Cognitive Interpersonal Model Research Articles

No Evidence for Cross-Sectional or Longitudinal Associations between Cognitive Flexibility Performances and Nutritional Status in a Cohort of Inpatients with Anorexia Nervosa.

According to the Cognitive-Interpersonal model of anorexia nervosa (AN), the combined influence of cognitive and socio-emotional difficulties would constitute vulnerability and maintaining factors. Poor cognitive flexibility is one of the endophenotypic candidates (i.e., a trait marker) of the disorder, but few studies have examined its association with illness symptom variations, notably weight status. The study aimed to evaluate the relationships between cognitive flexibility performances and nutritional status indices (BMI; body composition) at different times of the disorder. Cross-sectional and longitudinal associations between cognitive flexibility (TAP 2.1) and nutritional status indices, along with anxious and depressive (HAD) and eating disorder (EDE-Q) symptomatology were investigated using univariate and multivariate analyses in a cohort of AN inpatients evaluated at hospital admission (N = 167) and discharge (N = 94). We found no or negligible associations between nutritional status and HAD or EDE-Q scores or cognitive flexibility performances, either cross-sectionally or longitudinally. Cognitive performances did not significantly differ between the AN subtypes. In agreement with the Cognitive-Interpersonal model of AN, cognitive flexibility is independent of nutritional status, as well as the AN subtype. It is also independent of the levels of anxious, depressive, or ED symptomatology. A new therapeutic approach targeting cognitive flexibility and intolerance to change could benefit severely emaciated people with AN, regardless of disease subtype and level of dysphoria.

Cognitive and Interpersonal Factors in Adolescent Inpatients with Anorexia Nervosa: A Network Analysis

The cognitive-interpersonal model of anorexia nervosa (AN) posits that cognitive and interpersonal traits contribute to the development and maintenance of AN. We investigated cognitive and interpersonal factors put forward by the model in a sample of 145 adolescent inpatients with AN using network analysis. Our main outcomes included core eating disorder symptoms, cognitive style, socio-affective factors, and mood symptoms. We estimated a cross-sectional network using graphical LASSO. Core and bridge symptoms were identified using strength centrality. Goldbricker was used to reduce topological overlap. The node with the highest strength centrality was Concern over Mistakes, followed by Eating Preoccupation, Social Fear, and Overvaluation of Weight and Shape. The nodes with the highest bridge strength were Concern over Mistakes, Doubt about Actions, Overvaluation of Weight and Shape, and Depression. Notably, both performance on a cognitive flexibility task and BMI were not connected to any other nodes and were subsequently removed from the final network. We provide partial support for the cognitive-interpersonal model while also supporting certain premises put forward by the transdiagnostic cognitive-behavioral model. The high centrality of Concern over Mistakes and Social Fear supports the theory that both cognitive and interpersonal difficulties contribute to AN, particularly in adolescence.

Biased and inflexible interpretations of ambiguous social situations: Associations with eating disorder symptoms and socioemotional functioning.

Research indicates that difficulties across multiple socioemotional functioning domains (e.g., social emotion expression/regulation, response to social elicitors of emotion) and negatively biased interpretations of ambiguous social situations may affect eating disorder symptoms. The impact of inflexible interpretations of social situations on eating disorder symptoms is less clear. The present study therefore examined relations between inflexible and biased social interpretations, socioemotional functioning, and eating disorder symptoms. A total of 310 participants from the general population, recruited from an online crowdsourcing platform, completed measures of socioemotional functioning (e.g., rejection sensitivity, negative social exchange), eating disorder symptoms, and positive and negative interpretation bias and inflexibility on a single measurement occasion. Socioemotional functioning impairments (Pillai's trace=0.11, p < .001), but not negative (β=.07, p =.162) or positive (β=-.01, p =.804) interpretation bias or inflexible interpretations (β=.04, p =.446), were associated with eating disorder symptoms in multiple regression models. In network analyses controlling statistically for multiple markers of socioemotional functioning, eating disorder symptoms were directly associated with negative (but not positive) interpretation bias. Inflexible interpretations were indirectly linked to symptoms via co-dampening of positive emotions. Exploratory causal discovery analyses suggested that several socioemotional functioning variables (social anxiety, depression, negative social exchange) may cause eating disorder symptoms. Consistent with cognitive-interpersonal models of disordered eating, our results suggest that less accurate (biased, inflexible) interpretations of social information contribute to patterns of cognition (anxious anticipation of rejection) and emotion regulation (down-regulation of positive social emotion) thought to encourage disordered eating. This study suggests that less accurate interpretations of ambiguous social information encourage anxious anticipation of rejection and downregulation of positive social emotions, both of which are thought to promote eating disorder symptoms. Knowledge provided by this study about the likely relations between interpretive processes, social/emotional functioning, and eating disorder symptoms may help inform treatments for eating disorders, particularly those that attempt to modify patterns of interpretation.

Adaptation and Implementation of an Intervention Programme on Spanish Carers and Adolescent Patients With an Eating Disorder: Study Protocol of a Randomized Controlled Trial.

Introduction: One of the major problems with inpatient treatment of adolescent girls with an eating disorder (ED) is that the strategies learned during their hospital stay are not easily applied or maintained in their daily lives, and this has been related to high rates of relapse and readmission. The ECHOMANTRA programme was developed to optimize outcomes during and following inpatient or day-patient treatment. ECHOMANTRA is based on interventions for carers (Experienced Carers Helping Others, ECHO) and patients (Maudsley Model of Anorexia Nervosa Treatment for Adults, MANTRA) and is developed from the cognitive interpersonal model of anorexia (Schmidt and Treasure, 2006; Treasure and Schmidt, 2013). This study aims to describe the study protocol of a randomized controlled trial (RCT) for evaluating the efficacy of an adaptation of a novel intervention for patients and carers (ECHOMANTRA) to be implemented as an add-on to treatment-as-usual (TAU).Method: In a multi−center pilot RCT, 80 female adolescent patients with a DSM-5 diagnosis of an ED and their carers will be invited to participate in the study. They will then be randomized to receive either the ECHOMANTRA intervention as an add-on to TAU or TAU alone. A repeated measures design will be conducted across four time points. Primary outcomes will be patient psychological well-being and eating disorder symptoms, and secondary outcomes will include body mass index, obsessive-compulsive symptoms, perfectionism, motivation to change and psychosocial adjustment. For carers, outcome variables will include psychological well-being, expressed emotion, accommodation and enabling behaviors, burden, and care skills.Discussion: The results from this trial will establish the effectiveness of ECHOMANTRA and may reveal whether and to what extent this novel intervention can optimize outcomes during and following inpatient treatment. This study will also provide the adaptation of the ECHOMANTRA in the Spanish context for inpatient/day-care treatment.

Cognitive Interpersonal Model for Anorexia Nervosa Revisited: The Perpetuating Factors that Contribute to the Development of the Severe and Enduring Illness.

The cognitive interpersonal model was outlined initially in 2006 in a paper describing the valued and visible aspects of anorexia nervosa (Schmidt and Treasure, 2006). In 2013, we summarised many of the cognitive and emotional traits underpinning the model (Treasure and Schmidt, 2013). In this paper, we describe in more detail the perpetuating aspects of the model, which include the inter- and intrapersonal related consequences of isolation, depression, and chronic stress that accumulate in the severe and enduring stage of the illness. Since we developed the model, we have been using it to frame research and development at the Maudsley. We have developed and tested interventions for both patients and close others, refining the model through iterative cycles of model/intervention development in line with the Medical Research Council (MRC) framework for complex interventions. For example, we have defined the consequences of living with the illness on close others (including medical professionals) and characterised the intense emotional reactions and behaviours that follow. For the individual with an eating disorder, these counter-reactions can allow the eating disorder to become entrenched. In addition, the consequent chronic stress from starvation and social pain set in motion processes such as depression, neuroprogression, and neuroadaptation. Thus, anorexia nervosa develops a life of its own that is resistant to treatment. In this paper, we describe the underpinnings of the model and how this can be targeted into treatment.

The cognitive-interpersonal model of disordered eating: A test of the mediating role of alexithymia.

The cognitive-interpersonal model proposes that high levels of attention to detail and cognitive rigidity confer risk for the development of eating disorders (EDs) and that socioemotional deficits, such as alexithymia, contribute to their maintenance. However, no studies have examined the direct and indirect relationships of these constructs. We investigated the mediating role of specific alexithymia traits (difficulties describing feelings, difficulties identifying feelings, and externally oriented thinking) on the relationship between attention to detail, cognitive rigidity, and ED symptoms while controlling for anxiety and depression symptoms. Four hundred and one nonclinical female participants (M = 20.57, SD = 4.99 years old) completed self-report measures assessing the variables of interest. Path analyses revealed that difficulties identifying feelings was the only significant mediator between attention to detail and cognitive rigidity to ED symptoms. However, these mediation effects became nonsignificant after controlling for anxiety and depression. Difficulties identifying feelings may in part underlie the relationship between attention to detail and cognitive rigidity and ED symptoms, providing support for the cognitive-interpersonal model. However, these relationships are heavily influenced by anxiety and depression symptoms. Enhancing individual's ability to identify emotional states may help to decrease ED symptoms for individuals who report high levels of attention to detail and cognitive rigidity.

Premorbid and Illness-related Social Difficulties in Eating Disorders: An Overview of the Literature and Treatment Developments.

Background: Social difficulties in eating disorders can manifest as predisposing traits and premorbid difficulties, and/or as consequences of the illness.Objective: The aim of this paper is to briefly review the evidence of social problems in people with eating disorders and to consider the literature on treatments that target these features.Method: A narrative review of the literature was conducted.Results: People with eating disorders often manifest traits, such as shyness, increased tendency to submissiveness and social comparison, and problems with peer relationships before illness onset. Further social difficulties occur as the illness devel-ops, including impaired social cognition and increased threat sensitivity. All relationships with family, peers and therapists are compromised by these effects. Thus, social difficulties are both risk and maintaining factors of eating disorders and are suitable targets for interventions. Several forms of generic treatments (e.g. interpersonal psychotherapy, cognitive analytic therapy, focal psychodynamic therapy) have an interpersonal focus and show some efficacy. Guided self-management based on the cognitive interpersonal model of the illness directed to both individuals and support persons has been found to im-prove outcomes for all parties. Adjunctive treatments that focus on specific social difficulties, such as cognitive remediation and emotion skills training and cognitive bias modification have been shown to have a promising role.Conclusion: More work is needed to establish whether these approaches can improve on the rather disappointing outcomes that are attained by currently used treatments for eating disorders

Supporting Carers of Children and Adolescents with Eating Disorders in Austria (SUCCEAT): Study protocol for a randomised controlled trial.

Supporting Carers of Children and Adolescents with Eating Disorders in Austria (SUCCEAT) is an intervention for carers of children and adolescents with anorexia nervosa and atypical anorexia nervosa. This paper describes the study protocol for a randomised controlled trial including the process and economic evaluation. Carers are randomly allocated to one of the 2 SUCCEAT intervention formats, either 8 weekly 2‐hr workshop sessions (n = 48) or web‐based modules (n = 48), and compared with a nonrandomised control group (n = 48). SUCCEAT includes the cognitive‐interpersonal model, cognitive behavioural elements, and motivational interviewing. The goal is to provide support for carers to improve their own well‐being and to support their children. Outcome measures include carers' distress, anxiety, depression, expressed emotions, needs, motivation to change, experiences of caregiving, and skills. Further outcome measures are the patients' eating disorder symptoms, emotional problems, behavioural problems, quality of life, motivation to change, and perceived expressed emotions. These are measured before and after the intervention, and 1‐year follow‐up.

A Pilot, Multicentre Pragmatic Randomised Trial to Explore the Impact of Carer Skills Training on Carer and Patient Behaviours: Testing the Cognitive Interpersonal Model in Adolescent Anorexia Nervosa.

The aim of the study is to establish the acceptability, feasibility and approximate size of the effect of adding a carer intervention [Experienced Caregivers Helping Others (ECHO)] to treatment as usual (TAU) for adolescents with anorexia nervosa. The study is a pilot randomised trial comparing TAU (n = 50) alone or TAU plus ECHO with (n = 50) or without (n = 49) telephone guidance. Effect sizes (ESs) were regression coefficients standardised by baseline standard deviations of measure. Although engagement with ECHO was poor (only 36% of carers in the ECHO group read over 50% of the book), there were markers of intervention fidelity, in that caregivers in the ECHO group showed a moderate increase in carer skills (ES = 0.4) at 12months and a reduction in accommodating and enabling behaviour at 6months (ES = 0.17). In terms of efficacy, in the ECHO group, carers spent less time care giving (ES = 0.40, p = 0.04) at 1year, and patients had a minor advantage in body mass index (ES = 0.17), fewer admissions, decreased peer problems (ES = -0.36) and more pro-social behaviours (ES = 0.53). The addition of telephone guidance to ECHO produced little additional benefit. The provision of self-management materials for carers to standard treatment for adolescent anorexia nervosa shows benefits for both carers and patients. This could be integrated as a form of early intervention in primary care. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Transition Care in Anorexia Nervosa Through Guidance Online from Peer and Carer Expertise (TRIANGLE): Study Protocol for a Randomised Controlled Trial.

ISRCTN registry ISRCTN14644379, 08/12/2016. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

The Psychological Effects of Short-Term Fasting in Healthy Women.

The study aimed to investigate affective responses to 18-h fasting in healthy controls. In particular, the study focused on self-reported mood, irritability, sense of achievement, reward, pride, and control. Participants were a non-clinical sample of 52 women with a mean age of 25. A repeated-measures design was used, whereby participants provided diary measures of psychological variables throughout both 18-h fasting and non-fasting periods. Fasting led to increased irritability, and also to positive affective experiences of increased sense of achievement, reward, pride, and control. Even short-term fasting in healthy controls can lead to positive psychological experiences. This lends support to cognitive-behavioral and cognitive-interpersonal models of ANR, which suggest that dietary restriction is maintained through positive reinforcement.

An examination of the impact of care giving styles (accommodation and skilful communication and support) on the one year outcome of adolescent anorexia nervosa: Testing the assumptions of the cognitive interpersonal model in anorexia nervosa

BackgroundThe cognitive interpersonal model predicts that parental caregiving style will impact on the rate of improvement of anorexia nervosa symptoms. The study aims to examine whether the absolute levels and the relative congruence between mothers' and fathers' care giving styles influenced the rate of change of their children's symptoms of anorexia nervosa over 12 months. MethodsTriads (n=54) consisting of patients with anorexia nervosa and both of their parents were included in the study. Caregivers completed the Caregiver Skills scale and the Accommodation and Enabling Scale at intake. Patients completed the Short Evaluation of Eating Disorders at intake and at monthly intervals for one year. Polynomial Hierarchical Linear Modeling was used for the analysis. ResultsThere is a person/dose dependant relationship between accommodation and patients' outcome, i.e. when both mother and father are highly accommodating outcome is poor, if either is highly accommodating outcome is intermediate and if both parents are low on accommodation outcome is good. Outcome is also good if both parents or mother alone have high levels of carer skills and poor if both have low levels of skills. LimitationsIncluding only a sub-sample of an adolescent clinical population; not considering time spent care giving, and reporting patient's self-reported outcome data limits the generalisability of the current findings. ConclusionAccommodating and enabling behaviours by family members can serve to maintain eating disorder behaviours. However, skilful behaviours particularly by mothers, can aid recovery. Clinical interventions to optimise care giving skills and to reduce accommodation by both parents may be an important addition to treatment for anorexia nervosa.

Self-Help And Recovery guide for Eating Disorders (SHARED): study protocol for a randomized controlled trial.

BackgroundWe describe the theoretical rationale and protocol for Self-Help And Recovery guide for Eating Disorders (SHARED), a trial investigating whether a guided self-care intervention (Recovery MANTRA) is a useful addition to treatment as usual for individuals with anorexia nervosa. Recovery MANTRA, a 6-week self-care intervention supplemented by peer mentorship, is a module extension of the Maudsley Model of Treatment for Adults with Anorexia Nervosa and targets the maintenance factors identified by the cognitive-interpersonal model of the illness.MethodsPatients accessing outpatient services for anorexia nervosa are randomized to either treatment as usual or treatment as usual plus Recovery MANTRA. Outcome variables include change in body weight at the end of the intervention (primary) and changes in body weight and eating disorder symptoms at immediate and extended follow-up (6-months; secondary). Change is also assessed for the domains identified by the theoretical model, including motivation, hope, confidence to change, positive mood, cognitive flexibility, therapeutic alliance and social adjustment. Feedback from peer mentors is gathered to understand the impact on their own well-being of providing guidance.DiscussionResults from this exploratory investigation will determine whether a larger clinical trial is justifiable and feasible for this affordable intervention, which has potential for high reach and scalability.Trial registrationClinicalTrials.gov NCT02336841.

Delivering effective therapeutic interventions for men with severe personality disorder within a high secure prison

The Fens Unit is a government-initiated facility for male prisoners reaching criteria for Dangerous and Severe Personality Disorder (DSPD). Prisoners are assessed using a standardised process; those meeting criteria engage in a five-year treatment programme using a cognitive interpersonal model. Personality disorder is seen as a combination of coping strategies, developed in response to experience, which results in dysfunctions of thinking, feeling, behaviour and interpersonal relationships. These dysfunctions are linked to offending. Therefore, in order to reduce risk, multiphasic interventions – individual and group therapies – specifically target each dysfunction area, focusing on the developmental experiences that generated them. Each man's individual risk factors become treatment targets that are addressed in every aspect of the programme. All staff on the unit, clinical and operational, attempt to improve the quality of interpersonal relationships the prisoner has access to in order to create remedial experiences that are necessary to attain the capacity to develop socially adaptive cognitive, emotional and behavioural responses. This paper describes the treatment provided to these prisoners and the outcomes for the first cohort to have completed treatment (n=18). Results indicate that there is a reduction in violent behaviour, a higher than expected attendance at therapy, a decrease in actuarial risk measures and the majority of men are successfully managed in lower security after programme completion.

The cognitive-interpersonal maintenance model of anorexia nervosa revisited: a summary of the evidence for cognitive, socio-emotional and interpersonal predisposing and perpetuating factors.

AimTo describe the evidence base relating to the Cognitive-Interpersonal Maintenance Model for anorexia nervosa (AN).BackgroundA Cognitive-Interpersonal Maintenance Model maintenance model for anorexia nervosa was described in 2006. This model proposed that cognitive, socio-emotional and interpersonal elements acted together to both cause and maintain eating disorders.MethodA review of the empirical literature relating to the key constructs of the model (cognitive, socio-emotional, interpersonal) risk and maintaining factors for anorexia nervosa was conducted.ResultsSet shifting and weak central coherence (associated with obsessive compulsive traits) have been widely studied. There is some evidence to suggest that a strong eye for detail and weak set shifting are inherited vulnerabilities to AN. Set shifting and global integration are impaired in the ill state and contribute to weak central coherence. In addition, there are wide-ranging impairments in socio-emotional processing including: an automatic bias in attention towards critical and domineering faces and away from compassionate faces; impaired signalling of, interpretation and regulation of emotions. Difficulties in social cognition may in part be a consequence of starvation but inherited vulnerabilities may also contribute to these traits. The shared familial traits may accentuate family members’ tendency to react to the frustrating and frightening symptoms of AN with high expressed emotion (criticism, hostility, overprotection), and inadvertently perpetuate the problem.ConclusionThe cognitive interpersonal model is supported by accumulating evidence. The model is complex in that cognitive and socio-emotional factors both predispose to the illness and are exaggerated in the ill state. Furthermore, some of the traits are inherited vulnerabilities and are present in family members. The clinical formulations from the model are described as are new possibilities for targeted treatment.

A Cognitive-Interpersonal Model of Adolescent Depression: The Impact of Family Conflict and Depressogenic Cognitive Styles

The goal of the study is to examine whether family conflict generates peer-related stress and subsequent depressive symptoms among adolescents. In addition, in the context of the proposed mediation model, we examine whether negative cognitive styles about the self, cause, and consequences moderate the mediational pathway between peer stress and depressive symptoms. The study includes 179 adolescents (71 boys, 108 girls) ages 12 to 18, and the majority of the participants are Caucasian (79.5%). At the initial assessment, participants completed self-report measures regarding family conflict, negative cognitive style, stress, and depressive symptoms. Participants also completed 3 subsequent self-report assessments every 6 weeks in which information regarding stress and depressive symptoms were collected. Both within- and between-subject analyses indicate that dependent interpersonal peer stress partially mediates the relationship between greater family conflict and higher levels of depressive symptoms. Moreover, results of our moderated-mediation model indicate that negative cognitive styles regarding the self and cause, but not consequences, moderate the mediational pathway between peer stress and depressive symptoms. These findings underscore the importance of examining more comprehensive models that incorporate both cognitive and interpersonal vulnerability.

CBT for Culture Change: Formulating Teams to Improve Patient Care

Increasingly, clinical psychologists and CBT trained clinicians work with and within teams. The cognitive model enables us to formulate the processes maintaining distress, and work with people to effect change. The model tends to be used to understand individuals' difficulties, but may be effective in making sense of problems within teams. This study aimed to (i) explore the value of the cognitive model in formulating key staff-service user relationships; and (ii) determine whether such an approach would yield useful team based interventions. The cognitive interpersonal model was used to develop an idiosyncratic conceptualization of key staff-service user interactions in an in-patient setting. This then informed management team planning aimed at improving provision for service users, and staff experience. Additionally, frequency of challenging behaviours and levels of staff burnout were assessed before and after service changes, as preliminary outcome data. The team formulation was effective in (i) making sense of interactions contributing to the maintenance of service users' challenging behaviours and staff burnout, and (ii) deriving systemic interventions likely to effect change. This was then used to guide service development planning. In support of a CBT approach to understanding and intervening with teams, preliminary data indicate that staff burnout and incidents of challenging behaviours reduced over time. The cognitive interpersonal model can be used to formulate relationships within teams and guide systemic change. This is likely to have a beneficial impact for both service users and staff.

Life Stress and the Accuracy of Cognitive Appraisals in Depressed Youth

This study investigated the accuracy of depressed youths' appraisals of naturally occurring life events. Participants (49% girls; M age = 12.44 years) with clinical diagnoses of depression (n = 24), subsyndromal symptoms of depression (n = 29), and no symptoms of psychopathology (n = 36) completed semi-structured interviews of life stress. As predicted, depressed youth experienced more independent and self-generated interpersonal stress than did nonsymptomatic youth. Consistent with a cognitive bias, clinically depressed youth overestimated the stressfulness of events and overestimated their contribution to events relative to nonsymptomatic youth. Youth with subsyndromal symptoms demonstrated similar, although typically less severe, impairment than those with clinical depression. Results contribute to cognitive-interpersonal models of depression by illustrating the need to consider both realistic interpersonal difficulties and biased appraisals of experiences.

DYSFUNCTIONAL ATTITUDES AND ATTACHMENT STYLE AMONG CLINICALLY DEPRESSED ADULTS

Previous research has found an association between adult attachment style and symptoms of depression among university students and indicated that this relationship may be mediated by dysfunctional attitudes. The present study represents an initial step toward extending these findings to a clinical sample with more severe forms of depression. A sample of psychiatric outpatients diagnosed with major depressive disorder (n = 54) completed measures of adult attachment style, dysfunctional attitudes, and depression. An association was found between insecure attachment style and depression severity. This association was partially mediated by dysfunctional attitudes. These findings are consistent with cognitive-interpersonal models of depression that propose that adverse early experiences may contribute to vulnerability for depression through the establishment of dysfunctional attitudes.

Conceptions of relationships in children with depressive and aggressive symptoms: social-cognitive distortion or reality?

This research tested skill-deficit and cognitive-distortion models of depression and aggression in 615 fifth- and sixth-grade children. Children completed a measure of their generalized conceptions of relationships in the peer domain and their level of depressive symptoms. Teachers completed measures of social competence, social status, and aggression. As anticipated, children with higher levels of depressive symptoms, either alone or in combination with aggression, demonstrated more negative conceptions of both self and peers than did nonsymptomatic children. Conceptions of relationships did not differentiate between aggressive and nonsymptomatic children. Children with depressive symptoms and children with aggressive symptoms displayed unique profiles of social competence deficits and problematic status in the peer group. Analysis of the accuracy of children's conceptions of relationships revealed support for both skill-deficit and cognitive-distortion models. Consistent with a skill-deficit model, children with depressive and depressive-aggressive symptoms were sensitive to actual differences in their social status. In contrast, aggressive children showed an insensitivity to social cues. Consistent with a cognitive-distortion model, children with depressive and depressive-aggressive symptoms had more negative conceptions than would be expected given their social status, whereas aggressive-unpopular children demonstrated a self-enhancement bias. These findings indicate the importance of integrated cognitive-interpersonal models of depression and aggression that incorporate multiple pathways among social-cognitive, interpersonal, and emotional functioning.