Motivation and emotion/Book/2014/Depression and motivation

Overview
Motivation factors can play a role in the onset, diagnosis and recovery from depression (Burns, Westra, Trockel & Fisher, 2013). Research findings support the suggestion that a disposition to depression could be characterised by a low motivation approach systems (Vergara & Roberts, 2011). Furthermore, it is suggested that symptoms that are present in depression could be caused by dysfunctions in motivational systems (Vergara & Roberts, 2011). This chapter will explore the relationship between depression and motivation in regards to the development, diagnosis, treatment and defeat of depression.

What is motivation?
Motivation is the driving force behind our needs and behaviours, particularly goal-directed behaviours (Colman, 2009). Motivation is the force or drive that stimulates and encourages us to undertake, persist with, and complete tasks and goals (Colman, 2009). Such goal directed behaviours include biological needs such as thirst, hunger and sex, additionally goal directed behaviours also include social needs such as companionship and achievement (Colman, 2009).

Motivated directed behaviour can be split into two subtypes: | Intrinsic and | Extrinsic (Wright & Wiediger, 2007). Intrinsic behaviour can be described as behaviour undertaken for oneself, from an internal motivator (Wright & Wiediger, 2007). An example of such behaviour is a drop in bodily water levels, which results in an increased thirst, motivating one to drink. Alternatively, extrinsic motivation is behaviours influenced by external forces, such as performing a particular behaviour to please someone else (Wright & Wiediger, 2007).

What is depression?
Depression is a mood defined by sadness, pessimistic thoughts, despair and feelings of worthlessness or guilt (Colman, 2009). |Depression, as a mood, can also be accompanied by anhedonia, changes in weight and eating patterns, and changes in sleeping patterns (Colman, 2009). Depression, as a mood, can be an indicator to many different psychiatric disorders (Colman, 2009).

Generally, when people are referring to depression they are referring to |Major Depressive Disorder (MDD). MDD is a psychiatric disorder characterised by an intense, ongoing depressed mood, referred to as a Major Depressive Episode (MDE; Colman, 2009). MDEs are mood episodes, primarily featuring a depressed mood, which is ongoing for at least two weeks (Colman, 2009). To be diagnosed with a MDE or MDD, a set of symptoms must be met, which are outlined below.

Symptoms of depression
The diagnosis of MDD is outlined in the DSM-5 (American Psychiatric Association, 2013), which is the diagnostic criteria used by doctors across Australia. A simple version of this criterion is outlined below, with criteria A-C representing a MDE and criteria A-E representing MDD.



A)	Five or more of the following symptoms presents over a two week period, with at least symptom (1) or (2) present.


 * 1) Depressed mood
 * 2) Anhedonia
 * 3) Considerable change is weight of eating habits
 * 4) Insomnia or Hypersomnia
 * 5) Psychomotor agitation or retardation
 * 6) Fatigue or loss of energy
 * 7) Feeling of worthlessness and excessive guilt
 * 8) Indecisiveness and trouble concentrating
 * 9) Suicidal ideation

B)	The symptoms cause significant distress or impairment of functioning.

C)	The symptoms can’t be attributed to another medical condition.

D)	The symptoms aren’t better explained by another psychiatric disorder.

E)	No previous manic or hypomanic episode.

Lack of motivation
While a lack of motivation is not a specific criteria of depression diagnosis, changes in motivation are commonly seen among people with depression. Furthermore, changes in motivation and desires are underlying factors to many symptoms of depression. Beck & Alford (2009) identified four major changes in motivation that can be present in depressed patients, which are outlined below.

The loss of will or motivation is a prominent feature of depression (Beck & Alford, 2009). Paralysis of will can include anything from a lack of motivation to socialise, to the lack of motivation to complete the most basic functions that are essential to life, such as eating (Beck & Alford, 2009). Patients can not only feel a lack of motivation, but in severe cases, they can believe that they are completely incapable of completing tasks (Beck & Alford, 2009).
 * Paralysis of will

Although not all depressed patients display this feature, many do express a desire to change the normal pattern of their life (Beck & Alford, 2009). Expressions of this can range from daydreaming about a different life to frequently getting drunk to escape reality (Beck & Alford, 2009). In severe cases, patients may completely lose motivation to engage in one’s life, preferring to stay in bed and not face the day (Beck & Alford, 2009).
 * Avoidance, escapist and withdrawal wishes

Suicidal ideation is a common feature of depression, expressed through the desire to die or to kill oneself (Beck & Alford, 2009). Suicidal wishes can range from passing thoughts that one would be better off dead, to specific plans or attempts (Beck & Alford, 2009).
 * Suicidal wishes

In the terms of motivation changes, this factor describes a change from an independent patient to one who desires help in their everyday life (Beck & Alford, 2009). Manifestation of this can range from the patient no longer wanting to complete certain tasks, so getting someone else to do them, to in more severe cases, having no motivation to do anything, and relying on another person to complete all tasks and solve all problems from them (Beck & Alford, 2009).
 * Increased dependency

Anhedonia


Anhedonia is an inability to desire or feel pleasure from previously enjoyable activities (Colman, 2009). Anhedonia is a core symptom of depression. Furthermore, it distinguishes depression for other psychiatric disorders (Treadway, Buckholtz, Schwartzman, Lambert & Zald, 2009). Anhedonia can refer to a person’s lack of motivation or interest in undertaking pleasurable activities, or it can refer to a person who still undertakes desirable activities, but dosen't gain any gratification or enjoyment from completing these activities (Gilbert, 2007). Anhedonia also disengages people from their everyday lives and responsibilities by diminishing the desire to complete their daily roles, such as working, cleaning and maintaining relationships (Cline-Brown & Watson, 2005).

Research by Treadway et. al. (2009) found a significant relationship between a decreased motivation and the presence of anhedonia, and furthermore suggest that anhedonia is a result of alterations in regards to the processing of rewards, such as pleasure, and results in a lack of motivation for these rewards. Similarly, Treadway, Bossaller, Shelton & Zald (2012) reported that patients with anhedonia were less able to effectively use relevant information about reward and cost values of a particular task to guide their decisions. Such research indicates that there is a complex change in thinking patterns and decision making in people with anhedonia, resulting in a lack of motivation or experience of pleasure.

Learned helplessness
While there are many theories of depression and theories of motivation, the theory of |learned helplessness applies motivation directly to the development of depression. Learned helplessness is a result of an animal or person learning that it has no control over its environment or what happens to it, so as a result it stops trying to change its circumstances and passively and helplessly allows negative things to happen (Petri & Govern, 2012).

Learned helplessness is an important theory in understanding motivation, as the theory suggests one's motivation to react in a situation depends on outcomes from similar situations in the past (Petri & Govern, 2012). If an organism has learned in the past that they cannot have an effect on a particular situation, they will have little motivation to react to it in the future (Petri & Govern, 2012). This notion that the organism cannot control the situation then becomes generalised to most situations, and motivation to react to anything is dramatically reduced (Petri & Govern, 2012).

The lack of motivation to change one's circumstances seen in depression has striking parallels to the learned helplessness theory, which was noted by Seligman, and research confirmed that learned helplessness has a direct correlation with depression (Petri & Govern, 2012; Klein, Fencil-Morse & Seligman, 1976). People who face uncontrollable negative circumstances may learn they have little control over these situations, and then generalise that they have no control over all of their lives, resulting in the lack of motivation seen in depressed patients (Petri & Govern, 2012; Klein, Fencil-Morse & Seligman, 1976).

An aspect of treating depression may include teaching patients that they do have control over the situation, or teaching them to distinguish between controllable and uncontrollable situations, and helping them to realise that uncontrollable situations are not their fault (Petri & Govern, 2012; Klein, Fencil-Morse & Seligman, 1976).

Personality types that encompass depression and motivation: behavioural activation & inhibition systems
There are two basic and all-encompassing personality styles which are primarily linked to whether people have more activity in their left or right prefrontal lobe (Reeve, 2009). People with a more active left prefrontal lobe are more inclined to a positive emotionality, and people with a more active right prefrontal lobe are more vulnerable to a negative emotionality (Reeve, 2009). These differences in brain systems are referred to as the behavioural activation system (BAS) and behavioural inhibition system (BIS) (Goldberg; 2010; Reeve, 2009). The BAS is associated with a more active left prefrontal lobe, and with a positive-incentive motivation system (Goldberg; 2010; Reeve, 2009). A high score on BAS items is related with how responsive a person is to rewards, how they experience positive emotions, and is also correlated with the traditional personality dimension of |Extraversion (Reeve, 2009). The BIS is associated with a more active right prefrontal lobe, and high scores on BIS items is associated to sensitivity to threats, punishments and the experience of negative emotions, and it also correlated to the traditional personality type of |Neuroticism (Reeve, 2009; Goldberg; 2010).

Although the BIS/BAS inventories were originally concerned with anxiety issues, they have also been successfully applied to depression, with the presence of depression being associated with defects in BAS functioning, and high BIS functioning (Goldberg, 2010). A study by Kasch, Rottenberg, Arnow & Gotlib (2002) found that, compared to non-depressed participants, the depressed participants reported higher BIS levels and lower BAS levels. Overall, Kasch et al. (2002) concluded that a deficient BAS system, which is associated with motivation, incentive and positive emotions, can negatively affect the onset and course of depression.

What motivates people to attempt suicide or self-injury?
Suicide, defined as deliberately killing oneself (Colman, 2009), and self-injury, described as intentional harm to one’s own body without suicidal intent (Polk & Liss, 2009) are two of the serious risks of depression and other psychiatric diseases.

In a study by Xie et al. (2014) which studied | Suicidal motivations, they found that suicidal thoughts are created due to a combination of when a patient experiences decreased motivation to experience pleasure, and an increased motivation to escape emotional pain. In a study by Hankoff (1976), he explored the self-reported reason for 151 people who attempted suicide. He found that 9% of the attempts occurred in a crisis situation, usually the recent or impending death of a loved one, and patients displayed feelings of hopelessness. He found that 56% of suicide attempts were committed due to stress, an impulsive, heat of the moment reaction, and this cohort of people were significantly younger than the other groups. Lastly, the final group he identified were suicide attempts by people with a serious psychiatric disorder, which accounted for 35% of the participants.

| Motivations for self-injury are to be considered separately, as the goal of self-injury is not to kill oneself, unlike suicide. In a study by Polk & Liss (2009) 154 participants who reported self-injury, 63% of which had a psychiatric diagnosis, were asked about their motivations for self-injury. Polk & Liss (2009) identified six categories for motivations of self-harm, which are listed below in order of most common to least common. The six categories accounted for 96% of the responses, and only 26% of participants reported more than one of these reasons.


 * To release emotions or to express emotional pain in a physical manifestation
 * To reduce feelings of numbness or dissociation and to feel alive
 * In response to feeling out of control, participants self-injured in order to feel in control of something in their lives
 * Self-harming as a form of punishment, with participants reporting it a punishment for a mistakes or imperfections
 * To prevent themselves from attempting suicide, or from hurting others
 * To act as a distraction from real life or internal pain, or to avoid flashbacks

Motivation in getting and adhering to treatment
Barriers in seeking treatment, and non-adherence to treatment, are commonly reported as serious problems in the mental health care system (Mohr et al., 2010; Bollini, Tibaldi, Testa & Munizza, 2004). Brody et al (1997; as cited in Mohr et al. 2010) reported that approximately 20% of people that were recommended psychological treatment actually received treatment. With the aim of helping to improve the rate of people seeking treatment, Mohr et al. (2010) conducted research to identify the barriers between patients and treatment. They found 9 items that people reported as possible barriers between themselves and treatment outlined below. Of these reasons, Mohr et al.'s (2010) findings suggest that barriers 1, 3, 8 and 9 appeared to be the biggest barriers, while items 2, 4 and 7 have little influence of the probability of seeking treatment or not.



Table 1. Overview of barriers to getting treatment for depression.

While seeking treatment is a serious issue, non-adherence to treatment is also a prevalent problem. This is seen in Wiezbicki & Pekariks (1993; as cited in Mohr et al. 2010) study that reported that 50% of patients dropout of treatment before completion. In a study by Bollini et al., (2004) they asked patients with depression what the major motivators for non-adherence to antidepressant medication were. According to the patients the major reasons that motivated them to not comply with treatment were as follows, in order of most common reason to the least common:
 * Difficultly accepting the diagnosis and the need for treatment and antidepressants.
 * Belief that they no longer required the drug because they were feeling better.
 * The occurrence of adverse reactions
 * Fear of drug addiction
 * Long expected length of time the drug is required to be taken.

Studies such as these can help mental health professionals to improve treatment programs, help alleviate patients concerns, and help motive people to seek and comply with treatment.

Motivational interviewing
Motivational interviewing is a client-focused technique that focuses on the perspectives and worries of the individual with aims to increase the motivation of the client (Arkowitz & Burke, 2007). It is a technique used normally in collaboration with another therapy in the treatment of depression (Arkowitz & Burke, 2007). While there are many different treatments for depression, usually, depression is treated with multiple techniques, because not all techniques work for everyone (Arkowitz & Burke, 2007). Motivational interviewing is used to address two of the most prevalent issues for patients with depression: lack of intrinsic motivation and lack of motivation to change their circumstances (Arkowitz & Burke, 2007). When applied in a therapeutic environment, it is a technique that encourages the client to take control of their issues, by identifying their own problems and possible solutions (Arkowitz & Burke, 2007). Motivational interviewing, when used in collaboration with other therapeutic and biological techniques, can be an effective way to treat depression and improve motivational levels of depressed clients (Arkowitz & Burke, 2007).

Increasing your motivation in everyday life
There are many techniques you can implement in your own life to help you increase motivation, maybe to stick to a diet, or just to get that little bit more study done. There are many self-help books that will talk about many ways to increase your motivation, but here we will talk about some of the techniques I have found most helpful for increasing my motivation to study.

Humans are motivated to complete behaviour if the reward is perceived to be desirable, or if the punishment for non-completion is seen as undesirable (Chyung & Berg, 2010). A rewards program can be a great way to increase productivity, but it is important that the reward is meaningful, fair and relevant to those receiving it, which is subjective (Chyung & Berg, 2010). The simplest form of a rewards program is giving a child pocket money for completing their chores. When implementing one in your own life, you choose something valuable to yourself, whether it be going to the movies or a chocolate bar, and not allow yourself the reward until you have completed your goal.
 * Incentives.

Setting goals and sub-goals are great ways increase motivation and productivity. Having goals can help you focus your attention and concentration, and they can boost your self-confidence as you complete them (Burton & Raedeke, 2008). Furthermore, they can help prevent or manage stress by having a plan, help create a positive mental attitude, and improve you intrinsic motivation (Burton & Raedeke, 2008). It’s very important when setting goals that they are realistic goals, as if they are unattainable you won’t receive the mental benefits of completing them (Burton & Raedeke, 2008). When setting goals, rather than setting one big goal of “I want to complete this essay by Friday” set sub goals of “I want to complete the first paragraph today, and the second tomorrow etc.” and as you reach each sub-goal it will motivate you on to completing the end goal.
 * Goals.

There are many aspects of life where routine is good, such as getting to sleep at night or getting the kids to school, but for work and study, doing the same thing every day can be a drain. Having a mundane set routine can have negative effects on well-being (Feather, 1990) and it can become stale for even the most dedicated student (Ramsland, 1992). Taking a break, varying routine, and doing something new can help recharge your interest. It can be anything from taking a break and reading a book, or changing the location or manor you usually study in (Ramsland, 1992).
 * Vary routine.

Conclusion
This chapter reviewed many of the different ways that the motivation and depression interact. Hopefully this chapter has shown you how important motivation can be for a productive and happy lifestyle, and highlighted how when motivation goes wrong that it can foster depression.

The main take-away points of this chapter were:


 * To understand what depression and motivation are
 * How lack of motivation is important with the diagnosis of depression.
 * How motivation influences the onset of depression.
 * What motivates people to self-harm.
 * How motivation can be used to help treatment of depression; and,
 * How you can help increase your motivation in your everyday life.

Quiz
{ Which statement below is true about the Behavioural Activation System? - It is associated with a more active right prefrontal lobe. + It is associated with the personaility dimension of extraversion. - It is associated with the learned helplessness theory of depression. - It is associated with the personaility dimension of neuroticism.
 * type=""}

{ Which reason is the most commonly reported reason for self harm? - As a form of punishment. - To reduce feelings of numbness. - As a reponse to feeling out of control. + To express emotion pain is a physical way.
 * type=""}

{ Which of following reasons is considered a large barrier to getting treatment for depression? - Lack of motivation. + Stigma. - Participation restriction. - Negitive evaluations of therapy.
 * type=""}

{ Which of the following is not a manifestation of lack of motivation present in depressed patients as reported by Beck & Alford (2009)? + Anhedonia. - Paralysis of will. - Suicidal wishes. - Increased dependency.
 * type=""}