The effects of preventive cognitive therapy on emotional reasoning and
rumination in remitted major depressive disorder patients
Marieke Ribberink (12156388)
aa University of Amsterdam, Amsterdam, The Netherlands
SUPERVISORS
M.E. Bestenb M.J. van Tolb
b University Medical Centre Groningen
ARTICLEINFO Wordcount abstract: 263 Wordcount paper: 5634 Received 20 November 2020 Keywords: Rumination
Preventive Cognitive Therapy Major Depressive Disorder Relapse
Emotional reasoning
ABSTRACT
Depressive relapse is a major health issue with relapse rates elevating after every depressive episode, with 40-60% after one episode, 60% after a second, and 90% after a third episode. Preventive Cognitive Therapy (PCT) is a promising therapy to keep remitted major depressive disorder (MDD) patients from relapsing through identifying dysfunctional attitudes and changing these with co gnitive techniques. At the moment little is known about the working mechanisms behind PCT. Rumination on negative and positive affect and emotional reasoning were proposed as possible underlying mechanisms of PCT. This research measured rumination on positive and negative affect and emotional reasoning before and after three months of PCT in remitted MDD patients. Two conclusions could be made from this research. Firstly, no significant effect was found of PCT on rumination on negative affect, self-focused and emotion-focused rumination on positive affect, and emotional reasoning. It is suggested that PCT may not target repetitive thinking or alternatively that remitted MDD patients do not abnormally engage in rumination. In addition, no valid conclusion cou ld be made from the results about emotional reasoning, due to loss of data and small sample size. Secondly, a significant effect was found of PCT on dampening positive effect; lowering the amount of dampening after therapy. This is a promising result since dampening has been linked to more depressive symptoms, thus dampening seems to be one of the working mechanisms behind PCT. This research helped to better understand the underlying mechanisms of PCT and made another step in providing the best and most efficient therapy for individuals who are vulnerable to depressive relapse.
1. Introduction
It is estimated that approximately 20% of the world population endures Ma jor Depressive Disorder (MDD) at some point in their life (Kessler et a l., 2005). MDD is a pa rticularly important health issue since rela pse ra tes are very high a nd these ra tes elevate a fter every depressive episode, with 40-60% a fter one episode, 60% a fter a second, a nd 90% after a third episode (Eaton et a l., 2008; Moffitt et a l., 2009; Solomon et a l., 2000). The World Health Orga niza tion estimates that the total cost for the global economy is 1 trillion US$ per yea r due to lost productivity of individuals with depression a nd a nxiety disorders (World Hea lth Orga nization, 2019). Due to this immense impact, it is very important to find a fitting thera py to reduce the economic and personal burden of depression.
A promising therapy to reduce depressive symptomatology is Preventive Cognitive Therapy (PCT), which focuses on cha nging core beliefs a bout yourself a nd is supposed to improve emotion regula tion skills. PCT is ba sed on cognitive thera py which is given during a depressive episode, while PCT is given when pa tients a re in remission of their depressive episode. Cognitive therpay was proven to induce long-lasting preventive effects, as effective as the use
of a ntidepressant medication or non-therapeutic
interventions (Dobson et a l., 2008; Hollon et a l., 2005; Vittengl, Cla rk, Dunn, & Jarrett, 2007; Bockting et al., 2018; de Jonge et a l., 2019). Additional resea rch, mostly by the tea m of Bockting, looked into the effects of PCT in the remitted sta te. Even in the remitted sta te PCT proved to lower the rela pse rates and these preventive effects lasted for up to 10 years (Biesheuvel-Leliefeld et al., 2015; Bockting et a l., 2015; Bockting, Spinhoven, Wouters, Koeter, & Schene, 2009). Furthermore, the thera py was especially effective for individuals who experienced numerous previous depressive episodes, lowering the rela pse rate from 72% to 46% after a year (Bockting et a l., 2005).
Nevertheless, therapy does not a lways work for everyone in preventing rela pse. Currently, there is little understanding of the working mechanisms behind PCT, media ting the lowering of depressive rela pse a nd who would benefit from the thera py the most. It is suggested by Bockting and collea gues (2006) that PCT helps with internally provoked rela pse, such as negative emotions and thinking patterns due to stress, but will not be a s effective for externally provoked rela pse due to severe life events. To understand who will benefit from PCT, it is very important to further investigate which mental mechanisms a re ta rgeted with this therapy, since only the people who ha ve abnormal functioning in these mechanisms would benefit from PCT. Abnormal a ttention to negative internal a nd or external information has been proven to be one of the key mechanisms for vulnerability for rela pse (Beck, 2008; Disner, Beevers, Ha igh, & Beck, 2011). It is proposed tha t due to dysfunctional attitudes individuals vulnerable for depression ha ve a bia s in information processing, skewing the information processing to a more nega tive interpretation
(Beck , 2008). Two mechanisms that are possibly triggered due to these dysfunctional a ttitudes, a re rumination and emotional reasoning. It is proposed that internal mechanisms such a s rumination a nd emotional rea soning ca n induce skewed information processing, lea ding to a n enhanced focus on negative information and possibly heighten the risk of depressive rela pse.
Rumination
Rumination is a key fa ctor in the vulnerability for depression. Rumination is best cha racterized by repetitive thinking a bout the causes, consequences, a nd symptoms of one’s negative affect (sadness) and the circumstances rela ted to this nega tive a ffect (Nolen-Hoeksema, 1991; (Conwa y, Csa nk, Holm, & Bla ke, 2000). Rumination has been metioned a s a cognitive emotion regula tion strategy (Ga rnefski, Kra a ij & Spinhoven, 2001) a nd linked to stressful events (Alloy et a l., 2000), social phobia (Smith & Alloy, 2009), and the inability to a chieve a set goal (Martin, Tesser & McIntosh 1993). In a review on rumination, Smith & Alloy (2009) hypothesized that: “rumination is most likely triggered by the rea liza tion of the discrepancy between the current a nd desired sta tus a nd the negative a ffect that accompanies this realization. In which rumination is used to a void processing this nega tive a ffect”.
Rumination ha s been mentioned a s a key process in
ma intaining MDD (Nolen-Hoeksema, Wisco, &
Lyubomirsky, 2008). Furthermore, it ha s been a ssociated with longer a nd deepened episodes of depression and ongoing depressed mood (Nolen-Hoeksema et a l., 2008) as well a s a reduction in willingness to pa rticipate in pleasant or distra cting activities (Lyubomirsky & Nolen-Hoeksema, 1993). In addition, the study of Cooney, Joormann, Eugène, Dennis, a nd Gotlib (2010) linked rumination to worsening of nega tive mood sta tes, grea ter a ffective responding to nega tive material, a nd increa sed access to nega tive memories. Ruminative thinking, especially spontaneously, ca n be linked to MDD considering MDD patients gravitate to more pa st-related, self-rela ted, a nd nega tive thinking (Hoffmann, Banzhaf, Ka nske, Bermpohl & Singer, 2016). This ma kes rumination a possible mechanism to ta rget in thera py. Besides rumination a bout nega tive a ffect, rumination about positive a ffect has a lso been proposed to be equally important in rela tion to depression (Raes, Daems, Feldman, Johnson, & Va n Gucht, 2009). The paper of Raes, Smets, Nelis, en Schoofs (2012) mentioned tha t several studies reported tha t positive rumination predicted depressive symptoms.
There a re some studies that found that rumination can be a djusted by different kinds of cognitive therapies. Watkins a nd others (2007) conducted a n experiment into rumination-focused cognitive beha vior thera py for individuals dia gnosed with residua l depression and found significant improvement in depressive symptoms, rumination, and co-morbid disorders. Resultingly, from a ll pa rticipants, 71% responded and 50% a chieved full remission. Furthermore,
Micha lak, Hölz, and Teismann (2011) measured rumination in formerly depressed patients before a nd after mindfulness-ba sed cognitive thera py a nd found tha t rumination significa ntly decreased a fter therapy. Moreover, the post-trea tment levels of rumination predicted the risk of relapse of ma jor depressive disorder in the 12-month follow-up period. Less is known a bout the effects of PCT on rumination in individuals vulnerable to depressive relapse. To ga in insight into positive a nd negative rumination as key fa ctors in the rela pse of depression it is a lso important to investiga te rumination in remitted MDD patients and how preventive cognitive therapy could be beneficial.
Emotional reasoning
Another key factor in the vulnerability for depression is emotional reasoning. Emotional reasoning is a thinking style tha t contributes to developing depression (Beck & Emery, 1985; Dozois & Beck 2008). Emotional rea soning is the tendency to use one’s emotional state to form conclusions about oneself and one’s surroundings rather than using objective information (Arntz, Ra uner & va n den Hout, 1995). For example, ‘I feel anxious, therefore this bug must be dangerous’ or ‘I feel sad, therefore I must have performed badly on my test’ (Arntz et al., 1995).
Limited resea rch ha s been conducted on emotional rea soning. In total four studies on emotional rea soning and depression were found. Muris et a l., (2000) found a positive a ssociation between emotional rea soning a nd levels of a nxiety a nd depression in a non-clinical child sa mple. In contrast, Berle a nd Moulds (2013a) found no significant difference in mean emotional rea soning scores between depressed a nd depressed pa rticipants. The non-depressed group however consisted of fifty percent of previously depressed individua ls. Moreover, within this non-depressed group, there was a significa nt difference in some results of emotional rea soning between the previously depressed participants and the never-depressed participants (Berle & Moulds, 2013a). This could suggest that there is a significa nt difference between participants that have never been depressed and currently depressed individua ls. In a nother study, Berle a nd Moulds (2013b) mea sured emotional rea soning in high a nd low dysphoric university students a nd found a sma ll-sized positive a ssociation between emotional rea soning a nd depressive symptoms in high dysphoric students, especially when students made self-referent interpretations of situa tions. Furthermore, Berle a nd Moulds (2016) looked into the effects of cognitive-behavioral therapy in individuals with an a nxiety disorder a nd a lthough the thera py slightly improved symptoms of a nxiety a nd depression, there wa s no corresponding change in emotional rea soning. Only a small improvement in emotional rea soning a bout the conclusion ‘oneself is incompetent’ was found (Berle et al., 2016). As expla ined a bove the conclusions a bout emotional rea soning a nd depression a re incompatible. This could be expla ined by the fact that there are just a few experiments
done on this subject a nd all experiments were done in different population samples. In addition, the studies did not use the exact same task to measure emotional reasoning. The initia l ta sk was focused on people with anxiety disorders and the resea rchers tried to a lter the task to measure emotional rea soning in individua ls with different mood disorders. Moreover, the studies had some limitations rega rding small sa mple sizes a nd sma ll effect sizes. Altogether it is still important to further investiga te if individuals tha t are sensitive to depression engage more in emotional reasoning due to dysfunctional a ttitudes a nd if this bia sed information processing ca n be reduced through PCT.
The current resea rch will focus on the resea rch question: ‘How does preventive cognitive therapy change emotional
reasoning in remitted MDD patients and how do these changes correlate to changes in rumination after therapy?’.
Due to the la ck of resea rch systematically studying the link between emotional rea soning, rumination, and vulnerability of rela pse of depression it is important to further examine this potential a ssociation. The pa rallel between emotional rea soning a nd rumination is very interesting since both processes enhance nega tive emotional sta tes, which is proposed to underlie the mechanism of sustained low mood a nd vulnera bility for rela psing into a new dep ressive episode. It is proposed that emotional rea soning leads to a more nega tive view towa rds life, which triggers nega tive rumination. It is here hypothesized tha t remitted MDD pa tients will pa rticipate less in emotional rea soning and rumination a fter preventive cognitive thera py. Remitted MDD pa tients will be recruited a nd screened to partake in the experiment. The experiment consists of a set of questionnaires a nd ta sks both before a nd a fter the PCT intervention. This resea rch will focus on the Leuven Ada ption of the Rumination on Sa dness Sca le (LARSS) (Ra es, Hermans, Willia ms, Bijttebier, & Eelen, 2008) and the Responses on Positive Affect Sca le, Dutch version (RPA-NL) (Ra es, Da ems, Feldman, Johnson, & Va n Gucht, 2009) questionnaires to mea sure positive a nd negative rumination. In a ddition, the data of an a dapted form of the emotional reasoning task of Arntz et a l. (1995) will be used. This ta sk focuses on measuring emotional rea soning that could be linked to depression instead of emotional reasoning tha t focuses on anxiety. It is expected that the scores on the rumination questionnaires and emotional rea soning task will be lower a fter the therapy. Furthermore, it is expected to find a correla tion between the pre- a nd post-intervention data of the LARSS questionnaire and the emotional rea soning task. 2. Material & methods
2.1 Trial design
The current study ha s a longitudinal design within the context of a ra ndomized controlled tria l. The experiment consists of ba seline measurements (T0), a 3 -month intervention in which participants were ra ndomized to eight sessions of PCT or to the waiting list condition (in a ra tio of 2:1), post-treatment mea surements (T1), a nd follow up
mea surements 18 months a fter the therapy (see Figure 1). The resea rch wa s a pproved by the medical ethical commission Groningen (METC nr.: 2015.284 – ABR: 53205) a nd a ll pa rticipants signed a written Informed Consent.
2.2 Participants
For this study, the dataset of the depression study from the University Medica l Center Groningen is used (NEW-PRIDE: METc 2015/284 – ABR: 53205). In tota l 100 individuals pa rticipated in the study, 25 hea lthy controls, a nd 75 rMDD pa tients. Pa rticipants were Dutch na tive spea kers a nd were both males and females between the age of 18-55 years. To a nswer the resea rch question of the current thesis, da ta of 50 rMDD pa tients in the treatment group wa s used. The other rMDD pa tients were put on a wa iting list in between T0 a nd T1 a nd were given the option to receive preventive-cognitive therapy a fter the follow-up mea surement at T1.
The rMDD participants needed to meet the following criteria to ensure high vulnera bility for rela pse of depressive episodes: Firstly, they should have experienced a t least two Ma jor Depressive Episodes in the pa st 5 yea rs. Secondly, they should be in remission from their la st Major Depressive Episode for a t least 2 months, but no longer than two years. For their la st episode, they should not ha ve received any form of protocolized psychological therapy. Furthermore, the pa rticipants should be off a ny a nti-depressant medication for a t lea st 4 weeks a t the sta rt of the clinical resea rch. In a ddition, the participants should be in good hea lth and were excluded if they had neurological problems (epilepsy, dementia, neuromuscular disorders), a lcohol or drug dependencies, a history of contusion cerebri with >15 minutes loss of consciousness, a nd or uncorrectable visual impa irments. There were extra exclusion criteria due to MRI mea surements that were part of the total experiment; metal impla nts, cla ustrophobia, pregna ncy, the risk of ha ving metal pa rticles in the eyes due to manual work without eye protection, and the refusal to be informed of any structural bra in a bnormalities when detected during the experiment.
2.3 Screening
To va lida te the former depressive episodes a screening was conducted in which the pa rticipants needed to meet the criteria of a n MDD dia gnosis lifetime a ccording to the Structured Clinica l Interview for DSM-IV Axis I Disorders (SCID-I; Spitzer et a l., 1992). The pa rticipants were excluded if the screening with the SCID displa yed any current DSM-IV Axis-I dia gnosis. Moreover, the score on the Inventory of Depressive Symptomatology (IDS-SR30) ha d to be lower tha n 14 indicating the a bsence of current depression psychopathology (Rush et al., 2000). During the screening, the Dutch Adult Reading Test was conducted to test for normal intelligence (IQ >85) (DART; Schmand et a l., 1991).
2.4 Outcome measures
Rumination
Rumination wa s measured with the RPA-NL a nd LARSS questionnaires. These measurements were conducted twice, before a nd a fter the intervention. The RPA-NL mea sures ruminative a nd Da mpening thinking a s a response to positive a ffect (Raes et a l., 2009). Ruminative thinking can be split up into Emotion-focused rumina tion a nd Self-focused rumination. The questionnaire is a tra nslation of the RPA developed by Feldman, Joorman, & Johnson (2008) a nd replica tes the origina l three-solution with a n internal consistency of >0.72. The questionnaire consists of 17 questions a nd took 5 minutes to a dminister. The questionnaire wa s conducted at home a week before T0 and T1.
The LARSS questionnaire wa s a lso developed by Raes and collea gues (2008) a nd measures ruminative thoughts on sa dness. The ruminative thoughts on sa dness can be divided into three subscales; Causality analysis “ruminating about the rea sons of my sa dness”, Understanding “Ruminating about the meaning of my sadness” and Uncontrollability “Uncontrollability of the ruminative thinking on my sadness” (Raes et al., 2008). The psychometric properties a nd subscales have been verified to have good relia bility and va lidity (Raes et al., 2008). The questionnaire consists of 21 questions, took 10 minutes to administer, a nd was conducted a t home a week before T0 a nd T1.
Figure 1: Overview of the total experiment with the relevant measurements highlighted in blue Emotional reasoning task
The emotional rea soning ta sk measures the a mount of emotional rea soning a s a response to fa ctual situa tions. The ta sk consisted of 12 positive a nd 12 negative factual situa tions. Fifty percent of the situa tions ended with a mood description during the situation, while the other half of the time no mood description wa s a dded to a ct as a neutral control. In the case of the positive stories the mood wa s ha ppy and in the ca se of the nega tive stories, the
mood wa s sad. Following will be a n example of a negative factual situation; e.g. ‘You need to get breakfast for the
next morning. In the supermarket, you notice that you are in the mood for a snack and it would be convenient to also get dinner for tomorrow. At home, you notice you forgot to buy breakfast’. Mood description example: ‘you feel sad’/no mood added. The participants were instructed to
ima gine themselves in the sta ted situations. After reading the story the pa rticipants got two questions. Firstly, an
emotional response wa s prompted, a nd the pa rticipants were a sked how intensely they would respond in the given situa tion. These emotional responses could be both general or more specific (e.g. general: ‘I am worthless’ specific ‘I am a very muddled person’). The participant a nswered this question on a Visua l Ana logue Scale (VAS:0-100, va rying from no a greement to total a greement), resulting in a VAS-score. Secondly, a factual question wa s prompted a bout the situation to test memory performance (e.g. ‘What were you in the mood for? A
snack/ something healthy/ something to drink’). The task
wa s a dministered at the Neuroimaging Centre Groningen a t T0 a nd T1 a nd took 20 minutes to perform. The content of the emotional reasoning task was different for T0 and T1 resulting in two versions of the ta sk. Version one and two were ra ndomly a ssigned for each participant.
2.5 Intervention therapy
During the intervention phase, the pa rticipants received preventive-cognitive thera py (PCT) nea r their home a ddress. PCT consisted of eight sessions of ea ch 45 minutes of protocolized face to face therapy. Each session ha d a fixed structure with a genda-setting, a review of homework, a n expla nation of the ra tionale for each session, a nd an a ssignment of homework.
Initia lly, the ma in focus of the PCT lied on the identification of nega tive thoughts a nd dysfunctional a ttitudes utilizing, a mong other things, self -report questionnaires. La ter on, the focus shifted towards cha nging these attitudes by pra cticing different cognitive techniques; Socra tic questioning a nd identification of positive a ttitudes. During the entire intervention phase, pa rticipants were instructed to keep a dia ry of positive experiences to enhance positive memories. Ultimately, a personal prevention pla n wa s constructed with specific rela pse prevention strategies.
2.6 Procedure
After signing the informed consent, the research started with the screening tha t wa s expla ined before. The experimental part of the research had four phases starting with ba seline measurements (T0) including a clinica l,
neuropsychological, a nd fMRI-examination with
simulta neous pupil dila tion measurements (see Figure 1). Followed by a three-month intervention phase including the preventive cognitive therapy sessions. The third phase (T1) consisted of post-treatment measurements including identica l mea surements a s T0 a nd some a dditional questionnaires. Moreover, in the third pha se (T1), the depression section of the SCID-I wa s a dministered again to identify the recurrence of a depressive episode during the intervention phase. The fourth phase (T2) was a follow-up clinica l examination a nd happened 18-months a fter T0. An overview of the experiment can be found in figure 1, the mea surements used to a nswer the research question a re highlighted in blue. The participants received €25,- per session, thus a maximum of €75,- for the whole
experiment besides extra compensation for tra vel costs if necessary.
2.7 Data analysis
To study whether changes in rumina tion before a nd after trea tment could be observed, separate paired t-tests will be conducted for a ll the subscales of the RPA and LARSS questionnaires. For a ll tests, a within-subject design is performed with the mean rumination score of the different subscales a s the dependent va ria ble a nd experimental pha se (T0 vs. T1) a s the categorical independent variable. Following, a ssumptions of pa rametric testing will be tested; Shapiro Wilk for normality and Levene’s test for va ria nces. If a ssumptions a re met a paired t-test will be used for the subscale. If not, a Wilcoxon Matched-Pairs Test will be ca rried out.
To study changes in emotional rea soning before and after trea tment, a within-subjects repeated measures ANOVA is performed with the mean VAS-score of the emotional rea soning task as the dependent variable and experimental pha se (T0 vs. T1), presence of induction (induction vs. no induction), a nd the va lence (positive vs. nega tive) as independent va ria bles. Next, the a ssumption for pa rametric testing is conducted; Sha piro Wilk for normality. Mauchly’s test for sphericity is not tested since the current da ta only ha d 1 repea ted mea sure. If a ssumptions are met a repeated measures ANOVA will be conducted. If the assumptions are not met a Friedman’s test will be conducted.
If significa nt differences are found between the T0 and T1 mea surements for the different parameters a correlation will be conducted between the rumination questionnaires a nd the emotional rea soning task. Analyses are performed using R studio (version 1.3.1093). The alpha significance level for a ll tests is 0.05.
3. Results
In total 9 participants were excluded from the LARSS and RPA-NL a nalysis and 1 participant was excluded from the emotional reasoning task a nalysis because of incomplete results. Resultingly the data of 41 participants (Age: M= 36.2191; SD=11.0510; 11 male; 29 females) was used for the a nalysis of the RPA-NL a nd LARSS questionnaires a nd the da ta of 20 pa rticipants (Age: M= 37.5; SD=9.5669; 7 ma le; 11 females) wa s used for the data a nalysis of the emotional rea soning ta sk. Due to a progra mming mistake in the emotional reasoning task, a considerable a mount of data from half of the participants wa s lost. For the a nalysis, only the data that was complete for a ll pa rticipants wa s used. The reduced data set had a correla tion higher than 0.9 with the complete data. First, the results of the LARSS questionnaire will be presented followed by the results of the RPA-NL questionnaire and the results of the emotional reasoning task.
Figure 2: Boxplot of the mean causality scores of negative rumination of the LARSS questionnaire on T0 and T1. The boxplot shows the inter quartile range, median and the whiskers mark the minimum and maximum scores.
Figure 3: Boxplot of the mean understanding scores of negative rumination of the LARSS questionnaire on T0 and T1. The boxplot shows the interquartile range, median and the whiskers mark the minimum and maximum scores
3.1 LARSS
Not a ll subscales of the LARSS met the a ssumptions of pa rametric testing. There was no reason to assume that the subscales Understanding (T0: W = 0.97, p = 0.34; T1: W = 0.97, p = 0.45) a nd Uncontrolla bility (T0: W = 0.97, p = 0.34; T1: W = 0.98, p-value = 0.55) were not normally distributed. On the other hand, the subscale Causality did not meet the a ssumption of normality on T0 (T0: W = 0.95, p = 0.046; T1: W = 0.97, p = 0.45). For a ll subscales there wa s no rea son to a ssume tha t there was any difference in the va ria nce between T0 a nd T1
(Understanding: F(1,80)=2.82, p =0.097;
Uncontrolla bility: F(1,80)=1.1208, p =0.2929; Causality:
F(1,80)=1.3501, p =0.2487). The results of the subscales
Understanding, a nd Uncontrolla bility were a nalysed with
Figure 4: Boxplot of the mean uncontrollability scores of negative rumination of the LARSS questionnaire on T0 and T1. The boxplot shows the interquartile range, median and the whiskers mark the minimum and maximum scores.
a pa ired t-test a nd the results of the Ca usality subscale were a nalysed with the Wilcoxon Matched-Pairs test. No significa nt difference was found between T0 and T1 for the Understanding subscale (t(40)=-0.6228, p =0.5369), Uncontrolla bility subscale (t(40)=1.7554, p =0.08684) a nd Causality subscale (W=915.5, p =0.4881). The results a re visua lly presented in figure 2 a nd 3 a nd 4.
3.2 RPA-NL
The a ssumptions for normality a nd simila r varia nce were a lso tested for the subscales of the RPA-NL questionnaires. There wa s no rea son to a ssume that the Emotion-focused rumination subscale wa s not normally distributed (T0: W = 0.94844, p = 0.06172; T1 W = 0.97365, p = 0.45), but the data of the Da mpening (T0: W = 0.93969, p = 0.03068; T1: W = 0.90125, p = 0.001806) a nd Self-focused (T0: W = 0.91562, p = 0.004957; T1: W = 0.93403, p = 0.0197) subscales were not normally distributed on both T0 and T1. The results of the Levene-test showed no significa nt difference between the va ria nces of the subscales on T0 a nd T1 (Emotion-focused: F(1,80)=0.6594, p =0.4192; Dampening:
F(1,80)=1.1093, p =0.2954; Self-focused:
F(1,80)=0.0494, p =0.8247). Resultingly, the data of the
Emotion-focused subscale was a nalysed with a paired t-test a nd the da ta of the other two subscales with the Wilcoxon Ma tched-Pairs Test. The t-test showed no significa nt difference in Emotion-focused rumination scores between T0 and T1 (t(40)=-1.6929, p =0.09824). There wa s a lso no significant difference in Self -focused rumination scores between T0 a nd T1 (W=742.2, p =0.363). The a nalyses of the Da mpening rumination scores showed a significant difference between T0 and T1 (W=1064, p =0.03728). The da ta of the subscales are visua lly presented in figure 5, 6 a nd 7.
Figure 5: Boxplot of the mean Self-focused positive rumination before and after therapy. The boxplot displays the inter quartile range and median and the whiskers mark the minimum and maximum scores.
Figure 6: Boxplot of the mean Emotion -focused positive rumination before and after therapy. The boxplot displays the inter quartile range and median and the whiskers mark the minimum and maximum scores.
3.3 Emotional reasoning task
The da ta of the emotional rea soning ta sk wa s visua lly checked for normality and there wa s no reason to assume tha t the da ta is not normally distributed. The repea ted-mea sures ANOVA ga ve the main effects of Experimental pha se, Induction, Va lence, a nd the intera ction effects between them. The ma in effects of Experimental phase (F(1,19)= 2.002, p = 0.173), presence of Induction (F(1,19)= 3.710, p = 0.069) and Valence (F(1,19)= 4.228,
p = 0.054) a ll showed no significant results. Moreover, the
intera ction effects a lso showed no significant results for
Figure 7: Boxplot of mean Dampening rumination scores before and after therapy. The boxplot displays the inter quartile range and median and the whiskers mark the minimum and maximum scores.
Induction x Va lence (F(1,19)= 0.682, p = 0.419); Induction x Experimental pha se (F(1,19)= 0.249, p= 0.624); Va lence x Experimental phase (F(1,19)= 1.896, p =0.185) a nd Induction x Va lence x Experimental phase (F(1,19)=0.465, p =0.504). The results of the emotional rea soning ta sk a re shown in figure 8 (see next page).
3.4 Correlations
Since no significa nt effect wa s found on the emotional rea soning ta sk, the correla tion a nalysis between the emotional rea soning ta sk a nd rumination questionnaires will not be conducted.
4. Discussion
This resea rch focused on answering the research question: ‘How does preventive cognitive therapy change emotional
reasoning in remitted MDD patients and how do these changes correlate to changes in rumination after therapy?’ by examining the effects of PCT on rumination
a nd emotional rea soning to better understand the mechanisms underlying PCT a nd the rela tion between rumination a nd emotional rea soning. The results of the da ta-analysis will be discussed per parameter starting with the LARSS questionnaire, followed by the RPA-NL questionnaire a nd the emotional rea soning ta sk. The results will be compared to previous resea rch a nd how they fit in the fra mework of the current understanding a bout rumination, emotional reasoning, a nd PCT.
4.1 Ruminating on negative affect
With the results of the LARSS the resea rch question: ‘How does PCT influence rumination on negative affect
in remitted MDD patients?’ ca n be a nswered. No
significa nt effect wa s found for a ny of the subscales of rumination on negative a ffect.
Figure 8: Boxplot of the mean VAS-scores on the emotional reasoning task on T0 and T1. The bottom displays the presence of induction at the stories, while the top displaces the valence of the stories. Moreover, blue indicates the VAS -scores at T0 and yellow indicates the VAS-scores at T1. The y-axis displays the VAS-score. The boxplot displays the inter quartile range, median and the whiskers mark the minimum and maximum VAS -scores.
Resultingly it ca n be concluded that there is no rea son to a ssume that three months of PCT changes rumination over the meaning of one’s sadness and the reason why one is sa d in remitted MDD patients. Moreover, PCT also does not improve or worsen the controlla bility over the amount of rumination on one owns sadness.
Resea rch of Ra es a nd collea gues (2008) proposed that uncontrolla bility of ruminating is most closely related to depressive symptoms a nd thought suppression. While rumination over the reason of one’s sadness is probably not rela ted to depression or could even be beneficial. Rumination over the mea ning of one’s sa dness is proposed to lie in between being moderately rela ted to depression. Although the results were not significa nt in remitted MDD pa tients PCT did seem to influence uncontrolla bility of rumina tion more than the ca usality a nd understanding of rumination.
The results were incoherent with previous litera ture on rumination. Micha lik a nd collea gues (2011) found reduction in rumination a fter mindfulness based cognitive thera py in remitted MDD pa tients and Wa tkins (2007) a lso found a reduction in rumination a fter rumination-focused cognitive beha vioural thera py for residual depression. However, the sa mple sizes of both studies were very sma ll a nd The Ruminative Response Scale of the Response Styles Questionnaire (RRS; Nolen
-Hoeksema, 1991) wa s used instea d of the LARSS to mea sure rumination on negative a ffect. So, comparisons of the results should be taken with ca ution.
In this resea rch the rumination scores of remitted MDD pa tients a re not compared to hea lthy controls. If there would be no difference between remitted MDD patients a nd healthy controls, this could explain why no significant effect is found in the current research between pre- and post-therapy rumination scores. If rumination on negative a ffect is not a bnormally present in remitted MDD patients the thera py probably would not ha ve a big influence. Which would indica te tha t lowering rumina tion on nega tive a ffect is not one of the working mechanisms of PCT to lower rela pse in remitted MDD patients, since it is supposed that rumination on negative affect as measured by the LARSS is not very present within these patients.
4.2 Rumination on positive affect
With the results of the RPA-NL the resea rch question: ‘How does PCT influence rumination on positive affect in
remitted MDD patients?’ can be a nswered. There was no
significa nt effect found of PCT on self-focused and emotion-focused rumina tion on positive a ffect. The results a re in a ccordance with previous litera ture, where no significa nt relation between history of depression and positive rumination wa s found (Johnson, McKenzie, & McMurrich, 2007; Werner-Seidler, Ba nks, Dunn, &
Moulds, 2013). This suggests that positive rumination is insubstantially present in remitted MDD pa tients, resulting in no significa nt effect of PCT.
PCT did significa ntly influence the amount of dampening on positive affect in remitted MDD patients. After therapy pa rticipants were less likely to dampen positive affect than before therapy. This wa s coherent with the expectations a nd previous literature. Da mpening wa s proven to be higher a mong formerly depressed individuals compared to never depressed individua ls a t the sa me level as currently depressed pa rticipants (Werner-Seidler et a l., 2013; Nelis, Holmes, & Ra es, 2015). In a ddition higher levels of depressive symptoms can be predicted by higher levels of da mpening in non-clinical student sa mples (Feldma n et a l. 2008; Raes et a l. 2009; Werner-Seidler et a l. 2013), even above a nd beyond ruminative responses to nega tive affect (Feldman et a l. 2008; Raes et a l. 2009). While PCT ma y not influence Self-focused and emotion focused rumina tion it does improve the a mount of da mpening on positive a ffect, which is beneficial for remitted MDD patients, since dampening ha s been linked to more depressive symptoms.
Ta ken the results on rumination on positive a nd negative a ffect together it is striking tha t PCT only seems to help with da mpening. Da mpening does not fa ll under the description of repetitive thinking, while a ll the other subscales do include repetitive thinking a bout a certain a spect of their mood. Besides the former explanation it is a lso possible that PCT does not lower repetitive thinking, but is good in conceding one’s own positive affect, which ca n be very beneficia l to prevent depressive rela pse.
4.3 Emotional reasoning
In a ddition, this resea rch tried to a nswer the question; ‘How does PCT influence emotional reasoning in remitted
MDD patients?’. There wa s no significant effect of PCT
on the a mount of emotional reasoning in remitted MDD pa tients. Which is incoherent with the expectations. Since PCT focusses on changing nega tive focused a ttitudes to more neutral or positive a ttitudes, which presumably would lea d to less emotional rea soning. The result should be ta ken with some ca ution since the current study had some limitations. The emotional reasoning task was based on the emotional rea soning ta sk of Arntz (1995), but cha nged to test emotional rea soning in depressed individuals a nd this version of the test ha s not been va lida ted, so more resea rch is necessary on this ta sk to ma ke sure it is a relia ble test. In a ddition, a considerable a mount of the data got lost, so the data wa s incomplete. This in combination with the small sample size, the results a re only a n indica tion of the rela tionship between emotional rea soning, remitted MDD pa tients a nd PCT. The results do fit in the framework of previous research of Berle a nd Moulds (2013a), who a lso did not find clear emotional reasoning scores in participants with (remitted) depression. Berle a nd Moulds (2016) also did not find any
effect of cognitive beha vioural thera py on emotional rea soning. This resea rch does not give a ny indication that PCT influences emotional rea soning in remitted MDD pa tients, however, no clear statements can be made due to the limita tions a nd limited previous literature on the topic. Due to no significant results and the shortcomings of the emotional rea soning da ta a s previously mentioned, no conclusion can be made with rega rds to the proposed link between emotional rea soning a nd rumination on negative a ffect.
5. Conclusion
After reviewing a ll the different parameters, the research question: ‘How does preventive cognitive therapy change
emotional reasoning in remitted MDD patients and how do these changes correlate to changes in rumination after therapy?’ ca n be a nswered. There wa s no significant
effect of PCT on rumina tion on nega tive affect, self-focused a nd emotion-self-focused rumination on positive a ffect a nd emotional rea soning. This suggests tha t PCT does not target repetitive thinking or that rumination is not a s present in remitted MDD pa tients a s in currently depressed patients. Due to the limitations of the emotional rea soning ta sk, validation of the task and more research on the topic is necessary before a ny conclusions can be ma de. PCT did significa ntly improve the tendency of remitted MDD patients to dampen positive a ffect. Since da mpening ha s been rela ted to more depressive symptoms, this could be a mechanism through which PCT prevents rela pse. Future research could focus more in depth on the effects of PCT on dampening positive affect a nd how this hopefully lowers the vulnerability for relapse in remitted MDD patients, while a lso continue trying to understand the other underlying mechanisms of PCT. For now, a nother step is ma de in understanding the mechanisms underlying PCT a nd how the therapy can help individuals remitted from depression from not rela psing a gain. So, in the future individuals ca n get the best a nd most efficient therapy in ba ttling depression and preventing rela pse.
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