Stepwise Latent Class Models for Explaining Group-Level Outcomes Using Discrete Individual-Level Predictors.

Explaining group-level outcomes from individual-level predictors requires aggregating the individual-level scores to the group level and correcting the group-level estimates for measurement errors in the aggregated scores. However, for discrete variables it is not clear how to perform the aggregation and correction. It is shown how stepwise latent class analysis can be used to do this. First, a latent class model is estimated in which the scores on a discrete individual-level predictor are used to construct group-level latent classes. Second, this latent class model is used to aggregate the individual-level predictor by assigning the groups to the latent classes. Third, a group-level analysis is performed in which the aggregated measures are related to the remaining group-level variables while correcting for the measurement error in the class assignments. This stepwise approach is introduced in a multilevel mediation model with a single individual-level mediator, and compared to existing methods in a simulation study. We also show how a mediation model with multiple group-level latent variables can be used with multiple individual-level mediators and this model is applied to explain team productivity (group level) as a function of job control (individual level), job satisfaction (individual level), and enriched job design (group level).

Autonomy-connectedness and internalizing-externalizing personality psychopathology, among outpatients.

OBJECTIVES: The aims of this research were to investigate gender differences in levels of autonomy-connectedness, Axis I Psychopathology, and higher order factors of internalizing and externalizing personality psychopathology and, second, to investigate the association between these variables. DESIGN: The design of this research is cross-sectional and multicentered. METHODS: We used self-report questionnaires, factor analysis, and regression analysis. RESULTS: We found evidence for a significant role of autonomy-connectedness in Axis I Psychopathology. This was especially true for women, who were found to be more sensitive to others and sensitivity to others was strongly associated with Axis I Psychopathology. Maybe due to the research sample no evidence was found for an association of autonomy-connectedness with externalizing psychopathology. As to the role of autonomy-connectedness in internalizing psychopathology, we found that a lack of self-awareness or a capacity of managing new situations, combined with a high sensitivity to others, were associated with internalizing psychopathology. Women appeared to be more sensitive to others and to report higher levels of Axis I Psychopathology than men. CONCLUSION: We conclude that autonomy-connectedness plays an important role in Axis I Psychopathology as well as in internalizing Axis II pathology. Treatment of Axis I and internalizing Axis II psychopathology should therefore also focus on autonomy problems.

Psychometric properties of three instruments to measure recovery.

BACKGROUND: The process of recovery is gaining more and more attention within health care for patients with severe mental illness. Therefore, instruments to measure recovery can be useful for clinical and research purposes. AIMS: This study evaluates the psychometric properties of three instruments pertaining to recovery for possible application in the Netherlands. The Recovery Attitude Questionnaire and the Recovery Knowledge Inventory were investigated among 210 mental health professionals, and the Recovery Promoting Relationship Scale was administered to 142 mental health consumers. METHODS: The factor structure, reliability and internal consistency were examined using the same analysis strategy. First, each questionnaire was submitted to a confirmatory factor analysis based on the factorial structure proposed by the original developers of the questionnaire. In case of a bad fit, an exploratory factor analysis was conducted. Based on factor analyses, subscales were formed for each questionnaire and the internal consistency (Cronbach's alpha) was assessed. In all three cases the final principal axes solution was obliquely rotated by means of the OBLIMIN rotation procedure. RESULTS: The originally proposed factor structure did not yield an acceptable fit in any of the Dutch samples. After analyses, three instruments are proposed that are suitable for research on recovery-oriented competencies and the recovery-promoting relationship for professionals working with people with serious mental illness in the Netherlands. CONCLUSIONS: The results in this study may be a step forward and give a new impulse to stimulate research in mental health recovery.

Factor structure of self-reported clinical disorders and personality disorders: a review of the existing literature and a factor analytical study.

OBJECTIVES: The aim of this research is to add to the current understanding of the latent factor structure of personality disorders by performing a review of the existing literature (Study 1) and a factor analytical study on the factor structure and the relationship between self-reported Axis I and Axis II psychopathology (Study 2). DESIGN: The current research (Study 2) is cross-sectional and multicenter. RESULTS: We found support for the assumption that the borderline personality disorder is a multidimensional construct. Second, we found evidence for a single-factor structure of the narcissistic, dependent as well as the avoidant personality disorder. Third, we found support for the current Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) distinction between Axis I and Axis II, Axis I psychopathology being explained by the factor neuroticism and Axis II disorders to be further subdivided into the higher order factors of internalizing and externalizing pathology. CONCLUSIONS: An adaptation to the current DSM-IV borderline personality criteria should be made, while various findings show that the borderline construct is multidimensional. Second, deletion of the dependent and narcissistic personality in the DSM-V might be unjust. Third, Axis I psychopathology can be explained by the factor neuroticism, and Axis II disorders should be further subdivided into the higher order factors of internalizing and externalizing pathology.

The multiple propensity score as control for bias in the comparison of more than two treatment arms: an introduction from a case study in mental health.

BACKGROUND AND OBJECTIVE: The propensity score method (PS) has proven to be an effective tool to reduce bias in nonrandomized studies, especially when the number of (potential) confounders is large and dimensionality problems arise. The PS method introduced by Rosenbaum and Rubin is described in detail for studies with 2 treatment options. Since in clinical practice we are often interested in the comparison of multiple interventions, there was a need to extend the PS method to multiple treatments. It has been shown that in theory a multiple PS method is possible. So far, its practical application is rare and a practical introduction lacking. METHODS: A practical guideline to illustrate the use of the multiple PS method is provided with data from a mental health study. The multiple PS is estimated with a multinomial logistic regression analysis. The multiple PS is the probability of assignment to each treatment category. Subsequently, to estimate the treatment effects while controlling for initial differences, the multiple PSs, calculated for each treatment category, are included as extra predictors in the regression analysis. RESULTS: With the multiple PS method, balance was achieved in all relevant pretreatment variables. The corrected estimated treatment effects were somewhat different from the results without control for initial differences. CONCLUSIONS: Our results indicate that the multiple PS method is a feasible method to adjust for observed pretreatment differences in nonrandomized studies where the number of pretreatment differences is large and multiple treatments are compared.

The use of propensity score methods in psychotherapy research. A practical application.

BACKGROUND: Randomized controlled trials are considered the best scientific proof of effectiveness. There is increasing concern, though, about their feasibility in psychotherapy research. We discuss a quasi-experimental study design for situations in which a randomized controlled trial is not feasible. Here, as an alternative strategy, the propensity score (PS) method is used to correct for selection bias. METHODS: We used data from a Dutch research project, SCEPTRE (Study on Cost-Effectiveness of Personality Disorder Treatment). The sample consisted of 749 psychotherapy patients with personality pathology. We tested whether the PS method was useful and applicable. We examined differences between 2 treatment groups (short vs. long treatment duration) in pretreatment characteristics before and after PS correction. This revealed the impact of the PS on outcome differences. RESULTS: The PS offered statistical control over observed pretreatment differences between patients in a non-randomized study. CONCLUSIONS: When a randomized controlled trial is not possible, this quasi-experimental design using the PS could be a feasible alternative. Its advantages and limitations are discussed. Implemented carefully, this method is promising for future effectiveness research.

Social reactions to adult crying: the help-soliciting function of tears.

The authors investigated how people believe they respond to crying individuals. Participants (N = 530) read 6 vignettes describing situations in which they encountered a person who either cried or did not cry. Participants reported they would give more emotional support to and express less negative affect toward a crying person than a noncrying person. However, regression analyses revealed that participants judged a crying person less positively than a noncrying person and felt more negative feelings in the presence of a crying person than a noncrying person. The valence of the situation strongly moderated these reactions. Overall, results support the theory that crying is an attachment behavior designed to elicit help from others.

Predicting group-level outcome variables from variables measured at the individual level: a latent variable multilevel model.

In multilevel modeling, one often distinguishes between macro-micro and micro-macro situations. In a macro-micro multilevel situation, a dependent variable measured at the lower level is predicted or explained by variables measured at that lower or a higher level. In a micro-macro multilevel situation, a dependent variable defined at the higher group level is predicted or explained on the basis of independent variables measured at the lower individual level. Up until now, multilevel methodology has mainly focused on macro-micro multilevel situations. In this article, a latent variable model is proposed for analyzing data from micro-macro situations. It is shown that regression analyses carried out at the aggregated level result in biased parameter estimates. A method that uses the best linear unbiased predictors of the group means is shown to yield unbiased estimates of the parameters.

Personality, psychological stress, and self-reported influenza symptomatology.

BACKGROUND: Psychological stress and negative mood have been related to increased vulnerability to influenza-like illness (ILI). This prospective study re-evaluated the predictive value of perceived stress for self-reported ILI. We additionally explored the role of the negative affectivity and social inhibition traits. METHODS: In this study, 5,404 respondents from the general population were assessed in terms of perceived stress, personality, and control variables (vaccination, vitamin use, exercise, etc.). ILI were registered weekly using self-report measures during a follow-up period of four weeks. RESULTS: Multivariable logistic regression analysis on ILI was performed to test the predictive power of stress and personality. In this model, negative affectivity (OR = 1.05, p = 0.009), social inhibition (OR = 0.97, p = 0.011), and perceived stress (OR = 1.03, p = 0.048) predicted ILI reporting. Having a history of asthma (OR = 2.33, p = < 0.0001) was also associated with ILI reporting. Older age was associated with less self-reported ILI (OR = 0.98, P = 0.017). CONCLUSION: Elderly and socially inhibited persons tend to report less ILI as compared to their younger and less socially inhibited counterparts. In contrast, asthma, trait negative affectivity, and perceived stress were associated with higher self-report of ILI. Our results demonstrate the importance of including trait markers in future studies examining the relation between stress and self-report symptom measures.

Bias in Point Estimates and Standard Errors of Mokken's Scalability Coefficients.

Mokken scale analysis uses three types of scalability coefficients to assess the quality of (a) pairs of items, (b) individual items, and (c) an entire scale. Both the point estimates and the standard errors of the scalability coefficients assume that the sample ordering of the item steps is identical to the population ordering, but due to sampling error, the sample ordering may be incorrect and, consequently, the estimates and the standard errors may be biased. Two simulation studies were used to investigate the bias of the estimates and the standard errors of the scalability coefficients, as well as the coverage of the 95% confidence intervals. Distance between item steps was the most important design factor. In addition, sample size, number of items, number of answer categories, and item discrimination were included in the design. Bias of the standard errors was negligible. Bias of the estimates was largest when all item steps were identical in the population, especially for small sample sizes. Furthermore, bias of the estimates decreased as number of answer categories increased and as item discrimination decreased. Coverage of the 95% confidence intervals was close to .950, but for small sample size coverage deteriorated. Coverage also became poorer as number of items increased, in particular for dichotomous items.

The role of sex, attachment and autonomy-connectedness in personality functioning.

Previous studies have found significant relationships among sex, attachment and autonomy-connectedness and DSM-IV personality characteristics. In the present study, we aimed to add to the current knowledge about attachment-related aspects of personality pathology, by examining the relationships of these same variables with dimensions of pathological personality structure as conceptualized by Kernberg. The study was performed among 106 ambulatory patients from a Dutch mental healthcare institute. A path model based upon neo-analytical object relation theory and attachment theory was tested. We expected significant associations among sex, attachment, autonomy and aspects of personality functioning. Both insecure attachment styles as well as the autonomy-connectedness components of sensitivity to others (SO) and capacity of managing new situations predicted general personality dysfunctioning significantly. More specifically, reality testing was negatively predicted by the autonomy component of capacity of managing new situations, and aggression was significantly predicted by sex as well as both insecure attachment styles. We advise scientists as well as clinicians to be alert on sex differences in autonomy-connectedness and aspects of personality dysfunctioning. Taking sex-specific variations in attachment and autonomy into account next to a more explicit focus on insecure attachment styles and autonomy problems may enhance, the current relatively low, treatment effectiveness for personality pathology.

The relationships among part-time work, work-family interference, and well-being.

The authors investigated the effect of part-time work on work-family interference and well-being among 160 part-time and 29 full-time employed mothers (with a partner) working at 2 insurance companies in the Netherlands. The authors controlled for working part time as a strategy for reducing work-family imbalance and found that part-time work was associated with a lower level of work-to-family interference. Also, high levels of work-family interference were associated with diminished well-being. Work-to-family interference played a mediating role in the relationship between part-time work and well-being. Results indicate that part-time jobs can enhance the work-family balance not only for those explicitly choosing part-time employment as a means to reduce work-family imbalance but also for other employees.

Testing hypotheses involving Cronbach's alpha using marginal models.

We discuss the statistical testing of three relevant hypotheses involving Cronbach's alpha: one where alpha equals a particular criterion; a second testing the equality of two alpha coefficients for independent samples; and a third testing the equality of two alpha coefficients for dependent samples. For each of these hypotheses, various statistical tests have been proposed. Over the years, these tests have depended on progressively fewer assumptions. We propose a new approach to testing the three hypotheses that relies on even fewer assumptions, is especially suited for discrete item scores, and can be applied easily to tests containing large numbers of items. The new approach uses marginal modelling. We compared the Type I error rate and the power of the marginal modelling approach to several of the available tests in a simulation study using realistic conditions. We found that the marginal modelling approach had the most accurate Type I error rates, whereas the power was similar across the statistical tests.

Course of recovery and prediction of outcome in young patients in a prolonged vegetative or minimally conscious state after severe brain injury: An exploratory study.

AIMS: To explore the course of recovery of consciousness and factors predicting the outcome of severe brain injury with a prolonged period of unconsciousness in children and young adults receiving a specialized rehabilitation treatment, the Early Intensive Neurorehabilitation Programme (EINP). METHODS: A cohort of forty-four patients aged 1.6-25.5 years (M=16.0) with traumatic acquired brain injury (TBI) or non-traumatic acquired brain injury (nTBI) were examined using the Western Neuro Sensory Stimulation Profile every two weeks, from the application for EINP until discharge. The level of consciousness was assessed with the Post-Acute Level of Consciousness Scale, and the level of disability was determined by the Disability Rating Scale. Long-term level of disability of all TBI patients (N=32) was assessed between 2.0 and 4.4 years after discharge from EINP. RESULTS: Two-thirds of all patients recovered to consciousness. Three recovery patterns were identified: remaining in a vegetative state (VS), slow recovery of consciousness, and fast recovery of consciousness. In the long-term, 11 of the TBI patients were severely disabled, 13 were moderately disabled, and 4 were mildly disabled. All TBI patients who were in VS at discharge either had deceased, or recovered to a very severely disabled state. CONCLUSIONS: Three recovery patterns identified in an early stage after starting EINP made it possible to predict long-term level of disability.

The impact of premature childbirth on parental bonding.

The development of an affectionate parent-infant bond is essential for a newborn infant's survival and development. However, from evolutionary theory it can be derived that parental bonding is not an automatic process, but dependent on infants' cues to reproductive potential and parents' access to resources. The purpose of the present study was to examine the process of bonding in a sample of Dutch mothers (n = 200) and fathers (n = 193) of full-term (n = 69), moderately premature (n = 68), and very premature infants (n = 63). During the first month postpartum parents completed the Pictorial Representation of Attachment Measure (PRAM) and Postpartum Bonding Questionnaire (PBQ). Longitudinal analyses revealed that mothers' PRAM scores decreased after moderately preterm delivery, whereas decreases in PRAM scores occurred in both parents after very preterm delivery. As lower PRAM scores represent stronger feelings of parent-infant connectedness, our findings suggest a higher degree of bonding after premature childbirth. Results of the PBQ analysis were in line with PRAM outcomes, as parents of preterm infants reported less bonding problems compared to parents of full-terms. These findings support the hypothesis that in affluent countries with adequate resources, bonding in parents of preterm infants on average may be higher than in parents of full-term infants.

Mokken Scale Analysis for Dichotomous Items Using Marginal Models.

Scalability coefficients play an important role in Mokken scale analysis. For a set of items, scalability coefficients have been defined for each pair of items, for each individual item, and for the entire scale. Hypothesis testing with respect to these scalability coefficients has not been fully developed. This study introduces marginal modelling as a framework to derive the standard errors for the scaling coefficients and test hypotheses about these coefficients. Several examples demonstrate the possibilities of marginal modelling in Mokken scale analysis. These possibilities include testing whether Mokken's criteria for a scale are satisfied, testing whether scalability coefficients of different items are equal, and testing whether scalability coefficients are equal across different groups.

Predicting individual differences in autonomy-connectedness: the role of body awareness, alexithymia, and assertiveness.

Autonomy-connectedness is the capacity for being on one's own as well as for satisfactorily engaging in interpersonal relationships. Associations have been shown between autonomy-connectedness components (self-awareness, sensitivity to others, and the capacity for managing new situations) and various indices of psychopathology. Both in a theoretical sense as well as for enhancing treatment and prevention, it is relevant to identify which factors most powerfully predict individual differences in autonomy-connectedness: body awareness, alexithymia, or assertiveness. The present study examined this question in a clinical sample of women who were diagnosed as having autonomy problems (N=52) and in a female nonclinical community sample (N=59). In line with expectations, assertiveness was a strong predictor of (all three components of) autonomy-connectedness, as was emotionalizing, one of the alexithymia-components, but the latter in an opposite direction than we had expected: the higher an individual's ability to emotionalize was, the less self-aware and capable to manage new situations that person was, and the more sensitive to others. Cognitive alexithymia contributed to self-awareness as well as to the capacity for managing new situations, and one of the components of body awareness appeared to predict capacity for managing new situations. Our results indicate that assertiveness training and the enhancement of emotion regulation are important elements of autonomy-connectedness targeted interventions.

The relationships of antisocial behavior with attachment styles, autonomy-connectedness, and alexithymia.

The present study was aimed at investigating the relationships among attachment styles, autonomy-connectedness (self-awareness, sensitivity to others, and capacity for managing new situations), alexithymia, and antisocial behavior among 202 college students (67 men and 135 women). We were particularly interested in sex differences in the levels of these variables as well as their associations. Sex differences were expected in types of insecure attachment styles, patterns of autonomy-connectedness, and levels of self-reported antisocial and passive-aggressive behavior. All expected sex differences were indeed found. Furthermore, the model that we hypothesized was partly confirmed: For men, anxious attachment had a stronger direct and positive effect on antisocial behavior than for women, and the positive effect of anxious attachment on passive-aggressive behavior was smaller for women than for men. Interestingly, capacity for managing new situations had a main and mediating effect on antisocial behavior. Sensitivity to others appeared as a mediator between anxious attachment style and passive-aggressive behavior. Contrary to expectations, fantasizing (a component of alexithymia) had a strong, negative association with antisocial behavior. The results are discussed against the background of other recent findings concerning alexithymia and autonomy- connectedeness.

Relations between dietary restraint, depressive symptoms, and binge eating: A longitudinal study.

OBJECTIVE: Temporal relations between dietary restraint, depressive symptoms, and binge eating were tested by means of three competing models positing that (1) dietary restraint and depressive symptoms predict future increases in binge eating, (2) binge eating predicts future increases in dietary restraint and depressive symptoms, and (3) binge eating is reciprocally related to these two factors. METHOD: Longitudinal data from a community sample of Dutch females (N = 143; M age = 19.6) was used to test these relations while controlling for initial levels of these factors. RESULTS: Dietary restraint did not predict future increases in binge eating, nor did binge eating predict future increases in dietary restraint. Depressive symptoms predicted future increases in binge eating, but binge eating did not predict future increases in depressive symptoms. CONCLUSION: Although this study had limited statistical power, the pattern of relations and effect sizes suggest that depressive symptoms, but not dietary restraint, increase risk of binge eating for late adolescent females.

Inner body and outward appearance: the relationships between appearance orientation, eating disorder symptoms, and internal body awareness.

This study investigated the associations of appearance orientation and eating disorder symptoms with internal body awareness in an eating-disordered group of women and a general sample of women. In the eating-disordered group, appearance orientation was positively associated with internal body awareness. Eating disorders symptoms were negatively related to the awareness of bodily signals. No significant associations were found in the general sample of women. The results indicate that in eating-disordered individuals preoccupation with the body and eating-disordered behaviors are not only negatively associated with hunger, but with awareness of other bodily signals as well.