Experiential Avoidance and Hyperreflexivity as Variables Associated with Depression: A Process-Based Approach

Resumen

La depresión es un problema importante de salud pública que afecta a una proporción significativa de adultos jóvenes, como los estudiantes universitarios. Para su estudio se ha propuesto un enfoque basado en procesos, que busca identificar variables psicológicas transdiagnósticas que puedan ser objeto de cambio en las intervenciones psicoterapéuticas. El propósito de este trabajo fue analizar la interrelación entre un conjunto de variables de proceso (fusión cognitiva, rumia y evitación experiencial), así como examinar la relación entre cada una de estas variables y la depresión en 368 estudiantes universitarios de entre 18 y 29 años (M = 21.35, DE = 2.36, 77.7 % mujeres). Se halló que la fusión cognitiva y la rumia conformaban una variable global denominada hiperreflexividad, mientras que la evitación experiencial constituía un constructo diferente. Al analizar un modelo de ecuaciones estructurales, se encontró que solo la hiperreflexividad predecía significativamente la depresión. Se discuten estos resultados y sus posibles implicaciones para la práctica clínica. Se recomienda seguir estudiando la hiperreflexividad como una variable supraordinada de relevancia para la psicopatología.

Palabras clave:

Depresión fusión cognitiva rumia evitación experiencial hiperreflexividad

Citas

Alzahrani, F., Alshahrani, N. Z., Abu, A., Zarbah, A., Abu, S., & Mamun, M. A. (2022). Prevalence and factors associated with mental health problems in Saudi general population during the coronavirus disease 2019 pandemic: A systematic review and meta-analysis. PsyCh Journal, 11(1), 18-29. https://doi.org/10.1002/pchj.516

Ato, M., López-García, J. J., & Benavente, A. (2013). A classification system for research designs in psychology. Anales de Psicología / Annals of Psychology, 29(3), 1038- 1059. https://doi.org/10.6018/analesps.29.3.178511

Auerbach, R. P., Mortier, P., Bruffaerts, R., Alonso, J., Benjet, C., Cuijpers, P., Demyttenaere, K., Ebert, D. D., Green, J. G., Hasking, P., Murray, E., Nock, M. K., Pinder-Amaker, S., Sampson, N. A., Stein, D. J., Vilagut, G., Zaslavsky, A. M., Kessler, R. C. & WHO WMH-ICS Collaborators. (2018). WHO World Mental Health Surveys International College Student Project: Prevalence and distribution of mental disorders. Journal of Abnormal Psychology, 127(7), 623-638. https://doi. org/10.1037/abn0000362

Bardeen, J. R., & Fergus, T. A. (2016). The interactive effect of cognitive fusion and experiential avoidance on anxiety, depression, stress and posttraumatic stress symptoms. Journal of Contextual Behavioral Science, 5(1), 1-6. https://doi.org/10.1016/j.jcbs.2016.02.002

Barlow, D. H., Farchione, T. J., Bullis, J. R., Gallagher, M. W., Murray-Latin, H., Sauer-Zavala, S., Bentley, K. H., Thompson-Hollands, J., Conklin, L. R., Boswell, J. F., Ametaj, A., Carl, J. R., Boettcher, H. T., & Cassiello-Robbins, C. (2017). The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders compared with diagnosis-specific protocols for anxiety disorders: A randomized clinical trial. JAMA Psychiatry, 74(9), 875-884. https://doi.org/10.1001/ jamapsychiatry.2017.2164

Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. The Guilford Press.

Berzonsky, M. D., & Kinney, A. (2019). Identity processing style and depression: The mediational role of experiential avoidance and self-regulation. Identity: An International Journal of Theory and Research, 19(2), 83-97. https:// doi.org/10.1080/15283488.2019.1567341

Brown, T. A. (2015). Confirmatory factor analysis for applied research (2nd ed.). Guilford Press.

Calderón, M., Gálvez-Buccollini, J. A., Cueva, G., Ordoñez, C., Bromley, C., & Fiestas, F. (2012). Validación de la versión peruana del PHQ-9 para el diagnóstico de depresión [Validation of the Peruvian version of the PHQ-9 for diagnosing depression]. Revista Peruana de Medicina Experimental y Salud Pública, 29(4), 578-579. https:// doi.org/10.17843/rpmesp.2012.294.409

Cookson, C., Luzon, O., Newland, J., & Kingston, J. (2020). Examining the role of cognitive fusion and experiential avoidance in predicting anxiety and depression. Psychology and Psychotherapy: Theory, Research and Practice, 93(3), 456-473. https://doi.org/10.1111/ papt.12233

Cova, F., Rincón, P., & Melipillán, R. (2009). Reflexión, rumiación negativa y desarrollo de sintomatología depresiva en adolescentes de sexo femenino [Reflection, negative rumination and development of depressive symptomatology in female adolescents]. Terapia Psicológica, 27(2), 155-160. https://doi.org/10.4067/ S0718-48082009000200001

Cribb, G., Moulds, M. L., & Carter, S. (2006). Rumination and experiential avoidance in depression. Behaviour Change, 23(3), 165-176. https://doi.org/10.1375/ bech.23.3.165

Davey, G. C. L., & Wells, A. (2006). Worry and its psychological disorders: Theory, assessment and treatment. Wiley Publishing. https://doi.org/10.1002/9780470713143

Ferro-García, R., & Valero-Aguayo, L. (2017). Hipótesis transdiagnóstica desde la psicoterapia analítica funcional: La formación del Yo y sus problemas [A transdiagnostic hypothesis from Functional Analytic Psychotherapy: The problems in the formation of the Self]. Revista Brasileira de Terapia Comportamental e Cognitiva, 19(3), 145- 165. https://doi.org/10.31505/rbtcc.v19i3.1060

Gámez, W., Chmielewski, M., Kotov, R., Ruggero, C., Suzuki, N., & Watson, D. (2014). The Brief Experiential Avoidance Questionnaire: Development and initial validation. Psychological Assessment, 26(1), 35-45. https://doi.org/10.1037/a0034473

García, R., Valencia, A. I., Hernández-Martínez, A., & Rocha, T. E. (2017). Pensamiento rumiativo y depresión entre estudiantes universitarios: Repensando el impacto del género [Rumination and depression among college students: Rethinking the impact of gender-role]. Interamerican Journal of Psychology, 51(3), 406-416. https://www.journal.sipsych.org/index.php/IJP/article/ view/384/pdf

Gillanders, D. T., Bolderston, H., Bond, F. W., Dempster, M., Flaxman, P. E., Campbell, L., Kerr, S., Tansey, L., Noel, P., Ferenbach, C., Masley, S., Roach, L., Lloyd, J., May, L., Clarke, S., & Remington, B. (2014). The development and initial validation of the Cognitive Fusion Questionnaire. Behavior Therapy, 45(1), 83-101. https:// doi.org/10.1016/J.BETH.2013.09.001

Goldfried, M. R. (2019). Obtaining consensus in psychotherapy: What holds us back? American Psychologist, 74(4), 484-496. https://doi.org/10.1037/amp0000365

González, M., Ibáñez, I., & Barrera, A. (2017). Rumiación, preocupación y orientación negativa al problema: Procesos transdiagnósticos de los trastornos de ansiedad, de la conducta alimentaria y del estado de ánimo [Rumination, worry and negative problem orientation: Transdiagnostic processes of anxiety, eating behavior and mood disorders]. Acta Colombiana de Psicología, 20(2), 30-41. https://doi.org/10.14718/ACP.2017.20.2.3

Gutiérrez, I., Quesada, J. A., Gutiérrez, A., Nouni, R., & Carratalá, M. C. (2021). Depresión, ansiedad y salud autopercibida en estudiantes de Medicina: Un estudio transversal [Depression, anxiety and self-perceived health in medical students: A cross-sectional study]. Revista Española de Educación Médica, 2(2), 21-31. https://doi.org/10.6018/edumed.470371

Hanel, P. H., & Vione, K. C. (2016). Do student samples provide an accurate estimate of the general public? PloS One, 11(12), Article e0168354. https://doi.org/10.1371/journal.pone.0168354

Harvey, A. G., Watkins, E. R., Mansell, W., & Shafran, R. (2004). Cognitive behavioural processes across psychological disorders: A transdiagnostic approach to research and treatment (First edition). Oxford University Press

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and Commitment Therapy: An experiential approach to behavior change. Guilford Press. Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and Commitment Therapy: The process and practice of mindful change (2nd ed.). Guilford Press.

Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. M., & Strosahl, K. (1996). Experiential avoidance and behavioral disorders: A functional dimensional approach to diagnosis and treatment. Journal of Consulting and Clinical Psychology, 64(6), 1152-1168. https://doi. org/10.1037/0022-006X.64.6.1152

Hernández-Yépez, P. J., Muñoz-Pino, C. O., Ayala-Laurel, V., Contreras-Carmona, P. J., Inga-Berrospi, F., Vera-Ponce, V. J., Failoc-Rojas, V. E., Pereira-Victorio, C. J., & ValladaresGarrido, M. J. (2022). Factors associated with anxiety, depression, and stress in Peruvian university students during the COVID-19 pandemic. International Journal of Environmental Research and Public Health, 19(21), Article 14591. https://doi.org/10.3390/ijerph192114591

Hofmann, S. G. (2020). Imagine there are no therapy brands, it isn’t hard to do. Psychotherapy Research, 30(3), 297- 299. https://doi.org/10.1080/10503307.2019.1630781

Hofmann, S. G., & Hayes, S. C. (2019). The future of intervention science: Process-based therapy. Clinical Psychological Science, 7(1), 37-50. https://doi. org/10.1177/2167702618772296

Hofmann, S. G., & Hayes, S. C. (2022). Hacia una terapia basada en procesos. Psara.

Hofmann, S. G., Hayes, S. C., & Lorscheid, D. N. (2021). Learning process-based therapy: A skills training manual for targeting the core processes of psychological change in clinical practice (First Edition). Context Press.

Hong, R. Y., & Cheung, M. W.-L. (2015). The structure of cognitive vulnerabilities to depression and anxiety: Evidence for a common core etiologic process based on a meta-analytic review. Clinical Psychological Science, 3(6), 892- 912. https://doi.org/10.1177/2167702614553789

Hu, L., & Bentler, P. M. (1999). Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Structural Equation Modeling: A Multidisciplinary Journal, 6(1), 1-55. https://doi. org/10.1080/10705519909540118

Huarcaya-Victoria, J. (2020). Consideraciones sobre la salud mental en la pandemia de COVID-19 [Mental health considerations about the COVID-19 pandemic]. Revista Peruana de Medicina Experimental y Salud Pública, 37(2), 327-334. https://doi.org/10.17843/ rpmesp.2020.372.5419

Kerr, E. S. (2010). Investigation of the relationship between depression, rumination, metacognitive beliefs and cognitive fusion [Doctoral Thesis]. University of Edinburgh. http://hdl.handle.net/1842/5626

Kline, R. B. (2016). Principles and practice of structural equation modeling (4th ed.). The Guilford Press.

Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606-613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x

Lawson, K. M., & Robins, R. W. (2021). Sibling constructs: What are they, why do they matter, and how should you handle them? Personality and Social Psychology Review, 25(4), 344-366. https://doi. org/10.1177/10888683211047101

Lucena-Santos, P., Pinto-Gouveia, J., Carvalho, S. A., & Oliveira, M. da S. (2018). Is the widely used two-factor structure of the Ruminative Responses Scale invariant across different samples of women? Psychology and Psychotherapy: Theory, Research and Practice, 91(3), 398-416. https://doi.org/10.1111/papt.12168

Lupton-Smith, C., Badillo-Goicochea, E., Chang, T.-H., Maniates, H., Riehm, K. E., Schmid, I., & Stuart, E. A. (2022). Factors associated with county-level mental health during the COVID-19 pandemic. Journal of Community Psychology, 50(5), 2431-2442. https://doi. org/10.1002/jcop.22785

Mansell, W. (2019). Transdiagnostic psychiatry goes above and beyond classification. World Psychiatry, 18(3), 360- 361. https://doi.org/10.1002/wps.20680

Mansell, W., & McEvoy, P. M. (2017). A test of the core process account of psychopathology in a heterogenous clinical sample of anxiety and depression: A case of the blind men and the elephant? Journal of Anxiety Disorders, 46, 4-10. https://doi.org/10.1016/J.JANXDIS.2016.06.008

Morales, C. (2017). La depresión: Un reto para toda la sociedad del que debemos hablar [Depression: A society’s challenge we need to discuss]. Revista Cubana de Salud Pública, 43(2), 136-138. https://revsaludpublica.sld.cu/ index.php/spu/article/view/999

Moroz, M., & Dunkley, D. M. (2019). Self-critical perfectionism, experiential avoidance, and depressive and anxious symptoms over two years: A three-wave longitudinal study. Behaviour Research and Therapy, 112, 18- 27. https://doi.org/10.1016/j.brat.2018.11.006

Muñoz-Martínez, A. M., & Naismith, I. (2022). Social connectedness, emotional regulation, and health behaviors as correlates of distress during lockdown for COVID-19: A diary study. Applied Psychology: Health and Well-Being, 15(2), 536-560. https://doi.org/10.1111/aphw.12395

Nolen-Hoeksema, S. (1991). Responses to depression and their effects on the duration of depressive episodes. Journal of Abnormal Psychology, 100(4), 569-582. https://doi.org/10.1037/0021-843X.100.4.569

Nolen-Hoeksema, S., Morrow, J., & Fredrickson, B. L. (1993). Response styles and the duration of episodes of depressed mood. Journal of Abnormal Psychology, 102(1), 20-28. https://doi.org/10.1037/0021-843X.102.1.20

Nolen-Hoeksema, S., Wisco, B. E., & Lyubomirsky, S. (2008). Rethinking rumination. Perspectives on Psychological Science, 3(5), 400-424. https://doi. org/10.1111/j.1745-6924.2008.00088.x

Nuttgens, S. (2023). Of interventive doppelgangers and other barriers to evidence-based practice in psychotherapy. Journal of Psychotherapy Integration, 33(1), 20-33. https://doi.org/10.1037/int0000279

O’Loughlin, C. M., Bennett, D. S., & O’Hayer, C. V. (2020). The nomological network of cognitive fusion among people living with HIV: Associations with rumination, shame, and depressive symptoms. Journal of Contextual Behavioral Science, 15, 245-252. https://doi. org/10.1016/j.jcbs.2020.01.012

Pan American Health Organization. (2021). Salud Mental. https://www.paho.org/es/temas/salud-mental Pérez-Álvarez, M. (2008). Hyperreflexivity as a condition of mental disorder: A clinical and historical perspective. Psicothema, 20(2), 181-187. https://www.psicothema. com/pdf/3445.pdf

Pérez-Álvarez, M. (2012a). Las raíces de la psicopatología moderna. La melancolía y la esquizofrenia [The roots of modern psychopathology. Melancholia and schizophrenia]. Pirámide.

Pérez-Álvarez, M. (2012b). Third-generation therapies: Achievements and challenges. International Journal of Clinical and Health Psychology, 12(2), 291-310. http:// www.aepc.es/ijchp/articulos.php?coid=English&id=413

Pérez-Álvarez, M. (2014). Las terapias de tercera generación como terapias contextuales [Thid-generation therapies as contextual therapies]. Síntesis.

Rochefort, C., Baldwin, A. S., & Chmielewski, M. (2018). Experiential avoidance: An examination of the construct validity of the AAQ-II and MEAQ. Behavior Therapy, 49(3), 435-449. https://doi.org/10.1016/j. beth.2017.08.008

Romero-Moreno, R., Márquez-González, M., Losada, A., Fernández-Fernández, V., & Nogales-González, C. (2015). Rumiación y fusión cognitiva en el cuidado familiar de personas con demencia [Rumination and cognitive fusion in dementia family caregivers]. Revista Española de Geriatría y Gerontología, 50(5), 216-222. https://doi.org/10.1016/j.regg.2015.02.007

Ruiz, F. J., Suárez-Falcón, J. C., Riaño-Hernández, D., & Gillanders, D. T. (2017). Psychometric properties of the Cognitive Fusion Questionnaire in Colombia. Revista Latinoamericana de Psicología, 49(1), 80-87. https:// doi.org/10.1016/J.RLP.2016.09.006

Sánchez-Carlessi, H. H., Yarlequé-Chocas, L. A., JavierAlva, L., Nuñez, E. R., Arenas-Iparraguirre, C., Matalinares-Calvet, M. L., Gutiérrez-Santayana, E., Egoavil-Medina, I., Solis-Quispe, J., & FernandezFigueroa, C. (2021). Anxiety, depression, somatization and experiential avoidance indicators in Peruvian university students in quarantine by COVID-19. Revista de la Facultad de Medicina Humana, 21(2), 346-353. https:// doi.org/10.25176/RFMH.v21i2.3654

Savalei, V. (2019). A comparison of several approaches for controlling measurement error in small samples. Psychological Methods, 24(3), 352-370. https://doi. org/10.1037/met0000181

Shah, S. M. A., Mohammad, D., Qureshi, M. F. H., Abbas, M. Z., & Aleem, S. (2021). Prevalence, psychological responses and associated correlates of depression, anxiety and stress in a global population, during the Coronavirus Disease (COVID-19) pandemic. Community Mental Health Journal, 57(1), 101-110. https://doi.org/10.1007/ s10597-020-00728-y

Stein, A. T., Medina, J. L., Rosenfield, D., Otto, M. W., & Smits, J. A. J. (2020). Examining experiential avoidance as a mediator of the relation between anxiety sensitivity and depressive symptoms. Cognitive Behaviour Therapy, 49(1), 41-54. https://doi.org/10.1080/16506073.2018.15 46768

Takano, K., & Tanno, Y. (2009). Self-rumination, self-reflection, and depression: Self-rumination counteracts the adaptive effect of self-reflection. Behaviour Research and Therapy, 47(3), 260-264. https://doi.org/10.1016/j. brat.2008.12.008

Thanoi, W., & Klainin-Yobas, P. (2015). Assessing rumination response style among undergraduate nursing students: A construct validation study. Nurse Education Today, 35(5), 641-646. https://doi.org/10.1016/j. nedt.2015.01.001

Treynor, W., Gonzalez, R., & Nolen-Hoeksema, S. (2003). Rumination reconsidered: A psychometric analysis. Cognitive Therapy and Research, 27(3), 247-259. https://doi.org/10.1023/A:1023910315561

Tyndall, I., Waldeck, D., Pancani, L., Whelan, R., Roche, B., & Dawson, D. L. (2019). The Acceptance and Action Questionnaire-II (AAQ-II) as a measure of experiential avoidance: Concerns over discriminant validity. Journal of Contextual Behavioral Science, 12, 278-284. https:// doi.org/10.1016/j.jcbs.2018.09.005

Valencia, P. D. (2019). Does the Acceptance and Action Questionnaire II really measure experiential avoidance? Revista Evaluar, 19(3), 42-53. https://doi. org/10.35670/1667-4545.v19.n3.26776

Valencia, P. D. (2020). Initial psychometric evaluation of the Perseverative Thinking Questionnaire in Peruvian undergraduates. Liberabit, 26(2). https://doi.org/10.24265/ liberabit.2020.v26n2.05

Valencia, P. D., & Falcón, C. (2019). Estructura factorial del Cuestionario de Fusión Cognitiva en universitarios de Lima [Factor structure of the Cognitive Fusion Questionnaire in university students from Lima]. Interacciones. Revista de Avances en Psicología, 5(2). https://doi.org/10.24016/2019.v5n2.167

Valencia, P. D., & Paredes-Angeles, R. (2022). Revisiting the factor structure of the Ruminative Response Scale: A bifactor approach. Trends in Psychology. https://doi. org/10.1007/s43076-022-00214-2

Vidal-Arenas, V., Bravo, A., Ortet-Walker, J., Ortet, G., Mezquita, L., & Ibáñez, M. (2022). Neuroticism, rumination, depression and suicidal ideation: A moderated serial mediation model across four countries. International Journal of Clinical and Health Psychology, 22(3), Article 100325. https://doi.org/10.1016/j.ijchp.2022.100325

Villarreal-Zegarra, D., Copez-Lonzoy, A., Bernabé-Ortiz, A., Melendez-Torres, G. J., & Bazo-Alvarez, J. C. (2019). Valid group comparisons can be made with the Patient Health Questionnaire (PHQ-9): A measurement invariance study across groups by demographic characteristics. PLOS ONE, 14(9), Article e0221717. https:// doi.org/10.1371/journal.pone.0221717

Villarroel, A & Terlizzi, P. (2020). Symptoms of depression among adults: United States, 2019. https://www.cdc. gov/nchs/data/databriefs/db379-H.pdf

Vinaccia, S., & Ortega, A. (2020). Variables asociadas a la ansiedad-depresión en estudiantes universitarios [Variables related to anxiety-depression in university students]. Universitas Psychologica, 19, 1-13. https:// doi.org/10.11144/Javeriana.upsy19.vaad

Wang, Y., Kala, M. P., & Jafar, T. H. (2020). Factors associated with psychological distress during the coronavirus disease 2019 (COVID-19) pandemic on the predominantly general population: A systematic review and meta-analysis. PLOS ONE, 15(12), Article e0244630. https://doi.org/10.1371/journal.pone.0244630

Wilson, K. G., & Luciano, C. (2002). Terapia de Aceptación y Compromiso: Un tratamiento conductual orientado a los valores [Acceptance and Commitment Therapy: A behavioral therapy oriented to values]. Pirámide.

Wolgast, M. (2014). What does the Acceptance And Action Questionnaire (AAQ-II) really measure? Behavior Therapy, 45(6), 831-839. https://doi.org/10.1016/j. beth.2014.07.002

World Health Organization. (2021). Depressive disorder (depression). https://www.who.int/news-room/fact-sheets/ detail/depression

Xiong, J., Lipsitz, O., Nasri, F., Lui, L. M. W., Gill, H., Phan, L., Chen-Li, D., Iacobucci, M., Ho, R., Majeed, A., & McIntyre, R. S. (2020). Impact of COVID-19 pandemic on mental health in the general population: A systematic review. Journal of Affective Disorders, 277, 55-64. https://doi.org/10.1016/j.jad.2020.08.001

Yuan, K.-H., & Bentler, P. M. (2000). Three likelihood-based methods for mean and covariance structure analysis with nonnormal missing data. Sociological Methodology, 30(1), 165-200. https://doi.org/10.1111/0081-1750.00078

Citado por