Thought–Action Fusion in Individuals with a History of Recurrent Depression and Suicidal Depression: Findings from a Community Sample

Thought–Action Fusion in Individuals with a History of Recurrent Depression and Suicidal... Although suicidal ideation is one of the most consistent symptoms across recurrent episodes of depression, the mechanisms underpinning its maintenance are poorly understood. In order to develop effective treatments for suicidally depressed patients, understanding what maintains suicidal distress is critical. We hypothesised that Thought–Action Fusion (TAF), i.e., to assume that having a thought has real world consequences, originally described in Obsessive–Compulsive Disorder, might be a bias in recurrently suicidally depressed people. To assess this, we revised the original TAF scale, and assessed TAF in three samples: healthy controls, recurrently depressed individuals with no history of suicidality (D-NS) and individuals with a history of recurrent suicidal depression (D-S). Exploratory and confirmatory factor analyses indicated a three-factor solution of TAF: (1) TAF for uncontrollable events, (2) self-suicidal TAF for suicidal acts related to oneself, and (3) TAF for positive controllable events. Compared to healthy controls, the D-NS group reported significantly higher total TAF, TAF uncontrollable, and TAF self-suicidal subscales, whilst positive controllable TAF was lower compared to healthy controls. Both D-S and D-NS samples reported higher TAF for suicidal thought compared to healthy controls, i.e., believing that hav- ing suicidal thoughts means they will act on them, however in the context of low mood this became more pronounced for the D-S group. These findings suggest that targeting TAF both in suicidal and non-suicidal depression has merit. Keywords Thought–action fusion · Suicidal ideation · Self-harm · Suicide · Depression Introduction to such cognitions, and whilst for some people suicidal thoughts are fleeting and temporary (Nock et al. 2009), for Although suicidal cognitions are a common feature of major others they tend to persist and cause distress. Likewise, even depression, they are also prevalent among people seeking in people with severe recurrent depression, the degree of health care (Scott et al. 2012) and observed to some degree distress that suicidal thoughts and images evoke varies mark- in general population samples (Crosby et al. 2011). Inter- edly (e.g.; Crane et al. 2014). We have previously suggested estingly, people differ in the way they experience and react that vulnerable individuals’ relationship with and responses to suicidal cognitions are critical in determining whether sui- cidal cognitions persist and potentially escalate and that such persistence is most likely when individuals respond to sui- Electronic supplementary material The online version of this article (https ://doi.org/10.1007/s1060 8-018-9924-7) contains cidal thoughts with rumination and suppression (Williams supplementary material, which is available to authorized users. et al. 2016). In line with this hypothesis Pettit et al. (2009) have found that suppression of suicidal thoughts increases * B. Gjelsvik their severity over time. bergljot.gjelsvik@psych.ox.ac.uk Although it is established that differences in response Department of Psychiatry, University of Oxford, Oxford, UK to suicidal cognitions exist in patient and general popula- Department of Psychology, University of Oslo, Oslo, Norway tion samples, relatively little is known about the factors that determine these. However, models of Obsessive–Compul- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford OX37JX, UK sive Disorder (OCD); (e.g., Clark 1999), in which distress- ing and intrusive thoughts are core symptoms, may suggest University of Kentucky, Lexington, USA Vol:.(1234567890) 1 3 Cognitive Therapy and Research (2018) 42:782–793 783 potential candidate mechanisms. One relevant concept found that both global TAF and TAF-Likelihood were more arising from the OCD literature is Thought–Action Fusion strongly associated with obsessive–compulsive symptoms (TAF); (Rachman 1993; Shafran et  al. 1996; Craig and than with measures of depression and worry, suggesting that Lafreniere 2016). TAF was introduced by Rachman (1993) to the extent that TAF is observed in depressive populations to describe a phenomenon in which a person believes that it may be present primarily where there is also thought con- the mere presence of intrusive thoughts can influence events tent which has an obsessive quality. in the real world. Rachman (1993) describes two compo- One reason for thinking that TAF may be relevant to nents of TAF: First, ‘morality TAF’ describes the tendency suicidal ideation is that it has previously been suggested to assume that the occurrence of certain intrusions implies that suicidal thoughts present as a form of rigid rumina- immorality of character (e.g., intrusions about killing equal tion (Kerkhof and van Spijker 2011; see also; Rogers and being a bad person). Second, ‘likelihood TAF’ describes Joiner 2017), the engagement with which can be character- the view that the mere presence of thoughts has real life ised as obsessive. Further, the distressing and often graphic consequences and could, for example, increase the likeli- content of suicidal urges (e.g., ‘I could hang myself in the hood of catastrophic events (e.g., intrusions about killing back garden’) could be seen to have more in common with somebody make it more likely it will happen). TAF has obsessions as seen in OCD (e.g., losing control and harm- been proposed to promote engagement in strategies (e.g., ing oneself or others), than depressed non-suicidal thoughts suppression, worry, rumination, neutralising behaviours) (e.g., ‘I’m no good’). However, the strong ruminative nature intended to control intrusions, prompted by the perceived of non-suicidal depression (e.g., Liu et al. 2017) indicates probability of the thought content happening, and/or by the that TAF might also be relevant here. Thus, there appears to misinterpretation that a person is responsible for harm unless be merit in exploring the potential commonalities between they take action to prevent it (Rachman 1993; Rassin et al. OCD intrusions and suicidal cognitions, and to compare this 2000). Importantly, however, since attempts to suppress with non-suicidal depression. It is also possible that one pos- unwanted thoughts have been found in many cases to lead sible reason why existing studies of TAF in depression have to a paradoxical increase in their frequency (Abramowitz not yielded strong findings, is that the standard measure to et al. 2001) and intensity (Wegner 1994), TAF is likely to assess TAF, TAF-R (Shafran et al. 1996), was developed to contribute to the escalation of symptoms over time. Indeed, assess TAF in OCD, and so may be less sensitive to identify Rassin et al. (1999) found that experimentally induced TAF TAF in other domains, such as in depression and suicidality. led to an increase in intrusions and perceived discomfort in Thus, it is possible that TAF may also be observed in people healthy controls. with depression, particularly where there are thoughts with Whilst several studies have found a strong relationship an obsessive quality, if items were appropriately worded to between OCD and TAF (e.g., Amir et al. 2001; Shafran et al. elicit it. 1996), some studies have shown that when depression is If TAF is present in people suffering from suicidal controlled for, the association between OCD and TAF is depression what impact would this have for symptom no longer significant (O’Leary et al. 2009; Jonsson et al. maintenance and exacerbation? In OCD, it is suggested 2011). Nevertheless, to our knowledge, only two studies that TAF increases the distress associated with intrusive have examined TAF in depressed samples (Abramowitz et al. thoughts and compounds attempts to neutralise them 2003; Meyer and Brown 2013). Abramowitz et al. (2003) (Rassin et al. 1999; Rachman 1997). However, there is compared TAF in OCD samples to other anxiety disorder no suggestion that TAF increases the actual likelihood of samples, clinically depressed patients and healthy controls. enactment of such thoughts. Likewise, it might be sug- They found that OCD patients had higher likelihood-TAF gested that TAF related to suicidal thoughts would simi- for others-related events compared to depressed patients, larly increase distress and cognitive preoccupation, but patients with social phobia and healthy controls, but not would not increase risk of enactment. However, suicidal higher likelihood TAF for self-related events. However, cognition is characterised not only by explicit thoughts and there were no overall differences across groups on Morality images related to suicidal acts, but also to broader cogni- TAF. Inferences about group differences across depressed tions including those relating to perceived burdensome- and OCD samples were complicated by the OCD sample ness (e.g., ‘my death is worth more than my life to others’; scoring higher on the Beck Depression Inventory (BDI) Van Orden et al. 2010) and entrapment (‘nobody can help than the depressed sample. However, in this study depres- me out of this mess’; Williams 2014). Although entirely sion was secondary to the focus on anxiety disorders, and the hypothetical, it is possible to speculate that if TAF also sample of depressed patients was small (n = 19). Meyer and operated in relationship to these thoughts, the responsibil- Brown (2013), in contrast, examined TAF in a large clini- ity they evoke (e.g., to unburden the family) might serve as cal sample including both depressed and anxious patients. a volitional moderator (O’Connor 2011), reinforcing and Using the TAF scale developed by Shafran et al. (1996), they promoting suicidal distress, and facilitating the progress 1 3 784 Cognitive Therapy and Research (2018) 42:782–793 from thoughts to acts. To the best of our knowledge, how- a revision of the items would be required in order to make ever, no studies have systematically examined TAF in sui- the scale more amenable to depression and suicidality. cidal depression, nor compared TAF in this population to individuals with a history of non-suicidal depression and Assessment of Thought–Action Fusion healthy controls. If TAF is present in people with recurrent suicidal The first version of the Thought Action Fusion Scale depression, a second issue concerns its mood depend- (Shafran et  al. 1996) was explicitly developed for use ence. Cognitive science accounts of recurrent depression with OCD patients, and consisted of 34 items, which, fol- (i.e., the Differential Activation framework) posit that lowing factor analyses and revisions, led to the 19 item in people with a history of recurrent depression, depres- Thought–action fusion scale-revised (TAF-R). This scale sive and suicidal thoughts can be reactivated by subtle consisted of three subscales all denoting negative events: and transient changes in mood (Williams et  al. 2016; TAF-moral (12 items), TAF-likelihood-self (i.e., TAF likeli- Scherrer et  al. 2014; Brockmeyer et  al. 2012). Indeed, hood for self-related events; 3 items) and TAF-likelihood- mood-dependent changes in dysfunctional thinking have other (i.e., TAF likelihood for self-related events: 4 items). been shown to predict depressive relapse in previously Overall, the TAF literature shows that the three factors of depressed patients (Segal et al. 2006). Such reactivation TAF-R have good reliability, as reflected in Cronbach’s involves not just negative content but also maladaptive alphas ranging from 0.75 to 0.89 (Rassin et al. 2001). cognitive processes. For example, our previous work has Whilst it seems clear that patients suffering from anxiety shown that people with a history of suicidal depression can disorders report higher TAF than healthy controls on the be distinguished from those with a history of non-suicidal probability dimension (e.g., Rassin et al. 2001), comparisons depression in the extent to which increases in negative with other clinical groups are sparse. Two revisions of the mood impair interpersonal problem solving, a cognitive original scale have since been made; one including TAF for deficit characteristic of people at times of suicidal crisis thoughts about positive events happening to self and others, (Williams et al. 2005). Likewise, people with a history across domains of both gain and harm avoidance (Craig and of suicidality report more hopeless thoughts when asked Lafreniere 2016), and one including items about likelihood to imagine being in a slightly sad mood, and this meas- of preventing harm by means of positive thoughts (Amir ure of hopelessness reactivity predicts actual cognitive et al. 2001). To our knowledge, no TAF scale has been devel- deficits in positive future thinking after an experimental oped to specifically assess TAF for depression or suicidality. mood challenge (e.g.; Williams et al. 2008). Some forms Shafran et al. (1996) have noted that responses on the of mood-dependent dysfunctional thinking (e.g., entrap- TAF tended to be idiosyncratic, and that the scale would be ment) have also been shown to increase the risk of suicidal most usefully considered as a clinical tool to identify idi- behaviour longitudinally (O’Connor et al. 2013). If TAF is osyncratic beliefs, rather than generating sum-scores. More- also observed in people with a history of recurrent suicidal over, they emphasised that the construct of TAF was in its depression, a first step in examining whether this bias pre- early stages and that associated metacognitions, specificity dicts subsequent suicidal relapse is to investigate whether to OCD, and clinical implications were still unclear. Further- such potential endorsement of thoughts increases in the more, with the notable exception of Craig and Lafreniere’s context of transient low mood. Identifying factors uniquely (2016) examination on TAF for positive events, the TAF affected by changes in mood is helpful in understanding literature has focussed solely on negative events (e.g., being what serves to maintain and progress suicidal crises, and in a car accident, either self or other; Shafran et al. 1996). in formulating potential clinical targets. Indeed, although Another important dimension which has not been assessed as stated above there is relatively little research explor- in existing versions of the TAF-R but which might influence ing TAF in depression, Shafran et  al. (1996) suggest a the extent to which TAF is observed is the controllability reciprocal relationship between mood disorders and TAF, of the event to which a thought relates. There is some evi- in which depression might increase the occurrence and dence that thinking about an event increases the likelihood believability of thoughts, and in which TAF, in turn, might of engaging in that behaviour at least for desirable actions exacerbate low self-esteem, depression and anxiety. (e.g., imagining to vote and subsequently doing so; Libby Thus, there appears to be a strong rationale for exploring et al. 2007), and thus there is to some degree a reality to the the potential presence of TAF in individuals with a history belief that thinking about a potentially self-initiated action of suicidal depression, including the extent to which TAF may increase its probability. In contrast, there is no evidence might be mood-state dependent, and elevated at times of low that thinking about uncontrollable actions has any bearing on mood or crisis. However, since the original TAF scale was one’s behaviour. As such it is possible that pathological TAF developed for OCD, for the present study we considered that may be most easily observed when it relates to the likelihood of other-initiated actions (e.g., friend committing a crime) 1 3 Cognitive Therapy and Research (2018) 42:782–793 785 or self-relevant uncontrollable actions (e.g., being called to Methods Jury duty) for which there is no logical mechanism through which thought might lead to action. Controllability may be Participants a particularly relevant aspect of TAF in the context of both suicidal and non-suicidal depression given the emphasis on The current study reports on a cross-sectional online survey locus of control in depressive and suicidal symptomatology. of adults. All participants were recruited online. Participants Thus, both the self-other and controllable-uncontrollable were recruited from the following three groups: Individu- dimensions appear important in understanding the phenom- als who were currently well but had a history of suicidal enon in the context of recurrent suicidal and non-suicidal depression (D-S) or non-suicidal depression (D-NS); and depression. Finally, in terms of convergent validity, despite Healthy Controls (HC). Participants were eligible for inclu- the theoretical emphasis on TAF eliciting control strategies, sion if they were (a) between 18 and 70 years of age, (b) little is known about relationship of TAF to relevant cogni- fluent in English, (c) currently well at the time of inclu- tive strategies other than obsessionality, such as suppression, sion i.e., meeting the National Institute on Mental Health rumination as well as a divergent construct, trait mindfulness guidelines for recovery or remission (Frank et  al. 1991, (i.e., the capacity to pay attention to momentary experience including minimal symptoms of depression at no more than with acceptance and non-judgement, Baer et al. 2006, 2008). a mild level for the previous 8 weeks) and (d) able to provide The objectives of the present study were therefore to informed consent. For both the D-S and D-NS groups, the examine TAF in suicidal and non-suicidal depression as following additional inclusion criteria applied: A minimum compared to healthy controls, and also to examine the effect of ≥ 3 episodes of depression, defined by DSM-IV criteria of a mood induction within the two depressed groups. To for a history of Recurrent Major Depression, of which two address the above issues concerning the measurement of must have occurred within the last 5 years and at least one TAF we (a) developed and validated a TAF scale adapted within the last 2 years, and being currently well defined as to include items whose content was relevant to suicidal meeting the National Institute on Mental Health guidelines depression (including items with both positive and nega- for recovery or remission (Frank et al. 1991) at the time of tive content, including suicide related content), and which inclusion (i.e., minimal symptoms of depression at no more included items covering both self-other and controllable- than a mild level for the previous 8 weeks). Inclusion in the uncontrollable dimensions using exploratory and confirma- D-S group required a reported history of recurrent suicidal tory factor analysis, (b) compared the derived TAF scale ideation and/or behaviour. Participants were excluded if they in individuals with a history of suicidal depression and reported current or past symptoms of (a) obsessive–compul- non-suicidal depressed compared to non-clinical controls, sive disorder (OCD), (b) substance abuse, (c) bipolar disor- and (c) examined whether TAF increased in the depressed der (including manic episodes during the last 6 months), and groups when these groups were asked to respond from the (d) a diagnosis of schizophrenia. perspective of a time of crisis, as compared to their baseline responses. We hypothesised (1) that total TAF score would Procedure correlate positively with suppression and rumination and correlate negatively with facets of trait mindfulness across Participants were recruited through adverts in newslet- the sample as a whole, (2) that total TAF would be related ters and flyers in the community and online, calling for linearly to lifetime depression severity (i.e., increased in healthy controls as well as individuals with a history of sui- depressed controls compared to healthy controls and high- cidal and non-suicidal depression but who were currently est in individuals with a history of suicidal depression), (3) well (see above). The survey link was active from March that if a factor emerged that reflected item content related through August 2016. Prior to participation, individuals self- to suicidality that this factor would be higher in individuals screened online to ascertain that they were all currently well, with a history of suicidal depression than in non-suicidal and to ensure appropriate assignment to one of the follow- depressed and healthy controls and compared to other factors ing three groups: Depressed-suicidal (D-S); individuals who for this group due to its salience, and (4) that TAF would were currently well but had a history of suicidal depression, increase for clinical groups when reported in the context of Depressed-Non-Suicidal (D-NS); individuals with a history low mood as compared to baseline. of depression but no suicidality, and Healthy Controls (HC). We recruited participants who were currently well or in remission (as above) at entry to the study to enable us to explore both (a) whether there are trait differences (either pre-existing first onset of depression or persisting as a scar effect) between individuals with a history of depression and 1 3 786 Cognitive Therapy and Research (2018) 42:782–793 those without and (b) whether there are differences between mood (e.g. the Anxiety Sensitivity Index; Peterson and Reiss participants’ responses when they reported on TAF at base- 1992; the Leiden Index of Depression Sensitivity; Van der line and when asked to imagine a time of crisis. Moreo- Does 2002), assessed independently of an experimental ver, assessing TAF for suicidal events in close proximity to context, asking conditional questions about their worst ever episode of self-harm would have been confounded with the crisis in addition to questions about their current state. Thus, event in question just having taken place. Assessing individ- participants completed the same scale twice: Participants uals in remission from depression minimised this risk. The in the D-S and D-NS group (but not healthy controls) were protocol for this study was reviewed and approved by Oxford asked to first complete the TAF scale according to how University’s Central University Research Ethics Committee they were currently feeling (e.g., ‘How well do the follow- (CUREC; protocol number MSD-IDREC-C2-2014-030). ing statements describe how you are currently feeling?’), Following online screening, eligible participants were and subsequently to complete them from the viewpoint of informed about the study procedures through an electronic their worst (depressive and/or suicidal) crisis (i.e., ‘Now we information sheet, and consent was obtained electronically would like you to describe how well the statements describe before proceeding to complete the survey. Upon completion how you typically feel at a time of crisis’). This was based participants received a £10 Amazon voucher via email as on the assumption, derived from previous work, that taking reimbursement. the perspective of a previous crisis would enable individuals to respond in a way that mirrors responses occurring after Measures experimentally induced mood (e.g. Williams et al. 2008), expected to affect their responses on the revised TAF scale. Thought–Action Fusion‑Suicidal Revision (TAF‑SR) The Ruminative Response Scale The first version of the Thought Action Fusion Scale (Shafran et al. 1996) was explicitly developed for use with The Ruminative Response Scale (RRS, Nolen-Hoeksema OCD patients, and consisted of 34 items, which, following and Morrow 1991) is a 22-item self-report scale assessing factor analyses and revisions, led to the 19 item TAF-R. different facets of self-reflective thinking. Participants are TAF-Suicidal Revision was based on this 19-item TAF-R asked to rate how much they engage in different cognitive (Shafran et al. 1996). As Morality TAF is not directly related responses on a 4-point scale, ranging from 1 (never) to 4 to the occurrence of actual events in the real world but rather (always). Treynor, Gonzalez and Nolen-Hoeksema (2003) reflects a belief about the significance of events, we focussed identified three subscales of the RRS: depression-related exclusively on the likelihood aspect of TAF due to our inter- rumination (12 items, e.g., “think about how hard it is to est in measuring people’s beliefs about their thoughts having concentrate”), brooding (five items, e.g., “think ‘Why can’t a direct influence on outcomes in the real world. Moreover, I handle things better?’”), and reflection (five items, e.g., we were interested in whether TAF for suicidal content was “Analyze recent events to try and understand why you are different from TAF for other content; thus, a revision was depressed”). The RRS shows acceptable internal consist- required. We expanded the original self-other dimension ency for brooding (α = 0.68), and good internal consistency (i.e., events happening to oneself or to friends or relatives) for depression-related rumination (α = 0.86) and reflection with (a) valence of events (i.e., positive versus negative) (b) (α = 0.73) (Brennan et al. 2015). whether events were suicidal or non-suicidal and (c) control- lability of events (e.g., eating healthily versus plane crash). The Five‑Facet Mindfulness Questionnaire In order to validate these additional parameters, participants rated the degree to which they found the item phrasing to The Five-Facet Mindfulness Questionnaire (FFMQ; Baer reflect controllability (i.e., the degree to which the event et al. 2006, 2008) consists of five facets assumed to be key was extraneous or self-determined) and valence (negative aspects of mindfulness as a dispositional variable (Observ- or positive), respectively, on a VAS scale (i.e., from 0 to ing, Describing, Non-Judging of inner experience, Non- 100) (see Table S2). Items were mirrored; i.e., there was Reactivity to inner experience and Acting with awareness). an equal number of items describing events related to self The five facets are measured by rating how true each item and other, respectively. The original revision consisted of within each facet is for participants on a general basis on a 30 items rated on a 5-point Likert scale from 1 (Disagree 5-point scale ranging from 1 (never or very rarely true) to 5 strongly) to 5 (Agree strongly), thus resulting in a possi- (very often or always true). The internal consistency for the ble score range from 30 to 150. The items are outlined in scale overall has been shown to be good, with Cronbach’s Table 1. To capture potential mood-dependency of TAF in alphas ranging from 0.75 to 0.91 (Baer et al. 2006), and the the clinical groups, we applied the same principle as other five facets have shown good to excellent internal consistency questionnaires assessing vulnerability in the context of low (Cronbach’s alphas ranging from 0.75 to 0.91). However, a 1 3 Cognitive Therapy and Research (2018) 42:782–793 787 Table 1 Thought action fusion items, factor loadings and item-total correlation for second random half of the sample (n = 181) No. Description Factor loadings Factor Item-total correla- “If I think [ ], this increases the chance [ ].” Factor 1 Factor 2 Factor 3 tion 1 of myself having fun on a holiday that I will have fun on a holiday − 0.11 − 0.12 0.73 PC 0.16 2 of myself donating to charity that I will donate to charity − 0.11 0.76 PC 0.27 3 of myself eating healthily that I will eat healthily − 0.15 0.62 PC 0.14 4* of myself lying to someone that I will lie to someone 0.15 0.32 0.12 – 0.47 5* of myself cheating on my taxes that I will cheat on my taxes÷ 0.53 0.11 – 0.63 6* of myself deliberately parking illegally in that I will deliberately park illegally in a 0.51 – 0.58 a disabled car parking space disabled car 7 of myself winning the lottery that I win the lottery 0.69 UC 0.74 8* of a stranger doing something kind for me that this will happen 0.48 0.22 – 0.58 9 of myself finding money on the street that I will find money on the street 0.68 UC 0.72 10* of myself becoming ill that I will become ill 0.18 0.32 – 0.38 11 of my house being burgled that my house will be burgled 0.73 0.11 UC 0.83 12 of myself being in a plane crash that I will be in a plane crash 0.78 UC 0.75 13 about me killing myself that I will kill myself 1.04 SS 0.60 14 about harming myself that I will harm myself 0.60 SS 0.43 15 about harming myself with the intention that I will harm myself with the intention 0.16 0.76 SS 0.65 to die to die 16 of a relative/friend having fun on a of him/her having fun on a holiday 0.80 − 0.12 UC 0.73 holiday 17 of a relative/friend donating to a charity of him/her donating to a charity 0.71 UC 0.70 18 of a relative/friend eating healthily of him/her eating healthily 0.78 UC 0.72 19* a relative/friend lying to someone that he/she will lie to someone 0.86 – 0.83 20* of a relative/friend cheating on their taxes that he/she will cheat on their taxes 0.91 – 0.84 21* of a relative/friend deliberately parking that he/she will deliberately park illegally 0.82 − 0.14 – 0.76 illegally in a disabled car parking space in a disabled car parking space 22 of a relative/friend winning the lottery he/she will win the lottery 0.90 UC 0.84 23* of a stranger doing something kind for a that this will happen 0.83 – 0.78 relative/friend 24 a relative/friend finding money on the that he/she will find money on the street 0.87 − 0.10 UC 0.79 street 25* of a relative/friend becoming ill that he/she will become ill 0.82 − 0.16 – 0.79 26 of a relative/friend’s house being burgled that his/her house will be burgled 0.76 UC 0.79 27 of a relative/friend being in a plane crash that he/she will be in a plane crash 0.75 UC 0.78 28 about a relative/friend killing themselves that he/she will kill themselves 0.82 UC 0.86 29 about a relative/friend harming them- that he/she will harm themselves 0.88 UC 0.83 selves 30 about a relative/friend harming them- that he/she will harm themselves with the 0.88 UC 0.86 selves with the intention to die intention to die *These items were removed from the scale after exploratory factor analysis Extracted factors correspond to uncontrollable (UC), self-suicidal (SS), and positive controllable (PC) four-factor model has been shown to have a better fit in non- assesses chronic thought suppression using a 5-point scale meditating samples (e.g., Siegling and Petrides 2016) and (1 = “strongly disagree” to 5 = “strongly agree”). Psycho- we therefore performed subscale analyses. metric properties show good internal consistency (α = 0.89) (Muris et al. 1996). Factor analyses indicate that the 15-item The White Bear Suppression Inventory scale consists of two related factors: the tendency to suppress thoughts, and the frequency of experiencing unwanted intru- The White Bear Suppression Inventory (WBSI; Wegner sive thoughts (e.g., Schmidt et al. 2009), indicating that a high and Zanakos 1994) is a 15-item self-report inventory which frequency of intrusions does not necessarily equal a high level 1 3 788 Cognitive Therapy and Research (2018) 42:782–793 of suppression. We used the suicidal revision developed by Group Differences in TAF Pettit et al. (2009) for the D-S group, and the original scale for the healthy controls and D-NS group. To analyse differences in TAF between groups, we per - formed multiple linear regression analyses on TAF scores Data Analysis as dependent variable and group membership as independ- ent variable. Analyses were conducted both unadjusted and Exploratory Factor Analysis adjusted for potential confounding variables (i.e., age and gender). Instead of regression coefficient p-values based on All data analyses for the exploratory factor analysis (EFA) the t-distribution, p-values were computed by means of per- were performed by using the psych package (Revelle 2014) mutation analysis using the lmPerm package in R (Wheeler in R 3.4.1 (R Core Team 2017). First, principal axis factor et al. 2016), which avoids relying on (often unmet) assump- analysis in conjunction with parallel analysis was run using tions of homogeneity of variances and normality (Kabacoff maximum likelihood estimation to determine the number 2015) and is similar to bootstrapping analyses. of factors for factor analysis. As recommended, we used parallel analysis in conjunction with a scree plot and Kai- Comparison of TAF in Normal and Crisis State ser’s criteria (eigenvalue > 1 rule) to have multiple criteria for determining the number of factors (Hayton et al. 2004). To examine whether there was a significant difference in Results from principal axis factor analysis informed EFA the degree to which the two clinical groups’ TAF scores that was conducted on the determined number of factors. changed as a result of the mood induction, linear regres- The sample was split randomly into two subsamples. EFA sion analyses were conducted with the TAF scores in the was then performed on one subsample, again applying maxi- mood induction condition as outcome variable, with pre- mum likelihood estimation and promax rotation to allow for dictors being group membership (0 = D-NS, 1 = D-S), the correlation between factors. Based on EFA results, items TAF scores before mood induction, and the interaction term were explored on uniqueness and factor loadings to identify of theses variables. Again, p-values were estimated using items that could be deleted. permutation-based regression. Confirmatory Factor Analyses Results To validate the solution identified by EFA, confirmatory fac- tor analyses (CFA) were performed on the second half of the Participant Characteristics sample using MPlus 7.4 (Muthén and Muthén 2007–2014). Model fit was evaluated by inspecting χ statistics, the com- The sample consisted of N = 361 individuals, consisting of parative fit index (CFI), the Tucker–Lewis index (TLI), and 130 HC, 134 D-NS, and 97 D-S individuals (the random the root mean square error of approximation (RMSEA). subsamples consisted of N = 181 and N = 180, respectively). According to recommendations in the literature, CFI and Baseline characteristics of the full sample and subgroups TLI values of 0.95 or greater and RMSEA values of 0.06 or are shown in Table S1. Gender, education, ethnicity, and lower were considered as indicating good fit (Hu and Bentler employment differed significantly across subsamples, with 1999). Robust maximum likelihood estimation procedures significantly higher number of men in the depressed non- were employed to account for non-normality. suicidal group (p < 0.05). Internal Consistency and Convergent Validity Factor Analysis To assess internal consistency, we computed Cronbach’s α The number of factors obtained by principal axis factor and Omega Total for the total score and factor-based sub- analysis was cross-validated using the Kaiser criteria (3 scales. Omega Total was chosen as additional metric for factors > eigenvalue of 1), a scree plot (3 factors above internal consistency since assumptions for Cronbach’s α are break), and parallel analysis (4 factors > 95th percentile rarely met in practice (McNeish 2017). Convergent valid- of simulated eigenvalues; see Fig. S1). Although parallel ity was assessed by computing Pearson correlations of TAF analysis diverted from a 3-factor solution, this solution was total and factor-based subscales with other scales. Correla- taken forward since the difference between observed and tions were compared using Fisher’s z-transformation. simulated eigenvalues for the fourth factor was negligible. EFA of this 3-factor solution with maximum likelihood estimation and promax rotation revealed a relatively clear cut factor structure (see Table 1): Factor 1 (Uncontrollable 1 3 Cognitive Therapy and Research (2018) 42:782–793 789 TAF) combined 24 items describing uncontrollable events (TAF total: r = .38, TAF Uncontrollable: r = .4) but not with related to either self and/or other (e.g., being in a plane the other WBSI subscales Thought Suppression (r = − .05) crash, winning the lottery, others’ self-harm), Factor 2 and Self-Distraction (r = − .08). Moreover, WBSI-Unwanted (Suicidal TAF) combined three items that were related to Intrusive Thoughts was moderately correlated with TAF own self-harm or suicide (i.e., not others’ self-harm) and self-suicidal (r = .31). were hence controllable (logically, if not phenomenologi- cally), and Factor 3 (Controllable TAF) combined three TAF Across Groups items with self-related positive content that were also con- trollable (e.g., myself having fun on a holiday). The per- Results from multiple regression analyses in conjunction centage of variance explained by these factors was 44.1, with permutation tests revealed significant differences in 7.5, and 5.8 for factors 1, 2, and 3, respectively. TAF between groups (see Table S5). The D-NS group had The number of items was reduced from 30 to 20 items significantly higher total TAF, uncontrollable TAF, self-sui- based on low factor loadings (5 items below 0.5) as well cidal TAF, and lower positive controllable TAF when com- as keeping with item mirroring in the self-other category pared with healthy controls. Contrary to our hypothesis, the (5 corresponding items; see Table 1). All item reductions D-S group did not show differences to HCs on overall TAF, were from the uncontrollable TAF subscale. uncontrollable TAF, and positive controllable TAF, but did Next, CFA was conducted on the reduced 20-item show significantly higher self-suicidal TAF. version of the TAF-SR. More specifically, a model with three correlated latent factors, where all 14 items Differences Between Normal and Crisis State describing uncontrollable events loaded on one factor, the three items related to self-harm loaded on another fac- Finally, we tested whether the two clinical groups differed in tor, and the three items describing controllable positive how their TAF scores changed from normal to crisis states events loaded on a third factor. Results indicated good using permutation-based linear regression of outcome cri- model fit; χ (167) = 250.52, CFI = 0.95, TLI = 0.95, sis state TAF with predictors being dummy-coded group, RMSEA = 0.053 (90% CI 0.039–0.066) of the three-factor normal state TAF, and their interaction. D-NS individuals solution. We compared the three-factor model to a sin- increased significantly more than D-S individuals from nor - gle factor model where all items loaded on one overall mal to crisis states on total and uncontrollable TAF scores. TAF factor. However, fit for this model was not adequate; In contrast, the D-S group increased significantly more for χ (170) = 429.18, CFI = 0.85, TLI = 0.83, RMSEA = 0.092 suicidal TAF and decreased significantly more for the TAF (90% CI 0.081–0.103). positive controllable (Table S6). Convergent and Discriminant Validity Discussion Cronbach’s α and Omega Total showed good to excellent Twenty years ago, Shafran et al. (1996) suggested that TAF internal validity for total TAF (α = 0.94, ω = 0.94), uncon- might reinforce depressive symptoms in mood disorders; trollable TAF (α = 0.96, ω = 0.96), and self-suicidal TAF however, to our knowledge, only two studies have since (α = 0.86, ω = 0.87). Internal consistency was only moderate examined TAF in depression (Abramowitz et  al. 2001; for positive controllable TAF (α = 0.68, ω = 0.69). Meyer and Brown 2013). The goal of this study was to Associations between TAF and other scales are presented compare TAF in people with a history of suicidal depres- in a correlation matrix in Table S3. Total TAF score, uncon- sion to TAF in individuals with a history of non-suicidal trollable TAF, and self-suicidal TAF correlated moderately depression and healthy controls, and to revise and adapt the with RRS. Looking at RRS subscales (Table S4) revealed Thought–Action Fusion Scale (Shafran et al. 1996) for this somewhat stronger correlations between TAF scales and purpose. To our knowledge, this is the first study to demon- the Reflection and Depression subscales as compared to the strate thought-action fusion in both non-suicidal and sui- Brooding subscale (z = 2.84, p < 0.01). Correlations to other cidal depression. Our study produced three major findings, scales (BRFL, WBSI, SMQ, FFMQ) was low. However, described below. subscale analyses for FFMQ and WBSI yielded somewhat different findings. There was a significant moderate correla- 1. Development of Thought–Action Fusion tion between the Describing subscale of the FFMQ and TAF Scale‑Suicidal Revision total (r = .4) and TAF self-suicidal (r = .32) (Table S4). The correlation matrix (Table S4) indicates that TAF was mod- The first set of findings relates to adaptation of the origi- erately correlated with WBSI: Unwanted Intrusive Thoughts nal TAF scale to suicidal and non-suicidal depression. The 1 3 790 Cognitive Therapy and Research (2018) 42:782–793 factor analysis pointed to controllability of events as a key Positive Controllable TAF suggests that, whilst from a sta- parameter for TAF in this sample. This is reflected both in tistical point of view the overarching TAF score is valid, in Uncontrollable and Controllable TAF, and TAF for suicidal practical terms the Positive Controllable TAF items contrib- events, which are logically controllable, yet not necessar- ute only to a minor degree to the overall TAF factor. Unlike ily perceived as such given the typically decreased sense of Craig and Lafreniere’s scale, there was no evidence of a agency in this population. These findings extend the existing distinct positive TAF. However, in their work on Positive TAF literature, which has focussed solely on uncontrollable TAF, Craig and Lafreniere (2016) differentiated between events (e.g., car accident, being injured in a fall, falling ill). positive-gain and harm-avoidance categories, whereas in Test of convergent and discriminant validity indicated this study we focussed on positive-gain only. Given the large that TAF was not associated with total WBSI score, contrary proportion of clinical subjects, including harm-avoidance to our hypothesis. However, TAF was positively correlated might have yielded different results. with the WBSI subscale ‘unwanted intrusive thoughts’, in keeping with Rassin et al.’s (1999) suggestion that TAF is 2. Differences in TAF Between Groups linked to the tendency to experience a high frequency of intrusions, and empirical evidence that TAF predicts fre- Concerning the second main finding, we found important quency and perceived controllability of unwanted mental differences in Total TAF between clinical groups and healthy intrusions (Purdon and Clark 1994). This introduces the pos- controls. However, our hypothesis that TAF would be high- sibility that TAF is related not just to perceived controllabil- est in D-S, intermediate in D-NS and lowest in HC was not ity of an imagined event (e.g.; perceiving of being in a plane confirmed. Indeed, whilst total TAF was relatively similar crash as uncontrollable), but also to the perceived control- in D-S and healthy controls, total TAF and Uncontrollable lability of the cognition itself (e.g., I can’t stop my thoughts). TAF were significantly higher in the D-NS group. Whilst In addition to associations with unwanted intrusions, TAF problem-solving and goal-directed behaviour are likely to be (both total and subscales) was strongly positively correlated impaired in individuals with a history of recurrent depres- with rumination. These findings suggest acceptable conver - sion, the D-NS appear to have an elevated belief in their gent validity, and lends partial support to Rachman’s (1997) capacity to control the world through their thinking. Such a hypothesis of a link between TAF and rumination. However, belief may parallel with the positive beliefs about rumination it is not possible to draw conclusions about the potentially and problem-solving as regulatory behaviour (e.g., Watkins causal nature of the association on the basis of this dataset. and Baracaia 2001) but appears to extend to the relation- Further research is required to better understand the mecha- ship between participants’ thoughts and the occurrence of nisms linking TAF to rumination and perceived intrusive- events outside their own and other’s control. The D-S group, ness of thoughts, and the direction of causality. on the other hand, does not show this bias. One possibility The correlation between the reflection subtype of rumina- is that for those with recurrent depression, general TAF is tion and TAF was significantly stronger than between brood- actually protective, and that in its absence, repeated negative ing and TAF. Brooding has been shown to have a stronger experiences will result in the high levels of hopelessness association with recurrent depression than reflection and characteristic of those who experience suicidal ideation or to be linked to poorer outcome longitudinally (Treynor engage in suicidal behaviour. et al. 2003). However, both reflection and TAF might lock Contrary to our hypothesis, there was also no basis in thoughts at an abstract level of cognition, thereby reinforc- the findings for distinguishing between the D-S and D-NS ing an abstract-analytical style of processing and potentially group on Self-Suicidal TAF when participants completed reinforcing existing deficits in problem-solving-indeed, the measure reporting from a perspective of being well. It is reflection has been found to be linked to suicidal ideation in possible that Self-Suicidal TAF is underpinned by different patients with a history of suicide attempts (Surrence et al. beliefs in these two groups, e.g., that D-NS perceive them as 2009). more controllable than the D-S group, however, this awaits Given the poor fit of a five-facet model to non-meditator further scrutiny. Moreover, the prediction that for the D-S samples (e.g., Curtiss and Klemanski 2014), subscale analy- group, the salience of suicidal thoughts would override the ses of FFMQ were considered more relevant in this context. self-other distinction was not met, indicating that it is pri- The negative correlation between TAF total and the FFMQ marily in thinking about self-relevant, suicidal themes that subscales Describing and Acting with awareness partially TAF is activated. corroborates the discriminant validity of the scale, given the emphasis of these facets on de-identification with thought. 3. TAF Before and After Mood Induction The excellent model fit for the hierarchical CFA indi- cates that the total TAF factor represents the three factor- Our findings show that TAF increases in both clinical groups based subscales well. However, the low factor loading with following a mood induction. The mean changes across states 1 3 Cognitive Therapy and Research (2018) 42:782–793 791 and groups (Table S6) suggest possible mood-dependency of history of depression, thereby suggesting that mere questions self-suicidal TAF. The increase in Total and Uncontrollable outside the experimental context have the power to induce TAF from normal to crisis states in the D-NS group (com- transient dysphoric mood or enable individuals to respond in pared to the D-S group) suggests that as D-NS become dis- a way that mirrors responses occurring after experimentally tressed they increase their belief in their capacity to control induced mood (e.g.; Williams et al. 2008). Future studies events and occurrences through their thoughts. In contrast, are required using larger clinical and non-clinical samples self-suicidal TAF increased and Positive Controllable TAF and experimental designs in which predictions about mood decreased from normal to crisis states in the D-S relative to dependency of TAF and its impact on other key maintenance the D-NS group, suggesting that as the D-S group become mechanisms can be tested. Fourth, the current data set did more distressed they experience not only more suicide- not enable differentiating TAF in those with a history of related TAF but a reduction in their belief in their capacity to recurrent suicidal ideation from those with a history of sui- influence positive controllable events through their thoughts. cidal behaviour. Potential differences await scrutiny. Diminished positive controllable TAF may reflect a rise in hopelessness occurring when in the imagined crisis state, in keeping with a differential activation theory of hopelessness/ Conclusion suicidality (Williams et al. 2008). Together with findings of group differences, these data suggest that that differences in It is possible that TAF reinforces an abstract-analytical style TAF between D-NS and D-S individuals become more pro- of processing involved in the maintenance of depressive nounced in the context of low mood. This points to suicidal (Watkins 2008) and suicidal distress (Williams et al. 2016). and positive controllable TAF as useful clinical targets. If so, TAF would be an obvious clinical target. However, this awaits further experimental and longitudinal scrutiny. Stud- Limitations ies exploring TAF modification are scarce (see Jonsson et al. 2011; Siwiec et al. 2017), and in furthering our understand- The current findings need to be interpreted in the context ing of the feasibility of modifying TAF in depressed and of the following limitations: First, the study is limited by suicidal populations, the link between TAF, problem-solv- sample size (N = 361). Common rule of thumbs for CFA ing, executive functioning and cognitive flexibility require include, but are not limited to: N ≥ 200, and ratio of N to the further experimental scrutiny. number of variables (p), N/p ≥ 10 (Myers et al. 2011). In the CFA, there were 167 free parameters, whereas the conven- Funding This study was funded by University of Oslo Department of Psychology, Norway. tion is five participants per free parameter (Bentler and Chou 1987). However, such rules of thumbs have been widely Compliance with Ethical Standards criticised as having limited validity when applied to real data, as adequate sample size for both EFA and CFA rely on Conflict of Interest Dr. Gjelsvik, Mr. Kappelmann, Professor von factors that would typically vary across studies (Myers et al. Soest, Miss Hinze, Professor Baer, Professor Hawton and Dr. Crane all 2011). Replications in larger samples are required. Second, declare that they have no conflict of interest. the study was limited by its cross-sectional design, and we Informed Consent All procedures performed in studies involving cannot establish causality between TAF and suicidal and human participants were in accordance with the ethical standards of the non-suicidally depressive distress. However, we have intro- institutional research committee and with the 1964 Helsinki declaration duced a theoretical rationale for why TAF might be critical and its later amendments or comparable ethical standards. Informed in the suicidal trajectory, and the results suggest that this consent was obtained from all individual participants included in the study. might also apply to maintenance of non-suicidal depression. This awaits scrutiny in studies adopting experimental and Animal Rights Statements No animal studies were carried out by the longitudinal designs. authors for this article. Third, given that the survey took place entirely online, the mood induction was carried out outside an experimental Open Access This article is distributed under the terms of the Crea- context. Thus, we cannot ascertain that the conditional ques- tive Commons Attribution 4.0 International License (http://creat iveco tions entailing revisiting a time of crisis genuinely led to a mmons.or g/licenses/b y/4.0/), which permits unrestricted use, distribu- tion, and reproduction in any medium, provided you give appropriate drop in mood or simply encouraged participants to respond credit to the original author(s) and the source, provide a link to the ‘as-if’ in such a mood. Findings relating to changes from Creative Commons license, and indicate if changes were made. baseline to crisis state requires experimental validation. Nevertheless, questionnaires adopting conditional questions (e.g., the LEIDS; Van der Does 2002) have been able to reliably distinguish between individuals with and without a 1 3 792 Cognitive Therapy and Research (2018) 42:782–793 Kabacoff, R. (2015). R in action: Data analysis and graphics with R. References Shelter Island, NY: Manning Publications. 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Thought–Action Fusion in Individuals with a History of Recurrent Depression and Suicidal Depression: Findings from a Community Sample

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Medicine & Public Health; Quality of Life Research; Clinical Psychology; Cognitive Psychology
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Abstract

Although suicidal ideation is one of the most consistent symptoms across recurrent episodes of depression, the mechanisms underpinning its maintenance are poorly understood. In order to develop effective treatments for suicidally depressed patients, understanding what maintains suicidal distress is critical. We hypothesised that Thought–Action Fusion (TAF), i.e., to assume that having a thought has real world consequences, originally described in Obsessive–Compulsive Disorder, might be a bias in recurrently suicidally depressed people. To assess this, we revised the original TAF scale, and assessed TAF in three samples: healthy controls, recurrently depressed individuals with no history of suicidality (D-NS) and individuals with a history of recurrent suicidal depression (D-S). Exploratory and confirmatory factor analyses indicated a three-factor solution of TAF: (1) TAF for uncontrollable events, (2) self-suicidal TAF for suicidal acts related to oneself, and (3) TAF for positive controllable events. Compared to healthy controls, the D-NS group reported significantly higher total TAF, TAF uncontrollable, and TAF self-suicidal subscales, whilst positive controllable TAF was lower compared to healthy controls. Both D-S and D-NS samples reported higher TAF for suicidal thought compared to healthy controls, i.e., believing that hav- ing suicidal thoughts means they will act on them, however in the context of low mood this became more pronounced for the D-S group. These findings suggest that targeting TAF both in suicidal and non-suicidal depression has merit. Keywords Thought–action fusion · Suicidal ideation · Self-harm · Suicide · Depression Introduction to such cognitions, and whilst for some people suicidal thoughts are fleeting and temporary (Nock et al. 2009), for Although suicidal cognitions are a common feature of major others they tend to persist and cause distress. Likewise, even depression, they are also prevalent among people seeking in people with severe recurrent depression, the degree of health care (Scott et al. 2012) and observed to some degree distress that suicidal thoughts and images evoke varies mark- in general population samples (Crosby et al. 2011). Inter- edly (e.g.; Crane et al. 2014). We have previously suggested estingly, people differ in the way they experience and react that vulnerable individuals’ relationship with and responses to suicidal cognitions are critical in determining whether sui- cidal cognitions persist and potentially escalate and that such persistence is most likely when individuals respond to sui- Electronic supplementary material The online version of this article (https ://doi.org/10.1007/s1060 8-018-9924-7) contains cidal thoughts with rumination and suppression (Williams supplementary material, which is available to authorized users. et al. 2016). In line with this hypothesis Pettit et al. (2009) have found that suppression of suicidal thoughts increases * B. Gjelsvik their severity over time. bergljot.gjelsvik@psych.ox.ac.uk Although it is established that differences in response Department of Psychiatry, University of Oxford, Oxford, UK to suicidal cognitions exist in patient and general popula- Department of Psychology, University of Oslo, Oslo, Norway tion samples, relatively little is known about the factors that determine these. However, models of Obsessive–Compul- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford OX37JX, UK sive Disorder (OCD); (e.g., Clark 1999), in which distress- ing and intrusive thoughts are core symptoms, may suggest University of Kentucky, Lexington, USA Vol:.(1234567890) 1 3 Cognitive Therapy and Research (2018) 42:782–793 783 potential candidate mechanisms. One relevant concept found that both global TAF and TAF-Likelihood were more arising from the OCD literature is Thought–Action Fusion strongly associated with obsessive–compulsive symptoms (TAF); (Rachman 1993; Shafran et  al. 1996; Craig and than with measures of depression and worry, suggesting that Lafreniere 2016). TAF was introduced by Rachman (1993) to the extent that TAF is observed in depressive populations to describe a phenomenon in which a person believes that it may be present primarily where there is also thought con- the mere presence of intrusive thoughts can influence events tent which has an obsessive quality. in the real world. Rachman (1993) describes two compo- One reason for thinking that TAF may be relevant to nents of TAF: First, ‘morality TAF’ describes the tendency suicidal ideation is that it has previously been suggested to assume that the occurrence of certain intrusions implies that suicidal thoughts present as a form of rigid rumina- immorality of character (e.g., intrusions about killing equal tion (Kerkhof and van Spijker 2011; see also; Rogers and being a bad person). Second, ‘likelihood TAF’ describes Joiner 2017), the engagement with which can be character- the view that the mere presence of thoughts has real life ised as obsessive. Further, the distressing and often graphic consequences and could, for example, increase the likeli- content of suicidal urges (e.g., ‘I could hang myself in the hood of catastrophic events (e.g., intrusions about killing back garden’) could be seen to have more in common with somebody make it more likely it will happen). TAF has obsessions as seen in OCD (e.g., losing control and harm- been proposed to promote engagement in strategies (e.g., ing oneself or others), than depressed non-suicidal thoughts suppression, worry, rumination, neutralising behaviours) (e.g., ‘I’m no good’). However, the strong ruminative nature intended to control intrusions, prompted by the perceived of non-suicidal depression (e.g., Liu et al. 2017) indicates probability of the thought content happening, and/or by the that TAF might also be relevant here. Thus, there appears to misinterpretation that a person is responsible for harm unless be merit in exploring the potential commonalities between they take action to prevent it (Rachman 1993; Rassin et al. OCD intrusions and suicidal cognitions, and to compare this 2000). Importantly, however, since attempts to suppress with non-suicidal depression. It is also possible that one pos- unwanted thoughts have been found in many cases to lead sible reason why existing studies of TAF in depression have to a paradoxical increase in their frequency (Abramowitz not yielded strong findings, is that the standard measure to et al. 2001) and intensity (Wegner 1994), TAF is likely to assess TAF, TAF-R (Shafran et al. 1996), was developed to contribute to the escalation of symptoms over time. Indeed, assess TAF in OCD, and so may be less sensitive to identify Rassin et al. (1999) found that experimentally induced TAF TAF in other domains, such as in depression and suicidality. led to an increase in intrusions and perceived discomfort in Thus, it is possible that TAF may also be observed in people healthy controls. with depression, particularly where there are thoughts with Whilst several studies have found a strong relationship an obsessive quality, if items were appropriately worded to between OCD and TAF (e.g., Amir et al. 2001; Shafran et al. elicit it. 1996), some studies have shown that when depression is If TAF is present in people suffering from suicidal controlled for, the association between OCD and TAF is depression what impact would this have for symptom no longer significant (O’Leary et al. 2009; Jonsson et al. maintenance and exacerbation? In OCD, it is suggested 2011). Nevertheless, to our knowledge, only two studies that TAF increases the distress associated with intrusive have examined TAF in depressed samples (Abramowitz et al. thoughts and compounds attempts to neutralise them 2003; Meyer and Brown 2013). Abramowitz et al. (2003) (Rassin et al. 1999; Rachman 1997). However, there is compared TAF in OCD samples to other anxiety disorder no suggestion that TAF increases the actual likelihood of samples, clinically depressed patients and healthy controls. enactment of such thoughts. Likewise, it might be sug- They found that OCD patients had higher likelihood-TAF gested that TAF related to suicidal thoughts would simi- for others-related events compared to depressed patients, larly increase distress and cognitive preoccupation, but patients with social phobia and healthy controls, but not would not increase risk of enactment. However, suicidal higher likelihood TAF for self-related events. However, cognition is characterised not only by explicit thoughts and there were no overall differences across groups on Morality images related to suicidal acts, but also to broader cogni- TAF. Inferences about group differences across depressed tions including those relating to perceived burdensome- and OCD samples were complicated by the OCD sample ness (e.g., ‘my death is worth more than my life to others’; scoring higher on the Beck Depression Inventory (BDI) Van Orden et al. 2010) and entrapment (‘nobody can help than the depressed sample. However, in this study depres- me out of this mess’; Williams 2014). Although entirely sion was secondary to the focus on anxiety disorders, and the hypothetical, it is possible to speculate that if TAF also sample of depressed patients was small (n = 19). Meyer and operated in relationship to these thoughts, the responsibil- Brown (2013), in contrast, examined TAF in a large clini- ity they evoke (e.g., to unburden the family) might serve as cal sample including both depressed and anxious patients. a volitional moderator (O’Connor 2011), reinforcing and Using the TAF scale developed by Shafran et al. (1996), they promoting suicidal distress, and facilitating the progress 1 3 784 Cognitive Therapy and Research (2018) 42:782–793 from thoughts to acts. To the best of our knowledge, how- a revision of the items would be required in order to make ever, no studies have systematically examined TAF in sui- the scale more amenable to depression and suicidality. cidal depression, nor compared TAF in this population to individuals with a history of non-suicidal depression and Assessment of Thought–Action Fusion healthy controls. If TAF is present in people with recurrent suicidal The first version of the Thought Action Fusion Scale depression, a second issue concerns its mood depend- (Shafran et  al. 1996) was explicitly developed for use ence. Cognitive science accounts of recurrent depression with OCD patients, and consisted of 34 items, which, fol- (i.e., the Differential Activation framework) posit that lowing factor analyses and revisions, led to the 19 item in people with a history of recurrent depression, depres- Thought–action fusion scale-revised (TAF-R). This scale sive and suicidal thoughts can be reactivated by subtle consisted of three subscales all denoting negative events: and transient changes in mood (Williams et  al. 2016; TAF-moral (12 items), TAF-likelihood-self (i.e., TAF likeli- Scherrer et  al. 2014; Brockmeyer et  al. 2012). Indeed, hood for self-related events; 3 items) and TAF-likelihood- mood-dependent changes in dysfunctional thinking have other (i.e., TAF likelihood for self-related events: 4 items). been shown to predict depressive relapse in previously Overall, the TAF literature shows that the three factors of depressed patients (Segal et al. 2006). Such reactivation TAF-R have good reliability, as reflected in Cronbach’s involves not just negative content but also maladaptive alphas ranging from 0.75 to 0.89 (Rassin et al. 2001). cognitive processes. For example, our previous work has Whilst it seems clear that patients suffering from anxiety shown that people with a history of suicidal depression can disorders report higher TAF than healthy controls on the be distinguished from those with a history of non-suicidal probability dimension (e.g., Rassin et al. 2001), comparisons depression in the extent to which increases in negative with other clinical groups are sparse. Two revisions of the mood impair interpersonal problem solving, a cognitive original scale have since been made; one including TAF for deficit characteristic of people at times of suicidal crisis thoughts about positive events happening to self and others, (Williams et al. 2005). Likewise, people with a history across domains of both gain and harm avoidance (Craig and of suicidality report more hopeless thoughts when asked Lafreniere 2016), and one including items about likelihood to imagine being in a slightly sad mood, and this meas- of preventing harm by means of positive thoughts (Amir ure of hopelessness reactivity predicts actual cognitive et al. 2001). To our knowledge, no TAF scale has been devel- deficits in positive future thinking after an experimental oped to specifically assess TAF for depression or suicidality. mood challenge (e.g.; Williams et al. 2008). Some forms Shafran et al. (1996) have noted that responses on the of mood-dependent dysfunctional thinking (e.g., entrap- TAF tended to be idiosyncratic, and that the scale would be ment) have also been shown to increase the risk of suicidal most usefully considered as a clinical tool to identify idi- behaviour longitudinally (O’Connor et al. 2013). If TAF is osyncratic beliefs, rather than generating sum-scores. More- also observed in people with a history of recurrent suicidal over, they emphasised that the construct of TAF was in its depression, a first step in examining whether this bias pre- early stages and that associated metacognitions, specificity dicts subsequent suicidal relapse is to investigate whether to OCD, and clinical implications were still unclear. Further- such potential endorsement of thoughts increases in the more, with the notable exception of Craig and Lafreniere’s context of transient low mood. Identifying factors uniquely (2016) examination on TAF for positive events, the TAF affected by changes in mood is helpful in understanding literature has focussed solely on negative events (e.g., being what serves to maintain and progress suicidal crises, and in a car accident, either self or other; Shafran et al. 1996). in formulating potential clinical targets. Indeed, although Another important dimension which has not been assessed as stated above there is relatively little research explor- in existing versions of the TAF-R but which might influence ing TAF in depression, Shafran et  al. (1996) suggest a the extent to which TAF is observed is the controllability reciprocal relationship between mood disorders and TAF, of the event to which a thought relates. There is some evi- in which depression might increase the occurrence and dence that thinking about an event increases the likelihood believability of thoughts, and in which TAF, in turn, might of engaging in that behaviour at least for desirable actions exacerbate low self-esteem, depression and anxiety. (e.g., imagining to vote and subsequently doing so; Libby Thus, there appears to be a strong rationale for exploring et al. 2007), and thus there is to some degree a reality to the the potential presence of TAF in individuals with a history belief that thinking about a potentially self-initiated action of suicidal depression, including the extent to which TAF may increase its probability. In contrast, there is no evidence might be mood-state dependent, and elevated at times of low that thinking about uncontrollable actions has any bearing on mood or crisis. However, since the original TAF scale was one’s behaviour. As such it is possible that pathological TAF developed for OCD, for the present study we considered that may be most easily observed when it relates to the likelihood of other-initiated actions (e.g., friend committing a crime) 1 3 Cognitive Therapy and Research (2018) 42:782–793 785 or self-relevant uncontrollable actions (e.g., being called to Methods Jury duty) for which there is no logical mechanism through which thought might lead to action. Controllability may be Participants a particularly relevant aspect of TAF in the context of both suicidal and non-suicidal depression given the emphasis on The current study reports on a cross-sectional online survey locus of control in depressive and suicidal symptomatology. of adults. All participants were recruited online. Participants Thus, both the self-other and controllable-uncontrollable were recruited from the following three groups: Individu- dimensions appear important in understanding the phenom- als who were currently well but had a history of suicidal enon in the context of recurrent suicidal and non-suicidal depression (D-S) or non-suicidal depression (D-NS); and depression. Finally, in terms of convergent validity, despite Healthy Controls (HC). Participants were eligible for inclu- the theoretical emphasis on TAF eliciting control strategies, sion if they were (a) between 18 and 70 years of age, (b) little is known about relationship of TAF to relevant cogni- fluent in English, (c) currently well at the time of inclu- tive strategies other than obsessionality, such as suppression, sion i.e., meeting the National Institute on Mental Health rumination as well as a divergent construct, trait mindfulness guidelines for recovery or remission (Frank et  al. 1991, (i.e., the capacity to pay attention to momentary experience including minimal symptoms of depression at no more than with acceptance and non-judgement, Baer et al. 2006, 2008). a mild level for the previous 8 weeks) and (d) able to provide The objectives of the present study were therefore to informed consent. For both the D-S and D-NS groups, the examine TAF in suicidal and non-suicidal depression as following additional inclusion criteria applied: A minimum compared to healthy controls, and also to examine the effect of ≥ 3 episodes of depression, defined by DSM-IV criteria of a mood induction within the two depressed groups. To for a history of Recurrent Major Depression, of which two address the above issues concerning the measurement of must have occurred within the last 5 years and at least one TAF we (a) developed and validated a TAF scale adapted within the last 2 years, and being currently well defined as to include items whose content was relevant to suicidal meeting the National Institute on Mental Health guidelines depression (including items with both positive and nega- for recovery or remission (Frank et al. 1991) at the time of tive content, including suicide related content), and which inclusion (i.e., minimal symptoms of depression at no more included items covering both self-other and controllable- than a mild level for the previous 8 weeks). Inclusion in the uncontrollable dimensions using exploratory and confirma- D-S group required a reported history of recurrent suicidal tory factor analysis, (b) compared the derived TAF scale ideation and/or behaviour. Participants were excluded if they in individuals with a history of suicidal depression and reported current or past symptoms of (a) obsessive–compul- non-suicidal depressed compared to non-clinical controls, sive disorder (OCD), (b) substance abuse, (c) bipolar disor- and (c) examined whether TAF increased in the depressed der (including manic episodes during the last 6 months), and groups when these groups were asked to respond from the (d) a diagnosis of schizophrenia. perspective of a time of crisis, as compared to their baseline responses. We hypothesised (1) that total TAF score would Procedure correlate positively with suppression and rumination and correlate negatively with facets of trait mindfulness across Participants were recruited through adverts in newslet- the sample as a whole, (2) that total TAF would be related ters and flyers in the community and online, calling for linearly to lifetime depression severity (i.e., increased in healthy controls as well as individuals with a history of sui- depressed controls compared to healthy controls and high- cidal and non-suicidal depression but who were currently est in individuals with a history of suicidal depression), (3) well (see above). The survey link was active from March that if a factor emerged that reflected item content related through August 2016. Prior to participation, individuals self- to suicidality that this factor would be higher in individuals screened online to ascertain that they were all currently well, with a history of suicidal depression than in non-suicidal and to ensure appropriate assignment to one of the follow- depressed and healthy controls and compared to other factors ing three groups: Depressed-suicidal (D-S); individuals who for this group due to its salience, and (4) that TAF would were currently well but had a history of suicidal depression, increase for clinical groups when reported in the context of Depressed-Non-Suicidal (D-NS); individuals with a history low mood as compared to baseline. of depression but no suicidality, and Healthy Controls (HC). We recruited participants who were currently well or in remission (as above) at entry to the study to enable us to explore both (a) whether there are trait differences (either pre-existing first onset of depression or persisting as a scar effect) between individuals with a history of depression and 1 3 786 Cognitive Therapy and Research (2018) 42:782–793 those without and (b) whether there are differences between mood (e.g. the Anxiety Sensitivity Index; Peterson and Reiss participants’ responses when they reported on TAF at base- 1992; the Leiden Index of Depression Sensitivity; Van der line and when asked to imagine a time of crisis. Moreo- Does 2002), assessed independently of an experimental ver, assessing TAF for suicidal events in close proximity to context, asking conditional questions about their worst ever episode of self-harm would have been confounded with the crisis in addition to questions about their current state. Thus, event in question just having taken place. Assessing individ- participants completed the same scale twice: Participants uals in remission from depression minimised this risk. The in the D-S and D-NS group (but not healthy controls) were protocol for this study was reviewed and approved by Oxford asked to first complete the TAF scale according to how University’s Central University Research Ethics Committee they were currently feeling (e.g., ‘How well do the follow- (CUREC; protocol number MSD-IDREC-C2-2014-030). ing statements describe how you are currently feeling?’), Following online screening, eligible participants were and subsequently to complete them from the viewpoint of informed about the study procedures through an electronic their worst (depressive and/or suicidal) crisis (i.e., ‘Now we information sheet, and consent was obtained electronically would like you to describe how well the statements describe before proceeding to complete the survey. Upon completion how you typically feel at a time of crisis’). This was based participants received a £10 Amazon voucher via email as on the assumption, derived from previous work, that taking reimbursement. the perspective of a previous crisis would enable individuals to respond in a way that mirrors responses occurring after Measures experimentally induced mood (e.g. Williams et al. 2008), expected to affect their responses on the revised TAF scale. Thought–Action Fusion‑Suicidal Revision (TAF‑SR) The Ruminative Response Scale The first version of the Thought Action Fusion Scale (Shafran et al. 1996) was explicitly developed for use with The Ruminative Response Scale (RRS, Nolen-Hoeksema OCD patients, and consisted of 34 items, which, following and Morrow 1991) is a 22-item self-report scale assessing factor analyses and revisions, led to the 19 item TAF-R. different facets of self-reflective thinking. Participants are TAF-Suicidal Revision was based on this 19-item TAF-R asked to rate how much they engage in different cognitive (Shafran et al. 1996). As Morality TAF is not directly related responses on a 4-point scale, ranging from 1 (never) to 4 to the occurrence of actual events in the real world but rather (always). Treynor, Gonzalez and Nolen-Hoeksema (2003) reflects a belief about the significance of events, we focussed identified three subscales of the RRS: depression-related exclusively on the likelihood aspect of TAF due to our inter- rumination (12 items, e.g., “think about how hard it is to est in measuring people’s beliefs about their thoughts having concentrate”), brooding (five items, e.g., “think ‘Why can’t a direct influence on outcomes in the real world. Moreover, I handle things better?’”), and reflection (five items, e.g., we were interested in whether TAF for suicidal content was “Analyze recent events to try and understand why you are different from TAF for other content; thus, a revision was depressed”). The RRS shows acceptable internal consist- required. We expanded the original self-other dimension ency for brooding (α = 0.68), and good internal consistency (i.e., events happening to oneself or to friends or relatives) for depression-related rumination (α = 0.86) and reflection with (a) valence of events (i.e., positive versus negative) (b) (α = 0.73) (Brennan et al. 2015). whether events were suicidal or non-suicidal and (c) control- lability of events (e.g., eating healthily versus plane crash). The Five‑Facet Mindfulness Questionnaire In order to validate these additional parameters, participants rated the degree to which they found the item phrasing to The Five-Facet Mindfulness Questionnaire (FFMQ; Baer reflect controllability (i.e., the degree to which the event et al. 2006, 2008) consists of five facets assumed to be key was extraneous or self-determined) and valence (negative aspects of mindfulness as a dispositional variable (Observ- or positive), respectively, on a VAS scale (i.e., from 0 to ing, Describing, Non-Judging of inner experience, Non- 100) (see Table S2). Items were mirrored; i.e., there was Reactivity to inner experience and Acting with awareness). an equal number of items describing events related to self The five facets are measured by rating how true each item and other, respectively. The original revision consisted of within each facet is for participants on a general basis on a 30 items rated on a 5-point Likert scale from 1 (Disagree 5-point scale ranging from 1 (never or very rarely true) to 5 strongly) to 5 (Agree strongly), thus resulting in a possi- (very often or always true). The internal consistency for the ble score range from 30 to 150. The items are outlined in scale overall has been shown to be good, with Cronbach’s Table 1. To capture potential mood-dependency of TAF in alphas ranging from 0.75 to 0.91 (Baer et al. 2006), and the the clinical groups, we applied the same principle as other five facets have shown good to excellent internal consistency questionnaires assessing vulnerability in the context of low (Cronbach’s alphas ranging from 0.75 to 0.91). However, a 1 3 Cognitive Therapy and Research (2018) 42:782–793 787 Table 1 Thought action fusion items, factor loadings and item-total correlation for second random half of the sample (n = 181) No. Description Factor loadings Factor Item-total correla- “If I think [ ], this increases the chance [ ].” Factor 1 Factor 2 Factor 3 tion 1 of myself having fun on a holiday that I will have fun on a holiday − 0.11 − 0.12 0.73 PC 0.16 2 of myself donating to charity that I will donate to charity − 0.11 0.76 PC 0.27 3 of myself eating healthily that I will eat healthily − 0.15 0.62 PC 0.14 4* of myself lying to someone that I will lie to someone 0.15 0.32 0.12 – 0.47 5* of myself cheating on my taxes that I will cheat on my taxes÷ 0.53 0.11 – 0.63 6* of myself deliberately parking illegally in that I will deliberately park illegally in a 0.51 – 0.58 a disabled car parking space disabled car 7 of myself winning the lottery that I win the lottery 0.69 UC 0.74 8* of a stranger doing something kind for me that this will happen 0.48 0.22 – 0.58 9 of myself finding money on the street that I will find money on the street 0.68 UC 0.72 10* of myself becoming ill that I will become ill 0.18 0.32 – 0.38 11 of my house being burgled that my house will be burgled 0.73 0.11 UC 0.83 12 of myself being in a plane crash that I will be in a plane crash 0.78 UC 0.75 13 about me killing myself that I will kill myself 1.04 SS 0.60 14 about harming myself that I will harm myself 0.60 SS 0.43 15 about harming myself with the intention that I will harm myself with the intention 0.16 0.76 SS 0.65 to die to die 16 of a relative/friend having fun on a of him/her having fun on a holiday 0.80 − 0.12 UC 0.73 holiday 17 of a relative/friend donating to a charity of him/her donating to a charity 0.71 UC 0.70 18 of a relative/friend eating healthily of him/her eating healthily 0.78 UC 0.72 19* a relative/friend lying to someone that he/she will lie to someone 0.86 – 0.83 20* of a relative/friend cheating on their taxes that he/she will cheat on their taxes 0.91 – 0.84 21* of a relative/friend deliberately parking that he/she will deliberately park illegally 0.82 − 0.14 – 0.76 illegally in a disabled car parking space in a disabled car parking space 22 of a relative/friend winning the lottery he/she will win the lottery 0.90 UC 0.84 23* of a stranger doing something kind for a that this will happen 0.83 – 0.78 relative/friend 24 a relative/friend finding money on the that he/she will find money on the street 0.87 − 0.10 UC 0.79 street 25* of a relative/friend becoming ill that he/she will become ill 0.82 − 0.16 – 0.79 26 of a relative/friend’s house being burgled that his/her house will be burgled 0.76 UC 0.79 27 of a relative/friend being in a plane crash that he/she will be in a plane crash 0.75 UC 0.78 28 about a relative/friend killing themselves that he/she will kill themselves 0.82 UC 0.86 29 about a relative/friend harming them- that he/she will harm themselves 0.88 UC 0.83 selves 30 about a relative/friend harming them- that he/she will harm themselves with the 0.88 UC 0.86 selves with the intention to die intention to die *These items were removed from the scale after exploratory factor analysis Extracted factors correspond to uncontrollable (UC), self-suicidal (SS), and positive controllable (PC) four-factor model has been shown to have a better fit in non- assesses chronic thought suppression using a 5-point scale meditating samples (e.g., Siegling and Petrides 2016) and (1 = “strongly disagree” to 5 = “strongly agree”). Psycho- we therefore performed subscale analyses. metric properties show good internal consistency (α = 0.89) (Muris et al. 1996). Factor analyses indicate that the 15-item The White Bear Suppression Inventory scale consists of two related factors: the tendency to suppress thoughts, and the frequency of experiencing unwanted intru- The White Bear Suppression Inventory (WBSI; Wegner sive thoughts (e.g., Schmidt et al. 2009), indicating that a high and Zanakos 1994) is a 15-item self-report inventory which frequency of intrusions does not necessarily equal a high level 1 3 788 Cognitive Therapy and Research (2018) 42:782–793 of suppression. We used the suicidal revision developed by Group Differences in TAF Pettit et al. (2009) for the D-S group, and the original scale for the healthy controls and D-NS group. To analyse differences in TAF between groups, we per - formed multiple linear regression analyses on TAF scores Data Analysis as dependent variable and group membership as independ- ent variable. Analyses were conducted both unadjusted and Exploratory Factor Analysis adjusted for potential confounding variables (i.e., age and gender). Instead of regression coefficient p-values based on All data analyses for the exploratory factor analysis (EFA) the t-distribution, p-values were computed by means of per- were performed by using the psych package (Revelle 2014) mutation analysis using the lmPerm package in R (Wheeler in R 3.4.1 (R Core Team 2017). First, principal axis factor et al. 2016), which avoids relying on (often unmet) assump- analysis in conjunction with parallel analysis was run using tions of homogeneity of variances and normality (Kabacoff maximum likelihood estimation to determine the number 2015) and is similar to bootstrapping analyses. of factors for factor analysis. As recommended, we used parallel analysis in conjunction with a scree plot and Kai- Comparison of TAF in Normal and Crisis State ser’s criteria (eigenvalue > 1 rule) to have multiple criteria for determining the number of factors (Hayton et al. 2004). To examine whether there was a significant difference in Results from principal axis factor analysis informed EFA the degree to which the two clinical groups’ TAF scores that was conducted on the determined number of factors. changed as a result of the mood induction, linear regres- The sample was split randomly into two subsamples. EFA sion analyses were conducted with the TAF scores in the was then performed on one subsample, again applying maxi- mood induction condition as outcome variable, with pre- mum likelihood estimation and promax rotation to allow for dictors being group membership (0 = D-NS, 1 = D-S), the correlation between factors. Based on EFA results, items TAF scores before mood induction, and the interaction term were explored on uniqueness and factor loadings to identify of theses variables. Again, p-values were estimated using items that could be deleted. permutation-based regression. Confirmatory Factor Analyses Results To validate the solution identified by EFA, confirmatory fac- tor analyses (CFA) were performed on the second half of the Participant Characteristics sample using MPlus 7.4 (Muthén and Muthén 2007–2014). Model fit was evaluated by inspecting χ statistics, the com- The sample consisted of N = 361 individuals, consisting of parative fit index (CFI), the Tucker–Lewis index (TLI), and 130 HC, 134 D-NS, and 97 D-S individuals (the random the root mean square error of approximation (RMSEA). subsamples consisted of N = 181 and N = 180, respectively). According to recommendations in the literature, CFI and Baseline characteristics of the full sample and subgroups TLI values of 0.95 or greater and RMSEA values of 0.06 or are shown in Table S1. Gender, education, ethnicity, and lower were considered as indicating good fit (Hu and Bentler employment differed significantly across subsamples, with 1999). Robust maximum likelihood estimation procedures significantly higher number of men in the depressed non- were employed to account for non-normality. suicidal group (p < 0.05). Internal Consistency and Convergent Validity Factor Analysis To assess internal consistency, we computed Cronbach’s α The number of factors obtained by principal axis factor and Omega Total for the total score and factor-based sub- analysis was cross-validated using the Kaiser criteria (3 scales. Omega Total was chosen as additional metric for factors > eigenvalue of 1), a scree plot (3 factors above internal consistency since assumptions for Cronbach’s α are break), and parallel analysis (4 factors > 95th percentile rarely met in practice (McNeish 2017). Convergent valid- of simulated eigenvalues; see Fig. S1). Although parallel ity was assessed by computing Pearson correlations of TAF analysis diverted from a 3-factor solution, this solution was total and factor-based subscales with other scales. Correla- taken forward since the difference between observed and tions were compared using Fisher’s z-transformation. simulated eigenvalues for the fourth factor was negligible. EFA of this 3-factor solution with maximum likelihood estimation and promax rotation revealed a relatively clear cut factor structure (see Table 1): Factor 1 (Uncontrollable 1 3 Cognitive Therapy and Research (2018) 42:782–793 789 TAF) combined 24 items describing uncontrollable events (TAF total: r = .38, TAF Uncontrollable: r = .4) but not with related to either self and/or other (e.g., being in a plane the other WBSI subscales Thought Suppression (r = − .05) crash, winning the lottery, others’ self-harm), Factor 2 and Self-Distraction (r = − .08). Moreover, WBSI-Unwanted (Suicidal TAF) combined three items that were related to Intrusive Thoughts was moderately correlated with TAF own self-harm or suicide (i.e., not others’ self-harm) and self-suicidal (r = .31). were hence controllable (logically, if not phenomenologi- cally), and Factor 3 (Controllable TAF) combined three TAF Across Groups items with self-related positive content that were also con- trollable (e.g., myself having fun on a holiday). The per- Results from multiple regression analyses in conjunction centage of variance explained by these factors was 44.1, with permutation tests revealed significant differences in 7.5, and 5.8 for factors 1, 2, and 3, respectively. TAF between groups (see Table S5). The D-NS group had The number of items was reduced from 30 to 20 items significantly higher total TAF, uncontrollable TAF, self-sui- based on low factor loadings (5 items below 0.5) as well cidal TAF, and lower positive controllable TAF when com- as keeping with item mirroring in the self-other category pared with healthy controls. Contrary to our hypothesis, the (5 corresponding items; see Table 1). All item reductions D-S group did not show differences to HCs on overall TAF, were from the uncontrollable TAF subscale. uncontrollable TAF, and positive controllable TAF, but did Next, CFA was conducted on the reduced 20-item show significantly higher self-suicidal TAF. version of the TAF-SR. More specifically, a model with three correlated latent factors, where all 14 items Differences Between Normal and Crisis State describing uncontrollable events loaded on one factor, the three items related to self-harm loaded on another fac- Finally, we tested whether the two clinical groups differed in tor, and the three items describing controllable positive how their TAF scores changed from normal to crisis states events loaded on a third factor. Results indicated good using permutation-based linear regression of outcome cri- model fit; χ (167) = 250.52, CFI = 0.95, TLI = 0.95, sis state TAF with predictors being dummy-coded group, RMSEA = 0.053 (90% CI 0.039–0.066) of the three-factor normal state TAF, and their interaction. D-NS individuals solution. We compared the three-factor model to a sin- increased significantly more than D-S individuals from nor - gle factor model where all items loaded on one overall mal to crisis states on total and uncontrollable TAF scores. TAF factor. However, fit for this model was not adequate; In contrast, the D-S group increased significantly more for χ (170) = 429.18, CFI = 0.85, TLI = 0.83, RMSEA = 0.092 suicidal TAF and decreased significantly more for the TAF (90% CI 0.081–0.103). positive controllable (Table S6). Convergent and Discriminant Validity Discussion Cronbach’s α and Omega Total showed good to excellent Twenty years ago, Shafran et al. (1996) suggested that TAF internal validity for total TAF (α = 0.94, ω = 0.94), uncon- might reinforce depressive symptoms in mood disorders; trollable TAF (α = 0.96, ω = 0.96), and self-suicidal TAF however, to our knowledge, only two studies have since (α = 0.86, ω = 0.87). Internal consistency was only moderate examined TAF in depression (Abramowitz et  al. 2001; for positive controllable TAF (α = 0.68, ω = 0.69). Meyer and Brown 2013). The goal of this study was to Associations between TAF and other scales are presented compare TAF in people with a history of suicidal depres- in a correlation matrix in Table S3. Total TAF score, uncon- sion to TAF in individuals with a history of non-suicidal trollable TAF, and self-suicidal TAF correlated moderately depression and healthy controls, and to revise and adapt the with RRS. Looking at RRS subscales (Table S4) revealed Thought–Action Fusion Scale (Shafran et al. 1996) for this somewhat stronger correlations between TAF scales and purpose. To our knowledge, this is the first study to demon- the Reflection and Depression subscales as compared to the strate thought-action fusion in both non-suicidal and sui- Brooding subscale (z = 2.84, p < 0.01). Correlations to other cidal depression. Our study produced three major findings, scales (BRFL, WBSI, SMQ, FFMQ) was low. However, described below. subscale analyses for FFMQ and WBSI yielded somewhat different findings. There was a significant moderate correla- 1. Development of Thought–Action Fusion tion between the Describing subscale of the FFMQ and TAF Scale‑Suicidal Revision total (r = .4) and TAF self-suicidal (r = .32) (Table S4). The correlation matrix (Table S4) indicates that TAF was mod- The first set of findings relates to adaptation of the origi- erately correlated with WBSI: Unwanted Intrusive Thoughts nal TAF scale to suicidal and non-suicidal depression. The 1 3 790 Cognitive Therapy and Research (2018) 42:782–793 factor analysis pointed to controllability of events as a key Positive Controllable TAF suggests that, whilst from a sta- parameter for TAF in this sample. This is reflected both in tistical point of view the overarching TAF score is valid, in Uncontrollable and Controllable TAF, and TAF for suicidal practical terms the Positive Controllable TAF items contrib- events, which are logically controllable, yet not necessar- ute only to a minor degree to the overall TAF factor. Unlike ily perceived as such given the typically decreased sense of Craig and Lafreniere’s scale, there was no evidence of a agency in this population. These findings extend the existing distinct positive TAF. However, in their work on Positive TAF literature, which has focussed solely on uncontrollable TAF, Craig and Lafreniere (2016) differentiated between events (e.g., car accident, being injured in a fall, falling ill). positive-gain and harm-avoidance categories, whereas in Test of convergent and discriminant validity indicated this study we focussed on positive-gain only. Given the large that TAF was not associated with total WBSI score, contrary proportion of clinical subjects, including harm-avoidance to our hypothesis. However, TAF was positively correlated might have yielded different results. with the WBSI subscale ‘unwanted intrusive thoughts’, in keeping with Rassin et al.’s (1999) suggestion that TAF is 2. Differences in TAF Between Groups linked to the tendency to experience a high frequency of intrusions, and empirical evidence that TAF predicts fre- Concerning the second main finding, we found important quency and perceived controllability of unwanted mental differences in Total TAF between clinical groups and healthy intrusions (Purdon and Clark 1994). This introduces the pos- controls. However, our hypothesis that TAF would be high- sibility that TAF is related not just to perceived controllabil- est in D-S, intermediate in D-NS and lowest in HC was not ity of an imagined event (e.g.; perceiving of being in a plane confirmed. Indeed, whilst total TAF was relatively similar crash as uncontrollable), but also to the perceived control- in D-S and healthy controls, total TAF and Uncontrollable lability of the cognition itself (e.g., I can’t stop my thoughts). TAF were significantly higher in the D-NS group. Whilst In addition to associations with unwanted intrusions, TAF problem-solving and goal-directed behaviour are likely to be (both total and subscales) was strongly positively correlated impaired in individuals with a history of recurrent depres- with rumination. These findings suggest acceptable conver - sion, the D-NS appear to have an elevated belief in their gent validity, and lends partial support to Rachman’s (1997) capacity to control the world through their thinking. Such a hypothesis of a link between TAF and rumination. However, belief may parallel with the positive beliefs about rumination it is not possible to draw conclusions about the potentially and problem-solving as regulatory behaviour (e.g., Watkins causal nature of the association on the basis of this dataset. and Baracaia 2001) but appears to extend to the relation- Further research is required to better understand the mecha- ship between participants’ thoughts and the occurrence of nisms linking TAF to rumination and perceived intrusive- events outside their own and other’s control. The D-S group, ness of thoughts, and the direction of causality. on the other hand, does not show this bias. One possibility The correlation between the reflection subtype of rumina- is that for those with recurrent depression, general TAF is tion and TAF was significantly stronger than between brood- actually protective, and that in its absence, repeated negative ing and TAF. Brooding has been shown to have a stronger experiences will result in the high levels of hopelessness association with recurrent depression than reflection and characteristic of those who experience suicidal ideation or to be linked to poorer outcome longitudinally (Treynor engage in suicidal behaviour. et al. 2003). However, both reflection and TAF might lock Contrary to our hypothesis, there was also no basis in thoughts at an abstract level of cognition, thereby reinforc- the findings for distinguishing between the D-S and D-NS ing an abstract-analytical style of processing and potentially group on Self-Suicidal TAF when participants completed reinforcing existing deficits in problem-solving-indeed, the measure reporting from a perspective of being well. It is reflection has been found to be linked to suicidal ideation in possible that Self-Suicidal TAF is underpinned by different patients with a history of suicide attempts (Surrence et al. beliefs in these two groups, e.g., that D-NS perceive them as 2009). more controllable than the D-S group, however, this awaits Given the poor fit of a five-facet model to non-meditator further scrutiny. Moreover, the prediction that for the D-S samples (e.g., Curtiss and Klemanski 2014), subscale analy- group, the salience of suicidal thoughts would override the ses of FFMQ were considered more relevant in this context. self-other distinction was not met, indicating that it is pri- The negative correlation between TAF total and the FFMQ marily in thinking about self-relevant, suicidal themes that subscales Describing and Acting with awareness partially TAF is activated. corroborates the discriminant validity of the scale, given the emphasis of these facets on de-identification with thought. 3. TAF Before and After Mood Induction The excellent model fit for the hierarchical CFA indi- cates that the total TAF factor represents the three factor- Our findings show that TAF increases in both clinical groups based subscales well. However, the low factor loading with following a mood induction. The mean changes across states 1 3 Cognitive Therapy and Research (2018) 42:782–793 791 and groups (Table S6) suggest possible mood-dependency of history of depression, thereby suggesting that mere questions self-suicidal TAF. The increase in Total and Uncontrollable outside the experimental context have the power to induce TAF from normal to crisis states in the D-NS group (com- transient dysphoric mood or enable individuals to respond in pared to the D-S group) suggests that as D-NS become dis- a way that mirrors responses occurring after experimentally tressed they increase their belief in their capacity to control induced mood (e.g.; Williams et al. 2008). Future studies events and occurrences through their thoughts. In contrast, are required using larger clinical and non-clinical samples self-suicidal TAF increased and Positive Controllable TAF and experimental designs in which predictions about mood decreased from normal to crisis states in the D-S relative to dependency of TAF and its impact on other key maintenance the D-NS group, suggesting that as the D-S group become mechanisms can be tested. Fourth, the current data set did more distressed they experience not only more suicide- not enable differentiating TAF in those with a history of related TAF but a reduction in their belief in their capacity to recurrent suicidal ideation from those with a history of sui- influence positive controllable events through their thoughts. cidal behaviour. Potential differences await scrutiny. Diminished positive controllable TAF may reflect a rise in hopelessness occurring when in the imagined crisis state, in keeping with a differential activation theory of hopelessness/ Conclusion suicidality (Williams et al. 2008). Together with findings of group differences, these data suggest that that differences in It is possible that TAF reinforces an abstract-analytical style TAF between D-NS and D-S individuals become more pro- of processing involved in the maintenance of depressive nounced in the context of low mood. This points to suicidal (Watkins 2008) and suicidal distress (Williams et al. 2016). and positive controllable TAF as useful clinical targets. If so, TAF would be an obvious clinical target. However, this awaits further experimental and longitudinal scrutiny. Stud- Limitations ies exploring TAF modification are scarce (see Jonsson et al. 2011; Siwiec et al. 2017), and in furthering our understand- The current findings need to be interpreted in the context ing of the feasibility of modifying TAF in depressed and of the following limitations: First, the study is limited by suicidal populations, the link between TAF, problem-solv- sample size (N = 361). Common rule of thumbs for CFA ing, executive functioning and cognitive flexibility require include, but are not limited to: N ≥ 200, and ratio of N to the further experimental scrutiny. number of variables (p), N/p ≥ 10 (Myers et al. 2011). In the CFA, there were 167 free parameters, whereas the conven- Funding This study was funded by University of Oslo Department of Psychology, Norway. tion is five participants per free parameter (Bentler and Chou 1987). However, such rules of thumbs have been widely Compliance with Ethical Standards criticised as having limited validity when applied to real data, as adequate sample size for both EFA and CFA rely on Conflict of Interest Dr. Gjelsvik, Mr. Kappelmann, Professor von factors that would typically vary across studies (Myers et al. Soest, Miss Hinze, Professor Baer, Professor Hawton and Dr. Crane all 2011). Replications in larger samples are required. Second, declare that they have no conflict of interest. the study was limited by its cross-sectional design, and we Informed Consent All procedures performed in studies involving cannot establish causality between TAF and suicidal and human participants were in accordance with the ethical standards of the non-suicidally depressive distress. However, we have intro- institutional research committee and with the 1964 Helsinki declaration duced a theoretical rationale for why TAF might be critical and its later amendments or comparable ethical standards. Informed in the suicidal trajectory, and the results suggest that this consent was obtained from all individual participants included in the study. might also apply to maintenance of non-suicidal depression. This awaits scrutiny in studies adopting experimental and Animal Rights Statements No animal studies were carried out by the longitudinal designs. authors for this article. Third, given that the survey took place entirely online, the mood induction was carried out outside an experimental Open Access This article is distributed under the terms of the Crea- context. Thus, we cannot ascertain that the conditional ques- tive Commons Attribution 4.0 International License (http://creat iveco tions entailing revisiting a time of crisis genuinely led to a mmons.or g/licenses/b y/4.0/), which permits unrestricted use, distribu- tion, and reproduction in any medium, provided you give appropriate drop in mood or simply encouraged participants to respond credit to the original author(s) and the source, provide a link to the ‘as-if’ in such a mood. Findings relating to changes from Creative Commons license, and indicate if changes were made. baseline to crisis state requires experimental validation. Nevertheless, questionnaires adopting conditional questions (e.g., the LEIDS; Van der Does 2002) have been able to reliably distinguish between individuals with and without a 1 3 792 Cognitive Therapy and Research (2018) 42:782–793 Kabacoff, R. (2015). R in action: Data analysis and graphics with R. References Shelter Island, NY: Manning Publications. 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