Background: The only treatment specifically developed for chronic depression, the Cognitive Behavioral Analysis System of Psychotherapy (CBASP), is based amongst others on the hypothesis that chronically depressed patients (CD) show considerable deficits of affective theory of mind (ToM) capabilities. Data are scarce, however, and it remains unclear if ToM deficits are specific or if they arise from global cognitive deficits associated with depression. This study investigates the specific deficits of affective ToM abilities in CD. Sampling and Methods: ToM abilities were assessed in 26 medication-free CD and 26 matched healthy controls (HC) by means of a previously established false-belief ToM cartoon task. Since the task allowed an intern control for cognitive factors - operationalized in a visuospatial ToM task - it was possible to investigate specific affective ToM deficits. Results: As hypothesized, the CD showed a significant specific slowdown of affective ToM compared to cognitive ToM (3rd person perspective) when compared to HC. Simultaneously, we observed a general deterioration of all ToM functions in CD. Conclusions: This study provides evidence that CD have a mentalization deficit, specifically for affective ToM functions. This deficit is combined with a general deterioration of ToM functions, most likely attributable to frequently described cognitive deficits in depression.

Keywords:
Affective disorders, Chronic depression, Theory of mind, Cognitive empathy, Mentalizing, CBASP
1.
Jacobi F, Wittchen HU, Holting C, Hofler M, Pfister H, Muller N, Lieb R: Prevalence, co-morbidity and correlates of mental disorders in the general population: results from the German Health Interview and Examination Survey (GHS). Psychol Med 2004;34:597-611.
2.
Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE: Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the national comorbidity survey replication. Arch Gen Psychiatry 2005;62:593-602.
3.
Greenberg PE, Kessler RC, Birnbaum HG, Leong SA, Lowe SW, Berglund PA, Corey-Lisle PK: The economic burden of depression in the United States: how did it change between 1990 and 2000? J Clin Psychiatry 2003;64:1465-1475.
4.
Murray CJ, Vos T, Lozano R, Naghavi M, Flaxman AD, et al: Disability-Adjusted Life Years (DALYS) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012;380:2197-2223.
5.
Arnow BA, Constantino MJ: Effectiveness of psychotherapy and combination treatment for chronic depression. J Clin Psychol 2003;59:893-905.
6.
Dunner DL: Acute and maintenance treatment of chronic depression. J Clin Psychiatry 2001;62(suppl 6):10-16.
7.
Gilmer WS, Trivedi MH, Rush AJ, Wisniewski SR, Luther J, Howland RH, Yohanna D, Khan A, Alpert J: Factors associated with chronic depressive episodes: a preliminary report from the STAR-D project. Acta Psychiatr Scand 2005;112:425-433.
8.
Klein DN, Santiago NJ: Dysthymia and chronic depression: introduction, classification, risk factors, and course. J Clin Psychol 2003;59:807-816.
9.
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, DSM-IV, ed 4. Washington, APA, 1994.
10.
Agosti V: One-year clinical and psychosocial outcomes of early-onset chronic depression. J Affect Disord 1999;54:171-175.
11.
Agosti V, Ocepek-Welikson K: The efficacy of imipramine and psychotherapy in early-onset chronic depression: a reanalysis of the National Institute of Mental Health Treatment of Depression Collaborative Research Program. J Affect Disord 1997;43:181-186.
12.
Ghaemi SN: Why antidepressants are not antidepressants: STEP-BD, STAR*D, and the return of neurotic depression. Bipolar Disord 2008;10:957-968.
13.
Kocsis JH: Pharmacotherapy for chronic depression. J Clin Psychol 2003;59:885-892.
14.
Markowitz JC: Psychotherapy of dysthymic disorder; in Kocsis JH, Klein DN (eds): Diagnosis and Treatment of Chronic Depression. New York, Guilford Press, 1995, pp 146-168.
15.
Cassano GB, Akiskal HS, Perugi G, Musetti L, Savino M: The importance of measures of affective temperaments in genetic studies of mood disorders. J Psychiatr Res 1992;26:257-268.
16.
Keller MB, McCullough JP, Klein DN, Arnow B, Dunner DL, Gelenberg AJ, Markowitz JC, Nemeroff CB, Russell JM, Thase ME, Trivedi MH, Zajecka J: A comparison of nefazodone, the cognitive behavioral-analysis system of psychotherapy, and their combination for the treatment of chronic depression. N Engl J Med 2000;342:1462-1470.
17.
Chapman DP, Whitfield CL, Felitti VJ, Dube SR, Edwards VJ, Anda RF: Adverse childhood experiences and the risk of depressive disorders in adulthood. J Affect Disord 2004;82:217-225.
18.
Korkeila K, Korkeila J, Vahtera J, Kivimaki M, Kivela SL, Sillanmaki L, Koskenvuo M: Childhood adversities, adult risk factors and depressiveness: a population study. Soc Psychiatr Psychiatr Epidemiol 2005;40:700-706.
19.
Lizardi H, Klein DN, Ouimette PC, Riso LP, Anderson RL, Donaldson SK: Reports of the childhood home environment in early-onset dysthymia and episodic major depression. J Abnorm Psychol 1995;104:132-139.
20.
Wiersma JE, Hovens JG, van Oppen P, Giltay EJ, van Schaik DJ, Beekman AT, Penninx BW: The importance of childhood trauma and childhood life events for chronicity of depression in adults. J Clin Psychiatry 2009;70:983-989.
21.
Berndt ER, Koran LM, Finkelstein SN, Gelenberg AJ, Kornstein SG, Miller IM, Thase ME, Trapp GA, Keller MB: Lost human capital from early-onset chronic depression. Am J Psychiatry 2000;157:940-947.
22.
Hammen C, Brennan PA: Interpersonal dysfunction in depressed women: impairments independent of depressive symptoms. J Affect Disord 2002;72:145-156.
23.
Miller IW, Keitner GI, Schatzberg AF, Klein DN, Thase ME, Rush AJ, Markowitz JC, Schlager DS, Kornstein SG, Davis SM, Harrison WM, Keller MB: The treatment of chronic depression. Part 3. Psychosocial functioning before and after treatment with sertraline or imipramine. J Clin Psychiatry 1998;59:608-619.
24.
Petty SC, Sachs-Ericsson N, Joiner TE Jr: Interpersonal functioning deficits: Temporary or stable characteristics of depressed individuals? J Affect Disord 2004;81:115-122.
25.
McCullough JP: Treatment for chronic depression: cognitive behavioral analysis system of psychotherapy. New York, Guilford Press, 2003.
26.
Piaget J: Intelligence and Affectivity: Their Relationship during Child Development. Palo Alto, Annual Reviews, 1981.
27.
McCullough JP: Treatment for chronic depression using cognitive behavioral analysis system of psychotherapy (CBASP). J Clin Psychol 2003;59:833-846.
28.
Dannlowski U, Kugel H, Huber F, Stuhrmann A, Redlich R, Grotegerd D, Dohm K, Sehlmeyer C, Konrad C, Baune BT, Arolt V, Heindel W, Zwitserlood P, Suslow T: Childhood maltreatment is associated with an automatic negative emotion processing bias in the amygdala. Hum Brain Mapp 2013;34:2899-2909.
29.
Grant MM, Cannistraci C, Hollon SD, Gore J, Shelton R: Childhood trauma history differentiates amygdala response to sad faces within MDD. J Psychiatr Res 2011;45:886-895.
30.
van Harmelen AL, van Tol MJ, Demenescu LR, van der Wee NJ, Veltman DJ, Aleman A, van Buchem MA, Spinhoven P, Penninx BW, Elzinga BM: Enhanced amygdala reactivity to emotional faces in adults reporting childhood emotional maltreatment. Soc Cogn Affect Neurosci 2013;8:362-369.
31.
Premack DG, Woodruff G: Does the chimpanzee have a theory of mind? Behav Brain Sci 1978;1:515-526.
32.
Frith U, Frith CD: Development and neurophysiology of mentalizing. Philos Trans R Soc Lond B Biol Sci 2003;358:459-473.
33.
Walter H: Social cognitive neuroscience of empathy: concepts, circuits, and genes. Emot Rev 2012;4:9-17.
34.
Shamay-Tsoory SG, Aharon-Peretz J: Dissociable prefrontal networks for cognitive and affective theory of mind: a lesion study. Neuropsychologia 2007;45:3054-3067.
35.
Nemeroff CB, Heim CM, Thase ME, Klein DN, Rush AJ, Schatzberg AF, Ninan PT, McCullough JP Jr, Weiss PM, Dunner DL, Rothbaum BO, Kornstein S, Keitner G, Keller MB: Differential responses to psychotherapy versus pharmacotherapy in patients with chronic forms of major depression and childhood trauma. Proc Natl Acad Sci USA 2003;100:14293-14296.
36.
Schramm E, Zobel I, Dykierek P, Kech S, Brakemeier EL, Kulz A, Berger M: Cognitive behavioral analysis system of psychotherapy versus interpersonal psychotherapy for early-onset chronic depression: a randomized pilot study. J Affect Disord 2011;129:109-116.
37.
van Randenborgh A, Huffmeier J, Victor D, Klocke K, Borlinghaus J, Pawelzik M: Contrasting chronic with episodic depression: an analysis of distorted socio-emotional information processing in chronic depression. J Affect Disord 2012;141:177-184.
38.
Wilbertz G, Brakemeier EL, Zobel I, Harter M, Schramm E: Exploring preoperational features in chronic depression. J Affect Disord 2010;124:262-269.
39.
Zobel I, Werden D, Linster H, Dykierek P, Drieling T, Berger M, Schramm E: Theory of mind deficits in chronically depressed patients. Depress Anxiety 2010;27:821-828.
40.
Boeker H, Schulze J, Richter A, Nikisch G, Schuepbach D, Grimm S: Sustained cognitive impairments after clinical recovery of severe depression. J Nerv Ment Dis 2012;200:773-776.
41.
Levin R, Heller W, Mohanty A, Herrington J, Miller G: Cognitive deficits in depression and functional specificity of regional brain activity. Cogn Ther Res 2007;31:211-233.
42.
Porter RJ, Bourke C, Gallagher P: Neuropsychological impairment in major depression: its nature, origin and clinical significance. Aust N Z J Psychiatry 2007;41:115-128.
43.
Taylor Tavares JV, Drevets WC, Sahakian BJ: Cognition in mania and depression. Psychol Med 2003;33:959-967.
44.
Rush AJ, Gullion CM, Basco MR, Jarrett RB, Trivedi MH: The Inventory of Depressive Symptomatology (IDS): psychometric properties. Psychol Med 1996;26:477-486.
45.
Schnell K, Bluschke S, Konradt B, Walter H: Functional relations of empathy and mentalizing: an fMRI study on the neural basis of cognitive empathy. NeuroImage 2011;54:1743-1754.
46.
Walter H, Schnell K, Erk S, Arnold C, Kirsch P, Esslinger C, Mier D, Schmitgen MM, Rietschel M, Witt SH, Nothen MM, Cichon S, Meyer-Lindenberg A: Effects of a genome-wide supported psychosis risk variant on neural activation during a theory-of-mind task. Mol Psychiatry 2011;16:462-470.
47.
Montgomery SA, Asberg M: A new depression scale designed to be sensitive to change. Br J Psychiatry 1979;134:382-389.
48.
Elliott R, Sahakian BJ, McKay AP, Herrod JJ, Robbins TW, Paykel ES: Neuropsychological impairments in unipolar depression: the influence of perceived failure on subsequent performance. Psychol Med 1996;26:975-989.
49.
Shah PJ, Ebmeier KP, Glabus MF, Goodwin GM: Cortical grey matter reductions associated with treatment-resistant chronic unipolar depression. Controlled magnetic resonance imaging study. Br J Psychiatry 1998;172:527-532.
50.
Baron-Cohen S, Leslie AM, Frith U: Does the autistic child have a ‘theory of mind'? Cognition 1985;21:37-46.
51.
Baron-Cohen S, Tager-Flusberg H, Cohen DJ: Understanding Other Minds: Perspectives from Developmental Cognitive Neuroscience, ed 2. Oxford, Oxford University Press, 2000.
52.
Frith U: Autism and theory of mind in everyday life. Soc Dev 1994;3:108-124.
53.
Brune M: ‘Theory of mind' in schizophrenia: a review of the literature. Schizophr Bull 2005;31:21-42.
54.
Harrington L, Siegert RJ, McClure J: Theory of mind in schizophrenia: a critical review. Cogn Neuropsychiatry 2005;10:249-286.
55.
Blakemore SJ, Sarfati Y, Bazin N, Decety J: The detection of intentional contingencies in simple animations in patients with delusions of persecution. Psychol Med 2003;33:1433-1441.
56.
Montag C, Dziobek I, Richter IS, Neuhaus K, Lehmann A, Sylla R, Heekeren HR, Heinz A, Gallinat J: Different aspects of theory of mind in paranoid schizophrenia: evidence from a video-based assessment. Psychiatry Res 2011;186:203-209.
57.
Lee L, Harkness KL, Sabbagh MA, Jacobson JA: Mental state decoding abilities in clinical depression. J Affect Disord 2005;86:247-258.
58.
Uekermann J, Channon S, Lehmkamper C, Abdel-Hamid M, Vollmoeller W, Daum I: Executive function, mentalizing and humor in major depression. J Int Neuropsychol Soc 2008;14:55-62.
59.
Wang YG, Wang YQ, Chen SL, Zhu CY, Wang K: Theory of mind disability in major depression with or without psychotic symptoms: a componential view. Psychiatry Res 2008;161:153-161.
60.
Fischer-Kern M, Fonagy P, Kapusta ND, Luyten P, Boss S, Naderer A, Bluml V, Leithner K: Mentalizing in female inpatients with major depressive disorder. J Nerv Ment Dis 2013;201:202-207.
61.
Inoue Y, Tonooka Y, Yamada K, Kanba S: Deficiency of theory of mind in patients with remitted mood disorder. J Affect Disord 2004;82:403-409.
62.
Baron-Cohen S, Wheelwright S, Hill J, Raste Y, Plumb I: The ‘Reading the Mind in the Eyes' Test revised version: a study with normal adults, and adults with Asperger syndrome or high-functioning autism. J Child Psychol Psychiatry 2001;42:241-251.
63.
Fonagy P, Target M, Steele H, Steele M: Reflective-Functioning Manual, v5.0, for Application to Adult Attachment Interviews. London, University College London, 1998.
64.
George C, Kaplan N, Main M: The Adult Attachment Interview. Berkeley, University of California, Department of Psychology, 1985.
65.
Doody GA, Gotz M, Johnstone EC, Frith CD, Owens DG: Theory of mind and psychoses. Psychol Med 1998;28:397-405.
66.
Preston SD, de Waal FB: Empathy: Its ultimate and proximate bases. Behav Brain Sci 2002;25:1-20; discussion 20-71.
67.
Dziobek I, Fleck S, Kalbe E, Rogers K, Hassenstab J, Brand M, Kessler J, Woike JK, Wolf OT, Convit A: Introducing MASC: a movie for the assessment of social cognition. J Autism Dev Disord 2006;36:623-636.
68.
Hass RG: Perspective taking and self-awareness: draw an ‘E' on your forehead. J Pers Soc 1984;46:788-798.
69.
Tager-Flusberg H, Sullivan K: A componential view of theory of mind: evidence from Williams syndrome. Cognition 2000;76:59-90.
70.
Inoue Y, Yamada K, Kanba S: Deficit in theory of mind is a risk for relapse of major depression. J Affect Disord 2006;95:125-127.
© 2015 S. Karger AG, Basel
2015
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.