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Psychopathology and positive emotions in daily life Vera E Heininga

1

and Peter Kuppens

2

Inthisshortreview,wedescriberecenttrendsfromEcological MomentaryAssessment(EMA)researchinvestigatingpositive affect(PA)inrelationtomooddisorders.Asidefromnotable exceptions(e.g.mania),mostmooddisordersinvolverelatively lowerlevelsofPAindailylife,oftencombinedwithalargerlevel ofvariabilityinPA.Inreactiontopositiveevents,studiesshowa puzzling‘moodbrightening’effectinindividualswithmood disordersymptomsthatsuggestshyperresponsivenessto real-liferewards.Studiesintoanhedonia(i.e.lackof,orlower levelsofPA)suggestthathigh-arousalPAandanticipatoryPA arepotentialtargetsforintervention.DespitePA-focusedEMA- interventionsbearpromisesofgreatertherapeutic

effectiveness,sofar,thesepromiseshavenotmaterializedyet.

Addresses

1UniversityofGroningen,FacultyofBehaviouralandSocialSciences, DepartmentofDevelopmentalPsychology,GroteKruisstraat2/1, 9712TSGroningen,TheNetherlands

2LeuvenUniversity,FacultyofPsychologyandEducationalSciences, QuantitativePsychologyandIndividualDifferences,Tiensestraat102, Box3713,3000Leuven,Belgium

Correspondingauthor:Heininga,VeraE(v.e.heininga@rug.nl)

CurrentOpinioninBehavioralSciences2020,39:10–18 ThisreviewcomesfromathemedissueonPositiveAffect

EditedbyGillesPourtois,DisaSauter,BlairSaundersandHenkvan Steenbergen

https://doi.org/10.1016/j.cobeha.2020.11.005

2352-1546/ã2020TheAuthor(s).PublishedbyElsevierLtd.Thisisan openaccessarticleundertheCCBYlicense(http://creativecommons.

org/licenses/by/4.0/).

Introduction

Inmood disorders feelingsor emotions are distorted or inconsistent with its context to such an extent that it interferes with one’s ability to function [1]. Mood dis- ordersincludeBipolarDisorder,Dysthymia,Cyclothymic Disorder, Premenstrual Dysphoric Disorder, and Major Depressive Disorder (MDD), and affect approximately 10% of the population each year [2,3]. Research on affective psychopathology is predominantly focused on stressand Negative Affect (NA). In recent years, how- ever,therehasbeenincreasingattentionandrecognition thatrewarding experiencesandPositive Affect(PA), or thelackthereof(i.e.anhedonia),isatleastequallyimpor- tant for the understanding, treatment of, and recovery from,mooddisorders.

PA generally refers to the experience of pleasurable emotions, such as happiness, relaxation, enthusiasm, andjoy, andvaries over time asa function ofsubjec- tivelyappraisedcontext[4,5].Whenitcomestounder- standing the nature of PAin the context of people’s daily life, Ecological Momentary Assessment (EMA) studieshaveexaminedthelevelofPA,itsfluctuations, and interaction with contexts in both healthy and clinical populations. EMA is a structured diary tech- niquetosamplesubjective experiences,behaviorand contextintheflowofdailylife,typicallyusingsmart- phone technology. Its naturalistic approach ensures ecologicallyvalid data (i.e. generalizable to real-life), Participantstypically fill out structureddiariesmulti- pletimesaday(e.g.fivetimesaday),thatareassessed at fixed or random time points, and across multiple consecutives days (e.g. for 30 days). The high fre- quency in longitudinal sampling enables researchers toshed light on the nature of mood disorders on the micro-level.Forexample,towhatextentdepressionis linkedtoPAchangesacrossminutesorhours,andthe extenttowhichtheseshort-termchangesinPAco-vary withbehaviororothercontextualfactorsovertime.In addition, compared to retrospective questionnaires that asks patients to report on symptoms during the pastweeks ormonths,the frequentsamplinginEMA studiesreduces recallbias.Inthatsense, EMAmeth- ods can not only validate diagnostic criteria in daily life,butalsogobeyondbyprovidingnovelinsightsinto the micro-processes and mechanisms of mood disorders.

Inwhatfollows,wereview someof themostimportant advancementsofEMAresearchinPAandpsychopathol- ogyover thelastfiveyears.

PositiveAffect (PA)indaily life

In EMA studies, PA is typically operationalized as the mean of a set of adjective rating scales. For example, participantsareasked‘Howdoyoufeelatthemoment?’

followed by the adjectives ‘relaxed’, ‘happy’, and

‘cheerful’ and a slider-scale anchored with ‘not at all’

(outerleft)and‘verymuch’(outerright).Often,butnot always,thesetofaffectiveitemsisbasedonthePositive AffectandNegative AffectSchedule[6],or isbasedon circumplexmodelsofaffect[7,8]withtheselectionmade to balance high and low arousal items [9]. The most frequently used adjectives used to describe PA in EMAresearchinrelationtomooddisordersoverthelast two years are feeling relaxed, happy, and cheerful (see Figure1).

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EMA studies have linked compromised mental health andmooddisorderstovariousalterationsinPAfunction- ing,suchasreducedPAcomplexityandPAflexibilityin daily life [10],blunted PA reactivityto daily life stress ([11]) and reduced expectations of future PA (Note:

when having a history of depression, but not bipolar disorder; [12]). The most robust finding, however, is theconsistentlinkbetweenlowerpsychologicalwellbe- ing or increased mood disorder symptomatology and lower mean levels of PA [10,12,13,14,15,16,17,18,20].

One exceptionshould be noted though,namely in the manicphasesofbipolardisorder,whichmanifestsas(too) high levelsofPA.

PA dynamics inmood disorders

Inadditiontotherobustlinkbetweenmooddisordersand lower mean level is PA in daily life, EMA researchers explored the link between mood disorders and the dynamic nature of PA. PA dynamics are quantitative descriptions of PA summarizing how PA unfolds and fluctuatesovertime.Forexample,emotionalvariability, operationalizedas theaveragewithin-personvariancein affectoraveragewithin-personStandardDeviation(SD) in affect, summarizes the dispersion in PA levels. In addition,therearemorecomplexaffectivedynamicssuch as inertia (i.e. auto-correlation or auto-regression coeffi- cient;summarizeshowself-predictiveaffectisovertime),

Figure1

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2 2 2 2

3 3

4 4 4 4 4

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alert amazed at ease confident content delighted enjoying myself even temper euphoric globally feeling well jittery safe surprised warm active attentive inspired strong excited lively calm determined interested joyful proud energetic enthusiastic satisfied cheerful happy relaxed

Current Opinion in Behavioral Sciences

TheEcologicalMomentaryAssessments(EMA)itemsusedtoassessPositiveAffect,extractedfrom17EMAstudiesthatreportedonPAand mooddisordersbetween2018andJune2020.NumberontheX-axisreflectsnumberofstudiesthatusedtheEMA-itemdipictedontheY-axis.

WesearchedinWebofScience(WoS)CoreCollectionelectronicdatabaseforEnglish-languagepaperspublishedbetween2018andJune 2020usingthefollowingkeyterms:‘positiveemotion*’OR‘positiveaffect*’OR‘positivemood*’ORpleasur*ORwell?beingOReudaimon*;and

‘Mooddisorder*’OR‘Affect*disorder*’OR‘Bipolar*’OR‘BipolarDisorder*’ORDepress*OR‘MajorDepressiveDisorder’ORMDDORanhedoni*;

and‘Experiencesampling’OR‘EcologicalMomentaryAssessment*’OR‘ExperienceSamplingMethod’OR‘structureddiarymethod*’OR

‘intensivelongitudinalassessment*’OR‘real-timedatacapturestud*’OR‘eventsampl*’OR‘beeperstud*’OR‘ambulatorystud*’intitle,abstract, authorkeywords,andKeywordsPlus.Fromthe90articles,24weremarkedasrelevantbecausethey(1)explicitlyorimplicitlyhandledthesubject ofpositiveaffectoranhedonia;(2)hadafocusonmentalhealthormooddisorder,and(3)usedEMA.Weexcludedstudiesthatfocusedon(1) genetics,orneurologicalunderpinnings;(2)methodologicalstudies;and(3)studiesthatdidnotreportonPAitems,leaving17recentEMAstudies forextractionofPAitems.

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summarizeshowunstableaffectisovertime).Foravisual illustrationof thesedynamics,seeFigure2.

Recent EMA studies report paradoxical results in this respect. Whereas some studies found no association between PA dynamics and mood disorders [14,17], others have linked symptoms of mood disorders and low psychological well-being to greater variability in PA ([15]in high-arousal PA; first studyof [16,19,21]), and/ormoreinertPA[16,22,23].Inthemeta-analyseson therelation betweenaffectdynamicsand psychological well-being, lowerwell-being was characterized byboth greater variability and inertiairrespective of ESM time frame [16]. However, this inertia-variability paradox is resolved when taking the overlap among the mean, variability, and inertia into account (i.e. by controlling foroneortheother).Indeed,althoughPAdynamicsare interrelated,thedifferencesbetweengroupsinthelevel ofvariability(e.g. variance)andthelevelofinertia(e.g.

autocorrelation)inPAaretypicallyexaminedinisolation.

EMAresearchonnegativeaffectandwellbeingsuggests that, when adjusted for the overlap, inertia adds little predictivevalueinthepredictionofmooddisordersover andabovethelowerlevelofPAandlargerspreadinPA levels([24,25,26];seealsoFigure 2).

In people with bipolar disorder, after controlling for differences in individuals’ mean PA, variability in PA stillprovidesuniqueandadditionalinformation[19,21].

However, over-and-abovethe PA mean and variability, the auto-correlation of PA (inertia) likely adds limited informationinpredictingpsychologicalhealth[25].

Real-lifereward responsivenessandmood brightening

The EmotionContext Insensitivitytheory andpositive attenuation hypothesis predict attenuated emotional reactivitytopositiveemotionalstimuliinthedailylives ofdepressedindividuals[27].Inlinewiththishypothesis and theory, depression is consistently associated with reduced reward responsiveness in experimental studies andneurologicalstudiesinthelaboratory[28–31].Instark contrast,resultsfromEMAstudiesshoweithernodiffer- encesindepressedindividuals’rewardresponsiveness,or evidence for theopposite: a ‘mood brightening effect’, defined as a greater improvement in the mood of depressed individuals in the hours after they report havingexperiencedapositiveevent.3

alarger decreasein NA and larger increase in PA after positiveeventsin depressedversusnon-depressedindi- viduals[32].MostEMAstudiesthereafterpredominantly focused on the brightening in NA (e.g. Ref. [33]).

Althoughinstarkcontrasttotheoryandempiricalresults fromthelaboratory, themoodbrightening effectin PA seemsrobustand,comparedtoanxiety,specifictodepres- sion—withmoreseverelydepressedindividualsshowing greaterbrightening[34].Interestingly,anticipatingnext- daypositiveeventsseemtoproducesimilarmoodbright- eningeffects [35].

Sofar,severalfactorshavebeenexcludedasthedriving forcebehindthemoodbrighteningeffect[36].First,the scarcity in positive events that is often observed in depressed patients (i.e. contrast hypothesis). Second, thelowerthresholdtoappraisepositiveeventsaspositive and,third, flooreffects in PAthatmaycreate relatively larger room for improvement in the PA of depressed individuals Perhaps, emotion regulation might (partly) explain mood brightening effects. For NA, depressed individuals’tendencytoruminate(i.e.focusedattention tonegativeeventsandmoods)mightbeloweredbythe experience of a positive event to an extent that they ruminate less than controls, and the subsequent lower levelof NApresentsitselfasamoodbrighteningeffect [33].

Anotherexplanationforthediscrepancybetweentheory andEMAresultsonrewardresponsivenesscouldbethat PAreactivitytotheself-reportedpleasantnessofanevent is a suboptimal operationalization. Bakker et al. [37]

arguedthatexperimentaltasksandbehavioralactivation therapy typically involve approach-based rewards, sug- gestingthat situationsin whichone canencounterrela- tivelymanyrewards(e.g.engagingwithfriends,working orbeingphysicallyactive;hereafter‘activebehavior’)isa betteroperationalizationortranslationofrewardsindaily life than (pleasantness ratings of) positive events.

Remarkably, when operationalizing reward responsive- nessindailylifeasPAreactivitytoactivebehavior,inline withtheory,theauthorsindeedobserveabluntedreward responsivenessinindividualswithdepressivesymptoms.

However, the new operationalization is still awaiting replication.Heininga et al. [14] exploredbothoperatio- nalizationsofrewardresponsivenessinthedailylivesof depressed patients and healthy controls, but found no differencebetweenbothgroupsinPAreactivitytoposi- tiveevents,norinPAreactivity toactive behavior.

Anhedoniaindailylife

TobetterunderstandPAinmooddisorders,itmayalsobe useful to shift the focus from syndromes to symptoms [38]. Anhedonia is one of the two core symptoms of depression and is clinically understood as ‘a markedly diminished interest or pleasure in all, or almost all,

3ItshouldbenotedthatonerecentEMAstudyreportedreduced reward responsiveness in depressedindividuals, but, instead of the changeinPAafterpleasantactivitiesorevents,rewardresponsiveness wasoperationalizedasthepleasantnessratingofdailyactivities[61], betterknownasappraisal.

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activitiesoftheday’duringthepasttwoweeks[1].Based onadvances inneurologyandexperimentalpsychology, anhedonia is now understood as impairments in the ability toexperience reward(i.e.deficit in‘liking’;con- summatory anhedonia), pursue reward (i.e. deficit in

‘wanting’; anticipatory anhedonia) and/or learn about reward ([39–42];butseeRef.:[43]).

Withregardto‘liking’indailylife,anhedoniaislinkedto lowerappraisalofpositiveevents(i.e.positiveeventsare rated less pleasurable; [15]; but see Ref.: [20]), fewer positiveeventexperiences[20],andlowerlevelsofPAin daily life[14,15,20,44]. Beyondthese descriptivestatis- tics, anhedonic versus non-anhedonic individuals also show differences in their associations between events and PAover time.Consummatoryhigh-arousal PA(e.g.

feeling ‘energetic’, ‘enthusiastic’, and ‘cheerful’) might beofspecialinteresttobetterunderstandanhedonia,as individuals with anhedoniashow ‘mood brightening’in high-arousalPAbutnotlow-arousalPA[15],andshowa diminished favorableimpactonaffectiveexperiencesin individuals with anhedonia [44]. That is, compared to healthy controls, high-arousal PA in individuals with anhedonia istypically followed byagreater increase in NAandstress,andagreaterdecreaseinPAandphysical activityapproximatelysixhourslater (seeFigure 3).

With regard to ‘wanting’, EMA studies suggest that alterations in motivationand anticipation mightalso be avulnerabilitymarkerformooddisorders.Forexample, low PA in anhedoniais associated with lower levelsof motivationsixhourslater[45],andtheresultssuggestthat

individualswithanhedoniaareatriskforanegativespiral of low PAandlow motivation.Furthermore,depressive symptoms are also linked to diminished anticipatory pleasure experiences[46], and a weaker link between anticipatorypleasureandactivebehavior[37].Together, theseEMAadvancessuggestthat,inadditiontoalower meanlevelofPA,individualswithdepressivesymptoms are less able or less motivated to modify their daily behaviorsasafunctionof rewardanticipation.

Withregardtodeficitsinrewardlearninginthedailylives of individuals with anhedonia, advances show that the EMA timeframe is key. Without conscious processing, individualslearnabouttherewardvalueofeachcontext and activity by creating associations with co-occurring rewarding experiencessuch asPA. Theseimplicit asso- ciations,in turn,increasethelikelihoodthatindividuals engage insimilar contexts and activitiessemi-randomly assessed approximately 90min later and the next day [47].However,suchassociativelearningeffectswerenot replicated when using a short-term retrospective ESM design with fixed beeps approximately six hours apart [48].MoreEMAresearchisthusneededtodeterminethe optimaldesigntoinvestigaterewardlearningindailylife.

PA-focused dailylife interventions

Giventhattheone-size-fits-alltreatmentapproachisnot alwayseffective, EMAInterventions(EMIs) havebeen put forward as a promisingtool to personalize affective disordertreatmentsandimprovetheireffectiveness(e.g.

Refs.[49–52]).Sofar,threeEMIshavebeendeveloped thatfocusonPAand (symptomsof) mooddisorders.

Figure2

Current Opinion in Behavioral Sciences

HypotheticalexampleofhowPAunfoldsovertimeinindividualswithmooddisorderversushealthycontrols.Basedonindividualpatientdata fromHeiningaetal.[14].

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InthefirstRandomizedControlledTrials(RCT)ESM-I study,depressivesymptomswereeffectivelyreducedby sixweeklysessionsofESM-basedPA-feedback[53].The feedback purely descriptive, for example, graphically showingpatients’ownlevelofPAacrossdifferentsitua- tions. A follow-up study revealed that the decrease in depressive symptoms was preceded by a decrease in sedentary behaviorsandan increasein physicalactivity and social behaviors [54], suggesting that lifestyle changesmaybepart oftheremedy.Itshould benoted though that, although patients’ depressive complaints reduced according to the Hamilton Depression Rating

ScaleandtheInventoryofDepressiveSymptoms,accord- ingtotheEMAassessments,patients’momentarylevels ofPAdidnotchangeduringtheintervention[55].

Next, beyond mere descriptive feedback, van Roekel etal. [20,56,57]showed thatevaluative feedbackin the formofESM-basedrecommendationsonhowtochange one’slifestylemight beamore effectivewayto reduce depressivesymptoms–atleastinasubclinicalsample.

Albeiteffectsizesweresmall,andparticipantsshowedno marked decrease in depressive symptoms according to the Patient Health Questionnaire, self-monitoring in

No anhedonia Anhedonia

Current Opinion in Behavioral Sciences

AdaptedfromFigure2ofBosetal.[44].Networksofanhedonicandnon-anhedonicindividualsshowingthestrengthoftheIRFassociations estimatedthroughautomatedimpulseresponsefunctionanalysis(IRF).Green(solid)arrowsindicatepositiveassociationsbetweenvariables;red (dashed)arrowsnegativeones.Thestrongeraparticularassociation,thethickerandbrighterthecolorofthearrow.

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combinationwithspecific recommendationsforlifestyle changes effectively increased participants’ PA levels throughout daily life, suggesting evaluative feedback may also be an effective way to augment the efficacy of regulardepressiontreatment.Inlinewiththesefind- ings, indeed, recent advances on Behavioral Activation treatments suggest that these treatments may work by targeting(low)reward responsivenessdirectly[42,58].

Finally,Bastiaansenetal.[59,60]translatedthesefind- ingstoclinicalpracticebyprovidingbothdescriptiveand evaluative Behavioral Activation based feedback on patients’ PA, but found noevidence for improvements compared to patients’ PA who followed treatment as usual, nor evidence for an increase in EMI-specific empowerment or social functioning of patients. When comparingthestudyofBastiaansenetal.to thestudyof

Figure4

Time in months

Time in months

Current Opinion in Behavioral Sciences

Upperpart:adaptedFigure3bfromKrameretal.[53].Lowerpart:adaptedFigure2fromAppendixDfromBastiaansenetal.[60].Plotsshow predictedlinesplottedacrosstime(intention-to-treatanalysis).IDS=InventoryofDepressiveSymptomatology.Post-EMA=assessmentinthe weekafterthe28-dayinterventionperiod.FU=FollowUpassessment.InthestudyofBastiaansenetal.[60],duringthe28-dayintervention period,patientsreceivedweeklyfeedbackoneitherpositiveaffectandactivities(Do-module;experimental1)ornegativeaffectandthinking patterns(Think-module;experimental2).

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control groups of both studies (i.e. treatment as usual).

Whereas in Kramer’s study the treatment as usual was medication which only marginally improved patients moods, in the study of Bastiaansen et al., treatment as usualconsistedofmedicationcombinedwithpsychother- apy which was more effective in improving patients’

moods in the control group. Although the PA-focused EMIdidnot gobeyond theefficacy of medicationand psychotherapy,Bastiaansenetal.,concludethatitmaybe worthwhiletoinvestigatewhetherEMIscanbeblended with routine mental health services as they have the potential to make psychotherapy treatments more time-efficientfor therapistswithoutsacrificingefficacy.

Conclusions

Recentadvances in the fieldof PositiveAffective (PA) andmooddisordersindailylifesuggestthatpeoplewith mood disorders typically experience relatively lower levels of PA in daily life, possibly combined with a reduced anticipatory PA, and moment-to-moment vari- abilityinPAinbipolardisorder.FutureEMAstudiesinto mood disorders may benefit from incorporating both consummatoryPA (as experienced in-the-moment) and anticipatory PA (looking forward to future activities or contexts). Social contexts, stress and motivation seem closelyrelatedtoPAinthedailylivesofindividualswith anhedonia, and unravelling its underlying mechanisms maybeanimportantnextstepinfine-tuningtreatments formooddisorder.

Evidencefrom laboratory settings versusEMA appears paradoxical, as laboratory studies show blunted reward responses in depression, whereas EMA studies show evidencefor theopposite(i.e. a‘PAbrighteningeffect’

inresponsetopositiveevents).Toreconcilebothstrands ofliterature,futurestudiesmaybenefitfromamore in- depthanalysisintothetypeofpositiveevents,aswellas theoperationalizationsofrewardresponsivenessindaily life.Forexample,byexploring possiblerelevantdiffer- encesin thetypesof positiveevents(e.g. intrapersonal/

interpersonalevents,orsocial/non-socialevents),andPA reactivity to positive events active behavior, while also includingreward-related laboratory test batteriesin the sameEMAstudyparticipants.Thatway,rewardrespon- sivenessindailylifecouldbe‘calibrated’bycomparing correlational patterns. Another promising direction for futureresearch wouldbe to investigatethe moderating effectsofPAregulationstrategiesonPAbrighteningafter positiveeventsand/oractive behavior.

AlthoughthepromisedtherapeuticefficacyofEMIshas notfullymaterialized(yet),PA-focusedEMIsthataimto alterbehaviorindailylifeseemacost-effectiveandeasily accessible alternative for patients who cannot receive standardBehavioral Activationtherapy,or notyet.Fur- thermore,EMIsmayhelptounderstandthemechanisms

treatment.ThereareindicationsthatfuturePA-focused EMIs may bemost effective whentargeting both con- summatoryandanticipatoryPAaswellasthestrengthof the connection between both, and involve a type of evaluativefeedbackwhich ispreferablyintegratedwith face-to-facetherapistguidancesessions.

Conflictofintereststatement Nothingdeclared.

CRediTauthorship contributionstatement VeraEHeininga:Conceptualization,Investigation,Visu- alization,Datacuration,Writing-originaldraft,Writing- review & editing. Peter Kuppens: Conceptualization, Writing-review& editing.

Acknowledgement

ThisworkwassupportedbytheC1grantbytheKULeuvenResearch Council(C14/19/054).

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29. ForbesEE,DahlRE:Researchreview:alteredrewardfunction inadolescentdepression:what,whenandhow?:reward functionandadolescentdepression.JChildPsychol Psychiatry2012,53:3-15http://dx.doi.org/10.1111/j.1469- 7610.2011.02477.x.

30. KerenH,O’CallaghanG,Vidal-RibasP,BuzzellGA,BrotmanMA, LeibenluftE,PanPM,MeffertL,KaiserA,WolkeSetal.:Reward processingindepression:aconceptualandmeta-analytic reviewacrossfMRIandEEGstudies.AmJPsychiatry2018, 175:1111-1120http://dx.doi.org/10.1176/appi.

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31. RottenbergJ,HindashAC:Emergingevidenceforemotion contextinsensitivityindepression.CurrOpinPsychol2015,4:1- 5http://dx.doi.org/10.1016/j.copsyc.2014.12.025.

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An in-depth studyofthepuzzling ‘Brightening’effect, aswell asan analysisoftheextentofspill-overtootherdomainsofpsychological functioning.

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38. FriedEI,NesseRM:Depressionisnotaconsistentsyndrome:

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