Specific meaning

The original contextual ratings of severity of threat have been used as a basis for taking account of more specific aspects of meaning. Severe events preceding an onset of depression generally involve loss, if this is defined broadly not only in terms of loss of a person but loss of a role or a cherished idea—the latter about oneself or someone close.(37) (In contrast, events preceding the onset of anxiety tend to involve 'danger'—the threat of future loss.) However, although loss is typically present it may not be the factor of central aetiological importance. Tab!e.,2 illustrates this by the development of a more comprehensive rating scheme—again carried out by the investigator. Four overall types of meaning are considered, covering in all nine categories. The ratings are hierarchical. Where more than one rating is possible the highest on the scale is taken. The first three categories concern possible types of humiliation, i.e. the likelihood of the event provoking a sense of being put down or a marked devaluation of self. The first category, for example, covers separating from a partner or a lover where they either took the initiative or the respondent was

'forced' to leave or break off a relationship because of violence or the discovery of infidelity.

Table 2 Onset by type of severe event over 2-year period in the Islington community series

Events associated with entrapment, the second main type, had to have failed to meet criteria for one of the three humiliation categories. Such events emphasized the fact of being imprisoned in a punishing situation that had gone on for some time. The third type deals with four kinds of loss (in the absence of humiliation or entrapment) with the final type, danger, involving threat of a future loss. (3Z>

The table shows whether a particular severe event (or sequence of closely related events) was followed by an onset, taking the event (or sequence) nearest the onset when there was more than one event within 6 months of onset. Using a 2-year period for the Islington women, it shows that there were large differences in risk by event type. If events involving humiliation are combined with those of entrapment, risk was increased threefold. (38> The relatively low risk associated with loss alone, except following a severe event involving a death, suggests that while the majority of depressogenic events involve loss, something more than this is usually involved and that the experience of humiliation or entrapment associated with the loss is often critical.

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