Di'.rrlers.,{'reric.n Psychiatric Association : washington. DC. Frank. E. (1999). Inrerpersonal and social rhythm therapy prevents clepressi'e synptomarology in ...
Ps,t'cltoIogi c'uI iVIetlit'ine. 2005. 35, 69-7 L O 2004CarnbridgeUniversity Press DO I : 10.1 01 7 ,i S0 0 3 3 2 9 1 1 0 4 0 0 2 9Pri 1 0 ntedtn the United Kinsdom
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Senseof hyper-posltrveselfand response to cognitivetherapyin bipolar disorder DOMINIC LAM*, KIM WRIGHT eno PAK SHAM Instituteof Psychicttrv. London. UK
ABSTRACT lntroduction. Cognitive therapy (CT) for bipolar disorder emphasizesthe monitoring and regulation of mood, thoughtsand behaviour.The Senseof Hyper-PositiveSelfScale(SHPSS)measures the extent to which bipolar patientsvalue themselvesand perceivethemselvesto possesspersonal attributes (e.g. dynamism, persuasiveness and productiveness)associatedwith a state of being 'mildly high', which does not reach the severityof clinical hypomania.It is hypothesizedthat pertientswho scorehighly on the SHPSSdo not respondwell to cognitivetherapy. Vlethod. One hundred and three bipolar-I patientswere randomizedinto CT and control groups. The SHPSSwas administeredat baselineand at a 6-month follow-up. Result. The SHPSS had good test-retest reliability after 6 months. At baseline, the GoalAttainment Dysfunctional Attitudes contributed significantlyto the SHPSSscoresafter the mood measureswere controiled for in a regressionanalysis.There was a significantinteraction between baselineSHPSS scoresand group allocationin predictingrelapseduring therapy. Patientswho scored highly on the SHPSS had a significantlyincreasedchanceof relapseafter controlling for mood scores,levels of social functioning at recruitment,and the previous number of bipolar episodes. Conclusion.Not all patientsbenefitedfrom CT. For patientswith high SHPSSscores,CT was less etlicacious.The results also indicate that future studiescould evaluate tar-eetingthese attributes and dysfunctionalbeliefswith intensivecognitive behaviouraitechniques.
INTRODUCTION Despite the use of mood stabilizers,bipolar disorder still runs a colirseof high frequencyof relapses(Prien & Potter, 1990; Solomon et ul. 1995; Moncrieff, 1995; Goodwin,2002). New entipsychoticssuchas clozapineand olanzapine need more researchas the adverseside-effects associatedwith these antipsychoticsmay outweigh the benefits(Kusumakar. 2002). Psychotherapiesspecificallydesignedfor bipolar disorder have been sparsebut emerging, particularly in the last 5 years. These include cognitive therapy (CT) to increasemedication ' ' A d d r e s s t o r c o r r e s p o n d e n c e :D o m i n i c L a m , P s y c h o l o g y l ) e p e r r t m e n t .H e n r y W e l l c o m e B u i i d i n g . I n s t i t u t e o f P s v c h i a t r y , D e C l e s p i g n yP a r k . L o n d o n S E 5 U A F . U K . ( E r n a i l: s p j t d h l r i i o p . k c l . a cu.k )
compliance (Cochran, 1984), family-focused treatment (Miklowttz et al. 2000),interpersonal and socialrhythm therapy(Frank, 1999),teaching patients to identify prodromes and seek medical help early (Perry er ul. 1998) and the two small CT pilot studies(Lam et al. 2000; S c o t te t a l . 2 0 0 1 ) . Lam et ul. (2003) reported a randomized controlled study of CT for bipolar disorder. One hundred and three DSM-IV (APA, 1994) bipolar-I patients suffering from frequent relapses were randomized into CT or control groups. The CT group receivedCT adapted for bipolar illness(Lam et ol. 1999)as well as mood stabilizers.Therapy consistedof a relapseprevention approach and lasted 6 months. In addition to standardCT for depression(Beck et ul. l9l9), the relapse prevention approach also
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emphasizedthe use of cognitive behavioural value being creative.productive, optimistic and skills to monitor mood and to modify behav- dynamic. Likewise individuals rvho believethat iour in order to preventprodromal stagesfrom they should be happy all the time would value developinginto full-blown episodes.The import- the personal attributes of being outgoing and ance of sleep and routine was emphasizedto entertaining.It is hypothesizedthat unrealistic triggering a manic episode and extreme goal-attainmentdysfunctional beavoid sleeplessness 'senseof hyper-positive and therapiststargetedunrealistic,high-striving liefs contribute to this goal-attainment cognitions. Both promoting self independentof current mood measuresof a good daily routine and the detection of and both depressionand mania. This paper reports the resultsof testingthese coping with prodromes involve monitoring and regulating.Therapistsaim to teachpatientstech- hypothesesin the context of bipolar relapses niques for monitoring, examiningand changing at the end of 6 months of intenseCT for relapse their dysfunctional thinking and behaviour.CT prevention.The full resultsof the first l2 months of the study are reported elsewhere(Lam et ul. produced significantand beneficialeffects. pro2003). a that observed it is However, clinically a state in being patients like portion of bipolar of constant high arousal, positive mood and Hypotheses being behaviourally active. This state of mild (1) Patients who have a high score on the 'high', though not reachingthe severityof clinSHPSSwould not respondwell to a course of ical hypomania, often leads to chaotic routine relapse prevention CT, which emphasizesthe and highly driven behaviour(Lam et al. 1999). importanceof regulatingmood and behaviour Furthermore, such patients perceivethemselves within a narrower range of intensity. to possessthe personal attributes associated (2) The extreme goal-attainment dysfuncwith being mildly high and valuetheseattributes tional beliefs at baselinecontribute to the paas desirable.Theseattributesincludebeingmore tients' scoreson the SHPSSat baselineafter the persuasive, creative,dynamic,entertaining.outbaselinemood scoresare controlled for. going, and so on. They often aspire to achieve 'sense of hyper-positiveself'. Hence, this this outlook on life is contrary to the relapsepre- METHOD vention goalsof regulatingmood and behaviour criteria within a narrower range of intensity. It is hy- Inclusion and exclusion pothesized that these patients with high levels The inclusioncriteria wereas follows: 'senseof hyper-positiveself' do not respond ( l ) D S M - I V B i p o l a r - Id i s o r d e r . of (2) Prescribedprophylacticmedicationat an weil to therapy and will continue to have freadequatedose according to the British quent relapses.These attributes were assessed Natio nal F orm r,rlzrry. by the Sense of, Hyper-Positive Self Scale (3) Age between18 and 70 years. ( S H P S S )i n t h i s s t u d y . (4) At least two episodesin the last 2 years Studieshave reported that certain high goalor three episodesin the last 5 years in attainment or high achievementstriving beliefs order to identify a subgroup vulnererble are vulnerability factors in bipolar disorder to relapses. ( R o s e n f a r be t a l . 1 9 9 8 ; L o z a n o & J o h n s o n , (5) Currently not fulfilling criteria for a bi2001). Lam et al. (2004) found that euthymic polar episode. bipolar patients scored significantlyhigher on (6) Beck Depressionlnventory (BDI; Beck the goal-attainment subscalein the Dysfuncet ul. 196l) rating of < 30 and Mania tional Attitudes Scale(DAS) than euthymicuniRating Scale(MRS) rating of < 9. polar patients.The DAS high-goal-attainment 'lf I try hard Patientscurrently in an acuteepisode.definedas subscaleconsistsof items suchas, enough I should be able to excel at anything fulfiliing DSM-lV criteria for major depression I a t t e m p t ' e r n d ' Is h o u l db e h a p p ya l l t h e t i m e ' . or mania. were excluded in order to avoid Individuals who believein their own ability to therapistshaving to usethe majority of therapy excel at ernythingthey attempt or their ability sessionsto treat an acute episode. Patients' to solve problemsquickly and effortlesslywould exclusioncriteria were: activelv suicidal (BDI
Respon.seto c'ogttitit,ethercry),in bipolur disorder
7l
suicideitem scoreof 3) and currently fulfilline notes.The number of days in bipolar episodes criteriafor substanceusedisorders. was defined as days during which patients ful_ filled DSM-IV criteriafor bipolar episodesfrom Procedure the SCID interview. Medication compliance All patients were receiving or_rt-patient treat- was monitored by questionnairesreturned by ment at recruitment. They were either referred the patientsand every6 months by key-workers by their psychiatristor contacteddirectly via from the psychiatricservice that had most con_ a list of patients who had had blood taken t a c t w i t h t h e p a t i e n t . for serum levelsof mood stabilizersin the last 12 months. After the srudy had been lully ex_ Measures plained,written informed consentwas obtained. Senseo.fHyper'-PositiveSrlf' Sc'ule(.tHp.S.S) Patientswere interviewedusing the Structured The scale, which was devised for this study, Clinical Instrument (SCID) for DSM-lV (First et ul. 1996)and the Medical ResearchCouncil consists of seven adjectives which bipolar (MRC) Social Fr-rnctioning(Hurry et ctt. l9g3). patientsuse to describethe positive attritutes Two researchassistantswith a bachelor'sor they possesswhen they are in a mildly .high. master'sdegreein psychologywere trained to state.Theseare: confident.dynamic. adorable, u s et h e S C I D f o r D S M - I V d i a g n o s i sa n d M R C entertaining,out,eoing,optimistic and creative. Social Functioning ratin_es.There was 100% Patientswereaskedto rate eachattributetwice: 'how well thesewords describeyou most of the a_qreement for the dia_enosis of bipolar disorder 'ideally how you would like yourself and manic and depressedepisodesfor the first t i m e ' a n d five patientswho enteredthe study. The inter_ to be'. Each :rdjectivewas rated on a seven_ rater reliability ranged from 0.91 to 0.16 for point scalefrorn I (not at all) to 7 (extremely). the different areasof social functioning with the The two anchoring points were labelled in ex_ l0 trainin_qcases.After the interview,patients treme terms to reflect the overvaluing of these filled out the questionnaires, which incltidedthe personalattributes.A total score was derived SHPSS :rnd the DAS-24 for bipolar disorder by summing up the score of each attribr_rte. A (Lam et ctl. 2004). The Mill Hill Vocabulary. high scoreon this scalewas designedto cztpture 1995edition was also administeredon recruit_ mildly elated (a state of positive mood, high arousaland being behaviourallyactive.thoLreh ment als:ln estimateoi IQ for the sample. Patientswho fr"rlfilledthe study criieria were n o t c l i n i c a l l y h y p o m a n i c o r m a n i c ) b i p o l a r randomly erllocatedinto the CT group or the patientsi.vho valuc these attributes assoclated control groLrpby using sequentizrlly nr-rmbered with mild elation eind perceive themselvesto theseattributes. and sealed opaque envelopes.The allocation possess sequence was generatedprior to the recruitment of patientsby a computer pro_eram.The con_ MurtictRutirtg Sr:ule(MRS; Bechet ul. l97g) trol group received'minimal psychiatriccare', This scaleconsistsof l l items that map into which was defined as mood stabilizersat a symptoms associatedwith mania. Each item recommended level with regular psychiatric is rated on i'r five-point scale (0 : not present: f o l l o w - u p a s o u t p a t i e n t s .T h e C T - g i o u p r e _ I : m i l d : 2 : m o d e r a t e : 3 _ m a r k e d : a n d 4 ceivedCT plus 'minimal psychiatricCare'.T1-,. s e v e r eo r e . r t r e m e )T. h e t o t a l s c o r e sa r e i n t e r _ fguf therapistsin this str_rdy were clinical psy_ p r e t e d a s : 0 - 5 : n o m a n i a: 6 - 9 : h y p o r n u n i a chologists (three lnen aind one woman) with ( m i l d ) ; 1 0 - 1 4 : p r o b a b l em a n i a ; l 5 o i r r r o r e: a minimum of 5 yezrrs'post-qualificationex_ definite mania. The scale has good inter-rater perience. reliabilityand construcrvalidity. lndependent utssessors. who were blind to the patients' group status,assessed patientsat Sltort t,ersiortrt/ Dt,s/inctionctlAttittule Scule 6 months usin_e the SCID to determinerelanse ./or Bipolar Disor"rler(DAS: BD, Lam et ul. :t?!Lls Relapsewas defined as any episodetirat 2004) fulfilled DSM-lV criteria for major depression, T h i s D A S : B D c o n s i s t e do f 2 4 i r e m s . I r i s mania or hypomzrnia.Hospital admissionsand derived from a principal component anz,rlysis episodeswere confirmed by pzttients'medical str"rdy using 143bipolar-Iparienrswho filled in a
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24-item version of the DAS (Power et cLl.1994). Each item was rated on a seven-pointscale 'totally agree' through 'neutral' ranging from 'totally disagree'.Three factorswerederived: to 'Goal-Attainment', accounted for factor l, 'Depen25'0o/oof the total variance;factor 2, d e n c y ' , a c c o u n t e dl o r l 1 ' 0 % o f t h e t o t a l v a r i 'Achievement', accountedfor ance: factor 3. 8'2% of the total variance.The scoresof euthymic bipolar patients (iz:49) were significantly higher than euthymic unipolar patients(n:25') in factor I'Goal-Attainment'. Goal-attainment also correlatedwith past hospitalizationsdue to mania. The Goal-Attainment subscalewas thought to capture the highly motivated attitudes describedby the Behavioural Activation System Theory and the highly driven attitudes in the cognitive model for bipolar disorder.
taking it altogether. This measure provides more detailed information about whether patients have been taking their medication. The questionnairewas sent out monthly to the patient and at 6 months to the clinician, r€spectively. Analysis
Logistic regressionanalysiswas used when the dependentvariablewas categorical,for example to compare the proportions of patients who relapsedin the two groups. Multiple regression analysiswas usedwhen the dependentvariables were ordinal. Where applicabie,adjustmentsfor differencesin the relevantmeasuresat baseline were carried out by analysis of co-variance (ANCOVA) or regressions.Hierarchical muitiple regression was used to test the main hypothesis about the moderating effect of the Beck DepressionInventorl'(BDI; Beck et ttl. SHPSS on therapy. The relevant co-variates 1 9 61 ) were enteredfirst to control for their potentially This is a well-known21-iteminventorydesigned confoundingeffects:theseincluded:DAS Goalto measurethe severity of depressionin adults Attainment scores;number of past bipolar epiand adolescents.It enquiresinto the somatic,, s o d e s ;M R C S o c i a l F u n c t i o n i n gs c o r e s ,M R S cognitiveand behaviouralaspectsof depression total scoresand BDI total scoresin biock I ; in the last week. E,achitem is scoredon a four- group allocation in block 2; and SHPSS in block 3. The interactive effect of group allopoint scale. cation and SHPSSwas finally enteredin block 4 Merlical ReseurchCouncil Sociul Per.formcmce of the logistic regressionto test the main hy(MRC-SPS; Hurry et ul. 1983) Sc:heclule potheses.Individual items of the DAS Goalscalebasedon a semi- Attainment subscalewere used as independent This is an observer-rated structuredinterviewthat providesa quantitative variables with the SHPSS as the dependent assessmentof social performance in the last variable in multiple regressionswith the basemonth. The informant is the patient. The inter- line BDI and MRS controlled for. Owing to view is directed towards actual behaviour and multiple testing, a p value of 0'01 was set as performancein eacharea and is rated on a four- statisticallysignificantin theseregressions.All point scale.The schedulecovers eight areersof analysesreported in this paper AIe intentionsocial performance: household management, to-treat analyses.All testsfor hypothesizeddifemployment, money management,intimate re- ferenceswere one-tailed.Otherwise all p values lationship,childcare,non-intimaterelationship, were two-tailed. and cbping with emergency.An overall score is obtainedby totalling the scores. RESULTS (MCQ ; Patients' characteristics Medicution ComplianceQuestiortnuire Lam et u\.2000) A total ol 361 potentialpatientswere contacted This is a report of compliancewith any pre- to take part in the study. Of these,154 patients scribed mood stabilizers.Respondentshad a refused to take part and 55 were found to be choiceof noting whetherthe patient in the past unsuitableafter the initial telephonescreening. month had: never missed taking their medi- A total of 158patientswereinterviewed.Of the cittion, missedtaking it once or twice, missed patientswho wereinterviewed.the main reasons taking it betweenthree and seventimes,missed for non-inclusion were: not enor-ighepisodes taking it more than seven times. or stopped in the last 5 years, not prescribedany mood
Re.ypon.;e to t'ognitive therupr in bipolctr disorder
1.,
Table l. Initial c'huracteristicsof'groups (ntecm.s s c o r e s( P e a r s o n r : 0.35p , < 0 ' 0 i t w o - t a i l e da ) nd ure .sltoy,t1us .ytcmdurcldet,itttiotts tt,ith perc,ent- t h e S H P S Su s u a l s c o r e s( P e a r s o nr : 0 . 3 0 , p< lges irt p ur enth ese.s) 0 ' 0 1 ) b u t n o t w i t h t h e S H P S SI d e a l s c o r e s I. n CT group
Control group
M e a na g e( y e a r s ) 4 6 . 4( 1 2 . 1 ) 4l.j (10.g) Femalesr"rbjects 54.0% 51'.0% M e a n z r g eo f o n s e r 2 8 . 1( t 1 . 4 ) 1 6 . 2( 9 . 5 ) Mean BDI t2 8 (9.4) l4.l il0.7) MeanHAMD 5 . 1( 5 . 4 ) 6 . 5( 6 . 0 ) \lean M RS t.0 tj.t) l.B(t I ) V l e a np r e v i o u sd e p r e s s i o n e p i s o d e s 5 . 8( 8 0 ) 5.1(4.2) M e a n p r e v i o u sm a n i ce p i s o d e s 5 .j ( 6 . 1 ) 3 . 9( 2 . 9 ) M e a n p r e v i o u sh y p o m a n i ce p i s o d e s I . j ( 2 . 7 ) 0.2(0.5) M e a n p r e v i o r " rhso s p i t a l i z a t i o n 6 . 3( 5 9 ) 5.1(6.3) M e a n S H P S Ss c o r e s 5 8 . 9( 9 . 7 ) 5 7 . 0( 1 0 5 ) M e a n D A S G o a l - A t t a i n m e n ts c o r - e s1 5 . 4 0( 8 . 0 ) 2 4 . 4 1( 7 . 9 ) P r o p o r t i o no l p a t i e n t so n One mood stabilizer 80.4o/o 90.4o/o Two moodstabilizers 1 96 % 9.6% Antidepressants 25.5% 34.60/o Mqor tranquillizers 5 1 . 0% 40.4n/o S o c i a lc l a s s( O t i i c eo l P o p r " r l a t i o n C e n s u sa n d S L r r v e y s1.9 9 1 ) SocialclassI ilB%(6/51) n.5%(6i52) S o c i z tcl l a s s2 3 5 . 3 " / "( 1 8 1 5 1 )3 6 . 5" 1 ,( | D i s Z ) S o c i a lc l a s s3 3 9 . 2 " A( 2 0 1 5 1 )3 8 . 5% ( 2 0 t 1 5 2 ) S o c i i r i c l a s4 s 9.8%(5,51) 5.g%(3i52) S o c i a lc l a s s5 j . 7 " , / "( 4 1 5 2 ) 3 . 9 o / "( 2 5 l ) I Q - M i l l H i l l V o c a b u l i i r y( R a v e ne t t r l . l 9 9 5 ) Above average l l . 6 0 . / ,(,9 i 5 l ) 2 1 . 2 o / (o1l / , 5 2 ) Average 1 i . t n / oe 4 i 5 1 1 3 g . 5% ( 2 0 / 5 2 ) B e i o wa v e r a q e 3 5 . 3 9 ,(il,8 r 5 l ) 4 0 . 3 n /(o2 1 , 5 2 ) B D I . B e c k D e p r e s s i o nI n v e n t o r y ; H A M D . H a m i l t o n D e o r e s s i o n R a t i n gS c . l e : \ 4 R S . M . n i r r R a t i n s S e * l e ;S H p S S .S e n s eo f H v p . r P o s i t i v eS e l fS c a l e ;D A S . D y s f u n c t i o n aA l t t i t u d e sS c a l e .
termsof test-retestreliability,the SHpSS scores at baseline and month six correlated significantiy in the control group (Pearsonr.:0.6g, p < 0 ' 0 0 1 ) .T h e c o r r e l a t l o no f t h e S H p S S s c o r e s at baselineand 6 months in the CT group was l e s ss r g n i f i c a n( tP e a r s o nr : 0 . 3 4 , p : 0 . 0 3 ) . T h e r e were no significant gender differencesin the s c o r e s( m a l e: 5 7 . J , s . D :. l 0 . g ; f e m a l e : 5 g . 3 , s.D.:9 6). There was also no significantcorrelation betweenage and SHPSSmean scores. Relationshipsbetweenthe main variablesat baseline Table 2 summarizesthe intercorrelations betweenthe scoresfor SHPSSTotal, SHPSSldeal, SHPSSUsual, BDI, MRS, MRC Social Functioning and DAS Goal-Attainment at baseline. The SHPSSTotal scorescorrelatedsignificantly with the SHPSSIdeal scores(pearsonr:0.J5, p < 0 ' 0 1 t w o - t a i l e d )a n d S H P S S U s u a l s c o r e s (Pearson r:0.9J , p < 0.01 two-tailed). The SHPSS Ideal scores and rhe SHPSS Usual scorescorrelated significantly with each other (Pearsonr - 0.33,p < 0.0I two-tailed).The BDI scorescorreiated significantly with the SHpSS T o t a l s c o r e s( P e a r s o nr - - 0 . 5 1 , p < 0 . 0 1 t w o tailed) and the SHPSS Usual scores(pearson r : 0'59, p < 0.0I two-tailed) but not with SHPSS Ideal scores.There were no significant correlationsbetweenthe MRS scoresand any of the SHPSS scores.The MRC Social Functioning scorescorrelated significantly with the S H P S St o t a l s c o r e s( P e a r s o nr : - 0 . 3 4 , p < 0 . 0 1 two-tailed),the SHPSS Usual scores(pearson r - - 0 ' 3 8 , p < 0 . 0 1 t w o - t a i l e d ) ,a n d t h e B D I s c o r e s( P e a r s o rn- - 0 . 4 8 , p < 0 . 0 1 t w o - t a i i e d ) .
stabiiizers,and did not fulfii DSM-IV criteria for bipolar-I. Six patients who fulfiiled recruitment criteria declined to participate owing to commitmentsat work. In the end 103patients were recruited into the study and randomlv ellocated i n t o t h e C T g r o u pl n : 5 1 ) a n d c o n t r o l group (n:52) respective ly. Table I summartzes the demographicand clinical featuresof the CT and control groups. There were no significant differencesbetweenthe two groups in any of the initial characteristics summarizedin Table l. .SHP.S.S and DAS Goal-Attainmentscore.s A multiple linear regressionwas carried out with Validationof the SHPSS the baselinescoresof the DAS Goal-Attainment The sample had a SHPSS total score of 5g.0 subscale,BDI and MRS as the independent ( s . o . : l 0 ' 0 9 ) , t o t a l S H P S SU s u a l s c o r eo f 2 3 . 9 variablesand the SHPSS Total Scoresas the ( s . o .: 7 ' 0 ) a n d a t o t a l S H P S SI d e a ls c o r eo f 3 4 . 1 dependentvariable, In block l. the BDI and ( s . o .: 5 ' 3 ) . I n t e r m so f i n t e r n a lc o n s i s t e n c yt h, e MRS scores were entered.In block 2, the DAS Cronbach alphas were 0.83 for SHPSS Total, goal attainmentsubscalewas put in. The final 0 ' 1 9 f o r S H P S S U s u a l a n d 0 . 8 3 f o r S H P S S r n o d e lw a s s i g n i f i c a n w t ith R2:0.33, F:15.7, Norrnal.The nr,rmber of previousmanicepisodes d f ( 3 , 9 4 ) , p < 0 . 0 1 . A f t e r c o n t r o l l i n g f o r B D I correlated si_enificantlywith the SHPSS total and MRS. DAS goal attainment contributed
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Table2.
Pettrson correlotions oJ'the mein yctriubles ut ret'ruitnrcnt SHPSS Total
S H P S ST o t a i S H P S SU s u a l S H P S SI d e a l MRS BDI M R C S o c i a lF u n c t i o n i n g
SHPSS Usual
SHPSS Ideal
0 . 8 7 **
0 75** 0.33**
iVIRS
BDI
-0.02 0.07 -0.13
-0.51** -0.59** -0.19 - 0.06
VIRC Social FLrnctioning
DAS Coal-,A.ttainment
-0.34** - 0.38** -0.16 -0.11 ** 0.48
0.i9 0 .l l 0'20 0 .i 0 0'12 004
S H P S S ,S e n s eo f H y p e r - P o s i t i v eS e l f S c a l e ; M R S . M a n i a R a t i n g S c a l e :B D I . B e c k D e p r e s s i o nI n v e n t o r y : i v l R C , f u l e d i c a lR e s e a r c h C o L r n c i iD l AS, DysfunctionaA l t t i t u d e sS c a l e . ** p
