The Ghent Psychotherapy Study: A Pragmatic, Stratified, Randomized Parallel Trial into the Differential Efficacy of Psychodynamic and Cognitive-Behavioral Interventions in Dependent and Self-Critical Depressive Patients.

INTRODUCTION: Different types of psychotherapy are effective for treating major depressive disorder across groups yet show large within-group differences. Patient personality style is considered a potentially useful variable for treatment matching. OBJECTIVE: This study is the first experimental test of the interaction between therapeutic approach and patients' dependent versus self-critical personality styles. METHODS: A pragmatic stratified parallel trial was carried out with 100 adult patients diagnosed with DSM-IV-TR major depressive disorder. They were randomly assigned to short-term (16-20 sessions) cognitive behavioral therapy (CBT) or short-term psychodynamic psychotherapy (STPP). Patients were assessed at baseline, during therapy, post-therapy, and at 3- and 6-month follow-up. Primary outcome is depression severity measured by the Hamilton Rating Scale for Depression posttreatment. Primary analysis was by intention to treat. This trial is registered with the ISRCTN registry (www.isrctn.com), number ISRCTN17130982. RESULTS: The intention-to-treat sample consisted of 100 participants; 40 with self-critical and 60 with dependent personality styles were randomized to either CBT (n = 50) or STPP (n = 50). We observed no interaction effect (-0.34 [-6.14, 5.46]) between therapy and personality style and found no evidence for a difference in effectiveness between the treatments in general in terms of symptom reduction and maintained benefits at 6-month follow-up. CONCLUSION: We found no evidence that dependent versus self-critical personality styles moderate the relation between treatment and outcome in depression. Research using individual patient data could gain further insight into why specific therapeutic approaches work better for specific patients.

Nonlinear mediation analysis with high-dimensional mediators whose causal structure is unknown.

With multiple possible mediators on the causal pathway from a treatment to an outcome, we consider the problem of decomposing the effects along multiple possible causal path(s) through each distinct mediator. Under a path-specific effects framework, such fine-grained decompositions necessitate stringent assumptions, such as correctly specifying the causal structure among the mediators, and no unobserved confounding among the mediators. In contrast, interventional direct and indirect effects for multiple mediators can be identified under much weaker conditions, while providing scientifically relevant causal interpretations. Nonetheless, current estimation approaches require (correctly) specifying a model for the joint mediator distribution, which can be difficult when there is a high-dimensional set of possibly continuous and noncontinuous mediators. In this article, we avoid the need to model this distribution, by developing a definition of interventional effects previously suggested for longitudinal mediation. We propose a novel estimation strategy that uses nonparametric estimates of the (counterfactual) mediator distributions. Noncontinuous outcomes can be accommodated using nonlinear outcome models. Estimation proceeds via Monte Carlo integration. The procedure is illustrated using publicly available genomic data to assess the causal effect of a microRNA expression on the 3-month mortality of brain cancer patients that is potentially mediated by expression values of multiple genes.

Which behaviour change techniques are effective to promote physical activity and reduce sedentary behaviour in adults: a factorial randomized trial of an e- and m-health intervention.

BACKGROUND: E- and m-health interventions are promising to change health behaviour. Many of these interventions use a large variety of behaviour change techniques (BCTs), but it's not known which BCTs or which combination of BCTs contribute to their efficacy. Therefore, this experimental study investigated the efficacy of three BCTs (i.e. action planning, coping planning and self-monitoring) and their combinations on physical activity (PA) and sedentary behaviour (SB) against a background set of other BCTs. METHODS: In a 2 (action planning: present vs absent) × 2 (coping planning: present vs absent) × 2 (self-monitoring: present vs absent) factorial trial, 473 adults from the general population used the self-regulation based e- and m-health intervention 'MyPlan2.0' for five weeks. All combinations of BCTs were considered, resulting in eight groups. Participants selected their preferred target behaviour, either PA (n = 335, age = 35.8, 28.1% men) or SB (n = 138, age = 37.8, 37.7% men), and were then randomly allocated to the experimental groups. Levels of PA (MVPA in minutes/week) or SB (total sedentary time in hours/day) were assessed at baseline and post-intervention using self-reported questionnaires. Linear mixed-effect models were fitted to assess the impact of the different combinations of the BCTs on PA and SB. RESULTS: First, overall efficacy of each BCT was examined. The delivery of self-monitoring increased PA (t = 2.735, p = 0.007) and reduced SB (t = - 2.573, p = 0.012) compared with no delivery of self-monitoring. Also, the delivery of coping planning increased PA (t = 2.302, p = 0.022) compared with no delivery of coping planning. Second, we investigated to what extent adding BCTs increased efficacy. Using the combination of the three BCTs was most effective to increase PA (x2 = 8849, p = 0.003) whereas the combination of action planning and self-monitoring was most effective to decrease SB (x2 = 3.918, p = 0.048). To increase PA, action planning was always more effective in combination with coping planning (x2 = 5.590, p = 0.014; x2 = 17.722, p < 0.001; x2 = 4.552, p = 0.033) compared with using action planning without coping planning. Of note, the use of action planning alone reduced PA compared with using coping planning alone (x2 = 4.389, p = 0.031) and self-monitoring alone (x2 = 8.858, p = 003), respectively. CONCLUSIONS: This study provides indications that different (combinations of) BCTs may be effective to promote PA and reduce SB. More experimental research to investigate the effectiveness of BCTs is needed, which can contribute to improved design and more effective e- and m-health interventions in the future. TRIAL REGISTRATION: This study was preregistered as a clinical trial (ID number: NCT03274271 ). Release date: 20 October 2017.

A Network Analysis of Potential Antecedents and Consequences of Pain-Related Activity Avoidance and Activity Engagement in Adolescents.

OBJECTIVE: This study sets out to identify potential daily antecedents and consequences of pain-related activity avoidance and engagement behavior in adolescents with chronic pain. METHODS: Adolescents (N = 65, Mage = 14.41) completed baseline self-reports and a diary for 14 days. Afternoon and evening reports were used to infer a network structure of within-day associations between pain intensity, pain-related fear, pain catastrophizing, affect, and pain-related activity avoidance and engagement behavior. Baseline psychological flexibility was examined as a potential resilience factor. RESULTS: Activity avoidance in the evening was predicted by pain-related fear and avoidance earlier that afternoon. Activity engagement was predicted by positive affect and activity engagement in the afternoon. Pain-related behavior in the afternoon was not related to subsequent changes in pain intensity, pain-related fear, pain catastrophizing, or affect. Pain-related fear in the afternoon was predictive of increased levels of pain and pain catastrophizing in the evening. Both pain-related fear and pain catastrophizing in the evening were predicted by negative affect in the afternoon. Psychological flexibility was associated with lower levels of daily activity avoidance and buffered the negative association between pain intensity and subsequent activity engagement. CONCLUSIONS: This study provides insight into unique factors that trigger and maintain activity avoidance and engagement and into the role of psychological flexibility in pediatric pain. Future work should focus on both risk and resilience factors and examine the role of psychological flexibility in chronic pediatric pain in greater detail.

Estimation of Controlled Direct Effects in Longitudinal Mediation Analyses with Latent Variables in Randomized Studies.

In a randomized study with longitudinal data on a mediator and outcome, estimating the direct effect of treatment on the outcome at a particular time requires adjusting for confounding of the association between the outcome and all preceding instances of the mediator. When the confounders are themselves affected by treatment, standard regression adjustment is prone to severe bias. In contrast, G-estimation requires less stringent assumptions than path analysis using SEM to unbiasedly estimate the direct effect even in linear settings. In this article, we propose a G-estimation method to estimate the controlled direct effect of treatment on the outcome, by adapting existing G-estimation methods for time-varying treatments without mediators. The proposed method can accommodate continuous and noncontinuous mediators, and requires no models for the confounders. Unbiased estimation only requires correctly specifying a mean model for either the mediator or the outcome. The method is further extended to settings where the mediator or outcome, or both, are latent, and generalizes existing methods for single measurement occasions of the mediator and outcome to longitudinal data on the mediator and outcome. The methods are utilized to assess the effects of an intervention on physical activity that is possibly mediated by motivation to exercise in a randomized study.

A quest for self-soothing: A systematic case study into emotion-focused therapy with an emotionally avoidant client who committed sexual offenses.

OBJECTIVE: The current study is part of a multiple case study that investigated the emotional change in individuals who have committed sexual offenses (ISOs). This case study highlights how one client used sex as a maladaptive coping strategy to suppress negative emotions. METHOD: A mixed-methods design was used to track changes in the client's affect regulation (AR) during four phases, including a baseline (Phase A), treatment as usual (Phase B), treatment with an emotion-focused therapy (EFT) component added (Phase C), and follow up (Phase A). RESULTS: The qualitative description with verbatim clinical vignettes, revealed deeper insight into some important steps and hindrances and the impact of specific EFT-interventions. Quantitative analysis of self-report and observational measures showed a significant improvement in the client's AR across different phases of treatment. CONCLUSIONS: The study improves our knowledge of the emotional change in ISOs during treatment and illustrates some key interventions, steps, and hindrances.

A bootstrap version of the Hausman test to assess the impact of cluster-level endogeneity beyond the random intercept model.

In the random intercept model for clustered data, the random effect is typically assumed to be independent of predictors. Violation of this assumption due to unmeasured cluster-level confounding (endogeneity) induces bias in the estimates of effects of within-cluster predictors. Treating cluster-specific intercepts as fixed rather than random avoids this bias. The Hausman test contrasts the fixed effect estimator with the traditional random effect estimator in the random intercept model to test for the presence of cluster-level endogeneity and has a known asymptotic χ2 -distribution under correct model specification. Unmeasured cluster-level heterogeneity may, however, interact with predictors as well, necessitating random slope models. Relying on either cluster or residual resampling in a bootstrap procedure, we propose two extensions of the Hausman test that can easily be used beyond the random intercept model. We compare the original Hausman test and its robust version to the newly proposed bootstrap tests in terms of empirical type I error rate and power. Under additive unmeasured heterogeneity, all methods perform equally well, whereas the original and robust Hausman tests are too liberal or too conservative under additional slope heterogeneity, both bootstrap Hausman tests maintain appropriate performance. Moreover, both bootstrap tests show robustness against misspecification in the presence of unit-level heteroscedasticity and temporal correlation.

Ensemble representation for multiple facial expressions: Evidence for a capacity limited perceptual process.

We tested the processing capacity of establishing ensemble representation for multiple facial expressions using the simultaneous-sequential paradigm. Each set consisted of 16 faces conveying a variable amount of happy and angry expressions. Participants judged on a continuous scale the perceived average emotion from each face set (Experiment 1). In the simultaneous condition, the 16 faces were presented concurrently; in the sequential condition, two sets, each containing eight faces, were presented successively. Results showed that judgments varied depending on the number of happy versus angry faces contained in the sets and were sensitive at the single trial level to the perceived mean emotion intensity (based on postexperiment ratings), providing evidence of a genuine mean representation rather than the mere use of a single face or enumeration. Experiments 2 and 3 replicated Experiment 1, but implemented a different response format (binary choices) and added masks following each display, respectively. Importantly, in all three experiments, performance was consistently better in the sequential than in the simultaneous condition, revealing a limited-capacity process. A set of control analyses ruled out the use of enumeration or mere subsampling by the participants to perform the task. Collectively, these results indicate that participants could readily extract mean emotion from multiple faces shown concurrently in a set, but this process is best conceived as being capacity limited.

More Precise Estimation of Lower-Level Interaction Effects in Multilevel Models.

In hierarchical data, the effect of a lower-level predictor on a lower-level outcome may often be confounded by an (un)measured upper-level factor. When such confounding is left unaddressed, the effect of the lower-level predictor is estimated with bias. Separating this effect into a within- and between-component removes such bias in a linear random intercept model under a specific set of assumptions for the confounder. When the effect of the lower-level predictor is additionally moderated by another lower-level predictor, an interaction between both lower-level predictors is included into the model. To address unmeasured upper-level confounding, this interaction term ought to be decomposed into a within- and between-component as well. This can be achieved by first multiplying both predictors and centering that product term next, or vice versa. We show that while both approaches, on average, yield the same estimates of the interaction effect in linear models, the former decomposition is much more precise and robust against misspecification of the effects of cross-level and upper-level terms, compared to the latter.

Stepfamilies Doing Family: A Meta-Ethnography.

The present review examines how stepfamily members without a shared history co-construct a shared family identity and what family processes are relevant in this stepfamily formation. Three databases (Web of Science, PsycInfo, and ProQuest) were systematically searched, resulting in 20 included qualitative studies. The meta-ethnography approach of Noblit and Hare allowed synthesizing these qualitative studies and constructing a comprehensive framework of stepfamilies doing family. Three interdependent family tasks were identified: (a) honoring the past, (b) marking the present, and (c) investing in the future. Stepfamily members' experiences of these family tasks are strongly affected by the dominant societal perspectives and characterized by an underlying dialectical tension between wanting to be like a first-time family and feeling the differences in their family structure at the same time. These findings clearly demonstrate the family work that all stepfamily members undertake and provide a broader context for interpreting stepfamilies' co-construction of a new family identity.

Flexible Mediation Analysis With Multiple Mediators.

The advent of counterfactual-based mediation analysis has triggered enormous progress on how, and under what assumptions, one may disentangle path-specific effects upon combining arbitrary (possibly nonlinear) models for mediator and outcome. However, current developments have largely focused on single mediators because required identification assumptions prohibit simple extensions to settings with multiple mediators that may depend on one another. In this article, we propose a procedure for obtaining fine-grained decompositions that may still be recovered from observed data in such complex settings. We first show that existing analytical approaches target specific instances of a more general set of decompositions and may therefore fail to provide a comprehensive assessment of the processes that underpin cause-effect relationships between exposure and outcome. We then outline conditions for obtaining the remaining set of decompositions. Because the number of targeted decompositions increases rapidly with the number of mediators, we introduce natural effects models along with estimation methods that allow for flexible and parsimonious modeling. Our procedure can easily be implemented using off-the-shelf software and is illustrated using a reanalysis of the World Health Organization's Large Analysis and Review of European Housing and Health Status (WHO-LARES) study on the effect of mold exposure on mental health (2002-2003).

The decision to have an abortion from both partners' perspectives: a dyadic analysis.

OBJECTIVES: Male partners are often involved in induced abortion although they have no legal rights. It is, however, unknown how women's thoughts and feelings regarding the decision for abortion are associated with the decisional experiences of the involved male partners and vice versa. METHODS: Flemish women and their involved male partners (IMP) filled out a questionnaire on abortion motives and feelings of decisiveness in the abortion centre waiting room (N = 106 couples). Actor Partner Interdependence Models investigated whether the decisiveness of one partner was associated with a subjective feeling of autonomy (high internal, low external abortion motivation) and decisiveness of the other partner, above and beyond the own feeling of autonomy and personal vulnerabilities for being uncertain. RESULTS: Partner congruence in motivation and decisiveness was substantial (r= 0.23 to 0.42), especially for cohabiting partners. The IMPs were less internally motivated for the abortion than the women but both partners reported more internal than external motives, and they both tended to feel certain. In contrast to the women, a higher subjective feeling of autonomy in the IMPs was not associated with feeling more certain. When accounting for partners' living situation, levels of uncertainty were not only associated with personal vulnerabilities for being uncertain, but were also related to the degree of uncertainty and subjective level of autonomy of the other partner. CONCLUSIONS: Partners' thoughts and feelings regarding the decision for abortion partially have an interpersonal basis and mostly run parallel despite an inherent gender difference in level and importance of decision autonomy.

Sex in Its Daily Relational Context.

INTRODUCTION: The present study measured the daily correlates of sexual behavior in an ecologically valid context by relying on a daily diary approach. AIM: Examining the dyadic and multicomponent nature of sexual behavior is essential to create valid models of sexual responding that are better aligned with the day-to-day context of having sex in a relationship. METHODS AND MAIN OUTCOME MEASURES: During 3 weeks, heterosexual couples completed, two times a day, an electronic diary to report on mood, own and perceived partner behavior, relational feelings (in the evening), sexual activity, physical intimacy, and masturbation (in the morning). This design allowed testing bidirectional temporal associations between daily context and different types of sexual behavior. RESULTS: Positive mood, displays of positive partner behavior, perceived positive partner behavior, and positive relational feelings predicted more sexual activity and intimacy in men, which then further increased their positive mood, perceived positive partner behavior, and positive feelings about the relationship on the following day. Women showed a similar pattern of predictors regarding sexual activity as men, though the effect of sexual behavior on next-day feelings and behavior was more relationship-oriented rather than affecting personal mood. Intimacy was related to almost all daily variables in women, but related only to own and perceived positive partner behavior and positive relational feelings the next day. Several partner effects also reached significance, and these were more influential in predicting male than female intimacy. Solitary sexual activity showed a different pattern of results than dyadic sexual activity, with men experiencing masturbation as negatively in the context of their relationship. CONCLUSION: These results confirm the regulatory function of sex and intimacy in maintaining a positive relational climate and indicate that the quality of the everyday relational context is important to get partners in the mood to act in a sexual way.

When Is Helping your Partner with Chronic Pain a Burden? The Relation Between Helping Motivation and Personal and Relational Functioning.

OBJECTIVE: Self-determination theory (SDT) may be a useful framework to understand why chronic pain affects partners. SDT postulates that individuals can engage in helping behaviors for different motives varying from more autonomous or volitional motives to more controlled or pressured motives. This article examines the relationship between partners' type of motivation to help (i.e., autonomous vs controlled) and their personal and relational functioning. Furthermore, mechanisms underlying this relationship (i.e., helping exhaustion and relationship-based need satisfaction) were examined. METHODS: In a sample of 48 couples, of which one partner had chronic pain (36 female patients), questionnaires measuring life satisfaction, positive and negative affect, anxiety and depressive feelings, relationship quality and relationship-based need satisfaction were filled out. Individuals with chronic pain (ICPs) also reported on pain intensity and disability whereas partners were requested to report on motives for helping and helping exhaustion. RESULTS: Data analysis with Structural Equation Modeling revealed that autonomous, relative to controlled, motives for helping among partners related positively to partners' well-being and relationship quality, and negatively to distress. The experience of helping exhaustion and relationship-based need satisfaction mediated these associations. Moreover, partners' autonomous helping motivation related positively to patient-reported relationship quality among ICPs high in pain intensity. CONCLUSIONS: Applying SDT in a context of pain provides new insights into why chronic pain affects partners and how partners impact patient outcome. Directions for future research are outlined.

The Role of Dyadic Sexual Desire Similarity in Predicting Sexual Behaviors in Cohabitating Couples: An Ecological Momentary Assessment Study.

Although researchers are increasingly paying attention to the dyadic nature of sexual desire and its relevance to sexual and relational outcomes, our understanding of how sexual desire operates on a couple level and how it may influence the occurrence of sexual activity in relationships remains limited. This study used ecological momentary assessments to explore to what extent similarity in levels of desire for sex with one's sexual partner, or dyadic sexual desire, was associated with sexual initiations, receptivity to one's partner's initiations, and partnered sexual activity, and how these associations were moderated by perceived partner support. Ninety-four cohabitating couples (M age = 26.30, SD = 7.60) provided six reports a day for 10 consecutive days. We used response surface analysis to examine the associations among both the degree and direction of (dis)similarity in partners' dyadic desire and each of the three outcome variables. Our results revealed that although partners tended to experience similar levels of desire on a moment-to-moment basis, similarity in desire levels was not associated with the three outcome variables. Rather, higher desire within couples predicted each partner's behavioral outcomes. At lower levels of perceived partner support, dyadic sexual desire was negatively associated with women's receptivity to sexual initiations by their partners, indicating high context-sensitivity of women's sexual responding. These findings offer new insights into the links between the similarity in partners' levels of dyadic desire and sexual behaviors in couples, suggesting the need for increased focus on maintaining desire and promoting perceived partner support in clinical practice.

Is passion contagious in coach-athlete dyads? A dyadic exploration of the association between passion, affective and need-based experiences in individual sports.

The Dualistic Model of Passion distinguishes between harmonious and obsessive passion, which are associated with athletes' and coaches' adjustments. Whereas prior research sampled either athletes or coaches, the present study used a dyadic approach to explore the bidirectional influence of passion on affective experiences in coaches and athletes. Using a cross-sectional dyadic design, 198 coach-athlete dyads involved in an individual sport at different competition levels, reported on their passion, need-based, and affective experiences. Both actor effects (i.e., intrapersonal dynamics within athletes or coaches) and partner effects (i.e., interpersonal dynamics from coach to athlete and vice versa) were examined. Furthermore, dyadic mediation models were used to investigate the potential mediating role of need-based experiences in the association between passion and affective experiences. Results unveiled compelling evidence for actor effects, indicating that one's own harmonious passion was positively related to one's own more adaptive outcomes and negatively to one's own more maladaptive outcomes, whereas obsessive passion was positively related to maladaptive outcomes. Further, very limited evidence for partner effects, in which coaches' passion affected athletes' outcomes or vice versa, was found. The dyadic mediation models underscored the role of need-based experiences in mediating the association between passion and affective experiences, but only at the intrapersonal level. As such, one's own passion experiences were related to one's own need-based experiences, which in turn were related to one's own affective experiences. The study provided no evidence for interpersonal mediation effects.

Prediction Model for Defects in Lead and Lead-free Aprons.

ABSTRACT: Personal radiation protective equipment (PRPE) is prone to defects in the attenuating layers, resulting in inadequate protection. Hence, quality control (QC) of PRPE is needed to assess its integrity. Unfortunately, QC of PRPE is laborious and time consuming. This study aimed to predict the QC outcome of PRPE without x-ray imaging based on readily available predictors. PRPE QC data of a general hospital from 2018 to 2023 was used for both prediction models based on logistic regression and random forests (RF). The data were divided into a training set containing all data from 2018 to 2022 and a holdout set containing the data from 2023. The predictors were brand, age, size, type, visual defects, and department. The prediction performances were compared using confusion matrices and visualized with receiver operating characteristic (ROC) curves. Prediction accuracies of at least 80% were achieved. Further model tuning especially improved the RF model to a precision up to 97% with a sensitivity of 80% and specificity of 86%. All predictors, except visual defects, significantly impacted the probability of passing. The predictor brand had the largest contribution to the predictive performance. The difference in pass probability between the best-performing and the worst-performing brand was 35.1%. The results highlight the potential of predicting PRPE QC outcome without x rays. The proposed prediction approach is a significant contribution to an effective QC strategy by reducing time consuming x-ray QC tests and focusing on garments with higher probability of being defective. Further research is recommended.

Multiple synergistic effects of emotion and memory on proactive processes leading to scene recognition.

Visual scene recognition is a proactive process through which contextual cues and top-down expectations facilitate the extraction of invariant features. Whether the emotional content of the scenes exerts a reliable influence on these processes or not, however, remains an open question. Here, topographic ERP mapping analysis and a distributed source localization method were used to characterize the electrophysiological correlates of proactive processes leading to scene recognition, as well as the potential modulation of these processes by memory and emotion. On each trial, the content of a complex neutral or emotional scene was progressively revealed, and participants were asked to decide whether this scene had previously been encountered or not (delayed match-to-sample task). Behavioral results showed earlier recognition for old compared to new scenes, as well as delayed recognition for emotional vs. neutral scenes. Electrophysiological results revealed that, ~400 ms following stimulus onset, activity in ventral object-selective regions increased linearly as a function of accumulation of perceptual evidence prior to recognition of old scenes. The emotional content of the scenes had an early influence in these areas. By comparison, at the same latency, the processing of new scenes was mostly achieved by dorsal and medial frontal brain areas, including the anterior cingulate cortex and the insula. In the latter region, emotion biased recognition at later stages, likely corresponding to decision making processes. These findings suggest that emotion can operate at distinct and multiple levels during proactive processes leading to scene recognition, depending on the extent of prior encounter with these scenes.

An examination of the reciprocal associations between physical activity and anxiety, depressive symptoms, and sleep quality during the first 9 weeks of the COVID-19 pandemic in Belgium.

During the initial outbreak of the global COVID-19 pandemic, many countries imposed a total lockdown (containment at home). Although it was still allowed in Belgium to be physically active or exercise with people from your household in the vicinity of your home, engaging in sports or physical activity in a group or club context was no longer permitted. To examine whether a lack of physical activity was potentially threatening to the mental well-being of citizens and vice versa, the present study examined concurrent and reciprocal relationships between physical activity and anxiety, depressive symptoms, and sleep quality during the COVID-19 lockdown in a 9-week longitudinal design. In a sample of 983 Belgian adults (75.1% female; M age = 43.78, range = 18-82 years), we explored these relationships at both the between- and within-person levels through random intercept cross-lagged panel models. The findings indicate that more physical activity was associated with lower symptoms of anxiety and depression and better sleep quality, a finding observed both at the between-person (across weeks; ßanxiety = -0.25, ßdepression = -0.30, ßsleep quality = 0.24, p < .001) and within-person level (within weeks; ßanxiety = -0.10, ßdepression = -0.14, ßsleep quality = 0.11, p < .05). Moreover, at the within-person level, an increase in feelings of anxiety and depression at one moment predicted lower levels of physical activity one week later (ßanxiety = -0.04, ßdepression = -0.06, p < .05). Since poor mental health poses a threat to the maintenance of physical activity, the current findings suggest that it is critical to invest in the mental health of individuals during distressing times.

Daily Sexual Behavior, Sexual Esteem, and Body Image in Transgender and Cisgender Individuals.

Multiple surveys have suggested that transgender individuals show lower sexual well-being than cisgender individuals. Most studies, however, are limited in terms of ecological validity and memory bias and cross-sectional in nature. These issues are less prevalent in diary studies monitoring responses over time at home. For three weeks, 47 transgender (M age = 29.00, SD = 11.62) and 52 cisgender individuals (M age = 32.90, SD = 11.44) reported daily on their sexual behavior, sexual esteem and body image. Using multilevel model analyses, we investigated the daily associations between these variables, and addressed differences between transgender and cisgender individuals. We found that in transgender individuals, intimacy predicted sexual esteem; sexual openness predicted sexual esteem and body image; and sexual esteem predicts intimacy, masturbation, and sexual openness on the daily level. While transgender individuals scored lower on daily sexual esteem and body image than cisgender individuals, groups did not differ in daily sexual behavior. They also did not differ in any of the predictive relations described above, but we did find that the association between masturbation and body image was moderated by a cisgender identity, and sexual esteem predicted sexual activity more positively in cisgender compared to transgender individuals. These results complement findings from cross-sectional studies and indicate how transgender individuals struggling with sexuality can increase sexual openness. Implications for clinical practice are that clinicians discussing sexuality with their transgender patients should not define sexual activity too narrowly, and that sexual esteem might be a relevant factor in determining sexual behavior.