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Hjerresen TS, Bentz M, Nejad AB, Raffin E, Andersen KW, Hulme OJ, Siebner HR, Plessen KJ. Performing well but not appreciating it - A trait feature of anorexia nervosa. JCPP ADVANCES 2024; 4:e12194. [PMID: 38486955 PMCID: PMC10933629 DOI: 10.1002/jcv2.12194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 07/28/2023] [Indexed: 03/17/2024] Open
Abstract
Background Despite advances in the etiology of anorexia nervosa (AN), a large subgroup of individuals does not profit optimally from treatment. Perfectionism has been found to be a risk factor predicting the onset, severity, and duration of AN episodes. To date, perfectionism has been studied predominantly by the use of self-report questionnaires, a useful approach that may, however, be impacted by demand characteristics, or other distortions of introspective or metacognitive access. Methods Here we circumvent these problems via a behavioral paradigm in which participants perform a modified Go/NoGo task, whilst self-evaluating their performance. We compared a group of 33 adolescent females during their first episode of AN (age = 16.0) with 29 female controls (age = 16.2), and 23 adolescent girls recovered from AN (age = 18.3) with 23 female controls (age = 18.5). The controls were closely matched by intelligence quotient and age to the two clinical groups. Results First-episode AN and control participants performed equally well on the task (reaction time and errors of commission), whereas the recovered group displayed significantly faster reaction times but incurred the same error rate. Despite performing at least as good as and predominantly better than control groups, both clinical groups evaluated their performances more negatively than controls. Conclusion We offer a novel behavioral method for measuring perfectionism independent of self-report, and we provide tentative evidence that this behavioral manifestation of perfectionism is evident during first-episode AN and persists even after recovery.
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Affiliation(s)
- Tine Schuppli Hjerresen
- Child and Adolescent Mental Health CenterCopenhagen University Hospital ‐ Mental Health Services CPHCopenhagenDenmark
- Danish Research Centre for Magnetic ResonanceCentre for Functional and Diagnostic Imaging and ResearchCopenhagen University Hospital ‐ Amager and HvidovreCopenhagenDenmark
- Department of Clinical MedicineFaculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
| | - Mette Bentz
- Child and Adolescent Mental Health CenterCopenhagen University Hospital ‐ Mental Health Services CPHCopenhagenDenmark
| | | | - Estelle Raffin
- Danish Research Centre for Magnetic ResonanceCentre for Functional and Diagnostic Imaging and ResearchCopenhagen University Hospital ‐ Amager and HvidovreCopenhagenDenmark
- Defitech Chair of Clinical NeuroengineeringNeuro‐X Institute and Brain Mind Institute (BMI)Swiss Federal Institute of Technology (EPFL)GenevaSwitzerland
| | - Kasper Winther Andersen
- Danish Research Centre for Magnetic ResonanceCentre for Functional and Diagnostic Imaging and ResearchCopenhagen University Hospital ‐ Amager and HvidovreCopenhagenDenmark
| | - Oliver James Hulme
- Danish Research Centre for Magnetic ResonanceCentre for Functional and Diagnostic Imaging and ResearchCopenhagen University Hospital ‐ Amager and HvidovreCopenhagenDenmark
- London Mathematical LaboratoryLondonUK
- Department of PsychologyUniversity of CopenhagenCopenhagenDenmark
| | - Hartwig Roman Siebner
- Danish Research Centre for Magnetic ResonanceCentre for Functional and Diagnostic Imaging and ResearchCopenhagen University Hospital ‐ Amager and HvidovreCopenhagenDenmark
- Department of Clinical MedicineFaculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
- Department of NeurologyCopenhagen University Hospital Bispebjerg and FrederiksbergCopenhagenDenmark
| | - Kerstin Jessica Plessen
- Child and Adolescent Mental Health CenterCopenhagen University Hospital ‐ Mental Health Services CPHCopenhagenDenmark
- Division of Child and Adolescent PsychiatryDepartment of PsychiatryUniversity Hospital LausanneLausanneSwitzerland
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van Riel L, van den Berg E, Polak M, Geerts M, Peen J, Ingenhoven T, Dekker J. Exploring effectiveness of CBT in obese patients with binge eating disorder: personality functioning is associated with clinically significant change. BMC Psychiatry 2023; 23:136. [PMID: 36879204 PMCID: PMC9990274 DOI: 10.1186/s12888-023-04626-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 02/22/2023] [Indexed: 03/08/2023] Open
Abstract
BACKGROUND Binge eating disorder (BED), as the most prevalent eating disorder, is strongly related to obesity and other somatic and psychiatric morbidity. Despite evidence-based treatments a considerable number of BED patients fail to recover. There is preliminary evidence for the association between psychodynamic personality functioning and personality traits on treatment outcome. However, research is limited and results are still contradictory. Identifying variables associated with treatment outcome could improve treatment programs. The aim of the study was to explore whether personality functioning or personality traits are associated with Cognitive Behavioral Therapy (CBT) outcome in obese female patients with BED or subthreshold BED. METHODS Eating disorder symptoms and clinical variables were assessed in 168 obese female patients with DSM-5 BED or subthreshold BED, referred to a 6-month outpatient CBT program in a pre-post measurement design. Personality functioning was assessed by the Developmental Profile Inventory (DPI), personality traits by the Temperament and Character Inventory (TCI). Treatment outcome was assessed by the Eating Disorder Examination-Questionnaire (EDE-Q) global score and self-reported binge eating frequency. According to the criteria of clinical significance, 140 treatment completers were categorized in four outcome groups (recovered, improved, unchanged, deteriorated). RESULTS EDE-Q global scores, self-reported binge eating frequency and BMI significantly decreased during CBT, where 44.3% of patients showed clinically significant change in EDE-Q global score. Treatment outcome groups showed significant overall differences on the DPI Resistance and Dependence scales and the aggregated 'neurotic' scale. Significant overall differences were found between groups on TCI Harm avoidance, although post hoc t-tests were non-significant. Furthermore, multiple logistic regression analysis, controlling for mild to moderate depressive disorder and TCI harm avoidance showed that 'neurotic' personality functioning was a significant negative predictor of clinically significant change. CONCLUSION Maladaptive ('neurotic') personality functioning is significantly associated with a less favorable outcome after CBT in patients with binge eating. Moreover, 'neurotic' personality functioning is a predictor of clinically significant change. Assessment of personality functioning and personality traits could support indication for more specified or augmented care, tailored towards the patients' individual strengths and vulnerabilities. TRIAL REGISTRATION This study protocol was retrospectively evaluated and approved on 16-06-2022 by the Medical Ethical Review Committee (METC) of the Amsterdam Medical Centre (AMC). Reference number W22_219#22.271.
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Affiliation(s)
- Laura van Riel
- Centre for Eating Disorders and Obesity, Novarum, Arkin Institute of Mental Health, Amsterdam, The Netherlands. .,Centre for Personality Disorders, NPI, Arkin Institute of Mental Health, Amsterdam, The Netherlands.
| | - Elske van den Berg
- Centre for Eating Disorders and Obesity, Novarum, Arkin Institute of Mental Health, Amsterdam, The Netherlands
| | - Marike Polak
- Department of Psychology, Education & Child Studies (DPECS), Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Marjolein Geerts
- Centre for Eating Disorders and Obesity, Novarum, Arkin Institute of Mental Health, Amsterdam, The Netherlands
| | - Jaap Peen
- Department of Research, Arkin Institute of Mental Health, Amsterdam, The Netherlands
| | - Theo Ingenhoven
- Centre for Personality Disorders, NPI, Arkin Institute of Mental Health, Amsterdam, The Netherlands
| | - Jack Dekker
- Department of Research, Arkin Institute of Mental Health, Amsterdam, The Netherlands
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Petersson S, Birgegård A, Brudin L, Mantilla EF, Monell E, Clinton D, Björck C. Initial self-blame predicts eating disorder remission after 9 years. J Eat Disord 2021; 9:81. [PMID: 34233765 PMCID: PMC8261969 DOI: 10.1186/s40337-021-00435-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 06/21/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Research into predictors of outcome in eating disorders (ED) has shown conflicting results, with few studies of long-term predictors and the possible importance of psychological variables that may act as risk- and maintenance factors. AIM To identify baseline predictors of ED remission nine years after initial clinical assessment using self-report measures of ED psychopathology, psychiatric symptoms, and self-image in a sample of adult ED patients (N = 104) treated at specialist units in Stockholm, Sweden. Sixty patients participated in the follow-up, of whom 41 patients (68%) had achieved remission. RESULTS Results suggested that the only significant predictor of diagnostic remission after nine years was initial levels of self-blame. CONCLUSION In order to ensure long-term recovery in ED it may be important for clinicians to widen their therapeutic repertoire and utilise techniques that reduce self-blame and increase self-compassion. It is difficult to predict how an eating disorder will develop, and research has found varying factors that affect the outcome of the condition. Recovery rates vary from nearly nil to over 90%. This variation could be explained by different research factors, but are more likely due to varying definitions of 'recovery', with less stringent definitions yielding high recovery rates and more stringent definitions yielding lower rates. The present study investigated whether the severity of eating disorder symptoms and other psychiatric symptoms could predict recovery nine years from first admission to specialised eating disorder care. Sixty patients at three eating disorder treatment units participated, and their scores on self-report measures of symptoms were used as predictor variables. Forty-one participants had no eating disorder diagnosis at nine-year follow-up. Most participants with binge-eating disorder had recovered, while the poorest outcome was found for anorexia nervosa with slightly over half of patients recovered after nine years. The only predictor for the nine-year outcome was a higher initial rating of self-blame, measured with the Structural Analysis of the Social Behavior. It was concluded that it may be important for clinicians to detect and address self-blame early in the treatment of eating disorders in order to enhance the possibility of recovery. Treatment should focus on reducing self-blame and increasing self-acceptance.
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Affiliation(s)
- Suzanne Petersson
- Department of Rehabilitation, Kalmar Regional Council, Hus 13, plan 7, 391 85, Länssjukhuset, Kalmar, Sweden.
- Department for Medicine and Optometry, Linnaeus University, Kalmar, Sweden.
| | - Andreas Birgegård
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Lars Brudin
- Department of Clinical Physiology, Region Kalmar County, Kalmar, Sweden
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Emma Forsén Mantilla
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Centre for Psychiatry Research, Stockholm Health Care Services, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Elin Monell
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - David Clinton
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Institute for Eating Disorders, Villa Sult, Oslo, Norway
| | - Caroline Björck
- Department of Neurobiology, Care Sciences and Society (NVS), Karolinska Institutet, Stockholm, Sweden
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Psychological Risk Factors for the Development of Restrictive and Bulimic Eating Behaviors: A Polish and Vietnamese Comparison. Nutrients 2021; 13:nu13030910. [PMID: 33799636 PMCID: PMC8001869 DOI: 10.3390/nu13030910] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/02/2021] [Accepted: 03/09/2021] [Indexed: 12/14/2022] Open
Abstract
The aim of this paper is to identify psychological factors which are culture specific or common predictors for restrictive and bulimic behaviors towards eating for young women raised in different cultures. The study included 661 young women from Poland (n = 233) and Vietnam (n = 428). Subjects filled-in the Eating Disorders Inventory (EDI-3) and the Multidimensional Body-Self Relations Questionnaire-Appearance Scales (MBSRQ-AS), and body measurements were collected to calculate anthropometric indices. Women form Vietnam were less satisfied with their appearance than were their Polish peers, but Vietnamese showed a lower level of preoccupation with being overweight and fear of obesity. Intercultural differences indicate that Vietnamese women show greater intensities for psychological variables, connected with restrictive and bulimic eating behaviors, verified in the research model: low self-esteem, personal alienation, interpersonal insecurity, interpersonal alienation, emotional dysregulation, interoceptive deficits, perfectionism and asceticism, and anxiety.
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Rania M, Monell E, Sjölander A, Bulik CM. Emotion dysregulation and suicidality in eating disorders. Int J Eat Disord 2021; 54:313-325. [PMID: 33205495 PMCID: PMC7984062 DOI: 10.1002/eat.23410] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 10/29/2020] [Accepted: 10/30/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Suicidality in eating disorders (EDs) is high, and identification of therapeutically targetable traits associated with past, current, and future suicidality is of considerable clinical importance. We examined overall and ED subtype-specific associations among suicidal ideation, suicide attempts, and general and specific aspects of emotion dysregulation in a large sample of individuals with ED, at presentation for treatment and 1-year follow-up. METHOD Using registry data from 2,406 patients, scores on the Difficulties in Emotion Dysregulation Scale (DERS) at initial registration were examined as predictors of recent suicidal ideation and self-report lifetime suicide attempts. Associations were examined in the full sample and in each ED subtype. In 406 patients, initial DERS scores were examined as predictors of suicidality at 1-year follow-up. RESULTS Overall DERS was associated with suicidal ideation and suicide attempts, even when adjusting for ED psychopathology and current depression. Perceived lack of emotion regulation strategies showed unique associations with suicidal ideation and suicide attempts, both in the full sample and in most ED subtypes. Initial DERS was also associated with follow-up suicidal ideation and suicide attempts, although this association did not remain when adjusting for past suicidality. DISCUSSION Results suggest that emotion dysregulation may be a potential mechanism contributing to suicidality in EDs, beyond the effects of ED psychopathology and current depression. Although the prevalence of suicidality differs across ED subtypes, emotion dysregulation may represent a risk trait for future suicidality that applies transdiagnostically. Results support addressing emotion dysregulation in treatment in order to reduce suicidality.
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Affiliation(s)
- Marianna Rania
- Department of Health SciencesUniversity Magna Graecia of CatanzaroCatanzaroItaly
- Center for Clinical Research and Treatment of Eating DisordersMater Domini University HospitalCatanzaroItaly
- Department of Medical Epidemiology and BiostatisticsKarolinska InstitutetStockholmSweden
| | - Elin Monell
- Department of Medical Epidemiology and BiostatisticsKarolinska InstitutetStockholmSweden
- Centre for Psychiatry Research, Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden
- Stockholm Health Care ServicesRegion StockholmStockholmSweden
| | - Arvid Sjölander
- Department of Medical Epidemiology and BiostatisticsKarolinska InstitutetStockholmSweden
| | - Cynthia M. Bulik
- Department of Medical Epidemiology and BiostatisticsKarolinska InstitutetStockholmSweden
- Department of PsychiatryUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
- Department of NutritionUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
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Monell E, Clinton D, Birgegård A. Self-directed behaviors differentially explain associations between emotion dysregulation and eating disorder psychopathology in patients with or without objective binge-eating. J Eat Disord 2020; 8:17. [PMID: 32377341 PMCID: PMC7193412 DOI: 10.1186/s40337-020-00294-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 04/02/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Emotion dysregulation and negative self-directed behaviors are key characteristics of eating disorders (EDs), but their interaction in relation to ED psychopathology is insufficiently explored, and empirically robust and clinically relevant models are needed. METHODS This study examined whether the association between emotion dysregulation and ED psychopathology was mediated by different negative self-directed behaviors in 999 ED patients divided into two sub-samples based on absence or presence of objective binge-eating episodes (OBE). Several simple and extended mediation models were examined using the Difficulties in Emotion Regulation Scale (DERS) as independent variable, the Structural Analysis of Social Behavior (SASB) as mediator, and the Eating Disorder Examination Questionnaire (EDE-Q) as dependent variable. RESULTS An associational pathway was found where higher emotion dysregulation was associated with more negative self-directed behaviors, which in turn was associated with higher ED psychopathology. Self-directed behaviors of importance differed between patient groups. In participants without OBE, lower self-love and higher self-attack were influential, whereas in participants with OBE, lower self-affirmation and higher self-blame were influential. CONCLUSIONS Self-directed behaviors may help to explain the association between emotion dysregulation and ED psychopathology. Our findings have both theoretical and clinical implications that are pathology-specific. Addressing specific self-directed behaviors could be an important way of helping patients deal with their emotions in relation to ED psychopathology.
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Affiliation(s)
- Elin Monell
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institute, and Stockholm Health Care Services, Stockholm County Council, Norra Stationsgatan 69, SE-11364 Stockholm, Sweden
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - David Clinton
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institute, and Stockholm Health Care Services, Stockholm County Council, Norra Stationsgatan 69, SE-11364 Stockholm, Sweden
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Institute for Eating Disorders, Oslo, Sweden
| | - Andreas Birgegård
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institute, and Stockholm Health Care Services, Stockholm County Council, Norra Stationsgatan 69, SE-11364 Stockholm, Sweden
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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Li Z, Dandil Y, Toloza C, Carr A, Oyeleye O, Kinnaird E, Tchanturia K. Measuring Clinical Efficacy Through the Lens of Audit Data in Different Adult Eating Disorder Treatment Programmes. Front Psychiatry 2020; 11:599945. [PMID: 33335491 PMCID: PMC7736031 DOI: 10.3389/fpsyt.2020.599945] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 11/10/2020] [Indexed: 12/28/2022] Open
Abstract
Background: Audit data is important in creating a clear picture of clinical reality in clinical services, and evaluating treatment outcomes. This paper explored the data from an audit of a large national eating disorder (ED) service and evaluated the outcome of inpatient and day treatment programmes for patients with anorexia nervosa (AN) with and without autistic traits. Methods: Four hundred and seventy-six patients receiving treatment for AN at inpatient (IP), day-care (DC) and step-up (SU) programmes were assessed at admission and at discharge on the following measures: autistic traits, body-mass-index (BMI), ED symptoms, depression and anxiety symptoms, work and social functioning, and motivation for change. Outcomes were analyzed first at a within-group level based on change in mean scores and then at an individual level based on the clinical significance of improvement in eating disorder symptoms. Outcomes were compared between patients with high autistic traits (HAT) and low autistic traits (LAT) in each programme. Results: The findings suggest that 45.5% of DC and 35.1% of IP patients showed clinically significant changes in ED symptoms following treatment. Co-occurring high autistic traits positively predicted improvement in ED symptoms in IP setting, but was a negative predictor in DC. In IP, more HAT inpatients no longer met the BMI cut-off for AN compared to LAT peers. In terms of general psychopathology, patients with AN and HAT exhibited more severe depression symptoms, anxiety symptoms and social functioning impairment than their LAT peers, and these symptoms stayed clinically severe after treatment. Conclusions: Patients with AN and hight autistic traits are more likely than their peers with low autistic traits to show weight restoration and improvement in ED systems after inpatient treatment. This reverses in DC, with high autistic trait patients less likely to improve after treatment compared to low autistic trait patients. Our results suggest that inpatient treatment with individualized and structured routine care may be an effective model of treatment for patients with AN and high autistic traits.
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Affiliation(s)
- Zhuo Li
- Department of Psychological Medicine, King's College London, Institute of Psychology, Psychiatry and Neuroscience, London, United Kingdom
| | - Yasemin Dandil
- Department of Psychological Medicine, King's College London, Institute of Psychology, Psychiatry and Neuroscience, London, United Kingdom.,National Eating Disorders Service, South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - Cindy Toloza
- National Eating Disorders Service, South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - Anna Carr
- National Eating Disorders Service, South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - Oyenike Oyeleye
- National Eating Disorders Service, South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - Emma Kinnaird
- Department of Psychological Medicine, King's College London, Institute of Psychology, Psychiatry and Neuroscience, London, United Kingdom
| | - Kate Tchanturia
- Department of Psychological Medicine, King's College London, Institute of Psychology, Psychiatry and Neuroscience, London, United Kingdom.,National Eating Disorders Service, South London and Maudsley NHS Foundation Trust, London, United Kingdom.,Department of Psychology, Illia State University, Tbilisi, Georgia
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