The importance of multicomponent interactions

The biopsychosocial approach, then, focuses on interactions, and so we need to conceptualise what kinds of interactions are salient, and to recognise the importance of feedback and feed-forward processes. We can depict possible domains of interaction relevant to depression with a simple flow diagram derived from numerous studies on various elements of depression. This is given in Figure 6.2 and depicts early vulnerability factors, current

Figure 6.2 Biopsychosocial interactions in depression

vulnerability, and provoking agents or triggers. Each of these alone or in combination affects physiological states, appraisal processes (for example, of self, world, and future), and coping behaviours, and gives rise to the symptoms of depression.

Note that there are arrows across and between processes. For example, early vulnerability factors (such as abuse) can affect how people engage their social lives (for example, have difficulty in developing supportive, stable, and intimate relationships), making them more currently vulnerable (for example, poor social support) and susceptible to stressors (such as early pregnancy) (see Andrews, 1998). As Hankin and Abramson (2001) note, some events can be independent (such as collapse of the stock market and financial or job loss), but others are dependent (for example, some personality dispositions reduce the probability of developing close supportive relationships and increase the probability of relationship breakup and conflict). Thus, early vulnerability, current vulnerability, and provoking agents can interact.

Physiological changes themselves, as may stem from a major life stress (such as loss of one's job), can interact, as, for example, the discovered interactions between the endocrine and immune systems, each of which can affect neurotransmitter systems and mood (Anisman & Merali, 1999). Physiological processes also affect cognitive processes. For example, increasing levels of cortisol (a stress hormone) tend to focus attention on threats and negative events; animals with high cortisol are more sensitive and attentive to possible threats than low-cortisol animals (Rosen & Schulkin, 1998; Toates, 1995), and, as we will note below, people from abusive backgrounds have high levels of cortisol. In a major review, Taylor et al. (2000) explored how differences in gender evolution and sex hormones can differently affect stress and depression in the genders. They called for greater gender-sensitive research.

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