International Journal of Clinical and Health Psychology (2019) 19, 160---164

International Journal
of Clinical and Health Psychology
www.elsevier.es/ijchp

BRIEF REPORT

Cognitive rigidity in patients with depression and

fibromyalgia
Mari Aguilera a,∗ , Clara Paz b , Victoria Compañ c , Juan Carlos Medina c , Guillem Feixas c,d

a
Department of Cognition, Development and Educational Psychology, Universitat de Barcelona, Spain
b
School of Psychology, Universidad de Las Américas, Ecuador
c
Department of Clinical Psychology and Psychobiology, Universitat de Barcelona, Spain
d
The Institute of Neurosciences, Universitat de Barcelona, Spain

Received 8 November 2018; accepted 7 February 2019

Available online 11 March 2019

KEYWORDS Abstract
Fibromyalgia; Background/Objective: The comorbidity of depression and fibromyalgia chronic syndrome has
Depression; been well documented in the literature; however, the cognitive structure of these patients
Cognitive rigidity; has not been assessed. Previous results reported variability in cognitive rigidity in depressive
Ex post facto study patients, the key for this might be the presence of chronic physical pain such as fibromyalgia.
The present study explores and compares the cognitive rigidity and differentiation, between
patients with depression with and without fibromyalgia syndrome.
Method: Thirty one patients with depression and fibromyalgia were matched, considering age,
sex and number of depressive episodes, with 31 patients with depression but without fibromyal-
gia diagnosis. Cognitive rigidity and differentiation were measured with the repertory grid
technique.
Results: The results indicated that depressed patients with fibromyalgia presented higher levels
of depressive symptoms, greater cognitive rigidity and lower cognitive differentiation than those
without fibromyalgia.
Conclusions: The results might inform future treatments to address the cognitive structure of
these patients.
© 2019 Asociación Española de Psicologı́a Conductual. Published by Elsevier España, S.L.U. This
is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/
by-nc-nd/4.0/).

∗ Corresponding author. Mundet, Ponent, Desp. 3510, Pg. Vall D’Hebron, 171, 08035 Barcelona, Spain.
E-mail address: mari.aguilera@ub.edu (M. Aguilera).

https://doi.org/10.1016/j.ijchp.2019.02.002
1697-2600/© 2019 Asociación Española de Psicologı́a Conductual. Published by Elsevier España, S.L.U. This is an open access article under
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Cognitive rigidity in patients with depression and fibromyalgia 161

PALABRAS CLAVE Rigidez cognitiva en pacientes con depresión y fibromialgia

Fibromialgia;
Resumen
Depresión;
Antecedentes/Objetivo: La comorbilidad de la depresión y la fibromialgia ha sido bien docu-
Rigidez cognitiva;
mentada en la literatura. Sin embargo, la estructura cognitiva de estos pacientes no ha sido
Estudio ex post facto
evaluada. Estudios previos muestran variabilidad en medidas de rigidez cognitiva en pacientes
con depresión. Los síndromes físicos crónicos podrían ser una variable clave para explicar esta
variabilidad presente en estudios previos. El presente estudio explora y compara la rigidez y
la diferenciación cognitiva entre paciente con depresión que tienen y aquellos que no tienen
fibromialgia.
Método: Treinta y un pacientes con depresión y fibromialgia fueron emparejados, considerando
edad, sexo y números de episodios depresivos con 31 pacientes con depresión, pero sin diag-
nóstico de fibromialgia.
Resultados: Los resultados indican que los pacientes que presentan depresión y fibromialgia
evidencian niveles más altos de síntomas depresivos, mayor rigidez cognitiva y menor diferen-
ciación cognitiva que los pacientes sin fibromialgia.
Conclusiones: Estos resultados podrían ser considerados al momento de crear tratamientos
ajustados a la estructura cognitiva de estos pacientes.
© 2019 Asociación Española de Psicologı́a Conductual. Publicado por Elsevier España, S.L.U.
Este es un artı́culo Open Access bajo la licencia CC BY-NC-ND (http://creativecommons.org/
licenses/by-nc-nd/4.0/).

Depressive disorder is one of the most severe health 90% of depressive symptoms, and a rate between 62 to 86%
problems in our society because of its disabling effects, of comorbidity with a diagnosis of depression (Veltri et al.,
and societal and economic burden (Whiteford, Ferrari, 2012). These rates were significantly higher compared with
Degenhardt, Feigin, & Vos, 2015). Moreover, it has been general population, and indeed, with other chronic pain dis-
associated with several health issues (Brandolim Becker orders (Gormsen, Rosenberg, Bach, & Jensen, 2010).
et al., 2018; Chen et al., 2019; Nieto, Hernández-Torres, The objective of the present study was to explore cog-
Pérez-Flores, & Montón, 2018). An ‘‘all-or-nothing’’ think- nitive rigidity and differentiation in depressed patients
ing pattern (a tendency to extreme or catastrophic thinking) and patients with comorbid FM. We hypothesized that
has been described as a core aspect of depressive cogni- participants with depression and fibromyalgia would have
tion (Al-Mosaiwi & Johnstone, 2018; Antoniou, Bongers, & higher levels of depression, polarization and lower cognitive
Jansen, 2017). differentiation than participants with depression without
From a personal construct theory viewpoint, it has been fibromyalgia.
suggested that depressed patients organize the construing
of themselves, others and the world in relatively polar-
ized, monolithic terms that are resistant to modification and Method
revision (Neimeyer, 1985). In fact, using the Repertory Grid
Technique (RGT) the configuration of the construct system Participants
in depressed patients has been defined as presenting high
polarization (Neimeyer & Feixas, 1992) ----the tendency of This study analyze data from a previous randomized con-
more extreme ratings---- an low cognitive differentiation---- trolled trial (Feixas et al., 2016), which assessed the efficacy
measured by means of the percentage of variance accounted of a dilemma-focused intervention, a new variant of cogni-
by the first factor (PVAFF; Kovářová & Filip, 2015) resulting tive therapy for depression (Feixas & Compañ, 2016). All
from the analysis of each grid data matrix. patients (N = 141) in that study met the criteria for either
However, recent findings suggested similar mean, but Major Depressive Disorder or Dysthymia (or both) as assessed
also high variability, in polarization and in PVAFF between a with the structured clinical interview for DSM-IV axis I dis-
group of depressed patients and a non-clinical group (Feixas, orders (SCID-I-CV; First, Spitzer, Gibbon, & Williams, 1996).
Erazo-Caicedo, Harter, & Bach, 2008). This result might be Also as an inclusion criterion, patients had to score more
explained by the great amount of clinical variability among than 19 on the Beck’s Depression Inventory-II (BDI-II; Beck,
depressed patients. In fact, high rates of comorbidity with Steer, & Brown, 1996).The study protocol was approved by
chronic syndromes related with pain have been reported the Bioethics Committee of the University of Barcelona (Ref.
(Velly & Mohit, 2018). Ohayon and Schatzberg (2003) indi- IRB0003099). All the participants signed an informed consent
cated that around 43.4% of the individuals who met criteria document before enrolling.
for depression also had a chronic painful physical condi- From those, 31 (22%) had a concurrent diagnosis of FM
tion compared to 16.1% in the general population. Studies at baseline. These patients were the target of the present
in fibromyalgia (FM) also showed a life-span prevalence of study. Their mean age was 50.45 years (SD = 9.60), with
162 M. Aguilera et al.

Table 1 Comparison of depressive patients with and without a concurrent diagnosis of fibromyalgia.
Depression (n = 31) Depression+FM (n = 31) t-test Effect size

Mean SD Mean SD t p Cohen’s d 95% CI

BDI-II 36.16 8.55 40.74 9.62 -1.98 .03 0.49 [0.01, 1.01]
Polarization 31.02 13.80 39.54 17.07 -2.16 .02 0.54 [0.04, 1.05]
PVAFF 43.13 11.27 48.67 11.46 -1.92 .03 0.48 [-0.20, 0.99]
Note. FM = Fibromyalgia; BDI-II= Beck Depression Inventory-II; PVAFF= Percentage of Variance Accounted by the First Factor.

an average of 2.06 depressive episodes (SD = 1.21). They Statistical analysis

reported a mean pain intensity of 76.21 (SD = 20.73) in
the visual analogue scale (VAS; Price, McGrath, Rafii, & One-tailed independent samples t-tests were performed
Buckingham, 1983), a 100-mm line for the assessment of using SPSS 23.0 (IBM Corp., 2015). Cohen’s d effect sizes
pain intensity; and an average of 8.14 years (SD = 6.4) with were calculated for each dependent variable.
FM diagnosis. The comparison group was a paired sample
of 31 patients from the same trial who did not have the
diagnosis of FM and who had not reported high levels of Results
pain intensity (scored lower than 50 in VAS). Variables used
for matching this control sample to the FM group were age As shown in Table 1, significant differences were found
(M = 50.85; SD = 9.47), sex (28 females and 3 males) and between both samples for depressive symptoms, polar-
number of depressive episodes (M = 1.96; SD = 1.43). Both ization and PVAFF. Depressed patients with FM presented
groups were also comparable in terms of time elapsed, in significantly higher BDI-II scores, higher polarization and
years, from the first episode (M = 12.48; SD = 11.46 for higher PVAFF than those without FM. The two groups were
the target group and M = 10.45; SD = 9.78, for the control different in their degree of symptom severity, polarization
group). and cognitive differentiation with a medium effect size. No
statistical differences were found in the number of con-
structs elicited in the grids of both samples.

Discussion
Instruments Our results, along with the review of Goesling, Clauw and
Hasset (2013), indicated that at least for some patients,
The repertory grid technique (Feixas & Cornejo, 2002), depression might be associated with the experience of pain.
a semi-structured interview created to study personal Twenty per cent of our sample had a concurrent diag-
constructs, was used for assessing cognitive structure. Con- nosis of FM. This result is convergent with that reported
structs were elicited in each patient from comparisons for patients with other chronic pain disorders (Ohayon &
among a set of elements (e.g., self, family relatives, friends, Schatzberg, 2003; Réthelyi, Berghammer, & Kopp, 2001). It
ideal self), followed by rating these elements for each con- is worthy to mention that this percentage rose to 60% if
struct with a 7-point Likert scale. This resulted in construct we took into account patients who experienced a high level
data matrix from which several measures were derived using of pain (over 50 in VAS). Interestingly, our results indicated
specialized software (GRIDCOR v 4.0; Feixas & Cornejo, that depressed patients with comorbid FM scored higher
2002). For the present study (see Feixas, Montesano, Erazo- in depressive symptomatology. Further analyses of BDI-II
Caicedo, Compañ, & Pucurull, 2014 for a wider variety of showed higher scores in the FM comorbid group in the items
measures), the PVAFF resulting from a factor analysis of the concerning pessimism, irritability, concentration/difficulty,
grid data was used as an indicator of unidimensional think- tiredness or fatigue and loss of interest in sex. The nature of
ing (Feixas, Bach, & Laso, 2004). The higher the percentage, the relationship between pain and depression needs further
the smaller the room for other dimensions of meaning to studies to develop a better understanding in the future.
take prominence in construing self and others. The second Pain experience in depression seems to be associated
grid measure used in this study was polarization, computed also to cognitive structure. Polarized construing emerged
simply as the percentage of extreme ratings (1 or 7) in the as the most distinctive cognitive structure between the
grid data matrix. Most authors support the construct valid- two groups. Although the tendency to construe themselves
ity of the RGT as the notions employed (e.g., ‘‘personal in extreme terms had been proposed as characteristic of
construct’’) are directly derived from the theory. Several individuals with depression (Neimeyer, 1985), depressed
studies have reported test-retest reliability scores of .71-.77 patients with comorbid FM showed higher scores in polar-
for the elements, and of .48-.69 for the elicited constructs ization with a medium effect size. Moreover, PVAFF showed
(see Feixas & Cornejo, 1996; for a review). A recent study a similar pattern indicating that depressed comorbid FM
(Trujillo, 2016), in the same local context as the present one, patients presented lower levels of differentiation in their
yielded a test-retest reliability score of .84 for the PVAFF, dimensions of meaning. These results converged with those
and of .81 polarization measure. reported by Neimeyer and Feixas (1992), in which structural
Cognitive rigidity in patients with depression and fibromyalgia 163

cognitive measures such as cognitive differentiation and Feixas, G., & Compañ, V. (2016). Dilemma-focused intervention for
polarization accounted for a specific factor of rigidity in unipolar depression: A treatment manual. BMC Psychiatry, 16,
depressive patients. 235, http://doi.org/10.1186/s12888-016-0947-x.
The small size of the study is a limitation for the exter- Feixas, G., & Cornejo, J. M. (1996). Manual de la técnica de la rejilla
nal validity of the study. But, in spite of the fact that our mediante el programa RECORD v.2. In 0. Barcelona: Paidós.
study focused on a few aspects and also that larger samples Feixas, G., & Cornejo, J.M. (2002). GRIDCOR: Correspondence
analysis for grid data v.4.0 [Computer software and reper-
may be needed, our findings if confirmed in other stud-
tory gridmanual]. Retrieved from www.terapiacognitiva.net/
ies might have relevant implications for clinical treatment record.
of depressed patients with comorbid FM. For patients with Feixas, G., Erazo-Caicedo, M. I., Harter, S. L., & Bach, L. (2008).
chronic pain, increasing their cognitive complexity might Construction of Self and Others in Unipolar Depressive Disor-
lead to better therapeutic results. In that sense, attune- ders: A Study Using Repertory Grid Technique. Cognitive Therapy
ment to the patients’ views of themselves and of the world and Research, 32, 386---400, http://doi.org/10.1007/s10608-
can be a relevant factor to help promoting an evolution of 007-9149-7.
these patients’ meaning systems (in terms of cognitive flex- Feixas, G., Montesano, A., Erazo-Caicedo, M. I., Compañ, V.,
ibility) to increase their capacity to deal with current and & Pucurull, O. (2014). Implicative dilemmas and symptom
future events and problems. severity in depression?: A preliminary and content analy-
sis study. Journal of Constructivist Psychology, 27, 37---40,
Overall, our study points to the need for more attention
http://doi.org/10.1080/10720537.2014.850369.
to the role of chronic pain in the study and treatment of First, M., Spitzer, R., Gibbon, M., & Williams, J. (1996). Structured
depressed patients. Maybe models of depression should dif- Clinical Interview for DSM-IV Axis I disorders Clinician Version
ferentiate between depressed patients with a chronic pain (SCID-CV). New York, NY: Biometrics Research Department.
condition, such as FM, and those without pain. In addition, Goesling, J., Clauw, D. J., & Hassett, A. L. (2013). Pain
treatment strategies and efficacy studies should follow that and depression: An integrative review of neurobiological and
line as well. psychological factors. Current Psychiatry Reports, 15, 421,
http://doi.org/10.1007/s11920-013-0421-0.
Gormsen, L., Rosenberg, R., Bach, F. W., & Jensen, T. S.
Funding (2010). Depression, anxiety, health-related quality of life
and pain in patients with chronic fibromyalgia and neuro-
This work was funded by Ministerio de Ciencia e Innovación pathic pain. European Journal of Pain, 14(127), e1-127.e8.
[PSI2011-23246]. http://doi.org/10.1016/j.ejpain.2009.03.010.
IBM Corp. (2015). IBM SPSS Statistics for Windows, Version 23.0.
Armonk, NY: IBM Corp.
References Kovářová, M., & Filip, M. (2015). Integrating the Differentiated:
A Review of the Personal Construct Approach to Cognitive
Al-Mosaiwi, M., & Johnstone, T. (2018). In an Absolute State: Ele- Complexity. Journal of Constructivist Psychology, 28, 342---366,
vated Use of Absolutist Words Is a Marker Specific to Anxiety. http://doi.org/10.1080/10720537.2014.994693.
Depression, and Suicidal Ideation. Clinical Psychological Sci- Neimeyer, R. A. (1985). Personal constructs and depression:
ence, 6, 529---542, http://doi.org/10.1177/2167702617747074. Research and clinical implications. In E. Button (Ed.), Personal
Antoniou, E. E., Bongers, P., & Jansen, A. (2017). The mediating role Construct Theory and Mental Health (pp. 82---102). London:
of dichotomous thinking and emotional eating in the relation- Croom Helm.
ship between depression and BMI. Eating Behaviors, 26, 55---60, Neimeyer, R., & Feixas, G. (1992). Cognitive assessement in depres-
http://doi.org/10.1016/j.eatbeh.2017.01.007. sion: A comparison in some existing measures. Journal of
Beck, A., Steer, R., & Brown, G. (1996). Manual for the Beck Personality, 8, 47---56.
Depression Inventory- Second edition (BDI-II). San Antonio, TX: Nieto, A., Hernández-Torres, A., Pérez-Flores, J., & Montón, F.
Psychological Corporation. (2018). Depressive symptoms in Friedreich ataxia. Interna-
Brandolim Becker, N., de Jesus, S. N., Viseu, J. N., Stobäus, C. D., tional Journal of Clinical and Health Psychology, 18, 18---26,
Guerreiro, M., & Domingues, R. B. (2018). Depression and quality http://doi.org/https://doi.org/10.1016/j.ijchp.2017.11.004.
of life in older adults: Mediation effectd of sleep quality. Inter- Ohayon, M. M., & Schatzberg, A. F. (2003). Using Chronic
national Journal of Clinical and Health Psychology, 18, 8---17, Pain to Predict Depressive Morbidity in the General
http://doi.org/10.1016/j.ijchp.2017.10.002. Population. Archives of General Psychiatry, 60, 39,
Chen, Y. P., Wang, S. M., Wu, Y., Lin, H. Y., Wu, C. C., http://doi.org/10.1001/archpsyc.60.1.39.
Chuang, T. Y., Ho, W. P., Kuo, Y. J., Leu, T. H., & Lin, Price, D., McGrath, P., Rafii, A., & Buckingham, B. (1983). The
C. Y. (2019). Worsen depression after viscosupplementation validation of visual analogue scales as ratio scale measures
treatment for geriatric people with knee osteoarthritis? Inter- for chronic and experimental pain. Pain. Retrieved from,
national Journal of Clinical and Health Psychology, 19, 31---40, http://www.sciencedirect.com/science/article/pii/0304395
http://doi.org/10.1016/j.ijchp.2018.10.001. 983901264.
Feixas, G., Bach, L., & Laso, E. (2004). Factors affecting Réthelyi, J. M., Berghammer, R., & Kopp, M. S. (2001).
interpersonal constructs differentiation when measured using Comorbidity of pain-associated disability and depres-
the repertory grid. Journal of Constructivist Psychology, 17, sive symptoms in connection with sociodemographic
297---311, http://doi.org/10.1080/10720530490483202. variables: results from a cross-sectional epidemiological
Feixas, G., Bados, A., García-Grau, E., Paz, C., Montesano, A., survey in Hungary. Pain, 93, 115---121. Retrieved from
Compañ, V., Salla, M., Aguilera, M., Trujillo, A., Cañete, J., http://www.ncbi.nlm.nih.gov/pubmed/11427322.
Medeiros, L., Soriano, J., Ibarra, M., Medina, J. C., Ortíz, Trujillo, A. (2016). Técnica de la rejilla interpersonal: Un estudio
E., & Lana, F. (2016). A dilemma-focused intervention for de validación en población comunitaria [Interpersonal repertory
depression: A multicenter, randomized controlled trial witha grid technique: A validation study in a community population]
a 3 month follow-up. Depression and Anxiety, 33, 862---869, (Unpublished doctoral dissertation). Universitat de Barcelona,
http://doi.org/10.1002/da.22510. Spain.
164 M. Aguilera et al.

Velly, A. M., & Mohit, S. (2018). Epidemiology of pain Whiteford, H. A., Ferrari, A. J., Degenhardt, L., Feigin, V.,
and relation to psychiatric disorders. Progress in Neuro- & Vos, T. (2015). The global burden of mental, neuro-
Psychopharmacology and Biological Psychiatry, 87, 159---167, logical and substance use disorders: An analysis from the
http://doi.org/10.1016/j.pnpbp.2017.05.012. global burden of disease study 2010. PLoS ONE, 10, 1---14,
Veltri, A., Scarpellini, P., Piccinni, Conversano Giacomelli, C., Bom- http://doi.org/10.1371/journal.pone.0116820.
bardieri, S., Bazzichi, L., & DellÓsso, L. (2012). Methodological
approach to depressive symptoms in fibromyalgia patients. Clin-
ical and Experimental Rheumatology, 74(Suppl.), 136---140.