Exploring Interpersonal Relationship of Female Patients with Persistent Depressive Disorder: A Qualitative Study with a Phenomenological Approach

1. Background

Depression is a prevalent psychological disorder, and according to the World Health Organization (2020), more than 264 million people worldwide suffer from depression (1). Compared with acute major depression, chronic depression is more associated with comorbidities, significant functional impairment, interpersonal problems, access to health care, suicide attempt, and hospitalization (2).

According to changes in the classification of mental disorders, the chronic form of depression is called persistent depressive disorder (PDD), and based on DSM-V, this diagnosis includes both diagnostic categories of major depressive disorder and dysthymia. The main feature of chronic depressive disorder is a depressed mood that persists most of the day and almost every day for at least two years. Besides, there might be problems with appetite, sleep, energy, self-esteem, and concentration (3). The risk of depression and other chronic depressions in women is almost twice as high as men (4).

Individuals with PDD live in a vicious cycle of monotony. When they talk about themselves and their experiences phenomenologically, their sense of despair indicates that they see the present as a reflection of the past. Their predictions are always monotonous and frustrating. These phenomenological self-reports show that the perception of “time” has stopped for these people, and they live without considering a future for themselves and expecting change (5).

The problem of interpersonal relationships is one of the areas in the lives of individuals with PDD known as both cause and effect. The family-social perspective emphasizes the role of interpersonal factors in depression. Researchers reported that individuals with depression often have poor social and communication skills. The presence of deficiencies in the social skills of an individual with depression can make others upset. Therefore, they avoid interacting with him. As a result, individuals with depression have fewer social relationships, receive fewer rewards, and participate less in social interactions (6).

Sociocultural theorists believe that unipolar depression is strongly influenced by the social context surrounding the individual (6). Although the life experience of people with depression has been explored in various studies, it is necessary to examine the lived experience of these people in the context of indigenous culture as well, because the social and cultural characteristics of any society can affect vulnerability, precipitating factors, disease persistent factors, and even their type of experiences and beliefs. In fact, it seems that culture shapes the way people perceive and reason (7).

2. Objectives

Because there is no better source than the individuals with PDD for the phenomenological understanding of their depression, to better understand the suffering of women with PDD, their living experience was explored using a phenomenological approach.

3. Methods

3.1. Participants

The statistical population of this study was women with PDD referring to medical centers in Isfahan. They were referred to the researcher by five psychiatrists (experts in mood disorders) and selected by purposive sampling from those who experienced PDD and had enough information about it. This allows for understanding the lived experience. The sample size does not matter in qualitative studies, and the saturation stage is of crucial importance. The saturation process determines the duration of the phenomenological interview. When the narrations are repeated, and a participant provides no new information, information saturation will be reached, and sampling will stop (8).

In-depth interviews were conducted with 24 women with PDD; however, the experiences of 21 of them were useful. Three participants were not able to clearly express their experiences. The mean age of participants was 43 years. One of them was single, 19 cases were married, and one was divorced. The demographic features of the subjects are provided in Table 1.

The inclusion criteria were (1) being woman; (2) minimum education level of high school; (3) the age range of 20 - 50 years; (4) diagnosis of PDD based on DSM-V diagnostic criteria; and (5) the ability to share experiences. The exclusion criteria were (1) severe physical illness, mental retardation, psychotic disorders, and cognitive disorders (such as dementia) and (2) having suicidal ideation or the possibility of suicidal ideation that necessitates immediate intervention.

3.2. Data Collection

Data collection was done using a phenomenological approach. In phenomenology, a person’s lived experience of an event is fully described. This approach emphasizes that only people who have experienced the considered phenomenon can transfer their experience to the outside world. Thus, by doing so, an understanding of the phenomenon is obtained by people who have lived that experience (8).

Interview sessions were held at Shahid Motahari Clinic in Isfahan. An initial interview session was conducted with each participant, and explanations were provided on the procedure. After obtaining the participants’ consent to participate in the interview, in-depth interviews were conducted by the first author of the study to examine their lived experiences of suffering in their relationships. At this stage, the primary data collection method was in-depth and exploratory interviews with open-ended questions, which makes it possible for the participants to describe their experiences with the studied phenomenon fully. The required number of interview sessions and the duration of the interviews ranged between 60 and 120 minutes. The interviews continued until the data saturation was reached, i.e., until no new codes were obtained. The questions assessed interpersonal experiences. Some of the interview questions are as follows.

What was the reaction of those around you when you experienced depression for the first time? How did you feel about their reaction? How did they feel about you? How do you feel about the reaction of others? How do others feel when they are with you? What is bothering you in interpersonal relationships? How do you feel about others, especially the significant people in your life? Other questions were also asked depending on the participants’ responses. To further clarify their experience, some more questions were asked, such as “Can you give me more information about this?” “What do you mean?” and “Can you give an example?”

3.3. Analysis of Data

The data analysis was conducted using Giorgi’s method (9). The researcher took a phenomenological approach in the first stage and disregarded the theoretical, cultural, and empirical assumptions. In the second step, the researcher read the interview transcripts several times non-judgmentally to understand the meaning of the experience related to the phenomenon from the participants’ viewpoint. In other words, the aim was to gain a general sense and understanding of each participant’s viewpoints. In the third step, the researcher identified the meaning units, i.e., a word or a paragraph. Important words, phrases, or parts of the interview relevant to the participants’ experiences of the phenomenon were identified. Slashes were placed to separate meaning units. This process continued until the end of the transcript of each interview until the meaning units were identified. In the fourth step, which is considered as the most important one, meaning units were transformed into important psychological expressions. In the last stage, the structure of all participants’ general meaning units was extracted by focusing on the dimensions of their common experiences. Components were formed that ultimately formed the main themes.

3.4. Validation

We used the four criteria of Lincoln and Guba (1985) to find data precision, namely, credibility, transferability, dependability, and conformability (10). To ensure the credibility of the data, we returned the findings to participants to confirm, refine, or enrich their content. To increase the data transferability, we analyzed the data in a stepwise fashion using the Giorgi method and reported the data collection and analysis process in detail so that others can replicate this research. To ensure the dependability of the data, a researcher who was not a member of the research team, re-coded some of the interviews. The high level of agreement in the codes indicated that the data supported the findings. To ensure data conformity, we presented the findings to some patients who did not participate in the study to examine the similarities between the research findings and their experiences.

3.5. Ethical Considerations

The ethical issues observed in this study were as follows. (1) This research was approved by the Research Ethics Committee of the University of Isfahan (code: IR.UI.REC.1396.027); (2) before the start of the interview, general explanations were given about the content of the interview, and the participants signed a consent form to participate in the research; (3) participants were allowed to discontinue the interview session at any time; (4) participants’ consent was obtained for recording interviews; they were also assured that the information would be confidential and the interview transcripts and their audio files would be deleted after analysis; and (5) participants referred to disturbing experiences, such as child abuse, relationship breakdowns, and suicide attempts. Depending on the participant’s need, some intervention sessions were held targeting that disturbing experience.

4. Results

The main themes and sub-themes that reflect the interpersonal lived experiences of women with PDD are listed in Box 1. The main themes were: (1) Feeling empty of love and compassion (2) feeling ignored (3) ignoring others’ needs, conditions, and sufferings (4) feeling of being annoying to others, and 5) feeling confused and helpless in relationships (Box 1).

4.1. Feeling Empty of Love and Compassion

This theme included the four sub-themes of feeling no self-compassion, thirsty for being loved, becoming hard-hearted, and feeling failed to express love. Participants of the study described a deep sense of unkindness towards themselves and others, especially their loved ones. They said that they did not like themselves and experienced negative feelings about themselves. Most of the participants experienced unpleasant feelings about themselves, especially anger, hatred, and dissatisfaction.

4.1.1. Feeling no Self-compassion

Baran, a 38-year-old divorced participant, experienced this feeling because she believed she did not perform well in any part of her life. She said:

I hate myself because I think I am too weak; If I were stronger, I could save my marriage, and I could achieve my goals. I feel there is something inside me; there is someone inside me and behind me. I feel she is angry with me. I do not know who she is, but I often feel this way.

4.1.2. Thirsty for Being Loved

Some of the participants expressed their need to be loved, understood, admired, and supported. Elham, a 44-year-old participant who feels a great need to be loved, said:

Nobody understands me. Nobody likes me. I feel very lonely. Even my parents do not like me. They are too expectant and do not respond to my love.

Azadeh, a 40-year-old participant, had the same feeling and felt sad for it. She expressed her feelings through a simile.

I do not know what happened to me. I think the problems in my life have hardened my heart. My heart is full of holes like igneous rocks that are very difficult to fill, and only love can fill it. I hate myself because I am so different from what I want to be. I am not kind to myself at all.

4.1.3. Feeling Failed to Express Love

Elham believed that she could not express her love to her loved ones because they never loved her. She said:

Sometimes I am not sure if I love my children or not. I cannot express my love to my daughter because my parents and husband did not love me. Sometimes I feel empty of love, and I cannot love anyone. My husband expects me to express my love for him, but I do not know where I can find this love. I often talk to my children angrily and spend very little time with them.

4.1.4. Becoming Hard-hearted

Like some other participants, Elham felt that she has become hard-hearted. She said:

When I get very angry, I want to hurt my husband; sometimes, I like to visualize his death, funeral, and burial.

4.1.5. Unloved Impression From Others’ Behavior

Some participants experience reactions from others that contain negative messages, such as insignificance and rejection. Raha, a 38-year-old woman, complained about her children’s unreasonable expectations. She said:

I love my daughters, but they do not understand me and expect too much. They think my depression is fake, and they mistakenly think I can control my depression.

4.2. Feeling Ignored

4.2.1. Feeling Sacrificed

Feeling ignored was experienced by some of the participants. Some feel that they live only for others, and others’ needs and desires are always a priority. Sepideh, a 45-year-old participant, believed that she has dedicated herself to her children, and this feeling annoyed her. She said:

As far as I remember, I have always been worried about my children’s future, health, etc. I dedicated myself to my children; I do not care about myself. I think all my daily activities should be dedicated to my children. I always ignored myself.

Akram, a 25-year-old participant, lost her mother about ten years ago. The death of her mother negatively influenced her life. During these years, she has had new roles in her family and sacrificed herself for them. She was tired and willing to change the situation, but she did not know how to do it. She said:

I am too tired. I have come to terms with many things. My aunt used to tell me that I am the mother of the rest of the family. I must be a sister to my brothers and sisters. I have to be a girl to my father. I always listen to them sympathetically and do everything I can for them. But now, I am exhausted. None of them understand me. For example, if I cannot cook one day, they become angry with me, as if I am their servant. I am like a dead tree in the middle of the desert with no other trees around and no one to take care of it. I am really tired. I do not know how to save myself. I have come to a dead end.

4.2.2. Unfulfilled Psychological Needs

Most participants experienced unpleasant situations in childhood, adolescence, or even adulthood. As a result, some of their psychological needs, including self-worth, competence, safety, and self-efficacy were not adequately addressed. Some of them were frequently exposed to situations where these needs were suppressed.

Sepideh expressed her unpleasant childhood experiences as follows.

We were six children in the family. We had no love for our father. Not once did he hug us. He was nearly always angry and beat us, and my mother badly. He was always nervous. I was the first child, and I was very anxious. My relatives said that I cried a lot when I was born, and my father slapped me when I cried but did not stop crying. No love was ever expressed to me.

Elham, a 44-year-old participant, considered herself as a victim of her parents’ behavior and was angry with them. She talked about the disturbing behavior of her husband and children.

My husband continually compares me to his mother. He says I am not good at housekeeping, cooking, and even being a partner. He is not happy with me. My children also disrespect me. They say I am not a good mother to them, or I do not know how to cook. I am disappointed.

4.3. Ignoring Others’ Needs, Conditions, and Sufferings

The fourth theme was ignoring others’ needs, conditions, and sufferings. Participants stated that they have distanced themselves from their family roles and are not doing what they should do for life and those around them.

4.3.1. Feeling Self-centered

Maryam said:

I passed on the stress that my husband put on me to the children. I yelled and harassed them. I even sometimes beat my daughter.

Baran said:

It is hard for me to show that I do not know something because of my false pride. I could not progress in many cases because of my pride. I behaved arrogantly, even toward my own mother. I love to hug and kiss her so much, but I never do so.

4.3.2. Feeling Excessive Demanding

Leila said:

I say to myself, why should I respect my mother-in-law? She belittles me. She treats me like this because of my parents. It is as if a person who is depressed becomes a creditor of everyone. She hates everyone. I ask myself why my husband does not buy me a car. Why should I ask my husband for money? That is why sometimes I decide to cause trouble for my husband. Sometimes I say that those who choose to betray to destroy my dignity think they are behaving in this way.

4.3.3. Feeling of Indifference to Others

Azadeh, a 40-year-old participant, talked about ignoring his husband’s needs. She sayid:

I ignore my husband’s needs. I do not make the best breakfast for him. I do not have sex with him because I think love is a precondition for sex, and I do not love him.

4.4. Feeling of Being Annoying to Others

The theme of “feeling of being annoying to others” comprised the two sub-themes of arousing negative feelings in others and the contagious nature of depression. Most participants believed that they caused bad feelings, such as anger, hatred, and helplessness in their family members.

4.4.1. Arousing Negative Feelings in Others

Rana was very disappointed. She tried different ways to help herself but to no avail. Thus, she thought that death was better than living, mainly because of her family. She described her feeling as follows”.

I am fed up with life problems. I do not know what to do. Now I think death is the best option for me. It is soothing. My death might hurt my family for a few hours, but now I hurt them every minute, especially my daughter. Death is easier for me.

4.4.2. Contagious Nature of Depression

Some participants, such as Mahnaz, a 43-year-old participant, believed that depression is contagious. She was worried about passing depression and anxiety to her children. She believed that depression negatively influenced their relationship. She talked about her feeling as follows:

When I am depressed, I am like a dead woman who cannot move. I am not happy. In such a situation, my children say that their mother is sick again. My mood affects their relationship at home. I pass on depression and anxiety to my children.

4.5. Feeling Confused and Helpless in Relationships

This theme included the four sub-themes of the feeling of suffering from a lowered tolerance threshold, the conflict between being alone and being in a crowd, willingness to be alone, and feeling unable to manage relationships with others. Most of the participants experienced various problems in their relationships. Some of them pointed to their lowered tolerance threshold in interpersonal relationships.

4.5.1. Feeling of Suffering From a Lowered Tolerance Threshold

Farnaz, a 45-year-old participant, suffered from excessive sympathy with the sufferings of others. She believed that the lowered threshold of tolerance made her weak in listening to the sufferings of others. She said:

I am so weak that even trivial matters upset me. For example, I get very upset when someone tells me about their life problems or illnesses. I am overwhelmed by fear. I feel anxiety and pain in my chest. I am not strong. I want to be a strong person.

4.5.2. Feeling Unable to Manage Relationships with Others

Farnz’s relationship with her husband was also unsatisfactory, and she believed that she could not manage her relationship. She said:

I do not know how to treat my husband. When he misbehaves, I get angry and cannot control myself. I talk to him out loud and compare him to other men, and then I blame myself for this behavior.

Interpersonal relationships are the primary source of suffering for Mahtab, a 24-year-old participant. It was difficult for her to build and maintain a relationship. She believed that she has poor social skills. She talked about her feelings:

I prefer not to start a relationship, but I cannot continue it even if it does. The people I am in contact with do not like to continue their relationship with me. Because I do not talk much, and I am afraid of being rejected and judged by others regarding my personality and appearance.

4.5.3. Willingness to be Alone

Some of the participants preferred loneliness over being with others. Sepideh, a 45-year-old participant, said:

I do not make frequent contact with my friends. I prefer loneliness. Sometimes I like to be in crowd, but after a few days, I get bored. Part of what people say is upsetting, and part of it is boring, so I stay away from them.

4.5.4. Conflict Between Being Alone and Being in a Crowd

Baran, a 38-year-old participant, was hesitant to be with others. She was annoyed by being with others, yet she did not like being alone. She said:

I am not interested in going to parties. I prefer to stay in my room. I cannot be with my family or relatives; I have no interest in talking to them, though I suffer from loneliness. I do not know why I am so lonely and have no one to share my thoughts and feelings with.

5. Discussion

Examining the experiences of people with mental disorders provides an opportunity to understand their experiences and life situations. Interpersonal relationships are one of the most critical areas in the lives of individuals with PDD. The interpersonal experiences of these individuals were examined in this study. Five main themes emerged, namely (1) Feeling empty of love and compassion; (2) feeling of being ignored; (3) ignoring others’ needs, conditions, and sufferings; (4) feeling of being annoying to others, and (5) feeling of being confused and helpless in relationships. The sub-themes of becoming hard-hearted, becoming excessively demanding, and the conflict between being alone or in a crowd were not reported in previous studies.

Feeling empty of love and compassion was one of the interpersonal themes of the present study. This theme was also cited in previous studies (11-13). Various studies have indicated a negative relationship between depression and self-compassion (14). The results of the study by Gilbert and Procter (15) showed that patients with chronic mental health problems often have doubts, fears, and resistance in the first attempts at compassion. They are often doubtful whether self-compassion is worthwhile or not and see it as a sign of weakness. In fact, one of the reasons for fear of showing compassion to others is that some people confuse compassion with passivity and are afraid of showing their weakness and passivity by showing compassionate behaviors (16).

According to our results, all three directions of compassion, namely self-compassion, compassion for others, and receiving compassion from others (17) were difficult for the individual with depression (13).

Joyner (18) reported the feeling of being annoying to others. Joyner (18) believed that individuals with chronic depression suffer from the fact that their depressive manifestations harm significant people in their lives. In fact, they feel responsible for causing emotional pain in significant people and ignoring them. This suffering causes a sense of guilt and fear. Hooley et al. (cited in Butcher et al.) (19) also pointed out that one of the problematic consequences of depression in interpersonal relationships is that it can pass to other family members; the depressed person’s behaviors can create negative emotions in the loved ones. Some other researchers (18, 20) believed the same.

Regarding the theme of being ignored, most participants complained about the lack of a supportive individual in their past and present lives, i.e., an individual who expresses his love and affection unconditionally, respects and understands them. The experience of distressing events early in life (e.g., mother’s cold emotional relationships, troubled parental relationships, parental divorce, parental loss, family member’s mental disorders, neglect, and abuse) can have negative psychological consequences for the individual, including depression (21-23).

Having high expectations of others and rejection of opposing views are instances of the participants’ experiences that somehow pinpoint self-centeredness. The same was reported in previous research (18, 24). Self-centeredness and lack of empathy with others lead the individual to life without social relations (25). As some of the participants reported, they become indifferent to the needs of others due to depression. They believe that as a result of depression, they neither care about the needs and sufferings of others nor the impact of their behavior on others.

The lowered tolerance threshold, the tendency to be alone, the conflict between being alone and being with others, and the inability to manage relationships are among the emotions experienced by the participants of the present study in their interpersonal relationships. It is believed that depression is associated with communication skills problems. Individuals with depression commonly evaluate their social skills more negatively than non-depressed ones (26).

The depressed individuals’ problems in their relationships and interpersonal styles have also been reported in different studies (27-30). Fear of others’ judgments and lack of skills, such as courage, expressing feelings and needs, and problem-solving have led to helplessness in managing relationships (31). Therefore, they decide to avoid relationships. As McCullough and Clark (5) pointed out, pervasive interpersonal fear-avoidance is a hallmark of the pathology of an individual with chronic depression. Interpersonal behaviors, such as avoiding social situations or conflict due to the loss of positive social reinforcement play a role in the persistence of depression (32).

5.1. The Role of Culture in the Lived Experience of Women with PDD

Although the experience of depression has shared aspects in different cultures, the effect of culture and social conditions on differentiating this experience should not be neglected. Therefore, it is better to examine this experience in the cultural context of the study population. In fact, cultural factors play a crucial role in causing and exacerbating depression.

Each province or city has its own culture and customs that can directly or indirectly influence individuals’ physical and mental health. Rahmani (33) reported that characteristics, such as adherence to etiquette and caution are among Isfahan culture’s prominent characteristics. These traits can affect both the emotional and cognitive experiences of depression and the severity of depressive symptoms.

Excessive adherence to etiquette and discipline can lead to emotional vulnerability, especially when others do not observe such etiquette. This commitment can lead to extreme expectations of oneself and others to follow certain order and standards, and if expectations are not met, feelings of anger or guilt will arouse. Task orientation is one of the essential components of the mentioned culture, but extreme task-orientation causes suffering to individuals. The concept of human rights is less taken into account in Eastern culture. An individual raised in this educational paradigm finds himself or herself in debt to others. However, this feeling of morbid indebtedness gradually turns into a neurotic entitlement associated with the theme of self-centeredness and the sub-theme of excessively demanding.

Due to the excessive adherence to order and etiquette (33), perfectionism seems prominent in Isfahan’s culture. Perfectionism can reduce the individual’s inner satisfaction, which can result in being unkind to himself. In perfectionism, an individual never reaches the desired point; therefore, he does not usually experience inner satisfaction and might constantly blame himself for this failure. Conditional love for others or being loved by others (to achieve perfectionist goals) is the underlying cause of these annoying feelings. Regarding the feelings of confusion and helplessness in the relationships of individuals with depression, having high expectations of oneself and others can be attributed to this cultural feature.

The experience of the inability to express feelings and needs in the participants of this study can be explained by the cultural characteristics of caution and conservatism. The fear of being judged, upsetting another, or fear of feeling guilt are the underlying causes that prevent self-expression. In addition, self-expression is considered rude or disgusting behavior in this culture, causing the suppression of emotions and suffering by an individual with depression.

5.2. Clinical Implications of the Research

Regarding the experiences of women with PDD who participated in this study, it can be stated that the themes obtained from the experiences of women with depression in Isfahan indicated that different components should be considered in the therapeutic relationship and the treatment approach used. These patients’ suffering is due to the lack of self-compassion and showing compassion for others, deprivation of receiving love from others, and inability to cope with negative emotions and effective management of interpersonal relationships.

Compassion is a valuable asset, the lack of which has negative consequences, such as depression, and it was quite evident among the participants of this study. Therefore, it is necessary to include compassion in educational interventions to treat these people and the educational programs to increase compassion for oneself and others. One of the primary sources of suffering for people with depression is the inability to manage relationships effectively; therefore, it is necessary to train them to build and maintain relationships. They should also be provided with appropriate strategies for coping with distressing feelings, such as sadness, fear, anger, boredom, and hatred, causing problems in interpersonal relationships. In general, considering all the components of these individuals’ experiences, it is necessary to use interventions that address all these components. Furthermore, due to this disorder’s chronicity, it is required to conduct interventions and long-term follow-ups.

5.3. Limitations and Suggestions for Future Research

There were two main limitations in the present study that should be addressed in future research. The first limitation goes back to generalizations. The present study findings cannot be generalized to a larger population, especially men with PDD. Therefore, it is suggested to examine the lived experience of men and women with PDD in different cultures. Another limitation of this study is related to the interview questions. Future researchers are suggested to include questions about adaptation experiences, coping styles, and pharmacological and psychological intervention experiences of these individuals as they can provide valuable information to clinicians. It is also suggested that future researchers examine how social characteristics, such as gender, marital status, employment status, and ethnicity affect the meaning that individuals attribute to depression.