Abhinav Anand (20/908)

Department of Psychology, Zakir Husain Delhi College, University of Delhi

528: B. A. (Hons.) Psychology

Dr. Nisha Jaiswal

November 18, 2022

Introduction

According to the American Psychological Association, “Cognitive distortions are inaccurate

thought patterns, beliefs, or perceptions that contribute to negative thinking. “Cognitive
distortions are negatively biased errors in thinking that are purported to increase vulnerability to
depression (Dozois & Beck, 2008). Internal mental filters or biases known as cognitive
distortions amplify our suffering, feed our worry, and reinforce our negative self-perceptions.
Cognitive distortions can result from poor methods of handling stressful situations. These ways
of thinking might occasionally be helpful wAhen we are dealing with a challenging
situation. When taken temporarily, they may lower stress levels or maintain self-esteem. In
response to circumstances, people have instinctive thoughts, which trigger emotional and
behavioral reactions. Automatic thoughts frequently reflect an individual's fundamental ideas
on critical facets of themselves, other people, and the universe. Though widespread, cognitive
distortions might be challenging to spot if you don't know what to look for. Many come to mind
automatically. Because of how ingrained they are, the thinker frequently is unaware of his or
her ability to alter them. Many eventually come to think that's the way things are. One's
mental health can be severely harmed by cognitive distortions, which can result in elevated
stress, sadness, and anxiety. These habitual thinking processes, if uncontrolled, can solidify and
have a detrimental impact on your ability to make sensible, logical judgments.

People frequently mix up distortions with dissonance, yet there are significant differences
between the two. Cognitive distortions are skewed viewpoints we adopt about ourselves and the
environment. We unwittingly encourage these unreasonable ideas and opinions throughout
time. For example, “I am a failure.” A scenario with opposing attitudes, beliefs, or behaviors is
referred to as cognitive dissonance. As a result, there is a mental discomfort that causes one of
the attitudes, beliefs, or actions to change in order to ease the discomfort and reestablish
equilibrium. For example, when people smoke (behavior) and they know that smoking causes
cancer (cognition), they are in a state of cognitive dissonance. The American Psychological
Association defines cognitive dissonance as "an unpleasant psychological state resulting from
inconsistency between two or more elements in a cognitive system." The mental discomfort that
occurs from having two contradictory views, values, or attitudes is referred to as cognitive
dissonance. Due to the desire for consistency in attitudes and perceptions, this conflict can
make people feel uneasy or uncomfortable.

Types of cognitive distortions

Aaron Beck first proposed the theory behind cognitive distortions and David Burns was
responsible for popularizing it with common names and examples for the distortions.

a. Filtering. - We take the negative details and magnify them while filtering out all
positive aspects of a situation. For instance, a person may pick out a single,
unpleasant detail and dwell on it exclusively so that their vision of reality becomes
darkened or distorted.

b. Polarized Thinking. - Things are either “black-or-white.” We have to be perfect or

we’re a failure–there is no middle ground. You place people or situations in
“either/or” categories, with no shades of gray or allowing for the complexity of
most people and situations. If your performance falls short of perfect, you see
yourself as a total failure.

c. Overgeneralization. - We come to a general conclusion based on a single incident or

piece of evidence. If something bad happens once, we expect it to happen over and
over again. A person may see a single, unpleasant event as a never-ending pattern
of defeat.

d. Jumping to Conclusions. - Without individuals saying so, we know what they are
feeling and why they act the way they do. In particular, we are able to determine
how people are feeling toward us. For example, a person may conclude that
someone is reacting negatively toward them and don’t actually bother to find out if
they are correct. Another example is a person may anticipate that things will turn
out badly, and will feel convinced that their prediction is already an established fact.

e. Catastrophizing. - We expect disaster to strike, no matter what. This is also referred

to as “magnifying or minimizing.” We hear about a problem and use what if
questions (e.g., “What if tragedy strikes?” “What if it happens to me?”). For
example, a person might exaggerate the importance of insignificant events (such as
 their mistake, or someone else’s achievement). Or they may inappropriately shrink
the magnitude of significant events until they appear tiny (for example, a person’s
own desirable qualities or someone else’s imperfections). Personalization. -
Thinking that everything people do or say is some kind of reaction to us. We also
compare ourselves to others trying to determine who is smarter, better looking, etc.
A person sees themselves as the cause of some negative external event that they
were in fact, not responsible for. For example, “We were late to the dinner party
and caused the hostess to overcook the meal. If I had only pushed my husband to
leave on time, this wouldn’t have happened.”

f. Control Fallacies. - If we feel externally controlled, we see ourselves as helpless a

victim of fate. For example, “I can’t help it if the quality of the work is poor, my
boss demanded I work overtime on it.” The fallacy of internal control has us
assuming responsibility for the pain and happiness of everyone around us. For
example, “Why aren’t you happy? Is it because of something I did?”

g. The fallacy of Fairness. - We feel resentful because we think we know what is fair,
but other people won’t agree with us. We are convinced that “Life is always fair.”
People who go through life applying a measuring ruler against every situation
judging its “fairness” will often feel bad and negative because of it.

h. Blaming. - We hold other people responsible for our pain, or take the other track
and blame ourselves for every problem. For example, “Stop making me feel bad
about myself!” Nobody can “make” us feel any particular way — only we have
control over our own emotions and emotional reactions.

Factors leading to cognitive distortions

Seeing that cognitive distortion has multiple causes is empowering because it gives us more
tools for breaking them down. It also allows us to more easily understand or explain how and
why a certain treatment or app works in certain cases but not others.

1. Cultural factors - For example, racism is highly cultural, and racist ideas are loaded
with cognitive distortions, including overgeneralizations, negative labelling, all-or-
 nothing thinking, and a “mental filter”, that lead to negative pictures of certain races
and positive pictures of others. The same goes for other biases, like sexism,
homophobia, etc.

2. Individual social factors - People pick up ideas, beliefs, and ways of thinking from
other people. If we are surrounded by people who we know, like, and trust, who are
telling or teaching us things that contain cognitive distortions, we will be likely
to pick them up. We also can pick things up from reading.

3. The pressure that leads people to make snap judgments - Cognitive distortions are
more easily unraveled when people have time to examine them, reflect on them,
question them, or even test them. If people are placed in a fast-paced environment
where they are forced to use oversimplified thinking, they will have more cognitive
distortions.

4. Fear, anger, and group conflict - When people are angry or afraid, they are more
likely to exhibit cognitive distortions, especially those relating to seeing others as an
enemy or threat. ‘Us vs them’ mentalities extend this to a group level, often
creating whole ideologies riddled with cognitive distortions.

5. Biochemical or physiological conditions - Biochemical and physiological

conditions, including nutritional deficiencies, genetic conditions, hormonal
disorders, side-effects of drugs, and all sorts of other micro factors can influence
thinking, increasing the likelihood of cognitive distortions. Things that elevate
stress, fear, or anger can lead to cognitive distortions characteristic of these feelings,
and things that lead to depression or depressed mood can lead to distortions, just as
things that contribute to a manic state can lead to an opposite type of distortions.
Similarly, things that maintain homeostasis and overall health (like exercise and a
well-balanced diet) tend to have a mitigating or protective effect against cognitive
distortions, by normalizing people’s mood or mental state.

6. Habit and the distortions themselves - Ways of thinking have a way of reinforcing
themselves. If a person thinks in a certain way for a long time, it can make it more
likely that they keep thinking in that way. Habit can include both patterns in the
 brain itself, and ways of thinking, and things that involve external behaviors, such
as a person engaging in choices or behaviors that reinforce their ways of thinking,
such as choosing to associate with people who reinforce their ways of thinking.

Other contributory factors that could trigger cognitive distortions are:

One’s subjective experiences (mood dependent, depressed, joyful, etc.) plays a role in the
cognitive interpretations of the event, and if such interpretations are falsely associated with a
potential payoff in that event, then it is imbibed in the thought process. It leads to cognitive
misrepresentation. The problem starts, when the evidence from our situation says, such
interpretations don't yield any payoffs, even though it might lead to potential loss. In such a
scenario, one’s inability to re-interpret and regulate their behaviour (analyzing the benefits,
risks and costs), allows the misrepresented reality to persist. It facilitates the momentary
distortion state to influence our decision-making mechanisms.

The other biological causes could be lack of adequate cognitive resources to perceive the
reality, or an underdeveloped cognitive system, or disorganized functional specialization of our
brain or the network of cognitive systems is not well configured. To illustrate this, the neural
circuits underlying each cognitive function, and how the rewiring leads to cognitive distortions
can be listed. I’ll just list the popular examples: Amygdala is often associated with the domain
of emotion; prefrontal cortex is often talked about in the context of decision making. One can
come up with many integrations of brain regions with amygdala, and prefrontal cortex, the
functional networks can be drawn. If any improper configuration is found in these networks, it
will deter cognitive control. Genetics, and personality traits, such as resilience, persistence, and
attitude also play crucial roles and may lead to cognitive distortions.

Severe psychological trauma suffered as a child, such as emotional, physical, or sexual abuse
predispose a person to develop cognitive distortions later in their life.
Risk factors that increase the chances of distortions

Genetics as a risk factor

There is evidence of heritability in depression. That is, people who are genetically similar are
more likely to experience depression than those who are genetically dissimilar. Research
findings of this type often result in people erroneously assuming that if someone you are
genetically similar to–such as a parent–has suffered from depression, it necessarily means
that you will suffer from it. It actually means that you are more vulnerable to
experiencing depression if someone you are genetically similar to has suffered from it.

Whether a genetic risk factor results in you actually suffering from depression depends on
whether it is combined with an ‘environmental trigger’ which results in the depression
manifesting itself. These environmental triggers typically involve significant stress in one
or more key aspects of your life such as work or school, relationships and finances.

If one is able to manage their life in such a manner that these significant stressors do not occur
or are short-lived, there is less likelihood that being at risk for depression because of genetics
will manifest itself in them experiencing depression. If these stressors occur for an extended
period of time without being able to reduce or eliminate them, there is an increased likelihood
that the genetic vulnerability will result in their experiencing depression.

Cognitive risk factors

Cognitive risk factors for depression involve tendencies to interpret events in negatively
distorted ways. The result is that when a stressful life event occurs, it is likely to trigger
depression because of the tendency to interpret these events in a manner which has a negative
effect on mood. For example, if a person’s thinking is such that they tend to jump to
conclusions without sufficient evidence, then if someone close to them were upset they may
assume without sufficient evidence that they were the reason the person was upset.

In other words, their tendency to think in negatively distorted ways would be a risk factor
which combined with an environmental trigger—someone close to them being upset—would
result in their experiencing depression. In this example, were the person not to have the risk
factor of distorted thinking that same environmental event—the person being upset—would
have been less likely to trigger an experience of depression.

Cognitive risk factors for depression can also involve negative ‘underlying assumptions’
which guide people’s thinking as they enter situations such as “If I approach someone, they
won’t like me”. Often accompanying negative underlying assumptions are negative core
beliefs. These are deeply held negative views of oneself, other people or the world such as “I
am inadequate” “People are malicious” and “The world is scary”. These deeply held negative
ways of thinking serve as additional cognitive risk factors for depression because they are
often brought to the surface when stressful events occur with a resulting negative effect on
one’s mood.

Unlike with genetics, when a person has negative thinking tendencies, they can take steps
to make this less of a risk factor for depression.

Effects of cognitive distortions

While Beck did not believe distorted thinking directly caused mental health concerns, he did find
cognitive distortions to be a factor in the development of chronic conditions.

Cognitive distortions have been linked to the following:

1. Depression

Depression is a mood illness characterized by chronic sadness, emptiness, and loss

of joy. It is distinct from the mood swings that most individuals encounter on
a daily basis. Major life events, such as death or job loss, might set off depression.

2. Anxiety

Anxiety can mean nervousness, worry, or self-doubt. Sometimes, the cause of

anxiety is easy to spot, while other times it may not be. Everyone feels some level
of anxiety once in a while. But overwhelming, recurring, or “out of nowhere” dread
can deeply impact people.

3. Psychotic episodes
 Psychosis is a state of mind that involves disruptions in areas of brain functioning
including cognition, perception, processing, and emotion. Historically, psychosis
was used to refer to any mental health condition that interfered with normal
functioning. Currently, the most common definition of psychosis is an episode that
causes someone to disconnect in some way from reality.

4. Obsessions and compulsions

Obsessions are persistent, unwanted thoughts about a certain topic. Compulsions

are repetitive behaviors or mental acts which one feels compelled to perform.
People diagnosed with obsessive compulsive disorder (OCD) often act out
compulsions in response to their obsessions.

5. Stress

Stress is often defined as a bodily response to the demands of life. But there are also
emotional and mental aspects of stress. It is experienced as thoughts and feelings as
well as in the body.

6. Sleep issues

Sleep-wake disorders are marked by disturbances in sleep patterns. They may

impact

physical, mental, and emotional health. External factors can cause sleep disorders.
These may include anxiety, depression, trauma, or a life transition.

7. Suicidal ideation

Suicidal ideation is a common medical term for thoughts about suicide. Thoughts
may be fleeting in nature, or they may persist and resolve into a formulated plan.
Many people who experience suicidal thoughts do not die by suicide, although they
may exhibit suicidal behavior or make suicide attempts. People who find
themselves experiencing suicidal thoughts or behaviors may find that they do so as
a result of conditions such as depression, hopelessness, severe anxiety, insomnia, or
panic attacks. Not all people who are diagnosed with these or other medical or
mental health conditions will experience suicidal ideation, but some may.
Treatment of cognitive distortion

Various activities may be effective in treating cognitive distortions. Before treatment starts, the
distortion typically being addressed will be recognized. This makes it more likely that the
treatments will be suitable for the particular sort of distorted thinking being experienced.

Some techniques commonly used in therapy:

1. The double-standard method: This method involves positive, compassionate

self-talk, such as the type of talk a person might use to encourage a friend.

2. The survey method: People in therapy are encouraged to take the opinions of other
people into account in order to gauge whether their attitudes are realistic.

3. Analyzing the evidence involves thoroughly examining an experience with the

purpose of objectively determining any realistic basis for negative thinking.

4. Thinking in shades of gray can help a person examine an experience or situation

on a scale from 0-100 instead of taking an all-or-nothing approach.

5. Reattribution involves examining a problematic situation to determine what

external factors may have contributed to the event, rather than solely blaming the
self.

Therapy can often help people become more aware of the cognitive distortions affecting
thoughts and behavior. Those who experience more extreme forms of distorted thinking may
benefit from cognitive restructuring in work with a qualified mental health professional.
Therapy forms such as rational emotive behavioral therapy (REBT) and cognitive behavioral
therapy (CBT) have been shown to be effective in the process of readjusting automatic
thoughts, improving moods, and fostering positive behaviors and a greater sense of well-being.

Rational Emotive Behavioral Therapy (REBT), developed by Albert Ellis in 1955 and
originally called rational therapy, laid the foundation for what is now known as cognitive
behavioral therapy. REBT is built on the idea that how we feel is largely influenced by how we
think. As is implied by the name, this form of therapy encourages the development of rational
thinking to facilitate healthy emotional expression and behavior.

Cognitive behavioral therapy (CBT) is a short-term form of behavioral treatment. It helps

people problem-solve. CBT also reveals the relationship between beliefs, thoughts, and
feelings, and the behaviors that follow. Through CBT, people learn that their perceptions
directly influence how they respond to specific situations. In other words, a person’s thought
process informs their behaviors and actions.

Definition of depression

Depression is a mood illness characterized by chronic sadness, emptiness, and loss of joy. It is
distinct from the mood swings that most individuals encounter on a daily basis. Major life
events, such as death or job loss, might set off depression. However, depression is separate
from the negative emotions that a person may experience temporarily in response to a traumatic
life event. It is distinguished by prolonged sadness and a loss of interest or pleasure in formerly
rewarding or pleasurable activities. It can also interfere with sleep and appetite. Tiredness and
lack of attention are common symptoms. Depression is a leading cause of disability around the
world and makes a major contribution to the global burden of disease. Depression's
consequences can be long-lasting or recurring, and they can significantly impact on a person's
capacity to function and live a fulfilling life. (American Psychological Association)

Prevalence of depression

Depression is a prevalent illness worldwide, affecting an estimated 3.8% of the population,

including 5.0% of adults and 5.7% of persons over the age of 60. Approximately 280 million
people in the world suffer from depression including 2.7% of men and 4.1% of women.

Types of depression

Major depressive disorder

Diagnostic criteria for major depression requires a person to be in depressive episode and never
have manic, hypomanic or mixed episodes. Depressive episodes are marked by losing interest
in formerly pleasurable activities for at least 2 weeks and depressed mood. Other symptoms
such as change in sleep or appetite, or feeling of worthlessness, weight loss or gain, feeling
restless and agitated, or else very sluggish and slowed down physically or mentally, being tired
and without energy, having trouble concentrating or making decisions, thoughts of suicide etc.
might be seen in person suffering from MDD.

Persistent Depressive Disorder

Persistent depressive disorder is characterized by persistently depressed mood most of the day,
for more days than not, for at least 2 years. This term is used to describe two conditions
previously known as dysthymia (low-grade persistent depression) and chronic major
depression. In addition, individuals must have at least two of six additional symptoms when
depressed. Periods normal mood may occur briefly, but they usually last for only a few days to
a few weeks (and for a maximum of 2 months). These intermittently normal moods are one of
the most important characteristics distinguishing consistent depressive disorder from MDD.
Nevertheless, in spite of the intermittently normal moods, because of its chronic course people
with persistent depressive disorder show poorer outcomes and as much impairment as those
with major depression.

Postpartum Depression

Pregnancy can bring about significant hormonal shifts that can often affect a woman's moods.
Depression can have its onset during pregnancy or following the birth of a child.
Currently

classified as depression with peripartum onset, postpartum depression is more than that just the
‘baby blues. Mood changes, anxiety, irritability, and other symptoms are not uncommon after
giving birth and often last up to two weeks. PPD symptoms are more severe and longer-lasting.
Such symptoms can include low mood, feelings of sadness, severe mood swings, social
withdrawal, trouble bonding with your baby, appetite changes, feeling helpless and hopeless,
loss of interest in things you used to enjoy, feeling inadequate or worthless, thoughts of hurting
yourself or your baby etc. Postpartum Depression can range from a persistent lethargy and
sadness that requires medical treatment all the way up to postpartum psychosis, a condition in
which the mood episode is accompanied by confusion, hallucinations, or delusions. If left
untreated, the condition can last up to a year. Fortunately, research has found that treatments
such as antidepressants, counseling, and hormone therapy can be effective.

Premenstrual Dysphoric Disorder

This disorder is diagnosed if a woman has had a certain set of symptoms in the majority of her
menstrual cycles for the past year. In particular, she must have at least one of the following four
symptoms in the final week before the onset of menses; these symptoms must start to improve
within a few days after the onset of menses, and become minimal or absent in the week post-
menses. The four symptoms of which one must occur include (1) marked affective lability such
as mood swings; (2) marked irritability or anger or increased interpersonal conflicts; (3) marked
depressed mood or feeling of hopelessness or self-deprecating thoughts or (4) marked anxiety,
tension or feeling of being keyed up. This is one form of depression where hormones clearly
play an important role.

Atypical Depression

Atypical depression (current terminology refers to this as depressive disorder with atypical
features) is a type of depression that doesn't follow what was thought to be the "typical"
presentation of the disorder. Atypical depression is actually more common than the name might
imply. Unlike other forms of depression, people with atypical depression may respond better to
a type of antidepressant known as a monoamine oxidase inhibitor (MAOI). Various symptoms
include:

❖ Excessive eating or weight gain

❖ Excessive sleep

❖ Fatigue, weakness, and feeling "weighed down"

❖ Intense sensitivity to rejection

❖ Strongly reactive moods

Causal factors

Biological Factors

Genetic Influences

Family studies have shown that the prevalence of mood disorders is approximately two to three
times higher among blood relatives of persons with clinically diagnosed unipolar depression
than it is in the population at large (e.g., Levinson, 2006, 2009; Wallace et al., 2002). More
importantly, however, twin studies, which can provide much more conclusive evidence of
genetic influences on a disorder, also suggest a moderate genetic contribution to unipolar
depression. Evidence for a genetic contribution to milder but chronic forms of unipolar
depression such as dysthymia is very slim, probably because there has been very little research
on the topic (Klein, 2008). However, it seems very probable that there is a genetic. contribution
to dysthymia because of its strong link to elevated levels of the personality trait neuroticism.

Neurochemical Factors

Evidence suggests that depression may arise from disruptions in the balance of
neurotransmitters. These are substances that regulate and mediate the activity of the brain's
nerve cells. Early attention in the 1960s and 1970s focused primarily on norepinephrine and
serotonin. Electroconvulsive therapy and antidepressant medications were used to treat severe
mood disorders. The monoamine neurotransmitters are involved in the regulation of behavioral
activity, stress, emotional expression, and vegetative functions (involving appetite, sleep, and
arousal).

Thase & Denko, 2008: Some studies have found exactly the opposite of what is predicted by
the monoamine hypothesis. This could be because of altered functioning of postsynaptic
receptors (Thase, 2009; Thase et al., 2002).

Neurophysiological and Neuroanatomical Influence

People with depression show an imbalance between activity in the left and right sides of the prefrontal
regions of the brain. The left-sided activity is thought to be related to symptoms of reduced positive affect
and approach behaviors to rewarding stimuli. The right-side activity is associated with increased vigilance
for threatening information. Abnormalities have also been detected in several other brain areas in patients
with depression. This could be related to their biased attention to negative emotional information.
Evidence of decreased volume in never-depressed individuals suggest reductions in hippocampal volume
may precede the onset of depression (Chen et al., 2010).

Sleep and Other Biological Rhythms

Sleep is a cycle of five stages that occur throughout the night. REM sleep (rapid eye
movement sleep) is characterized by rapid eye movements and dreaming as well as other
bodily changes. Research has found that many patients with depression enter the first period
of REM sleep after only 60 minutes or less of sleep.

Circadian Rhythms

Humans have many circadian (24-hour, or daily) cycles other than sleep, including body
temperature, propensity to REM sleep, and secretion of cortisol, thyroid-stimulating hormone,
and growth hormone (Thase, 2009; Thase et al., 2002). These circadian rhythms are controlled
by two related central “oscillators,” which act as internal biological clocks. Research has found
some abnormalities in all of these rhythms in patients with depression, though not all patients
show abnormalities in all rhythms (Howland & Thase, 1999; Thase, 2009). Although the exact
nature of the dysfunctions is not yet known, some kind of circadian rhythm dysfunction may
play a causal role in many of the clinical features of depression. Two current theories are (1)
that the size or magnitude of the circadian rhythms is blunted, and (2) that the various circadian
rhythms that are normally well synchronized with each other become desynchronized or
uncoupled (Howland & Thase, 1999; Thase et al., 2002).

Sunlight and Seasons

Another, rather different kind of rhythm abnormality or disturbance is seen in people with
seasonal affective disorder, in which most of those affected seem to be responsive to the
totalquantity of available light in the environment (Oren & Rosenthal, 1992). A majority
(but not all) become depressed in the fall and winter and normalize in the spring and
summer (Goodwin & Jamison, 2007; Howland & Thase, 1999). Research in animals has
also documented that many seasonal variations in basic functions such as sleep, activity,
and appetite are related to the amount of light in a day (which, except near the equator, is
much greater in summer than in winter). Patients with depression who fit the seasonal
pattern usually show increased appetite and hypersomnia rather than decreased appetite and
insomnia (Howland & Thase, 1999). They also have clear disturbances in their circadian
cycles, showing weaker 24-hour patterns than are found in individuals who are not
depressed (Goodwin & Jamison, 2007; Howland & Thase, 1999). A good deal of research
on patients with seasonal affective disorder supports the therapeutic use of controlled
exposure to light, even artificial light, which may work by reestablishing normal biological
rhythms (Fava & Rosenbaum, 1995; Goodwin & Jamison, 2007). Although anti-depressant
medications can also be useful, the use of light therapy is more cost-efficient in the long
term (Cheung et al., 2012).

Psychological Causal Factors

The evidence for important psychological causal factors in most unipolar mood disorders is at
least as strong as the evidence for biological factors. However, it is likely that the effects of at
least some psychological factors such as stressful life events are mediated by a cascade of
underlying biological changes that they initiate. One way in which stressors may act is through
their effects on biochemical and hormonal balances and on biological rhythms (Hammen,
2005; Monroe, 2008).

Stressful Life Events as Causal Factors

Psychological stressors are known to be involved in the onset of a variety of disorders, ranging
from some of the anxiety disorders to schizophrenia. Many studies have shown that severely
stressful life events often serve as precipitating factors for unipolar major depression. People
with depression who have experienced a stressful life event tend to show more severe
depressive symptoms. An important distinction has been made between stressful life events that
are independent of the person’s behavior and personality (independent life events, such as
losing a job because one’s company is shutting down or having one’s house hit by a hurricane)
and events that may have been at least partly generated by the depressed person’s behavior or
personality (dependent life events).
Mildly Stressful Events and Chronic Stress

Whether mildly stressful events are also associated with the onset of depression is much more
controversial, with conflicting findings in the literature. However, studies applying the more
sophisticated and complex strategies for assessing life stress have generally not found minor
stressful events to be associated with the onset of clinically significant depression (e.g.,
Dohrenwend et al., 1995; Stueve et al., 1998). A number of good studies have demonstrated
that chronic stress is associated with increased risk for the onset, maintenance, and recurrence
of major depression.

Vulnerability and Responses to Stressors

There are important individual differences in how people respond to the experiences of episodic
or chronic life stress. Women at genetic risk for depression are three times more likely to
respond to severely stressful life events with depression, while those at low genetic risk are less
vulnerable. In the past 25 years, researchers have sought to determine which vulnerability and
protective factors are most powerful in predicting onset and maintenance of depression.

Effects of depression

Depression can have a strong effect on every aspect of your life, such as the way you sleep and
eat, your education and career, your relationships, and your health. People suffering from
depression frequently have comorbid disorders, such as alcohol and drug abuse or other
addictions. Depression does not only affect the patient, but also the people around him, such as
his friends, his family, and his co-workers. Moreover, depression may also affect your
performance at work and your concentration. To sum up, depression can impact one’s personal,
academic or/and professional life.

As the field of clinical behavior analysis grows, it will benefit from analyses of increasingly
complex and common clinical phenomena, especially those with significant public health
implications. One such phenomenon is clinical depression, considered to be the “common
cold” of outpatient populations. Up to 25 million people in the United States alone meet criteria
for some type of depressive disorder in a given year (M. B. Keller, 1994). Depressive disorders
also result in considerable financial expenditure including time spent away from the
workplace and an increase in health care costs. Based on broad measures that include work
absenteeism, treatment costs, and other factors, the annual economic cost of depressive
disorders in the United States may be over $40 billion (Antonouccio, Thomas, & Danton,
1997). Suicide is the ultimate cost.

Perhaps nowhere in clinical psychology is the medicalization of behavioral problems more

complete than with depression. Depression is largely seen by the general public and mainstream
media as a neuropsychiatric illness (e.g., Wingert & Kantrowitz, 2002) with a fluctuating
course that is best described in disease-state terms such as disorder, episodes, remission,
recovery, relapse, and recurrence (Frank et al., 1991). An additional assumption is that this
disorder may be diagnosed and labeled using the symptom checklists of the standard diagnostic
system, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American
Psychiatric Association, 2000). The basic ontological assumption is that depression is an illness
that occurs episodically and can be described adequately in medical terms. Thus, more
depression is treated in primary care than in any other mental health or health care setting
(Kessler, McGonagle, Swartz, Blazer, & Nelson, 2003; Shapiro, 1984), and guidelines for
treatment in these settings recommend antidepressant treatment without specialty referral unless
the patient has complicating factors such as comorbid substance use or suicide risk (Schulberg,
Katon, Simon, & Rush, 1998). Even in these cases, speciality referral is first to psychiatry for
medication management, and only a small number of individuals diagnosed with depression
will be seen by a clinical psychologist, much less a behaviorally oriented practitioner.

The Effects of Depression on Your Body

Depression is technically a mental disorder, but it also has a strong effect on your physical
health. Clinical Depression can interrupt your day-to-day life and cause a ripple effect of
additional symptoms on your entire body.

❖ Central Nervous System

Older people may experience issues recognizing cognitive changes as it is quite easy to
dismiss the indications of depression as identified with "getting older". According to the
American Psychological Association, older adults who are suffering from depression have
trouble with memory loss and reaction time during regular activities when compared to
more youthful grown-ups with depression. Abnormal function of brain messengers
(neurotransmitters), for example, serotonin, can change your pain tolerance. This implies
that you become progressively sensible to pain, particularly back pain. Subsequently,
depression can cause migraines, chronic body throbs, and pain that may not react to
prescription.

Individuals with depression may have trouble keeping up an ordinary work routine or
satisfying social norms. This could be due, for example, to the inability to concentrate on
work-related problems and difficulty in making decisions. They can also suffer memory
losses.

A few people who are depressed may resort to alcohol or medications, which would make
them more vulnerable to reckless behaviour. Someone with depression may deliberately
abstain from discussing his issues or attempt to cover them. Individuals who suffer from
depression may end up attempting suicide or harming themselves.

❖ Digestive System

Depression may play a substantial part in impacting one’s appetite. Some depressed
individuals can react by overeating. This can lead to weight increase and obesity-related
illnesses. One may even lose his/her appetite completely or neglect to eat the correct
quantity of food. An abrupt loss of enthusiasm for eating in older adults can prompt a
condition called geriatric anorexia. Eating issues can provoke malnutrition, and
constipation and consequently weaken your body's resistance to germs hence causing more
serious diseases.

❖ Cardiovascular & Immune Systems

Depression and stress are tightly related. Stress can increase your blood pressure and
prompt coronary illness. Repeated cardiovascular issues are more connected to depression
than to other conditions like smoking, diabetes, hypertension, and elevated cholesterol.
Depression and stress may negatively affect the resistant framework, making you more and
more vulnerable to contaminations and diseases.
 Both somatic and cognitive symptoms of depression significantly correlate with
psychosocial functioning even after controlling for the effects of pain level, trait anxiety,
and trait anger. Somatic symptoms of depression were significantly correlated with
physical functioning after pain level, anxiety and anger were controlled. (Holzberg 2017)

Treatment of depression

Various psychological treatments are available for depressive disorders. Some of them are
briefly listed below. In general, a combination of an antidepressant plus a psychological
treatment is better than either treatment alone. Typically, most psychological treatments for
depression last in the range of 12-20 weekly sessions of 1-2 hours per session.

Those most commonly used for moderate or severe depression are:

❖ Cognitive Behavioural Therapy (CBT)

CBT is a combination of cognitive therapy and behavioural therapy. In short, CBT helps people
to achieve changes in the way that they think, feel and behave.

Cognitive behavioral therapy (CBT) is one of the most evidence-based psychological

interventions for the treatment of several psychiatric disorders such as depression, anxiety
disorders, somatoform disorder, and substance use disorder. The uses are recently extended to
psychotic disorders, behavioural medicine, marital discord, stressful life situations, and many
other clinical conditions.A sufficient number of researches have been conducted and shown the
efficacy of CBT in depressive disorders. A meta-analysis of 115 studies has shown that CBT is
an effective treatment strategy for depression and combined treatment with pharmacotherapy is
significantly more effective than pharmacotherapy alone. Evidence also suggests that the
relapse rate of patients treated with CBT is lower in comparison to the patients treated with
pharmacotherapy alone.Treatment guidelines for depression suggest that psychological
interventions are an effective and acceptable strategy for treatment. Psychological interventions
are most commonly used for mild-to-moderate depressive episodes. As per the prevailing
situations in India with regards to significantly lesser availability of trained therapists in most of
the places and patients' preferences, pharmacological interventions are offered as the first-line
treatment modalities for the treatment of depression.
Patients with severe depression with psychosis and/or suicidality might be difficult to manage
with CBT alone and need medications and other treatments before considering CBT. Organicity
should be ruled out using clinical evaluation and relevant investigations, as and when required.

A detailed diagnostic assessment is needed for the assessment of psychopathology, premorbid

personality, diagnosis, severity, presence of suicidal ideations, and comorbidities. A baseline
assessment of severity using a brief scale will be helpful in mutual understanding of severity
before starting therapy and also to track the progress. Clients with a depressive illness often
fail to recognize early improvement and undermine any positive change. An objective rating
scale hence helps in pointing out the progress and can also help in determining the agenda
during the therapy process. Beck Depression Inventory (A. T. Beck, Steer, and Brown, 1996),
the Depression Anxiety Stress Scales (Lovibond and Lovibond, 1995), Montgomery-Asberg
Depression Rating Scale, and Hamilton Rating Scale for Depression are useful rating scales for
this purpose. The assessment for CBT in depression is, however, different from diagnostic
assessment.

Interpersonal Psychotherapy (IPT)

Interpersonal psychotherapy (Klerman, Weissman, Rounsaville, & Chevron, 1984) focuses on

resolving interpersonal problems and stresses in existing relationships and/ or building the
skills to form important new interpersonal relationships. IPT is based on the idea that our
personal relationships may play a large role in affecting our mood and mental state. The
therapist helps us to change our thinking and behaviour and improve our interaction with
others. For example, IPT may focus on issues such as bereavement or disputes with others that
may be contributing to depression. Interpersonal therapy, or IPT, is a short-term, focused
treatment for depression.

Studies have shown that IPT, which addresses interpersonal issues, maybe at least as effective
as short-term treatment with antidepressants for mild to moderate forms of clinical depression.

Originally developed to treat depression in adults, it has been shown to be effective in treating
adolescent depression and is commonly recommended as a treatment for depression in
children. Events surrounding interpersonal relationships do not cause depression. But
depression occurs within an interpersonal context and affects relationships and the roles of
people within those relationships. By addressing interpersonal issues, interpersonal therapy for
depression puts emphasis on the way symptoms is related to a person's relationships, including
family and peers.

The immediate goals of treatment are rapid symptom reduction and improved social
adjustment. The long-term goal is to enable people with depression to make their own needed
adjustments. When they can do that, they are better able to cope with and reduce depressive
symptoms.

Interpersonal therapy is a manual-based treatment. That means the therapist strictly adheres to a
treatment process whose effectiveness is supported by evidence. IPT is a short-term treatment
option that typically consists of 12 to 16 one-hour weekly sessions. The therapist focuses on
identifiable problems in how an individual interacts with or doesn't interact with others. When
those problems are addressed, the patient realizes a benefit in their experience of symptoms.

Except to check on their severity and the effect of the various treatments, symptoms are not
addressed in therapy sessions. Instead, the therapist works collaboratively with the patient,
either individually or in a group, to identify and then address one or two significant problems in
their interactions. The number of problems addressed is deliberately limited to one or two for
the whole course of treatment. The result is an intense focus on how to make the necessary
adjustments in interpersonal situations that will help reduce symptoms of depression.

The types of problems addressed fall into four categories:

1. Interpersonal disputes or conflicts. These disputes occur in marital, family, social,

school, or work settings. The disputes emerge from differing expectations of a
situation. They become a problem that needs to be addressed when the conflicts
that come from the expectations lead to significant distress.

2. Role transitions. Changing circumstances, whether they're developmental, stem

from shifts in work or social settings, or result from a life event or end of a
relationship, require adaptations from the individual. With depression, those
changes are felt as losses and contribute to the depression.
 3. Grief. In IPT, grief is the experience of loss through death. Grief becomes a
problem when it is delayed or becomes excessive so that it lasts beyond the
normal time for bereavement.

4. Interpersonal deficits. This refers to the patient reporting "impoverished"

personal relationships either in number or in quality.

Interpersonal therapy typically takes place in one-hour sessions, usually weekly, that continues
for 12 to 16 weeks. Depending on the severity of the depression, sessions might be continued
for an additional four or more weeks. If you were being treated for depression with
interpersonal therapy, the first few sessions, usually from one to three weeks, would be used for
assessing your depression, orienting you to the IPT focus and process, and identifying specific
interpersonal issues or problems you have. Together, you and the therapist would create a
record of your interpersonal issues, rank them, and decide which one or two issues seemed
most important to address in terms of your depression. At least the next eight sessions would be
focused on addressing those issues -- understanding them more, looking for adjustments that
you can make, and then applying those adjustments. Throughout this portion of the therapy, the
therapist would use a number of different techniques, including among others:

Clarification, which has the purpose of helping you recognize and get beyond your own biases
in understanding and describing your interpersonal issues.

● Supportive listening.

● Role-playing.

● Communication analysis.

Encouragement of affect is a process that will let you experience unpleasant or unwanted
feelings and emotions surrounding your interpersonal issues in a safe therapeutic environment.
When you do, it becomes easier to accept those feelings and emotions as part of your
experience. The entire focus of the sessions will be on addressing the identified issues. This is
hard for some individuals to get used to -- especially those who are familiar with more
traditional, open-ended and introspective approaches to therapy. It may take you several weeks
before your own primary focus shifts to the IPT approach. Another important aspect of the IPT
process is an emphasis on terminating therapy. From the beginning, the patient is aware that
therapy is defined by a limited amount of time. In the final four or so weeks of therapy, the
sessions will turn to termination issues. With IPT, termination of therapy is seen as a loss to be
experienced by the patient. So you would be asked to consider what the loss means to you.
What issues does it bring up, and how can you apply the interpersonal adjustments that you've
learned to make over the course of therapy to evaluate and get through the loss? The idea is for
the patient to become more aware of their ability to deal with interpersonal problems that have
kept them from being able to actively manage the symptoms of depression.

Review of Literature

Aiman et al (2021) conducted a study to contribute as well as spread knowledge to the

community's understanding of coping strategies, cognitive distortions and depression. Further,
this research also examined the association among coping strategies, cognitive distortions and
depression in university students. A purposive sampling technique and cross-sectional study
design were used to carry out current study. Two hundred participants (male, n= 100; female,
n= 100) with age ranged from 18 to 26 (M= 22.6, SD= 1.10) years were recruited from different
public and private university students of Rawalpindi and Islamabad, Pakistan, in 2021. Three
instruments were used to measure cognitive distortions, coping strategies, and symptoms of
depression in university students. This present study’s results illustrated that cognitive
distortion was statistically positively significant associated with denial coping strategy,
emotional support coping strategy, behavioral disengagement coping strategy, self-blame
coping strategy, and depression in university students.

Bartczak et al (2015) in this study aimed to see if and how the intensity of depression
correlates with the cognitive representation of notions, and if any influence is reversed during
remission. The cognitive representation indices used were the valence and number of metaphors
produced for a notion. Three adult groups took part: persons with depression (n = 30), persons
in remission (n = 12), and a control group (n = 30). Five notions were considered: PAST,
FUTURE, JOY, SADNESS, and HAPPINESS. The Questionnaire of the Metaphorical
Conceptualization of a Notion was used. The results showed that (a) depressive subjects did
not have problems with metaphorical processing,

(b) depressive subjects demonstrated strong interpretational negativism, (c) subjects during
remission did not present distorted conceptual processing. The results are discussed in the
context of theories of automatic metaphor processing, and conceptions of cognitive depressive
distortions, in tasks requiring effort and substantial involvement of cognitive resources.

Blake et al (2018) in their paper aimed to describe CEs in depressed patients and examined the
relationship between CEs and the severity of depression. Participants (N = 45) undergoing
cognitive therapy were assessed for CEs and for depression in session three using the Cognitive
Errors Rating System and the Beck Depression Inventor. Participants had more negative CEs
than positive, and the most prevalent cluster of CEs was a selective abstraction. Participants
deemed as being “high distorters” on the CERS had significantly more negative CEs, but not
positive CEs, than “low distorters” despite not differing on BDI scores. Psychotherapy research
and practice implications are discussed.

Caouette et al (2016) tested ECI in a social context to examine how depression relates to
affective responses to social acceptance and rejection outcomes. Furthermore, they aimed to
identify cognitive mechanisms linking depression with affective response to social feedback.
Finally, they tested whether these processes are similar for social anxiety.90 participants (age
18–26 years; 53 women) completed the two-visit Chatroom task. At Visit 1 they rated their
expectations about being liked by 60 peers. At Visit 2 they completed self-reports of depressive
and social anxiety symptoms, and of cognitive flexibility, then received acceptance or rejection
feedback from each peer and rated their affective response. Greater depressive symptoms
related to negative expectancy bias, lower cognitive flexibility, and less positive affective
response to acceptance, but did not relate to rejection. Negative expectations and cognitive
flexibility mediated the relationship between depressive symptoms and affective response for
acceptance; only negative expectations mediated rejection responses. These cognitive
mechanisms were not related to social anxiety.

Jager-Hyman. et al (2014) examined whether those who recently attempted suicide are more
likely to engage in cognitive distortions than those who have not recently attempted suicide in
an ethnically diverse sample. To achieve this aim, various ognitive distortions that
demonstrated adequate reliability were examined in individuals who recently attempted suicide
and psychiatric controls including externalizing of self-worth, fortune telling, comparison to
others, magnification, labeling and arbitrary inference. In this study, 111 participants who
attempted suicide in the 30 days prior to participation and 57 psychiatric control participants
were considered and their cognitive distortions, depression, and hopelessness were measured.
The Inventory of Cognitive Distortions was used to assess cognitive distortions and Beck
Depression Inventory-II was used. Individuals who recently attempted suicide scored
significantly higher on the BDI than individuals in the psychiatric control group. Findings of
the study support the hypothesis that individuals who recently attempted suicide are more likely
than psychiatric controls to experience cognitive distortions, even when controlling for
depression and hopelessness. Fortune telling was the only cognitive distortion uniquely
associated with suicide attempt status. However, fortune telling was no longer significantly
associated with suicide attempt status when controlling for hopelessness.

Katherine (2014) built upon the previous academic literature which consistently found that
poets and writers suffer from higher rates of psychological disturbance than the general
population with an analysis of what is lacking in the research. Her study examined cognitive
distortions, a known indicator of depression, in writing samples of 36 eminent depressed
authors and 36 eminent nondepressed authors. Results indicated that depressed authors have
more cognitive distortions in their writings than non-depressed authors. However, greater
significance was found between poets and prose writers, with poets having substantially more
cognitive distortions in their works. An interaction effect was found between the study group
(depressed or control) and medium (poetry or prose) indicating that nondepressed prose writers
had significantly fewer cognitive distortions than non-depressed poets, depressed poets, and
depressed writers.

Kube et al (2020) linked the findings from cognitive neuroscience with those from psychiatry
to argue that the conventional cognitive model may profit from a reformulation that takes into
account the most recent Bayesian models of the brain. They argued that good human learning is
often based on generating predictions and experiencing disparities between projected and real
occurrences or experiences. This is done by making use of a predictive processing account.
They provided evidence that suggests depression distorts this learning mechanism: According
to a recent study, depressed individuals frequently reevaluate favorable material negatively or
ignore it if it matches their negative expectations, resulting in biased learning and ongoing
unfavorable predictions. They also went through the neurophysiological explanations for these
difficulties in handling prediction mistakes in depressed individuals. They summarised these
findings and offer a novel mechanistic model of depression that suggests those who suffer from
depression have the propensity to expect primarily negative outcomes, which they subjectively
perceive as confirmed as a result of reappraising unconvincing evidence, leading to a negative
feedback loop that reinforces itself. In terms of computation, the key contender for pathology is
too much precision given to negative prior beliefs, together with a reduction in positive
prediction mistakes. We end by pointing to the therapeutic implications of this model and
suggesting potential future areas for research into its behavioral and neurophysiological
foundations.

Kuru et al (2018) compared patients with SAD to a healthy control group in terms of cognitive
distortions and investigated the association between cognitive distortions and levels of anxiety
and sadness in SAD patients. From two samples—one non-clinical and the other clinical with
SAD—102 people were included. After a diagnostic interview, patients were assessed using the
Liebowitz Social Anxiety Scale, Cognitive Distortions Scale (CDS), State-Trait Anxiety
Inventory, and Beck Depression Inventory. Total CDS was considerably different between the
patient and control groups, and the patient group's level of most cognitive distortions was
significantly greater than the controls. With a range of 0.316–0.676, substantial correlations
between the measures were discovered when the relationships between social anxiety, state and
trait anxiety levels, depressive symptoms, and cognitive distortions were examined.

Mercan et al (2021) in this study found out how cognitive distortions affect how people
communicate their emotions as well as how much anxiety and despair they experience. A
"Descriptive Cross-Sectional" experiment was used for the study's design. 200 first- and
second-grade university students were administered face-to-face surveys between September
and November 2019 to gather data for this purpose. Utilizing the proper statistical analysis, data
analysis was carried out. Intimacy expression subscale scores declined as emotional reasoning
subscale scores rose, according to the data analysis. The subscale score for negative emotional
expression increased along with the subscale scores for mind reading and catastrophizing. It
was seen that the overall scores of the Beck Depression and Anxiety Scales increased when the
total score of the Cognitive Distortions Scale increased. This study discovered that people's
cognitive distortions had an impact on their emotional expression, as well as their degrees of
despair and anxiety. The outcomes of our efforts in providing the person with psychological
assistance might be instructive.

Nasira et al (2010) in his study aimed to look at cognitive distortion and depression among
juvenile delinquents in Malaysia. Subjects for this study were 316 juvenile delinquents, 164
male and 152 female between 12 and 18 years of age who were undergoing rehabilitation in
four rehabilitation centers (schools) and two prisons for juvenile delinquents/centers (school).
Briere’s Cognitive Distortion Scale (CDS) was used to measure cognitive distortion and
Reynolds Adolescent Depression Scale (RADS) was used to measure depression. Results of
this study showed that there was a positive significant correlation between cognitive distortion
and depression. Results also indicated that there was a positive significant correlation between
cognitive distortion and all the five dimensions of cognitive distortion: self-critique, self-blame,
helplessness, hopelessness and preoccupation with danger.

Otaa et al (2020) in this study examined the relationship between cognitive distortion,
depressive symptoms, and social adaptation. The final analyzed sample consisted of 430
employees of a manufacturing company in Japan (74.2% male, 24.7% female, 1.2% unknown).
Participants completed the Worker's Cognitive Distortion Scale (WCDS), Beck Depression
Inventory-Second Edition (BDI-II), and Social Adaptation Self-Evaluation Scale (SASS). The
WCDS was further divided into two subscales: self-contained cognitive distortion (WCDS-S)
and environment dependent cognitive distortion (WCDS-E). We used a covariance structure
analysis for the main analysis and examined the relationship between these three variables’
scores. The results revealed that both the WCDS-S and WCDS-E affected social adaptation
indirectly via depressive symptoms, and that the WCDS-S additionally affected social
adaptation directly. It was further revealed that the WCDS-S exerted a greater effect on
depressive symptoms than the WCDS-E. Limitations: The participants were healthy cases. As
such, one must be cautious about applying the results of healthy cases to clinical cases.
Rana et al (2017) assessed the automatic thoughts of patients having depressive illness and
evaluated and compared the changes after therapy; i.e. Psychotherapy and pharmacotherapy.
Beck Depression Inventory was used to screen the level of depressive symptoms. Automatic
thoughts were assessed by the Automatic Thought Questionnaire-Revised before initiating
therapy and after completion of therapy for comparison. Among the total 135 patients, 53
(39.3%) had moderate, 47 (34.8%) had severe depressive and 35 (25.9%) had mild depressive
symptoms before therapeutic interventions. Negative automatic thoughts were significantly
present in depressed patients and reduced after all three interventions. Negative automatic
thoughts of hopelessness, anxiety and inability to cope were significantly reduced after therapy.

Rnic et al (2016) in their research aimed to understand that cognitive distortions are negative
biases in thinking that are theorized to represent vulnerability factors for depression and
dysphoria. The study examined the correlations between the frequency and impact of cognitive
distortions across both social and achievement-related contexts and types of humor. Cognitive
distortions were associated with reduced use of adaptive Affiliative and Self-Enhancing humor
styles and increased use of Aggressive or Self-Defeating humor. This suggests that distorted
negative thinking may interfere with an individual's ability to adopt a humorous and cheerful
outlook on life (ie, Self-Enhanced humor) as a way of regulating emotions and coping with
stress, thereby resulting in elevated depressive symptoms.

Strohmeier et al (2016) In the current chart review study, self-reported cognitive distortions,
symptoms of attention-deficit/hyperactivity disorder (ADHD), and co-occurring symptoms of
depression and anxiety were compared in a clinical sample of individuals with ADHD. A
university-based outpatient clinic specializing in adult ADHD required thirty individuals to
complete surveys assessing cognitive distortions, ADHD, anxiety, sadness, and hopelessness as
part of the routine diagnostic evaluation methodology. A series of correlational studies
examined the association between self-reported cognitive distortions, ADHD, anxiety,
sadness, and despair. Self-reported cognitive distortions and ADHD showed a robust and
positive connection, according to the findings. Perfectionism emerged as the category of
cognitive distortion that was most commonly supported after tabulating responses to individual
items on the scale of cognitive distortions. These findings' further clinical ramifications are
presented.
Wilson et al (2011) aimed to understand the role of problem orientation and cognitive
distortions in depression where the extent to which specific cognitive distortions and symptoms
of anxiety and depression are associated with negative problem orientation (NPO) in a sample
of 285 young adults aged 18–25 years was assessed. They found that cognitive distortions and
depressive symptoms were strong predictors and explained approximately half of the variance
in NPO. Results also found that the relationship between cognitive distortions and NPO was
strengthened as depressive symptoms became more intense. The distortion ‘You think you
know what the future will bring; you expect disaster and gloom’ had the strongest individual
association with NPO and depressive symptoms.

Yüksel et al (2019) aimed to determine the relationship between depression, anxiety, cognitive
distortions, and psychological well‐being among nursing students. This descriptive,
correlational, cross‐sectional study was conducted with 330 nursing students. Data were
collected using the Beck Depression Inventory (BDI), the Beck Anxiety Inventory (BAI), the
Cognitive Distortion Scale (CDS), and the Psychological Well‐being Scale (PWBS). The
PWBS negatively correlated with the BDI, BAI, and CDS (P < .05). Preoccupation with
danger was the strongest predictor, followed by hopelessness, self‐blame, total CDS and BDI
(P < .05). Nursing students should be evaluated for psychological well‐being to prevent
psychiatric symptoms such as anxiety and depression.

Methodology

Preliminary Information

Participant 1

Name- Pulkit

Age- 21

Sex- Male

Participant 2
Name- Palak

Age- 19

Sex- Female

Rapport Formation

An engaging but casual conversation was held with Participant 1 to put them at ease. Once the
participant felt comfortable, they were introduced to the experiment and given the following
instructions. A similar conversation was held with Participant 2 to make them feel comfortable.
After receiving an affirmative response, the researcher began with the study.

Instructions

The instructions pertaining to the current study were read out from the Cognitive Distortions
Scale Manual (Briere, 2020)

Introspective Report

Participant 1

"I've never filled out questionnaires that are so intimate and reveal so much about myself, so the
exam was quite intriguing and a new chance for me. I hope I was able to assist the test's creator,
and I'm interested in the outcomes.”

Participant 2

“The test was very interesting and new opportunity for me, I have never filled out such
questionnaires that are so personal and tell me something about myself. I hope I helped out the
administrator of the test and would like to know about the results.”

Behavioural Report
Participant 1

Participant looked excited to learn about the test. He asked several questions throughout and was
very talkative and chirpy through his body language. He was very interested in knowing about
the reason behind why the test was being administered. He had a pleasant smile on his face
throughout the test and completed it within minutes. He had a confident and sure body language
and appeared to be satisfied with her responses.

Participant 2

The participant's body language during the exam suggested that she was worn out and fatigued.
Despite having a scruffy and unkempt appearance, she acted politely toward the examiner. She
took some time to comprehend the goal of the test before really starting it. She appeared to have
had little sleep because of the black bags beneath his eyes. The majority of the test was quiet and
serene. She requested for water in between and towards the conclusion of the test, she was
beginning to become restless, but she finished it on time and appeared relieved.

Sample

The sample consisted of 140 participants (n=140), ranging from 18-50 years of age. The clinical
group consisted of 70 participants diagnosed with depression; and the remaining 70 were in the
control group, with no diagnosis of any mental illness. T-test was conducted to find out any
significant difference in cognitive distortions between clinically depressed population and
control group.

Measures

The Cognitive Distortion Scale (CDS; Briere, 2000b) is 40-item test that measures five cognitive
symptoms or distortions found among those who have experienced interpersonal victimization:
Self-Criticism, Self-Blame, Helplessness, Hopelessness, and Preoccupation with Danger.
Scoring is done on a 5-point Likert Scale. Elevated scores on each scale indicate higher levels of
cognitive distortions and vice versa.
Reliability of CDS

The 5 scales of the CDS were analysed for internal consistency in the normative sample using
the alpha statistic. Reliability coefficients for the CDS scales ranged 0.89 (for PWD) to 0.97 (for
HOP) with an overall mean CDS scale alpha of 0.93. Inter correlation between scales were also
found out. CDS raw scale scores were significantly intercorrelated in the standardization sample.
Lowest correlation was found between HOP and SC scale and highest was found between HLP
and SB.

Validity of CDS

Data on the CDS are presented with reference to 3 types of validity: construct, convergent and
discriminant. In order to examine the convergent and discriminant validity of the CDS Scales
relative to other cognitive scales, the CDS was administered to participants in the validation
sample along with the BHS, MDI and TSIBS.

Norms of CDS

The norms for CDS were developed on the basis of a normative sample consisting of 294 males
and 261 females. The scale consists of standard T score norms, gender norms as well as mean
and standard deviation for each subscale.

Individual Procedure

For the present study, we tried to study the cognitive distortion of a depressed individual as well
as an individual not suffering from any mental illness. Initially a depressed individual was
approached in a hospital. He was asked to settle down comfortably. Informed consent was taken.
After receiving the informed consent, the administrator established a rapport with the participant
after which he was briefed about the questionnaire and asked to fill it along with proper
instructions. During the process, participant’s behavioral note was taken. After the participant
was done filling the questionnaire, he was asked to write an introspective report. A data sheet
was formed based on the responses and the raw scores were converted into T – scores. The same
process was repeated with the participant not suffering from any psychological disorder in a
normal setting.
Group Procedure

All the individual data was combined into a group data. Group data sample included male and
female (n=140). The sample consisted of 70 individuals who were clinically diagnosed with
depression and 70 individuals who were not clinically diagnosed with any mental illness. The
sample was from Delhi NCR. The mean of the T -scores were calculated and the t-test was done
for each subscale to find out if there was any significant difference between the clinically
depressed group and the control group which did not suffer from any mental illness.

Results

TABLE SHOWING THE MEAN OF CONTROL GROUP AND CLINICAL GROUP FOR
VARIOUS SUBSCALES

SCALE NAME CONTROL GROUP CLINICAL GROUP

MEAN
MEAN

Self-Criticism 63.27 80.21

Self-Blame 69.26 85.61

Helplessness 66.31 86.85

Hopelessness 57.16 81.31

Preoccupation with Danger 64.26 81.33

*p<0.05 **p<0.01
df=138

Name of Subscale Control Group Mean Clinical Group Mean

Self-Criticism (SC) 63.27 80.21

Self-Blame (SB) 69.26 85.61

Helplessness (HLP) 66.31 86.85

Hopelessness (HOP) 57.16 81.31

Preoccupation with Danger 64.26 81.33

(PWD)

*p<0.05 **p<0.01

Df =138

t-TEST OF VARIOUS SUBSCALES FOR CONTROL GROUP AND CLINICAL GROUP

SCALE NAME CONTROL GROUP CLINICAL GROUP t-test

MEAN
MEAN

Self-Criticism 63.27 80.21 5.67**

Self-Blame 69.26 85.61 6.7**

Helplessness 66.31 86.85 9.23**

Hopelessness 57.16 81.31 9.82**

Preoccupation with 64.26 81.33 7.1**

Danger

*p<0.05 **p<0.01 df=138

t-score OF VARIOUS SUBSCALES FOR CONTROL PARTICIPANT AND CLINICAL
PARTICIPANT

SCORES
S.No. NAME OF SCALE NON-DEPRESSED DEPRESSED
RAW SCORE T SCORE RAW SCORE T SCORE
1 Self-Criticism (SC) 21 67 25 74

2 Self-Blame (SB) 18 75 31 98

3 Helplessness (HLP) 14 61 31 100

4 Hopelessness (HOP) 10 50 29 98

5 Preoccupation with 19 73 26 93
Danger (PWD)
INTERPRETATION AND DISCUSSION

The aim of the study is to measure the cognitive distortion between depressed and non-
depressed individuals. P M is a 19-year-old girl who is a friend of the researcher. She was
diagnosed with depression in 2020, she was admitted following the diagnose for a month and
received therapy for 1 year. She is off medication now. She willingly participated in this study. P
K is a 21-year-old boy and is a good friend of the researcher. He has never been diagnosed with
any psychological disorder. He is a very social person. He was taken as a participant in the
control group. The cognitive distortion scales (CDS) is a brief 40 item test of dysfunctional
cognitions. The scales of the CDS assess five types of cognitive distortion: Self-criticism,
Helplessness, Hopelessness, Self-Blame, and preoccupation with danger.

Self-criticism scale measures low self-esteem and self-devaluation, as expressed in the tendency
to criticize or devalue oneself, both internally and to others. High scores often reflect a view of
self as intrinsically bad, unattractive, unintelligent, or unacceptable. The T score of P K for self-
criticism scale is 67. A score of 67 indicates that he displays average self-criticism. The T score
of P M for self-criticism is 74. The score is 2 standard deviations above the mean, this shows that
self-criticism of P M is clinically significant. She has responded that she very often calls herself
names and often feels unattractive. Individuals with clinical elevations on this scale are likely to
view themselves in an especially negative light and to report repetitive negative thought about
their intrinsic badness or unacceptability.

Self-Blame scale measures the extent to which the respondent blames himself or herself for
negative, unwanted events that have transpired in his/her life. This may include blaming oneself
for a detrimental experience that was out of one’s control. The T score of P K for self-blame is
75. This shows that P K is a little above average on self-blame scale. The T score of P M for self-
blame scale is 98. This indicates that the cognitive distortion for self-blame is clinically
significant. She has answered that she often blames himself for something that has happened to
her, and thinks that she deserved a bad thing that happened to her. She very often blames herself
for his troubles, often feels ashamed about something that happened to her, and feels guilty about
something that was done to her very often. Respondents with elevated self-blame scores tend to
make negative internal attributions regarding the meaning of adverse life experiences, believing
that they are personally responsible for negative outcomes.

Helplessness scale taps the perception of being unable to control important aspects of one’s life.
Individuals with high score are likely to assume that their efforts will be unsuccessful, sometimes
leading to passivity in the face of challenge or danger. The T score of P K for helplessness is 61.
The score indicates that the person is above average for feeling helplessness. The T score of P M
for helplessness is 100. This again indicates clinically significant T score for helplessness. She
has responded that she often feels like she doesn’t have much control over what happens to her,
she thinks often that things will never get much better, and often feels like bad things happen to
her no matter how hard she tries to keep them from happening, and feels like she has no control
over what happens in her life often. Individuals with high helplessness scores may be especially
likely to assume that their efforts to change and unwanted or problematic situation will be
unsuccessful, sometimes leading to passivity or avoidance in the face of challenge or danger. The
assumed inability to influence negative events in one’s life is often projected into the future,
hence there is high correlation between the helplessness and hopelessness scale.

Hopelessness scale measures the extent to which the respondent believes that the future is bleak
and that he or she is destined to suffer or fail. The T score of P K for hopelessness is 50. A score
of 50 shows that the person is low on hopelessness scale and does not feel the future is bleak.
The T score of P M for hopelessness is 98. This again shows hopelessness is clinically
significant in the person. She has responded that she often feels hopeless about the future, she
often thinks that her life would never improve, and that things will never get much better Those
with elevated hopelessness scores are often characterised as pessimistic, and they may be
especially likely to avoid (or fail to persevere in) activities that require an expectation of a
potentially positive future outcome.

Preoccupation with Danger scale evaluates the tendency to view the world, especially the
interpersonal domain, as a dangerous place. Individuals with elevated PWD scores may assume
that objectively benign circumstances contain risk of emotional or physical outcomes. The T
score of P K for preoccupation with danger is 73, the scores lie within normal limits. The T score
of P M for Preoccupation with Danger is 93. The T score of 93 indicates that the score is
clinically significant. She has responded that she often feels that the world seems dangerous, and
very often thinks that people were trying to take advantage of him. This implies that clinically
depressed individuals who score high on the PWD scale are more likely to perceive the world
around them as threatening. As a result, they are often hypervigilant to danger and anticipate
critical events which may carry emotional or physical risks.

For all the sub-scales the scores of participants who has been diagnosed with depression are
clinically significant and more than two standard deviations away from the mean, while for all
the sub-scales the scores of participants who is a healthy control and not diagnosed with
depression or any other psychological disorder lies near mean. The results are in line with the
results of previous researches.). Studies using self-report questionnaires demonstrate that
Cognitive errors are more prevalent in individuals with depression than in non-depressed
individuals (Gupta & Kar, 2008) and that Cognitive errors are related to depression severity
(Miranda & Mennin, 2007). Cognitive errors (CEs) are evidenced to be related to depressive
thinking in major depressive disorder (Beck Et Al., 1979; Dozois & Beck, 2008 In a study
conducted by Marton & Kutcher (1995) Cognitive distortion was associated with more severe
symptoms of depression, lack of social self-confidence and greater introversion. (Marton &
Kutcher,1995)

Group Interpretation

The aim of the present research was to study the difference in the presence of cognitive
distortions in people with and without depression by administering the Cognitive Distortion
Scale (CDS). Our findings indicate that people diagnosed with clinical depression tend to
experience more cognitive distortions, Cognitive theories of the aetiology of depression in
adulthood have received widespread acceptance. To date there is little evidence of the role of
cognitive distortion in the etiology of depression, people with depression had significantly
greater cognitive distortion than people without depression (Kutcher 2018) Although Beck's
(1967, 1976) cognitive model of depression has provided the impetus for a great deal of research
concerning the role of dysfunctional cognitions in depression, relatively few standardized
procedures have been developed to assess Beck's construct of cognitive distortion. Whenever
grouped data are compared, depressed patients have consistently displayed greater cognitive
distortion than non-depressed individuals (Barnett 2017).

To examine the difference between clinically non-depressed and depressed participants on the
cognitive distortion of self-criticism, self-blame, hopelessness, helplessness and preoccupation
with danger the t-independent test was used. Each sub-scale was individually and critically
evaluated to understand the cognitive distortions of the clinical and control group and how the
different scales vary throughout the population.

Self- Criticism

This is the first scale on the CDS manual. Low self-esteem and self-devaluation are measured as
a tendency to criticize or devalue oneself, both internally and to others. High scores frequently
reflect an intrinsically negative, unattractive, unintelligent, or unacceptable view of oneself.

Mean of the cognitive distortions experienced by the clinical group was found to be (M=80.21T)
and for the control group, the mean was found to be (M=63.27T). A T value of 5.67 was
obtained between the 2 groups, which was found to be significant at 0.01 level, indicating that
depressed participants show higher levels of self-criticism than those without depression. 

Self-criticism is a measure of low self-esteem and self-devaluation since it shows a person's

tendency to be critical of or undervalue themselves, both to oneself and to others. High scores
obtained by the depressed population reflect a view of self as intrinsically bad, unattractive,
unintelligent, or unacceptable. High self-criticism may affect a person’s social and romantic
relationships which may further worsen their condition. Participants with clinically significant
levels of self-criticism, such as those suffering from depression, are likely to put themselves
down, hate themselves and call themselves names. There is also a possible presence of feelings
of failure, remorse, and worthlessness. 

Self-criticism has been found to play a role in common mental health difficulties.  Positive
relations have been found between self-criticism and symptoms of eating disorders, social
anxiety disorder, personality disorders, and psychotic symptoms, (Werner, Tibubos, Rohrmann,
& Reiss, 2019). 
It has also been found to predict symptoms of psychopathology, more strongly for depression,
(McIntyre, Smith & Rimes,2018). Self-criticism involving feelings of inadequacy and hate
mediates an individual’s stress-depression and stress-anxiety pathways, (Kotera, Dosedlova,
Andrzejewski, Kaluzeviciute, & Sakai, 2022).  Results of this study are in line with previous
studies that show a relationship between self-criticism and Major Depressive Disorder, its
severity and specific depressive symptoms, (Luyten, Sabbe, Blatt, Meganck, Jansen, Grave, et
al., 2007). Specifically, across studies, self-criticism has been found to significantly predict
depression, (Aruta, Antazo, Briones-Diato, Crisostomo, Canlas & Peñaranda, 2021) and an
increase in its symptoms over time, (McIntyre, et.al, 2018)).

Self-Blame

Next scale is Self - blame. It measures the extent to which the respondent blames himself or
herself for negative, unfavourable events in his or her life. This could include blaming oneself
for a negative experience that was beyond one's control.

Mean of the cognitive distortions experienced by the clinical group was found to be (M=85.61T)
whereas for the control group, it was found to be (M=69.26T). A T value of 6.7 was obtained
between the two groups, which was found to be significant at 0.01 level, implying that depressed
participants show higher levels of self-blame than those without depression. 

In other words, depressed participants show higher levels of self-blame as compared to the non-
depressed participants. Participants with depression are much more likely to distort their reality
by engaging in self-blame as compared to non-depressed participants. The participants in the
depressed group are much more likely to over-attribute negative responsibility as a part of their
cognitive emotional state as compared to participants in the non-depressed group. Self-blame
predicted subsequent symptoms of depression and PTSD. Self-blame predicted subsequent
symptoms of depression and PTSD. Self-blame is a cognitive process in which an individual
attributes the occurrence of a stressful event to oneself. Self-blame is one of the most toxic forms
of emotional abuse. It amplifies our perceived inadequacies, whether real or imagined, and
paralyzes us before we can even begin to move forward. According to Beck's (1967) theory of
depression, the depressed individual blames him/herself for negative outcomes, particularly
personal failures. Typically, self-blame items are “Thinking that you deserved a bad thing that
happened to you”. “Being mad at yourself for getting hurt by someone”, and blaming yourself
for something, even though it probably wasn’t your fault.” This helps us in understanding that
respondents with elevated Self-blame scores tend to make negative internal attributions
regarding the meaning of adverse life experiences, believing that they are personally responsible
for negative outcomes. In fact, self-blame is a relatively common sequel of interpersonal
victimization, especially when reinforced by individuals in the victim's immediate environment
and/or culture (Graham &Juvonen,1998). In other instances, Self Blame might also be elevated
because the individual correctly perceives some responsibility for an act that occurred against
him or herself, but the elevation may be beyond the actual level of responsibility.

In a study by Zahn et al. (2015), it was found that among 132 patients with remitted major
depressive disorder, 85 % of them reported feelings of inadequacy and self-blaming emotions as
the most bothersome symptoms of the disorder. Cognitive models predict that vulnerability to
major depressive disorder (MDD) is due to a bias to blame oneself for failure in a global way
resulting in excessive self-blaming emotions, decreased self-worth, hopelessness and depressed
mood. Therefore, the research evidence strongly suggests the interconnection between self-blame
and depression. Our findings are in line with existing research evidence. Greater levels of self-
blame, rumination, and/or catastrophizing as coping mechanisms were highly associated with
higher depression ratings in both groups including men and women (Garnefski, Teerds, Kraaij,
Legerstee & Commer, 2004).

Helplessness

This scale measures helplessness. It taps into the feeling of being powerless over important
aspects of one's life. Individuals with high scores are more likely to believe that their efforts will
be futile, which can lead to passivity in the face of a challenge or danger.

For the clinical group, the mean was found to be (M=86.65T), while for the control group, it was
found to be (M=66.31T). A T value of 9.23 was obtained between the two groups, which was
found to be significant at 0.01 level, implying that depressed participants show higher levels of
helplessness than those without depression.
The findings indicate that helplessness may have mediated the effect between cognitive distortions and
depression. That is, cognitive distortions may have caused feelings of helplessness and low self-efficacy,
and in this way, had indirect effects on depression.  Kim (2018) in his study however observed that
cognitive distortions are inaccurate ways of attending to or conferring meaning on experiences. An
individual with cognitive distortion perceives things, people and experiences in a distorted manner and is
different from other individuals with no cognitive distortion but it is also essential to point out here that
such observations are to be further re-examined to find out an objective answer.

With respect to the subscale of helplessness it was found that people with clinical
depression.This conclusion is in line with another study by Bartczak (2014) that revealed defence
mechanisms activated cognitive distortions, which in turn intensified the severity of depression.
It can be said that cognitive distortions are important predictors of psychological well‐being.
Results of the study conducted by Zachary et al (1999) indicated that depression was
significantly correlated with higher scores on measures of learned helplessness and cognitive
distortions and lower scores on a measure of self-efficacy. Significant correlations were also
found among helplessness, cognitive distortions, and self-efficacy. Harrington et al. observed
that depressed adolescents are at a greater risk of developing further episodes of depression in
later adolescents and adulthood.

Hopelessness

The fourth scale is hopelessness, this scale shows the degree to which a respondent believes the
future is bleak and that he or she is doomed to suffer or fail. Individuals with a high score are
often classified as pessimistic, and they may struggle to maintain in activities that require an
expectation or a positive future outcome.

For the clinical group, the mean was found to be (M=81.3`T), whereas for the control group, it
was found to be (M=57.16 T). A T value of 9.82 was obtained between the two groups, which
was found to be significant at 0.01 level, suggesting that depressed participants show higher
levels of hopelessness than the non-depressed population. 

Through the analysis of the data people with depression tend to experience more cognitive
distortions and experience hopelessness than the participants in the control group without any
mental illness. According to the American Psychological Association’s dictionary for
psychology, Hopelessness is defined as the feeling that one will not experience positive emotions
or an improvement in one’s condition. Hopelessness is common in severe major depressive
episodes and other depressive disorders and is often implicated in suicides and attempted
suicides. It is also interesting to note here that both depression and hopelessness were sensitive to
changes in suicide risk. All analyses conducted by Richard et al (2018) indicated that,
hopelessness correlated more highly with suicide intent than did depression. With respect to the
subscale of hopelessness, recent researches have established hopelessness as a key mediating
variable between depression and suicide intent and behaviour. The relative roles of hopelessness
and other cognitive characteristics of suicidal individuals, such as cognitive rigidity and poor
problem-solving skills, have been examined and models of suicidal behaviour proposed. Adding
on to this, the relation of hopelessness to levels of depression and suicidal intent was explored
both psychometrically and clinically by Weissman et al (2017). The results support previous
reports that hopelessness is the key variable linking depression to suicidal behaviour.
Furthermore, our results are substantiated by another study by Strohmeier et al (2017) who
identified significant relationships between total self-reported cognitive distortions and
depression, and hopelessness.

Preoccupation with Danger

The fifth scale on the cognitive distortion scale is ‘preoccupation with danger’. It assesses the
predisposition to view the world as a dangerous place, particularly the interpersonal domain.
Individuals with high PWD scores may believe that even innocuous circumstances carry the risk
of adverse emotional or physical outcomes.

Mean of the cognitive distortions experienced by the clinical group was found to be (M=81.33T)
and for the control group, the mean was found to be (M=64.26T). A T value of 7.1 was obtained
between the two groups, which was found to be significant at 0.01 level, implying that depressed
participants are more preoccupied with danger as compared to those without depression. 

As a result, they are often hypervigilant to danger and anticipate critical events which may carry
emotional or physical risks. Nasir & Zainah (2011) conducted a study on juvenile adolescents to
investigate their experience of cognitive distortions and its correlation with depression. Among
all the domains of cognitive distortions, helplessness and preoccupation with danger were found
to be significant predictors of depression. In a similar study conducted by Abdullah & Saleh
(2011) on rape victims, strong correlation was found between self-blame, self-criticism,
helplessness, preoccupation with danger and depression.

On the other hand, the participants from the non-depressed sample scored lower on the
preoccupation with danger scale, indicating that they are less consumed with anticipating
dangerous events and see the world as a safer place.

A longitudinal study by Mcgrath (2002) examined how depressive symptoms relate to children's
self-perceptions and to estimates of children's cognitive distortions about the self in a nonclinical
sample of children who were followed from 4th grade through 6th grade. Report card grades
measured children's academic competence, and teachers' ratings of children's level of peer
acceptance at school indicated social acceptance. Self-reported depressive symptoms predicted a
change in children's negative views of the self. Moreover, the self-perceptions of children who
exhibited more symptoms of depression appeared to reflect an underestimation of their actual
competence. Children's negative self-perceptions and underestimations about the self were not,
however, associated with a subsequent change in depressive symptoms.

According to the current academic study, results show individuals with elevated PWD scores
may be interpreted as they are cognizant to danger, and they may believe that neutral

environmental circumstances or events pose a risk of harm to them. Cognitive distortions

such as catastrophizing, control fallacies, blaming, global labelling, etc. are some
manifestations of how negative thought processes can take over an individual’s mind.

Conclusion

The Cognitive Distortion Scale is a brief 40 item scale reliable standardized measure of cognitive
distortions that appears to have construct, convergent and discriminant validity in the general
population and clinical samples. The results show us that cognitive distortions are more in
clinically diagnosed depressed people than the control group (non-depressed population)
accepting hypothesis 1 stating that “The people who are clinically depressed will have more
cognitive distortions than the people non depressed population”.

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