Centrality of Self-Criticism in Depression and Anxiety Experienced by Breast Cancer Patients Undergoing Short-Term Psychodynamic Psychotherapy

Abstract

Introduction

Depression and anxiety are prevalent in women suffering from breast cancer. However, the determinants of depression and anxiety in this population are not well known, particularly in the context of psychotherapy. Drawing from Blatt’s theory, we examined the role of Depressive Personality Vulnerability (DPV) in depression and anxiety experienced in female sufferers of breast cancer treated for depression as part of a Randomized Clinical Trial.

Methods

Seventy-eight patients were treated by Short-Term Psychodynamic Psychotherapy and 79 patients by Treatment as Usual. Assessments were conducted pre-treatment, at termination, and at six-month follow-up. Main outcomes were the depression and anxiety subscales of the Hospital Depression and Anxiety Scale. Predictors were pre-treatment dependency, self-criticism, and self-efficacy, assessed via the Depressive Experiences Questionnaire. Analyses targeted associations of these dimensions with baseline levels, main effects on pretreatment-termination and pretreatment-follow-up changes in depression and anxiety, and DPV by treatment interactions.

Results

Consistent with our hypotheses, self-criticism – implicated in previous research as a serious dimension of vulnerability to psychopathology – predicted elevated levels, as well as pretreatment-follow-up changes, in both depression and anxiety. However, self-criticism also augmented the effect of STPP (compared with TAU) on depression in the pretreatment-termination period.

Conclusions

These findings highlight the centrality of self-criticism for both risk and resilience processes in breast cancer.

DISCLOSURE STATEMENT

No potential conflict of interest was reported by the author(s).

STATEMENT OF ETHICS

The study was approved by the Ethics Committees of the State of Rhineland-Palatinate [reference number 837.380.06 (5478)] and the University of Leipzig [reference number 218-2007]. Following detailed information and written informed consent, eligible, consecutive patients were entered into the study and filled out the screening questionnaire.

AUTHOR CONTRIBUTIONS

GS conceived the analyses together with MB (PI of the original study); they wrote the paper together. RB conducted extensive literature reviews and contributed to the writing of the Introduction section. EB and RZ were co PIs of the original study, provided the data and contributed to the manuscript and its revisions.

Notes

1. CBT = Cognitive Behavioral Therapy, STPP = Short-Term Psychodynamic Psychotherapy, DPV = Depressive Personality Vulnerability, TAU= Treatment as Usual, ITT = Intent-to-Treat, DEQ = Depressive Experiences Questionnaire, RCT = randomized controlled trial, HADS = Hospital Anxiety and Depression Scale.

2. There is some evidence that the dependency factor of the DEQ is comprised of two subscales, one adaptive and the other maladaptive (e.g., Connectedness and Neediness, see Rude & Burnham, 1995). Campos et al. (2012) used this distinction between the two subscales of dependency in their cross-sectional study of distress in breast cancer, finding that neediness constitute a risk factor. We have repeated our analyses using the connectedness/neediness distinction, but did not find any difference between the two subscales. Nor did we detect any additional effect using this distinction. Hence, we present our results using the original DEQ-dependency factor.

3. An anonymous reviewer astutely suggested that two background variables may play a role in treatment outcome: 1. The interval time between measurements, which was larger in STPP than in TAU, and 2. Receiving past therapy, i.e., prior to the beginning of this trial. We examined these variables. With respect to interval time, it neither altered the results nor predicted outcome. With respect to past therapy, overall it did not change the results. However, we did find that past psychotherapy predicted depression and anxiety at follow-up (neither pretreatment or termination), but the direction of effect was opposite to this reviewer’s (and our) intuition: Those having past therapy reported a rank order increase in depression and anxiety at follow-up. In line with this effect, we also found consistent associations – cross-sectional and prospective – between past therapy and self-criticism. Thus, at least in this study, having past therapy is actually associated with a greater depressive personality vulnerability (=self-criticism) and more symptoms at follow-up. It is not clear why this is the case.

Additional information

Funding

As specified in Beutel et al. (2014), this work was supported by the German Cancer Aid [107457, 109379 and 107870, 109381]. Clinical Trial registration ISRCTN96793588.