Article in British Journal of Clinical Psychology (early view). Abstract:
Objectives
The notion of intra-psychic conflict has been present in psychopathology for more than a century within different theoretical orientations. However, internal conflicts have not received enough empirical attention, nor has their importance in depression been fully elaborated. This study is based on the notion of cognitive conflict, understood as implicative dilemma, and on a new way of identifying these conflicts by means of the repertory grid technique. Our aim is to explore the relevance of cognitive conflicts among depressive patients.
Design
Comparison between persons with a diagnosis of major depressive disorder and community controls.
Methods
161 patients with major depression and 110 non-depressed participants were assessed for presence of implicative dilemmas and level of symptom severity. The content of these cognitive conflicts was also analysed.
Results
Repertory grid analysis indicated conflict (presence of implicative dilemma/s) in a greater proportion of depressive patients than in controls. Taking only those grids with conflict, the average number of implicative dilemmas per person was higher in the depression group.
In addition, participants with cognitive conflicts displayed higher symptom severity. Within the clinical sample, patients with implicative dilemmas presented lower levels of global functioning and a more frequent history of suicide attempts.
Conclusions
Cognitive conflicts were more prevalent in depressive patients and were associated with clinical severity. Conflict assessment at pre-therapy could aid in treatment planning to fit patient characteristics.
Practitioner Points
• Internal conflicts have been postulated in clinical psychology for a long time but there is little evidence about its relevance due to the lack of methods to measure them.
• We developed a method for identifying conflicts using the Repertory Grid Technique.
• Depressive patients have higher presence and number of conflicts than controls.
• Conflicts (implicative dilemmas) can be a new target for intervention in depression.
Cautions/Limitations
• A cross-sectional design precluded causal conclusions.
• The role of implicative dilemmas in the causation or maintenance of depression cannot be ascertained from this study.
The Role of Anxiety Sensitivity in Obsessive-Compulsive Disorder Treatment Ou...Rogers Memorial Hospital
Anxiety Sensitivity (AS) is the fear of bodily sensations related to anxiety due to beliefs that they are harmful. While considerable attention has focused on the link between AS and panic disorder, less research has examined AS in OCD. Calamari and colleagues (2008) found that AS was significantly associated with OCD severity, even after controlling for cognitive risk factors. The present study examined changes in AS over the course of treatment in 337 individuals with an OCD diagnosis and Y-BOCS-SR score of 16 or higher. Multiple regression analysis demonstrated that all variables significantly decreased from admission to discharge. Adding the ASI change over treatment to the multiple regression increased variance accounted for significantly, suggesting that changes in AS may play an important role in the treatment of OCD, and that targeting AS may be beneficial. Limitations and future directions are discussed.
Previous research shows deficits in Executive Function (EF) in patients with anxiety and depression. Recent studies have shown that EF measured by neuro-imaging and Neuro-psychological tests predicts treatment outcomes for depression, but it is unclear whether they predict outcomes for anxiety. Neuro-imaging and
Neuro-psychological tests are effective but intensive procedures that may not always be accessible to clinicians. Previous research has explored the viability of questionnaire measures of EF. A previous study suggests that the Revised by executive Questionnaire (DEX-R) predicts concurrent depression and anxiety; however, it is unclear how comorbidity influenced these results. The purpose of the current study was to investigate whether a questionnaire measure of EF could predict concurrent depression and anxiety and well as outcomes following treatment. A total of 206 psychiatric outpatients with major depression or anxiety disorders completed the DEX-R prior to Group Cognitive Behavioral Therapy (GCBT). They also completed anxiety and depression scales at pre-and post-treatment. Executive dysfunction predicted symptom severity for pre-treatment anxiety after controlling for comorbid depression, and for pre-treatment depression after controlling for comorbid anxiety. Symptom severity in anxiety was predicted by specific executive deficits in inhibition; symptom severity in depression was predicted by executive problems with volition and social regulation.
DEX-R significantly predicted post-treatment symptoms of anxiety but not depression following treatment in GCBT. It was concluded that EF deficits are associated with both anxiety and depressive disorders and predict responsiveness to treatment for anxiety patients. Screening of psychiatric patients for EF and, where indicated, incorporation of neurocognitive training strategies into therapy, may improve treatment outcomes.
A critical review of three articles reveals flawed empirical
evidence underpinning the case for integrating pharmacotherapy and
psychotherapy. Medical model dominance favors biology in a diathesis/
stress framework, creating myths of valid diagnosis, underlying biological
causes, and targeted pharmacological treatments. Meanwhile, a for-profit
pharmaceutical industry influences clinical trials, constructing an illusory
justification for medical intervention and bolstering the integration hypothesis.
The apparent logic of integration threatens to diminish the crucial,
empirically supported role of clients in psychotherapy outcome.
The authors call for the inclusion of client feedback in intervention
choices, based on accurate, unbiased information, and a continued critique
of pharmacotherapy
Health Psychology Psychological Adjustment to the Disease, Disability and Lossijtsrd
This article discusses the psychological adjustment of adults to severe or incurable diseases or other loss. The stress that results from a diagnosis of illness or loss depends on many factors, such as the beliefs of each individual and the social context. Considering the diversity of human perceptions, feelings and behaviors, it was considered important for the present study to include a theory of stress and treatment related to physical illness. At the center of attention are end stage individuals, not their organic problems but mainly their psychological state and that of their families. Reference is then made to the loss of loved one and the period of mourning. As regards the disease response, there is a difference between the immediate reaction to loss, what we call mourning, and the adaptation to a new way of life without the loved one. Finally, the role of therapeutic communication between patients and their families and mental health professionals, as well as the need to maintain psychological balance, is also described. Agathi Argyriadi | Alexandros Argyriadis ""Health Psychology: Psychological Adjustment to the Disease, Disability and Loss"" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-3 | Issue-3 , April 2019, URL: https://www.ijtsrd.com/papers/ijtsrd23200.pdf
Paper URL: https://www.ijtsrd.com/humanities-and-the-arts/psychology/23200/health-psychology-psychological-adjustment-to-the-disease-disability-and-loss/agathi-argyriadi
Sample 3 bipolar on female adult populationNicole Valerio
Hello Sir
We are a premier academic writing agency with industry partners in UK, Australia and Middle East and over 15 years of experience. We are looking to establish long-term relationships with industry partners and would love to discuss this opportunity further with you.
Thanks & Regards
visit our website.
www.onlineassignmenthelp.com.au
www.freeassignmenthelp.com
www.btechndassignment.cheapassignmenthelp.co.uk
www.cheapassignmenthelp.com
www.cheapassignmenthelp.co.uk/
http://www.cheapassignmenthelp.net/
Reviewing Cognitive Treatment for Eating Disorders: From Standard CBT Efficac...State of Mind
Reviewing Cognitive Treatment for Eating Disorders: From Standard CBT Efficacy to Worry, Rumination and Control Focused Interventions - EACBT 2015 Jerusalem
The Role of Anxiety Sensitivity in Obsessive-Compulsive Disorder Treatment Ou...Rogers Memorial Hospital
Anxiety Sensitivity (AS) is the fear of bodily sensations related to anxiety due to beliefs that they are harmful. While considerable attention has focused on the link between AS and panic disorder, less research has examined AS in OCD. Calamari and colleagues (2008) found that AS was significantly associated with OCD severity, even after controlling for cognitive risk factors. The present study examined changes in AS over the course of treatment in 337 individuals with an OCD diagnosis and Y-BOCS-SR score of 16 or higher. Multiple regression analysis demonstrated that all variables significantly decreased from admission to discharge. Adding the ASI change over treatment to the multiple regression increased variance accounted for significantly, suggesting that changes in AS may play an important role in the treatment of OCD, and that targeting AS may be beneficial. Limitations and future directions are discussed.
Previous research shows deficits in Executive Function (EF) in patients with anxiety and depression. Recent studies have shown that EF measured by neuro-imaging and Neuro-psychological tests predicts treatment outcomes for depression, but it is unclear whether they predict outcomes for anxiety. Neuro-imaging and
Neuro-psychological tests are effective but intensive procedures that may not always be accessible to clinicians. Previous research has explored the viability of questionnaire measures of EF. A previous study suggests that the Revised by executive Questionnaire (DEX-R) predicts concurrent depression and anxiety; however, it is unclear how comorbidity influenced these results. The purpose of the current study was to investigate whether a questionnaire measure of EF could predict concurrent depression and anxiety and well as outcomes following treatment. A total of 206 psychiatric outpatients with major depression or anxiety disorders completed the DEX-R prior to Group Cognitive Behavioral Therapy (GCBT). They also completed anxiety and depression scales at pre-and post-treatment. Executive dysfunction predicted symptom severity for pre-treatment anxiety after controlling for comorbid depression, and for pre-treatment depression after controlling for comorbid anxiety. Symptom severity in anxiety was predicted by specific executive deficits in inhibition; symptom severity in depression was predicted by executive problems with volition and social regulation.
DEX-R significantly predicted post-treatment symptoms of anxiety but not depression following treatment in GCBT. It was concluded that EF deficits are associated with both anxiety and depressive disorders and predict responsiveness to treatment for anxiety patients. Screening of psychiatric patients for EF and, where indicated, incorporation of neurocognitive training strategies into therapy, may improve treatment outcomes.
A critical review of three articles reveals flawed empirical
evidence underpinning the case for integrating pharmacotherapy and
psychotherapy. Medical model dominance favors biology in a diathesis/
stress framework, creating myths of valid diagnosis, underlying biological
causes, and targeted pharmacological treatments. Meanwhile, a for-profit
pharmaceutical industry influences clinical trials, constructing an illusory
justification for medical intervention and bolstering the integration hypothesis.
The apparent logic of integration threatens to diminish the crucial,
empirically supported role of clients in psychotherapy outcome.
The authors call for the inclusion of client feedback in intervention
choices, based on accurate, unbiased information, and a continued critique
of pharmacotherapy
Health Psychology Psychological Adjustment to the Disease, Disability and Lossijtsrd
This article discusses the psychological adjustment of adults to severe or incurable diseases or other loss. The stress that results from a diagnosis of illness or loss depends on many factors, such as the beliefs of each individual and the social context. Considering the diversity of human perceptions, feelings and behaviors, it was considered important for the present study to include a theory of stress and treatment related to physical illness. At the center of attention are end stage individuals, not their organic problems but mainly their psychological state and that of their families. Reference is then made to the loss of loved one and the period of mourning. As regards the disease response, there is a difference between the immediate reaction to loss, what we call mourning, and the adaptation to a new way of life without the loved one. Finally, the role of therapeutic communication between patients and their families and mental health professionals, as well as the need to maintain psychological balance, is also described. Agathi Argyriadi | Alexandros Argyriadis ""Health Psychology: Psychological Adjustment to the Disease, Disability and Loss"" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-3 | Issue-3 , April 2019, URL: https://www.ijtsrd.com/papers/ijtsrd23200.pdf
Paper URL: https://www.ijtsrd.com/humanities-and-the-arts/psychology/23200/health-psychology-psychological-adjustment-to-the-disease-disability-and-loss/agathi-argyriadi
Sample 3 bipolar on female adult populationNicole Valerio
Hello Sir
We are a premier academic writing agency with industry partners in UK, Australia and Middle East and over 15 years of experience. We are looking to establish long-term relationships with industry partners and would love to discuss this opportunity further with you.
Thanks & Regards
visit our website.
www.onlineassignmenthelp.com.au
www.freeassignmenthelp.com
www.btechndassignment.cheapassignmenthelp.co.uk
www.cheapassignmenthelp.com
www.cheapassignmenthelp.co.uk/
http://www.cheapassignmenthelp.net/
Reviewing Cognitive Treatment for Eating Disorders: From Standard CBT Efficac...State of Mind
Reviewing Cognitive Treatment for Eating Disorders: From Standard CBT Efficacy to Worry, Rumination and Control Focused Interventions - EACBT 2015 Jerusalem
Pucurull, O., Feixas, G., Aguilera, M. C. & Carrera, M. J. (2011). What Changes in the Personal Construct System During Psychotherapy? A Naturalistic Study of Brief Construct Therapy. Presented at the 19th. International Congress on Personal Construct Psychology. Boston, MA.
The multi center dilemma project, an investigation on the role of cognitive c...Guillem Feixas
The Multi-Center Dilemma Project is a collaborative research endeavour aimed at determining the role of dilemmas —a kind of cognitive conflict, detected by using an adaptation of Kelly’s Repertory Grid Technique— in a variety of clinical conditions. Implicative dilemmas appear in one third of the non-clinical group (n = 321) and in about
half of the clinical group (n = 286), the latter having a proportion of dilemmas that doubles that of the non-clinical sample. Within the clinical group, we studied 87 subjects, after completing a psychotherapy process, and found that therapy helps to dissolve those dilemmas. We also studied, independently, a group of subjects diagnosed with social phobia (n = 13) and a group diagnosed with irritable bowel syndrome (n = 13) in comparison to non-clinical groups. In both health related problems, dilemmas seem to be quite relevant. Altogether, these studies, though preliminary (and with a small group size in some cases), yield a promising perspective to the unexplored area of the role of cognitive conflicts as an issue to consider when trying to understand some clinical conditions, as well as a focus to be dealt with in psychotherapy when dilemmas are identified.
Research-Based Interventions: Dissociative Identity Disorder 1
THIS IS AN EXAMPLE PLEASE DO NO COPY DO NOT PLAGiarism
Research-Based Interventions: Dissociative Identity Disorder
“Dissociative identity disorder is characterized by the presence of two or more identities or personality states, each with its relatively enduring pattern of perceiving, relating to, and thinking about the environment and the self” (Vermetten, Schmahl, Lindner, Loewenstein, & Bremner, 2006). There are many characteristics used that accompany Dissociative Disorder (DID). One method to understanding would be to know how the disorders are classified and defined. DID may be conceptualized effectively using the diathesis-stress model. There are many different intervention strategies for this disorder as well. Over time researchers have discovered the most effective treatments and interventions that can be used regarding DID. When one dissociates, the person may not have conscious awareness of what is happening (Vermetten, Schmahl, Lindner, Loewenstein, & Bremner, 2006).
Peer-reviewed Articles
One limitless, longitudinal, naturalistic, and prospective study investigated childhood maltreatment (CM) in adult intimate partner violence (IPV) victims among Dissociative Disorder (DD) patients with Dissociative Identity Disorder with CM rates of 80-95% and severe dissociative symptoms (Webermann, Brand, & Chasson, 2014). The methods of this study include 275 DD outpatient therapy patients who completed a self-reported measure of dissociation (Webermann, Brand, & Chasson, 2014). Analyses assessed associations between CM typologies, trait dissociation, and IPV (Webermann, Brand, & Chasson, 2014). The results of this study include emotional and physical child abuse associated with childhood witnessing of domestic violence, physical, and emotional IPV (Webermann, Brand, & Chasson, 2014) Two-tailed independent samples t -tests and z-tests were used in this study to represent data as well. “As an effect size, odds ratios (ORs) were calculated to predict the likelihood of a participant being in an abusive adult relationship if they experienced a particular type of CM” (Webermann, Brand, & Chasson, 2014, p. 5).
A double-blind study was conducted including 15 females with DID compared to 23 without psychopathology., chosen by self-disclosure results of a questionnaire along with a structured clinical interview by psychiatrists The objective was to examine the volumetric differences between amygdala and hippocampal volumes in patients with dissociative identity disorder, a disorder that has been associated with a history of severe childhood trauma (Vermetten, Schmahl, Lindner, Loewenstein, & Bremner, 2006). These researchers used MRI to measure volumes of the amygdala and hippocampus. The results included the volume of the hippocampus being 19.2 % smaller and the amygdala being 31.6% smaller in patients with DID when compared to the other subjects without psychopath ...
ALCohoL ReSeARCh C u r r e n t R e v i e w s506 Alcohol .docxADDY50
ALCohoL ReSeARCh: C u r r e n t R e v i e w s
506 Alcohol Research: C u r r e n t R e v i e w s
Resilience to Meet the
Challenge of Addiction
Psychobiology and Clinical Considerations
Tanja N. Alim, M.D.; William B. Lawson, M.D.; Adriana Feder, M.D.; Brian M.
Iacoviello, Ph.D.; Shireen Saxena, M.S.; Christopher R. Bailey; Allison M.
Greene, M.S.; and Alexander Neumeister, M.D.
Tanja N. Alim, M.D., is an assis-
tant professor and William B.
Lawson, M.D., is a professor
and chair of the Department
of Psychiatry, both at the
Department of Psychiatry and
Behavioral Sciences, Howard
University, Washington, DC.
Adriana Feder, M.D., is an assistant
professor; Brian M. Iacoviello,
Ph.D., is a postdoctoral fellow;
and Shireen Saxena, M.S.,
Christopher R. Bailey, and
Allison M. Greene, M.S., are
research associates; all at the
Mood and Anxiety Disorders
Program, Department of Psychiatry,
Mount Sinai School of Medicine,
New York, New York.
Alexander Neumeister, M.D., is
a professor in the Department of
Psychiatry and Radiology, New
York University Langone Medical
Center, New York, New York.
Acute and chronic stress–related mechanisms play an important role in the
development of addiction and its chronic, relapsing nature. Multisystem adaptations in
brain, body, behavioral, and social function may contribute to a dysregulated
physiological state that is maintained beyond the homeostatic range. In addition,
chronic abuse of substances leads to an altered set point across multiple systems.
Resilience can be defined as the absence of psychopathology despite exposure to
high stress and reflects a person’s ability to cope successfully in the face of adversity,
demonstrating adaptive psychological and physiological stress responses. The study of
resilience can be approached by examining interindividual stress responsibility at
multiple phenotypic levels, ranging from psychological differences in the way people
cope with stress to differences in neurochemical or neural circuitry function. The
ultimate goal of such research is the development of strategies and interventions to
enhance resilience and coping in the face of stress and prevent the onset of addiction
problems or relapse. Key WoRDS: Addiction; substance abuse; stress; acute stress
reaction; chronic stress reaction; biological adaptation to stress; psychological
response to stress; physiological response to stress; resilience; relapse; coping
skills; psychobiology
evidence from different disciplinessuggests that acute and chronicstress–related mechanisms play
an important role in both the develop-
ment and the chronic, relapsing nature
of addiction (Baumeister 2003; Baumeister
et al. 1994; Brady and Sinha 2005).
Stress is defined as the physiological
and psychological process resulting from
a challenge to homeostasis by any real
or perceived demand on the body
(Lazarus and Fokman 1984; McEwen
2000; Selye 1976). Stress often induces
multisystem adaptations that occur in
the brain and .
ALCohoL ReSeARCh C u r r e n t R e v i e w s506 Alcohol .docxSHIVA101531
ALCohoL ReSeARCh: C u r r e n t R e v i e w s
506 Alcohol Research: C u r r e n t R e v i e w s
Resilience to Meet the
Challenge of Addiction
Psychobiology and Clinical Considerations
Tanja N. Alim, M.D.; William B. Lawson, M.D.; Adriana Feder, M.D.; Brian M.
Iacoviello, Ph.D.; Shireen Saxena, M.S.; Christopher R. Bailey; Allison M.
Greene, M.S.; and Alexander Neumeister, M.D.
Tanja N. Alim, M.D., is an assis-
tant professor and William B.
Lawson, M.D., is a professor
and chair of the Department
of Psychiatry, both at the
Department of Psychiatry and
Behavioral Sciences, Howard
University, Washington, DC.
Adriana Feder, M.D., is an assistant
professor; Brian M. Iacoviello,
Ph.D., is a postdoctoral fellow;
and Shireen Saxena, M.S.,
Christopher R. Bailey, and
Allison M. Greene, M.S., are
research associates; all at the
Mood and Anxiety Disorders
Program, Department of Psychiatry,
Mount Sinai School of Medicine,
New York, New York.
Alexander Neumeister, M.D., is
a professor in the Department of
Psychiatry and Radiology, New
York University Langone Medical
Center, New York, New York.
Acute and chronic stress–related mechanisms play an important role in the
development of addiction and its chronic, relapsing nature. Multisystem adaptations in
brain, body, behavioral, and social function may contribute to a dysregulated
physiological state that is maintained beyond the homeostatic range. In addition,
chronic abuse of substances leads to an altered set point across multiple systems.
Resilience can be defined as the absence of psychopathology despite exposure to
high stress and reflects a person’s ability to cope successfully in the face of adversity,
demonstrating adaptive psychological and physiological stress responses. The study of
resilience can be approached by examining interindividual stress responsibility at
multiple phenotypic levels, ranging from psychological differences in the way people
cope with stress to differences in neurochemical or neural circuitry function. The
ultimate goal of such research is the development of strategies and interventions to
enhance resilience and coping in the face of stress and prevent the onset of addiction
problems or relapse. Key WoRDS: Addiction; substance abuse; stress; acute stress
reaction; chronic stress reaction; biological adaptation to stress; psychological
response to stress; physiological response to stress; resilience; relapse; coping
skills; psychobiology
evidence from different disciplinessuggests that acute and chronicstress–related mechanisms play
an important role in both the develop-
ment and the chronic, relapsing nature
of addiction (Baumeister 2003; Baumeister
et al. 1994; Brady and Sinha 2005).
Stress is defined as the physiological
and psychological process resulting from
a challenge to homeostasis by any real
or perceived demand on the body
(Lazarus and Fokman 1984; McEwen
2000; Selye 1976). Stress often induces
multisystem adaptations that occur in
the brain and .
1PAGE 21. What is the question the authors are asking .docxfelicidaddinwoodie
1
PAGE
2
1. What is the question the authors are asking?
They asked about a reduction in judgmental biases regarding the cost and probability associated with adverse social events as they are presumed as being mechanisms for the treatment of Social Anxiety Disorder (SAD). Also, the authors poised on the changes in judgmental biases as mechanisms to explain cognitive-behavioral therapy for social anxiety disorder. On top of that, they stated that methodological limitations extant studies highlight the possibility that rather than causing symptom relief, a significant reduction in judgmental biases tends to be consequences of it or correlate. Considerably, they expected cost bias at mid-treatment to be a predictor of the treatment outcome.
2. Why do the authors believe this question is important?
According to the authors, this question was relevant as methodological limitations of present studies reflect on the possibility that instead of causing symptom belief, a significant reduction in judgmental biases can be consequences or correlated to it. Additionally, they ought to ascertain the judgment bias between treated and non-treated participants. Significantly, this was important as they had to determine the impact of pre and post changes in cost and probability of the treatment outcomes. But, probability bias at mid-treatment was a predictor of the treatment outcome contrary to the cost bias at mid-treatment that could not be identified as a significant predictor of the treatment outcome.
3. How do they try to answer this question?
They conducted a study to evaluate the significant changes in judgmental bias as aspects of cognitive-behavioral therapy for social anxiety disorders. To do this, they conducted a study using information from two treatment studies; an uncontrolled trial observing amygdala activity as a response to VRE (Virtual Reality Exposure Therapy) with the use of functional magnetic resonance imaging and a randomized control trial that compared Virtual Reality Exposure Therapy with Exposure Group Therapy for SAD. A total of 86 individuals who met the DSM-IV-TR criteria for the diagnosis of non-generalized (n=46) and generalized (n=40) SAD participated. After completing eight weeks of the treatment protocol, the participants who identified public speaking as their most fearsome social situation were included. The SCID (Structured clinical interview for the DSM-IV) was used to ascertain diagnostic and eligibility status on Axis 1 conditions within substance abuse, mood and anxiety disorder modules. The social anxiety measures were measured with the use of BFNE (Brief Fear of Negative Evaluation), a self-reporting questioner that examined the degree to which persons fear to be assessed by other across different social settings. Additionally, the OPQ (Outcome Probability Questionnaire) self-reporting questionnaire was used to evaluate individual’s estimate on the probability that adverse, threatening events will occur at t ...
Understanding Oncology Nurses’ Grief: A Qualitative Meta-AnalysisLisa Barbour
Barbour, L. C. (2016, September 16-18). Understanding oncology nurses’ grief: A qualitative meta-analysis. A presentation at the Athabasca University 2016 Graduate Student Conference, Edmonton, AB.
Konflikt poznawczy w psychoterapii: perspektywa konstruktywistyczna [El confl...Guillem Feixas
Jasiński, M. y Feixas, G. (2015, octubre). Konflikt poznawczy w psychoterapii: perspektywa konstruktywistyczna [El conflicto cognitivo en psicoterapia: perspectiva constructivista]. Comunicación presentada en el Simposio W poszuiwaniu znaczeń en el Konferencja Trzech Sekcji. Między dobrem pacjenta, dobrem terapeuty a dobrem systemu: dylematy etyczne w psychoterapii [Entre el bien del paciente, terapeuta y sistema: dilemas éticos en psicoterapia], Cracovia, Polonia.
A Constructivist-Process View of (De-)Radicalisation: A Person-Context DiagramGuillem Feixas
A general schema by Guillem Feixas & David A. Winter, 2016
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
Negative views of self or internal conflictsGuillem Feixas
Feixas, G. y Montesano, A. (2015, Marzo). Negative Views of Self or Internal Conflicts as Targets of Psychotherapy, In G. Feixas (Chair), Conflict in Meaning Systems: Perspectives and Implications for Mental Health and Psychotherapy del International Convention of Psychological Science, Amsterdam, Holanda.
Feixas, G. (2015, Marzo). Conflict in Meaning Systems: Perspectives and Implications for Mental Health and Psychotherapy. Symposium Chair en el International Convention of Psychological Science, de la APS (Association for Psychological Science), Amsterdam, Holanda.
Efectividad de un programa terapéutico integrado para trastornos graves de la...Guillem Feixas
Abstract
Introducción
En los últimos 25 años varios estudios han mostrado la eficacia de diversas intervenciones psicológicas para los trastornos graves de la personalidad. Sin embargo, la generalización de estos resultados positivos desde entornos con larga tradición investigadora a condiciones de práctica habitual ha sido cuestionada, reclamándose la replicación en estudios pragmáticos.
Métodos
Este estudio pragmático compara las hospitalizaciones y las visitas a Urgencias antes y durante un programa terapéutico de 6 meses para trastornos graves de la personalidad y 36 meses después del inicio. El programa terapéutico, que integra varias intervenciones específicas en un encuadre coherente, se realizó en un entorno de práctica habitual. Se incluyeron 51 pacientes evaluados de acuerdo con criterios DSM-IV por medio de la versión española de la Entrevista Clínica Estructurada para Trastornos de la Personalidad (SCID-II).
Resultados
Las características clínicas evidenciaron un grupo de pacientes muy graves, de los que el 78,4% cumplía criterios de trastorno límite de la personalidad. El porcentaje de pacientes hospitalizados y que visitaron Urgencias, así como el número de días de hospitalización y de visitas a Urgencias, se redujo significativamente durante el tratamiento, y esta mejoría se mantuvo en el tiempo.
Conclusiones
Un tratamiento integrado para trastornos graves de la personalidad puede ser efectivo para reducir las readmisiones o las estancias hospitalarias prolongadas cuando es implementado por clínicos en condiciones de práctica habitual.
Abstract
Introduction
Over the past 25 years, several studies have shown the efficacy of a number of psychological interventions for severe personality disorders. However, the generalizability of these positive results from long traditional research settings to more ordinary ones has been questioned, requiring a need for replication in pragmatic studies.
Methods
This pragmatic study compares hospitalizations and Emergency Room visits before and during a 6-month therapeutic program for severe personality disorders, and at 36 months after starting it. The therapeutic program, which integrates several specific interventions within a coherent framework, was carried out in an ordinary clinical setting. Fifty-one patients, evaluated according DSM-IV criteria by using the Spanish version of the Structured Clinical Interview for Personality Disorders (SCID-II), were included.
Results
The clinical characteristics showed a group of severely disturbed patients, of which 78.4% met criteria for borderline personality disorder. The percentage of patients hospitalized and visiting the Emergency Room, as well as the number of days of hospitalization and Emergency Room visits was significantly reduced during the treatment, and this improvement was maintained throughout.
Conclusions
An integrated treatment for severe personality disorders could be ef
Tanto con las tareas como en los rituales se trata de que varios miembros de la familia hagan cosas conjuntamente. Enalgunas ocasiones, estas tareas se ponen al servicio de
la promoción de alianzasalternativas a las existentes, en lo que se denomina reestructuración de límites.A veces también permiten manifestar simbólicamente significados familiaresno explícitos. Podemos distinguir varias modalidades.
Reformulación. Tal y como Watzlawick, Weakland y Fisch (1974) lo describen en su obra Cambio:
… reformular significa cambiar el fondo o la visión conceptual y/o emocional en relación con la cual se experimenta una situación poniéndola dentro de otro
marco que se adapta, tan bien o mejor que aquél, a los “hechos” de la misma situación concreta, cambiando así completamente su significado.
El genograma en terapia familiar sistémica Guillem Feixas
El genograma es una representación gráfica (en forma de árbol genealógico) de la información básica de, al menos, tres generaciones de una familia. Incluye información
sobre su estructura, los datos demográficos de los miembros y las relaciones que mantienen entre ellos. De esta forma, proporciona a “golpe de vista” una gran
cantidad de información, lo que permite no sólo conocer a la familia, sino realizar hipótesis acerca de la relación entre el problema y el contexto familiar, la evolución del
problema a lo largo del tiempo, su relación con el ciclo vital de la familia, etc.
La efectividad de la psicoterapia es un campo de interés que ha generado numerosas investigaciones. Diversas variables como son la alianza terapéutica, el estilo de convivencia o comunicación familiar, así como la percepción del ajuste marital han sido estudiadas para valorar el efecto que la psicoterapia ejerce. A continuación exponemos brevemente algunos instrumentos de medida que permiten evaluar el cambio terapéutico en el marco de la terapia familiar y de pareja.
El equipo como instrumento de intervención Guillem Feixas
Navarro (1992) desglosa las diferentes funciones que puede cumplir el equipo terapéutico en terapia familiar sistémica: El equipo actúa como un grupo observador
en las tareas de evaluación familiar, ofrece ayuda al terapeuta en la toma de decisiones o en situaciones comprometidas dentro de la sesión (p. ej., cuando el
terapeuta se enfrasca en una discusión no productiva con la familia) y, por último, puede actuar en sí mismo como un instrumento de intervención.
Partiendo de la idea de familia como sistema, el síntoma se concibe dentro del contexto familiar en el que se da, dentro del patrón interaccional en el que se produce. En este sentido, comprender el síntoma implica conocer cómo se concatena con todas las demás conductas de la familia (causalidad circular).
Las cartas terapéuticas en el modelo sistémico Guillem Feixas
Las cartas terapéuticas son un recurso narrativo de gran interés en la terapia. Pueden encontrarse muchos antecedentes del uso de cartas en los inicios del modelo sistémico.
Conflictos cognitivos en síndrome del intestino irritable (SII), un estudio e...Guillem Feixas
En este estudio descriptivo transversal se exploran algunas características cognitivas y sintomáticas de 13 pacientes consultantes con Síndrome del Intestino Irritable (SII) comparados con una muestra de 63 sujetos no consultantes sin síntomas del SII ni psicopatológicos. El 92% de los primeros cumple criterios para algún trastorno
del eje I del DSM-IV y su diagnóstico principal puede agruparse en dos categorías: trastornos por ansiedad y por somatización. En conjunto, los pacientes con SII
muestran más conflictos cognitivos detectados mediante la Técnica de Rejilla (TR) de Kelly que los sujetos normales. Considerando el subgrupo de trastorno por somatización, se observa una tendencia mucho más acentuada a mostrar mayor número de estos conflictos, así como una tendencia clara a presentar mayor polarización y, a su vez, menor complejidad cognitiva (diferenciación), con respecto tanto a los sujetos asintomáticos como a los diagnosticados por trastorno de ansiedad; por su parte, éstos muestran una menor autoestima.
Dilemas implicativos e ajustamento psicológico, um estudo com alunos recém ch...Guillem Feixas
Neste artigo apresentamos uma investigação focalizada no ajustamento psicológico e na experiência pessoal de alunos recém-chegados à Universidade. O nosso objectivo consistiu, por um lado, em analisar as dificuldades no ajustamento psicológico que estes alunos manifestam, quer através da presença de sintomatologia psicopatológica quer através das dificuldades na resolução de problemas de vida, e por outro, analisar se estas dimensões estão relacionadas com a presença de dilemas
implicativos. Participaram neste estudo descritivo transversal 48 alunos que frequentavam pela primeira vez a Universidade do Minho. Os dilemas implicativos foram identificados através da Grelha de Repertório de Kelly, os sintomas psicopatológicos foram avaliados através do SCL-90-R e as dificuldades na resolução de problemas foram identificadas com o Inventário de Resolução de Problemas. Os resultados indicam uma correlação negativa e altamente significativa entre a presença de sintomatologia psicopatológica e as competências de resolução de problemas. Os resultados sugerem, ainda, que a relação entre a presença de dilemas e a sintomatologia psicopatológica, e a relação entre presença de dilemas e dificuldades na resolução de problemas, embora não significativas, são no sentido esperado. Discutimos as implicações destes resultados
para a compreensão dos desafios que a transição para a Universidade pode constituir no ajustamento psicológico dos estudantes.
Manual de intervención en dilemas implicativosGuillem Feixas
The notion that human beings face internal conflicts is very old in the field of psychotherapy. Also, it is common the idea that symptoms could be derived from those
conflicts. However, attempts for developing ways of appraising those conflicts so that they can be measured and tested empirically are almost inexistent. Precisely, the Multi-Centre Dilemma Project is aimed at investigating the role of those conflicts, termed implicative dilemmas or dilemmatic constructs, in health using the Repertory Grid
Technique as a method to identify them. So far, a higher presence of those conflicts has been found in a variety of clinical problems (depression, social phobia, somatic
problems, etc.) in comparison to non-clinical samples. Therefore, it seems convenient to develop a form of intervention aimed to dealing and resolving these conflicts.
In this paper a therapy manual focused on implicative dilemmas resolution is presented. It consists of a structured intervention for 15 sessions, designed mainly for
research and training in psychotherapy, and based on Personal Construct Psychotherapy.
Somatización y conflictos cognitivos, estudio exploratorio con una muestr cli...Guillem Feixas
Los problemas de somatización generan un elevado consumo de recursos y algunos tratamientos habituales resultan ineficaces o contraproducentes. Parece necesario un abordaje multidisciplinar que ofrezca un tratamiento integral a estos pacientes. Esta perspectiva debería tener en cuenta factores cognitivos poco estudiados como la construcción subjetiva del sí mismo, los síntomas y los
demás. De ahí el interés de estudiar los conflictos cognitivos, que podrían erigirse en barreras subjetivas
para la curación. El objetivo de este estudio es investigar las relaciones entre los dilemas implicativos, un tipo de conflicto cognitivo que puede detectarse con la Técnica de Rejilla, y una escala de somatización. Los resultados sugieren que las puntuaciones en somatización son más
elevadas en personas con dilemas implicativos, y la presencia de estos conflictos predice mejor la somatización que el sexo, la edad, la autoestima o la diferenciación cognitiva.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
Follow us on: Pinterest
Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
HOT NEW PRODUCT! BIG SALES FAST SHIPPING NOW FROM CHINA!! EU KU DB BK substit...GL Anaacs
Contact us if you are interested:
Email / Skype : kefaya1771@gmail.com
Threema: PXHY5PDH
New BATCH Ku !!! MUCH IN DEMAND FAST SALE EVERY BATCH HAPPY GOOD EFFECT BIG BATCH !
Contact me on Threema or skype to start big business!!
Hot-sale products:
NEW HOT EUTYLONE WHITE CRYSTAL!!
5cl-adba precursor (semi finished )
5cl-adba raw materials
ADBB precursor (semi finished )
ADBB raw materials
APVP powder
5fadb/4f-adb
Jwh018 / Jwh210
Eutylone crystal
Protonitazene (hydrochloride) CAS: 119276-01-6
Flubrotizolam CAS: 57801-95-3
Metonitazene CAS: 14680-51-4
Payment terms: Western Union,MoneyGram,Bitcoin or USDT.
Deliver Time: Usually 7-15days
Shipping method: FedEx, TNT, DHL,UPS etc.Our deliveries are 100% safe, fast, reliable and discreet.
Samples will be sent for your evaluation!If you are interested in, please contact me, let's talk details.
We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
2. sample, patients with IDs presented lower levels of global functioning and a more frequent
history of suicide attempts.
Conclusions. Cognitive conflicts were more prevalent in depressive patients and were
associated with clinical severity. Conflict assessment at pre-therapy couldaid in treatment
planning to fit patient characteristics.
Practitioner points
Internal conflicts have been postulated in clinical psychology for a long time but there is little evidence
about its relevance due to the lack of methods to measure them.
We developed a method for identifying conflicts using the Repertory Grid Technique.
Depressive patients have higher presence and number of conflicts than controls.
Conflicts (implicative dilemmas) can be a new target for intervention in depression.
Cautions/Limitations
A cross-sectional design precluded causal conclusions.
The role of implicative dilemmas in the causation or maintenance of depression cannot be ascertained
from this study.
Recent research has produced growing evidence for the role of cognitive factors (e.g.,
automatic thoughts, dysfunctional schemas, attribution bias) in the onset and
maintenance of depression (e.g., Abramson et al., 2002). However, internal conflicts
have not been considered in the cognitive model of depression even when they have
been quite a common notion in psychology for more than a century. Indeed, various
psychological theories have underlined the relevance of intrapsychic conflicts leading
people to internal struggles that might block their development, giving rise to
suffering and symptoms. Foremost, the importance of intrapsychic conflict is
highlighted in virtually all psychoanalytic theories (e.g., Horowitz, 1988). Furthermore,
a classical notion addressing internal conflict is that of cognitive dissonance, but we
can find other more clinically oriented approaches such as those of Grawe’s (2004)
incongruence theory, and widely used concepts of resistance and ambivalence in
psychotherapy (e.g., Engle Arkowitz, 2006). Another approach, Perceptual Control
Theory (Powers, 2005) proposes a major role of goal conflict and influenced Grawe’s
(2004) work. More recently, it has led to the development of method of levels, a
transdiagnostic cognitive therapy which focuses specifically on conflict formulation
(e.g., Carey, 2008; Mansell, Carey, Tai, 2012). These authors consider conflicts as
common processes underlying psychological distress and so aim at resolving them
through reorganizing conflictual cognitive control systems. Unfortunately, and in
contrast with the relative abundance of clinical literature, intrapersonal conflict is yet
an underresearched topic within contemporary clinical psychology. Empirical research
about this topic is needed to clarify to what extent cognitive conflicts might play a
role in the onset and maintenance of psychological disorders, and whether they could
be important in explaining some patients’ difficulties for change (Michalak, Heidenr-
eich, Hoyer, 2011).
The growing literature around intrapersonal conflict and its role in psychological
distress has supported the idea that, although conflict might be quite a common
phenomenon, some forms of unresolved inner conflict lies at the core of many
psychopathological manifestations (e.g., Carey, 2008; Lauterbach, 1996; Mansell, 2005).
Broadly, two kinds of methods have been used to investigate the role of intrapersonal
2 Guillem Feixas et al.
3. conflicts. On the one hand, various approaches created specific methods for measuring
implicit conflicts. For instance, psychodynamic theories developed operationalized
systems for assessing conflict as a crucial diagnostic axe (e.g., Cierpka, Rudolf, Grande,
Stasch, 2007; Luborsky, 1977; Perry, 1990). Lauterbach (1996; Lauterbach Newman,
1999) developed the intrapersonal conflict test for quantifying conflict based on Heider’s
(1946) balance theory and, thus, defined conflict as inconsistency between attitudes and
beliefs. Studies using these methods have reported correlations between conflicts and
symptom severity (e.g., Renner Leibetseder, 2000) and reduction of conflict after
psychotherapy (e.g., Hoyer, Fecht, Lauterbach, Schneider, 2001). A common feature of
these methods is that the elements involved in these conflicts are defined a priori by the
researcher.
On the other hand, a second cluster of approaches have developed methods for
quantifying conflict among ideographically generated personal goals (e.g., Emmons
King, 1988; Little, Salmera-Aro, Phillips, 2007). Research on this topic has shown that
goal conflict influenced subjective well-being and life satisfaction (see Riediger, 2007, for a
review). High levels of goal conflicts were associated with increased levels of negative
affect, depression, neuroticism, and psychosomatic complains (see Michalak et al., 2011,
for a review). These methods are based mainly on motivational conflicts (e.g.,
approach-avoidance) and restricted to conscious interference between goals (as reported
by participants). Therefore, they may be more sensitive to social desirability and
self-presentation effects which may limit their applicability in psychotherapy. This vein of
research has shown, nonetheless, how conflict, as a motivational factor, influences
experience and behaviour generating behaviour inhibition, motivational deficits, and
difficulties in action control (e.g., Emmons, King, Sheldon, 1993). It is reasonable to
assume that these difficulties can be contributing to a variety of depressive symptoms
(e.g., reduced activity), to their persistence over time and, especially, to the engagement
of clients in the process of therapeutic change. But further empirical studies are warranted
to verify the extent and nature of the influence of conflict on depression and other
disorders.
In this article, we build on existing support for the relevance of conflicts by studying
the role of a particular variety of cognitive conflict, called implicative dilemma (ID) (see
Feixas, Saul, Avila, 2009), in a sample of patients diagnosed with major depression. Our
study is based on Kelly’s personal construct theory (1955/1991) which provides a suitable
conceptual and methodological framework for the empirical study of internal conflicts
related to the construction of the self. In brief, Kelly’s theory explores the subjective way
in which people construct their experience by analysing their personal constructs, which
are bipolar dimensions of personal meanings (e.g., being depressed vs. happy). This
theory holds an agentive (Bandura, 2001) and proactive vision of human beings, and so
asserts that individuals regulate motivational, emotional processes, and actions on the
basis of the congruence or discrepancy between the construction of the ‘self’ and the
‘ideal self’ (coinciding with Carver Scheier, 1998; Cervone Shoda, 1999; Higgins,
1987). But self-ideal discrepancy is not necessarily a conflict. For conceptualizing
conflicts, personal construct theory acknowledges that humans may employ a variety of
constructions which are inferentially incompatible with each other (Kelly’s fragmen-
tation corollary). From this perspective, it is likely that dilemmas arise when a person
has to reconcile the self with personally held values. For instance, Rowe (1971)
described the case of a chronic depressive patient who faced the dilemma between
staying depressed (associated in her construct system with ‘being human’) or change,
and become a ‘destructive’ or ‘unpleasant’ person (according to her own vision). This
Cognitive conflicts in major depression 3
4. was conflict stemming from the particular configuration of implications of her
construct system.
Kelly’s Repertory Grid Technique (RGT; Feixas Cornejo, 2002; Fransella, Bell,
Bannister, 2004) allows for an individually tailored assessment of conflictual configura-
tions of personalconstructs within the client’s cognitive system.Specifically, the notion of
ID (Feixas Saul, 2004; Feixas et al., 2009) makes reference to those conflicts in which a
desired change (e.g., stop being depressed) implies an unwished change (e.g., becoming
unpleasant). In this example, we see that a change in specific, symptom level aspects
implies a change in identity (i.e., becoming a different kind of person). Operationally, two
types of personal constructs are involved in an ID. On the one hand, discrepant constructs
are those in which the person perceives a significant discrepancy between the ‘present
self’ and the ‘ideal self’ so that one pole of the construct describes the present and the
other pole the ideal self. They typically signify areas of malaise, such as symptoms in which
change from one pole to the opposite one is desired. On the other hand, congruent
constructs represent areas of self-satisfaction (as indicated by the similarity between the
present and the ideal self, both described by one construct pole) which might be
connected to personal values or beliefs. In the example of Figure 1, the participant
considered herself as being the kind of person who ‘does not love herself’ (left pole) but
she would like to start ‘loving herself’ (right pole of the discrepant construct). At the same
time, in congruency with her ideal self, she considered herself as being ‘protective’ (left
pole) and did not want to become ‘unemotional’ (right pole of the congruent construct;
note that all these constructs are personal, i.e., her own words). The RGT allows for the
calculation of correlations among all the constructs elicited from the interviewee. So,
whenever an association is found between the desired pole of the discrepant construct
(‘love herself’ in Figure 1) and the undesirable pole of the congruent construct
(‘unemotional’ in Figure 1), an ID is identified. Therefore, discrepant constructs per se
do not represent a conflict but just a discrepancy, a goal that should be attained. Rather, it
is the conflictive association between a discrepant and a congruent construct which
causes conflict. In these cases, the need for change (she wants to love herself) might be
hindered by the need for self-ideal congruency (continue being protective). What an ID
tells us is that the need for change expressed by the discrepant construct is in conflict with
the need for coherence expressed by the congruent construct. Thus, the patient
unwittingly hesitates in taking a clear course of action because striving for loving herself
has negative implications for her identity. In the view of such a dilemma, change may be
Figure 1. Example of an implicative dilemma of a depressed patient from the clinical sample.
4 Guillem Feixas et al.
5. less likely to occur because abandoning the symptoms would result in invalidation of core
aspects of the self.
The measure of IDs is both standardized and quantifiable in structure, and idiographic
in content. It is also relevant for explaining both symptom maintenance and ambivalence
towards change. In addition, it lessens the effect of social desirability given that conflicting
constructs are detected from grid data using a structured computerized procedure (see
below) which is not evident to the subject and does not employ any explicit question
about conflicts. Thus, this method using IDs could constitute an integration of the
advantages of the aforementioned approaches considering that it assesses conflict in a
way which is not based in the explicit wording of a contradiction or conflict by the
interviewees but by means of more implicit associations among their specific self-gen-
erated goals (personal constructs).
Early studies within the Multicenter Dilemma Project (Feixas Saul, 2004; www.usal.
es/tcp) showed the relevance of IDs across various clinical samples over other types of
cognitive conflicts. For instance, Feixas et al. (2009) found that more than half of a group
of patients seeking psychotherapy (n = 284) presented this type of cognitive conflict. By
contrast, less than a third of the non-clinical group (n = 322) did so. This significant
difference was not found with other existing procedures to identify conflicts such as
unbalanced triads (e.g., Sheehan, 1981). In a subsequent study with 87 patients it was
found that most patients who presented conflicts at the initial psychotherapy assessment
did not have those conflicts at post-therapy. Also, resolution of IDs was associated with
symptom improvement (Feixas, Saul, Winter, Watson, 2008). In fact, in those cases in
which conflicts were not resolved had a poorer outcome. These studies suggest that IDs
could be targeted for psychotherapeutic intervention and their resolution could be
pursued as a way out from suffering, blockage, and recurrence.
Although several treatments have proved their effectiveness in the treatment of
depression, more than 20% of all patients with a major depressive episode develop a
chronic course (Angst, Gamma, R€ossler, Ajdacic, Klein, 2009; Rubio et al., 2011). To
date, there are no conclusive data about risk factors for chronic depression (H€olzel,
Harter, Reese, Kriston, 2011) neither consistent markers nor diagnostic tests to predict
recovery (Solomon et al., 2008). Furthermore, duration of illness and intervals between
episodes are highly variable from one patient to another which limits clinical decision
making. In this sense, cognitive conflicts might help expand cognitive models of
depression and provide a theoretical explanation as well as practical procedures to
approach relapse and chronicity. The notion of ID seems particularly suitable for that
because it encompasses both the patient’s need for change and his or her need for
continuity.
Preliminary evidence for increased levels of conflict in depressed patients comes from
studies showing significant associations between emotional distress and intergoal
interference or attitude inconsistencies. In regard to goal conflicts, although two studies
found that conflict was associated with higher levels of depression, two studies failed to
replicate the findings in undergraduate and in outpatient samples (see Michalak et al.,
2011, for a review). In addition, a clinical study (P€uschel, Schulte, Michalak, 2011)
associated motive-goal discrepancies with higher levels of depression and reduced sense
of coherence. Research using Lauterbach’s assessment of conflict found inverse
relationships between conflict and mood in non-clinical samples. Furthermore, a recent
study comparing depressed inpatients and controls showed large differences in
conflictual constellations (Stangier, Ukrow, Schermelleh-Engel, Grabe, Lauterbach,
2007). Finally, two preliminary studies, one with a sample of mixed depressive disorders
Cognitive conflicts in major depression 5
6. (Feixas, Montesano, Erazo-Caicedo, Compa~n, Pucurull, 2014) and another with
dysthymic patients (Montesano et al., 2014), found higher percentages of clinical
participants presenting with IDs as compared to controls. However, to our knowledge, a
systematic evaluation of cognitive conflicts in major depression has not yet been
conducted.
This study explored the relevance of IDs to major depression by testing three
hypotheses. First, based upon previous findings, we hypothesized that IDs would appear
in greater frequency and proportion in depressed than non-depressed participants. The
results of the above mentioned previous studies were promising but had important
methodological limitations such as heterogeneity of diagnosis, small sample size, or
inadequate control groups. To increase the generalizability of those findings, this study
investigates the role of IDs in major depression by (1) using more careful sampling
processes, (2) increasing the number of participants, and (3) refining the assessment
methodology.
Our second hypothesis proposed that presence and number of IDs would be
associated with different clinically relevant variables. Concretely, we expected that
participants presenting with IDs would display higher levels of symptom severity, poorer
global functioning, and higher prevalence of recurrent episodes. Finally, we explored the
content of constructs forming IDs. In accordance with previous findings (Montesano
et al., 2014) and the theoretical structure represented in Figure 1, we expected that
discrepant constructs would reflect predominantly emotional content connected to
depressive symptoms (e.g., happy vs. depressed), whereas congruent constructs would
be mostly of moral nature (e.g., good vs. bad) usually considered typical of core
constructs, values, and beliefs. We predicted that this thematic configuration would differ
from that of non-depressed participants.
Methods
Participants
The overall sample of the study consisted of 271 participants of both genders distributed
in two different groups, 161 depressed patients and 110 controls. For the major
depression sample inclusion criteria were as follows: (1) 18–70 years of age, (2) meeting
DSM-IV-TR (APA, 2000) criteria for major depression, and (3) a score of more than 19 on
the Beck Depression Inventory, second edition (BDI-II; Beck, Brown, Steer, 1996).
Exclusion criteria were (1) presence of bipolar, schizophrenia or schizoaffective
disorders, (2) presence of psychotic symptoms, (3) current substance abuse, and (4)
organic mental disorder, brain dysfunction or pervasive developmental delay. These
criteria were adopted following the example of similar studies. In regard to patients’
recruitment, 233 patients were referred to the study but 47 were initially excluded due to
several reasons (not meeting age inclusion criterion, declining to participate, or not
answering the phone). Of the 186 who were assessed, 19 were excluded because they did
not meet diagnostic criteria and six rejected further participation in the study. Finally, the
clinical sample was composed of 161 patients (78.3% females) recruited from several
community health care centres of the city of Barcelona (Spain) and its surrounding area.
The presence of other comorbid diagnoses was not criterion of exclusion, but it was
recorded as a variable and controlled in statistical analyses. About 40% of participants
presented with another Axis I diagnosis: panic disorder, 18.6%; panic disorder with
agoraphobia, 8.7%; dysthymic disorder, 6.2%; post-traumatic stress disorder,3.7%; anxiety
6 Guillem Feixas et al.
7. disorder not specified, 1.9%; anorexia nervosa, 0.6%. Patients meeting the inclusion
criteria and willing to participate in the study gave written informed consent on forms
approved by local research ethics committees.
The non-clinical sample was composed of 110 participants (71.8% females). The
inclusion criteria were as follows: (1) 18–65 years of age, (2) to score less than 14 on the
BDI-II (toensure that they did not present significant depressive symptomatology), and (3)
no history of psychiatric or neurological illness.
The demographic and clinical characteristics of participants are summarized in
Table 1. No significant differences were found between the two groups in gender, age,
and years of education whereas, as expected, samples differed significantly in BDI-II scores
and number of constructs (e.g., Feixas, Erazo, Harter, Bach, 2008; Feixas, Saul, et al.,
2008).
Instruments and measures
Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I; First, Spitzer, Gibbon, Williams,
1996)
The SCID-I is a semistructured interview that includes modules designed to assess either
the lifetime or current experience of categorically defined DSM-IV-TR Axis I psychiatric
disorders. SCID-I diagnoses display adequate test–retest reliability for major depressive
disorder in clinical samples (K = .66; Lobbestael, Leurgans, Arntz, 2011). Information
regarding diagnosis, global assessment scale scores, and history of suicide attempts was
also gathered for each depressed participant.
Beck Depression Inventory-II (BDI-II; Beck et al., 1996)
The BDI-II is a self-report measure of depression that has demonstrated strong internal
consistency in psychiatric outpatients (.92). It was used to assess participants’ symptom
severity. Jacobson and Truax (1991) formula to distinguish functional and dysfunctional
population yielded a cut-off of 16.92 using Spanish normative data (Sanz Vazquez,
2011). Having that score as a reference, we limited to 14 the maximum score for the
controlgroup and a minimum of 19 for the clinicalsample as a way to control the symptom
level within groups.
Repertory Grid Technique
The RGT is a constructivist assessment procedure originally proposed by Kelly (1955/
1991). It is a semistructured interview in which the interviewer first elicits elements
Table 1. Demographic characteristics of depressed patients and non-clinical participants
Characteristics Depression group Control group p value
Gender (female:male) 126:35 79:31 .29
Age (M; SD) 47.1; 11.3 44.5; 14.4 .11
Years of education (M; SD) 11.9; 2.4 12.2; 3.8 .52
No. of constructs (M; SD) 18.8; 5.1 23.2; 7.4 .001
BDI-II (M; SD) 36.1; 9.8 5.3; 4.4 .001
Note. M = mean; SD = standard deviation; BDI-II = Beck Depression Inventory II.
Cognitive conflicts in major depression 7
8. (present self, ideal self, and significant others identified by the participant). Then, these
elements are considered in dyads (two elements at a time) to elicit personal constructs by
asking for similarities and differences between each pair of elements (e.g., both mother
and sister are ‘friendly’). For each similarity or difference described by the participant, an
opposite construct pole is also elicited (e.g., ‘friendly vs. unconcerned’). Elicitation
continues until the person is unable to generate additional constructs and, then, the
interviewer asks the participant to rate each element on each of the elicited personal
constructs. These ratings use a 7-point Likert scale ranging from very much like the left
pole of the construct to very much like the contrasting right pole. This provides a matrix of
ratings for each participant’s grid, with columns representing important people of her or
his interpersonal world (elements) and rows representing construct dimensions (see
Figure 2 for an example). Several indexes can be obtained through the mathematical
analysis of the grid matrix; for the purpose of this study, two measures related to IDs were
used:
(1) Presence of IDs: According to Feixas and Saul (2004) a construct is classified as
discrepant whenever the ratings assigned to the element ‘present self’ and the
element ‘ideal self’ differ on 4 or more points within the 7-point scale used.
Conversely, those constructs in which the score given to ‘present self’ and ‘ideal self’
coincide (or there is no more than 1-point difference) are identified as congruent
constructs. Whenever either of the two elements is rated as 4 (the middle point),
then it is excluded from this classification. An ID is detected whenever the
correlation between the ratings given to a discrepant construct and those given to a
congruent construct is .35 or higher so that the desired pole of the discrepant
construct is associated with the undesired pole of the congruent construct (see
Figure 1). It is important to note that the desirability of the poles is regarded by the
score that participants give to their element ‘ideal-self’ for each construct. The
cut-off of .35 is based on Cohen’s guidelines (1988) indicating that a correlation
Figure 2. Example of the repertory grid of a patient of the clinical sample.
8 Guillem Feixas et al.
9. equal or higher than .30 implies a medium strength of the relationship for which we
have summed a conservative add-on of .05 points.
(2) Percentage of implicative dilemmas (PID): This percentage reveals the number of
IDs in a participant’s grid taking into account its size. Since the number of constructs
elicited during RGT administration varies across participants (thus influencing the
possible number of IDs within a grid) this measure is calculated by dividing the
number of dilemmas of a grid by the total number of possible combinations of
constructs of such grid taking two at a time. The resulting proportionis multiplied by
100 to find the percentage.
The reliability of the RGT has been estimated with test–retest studies providing stability
scores of 71–77% for the elements, and 47.7–69% for the elicited constructs. With respect
to the measures derived from the RGT, studies provide test–retest correlations ranging
from .61 to .95 (Feixas, Lopez Moliner, Navarro Montes, Tudela Marı, Neimeyer, 1992;
see Feixas Cornejo, 2002, for a review).
Classification System for Personal Constructs (CSPC; Feixas, Geldschl€ager, Neimeyer, 2002)
The CSPC is a system designed to analyse and classify the content of personal
constructs derived from constructivist assessment procedures, and particularly from
the RGT. The CSPC is composed of 45 exclusive and mutually excluding categories
arranged into six thematic areas (moral, emotional, relational, personal, intellectual,
specific values, and interests). Feixas et al. (2002) reported a high reliability index for
the CSPC (K = .93). It has already been applied to personal constructs of depressed
(Montesano, Feixas, Varlotta, 2009) and fibromyalgia patients (Compa~n et al.,
2011).
Procedure
Participants in the depressed group were recruited through medical referrals from several
health care centres from the city of Barcelona from 2008 to 2011. After referral they were
contacted for assessment sessions in their respective centres. Two independent and
specifically trained master-level students administered the instruments in face-to-face
interviews. These evaluators used the SCID-I, the BDI-II and other supplemental
information to determine if the patient met inclusion criteria. Control group participants
were recruited through agreements with cultural and civic associations to which free
psycho-educational talks were offered in compensation for their participation in the
study. Also, a call was made among graduate and undergraduate students to refer
non-clinical participants (friends and relatives) for the study. Non-depressed participants
were also administered the BDI-II to rule out depressive symptoms and to ensure the
fulfilment of inclusion criteria. All participants provided informed consent. A second
appointment was then scheduled to complete the assessment process with the RGT.
Conflicts were analysed post hoc with the GRIDCOR v. 4.0 (Feixas et al., 2002) software
and exported into the Statistical Package for Social Sciences version 20.0 (IBM
Corporation, Armonk, New York, NY, USA) datasheet for further analyses. Finally, two
independent well-trained graduate and undergraduate students codified with the CSCP
the content of the 907 constructs forming participants’ IDs (K = .98; p .001). Raters did
not know whether the grids corresponded to the clinical or the comparison group nor the
hypotheses of the study.
Cognitive conflicts in major depression 9
10. Results
Presence and number of implicative dilemmas
With the purpose of checking whether the proportion of participants presenting at least
one ID was different across samples, a chi-square test for independence was performed.
The results indicated a statistically significant association between presence of IDs and
type of sample – v2
(1, N = 271) = 30.08; p .001 – with a moderate effect size
(φ= À.33). As shown in Table 2, IDs were found in more than two-thirds of the
depression sample in contrast to about one-third of controls. To examine the influence of
gender, the proportion of male and female participants with and without IDs was
compared within both samples. Similar proportions of participants with and without IDs
were found in the clinical (females = 69 vs. 31%; males = 65.7 vs. 34.3%) and the
non-clinical samples (females = 34.2 vs. 65.8%; males = 35.5 vs. 64.5%). As expected,
there were no statistical differences between gender and presence of IDs in the
depression group – v2
(1) = 0.14; p = .71 – neither in the comparison group –
v2
(1) = 0.17; p = .89. The influence of presenting a comorbid diagnosis within the
clinical sample was also tested, with results indicating no differences – v2
(1) = 0.20;
p = .88 – in the presence nor in the number of IDs (U = 3,008; p = .69) between clinical
participants with (M = 2.60; SD = 3.76) and without (M = 2.71; SD = 3.65) another Axis
I diagnosis.
With respect to the number of IDs, an independent samples t-test was conducted to
compare the number of IDs between participants presenting IDs of both groups. There
was a significant difference – t(94.37) = À3.27; p = .002 – in PID scores for depressed
(M = 3.90; SD = 3.88) and control participants (M = 2.04; SD = 2.65). The magnitude of
the differences (mean difference = À1.85, 95% CI: À2.98 to À.73) was large (d = .67).
Implicative dilemmas and clinical measures
Several analyses were performed to test the relationship of IDs with various clinically
relevant variables. Significant differences were found – t(249) = À5.47, p .001
(two-tailed) g2
= .10 (medium effect) – in BDI-II scores for participants with
(M = 28.55; SD = 15.53; n = 148) and without IDs (M = 17.58; SD = 17.13; n = 123).
To explore the relationship between symptom severity and number of IDs (in participants
presenting IDs), BDI-II and PID correlations were calculated using Spearman’s coefficient.
There was a medium positive correlation between the two variables (q =.29, n = 148,
p = .001). PID scores explained 8.41% of the variance in respondent’s scores on BDI-II.
Table 2. Presence of implicative dilemmas
Presence of implicative dilemmas
No Yes
Depression, n = 161
Fr 51 110
% 31.7 68.3
Non-clinical, n = 110
Fr 72 38
% 65.5 34.5
Note. Fr = frequency.
10 Guillem Feixas et al.
11. The relationship between IDs and chronicity was inspected attending to the
recurrence of major depression episodes. In regard to presence of IDs and type of
diagnosis (single episode vs. recurrent), no significant difference was found – v2
(1,
n = 161) = 0.93; p = .33. However, it is worth highlighting that of the patients with a
diagnosis of recurrent depression (n = 80), 72.5% presented IDs, and 27.5% did not.
Furthermore, comparing the number of dilemmas for those participants presenting with
IDs, a Mann–Whitney test (U = 1,140; z = À2.20, p = .03, r = .21, small effect) indicated
a significant difference in the PID of single episode (M = 3.24; SD = 3.86; n = 52) and
recurrent depression patients (M = 4.49; SD = 3.84; n = 58).
The level of global functioning of depressed participants was examined in relation to
the presence and number of IDs. Significant differences in the global assessment scale
scores were found for participants with IDs (M = 56.3; SD = 7.3; n = 110) and without
IDs – M = 59.7; SD = 7.3; n = 51, t(159) = 2.76, p = .006; g2
= .046, medium effect. In
addition, Spearman’s correlation coefficient revealed a moderate negative correlation of
global functioning with the PID, q = À.26, n = 161, p = .001. Another clinical issue
observed was the relationship between IDs and suicide attempts. Within the clinical
sample, 22 depressive patients (13.7%) had tried to commit suicide at least once. Among
these, 19 (86%) presented IDs while three did not. The BDI-II mean of these participants
was examined to check out whether this difference was attributable to the level of
symptomatology. Patients with IDs showed a lower score (M = 36.68; SD = 11.41) than
participants without conflicts (M = 45; SD = 4). Small sample size precluded further
statistical comparisons between these groups.
Content analysis of implicative dilemmas
Since previous results indicated that IDs might be a relevant structure in the cognition of
major depressive patients, a content analysis of its components was performed. We
observed statistically significant differences when comparing depressive patients and
controls with respect to the content of congruent – v2
(5, n = 546) = 19.5; p = .002;
Cramer’s V = .189 – and discrepant constructs – v2
(5, n = 332) = 15.76; p = .008;
Cramer’s V = .218. With regard to congruent constructs, moral (e.g., responsible vs.
irresponsible) and relational (e.g., tolerant vs. authoritarian) areas were more prevalent in
the clinical sample, and congruent constructs were more emotional (visceral vs. rational)
and personal (organized vs. disorganized) in the comparison group. On the other hand,
discrepant constructs were more frequently coded as emotional for the clinical sample
and as intellectual for non-depressed participants, according to the adjusted standardized
residual values (cut-off point of 1.96 for an a = .05, see Table 3).
We also tested whether discrepant and congruent constructs presented different areas
of content within the clinical sample and which categories were more relevant for each
type of construct. Results showed that congruent constructs differed significantly
(medium effect size) from discrepant constructs in the type of content coded – v2
(5,
n = 684) = 121.15; p .001; Cramer’s V = .421. Congruent constructs belonged mostly
to the moral and relational areas, whereas discrepant constructs were predominantly of
emotional and personal content. For congruent constructs, the most frequent categories
within the moral area were ‘altruist–selfish’ (30.5%), ‘good person–badperson’ (24%), and
‘responsible–irresponsible’ (16.2%). Categories within the relational area were ‘pleasant–
unpleasant’ (17.7%), ‘tolerant–authoritarian’ (16.9%), and ‘extroverted–introverted’
(15.4%). On the other hand, the most frequent categories for discrepant constructs
within the emotional area were ‘balanced–unbalanced’ (32.7%), ‘optimistic–pessimistic’
Cognitive conflicts in major depression 11
12. (23.5%), and specific emotions (22.4%). In the personal area only the category ‘strong–
weak’ (20%) stood out.
Discussion
This study provided promising evidence for the relevance of IDs in major depression.
Indeed, inverse patterns were observed between samples: while over two thirds of
depressed patients presented at least one ID in their repertory grids, when assessed in the
control group this proportion was only one third. This difference was underlined by the
fact that, among those with at least one ID, depressed participants doubled the number of
IDs of controls. So, results indicated differences between depressed and non-depressed
participants regarding both prevalence of subjects with conflicts and individual frequency
of conflicts. Results from this study not only confirm those of a preliminary study of Feixas
et al. (2014) with depressive patients but they are also consistent with previous findings
pointing out that IDs are more frequent in a variety of clinical samples (e.g., Compa~n et al.,
2011; Dada, Feixas, Compa~n, Montesano, 2012; Melis et al., 2011) including dysthymia
(Montesano et al., 2014). Arguably, this type of cognitive conflict is not specific to
depression but might cut across several diagnoses. Nevertheless, the proportion of
participants with IDs in our study was higher than in other diagnostic entities, which lead
us to consider that IDs play a significant role in depression.
The relevance of cognitive conflicts in major depression becomes more noticeable by
observing the relationship between IDs and some clinical measures. In regard to symptom
severity, higher levels of symptoms were associated with both presence and number of
IDs in the sample as a whole. However, the correlation between BDI-II and PID explained
8.4% of the variance which is only a moderate support for the hypothesis that the number
of these cognitive conflicts is associated with higher level of symptoms. It might also be
the case that the relationship between symptom level and number of IDs is not linear. It
would be informative to explore with a prospective design whether these cognitive
Table 3. Differences between groups in the content of congruent and discrepant constructs forming
implicative dilemmas
Moral Emotional Relational Personal Intellectual Specific interests
CC
Depressed
% 36.7 11.2 31 13.6 1.7 6
Asr 2.2 À2.3 2.1 À2.8 À1.5 0.2
Non-clinical
% 26.2 19 21.4 23.8 4 5.6
Asr À2.2 2.3 À2.1 2.8 1.5 À0.2
DC
Depressed
% 11 37.1 21.6 26.5 2.7 1.1
Asr 1.3 2.1 À0.9 À0.5 À2.8 À1.8
Non-clinical
% 5.9 23.5 26.5 29.4 10.3 4.4
Asr À1.3 À2.1 0.9 0.5 2.8 1.8
Note. CC = congruent constructs; DC = discrepant constructs; Asr = adjusted standardized residuals.
12 Guillem Feixas et al.
13. conflicts are associated with higher rates of relapse and recurrence. In this study, we used
a retrospective measure of chronicity comparing patients with a single episode to patients
with a recurrent diagnosis. Our results indicated no significant difference between groups
in relation to the presence of IDs, but patients with recurrent depression showed a
tendency towards a higher number of IDs. Future research should include also more
refined assessments of the course of the disorder taking into account, for instance, age of
onset, number of episodes, and time between them.
An unexpected finding of the study was that clinical participants with IDs might
have a higher risk of committing suicide. Although the low number of cases precluded
performing statistical analyses, an inspection of BDI-II scores allowed us to discard
attributing this effect to symptom severity. In fact, there were only three patients who
did not present any cognitive conflicts of the 22 who tried to commit suicide. These
three participants showed BDI-II scores much higher than the mean of the clinical
sample. By contrast, the remaining 19 showed almost the same symptom severity than
the whole clinical group. These preliminary results warrant further research to
elucidate whether presence of identity-related conflicts, and the blockage associated
with them, could be considered as a marker of suicidal attempts and constitute a
mediating factor in the cognitive processes involved in suicidal behaviour of depressed
patients.
Differences between groups were also found in relation to the global assessment scale.
Among depressed participants, those who presented one or more IDs tended to display
lower levels of global functioning. Likewise, number of dilemmas was inversely associated
with global functioning scores indicating that patients with many IDs in their grids had a
poorer level of functioning. Epidemiological studies point out that most major depressive
patients tend to have, at some point in their evolution, substantial impairment of family,
work, or social life (Kessler et al., 2003). This study suggests that those patients with more
IDs might be contributing the most to those unfortunate effects.
Content analysis of the patients’ personal constructs offers a clearer image of how IDs
might be involved in symptom maintenance. As shown above, these identity-related
conflicts in depressed patients involve the association of symptom improvement with
undesired qualities such as negative moral values or undesired relational positions. This
reinforces the hypothesis that change may be less likely to occur (unless these dilemmas
are dealt with in the therapy context) because eliminating the symptoms would imply also
abandoning core constructs, values, or beliefs. To a large extent, our results concur with
Rowe’s observation (1983) about a typical depressive dilemma ‘I’d rather be good than
happy’ (p. 87).
Limitations and clinical implications
While the results of this study have clarified the role of IDs in major depression, there are
limitations which need to be considered when interpreting the results and looking at
clinical implications. First of all, it is important to note that the cross-sectional design of
this study precluded causal analysis of reported associations. Second, as mentioned above,
prospective design research is needed to determine the influence of IDs over the clinical
course and rates of relapse and recurrence in depression. Third, in this study, the role of
negative self- views of depressed participant’s was not controlled. Arguably, the higher
intensity and prevalence of conflicts may respond to increased negativity of depressed
participants’ grid-ratings. However, it is important to note that the measure of IDs
involves not only negative but also positive self-constructions. For every discrepant
Cognitive conflicts in major depression 13
14. construct there is another congruent. In the light of our results, future research should
elucidate whether the self of depressed patients is predominantly conflictual or negative.
Fourth, we did not control the use of medication. Typically, drug treatments vary both
within and between subjects, and this might have influenced the findings regarding
recurrence and severity of symptoms. Finally, another limitation affecting generalizabil-
ity is that our samples were selected so to include those individuals with high and low
levels of symptom severity for clinical and control groups respectively. Although this
selection helped to better depict the differences between samples, it is known that the
distribution of depressive symptoms in clinical (diagnosis of major depression) and
general populations overlap.
Our findings nonetheless lead us to some preliminary clinical implications. First, the
concept of ID might help explain the difficulties that therapists frequently encounter
in fully engaging depressed patients into therapeutic change. For instance, a
prototypical intervention in cognitive therapy for depression consists of identifying
negative self-appraisals and directly challenging patients’ beliefs about themselves.
However, such intervention would increase its efficiency by taking into account the
possible positive attributes related to symptoms and negative self-perceptions. In doing
so, the intervention could better help in decreasing the chance of symptom
persistence, which may manifest itself in ‘resistance’ to change or relapse, due to
the lack of compatibility of the proposed change with the self-system. In this sense, it
is important to remark that the concept of ID takes into account not only the need for
change (discrepant constructs) but also the need for continuity and identity coherence
(congruent constructs). Second, therapeutic strategies aiming at resolving cognitive
conflicts should be helpful in alleviating depressive symptomatology. For instance,
psychological interventions could specifically target dilemmas insofar as they could
constitute a focus of therapeutic work and allow individualizing the design of the
treatment to fit patient subjective experience. It is noteworthy that although the
concept of ID arose from a particular theoretical framework (personal construct
theory), a dilemma-focused intervention could constitute an ‘add-on’ for a broad range
of therapeutic models as it is being tested out in combination with CBT (Feixas et al.,
2013). Thirdly, IDs can be detected by means of the RGT. Thus, treatment procedures
for preventing future relapses may benefit from screening for the presence of such
conflicts and targeting those for intervention in case they appear in the patient’s grid.
Certainly, knowledge of cognitive conflicts hindering change processes could shed
light on the personal factors that maintain or worsen the disorder.
As said, there are already some therapeutic models that pay special attention to
conflicts and ambivalent appraisals in relation to change processes. For example, the
motivational interviewing model upholds that depressed patients tend to be ambiv-
alent towards change. Decisional balance becomes then a preferred intervention
(Arkowitz Miller, 2008). Coherence therapy (e.g., Ecker Hulley, 2008) also pointed
out that symptom maintenance is linked to the need of preserving the coherence of
self-identity. The aforementioned method of levels therapy focuses exclusively on
addressing conflict. Our findings could be seen as empirical support for these models
addressing ambivalence and conflict in the psychotherapeutic process. Regardless of
the actual model adopted, it seems reasonable to assume that identity-related conflicts
play a relevant role in depressed patients’ cognitive system and change processes.
Furthermore, it raises the need for the study of the effectiveness of a dilemma-focused
intervention for major depression (Feixas et al., 2013), which should mainly set the
agenda for our future research.
14 Guillem Feixas et al.
15. Acknowledgements
We are indebted to the following institutions and centres for their collaboration in this study:
Institut Catala de la Salut (CAP Manso), CAP Les Hortes, CSM Nou Barris, Parc de Salut Mar
(CSMA Martı Julia), and Capio Hospital General de Catalunya (Institut Trastorn Lımit). We also
thank Anna V. Pooley for help in English editing of this manuscript. Finally, we acknowledge
that this project was partially funded by the Spanish Ministry of Science and Innovation (ref.
PSI2008-00406).
References
Abramson, L. Y., Alloy, L. B., Hankin, B. L., Haeffel, G. J., MacCoon, D. G., Gibb, B. E. (2002).
Cognitive vulnerability-stress models of depression in a self-regulatory and psychobiological
context. In I. H. Gotlib C. L. Hammen (Eds.), Handbook of depression (3rd ed., pp. 268–294).
New York, NY: Guilford Press.
American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders
(4th ed., rev.). Washington, DC: Author.
Angst, J., Gamma, A., R€ossler, W., Ajdacic, V., Klein, D. (2009). Long-term depression versus
episodic major depression: Results from the prospective Zurich study of a community sample.
Journal of Affective Disorders, 115, 112–121. doi:10.1016/j.jad.2008.09.023
Arkowitz, H., Miller, W. R. (2008). Learning, applying and extending motivational interviewing. In
H. Arkowitz, H. A. Westra, W. R. Miller S. Rollnick (Eds.), Motivational interviewing in the
treatment of psychological problems (pp. 1–25). New York, NY: Guilford.
Bandura, A. (2001). Social cognitive theory: An agentive perspective. Annual Review of Psychology,
52, 1–26. doi:10.1146/annurev.psych.52.1.1
Beck, A. T., Brown, G., Steer, R. A. (1996). Beck Depression Inventory II Manual. San Antonio,
TX: The Psychological Corporation.
Carey, T. A. (2008). Conflict, as the Achilles heel of perceptual control, offers a unifying approach to
the formulation of psychological problems. Counselling Psychology Review, 23, 5–16.
Carver, C. S., Scheier, M. F. (1998). On the self-regulation of behaviour. Cambridge, UK:
Cambridge University Press.
Cervone, D., Shoda, Y. (1999). The coherence of personality: Social cognitive bases of
consistency, variability, and organization. New York, NY: Guilford.
Cierpka, M., Rudolf, G., Grande, T., Stasch, M. (2007). Operationalised psychodynamic
diagnostics (OPD). Clinical relevance, reliability and validity. Psychopathology, 40, 209–220.
doi:10.1159/000101363
Cohen, J. W. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ:
Lawrence Erlbaum Associates.
Compa~n, V., Feixas, G., Varlotta, N., Torres, M., Aguilar, A., Dada, G., Saul, L. A. (2011). Cognitive
factors in fibromyalgia: The role of self-concept and identity related conflicts. Journal of
Constructivist Psychology, 24, 1–22. doi:10.1080/10720537.2011.530492
Dada, G., Feixas, G., Compa~n, V., Montesano, A. (2012). Self construction, cognitive conflicts and
disordered eating attitudes in young women. Journal of Constructivist Psychology, 25, 70–89.
doi:10.1080/10720537.2012.629117
Ecker, B., Hulley, L. (2008). Coherence therapy. In J. D. Raskin S. K. Bridges (Eds.), Studies in
meaning (pp. 57–84, Vol. 3). New York, NY: Pace University Press.
Emmons, R. A., King, L. A. (1988). Conflict among personal strivings: Immediate and long-term
implications for psychological and physical well-being. Journal of Personality and Social
Psychology, 54, 1040–1048. doi:10.1037/0022-3514.54.6.1040
Emmons, R. A., King, L. A., Sheldon, K. (1993). Goal conflict and the self-regulation of action. In
D.M. Wegner J.W. Pennebaker (Eds.), Handbook of mental control. Century psychology
series (pp. 528–551). Englewood Cliff, NJ: Prentice-Hall, Inc.
Cognitive conflicts in major depression 15
16. Engle, D. E., Arkowitz, H. (2006). Ambivalence in psychotherapy: Facilitating readiness to
change. New York, NY: Guilford Press.
Feixas, G., Bados, A., Garcıa-Grau, E., Montesano, A., Dada, G., Compa~n, V., . . . Winter, D. (2013).
Efficacy of a dilemma-focused intervention for unipolar depression: Study protocol for a
multicenter randomized controlled trial. Trials, 14, 144. doi:10.1186/1745-6215-14-144
Feixas, G., Cornejo, J.M. (2002). Correspondence analysis for grid data [Computer Software]
and reperory grid manual. Barcelona, Spain: Psimedia. Retrieved from http://www.
terapiacognitiva.net/record
Feixas, G., Erazo, M. I., Harter, S., Bach, L. (2008). Construction of self and others in unipolar
depressive disorders: A study using Repertory Grid Technique. Cognitive Therapy Research,
32, 386–400. doi:10.1007/s10608-007-9149-7
Feixas, G., Geldschl€ager, H., Neimeyer, R. A. (2002). Content analysis of personal constructs.
Journal of Constructivist Psychology, 15, 1–19. doi:10.1080/107205302753305692
Feixas, G., Lopez Moliner, J., Navarro Montes, J., Tudela Marı, M., Neimeyer, R. A. (1992). The
stability of structural measures derived from repertory grids. International Journal of Personal
Construct Psychology, 5, 353–367. doi:10.1080/08936039208404939
Feixas, G., Montesano, A., Erazo-Caicedo, M. I., Compa~n, V., Pucurull, O. (2014). Implicative
dilemmas and symptom severity in depression: A preliminary and content analysis study.
Journal of Constructivist Psychology, 27, 31–40. doi:10.1080/10720537.2014.850369
Feixas, G., Saul, L. A. (2004). The Multi-Center Dilemma Project: An investigation on the role of
cognitive conflicts in health. Spanish Journal of Psychology, 7, 69–78.
Feixas, G., Saul, L. A., Avila, A. (2009). Viewing cognitive conflicts as dilemmas: Implications for
mental health. Journal of Constructivist Psychology, 22, 141–169. doi:10.1080/1072053080
2675755
Feixas, G., Saul, L., Winter, D., Watson, S. (2008). Un estudio naturalista sobre el cambio de los
conflictos cognitivos durante la psicoterapia [A naturalistic study about change in cogntive
conficts during psychotherapy]. Apuntes de Psicologıa, 26, 243–255.
First, M. B., Spitzer, R. L., Gibbon, M., Williams, J. B. W. (1996). Structured Clinical Interview for
DSM-IV Axis I Disorders, Clinician Version (SCID-CV). Washington, DC: American Psychiatric
Press Inc.
Fransella, F., Bell, R., Bannister, D. (2004). A manual for Repertory Grid Technique. London, UK:
John Wiley Sons.
Grawe, K. (2004). Psychological therapy. Seattle, WA: Hogrefe.
Heider, F. (1946). Attitudes and cognitive organization. Journal of Psychology, 21, 107–112.
Higgins, E. T. (1987). Self-discrepancy: A theory relating self and affect. Psychological Review, 94,
319–340. doi:10.1037//0033-295X.94.3.319
H€olzel, L., Harter, M., Reese, C., Kriston, L. (2011). Risk factors for chronic depression. A
systematic review. Journal of Affective Disorders, 129, 1–13. doi:10.1016/j.jad.2010.03.025
Horowitz, M. J. (1988). Introduction to psychodynamics. New York, NY: Basic Books.
Hoyer, J., Fecht, J., Lauterbach, W., Schneider, R. (2001). Changes in conflict, symptoms, and
well-being during psychodynamic and cognitive-behavioral alcohol inpatient treatment.
Psychotherapy and Psychosomatics, 70, 209–215. doi:10.1159/000056255
Jacobson, N. S., Truax, P. (1991). Clinical significance: A statistical approach to defining
meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology,
59, 12–19. doi:10.1037//0022-006X.59.1.12
Kelly, G. A. (1955/1991). The psychology of personal constructs. New York, NY: Routledge.
Kessler, R. C., Berglund, P., Demler, O., Jin, R., Koretz, D., Merikangas, K. R., . . . Wang, P. S. (2003).
The epidemiology of major depressive disorder: Results from the National Comorbidity Survey
Replication (NCS-R). Journal of American Medical Association, 289, 3095–3105. doi:10.1001/
jama.289.23.3095
Lauterbach, W. (1996). The measurement of personal conflict. Psychotherapy Research, 6, 213–
225. doi:10.1080/10503309612331331718
16 Guillem Feixas et al.
17. Lauterbach, W., Newman, C. F. (1999). Computerized intrapersonal conflict assessment in
cognitive therapy. Clinical Psychology and Psychotherapy, 6, 1–18. doi:10.1002/(SICI)
1099-0879(199911)6:5357::AID-CPP2083.0.CO;2-3
Little, B. R., Salmera-Aro, K., Phillips, S. D. (2007). Personal project pursuit: Goals, action and
human flourishing. Mahwah, NJ: Lawrence Erlbaum.
Lobbestael, J., Leurgans, M., Arntz, A. (2011). Inter-rater reliability of the Structured Clinical
Interview for DSM-IV Axis I Disorders (SCID I) and Axis II Disorders (SCID II). Clinical
Psychology Psychotherapy, 18, 75–79. doi:10.1002/cpp.693
Luborsky, L. (1977). Measuring a pervasive psychic structure in psychotherapy: The core conflictual
relationship theme. In N. Freedman S. Grand (Eds.), Communicative structures and psychic
structures (pp. 367–395). New York, NY: Plenum.
Mansell, W. (2005). Control theory and psychopathology: An integrative approach. Psychology and
Psychotherapy: Theory, Research and Practice, 78, 1–40. doi:10.1348/147608304X21400
Mansell, W., Carey, T. A., Tai, S. J. (2012). A transdiagnostic approach to CBT using method of
levels therapy: Distinctive features. London, UK: Routledge.
Melis, F., Feixas, G., Varlotta, N., Gonzalez, L. M., Ventosa, A., Krebs, M., Montesano, A. (2011).
Conflictos cognitivos (dilemas) en pacientes diagnosticados con Trastornos de Ansiedad
[Cognitive conflicts (dilemmas) in patients diagnosed with anxiety disorders]. Revista
Argentina de Clınica Psicologica, XX, 41–48.
Michalak, J., Heidenreich, T., Hoyer, J. (2011). Goal conflicts and goal integration: Theory,
assessment, and clinical implications. In W. M. Cox E. Klinger (Eds.), Handbook of
motivational counseling: Goal-based approaches to assessment and intervention with
addiction and other problems (2nd ed., pp. 89–107). London, UK: Wiley.
Montesano, A., Feixas, G., Erazo-Caicedo, M. I., Saul, L. A., Dada, G., Winter, D. (2014). Cognitive
conflicts and symptom severity in Dysthymia: “I’drather be good than happy”. Salud Mental, 37,
41–48.
Montesano, A., Feixas, G., Varlotta, N. (2009). Analisis de contenido de constructos personales
en la depresion [Content analysis of personal contructs in depression]. Salud Mental, 32,
371–379.
Perry, J. C. (1990). The psychodynamic conflict rating scales. Cambridge, MA: The Cambridge
Hospital.
Powers, W. T. (2005). Behavior: The control of perception (2nd ed.). New Canaan, CT: Benchmark.
P€uschel, O., Schulte, D., Michalak, J. (2011). Be careful what you strive for. The significance of
motive-goal-congruence for depressivity. Clinical Psychology and Psychotherapy, 18, 23–33.
doi:10.1002/cpp.697
Renner, W., Leibetseder, M. (2000). The relationship of personal conflict and clinical symptoms in
a hight-conflict and a low-conflict subgroup: A correlational study. Psychotherapy Research, 10,
321–336. doi:10.1093/ptr/10.3.321
Riediger, M. (2007). Interference and facilitation among personal goals: Age difference and
associations with well-being and behavior. In B. R. Little, K. Salmera-Aro S. D. Philips (Eds.),
Personal project pursuit: Goals, action and human flourishing (pp. 119–143). Mahwah, NJ:
Lawrence Erlbaum.
Rowe, D. (1971). Poor prognosis in a case of depression as predicted by the repertory grid. British
Journal of Psychiatry, 118, 297–300. doi:10.1192/bjp.118.544.297
Rowe, D. (1983). Depression: The way out of your prison. London, UK: Routledge and Kegan Paul.
Rubio, J. M., Markowitz, J. C., Alegrıa, A., Perez-Fuentes, G., Liu, S., Lin, K., Blanco, C. (2011).
Epidemiology of chronic and nonchronic major depressive disorder: Results from the national
epidemiologic survey on alcohol and related conditions. Depression and Anxiety, 28, 622–631.
doi:10.1002/da.20864
Sanz, J., Vazquez, C. (2011). Adaptacion espa~nola del Inventario para de Depresion de Beck-II
(BDI-II) [Spanish adaptation of the Beck Depression Inventory II]. Madrid, Spain: Pearson
Education.
Cognitive conflicts in major depression 17
18. Sheehan, M. J. (1981). Constructs and “conflict” in depression. British Journal of Psychology, 72,
197–209. doi:10.1111/j.2044-8295.1981.tb02176.x
Solomon, D. A., Leon, A. C., Coryell, W., Mueller, T. I., Posternak, M., Endicott, J., Keller, M. B.
(2008). Predicting recovery from episodes of major depression. Journal of Affective Disorders,
107, 285–291. doi:10.1016/j.jad.2007.09.001
Stangier, U., Ukrow, U., Schermelleh-Engel, K., Grabe, M., Lauterbach, W. (2007). Intrapersonal
conflict in goals and values of patients with unipolar depression. Psychotherapy and
Psychosomatics, 76, 162–170. doi:10.1159/000099843
Received 8 August 2013; revised version received 4 March 2014
18 Guillem Feixas et al.