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My task now is to show that depression undermines personal autonomy. Such a claim is hardly controversial, as most accept that the depressed worldview frequently misrepresents reality and, on just about any account, sets back autonomy. However, I want to be quite specific about the nature and mechanism of skewed perception in depression, in order to later tease apart the differential effects of psychotherapy and ADM on autonomy in this disorder. First, I will detail the negative information-processing biases that lead to false pessimism and show how depressed affect is a pivotal mediator of this distorted thinking. While acknowledging negative biases as a primary threat to autonomy, I go on to argue that a failure to understand depressed affect as a reinforcer of confounding pessimistic beliefs further sets back autonomy. Next, I show how stressors can precipitate depressive episodes and that information linking stressful life events to depression is likely to be material to the afflicted person. Yet, I argue that two factors conspire to obscure that connection. First, I show that a prevalent medical conception of depression as a primary disorder of brain chemistry deters the elucidation and management of stressors. Second, I show that negative attributions warp stressor appraisals by overemphasizing personal inadequacies as causal and fostering inaccurate forecasts of wide-ranging and enduring adversity. I conclude that a failure to hold justified beliefs about the poor evidential value of depressed affect erodes autonomy in depression and, more specifically, undermines the autonomy of stressor-related decisions. 4.1 The Cognitive Approach to Depression I will make claims about biased thinking and stressors in the context of a cognitive approach to depression. It is necessary, then, to provide background on depression generally and on a cognitive theory in particular. Depression: Disorder of Affect, Disorder of Autonomy 4 66 Chapter 4 A definition with broad currency comes from the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV-TR), of the American Psychiatric Association. It states the following: The essential feature of a Major Depressive Episode is a period of at least 2 weeks during which there is either depressed mood or the loss of interest or pleasure in nearly all activities. In children and adolescents the mood may be irritable rather than sad. The individual must also experience at least four additional symptoms drawn from a list that includes changes in appetite or weight, sleep, and psychomotor activity; decreased energy; feelings of worthlessness or guilt; difficulty thinking, concentrating or making decisions; or recurrent thoughts of death or suicidal ideation, plans, or attempts. . . . The episode must be accompanied by clinically significant distress or impairment in social, occupational, or other important areas of functioning. For some individuals with milder episodes, functioning may appear to be normal, but requires markedly increased effort.1 The DSM-IV-TR includes an additional group of specifiers of severity. In mild depression, “few, if any, symptoms in excess of those required to make the diagnosis are present, and symptoms result in no more than minor impairment in social or occupational functioning.” In depression of moderate severity, “symptoms or functional impairment between mild and severe are present.” In severe cases, “many symptoms in excess of those required to make the diagnosis, or several symptoms that are particularly severe, are present, or the symptoms result in marked impairment in social or occupational functioning.”2 While the DSM criteria for depression are an accepted benchmark for most health professionals working in the field, their propagation has also generated controversy. A notable recent critique comes from Allan Horwitz and Jerome Wakefield, who argue that DSM improperly merges normal experiences of sadness with diagnoses of depressive disorder. Key to their concern is what they see as the inability of DSM to differentiate between sadness as a response to loss or other distressing circumstances and socalled sadness “without cause.”3 On their account, this distinction is crucial, as it is only sadness, or depression, “without cause” that truly qualifies as a disorder. The contextual nature of much depression is central to my own argument , and I will spend some time elaborating it. And Horwitz and Wakefield might ultimately be shown correct that DSM “overpathologizes” many people with quite legitimate sadness in the face of adversity. However, the debate over precisely where to establish the definitional boundary for depressive disorder has only tangential relevance to the claims made here. For my argument, DSM criteria are helpful in establishing uniformity [18.220.16.184] Project MUSE (2024-04-26 12:19...

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