Impairment in social and familial relationships

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Difficulties in social functioning are concomitant to depressive disorders. (5,Z,62) Previous research found that patients experienced a reduction of social relationships, with feeling of social discomfort, loneliness, and boredom.(6) Depressed patients seem lower in social self-confidence, they socialize less, and participate in social interaction less fully than do never-depressed persons.(62) In other words, depressed individuals do not make active effort to develop and sustain reciprocally supportive social relationships. The concept of social support has been widely used to predict general health and more specifically psychiatric symptoms. (63> Previous research revealed that the degree of integration in a social network, or structural support, have a direct positive effect on well being, reducing negative outcomes in both high- and low-stress life events. Among depressed individuals, dysfunctioning in social activities has been found to persist a long time after remission from the depressive episode/6,64) The social dysfunctioning concerns more specifically marital, parental, and familial relationships.

The relationship between marital disturbance and affective disorder has received increased attention over the two past decades. First, descriptive studies have suggested that marital conflict correlates highly with concomitant depression,(65) and marital therapy has been found to be effective in reducing the symptoms of depression, alone(66) as well as in combination with pharmacotherapy/67) Further, previous research found dysfunctional patterns of communication in couples with a depressed spouse. Specifically, compared with their non-depressed counterparts, depressed couples have been found to exhibit more friction, lack of affection, lower levels of constructive problem solving, mutual self-disclosure, and reciprocal support. (Z6,69> The lack of a confiding and intimate relationships leaves individuals vulnerable to depression/7,7 Z1) Finally, marital distress may also exacerbate difficulties experienced in extramarital relationships, (72) thereby increasing introverted behaviour and social isolation. In a similar manner, the absence of a marital partner may hasten the onset of depression among vulnerable individuals. (73)

Parental relationships also seem to have a great impact in the course of affective disorders. A variety of authors have emphasized the importance of the quality of early experiences with parents in the development of adult depression. Beck^4 explicitly attributed the development of negative cognition and negative schemata of self to critical disapproving parents, and later Blatt and collaborators (75) suggested that the vulnerability to depression arises from impairment in relationships with parents. In general, depressive individuals described both mother and father as lacking warmth and a caring attitude, and being overly controlling, which involves intrusiveness, overprotection, and control through guilt.(7 ,77) For example, Andrews and Brown(78> found that women who became depressed following occurrence of major life events were more likely to report lack of adequate parental care or hostility from their mothers than those who did not become depressed. In summary, perceived lack of parental warmth, acceptance, and affection has consistently been associated with depression, however the evidence for a relationship between parental negative control and affective disorders is less clear. Specifically, some investigators have found that depressed people perceive their mothers to have been overly protective and intrusive, and both parents to have used guilt and anxiety-provoking strategies to exercise control over them; however, contrary findings have also been reported/79,80

Studies on parental representation are generally retrospective, i.e. the parental representation of depressed patients is compared to those of non-depressed controls. Consequently, the depressed subjects' negative view of parents may be distortions due to the affective disorder rather than accurate recollections. Gotlib et al.(H) found that the perceptions of maternal caring and overprotectiveness experiences by moderately depressed individuals do not shift with remission of their depressed mood, and may be considered as stable perceptions. Thus, this study supports the notion that depressed adults had more negative relationships with their parents than have non-depressed persons.

In addition to marital and parental relationships, the quality of the familial relationships, in general, has been shown to have a significant impact on mental health/8 ,83) When the quality of the family relationships is evaluated, studies have consistently found that when family members are critical, unsupportive, or generally display negative attitudes towards the depressed member, these behaviours lead to less likelihood of recovery or greater likelihood of a relapse of depression for the depressed family member/8 ,85and 86)

In summary, the quality of social and familial relationships appear to set the stage of depression. Social maladjustment at recovery may represent a risk factor that predisposes to further recurrent episodes. Individuals who experienced negative parental and familial relationships may be vulnerable to depression, and children exposed to such experiences may become depressed/8,88) Most of the research to date is correlational, and cannot establish a causal link between negative relationships and the onset of affective disorders. Nevertheless, the associations are robust and well replicated, suggesting that disruption of social relationships may be a critical vulnerability factor for affective disorder.

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