Self-report and Cognitive Processing Measures of Depressive Thinking Predict Subsequent Major Depressive Disorder

Neurobiology and systems biology of stress resilience

Stress resilience is the phenomenon that some people maintain their mental health despite exposure to adversity or show only temporary impairments followed by quick recovery. Resilience research attempts to unravel the factors and mechanisms that make resilience possible and to harness its insights for the development of preventative interventions in individuals at risk for acquiring stress-related dysfunctions. Biological resilience research has been lagging behind the psychological and social sciences but has seen a massive surge in recent years. At the same time, progress in this field has been hampered by methodological challenges related to finding suitable operationalizations and study designs, replicating findings, and modeling resilience in animals. We embed a review of behavioral, neuroimaging, neurobiological, and systems biological findings in adults in a critical methods discussion. We find preliminary evidence that hippocampus-based pattern separation and prefrontal-based cognitive control functions protect against the development of pathological fears in the aftermath of singular, event-type stressors [as found in fear-related disorders, including simpler forms of posttraumatic stress disorder (PTSD)] by facilitating the perception of safety. Reward system-based pursuit and savoring of positive reinforcers appear to protect against the development of more generalized dysfunctions of the anxious-depressive spectrum resulting from more severe or longer-lasting stressors (as in depression, generalized or comorbid anxiety, or severe PTSD). Links between preserved functioning of these neural systems under stress and neuroplasticity, immunoregulation, gut microbiome composition, and integrity of the gut barrier and the blood-brain barrier are beginning to emerge. On this basis, avenues for biological interventions are pointed out.

Development and psychometric evaluation of a scrambled sentences test specifically for worry in individuals with generalised anxiety disorder

The tendency to draw negative conclusions from ambiguous information (interpretation bias) is prevalent across emotional disorders and plays a key role in the development and maintenance of pathological worry and anxious mood. Assessing interpretation bias using valid and reliable measures is central to empirical research. A commonly used measure of interpretation bias is the scrambled sentences test (SST), originally relating to depression. Given the association between interpretation bias and worry, we aimed to develop and psychometrically evaluate a new version of the SST with items pertaining to common worry domains for use in worry and anxiety research. In Studies 1-3 (analogue samples, combined N = 288), the new worry SST showed excellent construct validity (moderate-to-strong associations with worry and anxiety-related measures), and reliability (split-half and test-retest reliability). We confirmed construct validity in Study 4 (N = 215 individuals with generalised anxiety disorder). Furthermore, we demonstrated version specificity in analogue and clinical samples: the worry SST was associated with trait worry but not trait rumination, while the original depression SST largely showed the opposite pattern. Overall, the new worry SST is a psychometrically robust measure that may be especially useful for research into cognitive processes underpinning worry and anxiety.

Decoding of Processing Preferences from Language Paradigms by Means of EEG-ERP Methodology: Risk Markers of Cognitive Vulnerability for Depression and Protective Indicators of Well-Being? Cerebral Correlates and Mechanisms

Depression is a frequent mental affective disorder. Cognitive vulnerability models propose two major cognitive risk factors that favor the onset and severity of depressive symptoms. These include a pronounced self-focus, as well as a negative emotional processing bias. According to two-process models of cognitive vulnerability, these two risk factors are not independent from each other, but affect information processing already at an early perceptual processing level. Simultaneously, a processing advantage for self-related positive information including better memory for positive than negative information has been associated with mental health and well-being. This perspective paper introduces a research framework that discusses how EEG-ERP methodology can serve as a standardized tool for the decoding of negative and positive processing biases and their potential use as risk markers of cognitive vulnerability for depression, on the one hand, and as protective indicators of well-being, on the other hand. Previous results from EEG-ERP studies investigating the time-course of self-referential emotional processing are introduced, summarized, and discussed with respect to the specificity of depression-related processing and the importance of EEG-ERP-based experimental testing for well-being and the prevention and treatment of depressive disorders.

'Relearning how to think': A brief online intervention to modify biased interpretations in emotional disorders-study protocol for a randomised controlled trial

Background

Cognitive biases play an important role in the development and maintenance of emotional disorders, such as depression and anxiety. Novel procedures, known as Cognitive Bias Modification (CBM), aim to reduce these dysfunctional information processing modes. This study develops a brief clinically based online intervention programme to modify biased interpretations in depression and anxiety (CBM-I_Clin), overcoming some methodological issues that have been addressed in previous literature.

Methods

Volunteer participants will be recruited via social media and posters at the university. They will be randomly assigned to an experimental group or a waiting list control group. Both groups will complete two assessment sessions (before and after the intervention) consisting of questionnaires measuring cognitive and emotional variables as well as experimental tasks measuring cognitive biases (i.e. attention, memory, and interpretation). After the first assessment session, only participants in the experimental group will receive a link to follow the four CBM-I_Clin sessions at home. All participants will receive, via email, follow-up questionnaires 2 weeks and 3 months after the second assessment.

Discussion

This study will test the 'Relearning how to think', an online programme potentially beneficial to modify cognitive biases in emotional disorders. Several limitations of previous CBM procedures are addressed, and the impact of the programme both on objective cognitive bias tasks and clinical symptoms will be explored.

Trial registration

ClinicalTrials.gov NCT03987477. Prospectively registered on June 17, 2019

Interpreting ambiguous emotional information: Convergence among interpretation bias measures and unique relations with depression severity

This study aimed to examine the convergence among interpretation bias measures and their associations with depressive symptom severity. Research into interpretation biases employs measures of interpretation bias interchangeably, however, little is known about the relationship between these measures. Participants (N = 82 unselected undergraduate students; 59 female) completed four computer-based interpretation bias tasks in a cross-sectional design study. Indirect measures, based on participants' reaction times, were not correlated with each other and had poor split-half reliability. Direct measures were more strongly correlated with depressive symptoms than indirect measures, but only the Scrambled Sentences Task explained a reliable unique portion of the variance in depressive symptoms. Interpretation bias tasks may not measure the same cognitive process and may differ in the extent to which they are a cognitive marker of depression-linked interpretation bias. These findings help to improve the measurement of and theory underlying interpretation bias and depressive symptoms.

The prevalence and clinical impairment of subthreshold PTSD using DSM-5 criteria in a national sample of Korean firefighters

BACKGROUND

Firefighters are at high risk for subthreshold and full-threshold posttraumatic stress disorder (PTSD) due to their frequent exposure to various traumatic events. Although individuals with subthreshold PTSD have increased impairment, often needing treatment, the rates of subthreshold PTSD in firefighters remain unknown. Moreover, there is currently no consensus regarding the definition of subthreshold PTSD. The purpose of this study was to investigate the rates and clinical impairment of subthreshold PTSD according to various definitions in a national sample of firefighters.

METHODS

A total of 45,698 Korean firefighters completed self-reported questionnaires to assess the severity of PTSD symptoms, suicidal behavior, depression, alcohol use problems, and PTS-related functional impairment. Six different definitions used in the literature were used to calculate the prevalence rate of subthreshold PTSD. Multivariable linear regression and analysis of variance were performed to identify the relationship of subthreshold PTSD with suicidal behavior, depression, alcohol use problems, and PTS-related functional impairment.

RESULTS

The rate of full-threshold PTSD was 2.63%, and the rate of subthreshold PTSD ranged from 1.79% to 17.98%. The individuals with subthreshold PTSD most commonly failed the D criteria, which included negative alterations in cognition and mood. Regardless of the definition used, subthreshold PTSD was found to be associated with increased suicidal behavior, depression, alcohol use problems, and functional impairment.

CONCLUSIONS

Subthreshold PTSD appears to be equal to or more frequent than full-threshold PTSD in Korean firefighters and associated with various negative clinical outcomes. Further effort to detect and treat subthreshold PTSD in firefighters may be essential.

Positivity-approach training for depressive symptoms: A randomized controlled trial

OBJECTIVE

Depression is highly comorbid and depressive symptoms are very common. Symptom severity adversely affects treatment outcome and later health status. Established interventions for depression leave ample room for improvement. Short interventions that target specific vulnerabilities emerge as plausible augmentation strategies. In this study, we tested the efficacy of a computerized general positivity-approach training and its effect on depressive symptoms.

METHODS

Patients (N = 240) with various diagnoses of mental disorders who received treatment-as-usual in an inpatient setting were randomly assigned to also receive either 4 sessions of a positivity-approach training or 4 sessions of sham training. Depression severity was assessed at baseline and post-treatment. Training data were analyzed for a subset of 111 patients.

RESULTS

Depressive symptoms were reduced more after positivity-approach training than after sham training. Initial depression symptom severity moderated the intervention effects, such that approach tendencies and depression symptoms were only affected positively among patients with higher levels of initial depression symptom severity.

CONCLUSIONS

The findings provide preliminary support for positivity-approach training as an add-on treatment option for depressive symptoms.

Changes in depressed patients' self-statements

Objective: Individuals' use of self-statements reflecting self-criticism, a sense of inadequacy, and low self-worth has been linked to the incidence, severity, and recurrence of major depressive disorder [de Graaf, L. E., Huibers, M. J. H., Cuijpers, P., & Arntz, A. (2010). Minor and major depression in the general population: Does dysfunctional thinking play a role? Comprehensive Psychiatry, 51(3), 266-274. doi:10.1016/j.comppsych.2009.08.006; Riso, L. P., du Toit, P. L., Blandino, J. A., Penna, S., Dacey, S., Duin, J. S., … Ulmer, C. S. (2003). Cognitive aspects of chronic depression. Journal of Abnormal Psychology, 112(1), 72-80. doi:10.1037/0021-843X.112.1.72]. The present study used an observer-rated measure, the Structural Analysis of Social Behavior [Benjamin, L. S. (1974). Structural Analysis of Social Behavior. Psychological Review, 81(5), 392-425. doi:10.1037/h0037024], to examine patients' self-directed communication over the course of psychotherapy.Method: Self-talk in early and late therapy sessions was examined using cases (N = 44) from the cognitive therapy arm of Jacobson and colleagues' component study of cognitive therapy for depression [Jacobson, N. S., Dobson, K. S., Truax, P. A., Addis, M. E., Koerner, K., Gollan, J. K., … Prince, S. E. (1996). A component analysis of cognitive-behavioral treatment for depression. Journal of Consulting and Clinical Psychology, 64(2), 295-304. doi:10.1037/0022-006x.64.2.295, Jacobson, N. S., Dobson, K. S., Truax, P. A., Addis, M. E., Koerner, K., Gollan, J. K., … Prince, S. E. (2000). A component analysis of cognitive-behavioral treatment for depression. Prevention & Treatment, 3(1). doi:10.1037/1522-3736.3.1.323a]. We identified changes at treatment termination, and used hierarchical multiple regression to examine whether improvements in patient self-talk influenced treatment outcome up to 24 months post-termination.Results: Trends indicate that patients used friendlier and less critical self-statements at the end of treatment. Decreased self-critical behaviour was associated with fewer symptoms at the end of treatment and up to one year later; increased self-acceptance was linked to symptom improvement a year and a half after termination.Conclusion: Consistent with cognitive theory, reduced self-criticism was associated with better treatment outcomes. Longer-term improvement was linked to the development of friendlier and more accepting self-referential behaviour.

A Computerized Version of the Scrambled Sentences Test

The scrambled sentences test (SST), an experimental procedure that involves participants writing down their cognitions, has been used to elicit individual differences in depressiveness and vulnerability to depression. We describe here a modification of the SST to adapt it to computerized administration, with a particular view of its use in large samples and functional neuroimaging applications. In a first study with the computerized version, we reproduce the preponderance of positive cognitions in the healthy and the inverse association of these cognitions with individual measures of depressiveness. We also report a tendency of self-referential cognitions to elicit higher positive cognition rates. In a second study, we describe the patterns of neural activations elicited by emotional and neutral sentences in a functional neuroimaging study, showing that it replicates and extends previous findings obtained with the original version of the SST. During the formation of emotional cognitions, ventral areas such as the ventral anterior cingulus and the supramarginal gyrus were relatively activated. This activation pattern speaks for the recruitment of mechanisms coordinating motivational and associative processes in the formation of value-based decisions.

Adaptation of the Scrambled-Sentences Task to Assess "Shattered Assumptions:" Construction of the Test and Investigation of Neural Substrates in an fMRI Study

BACKGROUND

Increasing recognition is being given to the importance of cognitions observed in posttraumatic conditions. These cognitions may reflect the activation of negative schemas. The aim of this work was to evaluate the feasibility of the scrambled-sentences task (SST) to assess individual differences in attributions commonly observed after traumas. Originally developed to assess the tendency to activate negative cognitions in individuals predisposed to depression, the SST is a laboratory task the outcome of which has been shown to predict depression relapse and is associated with depressiveness.

SAMPLING AND METHODS

We used content from self-rating scales for assessment of the activation of trauma-related schemas to develop a trauma-related SST and evaluated its performance in a behavioral study (n = 43) and a functional neuroimaging study (n = 20).

RESULTS

In the healthy sample in which we tested it, the trauma-related SST was strongly associated with individual differences in negative affect (scores in depressiveness and neuroticism scales) as well as with the scores on trauma-related cognition scales. However, we failed to detect a clear specificity of trauma-related cognitions in correlations with scores on the trauma-related scales in the healthy participants. The neuroimaging data demonstrated activation of a ventral network of areas that included the perisylvian/temporal cortex and the peri-cingular cortex in handling trauma-related relative to neutral material, replicating previous neuroimaging studies of the SST.

CONCLUSION

The shattered-assumptions SST demonstrated strong associations with individual differences in all of the rating scales used in the study, suggesting its usefulness in capturing aspects of affective psychopathology. The neuroimaging study confirmed the capacity of this task to elicit specific activations. In future studies, evaluation of the conditions in which these neural substrates are active may shed light on the mechanism of schema selection.

Change in Biased Thinking in a Treatment Based on the Motive-Oriented Therapeutic Relationship for Borderline Personality Disorder

Biased thinking is a common feature of patients presenting with borderline personality disorder (BPD). For the treatment of BPD, it was shown that the individualizing of the treatment, by using the motive-oriented therapeutic relationship (MOTR), had a beneficial short-term effect on process and outcome. So far, it remains unclear what the role of early change in biased thinking is in these treatments. The present study aims to assess whether there is a link between the MOTR, change in biased thinking, and outcome. The sample (N = 60) is based on a randomized controlled trial with two conditions: (a) 30 patients in a 10-session version of psychiatric management, and (b) 30 patients in a 10-session version of psychiatric management augmented with the MOTR. For each patient, three sessions (intake, middle, late) were selected, transcribed, and rated using the Cognitive Errors Rating Scale (CERS). An overall decrease of negative cognitive errors during 10 sessions of treatment was observed, independently of the treatment condition. No specific effect related to change in biased thinking may be attributed to the individualizing of the treatment. These results are discussed with regard to mechanisms of change in treatments for BPD, in particular with regard to the central role that biased thinking, as well as the MOTR, might play early in treatment.

Changing views of emotion regulation and neurobiological models of the mechanism of action of psychotherapy

Influential neurobiological models of the mechanism of action of psychotherapy attribute its success to increases of activity in prefrontal areas and decreases in limbic areas, interpreted as the successful and adaptive recruitment of controlled processes to achieve emotion regulation. In this article, we review the behavioral and neuroscientific evidence in support of this model and its applicability to explain the mechanism of action of psychotherapy. Neuroimaging studies of explicit emotion regulation, evidence on the neurobiological substrates of implicit emotion regulation, and meta-analyses of neuroimaging studies of the effect of psychotherapy consistently suggest that areas implicated in coding semantic representations play an important role in emotion regulation not covered by existing models based on controlled processes. We discuss the findings that implicate these same areas in supporting working memory, in encoding preferences and the prospective outcome of actions taken in rewarding or aversive contingencies, and show how these functions may be integrated into process models of emotion regulation that depend on elaborate semantic representations for their effectiveness. These alternative models also appear to be more consistent with internal accounts in the psychotherapeutic literature of how psychotherapy works.

Mental Imagery-Based Training to Modify Mood and Cognitive Bias in Adolescents: Effects of Valence and Perspective

Mental imagery has a powerful impact on emotion and cognitive processing in adults, and is implicated in emotional disorders. Research suggests the perspective adopted in mental imagery modulates its emotional impact. However, little is known about the impact of mental imagery in adolescence, despite adolescence being the key time for the onset of emotional dysfunction. We administered computerised positive versus mixed valence picture-word mental imagery training to male adolescent participants (N = 60, aged 11–16 years) across separate field and observer perspective sessions. Positive mood increased more following positive than mixed imagery; pleasantness ratings of ambiguous pictures increased following positive versus mixed imagery generated from field but not observer perspective; negative interpretation bias on a novel scrambled sentences task was smaller following positive than mixed imagery particularly when imagery was generated from field perspective. These findings suggest positive mental imagery generation alters mood and cognition in male adolescents, with the latter moderated by imagery perspective. Identifying key components of such training, such as imagery perspective, extends understanding of the relationship between mental imagery, mood, and cognition in adolescence.

Childhood abuse and vulnerability to depression: cognitive scars in otherwise healthy young adults

Models of depression vulnerability posit that negative early experiences, such as exposure to childhood abuse (CA), increase vulnerability to depression later in life. Though most victims of CA do not go on to develop depression, the question remains as to whether these individuals retain cognitive 'scars' that may contribute to depression vulnerability. The present study examined the relationship between self-reported, retrospective CA and cognitive vulnerability to depression in a carefully selected sample of young adults without current or past psychopathology. We measured cognitive vulnerability with both a self-report questionnaire, the Dysfunctional Attitudes Scale (DAS), and a measure of information processing bias, the Scrambled Sentences Test (SST). Self-reported severity of CA was associated with increased cognitive vulnerability to depression on both the DAS and SST. Vulnerability to depression as measured by the SST, but not by the DAS, prospectively predicted increases in depressive symptoms over a 6-month period. Scores on the SST also interacted with CA to predict increases in depressive symptoms. These findings demonstrate the pernicious effects of CA even in those without current or past psychopathology.

The Evolving Construct of Posttraumatic Stress Disorder (PTSD): DSM-5 Criteria Changes and Legal Implications

In the DSM-5, the diagnosis of posttraumatic stress disorder (PTSD) has undergone multiple, albeit minor, changes. These changes include shifting PTSD placement from within the anxiety disorders into a new category of traumatic and stressor-related disorders, alterations in the definition of a traumatic event, shifting of the symptom cluster structure from three to four clusters, the addition of new symptoms including persistent negative beliefs and expectations about oneself or the world, persistent distorted blame of self or others, persistent negative trauma-related emotions, and risky or reckless behaviors, and the addition of a dissociative specifier. The evidence or lack thereof behind each of these changes is briefly reviewed. These changes, although not likely to change overall prevalence, have the potential to increase the heterogeneity of individuals receiving a PTSD diagnosis both by altering what qualifies as a traumatic event and by adding symptoms commonly occurring in other disorders such as depression, borderline personality disorder, and dissociative disorders. Legal implications of these changes include continued confusion regarding what constitutes a traumatic stressor, difficulties with differential diagnosis, increased ease in malingering, and improper linking of symptoms to causes of behavior. These PTSD changes are discussed within the broader context of DSM reliability and validity concerns.

The effects of juvenile stress on anxiety, cognitive bias and decision making in adulthood: a rat model

Stress experienced in childhood is associated with an increased risk of developing psychiatric disorders in adulthood. These disorders are particularly characterized by disturbances to emotional and cognitive processes, which are not currently fully modeled in animals. Assays of cognitive bias have recently been used with animals to give an indication of their emotional/cognitive state. We used a cognitive bias test, alongside a traditional measure of anxiety (elevated plus maze), to investigate the effects of juvenile stress (JS) on adulthood behaviour using a rodent model. During the cognitive bias test, animals were trained to discriminate between two reward bowls based on a stimulus (rough/smooth sandpaper) encountered before they reached the bowls. One stimulus (e.g. rough) was associated with a lower value reward than the other (e.g. smooth). Once rats were trained, their cognitive bias was explored through the presentation of an ambiguous stimulus (intermediate grade sandpaper): a rat was classed as optimistic if it chose the bowl ordinarily associated with the high value reward. JS animals were lighter than controls, exhibited increased anxiety-like behaviour in the elevated plus maze and were more optimistic in the cognitive bias test. This increased optimism may represent an optimal foraging strategy for these underweight animals. JS animals were also faster than controls to make a decision when presented with an ambiguous stimulus, suggesting altered decision making. These results demonstrate that stress in the juvenile phase can increase anxiety-like behaviour and alter cognitive bias and decision making in adulthood in a rat model.

Neural mechanisms of the cognitive model of depression

In the 40 years since Aaron Beck first proposed his cognitive model of depression, the elements of this model--biased attention, biased processing, biased thoughts and rumination, biased memory, and dysfunctional attitudes and schemas--have been consistently linked with the onset and maintenance of depression. Although numerous studies have examined the neural mechanisms that underlie the cognitive aspects of depression, their findings have not been integrated with Beck's cognitive model. In this Review, we identify the functional and structural neurobiological architecture of Beck's cognitive model of depression. Although the mechanisms underlying each element of the model differ, in general the negative cognitive biases in depression are facilitated by increased influence from subcortical emotion processing regions combined with attenuated top-down cognitive control.