Ed Beckham, Ph.D.--Depression

Depression is sometimes called the blues, melancholy, sadness, or a "down" feeling. But whatever it is called, it is an experience many people have had. In one national survey, 30% of persons indicated that they had persistently experienced at least two weeks of feeling depressed sometime during their life. However, feeling depressed is not the same thing as having the clinical disorder of depression. The actual disorder is a collection of several interlocking symptoms involving emotional feelings, loss of interest, changes in biological functioning, and loss of the ability to think clearly.

Family and friends who do not understand the true nature of depression may inadvertently make the depressed person feel worse by suggesting that they need to "snap out of it" or do certain things to feel better, such as buying new clothes, going to a movie, and so on. These are simplistic suggestions. One shot remedies are only temporary ways of coping, and persons with a depressive illness cannot "snap out of it" any more than a person with the flu can snap out of that illness.

Depression, as mental health professionals use the term, is more than a sad feeling. Sadness is often a normal emotional reaction to certain situations. Depression, however, goes beyond simply being sad. It can be thought of as an excessive reaction of the mind and body to stress. Typically, it involves several of the following symptoms:

2. appetite change (either increased or decreased) and weight change (increased or decreased)

5. slowed physical movements (or the opposite, being agitated and unable to sit still)

8. loss of interest and pleasure in activities which normally would be enjoyable

Severe depression can have a life of its own, and while there are things a person can do to influence it, it cannot be simply willed away. Think, for example, of how it feels to have the flu. A person can influence whether they get well or not. They can stay in bed and rest, or they can continue to push themselves. In the latter case, it will probably take longer to get well than if they took care of themselves. This is a double message which is important for depressed clients to hear: You have control, but you do not have total control. You can influence the course of your depression, but you cannot make it go away immediately. It is important to realize this so that you do not blame yourself for taking time to get well. On the other hand, you also need to know that there is hope. There are things which you can do to help yourself.

Depression occurs in a variety of forms. While all depressions may look alike in some ways, there are some important differences. No single symptom, not even depressed mood, is present in everyone who is depressed. It is the overall cluster of symptoms which is used to diagnose depression.

A major depression involves a deep, persistent sadness or loss of interest and numerous symptoms. For at least two weeks, the person must experience problems with at least five of the symptoms of depression which are listed on the previous page. One symptom must be either depressed mood or pervasive loss of interest. One in four women and one in ten men will experience a major depression in their lifetime.

An important distinction in diagnosis is between unipolar and bipolar depressions. Bipolar depressions have two "poles," or opposite ends. One pole is a high, euphoric, manic state in which the person is overly energetic, optimistic, and impulsive. The other pole is a severe depressive state in which the person is tired, pessimistic, and has to push themselves to function. Bipolar depression is a biochemical illness of the brain caused by a person's genes. It must be initially treated by medication, although counseling is almost always needed, too because of the destruction the disorder leaves in its wake. The high periods of bipolar disorder can be as problematic as the low periods. But they are a problem in a different way. Wild spending sprees, poor decisions, and fights with family members are just a few of the complications which may occur. Even though manic periods definitely have a biological cause, family, friends, and bosses are not likely to understand this concept. As a result, the things which manic persons do in their "high" periods can cause people to turn away from them and blame them. It can cause them to lose jobs, marriages, and friendships.

Unipolar depression, on the other hand, has one "pole." It consists of one or more major depressions without any manic periods. Unipolar depressions tend to arise from a complex array of factors including stress, negative thinking, disturbed relationships, and genetic and biochemical factors. Some people, because of their family genetic history, have more of a tendency to develop depression than others, and it takes less stress to send them into an episode. Other persons may not have a strong tendency towards developing depression, but given enough difficult, stressful circumstances, they may also develop the syndrome.

Another common type of depression is Dysthymic Disorder. Dysthymic Disorder is a long term, chronic state of mild depression lasting at least a couple of years. For persons with his disorder, mild depression has become the usual state of affairs. They do not have all of the symptoms for a major depression for a two week period, but they are impaired and cannot function well as well as they otherwise might.

Double depression describes what occurs when a person with Dysthymic Disorder goes on to develop a major depression. This is not uncommon. Persons with Dysthymic Disorder often develop more severe depression under stress.

Some clients do not have any of the above disorders. They have been exposed to a stress and have had unpleasant depressive symptoms, but these are not severe enough to qualify as a major depression. Nor have their symptoms persisted long enough to qualify as a Dysthymic Disorder. In these situations, the diagnosis of Adjustment Disorder with Depressed Mood is used. Since adjustment disorders are less severe and are associated with stress, if the stressful event goes away, the depression generally does as well.

There are a variety of theories about how people become depressed. However, it is clear that once a person is depressed, they have a great many negative thoughts and that these thoughts help to perpetuate their depression. These are typically about themselves, their situation in the world, and/or their future.

Which do you think is most important in causing depression--negative thoughts people have about themselves? Negative thoughts about their situation? Or negative thoughts about what will happen in their future?

Negative thoughts in the three areas (self, world and future) both cause depression and are caused by depression. When a person becomes depressed, negative thoughts are initially likely to be one or more particular stressful situations. However, after a person is depressed, negative thoughts can be about anything. A depressed person does not have to try to think these negative thoughts. They occur almost automatically. They are especially likely to happen when persons are by themselves, in a boring situation, or doing something that takes no effort or thinking on their part. Because of this, they are called automatic negative thoughts (ANTs). One client called these "popcorn thoughts" because of the way they just popped up in her mind. Automatic negative thoughts make the depressed person feel more depressed because they seem so true and so realistic. Most of the time the thoughts are not realistic, however, and dwelling on automatic negative thoughts causes more depression. Depressed persons need to have some times when they are distracted and thus not have to deal with their negative thoughts. They need some time to rest. At other times, they need to confront those thoughts as being illogical and work to replace them with more realistic thoughts.

As you read this, you may become aware of certain automatic negative thoughts. For example, you might think, "I can't learn anything;" "everybody else must be able to understand this better than I can," and so on. Remember that when you are depressed, your memory and concentration may be impaired. If you have to reread parts of this, do not jump to conclusions. It is not important to learn this information quickly. Just try to focus on understanding some parts that are useful to you. On the other hand, your thought may be, "This isn't going to help me." This, too, could be an automatic negative thought. Such skepticism is fine, as long as you can also be skeptical of your own negative thoughts! In depression, people are often skeptical of everything positive, but they are not skeptical towards their own depressive ideas.

The problems with distorted, negative thinking have been discussed at length in Chapter/handout 3 "Coping with Negative Thinking." Understanding the types of negative thoughts provides a person with a kind of tool kit. Anyone learning carpentry needs to understand what a hammer is and how to use it. They would need to be able to name and describe a variety of tools. It wouldn't be useful to simply say, "I have some tools here." Being able to label things gives people greater understanding and power over them. In the same way, depressed persons often sense negative thoughts swarming around in their minds but aren't able to sort them out. Being able to label them can lead to understanding and to a type of power over them. Since these were described in more detail in Chapter handout 3, they will only be summarized here:

2. Disqualifying the positive. This involves negating something positive which has happened. A depressed person will often turn down a compliment, saying something such as, "I didn't really do anything important." Inwardly, the person may be disqualifying the compliment by thinking something such as, "They don't really mean it; they're just trying to be nice."

3. Overgeneralizing. A typical statement from a depressed person is "I can't do anything right". Such a statement would be ignoring the positive and overgeneralizing about their inability to carry out tasks correctly. They have never been a success? At anything? Statements that use the words "anything," "nothing," "always", "never", "ever", "everyone", "no one," etc., are very likely to be overgeneralizations." The use of these words amplifies negative thoughts and situations, thereby increasing depressive feelings.

Catastrophizing involves an extreme overreaction to an event, and exaggeration involves magnifying an event in the mind. An example of exaggeration would be getting a minor criticism from one's boss and thinking, "He really chewed me out." Catastrophizing goes far beyond simple exaggeration. It sometimes links together one imagined event after another until in the person's mind a true catastrophe results ("This will happen, and then this will happen, and then this will happen, and in the end, it will just be awful.").

5. "Should" statements. Thoughts which use the words "should" and "ought" aimed at the self tend to produce guilt and feelings of inadequacy. These types of statements tend to be moralizing. That is, they tend to turn situations into moral issues. While there are clearly issues of morality in life which deserve "should" thoughts (killing, stealing, child abuse), depressed persons often bring this kind of thinking into a wide variety of everyday circumstances, creating an extra emotional burden on themselves ("I should clean house better;" "I should cook better meals;" "I should be nicer to my kids when they get home;" "I should be advancing faster and getting more promotions;" etc.).

6. All or nothing thinking. Sometimes depressed persons conclude from a small failure that they are a total failure or after losing their temper with their children that they are a terrible parent. This kind of thinking implies that there is no gray area in between total success and total failure, between total adequacy and total ineptness. This is "all or nothing" thinking. It ignores the fact that for 99.99% of us, our actions fall in between the absolute best and absolute worst. All or nothing thinking states that "either I perform action 'X' perfectly well, or I am a total failure."

7. Mindreading. Mindreading is a type of jumping to conclusions about a situation. This is "knowing" what another person is thinking without having any really good evidence. A depressed person might "know" that others are unhappy with him or making fun of him.

8. Fortune telling. Like mind reading, fortune telling is a type of jumping to conclusions. However, rather than jumping to conclusions about what people are thinking, it is about what will happen in the future. In depression, this might involve concluding that the person will never recover from his depression, believing that he won't get the job that he wants, or thinking that his wife will leave him.

9. Reverse Fortune Telling. In depression, persons often second guess their past decisions with "what if" thoughts and "if only" thoughts. "If only I had reared my children differently, they would have turned out better." "If only I had been nicer to my husband, he wouldn't have left me." Reverse fortune telling involves jumping to conclusions about what the present would be like if one had acted differently in the past. These thoughts are untestable and can neither be proven nor disproved. It makes little sense to torture oneself with a thought that can never be proven one way or another.

10. Emotional reasoning. This type of negative thinking involves basing thoughts on feelings rather than the other way around. It is more logical to base one's feelings on the facts of a situation. "Intuition" will make the depressed person believe a variety of "facts" which are really not true.

11. Personalization. Depressed individuals sometimes view negative events as being aimed at them or caused by them when in reality they were not. Thus, for example, a teacher might send out a note to parents saying that it is important for them to make sure that children have their lunch money when they arrive at school. A depressed parent might feel sure that the teacher is upset with them personally and that the note is aimed just at them.

12. Mislabeling. Depressed persons tends to label their behavior or situations they are in using very negative terms. If they are having difficulty getting motivated, they may blame themselves for being "lazy." If they are having difficulty thinking clearly and remembering things, they may tell themselves that they are "stupid." These are likely to be far from the truth. The depressed person is often physically tired and may also be very uninterested in doing things. But these are temporary symptoms ands quite different from being "lazy," which is an ingrained character trait. Similarly, having difficulty concentrating and thinking clearly is a typical symptom and has nothing to do with lack of intelligence.

Aren't negative thoughts realistic at times? After all, don't bad things happen to people?

Yes, bad things do happen. However, depression has a way of making even bad situations seem worse than they are. If you are clinically depressed, then you can be pretty sure that some of your negative thoughts are excessive and exaggerated. After applying cognitive therapy to your thoughts, things may not seem rosy, but they are likely to seem less gloomy. Depressive thinking demoralizes a person far beyond what situations and circumstances usually warrant.

The use of the four column technique was demonstrated in Chapter/handout 3. Here is an example of how negative thinking can lead to depression and how this technique can be used to combat such thoughts.

First, the person writes down the objective situation which was occurring when they began to feel depressed:

The next step makes it clear how the situation led to the depressive feelings. This involves writing down the automatic negative thoughts in the second column. These thoughts act as a kind of bridge between the event and the feelings:

These three columns make it clear why the person became depressed. The negative thoughts in the middle link the situation to the depressed feelings. Without the thoughts in the second column, there would have been no depression. Perhaps the person would have just lost interest in the party and gone home. Or perhaps he would have tried to stir up some excitement. However, because of the negative thoughts that he is having, he is demoralized him to the point that he starts to give up trying to have fun.

The final step in the four column process is to challenge the negative thoughts. This is where the real coping begins because it is an opportunity to change the way the person is looking at the situation.

First, write down very clearly the negative thoughts you are having. Don't let them remain vague in your mind.

Don't start a negative thought with a "maybe." For example, don't try to challenge a thought such as, "Maybe my boyfriend won't call tonight." If you are feeling depressed about it, you are probably thinking on some level, "My boyfriend won't call tonight." This type of a strong negative thought is easier to challenge. For example, it is easier to challenge the thought "I will fail the test" than it is to challenge the thought "I might fail the test."

Don't label yourself as "stupid" for having negative thoughts or tell yourself that you "shouldn't" have them. This is just more depressive thinking. It may temporarily suppress negative thoughts to tell yourself that you shouldn't have them, but this just leads to more feelings of inadequacy and thus more depression.

Look at evidence which would dispute your depressive thoughts. Don't just play Pollyanna and tell yourself that they are not true. Finding evidence contrary to your negative thoughts can be difficult to do if you are very depressed since your mind is biased towards seeing the negative. This is where you may most need the help of a therapist or a friend.

Examine your logic leading to your negative thoughts. For example, look at the list of cognitive distortions to see if your thoughts fit into any of those categories.

Look for alternative explanations of the upsetting situation. There are usually a variety of ways of seeing most situations.

Keep a notebook (or least take note in your mind) of your fortune telling thoughts. Persons who have negative thoughts about the future often fail to follow up on them. It is important to have some kind of record about what actually happens. For example, suppose a person is very anxious and depressed because they believe that they are going to do a very poor job at giving a speech. When the day of the speech comes, they deliver it satisfactorily, and they go on. They breathe a sigh of relief that it wasn't as bad as they thought. But they forget just how worried they were. They forget how they just knew that it would go terribly. As a result, they do not learn from experience. Then the next time that they have fortune telling thoughts, they are again sure that they know what is going to happen. Keeping a notebook and following up on these thoughts is one way of combating fortune telling. It is important when using this technique not to fall prey to self-fulfilling prophecies. That is, it is very possible for someone who expects events to go wrong to somehow unconsciously facilitate this happening. In addition, the cognitive error of focusing on the negative can make it seem that everything is going wrong when it is not.

"This is going to be a terrible day. I can just feel in my gut that things will go wrong today."

I'll keep a record of what happens today, and I'll make sure to write down both the positive and the negative events that happen.

Some negative thoughts can't be challenged easily because there is not much definite information or data one way or another. Simply waiting to see what happens may not provide the necessary facts; there may have to be a deliberate attempt to obtain information. For example, if you are engaged in mindreading thoughts that someone else is unhappy with you, it can be useful simply to ask the person if they are upset, and if so, about what.

Sometimes people have negative assumptions about what will happen if they try to behave in a healthy manner. Their fortune telling thoughts keep them from doing what they need to do in their own interest:

If I tell my husband how I feel, he will be angry at me and stomp out of the house.

Each of these predictions is a type of fortune telling, and each one lends itself to performing an experiment. The person with the negative thoughts may not have any real information about what would happen in these situations because they have always stopped themselves from doing what was necessary to prove or disprove the thought.

Despite the fact that they are often not very clear in the person's mind, underlying attitudes can shape how people see the world. What makes a person worthwhile? What makes life worth living? How does a "real woman" or a "real man" behave? Just as a person who holds a red lens up to their eye sees everything red, our underlying attitudes color how we see events. Some people see every situation as requiring them to gain the approval of others. Other people see most situations as instances where they may need to achieve and excel. Still others see most life situations as requiring self-control. Each of these ways of thinking defines for some people their reason for living and what they believe makes them worthwhile (I am worthwhile if I achieve; I am worthwhile if people approve of me; etc.). These underlying attitudes, two edged swords. They can not only make persons feel worthwhile, they can also make them feel inadequate and think that they are worthless if they are not lived up to.

I must be approved of by everyone. If someone dislikes me or disapproves of me, there must be something wrong with me.

If I am not always in control of my feelings and actions, then I am weak. And if I am weak, I am worthless.

I must do everything I do in the best possible way (that is, perfectly) or I'm not worthwhile.

Perfectionistic attitudes have been found to be particularly prone to cause depression. In one study of persons in treatment for depression, the higher the levels of perfectionism, the less likely it was for the person to improve. It didn't matter whether they were in cognitive therapy working on negative thoughts, receiving medication, or in some other form of treatment. Perfectionism was a roadblock to significant improvement in all the forms of therapy offered. The implications of this are very clear. Although some depressed persons see perfectionism as a very logical approach to life, it is actually a landmine in the road to success and happiness.

It is not always necessary to deal with underlying negative attitudes to get out of depression. Clearly, there are times when circumstances improve or when the passage of time helps the person to feel better. However, when negative assumptions are not dealt with, then the person is likely to be just as vulnerable to future depression if stresses occur again. It is not easy for peoples to change these attitudes by themselves, and discussions with a therapist are often helpful and sometimes necessary.

1. What kinds of stresses have caused you to be depressed in the past? Does this tell you anything about your depressive attitudes? For example, have you tended to become depressed following relationship breakups? Being disapproved of by someone important to you? Experiencing school failure or a job setback? How about after making a mistake?

3. As you consider your answers to questions 1 and 2, does it appear that there are particular kinds of stresses to which you are most vulnerable?

Depressive assumptions and stressful life events can team up to cause low self-esteem and depression. For example, consider what happens with the following combination of a depressive attitude and a corresponding event:

In this case, the attitude and the event go together to create feelings of worthlessness and depression. The particular attitude and the particular event fit together hand in glove. Making a "D" in a course or even an "F" might be less likely to trigger depression in this person, given their basic attitudes about what makes them valuable. The person is basing their self esteem on love, not on success. (The exception to this would be if they thought that people would love them less for making poor grades.)

Each of the depressive attitudes can lead to low self-esteem or feelings of worthlessness if the right stress occurs. Think of it as a jigsaw puzzle in which certain pieces fit together. If a person believes they must succeed and do well in everything they attempt, then not getting an expected raise or promotion can be a severe blow to their self-esteem. It may even lead to clinical depression. On the other hand, if members of his family are upset with him and avoiding him, it may cause sadness, but still not result in depression because his underlying attitudes regarding self-worth are not based on love and approval.

--Trying to do everything perfectly may so overwhelm a person that they may never get started. They may then get less done than if they tried to do a good or adequate job.

--A person may spend so much time on details that little work gets done overall.

--Doing things perfectly is not really possible. Thus, it is inevitable that the person will feel inadequate at some point.

2. "I must succeed in everything I undertake. I must never fail or else I am worthless."

--If an individual fails at one thing, is she supposed to ignore and overlook all of the things that she does right?

--This way of thinking can cause such a fear of failure that a person will not take even minor risks. This can cause them to be immobilized.

--Some of the people who have accomplished the most in history have had significant failures as well as successes.

3. "It is terrible to be disapproved of. If someone disapproves of me, I must have done something wrong."

--If it appears that we are pleasing everyone, we are probably only succeeding in being wishy-washy and having few if any real principles.

--This would mean that other people's opinions are automatically more valid than my own.

--Since someone will always disapprove of us, we are doomed to always feel inadequate and unhappy.

--Whether we are loved does not change our intrinsic self-worth. It is very important to be loved, but it does not reach into the core of our being and change who we are.

--If we must be loved to feel worthwhile, we are likely to be a doormat in a relationship for fear of losing it.

--A person's value to society comes more from the love and concern they give than from the love they receive.

5. "I must be in control of my emotions and actions at all times or I am weak and worthless."

--No one can be in control at all times. This is a myth perpetuated by Hollywood heroes in action movies. We cannot live our lives according to a Hollywood script.

--Emotions cannot always be controlled. Furthermore, a person who attempts to have tight control over their feelings has difficulty being spontaneous and having fun. They may also tend to try to control others and so are not much fun to be around.

--A person who has this idea and gets depressed is then likely to get even more depressed because they will tend to blame themselves for not being in control of their situation and feelings.

--Part of the fun of life is being spontaneous and seeing what will happen next in life.

Overcoming Suicidal Thoughts and Impulses: Using Problem Solving to Find Solutions to Difficulties

Suicide can be thought of as a last ditch, desperate means of solving a problem. The problem usually consists of an external component (such as a legal problem or a relationship disappointment) and an internal feeling of pain. The person usually feels that all possible means of dealing with the problem have been exhausted and that there are no good alternatives left. Usually, this is not true, although it may be necessary to get help from a friend or therapist to see the alternatives which have been missed. Get someone to help you see some new solutions to problems that you have not yet been able to see. Get away from any rigid, all or nothing thinking. When persons are stuck in trying to solve a problem, they often feel that there are only one or two ways to solve it. When they feel that neither of them is working, then they tend to feel helpless and hopeless. In reality, there are often a variety of solutions to a problem. None of them may be perfect, but almost every one of them is likely to be better than suicide. Oftentimes, there may be multiple problems, which is particularly confusing to a person who is already depressed, tired, and having difficulty concentrating. A therapist can be very helpful in pulling apart the different problems and helping to find solutions for each.

Overcoming Suicidal Thoughts and Impulses: Distracting Yourself Until They Pass

Usually, suicidal thoughts don't last for more than a few hours at a time. By remembering that such impulses usually pass, it is easier to find ways to distract yourself temporarily. If you can get past the moment, then you may change your mind about wanting to kill yourself. The first step is just to get through the night or the next few hours. Contact a friend. Then reconsider your situation. Delay acting on your suicidal thoughts. Keep your choices open. As long as you are living, you have the choice to stay alive or not to. But once you are dead, you have no choices. Give yourself the chance to change your mind. Once the crisis passes, develop a plan for how you will deal with the thoughts and impulses if they occur again.

Overcoming Suicidal Thoughts and Impulses: Obtaining Help and Social Support

Don't isolate yourself. It is vital to garner social support. It's time to call in your favors from people. This is no time to be independent and strong and to try to go it alone. Suicidal thoughts and actions are often triggered by the loss of a relationship. If you have lost a person through divorce or death, then your needs for companionship are likely to be greater. You may be feeling intense loneliness. Ask for help. Set up a support network of individuals who understand your feelings and who agree ahead of time to be supportive.

If there is a family crisis behind your urges to kill yourself, it may be helpful to turn to the member of the family who is most stable, supportive, and calm for help. Let that relative know that you have a problem and what it is. See if there is something they can do tho help you through the crisis.

If you feel that you are facing overwhelming demands that you cannot possibly fulfill or carry out by yourself, ask for help from others. If your family is not willing to provide the support that you need, there are people who will be glad to help you, such as local telephone hot lines, depression support groups, church groups, friends, a therapist, a minister, and others.

Form a strong relationship with your therapist. They are there to help you. If you feel that you need more frequent sessions with your therapist, ask for them. If your therapist does not seem to give you the amount or kind of support that you need, discuss that issue in your therapy session. Find out what the rules are about contacting them in a crisis. However, don't stop at finding out what the therapist's guidelines are.

Make a contract with a friend or family member to stay alive. Have a firm agreement to call them and to see them before hurting yourself. Some persons are leery of making such a contract. They feel that they are giving away their freedom to someone else. Two things need to be said about this. First, you are not giving away your freedom. You are preserving it. As already mentioned, dead people are not free; only living people are free. Secondly, if you cannot make an indefinite contract, make a contract for a limited period of time--a month, two weeks, or even one week. That way you are not committing yourself "forever."

Create a contract between you and your therapist that you will not harm yourself before coming in for another session. (It is not enough only to contract that you will wait until talking with them on the phone).

Avoid substance use because it increases the chances of following through on suicidal thoughts. Drugs and alcohol impair judgement and lower a person's inhibitions. Moreover, alcohol and many drugs are depressants. If you need a medication to help you feel better, get a prescription for an antidepressant or anti-anxiety medication from a physician. However, make sure that the doctor knows that you are suicidal so that she can prescribe one which cannot be used to harm yourself.

Make it harder for you to kill yourself on a whim or an impulse. Give any lethal medications or weapons that might be used to hurt yourself to someone else. Get rid of all guns in the house. Don't leave temptation lying around. You may even need to avoid driving at times if you find yourself having the impulse to wreck your car.

There are in reality two "you's". There is the suicidal you in the present, and then there is the you in the future that will be glad to be alive. Your therapist and friends are trying to keep you alive because they know the future "you" will be happy to still be living. Not all of your personality wants to commit suicide. The fact that you are still alive to read this means that a part of you has not wanted to die and has kept you alive up to this point. Remember that suicide is a permanent solution to a temporary problem.

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*Negative Thoughts in The Area of*	*Can Lead To*
View of self	Feelings of worthlessness, guilt and helplessness
View of World	Distrust, cynicism, alienation
View of Future	Hopeless thoughts and feelings, despair, feeling that there is nothing to look forward to, giving up

Attitude	Strongly Disagree	Disagree	Not Sure	Agree	Strongly Agree
If I fail at something, it means that I am inadequate or worthless.
If I do not accomplish something which is very important to me, then I am a failure.
If someone that I love does not love me, then it means that I am unlovable and worthless.
I must be approved of by everyone. If someone dislikes me or disapproves of me, there must be something wrong with me.
If I am not always in control of my feelings and actions, then I am defective and/or weak.
If I do not strive for perfection, I am likely to turn out to be mediocre and worthless.

Attitude	"I am worthwhile only if I am loved."
+ Event	"My wife left me."
=Result	"I am worthless."

Ed Beckham, Ph.D.--On Depression