Transdiagnostic Nature Research Articles

What Emotion Regulation Strategies are Associated with a General Psychopathology Factor (p) in Adolescence? Identifying Possible Transdiagnostic Targets for Intervention.

Mental health problems in adolescence are increasing and there is an urgent call for transdiagnostic interventions, as most adolescents experience problems across multiple domains. Research has identified a general psychopathology factor (p) capturing the shared variance across mental health problems. In parallel, there is empirical support for the transdiagnostic nature of emotion regulation. In the current study, we explore the associations between p and emotion regulation strategies to identify which strategies may be promising targets for intervention. Data from the population-based Youth and Mental Health Study (YAMHS) (N = 2,464, mean age 13.7years, SD 0.6) was used. The fit of different structural models of emotion regulation and psychopathology were compared, and latent factors from the final models were included in multiple regression analyses to explore the associations between p and emotion regulation strategies. A bifactor exploratory structural equation model (B-ESEM) showed best fit for modelling p. For emotion regulation strategies, an ESEM model showed best fit, including Rumination, Reactive Impulsivity, Distraction, Non-Acceptance, Problem Solving, Social Support, and Proactive Behavior. Results showed that a higher score on p was predicted by higher scores on the emotion regulation strategies Rumination (β = .38, p < .001) and Reactive Impulsivity (β = .35, p < .001), and lower scores on Problem Solving (β = -.15, p < .001). The results indicate that Rumination and Reactive Impulsivity have the strongest associations with p and may be promising targets for mental health interventions for adolescents.

Developing a transdiagnostic Ecological Momentary Assessment protocol for psychopathology.

The network approach to psychopathology posits that mental disorders emerge from dynamic interactions among psychopathology-relevant variables. Ecological Momentary Assessment (EMA) is frequently used to assess these variables in daily life. Considering the transdiagnostic nature of the network approach to psychopathology, this study describes the development of a transdiagnostic EMA protocol for psychopathology. First, 96 clinicians completed an online survey, providing three EMA constructs for up to three disorders they specialize in, and three EMA constructs relevant across disorders (transdiagnostic constructs). Second, 12 focus groups were conducted with clinical experts for specific types of diagnoses (e.g., mood disorders, anxiety disorders). Finally, a selection of items was reached by consensus. Two raters independently coded the online survey responses with an inter-rater agreement of 87.3%. Jaccard indices showed up to 52.6% overlap in EMA items across types of diagnoses. The most frequently reported transdiagnostic constructs were mood, sleep quality, and stress. A final set of EMA items is created based on items' frequency and informativeness, ensuring completeness across diagnoses and minimizing burden. The described procedure resulted in a feasible EMA protocol to examine psychopathology transdiagnostically. Feasibility was helped by the overlap in mentioned symptoms across disorders. Such overlap raises questions about the validity of DSM categories.

Genetic Associations of Anhedonia: Insights into Overlap of Mental and Somatic Disorders.

Anhedonia is characterized by a reduced ability to anticipate, experience, and/or learn about pleasure. This phenomenon has a transdiagnostic nature and is one of the key symptoms of mood disorders, schizophrenia, addictions, and somatic conditions. To evaluate the genetic architecture of anhedonia and its overlap with other mental disorders and somatic conditions. We performed a genome-wide association study of anhedonia on a sample of 4,520 individuals from a Russian non-clinical population. Using the available summary statistics, we calculated polygenic risk scores (PRS) to investigate the genetic relationship between anhedonia and other psychiatric or somatic phenotypes. No variants with a genome-wide significant association were identified. PRS for major depression, bipolar disorder, and schizophrenia were significantly associated with anhedonia. Conversely, no significant associations were found between PRS for anxiety and anhedonia, which aligns well with existing clinical evidence. None of the PRS for somatic phenotypes attained a significance level after correction for multiple comparisons. A nominal significance for the anhedonia association was determined for omega-3 fatty acids, type 2 diabetes mellitus, and Crohn's disease. Anhedonia has a complex polygenic architecture, and its presence in somatic diseases or normal conditions may be due to a genetic predisposition to mood disorders or schizophrenia.

Assessment of affective dysregulation in children: development and evaluation of a semi-structured interview for parents and for children

BackgroundChildren with affective dysregulation (AD) show an excessive reactivity to emotionally positive or negative stimuli, typically manifesting in chronic irritability, severe temper tantrums, and sudden mood swings. AD shows a large overlap with externalizing and internalizing disorders. Given its transdiagnostic nature, AD cannot be reliably and validly captured only by diagnostic categories such as disruptive mood dysregulation disorder (DMDD). Therefore, this study aimed to evaluate two semi-structured clinical interviews—one for parents and one for children.MethodsBoth interviews were developed based on existing measures that capture particular aspects of AD. We analyzed internal consistencies and interrater agreement to evaluate their reliability. Furthermore, we analyzed factor loadings in an exploratory factor analysis, differences in interview scores between children with and without co-occurring internalizing and externalizing disorders, and associations with other measures of AD and of AD-related constructs. The evaluation was performed in a screened community sample of children aged 8–12 years (n = 445). Interrater reliability was additionally analyzed in an outpatient sample of children aged 8–12 years (n = 27).ResultsOverall, internal consistency was acceptable to good. In both samples, we found moderate to excellent interrater reliability on a dimensional level. Interrater agreement for the dichotomous diagnosis DMDD was substantial to perfect. In the exploratory factor analysis, almost all factor loadings were acceptable. Children with a diagnosis of disruptive disorder, attention-deficit/hyperactivity disorder, or any disorder (disruptive disorder, attention-deficit/hyperactivity disorder, and depressive disorder) showed higher scores on the DADYS interviews than children without these disorders. The correlation analyses revealed the strongest associations with other measures of AD and measures of AD-specific functional impairment. Moreover, we found moderate to very large associations with internalizing and externalizing symptoms and moderate to large associations with emotion regulation strategies and health-related quality of life.ConclusionsThe analyses of internal consistency and interrater agreement support the reliability of both clinical interviews. Furthermore, exploratory factor analysis, discriminant analyses, and correlation analyses support the interviews’ factorial, discriminant, concurrent, convergent, and divergent validity. The interviews might thus contribute to the reliable and valid identification of children with AD and the assessment of treatment responses.Trial registrationADOPT Online: German Clinical Trials Register (DRKS) DRKS00014963. Registered 27 June 2018.

Impulsivity: A Transdiagnostic Approach to Understanding Adolescent Substance Use

Impulsivity: A Transdiagnostic Approach to Understanding Adolescent Substance Use

The Associations of Exposome Score with Various Domains of Psychopathology: A Network Analysis in a Non-Clinical Sample.

The intricate correlation between environmental exposures and mental health outcomes is increasingly acknowledged in psychiatric research. This study investigated the relationship between cumulative environmental risk factors, as represented by the exposome score (ES), and various domains of psychopathology within a non-clinical sample using a network analysis. We recruited 1100 participants (aged 18-35 years, 51.4% females) via a computer-assisted web interview, assessing psychopathological symptoms using standardized questionnaires. Environmental exposures, including season of birth, obstetric complications, advanced paternal age, childhood trauma, cannabis use, and urban upbringing, were self-reported to calculate the ES. A network analysis revealed significant associations of the ES with psychotic-like experiences (PLEs) (weight = 0.113), manic (weight = 0.072), and attention-deficit/hyperactivity disorder symptoms (weight = 0.062). These connections did not differ significantly with respect to their weights. Depressive symptoms had the highest centrality and predictability. The mean predictability across all nodes included in the network was 0.344. These findings underscore the transdiagnostic nature of environmental exposures, aligning with previous research indicating broad associations between the ES and various facets of psychopathology. Our results suggest that the ES may not specifically correlate with PLEs but may indicate the risk of a broader psychopathology.

The Contrast Avoidance Model: Conclusion and synthesis of new research in the special issue

In this special series, new research on the Contrast Avoidance Model (CAM) was presented, including studies on the role of CAM in the maintenance of chronic worry, the incremental validity of CAM, CAM as a mediator of the association between generalized anxiety disorder (GAD) and other variables, CAM as transdiagnostic, and interpersonal behaviors as a means to avoid negative emotional contrasts (NECs). Furthermore, the role of perseverative thought in relation to positive emotional contrasts (PECs) was explored. Studies indicated that higher worry was positively and negatively reinforced, a factor that is likely to contribute to the maintenance of GAD. Further, research demonstrated that CAM contributed unique variance to understanding GAD above and beyond other variables associated with GAD, such as intolerance of uncertainty and negative problem orientation. Additional research revealed the transdiagnostic nature of contrast avoidance, as well as the association between contrast avoidance and problem-solving deficits. In addition, both worry and rumination increased the likelihood of PECs. Further, data suggested that anxious individuals may use interpersonal strategies to avoid NECs. Finally, savoring positive emotions was found to reduce contrast avoidance, providing a novel intervention strategy to address contrast avoidance in individuals with GAD.

Thalamo-cortical circuits associated with trait- and state-repetitive negative thinking in major depressive disorder

BackgroundRepetitive negative thinking (RNT), often referred to as rumination in the mood disorders literature, is a symptom dimension associated with poor prognosis and suicide in major depressive disorder (MDD). Given the transdiagnostic nature of RNT, this study aimed to evaluate the hypothesis that neurobiological substrates of RNT in MDD may share the brain mechanisms underlying obsessions, particularly those involving cortico-striatal-thalamic-cortical (CSTC) circuits. MethodsThirty-nine individuals with MDD underwent RNT induction during fMRI. Trait-RNT was measured by the Ruminative Response Scale (RRS) and state-RNT was measured by a visual analogue scale. We employed a connectome-wide association analysis examining the association between RNT intensity with striatal and thalamic connectivity. ResultsA greater RRS score was associated with hyperconnectivity of the right mediodorsal thalamus with prefrontal cortex, including lateral orbitofrontal cortex, along with Wernicke's area and posterior default mode network nodes (t = 4.66–6.70). A greater state-RNT score was associated with hyperconnectivity of the right laterodorsal thalamus with bilateral primary sensory and motor cortices, supplementary motor area, and Broca's area (t = 4.51–6.57). Unexpectedly, there were no significant findings related to the striatum. ConclusionsThe present results suggest RNT in MDD is subserved by abnormal connectivity between right thalamic nuclei and cortical regions involved in both visceral and higher order cognitive processing. Emerging deep-brain neuromodulation methods may be useful to establish causal relationships between dysfunction of right thalamic-cortical circuits and RNT in MDD.

Many Facets of Eating Disorders: Profiling Key Psychological Features of Anorexia Nervosa and Binge Eating Disorder.

Objective. The present study employs a profile analysis to identify and compare psychological features and core eating disorder (ED) symptoms in clinical samples of patients with anorexia nervosa (AN) and binge eating disorder (BED) and the general population (GP). Methods. A sample comprising 421 participants (142 patients with AN; 139 patients with BED; and 140 participants from the GP) was surveyed with the Eating Disorder Inventory-3 (EDI-3). Individuals with AN and BED were recruited and tested during their first week of a multidisciplinary inpatient program for weight loss and rehabilitation at the 'Rete DCA USL Umbria 1' (Eating Disorders Services), Italy. Results. The findings suggest distinct patterns of symptom presentation between the three samples across all the EDI-3 dimensions-with both the AN and BED groups scoring significantly higher than the GP. Patients with AN registered greater scores in all the psychological trait scales and the drive for thinness ED-specific dimension of the EDI-3 compared with their BED counterpart-which, instead, scored higher in the bulimia and body dissatisfaction subscales. These data support the transdiagnostic nature of the main risk factors for the onset and maintenance of EDs-which would vary in severity levels-and the existence of disease-specific pathways giving rise to AN and BED. Conclusion. This study for the first time compares patients with AN and BED with a non-clinical sample on main ED psychological features. This might inform classification approaches and could have important implications for the development of prevention and early intervention programs.

Examining the associations between difficulties in emotion regulation and symptomatic outcome measures among individuals with different mental disorders.

Difficulties in emotion regulation (ER) abilities have been found to play a central role in different psychiatric disorders. However, researchers rarely compare ER across different diagnostic groups. In the current study, we examined ER and its relation to functional and symptomatic outcome among three distinct diagnostic groups: people with schizophrenia (SCZ), people with emotional disorders (EDs; i.e., depression and/or anxiety), and individuals without any psychiatric diagnosis (controls). Participants in this study comprised 108 adults who requested psychotherapy at a community clinic in the year 2015 and between 2017 and 2019. Clients were interviewed and filled out questionnaires measuring depression, distress, and difficulties in ER abilities. Results showed that individuals with psychiatric diagnoses reported higher levels of difficulties in ER abilities than did controls. Moreover, there were very few differences in levels of ER difficulty between SCZ and EDs. Further, the associations between maladaptive ER and psychological outcomes were significant in each diagnostic group, and especially for SCZ. Our study indicates that difficulties in ER abilities partially have a transdiagnostic nature, and that these difficulties are associated with psychological outcomes among both clinical populations and controls. There were very few differences in levels of ER ability difficulties between SCZ and EDs, suggesting that the two groups share difficulties in relating and responding to emotional distress. The associations between difficulties in ER abilities and outcome were more robust and stronger among SCZ than the other groups, highlighting the potential contribution of targeting ER abilities in the treatment of schizophrenia.

Perfectionistic Children and Their Parents: Is There Room for an Intergenerational Transmission? A Study of a Clinical Sample of Italian Children and Their Parents.

The relationship between maladaptive perfectionism and Internalizing (ID) and Externalizing Disorders (ED) in children needs to be better understood, along with the intergenerational transmission of these traits from parents to children. The present work aimed to share light on both these issues. 39 children with ID, 19 with ED, and their parents were recruited*. The Multidimensional Perfectionism Scale, the Big Five Inventory, the Child and Adolescent Perfectionism Scale, and the Hierarchical Personality Inventory for Children were used. The association between parent personality and perfectionism traits and children's perfectionism dimensions was evaluated through hierarchical regression analysis. ID and ED groups did not differ significantly concerning perfectionism. Fathers presented higher scores than mothers in Self-Oriented Perfectionism, Other-Oriented Perfectionism, and Socially-Prescribed Perfectionism. Parents of children with ID report higher levels of Obedience in their children, while parents of children with ED reported higher levels of Creativity and Perseverance. Significant associations were found between perfectionism in parents and their children, as well as between perfectionism and the personality of children. Results suggest a transdiagnostic nature of Perfectionism and support the transgenerational transmission of the personality traits investigated.

Psychometric Properties of the Iranian Version of Contrast Avoidance Questionnaires: Could Contrast Avoidance Be a New Transdiagnostic Construct?

The contrast avoidance model (CAM) hypothesizes that individuals with chronic worry recruit worry to create and maintain a negative emotional state to avoid sudden increases in negative emotions. Preliminary evidence using the contrast avoidance questionnaires (CAQs) suggests that there might be a similar mechanism across mood and other anxiety disorders. To continue to assess the CAQs, they should be adapted for other languages and evaluated across multiple symptom domains. The present study aimed to develop the Persian versions of the CAQs and examine the transdiagnostic nature of CAM across two studies. A large Persian-speaking college student sample (Total n = 1438) was used to evaluate the factor structure of the CAQs (Study 1) and the psychometric properties of CAQs (Study 2). Results supported the two-factor structure of the CAQ-W (worry) and CAQ-GE (general emotion). Results showed that CAQ-W was a significant predictor of anxiety-related measures. However, CAQ-GE and IUS-12 significantly predicted depressive and other symptoms over the CAQ-W. Results demonstrated excellent psychometric properties. They indicate that contrast avoidance, measured via CAQ-GE, could be a transdiagnostic construct, and CAQ-W may be more sensitive to anxiety-specific contrast avoidance among Persian speaking and/or Iranian individuals.

Submissive behavior as a transdiagnostic construct: Associations with internalizing symptoms and distress intolerance.

Submissive behavior is associated with significant impairment and negative life outcomes. The goal of the present study was to determine the transdiagnostic nature of submissive behavior by observing its association with internalizing symptoms (i.e., social anxiety, depression, and worry) and distress intolerance. Additionally, we sought to determine the moderating role of gender in these relationships. We used a community sample (N = 208) to evaluate the hypothesized relationships between submissive behavior and internalizing symptoms. All three internalizing symptoms were uniquely associated with greater submissive behavior when covarying for each other. Distress intolerance was also uniquely positively related to submissive behavior respective of general distress. Moderation analyses revealed that the associations between social anxiety, worry, and distress intolerance with submissive behavior were stronger in men rather than women. The present study provides novel evidence for the relevance of submissive behavior to internalizing symptoms and distress intolerance. We discuss clinical implications and directions for future research.

Analysis of the transdiagnostic nature of prepulse inhibition of the startle response: a systematic review with implications for neuropsychopharmacology research

Analysis of the transdiagnostic nature of prepulse inhibition of the startle response: a systematic review with implications for neuropsychopharmacology research

Perfectionism: Its Structure, Transdiagnostic Nature, and Cognitive Behavioral Therapy

The term perfectionism is often characterized by insisting that everything should be perfect and flawless, believing in only one truth, and having difficulty transforming perspectives and thoughts. Although perfectionism is not a newly introduced concept in the literature, it has recently become one frequently aired both in research and daily life. The popularity of the concept in empirical studies stems from both its dual nature and its alleged roles in the origin, emergence, retention, and treatment of various psychological disorders. Indeed, despite the abundance of evidence that perfectionism is multifaceted within two major dimensions (perfectionist strivings and perfectionist concerns), it is still debated that the dimensions in different numbers better represent the construct. In addition, the relevant literature hosts diverse views and criticisms about which sub-dimensions the two higher-order dimensions will consist of, whether the conceptual content of a combination of these sub-dimensions is positive or negative, and how to calculate the total impact of the sub-dimensions. On the other hand, previous research consistently addressed the relationship of perfectionism with different psychopathologies and comorbidities. In this respect, it is also deemed important to discuss perfectionism in psychotherapy because even settling perfectionist traits may bring about improvements in more than one disorder associated with perfectionism. Thus, the Cognitive Behavioral Approach (CBT) conceptualized perfectionism (clinical perfectionism) and presented techniques for therapy. Moreover, the evidence is also proliferating for the efficiency of CBT for perfectionism. Therefore, in this article, the current literature on the structure, transdiagnostic nature and cognitive behavioral therapy of perfectionism has been reviewed.

"I just want to be certain": psychometric properties and predictive role of the Intolerance of Uncertainty Scale-12

Introduction: Intolerance of uncertainty (IU) is a transdiagnostic vulnerability factor characterized by a negative reaction at an emotional, cognitive, and behavioral level to uncertain situations. Aim: The current study investigates the factor structure, reliability, and convergent validity of the Iranian version of the intolerance of uncertainty scale-12 and its predictive role in anxiety, depression, and contrast avoidance (CA). Method: This is a cross-sectional, psychometric study. Two large samples (N1=1210, N2=228) were collected with the convenience sampling method from three university students in Zanjan city (i.e., University of Medical Sciences, Azad University, and Payame Noor University) who were studying from February to July 2020. Data were collected using CAQ-GE, BAI, BDI-II, GAD-7 and IUS-12. The data were analyzed with Mplus 7.4, Amos 24, and SPSS 26 software. Results: EFA and CFA supported the two-factor model for IUS-12. In addition, the results indicated that the IUS-12 has an excellent convergent validity (p&lt;0.01) and an acceptable internal consistency (α=0.89). Regression analysis results confirmed the predictive role of IUS-12 in predicting anxiety and depression and pointed out the possible transdiagnostic nature of the CA. Conclusion: Iranian version of IUS-12 showed good psychometric properties and a robust two-factor structure. Therefore, using it in predicting constructs related to anxiety and depression could help us extend our knowledge of the underlying factors of psychiatric disorders.

Spatiotemporal Psychopathology – An integrated brain-mind approach and catatonia

Catatonia is featured by complex symptoms combining motor, affective and behavioral phenomena as well as by its syndrome character with trans-diagnostic occurrence. It paradigmatically shows the limits of current forms of psychopathology like affective and cognitive approaches with respect to both clinical symptoms and brain mechanisms. We therefore suggest Spatiotemporal Psychopathology (STPP) which, as recently introduced, is here developed further following the latest findings in both clinical psychiatry and neuroscience. STPP is characterized by two core features: (i) an experience-based approach that accounts for symptoms primarily in terms of first-person experience of time-space as distinct from third-person observation of specific functions and related behavior; (ii) an integrated brain-mind approach where the brain's neural topography and dynamic, e.g., inner time and space, are shared by the mind's mental topography and dynamic, e.g., time-space experience, as their “common currency”. We demonstrate how these two features can well account for both symptom complexity and trans-diagnostic nature of catatonia. In conclusion, catatonia can serve as paradigmatic example for the need to develop a more comprehensive psychopathological approach in psychiatry. This is provided by STPP that allows integrating subjective experience, clinical symptoms and the brain's neural activity in terms of their inner space-time, e.g., topography and dynamic.

Exploring the living experience of shame; protector or persecutor?

PurposeThe purpose of this opinion piece is to give voice to the living experience of shame within myself as the author, both psychologically and physically. This is in the hope to increase awareness among others who experience shame and mental health professionals tasked with supporting people in emotional distress.Design/methodology/approachThe author has written a biographical piece outlining her experiences of living with shame and used rich, provocative and metaphorical language in describing the events which led to this and the impact this has had on my quality of life. The author has positioned shame as a character playing a role in her life.FindingsThis piece reveals the inner turmoil experienced when living alongside shame and the resilience and fortitude needed to understand the role of shame and how it developed. With this knowledge and awareness, the author has found it is possible to move forward in life.Research limitations/implicationsThe author has lived through adverse and challenging early life experiences within a difficult family environment. The author has shown that it is possible to undertake a healing journey and to come to an acceptance of shame within my own life and still move forward to create supportive relationships with others and a life worth living. These are often the stories of those people who survive great difficulty and still go on to help and support other people.Practical implicationsThe author has found and experienced that loving and supportive relationships give the best chance of healing from early life adversities. The author has also found that shame plays an interesting role as both necessary and painful. Moving forward from the distress often associated with shame is a long journey but one that is possible.Social implicationsThe author has aimed to make clear that exploration and education about the lived experience of shame is both helpful for those who suffer and those who intend to help within the mental health professions. Listening to the stories of people with living experiences is vital and plays as important a role as academic theory and learning.Originality/valueThis is a subjective living experience of shame and, in that way, adds to the helpful canon of stories that can inform our understanding of distress and the ability to help. The author has described shame as a character playing a role in her life and belief that this is an interesting way to view this. This piece also contains stories regarding the genesis of shame which are unique to her. The author understands and makes clear that his experience does not necessarily translate or relate to anyone else but stands on its own merit. The author hopes to have much more to contribute in terms of others’ understanding of emotional distress and shame, especially considering its transdiagnostic nature.

Transdiagnostic Patterns of Sensory Processing in Autism and ADHD.

Sensory processing abilities are highly variable within and across people diagnosed with autism and attention-deficit/hyperactivity disorder (ADHD). This study examined the transdiagnostic nature of sensory processing abilities, and their association with features of autism and ADHD, in a large sample of autistic people (n = 495) and people with ADHD (n = 461). Five similar data-driven sensory phenotypes characterized sensory processing abilities, and showed similar patterns of association with features of autism and ADHD, across both diagnostic groups. These results demonstrate the transdiagnostic nature of sensory processing abilities, while contributing to a growing body of literature that suggests the autism and ADHD diagnostic labels have poor explanatory power.

Lived experience perspectives on a definition of eating disorder recovery in a sample of predominantly white women: a mixed method study

BackgroundThere has recently been a push for recovery-focused research in the eating disorder (ED) field, starting with a consensus definition of recovery. One definition, in particular, proposed by Bardone-Cone et al. [21] has received considerable attention given its transdiagnostic nature and validation studies. However, no studies to date have elicited lived experience views of this definition. The goal of the current study was to examine perspectives on this definition of recovery from individuals with a past or present ED and to determine whether participant agreement with the model differed based on diagnostic history or current symptom severity.MethodsSixty-two individuals (95.2% women; 91.9% White/European) participated in a 1–2 h interview aimed at capturing their perspectives on ED recovery. Transcripts were analyzed using qualitative content analysis and codebook thematic analysis to examine agreement with and thoughts on Bardone-Cone’s definition of recovery, respectively. Chi-squared tests of independence and binary logistic regression were computed to determine whether agreement with the definition differed across diagnostic history and self-reported symptoms.ResultsAlthough some participants indicated acceptance of the definition, the majority expressed concerns related to its categorical nature, proposed criteria, feasibility, language, and applications. There were no differences in acceptance based on diagnostic history or current symptom severity.ConclusionA single definition of recovery does not seem to fit individuals’ lived ED experience. Future research may benefit from distinguishing between recovery as an individually-defined phenomenon and related constructs such as remission (i.e., loss of diagnosis or absence of clinical symptoms). A more comprehensive multi-faceted, and person-centered model of recovery may have merit in clinical settings.