IB C fi M a b c d R A h 1 tnternational Journal of Clinical and Health Psychology (2019) 19, 160--164 www.elsevier.es/ijchp International Journal of Clinical and Health Psychology RIEF REPORT ognitive rigidity in patients with depression and bromyalgia ari Aguileraa,∗, Clara Pazb, Victoria Compan˜c, Juan Carlos Medinac, Guillem Feixasc,d Department of Cognition, Development and Educational Psychology, Universitat de Barcelona, Spain School of Psychology, Universidad de Las Américas, Ecuador Department of Clinical Psychology and Psychobiology, Universitat de Barcelona, Spain The Institute of Neurosciences, Universitat de Barcelona, Spain eceived 8 November 2018; accepted 7 February 2019 vailable online 11 March 2019 KEYWORDS Fibromyalgia; Depression; Cognitive rigidity; Ex post facto study Abstract Background/Objective: The comorbidity of depression and fibromyalgia chronic syndrome has been well documented in the literature; however, the cognitive structure of these patients has not been assessed. Previous results reported variability in cognitive rigidity in depressive patients, the key for this might be the presence of chronic physical pain such as fibromyalgia. The present study explores and compares the cognitive rigidity and differentiation, between patients with depression with and without fibromyalgia syndrome. Method: Thirty one patients with depression and fibromyalgia were matched, considering age, sex and number of depressive episodes, with 31 patients with depression but without fibromyal- gia diagnosis. Cognitive rigidity and differentiation were measured with the repertory grid technique. Results: The results indicated that depressed patients with fibromyalgia presented higher levels of depressive symptoms, greater cognitive rigidity and lower cognitive differentiation than those without fibromyalgia. Conclusions: The results might inform future treatments to address the cognitive structure of these patients. © 2019 Asociacio´n Espan˜ola de Psicolog´ıa Conductual. Published by Elsevier Espan˜a, S.L.U. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/ by-nc-nd/4.0/).∗ Corresponding author. Mundet, Ponent, Desp. 3510, Pg. Vall D’Hebron, 171, 08035 Barcelona, Spain. E-mail address: mari.aguilera@ub.edu (M. Aguilera). ttps://doi.org/10.1016/j.ijchp.2019.02.002 697-2600/© 2019 Asociacio´n Espan˜ola de Psicolog´ıa Conductual. Published by Elsevier Espan˜a, S.L.U. This is an open access article under he CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Cognitive rigidity in patients with depression and fibromyalgia 161 PALABRAS CLAVE Fibromialgia; Depresión; Rigidez cognitiva; Estudio ex post facto Rigidez cognitiva en pacientes con depresión y fibromialgia Resumen Antecedentes/Objetivo: La comorbilidad de la depresión y la fibromialgia ha sido bien docu- mentada en la literatura. Sin embargo, la estructura cognitiva de estos pacientes no ha sido evaluada. Estudios previos muestran variabilidad en medidas de rigidez cognitiva en pacientes con depresión. Los síndromes físicos crónicos podrían ser una variable clave para explicar esta variabilidad presente en estudios previos. El presente estudio explora y compara la rigidez y la diferenciación cognitiva entre paciente con depresión que tienen y aquellos que no tienen fibromialgia. Método: Treinta y un pacientes con depresión y fibromialgia fueron emparejados, considerando edad, sexo y números de episodios depresivos con 31 pacientes con depresión, pero sin diag- nóstico de fibromialgia. Resultados: Los resultados indican que los pacientes que presentan depresión y fibromialgia evidencian niveles más altos de síntomas depresivos, mayor rigidez cognitiva y menor diferen- ciación cognitiva que los pacientes sin fibromialgia. Conclusiones: Estos resultados podrían ser considerados al momento de crear tratamientos ajustados a la estructura cognitiva de estos pacientes. © 2019 Asociacio´n Espan˜ola de Psicolog´ıa Conductual. Publicado por Elsevier Espan˜a, S.L.U. Este es un art´ıculo Open Access bajo la licencia CC BY-NC-ND (http://creativecommons.org/ licenses/by-nc-nd/4.0/). 9 o 2 g o n a p h d fi M P T t o t p M w o A t S t IDepressive disorder is one of the most severe health problems in our society because of its disabling effects, and societal and economic burden (Whiteford, Ferrari, Degenhardt, Feigin, & Vos, 2015). Moreover, it has been associated with several health issues (Brandolim Becker et al., 2018; Chen et al., 2019; Nieto, Hernández-Torres, Pérez-Flores, & Montón, 2018). An ‘‘all-or-nothing’’ think- ing pattern (a tendency to extreme or catastrophic thinking) has been described as a core aspect of depressive cogni- tion (Al-Mosaiwi & Johnstone, 2018; Antoniou, Bongers, & Jansen, 2017). From a personal construct theory viewpoint, it has been suggested that depressed patients organize the construing of themselves, others and the world in relatively polar- ized, monolithic terms that are resistant to modification and revision (Neimeyer, 1985). In fact, using the Repertory Grid Technique (RGT) the configuration of the construct system in depressed patients has been defined as presenting high polarization (Neimeyer & Feixas, 1992) ----the tendency of more extreme ratings---- an low cognitive differentiation---- measured by means of the percentage of variance accounted by the first factor (PVAFF; Kovárˇová & Filip, 2015) resulting from the analysis of each grid data matrix. However, recent findings suggested similar mean, but also high variability, in polarization and in PVAFF between a group of depressed patients and a non-clinical group (Feixas, Erazo-Caicedo, Harter, & Bach, 2008). This result might be explained by the great amount of clinical variability among depressed patients. In fact, high rates of comorbidity with chronic syndromes related with pain have been reported (Velly & Mohit, 2018). Ohayon and Schatzberg (2003) indi- cated that around 43.4% of the individuals who met criteria for depression also had a chronic painful physical condi- tion compared to 16.1% in the general population. Studies in fibromyalgia (FM) also showed a life-span prevalence of d a s0% of depressive symptoms, and a rate between 62 to 86% f comorbidity with a diagnosis of depression (Veltri et al., 012). These rates were significantly higher compared with eneral population, and indeed, with other chronic pain dis- rders (Gormsen, Rosenberg, Bach, & Jensen, 2010). The objective of the present study was to explore cog- itive rigidity and differentiation in depressed patients nd patients with comorbid FM. We hypothesized that articipants with depression and fibromyalgia would have igher levels of depression, polarization and lower cognitive ifferentiation than participants with depression without bromyalgia. ethod articipants his study analyze data from a previous randomized con- rolled trial (Feixas et al., 2016), which assessed the efficacy f a dilemma-focused intervention, a new variant of cogni- ive therapy for depression (Feixas & Compan˜, 2016). All atients (N = 141) in that study met the criteria for either ajor Depressive Disorder or Dysthymia (or both) as assessed ith the structured clinical interview for DSM-IV axis I dis- rders (SCID-I-CV; First, Spitzer, Gibbon, & Williams, 1996). lso as an inclusion criterion, patients had to score more han 19 on the Beck’s Depression Inventory-II (BDI-II; Beck, teer, & Brown, 1996).The study protocol was approved by he Bioethics Committee of the University of Barcelona (Ref. RB0003099). All the participants signed an informed consent ocument before enrolling. From those, 31 (22%) had a concurrent diagnosis of FM t baseline. These patients were the target of the present tudy. Their mean age was 50.45 years (SD = 9.60), with 162 M. Aguilera et al. Table 1 Comparison of depressive patients with and without a concurrent diagnosis of fibromyalgia. Depression (n = 31) Depression+FM (n = 31) t-test Effect size Mean SD Mean SD t p Cohen’s d 95% CI BDI-II 36.16 8.55 40.74 9.62 -1.98 .03 0.49 [0.01, 1.01] Polarization 31.02 13.80 39.54 17.07 -2.16 .02 0.54 [0.04, 1.05] PVAFF 43.13 11.27 48.67 11.46 -1.92 .03 0.48 [-0.20, 0.99] FF= a r t B p F o d p f ( n g y t g I T a c s a i s d s 2 C m g i t t g s g i c s f ( ( y a S O u w R A b i s h d a s s D O H d T n f S i w o t i s c t t s a a t i i p iNote. FM = Fibromyalgia; BDI-II= Beck Depression Inventory-II; PVA n average of 2.06 depressive episodes (SD = 1.21). They eported a mean pain intensity of 76.21 (SD = 20.73) in he visual analogue scale (VAS; Price, McGrath, Rafii, & uckingham, 1983), a 100-mm line for the assessment of ain intensity; and an average of 8.14 years (SD = 6.4) with M diagnosis. The comparison group was a paired sample f 31 patients from the same trial who did not have the iagnosis of FM and who had not reported high levels of ain intensity (scored lower than 50 in VAS). Variables used or matching this control sample to the FM group were age M = 50.85; SD = 9.47), sex (28 females and 3 males) and umber of depressive episodes (M = 1.96; SD = 1.43). Both roups were also comparable in terms of time elapsed, in ears, from the first episode (M = 12.48; SD = 11.46 for he target group and M = 10.45; SD = 9.78, for the control roup). nstruments he repertory grid technique (Feixas & Cornejo, 2002), semi-structured interview created to study personal onstructs, was used for assessing cognitive structure. Con- tructs were elicited in each patient from comparisons mong a set of elements (e.g., self, family relatives, friends, deal self), followed by rating these elements for each con- truct with a 7-point Likert scale. This resulted in construct ata matrix from which several measures were derived using pecialized software (GRIDCOR v 4.0; Feixas & Cornejo, 002). For the present study (see Feixas, Montesano, Erazo- aicedo, Compan˜, & Pucurull, 2014 for a wider variety of easures), the PVAFF resulting from a factor analysis of the rid data was used as an indicator of unidimensional think- ng (Feixas, Bach, & Laso, 2004). The higher the percentage, he smaller the room for other dimensions of meaning to ake prominence in construing self and others. The second rid measure used in this study was polarization, computed imply as the percentage of extreme ratings (1 or 7) in the rid data matrix. Most authors support the construct valid- ty of the RGT as the notions employed (e.g., ‘‘personal onstruct’’) are directly derived from the theory. Several tudies have reported test-retest reliability scores of .71-.77 or the elements, and of .48-.69 for the elicited constructs see Feixas & Cornejo, 1996; for a review). A recent study Trujillo, 2016), in the same local context as the present one, ielded a test-retest reliability score of .84 for the PVAFF, nd of .81 polarization measure. a p d rPercentage of Variance Accounted by the First Factor. tatistical analysis ne-tailed independent samples t-tests were performed sing SPSS 23.0 (IBM Corp., 2015). Cohen’s d effect sizes ere calculated for each dependent variable. esults s shown in Table 1, significant differences were found etween both samples for depressive symptoms, polar- zation and PVAFF. Depressed patients with FM presented ignificantly higher BDI-II scores, higher polarization and igher PVAFF than those without FM. The two groups were ifferent in their degree of symptom severity, polarization nd cognitive differentiation with a medium effect size. No tatistical differences were found in the number of con- tructs elicited in the grids of both samples. iscussion ur results, along with the review of Goesling, Clauw and asset (2013), indicated that at least for some patients, epression might be associated with the experience of pain. wenty per cent of our sample had a concurrent diag- osis of FM. This result is convergent with that reported or patients with other chronic pain disorders (Ohayon & chatzberg, 2003; Réthelyi, Berghammer, & Kopp, 2001). It s worthy to mention that this percentage rose to 60% if e took into account patients who experienced a high level f pain (over 50 in VAS). Interestingly, our results indicated hat depressed patients with comorbid FM scored higher n depressive symptomatology. Further analyses of BDI-II howed higher scores in the FM comorbid group in the items oncerning pessimism, irritability, concentration/difficulty, iredness or fatigue and loss of interest in sex. The nature of he relationship between pain and depression needs further tudies to develop a better understanding in the future. Pain experience in depression seems to be associated lso to cognitive structure. Polarized construing emerged s the most distinctive cognitive structure between the wo groups. Although the tendency to construe themselves n extreme terms had been proposed as characteristic of ndividuals with depression (Neimeyer, 1985), depressed atients with comorbid FM showed higher scores in polar- zation with a medium effect size. Moreover, PVAFF showed similar pattern indicating that depressed comorbid FM atients presented lower levels of differentiation in their imensions of meaning. These results converged with those eported by Neimeyer and Feixas (1992), in which structural ia F F F F F F G G I K N N N O P R TCognitive rigidity in patients with depression and fibromyalg cognitive measures such as cognitive differentiation and polarization accounted for a specific factor of rigidity in depressive patients. The small size of the study is a limitation for the exter- nal validity of the study. But, in spite of the fact that our study focused on a few aspects and also that larger samples may be needed, our findings if confirmed in other stud- ies might have relevant implications for clinical treatment of depressed patients with comorbid FM. For patients with chronic pain, increasing their cognitive complexity might lead to better therapeutic results. 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