La depresión: ¿un trastorno dimensional o categorial?
- Autores: Diana Agudelo, Charles D. Spielberger, Gualberto Buela Casal
- Localización: Salud mental, ISSN 0185-3325, Vol. 30, Nº. 3, 2007, págs. 20-28
- Idioma: español
- Enlaces
- Dialnet Métricas: 5 Citas
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Resumen
- español
El tema del carácter dimensional o categorial de la depresión, así como de otros trastornos mentales, es un asunto de gran relevancia científica y clínica. Las implicaciones de la existencia de un modelo categorial en la actualidad para definir y estimar la presencia de un cuadro clínico se ven reflejadas en los datos epidemiológicos, los resultados de las investigaciones y los mismos instrumentos de medida, así como en los programas de intervención que se llevan a cabo.
No es nuevo en la Psicología y en la Psiquiatría pensar en la existencia de factores asociados a la personalidad, capaces de explicar buena parte de las condiciones crónicas de muchos trastornos, y a pesar de que en los manuales diagnósticos vigentes se diferencian los distintos tipos de trastornos del estado de ánimo, muchas investigaciones ponen de manifiesto la posibilidad de considerar la depresión a lo largo de un continuo, donde en el extremo menos grave se encontraría la personalidad depresiva y en el extremo más grave el trastorno depresivo mayor.
En este sentido, se ha planteado la existencia de cierta forma de vulnerabilidad que explicaría la respuesta diferencial en cuanto a depresión se refiere. Así, se ha hablado de factores cognitivos que unidos a factores sociales y genéticos, aumentan el riesgo de sufrir síntomas depresivos crónicos.
La consideración de la existencia de un trastorno depresivo de la personalidad se ampara en la presencia de síntomas que sin cumplir los criterios de gravedad y frecuencia necesarios para dar cuenta de un episodio depresivo mayor, sí generan un patrón de respuesta sistemático que afecta el estado de ánimo. Esta condición ha sido descrita en los manuales como distimia que, debido a su permanencia en el tiempo, podría llegar a ser una condición subsumida por el trastorno de personalidad. Dando cuenta, en este sentido, de un continuo con la normalidad, se le puede identificar como el rasgo que describe el neuroticismo y en cuyo recorrido pueden aparecer entidades discretas, diferentes cuantitativa y cualitativamente que marcarían la presencia de entidades categoriales.
La estimación del carácter dimensional de la depresión está apoyada por la evidencia de la distinción entre los trastornos en función de la gravedad de afectación, de tal forma que dentro de las implicaciones directas para considerar la depresión como un constructo dimensional es necesario admitir la relación de lo psicopatológico con los procesos normales como una diferencia de carácter cualitativo.
Una de las implicaciones que conlleva a considerar la existencia de la depresión como una dimensión, es suponer el desarrollo de nuevas formas de evaluación capaces de diferenciar entre rasgos estables y estados puntuales de la afectación sobre el ánimo, ya que en la actualidad, la mayor parte de los cuestionarios de evaluación está basada en la clasificación categorial lo que dificulta la estimación de la condición dimensional. Adicionalmente, dado que la mayoría de estos instrumentos han sido desarrollados sobre la base de la existencia de la presencia o la ausencia del cuadro en función de los criterios diagnósticos, no es posible establecer sensibilidad sobre la determinación de niveles de afectación menos graves, que en la labor clínica tienen una gran relevancia pues permiten una estimación de la mejoría con la disminución de la sintomatología.
Lo anterior supone el desarrollo de alternativas de intervención más puntuales, dirigidas incluso a procesos preventivos frente a los posibles factores de vulnerabilidad frente al desarrollo de importantes trastornos como los tipificados en los trastornos del estado de ánimo, mismos que constituyen un importante problema de salud pública en la actualidad.
- English
One of the crucial subjects, either for the clinical or scientific activity, is the dimensional or categorical character of depression and other mental diseases. Each approach is different from the theoretical and epistemological points of view.
At presence, the categorical model for the definition and estimation of the presence of a disorder are reflected in the data on epidemiology, the results of investigations, instruments and the interventions. These elements are related to a system of thinking which results in a particular form of conceiving the psychopathology and intervention. Nevertheless, the strong influence of the categorical model in which the disorders are defined as a group of accomplished criteria has not prevented from development of a dimensional model. The latter postulates the existence of a continuum between the normality and pathology which correspond with dimensions, levels and severity related to the certain behaviours, traits or even symptoms.
The interest in the dimensional approach to psychopathology, in general and in mood disorders, is caused by the observation in clinics which indicate, for example, that many patients do not improve with medicines and present residual symptoms during long periods of time. For these reasons, some personality factors which would explain the chronic symptoms of disorders have been proposed in Psychology and Psychiatry. Although the diagnostic manuals consider different types of mood disorders, many investigations have showed the possibility to consider depression as a continuum, where the least severe extreme would be the depressive personality and the most severe, major depression.
According to the abovementioned proposal, it is possible that some people present certain vulnerability which would explain the different answers in case of depression. Cognitive factors, together with social and genetic factors increase the risk of chronic depressive symptoms. The catastrophic perception of self, the world and future, the dichotomous thinking and tunnel vision are the cognitive factors associated with the presence of the mood disorders symptoms. Additionally, some studies show the importance of gender, as women are more prone to develop depression and similar disorders which is related to traditional social roles. This can be caused by the need to sacrifice the professional career to dedicate time to housework, or to assume multiple roles. Concerning the genetic factors, the presence of first degree relatives with mood disorders increases the risk of development of depression or dysthymia.
The consideration of depressive personality is based on the presence of symptoms which do not fulfil the criteria of severity and frequency of major depression but do affect the mood. The presence of these stable traits is related to major chronicity and worse prognosis. This condition has been described in manuals as dysthymia. Nevertheless, as it remains relatively stable in time it could be understood as a personality disorder. The disorder would be a continuum with the normality similar to this described as neuroticism in which some entities are qualitatively and quantitatively different which represent the categories.
The analysis of what has been described above shows the possibility of differentiation between the mood disorders which are related to the dimensional focus where some traits increase the vulnerability to develop them. On the other hand, the categorical focus requires the accomplishment of the diagnostic criteria.
The cognitive models also support the existence of depressive personality disorder. These models emphasize the importance of schemes in thinking which are created in childhood together with the attachment to the caretaker. The schemes are the basis for the future relationships which in case of mood disorders are always perceived with continuous thread of abandonment and lost. On the other hand, the behavioural models emphasize the patterns of negative interpersonal interaction in childhood, as the factors which predispose to the development of depression, whereas the psychodynamic theories establish the successive lost during the lifetime as the principal cause of mood disorders. All these theories show the existence of unfavourable emotional conditions which cause a certain vulnerability to develop symptoms of depression.
The dimensional focus on depression is also supported by the evidence on the distinction between the disorders according to the severity. The difference between the normality and the psychopathology is not as clear as in the categorical focus. There is a necessity to develop new forms of evaluation which would enable the differentiation between the stable traits and punctual states of mood. At presence, most of the questionnaires are based on the categorical classification which makes the estimation from the dimensional point of view more difficult. On the other hand, the measures which provide differentiation between the traits and states are an alternative to estimate the stable conditions which would be related to the depressive personality and also specific reactions which depend on the present situation.
Most of the instruments have been developed on the basis of the categorical model in which the diagnosis is the presence or absence of a disorder according to the diagnostic criteria. For this reason they do not have sufficient sensitivity to determinate less severe levels which are also important in clinical interventions as they allow the estimation of the improvements and decrease of symptomatology. The dimensional focus allows the preventive interventions in mood disorders which are very important to solve this serious health problem in the population.
- español
