Advances in Psychology Research Volume 44

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ADVANCES IN PSYCHOLOGY RESEARCH Advances in Psychology Research, v. 44 Alexandra Columbus (Editor) ISBN 1-60021-150-X Advances in Psychology Research, v. 43 Alexandra Columbus (Editor) ISBN 1-60021-105-4 Advances in Psychology Research, v. 42 Alexandra Columbus (Editor) ISBN 1-60021-104-6 Advances in Psychology Research, v. 41 Alexandra Columbus (Editor) ISBN 1-60021-061-9 Advances in Psychology Research, v. 40 Alexandra Columbus (Editor) ISBN 1-59454-836-6 Advances in Psychology Research, v. 39 Alexandra Columbus (Editor) ISBN 1-59454-420-4 Advances in Psychology Research, v. 38 Alexandra Columbus (Editor) ISBN 1-59454-478-6 Advances in Psychology Research, v. 37 Alexandra Columbus (Editor) ISBN 1-59454-262-7 Advances in Psychology Research, v. 36 Alexandra Columbus (Editor) ISBN 1-59454-255-4 Advances in Psychology Research, v. 35 Alexandra Columbus (Editor) ISBN 1-59454-079-9 Advances in Psychology Research, v. 34 Serge P. Shohov (Editor) ISBN 1-59454-079-9 Advances in Psychology Research, v. 33 Serge P. Shohov (Editor) ISBN 1-59454-078-0 Advances in Psychology Research, v. 32 Serge P. Shohov (Editor) ISBN 1-59033-969-X Advances in Psychology Research, v. 31 Serge P. Shohov (Editor) ISBN 1-59033-985-1 Advances in Psychology Research, v. 30 Serge P. Shohov (Editor) ISBN 1-59033-943-6 Advances in Psychology Research, v. 29 Serge P. Shohov (Editor) ISBN 1-59033-921-5 Advances in Psychology Research, v. 28 Serge P. Shohov (Editor) ISBN 1-59033-868-5 Advances in Psychology Research, v. 27 Serge P. Shohov (Editor) ISBN 1-59033-803-0

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ADVANCES IN PSYCHOLOGY RESEARCH, VOLUME 44

ALEXANDRA COLUMBUS EDITOR

Nova Science Publishers, Inc. New York

Copyright © 2006 by Nova Science Publishers, Inc.

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CONTENTS Preface

ix

Chapter 1

Neuroanatomical Basis of Bipolar Disorder Toshiya Murai

Chapter 2

Fifty-Five Years of Lithium Therapy in Contemporary Psychiatry Janusz K. Rybakowski

17

Psychotherapy and Patient Preferences for the Treatment of Major Depression in Primary Care Patrick Raue and Herbert C. Schulberg

37

Concept of Self in Holistic Medicine: Coming from Love, Freeing the Soul, the Ego and the Physical Self Søren Ventegodt and Joav Merrick

59

Chapter 3

Chapter 4

1

Chapter 5

The Foundation of the Self and the Assessment of Self-Esteem Ata Ghaderi

Chapter 6

Hanging Out or Hanging In?: Young Females’ Socioemotional Functioning and the Changing Motives for Dating and Romance Melanie J. Zimmer-Gembeck and Karen J. Gallaty

87

Forgetting as a Consequence of Remembering: Retrieval-Induced Forgetting and the Malleability of Memory Malcolm D. MacLeod and Jo Saunders

113

Chapter 7

69

Contents of Earlier Volumes

137

Index

145

PREFACE Advances in Psychology Research presents original research results on the leading edge of psychology research. Each article has been carefully selected in an attempt to present substantial research results across a broad spectrum. It is essential to characterize the underlying neural circuitry to elucidate the pathophysiological mechanism of bipolar disorder. Two complementary approaches are possible on this issue. First, there are a series of structural neuroimaging studies comparing bipolar disorder subjects with control subjects. In particular, using volumetric analyses of structural MRI, anatomical changes have been reported in several brain structures, including the subgenual prefrontal cortex and amygdala. Second, there are sporadic case reports of de novo bipolar disorder after focal brain damage, such as stroke or traumatic brain injury. These unique cases provide clues to elucidate the essential neural substrates of bipolar disorder. The importance of an orbitofrontal, extensive right hemispheric, thalamic, and temporal basal lesion has been suggested. In chapter 1, the author describes a representative case of de novo bipolar disorder after traumatic brain injury, reviews the relevant literature, and suggests a possible neuroanatomical basis for bipolar disorder. Although the existing evidence should be taken as preliminary, it implies that structural abnormalities in fronto-subcortical networks as well as specific limbic or paralimbic structures, which are involved in regulating the normal subjective emotional experience, might play a critical role in the mechanism of bipolar disorder. Lithium therapy was introduced into contemporary psychiatry in 1949 due to a serendipitous finding of Australian psychiatrist, John Cade. In chapter 2, the main events connected with the modern history of lithium have been discussed that occurred in five decades: 1949-1959; 1959-1969; 1969-1979; 1979-1989; 1989-1999 as well as in recent five years: 1999-2004. They include the evidence for psychotropic effects of lithium (antimanic, mood-stabilizing, antidepressant, antisuicidal) as well as other biological effects (antiviral, immunomodulatory, neuroprotective), studies on mechanism of action of this ion as well as the main organizational and cultural facts. Fifty-five years of lithium therapy in psychiatry made a tremendous impact on both psychiatry and general neuroscience. The authors in chapter 3 describe the small body of research investigating the effectiveness of psychotherapy for treating major depression experienced by primary care patients, and the nature of patient treatment preferences and their impact on treatment adherence and outcome. They conclude that depression-specific, short-term psychotherapies such as CT, CBT, IPT, and PST effectively treat acute major depression in primary care

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Alexandra Columbus

practice and achieve one-year outcomes superior to those achieved by the primary care physician’s usual care. No outcome differences emerge when psychotherapy alone is compared to antidepressant treatment alone, or to psychotherapy combined with antidepressant treatment. The majority of primary care patients prefer psychotherapy or counseling. While inconclusive, research to date has not documented a positive impact of meeting patient preferences on subsequent treatment adherence or clinical outcome. René Descartes, Sigmund Freud and Anna Freud have developed the concept of self and the latter focused on ego development and self-interpretation. These concepts have also been used in counseling, where self-consistency has been seen as a primary motivating force in human behavior and psychotherapy can be seen as basically a process of altering the ways that individuals see themselves. In holistic medicine we believe that there is an ego connected to the brain-mind and a deeper self, connected to the wholeness of the person (the soul), but we have yet another self connected to the body mind taking care of our sexuality. So this three-some of selves (ego, the body and the soul) must function and this is done best under the leadership of our wholeness, the deep self. Chapter 4, with a few case stories, illustrates the holistic medicine mindset concerned with the concept of self. The concept of the self is a completely verbal construction and it’s definition, apart from problems of arriving at a consensus in the scientific community, is highly dependent on verbal behavior and social norms in each society. In chapter 5, the author presents a condensed review of a variety of definitions and operationalization of the concept of self based on different psychological theories. The author argues that the inherent approaches and premises in these theories result in specific consequences for the assessment of the features and qualities of the self in each individual. While some theories stress the significance of the individual's broad social context for the formation of self, others focus more specifically on early interactions between the individual and its caregivers during childhood, and still other theories highlight the importance of the behavior of the individual instead of relying on mentalistic concepts. Given the differences in theoretical perspectives and approaches, selfconcept and self-esteem have been measured in a variety of ways. The complexity of the concept as well as lack of theoretical agreement and empirical data has resulted in accepting a general definition of self-esteem, which is mirrored in the broad use of the Rosenberg’s Scale for self-esteem (RSE). Although RSE has excellent psychometric properties, it constitutes a unidimensional scale that does not capture the complexity of self-esteem (i.e the evaluative dimension of self-concept). Self-esteem can be defined as the sense of contentment and acceptance that results from a person's appraisal of one's own worth, attractiveness, competence, and ability to satisfy one's aspirations. Given the multidimensionality of the concept, there are a few alternatives to the RSE, such as the Coopersmith Self-Esteem Inventory, and Self-Concept Questionnaire. In this chapter, the psychometric properties of the Self-Concept Questionnaire (SCQ) will be presented and its conceptual composition will be related to the earlier mentioned theories on the concept of Self. It is concluded that given its multidimensionality and encouraging psychometric properties, the SCQ can be a valuable instrument in assessing self-esteem in clinical settings as well as in the studies of the general population. Drawing from recent theories of the development of heterosexual romantic relationships during adolescence and emerging adulthood, the associations among females’ socioemotional functioning (positive well-being, negative affect, loneliness), romantic affiliation and support, and qualities of relationships with family and best female friends were investigated in chapter

Preface

xi

6. Female participants completed assessments at ages 18, 20 and 23. As predicted, age-related differences in associations between females’ socioemotional functioning and aspects of romantic relationships were found. After adjusting for the quality of relationships with family and best friends at each age, findings showed that an estimate of the amount of time spent (i.e., affiliation) with romantic partners was associated with only one aspect of socioemotional functioning at age 18 (reduced loneliness), but at age 20, more romantic affiliation was associated with all three aspects of socioemotional functioning, including better psychological well-being and reduced negative affect and loneliness. In addition, quality of relationships with family and best female friends significantly covaried with socioemotional functioning at age 18, but not at age 20. In contrast to the findings for romantic affiliation, only one of aspect of females’ socioemotional functioning at age 20 positive well-being – was improved with higher levels of romantic support (e.g., intimacy and nurturance). However, a higher level of romantic support at age 23 was accompanied by more positive well-being, and reduced negative affect and loneliness. These age-related associations among romantic affiliation, romantic support and socioemotional functioning suggest that girls most salient motivation for romance at each age is largely associated with their socioemotional functioning at that age. At age 18 and 20, affiliation – someone to spend time with - is the most salient motivation for romantic involvement, while at age 23 the motivation for romance has shifted to intimacy, support and security. These findings are consistent with recent theories of qualitative changes in romance from early adolescence to emerging adulthood (Brown, 1999; Connolly & Goldberg, 1999), but show that romantic support, apart from family and friend support, may provide independent benefits for individual functioning somewhat later than expected. Chapter 7 considers some of the most recent advances in experimental psychology regarding the role of inhibitory control in the production of misinformation effects in memory; that is, the tendency to report misleading post-event information in preference to original material. Specifically, we report our findings from a series of studies using the retrieval practice paradigm (cf. Anderson, Bjork & Bjork, 1994) that explore how retrievalinduced forgetting (i.e., the tendency to forget material as a consequence of retrieving other related material) may be involved in promoting misinformation effects. We then consider how to establish experimentally that the mechanism underlying this relationship is inhibitory. In doing so, we outline the independent probe technique (Anderson & Spellman, 1995); that is, the use of novel retrieval cues at test rather than those cues used during the initial stages of the retrieval practice paradigm. Our findings clearly indicate that misinformation effects emerged only under conditions where retrieval-induced forgetting remained active and that the retrieval-induced forgetting observed in our studies was due to inhibitory control. Implications for our understanding of how memory is updated; the design of experimental paradigms that consider the role of active forgetting in memory; and the development of police investigative techniques are also explored.

In: Advances in Psychology Research, Volume 44 Editor: Alexandra Columbus, pp. 1-15

ISBN 1-60021-150-X © 2006 Nova Science Publishers, Inc.

Chapter 1

NEUROANATOMICAL BASIS OF BIPOLAR DISORDER Toshiya Murai∗ Department of Psychiatry, Graduate School of Medicine, Kyoto University Shogoin-Kawaharacho 54, Kyoto, Japan

ABSTRACT It is essential to characterize the underlying neural circuitry to elucidate the pathophysiological mechanism of bipolar disorder. Two complementary approaches are possible on this issue. Firstly, there are a series of structural neuroimaging studies comparing bipolar disorder subjects with control subjects. In particular, using volumetric analyses of structural MRI, anatomical changes have been reported in several brain structures, including the subgenual prefrontal cortex and amygdala. Secondly, there are sporadic case reports of de novo bipolar disorder after focal brain damage, such as stroke or traumatic brain injury. These unique cases provide clues to elucidate the essential neural substrates of bipolar disorder. The importance of an orbitofrontal, extensive right hemispheric, thalamic, and temporal basal lesion has been suggested. In this paper, the author describes a representative case of de novo bipolar disorder after traumatic brain injury, reviews the relevant literature, and suggests a possible neuroanatomical basis for bipolar disorder. Although the existing evidence should be taken as preliminary, it implies that structural abnormalities in fronto-subcortical networks as well as specific limbic or paralimbic structures, which are involved in regulating the normal subjective emotional experience, might play a critical role in the mechanism of bipolar disorder.

INTRODUCTION Recent advances in neuroimaging have opened unprecedented possibilities to elucidate the pathophysiological mechanisms of bipolar disorder. Multiple imaging modalities are available including computed tomography (CT) or magnetic resonance imaging (MRI) for

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Toshiya Murai

structural imaging, single photon emission computerized tomography (SPECT), positron emission tomography (PET) or functional MRI (fMRI) to assess the functional state of the brain. Furthermore, regional concentrations of various chemicals can be estimated by magnetic resonance spectroscopy (MRS), and receptor imaging is realized by SPECT or PET using receptor-specific radioligands. Among many modalities of investigation, this paper is devoted to reviewing structural neuroimaging studies on bipolar disorder. Structural imaging studies can be divided into two categories. First, there are a series of studies comparing bipolar disorder subjects with control subjects. These studies are performed by CT or MRI, but MRI offers increased opportunities to delimitate specific brain regions. Thus, this chapter exclusively reviews volumetric MRI studies. The other line of study involves the documentation of the brain regions involved in patients with de novo bipolar disorder after focal brain damage. These two complementary approaches provide clues to elucidate the essential neural substrate of bipolar disorder.

VOLUMETRIC STUDIES IN A POPULATION WITH BIPOLAR DISORDER Ventricular volumes were the most frequent targets of investigation in early volumetric studies using CT. MRI with its better resolution between gray and white matter has enabled the investigation of specific cortical and subcortical structures, and abnormalities of these structures in bipolar disorder have been reported over the past two decades (Tables 1 to 9). Brain structures, which have been most extensively investigated, are medial temporal structures (hippocampus, amygdala), subcortical structures (thalamus, striatum), and prefrontal structures (especially subgenual prefrontal cortex).

Temporal Lobe (Table 1) The temporal lobe includes several structures which are involved in normal mood regulation and thus are potentially important in the neurophysiology of bipolar disorder. Early studies measuring the volume of the entire temporal lobe produced mixed results; two studies reported reduced temporal lobe volume in patients with bipolar disorder [1, 2], while no significant difference [3, 4], or increased temporal lobe volume was also reported [5]. However, these early findings have not been replicated in recent studies, most of which uses imaging technique with higher spatial resolution, and have found no abnormalities in the temporal lobe volume in subjects with bipolar disorder [6-11]. As the temporal lobe includes structurally and functionally heterogeneous structures, i.e., primary auditory, unimodal and heteromodal association cortex, paralimbic and limbic areas, measuring the volume of specific substructures would be more meaningful.

∗

E-mail: [email protected]; Telephone: +81 75 751 3383; Fax: +81 75 751 3246

Neuroanatomical Basis of Bipolar Disorder

3

Table 1. Volumetric Studies in Bipolar Disorder: Entire Temporal Lobe Author

Subjects

Age

Comparison

Hauser et al 1989

15 BP

40.5 (12.8)

21 NC

Johnstone et al 1989 Altshuler et al 1991 Swayze et al 1992

20 BP

38.9 (8.2)

10 BP

39.8 (9)

21 SCZ 21 NC 10 NC

48 BP

Harvey et al 1994

26 BP

33.4 (M) 34.6 (F) 35.6

54 SCZ 47 NC 34 NC

Pearlson et al 1997 Altshuler et al 1998 Roy et al 1998

27 BP

31.8 (7.8)

12 BP

50.8 (13.3)

14 BP

35.9 (7.2)

Altshuler et al 2000 Hauser et al 2000

24 BP

50.2 (12.7)

25 BP I 22 BP II 24 BP

41.8 (10.5) 39.4 (10.2) 35 (10)

46 SCZ 60 NC 14 SCZ 18 NC 22 SCZ 15 NC 20 SCZ 18 NC 19 NC

Brambilla et al 2003

36 NC

Spatial resolution 0.5 T MRI 10 mm 12 slices 0.15 T MRI 8 mm 6 to 10 slices 0.5 T MRI 10 mm 12 slices 0.5 T MRI 10 mm 8 slices 0.5 T MRI 5 mm 20 slices 1.5 T MRI 3 mm contiguous 1.5 T MRI 1.4 mm contiguous 1.5 T MRI 5 mm 1-mm gap 1.5 T MRI 1.4 mm contiguous 0.5 T MRI 5 mm contiguous 1.5 T MRI 1.5 mm contiguous Methods

Findings (diff. with NC) Smaller bilateral TL No significant difference Smaller bilateral TL No significant difference Larger left TL No significant difference No significant difference No significant difference No significant difference No significant difference No significant difference

NC: normal control, BP: bipolar disorder, SCZ: schizophrenia, TL: temporal lobe

Hippocampus (Table 2) Among the substructures of the temporal lobe, the hippocampus has been most frequently investigated. Apart from a recent study which reported a smaller hippocampus in adults and adolescent patients with bipolar disorder [12], most studies reported no significant difference in the volume of the hippocampus between patients with bipolar disorder and normal healthy subjects [1, 4, 6-10, 13-16]. This contrasts with the frequently reported findings of hippocampus volume reduction in schizophrenia [17].

Amygdala (Table 3) As neural substrates of normal mood regulation are suspected to be involved in the pathogenesis of bipolar disorder, many studies have investigated amygdala, which is known to play a key role in human emotional cognition. Imaging techniques with good spatial resolution have enabled the volumetric analysis of amygdala, and abnormalities in this structure have been reported repeatedly. Unfortunately, the results are variable, or even contradictory among the studies. Four studies reported an increased volume of amygdala [6-8, 13]. On the other hand, three studies reported smaller amygdala in bipolar disorder [10, 12, 18], As two of the latter studies [12, 18] investigated younger subjects, the conflicting

4

Toshiya Murai

findings may have resulted from the difference of age at disease onset, disease duration, or duration of mood stabilizer treatments. Alternatively, the inconsistent results may have been caused by technical limitations, as precise delineation of the amygdala from adjacent gray matter tissues is difficult even with high resolution MRI. Table 2. Volumetric Studies in Bipolar Disorder: Hippocampus Findings (diff. with NC)

Author

Subjects

Age

Comparison

Methods

Resolution

Hauser et al 1989* Swayze et al 1992* Pearlson et al 1997 Altshuler et al 1998 Hirayasu et al 1998* Sax et al 1999 Strakowski et al 1999 Altshuler et al 2000 Hauser et al 2000 Strakowski et al 2002

15 BP

40.5 (12.8)

21 NC

0.5 T MRI

48 BP

12 BP

50.8 (13.3)

1.5 T MRI

16 AP (14 BP, 2 UP) 17 BP

23.7 (4.0)

1.5 T MRI

1.5 mm

27 (6)

54 SCZ 47 NC 46 SCZ 60 NC 14 SCZ 18 NC 17 SCZ 18 NC 12 NC

0.5 T MRI

27 BP

33.4 (M) 34.6 (F) 31.8 (7.8)

10 mm 12 slices 10 mm 8 slices 3 mm contiguous 1.4 mm

1.5T MRI

Contiguous

24 BP

27 (6)

22 NC

1.5 T MRI

24 BP

50.2 (12.7)

1.5 T MRI

25 BP I 22 BP II 18 first 17 multiple episode BP 36 BP (14 adolescent, 22 adults) 24 BP

41.8 (10.5) 39.4 (10.2) 22 (6) 25 (6)

20 SCZ 18 NC 19 NC

0.5 T MRI

32 NC

1.5 T MRI

1 mm contiguous 1.4 mm contiguous 5 mm 15 slices 1.5 mm contiguous

No significant difference No significant difference No significant difference No significant difference No significant difference No significant difference No significant difference No significant difference No significant difference No significant difference

31.0 (14.1)

56 NC

1.5 T MRI

1.2 mm contiguous

Smaller hippocampus

35 (10)

36 NC

1.5 T MRI

1.5 mm contiguous

No significant difference

Blumberg et al 2003 Brambilla et al 2003

1.5 T MRI

NC: normal control, BP: bipolar disorder, SCZ: schizophrenia, AP: affective psychosis, UP: unipolar depression * Measurement of amygdala-hippocampal complex

Superior Temporal Gyrus (Table 4) Superior temporal gyrus (STG) is another temporal lobe structure that has been specifically investigated in the volumetric analysis of bipolar disorder. Pearlson et al. [10] reported an increased volume of right anterior STG in subjects with bipolar disorder, however, this finding has not been replicated in other studies, including a recent study [8, 16, 19].

Neuroanatomical Basis of Bipolar Disorder

5

Table 3. Volumetric Studies in Bipolar Disorder: Amygdala Author

Subjects

Age

Pearlson et 27 BP 31.8 (7.8) al 1997 Altshuler et 12 BP 50.8 (13.3) al 1998 Strakowski 24 BP 27 (6) et al 1999 Altshuler et 24 BP 50.2 (12.7) al 2000 Brambilla et 24 BP 35 (10) al 2003 Blumberg et 36 BP (14 31.0 (14.1) al 2003 adolescent, 22 adults) DelBello et 23 BP 16.3 (2.4) al 2004

Comparison

Methods

Resolution

Findings (diff. with NC)

46 SCZ 60 NC 14 SCZ 18 NC 22 NC

1.5 T MRI

3 mm contiguous 1.4 mm contiguous 1 mm contiguous 1.4 mm contiguous 1.5 mm contiguous 1.2 mm contiguous

Smaller left amygdala Larger amygdala Larger amygdala Larger amygdala Larger left amygdala Smaller amygdala

1.5 mm contiguous

Smaller amygdala

1.5 T MRI 1.5 T MRI

20 SCZ 18 NC 36 NC

1.5 T MRI 1.5 T MRI

56 NC

1.5 T MRI

20 NC

1.5 T MRI

NC: normal control, BP: bipolar disorder, SCZ: schizophrenia, AP: affective psychosis, UP: unipolar depression

Table 4. Volumetric Studies in Bipolar Disorder: Superior Temporal Gyrus Author

Subjects

Schlaepfer et 27 BP al 1994 Pearlson et al 27 BP 1997 Hirayasu et al 16 AP (14 1998 BP, 2 UP) Brambilla et al 24 BP 2003

Age

Comparison

Methods

Resolution

Findings (diff. with NC)

34.9 (8.6)

46 SCZ 60 NC 46 SCZ 60 NC 17 SCZ 18 NC 36 NC

1.5 T MRI

5 mm contiguous 3 mm contiguous 1.5 mm contiguous 1.5 mm contiguous

No significant difference Larger right anterior STG No significant difference No significant difference

34.9 (8.6) 23.7 (4.0) 35 (10)

1.5 T MRI 1.5 T MRI 1.5 T MRI

NC: normal control, BP: bipolar disorder, SCZ: schizophrenia, AP: affective psychosis, UP: unipolar depression, STG: superior temporal gyrus

Other Temporal Structures (Table 5) Other temporal structures have also been investigated. No abnormalities have been demonstrated in the parahippocampal gyrus [6, 10, 16]. A recent study using voxel-based morphometry demonstrated a smaller left temporal pole in bipolar disorder [20].

6

Toshiya Murai Table 5. Volumetric Studies in Bipolar Disorder: Other Temporal Structures Author

Pearlson et al 1997 Hirayasu et al 1998 Altshuler et al 2000 Kasai et al 2003

Subjects

Age

Comparison

Methods

27 BP

31.8 (7.8)

46 SCZ 60 NC

16 AP (14 23.7 (4.0) BP, 2 UP)

17 SCZ 18 NC

1.5 T MRI 3mm contiguous 1.5 T MRI 1.5 mm contiguous 1.5 T MRI 1.4 mm contiguous 1.5 T MRI 1.5 mm contiguous

24 BP

50.2 (12.7)

20 SCZ 18 NC

26 AP (24 23.2 (5.0) BP)

27 SCZ 29 NC

Investigated structures Entorhinal cortex, parahippocampal gyrus Parahippocampal gyrus

Findings (diff. with NC) No significant difference

Parahippocampal gyrus

No significant difference

Insula, Temporal pole

Smaller left temporal pole

No significant difference

NC: normal control, BP: bipolar disorder, SCZ: schizophrenia, AP: affective psychosis, UP: unipolar depression

Subgenual Prefrontal Cortex (Table 6) Anatomical investigation of the subgenual prefrontal cortex (SGPFC), corresponding to the subgenual part of Brodmann Area 24 was motivated by a PET study that revealed reduced subgenual metabolic activity in subjects with bipolar disorder [21]. The SGPFC is of particular interest as it has extensive reciprocal connections with structures important for normal emotional processing, such as the orbitofrontal cortex, amygdala, hypothalamus, nucleus accumbens, and medial thalamic nuclei. Two of four studies that investigated this structure reported decreased volume of the left SGPFC in patients with bipolar disorder with a family history [21, 22]. One study demonstrated right SGPFC volume reduction [23], while one revealed no significant difference in familial as well as in non-familial bipolar subjects [24]. Table 6. Volumetric Studies in Bipolar Disorder: Subgenual Prefrontal Cortex Author Drevets et al 1997 Hirayasu et al 1999

Subjects

21 BP with family history 24 AP (21 BP, 3 UP), (14 with family history) Brambilla et 27 BP, (12 with al 2002 family history) Sharma et al 12 BP 2003

Age 35 (8.2) 23.7 (5.1)

35 (11) 38.3 (6.2)

Comparison Methods

Resolution

17 UP 21 NC 17 SCZ 20 NC

1.5 T MRI 1.5 T MRI

1 x 1 x 25 mm voxels 1.5 mm contiguous

18UP 38 NC 6 NC

1.5 T MRI 4.0 T MRI

1.5 mm contiguous

Findings (diff. with NC) Smaller left SGPFC Smaller left SGPFC in patients with family history No significant difference Smaller right SGPFC

NC: normal control, BP: bipolar disorder, SCZ: schizophrenia, AP: affective psychosis, UP: unipolar depression

Neuroanatomical Basis of Bipolar Disorder

7

Other Frontal Structures (Table 7) In addition to SGPFC described above, the volume of the frontal lobe structures has been investigated in several studies. Two studies reported that patients with bipolar disorder have reduced frontal/ prefrontal volumes [14, 25], while the other reported no difference [13]. Sub-regions of the frontal lobes have also been investigated [21, 26, 27] and some specific divisions of prefrontal gray matter have been demonstrated to be smaller in bipolar disorder in a recent study [27]. Table 7. Volumetric Studies in Bipolar Disorder: Other Frontal Structures Author

Subjects

Age

Comparison

Coffman et al 30 BP (with 32.0 (6.2) 1990 psychotic features) Strakowsiki 17 BP (first 28.4 (6.8) et al 1993 episode) Drevets et al 21 BP with 35 (8.2) 1997 family history Strakowski et 24 BP 27 (6) al 1999

52 NC

Sax et al 1999 LopezLarson et al 2002

16 NC 17 UP 21 NC 22 NC

17 BP

27 (6)

12 NC

17 BP

29 (7)

12 NC

Measured brain volume 1.5 T MRI Frontal cortex 3 mm Methods

1.5 T MRI 6 mm 1.5 T MRI 1 x 1 x 25 mm voxels 1.5 T MRI 1 mm contiguous 1.5T MRI contiguous 1.5 T MRI 1 mm contiguous

Cingulate gyrus Dorsal anterior cingulated gyrus Prefrontal cortex

Findings (diff. with NC) Trend to smaller frontal area No significant difference No significant difference No significant difference

Prefrontal cortex Smaller predrontal cortex Prefrontal cortex Smaller left (superior, superior and middle middle, inferior, prefrontal, and right orbital, middle and inferior cingulate.) prefrontal gray matter

NC: normal control, BP: bipolar disorder, UP: unipolar depression

Thalamus (Table 8) Subcortical structures, namely the thalamus, striatum, and globus pallidus, constitute a component of fronto-subcortical neuronal circuits, and play an important role in mood regulation [28, 29]. Among subcortical structures, the thalamus has been most extensively investigated. Most volumetric studies have revealed no statistical difference in the size of the thalamus between bipolar subjects and normal controls [10, 14, 18, 26, 30, 31], while a few reported a larger thalamus in bipolar patients [13, 32].

Basal Ganglia (Table 9) A larger putamen in bipolar subjects has been reported in one recent study [18], and another reported a trend towards a larger striatum and globus pallidus in bipolar subjects

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[13]. In addition, two other studies reported abnormalities in the structure of the basal ganglia in a subpopulation of the bipolar subjects. However, the majority of studies demonstrate no abnormalities in these structures [4, 14, 26, 32, 33]. Table 8. Volumetric Studies in Bipolar Disorder: Thalamus Author

Subjects

Age

Strakowsiki et 17 BP (first 28.4 (6.8) al 1993 episode) Dupont et al 36 BP 36.6 (10.8) 1995 Pearlson et al 27 BP 31.8 (7.8) 1997 Strakowski et 24 BP 27 (6) al 1999 Sax et al 1999 17 BP (acute 27 (6) mania) Caetano et al 25 BP 34.4 (9.8) 2001 Strakowski et 18 first 22 (6) 25 (6) al 2002 17 multiple episode BP DelBello et al 23 BP 16.3 (2.4) 2004

Comparison

Methods

Resolution

16 NC

1.5 T MRI

30 UP 26 NC 46 SCZ 60 NC 22 NC

1.5 T MRI

1.5 T MRI

12 NC

1.5 T MRI

6 mm contiguous 5 mm 2.5 mm gap 3 mm contiguous 1 mm contiguous Not described

17 UP 39 NC 32 NC

1.5 T MRI 1.5 T MRI

20 NC

1.5 T MRI

1.5 T MRI

Findings (diff. with NC) No significant difference Larger thalamus

1.5 mm contiguous 1.5 mm contiguous

No significant difference Trend toward larger thalamus No significant difference No significant difference No significant difference

1.5 mm contiguous

No significant difference

NC: normal control, BP: bipolar disorder, SCZ: schizophrenia, UP: unipolar depression

SUMMARY OF THE VOLUMETRIC STUDIES IN BIPOLAR DISORDER There are mixed results, partially caused by the heterogeneity of technical standards of image acquisition and analysis. The volume abnormalities of the entire temporal lobe or the hippocampus are not supported. Amygdala is a potentially interesting anatomical structure in the mechanism of bipolar disorder considering its role in normal emotional cognition. However, due to the surprising inconsistency of the results published (some multiple studies reported larger amygdala, while other multiple studies reported smaller amygdala), it is difficult to interpret them, even if the difference of patients’ demographics or clinical features, or the methodological differences among studies are considered. Smaller left SGPFC, especially in patients with a family history of bipolar disorder, is an interesting finding in recent studies of higher spatial resolution, although further replication is needed. Early hypotheses and lesion studies (described below) suggested a lateralized right hemispheric dysfunction in bipolar disorder. However, the volumetric studies do not consistently support this notion in any of the investigated structures.

Neuroanatomical Basis of Bipolar Disorder

9

Table 9. Volumetric Studies in Bipolar Disorder: Basal Ganglia Author

Subjects

Comparison

Methods

Swayze et al 48 BP 33.4 (M) 1992 34.6 (F) Strakowsiki et 17 BP (first 28.4 (6.8) al 1993 episode) Aylward et al 30 BP 37.9 (M) 1994 40.7 (F) Dupont et al 36 BP 36.6 (10.8) 1995 Strakowski et 24 BP 27 (6) al 1999

54 SCZ 47 NC 16 NC

0.5 T MRI 1.5 T MRI

30 NC

1.5T MRI

30 UP 26 NC 22 NC

1.5 T MRI 1.5 T MRI

Sax et al 1999

27 (6)

12 NC

1.5T MRI

36 (10)

22 NC

1.5 T MRI

22 (6) 25 (6)

32 NC

1.5 T

16.3 (2.4)

20 NC

1.5 T MRI

17 BP

Brambilla et al 22 BP 2001 Strakowski et 18 first al 2002 17 multiple episode BP DelBello et al 23 BP 2004

Age

Findings (diff. with NC) 10 mm No significant 8 slices difference 6 mm No significant contiguous difference 5mm Larger right and left caudate in male BP 5 mm No significant 2.5 mm gap difference 1 mm Trend toward larger contiguous striatum and glubus pallidus volume Not described No significant difference 1mm No significant difference 1.5 mm Larger Putamen in contiguous first episode patients Resolution

1.5 mm contiguous

Larger putamen

NC: normal control, BP: bipolar disorder, SCZ: schizophrenia, UP: unipolar depression

SECONDARY BIPOLAR DISORDER DUE TO BRAIN INJURY Focal brain injuries such as stroke or traumatic brain injury may sporadically cause a single manic episode. Although more rarely, patients with multiple manic (and depressive) episodes followed by focal brain lesions have also been reported. The frequently reported lesions as a cause of mania are those of the thalamus, temporobasal cortex, orbitofrontal cortex, and extensive right hemisphere. Orbitofrontal damage typically causes persistent personality change with behavioral abnormalities such as euphoria or disinhibitory tendency. Mania is sometimes observed in this condition, though the course of the mood disturbance is typically characterized by pure mania rather than bipolar disorder alternating with depression [34]. Extensive right hemispheric damage is often associated with anosognosia or denial of illness, especially in the acute phase of brain injury. Mania or hypomania is sometimes observed in this condition. Mania after various thalamic lesions has been reported [35-45]. The paramedian thalamic artery, which arises from the posterior cerebral artery, often sends branches bilaterally. As a consequence, its occlusion often causes bilateral infarction [46]. Generally, the neuropsychiatric sequel of bilateral paramedian infarct is characterized by apathy with hypersomnia. However, mania after bilateral paramedian thalamic infarct has also been sporadically reported [35, 37, 39, 44]. In these patients, prefrontal hypoperfusion due to thalamo-frontal diaschisis is suspected [35]. Secondary mania after unilateral thalamic lesion has also been reported, and all of the reported cases with unilateral thalamic lesion have right

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thalamic damage [36, 38, 40-43, 45]. Lesion location within the thalamus is variable among these patients with unilateral thalamic damage. The temporobasal cortex is another region whose damage is a potential cause of secondary mania. Out of 60 consecutive patients after traumatic brain injury, Jorge et al. [47] detected post-traumatic mania in six patients. By clinico-anatomical correlation, they found that a temporal basal polar lesion is the only correlation with post-traumatic mania. Recently, we reported a patient who developed secondary bipolar disorder after traumatic brain injury with a left temporal polar lesion [48]. The case history is briefly summarized here as a demonstration of secondary bipolar disorder after focal brain injury. K.S., a 48-year-old woman, who had no previous history of psychiatric or neurological diseases, sustained a head injury in a traffic accident. Losing consciousness, she was admitted to a regional hospital. After recovering consciousness after two days, she was observed to be relatively calm and hypersomniac. However, her family noticed a dramatic change in her behaviour six weeks after the accident. K.S. suffered extreme insomnia, but was unmoved by her lack of sleep. She began to visit neighbours very early in the morning or make frequent phone calls to her relatives. She became irritable and easily angered over trivial events. Three weeks after the beginning of this manic and hyperactive phase, she suddenly became hypoactive. In marked contrast with the preceding three weeks, she stayed in bed all day, complaining of general malaise and appetite loss. She lost interest in all daily activities. Following this hypoactive, depressive phase, manic and depressive episodes similar to the initial phases alternated. Each manic or depressive episode had an average duration of about one month. Finally, K.S. was referred to our psychiatric department in her fifth manic phase. In our initial examination, K.S. was elated, talkative, and easily distracted from the current topic. She lacked insight into her behavioural abnormalities, and often interrupted the conversation between the examiner and her husband. On MRI, a high intensity area on T2-weighted images was found in the left temporal pole, indicating traumatic contusion (Figure 1). Other brain areas, including the frontal lobes and medial temporal structures such as the hippocampus and amygdala, were intact. 99mTc-ECD-SPECT revealed a reduction of blood flow in the same area. Neuropsychological examination revealed that her general intellect was within the normal range, with a mini-mental state examination score of 30/30 and a Wechsler Adult Intelligence Scale Revised score of VIQ/PIQ/FIQ = 97/84/91. Her learning ability was also normal with a Wechsler Memory Scale Revised (WMS-R) score of [verbal memory index]/[visual memory index]/[general memory index]/[delayed memory index] = 101/98/100/102. Pharmacotherapy was started at the beginning of her sixth manic phase. Initially, up to 800 mg/day of valproic acid was administered, together with benzodiazepine administration for sleep disturbance. As this regimen did not prevent this mood cycling, up to 800 mg/day of lithium carbonate was coadministered, and her mood swings finally subsided. Due to the frequent switching between manic and depressive phases, the mood disturbance of the patient fulfils the criteria of rapid cycling bipolar disorder. One of the main questions about the mechanism of bipolar disorder is why patients suffer from not only single episodes of mania but multiple alternating episodes of mania or depression. Thus, the clinico-anatomical investigation of rapid-cycling bipolar disorder is of particular interest in the search for the neuroanatomical basis of mood-swings in bipolar disorder. As K.S. was observed to develop multiple manic and depressive episodes with relative periodicity, her behavioural change cannot be explained by a persistent disinhibitory tendency or euphoria,

Neuroanatomical Basis of Bipolar Disorder

11

which is often observed after orbitofrontal injury. Although the relative importance of right temporobasal damage has been suggested [49], our case study demonstrates that bipolar disorder does develop after left-lateralized damage in this structure.

Figure 1. Coronal and axial T2-weighted MRI showing high signal intensity areas in the left temporal pole. The left side of the figure corresponds to the right side of the brain.

SUMMARY OF THE VOLUMETRIC AND LESION STUDIES The above described volumetric as well as lesion studies support the hypothesis that bipolar disorder is more likely to be associated with the impairment of networks involving multiple brain structures, rather than with the impairment of a single specific structure. Both in the volumetric and lesion studies, anterior temporal limbic and paralimbic structures have been implicated in the pathophysiology of bipolar disorder. As the anterior temporal structures such as amygdala or temporopolar cortex are known to play a key role in the recognition of emotional valence of the stimuli [50, 51], malfunctioning of these structures may facilitate the skewed attribution of affective tone to everyday experiences, which in turn may elicit global dysregulation of mood. The involvement of the thalamus in the development of bipolar disorder has been supported by lesion studies. Although most volumetric studies showed no abnormality in the thalamus, these negative findings may be explained by the findings that MRI volumetry cannot examine abnormalities of specific thalamic nuclei, which are functionally distinct from one another. Indeed, as lesion studies show, a specific subdivision of the thalamus, namely the paramedian part of the thalamus, appears to be critical. This division of the thalamus has a projection to the orbitofrontal cortex and constitutes the orbitofrontal circuit, one of the fronto-subcortical networks [29]. As orbitofrontal damage is also known to cause

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Toshiya Murai

mania in lesion studies, the involvement of thalamic abnormalities in the development of bipolar disorder may be explained by the dysfunction of this network. Another structure of potential importance is the left SGPFC, suggested by volumetric studies. As there have been no lesion studies in which brain damage was restricted to the left SGPFC while sparing the surrounding structures, the distinctive functional role of the SGPFC should be investigated further. However, lesion studies generally do not contradict volumetric studies as disinhibitory and euphoric behavioural changes are known to be associated with extensive ventromedial prefrontal lesions, which often include SGPFC. Due to the mixed results thus far reported, any assumption regarding the neuroanatomical basis of bipolar disorder should be taken as preliminary. However, what is interesting is that the structures implicated as abnormal in bipolar disorder are those that are known to be involved in emotional processing in normal subjects. More specifically, frontosubcortical networks, especially the orbitofrontal circuit, appear to be important. In addition, the amygdala, one of the main open connections from this circuit, and basotemporal paralimbic structures with a reciprocal connection to the amygdala, is of potential importance.

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[24] Brambilla P, Nicoletti MA, Harenski K, et al. Anatomical MRI study of subgenual prefrontal cortex in bipolar and unipolar subjects. Neuropsychopharmacology. Nov 2002;27(5):792-799. [25] Coffman JA, Bornstein RA, Olson SC, Schwarzkopf SB, Nasrallah HA. Cognitive impairment and cerebral structure by MRI in bipolar disorder. Biol Psychiatry. Jun 1 1990;27(11):1188-1196. [26] Strakowski SM, Wilson DR, Tohen M, Woods BT, Douglass AW, Stoll AL. Structural brain abnormalities in first-episode mania. Biol Psychiatry. Apr 15-May 1 1993;33(89):602-609. [27] Lopez-Larson MP, DelBello MP, Zimmerman ME, Schwiers ML, Strakowski SM. Regional prefrontal gray and white matter abnormalities in bipolar disorder. Biol Psychiatry. Jul 15 2002;52(2):93-100. [28] Soares JC, Mann JJ. The anatomy of mood disorders--review of structural neuroimaging studies. Biol Psychiatry. Jan 1 1997;41(1):86-106. [29] Tekin S, Cummings JL. Frontal-subcortical neuronal circuits and clinical neuropsychiatry: an update. J Psychosom Res. Aug 2002;53(2):647-654. [30] Caetano SC, Sassi R, Brambilla P, et al. MRI study of thalamic volumes in bipolar and unipolar patients and healthy individuals. Psychiatry Res. Dec 30 2001;108(3):161-168. [31] Strakowski SM, Adler CM, DelBello MP. Volumetric MRI studies of mood disorders: do they distinguish unipolar and bipolar disorder? Bipolar Disorders. April 01, 2002 2002;4(2):80-88. [32] Dupont RM, Jernigan TL, Heindel W, et al. Magnetic resonance imaging and mood disorders. Localization of white matter and other subcortical abnormalities. Arch Gen Psychiatry. Sep 1995;52(9):747-755. [33] Brambilla P, Harenski K, Nicoletti MA, et al. Anatomical MRI study of basal ganglia in bipolar disorder patients. Psychiatry Res. Apr 10 2001;106(2):65-80. [34] Starkstein SE, Fedoroff P, Berthier ML, Robinson RG. Manic-depressive and pure manic states after brain lesions. Biol Psychiatry. Jan 15 1991;29(2):149-158. [35] Benke T, Kurzthaler I, Schmidauer C, Moncayo R, Donnemiller E. Mania caused by a diencephalic lesion. Neuropsychologia. 2002;40(3):245-252. [36] Leibson E. Anosognosia and mania associated with right thalamic haemorrhage. J Neurol Neurosurg Psychiatry. Jan 2000;68(1):107-108. [37] McGilchrist I, Goldstein LH, Jadresic D, Fenwick P. Thalamo-frontal psychosis. Br J Psychiatry. Jul 1993;163:113-115. [38] Trimble MR, Cummings JL. Neuropsychiatric disturbances following brainstem lesions. Br J Psychiatry. Jan 1981;138:56-59. [39] Gentilini M, De Renzi E, Crisi G. Bilateral paramedian thalamic artery infarcts: report of eight cases. J Neurol Neurosurg Psychiatry. Jul 1987;50(7):900-909. [40] Bogousslavsky J, Ferrazzini M, Regli F, Assal G, Tanabe H, Delaloye-Bischof A. Manic delirium and frontal-like syndrome with paramedian infarction of the right thalamus. J Neurol Neurosurg Psychiatry. Jan 1988;51(1):116-119. [41] Starkstein SE, Boston JD, Robinson RG. Mechanisms of mania after brain injury. 12 case reports and review of the literature. J Nerv Ment Dis. Feb 1988;176(2):87-100. [42] Kulisevsky J, Berthier ML, Pujol J. Hemiballismus and secondary mania following a right thalamic infarction. Neurology. Jul 1993;43(7):1422-1424.

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[43] Daum I, Ackermann H. Frontal-type memory impairment associated with thalamic damage. Int J Neurosci. Aug 1994;77(3-4):187-198. [44] Fukatsu R, Fujii T, Yamadori A, Nagasawa H, Sakurai Y. Persisting childish behavior after bilateral thalamic infarcts. Eur Neurol. 1997;37(4):230-235. [45] Vuilleumier P, Ghika-Schmid F, Bogousslavsky J, Assal G, Regli F. Persistent recurrence of hypomania and prosopoaffective agnosia in a patient with right thalamic infarct. Neuropsychiatry Neuropsychol Behav Neurol. Jan 1998;11(1):40-44. [46] Mori E. Impact of subcortical ischemic lesions on behavior and cognition. Ann N Y Acad Sci. Nov 2002;977:141-148. [47] Jorge RE, Robinson RG, Starkstein SE, Arndt SV, Forrester AW, Geisler FH. Secondary mania following traumatic brain injury. Am J Psychiatry. Jun 1993;150(6):916-921. [48] Murai T, Fujimoto S. Rapid cycling bipolar disorder after left temporal polar damage. Brain Inj. Apr 2003;17(4):355-358. [49] Starkstein SE, Mayberg HS, Berthier ML, et al. Mania after brain injury: neuroradiological and metabolic findings. Ann Neurol. Jun 1990;27(6):652-659. [50] Adolphs R, Tranel D, Damasio H, Damasio A. Impaired recognition of emotion in facial expressions following bilateral damage to the human amygdala. Nature. Dec 15 1994;372(6507):669-672. [51] Royet JP, Zald D, Versace R, et al. Emotional responses to pleasant and unpleasant olfactory, visual, and auditory stimuli: a positron emission tomography study. J Neurosci. Oct 15 2000;20(20):7752-7759.

In: Advances in Psychology Research, Volume 44 Editor: Alexandra Columbus, pp. 17-35

ISBN 1-60021-150-X © 2006 Nova Science Publishers, Inc.

Chapter 2

FIFTY-FIVE YEARS OF LITHIUM THERAPY IN CONTEMPORARY PSYCHIATRY Janusz K. Rybakowski* Department of Adult Psychiatry Poznan University of Medical Sciences, Poznan, Poland

ABSTRACT Lithium therapy was introduced into contemporary psychiatry in 1949 due to a serendipitous finding of Australian psychiatrist, John Cade. In this chapter, the main events connected with the modern history of lithium have been discussed that occurred in five decades: 1949-1959; 1959-1969; 1969-1979; 1979-1989; 1989-1999 as well as in recent five years: 1999-2004. They include the evidence for psychotropic effects of lithium (antimanic, mood-stabilizing, antidepressant, antisuicidal) as well as other biological effects (antiviral, immunomodulatory, neuroprotective), studies on mechanism of action of this ion as well as the main organizational and cultural facts. Fifty-five years of lithium therapy in psychiatry made a tremendous impact on both psychiatry and general neuroscience.

INTRODUCTION Psychotropic properties of lithium had probably been known in the antiquity. In the 2nd century, Roman physician, Soranus of Efez, in his book: “On acute and chronic diseases” recommended drinking alkali mineral water to persons with nervous ailments. As we know now, such springs contain a lot of lithium ions. However, the identification of lithium as a chemical element was not until 1817, when Swedish chemist, Johann Augusto Arfwedson, *

Correspondenceconcerning this article should be addressed to: Janusz K. Rybakowski, Department of Adult Psychiatry, Poznan University of Medical Sciences, Szpitalna 27/33, 60-572 Poznan, Poland. E-mail: [email protected]

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working in Berzelius’ laboratory, found it as an ingredient of mineral petalite occurring in Swedish island Utö [2]. In the half of 19th century it was discovered that lithium urate salt belongs to the best soluble urates. For this reason, lithium was tried for the treatment of gout and other rheumatic diseases, where an excess of urate deposits was suspected. This kind of treatment was initiated by English physician Archibald Garrod [27]. At the end of 19th century, some researchers, as, for example Danish physician, Carl Lange, regarded also mental mania or depression as the result of disturbances of uric acid metabolism in central nervous system (gout of the brain) and recommended to use lithium salts for their treatment [45]. However, such concept, being ahead of contemporary psychopharmacology by several decades, had not been sufficiently widespread. It was not until several decades later that John Cade, Australian psychiatrist working in Melbourne, performed experiments aiming to explain a possible pathogenic role of uric acid in mania. He found that the urine from manic patients was particularly toxic to guinea pigs. When the pigs were given lithium urate, they showed significantly less symptoms of toxicity and were significantly calmed. It appeared, however, that a similar effect (calming and lethargic-like state) could be obtained by giving the pigs other lithium salts, e.g. lithium carbonate. As a next step, Cade made himself volunteer and took several doses of lithium carbonate himself without observing any harmful effect. Subsequently, he decided to administer lithium carbonate to ten patients with acute and chronic manic states. The beneficial results exceeded his expectations. While a spontaneous remission could not be excluded in some patients with acute mania, a significant improvement in patients with chronic manic symptoms lasting several months was remarkable. The publication of John Cade in the Medical Journal of Australia in 1949, where he reported these results, may be regarded as the beginning of lithium introduction into contemporary psychiatric pharmacotherapy and also, as an advent of modern clinical psychopharmacology [18]. The history of lithium in modern psychopharmacology has now been 55 years old. During this time, remarkable discoveries took place both in psychopharmacology and also in psychiatric neuroscience. The author of this article embarked on a fascinating scientific trip of lithium research from early 1970s. So, in this narrative about the history of lithium, since the third decade of lithium therapy, some personal contribution of him to the lithium research will be also mentioned.

FIRST DECADE OF LITHIUM THERAPY 1949-1959 During the first decade of lithium existence in contemporary psychiatric therapy, the main attempts were made to verify lithium therapeutic action in manic states. However, the circumstances for doing this were not too favorable. First, in the United States in late 1940s, the recommendations for low-salt diet were implemented for patients with cardiovascular diseases. It seemed that, for this aim, lithium chloride could be a good replacement for sodium chloride in the diet. However, as was demonstrated in 1960s, low sodium intake results in the enhancement of lithium reabsorption in kidneys what leads to an increase of lithium concentration in the organism and impending lithium toxicity. Consequently, several cases of lithium intoxications were reported, and some

Fifty-Five Years of Lithium Therapy in Contemporary Psychiatry

19

also with fatal outcome [21]. As a reaction to these events, Food and Drug Administration agency issued a warning against using lithium salts. Paradoxically, it happened in the same year in which Cade reported his remarkable therapeutic results with lithium in mania. Second, the introduction of antipsychotic and antidepressant drugs in 1950s and the therapeutic breakthrough in psychiatry due to this phenomenon, resulted in a significant decrease of interest in lithium as a potential psychotropic agent. However, clinical observations on the treatment of manic states with lithium have been accumulated. They continued in Australia and were also transferred into European ground, especially into Denmark. In 1951, two years after Cade’s publication, two other Australian psychiatrists, Noack and Trautner reported on favorable results on lithium administration in their group of manic patients. They noticed improvement in 29 out of 30 patients they treated with lithium [59]. On the other hand, in Denmark, the first placebo-controlled study on lithium in mania was performed. The man who did this was Danish psychiatrist Mogens Schou who, in subsequent years, became a person who gave the real momentum to lithium research. His controlled study with lithium included 38 patients with mania, among them 30 with “classic” mania, i.e. with pure affective symptoms. Among patients with typical mania, a remarkable improvement was observed in twelve patients, some improvement in 15 of them and in three, lithium did not exert any effect. Also, for the first time, the patients had systematic measurements of serum lithium concentration, and six patients had also lithium assessment in cerebrospinal fluid. It was found that these concentrations were within the range 0.5-2.0 mmol/l. These observations made an important step for future establishing a relationship between lithium concentration in serum and its therapeutic activity as well as toxicity [74]. In 1957, Mogens Schou published first interdisciplinary review on pharmacology, biochemistry and clinics of lithium ion [75].

SECOND DECADE OF LITHIUM THERAPY 1959-1969 The second decade of lithium therapy revealed entirely novel pharmacological effect of this ion, namely, its “prophylactic” action in mood disorders. Such effect was conceptualized as preventing by lithium the new affective episodes and recurrences. Previous observations suggested a possibility of preventing by lithium the recurrences of manic episodes with its prolonged administration. However, in the beginning of 1960s, two reports appeared based on the observations of several-year duration pointing to a possibility of preventing by lithium both manic and depressive recurrences in both manic-depressive and recurrent depressive illness. They were authored by British psychiatrist Hartigan [37] and by Danish psychiatrist Baastrup [4]. The Hartigan’s report published in British Journal of Psychiatry in 1963 was a three-year observation of lithium administration to 7 patients with manic-depressive illness and to 8 patients with recurrent depression. He found that in 6 patients from the first group and in 6 patients from the second group there were no illness recurrences during the observation period. Hartigan suggested a possibility of “prophylactic” action of lithium while Mogens Schou in the same year used the terms such as “normothymic” or “moodnormalizing” for describing the effect of this ion [76]. In psychiatric literature, the term “mood-normalizing” or alternatively “mood-stabilizing” had been not in widespread use until

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1990s. On the other hand, the term “normothymic” was recently popularized only in some countries, Poland being the one of them. In 1967, Baastrup and Schou summarized their experiences with long-term lithium treatment (mean: 6 years) in 88 patients with both unipolar and bipolar affective illness who had started lithium as inpatients of psychiatric hospital in Glostrup (Denmark). They found that the mean duration of morbidity (depressive or manic) while staying on lithium was 2 weeks per year. This contrasted with the mean duration of morbidity preceding lithium treatment, which was 13 weeks per year. They argued that their results strongly suggest that lithium may possess “prophylactic” activity in mood disorders [5]. Their article, published in the Archives of General Psychiatry, stirred a hot debate in psychiatric community. The voices were also raised with totally refuting the possibility of any prophylactic action of lithium. As the example for these, the article of British authors, Blackwell and Shepard, published in Lancet can be given. The title of the article was: “Prophylactic lithium: another therapeutic myth?” [16]. Clearly, such controversy could be only resolved on the basis of controlled studies which had to be performed in the following years.

THIRD DECADE OF LITHIUM THERAPY 1969-1979 The third decade of lithium therapy starts with a series of double-blind, placebocontrolled studies aiming at the verification of supposedly prophylactic action of lithium. During the period 1970-1973 the results of eight such studies were published [6, 20, 22, 39, 53, 61, 62, 79]. These studies were performed in Europe (in Denmark and Great Britain) and in the USA. In six of them, discontinuation design was employed: patients already in lithium maintenance treatment were switched double-blind at a given point to either placebo or continued lithium. In one study [20], “start” design was used: patients not previously given lithium prophylactically were allocated randomly to double-blind maintenance treatment with lithium or placebo. In one study [79], mixed discontinuation and start design was employed. As a criterion for study entry, a course of illness in preceding two years before starting lithium (e.g. frequency of episodes) was taken into account. A recurrence of the illness was defined as a mood swing episode severe enough to necessitate either hospitalization or regular antidepressant or antimanic treatment. The analysis of all studies showed that significantly fewer patients both with manic-depressive and recurrent depressive illness suffered relapse among those given lithium (mean 30%, range 0-57%) than among those given placebo (mean 70%, range 33-95%). The studies where differences were not significant involved small patient groups or short trial periods [22, 53]. It appears that the results of these studies made a strong argument for lithium prophylactic activity in recurrent mood disorder, both bipolar and unipolar. Another aspect of clinical lithium investigation in this period is an attempt to answer the question whether lithium, besides of its prophylactic activity against mania and depression exerts also antidepressant effect during acute depressive episode. The results of 10 controlled clinical studies performed until this time, were summarized by Mendels [54]. The analysis suggested that in a proportion of patients with acute depressive episode, and particularly in those with bipolar mood disorder, lithium exerts a significant therapeutic antidepressant activity. At the Department of Psychiatry, University of Medical Sciences in Poznan, an open

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study of lithium carbonate treatment used as a monotherapy was performed on 39 patients with acute depressive episode. After 4 weeks of lithium administration, 23 patients (59%) were assessed as much improved. There were no differences as to lithium antidepressant efficacy between patients with bipolar and unipolar mood disorder [63]. Interesting results were obtained in multicenter Scandinavian study including a large population of depressive patients. In was found that combination treatment, i.e. adding lithium to tricyclic antidepressants brought about a better antidepressant effect in patients with depression than using these antidepressants as monotherapy [47]. This work may serve as a precursor to subsequent studies on lithium augmentation of antidepressant drugs in treatment-resistant depression. Early 1970s marks also the first studies aimed at the elucidating biochemical mechanism of psychotropic lithium action. Pharmacological mechanism of lithium is due to the properties of lithium ion, which, similarly, like sodium and potassium belongs to the first group of periodic table elements. Supposedly, lithium could influence some abnormality of ionic transport associated with mood disorders. But is lithium transported across membrane similarly like sodium or potassium? Using erythrocyte membrane as a research model, a novel mechanism governing lithium transport across membrane, namely lithium-sodium countertransport mechanism was discovered [36]. The author of this review participated in a research group which demonstrated that lithium-sodium countertransport system is the major route of lithium efflux from the cells and the activity of this mechanism in human subjects is inversely related to lithium accumulation in erythrocytes [64]. Intracellular lithium accumulation in human patients can be approximated by measuring the erythrocyte lithium ratio (expressed as the intraerythrocyte lithium concentration/ plasma lithium concentration. In several papers, including own, it was shown that bipolar patients had higher lithium ratio than control healthy subjects [65]. Therefore, a discovery of specific mechanism of lithium transport across the cell membrane resulted in advancing a hypothesis, postulating a hereditary disturbance of this mechanism in bipolar mood disorder [60]. However, this hypothesis was not pursued further in molecular genetic studies and also did not explain a possible mechanism of lithium action connected with this transport system. In 1975 in Madison, Wisconsin, the Lithium Information Center was created, with biggest database on lithium [10]. Also in 1976, the first major handbook on lithium research and therapy was published [42]. In the following years, first international conferences on lithium were organized: in 1977, the First British Lithium Congress in Lancaster, and in 1978, the conference titled: Lithium – Controversies and Unresolved Issues - in New York.

FOURTH DECADE OF LITHIUM THERAPY 1979-1989 The fourth decade of contemporary lithium therapy marks the period of most extensive use of lithium for therapeutic and prophylactic purposes and also intensive research on the biological and pharmacological properties of this ion. It was estimated that in a majority of European countries and in the USA 1-2 person per 1000 was receiving lithium mainly for prophylactic purposes. The number of publications on lithium in 1965-1985 had shown an exponential growth. While in mid-1960s there were 50 publications each year on lithium, this number increased by mid-1980s to about 1500 [10]. In 1980, the first edition of Mogens

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Schou’s book “Lithium treatment of manic-depressive illness” appeared, a short publication addressed for patients and their lithium therapists [76]. The book had several subsequent editions, the last being of 2004. The report on own experience with prophylactic activity of lithium in 61 patients with bipolar affective illness was published in 1980 [66]. The duration of illness before lithium therapy was 1-30 years (mean 8 years), and within two years prior to lithium each patient had at least two affective episodes. The duration of lithium therapy ranged between 1-8 years (mean 4.6 years). The efficacy of lithium prophylaxis was assessed by “mirror image” design comparing the course of illness in each patient in identical period before and during lithium administration. In the group of patients studied, lithium administration resulted in 71% reduction in number of affective episodes and in 72% reduction of psychiatric hospitalizations. In 44% of patients there were no affective episodes on lithium, in 28% the number of episodes decreased by ≥ 50% compared to pre-lithium period while in 28% of patients any significant effect of lithium could be observed. At the beginning of 1980, further interesting properties of lithium, both clinical and biological were revealed. Canadian psychiatrists (De Montigny et al.) made an observation that in depressive patients with poor response to antidepressant treatment, adding lithium resulted in a significant improvement. In some patients spectacular effects were observed within several days. This effect was termed “therapeutic augmentation” and lithium became for many years the main drug used for augmentation of antidepressant drugs in treatmentresistant depression [23]. The first Polish study on this subject performed by Rybakowski and Matkowski was published in 1987 comprising 10 patients with depression in the course of unipolar or bipolar affective illness and unsatisfactory response to antidepressant treatment. Adding lithium resulted in a significant improvement and in 6 patients, a state of remission was obtained after 4 weeks of lithium administration [67]. On a biological level, British researchers from the University of Birmingham found that lithium, in concentration 5-30 mmol/l inhibits the replication of herpes viruses HSV-1 and HSV-2 on the model of baby hamster kidney cells [78]. Further investigations have ascribed this effect to a blocking of viral DNA synthesis by lithium [17] or to lithium competition with Mg ions catalyzing enzymatic reaction of the virus [7]. Some anecdotal reports appeared pointing to a possibility of remission of herpes infection during lithium prophylaxis [29, 46]. The study of this issue involving a large population of lithium prophylactic patients will be described later. The studies of the mechanisms of lithium action focused in 1980s on the effect of this ion on intracellular signaling and especially on second-messenger systems. Two such systems aroused special interest: adenylate cyclase and phosphatidylinositol system. It was found that lithium may have inhibitory action on adenylate cyclase system [13]. Furthermore, it was hypothesized that lithium may act on G-protein which makes further step of this system and normalize its postulated hyperfunction in bipolar illness [3]. However, it has appeared that the action on lithium on the phosphatidylinositol system may be more important for lithium mechanism of action. Following reports of specific lithium inhibition of inositol monophosphatase and other elements of this system, Berridge et al [15] proposed that this may be the site of clinical action of lithium. The findings on a specificity of lithium action on this system have subsequently been replicated. However, two decades later it was shown that three classic mood-stabilizing drugs (lithium, carbamazepine and valproate inhibit the collapse of sensory neuron growth cones and increase growth cone area thus reversing the

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action of inositol on this experimental model. There the inositol system may be implicated in a common mechanism of action of main mood-normalizing drugs [84]. In 1980s, lithium prophylaxis was also reflected in non-professional literature. Several autobiographic books appeared on the favorable effect of lithium therapy in some celebrity persons. The most important books are the autobiography of molecular biologist, Salvador Luria, Nobel laureate in physiology and medicine in 1969 [48] and of famous American movie star, Patty Duke [25]. The second British Lithium Congress took place in Wolverhampton in 1988. In the same year, the international group for the study of lithium (IGSLI) was founded by three lithium researchers: Mogens Schou (Denmark), Bruno Müller-Oerlinghausen (Germany) and Paul Grof (Canada). The chief goal of the group was to work on controversial topics related to lithium treatment using excellent methods and working with a large number of patients. Such goal could only be accomplished with a multicentre approach. Within one year – the IGSLI was joined by Vienna and Prague groups and subsequently – by several others.

FIFTH DECADE OF LITHIUM THERAPY 1989-1999 Forty years of lithium therapy resulted also in creating a new scientific journal which could be devoted entirely to the role of this ion in medicine and especially in psychiatry. Such journal “Lithium” was introduced in 1990, with F.N. Johnson from the University of Lancaster, as the Editor, and N. J. Birch (UK), P.Goodnick (USA), J.W.Jefferson (USA), A. Koukopoulos (Italy), H. Lôo (France), P.Westergaard (Denmark) and S. Watanabe (Japan) as the Associate Editors. Editorial Advisory Board included M. Abou-Saleh (UK), S.Christensen (Denmark), H.Dufour (Switzerland), R.R.Fieve (USA), V. Gallicchio (USA), W. Greil (Germany), P.Grof (Canada), D.A.Hart (Canada), G. Hines (USA), D. Horrobin (UK), G. Johnson (Australia), B. Müller-Oerlinghausen (Germany), P. J. Perry (USA), P. Plenge (Denmark), J. Rybakowski (Poland), M. Schou (Denmark), K. Thomsen (Denmark), S. P. Tyrer (UK), T.A.Wehr (USA), Yang Shan Ming (China). The journal was published quarterly by Churchill Livingstone. Paradoxically, the advent of “Lithium” as a journal coincided with relative general decrease in the interest of lithium occurring in the fifth decade of lithium therapy. The journal existed for five years: 1990-1994. Several factors which took place in the fifth decade of lithium therapy contributed to the decrease of its importance what also resulted in a slower pace of lithium research. The first was an introduction into psychiatric therapy new generation of antidepressant and antipsychotic medications. Also, the alternatives to lithium as mood-normalizing drugs such as valproate and carbamazepine were widely employed, and in the USA, the use of valproates gradually replaced lithium prophylaxis in a substantial proportion of patients. On the other hand, carbamazepine has been increasingly used in Europe. An introduction of new generation of antipsychotic drugs such as clozapine, olanzapine and risperidone also prompted their possible application in bipolar illness. In mid-1990s clozapine was shown to have mood-normalizing properties and in late 1990s olanzapine was registered for the treatment of bipolar disorder on account of the results of controlled trials showing unequivocal effect in mania [44]. A broad definition of mood stabilizer was accepted in that the drug benefits at least one primary aspect of bipolar illness (mania, depression, cycling

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frequency, number of episodes, subthreshold symptoms) without worsening any other aspect of the illness [73]. The author of this review in collaboration with Dr Jay D. Amsterdam from Department of Psychiatry, University of Pennsylvania, Philadelphia, undertook the study aiming to verify a possible antiviral effect of lithium against herpes infections. The most frequent clinical form of human herpes infections is localized in the oral-labial and perilabial region, due mainly to HSV-1 type. It occurs in about one-third of the population and its course is characterized by recurrences. The frequency of recurrence of labial herpes infections was investigated in patients receiving lithium carbonate for the prophylaxis of manic and depressive relapses. The effect of lithium therapy was also compared with the effect of chronic treatment with antidepressant drugs. A retrospective study was performed on two patient populations: Polish and American. Polish patients comprised 69 persons (24 male, 45 female) with affective illness taking lithium carbonate for at least 1 year (mean 8+5 years) at an outpatient clinic in the Department of Psychiatry, University of Medical Sciences in Poznan. The study performed in the USA included 104 patients with affective illness taking lithium carbonate or antidepressant drugs (tricyclics, MAO inhibitors, trazodone, fluoxetine) for at least one year at the Depression Research Unit Department of Psychiatry, University of Pennsylvania. Patients on lithium and antidepressants were matched according to gender (21 male and 31 female in each group), age, and duration of antidepressant treatment (mean 5 years in both groups). The percentage of recurrent labial herpes in all groups ranged between 38% and 48%. The assessment of recurrence rates for labial herpes infections before and during pharmacological treatment made in Polish patients showed that among 28 patients with recurrent herpes before lithium treatment, in 13 patients (46%), a total disappearance of recurrences was observed, in seven the frequency diminished, in six remained the same and in two it increased. The overall decrease was 64% compared to pre-lithium period. In American patients, the frequency of labial herpes recurrences significantly diminished in the group of lithium prophylaxis patients (73% decrease), but this was not the case in the group of patients taking antidepressant drugs (decrease of 8% vs before lithium). In Polish group, where lithium concentration in erythrocytes was also estimated, the difference in the recurrences of herpes was highly significant in the group of patients with a mean plasma lithium level of 0.65 mmol/l or over and with an erythrocyte lithium level of 0.35 mmmol/l and above while below these values, the difference was of borderline statistical significance [68]. The results of own study on lithium augmentation of antidepressant drugs in treatmentresistant depression were published in 1992. The sample included 51 patients with refractory depression in the course of bipolar or unipolar mood disorder in which lithium was added to ongoing antidepressant treatment for 28 days, in concentration about 0.7 mmol/l. The remission after this time was obtained in 28 patients (55%). Better effect of lithium was shown in bipolar than unipolar patients, with subjects with lower pre-lithium severity of depression and in 20 patients showing rapid improvement (within 7 days of lithium addition). Factors such as age, gender, number of prior antidepressant treatment) did not show any association with the outcome of lithium augmentation [69]. Another possible clinical effect of lithium, extremely important for psychiatric practice has been postulated since 1972 [9]. It has been observed that patients taking lithium may have lower tendency for suicidal behavior as if lithium produced a protective action in this respect.

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Twenty years later, in 1992, the results of the first systematic study performed by German investigators convincingly demonstrated an antisuicidal effect of lithium long-term treatment. Sixty-eight patients with affective disorders and receiving lithium prophylaxis in a specialized lithium clinic were followed up for 8 years on average. They all attempted suicide at least once before onset of lithium prophylaxis. Fifty-five patients took their lithium regularly and 13 discontinued the drug during the period of follow-up. One third of those patients having discontinued medication died from suicide, and multiple suicidal attempts were observed in this group of patients in a period from 2 weeks – 44 months following lithium discontinuation. Only one suicide occurred in patients with regular lithium intake and proven compliance during the last check before death. The authors concluded, based on the results obtained, that lithium may have specific antisuicidal effect even in patients not responding satisfactorily in terms of reduced number of affective episodes [57]. In another German study, published several years later, a retrospective comparison was done on the effect of lithium and another mood-normalizing drug, carbamazepine, given for a period over 2.5 years on suicidal behavior. While in the lithium group no suicidal act was observed, in the carbamazepine group, 4 completed suicides and 5 suicidal acts occurred [80]. Also in 1992, the paper was published showing that the long-term treatment with lithium may exert a favorable effect on the mortality of patients with manic-depressive and schizoaffective illness. Such mortality is 2-3 times of the general population. The paper can be regarded as a product of scientific collaboration of IGSLI group. The data were gathered from 827 manic-depressive patients coming from four centers, receiving lithium for more than one year. The average duration of treatment was 81 months and the total time on lithium was 5600 patient-years. The mortality risk was calculated for each patient. It was found that in the group of patients studied the standardized mortality ratio did not differ from that of general population [58]. In the following paper published three years later by the same group it was postulated that a reduction of mortality rate by lithium in affective patients is due to a reduction of excess both suicidal and cardiovascular mortality [1]. In the mid-1990s, debates also started about the real efficacy of lithium prophylaxis. It was found that in naturalistic settings the prophylactic effect of lithium was less marked than obtained in controlled clinical trials performed in academic centers [35, 43]. In some patients, the effect of lithium tended to diminish over time despite continuous drug administration [49]. However, other researchers did not find indication of a reduction in prophylactic effect of lithium during long-term treatment [14]. In the most critical article by Moncrieff [55], it was argued that discontinuation studies performed in early 1970s were not proper design for address the question of lithium prophylaxis, particularly because of mounting evidence that lithium withdrawal may precipitate a relapse (mostly manic one). The author indicated that lithium efficacy was not shown according to standards of the “evidence based medicine”. The article evoked a strong response from many lithium researchers. The founder of Lithium Information Center, dr Jefferson, pointed that lithium, being not an ideal drug, still remains a standard of efficacy for the prophylaxis of bipolar affective illness, the treatment of mania and the augmentation of antidepressant drugs.[41]. Forty years of experiences with lithium prophylaxis allowed delineate a group of patients with remarkable therapeutic response to lithium. In such patients, the illness simply “stopped” and no further recurrences have been observed even in the course of many years of lithium treatment. Such concept of “excellent lithium responders” was introduced by Paul Grof [34]. It turned out that the percentage of “excellent lithium responders” makes about 1/3 of all

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lithium treated patients, while in the first years of lithium therapy it was estimated as 40-50%. With the advent of molecular genetics, “excellent lithium responders” were regarded as a distinct clinical endophenotype of bipolar illness and used in such studies. A non-scientific publication connected with lithium therapy which had the biggest impact on both scientific and non-scientific community was that of the “Unquiet Mind” which appeared in 1995 [40]. The book was written by Kay Redfield Jamison, the professor of psychiatry at the Johns Hopkins University in Baltimore. Five years earlier, Kay Jamison coauthored with Frederic Goodwin, former chief of the National Institutes of Mental Health, a fundamental book on bipolar mood disorder: “Manic-Depressive Illness” [30]. “Unquiet Mind” is an autobiographic book which describes long-term successful struggle with bipolar illness, where lithium treatment was an invaluable help. It was the first time in the history of literature that manic-depressive illness and lithium therapy was described not only from a point of view of suffering patient but also from a subjective approach of the expert professional. In the fifth decade of lithium therapy, lithium researchers were gathered on several major lithium congresses. The Third British Lithium Congress took place in Wolverhampton, UK, in 1992. The Malta Lithium Congress was organized in St Paul’s Bay (Malta) in 1995, and two years later the Lithium South Africa conference was held in Johannesburg. On the occasion of 50th anniversary of introducing lithium into psychiatric therapy, a conference “Lithium 1999” was organized in Lexington, KY, USA, in 1999.

RECENT FIVE YEARS OF LITHIUM THERAPY 1999-2004 Recent years have been marked with an introduction of new drugs as mood-stabilizers for the treatment and prophylaxis of bipolar illness. After clozapine and olanzapine, other new generation antipsychotic drugs were tested, such as risperidone and quetiapine and their usefulness positively assessed. Also, new generation anticonvulsants, especially lamotrigine were found to possess definite mood-stabilizing properties. However, if the strict definition of mood stabilizer was applied, i.e. efficacy in treating acute manic and depressive symptoms and in prophylaxis of manic and depressive recurrences in bipolar mood disorder, only lithium fully fulfills these criteria, and other drugs only partially, as was shown in recent comprehensive meta-analysis of available studies [12]. In 2000, a review paper written by the author of this article was published summarizing the data obtained mainly in recent two decades on the antiviral and immunomodulatory effect of lithium. The results of experimental and clinical studies showing antiviral effects of lithium, particularly against herpes viruses were reviewed and the presentation of reports showing therapeutic action of oral and topical lithium administration on labial and genital herpes in non-affective subjects was done. The data were also presented coming from both experimental and clinical studies showing favorable effects of lithium on many parameters of cellular and humoral immunity. Some evidence was also provided that lithium may alleviate the immune-endocrine component concomitant to an acute affective episode, such as acute phase reaction, cytokine secretion and hyperactivation of hypothalamic-pituitary-adrenal axis. It was speculated that the antiviral and immunomodulatory properties of lithium may

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contribute to psychotropic actions of this drug, especially prevention of recurrences in affective illness and perhaps also to decreased mortality of lithium-treated patients [70]. As a reaction to possible speculation about decreasing effect of lithium in recent decades, further analyses were performed trying to verify this. The issue was addressed in a review paper of Baldessarini and Tondo [8]. Based on the analysis of published reports as well as on the clinical effects on 360 bipolar patients who entered into lithium maintenance monotherapy after 1970, the authors did not find the evidence that prophylactic lithium efficacy shows the signs of abating. At outpatient clinic, Department of Psychiatry, University of Medical Sciences in Poznan, where lithium prophylaxis was introduced at the beginning of 1970s, we attempted to compare patients entering lithium prophylaxis in two subsequent decades: in 1970s and 1980s. We were interested 1) whether patients entering lithium in these two decades had different pre-lithium clinical characteristics and 2) whether they differed in clinical course during 10 years of lithium prophylaxis 3) whether any elements of this therapeutic procedure were different in these two decades. The inclusion criterion was that patient had a diagnosis of bipolar affective illness and that had been staying on lithium continuously for at least ten years. We assumed that the evaluation of patients during such long a period of lithium administration may be necessary for the adequate assessment of clinical course of illness on the drug. As for year 1999, such criteria were fulfilled by 60 patients entering lithium during 1971-1980 and by 49 patients entering lithium in 1981-1989. No significant differences between two groups of patients were found as to the distribution of gender, the frequency of bipolar II category, the percentage of patients with family history of affective illness, the rate of employment at the start of lithium as well as the age of onset of illness, the age of starting lithium and the period from onset of illness to the beginning of lithium prophylaxis. Patients entering lithium in two periods studied showed some differences of clinical course. While the total number of affective episodes was similar, patients who started lithium in earlier period had significantly higher number of manias and lower of depressions than patients entering lithium in 1980s. Also, the number of hospitalization tended to be higher in earlier patients. The duration of affective morbidity in one year prior to lithium was not different in two groups. Except for a trend for greater number of depression in the first year of lithium prophylaxis, no significant differences between two groups were found. The percentage of patients without episodes throughout ten years of lithium prophylaxis (excellent lithium responders) was slightly lower in 1980s patients (27% vs 35%) but insignificantly so [71]. No significant difference was found between two groups as to the frequency of somatic diseases and the percentage of recurrences apparently related to stress. The daily dose of lithium was slightly lower in 1980s group and the mean lithium level was significantly lower in these patients (0.62 vs 0.66 mmol/l, respectively). This may reflect recommendation for lower prophylactic lithium concentrations put forward in the 1980s in Europe [77]. Consequently, the occurrence of such side effects as thirst, polyuria and tremor was insignificantly lower in patients of 1980s compared with earlier group. The frequency of thyroid side effects was similar in both groups. It should be mentioned that American recommendations for lithium concentration in prophylactic administration have been higher than in Europe (between 0.8-1.0 mmol/l) [28].

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Janusz K. Rybakowski Table 1. Comparison of the course of the illness between patients entering lithium prophylaxis in 1970s and 1980

First year of lithium prophylaxis Patients with depressions (n/%) Patients with mania (n/%) Patients hospitalized (n/%) Patients without episodes (n/%) Five years on lithium prophylaxis Patients with depressions (n/%) Patients with manias (n/%) Patients hospitalized (n/%) Patients without episodes (n/%) Ten years on lithium prophylaxis Patients with depressions (n/%) Patients with manias (n/%) Patients hospitalized (n/%) Patients without episodes (n/%)

Patients entering lithium in 1970s (n=60)

Patients entering lithium in 1980s (n=49)

Difference

6 (10%) 6 (10%) 7 (12%) 49 (82%)

11 (22%) 6 (12%) 6 (12%) 36 (73%)

P<0.1 NS NS NS

19 (32%) 24 (40%) 24 (40%) 30 (50%)

16 (33%) 24 (49%) 23 (47%) 24 (49%)

NS NS NS NS

23 (38%) 32 (53%) 34 (57%) 21 (35%)

22 (45%) 32 (65%) 34 (69%) 13 (27%)

NS NS NS NS

After more than 20 years of experiences with lithium augmentation in treatment-resistant depression, an updated review of the evidence was presented in 2003 by Bauer et al [11]. Twenty-seven studies were meta-analyzed, including 803 depressed patients. The majority of randomized controlled trials has demonstrated substantial efficacy of lithium augmentation in partial and non-responders to antidepressant treatment. In the placebo controlled trial, the mean response rate in the lithium group was 45% and in the placebo group 17%. Approximately 50% of patients responded to lithium augmentation within 4 weeks. The results of this analysis suggest that lithium addition is still most well-documented augmentation strategy in refractory depression. Also in 2003, a paper appeared confirming antisuicidal effect of lithium on American ground. The first author was F.K. Goodwin who jointly with Kay Jamison wrote the fundamental textbook on manic-depressive illness. A comparison was made of lithium with valproate, the drug which in 1990s in USA outnumbered several-fold lithium in its use for prophylactic purposes in bipolar patients. Population-based sample of more than 20 thousand persons aged 14 years or older who had at least 1 outpatient diagnosis of bipolar disorder and at least 1 filled prescription for lithium or valproate (divalproex) were analyzed. After adjustment for all variables, it was found that the risk of suicide death was 2.7 times higher during treatment with divalproex than during treatment with lithium. Corresponding hazard ratios were for suicide attempts resulting in hospitalization 1.7, and for suicide attempts diagnosed in the emergency department 1.8 [31]. The development of molecular-genetic studies prompted the research of genetic determination of lithium response. Using “excellent lithium responders” as a clinical endophenotype of bipolar illness, some chromosome loci (15q14 and 7q11.2) were identified as linked to excellent lithium response [82]. Also, some candidate genes were found,

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associated with very good response to lithium, including phospholipase C gene [81] and serotonin transporter gene [72]. However, the most intriguing discovery connected with lithium in recent five years was an evidence for neuroprotective effect of this ion. The origin of such studies was generated by new biological hypotheses of depression and manic-depressive illness pointing on disturbances of synaptic plasticity and impaired neurogenesis in these pathological conditions [50]. Favorable effects on neuronal plasticity were postulated as an element of therapeutic action of antidepressants and mood normalizing drugs. It was demonstrated that moodstabilizing drugs and lithium in particular may act to prevent neuronal damage and tissue loss that occur in the brain of patients with bipolar disorders. Lithium has been shown to produce neuroprotective effects by multiple mechanisms. One target of such effect has been the brain-derived neurotrophic factor (BDNF), an important modulator of neuronal proliferation and synaptic plasticity. Lithium administration induces BDNF and its receptor in frontal cortex and hippocampus of experimental animals [26, 38]. Another mechanism in mediating such effect can be up-regulation by lithium the cytoprotective protein Bcl-2 (B-cell leukemia 2) in the brain both in vitro and in vivo. [51]. Lithium was also shown to stimulate the process of neurogenesis in the hippocampus [19]. Furthermore, an increase of grey matter was reported in bipolar patients during treatment with lithium [56]. Undoubtedly, the object of main interest in relation to lithium neuroprotective mechanism is the enzyme, glucogen synthase kinase 3 (GSK-3). This enzyme participates in many processes of intracellular signaling. It induces apoptosis and plays also pathogenic role in neurodegerative diseases, e.g. it stimulates amyloid production in Alzheimer’s disease [32]. Interestingly, in fruit fly, an ortholog of GSK-3 regulates circadian rhythms what may remind the disruption of such rhythms in patients with bipolar illness [52]. The inhibition of GSK-3 by lithium was shown in 1996 and since this time the evidence has accumulated for lithium to be the direct inhibitor of this enzyme both in vitro and in vivo. [33]. Recently, suggestions have been advanced for trying lithium in neurodegenerative disorders. The rationale of such attempt in Alzheimer’s disease would be the role of GSK-3 in the pathogenesis of this illness and a possibility of mental plaque removal by inhibition of the enzyme [24]. Lithium was also found to inhibit neuronal lesions in a rat model of Huntington disease and rescue death in Huntington’s disease cell models, mediated partially by GSK-3 mechanism [83]. These proposals have been seriously addressed by the IGSLI group, which, in 2002 –converted into a registered association with Michel Bauer as the president. During productive meetings of this group – in 2002 in Prague, and in 2003 in Berlin, several common projects have been advanced such as investigating possible neuroprotective (and procognitive) effects of long-term lithium administration to bipolar patients and a study of lithium treatment in Huntington’s disease.

CONCLUDING REMARKS Fifty five years of lithium therapy in psychiatry made a tremendous impact on both psychiatry and general neuroscience. The introduction of lithium into psychiatric therapy initiated modern psychopharmacology. The publication of Cade on lithium treatment in

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mania in 1949 preceded by three years the publication of French psychiatrists describing the first use of antipsychotic drug. In 1960s lithium turned out to be the first psychotropic drug which not only treated an acute episode of psychiatric illness but, if used longitudinally, dramatically changed the course of disease. In a proportion of patients lithium could restore the functioning to premorbid level. Thus, lithium became the precursor of pharmacological prophylaxis of psychiatric illness. The evidence has also accumulated that lithium, apart from its preventive action against affective resurrences in mood disorder exerts a definite antisuicidal effect, which can only be matched with such effect of clozapine in patients with schizophrenia. Concomitantly with psychotropic effect, lithium produces a plethora of favorable biological actions such as antiviral (antiherpetic), immunomodulatory and recently found – neurotropic effect. These may not only contribute to reducing morbidity and mortality in affective patients treated longitudinally with lithium but may also give rise to novel applications of this drugs. It seems that after a period of relative decline of interest in 1990s, lithium research and therapy is beginning to be on the rise again. The fifty-five years of the history of lithium in contemporary psychiatry brings about a thoughtful reflection how such simple chemical element, the lightest of alkali metals, can cause such profound changes in the functioning of organism, and especially of the organ of mood and thinking as is the human brain.

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[29] Gilis A. Lithium in herpes simplex. Lancet 1983, ii, 516. [30] Goodwin FK, Jamison KR. Manic-Depressive Illness. Oxford University Press, OxfordNew York 1990 (second edition will appear in 2006). [31] Goodwin FK, Fireman B, Simon GE, Hunkeler EM, Lee J, Revicki D. Suicide risk in bipolar disorder during treatment with lithium and divalproex. J Am Med Ass 2003, 290, 1467-1473. [32] Gould TD, Zarate CA, Manji HK. Glycogen synthase kinase-3: a target for novel bipolar disorder treatments. J Clin Psychiatry 2004, 65, 10-21. [33] Gould TD, Chen G, Manji HK. In vivo evidence in the brain for lithium inhibition of glycogen synthase kinase-3. Neuropsychopharmacology 2004, 29, 32-38. [34] Grof P. Excellent lithium responders: people whose lives have been changed by lithium prophylaxis. In: Birch NJ, Gallicchio VS, Becker RW ed. Lithium: 50 Years of Psychopharmacology, New Perspectives in Biomedical and Clinical Research. Cheshire, Connecticut, Weidner Publishing Group, 1999:36-51. [35] Guscott R, Taylor L. Lithium prophylaxis in recurrent affective illness. Efficacy, effectiveness and efficiency. Br J Psychiatry 1994, 164, 741-746. [36] Haas M, Schooler J, Tosteson DC. Coupling of lithium to sodium transport in human red cells. Nature 1975, 258, 425-427. [37] Hartigan GP. The use of lithium salts in affective disorders. Br J Psychiatry 1963; 109:810-814. [38] Hashimoto R, Takei N, Shimazu K, Chrust L, Lu B, Chuang DM. Lithium induces brain-derived neurotrophic factor and activates TrkB in rodent cortical neurons: an essential step for neuroprotection against glutamate neurotoxicity. Neuropharmacol 2002, 43, 1173-1179. [39] Hullin RP, McDonald R, Allsopp MN. Prophylactic lithium in recurrent affective disorders. Lancet 1972; 1: 1044-1046. [40] Jamison KR. An Unquiet Mind. A Memoir of Moods and Madness. Knopf, New York 1995. [41] Jefferson JW. Lithium: still effective despite its detractors. Br Med J 1998, 316, 13301331. [42] Johnson FN (ed). Lithium Research and Therapy. Academic Press, London, 1975. [43] Johnson RE, McFarland BH. Lithium use and discontinuation in a health maintenance organization. Am J Psychiatry 1996;153:993-1000. [44] Keck PE, McElroy SL, Strakowski SM. Anticonvulsants and antipsychotics in the treatment of bipolar disorder. J Clin Psychiatry 1998; 59 (suppl.6): 74-81. [45] Lange C. Periodische Depressionzustände und ihre Pathogenesis auf dem Boden der harnsäuren Diathese. Verlag von Leopold Voss, Hamburg und Leipzig, 1896. [46] Lieb J. Remission of recurrent herpes infection during therapy with lithium. N Eng J Med 1979, 301, 942. [47] Lingjaerde O, Edlund AH, Gormsen CA, Gottfries CG, Haugstad A, Hermann IL, Hollnagel P, Makimattila A, Rasmussen KE, Remvig J, Robak OH. The effect of lithium carbonate in combination with tricyclic antidepressants in endogenous depression. Acta Psychiatr Scand 1974, 50, 233-242. [48] Luria SE. A Slot Machine, a Broken Test Tube: An Autobiography. Harper and Row, New York 1984.

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[49] Maj M, Pirozzi R, Magliano L. Late non-response to lithium prophylaxis in bipolar patients: prevalence and predictors. J Affect Disord 1996; 39:39-42. [50] Manji HK, Duman RS. Impairments of neuroplasticity and cellular resilience in severe mood disorders: implications for the development of novel therapeutics. Psychopharmacol Bull 2001, 35, 5-49. [51] Manji HK, Moore GJ, Chen G. Lithium up-regulates the cytoprotective protein Bcl-2 in the CNS in vivo: a role for neurotrophic and neuroprotective effects in manic depressive illness. J Clin Psychiatry 2000, 61, Suppl9, 82-96. [52] Martinek S, Inogog S, Manoukian AS, Young MW. A role for the segment polarity gene shaggy/GSK-3 in the Drosophila circadian clock. Cell 2001, 105, 769-779. [53] Melia PI. Prophylactic lithium: a double-blind trial in recurrent affective disorders. Br J Psychiatry 1970; 116: 621-624. [54] Mendels J. Lithium in the treatment of depression. Am. J. Psychiatry 1976, 133, 373378. [55] Moncrieff J. Lithium: evidence reconsidered. Br J Psychiatry 1997, 171, 113-119. [56] Moore GJ, Bebchuk JM, Wilds IB, Chen G, Manji HK. Lithium-induced increase in human brain grey matter. Lancet 2000, 356, 1241-1242. [57] Müller-Oerlinghausen B, Müser-Causemann B, Volk J. Suicides and parasuicides in a high-risk patient group on and off lithium long-term medication. J Affect Disord 1992, 25, 261-270. [58] Müller-Oerlinghausen B, Ahrens B, Grof E, Grof P, Lenz G, Schou M, Simhandl C, Thau K, Volk J, Wolf R, Wolf T. The effect of long-term lithium treatment on the mortality of patients with manic-depressive and schizoaffective illness. Acta Psychiatr Scand 1992, 86, 218-222. [59] Noack CH, Trautner EM. The lithium treatment of maniacal psychosis. Med J Aust 1951, 38, 219-222. [60] Ostrow DG, Pandey GN, Davis JM, Hurt SW, Tosteson DC. A heritable disorder of lithium transport in erythrocytes of a subpopulation of manic-depressive patients. Am J Psychiatry 1978, 135, 1070-1078. [61] Prien RF, Caffey EM, Klett CJ. Prophylactic efficacy of lithium carbonate in manicdepressive illness. Arch Gen Psychiatry 1973; 28: 337-341. [62] Prien RF, Klett CJ, Caffey EM. Lithium carbonate and imipramine in prevention of affective episodes. A comparison in recurrent affective illness. Arch Gen Psychiatry 1973, 29, 420-425. [63] Rybakowski J, Chlopocka M, Lisowska J. Czerwinski A. A study of lithium carbonate efficacy in endogenous depressive syndromes (in Polish). Psychiatr Pol 1974, 8, 129135. [64] Rybakowski J, Frazer A, Mendels J, Ramsey TA. Prediction of the lithium ratio observed clinically by means of an in vitro test. Clin. Pharmacol Ther 1977, 22, 465469. [65] Rybakowski J, Frazer A, Mendels J, Ramsey TA. Erythrocyte accumulation of the lithium ion in control subjects and patients with primary affective disorder. Commun Psychopharmacol 1978, 2, 99-104. [66] Rybakowski J, Chlopocka-Wozniak M, Kapelski Z. Clinical assessment of prophylactic efficacy of long-term lithium administration in patients with endogenous depressive syndromes (in Polish). Psychiatr Pol 1980, 14, 357-361.

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[67] Rybakowski J, Matkowski K. Synergistic action of lithium and antidepressant drugs in endogenous depression (in Polish). Psychiatr Pol 1987, 21, 115-120. [68] Rybakowski JK, Amsterdam JD. Lithium prophylaxis and recurrent labial herpes infections. Lithium 1991, 2, 43-47. [69] Rybakowski J, Matkowski K. Adding lithium to antidepressant therapy: factors related to therapeutic potentiation. Eur Neuropharmacol 1992, 2, 161-165. [70] Rybakowski JK. Antiviral and immunomodulatory effect of lithium. Pharmacopsychiatry 2000, 33, 159-164. [71] Rybakowski JK, Chlopocka-Wozniak M, Suwalska A. The prophylactic effect of longterm lithium administration in bipolar patients entering treatment in the 1970s and 1980s. Bipolar Disord 2001, 3, 63-67. [72] Rybakowski JK, Suwalska A, Czerski PM, Dmitrzak-Weglarz M, LeszczynskaRodziewicz A, Hauser J. Prophylactic effect of lithium in bipolar affective illness may be related to serotonin transporter genotype. Pharmacol Reports 2005, 57, 124-127. [73] Sachs GS. Treatment-resistant bipolar depression. Psychiatr Clin North Am 1996, 19, 215-236. [74] Schou M, Juel-Nielsen N, Strömgren E. The treatment of manic psychoses by the administration of lithium salts. J Neurol Neurosurg Psychiatry 1954, 17, 250-260. [75] Schou M. Biology and the pharmacology of lithium ion. Pharmacol Rev 1957, 9, 17-58. [76] Schou M. Normothymics, “mood-normalizers”. Are lithium and imipramine drugs specific for affective disorders? Br J Psychiatry 1963, 108, 803-809. [77] Schou N. Lithium Treatment of Manic-Depressive Illness. A Practical Guide. Karger, Basel, 1980. [78] Schou M. Laboratory monitoring. In: Depression & Mania. Modern Lithium Therapy. Oxford: IRL Press, 1987: 105-107. [79] Skinner GRB, Hartley C, Buchan A, Harper L, Gallimore P. The effect of lithium chloride on the replication of herpes simplex virus. Med Microbiol Immunol 1980, 168, 258-265. [80] Stallone F, Shelley E, Mendlewicz J, Fieve RR. The use of lithium in affective disorders, III: a double-blind study of prophylaxis in bipolar disorder. Am J Psychiatry 1973; 130: 1006-1010. [81] Thies-Flechtner K, Müller-Oerlinghausen B, Seibert W, Walter A, Greil W. Effect of prophylactic treatment on suicide risk in patients with major affective disorders. Data from a randomized prospective trial. Pharmacopsychiatry 1996, 29, 103-107. [82] Turecki G, Grof P, Cavazzoni P, Duffy A, Grof E, Ahrens B, Berghofer A, MüllerOerlinghausen B, Dvorakova M, Libigerova E, Vojtechovsky M, Zvolsky P, Joober G, Nilsson A, Prochazka H, Licht RW, Rasmussen NA, Schou M, Vestergaard P, Holzinger A, Schumann C, Thau K, Rouleau GA, Alda M. Evidence for a role of phospholipase C-gamma 1 in the pathogenesis of bipolar disorder. Mol Psychiatry 1998, 3, 534-538. [83] Turecki G, Grof P, Grof E, D’Souza V, Lebuis L, Marineau C, Cavazzoni P, Duffy A, Betard C, Zvolsky P, Robertson C, Brewer C, Hudson TJ, Rouleau GA, Alda M. Mapping susceptibility genes for bipolar disorder: a pharmacogenetic approach based on excellent response to lithium. Mol Psychiatry 2001, 5, 570-578.

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[84] Wei H, Qin ZH, Senatorov VV, Wei W, Wang Y, Qian Y, Chuang DM. Lithium suppresses excitotoxicity-induced striatal lesions in a rat model of Huntington’s disease. Neuroscience 2001, 106, 603-612. [85] Williams RS, Cheng L, Mudge AW, Harwood AJ. A common mechanism of action for three mood-stabilizing drugs. Nature 2002, 17, 292-295.

In: Advances in Psychology Research, Volume 44 Editor: Alexandra Columbus, pp. 37-57

ISBN 1-60021-150-X © 2006 Nova Science Publishers, Inc.

Chapter 3

PSYCHOTHERAPY AND PATIENT PREFERENCES FOR THE TREATMENT OF MAJOR DEPRESSION IN PRIMARY CARE Patrick Raue∗ and Herbert C. Schulberg Weill Medical College of Cornell University, NY

ABSTRACT We describe the small body of research investigating the effectiveness of psychotherapy for treating major depression experienced by primary care patients, and the nature of patient treatment preferences and their impact on treatment adherence and outcome. We conclude that depression-specific, short-term psychotherapies such as CT, CBT, IPT, and PST effectively treat acute major depression in primary care practice and achieve oneyear outcomes superior to those achieved by the primary care physician’s usual care. No outcome differences emerge when psychotherapy alone is compared to antidepressant treatment alone, or to psychotherapy combined with antidepressant treatment. The majority of primary care patients prefer psychotherapy or counseling. While inconclusive, research to date has not documented a positive impact of meeting patient preferences on subsequent treatment adherence or clinical outcome.

INTRODUCTION Appropriate procedures for treating the major depression experienced by primary care patients have been the subject of randomized controlled trials conducted since the early 1980s by British and American investigators. Stimulated in part by the availability of valid and efficient procedures for diagnosing this mood disorder in the ambulatory medical sector, ∗

Correspondence concerning this article should be addressed to Patrick J. Raue, Ph.D., Weill Medical College of Cornell University, 21 Bloomingdale Road, White Plains, NY 10605. E-mail: [email protected].

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researchers have studied whether psychotherapeutic and pharmacologic interventions found efficacious with depressed psychiatric patients achieve similar outcomes with depressed primary care patients. The need to demonstrate cross-sector efficacy stemmed from ambiguities as to whether major depression diagnosed in the medical and psychiatric sectors has a similar etiology, symptom manifestation, severity level, and clinical course (Blacker & Clare, 1987; Schulberg, Block, & Coulehan, 1989). Randomized controlled trials (RCTs) exploring this issue with regard to pharmacotherapy have proceeded within the features of well-established methodologies, and have established that antidepressant medications are equally efficacious with primary care and psychiatric patients (Agency for Health Care Policy and Research Depression Guideline Panel, 1993). However, psychotherapy researchers investigating the impact of primary care-based psychosocial interventions within the methodology of an RCT have been confronted by unique challenges. Thus, they have had to deal with: (a) scientific complexities such as facilitating adherence to a psychologicallyoriented treatment of the mood disorder even though patients expected to be treated for a physical illness; and (b) attracting the resources needed for costly randomized psychotherapy trials in the absence of generous fiscal support resembling that provided by the drug industry for pharmacotherapy research. Given such scientific and practical challenges, an empiric base presently is available for determining when psychotherapy, medication, or a combination of the two is the treatment of choice for primary care patients experiencing major depression. This chapter first describes available depression-specific psychotherapies. We then highlight conclusions about psychotherapy’s effectiveness that we judge valid even though derived from a limited knowledge base, and we emphasize clinical options still requiring further study. Finally, we discuss emerging directions in primary care including the consistent finding that the majority of depressed primary care patients state a preference for psychosocial rather than pharmacologic treatment of their mood disorder (Dwight-Johnson, Sherbourne, Liao, & Wells, 2000; Cooper-Patrick, Gonzales, Rost, Meredith, Rubenstein, & Ford, 1998; Churchill, Khaira, Gretton, Chilvers, Dewey, Duggan, & Lee, 2000). In light of these stated preferences, it is useful to examine whether granting a patient’s choice of psychotherapy influences his or her adherence to this treatment, and the clinical advantages that it achieves.

DEPRESSION-SPECIFIC PSYCHOTHERAPIES Earlier studies of whether a depression resolved when treated psychotherapeutically investigated such interventions regardless of whether they were generic in nature, e.g. counseling, or had incorporated principles and techniques specific to the mood disorder, e.g. cognitive therapy (Nathan & Gorman, 2002). As theoretical models of depression’s etiology, onset, and clinical course have become increasingly refined, so have the psychotherapies based on them become increasingly detailed. This has led to the preparation of treatment manuals which guide the clinician through each of the therapy’s sequential phases, and which seek to ensure that the clinician is adhering to the technical features deemed critical for the psychotherapy’s efficacy. Treatment manuals have been developed by Beck, Rush, Shaw, and Emery (1979) for cognitive therapy, by Klerman, Weissman, Rounsaville, and Chevron (1984) for interpersonal psychotherapy, and by Hegel, Barrett, Oxman, Mynors-Wallis, and

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Gath (1999) who modified Nezu, Nezu, and Perri’s (1989) problem solving therapy for primary care practice. These manuals provide detailed protocols that guide clinicians subscribing to each therapy’s theoretic orientation on modes of interacting with their patients and techniques for focusing the treatment process. It is important to note that these manualized psychotherapies are all of short-term duration and thus remain relatively compatible with the restrictions imposed by managed care reviewers on psychotherapy’s scope and duration. Interpersonal psychotherapy (IPT) is strongly influenced by psychodynamic theory and emphasizes patients’ current interpersonal relationships (Klerman et al., 1984). According to IPT, depression is related to one or more of these four problem areas: unresolved grief, role transitions, interpersonal disputes, and interpersonal deficits. The IPT therapist helps patients identify and clarify relevant problem areas, increase their awareness of how interpersonal relationships contribute to depression, and develop more successful strategies for dealing with current interpersonal problems. For example, a patient with a problem related to role transition would be encouraged to mourn and accept the loss of previously held roles, regard new roles as positive, and successfully cope with the demands of the new roles. Cognitive and behavioral psychotherapies are more strongly rooted in learning theory (Beck et al., 1979). Cognitive psychotherapy considers depression an affective response to negative beliefs or interpretations of events. The cognitive therapist helps patients identify, challenge, and modify these unproductive beliefs. Behavioral therapy considers depression to result from a low rate of response-contingent positive reinforcements. The patient is encouraged to participate in pleasant activities or build the assertive social skills needed to elicit positive social responses. Problem solving therapy (PST; Nezu et al., 1989), which is delivered within the principles of cognitive and behavioral therapy, was adapted to the needs of depressed primary care patients (PST-PC, Hegel et al., 1999). PST-PC teaches patients how to solve psychosocial problems within a seven-stage process during which a problem is defined, possible solutions identified, and preferred ones implemented. The goals of PST-PC are to increase patients’ understanding of the link between life problems and depression, improve their ability to define and break down problems into discrete components, enhance their skill in applying problem solving procedures, and increase success experiences solving problems. Adaptations of this type of therapy to the primary care setting include shortening the treatment length to 4-6 sessions, shortening the session duration to 30 minutes, and broadening its implementation beyond mental health specialists to a range of health professionals (e.g., nurses, physicians) when given appropriate training.

THE PRIMARY CARE PSYCHOTHERAPY EVIDENCE BASE Various criteria can be applied to the determination of whether a psychotherapy is sufficiently “evidence-based” or “empirically supported” to warrant inclusion in a compendium of treatments for depression (Westen & Morrison, 2001). Given the methodological flaws in earlier primary care psychotherapy research noted by Brown and Schulberg (1995), Schulberg, Raue, and Rollman (2002) proposed that, in addition to use of a depression-specific manualized psychotherapy, a randomized controlled trial must utilize

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standardized diagnostic instruments and an appropriate comparison arm for its findings to be judged meaningful. The Diagnostic Interview Schedule (Robins, Helzer, Croughan, & Ratcliff, 1981), the PRIME-MD (Spitzer, Williams, Kroenke, Linzer, deGruy, Hahn, et al., 1994), and the PHQ-9 (Spitzer, Kroenke, & Williams, 1999) are all standardized instruments whose structured format facilitates their administration to primary care patients. With the growing interest in the effectiveness of depression-specific psychotherapy delivered in routine primary care practice, researchers now consider the “usual care” available from primary care physicians (which may or may not include counseling) a scientifically acceptable yardstick against which to compare psychotherapy’s impact (Schulberg, Coulehan, Block, Lave, Rodriguez, Scott, et al., 1993). With the diagnostic focus limited to major depression, eight clinical trials have incorporated the above methodological features. However, even within this restricted set of research reports, other key design elements differ markedly. Thus, (a) the time points at which investigators assessed outcome ranged from two to twelve months; (b) clinical outcome indices included absolute change in depressive severity, percentage of patients achieving a 50% or greater reduction in depressive severity, and/or the percentage of patients achieving recovery at a designated time point; (c) the intervention against which psychotherapy’s outcome was compared could be either usual care provided by a primary care physician, an antidepressant medication, such a medication combined with psychotherapy, or a drug placebo; and (d) psychotherapy was provided either alone, or as one element of multi-modal care management. Given these differences, the database for assessing psychotherapy’s effectiveness in primary care practice is quite variable on several key design features despite its conformance with minimal contemporary standards for a scientifically acceptable RCT.

DOES PSYCHOTHERAPY ALONE EFFECTIVELY TREAT MAJOR DEPRESSION IN PRIMARY CARE PRACTICE? The following analysis recognizes that psychotherapy’s utility for treating major depression in primary care practice depends not only on its clinical outcomes but also upon its cost-effectiveness, availability of competent therapists, adequate insurance coverage, etc. (Schulberg et al., 2002). Nevertheless, for purposes of constructing consensus guidelines about whether and when to recommend psychotherapy alone or in combination with medication as the treatment for major depression in primary care practice, we focus our analysis and conclusions solely on the clinical findings drawn from available RCTs. Six of the eight primary care RCTs conducted since the early 1980s were directed by British investigators (Blackburn, Bishop, Glen, Whalley, & Christie, 1981; Teasdale, Fennel, Hibbert, & Amies, 1984; Ross & Scott, 1985; Scott & Freeman, 1992; Mynors-Wallis, Gath, Lloyd-Thomas, & Tomlinson, 1995; Mynors-Wallis, Gath, Day, & Baker, 2000) and two by American researchers (Katon, Robinson, von Korff, Lin, Bush, Ludman, et al., 1996; Schulberg, Block, Madonia, Scott, Rodriguez, Imber, et al., 1996). Five of the RCTs investigated outcomes for patients treated with cognitive or cognitive-behavioral therapy (Blackburn et al., 1981; Teasdale et al., 1984; Ross & Scott, 1985; Scott & Freeman, 1992; Katon et al., 1996), two investigated outcomes for problem-solving therapy (Mynors-Wallis

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et al., 1995; Mynors-Wallis et al., 2000), and one for interpersonal psychotherapy (Schulberg et al., 1996). As was noted previously, primary care RCTs have utilized differing comparison arms for assessing psychotherapy’s effectiveness. In the five RCTs utilizing a primary care physician’s usual care as the alternative to psychotherapy, two found cognitive therapy and usual care equally effective in markedly reducing depressive severity on the selected outcome index (Teasdale et al., 1984; Scott & Freeman, 1992). However, psychotherapy produced a significantly better outcome than usual care in the other RCT of cognitive behavioral therapy (Ross & Scott, 1985), in the study of cognitive behavioral therapy plus medication adherence (Katon et al., 1996), and in the study of interpersonal psychotherapy (Schulberg et al., 1996). When a medication placebo served as the comparison arm, problem solving therapy produced the clinically superior outcome (Mynors-Wallis et al., 1995). The effectiveness of psychotherapy alone also has been compared with antidepressant medications, the first-line intervention typically utilized by primary care physicians when treating major depression (Pincus, Tanielian, Marcus, Olfson, Zarin, Thompson, et al., 1998). In the RCTs studying clinical outcomes for psychotherapy alone and such medications alone, investigators found similar improvement on the outcome index when the major depression was treated with either of these interventions (Scott & Freeman, 1992; Mynors-Wallis et al., 1995; Mynors-Wallis et al., 2000; Schulberg et al., 1996). The AHCPR Depression Guideline Panel (1993), the American Psychiatric Association (2000), and the Canadian Depression Work Group (Segal, Whitney, Lam, et al., 2001) judged psychotherapy alone effective but recommended that it be restricted as a monotherapy to mild-moderate episodes of major depression. However, Schulberg, Pilkonis, and Houck (1998) found interpersonal psychotherapy alone as effective as the antidepressant medication nortriptyline when treating the subgroup of primary care patients with more severe episodes of this mood disorder (mean baseline 17-item Hamilton Rating Scale for Depression score of 26; HRSD; Hamilton, 1960). This suggests the need for further research on the relationship between depressive severity and psychotherapeutic effectiveness in primary care populations experiencing both a mood disorder and physical illness. In addition to comparing psychotherapy and pharmacotherapy as monotherapies for major depression, two primary care research teams have compared the clinical outcome achieved by psychotherapy alone and psychotherapy delivered concurrently with an antidepressant medication. Blackburn et al. (1981) found that 81.8% of patients provided cognitive therapy plus a medication recovered at five months compared to 72.7% of those provided CT alone, a nonsignificant trend. Mynors-Wallis, et al. (2000) found no differences in 12-month recovery rates among patients receiving problem-solving therapy alone or PST plus a medication (62% vs. 66%). Given this small primary care data set concerning the relative utility of combined treatment, can findings from studies conducted with depressed psychiatric outpatients more definitively inform such practice in the ambulatory medical sector? Earlier reviews of pertinent research (Manning, Markowitz, & Frances, 1992; Robinson, Berman, & Niemeyer, 1990; Wexler & Cicchetti, 1992) almost uniformly concluded that combined therapy offers no clinical advantage over either intervention delivered as a monotherapy. More recently, Pettit, Voelz, and Joiner (2001) concluded that the advantage of psychotherapy combined with medication is modest and generally not great enough to influence choice of intervention during treatment’s acute phase. However, some studies do indicate that combined therapy’s effectiveness relative to monotherapy should influence treatment choice (Thase, Greenhouse,

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Frank, Reynolds, Pilkonis, Hurley, et al., 1997; De Jonghe, Kool, van Aalst, Dekker, & Peen, 2001; Pampallona, Bollini, Tibaldi, Kupelnick, & Munizza, 2004). Thase et al.’s (1997) “mega-analysis” of six RCTs conducted at the University of Pittsburgh found patients scoring >19 on the 17-item HRSD to benefit more from combined therapy than monotherapy, while there were no differences among less severely depressed patients. Since the major depression of primary care patients typically is of the less severe type (Coyne, Fechner-Bates, & Schwenk, 1994), combined therapy likely will be initiated with but a minority of the depressed primary care patients. Keller, McCullough, Klein, Arnow, Dunner, Gelenberg, et al. (2000) found an antidepressant medication combined with a cognitive-behavioral system of psychotherapy superior to monotherapy in treating chronic or recurrent depression. Again, however, this finding is minimally relevant to routine primary care practice since patients experiencing this mood disorder subtype will likely be referred to the specialty psychiatric sector. Virtually all of the primary care and psychiatric studies of monotherapy versus combined therapy have focused on their efficacy during the acute phase of treatment. A recent review (Pampallona et al., 2004), however, concluded that patients receiving combined treatment benefit more than those receiving drug treatment alone, regardless of whether the treatment was acute or longer than 12 weeks. In addition, patients who received combined treatment lasting longer than 12 weeks were less likely to drop out of treatment, suggesting that one function of psychotherapy may be to keep patients in treatment. With regard to their relative advantages in preventing the recurrence of a depressive episode, two Pittsburgh RCTs achieved differing results. Frank, Kupfer, Perel, Cornes, Jarrett, Mallinger, et al. (1990) found three-year survival rates for midlife psychiatric patients treated with psychotherapy and medication during the maintenance phase to resemble those of patients provided pharmacotherapy alone. In a study of older psychiatric patients, however, Reynolds, Frank, Perel, Imber, Cornes, Miller, et al. (1999) determined that maintenance phase medication combined with psychotherapy is the optimal clinical strategy for preserving recovery. Our analysis of the relative outcomes achieved by psychotherapy alone and combined therapy points to the complexity of designing and conducting such research (White & Walden, 2000) and the need for additional studies which control for key variables such as history of prior depression, severity of the episode at baseline, etc. While prior studies have investigated combined therapy delivered concurrently during treatment’s acute phase, we also need to study combined therapy's efficacy when it is delivered sequentially. Thus, RCTs should investigate the impact of medication when used to augment psychotherapy that has produced only a partial response, or when serving as an alternative to psychotherapy that has produced no response. The currently available evidence about combined treatment’s effectiveness as an augmentation or crossover strategy has been judged as equivocal by the Canadian Depression Work Group (Segal, Kennedy, Cohen, et al., 2001). What implications do these reports have for the choice of psychotherapist? Outcome does not appear related to the psychotherapist’s discipline since the clinicians achieving successful outcomes in the previously cited RCTs of psychotherapy alone, or as part of combined therapy, included psychiatrists, clinical psychologists, nurses, and general practitioners. Thus, individual competency with a particular psychotherapy rather than professional discipline should guide the selection of clinicians to deliver interventions of known efficacy, a principle that necessarily can be most readily implemented in urban areas and/or in geographic settings with access to extensive academic resources. We would note, however, that even in such

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locales primary care physicians are unlikely to obtain the training and schedule the practice time needed to deliver a depression-specific psychotherapy conforming to treatment manual standards despite evidence that physicians indeed can function at this quality level when so motivated and facilitated (Mynors-Wallis et al., 2000). When patients are being treated concurrently with psychotherapy and an antidepressant medication, a decision is necessary as to whether both treatments should be delivered by a single clinician, or be split between the psychotherapist and a medication-prescribing physician. Past analyses of this issue focused on clinical and ideological parameters (Beitman & Klerman, 1991) but in recent years attention has shifted to the decision’s economic implications. Thus, Goldman, McCulloch, Cuffel, Zarin, Suarez, and Burns (1998) argue that integrated treatment in a managed care network delivered by a single physician is no more costly than split treatment including a lower paid non-physician. It is highly unlikely, however, that a depressed patient can receive combined treatment from a single clinician in primary care practice unless management of the mood disorder is “carved out” to a behavioral health organization. When it is not, psychotherapy will likely be delivered by a nonphysician, and pharmacotherapy by the primary care physician. We conclude from the above analyses that a depression-specific psychotherapy (CT, CBT, IPT, or PST) provided alone by a competent clinician effectively treats major depression in primary care practice. It achieves outcomes in the 12 months following baseline that are statistically superior to those produced by the primary care physician’s usual care, and are comparable to those achieved by an antidepressant alone. The clinical as well as statistical robustness of this conclusion is supported by the effect sizes achieved by the above treatments. They range from 1.66-2.32 when calculated in relation to the pre-post changes in the depression severity score, and from 1.39-2.05 in relation to a remission index. These magnitudes are indicative of true clinical change in pre-post depressive status. We acknowledge that the primary care database for deriving this conclusion about the effectiveness of psychotherapy alone is relatively small and restricted. Nevertheless, the findings are drawn from RCTs in which the outcomes were virtually uniform in their direction, subject groups met diagnostic criteria for major depression, and they experienced at least moderate levels of depressive severity. Psychotherapy alone also appears as effective as combined treatment for mild/moderate episodes of major depression, the predominant clinical pattern presenting in primary care practice.

WHAT IS THE FRAMEWORK FOR DETERMINING WHETHER AND WHEN PSYCHOTHERAPY ALONE IS EFFECTIVE? The determination of whether psychotherapy effectively treats the primary care patient’s major depression and when maximal therapeutic benefit has been reached generally is based on the degree of symptomatic improvement occurring since baseline. As was noted previously, primary care RCTs have assessed a patient’s clinical course in several ways. We suggest that absolute symptomatic change since treatment’s onset, or a 50% reduction in depressive severity, is the pertinent criterion for judging whether clinical improvement is evident and continued psychotherapy alone is warranted. We consider the criterion of

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“recovery” (e.g. 17-item HRSD score <8) pertinent to the judgment of whether maximal therapeutic benefits have been achieved. Our review of the eight primary care RCTs indicates that none directly addressed the above questions. Nevertheless, reasonably meaningful answers can be deduced from the published data since treatment intensity in these RCTs was adequate for this analysis. Thus, psychotherapy alone ranged from six sessions for problem-solving therapy (Mynors-Wallis et al., 1995; Mynors-Wallis et al., 2000) and cognitive therapy as part of a multi-modal intervention (Katon et al., 1996) to 10-15 sessions of cognitive therapy (Schulberg et al., 1993; Blackburn et al., 1981; Teasdale et al., 1984; Ross & Scott, 1985) and 12 sessions of interpersonal psychotherapy (Schulberg et al., 1996). While the cognitive therapy provided depressed patients in Katon et al.’s (1996) RCT was compacted into a six-week treatment episode, the psychotherapies delivered in the remaining RCTs extended over a 12-16 week duration. Thus, subjects in these studies met the six-eight session criterion for adequate exposure to treatment utilized by Howard, Kopta, Krause, and Orlinsky (1986) in their analysis of the dose-effect relationship in psychotherapy. We found extent of clinical improvement after the initial 4-6 weeks of psychotherapy to range from a 20% reduction in baseline HRSD scores for patients provided interpersonal psychotherapy (Schulberg et al., 1996) to a 56% reduction in such scores for patients treated with problem solving therapy (Mynors-Wallis et al., 1995). While problem solving therapy produced the most immediate improvement, all psychotherapies produced steady improvement in clinical status over time. After four months, baseline depressive severity had been reduced by 50%-63% in all psychotherapy RCTs. Given this pattern of continuous clinical improvement during the initial 12-16 weeks of psychotherapy, we consider 6-8 weeks post-baseline an appropriate time point for gauging whether this intervention is proving beneficial and its continuation as a monotherapy justified. This recommendation is consistent with the finding by Shapiro, Barkham, Rees, Hardy, Reynolds, and Startup (1994) that 16session psychotherapy has an advantage over 8-session treatment only for severely depressed patients (i.e. mean baseline Beck Depression Inventory score of 30; Beck, Ward, Mendelson, Mock, & Erlbaugh, 1961). With regard to ascertaining when maximal therapeutic benefit has been derived from psychotherapy, fewer data are available for this judgment. Howard et al. (1986) determined that 46% of patients treated with long-term psychotherapy in mental health facilities improved after eight sessions and 73% after 26 sessions. However, primary care RCTs assessing clinical course for periods up to one year suggest that clinical status remains stable after four months of short-term psychotherapy (Lave, Frank, Schulberg, & Kamlet, 1998). This likely indicates that maximal therapeutic benefit has been achieved at this point with a time-limited treatment. We would caution, nevertheless, that psychotherapy not necessarily be terminated after four months since few data are available to clarify whether continuation or maintenance phase psychotherapy alone, even at a reduced level of intensity, protects against relapse. The need for research about psychotherapy’s sustained effectiveness is underlined by Westen and Morrison’s (2001) finding that only 36%-38% of depressed patients who improved remained improved up to 24 months post-baseline.

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WHAT FACTORS PREDICT CLINICAL OUTCOME FOR PSYCHOTHERAPY ALONE IN PRIMARY CARE PRACTICE? While 50%-60% of depressed primary care patients treated psychotherapeutically recover, the remaining 40%-50% provided this monotherapy do not. Distinguishing patient factors associated with the former and latter outcomes would possibly direct psychotherapists to customized interventions and, thereby, potentially improve recovery rates. Numerous investigators have sought to identify such distinguishing factors in studies of depressed psychiatric samples. For example, Sotsky, Glass, Shea, Pilkonis, Collins, Elkin, et al. (1991) identified six patient characteristics in addition to depressive severity predicting outcomes across both cognitive behavioral therapy and interpersonal psychotherapy. However, relatively few investigators have analyzed factors influencing outcome of depressed primary care patients whose symptom presentation is predominantly physical rather than affective, and who are experiencing physical illnesses of varying severity which could adversely influence the treatment process. With regard to the small number of outcome-related studies conducted with depressed primary care samples, few are specific to psychotherapy. Thus, Schulberg, McClelland, and Gooding (1987) conducted an observational study of patients provided no standardized treatment of their depression. They found lifetime psychiatric symptoms positively related to persisting major depression six months post-baseline. Extensive psychopathology was similarly identified by Brown, Schulberg, Madonia, Shear, and Houck (1996) as adversely influencing outcome. Depressed patients with lifetime panic disorder had significantly poorer recovery rates regardless of whether they were treated with psychotherapy or an antidepressant medication. Patients treated with interpersonal psychotherapy were significantly more likely to have recovered from their episode of major depression at eight months when lacking a lifetime history of generalized anxiety disorder or panic disorder, and exhibiting no current Axis II personality disorder (Brown, Schulberg, & Prigerson, 2000). The adverse impact of personality factors on outcome was also detected by other investigators. Patience, McGuire, Scott, and Freeman (1995) found the presence of personality pathology to delay recovery from major depression across all treatment modes, and Katon, Lin, von Korff, Bush, Walker, Simon, et al. (1994) found higher initial neuroticism to significantly predict the severity of affective symptoms at four months in patients treated with antidepressant medications. In contrast to the previous reports that identified various patient-related factors associated with outcome, Mynors-Wallis et al. (1995) found no clinical, demographic, or psychosocial variables related to change in depressive severity among patients treated with problem-solving therapy. More recently, Alexopoulos, Katz, Bruce, Heo, Ten Have, Raue et al. (in press) found that comorbid anxiety disorders, hopelessness, and limitations in both physical and emotional functioning were associated with low remission rates among elderly patients treated with either antidepressant medication, interpersonal psychotherapy, or a physician’s usual care. What judgments may be drawn from this limited database? It appears that the more extensive the co-occurring Axis I and Axis II psychopathology, the more difficult and delayed is the primary care patient’s recovery from major depression. Medical comorbidity is another factor hypothesized as adversely affecting the primary care patient’s recovery from an episode of major depression. Earlier studies such as those by

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Popkin, Callies, and Mackenzie (1985), Kukull, Koepsell, Inui, Borson, Okimoto, Raskind, et al. (1986), and Schulberg, McClelland, and Gooding (1987) found depressive outcomes significantly poorer for patients with comorbid medical illnesses. More recent studies such as those completed by Koike, Unutzer, and Wells (2002) and Iosifescu, Nierenberg, Alpert, Smith, Bitran, Dording, et al. (2003) continue to report such a relationship. Theoretical models to explain the manner wherein depression and physical illnesses interact to impede the patient’s recovery from the mood disorder have been proposed by Katon (2003), and empiric tests of these formulations are now indicated.

PATIENT TREATMENT PREFERENCES A body of literature has developed in recent years regarding patient treatment preferences, and their impact on treatment adherence and effectiveness (van Schaik, Klijn, van Hout, van Marwijk, Beekman, de Hann, et al, 2004). Treatment preferences may be important in accounting for the significant number of patients who fail to become engaged in or adhere to interventions offered in primary care, whether they be antidepressant medication or psychotherapy. Nonadherence can be defined in numerous ways, including failing to initiate a recommended or prescribed treatment, limited use or misuse of treatment, failure to become engaged in treatment, and early termination treatment. Nonadherence or poor adherence can lead to compromised treatment efficacy and poor outcomes. Randomized clinical trials have reported remission rates that differ substantially when outcomes are compared for “intent to treat” and “treatment completer” cohorts, e.g., 49% vs. 69%, respectively, in Schulberg, et al.’s (1996) study of depressed mid-life primary care patient participants. In this study, only one-third of participants completed a full-course of psychotherapy. A patient’s decision not to initiate the treatment process, or to terminate it prematurely, often stems from his or her disappointment or dissatisfaction with not having a priori treatment preferences met. What is known about the preferences that depressed primary care patients bring to the clinical encounter? The most commonly stated choice of treatment by depressed patients is counseling or psychotherapy. In studies conducted by Cooper-Patrick et al. (1998), Churchill et al. (2000), and Dwight-Johnson et al. (2000), 50%-86% of depressed mid-life patients preferred a psychosocial intervention, while only a minority preferred medications as the initial intervention. In a randomized controlled trial conducted with older depressed primary care patients, Unutzer, Katon, Callahan, Williams, Hunkeler, Harpole, et al. (2002) found 51% to prefer counseling and 39% medications. Furthermore, 73% of the general practice patients interviewed by Zeitlin, Katona, D’Ath, and Katona (1997) judged antidepressant medications “very” addictive, and only 26% considered them “very” effective. Factors associated with choice of a psychosocial intervention in these studies were female gender, African American racial status, no prior medication treatment, concern that medications are addictive, and prior success with this intervention. Factors associated with preference for medication were greater depressive severity and prior success with medication. Despite these findings, most depressed patients display limited understanding of the availability and efficacy of standard treatments for their mood disorder (Goldney, Fisher, Wilson, & Cheok, 2002). Based on this, an important issue regards the nature of information

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considered by patients in formulating their treatment preference, and whether interventions that involve education and that actively engage patients in a negotiation process lead to more informed preferences and subsequent adherence to the selected treatment.

Treatment Negotiation The seminal body of research on treatment choice was conducted by Lazare, Eisenthal, and Wasserman (1975), who refined procedures for the patient and clinician to “negotiate” a “customer-based” treatment plan in the ambulatory psychiatric setting. Lazare et al. found that patients seeking help have one or more requests or preferences for treatment, including advice, support, insight, and medical treatment. Lazare et al. argue that one result of a clinician eliciting a patient’s requests or preferences for treatment is that the patient will be more willing to listen to the clinician when he/she knows the request has been heard. This verbalization by the patient of a request for treatment is the first step in the treatment negotiation process. Lazare et al. describe this negotiation process as a mutual attempt by the participants to influence each other, with the patient educating the clinician about his/her needs, beliefs, and attitudes, and the clinician educating the patient about his/her formulation of the patient’s condition and appropriate treatment options. The negotiation, while not necessarily providing patients what they initially want, actively solicits their participation in treatment planning. Adherence in this context refers to a mutually agreed-upon plan as opposed to a straightforward clinician recommendation. Research has shown that the negotiated approach to treatment is associated with greater patient satisfaction, feeling helped, and feeling better following the initial interview (Eisenthal, Emery, Lazare, & Udin, 1979). In addition, negotiated, in contrast to nonnegotiated treatment plans, were significantly related to patient adherence with the plan. Another significant predictor of adherence was the patient getting the treatment plan he/she wanted. Related studies in the primary care sector (Brody, Miller, Lerman, Smith, & Caputo, 1989; Cooper-Patrick, Powe, Jenckes, Gonzales, Levine, & Ford, 1997; Dwight-Johnson, Unutzer, Sherbourne, Tang, & Wells, 2001) have supported the value of a negotiated treatment plan and the importance of the patient playing an active rather than passive role in formulating it. For example, Brody et al. (1989) found that primary care patients who perceived themselves as actively involved in their general medical care reported greater satisfaction with their physician, greater sense of control over their illness, and greater symptomatic improvement than did “passive” patients. Cooper-Patrick et al. (1997) conducted in-depth focus groups with depressed primary care patients and health care professionals about their attitudes about depression treatment, so as to understand patient help-seeking behavior and preferences for depression care. Patients expressed more concern than did health care professionals regarding the impact of spirituality, social support systems, coping strategies, life experiences, patient-provider relationships, and attributes of specific treatments (e.g., side effects, effectiveness, treatment length, etc.). In comparison to white patients, African-American patients raised more concerns regarding spirituality and stigma. Dwight-Johnson et al. (2001) found that a primary care quality improvement program designed to accommodate patient depression treatment choice increased the likelihood that

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these patients initiated treatment, compared to those receiving usual care. In addition, patients in intervention clinics were more likely to receive their preferred treatment approach.

Counteracting Biases about Treatment Risks Another component of successful treatment negotiation involves consideration of how patients evaluate risks associated with a particular treatment. Tversky and Kahneman’s (1974, 1981) groundbreaking work on decision making has demonstrated that people often make decisions without fully analyzing all relevant factors, and tend to rely on rules of thumb such as the availability bias (e.g., reliance on recent experiences). People also tend to avoid risk taking if the risk is framed as a potential loss as opposed to a potential gain. More recently, Ness (2002) has described how these biases operate in medical patients, particularly those with psychiatric problems like depression, and how physicians can counteract them when discussing treatment options. From this perspective, perception of the risks involved from a particular treatment option is heightened by irrational fears of unfamiliar approaches, lack of control, and possible harm to self. Depression and its associated cognitive and problem solving deficits may also result in negative, passive attitudes and a tendency to overestimate the risks of treatment while underestimating its benefits. Ness presents a model of treatment negotiation that extends beyond simple information giving to a mutual process involving the exploration of patient views and attitudes, educating the patient, counteracting his/her potentially biased judgments, and questioning how well the patient understands and evaluates the options. The ultimate goal of this process is to allow patients to make more informed decisions based on their own preferences, beliefs, and personality.

Negotiated Treatment and Outcomes The previous literature, from many different but complementary perspectives, highlights the conceptual significance of the manner in which the treatment engagement process is negotiated, and the centrality of patient preferences to it. What is known, then, about the manner in which the treatment negotiation process relates to clinical outcomes? Only one such study has been conducted with a cohort of mid-life depressed primary care patients. The reports of Bedi, Chilvers, Churchill, Dewey, Duggan, Fileding, et al. (2000) of four-month outcomes and Chilvers, Dewey, Fielding, Gretton, Miller, Palmer, et al. (2001) of twelvemonth outcomes with this population found generic counseling and antidepressant medication to produce similar improvement rates regardless of whether the patient had selected the treatment or been randomized to it. The investigators, therefore, concluded that accommodating patient preference in the treatment assignment confers no additional benefit. However, the study’s methodology required that patients initially be randomized to either counseling or medication. Only patients refusing the randomized assignment were then offered their personal preference. Thus, the randomized subgroups likely included at least some patients whose a priori treatment preference was not met, but who nevertheless continued participating in the randomized treatment assignment despite their dislike of it. Outcome differences associated with a priori treatment preferences, therefore, could not be tested since the randomized subgroups were heterogeneous rather than homogeneous on the

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critical variable of a priori treatment preference. Innovative approaches such as the “partially randomized patient-preference design,” which is rarely used in psychiatric research (Ten Have, Coyne, Salzer, & Katz, 2003), permit a more valid test of whether accommodating treatment preferences, or use of a more negotiated treatment approach improves adherence and clinical outcome.

DISCUSSION Our review of primary care RCTs investigating psychotherapy’s effectiveness leads us to recommend that physicians consider this intervention a meaningful option for patients experiencing major depression. The clinical outcomes produced by psychotherapy alone during the acute phase of treatment rival those of antidepressant medications alone when treating mild/moderate episodes of this mood disorder. Thus, findings from the primary care RCTs resemble those obtained with RCTs conducted in psychiatric settings (Gabbard, 2001). The AHCPR Depression Treatment Guideline Panel (1993), the American Psychiatric Association (2000), and the Canadian Depression Work Group (Segal, Whitney, Lam, et al., 2001) favor pharmacotherapy as the treatment of choice for more severe depressive episodes. However, the empiric basis for extending this preference to primary care practice is questionable. It may even be inappropriate given the finding by Schulberg et al. (1998) that psychotherapy and pharmacotherapy as monotherapies achieved comparable outcomes even with a subgroup of severely depressed primary care patients. With regard to choosing between psychotherapy alone and this treatment combined with antidepressant medication, the primary care database is limited. We, therefore, should consider pertinent psychiatric RCTs for possible guidance. This latter body of research suggests that combined treatment as the initial intervention is most applicable to more severe depressive episodes (Thase et al., 1997) and to episodes with more chronic and recurrent features (Keller et al., 2000). Since such episodes are best managed in the specialty mental health sector, only occasionally is combined treatment likely to be the treatment of choice in routine primary care practice. Given these findings about psychotherapy’s effectiveness in reducing depressive symptomatology, we also must note that the proportion of individuals treated with psychotherapy for mood disorders in all settings declined from 71.1% to 60.2% between 1987-1997 (Olfson, Marcus, Druss, Ellinson, Tanielian, & Pincus, 2002). During this same time period, the proportion prescribed antidepressant medications increased from 37.2% to 74.5%. This national trend undoubtedly is associated with managed care’s fiscal and practical constraints on the delivery of psychotherapy, and the advent of better-tolerated antidepressants readily prescribed by primary care physicians. The clinical and costeffectiveness of this shifting treatment pattern remains to be determined, however. Lave et al. (1998) concluded from data gathered in the Schulberg et al. (1996) RCT that psychotherapy delivered by mental health specialists is more costly but also more effective than the “usual care” pharmacotherapy delivered by primary care physicians. Policy makers, therefore, must judge the propriety of further curtailing psychotherapy because of its higher costs and accepting the risk of poorer clinical outcomes associated with routine primary care pharmacotherapy (Sturm & Wells, 1995).

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Our analysis of psychotherapy’s effectiveness in the treatment of patients experiencing major depression undoubtedly would benefit from research on additional factors affecting its utility in primary care practice. Thus, we strongly suggest studying the impact of physical illness co-occurring with the mood disorder. Since the probability of persisting depression is related to the presence of co-occurring physical illnesses, is there a severity of such illness beyond which psychotherapy alone must be augmented with or replaced by antidepressant medication? In a related vein, what is the impact of a patient’s preference for psychotherapy or counseling on the treatment’s effectiveness? Several studies (Dwight-Johnson et al., 2000; Cooper-Patrick et al., 1998; Churchill et al., 2000) found that 50-86% of depressed primary care patients prefer to be treated with a psychosocial intervention. However, Bedi et al. (2000) and Chilvers et al. (2001) found such patient preference to confer no additional benefit on outcome. Nevertheless, patient preference is a complex concept incorporating both psychological and methodological dimensions. For example, the manner in which a patient’s preferences are elicited and the point in the recruitment and informed consent process when this occurs can profoundly influence the patient’s stated preference. Ten Have et al. (2003), therefore, suggest experimenting with “reengineered” randomization designs that provide potential research subjects with differing degrees of autonomy in choosing the treatment to which they will be assigned. We restricted the above review of primary care psychotherapy RCTs to those in which the psychosocial intervention was depression-specific given the increasingly refined theoretic models of the mood disorder’s etiology, onset, and clinical course. However, psychotherapy or counseling provided in real world practice is most commonly of a generic, non-manualized format. Two recent British RCTs have successfully employed non-depression specific counseling when treating this disorder in primary care practice. That by Bedi et al. (2000) found generic counseling to achieve clinical outcomes comparable to that of anti-depressant medications; that by Ward, King, Lloyd, Bower, Sibbald, Farrelly, et al. (2000) found nondirective counseling and cognitive behavior therapy to achieve similar outcomes. A recent review (Bower, Rowland, & Hardy, 2003) of seven trials of counseling in primary care (including the above two studies) reported that counseling resulted in significantly more reductions in depression and anxiety than usual physician care in the short-term, but not the long-term (i.e., more than 6 months). These findings are intriguing given the complexities of recruiting and paying clinicians to provide depression-specific psychotherapy of treatment manual quality in primary care settings. At the least, these British studies force us to reopen the question of whether generic counseling as commonly provided in primary care practices is an effective component of the treatment armamentarium applicable to major depression in the ambulatory medical sector. Another current direction in primary care is use of care managers to assist physicians in treating patients with major depression. Care managers function by making treatment recommendations, monitoring patient clinical status, and encouraging patient adherence to treatment. In some studies, care managers have provided manualized psychotherapy. An important question in this context is what training is necessary so that allied health professionals such as nurses and social workers lacking extensive psychotherapy experience can deliver the treatment effectively. In the PROSPECT study (Bruce, Ten Have, Reynolds, Katz, Schulberg, Mulsant, et al., 2004) where Interpersonal Psychotherapy was offered as an alternative to pharmacotherapy, care managers had varying levels of experience with

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depression in primary care and with psychotherapeutic approaches. An extensive 2-month training period was used to train all care managers in Interpersonal Psychotherapy, and ongoing supervision was provided (Schulberg, Bryce, Chism, Mulsant, Rollman, Bruce, et al., 2001). Similarly, efforts to train non-mental health professionals such as community nurses to administer Problem Solving Treatment in primary care (PST-PC) have been found to be feasible and effective (Mynors-Wallis, Gath, et al., 1995; Mynors-Wallis, Davies, Gray, Barbour, & Gath, 1997). These examples of care management approaches are particularly promising methods of treating depressed primary care patients, given the competing demands on physicians’ time and the reluctance of many patients, particularly older ones, to follow up on referrals to mental health specialists (Waxman, Carner, & Klein, 1984; Ganguli, Mulsant, Richards, Stoehr, & Mendelsohn, 1997).

REFERENCES Agency For Health Care Policy and Research Depression Guideline Panel, U.S. Dept. of Health and Human Services. (1993). Clinical Practice Guideline, Depression In Primary Care: Vol. 2. Treatment of Major Depression. AHCPR Publication No. 930551. Washington, DC: U.S. Government Printing Office. Alexopoulos, G., Katz, I., Bruce, M., Heo, M., Ten Have, T., Raue, P., Bogner, H., Schulberg, H., Mulsant, B., Reynolds, C., and the PROSPECT Group (2005). Remission in depressed geriatric primary care patients: A report from the PROSPECT study. American Journal of Psychiatry, 162, 718-724. American Psychiatric Association. (2000). Practice guideline for the treatment of patients with major depressive disorders (revision). American Journal of Psychiatry, 157 (April Suppl.), 1-45. Beck, A., Rush, A., Shaw, B., & Emery, G. (1979). Cognitive Therapy of Depression. New York: Guilford Press. Beck, A., Ward, C., Mendelson, M., Mock, J., Erlbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561-571. Bedi, N., Chilvers, C., Churchill, R., Dewey, M., Duggan, C., Fielding, K., Gretton, V., Miller, P., Harrison, G., Lee, A., & Williams, I. (2000). Assessing effectiveness of treatment of depression in primary care. British Journal of Psychiatry, 177, 312-318. Beitman, B., & Klerman, G. (Eds.) (1991). Integrating Pharmacotherapy and Psychotherapy. Washington, D.C.: American Psychiatric Press. Blackburn, I., Bishop, S., Glen, A., Whalley, L., & Christie, J. (1981). The efficacy of cognitive therapy in depression: A treatment trial using cognitive therapy and pharmacotherapy, each alone and in combination. British Journal of Psychiatry, 139, 181-189. Blacker, C., & Clare A. (1987). Depressive disorder in primary care. British Journal of Psychiatry, 150, 737-751. Bower, P., Rowland, N., & Hardy, R. (2003). The clinical effectiveness of counseling in primary care: A systematic review and meta-analysis. Psychological Medicine, 33, 203215.

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Brody, D., Miller, S., Lerman, C., Smith, D., & Caputo, G. (1989). Patient perception of involvement in medical care. Journal of General Internal Medicine, 4, 506-511. Brown, C., & Schulberg, H. (1995). The efficacy of psychosocial treatments in primary care: A review of randomized clinical trials. General Hospital Psychiatry, 17, 414-424. Brown, C., Schulberg, H., Madonia, M., Shear, M., & Houck, P. (1996). Treatment outcomes for patients with major depression and lifetime anxiety disorders. American Journal of Psychiatry, 153, 1293-1300. Brown, C., Schulberg, H., & Prigerson, H. (2000). Factors associated with symptomatic improvement and recovery from major depression in primary care patients. General Hospital Psychiatry, 22, 242-250. Bruce, M., Ten Have, T., Reynolds, C., Katz, I., Schulberg, H., Mulsant, B., Brown, G., McAvay, G., Pearson, J., & Alexopoulos, G. (2004). Reducing suicidal ideation and depressive symptoms in depressed older primary care patients. Journal of the American Medical Association, 291, 1081-1091. Chilvers, C., Dewey, M., Fielding, K., Gretton, V., Miller, P., Palmer, B., Weller, D., Churchill, R., Williams, I., Bedi, N., Lee, L., & Harrison, G. (2001). Antidepressant drugs and generic counselling for treatment of major depression in primary care: randomized trial with patient preference arms. British Medical Journal, 322, 1-5. Churchill, R., Khaira, M., Gretton, V., Chilvers, C., Dewey, M., Duggan, C., & Lee, A. (2000). Treating depression in general practice: factors affecting patients’ treatment preferences. British Journal of General Practice, 50, 905-906. Col, N., Fanale, J., & Kronholm, P. (1990). The role of medication noncompliance and adverse drug reactions in hospitalizations of the elderly. Archives of Internal Medicine, 150, 841-845. Cooper-Patrick, L., Gonzales, J., Rost, K., Meredith, L., Rubenstein, L. & Ford, D. (1998). Patient preferences for treatment of depression. International Journal of Psychiatry in Medicine, 28, 382-383. Cooper-Patrick, L., Powe, N., Jenckes, M., Gonzales, J., Levine, D., Ford, D. (1997). Identification of patient attitudes and preferences regarding treatment of depression. Journal of General Internal Medicine, 12, 431-438. Coyne, J., Fechner-Bates, S., & Schwenk, T. (1994). The prevalence, nature, and comorbidity of depressive disorders in primary care. General Hospital Psychiatry, 16, 267-276. De Jonghe, F., Kool, S., van Aalst, G., Dekker, J., & Peen, J. (2001). Combining psychotherapy and antidepressants in the treatment of depression. Journal of Affective Disorders, 64, 217-229. Dwight-Johnson, M., Sherbourne, C., Liao, D., & Wells, K. (2000). Treatment references among depressed primary care patients. Journal of General Internal Medicine, 15, 527534. Dwight-Johnson, M., Unutzer, J., Sherbourne, C., Tang, L., Wells, K. (2001). Can quality improvement programs for depression in primary care address patient preferences for treatment? Medical Care, 39, 934-944. Eisenthal, S., Emery, R., Lazare, A., & Udin, H. (1979). ‘Adherence’ and the negotiated approach to patienthood. Archives of General Psychiatry, 36, 393-398.

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Frank, E., Kupfer, D., Perel, J., Cornes, C., Jarrett, D., Mallinger, A., Thase, M., McEachran, A., & Grochocinski, V. (1990). Three-year outcomes for maintenance therapies in recurrent depression. Archives of General Psychiatry, 47, 1093-1099. Gabbard, G. (2001). Empirical evidence and psychotherapy: A growing scientific base. American Journal of Psychiatry, 158, 1. Ganguli, M., Mulsant, B., Richards, S., Stoehr, G., & Mendelsohn, A. (1997). Antidepressant use over time in a rural older adult population: The MoVIE Project. Journal of the American Geriatrics Society, 45, 1501-1503. Goldman, W., McCulloch, J., Cuffel, B., Zarin, D., Suarez, A., & Burns, B. (1998). Outpatient utilization patterns of integrated and split psychotherapy and pharmacotherapy for depression. Psychiatric Services, 49, 477-482. Goldney, R., Fisher, L., Wilson, D., Cheok, F. (2002). Mental health literacy of those with major depression and suicidal ideation: An impediment to help seeking. Suicide and Life-Threatening Behavior, 32, 394-403. Hamilton, M. (1960). A rating scale for depression. Journal of Neurology, Neurosurgery and Psychiatry, 23, 56-62. Hegel, M., Barrett, J., Oxman, T., Mynors-Wallis, L., & Gath, D. (1999). Problem-Solving Treatment For Primary Care (PST-PC): A Treatment Manual For Depression. Unpublished manuscript, Dartmouth Medical College. Howard, K., Kopta, S., Krause, M., & Orlinsky, D. (1986). The dose-effect relationship in psychotherapy. American Psychologist, 41, 159-164. Iosifescu, D., Nierenberg, A., Alpert, J., Smith, M., Bitran, S., Dording, C., & Fava, M. (2003). The impact of medical comorbidity on acute treatment in major depressive disorder. American Journal of Psychiatry, 160, 2122-2127. Katon, W. (2003). Clinical and health services relationships between major depression, depressive symptoms, and general medical illness. Biological Psychiatry, 54, 216-226. Katon, W., Lin, E., von Korff, M., Bush, T., Walker, E., Simon, G., & Robinson, P. (1994). The predictors of depression in primary care. Journal of Affective Disorders, 31, 81-90. Katon, W., Robinson, P., von Korff, M., Lin, E., Bush, T., Ludman, E., Simon, G., & Walker, E. (1996). A multifaceted intervention to improve treatment of depression in primary care. Archives of General Psychiatry, 53, 924-932. Keller, M., McCullough, P., Klein, D., Arnow, B., Dunner, D., Gelenberg, A., Markowitz, J., Nemeroff, C., Russell, J., Thase, M., Trivedi, M., Zajecka, J., Blalock, J., Borian, F., DeBattista, C., Fawcett, J., Hirschfeld, R., Jody, D., Keitner, G., Kockis, J., Koran, L., Kornstein, S., Manber, I., Ninan, P., Rothbaum, B., Rush, A., Schatzberg, A., & Vivian, D. (2000). A comparison of nefazadone, the cognitive behavioral- analysis system of psychotherapy, and their combination for the treatment of chronic depression. New England Journal of Medicine, 342, 1462-1470. Klerman, G., Weissman, M., Rounsaville, B., & Chevron, E. (1984). Interpersonal Psychotherapy of Depression. New York: Basic Books. Koike, A., Unutzer, J., & Wells, K. (2002). Improving the care for depression in patients with comorbid medical illness. American Journal of Psychiatry, 159, 1738-1745. Kukull, W., Koepsell, T., Inui, T., Borson, S., Okimoto, J., Raskind, M., & Gale, J. (1986). Depression and physical illness among elderly general medical clinic patients. Journal of Affective Disorders, 10, 153-162.

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Robins, L., Helzer, J., Croughan, J., & Ratcliff, K. (1981). The National Institute of Mental Health Diagnostic Interview Schedule: Its history, characteristics, and validity. Archives of General Psychiatry, 38, 381-389. Robinson, L., Berman, J., & Niemeyer, R. (1990). Psychotherapy for the treatment of depression: A comprehensive review of controlled outcome research. Psychological Bulletin, 108, 30-49. Ross, M., & Scott, M. (1985). An evaluation of the effectiveness of individual and group cognitive therapy in the treatment of depressed patients in an city health center. Journal of the Royal College of General Practitioners, 35, 239-242. Schulberg, H., Block, M., & Coulehan, J (1989). Treating depression in primary care practice. An application of decision analysis. General Hospital Psychiatry, 11, 208- 215. Schulberg, H., Block, M., Madonia, M., Scott, C., Rodriguez, E., Imber, S., Perel, J., Lave, J., Houck, P., & Coulehan, J. (1996). Treating major depression in primary care practice: eight-month clinical outcomes. Archives of General Psychiatry, 53, 913-919. Schulberg, H., Bryce, C., Chism, K., Mulsant, B., Rollman, B., Bruce, M., Coyne, J., Reynolds, C., & the PROSPECT Group. (2001). Managing late-life depression in primary care practice: a case study of the health specialist’s role. International Journal of Geriatric Psychiatry, 16, 577-584. Schulberg, H., Coulehan, J., Block, M., Lave, J., Rodriguez, E., Scott, C., Madonia, M., Imber, S., & Perel, J. (1993). Clinical trials of primary care treatments for major depression: Issues in design, recruitment, and treatment. International Journal of Psychiatric Medicine, 23, 29-42. Schulberg, H., McClelland, M., & Gooding, W. (1987). Six-month outcomes for patients with major depressive disorder. Journal of General Internal Medicine, 2, 312-317. Schulberg, H., Pilkonis, P., & Houck, P. (1998). The severity of major depression and choice of treatment in primary care practice. Journal of Consulting and Clinical Psychology, 66, 932-938. Schulberg, H., Raue, P., & Rollman, B. (2002). The effectiveness of psychotherapy in treating depressive disorders in primary care practice: Clinical and cost perspectives. General Hospital Psychiatry, 24, 203-212. Scott, A., & Freeman, C. (1992). Edinburgh primary care depression study: treatment outcome, patient satisfaction, and cost after 16 weeks. British Medical Journal, 304, 883-887. Segal, Z., Kennedy, S., Cohen, L., & the CANMAT Depression Work Group. (2001). Clinical Guidelines For The Treatment of Depressive Disorders. V. Combining psychotherapy and pharmacotherapy. Canadian Journal of Psychiatry, 46 (Suppl. 1), 59S-62S. Segal, Z., Whitney, D., Lam, R., & the CANMAT Depression Work Group. (2001). Clinical Guidelines for the Treatment of Depressive Disorders. III. Psychotherapy. Canadian Journal of Psychiatry, 46 (Suppl. 1), 29S-37S. Shapiro, D., Barkham, M., Rees, A., Hardy, G., Reynolds, S., & Startup, M. (1994). Effects of treatment duration and severity of depression on the effectiveness of cognitivebehavioral and psychodynamic-interpersonal psychotherapy. Journal of Consulting and Clinical Psychology, 62, 522-534. Sotsky, S., Glass, D., Shea, M., Pilkonis, P., Collins, J., Elkin, I., Watkins, J., Imber, S., Leber, W., Moyer, J., Oliveri, M. (1991). Patient predictors of response to

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White, R., & Walden, M. (2000). Obstacles to a randomised controlled trial of intensive dynamic psychotherapy: an account of the New South Wales Section of Psychotherapy outcomes project. Australian and New Zealand Journal of Psychiatry, 34, 271-278. Zeitlin, D., Katona, C., D’Ath, P., & Katona, P. (1997). Attitudes to depression in primary care attendees: Effects of age and depressive symptoms. Primary Care Psychiatry, 3, 17-20.

In: Advances in Psychology Research, Volume 44 Editor: Alexandra Columbus, pp. 59-67

ISBN 1-60021-150-X © 2006 Nova Science Publishers, Inc.

Chapter 4

CONCEPT OF SELF IN HOLISTIC MEDICINE: COMING FROM LOVE, FREEING THE SOUL, THE EGO AND THE PHYSICAL SELF Søren Ventegodt,∗ Nordic School of Holistic Medicine; Quality of Life Research Center; Quality of Life Research Clinic, Copenhagen, Denmark

Joav Merrick National Institute of Child Health and Human Development; Center for Disability and Human Development; Center for Multidisciplinary Research in Aging; Ben Gurion University of the Negev, Beer-Sheva; Division for Mental Retardation, Ministry of Social Affairs, Jerusalem, Israel

ABSTRACT René Descartes, Sigmund Freud and Anna Freud have developed the concept of self and the latter focused on ego development and self-interpretation. These concepts have also been used in counseling, where self-consistency has been seen as a primary motivating force in human behavior and psychotherapy can be seen as basically a process of altering the ways that individuals see themselves. In holistic medicine we believe that there is an ego connected to the brain-mind and a deeper self, connected to the wholeness of the person (the soul), but we have yet another self connected to the body mind taking care of our sexuality. So this three-some of selves (ego, the body and the soul) must function and this is done best under the leadership of our wholeness, the deep self. This chapter with a

∗

Correspondence concerning this article should be addressed to Dr. Søren Ventegodt, E-Mail: [email protected]. Website: www.livskvalitet.org. or Dr. Joav Merrick E-Mail: [email protected]. Website: www.nichd-israel.com.

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Søren Ventegodt and Joav Merrick few case stories illustrate the holistic medicine mindset concerned with the concept of self.

Keywords: Ego development, body, soul, purpose of life, holistic health

INTRODUCTION Philosophically the self has always been problematic. Millions of Buddhists believe in the concept on ”anata” meaning no-self and many more scientists and physicians of today believe that we are only chemical machines making the concept of consciousness and the self a matter of mere self-illusion. In psychoanalysis and related systems we have the ego, the super ego and the id, in psychology we have a self that is the person’s self reference, his interpretation of own personified existence[1-4]. In holistic medicine we normally have an ego connected to the brain- mind, and a deeper self, connected to the wholeness of the person (often in religion and philosophy called the “soul”) [5-19]. We have yet another self connected to the body mind taking care of our sexuality [20]. So this three-some of selves must function, which is done best under the leadership of our wholeness, the deep self. To call it deep is really strange, because when you come from this self, you are not really coming from any depth, but only from yourself. The term is appropriate in education as most students are familiar to some extend with their ego, and to some extent with their sexual bodily self, but not with their totality. To discover this vast hall of existence in oneself often gives a feeling of revelation, of realizing that we are divine creates. The soul is close to God in our inner experience, and many religious experiences [21] thus come after discovering this existential layer in one self. What is interesting for medicine is that many people experience a dramatic improvement in their quality of life, general ability and health, when they break through to this dimension of “higher self”, as it can be called [5-19]. The term “higher” might be justified from the reference to the person’s wholeness, higher then signifying “the top of the hierarchy of entities of this person”.

PURPOSE OF LIFE: THE ESSENCE OF SELF In the scientific holistic medicine we intent to improve QOL, health and ability, all in one process [22,23]. The only way to do this is by re-establishing the patient’s existential coherence [19,24,25]. This is often done in the holistic clinic by the rehabilitation of the patient in the three dimensions of love, consciousness and sexuality [15]. The most important being love. To rehabilitate the patients ability to love is done by helping the patient to acknowledge his existential depth, meaning his wholeness and what we call “the essence of the soul” or the purpose of life. The purpose of life, or life mission [13] is the primary talent of that person and when this talent is taken into use, the person can contribute in a constructive and valuable way in his close environment and society. Realising this value to other people is often making the person very happy, which will facilitate the person to go to

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the next level of unconditional love. When a person realises that the meaning of life is to give from the bottom of his soul with what he himself has been gifted to other people will awaken a happiness in the person that is so sufficient that no more is needed. This person can now give without wanting or needing anything in return. He has become a source of love, a source of value for his family and environment. Living the purpose of life is an experience as being in the state of existence that we were originally meant to be in. This is realising our self [27]. So love is only realised though the wholeness, the deep self or the soul. When we come from love we give from the core of our soul, and we give from our essence. On doing this, all human talents can be recruited to support this key intension of manifesting love, expressing our purpose of life [14]. Box 1: The Life Mission Theory [13] The phases listed below chart the life and disease history of an individual (II-VII). At the outset, let us assume that a human being begins his or her existence with a plan or an ambition for a good and healthy life. We may put this assumption of a primordial plan in quite abstract terms (I): I.

Life Mission. Let us assume that at the moment of conception all the joy, energy and wisdom that our lives are capable of supporting are expressed in a “decision” as to the purpose of our lives. This first “decision” is quite abstract and all-encompassing and holds the intentions of the entire life for that individual. It may be called the personal mission or the life mission. This mission is the meaning of life for that individual. It is always constructive and sides with life itself. II. Life pain. The greatest and most fundamental pain in our lives derives from the frustrations encountered, when we try to achieve our personal mission, be they frustrated attempts to satisfy basic needs or the failure to obtain desired psychological states. III. Denial. When the pain becomes intolerable we can deny our life mission by making a counter-decision, which is then lodged in the body and the mind, partially or entirely cancelling the life mission. IV. Repair. One or several new life intentions, more specific than the original life mission, may now be chosen relative to what is possible henceforth. They replace the original life mission and enable the person to move forward again. They can, in turn, be modified, when they encounter new pains experienced as unbearable. (Example: Mission #1: “I am good.” Denial #1: “I am not good enough.” Mission #2: “I will become good,” which implies I am not). V. Repression and loss of responsibility. The new life intention, which corresponds to a new perspective on life at a lower level of responsibility, is based on an effective repression of both the old life mission and the counter-decision that antagonises and denies it. Such a repression causes the person to split in a conscious and one or more unconscious/subconscious parts. The end result is that we deny and repress parts of ourselves. Our new life intention must always be consistent with what is left undenied. VI. Loss of physical health. Human consciousness is coupled to the wholeness of the organism through the information systems that bind all the cells of the body into a unity. Disturbances in consciousness may thus disturb the organism's information systems, resulting in the cells being less perfectly informed as to what they are to do where. Disruptions in the necessary flow of information to the cells of the organism and tissues hamper the ability of the cells to function properly. Loss of cellular functionality may eventually result in disease and suffering. VII. Loss of quality of life and mental health. In psychological and spiritual terms, people who deny their personal mission gradually lose their fundamental sense that life has meaning, direction and coherence. They may find that their joy of life, energy to do important things and intuitive wisdom are slowly petering out. The quality of their lives is diminished and their mental health impaired. VIII . Loss of functionality. When we decide against our life mission we invalidate our very existence. This shows up as reduced self-worth and self-confidence. Thus, the counter-decisions compromise not only our health and quality of life, but also our basic powers to function physically, psychologically, socially, at work, sexually, etc.

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Quite surprisingly this means that almost everybody contains huge hidden resources that can be mobilised. The experience of becoming oneself and finding the ability to love seems to be the biggest resource a patient can find. Often this is the initiation of an intense self-healing process [28,29]. The background for the life mission theory [13] can be found in box 1.

THE SELF AND HEALING When the patient enters the process of existential healing, we have found three steps that integrates old traumas and develops a positive philosophy of life: 1) to feel, 2) to understand and 3) to let go of negative beliefs and decisions (which has been formulated in “the holistic process theory of healing”[22]). What this process does to a person is a rather peculiar thing: first the negative emotions from old traumas appear in the consciousness; second the repressed and forgotten contexts appear in the mind, where hidden and neurotic patterns are confronted and seen, and finally the many negative beliefs and attitudes collected though life failures are dismissed to reveal a natural and positive philosophy of life. The negative attitudes are really what give the brain-mind ego its lack of transparency. A sound ego is transcendent and allows the deep wishes of the soul (the wholeness) to be manifested in the mind and fulfilled by the person using all of the rich possibilities in this world. In the same way the self of the body-mind will become visible and present, when shame, guild and other feelings related to sexuality and the body are processed and old traumatic life events integrated through holistic existential therapy [30-32]. So the three selves of a person, the ego, the body and the soul are closely related in the sound person. In the sick person these are often widely apart [33-35]. Sexuality is repressed and the body’s urges distorted and perverted, the soul and the true direction of the person is left out of the persons reach, and the mind is occupied with sheer survival. Rehabilitation of existence is really rehabilitation of the soul, mind and body. The mind ego must become transparent (see box 2). The body’s self must become free and happy. The soul must come into power to manifest its love and be a coherent part of the universe [36]. Box 2: The Process of Healing and the Ego [14] The ego is our description of self in the brain-mind. It is important to notice that personal development is a plan not for the elimination of the ego, but for its cultivation. An existentially sound person will always have an operative mental ego, but it is centered on the optimal verbal expression of the life mission. Such an ego is not in conflict with one’s true self, but supports the life and wholeness of the person, although in an invisible and seamless way. The more developed the person, the more talents are taken into use. So, although the core of existence remains the same throughout life, the healthy person continues to grow. As the number of talents we can call upon is unlimited, the journey ends only at death.

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Case Story 1 A female artistic painter, aged 42 years with tinnitus, migraine, herpes simplex 1 and 2, low back pain, treatment-resistant genital warts, sun allergy and depression. Despite her age, Mia was already in a very poor condition, physically and mentally. But she possessed something special, an alertness and interest in the spiritual world. She wanted to develop as a person, which meant that she was ready to assume responsibility and take the rather bitter, holistic medicine offered her. We met in a good and sincere way. Processing her painful personal history took her directly to her life purpose. Following this acknowledgement her art began to flourish and grow like never before. Suddenly, she could do things that she had not even come close to doing before, and her art expressed her new state of acceptance and understanding of good and evil, beautiful and ugly, muck and mire and sky and light. Having acknowledged her life purpose, Mia largely became able to manage on her own. She could now develop further without our help. The clinical therapeutic work of guiding her through the pain that made her ill and blocked her enjoyment of life and self-expression was now finished. Her body and soul have largely healed, her tinnitus almost gone and most of the time she cannot hear it at all. Obviously, this patient may become physically ill again, but her resistance and inner equilibrium appeared to be much greater than before, so next time she is likely to recover much faster.

This woman seemed to have almost all her diseases caused by inner conflicts between her ego and her true self. When the conflicts were solved in the holistic therapy, most of her seemingly incurable diseases disappeared at the same time.

Case Story 2 The next case story was written by a Rosen Body Work practitioner at the Quality of Life Research Center in Copenhagen. It is instructive as it shows an important aspect of how the conflict of the ego versus the true self is related to the subjective problems of a male with heart problems. Male, aged 55 years with the question if he had heart problems. This patient was a family man and manager of a private firm. He seemed a happy and extrovert man with a good grip on things. However, his body was heavy and his muscles very hard. Shortly before he started at the clinic, he had been in hospital with a blood clot in his heart and was taking medication for hypertension. Most of the times he was on the couch he fell into a deep sleep that was frequently interrupted by some very violent jerks throughout the body, which he called his electric shocks. Several times during the period when he came to our clinic he was admitted to the hospital with extreme cardiac pain and angina. Eventually he started medication for these symptoms and on the waiting list for bypass surgery. During some of his private sessions he became aware of some of the things that had greatly influenced his life, including an alcoholic father, who had been violent towards his mother. As a very young he received electroconvulsive therapy for severe depression. After he had realised this, the jerks that used to wake up both him and his wife ceased or diminished. It also became apparent that he was taking strong antidepressants and had done so for years. He choose to reduce dosage so that he was far below the daily dose, and he was doing well without the excessive medication. Throughout the therapy he had some major problems with his staff and he felt they had taken a dislike to him. I (SV) had other clients from that workplace, and it turned out that others

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Søren Ventegodt and Joav Merrick shared his belief. The patient mobilised all his strength to give notice and start again from scratch in another firm, where he is working today. At some point he was again admitted to the hospital with extreme pain and angina that was considered to be life threatening, so he was transferred to a cardiology ward for surgery at the earliest opportunity. However, when the cardiologists examined him thoroughly they could not find any disorder or defect in the heart or surrounding blood vessels, so they discharged him again. During the last private session with the patient he was truly happy about life, and full of vigour to devote to his family and friends. His jerks and cardiac problems had vanished completely, and he was enjoying his new job.

What happened here according to the theory of the ego presented in this chapter is, that the man finally let go of his cold and frozen-hearted ego, which was suppressing his feelings and emotions. It was also beneficial for his subjective experience of his heart, his quality of life, working life and ability of functioning in general. The method of Marion Rosen Body Work [37] and other body therapies that make the patient note the feelings located in the body are effective tools in holistic medicine. Sometimes the patient can verbalise his feelings and let go of the limiting beliefs that keep them bound to the narrow world of the ego. For many middle-aged men, their Achilles heal is allowing themselves to feel. Often, it is extremely unpleasant for a grown-up man in a managerial position to register the old feelings from his childhood of being small, frightened or helpless. It is quite simply an insult to his ego, that he is still harboring such feelings. To release them seemingly relieved his angina.

CONCLUSIONS René Descartes (1596-1650) wrote in 1644 the book “Principles of philosophy” [38] perceived as a milestone in reflection on the non-physical inner self. He proposed that doubt was a principal tool of disciplined examination, but he could not doubt that he doubted. He rationalized that if he doubted, he was thinking and therefore must exist and therefore existence depended upon perception. Concept of self was also part of the writings of Sigmund Freud (1856-1939) [1,39], who developed further and new understanding of the importance of internal mental processes. Freud hesitated to make self-concept a primary psychological unit in his theories, but his daughter Anna Freud (1895-1982) [40] focused on ego development and self-interpretation. In counseling the psychologist Prescott Lecky (1892-1941) created a personality theory, but was never able to collect his writing into a completed form until his former Columbia University students in 1945 published a small posthumous volume [41], where selfconsistency was seen as a primary motivating force in human behavior. Others [42] have used the self-concept in counseling interviews and argued that psychotherapy is basically a process of altering the ways that individuals see themselves. In holistic medicine we believe that there is an ego connected to the brain-mind and a deeper self, connected to the wholeness of the person (the soul), but we have yet another self connected to the body mind taking care of our sexuality [20]. So this three-some of selves (ego, the body and the soul) must function and this is done best under the leadership of our

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wholeness, the deep self. This chapter with a few case stories illustrate the holistic medicine mindset concerned with the concept of self.

ACKNOWLEDGEMENTS This chapter reported results from the Danish Quality of Life Surveys, the planning and execution of which would not have been possible without the aid of Dorte Loldrup Poulsen, Jørgen Hilden and the late Bengt Zachau-Christiansen. Funds were received from eleven Danish Foundations, including The 1991 Pharmacy, the Goodwill, the JL, E. Danielsens & Wife’s, Emmerick Meyer’s, the Frimodt-Heineken, the Family Hede Nielsen’s, Petrus Andersen’s, C.P. Frederiksen’s and the Wedell-Wedellsborgs Foundations, and IMK Almene Fond. The research was approved by the Copenhagen Ethical Committee under numbers (KF) V 100.1762/90 and (KF) 01-502/93.

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Freud S. Mourning and melancholia. London: Penguin, 1984. Jung CG. Man and his symbols. New York: Anchor Press, 1964. Sulivan HS. Interpersonal theory and psychotherapy, London: Routledge, 1996. Horney K. Our inner conflicts: A constructive theory of neurosis. London: WW Norton, 1948. Ventegodt S, Andersen NJ, Merrick J. Quality of life philosophy: when life sparkles or can we make wisdom a science? Scientific World Journal 2003;3:1160-3. Ventegodt S, Andersen NJ, Merrick J. QOL philosophy I: Quality of life, happiness, and meaning of life. Scientific World Journal 2003;3:1164-75. Ventegodt S, Andersen NJ, Kromann M, Merrick J. QOL philosophy II: What is a human being? Scientific World Journal 2003;3:1176-85. Ventegodt S, Merrick J, Andersen NJ. QOL philosophy III: Towards a new biology. Scientific World Journal 2003;3:1186-98. Ventegodt S, Andersen NJ, Merrick J. QOL philosophy IV: The brain and consciousness. Scientific World Journal 2003;3:1199-1209. Ventegodt S, Andersen NJ, Merrick J. QOL philosophy V: Seizing the meaning of life and getting well again. Scientific World Journal 2003;3:1210-29. Ventegodt S, Andersen NJ, Merrick J. QOL philosophy VI: The concepts. Scientific World Journal 2003;3:1230-40. Ventegodt S, Andersen NJ, Merrick J. Editorial: Five theories of human existence. Scientific World Journal 2003;3:1272-76. Ventegodt S. The life mission theory: A theory for a consciousness-based medicine. Int J Adolesc Med Health 2003;15(1):89-91. Ventegodt S, Andersen NJ, Merrick J. The life mission theory II: The structure of the life purpose and the ego. Scientific World Journal 2003;3:1277-85. Ventegodt S, Andersen NJ, Merrick J. The life mission theory III: Theory of talent. Scientific World Journal 2003;3:1286-93.

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[16] Ventegodt S, Merrick J. The life mission theory IV. Theory of child development. Scientific World Journal 2003;3:1294-1301. [17] Ventegodt S, Andersen NJ, Merrick J. The life mission theory V. A theory of the antiself and explaining the evil side of man. Scientific World Journal 2003;3:1302-13. [18] Ventegodt S, Andersen NJ, Merrick J. The life mission theory VI: A theory for the human character. Scientific World Journal 2004;4:859-80. [19] Ventegodt S, Flensborg-Madsen T, Andersen NJ, Merrick J. Life Mission Theory VII: Theory of existential (Antonovsky) coherence: a theory of quality of life, health and ability for use in holistic medicine. Scientific World Journal 2005;5:377-89. [20] Ventegodt S, Vardi G, Merrick J. Holistic adolescent sexology: How to counsel and treat young people to alleviate and prevent sexual problems. BMJ Rapid responses 15 Jan 2005. http://bmj.com/cgi/eletters/330/7483/107#92872 [21] Buber M. I and thou. New York: Charles Scribner, 1970. [22] Ventegodt S, Andersen NJ, Merrick J. Holistic Medicine III: The holistic process theory of healing. Scientific World Journal 2003;3:1138-46. [23] Ventegodt S, Andersen NJ, Merrick J. Holistic Medicine IV: Principles of existential holistic group therapy and the holistic process of healing in a group setting. Scientific World Journal 2003;3:1388-1400. [24] Antonovsky A. Health, stress and coping. London: Jossey-Bass, 1985. [25] Antonovsky A. Unravelling the mystery of health. How people manage stress and stay well. San Francisco: Jossey-Bass, 1987. [26] Fromm E. The art of loving. New York: Harper Collins, 2000. [27] Maslow AH. Toward a psychology of being, New York: Van Nostrand, 1962. [28] Spiegel D, Bloom JR, Kraemer HC, Gottheil, E. Effect of psychosocial treatment on survival of patients with metastatic breast cancer. Lancet 1989;2(8668), 888-91. [29] Ventegodt S, Morad M, Merrick J. Clinical holistic medicine: Induction of Spontaneous Remission of Cancer by Recovery of the Human Character and the Purpose of Life (the Life Mission). Scientific World Journal 2004;4:362-77. [30] Ventegodt S, Merrick J. Clinical holistic medicine: Applied consciousness-based medicine. Scientific World Journal 2004;4:96-9. [31] Ventegodt S, Morad M, Merrick J. Clinical holistic medicine: Classic art of healing or the therapeutic touch. Scientific World Journal 2004;4:134-47. [32] Ventegodt S, Morad M, Merrick J. Clinical holistic medicine: The “new medicine”, the multi-paradigmatic physician and the medical record. Scientific World Journal 2004;4:273-85. [33] Ventegodt S, Merrick J, Andersen NJ. Quality of life theory I. The IQOL theory: An integrative theory of the global quality of life concept. Scientific World Journal 2003;3:1030-40. [34] Ventegodt S, Merrick J, Andersen NJ. Quality of life theory II. Quality of life as the realization of life potential: A biological theory of human being. Scientific World Journal 2003;3:1041-9. [35] Ventegodt S, Merrick J, Andersen NJ. Quality of life theory III. Maslow revisited. Scientific World Journal 2003;3:1050-7. [36] Ventegodt S, Flensborg-Madsen T, Andersen NJ, Nielsen M, Morad M, Merrick J. Global quality of life (QOL), health and ability are primarily determined by our

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consciousness. Research findings from Denmark 1991-2004. Social Indicator Res 2005;71: 87-122. Rosen M, Brenner S. Rosen method bodywork. Accesing the unconscious through touch. Berkeley, CA: North Atlantic Books, 2003. Descartes R. Principles of philosophy (translated by Miller VR, Miller RP). Dordrecht: D Reidel, 1983. Freud S. The interpretation of dreams. In the complete psychological works of Sigmund Freud. London: Hogarth Press, 1962. Freud A. The ego and the mechanisms of defense: The writings of Anna Freud. Guilford, CT: Int Univ Press,1967. Lecky P. Self-consistency: A theory of personality. New York: Island Press, 1945. Raimy VC. Self-reference in counseling interviews. J Consult Psychol 1948;12:153-63.

In: Advances in Psychology Research, Volume 44 Editor: Alexandra Columbus, pp. 69-86

ISBN 1-60021-150-X © 2006 Nova Science Publishers, Inc.

Chapter 5

THE FOUNDATION OF THE SELF AND THE ASSESSMENT OF SELF-ESTEEM Ata Ghaderi∗ Department of Psychology, Uppsala University, Uppsala, Sweden

ABSTRACT The concept of the self is a completely verbal construction and it’s definition, apart from problems of arriving at a consensus in the scientific community, is highly dependent on verbal behavior and social norms in each society. In this chapter, the author presents a condensed review of a variety of definitions and operationalization of the concept of Self based on different psychological theories. The author argues that the inherent approaches and premises in these theories result in specific consequences for the assessment of the features and qualities of the Self in each individual. While some theories stress the significance of the individual's broad social context for the formation of Self, others focus more specifically on early interactions between the individual and its caregivers during childhood, and still other theories highlight the importance of the behavior of the individual instead of relying on mentalistic concepts. Given the differences in theoretical perspectives and approaches, self-concept and self-esteem have been measured in a variety of ways. The complexity of the concept as well as lack of theoretical agreement and empirical data has resulted in accepting a general definition of self-esteem, which is mirrored in the broad use of the Rosenberg’s Scale for self-esteem (RSE). Although RSE has excellent psychometric properties, it constitutes a unidimensional scale that does not capture the complexity of self-esteem (i.e the evaluative dimension of self-concept). Selfesteem can be defined as the sense of contentment and acceptance that results from a person's appraisal of one's own worth, attractiveness, competence, and ability to satisfy one's aspirations. Given the multidimensionality of the concept, there are a few alternatives to the RSE, such as the Coopersmith Self-Esteem Inventory, and SelfConcept Questionnaire. In this chapter, the psychometric properties of the Self-Concept ∗

Correspondence to: Ata Ghaderi. Department of Psychology, Box 1225 , SE-751 42 Uppsala, Sweden; E-mail: [email protected]; Phone: +46 (18) 471 79 86; Fax: +46 (18) 471 21 23

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Ata Ghaderi Questionnaire (SCQ) will be presented and its conceptual composition will be related to the earlier mentioned theories on the concept of Self. It is concluded that given its multidimensionality and encouraging psychometric properties, the SCQ can be a valuable instrument in assessing self-esteem in clinical settings as well as in the studies of the general population.

INTRODUCTION The term self has many meanings, and it has been used in many different ways. The concept of self is made of meaning, which is a symbolic, social and linguistic phenomenon (Baumeister, 1999). As pointed out by Baumeister (1999), without symbols or language, there would be no such concept as self. Thus, self should be regarded as a product of verbal/symbolic behavior. In the everyday use of the term, self also encompasses the body that is made out of biochemical substances. Given the verbal and paradoxical nature of the self (being both stable and in change), its multidimensional, hierarchical nature, as well as its relation to many other variables, it is not surprising that a firm, generally accepted, scientific and operational definition of self that facilitates both prediction and influence in research has been absent within psychology. Some researchers view Self as a central entity in the structure of social knowledge (e.g. Kihlstrom & Klein, 1994). James’ (1980) distinction between two fundamental aspects of the self, and his descriptions of self as hierarchical and multidimensional set the scene for many of the contemporary theoretical views on self (Harter, 1998). As excellently outlined by Harter (1998), the contribution of interactionists such as Cooley, and Mead (Cooley, 1902; Mead, 1934) through their primary emphasis on how social interactions with others profoundly shape the self must also be acknowledged as an important input to the bodies of knowledge that have found their ways into contemporary theories of the self and its aspects. Paramount in their thinking is the role of the opinions of others in shaping the self-concept through social interactions (Harter, 1998). Contemporary theories that also focus on the development of the self and have stimulated empirical research (e.g. attachment theory, social psychological theories, and theories applying a constructivist perspective (See Baumeister & Vohs, 2003; Markus & Nurius, 1986; Sroufe, 1990; Stern, 1985) emphasize a variety of functions that the self performs (Harter, 1998). Although there are many similarities between these theories, and despite their theoretically somewhat coherent views on the construction and development of the self, they still employ a significant number of latent variables, hypothetical constructs, and axioms in need of further empirical elucidation which makes them methodologically less palatable to more empirically oriented scientists. Alternatively, they are not able to present a technical, non-mentalistic account of the development of the self. As an example, most of the developmental memory researchers such as Fivush and Hudson (1990) , Nelson (1993), or Bates (1990) emphasize the role of language in establishing a personal narrative. Furthermore, as Harter (1998) explains, they hypothesize that the mastery of language in general, and of personal pronouns in particular, enables young children to think and talk about, and to expand their categorical knowledge about their “self”. Although this excellent hypothesis is partly backed-up by empirical observations, in contrast to some psychoanalytic hypotheses such as infant’s inability to differentiate themselves from their caregivers during the first months of their lives, there is a need for a more technical, and

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integrated account of how and through exactly what processes the self emerges and develops when children learn to use the language in social interactions. The centrality of the self (Greenwald et al., 2002), as will be shown later, can be represented by its association to many other concepts, objects, relations, etc which are highly connected to each other. A theory that integrates what many other earlier theories have touched upon, or stated in hypothetical terms, and in some cases partly supported by data, comes from a totally unexpected direction: from radical behaviorists. Relational Frame Theory (FRT) (Hayes et al., 2001) is a psychological theory of human language and cognition that provides a comprehensive, technical, and testable analysis of emergence and development of the self that also helps researchers to achieve the goals of prediction and control. According to RFT, self or self-awareness is defined in behavioral terms as verbal discrimination of one’s own behavior (i.e. behaving verbally with regard to one’s own behavior). Language-able humans are capable of relational responding, i.e. responding to one event in term of another. It has been empirically shown that organisms can respond to formal relations (e.g. taller, smaller, dimmer, etc.) between stimuli (e.g. Reese, 1968). Such nonarbitrary relations are based on the formal properties of the stimuli (Bernes-Holmes et al., 1999) (i.e. one object is taller or dimmer, etc.). Humans, on the other hand, can respond to relations that are controlled, not by the formal properties of the stimuli, but by specific contextual cues (Bernes-Holmes et al., 1999). Social interactions during early childhood comprise explicit training (e.g. pointing to a dog and saying dog, as well as saying dog and pointing to a dog), reinforcement and praise establishes contextual control for relational responding. When a child has been exposed to enough of this relational training, derived relational responding emerges (Bernes-Holmes et al., 1999) (i.e. if a relation between A and B is established, the child derives the relation between B and A). Deriving relations is therefore not a genuinely novel behavior, but a type of generalized operant behavior - unreinforced behavior that occurs because it is functionally similar to other behaviors that have been reinforced (Bernes-Holmes et al., 1999). Learned relational responding that can come under the control of arbitrary contextual cues (e.g. a word, a sound, a gesture, etc.), not solely the formal properties of relatad nor direct experience with them is called arbitrarily relational responding (Hayes et al., 2001). Relational frames in RFT is a type of arbitrarily applicable relational responding that has some specific defining features. It should be noted that the term relational frames is not a mentalistic or hypothetical concept, and although is a substantive, it refers to relating events relationally. Relational frames or relating events relationally is an operant behavior, which is characterized by mutual entailment, combinatory mutual entailment and transformation of stimulus functions. Mutual entailment refers to the fundamental bidirectionality of relational frames. Mutual entailment applies when, in a given context, A is related in a characteristic way to B, and as a result B is now related in another complementary characteristic way to A. No non-human animal has ever demonstrated mutual entailment when relating stimuli on non-formal dimensions (Blackledge, 2003). Combinatorial entailment refers to a derived stimulus relation in which two or more stimulus relations (trained or derived) mutually combine (Hayes et al., 2001). As an example, if A in a certain context is related to B and B is related to C, then A and C are mutually related in that context. The third defining feature of relational frames (i.e., transformation of stimulus functions) refers to the change in the function of a stimulus when it becomes related to another stimulus. If a child wants to taste the wine that her parents are drinking, and the parents say no, wine is bad, you may have 7-up which is as good as Coke, there will be a

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transformation of functions from Coke to 7-up that the child has never had. Furthermore, although the child never had a direct experience of wine, it will acquire the stimulus function of bad, from being neutral, because it becomes related to Coke in an opposite relation. There exist a long variety of relation frames, such as the same, better, longer, stronger, more valuable, under, over, similar, different etc. RFT shows how humans develop three types of self, using perspective taking frames of I and You, Here and There, and Now and Then (Barnes & Rosch, 1997). The learning process of perspective taking is shaped by adults in the child’s environment. These frames of perspective are unlike most other relational frames because they do not seem to have formal or non-arbitrary, non-verbal counterparts. The physical properties of perspective taking frames are only abstracted in the context of relational frames (Hayes et al., 2001). Young children have a hard time with the issue of perspective (Hayes, 1984). Gradually, they learn, through operant conditioning (corrections by care-givers, and praise when the right answer is given), that what they see from their perspective is not always the same as what others see from their perspective, and they learn through multi-exemplar training and conditioning that they always see from a particular locus or perspective. What they see or do changes, but the locus does not. The perspective becomes “I”. The power of RFT lies in its non-mentalistic and empirically driven explanations with the potential of addressing the problems inherent in the paradoxical nature of self. In combination with an elaborated relational repertoire, perspective taking can establish three types of self: 1) self as the content of verbal relations (i.e. the conceptualized self), 2) self as an ongoing process of verbal relations (i.e. the knowing self), and 3) self as the context of verbal relations (i.e. the observing self, or conscious self) (Hayes et al., 2001). Self as the content of verbal behavior is ubiquitous. The conceptualized self, which is the most readily accessible sense of self, is the descriptive and evaluative relational networks that we construct (e.g. I am a failure. I am a kind person, etc). This sense of self is well elaborated, multi-layered, and rigid (Hayes et al., 2001), because it touches upon every aspect of life, it is attached to strong social contingencies, and it is historical. Much of our socialization about what to do in life situations is tied to an ongoing process of verbal self-awareness (Hayes et al., 1999). The knowing self or self as process refers to awareness of and utilizing ongoing behavioral processes. Emotional talk is perhaps the best example. Finally, Self as context can be viewed as the purest aspect of self, the mere perspective from here and now with no content. If you ask many, many questions of a person, the only thing that will be consistent in not the content of the answers, but the context from which the answers occur. “I, Here, and Now” is the self that is left behind when all of the content differences are subtracted out (Hayes et al., 2001). Baumeister (1999) suggests that there might be a stable core to the self, but different parts or versions of the self are apparent in different circumstances. Self as context might be viewed as the stable core of the self as suggested by Baumeister (1999), which always remains the same regardless of aging, events or different experiences. It also mirrors what William James (James, 1980; James, 1982) referred to as the I-self, in contrast to the Me-self, the former showing more specific forms of awareness such as distinctness as a person and a sense of personal continuity through time. An important difference is though the James (1890) distinction between implicit and explicit levels of self-knowledge. Self as context according to RFT emerges with language while James’ I-self or the implicit self as it is referred to by contemporary scientist (e.g. Case, 1991) is basically not dependent on any conscious identification or recognition. Future infancy research might show the validity of such distinction, and whether what is attributed to implicit self can be qualified as an entity.

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Although no theories have yet succeeded to present a definition of the self that can be agreed upon universally, numerous scientists (e.g. Rosenberg, Baumeister, and Coopersmith) have spent years of research on the emergence and implication of self-concept, self-esteem and self-identity. Within social psychology, self-concept has been defined as “the individual’s belief about himself or herself, including the person’s attributes and who and what the self is” (Baumeister, 1999). Other social psychologist (e.g. Kihlstrom & Cantor, 1984; Markus, 1983) view the self as a multifaceted phenomenon, as a set of schemas, images, conceptions, prototypes, goals or tasks. Although there is a reasonable amount of information about how self-concept develops, there is still much to learn about the processes and mechanisms that form self-concept. Interestingly, as Baumeister (1999) observed: “When researchers set out to study self-concept, they usually end up studying self-esteem”. This is most probably due to difficulties in measuring self-concept, broad and imprecise definitions available, and the importance of self-esteem. Self-esteem refers to one's sense of worth or importance; it is an attitude-positive or negative-held about the self, and includes both cognitive and affective elements (Rosenberg, 1979). Self-esteem is thus the evaluative dimension of the self-concept (Baumeister, 1999). There is no question about the close relationship between self-esteem and self-concept. It has been shown that people with low self-esteem have more poorly defined self-concepts (Baumeister, 1993). Consequently, a critical element of healthy self-esteem is having realistic, clear self-concepts. A related concept is self-efficacy, which refers to one's sense of self-mastery, competence, or power (Bandura, 1977; Gecas, 1982; 1989). There is substantial evidence suggesting that self-esteem and self-efficacy are highly and positively interrelated (e.g., Gecas, 2001). That is, if a person increases his or her sense of competence, it is likely that this will also increase their sense of worth, and vice versa. Although many other interesting aspects of the self such as self-regulation and self-control might be regarded as more central and significant in predicting and influencing human behavior (Morf & Mischel, 2002; Strauman, 2002), the rest of this chapter focuses on the significance of selfesteem and its measurement. Any review of the literature on self esteem results in a large number of definitions of the term. Probably, one of the best definitions is provided by Robson (1989): Self-esteem can be defined as the sense of contentment and acceptance that results from a person's appraisal of one's own worth, attractiveness, competence, and ability to satisfy one's aspirations. The association between self-esteem and psychiatric disorders such as depression, psychosis, and eating disorders has been demonstrated in numerous studies (e.g. de-Man et al., 2001; Fairburn et al., 1999; Fairburn et al., 1997; Krabbendam et al., 2002; Miller et al., 1989; Vilhjalmsson et al., 1998). Consequently, accurate assessment of self-esteem is important, especially in prevention interventions and for identifying at risk groups, given the role of low self-esteem in the processes that set the scene for psychiatric disorders. On the other hand, critical reviews of the significance of self-esteem (e.g. Baumeister et al., 2003) has shown that there is only a modest correlation between self-esteem and school performance, and high selfesteem does not present children from smoking, drinking, taking drugs, etc. Baumeister and colleagues (2003) suggest that the benefits of high self-esteem fall into two categories: Enhanced initiative and pleasant feelings. Moreover, their literature review shows that although the effect of high self-esteem is negligible, one important exception exists: High self-esteem decreases the risk of bulimia among young women. Although there is already a widely used instrument for the assessment of self-esteem (i.e. Rosenberg’s self-esteem scale) it constitutes a one-dimensional scale that despite of the

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excellent psychometric properties does not capture the complexity of self-esteem. Assessing the inherent dimensions of self-esteem (i.e. the subjective sense of significance, worthiness, appearance and social acceptability, competence, resilience and determination, control over personal destiny, and value of existence) can improve the predictive power of the concept in clinical settings as well as the studies in the general population. Given the assumption above, an instrument capturing the complex nature of self-esteem is most desirable. Although the most common instrument for assessing self-esteem is the Rosenberg’s Scale for self-esteem (Rosenberg, 1979), a variety of other measures such as the Coopersmith SelfEsteem Inventory (Ahmed et al., 1985), and the Self-Rating Scale by Fleming and Courtney (1984) which is an outgrowth of the Feelings of Inadequacy Scale have also shown acceptable to good reliability and validity, and have been used in various studies. The Coopersmith Self-Esteem Inventory was designed to assess attitude toward oneself in general, and in various context such as peers, parents, school, and personal interests. There are two forms, a School Form (ages 8-15) and an Adult form (ages 16 and older) (Blascovich & Tomaka, 1991; Pervin, 1993). The respondents is asked to rate whether a set of 50 generally favorable or unfavorable aspects of a person are "like me" or "not like me". According to Blascovich and Tomaka (1991) it posses acceptable reliability (internal consistency and test-retest) and validity (convergent and discriminant). For systematic reviews of the well-known measures of self-esteem, the reader is recommended to sources such as Blascovich and Tomaka (1991), Fisher (1997), or Winter and colleagues (2002). In the following, the psychometric properties of the Self-concept Questionnaire (SCQ)((Robson, 1989) which was devised to address the shortcomings of the currently available scales of self-esteem, among others the Rosenberg’s scale will be described.

THE EMPIRICAL STUDY: INVESTIGATING THE PSYCHOMETRIC PROPERTIES OF THE SELF-CONCEPT QUESTIONNAIRE (SCQ)1 The SCQ is a self-report measure, consisting of 30 items (e.g., “I have control over my life,” “I feel emotionally mature,” “I can like myself even if others don’t”), and is designed to measure self-esteem (Robson, 1989). The selected name (i.e. self-concept questionnaire) might be misleading in making the reader think of a measure that captures self-concept. However, it focuses on only the evaluative aspect of the self-concept, which is self-esteem. Robson (1988) conducted a theoretical review, which resulted in identification of seven components of self-esteem that constituted the basis for the formulation of the questions in the SCQ. The scoring is performed on an eight-point scale, ranging from “completely disagree” to “completely agree.”The SCQ has proved to have good reliability (Cronbach’s alpha of .89) and high validity (clinical validity of .70) (Robson, 1989). One independent psychometric evaluation of the SCQ (Addeo et al., 1994) provided support for assuming the SCQ to be a reliable and valid instrument for assessing self-esteem. The reliability of the SCQ in terms of test-retest reliability and internal consistency would be investigated in the present study. Convergent and discriminative validity of the SCQ will be investigated by 1

The data, the tables and the core content of the empirical study are reproduced with permission from European Journal of Psychological Assessment, Vol. 21 (2), 2005, pp. 139-146. © 2005 by Hogrefe & Huber Publishers · Seattle · Toronto · Göttingen · Bern

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comparing the SCQ with other measures of self-esteem, and by analyzing its ability to distinguish different sub-samples of subjects along some criterion variables characterized by different levels of self-esteem. A replication of the Robson’s factor solution was not expected because self-esteem is a completely verbal construction. Its definition, apart from problems of arriving at a consensus in the scientific community, as discussed by Robson (Robson, 1988), is highly dependent on verbal behavior (Hayes et al., 2001) and social norms (Wells & Marwell, 1976) in each society. This should per definition result in at least some differences in different contexts (i.e. languages and societies). However, it was expected that major parts of the factor solution by Robson be reproduced if the instrument is to be regarded as a valid measure of a construction that can be used in scientific contexts. Given the assumptions above, and methodological issues, confirmatory factor analysis was not used.

METHOD Participants A number of questionnaires were administered to the following three samples: 1) a nationwide representative sample of 826 women between the ages of 18 and 30 that were assessed twice, with a two-years interval, 2) a clinical sample (n=43), consisting of patients with bulimia nervosa and eating disorders not otherwise specified, and 3) a non-clinical sample of undergraduate psychology students (n=124). The national sample was recruited for a longitudinal study on the risk factors for the development of eating disorders. As it has been previously shown (Ghaderi & Scott, 1999), this sample can be considered as representative for women between 18 and 30 years in Sweden. The characteristics of this sample are shown in Table 1. The clinical sample consisted of 43 women who were recruited for participation in a study examining the efficacy of pure and guided self-help for bulimia nervosa and eating disorders not otherwise specified (see Table 1). The student sample consisted of 124 students (81% females, and 19% males) recruited from the master’s program for clinical psychology. The characteristics of the sample are shown in Table 1. The students’ BMI was determined from self-reported height and weight. Validity of self-reported measures of height and weight has been confirmed against anthropometric measures (Whitaker et al., 1990).

Measures Self-Concept Questionnaire (SCQ) As mentioned earlier, the SCQ is a self-report measure, consisting of 30 items, and designed to measure self-esteem (Robson, 1989). The SCQ has proved to have good reliability (Cronbach’s alpha of .89) and good validity (clinical validity of .70, i.e. the correlation between the scores on the SCQ and estimates of self-esteem made by experienced clinicians on a 10-point visual analog scale for a sample of psychiatric patients)(Robson, 1989). The SCQ was translated into Swedish and then back translated into English in order to

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obtain accuracy in the translation. After the re-translation into English and some minor changes, the translated questionnaire seemed to measure the same constructs. Table 1. Demographic characteristics of the samples.

Age: mean (SD) Marital status Married Divorced/separated Living together Single Education Primary school, uncompleted Primary school, completed High school Vocational education College/university Occupation Employed Student/at school Unemployed On sick pay/other Diagnoses Bulimia nervosa EDNOS* BMI: mean (SD)

Nationwide sample, T1 N=826 % (n)

Nationwide sample, T2 N=826 % (n)

Clinical sample N=43 % (n)

Student sample N=124 % (n)

23.7 (3.7)

25.6 (3.7)

27.1 (9.9)

28.8 (6.3)

12.5 (103) 1.1 (9) 40.2 (332) 46.3 (382)

16.3 (134) 1.7 (14) 42.5 (349) 39.5 (324)

9 (4) 2 (1) 19 (8) 70 (30)

18 (22) 3 (4) 27 (33) 53 (65)

3.27 (27)

.4 (3)

2 (1)

-

13.56 (112)

6.2 (51)

14 (6)

-

64.89 (536) 3.27 (27) 15.01 (124)

65.7 (539) 4.3 (35) 23.5 (193)

63 (27) 5 (2) 16 (7)

80 (99) 20 (25)

42.9 (354) 42.0 (347) 13.2 (109) 2 (16)

58.7 (485) 30.4 (251) 9.6 (79) 1.3 (11)

21 (9) 63 (27) 7 (3) 9 (4)

100 (100) -

1.7 (14) 0.9 (7) 22.6 (3.8)

1.33 (11) 1.81 (15) 23.1 (4.2)

11 (26) 32 (74) 24,5 (5.9)

1.6 (2) 2.4 (3) 22.2 (4.1)

*

EDNOS: Eating disorders not otherwise specified (i.e., subthreshold bulimia nervosa and anorexia nervosa, binge eating disorder and subthreshold binge eating disorder).

Rosenberg Self-Esteem Scale (RSE) As it has been explained earlier, the RSE scale is a widely used instrument for measuring global self-esteem. It consists of 10 items with a four-point response scale, from strongly agree to strongly disagree. The RSE yields a 7-point scale (0-6) with higher scores indicating lower self-esteem. The RSE was chosen as a standard measure of self-esteem given its excellent psychometric properties (Kernis et al., 1989; Rosenberg, 1979) and critical reviews (e.g. Blascovich & Tomaka, 1991) confirming this assertion . Eating Disorders Inventory-2 (EDI-2) The EDI-2 is a widely used self-report measure of symptoms of eating disorders. It consists of 91 questions, 64 of which are from the original version of the EDI (Garner et al., 1984) that provides standardized subscales on eight dimensions that are clinically relevant to

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ED. The additional 27 items adds three new constructs that form the EDI provisional subscales (Garner, 1991). The questions are answered on a 6-point scale from always to never. Item examples are “I feel ineffective in the world“, “I eat when I am upset“, and “I feel inadequate”. The Swedish version of the EDI has been validated (Norring & Sohlberg, 1988) and normative information for the Swedish population of students and patients is available. The reliability and validity of the EDI has been established in several studies, and corroborated in Swedish studies (Nevonen & Broberg, 2001; Norring & Sohlberg, 1988). In the present study, as in the Swedish validation studies, the participants' responses to the EDI were scored according to the instructions in the original manual (Garner et al., 1983), by which the most pathological responses scores 3 points, the adjacent response scores 2, and the next 1, with the remaining three scoring 0 points. The ineffectiveness subscale of the EDI-2 was used to assess the validity of the SCQ.

Eating Disorders Examination (EDE) The EDE (Cooper & Fairburn, 1987; Fairburn & Cooper, 1993) that is considered to be the gold standard for assessing specific psychopathology of eating disorders (Fairburn & Beglin, 1994; Rosen et al., 1990; Wilson & Smith, 1989) is a semi-structured interview that assesses the two key behavioral aspects of eating disorders and provides operationally defined eating disorder diagnoses. The EDE was used to establish the diagnoses for the clinical sample. The EDE measures the severity of the characteristic psychopathology of eating disorders including frequency of objective binge eating, purging behavior (self-induced vomiting, laxative or diuretic use or excessive training), dietary restraint, and concerns about weight and shape.

Procedure A composite of questionnaires, including the SCQ, was sent out to the participants in the national sample. They were asked to participate in a nationwide study on risk factors for eating disorders and to fill in and return the questionnaires to the authors. They were also informed that they would be followed up after two years. Thus the sample responded twice to the SCQ. In the clinical sample, several questionnaires including the SCQ, and EDI-2, were sent out to the potential participants in the treatment studies, after a comprehensive phone screening. When the questionnaires were filled in and returned, the patients were then scheduled for an assessment interview by means of the Eating Disorder Examination (EDE) to establish the eating disorders diagnoses. Those who did not fulfill the diagnostic criteria for bulimia nervosa or eating disorders not otherwise specified according to the DSM-IV (American Psychiatric Association, 1994)(i.e. subthreshold bulimia nervosa and anorexia nervosa and threshold and subthreshold binge eating disorder) were then excluded. In the student sample, the students were given course credits for anonymously responding to a composite of questionnaires, including the SCQ that would be followed by another set of questionnaires after 2 weeks. The first set of the questionnaire were returned by 144 students, and 124 of them responded again to the second.

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Statistical Analyses Principal component analysis was used to examine the factor structure of the SCQ. In addition to investigating the results of the Scree test and Kaiser-Guttman Criterion for deciding on the number of factors to extract, parallel analysis (Horn, 1965; Glorfeld, 1005) was applied using SPSS syntax suggested by O’Conner (2000). To assess the test-retest reliability, the students’ responses to the SCQ at the two time points were compared using Pearson’s correlation, and t-test. Pearson’s correlation was used to test the convergence between the SCQ and the ineffectiveness subscale of the EDI-2, and Rosenberg’s self-esteem scale. Internal consistency was measured using Cronbach’s alpha.

RESULTS Factor Structure of the SCQ A principal component analysis (PCA) was conducted on the data from first wave of the nationwide sample. It resulted in six factors, indicated by the Scree test and the Kaiser Criterion (i.e. only factors with eigenvalues greater than 1 were retained). However, only one item (No. 6: I am not embarrassed to let people know my opinion) loaded on the sixth factor. Consequently, it was removed, and the five-factor solution, which is the best interpretable solution, was retained. Then the communalities based on the five-factor solution and the 2 corresponding multiple R for each item was investigated in order to see whether there were 2 any instances where the R was high and the corresponding communality was low. This would suggest the need to retain one or more additional factors. However, this was not the case for any of the items. These 5 factors together explained 45.8% of the variance. Parallel analysis also suggested a five-factor solution as most appropriate. It should be mentioned, however, that the eigenvalues in item-level raw data based on dichotomous or Likert response scales cannot be meaningfully compared to the eigenvalues from parallel analyses based on normally distributed random numbers. Instead, one should determine the number of factors or components by first finding the eigenvalues for the raw-data matrix of tetrachoric or polychoric correlations, and then compare these eigenvalues to those that are produced by the computer-generated random data (O’Connor, 2000). Consequently, the subsequent factor analysis should be conducted on the raw-data matrix of tetrachoric or polychoric correlations and not on Pearson correlations. However, since the parallel analysis resulted in the same factor solution as the Kaiser criterion, the PCA was carried on using standard procedures. Using the varimax orthogonal rotation, each items loaded heavily on one single factor, and low on other factors. The factor loadings for the rotated factor structure of the SCQ items are presented in Table 2. As seen on Table 2, the first factor, named “Contentment and worthiness” embraces five of the six items that were part of the same factor in the factor analysis made by Robson (Robson, 2002) who constructed the SCQ. The content of the other three items that loaded on this first factor focuses on contentment and worthiness.

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Table 2. Factor pattern loadings of the five-factor orthogonal rotation (n=729, case-wise deletion). Items SCQ 5* SCQ17* SCQ18 SCQ19* SCQ21* SCQ26 SCQ27* SCQ29 SCQ 2* SCQ 9* SCQ15* SCQ23* SCQ30* SCQ11 SCQ13 SCQ14 SCQ22 SCQ 1 SCQ 3 SCQ 4* SCQ 7* SCQ 8* SCQ10 SCQ20* SCQ24 SCQ25* SCQ28

SCQ12 SCQ16 Variance

Factor 1: Contentment and worthiness There are lots of things I’d change about myself if I could. I often feel humiliated. I can usually make up my mind and stick to it. Everyone else seems much more confidant and contented than me. I often worry about what other people are thinking about me. I feel emotionally mature. When people criticize me I often feel helpless and second-rate. I can like myself even when others don’t. Factor 2: Attractiveness, approval by others I’m easy to like. Most people find me reasonably attractive. I have a pleasant personality. I look awful these days. Those who know me well are fond of me. Factor 3: Determinism and significance Most people would take advantage of me if they could. It would be boring if I talked about myself. When I am successful, there’s usually a lot of luck involved. There’s a lot of truth in saying “what will be, will be”. Factor 4: Confidence and value of existence I have control over my own life. I never feel down in the dumps for very long. I can never seem to achieve anything worthwhile. I don’t care what happens to me. I seem to be very unlucky. I’m glad I am who I am. Even when I quite enjoy myself there doesn’t seem much purpose to it all. If I really try, I can overcome most of my problems. It’s pretty tough to be me. When progress is difficult, I often find myself thinking it’s not worth the effort. Factor 5: Resilience I am a reliable person. If a task is difficult that just makes me all the more determined.

F1

Factor loadings F2 F3 F4

F5

-.52

.32

.11

-.27

.16

-.41 .57 -.57

-.13 .01 -.24

-.33 .12 -.31

.33 .14 .32

.06 .26 -.06

-.67

-.15

-.25

.15

.06

.36 -.67

-.15 -.08

-.01 -.21

.23 .18

.30 .19

.57

-.17

.06

.29

.01

-.00 .18 .11 .29 .18

.57 .70 .68 -.44 .52

-.13 -.03 -.09 -.22 -.03

.19 .01 .18 .34 .19

.28 -.19 .24 -.20 .25

.06 .24 .15

-.07 -.23 -.25

-.47 -.51 -.60

.21 .03 .08

.36 -.01 .12

-.03

.15

-.62

.09

.01

.23 .27 .27 -.10 .08 .34 .23

-.24 .00 -.26 -.22 -.10 -.41 -.11

-.02 .08 -.39 -.25 -.38 -.08 -.18

-.63 -.62 .52 .58 .53 -.54 .69

.13 .06 .04 .16 -.12 .07 .10

.12 .44 .25

-.10 -.12 .02

.11 -.09 -.24

-.48 .51 .56

.16 -.04 .09

-.03 .29

-.18 -.03

-.09 -.04

.11 .04

-.71 -.49

.12

.09

.07

.13

.05

Items marked with * were reported to load on the same factor in the factor analysis conducted by Robson Robson (2002).

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The second factor was named “Attractiveness and approval by others” since it consisted of exactly the same items as those loading on a corresponding factor in the analysis by Robson. The third factor is a new constellation, named “Determinism”. It consists of four items, of which 2 were item 14 and 22 that were omitted in the factor analysis by Robson. In constructing the SCQ, Robson (Robson, 1989) gathered questions that were supposed to be part of the following seven domains of self-esteem: 1-subjective sense of significance, 2worthiness, 3- appearance and social acceptability, 4-competence, 5- resilience and determination, 6- control over personal destiny, and 7-the value of existence. Item 14 (When I am successful, there’s usually a lot of luck involved) and 22 (There’s a lot of truth in saying “what will be, will be”) that load on factor three are typical examples of deterministic thinking while items 11 and 14 are more ambiguous. The fourth factor was called “Confidence and value of existence” because five (items 4, 7, 8, 20, and 25) of the six items that loaded on a similar factor (Value of existence) in a previous analysis (Robson, 2002) were present on this factor. The other items loading on this factor are about control and confidence. The last factor consisted of item 12 (I am a reliable person) and 16 (If a task is difficult that just makes me all the more determined). This factor was named Resilience.

Validation of the Factor Structure of the SCQ In order to validate the resulted factor structure, the analysis was repeated with the same sample that was followed up after two years (n=826), and first and second half of these samples, as well as the student sample (n=124) that was assessed twice with 3 weeks in between. The principal component analyses resulted in 6 factors again with the population sample, with the last factor consisting of one single item as in the previous first analysis. The factor analyses in the student sample resulted in 5 factors. Across these validation analyses, almost all of the items loaded on the same factors. The exceptions concerned item 6 (I am not embarrassed to let people know my opinion), item 13 (It would be boring if I talked about myself), item 17 (I feel often humiliated), and item 26 (I feel emotionally mature). These items loaded often moderately on several factors, which is not surprising given their content.

Intercorrelations between Factors The intercorrelations between the factors and the SCQ total score showed moderate to high correlations between the factors and the SCQ total score, with the exception of second factor, while the factors correlated modestly to moderately with each other (Table 3). Although the second factor (i.e. attractiveness and approval by others) showed to be consistently reproducible in the validating factor analyses (i.e. analysis on the first or second half of the same sample, and other samples) the correlation between factor 2 and the total SCQ remained at moderate level (.32-.38). As Table 3 shows, all the factors of the SCQ correlate negatively with the RSE as expected, with zero order correlation ranging from -.25 to -.78. A similar pattern of correlations emerged when the correlations

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between the SCQ factors and the ineffectiveness subscale of the EDI (also measuring self-esteem) were calculated. The correlations between the factors of the SCQ with the RSE and the Ineffectiveness subscale of the EDI were very similar in the second wave of the assessment in the student sample. Table 3. Intercorrelations between the factors and the SCQ sum total.

Factor 1 Factor 2 Factor 3 Factor 4 Factor 5

SCQ (total) -.59 .34 -.62 -.50 .42

Factor 1

Factor 2

Factor 3

Factor 4

-.14 .41 .35 -.14

-.13 -.06 .23

.40 -.21

-.12

The Reliability of SCQ The students’ responses to the SCQ on both occasions were highly correlated r= .89 (P<.0001). It was also checked by means of t-test, which showed no significant difference (t(123)=-.80, P=.43) between the SCQ total scores from the first and second assessment point. The SCQ showed high homogeneity (Cronbach’s alpha .89) in the first wave of the national sample, and the corresponding value when participants were followed up (after two years) was .91. In the student sample, the alpha was .86 and .89, respectively for the first and second set of questionnaires answered by the students. In the clinical sample (n=43) the alpha was .83.

Validity of the SCQ The SCQ total scores from both the first and second set of questionnaires in the student sample were used to study the convergent validity of the SCQ, by examining the correlation between the SCQ and the Rosenberg’s self-esteeem scale (RSE). The Pearson correlation coefficient were r=-.65 (P<.0001) and r=-.80 (P<.0001) respectively. The corresponding correlation in the clinical sample (n=43) was -.81 (P<.001). In addition, the relation between the SCQ and the ineffectiveness subscale of the EDI in the student sample, and the clinical sample were also high: r=-.80, (P<.001), and r=-.78, (P<.001), respectively. A large number of empirical studies have shown that individuals with eating disorders report lower self-esteem compared to controls (e.g Akan & Grilo, 1995; Button et al., 1996; Silverstone, 1990; Walters & Kendler, 1995). Evidence of the discriminant validity of the SCQ can be shown in differences in the SCQ scores between the clinical and non-clinical groups. In the national study, those who met the diagnostic criteria for eating disorders (n=24) had significantly (F(1,993)=27.0, P=.0000003) lower scores on the SCQ (M=130, SD=22.5) compared to those without eating disorders (M=152, SD=20.4) (Ghaderi & Scott, 1999). The mean SCQ for the clinical sample in the present study was 125 (SD=20.8), while the mean for the student sample was 155 (SD=18.3) at the first assessment point, and 156 (SD=19.4) when they were reassessed.

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CONCLUSION The results from the present study lend support for the reliability and validity of the Swedish version of the SCQ. The factor analyses clearly showed that the SCQ comprises several factors, and that a five-factor solution seems to be a reproducible and meaningful constellation. The five-factor solution accounted for 46% of the variance. The outcome resembles the findings from the factor analysis by the constructer of the SCQ (Robson, 2002). The only independent study of the SCQ has been done by Addeo and colleagues (Addeo et al., 1994). The factor analysis by Addeo resulted in 3 factors that are largely in line with those factors extracted by Robson. Both Robson (1989), and Addeo and colleagues (1994) conducted a maximum likelihood factor analysis with oblimin (oblique) and equamax (orthogonal) rotations. In the present study, the first factor contained 5 of the 6 items that were part of the “Contentment and worthiness” factor in Robsons analysis, and several of them are in the corresponding factor in the study by Addeo et al. (1994). The second factor, “Attractiveness and approval by others”, converged completely with Robson’s analysis. The third factor, named “Determinism”, was a new factor. However, Robson chose items from seven domains of self-esteem, one of which was determinism. Especially, items 14 and 22 in this third factor do load on an own factor consistently when the replicability of the factor solution has been examined repeatedly. In the fourth factor, labeled “Confidence and value of existence”, five of the six items from the “Value of existence” in the factor solution by Robson are included, as well as several items that were part of the “Competence” factor and “Autonomous self-regard” in Robson’s analysis. Finally, the last factor consists of only two items, of which the item 16 was the most robust one in validation analyses. Because of the content of it, the factor was labeled “Resilience”. When compared to the findings by Robson (2002) and Addeo, et al. (1994), the present factor structure seems to be a meaningful solution given the content of the items on each factor. As mentioned previously, some of the items were less consistent in the validating factor analyses, but the nature of the content of these items makes them vague. This might explain the inconsistency of these items in factor analyses, and the relatively moderate loading of these items on several factors in different analyses. Furthermore, inconsistent results could be due to different rotation criteria as well. The SCQ showed high convergent and discriminative validity as seen by the correlation between the SCQ and the RSE, and the ineffectiveness subscale of the EDI as well as the distinct differences in SCQ total scores between the clinical and non-clinical sample. In the study by Robson (1989), the correlation between the SCQ and the RSE in the clinical sample was .85. Addeo et al (1994) reported a correlation of .84 among students. In the present study the corresponding correlation in the clinical sample was-.81 (the negative sign is because the original version of the RSE and coding was used where high scores indicate low self-esteem). In the student sample the correlation observed was between -.65 and -.80. Furthermore, the SCQ clearly differentiated the group of participants with and without eating disorders as seen from the results of the nationwide study. The pattern of the intercorrelations of the dimensions of the SCQ in the nationwide sample suggests that the dimensions posses a moderate level of differential construct validity.

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Finally, the SCQ showed high reliability as shown by high test-retest reliability and internal consistency in terms of Chronbach’s alpha. The available data from the present and other studies support the conclusion that selfesteem is composed of several dimensions, and that SCQ is a reliable and valid instrument for assessing self-esteem. In summary, the findings confirm that the Swedish version of the SCQ possesses good psychometric properties and thereby, it is recommended for assessing self-esteem, both in clinical settings, and in the studies in the general population. In clinical contexts, the multidimensional screening and evaluation of self-esteem might be more valuable than a unidimensional assessment, especially in order to assess the possible treatment effects and in conducting mediational analyses. Rosenberg’s scale is, on the other hand, easy to administer and provides a robust and general rating of the individual’s self-esteem. The choice of instrument for assessing self-esteem should be based on not only the psychometric properties of the scales available, but also the context and aim of the study.

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In: Advances in Psychology Research, Volume 44 Editor: Alexandra Columbus, pp. 87-112

ISBN 1-60021-150-X © 2006 Nova Science Publishers, Inc.

Chapter 6

HANGING OUT OR HANGING IN?: YOUNG FEMALES’ SOCIOEMOTIONAL FUNCTIONING AND THE CHANGING MOTIVES FOR DATING AND ROMANCE Melanie J. Zimmer-Gembeck∗ and Karen J. Gallaty Griffith University – Gold Coast, Queensland, Australia

ABSTRACT Drawing from recent theories of the development of heterosexual romantic relationships during adolescence and emerging adulthood, the associations among females’ socioemotional functioning (positive well-being, negative affect, loneliness), romantic affiliation and support, and qualities of relationships with family and best female friends were investigated. Female participants completed assessments at ages 18, 20 and 23. As predicted, age-related differences in associations between females’ socioemotional functioning and aspects of romantic relationships were found. After adjusting for the quality of relationships with family and best friends at each age, findings showed that an estimate of the amount of time spent (i.e., affiliation) with romantic partners was associated with only one aspect of socioemotional functioning at age 18 (reduced loneliness), but at age 20, more romantic affiliation was associated with all three aspects of socioemotional functioning, including better psychological well-being and reduced negative affect and loneliness. In addition, quality of relationships with family and best female friends significantly covaried with socioemotional functioning at age 18, but not at age 20. In contrast to the findings for romantic affiliation, only one of aspect of females’ socioemotional functioning at age 20 - positive well-being – was improved with higher levels of romantic support (e.g., intimacy and nurturance). However, a higher level of romantic support at age 23 was accompanied by more positive well-being, and reduced negative affect and loneliness. These age-related associations among romantic affiliation, ∗

School of Psychology, Griffith University-Gold Coast Campus, PMB50 GCMC, QLD 9726 AUSTRALIA, [email protected].

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Melanie J. Zimmer-Gembeck and Karen J. Gallaty romantic support and socioemotional functioning suggest that girls most salient motivation for romance at each age is largely associated with their socioemotional functioning at that age. At age 18 and 20, affiliation – someone to spend time with - is the most salient motivation for romantic involvement, while at age 23 the motivation for romance has shifted to intimacy, support and security. These findings are consistent with recent theories of qualitative changes in romance from early adolescence to emerging adulthood (Brown, 1999; Connolly & Goldberg, 1999), but show that romantic support, apart from family and friend support, may provide independent benefits for individual functioning somewhat later than expected.

Keywords: romantic relationships, loneliness, psychological well-being, dating, friendship

INTRODUCTION Recently, Friends, the popular U.S. television show, ended after a decade. Many, if not most, of the 20 million plus viewers began watching this weekly show in their teens. As the show continued year after year, these viewers went through late adolescence, emerging adulthood and were young adults by the last year of this series. Just as the characters on Friends made many social transitions throughout their years of the show, recent theories (Brown, 1999; Connolly & Goldberg, 1999) have described how middle and late adolescents focus on affiliation with friends and dating -- hanging out, having fun, doing things together, meeting new people. As they get older, maintaining close friendships remains important, but there is increasing emphasis on intimacy, commitment and close dyadic relationships with romantic partners – having a partner who is committed and a source of security – someone who hangs in there during good and bad times. In fact, recent research has supported this developmental progression. In reviews of developmental studies conducted in recent years, authors have concluded that there are age-related changes in friendships and heterosexual romantic relationships during adolescence and emerging adulthood that support the generalization of these observed changes (Brown, 1999; Collins, 2003; Connolly & Goldberg, 1999; Shulman & Seiffge-Krenke, 2001; Zimmer-Gembeck, 1999). In the romantic domain, romantic affection and commitment that comes with an increase in motives for intimacy with another become more salient during emerging adulthood (age 18 to 25; Arnett, 2000), while the affiliative motives that inspire romantic relationships in the earlier years of adolescence (perhaps prior to age 20 or so) decline with age. Authors of two recent reviews of the empirical literature have proposed stage theories of heterosexual romantic relationship development that reflect these changes (Brown, 1999; Connolly & Goldberg, 1999). It is clear that the nature of romantic relationships changes during the age periods of adolescence and emerging adulthood, and it is likely that the motives for relationship formation also show age changes. Romantic involvements are one type of interpersonal relationship that becomes increasingly important in adolescence and emerging adulthood (Larson et al., 1999). For example, more time is spent with romantic partners in late adolescence (age 18 and after) than in middle or earlier adolescence (Zimmer-Gembeck, 1999), adolescent romantic experiences can be less defined as they may be casual and relatively shorter when compared to young adult romance (Feiring, 1996), and a focus on the future and commitment in relationships increase with age (Furman, Brown, & Feiring, 1999;

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Collins, 2003). However, there has been no investigation of whether the motives of romantic relationships and the different aspects of romantic involvement that come from these motives within each age period are the most important correlates of socioemotional functioning at that age. The aim of the study reported in this chapter was to determine whether particular qualities of romantic relationships that reflect and fulfill the most salient motives of a particular age period would be predictive of psychosocial well-being, negative affect and loneliness within the same age period.

FEMALES, GENDER DIFFERENCES, SOCIOEMOTIONAL FUNCTIONING, AND RELATIONSHIPS The participants in the current study were young females followed forward from age 18 to 23. Only females were included because of the focus in this study on negative affect, wellbeing, and interpersonal relationships with romantic partners, friends, and family. There is evidence that females have more difficulties with depressive affect and reduced socioemotional well-being during adolescence and emerging adulthood when compared to males. In addition, females may be more vulnerable to interpersonal problems than males, and the meaning of romantic relationships in adolescence and emerging adulthood may be different for girls compared to boys. There have been many reports of adolescent sex differences in negative affect and other aspects of well-being. At about the same age that interests in romantic relationships increase, rates of depressive symptoms rise, and this increase is especially prominent among girls (Nolen-Hoeksema, 2001). By adolescence, females have higher rates of depression than males, and multiple theories link these gender differences to females’ greater exposure to interpersonal stress and elevated reactivity to these stressors when they occur (e.g., Cicchetti & Toth, 1998; Crick & Zahn-Waxler, 2003; Nolen-Hoeksema, 2001; Rudolph, 2002). Girls do seem to be more likely than boys to respond negatively to interpersonal stress (Crick & Nelson, 2002; see Rudolph, 2002 for a review). Hence, compared to males, the well-being of females is more likely to be negatively influenced by the difficulties and positive support within romantic relationships during adolescence and emerging adulthood. For example, in one longitudinal study that followed young people from age 12 to 16, romantic relationships were more strongly associated with changes in functioning among girls than boys (ZimmerGembeck, Siebenbruner, & Collins, 2001) and a study relying on a U.S. national sample (AddHealth) also found that the well-being of girls was more negatively affected by romantic involvement (Joyner & Udry, 2000). Additionally, during the adolescent years, the nature of close relationships for females and males has been found to differ. Although limited information is available, some studies have reported that females are more likely to be involved with older romantic partners, while males are often involved with same age females until late adolescence when they begin to have romantic partners who are younger in age (Carver, Joyner, & Udry, 2003; Larson, Wilson, Brown, Furstenberg, Jr., & Verma, 2002). On average, adolescent girls report longer romantic relationships than boys (Carver et al., 2003). Females have also reported more interest in romantic involvements, and more intimacy and commitment with their romantic partners when compared to same age males (Buhrmester & Furman, 1987; Carver et al.,

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2003; Lempers & Clark-Lempers, 1993). Also, gender differences in the association between friendship and self-esteem have been reported (Azmitia, 2002; Franco & Levitt, 1998). In one cross-sectional study of students in grades 11 and 12 (Thomas & Daubman, 2001), qualities of girls’ relationships with friends were associated with their self-esteem, but there was no association between qualities of males’ friendships and their self-esteem. In this study, it also was revealed that girls had significantly lower self-esteem than boys, and girls rated their relationships as stronger, more interpersonally rewarding, and more stressful than boys did. Further, girl’s self-esteem was positively correlated with the quality of their cross-gender best friend, however self-esteem was not correlated with the quality of their same-gender friendship. For boys, self-esteem did not correlate with the quality of their same or cross gender best friendships. Overall, females may be more vulnerable to negative relational experiences, but they also may benefit more from closeness and intimacy. Further, this study highlighted the importance of cross-gender relationships particularly for adolescent girl’s self-esteem. At least three explanations have been proposed to account for the greater vulnerability to the negative features of interpersonal relationships among females as compared to males. First, girls are more likely to be socialized to value relationships and connectedness while males are more likely to be socialized to value individuality and self-reliance (Gilligan, 1982; Thomas & Daubman, 2001). Hence, girls may attend to and place more importance on relationships. When these relationships are supportive or stressful, the impact may be greater for females than males because of these gender differences in salience. Second, girls’ selfesteem may be more dependent on approval from others (Franco & Levitt, 1998), as girls have been found to use relationships to define themselves more than males (Thomas & Daubman, 2001). Third, females typically report greater closeness, exclusivity, and intimacy in their friendships and hold higher expectations of loyalty and commitment than do males (Azmitia, 2002; Franco & Levitt, 1998). This may result in girls experiencing more dyadic stress and support within very intimate relationships than boys.

HETEROSEXUAL ROMANTIC RELATIONSHIPS DURING ADOLESCENCE AND EMERGING ADULTHOOD The majority of young people have their first steady romantic relationship between the ages of 13 and 18 (Collins, 2003; Furman et al., 1999; Zimmer-Gembeck, 1999, 2002). Romantic relationships are very important to most young people. In one study, adolescents were more likely to attribute strong emotions, such as depression and happiness, to romantic relationships than to school or family (Larson, Clore, & Wood, 1999). Further, even at age 17-18, romantic relationships often last longer than 6 months, with more than 50% continuing for 11 months or longer (Carver et al., 2003; Zimmer-Gembeck, 1999). Dating and romantic relationships represent a major developmental marker in adolescence (Adams, Laursen & Wilder, 2001; Quatman, Sampson, Robinson & Watson, 2001; Shulman & Kipnis, 2001). In eleventh and twelfth grade, adolescents think about romantic relationships on average five to eight hours a week (Richards et al., 1998). In addition to this time spent thinking, older adolescent girls spend about 10 hours/week with a boy, while older adolescent boys spend about 5 hours/week with a girl (Richards et al., 1998).

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By tenth grade, those with romantic partners report social interaction to be most frequent with romantic partners, over and above interaction with parents, friends, and siblings. Young people also perceive their romantic relationships as one of the most influential and closest relationships that they have (Laursen & Williams, 1997). These statistics underscore the salience of romantic relationships for many adolescents even by age 16-18.

Functions and Risks of Romance There are many functions of dating and romantic relationships during adolescence and emerging adulthood. In classic studies, relationship functions were identified, such as recreation, socialization, status achievement, intimacy, companionship, sexual experimentation, and mate selection (McCabe, 1984; Rice, 1984; Skipper & Nass, 1966). Furman and Buhrmester (1992) emphasized the function of providing a source of support, and found that romantic partners become significant sources of support by the late teens or early 20s (university age). Among emerging adults (aged 20 years), romantic love has been found to consist of closeness, friendship, affection, support, attraction and sexual intimacy (Seiffge-Krenke, Shulman and Klessinger, 2001). Evidence has indicated that adolescents regard the influence of romantic relationships as equal to that of parent-child relationships and greater than that of friendships (Adams et al., 2001). Adolescent romantic relationships offer opportunities to develop interdependent interconnections, a description used to define the term closeness (Adams et al., 2001). Conversely, romantic partners may be a source of stress, conflict and other negative interactions, especially as young people get older and increasingly depend on a partner as a source of intimacy and support (Joyner & Udry, 2000; Kasian & Painter, 1992; Nieder & Seiffge-Krenke, 2001). Romantic partners also function as a source of affiliation and companionship – someone to do things with either alone or in a friendship group (Brown, 1999), especially in the teen years. Romantic interests are also associated with much emotional upheaval (Larson, Clore, & Wood, 1999). Adolescents tend to report higher rates of both extremely positive and extremely negative emotions than adults and from hour to hour, adolescents experience wide variability in their emotional states (Larson & Richards, 1994; Larson, Clore & Wood, 1999). These highly variable emotional states have been linked to romantic relationships, with two studies using diary methods finding that those who had a boyfriend or girlfriend during the week of sampling reported wider daily emotional swings than those who did not (Larson et al., 1980; Richards & Larson, 1990). In another study by Richards et al., (1998) adolescents in the company of the opposite sex had moods that were more positive, reporting that they felt more attractive, great, and more important than when with their same sex peers. In contrast, when not with members of the other sex, adolescents reported less favorable moods and had lowered emotional and motivational states due to dysphoria associated with missing and longing for the person not with them (Richards et al., 1998). In terms of mental health then, it is not surprising that romantic relationships can be a context for positive functioning and support, as well as maladaptation. While some developmental models have underscored the potential risk dating poses for adolescent development and well-being (Cauffman & Steinberg, 1996; Wright, 1982), others have characterized dating as a critical stage-salient task that provides a healthy forum for fostering interpersonal skills and competence (Feiring, 1996; McCabe, 1984; Samet & Kelly, 1987;

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Sullivan, 1953). Furthermore, relatively few studies (e.g., Davies & Windle, 2000; ZimmerGembeck et al., 2001) have integrated the positive and negative perspectives on the association between dating and psychosocial functioning. Assessments of negative and positive functioning were included in the current study.

Theories of Romantic Development during Adolescence and Emerging Adulthood Theories (Brown, 1999; Connolly & Goldberg, 1999) have described how the primary purpose of romantic relationships in the middle and late teen years may be affiliation rather than the provision of support and security. Brown (1999) theorized that in the late teen years, most adolescents are in one of two romantic development phases. He labeled these two phases as status and affection. Similarly, Connolly and Goldberg (1999) labeled similar phases affiliative and intimate. Early in romantic development (i.e., in the status / affiliation phase), young people would be expected to have either fairly superficial romantic relationships that revolve around affiliation and group activities or begin to take initial steps to develop more sustained relationships with greater affection and intimacy. However, in either case, relationships in these stages are not marked by long-term commitments and attachment formation. As such, romantic relationships in the late teen years would not be expected to replace the support of parents and friends, but may be most important because of the capacity to promote and maintain positive relationships within the friendship group, while providing an additional source of status and companionship (Connolly, Furman, & Konarski, 2000). In the current study, it was expected that romantic relationships in the late teen years (i.e., age 18 in the current study) would fulfill affiliative rather than intimacy motives. Therefore, it was not expected that support by romantic partners (e.g., intimacy and nurturance), would be associated with well-being after accounting for support from family members and same-sex friends. In contrast, a marker of affiliation, time spent with romantic partners, was expected to be associated with well-being at age 18 even after accounting for qualities of other relationships with family and friends. Romantic interests and involvements progress during adolescence and emerging adulthood until they eventually come to more closely resemble adult romantic attachments (Furman et al., 1999). Brown (1999) has labeled this last phase of romantic relationship development the bonding phase. He proposed that later marriage (on average age 25 to 27) has pushed the bonding phase back to the emerging adult years (about age 23-25; see also Larson et al., 2002). Similarly, Connolly and Goldberg (1999) called this the committed phase. Among individuals in committed relationships, satisfaction with the couple relationship has been associated with the provision of social support, and, in turn, support from partners has been associated with better individual mental and physical well-being (see reviews by Burman & Margolin, 1992; De Jong-Giervald, 1986). In the current study, an association between these positive qualities in romantic relationships and well-being was expected to emerge by age 23 even after accounting for relationships with family and friends. As affiliation motives were anticipated to be less prominent with increasing age, the importance of time spent with romantic partners for well-being was predicted to decline by age 23.

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SOCIOEMOTIONAL FUNCTIONING AND RELATIONSHIPS WITH PARTNERS, FAMILY AND FRIENDS Romantic Relationships Negative affect is one aspect of well-being that was assessed in the current study. The emotions of adolescent romance have been associated with depressive symptoms (Joyner & Udry, 2001; Monroe et al., 1999). Two short-term (approximately 1-year) longitudinal studies of adolescent affective functioning identified romantic relationships, especially romantic dissolution, as interpersonal stressors that directly influenced depressive symptoms (Joyner & Udry, 2001) and predicted the onset of new major depressive disorder (Monroe et al., 1999). A handful of other studies have reported that romantic involvement during adolescence is associated with individual behavioral, emotional and social functioning (e.g., ZimmerGembeck et al., 2001; Downey, Freitas, Michaelis, & Khouri, 1998). In addition to measuring negative affect, positive well-being and loneliness were also assessed in the current study. Adolescents who have had success with long-term romantic relationships do perceive themselves to be more socially competent and to have greater romantic appeal (Zimmer-Gembeck et al., 2001). Spending time with members of the other sex has also been associated with greater social competence (Darling, Dowdy, Lee Van Horn, & Coldwell, 1999; Feiring & Lewis, 1991). Social competence and romantic appeal have been associated with self-esteem in past research (Harter, 1999) providing some support for the alternative hypothesis – that some forms of romantic involvement may promote wellbeing rather than increase negative affect. Other support for the positive impact of romantic relationships on well-being comes from a longitudinal study of high school student. Davies and Windle (2000) observed that the transition to a steady relationship among 701 adolescents (M age = 16) was accompanied by a significant decrease in depressive symptoms, but also associated with a significant increase in minor problem behavior. However, no past studies have accounted for qualities of relationships with parents and friends when examining the influence of romantic relationships on emotional and social functioning. Since romantic relationships do not exist in an interpersonal vacuum and there is some evidence that individuals who have good relationships with family and friends also have good relationships with romantic partners (Collins & Sroufe, 1999), other close relationships should be considered in order to make conclusions about the independent association between wellbeing and qualities of romantic involvement and relationships.

Family Relationships Attachment theory has provided a foundation for understanding close relationships that are based on security and commitment (Overbeek, Vollebergh, Engels, & Meeus, 2003; Weiss, 1998). For most people, attachment relationships with primary caregivers are expected to be the first sources of validation and support (Feiring & Taska, 1996; Overbeek et al., 2003). Attachment theorists have shown the importance of secure parent-child relationships as a foundation for positive functioning (Berlin & Cassidy, 1999). In the area of parental attributes, classic research by Coopersmith (1967) found that some of the parenting attributes

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important for children’s self-esteem include being accepting, affectionate, involved, encouraging and democratic, while disciplinary methods should be non-coercive. Although relationships with caregivers are transformed during adolescence and emerging adulthood (Collins & Repinski, 1994; Collins & Sroufe, 1999), attachment features of the parent-adolescent relationship are usually maintained. Parents continue to be a source of support and security for young people throughout adolescence. Parents usually maintain this role in emerging adulthood, even as romantic relationships may begin to emerge as attachment relationships by providing a source of emotional security (Ainsworth, 1989; Van Wel, Ter Bogt, & Raaijmakers, 2002). The relationships that young people have with their parents have been found to continue to impact well-being into late adolescence and emerging adulthood. For example, in a cross-sectional study of students age 16 to 20 years, those with better parent relationships had relatively higher self-esteem and life satisfaction, and reduced negative affect (depression and anxiety; Armsden & Greenberg, 1987). Similarly, in crosssectional analyses by Overbeek et al. (2003), it was reported that adolescents age 15-19 with relatively lower levels of parental attachment had more emotional disturbance. Yet, in this study, earlier parental attachment did not predict disturbance three years later.

Friends Independent of the impact of parents and romantic relationships, the quality of friendships, especially same-sex friendships, has been associated with positive adaptation (Bagwell, Schmidt, Newcomb, & Bukowski, 2001; Franco & Levitt, 1998; Roberts et al., 2000). Friends can be an important additional source of advice, support and respect, especially as young people move outside the family home (Berndt, 2002). Multiple studies have found that peer relationships have an influence on adolescent development and adaptation that is independent of the influence of family relationships (Franco & Levitt, 1998; Roberts et al., 2000). Adolescents with supportive friends have been found to have higher global self-esteem, better social adjustment, and are better able to cope with stressors compared to those with lower quality friendships (Gauze, Bukowski, Aquan-Assee, & Sippola, 1996; Hartup & Stevens, 1999; Keefe & Berndt, 1996). Also, having close friendships in adolescence has been associated with higher self-worth in emerging adulthood (Bagwell et al., 2001), and adult female friendships have been shown to important to many aspects of individual well-being (Knickmeyer, Sexton, & Nishimura, 2002). Furthering from Sullivan’s (1953) hypothesis that intimate friendships can increase feelings of self-worth in adolescence, researchers have studied a number of positive indicators of friendship quality including trust, loyalty, affection, emotional support, and prosocial behavior as well as a number of negative indicators including conflict, rivalry, competition, and domination tactics (Berndt, 2002). The literature reveals that, consistent with Sullivan’s theory, adolescents who have high quality friendships (i.e., friendships high in positive features and low in negative features) in general have higher global self-esteem, improved social adjustment, and an increased ability to cope with stressors compared to those adolescents with low quality friendships (i.e., friendships low in positive features and high in negative features, Gauze, Bukowski, & Aquan-Assee, 1996; Hartup & Stevens, 1999; Keefe & Berndt, 1996; Townsend, McCracken, & Wilton, 1988).

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Study Aims In this longitudinal study of girls from age 18 to 23, positive well-being, negative affect, and loneliness were expected to be associated with different aspects of romantic relationships at different ages. The different associations were expected to reflect age-related changes in the motives for romantic relationships. The two motives of interest were affiliation and intimacy/security (e.g., nurturance, intimacy, support). In other words, one reason for involvement in romantic relationships is to affiliate with others, spend time together, and have fun; this motivation was expected to be most salient in the teen years. A second reason for involvement in romantic relationships is to develop an intimate and nurturing association with another that includes a sense of security and trust, and provides support and happiness in stressful and other times of life; this motivation was expected to emerge as most salient after the teen years. Hence, one aim of the current investigation was to determine whether socioemotional functioning was associated with support within romantic relationships, measured as a range of positive qualities including intimacy and nurturance, after the teen years but not during the teens years. In the current study, a second aim was to examine the other motive of romance affiliation with romantic partners. Therefore, an additional aspect of romantic involvement, a measure of affiliation (i.e., time spent with romantic partner) was investigated. Based on theories of the development of romantic relationships during adolescence and emerging adulthood (Brown, 1999; Connolly & Goldberg, 1999), it was expected that the associations between romantic affiliation and socioemotional functioning would be stronger in the teen years than later, as affiliation motivation in the romantic domain was expected to be more salient than intimacy/security motivation during the teenage years. Finally, negative interactions (e.g., conflict) in romantic relationships were also examined. It was expected that the association between negative interactions and socioemotional functioning would be stronger in emerging adulthood than in adolescence for two primary reasons. First, more committed relationships have formed by emerging adulthood and these relationships can have both positive and negative qualities simultaneously (Kasian & Painter, 1992). Second, by emerging adulthood, young people have more experience with balancing and negotiating both the positive and negative aspects of their close relationships. Additionally, the issue in the current study was one of asking when qualities of romantic relationships have independent influences on well-being. There have been many investigations that have established the importance of family and friends in adolescence for individual functioning (Berndt, 2002; Eccles, Early, Fraser, Belansky, & McCarthy, 1997; Overbeek et al., 2003; Parker & Asher, 1987) and continuity between qualities of parent and peer relationships, and romantic relationships have been found (Conger, Cui, Bryant & Elder, 2000; Möller & Stattin, 2001; Taradash, Connolly, Peplar, Craig, & Costa, 2001). In sum, age-related differences in associations between females’ socioemotional functioning and qualities of romantic relationships (support and intimacy, affiliation, and negative interactions) were tested in the current study. Independent effects of relationships with family and friends on socioemotional functioning were also investigated. After accounting for support from family and friends, it was expected that females’ socioemotional functioning would be more strongly associated with romantic support and conflict at ages 20 and 23 as compared to age 18. Conversely, it was hypothesized that females’ socioemotional

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functioning would be more strongly associated with romantic affiliation at age 18 compared to ages 20 and 23.

METHOD Participants At Time 1 (T1), participants were 101 white females between the ages of 17 and 19 who had recently graduated from high school (M = 18.2; SD = 0.7). There is evidence that patterns of dating vary by race/ethnicity (Phinney, Jensen, Olsen, & Cundick, 1990) and evidence of gender differences in the nature and importance of peer relationships (see Introduction). Because of this, only white females were included in the current study. Participants were recruited from two sites, including the graduating senior class from a large urban high school in the Northwestern United States and the incoming first year class of a large urban university in the Northwestern United States. The study was announced in five senior English classes of the high school. If interested, students supplied their names, ages, race/ethnicities, addresses, and phone numbers. Only three students did not supply their names. Of these students, 49 white females expressed interest in participating in the study and 37 (76%) were interviewed in the summer after their senior year. Three potential participants changed their minds, two did not attend scheduled interview sessions, and seven could not be contacted. Structured interviews and questionnaires were completed with each participant separately at the high school or at the interviewees' homes. These participants were entered into a drawing to win prizes ($50 or $100 or movie passes). The remaining 64 participants were recruited through random telephone calls made to female freshman in the first few weeks of university (74 females were contacted). Participants were required to have graduated from high school in the school year prior to data collection. Interviews were conducted at the university or the interviewees' homes. These individuals were paid $10 for their participation. For the second assessment (T2), 63 participants were located and 61 (60%) participated. Because this study was not originally designed to be longitudinal, T2 data collection faced extra challenges to re-contact participants. By the third assessment (T3), Internet searching tools were much improved. As such, 77 individuals were located and 72 (71%) participated. At T1, 57% of participants were in a steady romantic relationship, no participant was married and one person reported a steady relationship with a female. At T2, 67% of participants reported they were involved in a steady romantic relationship. The mean length of steady romantic relationships was similar at T1 and T2 interviews, M = 14.19 and 14.97 months with ranges from 2 to 50 and 1 to 48, respectively. At T3, 72% of participants reported they were involved in a steady romantic relationship, 13 participants (18%) were married, and the average length of relationship with a romantic partner was 28 months with a range from 1 to 84 months. At T3, three participants reported current, steady romantic relationships with females. Only two participants had the same romantic partner throughout the study and only 15 participants had a romantic partner at all three waves of data collection. Hence, most participants changed partners and most had no steady romantic partner at least one time. As

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such, data were analyzed for each wave of data collection separately and results were compared between waves.

Procedure The T1 assessment included an individual interview about involvement with romantic relationships from grades 9 to 12, as well as the completion of a self-report questionnaire. Only data from the questionnaire were used in the current study. T2 (1998) and T3 (2001) assessments were completed approximately two and five years later when almost all participants were age 20 and 23. T2 and T3 data collection were completed via mail. Upon the T1 interview, a participant signed consent forms. Parental consent was obtained for participants under 18-years-old. The consent form informed participants and their parents that this was a study of high school relationships to learn how relationships with friends and boyfriends change while in high school and about their current relationships and well-being. The portion of the interview and survey described here took between 20 and 40 minutes to complete. Appropriate ethical approvals were obtained for all phases.

Measures Qualities of Relationships with Romantic Partners and Best Female Friends The Networks of Relationships Inventory (NRI; Furman & Buhrmester, 1985) was used to assess support from romantic partners and friends. All items were completed about the current (or most recent past) romantic partner and current female best friend (other than a romantic partner). As suggested by the authors of the measure, social support scores were calculated based on seven subscale scores (21 items) - reliable alliance (“How sure are you that this relationship will last no matter what?”), affection (“How much does this person like or love you?”), admiration (“How much does this person treat you like you’re admired and respected?”), instrumental aid (“How much does this person help you figure out or fix things?”), companionship “How much do you play around and have fun with this person?”), intimacy (“How much do you share your secrets and private feelings with this person?”) and nurturance (“How much do you take care of this person?”). Only individuals with a romantic partner at the time of questionnaire completion were included in analyses that involved support from partners. The support composites had high reliability, Cronbach’s α = .93 for current romantic partner, Cronbach’s α = .90 for best friend when averaged across T1, T2 and T3. Romantic partner support was not significantly correlated with friend support at any age, r ranged from .03 to .17. Negative Interactions with Romantic Partners Nine items of the NRI (Furman & Buhrmester, 1985) were used to assess negative interactions with romantic partners. Items assessed conflict (“how much do you and this person get upset with or made at each other?”), antagonism (“How much do you and this person get on each other’s nerves?”) and punishment (“How much does this person scold you

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for doing something you’re not supposed to do?”). The reliability of the measure was high, average Cronbach’s α = .88.

Affiliation with Romantic Partners To measure affiliation with romantic partners, each participant reported the amount of time (outside of school and work) that she spent with her romantic partner in a typical week. A visual-analog scale with a range from 0 to 100 was used. Individuals without a romantic partner at the time of survey completion were instructed to respond with a zero. Because of these zero scores and the resulting positive skew of this variable, a log10 transformation was conducted after adding 1 to all scores. These transformed values for time spent with romantic partners were used in all analyses. Correlations between transformed values of time spent with romantic partners and support from partners at T1, T2 and T3 were moderate, r = .37, r = .28 and r = .45, all p < .05, respectively. Quality of Family Relationships Participants completed the Self-image Questionnaire for Young Adolescents (SIQYA; Peterson, Schulenberg, Abramowitz, Offer, & Jarcho, 1984). The subscale of family relationships was used in the current study. This subscale included 17 items that assess various aspects of parent-adolescent relationships including warmth and support (e.g., “I can count on my parents most of the time”, “I feel that I have a part in making family decisions”). This scale had high internal consistency in this study, α = .89. Socioemotional Functioning Negative affect (depression/anxiety), positive well-being and loneliness were the indicators of individual well-being. Negative affect was measured with the anxiety and depression subscales (seven items) of The Psychological General Well-Being Index (PGWB; Dupuy, 1984; Veit & Ware, Jr., 1983). An example item is ‘Have you felt sad, discouraged, hopeless, or had so many problems that you wondered if anything was worthwhile during the past month?” Items had response options from 1 (extremely or definitely) to 6 (not at all). Positive well-being was assessed with a three-item subscale of the PGWB. An example item is “How happy, satisfied, or pleased have you been with your life during the past month?” with options from 1 (could not be more satisfied or pleased) to 6 (very dissatisfied). In previous research, there is evidence of high internal consistency, Cronbach’s α > .90, and validity of the PGWB measure with a correlation of r = .47 with interviewer’s ratings of depression, an average correlation of r = .69 with six other depression scales, and an average correlation of r = .64 with three other anxiety scales (Fazio, 1977). Reliability also was high in the current study, all α > .90. The Revised UCLA Loneliness Scale (Russell, Peplau, & Cutrona, 1980) was used to measure loneliness at each time of measurement. An example item is “I feel left out” with response options from 1 (never) to 4 (often). Reliabilities of measures were good, all Cronbach’s α > .75. In previous research, this scale has had high internal consistency, α = .94, and good concurrent validity with measures such as introversion-extroversion, anxiety, a self-labeling loneliness index, involvement in social activities and number of friends (Russell et al., 1980). Reliability also was high in the current study, all α > .90.

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RESULTS Females’ Socioemotional Functioning and Romantic Relationship Qualities Table 1 summarizes bivariate correlations among positive well-being, negative affect, loneliness, and qualities of interpersonal relationships. Positive well-being, negative affect, and loneliness were more strongly associated with romantic partner support and negative interactions with partners at age 23 compared to age 18. Similarly, negative affect was more strongly negatively associated with romantic partner support at age 23 compared to age 20. Only after the teen years was positive well-being significantly better and loneliness significantly lower when romantic partners were more supportive; at age 20 and 23, support from romantic partners was significantly associated with positive well-being, r = .40 and .39, both p < .01, and loneliness, r = -.31, p < .05 and r = -.51, p < .01. Additionally, at age 23, romantic support was significantly associated with negative affect r = -.49, p < .01. At age 18, no significant associations between females’ socioemotional functioning and romantic support were found. Similar findings emerged when associations between measures of socioemotional functioning and negative interactions with romantic partners were examined. Significant associations between socioemotional functioning and negative interactions were only found at age 23. Individuals with relatively more negative interactions with partners had lower positive well-being, r = -.46, p < .01, higher levels of negative affect, r = .47, p < .01, and higher levels of loneliness, r = .48, p < .01. As predicted and in contrast with findings regarding support and negative interactions with romantic partners, well-being was significantly associated with affiliation with romantic partners (i.e., time spent with partners) at age 18 and 20, but not at age 23. At age 18, females who spent more time with partners were also relatively lower in loneliness, r = -.23, p < .05. At age 20, females who spent more time with partners had relatively better positive wellbeing, r = .47, p < .01, while affiliation with romantic partners was negatively associated with negative affect, r = -.36, p < .01, and loneliness, r = -.28, p < .05.

The Independent Contribution of Romantic Relationships to Well-Being Socioemotional Functioning, Support and Negative Interactions within Romantic Relationships Hierarchical regression analyses were used to examine independent associations between the dependent variables of positive well-being, negative affect and loneliness, and support from romantic partners after accounting for support from family and friends at each age. At age 18, all measures of socioemotional functioning were significantly associated with quality of family relationships, but not significantly associated with support from friends and romantic partners (see Table 2). At age 20, positive well-being was positively associated with support from romantic partners after accounting for support from friends and partners, while loneliness was the only aspect of well-being associated with family support. By age 23, all

Table 1. Pearson correlations between Experiences in Interpersonal Relationships and Well-being at Ages 18, 20 and 23 Time 1 (age 18) Time 2 (age 20) Time 3 (age 23) Positive Negative Positive Negative Positive Negative Loneliness Loneliness Loneliness well-being affect well-being affect well-being affect

Relationship Experiences

Quality of family relationships Friend social support Romantic partner social support Romantic partner negative interactions Romantic partner affiliation (time spent)a

.26† .25† .14 -.15 .00

-.51† -.29† -.06 .20 -.08

-.40† -.33† -.09 .12 -.23*

.14 -.17 .40† -.27 .47†

-.11 .15 -.13 .04 -.36†

-.19 -.20 -.31* .18 -.28*

.19 -.05 .39† -.46† .21

-.23* .14 -.49† .47† -.12

-.32† -.10 -.51† .48† -.13

*

p < .05. †p < .01. Time 1 N ranged from 57 to 101. Time 2 N ranged from 41 to 61. Time 3 N ranged from 52 to 72. a log10 transformed.

Table 2. Standardized results of regressing measures of well-being on qualities of friend and family relationships and support from romantic partners

Independent variables

Positive well-being

Step 1, R2 Quality of family relationships, β Friend social support, β Step 2, ∆R2 Quality of family relationships, β Friend social support, β Romantic partner social support, β

.16† .32* .20 .03 .32* .23 .19

*

p < .05. †p < .01. Time 1 N = 57, Time 2 N = 41, Time 3 N = 52.

Time 1 (age 18) Negative Loneliness affect

.37† -.56† -.15 .01 -.56† -.18 -.11

.26† -.46† -.15 .02 -.46† -.17 -.13

Positive well-being

.10 .30 -.12 .11* .19 -.13 .34*

Time 2 (age 20) Negative Loneliness affect

.08 -.10 .27 .01 -.07 .27 -.11

.18* -.40* -.13 .03 -.34* -.12 -.20

Positive well-being

.07 .26 .06 .10* .17 .02 .34*

Time 3 (age 23) Negative Loneliness affect

.06 -.25 .06 .21† -.13 .13 -.48†

.12* -.31* -.11 .18† -.19 -.05 -.45†

Table 3. Standardized results of regressing measures of well-being on qualities of friend and family relationships and negative interactions with romantic partners Time 1 (age 18) Time 2 (age 20) Time 3 (age 23) Positive Negative Positive Negative Positive Negative Loneliness Loneliness Loneliness well-being affect well-being affect well-being affect

Independent variables

Step 1 Step 2, ∆R2 Quality of family relationships, β Friend social support, β Romantic partner negative interactions, β

.01 .32* .18 -.12

.02 -.56† -.13 .16

.01 -.46† -.14 .08

.06 .27 -.13 -.25

Same as Table 2 .00 -.10 -.27 .04

.02 -.39* -.12 .14

.16 .11 .07 -.32†

.17 -.09 .05 .44†

.15 -.15 -.12 .42†

*

p < .05. †p < .01. Time 1 N = 57, Time 2 N = 41, Time 3 N = 52.

Table 4. Standardized results of regressing measures of well-being on qualities of friend and family relationships, and time spent with romantic partners

Independent variables

Step 1, R2 Quality of family relationships, β Friend social support, β Step 2, ∆R2 Quality of family relationships, β Friend social support, β Romantic partner affiliationa, β *

p < .05. †p < .01. Time 1 N = 99, Time 2 N = 61, Time 3 N = 72. a time spent, log10 transformed.

Positive well-being

.11† 22* .20* .00 .22* .20* .01

Time 1 (age 18) Negative Loneliness affect

.31† -.47† -.22* .01 -.48† -.21* -.12

.22† -.36† -.24* .06 -.38† -.22* -.25†

Time 2 (age 20) Time 3 (age 23) Positive Negative Positive Negative Loneliness Loneliness well-being affect well-being affect

.04 .15 -.14 .24† .15 -.14 .50†

.06 -.11 .22 .12* -.17 .14 -.36†

.05 -.20 -.10 .12* -.25 -.17 -.36*

.04 .19 -.02 .04 .18 .01 .20

.07 -.24* .12 .01 -.23 .11 -.10

.12* -.32† -.14 .02 -.31† -.16 -.14

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three measures of socioemotional functioning were independently associated with support from romantic partners, but not associated with support from family and friends.1 Similar, but separate, hierarchical regression analyses were used to examine the parallel associations between females’ socioemotional functioning and negative interactions with romantic partners after accounting for the influence of support from family and friends (see Table 3). When associations between socioemotional functioning and negative interactions were compared to associations between socioemotional functioning and support from romantic partners, similar results emerged with only one exception; there was no significant association between socioemotional functioning and partner negative interactions at age 20.

Affiliation: Time Spent with Romantic Partners Again, separate hierarchical regression analyses were used to examine the associations between females’ socioemotional functioning and affiliation with romantic partners after accounting for the influence of support from family and friends (see Table 4). In contrast to the earlier models which only included participants with romantic partners, all participants, whether they had a romantic partner at the time of survey completion or not, could be included in analyses; those without romantic relationships at the time of survey completion indicated a score of 0 for time spent. Table 4 shows that all three measured aspects of females’ socioemotional functioning at age 18 were associated with support from family and friends. Regarding associations between socioemotional functioning and romantic affiliation at age 18, females were less lonely when they spent more time with their romantic partners, but positive well-being and negative affect were not significantly associated with time with partners. At age 20, somewhat the converse was found. There was little association of well-being measures with support from family or friends, but all aspects of socioemotional functioning were significantly associated with affiliations with romantic partners. At age 23, socioemotional functioning was not associated with affiliation with partners.

DISCUSSION During the years of adolescence and emerging adulthood (about age 18 to 25) a number of developmental tasks are faced in preparation for the transition into adulthood (Arnett, 2000). Developing close, intimate couple relationships and finding satisfying life directions, work and other interests may be of most importance. Foundations that are built at this time of life may have enduring ramifications for positive social relationships, individual development, and success or problems in later adult life (Zimmer-Gembeck, 2002). During emerging adulthood, young people have experiences and make choices that can impact their success transitioning into adulthood and their future well-being. For example, the choice of close relationships at this time may be critical as these are the relationships that may go with adolescents into the future, providing them with their major sources of support to cope with challenges, helping them to find satisfying life experiences, and assisting them to feel

1

We also included marital status (married or not) in the age 23 models as a covariate. The findings were similar to those reported in Tables 2, 3, and 4.

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competent, connected and cared for. These relationships add significantly to their social capital. These relationships, and the positive and negative emotions that accompany them, likely result in problems for some and provide opportunities for growth for others. Overall, these relationships frequently become new sources of support and stress during adolescence (Monroe, Rohde, Seeley, & Lewinsohn, 1999; Zimmer-Gembeck, 2002), and often act as a vehicle for the adolescent to work though self-concept and individuation issues, as well as gaining access to these additional sources of intimacy and support. Yet, even though romantic relationships become a major source of support and stress, the associations between romantic relationship qualities and well-being, such as negative affect, depression, loneliness and positive aspects of well-being, during this time of life has only begun to be examined. As described in this chapter, a group of females participated in three assessments between late adolescence and emerging adulthood (at age 18, 20, and 23). A pattern of findings emerged that provide support for recently proposed stage theories of the development of romantic relationships during adolescence and emerging adulthood (Brown, 1999; Connolly & Goldberg, 1999). The patterns of associations between individual socioemotional functioning and the various aspects of romantic relationships showed that females’ positive well-being, negative affect and loneliness are influenced by romantic relationships in ways consistent with age-related differences in affiliation and intimacy/security motives within the romantic domain. In particular, at age 18, affiliation motives for romantic relationships were expected to be more salient and prominent than intimacy/security motives in the romantic domain. This was supported by finding that, at age 18, reduced loneliness is associated with spending more time with romantic partners and, in contrast, no measure of socioemotional functioning is associated with romantic support, including such aspects as intimacy, nurturance and satisfaction. Hence, consistent with the expectation that affiliation motives would be predominant at age 18, girls at age 18 are less lonely when they spend more time with their romantic partners, but romantic support did not affect socioemotional functioning, and this was true even after accounting for associations between individual well-being and support from family and same-sex best friend relationships. Importantly, features of family relationships seemed to most strongly covary with socioemotional functioning at this age, and there were some findings that indicated that support from best female friends may also be important at age 18. Although it was not predicted that affiliation motives would still predominate at age 20, it seemed that these motives remained more salient than intimacy motives within the romantic domain when the girls were age 20. At this age, all measured aspects of well-being, including positive well-being, negative affect and loneliness, are relatively more positive when girls’ spend more time with their romantic partners. In contrast, consistent with the conclusion that intimacy/security motives are not as salient in the romantic domain at this age, only one measured aspect of socioemotional functioning, psychological well-being, was associated with support from partners at 20 and no aspect of socioemotional functioning was associated with negative romantic interactions. In total, findings at age 18 and 20 suggest that affiliation with romantic partners is important for socioemotional functioning at age 18, but affiliation motives are even more prominent at age 20 than at age 18. In contrast, the importance of intimacy/security motives in the romantic domain for socioemotional functioning is just emerging at age 20. Hence, even as late as age 20, affiliation seems to be the primary motive

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and benefit of romantic relationships for individual functioning. In other words, before and at age 20, the benefit of romantic relationships primarily comes with spending time together, regardless of the level of intimate interactions that form the content of this time together. In contrast to the expected age-related declines in the importance of affiliation motives in romance, intimacy motives in romantic relationships were expected to be most salient by age 23. This hypothesis was supported. By age 23, all measured aspects of socioemotional functioning were associated with support from romantic partners, suggesting that intimacy motives are important at this age. At age 23, females with more support from romantic partners had elevated positive well-being and lower negative affect and loneliness. Also in support of this hypothesis, no measure of well-being was significantly associated with affiliation with romantic partners at age 23. This suggests that intimacy had become a more salient romantic motive than affiliation by age 23.

Family, Friends and Romantic Partners It is important to note that, at each age, the independent contributions of family relationships and same-sex friendships were simultaneously investigated in multivariate regression analyses. Somewhat surprisingly, current study findings indicated the primary importance of support from family relationships and same-sex friends for well-being, rather than romantic relationships, at age 18. Higher levels of positive well-being and reduced depressive affect and loneliness were found when girls had more support from family members and same-sex best friends. Social support from family and friends seem to be important correlates of girls’ socioemotional functioning at age 18. However, evidence presented in this chapter shows that these relationships may have smaller independent links with well-being when girls on are in their 20s and romantic relationships become the strongest correlate of girls’ socioemotional functioning. In the past, most research on socioemotional functioning and social relationships has focused on family relationships, same-sex friendships and peer groups (e.g., Gauze et al., 1996; Hartup & Stevens, 1999). Examinations of the impact of adolescent and emerging adult romantic relationships, independent from the influence of friends and family, have been much less common. Because relationships with family and same-sex friends have been found to be important to females’ socioemotional functioning in both adolescence and emerging adulthood, and there has been some evidence on continuity of qualities between family, friend and romantic relationships (Collins & Sroufe, 1999; Feeney & Noller, 1990; Furman & Wehner, 1994, 1997), qualities of family relationships and same-sex friendship were important to consider along with romantic relationships. As such, there was an additional focus on controlling for the influence of other relationships to determine when well-being was independently associated with qualities of romantic relationships. Although findings support theory (Brown, 1999; Connolly & Goldberg, 1999) and hypotheses, it was somewhat unexpected that females’ affiliation with romantic partners was associated with all of the measured aspects of socioemotional functioning at age 20 and not after. It was also surprising that support and intimacy with partners was associated with all these aspects of more support from romantic partners socioemotional functioning at age 23 and not before. It must be concluded that positive well-being, negative affect and loneliness do not have much of an independent association with romantic relationship support until after

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age 18, possibly not most consistently until the mid-20s. It appears from the findings that family and same-sex friends remain critical supports for girls prior to this time of life. This evidence supports the current writing about the extended period of adolescence in Western societies of today (Arnett, 1999; Larson et al., 2002), with delays in the formation of close couple relationships until the mid-20s or beyond and marriage or similar commitments not made until the late 20s for both females and males (Brooks-Gunn & Paikoff, 1997; Collins, 2003; Modell, 1989). Hence, many adolescents may continue to gain a sense of belonging and most of their support from family and friends until they have aged into the third decade of life. This also suggests that the social competencies needed in later phases of romantic development, such as trust, negotiation and intimate communication, disclosure, reciprocity, and the ability to provide security for another and commitment, may not be experienced until beyond age 20 (Brown, 1999; Feiring, 1996; Furman & Wehner, 1994).

Limitations of the Current Study Although this study was longitudinal in design, cross-sectional segments were examined and compared. Hence, limitations are the inability to draw causal conclusions, including the potential of converse associations between well-being and relationship qualities; well-being may promote more support from friends and family at age 18, more affiliation with partners at age 20, and more intimate interactions with partners at age 23. Another limitation was the lack of information that would allow for a consideration of the specific content of support within romantic relationships (see Collins, 2003; Nieder & Seiffge-Krenke, 2001). Consideration of interactional content, and the potential for support and intimate interactions to change with age yields another possible explanation of study findings that could be an alternative to the motivational or functional explanation that has been proposed in this chapter. For example, in the late teen years, the support from romantic partners may be of a form that is not as beneficial to socioemotional functioning, while the content of support provided by partners as individuals move into their mid-20s may change so that interactions are more relevant to maintaining positive well-being and reducing negative affect. For example, support and intimate interactions may be based increasingly on a history of knowledge of the other, their perceptions of stress, their coping behaviors and other factors, making it more beneficial to each partner’s happiness. Romantic partners may increasingly converse about their day-to-day hassles and assist each other to cope by problem-solving and strategizing. Romantic partners in the mid-20s compared to the late teen years may be more reliable sources of instrumental aid, and they may be more knowledgeable about stress and coping from their own experiences and changing developmental level, and be better able to cope themselves and assist others. Yet, there is evidence that continuity in the content of support at ages in this study should have occurred making a motivational explanation of results more feasible. Brown (1999) has noted that the affection stage of romantic development is marked by these kinds of interactions, which include relational longevity and some level of commitment into the future. Others have claimed that longevity and commitment begin to emerge as early as age 17 (Nieder & Seiffge-Krenke, 2001). Many adolescent relationships are lengthy with approximately 60% of older teens having relationships of 11 months or longer (Carver et al., 2003). Adolescents this age also have

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conceptions of romantic relationships that are comparable to adults’ conceptions (Levesque, 1993). Another possibility is that stress, such as relationship dissolution, may be a more common experience in the teens than in the 20s and this stress of romance may cancel out or not outweigh the support provided by romantic partners. Hence, there may be no net impact of support on well-being in the late teen years, but stress may decline with age allowing support to provide benefits in the mid-20s. No studies could be located that have examined this in the late teens and 20s. In a study of younger adolescents, Nieder and Seiffge-Krenke (2001) reported that romantic stress declined from age 14 to 15 and remained stable until age 17. It is uncertain whether this stability is maintained into the 20s. Nevertheless, this seems to be an unlikely explanation for the findings presented in this chapter; negative interactions were measured and there were no association between any measure of socioemotional functioning and negative interactions with romantic partners at age 18 and 20, while these associations were found at age 23. This suggests that conflict becomes more, rather than less, strongly associated with socioemotional functioning with increasing age. Even controlling for relationships with family and friends, romantic relationships are both a source of support and conflict, with the potential to influence well-being by age 23.

Future Research and Conclusions Overall, study findings show that a range of features of romantic relationships needs to be considered when examining the impact on individual socioemotional functioning. Only a few features of relationships were examined here. There are many other factors to consider in future research including, for example, the characteristics of the other in the relationship, the similarity or difference between partners, the activities that partners share, and expectancies or perceptions about relationships (Collins, 2003). In addition, replication of this study with a larger sample of young females, and studies of males are, of course, necessary. There is some evidence that males may not value close dyadic intimacy as greatly as females (Buhrmester & Furman, 1987; Eaton, Mitchell & Jolley, 1991; Lempers & Clark-Lempers, 1993; Sharabany, Gershoni, & Hofman, 1981). Given these differences, males may have somewhat different motives for romantic relationships or males’ motives may follow a different age-related developmental progression than those of females. In conclusion, romantic relationships are important to middle and late adolescents and deserve our attention (Collins, 2003; Furman et al., 1999), but they may be even more central to the social worlds and have more impact on the socioemotional functioning of emerging adults. In addition, it is useful to take a developmental approach to understanding the important features of interpersonal relationships at any age and to include examinations of how these relationship features are associated with individual development and well-being. Although previous research has shown that there are individual differences in the developmental trajectories of romance (Davies & Windle, 2000; Zimmer-Gembeck, 1999) with some adolescents forming first steady romantic relationships earlier than others or having sexual interactions at earlier or later ages (Horne & Zimmer-Gembeck, 2006; Siebenbruner, Zimmer-Gembeck, & Egeland, in press; Zimmer-Gembeck & Helfand, 2006), evidence presented in the current chapter provides some evidence that there are aspects of romantic development that may be fairly common within age periods. Considering this study

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in combination with previous research suggests that, as argued in Life-span Developmental Theory (Baltes, Reese, & Lipsitt, 1980), age-related patterns of development and individual differences in developmental trajectories may exist simultaneously when studying romantic development and well-being.

ACKNOWLEDGEMENTS Some data collection for this project was collected while the first author was a NIMH postdoctoral fellow at the Life Course Center and Institute of Child Development, University of Minnesota. Portions of this paper were presented at the 2004 meeting of the Society for Research on Adolescence. Thanks to all my dissertation participants for sharing their personal details over the years. Also, thanks to Professor Ellen Skinner for all her support in the early stages of this project. Sharon Horne at Griffith University-Gold Coast assisted with tracking and contacting of participants at T3, and conversations with Sharon and Carolyn Vickers made extremely valuable contributions to this project.

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Gauze, C., Bukowski, W. M., Aquan-Assee, J., & Sippola, L. K. (1996). Interactions between family environment and friendship and associations with self-perceived well-being during adolescence. Child Development, 67(5), 2201-2216. Harter, S. (1999). The construction of the self: A developmental perspective. New York: The Guilford Press. Hartup, W. W., & Stevens, N. (1999). Friendships and adaptation across the life span. Current Directions in Psychological Science, 8, 76-79. Horne, S., & Zimmer-Gembeck, M. J. (2006). The Female Sexual Subjectivity Inventory: Development and validation of an instrument for late adolescents and emerging adults. Psychology of Women Quarterly, 30, 125-138 Joyner, K., & Udry, J. R. (2000). You don’t bring me anything but down: Adolescent romance and depression. Journal of Health and Social Behavior, 41, 369-391. Kasian, M., & Painter, S. L. (1992). Frequency and severity of psychological abuse in a dating population. Journal of Interpersonal Violence, 7, 350-364. Keefe, K., & Berndt, T. J. (1996). Relations of friendship quality to self-esteem in early adolescence. Journal of Early Adolescence, 16, 110-129. Knickmeyer, N., Sexton, K., & Nishimura, N. (2002). The impact of same-sex friendships on the well-being of women: A review of the literature. Women & Therapy, 25, 37-59. Larson, R. W., Clore, G. L., & Wood, G. A. (1999). The emotions of romantic relationships: Do they wreak havoc on adolescents? In W. Furman, B. B. Brown, & C. Feiring (Eds.), The development of romantic relationships in adolescence (pp. 19-49). New York: Cambridge University Press. Larson, R. W., Wilson, S., Brown, B. B., Furstenberg, Jr., F. F., & Verma, S. (2002). Changes in adolescents’ interpersonal experiences: Are they being prepared for adult relationships in the twenty-first century? Journal of Research on Adolescence, 12, 3168. Lempers, J.D., & Clark-Lempers, D.S. (1993). A functional comparison of same-sex and opposite-sex friendships during adolescence. Journal of Adolescent Research, 8, 89-108.. Levesque, R. J. R. (1993). The romantic experience of adolescents in satisfying love relationships. Journal of Youth and Adolescence, 22, 219-251. McCabe, M. P. (1984). Toward a theory of adolescent dating. Adolescence, 19, 159-170. Modell, J. (1989). Into one’s own: From youth to adulthood in the United States 1920-1975. Berkeley, CA: University of California Press. Möller, K., & Stattin, H. (2001). Are close relationships in adolescence linked with partner relationships in midlife? A longitudinal, prospective study. International Journal of Behavioral Development, 25, 69-77. Monroe, S. M., Rohde, P., Seeley, J. R., & Lewinsohn, P. M. (1999). Life events and depression in adolescence: Relationship loss as a protective risk factor for first onset of major depressive disorder. Journal of Abnormal Psychology, 108, 606-614. Nieder, T., & Seiffge-Krenke, I. (2001). Coping with stress in different phases of romantic development. Journal of Adolescence, 24, 297-311. Nolen-Hoeksema, S. (2001). Gender differences in depression. Current Directions in Psychological Science, 10, 173-176.

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Overbeek, G., Vollebergh, W., Engels, R., Meeus, W. (2003). Parental attachment and romantic relationships: Associations with emotional disturbance during late adolescence. Journal of Counseling Psychology, 20, 28-39. Parker, J. G., & Asher, S. R. (1987). Peer relations and later personal adjustment: Are low-accepted children at risk? Psychological Bulletin, 102, 357-89. Peterson, A. C., Schulenberg, J., Abramowitz, R. H., Offer, D., & Jarcho, H. D. (1984). A self-image questionnaire for young adolescents (SIQYA): Reliability and validity studies. Journal of Youth and Adolescence, 13, 93-111. Phinney, V. G., Jensen, L. C., Olsen, J. A., & Cundick, B. (1990). The relationship between early development and psychosexual behaviors in adolescent females. Adolescence, 25, 321-332. Rice, F. P. (1984). The adolescent: Development, relations, and culture (4th Ed.). Boston: Allyn & Bacon. Roberts, A., Seidman, E., Pedersen, S., Chesir-Teran, D., Allen, L., Aber, J. L. et al. (2000). Perceived family and peer transactions and self-esteem among urban early adolescents. Journal of Early Adolescence, 20, 68-92. Rudolph, K. D. (2002). Gender differences in emotional responses to interpersonal stress during adolescence. Journal of Adolescent Health, 30, 3-13. Russell, D., Peplau, L. A., & Cutrona, C. E. (1980). The Revised UCLA Loneliness Scale: Concurrent and discriminant validity evidence. Journal of Personality and Social Psychology, 39, 472-480. Sharabany, R., Gershoni, R., & Hofman J. E. (1981). Girlfriend, boyfriend: Age and sex differences in intimate friendship. Developmental Psychology, 17, 800-808. Shulman, S., & Seiffge-Krenke, I. (2001). Adolescent romance: Between experience and relationships. Journal of Adolescence, 24, 417.428. Siebenbruner, J., Zimmer-Gembeck, M. J., & Egeland, B. (in press). Sexual partners and contraceptive use: A 16-year prospective study predicting abstinence and risk behavior. Journal of Research on Adolescence. Skipper, Jr., J. K. & Nash, G. (1966). Dating behavior: A framework for analysis and an illustration. Journal of Marriage and the Family, 28, 412-420. Taradash, A., Connolly, J., Peplar, D., Craig, W., & Costa, M.. (2001). The interpersonal context of romantic autonomy in adolescence. Journal of Adolescence, 24, 365-377. Thomas, J. J., & Daubman, K. A. (2001). The relationship between friendship quality and self-esteem in adolescent girls and boys. Sex Roles, 45, 53-65. Van Wel, F., Ter Bogt, T., & Raaijmakers, Q. (2002). Changes in the parental bond and the well-being of adolescents and young adults. Adolescence, 387, 317-333. Veit, C. T., & Ware, Jr., J. E. (1983). The structure of psychological distress and well-being in general populations. Journal of Consulting and Clinical Psychology, 51, 730-742. Weiss, R. S. (1998). A taxonomy of relationships. Journal of Social and Personal Relationships, 15, 671-683. Zimmer-Gembeck, M. J. (1999). Stability, change, and individual differences in involvement with friends and romantic partners among adolescent females. Journal of Youth and Adolescence, 28, 419-438. Zimmer-Gembeck, M. J. (2002). The development of romantic relationships and adaptations in the system of peer relationships. Journal of Adolescent Health, 31, 216-225.

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In: Advances in Psychology Research, Volume 44 Editor: Alexandra Columbus, pp. 113-135

ISBN 1-60021-150-X © 2006 Nova Science Publishers, Inc.

Chapter 7

FORGETTING AS A CONSEQUENCE OF REMEMBERING: RETRIEVAL-INDUCED FORGETTING AND THE MALLEABILITY OF MEMORY Malcolm D. MacLeod∗ University of St. Andrews, St. Andrews, Fife, Scotland

Jo Saunders University of Swansea, UK

ABSTRACT This article considers some of the most recent advances in experimental psychology regarding the role of inhibitory control in the production of misinformation effects in memory; that is, the tendency to report misleading post-event information in preference to original material. Specifically, we report our findings from a series of studies using the retrieval practice paradigm (cf. Anderson, Bjork & Bjork, 1994) that explore how retrieval-induced forgetting (i.e., the tendency to forget material as a consequence of retrieving other related material) may be involved in promoting misinformation effects. We then consider how to establish experimentally that the mechanism underlying this relationship is inhibitory. In doing so, we outline the independent probe technique (Anderson & Spellman, 1995); that is, the use of novel retrieval cues at test rather than those cues used during the initial stages of the retrieval practice paradigm. Our findings clearly indicate that misinformation effects emerged only under conditions where retrieval-induced forgetting remained active and that the retrieval-induced forgetting observed in our studies was due to inhibitory control. Implications for our understanding of how memory is updated; the design of experimental paradigms that consider the role of active forgetting in memory; and the development of police investigative techniques are also explored.

∗

Address for correspondence: Malcolm D. MacLeod, Social & Applied Cognition Lab, School of Psychology, University of St. Andrews, St. Andrews, Fife, Scotland, KY16 9JU; Tel: +44 (0)1334-462064; Fax: +44 (0)1334463042; Email: [email protected]

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INTRODUCTION In our quest to understand how memory works, researchers often face the problem of how to make everyday phenomena the focus of empirical study. Foremost amongst these myriad challenges is the design of appropriate experimental paradigms that permit memory to be explored in a controlled manner yet retain sufficient realism to allow extrapolation to the real world. For those who are primarily interested in solutions to applied problems, a high level of control can appear artificial and remote from the contexts and factors associated with memory in the real world. For other researchers, however, experimental control is paramount (e.g., Banaji & Crowder, 1989). While arguments can be made regarding the utility of studies that have high ecological validity, we are of the opinion that this should never be at the expense of experimental control. We wish to be clear that this preference is not due to our lack of interest in applied problems - in fact, the converse is true. Rather, we believe that good applied research is, without exception, based on well-designed and tightly controlled experimentation. Thus, in our view, highly controlled studies offer the greatest potential - both in terms of how to advance theory and the development of solutions to real world problems. Indeed, there is much to commend the sentiment expressed by Banaji and Crowder (1989) that ‘…the complexity of a phenomenon is a compelling reason to seek, not abandon the laboratory’ (p.1112). Unfortunately, all too often the complexity of the phenomena of interest is given as the raison d’etre for poorly controlled research. In order to illustrate our point of view, the present article details some of the most recent experimental studies concerning the mechanisms underlying one of the most researched of all memory phenomena - the misinformation effect. This effect refers to the bias towards unwittingly recalling misinformation (i.e., information inconsistent with that originally presented) in preference to original material (Loftus, 1979a; Loftus, Miller & Burns, 1978). In considering this body of research, we hope to demonstrate how, through controlled experimentation, it is possible to enhance our understanding not only of those conditions most likely to give rise to misinformation effects in the real world but also the complex relationship that exists between forgetting and remembering.

THE MISINFORMATION EFFECT Despite the fact that much of the pioneering work on the misinformation effect was carried out almost thirty years ago (Loftus, 1979a; Loftus, et al., 1978; Loftus & Palmer, 1974), its influence in cognitive psychology remains strong. The standard misinformation paradigm (cf. Loftus, et al., 1978) involves the presentation of a target incident such as an accident or crime scene in the form of a slide sequence, video, or piece of prose. On encoding this material, participants are presented with a series of questions about the target event. Unknown to the participants, however, a piece of misinformation (i.e., information inconsistent with that originally presented) is embedded within one of the questions. For example, participants could be asked about a car that passed by a ‘Yield’ sign whereas, in fact, the car in question had actually passed by a ‘Stop’ sign or vice versa (cf. Loftus, et al., 1978). Following a short delay, participants are asked to choose which slides they had seen

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previously in a two-alternative forced-choice recognition task. For non-critical items, participants are required to choose between a novel slide and the original whereas, for the critical item (i.e., where misinformation had been introduced), participants have to choose between the original and the misinformation item (e.g., ‘Yield’ versus a ‘Stop’ sign). In their seminal study, Loftus and colleagues found that 59% of participants who were misled in this way chose the misinformation item in contrast to only 25% of non-misled participants. Although the magnitude of this particular effect can be modified by a range of cognitive and social factors (see Wright & Davies, 1999 for a review), its robustness has never been in question (see e.g., Belli, 1989; Bekerian & Bowers, 1983; Chandler, Gargano & Holt, 2001; Christiaansen & Ochalek, 1983; Dodson & Reisberg, 1991; Lindsay & Johnson, 1989a, 1989b; Pirolli & Mitterer, 1984). There are several reasons why this work has proved to be important. Although it had been appreciated for some time that eyewitness reports could be modified by the form of questions employed to elicit information from witnesses (Binet, 1900, 1905; Harris, 1973; Loftus & Zanni, 1975; Stern, 1939), Loftus’ work has proved instrumental in prompting us to think about whether the unwitting introduction of misinformation may actually result in the distortion of memory rather than simply influencing its report. Loftus et al (1978) identified that one of the problems with the leading question paradigm was a mismatch between the stimuli used during the study phase and final test. Specifically, while the study phase generally consisted of a visual presentation, verbal tests were usually employed at final test that may have biased retrieval towards the verbal misinformation. From a theoretical viewpoint, therefore, the extent to which the leading question paradigm could reveal anything about the nature of memory was somewhat limited. By introducing a recognition test as the final phase of the misinformation paradigm, however, it became possible to determine the availability of the memorial representation for the original item following the introduction of misinformation. Arguably, it is the attention to experimental details such as this that has kept the study of the misinformation effect at the forefront of applied cognitive research for almost thirty years. Having identified the possibility that the study of misinformation effects could provide important insights into how memories are subject to destructive updating by newer, inconsistent material (Loftus, 1979ab; Loftus et al., 1978), Loftus also sought to eliminate alternative accounts for her findings. In doing so, her research indicated that motivational factors and demand characteristics appeared to have little impact on the production of such effects. Monetary incentives failed to improve recall accuracy (Loftus, 1979a) as did the provision of opportunities to change initial responses (Loftus, 1979) and warnings to participants that false information may have been introduced (Greene, Flynn & Loftus, 1982). In addition to eliminating competing explanations for her findings, Loftus also sought to gather additional supportive evidence that was consistent with a destructive updating account of the misinformation effect. In particular, Loftus’ use of reaction time methodology allowed her to infer whether integration between memory for the original item and memory for the misinformation is likely to have taken place. The rationale behind this approach was that, if misled participants could be shown to be slower in choosing an item at test, this would be consistent with the extra time needed to resolve two conflicting representations. If, on the other hand, response times could be shown to be fast, it would suggest that any conflict between the original and the misinformation had already been resolved and that the misinformation is likely to have been integrated into memory for the target event shortly after

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the introduction of the misinformation. The fact that Loftus and colleagues found misled participants to react quickly to critical items provided support for the thesis that the misinformation effect is a product of memory change (see Cole & Loftus, 1979; Loftus, Donders, Hoffman & Schooler, 1989). Loftus also considered the possibility that the introduction of misinformation could disrupt the original memory trace in such a way that a blended representation of the original item and misinformation may be produced (Loftus, Schooler & Wagenaar, 1985; Metcalfe, 1990). This idea derives from earlier work by Loftus (1975; 1977) in which participants who had been misled about the colour of an object, tended towards a compromise option (i.e., some combination of the original and misinformation) rather than choosing the original or misinformation item. Thus, if the original target item had been ‘green’ and the misinformation suggested the target item had been ‘blue’, participants tended towards a ‘bluish-green’ compromise at test. On further detailed experimentation, however, it became apparent that the empirical evidence for such a blending mechanism was not particularly strong. Memory blending is not an easy phenomenon to study given that there are relatively few instances of items that can be blended to form a single object. For example, there is no obvious blend for ‘Yield’ and ‘Stop’ signs, or for Coke and 7-Up cans. Even when exploring memory for materials that had the potential to be blended (e.g., colour), Belli (1988) found that misled participants tended to favour either the original or the misinformation item at test rather than any compromise option. As with many lines of experimental enquiry, the paradigms employed by researchers tend to be influenced by what has gone before; that is, we tend to build upon existing knowledge and techniques. This approach has the advantage that we don’t have to keep ‘re-inventing the wheel’ but it can also have the disadvantage that some of the problems associated with earlier paradigms can be unwittingly transferred to current ones. Chandler (1989) has made the point that the misinformation paradigm is arguably no different in this regard given that parallels can be drawn between it and the A-B, A-D paired associate paradigm which was extensively employed during the classic interference era. According to Chandler’s rationale, the target incident in the misinformation paradigm can be considered the equivalent of the A stimulus, the original target item the equivalent of the B response, and the misinformation item the equivalent of the D response. Chandler and colleagues have argued (e.g., Chandler, 1989, 1993; Chandler & Gargano, 1995) that misinformation effects can best be viewed as a form of retroactive interference; that is, the learning of new information during an interpolated task (e.g., questionnaire or post-event narrative) can interfere with our ability to recall original target items. In other words, the standard misinformation paradigm fosters retroactive interference and that this interference is the cause of the misinformation effect. In a series of carefully constructed studies, Chandler demonstrated that the retrieval availability of the original item increases as retroactive interference dissipates, thereby suggesting that memory for the original item has neither been erased nor altered. Consistent with this interference interpretation, Chandler and Gargano (1995, 1998) have also demonstrated that misinformation dissimilar to the original target item creates less interference and a consequent reduction in the level of misinformation reported at test. As a way of minimising such interference effects, Chandler et al (2001) emphasised the importance of reinstating retrieval cues that specifically access information contained in memory for the original event. By encouraging participants to reinstate contextual cues that

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are unique to the original event, memory for the original item can be accessed in preference to memory for the misinformation. Consistent with this view, Bekerian and Bowers (1983) have argued that the misinformation effect may be a function of a mismatch between encoding and retrieval cues. Specifically, thematic cues associated with the temporal order of the original presentation may provide vital cues for the subsequent retrieval of information about the target incident. They pointed out that, in the standard misinformation paradigm, the slides in the final test phase are presented in random order thereby eliminating thematic cues. Bekerian and Bowers demonstrated that when retrieval conditions at test are sufficiently strong to reinstate the retrieval conditions present at encoding (i.e., when the original temporal order is reinstated), the original item tends to be chosen at test. Conversely, when retrieval conditions at test fail to match conditions at encoding (i.e., random order of presentation at final test), participants are more likely to rely upon their most recent memory for the target event and consequently choose the misinformation item. Here then is empirical evidence to suggest that, given the provision of appropriate retrieval cues, it is possible to access memory for the original item; that is, the memorial representation for the original item still exists and appears not to have been subject to destructive updating (see also Eakins, Schreiber & Marshall, 2003; Lindsay & Johnson, 1989b) Amongst other significant challenges to Loftus’ destructive updating account, Lindsay and Johnson (1989a) demonstrated that, where participants were encouraged to attend to information concerning memory source, it was possible to eliminate misinformation effects. Although this can be interpreted as another co-existence account of the misinformation effect, it differs in that it does not propose any difficulty in retrieving the original item. Rather, the source monitoring explanation suggests that misled participants believe that the misinformation had actually occurred in the original target event. Such misattributions are likely to occur because the original and misinformation items both concern the same event. As the two sources for these items are highly similar, the standard misinformation paradigm arguably fosters ideal conditions for source misattribution errors to occur. Where similarity of source is reduced (by increasing the temporal distinctiveness of the material), a concomitant reduction in misinformation effects is observed (Lindsay, 1990). Lindsay and Johnson (1989b) also showed that it was possible to produce misinformation effects under conditions in which the misinformation was presented before the target event. They argued that the demonstration of this ‘reversed suggestibility effect’ is difficult to reconcile with a destructive updating account in which original material is updated by later (i.e., newer) material. Their work also suggested that the two-alternative forced-choice recognition test employed in the standard misinformation paradigm may actually encourage participants to base their judgements on feelings of familiarity. For critical slides, misled participants may choose the misinformation slide because it seems more familiar to them and mistakenly believe that the item had occurred in the original presentation. Related work by Zaragoza and colleagues (Zaragoza & Lane, 1994; Zaragoza & Koshmider, 1989), however, has indicated that misled participants can choose the misinformation item at test despite being aware that they could not remember seeing it in the original event. Thus, it would seem that participants can be aware of the source of memories but still favour the misinformation item, thereby indicating that source confusion cannot always provide an adequate account of the misinformation effect.

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Some researchers have taken the view that the standard misinformation paradigm (cf. Loftus, et al., 1978) tells us little about memory updating because of the problems of demand characteristics (i.e., implicit biases within the paradigm itself). McCloskey and Zaragoza (1985) demonstrated that where the two-alternative forced choice recognition test comprised a choice between an original item (e.g., a spanner) and a completely novel item (e.g., a screwdriver) rather than the standard procedure where the choice would be between an original item (e.g., a spanner) and a misinformation item (e.g., a hammer), memory performance for misled participants was little different from that of non-misled controls. The rationale behind McCloskey and Zaragoza’s modified test is that, if the introduction of misinformation results in the destructive updating of memory for original material (cf. Loftus, et al., 1978), misled participants could be expected to choose the original item less often than would participants who had not been misled. The fact that there was no difference between misled participants and controls led McCloskey and Zaragoza to surmise that Loftus’ misinformation paradigm provides no conclusive evidence that the introduction of misinformation modifies memory for original material. See also Zaragoza, McCloskey & Jamis (1987) and Weinberg, Wadsworth & Baron (1983) for further discussion of demand characteristics and how they affect the production of misinformation effects. There can be little doubt that social factors have the potential to influence report. The effect of others on social judgements is well-documented in the social literature (e.g., Asch, 1951). Great care, therefore, needs to be taken to minimise the effects of demand characteristics in misinformation studies. In our view, however, it is unlikely that misinformation effects can be attributed entirely to demand characteristics. On the one hand, we have a number of compelling studies that indicate the co-existence of memories for both the original and the misinformation item. In other words, one’s ability to access original material from memory is largely seen as a function of employing the most appropriate retrieval cues. On the other hand, we have equally compelling reaction time data which indicate that some form of integration is likely to have taken place shortly after the introduction of the misinformation item (Loftus, Donders, et al., 1989). Of course, this body of research may simply suggest that the misinformation effect can be multiply determined - a possibility that has already been acknowledged by Loftus (e.g., Loftus & Hoffman, 1989; Loftus, Korf & Schooler, 1989). In our view, however, it is also likely that we have revealed only part of the picture. Traditionally, memory has been characterised by passive processes such as interference and decay – the same processes that have been implicated in the production of the misinformation effect. We are currently engaged in a programme of research, however, which indicates that more active forgetting mechanisms may provide a credible alternative explanation as to why memorial representations for original material appear lost under certain conditions but available to conscious inspection under others. In the remainder of this article, therefore, we detail an active forgetting mechanism that we believe may contribute to the production of misinformation effects and help to explain this complex pattern of findings.

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RETRIEVAL-INDUCED FORGETTING Our current programme of research has led us to consider the possible role of retrievalinduced forgetting in the production of misinformation effects. Retrieval-induced forgetting (Anderson, Bjork & Bjork, 1994; Anderson & Spellman, 1995) refers to a form of forgetting that occurs as a consequence of remembering other related material. The basic rationale for this phenomenon stems from the observation that the cues we typically employ during memory retrieval are insufficiently specified. This means that there is a tendency to access not only the material we wish to remember but also unwanted related material that, in turn, provides unwelcome competition for recall. The problem for memory, therefore, is how to deal with unwanted competition from related memories during retrieval. Anderson and colleagues have suggested that memory accomplishes this feat via a form of suppression or active inhibition that renders unwanted competitors unavailable to conscious inspection. In much the same way that inhibition is thought to be responsible for resolving competition at other levels of information processing, inhibition may be responsible for resolving competition during memory retrieval (see Anderson & Bjork, 1994; Anderson & Neely, 1996). Retrieval-induced forgetting is typically demonstrated using the retrieval practice paradigm (Anderson et al., 1994) which comprises four phases: study, retrieval practice, distractor, and final test. In the study phase, participants are presented with a series of category-exemplar pairs and instructed to memorize the items (e.g., fish-bream, fish-trout, fish-flounder, fish-salmon, flower-tulip, flower-anemone, flower-rose, flower-daffodil). Participants are then instructed to perform retrieval practice on half the studied exemplars from half the categories using cued stem tests (e.g., fish-br____, fish-tr____). Each of these cued exemplars is typically presented three times. Following a distractor task, participants are then cued with each category name (e.g., fish, flower) and asked to recall all the exemplars originally presented. In these kinds of retrieval practice studies, recall performance for three types of exemplars is assessed: Rp+ items (i.e., practiced exemplars from practiced categories, bream); Rp- items (i.e., unpracticed items from practiced categories, salmon); and Nrp items (i.e., unpracticed items from unpracticed categories, tulip). The basic idea here is that if remembering some items from a category inhibits memory for other related material, then we should see poorer recall performance for unpracticed items from the same categories as practiced items than for unpracticed items from previously unpracticed categories. In other words, despite Rp- items and Nrp items being treated in the same way (i.e., both are unpracticed), Rp- items should be recalled more poorly than Nrp items by virtue of sharing the same retrieval cue as practiced items. See Figure 1 for an example of retrieval-induced forgetting (Macrae & MacLeod, 1999, Study 1). Importantly, the mere presentation of items without retrieval practice is insufficient for retrieval-induced forgetting to emerge (Anderson, Bjork & Bjork, 2000). Rather, the act of retrieval is a necessary prerequisite to set up the inhibition of related unpracticed items.

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0.8 0.7 0.6 0.5 Proportion 0.4 recall 0.3 0.2 0.1 0 Rp+

Rp-

Nrp

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Figure 1. Guided retrieval practice and retrieval-induced forgetting. The presence of retrieval-induced forgetting is measured by comparing recall performance for Rp- items with Nrp items (i.e., (Rp-) – Nrp). Rp+ = practiced items from practiced category. Rp- = unpracticed items from practiced category. Nrp = unpracticed items from unpracticed category. From Macrae and MacLeod (1999, Study 1).

APPLICABILITY TO THE REAL WORLD On reviewing the retrieval-induced forgetting literature, however, it would be easy to gain the impression that these effects might be limited to the rather esoteric world of learning category-exemplar pairs. With this in mind, Macrae and MacLeod (1999) set out to explore whether retrieval-induced forgetting also applied to the social world. They argued that it is one thing to forget previously encountered items of fruit or drink but that it may be an entirely different matter to inhibit the retrieval of information encountered in meaningful social contexts. Also, given that participants in retrieval-induced forgetting studies are typically instructed to remember target material prior to retrieval practice, the encoding conditions could be critical for inhibition to occur; that is, the initial instruction to remember the presented material could prove central for inhibition to take place. This point is of particular relevance to our understanding of eyewitnessing given that the inherent ambiguity of many criminal episodes means that we are seldom aware that what has been witnessed is of any importance until after the event. Using a set of traits describing two hypothetical individuals (Bill and John), Macrae and MacLeod showed that selective retrieval practice on traits about one of the individuals (i.e, the target) resulted in poorer recall performance for unpracticed traits about that target person relative to unpracticed traits about the non-target person, despite the fact that no explicit

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instructions had been given to remember the presented material. They also showed that retrieval-induced forgetting can be elicited even when participants are motivated to remember all the presented material (e.g., under mock examination conditions). Macrae and MacLeod presented participants with facts about two fictitious islands, Tok and Bilu (e.g., the main cash crop on Bilu is maize). Despite the fact that the participants were all university students and well-accustomed to studying and sitting examinations, participants still showed the typical retrieval-induced forgetting effect. Thus, it would appear that even when people are well-motivated – as honest eyewitnesses are likely to be – retrieval-induced forgetting still emerges. Finally, Macrae and MacLeod demonstrated that the amount of retrieval practice had little effect on the magnitude of the retrieval-induced forgetting effect. From an applied point of view, this is a particularly important point given that its relevance to understanding forgetting in the real world would have been severely limited if large amounts of retrieval practice had been deemed necessary for the effect to emerge. Given the apparent robustness and ease with which retrieval-induced forgetting can be produced, it is easy to appreciate its possible impact on everyday life. Arguably, nowhere is this more apparent than in the field of eyewitnessing where naturally occurring conditions (e.g., repeated questioning by police, lawyers, family members and colleagues about a witnessed event) may give rise to exactly those conditions that promote the inhibition of related memories. In order to explore this possibility, Shaw, Bjork and Handal (1995) examined memory for visually presented stimuli under conditions analogous to those experienced by eyewitnesses. Specifically, participants were told to imagine that they had attended a party and that, on leaving the party, they noticed that their wallet was missing. Participants were instructed to watch a series of slides of a student’s flat and to pay close attention to the details contained therein in order to assist police with their enquiries. The slides contained a number of household items plus two categories of target items (i.e., college sweatshirts and college schoolbooks). The retrieval practice phase of the study comprised questions about the target items which, in turn, produced evidence of retrieval-induced forgetting. In other words, guided retrieval practice on one of the classes of items (e.g., college sweatshirts) resulted in a significant decrease in recall performance for unpracticed items from the same category relative to recall performance for unpracticed items from the unpracticed category (e.g., college schoolbooks). The relevance of this form of active forgetting to the real world was further explored in a recent set of studies by MacLeod (2002). In the first study, participants were asked to imagine that they were police officers attending the scene of a crime and to pay close attention to a series of slides depicting a number of items ostensibly stolen from two houses (House A and House B). Guided retrieval practice resulted in retrieval-induced forgetting. Thus, it would appear that for retrieval-induced forgetting to occur, well-established semantic links are not required as in the case of exemplars of fruit, plants, or animals. Rather, it would appear that retrieval-induced forgetting can occur for recently learned semantic information. This study also provided clear evidence that the observed effects could not be accounted for by output interference; that is, the tendency for items recalled first to interfere with the recall of subsequent items (see also MacLeod & Macrae, 2001; Macrae & MacLeod, 1999). The second study by MacLeod (2002) explored the relevance of retrieval-induced forgetting to eyewitnessing by considering the effects of guided retrieval practice on memory for details about a fraudulent event (i.e., a bogus charity collection). In this study, however, participants were neither provided with information that drew attention to particular items for

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encoding nor any explicit category information with which to organise the witnessed material. In doing so, this study set out to mimic the kind of visual information typically available to real-life witnesses. If inhibitory mechanisms in memory have importance beyond the confines of the laboratory, then it should be possible to demonstrate retrieval-induced forgetting for information that can be mapped on to either pre-existing schemata or where the method of organising the material is implicit within the witnessed episode. Pilot work demonstrated that participants who viewed the bogus charity incident organised their recollection via the two women portrayed in the sequence of slides (i.e., a blonde and a brunette). This pilot work also offered the opportunity to identify the most common descriptive items recalled about each woman. These, in turn, formed the subject of the guided retrieval practice procedure. Despite the absence of any explicit organising principal around which the material could be organised, participants clearly organised material around the most salient perceptual dimensions (i.e., the two women). Guided retrieval practice again resulted in retrieval-induced forgetting effects. Thus, this study indicates that retrieval-induced forgetting is possible for recently learned semantic information even in the absence of explicit organising or grouping information. It would appear from these studies that, at the very least, there is a need to be as comprehensive as possible in the questioning of witnesses because of the risk that selective retrieval can result in the forgetting of other items that may ultimately prove important to the successful investigation or prosecution of a case (see Shaw et al., 1995). MacLeod has also raised the possibility that the kind of forgetting produced by guided retrieval practice may also be implicated in the production of misinformation effects.

RETRIEVAL-INDUCED FORGETTING AND THE MISINFORMATION EFFECT In the standard misinformation paradigm (cf. Loftus et al., 1978), participants are presented with a post-event questionnaire that probes memory for the previously witnessed target event. Inevitably, however, such questions do not constitute an exhaustive retrieval of all information known about that target event but rather focuses on a subset of items. The selective retrieval of information in the standard misinformation paradigm, therefore, may constitute exactly those conditions likely to promote retrieval-induced forgetting for items that were not the subject of the initial enquiry. If we consider this possibility further it is possible that, should misinformation be inadvertently introduced about an inhibited item, subsequent tests of memory for that item might result in a preference for the post-event misinformation given that memory for the original material may no longer be available for retrieval. Thus, if we return to our earlier example from Loftus et al (1978): ‘Did another car pass the red Datsun while it was stopped at the stop sign?’, the request for information concerns a second possible car. In addressing this question, there is no requirement to retrieve information about the type of sign at which the Datsun was stopped. Assuming that no other question focuses on memory for the type of sign, memory for a ‘Yield’ sign may subsequently become inhibited to the extent that only post-event information (i.e., that it was a ‘Stop’ sign) remains available for retrieval.

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In the real world, insufficient time or resources may mean that extensive police interviews may not be carried out. Incomplete retrieval of the material known about a witnessed event may, in turn, produce retrieval-induced forgetting for those items of information that had not been the subject of retrieval. Our thinking goes one stage further; that is, the incomplete retrieval of information about an event may also produce exactly those conditions that promote the incorporation of misinformation into memory by honest eyewitnesses. In other words, where misinformation has inadvertently been introduced about an item that has been the subject of retrieval-induced forgetting, only the misinformation may remain available to conscious inspection. In order to explore this possibility, we embarked on a set of studies that examined the relationship between retrieval-induced forgetting and the production of misinformation effects (see Saunders & MacLeod, 2002). Using a variant of the basic retrieval practice paradigm, we set out to investigate whether misinformation effects would be apparent where inconsistent post-event information had been introduced about Rp- items (i.e., items that had been inhibited as a result of selected retrieval practice of other related items). If our reasoning is correct, we could also expect that where misinformation is introduced about non-inhibited items (i.e., Rp+ or Nrp items) significant misinformation effects would fail to emerge.

STUDY 1 Study Phase Participants were presented with items ostensibly stolen from two houses (i.e., Jones’ and the Smith’s). Information was presented in the form of two narratives about two separate burglaries. Order of presentation of the two narratives was counterbalanced throughout. Information about the burglaries was contained within a booklet that also contained a number of distractor tasks in addition to the retrieval practice questions. Participants were prompted through each stage of the booklet by the experimenter. The first part of each narrative contained scene-setting information about when and where the burglary had occurred. Ten items were described as having been stolen from the Smith’s house and ten items from the Jones’ house. Each item was embedded within a set of sentences describing where the stolen item had originally been in located within the house. (e.g., ‘The television had been in the sitting room, which is at the front of the house. It was sitting in the corner of the room. The remote control for it hadn’t been taken.’) Earlier pilot work had established that the items chosen for each household were considered believable as potential stolen items in a burglary. On completing the first narrative, participants were instructed to read the second narrative. The stolen items were presented in blocked format (i.e., all items about the Jones’ house followed by the Smith’s house or vice versa) and their presentation fully randomized within each block. The information sets for each house were divided into two subgroups (each containing five items) for the purpose of creating a practiced (i.e., Rp+) and an unpracticed (i.e., Rp-) set of items for each theft.

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Retrieval Practice Immediately after the study phase, participants were presented with a series of questions about one of the subsets of stolen items from one of the houses, thereby creating Rp+, Rp-, and Nrp items sets. This series of questions comprised three sets of questions about five of the stolen items (i.e., 15 questions in total). In order to maximise the effects of retrieval practice, we adopted the procedure suggested by Landauer and Bjork (1978) whereby, on each successive set of retrieval practice questions, the inherent difficulty of the question sets increased. Question difficulty had been determined in earlier pilot work. Counterbalancing ensured that each item appeared equally often as Rp+, Rp- and Nrp items. Participants were required to write down all the stolen items they could remember from those presented originally. This served as a manipulation check that retrieval-induced forgetting had occurred in all experimental conditions. We also included a control condition in which participants received retrieval practice for the names of capital cities (e.g., ‘The capital city of Cuba is Ha____’ ). In doing so, we ensured that participants in the control were engaged in the same type of task (i.e., retrieval) but that it was ‘non-relevant’ in the sense that the questions concerned material unrelated to the items presented in the study phase. Each of the three retrieval practice phases was followed by a distractor task. On completion of the retrieval practice phase, participants were presented with a piece of misinformation about an Rp+, Rp-, or Nrp item. Participants in the control condition also received a piece of misinformation about one of the thefts, thereby providing a baseline level of misinformation reported in the absence of relevant retrieval practice. Only one misinformation was incorporated into each set of 12 questions so as not to arouse suspicions about the true nature of the study. Critical items that were the subject of misinformation were counterbalanced throughout for each condition.

Final Test The final task comprised a series of multiple-choice questions that probed memory for the stolen items. For non-critical items (i.e., where no misinformation had been presented), participants had to choose between the originally presented items and two new erroneous items. For the critical item, however, participants were required to choose between the original, the misinformation and a new item. On completion, participants were debriefed, thanked for their participation, and dismissed. (See Saunders & MacLeod, 2002 for further details of the materials and procedures employed).

Results Retrieval practice rates were 90.6%, 88.8% and 87.7% for the MisRp+ (i.e., where misinformation had been introduced about a practiced item), MisRp- (i.e., where misinformation had been introduced about a non-practiced item from the practiced set), and MisNrp conditions (i.e., where misinformation had been introduced about a non-practiced item from the unpracticed set), respectively. In order to establish an adequate test of our hypothesis that retrieval-induced forgetting facilitates the production of misinformation

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effects, we first confirmed that retrieval-induced forgetting had occurred in all the experimental conditions (see Figure 2). Indeed, across all treatment conditions, mean recall performance for unpracticed items from the unpracticed set was .43 whereas for unpracticed items from the practiced set mean recall performance was only .26. The magnitude of the difference between Rp- and Nrp items (i.e., the retrieval-induced forgetting effect) was also found to be highly comparable to other studies of retrieval-induced forgetting (Anderson et al., 1994; Anderson & Spellman, 1995; MacLeod, 2002; MacLeod & Macrae, 2001; Macrae & MacLeod, 1999).

0.9 0.8 0.7 0.6 Proportion 0.5 recall 0.4

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Figure 2. Proportion recall of each item type across misinformation conditions. Significant retrievalinduced forgetting effects occurred in each condition where participants engaged in relevant retrieval practice. Rp+ = practiced items from practiced category. Rp- = unpracticed items from practiced category. Nrp = unpracticed items from unpracticed category. From Saunders and MacLeod (2002, Study 1).

Additionally, we confirmed that Nrp recall performance in each of the treatment conditions (overall M = 0.43) was significantly lower than that achieved in the control condition (M = 0.56). Thus, we can be confident that the observed differences between Rpand Nrp items in the treatment conditions was not due to an inflation of the Nrp baseline performance but rather to a real drop in Rp- recall performance. Having demonstrated the presence of retrieval-induced forgetting in all three treatment conditions, we then turned to consider the critical issue of whether the misinformation effect is dependent upon retrieval-induced forgetting. The principal comparison of interest here is between the level of misinformation reported in the MisRp- condition where misinformation was introduced about an item that was subject to retrieval-induced forgetting versus the levels

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of misinformation reported in the MisRp+ and MisNrp conditions where misinformation was introduced about items that had not been subject to retrieval-induced forgetting. We found that in the MisRp- condition, 60% of participants chose the misinformation in comparison to 16% in the MisRp+ and 20% in the MisNrp conditions (see Figure 3). Chi-square analysis confirmed that there was no significant difference in the proportion of participants reporting misinformation in either the MisRp+ or MisNrp conditions compared with controls where no relevant retrieval practice had taken place.

0.7 0.6 0.5 Proportion of 0.4 misinformation effects 0.3 0.2 0.1 0 MisRp+

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Figure 3. Proportion of misinformation effects reported. Significantly more misinformation effects were found when misleading post-event information was introduced on an item that had been subject to retrieval-induced forgetting (i.e., MisRp- condition) than where it was presented about items that had not been subject to retrieval-induced forgetting (i.e., MisRp+, MisNrp, and MisControl conditions). MisRp+ = misinformation presented about Rp+ item. MisRp- = misinformation presented about Rpitem. MisNrp = misinformation presented about Nrp item. MisControl = misinformation presented about Control item. From Saunders and MacLeod (2002, Study 1).

We also noted that there was no significant difference in the final test performance across conditions for non-critical items (85%, 89%, 86% and 91% correct for the MisRp+, MisRp-, MisNrp, and control conditions, respectively). Thus, it would seem unlikely that the misinformation effect produced in the MisRp- conditions was due to poorer overall recall performance at time of test. In summary, this study provides us with a clear illustration that the retrieval practice of a subset of items can create conditions ideal for the promotion of misinformation effects. It would appear that when misinformation is introduced about items that have been subject to retrieval-induced forgetting, participants are significantly more likely to choose the misleading information during final test. In contrast, where misinformation is introduced

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about an item that has not been subject to retrieval-induced forgetting, the level of misinformation reported is no different from controls where no relevant retrieval practice had occurred.

STUDY 2 In order to test our hypothesis further, we posed an even more stringent test. As we and others have argued that retrieval-induced forgetting is the result of an active inhibitory mechanism (Anderson & Spellman 1995; Anderson & Green, 2001; Saunders & MacLeod, in press), it could be expected that misinformation effects would emerge only where that inhibition remains active. MacLeod and Macrae (2001) had previously demonstrated that, at least for certain kinds of information, the effects of retrieval-induced forgetting are transient. Specifically, they showed that where a 24-hour delay had been inserted between retrieval practice and final recall, the typical pattern of retrieval-induced forgetting disappeared. In contrast, the insertion of a 24-hour delay between original presentation and retrieval practice produced the typical retrieval-induced forgetting effect. MacLeod and Macrae argued that the transient nature of retrieval-induced forgetting reflects the need for flexibility in the selection of the material retrieved from memory in order to meet current or anticipated information processing goals. From one day to the next, we have little way of knowing what tasks we will be required to perform and what information from memory will ultimately prove critical for the completion of these tasks. Thus, MacLeod and Macrae have argued that it would not be particularly adaptive to render some forms of information permanently inaccessible given that this information may be just what is required in order to complete a future task. We used the transient nature of retrieval-induced forgetting to test our hypothesis further that misinformation effects are dependent upon retrieval-induced forgetting. Specifically, we predicted that where misinformation was introduced about a critical item that was still subject to retrieval-induced forgetting, the typical misinformation effect would emerge. In contrast, the introduction of misinformation about an item that had been subject to retrieval-induced forgetting but which was no longer inhibited, should fail to produce a misinformation effect. In order to test our hypothesis, we used the same materials as those employed in our first study. In this particular study, however, misinformation was introduced about Rp- items only (i.e., those items that were subject to retrieval-induced forgetting). Misinformation was introduced either following a free recall procedure in which participants experienced a 24hour delay between study and retrieval practice or following a 24-hour delay between retrieval practice and free recall. Manipulation checks were consistent with MacLeod and Macrae’s original findings. Importantly, we found that misinformation effects emerged only where retrieval-induced forgetting remained active; that is, where no delay had been inserted between any stages of the retrieval practice paradigm, or where a 24-hr delay was inserted between study and retrieval practice. No significant misinformation effects emerged where a 24-hour delay had been inserted between retrieval practice and recall (see Figure 4).

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0.9 0.8 0.7

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Figure 4. Proportion of participants reporting each item type on the free recall and forced-choice recognition test. When free recall was delayed by 24 hours retrieval-induced forgetting and misinformation effects were absent. When retrieval practice was delayed by 24 hours, or no delay occurred, both retrieval-induced forgetting and misinformation effects were detected. From Saunders and MacLeod (2002, Study 2).

DISCUSSION Our programme of research was designed to explore the extent to which retrieval-induced forgetting could promote the production of misinformation effects. In the present article we have detailed two of our initial studies in this field (Saunders & MacLeod, 2002). Both of these studies provide strong inference that retrieval-induced forgetting is a potent mechanism in facilitating misinformation effects. It is unlikely that the misinformation effects observed in our study can be attributed to demand characteristics (cf. McCloskey & Zaragoza, 1985) as it could have been expected that misinformation effects would have emerged across all conditions given that any demand characteristics would have been equivalent. Instead, we found in Study 1 that misinformation effects emerged only where misinformation had been introduced about items that had been subject to retrieval-induced forgetting. Similarly, it would be difficult to argue that the misinformation effect observed in the MisRp- condition (Study 1) was due to a failure to encode the critical item given the high level of recall performance for non-critical items across all conditions, or that some form of spontaneous forgetting might have occurred given that new erroneous information tended not to be chosen at test.

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Our interpretation that misinformation effects are facilitated by retrieval-induced forgetting is further supported by our second study in which we demonstrated that misinformation effects emerged only where retrieval-induced forgetting remained active. Also, the observed pattern of retrieval-induced forgetting observed in this study supports MacLeod and Macrae’s (2001) earlier findings that the effects of retrieval-induced forgetting are, at least under certain conditions, transient. One interpretation for this transient aspect of inhibitory processing is that memory needs to be flexible in order to meet the demands of a complex and constantly changing social world. For many kinds of information, it would make little sense to inhibit information on a more permanent basis as unknown future processing goals may require the processing of such information. This feature of inhibitory processing, however, also permitted us to explore further the role of retrieval-induced forgetting in the production of misinformation effects. From our studies it is clear that misinformation effects were produced only where there was evidence that retrieval-induced forgetting remained active. Where it had dissipated, in contrast, misinformation effects failed to emerge. Inevitably, however, our findings raise further questions and issues of theoretical and applied interest. The most obvious of these concerns the nature of the mechanism underlying retrieval-induced forgetting. As we intimated earlier, retrieval-induced forgetting can be caused by both non-inhibitory and inhibitory means. The present studies illustrate a strong relationship between retrieval-induced forgetting and the production of misinformation effects but do not provide conclusive evidence that the underlying mechanism is inhibitory. While there is good reason to think that the kind of retrieval-induced forgetting found using the retrieval practice paradigm is inhibitory and that output interference and source confusion were not significant contributors to the observed effects (see Saunders & MacLeod, 2002), there remains a need to provide more compelling data that the misinformation effects produced using this modified misinformation paradigm are a function of inhibitory control. In order to establish if this is the case, we must first determine the nature of the processes underlying the retrieval-induced forgetting effect found with our materials. To date, the best means of establishing whether retrieval-induced forgetting is caused by inhibition or not is via the independent cue technique (cf. Anderson and Spellman, 1995). This procedure involves the use of novel retrieval cues at final test rather than employing those retrieval cues used during initial study and retrieval practice. Anderson and Spellman’s rationale is that if the drop in recall performance for Rp- items is a consequence of non-inhibitory mechanisms (e.g., blocking) then it could be expected that the use of novel cues at final test would permit the Rp- items to be accessed (i.e., they should become retrievable). In other words, the typical retrieval-induced forgetting should fail to emerge if non-inhibitory mechanisms are responsible for its production. Anderson and Spellman and others (Anderson & Green, 2001; Saunders & MacLeod, in press), have demonstrated that Rp- items fail to emerge at final test despite the use of such novel retrieval cues, thereby providing strong inference that the Rpitems themselves had been inhibited. See Figure 5 for an example of independent cueing.

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Retrieval Practice Cue

Independent Cue

RED

fire truck

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FRUIT

strawberry

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Figure 5. Cue-independent forgetting. Inhibitory theories of retrieval-induced forgetting assume that the memory trace for the Rp- item (e.g., RED- strawberry) is actively inhibited due to its prior competition with the Rp+ items for retrieval. If the memory trace has been inhibited, the employment of independent retrieval cues (e.g., FRUIT) will be unsuccessful in overcoming inhibition.

Of course, if the active inhibition of the memorial trace is a necessary prerequisite for the production of misinformation effects, then the Rp- item is not the only item that may potentially be vulnerable to misleading post-event information. Anderson and Spellman (1995) previously demonstrated that items from an unrelated and unpracticed category can be inhibited due to their relationship with items from the practiced category. Specifically, items from the unpracticed category that share a retrieval cue with Rp- items (i.e., Nrp-similar items) are themselves vulnerable to inhibition. While these Nrp-similar items may not directly compete with Rp+ items for retrieval they are, nevertheless, related to items that do compete (i.e., Rp- items) and, thus, Nrp-similar items may suffer the same fate as that of Rp- items. Conversely, items from the unpracticed category that do not share a retrieval cue with any of the exemplars from the practiced category (i.e., Nrp-dissimilar items) are not subject to inhibitory control, presumably because such items neither compete for retrieval with Rp+ items, nor are they related to items inhibited due to retrieval competition (i.e., Rp- items). Extending this line of research, Saunders and MacLeod (in press) have recently determined (using the independent cue technique, cf. Anderson & Spellman, 1995) that items from the unpracticed category that share retrieval cues with items from the practiced category are susceptible to inhibitory effects. Consistent with Anderson and Spellman, we found that Nrp items that share retrieval cues with Rp- items were vulnerable to inhibitory effects but, additionally, we found that Nrp items that share retrieval cues with Rp+ items were also inhibited. Recall performance for items from the unpracticed category that were semantically

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dissimilar to items from the practiced category were not subject to inhibitory control and were recalled at a level similar to that observed for the between-subjects baseline control. Having determined which items are most likely to be inhibited, our next step is to evaluate the inhibitory account of misinformation effects by adapting our misinformation paradigm for use with the independent cue method. To address this goal, we need to add the necessary misinformation and recognition phases to the retrieval practice paradigm that we employed in Saunders and MacLeod (in press). If we are correct in our assertion that the inhibition of the original item facilitates the introduction of post-event misleading information, then all the items we determine to be inhibited should also be susceptible to misleading post-event information. Specifically, misinformation effects should occur in those conditions where misleading information is introduced about Rp- items, and also Nrp items that are semantically related to either Rp+ or Rp- items. Conversely, misinformation effects should not arise in conditions where misleading information is introduced about non-inhibited items (i.e., Nrp-dissimilar items). While our research provides a novel theoretical account of how misinformation effects are produced it also has the potential to inform us about possible solutions to practical memory problems. Specifically, experimental research that examines the influence of inhibitory retrieval processes, and their role in misinformation effects, may help to explain some of the memory distortions that typify honest eyewitness errors memory and even false memory syndrome, as well as providing insight into the design of more effective interview techniques. As argued elsewhere (e.g., MacLeod, 2002; Saunders & MacLeod, 2002), any interview technique that requires the selective retrieval of information may prove vulnerable to inhibitory control, and the production of misinformation effects. A practical concern, therefore, is that the method employed to solicit information from witness memory may also prove to be the very procedure that leaves witnesses vulnerable to forgetting previously unsolicited details and the subsequent report of misleading post-event information. Our concern with the combined effects of inhibition and misleading post-event information seems particularly timely given the proliferation of alternative investigative methods. Over the past few decades, interview methods such as the cognitive interview, guided memory interview and structured interview, have been championed by basic and applied researchers alike for their ability to enhance retrieval performance in comparison to the standard police interview. While many studies suggest that the specific techniques employed in such interviews can significantly increase the recall of details about a target event (e.g., Fisher, Geiselman & Raymond, 1987; Koehnken, Thurer & Zorberbier, 1994), and the recognition accuracy of suspects (e.g., Malpass & Devine, 1981), all these techniques tend to result in only a sub-set of details about the witnessed event being solicited. Additionally, if questioning results in the unintentional inhibition of memory traces that have not been subject to retrieval practice, then such interview methods may be particularly illequipped for dealing with kind of problem outlined in this article. For example, the retrieval methods employed by the cognitive interview assume that the inability of a witness to remember certain details is due largely to cue-dependent forgetting. Specifically, it is assumed that the failure to retrieve specific information is due to the use of inappropriate retrieval cues or interference having occurred along the retrieval route between the cue and the memory trace. Such cue-dependent forgetting can be overcome simply through employing more appropriate retrieval cues that utilise retrieval routes free from such interference. Unfortunately, if details of an event have been forgotten due to inhibition of the memory trace

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then such retrieval methods will not prove effective. Thus, irrespective of the quality or the quantity of the retrieval cues and retrieval routes provided, inhibited memories may remain stubbornly unavailable to retrieval. In sum, alternative questioning methods to the standard police interview may be just as susceptible to inhibitory control and, in turn, the unwitting introduction of misinformation. Only through further controlled experimentation are we likely to fully understand the complex relationship between forgetting and remembering and, in doing so, determine the means by which misinformation effects may be minimised in the real world.

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Loftus, E.F. & Palmer, J.C. (1974). Reconstruction of automobile destruction: An example of the interaction between language and memory. Journal of Verbal Learning & Verbal Behavior, 13, 585-89. Loftus, E.F., Schooler, J.W. & Wagenaar, W.A. (1985). The fate of memory: Comment on McCloskey and Zaragoza. Journal of Experimental Psychology: General, 114, 375-80. Loftus, E.F. & Zanni, G. (1975). Eyewitness testimony: The influence of the wording of a question. Bulletin of the Psychonomic Society, 5, 86-88. MacLeod, M.D. (2002). Retrieval-induced forgetting in eyewitness memory: Forgetting as a consequence of remembering. Applied Cognitive Psychology, 16, 135-149. MacLeod, M.D. & Macrae, C.N. (2001). Gone but not forgotten: The transient nature of retrieval-induced forgetting. Psychological Science, 12, 148-152. Macrae, C.N. & MacLeod, M.D. (1999). On recollections lost: When practice makes imperfect. Journal of Personality and Social Psychology, 77, 163-473. McCloskey, M. & Zaragoza, M. (1985). Misleading postevent information and memory for events: Arguments and evidence against memory impairment hypotheses. Journal of Experimental Psychology: General, 114, 1-16. Malpass, R.S. & Devine, P.G. (1981). Guided memory in eyewitness identification. Journal of Applied Psychology, 66, 343-350. Metcalfe, J. (1990). Composite Holographic Associative Recall Model (CHARM) and blended memories in eyewitness testimony. Journal of Experimental Psychology: General, 119, 145-60. Pirolli, P.L. & Mitterer, J.O. (1984). The effect of leading questions on prior memory: Evidence for the coexistence of inconsistent memory traces. Canadian Journal of Psychology, 38, 135- 41. Saunders, J. & MacLeod, M.D. (2002). New evidence on the suggestibility of memory: The role of retrieval-induced forgetting in misinformation effects. Journal of Experimental Psychology: Applied, 8, 127-142. Saunders, J. & MacLeod, M.D. (in press). Can inhibition resolve retrieval competition through the control of spreading activation? Memory & Cognition. Shaw, J.S. III, Bjork, R.A. & Handal, A. (1995). Retrieval-induced forgetting in an eyewitness-memory paradigm. Psychonomic Bulletin & Review, 2, 249-253. Stern, W. (1939). The psychology of testimony. Journal of Abnormal & Social Psychology, 34, 3-20. Weinberg, H.I., Wadsworth, J. & Baron, R.S. (1983). Demand and the impact of leading questions in eyewitness testimony. Memory & Cognition, 11, 101-04. Wright, D.B. & Davies, G.M. (1999). Eyewitness testimony. In F.Durso (Ed.), Handbook of applied cognition (pp. 789-818). New York: John Wiley & Sons. Zaragoza, M.S. & Koshmider, J.W. (1989). Misled subjects may know more than their performance implies. Journal of Experimental Psychology: Learning, Memory & Cognition, 15, 246-55. Zaragoza, M.S. & Lane, S.M. (1994). Source misattributions and the suggestibility of eyewitness memory. Journal of Experimental Psychology: Learning, Memory & Cognition, 20, 934-45. Zaragoza, M.S. & McCloskey, M., & Jamis, M. (1987). Misleading postevent information and recall of the original event: Further evidence against the memory impairment

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CONTENTS OF EARLIER VOLUMES Advances in Psychology, Volume 43 Chapter 1

Clinical and Psychosocial Correlates of Obsessive Compulsive Symptoms in Schizophrenia Paul H. Lysaker and Kriscinda A. Whitney

Chapter 2

Obsessive-Compulsive Disorder Following Acquired Brain Injury: A Clinical Neuropsychology Perspective B. Rudi Coetzer

Chapter 3

Speed and Accuracy of Obsessive-Compulsive Patients in Fronto-Subcortical Neuropsychological Tasks M. Angeles Jurado, Carme Junqué, Maria Mataró Julio Vallejo and Purificación Salgado

Chapter 4

Brain Imaging Studies in Obsessive Compulsive Disorder Köksal Alptekin, Berna Binnur Akdede, Yıldız Akvardar and Almila Erol

Chapter 5

Error Monitoring in Patients with Tourette’s Syndrome and Co-Morbid Obsessive Compulsive Disorder Sandra Verena Müller, Kirsten Müller-Vahl, Sönke Johannes and Thomas F. Münte

Chapter 6

Non Vocal Auditory Warning Signals: Judgment of Urgency and Informational Content A. Guillaume and C. Drake

Chapter 7

Coping with Physical Trauma: Development of a Specific Coping Instrument Mimmie Willebrand

Chapter 8

Managing Dental Anxiety in Children M. O. Folayan

Chapter 9

Attachment at Work Elizabeth Neustadt and Adrian Furnham

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Contents of Earlier Volumes

Advances in Psychology, Volume 41 Chapter 1

Leadership: Psychological Influences and Applications Sandra Speedy, Debra Jackson and Sally Borbasi

Chapter 2

The Involvement of Political Leadership in Conflict Resolution Yair Amichai-Hamburger, Jona M. Rosenfeld and Baruch Ovadia

Chapter 3

The Development of Allied Health Leaders for Dean Positions in Schools or Colleges of Allied Health Richard Bamberg and Elizabeth Layman

Chapter 4

The Psychopathic Criminal Mother: A Case Study of her Two Adult Daughters’ Expression of Basic Mistrust Eric A. Kreuter

Chapter 5

Mental Representations of Statistical Information Gary L. Brase and Aron K. Barbey

Chapter 6

Exploratory Subgrouping in CFS: Infectious, Inflammatory, and Other Karina M. Corradi, Leonard A. Jason and Susan R. Torres-Harding

Chapter 7

Human Rights and Psychology Ethics Codes in Argentina Andrea Ferrero

Advances in Psychology, Volume 40 Chapter 1

A Search for the “Hot” Cognitions in a Clinical and a Non-Clinical Context: Appraisal, Attributions, Core Relation Theme, Irrational Beliefs, and Their Relation to Emotion Daniel David,, Alin David, Ghinea Cristina, Bianca Macavei and Eva Kallay

Chapter 2

Social Desirability Measures and the Validity of Self-Reports: A Comprehensive Search for Moderated Relationships in Five-Factor Model Space Brian P. O’Connor

Chapter 3

The Internality Bias in Social Judgments: A Sociocognitive Approach Pascal Pansu

Chapter 4

Bipolar Disorder and Creativity: Investigating a Possible Link Rebecca Lloyd-Evans, Mark Batey and Adrian Furnham

Contents of Earlier Volumes Chapter 5

Genetic Relatedness Distinctions through Facial Resemblance Josephine Todrank and Giora Heth

Chapter 6

Behavioral Correlates of Facial Recognition of Emotions in Children and Young Adolescents Trish Vandiver and Jacqueline Duran

Chapter 7

Epigenetic Approach to the Perinatal Development of Affective Processes in Normal and at-Risk Newborns Robert Soussignan, Jaqueline Wendland and Benoist Schaal

Chapter 8

Large-Scale Prevention of Alcohol-Impaired Driving: A Review Kelli England Will, and Cynthia L. Shier

Advances in Psychology, Volume 39 Chapter 1

A Study of Group Defensive Mechanisms Wladimir A. Stroh

Chapter 2

Self and Partner's Parental Attachment History as Predictors of Desires for Greater Closeness and Autonomy in Close Relationships Brian P. O'Connor, Fortunata Perna, Joy Harrison and Erin Poulter

Chapter 3

Need for Closure, National Attachment, and Attitudes Toward International Conflict: Distinguishing the Roles of Patriotism and Nationalism Agnieszka Golec, Christopher M. Federico, Aleksandra Cislak and Jessica L. Dial

Chapter 4

User Expectations of Door Lock Control Devices Hwa Shik Jung

Chapter 5

Individual Differences in Web Search Behavior: Impacts of Users' Cognitive Style, Search Experience and Self-Assessed Problem-Solving Ability Kyung-Sun Kim

Chapter 6

Overtraining Facilitates Extradimensional Shift Learning Under a Specific Condition in Rats Esho Nakagawa

Chapter 7

Serotonergic Receptor Subtypes in Male Mouse and Rat Sexual Arousal Tamara G. Amstislavskaya and Nina K. Popova

Chapter 8

Personality Characteristics of 4-H Volunteer Leaders John R. Reddon and Darrell M. Toma

139

140

Contents of Earlier Volumes

Advances in Psychology, Volume 37 Chapter 1

Psychoanalysis and Computerized Content Analysis of Natural Language and the Measurement of Neurobiological Dimensions Louis A. Gottschalk

Chapter 2

A Psychology of Loss: A Potentially Integrating Psychology for the Future Study of Adverse Life Events Judith A. Murray

Chapter 3

Psychological Evaluation of Patients with a Nodular Goiter Before and After Surgical Treatment Zorica V. Čaparevic, Vladimir M. Diligenski, Dragos M. Stojanovic and Gradimir D. Bojkovic

Chapter 4

Denial of Illness: A Concept in Search of Refinement Walter Vandereycken

Chapter 5

Self And Partner's Parental Attachment History as Predictors of Desires for Greater Closeness and Autonomy in Close Relationships Brian P. O'Connor, Fortunata Perna, Joy Harrison, and Erin Poulter

Chapter 6

What You See is Never What You Get: Top-Down Influences From Beliefs, Expectations, and Emotional Processes Bias Perception and Memory Sabine Windmann

Chapter 7

Which is a Determinant Factor of Symmetry of Transfer Effect of Matching-(or Non-matching)-toSample Learning in Rats, Either an Inherent Bias Toward the Old Stimulus, or Amount of Preshift Training? Esho Nakagawa

Chapter 8

Short Overseas Business Trips: A Respite or Source of Stress? Mina Westman and Dalia Etzion

Advances in Psychology, Volume 36 Chapter 1

Forgiveness: The Self and the Norm Mélanie Gauché, Etienne Mullet and Gérard Chasseigne

Chapter 2

Toward an Understanding of the Sources of Influence on Male and Female Executive Decision-Making Under Risk and Uncertainty: Individual, Group and Organizational-Level Factors A. R. Elangovan and Leonard Karakowsky

Contents of Earlier Volumes Chapter 3

Security or Opportunity: The Effects of Individual and Situational Factors on Risk Information Preference R. Lion and Ree M. Meertens

Chapter 4

Risk Evaluation and Accident Analysis Dongo Rémi Kouabenan and Bernard Cadet

Chapter 5

Gender and Personality Across Life Span: A Comparison Based on Self-Ratings on the Polish Adjective List Piotr Szarota, Robert B. Kosek and Agnieszka Borowiak

Chapter 6

Defense Mechanisms: Their Relation to Personality and Health. An Exploration of Defense Mechanisms Assessed by the Defense-Q Michael Wm. MacGregor and Trevor R. Olson

Chapter 7

Transformative Psychological Intervention-The Family Justice Team: Treatment for “Anomie” in Singapore and Japan Joseph Paul Ozawa

Chapter 8

Can Motor States Influence Semantic Processing? Evidence from an Interference Paradigm Ezequiel Morsella and Robert M. Krauss

Chapter 9

Clinical Assessment of Self-Injurious Behaviors: An Overview of Rating Scales and Self-Reporting Questionnaires Laurence Claes, Walter Vandereycken and Hans Vertommen

Chapter 10

Lessons in Leadership: The Robert Wood Johnson Foundation Executive Nurse Fellows Program Janis P. Bellack, Robin L. Morjikian, Mary T. Dickow, Marilyn P. Chow and Edward H. O’Neil

Advances in Psychology, Volume 35 Chapter 1

What You See is Never what You Get: Dissociating Top-Down Driven Biases in Perception and Memory from Bottom-Up Processes Sabine Windmann

Chapter 2

Individual Differences in Web Search Behavior: Impacts of Users’ Cognitive Style, Search Experience and Self-Assessed Problem-Solving Ability Kyung-Sun Kim

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142

Contents of Earlier Volumes

Chapter 3

Gifted Children’s Identity Formation: Influential Factors and Significance Li Zuo

Chapter 4

Reconceptualizing Moral Judgment within a Reflectivity Framework Wan-chi Wong, Ka-ming Wong and Amy Chak

Chapter 5

Growing and Learning in the Greek Cypriot Family Context Stelios N. Georgiou

Chapter 6

Detailed Comparison of Closed Testing Procedures for Pairwise Testing of Means Philip H. Ramsey

Chapter 7

The Flynn Effect and LD Classification: Empirical Evidence of IQ Score Changes that Could Affect Diagnosis Stephen D. Truscott and Martin A. Volker

Advances in Psychology, Volume 34 Part I:

Cognitive Psychology

Chapter 1

Alexithymia as an Affecto-Cognitive Personality Construct Shulamith Kreitler

Chapter 2

Children’s and Adults’ Use of Notation and Its Influence on Memory Strategies Michelle Eskritt

Chapter 3

Carving up the Patchwise Transform: Towards a Filter Combination Model for Spatial Vision Tim S. Meese and Mark A. Georgeson

Part II:

Physiological Psychology

Chapter 4

Exponential Model of Pressure-Volume Relationship in the Finger Artery: Theoretical and Experimental Evaluation of Vascular Tone under Mental Stress and Reactive Hyperemia Gohichi Tanaka, Yukihiro Sawada, Kenta Matsumura, Ken-ichi Yamakoshi and Okayasu Takako

Part III:

Behavioral Psychology

Chapter 5

Humor Usage during Recalled Conflicts: The Effect of Form and Sex on Recipient Evaluations Amy M. Bippus

Contents of Earlier Volumes Chapter 6

Deception Confidence in Romantic Relationships: Confidently Lying to the One You Love Tim Cole

Chapter 7

How Motivational Inferences Influence Post-Suppressional Rebound Jens Förster and Nira Liberman

Chapter 8

Project EX: An Active Plan of Empirical Research for Adolescent Tobacco Use Cessation Steve Sussman, William J. McCuller, Cindy Zheng and Clyde W. Dent

Chapter 9

Defining Codependency: A Thematic Analysis of Published Definitions Greg E. Dear, Clare M. Roberts and Lois Lange

Chapter 10

A Longitudinal Study of Prosocial and Antisocial Behavior of Hong Kong Chinese Adolescents: The Influence of Parents, Peers, and Teachers Hing Keung Ma, Ka Keung Tam, Daniel T.L. Shek and Ping Chung Cheung

Chapter 11

Integrity in Professional Settings: Individual and Situational Influences Michael D. Mumford, Mary Shane Connelly and Lyle E. Leritz

Advances in Psychology, Volume 33 Part I:

Cognitive Psychology

Chapter 1

Language Comprehension in Complex Environments: Distraction by Competing Speech in Young and Older Adult Listeners Arthur Wingfield, Patricia A. Tun, Gail O'Kane, and Jonathan E. Peelle

Chapter 2

The Europe-America Bias: Where a Historical Event Occurred Affects When People Think it Occurred Avital Moshinsky and Maya Bar-Hillel

Chapter 3

Current Issues Related to Psychological Time Simon Grondin

Chapter 4

The Detection and Retrieval of Spelling in Older Adults Lise Abrams and Jennifer H. Stanley

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Contents of Earlier Volumes

Part II:

Physiological Psychology

Chapter 5

Modifications of Protein Kinase of Type C (PKC) in Obsessive-Compulsive Patients Before and After Treatments Donatella Marazziti, Stefano Baroni, Irene Masala, Laura Betti and Gino Giannaccini

Chapter 6

Participation of Cholinergic Muscarinic System in the Neuroimmune Mechanisms Involved in a Chronic Mild Stress Model of Depression G. A. Cremaschi, D. M. Silberman, M. L. Barreiro Arcos, V. Ayelli-Edgar and A. M. Genaro

Chapter 7

The Role of Mood States in the Development of Cardiovascular Disease: Implications of a Motivational Analysis of Cardiovascular Reactivity in Active Coping Guido H. E. Gendolla and Michael Richter

Chapter 8

Use of Selective Serotonin Reuptake Inhibitors in Neuropsychiatric Disorders Meera Vaswani, Subramanyam Ramesh, Harish Kalra and Rajesh Sagar

Part III:

Behavioral Psychology

Chapter 9

Leisure Motivation in Relation to Psychosocial Adjustment Michelle M. Munchua-DeLisle and John R. Reddon

Chapter 10

Support Reciprocity and Depression Among Children Hirokazu Taniguchi and Mitsuhiro Ura

Chapter 11

Need for Closure, National Attachment, and Attitudes Toward International Conflict: Distinguishing the Roles of Patriotism and Nationalism Agnieszka Golec, Christopher M. Federico, Aleksandra Cislak and Jessica L. Dial

INDEX A acceptance, xi, 63, 69, 73, 132 access, 42, 103, 116, 117, 118, 119 accounting, 46, 92, 95, 99, 102, 103 accumulation, 21, 33 accuracy, 76, 115, 131 achievement, 91 acid, 10 activation, x, 134 active coping, 144 adaptation, 94, 110 adjustment, 28, 94, 107, 109, 111 adolescence, xi, 87, 88, 89, 90, 91, 92, 93, 94, 95, 102, 103, 104, 105, 107, 108, 109, 110, 111, 112 adolescent boys, 90 adolescent female, 111 adolescents, 13, 88, 90, 91, 92, 93, 94, 102, 105, 106, 108, 109, 110, 111, 112 Adult, 143 adult population, 53 adulthood, xi, 87, 88, 89, 91, 92, 94, 95, 102, 103, 104, 107, 110 adults, 3, 4, 5, 13, 72, 86, 91, 106, 110, 111 affect, xi, 87, 89, 93, 94, 95, 98, 99, 100, 101, 102, 103, 104, 105, 118, 133 affective disorder, 12, 13, 31 age, xi, 4, 24, 27, 57, 63, 87, 88, 89, 90, 91, 92, 93, 94, 95, 97, 99, 100, 101, 102, 103, 104, 105, 106 agent, 19, 30 age-related, xi, 87, 88, 95, 103, 104, 106, 107 aging, 72 agnosia, 15 alertness, 63 allergy, 63 alternative, 41, 42, 50, 93, 105, 115, 117, 118, 131 alternative hypothesis, 93 alternatives, xi, 23, 69

ambiguity, 120 American Psychiatric Association, 41, 49, 51, 77, 83 American Psychological Association, 54 amygdala, ix, 1, 2, 3, 4, 5, 6, 8, 10, 11, 12, 13, 15 anatomy, 14 anger, 85 angina, 63, 64 animals, 29, 121 anorexia, 76, 77, 84 anorexia nervosa, 77, 84 antagonism, 97 antidepressant, x, 17, 19, 20, 22, 23, 24, 25, 28, 34, 37, 38, 40, 41, 42, 43, 45, 46, 48, 49, 50, 54 antidepressant medication, 41, 42, 46, 48 antipsychotic, 19, 23, 26, 30 antipsychotic drugs, 23, 26 anxiety, 45, 50, 52, 94, 98 anxiety disorder, 45, 52 apathy, x, 9 apoptosis, 29 appetite, 10 applied research, 114, 131 Argentina, 138 argument, 20 arousal, 85 artery, 9, 14 assessment, xi, 19, 24, 27, 33, 69, 73, 77, 81, 83, 84, 96, 97, 133 assignment, 48 association, ix, 2, 24, 29, 71, 73, 90, 92, 93, 95, 102, 104, 106, 108 assumptions, 75 attachment, 70, 92, 93, 94, 107, 111 attachment theory, 70, 107 attention, 43, 106, 115, 121, 132 attitudes, 47, 48, 52, 62, 83, 84, 85 attractiveness, xi, 69, 73, 80 attribution, 11

Index

146 auditory stimuli, 15 Australia, 18, 19, 23, 31, 87 autonomy, 50, 109, 111 availability, 37, 40, 46, 48, 115, 116 awareness, 39, 72

B back pain, 63 bankruptcy, 132 basal ganglia, 8, 14 basic needs, 61 Beck Depression Inventory, 44 behavior, x, 15, 25, 47, 50, 69, 70, 71, 75, 77, 83, 85, 111 behavior therapy, 50 behavioral aspects, 77 behavioral dimension, 84 behaviorists, 71 beneficial effect, x benzodiazepine, 10 bias, 48, 114 bipolar disorder, ix, x, 1, 2, 3, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 23, 28, 32 bipolar illness, 22, 23, 26, 29 blood, 10, 63 blood clot, 63 blood flow, 10 blood vessels, 64 BMI, 75, 76 body, x, 37, 46, 47, 49, 59, 60, 61, 62, 63, 64, 70, 83, 114, 118 body image, 83 bonding, 92 boys, 89, 90, 111 brain, ix, x, 1, 2, 7, 9, 10, 11, 12, 13, 14, 15, 18, 29, 30, 31, 32, 59, 60, 62, 64, 65 brainstem, 14 breast cancer, 66 bulimia, 73, 75, 76, 77, 84, 86 bulimia nervosa, 75, 76, 77, 84, 86

C Canada, 23 cardiovascular disease, 18, 144 caregivers, xi, 69, 70, 93, 94 case study, 11, 55 cell, 21, 29 central nervous system, 18 cerebral asymmetry, 13 child development, 66

childhood, xi, 64, 69, 71, 83, 86, 109 children, 70, 72, 73, 84, 108, 111, 144 China, 23 cholinergic muscarinic system, 144 chromosome, 28 chronic mild stress (CMS), 144 circadian rhythm, 29 circadian rhythms, 29 classes, 96, 121 clients, 63 clinical psychology, 75 clinical trials, 25, 40, 46, 52, 109 close relationships, 89, 93, 95, 102, 109, 110 clozapine, 23, 26, 30 CNS, 33 coding, 82 cognition, 3, 8, 15, 71, 83, 85, 132, 134 cognitive psychology, 114, 143 cognitive research, 115 cognitive therapy, 38, 41, 44, 51, 55 coherence, 60, 61, 66 cohort, 48 collaboration, 24, 25 combined effect, 131 commitment, 85, 88, 89, 90, 93, 105 communication, 105 community, x, 20, 26, 51, 54, 56, 69, 75, 84 comorbidity, 45, 53 competence, xi, 69, 73, 74, 80, 91, 93, 108, 109 competency, 42 competition, 22, 94, 119, 130, 134 complexity, xi, 42, 69, 74, 114 compliance, 25 components, 39, 74, 78 composites, 97 composition, xi, 70 computed tomography, 1 concentration, 18, 19, 21, 22, 24, 27 conception, 61 conditioning, 72 conflict, 62, 63, 91, 94, 95, 97, 106, 115 confusion, 117, 129 consciousness, 10, 60, 61, 62, 65, 66, 67 consensus, x, 40, 69, 75 consent, 97 construct validity, 82 construction, x, 69, 70, 75, 110 context, 47, 50, 71, 74, 83, 91, 111 continuity, 72, 95, 104, 105 control, ix, 1, 2, 3, 4, 5, 6, 7, 8, 9, 21, 33, 42, 47, 71, 74, 79, 80, 84, 113, 114, 123, 124, 125, 126, 129, 130, 131, 132, 134 control condition, 124, 125, 126

Index controlled studies, 20, 114 controlled trials, 23, 28, 37 contusion, 10 convergence, 78 coping, 47, 66, 105 core, 142 correlation, x, 10, 73, 75, 78, 80, 81, 82, 98 correlation coefficient, 81 cortex, 2, 6, 7, 9, 10, 11, 13 cortical neurons, 32 costs, 49 counsel, 66 counseling, 46, 48, 50, 51, 64, 67 coverage, 40 creativity, ix, x crime, 114, 121 cross-sectional study, 90, 94 Cuba, 124 cues, 71, 113, 116, 117, 119, 129, 130, 131 cultivation, 62 culture, 111 cycling, 10, 15, 23

D damage, ix, 1, 2, 9, 10, 11, 12, 15, 29 data collection, 96, 97, 107 data set, 41 database, 21, 40, 43, 45, 49 dating, 88, 91, 96, 109, 110, 112 death, 25, 28, 29, 62 decay, 118 decision making, 48 decisions, 48, 56, 61, 62, 98 defense, 67 Defense-Q, 141 definition, xi, 23, 26, 69, 70, 73, 75 delirium, 14 delivery, 49 demand, 115, 118, 128 demand characteristic, 115, 118, 128 demographics, 8 denial, 9 Denmark, 19, 20, 23, 59, 67 dependent variable, 99 deposits, 18 depression, x, 4, 5, 6, 7, 8, 9, 10, 18, 19, 20, 22, 23, 24, 27, 28, 29, 30, 31, 32, 33, 34, 37, 38, 39, 40, 41, 42, 43, 45, 46, 47, 48, 50, 51, 52, 53, 54, 55, 56, 57, 63, 73, 84, 86, 89, 90, 94, 98, 103, 108, 110, 144 depressive symptomatology, 49 depressive symptoms, 26, 52, 89, 93

147

destruction, 134 detection, 143 determinism, 82 developmental psychology, 107 diagnostic criteria, 43, 77, 81 diet, 18 dimensionality, 84 disappointment, 46 discipline, 42 disclosure, 105 discrimination, 71 disorder, ix, x, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 21, 31, 32, 33, 34, 38, 41, 45, 50, 51, 53, 55, 56, 64, 76, 77, 84, 85, 110 dissatisfaction, 46 distortions, 131, 133 distraction, 143 distress, 111 distribution, 27 diuretic, 77 division, 11 DNA, 22 domain, 88, 95, 103 dosage, 63 double-blind trial, 33 Drosophila, 33 drug treatment, 42 drugs, 19, 21, 22, 23, 24, 25, 26, 29, 30, 34, 35, 52, 73 DSM, 77 DSM-IV, 77 duration, 4, 10, 19, 20, 22, 24, 25, 27, 39, 44, 55 dysphoria, 91 dysthymia, x

E eating, 73, 75, 76, 77, 81, 82, 83, 84, 85, 86 eating disorders, 73, 75, 76, 77, 81, 82, 84, 86 ecology, 109 ego, vii, x, 59, 60, 62, 63, 64, 65, 67 elderly, 45, 52, 53, 56 emergence, 71, 73, 108 emission, 2 emotion, 15 emotional experience, ix, 1 emotional responses, 111 emotional state, 91 emotional valence, 11 emotions, 64, 90, 93, 110 employment, 27, 130 encoding, 114, 117, 120, 122 endocrine, 26

Index

148 endogenous depression, 34 England, 53, 132, 139 enlargement, 12, 13 environment, 60, 72 equilibrium, 63 erythrocyte, 21, 24 ethnicity, 96 etiology, 38, 50 euphoria, 9, 10 Europe, 20, 23, 27, 143 Europe-America bias (EAB), 143 everyday life, 121 evidence, ix, x, 1, 17, 25, 26, 27, 28, 29, 30, 31, 32, 33, 39, 42, 43, 53, 73, 89, 93, 96, 98, 104, 105, 106, 111, 115, 116, 117, 118, 121, 129, 134 evil, 63, 66 examinations, 106 excitotoxicity, 35 execution, 65 expectation, 103 experimental condition, 124, 125 exposure, 44, 89 expression, 31, 62 extrapolation, 114 extroversion, 98 extrovert, 63

F facial expression, 15 Factor, 140 factor analysis, 75, 78, 79, 80, 82 failure, 46, 61, 72, 128, 131 family, xi, 6, 7, 8, 10, 27, 61, 63, 87, 89, 90, 92, 93, 94, 95, 98, 99, 100, 101, 102, 103, 104, 105, 106, 108, 110, 111, 121 family environment, 110 family history, 6, 8, 27 family members, 92, 104, 121 family relationships, 94, 98, 100, 101, 103, 104 family support, 99 feelings, 62, 64, 73, 94, 97, 117 females, 75, 84, 89, 90, 96, 99, 102, 103, 104, 105, 106, 108 fish, 119 flexibility, 127 fluid, 19 fluoxetine, 24 focus groups, 47 focusing, 39 forgetting, 113, 114, 118, 119, 120, 121, 122, 123, 124, 125, 126, 127, 128, 129, 130, 131, 134 framing, 56

France, 23 free recall, 127, 128 friend support, xii, 88, 97 friends, xi, 64, 87, 88, 89, 90, 91, 92, 93, 94, 95, 97, 98, 99, 102, 103, 104, 105, 106, 108, 111 friendship, 88, 90, 91, 92, 94, 104, 107, 109, 110, 111 frontal cortex, 29 frontal lobe, ix, 7, 10 functional MRI, 2

G gender, 24, 27, 46, 89, 90, 96 gender differences, 89, 90, 96 gene, 29, 33 general practitioner, 56 generalization, 88 generalized anxiety disorder, 45, 56 generation, 23, 26 genes, x, 28, 34 genetics, ix, 26 genital herpes, 26 genital warts, 63 genotype, 34 Germany, 23 gift, x gifted, 61 girls, xi, 88, 89, 90, 95, 103, 104, 105, 111 globus, 7 glutamate, 32 glycogen, 32 goals, 39, 71, 73, 129 God, 60 gold, 77 gout, 18 grades, 90, 97 gray matter, 4, 7, 13 Great Britain, 20 grief, 39 group activities, 92 group therapy, 66 grouping, 122 groups, 20, 23, 24, 27, 43, 73, 81, 104 growth, 21, 22, 103 guidance, 49 guidelines, 40

H happiness, 61, 65, 83, 90, 95, 105 harm, 48

Index head injury, 10 healing, 62, 66 health, 32, 39, 43, 47, 50, 53, 55, 60, 61, 66, 108 health care, 47 health care professionals, 47 health problems, 108 health services, 53 height, 75 herpes, 22, 24, 26, 32, 34, 63 herpes infections, 24 herpes simplex, 34, 63 heterogeneity, 8 high school, 93, 96, 97 hip, 88 hippocampus, 2, 3, 4, 8, 10, 29 History, 140 holistic medicine, vii, x, 59, 60, 63, 64, 66 homogeneity, 81 Hong Kong, 143 hopelessness, 45 hospitalization, 20, 27, 28 hostility, 85 human animal, 71 human behavior, x, 59, 64, 73 human brain, 33 human subjects, 21 humoral immunity, 26 hypertension, 63 hypothalamus, 6 hypothesis, ix, 11, 21, 31, 70, 94, 104, 124, 127, 135

I ideas, x identification, 17, 72, 74, 134 identity, 83, 107 imaging modalities, 1 immunomodulatory, x, 17, 26, 30, 34 implementation, 39 in vitro, 29, 33 incentives, 115 inclusion, 27, 39 indication, 25 indicators, 94, 98 indices, 40 individual development, 106 individual differences, 106, 111 Individual Differences, 141 individuality, 90 industry, 38 infancy, 72, 107 infarction, 9, 14 infection, 22, 32

149

inflation, 125 influence, 21, 41, 45, 47, 50, 70, 91, 93, 94, 102, 104, 106, 114, 118, 131, 134 Influence, 140, 141, 142, 143 information processing, 119, 127 informed consent, 50 inhibition, ix, 22, 29, 32, 119, 120, 121, 127, 129, 130, 131, 132, 134 inhibitor, 29 initiation, 62 injury, ix, 1, 9, 10, 11, 14, 15 inositol, 22 input, 70 insertion, 127 insight, 10, 47, 131 instruction, 120 instruments, 40 insurance, 40 integration, 112, 115, 118, 133 intellect, 10 intensity, 10, 11, 44 intent, 46, 60 intentions, 61 interaction, 91, 134 interactions, xi, 69, 70, 71, 95, 97, 99, 101, 102, 104, 105, 106 interest, 6, 10, 19, 22, 23, 29, 30, 40, 63, 89, 95, 96, 114, 125, 129 interference, 116, 118, 121, 129, 131, 132, 133 internal consistency, 74, 83, 98 internet, 59 interpersonal relations, 39, 88, 89, 90, 99, 106 interpersonal relationships, 39, 89, 90, 99, 106 interpersonal skills, 91 interpretation, x, 59, 60, 64, 67, 116, 129 interval, 75 intervention, 40, 41, 44, 46, 48, 49, 50, 53 interview, 47, 77, 84, 96, 97, 131, 133 intimacy, xi, 87, 88, 89, 90, 91, 92, 95, 97, 103, 104, 106, 108, 109 introversion, 98 ions, 17, 22 IQ, 142 Israel, 59 Italy, 23

J Japan, 1, 23, 141 judgment, 44

Index

150

K kidney, 22 kidneys, 18 knowledge, 38, 70, 85, 105, 116

L labeling, 98 lack of control, 48 language, 70, 71, 85, 132, 134 latent inhibition, ix lawyers, 121 lead, 46, 47 leadership, x, 59, 60, 64, 132 Leadership, 141 learning, 10, 39, 72, 85, 116, 120, 133 learning process, 72 leisure, 144 leisure motivation, 144 lesions, 9, 15, 29, 35 leukemia, 29 life experiences, 47, 102 life satisfaction, 94 life span, 110 lifetime, 45, 52 likelihood, 47, 82 limitation, 105 links, 104, 121 literacy, 53 lithium, x, 10, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34 location, 10 locus, 72 loneliness, xi, 87, 88, 89, 93, 95, 98, 99, 103, 104 longevity, 105 longitudinal study, 75, 89, 93, 95 long-term memory, 132 love, vii, 59, 60, 62, 91, 97, 110 loyalty, 90, 94

M magnetic resonance, 1, 12, 13 magnetic resonance imaging, 1, 12, 13 magnetic resonance spectroscopy, 2 major depression, x, 37, 38, 40, 41, 42, 43, 45, 49, 50, 52, 53, 54, 55, 56 major depressive disorder, 56, 93 malaise, 10 males, 75, 89, 90, 105, 106, 108 management, 40, 43, 51, 56

mania, 8, 9, 10, 12, 13, 14, 15, 18, 19, 20, 23, 25, 28, 30 manic, x, 9, 10, 14, 18, 19, 24, 25, 26, 33, 34 manic symptoms, 18 manic-depressive illness, 19, 26, 29 manipulation, 124 marital status, 102 marriage, 92, 105 mastery, 70 matching, 140 matrix, 78 meanings, 70 measurement, 12, 73, 84, 86, 98 measures, 74, 75, 77, 98, 99, 100, 101, 102 medication, 25, 33, 38, 40, 41, 42, 43, 45, 46, 48, 49, 50, 52, 54, 63 memory, 10, 15, 70, 113, 114, 115, 116, 117, 118, 119, 121, 122, 123, 124, 127, 129, 130, 131, 132, 133, 134 memory performance, 118 memory retrieval, 119, 132 men, 12, 64, 132 mental health, 39, 44, 49, 51, 56, 61, 85, 91 mental health professionals, 51, 56 mental processes, 64 mental state, 10 metabolism, 18 metals, 30 methodology, 38, 48, 115 mineral water, 17 minority, 42, 46 models, 29, 38, 46, 50, 91, 102 momentum, 19 monitoring, 34, 50, 117 mood, x, 2, 3, 7, 9, 10, 11, 13, 14, 17, 19, 20, 21, 22, 23, 24, 25, 26, 29, 30, 31, 33, 34, 35, 37, 38, 41, 42, 43, 46, 49, 50, 144 mood disorder, 13, 14, 19, 20, 21, 24, 26, 30, 33, 37, 38, 41, 42, 43, 46, 49, 50 mood states, 144 mood swings, 10 morbidity, 20, 27, 30, 52 mortality, 25, 27, 30, 33 mortality rate, 25 mortality risk, 25 motivation, xi, 88, 95 motives, 88, 92, 95, 103, 104, 106 MRI, ix, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 MRS, 2 multidimensional, 70, 83 multiple-choice questions, 124 muscles, 63

Index

N Nakagawa, 140 narratives, 123 needs, 39, 106, 118, 129 negative attitudes, 62 negative emotions, 62, 91, 103 negative relation, 90 negotiating, 95 negotiation, 47, 48, 105 network, 12, 43 neurodegenerative disorders, 29 neuroimaging, ix, 1, 2, 14 neuroleptics, 30 neurological disease, 10 neuronal circuits, 7, 14 neuroprotection, 32 neuroticism, 45 New South Wales, 57 New Zealand, 57 North America, 84 nuclear magnetic resonance, 12 nuclei, 6, 11 nucleus, 6 nurses, 39, 42, 50, 54 nurturance, xi, 87, 92, 95, 97, 103

O observations, 19, 70 occlusion, 9 olanzapine, 23, 26 older adults, 143 operant conditioning, 72 organ, 30 organism, 18, 30, 61 organization, 32, 43 orientation, 39 outline, 113 output, 121, 129 overload, x

P pain, 61, 63 panic disorder, 45 parent-adolescent relationships, 98 parenting, 93 parents, 71, 74, 91, 92, 93, 94, 97, 98 passive, 47, 48, 118 pathogenesis, 3, 29, 34 pathology, 45

151

pathophysiology, 11 pathways, 109 PCA, 78 Pe, 140 Pearson correlations, 100 peer rejection, 107 peer relationship, 94, 95, 96, 111 peers, 74, 91, 108 perceptions, 105, 106, 109 periodicity, 10 permit, 49, 114, 129 personal history, 63 personal relationship, 109 personality, 9, 45, 48, 54, 64, 67, 79, 84 personality disorder, 45, 54 personality factors, 45 perspective, 48, 61, 70, 72, 86, 108, 109, 110 PET, 2, 6 pharmacological treatment, 24 pharmacology, 19, 34 pharmacotherapy, 18, 38, 41, 42, 43, 49, 50, 51, 53, 54, 55, 56 physical health, 61 physical properties, 72 physical well-being, 92 physiology, 23 pigs, 18 placebo, 19, 20, 28, 40, 41, 54 planning, 47, 65 plants, 121 plasma, 21, 24 plasticity, 29 PM, 34 Poland, 17, 20, 23 polarity, 33 police, 113, 121, 123, 131, 133 polyuria, 27 poor, 22, 46, 63 population, xi, 21, 22, 24, 25, 48, 70, 74, 77, 80, 83, 84, 86, 110 positive reinforcement, 39 positive relation, 92 positron, 2, 15 positron emission tomography, 2, 15 potassium, 21 power, 62, 72, 73, 74 prediction, 70, 71, 84 predictors, 33, 53, 55, 107 preference, 38, 46, 47, 48, 49, 50, 52, 113, 114, 117, 122 prefrontal cortex, ix, 1, 2, 6, 13, 14 preparation, 38, 102 pressure, 132

Index

152 prevention, 27, 31, 33, 73 principal component analysis, 78 principle, 42 probability, 50 probe, 113 problem behavior, 93 problem solving, 39, 41, 44, 48, 54 problem-solving, 40, 41, 44, 45, 54, 105 production, 29, 113, 115, 118, 119, 122, 123, 124, 128, 129, 130, 131 program, 47, 75 Project EX, 143 proliferation, 29, 131 prophylactic, 19, 20, 21, 22, 25, 27, 28, 30, 33, 34 prophylaxis, 22, 23, 24, 25, 26, 27, 28, 30, 31, 32, 33, 34 prosocial behavior, 94 protein kinase, 144 protein kinase C (PKC), 144 psychiatric disorders, 73, 86 psychiatric illness, 30 psychiatric patients, 38, 42, 75 psychiatrist, x, 17, 18, 19 psychoanalysis, 60 psychological time, 143 psychological well-being, xi, 87, 88, 103, 107 psychologist, 64, 73 psychology, ix, 56, 60, 66, 70, 75, 85, 113, 134 psychometric properties, xi, 69, 74, 76, 83 psychopathology, x, 45, 77, 84, 108 psychopharmacology, 18, 29 psychoses, 30, 34 psychosis, 4, 5, 6, 13, 14, 30, 33, 73, 85 psychosocial adjustment, 144 psychosocial functioning, 112 psychotherapy, x, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 49, 50, 52, 53, 54, 55, 56, 57, 59, 64, 65 punishment, 97

Q quality improvement, 47, 52 quality of life, 61, 66, 109 questioning, 48, 121, 122, 131 quetiapine, 26

R race, 96 random numbers, 78 range, 10, 19, 20, 39, 43, 44, 95, 96, 98, 106, 115 rating scale, 53

ratings, 98 reaction time, 115, 118 realism, 114 reality, 133 reasoning, 123 recall, 115, 116, 119, 120, 121, 125, 126, 127, 128, 129, 131, 132, 134 recalling, 114 receptors, 30 reciprocity, 105 recognition, 11, 15, 72, 115, 117, 118, 128, 131, 132, 133 recognition phase, 131 recognition test, 115, 117, 118, 128, 132, 133 reconcile, 117 recovery, 40, 41, 42, 44, 45, 52 recreation, 91 recruiting, 50 recurrence, 15, 20, 24, 42 reduction, 3, 6, 10, 12, 13, 22, 25, 40, 43, 44, 116, 117 reflection, 30, 64 reflexivity, 83 regression, 99, 102, 104 regulation, 2, 3, 7, 29, 83, 85, 86, 109 rehabilitation, 60, 62 reinforcement, 71 relapses, 24 relationship, ix, 19, 41, 44, 46, 53, 73, 84, 88, 91, 92, 93, 94, 96, 97, 103, 105, 106, 107, 111, 113, 114, 123, 129, 130, 132 relationships, xi, 39, 47, 53, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 99, 100, 101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111 relevance, 120, 121 reliability, 74, 75, 77, 82, 83, 97, 98 religion, 60 remembering, 84, 114, 119, 132, 134 remission, 18, 22, 24, 43, 45, 46 René Descartes, 64 replacement, 18 replication, 8, 22, 31, 34, 75, 106 repression, 61 resilience, 33, 74, 80 resistance, 63, 133 resolution, 2, 3, 8 resources, 38, 42, 62, 123 response time, 115 responsibility, 61, 63 retrieval, 113, 115, 116, 117, 118, 119, 120, 121, 122, 123, 124, 125, 126, 127, 128, 129, 130, 131, 132, 133, 134, 143 retroactive interference, 116, 132

Index rheumatic diseases, 18 right hemisphere, 9 risk, 28, 32, 33, 34, 48, 49, 73, 75, 77, 85, 91, 110, 111, 122 risk factors, 75, 77, 85 risperidone, 23, 26 robustness, 43, 115, 121 romantic involvements, 89 romantic relationship, xi, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 102, 103, 104, 105, 106, 108, 109, 110, 111 Rosenberg Self-Esteem Scale, 76 rotations, 82 Rouleau, 34

S salts, 18, 19, 31, 32, 34 same-sex friendships, 94, 104, 110 sample, 24, 28, 75, 76, 77, 78, 80, 81, 82, 83, 86, 89, 106 sampling, 91 satisfaction, 47, 55, 92, 103 schizophrenia, 3, 4, 5, 6, 8, 9, 12, 13, 30 school, 73, 74, 76, 90, 96, 97, 98 school performance, 73 scores, 44, 75, 76, 77, 81, 82, 97, 98 search, 10 searching, 96 secretion, 26 security, xi, 88, 92, 93, 94, 95, 103, 105 selective serotonin reuptake inhibitors (SSRIs), 144 self, vii, x, 48, 56, 59, 60, 61, 62, 63, 64, 66, 69, 70, 71, 73, 74, 75, 76, 77, 78, 80, 81, 82, 83, 84, 85, 86, 90, 93, 94, 97, 98, 103, 107, 108, 109, 110, 111 self esteem, 73, 85 self-awareness, 71 self-concept, xi, 64, 69, 70, 73, 74, 85, 103, 109 self-consistency, x, 59, 64 self-control, 73 self-efficacy, 73 self-esteem, xi, 69, 73, 74, 75, 76, 78, 80, 81, 82, 83, 84, 85, 86, 90, 93, 94, 107, 108, 109, 110, 111 self-expression, 63 self-identity, 73 self-image, 111 Self-Injurious Behaviors, 141 self-knowledge, 72 self-regard, 82 self-regulation, 73 self-worth, 61, 94 semantic information, 121, 122

153

sensitivity, 109 series, ix, 1, 2, 20, 88, 113, 114, 116, 119, 121, 124 serotonin, 29, 34 serum, 19, 31 severity, 24, 38, 40, 41, 42, 43, 44, 45, 46, 50, 55, 77, 110 sex differences, 89, 109, 111 sexual behavior, 108 sexuality, x, 59, 60, 62, 64 shame, 62 shape, 70, 77 shaping, 70 sharing, 107, 119 siblings, 91 side effects, 27 sign, 82, 114, 122 similarity, 106, 117 Singapore, 141 sites, 96 sleep disturbance, 10 smoking, 73 social activities, 98 social behavior, 85 social capital, 103 social competence, 93 social context, xi, 69, 120 social development, 107 social network, 109 social norms, x, 69, 75 social order, 84 social psychology, 73 social relations, 102, 104 social relationships, 102, 104 social skills, 39 social support, 47, 92, 97, 100, 101 social workers, 50 socialization, 72, 91 sodium, 18, 21, 32 South Africa, 26 specificity, 12, 22 spectrum, ix speculation, 27 speech, 143 spelling, 143 spirituality, 47, 85 SPSS, 78 stability, 106 stabilizers, 26 stages, 92, 107, 113, 127 standards, 8, 25, 40, 43 statistics, 91 stigma, 47 stimulus, x, 71, 85, 116

Index

154 strategies, 39, 47 strength, 64 stress, xi, 27, 66, 69, 85, 89, 90, 91, 103, 105, 106, 107, 110, 111 stressors, 89, 93, 94 striatum, 2, 7, 9 stroke, ix, 1, 9 students, 60, 64, 75, 77, 81, 82, 90, 94, 96 subjective experience, 64 substitutes, 31 substrates, ix, 1, 3 suicidal behavior, 24 suicidal ideation, 52, 53 suicide, 25, 28, 30, 34, 86 suicide attempts, 28 summer, 96 Sun, 139, 141 supervision, 51 supply, 96 support reciprocity, 144 suppression, 119 survival, 42, 62, 66 survival rate, 42 susceptibility, x, 34 suspects, 131 Sweden, 69, 75 switching, 10 Switzerland, 23 symbols, 65, 70 symptom, 38, 45 symptoms, 18, 19, 24, 45, 53, 57, 63, 76, 93 synaptic plasticity, 29 syndrome, 14, 131 synthesis, 22 systems, 22, 47, 60, 61

T tactics, 94 talent, 60, 65 targets, 2 taxonomy, 111, 132 telephone, 96 television, 88, 123 temporal lobe, 2, 4, 8, 12, 13 test-retest reliability, 74, 78, 83 thalamus, 7, 10, 11 theory, 39, 62, 64, 65, 66, 67, 71, 83, 85, 93, 104, 107, 109, 110, 114 therapeutic benefits, 44 therapeutics, 33 therapists, 22, 40

therapy, x, 17, 18, 19, 20, 21, 22, 23, 24, 26, 29, 30, 31, 32, 34, 38, 39, 40, 41, 42, 44, 45, 51, 56, 62, 63, 85 thinking, 30, 64, 70, 79, 80, 90, 123 threshold, 77 thyroid, 27 time, xi, 18, 19, 20, 24, 25, 26, 29, 40, 43, 44, 49, 51, 53, 63, 72, 78, 87, 88, 90, 92, 93, 95, 96, 97, 98, 99, 100, 101, 102, 103, 105, 115, 123, 126 tinnitus, 63 tissue, 29 toxicity, 18, 19 tracking, 107 traffic, 10 training, 39, 43, 50, 71, 77 traits, 120 transactions, 111 transformation, 71, 98 transition, 39, 83, 86, 93, 102, 109 transitions, 39, 88, 108 translation, 76 transparency, 62 transport, 21, 32, 33 traumatic brain injury, ix, 1, 9, 10, 15 tremor, 27 trend, 7, 27, 41, 49 trial, 20, 28, 31, 34, 39, 46, 51, 52, 54, 56, 57 tricyclic antidepressant, 31 tricyclic antidepressants, 21, 32

U UK, 23, 26, 113 uncertainty, 56 uniform, 43 United States, 18, 96, 110 universe, 62 university students, 121 updating, 115, 117, 118 urban areas, 42 uric acid, 18 urine, 18

V vacuum, 93 validation, 77, 80, 82, 93, 110 validity, ix, 55, 72, 74, 75, 77, 81, 82, 83, 98, 111, 114 values, 24, 98 variability, 91 variable, 3, 10, 40, 49, 91, 98

Index variables, 28, 42, 45, 70, 75, 100, 101 variance, 78, 82 victimization, 108 viruses, 22, 26, 31 vulnerability, 85, 90

W well-being, xi, 87, 89, 91, 92, 93, 94, 95, 97, 98, 99, 100, 101, 102, 103, 104, 105, 106, 110, 111 white matter, 2, 14 William James, 72 withdrawal, 25

155

witnesses, 115, 122, 131 women, 75, 83, 110, 122 words, 95, 104, 116, 118, 119, 121, 123, 129 work, 21, 23, 30, 48, 61, 63, 98, 102, 103, 114, 115, 116, 117, 122, 123, 124 workplace, 63 worry, 79 writing, 64, 105

Y young adults, 88 young women, 73