Adolescents’ Understanding of The Dynamics of Depression

Advances in the understanding of depression have characterized the last two decades [2]. New statistical techniques such as path analysis that have allowed for more complex, comprehensive models where several predictor variables can be included, simultaneously [3,4]. A variety of sequential and developmental analyses have enhanced our appreciation for the precursors and consequences of depressive experiences over time.

New questionnaires have also been added to the study of depression in children and adolescents. For example, our own most recent Dimensions of Depression Profile for Children and Adolescents now taps six theoretically-derived features of depression in children and adolescence: (a) depressed affect, (b) energy, (c) self-esteem, (d) self-blame, (e) hopelessness, and (f) suicidal ideation [1]. This instrument allows for a detailed examination of the different dimensions of depression, highlighting which, for individuals in any given sample, predominantly document the self-reported depressive experience for youth.

In this article, however, I shall adopt a different approach, based on our interviews and open-ended survey questions administered to adolescents from normative samples who report depressed affect, on the instrument described above. The responses of such teenagers have broadened our comprehension of the dynamic of depression, identifying more complex dimensions not captured by existing models or questionnaires. First, I will present data revealing that adolescents, when asked, do not merely experience depression as profound sadness but as a combination of sadness and anger. This raises the question of just who is the target of such anger, the self, as Freud argued, or a significant other? Second, the answer to this question led us to query adolescents about the causes of depression; do they represent the actions of the self or actions of others against the self? Adolescents’ answers have also caused us to rethink the applicability to adolescents of Freud’s formulation about depression which was developed for adults [5]. Third, it has been well-documented that low self-esteem accompanies depressed affect. But does the experience of low self-esteem precede the feelings of depression or follow them? We asked depressed adolescents this very question, directly. Their answers were quite illuminating. Finally, how do the answers to this question predict how depression is experienced in terms of its causes? I will argue that neither our sophisticated sequential models nor our thoughtfully constructed questionnaires will provide the answers to these trenchant queries. In our scientific zeal for more complex and comprehensive statistical techniques, we tend to forget that the location of depression resides in the minds and hearts of teenagers, so afflicted. I will argue that we need to return to the experiential font of wisdom for an understanding of depression, we need to ask, and listen to, adolescents themselves. Their answers tell a fascinating story.

In individual interviews with adolescents, we initially gleaned some interesting insights in terms of the emotions that were experienced during their depression. One adolescent male lamented, “When I am depressed I feel very sad, because other people have hurt me, but I am also very angry at them too, for not caring, for rejecting me.” We learned that other adolescents voiced similar accounts of their emotional experience when depressed. In a pilot interview study of 12 adolescents from our normal sample who had indicated on our questionnaire that they frequently were depressed, 11 out of the 12 spontaneously mentioned that they felt angry or frustrated, in addition to feeling overwhelmingly sad [3].

This finding was not entirely novel. In fact Freud, himself, asserted that depression is experienced by adults as a combination of sadness and anger [5]. The primary emotion of extreme sadness, typically over the actual or psychological loss of a significant other, was accompanied by acute anger or rage. The unique contribution of Freud’s formulation was that it is often socially inappropriate or psychologically ill advised to direct such anger toward the lost other, for adults it is ill-advised. Thus, adults defensively direct or displace the anger toward a more available target, the self. Subsequent studies in the clinical literature eventually documented the co-occurrence of sadness and anger toward the self in adult depression [6,7]. Thus, it seemed fruitful to examine the co-occurrence of sadness and anger in a normal sample of adolescents who admitted to the experience of frequent and intense depression. Of particular interest was the target of the adolescent anger component: Are they angry at the self, as Freud hypothesized for adults? Or are they angry at the presumed offending other?

There is precedence for studying emotion combinations in both children and adolescents. In the 1980’s, a number of investigators, including our own research group, had turned their attention to the experience of mixed emotions [4,8-12]. Our own work has demonstrated a normative five-stage developmental sequence governing the appreciation that one can experience two different emotions at the same time. These findings indicate that by middle childhood, children acknowledge the simultaneous occurrence of a variety of emotion combinations including sadness and anger. Thus, is seemed fruitful to extend our inquiry to the phenomenological experience of depression as an emotion blend among adolescents.

Based on these considerations, we anticipated that among a subgroup of adolescents in our normative sample, namely, those who report frequent episodes of depression, most would report that they experience depression as a mix of sadness and anger. However, with regard to the anger component, a critical question involved the particular target or object of the anger. Most interesting, is anger directed toward the self, as psychoanalytic formulations of depression among adults would argue? Or is anger directed toward offending others? [5,13-16]. Previous clinical observations of adolescents by Cantor and by Pfeffer had suggested that at this particular developmental level, depression is often manifest as anger toward others [17,18]. It was speculated that adolescents had not yet developed the social inhibitions or defenses that would prevent them from expressing their anger directly toward significant others, thus accounting for the difference between depressed adults and adolescents. Based on these observations, we predicted that in describing the emotions that they experience when depressed, the majority of adolescents would report anger toward others, either as the primary emotion or in combination with anger directed toward the self.

Our first hypothesis, namely, that the majority of adolescents would report anger, in addition to sadness, when they are depressed was supported. Eighty percent of the students sampled selected sadness and anger as the two emotions that most typically experienced when they were depressed. Thus, the findings support the view that depression in adolescence is best characterized as an emotion blend, consistent with existing formulations including the psychoanalytic perspective [5]. They also bolstered the developmental evidence emphasizing the emergence of the ability to experience two emotions simultaneously [12]. In addition, they mirrored the emphasis on comorbidity within the clinical literature, expressed as the display of internalizing and externalizing symptoms, concurrently [6,19].

We next turned our attention to the target of the anger component of depression. We predicted that the majority of students who experienced depression would report anger toward significant others or would admit to anger toward others in combination with anger toward the self. Consistent with these expectations, 39% of the adolescents report anger, only toward others, with another 40% citing both anger toward others and anger toward the self. Thus, almost 80% cited anger toward others (in combination with sadness) as critical to their experience of depression. However, we did not know why they experienced anger, either toward others or toward the self: Was the anger toward either of these targets justifiable? For the answer, we needed to inquire into adolescents’ perceptions of the specific causes of depression.

From a developmental perspective, it is noteworthy that depressed adolescents within a normative sample do not report the emotional experience more predictable from the psychoanalytic perspective on adult depression, namely, that the anger component would be primarily directed toward the self. In an attempt to unravel this seeming disparity, we next directed our empirical attention to the reported causes of depression among such adolescents. 

We began with open-ended questions, asking participants for whom depression was common to “think back to the most depressing thing that has happened to you in the past year and describe that event. The majority of adolescents’ descriptions could be categorized into the following eight categories:

1. Psychological harm to the self by others. For example, “Someone made me feel bad.” “They hurt my feelings, they teased me.”
2. Physical harm to the self by others. For example, “Another kid physically hurt me, he beat me up, he hit me.” “They did something to stuff I own, they broke it or stole something that was mine.”
3. Death of someone close to me. For example, “My favorite grandfather died.” “My best dog got hit by a car and died.”
4. Separation from someone close. For example, “A really good friend moved away.” “My parents got divorced and my dad moved out.”
5. Conflict with someone close. For example, “I wasn’t getting along with someone who had been my best friend.” “I was fighting with my parents all the time, they just didn’t understand me.”
6. Rejection by someone close. For example, “I felt rejected by my boyfriend who left me.” “The kids at school no longer wanted to be my friend.”
7. Loneliness. For example, “I felt lonely and wished I had a best friend.” “All the other girls had a boyfriend and I didn’t, I was lonely.”
8. Incompetence of the self. For example, “I screwed up on important tests and got a bad grade”. “I didn’t like something about myself, I was always messing up.”

Of interest is that the vast majority of the causes generated by adolescents involved negative actions of others toward the self, various forms of psychological or physical harm, loss or insult, conflict or rejection. Only the last category explicitly made reference to negative actions by the self. Intuitively, therefore, it was plausible that adolescents who experienced depression would not only be sad but would experience anger toward another. If, as adolescents, they lacked the social inhibitions to stifle such angry responses, this would account for their direct acknowledgement of these external causes of their anger that accompanied the sadness of depression.

We pursued the target of the anger further, asking a separate sample of adolescents to rate, for each cause, just how much anger they would feel toward the other and how much they would feel anger toward the self. They rated their level of anger on a four-point scale where a 4 represents the highest and a 1 the lowest level of anger. These anger scores are presented below, for each of the eight causes identified previously.

 

Cause of depression	Anger at others	Anger at self
Psychological harm to self by others	3.04	1.81
Physical harm to self by others	3.54	2.45
Death of a close significant other	3.03	2.45
Separation from significant other	3.19	2.29
Conflict with significant other	3.29	2.5
Rejection by significant other	3	2.47
Loneliness	3.12	2.75
Incompetence of the self	2.89	2.78

Table 1: Anger scores for eight causes.

As would be expected, the pattern revealed that the first six causes that clearly represented actions of others against the self also yielded the highest scores for anger at others. Moreover, these scores were all significantly higher than the much lower scores for anger at the self. Loneliness, though also significant, revealed a smaller difference, suggesting that adolescents take some responsibility for being lonely, although they are also anger at others, presumably blaming them, as well. Incompetence of the self, predictably, revealed the highest level of anger at the self but adolescent also expressed the same level of anger toward others, interestingly, although anger toward others was the lowest such score, compared to anger at others for the other causes. However, these results document the prediction that the primary causes of depression for adolescents clearly evoke anger toward those others presumed to be responsible for one’s depressive reactions.

In future research, it would be of interest to determine the primary self-reported causes of depression for adults, including the level of anger toward others and toward the self, associated with each cause. These findings would allow us to determine whether there is a developmental shift between adolescence and adulthood. Depressed adults may well assume more responsibility for their role in negative social interactions directing more anger toward the self, consistent with the psychoanalytic position. Alternatively, adults may experience anger toward others but are less likely to express it; that is, adults may have developed greater inhibitions against the display of anger or aggressive impulses toward others. For example, several researchers have reported suppressed anger and hostility in depressed adults [20-22]. These issues deserve further study, however, because they suggest that the experience and/or the expression of the components of depression, particularly the target of one’s anger, may well undergo change between adolescence and adulthood.

Thus far, the findings we have presented bear witness to the fact that adolescents have much to say about their own depressive reactions. They validate the claims that depression is experienced as a combination of profound sadness coupled with anger. They further indicate that much of this anger is directed toward significant others although some adolescents also indicate that they feel somewhat lower levels of anger at the self. Our confidence in the meaningfulness of adolescent self-report was also bolstered by adolescents’ description of appropriate causes of depression that would justify the experience of both anger toward others as well as anger toward the self. Their ratings of the level of anger toward others versus level of anger toward the self, as a function of the causes of depression, represented a legitimate pattern.

Would adolescents’ understanding of the dynamics of depression extend to a related dimension, namely, the very powerful relationship between global self-esteem and depressed affect? In our own research (see Harter, 1999, 2012), across numerous studies with adolescents, this correlation hovers around .80.Even more importantly, would adolescents have insights into the directionality of this relationship? That is, which, in their experience comes first? Is it that one first evaluates the self as lacking in worth which then produces depressed affect, as a combination of sadness and anger? Alternatively, does one first come to experience the emotions that define depression, which are then followed by low self-esteem? Does this question of directionality even make sense to adolescents? Does it actually define their personal experience? And is it in their emotional vocabulary to verbally describe this sequence in a compelling fashion? Would any such description really add to our understanding of depression? Based upon subsequent research, we pursued these questions. 

One could argue that any such verbalizations do not speak nearly as convincingly to the issue of directionality as the newer statistical procedures which can directly examine the sequential link between self-esteem and depressed affect. Our own research group was initially enamored with the potential of path-analytic techniques to provide the definitive answer to the question of directionality, rather than depend upon the verbal descriptions of adolescents. In fact, we had produced a model of the causes and consequences of depression. We postulated two initial causes in the chain, competence in domains deemed important in combination with social support from significant others, namely, parents and peers. Negative causes first produced an evaluation of low self-esteem [23,24]. 

With regard to directionality, we hypothesized that such low self-esteem, in turn, produced feelings of depression. To complete the casual chain, we predicted that suicidal ideation was a major consequence of depression. We fell victim to powerful theorizing in the 1980’s concerning the directionality of the links between cognition and affect, where cognitions, in this case about the self, were granted primacy over emotions. Our model, evaluated through path-analytic techniques, with a variety of standard goodness of fit indices, clearly explained the data. 

However, was there an alternative model that path analysis could address, with the same data set? We examined such an alternative model in asking the following question: With any two variables like self-esteem and depressed affect that were so highly correlated (r = .80), what would be the outcome of the path-analytic modeling if the directionality of self-esteem and depressed affect were reversed, with depressed affect preceding self-esteem? Wouldn’t the model fit the data just as well? We performed the relevant statistical analyses and, as expected, the model did fit the data just as well, with the same indices of the goodness of fit [3]. Thus, under such circumstances, with variables that are correlated so highly, the statistical modeling techniques cannot determine directionality.

Secondly, my interviews with those adolescents, who had indicated to us on our self-report measure that they were depressed, gave a more complex picture with regard to directionality. Some participants did acknowledge that they first experienced low self-esteem and then were subsequently plagued by the emotions defining depression. Yet other adolescents were insistent that certain events would first provoke feelings of depression followed by negative evaluations of the self and their descriptions were equally compelling. 

Thus, we designed a procedure to assess depressed adolescents’ perception of the directionality of self-esteem and depressed affect. They were asked to decide “which comes first?” They were instructed that students their age have told us that often “not liking themselves” and “feeling depressed” go together. However, some students feel that not liking themselves comes first, whereas for other students it’s just the opposite, they first feel depressed. We asked them to reflect on what was true for them. Specifically, they were to pick one of the following two options: 1) I first feel like I don’t like myself and then that makes me feel depressed” or 2) I first feel depressed and then that makes me feel like I don’t like myself (The order of these options was counterbalanced across participants). After they picked the option that best characterized their own experiences, they were asked to provide, in writing, a brief description of an event that represented an example of the sequence that they had selected.

The findings revealed that approximately half of the sample indicated that the self-esteem component came first; the other half of the sample responded that the depressed affect option was first experienced. We could not trust the meaningfulness of this result; it could have reflected mere random responding. Thus, we turned to a content analysis of the causes they had given as examples for their directionality selection. There was little overlap in the examples they provided suggesting that the distinction between the two directionalities was very real and their answers quite telling. What were the specific causes cited by members of each directionality group?

Students selecting this directionality cited examples in which they were dissatisfied with some attribute of the self, associated with low self-esteem, which then caused them to feel depressed. 1) Physical appearance headed the list, cited by 70% of the adolescents, twice as many females than males. For example, “When I try to do something with my face and hair, it never works out and I think I am ugly and then I get depressed”. 2) Lack of competence was the next most prevalent category (21%), for example, “In sports, I watch other kids do what seems to be an easy sport and then when I try it, it doesn’t even look like the sport and that makes me feel depressed.” 3) Dissatisfaction with one’s behavior or conduct in social situations (9%), for example, “First I think I am not a very good friend and then that makes me feel depressed.” (Table 2). Thus, the causes of the self-esteem-depression link in this directionality group reside in self-attributes where they find the self physically inadequate, incompetent, or socially wanting, which in turn produces low-self-esteem.

 

Directionally orientations examples
Low self-esteem precedes depressed affect
Appearance	“When I try to do something with my face and hair and it doesn’t work out and I think maybe I am ugly, then I get depressed.”
	“I didn’t like it that I was short, so I became depressed.”
	“I don’t like the way I look and then I get depressed because I think I can’t change.”
	“When I look in the mirror, I think I am ugly and then that makes me depressed.”
	“When I don’t do my hair the way I want it and it isn’t cute, then it makes me depressed.”
	“I look in the mirror and don’t like something about me, my hair, my body and I get depressed.”
	“My nose and my feet are too big and then I look at other people and it’s depressing,”
Competence	“I watch the people in sports do what seems to be an easy sport and then when I try it, it doesn’t even look like the sport, so I get depressed.”
	“Once I was trying to draw something and I couldn’t do it so I hated myself and then I got depressed.”
	“I mess up at my schoolwork and then I hate myself and I get depressed about it. I’m capable but I just don’t work hard enough.”
	“I was pitching and the first two batters I walked, and I then I hit the third one with the ball, and so the coach took me out. I was really down on myself and felt depressed the rest of the day.”
	“I played really bad at soccer and felt like the loss was my fault so it made me depressed.”
Dissatisfaction with social behavior or conduct with others	“First, I think I am not a good friend and then that makes me depressed.”
	“I blew up at my best friend and got mad at myself for losing my temper and then felt bad about it, really depressed.”
	“I first felt like I didn’t like myself because I yelled at my mom and they I felt depressed.”
Depressed affect precedes low self-esteem
Rejection	“I was feeling depressed because all of my friends went to the amusement park and the acted like they didn’t want me to go with them. Then I felt like I was a boring person and I didn’t like myself.”
	“I got depressed because I felt left out of something and then I feel like I don’t have any friends and that nobody likes me, and then I didn’t like myself.”
	“I got depressed because people called me a nerd. Half of the people I know say I’m a nerd, so I don’t liked myself and how I act.”
	“My mom got on my case because of my grades and said she was really disappointed with me, it was like she was rejecting me which made me feel depressed and then I got disappointed in myself.”
Conflict	“Every time I get into it with my mom, she always yells at me and then I get depressed and think of things that make me hate myself.”
	“I got depressed because I got into a fight with my friend and thought I was not a good person.”
	“My mom got really mad at me for not doing my chores; at first I got mad, and then I became depressed about it, and wondered if I was a good person or not.”
Loss	“I usually get depressed because I can’t accept my father’s dying and then I feel like it’s my fault that he died and I don’t like myself.”
	“My grandfather died and that depressed me because I thought it was my fault, I didn’t visit him enough.”
	“My boyfriend broke up with me and I got really depressed, I wasn’t sure what happened, what I had done, and felt terrible about myself.”

Table 2: Examples of Descriptions for each Directionality Orientation.

In contrast to the group above, adolescents for whom the experience of depressed affect comes first invariably described actions performed by others against the self. The vast majority of responses could be captured by three categories that do not overlap with those described by those citing the alternative directionality. 1) Rejection by others was the most common (58%), for example, “I was feeling depressed because all of my friends went to the amusement park and they acted like they didn’t want me to go with them; then I felt like I was a boring person and I didn’t like myself.” 2) Conflict with others (29%), for example, “Every time I get into it with my mom, she always yells at me and I get depressed and then I think of things that make me hate myself.” 3) Loss of a person or pet (13%), either through death or termination of the relationship with the person, for example, “I usually get depressed because I can’t accept my father’s dying, and then I usually feel that it is my fault that he died and I don’t like myself (Table 2).

These findings on the reasons given for the directionality selected are quite compelling. Those in the low-self-esteem-to-depressed-affect subgroup clearly identified features of the self that occurred at the beginning of the causal chain. In contrast, the depressed-affect-to-low-self-esteem subgroup described actions of other against the self that held primacy, in time. Thus, directionality represents an important dynamic in adolescents’ experience of depression and would appear to have implications for treatment. For those in the first group, one would want to initially focus on the basis for negative evaluations of the self as a fruitful avenue to explore. For those endorsing the second orientation, the initial focus of treatment would undoubtedly be the conflictual or non-gratifying relationships with significant others.