Psychotherapy for depression under the (speculative) assume of a "depression memory" due to a structural change in the neurobiological reward system

Abstract

Based on an integrative cognitive-behavioral and biological approach, depression results from failed attempts to appropriately cope with the negative feelings that result from stressful situations. In a longer-lasting, emotionally harmful situation, quick strong but not long-term effective avoiding-coping strategies are used to relieve the negative emotional state. One such coping strategy entails the avoidance of movement and action activities (passivity in behavior), which constitute the later behavioral symptoms of depression. Scientific investigations have shown that it is not only drugs but also (rewarding) behaviors that are capable (by means of positive reinforcement and negative reinforcement) of causing profound structural physiological changes in the reward system. It is assumed that avoidance-based coping strategies provide strong and immediate emotional relief (reward). This increases the likelihood of reusing the respective coping strategy; further, the positive effect (i.e., emotional relief) is short-lived, and the stressor is not eliminated. As a result of the frequent and conditioned use of avoidance-based coping strategies, the structures of the reward center change and a “depression memory” develops. In certain stimulus constellations (including stimulus generalization), learned “relief strategies,” which serve as the depressive behavioral patterns (behavioral inactivity), are predominantly triggered automatically. A clearly formulated behavioral intention does not have to exist. The result of depression memory is that the behavioral symptoms of depression now dominate the reward system, which in turn suppresses executive brain functions. Underactivity and a loss of control in the regions of the brain that are involved in movement or action activities is accompanied by overactivity in the regions of the brain that are involved in cognitive functions (e.g., excessive negative thoughts, brooding, self-doubt). In particular, the dysfunctionality of the reward system, which has not received sufficient scientific attention to date, poses a special challenge to the therapist. An important therapeutic goal is therefore the restoration of the reward system (i.e. the use of constructive strategies for short-term and long-term coping) and the removal of maladaptive behavior from the dominance of the reward system. It is required to develop a wide range of rewards-effective alternatives (activities, interests, coping strategies) that improve the psychological balance, enable constructive emotion regulation and overcome the feeling of "helplessness".