SSCP Journal Club Week 8 - Emotion-regulation strategies across psychopathology: A meta-analytic review

This week's article is entitled Emotion-regulation strategies across psychopathology: A meta-analytic review.  The article can be found here.

Overview

·         examine the relationships between dispositional (patterns over time) emotion-regulation strategies  - acceptance, avoidance, problem solving, reappraisal, rumination and suppression - and psychopathology - anxiety, depression, eating and substance use disorder

o   effect size of relationship across disorders (sensitivity)

§  large: rumination; medium – large: avoidance, problem solving and suppression; small – medium: reappraisal, acceptance

o   effect size of relationship between each strategy and disorder (specificity)

§  internalizing disorders more consistently associated with regulatory strategies than externalizing

o   moderation effect of sample (normative vs. clinical)

§  multi-sample approach is very important

Models of Emotion Regulation

·         emotion regulation – “processes through which individuals modulate their emotions consciously and unconsciously to appropriately respond to environmental demands”

·         many disorders are viewed as a result of difficulty managing emotion – leads to more severe periods of distress (anxiety/depression) or using substances to regulate (eating/substance)

·         as such many therapeutic approaches incorporate emotion regulation training (DBT, EMFT, ACT, ERT)

·         strategies hypothesized to be protective against psychopathology

·         reappraisal  - generating benign or positive interpretations or perspectives on a stressful situation to reduce distress (CBT)

·         problem solving – conscious attempts to change a stressful situation or its consequences (brainstorming, planning course of action, etc...) – indirect attempt to regulate emotions by reducing stressors

·         acceptance – mindfulness as non-elaborative, non-judgmental, present-centered awareness in which thoughts, feelings and sensations are accepted as they are

·         strategies hypothesized to be risk factors for psychopathology

·         suppression

o   suppression of emotional expression - reduce outward expression and subjective experience in short term but not emotion or physiological arousal over the long term

o   suppression of unwanted thoughts – attempts to suppress result in increased accessibility and physiological arousal

o   chronic suppression prevents habituation and leads to hypersensitivity to depression and anxiety-related thoughts/symptoms

·         avoidance - two-stage theory of fear (Mowrer 1947) – fear acquired through classical conditioning, avoidance precludes extinction, fear maintained via operant conditioning

·         rumination – repetitively focus on experience of emotion and its causes/consequences, reduces problem solving  and immobilizes in indecision, binging as an attempt to escape from aversive self-awareness maintained by rumination

Measuring Emotion Regulation – this meta-analysis  includes self report only

·         many self report scales – measure dispositional tendencies (supposedly assess what people do across time and context) but may require a level of insight and meta-cognition that not everyone is capable of, confound experience of emotion with its regulation and overlap with criterion measures

·         some observational methods – can test hypotheses about short term effects of strategies but do not assess tendencies; usually focus on one or two at a time; heterogeneous in design and outcome variables

Results

·         random-effect model of the correlation coefficients for each strategy collapsed across disorders

o   avoidance: r = .38*                                  problem solving: r = -.31*

o   suppression: r = .34*                                              reappraisal: r = -.14*

o   rumination: r = .49*                                                acceptance : r = -.19 (NS)

·         moderation analyses – collapsed

o   sample type (clinical pop had larger effect size)

§  significant - rumination, suppression

§  marginally significant – avoidance, problem solving

o   age group (adults had stronger relationship than children/adolescents)

§  significant - problem solving & suppression

§  not significant – rumination

·         random-effect model of the correlation coefficients for each combination of strategy and disorder

o   avoidance – anxiety (r = .37*), depression (r = .48*) & eating (r = .18*)

o   rumination – anxiety (r = .42*), depression (r = .55*),  eating (r = .26*) & substance (r = .21*)

o   suppression - anxiety (r = .29*), depression (r = .36*) & eating (r = .36*)

o   problem solving – anxiety (r = -.27*), depression (r = -.33*) & eating (r = -.29*)

o   reappraisal – anxiety (r = -.13 marginal), depression (r = -.17*) & eating (r = -.05 MS)

o   acceptance – anxiety (r = -.25 NS) & depression (-.20 NS)

·         moderation analyses – each combination

o   sample type (clinical pop had larger effect size)

§  significant – rumination + anxiety, avoidance + depression, rumination + depression, suppression + eating

§  marginally significant – problem solving + depression, avoidance + eating

o   age group (adults had stronger relationship than children/adolescents)

§  significant - problem solving + depression & suppression + depression

§  not significant – rumination + depression

Conclusions

·         each strategy was associated with overall psychopathology in the predicted direction

o   some more strongly related to overall psychopathology than others and maladaptive ones were more strongly related than adaptive ones – the presence of a maladaptive strategy is more deleterious than absence of particularly adaptive strategies

·         some strategies were more closely related to depression/anxiety (mood) than substance/eating (externalizing)  – rumination, avoidance and reappraisal

o   likely the relationships are more complex in externalizing disorders - might be moderated by reward sensitivity and/or eating and substance use may be strategies in their own right or used as part of a cluster of strategies

o   effect sizes may also be less reliability in this analysis

·         strength of relationships are likely a function of clinical severity and underscore the importance of using a multi-sample approach

·         children and adults reported similar relationships with psychopathology + rumination only – rumination may be a more primitive, automatic response; children may be less likely to report on use of problem solving and suppression bc require executive control and meta-cognition

·         the small relationships between psychopathology and acceptance and reappraisal are surprising given they are incorporated into major treatments (ACT, CBT) – but the data doesn’t allow clarification of the relationship between avoidance and reappraisal

·         future research

o   model relationships between strategies + psychopathology using latent factors (personality traits, attention)

o   examine strategies temporally

o   examine relationship between strategies + psychopathology at the dispositional and state levels simultaneously (measured spontaneously and in an ecologically valid environment)

·         limitations of the literature

o   number of effect sizes for combos of strategies and disorders is small

o   very few studies examine context-specificity and flexibility hypotheses

SSCP Journal Club - Week 7: A review of technology-assisted self-help and minimal contact therapies for anxiety and depression

This week's article is A review of technology-assisted self-help and minimal contact therapies for anxiety and depression: Is human contact necessary for therapeutic efficacy?  The article can be found here.

The present review provides a critical examination of studies (to 2010) of technology-assisted treatments for anxiety and depression. The review included treatments that were almost wholly self-administered (with almost no therapist contact throughout the course of treatment), those that were considered “self-help” (with up to 90 min of therapist guidance in using the treatment), those consisting of “minimal contact” (more than 90 min of therapist guidance), and those that serve merely as an adjunct to what is primarily in-person therapy.

Potential benefits of technology-assisted treatment- 
· Cost-effective: estimated savings of $540-$630 when compared to individual CBT (Newman, Kenardy, Herman, & Taylor, 1997; Newman, Consoli, & Taylor, 1999).
· Ease of dissemination of EBTs including access for rural communities  (e.g., Newman, Consoli, & Taylor, 1997; Palmer, Bor, & Josse, 2000; Yager, 2001).
·  Less time-intensive (Newman, 2000; Newman, Erickson, Przeworski, & Dzus, 2003).
· Improved logistics: structured instructions for use, provide immediate feedback to clients, portability, may lead to easier implementation.

Previous examinations of technology-assisted treatment- Previous reviews of technology-assisted treatments for anxiety and depression found overall that they were efficacious alternatives to traditional therapy treatments. Only 1 review (Newman et al., 2003) considered the optimum degree of therapist contact for specific disorders but only looked at studies until 2000. Over 100 relevant papers have been published since 2000 so an update is needed. (I would argue that a further update is now needed in 2015).

Purpose of current review:
· comprehensively review the treatment studies of different technological applications to psychotherapy for anxiety and mood through 2009, specific to each disorder.
· continue to include previously reviewed studies.
· provide conclusions regarding the degree of therapist contact that is advisable for specific anxiety and mood disorders.

Anxiety disorders. The authors then comprehensively reviewed the literature of treatments for the following anxiety disorders:

· “Mixed” anxiety disorders -the most cost-effective option for mixed anxiety disorders, may be self-administered bibliotherapy exposure (but this is based on 1 study; Ghosh et al., 1988) Most controlled findings for mixed anxiety disorders support the use of minimal contact treatments as the optimal level of therapist contact.

·  Obsessive-compulsive disorder – Although one quasi-experiment showed that when the technology- assisted intervention was used as an adjunct to therapist-delivered exposure and response prevention, participants required fewer sessions with the therapist but did as well (Nakagawa et al., 2000), additional limitations suggest that technology- assisted treatments are not optimal for OCD.

· Panic disorder- Effective treatment involving a computer-administered program appears to entail minimal therapist contact (as little as 150 min;  

· Social phobia- Promising reductions in social phobia symptoms have been shown with primarily self-help interventions focused on attention retraining and exposure delivered in a clinic as well as with minimal contact computer treatments used at home.

· Generalized anxiety disorder and posttraumatic stress disorder- For the treatment of GAD, primarily self-help attention retraining holds some promise and for the treatment of PTSD, minimal-contact Internet sites hold promise. However, due to methodological difficulties, more studies are needed before any conclusions can be drawn.

· Simple phobia- Almost all of the studies involved virtual reality or computer-assisted exposure methods used in a lab or clinic. Ultimately, more research is needed regarding the optimal amount of therapist contact.

Depression. The authors then comprehensively reviewed the literature of technology-based depression treatments:

· Subthreshold depression- Few studies employed self-administered interventions and all targeted individuals with subthreshold depression. Results suggest these interventions may not be optimal for such individuals. Compliance was low.  A self-help intervention that includes a brief motivational interview also holds some promise but needs further testing.

· Major depression - There were several methodological shortcomings to these studies. For clinical levels of depression, self-help and self-administered computer treatments have not been tested without receipt of additional medical services. The most cost-effective option tested for these individuals was a 250-minute minimal contact treatment (Wright et al., 2005) but replication is needed.

Overall conclusions:

Taken together, efficacy has been demonstrated for computerized interventions anxiety and depression. The most evidence was for studies of mixed anxiety disorders, panic disorder, and social phobia. More through examination is needed for treatments of GAD, OCD, and PTSD.

When treatments are used at home with little human contact, compliance is lower. Taking attrition and compliance rates into account, minimal contact therapies have been most beneficial for the greatest variety of disorders (although there is disorder specific variability). This suggests some degree of interaction with a therapist is important in the treatment of anxiety and depression.

Future Research:

· newer technological advances yet to be tested therapeutically:

     Skype or Voice over Internet Protocols (see Strong, 2010, July 30); interactive virtual reality, such as Second Life (Gorini, Gaggioli, Vigna, & Riva, 2008); automated ecological momentary intervention (Heron & Smyth, 2010).

· need to address methodological problems

 include follow-up assessments

o   assess if treatment led to clinically significant change

o   provide data about software quality, level of engagement/immersion

o   evaluate for diverse groups of individuals (incl. children), those with co-morbid conditions

·          make full use of existing technologies (e.g., mobile phone and palmtop software, automated text messaging, physiological feedback)

·          dismantling studies to determine the therapeutic and technological components of treatment

Discussion Questions:

1.    The authors conclude (based on the evidence available in 2010) that some contact with a live in-person therapist seems to be necessary for optimum treatment of anxiety and depression. There has been wide growth in the proliferation and use of technology (i.e., some folks seem to be with their cell phones 24/7) and the availability of options for integrating technology and EBTs (e.g., CBT apps). The self-administered/ self-help options described in the article have become increasingly sophisticated, user-friendly, and portable.

Do you think if an updated review was published today, that it would come to the same conclusion about the need for some therapist contact for the effective treatment of anxiety and depression?

2.    Suppose that an updated review came to the conclusion that some degree of therapist contact is not necessary for the optimum treatment of these disorders or that primarily self-help/ self-administered technology-based treatment was as effective (and more cost-effective) than in person contact with a therapist.  Does this have the potential to change the way that we practice therapy or the role of the clinician?

3.    Is there the possibility that in-person therapists could become more or less obsolete?  In much the same way that the cost-effectiveness of mid-level practitioners has changed the field of therapy, will the cost-effectiveness of technology-based treatments have a substantive effect on the field?

4.    The potential benefits of technology- assisted treatments have been made clear (such as cost-effectiveness, ease of dissemination especially to rural communities and other areas that lack trained mental health professionals and to those who do not pursue traditional treatment options due to stigma or lack of transportation). There has been less focus on the potential costs associated with these treatments.

The review noted the lower compliance and completion rates associated with at-home treatments. Are there other potential liabilities that arise with the implementation of technology-based treatment?

SSCP Journal Club - Week 6: Stress generation in depression: A systematic review of the empirical literature and recommendations for future study

This week's journal article is Stress generation in depression: A systematic review of the empirical literature and recommendations for future study

It can be found here

Article Objective- 

The present review provides a systematic examination of the stress generation literature to date, with specific focus given to depression and depressogenic risk factors (i.e., past stress, negative cognitive styles, and personality and interpersonal vulnerabilities) as predictors of the stress generation effect, as well as gender differences in stress generation, the sequelae of generated stress, and the relative specificity of this phenomenon to depression.

Relationship between stress and risk of depression has been documented in:

• Episodic/Acute Stressors (Kendler et al, 1998)
• Chronic Stress (Hammen, 2005 for review)
• Recent negative life events (Gibbs et al., 2003)
• Early negative life events (Harkness et al., 2006)
• Children (Cole and Turner, 1993)
• Adolescent (Tram and Cole, 2000)
• Young adult (Hankin et al., 2005)
• Geriatric samples (Fiske et al., 2003)

Early Theories: Stress Exposure Models of Depression - Stressful life events significantly increase individual susceptibility to the onset of depression. Next generation models that have received empirical support include:

• Biological diathesis-stress models (see Levinson, 2006 for a recent review)
• Bio-cognitive mediational models (Beevers et al., 2009; Hilt,et al., 2007)
• Cognitive diathesis-stress models (Abramson, et al. 1989; Beck, 1967,1987)
• Cognitive-developmental mediational conceptualizations (Cole, 1990, 1991)
• Interpersonal diathesis-stress theories (Joiner, et al., 1999; see Van Orden et al., 2005 for a review)

More Recent Theory: Stress Generation Model of Depression- while the traditional stress exposure model of depression very much remains an important focus of research, increasing consideration also has been given to a complimentary and similarly important process, whereby depression, or depressogenic vulnerability factors, plays an active role in generating the very stresses that place individuals at heightened risk for future depression.

Method:

·         Due to the otherwise broad nature of this research, the present review only considered articles that provided a specific test of the stress generation hypothesis.

·         Articles were included if:

o   they assessed multiple dependent life events by themselves, or distinguished them from independent ones, and

o   examined them in relation to relevant predictors, thus offering a fairly clean and direct test of the stress generation hypothesis.

·         Articles were identified individually through a PsycINFO search

·         Totaled 57 relevant articles

Predictors of stress generation. The authors then comprehensively reviewed the literature of the following 5 different predictors of stress generation. Citations for the most interesting/seminal work included:

·         Depression (Page 4)- those with reported symptoms of depression report higher rates of dependent episodic stressors than other conditions (Hammen, 1991; Harkness et al., 1999; Shih and Eberhart, 2008)
·         Stress (Page 6)- Depressive symptomatology alone does not seem adequately to account for the stress generation pattern, as heightened levels of negative dependent life stress also have been found to occur during periods of remission. Just as past depression consistently has been found to be a strong predictor of future depression, so may past stress predict future stress. (Hammen et al., 2009; Daley et al., 1997)
·         Negative cognitive style (Page 7)- Stress generation, in large part, is also the product of enduring maladaptive characteristics and behaviors of the individual, several cognitive and personality factors have been implicated in the generation of dependent stress. (Harkness and Stewart, 2007; Shih et al., 2009; Simons et al, 1993; for hopelessness research, see Joiner et al., 2005a & b)
·         Personality and interpersonal vulnerabilities (Page 8)- The authors also reviewed the studies investigating the generation of dependent or interpersonal stress in relation to a number of individual personality and interpersonal characteristics (i.e., Axis II patholoty).

o   PD clusters and depression: Daley et al., 2000, 2006, 1998

o   Neuroticism and Stress Generation: Kercher et al., 2009;

o   Maladaptive coping and problem solving strategies in stress generation: Holahan et al., 2005; Barker, 2007

o   Attachment  styles as risk factors of stress generation (Bottonari et al., 2007

o   Dependency and Reassurance-seeking and stress generation (Shahar and Priel, 2003; Shih et al., 2009)

o   Sociotropy and autonomy as predictors of stress generation (Beck 1983; for chronic stress see Nelson et al., 2001; for acute stress see Shih et al, 2006)

o   FUTURE RESEARCH NOTE FROM AUTHORS: Although these studies provide general support for interpersonal characteristics, in the form of attachment styles, coping strategies, dependency, sociotropy, autonomy, and reassuranceseeking, as contributors to stress generation, research on the unique effect of different interpersonal vulnerabilities is still relatively lacking (see Shahar et al., 2004, for an exception, albeit without distinguishing between dependent and independent stresses in the relevant mediational analyses). It would be important for future research to address this gap in the literature by evaluating multiple interpersonal vulnerabilities simultaneously in prospectively predicting dependent stress, as this approach would allow for a determination of their individual unique and cumulative or additive contribution to the stress generation effect.

·         Gender differences in stress generation (page 12)-  an emerging finding in the literature suggests that there may be a gender difference in the stress generation pattern. Specifically, it may be of greater relevance to women than men. (Rudolph and Hammen 1999, 2000; Barker, 2007; Stafford et al., 2007). The authors report there is some evidence that the female gender:

o   is associated with the generation of dependent stresses

o   Mediates of depression

o   moderates the stress generation effect of depression

o   is mediated in its relation with generated stress by interpersonal vulnerabilities

o   moderates the effect of cognitive and interpersonal predictors of dependent stress.

The authors conclude the review by examining:

·         The Sequelae of generated stress (Page 13)- the degree to which stress generation contributes directly to subsequent depressive symptomatology and diagnoses. Kendler et al (1999) suggests this may be true based on dependent stressors, particularly interpersonal ones, being more strongly associated with depression compared to independent stressors. (for additional evidence see Davila et al., 1995, 1997; Bos et al., 2007)
·         Specificity of stress generation to depression- Stress generation may also be involved in the onset of other disorders (Hammen et al., 2006; Harkness and Luther 2001)

o   Note: A great deal of the studies involving direct comparison between disorders generally spport the view of stress generation being specific to depression (e.g., Wingate and Joiner, 2004; Hammen, 1991)

Future Research ideas

·         There is now a substantial amount of support for the stress generation effect in depression, with many studies replicating the original finding (Hammen, 1991) that depression is associated with subsequent occurrence of dependent stress. The majority of these studies, however, have focused on episodic stress, and very little attention has been devoted to establishing the generation of chronic stress. A great deal of research is needed in the area of the onset of depression (and other disorders) following chronic stress.
·         The involvement of other cognitive vulnerabilities in stress generation are in need of more rigorous research, such as dysfunctional attitudes, rumination, and low self-perceived competence.
·         Although studies on personality and interpersonal vulnerabilities have provided more consistent support for their involvement in stress generation, these vulnerabilities have largely been considered in isolation, precluding any evaluation of their unique and potential additive or cumulative effects on stress generation. Future research should also examine the inter-relations between multiple cognitive and interpersonal vulnerabilities in increasing the occurrence of stressful life events.
·         Much more research is needed on gender differences and stress generation to better understand the etiology of these differences.
·         Thus far, it seems fairly well established that the stress generation effect is specific to dependent stress, particularly within interpersonal domains. Finer-level analyses of these dependent stresses may also be possible, however, by considering domain-specific stresses (e.g., work-, peer-, and family-related stress; Hammen, 2006).
·         Prior methodological issues that could be improved upon:

o   The reliance on self-report

o   The operationalization of stress in the literature

Discussion Questions:

1.    Given the strong interconnection between stress and depression, can these two constructs ever be truly disentangled? Are there measures outside of self report that could be used to better distinguish what is going on between the two?
2.    What other forms of psychopathology may stress generation be involved in? And to that effect, what other forms of psychopathology can depression lead to, and how can we distinguish between the two?
3.    I found a lot of the literature cited in the section about specificity of stress generation to be interesting, as I would expect stress to impact the episodic onset of many of the disorders they discussed, such as Bipolar. Could disorders such as bipolar be more affected by chronic stress given the nature of their consistently rocky interpersonal relationships?
4.    Do generated stressors match one’s underlying responsible vulnerabilities? That is, does one’s vulnerabilities uniquely predict their pattern of generated stress?

SSCP Journal Club - Week 5: Psychological flexibility as a fundamental aspect of health

This week's article was entitled Psychological flexibility as a fundamental aspect of health (Kashdan & Rottenberg, 2010). The authors state that the aim of their review is to integrate work on emotion regulation, mindfulness/acceptance, social and personality psychology, and neuropsychology in order to better understand the concept of psychological flexibility and identify avenues for future research.   This week's article can be found here.

Psychological flexibility is the ability to: “recognize and adapt to various situational demands; shift mindsets or behavioral repertoires when these strategies compromise personal or social functioning; maintain balance among important life domains; and be aware, open, and committed to behaviors that are congruent with deeply held values.” (p. 865)

1. Evidence for the health benefits of psychological flexibility

• Research demonstrates the benefits of being able to shift one’s mental and behavioral responses
• Self-regulation of emotions (i.e., the ability to flexibly modify emotional responses to best match the situation) is more important for psychological well-being than simply striving to increase “positive” emotions and decrease “negative” ones
• “Negative” emotions like anger can be productive toward desirable goals in certain contexts (e.g., confronting someone about a wrongdoing)
• Also, devoting resources to regulate emotional experiences (decreasing the negative or increasing the positive) diverts time and effort from other goals
• This idea is in line with Acceptance and Commitment Therapy (ACT)
• The ability to regulate behavior (e.g., coping strategies) based on the situation is similarly predictive of real-world adjustment above and beyond any one particular regulatory strategy
• Rigid adherence to a coping strategy may become problematic, and it may not be that case that certain regulatory strategies (e.g., cognitive reappraisal) are always better than others (e.g., thought suppression)
• Balance among important life domains (e.g., work, school, relationships) is also beneficial
• Important to have little discrepancy between one’s actual day-to-day activities and one’s ideal balance
• It is also effective to be able to shift focus between different time perspectives (past/present/future); at times it is ideal to be immersed in the present moment, and other times to be focused on the future (e.g., clarifying future goals), and other times to recall the past (e.g., extracting lessons from previous experiences)

2. Psychopathology and (in)flexibility

• Inflexibility (e.g., avoidance of negative emotions, lack of contextual sensitivity, rigid behavioral responses etc.) often leads to psychopathology
• Examples in depression: pervasive low mood, rumination (i.e., perseverative, circular thinking), and inflexible attributional style (internal, stable, global attributions)
• Examples in anxiety disorders: experiential avoidance (rigidly judging certain experiences – like anxiety – as unacceptable), behavioral avoidance of anxiety-provoking stimuli/situations becomes the default behavioral response, repetitive behaviors (e.g., worry in GAD, compulsions in OCD)
• It has been challenging to integrate the manifestations of inflexibility across research areas
• One opportunity for integration is by studying cardiac vagal control (CVC), which is tied to parasympathetic nervous system functioning (measured by beat-to-beat variability in HR) and may facilitate adjustment to changing environmental conditions
• Correlational data suggests that CVC may be related to other elements of flexibility (e.g., overcoming attentional interference in the Stroop task)
• Research is being conducted on manipulating resting CVC levels (e.g., using exercise routines) in order to observe effects on psychological functioning
• Currently, it is still unclear whether inflexibility is an antecedent or a consequence of psychopathology

3. The building blocks of psychological flexibility

• 3 factors that influence the likelihood of being psychologically flexible
• Executive functioning or the ability to re-focus or rapidly shift cognitive sets and attention, which is important for self-control and goal-directed behaviors
• Someone who is psychologically flexible is more able to (a) determine what a situation requires, and (b) organize and prioritize strategies that “fit” the situation (vs. reverting to default strategies)
• Also a flexible individual is more able to: (a) tolerate distress, and be open and receptive toward inevitable negative emotions, thoughts, and sensations, and (b) detach from thoughts and feelings as temporary internal experiences (vs. objective reality or something that needs to be regulated), which is important because attempts to avoid, alter, or remove “negative” internal experiences paradoxically only ties a person closer to them
• Working memory and recall are also important for selecting situationally-appropriate responses and facilitates learning
• Default states: delicate balance between investing effort in surroundings vs. conserving mental energy for the future
• Heuristics and stereotypes allow us to make efficient decisions
• But they are resistant to reconsideration and change which can be problematic
• Goal of psychological flexibility is to be able to override habits and biases when needed, incorporate other relevant information, and consider personal/situational variability
• Personality configurations
• Neuroticism (i.e., tendencies to experience negative emotions more frequently, intensely, and readily and for longer periods of time) makes it challenging to behave flexibly
• Experience of positive affect allows us to access a wider array of thoughts and behaviors and facilitates flexibility (e.g., considering multiple aspects of a situation and selecting the most effective solution)
• Openness to experiences (e.g., considering multiple perspectives, finding alternate routes to obstacles) demonstrates a willingness to make room for positive and negative feelings that often arise when confronting new, complex, and uncertain stimuli
• Opposites = intolerance of uncertainty and need for closure; prioritize certainty instead of coping with the complexity of reality (and at the expense of learning/growth)
• Self-control (related to conscientiousness): we need to be able to delay gratification and resist impulses/urges in order to be flexible with behavioral routines

4. Recommendations for future research

• Need for prospective studies examining inflexibility as a predictor of onset in high risk populations in order to better determine direction of causality
• Can we intervene to enhance flexibility (or even prevent the development of psychopathology)?
• ACT approaches are promising, but also even more traditional approaches (e.g., cognitive therapy) involve thinking/behaving flexibly and could be examined
• Importance of ecological momentary assessment (EMA) data which allows researchers to examine the dynamic aspects of flexibility in real-world contexts vs. simply relying on global static measures like the Acceptance and Action Questionnaire (AAQ)

Discussion questions

1. Some lessons from this literature review were surprisingly at odds with things I have learned previously (e.g., the problems with thought suppression as discussed in exposure and response prevention and the benefits to being in the present moment as discussed in mindfulness modules of DBT). Instead, the authors state that one’s ability to be flexible both with one’s coping strategies and one’s focus on the past/present/future is the key – which I think is a really interesting and appealing lesson. Does this idea surprise anyone else?
2. The authors state that some of the symptoms of depression and anxiety (e.g., rumination, compulsions, worry) are problems with inflexibility, which I thought was an interesting and novel conceptualization. Does this idea resonate with others based on clients you have worked with?
3. After discussing extensive adaptive benefits of flexibility, the authors also raise the question of whether flexibility may ever be problematic (e.g., does it ever lead to instability and impulsiveness). They also suggest that there may be moderators that predict whether or not flexibility is impairing - any ideas of moderating factors that may lead to flexibility being maladaptive?

Journal Club Week 4: Perfectionism as a transdiagnostic process: A clinical review

This week's journal club article, "Perfectionism as a transdiagnostic process: A clinical review" (Egan, Wade, & Shafran 2011) can be found here.

 

A few definitions to get us started:

• Transdiagnostic – a risk factor or maintaining mechanism for multiple disorders
• Clinical perfectionism – “overdependence on self-evaluation on the determined pursuit of personally demanding, self-imposed standards in at least one high salient domain, despite adverse consequences” (Shafran 2002). Perfectionism is maladaptive when a person bases their self-worth on achievement.

Notes:

 

Perfectionism: personality characteristic, set of cognitive behavioral features, symptom of psychopathology, or process?

• Process – an aspect of cognition or behavior that may contribute to the maintenance of a psychological disorder

 Measures/Dimensions of Perfectionism

• Frost Multidimensional Perfectionism Scale (FMPS)
  • Personal Standards (PS)
  • Concern over Mistakes (CM)
  • Doubts about Actions (DA)
  • Parental Expectations (PE)
  • Parental Criticism (PC)
  • Organization (O)
• Hewitt Multidimensional Perfectionism Scale (HMPS)
  • Self-oriented
  • Other-oriented
  • Socially-prescribed
• Factor analysis of both scales:
  • Maladaptive evaluative concerns (CM, DA, PC, PE, self-oriented)
  • Positive achievement striving (PS, O, other-oriented)

Elevated perfectionism across disorders:

• Eating disorders (CM, PS)
• Depression (self-oriented, socially-prescribed)
• Bipolar disorder (vulnerability for mood swings)
• Suicidal ideation and behavior (socially-prescribed)
• Anxiety
  • OCD (CM, PS, DA, socially-prescribed)
    • Interferes with ability to engage in ERP, predicts treatment outcome
  • Social anxiety (CM, DA, socially-prescribed)
    • Improvements in perfectionism after treatment
  • Panic disorder (socially-prescribed)
• OCPD (perfectionism is a criteria for diagnosis; rigidity)

Transdiagnostic approach can explain comorbidity due to shared:

• Maintenance mechanisms
  • included in multiple cognitive behavior models of disorders (social phobia, OCD, eating disorders)
• Risk factors

Negative impact on treatment outcome (depression, eating disorders)

• Interferes with therapeutic alliance
• Poorer social networks
• Poorer ability to cope with life stress

Treatment of perfectionism reduces symptoms across disorders (depressions, anxiety, eating disorders)

 

Clinical implications:

• Case conceptualization
• Address specifically and early in treatment – especially if barrier to change
• How to treat – increase motivation to change, self monitor maintenance mechanisms, address cognitive biases and self-criticisms

 

Discussion Qs:

1. The article suggests treating perfectionism early in treatment if it is interfering with treatment of the presenting problem. Has this ever come up with a client you've seen? How have you addressed it, if at all?
2. Data on treatment of perfectionism seem a little weak – several studies showed no significant difference across treatments or between treatment/waitlist. Is treating perfectionism separately worth it? Is the effectiveness really that different than CBT for anxiety/depression?
3. Do you agree that perfectionism should be addressed as a process, rather than as a "personality characteristic, set of cognitive behavioral features, or symptom of psychopathology?" Why or why not?
4. Perfectionism is referenced in depression, eating disorders, and some anxiety disorders. Are there any other disorder in which perfectionism might play a role?
5. In general, what are your thoughts on a transdiagnostic approach to psychopathology? Does this seem like an avenue worth pursuing in treatment outcome research?