An interactive-synergetic approach to the assessment of personality vulnerability to depression: Illustration using the adolescent version of the Depressive Experiences Questionnaire

Repetitive negative thinking during ambiguous situations: Interactive roles of looming cognitive style and intolerance of uncertainty

BACKGROUND AND OBJECTIVES

Looming cognitive style (LCS) and intolerance of uncertainty (IUC) are both cognitive risk factors that play an important role in development of anxiety disorders. Even though both are known to be triggered by ambiguous situations, there is inadequate research on how they predict anxiety and repetitive negative thinking (RNT) patterns in response to ambiguity. The current study aimed to examine the interactive association of IUC and LCS with state anxiety and intensity of RNT following exposure to a stressor that involves ambiguity.

METHODS

Data were collected from 292 (153 women) individuals aged between 18 and 63 (M = 20.82, SD = 5.20) who were administered self-report measures of LCS, IUC, and anxiety followed by a vignette describing an ambiguous situation. State RNT and anxiety were assessed following exposure to the vignette.

RESULTS

The results indicated that IUC moderated the association of physical looming with state RNT. Individuals who have elevated levels of both physical looming and IUC reported experiencing more higher frequency of RNT when compared with other individuals.

LIMITATIONS

Although the manipulation check has shown that the scenario is effective it was not pilot tested. Also, since the manipulation was conducted online, the manipulation may not have been presented in a standardized way to all the participants.

CONCLUSIONS

Overall, the study shows that the two risk factors enhance each other's effect and lead to more intense levels of repetitive, uncontrollable, and distressing thoughts following exposure to ambiguity.

Anxiety and emotional-behavioral problems of adolescents in China: evidence for a serial mediation model of alexithymia and dependency

High prevalence of emotional and behavioral problems among Chinese adolescence has been reported. This study seeks to investigate the mediating effect of alexithymia and dependency on anxiety and emotional-behavioral problems among adolescents. The study population included 519 adolescents. The assessments included the completion of standardized scales such as the Multidimensional Anxiety Scale (MASC), the Toronto Alexithymia Scale (TAS-20), the Depressive Experiences Questionnaire (DEQ), the Strengths and Difficulties Questionnaire (SDQ). Independent-sample t-tests, bivariate correlation, and serial mediation analyses were performed using SPSS23.0. Bivariate analyses revealed that anxiety, emotional-behavioral problem, alexithymia, and dependency were positively correlated. Alexithymia and dependency play a significant role in mediating the effect of multidimensional anxiety on emotional-behavioral problems. The effects of the two mediating paths were 69.86% and 7.81% for indirect effect through alexithymia, dependency, and specific indirect effect by alexithymia and dependency was 12.33%. Anxiety and emotional-behavioral problems mediate the relationship between alexithymia and dependency.

Perfectionism, efficacy, and daily coping and affect in depression over 6 months

OBJECTIVE

This study examined how perfectionism and efficacy impacted the maintenance of daily coping and affect in depression over six months.

METHOD

Forty-six depressed patients (69.6% female, mean age = 41.11 years) completed measures of perfectionism dimensions (self-critical, personal standards), efficacy, and depressive severity at Time 1. Participants then completed daily diaries of stress appraisals, coping, and affect for 7 consecutive days at Time 1 and Time 2, 6 months later.

RESULTS

Perfectionism dimensions and efficacy were differentially correlated with appraisals, coping, and affect across Times 1 and 2. Behavioral disengagement tendencies mediated the relation between self-critical perfectionism and daily negative affect over 6 months, controlling for depressive severity. Efficacy was related to daily positive affect over 6 months through problem-focused coping tendencies.

CONCLUSIONS

Results highlight the importance of addressing perfectionism, efficacy, and daily coping tendencies to more effectively reduce distress and bolster resilience in people with depression.

The Association of Negative Urgency with Psychological Distress: Moderating Role of Proactive Coping Strategies

Negative urgency, which is the tendency to act impulsively under the influence of negative emotions, is a risk factor for various psychological disorders including anxiety and depression. In contrast, proactive coping is a future oriented coping strategy that aims to prepare the self for future stressors by reappraising the stressors as challenges or keep oneself prepared for impending losses. Although the effect of proactive coping and preventive coping strategies on reducing depression and anxiety has been consistently documented, the association of their interaction with risk factors received little attention. In the current study, the moderator roles of two dimensions of Proactive Coping strategies in the association of negative urgency with anxiety and depression, is examined. Data were collected from 404 individuals (255 women) aged 18 to 59 (M = 31.29, SD = 11.70) through scales assessing negative urgency, proactive coping, anxiety and depression from a community sample. The results revealed that the interaction of proactive coping with negative urgency to be significantly associated with individual differences in depression scores, indicating that appraising the threats as challenges may have potential for buffering the effects of negative urgency on depression. However, a similar pattern was not observed for anxiety or preventive coping.

Negative urgency and time perspective: interactive associations with anxiety and depression

Time perspective, which refers to a mechanism of automatically assigning experiences into temporal categories (as past, present, and future), is argued to be a fundamental dimension in the construction of psychological time in addition to acting as a vulnerability factor for psychological disorders. Negative urgency is another vulnerability factor for psychological disorders that are characterized by engaging in impulsive actions when one is under the influence of negative emotions. The current study aimed to examine how the interaction of different dimensions of time perspective and negative urgency are connected with anxiety and depression. Data were gathered from 404 (255 women) individuals between ages 18 and 65 through measures of time perspective, negative urgency, anxiety, and depression. The results showed that while the interaction of negative urgency with past negative time perspective was associated with depression, a similar pattern was not observed for other dimensions of time perspective. Particularly, negative urgency appeared to boost the negative impact of being past-oriented. Similarly, only the interaction of future time perspective with negative urgency was associated with anxiety, indicating that tending to focus on the events that are likely to take place in the future is associated with elevated levels of anxiety in individuals with high levels of negative urgency.

Self-criticism, interpersonal conditions, and biosystemic inflammation in suicidal thoughts and behaviors within mood disorders: A bio-cognitive-interpersonal hypothesis

We review the theoretical and empirical literature on the role of self-concept in suicidal behavior in the context of mood disorders (i.e., unipolar depression and bipolar spectrum disorders). The main themes emanating from this review are then juxtaposed against (a) the Interpersonal-Psychological Theory of Suicide and (b) biological research on the role of inflammatory processes in suicidality. Such a juxtaposition paves the way for a bio-cognitive-interpersonal hypothesis. Pathologies of the self-concept-primarily self-criticism-propel mood disorder sufferers to generate interpersonal stress that culminates in two proximal causes of suicidality: thwarted belongingness and perceived burdensomeness. In turn, these two interpersonal conditions set in motion systemic biosystemic inflammation, serving as a proximal cause for suicidality in mood disorders. We conclude by describing a research project aimed at testing this hypothesis, and by outlining pertinent implications for assessment, treatment, and prevention.

Moderator Role of Looming Cognitive Style (LCS) in the Relationship Between Attentional Control and Anxiety: Difference Between Shifting and Focusing Dimensions

Attentional control (AC) that is composed of shifting and focusing dimensions had been suggested as a transdiagnostic risk factor, associated with development and maintenance of various psychological disorders. In comparison, Looming Cognitive Style (LCS) had been documented as a trait-based, disorders-specific characteristic that is linked to high levels of subjectively felt anxiety. The present study investigated whether individual differences in LCS moderated the association of shifting and focusing with anxiety. Participants were 402 individuals between ages 18 and 68 recruited through advertisements posted on various forums, e-mail groups, and social media websites. They filled out questionnaires assessing AC, LCS, anxiety, and depression online. Results of the moderation analyses indicated that at high levels of LCS, low attentional shifting ability was associated with more intense anxiety. A similar relationship with LCS was not observed for focusing. In conclusion, for individuals who have high LCS and low shifting ability, content of and distress coming from looming images is experienced in a more intense manner due to difficulty in shifting to another (perhaps less anxiety provoking) content more flexibly. The findings are providing support for the interactive-synergistic perspective, indicating that deficits in shifting capacity may potentiate negative impact of looming cognitions.

Psychometric Aspects of the Depressive Experiences Questionnaire: Implications for Clinical Assessment and Research

The Depressive Experiences Questionnaire (DEQ) is a self-report measure that assesses self-criticism and dependency, 2 personality traits that confer vulnerability to depression (Blatt, 2004 ). Over several decades, different, shortened versions of the DEQ have been constructed to offer an alternative to the complex scoring procedure of the original DEQ. This study explores the factor structure as well as the construct and convergent validity of the DEQ by comparing a clinical and nonclinical sample. We also compared the original DEQ with 5 shortened versions. There were 621 participants (358 university students and 263 outpatients). Fit indexes for models of the original DEQ did not meet minimum fit criteria. Moreover, the only versions with satisfactory fit were the Theoretical Depressive Experiences Questionnaire-21 (TDEQ-21) and the Theoretical Depressive Experiences Questionnaire-12 (TDEQ-12), which also showed acceptable construct and convergent validity. Finally, the diagnostic and clinical applicability of the DEQ is discussed.

In Eating-Disordered Inpatient Adolescents, Self-Criticism Predicts Nonsuicidal Self-Injury

We examined the role of depressive traits-self-criticism and dependency-in nonsuicidal self-injury (NSSI) and suicidal ideation among inpatient adolescents with eating disorders. In two studies (N = 103 and 55), inpatients were assessed for depressive traits, suicidal ideations, and NSSI. In Study 2, motivation for carrying out NSSI was also assessed. In both studies, depression predicted suicidal ideation and self-criticism predicted NSSI. In Study 2, depression and suicidal ideation also predicted NSSI. The automatic positive motivation for NSSI was predicted by dependency and depressive symptoms, and by a two-way interaction between self-criticism and dependency. Consistent with the "self-punishment model," self-criticism appears to constitute a dimension of vulnerability for NSSI.

Stress resilience in adolescence and subsequent antidepressant and anxiolytic medication in middle aged men: Swedish cohort study

It is unclear whether psychological resilience to stress in adolescence represents a persistent characteristic relevant to the subsequent risk for depression and anxiety in later adulthood. We aimed to test whether low psychological stress resilience assessed in adolescence is associated with an increased risk of receiving medication for depression and anxiety in middle age. We utilized Swedish register-based cohort study. Men born between 1952 and 1956 (n = 175,699), who underwent compulsory assessment for military conscription in late adolescence were followed to examine subsequent risk of pharmaceutically-treated depression and anxiety in middle age, from 2006 to 2009 corresponding to ages between 50 and 58 years, using Cox regression. The associations of stress resilience with prescription of antidepressant and anxiolytics medication through potential mediating factors cognitive and physical function and adult socioeconomic factors were calculated. Low stress resilience was associated with elevated risks for antidepressant (hazard ratio (HR):1.5 (95% CI 1.4 1.6)) and anxiolytics (HR:2.4 (CI 2.0 2.7)) medication. Adjustment for measures of childhood living circumstances attenuated the associations somewhat. Around a third of association with low stress resilience, and a half of that with moderate resilience, was mediated through cognitive and physical function in adolescence and adult socioeconomic factors. The magnitude of the inverse association of higher cognitive function with antidepressant medication was eliminated among those with low stress resilience. These results indicate that low stress resilience in adolescence is associated with an increased risk for antidepressant and anxiolytics medication over 30 years later, in part mediated through developmental factors in adolescence and socioeconomic circumstances in adulthood, and low stress resilience can diminish or eliminate the inverse association of higher cognitive function with antidepressant medication.

The Portuguese Version of the Depressive Experiences Questionnaire (DEQ): Results from a Validation Program in Clinical and non Clinical Samples

The Depressive Experiences Questionnaire (DEQ, Blatt, D’Afflitti, & Quinlan, 1976, 1979), a self-report measure used in personality research, assesses the constructs of Dependency and Self-Criticism as vulnerability factors in depression (Blatt, 1974, 1990, 2004) and psychopathology more generally (Blatt, 2008; Blatt & Shichman, 1983). This study establishes a Portuguese version of the DEQ with six samples: a bilingual sample to test the measurement equivalence of the Portuguese DEQ, and two college student samples, two community samples and a clinical sample, to test the reliability, factor structure and criterion, convergent and predictive validity of this translation of the DEQ. A measure of depression (Center for Epidemiologic Studies Depression Scale; CES-D; Radloff, 1977) and of general psychopathology (Brief Symptom Inventory; BSI; Derogatis, 1993) evaluated the convergent validity of the DEQ. Findings indicate satisfactory reliability and validity of the Portuguese DEQ, and the value of the DEQ for investigating the relationship between personality and depression and between personality and psychopathology more generally. It is important to note, however, that these conclusions are based on a limited clinical sample. Additional reliability and validity data are needed with a larger clinical sample.

Cognitive vulnerability to anxiety in the stress generation process: further investigation of the interaction effect between the looming cognitive style and anxiety sensitivity

BACKGROUND AND OBJECTIVES

The goal of the present study was to replicate and extend previous research on the relationship between stress generation and two well-documented anxiety related cognitive vulnerabilities, Looming Cognitive Style (LCS) and Anxiety Sensitivity (AS). We first sought to replicate findings that LCS and AS augment each other's stress generation effect. Next, we expanded upon these findings by conducting fine grained analyses not possible in the prior study, by using the third edition of the Anxiety Sensitivity Index (Taylor et al., 2007) and examined the individual facets of AS, which includes: Mental Incapacitation (fear of mental impairment), Physical (fear of catastrophic outcomes such as death), and Social (fear of being noticed for trembling, blushing) facets.

METHODS

We followed 99 female undergraduates who were assessed twice over a six-week interval.

RESULTS

First, the results replicated a previous study and showed that LCS and AS magnified each other's impact on stress generation. Second, analyses using the individual subscales of AS indicated significant interactions between LCS and the Mental Incapacitation and Physical facets of AS but not the Social facet.

LIMITATIONS

Limitations of the present study include reliance on self-report measures and the use of a female only sample. Using such a sample is consistent with previous literature, but limits generalizability to males.

CONCLUSIONS

The present findings are consistent with the emerging view that stress generation is an active, transactional process and that anxiety-related cognitive styles (much like depressive styles) contribute to stress generation.

The Depressive Experiences Questionnaire: construct validity and prediction of depressive symptoms in a sample of Chinese undergraduates

BACKGROUND

The Depressive Experiences Questionnaire (DEQ) was developed to measure two dimensions of depression-prone personality, Dependency and Self-criticism. We investigated the construct validity and prediction of DEQ in a Chinese sample, and explored whether Blatt's conceptualizations of depression-prone personality variables are appropriate for the Chinese context.

METHODS

The original version of the DEQ was translated into Chinese (DEQ-C). During the initial assessment, 640 Chinese university students completed the DEQ-C and the Center for Epidemiologic Studies Depression Scale (CES-D). Six months later, the CES-D was re-administered.

RESULTS

A principal components analysis yielded a three-factor model that was consistent with Blatt's theory. However, these three factors emerged in a different order in comparison to the original sample. Factorial validity was also acceptable with low correlations between each DEQ-C factor in males (r=.01 approximately -0.14), and females (r=0.19 approximately 0.28). Convergent validity was supported by significant positive correlations between the CES-D and both Dependency and Self-criticism. Predictive validity was demonstrated by hierarchical multiple regression analyses showing that Self-criticism predicted increased depressive symptoms both in males (beta=0.27, p<0.01) and in females (beta=0.16, p<0.05); Dependency predicted levels of depressive symptoms only in females (beta=0.11, p<0.05).

CONCLUSIONS

The Chinese version of the DEQ demonstrated satisfactory validity, including construct validity and predictive validity, the DEQ-C can be considered as an appropriate tool for assessing personality vulnerability to depression in Chinese college students.

Cognitive vulnerability to anxiety in the stress generation process: interaction between the Looming Cognitive Style and Anxiety Sensitivity

This study sought to extend the investigation of cognitive-personality vulnerability in the stress generation process to the field of anxiety. We examined two well documented cognitive vulnerabilities to anxiety: the Looming Cognitive Style (LCS) and Anxiety Sensitivity (ASI). Investigating 72 undergraduates who were assessed twice over a 4-month interval, we found support for the hypothesis that the two cognitive vulnerabilities to anxiety augment each other's stress generating effect. Results indicated that combination of LCS and ASI together had a far stronger stress generation effect that would just one factor alone. Each factor was positively associated with Time 2 stressful events under high levels of the other, but not under low levels. Thus findings revealed that the joint combination of the two cognitive vulnerabilities seemed to play a particularly marked role over a 4-month time interval. These findings are important because they are among the first to show stress generation effects for anxiety-related cognitive styles.

Quality of depression among suicidal inpatient youth

This study examined the relationship between suicidality and dependent and self-critical depression among adolescents. Ninety-six adolescents participated: 32 suicidal inpatients, 32 nonsuicidal inpatients and 32 healthy controls. The groups were matched for gender, age and education. Participants completed the Depressive Experience Questionnaire for Adolescents (DEQ-A), the Cognition Checklist (CCL), and the Multi-Attitude Suicidal Tendencies Scale (MAST). Results indicated that suicidal adolescents have significantly higher levels of self-critical and dependent depression, compared to nonsuicidal inpatients and healthy controls. The distinctive quality of depression among suicidal adolescents suggests assessment and treatment strategies for these individuals.

Patients' self-criticism is a stronger predictor of physician's evaluation of prognosis than pain diagnosis or severity in chronic pain patients

The experience of pain is influenced by patients' personality, social and cultural background, and patient-doctor interaction. This study examines the role of self-reported pain, pain diagnosis, age, gender, depression, and the personality trait of self-criticism (defined as individuals' tendency to set unrealistically high self-standards and to adopt a punitive stance toward one's self), in determining physicians' view of expected prognosis in response to chronic pain management. Before the first visit to a tertiary chronic pain clinic, patients provided information regarding their perceived pain, depression, and self-criticism. Immediately subsequent to the visit, physicians' evaluated expected prognosis. Participating physicians were blinded to the patient's psychosocial variables collected. Sixty-four patients with chronic pain (34 women and 30 men) with various diagnoses were included. Patients' age, gender, pain diagnosis, self-reported pain, and depression did not significantly correlate with physician's estimation of expected prognosis. In contrast, patients' self-criticism emerged as an independent predictor of physicians' pessimism regarding outcome. Thus, in the chronic pain clinic setting, patients' personality, rather than self-reported pain experience, determines doctor's clinical judgment of expected prognosis.

PERSPECTIVE

Chronic pain is a multimodal negative experience that is determined by physiological, cognitive, personological, and interpersonal factors. In line with this observation, we found patients' personality, specifically, their self-criticism, determines physicians' clinical judgment of expected prognosis.

Short-term predictive effects of the looming cognitive style on anxiety disorder symptoms under restrictive methodological conditions

The looming cognitive style (LCS), an overarching cognitive vulnerability for anxiety syndromes, pertains to a tendency to construct dynamic expectations (mental scenarios, images) of negative events as progressively increasing in danger and rapidly escalating in risk. This study tested the hypothesis that the LCS has functions as a cognitive antecedent and moderator for even short-term changes over a brief time interval in anxiety syndromes (worry, obsessive-compulsive disorder (OCD) symptoms, social anxiety, general anxiety) under restrictive methodological conditions. These included: (a) a one-week interval during which very little changes in anxiety were observed, and (b) controlling for participants' depression and intolerance of uncertainty. As hypothesized by our model, the looming cognitive style predicted short-term changes in worry and OCD symptoms over the week interval, and tended to predict changes in social (audience) anxiety. This style also functioned as a moderator and predicted changes in OCD symptoms among participants already high on this anxiety outcome. Intolerance of uncertainty predicted changes in social (audience) anxiety but not changes in OCD symptoms or worry. These findings support the looming vulnerability theory of anxiety, and encourage further attention into the possible role of the LCS as a cognitive antecedent and moderator of changes in a spectrum of anxiety syndromes.

The social context of adolescent suicide attempts: interactive effects of parent, peer, and school social relations

An ecological developmental model of adolescent suicidality was used to inform a hierarchical logistic regression analysis of longitudinal interactions between parent, peer, and school relations and suicide attempts. Reanalyzing data from the National Longitudinal Study of Adolescent Health, it was found that parent relations were the most consistent protective factor, and among boys with prior suicide attempts, school relations augmented the effects of parent relations when peer relations were low. Results indicated the need to understand suicidal behavior as a component of interactive social processes in the design of clinical interventions.

Personality strengths in adolescence and decreased risk of developing mental health problems in early adulthood

The aim of this study was to investigate whether personality strengths during adolescence are associated with decreased risk of developing psychiatric disorders, educational or occupational problems, violent or criminal behaviors, and interpersonal difficulties during early adulthood. A representative community sample of 688 mothers from upstate New York and their offspring was interviewed in the period of 1985-1986 (mean offspring age = 16 years) and in that of 1991-1993 (mean offspring age = 22 years). Results showed that youths with numerous personality strengths at the mean age of 16 years were at a decreased risk of developing psychiatric disorders, educational and occupational problems, interpersonal difficulties, and criminal behaviors at the mean age of 22 years. These associations remained significant after controlling for age, sex, socioeconomic status, verbal intelligence, preexisting psychiatric disorders, and corresponding problems at the mean age of 16 years. Although youths with fewer personality strengths who experienced numerous stressful events were at elevated risk of developing psychiatric disorders during early adulthood, those with a higher number of personality strengths at the mean age of 16 years did not share this vulnerability. We conclude that personality strengths during adolescence may contribute to a decreased risk of developing a wide range of adverse outcomes during early adulthood. Systematic evaluation of character strengths may improve the clinical assessment of adolescents.

Self-criticism and depressive symptomatology interact to predict middle school academic achievement

Although previous research has implicated adolescent depression in academic difficulties, few studies have explored the role of cognitive/personality factors in this area. To address this gap, the present study examines the role of self-criticism in academic functioning among early adolescent students over a 1-year interval. We hypothesized and found that adolescent self-criticism and depressive symptomatology interacted to predict decreased grade point average (GPA) over time, an interaction that was found predominantly in boys. This finding illustrates the need to integrate research on personality and psychopathology into educational psychology.

Immature dependence and self-criticism predict the recurrence of major depression

This research examined the associations of unipolar depression with immature dependence and self-criticism (S.J. Blatt et al., 1995) in a sample of graduate students with a diagnosed history of depression. A battery of tests was completed by 158 students, and a subset (n =102) was reached approximately 20 months later for the assessment of new depressive onsets. Self-criticism and neuroticism were uniquely associated with a past history of depression, and self-criticism and immature dependence interacted in predicting past occurrences of depression. Self-criticism was increasingly associated with past depressive episodes as level of immature dependence increased. The interaction of immature dependence and self-criticism was also evident in predicting future occurrence of depression after controlling statistically for the effects of current symptoms, neuroticism, certain Axis II diagnoses, and number of previous depressive episodes. This interactive effect suggests that individuals with high levels of both self-criticism and immature dependence are particularly prone to depressive episodes.

Staying well with bipolar disorder

OBJECTIVE

The research aimed to investigate how people diagnosed with bipolar mood disorder avoided episodes of illness and managed to stay well. The research also examined the role that personal, social and environmental factors played in helping people with bipolar mood disorder to stay well.

METHOD

This project used a combination of qualitative research methods. The design contained three (3) components: recruitment from general community, preliminary written questionnaire and semistructured interviews. To meet the criteria for inclusion, the participant must have stayed well for the past 2 years. The two main analytical categories were 'stay well concept' and 'strategies to stay well'. The main category 'strategies to stay well' contained a number of subcategories. These subcategories were acceptance of diagnosis, mindfulness, education, identify triggers, recognize warning signals, manage sleep and stress, make lifestyle changes, treatment, access support, and stay well plans.

RESULTS

100 people were eligible for inclusion in the study. The sample included 63 women and 37 men. The ages ranged from 18 to 83 years, with 86% over the age of 30. Duration of time since last episode of illness ranged from 2 years to >50 years. In the sample, 76% of participants were in paid employment. In addition, 36% of participants were parents. Participants actively managed bipolar disorder by developing a range of strategies to stay well. These strategies were based on participants' individual needs and social contexts. The strategies included acceptance of the diagnosis, education about bipolar disorder, identifying both triggers and warning signals, adequate amounts of sleep, managing stress, medication and support networks.

CONCLUSION

Staying well involved participants being mindful of their illness, which enabled them to develop an individual stay-well plan, including intervention strategies to prevent episodes of illness.

The person in recovery from acute and severe psychosis: the role of dependency, self-criticism, and efficacy

The role of 3 personality dimensions (i.e., dependency, self-criticism, and efficacy) in recovery from an acute and severe psychosis was examined. Conceptualizing psychosis as involving difficulties in establishing psychological boundaries, the authors hypothesized that dependency has a greater disruptive effect on recovery than self-criticism. Results of a reanalysis of longitudinal data (N = 76) of people with schizophrenia spectrum disorders during recovery from acute psychosis were consistent with this hypothesis: Dependency predicted depressive and negative symptoms, and, under low efficacy, perceived loss of independence and insight into the presence of the illness. These findings elucidate the central role of interpersonal relatedness as a foundation for self-definition in recovery from psychosis.