Preliminary Evidence for a Nexus between Rumination, Behavioural Avoidance, Motive Satisfaction and Depression

Association between the Behavioral Activation Mechanism and Depression Severity: Focusing on Avoidance Patterns of University Students

Subthreshold depression is a risk factor for depression among university students. Positive environmental reinforcement is a significant mediator of avoidance and depression in healthy university students. However, this relationship is understudied in those with subthreshold depression or depression. Therefore, this study examined these associations in healthy university students and those who fit the criteria for subthreshold depression or depression. We conducted an online survey with 1200 undergraduate students (600 women and 600 men, mean age = 20.61, SD = 1.59). The results revealed significant differences in avoidance patterns (behavioral social, behavioral nonsocial, cognitive social, and cognitive nonsocial), with participants with depression presenting the highest scores. The results of the mediation analysis were similar to those of previous studies in healthy groups. However, in the subthreshold-depression group, positive environmental reinforcement was mediated by behavioral social and behavioral non-social avoidance and depressive symptoms. In the group with depression, positive environmental reinforcement was mediated only by behavioral nonsocial avoidance and depressive symptoms. Associations between avoidance patterns, positive environmental reinforcement, and depressive symptoms vary with the degree of depressive symptoms. The results revealed by this study provide new foundational insights to prevent subthreshold depression among university students from deteriorating into depression.

Motive Satisfaction Among Patients with Chronic Primary Pain: A Replication

We set out to replicate findings of significant (a) reductions in pain, psychological distress, and motivational incongruence (i.e., insufficient motive satisfaction) after interdisciplinary multimodal pain treatment and (b) associations between reductions in motivational incongruence (i.e., improved motive satisfaction) and decreases in psychological distress (Vincent et al., Journal of Clinical Psychology in Medical Settings 28:331-343, 2021). 475 Patients with chronic primary pain completed standardized self-reported questionnaires assessing motivational incongruence, psychological distress, pain intensity, and pain interference at intake and discharge from a tertiary psychosomatic university clinic. We used hierarchical linear models to analyze motivational incongruence's effects on psychological distress. We partially replicated Vincent et al.'s findings. Significant reductions in pain, psychological distress, and motivational incongruence after treatment were found. Reductions in motivational incongruence were associated with reductions in psychological distress. Similarly, a better motive satisfaction mediated the relationship between pain interference and psychological distress. Our findings show that reducing motivational incongruence may be a key component of treating chronic primary pain; we recommend to assess and target motivational incongruence to improve interdisciplinary multimodal pain treatment.

Avoidant coping as mediator of the relationship between rumination and mental health among family caregivers of Chinese breast cancer patients

INTRODUCTION

Family caregivers of cancer patients were often referred to the 'forgotten patients', yet little researches have been conducted on their mental health. Rumination might put family caregivers at risk for psychological distress during the caregiving, such as stress and anxiety. The aim of the present study was to explore the relationship between rumination, stress and anxiety among family caregivers of breast cancer patients in China and examine the mediating role of avoidant coping in this relationship.

METHODS

Face-to-face questionnaire interviews were conducted with a sample of 99 caregivers from the public oncology hospital. They were assessed with stress, anxiety, rumination and avoidant coping by Chinese Perceived Stress Scale, Zung's Self-Rating Anxiety Scale, Ruminative Responses Scale and Coping Strategy Indicator. Structural equation modelling was applied to assess the mediation analysis.

RESULTS

The reporting scores of participants indicated the incidence of anxiety was 17.2%. Rumination could directly predict stress (β = 0.58, p < 0.01) and anxiety (β = 0.46, p < 0.01) and also predict stress and anxiety via the mediator of avoidant coping (stress: β = 0.087, p < 0.01; anxiety: β = 0.109, p < 0.01).

CONCLUSIONS

The important role played by family caregivers in supporting breast cancer patients is well recognised. The findings suggested that rumination and avoidant coping may be two critical risk factors for family caregivers of breast cancer developing stress and anxiety. This study highlights the importance of preventing avoidant coping, which plays a critical role for developing interventions for this vulnerable group.

Motive Satisfaction in Chronic Pain Patients: Does It Improve in Multidisciplinary Inpatient Treatment and, if so, Does It Matter?

According to consistency theory, insufficient motive satisfaction (motivational incongruence) is associated with psychological distress and mental disorders. High levels of distress and comorbid psychological disorders are common in patients with chronic pain. The aim of the present study was to investigate the role of motivational incongruence in chronic pain patients and the association of incongruence change with symptom improvement. Inpatients with chronic pain in multimodal interdisciplinary treatment (n = 177) completed questionnaires measuring motivational incongruence, psychological distress, pain intensity and pain interference at the beginning and end of a multimodal interdisciplinary inpatient treatment program at a tertiary psychosomatic university clinic. Results demonstrated that pain and motivational incongruence were significantly reduced at post-treatment, and reductions in incongruence were associated with reductions in psychological distress. In particular, better satisfaction of approach motives mediated the association between reduction of pain interference and psychological distress at post-treatment. Findings suggest that a reduction of motivational incongruence may be part of successful treatment of chronic pain.

Sequential multiple mediation of cognitive fusion and experiential avoidance in the relationship between rumination and social anxiety among Chinese adolescents

BACKGROUND AND OBJECTIVES

The potential mechanism by which rumination influences social anxiety through cognitive fusion and experiential avoidance proposed by the Acceptance and Commitment Therapy model has not been well-documented. This study, therefore, aimed to examine the sequential multiple mediation of the two processes.

DESIGN

A cross-sectional survey was conducted.

METHOD

A total of 233 Chinese adolescents (42.06% girls) completed a set of printed self-report questionnaires measuring rumination, cognitive fusion, experiential avoidance, and social anxiety. The SPSS macro PROCESS (model 6) was used to test a sequential mediating model. A 95% confidence interval (CI) was calculated with 5000 bootstrapping re-samples.

RESULTS

Bootstrap analyses indicated that there were indirect effects of rumination on social anxiety mediated by cognitive fusion together with experiential avoidance (B = 0.098, BootSE = 0.032, CI = 0.045 to 0.170), or solely by experiential avoidance (B = 0.048, BootSE = 0.020, CI = 0.014 to 0.093). The mediation of cognitive fusion alone was not significant (B = 0.065, BootSE = 0.038, CI = -0.006 to 0.144).

CONCLUSIONS

The results indicated the sequential mediating role of cognitive fusion and experiential avoidance, and the relative prominence of the latter in the association between rumination and social anxiety.

Examining the role of cognitive fusion and experiential avoidance in predicting anxiety and depression

OBJECTIVES

Acceptance and Commitment Therapy (ACT) proposes that cognitive fusion and experiential avoidance are inter-related processes underpinning distress. This study investigated whether worry, rumination, and stressful life events on the one hand and anxiety and depression on the other hand were mediated by cognitive fusion and experiential avoidance (bidirectional serial association).

DESIGN

A questionnaire design was conducted cross-sectionally in a clinical sample (study 1; N = 57) and cross-sectionally and longitudinally in a non-clinical student sample (study 2; N = 106 and N = 97 respectively).

METHODS

Participants completed measures of worry, rumination, stressful life events (predictors), cognitive fusion, experiential avoidance (mediators), anxiety, and depression (outcomes) at T1. In study 2, anxiety and depression were measured again 6 weeks later.

RESULTS

In the clinical sample, the bidirectional relationship between experiential avoidance and cognitive fusion accounted for a significant proportion of the association between rumination and depression, and stressful life events and anxiety and depression. The association between worry and anxiety was mediated by cognitive fusion → experiential avoidance only. In the non-clinical sample, in both cross-sectional and longitudinal analyses, cognitive fusion independently mediated the association between predictors and outcomes, as well as the experiential avoidance → cognitive fusion pathway.

CONCLUSIONS

The bidirectional association between cognitive fusion and experiential avoidance was most predictive of distress in the clinical sample. In the non-clinical sample, cognitive fusion and the experiential avoidance → cognitive fusion pathway demonstrated more explanatory value. Given the cross-sectional nature of most of the data, the findings provide theoretical (as opposed to empirical) support for the models tested.

PRACTITIONER POINTS

Interventions designed to reduce cognitive fusion may be a useful early intervention for sub-clinical anxiety and depression. Interventions focused on reducing both cognitive fusion and experiential avoidance may be helpful for individuals presenting with clinical anxiety and depression. Individuals presenting with particularly high levels of experiential avoidance may benefit from initial work defusing from difficult thoughts, as an inroad for reducing experiential avoidance, anxiety, and depression. Likewise, those with rigid cognitive fusion may benefit from initial work around acceptance skills to create a context that better supports defusion.

Emotional competence predicts outcome of an inpatient treatment program for burnout

BACKGROUND

Previous research has shown an association between burnout and low emotional competence (EC), defined as the ability to adequately regulate the intensity and expression of emotions. EC might also play a maintaining role in depression. The current paper aimed at studying the effect of improved EC on the course of burnout and depression.

METHODS

113 psychiatric inpatients completed a set of standardized self-report questionnaires at intake, discharge and three months after treatment, assessing EC, burnout, and depression. Multi-level analyses investigated the effect of improved EC on burnout and depression.

RESULTS

Improved EC including a better emotion regulation during treatment predicted favourable treatment outcomes regarding burnout and depression symptoms.

LIMITATIONS

The present results should be considered in light of some methodological limitations. Most importantly, the patient sample consists of patients of one inpatient ward and is therefore not representative of all burnout patients.

CONCLUSIONS

This study supports EC as a putative mechanism of change in the multimodal treatment of inpatients with a stress-related depressive disorder and burnout. Clinical and research consequences of the findings will be discussed.

Is repetitive negative thinking a transdiagnostic process? A comparison of key processes of RNT in depression, generalized anxiety disorder, obsessive-compulsive disorder, and community controls

BACKGROUND AND OBJECTIVES

The transdiagnostic view of repetitive negative thinking (RNT) claims that different forms of RNT are characterized by identical processes that are applied to disorder-specific content. The purpose of the study was to test whether the processes of RNT differ across major depression disorder (MDD), generalized anxiety disorder (GAD), and obsessive-compulsive disorder (OCD).

METHODS

Forty-two individuals diagnosed with MDD, 35 individuals with GAD, 41 individuals with OCD, and 35 community controls were asked to think of a typical RNT episode and to rate its processes (core processes; use of mental capacity, unproductivity, abstractness, verbal quality, duration). Ratings were compared across groups using planned contrasts and analysis of variance.

RESULTS

All individuals with a clinical diagnosis rated the key processes of RNT and avoidance function of RNT as higher than healthy controls. There were no differences between individuals diagnosed with MDD, GAD or OCD on key processes and avoidance function of RNT.

LIMITATIONS

Results are based on retrospective self-reports, which might restrict validity of the measurements.

CONCLUSIONS

Data support the transdiagnostic hypothesis of RNT. Transdiagnostic prevention and intervention techniques seem highly recommendable given these findings.

Facing others' misfortune: Personal distress mediates the association between maladaptive emotion regulation and social avoidance

Previous research has linked the use of certain emotion regulation strategies to the vicarious experience of personal distress (PD) and empathic concern (EC). However, it has not yet been tested whether (1) vicarious PD is positively associated with maladaptive emotion regulation strategies, (2) vicarious EC is positively associated with adaptive emotion regulation strategies or whether (3) PD and EC mediate the link between emotion regulation and reports of approach/avoidance in response to a person in distress. To that end, we assessed people’s reports of PD (i.e., anxious, troubled and upset) and EC (i.e., concerned, sympathetic and soft-hearted) in response to a video depicting a person in a threatening situation (n = 78). Afterwards, we assessed participants’ reports of avoidance and approach with regard to the character and their disposition to use maladaptive and adaptive emotion regulation strategies. Results showed that both PD and EC were positively related to maladaptive strategies and negatively related to adaptive strategies, and that the association between maladaptive regulation strategies (i.e., rumination) and the willingness to avoid the person in distress was mediated by reports of greater PD. This study thus expands previous evidence on the relationship between maladaptive regulation strategies and affective empathy and provides novel insights into the main role that PD plays in the association between maladaptive strategies and social avoidance.

The relationship of self-compassion and depression: Cross-lagged panel analyses in depressed patients after outpatient therapy

BACKGROUND

Previous cross-sectional studies suggest that self-compassion and depressive symptoms are consistently negatively associated. Although it is often implicitly assumed that (a lack of) self-compassion precedes depressive symptoms, so far no study has tested whether (lack of) self-compassion is a cause or a consequence of depressive symptoms, or both.

METHOD

To examine such reciprocal effects, we used data of 125 depressed outpatients after a time limited cognitive-behavioral psychotherapy. We assessed self-compassion and depressive symptoms via self-report measures and the presence of a major depressive episode directly after therapy, as well as 6 and 12 months later.

RESULTS

Cross-lagged panel analyses indicated that (lack of) self-compassion significantly predicted subsequent depressive symptoms while controlling for autoregressive effects, whereas depressive symptoms did not predict subsequent levels of self-compassion. This was also the case for the relationship between self-compassion and the presence of a major depressive episode. The same patterns also occurred when we separately tested the reciprocal effects for two composite sub-measures of either positive or negative facets of self-compassion.

LIMITATIONS

Causality cannot be inferred from our results. Depressive symptoms and self-compassion could still be causally unrelated, and a third variable could account for their negative association.

CONCLUSIONS

These findings support the notions that (a lack of) self-compassion could serve as a vulnerability factor for depression and that cultivating self-compassion may deserve a focus in depression prevention programs or treatments.

First-person Pronoun Use in Spoken Language as a Predictor of Future Depressive Symptoms: Preliminary Evidence from a Clinical Sample of Depressed Patients

Several theories suggest that self-focused attention plays an important role in the maintenance of depression. However, previous studies have predominantly relied on self-report and laboratory-based measures such as sentence completion tasks to assess individual differences in self-focus. We present a prospective, longitudinal study based on a sample of 29 inpatients with clinical depression, investigating whether an implicit, behavioural measure of self-focused attention, i.e., the relative frequency of first-person singular pronouns in naturally spoken language, predicts depressive symptoms at follow-up over and above initial depression. We did not find a significant cross-sectional association between depressive symptoms and first-person singular pronoun use. However, first-person singular pronoun use significantly predicted depressive symptoms approximately 8 months later, even after controlling for depressive symptoms at baseline or discharge. Exploratory analyses revealed that this effect was mainly driven by the use of objective and possessive self-references such as 'me' or 'my'. Our findings are in line with theories that highlight individual differences in self-focused attention as a predictor of the course of depression. Moreover, our findings extend previous work in this field by adopting an unobtrusive approach of non-reactive assessment, capturing naturally occurring differences in self-focused attention. We discuss possible clinical applications of language-based assessments and interventions with regard to self-focus. Copyright © 2016 John Wiley & Sons, Ltd.

KEY PRACTITIONER MESSAGE

Naturally occurring individual differences in first-person singular pronoun use provide an unobtrusive way to assess patients' automatic self-focused attention. Frequent use of first-person singular pronouns predicts an unfavourable course of depression. Self-focused language might offer innovative ways of tracking and targeting therapeutic change.

Me, myself, and I: self-referent word use as an indicator of self-focused attention in relation to depression and anxiety

Self-focused attention (SFA) is considered a cognitive bias that is closely related to depression. However, it is not yet well understood whether it represents a disorder-specific or a trans-diagnostic phenomenon and which role the valence of a given context is playing in this regard. Computerized quantitative text-analysis offers an integrative psycho-linguistic approach that may help to provide new insights into these complex relationships. The relative frequency of first-person singular pronouns in natural language is regarded as an objective, linguistic marker of SFA. Here we present two studies that examined the associations between SFA and symptoms of depression and anxiety in two different contexts (positive vs. negative valence), as well as the convergence between pronoun-use and self-reported aspects of SFA. In the first study, we found that the use of first-person singular pronouns during negative but not during positive memory recall was positively related to symptoms of depression and anxiety in patients with anorexia nervosa with varying levels of co-morbid depression and anxiety. In the second study, we found the same pattern of results in non-depressed individuals. In addition, use of first-person singular pronouns during negative memory recall was positively related to brooding (i.e., the assumed maladaptive sub-component of rumination) but not to reflection. These findings could not be replicated in two samples of depressed patients. However, non-chronically depressed patients used more first-person singular pronouns than healthy controls, irrespective of context. Taken together, the findings lend partial support to theoretical models that emphasize the effects of context on self-focus and consider SFA as a relevant trans-diagnostic phenomenon. In addition, the present findings point to the construct validity of pronoun-use as a linguistic marker of maladaptive self-focus.

Differentiating early-onset chronic depression from episodic depression in terms of cognitive-behavioral and emotional avoidance

BACKGROUND

Although chronic depression is associated with lower global functioning and poorer treatment response than episodic depression, little is known about the differences between these two forms of depression in terms of psychological factors. Thus, the present study aimed at differentiating chronic and episodic depression regarding cognitive-behavioral and emotional avoidance that have been proposed as important risk factors for depression and promising targets for the treatment of depression.

METHODS

Thirty patients with early onset chronic depression were compared with 30 patients with episodic depression and 30 healthy, never-depressed controls in terms of self-reported cognitive-behavioral (social and non-social) and emotional avoidance.

RESULTS

Chronically depressed patients reported more avoidance than healthy controls in each of the measures. Moreover, they reported more cognitive-nonsocial and behavioral-nonsocial as well as behavioral-social and emotional avoidance (in the form of restricted emotional expression to others) than patients with episodic depression. This kind of emotional avoidance also separated best between chronically and episodically depressed patients. Furthermore, general emotion avoidance and behavioral-social avoidance were positively correlated with levels of depression in chronically depressed patients.

LIMITATIONS

The results are based on self-report data and should thus be interpreted with caution. Additionally, the cross-sectional design limits any causal conclusions.

CONCLUSIONS

The findings underscore the relevance of cognitive-behavioral and emotional avoidance in differentiating chronic from episodic depression and healthy controls and advocate a stronger focus on maladaptive avoidance processes in the treatment of chronic depression.