Agoraphobia is characterized by the avoidance of places such as shopping centers, bridges, tunnels, and crowds due to fear of experiencing intense and often debilitating anxiety symptoms and is commonly diagnosed in young to middle-aged adults and women. When entrenched, agoraphobia imposes severe restrictions on the person’s capacity to venture out of the home. Evidence supports the use of CBT in treating the disorder. Key elements of intervention include psychoeducation, cognitive restructuring, breathing retraining to curtail panic symptoms, strategies to reduce general physical symptoms of anxiety, exposure to interoceptive anxiety-provoking stimuli, and, crucially, gradual in vivo exposure to overcome avoidance. Medications, particularly the SSRI class of drugs, may add to the effects of CBT in some patients. Sole treatment with SSRIs may be necessary where patients are unable or unwilling to pursue CBT. Treatment outcomes are more favorable when a management plan is developed collaboratively with a motivated patient and with partners and family involved in treatment. Booster CBT sessions may improve treatment outcomes. Recent developments include online programs, apps, and virtual reality platforms to facilitate exposure to anxiety-provoking situations within a CBT framework. Alternative forms of psychotherapy should be considered if CBT has little impact.

Introduction

The use of adjunctive psychological interventions represents an important new dimension to the treatment and management of bipolar disorder and especially Bipolar II Disorder (BP II). These interventions are gradually gaining in popularity amongst clinicians who wish to develop a comprehensive management plan once depressive or hypomanic episodes have been stabilised with medication. The impetus for this new emphasis has largely been driven by the recognition that individual differences in the severity, course and outcome of the disorder over time are not fully explained by biological factors and physical treatments alone. Furthermore, there has been increasing acceptance of stress-vulnerability models which highlight interactions between psychological, social and biological factors – which in turn play a significant role in the maintenance and recurrence of several serious psychiatric illnesses, including bipolar disorder and schizophrenia. Over the last decade, interest has also shifted to psychosocial factors which affect social and occupational functioning, treatment adherence and suicidality, and which are particularly amenable to psychological interventions (American Psychiatric Association, 2002).

Much has already been written about psychological interventions for unipolar depression and there is evidence to suggest that many of these strategies may also be useful in treating the depression that accompanies bipolar disorder. Thus, this chapter will primarily focus on addressing hypomanic symptoms and on managing the phasic nature of BP II.

Psychological interventions such as self-monitoring of symptoms and mood have usually been employed during the prodrome and/or the recovery phase of an episode (Perry et al., 1999; Lam et al., 2003).

Rejection sensitivity style

This personality style is characterised by a tendency to worry about being rejected or abandoned by others. Key characteristics include being acutely tuned in to others' emotional needs and prone to feeling rejected. People with features of this personality style also tend to base their self-worth on others' perceptions of them and worry about the quality of their relationships with others. Although they may recognise that they tend to ‘lose themselves’ in relationships and become too attached, they are generally unable to prevent such pathological types of attachments from forming. As a direct result of their fears of abandonment, people with characteristics of the rejection sensitivity personality style may act in ways to please others at the expense of their own emotional health. Often, they may engage in and persist with abusive or dangerous relationships with others rather than leave the relationship altogether.

Key features of the Rejection Sensitivity Personality Style (derived from our Temperament and Personality Questionnaire):

• Worries about the quality of their relationships.

• Worries about being rejected or abandoned by others.

• Fears that their relationships may end.

• Feels as if their emotions are not reciprocated in relationships.

• Worries about what others think.

• Distressed about being alone.

When they experience difficulties in their relationships, such individuals may report feelings of intense emptiness and despair.

Anxious worrying style

While many people experience periods of worry in their lives, those with an anxious worrying temperament have a tendency to worry most of the time, seemingly over the most trivial incidents and situations. They are often described by others as being ‘highly strung’ or ‘nervy’. Domains of anxiety may include worrying that the worst will happen even after minor events, being especially sensitive about unexpected changes in their immediate environment, and getting upset over minor things that go wrong. People with this type of temperament are easily upset and stressed, and can seem tense and jumpy. When distressed, they tend to find comfort in talking to close friends about their worries and in seeking reassurance, or going quiet and keeping to themselves. Sometimes they may resort to temporary relief from their worries by engaging in pleasurable activities as a means of distraction.

Key characteristics of the Anxious Worrying Temperament (derived from our Temperament and Personality Questionnaire):

• High levels of autonomous arousal.

• Easily rattled and upset.

• Tense and nervy.

• Worry over minor things.

• Take things too personally.

• Worry that the worst will happen.

When stressed, key personality features of the anxious worrier, such as ruminative and catastrophic thoughts, worsen. When such thoughts begin to focus on excessive self-doubt, and pessimism about the future, together with a sense of ineffectiveness or helplessness, a depressive episode may arise.

Social avoidance personality style

People with features of this personality style tend to shy away from social stimulation and are usually reluctant to socialise or mix with others at parties or other social gatherings. They may appear shy or distant around people, especially those they have not previously met. Features of this personality style include a preference for solitude and solitary activities. There is the danger that, when stressed or upset, people with features of this type of personality style completely withdraw from social activity and thus hinder the likelihood of deriving support from others, including seeking professional help.

Key features of the Social Avoidant Personality Style (derived from our Temperament and Personality Questionnaire):

• Dislikes social stimulation or mixing with others.

• Avoids parties and other social gatherings.

• Reserved in social situations.

• Quiet around others.

• Holds back on meeting new people.

• Prefers own company to that of others.

High levels of anxiety and self-criticism in social situations may characterise this personality style. There may also be a history of early adverse experiences surrounding social situations, such as being bulled or humiliated at school or teased by siblings at home. People with features of this personality style may have organised their lives to exclude or minimise interaction with others. For example, by choosing occupations that require solitary rather than team activities, and maintaining a small group of friends and acquaintances who are unlikely to threaten or make demands on their time.

Introduction

We view melancholic depression as a quintessential biological ‘disease’, and therefore preferentially responsive to biologically weighted treatments. As noted earlier, episodes may be precipitated or triggered by stressors such as interpersonal or work crises (and particularly those occurring early on in the life of the disorder), or may occur without any seeming trigger (i. e. ‘endogenous’ in the old terminology). For some individuals, there may be a seasonal predilection, with episodes being more likely to occur in spring, perhaps because of the rapid increase in luminosity stimulating the pineal gland. The point here is that ‘stressors’ may operate across a number of parameters.

For those with a lifetime unipolar course (episodes of melancholic depression only and no ‘highs’), onset is rare at a young age, with episodes being more likely to commence in middle age or later. In those whose lifetime course is bipolar, episodes of melancholic or psychotic depression can occur at a much younger age, including in the teen years. We have a working principle (which, like most principles, is waiting rejection by a rush of exceptions) that: an episode of melancholic or psychotic depression in an individual aged less than 40 years of age is indicative of bipolar disorder being either present or being likely in the future. For such young subjects, we encourage close questioning about features of ‘highs’.

There are major problems in modelling the depressive disorders and in evaluating available treatments. In the last few decades, the Diagnostic and Statistical Manual of Mental Disorders (DSM) (American Psychiatric Association, 1994) model has dominated the classification of depression. It shares its largely dimensional model with the World Health Organisation's International Classification of Diseases (ICD-10) (World Health Organization, 1992) recent classificatory system. Thus, the current dominant model for conceptualising the depressive disorders is a dimensional or continuum view – with depression essentially seen as a single condition varying by severity.

We have long argued for a differing paradigm: one that allows (on the basis of specific clinical features) categorical status to certain expressions of depression such as melancholia and psychotic depression. However, once these more categorical conditions are excluded from the broad landscape of ‘depressive disorders’, there are difficulties in modelling the heterogeneous residue of non-melancholic conditions, as they are not categorical, vary in their status (as disorders, conditions, and stress responses) and are often multi-axial. For these, we favour a ‘spectrum’ model: viewing them as reflecting an interaction between salient life stresses and personality style.

In addition to challenging current diagnostic models we also challenge the ‘evidence base’ for evaluating antidepressant therapies. We question the reliability or ‘gold standard’ value offered by evidence-based approaches, at least as currently undertaken. We do not dispute the ideal – whereby judgements about the effectiveness of available antidepressant treatments benefit from randomised control trials (or RCTs) – when such data provide objective, impartial, systematic, and valid information.

The expatriate Australian psychiatrist, Barney Carroll, wrote that to understand depression is to understand psychiatry (Carroll, 1989). ‘Depression’ presents the greatest challenges and the greatest risk of hubris. It is a fantasy to imagine that a clear-cut typology either exists or can be readily derived, and the road to that castle is littered with numerous classificatory systems, variably proposed by observant clinicians and/or opinionated academics. The opinionated are now regressed to the mean by Consensus Committee processes, a theoretically constructive strategy but one that is disappointing in practice because of their reliance on formal evidence-based data while their risk-free ambience tends to reify the orthodox.

The previous chapter considered how ‘clinical depression’ can be defined, differentiated (phenomenologically from grief and anxiety), and diagnosed – all relatively straightforward issues in comparison to this chapter's domain. Here we seek to tackle a more difficult task: considering whether meaningful depressive disorders can be differentiated or cleaved from each other, whether such differentiation is absolute or a matter of degree (i. e. independence or interdependence), and then present a differentiated model (of ‘meaningful’ depressive conditions) which, we argue, allows differential treatment approaches to be provided on a more rational basis.

It is in our nature as human beings to seek simple models to assist us through life and, if a simple taxonomy did have explanatory power, we would all be most appreciative.

As noted in Chapter 1, the binary model of depression viewed one ‘type’ of depression (i. e. reactive or neurotic depression) as essentially being a response to a major or salient life-event stressor. By contrast, the other type of depression (endogenous or melancholic) was seen as a condition that occurred without any such trigger, with the term ‘endogenous’ emphasising that the depression came from ‘within’ rather than from stressors and the environment. We now turn to examine the role of life-event stressors in those with non-melancholic disorders. Life-event stressors may, theoretically, be all-explanatory and contribute totally to the onset of the depressive disorder. Terms such as ‘reactive depression’ and ‘adjustment disorder with depressed mood’ emphasise the contribution of a life event and do not recognise any predisposing or other factor. While life events may vary in their magnitude, one could posit that most of these ‘pure state’ reactions are likely to be in response to cataclysmic or extremely severe depressing events, and where it might be imagined that most people would develop such a depressive condition.

In many ways, these reactions are extensions of ‘normal depression’. Studies of non-clinical groups suggest that most people experience depressed moods following relevant triggering events but that, for most these states last only minutes, hours, or days. Thus, most human beings experience a spontaneous remission of such moods with the mood state self-remitting, either naturally or in response to some (presumed) positive outcome.

It has been estimated that up to 50% of Australians who suffer from a depressive disorder may seek self-help or non-medical complementary treatments for their condition. The popularity of natural and alternative treatment lies in their easy availability and low cost, positive associations with optimal health, and social acceptability. Other reasons for their popularity may relate to feelings of self-efficacy and self-direction in matters of personal health and well-being.

Natural and alternative treatments are those practices that are not within the range of mainstream acceptable treatments. Research has indicated that these practices may have some efficacy for some presentations of non-melancholic depression, but are unlikely to be of primary benefit to those who suffer from melancholic or psychotic depression or bipolar disorder.

The range of natural and alternate treatments

There are many types of natural and alternate treatments for depressive disorders, some of which are only just beginning to gain credibility among professionals and the mainstream medical establishment. With the exception of a handful of treatments, the clinical efficacy of the vast majority of these treatments has not yet been empirically determined in randomised controlled trials (RCTs). Furthermore, it is only possible to speculate on how personality features in non-melancholic depression may affect the use of natural and alternative treatments, treatment compliance, and clinical efficacy.