2 Critical Risk Factors for Depression

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A recent paper by Bishop et al. investigates the relationship between depression and early maladaptive schemas—negative patterns of perception or belief that develop early in life.

Some examples of such beliefs are: “I am a failure,” “I am worthless and unlovable,” and “People will reject me if they got to know the real me.”

The review, published in the February issue of Clinical Psychology & Psychotherapy, concludes that Defectiveness/Shame and Social Isolation schemas are the biggest cognitive risk factors for depression.

Investigating Early Maladaptive Schemas and Depression

The paper reviewed fifty-one studies (N = 17,830).

Design: Most were cross-sectional (only two employed a longitudinal design).

Sample size: Ranged from 38 to 1,529 participants.

Sample average age: 18.5 to 69.2 years.

Gender: Most studies included both genders (seven, only women).

Sample types: 15 clinical samples (e.g., major depressive disorder, bipolar disorder, childhood abuse); 21 non-clinical samples (e.g., high school or college students, general population); 15 case-control designs.

Results

A series of meta-analyses showed that all early maladaptive schemas were cognitive risk factors for developing depression in adulthood. But those with greater depression severity tended to endorse schemas “relating to feeling like they do not belong or fit in, that they are flawed, bad or invalid.”

Overall, depression showed:

• Small associations with the schemas of self-sacrifice, entitlement, and unrelenting standards.
• Moderate associations with abandonment, approval-seeking, dependence/incompetence, emotional deprivation, emotional inhibition, enmeshment, failure, insufficient self-control, mistrust/abuse, negativity/pessimism, punitiveness, subjugation, and vulnerability to harm.
• Large associations with defectiveness/shame and social isolation.

See my previous contribution to Psychology Today to learn more about the 18 maladaptive schemas mentioned above.

From Shame and Social Isolation to Depression

So, the biggest cognitive risk factors for depression are shame and social isolation.

What is shame? Shame is a painful emotion that involves a potential or actual negative evaluation of the self.

Shame is not necessarily maladaptive. Like healthy pride or appropriate guilt, the right amount of shame has useful social functions.

For instance, shame alerts us to changes in social status or valued relationships. And a key function of shame may be to reduce the likelihood of social threats—i.e., being devalued, rejected, excluded, or ostracized.

In contrast, toxic shame—and chronically unmet needs for acceptance and belonging—may play a role in the development and/or maintenance of a variety of mental health conditions.

Some examples are eating disorders, borderline or narcissistic pathology, and, particularly, mood disorders, including suicidal behaviors.

One reason toxic shame is associated with mood disorders and depression is this: Excessive or chronic shame can make one feel unloved or unwanted by important others (parents, romantic partners); this thwarted sense of belonging and resultant chronic loneliness then increases the risk of depression and suicide.

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Another reason toxic shame is linked with depression and suicide may be related to low social rank. Both depression and shame often involve feeling defeated, inferior, and even trapped (e.g., in an inadequate body, job, or life). And in both shame and depression, there is a desperate desire to escape—from one’s stressful situation, lowly position, embarrassing or humiliating memories, etc.

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Coping Strategies and Treatment for Shame

The research review found that early maladaptive schemas are cognitive risk factors for depression.

Depression was linked most strongly to early maladaptive schemas of defectiveness/shame and social isolation.

This means individuals most likely to develop depression tend to:

• Feel lonely, different, and disconnected, often fearing that they do not belong or fit in.
• Believe they are bad and defective—deeply flawed or inherently unlovable if exposed for who they really are.

Without therapy, maladaptive schemas are often strengthened and perpetuated through schema-congruent situations and ineffective coping strategies.

For instance, due to an intense fear of rejection and abandonment, those ashamed of who they are (i.e., feeling deeply flawed and unlovable) may cope with shame by isolating themselves or keeping others at a distance. This is not an effective coping strategy because it limits the opportunity to test whether one’s assumptions are true, such as the assumption that people will reject the individual if they discover that he or she has shortcomings.

Not testing the assumptions maintains the belief that one is indeed deeply flawed and unlovable, unable to fit in or belong anywhere.

The good news is that it is possible to heal shame through therapy:

Compassion-focused therapies may be particularly helpful in treating shame. These therapies teach patients how to, among other things, balance the emotion regulation systems, experience feelings of safety and warmth, reduce resistance to self-compassion, and respond to self-criticism with self-kindness.

And schema therapy may be useful in the treatment of not just shame but also other early maladaptive schemas and in reducing the risk of mental illness.

Schema therapy helps patients identify core emotional needs (e.g., need for safety, emotional nurturance, freedom, autonomy) and choose healthy and adaptive ways of having their core needs met. They also learn effective coping techniques, ways to improve their relationships, and strategies for thinking more flexibly.

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