Measuring cognitive fusion in depression using a modified Dysfunctional Attitudes Scale. Brian Kearney Senior Clinical Psychologist, Mood Disorders Unit, Northside Clinic, 2 Greenwich Rd Greenwich NSW Australia Acknowledgements: Patrick Sheehan, Natalie Katalinic. Thank you to Dr Robert Zettle & Dr J.T Blackledge who gave feedback on earlier versions of this paper.

FUSION “The tendency of humans to get caught up in the content of what they are thinking so that it dominates over other useful sources of behavioural regulation” (Luoma et al, 2007).

DEFUSION “… defusion techniques involve a variety of actions designed to expose thoughts as thoughts rather than binding realities” (Blackledge, 2007). Techniques: – Eg., Titchener’s repetition (“milk”) ACT-derived defusion strategies can reduce the believability of negative thoughts. – Eg., Masuda et al (2009) found Titchener’s Repetition (20-30 sec) reduced emotional discomfort & believability of negative self- referent stimuli in undergraduates

Measurement of Fusion and Defusion Automatic Thoughts Questionnaire Believability ratings (ATQ-B) Zettle & Hayes (1986). – Negative self-referent thoughts – Rated on 1-5 scale on frequency & believability – ACT depression treatment scores on Believability ratings reduced independent of change in frequency rating Fusion Questionnaire (FQ) Bolderston, Gillanders, Dempster & Bond (unpublished). – Items describing fusion & defusion activities – FQ correlates highly with AAQ-II – FQ negatively correlates with life satisfaction

Gaps In the Literature Early stage Room for the development of measures that: – 1) Measure both fusion and defusion concurrently; – 2) Measure fusion and defusion directly; – 3) Can be used easily in clinical or applied settings.

This Study the “head versus heart” problem (Teasdale,1993) : – depressed patients describe intellectually “knowing” a negative cognition is not true, but nevertheless “feeling” it to be true provides two differing perspectives to shift between respondents experience their activity of perceiving the belief, as well the content of the belief. intellectual perspective maps on to ACT’s emphasis on: “what does your experience tell you?” Linehan’s heuristic of “wise” & “emotional” minds

AIMS 1) develop an easy to use measure using instructions that emphasise either fused (“feel is true”) or defused (“know is true”) responding, 2) assess whether this strategy will produce a defusion effect in a depressed sample using dysfunctional attitudes. 3) test predictions from the ACT model concerning the relationship of fused and defused evaluations of dysfunctional attitudes to depressed mood.

Hypotheses ACT makes the following predictions: 1) Defused (Intellectual) responding will predict Fused (Emotional) responding – (in that a person’s direct experiences are likely to be one influence on the degree to which they fuse with particular beliefs/rules); 2) Defused (Intellectual) responding will not predict depression; 3) Fused (Emotional) responding will predict depression.

PARTICIPANTS N = 84 Inpatients & outpatients of MDU Diagnosis: DSM-IV MDE 75% MDD & 25% Bipolar Selection criteria: – 18 – 70 years – BDI-II ≥ 20 – Nil ECT in past 3 months – Nil alcohol/substance abuse or organic brain syndrome

SAMPLE CHARACTERISTICS Age: Mean = (12.9) Gender: Females = 65% (n = 55) Married:57% Education (years) :Mean = 15.4 (3.1) BDI-II:Mean = (9.96)

MEASURES Beck Depression Inventory-II (BDI-II) (Beck et al, 1996) Dysfunctional Attitudes Scale-24 (Power et al, 1994) eg., “I should be happy all the time.” “I should always have complete control over my feelings.” “My life is wasted unless I am a success.” “What other people think of me is very important.” Original instructions: “This scale lists different attitudes or beliefs which people sometimes hold ….decide how much you agree or disagree with what it says.” …. Indicate the one “that best describes how you think.”

Modified Dysfunctional Attitudes Scales Defused-I: – “sometimes think. …. decide how much you think it is true. – indicate the one “that best describes how you think. …. according to what you believe is true not what you feel is true. ….. what you know in your head is right, instead of what feels right.” Fused-E: – “ …. sometimes feel. …. decide how much you feel it is true. – indicate the one “that best describes how you feel. ….. according to what you feel is true, not what you know intellectually is true. ….. what feels right, instead of what you know in your head is right.”

Results 1 Internal consistency: – Defused-I:α =.92 – Fused-E:α =.90 Correlations: – Defused-I & Fused-E:r =.44 (p < 0.001) – BDI & Defused-I:r =.23 (p = 0.053) – BDI & Fused-E:r =.37 (p < 0.01) Only the Fused-E version correlated significantly with the BDI. Suggesting that the two versions relate differently to depressive symptomology.

RESULTS 2 Defused-I:Mean = (28.63) Fused-E:Mean = (21.74) p < 0.01 Did depressed patients score differently accordiing to the two differing instructional sets? A 24-point difference was found between the Defused & Fused means, which is significant at the.01 level. A higher score means more dysfunctional, meaning the responses to the Fused version (Fused-E) were more dysfunctional.

Test of Mediation Hypotheses Fused-E (MV) Step 2 Step 3 Defused-I (IV) BDI (DV) Step1 and Step 4 (relationship to be significantly reduced by inclusion of MV) Step 1 - Not Significant: p=.053Consistent with ACT. Step 2 - Significant: p<.001 Consistent with ACT. Step 3 - Significant:p<.01Consistent with ACT. Step 4 - Not Significant: p=.546Consistent with ACT.

Test of Mediation Hypotheses A mediation model based on the ACT model was established to explore the relationships between Defused-I, Fused-E & BDI scores. The results can be summarized as follows: Step 1: Red line at bottom of the triangle: Defused-I did not predict BDI p = 0.053, consistent with the ACT model. Step 2: Left side of the triangle: Defused-I does predict Fused-E p < 0.001, as predicted by ACT model. Step 3: Right side of the triangle: Fused-E predicts BDI controlling for Defused-I p < 0.01 as predicted by the ACT model. Step 4: The two sides of the triangle: Defused-I does not predict BDI when controlling for Fused-E scores, p = 0.55, as predicted by ACT model. Sobel test - tests the prediction that the relationship between Defused-I & BDI will be significantly reduced when Fused-E is included, which was significant p < Indicating that the drop in level of significance from Step 1 to Step 4 is not due to artifact, rather to the inclusion of the Fused-E.

Correlations With BDI-II Factors The relationship between Fused-E & BDI was significant across both factors (Cognitive & Affective) of the BDI. Suggesting that the relationship is not simply explained by measurement artifact of both Fused-E & BDI asking about feelings (“feels true” and affective symptoms). Defused-IFused-E Affective-Somatic.193 (p=.086).321 (p<.01) Cognitive.189 (p=.091).454 (p<.001)

If DAS-I is prompting defusion, why are the participants remaining depressed? Defusion may be a temporary experience (Blackledge, 2007) Depressed participants may be able to defuse with prompting, but in the absence of guidance they may value the E more than I. Plus the BDI-II asks re symptoms across the prior 2 weeks, not present moment.

Comparison Means For comparison, mean scores using the original instructions from the published literature for currently depressed & recovered patient samples & a not-depressed sample are shown. DAS-I:Mean = (30.28) DAS-E:Mean = (22.0) Comparison DAS-24 (original instructions) means: – Depressed patients (1): – Recovered depressed (2): (22.81) – Community not depressed (2): (20.76) – Community not depressed (1):72.23 Suggesting that responding by currently depressed patients on the Defused-I may be similar to that of recovered depressives ie., that cueing defused responding could remove the mood-congruent bias of state depression. Farmer et al, (2001); Power et al, (1994).

Conclusions: Manipulating DAS instructions to promote two perspectives using intellectual and emotional instructions & asking participants to shift between them produced differential responding: a) the two versions correlate only moderately b) depressed patients score significantly differently on the two versions c) both versions relate differently to depressive symptomology. Only Fused (emotional) ratings appear to be directly related to depressive symptoms as measured by the BDI-II. Consistent with the ACT model.

Limitations Treatment-selected sample. Lack of inclusion of “traditional” instructions. Lack of control groups: non-depressed & recovered. “cannot be definitively ascribed to a disruption of verbally established functions” ie defusion (Blackledge, 2007).