Diagnosis criteria for major depression as per DSM IV [73] and a moderate depressive episode as per ICD-10 [74].
\r\n\t
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Currently, depressions have a share of 6.1% in total DALYs (DALY = Disability-Adjusted Life Year = as measure for disease burden), and thus are ranked at the 4th place in worldwide causes of disease [4]. It is expected that unipolar depression will become the main health-related cause of death in developed countries by 2020 [5,6]. In the E.U. alone, 18.5 million people have been diagnosed with major depression [7].
Depression involves numerous personal, family-related, social and economic consequences. Due to a high psychological burden, this disorder no longer allows the usual conduct of life; furthermore, not only does it represent a burden on the quality of life of the affected persons and close relatives but it is also connected to a significant economic impact. In the U.S.A. the costs incurred by treatment, morbidity and mortality amount to 83 billion USD per year [8]; in the United Kingdom the annual depression treatment costs for adults amount to 636 million euros [9]. In Europe, 28 billion euros are spent on treatment of affective disorders [10]. The socio-economic costs of depression for society as a whole amount to approx. 1% of the gross domestic product. However, the largest part of economic expenses is generated outside of the health system [11] and is related to the loss of work productivity, leisure-time opportunities and early mortality due to suicide [12,13].
During the past twenty years, there has not only been an enormous growth in the number of depressed patients, but the selection of antidepressant medication has been dramatically increased. Despite major advances in depression research and development of new antidepressant substances, the high rate of therapy-resistant and/or recurrent patients was not improved [14,15].
Although there is a general consensus that, based on evidence-based psychotherapy research in past decades, both antidepressants and psycho-therapeutic procedures are effective for treatment of depressive disorders [16-20], psycho-pharmacological treatment still represents first-choice therapy. However, clinical studies show that only approximately 30% of the patients show remission after first treatment with antidepressants [21]. In case of a severe and acute depression, stabilizing the patient through medication clearly takes precedence; however, in case of slight to moderate depression (without symptoms of delusions) the focus of treatment should initially be placed on psycho-therapeutic methods due to the limited success of psycho-pharmacological therapy [22,23]. There is an increasing number of patients who do not desire pharmacological treatment (pregnant women, children), or do not tolerate such treatment due to undesired side effects and/or interactions (cancer, pain, geriatric patients). In these cases, psychotherapy should be preferred [24-30]. Whilst psychotropic drugs act biologically, psychotherapy is effective via patient self-efficacy by changing cognitions and behavior. To numerous depressed patients, the cause of their disorder is explained as being a chemical imbalance that can only be treated with medication. It can be assumed that the probability of mobilizing self-coping mechanisms in terms of fighting disorders is particularly low in this patient group. The high recurrence rate (50% within one year after treatment) of depressed patients who received pharmacological treatment in the past seems to support this notion [31].
Rush et al. [32] compared the effectiveness of cognitive behavioral therapy (CBT) to pharmacotherapy in a group of depressed patients treated as out-patients and ascertained that CBT is superior to pharmacotherapy. Bellack and colleagues [33] came to similar conclusion in their study and pointed out that combination therapy - which is preferred by some researchers - even shows negative results because pharmacotherapy has an inhibiting effect on behavioral therapy in connection with depression. Kovacs et al. [34] showed that the recurrence rate with behavioral therapy is significantly lower as compared to pharmacotherapy; CBT also shows the termination of therapy less frequently, and, after a one year follow-up, CBT-treated patients show significantly greater favorable progress as compared to patients with antidepressant treatment [19,35-36]. However, in-patient depression treatment in Western Europe indicates a growing trend towards the combination of both approaches.
CBT is a scientifically founded, active, problem- and target-oriented, structured, temporally limited psychological treatment method that shows high effectiveness against both psychiatric disorders (anxiety, phobias, compulsions, addictive disorders) and physical disorders including eating disorders, pain disorders and tinnitus [29,37-38]. During the past four decades there has been a number of scientific studies supporting the significance and effectiveness of CBT in connection with affective disorders, particularly depression [17,19,39-41].
The primary goal of the following section is to provide an overview of the history of CBT as well as its clinical features and the behavior-therapeutic diagnostics of depressive disorder. In the subsequent sections the psychological disorder models of depression and corresponding therapeutic approaches will be explained by using clinical cases. The presented methods represent treatment fundamentals of depressive disorders requiring a competent therapist.
The specific order of the presented elements of treatment does not represent a rigid sequence of treatment steps, but rather a recommendation of therapy. Certain therapeutic elements can only be determined if the patient provides certain basic information, e.g., with severe depression the patient is expected to activate behavioral strategies before the introduction of cognitive techniques [31]. The intensity of depression, current symptoms, cognitive levels, motivation as well as current patient problems determine the speed and the systematic progress of therapy.
The correct duration and sequence of CBT is pivotal for successful treatment. CBT for unipolar depression requires 15 - 30 sessions [42]. In case of moderate and severe depression it is recommended to have two sessions per week for 4 - 5 weeks, followed by weekly sessions during the next 8 - 12 weeks and then sessions every other or every third week. Relatively infrequent contacts are sufficient for the maintenance of therapy success. The described strategies are performed in single-person settings but can be adapted to group and pair therapies. The same applies to age groups: CBT proved to be successful in the treatment of depression in children [43] as well as in aged patients [44,45,46].
Depressive disorders are included in the group of affective disorders in the major classification schemes (WHO – ICD-10, APA – DSM-IV). Affective disorders are psychiatric disorders where major symptoms include changes of mood or affectivity. The mood change is accompanied by change of activity levels in most cases (ICD-10). Although the terms "affect", "mood" and "emotion" are defined differently in most cases, many of these concepts exhibit similarities [47-48]. Here, affect is defined as an umbrella term that includes mood and emotion [49].
Feeling depressed does not particularly represent an onset of a disorder. However, depression is more than only a temporal change of mood or short-term sluggishness. The characteristic condition of a depressed patient is most commonly represented by the following symptoms:
Point prevalence of 2.3-4.9% [50-52] and lifetime prevalence between 13.3% and 17.1% have been identified for major depression in the general population [53]. Recent studies estimate that as many as 40% of women and 30% of men suffer from at least one episode of major depression during their life [54-56]. Although prevalence of bipolar disorders is identical in both genders in the western world [57], dysthymia, a relatively mild form of chronic depression, occurs almost twice as much in women as compared to men [53,57]. Significant gender-specific differences do not only apply to the frequency of occurrence of depressive disorders, but rather to their symptoms and accompanying diseases in adults [58-59]. Depressive disorders have also become more frequent in children of less than 11 years of age [56,60,61]; meta-analysis shows a prevalence rate of depression amounting to 2.8% in individuals younger than 13 years, and a rate of 5.7% in persons 13-18 years of age [62]. The symptoms are described similarly in both genders (depressed mood, concentration disorder, sleep problems); only after puberty can gender-specific differences be observed [58,63]. The prevalence rate of depression significantly increases with age and it is closely connected to family status and socio-economic circumstances [64]. However, the highest rate is present in 25-45 years old married women who have at least one child [65,66].
Disturbances of affective experience, such as anxiety, panic disorders, certain personality disorders and mourning sorrow, often show co-morbidity with depression. Depressive disorders are most frequently accompanied with panic disorders (40-80%), generalized anxiety disorder (50%), obsessive-compulsive disorder (3-30%), alcohol and drug abuse (30%), attention deficit disorder and suicide [67-70]. According to previously published data, 56% of the patients affected by serious depression have at least one suicide attempt, and 15% of the affected commit suicide [71]. Previous studies suggested that as much as 30-88% of suicides can be linked to depressive disorders in Europe [72].
Currently, there are two major classifications commonly used in describing the severity of depressive disorders. One is established by the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychological Association (APA) and the other one by the International Classification of Diseases (ICD-10) of WHO (Table 1). The differences between these classification systems are primarily in the number of the listed core symptoms which should be present for at least two weeks in both classifications, and in the classification of additional accompanying symptoms. If five of the described symptoms are present for more than two weeks, DSM-IV refers to the condition as "major depression". If only two to three symptoms have been simultaneously present for at least two years, DSM-IV diagnoses "dysthymia". In addition to diagnosing depressive disorders, both classification systems also determine its
According to ICD-10, at least 2 core symptoms and 2 other symptoms should be present for the diagnosis of a slight episode; a moderate depressive episode requires at least 2 core symptoms and 3-4 additional symptoms, and a severe episode can be diagnosed by the presence of at least 2 core symptoms and at least 4 other symptoms with less severity.
\n\t\t\t\t\t | \n\t\t\t\t\n\t\t\t\t\t | \n\t\t\t
At last 5 of the following symptoms that are present almost every day for two weeks | \n\t\t\tat least 2 core symptoms simultaneously that are present for two weeks | \n\t\t
1. depressive mood 2. significantly decreased interest/joy 3. tiredness, loss of energy 4. sleeplessness/increased sleep 5. psychomotor unrest, slowing 6. significant weight gain/loss 7. worthlessness, improper feelings of guilt 8. decreased cogitation, concentration problems, decreased decision-making ability 9. recurrent thoughts of death imagination of suicide without plan, or detailed planning of suicide | \n\t\t\t1. depressive mood 2. loss of interest, loss of joy 3. increased fatigability plus at least two to four of the following symptoms: 1. sleep disorders 2. worthlessness, feelings of guilt 3. decreased concentration and attentiveness 4. decreased appetite 5. suicidal thoughts or acts 6. pessimistic view of future | \n\t\t
These symptoms cause clinically significant impairments in the social, occupational or other fields of life in the most frequent cases, and cannot be explained by the direct effect of pharmacological treatment, substance abuse, another disease or simple sorrow.
In the 1950s, psychology as a scientific theory and practice underwent a major development. During this period, the first steps of behavioral therapy (BT) were developed independently in the USA and in England based on the knowledge gained in experimental psychology and subsequently developed learning theories. Right from the beginning, BT was a collective term for a variety of different therapeutic procedures. The common feature of these procedures is that, unlike personality, behavior - including cognitive, emotional and physical responses - can be built, reduced and modified during the lifetime of the individual [75].
The roots of cognitive BT and behavioral learning theories go back to ancient times. Epictetus, a Greek stoic philosopher, who is considered one of the major influences in the development of psychotherapy, wrote: "Men are disturbed, not by things, but by the principles and notions which they form concerning things". Freud (1900/1953) was the first modern-day scientist addressing the perception that symptoms and feelings are based on unconscious thoughts. Alfred Adler [76], who was an important proponent of individual psychology, noted that humans actually do not suffer from an experienced trauma, but rather from the perception of personal interpretation of the event. In the beginning of the 19th century, the phenomenological direction of philosophy had a great impact on the development of psychology and the maturation of CBT, as authors including Kant, Heidegger and Husserl established their theory on the control of conscious experiences [77].
The principal element of CBT, classical conditioning, is a behavioral learning theory founded by Russian physiologist I. P. Pavlov (1849-1936), stating that new and conditioned reflexes can be added to natural, mostly inherited, unconditioned reflexes by means of learning. Based on the knowledge of classical conditioning it is also possible to generalize or erase behavioral patterns [78]. John B. Watson, who is considered to be the founder of classical behaviorism, described mental processes, e.g. thoughts, as responses to the autonomic nervous system on external stimuli, and he attempted to explain behavior on the basis of conditioned reflexes described by Pavlov. He wrote: "
Contrary to classical conditioning, operant conditioning theory stated that spontaneous behavior is promoted or inhibited by the consequence that follows. In the 1950s, Burrhus Frederic Skinner further developed the concept of operant or instrumental conditioning. Skinner\'s approach was to positively or negatively impact behavior by means of subsequent consequences. Based on this theory, behavior is supported by positive consequences, while negative consequences result in reduction or deletion of certain behavioral elements. This concept corresponds to an S-R-C model, with a stimulus (S) followed by the response (R), and the consequences (C). The S-R-C model is considered to be one of the crucial elements of CBT even today [80]. The 1950s were also significantly influenced by the work of Mowrer (learning theory, 1947) and Dollar & Miller [81; 82], who created the first therapeutic models.
Initially, BT gave a very mechanistic idea of the human mind. Consciousness psychology limited itself to the externally observable human behavior and was based on the idea that such behavior could be shaped by environmental influences without taking genetic circumstances into consideration. Thus, the fundamental statement of BT was that behavior is learned by learning processes, and thus, incorrect behavior can be unlearned while desired behavior can be acquired by learning.
In the 1960s, as part of the so-called cognitive change, thoughts, emotions and attitudes progressively moved to the focus of CBT as principal approaches for explanation and treatment. One of the major sources of this paradigm shift was the integration of cognitive techniques in CBT; consequently, CBT became a valuable tool focusing primarily on strengthening the patient’s independent ability to solve problems. The cognitive method described first by Beck addresses negative modes of thoughts and the resulting schemes as the source of psychiatric disorders [77]. The emotion theory of Schachter and Singer [83] was followed by the A-B-C concept by Albert Ellis, the father of the rational-emotive therapy, determining that emotions are triggered by interpretation the current situations. Consequently, by changing the attitude and perception of the event, the emotion/mood can also be altered [84]. In addition to Beck and Ellis, the second wave of BT was also influenced by authors including Jacobson, Eysenck, Wolpe, Bandura, Lazarus, Meichenbaum and Ullrich, whose concepts of model learning, relaxation exercises, stress management, self-instruction and self-assurance training complemented the various methods of CBT.
From the 70s until today,, behavioral therapy has been subject to substantial development based on emotion-focused approaches, methods of self-regulation and training of specific skills, including Dialectical Behavior Therapy (DBT; [85]), Acceptance and Commitment Therapy (ACT; [86]), Cognitive Behavioral Analysis System of Psychotherapy (CBASP; [87], Mindfulness-Based Cognitive Therapy (MBCT; [88]), Positive Psychology, [89] and Scheme Therapy [90].
In contrast to the psychoanalytical approach, CBT does not perceive psychiatric disorders as consequences of suppression or expression of mental conflicts, but rather as consequences of maladjusted attitudes and errors in reasoning expressed through disturbed behavior. Thus, the disturbed behavior itself represents the problem that requires changing as a response to certain conditions.
Behavioral therapy offers an approach to enhance the patient’s own capacities. Its primary objectives include, amongst others, making the patients aware of counterproductive attitudes and disturbing thought patterns. These goals are identified via learning processes performed in the therapeutic situation and then modified step by step until the adequate behavior is generated. In the therapeutic process, the relation of therapist and client represents a pivotal factor. At the onset of therapy, the therapist offers a particularly high amount of support by helping clients with identification and solving their problems, and then increasingly delegating responsibilities and correspondingly promoting the patient’s ability to solve problems as well recognizing processes that eventually lead to self-determination and social competence. As Hautzinger stated:
Behavioral therapy intends to change problematic behavior by applying therapeutic methods. Disturbed behavior should be described precisely in order to enable differentiated use of these methods.
Despite the fact that clinical-psychological diagnostics is focused primarily on the collection of personality characteristics preferably across time and situation by means of clinical-psychological testing procedures, precise descriptions and quantification of behavior started only towards the end of the 1960s [91]. The diagnostics of depressive disorders in behavioral therapy is based on:
Criteria diagnostics (ICD-10, and DSM-IV; DSM-V as of May 2013)
Test-psychological diagnostics by using self-assessment and external assessment scales (e.g.
SORCK model of behavioral analysis
As a detailed description of behavioral-therapeutic diagnostics would exceed the scope of this chapter, we limit ourselves to a brief presentation of the SORCK model. Problem analysis is based on Skinner\'s learning theory and represents a diagnostic process crucial in behavioral therapy. Problem analysis connotes that the human behavior is controlled by preceding (triggering) and succeeding conditions. This represents the first components of the behavioral-diagnostic SORCK model: S-O-R-C = Stimulus – Organism - Response – Consequence. These conditions should be modified during therapy by using various methods [99]. Thus, behavioral diagnostics gather the patient’s responses during various situations of life as well as from the maintaining conditions and the cognitive schemes conditional to problems. Then the patient’s own coping efforts are determined, followed by the identification of the method that can be used to alter the disturbed behavior.
The first step of behavioral analysis is to describe in detail the problematic behavior or response (R) with regard to its topography, intensity and duration [100].
In the next step, the conditions preceding the disturbed behavior - the so-called triggering situations (S) - and the subsequent conditions - the so-called consequences (C) - are determined. Kanfer and Saslow [102] expanded the SRCK models proposed by Lindsley [103] by adding the variable "O" (“Organism” meaning biologic conditions of behavior). This includes relatively permanent (e.g. brain damage) and short-term functional disorders (e.g. consequences of increased alcohol consumption) [99]. According to Lindsley, every stimulus or situation (S) is followed by a response (R), correspondingly resulting in behavior-supporting or behavior-penalizing consequence (C) and a contingency (K) as long as the consequences follow the behavior. The above described SORCK model has been a subject of further development within the scope of the diagnostic process and has been complemented by the determination of dysfunctional thoughts controlling the behavior.
This model differentiates four types of consequences [104]:
C+ (positive reinforcement)
C- (direct punishment)
Ȼ+ (indirect punishment by omitting positive reinforcement)
Ȼ- (negative reinforcement by omitting direct punishment)
During problem analysis the therapist may collect sufficient information to formulate the intended objective together with the patient.
Depressive disorders are characterized by a multifactorial pathogenesis. Thus, above all psycho-social factors (such as stresses and strains, role conflicts, lack of social support), biological factors (genetic predisposition, neuroendocrine regulation), personality factors (introversion, inclination towards melancholy, “typus melancholicus”, etc.), outside factors (deprivation of light, etc.) as well as traumatic events all may play an important role. Detailed discussion of these factors would certainly exceed the scope of the present chapter; therefore, in this section we focus primarily on the three psychological generation models as these are mainly relevant for behavior-therapeutic treatment.
The hypothetic causes of generation and maintenance of a depressive syndrome that can be effectively treated with behavioral therapy are linked either to the behavior or the cognition of the patient.
According to the cognition-theoretical explanation, the basis of each depressive development is represented primarily by cognitive dysfunction; the thinking pattern of the depressed patient is characterized by logical errors such as selective perception, random drawing of conclusions, exaggerations, etc. Negative, burdensome life experiences, which manifest themselves as cognitive schemes, are triggering conditions leading to dysfunction by developing a set of negative perceptions (also called "cognitive triads”; [77]) regarding the
identity ("I am of no worth")
environment ("nobody loves me; everybody is against me")
future ("there is no point, nothing will improve").
The cognitive triad forces the depressed individual to deal with irrational negative thoughts that are plausible to him/her over and over again. The patient experiences these thoughts as being automatic, intractable, persistent and unintended. Such thoughts are always about topics such as hopelessness, low self-esteem or suicide. Beck holds this cognitive disorder responsible for all psychiatric features of depression. Depressed individuals usually aim very high and believe that the world always imposes insurmountable obstacles for them. They tend to make their own deficits or low level of ability responsible for unpleasant experiences. Thus, one of the primary goals of therapy is to teach the patients that in addition to their first-person observation (usually actually based on self-contempt), there are other principles of self-control such as self-reinforcement. Depressed individuals show the tendency to consider their thoughts as being a given fact without cross-checking them with reality. When following this theoretical model, the searching, questioning and modifying of automatic, unperceived thoughts - i.e. the basic attitude of the patient characterizing his/her behavior, emotions and thinking - will become the primary objective of therapy as detailed in section 8.3.
For the sake of completeness, it should be mentioned that some authors regard cognitive dysfunctions as being consequences and not the causes [105]. Tringer describes this theory as the theory of “uniform structure” (depressive-cognitive structure – DCS; [106]).
The concept of Ellis regarding the generation and maintenance of depressive symptoms [107] is very similar to Beck\'s concept. Ellis assumes that irrational thinking will result in psychiatric disorders and that both rational and logical thinking can be learned, correspondingly resulting in reduction of psychological stress. The main purpose of cognitive therapy according to Ellis is also the change of cognition and irrational beliefs (section 8.3), correspondingly changing emotions and disturbed behaviors. According to Ellis\' theory, emotions develop as a result of highly distorted attitudes and assessments accompanied by severe physical reactions and often trigger negative actions by the affected person due to past experiences.. These emotions are often maintained by means of talking to oneself (soliloquies; [107]).
If events are deemed to be uncontrollable (i.e. if self-behavior and its consequences are perceived independently from each other within the environment) and this perception is generalized, the individual gets into the stage of "learned helplessness", a term invented by Martin E. P. Seligman in 1967. According to Seligman, depression is co-induced by feelings of helplessness that follow apparently uncontrollable, unpleasant events. The causes a person attributes to the event are decisive for the experienced controllability of the events. In 1978, Abramson, Seligman and Teasdale modified the helplessness model and included into their system an attribution style determining how the non-controllability of situations is processed. In this system, attribution styles are categorized as internal vs. external, global vs. specific, and stable vs. instable. Internal attribution is based on the assumption that the cause of personal helplessness is within the individual itself. Thus, this dimension is also responsible for decreased self-esteem. Global attribution represents a rather general description of the causes of non-controllability; specific attribution is limited to well-describable elements. The stable attribution style includes persistent and/or recurrent uncontrolled conditions and may result in chronic helplessness. According to Seligman, depressed patients interpret failures internally, soundly and globally (e.g. "I am stupid"). In contrast, success is attributed to external, unstable and specific causes ("the good grade was by accident" or "this task was difficult at all"), resulting in feelings of helplessness, and eventually leading to depression [108].
Based on this theoretical model, the first step of therapy is to identify the attribution style of the depressed patient. Then, cognitions should be carefully examined in order to reveal the degree of reality, followed by an attempt to re-attribute them in order to alter the basic attitudes (section 8.3).
While the cognitive models state that the conscious change of cognition will alter behavior and the experience, behavior-theoretical models assume that the change of behavior will modify cognition and mood.
According to Lewinsohn, depressive disorders are generated as a consequence of the loss of positively reinforcing feedback from close environment. This model is connected to operant learning theory and based on the following assumptions:
A low rate of behavior-contingent positive reinforcement has a triggering effect on depressed behavior and maintains depression.
The total amount of positive reinforcers depends on three factors: (1) the scope of potentially reinforcing events and activities; (2) the quantity of reinforcers available at a certain point in time; and (3) the repertoire of the individual behavior to receive reinforcers.
Reduction of the usual positive reinforcers results in reduction of activity, correspondingly resulting in depressed mood, which in turn leads to increased avolition (lack of motivation to pursue meaningful goals) that further decreases normal activity and reduces the effect of positive reinforcers. In the course of time, the ability of positively interpret the reinforcers may significantly decrease due to the lack of "training". This will correspondingly trigger a vicious cycle, a downward spiral [109].
The depressed behavior will also be maintained and positively reinforced, at least in the short term, by social attention. Attention is usually paid to those complaining. However, the social reinforcement of the depressive symptoms may also turn against the depressed person; individuals that complain a lot will eventually be avoided, leading to more frequent complaining and correspondingly being avoided even more.
This theory can be utilized in crucial therapeutic approaches, i.e. promotion of activity level, increase of positive behavior-contingent reinforcers, reduction of depression-promoting activities (section 8.1) and the augmentation of certain social abilities (section 8.2).
Integrative models, as the term indicates, integrate both approaches mentioned above (cognitive and behavior-theoretical) and assume that depressive symptoms are conditioned both by dysfunctional cognitions as well as by reduction of the activity rate [41]. According to this model, behavior and cognition are in complex interaction with each other. Depressed patients sees themselves as being a good-for-nothing due to their own passivity and listlessness. This negative self-perception (cognition) contributes to a further reduction in activity rate (behavior), thus, further promoting negative self-opinion. When increasing their activity rate (behavior), patients will see that their mood will improve and their thoughts will change.
More recent multi-factor models [110, 111] extract six significant factors contributing to the generation and maintenance of depressive disorders (triggering events, vulnerability, increase of self-attentiveness, aversive conditions, disturbed automated behavioral patterns, and dysphoric prevailing mood). Moreover, the interpretation of this explanatory model can yield the three major pillars for depression therapy – support of pleasant activities (section 8.1), change of dysfunctional cognitions (section 8.3) and social competence training (section 8.2).
Since depression is a multi-factorial disorder, its treatment requires a multi-factorial approach. In addition to the stabilization of the patient during a severe acute episode or in case of slight to moderate depression addressed by chemotherapy, psychological approaches are increasingly utilized. Cognitive and behavior-therapeutic techniques are applied depending on the basic theoretical model described above, on the severity of depression and on present problems. Therapy is based on the identification and elimination of disorder-triggering and disorder-maintaining factors in the patient’s behavior or cognition. Treatment also has an indirect influence on emotional, somatic and motivational effects of the disorder [41].
CBT integrates behavior-modifying and cognitive techniques. Therapy of depression with CBT is based on three principal pillars:
building up daily activities (section 8.1);
training of social competencies (section 8.2); and
cognitive techniques (section 8.3).
The chapter at hand provides a collection of cognitive behavioral therapeutic strategies that can be utilized in the treatment of depressive disorders. There is a common consensus that the first therapeutic step is to increase the activity level of the unmotivated patient; after an increase in activity, the therapeutic effort can be focused on dysfunctional thoughts and low self-esteem of the patient by introducing cognitive techniques. However, the sequence of the presented methodical steps should be considered as suggestions for therapy only, and addressing the individual problems and requirements of the patient should remain a major focus during course of therapy.
Most depressed patients reduce their activities dramatically; they seldom participate in enjoyable activities and they usually withdraw themselves into isolation. These patients lose valuable social relationships and also deprive themselves of the possibility of having positive experiences. Such pathological processes often result in a vicious circle; the loss of pleasant events (positive reinforcement) increases depressed moods, tiredness and listlessness, consequently leading to the loss of ability and motivation to engage in activities and in isolation from the rest of the society. Paradoxically, depressed patients justify their self-isolation by the fact that their activity is useless and they only represent a burden to other people.. As a result of this attitude they reduce activities they used to perform in the past without any problems, and even if they start an activity, they will not finish it due to the lack of belief in a successful outcome [31].Thus, building up of activities that have a positive reinforcing effect on the patient (pleasant activities) and creation of a daily structure remains the first basic step of behavioral therapeutic treatment.
When the connection between maintaining a balanced activity level and self-controlled management of depression symptoms depression is established, the patient becomes conscious of the relationship between activity/passivity and mood. On the other hand, based on the basic principles of learning, the consequences of behavior have a significant impact on the frequency of repetition of these particular activities in the future, and consequently, activities with pleasant consequences will be performed more frequently in the future as compared to activities with unpleasant consequences. The principle of reinforcement can be systematically used to modify the patient’s behavior and to introduce new elements of behavior. Active build-up of daily activities improves one’s mood; a positive mood will contribute to pleasant activities and thus the vicious circle is broken. Furthermore, patients will be aware of the feeling of being able to actively control their own life.
In the initial part of the therapy the theoretical background of the concept of reinforcement as well as the importance of therapeutic exercises at home between individual sessions is explained to the patient. For successful treatment it is extremely important that the affected person understand that activity/passivity and mood are interacting factors. Depressed patients usually spend a lot of time with unyielding, empty activities such as speculation or activities that are absolutely necessary (cleaning, laundry), but don’t have any positive reinforcing effect and/or are not pleasant. A low activity level suppresses mood and forces the patient to retreat even more to a passive attitude, correspondingly reducing the probability of having positive experiences (i.e., lack of positive reinforcers). The reduction in frequency of pleasant experiences leading to increasingly suppressed mood eventually results in passivity and self-isolation. However, this downwards spiral can be reversed by systematically emphasizing that performing pleasant activities generates a positive mood and also increases the probability of planning further activities [41].
Depressed patients often report that they feel like they are in a continuous pointless and meaningless condition. According to Beck and colleagues [31], the most important purpose of the activity-increasing exercises is to give a structural content to the time spent in order to reduce the feeling of aimlessness. Recording the daily activities is crucial and often demonstrates the distorted cognition of the patients stating:
The building up of activities is usually done gradually, in small steps by interrupting the patients\' passivity and achieving a proper activity level. In the first step, the patient is asked to systematically observe his/her usual daily activities during the week. By using "activity diaries", the activities are recorded along with the associated mood. First-person observation is an important BT technique as it enables both the therapist and the patient to consciously observe a change in the patient’s condition, eventually resulting in the identification of depression-supporting behavior that can be corrected by therapy. By utilizing this method, patients learns to observe himself/herself and to associate activity level and the emotions; this provides momentum to the next step, i.e. the targeted increase of the positive activities.
Below there is an example for an activity diary filled in for three days, based on the research of Hautzinger [41]. For recording the mood and the attitude, the scale -5 to +5 is commonly used, with 0 being neutral mood, - 5 being severest negative mood and + 5 being highest positive mood.
\n\t\t\t\t\t | \n\t\t\t\t\n\t\t\t\t\t | \n\t\t\t\t\n\t\t\t\t\t | \n\t\t\t\t\n\t\t\t\t\t | \n\t\t\t\t\n\t\t\t\t\t | \n\t\t\t\t\n\t\t\t\t\t | \n\t\t\t\t\n\t\t\t\t\t | \n\t\t\t
9 am - 11 am | \n\t\t\t\n\t\t\t | Awake since 5 am, still in bed (-5) | \n\t\t\tAwake since 6 AM, breakfast in bed (-4) | \n\t\t\tAwake since 4 AM (-5) | \n\t\t\t\n\t\t\t | \n\t\t |
11 am - 1 pm | \n\t\t\t\n\t\t\t | Bathroom, breakfast ( -2) | \n\t\t\tCleaning, ironing ( -1) | \n\t\t\tFallen asleep (-4) | \n\t\t\t\n\t\t\t | \n\t\t |
1 pm - 3 pm | \n\t\t\t\n\t\t\t | Sofa, TV (-2) | \n\t\t\tLunch with granddaughter (+2) | \n\t\t\tEating (0) | \n\t\t\t\n\t\t\t | \n\t\t |
3 pm - 5 pm | \n\t\t\t\n\t\t\t | Visit of a colleague (+1) | \n\t\t\tShopping, snoozing in bed (0) | \n\t\t\tSofa, TV (-2) | \n\t\t\t\n\t\t\t | \n\t\t |
5 pm - 7 pm | \n\t\t\t\n\t\t\t | Dinner, TV (0) | \n\t\t\tSofa, TV (-3) | \n\t\t\tTV in bed, no hunger (-4) | \n\t\t\t\n\t\t\t | \n\t\t |
7 pm - 9 pm | \n\t\t\t\n\t\t\t | Bed, speculating (-4) | \n\t\t\tBed, speculating (-4) | \n\t\t\tTV in bed (-5) | \n\t\t\t\n\t\t\t | \n\t\t |
9 pm - 11 pm | \n\t\t\t\n\t\t\t | Bed, speculating (-4) \n\t\t\t | \n\t\t\tFallen asleep | \n\t\t\tSpeculating until 2 am (-5) | \n\t\t\t\n\t\t\t | \n\t\t |
In the following therapy session, the weekly plan is assessed by the therapist and the connection between the activity and corresponding mood is explained to the patient by using personal examples.
In the second step, a list of activities generating positive mood is created together with the patient. Then the patient attempts to integrate as many activities as possible from this list into the next weekly plan. This individual list is also used as a collection of potential reinforcers as therapy progresses [41].
At the next stage, an activity plan for the whole next week, including activities that the patient wants to perform, is created together with the therapist. This time the schedule is more detailed and includes information regarding the place and the people associated with positive activities as well as the corresponding mood.
Some patients may voluntarily participate in some activities without enjoying them. This may be due to the fact that 1) they did not perceive these activities as being pleasant even before the depressive episode; 2) negative cognitions suppress any feelings of happiness; or 3) these feelings are disregarded selectively [31]. The exercise described above helps the patient to experience happiness again.
The activities should be defined by the patient (important for intrinsic motivation); the therapist may support the patient’s objective by requesting activities enjoyed in the past and/or by using a pre-defined list of pleasant activities [41,112]. Many depressed patients feel that they are not able to perform a particular activity. This should be accepted by the therapist; however, the therapist should motivate patients to perform minor activities and explain to them that since passivity has been of no help in the past, another strategy should be tried. Cognitive testing (imaginative exercise) of certain activities is a good compromise with highly unmotivated patients.
After successfully performing the activities defined as in the daily or weekly plan, the patient then records the mood changes in the diary. It is particularly important to schedule activities that are not performed alone in order to maintain social contacts and improve social skills (described in the next section).
When in a negative mood, depressed patients tend to set unrealistically high expectations for themselves; therefore, often they won’t even start the activity because of fear of failure. Consequently, if they do not achieve a particular goal, they attribute the lack of success to their own inability. Often patients start an activity but won’t finish it. An activity started but not completed is regarded as a failure by the patient. Therefore, the therapist\'s task is to make patients understand that it is unlikely that they will be able to perform as originally planned and that even an attempt is much better than doing nothing; additionally, it is important to emphasize that completing an activity depends both on external factors (weather, other people’s availability, etc.) as well as internal factors (concentration, fatigue).
Objectives of these activities are generally based on the SMART principle [113]:
First, the patient should provide a definition of attractiveness. Activities for achieving this objective are integrated into the weekly plan, e.g. going to the hairdresser, participating in a make-up class, going to the gym, performing sports (which?), buying more trendy clothes, etc.
Activities for achieving this objective: Inviting friends for dinner, planning an evening with friends at the movie theatre, inviting friends for a game night, doing sports together with friends etc.
Activities for achieving the objective: Get language books, get a private teacher, take a language class, go abroad, etc.
The patient needs to learn how to deal with unpleasant experiences. During the course of therapy, the patient needs to understand that certain not very pleasant activities may actually be fun and satisfactory. However, additional reinforcers need to be integrated into weekly activity plans in order to achieve this goal. The patient must learn that some activities have direct pleasant consequences but will have negative consequences in the long term. In contrast, some activities have immediate unpleasant consequences but positive effects in the long term. The problem is that patients suffering from depression tend to have a short-term view on things and therefore, as therapy advances, activities that are less pleasant in the short term but have positive effects in the long term need to be integrated into the weekly plan. Following each activity the patient will record the associated mood and, even more importantly, the reward after successful performance of each activity (from the individual list of pleasant activities). A positive reward for successfully performed but less pleasant activities will increase motivation to start an unpleasant activity with unpleasant short-term but pleasant long-term consequences. The reward or reinforcer becomes the source of positive emotions.
The patient wakes up every morning at 10 a.m., has breakfast in bed, does not leave bed but instead watches TV or doesn’t think about anything specific. During her therapy session it is agreed that she will get up at 8 a.m., has breakfast in the kitchen and then takes a short walk outside for at least half an hour. In this case, depression-supporting behavior has been replaced by positively perceived activities.
Parallel to the modification of the problematic behavior, it is recommended to develop a cognitive, physiologic and motor behavioral repertoire that corresponds to positive experiences and utilizes the elements of so-called euthymic therapy. During this therapy the patient again learns to consciously enjoy positive experiences without negative emotions. The emphasis is on being happy without any remorse, since most depressed patients feel that they do not get and do not deserve anything positive out of life. Consequently, these patients will do anything, usually subconsciously, to block out positive experiences. Euthymic therapy was used with great success during the treatment of depressed patients in the Psychiatric Clinic in Mannheim, Germany, in the 1980s; since then the method has also been used to treat other psychiatric disorders.. During therapeutic sessions patients learn to focus their attention on sensory perception and consciously enjoy various visual, auditory, tactile, gustatory and olfactory stimuli according to the instructions of the therapist and in order to learn to focus on and enjoy the present moment [114]. This therapy eventually increases patient self-confidence and self-perception. The learned pleasant experiences can be utilized during daily activities by developing a list of pleasant experiences the patient mentioned during sessions.
The use of so-called ‘happiness diaries’ has proved to be extremely successful in depression therapy. At the end of the day patients should review their daily activities and record the ones they enjoyed and their corresponding positive thoughts and events. This method is based on ‘positive psychology’ according to Seligman [89]. With this approach happiness in life depends on conscious optimistic perception that can be learned through practice. Happiness diaries play two pivotal roles in the treatment of depression. The first role is consciously focusing on positive experiences in the present. The second role of happiness diaries is particularly useful when the patient’s mood is low. In this case the patient can replay former positive experiences. Since the imagined situation triggers similar physiological processes to the ones that were induced by real events, this method can dramatically improve the patient’s mood.
In psychology, social competency has become a very frequent term that is only rarely defined in a clear manner. This term subsumes abilities and skills such as self-confidence, enforcement of desires, denial of requests, emotional freedom, assertiveness, socializing and cultivating contacts, communication skills etc. [115]. While Wolpe and Salter state that social problems are the result of inhibiting personality characteristics [116,117], Lazarus indicates that these problems may be rooted in incorrectly learned social behavior [118]. Ullrich de Muynck and Ullrich [119] complemented these theories with cognitive variables such as the attitude towards oneself and social perceptions. They define social competence as ‘self-confidence’ that includes recognizing and enforcing the needs and demands of the individual [120].
Therapeutic examination reveals that depressed people often organize their interpersonal interactions in an impeding manner. They complain constantly, hide their positive emotions, look for contacts with others less actively, are more sensitive to criticism and rejection, do not or only improperly support their own opinion, and lack confidence and assertiveness. These interaction characteristics, combined with unfavorable non-verbal communication forms such as a quiet voice, bent posture, infrequent eye contact, may result in social isolation. Often patients are faced with painful experiences in the beginning of behavioral therapy when experiencing drawbacks in interpersonal interactions during new daily activities.
The objective of social competence training is to support the patient’s self-confident behavior. During the course of therapy patients learns to properly communicate, to state their wishes, opinions and positive emotions, to use services offered by others, to develop problem-solving skills, and to understand the connection between mood and self-esteem.
Practicing social competence includes several methods that are based on teaching socially expected behavior via modelling and role play. Social competence is composed of skills that include, among others, self-confident behavior, problem solving and communication competencies, the ability to express one’s own wants and feelings, and proper reaction to criticism. It has been previously reported that practicing certain behavioral sequences (behavior rehearsal) as well as role plays help to create and maintain socially competent behavior [121]. After explaining the social problem to the patient, a realistic role play situation is designed and verbal (expression, volume), non-verbal (mimic), interactive (such as active listening) and motor components (posture, etc.) of the proper behavior are determined [122]. Following the initial analysis of the strengths and weaknesses of the patient\'s behavior, the desired outcome of the situation is identified together with the participation of the therapist, and the problematic situation is practiced with any required corrections within the therapeutic setting until the required behavior is achieved. Then the learned behavior is transferred to everyday situations and tested regularly.
In the first behavior-therapeutic role play, the therapist takes the role of the customer and Mr. M. plays his own role as the salesperson. The therapist observes the strengths and weaknesses of the patient. Mr. M. approaches the customer but maintains a distance, stops with his side facing towards the customer and talks to the customer in a quiet voice. At the end of role play the therapist gives feedback to Mr. M. First, the therapist describes the positive aspects of behavior.
Therapist:
Prior to the role play the therapist explains the verbal and nonverbal aspects of a self-confident behavior (eye contact, relaxed posture, articulate speech, etc.) and emphasizes the importance of repeated positive self-instructions (“I will succeed”, “I have a right to do this”, “I will be convincing”, etc.). After the play it is crucial to acknowledge the enthusiasm and the progress of the patient; it is also important to emphasize that the learning process takes time and effort.
Ms. F.: "
An additional problem emerges during Ms. F.’s communication of with her mother-in-law. Ms. F. wants her son to take a nap after lunch and does not want him to eat sweets. During her time off, she can control this by herself; however, on workdays, when her son is with her mother-in-law, her son eats sweets and he can refuse the nap. Ms. F. wants to present her will properly to her mother-in-law.
In this case, two different problem situations are role-played and practiced. In the first role play, the behavior of Ms. F., when interacting with her colleague at the office, is identified by the therapist playing the role of the colleague. Ms. F. is instructed to ask the colleague nicely to refill the stationery by herself during her work time. During the role play, the therapist observes the strengths and weaknesses in Ms. F.’s behavior as she insecurely explains to him with a quiet voice that she does not want the mess on the desk. After the end of the role play, the therapist gives feedback on Ms. F.’s performance. First, the strengths of the patient are highlighted.
Therapist: "
Then, the therapist focuses on the elements of Ms. F.’s behavior that need correction.
Therapist: "
In the second role play, Ms. F.’s behavior and communication with her mother-in-law are practiced. The therapist asks Ms. F. to clearly state her desires.
Ms. F.: "
The therapist explains to Ms. F. the importance of positively formulating the desires and objectives (to not state the things that you do not want, but the things you want).
Ms. F. tries again: "
Therapist: "
Using this technique the problematic situation is practiced with the required corrections until the targeted behavior of the patient is fully achieved. The patient\'s "homework" is to test the learned behavior in everyday situations.
In this session we have discussed the one of the most crucial component of the social competence for the depressed patient, the training of the self-confident behavior. As we have previously described, social competence includes several other skills as well that are not detailed in this chapter. Obviously, the patient’s individual shortages are in focus during the therapy of depression (learn how to say no to an unpleasant request, start a conversation with a stranger, reveal emotions, etc.). These elements are practiced using the similar methodology to the one mentioned above.
Problem-solving training belongs to the standard methods of behavioral therapy. It is highly structured didactically and it is usually combined with other therapeutic methods. The various concepts of this method do not differ significantly from each other. In the following, we will present the 5-level model described by D´Zurilla.
According to D´Zurilla and Goldfried [123], problem-solving is a behavioral process, including cognitive operations, that elaborates a number of efficient possible actions for problematic situations and that supports decision for one of these alternatives [120]. For this reason this method is classified as a cognitive strategy by some authors, while others mention it among the behavior-modifying elements. However, the current trend of CBT does not draw a strict boundary between these two fields.
With depressed patients the repertoire of their problem-solving abilities is often insufficient and their motivation to actively deal with problems is inadequate. Patients perceive these problems as being unsolvable per se and they do not attempt to address them because of the possibility of failure. Problem-solving training helps patients identify and name their problems, develop alternatives for problem solving, make decisions and to correspondingly decrease their feeling of hopelessness and at the same time increase self-efficacy.
D´Zurilla and Goldfried [123] describe a 5-level training model for gaining skills in solving problems:
The first level is used for general orientation by patients realizing their ‘problems.’ As this term is quite complex, Fliegel and colleagues [120] proposed the word “difficulties’ in a therapeutic context and they state that burdensome situations connected to patient uncertainty, dissatisfaction or anxiety should be avoided.
After successful recognition of the problem, the next level includes detailed identification of the ‘difficulty’ and comprehensive analysis of the problematic situation. During this stage the therapist will ask patients about their own experiences concerning the troublesome situation and their thoughts and emotions. At this point patients should also formulate their own objectives, i.e. describe the desired status so that the situation is not burdensome any more, but instead rather pleasant or at least acceptable. Patients should also consider what they are willing to do to achieve this desired status as well as the impacts or side effects of the new situation.
In the next step, alternatives for actions required for achieving the objective are elaborated and recorded. The more practical and problem-solving strategies are developed by the patient, the higher the possibility is that at least one useful idea will be identified to solve the problem.
At the decision stage all alternative actions are recorded with their short-term and long-term consequences impacting the patient and the patient’s environment. Considerations can be presented as a matrix that simplifies the presentation of the alternative actions and their corresponding consequences.
In the last step, the most favorable solution is selected and imposed. Imagination techniques are helpful for improving patient decision-making skills. As stated in section 8.1, patients are instructed to perform the activity in their mind first (compare it with ‘covert modelling’ Rational-Emotive-Therapy by Ellis [107]) since imagining the situation usually triggers the same physical reaction and emotions as the ones associated with the real situation.
A 27-year old female patient wants to move in with her fiancé. Her fiancé’s parents own a large rural house that would also offer enough space for the couple and it would only impose a slight financial burden for utility costs. However, the patient and her fiancé work in a city approximately 20 kilometers away and they need to use a car or a bus for commuting. Furthermore, the patient is worried about being forced to helping her parents-in-law with their farm work during her spare time in order to express the couple’s gratitude for housing, or to nurse his parents in case of illness, as this is customary in rural regions. She considered a town apartment as the first alternative action. Although the apartment is expensive the couple would not have to commute and they would be independent from his parents. The second possibility would be the rural house of the parents-in-law, which is more favorable in terms of costs but would include the necessity of commuting and also pose a threat of conflicts with his parents and correspondingly with her partner. She also considered a third possibility where the couple would live in the parents\' house and pay a reasonable rent in addition on top of utility costs. This solution would also include a contract in the agreement regarding any work she would be willing/not willing to do on the farm. After considering the pros and cons, the patient selected the first solution.
If realization of the most favorable action strategy does not generate the desired benefit for the patient the next best alternative can be tried and the matrix can be supplemented with new aspects.
Providing help to others offers several benefits regarding the treatment of depression. First, this competence-oriented exercise increases the feeling of personal efficacy; second, self-centered ways of thinking which are typical for depression (speculating on the patient’s own problems and sadness) is changed as the affected person focuses on the problems of others [124].
The following section focuses on therapy that is based on the principles of cognitive learning. Nevertheless it must be emphasized that the most accepted structure of CBT does not make a strict separation between classical behavioristic methods and cognitive techniques. Experience shows that these two components a closely correlated and complement each other.
During life, each individual attains - by learning and undergoing experiences - certain cognitive patterns that are typical for situations – so-called schemes – and that may differ with each person, but that are relatively constant interpersonally. These cognitive patterns define our expectations, attitudes and beliefs that are mainly unconscious and contribute to the structure and assessment of the conscious self.
Psychopathologic conditions such as depression are characterized by dysfunctional schemes that manifest in dysfunctional basic attitudes and are expressed by means of uncontainable negative thoughts (this sequence also corresponds to the cognitive hierarchy according to Beck [31]. If such schemes are activated, they have a major effect on cognitive information processing, on the type and quality of the experience and eventually on the behavior.
Depressed patients tend to exhibit errant, one-sided, absolutist ways of thinking, so-called cognitive distortions, that are expressed through exaggerations, generalizations, black and white thinking, understatement as well as over-generalizations. Cognitive techniques can be utilized to detect and correct such improper cognitions (automatic thoughts) and their corresponding basic assumptions that result in the disturbed behavior and that are connected to oppressive emotions. Learning cognitive techniques helps the patient replace dysfunctional cognitions with ways of thinking appropriate for a particular situation and to identify and use the central role of cognition for adjusting emotions. Thus, the objectives of the cognitive therapy include manipulating negative expectations and abnormal self-perceptions by means of the identification of abnormal belief systems.
In the cognitive stage of therapy there is a comparatively high amount of verbal communication between the patient and the therapist that enables the therapist to collect sufficient information in order to be able to enter into the patient\'s world and understand his or her organization of reality. The therapist must clearly understand the patient’s thought pattern associated with his or her symptoms as well as the way the patient assesses these symptoms. It is also crucial for the therapist to explain to the patient that they will jointly examine these thoughts that are by no means objective representations of reality, as experience shows that cognition is seriously distorted in depression. The therapist also needs to explain that a particular situation can be interpreted differently depending on the observer. Depressed individuals tend to evaluate situations negatively and thoughts, emotions and behavior generate a chain reaction. The patient must understand that a disorder is created by the way one assesses a situation.
In summary, the objectives of cognitive techniques can be identified as follows. The patient learns
not to accept his/her thoughts as facts,
how thoughts, emotions and behavior are connected to each other,
and how to develop a more objective and distant view concerning his/her own problems.
Cognitive restructuring is a gradual approximation based on the principles of cognitive hierarchy. In the first step, the patient’s negative automatic thoughts causing the unpleasant emotions are identified, as this can be determined most easily. After identifying distorted cognitions, the arduous situation is re-interpreted. Finally, the patient\'s dysfunctional basic attitudes which are based on deeper levels of consciousness and which are responsible for maintenance of depression can be identified and altered.
The ABC technique described by Ellis [107] is intended to differentiate thoughts, emotions and real facts, representing a very important step for identification of dysfunctional automatic thoughts. Using the ABC technique, the affected person learns that a situation or an event can be explained differently depending on the point of view and any consequent emotions depend on the interpretation of the event. In the ABC technique "A" refers to acting event, "B" to beliefs, thoughts and interpretation of the situation, and "C" to consequences, i.e. the emotions that are triggered by the thoughts and beliefs and that determine the subsequent behavior.
B. Thoughts: “She does not like me.”
C. Emotions: Feeling depressed.
Using this example, patients realize that their own thoughts actually trigger the negative emotion. The patient may ask:
In the next step the patient may try to develop helpful alternative thoughts instead of dysfunctional cognitions:
B. Thoughts: “She did not see me.”
C. Emotions: Neutral.
The Socratic dialogue is a cognitive CBT intervention technique described by Beck. Instead of didactic explanations and persuasive attempts by the therapist, the objective of this technique is to encourage the patient to uncover his or her own unprofitable way of thinking. This kind of verbal communication scarcely causes resistance since targeted questions enable patients to see their own problems from a different point of view and helps them learn to dissociate from distorted cognitions while gaining an objective view of the situation. As depressed individuals have a deficient ability of adequately understand certain problems, the open-question technique enables patients to see the correlation between mental structures (thoughts, emotions and behavior) and their personal experiences via self-awareness. The therapist uses Socratic questions to collect information regarding a problem and gives feedback to the patient by means of a brief summary showing that the therapist actively listens and correctly understands the patient. The Socratic dialogue is based on so-called negative automatic thoughts (NAT) that imply dysfunctional attitudes and that can be changed during the course of the therapy. In a first step these dysfunctional attitudes and persuasions are recognized by identifying negative automatic thoughts with the therapist carefully pointing out the embedded conflicts. Eventually, the questioning results in a new and more realistic perception of the problem.
NATs are highly distorted defects (over-generalization, dichotomous thinking), and one of the primary goals of therapy is to verify their degree of reality by the patient explaining a number negatively interpreted past situations. In addition to the Socratic dialogue, recording the patient’s troublesome thoughts in writing is a common method for identifying NATs. For depressed patients it is often difficult to describe their cognitions; in this case the therapist should point out that changes of emotions are good indicators for NATs. Experience shows that patients can identify negative emotions more easily than cognitions.
Therapist.: “
Patient: “
The patient should also assess the intensity of his or her emotions on a scale from 1 to 100% and understand that certain emotional variations are not pathological. The patient should also focus on emotions with the intensity of more than 40% since NAT generally associated with intense affects [125].
If the patient cannot name the depressive cognitions, it may be helpful to illustrate the troubling negative situation in a
\n\t\t\t\t\t | \n\t\t\t\t\n\t\t\t\t\t | \n\t\t\t\t\n\t\t\t\t\t | \n\t\t\t
Call from company during vacation | \n\t\t\tanxiety, doubt 80% | \n\t\t\tThey want to fire me. | \n\t\t
The neighbor did not say hello | \n\t\t\tdepressed, sad 50% | \n\t\t\tShe does not like me; she is angry at me. | \n\t\t
Thinking of chores | \n\t\t\thopeless, depressed 70% | \n\t\t\tHow can I cope with all this? | \n\t\t
Three-column table for identification of negative automatic thoughts
After successful identification of NATs based on the description of the problematic situation and the recognition of arduous emotions, the patient should perform a
The 15-year old son of a female patient is told that he is failing one of his courses.
Patient: “
Cognitive restructuring can be reached by Socratic interviewing performed empathically and carefully within the scope of a collaborative relationship that leads the patient to self-awareness [126]. In this particular case the patient should ask herself if one should really be responsible for everything, and then she should recognize that events usually have multiple causes (reattribution).
Depressed individuals measure themselves and the rest of the world with distorted criteria; they are significantly stricter with themselves than with others. Thus, patients must learn that there are other principles of self-control in addition to their first-person observation focused on self-denunciation, e.g. self-reinforcement.
Therapist: “
Therapist: “
Therapist: “
The following questions could also be helpful:
Therapist: “
Or: “
The degree of reality of this statement is verified using a 7-column table [128], where any cognitive distortions can be analyzed. In the thoughts diary, the above described ‘three-column technique’ which includes the problematic situation, the correspondingly connected emotional state as well as the NATs, is complemented with arguments FOR and AGAINST the distorted assumption of the patient. The patient should reassess his or her assumption to find other alternatives for different explanations of the situation; then, the alternative hypothesis should be used to reassess the original emotion.
\n\t\t\t\t\t | \n\t\t\t\t\n\t\t\t\t\t | \n\t\t\t\t\n\t\t\t\t\t | \n\t\t\t\t\n\t\t\t\t\t | \n\t\t\t\t\n\t\t\t\t\t | \n\t\t\t\t\n\t\t\t\t\t | \n\t\t\t\t\n\t\t\t\t\t | \n\t\t\t
Call from company during vacation | \n\t\t\tanxiety, doubt 80% | \n\t\t\tThey want to fire me. | \n\t\t\tnone | \n\t\t\tI recently got a pay raise. | \n\t\t\tMaybe they need me to fill in for a sick co-worker. | \n\t\t\t0% | \n\t\t
The neighbour did not say hello. | \n\t\t\tdepressed 50% | \n\t\t\tShe is angry with me. | \n\t\t\tnone | \n\t\t\tTwo days ago we had coffee together. | \n\t\t\tShe did not see me. | \n\t\t\t10% | \n\t\t
I think of chores. | \n\t\t\tdepressed 90% | \n\t\t\tNobody needs me, I am good for nothing. | \n\t\t\tMy daughter lives her own life. | \n\t\t\tShe asked for my advice yesterday. | \n\t\t\tCould do something every day. | \n\t\t\t30% | \n\t\t
Seven-column table: Examples for verification of degree of reality of distorted perception and corresponding corrections
The last step of cognitive restructuring is
However, it is also possible that the gathered ‘evidence’ actually supports the negative assumption of the patient
The seven-column technique helps patients discover cognitive defects that represent the actual basis of their depressed mood. Burns [129] lists 10 cognitive distortions:
dichotomous thinking (“
over-generalization (“
negative filter (“…
non-consideration of positive experiences (patient devaluate good grades in school by saying that the test was easy)
jumping to conclusions (“
exaggeration/understatement (“
emotional reasoning (“
labelling (“
personalization (“
"should" statements (“
If symptom improvement can be observed, the next step in therapy is to introduce the exploration of dysfunctional attitudes in order to increase the susceptibility to depression [41,130].
Automatic thoughts and dysfunctional attitudes are similar since both are acquired by learning processes; both contain exaggerated and distorted basic principles, they are self-sustaining, and their correction requires special techniques [128].
Dysfunctional basic assumptions are characterized by defective logic and imbalance; their stable attitudes, rules and beliefs form part of our personality. They are organized mainly around topics such as performance, acceptance/rejection and control. Realizing dysfunctional attitudes is not easy, as they are stored in the deeper, hardly accessible layers of our cognitive hierarchy as compared to automatic thoughts, which are usually linked to a situation. However, these basic assumptions can be reduced by applying Socratic questions, using the dysfunctional attitudes scale [131] or by deviation of the cognitive process through cognitive hierarchies as demonstrated by the technique of a vertical arrow pointing down. During the application of this technique the therapist can tackle the problematic situation using the question
Patient: “
Therapist: “
Patient: “
Therapist: “
Patient: “…
Therapist: “
Patient: “
The following intervention techniques are used for modification of dysfunctional attitudes:
Dysfunctional basic belief: “
Correction: “
3. Dysfunctional beliefs can also be corrected by a change in perspective.
Dysfunctional attitude: “
Modified belief: “
The final module of the CBT, which usually comprises 2-3 sessions, focuses on making any positive changes achieved during therapy become permanent by conscious comprehension. Therapy success is evaluated together with the patient. During the evaluation the patient rates any subjective changes experienced during the progress of the therapy and compares them to the level of depression recorded at the beginning of therapy. Improvement is measured by comparing the patient’s advance on the 10-degree-scale described above. In addition, the patient verbally summarizes the experienced positive changes and identifies the elements of the treatment that contributed most to the healing process. This summary has two purposes: First, it is extremely important to make patients understand that the most important factor of their improvement is their self-efficacy; and second, the therapist should emphasize the necessity of continuous employment of coping strategies after the completion of therapy to prevent relapse. Moreover, with the help of the therapist the patient summarizes the strategies that are pivotal in recognizing the early signs of depression (e.g. sleep disturbances, agitation, mood swings) that can be utilized to prevent relapse. In order to stabilize positive cognitions the therapist should emphasize the importance of self-efficacy tools including cognitive restructuring, maintaining and enhancing social relationships, utilization of ‘happiness diaries’ as described above, etc. It is equally important to make patients aware of their future goals and to help them engage in positive experiences they enjoy.
Despite their improvement some patients may require a prolonged support of his or her therapist. In this case it is recommended that control sessions be scheduled after the first, third and sixth months; these sessions also offer an excellent opportunity to monitor the patient’s status during an extended period.
The purpose of this chapter is to understand how seven different sects in Islam, namely Sunni, Shia, Whabbi, Salafi, Berelvi, Sufi and Deobandi (Seven Sects) have different perspectives on creativity in Islam.1 As Islam is a complete way of life and the religious, financial and political platforms must be part of the assessment of creativity. Creativity in Islam can only be assessed by educated and intellectually qualified Islamic
Prior to this study, there has been research conducted examining how creativity is effective in Islam [2]. However, that research did not focus on how Seven Sects assesses creativity. It does not look at the required support of
This study was conducted by examining seven different leading Islamic traditions based in the UK. Each sect provided unique insight into their understanding and interpretations of Islamic scriptures and texts in relation to creativity and its assessment. This study demonstrates how perceptions and practices of differing Islamic traditions compare with each other.2 The uniqueness of creativity research in Islam is the explorative nature of this research that lends itself to qualitative studies, such as religious ethnography and discourse analysis will form two key approaches [3]. Religious ethnography will assist in eliciting responses from each of the Seven Sect’s representatives, and discourse analysis will be used to identify different perspectives [4].
Islam came at a time when there was prevalent ignorance in pre-Islamic Arabia. The Quran guided Muslims to be creative and to use their creativity for the benefit of humanity and in accordance with Sharia law and Islamic principles [5]. The Quran promoted creativity by providing examples of creativity to inspire and make Muslims understand in a greater depth. The Quran created a system that allowed Muslims to become focused on helping people and societies by being inventors of new theories and ideas. Science, math, biology, languages, culture, geography, psychology, sociology, algorithms, and many other areas began to take shape, assisting and creating new building blocks that lead to the great Islamic civilisations that followed.
Before examples are provided of the Quran promoting creativity, it is important to first examine an unsupported supposition amongst many Muslims. Muslims believe that Allah is the creator of the universe, therefore a question sometimes arises that can the word ‘
Another example, where Allah describes his creativity and also identifies creativity of the people in the Quran, is in the verse: ‘
The
Allah in His three challenges challenged the whole of creation to create a chapter as He has done in the
Prophet Muhammad (pbuH) understood that all answers can be obtained from the Quran and that if any matters required clarification, then Muslims could go to Islamic scholars who are learned in the Quran, Ahadith, and Sunnah. The Prophet (pbuH) required Muslims to be learned and acquire knowledge throughout their lifetime. It is important to explain that many sects—including Salafi, Deobandi, and Wahabi—do not believe in Ahadith and Sunnah but rely solely on the Quran. They believe that any individual can translate the Quran. The Sunni, Sufi, Shia, and Berelvi sects believe the contrary. Such debates have led to segregation between the sects, causing difficulties for dialogue and rapport5 [11].
To provide an example, the Prophet (pbuH) states: ‘O Abu Huraira! I have thought that none will ask me about it before you as I know your longing for the (learning of) Ahadiths.’ [12]. It was reported in the same
Scholars at the time of the Prophet pbuH were afraid that there may be a dispute about the reliance on the
In relation to the
To understand the importance of knowledge in Islam from which creativity is derived, it is important to examine the first revelation to Prophet pbuH which was: ‘
This is a very important revelation as the first revelation in Islam is asking the Prophet (pbuH) to read. By reading this revelation the reader would understand, by understanding the reader would gain knowledge and by gaining knowledge the reader would bring about new ideas and creativity. Allah is then saying ‘
The participants from the Seven Sects were asked the following semi-structured questions:
In Islam, what is creativity?
Do different traditions have different perceptions of creativity in Islam?
Does Islam promote creativity?
How do you view creativity?
Does Islam limit creativity?
Does Islamic Law block the expansion of creativity in Islam due to its stringent rules on ethics?
Do you believe Islam should have a greater contribution to creativity?
What is the process of determining creativity in Islam in the absence of any guidelines that one can follow?
What would you say has been the biggest prevention in the rise of Islamic creativity?
Sect | Response to Question 1 | Response to Question 2 | Response to Question 3 | Response to Question 4 | Response to Question 5 | Response to Question 6 | Response to Question 7 | Response to Question 8 | Response to Question 9 | |
---|---|---|---|---|---|---|---|---|---|---|
1 | Sunni | |||||||||
2 | Shia | |||||||||
3 | Wahabbi | |||||||||
4 | Deobandi | |||||||||
5 | Barelvi | |||||||||
6 | Salafi | |||||||||
7 | Sufi |
This study examined how the Seven Sect Islam assesses creativity. Seven interviews were carried out with
Islam is a religion that was revealed to Prophet Muhammad pbuH that incentivised the seeking of any knowledge for its believers [10]. It is important to note that Islam views knowledge as a base of human intelligence and creativity as a branch of that intelligence. Therefore when Islam refers to knowledge it is sometimes referring to creativity too. In the pursuit of any knowledge, Islam provides rewards in the hereafter to Muslims for any knowledge gained in this world. Islam incentivises the thought process of creativity, the journey and the destination of accumulating knowledge and creativity and those rewards are rewarded separately at each stage. Islam makes it lucrative for Muslims to seek any knowledge and as the Prophet pbuH states: ‘
Islam leads Muslims to question not only the existence of man but also the creation of mountains, trees, space and so forth [16]. Islam holds itself out to be questioned so that through such questioning knowledge can be gained progressing to the creation of theories and leading to creativity. Islam openly challenges its followers and non-believers to creativity even at the threat of its own existence [8, 10]. Islam uses itself as a mechanism, providing a platform to Muslims to bounce ideas against and advancing ones understanding and mind to grasp what Allah has created, why it was created and the open challenge by Allah to mankind to do better than what He has done [8, 10, 12, 17].
As a universal religion, Islam places great importance on creativity and innovation to create an
However, despite Islam seeking to create a ‘Middle Ummah’, Muslims have been faced with great difficulties due to religious interpretations of the terms
From the interviews, all informants understood what
On the question of Islam promoting creativity, Imam Nasar (Sunni) explained that Islam does promote creativity but only those things that are not against Islam. He provided an example that the translation of the Quran was a new creative idea after the demise of the Prophet pbuH. He stated that this benefits people and does not go against Islam. He also stated that some technologies that benefit people are allowed under Islam. Imam Alvi (Shia) agreed that Islam promotes creativity. He explained that Islam has asked Muslims to obtain knowledge even if you have to go to China. He explained that the word ‘China’ was never said by the Prophet pbuH but knowledge was so important and people just accepted that He pbuH had said it as it was good to obtain knowledge. He described that currently, people may feel that to be creative, one must obtain Western knowledge or from people that follow a different religion than Islam. He provided a response to that and said that Muslims have a right over knowledge so they should go where knowledge is even to other religions. Imam Chisti (Barelvi) believes that Islam allows all forms of creativity unless particular creativity is wrong. He highlighted that if Islam views something as wrong that thing will not be praised. Imam Rasab (Sufi) emphasised that Islam promoted creativity and it is divided into two categories: the good and bad
Imam Dawud (Salafi) explained that people create
The
Despite having such clear direction from the
On the question of there being different perceptions of
Imam Chisti (Barelvi) explained that there is one interpretation but different schools of thought have taken control of this issue from different angles. Imam Chisti (Barelvi) suggested that due to this control Muslims are not able to be creative. Imam Chisti (Barelvi) in his response to those that attempt to control the explanations of bida’h provided an example of Sahih Al Bukhari a collection of
Imam Rasab (Sufi) said that there are different explanations, but the definition is the same. He provided his own examples of Arabic grammar, the book version of the Quran, prayer timetable and even the mobile phone. He said that these developments are a benefit and accepted in Islam. Imam Dawud (Salafi) response was that there are different perceptions of
Imam Younas (Wahabi) and Imam Huzayf (Deobandi) both agreed with Imam Chisti (Barelvi) that there is one interpretation but different meanings. There are many different interpretations of the
In relation to the
Imam Nasar (Sunni), Imam Alvi (Shia), Imam Chisti (Barelvi) and Imam Rasab (Sufi) all agree that creativity is a necessity. Imam Dawud (Salafi) believed that
The Prophet (pbuH) states: ‘
On the question of Islam limiting creativity, Imam Nasar (Sunni) believes that there are limitations on creativity, which is for a Muslim to comply with the rule or obligations of Islam and that the creativity should not contradict Islamic principles or else it will be rejected. Imam Alvi (Shia) stated that Islam has not provided people with freedom but rather has asked them to remain within guidelines and that they should be within the Islamic guidelines. Imam Chisti (Barelvi) explained that if there is no
Imam Rasab (Sufi) explained that if
Imam Younas (Wahabi) explained that there is a complete ban on creativity, innovation or
However, the Prophet (pbuH) states: ‘
In response to those that oppose good
The difficulties due to religious interpretations or applications of
On the question of Shariah Law blocking creativity due to its ethics, Imam Nasar (Sunni) disagreed that
Imam Chisti (Barelvi) explained that Islam does not basically block
Imam Dawud (Salafi) explained that everything in worldly life is permissible unless we have sacred text prohibiting it. Imam Younas (Wahabi) proposed that a Mufti be approached to seek an answer to this question and Imam Huzayf (Deobandi) said
However, these interpretations prevent an open dialogue about creativity in the Islamic world. The importance of
An Islamic ruling under
The literal meaning of the
It has been a challenging time for
All informants, except for Imam Huzayf (Deobandi), believed that Islam or more specifically Muslims should have a greater contribution to creativity as Islam permits creativity. Imam Huzayf (Deobandi) did not have a response to this question.
All informants believed that if
The Hadith states: ‘If a question relates to your worldly matters you would know better about it, but if it relates to your religion then to me it belongs’ [32]. The Prophet (pbuH) has confirmed that the Muslims know better when it comes to their worldly affairs, which include necessities and through necessities comes creativity and innovation. The Prophet (pbuH) has confirmed that bid’ah is permissible in Islam, and He (pbuH) has also confirmed that it is up to the Muslim to decide his worldly affairs. Therefore, if the Ulemas and their congregations decide that they will not be creative or innovative then that is a choice that they have made as Shariah Law does restrict innovation but limits its function to avoid unlawfulness. Other than that, Shariah Law is not an obstacle to creativity but makes it an obligation to participate in creativity and innovation to assist Islam.
There are political, financial and international obstacles leading to environmental effects that prevent the rise of Islamic creativity. Imam Nasar (Sunni) stated that in every society, there are people that are against creativity and knowledge. In Islam, there are these ‘hardliner’ people, and these people start placing
Imam Alvi (Shia) stated that Muslims have not contributed to creativity, for some time, it is because Islam wants Muslims to follow it, and Muslims want Islam to follow them which leads to misunderstanding and stagnation of creativity. He stated that Muslims see Islam as a commodity that they can mould to their satisfaction. He explained that if Muslims want to achieve success and creativity then they need the
The other thing that is blocking creativity according to Imam Chisti (Beralvi) is small groups of self-styled scholars, self-styled Imams and self-styled teachers, who can speak good English but have no authenticity and misinterpret Islam. Imam Rasab (Sufi) stated that Muslims have become lazy and have started fighting between themselves. He explained that if a particular Muslim is doing a good job, the other person will say that is bad
Imam Dawud (Salafi) stated that all good comes from practising religion and Muslims have left practising. Imam Younas (Wahabi) believes that the whole idea was to benefit mankind and humanity, since this is not the case anymore and has not been the case for several centuries, greed has crept in and Muslims have gone away from their religion. Imam Huzayf (Deobandi) stated it is not the religion itself, it is probably the Muslims that are the prevention to creativity.
All informants believed that the guidelines to follow when addressing creativity in Islam must include either all or some of the following stages: the intention (of the creator), the
This study provides an Islamic Creativity Framework with reliance on the
Similarly to Abd-Allah’s work Al-Karasneh and Jubran study of ‘Islamic Perspective of Creativity: A Model for Teachers of Social Studies as Leaders’ [34] use the content analysis approach of the Quran to determine a model for teachers in social studies as leaders. Al-Karasneh and Jubran do not propose an Islamic creative framework despite the Quran being an analysis of their research. Their methodology relies heavily upon the primary source in Islam which is the Quran. They confirm that there is not a developed Islamic methodology of creativity and possibly for this reason they have created a methodology to teach creativity in Islam.
Al-Karasneh and Jubran then rely upon
The Seven Sects each have their own interpretations of scriptures, whoever, what binds them is the similarities and not the differences. Unfortunately, the differences between them are what separate them, creating the possibility of further debate which exceeds the bounds of open dialogue and rather leads to some sects being neglectful of the other’s beliefs. What is apparent is that the Seven Sects do believe that creativity can be accepted but for some (Whabbi, Salafi and Deobandi) this is limited to what was acceptable in the 6th Century. Despite advancements in technology at the very least on a social level, it is difficult to accept that innovation can only be accepted to what was available in the sixth century. Sunni, Shia, Berelvi and Sufi have a contrary view that innovation is acceptable, provided it brings about good to a greater amount of people. Islamic creativity it appears, is accepted widely, but may be due to religious and political aspects there is influence on certain sects not to accept, what can be defined as a wider acceptance of Islamic creativity by its followers. The scope of this study does not extend further than this and further academic contribution will be required to answer such research questions.
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His studies in robotics lead him not only to a PhD degree but also inspired him to co-found and build the International Journal of Advanced Robotic Systems - world's first Open Access journal in the field of robotics.",institutionString:null,institution:{name:"TU Wien",country:{name:"Austria"}}},{id:"441",title:"Ph.D.",name:"Jaekyu",middleName:null,surname:"Park",slug:"jaekyu-park",fullName:"Jaekyu Park",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/441/images/1881_n.jpg",biography:null,institutionString:null,institution:{name:"LG Corporation (South Korea)",country:{name:"Korea, South"}}},{id:"465",title:"Dr.",name:"Christian",middleName:null,surname:"Martens",slug:"christian-martens",fullName:"Christian Martens",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Rheinmetall (Germany)",country:{name:"Germany"}}},{id:"479",title:"Dr.",name:"Valentina",middleName:null,surname:"Colla",slug:"valentina-colla",fullName:"Valentina Colla",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/479/images/358_n.jpg",biography:null,institutionString:null,institution:{name:"Sant'Anna School of Advanced Studies",country:{name:"Italy"}}},{id:"494",title:"PhD",name:"Loris",middleName:null,surname:"Nanni",slug:"loris-nanni",fullName:"Loris Nanni",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/494/images/system/494.jpg",biography:"Loris Nanni received his Master Degree cum laude on June-2002 from the University of Bologna, and the April 26th 2006 he received his Ph.D. in Computer Engineering at DEIS, University of Bologna. On September, 29th 2006 he has won a post PhD fellowship from the university of Bologna (from October 2006 to October 2008), at the competitive examination he was ranked first in the industrial engineering area. He extensively served as referee for several international journals. He is author/coauthor of more than 100 research papers. He has been involved in some projects supported by MURST and European Community. His research interests include pattern recognition, bioinformatics, and biometric systems (fingerprint classification and recognition, signature verification, face recognition).",institutionString:null,institution:null},{id:"496",title:"Dr.",name:"Carlos",middleName:null,surname:"Leon",slug:"carlos-leon",fullName:"Carlos Leon",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Seville",country:{name:"Spain"}}},{id:"512",title:"Dr.",name:"Dayang",middleName:null,surname:"Jawawi",slug:"dayang-jawawi",fullName:"Dayang Jawawi",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Technology Malaysia",country:{name:"Malaysia"}}},{id:"528",title:"Dr.",name:"Kresimir",middleName:null,surname:"Delac",slug:"kresimir-delac",fullName:"Kresimir Delac",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/528/images/system/528.jpg",biography:"K. Delac received his B.Sc.E.E. degree in 2003 and is currentlypursuing a Ph.D. degree at the University of Zagreb, Faculty of Electrical Engineering andComputing. His current research interests are digital image analysis, pattern recognition andbiometrics.",institutionString:null,institution:{name:"University of Zagreb",country:{name:"Croatia"}}},{id:"557",title:"Dr.",name:"Andon",middleName:"Venelinov",surname:"Topalov",slug:"andon-topalov",fullName:"Andon Topalov",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/557/images/1927_n.jpg",biography:"Dr. Andon V. Topalov received the MSc degree in Control Engineering from the Faculty of Information Systems, Technologies, and Automation at Moscow State University of Civil Engineering (MGGU) in 1979. He then received his PhD degree in Control Engineering from the Department of Automation and Remote Control at Moscow State Mining University (MGSU), Moscow, in 1984. From 1985 to 1986, he was a Research Fellow in the Research Institute for Electronic Equipment, ZZU AD, Plovdiv, Bulgaria. In 1986, he joined the Department of Control Systems, Technical University of Sofia at the Plovdiv campus, where he is presently a Full Professor. He has held long-term visiting Professor/Scholar positions at various institutions in South Korea, Turkey, Mexico, Greece, Belgium, UK, and Germany. And he has coauthored one book and authored or coauthored more than 80 research papers in conference proceedings and journals. His current research interests are in the fields of intelligent control and robotics.",institutionString:null,institution:{name:"Technical University of Sofia",country:{name:"Bulgaria"}}},{id:"585",title:"Prof.",name:"Munir",middleName:null,surname:"Merdan",slug:"munir-merdan",fullName:"Munir Merdan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/585/images/system/585.jpg",biography:"Munir Merdan received the M.Sc. degree in mechanical engineering from the Technical University of Sarajevo, Bosnia and Herzegovina, in 2001, and the Ph.D. degree in electrical engineering from the Vienna University of Technology, Vienna, Austria, in 2009.Since 2005, he has been at the Automation and Control Institute, Vienna University of Technology, where he is currently a Senior Researcher. 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Much of biochemistry is devoted to enzymes, proteins that catalyze chemical reactions, enzyme structures, mechanisms of action and their roles within cells. Biochemistry also studies small signaling molecules, coenzymes, inhibitors, vitamins, and hormones, which play roles in life processes. Biochemical experimentation, besides coopting classical chemistry methods, e.g., chromatography, adopted new techniques, e.g., X-ray diffraction, electron microscopy, NMR, radioisotopes, and developed sophisticated microbial genetic tools, e.g., auxotroph mutants and their revertants, fermentation, etc. More recently, biochemistry embraced the ‘big data’ omics systems. Initial biochemical studies have been exclusively analytic: dissecting, purifying, and examining individual components of a biological system; in the apt words of Efraim Racker (1913 –1991), “Don’t waste clean thinking on dirty enzymes.” Today, however, biochemistry is becoming more agglomerative and comprehensive, setting out to integrate and describe entirely particular biological systems. The ‘big data’ metabolomics can define the complement of small molecules, e.g., in a soil or biofilm sample; proteomics can distinguish all the comprising proteins, e.g., serum; metagenomics can identify all the genes in a complex environment, e.g., the bovine rumen. 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Working with large volumes of data has given him a good command of big data processing tools and NoSQL databases. He has also been a visiting scholar at the Knowledge Engineering and Discovery Research Institute, Auckland University of Technology.",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"314575",title:"Dr.",name:"Jesus",middleName:null,surname:"L. Lobo",slug:"jesus-l.-lobo",fullName:"Jesus L. Lobo",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/314575/images/system/314575.png",biography:"Dr. Jesús López is currently based in Bilbao (Spain) working at TECNALIA as Artificial Intelligence Research Scientist. In most cases, a project idea or a new research line needs to be investigated to see if it is good enough to take into production or to focus on it. That is exactly what he does, diving into Machine Learning algorithms and technologies to help TECNALIA to decide whether something is great in theory or will actually impact on the product or processes of its projects. So, he is expert at framing experiments, developing hypotheses, and proving whether they’re true or not, in order to investigate fundamental problems with a longer time horizon. He is also able to design and develop PoCs and system prototypes in simulation. He has participated in several national and internacional R&D projects.\n\nAs another relevant part of his everyday research work, he usually publishes his findings in reputed scientific refereed journals and international conferences, occasionally acting as reviewer and Programme Commitee member. Concretely, since 2018 he has published 9 JCR (8 Q1) journal papers, 9 conference papers (e.g. ECML PKDD 2021), and he has co-edited a book. He is also active in popular science writing data science stories for reputed blogs (KDNuggets, TowardsDataScience, Naukas). Besides, he has recently embarked on mentoring programmes as mentor, and has also worked as data science trainer.",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"103779",title:"Prof.",name:"Yalcin",middleName:null,surname:"Isler",slug:"yalcin-isler",fullName:"Yalcin Isler",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRyQ8QAK/Profile_Picture_1628834958734",biography:"Yalcin Isler (1971 - Burdur / Turkey) received the B.Sc. degree in the Department of Electrical and Electronics Engineering from Anadolu University, Eskisehir, Turkey, in 1993, the M.Sc. degree from the Department of Electronics and Communication Engineering, Suleyman Demirel University, Isparta, Turkey, in 1996, the Ph.D. degree from the Department of Electrical and Electronics Engineering, Dokuz Eylul University, Izmir, Turkey, in 2009, and the Competence of Associate Professorship from the Turkish Interuniversity Council in 2019.\n\nHe was Lecturer at Burdur Vocational School in Suleyman Demirel University (1993-2000, Burdur / Turkey), Software Engineer (2000-2002, Izmir / Turkey), Research Assistant in Bulent Ecevit University (2002-2003, Zonguldak / Turkey), Research Assistant in Dokuz Eylul University (2003-2010, Izmir / Turkey), Assistant Professor at the Department of Electrical and Electronics Engineering in Bulent Ecevit University (2010-2012, Zonguldak / Turkey), Assistant Professor at the Department of Biomedical Engineering in Izmir Katip Celebi University (2012-2019, Izmir / Turkey). He is an Associate Professor at the Department of Biomedical Engineering at Izmir Katip Celebi University, Izmir / Turkey, since 2019. In addition to academics, he has also founded Islerya Medical and Information Technologies Company, Izmir / Turkey, since 2017.\n\nHis main research interests cover biomedical signal processing, pattern recognition, medical device design, programming, and embedded systems. He has many scientific papers and participated in several projects in these study fields. He was an IEEE Student Member (2009-2011) and IEEE Member (2011-2014) and has been IEEE Senior Member since 2014.",institutionString:null,institution:{name:"Izmir Kâtip Çelebi University",country:{name:"Turkey"}}},{id:"339677",title:"Dr.",name:"Mrinmoy",middleName:null,surname:"Roy",slug:"mrinmoy-roy",fullName:"Mrinmoy Roy",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/339677/images/16768_n.jpg",biography:"An accomplished Sales & Marketing professional with 12 years of cross-functional experience in well-known organisations such as CIPLA, LUPIN, GLENMARK, ASTRAZENECA across different segment of Sales & Marketing, International Business, Institutional Business, Product Management, Strategic Marketing of HIV, Oncology, Derma, Respiratory, Anti-Diabetic, Nutraceutical & Stomatological Product Portfolio and Generic as well as Chronic Critical Care Portfolio. A First Class MBA in International Business & Strategic Marketing, B.Pharm, D.Pharm, Google Certified Digital Marketing Professional. Qualified PhD Candidate in Operations and Management with special focus on Artificial Intelligence and Machine Learning adoption, analysis and use in Healthcare, Hospital & Pharma Domain. Seasoned with diverse therapy area of Pharmaceutical Sales & Marketing ranging from generating revenue through generating prescriptions, launching new products, and making them big brands with continuous strategy execution at the Physician and Patients level. Moved from Sales to Marketing and Business Development for 3.5 years in South East Asian Market operating from Manila, Philippines. Came back to India and handled and developed Brands such as Gluconorm, Lupisulin, Supracal, Absolut Woman, Hemozink, Fabiflu (For COVID 19), and many more. In my previous assignment I used to develop and execute strategies on Sales & Marketing, Commercialization & Business Development for Institution and Corporate Hospital Business portfolio of Oncology Therapy Area for AstraZeneca Pharma India Ltd. Being a Research Scholar and Student of ‘Operations Research & Management: Artificial Intelligence’ I published several pioneer research papers and book chapters on the same in Internationally reputed journals and Books indexed in Scopus, Springer and Ei Compendex, Google Scholar etc. Currently, I am launching PGDM Pharmaceutical Management Program in IIHMR Bangalore and spearheading the course curriculum and structure of the same. I am interested in Collaboration for Healthcare Innovation, Pharma AI Innovation, Future trend in Marketing and Management with incubation on Healthcare, Healthcare IT startups, AI-ML Modelling and Healthcare Algorithm based training module development. I am also an affiliated member of the Institute of Management Consultant of India, looking forward to Healthcare, Healthcare IT and Innovation, Pharma and Hospital Management Consulting works.",institutionString:null,institution:{name:"Lovely Professional University",country:{name:"India"}}},{id:"1063",title:"Prof.",name:"Constantin",middleName:null,surname:"Volosencu",slug:"constantin-volosencu",fullName:"Constantin Volosencu",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/1063/images/system/1063.png",biography:"Prof. Dr. Constantin Voloşencu graduated as an engineer from\nPolitehnica University of Timișoara, Romania, where he also\nobtained a doctorate degree. He is currently a full professor in\nthe Department of Automation and Applied Informatics at the\nsame university. Dr. Voloşencu is the author of ten books, seven\nbook chapters, and more than 160 papers published in journals\nand conference proceedings. He has also edited twelve books and\nhas twenty-seven patents to his name. He is a manager of research grants, editor in\nchief and member of international journal editorial boards, a former plenary speaker, a member of scientific committees, and chair at international conferences. His\nresearch is in the fields of control systems, control of electric drives, fuzzy control\nsystems, neural network applications, fault detection and diagnosis, sensor network\napplications, monitoring of distributed parameter systems, and power ultrasound\napplications. He has developed automation equipment for machine tools, spooling\nmachines, high-power ultrasound processes, and more.",institutionString:'"Politechnica" University Timişoara',institution:null},{id:"221364",title:"Dr.",name:"Eneko",middleName:null,surname:"Osaba",slug:"eneko-osaba",fullName:"Eneko Osaba",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/221364/images/system/221364.jpg",biography:"Dr. Eneko Osaba works at TECNALIA as a senior researcher. He obtained his Ph.D. in Artificial Intelligence in 2015. He has participated in more than twenty-five local and European research projects, and in the publication of more than 130 papers. He has performed several stays at universities in the United Kingdom, Italy, and Malta. Dr. Osaba has served as a program committee member in more than forty international conferences and participated in organizing activities in more than ten international conferences. He is a member of the editorial board of the International Journal of Artificial Intelligence, Data in Brief, and Journal of Advanced Transportation. He is also a guest editor for the Journal of Computational Science, Neurocomputing, Swarm, and Evolutionary Computation and IEEE ITS Magazine.",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"275829",title:"Dr.",name:"Esther",middleName:null,surname:"Villar-Rodriguez",slug:"esther-villar-rodriguez",fullName:"Esther Villar-Rodriguez",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/275829/images/system/275829.jpg",biography:"Dr. Esther Villar obtained a Ph.D. in Information and Communication Technologies from the University of Alcalá, Spain, in 2015. She obtained a degree in Computer Science from the University of Deusto, Spain, in 2010, and an MSc in Computer Languages and Systems from the National University of Distance Education, Spain, in 2012. Her areas of interest and knowledge include natural language processing (NLP), detection of impersonation in social networks, semantic web, and machine learning. Dr. Esther Villar made several contributions at conferences and publishing in various journals in those fields. Currently, she is working within the OPTIMA (Optimization Modeling & Analytics) business of TECNALIA’s ICT Division as a data scientist in projects related to the prediction and optimization of management and industrial processes (resource planning, energy efficiency, etc).",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"49813",title:"Dr.",name:"Javier",middleName:null,surname:"Del Ser",slug:"javier-del-ser",fullName:"Javier Del Ser",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/49813/images/system/49813.png",biography:"Prof. Dr. Javier Del Ser received his first PhD in Telecommunication Engineering (Cum Laude) from the University of Navarra, Spain, in 2006, and a second PhD in Computational Intelligence (Summa Cum Laude) from the University of Alcala, Spain, in 2013. He is currently a principal researcher in data analytics and optimisation at TECNALIA (Spain), a visiting fellow at the Basque Center for Applied Mathematics (BCAM) and a part-time lecturer at the University of the Basque Country (UPV/EHU). His research interests gravitate on the use of descriptive, prescriptive and predictive algorithms for data mining and optimization in a diverse range of application fields such as Energy, Transport, Telecommunications, Health and Industry, among others. In these fields he has published more than 240 articles, co-supervised 8 Ph.D. theses, edited 6 books, coauthored 7 patents and participated/led more than 40 research projects. He is a Senior Member of the IEEE, and a recipient of the Biscay Talent prize for his academic career.",institutionString:"Tecnalia Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"278948",title:"Dr.",name:"Carlos Pedro",middleName:null,surname:"Gonçalves",slug:"carlos-pedro-goncalves",fullName:"Carlos Pedro Gonçalves",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRcmyQAC/Profile_Picture_1564224512145",biography:'Carlos Pedro Gonçalves (PhD) is an Associate Professor at Lusophone University of Humanities and Technologies and a researcher on Complexity Sciences, Quantum Technologies, Artificial Intelligence, Strategic Studies, Studies in Intelligence and Security, FinTech and Financial Risk Modeling. He is also a progammer with programming experience in:\n\nA) Quantum Computing using Qiskit Python module and IBM Quantum Experience Platform, with software developed on the simulation of Quantum Artificial Neural Networks and Quantum Cybersecurity;\n\nB) Artificial Intelligence and Machine learning programming in Python;\n\nC) Artificial Intelligence, Multiagent Systems Modeling and System Dynamics Modeling in Netlogo, with models developed in the areas of Chaos Theory, Econophysics, Artificial Intelligence, Classical and Quantum Complex Systems Science, with the Econophysics models having been cited worldwide and incorporated in PhD programs by different Universities.\n\nReceived an Arctic Code Vault Contributor status by GitHub, due to having developed open source software preserved in the \\"Arctic Code Vault\\" for future generations (https://archiveprogram.github.com/arctic-vault/), with the Strategy Analyzer A.I. module for decision making support (based on his PhD thesis, used in his Classes on Decision Making and in Strategic Intelligence Consulting Activities) and QNeural Python Quantum Neural Network simulator also preserved in the \\"Arctic Code Vault\\", for access to these software modules see: https://github.com/cpgoncalves. He is also a peer reviewer with outsanding review status from Elsevier journals, including Physica A, Neurocomputing and Engineering Applications of Artificial Intelligence. Science CV available at: https://www.cienciavitae.pt//pt/8E1C-A8B3-78C5 and ORCID: https://orcid.org/0000-0002-0298-3974',institutionString:"University of Lisbon",institution:{name:"Universidade Lusófona",country:{name:"Portugal"}}},{id:"310576",title:"Prof.",name:"Erick Giovani",middleName:null,surname:"Sperandio Nascimento",slug:"erick-giovani-sperandio-nascimento",fullName:"Erick Giovani Sperandio Nascimento",position:null,profilePictureURL:"https://intech-files.s3.amazonaws.com/0033Y00002pDKxDQAW/ProfilePicture%202022-06-20%2019%3A57%3A24.788",biography:"Prof. Erick Sperandio is the Lead Researcher and professor of Artificial Intelligence (AI) at SENAI CIMATEC, Bahia, Brazil, also working with Computational Modeling (CM) and HPC. He holds a PhD in Environmental Engineering in the area of Atmospheric Computational Modeling, a Master in Informatics in the field of Computational Intelligence and Graduated in Computer Science from UFES. He currently coordinates, leads and participates in R&D projects in the areas of AI, computational modeling and supercomputing applied to different areas such as Oil and Gas, Health, Advanced Manufacturing, Renewable Energies and Atmospheric Sciences, advising undergraduate, master's and doctoral students. He is the Lead Researcher at SENAI CIMATEC's Reference Center on Artificial Intelligence. In addition, he is a Certified Instructor and University Ambassador of the NVIDIA Deep Learning Institute (DLI) in the areas of Deep Learning, Computer Vision, Natural Language Processing and Recommender Systems, and Principal Investigator of the NVIDIA/CIMATEC AI Joint Lab, the first in Latin America within the NVIDIA AI Technology Center (NVAITC) worldwide program. He also works as a researcher at the Supercomputing Center for Industrial Innovation (CS2i) and at the SENAI Institute of Innovation for Automation (ISI Automação), both from SENAI CIMATEC. He is a member and vice-coordinator of the Basic Board of Scientific-Technological Advice and Evaluation, in the area of Innovation, of the Foundation for Research Support of the State of Bahia (FAPESB). He serves as Technology Transfer Coordinator and one of the Principal Investigators at the National Applied Research Center in Artificial Intelligence (CPA-IA) of SENAI CIMATEC, focusing on Industry, being one of the six CPA-IA in Brazil approved by MCTI / FAPESP / CGI.br. He also participates as one of the representatives of Brazil in the BRICS Innovation Collaboration Working Group on HPC, ICT and AI. He is the coordinator of the Work Group of the Axis 5 - Workforce and Training - of the Brazilian Strategy for Artificial Intelligence (EBIA), and member of the MCTI/EMBRAPII AI Innovation Network Training Committee. He is the coordinator, by SENAI CIMATEC, of the Artificial Intelligence Reference Network of the State of Bahia (REDE BAH.IA). He leads the working group of experts representing Brazil in the Global Partnership on Artificial Intelligence (GPAI), on the theme \"AI and the Pandemic Response\".",institutionString:null,institution:null},{id:"241400",title:"Prof.",name:"Mohammed",middleName:null,surname:"Bsiss",slug:"mohammed-bsiss",fullName:"Mohammed Bsiss",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/241400/images/8062_n.jpg",biography:null,institutionString:null,institution:null},{id:"276128",title:"Dr.",name:"Hira",middleName:null,surname:"Fatima",slug:"hira-fatima",fullName:"Hira Fatima",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/276128/images/14420_n.jpg",biography:"Dr. Hira Fatima\nAssistant Professor\nDepartment of Mathematics\nInstitute of Applied Science\nMangalayatan University, Aligarh\nMobile: no : 8532041179\nhirafatima2014@gmal.com\n\nDr. Hira Fatima has received his Ph.D. degree in pure Mathematics from Aligarh Muslim University, Aligarh India. Currently working as an Assistant Professor in the Department of Mathematics, Institute of Applied Science, Mangalayatan University, Aligarh. She taught so many courses of Mathematics of UG and PG level. Her research Area of Expertise is Functional Analysis & Sequence Spaces. She has been working on Ideal Convergence of double sequence. She has published 17 research papers in National and International Journals including Cogent Mathematics, Filomat, Journal of Intelligent and Fuzzy Systems, Advances in Difference Equations, Journal of Mathematical Analysis, Journal of Mathematical & Computer Science etc. She has also reviewed few research papers for the and international journals. She is a member of Indian Mathematical Society.",institutionString:null,institution:null},{id:"417317",title:"Mrs.",name:"Chiedza",middleName:null,surname:"Elvina Mashiri",slug:"chiedza-elvina-mashiri",fullName:"Chiedza Elvina Mashiri",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Midlands State University",country:{name:"Zimbabwe"}}},{id:"352140",title:"Dr.",name:"Edina",middleName:null,surname:"Chandiwana",slug:"edina-chandiwana",fullName:"Edina Chandiwana",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Midlands State University",country:{name:"Zimbabwe"}}},{id:"342259",title:"B.Sc.",name:"Leonard",middleName:null,surname:"Mushunje",slug:"leonard-mushunje",fullName:"Leonard Mushunje",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Midlands State University",country:{name:"Zimbabwe"}}},{id:"347042",title:"Mr.",name:"Maxwell",middleName:null,surname:"Mashasha",slug:"maxwell-mashasha",fullName:"Maxwell Mashasha",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Midlands State University",country:{name:"Zimbabwe"}}},{id:"2941",title:"Dr.",name:"Alberto J.",middleName:"Jorge",surname:"Rosales-Silva",slug:"alberto-j.-rosales-silva",fullName:"Alberto J. Rosales-Silva",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Instituto Politécnico Nacional",country:{name:"Mexico"}}},{id:"437913",title:"Dr.",name:"Guillermo",middleName:null,surname:"Urriolagoitia-Sosa",slug:"guillermo-urriolagoitia-sosa",fullName:"Guillermo Urriolagoitia-Sosa",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Instituto Politécnico Nacional",country:{name:"Mexico"}}},{id:"435126",title:"Prof.",name:"Joaquim",middleName:null,surname:"José de Castro Ferreira",slug:"joaquim-jose-de-castro-ferreira",fullName:"Joaquim José de Castro Ferreira",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Aveiro",country:{name:"Portugal"}}},{id:"437899",title:"MSc.",name:"Miguel Angel",middleName:null,surname:"Ángel Castillo-Martínez",slug:"miguel-angel-angel-castillo-martinez",fullName:"Miguel Angel Ángel Castillo-Martínez",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Instituto Politécnico Nacional",country:{name:"Mexico"}}},{id:"289955",title:"Dr.",name:"Raja",middleName:null,surname:"Kishor Duggirala",slug:"raja-kishor-duggirala",fullName:"Raja Kishor Duggirala",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Jawaharlal Nehru Technological University, Hyderabad",country:{name:"India"}}}]}},subseries:{item:{id:"27",type:"subseries",title:"Multi-Agent Systems",keywords:"Collaborative Intelligence, Learning, Distributed Control System, Swarm Robotics, Decision Science, Software Engineering",scope:"Multi-agent systems are recognised as a state of the art field in Artificial Intelligence studies, which is popular due to the usefulness in facilitation capabilities to handle real-world problem-solving in a distributed fashion. The area covers many techniques that offer solutions to emerging problems in robotics and enterprise-level software systems. Collaborative intelligence is highly and effectively achieved with multi-agent systems. Areas of application include swarms of robots, flocks of UAVs, collaborative software management. Given the level of technological enhancements, the popularity of machine learning in use has opened a new chapter in multi-agent studies alongside the practical challenges and long-lasting collaboration issues in the field. It has increased the urgency and the need for further studies in this field. We welcome chapters presenting research on the many applications of multi-agent studies including, but not limited to, the following key areas: machine learning for multi-agent systems; modeling swarms robots and flocks of UAVs with multi-agent systems; decision science and multi-agent systems; software engineering for and with multi-agent systems; tools and technologies of multi-agent systems.",coverUrl:"https://cdn.intechopen.com/series_topics/covers/27.jpg",hasOnlineFirst:!0,hasPublishedBooks:!1,annualVolume:11423,editor:{id:"148497",title:"Dr.",name:"Mehmet",middleName:"Emin",surname:"Aydin",slug:"mehmet-aydin",fullName:"Mehmet Aydin",profilePictureURL:"https://mts.intechopen.com/storage/users/148497/images/system/148497.jpg",biography:"Dr. Mehmet Emin Aydin is a Senior Lecturer with the Department of Computer Science and Creative Technology, the University of the West of England, Bristol, UK. His research interests include swarm intelligence, parallel and distributed metaheuristics, machine learning, intelligent agents and multi-agent systems, resource planning, scheduling and optimization, combinatorial optimization. Dr. Aydin is currently a Fellow of Higher Education Academy, UK, a member of EPSRC College, a senior member of IEEE and a senior member of ACM. In addition to being a member of advisory committees of many international conferences, he is an Editorial Board Member of various peer-reviewed international journals. He has served as guest editor for a number of special issues of peer-reviewed international journals.",institutionString:null,institution:{name:"University of the West of England",institutionURL:null,country:{name:"United Kingdom"}}},editorTwo:null,editorThree:null,series:{id:"14",title:"Artificial Intelligence",doi:"10.5772/intechopen.79920",issn:"2633-1403"},editorialBoard:[{id:"275140",title:"Dr.",name:"Dinh Hoa",middleName:null,surname:"Nguyen",slug:"dinh-hoa-nguyen",fullName:"Dinh Hoa Nguyen",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRbnKQAS/Profile_Picture_1622204093453",institutionString:null,institution:{name:"Kyushu University",institutionURL:null,country:{name:"Japan"}}},{id:"20259",title:"Dr.",name:"Hongbin",middleName:null,surname:"Ma",slug:"hongbin-ma",fullName:"Hongbin Ma",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRhDJQA0/Profile_Picture_2022-05-02T08:25:21.jpg",institutionString:null,institution:{name:"Beijing Institute of Technology",institutionURL:null,country:{name:"China"}}},{id:"28640",title:"Prof.",name:"Yasushi",middleName:null,surname:"Kambayashi",slug:"yasushi-kambayashi",fullName:"Yasushi Kambayashi",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYOQxQAO/Profile_Picture_1625660525470",institutionString:null,institution:{name:"Nippon Institute of Technology",institutionURL:null,country:{name:"Japan"}}}]},onlineFirstChapters:{paginationCount:8,paginationItems:[{id:"83117",title:"Endothelial Secretome",doi:"10.5772/intechopen.106550",signatures:"Luiza Rusu",slug:"endothelial-secretome",totalDownloads:0,totalCrossrefCites:0,totalDimensionsCites:0,authors:[{name:"Luiza",surname:"Rusu"}],book:{title:"Periodontology - New Insights",coverURL:"https://cdn.intechopen.com/books/images_new/11566.jpg",subseries:{id:"1",title:"Oral Health"}}},{id:"83087",title:"Role of Cellular Responses in Periodontal Tissue Destruction",doi:"10.5772/intechopen.106645",signatures:"Nam Cong-Nhat Huynh",slug:"role-of-cellular-responses-in-periodontal-tissue-destruction",totalDownloads:8,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Periodontology - New Insights",coverURL:"https://cdn.intechopen.com/books/images_new/11566.jpg",subseries:{id:"1",title:"Oral Health"}}},{id:"82654",title:"Atraumatic Restorative Treatment: More than a Minimally Invasive Approach?",doi:"10.5772/intechopen.105623",signatures:"Manal A. 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