child, the latter may decode these messages correctly in that the parent is angry, but since the parent may not be conscious about it, the child does not pick up on the second important half of the message, that the parent has a problem with himself and his issue is unrelated to the child. Of course, one can learn to pick up on the self-blame and frustration of the parent, and therapists should become experts at reading between the lines in this fashion, but it requires experience, reflection and insight into transference and counter-transference phenomena, for example, to use the psychoanalytic terms.

In one study, hildren with social anxiety disorder scored significantly higher than anxious children without on the Social Communication Questionnaire (SCQ), reciprocal social interaction, communication and repetitive, restrictive and stereotyped behaviors subscales. They were also three times more likely to score above clinical cut-offs overall. (Halls et al., 2015) This shows that these children have difficulties with certain communication patterns. However, this may not be due to a social skills defict, but they may believe that they appear nervous during social encounters. (Cartwright-Hatton et al., 2005) It would further support the view that it is the flow of information, internally and externally, which is really at the base of social anxiety disorder and many other mental health conditions (Haverkampf, 2018b). These can, on the other hand, be influenced and changed through work on the communication petterns and individual uses.

Avoidance

Anxiety can lead to avoidance, which in turn can attach even more anxiety to the situations or behaviors which are being avoided. In social situations, not interacting with others deprives the person of continuously updating and honing the skills and confidence of interacting with others. Avoidance can thus lead to an increase rather than a decrease in anxiety in the long-run. While smaller skillsets seem to pla role, it is also important to keep in mind that the avoidance of internal and external flows in itself lowers the available quantity of meaningful information, which plays a significant role in increasing uncertainty about the world and oneself (Haverkampf, 2010a) and thus the levels of anxiety, while holding the tolerance for uncertainty constant.

Meaning

Individuals suffering from social anxiety do not see less relevance in social interactions, but often even more. It is not necessarily seeing more meaning, though, but a different kind. In therapy an important part is to rediscover meaning and find it in the things that are relevant to the patient. Relevant is anything that is close to his or her values, basic interests, aspirations, wants, wishes and desires.

However, someone with social anxiety may see the meaning in things differently from someone what does not suffer from it. Approaching someone of the opposite sex may be seen differently because of life experiences. Also, if different meaning is seen in it, the expectations can be different. Expectations that are so high that they are self-defeating can be a problem. However, to set expectations that are not too high and not too low mean having a view of reality that works for oneself.

Awareness of Thought Patterns

An important step in therapy thus to make the person aware of how anxiety affects one’s thinking. Individuals from anxiety often focus differently from other individuals. There is often a focus on worst outcomes and strong fears which are caused by it. Underlying this are often strong emotions or conflicts which need to be defended against. The danger and uncertainty is quite frequently inside oneself, rather than on the outside. An individual with a fear of flying may be more afraid of not containing oneself and not being able to leave the plain than anything else. Anxiety is the fear of crashing psychologically and the feelings of a dreaded uncertainty about oneself and one’s emotional states.

Awareness means observing the own thought patterns and gaining insight into them. This requires being receptive to this information from oneself and the ability to reflect on it. Important is being able to perceive the flow of information between the parts of oneself, and the ability to let the information flow freely.

Flow of Information

A free flow of information within oneself and with the environment is important to reduce the anxiety and physical symptoms associated with social anxiety. Often, such an openness has become difficult for people because of inadequate interaction patterns and a fear to change anything. In a therapeutic session, this can be changed in two ways. Interaction patterns can be experimented with in a therapeutic session and reflected upon. One objective should be to help the patient develop greater efficacy and confidence in his or her interactions with the environment.

Emotional Reconnection

If there have been adverse life experiences as a significant factor in the social anxiety, there can still be unresolved emotions underlying the anxiety. To resolve them means answering the hypothetical question, what one may have felt in the difficult situation, but then also seeing the strength that allowed one to pull through, which only becomes visible now. The goal is not necessarily to reconnect with only negative emotions form the past, but also the good ones, and emotions as a whole today.

If there is a disconnect, and emotional reconnection would be helpful, one should approach one’s feelings gradually. Especially in cases of social anxiety, it could be problematic trying this too fast. In any case, as internal and external communication go hand in hand, so do internal and external emotional connection. Someone who is disconnected from oneself will have a more difficult time to emotionally communicate with others or stay reflected and calm in situations where there is a potential for greater emotional communication, such as in romantic situations.

Experiencing the World

Social anxiety means potentially experiencing less of the world, although the higher sensitivity can at the same time let someone experience more. It is important again to note that many patients suffering from social anxiety disorder put themselves under an enormous pressure. Their more frequent feeling that they need to interact with others and live their lives in certain can add to the anxiety, rather than diminishing it. The more permanent solutions to this dilemma are, as outlined above, a greater connectedness with oneself and better insight into the own needs, values and aspirations. Work with the communication patterns a patient uses, as well as reflection on how she felt when engaged in activities and with other people in the past, sheds light on the ‘truer’ needs, values and aspirations. The focus is here completely on the patient and her experiences, not on the expectations of others. This focus establishes more meaning in the life of the patient and helps is the acquisition of more helpful communication patterns.

Communication Techniques

Various communication techniques can be helpful, not as an end in themselves, but to help the person have more confidence in oneself and to see communication not as something dangerous one needs to be guarded against, but as something that can help one meet one’s needs, wishes and expectations. Thus, the reason for communication techniques should be not an end in itself, but to increase one’s repertoire, ease and confidence in communicating with oneself and others.

Openness to others, a positive and welcoming attitude towards the messages of others and engaging in reflection on the interaction are some helpful approaches towards communication, but there are many others as well. Important is not to be deterred from the interaction when something unsuspected or disappointing happens, but to reflect on what it could mean, whether it is a message from outside or inside oneself. Genuinely new information is never meaningless and reflecting on it helps to gain more insight into the world. Social anxiety, on the other hand, is often a result of engaging with messages only superficially, rather than letting them resonate with oneself and determining what they might mean.

Technology can also play a useful role in gradually exposing oneself to potentially more anxiety provoking situations. For example, beginning with interactions with fewer communication channels, such as an online dating site, can make it easier to then move on to an in-person date. More information could already be screened in a less communication intensive setting before exposing oneself to the many communication channels of an actual physical date. Pierce demonstrated in a study a positive relationship between social anxiety (not comfortable talking with others face-to-face) and (1) talking with others online and (2) talking with others via text messaging. In contrast, there was a positive relationship between the lack of social anxiety (feeling “comfortable” talking with others) and making friends online. (Pierce, 2009) Gender differences were also pointed out in the study.

Breaking the Cycle of Anxiety

To break through the vicious cycle of anxiety, in which emotions like fear and anxiety cause safety thoughts and behaviors, which in turn reinforce feelings of fear, loneliness, sadness, and so forth, it is helpful to focus on identifying what is meaningful and having more of it in life. Communication helps in identifying and finding meaning, either communication with oneself or with others. The exchange of messages is like a learning process in which meaning can be identified, found and accumulated. Through meaningful interactions one accumulates more meaning, more connectedness with oneself and the world and reduces the need for thoughts and behaviors which are triggered by fears, guilt, self-blame and other negative emotions. This also helps against depression and anxiety.

Insight and connectedness reduce anxiety. Openness and receptiveness to information and messages can lead there. This can be practiced in therapy and brought from there into everyday life. The sense of competence helps build confidence in dealing with oneself and the environment. Important is to connect with oneself to a level that there is greater insight into what is truly important to oneself.

The Reward of Seeing More

Perceiving more meaning also makes interacting with others and oneself more meaningful. This has a positive effect on one’s interaction patterns, how and in which ways one relates to one’s environment and exchanges messages with it. People with social anxiety often see less in an interaction, although they often have a greater sensitivity and perceptiveness to see more. This has to do with a different focus on where to find a relevant and meaningful message in the interaction. For example, in an interaction with a romantic love interest, the socially anxious person may be too focused on signals and own thoughts about a possible rejection rather than on information from the other person that could help in getting to know that person.

An important step is therefore to become aware that what may be behind some of the social anxiety, or much of it, is actually something quite positive, something that can be used to one’s advantage. Central is merely how to use a heightened percetiveness and sensitivity to certain information signals for one’s benefit rather than to one’s detriment. In Communication-Focused Therapy, through work on communication patterns, within and without oneself, the selection and steering of information flows can be changed, which also directly impacts the information and meaning a person is exposed to. Since anxiety is tightly linked with the flow of information and the available information, changing internal and external communication patterns can lower anxiety quite substantially (Haverkampf, 2013, 2017i, 2017b).

Values, Needs and Aspirations

Beyond food, drink, a roof over one’s head and basic safety, humans have values, needs and aspirations that drive much of what they are doing throughout their lives. None of us is born to live the life of a Robinson Crusoe, and just like the fictional character, interpersonal interactions with others, as well as the intrapersonal communication that is tightly lined with it, are the main instruments to get these needs, values and aspirations met. The exchange of meaningful information is what brings about positive and lasting change in oneself and in the environment (Haverkampf, 2010b). The author has referred to the own needs, values and aspirations before as basic parameters because they can determine whether some information that has become available in a person is meaningful or not (Haverkampf, 2018h).

One of the most painful elements of social anxiety is that a person finds it more difficult to find the own needs met. It interferes with dating, in workplace situations or in academia. People suffering from this condition, do so in silence, which tends to make it even worse. To escape this vicious cycle, a new orientation towards the own values, needs and aspirations is needed (Haverkampf, 2013, 2017e). What helps to achieve this is through a better connectedness with oneself and others. The work on communication patterns in Communication-Focused Therapy can here be very helpful (Haverkampf, 2017e).

The Need for Communication

Living organisms constantly need to communicate within themselves and with others, and humans are not an exception. Close relationships in humans, for example, have been linked to a wide variety of psychological and other processes, including physical and mental health (Jones et al., 1990). Communication with others is needed to grow, innovate and propagate. Most of the human accomplishments in the arts, sciences and professions are based on the exchange of meaningful messages, communication. But communication is also to have one’s needs met and to survive in general. Even a hermit in the mountains needs to interact with his or her living mountain environment. People who enjoy nature usually do not want to shun communication but focus on an exchange with a nonhuman environment. Communication is fundamental to life itself.

Suffering from social anxiety does not mean a disinterest in people or an objection to being with them, rather the opposite. An indifference ot something does not lead to anxiety or the feelings that are commonly experienced by indidividuals with social anxiety. The latter are testamount to the importance a person with social anxiety attaches to interpersonal connections and the social realm. People with social anxiety may even be more sensitive and perceptive to social signals, though they may be minterpreted, and to the importance of social interactions. In one study, perceived closeness was greatest when the most socially anxious individuals interacted with each other (Kashdan & Wenzel, 2005). At the same time, in another study, when asked how an investigator viewed them based on that person’s facial expressions, socially anxious subjects made ratings that were consistently less favorable than the ratings made by subjects lower in social anxiety (Pozo et al., 1991). In other words, we have the semmingly paradoxical findings that people with social anxiety may experience social connections even mor eintensely, while possibly doubting them more in other situations. One explanation would be the fear of losing something very important. The more important social connections are to a person, the higher may also be the apprehensiveness about doing something wrong and losing it. Adding in higher anxiety levels to begin with, might give us a fairly adequate representation of the underlying dynamic in social anxiety.

Experimentation with adjustments to existing communication patterns and the development of new ones is the road that leads to less social anxiety (Haverkampf, 2017e, 2018d). The first steps can often be quite small for good reasons. It often helps people with social anxiety and shyness to connect with and appreciate their need and joy in communicating. Once communication is seen as a potential source of pleasure rather than a necessary task, it can become much easier, as ‘I want’ replaces ‘I should’. It often helps to take on a more investigatory perspective, donning a lab coat so to speak, and having fun observing the communication dynamics as they unfold in an interaction. The benefit is often twofold. Once one takes on an observer role it is easier to extricate oneself from the emotional vortex of being caught up insight a problematic interaction, while being able to better reflect and understand the dynamics. The greater awareness and space to experiment with new communication elements and patterns either in the current or a future situation can lead to a massive change in how effectively and satisfyingly one interacts with oneself and the world and thereby fulfils the own needs, values and aspirations.

Meaningful Messages as the Instrument of Change

Communication is the vehicle of change, and meaning drives it. The instruments are meaningful messages which are generated and received by the people who take part in these interactions. In a therapeutic setting, keeping the mutual flow of information relevant and meaningful brings about change in both people who take part in this process. The learning curve for the patient may be steeper in certain respects because he or she spends less time in this interaction style than a therapist. Over time, changes and sjudtments to in internal and external communication patterns facilitate a greater awareness for and processing of meaning (Haverkampf, 2010a, 2017c, 2018i).

Information underlies practically everything from physical quantum states and classical processes to psychological ones (Haverkampf, 2018g). Information Perceived emotions are also communicated information (Haverkampf, 2012b). In an interpersonal conext, meaning is generated from the information carried by signs.  Creation of meaning events in-therapy, for example, are change episodes that occur when a patient seeks to understand the meaning of an emotional experience (Clarke, 1996). Meaningful information is information which can bring about a change in the recipient of the information (Haverkampf, 2010a, 2018a). It has also been argued that information is objective, but inaccessible to humans, who exist exclusively in a world of meaning, while meaning is intersubjective, or based on shared agreement and understanding, rather than purely subjective (Mingers, 1995). However, the description of meaning as information that carries the potential to effect change may allow for a broader and more generally applicable delineation of the term. In Communication-Focused Therapy it is an important means of change dependent on the effective communication of the information that codes for it. Social anxiety illustrates quite brightly what happens when the process at one or more points affected by other factors, either within or outside the person. Social anxiety is primarily a communication problem, often alongside or based on generally higher levels of anxiety.

Embracing Change

In the case of social anxiety, embracing change can be associated with anxiety, while it can also be liberating because it means that there are no rigid rules one needs to adhere to other than those linked to the communication process itself, which has clear laws. Understanding these laws of communication, on the other hand, which humans subconsciously operate on and use as they accumulate experience in their interactions with others is essential to gain greater confidence in tolerating and working towards change. Basic communication concepts, such as what constitutes communication, how meaning is created, how information flows, and how communication processes are influenced, is usually not conscious. Reflecting on it and beginning to use it, however, can be especially helpful to sensitive people, who quite frequently have experienced social at some point in their lives. One might say that only those who do not care about people and themselves are entirely free from social anxiety, but this tantamount to the description of a sociopathic personality disorder.

Change should thus not be understood as changing oneself or one’s ability to perceive and be sensitive to the nuances of daily interactions, but to develop new communication patterns. Some of the techniques used in Communictaion-Focused Therapy have been described elwhere (Haverkampf, 2017a, 2017e, 2017i, 2018e). Important is the concept that external and internal communication patterns are closely related to each other, and that work on communication in therapy leads to change on both sides. Several of the techniques involve the use of certain communication elements and structures, such as a variety of the question (Haverkampf, 2017g) and other functional concepts.

Living

It is not the number of social contacts which is relevant. Having a few good friends is often worth more than thousands of contacts in an online social network. However, this does not mean friends have to be always physically present. Meeting friends online also allows for communication, while close physical contact in an intimate relationship is to most people important on a regular basis.

Important is that the communication patterns, the frequency and the interaction style fit the needs, values and aspirations of the individual. People who are shy can be quite happy with the intensity and frequency of their interactions, those with social anxiety are usually not. It is thus important to help individuals with social anxiety discover what is important to them and how they want to live their lives. Communication patterns change more easily when the change creates more meaning in the world of the patient (Haverkampf, 2012a). Communication-Focused Therapy thus aims first at creating greater awareness for the basic parameters of needs, values and aspirations to support the process of change in communication patterns (Haverkampf, 2010b, 2017a).

In the end, communication is an activity. One ultimately needs to do it. However, when one has worked on the own communication, developed awareness for them, gained insight into them and made it a habbit to experiment with them, communication becomes something to look forward to rather than something that causes apprehensiveness and anxiety.


Dr Jonathan Haverkampf, M.D. (Vienna) MLA (Harvard) LL.M. psychoanalytic psychotherapy (Zurich) trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. He is the author of several books and over a hundred articles. Dr Haverkampf has developed Communication-Focused Therapy® and written extensively about it. He also has advanced degrees in management and law. The author can be reached by email at jonathanhaverkampf@gmail.com or on the websites www.jonathanhaverkampf.ie and www.jonathanhaverkampf.com.

References

Beard, C., & Amir, N. (2008). A multi-session interpretation modification program: Changes in interpretation and social anxiety symptoms. Behaviour Research and Therapy, 46(10), 1135–1141. https://doi.org/10.1016/j.brat.2008.05.012

Beidel, D. C., Turner, S. M., & Dancu, C. V. (1985). Physiological, cognitive and behavioral aspects of social anxiety. Behaviour Research and Therapy, 23(2), 109–117. https://doi.org/10.1016/0005-7967(85)90019-1

Boelen, P. A., & Reijntjes, A. (2009). Intolerance of uncertainty and social anxiety. Journal of Anxiety Disorders, 23(1), 130–135. https://doi.org/10.1016/j.janxdis.2008.04.007

Boelen, P. A., Reijntjes, A., & Carleton, R. N. (2014). Intolerance of Uncertainty and Adult Separation Anxiety. Cognitive Behaviour Therapy, 43(2), 133–144. https://doi.org/10.1080/16506073.2014.888755

Caplan, S. E. (2007). Relations Among Loneliness, Social Anxiety, and Problematic Internet Use. CyberPsychology & Behavior, 10(2), 234–242. https://doi.org/10.1089/cpb.2006.9963

Cartwright-Hatton, S., Tschernitz, N., & Gomersall, H. (2005). Social anxiety in children: Social skills deficit, or cognitive distortion? Behaviour Research and Therapy, 43(1), 131–141. https://doi.org/10.1016/j.brat.2003.12.003

Clarke, K. M. (1996). Change processes in a creation of meaning event. Journal of Consulting and Clinical Psychology, 64(3), 465–470. https://doi.org/10.1037/0022-006X.64.3.465

Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B. (2014). Maximizing exposure therapy: An inhibitory learning approach. Behaviour Research and Therapy, 58, 10–23. https://doi.org/10.1016/J.BRAT.2014.04.006

Etkin, A., & Wager, T. D. (2007). Functional Neuroimaging of Anxiety: A Meta-Analysis of Emotional Processing in PTSD, Social Anxiety Disorder, and Specific Phobia. American Journal of Psychiatry, 164(10), 1476–1488. https://doi.org/10.1176/appi.ajp.2007.07030504

Gilbert, P. (2000). The relationship of shame, social anxiety and depression: the role of the evaluation of social rank. Clinical Psychology & Psychotherapy, 7(3), 174–189. https://doi.org/10.1002/1099-0879(200007)7:3<174::AID-CPP236>3.0.CO;2-U

Goldin, P. R., & Gross, J. J. (2010). Effects of mindfulness-based stress reduction (MBSR) on emotion regulation in social anxiety disorder. Emotion, 10(1), 83–91. https://doi.org/10.1037/a0018441

Grant, B. F., Hasin, D. S., Blanco, C., Stinson, F. S., Chou, S. P., Goldstein, R. B., Dawson, D. A., Smith, S., Saha, T. D., & Huang, B. (2005). The Epidemiology of Social Anxiety Disorder in the United States. The Journal of Clinical Psychiatry, 66(11), 1351–1361. https://doi.org/10.4088/JCP.v66n1102

Halls, G., Cooper, P. J., & Creswell, C. (2015). Social communication deficits: Specific associations with Social Anxiety Disorder. Journal of Affective Disorders, 172, 38–42. https://doi.org/10.1016/j.jad.2014.09.040

Haverkampf, C. J. (2010a). A Primer on Interpersonal Communication (3rd ed.). Psychiatry Psychotherapy Communication Publishing Ltd.

Haverkampf, C. J. (2010b). Communication and Therapy (3rd ed.). Psychiatry Psychotherapy Communication Publishing Ltd. http://www.jonathanhaverkampf.com

Haverkampf, C. J. (2012a). A Case of Severe Anxiety. J Psychiatry Psychotherapy Communication, 1(2), 35–40.

Haverkampf, C. J. (2012b). Feel! (1st ed.). Psychiatry Psychotherapy Communication Publishing Ltd.

Haverkampf, C. J. (2013). A Case of Social Anxiety. J Psychiatry Psychotherapy Communication, 2(1), 14–20.

Haverkampf, C. J. (2017a). Communication-Focused Therapy (CFT) (2nd ed.). Psychiatry Psychotherapy Communication Publishing Ltd.

Haverkampf, C. J. (2017b). Communication-Focused Therapy (CFT) for Anxiety and Panic Attacks. http://www.jonathanhaverkampf.in/wp-content/uploads/2018/06/Communication-Focused-Therapy-CFT-for-Anxiety-and-Panic-Attacks-2-Christian-Jonathan-Haverkampf.pdf

Haverkampf, C. J. (2017c). Communication-Focused Therapy (CFT) for Anxiety and Panic Attacks. J Psychiatry Psychotherapy Communication, 6(4), 91–95.

Haverkampf, C. J. (2017d). Communication-Focused Therapy (CFT) for OCD. J Psychiatry Psychotherapy Communication, 6(4), 102–106.

Haverkampf, C. J. (2017e). Communication-Focused Therapy (CFT) for Social Anxiety and Shyness. J Psychiatry Psychotherapy Communication, 6(4), 107–109.

Haverkampf, C. J. (2017f). Finding Your Dreams.

Haverkampf, C. J. (2017g). Questions in Therapy. J Psychiatry Psychotherapy Communication, 6(1), 80–81.

Haverkampf, C. J. (2017h). Social Anxiety and Medication (2). http://www.jonathanhaverkampf.com/

Haverkampf, C. J. (2017i). Treatment-Resistant Anxiety. J Psychiatry Psychotherapy Communication, 6(3), 61–67.

Haverkampf, C. J. (2018a). A Primer on Communication Theory.

Haverkampf, C. J. (2018b). Atypical Deprerssion. J Psychiatry Psychotherapy Communication, 9(4), 91–97.

Haverkampf, C. J. (2018c). Beginning to Communicate (3rd ed.). Psychiatry Psychotherapy Communication Publishing Ltd.

Haverkampf, C. J. (2018d). Communication-Focused Therapy (CFT) – Specific Diagnoses (Vol II) (2nd ed.). Psychiatry Psychotherapy Communication Publishing Ltd.

Haverkampf, C. J. (2018e). Communication Patterns and Structures.

Haverkampf, C. J. (2018f). Fear, Social Anxiety and Communication (3rd ed.). Psychiatry Psychotherapy Communication Publishing Ltd.

Haverkampf, C. J. (2018g). Information.

Haverkampf, C. J. (2018h). The Basic Parameters (3rd ed.). Psychiatry Psychotherapy Communication Publishing Ltd.

Haverkampf, C. J. (2018i). The Power of Meaning (1st ed.). Psychiatry Psychotherapy Communication Publishing Ltd.

Heimberg, R. G., Horner, K. J., Juster, H. R., Safren, S. A., Brown, E. J., Schneier, F. R., & Liebowitz, M. R. (1999). Psychometric properties of the Liebowitz social anxiety scale. Psychological Medicine, 29(1), 199–212.

Hezel, D. M., & McNally, R. J. (2014). Theory of mind impairments in social anxiety disorder. Behavior Therapy, 45(4), 530–540. https://doi.org/10.1016/j.beth.2014.02.010

Hirsch, C., Meynen, T., & Clark, D. (2004). Negative self‐imagery in social anxiety contaminates social interactions. Memory, 12(4), 496–506. https://doi.org/10.1080/09658210444000106

Hofmann, S. G., Meuret, A. E., Smits, J. A. J., Simon, N. M., Pollack, M. H., Eisenmenger, K., Shiekh, M., & Otto, M. W. (2006). Augmentation of Exposure Therapy With D-Cycloserine for Social Anxiety Disorder. Archives of General Psychiatry, 63(3), 298. https://doi.org/10.1001/archpsyc.63.3.298

Jones, W. H., Rose, J., & Russell, D. (1990). Loneliness and Social Anxiety. In Handbook of Social and Evaluation Anxiety (pp. 247–266). Springer US. https://doi.org/10.1007/978-1-4899-2504-6_9

Kashdan, T. B., & Wenzel, A. (2005). A transactional approach to social anxiety and the genesis of interpersonal closeness: Self, partner, and social context. Behavior Therapy, 36(4), 335–346. https://doi.org/10.1016/S0005-7894(05)80115-7

La Greca, A. M., & Harrison, H. M. (2005). Adolescent Peer Relations, Friendships, and Romantic Relationships: Do They Predict Social Anxiety and Depression? Journal of Clinical Child & Adolescent Psychology, 34(1), 49–61. https://doi.org/10.1207/s15374424jccp3401_5

La Greca, A. M., & Lopez, N. (1998). Social Anxiety Among Adolescents: Linkages with Peer Relations and Friendships. Journal of Abnormal Child Psychology, 26(2), 83–94. https://doi.org/10.1023/A:1022684520514

Leary, M. R. (1990). Responses to Social Exclusion: Social Anxiety, Jealousy, Loneliness, Depression, and Low Self-Esteem. Journal of Social and Clinical Psychology, 9(2), 221–229. https://doi.org/10.1521/jscp.1990.9.2.221

Leichsenring, F., Salzer, S., Beutel, M. E., Herpertz, S., Hiller, W., Hoyer, J., Huesing, J., Joraschky, P., Nolting, B., Poehlmann, K., Ritter, V., Stangier, U., Strauss, B., Stuhldreher, N., Tefikow, S., Teismann, T., Willutzki, U., Wiltink, J., & Leibing, E. (2013). Psychodynamic Therapy and Cognitive-Behavioral Therapy in Social Anxiety Disorder: A Multicenter Randomized Controlled Trial. American Journal of Psychiatry, 170(7), 759–767. https://doi.org/10.1176/appi.ajp.2013.12081125

Mansell, W., Clark, D. M., Ehlers, A., & Chen, Y.-P. (1999). Social Anxiety and Attention away from Emotional Faces. Cognition & Emotion, 13(6), 673–690. https://doi.org/10.1080/026999399379032

Mingers, J. C. (1995). Information and meaning: foundations for an intersubjective account. Information Systems Journal, 5(4), 285–306. https://doi.org/10.1111/j.1365-2575.1995.tb00100.x

Mogg, K., & Bradley, B. P. (2002). Selective orienting of attention to masked threat faces in social anxiety. Behaviour Research and Therapy, 40(12), 1403–1414. https://doi.org/10.1016/S0005-7967(02)00017-7

Phan, K. L., Fitzgerald, D. A., Nathan, P. J., & Tancer, M. E. (2006). Association between Amygdala Hyperactivity to Harsh Faces and Severity of Social Anxiety in Generalized Social Phobia. Biological Psychiatry, 59(5), 424–429. https://doi.org/10.1016/J.BIOPSYCH.2005.08.012

Pierce, T. (2009). Social anxiety and technology: Face-to-face communication versus technological communication among teens. Computers in Human Behavior, 25(6), 1367–1372. https://doi.org/10.1016/J.CHB.2009.06.003

Pozo, C., Carver, C. S., Weflens, A. R., & Scheier, M. F. (1991). Social Anxiety and Social Perception: Construing Others’ Reactions to the Self. Personality and Social Psychology Bulletin, 17(4), 355–362. https://doi.org/10.1177/0146167291174001

Rodebaugh, T. L., Holaway, R. M., & Heimberg, R. G. (2004). The treatment of social anxiety disorder. Clinical Psychology Review, 24(7), 883–908. https://doi.org/10.1016/J.CPR.2004.07.007

Schlenker, B. R., & Leary, M. R. (1982). Social anxiety and self-presentation: A conceptualization model. Psychological Bulletin, 92(3), 641–669. https://doi.org/10.1037/0033-2909.92.3.641

Schmidt, N. B., Richey, J. A., Buckner, J. D., & Timpano, K. R. (2009). Attention training for generalized social anxiety disorder. Journal of Abnormal Psychology, 118(1), 5.

Stangier, U., Schramm, E., Heidenreich, T., Berger, M., & Clark, D. M. (2011). Cognitive Therapy vs Interpersonal Psychotherapy in Social Anxiety Disorder. Archives of General Psychiatry, 68(7), 692. https://doi.org/10.1001/archgenpsychiatry.2011.67

Stein, M. B., & Stein, D. J. (2008). Social anxiety disorder. The Lancet, 371(9618), 1115–1125. https://doi.org/10.1016/S0140-6736(08)60488-2

Whiting, S. E., Jenkins, W. S., May, A. C., Rudy, B. M., Davis, T. E., & Reuther, E. T. (2014). The Role of Intolerance of Uncertainty in Social Anxiety Subtypes. Journal of Clinical Psychology, 70(3), 260–272. https://doi.org/10.1002/jclp.22024

World Health Organization. (1992). The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines. Geneva: World Health Organization.

This article is solely a basis for academic discussion and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition. Neither author nor publisher can assume any responsibility for using the information herein.

Trademarks belong to their respective owners. Communication-Focused Therapy, the CFT logo with waves and leaves, Dr Jonathan Haverkampf, Journal of Psychiatry Psychotherapy and Communication, and Ask Dr Jonathan are registered trademarks.

This article has been registered with the U.S. Copyright Office. Unauthorized reproduction, distribution or publication in any form is prohibited. Copyright will be enforced.

© 2016-2020 Christian Jonathan Haverkampf. All Rights Reserved

Unauthorized reproduction, distribution and/or publication in any form is prohibited.

The Misdiagnosis of ADHD in Adults (1)

The-Misdiagnosis-of-ADHD-in-Adults-1-Christian-Jonathan-Haverkampf-psychiatry-series-1

The Misdiagnosis of ADHD in Adults

Christian Jonathan Haverkampf, M.D.

Adult attention deficit hyperactivity disorder (ADHD) in adults is a childhood-onset, persistent, neurobiological disorder associated with high levels of morbidity and dysfunction estimated to afflict up to 5% of adults worldwide. It includes a combination of persistent problems, such as difficulty paying attention, hyperactivity and impulsive behavior, which can lead to unstable relationships, poor work or school performance, low self-esteem, and other problems.

The diagnosis is important to design an effective treatment plan with the patient, which often includes medication and psychotherapy or counselling. There is a wide variety of approaches in the diagnosis of adult ADHD, and this article aims at giving an overview of some of the more common ones. However, there is a high risk of misdiagnosing this condition. The ability to concentrate, for example, can also be affected in depression, PTSD, anxiety, psychosis and other conditions, as can the capacity for organizing and seeing through tasks, various aspects of memory and information retrieval and irritability.

Awareness for the communication patterns in the interaction with the patient, and how the patient communicates internally, are important tools in the diagnostic process and in treatment, improving the individualization of treatment and building and maintaining compliance. While the actual interaction with the patient is of primary diagnostic importance, standardized questionnaires and neuropsychological testing batteries are important to support a diagnosis and to adjust treatment.

Keywords: attention deficit hyperactivity disorder, ADHD, diagnosis, treatment, psychotherapy, psychiatry

Contents

Introduction. 4

Attention. 5

Executive Functioning. 5

Communication. 5

From Childhood to Adulthood: Hyperactivity vs Inattention. 6

Measurement Problems. 6

Misdiagnosis of ADHD.. 6

Autism.. 7

Trauma. 7

OCD.. 7

Bipolar Disorder. 7

Symptoms. 8

Diagnosing ADHD.. 9

Subtypes. 10

Assessment. 10

Communication. 10

The Clinical Interview.. 11

Semi-Structured Interviews. 11

CAADID.. 12

DIVA. 12

Computer-Assisted Diagnosis. 13

Questionnaires. 13

Self-Report Rating Scales. 14

Conners’s Adult ADHD Rating Scales (CAARS) 14

Current Symptoms Scale. 15

Adult ADHD Self-Report Scale–version 1.1 (ASRSv1.1) 15

Retrospective Assessments. 16

Wender Utah Rating Scale (WURS) 16

Non-Self Report Assessments. 16

Brown Attention-Deficit Disorder Rating Scale for Adults (Brown ADD-RS) 16

ADHD Investigator Symptom Rating Scale (AISRS) 17

Neuropsychological Testing. 17

Neurobiological Parameters. 20

Malingering. 20

Differential Diagnosis. 21

Comorbidity. 22

Psychosocial Functioning. 22

Conclusion. 23

References. 25

 

Introduction

Adult attention deficit hyperactivity disorder (ADHD) in adults is a childhood-onset, persistent, neurobiological disorder associated with high levels of morbidity and dysfunction estimated to afflict up to 5% of adults worldwide (Kessler et al., 2006). It includes a combination of persistent problems, such as difficulty paying attention, hyperactivity and impulsive behavior, which can lead to unstable relationships, poor work or school performance, low self-esteem, and other problems. Due concerns about overdiagnosis and overtreatment, many children and youth diagnosed with ADHD still receive no treatment or insufficient treatment (Giuliano & Geyer, 2017).

Using DSM-IV criteria, in a study by Wilens and colleagues, 93% of ADHD adults had either the predominately inattentive or combined subtypes-indicative of prominent behavioral symptoms of inattention in adults. (Wilens et al., 2009) ADHD often presents as an impairing lifelong condition in adults, yet it is currently underdiagnosed and treated in many European countries, leading to ineffective treatment and higher costs of illness. Instruments for screening and diagnosis of ADHD in adults are available and appropriate treatments exist, although more research is needed in this age group. (Kooij et al., 2010)

The diagnosis of ADHD in adults is a complex procedure which should refer to the diagnostic criteria of a diagnostic manual, such as the DSM or ICD. It normally includes the following information:

  • retrospective assessment of childhood ADHD symptoms
  • current adult ADHD psychopathology including symptom severity and pervasiveness,
  • functional impairment
  • quality of life
  • comorbidity

In order to obtain a systematic database for the diagnosis and evaluation of the course ADHD rating scales can be very useful. However, the interaction with the patient in the clinical interview should remain the central part of the diagnosis. (Haverkampf, 2017c, 2017a) Integrating elements of semi-structured questioning into the clinical interview can be helpful, while awareness for the communication patterns the patient uses is crucial. (Haverkampf, 2018c) Still, specific diagnostic criteria that are more sensitive and specific to adult functioning are needed. (Davidson, 2008)

Attention

When focusing on the diagnostic details, one may sometimes run the risk of losing sight of the bigger defining symptoms of ADHD. Attention deficit needs to be present for the diagnosis. Studies of adults with ADHD suggest that the most prominent symptoms of ADHD relate to inattention as opposed to hyperactivity and impulsivity. In a meta-analysis, Schoenlein and Engel integrated 24 empirical studies reporting results of at least one of 50 standard neuropsychological tests comparing adult ADHD patients with controls. Complex attention variables and verbal memory discriminated best between ADHD patients and controls. In contrast to results reported in children, executive functions were not generally reduced in adult ADHD patients. (Schoechlin & Engel, 2005)

Executive Functioning

Attention deficit hyperactivity disorder (ADHD) is associated with deficits in executive functioning. ADHD in adults is also associated with impairments in major life activities, particularly occupational functioning. Executive functioning deficits contribute to the impairments in occupational functioning that occur in conjunction with adult ADHD. Barkley and Murphy concluded in their study that ratings of executive functioning in daily life contribute more to such impairments than do executive functioning tests. The investigators hypothesize that one reason could be that each assesses a different level in the hierarchical organization of EF as a meta-construct. (Barkley & Murphy, 2010)

Communication

The exchange of information, internally and externally, is the process that is generally affected and gives rise to several of the observed symptoms. ADHD interferes with effective and helpful communication internally and externally, which causes several of the observed symptoms. (Haverkampf, 2010b) Internal and external communication patterns should thus be observed in diagnosis and worked with as an important focus later in treatment.

From Childhood to Adulthood: Hyperactivity vs Inattention

Prevalence of ADHD in adults declines with age in the general population, although the unclear validity of DSM–IV diagnostic criteria for this condition may have led to reduced prevalence rates by underestimation of the prevalence of adult ADHD. (Kessler et al., 2006) Symptoms start in early childhood and continue into adulthood. In some cases, ADHD is not recognized or diagnosed until the person is an adult. Adult ADHD symptoms may not be as clear as ADHD symptoms in children. In adults, hyperactivity often decreases, but struggles with impulsiveness, restlessness and difficulty paying attention usually continue. It is mostly these latter symptoms which can interfere significantly with an individual’s daily life.

Hyperactive–impulsive symptoms seem to decline more with increasing age, whereas inattentive symptoms of ADHD tend to persist. In a study by Millstein and colleagues, inattentive symptoms were most frequently endorsed in over 90% of ADHD adults. An assessment of current ADHD symptoms showed that 56% of adults had the combined ADHD subtype, 37% the inattentive only subtype, and 2% the hyperactive/impulsive subtype. Whereas females had fewer childhood hyperactive-impulsive symptoms than males, there were no gender differences in their ADHD presentation as adults. This suggests that the vast majority of adults with ADHD present with prominent symptoms of inattention. (Millstein, Wilens, Biederman, & Spencer, 1997) Decision-making is another important cognitive process which seems impaired in adults with ADHD (Mäntylä, Still, Gullberg, & Del Missier, 2012), and which can lead to impairment in several domains in life.

Measurement Problems

The decrease in ADHD symptoms over time may indicate true remission of symptoms, but it may also indicate that the symptom criteria are less robust in older rage groups. Michielsen and colleagues, for example, concluded in their epidemiological study on ADHD in older persons in the Netherlands that ADHD does not fade or disappear in adulthood. (Michielsen et al., 2012)

Misdiagnosis of ADHD

Rising rates of ADHD have led to the concern that ADHD is often misdiagnosed. The ability to concentrate, for example, can also be affected in depression, PTSD, anxiety, psychosis and other conditions, as can the capacity for organizing and seeing through tasks, various aspects of memory and information retrieval and irritability. There is evidence of medically inappropriate ADHD diagnosis and treatment in school-age children and less so for adults. In a study by Evans and colleagues, for example, age relative to peers directly affected a child’s probability of being diagnosed with ADHD. The relative age effect was present for both ADHD diagnosis and treatment with stimulants (Evans, Morrill, & Parente, 2010).

Autism

Because of the high frequency of ADHD symptoms in autism, children with autism may initially be misdiagnosed with ADHD. The core symptoms of ADHD (attention deficit, impulsivity, and hyperactivity) are part of autism, and autism and ADHD have similar underlying neuropsychological deficits (Mayes, Calhoun, Mayes, & Molitoris, 2012). On the other hand, the rate for children with autism spectrum disorder to be also diagnosed with ADHD is as high as 60% (Stevens, Peng, & Barnard-Brak, 2016).

Trauma

Trauma may also be misinterpreted as ADHD, particularly in children. Hyper-vigilance and dissociation, for example, could be mistaken for inattention. Impulsivity might be brought on by “a stress response in overdrive” (Ruiz, 2014). Cognitive and emotional disruptions that occur in response to trauma, such as difficulty concentrating, dysregulated affect, irritability, and hyperarousal, either overlap with ADHD symptomatology or exasperate it (Szymanski, Sapanski, & Conway, 2011).

OCD

Manifestations of OCD-related inattention may be misdiagnosed as ADHD symptoms, particularly again in children. In OCD only, current ADHD symptoms correlate with obsessive-compulsive symptoms There is a risk of misdiagnosis, especially in children when primarily relying on informants (Abramovitch, Dar, Mittelman, & Schweiger, 2013).

Bipolar Disorder

Bipolar disorder is also a neurodevelopmental disorder with onset in childhood and early adolescence and commonly persists into adulthood. Both disorders are often undiagnosed, misdiagnosed, and sometimes over diagnosed. The differentiation of these conditions is based on their clinical features, comorbidity, psychiatric family history, course of illness, and response to treatment (Marangoni, De Chiara, & Faedda, 2015). Children with bipolar disorder are more likely to present with

  • aggression and lack of remorse, while in ADHD a destructiveness is more likely due to carelessness.
  • severe temper tantrums, often of more than an hour in duration, which are less intense and shorter in ADHD
  • intentional misbehavior, which is in ADHD more likely to be due to inattentiveness
  • underestimating risk, while in ADHD there may be unawareness of risk
  • anger for longer periods of time, holding a grudge and being unforgiving, while in ADHD calm is usually restored within half an hour or considerably more quickly and the reasons for the anger forgotten
  • stimulation seeking due to boredom, while in ADHD the stimulation seeking is more general
  • amnesia for anger outbursts
  • flight of ideas (manic phase), while in ADHD the talkativeness is due to a lack of inhibition and can be influenced and redirected
  • decreased need for sleep
  • sleep inertia and slow awakening (unless in a manic phase)
  • rapidly changing mood shifts
  • suicidal ideation
  • symptoms that routinely improve on lithium, mood stabilizers, antipsychotics
  • symptoms that do not improve on stimulants

If both conditions are present, the mood disorder symptoms and the course of the bipolar condition are usually more severe, and the functional scores lower. Since the symptoms of a separate ADHD are often mistakenly assumed to be part of the bipolar conditions, patients with comorbid ADHD and BD are routinely underdiagnosed and undertreated (Klassen, Katzman, & Chokka, 2010).

Symptoms

Many people with ADHD have fewer symptoms as they age, but some adults continue to have major symptoms that interfere with daily functioning also in later stages of life. In adults, the main features of ADHD may include difficulty paying attention, impulsiveness and restlessness. This can make it more difficult to acquire new information, process it together with existing information and communicate with others.

Adults with ADHD may find it difficult to focus and prioritize, leading to missed deadlines and forgotten meetings or social plans. The inability to control impulses can range from impatience waiting in line or driving in traffic to mood swings and outbursts of anger. The difficulties in persisting with a task is probably a consequence of ineffective information transmission internally.

Adult ADHD symptoms may include:

  • Impulsiveness
  • Disorganization and problems prioritizing
  • Poor time management skills
  • Problems focusing on a task
  • Trouble multitasking
  • Excessive activity or restlessness
  • Poor planning
  • Low frustration tolerance
  • Frequent mood swings
  • Problems following through and completing tasks
  • Hot temper
  • Trouble coping with stress

Diagnosing ADHD

Extensive psychometric studies have provided empirical support for the symptom thresholds used to diagnose ADHD in children, and there is general agreement that ADHD can be reliably diagnosed in children using these formal diagnostic criteria. However, the reliability of the diagnosis of ADHD in adults is less clear. The task would become easier if there were a greater focus on operationalizing internal and external communication patterns, that can be observed, described by the patient or inferred from these observation and descriptions by an experienced therapist. These patterns have been described by the author in for ADHD (Haverkampf, 2017e, 2017a) as well as for several other mental health conditions (Haverkampf, 2010b, 2017d, 2018b). Diagnosis of adult attention-deficit hyperactivity disorder (ADHD) adults is difficult, as neither symptom report nor neuropsychological findings are specific to ADHD. However, the most information can still be gained in the clinical interview if the clinician is receptive to the various levels of information flows and integrates them into the overall assessment.

Subtypes

It is unclear whether the three subtypes recognized in the diagnostic manuals have a different underlying ethology or any other justification to separate them. However, they are frequently used in clinical practice and offer a rough symptom description which can also be useful for many non-medical questions, such as support in school or disability. The subtypes are:

  • ADHD combined type (ADHD-C; both inattentive and hyperactive–impulsive symptoms)
  • ADHD predominantly inattentive type (ADHD-I)
  • ADHD predominantly hyperactive–impulsive type (ADHD-H)

Assessment

The diagnosis of adult ADHD is a clinical decision-making process, where the emphasis lies on the clinical interview and anything that can support the information gained in it. There are no objective, laboratory-based tests that can establish this diagnosis. (Haavik, Halmøy, Lundervold, & Fasmer, 2010) Given the difficulties with the formal diagnostic criteria for ADHD, determining the diagnosis of ADHD in adults presents different challenges than determining the diagnosis in children (Riccio et al., 2005). There is no single neurobiological or neuropsychological test that can determine a diagnosis of ADHD on an individual basis (Rosler et al., 2006).

In most situations, an ADHD assessment should include a comprehensive clinical interview, as rating scales, an assessment of a broader spectrum of psychiatric and somatic conditions and information from third parties if available.

Communication

How patients exchange meaningful information with themselves and others to get their needs and aspirations met or in response to an interaction or a perception or sensation is of very high diagnostic values in most psychiatric conditions, including especially so also ADHD. Unfortunately, there is often a lack of focus on a patients’ internal and external communication, which could be diagnostically helpful in the diagnosis and treatment of ADHD. For example, the effectiveness of ADHD coaching in improving patients’ everyday life has been demonstrated. (Kubik, 2010) Since communication is the basic process by which individuals get their needs and aspirations met in everyday life, increasing their quality of life and integrating them into the community, which in itself can have a protective effect, exploring a patient’s communication patterns should be a primary goal of an assessment for the severity of ADHD. (Haverkampf, 2017f, 2017e, 2017b)

The clinical interview, and thus the interaction with the patient, is at the center of the diagnosis of ADHD. This may make the process more difficult to operationalize for randomized controlled studies if they fail to conceptualize information and communication in a clinical interview. A greater elucidation of communication processes has been described as beneficial by the author and several different techniques and approaches suggested.  (Haverkampf, 2010a)

The Clinical Interview

A comprehensive clinical interview is one of the most effective methods to make a diagnosis of ADHD (Adler, 2004; Jackson & Farrugia, 1997; Murphy & Adler, 2004; Wilens, Faraone, & Biederman, 2004). Open-ended questions about childhood and adult behaviors can be used to elicit information necessary to diagnose ADHD. Interviews also include questions regarding developmental and medical history, school and work history, psychiatric history, and family history of ADHD and other psychiatric disorders (Barkley, 2006).

The clinical interview also gives inside into the communication the patient uses, internally and externally, and how he or she attends to and processes meaningful information. (Haverkampf, 2010a, 2018a) This is important for the diagnosis and treatment of any mental health condition, but particularly also ADHD. (Haverkampf, 2017a)

Semi-Structured Interviews

Although many clinicians use unstructured interviews to assess adult ADHD, semistructured interviews do exist. One does not necessarily have to choose between either one, but it can be helpful to at least integrate semistructured elements into a clinical interview, which still offers the latitude to explore more freely, which can be important in assessing any comorbidities. Research suggests that semistructured clinical interviews can reliably and accurately be used for determining a diagnosis of ADHD in adults (Epstein & Kollins, 2006).

Comprehensive diagnostic interviews not only evaluate diagnostic criteria, but also assess different psychopathological syndrome scores, functional disability measures, indices of pervasiveness and information about comorbid disorders. Comprehensive procedures include the Brown ADD Diagnostic Form and the Adult Interview by Barkley and Murphy. The Wender Reimherr Interview which follows a diagnostic algorithm different from DSM-IV. The interview contains only items delineated from adult psychopathology and not derived from symptoms originally designed for use in children. (Rösler et al., 2006)

From a communication perspective, the etiology of ADHD consists generally of the same maladaptive communication and information handling patterns, whether in a child or an adult. However, given differences in developmental stages and environmental factors the symptoms and impairments can be different. Also, the chronicity and entrenchment of a particular patterns, in connection with developmental progress, can influence the phenomenology of the condition. To consider all these factors a certain flexibility and openness in the clinical interview is of paramount importance.

CAADID

The Conners Adult ADHD Diagnostic Interview for DSM-IV (CAADID), for example, assesses for the presence of the ADHD symptoms listed in the DSM-IV and collects information related to history, developmental course, ADHD risk factors, and comorbid psychopathology. Epstein and Kollines examined the test-retest reliability and concurrent validity of the CAADID for DSM-IV in a sample of thirty patients referred to an outpatient clinic. Kappa statistics for individual symptoms of inattention and hyperactivity-impulsivity were in the fair to good range for current report and retrospective childhood report. Kappa values for overall diagnosis, which included all DSM-IV symptoms, were fair for both current (adult) ADHD diagnosis (kappa = .67) and childhood report (kappa = .69). Concurrent validity was demonstrated for adult hyperactive-impulsive symptoms and child inattentive symptoms. (Epstein & Kollins, 2006)

DIVA

Another semi-structured interview is the Diagnostic Interview for ADHD in adults, which has gone through improvement updates. It has been compared to the CAADID and other ADHD severity scales, following the DSM-IV criteria. Ramos-Quiroga and colleagues carried out a transversal study on 40 out-patients with ADHD to check the criteria and concurrent validity of the DIVA 2.0 compared with the CAADID. The DIVA 2.0 interview showed a diagnostic accuracy of 100% when compared with the diagnoses obtained with the CAADID interview. The concurrent validity demonstrated good correlations with three self-reported rating scales: the Wender Utah Rating Scale (WURS), the ADHD-Rating Scale, and Sheehan’s Dysfunction Inventory. (Ramos-Quiroga et al., 2016) One advantage of the DIVA is that it is free to use.

Computer-Assisted Diagnosis

Supportive methods in diagnosing ADHD are being explored. Using computerized clinical decision support modules can in higher quality of care with respect to ADHD diagnosis including a prospect for higher quality of ADHD management in children. (Bergman et al., 2009) This is different from using computers for neuropsychological testing, where the patient interacts with the computer. Computer-assisted diagnosis tools could, for example, provide decision trees that are based on empirical insights. While this can be a valuable support for the clinician, it is important to keep in mind that the interactions with the patient is probably the most important instrument in the assessment of ADHD.

Questionnaires

Questionnaires may be underutilized in clinical practice. They often are easy to administer, score and interpret, while their reliability and validity can be quite high.

  • The Connors Adult ADHD Rating Scales (CAARS)
  • the Current Symptoms Scales by Barkley and Murphy (CSS)
  • the Adult Self Report Scale (ASRS) by Adler et al. and Kessler et al. and
  • the Attention Deficit Hyperactivity Disorder—Self Report Scale (ADHD-SR by Rösler et al.)

are self-report rating scales focusing mainly on the DSM-IV criteria, although the CAARS and CSS also have other forms.

  • The Wender-Utah Rating Scale (WURS) and

the Childhood Symptoms Scale by Barkley and Murphy aim at making a retrospective assessment of childhood ADHD symptoms.

  • The Brown ADD Rating Scale (Brown ADD-RS) and
  • the Attention Deficit Hyperactivity Disorder-Other Report Scale (ADHD-OR by Rösler et al.)

are instruments for use by clinicians or significant others.

Both self-rating scales and observer report scales quantify the ADHD symptoms by use of a Likert scale mostly ranging from 0 to 3, which makes comparison of follow-up tests easier.

Self-Report Rating Scales

Self-report checklists are commonly used in the assessment of ADHD. In addition to self-report rating scales, rating scales completed by an individual’s spouse or significant other can provide useful information in determining the individual’s overall life functioning. They are easy to administer, and a number of reliable and valid measures exist. Problems may be bias or malingering, which are difficult to control for. Distorted memories probably play a negligible role in rating scales that focus on current symptoms, but could become important in those screening for symptoms in childhood and adolescence.

Research has demonstrated that rating scales can accurately reflect the frequency and intensity of symptoms (Wadsworth & Harper, 2007) and, when used retrospectively, are valid indicators of symptomatology (Murphy & Schachar, 2000). Murphy and Schachar (2000) examined the validity of self-reported ratings of current and childhood ADHD symptoms by adults. In one study, participants’ ratings of their childhood ADHD symptoms were compared to their parents’ ratings of childhood symptoms. In a second study, participants’ ratings of their current ADHD symptoms were compared to a significant other’s rating of current symptoms. All correlations between self-ratings and parent ratings were significant for inattentive, hyperactive–impulsive, and total ADHD symptoms, as were correlations between self-ratings and significant other ratings.

Belendiuk and colleagues examined in 2007 the concordance of diagnostic measures for ADHD, including self-ratings and collateral versions of both rating scales and semistructured interviews. Results supported the findings of Murphy and Schachar, showing high correlations between self-reports and collateral reports of inattentive and hyperactive–impulsive symptoms. Results also demonstrated high correlations between self-report rating scales and diagnostic interviews. (Belendiuk, Clarke, Chronis, & Raggi, 2007)

Conners’s Adult ADHD Rating Scales (CAARS)

The CAARS (Conners, Erhart, & Sparrow, 1999) assesses ADHD symptoms in adults and comprises short, long, and screening self-report and observer rating scale forms. The CAARS produces eight scales, including scales based on DSM-IV criteria and an overall ADHD index. Internal consistency is good, with Cronbach’s alpha across age, scales, and forms ranging from .49 to .92 (Conners et al., 1999; Erhardt, Epstein, Connors, Parker, & Sitarenios, 1999). Test–retest reliability (1 month) estimates are high, ranging from .85 to .95 (Conners et al., 1999; Erhardt et al., 1999). The ADHD index produces an overall correct classification rate of 85%, and the sensitivity of the ADHD index has been estimated at 71% and the specificity at 75% (Conners et al., 1999).

Adler and colleagues compared the reliability, validity, and utility in a sample of adults with ADHD and also as an index of clinical improvement during treatment of self- and investigator ratings of ADHD symptoms via the CAARS. They analyzed data from two double-blind, parallel-design studies of 536 adult ADHD patients, randomized to 10-week treatment with atomoxetine or placebo. The CAARS demonstrated good internal consistency and inter-rater reliability, as well as sensitivity to treatment outcome. (Adler et al., 2008)

Taylor and colleagues retrieved 35 validation studies of adult ADHD rating scales and identified 14 separate scales. The majority of studies were of poor quality and reported insufficient detail. Of the 14 scales, the Conners’ Adult ADHD Rating scale and the Wender Utah Rating Scale (short version) had more robust psychometric statistics and content validity. (Taylor, Deb, & Unwin, 2011)

Current Symptoms Scale

The Current Symptoms Scale (Barkley & Murphy, 1998) is an 18-item selfreport scale with both a patient version and an informant version. It contains the 18 items from the diagnostic criteria in DSM-IV. Validity has been demonstrated through past findings of significant group differences between ADHD and control adults (Barkley, Murphy, DuPaul, & Bush, 2002). An earlier DSM-III version of the scale correlated significantly with the same scale completed by a parent (r = .75) and by a spouse or intimate partner of the ADHD adult (r = .65; Murphy & Barkley, 1996a).

Adult ADHD Self-Report Scale–version 1.1 (ASRSv1.1)

The ASRS-v1.1 (Adler, Kessler, & Spencer, 2003) is an 18-item measure based on the DSM-IV-TR criteria for ADHD that produces three scale scores. Questions are designed to suit an adult rather than a child, and the language provides a context for symptoms that adults can relate to. Internal consistency estimates are high, and the ASRS-v1.1 has been shown to have high concurrent validity (Adler et al., 2006).

Adler et al conducted a study to validate the pilot Adult ADHD Self-Report Scale (pilot ASRS) versus standard clinician ratings on the ADHD Rating Scale (ADHD RS). Sixty adult ADHD patients took the self-administered ADHD RS and then raters administered the standard ADHD RS. Internal consistency was high for both patient and rater-administered versions. The intra-class correlation coefficients (ICCs) between scales for total scores was also high, as were ICCs for subset symptom scores. There was acceptable agreement for individual items and significant kappa coefficients for all items. The pilot Adult ADHD Self-Report Scale symptom checklist was thus a reliable and valid scale for evaluating ADHD for adults and showed a high internal consistency and high concurrent validity with the rater-administered ADHD RS. (Adler et al., 2006)

Retrospective Assessments

Retrospective assessments collect information to help make a retroactive diagnosis of ADHD.

Wender Utah Rating Scale (WURS)

The WURS (Ward, Wender, & Reimherr, 1993) is based on items from the monograph Minimal Brain Dysfunction in Children (Wender, 1971), which is more detailed than the symptoms listed in the DSM or ICD-10. McCann and colleagues examined the factor structure and discriminant validity of the WURS in adults seeking evaluation for attention-deficit/hyperactivity disorder (ADHD). Three factors (Dysthymia, Oppositional/Defiant Behavior, and School Problems) accounted for 59.4% of the variance. In a stepwise discriminant function analysis, age and childhood school problems emerged as significant variables. The classification procedure correctly classified 64.5% of patients. Among those who did not have ADHD, only 57.5% were correctly classified compared with 72.1% among those with ADHD. The WURS thus appears to be sensitive in detecting ADHD, but it misclassified approximately half of those who do not have ADHD. (McCann, Scheele, Ward, & Roy-Byrne, 2000)

Non-Self Report Assessments

Brown Attention-Deficit Disorder Rating Scale for Adults (Brown ADD-RS)

The Brown ADD-RS (Brown, 1996; Brown & Gammon, 1991) assesses symptoms of ADHD in adults. It was developed before the DSM-IV concept of ADHD was published and focuses more on symptoms of inattention rather than hyperactivity and impulsivity. The scale shows high internal consistency (α = .96) and satisfactory validity (M. Weiss, Hechtman, & Weiss, 1999).

ADHD Investigator Symptom Rating Scale (AISRS)

To measure treatment response, the Adult ADHD Investigator Symptom Rating Scale (AISRS) was developed to better capture symptoms of ADHD in adult patients. The AISRS uses a semistructured interview methodology with suggested prompts for each item to improve interrater reliability. (Spencer et al., 2010) The authors analyzed psychometric properties of the AISRS total and AISRS subscales and compared them to the investigator rated version of the CAARS and the Clinical Global Impression-ADHD-Severity Scale using data from a placebo-controlled 6-month clinical trial of once-daily atomoxetine. Results showed that the AISRS and its subscales were robust, valid efficacy measures of ADHD symptoms in adult patients. Its anchored items and semistructured interview are mentioned as advancements over existing scales. (Spencer et al., 2010)

Neuropsychological Testing

Attention-deficit hyperactivity disorder (ADHD) is a behaviorally defined diagnosis. Despite the fact that neuropsychological tests have typically been used successfully to investigate the functional neuroanatomy of ADHD in neuroimaging research paradigms, these tests have been of surprisingly limited utility in the clinical diagnosis of the disorder. (Koziol & Stevens, 2012) Still, if used discriminatingly and with an understanding for their place in an assessment, neuropsychological testing can play a significant role in the assessment of ADHD. However, one needs to keep in mind that there is no single test or battery of tests that has adequate predictive validity or specificity to make a reliable diagnosis of ADHD. Although there seem to be differences between adults with ADHD and control participants on measures of cognitive functioning, these measures probably have limited predictive value in distinguishing ADHD from other psychiatric or neurological conditions that are associated with similar cognitive impairments (Wadsworth & Harper, 2007).

In adult ADHD, neuropsychological testing is most beneficial when the results are used to support conclusions based on history, rating scales, and analysis of current functioning. Cognitive assessments can be useful in that they can improve the validity of an ADHD assessment and be used in assessing the efficacy of pharmacological and/or psychological interventions (Epstein et al., 2003). Also, many researchers agree that a neuropsychological assessment will be most sensitive to ADHD when the assessment incorporates multiple, overlapping procedures measuring a broad array of attentional and executive functions (Alexander & Stuss, 2000; Cohen, Malloy, & Jenkins, 1998; Woods et al., 2002).

Important functional domains of neuropsychological tests are:

  • verbal ability
  • figural problem solving
  • abstract problem solving
  • executive function
  • fluency
  • simple attention
  • sustained attention
  • focused attention
  • verbal memory
  • figural memory

Woods and his colleagues (2002) reviewed the role of neuropsychological evaluation in the diagnosis of adults with ADHD. In their review of 35 studies, the authors found that the majority of the studies demonstrated significant discrepancies between adults with ADHD and normal control participants on at least one measure of executive function (i.e., the ability to assess a task situation, plan a strategy to meet the needs of the situation, implement the plan, make adjustments, and successfully complete the task; Riccio et al., 2005) or attention. Moreover, Woods et al. found that the most prominent and reliable executive function and attention measures that differentiated adults with ADHD were Stroop tasks (Stroop, 1935) and continuous performance tests (CPTs). (The Stroop phenomenon demonstrates that it is difficult to name the ink color of a color word if there is a mismatch between ink color and word. For example, the word GREEN printed in red ink. The CPT measures a person’s sustained and selective attention.)

Neuropsychological tests generally have a poor ability to discriminate between patients diagnosed with ADHD and patients not diagnosed with ADHD. Pettersson and colleagues investigated in their study the discriminative validity of neuropsychological tests and diagnostic assessment instruments in diagnosing adult ADHD in a clinical psychiatric population of 108 patients, 60 were diagnosed with ADHD. The Diagnostic Interview for ADHD in adults (DIVA 2.0) and Adult ADHD Self-Report Scale (ASRS) v.1.1 together with eight neuropsychological tests were investigated. All instruments showed poor discriminative ability except for the DIVA, which showed a relatively good ability to discriminate between the groups (sensitivity = 90.0; specificity = 72.9). A logistic regression analysis model with the DIVA and measures of inattention, impulsivity, and activity from continuous performance tests (CPTs) showed a sensitivity of 90.0 and a specificity of 83.3. This means that while the ability to discriminate between patients with and without ADHD is poor, variables from CPT tests can contribute to increasing the specificity by 10% if used in combination with the DIVA. (Pettersson, Söderström, & Nilsson, 2018)

Schoechlin and colleagues conducted a meta-analysis integrating 24 empirical studies reporting results of at least one of 50 standard neuropsychological tests comparing adult ADHD patients with controls. The 50 tests were categorized into the following 10 functional domains: verbal ability, figural problem solving, abstract problem solving, executive function, fluency, simple attention, sustained attention, focused attention, verbal memory, figural memory. For each domain a pooled effect size d′ was calculated. Complex attention variables and verbal memory discriminated best between ADHD patients and controls. Effect sizes for these domains were homogeneous and of moderate size (d′ between 0.5 and 0.6). In contrast to results reported in children, executive functions were not generally reduced in adult ADHD patients. (Schoechlin & Engel, 2005) Woods et al. (2002), on the other hand, concluded that although a general profile of attentional and executive function impairment is evident in adults with ADHD, expansive impairments in these domains (i.e., impairments on all attention and executive function tasks) is not common. Their review demonstrated inconsistencies in specific instruments across studies, indicating that adults with ADHD may not perform poorly on all attentional measures all the time. This finding is not surprising given the fact that adults with ADHD often demonstrate sporadic or inconsistent attention, which can be difficult to identify given the structure provided by the one-on-one testing environment (Barkley, 1998).

One popular family of measures for the assessment of attention and executive control is the continuous performance test (CPT). A review of the available research on CPTs reveals that they are quite sensitive to CNS dysfunction. This is both a strength and a limitation of CPTs in that multiple disorders can result in impaired performance on a CPT. The high sensitivity of CPTs is further complicated by the multiple variations of CPTs available, some of which may be more sensitive or demonstrate better specificity to ADHD in adults than others. If CPTs are to be used clinically, further research will be needed to answer the questions raised by this review. (Riccio & Reynolds, 2006).

Several theoretical models suggest that the core deficit of ADHD is a deficiency in response inhibition. While neuropsychological deficits in response inhibition are well documented in ADHD children, research on these deficits in adult ADHD populations is minimal. In a study by Epstein and colleagues, twenty-five adult ADHD patients, 15 anxiety-disordered adult patients, and 30 normal adults completed three neuropsychological tests of response inhibition: the Continuous Performance Test, Posner Visual Orienting Test, and the Stop Signal Task. ADHD adults demonstrated response inhibition performance deficits when compared to both normal adults and anxiety disordered adults only on the Continuous Performance Test. A similar pattern of differences was not observed on the other two neuropsychological tests. Differing results between tasks may be due to differences in test reliability, task parameters, or the targeted area of brain functioning assessed by each test. (Epstein, Johnson, Varia, & Conners, 2001)

Neurobiological Parameters

Abibullaev and colleagues proposed a decision support system in diagnosing ADHD through brain electroencephalographic signals. (Abibullaev & An, 2012) Lenartowicz and Loos concluded that while EEG cannot currently be used as a diagnostic tool, vast developments in analytical and technological tools in its domain anticipate future progress in its utility in the clinical setting. (Lenartowicz & Loo, 2014) However, the overall assessment still requires a clinical decision, which may depend on many factors, including the individual attitude towards the diagnosis held by the therapist.

Malingering

Malingering is an important issue in ADHD diagnosis and is defined as the conscious fabrication or exaggeration of physical or psychological symptoms in the pursuit of a recognizable goal. A diagnosis of ADHD can provide an individual with several benefits, including stimulant medication, disability benefits, tax benefits, and academic accommodations, and such benefits may motivate adults undergoing diagnostic evaluations for ADHD to exaggerate symptomatology on self-report measures and tests of neurocognitive functioning. Musso and colleagues identified and summarize nineteen peer-reviewed, empirical studies published between 2002 and 2011 that investigated malingered ADHD in college students. Few of the measures examined proved useful for detecting malingered ADHD. Most self-report questionnaires were not sensitive to malingering. While there is some variability in the usefulness of neuropsychological test failure, profiles between malingerers and individuals with ADHD were too similar to confidently detect malingered ADHD. Failure of three or more symptom validity tests proved most useful at detecting malingered ADHD. The authors concluded that there is substantial need for measures designed specifically for detecting malingered ADHD simulators are able to produce plausible profiles on most tools used to diagnose ADHD. (Musso & Gouvier, 2014)

Detection of faking can prove difficult with adults in particular, as clinicians often do not have access to a parent or sibling who can attest to prior history of ADHD symptoms or the resources to follow up do not exist. Moreover, adults often lack developmental documentation such as report cards, teacher evaluations, or prior psychological testing reports.

Quinn (2003) examined the issue of malingering by comparing the susceptibility of a self-report ADHD rating scale and a CPT to faking in an undergraduate sample of individuals with and without a diagnosis of ADHD. Results indicated that the CPT showed greater sensitivity to malingering than did the self-report scale and that a CPT can successfully discriminate malingerers from those with a valid diagnosis of ADHD. Given the potential benefits associated with an ADHD diagnosis, clinicians should include a symptom validity measure in their assessment battery. At present, however, there is no demonstrated best practice for this.

Suhr and colleagues utilized archival data from young adults referred for concerns about ADHD, divided into three groups: (1) those who failed a measure of noncredible performance (the Word Memory Test; WMT), (2) those who met diagnostic criteria for ADHD, and (3) controls with psychological symptoms but no ADHD. Results showed a 31% failure rate on the WMT. Those who failed the WMT showed clinical levels of self-reported ADHD symptoms and impaired neuropsychological performance. Neither self-report measures nor neuropsychological tests could distinguish ADHD from psychological controls, with the exception of self-reported current hyperactive/impulsive symptoms and Stroop interference. (Suhr, Hammers, Dobbinsbuckland, Zimak, & Hughes, 2008) These results underscore the effect of noncredible performance on both self-report and cognitive measures in ADHD.

It is difficult to tell how much a greater focus on the communication dynamics in a clinical interview can improve the problems around malingering. However, communication in its diverse synchronous forms is probably much more difficult to consciously influence and ‘fake’ than a simple task. However, a greater focus on communication patterns and dynamics also requires the skills and experience in the clinician to work with them.

Differential Diagnosis

Diagnosing ADHD in adults requires careful consideration of differential diagnoses, as it can be difficult to differentiate ADHD from a number of other psychiatric conditions (Pary et al., 2002), including major depression, bipolar disorder, generalized anxiety, obsessive–compulsive disorder (OCD), substance abuse or dependence, personality disorders (borderline and antisocial), and learning disabilities (Searight, Burke, & Rottnek, 2000). For example, differential diagnosis of ADHD from mood and conduct disorders may be difficult because of common features such a mood swings, inability to concentrate, memory impairments, restlessness, and irritability (Adler, 2004). Differential diagnosis of learning disabilities can also prove difficult because of the interrelated functional aspects of the disorders that have the common outcome of poor academic functioning (Adler, 2004; Jackson & Farrugia, 1997).

Comorbidity

High rates of comorbidities are also seen in adults with ADHD, with the majority having at least one additional psychiatric disorder. ADHD is associated with a high percentage of comorbid psychiatric disorders in every lifespan. In adulthood between 65–89% of all patients with ADHD suffer from one or more additional psychiatric disorders, above all mood and anxiety disorders, substance use disorders and personality disorders, which complicates the clinical picture in terms of diagnostics, treatment and outcome issues. (Sobanski, 2006) Outcome studies have demonstrated that individuals diagnosed with ADHD in childhood are at risk for developing comorbid conditions, some of which are likely secondary to ADHD-related frustration and failure.

The most frequent comorbid psychopathologies include mood and anxiety disorders, substance use disorders, and personality disorders. (Katzman, Bilkey, Chokka, Fallu, & Klassen, 2017) Biederman and colleagues (1993) found a relatively high incidence of lifetime diagnoses of anxiety disorders (43% to 52%), major depressive disorder (31%), ODD (29%), CD (20%), antisocial personality disorder (12%), and alcohol and drug dependencies (27% and 18%, respectively) in their sample of clinic-referred adults with ADHD. There are strong familial links and neurobiological similarities between ADHD and the various associated psychiatric comorbidities. Comparable rates of comorbidities have been found in men and women with ADHD, with the exception of men having higher rates of antisocial personality disorder. (Millstein et al., 1997)

With respect to ADHD subtypes in adults, Millstein and colleagues found higher rates of ODD, bipolar disorder, and substance use disorders in patients with the combined type of ADHD than in those with other subtypes and higher rates of ODD, OCD, and PTSD in patients with the hyperactive type than in those with the inattentive type.  In their study, Sprafkin and colleagues found that all three subtypes reported more severe comorbid symptoms than did a control group, with the combined group obtaining the highest ratings of comorbid symptom severity. The authors found that the ADHD symptom subtypes in adults are associated with distinct clinical correlates and conclude that the diversity of self-reported psychopathology in adults who meet symptom criteria for ADHD highlights the importance of conducting broad-based evaluations. (Sprafkin, Gadow, Weiss, Schneider, & Nolan, 2007)

Psychosocial Functioning

In addition to comorbid psychiatric disorders, adults with ADHD often complain of psychosocial difficulties, which can manifest in a significantly higher rate of separation and divorce and lower socioeconomic status, poorer past and current global functioning estimates, and higher occurrence of prior academic problems relative to the control group.

Murphy and Barkley (1996a) documented high rates of educational, employment, and marital problems in adults with ADHD. Multiple marriages were more common in the adult ADHD group, and significantly more adults with ADHD had performed poorly, quit, or been fired from a job and had a history of poorer educational performance and more frequent school disciplinary actions against them than did adults without ADHD. Low self-concept and low self-esteem are common secondary characteristics of adults with ADHD, often resulting from problematic educational experiences and interpersonal difficulties (Jackson & Farrugia, 1997). Adults with ADHD often have strong feelings of incompetence, insecurity, and ineffectiveness, and many of these individuals live with a chronic sense of underachievement and frustration (Murphy, 1995).

Conclusion

Variations in communication processes and patterns, both internally and externally, play an important role in the etiology and the symptomatology of ADHD. Unfortunately, there is not enough focus on them in diagnosis and treatment. The author has proposed a theoretical approach and several practical approaches elsewhere (Haverkampf, 2010b, 2017e, 2017d, 2018b) Since the symptoms of ADHD are consequences of maladaptive internal communication and processing mechanisms of meaningful information, while at the same time there are maladaptive external communication patterns with the world, which lead to the observed difficulties in the personal and professional life of the patient, a greater focus on communication is important.

The use of DSM-IV criteria for ADHD in adults has been criticized. Barkley (1998) suggests that applying current ADHD criteria to adults is not developmentally sensitive. The DSM-IV criteria for ADHD were designed for and selected based on studies with children (Riccio et al., 2005), and validation studies of ADHD criteria in adults have not been conducted (Belendiuk, Clarke, Chronis, & Raggi, 2007). It has thus been suggested that the symptom lists in DSM-IV may be inappropriately worded for adults and that diagnostic thresholds may be too stringent or restrictive when applied to adults (Heiligenstein, Conyers, Berns, & Smith, 1998). The level of impairment caused by ADHD symptoms may also be different between adults and children, and symptoms will likely affect more domains in adults. However, when looked at from a communication perspective, and when focusing on the basic of ADHD, such as the attention deficit, it seems possible to view ADHD as a condition where external and internal communication, including the receptiveness for and decoding of information, is altered in predictable patterns. (Haverkampf, 2017f)


Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. He is the author of several books and over a hundred articles. Dr Haverkampf has developed Communication-Focused Therapy® and written extensively about it. He also has advanced degrees in management and law. The author can be reached by email at jonathanhaverkampf@gmail.com or on the websites www.jonathanhaverkampf.ie and www.jonathanhaverkampf.com.

References

Abibullaev, B., & An, J. (2012). Decision Support Algorithm for Diagnosis of ADHD Using Electroencephalograms. Journal of Medical Systems, 36(4), 2675–2688. https://doi.org/10.1007/s10916-011-9742-x

Abramovitch, A., Dar, R., Mittelman, A., & Schweiger, A. (2013). Don’t judge a book by its cover: ADHD-like symptoms in obsessive compulsive disorder. Journal of Obsessive-Compulsive and Related Disorders, 2(1), 53–61. https://doi.org/10.1016/j.jocrd.2012.09.001

Adler, L. A., Faraone, S. V., Spencer, T. J., Michelson, D., Reimherr, F. W., Glatt, S. J., … Biederman, J. (2008). The Reliability and Validity of Self- and Investigator Ratings of ADHD in Adults. Journal of Attention Disorders, 11(6), 711–719. https://doi.org/10.1177/1087054707308503

Adler, L. A., Spencer, T., Faraone, S. V, Kessler, R. C., Howes, M. J., Biederman, J., & Secnik, K. (2006). Validity of pilot Adult ADHD Self-Report Scale (ASRS) to rate adult ADHD symptoms. Annals of Clinical Psychiatry, 18(3), 145–148.

Barkley, R. A., & Murphy, K. R. (2010). Impairment in occupational functioning and adult ADHD: the predictive utility of executive function (EF) ratings versus EF tests. Archives of Clinical Neuropsychology, 25(3), 157–173.

Belendiuk, K. A., Clarke, T. L., Chronis, A. M., & Raggi, V. L. (2007). Assessing the Concordance of Measures Used to Diagnose Adult ADHD. Journal of Attention Disorders, 10(3), 276–287. https://doi.org/10.1177/1087054706289941

Bergman, D. A., Beck, A., Rahm, A. K., Landsverk, J., Eastman, S., & Downs, S. M. (2009). The Use of Internet-Based Technology to Tailor Well-Child Care Encounters. PEDIATRICS, 124(1), e37–e43. https://doi.org/10.1542/peds.2008-3385

Davidson, M. A. (2008). Literature Review: ADHD in Adults. Journal of Attention Disorders, 11(6), 628–641. https://doi.org/10.1177/1087054707310878

Epstein, J. N., Johnson, D. E., Varia, I. M., & Conners, C. K. (2001). Neuropsychological Assessment of Response Inhibition in Adults With ADHD. Journal of Clinical and Experimental Neuropsychology, 23(3), 362–371. https://doi.org/10.1076/jcen.23.3.362.1186

Epstein, J. N., & Kollins, S. H. (2006). Psychometric Properties of an Adult ADHD Diagnostic Interview. Journal of Attention Disorders, 9(3), 504–514. https://doi.org/10.1177/1087054705283575

Evans, W. N., Morrill, M. S., & Parente, S. T. (2010). Measuring inappropriate medical diagnosis and treatment in survey data: The case of ADHD among school-age children. Journal of Health Economics, 29(5), 657–673. https://doi.org/10.1016/j.jhealeco.2010.07.005

Giuliano, K., & Geyer, E. (2017). ADHD: Overdiagnosed and overtreated, or misdiagnosed and mistreated? Cleveland Clinic Journal of Medicine, 84(11), 873.

Haavik, J., Halmøy, A., Lundervold, A. J., & Fasmer, O. B. (2010). Clinical assessment and diagnosis of adults with attention-deficit/hyperactivity disorder. Expert Review of Neurotherapeutics, 10(10), 1569–1580. https://doi.org/10.1586/ern.10.149

Haverkampf, C. J. (2010a). A Primer on Interpersonal Communication (3rd ed.). Dublin: Psychiatry Psychotherapy Communication Publishing Ltd.

Haverkampf, C. J. (2010b). Communication and Therapy (3rd ed.). Retrieved from http://www.jonathanhaverkampf.com

Haverkampf, C. J. (2017a). A Case of Severe ADHD. J Psychiatry Psychotherapy Communication, 6(2), 61–67.

Haverkampf, C. J. (2017b). A Case of Severe ADHD. J Psychiatry Psychotherapy Communication, 6(2), 31–36.

Haverkampf, C. J. (2017c). ADHD and Psychotherapy (2). Retrieved from http://www.jonathanhaverkampf.com/

Haverkampf, C. J. (2017d). Communication-Focused Therapy (CFT) (2nd ed.). Dublin: Psychiatry Psychotherapy Communication Publishing Ltd.

Haverkampf, C. J. (2017e). Communication-Focused Therapy (CFT) for ADHD. J Psychiatry Psychotherapy Communication, 6(4), 110–115.

Haverkampf, C. J. (2017f). Treatment-Resistant Adult ADHD. J Psychiatry Psychotherapy Communication, 6(1), 18–26.

Haverkampf, C. J. (2018a). A Primer on Communication Theory.

Haverkampf, C. J. (2018b). Communication-Focused Therapy (CFT) – Specific Diagnoses (Vol II) (2nd ed.). Dublin: Psychiatry Psychotherapy Communication Publishing Ltd.

Haverkampf, C. J. (2018c). Communication Patterns and Structures.

Katzman, M. A., Bilkey, T. S., Chokka, P. R., Fallu, A., & Klassen, L. J. (2017). Adult ADHD and comorbid disorders: clinical implications of a dimensional approach. BMC Psychiatry, 17(1), 302. https://doi.org/10.1186/s12888-017-1463-3

Kessler, R. C., Adler, L., Barkley, R., Biederman, J., Conners, C. K., Demler, O., … Zaslavsky, A. M. (2006). The Prevalence and Correlates of Adult ADHD in the United States: Results From the National Comorbidity Survey Replication. American Journal of Psychiatry, 163(4), 716–723. https://doi.org/10.1176/ajp.2006.163.4.716

Klassen, L. J., Katzman, M. A., & Chokka, P. (2010). Adult ADHD and its comorbidities, with a focus on bipolar disorder. Journal of Affective Disorders, 124(1–2), 1–8.

Kooij, S. J., Bejerot, S., Blackwell, A., Caci, H., Casas-Brugué, M., Carpentier, P. J., … Asherson, P. (2010). European consensus statement on diagnosis and treatment of adult ADHD: The European Network Adult ADHD. BMC Psychiatry, 10(1), 67. https://doi.org/10.1186/1471-244X-10-67

Koziol, L. F., & Stevens, M. C. (2012). Neuropsychological Assessment and The Paradox of ADHD. Applied Neuropsychology: Child, 1(2), 79–89. https://doi.org/10.1080/21622965.2012.694764

Kubik, J. A. (2010). Efficacy of ADHD Coaching for Adults With ADHD. Journal of Attention Disorders, 13(5), 442–453. https://doi.org/10.1177/1087054708329960

Lenartowicz, A., & Loo, S. K. (2014). Use of EEG to Diagnose ADHD. Current Psychiatry Reports, 16(11), 498. https://doi.org/10.1007/s11920-014-0498-0

Mäntylä, T., Still, J., Gullberg, S., & Del Missier, F. (2012). Decision Making in Adults With ADHD. Journal of Attention Disorders, 16(2), 164–173. https://doi.org/10.1177/1087054709360494

Marangoni, C., De Chiara, L., & Faedda, G. L. (2015, August 19). Bipolar Disorder and ADHD: Comorbidity and Diagnostic Distinctions. Current Psychiatry Reports, Vol. 17, pp. 1–9. https://doi.org/10.1007/s11920-015-0604-y

Mayes, S. D., Calhoun, S. L., Mayes, R. D., & Molitoris, S. (2012). Autism and ADHD: Overlapping and discriminating symptoms. Research in Autism Spectrum Disorders, 6(1), 277–285. https://doi.org/10.1016/j.rasd.2011.05.009

McCann, B. S., Scheele, L., Ward, N., & Roy-Byrne, P. (2000). Discriminant Validity of the Wender Utah Rating Scale for Attention-Deficit/Hyperactivity Disorder in Adults. The Journal of Neuropsychiatry and Clinical Neurosciences, 12(2), 240–245. https://doi.org/10.1176/jnp.12.2.240

Michielsen, M., Semeijn, E., Comijs, H. C., van de Ven, P., Beekman, A. T. F., Deeg, D. J. H., & Kooij, J. J. S. (2012). Prevalence of attention-deficit hyperactivity disorder in older adults in the Netherlands. British Journal of Psychiatry, 201(04), 298–305. https://doi.org/10.1192/bjp.bp.111.101196

Millstein, R. B., Wilens, T. E., Biederman, J., & Spencer, T. J. (1997). Presenting ADHD symptoms and subtypes in clinically referred adults with ADHD. Journal of Attention Disorders, 2(3), 159–166. https://doi.org/10.1177/108705479700200302

Musso, M. W., & Gouvier, W. D. (2014). “Why Is This So Hard?” A Review of Detection of Malingered ADHD in College Students. Journal of Attention Disorders, 18(3), 186–201. https://doi.org/10.1177/1087054712441970

Pettersson, R., Söderström, S., & Nilsson, K. W. (2018). Diagnosing ADHD in Adults: An Examination of the Discriminative Validity of Neuropsychological Tests and Diagnostic Assessment Instruments. Journal of Attention Disorders, 22(11), 1019–1031. https://doi.org/10.1177/1087054715618788

Ramos-Quiroga, J. A., Nasillo, V., Richarte, V., Corrales, M., Palma, F., Ibáñez, P., … Kooij, J. J. S. (2016). Criteria and Concurrent Validity of DIVA 2.0. Journal of Attention Disorders, 108705471664645. https://doi.org/10.1177/1087054716646451

Riccio, C. R., & Reynolds, C. R. (2006). Continuous Performance Tests Are Sensitive to ADHD in Adults but Lack Specificity. Annals of the New York Academy of Sciences, 931(1), 113–139. https://doi.org/10.1111/j.1749-6632.2001.tb05776.x

Rösler, M., Retz, W., Thome, J., Schneider, M., Stieglitz, R.-D., & Falkai*, P. (2006). Psychopathological rating scales for diagnostic use in adults with attention-deficit/hyperactivity disorder (ADHD). European Archives of Psychiatry and Clinical Neuroscience, 256(S1), i3–i11. https://doi.org/10.1007/s00406-006-1001-7

Ruiz, R. (2014). How childhood trauma could be mistaken for ADHD. The Atlantic.

Schoechlin, C., & Engel, R. (2005). Neuropsychological performance in adult attention-deficit hyperactivity disorder: Meta-analysis of empirical data. Archives of Clinical Neuropsychology, 20(6), 727–744. https://doi.org/10.1016/j.acn.2005.04.005

Sobanski, E. (2006). Psychiatric comorbidity in adults with attention-deficit/hyperactivity disorder (ADHD). European Archives of Psychiatry and Clinical Neuroscience, 256(S1), i26–i31. https://doi.org/10.1007/s00406-006-1004-4

Spencer, T. J., Adler, L. A., Meihua Qiao, M., Saylor, K. E., Brown, T. E., Holdnack, J. A., … Kelsey, D. K. (2010). Validation of the Adult ADHD Investigator Symptom Rating Scale (AISRS). Journal of Attention Disorders, 14(1), 57–68. https://doi.org/10.1177/1087054709347435

Sprafkin, J., Gadow, K. D., Weiss, M. D., Schneider, J., & Nolan, E. E. (2007). Psychiatric Comorbidity in ADHD Symptom Subtypes in Clinic and Community Adults. Journal of Attention Disorders, 11(2), 114–124. https://doi.org/10.1177/1087054707299402

Stevens, T., Peng, L., & Barnard-Brak, L. (2016). The comorbidity of ADHD in children diagnosed with autism spectrum disorder. Research in Autism Spectrum Disorders, 31, 11–18. https://doi.org/10.1016/j.rasd.2016.07.003

Suhr, J., Hammers, D., Dobbinsbuckland, K., Zimak, E., & Hughes, C. (2008). The relationship of malingering test failure to self-reported symptoms and neuropsychological findings in adults referred for ADHD evaluation. Archives of Clinical Neuropsychology, 23(5), 521–530. https://doi.org/10.1016/j.acn.2008.05.003

Szymanski, K., Sapanski, L., & Conway, F. (2011). Trauma and ADHD – Association or Diagnostic Confusion? A Clinical Perspective. Journal of Infant, Child, and Adolescent Psychotherapy, 10(1), 51–59. https://doi.org/10.1080/15289168.2011.575704

Taylor, A., Deb, S., & Unwin, G. (2011). Scales for the identification of adults with attention deficit hyperactivity disorder (ADHD): A systematic review. Research in Developmental Disabilities, 32(3), 924–938. https://doi.org/10.1016/J.RIDD.2010.12.036

Wilens, T. E., Biederman, J., Faraone, S. V, Martelon, M., Westerberg, D., & Spencer, T. J. (2009). Presenting ADHD symptoms, subtypes, and comorbid disorders in clinically referred adults with ADHD. The Journal of Clinical Psychiatry, 70(11), 1557–1562. https://doi.org/10.4088/JCP.08m04785pur

This article is solely a basis for academic discussion and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition. Neither author nor publisher can assume any responsibility for using the information herein.

Trademarks belong to their respective owners. Communication-Focused Therapy, the CFT logo with waves and leaves, Dr Jonathan Haverkampf, Journal of Psychiatry Psychotherapy and Communication, and Ask Dr Jonathan are registered trademarks.

This article has been registered with the U.S. Copyright Office. Unauthorized reproduction, distribution or publication in any form is prohibited. Copyright will be enforced.

This article is an expanded version of the article “The Diagnosis of ADHD in Adults” (2019) by the same author.

© 2020 Christian Jonathan Haverkampf. All Rights Reserved

Unauthorized reproduction, distribution and/or publication in any form is prohibited.

California Rocket Fuel – Combining Medication against Depression (1)

California-Rocket-Fuel-Combining-Medication-against-Depression-1-Christian-Jonathan-Haverkampf-psychiatry-series

A Review of Best Practice in the Treatment of ADHD (1)

A-Review-of-Best-Practice-in-the-Treatment-of-ADHD-1-Christian-Jonathan-Haverkampf-psychiatry-series

Communication-Focused Therapy (CFT) for Autism and Asperger Syndrome (2)

Communication-Focused-Therapy-CFT-for-Autism-and-Asperger-Syndrome-2-Christian-Jonathan-Haverkampf

Treatment of ADHD in Adults

Treatment-of-ADHD-in-Adults-2-Christian-Jonathan-Haverkampf-psychiatry-series