A PROSPECTIVE EXAMINATION OF BECKrsquoS COGNITIVE THEORY OF
DEPRESSION IN UNIVERSITY STUDENTS IN MAINLAND CHINA
by
DARREN STOLOW
A thesis submitted to the
Graduate School ndash New Brunswick
Rutgers The State University of New Jersey
In partial fulfillment of the requirements for the degree of
Master of Science
Graduate Program in Psychology
Written under the direction of
John R Z Abela PhD
And approved by
Robert Karlin PhD
Robert Woolfolk PhD
Benjamin Hankin PhD
________________________________
________________________________
________________________________
New Brunswick New Jersey
May 2011
ii
ABSTRACT OF THE THESIS
A Prospective Examination of Beckrsquos Cognitive Theory of Depression in University
Students in Mainland China
by DARREN STOLOW
Thesis Director
John R Z Abela PhD
The current multi-wave longitudinal study examined the applicability of Beckrsquos (1967
1983) cognitive theory of depression to university students in mainland China During an
initial assessment participants completed measures assessing dysfunctional attitudes and
depressiveanxious symptoms Participants subsequently completed measures assessing
negative events and depressiveanxious symptoms once a month for six months Results
provided support for the applicability of Beckrsquos cognitive theory to university students in
mainland China More specifically higher levels of dysfunctional attitudes were
associated with greater increases in depressive symptoms following the occurrence of
negative events At the same time contrary to findings obtained in Western samples
higher levels of dysfunctional attitudes were also associated with greater increases in
anxious symptoms following the occurrence of negative events These findings may
suggest that dysfunctional attitudes exhibit non-specificity as a predictor of depressive
symptoms in mainland China
iii
Table of Contents
Title Page i
Abstract ii
Table of Contents iii
List of Tables and Figures iv
Section I Introduction 1
Section II Methods 8
Section III Results 11
Section IV Discussion 16
Section V References 22
Section VI Tables and Figures 27
iv
List of Tables and Figures
Table 1 Demographic Variables 27
Table 2 Means Standard Deviations and Inter-correlations Between Time 1
Measures 28
Table 3 Dysfunctional Attitudes Predicting Within-Subject Fluctuations in
CES-D (Upper Section) and MASQ (Lower Section) Scores during the
Follow-up Interval 29
Figure 1 Predicted slope of the relationship between stress and depressive
symptoms (Left Panel) and anxious symptoms (Right Panel) as a function of
dysfunctional attitudes 30
1
INTRODUCTION
Depression in China
The results of epidemiological studies suggest that the prevalence rate of depression in
China has been rising in recent decades More specifically whereas research conducted
during the 1980s estimated the point-prevalence rate of depression to be 03 (Xiang
1986) research conducted during the 1990s estimated it to be 14 (Murray amp Lopez
1996) More recently findings from a comprehensive epidemiological survey
conducted within China yielded a one-month prevalence rate of depression of 60
(Phillips et al 2009) In response to this upward trend depression has become a major
public health concern in China increasingly drawing the attention of both Chinese and
Western mental health researchers One demographic group within Chinarsquos population that
has received considerable attention is Chinarsquos university student population Although no
formal epidemiological studies have been conducted examining the prevalence rate of
depression among university students recent reports in the Chinese media highlight the
growing problem of depression among this demographic (eg Qiang 2006) Most distressing
in these reports is the strong association noted between depression and suicidal behavior
Estimated mortality rates reveal that suicide is the leading cause of death among
Chinese young adults between the ages of 15 and 34 (Philipps Li amp Zhang 2002)
Despite these findings however little research has examined models of the etiology of
depression in university students in mainland China Furthermore of the studies
conducted the majority are cross-sectional providing little insight into causal
mechanisms
2
Cognitive Vulnerability-Stress Models of Depression
One theoretical perspective that has proven useful in understanding the
development of depression in Western young adults is the cognitive vulnerability-stress
perspective (Abela amp Hankin 2008) Cognitive theories of depression define
vulnerability as an internal and stable feature of an individual that predisposes himher
to develop depression following the occurrence of negative events (Ingram Miranda amp
Segal 1998) Cognitive models are fundamentally diathesis-stress models in that they
posit that depression is produced by the interaction between cognitive vulnerability
factors (the diatheses) and certain environmental conditions (the stressors) that trigger
such diatheses into operation (Ingram et al 1998) Evidence suggests that under
ordinary conditions individuals vulnerable to depression are indistinguishable from the
general population Only when confronted with certain stressors do differences between
vulnerable and non-vulnerable individuals emerge (Ingram et al 1998 Ingram amp
Luxton 2005 Monroe amp Simons 1991) For individuals who possess cognitive
vulnerability factors negative events trigger a pattern of negatively biased self-referent
information processing that initiates a downward spiral into depression Non-vulnerable
individuals react to such events with an appropriate level of distress and depressive
affect but do not spiral downwards into depression
Beckrsquos Cognitive Theory of Depression
One prominent cognitive vulnerably-stress model of depression is Beckrsquos (1967
1983) cognitive theory Central to Beckrsquos cognitive theory is the construct of schema
Beck defines schema as stored bodies of knowledge (ie mental representations of the
3
self and prior experiences) that are relatively enduring characteristics of a persons
cognitive organization When an individual is confronted with a situation the schema
most relevant to the situation is activated Schema activation subsequently influences
how the person perceives encodes and retrieves information regarding the situation
Beck proposed that certain individuals posses depressogenic schema that confer
vulnerability to depression Beck (1983) hypothesizes that depressogenic schemata are
typically organized as sets of dysfunctional attitudes such as ldquoI am nothing if a person I
love doesnrsquot like merdquo or ldquoIf I fail at my work then I am a failure as a personrdquo Among
individuals who possess depressogenic schema the occurrence of negative events
triggers a pattern of negatively biased self-referent information processing
characterized by negative errors in thinking (eg negatively skewed interpretations of
negative life events such as overgeneralization and catastrophizing) Negative errors in
thinking increase the likelihood that the individual will develop the negative cognitive
triad comprising three types of depressogenic thought patterns (1) negative views of
the self (eg the belief that one is deficient inadequate or unworthy) (2) negative
views of the world (eg construing life experiences in terms of themes of defeat or
disparagement) and (3) negative views of the future (eg the expectation that ones
difficulties will persist into the future and there is nothing one can do to change this)
According to the theory the development of the negative cognitive triad triggers the
onset of depressive symptoms
Research Support for Beckrsquos Cognitive Model of Depression
Prospective studies using Western university student samples have provided
support for Beckrsquos (1967 1983) cognitive theory of depression More specifically
4
several studies have found that dysfunctional attitudes interact with the occurrence of
negative life events to predict increases in depressive symptoms (Hankin Abramson
Miller Haeffel 2004 Hankin Fraley amp Abela 2005 Joiner Metalsky Lew amp Klocek
1999 Klocek Oliver amp Ross 1997 Brown Hammen Craske and Wickens 1995) as
well as a greater likelihood of developing a depressive episode (Hankin et al 2004) In
addition individuals possessing a high level of dysfunctional attitudes have been found
to be more likely to report a past history of depressive episodes (Alloy et al 2000) and
to experience future depressive episodes (Alloy et al 2006 Hankin et al 2004) than
individuals without such a vulnerability
Far less research has examined the applicability of Beckrsquos (1983 1967)
cognitive theory to Chinese samples Preliminary cross-sectional research however
has yielded findings consistent with the theoriesrsquo hypotheses For example Xu Li and
Wang (2007) found that psychiatric patients diagnosed with major depressive disorder
showed significantly higher levels of dysfunctional attitudes than did non-depressed
controls Simiarly Bian Yang and Li (2007) reported higher levels of dysfunctional
attitudes in remitted depressives as compared to normal controls Last several studies
conducted with Chinese university students have found higher levels of dysfunctional
attitudes ndash particularly those centered on themes of perfectionism - to be associated
with higher levels of psychiatric symptoms (eg Yang amp Zhang 2004 Yang 2007
Fang Qian Luo amp Zi 2009)
5
Goals of the current study
The primary goal of the current study was to examine the applicability of
Beckrsquos (1967 1983) cognitive theory of depression to university students in mainland
China The procedure involved an initial assessment during which students completed
measures assessing dysfunctional attitudes and symptoms of depression The procedure
also involved a series of six follow-up assessments occurring once a month for six
months during which symptoms of depression and the occurrence of negative events
were assessed The use of a multi-wave longitudinal design allowed us to take an
idiographic approach towards examining the diathesis-stress hypotheses of Beckrsquos
(1967 1983) theory More specifically we examined whether the slope of the
relationship between negative events and symptoms of depression within participants
varied across participants as a function of level of dysfunctional attitudes In line with
the vulnerability-stress hypothesis of Beckrsquos (1967 1983) cognitive theory we
hypothesized that higher levels of dysfunctional attitudes would be associated with
greater increases in depressive symptoms following the occurrence of negative events
The second objective of the current study was to examine the specificity of
dysfunctional attitudes as a predictor of depressive symptoms Beckrsquos (1967 1983)
theory posits that dysfunctional attitudes predict the development of depressive
symptoms but not symptoms of other forms of psychopathology Prospective studies
using Western university student (Alloy et al 2000 2006 Hankin Abramson Miller
amp Haeffel 2004) and adolescent samples (Hankin Wetter Cheely amp Oppenheimer
2008) have provided support for the specificity hypothesis of the theory More
specifically dysfunctional attitudes have been found to interact with negative events to
6
predict increases in depressive symptoms but not symptoms of anxiety or other
disorders in both university student (Hankin et al 2004) and adolescent samples
(Hankin et al 2008) Similarly although university students possessing a high level of
dysfunctional attitudes have been found to be more likely than other university students
to report a past history of depressive episodes (Alloy et al 2000) and to experience
future depressive episodes (Alloy et al 2006) they have not been found to differ from
their low-risk counterparts in terms of past history or future occurrence of other
psychological disorders (Alloy et al 2000 2006)
With respect to the current study it is possible that differences may emerge
between Chinese and Western samples in terms of the types of symptoms predicted by
dysfunctional attitudes More specifically cultural psychopathologists have proposed
that cultural factors shape the phenomenology of psychiatric symptoms as well as the
conceptualization and classification of disorders (Kleinman 2004 Mezzich et al
1999) As such the experience of psychopathology may exhibit unique features in
different cultures with diagnostic categories developed in one cultural context not being
valid in another (Kleinman 1977 1996) Neuresthenia known in China as shenjing
shuairuo (SJSR) is a diagnostic entity characterized by (1) physical and mental
weakness and fatigability (2) sleep disturbances (3) irritability and worry (4)
excitability (5) nervous pain and (6) memory difficulty (Taylor 2001) Historically
SJSR was a Western disease concept that subsequently evolved to become a widely
utilized diagnostic entity within China (Lee amp Wong 1995) Some cultural
psychopathologists have posited that SJSR represents a somatized form of depression
This claim however has been met with significant controversy (eg Lee 1997
7
Parker Gladstone amp Chee 2001 Xu JM 1987 Xu YX 1994 Zhang 1995)
Critics dispute the notion that Chinese psychiatric patients are ldquosomatizersrdquo who
manifest few or no emotional symptoms and who attribute distress to physical causes
Rather they argue that SJSR gained widespread acceptance in China as it was a non-
stigmatizing diagnosis that allowed individuals experiencing psychosocial distress to
seek help during a time in which traditional cultural beliefs and political influences led
to severe sanction and stigmatization of individuals suffering from mental illnesses
(Lee 1998 1999 Phillips 1998 Shixie 1989) At the same time other Chinese
researchers and clinicians have continued to defend neurasthenia as both a valid
diagnostic category and a clinically useful means of communicating with patients (Rin
amp Huang 1989 Yan 1989 Young 1989) Due to continued debate on this topic it is
essential that researchers examining models of vulnerability to depression within China
assess multiple symptom outcomes as the types of symptoms predicted by vulnerability
factors may vary as a function of cultural context Hence in the current study we also
assessed levels of anxious symptoms to provide a test of the specificity hypothesis of
Beckrsquos (1967 1983) cognitive theory
In order to provide a powerful examination of our hypotheses concerning (1) the
applicability of the diathesis-stress component of Beckrsquos (1967 1983) cognitive theory
to Chinese university students and (2) the specificity of dysfunctional attitudes as
predictors of depressive as opposed to anxious symptoms participantsrsquo scores on the
neuroticism subscale of the Five-factor Inventory (FFI-N) were included as a control
variable in all analyses Several critical reviews of the literature examining theories of
cognitive vulnerability to depression (eg Barnett amp Gotlib 1998 Coyne amp Whiffen
8
1995) have argued that cognitive vulnerabilities to depression such as that featured in
Beckrsquos cognitive theory may be equivalent to or reducible to trait neuroticism and thus
may not confer independent risk for depression In response to such claims a recent
study conducted with university students examining the degree of factorial
independence versus overlap between trait neuroticism and dysfunctional attitudes has
shown them to be distinct constructs each loading onto separate factors (Hankin et al
2007) At the same time however there remains a need to examine whether
dysfunctional attitudes and trait neuroticism represent unique risk factors for
depression particularly in young adults in China Hence in the current study
participantsrsquo scores on the neuroticism subscale of the Five-factor Inventory (FFI-N)
were included as a control variable in order to account for any of the variance in
fluctuations in depressive (and anxious) symptoms that may be shared between
dysfunctional attitudes and trait neuroticism thereby isolating and highlighting their
unique predictive effects
METHOD
Participants
Participants included 662 university students (aged 19-21) from Changsha ndash an
industrial city in the province of Hunan with a population of approximately 6000000
In terms of the annual gross domestic product Hunan ranks 23rd
(10336 RMB) out of
the 34 provinces in China placing it well below the national provincial average (micro =
29719 RMB SD = 47462 RMB National Bureau of Statistics of China 2006)
Demographic variables for the sample are presented in Table 1
9
Procedure
Consent forms were distributed to all students in participating classes Consent
rates were greater than 95 in all the classes After consent forms were collected
researchers returned to the school to meet with participating students Written consent
was obtained from each participant at the beginning of the initial assessment During
the initial assessment students completed a demographics form and each of the
following questionnaires (1) Center for Epidemiological Studies Depression Scale
(CES-D Radloff 1977) (2) Mood and Anxiety Symptom Questionnaire (MASQ
Clark amp Watson 1991) (3) Dysfunctional Attitudes Scale (DAS Weissman amp Beck
1978) and (4) NEO Five Factor Inventory- Neuroticism Subscale (FFI-N Costa amp
McCrae 1992) Once a month for the subsequent six-months researchers returned to
the school and met with participating students to conduct follow-up assessments At
each of these follow-up assessments students were asked to complete each of the
following questionnaires (1) CES-D (2) MASQ and (3) the General Academic
Social Hassles Scale for Students (GASHSS Blankstein amp Flett 1993)
Measures
The Chinese versions of all self-report measures were developed using the
back-translation method Original English versions were translated into Chinese by a
bilingual translator from the Psychology department at Second Xiangya Medical
College of Central South University Hunan Translated Chinese versions were then
back-translated into English by another bilingual translator from the Psychology
department at McGill University Quebec Original versions were then compared with
the back-translation If inconsistencies were found in the back-translation translators
10
worked together to make corrections to the final Chinese versions until all final
versions were agreed upon No items from any of the measures were removed or
significantly altered during the translation process
Depressive Symptoms Center for Epidemiological Studies Depression Scale
(CES-D Radloff 1977) The CES-D is a 20-item self-report measure designed to
assess depressive symptoms in the general population For each item participants are
asked to indicate how often they experienced the particular symptom over the last
week Responses range from 1 (eg rarely or none of the time) to 4 (eg most or all of
the time) Scores range from 20-80 with higher score indicating higher levels of
depressive symptoms In the current study the CES-D exhibited high internal
consistency with Cronbachrsquos alpha values ranging from 90 to 94 (micro = 2918 SD =
814) over the 7 time points
Anxious Symptoms Mood and Anxiety Symptom Questionnaire (MASQ
Watson amp Clark 1991) The MASQ is a 62-item questionnaire designed to assess both
specific and nonspecific depressive and anxious symptoms For each item participants
are asked to rate on a scale of 1 to 5 the extent to which they have felt this way ldquoduring
the past 24 hoursrdquo Within the current study we utilized the anxious symptoms (11
items) and anxious arousal (17 items) subscales which together provide an index of
overall anxious symptoms Higher scores on each subscale reflect greater levels of
anxious symptoms In the current study the MASQ exhibited high internal consistency
with Cronbachrsquos alpha values ranging from 90 to 95 (micro = 3847 SD = 1117) over the
7 time points
11
Dysfunctional Attitudes Dysfunctional Attitudes Scale (DAS Weissman amp
Beck 1978) The DAS (Form A) is a 40-item questionnaire designed to measure the
cognitive vulnerability factor featured in Beckrsquos cognitive theory Examples of items
include ldquoIf I do not do well all the time people will not respect merdquo ldquoIf a person asks
for help it is a sign of weaknessrdquo and ldquoMy value as a person depends greatly on what
others think of merdquo Items are rated on a 7-point Likert scale ranging from 1 (totally
disagree) to 7 (totally agree) providing a range of scores from 40 to 280 with higher
scores reflecting more dysfunctional attitudes In the current study the DAS exhibited
high internal consistency with Cronbachrsquos alphas of 89 and 88 obtained for the first
and second administrations respectively In addition a test-retest reliability coefficient
of 72 was obtained indicating strong stability over time
Neuroticism NEO Five Factor Inventory - Neuroticism Subscale (FFI-N
Costa amp McCrae 1992) The FFI-N is a 12- item self-report measure that assesses
neuroticism Examples of questions include I often feel inferior to others I am
seldom sad or depressed and Sometimes I feel completely worthless Items are rated
on a 5-point Likert scale ranging from 0 (strongly disagree) to 4 (strongly agree)
providing scores ranging from 0 to 48 with higher scores indicating higher levels of
neuroticism The NEO-FFI-N has proven reliable across different cultural samples and
item pools (Costa amp McCrae 1992) In the current study Cronbachs alpha was 81
indicating strong internal consistency
Negative Life Events General Academic Social Hassles Scale for Students
(GASHSS Blankstein amp Flett 1993) Participants completed a 30-item abbreviated
version of the GASHSS The measure is comprised of items assessing general hassles
12
(8 items) academic hassles (10 items) and social hassles (12 items) For each item
participants are asked to rate how persistent the given hassle was (ie its frequency and
duration) over the last 30 days (0 = no hassle not at all persistent to 6 = extremely
persistent hassle high frequency andor duration)
13
RESULTS
Descriptive Data
Means standard deviations and inter-correlations between Time 1 measures are
presented in Table 2
Prospective Diathesis-Stress Analyses - Depression
Multilevel modeling was used to test our hypothesis that higher levels of dysfunctional
attitudes would be associated with greater increases in depressive symptoms following
increases in stress Analyses were carried out using the SAS (version 81) MIXED
procedure and maximum likelihood estimation Our dependent variable was within-
subject fluctuations in CES-D scores during the follow-up interval (DEPRESSION)
Our primary predictors of DEPRESSION were DAS scores (DYSFUNCTIONAL
ATTITUDES) and fluctuations in GASHSS scores during the follow-up interval
(STRESS) As DYSFUNCTIONAL ATTITUDES is a between-subject predictor DAS
scores were standardized prior to analyses As STRESS is a within-subject predictor
STRESS reflects upward or downward fluctuations in an individualrsquos level of stress
compared to hisher mean level of stress
When fitting hierarchical linear models one must specify appropriate mean and
covariance structures Mean structures refer to the various fixed and random effect
components that can be included in the model Covariance structures refer to alternative
methods of specifying the pattern of covariance between observations taken from the
same subject at different time points It is important to note that mean and covariance
structures are not independent of one another Rather an appropriate covariance
structure is essential in order to obtain valid inferences for the parameters in the mean
14
structure Overparametrization of the covariance structure can lead to inefficient
estimation and poor assessment of standard errors (Altham 1984) On the other hand
too much restriction of the covariance structure can lead to invalid inferences when the
assumed structure does not hold (Altham 1984)
In our first set of analyses we were interested in examining the effects of
DYSFUNCTIONAL ATTITUDES STRESS and the DYSFUNCTIONAL
ATTITUDES STRESS interaction on participantrsquos CES-D scores during the follow-
up interval Consequently in line with Diggle Liang and Zegers (1994)
recommendation that one use a ldquosaturatedrdquo model for the mean structure while
searching for an appropriate covariance structure we chose a mean structure that
included DYSFUNCTIONAL ATTITUDES STRESS and the DYSFUNCTIONAL
ATTITUDES STRESS interaction Four additional effects were also included in this
mean structure First as different individuals report different levels of depressive
symptoms when at their own average level of stress a random effect for intercept was
included in the model Second given that STRESS is a within-subject predictor whose
effect is expected to vary from participant to participant a random effect for slope was
included in the model Third in order to control for individual differences in baseline
levels of depressive symptoms Time 1 CES-D scores were included in the model
Fourth in order to examine whether DYSFUNCTIONAL ATTITUDES represent a
vulnerability factor independent of neuroticism participantsrsquo FFI-N scores were
entered in the model
Commonly used covariance structures in studies in which multiple responses
are obtained from the same individual over time (and consequently within-subject
15
residuals over time are likely to be correlated) include compound symmetry first-order
autoregressive heterogeneous autoregressive and banded Toeplitz In order to select
one of these covariance structures for our analyses we fitted models using each
structure and chose the ldquobestrdquo fit based on Akaike information criterion (AIC and
AICC) and Schwarz Bayesian criterion (BIC) In all cases the best fit for our data was
a first-order heterogeneous autoregressive structure (ARH [1]) After choosing the
appropriate covariance structure we next examined the random-effects component of
our model
With respect to random effects the ARH [1] parameter (r = 31 plt001)
RE_INTERCEPT (plt001) and RE_SLOPE (plt001) were each significant and thus
were retained in the model The final results with respect to the fixed-effects
component of the model are presented in the upper section of Table 3 Of primary
importance the DYSFUNCTIONAL ATTITUDES STRESS interaction was a
significant predictor of fluctuations in depressive symptoms during the follow-up
interval In order to examine the form of this interaction the model summarized in the
upper section of Table 3 was used to calculate predicted CES-D scores for individuals
exhibiting either high or low levels of dysfunctional attitudes (plus or minus 15 SD)
who are experiencing either high or low levels of stress in comparison to their own
average level of stress (plus or minus 15 times mean within-subject SD) The results of
such calculations are presented in the left panel of Figure 1
Analyses were conducted for each DYSFUNCTIONAL ATTITUDES
condition examining whether the slope of the relationship between stress and
depressive symptoms significantly differed from 0 Analyses indicated that both
16
individuals exhibiting high (t(2459) = 862 p lt 0001) and low (t(2459) = 347 p lt
0001) levels of dysfunctional attitudes reported significantly higher levels of
depressive symptoms when experiencing high levels of stress than when experiencing
low levels of stress Planned comparisons of the slopes of the relationship between
stress and depressive symptoms however revealed that the slope was significantly
greater in individuals exhibiting high levels of dysfunctional attitudes (slope = 013)
than in individuals exhibiting low levels of dysfunctional attitudes (slope = 005
t(2459) = 328 p = 0001)
Prospective Diathesis-Stress Analyses - Anxiety
The same data-analytic approach as described above was used to examine
whether higher levels of dysfunctional attitudes would be associated with greater
increases in anxious symptoms following increases in stress Again in order to examine
whether DYSFUNCTIONAL ATTITUDES represent a vulnerability factor
independent of neuroticism participantsrsquo FFI-N scores were entered in the model
With respect to random effects the ARH[1] parameter (r = 23 p lt 001)
RE_INTERCEPT (plt001) and RE_SLOPE (plt001) were each significant and thus
were retained in the model The final results with respect to the fixed-effects
component of the model are presented in the lower section of Table 3 Of primary
importance the DYSFUNCTIONAL ATTITUDES STRESS interaction was a
significant predictor of within-subject fluctuations in anxious symptoms during the
follow-up interval In order to examine the form of this interaction the model
summarized in the lower section of Table 3 was used to calculate predicted MASQ
scores for individuals exhibiting either high or low levels of dysfunctional attitudes
17
(plus or minus 15 SD) who are experiencing either high or low levels of stress in
comparison to their own average level of stress (plus or minus 15 times mean within-
subject SD) The results of such calculations are presented on the right panel of in
Figure 1
Analyses were conducted for each DYSFUNCTIONAL ATTITUDES
condition examining whether the slope of the relationship between stress and anxious
symptoms significantly differed from 0 Analyses indicated that both individuals
exhibiting high (t(2470) = 768 p lt 0001) and low (t(2470) = 337 p lt 0001) levels of
dysfunctional attitudes reported higher levels of anxious symptoms when experiencing
high levels of stress than when experiencing low levels of stress Planned comparisons
of the slopes of the relationship between stress and anxious symptoms however
revealed that the slope was significantly greater in individuals exhibiting high levels of
dysfunctional attitudes (slope = 009) than in individuals exhibiting low levels of
dysfunctional attitudes (slope = 003 t(2470) = 278 p lt 001)
Additional Analyses
Given that the DYSFUNCTIONAL ATTITUDES STRESS interaction
prospectively predicted both symptoms of depression and anxiety two additional
analyses were conducted in order to examine (1) whether the DYSFUNCTIONAL
ATTITUDES STRESS interaction continued to be a significant predictor of within-
subject fluctuations in depressive symptoms after controlling for within-subject
fluctuations in anxious symptoms and (2) whether the DYSFUNCTIONAL
ATTITUDES STRESS interaction continued to predict within-subject fluctuations in
anxious symptoms after controlling for within-subject fluctuations in depressive
18
symptoms Such analyses allowed us to examine whether the above mentioned pattern
of findings may have been due to the high correlation observed in the current study
between depressive and anxious symptoms
Analyses were conducted in the same manner as described above with the
exception that an additional within-subject variable (ie DEPRESSION or ANXIETY)
was included in each model in order to control for within-subject fluctuations in the
alternate symptom With respect to the prediction of depressive symptoms the
DYSFUNCTIONAL ATTITUDES STRESS interaction remained a significant
predictor after controlling for within-subject fluctuations in anxious symptoms (β =
001 SE = 000 F = 410 p lt 05) With respect to the prediction of anxious
symptoms however the DYSFUNCTIONAL ATTITUDES STRESS interaction
was no longer a significant predictor after controlling for within-subject fluctuations in
depressive symptoms (β = 001 SE = 000 F = 148 p = 22)
DISCUSSION
The results of the current study provide support for the cross-cultural
applicability of Beckrsquos (1967 1983) cognitive theory to university students in Hunan
China More specifically consistent with hypotheses and with results obtained from
past research examining Beckrsquos cognitive theory in Western samples of university
students (Hankin et al 2004 Hankin et al 2005 Joiner et al 1999 Klocek et al
1997 Brown et al 1995) higher levels of dysfunctional attitudes were associated with
greater increases in depressive symptoms following increases in negative event
frequency during the six-month follow-up interval Given the considerable differences
between the current sample and Western samples in terms of demographic
19
characteristics and cultural factors such a finding strongly attests to the robustness of
Beckrsquos cognitive theory Moreover integrating the current findings with those obtained
in research examining Beckrsquos theory in other non-Western samples suggests that
Beckrsquos theory may represent a powerful explanatory model of the development of
depressive symptoms among individuals from diverse cultural settings For example
consistent with the theory higher levels of dysfunctional attitudes have been shown to
be associated with higher levels of depressive symptoms in Japanese (Tanaka et al
2006) Puerto-Rican (Bonilla Bernal Santos amp Santos 2003) Turkish (Sahin amp Sahin
1992) Norwegian (Chioqueta amp Stiles 2004) Singaporean (Oei Goh amp Kwon 1996)
and Swedish (Ohrt amp Thorell 1998) adult samples In addition it is important to note
that the current findings expand upon past correlational research examining the
association between dysfunctional attitudes and depression in Chinese samples through
the use of a multi-wave longitudinal design
When examining the specificity of dysfunctional attitudes as a predictor of
depressive symptoms the current study did not obtain support for specificity More
specifically contrary to the specificity hypothesis of Beckrsquos cognitive theory and to
results obtained in Western samples of university students (Alloy et al 2000 2006
Hankin et al 2004) higher levels of dysfunctional attitudes were associated with
greater increases in both depressive and anxious symptoms following increases in
negative event frequency There are two alternative ways of interpreting the non-
specificity finding observed in the current study First it is possible that the types of
thoughts individuals possessing high levels of dysfunctional attitudes experience
following negative events varies as a function of cultural context In other words in
20
Western samples such individuals may primarily experience the types of cognitions
that are associated with the development of depressive symptoms (ie appraisals of
personal loss and failure) In contrast in Chinese samples individuals possessing high
levels of dysfunctional attitudes may experience a wider array of cognitions some of
which are associated with the development of depressive symptoms and some of which
are associated with the development of anxious symptoms (ie evaluations of
impending threat or danger) Such an explanation would be consistent with Beckrsquos
cognitive content-specificity hypothesis (Clark amp Beck 1999) which posits that each
affective state and psychological disorder has a specific cognitive profile Second it is
possible that the types of symptoms individuals possessing high levels of dysfunctional
attitudes experience following negative events varies as a function of cultural context
More specifically it may be that dysfunctional attitudes specifically predict symptoms
of depression in both samples except that in Western samples depression manifests in
pure depressive symptoms whereas in Chinese samples depression manifests as a
combination of depressive and anxious symptoms Such an explanation would be
consistent with cultural psychopathologistsrsquo hypotheses that cultural factors shape the
phenomenology of psychiatric symptoms (Kleinman 2004 Mezzich et al 1999)
Moreover dysfunctional attitudes predicting a combination of depressive and anxious
symptoms in Chinese samples would be consistent with the construct of neurasthenia -
a construct hypothesized by some to represent a somatized form of depression that is
still widely seen within China (Lee amp Wong 1995)
Interesting in this regard and perhaps speaking to the primacy of depressive
symptoms in the current findings analyses indicated that the DYSFUNCTIONAL
21
ATTITUDES times STRESS interaction no longer predicted anxious symptoms after
controlling for depressive symptoms The reverse however was not true as the
DYSFUNCTIONAL ATTITUDES times STRESS interaction continued to predict
depressive symptoms after controlling for anxious symptoms
It is important to note that the current study employed a particularly
conservative approach to analyses in that we examined the effects of dysfunctional
attitudes on depressive and anxious symptoms after controlling for the effect of
neuroticism on such symptoms Providing particularly powerful support for Beckrsquos
(1967 1983) cognitive theory across analyses dysfunctional attitudes predicted levels
of depressive andor anxious symptoms experienced during the six month follow-up
interval independent of the effect of neuroticism Thus contrary to past critical reviews
of the cognitive literature (Barnett amp Gotlib 1998 Coyne amp Whiffen 1995) and
consistent with past findings (Hankin et al 2007) the current results indicate that
cognitive vulnerabilities to depression such as dysfunctional attitudes are not reducible
to trait neuroticism but rather represent factors that confer independent risk for
depression
Limitations and Future Directions
Several limitations of the current study should be noted First self-report
measures were used to assess depressive and anxious symptoms Although the CES-D
and MASQ both possess high degrees of reliability and validity it is difficult to draw
conclusions about clinically diagnosed depression or anxiety based on self-report
questionnaires Second self-report measures were used to assess stress Although
measures of stress that require participants only to indicate whether or not an event
22
occurred are less likely to be influenced by informant bias than those that ask
participants to rate the subjective impact of each event more sophisticated methods of
analysis such as interviewing procedures that assess contextual threat may provide
better assessments of stress Third the measures of dysfunctional attitudes stress and
depressive and anxious symptoms used in the current study were each Western-
developed Future research should examine these hypotheses using indigenous
measures in addition to Western-developed measures in order to assess possible
similarities andor differences in patterns of findings Fourth the current study only
examined depression and anxiety as symptom outcomes Future research conducted
within China should examine a wider array of symptom outcomes such as
somatization physical complaints and externalizing behaviors in order to provide a
more thorough and culturally sensitive test of the specificity hypotheses of Beckrsquos
cognitive model Fifth the current study examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese undergraduate students and thus the extent to which
our findings may be generalized to other demographics within Chinarsquos population is
unclear Last the current study broadly examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese university students Future research should examine
the constructs and processes posited by this model in greater detail in order to develop a
deeper understanding of how they may be uniquely molded by socio-cultural factors
Such research would benefit from examining the specific types of stressors experienced
by Chinese university students as they may vary as a function of socio-cultural factors
from those experienced by Western undergraduates For example severe pressure to
succeed academically in order to secure access to a limited number of post-
23
undergraduate educational opportunities - one of the few paths towards upward
mobility available to Chinese students seeking secure and gainful employment in what
has increasingly become a very highly competitive job market - may represent a
particularly salient stressor for the development of depressive symptoms among this
population (Qiang 2006)
In conclusion the results from the current study provide support for the
applicability of Beckrsquos cognitive theory to university students in mainland China More
specifically consistent with findings obtained in the West results indicate that
dysfunctional attitudes confer vulnerability to the development of depressive symptoms
following the occurrence of negative events in Chinese university students At the same
time however the current findings suggest cultural variation in the profile of
symptoms which emerge following the occurrence of negative events in cognitively
vulnerable individuals in Western and Chinese samples Specifically whereas in the
West dysfunctional attitudes have been shown to confer vulnerability to depressive
symptoms in Chinese university students dysfunctional attitudes appear to confer
vulnerability to a combined depressive and anxious symptom profile Future research
using more sophisticated assessments of stress and depressive symptoms more diverse
samples and symptom outcome measures and indigenously-developed measures is
likely to enhance our understanding of the cognitive and environmental mechanisms
underlying the development of depression in Chinese university students Discovering
that cognitive theories of vulnerability to depression extend to university students in
China highlights the potential role for cognitive-behavioral depression prevention and
treatment interventions in stemming the tide of distress experienced by this population
24
REFERENCES
Abela J R Z amp Hankin B L (2008) Cognitive vulnerability to depression in
children and adolescents A developmental psychopathology perspective In J
R Z Abela and B L Hankin (Eds) Handbook of child and adolescent
depression (pp 35-78) New York The Guilford Press
Alloy L B Abramson L Y Hogan M E Whitehouse W G Rose D T
Robinson MS Kim R S amp Lapkin J B (2000) The Temple-Wisconsin
cognitive vulnerability to depression project Lifetime history of axis-I
psychopathology in individuals at high and low cognitive risk for depression
Journal of Abnormal Psychology 109 403-418
Alloy L B Abramson L Y Whitehouse W G Hogan M E Panzarella C amp
Rose D T (2006) Prospective incidence of first onsets and recurrences of
depression in individuals at high and low cognitive risk for depression Journal
of Abnormal Psychology 115 145ndash156
Altham P M E (1984) Improving the precision of estimation by fitting a model
Journal of the Royal Statistical Society Series B 46 11
Barnett PA amp Gotlib I H (1988) Psychosocial functioning and depression
Distinguishing among antecedents concomitants and consequences
Psychological Bulletin 104 97-126
Beck AT (1967) Depression Clinical experimental and theoretical aspects New
York Harper amp Row
Beck AT (1983) Cognitive therapy of depression New perspectives In PJ Clayton
amp JE Barrett (Eds) Treatment of depression Old controversies and new
approaches New York Raven Press
Bian Q Yang K amp Li C (2007) Dysfunctional attitudes of patients with depression
or bipolar disorder Chinese Mental Health Journal 21 759-761
Blankstein K R amp Flett G L (1993) Development of the General Academic and
Social Hassles Scales for Students Unpublished manuscript
Bonilla J Bernal G Santos A amp Santos D (2003) A revised Spanish version of
the Beck Depression InventoryPsychometric properties with a Puerto Rican
sample of college students Journal of Clinical Psychology 60 119-130
Brown G P Hammen C L Craske M G amp Wickens T D (1995) Dimensions of
dysfunctional attitudes as vulnerabilities to depressive symptoms Journal of
Abnormal Psychology 104 431-435
25
Chioqueta A P amp Stiles T C (2004) Psychometric properties of the Norweigian
version of the Dysfunctional Attitude Scale (Form A) Cognitive Behaviour
Therapy 33 83-86
Clark DA amp Beck AT (1999) Cognitive theory and therapy of depression New
York John Wiley amp Sons Inc
Clark L A amp Watson D (1991) Tripartite model of anxiety and depression
Psychometric evidence and taxonomic implications Journal of Abnormal
Psychology 100 316ndash336
Costa P T amp McCrae R R (1992) NEO PI-R Professional manual Revised NEO
personality inventory NEO PR-R and NEO five-factor inventory NEO-RRI
Odessa FL Psychological Assessment Resources
Coyne J C amp Whiffen V E (1995) Issues in personality as diathesis for depression
The case of sociotropy-dependency and autonomy-self-criticism Psychological
Bulletin 118 358-378
Fang X Qian M Luo S amp Zi F (2009) A correlational study on college students
perfectionism parental rearing patterns and mental health Chinese Mental
Health Journal 23 56-59
Hankin B L Abramson L Y Miller N amp Haeffel G (2004) Cognitive
vulnerability-stress theories of depression Examining affective specificity in
the prediction of depression versus anxiety in three prospective studies
Cognitive Therapy and Research 28 309ndash345
Hankin BL Fraley RC amp Abela JRZ (2005) Daily depression and cognitions
about stress Evidence for a traitlike depressogenic cognitive style and the
prediction of depressive symptoms in a prospective daily diary study Journal of
Personality and Social Psychology 88 673-685
Hankin B L Lakdawalla Z Carter I L Abela J R Z amp Adams P (2007) Are
neuroticism cognitive vulnerabilities and self-esteem overlapping or distinct
risks for depression Evidence from confirmatory factor analyses Journal of
Social amp Clinical Psychology 26 29-63
Hankin B L Wetter E Cheely C amp Oppenheimer C W (2008) Becks cognitive
theory of depression in adolescence Specific prediction of depressive
symptoms and reciprocal influences in a multi-wave prospective study
International Journal of Cognitive Therapy 1 313-332
Ingram R E Miranda J amp Segal Z V (1998) Cognitive Vulnerability to
Depression New York NY Guilford Press
26
Ingram R E amp Luxton DD (2005) Vulnerability-stress models In BL Hankin amp
JRZ Abela (Eds) Development of psychopathology A vulnerability-stress
perspective (pp 32-46) Thousand Oaks CA Sage
Joiner T E Metalsky G I Lew A amp Klocek J (1999) Testing the causal
mediation component of Becks theory of depression Evidence for specific
mediation Cognitive Therapy and Research 23 401-412
Kleinman A (2004) Culture and depression New England Journal of Medicine 351
951-953
Kleinman A (1977) Depression somatization and the new cross-cultural psychiatry
Social Science and Medicine 11 3-10
Kleinman A (1996) How is culture important for DSM-IV In J E Mezzich A
Kleinmam H Fabrega Jr amp L Delores (Eds)Culture and psychiatric
diagnosis A DSM-IV perspective (pp 15-25) Washington DC US American
Psychiatric Association
Klocek J W Oliver J M amp Ross M J (1997) The role of dysfunctional attitudes
negative life events and social support in the prediction of depressive
dysphoria A prospective longitudinal study Social Behavior and Personality
25 23-136
Lee S (1997) A Chinese perspective on somatoform disorders Journal of
Psychosomatic Disorders 43 115-119
Lee S (1998) Estranged bodies simulated harmony and misplaced cultures
Neurasthenia in contemporary Chinese society Psychosomatic Medicine 60
448ndash457
Lee S (1999) Diagnosis postponed Shenjing shuairo and the transformation of
psychiatry in post-Mao China Culture Medicine and Psychiatry 23 349ndash380
Lee S amp Wong K C (1995) Rethinking neurasthenia the illness concepts of
shenjing shuairuo among Chinese undergraduates in Honk Kong Culture
Medicine and Psychiatry 19 91ndash111
Lee S Tsang A Huang YQ He YL Liu ZR Zhang MY Shen YC amp
Kessler RC (2009) The epidemiology of depression in metropolitan China
Psychological Medicine 39 735-747
Mezzich J E Kirmayer L J Kleinman A Fabrega Jr H Parron D L Good B
J Lin K amp Manson S M (1999) The place of culture in DSM-IV Journal
of Nervous and Mental Disease 187 457-464
27
Monroe S M amp Simons A D (1991) Diathesisndashstress theories in the context of life
stress research Implications for the depressive disorders Psychological
Bulletin 110 406ndash425
Murray C J L amp Lopez A D (1996) The global burden of disease Cambridge
Harvard University Press
National Bureau of Statistics of China (2006) The China 2005 statistical yearbook
China Statistics Press Beijing PR China
Oei T P S Goh Y Kwon S M(1996) A cross-cultural study of the integrated
cognitive model of depression Current Psychology of Cognition 15 265-281
Ohrt T amp Thorell L (1998) Dysfunctional Attitude Scale (DAS) Psychometrics and
norms of the Swedish version Scandinavian Journal of Behaviour Therapy 27
105-113
Parker G Gladstone G Chee KT (2001) Depression in the planetrsquos largest ethnic
group The Chinese American Journal of Psychiatry 158 857-864
Phillips M R Zhang J Shi Q Song Z Ding Z Pang S Li X Zhang Y amp
Wang Z (2009) Prevalence treatment and associated disability of mental
disorders in four provinces in China during 2001ndash05 an epidemiological
survey The Lancet 373 2041-2053
Phillips M R Li X amp Zhang Y (2002) Suicide rates in China Lancet 359 835-
840
Phillips M R (1998) The transformation of Chinarsquos mental health services The China
Journal 39 1ndash36
Qiang G (2006) Depression number one killer of Ivory Tower students China Daily
Retrieved from httpwwwchinadailycomcnchina2006-
1128content_744880htm
Radloff L S (1977) The CESndashD scale A self-report depression scale for research in
the general population Applied Psychological Measurement 1 385ndash401
Rin H amp Huang M G (1989) Neurasthenia as nosological dilemma Culture
Medicine and Psychiatry 13 215-226
Sahin NH amp Sahin N (1992) How dysfunctional are the dysfunctional attitudes in
another culture British Journal of Medical Psychology 65 17-26
Shixie L (1989) Neurasthenia in China Modern and traditional criteria for its
diagnosis Culture Medicine and Psychiatry 13 163-186
28
Tanaka N Uji M Hiramura H Chen Z Shikai N amp Kitamura T (2006)
Cognitive patterns and depression Study of a Japanese university student
population Psychiatry and Clinical Neuroscience 60 358-364
Taylor R E (2001) Death of neurasthenia and its psychological reincarnation a study
of neurasthenia at the National Hospital for the Relief and Cure of the Paralysed
and Epileptic Queen Square London 1870ndash1932 British Journal of
Psychiatry 179 550ndash557
Weissman A N amp Beck A T (1978 April) Development and validation of the
Dysfunctional Attitudes Scale A preliminary investigation Paper presented at
the annual meeting of the Educational Research Association Toronto Canada
Xiang M Z (1986) Epidemiological study of neuroses in 12 regions (districts) of
China Chinese Journal of Neurology and Psychiatry 19 87-91
Xu JM (1987) Some issues in the diagnosis of depression in China Canadian
Journal of Psychiatry 32 368-370
Xu Y X (1994) About ICD-10 Journal of Clinical Psychology and Medicine 4 224-
226
Xu Z Li Z amp Wang Z (2007) Dysfunctional attitudes and cognitive bias in major
depressive disorder Chinese Mental Health Journal 21 488-491
Yan H Q (1989) The necessity of retaining the diagnostic concept of neurasthenia
Culture Medicine and Psychiatry 13 139-145
Yang H (2007) The Test of the Chinese version of Frost Multi-dimensional
Perfectionism Scale Chinese Mental Health Journal 21 97-100
Yang H amp Zhang X (2004) Perfectionism and mental health of college students
(2004) Chinese Mental Health Journal 18 647-648
Young D (1989) Neurasthenia and related problems Culture Medicine and
Psychiatry 13 131-138
Zhang D (1995) Depression and culture A Chinese perspective Canadian Journal of
Counseling 29 227ndash233
29
TABLE(S)
Table 1 Demographic Variables
Age 2011
Gender Male
Female
472
523
Parentsrsquo Marital Status Married
Divorced
Single
Remarried
938
23
18
20
Fatherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
Government Official
51
356
187
95
124
91
Motherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
122
406
144
76
134
Fatherrsquos Education Some Primary School
Primary School
Some High School
High School
University
29
139
222
403
137
Motherrsquos Education Some Primary School
Primary School
Some High School
High School
University
63
192
264
350
76
Only Child No
Yes
331
667
Monthly Income lt 1000 RMB
1000 ndash 1500 RMB
1500 ndash 2000 RMB
2000 ndash 3000 RMB
3000 ndash 4000 RMB
4000 ndash 5000 RMB
gt 5000 RMB
334
204
175
140
59
20
20
30
Table 2 Means Standard Deviations and Inter-correlations Between Time 1 Measures
__________________________________________________________________
1 2 3
__________________________________________________________________
1 Depressive Symptoms 2963 (780)
2 Anxious Symptoms 52 3753 (918)
3 Dysfunctional Attitudes 48 33 18120 (2304)
4 Neuroticism 63 42 53 3110 (712)
_________________________________________________________________________
Note Means and standard deviations (in parentheses) are on the diagonal Depressive
Symptoms = Center for Epidemiological Studies Depression Scale Anxious Symptoms
= Mood and Anxiety Symptom Questionnaire Overall Anxiety subscale Dysfunctional
Attitudes = Dysfunctional Attitudes Scale Neuroticism = NEO Five Factor Inventory
Neuroticism subscale p lt 01
31
Table 3 Dysfunctional Attitudes Predicting Within-Subject Fluctuations in CES-D
Scores (upper section) and MASQ Scores (lower section) during the Follow-Up
Interval
______________________________________________________________________
β SE F df
______________________________________________________________________
Time 1 CESD-D 297 026 12987 1572
Stress 005 000 10860 12459
Neuroticism 134 027 2518 1572
Dysfunctional Attitudes -055 040 -183 1572
Dysfunctional Attitudes times Stress 001 000 1078 12459
______________________________________________________________________
Time 1 MASQ 502 033 23158 1575
Stress 006 000 8963 12470
Neuroticism 080 033 596 1575
Dysfunctional Attitudes -052 051 -106 1575
Dysfunctional Attitudes times Stress 002 001 774 12470
______________________________________________________________________
Note Time 1 CES-D = Time 1 Center for Epidemiological Studies Depression Scale
Stress = Within-Subject Fluctuations in General Academic Social Hassles Scale for
Students (GASHSS) scores during the follow-up interval Neuroticism = NEO Five
Factor Inventory Neuroticism subscale Dysfunctional Attitudes = Dysfunctional
Attitudes Scale Time 1 MASQ = Time 1 Mood and Anxiety Symptom Questionnaire
Overall Anxiety subscale p lt 05 p lt 01 p lt 001
32
FIGURES
Figure 1 Predicted slope of the relationship between stress and depressive
symptoms (left panel) and anxious symptoms (right panel) as a function of
dysfunctional attitudes
20
25
30
Low High
Pre
dic
ted
CE
S-D
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
25
30
35
40
Low High
Pre
dic
ted
MA
SQ
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
Intercept Intercept
ii
ABSTRACT OF THE THESIS
A Prospective Examination of Beckrsquos Cognitive Theory of Depression in University
Students in Mainland China
by DARREN STOLOW
Thesis Director
John R Z Abela PhD
The current multi-wave longitudinal study examined the applicability of Beckrsquos (1967
1983) cognitive theory of depression to university students in mainland China During an
initial assessment participants completed measures assessing dysfunctional attitudes and
depressiveanxious symptoms Participants subsequently completed measures assessing
negative events and depressiveanxious symptoms once a month for six months Results
provided support for the applicability of Beckrsquos cognitive theory to university students in
mainland China More specifically higher levels of dysfunctional attitudes were
associated with greater increases in depressive symptoms following the occurrence of
negative events At the same time contrary to findings obtained in Western samples
higher levels of dysfunctional attitudes were also associated with greater increases in
anxious symptoms following the occurrence of negative events These findings may
suggest that dysfunctional attitudes exhibit non-specificity as a predictor of depressive
symptoms in mainland China
iii
Table of Contents
Title Page i
Abstract ii
Table of Contents iii
List of Tables and Figures iv
Section I Introduction 1
Section II Methods 8
Section III Results 11
Section IV Discussion 16
Section V References 22
Section VI Tables and Figures 27
iv
List of Tables and Figures
Table 1 Demographic Variables 27
Table 2 Means Standard Deviations and Inter-correlations Between Time 1
Measures 28
Table 3 Dysfunctional Attitudes Predicting Within-Subject Fluctuations in
CES-D (Upper Section) and MASQ (Lower Section) Scores during the
Follow-up Interval 29
Figure 1 Predicted slope of the relationship between stress and depressive
symptoms (Left Panel) and anxious symptoms (Right Panel) as a function of
dysfunctional attitudes 30
1
INTRODUCTION
Depression in China
The results of epidemiological studies suggest that the prevalence rate of depression in
China has been rising in recent decades More specifically whereas research conducted
during the 1980s estimated the point-prevalence rate of depression to be 03 (Xiang
1986) research conducted during the 1990s estimated it to be 14 (Murray amp Lopez
1996) More recently findings from a comprehensive epidemiological survey
conducted within China yielded a one-month prevalence rate of depression of 60
(Phillips et al 2009) In response to this upward trend depression has become a major
public health concern in China increasingly drawing the attention of both Chinese and
Western mental health researchers One demographic group within Chinarsquos population that
has received considerable attention is Chinarsquos university student population Although no
formal epidemiological studies have been conducted examining the prevalence rate of
depression among university students recent reports in the Chinese media highlight the
growing problem of depression among this demographic (eg Qiang 2006) Most distressing
in these reports is the strong association noted between depression and suicidal behavior
Estimated mortality rates reveal that suicide is the leading cause of death among
Chinese young adults between the ages of 15 and 34 (Philipps Li amp Zhang 2002)
Despite these findings however little research has examined models of the etiology of
depression in university students in mainland China Furthermore of the studies
conducted the majority are cross-sectional providing little insight into causal
mechanisms
2
Cognitive Vulnerability-Stress Models of Depression
One theoretical perspective that has proven useful in understanding the
development of depression in Western young adults is the cognitive vulnerability-stress
perspective (Abela amp Hankin 2008) Cognitive theories of depression define
vulnerability as an internal and stable feature of an individual that predisposes himher
to develop depression following the occurrence of negative events (Ingram Miranda amp
Segal 1998) Cognitive models are fundamentally diathesis-stress models in that they
posit that depression is produced by the interaction between cognitive vulnerability
factors (the diatheses) and certain environmental conditions (the stressors) that trigger
such diatheses into operation (Ingram et al 1998) Evidence suggests that under
ordinary conditions individuals vulnerable to depression are indistinguishable from the
general population Only when confronted with certain stressors do differences between
vulnerable and non-vulnerable individuals emerge (Ingram et al 1998 Ingram amp
Luxton 2005 Monroe amp Simons 1991) For individuals who possess cognitive
vulnerability factors negative events trigger a pattern of negatively biased self-referent
information processing that initiates a downward spiral into depression Non-vulnerable
individuals react to such events with an appropriate level of distress and depressive
affect but do not spiral downwards into depression
Beckrsquos Cognitive Theory of Depression
One prominent cognitive vulnerably-stress model of depression is Beckrsquos (1967
1983) cognitive theory Central to Beckrsquos cognitive theory is the construct of schema
Beck defines schema as stored bodies of knowledge (ie mental representations of the
3
self and prior experiences) that are relatively enduring characteristics of a persons
cognitive organization When an individual is confronted with a situation the schema
most relevant to the situation is activated Schema activation subsequently influences
how the person perceives encodes and retrieves information regarding the situation
Beck proposed that certain individuals posses depressogenic schema that confer
vulnerability to depression Beck (1983) hypothesizes that depressogenic schemata are
typically organized as sets of dysfunctional attitudes such as ldquoI am nothing if a person I
love doesnrsquot like merdquo or ldquoIf I fail at my work then I am a failure as a personrdquo Among
individuals who possess depressogenic schema the occurrence of negative events
triggers a pattern of negatively biased self-referent information processing
characterized by negative errors in thinking (eg negatively skewed interpretations of
negative life events such as overgeneralization and catastrophizing) Negative errors in
thinking increase the likelihood that the individual will develop the negative cognitive
triad comprising three types of depressogenic thought patterns (1) negative views of
the self (eg the belief that one is deficient inadequate or unworthy) (2) negative
views of the world (eg construing life experiences in terms of themes of defeat or
disparagement) and (3) negative views of the future (eg the expectation that ones
difficulties will persist into the future and there is nothing one can do to change this)
According to the theory the development of the negative cognitive triad triggers the
onset of depressive symptoms
Research Support for Beckrsquos Cognitive Model of Depression
Prospective studies using Western university student samples have provided
support for Beckrsquos (1967 1983) cognitive theory of depression More specifically
4
several studies have found that dysfunctional attitudes interact with the occurrence of
negative life events to predict increases in depressive symptoms (Hankin Abramson
Miller Haeffel 2004 Hankin Fraley amp Abela 2005 Joiner Metalsky Lew amp Klocek
1999 Klocek Oliver amp Ross 1997 Brown Hammen Craske and Wickens 1995) as
well as a greater likelihood of developing a depressive episode (Hankin et al 2004) In
addition individuals possessing a high level of dysfunctional attitudes have been found
to be more likely to report a past history of depressive episodes (Alloy et al 2000) and
to experience future depressive episodes (Alloy et al 2006 Hankin et al 2004) than
individuals without such a vulnerability
Far less research has examined the applicability of Beckrsquos (1983 1967)
cognitive theory to Chinese samples Preliminary cross-sectional research however
has yielded findings consistent with the theoriesrsquo hypotheses For example Xu Li and
Wang (2007) found that psychiatric patients diagnosed with major depressive disorder
showed significantly higher levels of dysfunctional attitudes than did non-depressed
controls Simiarly Bian Yang and Li (2007) reported higher levels of dysfunctional
attitudes in remitted depressives as compared to normal controls Last several studies
conducted with Chinese university students have found higher levels of dysfunctional
attitudes ndash particularly those centered on themes of perfectionism - to be associated
with higher levels of psychiatric symptoms (eg Yang amp Zhang 2004 Yang 2007
Fang Qian Luo amp Zi 2009)
5
Goals of the current study
The primary goal of the current study was to examine the applicability of
Beckrsquos (1967 1983) cognitive theory of depression to university students in mainland
China The procedure involved an initial assessment during which students completed
measures assessing dysfunctional attitudes and symptoms of depression The procedure
also involved a series of six follow-up assessments occurring once a month for six
months during which symptoms of depression and the occurrence of negative events
were assessed The use of a multi-wave longitudinal design allowed us to take an
idiographic approach towards examining the diathesis-stress hypotheses of Beckrsquos
(1967 1983) theory More specifically we examined whether the slope of the
relationship between negative events and symptoms of depression within participants
varied across participants as a function of level of dysfunctional attitudes In line with
the vulnerability-stress hypothesis of Beckrsquos (1967 1983) cognitive theory we
hypothesized that higher levels of dysfunctional attitudes would be associated with
greater increases in depressive symptoms following the occurrence of negative events
The second objective of the current study was to examine the specificity of
dysfunctional attitudes as a predictor of depressive symptoms Beckrsquos (1967 1983)
theory posits that dysfunctional attitudes predict the development of depressive
symptoms but not symptoms of other forms of psychopathology Prospective studies
using Western university student (Alloy et al 2000 2006 Hankin Abramson Miller
amp Haeffel 2004) and adolescent samples (Hankin Wetter Cheely amp Oppenheimer
2008) have provided support for the specificity hypothesis of the theory More
specifically dysfunctional attitudes have been found to interact with negative events to
6
predict increases in depressive symptoms but not symptoms of anxiety or other
disorders in both university student (Hankin et al 2004) and adolescent samples
(Hankin et al 2008) Similarly although university students possessing a high level of
dysfunctional attitudes have been found to be more likely than other university students
to report a past history of depressive episodes (Alloy et al 2000) and to experience
future depressive episodes (Alloy et al 2006) they have not been found to differ from
their low-risk counterparts in terms of past history or future occurrence of other
psychological disorders (Alloy et al 2000 2006)
With respect to the current study it is possible that differences may emerge
between Chinese and Western samples in terms of the types of symptoms predicted by
dysfunctional attitudes More specifically cultural psychopathologists have proposed
that cultural factors shape the phenomenology of psychiatric symptoms as well as the
conceptualization and classification of disorders (Kleinman 2004 Mezzich et al
1999) As such the experience of psychopathology may exhibit unique features in
different cultures with diagnostic categories developed in one cultural context not being
valid in another (Kleinman 1977 1996) Neuresthenia known in China as shenjing
shuairuo (SJSR) is a diagnostic entity characterized by (1) physical and mental
weakness and fatigability (2) sleep disturbances (3) irritability and worry (4)
excitability (5) nervous pain and (6) memory difficulty (Taylor 2001) Historically
SJSR was a Western disease concept that subsequently evolved to become a widely
utilized diagnostic entity within China (Lee amp Wong 1995) Some cultural
psychopathologists have posited that SJSR represents a somatized form of depression
This claim however has been met with significant controversy (eg Lee 1997
7
Parker Gladstone amp Chee 2001 Xu JM 1987 Xu YX 1994 Zhang 1995)
Critics dispute the notion that Chinese psychiatric patients are ldquosomatizersrdquo who
manifest few or no emotional symptoms and who attribute distress to physical causes
Rather they argue that SJSR gained widespread acceptance in China as it was a non-
stigmatizing diagnosis that allowed individuals experiencing psychosocial distress to
seek help during a time in which traditional cultural beliefs and political influences led
to severe sanction and stigmatization of individuals suffering from mental illnesses
(Lee 1998 1999 Phillips 1998 Shixie 1989) At the same time other Chinese
researchers and clinicians have continued to defend neurasthenia as both a valid
diagnostic category and a clinically useful means of communicating with patients (Rin
amp Huang 1989 Yan 1989 Young 1989) Due to continued debate on this topic it is
essential that researchers examining models of vulnerability to depression within China
assess multiple symptom outcomes as the types of symptoms predicted by vulnerability
factors may vary as a function of cultural context Hence in the current study we also
assessed levels of anxious symptoms to provide a test of the specificity hypothesis of
Beckrsquos (1967 1983) cognitive theory
In order to provide a powerful examination of our hypotheses concerning (1) the
applicability of the diathesis-stress component of Beckrsquos (1967 1983) cognitive theory
to Chinese university students and (2) the specificity of dysfunctional attitudes as
predictors of depressive as opposed to anxious symptoms participantsrsquo scores on the
neuroticism subscale of the Five-factor Inventory (FFI-N) were included as a control
variable in all analyses Several critical reviews of the literature examining theories of
cognitive vulnerability to depression (eg Barnett amp Gotlib 1998 Coyne amp Whiffen
8
1995) have argued that cognitive vulnerabilities to depression such as that featured in
Beckrsquos cognitive theory may be equivalent to or reducible to trait neuroticism and thus
may not confer independent risk for depression In response to such claims a recent
study conducted with university students examining the degree of factorial
independence versus overlap between trait neuroticism and dysfunctional attitudes has
shown them to be distinct constructs each loading onto separate factors (Hankin et al
2007) At the same time however there remains a need to examine whether
dysfunctional attitudes and trait neuroticism represent unique risk factors for
depression particularly in young adults in China Hence in the current study
participantsrsquo scores on the neuroticism subscale of the Five-factor Inventory (FFI-N)
were included as a control variable in order to account for any of the variance in
fluctuations in depressive (and anxious) symptoms that may be shared between
dysfunctional attitudes and trait neuroticism thereby isolating and highlighting their
unique predictive effects
METHOD
Participants
Participants included 662 university students (aged 19-21) from Changsha ndash an
industrial city in the province of Hunan with a population of approximately 6000000
In terms of the annual gross domestic product Hunan ranks 23rd
(10336 RMB) out of
the 34 provinces in China placing it well below the national provincial average (micro =
29719 RMB SD = 47462 RMB National Bureau of Statistics of China 2006)
Demographic variables for the sample are presented in Table 1
9
Procedure
Consent forms were distributed to all students in participating classes Consent
rates were greater than 95 in all the classes After consent forms were collected
researchers returned to the school to meet with participating students Written consent
was obtained from each participant at the beginning of the initial assessment During
the initial assessment students completed a demographics form and each of the
following questionnaires (1) Center for Epidemiological Studies Depression Scale
(CES-D Radloff 1977) (2) Mood and Anxiety Symptom Questionnaire (MASQ
Clark amp Watson 1991) (3) Dysfunctional Attitudes Scale (DAS Weissman amp Beck
1978) and (4) NEO Five Factor Inventory- Neuroticism Subscale (FFI-N Costa amp
McCrae 1992) Once a month for the subsequent six-months researchers returned to
the school and met with participating students to conduct follow-up assessments At
each of these follow-up assessments students were asked to complete each of the
following questionnaires (1) CES-D (2) MASQ and (3) the General Academic
Social Hassles Scale for Students (GASHSS Blankstein amp Flett 1993)
Measures
The Chinese versions of all self-report measures were developed using the
back-translation method Original English versions were translated into Chinese by a
bilingual translator from the Psychology department at Second Xiangya Medical
College of Central South University Hunan Translated Chinese versions were then
back-translated into English by another bilingual translator from the Psychology
department at McGill University Quebec Original versions were then compared with
the back-translation If inconsistencies were found in the back-translation translators
10
worked together to make corrections to the final Chinese versions until all final
versions were agreed upon No items from any of the measures were removed or
significantly altered during the translation process
Depressive Symptoms Center for Epidemiological Studies Depression Scale
(CES-D Radloff 1977) The CES-D is a 20-item self-report measure designed to
assess depressive symptoms in the general population For each item participants are
asked to indicate how often they experienced the particular symptom over the last
week Responses range from 1 (eg rarely or none of the time) to 4 (eg most or all of
the time) Scores range from 20-80 with higher score indicating higher levels of
depressive symptoms In the current study the CES-D exhibited high internal
consistency with Cronbachrsquos alpha values ranging from 90 to 94 (micro = 2918 SD =
814) over the 7 time points
Anxious Symptoms Mood and Anxiety Symptom Questionnaire (MASQ
Watson amp Clark 1991) The MASQ is a 62-item questionnaire designed to assess both
specific and nonspecific depressive and anxious symptoms For each item participants
are asked to rate on a scale of 1 to 5 the extent to which they have felt this way ldquoduring
the past 24 hoursrdquo Within the current study we utilized the anxious symptoms (11
items) and anxious arousal (17 items) subscales which together provide an index of
overall anxious symptoms Higher scores on each subscale reflect greater levels of
anxious symptoms In the current study the MASQ exhibited high internal consistency
with Cronbachrsquos alpha values ranging from 90 to 95 (micro = 3847 SD = 1117) over the
7 time points
11
Dysfunctional Attitudes Dysfunctional Attitudes Scale (DAS Weissman amp
Beck 1978) The DAS (Form A) is a 40-item questionnaire designed to measure the
cognitive vulnerability factor featured in Beckrsquos cognitive theory Examples of items
include ldquoIf I do not do well all the time people will not respect merdquo ldquoIf a person asks
for help it is a sign of weaknessrdquo and ldquoMy value as a person depends greatly on what
others think of merdquo Items are rated on a 7-point Likert scale ranging from 1 (totally
disagree) to 7 (totally agree) providing a range of scores from 40 to 280 with higher
scores reflecting more dysfunctional attitudes In the current study the DAS exhibited
high internal consistency with Cronbachrsquos alphas of 89 and 88 obtained for the first
and second administrations respectively In addition a test-retest reliability coefficient
of 72 was obtained indicating strong stability over time
Neuroticism NEO Five Factor Inventory - Neuroticism Subscale (FFI-N
Costa amp McCrae 1992) The FFI-N is a 12- item self-report measure that assesses
neuroticism Examples of questions include I often feel inferior to others I am
seldom sad or depressed and Sometimes I feel completely worthless Items are rated
on a 5-point Likert scale ranging from 0 (strongly disagree) to 4 (strongly agree)
providing scores ranging from 0 to 48 with higher scores indicating higher levels of
neuroticism The NEO-FFI-N has proven reliable across different cultural samples and
item pools (Costa amp McCrae 1992) In the current study Cronbachs alpha was 81
indicating strong internal consistency
Negative Life Events General Academic Social Hassles Scale for Students
(GASHSS Blankstein amp Flett 1993) Participants completed a 30-item abbreviated
version of the GASHSS The measure is comprised of items assessing general hassles
12
(8 items) academic hassles (10 items) and social hassles (12 items) For each item
participants are asked to rate how persistent the given hassle was (ie its frequency and
duration) over the last 30 days (0 = no hassle not at all persistent to 6 = extremely
persistent hassle high frequency andor duration)
13
RESULTS
Descriptive Data
Means standard deviations and inter-correlations between Time 1 measures are
presented in Table 2
Prospective Diathesis-Stress Analyses - Depression
Multilevel modeling was used to test our hypothesis that higher levels of dysfunctional
attitudes would be associated with greater increases in depressive symptoms following
increases in stress Analyses were carried out using the SAS (version 81) MIXED
procedure and maximum likelihood estimation Our dependent variable was within-
subject fluctuations in CES-D scores during the follow-up interval (DEPRESSION)
Our primary predictors of DEPRESSION were DAS scores (DYSFUNCTIONAL
ATTITUDES) and fluctuations in GASHSS scores during the follow-up interval
(STRESS) As DYSFUNCTIONAL ATTITUDES is a between-subject predictor DAS
scores were standardized prior to analyses As STRESS is a within-subject predictor
STRESS reflects upward or downward fluctuations in an individualrsquos level of stress
compared to hisher mean level of stress
When fitting hierarchical linear models one must specify appropriate mean and
covariance structures Mean structures refer to the various fixed and random effect
components that can be included in the model Covariance structures refer to alternative
methods of specifying the pattern of covariance between observations taken from the
same subject at different time points It is important to note that mean and covariance
structures are not independent of one another Rather an appropriate covariance
structure is essential in order to obtain valid inferences for the parameters in the mean
14
structure Overparametrization of the covariance structure can lead to inefficient
estimation and poor assessment of standard errors (Altham 1984) On the other hand
too much restriction of the covariance structure can lead to invalid inferences when the
assumed structure does not hold (Altham 1984)
In our first set of analyses we were interested in examining the effects of
DYSFUNCTIONAL ATTITUDES STRESS and the DYSFUNCTIONAL
ATTITUDES STRESS interaction on participantrsquos CES-D scores during the follow-
up interval Consequently in line with Diggle Liang and Zegers (1994)
recommendation that one use a ldquosaturatedrdquo model for the mean structure while
searching for an appropriate covariance structure we chose a mean structure that
included DYSFUNCTIONAL ATTITUDES STRESS and the DYSFUNCTIONAL
ATTITUDES STRESS interaction Four additional effects were also included in this
mean structure First as different individuals report different levels of depressive
symptoms when at their own average level of stress a random effect for intercept was
included in the model Second given that STRESS is a within-subject predictor whose
effect is expected to vary from participant to participant a random effect for slope was
included in the model Third in order to control for individual differences in baseline
levels of depressive symptoms Time 1 CES-D scores were included in the model
Fourth in order to examine whether DYSFUNCTIONAL ATTITUDES represent a
vulnerability factor independent of neuroticism participantsrsquo FFI-N scores were
entered in the model
Commonly used covariance structures in studies in which multiple responses
are obtained from the same individual over time (and consequently within-subject
15
residuals over time are likely to be correlated) include compound symmetry first-order
autoregressive heterogeneous autoregressive and banded Toeplitz In order to select
one of these covariance structures for our analyses we fitted models using each
structure and chose the ldquobestrdquo fit based on Akaike information criterion (AIC and
AICC) and Schwarz Bayesian criterion (BIC) In all cases the best fit for our data was
a first-order heterogeneous autoregressive structure (ARH [1]) After choosing the
appropriate covariance structure we next examined the random-effects component of
our model
With respect to random effects the ARH [1] parameter (r = 31 plt001)
RE_INTERCEPT (plt001) and RE_SLOPE (plt001) were each significant and thus
were retained in the model The final results with respect to the fixed-effects
component of the model are presented in the upper section of Table 3 Of primary
importance the DYSFUNCTIONAL ATTITUDES STRESS interaction was a
significant predictor of fluctuations in depressive symptoms during the follow-up
interval In order to examine the form of this interaction the model summarized in the
upper section of Table 3 was used to calculate predicted CES-D scores for individuals
exhibiting either high or low levels of dysfunctional attitudes (plus or minus 15 SD)
who are experiencing either high or low levels of stress in comparison to their own
average level of stress (plus or minus 15 times mean within-subject SD) The results of
such calculations are presented in the left panel of Figure 1
Analyses were conducted for each DYSFUNCTIONAL ATTITUDES
condition examining whether the slope of the relationship between stress and
depressive symptoms significantly differed from 0 Analyses indicated that both
16
individuals exhibiting high (t(2459) = 862 p lt 0001) and low (t(2459) = 347 p lt
0001) levels of dysfunctional attitudes reported significantly higher levels of
depressive symptoms when experiencing high levels of stress than when experiencing
low levels of stress Planned comparisons of the slopes of the relationship between
stress and depressive symptoms however revealed that the slope was significantly
greater in individuals exhibiting high levels of dysfunctional attitudes (slope = 013)
than in individuals exhibiting low levels of dysfunctional attitudes (slope = 005
t(2459) = 328 p = 0001)
Prospective Diathesis-Stress Analyses - Anxiety
The same data-analytic approach as described above was used to examine
whether higher levels of dysfunctional attitudes would be associated with greater
increases in anxious symptoms following increases in stress Again in order to examine
whether DYSFUNCTIONAL ATTITUDES represent a vulnerability factor
independent of neuroticism participantsrsquo FFI-N scores were entered in the model
With respect to random effects the ARH[1] parameter (r = 23 p lt 001)
RE_INTERCEPT (plt001) and RE_SLOPE (plt001) were each significant and thus
were retained in the model The final results with respect to the fixed-effects
component of the model are presented in the lower section of Table 3 Of primary
importance the DYSFUNCTIONAL ATTITUDES STRESS interaction was a
significant predictor of within-subject fluctuations in anxious symptoms during the
follow-up interval In order to examine the form of this interaction the model
summarized in the lower section of Table 3 was used to calculate predicted MASQ
scores for individuals exhibiting either high or low levels of dysfunctional attitudes
17
(plus or minus 15 SD) who are experiencing either high or low levels of stress in
comparison to their own average level of stress (plus or minus 15 times mean within-
subject SD) The results of such calculations are presented on the right panel of in
Figure 1
Analyses were conducted for each DYSFUNCTIONAL ATTITUDES
condition examining whether the slope of the relationship between stress and anxious
symptoms significantly differed from 0 Analyses indicated that both individuals
exhibiting high (t(2470) = 768 p lt 0001) and low (t(2470) = 337 p lt 0001) levels of
dysfunctional attitudes reported higher levels of anxious symptoms when experiencing
high levels of stress than when experiencing low levels of stress Planned comparisons
of the slopes of the relationship between stress and anxious symptoms however
revealed that the slope was significantly greater in individuals exhibiting high levels of
dysfunctional attitudes (slope = 009) than in individuals exhibiting low levels of
dysfunctional attitudes (slope = 003 t(2470) = 278 p lt 001)
Additional Analyses
Given that the DYSFUNCTIONAL ATTITUDES STRESS interaction
prospectively predicted both symptoms of depression and anxiety two additional
analyses were conducted in order to examine (1) whether the DYSFUNCTIONAL
ATTITUDES STRESS interaction continued to be a significant predictor of within-
subject fluctuations in depressive symptoms after controlling for within-subject
fluctuations in anxious symptoms and (2) whether the DYSFUNCTIONAL
ATTITUDES STRESS interaction continued to predict within-subject fluctuations in
anxious symptoms after controlling for within-subject fluctuations in depressive
18
symptoms Such analyses allowed us to examine whether the above mentioned pattern
of findings may have been due to the high correlation observed in the current study
between depressive and anxious symptoms
Analyses were conducted in the same manner as described above with the
exception that an additional within-subject variable (ie DEPRESSION or ANXIETY)
was included in each model in order to control for within-subject fluctuations in the
alternate symptom With respect to the prediction of depressive symptoms the
DYSFUNCTIONAL ATTITUDES STRESS interaction remained a significant
predictor after controlling for within-subject fluctuations in anxious symptoms (β =
001 SE = 000 F = 410 p lt 05) With respect to the prediction of anxious
symptoms however the DYSFUNCTIONAL ATTITUDES STRESS interaction
was no longer a significant predictor after controlling for within-subject fluctuations in
depressive symptoms (β = 001 SE = 000 F = 148 p = 22)
DISCUSSION
The results of the current study provide support for the cross-cultural
applicability of Beckrsquos (1967 1983) cognitive theory to university students in Hunan
China More specifically consistent with hypotheses and with results obtained from
past research examining Beckrsquos cognitive theory in Western samples of university
students (Hankin et al 2004 Hankin et al 2005 Joiner et al 1999 Klocek et al
1997 Brown et al 1995) higher levels of dysfunctional attitudes were associated with
greater increases in depressive symptoms following increases in negative event
frequency during the six-month follow-up interval Given the considerable differences
between the current sample and Western samples in terms of demographic
19
characteristics and cultural factors such a finding strongly attests to the robustness of
Beckrsquos cognitive theory Moreover integrating the current findings with those obtained
in research examining Beckrsquos theory in other non-Western samples suggests that
Beckrsquos theory may represent a powerful explanatory model of the development of
depressive symptoms among individuals from diverse cultural settings For example
consistent with the theory higher levels of dysfunctional attitudes have been shown to
be associated with higher levels of depressive symptoms in Japanese (Tanaka et al
2006) Puerto-Rican (Bonilla Bernal Santos amp Santos 2003) Turkish (Sahin amp Sahin
1992) Norwegian (Chioqueta amp Stiles 2004) Singaporean (Oei Goh amp Kwon 1996)
and Swedish (Ohrt amp Thorell 1998) adult samples In addition it is important to note
that the current findings expand upon past correlational research examining the
association between dysfunctional attitudes and depression in Chinese samples through
the use of a multi-wave longitudinal design
When examining the specificity of dysfunctional attitudes as a predictor of
depressive symptoms the current study did not obtain support for specificity More
specifically contrary to the specificity hypothesis of Beckrsquos cognitive theory and to
results obtained in Western samples of university students (Alloy et al 2000 2006
Hankin et al 2004) higher levels of dysfunctional attitudes were associated with
greater increases in both depressive and anxious symptoms following increases in
negative event frequency There are two alternative ways of interpreting the non-
specificity finding observed in the current study First it is possible that the types of
thoughts individuals possessing high levels of dysfunctional attitudes experience
following negative events varies as a function of cultural context In other words in
20
Western samples such individuals may primarily experience the types of cognitions
that are associated with the development of depressive symptoms (ie appraisals of
personal loss and failure) In contrast in Chinese samples individuals possessing high
levels of dysfunctional attitudes may experience a wider array of cognitions some of
which are associated with the development of depressive symptoms and some of which
are associated with the development of anxious symptoms (ie evaluations of
impending threat or danger) Such an explanation would be consistent with Beckrsquos
cognitive content-specificity hypothesis (Clark amp Beck 1999) which posits that each
affective state and psychological disorder has a specific cognitive profile Second it is
possible that the types of symptoms individuals possessing high levels of dysfunctional
attitudes experience following negative events varies as a function of cultural context
More specifically it may be that dysfunctional attitudes specifically predict symptoms
of depression in both samples except that in Western samples depression manifests in
pure depressive symptoms whereas in Chinese samples depression manifests as a
combination of depressive and anxious symptoms Such an explanation would be
consistent with cultural psychopathologistsrsquo hypotheses that cultural factors shape the
phenomenology of psychiatric symptoms (Kleinman 2004 Mezzich et al 1999)
Moreover dysfunctional attitudes predicting a combination of depressive and anxious
symptoms in Chinese samples would be consistent with the construct of neurasthenia -
a construct hypothesized by some to represent a somatized form of depression that is
still widely seen within China (Lee amp Wong 1995)
Interesting in this regard and perhaps speaking to the primacy of depressive
symptoms in the current findings analyses indicated that the DYSFUNCTIONAL
21
ATTITUDES times STRESS interaction no longer predicted anxious symptoms after
controlling for depressive symptoms The reverse however was not true as the
DYSFUNCTIONAL ATTITUDES times STRESS interaction continued to predict
depressive symptoms after controlling for anxious symptoms
It is important to note that the current study employed a particularly
conservative approach to analyses in that we examined the effects of dysfunctional
attitudes on depressive and anxious symptoms after controlling for the effect of
neuroticism on such symptoms Providing particularly powerful support for Beckrsquos
(1967 1983) cognitive theory across analyses dysfunctional attitudes predicted levels
of depressive andor anxious symptoms experienced during the six month follow-up
interval independent of the effect of neuroticism Thus contrary to past critical reviews
of the cognitive literature (Barnett amp Gotlib 1998 Coyne amp Whiffen 1995) and
consistent with past findings (Hankin et al 2007) the current results indicate that
cognitive vulnerabilities to depression such as dysfunctional attitudes are not reducible
to trait neuroticism but rather represent factors that confer independent risk for
depression
Limitations and Future Directions
Several limitations of the current study should be noted First self-report
measures were used to assess depressive and anxious symptoms Although the CES-D
and MASQ both possess high degrees of reliability and validity it is difficult to draw
conclusions about clinically diagnosed depression or anxiety based on self-report
questionnaires Second self-report measures were used to assess stress Although
measures of stress that require participants only to indicate whether or not an event
22
occurred are less likely to be influenced by informant bias than those that ask
participants to rate the subjective impact of each event more sophisticated methods of
analysis such as interviewing procedures that assess contextual threat may provide
better assessments of stress Third the measures of dysfunctional attitudes stress and
depressive and anxious symptoms used in the current study were each Western-
developed Future research should examine these hypotheses using indigenous
measures in addition to Western-developed measures in order to assess possible
similarities andor differences in patterns of findings Fourth the current study only
examined depression and anxiety as symptom outcomes Future research conducted
within China should examine a wider array of symptom outcomes such as
somatization physical complaints and externalizing behaviors in order to provide a
more thorough and culturally sensitive test of the specificity hypotheses of Beckrsquos
cognitive model Fifth the current study examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese undergraduate students and thus the extent to which
our findings may be generalized to other demographics within Chinarsquos population is
unclear Last the current study broadly examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese university students Future research should examine
the constructs and processes posited by this model in greater detail in order to develop a
deeper understanding of how they may be uniquely molded by socio-cultural factors
Such research would benefit from examining the specific types of stressors experienced
by Chinese university students as they may vary as a function of socio-cultural factors
from those experienced by Western undergraduates For example severe pressure to
succeed academically in order to secure access to a limited number of post-
23
undergraduate educational opportunities - one of the few paths towards upward
mobility available to Chinese students seeking secure and gainful employment in what
has increasingly become a very highly competitive job market - may represent a
particularly salient stressor for the development of depressive symptoms among this
population (Qiang 2006)
In conclusion the results from the current study provide support for the
applicability of Beckrsquos cognitive theory to university students in mainland China More
specifically consistent with findings obtained in the West results indicate that
dysfunctional attitudes confer vulnerability to the development of depressive symptoms
following the occurrence of negative events in Chinese university students At the same
time however the current findings suggest cultural variation in the profile of
symptoms which emerge following the occurrence of negative events in cognitively
vulnerable individuals in Western and Chinese samples Specifically whereas in the
West dysfunctional attitudes have been shown to confer vulnerability to depressive
symptoms in Chinese university students dysfunctional attitudes appear to confer
vulnerability to a combined depressive and anxious symptom profile Future research
using more sophisticated assessments of stress and depressive symptoms more diverse
samples and symptom outcome measures and indigenously-developed measures is
likely to enhance our understanding of the cognitive and environmental mechanisms
underlying the development of depression in Chinese university students Discovering
that cognitive theories of vulnerability to depression extend to university students in
China highlights the potential role for cognitive-behavioral depression prevention and
treatment interventions in stemming the tide of distress experienced by this population
24
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children and adolescents A developmental psychopathology perspective In J
R Z Abela and B L Hankin (Eds) Handbook of child and adolescent
depression (pp 35-78) New York The Guilford Press
Alloy L B Abramson L Y Hogan M E Whitehouse W G Rose D T
Robinson MS Kim R S amp Lapkin J B (2000) The Temple-Wisconsin
cognitive vulnerability to depression project Lifetime history of axis-I
psychopathology in individuals at high and low cognitive risk for depression
Journal of Abnormal Psychology 109 403-418
Alloy L B Abramson L Y Whitehouse W G Hogan M E Panzarella C amp
Rose D T (2006) Prospective incidence of first onsets and recurrences of
depression in individuals at high and low cognitive risk for depression Journal
of Abnormal Psychology 115 145ndash156
Altham P M E (1984) Improving the precision of estimation by fitting a model
Journal of the Royal Statistical Society Series B 46 11
Barnett PA amp Gotlib I H (1988) Psychosocial functioning and depression
Distinguishing among antecedents concomitants and consequences
Psychological Bulletin 104 97-126
Beck AT (1967) Depression Clinical experimental and theoretical aspects New
York Harper amp Row
Beck AT (1983) Cognitive therapy of depression New perspectives In PJ Clayton
amp JE Barrett (Eds) Treatment of depression Old controversies and new
approaches New York Raven Press
Bian Q Yang K amp Li C (2007) Dysfunctional attitudes of patients with depression
or bipolar disorder Chinese Mental Health Journal 21 759-761
Blankstein K R amp Flett G L (1993) Development of the General Academic and
Social Hassles Scales for Students Unpublished manuscript
Bonilla J Bernal G Santos A amp Santos D (2003) A revised Spanish version of
the Beck Depression InventoryPsychometric properties with a Puerto Rican
sample of college students Journal of Clinical Psychology 60 119-130
Brown G P Hammen C L Craske M G amp Wickens T D (1995) Dimensions of
dysfunctional attitudes as vulnerabilities to depressive symptoms Journal of
Abnormal Psychology 104 431-435
25
Chioqueta A P amp Stiles T C (2004) Psychometric properties of the Norweigian
version of the Dysfunctional Attitude Scale (Form A) Cognitive Behaviour
Therapy 33 83-86
Clark DA amp Beck AT (1999) Cognitive theory and therapy of depression New
York John Wiley amp Sons Inc
Clark L A amp Watson D (1991) Tripartite model of anxiety and depression
Psychometric evidence and taxonomic implications Journal of Abnormal
Psychology 100 316ndash336
Costa P T amp McCrae R R (1992) NEO PI-R Professional manual Revised NEO
personality inventory NEO PR-R and NEO five-factor inventory NEO-RRI
Odessa FL Psychological Assessment Resources
Coyne J C amp Whiffen V E (1995) Issues in personality as diathesis for depression
The case of sociotropy-dependency and autonomy-self-criticism Psychological
Bulletin 118 358-378
Fang X Qian M Luo S amp Zi F (2009) A correlational study on college students
perfectionism parental rearing patterns and mental health Chinese Mental
Health Journal 23 56-59
Hankin B L Abramson L Y Miller N amp Haeffel G (2004) Cognitive
vulnerability-stress theories of depression Examining affective specificity in
the prediction of depression versus anxiety in three prospective studies
Cognitive Therapy and Research 28 309ndash345
Hankin BL Fraley RC amp Abela JRZ (2005) Daily depression and cognitions
about stress Evidence for a traitlike depressogenic cognitive style and the
prediction of depressive symptoms in a prospective daily diary study Journal of
Personality and Social Psychology 88 673-685
Hankin B L Lakdawalla Z Carter I L Abela J R Z amp Adams P (2007) Are
neuroticism cognitive vulnerabilities and self-esteem overlapping or distinct
risks for depression Evidence from confirmatory factor analyses Journal of
Social amp Clinical Psychology 26 29-63
Hankin B L Wetter E Cheely C amp Oppenheimer C W (2008) Becks cognitive
theory of depression in adolescence Specific prediction of depressive
symptoms and reciprocal influences in a multi-wave prospective study
International Journal of Cognitive Therapy 1 313-332
Ingram R E Miranda J amp Segal Z V (1998) Cognitive Vulnerability to
Depression New York NY Guilford Press
26
Ingram R E amp Luxton DD (2005) Vulnerability-stress models In BL Hankin amp
JRZ Abela (Eds) Development of psychopathology A vulnerability-stress
perspective (pp 32-46) Thousand Oaks CA Sage
Joiner T E Metalsky G I Lew A amp Klocek J (1999) Testing the causal
mediation component of Becks theory of depression Evidence for specific
mediation Cognitive Therapy and Research 23 401-412
Kleinman A (2004) Culture and depression New England Journal of Medicine 351
951-953
Kleinman A (1977) Depression somatization and the new cross-cultural psychiatry
Social Science and Medicine 11 3-10
Kleinman A (1996) How is culture important for DSM-IV In J E Mezzich A
Kleinmam H Fabrega Jr amp L Delores (Eds)Culture and psychiatric
diagnosis A DSM-IV perspective (pp 15-25) Washington DC US American
Psychiatric Association
Klocek J W Oliver J M amp Ross M J (1997) The role of dysfunctional attitudes
negative life events and social support in the prediction of depressive
dysphoria A prospective longitudinal study Social Behavior and Personality
25 23-136
Lee S (1997) A Chinese perspective on somatoform disorders Journal of
Psychosomatic Disorders 43 115-119
Lee S (1998) Estranged bodies simulated harmony and misplaced cultures
Neurasthenia in contemporary Chinese society Psychosomatic Medicine 60
448ndash457
Lee S (1999) Diagnosis postponed Shenjing shuairo and the transformation of
psychiatry in post-Mao China Culture Medicine and Psychiatry 23 349ndash380
Lee S amp Wong K C (1995) Rethinking neurasthenia the illness concepts of
shenjing shuairuo among Chinese undergraduates in Honk Kong Culture
Medicine and Psychiatry 19 91ndash111
Lee S Tsang A Huang YQ He YL Liu ZR Zhang MY Shen YC amp
Kessler RC (2009) The epidemiology of depression in metropolitan China
Psychological Medicine 39 735-747
Mezzich J E Kirmayer L J Kleinman A Fabrega Jr H Parron D L Good B
J Lin K amp Manson S M (1999) The place of culture in DSM-IV Journal
of Nervous and Mental Disease 187 457-464
27
Monroe S M amp Simons A D (1991) Diathesisndashstress theories in the context of life
stress research Implications for the depressive disorders Psychological
Bulletin 110 406ndash425
Murray C J L amp Lopez A D (1996) The global burden of disease Cambridge
Harvard University Press
National Bureau of Statistics of China (2006) The China 2005 statistical yearbook
China Statistics Press Beijing PR China
Oei T P S Goh Y Kwon S M(1996) A cross-cultural study of the integrated
cognitive model of depression Current Psychology of Cognition 15 265-281
Ohrt T amp Thorell L (1998) Dysfunctional Attitude Scale (DAS) Psychometrics and
norms of the Swedish version Scandinavian Journal of Behaviour Therapy 27
105-113
Parker G Gladstone G Chee KT (2001) Depression in the planetrsquos largest ethnic
group The Chinese American Journal of Psychiatry 158 857-864
Phillips M R Zhang J Shi Q Song Z Ding Z Pang S Li X Zhang Y amp
Wang Z (2009) Prevalence treatment and associated disability of mental
disorders in four provinces in China during 2001ndash05 an epidemiological
survey The Lancet 373 2041-2053
Phillips M R Li X amp Zhang Y (2002) Suicide rates in China Lancet 359 835-
840
Phillips M R (1998) The transformation of Chinarsquos mental health services The China
Journal 39 1ndash36
Qiang G (2006) Depression number one killer of Ivory Tower students China Daily
Retrieved from httpwwwchinadailycomcnchina2006-
1128content_744880htm
Radloff L S (1977) The CESndashD scale A self-report depression scale for research in
the general population Applied Psychological Measurement 1 385ndash401
Rin H amp Huang M G (1989) Neurasthenia as nosological dilemma Culture
Medicine and Psychiatry 13 215-226
Sahin NH amp Sahin N (1992) How dysfunctional are the dysfunctional attitudes in
another culture British Journal of Medical Psychology 65 17-26
Shixie L (1989) Neurasthenia in China Modern and traditional criteria for its
diagnosis Culture Medicine and Psychiatry 13 163-186
28
Tanaka N Uji M Hiramura H Chen Z Shikai N amp Kitamura T (2006)
Cognitive patterns and depression Study of a Japanese university student
population Psychiatry and Clinical Neuroscience 60 358-364
Taylor R E (2001) Death of neurasthenia and its psychological reincarnation a study
of neurasthenia at the National Hospital for the Relief and Cure of the Paralysed
and Epileptic Queen Square London 1870ndash1932 British Journal of
Psychiatry 179 550ndash557
Weissman A N amp Beck A T (1978 April) Development and validation of the
Dysfunctional Attitudes Scale A preliminary investigation Paper presented at
the annual meeting of the Educational Research Association Toronto Canada
Xiang M Z (1986) Epidemiological study of neuroses in 12 regions (districts) of
China Chinese Journal of Neurology and Psychiatry 19 87-91
Xu JM (1987) Some issues in the diagnosis of depression in China Canadian
Journal of Psychiatry 32 368-370
Xu Y X (1994) About ICD-10 Journal of Clinical Psychology and Medicine 4 224-
226
Xu Z Li Z amp Wang Z (2007) Dysfunctional attitudes and cognitive bias in major
depressive disorder Chinese Mental Health Journal 21 488-491
Yan H Q (1989) The necessity of retaining the diagnostic concept of neurasthenia
Culture Medicine and Psychiatry 13 139-145
Yang H (2007) The Test of the Chinese version of Frost Multi-dimensional
Perfectionism Scale Chinese Mental Health Journal 21 97-100
Yang H amp Zhang X (2004) Perfectionism and mental health of college students
(2004) Chinese Mental Health Journal 18 647-648
Young D (1989) Neurasthenia and related problems Culture Medicine and
Psychiatry 13 131-138
Zhang D (1995) Depression and culture A Chinese perspective Canadian Journal of
Counseling 29 227ndash233
29
TABLE(S)
Table 1 Demographic Variables
Age 2011
Gender Male
Female
472
523
Parentsrsquo Marital Status Married
Divorced
Single
Remarried
938
23
18
20
Fatherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
Government Official
51
356
187
95
124
91
Motherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
122
406
144
76
134
Fatherrsquos Education Some Primary School
Primary School
Some High School
High School
University
29
139
222
403
137
Motherrsquos Education Some Primary School
Primary School
Some High School
High School
University
63
192
264
350
76
Only Child No
Yes
331
667
Monthly Income lt 1000 RMB
1000 ndash 1500 RMB
1500 ndash 2000 RMB
2000 ndash 3000 RMB
3000 ndash 4000 RMB
4000 ndash 5000 RMB
gt 5000 RMB
334
204
175
140
59
20
20
30
Table 2 Means Standard Deviations and Inter-correlations Between Time 1 Measures
__________________________________________________________________
1 2 3
__________________________________________________________________
1 Depressive Symptoms 2963 (780)
2 Anxious Symptoms 52 3753 (918)
3 Dysfunctional Attitudes 48 33 18120 (2304)
4 Neuroticism 63 42 53 3110 (712)
_________________________________________________________________________
Note Means and standard deviations (in parentheses) are on the diagonal Depressive
Symptoms = Center for Epidemiological Studies Depression Scale Anxious Symptoms
= Mood and Anxiety Symptom Questionnaire Overall Anxiety subscale Dysfunctional
Attitudes = Dysfunctional Attitudes Scale Neuroticism = NEO Five Factor Inventory
Neuroticism subscale p lt 01
31
Table 3 Dysfunctional Attitudes Predicting Within-Subject Fluctuations in CES-D
Scores (upper section) and MASQ Scores (lower section) during the Follow-Up
Interval
______________________________________________________________________
β SE F df
______________________________________________________________________
Time 1 CESD-D 297 026 12987 1572
Stress 005 000 10860 12459
Neuroticism 134 027 2518 1572
Dysfunctional Attitudes -055 040 -183 1572
Dysfunctional Attitudes times Stress 001 000 1078 12459
______________________________________________________________________
Time 1 MASQ 502 033 23158 1575
Stress 006 000 8963 12470
Neuroticism 080 033 596 1575
Dysfunctional Attitudes -052 051 -106 1575
Dysfunctional Attitudes times Stress 002 001 774 12470
______________________________________________________________________
Note Time 1 CES-D = Time 1 Center for Epidemiological Studies Depression Scale
Stress = Within-Subject Fluctuations in General Academic Social Hassles Scale for
Students (GASHSS) scores during the follow-up interval Neuroticism = NEO Five
Factor Inventory Neuroticism subscale Dysfunctional Attitudes = Dysfunctional
Attitudes Scale Time 1 MASQ = Time 1 Mood and Anxiety Symptom Questionnaire
Overall Anxiety subscale p lt 05 p lt 01 p lt 001
32
FIGURES
Figure 1 Predicted slope of the relationship between stress and depressive
symptoms (left panel) and anxious symptoms (right panel) as a function of
dysfunctional attitudes
20
25
30
Low High
Pre
dic
ted
CE
S-D
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
25
30
35
40
Low High
Pre
dic
ted
MA
SQ
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
Intercept Intercept
iii
Table of Contents
Title Page i
Abstract ii
Table of Contents iii
List of Tables and Figures iv
Section I Introduction 1
Section II Methods 8
Section III Results 11
Section IV Discussion 16
Section V References 22
Section VI Tables and Figures 27
iv
List of Tables and Figures
Table 1 Demographic Variables 27
Table 2 Means Standard Deviations and Inter-correlations Between Time 1
Measures 28
Table 3 Dysfunctional Attitudes Predicting Within-Subject Fluctuations in
CES-D (Upper Section) and MASQ (Lower Section) Scores during the
Follow-up Interval 29
Figure 1 Predicted slope of the relationship between stress and depressive
symptoms (Left Panel) and anxious symptoms (Right Panel) as a function of
dysfunctional attitudes 30
1
INTRODUCTION
Depression in China
The results of epidemiological studies suggest that the prevalence rate of depression in
China has been rising in recent decades More specifically whereas research conducted
during the 1980s estimated the point-prevalence rate of depression to be 03 (Xiang
1986) research conducted during the 1990s estimated it to be 14 (Murray amp Lopez
1996) More recently findings from a comprehensive epidemiological survey
conducted within China yielded a one-month prevalence rate of depression of 60
(Phillips et al 2009) In response to this upward trend depression has become a major
public health concern in China increasingly drawing the attention of both Chinese and
Western mental health researchers One demographic group within Chinarsquos population that
has received considerable attention is Chinarsquos university student population Although no
formal epidemiological studies have been conducted examining the prevalence rate of
depression among university students recent reports in the Chinese media highlight the
growing problem of depression among this demographic (eg Qiang 2006) Most distressing
in these reports is the strong association noted between depression and suicidal behavior
Estimated mortality rates reveal that suicide is the leading cause of death among
Chinese young adults between the ages of 15 and 34 (Philipps Li amp Zhang 2002)
Despite these findings however little research has examined models of the etiology of
depression in university students in mainland China Furthermore of the studies
conducted the majority are cross-sectional providing little insight into causal
mechanisms
2
Cognitive Vulnerability-Stress Models of Depression
One theoretical perspective that has proven useful in understanding the
development of depression in Western young adults is the cognitive vulnerability-stress
perspective (Abela amp Hankin 2008) Cognitive theories of depression define
vulnerability as an internal and stable feature of an individual that predisposes himher
to develop depression following the occurrence of negative events (Ingram Miranda amp
Segal 1998) Cognitive models are fundamentally diathesis-stress models in that they
posit that depression is produced by the interaction between cognitive vulnerability
factors (the diatheses) and certain environmental conditions (the stressors) that trigger
such diatheses into operation (Ingram et al 1998) Evidence suggests that under
ordinary conditions individuals vulnerable to depression are indistinguishable from the
general population Only when confronted with certain stressors do differences between
vulnerable and non-vulnerable individuals emerge (Ingram et al 1998 Ingram amp
Luxton 2005 Monroe amp Simons 1991) For individuals who possess cognitive
vulnerability factors negative events trigger a pattern of negatively biased self-referent
information processing that initiates a downward spiral into depression Non-vulnerable
individuals react to such events with an appropriate level of distress and depressive
affect but do not spiral downwards into depression
Beckrsquos Cognitive Theory of Depression
One prominent cognitive vulnerably-stress model of depression is Beckrsquos (1967
1983) cognitive theory Central to Beckrsquos cognitive theory is the construct of schema
Beck defines schema as stored bodies of knowledge (ie mental representations of the
3
self and prior experiences) that are relatively enduring characteristics of a persons
cognitive organization When an individual is confronted with a situation the schema
most relevant to the situation is activated Schema activation subsequently influences
how the person perceives encodes and retrieves information regarding the situation
Beck proposed that certain individuals posses depressogenic schema that confer
vulnerability to depression Beck (1983) hypothesizes that depressogenic schemata are
typically organized as sets of dysfunctional attitudes such as ldquoI am nothing if a person I
love doesnrsquot like merdquo or ldquoIf I fail at my work then I am a failure as a personrdquo Among
individuals who possess depressogenic schema the occurrence of negative events
triggers a pattern of negatively biased self-referent information processing
characterized by negative errors in thinking (eg negatively skewed interpretations of
negative life events such as overgeneralization and catastrophizing) Negative errors in
thinking increase the likelihood that the individual will develop the negative cognitive
triad comprising three types of depressogenic thought patterns (1) negative views of
the self (eg the belief that one is deficient inadequate or unworthy) (2) negative
views of the world (eg construing life experiences in terms of themes of defeat or
disparagement) and (3) negative views of the future (eg the expectation that ones
difficulties will persist into the future and there is nothing one can do to change this)
According to the theory the development of the negative cognitive triad triggers the
onset of depressive symptoms
Research Support for Beckrsquos Cognitive Model of Depression
Prospective studies using Western university student samples have provided
support for Beckrsquos (1967 1983) cognitive theory of depression More specifically
4
several studies have found that dysfunctional attitudes interact with the occurrence of
negative life events to predict increases in depressive symptoms (Hankin Abramson
Miller Haeffel 2004 Hankin Fraley amp Abela 2005 Joiner Metalsky Lew amp Klocek
1999 Klocek Oliver amp Ross 1997 Brown Hammen Craske and Wickens 1995) as
well as a greater likelihood of developing a depressive episode (Hankin et al 2004) In
addition individuals possessing a high level of dysfunctional attitudes have been found
to be more likely to report a past history of depressive episodes (Alloy et al 2000) and
to experience future depressive episodes (Alloy et al 2006 Hankin et al 2004) than
individuals without such a vulnerability
Far less research has examined the applicability of Beckrsquos (1983 1967)
cognitive theory to Chinese samples Preliminary cross-sectional research however
has yielded findings consistent with the theoriesrsquo hypotheses For example Xu Li and
Wang (2007) found that psychiatric patients diagnosed with major depressive disorder
showed significantly higher levels of dysfunctional attitudes than did non-depressed
controls Simiarly Bian Yang and Li (2007) reported higher levels of dysfunctional
attitudes in remitted depressives as compared to normal controls Last several studies
conducted with Chinese university students have found higher levels of dysfunctional
attitudes ndash particularly those centered on themes of perfectionism - to be associated
with higher levels of psychiatric symptoms (eg Yang amp Zhang 2004 Yang 2007
Fang Qian Luo amp Zi 2009)
5
Goals of the current study
The primary goal of the current study was to examine the applicability of
Beckrsquos (1967 1983) cognitive theory of depression to university students in mainland
China The procedure involved an initial assessment during which students completed
measures assessing dysfunctional attitudes and symptoms of depression The procedure
also involved a series of six follow-up assessments occurring once a month for six
months during which symptoms of depression and the occurrence of negative events
were assessed The use of a multi-wave longitudinal design allowed us to take an
idiographic approach towards examining the diathesis-stress hypotheses of Beckrsquos
(1967 1983) theory More specifically we examined whether the slope of the
relationship between negative events and symptoms of depression within participants
varied across participants as a function of level of dysfunctional attitudes In line with
the vulnerability-stress hypothesis of Beckrsquos (1967 1983) cognitive theory we
hypothesized that higher levels of dysfunctional attitudes would be associated with
greater increases in depressive symptoms following the occurrence of negative events
The second objective of the current study was to examine the specificity of
dysfunctional attitudes as a predictor of depressive symptoms Beckrsquos (1967 1983)
theory posits that dysfunctional attitudes predict the development of depressive
symptoms but not symptoms of other forms of psychopathology Prospective studies
using Western university student (Alloy et al 2000 2006 Hankin Abramson Miller
amp Haeffel 2004) and adolescent samples (Hankin Wetter Cheely amp Oppenheimer
2008) have provided support for the specificity hypothesis of the theory More
specifically dysfunctional attitudes have been found to interact with negative events to
6
predict increases in depressive symptoms but not symptoms of anxiety or other
disorders in both university student (Hankin et al 2004) and adolescent samples
(Hankin et al 2008) Similarly although university students possessing a high level of
dysfunctional attitudes have been found to be more likely than other university students
to report a past history of depressive episodes (Alloy et al 2000) and to experience
future depressive episodes (Alloy et al 2006) they have not been found to differ from
their low-risk counterparts in terms of past history or future occurrence of other
psychological disorders (Alloy et al 2000 2006)
With respect to the current study it is possible that differences may emerge
between Chinese and Western samples in terms of the types of symptoms predicted by
dysfunctional attitudes More specifically cultural psychopathologists have proposed
that cultural factors shape the phenomenology of psychiatric symptoms as well as the
conceptualization and classification of disorders (Kleinman 2004 Mezzich et al
1999) As such the experience of psychopathology may exhibit unique features in
different cultures with diagnostic categories developed in one cultural context not being
valid in another (Kleinman 1977 1996) Neuresthenia known in China as shenjing
shuairuo (SJSR) is a diagnostic entity characterized by (1) physical and mental
weakness and fatigability (2) sleep disturbances (3) irritability and worry (4)
excitability (5) nervous pain and (6) memory difficulty (Taylor 2001) Historically
SJSR was a Western disease concept that subsequently evolved to become a widely
utilized diagnostic entity within China (Lee amp Wong 1995) Some cultural
psychopathologists have posited that SJSR represents a somatized form of depression
This claim however has been met with significant controversy (eg Lee 1997
7
Parker Gladstone amp Chee 2001 Xu JM 1987 Xu YX 1994 Zhang 1995)
Critics dispute the notion that Chinese psychiatric patients are ldquosomatizersrdquo who
manifest few or no emotional symptoms and who attribute distress to physical causes
Rather they argue that SJSR gained widespread acceptance in China as it was a non-
stigmatizing diagnosis that allowed individuals experiencing psychosocial distress to
seek help during a time in which traditional cultural beliefs and political influences led
to severe sanction and stigmatization of individuals suffering from mental illnesses
(Lee 1998 1999 Phillips 1998 Shixie 1989) At the same time other Chinese
researchers and clinicians have continued to defend neurasthenia as both a valid
diagnostic category and a clinically useful means of communicating with patients (Rin
amp Huang 1989 Yan 1989 Young 1989) Due to continued debate on this topic it is
essential that researchers examining models of vulnerability to depression within China
assess multiple symptom outcomes as the types of symptoms predicted by vulnerability
factors may vary as a function of cultural context Hence in the current study we also
assessed levels of anxious symptoms to provide a test of the specificity hypothesis of
Beckrsquos (1967 1983) cognitive theory
In order to provide a powerful examination of our hypotheses concerning (1) the
applicability of the diathesis-stress component of Beckrsquos (1967 1983) cognitive theory
to Chinese university students and (2) the specificity of dysfunctional attitudes as
predictors of depressive as opposed to anxious symptoms participantsrsquo scores on the
neuroticism subscale of the Five-factor Inventory (FFI-N) were included as a control
variable in all analyses Several critical reviews of the literature examining theories of
cognitive vulnerability to depression (eg Barnett amp Gotlib 1998 Coyne amp Whiffen
8
1995) have argued that cognitive vulnerabilities to depression such as that featured in
Beckrsquos cognitive theory may be equivalent to or reducible to trait neuroticism and thus
may not confer independent risk for depression In response to such claims a recent
study conducted with university students examining the degree of factorial
independence versus overlap between trait neuroticism and dysfunctional attitudes has
shown them to be distinct constructs each loading onto separate factors (Hankin et al
2007) At the same time however there remains a need to examine whether
dysfunctional attitudes and trait neuroticism represent unique risk factors for
depression particularly in young adults in China Hence in the current study
participantsrsquo scores on the neuroticism subscale of the Five-factor Inventory (FFI-N)
were included as a control variable in order to account for any of the variance in
fluctuations in depressive (and anxious) symptoms that may be shared between
dysfunctional attitudes and trait neuroticism thereby isolating and highlighting their
unique predictive effects
METHOD
Participants
Participants included 662 university students (aged 19-21) from Changsha ndash an
industrial city in the province of Hunan with a population of approximately 6000000
In terms of the annual gross domestic product Hunan ranks 23rd
(10336 RMB) out of
the 34 provinces in China placing it well below the national provincial average (micro =
29719 RMB SD = 47462 RMB National Bureau of Statistics of China 2006)
Demographic variables for the sample are presented in Table 1
9
Procedure
Consent forms were distributed to all students in participating classes Consent
rates were greater than 95 in all the classes After consent forms were collected
researchers returned to the school to meet with participating students Written consent
was obtained from each participant at the beginning of the initial assessment During
the initial assessment students completed a demographics form and each of the
following questionnaires (1) Center for Epidemiological Studies Depression Scale
(CES-D Radloff 1977) (2) Mood and Anxiety Symptom Questionnaire (MASQ
Clark amp Watson 1991) (3) Dysfunctional Attitudes Scale (DAS Weissman amp Beck
1978) and (4) NEO Five Factor Inventory- Neuroticism Subscale (FFI-N Costa amp
McCrae 1992) Once a month for the subsequent six-months researchers returned to
the school and met with participating students to conduct follow-up assessments At
each of these follow-up assessments students were asked to complete each of the
following questionnaires (1) CES-D (2) MASQ and (3) the General Academic
Social Hassles Scale for Students (GASHSS Blankstein amp Flett 1993)
Measures
The Chinese versions of all self-report measures were developed using the
back-translation method Original English versions were translated into Chinese by a
bilingual translator from the Psychology department at Second Xiangya Medical
College of Central South University Hunan Translated Chinese versions were then
back-translated into English by another bilingual translator from the Psychology
department at McGill University Quebec Original versions were then compared with
the back-translation If inconsistencies were found in the back-translation translators
10
worked together to make corrections to the final Chinese versions until all final
versions were agreed upon No items from any of the measures were removed or
significantly altered during the translation process
Depressive Symptoms Center for Epidemiological Studies Depression Scale
(CES-D Radloff 1977) The CES-D is a 20-item self-report measure designed to
assess depressive symptoms in the general population For each item participants are
asked to indicate how often they experienced the particular symptom over the last
week Responses range from 1 (eg rarely or none of the time) to 4 (eg most or all of
the time) Scores range from 20-80 with higher score indicating higher levels of
depressive symptoms In the current study the CES-D exhibited high internal
consistency with Cronbachrsquos alpha values ranging from 90 to 94 (micro = 2918 SD =
814) over the 7 time points
Anxious Symptoms Mood and Anxiety Symptom Questionnaire (MASQ
Watson amp Clark 1991) The MASQ is a 62-item questionnaire designed to assess both
specific and nonspecific depressive and anxious symptoms For each item participants
are asked to rate on a scale of 1 to 5 the extent to which they have felt this way ldquoduring
the past 24 hoursrdquo Within the current study we utilized the anxious symptoms (11
items) and anxious arousal (17 items) subscales which together provide an index of
overall anxious symptoms Higher scores on each subscale reflect greater levels of
anxious symptoms In the current study the MASQ exhibited high internal consistency
with Cronbachrsquos alpha values ranging from 90 to 95 (micro = 3847 SD = 1117) over the
7 time points
11
Dysfunctional Attitudes Dysfunctional Attitudes Scale (DAS Weissman amp
Beck 1978) The DAS (Form A) is a 40-item questionnaire designed to measure the
cognitive vulnerability factor featured in Beckrsquos cognitive theory Examples of items
include ldquoIf I do not do well all the time people will not respect merdquo ldquoIf a person asks
for help it is a sign of weaknessrdquo and ldquoMy value as a person depends greatly on what
others think of merdquo Items are rated on a 7-point Likert scale ranging from 1 (totally
disagree) to 7 (totally agree) providing a range of scores from 40 to 280 with higher
scores reflecting more dysfunctional attitudes In the current study the DAS exhibited
high internal consistency with Cronbachrsquos alphas of 89 and 88 obtained for the first
and second administrations respectively In addition a test-retest reliability coefficient
of 72 was obtained indicating strong stability over time
Neuroticism NEO Five Factor Inventory - Neuroticism Subscale (FFI-N
Costa amp McCrae 1992) The FFI-N is a 12- item self-report measure that assesses
neuroticism Examples of questions include I often feel inferior to others I am
seldom sad or depressed and Sometimes I feel completely worthless Items are rated
on a 5-point Likert scale ranging from 0 (strongly disagree) to 4 (strongly agree)
providing scores ranging from 0 to 48 with higher scores indicating higher levels of
neuroticism The NEO-FFI-N has proven reliable across different cultural samples and
item pools (Costa amp McCrae 1992) In the current study Cronbachs alpha was 81
indicating strong internal consistency
Negative Life Events General Academic Social Hassles Scale for Students
(GASHSS Blankstein amp Flett 1993) Participants completed a 30-item abbreviated
version of the GASHSS The measure is comprised of items assessing general hassles
12
(8 items) academic hassles (10 items) and social hassles (12 items) For each item
participants are asked to rate how persistent the given hassle was (ie its frequency and
duration) over the last 30 days (0 = no hassle not at all persistent to 6 = extremely
persistent hassle high frequency andor duration)
13
RESULTS
Descriptive Data
Means standard deviations and inter-correlations between Time 1 measures are
presented in Table 2
Prospective Diathesis-Stress Analyses - Depression
Multilevel modeling was used to test our hypothesis that higher levels of dysfunctional
attitudes would be associated with greater increases in depressive symptoms following
increases in stress Analyses were carried out using the SAS (version 81) MIXED
procedure and maximum likelihood estimation Our dependent variable was within-
subject fluctuations in CES-D scores during the follow-up interval (DEPRESSION)
Our primary predictors of DEPRESSION were DAS scores (DYSFUNCTIONAL
ATTITUDES) and fluctuations in GASHSS scores during the follow-up interval
(STRESS) As DYSFUNCTIONAL ATTITUDES is a between-subject predictor DAS
scores were standardized prior to analyses As STRESS is a within-subject predictor
STRESS reflects upward or downward fluctuations in an individualrsquos level of stress
compared to hisher mean level of stress
When fitting hierarchical linear models one must specify appropriate mean and
covariance structures Mean structures refer to the various fixed and random effect
components that can be included in the model Covariance structures refer to alternative
methods of specifying the pattern of covariance between observations taken from the
same subject at different time points It is important to note that mean and covariance
structures are not independent of one another Rather an appropriate covariance
structure is essential in order to obtain valid inferences for the parameters in the mean
14
structure Overparametrization of the covariance structure can lead to inefficient
estimation and poor assessment of standard errors (Altham 1984) On the other hand
too much restriction of the covariance structure can lead to invalid inferences when the
assumed structure does not hold (Altham 1984)
In our first set of analyses we were interested in examining the effects of
DYSFUNCTIONAL ATTITUDES STRESS and the DYSFUNCTIONAL
ATTITUDES STRESS interaction on participantrsquos CES-D scores during the follow-
up interval Consequently in line with Diggle Liang and Zegers (1994)
recommendation that one use a ldquosaturatedrdquo model for the mean structure while
searching for an appropriate covariance structure we chose a mean structure that
included DYSFUNCTIONAL ATTITUDES STRESS and the DYSFUNCTIONAL
ATTITUDES STRESS interaction Four additional effects were also included in this
mean structure First as different individuals report different levels of depressive
symptoms when at their own average level of stress a random effect for intercept was
included in the model Second given that STRESS is a within-subject predictor whose
effect is expected to vary from participant to participant a random effect for slope was
included in the model Third in order to control for individual differences in baseline
levels of depressive symptoms Time 1 CES-D scores were included in the model
Fourth in order to examine whether DYSFUNCTIONAL ATTITUDES represent a
vulnerability factor independent of neuroticism participantsrsquo FFI-N scores were
entered in the model
Commonly used covariance structures in studies in which multiple responses
are obtained from the same individual over time (and consequently within-subject
15
residuals over time are likely to be correlated) include compound symmetry first-order
autoregressive heterogeneous autoregressive and banded Toeplitz In order to select
one of these covariance structures for our analyses we fitted models using each
structure and chose the ldquobestrdquo fit based on Akaike information criterion (AIC and
AICC) and Schwarz Bayesian criterion (BIC) In all cases the best fit for our data was
a first-order heterogeneous autoregressive structure (ARH [1]) After choosing the
appropriate covariance structure we next examined the random-effects component of
our model
With respect to random effects the ARH [1] parameter (r = 31 plt001)
RE_INTERCEPT (plt001) and RE_SLOPE (plt001) were each significant and thus
were retained in the model The final results with respect to the fixed-effects
component of the model are presented in the upper section of Table 3 Of primary
importance the DYSFUNCTIONAL ATTITUDES STRESS interaction was a
significant predictor of fluctuations in depressive symptoms during the follow-up
interval In order to examine the form of this interaction the model summarized in the
upper section of Table 3 was used to calculate predicted CES-D scores for individuals
exhibiting either high or low levels of dysfunctional attitudes (plus or minus 15 SD)
who are experiencing either high or low levels of stress in comparison to their own
average level of stress (plus or minus 15 times mean within-subject SD) The results of
such calculations are presented in the left panel of Figure 1
Analyses were conducted for each DYSFUNCTIONAL ATTITUDES
condition examining whether the slope of the relationship between stress and
depressive symptoms significantly differed from 0 Analyses indicated that both
16
individuals exhibiting high (t(2459) = 862 p lt 0001) and low (t(2459) = 347 p lt
0001) levels of dysfunctional attitudes reported significantly higher levels of
depressive symptoms when experiencing high levels of stress than when experiencing
low levels of stress Planned comparisons of the slopes of the relationship between
stress and depressive symptoms however revealed that the slope was significantly
greater in individuals exhibiting high levels of dysfunctional attitudes (slope = 013)
than in individuals exhibiting low levels of dysfunctional attitudes (slope = 005
t(2459) = 328 p = 0001)
Prospective Diathesis-Stress Analyses - Anxiety
The same data-analytic approach as described above was used to examine
whether higher levels of dysfunctional attitudes would be associated with greater
increases in anxious symptoms following increases in stress Again in order to examine
whether DYSFUNCTIONAL ATTITUDES represent a vulnerability factor
independent of neuroticism participantsrsquo FFI-N scores were entered in the model
With respect to random effects the ARH[1] parameter (r = 23 p lt 001)
RE_INTERCEPT (plt001) and RE_SLOPE (plt001) were each significant and thus
were retained in the model The final results with respect to the fixed-effects
component of the model are presented in the lower section of Table 3 Of primary
importance the DYSFUNCTIONAL ATTITUDES STRESS interaction was a
significant predictor of within-subject fluctuations in anxious symptoms during the
follow-up interval In order to examine the form of this interaction the model
summarized in the lower section of Table 3 was used to calculate predicted MASQ
scores for individuals exhibiting either high or low levels of dysfunctional attitudes
17
(plus or minus 15 SD) who are experiencing either high or low levels of stress in
comparison to their own average level of stress (plus or minus 15 times mean within-
subject SD) The results of such calculations are presented on the right panel of in
Figure 1
Analyses were conducted for each DYSFUNCTIONAL ATTITUDES
condition examining whether the slope of the relationship between stress and anxious
symptoms significantly differed from 0 Analyses indicated that both individuals
exhibiting high (t(2470) = 768 p lt 0001) and low (t(2470) = 337 p lt 0001) levels of
dysfunctional attitudes reported higher levels of anxious symptoms when experiencing
high levels of stress than when experiencing low levels of stress Planned comparisons
of the slopes of the relationship between stress and anxious symptoms however
revealed that the slope was significantly greater in individuals exhibiting high levels of
dysfunctional attitudes (slope = 009) than in individuals exhibiting low levels of
dysfunctional attitudes (slope = 003 t(2470) = 278 p lt 001)
Additional Analyses
Given that the DYSFUNCTIONAL ATTITUDES STRESS interaction
prospectively predicted both symptoms of depression and anxiety two additional
analyses were conducted in order to examine (1) whether the DYSFUNCTIONAL
ATTITUDES STRESS interaction continued to be a significant predictor of within-
subject fluctuations in depressive symptoms after controlling for within-subject
fluctuations in anxious symptoms and (2) whether the DYSFUNCTIONAL
ATTITUDES STRESS interaction continued to predict within-subject fluctuations in
anxious symptoms after controlling for within-subject fluctuations in depressive
18
symptoms Such analyses allowed us to examine whether the above mentioned pattern
of findings may have been due to the high correlation observed in the current study
between depressive and anxious symptoms
Analyses were conducted in the same manner as described above with the
exception that an additional within-subject variable (ie DEPRESSION or ANXIETY)
was included in each model in order to control for within-subject fluctuations in the
alternate symptom With respect to the prediction of depressive symptoms the
DYSFUNCTIONAL ATTITUDES STRESS interaction remained a significant
predictor after controlling for within-subject fluctuations in anxious symptoms (β =
001 SE = 000 F = 410 p lt 05) With respect to the prediction of anxious
symptoms however the DYSFUNCTIONAL ATTITUDES STRESS interaction
was no longer a significant predictor after controlling for within-subject fluctuations in
depressive symptoms (β = 001 SE = 000 F = 148 p = 22)
DISCUSSION
The results of the current study provide support for the cross-cultural
applicability of Beckrsquos (1967 1983) cognitive theory to university students in Hunan
China More specifically consistent with hypotheses and with results obtained from
past research examining Beckrsquos cognitive theory in Western samples of university
students (Hankin et al 2004 Hankin et al 2005 Joiner et al 1999 Klocek et al
1997 Brown et al 1995) higher levels of dysfunctional attitudes were associated with
greater increases in depressive symptoms following increases in negative event
frequency during the six-month follow-up interval Given the considerable differences
between the current sample and Western samples in terms of demographic
19
characteristics and cultural factors such a finding strongly attests to the robustness of
Beckrsquos cognitive theory Moreover integrating the current findings with those obtained
in research examining Beckrsquos theory in other non-Western samples suggests that
Beckrsquos theory may represent a powerful explanatory model of the development of
depressive symptoms among individuals from diverse cultural settings For example
consistent with the theory higher levels of dysfunctional attitudes have been shown to
be associated with higher levels of depressive symptoms in Japanese (Tanaka et al
2006) Puerto-Rican (Bonilla Bernal Santos amp Santos 2003) Turkish (Sahin amp Sahin
1992) Norwegian (Chioqueta amp Stiles 2004) Singaporean (Oei Goh amp Kwon 1996)
and Swedish (Ohrt amp Thorell 1998) adult samples In addition it is important to note
that the current findings expand upon past correlational research examining the
association between dysfunctional attitudes and depression in Chinese samples through
the use of a multi-wave longitudinal design
When examining the specificity of dysfunctional attitudes as a predictor of
depressive symptoms the current study did not obtain support for specificity More
specifically contrary to the specificity hypothesis of Beckrsquos cognitive theory and to
results obtained in Western samples of university students (Alloy et al 2000 2006
Hankin et al 2004) higher levels of dysfunctional attitudes were associated with
greater increases in both depressive and anxious symptoms following increases in
negative event frequency There are two alternative ways of interpreting the non-
specificity finding observed in the current study First it is possible that the types of
thoughts individuals possessing high levels of dysfunctional attitudes experience
following negative events varies as a function of cultural context In other words in
20
Western samples such individuals may primarily experience the types of cognitions
that are associated with the development of depressive symptoms (ie appraisals of
personal loss and failure) In contrast in Chinese samples individuals possessing high
levels of dysfunctional attitudes may experience a wider array of cognitions some of
which are associated with the development of depressive symptoms and some of which
are associated with the development of anxious symptoms (ie evaluations of
impending threat or danger) Such an explanation would be consistent with Beckrsquos
cognitive content-specificity hypothesis (Clark amp Beck 1999) which posits that each
affective state and psychological disorder has a specific cognitive profile Second it is
possible that the types of symptoms individuals possessing high levels of dysfunctional
attitudes experience following negative events varies as a function of cultural context
More specifically it may be that dysfunctional attitudes specifically predict symptoms
of depression in both samples except that in Western samples depression manifests in
pure depressive symptoms whereas in Chinese samples depression manifests as a
combination of depressive and anxious symptoms Such an explanation would be
consistent with cultural psychopathologistsrsquo hypotheses that cultural factors shape the
phenomenology of psychiatric symptoms (Kleinman 2004 Mezzich et al 1999)
Moreover dysfunctional attitudes predicting a combination of depressive and anxious
symptoms in Chinese samples would be consistent with the construct of neurasthenia -
a construct hypothesized by some to represent a somatized form of depression that is
still widely seen within China (Lee amp Wong 1995)
Interesting in this regard and perhaps speaking to the primacy of depressive
symptoms in the current findings analyses indicated that the DYSFUNCTIONAL
21
ATTITUDES times STRESS interaction no longer predicted anxious symptoms after
controlling for depressive symptoms The reverse however was not true as the
DYSFUNCTIONAL ATTITUDES times STRESS interaction continued to predict
depressive symptoms after controlling for anxious symptoms
It is important to note that the current study employed a particularly
conservative approach to analyses in that we examined the effects of dysfunctional
attitudes on depressive and anxious symptoms after controlling for the effect of
neuroticism on such symptoms Providing particularly powerful support for Beckrsquos
(1967 1983) cognitive theory across analyses dysfunctional attitudes predicted levels
of depressive andor anxious symptoms experienced during the six month follow-up
interval independent of the effect of neuroticism Thus contrary to past critical reviews
of the cognitive literature (Barnett amp Gotlib 1998 Coyne amp Whiffen 1995) and
consistent with past findings (Hankin et al 2007) the current results indicate that
cognitive vulnerabilities to depression such as dysfunctional attitudes are not reducible
to trait neuroticism but rather represent factors that confer independent risk for
depression
Limitations and Future Directions
Several limitations of the current study should be noted First self-report
measures were used to assess depressive and anxious symptoms Although the CES-D
and MASQ both possess high degrees of reliability and validity it is difficult to draw
conclusions about clinically diagnosed depression or anxiety based on self-report
questionnaires Second self-report measures were used to assess stress Although
measures of stress that require participants only to indicate whether or not an event
22
occurred are less likely to be influenced by informant bias than those that ask
participants to rate the subjective impact of each event more sophisticated methods of
analysis such as interviewing procedures that assess contextual threat may provide
better assessments of stress Third the measures of dysfunctional attitudes stress and
depressive and anxious symptoms used in the current study were each Western-
developed Future research should examine these hypotheses using indigenous
measures in addition to Western-developed measures in order to assess possible
similarities andor differences in patterns of findings Fourth the current study only
examined depression and anxiety as symptom outcomes Future research conducted
within China should examine a wider array of symptom outcomes such as
somatization physical complaints and externalizing behaviors in order to provide a
more thorough and culturally sensitive test of the specificity hypotheses of Beckrsquos
cognitive model Fifth the current study examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese undergraduate students and thus the extent to which
our findings may be generalized to other demographics within Chinarsquos population is
unclear Last the current study broadly examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese university students Future research should examine
the constructs and processes posited by this model in greater detail in order to develop a
deeper understanding of how they may be uniquely molded by socio-cultural factors
Such research would benefit from examining the specific types of stressors experienced
by Chinese university students as they may vary as a function of socio-cultural factors
from those experienced by Western undergraduates For example severe pressure to
succeed academically in order to secure access to a limited number of post-
23
undergraduate educational opportunities - one of the few paths towards upward
mobility available to Chinese students seeking secure and gainful employment in what
has increasingly become a very highly competitive job market - may represent a
particularly salient stressor for the development of depressive symptoms among this
population (Qiang 2006)
In conclusion the results from the current study provide support for the
applicability of Beckrsquos cognitive theory to university students in mainland China More
specifically consistent with findings obtained in the West results indicate that
dysfunctional attitudes confer vulnerability to the development of depressive symptoms
following the occurrence of negative events in Chinese university students At the same
time however the current findings suggest cultural variation in the profile of
symptoms which emerge following the occurrence of negative events in cognitively
vulnerable individuals in Western and Chinese samples Specifically whereas in the
West dysfunctional attitudes have been shown to confer vulnerability to depressive
symptoms in Chinese university students dysfunctional attitudes appear to confer
vulnerability to a combined depressive and anxious symptom profile Future research
using more sophisticated assessments of stress and depressive symptoms more diverse
samples and symptom outcome measures and indigenously-developed measures is
likely to enhance our understanding of the cognitive and environmental mechanisms
underlying the development of depression in Chinese university students Discovering
that cognitive theories of vulnerability to depression extend to university students in
China highlights the potential role for cognitive-behavioral depression prevention and
treatment interventions in stemming the tide of distress experienced by this population
24
REFERENCES
Abela J R Z amp Hankin B L (2008) Cognitive vulnerability to depression in
children and adolescents A developmental psychopathology perspective In J
R Z Abela and B L Hankin (Eds) Handbook of child and adolescent
depression (pp 35-78) New York The Guilford Press
Alloy L B Abramson L Y Hogan M E Whitehouse W G Rose D T
Robinson MS Kim R S amp Lapkin J B (2000) The Temple-Wisconsin
cognitive vulnerability to depression project Lifetime history of axis-I
psychopathology in individuals at high and low cognitive risk for depression
Journal of Abnormal Psychology 109 403-418
Alloy L B Abramson L Y Whitehouse W G Hogan M E Panzarella C amp
Rose D T (2006) Prospective incidence of first onsets and recurrences of
depression in individuals at high and low cognitive risk for depression Journal
of Abnormal Psychology 115 145ndash156
Altham P M E (1984) Improving the precision of estimation by fitting a model
Journal of the Royal Statistical Society Series B 46 11
Barnett PA amp Gotlib I H (1988) Psychosocial functioning and depression
Distinguishing among antecedents concomitants and consequences
Psychological Bulletin 104 97-126
Beck AT (1967) Depression Clinical experimental and theoretical aspects New
York Harper amp Row
Beck AT (1983) Cognitive therapy of depression New perspectives In PJ Clayton
amp JE Barrett (Eds) Treatment of depression Old controversies and new
approaches New York Raven Press
Bian Q Yang K amp Li C (2007) Dysfunctional attitudes of patients with depression
or bipolar disorder Chinese Mental Health Journal 21 759-761
Blankstein K R amp Flett G L (1993) Development of the General Academic and
Social Hassles Scales for Students Unpublished manuscript
Bonilla J Bernal G Santos A amp Santos D (2003) A revised Spanish version of
the Beck Depression InventoryPsychometric properties with a Puerto Rican
sample of college students Journal of Clinical Psychology 60 119-130
Brown G P Hammen C L Craske M G amp Wickens T D (1995) Dimensions of
dysfunctional attitudes as vulnerabilities to depressive symptoms Journal of
Abnormal Psychology 104 431-435
25
Chioqueta A P amp Stiles T C (2004) Psychometric properties of the Norweigian
version of the Dysfunctional Attitude Scale (Form A) Cognitive Behaviour
Therapy 33 83-86
Clark DA amp Beck AT (1999) Cognitive theory and therapy of depression New
York John Wiley amp Sons Inc
Clark L A amp Watson D (1991) Tripartite model of anxiety and depression
Psychometric evidence and taxonomic implications Journal of Abnormal
Psychology 100 316ndash336
Costa P T amp McCrae R R (1992) NEO PI-R Professional manual Revised NEO
personality inventory NEO PR-R and NEO five-factor inventory NEO-RRI
Odessa FL Psychological Assessment Resources
Coyne J C amp Whiffen V E (1995) Issues in personality as diathesis for depression
The case of sociotropy-dependency and autonomy-self-criticism Psychological
Bulletin 118 358-378
Fang X Qian M Luo S amp Zi F (2009) A correlational study on college students
perfectionism parental rearing patterns and mental health Chinese Mental
Health Journal 23 56-59
Hankin B L Abramson L Y Miller N amp Haeffel G (2004) Cognitive
vulnerability-stress theories of depression Examining affective specificity in
the prediction of depression versus anxiety in three prospective studies
Cognitive Therapy and Research 28 309ndash345
Hankin BL Fraley RC amp Abela JRZ (2005) Daily depression and cognitions
about stress Evidence for a traitlike depressogenic cognitive style and the
prediction of depressive symptoms in a prospective daily diary study Journal of
Personality and Social Psychology 88 673-685
Hankin B L Lakdawalla Z Carter I L Abela J R Z amp Adams P (2007) Are
neuroticism cognitive vulnerabilities and self-esteem overlapping or distinct
risks for depression Evidence from confirmatory factor analyses Journal of
Social amp Clinical Psychology 26 29-63
Hankin B L Wetter E Cheely C amp Oppenheimer C W (2008) Becks cognitive
theory of depression in adolescence Specific prediction of depressive
symptoms and reciprocal influences in a multi-wave prospective study
International Journal of Cognitive Therapy 1 313-332
Ingram R E Miranda J amp Segal Z V (1998) Cognitive Vulnerability to
Depression New York NY Guilford Press
26
Ingram R E amp Luxton DD (2005) Vulnerability-stress models In BL Hankin amp
JRZ Abela (Eds) Development of psychopathology A vulnerability-stress
perspective (pp 32-46) Thousand Oaks CA Sage
Joiner T E Metalsky G I Lew A amp Klocek J (1999) Testing the causal
mediation component of Becks theory of depression Evidence for specific
mediation Cognitive Therapy and Research 23 401-412
Kleinman A (2004) Culture and depression New England Journal of Medicine 351
951-953
Kleinman A (1977) Depression somatization and the new cross-cultural psychiatry
Social Science and Medicine 11 3-10
Kleinman A (1996) How is culture important for DSM-IV In J E Mezzich A
Kleinmam H Fabrega Jr amp L Delores (Eds)Culture and psychiatric
diagnosis A DSM-IV perspective (pp 15-25) Washington DC US American
Psychiatric Association
Klocek J W Oliver J M amp Ross M J (1997) The role of dysfunctional attitudes
negative life events and social support in the prediction of depressive
dysphoria A prospective longitudinal study Social Behavior and Personality
25 23-136
Lee S (1997) A Chinese perspective on somatoform disorders Journal of
Psychosomatic Disorders 43 115-119
Lee S (1998) Estranged bodies simulated harmony and misplaced cultures
Neurasthenia in contemporary Chinese society Psychosomatic Medicine 60
448ndash457
Lee S (1999) Diagnosis postponed Shenjing shuairo and the transformation of
psychiatry in post-Mao China Culture Medicine and Psychiatry 23 349ndash380
Lee S amp Wong K C (1995) Rethinking neurasthenia the illness concepts of
shenjing shuairuo among Chinese undergraduates in Honk Kong Culture
Medicine and Psychiatry 19 91ndash111
Lee S Tsang A Huang YQ He YL Liu ZR Zhang MY Shen YC amp
Kessler RC (2009) The epidemiology of depression in metropolitan China
Psychological Medicine 39 735-747
Mezzich J E Kirmayer L J Kleinman A Fabrega Jr H Parron D L Good B
J Lin K amp Manson S M (1999) The place of culture in DSM-IV Journal
of Nervous and Mental Disease 187 457-464
27
Monroe S M amp Simons A D (1991) Diathesisndashstress theories in the context of life
stress research Implications for the depressive disorders Psychological
Bulletin 110 406ndash425
Murray C J L amp Lopez A D (1996) The global burden of disease Cambridge
Harvard University Press
National Bureau of Statistics of China (2006) The China 2005 statistical yearbook
China Statistics Press Beijing PR China
Oei T P S Goh Y Kwon S M(1996) A cross-cultural study of the integrated
cognitive model of depression Current Psychology of Cognition 15 265-281
Ohrt T amp Thorell L (1998) Dysfunctional Attitude Scale (DAS) Psychometrics and
norms of the Swedish version Scandinavian Journal of Behaviour Therapy 27
105-113
Parker G Gladstone G Chee KT (2001) Depression in the planetrsquos largest ethnic
group The Chinese American Journal of Psychiatry 158 857-864
Phillips M R Zhang J Shi Q Song Z Ding Z Pang S Li X Zhang Y amp
Wang Z (2009) Prevalence treatment and associated disability of mental
disorders in four provinces in China during 2001ndash05 an epidemiological
survey The Lancet 373 2041-2053
Phillips M R Li X amp Zhang Y (2002) Suicide rates in China Lancet 359 835-
840
Phillips M R (1998) The transformation of Chinarsquos mental health services The China
Journal 39 1ndash36
Qiang G (2006) Depression number one killer of Ivory Tower students China Daily
Retrieved from httpwwwchinadailycomcnchina2006-
1128content_744880htm
Radloff L S (1977) The CESndashD scale A self-report depression scale for research in
the general population Applied Psychological Measurement 1 385ndash401
Rin H amp Huang M G (1989) Neurasthenia as nosological dilemma Culture
Medicine and Psychiatry 13 215-226
Sahin NH amp Sahin N (1992) How dysfunctional are the dysfunctional attitudes in
another culture British Journal of Medical Psychology 65 17-26
Shixie L (1989) Neurasthenia in China Modern and traditional criteria for its
diagnosis Culture Medicine and Psychiatry 13 163-186
28
Tanaka N Uji M Hiramura H Chen Z Shikai N amp Kitamura T (2006)
Cognitive patterns and depression Study of a Japanese university student
population Psychiatry and Clinical Neuroscience 60 358-364
Taylor R E (2001) Death of neurasthenia and its psychological reincarnation a study
of neurasthenia at the National Hospital for the Relief and Cure of the Paralysed
and Epileptic Queen Square London 1870ndash1932 British Journal of
Psychiatry 179 550ndash557
Weissman A N amp Beck A T (1978 April) Development and validation of the
Dysfunctional Attitudes Scale A preliminary investigation Paper presented at
the annual meeting of the Educational Research Association Toronto Canada
Xiang M Z (1986) Epidemiological study of neuroses in 12 regions (districts) of
China Chinese Journal of Neurology and Psychiatry 19 87-91
Xu JM (1987) Some issues in the diagnosis of depression in China Canadian
Journal of Psychiatry 32 368-370
Xu Y X (1994) About ICD-10 Journal of Clinical Psychology and Medicine 4 224-
226
Xu Z Li Z amp Wang Z (2007) Dysfunctional attitudes and cognitive bias in major
depressive disorder Chinese Mental Health Journal 21 488-491
Yan H Q (1989) The necessity of retaining the diagnostic concept of neurasthenia
Culture Medicine and Psychiatry 13 139-145
Yang H (2007) The Test of the Chinese version of Frost Multi-dimensional
Perfectionism Scale Chinese Mental Health Journal 21 97-100
Yang H amp Zhang X (2004) Perfectionism and mental health of college students
(2004) Chinese Mental Health Journal 18 647-648
Young D (1989) Neurasthenia and related problems Culture Medicine and
Psychiatry 13 131-138
Zhang D (1995) Depression and culture A Chinese perspective Canadian Journal of
Counseling 29 227ndash233
29
TABLE(S)
Table 1 Demographic Variables
Age 2011
Gender Male
Female
472
523
Parentsrsquo Marital Status Married
Divorced
Single
Remarried
938
23
18
20
Fatherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
Government Official
51
356
187
95
124
91
Motherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
122
406
144
76
134
Fatherrsquos Education Some Primary School
Primary School
Some High School
High School
University
29
139
222
403
137
Motherrsquos Education Some Primary School
Primary School
Some High School
High School
University
63
192
264
350
76
Only Child No
Yes
331
667
Monthly Income lt 1000 RMB
1000 ndash 1500 RMB
1500 ndash 2000 RMB
2000 ndash 3000 RMB
3000 ndash 4000 RMB
4000 ndash 5000 RMB
gt 5000 RMB
334
204
175
140
59
20
20
30
Table 2 Means Standard Deviations and Inter-correlations Between Time 1 Measures
__________________________________________________________________
1 2 3
__________________________________________________________________
1 Depressive Symptoms 2963 (780)
2 Anxious Symptoms 52 3753 (918)
3 Dysfunctional Attitudes 48 33 18120 (2304)
4 Neuroticism 63 42 53 3110 (712)
_________________________________________________________________________
Note Means and standard deviations (in parentheses) are on the diagonal Depressive
Symptoms = Center for Epidemiological Studies Depression Scale Anxious Symptoms
= Mood and Anxiety Symptom Questionnaire Overall Anxiety subscale Dysfunctional
Attitudes = Dysfunctional Attitudes Scale Neuroticism = NEO Five Factor Inventory
Neuroticism subscale p lt 01
31
Table 3 Dysfunctional Attitudes Predicting Within-Subject Fluctuations in CES-D
Scores (upper section) and MASQ Scores (lower section) during the Follow-Up
Interval
______________________________________________________________________
β SE F df
______________________________________________________________________
Time 1 CESD-D 297 026 12987 1572
Stress 005 000 10860 12459
Neuroticism 134 027 2518 1572
Dysfunctional Attitudes -055 040 -183 1572
Dysfunctional Attitudes times Stress 001 000 1078 12459
______________________________________________________________________
Time 1 MASQ 502 033 23158 1575
Stress 006 000 8963 12470
Neuroticism 080 033 596 1575
Dysfunctional Attitudes -052 051 -106 1575
Dysfunctional Attitudes times Stress 002 001 774 12470
______________________________________________________________________
Note Time 1 CES-D = Time 1 Center for Epidemiological Studies Depression Scale
Stress = Within-Subject Fluctuations in General Academic Social Hassles Scale for
Students (GASHSS) scores during the follow-up interval Neuroticism = NEO Five
Factor Inventory Neuroticism subscale Dysfunctional Attitudes = Dysfunctional
Attitudes Scale Time 1 MASQ = Time 1 Mood and Anxiety Symptom Questionnaire
Overall Anxiety subscale p lt 05 p lt 01 p lt 001
32
FIGURES
Figure 1 Predicted slope of the relationship between stress and depressive
symptoms (left panel) and anxious symptoms (right panel) as a function of
dysfunctional attitudes
20
25
30
Low High
Pre
dic
ted
CE
S-D
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
25
30
35
40
Low High
Pre
dic
ted
MA
SQ
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
Intercept Intercept
iv
List of Tables and Figures
Table 1 Demographic Variables 27
Table 2 Means Standard Deviations and Inter-correlations Between Time 1
Measures 28
Table 3 Dysfunctional Attitudes Predicting Within-Subject Fluctuations in
CES-D (Upper Section) and MASQ (Lower Section) Scores during the
Follow-up Interval 29
Figure 1 Predicted slope of the relationship between stress and depressive
symptoms (Left Panel) and anxious symptoms (Right Panel) as a function of
dysfunctional attitudes 30
1
INTRODUCTION
Depression in China
The results of epidemiological studies suggest that the prevalence rate of depression in
China has been rising in recent decades More specifically whereas research conducted
during the 1980s estimated the point-prevalence rate of depression to be 03 (Xiang
1986) research conducted during the 1990s estimated it to be 14 (Murray amp Lopez
1996) More recently findings from a comprehensive epidemiological survey
conducted within China yielded a one-month prevalence rate of depression of 60
(Phillips et al 2009) In response to this upward trend depression has become a major
public health concern in China increasingly drawing the attention of both Chinese and
Western mental health researchers One demographic group within Chinarsquos population that
has received considerable attention is Chinarsquos university student population Although no
formal epidemiological studies have been conducted examining the prevalence rate of
depression among university students recent reports in the Chinese media highlight the
growing problem of depression among this demographic (eg Qiang 2006) Most distressing
in these reports is the strong association noted between depression and suicidal behavior
Estimated mortality rates reveal that suicide is the leading cause of death among
Chinese young adults between the ages of 15 and 34 (Philipps Li amp Zhang 2002)
Despite these findings however little research has examined models of the etiology of
depression in university students in mainland China Furthermore of the studies
conducted the majority are cross-sectional providing little insight into causal
mechanisms
2
Cognitive Vulnerability-Stress Models of Depression
One theoretical perspective that has proven useful in understanding the
development of depression in Western young adults is the cognitive vulnerability-stress
perspective (Abela amp Hankin 2008) Cognitive theories of depression define
vulnerability as an internal and stable feature of an individual that predisposes himher
to develop depression following the occurrence of negative events (Ingram Miranda amp
Segal 1998) Cognitive models are fundamentally diathesis-stress models in that they
posit that depression is produced by the interaction between cognitive vulnerability
factors (the diatheses) and certain environmental conditions (the stressors) that trigger
such diatheses into operation (Ingram et al 1998) Evidence suggests that under
ordinary conditions individuals vulnerable to depression are indistinguishable from the
general population Only when confronted with certain stressors do differences between
vulnerable and non-vulnerable individuals emerge (Ingram et al 1998 Ingram amp
Luxton 2005 Monroe amp Simons 1991) For individuals who possess cognitive
vulnerability factors negative events trigger a pattern of negatively biased self-referent
information processing that initiates a downward spiral into depression Non-vulnerable
individuals react to such events with an appropriate level of distress and depressive
affect but do not spiral downwards into depression
Beckrsquos Cognitive Theory of Depression
One prominent cognitive vulnerably-stress model of depression is Beckrsquos (1967
1983) cognitive theory Central to Beckrsquos cognitive theory is the construct of schema
Beck defines schema as stored bodies of knowledge (ie mental representations of the
3
self and prior experiences) that are relatively enduring characteristics of a persons
cognitive organization When an individual is confronted with a situation the schema
most relevant to the situation is activated Schema activation subsequently influences
how the person perceives encodes and retrieves information regarding the situation
Beck proposed that certain individuals posses depressogenic schema that confer
vulnerability to depression Beck (1983) hypothesizes that depressogenic schemata are
typically organized as sets of dysfunctional attitudes such as ldquoI am nothing if a person I
love doesnrsquot like merdquo or ldquoIf I fail at my work then I am a failure as a personrdquo Among
individuals who possess depressogenic schema the occurrence of negative events
triggers a pattern of negatively biased self-referent information processing
characterized by negative errors in thinking (eg negatively skewed interpretations of
negative life events such as overgeneralization and catastrophizing) Negative errors in
thinking increase the likelihood that the individual will develop the negative cognitive
triad comprising three types of depressogenic thought patterns (1) negative views of
the self (eg the belief that one is deficient inadequate or unworthy) (2) negative
views of the world (eg construing life experiences in terms of themes of defeat or
disparagement) and (3) negative views of the future (eg the expectation that ones
difficulties will persist into the future and there is nothing one can do to change this)
According to the theory the development of the negative cognitive triad triggers the
onset of depressive symptoms
Research Support for Beckrsquos Cognitive Model of Depression
Prospective studies using Western university student samples have provided
support for Beckrsquos (1967 1983) cognitive theory of depression More specifically
4
several studies have found that dysfunctional attitudes interact with the occurrence of
negative life events to predict increases in depressive symptoms (Hankin Abramson
Miller Haeffel 2004 Hankin Fraley amp Abela 2005 Joiner Metalsky Lew amp Klocek
1999 Klocek Oliver amp Ross 1997 Brown Hammen Craske and Wickens 1995) as
well as a greater likelihood of developing a depressive episode (Hankin et al 2004) In
addition individuals possessing a high level of dysfunctional attitudes have been found
to be more likely to report a past history of depressive episodes (Alloy et al 2000) and
to experience future depressive episodes (Alloy et al 2006 Hankin et al 2004) than
individuals without such a vulnerability
Far less research has examined the applicability of Beckrsquos (1983 1967)
cognitive theory to Chinese samples Preliminary cross-sectional research however
has yielded findings consistent with the theoriesrsquo hypotheses For example Xu Li and
Wang (2007) found that psychiatric patients diagnosed with major depressive disorder
showed significantly higher levels of dysfunctional attitudes than did non-depressed
controls Simiarly Bian Yang and Li (2007) reported higher levels of dysfunctional
attitudes in remitted depressives as compared to normal controls Last several studies
conducted with Chinese university students have found higher levels of dysfunctional
attitudes ndash particularly those centered on themes of perfectionism - to be associated
with higher levels of psychiatric symptoms (eg Yang amp Zhang 2004 Yang 2007
Fang Qian Luo amp Zi 2009)
5
Goals of the current study
The primary goal of the current study was to examine the applicability of
Beckrsquos (1967 1983) cognitive theory of depression to university students in mainland
China The procedure involved an initial assessment during which students completed
measures assessing dysfunctional attitudes and symptoms of depression The procedure
also involved a series of six follow-up assessments occurring once a month for six
months during which symptoms of depression and the occurrence of negative events
were assessed The use of a multi-wave longitudinal design allowed us to take an
idiographic approach towards examining the diathesis-stress hypotheses of Beckrsquos
(1967 1983) theory More specifically we examined whether the slope of the
relationship between negative events and symptoms of depression within participants
varied across participants as a function of level of dysfunctional attitudes In line with
the vulnerability-stress hypothesis of Beckrsquos (1967 1983) cognitive theory we
hypothesized that higher levels of dysfunctional attitudes would be associated with
greater increases in depressive symptoms following the occurrence of negative events
The second objective of the current study was to examine the specificity of
dysfunctional attitudes as a predictor of depressive symptoms Beckrsquos (1967 1983)
theory posits that dysfunctional attitudes predict the development of depressive
symptoms but not symptoms of other forms of psychopathology Prospective studies
using Western university student (Alloy et al 2000 2006 Hankin Abramson Miller
amp Haeffel 2004) and adolescent samples (Hankin Wetter Cheely amp Oppenheimer
2008) have provided support for the specificity hypothesis of the theory More
specifically dysfunctional attitudes have been found to interact with negative events to
6
predict increases in depressive symptoms but not symptoms of anxiety or other
disorders in both university student (Hankin et al 2004) and adolescent samples
(Hankin et al 2008) Similarly although university students possessing a high level of
dysfunctional attitudes have been found to be more likely than other university students
to report a past history of depressive episodes (Alloy et al 2000) and to experience
future depressive episodes (Alloy et al 2006) they have not been found to differ from
their low-risk counterparts in terms of past history or future occurrence of other
psychological disorders (Alloy et al 2000 2006)
With respect to the current study it is possible that differences may emerge
between Chinese and Western samples in terms of the types of symptoms predicted by
dysfunctional attitudes More specifically cultural psychopathologists have proposed
that cultural factors shape the phenomenology of psychiatric symptoms as well as the
conceptualization and classification of disorders (Kleinman 2004 Mezzich et al
1999) As such the experience of psychopathology may exhibit unique features in
different cultures with diagnostic categories developed in one cultural context not being
valid in another (Kleinman 1977 1996) Neuresthenia known in China as shenjing
shuairuo (SJSR) is a diagnostic entity characterized by (1) physical and mental
weakness and fatigability (2) sleep disturbances (3) irritability and worry (4)
excitability (5) nervous pain and (6) memory difficulty (Taylor 2001) Historically
SJSR was a Western disease concept that subsequently evolved to become a widely
utilized diagnostic entity within China (Lee amp Wong 1995) Some cultural
psychopathologists have posited that SJSR represents a somatized form of depression
This claim however has been met with significant controversy (eg Lee 1997
7
Parker Gladstone amp Chee 2001 Xu JM 1987 Xu YX 1994 Zhang 1995)
Critics dispute the notion that Chinese psychiatric patients are ldquosomatizersrdquo who
manifest few or no emotional symptoms and who attribute distress to physical causes
Rather they argue that SJSR gained widespread acceptance in China as it was a non-
stigmatizing diagnosis that allowed individuals experiencing psychosocial distress to
seek help during a time in which traditional cultural beliefs and political influences led
to severe sanction and stigmatization of individuals suffering from mental illnesses
(Lee 1998 1999 Phillips 1998 Shixie 1989) At the same time other Chinese
researchers and clinicians have continued to defend neurasthenia as both a valid
diagnostic category and a clinically useful means of communicating with patients (Rin
amp Huang 1989 Yan 1989 Young 1989) Due to continued debate on this topic it is
essential that researchers examining models of vulnerability to depression within China
assess multiple symptom outcomes as the types of symptoms predicted by vulnerability
factors may vary as a function of cultural context Hence in the current study we also
assessed levels of anxious symptoms to provide a test of the specificity hypothesis of
Beckrsquos (1967 1983) cognitive theory
In order to provide a powerful examination of our hypotheses concerning (1) the
applicability of the diathesis-stress component of Beckrsquos (1967 1983) cognitive theory
to Chinese university students and (2) the specificity of dysfunctional attitudes as
predictors of depressive as opposed to anxious symptoms participantsrsquo scores on the
neuroticism subscale of the Five-factor Inventory (FFI-N) were included as a control
variable in all analyses Several critical reviews of the literature examining theories of
cognitive vulnerability to depression (eg Barnett amp Gotlib 1998 Coyne amp Whiffen
8
1995) have argued that cognitive vulnerabilities to depression such as that featured in
Beckrsquos cognitive theory may be equivalent to or reducible to trait neuroticism and thus
may not confer independent risk for depression In response to such claims a recent
study conducted with university students examining the degree of factorial
independence versus overlap between trait neuroticism and dysfunctional attitudes has
shown them to be distinct constructs each loading onto separate factors (Hankin et al
2007) At the same time however there remains a need to examine whether
dysfunctional attitudes and trait neuroticism represent unique risk factors for
depression particularly in young adults in China Hence in the current study
participantsrsquo scores on the neuroticism subscale of the Five-factor Inventory (FFI-N)
were included as a control variable in order to account for any of the variance in
fluctuations in depressive (and anxious) symptoms that may be shared between
dysfunctional attitudes and trait neuroticism thereby isolating and highlighting their
unique predictive effects
METHOD
Participants
Participants included 662 university students (aged 19-21) from Changsha ndash an
industrial city in the province of Hunan with a population of approximately 6000000
In terms of the annual gross domestic product Hunan ranks 23rd
(10336 RMB) out of
the 34 provinces in China placing it well below the national provincial average (micro =
29719 RMB SD = 47462 RMB National Bureau of Statistics of China 2006)
Demographic variables for the sample are presented in Table 1
9
Procedure
Consent forms were distributed to all students in participating classes Consent
rates were greater than 95 in all the classes After consent forms were collected
researchers returned to the school to meet with participating students Written consent
was obtained from each participant at the beginning of the initial assessment During
the initial assessment students completed a demographics form and each of the
following questionnaires (1) Center for Epidemiological Studies Depression Scale
(CES-D Radloff 1977) (2) Mood and Anxiety Symptom Questionnaire (MASQ
Clark amp Watson 1991) (3) Dysfunctional Attitudes Scale (DAS Weissman amp Beck
1978) and (4) NEO Five Factor Inventory- Neuroticism Subscale (FFI-N Costa amp
McCrae 1992) Once a month for the subsequent six-months researchers returned to
the school and met with participating students to conduct follow-up assessments At
each of these follow-up assessments students were asked to complete each of the
following questionnaires (1) CES-D (2) MASQ and (3) the General Academic
Social Hassles Scale for Students (GASHSS Blankstein amp Flett 1993)
Measures
The Chinese versions of all self-report measures were developed using the
back-translation method Original English versions were translated into Chinese by a
bilingual translator from the Psychology department at Second Xiangya Medical
College of Central South University Hunan Translated Chinese versions were then
back-translated into English by another bilingual translator from the Psychology
department at McGill University Quebec Original versions were then compared with
the back-translation If inconsistencies were found in the back-translation translators
10
worked together to make corrections to the final Chinese versions until all final
versions were agreed upon No items from any of the measures were removed or
significantly altered during the translation process
Depressive Symptoms Center for Epidemiological Studies Depression Scale
(CES-D Radloff 1977) The CES-D is a 20-item self-report measure designed to
assess depressive symptoms in the general population For each item participants are
asked to indicate how often they experienced the particular symptom over the last
week Responses range from 1 (eg rarely or none of the time) to 4 (eg most or all of
the time) Scores range from 20-80 with higher score indicating higher levels of
depressive symptoms In the current study the CES-D exhibited high internal
consistency with Cronbachrsquos alpha values ranging from 90 to 94 (micro = 2918 SD =
814) over the 7 time points
Anxious Symptoms Mood and Anxiety Symptom Questionnaire (MASQ
Watson amp Clark 1991) The MASQ is a 62-item questionnaire designed to assess both
specific and nonspecific depressive and anxious symptoms For each item participants
are asked to rate on a scale of 1 to 5 the extent to which they have felt this way ldquoduring
the past 24 hoursrdquo Within the current study we utilized the anxious symptoms (11
items) and anxious arousal (17 items) subscales which together provide an index of
overall anxious symptoms Higher scores on each subscale reflect greater levels of
anxious symptoms In the current study the MASQ exhibited high internal consistency
with Cronbachrsquos alpha values ranging from 90 to 95 (micro = 3847 SD = 1117) over the
7 time points
11
Dysfunctional Attitudes Dysfunctional Attitudes Scale (DAS Weissman amp
Beck 1978) The DAS (Form A) is a 40-item questionnaire designed to measure the
cognitive vulnerability factor featured in Beckrsquos cognitive theory Examples of items
include ldquoIf I do not do well all the time people will not respect merdquo ldquoIf a person asks
for help it is a sign of weaknessrdquo and ldquoMy value as a person depends greatly on what
others think of merdquo Items are rated on a 7-point Likert scale ranging from 1 (totally
disagree) to 7 (totally agree) providing a range of scores from 40 to 280 with higher
scores reflecting more dysfunctional attitudes In the current study the DAS exhibited
high internal consistency with Cronbachrsquos alphas of 89 and 88 obtained for the first
and second administrations respectively In addition a test-retest reliability coefficient
of 72 was obtained indicating strong stability over time
Neuroticism NEO Five Factor Inventory - Neuroticism Subscale (FFI-N
Costa amp McCrae 1992) The FFI-N is a 12- item self-report measure that assesses
neuroticism Examples of questions include I often feel inferior to others I am
seldom sad or depressed and Sometimes I feel completely worthless Items are rated
on a 5-point Likert scale ranging from 0 (strongly disagree) to 4 (strongly agree)
providing scores ranging from 0 to 48 with higher scores indicating higher levels of
neuroticism The NEO-FFI-N has proven reliable across different cultural samples and
item pools (Costa amp McCrae 1992) In the current study Cronbachs alpha was 81
indicating strong internal consistency
Negative Life Events General Academic Social Hassles Scale for Students
(GASHSS Blankstein amp Flett 1993) Participants completed a 30-item abbreviated
version of the GASHSS The measure is comprised of items assessing general hassles
12
(8 items) academic hassles (10 items) and social hassles (12 items) For each item
participants are asked to rate how persistent the given hassle was (ie its frequency and
duration) over the last 30 days (0 = no hassle not at all persistent to 6 = extremely
persistent hassle high frequency andor duration)
13
RESULTS
Descriptive Data
Means standard deviations and inter-correlations between Time 1 measures are
presented in Table 2
Prospective Diathesis-Stress Analyses - Depression
Multilevel modeling was used to test our hypothesis that higher levels of dysfunctional
attitudes would be associated with greater increases in depressive symptoms following
increases in stress Analyses were carried out using the SAS (version 81) MIXED
procedure and maximum likelihood estimation Our dependent variable was within-
subject fluctuations in CES-D scores during the follow-up interval (DEPRESSION)
Our primary predictors of DEPRESSION were DAS scores (DYSFUNCTIONAL
ATTITUDES) and fluctuations in GASHSS scores during the follow-up interval
(STRESS) As DYSFUNCTIONAL ATTITUDES is a between-subject predictor DAS
scores were standardized prior to analyses As STRESS is a within-subject predictor
STRESS reflects upward or downward fluctuations in an individualrsquos level of stress
compared to hisher mean level of stress
When fitting hierarchical linear models one must specify appropriate mean and
covariance structures Mean structures refer to the various fixed and random effect
components that can be included in the model Covariance structures refer to alternative
methods of specifying the pattern of covariance between observations taken from the
same subject at different time points It is important to note that mean and covariance
structures are not independent of one another Rather an appropriate covariance
structure is essential in order to obtain valid inferences for the parameters in the mean
14
structure Overparametrization of the covariance structure can lead to inefficient
estimation and poor assessment of standard errors (Altham 1984) On the other hand
too much restriction of the covariance structure can lead to invalid inferences when the
assumed structure does not hold (Altham 1984)
In our first set of analyses we were interested in examining the effects of
DYSFUNCTIONAL ATTITUDES STRESS and the DYSFUNCTIONAL
ATTITUDES STRESS interaction on participantrsquos CES-D scores during the follow-
up interval Consequently in line with Diggle Liang and Zegers (1994)
recommendation that one use a ldquosaturatedrdquo model for the mean structure while
searching for an appropriate covariance structure we chose a mean structure that
included DYSFUNCTIONAL ATTITUDES STRESS and the DYSFUNCTIONAL
ATTITUDES STRESS interaction Four additional effects were also included in this
mean structure First as different individuals report different levels of depressive
symptoms when at their own average level of stress a random effect for intercept was
included in the model Second given that STRESS is a within-subject predictor whose
effect is expected to vary from participant to participant a random effect for slope was
included in the model Third in order to control for individual differences in baseline
levels of depressive symptoms Time 1 CES-D scores were included in the model
Fourth in order to examine whether DYSFUNCTIONAL ATTITUDES represent a
vulnerability factor independent of neuroticism participantsrsquo FFI-N scores were
entered in the model
Commonly used covariance structures in studies in which multiple responses
are obtained from the same individual over time (and consequently within-subject
15
residuals over time are likely to be correlated) include compound symmetry first-order
autoregressive heterogeneous autoregressive and banded Toeplitz In order to select
one of these covariance structures for our analyses we fitted models using each
structure and chose the ldquobestrdquo fit based on Akaike information criterion (AIC and
AICC) and Schwarz Bayesian criterion (BIC) In all cases the best fit for our data was
a first-order heterogeneous autoregressive structure (ARH [1]) After choosing the
appropriate covariance structure we next examined the random-effects component of
our model
With respect to random effects the ARH [1] parameter (r = 31 plt001)
RE_INTERCEPT (plt001) and RE_SLOPE (plt001) were each significant and thus
were retained in the model The final results with respect to the fixed-effects
component of the model are presented in the upper section of Table 3 Of primary
importance the DYSFUNCTIONAL ATTITUDES STRESS interaction was a
significant predictor of fluctuations in depressive symptoms during the follow-up
interval In order to examine the form of this interaction the model summarized in the
upper section of Table 3 was used to calculate predicted CES-D scores for individuals
exhibiting either high or low levels of dysfunctional attitudes (plus or minus 15 SD)
who are experiencing either high or low levels of stress in comparison to their own
average level of stress (plus or minus 15 times mean within-subject SD) The results of
such calculations are presented in the left panel of Figure 1
Analyses were conducted for each DYSFUNCTIONAL ATTITUDES
condition examining whether the slope of the relationship between stress and
depressive symptoms significantly differed from 0 Analyses indicated that both
16
individuals exhibiting high (t(2459) = 862 p lt 0001) and low (t(2459) = 347 p lt
0001) levels of dysfunctional attitudes reported significantly higher levels of
depressive symptoms when experiencing high levels of stress than when experiencing
low levels of stress Planned comparisons of the slopes of the relationship between
stress and depressive symptoms however revealed that the slope was significantly
greater in individuals exhibiting high levels of dysfunctional attitudes (slope = 013)
than in individuals exhibiting low levels of dysfunctional attitudes (slope = 005
t(2459) = 328 p = 0001)
Prospective Diathesis-Stress Analyses - Anxiety
The same data-analytic approach as described above was used to examine
whether higher levels of dysfunctional attitudes would be associated with greater
increases in anxious symptoms following increases in stress Again in order to examine
whether DYSFUNCTIONAL ATTITUDES represent a vulnerability factor
independent of neuroticism participantsrsquo FFI-N scores were entered in the model
With respect to random effects the ARH[1] parameter (r = 23 p lt 001)
RE_INTERCEPT (plt001) and RE_SLOPE (plt001) were each significant and thus
were retained in the model The final results with respect to the fixed-effects
component of the model are presented in the lower section of Table 3 Of primary
importance the DYSFUNCTIONAL ATTITUDES STRESS interaction was a
significant predictor of within-subject fluctuations in anxious symptoms during the
follow-up interval In order to examine the form of this interaction the model
summarized in the lower section of Table 3 was used to calculate predicted MASQ
scores for individuals exhibiting either high or low levels of dysfunctional attitudes
17
(plus or minus 15 SD) who are experiencing either high or low levels of stress in
comparison to their own average level of stress (plus or minus 15 times mean within-
subject SD) The results of such calculations are presented on the right panel of in
Figure 1
Analyses were conducted for each DYSFUNCTIONAL ATTITUDES
condition examining whether the slope of the relationship between stress and anxious
symptoms significantly differed from 0 Analyses indicated that both individuals
exhibiting high (t(2470) = 768 p lt 0001) and low (t(2470) = 337 p lt 0001) levels of
dysfunctional attitudes reported higher levels of anxious symptoms when experiencing
high levels of stress than when experiencing low levels of stress Planned comparisons
of the slopes of the relationship between stress and anxious symptoms however
revealed that the slope was significantly greater in individuals exhibiting high levels of
dysfunctional attitudes (slope = 009) than in individuals exhibiting low levels of
dysfunctional attitudes (slope = 003 t(2470) = 278 p lt 001)
Additional Analyses
Given that the DYSFUNCTIONAL ATTITUDES STRESS interaction
prospectively predicted both symptoms of depression and anxiety two additional
analyses were conducted in order to examine (1) whether the DYSFUNCTIONAL
ATTITUDES STRESS interaction continued to be a significant predictor of within-
subject fluctuations in depressive symptoms after controlling for within-subject
fluctuations in anxious symptoms and (2) whether the DYSFUNCTIONAL
ATTITUDES STRESS interaction continued to predict within-subject fluctuations in
anxious symptoms after controlling for within-subject fluctuations in depressive
18
symptoms Such analyses allowed us to examine whether the above mentioned pattern
of findings may have been due to the high correlation observed in the current study
between depressive and anxious symptoms
Analyses were conducted in the same manner as described above with the
exception that an additional within-subject variable (ie DEPRESSION or ANXIETY)
was included in each model in order to control for within-subject fluctuations in the
alternate symptom With respect to the prediction of depressive symptoms the
DYSFUNCTIONAL ATTITUDES STRESS interaction remained a significant
predictor after controlling for within-subject fluctuations in anxious symptoms (β =
001 SE = 000 F = 410 p lt 05) With respect to the prediction of anxious
symptoms however the DYSFUNCTIONAL ATTITUDES STRESS interaction
was no longer a significant predictor after controlling for within-subject fluctuations in
depressive symptoms (β = 001 SE = 000 F = 148 p = 22)
DISCUSSION
The results of the current study provide support for the cross-cultural
applicability of Beckrsquos (1967 1983) cognitive theory to university students in Hunan
China More specifically consistent with hypotheses and with results obtained from
past research examining Beckrsquos cognitive theory in Western samples of university
students (Hankin et al 2004 Hankin et al 2005 Joiner et al 1999 Klocek et al
1997 Brown et al 1995) higher levels of dysfunctional attitudes were associated with
greater increases in depressive symptoms following increases in negative event
frequency during the six-month follow-up interval Given the considerable differences
between the current sample and Western samples in terms of demographic
19
characteristics and cultural factors such a finding strongly attests to the robustness of
Beckrsquos cognitive theory Moreover integrating the current findings with those obtained
in research examining Beckrsquos theory in other non-Western samples suggests that
Beckrsquos theory may represent a powerful explanatory model of the development of
depressive symptoms among individuals from diverse cultural settings For example
consistent with the theory higher levels of dysfunctional attitudes have been shown to
be associated with higher levels of depressive symptoms in Japanese (Tanaka et al
2006) Puerto-Rican (Bonilla Bernal Santos amp Santos 2003) Turkish (Sahin amp Sahin
1992) Norwegian (Chioqueta amp Stiles 2004) Singaporean (Oei Goh amp Kwon 1996)
and Swedish (Ohrt amp Thorell 1998) adult samples In addition it is important to note
that the current findings expand upon past correlational research examining the
association between dysfunctional attitudes and depression in Chinese samples through
the use of a multi-wave longitudinal design
When examining the specificity of dysfunctional attitudes as a predictor of
depressive symptoms the current study did not obtain support for specificity More
specifically contrary to the specificity hypothesis of Beckrsquos cognitive theory and to
results obtained in Western samples of university students (Alloy et al 2000 2006
Hankin et al 2004) higher levels of dysfunctional attitudes were associated with
greater increases in both depressive and anxious symptoms following increases in
negative event frequency There are two alternative ways of interpreting the non-
specificity finding observed in the current study First it is possible that the types of
thoughts individuals possessing high levels of dysfunctional attitudes experience
following negative events varies as a function of cultural context In other words in
20
Western samples such individuals may primarily experience the types of cognitions
that are associated with the development of depressive symptoms (ie appraisals of
personal loss and failure) In contrast in Chinese samples individuals possessing high
levels of dysfunctional attitudes may experience a wider array of cognitions some of
which are associated with the development of depressive symptoms and some of which
are associated with the development of anxious symptoms (ie evaluations of
impending threat or danger) Such an explanation would be consistent with Beckrsquos
cognitive content-specificity hypothesis (Clark amp Beck 1999) which posits that each
affective state and psychological disorder has a specific cognitive profile Second it is
possible that the types of symptoms individuals possessing high levels of dysfunctional
attitudes experience following negative events varies as a function of cultural context
More specifically it may be that dysfunctional attitudes specifically predict symptoms
of depression in both samples except that in Western samples depression manifests in
pure depressive symptoms whereas in Chinese samples depression manifests as a
combination of depressive and anxious symptoms Such an explanation would be
consistent with cultural psychopathologistsrsquo hypotheses that cultural factors shape the
phenomenology of psychiatric symptoms (Kleinman 2004 Mezzich et al 1999)
Moreover dysfunctional attitudes predicting a combination of depressive and anxious
symptoms in Chinese samples would be consistent with the construct of neurasthenia -
a construct hypothesized by some to represent a somatized form of depression that is
still widely seen within China (Lee amp Wong 1995)
Interesting in this regard and perhaps speaking to the primacy of depressive
symptoms in the current findings analyses indicated that the DYSFUNCTIONAL
21
ATTITUDES times STRESS interaction no longer predicted anxious symptoms after
controlling for depressive symptoms The reverse however was not true as the
DYSFUNCTIONAL ATTITUDES times STRESS interaction continued to predict
depressive symptoms after controlling for anxious symptoms
It is important to note that the current study employed a particularly
conservative approach to analyses in that we examined the effects of dysfunctional
attitudes on depressive and anxious symptoms after controlling for the effect of
neuroticism on such symptoms Providing particularly powerful support for Beckrsquos
(1967 1983) cognitive theory across analyses dysfunctional attitudes predicted levels
of depressive andor anxious symptoms experienced during the six month follow-up
interval independent of the effect of neuroticism Thus contrary to past critical reviews
of the cognitive literature (Barnett amp Gotlib 1998 Coyne amp Whiffen 1995) and
consistent with past findings (Hankin et al 2007) the current results indicate that
cognitive vulnerabilities to depression such as dysfunctional attitudes are not reducible
to trait neuroticism but rather represent factors that confer independent risk for
depression
Limitations and Future Directions
Several limitations of the current study should be noted First self-report
measures were used to assess depressive and anxious symptoms Although the CES-D
and MASQ both possess high degrees of reliability and validity it is difficult to draw
conclusions about clinically diagnosed depression or anxiety based on self-report
questionnaires Second self-report measures were used to assess stress Although
measures of stress that require participants only to indicate whether or not an event
22
occurred are less likely to be influenced by informant bias than those that ask
participants to rate the subjective impact of each event more sophisticated methods of
analysis such as interviewing procedures that assess contextual threat may provide
better assessments of stress Third the measures of dysfunctional attitudes stress and
depressive and anxious symptoms used in the current study were each Western-
developed Future research should examine these hypotheses using indigenous
measures in addition to Western-developed measures in order to assess possible
similarities andor differences in patterns of findings Fourth the current study only
examined depression and anxiety as symptom outcomes Future research conducted
within China should examine a wider array of symptom outcomes such as
somatization physical complaints and externalizing behaviors in order to provide a
more thorough and culturally sensitive test of the specificity hypotheses of Beckrsquos
cognitive model Fifth the current study examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese undergraduate students and thus the extent to which
our findings may be generalized to other demographics within Chinarsquos population is
unclear Last the current study broadly examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese university students Future research should examine
the constructs and processes posited by this model in greater detail in order to develop a
deeper understanding of how they may be uniquely molded by socio-cultural factors
Such research would benefit from examining the specific types of stressors experienced
by Chinese university students as they may vary as a function of socio-cultural factors
from those experienced by Western undergraduates For example severe pressure to
succeed academically in order to secure access to a limited number of post-
23
undergraduate educational opportunities - one of the few paths towards upward
mobility available to Chinese students seeking secure and gainful employment in what
has increasingly become a very highly competitive job market - may represent a
particularly salient stressor for the development of depressive symptoms among this
population (Qiang 2006)
In conclusion the results from the current study provide support for the
applicability of Beckrsquos cognitive theory to university students in mainland China More
specifically consistent with findings obtained in the West results indicate that
dysfunctional attitudes confer vulnerability to the development of depressive symptoms
following the occurrence of negative events in Chinese university students At the same
time however the current findings suggest cultural variation in the profile of
symptoms which emerge following the occurrence of negative events in cognitively
vulnerable individuals in Western and Chinese samples Specifically whereas in the
West dysfunctional attitudes have been shown to confer vulnerability to depressive
symptoms in Chinese university students dysfunctional attitudes appear to confer
vulnerability to a combined depressive and anxious symptom profile Future research
using more sophisticated assessments of stress and depressive symptoms more diverse
samples and symptom outcome measures and indigenously-developed measures is
likely to enhance our understanding of the cognitive and environmental mechanisms
underlying the development of depression in Chinese university students Discovering
that cognitive theories of vulnerability to depression extend to university students in
China highlights the potential role for cognitive-behavioral depression prevention and
treatment interventions in stemming the tide of distress experienced by this population
24
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children and adolescents A developmental psychopathology perspective In J
R Z Abela and B L Hankin (Eds) Handbook of child and adolescent
depression (pp 35-78) New York The Guilford Press
Alloy L B Abramson L Y Hogan M E Whitehouse W G Rose D T
Robinson MS Kim R S amp Lapkin J B (2000) The Temple-Wisconsin
cognitive vulnerability to depression project Lifetime history of axis-I
psychopathology in individuals at high and low cognitive risk for depression
Journal of Abnormal Psychology 109 403-418
Alloy L B Abramson L Y Whitehouse W G Hogan M E Panzarella C amp
Rose D T (2006) Prospective incidence of first onsets and recurrences of
depression in individuals at high and low cognitive risk for depression Journal
of Abnormal Psychology 115 145ndash156
Altham P M E (1984) Improving the precision of estimation by fitting a model
Journal of the Royal Statistical Society Series B 46 11
Barnett PA amp Gotlib I H (1988) Psychosocial functioning and depression
Distinguishing among antecedents concomitants and consequences
Psychological Bulletin 104 97-126
Beck AT (1967) Depression Clinical experimental and theoretical aspects New
York Harper amp Row
Beck AT (1983) Cognitive therapy of depression New perspectives In PJ Clayton
amp JE Barrett (Eds) Treatment of depression Old controversies and new
approaches New York Raven Press
Bian Q Yang K amp Li C (2007) Dysfunctional attitudes of patients with depression
or bipolar disorder Chinese Mental Health Journal 21 759-761
Blankstein K R amp Flett G L (1993) Development of the General Academic and
Social Hassles Scales for Students Unpublished manuscript
Bonilla J Bernal G Santos A amp Santos D (2003) A revised Spanish version of
the Beck Depression InventoryPsychometric properties with a Puerto Rican
sample of college students Journal of Clinical Psychology 60 119-130
Brown G P Hammen C L Craske M G amp Wickens T D (1995) Dimensions of
dysfunctional attitudes as vulnerabilities to depressive symptoms Journal of
Abnormal Psychology 104 431-435
25
Chioqueta A P amp Stiles T C (2004) Psychometric properties of the Norweigian
version of the Dysfunctional Attitude Scale (Form A) Cognitive Behaviour
Therapy 33 83-86
Clark DA amp Beck AT (1999) Cognitive theory and therapy of depression New
York John Wiley amp Sons Inc
Clark L A amp Watson D (1991) Tripartite model of anxiety and depression
Psychometric evidence and taxonomic implications Journal of Abnormal
Psychology 100 316ndash336
Costa P T amp McCrae R R (1992) NEO PI-R Professional manual Revised NEO
personality inventory NEO PR-R and NEO five-factor inventory NEO-RRI
Odessa FL Psychological Assessment Resources
Coyne J C amp Whiffen V E (1995) Issues in personality as diathesis for depression
The case of sociotropy-dependency and autonomy-self-criticism Psychological
Bulletin 118 358-378
Fang X Qian M Luo S amp Zi F (2009) A correlational study on college students
perfectionism parental rearing patterns and mental health Chinese Mental
Health Journal 23 56-59
Hankin B L Abramson L Y Miller N amp Haeffel G (2004) Cognitive
vulnerability-stress theories of depression Examining affective specificity in
the prediction of depression versus anxiety in three prospective studies
Cognitive Therapy and Research 28 309ndash345
Hankin BL Fraley RC amp Abela JRZ (2005) Daily depression and cognitions
about stress Evidence for a traitlike depressogenic cognitive style and the
prediction of depressive symptoms in a prospective daily diary study Journal of
Personality and Social Psychology 88 673-685
Hankin B L Lakdawalla Z Carter I L Abela J R Z amp Adams P (2007) Are
neuroticism cognitive vulnerabilities and self-esteem overlapping or distinct
risks for depression Evidence from confirmatory factor analyses Journal of
Social amp Clinical Psychology 26 29-63
Hankin B L Wetter E Cheely C amp Oppenheimer C W (2008) Becks cognitive
theory of depression in adolescence Specific prediction of depressive
symptoms and reciprocal influences in a multi-wave prospective study
International Journal of Cognitive Therapy 1 313-332
Ingram R E Miranda J amp Segal Z V (1998) Cognitive Vulnerability to
Depression New York NY Guilford Press
26
Ingram R E amp Luxton DD (2005) Vulnerability-stress models In BL Hankin amp
JRZ Abela (Eds) Development of psychopathology A vulnerability-stress
perspective (pp 32-46) Thousand Oaks CA Sage
Joiner T E Metalsky G I Lew A amp Klocek J (1999) Testing the causal
mediation component of Becks theory of depression Evidence for specific
mediation Cognitive Therapy and Research 23 401-412
Kleinman A (2004) Culture and depression New England Journal of Medicine 351
951-953
Kleinman A (1977) Depression somatization and the new cross-cultural psychiatry
Social Science and Medicine 11 3-10
Kleinman A (1996) How is culture important for DSM-IV In J E Mezzich A
Kleinmam H Fabrega Jr amp L Delores (Eds)Culture and psychiatric
diagnosis A DSM-IV perspective (pp 15-25) Washington DC US American
Psychiatric Association
Klocek J W Oliver J M amp Ross M J (1997) The role of dysfunctional attitudes
negative life events and social support in the prediction of depressive
dysphoria A prospective longitudinal study Social Behavior and Personality
25 23-136
Lee S (1997) A Chinese perspective on somatoform disorders Journal of
Psychosomatic Disorders 43 115-119
Lee S (1998) Estranged bodies simulated harmony and misplaced cultures
Neurasthenia in contemporary Chinese society Psychosomatic Medicine 60
448ndash457
Lee S (1999) Diagnosis postponed Shenjing shuairo and the transformation of
psychiatry in post-Mao China Culture Medicine and Psychiatry 23 349ndash380
Lee S amp Wong K C (1995) Rethinking neurasthenia the illness concepts of
shenjing shuairuo among Chinese undergraduates in Honk Kong Culture
Medicine and Psychiatry 19 91ndash111
Lee S Tsang A Huang YQ He YL Liu ZR Zhang MY Shen YC amp
Kessler RC (2009) The epidemiology of depression in metropolitan China
Psychological Medicine 39 735-747
Mezzich J E Kirmayer L J Kleinman A Fabrega Jr H Parron D L Good B
J Lin K amp Manson S M (1999) The place of culture in DSM-IV Journal
of Nervous and Mental Disease 187 457-464
27
Monroe S M amp Simons A D (1991) Diathesisndashstress theories in the context of life
stress research Implications for the depressive disorders Psychological
Bulletin 110 406ndash425
Murray C J L amp Lopez A D (1996) The global burden of disease Cambridge
Harvard University Press
National Bureau of Statistics of China (2006) The China 2005 statistical yearbook
China Statistics Press Beijing PR China
Oei T P S Goh Y Kwon S M(1996) A cross-cultural study of the integrated
cognitive model of depression Current Psychology of Cognition 15 265-281
Ohrt T amp Thorell L (1998) Dysfunctional Attitude Scale (DAS) Psychometrics and
norms of the Swedish version Scandinavian Journal of Behaviour Therapy 27
105-113
Parker G Gladstone G Chee KT (2001) Depression in the planetrsquos largest ethnic
group The Chinese American Journal of Psychiatry 158 857-864
Phillips M R Zhang J Shi Q Song Z Ding Z Pang S Li X Zhang Y amp
Wang Z (2009) Prevalence treatment and associated disability of mental
disorders in four provinces in China during 2001ndash05 an epidemiological
survey The Lancet 373 2041-2053
Phillips M R Li X amp Zhang Y (2002) Suicide rates in China Lancet 359 835-
840
Phillips M R (1998) The transformation of Chinarsquos mental health services The China
Journal 39 1ndash36
Qiang G (2006) Depression number one killer of Ivory Tower students China Daily
Retrieved from httpwwwchinadailycomcnchina2006-
1128content_744880htm
Radloff L S (1977) The CESndashD scale A self-report depression scale for research in
the general population Applied Psychological Measurement 1 385ndash401
Rin H amp Huang M G (1989) Neurasthenia as nosological dilemma Culture
Medicine and Psychiatry 13 215-226
Sahin NH amp Sahin N (1992) How dysfunctional are the dysfunctional attitudes in
another culture British Journal of Medical Psychology 65 17-26
Shixie L (1989) Neurasthenia in China Modern and traditional criteria for its
diagnosis Culture Medicine and Psychiatry 13 163-186
28
Tanaka N Uji M Hiramura H Chen Z Shikai N amp Kitamura T (2006)
Cognitive patterns and depression Study of a Japanese university student
population Psychiatry and Clinical Neuroscience 60 358-364
Taylor R E (2001) Death of neurasthenia and its psychological reincarnation a study
of neurasthenia at the National Hospital for the Relief and Cure of the Paralysed
and Epileptic Queen Square London 1870ndash1932 British Journal of
Psychiatry 179 550ndash557
Weissman A N amp Beck A T (1978 April) Development and validation of the
Dysfunctional Attitudes Scale A preliminary investigation Paper presented at
the annual meeting of the Educational Research Association Toronto Canada
Xiang M Z (1986) Epidemiological study of neuroses in 12 regions (districts) of
China Chinese Journal of Neurology and Psychiatry 19 87-91
Xu JM (1987) Some issues in the diagnosis of depression in China Canadian
Journal of Psychiatry 32 368-370
Xu Y X (1994) About ICD-10 Journal of Clinical Psychology and Medicine 4 224-
226
Xu Z Li Z amp Wang Z (2007) Dysfunctional attitudes and cognitive bias in major
depressive disorder Chinese Mental Health Journal 21 488-491
Yan H Q (1989) The necessity of retaining the diagnostic concept of neurasthenia
Culture Medicine and Psychiatry 13 139-145
Yang H (2007) The Test of the Chinese version of Frost Multi-dimensional
Perfectionism Scale Chinese Mental Health Journal 21 97-100
Yang H amp Zhang X (2004) Perfectionism and mental health of college students
(2004) Chinese Mental Health Journal 18 647-648
Young D (1989) Neurasthenia and related problems Culture Medicine and
Psychiatry 13 131-138
Zhang D (1995) Depression and culture A Chinese perspective Canadian Journal of
Counseling 29 227ndash233
29
TABLE(S)
Table 1 Demographic Variables
Age 2011
Gender Male
Female
472
523
Parentsrsquo Marital Status Married
Divorced
Single
Remarried
938
23
18
20
Fatherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
Government Official
51
356
187
95
124
91
Motherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
122
406
144
76
134
Fatherrsquos Education Some Primary School
Primary School
Some High School
High School
University
29
139
222
403
137
Motherrsquos Education Some Primary School
Primary School
Some High School
High School
University
63
192
264
350
76
Only Child No
Yes
331
667
Monthly Income lt 1000 RMB
1000 ndash 1500 RMB
1500 ndash 2000 RMB
2000 ndash 3000 RMB
3000 ndash 4000 RMB
4000 ndash 5000 RMB
gt 5000 RMB
334
204
175
140
59
20
20
30
Table 2 Means Standard Deviations and Inter-correlations Between Time 1 Measures
__________________________________________________________________
1 2 3
__________________________________________________________________
1 Depressive Symptoms 2963 (780)
2 Anxious Symptoms 52 3753 (918)
3 Dysfunctional Attitudes 48 33 18120 (2304)
4 Neuroticism 63 42 53 3110 (712)
_________________________________________________________________________
Note Means and standard deviations (in parentheses) are on the diagonal Depressive
Symptoms = Center for Epidemiological Studies Depression Scale Anxious Symptoms
= Mood and Anxiety Symptom Questionnaire Overall Anxiety subscale Dysfunctional
Attitudes = Dysfunctional Attitudes Scale Neuroticism = NEO Five Factor Inventory
Neuroticism subscale p lt 01
31
Table 3 Dysfunctional Attitudes Predicting Within-Subject Fluctuations in CES-D
Scores (upper section) and MASQ Scores (lower section) during the Follow-Up
Interval
______________________________________________________________________
β SE F df
______________________________________________________________________
Time 1 CESD-D 297 026 12987 1572
Stress 005 000 10860 12459
Neuroticism 134 027 2518 1572
Dysfunctional Attitudes -055 040 -183 1572
Dysfunctional Attitudes times Stress 001 000 1078 12459
______________________________________________________________________
Time 1 MASQ 502 033 23158 1575
Stress 006 000 8963 12470
Neuroticism 080 033 596 1575
Dysfunctional Attitudes -052 051 -106 1575
Dysfunctional Attitudes times Stress 002 001 774 12470
______________________________________________________________________
Note Time 1 CES-D = Time 1 Center for Epidemiological Studies Depression Scale
Stress = Within-Subject Fluctuations in General Academic Social Hassles Scale for
Students (GASHSS) scores during the follow-up interval Neuroticism = NEO Five
Factor Inventory Neuroticism subscale Dysfunctional Attitudes = Dysfunctional
Attitudes Scale Time 1 MASQ = Time 1 Mood and Anxiety Symptom Questionnaire
Overall Anxiety subscale p lt 05 p lt 01 p lt 001
32
FIGURES
Figure 1 Predicted slope of the relationship between stress and depressive
symptoms (left panel) and anxious symptoms (right panel) as a function of
dysfunctional attitudes
20
25
30
Low High
Pre
dic
ted
CE
S-D
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
25
30
35
40
Low High
Pre
dic
ted
MA
SQ
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
Intercept Intercept
1
INTRODUCTION
Depression in China
The results of epidemiological studies suggest that the prevalence rate of depression in
China has been rising in recent decades More specifically whereas research conducted
during the 1980s estimated the point-prevalence rate of depression to be 03 (Xiang
1986) research conducted during the 1990s estimated it to be 14 (Murray amp Lopez
1996) More recently findings from a comprehensive epidemiological survey
conducted within China yielded a one-month prevalence rate of depression of 60
(Phillips et al 2009) In response to this upward trend depression has become a major
public health concern in China increasingly drawing the attention of both Chinese and
Western mental health researchers One demographic group within Chinarsquos population that
has received considerable attention is Chinarsquos university student population Although no
formal epidemiological studies have been conducted examining the prevalence rate of
depression among university students recent reports in the Chinese media highlight the
growing problem of depression among this demographic (eg Qiang 2006) Most distressing
in these reports is the strong association noted between depression and suicidal behavior
Estimated mortality rates reveal that suicide is the leading cause of death among
Chinese young adults between the ages of 15 and 34 (Philipps Li amp Zhang 2002)
Despite these findings however little research has examined models of the etiology of
depression in university students in mainland China Furthermore of the studies
conducted the majority are cross-sectional providing little insight into causal
mechanisms
2
Cognitive Vulnerability-Stress Models of Depression
One theoretical perspective that has proven useful in understanding the
development of depression in Western young adults is the cognitive vulnerability-stress
perspective (Abela amp Hankin 2008) Cognitive theories of depression define
vulnerability as an internal and stable feature of an individual that predisposes himher
to develop depression following the occurrence of negative events (Ingram Miranda amp
Segal 1998) Cognitive models are fundamentally diathesis-stress models in that they
posit that depression is produced by the interaction between cognitive vulnerability
factors (the diatheses) and certain environmental conditions (the stressors) that trigger
such diatheses into operation (Ingram et al 1998) Evidence suggests that under
ordinary conditions individuals vulnerable to depression are indistinguishable from the
general population Only when confronted with certain stressors do differences between
vulnerable and non-vulnerable individuals emerge (Ingram et al 1998 Ingram amp
Luxton 2005 Monroe amp Simons 1991) For individuals who possess cognitive
vulnerability factors negative events trigger a pattern of negatively biased self-referent
information processing that initiates a downward spiral into depression Non-vulnerable
individuals react to such events with an appropriate level of distress and depressive
affect but do not spiral downwards into depression
Beckrsquos Cognitive Theory of Depression
One prominent cognitive vulnerably-stress model of depression is Beckrsquos (1967
1983) cognitive theory Central to Beckrsquos cognitive theory is the construct of schema
Beck defines schema as stored bodies of knowledge (ie mental representations of the
3
self and prior experiences) that are relatively enduring characteristics of a persons
cognitive organization When an individual is confronted with a situation the schema
most relevant to the situation is activated Schema activation subsequently influences
how the person perceives encodes and retrieves information regarding the situation
Beck proposed that certain individuals posses depressogenic schema that confer
vulnerability to depression Beck (1983) hypothesizes that depressogenic schemata are
typically organized as sets of dysfunctional attitudes such as ldquoI am nothing if a person I
love doesnrsquot like merdquo or ldquoIf I fail at my work then I am a failure as a personrdquo Among
individuals who possess depressogenic schema the occurrence of negative events
triggers a pattern of negatively biased self-referent information processing
characterized by negative errors in thinking (eg negatively skewed interpretations of
negative life events such as overgeneralization and catastrophizing) Negative errors in
thinking increase the likelihood that the individual will develop the negative cognitive
triad comprising three types of depressogenic thought patterns (1) negative views of
the self (eg the belief that one is deficient inadequate or unworthy) (2) negative
views of the world (eg construing life experiences in terms of themes of defeat or
disparagement) and (3) negative views of the future (eg the expectation that ones
difficulties will persist into the future and there is nothing one can do to change this)
According to the theory the development of the negative cognitive triad triggers the
onset of depressive symptoms
Research Support for Beckrsquos Cognitive Model of Depression
Prospective studies using Western university student samples have provided
support for Beckrsquos (1967 1983) cognitive theory of depression More specifically
4
several studies have found that dysfunctional attitudes interact with the occurrence of
negative life events to predict increases in depressive symptoms (Hankin Abramson
Miller Haeffel 2004 Hankin Fraley amp Abela 2005 Joiner Metalsky Lew amp Klocek
1999 Klocek Oliver amp Ross 1997 Brown Hammen Craske and Wickens 1995) as
well as a greater likelihood of developing a depressive episode (Hankin et al 2004) In
addition individuals possessing a high level of dysfunctional attitudes have been found
to be more likely to report a past history of depressive episodes (Alloy et al 2000) and
to experience future depressive episodes (Alloy et al 2006 Hankin et al 2004) than
individuals without such a vulnerability
Far less research has examined the applicability of Beckrsquos (1983 1967)
cognitive theory to Chinese samples Preliminary cross-sectional research however
has yielded findings consistent with the theoriesrsquo hypotheses For example Xu Li and
Wang (2007) found that psychiatric patients diagnosed with major depressive disorder
showed significantly higher levels of dysfunctional attitudes than did non-depressed
controls Simiarly Bian Yang and Li (2007) reported higher levels of dysfunctional
attitudes in remitted depressives as compared to normal controls Last several studies
conducted with Chinese university students have found higher levels of dysfunctional
attitudes ndash particularly those centered on themes of perfectionism - to be associated
with higher levels of psychiatric symptoms (eg Yang amp Zhang 2004 Yang 2007
Fang Qian Luo amp Zi 2009)
5
Goals of the current study
The primary goal of the current study was to examine the applicability of
Beckrsquos (1967 1983) cognitive theory of depression to university students in mainland
China The procedure involved an initial assessment during which students completed
measures assessing dysfunctional attitudes and symptoms of depression The procedure
also involved a series of six follow-up assessments occurring once a month for six
months during which symptoms of depression and the occurrence of negative events
were assessed The use of a multi-wave longitudinal design allowed us to take an
idiographic approach towards examining the diathesis-stress hypotheses of Beckrsquos
(1967 1983) theory More specifically we examined whether the slope of the
relationship between negative events and symptoms of depression within participants
varied across participants as a function of level of dysfunctional attitudes In line with
the vulnerability-stress hypothesis of Beckrsquos (1967 1983) cognitive theory we
hypothesized that higher levels of dysfunctional attitudes would be associated with
greater increases in depressive symptoms following the occurrence of negative events
The second objective of the current study was to examine the specificity of
dysfunctional attitudes as a predictor of depressive symptoms Beckrsquos (1967 1983)
theory posits that dysfunctional attitudes predict the development of depressive
symptoms but not symptoms of other forms of psychopathology Prospective studies
using Western university student (Alloy et al 2000 2006 Hankin Abramson Miller
amp Haeffel 2004) and adolescent samples (Hankin Wetter Cheely amp Oppenheimer
2008) have provided support for the specificity hypothesis of the theory More
specifically dysfunctional attitudes have been found to interact with negative events to
6
predict increases in depressive symptoms but not symptoms of anxiety or other
disorders in both university student (Hankin et al 2004) and adolescent samples
(Hankin et al 2008) Similarly although university students possessing a high level of
dysfunctional attitudes have been found to be more likely than other university students
to report a past history of depressive episodes (Alloy et al 2000) and to experience
future depressive episodes (Alloy et al 2006) they have not been found to differ from
their low-risk counterparts in terms of past history or future occurrence of other
psychological disorders (Alloy et al 2000 2006)
With respect to the current study it is possible that differences may emerge
between Chinese and Western samples in terms of the types of symptoms predicted by
dysfunctional attitudes More specifically cultural psychopathologists have proposed
that cultural factors shape the phenomenology of psychiatric symptoms as well as the
conceptualization and classification of disorders (Kleinman 2004 Mezzich et al
1999) As such the experience of psychopathology may exhibit unique features in
different cultures with diagnostic categories developed in one cultural context not being
valid in another (Kleinman 1977 1996) Neuresthenia known in China as shenjing
shuairuo (SJSR) is a diagnostic entity characterized by (1) physical and mental
weakness and fatigability (2) sleep disturbances (3) irritability and worry (4)
excitability (5) nervous pain and (6) memory difficulty (Taylor 2001) Historically
SJSR was a Western disease concept that subsequently evolved to become a widely
utilized diagnostic entity within China (Lee amp Wong 1995) Some cultural
psychopathologists have posited that SJSR represents a somatized form of depression
This claim however has been met with significant controversy (eg Lee 1997
7
Parker Gladstone amp Chee 2001 Xu JM 1987 Xu YX 1994 Zhang 1995)
Critics dispute the notion that Chinese psychiatric patients are ldquosomatizersrdquo who
manifest few or no emotional symptoms and who attribute distress to physical causes
Rather they argue that SJSR gained widespread acceptance in China as it was a non-
stigmatizing diagnosis that allowed individuals experiencing psychosocial distress to
seek help during a time in which traditional cultural beliefs and political influences led
to severe sanction and stigmatization of individuals suffering from mental illnesses
(Lee 1998 1999 Phillips 1998 Shixie 1989) At the same time other Chinese
researchers and clinicians have continued to defend neurasthenia as both a valid
diagnostic category and a clinically useful means of communicating with patients (Rin
amp Huang 1989 Yan 1989 Young 1989) Due to continued debate on this topic it is
essential that researchers examining models of vulnerability to depression within China
assess multiple symptom outcomes as the types of symptoms predicted by vulnerability
factors may vary as a function of cultural context Hence in the current study we also
assessed levels of anxious symptoms to provide a test of the specificity hypothesis of
Beckrsquos (1967 1983) cognitive theory
In order to provide a powerful examination of our hypotheses concerning (1) the
applicability of the diathesis-stress component of Beckrsquos (1967 1983) cognitive theory
to Chinese university students and (2) the specificity of dysfunctional attitudes as
predictors of depressive as opposed to anxious symptoms participantsrsquo scores on the
neuroticism subscale of the Five-factor Inventory (FFI-N) were included as a control
variable in all analyses Several critical reviews of the literature examining theories of
cognitive vulnerability to depression (eg Barnett amp Gotlib 1998 Coyne amp Whiffen
8
1995) have argued that cognitive vulnerabilities to depression such as that featured in
Beckrsquos cognitive theory may be equivalent to or reducible to trait neuroticism and thus
may not confer independent risk for depression In response to such claims a recent
study conducted with university students examining the degree of factorial
independence versus overlap between trait neuroticism and dysfunctional attitudes has
shown them to be distinct constructs each loading onto separate factors (Hankin et al
2007) At the same time however there remains a need to examine whether
dysfunctional attitudes and trait neuroticism represent unique risk factors for
depression particularly in young adults in China Hence in the current study
participantsrsquo scores on the neuroticism subscale of the Five-factor Inventory (FFI-N)
were included as a control variable in order to account for any of the variance in
fluctuations in depressive (and anxious) symptoms that may be shared between
dysfunctional attitudes and trait neuroticism thereby isolating and highlighting their
unique predictive effects
METHOD
Participants
Participants included 662 university students (aged 19-21) from Changsha ndash an
industrial city in the province of Hunan with a population of approximately 6000000
In terms of the annual gross domestic product Hunan ranks 23rd
(10336 RMB) out of
the 34 provinces in China placing it well below the national provincial average (micro =
29719 RMB SD = 47462 RMB National Bureau of Statistics of China 2006)
Demographic variables for the sample are presented in Table 1
9
Procedure
Consent forms were distributed to all students in participating classes Consent
rates were greater than 95 in all the classes After consent forms were collected
researchers returned to the school to meet with participating students Written consent
was obtained from each participant at the beginning of the initial assessment During
the initial assessment students completed a demographics form and each of the
following questionnaires (1) Center for Epidemiological Studies Depression Scale
(CES-D Radloff 1977) (2) Mood and Anxiety Symptom Questionnaire (MASQ
Clark amp Watson 1991) (3) Dysfunctional Attitudes Scale (DAS Weissman amp Beck
1978) and (4) NEO Five Factor Inventory- Neuroticism Subscale (FFI-N Costa amp
McCrae 1992) Once a month for the subsequent six-months researchers returned to
the school and met with participating students to conduct follow-up assessments At
each of these follow-up assessments students were asked to complete each of the
following questionnaires (1) CES-D (2) MASQ and (3) the General Academic
Social Hassles Scale for Students (GASHSS Blankstein amp Flett 1993)
Measures
The Chinese versions of all self-report measures were developed using the
back-translation method Original English versions were translated into Chinese by a
bilingual translator from the Psychology department at Second Xiangya Medical
College of Central South University Hunan Translated Chinese versions were then
back-translated into English by another bilingual translator from the Psychology
department at McGill University Quebec Original versions were then compared with
the back-translation If inconsistencies were found in the back-translation translators
10
worked together to make corrections to the final Chinese versions until all final
versions were agreed upon No items from any of the measures were removed or
significantly altered during the translation process
Depressive Symptoms Center for Epidemiological Studies Depression Scale
(CES-D Radloff 1977) The CES-D is a 20-item self-report measure designed to
assess depressive symptoms in the general population For each item participants are
asked to indicate how often they experienced the particular symptom over the last
week Responses range from 1 (eg rarely or none of the time) to 4 (eg most or all of
the time) Scores range from 20-80 with higher score indicating higher levels of
depressive symptoms In the current study the CES-D exhibited high internal
consistency with Cronbachrsquos alpha values ranging from 90 to 94 (micro = 2918 SD =
814) over the 7 time points
Anxious Symptoms Mood and Anxiety Symptom Questionnaire (MASQ
Watson amp Clark 1991) The MASQ is a 62-item questionnaire designed to assess both
specific and nonspecific depressive and anxious symptoms For each item participants
are asked to rate on a scale of 1 to 5 the extent to which they have felt this way ldquoduring
the past 24 hoursrdquo Within the current study we utilized the anxious symptoms (11
items) and anxious arousal (17 items) subscales which together provide an index of
overall anxious symptoms Higher scores on each subscale reflect greater levels of
anxious symptoms In the current study the MASQ exhibited high internal consistency
with Cronbachrsquos alpha values ranging from 90 to 95 (micro = 3847 SD = 1117) over the
7 time points
11
Dysfunctional Attitudes Dysfunctional Attitudes Scale (DAS Weissman amp
Beck 1978) The DAS (Form A) is a 40-item questionnaire designed to measure the
cognitive vulnerability factor featured in Beckrsquos cognitive theory Examples of items
include ldquoIf I do not do well all the time people will not respect merdquo ldquoIf a person asks
for help it is a sign of weaknessrdquo and ldquoMy value as a person depends greatly on what
others think of merdquo Items are rated on a 7-point Likert scale ranging from 1 (totally
disagree) to 7 (totally agree) providing a range of scores from 40 to 280 with higher
scores reflecting more dysfunctional attitudes In the current study the DAS exhibited
high internal consistency with Cronbachrsquos alphas of 89 and 88 obtained for the first
and second administrations respectively In addition a test-retest reliability coefficient
of 72 was obtained indicating strong stability over time
Neuroticism NEO Five Factor Inventory - Neuroticism Subscale (FFI-N
Costa amp McCrae 1992) The FFI-N is a 12- item self-report measure that assesses
neuroticism Examples of questions include I often feel inferior to others I am
seldom sad or depressed and Sometimes I feel completely worthless Items are rated
on a 5-point Likert scale ranging from 0 (strongly disagree) to 4 (strongly agree)
providing scores ranging from 0 to 48 with higher scores indicating higher levels of
neuroticism The NEO-FFI-N has proven reliable across different cultural samples and
item pools (Costa amp McCrae 1992) In the current study Cronbachs alpha was 81
indicating strong internal consistency
Negative Life Events General Academic Social Hassles Scale for Students
(GASHSS Blankstein amp Flett 1993) Participants completed a 30-item abbreviated
version of the GASHSS The measure is comprised of items assessing general hassles
12
(8 items) academic hassles (10 items) and social hassles (12 items) For each item
participants are asked to rate how persistent the given hassle was (ie its frequency and
duration) over the last 30 days (0 = no hassle not at all persistent to 6 = extremely
persistent hassle high frequency andor duration)
13
RESULTS
Descriptive Data
Means standard deviations and inter-correlations between Time 1 measures are
presented in Table 2
Prospective Diathesis-Stress Analyses - Depression
Multilevel modeling was used to test our hypothesis that higher levels of dysfunctional
attitudes would be associated with greater increases in depressive symptoms following
increases in stress Analyses were carried out using the SAS (version 81) MIXED
procedure and maximum likelihood estimation Our dependent variable was within-
subject fluctuations in CES-D scores during the follow-up interval (DEPRESSION)
Our primary predictors of DEPRESSION were DAS scores (DYSFUNCTIONAL
ATTITUDES) and fluctuations in GASHSS scores during the follow-up interval
(STRESS) As DYSFUNCTIONAL ATTITUDES is a between-subject predictor DAS
scores were standardized prior to analyses As STRESS is a within-subject predictor
STRESS reflects upward or downward fluctuations in an individualrsquos level of stress
compared to hisher mean level of stress
When fitting hierarchical linear models one must specify appropriate mean and
covariance structures Mean structures refer to the various fixed and random effect
components that can be included in the model Covariance structures refer to alternative
methods of specifying the pattern of covariance between observations taken from the
same subject at different time points It is important to note that mean and covariance
structures are not independent of one another Rather an appropriate covariance
structure is essential in order to obtain valid inferences for the parameters in the mean
14
structure Overparametrization of the covariance structure can lead to inefficient
estimation and poor assessment of standard errors (Altham 1984) On the other hand
too much restriction of the covariance structure can lead to invalid inferences when the
assumed structure does not hold (Altham 1984)
In our first set of analyses we were interested in examining the effects of
DYSFUNCTIONAL ATTITUDES STRESS and the DYSFUNCTIONAL
ATTITUDES STRESS interaction on participantrsquos CES-D scores during the follow-
up interval Consequently in line with Diggle Liang and Zegers (1994)
recommendation that one use a ldquosaturatedrdquo model for the mean structure while
searching for an appropriate covariance structure we chose a mean structure that
included DYSFUNCTIONAL ATTITUDES STRESS and the DYSFUNCTIONAL
ATTITUDES STRESS interaction Four additional effects were also included in this
mean structure First as different individuals report different levels of depressive
symptoms when at their own average level of stress a random effect for intercept was
included in the model Second given that STRESS is a within-subject predictor whose
effect is expected to vary from participant to participant a random effect for slope was
included in the model Third in order to control for individual differences in baseline
levels of depressive symptoms Time 1 CES-D scores were included in the model
Fourth in order to examine whether DYSFUNCTIONAL ATTITUDES represent a
vulnerability factor independent of neuroticism participantsrsquo FFI-N scores were
entered in the model
Commonly used covariance structures in studies in which multiple responses
are obtained from the same individual over time (and consequently within-subject
15
residuals over time are likely to be correlated) include compound symmetry first-order
autoregressive heterogeneous autoregressive and banded Toeplitz In order to select
one of these covariance structures for our analyses we fitted models using each
structure and chose the ldquobestrdquo fit based on Akaike information criterion (AIC and
AICC) and Schwarz Bayesian criterion (BIC) In all cases the best fit for our data was
a first-order heterogeneous autoregressive structure (ARH [1]) After choosing the
appropriate covariance structure we next examined the random-effects component of
our model
With respect to random effects the ARH [1] parameter (r = 31 plt001)
RE_INTERCEPT (plt001) and RE_SLOPE (plt001) were each significant and thus
were retained in the model The final results with respect to the fixed-effects
component of the model are presented in the upper section of Table 3 Of primary
importance the DYSFUNCTIONAL ATTITUDES STRESS interaction was a
significant predictor of fluctuations in depressive symptoms during the follow-up
interval In order to examine the form of this interaction the model summarized in the
upper section of Table 3 was used to calculate predicted CES-D scores for individuals
exhibiting either high or low levels of dysfunctional attitudes (plus or minus 15 SD)
who are experiencing either high or low levels of stress in comparison to their own
average level of stress (plus or minus 15 times mean within-subject SD) The results of
such calculations are presented in the left panel of Figure 1
Analyses were conducted for each DYSFUNCTIONAL ATTITUDES
condition examining whether the slope of the relationship between stress and
depressive symptoms significantly differed from 0 Analyses indicated that both
16
individuals exhibiting high (t(2459) = 862 p lt 0001) and low (t(2459) = 347 p lt
0001) levels of dysfunctional attitudes reported significantly higher levels of
depressive symptoms when experiencing high levels of stress than when experiencing
low levels of stress Planned comparisons of the slopes of the relationship between
stress and depressive symptoms however revealed that the slope was significantly
greater in individuals exhibiting high levels of dysfunctional attitudes (slope = 013)
than in individuals exhibiting low levels of dysfunctional attitudes (slope = 005
t(2459) = 328 p = 0001)
Prospective Diathesis-Stress Analyses - Anxiety
The same data-analytic approach as described above was used to examine
whether higher levels of dysfunctional attitudes would be associated with greater
increases in anxious symptoms following increases in stress Again in order to examine
whether DYSFUNCTIONAL ATTITUDES represent a vulnerability factor
independent of neuroticism participantsrsquo FFI-N scores were entered in the model
With respect to random effects the ARH[1] parameter (r = 23 p lt 001)
RE_INTERCEPT (plt001) and RE_SLOPE (plt001) were each significant and thus
were retained in the model The final results with respect to the fixed-effects
component of the model are presented in the lower section of Table 3 Of primary
importance the DYSFUNCTIONAL ATTITUDES STRESS interaction was a
significant predictor of within-subject fluctuations in anxious symptoms during the
follow-up interval In order to examine the form of this interaction the model
summarized in the lower section of Table 3 was used to calculate predicted MASQ
scores for individuals exhibiting either high or low levels of dysfunctional attitudes
17
(plus or minus 15 SD) who are experiencing either high or low levels of stress in
comparison to their own average level of stress (plus or minus 15 times mean within-
subject SD) The results of such calculations are presented on the right panel of in
Figure 1
Analyses were conducted for each DYSFUNCTIONAL ATTITUDES
condition examining whether the slope of the relationship between stress and anxious
symptoms significantly differed from 0 Analyses indicated that both individuals
exhibiting high (t(2470) = 768 p lt 0001) and low (t(2470) = 337 p lt 0001) levels of
dysfunctional attitudes reported higher levels of anxious symptoms when experiencing
high levels of stress than when experiencing low levels of stress Planned comparisons
of the slopes of the relationship between stress and anxious symptoms however
revealed that the slope was significantly greater in individuals exhibiting high levels of
dysfunctional attitudes (slope = 009) than in individuals exhibiting low levels of
dysfunctional attitudes (slope = 003 t(2470) = 278 p lt 001)
Additional Analyses
Given that the DYSFUNCTIONAL ATTITUDES STRESS interaction
prospectively predicted both symptoms of depression and anxiety two additional
analyses were conducted in order to examine (1) whether the DYSFUNCTIONAL
ATTITUDES STRESS interaction continued to be a significant predictor of within-
subject fluctuations in depressive symptoms after controlling for within-subject
fluctuations in anxious symptoms and (2) whether the DYSFUNCTIONAL
ATTITUDES STRESS interaction continued to predict within-subject fluctuations in
anxious symptoms after controlling for within-subject fluctuations in depressive
18
symptoms Such analyses allowed us to examine whether the above mentioned pattern
of findings may have been due to the high correlation observed in the current study
between depressive and anxious symptoms
Analyses were conducted in the same manner as described above with the
exception that an additional within-subject variable (ie DEPRESSION or ANXIETY)
was included in each model in order to control for within-subject fluctuations in the
alternate symptom With respect to the prediction of depressive symptoms the
DYSFUNCTIONAL ATTITUDES STRESS interaction remained a significant
predictor after controlling for within-subject fluctuations in anxious symptoms (β =
001 SE = 000 F = 410 p lt 05) With respect to the prediction of anxious
symptoms however the DYSFUNCTIONAL ATTITUDES STRESS interaction
was no longer a significant predictor after controlling for within-subject fluctuations in
depressive symptoms (β = 001 SE = 000 F = 148 p = 22)
DISCUSSION
The results of the current study provide support for the cross-cultural
applicability of Beckrsquos (1967 1983) cognitive theory to university students in Hunan
China More specifically consistent with hypotheses and with results obtained from
past research examining Beckrsquos cognitive theory in Western samples of university
students (Hankin et al 2004 Hankin et al 2005 Joiner et al 1999 Klocek et al
1997 Brown et al 1995) higher levels of dysfunctional attitudes were associated with
greater increases in depressive symptoms following increases in negative event
frequency during the six-month follow-up interval Given the considerable differences
between the current sample and Western samples in terms of demographic
19
characteristics and cultural factors such a finding strongly attests to the robustness of
Beckrsquos cognitive theory Moreover integrating the current findings with those obtained
in research examining Beckrsquos theory in other non-Western samples suggests that
Beckrsquos theory may represent a powerful explanatory model of the development of
depressive symptoms among individuals from diverse cultural settings For example
consistent with the theory higher levels of dysfunctional attitudes have been shown to
be associated with higher levels of depressive symptoms in Japanese (Tanaka et al
2006) Puerto-Rican (Bonilla Bernal Santos amp Santos 2003) Turkish (Sahin amp Sahin
1992) Norwegian (Chioqueta amp Stiles 2004) Singaporean (Oei Goh amp Kwon 1996)
and Swedish (Ohrt amp Thorell 1998) adult samples In addition it is important to note
that the current findings expand upon past correlational research examining the
association between dysfunctional attitudes and depression in Chinese samples through
the use of a multi-wave longitudinal design
When examining the specificity of dysfunctional attitudes as a predictor of
depressive symptoms the current study did not obtain support for specificity More
specifically contrary to the specificity hypothesis of Beckrsquos cognitive theory and to
results obtained in Western samples of university students (Alloy et al 2000 2006
Hankin et al 2004) higher levels of dysfunctional attitudes were associated with
greater increases in both depressive and anxious symptoms following increases in
negative event frequency There are two alternative ways of interpreting the non-
specificity finding observed in the current study First it is possible that the types of
thoughts individuals possessing high levels of dysfunctional attitudes experience
following negative events varies as a function of cultural context In other words in
20
Western samples such individuals may primarily experience the types of cognitions
that are associated with the development of depressive symptoms (ie appraisals of
personal loss and failure) In contrast in Chinese samples individuals possessing high
levels of dysfunctional attitudes may experience a wider array of cognitions some of
which are associated with the development of depressive symptoms and some of which
are associated with the development of anxious symptoms (ie evaluations of
impending threat or danger) Such an explanation would be consistent with Beckrsquos
cognitive content-specificity hypothesis (Clark amp Beck 1999) which posits that each
affective state and psychological disorder has a specific cognitive profile Second it is
possible that the types of symptoms individuals possessing high levels of dysfunctional
attitudes experience following negative events varies as a function of cultural context
More specifically it may be that dysfunctional attitudes specifically predict symptoms
of depression in both samples except that in Western samples depression manifests in
pure depressive symptoms whereas in Chinese samples depression manifests as a
combination of depressive and anxious symptoms Such an explanation would be
consistent with cultural psychopathologistsrsquo hypotheses that cultural factors shape the
phenomenology of psychiatric symptoms (Kleinman 2004 Mezzich et al 1999)
Moreover dysfunctional attitudes predicting a combination of depressive and anxious
symptoms in Chinese samples would be consistent with the construct of neurasthenia -
a construct hypothesized by some to represent a somatized form of depression that is
still widely seen within China (Lee amp Wong 1995)
Interesting in this regard and perhaps speaking to the primacy of depressive
symptoms in the current findings analyses indicated that the DYSFUNCTIONAL
21
ATTITUDES times STRESS interaction no longer predicted anxious symptoms after
controlling for depressive symptoms The reverse however was not true as the
DYSFUNCTIONAL ATTITUDES times STRESS interaction continued to predict
depressive symptoms after controlling for anxious symptoms
It is important to note that the current study employed a particularly
conservative approach to analyses in that we examined the effects of dysfunctional
attitudes on depressive and anxious symptoms after controlling for the effect of
neuroticism on such symptoms Providing particularly powerful support for Beckrsquos
(1967 1983) cognitive theory across analyses dysfunctional attitudes predicted levels
of depressive andor anxious symptoms experienced during the six month follow-up
interval independent of the effect of neuroticism Thus contrary to past critical reviews
of the cognitive literature (Barnett amp Gotlib 1998 Coyne amp Whiffen 1995) and
consistent with past findings (Hankin et al 2007) the current results indicate that
cognitive vulnerabilities to depression such as dysfunctional attitudes are not reducible
to trait neuroticism but rather represent factors that confer independent risk for
depression
Limitations and Future Directions
Several limitations of the current study should be noted First self-report
measures were used to assess depressive and anxious symptoms Although the CES-D
and MASQ both possess high degrees of reliability and validity it is difficult to draw
conclusions about clinically diagnosed depression or anxiety based on self-report
questionnaires Second self-report measures were used to assess stress Although
measures of stress that require participants only to indicate whether or not an event
22
occurred are less likely to be influenced by informant bias than those that ask
participants to rate the subjective impact of each event more sophisticated methods of
analysis such as interviewing procedures that assess contextual threat may provide
better assessments of stress Third the measures of dysfunctional attitudes stress and
depressive and anxious symptoms used in the current study were each Western-
developed Future research should examine these hypotheses using indigenous
measures in addition to Western-developed measures in order to assess possible
similarities andor differences in patterns of findings Fourth the current study only
examined depression and anxiety as symptom outcomes Future research conducted
within China should examine a wider array of symptom outcomes such as
somatization physical complaints and externalizing behaviors in order to provide a
more thorough and culturally sensitive test of the specificity hypotheses of Beckrsquos
cognitive model Fifth the current study examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese undergraduate students and thus the extent to which
our findings may be generalized to other demographics within Chinarsquos population is
unclear Last the current study broadly examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese university students Future research should examine
the constructs and processes posited by this model in greater detail in order to develop a
deeper understanding of how they may be uniquely molded by socio-cultural factors
Such research would benefit from examining the specific types of stressors experienced
by Chinese university students as they may vary as a function of socio-cultural factors
from those experienced by Western undergraduates For example severe pressure to
succeed academically in order to secure access to a limited number of post-
23
undergraduate educational opportunities - one of the few paths towards upward
mobility available to Chinese students seeking secure and gainful employment in what
has increasingly become a very highly competitive job market - may represent a
particularly salient stressor for the development of depressive symptoms among this
population (Qiang 2006)
In conclusion the results from the current study provide support for the
applicability of Beckrsquos cognitive theory to university students in mainland China More
specifically consistent with findings obtained in the West results indicate that
dysfunctional attitudes confer vulnerability to the development of depressive symptoms
following the occurrence of negative events in Chinese university students At the same
time however the current findings suggest cultural variation in the profile of
symptoms which emerge following the occurrence of negative events in cognitively
vulnerable individuals in Western and Chinese samples Specifically whereas in the
West dysfunctional attitudes have been shown to confer vulnerability to depressive
symptoms in Chinese university students dysfunctional attitudes appear to confer
vulnerability to a combined depressive and anxious symptom profile Future research
using more sophisticated assessments of stress and depressive symptoms more diverse
samples and symptom outcome measures and indigenously-developed measures is
likely to enhance our understanding of the cognitive and environmental mechanisms
underlying the development of depression in Chinese university students Discovering
that cognitive theories of vulnerability to depression extend to university students in
China highlights the potential role for cognitive-behavioral depression prevention and
treatment interventions in stemming the tide of distress experienced by this population
24
REFERENCES
Abela J R Z amp Hankin B L (2008) Cognitive vulnerability to depression in
children and adolescents A developmental psychopathology perspective In J
R Z Abela and B L Hankin (Eds) Handbook of child and adolescent
depression (pp 35-78) New York The Guilford Press
Alloy L B Abramson L Y Hogan M E Whitehouse W G Rose D T
Robinson MS Kim R S amp Lapkin J B (2000) The Temple-Wisconsin
cognitive vulnerability to depression project Lifetime history of axis-I
psychopathology in individuals at high and low cognitive risk for depression
Journal of Abnormal Psychology 109 403-418
Alloy L B Abramson L Y Whitehouse W G Hogan M E Panzarella C amp
Rose D T (2006) Prospective incidence of first onsets and recurrences of
depression in individuals at high and low cognitive risk for depression Journal
of Abnormal Psychology 115 145ndash156
Altham P M E (1984) Improving the precision of estimation by fitting a model
Journal of the Royal Statistical Society Series B 46 11
Barnett PA amp Gotlib I H (1988) Psychosocial functioning and depression
Distinguishing among antecedents concomitants and consequences
Psychological Bulletin 104 97-126
Beck AT (1967) Depression Clinical experimental and theoretical aspects New
York Harper amp Row
Beck AT (1983) Cognitive therapy of depression New perspectives In PJ Clayton
amp JE Barrett (Eds) Treatment of depression Old controversies and new
approaches New York Raven Press
Bian Q Yang K amp Li C (2007) Dysfunctional attitudes of patients with depression
or bipolar disorder Chinese Mental Health Journal 21 759-761
Blankstein K R amp Flett G L (1993) Development of the General Academic and
Social Hassles Scales for Students Unpublished manuscript
Bonilla J Bernal G Santos A amp Santos D (2003) A revised Spanish version of
the Beck Depression InventoryPsychometric properties with a Puerto Rican
sample of college students Journal of Clinical Psychology 60 119-130
Brown G P Hammen C L Craske M G amp Wickens T D (1995) Dimensions of
dysfunctional attitudes as vulnerabilities to depressive symptoms Journal of
Abnormal Psychology 104 431-435
25
Chioqueta A P amp Stiles T C (2004) Psychometric properties of the Norweigian
version of the Dysfunctional Attitude Scale (Form A) Cognitive Behaviour
Therapy 33 83-86
Clark DA amp Beck AT (1999) Cognitive theory and therapy of depression New
York John Wiley amp Sons Inc
Clark L A amp Watson D (1991) Tripartite model of anxiety and depression
Psychometric evidence and taxonomic implications Journal of Abnormal
Psychology 100 316ndash336
Costa P T amp McCrae R R (1992) NEO PI-R Professional manual Revised NEO
personality inventory NEO PR-R and NEO five-factor inventory NEO-RRI
Odessa FL Psychological Assessment Resources
Coyne J C amp Whiffen V E (1995) Issues in personality as diathesis for depression
The case of sociotropy-dependency and autonomy-self-criticism Psychological
Bulletin 118 358-378
Fang X Qian M Luo S amp Zi F (2009) A correlational study on college students
perfectionism parental rearing patterns and mental health Chinese Mental
Health Journal 23 56-59
Hankin B L Abramson L Y Miller N amp Haeffel G (2004) Cognitive
vulnerability-stress theories of depression Examining affective specificity in
the prediction of depression versus anxiety in three prospective studies
Cognitive Therapy and Research 28 309ndash345
Hankin BL Fraley RC amp Abela JRZ (2005) Daily depression and cognitions
about stress Evidence for a traitlike depressogenic cognitive style and the
prediction of depressive symptoms in a prospective daily diary study Journal of
Personality and Social Psychology 88 673-685
Hankin B L Lakdawalla Z Carter I L Abela J R Z amp Adams P (2007) Are
neuroticism cognitive vulnerabilities and self-esteem overlapping or distinct
risks for depression Evidence from confirmatory factor analyses Journal of
Social amp Clinical Psychology 26 29-63
Hankin B L Wetter E Cheely C amp Oppenheimer C W (2008) Becks cognitive
theory of depression in adolescence Specific prediction of depressive
symptoms and reciprocal influences in a multi-wave prospective study
International Journal of Cognitive Therapy 1 313-332
Ingram R E Miranda J amp Segal Z V (1998) Cognitive Vulnerability to
Depression New York NY Guilford Press
26
Ingram R E amp Luxton DD (2005) Vulnerability-stress models In BL Hankin amp
JRZ Abela (Eds) Development of psychopathology A vulnerability-stress
perspective (pp 32-46) Thousand Oaks CA Sage
Joiner T E Metalsky G I Lew A amp Klocek J (1999) Testing the causal
mediation component of Becks theory of depression Evidence for specific
mediation Cognitive Therapy and Research 23 401-412
Kleinman A (2004) Culture and depression New England Journal of Medicine 351
951-953
Kleinman A (1977) Depression somatization and the new cross-cultural psychiatry
Social Science and Medicine 11 3-10
Kleinman A (1996) How is culture important for DSM-IV In J E Mezzich A
Kleinmam H Fabrega Jr amp L Delores (Eds)Culture and psychiatric
diagnosis A DSM-IV perspective (pp 15-25) Washington DC US American
Psychiatric Association
Klocek J W Oliver J M amp Ross M J (1997) The role of dysfunctional attitudes
negative life events and social support in the prediction of depressive
dysphoria A prospective longitudinal study Social Behavior and Personality
25 23-136
Lee S (1997) A Chinese perspective on somatoform disorders Journal of
Psychosomatic Disorders 43 115-119
Lee S (1998) Estranged bodies simulated harmony and misplaced cultures
Neurasthenia in contemporary Chinese society Psychosomatic Medicine 60
448ndash457
Lee S (1999) Diagnosis postponed Shenjing shuairo and the transformation of
psychiatry in post-Mao China Culture Medicine and Psychiatry 23 349ndash380
Lee S amp Wong K C (1995) Rethinking neurasthenia the illness concepts of
shenjing shuairuo among Chinese undergraduates in Honk Kong Culture
Medicine and Psychiatry 19 91ndash111
Lee S Tsang A Huang YQ He YL Liu ZR Zhang MY Shen YC amp
Kessler RC (2009) The epidemiology of depression in metropolitan China
Psychological Medicine 39 735-747
Mezzich J E Kirmayer L J Kleinman A Fabrega Jr H Parron D L Good B
J Lin K amp Manson S M (1999) The place of culture in DSM-IV Journal
of Nervous and Mental Disease 187 457-464
27
Monroe S M amp Simons A D (1991) Diathesisndashstress theories in the context of life
stress research Implications for the depressive disorders Psychological
Bulletin 110 406ndash425
Murray C J L amp Lopez A D (1996) The global burden of disease Cambridge
Harvard University Press
National Bureau of Statistics of China (2006) The China 2005 statistical yearbook
China Statistics Press Beijing PR China
Oei T P S Goh Y Kwon S M(1996) A cross-cultural study of the integrated
cognitive model of depression Current Psychology of Cognition 15 265-281
Ohrt T amp Thorell L (1998) Dysfunctional Attitude Scale (DAS) Psychometrics and
norms of the Swedish version Scandinavian Journal of Behaviour Therapy 27
105-113
Parker G Gladstone G Chee KT (2001) Depression in the planetrsquos largest ethnic
group The Chinese American Journal of Psychiatry 158 857-864
Phillips M R Zhang J Shi Q Song Z Ding Z Pang S Li X Zhang Y amp
Wang Z (2009) Prevalence treatment and associated disability of mental
disorders in four provinces in China during 2001ndash05 an epidemiological
survey The Lancet 373 2041-2053
Phillips M R Li X amp Zhang Y (2002) Suicide rates in China Lancet 359 835-
840
Phillips M R (1998) The transformation of Chinarsquos mental health services The China
Journal 39 1ndash36
Qiang G (2006) Depression number one killer of Ivory Tower students China Daily
Retrieved from httpwwwchinadailycomcnchina2006-
1128content_744880htm
Radloff L S (1977) The CESndashD scale A self-report depression scale for research in
the general population Applied Psychological Measurement 1 385ndash401
Rin H amp Huang M G (1989) Neurasthenia as nosological dilemma Culture
Medicine and Psychiatry 13 215-226
Sahin NH amp Sahin N (1992) How dysfunctional are the dysfunctional attitudes in
another culture British Journal of Medical Psychology 65 17-26
Shixie L (1989) Neurasthenia in China Modern and traditional criteria for its
diagnosis Culture Medicine and Psychiatry 13 163-186
28
Tanaka N Uji M Hiramura H Chen Z Shikai N amp Kitamura T (2006)
Cognitive patterns and depression Study of a Japanese university student
population Psychiatry and Clinical Neuroscience 60 358-364
Taylor R E (2001) Death of neurasthenia and its psychological reincarnation a study
of neurasthenia at the National Hospital for the Relief and Cure of the Paralysed
and Epileptic Queen Square London 1870ndash1932 British Journal of
Psychiatry 179 550ndash557
Weissman A N amp Beck A T (1978 April) Development and validation of the
Dysfunctional Attitudes Scale A preliminary investigation Paper presented at
the annual meeting of the Educational Research Association Toronto Canada
Xiang M Z (1986) Epidemiological study of neuroses in 12 regions (districts) of
China Chinese Journal of Neurology and Psychiatry 19 87-91
Xu JM (1987) Some issues in the diagnosis of depression in China Canadian
Journal of Psychiatry 32 368-370
Xu Y X (1994) About ICD-10 Journal of Clinical Psychology and Medicine 4 224-
226
Xu Z Li Z amp Wang Z (2007) Dysfunctional attitudes and cognitive bias in major
depressive disorder Chinese Mental Health Journal 21 488-491
Yan H Q (1989) The necessity of retaining the diagnostic concept of neurasthenia
Culture Medicine and Psychiatry 13 139-145
Yang H (2007) The Test of the Chinese version of Frost Multi-dimensional
Perfectionism Scale Chinese Mental Health Journal 21 97-100
Yang H amp Zhang X (2004) Perfectionism and mental health of college students
(2004) Chinese Mental Health Journal 18 647-648
Young D (1989) Neurasthenia and related problems Culture Medicine and
Psychiatry 13 131-138
Zhang D (1995) Depression and culture A Chinese perspective Canadian Journal of
Counseling 29 227ndash233
29
TABLE(S)
Table 1 Demographic Variables
Age 2011
Gender Male
Female
472
523
Parentsrsquo Marital Status Married
Divorced
Single
Remarried
938
23
18
20
Fatherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
Government Official
51
356
187
95
124
91
Motherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
122
406
144
76
134
Fatherrsquos Education Some Primary School
Primary School
Some High School
High School
University
29
139
222
403
137
Motherrsquos Education Some Primary School
Primary School
Some High School
High School
University
63
192
264
350
76
Only Child No
Yes
331
667
Monthly Income lt 1000 RMB
1000 ndash 1500 RMB
1500 ndash 2000 RMB
2000 ndash 3000 RMB
3000 ndash 4000 RMB
4000 ndash 5000 RMB
gt 5000 RMB
334
204
175
140
59
20
20
30
Table 2 Means Standard Deviations and Inter-correlations Between Time 1 Measures
__________________________________________________________________
1 2 3
__________________________________________________________________
1 Depressive Symptoms 2963 (780)
2 Anxious Symptoms 52 3753 (918)
3 Dysfunctional Attitudes 48 33 18120 (2304)
4 Neuroticism 63 42 53 3110 (712)
_________________________________________________________________________
Note Means and standard deviations (in parentheses) are on the diagonal Depressive
Symptoms = Center for Epidemiological Studies Depression Scale Anxious Symptoms
= Mood and Anxiety Symptom Questionnaire Overall Anxiety subscale Dysfunctional
Attitudes = Dysfunctional Attitudes Scale Neuroticism = NEO Five Factor Inventory
Neuroticism subscale p lt 01
31
Table 3 Dysfunctional Attitudes Predicting Within-Subject Fluctuations in CES-D
Scores (upper section) and MASQ Scores (lower section) during the Follow-Up
Interval
______________________________________________________________________
β SE F df
______________________________________________________________________
Time 1 CESD-D 297 026 12987 1572
Stress 005 000 10860 12459
Neuroticism 134 027 2518 1572
Dysfunctional Attitudes -055 040 -183 1572
Dysfunctional Attitudes times Stress 001 000 1078 12459
______________________________________________________________________
Time 1 MASQ 502 033 23158 1575
Stress 006 000 8963 12470
Neuroticism 080 033 596 1575
Dysfunctional Attitudes -052 051 -106 1575
Dysfunctional Attitudes times Stress 002 001 774 12470
______________________________________________________________________
Note Time 1 CES-D = Time 1 Center for Epidemiological Studies Depression Scale
Stress = Within-Subject Fluctuations in General Academic Social Hassles Scale for
Students (GASHSS) scores during the follow-up interval Neuroticism = NEO Five
Factor Inventory Neuroticism subscale Dysfunctional Attitudes = Dysfunctional
Attitudes Scale Time 1 MASQ = Time 1 Mood and Anxiety Symptom Questionnaire
Overall Anxiety subscale p lt 05 p lt 01 p lt 001
32
FIGURES
Figure 1 Predicted slope of the relationship between stress and depressive
symptoms (left panel) and anxious symptoms (right panel) as a function of
dysfunctional attitudes
20
25
30
Low High
Pre
dic
ted
CE
S-D
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
25
30
35
40
Low High
Pre
dic
ted
MA
SQ
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
Intercept Intercept
2
Cognitive Vulnerability-Stress Models of Depression
One theoretical perspective that has proven useful in understanding the
development of depression in Western young adults is the cognitive vulnerability-stress
perspective (Abela amp Hankin 2008) Cognitive theories of depression define
vulnerability as an internal and stable feature of an individual that predisposes himher
to develop depression following the occurrence of negative events (Ingram Miranda amp
Segal 1998) Cognitive models are fundamentally diathesis-stress models in that they
posit that depression is produced by the interaction between cognitive vulnerability
factors (the diatheses) and certain environmental conditions (the stressors) that trigger
such diatheses into operation (Ingram et al 1998) Evidence suggests that under
ordinary conditions individuals vulnerable to depression are indistinguishable from the
general population Only when confronted with certain stressors do differences between
vulnerable and non-vulnerable individuals emerge (Ingram et al 1998 Ingram amp
Luxton 2005 Monroe amp Simons 1991) For individuals who possess cognitive
vulnerability factors negative events trigger a pattern of negatively biased self-referent
information processing that initiates a downward spiral into depression Non-vulnerable
individuals react to such events with an appropriate level of distress and depressive
affect but do not spiral downwards into depression
Beckrsquos Cognitive Theory of Depression
One prominent cognitive vulnerably-stress model of depression is Beckrsquos (1967
1983) cognitive theory Central to Beckrsquos cognitive theory is the construct of schema
Beck defines schema as stored bodies of knowledge (ie mental representations of the
3
self and prior experiences) that are relatively enduring characteristics of a persons
cognitive organization When an individual is confronted with a situation the schema
most relevant to the situation is activated Schema activation subsequently influences
how the person perceives encodes and retrieves information regarding the situation
Beck proposed that certain individuals posses depressogenic schema that confer
vulnerability to depression Beck (1983) hypothesizes that depressogenic schemata are
typically organized as sets of dysfunctional attitudes such as ldquoI am nothing if a person I
love doesnrsquot like merdquo or ldquoIf I fail at my work then I am a failure as a personrdquo Among
individuals who possess depressogenic schema the occurrence of negative events
triggers a pattern of negatively biased self-referent information processing
characterized by negative errors in thinking (eg negatively skewed interpretations of
negative life events such as overgeneralization and catastrophizing) Negative errors in
thinking increase the likelihood that the individual will develop the negative cognitive
triad comprising three types of depressogenic thought patterns (1) negative views of
the self (eg the belief that one is deficient inadequate or unworthy) (2) negative
views of the world (eg construing life experiences in terms of themes of defeat or
disparagement) and (3) negative views of the future (eg the expectation that ones
difficulties will persist into the future and there is nothing one can do to change this)
According to the theory the development of the negative cognitive triad triggers the
onset of depressive symptoms
Research Support for Beckrsquos Cognitive Model of Depression
Prospective studies using Western university student samples have provided
support for Beckrsquos (1967 1983) cognitive theory of depression More specifically
4
several studies have found that dysfunctional attitudes interact with the occurrence of
negative life events to predict increases in depressive symptoms (Hankin Abramson
Miller Haeffel 2004 Hankin Fraley amp Abela 2005 Joiner Metalsky Lew amp Klocek
1999 Klocek Oliver amp Ross 1997 Brown Hammen Craske and Wickens 1995) as
well as a greater likelihood of developing a depressive episode (Hankin et al 2004) In
addition individuals possessing a high level of dysfunctional attitudes have been found
to be more likely to report a past history of depressive episodes (Alloy et al 2000) and
to experience future depressive episodes (Alloy et al 2006 Hankin et al 2004) than
individuals without such a vulnerability
Far less research has examined the applicability of Beckrsquos (1983 1967)
cognitive theory to Chinese samples Preliminary cross-sectional research however
has yielded findings consistent with the theoriesrsquo hypotheses For example Xu Li and
Wang (2007) found that psychiatric patients diagnosed with major depressive disorder
showed significantly higher levels of dysfunctional attitudes than did non-depressed
controls Simiarly Bian Yang and Li (2007) reported higher levels of dysfunctional
attitudes in remitted depressives as compared to normal controls Last several studies
conducted with Chinese university students have found higher levels of dysfunctional
attitudes ndash particularly those centered on themes of perfectionism - to be associated
with higher levels of psychiatric symptoms (eg Yang amp Zhang 2004 Yang 2007
Fang Qian Luo amp Zi 2009)
5
Goals of the current study
The primary goal of the current study was to examine the applicability of
Beckrsquos (1967 1983) cognitive theory of depression to university students in mainland
China The procedure involved an initial assessment during which students completed
measures assessing dysfunctional attitudes and symptoms of depression The procedure
also involved a series of six follow-up assessments occurring once a month for six
months during which symptoms of depression and the occurrence of negative events
were assessed The use of a multi-wave longitudinal design allowed us to take an
idiographic approach towards examining the diathesis-stress hypotheses of Beckrsquos
(1967 1983) theory More specifically we examined whether the slope of the
relationship between negative events and symptoms of depression within participants
varied across participants as a function of level of dysfunctional attitudes In line with
the vulnerability-stress hypothesis of Beckrsquos (1967 1983) cognitive theory we
hypothesized that higher levels of dysfunctional attitudes would be associated with
greater increases in depressive symptoms following the occurrence of negative events
The second objective of the current study was to examine the specificity of
dysfunctional attitudes as a predictor of depressive symptoms Beckrsquos (1967 1983)
theory posits that dysfunctional attitudes predict the development of depressive
symptoms but not symptoms of other forms of psychopathology Prospective studies
using Western university student (Alloy et al 2000 2006 Hankin Abramson Miller
amp Haeffel 2004) and adolescent samples (Hankin Wetter Cheely amp Oppenheimer
2008) have provided support for the specificity hypothesis of the theory More
specifically dysfunctional attitudes have been found to interact with negative events to
6
predict increases in depressive symptoms but not symptoms of anxiety or other
disorders in both university student (Hankin et al 2004) and adolescent samples
(Hankin et al 2008) Similarly although university students possessing a high level of
dysfunctional attitudes have been found to be more likely than other university students
to report a past history of depressive episodes (Alloy et al 2000) and to experience
future depressive episodes (Alloy et al 2006) they have not been found to differ from
their low-risk counterparts in terms of past history or future occurrence of other
psychological disorders (Alloy et al 2000 2006)
With respect to the current study it is possible that differences may emerge
between Chinese and Western samples in terms of the types of symptoms predicted by
dysfunctional attitudes More specifically cultural psychopathologists have proposed
that cultural factors shape the phenomenology of psychiatric symptoms as well as the
conceptualization and classification of disorders (Kleinman 2004 Mezzich et al
1999) As such the experience of psychopathology may exhibit unique features in
different cultures with diagnostic categories developed in one cultural context not being
valid in another (Kleinman 1977 1996) Neuresthenia known in China as shenjing
shuairuo (SJSR) is a diagnostic entity characterized by (1) physical and mental
weakness and fatigability (2) sleep disturbances (3) irritability and worry (4)
excitability (5) nervous pain and (6) memory difficulty (Taylor 2001) Historically
SJSR was a Western disease concept that subsequently evolved to become a widely
utilized diagnostic entity within China (Lee amp Wong 1995) Some cultural
psychopathologists have posited that SJSR represents a somatized form of depression
This claim however has been met with significant controversy (eg Lee 1997
7
Parker Gladstone amp Chee 2001 Xu JM 1987 Xu YX 1994 Zhang 1995)
Critics dispute the notion that Chinese psychiatric patients are ldquosomatizersrdquo who
manifest few or no emotional symptoms and who attribute distress to physical causes
Rather they argue that SJSR gained widespread acceptance in China as it was a non-
stigmatizing diagnosis that allowed individuals experiencing psychosocial distress to
seek help during a time in which traditional cultural beliefs and political influences led
to severe sanction and stigmatization of individuals suffering from mental illnesses
(Lee 1998 1999 Phillips 1998 Shixie 1989) At the same time other Chinese
researchers and clinicians have continued to defend neurasthenia as both a valid
diagnostic category and a clinically useful means of communicating with patients (Rin
amp Huang 1989 Yan 1989 Young 1989) Due to continued debate on this topic it is
essential that researchers examining models of vulnerability to depression within China
assess multiple symptom outcomes as the types of symptoms predicted by vulnerability
factors may vary as a function of cultural context Hence in the current study we also
assessed levels of anxious symptoms to provide a test of the specificity hypothesis of
Beckrsquos (1967 1983) cognitive theory
In order to provide a powerful examination of our hypotheses concerning (1) the
applicability of the diathesis-stress component of Beckrsquos (1967 1983) cognitive theory
to Chinese university students and (2) the specificity of dysfunctional attitudes as
predictors of depressive as opposed to anxious symptoms participantsrsquo scores on the
neuroticism subscale of the Five-factor Inventory (FFI-N) were included as a control
variable in all analyses Several critical reviews of the literature examining theories of
cognitive vulnerability to depression (eg Barnett amp Gotlib 1998 Coyne amp Whiffen
8
1995) have argued that cognitive vulnerabilities to depression such as that featured in
Beckrsquos cognitive theory may be equivalent to or reducible to trait neuroticism and thus
may not confer independent risk for depression In response to such claims a recent
study conducted with university students examining the degree of factorial
independence versus overlap between trait neuroticism and dysfunctional attitudes has
shown them to be distinct constructs each loading onto separate factors (Hankin et al
2007) At the same time however there remains a need to examine whether
dysfunctional attitudes and trait neuroticism represent unique risk factors for
depression particularly in young adults in China Hence in the current study
participantsrsquo scores on the neuroticism subscale of the Five-factor Inventory (FFI-N)
were included as a control variable in order to account for any of the variance in
fluctuations in depressive (and anxious) symptoms that may be shared between
dysfunctional attitudes and trait neuroticism thereby isolating and highlighting their
unique predictive effects
METHOD
Participants
Participants included 662 university students (aged 19-21) from Changsha ndash an
industrial city in the province of Hunan with a population of approximately 6000000
In terms of the annual gross domestic product Hunan ranks 23rd
(10336 RMB) out of
the 34 provinces in China placing it well below the national provincial average (micro =
29719 RMB SD = 47462 RMB National Bureau of Statistics of China 2006)
Demographic variables for the sample are presented in Table 1
9
Procedure
Consent forms were distributed to all students in participating classes Consent
rates were greater than 95 in all the classes After consent forms were collected
researchers returned to the school to meet with participating students Written consent
was obtained from each participant at the beginning of the initial assessment During
the initial assessment students completed a demographics form and each of the
following questionnaires (1) Center for Epidemiological Studies Depression Scale
(CES-D Radloff 1977) (2) Mood and Anxiety Symptom Questionnaire (MASQ
Clark amp Watson 1991) (3) Dysfunctional Attitudes Scale (DAS Weissman amp Beck
1978) and (4) NEO Five Factor Inventory- Neuroticism Subscale (FFI-N Costa amp
McCrae 1992) Once a month for the subsequent six-months researchers returned to
the school and met with participating students to conduct follow-up assessments At
each of these follow-up assessments students were asked to complete each of the
following questionnaires (1) CES-D (2) MASQ and (3) the General Academic
Social Hassles Scale for Students (GASHSS Blankstein amp Flett 1993)
Measures
The Chinese versions of all self-report measures were developed using the
back-translation method Original English versions were translated into Chinese by a
bilingual translator from the Psychology department at Second Xiangya Medical
College of Central South University Hunan Translated Chinese versions were then
back-translated into English by another bilingual translator from the Psychology
department at McGill University Quebec Original versions were then compared with
the back-translation If inconsistencies were found in the back-translation translators
10
worked together to make corrections to the final Chinese versions until all final
versions were agreed upon No items from any of the measures were removed or
significantly altered during the translation process
Depressive Symptoms Center for Epidemiological Studies Depression Scale
(CES-D Radloff 1977) The CES-D is a 20-item self-report measure designed to
assess depressive symptoms in the general population For each item participants are
asked to indicate how often they experienced the particular symptom over the last
week Responses range from 1 (eg rarely or none of the time) to 4 (eg most or all of
the time) Scores range from 20-80 with higher score indicating higher levels of
depressive symptoms In the current study the CES-D exhibited high internal
consistency with Cronbachrsquos alpha values ranging from 90 to 94 (micro = 2918 SD =
814) over the 7 time points
Anxious Symptoms Mood and Anxiety Symptom Questionnaire (MASQ
Watson amp Clark 1991) The MASQ is a 62-item questionnaire designed to assess both
specific and nonspecific depressive and anxious symptoms For each item participants
are asked to rate on a scale of 1 to 5 the extent to which they have felt this way ldquoduring
the past 24 hoursrdquo Within the current study we utilized the anxious symptoms (11
items) and anxious arousal (17 items) subscales which together provide an index of
overall anxious symptoms Higher scores on each subscale reflect greater levels of
anxious symptoms In the current study the MASQ exhibited high internal consistency
with Cronbachrsquos alpha values ranging from 90 to 95 (micro = 3847 SD = 1117) over the
7 time points
11
Dysfunctional Attitudes Dysfunctional Attitudes Scale (DAS Weissman amp
Beck 1978) The DAS (Form A) is a 40-item questionnaire designed to measure the
cognitive vulnerability factor featured in Beckrsquos cognitive theory Examples of items
include ldquoIf I do not do well all the time people will not respect merdquo ldquoIf a person asks
for help it is a sign of weaknessrdquo and ldquoMy value as a person depends greatly on what
others think of merdquo Items are rated on a 7-point Likert scale ranging from 1 (totally
disagree) to 7 (totally agree) providing a range of scores from 40 to 280 with higher
scores reflecting more dysfunctional attitudes In the current study the DAS exhibited
high internal consistency with Cronbachrsquos alphas of 89 and 88 obtained for the first
and second administrations respectively In addition a test-retest reliability coefficient
of 72 was obtained indicating strong stability over time
Neuroticism NEO Five Factor Inventory - Neuroticism Subscale (FFI-N
Costa amp McCrae 1992) The FFI-N is a 12- item self-report measure that assesses
neuroticism Examples of questions include I often feel inferior to others I am
seldom sad or depressed and Sometimes I feel completely worthless Items are rated
on a 5-point Likert scale ranging from 0 (strongly disagree) to 4 (strongly agree)
providing scores ranging from 0 to 48 with higher scores indicating higher levels of
neuroticism The NEO-FFI-N has proven reliable across different cultural samples and
item pools (Costa amp McCrae 1992) In the current study Cronbachs alpha was 81
indicating strong internal consistency
Negative Life Events General Academic Social Hassles Scale for Students
(GASHSS Blankstein amp Flett 1993) Participants completed a 30-item abbreviated
version of the GASHSS The measure is comprised of items assessing general hassles
12
(8 items) academic hassles (10 items) and social hassles (12 items) For each item
participants are asked to rate how persistent the given hassle was (ie its frequency and
duration) over the last 30 days (0 = no hassle not at all persistent to 6 = extremely
persistent hassle high frequency andor duration)
13
RESULTS
Descriptive Data
Means standard deviations and inter-correlations between Time 1 measures are
presented in Table 2
Prospective Diathesis-Stress Analyses - Depression
Multilevel modeling was used to test our hypothesis that higher levels of dysfunctional
attitudes would be associated with greater increases in depressive symptoms following
increases in stress Analyses were carried out using the SAS (version 81) MIXED
procedure and maximum likelihood estimation Our dependent variable was within-
subject fluctuations in CES-D scores during the follow-up interval (DEPRESSION)
Our primary predictors of DEPRESSION were DAS scores (DYSFUNCTIONAL
ATTITUDES) and fluctuations in GASHSS scores during the follow-up interval
(STRESS) As DYSFUNCTIONAL ATTITUDES is a between-subject predictor DAS
scores were standardized prior to analyses As STRESS is a within-subject predictor
STRESS reflects upward or downward fluctuations in an individualrsquos level of stress
compared to hisher mean level of stress
When fitting hierarchical linear models one must specify appropriate mean and
covariance structures Mean structures refer to the various fixed and random effect
components that can be included in the model Covariance structures refer to alternative
methods of specifying the pattern of covariance between observations taken from the
same subject at different time points It is important to note that mean and covariance
structures are not independent of one another Rather an appropriate covariance
structure is essential in order to obtain valid inferences for the parameters in the mean
14
structure Overparametrization of the covariance structure can lead to inefficient
estimation and poor assessment of standard errors (Altham 1984) On the other hand
too much restriction of the covariance structure can lead to invalid inferences when the
assumed structure does not hold (Altham 1984)
In our first set of analyses we were interested in examining the effects of
DYSFUNCTIONAL ATTITUDES STRESS and the DYSFUNCTIONAL
ATTITUDES STRESS interaction on participantrsquos CES-D scores during the follow-
up interval Consequently in line with Diggle Liang and Zegers (1994)
recommendation that one use a ldquosaturatedrdquo model for the mean structure while
searching for an appropriate covariance structure we chose a mean structure that
included DYSFUNCTIONAL ATTITUDES STRESS and the DYSFUNCTIONAL
ATTITUDES STRESS interaction Four additional effects were also included in this
mean structure First as different individuals report different levels of depressive
symptoms when at their own average level of stress a random effect for intercept was
included in the model Second given that STRESS is a within-subject predictor whose
effect is expected to vary from participant to participant a random effect for slope was
included in the model Third in order to control for individual differences in baseline
levels of depressive symptoms Time 1 CES-D scores were included in the model
Fourth in order to examine whether DYSFUNCTIONAL ATTITUDES represent a
vulnerability factor independent of neuroticism participantsrsquo FFI-N scores were
entered in the model
Commonly used covariance structures in studies in which multiple responses
are obtained from the same individual over time (and consequently within-subject
15
residuals over time are likely to be correlated) include compound symmetry first-order
autoregressive heterogeneous autoregressive and banded Toeplitz In order to select
one of these covariance structures for our analyses we fitted models using each
structure and chose the ldquobestrdquo fit based on Akaike information criterion (AIC and
AICC) and Schwarz Bayesian criterion (BIC) In all cases the best fit for our data was
a first-order heterogeneous autoregressive structure (ARH [1]) After choosing the
appropriate covariance structure we next examined the random-effects component of
our model
With respect to random effects the ARH [1] parameter (r = 31 plt001)
RE_INTERCEPT (plt001) and RE_SLOPE (plt001) were each significant and thus
were retained in the model The final results with respect to the fixed-effects
component of the model are presented in the upper section of Table 3 Of primary
importance the DYSFUNCTIONAL ATTITUDES STRESS interaction was a
significant predictor of fluctuations in depressive symptoms during the follow-up
interval In order to examine the form of this interaction the model summarized in the
upper section of Table 3 was used to calculate predicted CES-D scores for individuals
exhibiting either high or low levels of dysfunctional attitudes (plus or minus 15 SD)
who are experiencing either high or low levels of stress in comparison to their own
average level of stress (plus or minus 15 times mean within-subject SD) The results of
such calculations are presented in the left panel of Figure 1
Analyses were conducted for each DYSFUNCTIONAL ATTITUDES
condition examining whether the slope of the relationship between stress and
depressive symptoms significantly differed from 0 Analyses indicated that both
16
individuals exhibiting high (t(2459) = 862 p lt 0001) and low (t(2459) = 347 p lt
0001) levels of dysfunctional attitudes reported significantly higher levels of
depressive symptoms when experiencing high levels of stress than when experiencing
low levels of stress Planned comparisons of the slopes of the relationship between
stress and depressive symptoms however revealed that the slope was significantly
greater in individuals exhibiting high levels of dysfunctional attitudes (slope = 013)
than in individuals exhibiting low levels of dysfunctional attitudes (slope = 005
t(2459) = 328 p = 0001)
Prospective Diathesis-Stress Analyses - Anxiety
The same data-analytic approach as described above was used to examine
whether higher levels of dysfunctional attitudes would be associated with greater
increases in anxious symptoms following increases in stress Again in order to examine
whether DYSFUNCTIONAL ATTITUDES represent a vulnerability factor
independent of neuroticism participantsrsquo FFI-N scores were entered in the model
With respect to random effects the ARH[1] parameter (r = 23 p lt 001)
RE_INTERCEPT (plt001) and RE_SLOPE (plt001) were each significant and thus
were retained in the model The final results with respect to the fixed-effects
component of the model are presented in the lower section of Table 3 Of primary
importance the DYSFUNCTIONAL ATTITUDES STRESS interaction was a
significant predictor of within-subject fluctuations in anxious symptoms during the
follow-up interval In order to examine the form of this interaction the model
summarized in the lower section of Table 3 was used to calculate predicted MASQ
scores for individuals exhibiting either high or low levels of dysfunctional attitudes
17
(plus or minus 15 SD) who are experiencing either high or low levels of stress in
comparison to their own average level of stress (plus or minus 15 times mean within-
subject SD) The results of such calculations are presented on the right panel of in
Figure 1
Analyses were conducted for each DYSFUNCTIONAL ATTITUDES
condition examining whether the slope of the relationship between stress and anxious
symptoms significantly differed from 0 Analyses indicated that both individuals
exhibiting high (t(2470) = 768 p lt 0001) and low (t(2470) = 337 p lt 0001) levels of
dysfunctional attitudes reported higher levels of anxious symptoms when experiencing
high levels of stress than when experiencing low levels of stress Planned comparisons
of the slopes of the relationship between stress and anxious symptoms however
revealed that the slope was significantly greater in individuals exhibiting high levels of
dysfunctional attitudes (slope = 009) than in individuals exhibiting low levels of
dysfunctional attitudes (slope = 003 t(2470) = 278 p lt 001)
Additional Analyses
Given that the DYSFUNCTIONAL ATTITUDES STRESS interaction
prospectively predicted both symptoms of depression and anxiety two additional
analyses were conducted in order to examine (1) whether the DYSFUNCTIONAL
ATTITUDES STRESS interaction continued to be a significant predictor of within-
subject fluctuations in depressive symptoms after controlling for within-subject
fluctuations in anxious symptoms and (2) whether the DYSFUNCTIONAL
ATTITUDES STRESS interaction continued to predict within-subject fluctuations in
anxious symptoms after controlling for within-subject fluctuations in depressive
18
symptoms Such analyses allowed us to examine whether the above mentioned pattern
of findings may have been due to the high correlation observed in the current study
between depressive and anxious symptoms
Analyses were conducted in the same manner as described above with the
exception that an additional within-subject variable (ie DEPRESSION or ANXIETY)
was included in each model in order to control for within-subject fluctuations in the
alternate symptom With respect to the prediction of depressive symptoms the
DYSFUNCTIONAL ATTITUDES STRESS interaction remained a significant
predictor after controlling for within-subject fluctuations in anxious symptoms (β =
001 SE = 000 F = 410 p lt 05) With respect to the prediction of anxious
symptoms however the DYSFUNCTIONAL ATTITUDES STRESS interaction
was no longer a significant predictor after controlling for within-subject fluctuations in
depressive symptoms (β = 001 SE = 000 F = 148 p = 22)
DISCUSSION
The results of the current study provide support for the cross-cultural
applicability of Beckrsquos (1967 1983) cognitive theory to university students in Hunan
China More specifically consistent with hypotheses and with results obtained from
past research examining Beckrsquos cognitive theory in Western samples of university
students (Hankin et al 2004 Hankin et al 2005 Joiner et al 1999 Klocek et al
1997 Brown et al 1995) higher levels of dysfunctional attitudes were associated with
greater increases in depressive symptoms following increases in negative event
frequency during the six-month follow-up interval Given the considerable differences
between the current sample and Western samples in terms of demographic
19
characteristics and cultural factors such a finding strongly attests to the robustness of
Beckrsquos cognitive theory Moreover integrating the current findings with those obtained
in research examining Beckrsquos theory in other non-Western samples suggests that
Beckrsquos theory may represent a powerful explanatory model of the development of
depressive symptoms among individuals from diverse cultural settings For example
consistent with the theory higher levels of dysfunctional attitudes have been shown to
be associated with higher levels of depressive symptoms in Japanese (Tanaka et al
2006) Puerto-Rican (Bonilla Bernal Santos amp Santos 2003) Turkish (Sahin amp Sahin
1992) Norwegian (Chioqueta amp Stiles 2004) Singaporean (Oei Goh amp Kwon 1996)
and Swedish (Ohrt amp Thorell 1998) adult samples In addition it is important to note
that the current findings expand upon past correlational research examining the
association between dysfunctional attitudes and depression in Chinese samples through
the use of a multi-wave longitudinal design
When examining the specificity of dysfunctional attitudes as a predictor of
depressive symptoms the current study did not obtain support for specificity More
specifically contrary to the specificity hypothesis of Beckrsquos cognitive theory and to
results obtained in Western samples of university students (Alloy et al 2000 2006
Hankin et al 2004) higher levels of dysfunctional attitudes were associated with
greater increases in both depressive and anxious symptoms following increases in
negative event frequency There are two alternative ways of interpreting the non-
specificity finding observed in the current study First it is possible that the types of
thoughts individuals possessing high levels of dysfunctional attitudes experience
following negative events varies as a function of cultural context In other words in
20
Western samples such individuals may primarily experience the types of cognitions
that are associated with the development of depressive symptoms (ie appraisals of
personal loss and failure) In contrast in Chinese samples individuals possessing high
levels of dysfunctional attitudes may experience a wider array of cognitions some of
which are associated with the development of depressive symptoms and some of which
are associated with the development of anxious symptoms (ie evaluations of
impending threat or danger) Such an explanation would be consistent with Beckrsquos
cognitive content-specificity hypothesis (Clark amp Beck 1999) which posits that each
affective state and psychological disorder has a specific cognitive profile Second it is
possible that the types of symptoms individuals possessing high levels of dysfunctional
attitudes experience following negative events varies as a function of cultural context
More specifically it may be that dysfunctional attitudes specifically predict symptoms
of depression in both samples except that in Western samples depression manifests in
pure depressive symptoms whereas in Chinese samples depression manifests as a
combination of depressive and anxious symptoms Such an explanation would be
consistent with cultural psychopathologistsrsquo hypotheses that cultural factors shape the
phenomenology of psychiatric symptoms (Kleinman 2004 Mezzich et al 1999)
Moreover dysfunctional attitudes predicting a combination of depressive and anxious
symptoms in Chinese samples would be consistent with the construct of neurasthenia -
a construct hypothesized by some to represent a somatized form of depression that is
still widely seen within China (Lee amp Wong 1995)
Interesting in this regard and perhaps speaking to the primacy of depressive
symptoms in the current findings analyses indicated that the DYSFUNCTIONAL
21
ATTITUDES times STRESS interaction no longer predicted anxious symptoms after
controlling for depressive symptoms The reverse however was not true as the
DYSFUNCTIONAL ATTITUDES times STRESS interaction continued to predict
depressive symptoms after controlling for anxious symptoms
It is important to note that the current study employed a particularly
conservative approach to analyses in that we examined the effects of dysfunctional
attitudes on depressive and anxious symptoms after controlling for the effect of
neuroticism on such symptoms Providing particularly powerful support for Beckrsquos
(1967 1983) cognitive theory across analyses dysfunctional attitudes predicted levels
of depressive andor anxious symptoms experienced during the six month follow-up
interval independent of the effect of neuroticism Thus contrary to past critical reviews
of the cognitive literature (Barnett amp Gotlib 1998 Coyne amp Whiffen 1995) and
consistent with past findings (Hankin et al 2007) the current results indicate that
cognitive vulnerabilities to depression such as dysfunctional attitudes are not reducible
to trait neuroticism but rather represent factors that confer independent risk for
depression
Limitations and Future Directions
Several limitations of the current study should be noted First self-report
measures were used to assess depressive and anxious symptoms Although the CES-D
and MASQ both possess high degrees of reliability and validity it is difficult to draw
conclusions about clinically diagnosed depression or anxiety based on self-report
questionnaires Second self-report measures were used to assess stress Although
measures of stress that require participants only to indicate whether or not an event
22
occurred are less likely to be influenced by informant bias than those that ask
participants to rate the subjective impact of each event more sophisticated methods of
analysis such as interviewing procedures that assess contextual threat may provide
better assessments of stress Third the measures of dysfunctional attitudes stress and
depressive and anxious symptoms used in the current study were each Western-
developed Future research should examine these hypotheses using indigenous
measures in addition to Western-developed measures in order to assess possible
similarities andor differences in patterns of findings Fourth the current study only
examined depression and anxiety as symptom outcomes Future research conducted
within China should examine a wider array of symptom outcomes such as
somatization physical complaints and externalizing behaviors in order to provide a
more thorough and culturally sensitive test of the specificity hypotheses of Beckrsquos
cognitive model Fifth the current study examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese undergraduate students and thus the extent to which
our findings may be generalized to other demographics within Chinarsquos population is
unclear Last the current study broadly examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese university students Future research should examine
the constructs and processes posited by this model in greater detail in order to develop a
deeper understanding of how they may be uniquely molded by socio-cultural factors
Such research would benefit from examining the specific types of stressors experienced
by Chinese university students as they may vary as a function of socio-cultural factors
from those experienced by Western undergraduates For example severe pressure to
succeed academically in order to secure access to a limited number of post-
23
undergraduate educational opportunities - one of the few paths towards upward
mobility available to Chinese students seeking secure and gainful employment in what
has increasingly become a very highly competitive job market - may represent a
particularly salient stressor for the development of depressive symptoms among this
population (Qiang 2006)
In conclusion the results from the current study provide support for the
applicability of Beckrsquos cognitive theory to university students in mainland China More
specifically consistent with findings obtained in the West results indicate that
dysfunctional attitudes confer vulnerability to the development of depressive symptoms
following the occurrence of negative events in Chinese university students At the same
time however the current findings suggest cultural variation in the profile of
symptoms which emerge following the occurrence of negative events in cognitively
vulnerable individuals in Western and Chinese samples Specifically whereas in the
West dysfunctional attitudes have been shown to confer vulnerability to depressive
symptoms in Chinese university students dysfunctional attitudes appear to confer
vulnerability to a combined depressive and anxious symptom profile Future research
using more sophisticated assessments of stress and depressive symptoms more diverse
samples and symptom outcome measures and indigenously-developed measures is
likely to enhance our understanding of the cognitive and environmental mechanisms
underlying the development of depression in Chinese university students Discovering
that cognitive theories of vulnerability to depression extend to university students in
China highlights the potential role for cognitive-behavioral depression prevention and
treatment interventions in stemming the tide of distress experienced by this population
24
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Abela J R Z amp Hankin B L (2008) Cognitive vulnerability to depression in
children and adolescents A developmental psychopathology perspective In J
R Z Abela and B L Hankin (Eds) Handbook of child and adolescent
depression (pp 35-78) New York The Guilford Press
Alloy L B Abramson L Y Hogan M E Whitehouse W G Rose D T
Robinson MS Kim R S amp Lapkin J B (2000) The Temple-Wisconsin
cognitive vulnerability to depression project Lifetime history of axis-I
psychopathology in individuals at high and low cognitive risk for depression
Journal of Abnormal Psychology 109 403-418
Alloy L B Abramson L Y Whitehouse W G Hogan M E Panzarella C amp
Rose D T (2006) Prospective incidence of first onsets and recurrences of
depression in individuals at high and low cognitive risk for depression Journal
of Abnormal Psychology 115 145ndash156
Altham P M E (1984) Improving the precision of estimation by fitting a model
Journal of the Royal Statistical Society Series B 46 11
Barnett PA amp Gotlib I H (1988) Psychosocial functioning and depression
Distinguishing among antecedents concomitants and consequences
Psychological Bulletin 104 97-126
Beck AT (1967) Depression Clinical experimental and theoretical aspects New
York Harper amp Row
Beck AT (1983) Cognitive therapy of depression New perspectives In PJ Clayton
amp JE Barrett (Eds) Treatment of depression Old controversies and new
approaches New York Raven Press
Bian Q Yang K amp Li C (2007) Dysfunctional attitudes of patients with depression
or bipolar disorder Chinese Mental Health Journal 21 759-761
Blankstein K R amp Flett G L (1993) Development of the General Academic and
Social Hassles Scales for Students Unpublished manuscript
Bonilla J Bernal G Santos A amp Santos D (2003) A revised Spanish version of
the Beck Depression InventoryPsychometric properties with a Puerto Rican
sample of college students Journal of Clinical Psychology 60 119-130
Brown G P Hammen C L Craske M G amp Wickens T D (1995) Dimensions of
dysfunctional attitudes as vulnerabilities to depressive symptoms Journal of
Abnormal Psychology 104 431-435
25
Chioqueta A P amp Stiles T C (2004) Psychometric properties of the Norweigian
version of the Dysfunctional Attitude Scale (Form A) Cognitive Behaviour
Therapy 33 83-86
Clark DA amp Beck AT (1999) Cognitive theory and therapy of depression New
York John Wiley amp Sons Inc
Clark L A amp Watson D (1991) Tripartite model of anxiety and depression
Psychometric evidence and taxonomic implications Journal of Abnormal
Psychology 100 316ndash336
Costa P T amp McCrae R R (1992) NEO PI-R Professional manual Revised NEO
personality inventory NEO PR-R and NEO five-factor inventory NEO-RRI
Odessa FL Psychological Assessment Resources
Coyne J C amp Whiffen V E (1995) Issues in personality as diathesis for depression
The case of sociotropy-dependency and autonomy-self-criticism Psychological
Bulletin 118 358-378
Fang X Qian M Luo S amp Zi F (2009) A correlational study on college students
perfectionism parental rearing patterns and mental health Chinese Mental
Health Journal 23 56-59
Hankin B L Abramson L Y Miller N amp Haeffel G (2004) Cognitive
vulnerability-stress theories of depression Examining affective specificity in
the prediction of depression versus anxiety in three prospective studies
Cognitive Therapy and Research 28 309ndash345
Hankin BL Fraley RC amp Abela JRZ (2005) Daily depression and cognitions
about stress Evidence for a traitlike depressogenic cognitive style and the
prediction of depressive symptoms in a prospective daily diary study Journal of
Personality and Social Psychology 88 673-685
Hankin B L Lakdawalla Z Carter I L Abela J R Z amp Adams P (2007) Are
neuroticism cognitive vulnerabilities and self-esteem overlapping or distinct
risks for depression Evidence from confirmatory factor analyses Journal of
Social amp Clinical Psychology 26 29-63
Hankin B L Wetter E Cheely C amp Oppenheimer C W (2008) Becks cognitive
theory of depression in adolescence Specific prediction of depressive
symptoms and reciprocal influences in a multi-wave prospective study
International Journal of Cognitive Therapy 1 313-332
Ingram R E Miranda J amp Segal Z V (1998) Cognitive Vulnerability to
Depression New York NY Guilford Press
26
Ingram R E amp Luxton DD (2005) Vulnerability-stress models In BL Hankin amp
JRZ Abela (Eds) Development of psychopathology A vulnerability-stress
perspective (pp 32-46) Thousand Oaks CA Sage
Joiner T E Metalsky G I Lew A amp Klocek J (1999) Testing the causal
mediation component of Becks theory of depression Evidence for specific
mediation Cognitive Therapy and Research 23 401-412
Kleinman A (2004) Culture and depression New England Journal of Medicine 351
951-953
Kleinman A (1977) Depression somatization and the new cross-cultural psychiatry
Social Science and Medicine 11 3-10
Kleinman A (1996) How is culture important for DSM-IV In J E Mezzich A
Kleinmam H Fabrega Jr amp L Delores (Eds)Culture and psychiatric
diagnosis A DSM-IV perspective (pp 15-25) Washington DC US American
Psychiatric Association
Klocek J W Oliver J M amp Ross M J (1997) The role of dysfunctional attitudes
negative life events and social support in the prediction of depressive
dysphoria A prospective longitudinal study Social Behavior and Personality
25 23-136
Lee S (1997) A Chinese perspective on somatoform disorders Journal of
Psychosomatic Disorders 43 115-119
Lee S (1998) Estranged bodies simulated harmony and misplaced cultures
Neurasthenia in contemporary Chinese society Psychosomatic Medicine 60
448ndash457
Lee S (1999) Diagnosis postponed Shenjing shuairo and the transformation of
psychiatry in post-Mao China Culture Medicine and Psychiatry 23 349ndash380
Lee S amp Wong K C (1995) Rethinking neurasthenia the illness concepts of
shenjing shuairuo among Chinese undergraduates in Honk Kong Culture
Medicine and Psychiatry 19 91ndash111
Lee S Tsang A Huang YQ He YL Liu ZR Zhang MY Shen YC amp
Kessler RC (2009) The epidemiology of depression in metropolitan China
Psychological Medicine 39 735-747
Mezzich J E Kirmayer L J Kleinman A Fabrega Jr H Parron D L Good B
J Lin K amp Manson S M (1999) The place of culture in DSM-IV Journal
of Nervous and Mental Disease 187 457-464
27
Monroe S M amp Simons A D (1991) Diathesisndashstress theories in the context of life
stress research Implications for the depressive disorders Psychological
Bulletin 110 406ndash425
Murray C J L amp Lopez A D (1996) The global burden of disease Cambridge
Harvard University Press
National Bureau of Statistics of China (2006) The China 2005 statistical yearbook
China Statistics Press Beijing PR China
Oei T P S Goh Y Kwon S M(1996) A cross-cultural study of the integrated
cognitive model of depression Current Psychology of Cognition 15 265-281
Ohrt T amp Thorell L (1998) Dysfunctional Attitude Scale (DAS) Psychometrics and
norms of the Swedish version Scandinavian Journal of Behaviour Therapy 27
105-113
Parker G Gladstone G Chee KT (2001) Depression in the planetrsquos largest ethnic
group The Chinese American Journal of Psychiatry 158 857-864
Phillips M R Zhang J Shi Q Song Z Ding Z Pang S Li X Zhang Y amp
Wang Z (2009) Prevalence treatment and associated disability of mental
disorders in four provinces in China during 2001ndash05 an epidemiological
survey The Lancet 373 2041-2053
Phillips M R Li X amp Zhang Y (2002) Suicide rates in China Lancet 359 835-
840
Phillips M R (1998) The transformation of Chinarsquos mental health services The China
Journal 39 1ndash36
Qiang G (2006) Depression number one killer of Ivory Tower students China Daily
Retrieved from httpwwwchinadailycomcnchina2006-
1128content_744880htm
Radloff L S (1977) The CESndashD scale A self-report depression scale for research in
the general population Applied Psychological Measurement 1 385ndash401
Rin H amp Huang M G (1989) Neurasthenia as nosological dilemma Culture
Medicine and Psychiatry 13 215-226
Sahin NH amp Sahin N (1992) How dysfunctional are the dysfunctional attitudes in
another culture British Journal of Medical Psychology 65 17-26
Shixie L (1989) Neurasthenia in China Modern and traditional criteria for its
diagnosis Culture Medicine and Psychiatry 13 163-186
28
Tanaka N Uji M Hiramura H Chen Z Shikai N amp Kitamura T (2006)
Cognitive patterns and depression Study of a Japanese university student
population Psychiatry and Clinical Neuroscience 60 358-364
Taylor R E (2001) Death of neurasthenia and its psychological reincarnation a study
of neurasthenia at the National Hospital for the Relief and Cure of the Paralysed
and Epileptic Queen Square London 1870ndash1932 British Journal of
Psychiatry 179 550ndash557
Weissman A N amp Beck A T (1978 April) Development and validation of the
Dysfunctional Attitudes Scale A preliminary investigation Paper presented at
the annual meeting of the Educational Research Association Toronto Canada
Xiang M Z (1986) Epidemiological study of neuroses in 12 regions (districts) of
China Chinese Journal of Neurology and Psychiatry 19 87-91
Xu JM (1987) Some issues in the diagnosis of depression in China Canadian
Journal of Psychiatry 32 368-370
Xu Y X (1994) About ICD-10 Journal of Clinical Psychology and Medicine 4 224-
226
Xu Z Li Z amp Wang Z (2007) Dysfunctional attitudes and cognitive bias in major
depressive disorder Chinese Mental Health Journal 21 488-491
Yan H Q (1989) The necessity of retaining the diagnostic concept of neurasthenia
Culture Medicine and Psychiatry 13 139-145
Yang H (2007) The Test of the Chinese version of Frost Multi-dimensional
Perfectionism Scale Chinese Mental Health Journal 21 97-100
Yang H amp Zhang X (2004) Perfectionism and mental health of college students
(2004) Chinese Mental Health Journal 18 647-648
Young D (1989) Neurasthenia and related problems Culture Medicine and
Psychiatry 13 131-138
Zhang D (1995) Depression and culture A Chinese perspective Canadian Journal of
Counseling 29 227ndash233
29
TABLE(S)
Table 1 Demographic Variables
Age 2011
Gender Male
Female
472
523
Parentsrsquo Marital Status Married
Divorced
Single
Remarried
938
23
18
20
Fatherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
Government Official
51
356
187
95
124
91
Motherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
122
406
144
76
134
Fatherrsquos Education Some Primary School
Primary School
Some High School
High School
University
29
139
222
403
137
Motherrsquos Education Some Primary School
Primary School
Some High School
High School
University
63
192
264
350
76
Only Child No
Yes
331
667
Monthly Income lt 1000 RMB
1000 ndash 1500 RMB
1500 ndash 2000 RMB
2000 ndash 3000 RMB
3000 ndash 4000 RMB
4000 ndash 5000 RMB
gt 5000 RMB
334
204
175
140
59
20
20
30
Table 2 Means Standard Deviations and Inter-correlations Between Time 1 Measures
__________________________________________________________________
1 2 3
__________________________________________________________________
1 Depressive Symptoms 2963 (780)
2 Anxious Symptoms 52 3753 (918)
3 Dysfunctional Attitudes 48 33 18120 (2304)
4 Neuroticism 63 42 53 3110 (712)
_________________________________________________________________________
Note Means and standard deviations (in parentheses) are on the diagonal Depressive
Symptoms = Center for Epidemiological Studies Depression Scale Anxious Symptoms
= Mood and Anxiety Symptom Questionnaire Overall Anxiety subscale Dysfunctional
Attitudes = Dysfunctional Attitudes Scale Neuroticism = NEO Five Factor Inventory
Neuroticism subscale p lt 01
31
Table 3 Dysfunctional Attitudes Predicting Within-Subject Fluctuations in CES-D
Scores (upper section) and MASQ Scores (lower section) during the Follow-Up
Interval
______________________________________________________________________
β SE F df
______________________________________________________________________
Time 1 CESD-D 297 026 12987 1572
Stress 005 000 10860 12459
Neuroticism 134 027 2518 1572
Dysfunctional Attitudes -055 040 -183 1572
Dysfunctional Attitudes times Stress 001 000 1078 12459
______________________________________________________________________
Time 1 MASQ 502 033 23158 1575
Stress 006 000 8963 12470
Neuroticism 080 033 596 1575
Dysfunctional Attitudes -052 051 -106 1575
Dysfunctional Attitudes times Stress 002 001 774 12470
______________________________________________________________________
Note Time 1 CES-D = Time 1 Center for Epidemiological Studies Depression Scale
Stress = Within-Subject Fluctuations in General Academic Social Hassles Scale for
Students (GASHSS) scores during the follow-up interval Neuroticism = NEO Five
Factor Inventory Neuroticism subscale Dysfunctional Attitudes = Dysfunctional
Attitudes Scale Time 1 MASQ = Time 1 Mood and Anxiety Symptom Questionnaire
Overall Anxiety subscale p lt 05 p lt 01 p lt 001
32
FIGURES
Figure 1 Predicted slope of the relationship between stress and depressive
symptoms (left panel) and anxious symptoms (right panel) as a function of
dysfunctional attitudes
20
25
30
Low High
Pre
dic
ted
CE
S-D
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
25
30
35
40
Low High
Pre
dic
ted
MA
SQ
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
Intercept Intercept
3
self and prior experiences) that are relatively enduring characteristics of a persons
cognitive organization When an individual is confronted with a situation the schema
most relevant to the situation is activated Schema activation subsequently influences
how the person perceives encodes and retrieves information regarding the situation
Beck proposed that certain individuals posses depressogenic schema that confer
vulnerability to depression Beck (1983) hypothesizes that depressogenic schemata are
typically organized as sets of dysfunctional attitudes such as ldquoI am nothing if a person I
love doesnrsquot like merdquo or ldquoIf I fail at my work then I am a failure as a personrdquo Among
individuals who possess depressogenic schema the occurrence of negative events
triggers a pattern of negatively biased self-referent information processing
characterized by negative errors in thinking (eg negatively skewed interpretations of
negative life events such as overgeneralization and catastrophizing) Negative errors in
thinking increase the likelihood that the individual will develop the negative cognitive
triad comprising three types of depressogenic thought patterns (1) negative views of
the self (eg the belief that one is deficient inadequate or unworthy) (2) negative
views of the world (eg construing life experiences in terms of themes of defeat or
disparagement) and (3) negative views of the future (eg the expectation that ones
difficulties will persist into the future and there is nothing one can do to change this)
According to the theory the development of the negative cognitive triad triggers the
onset of depressive symptoms
Research Support for Beckrsquos Cognitive Model of Depression
Prospective studies using Western university student samples have provided
support for Beckrsquos (1967 1983) cognitive theory of depression More specifically
4
several studies have found that dysfunctional attitudes interact with the occurrence of
negative life events to predict increases in depressive symptoms (Hankin Abramson
Miller Haeffel 2004 Hankin Fraley amp Abela 2005 Joiner Metalsky Lew amp Klocek
1999 Klocek Oliver amp Ross 1997 Brown Hammen Craske and Wickens 1995) as
well as a greater likelihood of developing a depressive episode (Hankin et al 2004) In
addition individuals possessing a high level of dysfunctional attitudes have been found
to be more likely to report a past history of depressive episodes (Alloy et al 2000) and
to experience future depressive episodes (Alloy et al 2006 Hankin et al 2004) than
individuals without such a vulnerability
Far less research has examined the applicability of Beckrsquos (1983 1967)
cognitive theory to Chinese samples Preliminary cross-sectional research however
has yielded findings consistent with the theoriesrsquo hypotheses For example Xu Li and
Wang (2007) found that psychiatric patients diagnosed with major depressive disorder
showed significantly higher levels of dysfunctional attitudes than did non-depressed
controls Simiarly Bian Yang and Li (2007) reported higher levels of dysfunctional
attitudes in remitted depressives as compared to normal controls Last several studies
conducted with Chinese university students have found higher levels of dysfunctional
attitudes ndash particularly those centered on themes of perfectionism - to be associated
with higher levels of psychiatric symptoms (eg Yang amp Zhang 2004 Yang 2007
Fang Qian Luo amp Zi 2009)
5
Goals of the current study
The primary goal of the current study was to examine the applicability of
Beckrsquos (1967 1983) cognitive theory of depression to university students in mainland
China The procedure involved an initial assessment during which students completed
measures assessing dysfunctional attitudes and symptoms of depression The procedure
also involved a series of six follow-up assessments occurring once a month for six
months during which symptoms of depression and the occurrence of negative events
were assessed The use of a multi-wave longitudinal design allowed us to take an
idiographic approach towards examining the diathesis-stress hypotheses of Beckrsquos
(1967 1983) theory More specifically we examined whether the slope of the
relationship between negative events and symptoms of depression within participants
varied across participants as a function of level of dysfunctional attitudes In line with
the vulnerability-stress hypothesis of Beckrsquos (1967 1983) cognitive theory we
hypothesized that higher levels of dysfunctional attitudes would be associated with
greater increases in depressive symptoms following the occurrence of negative events
The second objective of the current study was to examine the specificity of
dysfunctional attitudes as a predictor of depressive symptoms Beckrsquos (1967 1983)
theory posits that dysfunctional attitudes predict the development of depressive
symptoms but not symptoms of other forms of psychopathology Prospective studies
using Western university student (Alloy et al 2000 2006 Hankin Abramson Miller
amp Haeffel 2004) and adolescent samples (Hankin Wetter Cheely amp Oppenheimer
2008) have provided support for the specificity hypothesis of the theory More
specifically dysfunctional attitudes have been found to interact with negative events to
6
predict increases in depressive symptoms but not symptoms of anxiety or other
disorders in both university student (Hankin et al 2004) and adolescent samples
(Hankin et al 2008) Similarly although university students possessing a high level of
dysfunctional attitudes have been found to be more likely than other university students
to report a past history of depressive episodes (Alloy et al 2000) and to experience
future depressive episodes (Alloy et al 2006) they have not been found to differ from
their low-risk counterparts in terms of past history or future occurrence of other
psychological disorders (Alloy et al 2000 2006)
With respect to the current study it is possible that differences may emerge
between Chinese and Western samples in terms of the types of symptoms predicted by
dysfunctional attitudes More specifically cultural psychopathologists have proposed
that cultural factors shape the phenomenology of psychiatric symptoms as well as the
conceptualization and classification of disorders (Kleinman 2004 Mezzich et al
1999) As such the experience of psychopathology may exhibit unique features in
different cultures with diagnostic categories developed in one cultural context not being
valid in another (Kleinman 1977 1996) Neuresthenia known in China as shenjing
shuairuo (SJSR) is a diagnostic entity characterized by (1) physical and mental
weakness and fatigability (2) sleep disturbances (3) irritability and worry (4)
excitability (5) nervous pain and (6) memory difficulty (Taylor 2001) Historically
SJSR was a Western disease concept that subsequently evolved to become a widely
utilized diagnostic entity within China (Lee amp Wong 1995) Some cultural
psychopathologists have posited that SJSR represents a somatized form of depression
This claim however has been met with significant controversy (eg Lee 1997
7
Parker Gladstone amp Chee 2001 Xu JM 1987 Xu YX 1994 Zhang 1995)
Critics dispute the notion that Chinese psychiatric patients are ldquosomatizersrdquo who
manifest few or no emotional symptoms and who attribute distress to physical causes
Rather they argue that SJSR gained widespread acceptance in China as it was a non-
stigmatizing diagnosis that allowed individuals experiencing psychosocial distress to
seek help during a time in which traditional cultural beliefs and political influences led
to severe sanction and stigmatization of individuals suffering from mental illnesses
(Lee 1998 1999 Phillips 1998 Shixie 1989) At the same time other Chinese
researchers and clinicians have continued to defend neurasthenia as both a valid
diagnostic category and a clinically useful means of communicating with patients (Rin
amp Huang 1989 Yan 1989 Young 1989) Due to continued debate on this topic it is
essential that researchers examining models of vulnerability to depression within China
assess multiple symptom outcomes as the types of symptoms predicted by vulnerability
factors may vary as a function of cultural context Hence in the current study we also
assessed levels of anxious symptoms to provide a test of the specificity hypothesis of
Beckrsquos (1967 1983) cognitive theory
In order to provide a powerful examination of our hypotheses concerning (1) the
applicability of the diathesis-stress component of Beckrsquos (1967 1983) cognitive theory
to Chinese university students and (2) the specificity of dysfunctional attitudes as
predictors of depressive as opposed to anxious symptoms participantsrsquo scores on the
neuroticism subscale of the Five-factor Inventory (FFI-N) were included as a control
variable in all analyses Several critical reviews of the literature examining theories of
cognitive vulnerability to depression (eg Barnett amp Gotlib 1998 Coyne amp Whiffen
8
1995) have argued that cognitive vulnerabilities to depression such as that featured in
Beckrsquos cognitive theory may be equivalent to or reducible to trait neuroticism and thus
may not confer independent risk for depression In response to such claims a recent
study conducted with university students examining the degree of factorial
independence versus overlap between trait neuroticism and dysfunctional attitudes has
shown them to be distinct constructs each loading onto separate factors (Hankin et al
2007) At the same time however there remains a need to examine whether
dysfunctional attitudes and trait neuroticism represent unique risk factors for
depression particularly in young adults in China Hence in the current study
participantsrsquo scores on the neuroticism subscale of the Five-factor Inventory (FFI-N)
were included as a control variable in order to account for any of the variance in
fluctuations in depressive (and anxious) symptoms that may be shared between
dysfunctional attitudes and trait neuroticism thereby isolating and highlighting their
unique predictive effects
METHOD
Participants
Participants included 662 university students (aged 19-21) from Changsha ndash an
industrial city in the province of Hunan with a population of approximately 6000000
In terms of the annual gross domestic product Hunan ranks 23rd
(10336 RMB) out of
the 34 provinces in China placing it well below the national provincial average (micro =
29719 RMB SD = 47462 RMB National Bureau of Statistics of China 2006)
Demographic variables for the sample are presented in Table 1
9
Procedure
Consent forms were distributed to all students in participating classes Consent
rates were greater than 95 in all the classes After consent forms were collected
researchers returned to the school to meet with participating students Written consent
was obtained from each participant at the beginning of the initial assessment During
the initial assessment students completed a demographics form and each of the
following questionnaires (1) Center for Epidemiological Studies Depression Scale
(CES-D Radloff 1977) (2) Mood and Anxiety Symptom Questionnaire (MASQ
Clark amp Watson 1991) (3) Dysfunctional Attitudes Scale (DAS Weissman amp Beck
1978) and (4) NEO Five Factor Inventory- Neuroticism Subscale (FFI-N Costa amp
McCrae 1992) Once a month for the subsequent six-months researchers returned to
the school and met with participating students to conduct follow-up assessments At
each of these follow-up assessments students were asked to complete each of the
following questionnaires (1) CES-D (2) MASQ and (3) the General Academic
Social Hassles Scale for Students (GASHSS Blankstein amp Flett 1993)
Measures
The Chinese versions of all self-report measures were developed using the
back-translation method Original English versions were translated into Chinese by a
bilingual translator from the Psychology department at Second Xiangya Medical
College of Central South University Hunan Translated Chinese versions were then
back-translated into English by another bilingual translator from the Psychology
department at McGill University Quebec Original versions were then compared with
the back-translation If inconsistencies were found in the back-translation translators
10
worked together to make corrections to the final Chinese versions until all final
versions were agreed upon No items from any of the measures were removed or
significantly altered during the translation process
Depressive Symptoms Center for Epidemiological Studies Depression Scale
(CES-D Radloff 1977) The CES-D is a 20-item self-report measure designed to
assess depressive symptoms in the general population For each item participants are
asked to indicate how often they experienced the particular symptom over the last
week Responses range from 1 (eg rarely or none of the time) to 4 (eg most or all of
the time) Scores range from 20-80 with higher score indicating higher levels of
depressive symptoms In the current study the CES-D exhibited high internal
consistency with Cronbachrsquos alpha values ranging from 90 to 94 (micro = 2918 SD =
814) over the 7 time points
Anxious Symptoms Mood and Anxiety Symptom Questionnaire (MASQ
Watson amp Clark 1991) The MASQ is a 62-item questionnaire designed to assess both
specific and nonspecific depressive and anxious symptoms For each item participants
are asked to rate on a scale of 1 to 5 the extent to which they have felt this way ldquoduring
the past 24 hoursrdquo Within the current study we utilized the anxious symptoms (11
items) and anxious arousal (17 items) subscales which together provide an index of
overall anxious symptoms Higher scores on each subscale reflect greater levels of
anxious symptoms In the current study the MASQ exhibited high internal consistency
with Cronbachrsquos alpha values ranging from 90 to 95 (micro = 3847 SD = 1117) over the
7 time points
11
Dysfunctional Attitudes Dysfunctional Attitudes Scale (DAS Weissman amp
Beck 1978) The DAS (Form A) is a 40-item questionnaire designed to measure the
cognitive vulnerability factor featured in Beckrsquos cognitive theory Examples of items
include ldquoIf I do not do well all the time people will not respect merdquo ldquoIf a person asks
for help it is a sign of weaknessrdquo and ldquoMy value as a person depends greatly on what
others think of merdquo Items are rated on a 7-point Likert scale ranging from 1 (totally
disagree) to 7 (totally agree) providing a range of scores from 40 to 280 with higher
scores reflecting more dysfunctional attitudes In the current study the DAS exhibited
high internal consistency with Cronbachrsquos alphas of 89 and 88 obtained for the first
and second administrations respectively In addition a test-retest reliability coefficient
of 72 was obtained indicating strong stability over time
Neuroticism NEO Five Factor Inventory - Neuroticism Subscale (FFI-N
Costa amp McCrae 1992) The FFI-N is a 12- item self-report measure that assesses
neuroticism Examples of questions include I often feel inferior to others I am
seldom sad or depressed and Sometimes I feel completely worthless Items are rated
on a 5-point Likert scale ranging from 0 (strongly disagree) to 4 (strongly agree)
providing scores ranging from 0 to 48 with higher scores indicating higher levels of
neuroticism The NEO-FFI-N has proven reliable across different cultural samples and
item pools (Costa amp McCrae 1992) In the current study Cronbachs alpha was 81
indicating strong internal consistency
Negative Life Events General Academic Social Hassles Scale for Students
(GASHSS Blankstein amp Flett 1993) Participants completed a 30-item abbreviated
version of the GASHSS The measure is comprised of items assessing general hassles
12
(8 items) academic hassles (10 items) and social hassles (12 items) For each item
participants are asked to rate how persistent the given hassle was (ie its frequency and
duration) over the last 30 days (0 = no hassle not at all persistent to 6 = extremely
persistent hassle high frequency andor duration)
13
RESULTS
Descriptive Data
Means standard deviations and inter-correlations between Time 1 measures are
presented in Table 2
Prospective Diathesis-Stress Analyses - Depression
Multilevel modeling was used to test our hypothesis that higher levels of dysfunctional
attitudes would be associated with greater increases in depressive symptoms following
increases in stress Analyses were carried out using the SAS (version 81) MIXED
procedure and maximum likelihood estimation Our dependent variable was within-
subject fluctuations in CES-D scores during the follow-up interval (DEPRESSION)
Our primary predictors of DEPRESSION were DAS scores (DYSFUNCTIONAL
ATTITUDES) and fluctuations in GASHSS scores during the follow-up interval
(STRESS) As DYSFUNCTIONAL ATTITUDES is a between-subject predictor DAS
scores were standardized prior to analyses As STRESS is a within-subject predictor
STRESS reflects upward or downward fluctuations in an individualrsquos level of stress
compared to hisher mean level of stress
When fitting hierarchical linear models one must specify appropriate mean and
covariance structures Mean structures refer to the various fixed and random effect
components that can be included in the model Covariance structures refer to alternative
methods of specifying the pattern of covariance between observations taken from the
same subject at different time points It is important to note that mean and covariance
structures are not independent of one another Rather an appropriate covariance
structure is essential in order to obtain valid inferences for the parameters in the mean
14
structure Overparametrization of the covariance structure can lead to inefficient
estimation and poor assessment of standard errors (Altham 1984) On the other hand
too much restriction of the covariance structure can lead to invalid inferences when the
assumed structure does not hold (Altham 1984)
In our first set of analyses we were interested in examining the effects of
DYSFUNCTIONAL ATTITUDES STRESS and the DYSFUNCTIONAL
ATTITUDES STRESS interaction on participantrsquos CES-D scores during the follow-
up interval Consequently in line with Diggle Liang and Zegers (1994)
recommendation that one use a ldquosaturatedrdquo model for the mean structure while
searching for an appropriate covariance structure we chose a mean structure that
included DYSFUNCTIONAL ATTITUDES STRESS and the DYSFUNCTIONAL
ATTITUDES STRESS interaction Four additional effects were also included in this
mean structure First as different individuals report different levels of depressive
symptoms when at their own average level of stress a random effect for intercept was
included in the model Second given that STRESS is a within-subject predictor whose
effect is expected to vary from participant to participant a random effect for slope was
included in the model Third in order to control for individual differences in baseline
levels of depressive symptoms Time 1 CES-D scores were included in the model
Fourth in order to examine whether DYSFUNCTIONAL ATTITUDES represent a
vulnerability factor independent of neuroticism participantsrsquo FFI-N scores were
entered in the model
Commonly used covariance structures in studies in which multiple responses
are obtained from the same individual over time (and consequently within-subject
15
residuals over time are likely to be correlated) include compound symmetry first-order
autoregressive heterogeneous autoregressive and banded Toeplitz In order to select
one of these covariance structures for our analyses we fitted models using each
structure and chose the ldquobestrdquo fit based on Akaike information criterion (AIC and
AICC) and Schwarz Bayesian criterion (BIC) In all cases the best fit for our data was
a first-order heterogeneous autoregressive structure (ARH [1]) After choosing the
appropriate covariance structure we next examined the random-effects component of
our model
With respect to random effects the ARH [1] parameter (r = 31 plt001)
RE_INTERCEPT (plt001) and RE_SLOPE (plt001) were each significant and thus
were retained in the model The final results with respect to the fixed-effects
component of the model are presented in the upper section of Table 3 Of primary
importance the DYSFUNCTIONAL ATTITUDES STRESS interaction was a
significant predictor of fluctuations in depressive symptoms during the follow-up
interval In order to examine the form of this interaction the model summarized in the
upper section of Table 3 was used to calculate predicted CES-D scores for individuals
exhibiting either high or low levels of dysfunctional attitudes (plus or minus 15 SD)
who are experiencing either high or low levels of stress in comparison to their own
average level of stress (plus or minus 15 times mean within-subject SD) The results of
such calculations are presented in the left panel of Figure 1
Analyses were conducted for each DYSFUNCTIONAL ATTITUDES
condition examining whether the slope of the relationship between stress and
depressive symptoms significantly differed from 0 Analyses indicated that both
16
individuals exhibiting high (t(2459) = 862 p lt 0001) and low (t(2459) = 347 p lt
0001) levels of dysfunctional attitudes reported significantly higher levels of
depressive symptoms when experiencing high levels of stress than when experiencing
low levels of stress Planned comparisons of the slopes of the relationship between
stress and depressive symptoms however revealed that the slope was significantly
greater in individuals exhibiting high levels of dysfunctional attitudes (slope = 013)
than in individuals exhibiting low levels of dysfunctional attitudes (slope = 005
t(2459) = 328 p = 0001)
Prospective Diathesis-Stress Analyses - Anxiety
The same data-analytic approach as described above was used to examine
whether higher levels of dysfunctional attitudes would be associated with greater
increases in anxious symptoms following increases in stress Again in order to examine
whether DYSFUNCTIONAL ATTITUDES represent a vulnerability factor
independent of neuroticism participantsrsquo FFI-N scores were entered in the model
With respect to random effects the ARH[1] parameter (r = 23 p lt 001)
RE_INTERCEPT (plt001) and RE_SLOPE (plt001) were each significant and thus
were retained in the model The final results with respect to the fixed-effects
component of the model are presented in the lower section of Table 3 Of primary
importance the DYSFUNCTIONAL ATTITUDES STRESS interaction was a
significant predictor of within-subject fluctuations in anxious symptoms during the
follow-up interval In order to examine the form of this interaction the model
summarized in the lower section of Table 3 was used to calculate predicted MASQ
scores for individuals exhibiting either high or low levels of dysfunctional attitudes
17
(plus or minus 15 SD) who are experiencing either high or low levels of stress in
comparison to their own average level of stress (plus or minus 15 times mean within-
subject SD) The results of such calculations are presented on the right panel of in
Figure 1
Analyses were conducted for each DYSFUNCTIONAL ATTITUDES
condition examining whether the slope of the relationship between stress and anxious
symptoms significantly differed from 0 Analyses indicated that both individuals
exhibiting high (t(2470) = 768 p lt 0001) and low (t(2470) = 337 p lt 0001) levels of
dysfunctional attitudes reported higher levels of anxious symptoms when experiencing
high levels of stress than when experiencing low levels of stress Planned comparisons
of the slopes of the relationship between stress and anxious symptoms however
revealed that the slope was significantly greater in individuals exhibiting high levels of
dysfunctional attitudes (slope = 009) than in individuals exhibiting low levels of
dysfunctional attitudes (slope = 003 t(2470) = 278 p lt 001)
Additional Analyses
Given that the DYSFUNCTIONAL ATTITUDES STRESS interaction
prospectively predicted both symptoms of depression and anxiety two additional
analyses were conducted in order to examine (1) whether the DYSFUNCTIONAL
ATTITUDES STRESS interaction continued to be a significant predictor of within-
subject fluctuations in depressive symptoms after controlling for within-subject
fluctuations in anxious symptoms and (2) whether the DYSFUNCTIONAL
ATTITUDES STRESS interaction continued to predict within-subject fluctuations in
anxious symptoms after controlling for within-subject fluctuations in depressive
18
symptoms Such analyses allowed us to examine whether the above mentioned pattern
of findings may have been due to the high correlation observed in the current study
between depressive and anxious symptoms
Analyses were conducted in the same manner as described above with the
exception that an additional within-subject variable (ie DEPRESSION or ANXIETY)
was included in each model in order to control for within-subject fluctuations in the
alternate symptom With respect to the prediction of depressive symptoms the
DYSFUNCTIONAL ATTITUDES STRESS interaction remained a significant
predictor after controlling for within-subject fluctuations in anxious symptoms (β =
001 SE = 000 F = 410 p lt 05) With respect to the prediction of anxious
symptoms however the DYSFUNCTIONAL ATTITUDES STRESS interaction
was no longer a significant predictor after controlling for within-subject fluctuations in
depressive symptoms (β = 001 SE = 000 F = 148 p = 22)
DISCUSSION
The results of the current study provide support for the cross-cultural
applicability of Beckrsquos (1967 1983) cognitive theory to university students in Hunan
China More specifically consistent with hypotheses and with results obtained from
past research examining Beckrsquos cognitive theory in Western samples of university
students (Hankin et al 2004 Hankin et al 2005 Joiner et al 1999 Klocek et al
1997 Brown et al 1995) higher levels of dysfunctional attitudes were associated with
greater increases in depressive symptoms following increases in negative event
frequency during the six-month follow-up interval Given the considerable differences
between the current sample and Western samples in terms of demographic
19
characteristics and cultural factors such a finding strongly attests to the robustness of
Beckrsquos cognitive theory Moreover integrating the current findings with those obtained
in research examining Beckrsquos theory in other non-Western samples suggests that
Beckrsquos theory may represent a powerful explanatory model of the development of
depressive symptoms among individuals from diverse cultural settings For example
consistent with the theory higher levels of dysfunctional attitudes have been shown to
be associated with higher levels of depressive symptoms in Japanese (Tanaka et al
2006) Puerto-Rican (Bonilla Bernal Santos amp Santos 2003) Turkish (Sahin amp Sahin
1992) Norwegian (Chioqueta amp Stiles 2004) Singaporean (Oei Goh amp Kwon 1996)
and Swedish (Ohrt amp Thorell 1998) adult samples In addition it is important to note
that the current findings expand upon past correlational research examining the
association between dysfunctional attitudes and depression in Chinese samples through
the use of a multi-wave longitudinal design
When examining the specificity of dysfunctional attitudes as a predictor of
depressive symptoms the current study did not obtain support for specificity More
specifically contrary to the specificity hypothesis of Beckrsquos cognitive theory and to
results obtained in Western samples of university students (Alloy et al 2000 2006
Hankin et al 2004) higher levels of dysfunctional attitudes were associated with
greater increases in both depressive and anxious symptoms following increases in
negative event frequency There are two alternative ways of interpreting the non-
specificity finding observed in the current study First it is possible that the types of
thoughts individuals possessing high levels of dysfunctional attitudes experience
following negative events varies as a function of cultural context In other words in
20
Western samples such individuals may primarily experience the types of cognitions
that are associated with the development of depressive symptoms (ie appraisals of
personal loss and failure) In contrast in Chinese samples individuals possessing high
levels of dysfunctional attitudes may experience a wider array of cognitions some of
which are associated with the development of depressive symptoms and some of which
are associated with the development of anxious symptoms (ie evaluations of
impending threat or danger) Such an explanation would be consistent with Beckrsquos
cognitive content-specificity hypothesis (Clark amp Beck 1999) which posits that each
affective state and psychological disorder has a specific cognitive profile Second it is
possible that the types of symptoms individuals possessing high levels of dysfunctional
attitudes experience following negative events varies as a function of cultural context
More specifically it may be that dysfunctional attitudes specifically predict symptoms
of depression in both samples except that in Western samples depression manifests in
pure depressive symptoms whereas in Chinese samples depression manifests as a
combination of depressive and anxious symptoms Such an explanation would be
consistent with cultural psychopathologistsrsquo hypotheses that cultural factors shape the
phenomenology of psychiatric symptoms (Kleinman 2004 Mezzich et al 1999)
Moreover dysfunctional attitudes predicting a combination of depressive and anxious
symptoms in Chinese samples would be consistent with the construct of neurasthenia -
a construct hypothesized by some to represent a somatized form of depression that is
still widely seen within China (Lee amp Wong 1995)
Interesting in this regard and perhaps speaking to the primacy of depressive
symptoms in the current findings analyses indicated that the DYSFUNCTIONAL
21
ATTITUDES times STRESS interaction no longer predicted anxious symptoms after
controlling for depressive symptoms The reverse however was not true as the
DYSFUNCTIONAL ATTITUDES times STRESS interaction continued to predict
depressive symptoms after controlling for anxious symptoms
It is important to note that the current study employed a particularly
conservative approach to analyses in that we examined the effects of dysfunctional
attitudes on depressive and anxious symptoms after controlling for the effect of
neuroticism on such symptoms Providing particularly powerful support for Beckrsquos
(1967 1983) cognitive theory across analyses dysfunctional attitudes predicted levels
of depressive andor anxious symptoms experienced during the six month follow-up
interval independent of the effect of neuroticism Thus contrary to past critical reviews
of the cognitive literature (Barnett amp Gotlib 1998 Coyne amp Whiffen 1995) and
consistent with past findings (Hankin et al 2007) the current results indicate that
cognitive vulnerabilities to depression such as dysfunctional attitudes are not reducible
to trait neuroticism but rather represent factors that confer independent risk for
depression
Limitations and Future Directions
Several limitations of the current study should be noted First self-report
measures were used to assess depressive and anxious symptoms Although the CES-D
and MASQ both possess high degrees of reliability and validity it is difficult to draw
conclusions about clinically diagnosed depression or anxiety based on self-report
questionnaires Second self-report measures were used to assess stress Although
measures of stress that require participants only to indicate whether or not an event
22
occurred are less likely to be influenced by informant bias than those that ask
participants to rate the subjective impact of each event more sophisticated methods of
analysis such as interviewing procedures that assess contextual threat may provide
better assessments of stress Third the measures of dysfunctional attitudes stress and
depressive and anxious symptoms used in the current study were each Western-
developed Future research should examine these hypotheses using indigenous
measures in addition to Western-developed measures in order to assess possible
similarities andor differences in patterns of findings Fourth the current study only
examined depression and anxiety as symptom outcomes Future research conducted
within China should examine a wider array of symptom outcomes such as
somatization physical complaints and externalizing behaviors in order to provide a
more thorough and culturally sensitive test of the specificity hypotheses of Beckrsquos
cognitive model Fifth the current study examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese undergraduate students and thus the extent to which
our findings may be generalized to other demographics within Chinarsquos population is
unclear Last the current study broadly examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese university students Future research should examine
the constructs and processes posited by this model in greater detail in order to develop a
deeper understanding of how they may be uniquely molded by socio-cultural factors
Such research would benefit from examining the specific types of stressors experienced
by Chinese university students as they may vary as a function of socio-cultural factors
from those experienced by Western undergraduates For example severe pressure to
succeed academically in order to secure access to a limited number of post-
23
undergraduate educational opportunities - one of the few paths towards upward
mobility available to Chinese students seeking secure and gainful employment in what
has increasingly become a very highly competitive job market - may represent a
particularly salient stressor for the development of depressive symptoms among this
population (Qiang 2006)
In conclusion the results from the current study provide support for the
applicability of Beckrsquos cognitive theory to university students in mainland China More
specifically consistent with findings obtained in the West results indicate that
dysfunctional attitudes confer vulnerability to the development of depressive symptoms
following the occurrence of negative events in Chinese university students At the same
time however the current findings suggest cultural variation in the profile of
symptoms which emerge following the occurrence of negative events in cognitively
vulnerable individuals in Western and Chinese samples Specifically whereas in the
West dysfunctional attitudes have been shown to confer vulnerability to depressive
symptoms in Chinese university students dysfunctional attitudes appear to confer
vulnerability to a combined depressive and anxious symptom profile Future research
using more sophisticated assessments of stress and depressive symptoms more diverse
samples and symptom outcome measures and indigenously-developed measures is
likely to enhance our understanding of the cognitive and environmental mechanisms
underlying the development of depression in Chinese university students Discovering
that cognitive theories of vulnerability to depression extend to university students in
China highlights the potential role for cognitive-behavioral depression prevention and
treatment interventions in stemming the tide of distress experienced by this population
24
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R Z Abela and B L Hankin (Eds) Handbook of child and adolescent
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Alloy L B Abramson L Y Hogan M E Whitehouse W G Rose D T
Robinson MS Kim R S amp Lapkin J B (2000) The Temple-Wisconsin
cognitive vulnerability to depression project Lifetime history of axis-I
psychopathology in individuals at high and low cognitive risk for depression
Journal of Abnormal Psychology 109 403-418
Alloy L B Abramson L Y Whitehouse W G Hogan M E Panzarella C amp
Rose D T (2006) Prospective incidence of first onsets and recurrences of
depression in individuals at high and low cognitive risk for depression Journal
of Abnormal Psychology 115 145ndash156
Altham P M E (1984) Improving the precision of estimation by fitting a model
Journal of the Royal Statistical Society Series B 46 11
Barnett PA amp Gotlib I H (1988) Psychosocial functioning and depression
Distinguishing among antecedents concomitants and consequences
Psychological Bulletin 104 97-126
Beck AT (1967) Depression Clinical experimental and theoretical aspects New
York Harper amp Row
Beck AT (1983) Cognitive therapy of depression New perspectives In PJ Clayton
amp JE Barrett (Eds) Treatment of depression Old controversies and new
approaches New York Raven Press
Bian Q Yang K amp Li C (2007) Dysfunctional attitudes of patients with depression
or bipolar disorder Chinese Mental Health Journal 21 759-761
Blankstein K R amp Flett G L (1993) Development of the General Academic and
Social Hassles Scales for Students Unpublished manuscript
Bonilla J Bernal G Santos A amp Santos D (2003) A revised Spanish version of
the Beck Depression InventoryPsychometric properties with a Puerto Rican
sample of college students Journal of Clinical Psychology 60 119-130
Brown G P Hammen C L Craske M G amp Wickens T D (1995) Dimensions of
dysfunctional attitudes as vulnerabilities to depressive symptoms Journal of
Abnormal Psychology 104 431-435
25
Chioqueta A P amp Stiles T C (2004) Psychometric properties of the Norweigian
version of the Dysfunctional Attitude Scale (Form A) Cognitive Behaviour
Therapy 33 83-86
Clark DA amp Beck AT (1999) Cognitive theory and therapy of depression New
York John Wiley amp Sons Inc
Clark L A amp Watson D (1991) Tripartite model of anxiety and depression
Psychometric evidence and taxonomic implications Journal of Abnormal
Psychology 100 316ndash336
Costa P T amp McCrae R R (1992) NEO PI-R Professional manual Revised NEO
personality inventory NEO PR-R and NEO five-factor inventory NEO-RRI
Odessa FL Psychological Assessment Resources
Coyne J C amp Whiffen V E (1995) Issues in personality as diathesis for depression
The case of sociotropy-dependency and autonomy-self-criticism Psychological
Bulletin 118 358-378
Fang X Qian M Luo S amp Zi F (2009) A correlational study on college students
perfectionism parental rearing patterns and mental health Chinese Mental
Health Journal 23 56-59
Hankin B L Abramson L Y Miller N amp Haeffel G (2004) Cognitive
vulnerability-stress theories of depression Examining affective specificity in
the prediction of depression versus anxiety in three prospective studies
Cognitive Therapy and Research 28 309ndash345
Hankin BL Fraley RC amp Abela JRZ (2005) Daily depression and cognitions
about stress Evidence for a traitlike depressogenic cognitive style and the
prediction of depressive symptoms in a prospective daily diary study Journal of
Personality and Social Psychology 88 673-685
Hankin B L Lakdawalla Z Carter I L Abela J R Z amp Adams P (2007) Are
neuroticism cognitive vulnerabilities and self-esteem overlapping or distinct
risks for depression Evidence from confirmatory factor analyses Journal of
Social amp Clinical Psychology 26 29-63
Hankin B L Wetter E Cheely C amp Oppenheimer C W (2008) Becks cognitive
theory of depression in adolescence Specific prediction of depressive
symptoms and reciprocal influences in a multi-wave prospective study
International Journal of Cognitive Therapy 1 313-332
Ingram R E Miranda J amp Segal Z V (1998) Cognitive Vulnerability to
Depression New York NY Guilford Press
26
Ingram R E amp Luxton DD (2005) Vulnerability-stress models In BL Hankin amp
JRZ Abela (Eds) Development of psychopathology A vulnerability-stress
perspective (pp 32-46) Thousand Oaks CA Sage
Joiner T E Metalsky G I Lew A amp Klocek J (1999) Testing the causal
mediation component of Becks theory of depression Evidence for specific
mediation Cognitive Therapy and Research 23 401-412
Kleinman A (2004) Culture and depression New England Journal of Medicine 351
951-953
Kleinman A (1977) Depression somatization and the new cross-cultural psychiatry
Social Science and Medicine 11 3-10
Kleinman A (1996) How is culture important for DSM-IV In J E Mezzich A
Kleinmam H Fabrega Jr amp L Delores (Eds)Culture and psychiatric
diagnosis A DSM-IV perspective (pp 15-25) Washington DC US American
Psychiatric Association
Klocek J W Oliver J M amp Ross M J (1997) The role of dysfunctional attitudes
negative life events and social support in the prediction of depressive
dysphoria A prospective longitudinal study Social Behavior and Personality
25 23-136
Lee S (1997) A Chinese perspective on somatoform disorders Journal of
Psychosomatic Disorders 43 115-119
Lee S (1998) Estranged bodies simulated harmony and misplaced cultures
Neurasthenia in contemporary Chinese society Psychosomatic Medicine 60
448ndash457
Lee S (1999) Diagnosis postponed Shenjing shuairo and the transformation of
psychiatry in post-Mao China Culture Medicine and Psychiatry 23 349ndash380
Lee S amp Wong K C (1995) Rethinking neurasthenia the illness concepts of
shenjing shuairuo among Chinese undergraduates in Honk Kong Culture
Medicine and Psychiatry 19 91ndash111
Lee S Tsang A Huang YQ He YL Liu ZR Zhang MY Shen YC amp
Kessler RC (2009) The epidemiology of depression in metropolitan China
Psychological Medicine 39 735-747
Mezzich J E Kirmayer L J Kleinman A Fabrega Jr H Parron D L Good B
J Lin K amp Manson S M (1999) The place of culture in DSM-IV Journal
of Nervous and Mental Disease 187 457-464
27
Monroe S M amp Simons A D (1991) Diathesisndashstress theories in the context of life
stress research Implications for the depressive disorders Psychological
Bulletin 110 406ndash425
Murray C J L amp Lopez A D (1996) The global burden of disease Cambridge
Harvard University Press
National Bureau of Statistics of China (2006) The China 2005 statistical yearbook
China Statistics Press Beijing PR China
Oei T P S Goh Y Kwon S M(1996) A cross-cultural study of the integrated
cognitive model of depression Current Psychology of Cognition 15 265-281
Ohrt T amp Thorell L (1998) Dysfunctional Attitude Scale (DAS) Psychometrics and
norms of the Swedish version Scandinavian Journal of Behaviour Therapy 27
105-113
Parker G Gladstone G Chee KT (2001) Depression in the planetrsquos largest ethnic
group The Chinese American Journal of Psychiatry 158 857-864
Phillips M R Zhang J Shi Q Song Z Ding Z Pang S Li X Zhang Y amp
Wang Z (2009) Prevalence treatment and associated disability of mental
disorders in four provinces in China during 2001ndash05 an epidemiological
survey The Lancet 373 2041-2053
Phillips M R Li X amp Zhang Y (2002) Suicide rates in China Lancet 359 835-
840
Phillips M R (1998) The transformation of Chinarsquos mental health services The China
Journal 39 1ndash36
Qiang G (2006) Depression number one killer of Ivory Tower students China Daily
Retrieved from httpwwwchinadailycomcnchina2006-
1128content_744880htm
Radloff L S (1977) The CESndashD scale A self-report depression scale for research in
the general population Applied Psychological Measurement 1 385ndash401
Rin H amp Huang M G (1989) Neurasthenia as nosological dilemma Culture
Medicine and Psychiatry 13 215-226
Sahin NH amp Sahin N (1992) How dysfunctional are the dysfunctional attitudes in
another culture British Journal of Medical Psychology 65 17-26
Shixie L (1989) Neurasthenia in China Modern and traditional criteria for its
diagnosis Culture Medicine and Psychiatry 13 163-186
28
Tanaka N Uji M Hiramura H Chen Z Shikai N amp Kitamura T (2006)
Cognitive patterns and depression Study of a Japanese university student
population Psychiatry and Clinical Neuroscience 60 358-364
Taylor R E (2001) Death of neurasthenia and its psychological reincarnation a study
of neurasthenia at the National Hospital for the Relief and Cure of the Paralysed
and Epileptic Queen Square London 1870ndash1932 British Journal of
Psychiatry 179 550ndash557
Weissman A N amp Beck A T (1978 April) Development and validation of the
Dysfunctional Attitudes Scale A preliminary investigation Paper presented at
the annual meeting of the Educational Research Association Toronto Canada
Xiang M Z (1986) Epidemiological study of neuroses in 12 regions (districts) of
China Chinese Journal of Neurology and Psychiatry 19 87-91
Xu JM (1987) Some issues in the diagnosis of depression in China Canadian
Journal of Psychiatry 32 368-370
Xu Y X (1994) About ICD-10 Journal of Clinical Psychology and Medicine 4 224-
226
Xu Z Li Z amp Wang Z (2007) Dysfunctional attitudes and cognitive bias in major
depressive disorder Chinese Mental Health Journal 21 488-491
Yan H Q (1989) The necessity of retaining the diagnostic concept of neurasthenia
Culture Medicine and Psychiatry 13 139-145
Yang H (2007) The Test of the Chinese version of Frost Multi-dimensional
Perfectionism Scale Chinese Mental Health Journal 21 97-100
Yang H amp Zhang X (2004) Perfectionism and mental health of college students
(2004) Chinese Mental Health Journal 18 647-648
Young D (1989) Neurasthenia and related problems Culture Medicine and
Psychiatry 13 131-138
Zhang D (1995) Depression and culture A Chinese perspective Canadian Journal of
Counseling 29 227ndash233
29
TABLE(S)
Table 1 Demographic Variables
Age 2011
Gender Male
Female
472
523
Parentsrsquo Marital Status Married
Divorced
Single
Remarried
938
23
18
20
Fatherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
Government Official
51
356
187
95
124
91
Motherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
122
406
144
76
134
Fatherrsquos Education Some Primary School
Primary School
Some High School
High School
University
29
139
222
403
137
Motherrsquos Education Some Primary School
Primary School
Some High School
High School
University
63
192
264
350
76
Only Child No
Yes
331
667
Monthly Income lt 1000 RMB
1000 ndash 1500 RMB
1500 ndash 2000 RMB
2000 ndash 3000 RMB
3000 ndash 4000 RMB
4000 ndash 5000 RMB
gt 5000 RMB
334
204
175
140
59
20
20
30
Table 2 Means Standard Deviations and Inter-correlations Between Time 1 Measures
__________________________________________________________________
1 2 3
__________________________________________________________________
1 Depressive Symptoms 2963 (780)
2 Anxious Symptoms 52 3753 (918)
3 Dysfunctional Attitudes 48 33 18120 (2304)
4 Neuroticism 63 42 53 3110 (712)
_________________________________________________________________________
Note Means and standard deviations (in parentheses) are on the diagonal Depressive
Symptoms = Center for Epidemiological Studies Depression Scale Anxious Symptoms
= Mood and Anxiety Symptom Questionnaire Overall Anxiety subscale Dysfunctional
Attitudes = Dysfunctional Attitudes Scale Neuroticism = NEO Five Factor Inventory
Neuroticism subscale p lt 01
31
Table 3 Dysfunctional Attitudes Predicting Within-Subject Fluctuations in CES-D
Scores (upper section) and MASQ Scores (lower section) during the Follow-Up
Interval
______________________________________________________________________
β SE F df
______________________________________________________________________
Time 1 CESD-D 297 026 12987 1572
Stress 005 000 10860 12459
Neuroticism 134 027 2518 1572
Dysfunctional Attitudes -055 040 -183 1572
Dysfunctional Attitudes times Stress 001 000 1078 12459
______________________________________________________________________
Time 1 MASQ 502 033 23158 1575
Stress 006 000 8963 12470
Neuroticism 080 033 596 1575
Dysfunctional Attitudes -052 051 -106 1575
Dysfunctional Attitudes times Stress 002 001 774 12470
______________________________________________________________________
Note Time 1 CES-D = Time 1 Center for Epidemiological Studies Depression Scale
Stress = Within-Subject Fluctuations in General Academic Social Hassles Scale for
Students (GASHSS) scores during the follow-up interval Neuroticism = NEO Five
Factor Inventory Neuroticism subscale Dysfunctional Attitudes = Dysfunctional
Attitudes Scale Time 1 MASQ = Time 1 Mood and Anxiety Symptom Questionnaire
Overall Anxiety subscale p lt 05 p lt 01 p lt 001
32
FIGURES
Figure 1 Predicted slope of the relationship between stress and depressive
symptoms (left panel) and anxious symptoms (right panel) as a function of
dysfunctional attitudes
20
25
30
Low High
Pre
dic
ted
CE
S-D
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
25
30
35
40
Low High
Pre
dic
ted
MA
SQ
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
Intercept Intercept
4
several studies have found that dysfunctional attitudes interact with the occurrence of
negative life events to predict increases in depressive symptoms (Hankin Abramson
Miller Haeffel 2004 Hankin Fraley amp Abela 2005 Joiner Metalsky Lew amp Klocek
1999 Klocek Oliver amp Ross 1997 Brown Hammen Craske and Wickens 1995) as
well as a greater likelihood of developing a depressive episode (Hankin et al 2004) In
addition individuals possessing a high level of dysfunctional attitudes have been found
to be more likely to report a past history of depressive episodes (Alloy et al 2000) and
to experience future depressive episodes (Alloy et al 2006 Hankin et al 2004) than
individuals without such a vulnerability
Far less research has examined the applicability of Beckrsquos (1983 1967)
cognitive theory to Chinese samples Preliminary cross-sectional research however
has yielded findings consistent with the theoriesrsquo hypotheses For example Xu Li and
Wang (2007) found that psychiatric patients diagnosed with major depressive disorder
showed significantly higher levels of dysfunctional attitudes than did non-depressed
controls Simiarly Bian Yang and Li (2007) reported higher levels of dysfunctional
attitudes in remitted depressives as compared to normal controls Last several studies
conducted with Chinese university students have found higher levels of dysfunctional
attitudes ndash particularly those centered on themes of perfectionism - to be associated
with higher levels of psychiatric symptoms (eg Yang amp Zhang 2004 Yang 2007
Fang Qian Luo amp Zi 2009)
5
Goals of the current study
The primary goal of the current study was to examine the applicability of
Beckrsquos (1967 1983) cognitive theory of depression to university students in mainland
China The procedure involved an initial assessment during which students completed
measures assessing dysfunctional attitudes and symptoms of depression The procedure
also involved a series of six follow-up assessments occurring once a month for six
months during which symptoms of depression and the occurrence of negative events
were assessed The use of a multi-wave longitudinal design allowed us to take an
idiographic approach towards examining the diathesis-stress hypotheses of Beckrsquos
(1967 1983) theory More specifically we examined whether the slope of the
relationship between negative events and symptoms of depression within participants
varied across participants as a function of level of dysfunctional attitudes In line with
the vulnerability-stress hypothesis of Beckrsquos (1967 1983) cognitive theory we
hypothesized that higher levels of dysfunctional attitudes would be associated with
greater increases in depressive symptoms following the occurrence of negative events
The second objective of the current study was to examine the specificity of
dysfunctional attitudes as a predictor of depressive symptoms Beckrsquos (1967 1983)
theory posits that dysfunctional attitudes predict the development of depressive
symptoms but not symptoms of other forms of psychopathology Prospective studies
using Western university student (Alloy et al 2000 2006 Hankin Abramson Miller
amp Haeffel 2004) and adolescent samples (Hankin Wetter Cheely amp Oppenheimer
2008) have provided support for the specificity hypothesis of the theory More
specifically dysfunctional attitudes have been found to interact with negative events to
6
predict increases in depressive symptoms but not symptoms of anxiety or other
disorders in both university student (Hankin et al 2004) and adolescent samples
(Hankin et al 2008) Similarly although university students possessing a high level of
dysfunctional attitudes have been found to be more likely than other university students
to report a past history of depressive episodes (Alloy et al 2000) and to experience
future depressive episodes (Alloy et al 2006) they have not been found to differ from
their low-risk counterparts in terms of past history or future occurrence of other
psychological disorders (Alloy et al 2000 2006)
With respect to the current study it is possible that differences may emerge
between Chinese and Western samples in terms of the types of symptoms predicted by
dysfunctional attitudes More specifically cultural psychopathologists have proposed
that cultural factors shape the phenomenology of psychiatric symptoms as well as the
conceptualization and classification of disorders (Kleinman 2004 Mezzich et al
1999) As such the experience of psychopathology may exhibit unique features in
different cultures with diagnostic categories developed in one cultural context not being
valid in another (Kleinman 1977 1996) Neuresthenia known in China as shenjing
shuairuo (SJSR) is a diagnostic entity characterized by (1) physical and mental
weakness and fatigability (2) sleep disturbances (3) irritability and worry (4)
excitability (5) nervous pain and (6) memory difficulty (Taylor 2001) Historically
SJSR was a Western disease concept that subsequently evolved to become a widely
utilized diagnostic entity within China (Lee amp Wong 1995) Some cultural
psychopathologists have posited that SJSR represents a somatized form of depression
This claim however has been met with significant controversy (eg Lee 1997
7
Parker Gladstone amp Chee 2001 Xu JM 1987 Xu YX 1994 Zhang 1995)
Critics dispute the notion that Chinese psychiatric patients are ldquosomatizersrdquo who
manifest few or no emotional symptoms and who attribute distress to physical causes
Rather they argue that SJSR gained widespread acceptance in China as it was a non-
stigmatizing diagnosis that allowed individuals experiencing psychosocial distress to
seek help during a time in which traditional cultural beliefs and political influences led
to severe sanction and stigmatization of individuals suffering from mental illnesses
(Lee 1998 1999 Phillips 1998 Shixie 1989) At the same time other Chinese
researchers and clinicians have continued to defend neurasthenia as both a valid
diagnostic category and a clinically useful means of communicating with patients (Rin
amp Huang 1989 Yan 1989 Young 1989) Due to continued debate on this topic it is
essential that researchers examining models of vulnerability to depression within China
assess multiple symptom outcomes as the types of symptoms predicted by vulnerability
factors may vary as a function of cultural context Hence in the current study we also
assessed levels of anxious symptoms to provide a test of the specificity hypothesis of
Beckrsquos (1967 1983) cognitive theory
In order to provide a powerful examination of our hypotheses concerning (1) the
applicability of the diathesis-stress component of Beckrsquos (1967 1983) cognitive theory
to Chinese university students and (2) the specificity of dysfunctional attitudes as
predictors of depressive as opposed to anxious symptoms participantsrsquo scores on the
neuroticism subscale of the Five-factor Inventory (FFI-N) were included as a control
variable in all analyses Several critical reviews of the literature examining theories of
cognitive vulnerability to depression (eg Barnett amp Gotlib 1998 Coyne amp Whiffen
8
1995) have argued that cognitive vulnerabilities to depression such as that featured in
Beckrsquos cognitive theory may be equivalent to or reducible to trait neuroticism and thus
may not confer independent risk for depression In response to such claims a recent
study conducted with university students examining the degree of factorial
independence versus overlap between trait neuroticism and dysfunctional attitudes has
shown them to be distinct constructs each loading onto separate factors (Hankin et al
2007) At the same time however there remains a need to examine whether
dysfunctional attitudes and trait neuroticism represent unique risk factors for
depression particularly in young adults in China Hence in the current study
participantsrsquo scores on the neuroticism subscale of the Five-factor Inventory (FFI-N)
were included as a control variable in order to account for any of the variance in
fluctuations in depressive (and anxious) symptoms that may be shared between
dysfunctional attitudes and trait neuroticism thereby isolating and highlighting their
unique predictive effects
METHOD
Participants
Participants included 662 university students (aged 19-21) from Changsha ndash an
industrial city in the province of Hunan with a population of approximately 6000000
In terms of the annual gross domestic product Hunan ranks 23rd
(10336 RMB) out of
the 34 provinces in China placing it well below the national provincial average (micro =
29719 RMB SD = 47462 RMB National Bureau of Statistics of China 2006)
Demographic variables for the sample are presented in Table 1
9
Procedure
Consent forms were distributed to all students in participating classes Consent
rates were greater than 95 in all the classes After consent forms were collected
researchers returned to the school to meet with participating students Written consent
was obtained from each participant at the beginning of the initial assessment During
the initial assessment students completed a demographics form and each of the
following questionnaires (1) Center for Epidemiological Studies Depression Scale
(CES-D Radloff 1977) (2) Mood and Anxiety Symptom Questionnaire (MASQ
Clark amp Watson 1991) (3) Dysfunctional Attitudes Scale (DAS Weissman amp Beck
1978) and (4) NEO Five Factor Inventory- Neuroticism Subscale (FFI-N Costa amp
McCrae 1992) Once a month for the subsequent six-months researchers returned to
the school and met with participating students to conduct follow-up assessments At
each of these follow-up assessments students were asked to complete each of the
following questionnaires (1) CES-D (2) MASQ and (3) the General Academic
Social Hassles Scale for Students (GASHSS Blankstein amp Flett 1993)
Measures
The Chinese versions of all self-report measures were developed using the
back-translation method Original English versions were translated into Chinese by a
bilingual translator from the Psychology department at Second Xiangya Medical
College of Central South University Hunan Translated Chinese versions were then
back-translated into English by another bilingual translator from the Psychology
department at McGill University Quebec Original versions were then compared with
the back-translation If inconsistencies were found in the back-translation translators
10
worked together to make corrections to the final Chinese versions until all final
versions were agreed upon No items from any of the measures were removed or
significantly altered during the translation process
Depressive Symptoms Center for Epidemiological Studies Depression Scale
(CES-D Radloff 1977) The CES-D is a 20-item self-report measure designed to
assess depressive symptoms in the general population For each item participants are
asked to indicate how often they experienced the particular symptom over the last
week Responses range from 1 (eg rarely or none of the time) to 4 (eg most or all of
the time) Scores range from 20-80 with higher score indicating higher levels of
depressive symptoms In the current study the CES-D exhibited high internal
consistency with Cronbachrsquos alpha values ranging from 90 to 94 (micro = 2918 SD =
814) over the 7 time points
Anxious Symptoms Mood and Anxiety Symptom Questionnaire (MASQ
Watson amp Clark 1991) The MASQ is a 62-item questionnaire designed to assess both
specific and nonspecific depressive and anxious symptoms For each item participants
are asked to rate on a scale of 1 to 5 the extent to which they have felt this way ldquoduring
the past 24 hoursrdquo Within the current study we utilized the anxious symptoms (11
items) and anxious arousal (17 items) subscales which together provide an index of
overall anxious symptoms Higher scores on each subscale reflect greater levels of
anxious symptoms In the current study the MASQ exhibited high internal consistency
with Cronbachrsquos alpha values ranging from 90 to 95 (micro = 3847 SD = 1117) over the
7 time points
11
Dysfunctional Attitudes Dysfunctional Attitudes Scale (DAS Weissman amp
Beck 1978) The DAS (Form A) is a 40-item questionnaire designed to measure the
cognitive vulnerability factor featured in Beckrsquos cognitive theory Examples of items
include ldquoIf I do not do well all the time people will not respect merdquo ldquoIf a person asks
for help it is a sign of weaknessrdquo and ldquoMy value as a person depends greatly on what
others think of merdquo Items are rated on a 7-point Likert scale ranging from 1 (totally
disagree) to 7 (totally agree) providing a range of scores from 40 to 280 with higher
scores reflecting more dysfunctional attitudes In the current study the DAS exhibited
high internal consistency with Cronbachrsquos alphas of 89 and 88 obtained for the first
and second administrations respectively In addition a test-retest reliability coefficient
of 72 was obtained indicating strong stability over time
Neuroticism NEO Five Factor Inventory - Neuroticism Subscale (FFI-N
Costa amp McCrae 1992) The FFI-N is a 12- item self-report measure that assesses
neuroticism Examples of questions include I often feel inferior to others I am
seldom sad or depressed and Sometimes I feel completely worthless Items are rated
on a 5-point Likert scale ranging from 0 (strongly disagree) to 4 (strongly agree)
providing scores ranging from 0 to 48 with higher scores indicating higher levels of
neuroticism The NEO-FFI-N has proven reliable across different cultural samples and
item pools (Costa amp McCrae 1992) In the current study Cronbachs alpha was 81
indicating strong internal consistency
Negative Life Events General Academic Social Hassles Scale for Students
(GASHSS Blankstein amp Flett 1993) Participants completed a 30-item abbreviated
version of the GASHSS The measure is comprised of items assessing general hassles
12
(8 items) academic hassles (10 items) and social hassles (12 items) For each item
participants are asked to rate how persistent the given hassle was (ie its frequency and
duration) over the last 30 days (0 = no hassle not at all persistent to 6 = extremely
persistent hassle high frequency andor duration)
13
RESULTS
Descriptive Data
Means standard deviations and inter-correlations between Time 1 measures are
presented in Table 2
Prospective Diathesis-Stress Analyses - Depression
Multilevel modeling was used to test our hypothesis that higher levels of dysfunctional
attitudes would be associated with greater increases in depressive symptoms following
increases in stress Analyses were carried out using the SAS (version 81) MIXED
procedure and maximum likelihood estimation Our dependent variable was within-
subject fluctuations in CES-D scores during the follow-up interval (DEPRESSION)
Our primary predictors of DEPRESSION were DAS scores (DYSFUNCTIONAL
ATTITUDES) and fluctuations in GASHSS scores during the follow-up interval
(STRESS) As DYSFUNCTIONAL ATTITUDES is a between-subject predictor DAS
scores were standardized prior to analyses As STRESS is a within-subject predictor
STRESS reflects upward or downward fluctuations in an individualrsquos level of stress
compared to hisher mean level of stress
When fitting hierarchical linear models one must specify appropriate mean and
covariance structures Mean structures refer to the various fixed and random effect
components that can be included in the model Covariance structures refer to alternative
methods of specifying the pattern of covariance between observations taken from the
same subject at different time points It is important to note that mean and covariance
structures are not independent of one another Rather an appropriate covariance
structure is essential in order to obtain valid inferences for the parameters in the mean
14
structure Overparametrization of the covariance structure can lead to inefficient
estimation and poor assessment of standard errors (Altham 1984) On the other hand
too much restriction of the covariance structure can lead to invalid inferences when the
assumed structure does not hold (Altham 1984)
In our first set of analyses we were interested in examining the effects of
DYSFUNCTIONAL ATTITUDES STRESS and the DYSFUNCTIONAL
ATTITUDES STRESS interaction on participantrsquos CES-D scores during the follow-
up interval Consequently in line with Diggle Liang and Zegers (1994)
recommendation that one use a ldquosaturatedrdquo model for the mean structure while
searching for an appropriate covariance structure we chose a mean structure that
included DYSFUNCTIONAL ATTITUDES STRESS and the DYSFUNCTIONAL
ATTITUDES STRESS interaction Four additional effects were also included in this
mean structure First as different individuals report different levels of depressive
symptoms when at their own average level of stress a random effect for intercept was
included in the model Second given that STRESS is a within-subject predictor whose
effect is expected to vary from participant to participant a random effect for slope was
included in the model Third in order to control for individual differences in baseline
levels of depressive symptoms Time 1 CES-D scores were included in the model
Fourth in order to examine whether DYSFUNCTIONAL ATTITUDES represent a
vulnerability factor independent of neuroticism participantsrsquo FFI-N scores were
entered in the model
Commonly used covariance structures in studies in which multiple responses
are obtained from the same individual over time (and consequently within-subject
15
residuals over time are likely to be correlated) include compound symmetry first-order
autoregressive heterogeneous autoregressive and banded Toeplitz In order to select
one of these covariance structures for our analyses we fitted models using each
structure and chose the ldquobestrdquo fit based on Akaike information criterion (AIC and
AICC) and Schwarz Bayesian criterion (BIC) In all cases the best fit for our data was
a first-order heterogeneous autoregressive structure (ARH [1]) After choosing the
appropriate covariance structure we next examined the random-effects component of
our model
With respect to random effects the ARH [1] parameter (r = 31 plt001)
RE_INTERCEPT (plt001) and RE_SLOPE (plt001) were each significant and thus
were retained in the model The final results with respect to the fixed-effects
component of the model are presented in the upper section of Table 3 Of primary
importance the DYSFUNCTIONAL ATTITUDES STRESS interaction was a
significant predictor of fluctuations in depressive symptoms during the follow-up
interval In order to examine the form of this interaction the model summarized in the
upper section of Table 3 was used to calculate predicted CES-D scores for individuals
exhibiting either high or low levels of dysfunctional attitudes (plus or minus 15 SD)
who are experiencing either high or low levels of stress in comparison to their own
average level of stress (plus or minus 15 times mean within-subject SD) The results of
such calculations are presented in the left panel of Figure 1
Analyses were conducted for each DYSFUNCTIONAL ATTITUDES
condition examining whether the slope of the relationship between stress and
depressive symptoms significantly differed from 0 Analyses indicated that both
16
individuals exhibiting high (t(2459) = 862 p lt 0001) and low (t(2459) = 347 p lt
0001) levels of dysfunctional attitudes reported significantly higher levels of
depressive symptoms when experiencing high levels of stress than when experiencing
low levels of stress Planned comparisons of the slopes of the relationship between
stress and depressive symptoms however revealed that the slope was significantly
greater in individuals exhibiting high levels of dysfunctional attitudes (slope = 013)
than in individuals exhibiting low levels of dysfunctional attitudes (slope = 005
t(2459) = 328 p = 0001)
Prospective Diathesis-Stress Analyses - Anxiety
The same data-analytic approach as described above was used to examine
whether higher levels of dysfunctional attitudes would be associated with greater
increases in anxious symptoms following increases in stress Again in order to examine
whether DYSFUNCTIONAL ATTITUDES represent a vulnerability factor
independent of neuroticism participantsrsquo FFI-N scores were entered in the model
With respect to random effects the ARH[1] parameter (r = 23 p lt 001)
RE_INTERCEPT (plt001) and RE_SLOPE (plt001) were each significant and thus
were retained in the model The final results with respect to the fixed-effects
component of the model are presented in the lower section of Table 3 Of primary
importance the DYSFUNCTIONAL ATTITUDES STRESS interaction was a
significant predictor of within-subject fluctuations in anxious symptoms during the
follow-up interval In order to examine the form of this interaction the model
summarized in the lower section of Table 3 was used to calculate predicted MASQ
scores for individuals exhibiting either high or low levels of dysfunctional attitudes
17
(plus or minus 15 SD) who are experiencing either high or low levels of stress in
comparison to their own average level of stress (plus or minus 15 times mean within-
subject SD) The results of such calculations are presented on the right panel of in
Figure 1
Analyses were conducted for each DYSFUNCTIONAL ATTITUDES
condition examining whether the slope of the relationship between stress and anxious
symptoms significantly differed from 0 Analyses indicated that both individuals
exhibiting high (t(2470) = 768 p lt 0001) and low (t(2470) = 337 p lt 0001) levels of
dysfunctional attitudes reported higher levels of anxious symptoms when experiencing
high levels of stress than when experiencing low levels of stress Planned comparisons
of the slopes of the relationship between stress and anxious symptoms however
revealed that the slope was significantly greater in individuals exhibiting high levels of
dysfunctional attitudes (slope = 009) than in individuals exhibiting low levels of
dysfunctional attitudes (slope = 003 t(2470) = 278 p lt 001)
Additional Analyses
Given that the DYSFUNCTIONAL ATTITUDES STRESS interaction
prospectively predicted both symptoms of depression and anxiety two additional
analyses were conducted in order to examine (1) whether the DYSFUNCTIONAL
ATTITUDES STRESS interaction continued to be a significant predictor of within-
subject fluctuations in depressive symptoms after controlling for within-subject
fluctuations in anxious symptoms and (2) whether the DYSFUNCTIONAL
ATTITUDES STRESS interaction continued to predict within-subject fluctuations in
anxious symptoms after controlling for within-subject fluctuations in depressive
18
symptoms Such analyses allowed us to examine whether the above mentioned pattern
of findings may have been due to the high correlation observed in the current study
between depressive and anxious symptoms
Analyses were conducted in the same manner as described above with the
exception that an additional within-subject variable (ie DEPRESSION or ANXIETY)
was included in each model in order to control for within-subject fluctuations in the
alternate symptom With respect to the prediction of depressive symptoms the
DYSFUNCTIONAL ATTITUDES STRESS interaction remained a significant
predictor after controlling for within-subject fluctuations in anxious symptoms (β =
001 SE = 000 F = 410 p lt 05) With respect to the prediction of anxious
symptoms however the DYSFUNCTIONAL ATTITUDES STRESS interaction
was no longer a significant predictor after controlling for within-subject fluctuations in
depressive symptoms (β = 001 SE = 000 F = 148 p = 22)
DISCUSSION
The results of the current study provide support for the cross-cultural
applicability of Beckrsquos (1967 1983) cognitive theory to university students in Hunan
China More specifically consistent with hypotheses and with results obtained from
past research examining Beckrsquos cognitive theory in Western samples of university
students (Hankin et al 2004 Hankin et al 2005 Joiner et al 1999 Klocek et al
1997 Brown et al 1995) higher levels of dysfunctional attitudes were associated with
greater increases in depressive symptoms following increases in negative event
frequency during the six-month follow-up interval Given the considerable differences
between the current sample and Western samples in terms of demographic
19
characteristics and cultural factors such a finding strongly attests to the robustness of
Beckrsquos cognitive theory Moreover integrating the current findings with those obtained
in research examining Beckrsquos theory in other non-Western samples suggests that
Beckrsquos theory may represent a powerful explanatory model of the development of
depressive symptoms among individuals from diverse cultural settings For example
consistent with the theory higher levels of dysfunctional attitudes have been shown to
be associated with higher levels of depressive symptoms in Japanese (Tanaka et al
2006) Puerto-Rican (Bonilla Bernal Santos amp Santos 2003) Turkish (Sahin amp Sahin
1992) Norwegian (Chioqueta amp Stiles 2004) Singaporean (Oei Goh amp Kwon 1996)
and Swedish (Ohrt amp Thorell 1998) adult samples In addition it is important to note
that the current findings expand upon past correlational research examining the
association between dysfunctional attitudes and depression in Chinese samples through
the use of a multi-wave longitudinal design
When examining the specificity of dysfunctional attitudes as a predictor of
depressive symptoms the current study did not obtain support for specificity More
specifically contrary to the specificity hypothesis of Beckrsquos cognitive theory and to
results obtained in Western samples of university students (Alloy et al 2000 2006
Hankin et al 2004) higher levels of dysfunctional attitudes were associated with
greater increases in both depressive and anxious symptoms following increases in
negative event frequency There are two alternative ways of interpreting the non-
specificity finding observed in the current study First it is possible that the types of
thoughts individuals possessing high levels of dysfunctional attitudes experience
following negative events varies as a function of cultural context In other words in
20
Western samples such individuals may primarily experience the types of cognitions
that are associated with the development of depressive symptoms (ie appraisals of
personal loss and failure) In contrast in Chinese samples individuals possessing high
levels of dysfunctional attitudes may experience a wider array of cognitions some of
which are associated with the development of depressive symptoms and some of which
are associated with the development of anxious symptoms (ie evaluations of
impending threat or danger) Such an explanation would be consistent with Beckrsquos
cognitive content-specificity hypothesis (Clark amp Beck 1999) which posits that each
affective state and psychological disorder has a specific cognitive profile Second it is
possible that the types of symptoms individuals possessing high levels of dysfunctional
attitudes experience following negative events varies as a function of cultural context
More specifically it may be that dysfunctional attitudes specifically predict symptoms
of depression in both samples except that in Western samples depression manifests in
pure depressive symptoms whereas in Chinese samples depression manifests as a
combination of depressive and anxious symptoms Such an explanation would be
consistent with cultural psychopathologistsrsquo hypotheses that cultural factors shape the
phenomenology of psychiatric symptoms (Kleinman 2004 Mezzich et al 1999)
Moreover dysfunctional attitudes predicting a combination of depressive and anxious
symptoms in Chinese samples would be consistent with the construct of neurasthenia -
a construct hypothesized by some to represent a somatized form of depression that is
still widely seen within China (Lee amp Wong 1995)
Interesting in this regard and perhaps speaking to the primacy of depressive
symptoms in the current findings analyses indicated that the DYSFUNCTIONAL
21
ATTITUDES times STRESS interaction no longer predicted anxious symptoms after
controlling for depressive symptoms The reverse however was not true as the
DYSFUNCTIONAL ATTITUDES times STRESS interaction continued to predict
depressive symptoms after controlling for anxious symptoms
It is important to note that the current study employed a particularly
conservative approach to analyses in that we examined the effects of dysfunctional
attitudes on depressive and anxious symptoms after controlling for the effect of
neuroticism on such symptoms Providing particularly powerful support for Beckrsquos
(1967 1983) cognitive theory across analyses dysfunctional attitudes predicted levels
of depressive andor anxious symptoms experienced during the six month follow-up
interval independent of the effect of neuroticism Thus contrary to past critical reviews
of the cognitive literature (Barnett amp Gotlib 1998 Coyne amp Whiffen 1995) and
consistent with past findings (Hankin et al 2007) the current results indicate that
cognitive vulnerabilities to depression such as dysfunctional attitudes are not reducible
to trait neuroticism but rather represent factors that confer independent risk for
depression
Limitations and Future Directions
Several limitations of the current study should be noted First self-report
measures were used to assess depressive and anxious symptoms Although the CES-D
and MASQ both possess high degrees of reliability and validity it is difficult to draw
conclusions about clinically diagnosed depression or anxiety based on self-report
questionnaires Second self-report measures were used to assess stress Although
measures of stress that require participants only to indicate whether or not an event
22
occurred are less likely to be influenced by informant bias than those that ask
participants to rate the subjective impact of each event more sophisticated methods of
analysis such as interviewing procedures that assess contextual threat may provide
better assessments of stress Third the measures of dysfunctional attitudes stress and
depressive and anxious symptoms used in the current study were each Western-
developed Future research should examine these hypotheses using indigenous
measures in addition to Western-developed measures in order to assess possible
similarities andor differences in patterns of findings Fourth the current study only
examined depression and anxiety as symptom outcomes Future research conducted
within China should examine a wider array of symptom outcomes such as
somatization physical complaints and externalizing behaviors in order to provide a
more thorough and culturally sensitive test of the specificity hypotheses of Beckrsquos
cognitive model Fifth the current study examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese undergraduate students and thus the extent to which
our findings may be generalized to other demographics within Chinarsquos population is
unclear Last the current study broadly examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese university students Future research should examine
the constructs and processes posited by this model in greater detail in order to develop a
deeper understanding of how they may be uniquely molded by socio-cultural factors
Such research would benefit from examining the specific types of stressors experienced
by Chinese university students as they may vary as a function of socio-cultural factors
from those experienced by Western undergraduates For example severe pressure to
succeed academically in order to secure access to a limited number of post-
23
undergraduate educational opportunities - one of the few paths towards upward
mobility available to Chinese students seeking secure and gainful employment in what
has increasingly become a very highly competitive job market - may represent a
particularly salient stressor for the development of depressive symptoms among this
population (Qiang 2006)
In conclusion the results from the current study provide support for the
applicability of Beckrsquos cognitive theory to university students in mainland China More
specifically consistent with findings obtained in the West results indicate that
dysfunctional attitudes confer vulnerability to the development of depressive symptoms
following the occurrence of negative events in Chinese university students At the same
time however the current findings suggest cultural variation in the profile of
symptoms which emerge following the occurrence of negative events in cognitively
vulnerable individuals in Western and Chinese samples Specifically whereas in the
West dysfunctional attitudes have been shown to confer vulnerability to depressive
symptoms in Chinese university students dysfunctional attitudes appear to confer
vulnerability to a combined depressive and anxious symptom profile Future research
using more sophisticated assessments of stress and depressive symptoms more diverse
samples and symptom outcome measures and indigenously-developed measures is
likely to enhance our understanding of the cognitive and environmental mechanisms
underlying the development of depression in Chinese university students Discovering
that cognitive theories of vulnerability to depression extend to university students in
China highlights the potential role for cognitive-behavioral depression prevention and
treatment interventions in stemming the tide of distress experienced by this population
24
REFERENCES
Abela J R Z amp Hankin B L (2008) Cognitive vulnerability to depression in
children and adolescents A developmental psychopathology perspective In J
R Z Abela and B L Hankin (Eds) Handbook of child and adolescent
depression (pp 35-78) New York The Guilford Press
Alloy L B Abramson L Y Hogan M E Whitehouse W G Rose D T
Robinson MS Kim R S amp Lapkin J B (2000) The Temple-Wisconsin
cognitive vulnerability to depression project Lifetime history of axis-I
psychopathology in individuals at high and low cognitive risk for depression
Journal of Abnormal Psychology 109 403-418
Alloy L B Abramson L Y Whitehouse W G Hogan M E Panzarella C amp
Rose D T (2006) Prospective incidence of first onsets and recurrences of
depression in individuals at high and low cognitive risk for depression Journal
of Abnormal Psychology 115 145ndash156
Altham P M E (1984) Improving the precision of estimation by fitting a model
Journal of the Royal Statistical Society Series B 46 11
Barnett PA amp Gotlib I H (1988) Psychosocial functioning and depression
Distinguishing among antecedents concomitants and consequences
Psychological Bulletin 104 97-126
Beck AT (1967) Depression Clinical experimental and theoretical aspects New
York Harper amp Row
Beck AT (1983) Cognitive therapy of depression New perspectives In PJ Clayton
amp JE Barrett (Eds) Treatment of depression Old controversies and new
approaches New York Raven Press
Bian Q Yang K amp Li C (2007) Dysfunctional attitudes of patients with depression
or bipolar disorder Chinese Mental Health Journal 21 759-761
Blankstein K R amp Flett G L (1993) Development of the General Academic and
Social Hassles Scales for Students Unpublished manuscript
Bonilla J Bernal G Santos A amp Santos D (2003) A revised Spanish version of
the Beck Depression InventoryPsychometric properties with a Puerto Rican
sample of college students Journal of Clinical Psychology 60 119-130
Brown G P Hammen C L Craske M G amp Wickens T D (1995) Dimensions of
dysfunctional attitudes as vulnerabilities to depressive symptoms Journal of
Abnormal Psychology 104 431-435
25
Chioqueta A P amp Stiles T C (2004) Psychometric properties of the Norweigian
version of the Dysfunctional Attitude Scale (Form A) Cognitive Behaviour
Therapy 33 83-86
Clark DA amp Beck AT (1999) Cognitive theory and therapy of depression New
York John Wiley amp Sons Inc
Clark L A amp Watson D (1991) Tripartite model of anxiety and depression
Psychometric evidence and taxonomic implications Journal of Abnormal
Psychology 100 316ndash336
Costa P T amp McCrae R R (1992) NEO PI-R Professional manual Revised NEO
personality inventory NEO PR-R and NEO five-factor inventory NEO-RRI
Odessa FL Psychological Assessment Resources
Coyne J C amp Whiffen V E (1995) Issues in personality as diathesis for depression
The case of sociotropy-dependency and autonomy-self-criticism Psychological
Bulletin 118 358-378
Fang X Qian M Luo S amp Zi F (2009) A correlational study on college students
perfectionism parental rearing patterns and mental health Chinese Mental
Health Journal 23 56-59
Hankin B L Abramson L Y Miller N amp Haeffel G (2004) Cognitive
vulnerability-stress theories of depression Examining affective specificity in
the prediction of depression versus anxiety in three prospective studies
Cognitive Therapy and Research 28 309ndash345
Hankin BL Fraley RC amp Abela JRZ (2005) Daily depression and cognitions
about stress Evidence for a traitlike depressogenic cognitive style and the
prediction of depressive symptoms in a prospective daily diary study Journal of
Personality and Social Psychology 88 673-685
Hankin B L Lakdawalla Z Carter I L Abela J R Z amp Adams P (2007) Are
neuroticism cognitive vulnerabilities and self-esteem overlapping or distinct
risks for depression Evidence from confirmatory factor analyses Journal of
Social amp Clinical Psychology 26 29-63
Hankin B L Wetter E Cheely C amp Oppenheimer C W (2008) Becks cognitive
theory of depression in adolescence Specific prediction of depressive
symptoms and reciprocal influences in a multi-wave prospective study
International Journal of Cognitive Therapy 1 313-332
Ingram R E Miranda J amp Segal Z V (1998) Cognitive Vulnerability to
Depression New York NY Guilford Press
26
Ingram R E amp Luxton DD (2005) Vulnerability-stress models In BL Hankin amp
JRZ Abela (Eds) Development of psychopathology A vulnerability-stress
perspective (pp 32-46) Thousand Oaks CA Sage
Joiner T E Metalsky G I Lew A amp Klocek J (1999) Testing the causal
mediation component of Becks theory of depression Evidence for specific
mediation Cognitive Therapy and Research 23 401-412
Kleinman A (2004) Culture and depression New England Journal of Medicine 351
951-953
Kleinman A (1977) Depression somatization and the new cross-cultural psychiatry
Social Science and Medicine 11 3-10
Kleinman A (1996) How is culture important for DSM-IV In J E Mezzich A
Kleinmam H Fabrega Jr amp L Delores (Eds)Culture and psychiatric
diagnosis A DSM-IV perspective (pp 15-25) Washington DC US American
Psychiatric Association
Klocek J W Oliver J M amp Ross M J (1997) The role of dysfunctional attitudes
negative life events and social support in the prediction of depressive
dysphoria A prospective longitudinal study Social Behavior and Personality
25 23-136
Lee S (1997) A Chinese perspective on somatoform disorders Journal of
Psychosomatic Disorders 43 115-119
Lee S (1998) Estranged bodies simulated harmony and misplaced cultures
Neurasthenia in contemporary Chinese society Psychosomatic Medicine 60
448ndash457
Lee S (1999) Diagnosis postponed Shenjing shuairo and the transformation of
psychiatry in post-Mao China Culture Medicine and Psychiatry 23 349ndash380
Lee S amp Wong K C (1995) Rethinking neurasthenia the illness concepts of
shenjing shuairuo among Chinese undergraduates in Honk Kong Culture
Medicine and Psychiatry 19 91ndash111
Lee S Tsang A Huang YQ He YL Liu ZR Zhang MY Shen YC amp
Kessler RC (2009) The epidemiology of depression in metropolitan China
Psychological Medicine 39 735-747
Mezzich J E Kirmayer L J Kleinman A Fabrega Jr H Parron D L Good B
J Lin K amp Manson S M (1999) The place of culture in DSM-IV Journal
of Nervous and Mental Disease 187 457-464
27
Monroe S M amp Simons A D (1991) Diathesisndashstress theories in the context of life
stress research Implications for the depressive disorders Psychological
Bulletin 110 406ndash425
Murray C J L amp Lopez A D (1996) The global burden of disease Cambridge
Harvard University Press
National Bureau of Statistics of China (2006) The China 2005 statistical yearbook
China Statistics Press Beijing PR China
Oei T P S Goh Y Kwon S M(1996) A cross-cultural study of the integrated
cognitive model of depression Current Psychology of Cognition 15 265-281
Ohrt T amp Thorell L (1998) Dysfunctional Attitude Scale (DAS) Psychometrics and
norms of the Swedish version Scandinavian Journal of Behaviour Therapy 27
105-113
Parker G Gladstone G Chee KT (2001) Depression in the planetrsquos largest ethnic
group The Chinese American Journal of Psychiatry 158 857-864
Phillips M R Zhang J Shi Q Song Z Ding Z Pang S Li X Zhang Y amp
Wang Z (2009) Prevalence treatment and associated disability of mental
disorders in four provinces in China during 2001ndash05 an epidemiological
survey The Lancet 373 2041-2053
Phillips M R Li X amp Zhang Y (2002) Suicide rates in China Lancet 359 835-
840
Phillips M R (1998) The transformation of Chinarsquos mental health services The China
Journal 39 1ndash36
Qiang G (2006) Depression number one killer of Ivory Tower students China Daily
Retrieved from httpwwwchinadailycomcnchina2006-
1128content_744880htm
Radloff L S (1977) The CESndashD scale A self-report depression scale for research in
the general population Applied Psychological Measurement 1 385ndash401
Rin H amp Huang M G (1989) Neurasthenia as nosological dilemma Culture
Medicine and Psychiatry 13 215-226
Sahin NH amp Sahin N (1992) How dysfunctional are the dysfunctional attitudes in
another culture British Journal of Medical Psychology 65 17-26
Shixie L (1989) Neurasthenia in China Modern and traditional criteria for its
diagnosis Culture Medicine and Psychiatry 13 163-186
28
Tanaka N Uji M Hiramura H Chen Z Shikai N amp Kitamura T (2006)
Cognitive patterns and depression Study of a Japanese university student
population Psychiatry and Clinical Neuroscience 60 358-364
Taylor R E (2001) Death of neurasthenia and its psychological reincarnation a study
of neurasthenia at the National Hospital for the Relief and Cure of the Paralysed
and Epileptic Queen Square London 1870ndash1932 British Journal of
Psychiatry 179 550ndash557
Weissman A N amp Beck A T (1978 April) Development and validation of the
Dysfunctional Attitudes Scale A preliminary investigation Paper presented at
the annual meeting of the Educational Research Association Toronto Canada
Xiang M Z (1986) Epidemiological study of neuroses in 12 regions (districts) of
China Chinese Journal of Neurology and Psychiatry 19 87-91
Xu JM (1987) Some issues in the diagnosis of depression in China Canadian
Journal of Psychiatry 32 368-370
Xu Y X (1994) About ICD-10 Journal of Clinical Psychology and Medicine 4 224-
226
Xu Z Li Z amp Wang Z (2007) Dysfunctional attitudes and cognitive bias in major
depressive disorder Chinese Mental Health Journal 21 488-491
Yan H Q (1989) The necessity of retaining the diagnostic concept of neurasthenia
Culture Medicine and Psychiatry 13 139-145
Yang H (2007) The Test of the Chinese version of Frost Multi-dimensional
Perfectionism Scale Chinese Mental Health Journal 21 97-100
Yang H amp Zhang X (2004) Perfectionism and mental health of college students
(2004) Chinese Mental Health Journal 18 647-648
Young D (1989) Neurasthenia and related problems Culture Medicine and
Psychiatry 13 131-138
Zhang D (1995) Depression and culture A Chinese perspective Canadian Journal of
Counseling 29 227ndash233
29
TABLE(S)
Table 1 Demographic Variables
Age 2011
Gender Male
Female
472
523
Parentsrsquo Marital Status Married
Divorced
Single
Remarried
938
23
18
20
Fatherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
Government Official
51
356
187
95
124
91
Motherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
122
406
144
76
134
Fatherrsquos Education Some Primary School
Primary School
Some High School
High School
University
29
139
222
403
137
Motherrsquos Education Some Primary School
Primary School
Some High School
High School
University
63
192
264
350
76
Only Child No
Yes
331
667
Monthly Income lt 1000 RMB
1000 ndash 1500 RMB
1500 ndash 2000 RMB
2000 ndash 3000 RMB
3000 ndash 4000 RMB
4000 ndash 5000 RMB
gt 5000 RMB
334
204
175
140
59
20
20
30
Table 2 Means Standard Deviations and Inter-correlations Between Time 1 Measures
__________________________________________________________________
1 2 3
__________________________________________________________________
1 Depressive Symptoms 2963 (780)
2 Anxious Symptoms 52 3753 (918)
3 Dysfunctional Attitudes 48 33 18120 (2304)
4 Neuroticism 63 42 53 3110 (712)
_________________________________________________________________________
Note Means and standard deviations (in parentheses) are on the diagonal Depressive
Symptoms = Center for Epidemiological Studies Depression Scale Anxious Symptoms
= Mood and Anxiety Symptom Questionnaire Overall Anxiety subscale Dysfunctional
Attitudes = Dysfunctional Attitudes Scale Neuroticism = NEO Five Factor Inventory
Neuroticism subscale p lt 01
31
Table 3 Dysfunctional Attitudes Predicting Within-Subject Fluctuations in CES-D
Scores (upper section) and MASQ Scores (lower section) during the Follow-Up
Interval
______________________________________________________________________
β SE F df
______________________________________________________________________
Time 1 CESD-D 297 026 12987 1572
Stress 005 000 10860 12459
Neuroticism 134 027 2518 1572
Dysfunctional Attitudes -055 040 -183 1572
Dysfunctional Attitudes times Stress 001 000 1078 12459
______________________________________________________________________
Time 1 MASQ 502 033 23158 1575
Stress 006 000 8963 12470
Neuroticism 080 033 596 1575
Dysfunctional Attitudes -052 051 -106 1575
Dysfunctional Attitudes times Stress 002 001 774 12470
______________________________________________________________________
Note Time 1 CES-D = Time 1 Center for Epidemiological Studies Depression Scale
Stress = Within-Subject Fluctuations in General Academic Social Hassles Scale for
Students (GASHSS) scores during the follow-up interval Neuroticism = NEO Five
Factor Inventory Neuroticism subscale Dysfunctional Attitudes = Dysfunctional
Attitudes Scale Time 1 MASQ = Time 1 Mood and Anxiety Symptom Questionnaire
Overall Anxiety subscale p lt 05 p lt 01 p lt 001
32
FIGURES
Figure 1 Predicted slope of the relationship between stress and depressive
symptoms (left panel) and anxious symptoms (right panel) as a function of
dysfunctional attitudes
20
25
30
Low High
Pre
dic
ted
CE
S-D
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
25
30
35
40
Low High
Pre
dic
ted
MA
SQ
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
Intercept Intercept
5
Goals of the current study
The primary goal of the current study was to examine the applicability of
Beckrsquos (1967 1983) cognitive theory of depression to university students in mainland
China The procedure involved an initial assessment during which students completed
measures assessing dysfunctional attitudes and symptoms of depression The procedure
also involved a series of six follow-up assessments occurring once a month for six
months during which symptoms of depression and the occurrence of negative events
were assessed The use of a multi-wave longitudinal design allowed us to take an
idiographic approach towards examining the diathesis-stress hypotheses of Beckrsquos
(1967 1983) theory More specifically we examined whether the slope of the
relationship between negative events and symptoms of depression within participants
varied across participants as a function of level of dysfunctional attitudes In line with
the vulnerability-stress hypothesis of Beckrsquos (1967 1983) cognitive theory we
hypothesized that higher levels of dysfunctional attitudes would be associated with
greater increases in depressive symptoms following the occurrence of negative events
The second objective of the current study was to examine the specificity of
dysfunctional attitudes as a predictor of depressive symptoms Beckrsquos (1967 1983)
theory posits that dysfunctional attitudes predict the development of depressive
symptoms but not symptoms of other forms of psychopathology Prospective studies
using Western university student (Alloy et al 2000 2006 Hankin Abramson Miller
amp Haeffel 2004) and adolescent samples (Hankin Wetter Cheely amp Oppenheimer
2008) have provided support for the specificity hypothesis of the theory More
specifically dysfunctional attitudes have been found to interact with negative events to
6
predict increases in depressive symptoms but not symptoms of anxiety or other
disorders in both university student (Hankin et al 2004) and adolescent samples
(Hankin et al 2008) Similarly although university students possessing a high level of
dysfunctional attitudes have been found to be more likely than other university students
to report a past history of depressive episodes (Alloy et al 2000) and to experience
future depressive episodes (Alloy et al 2006) they have not been found to differ from
their low-risk counterparts in terms of past history or future occurrence of other
psychological disorders (Alloy et al 2000 2006)
With respect to the current study it is possible that differences may emerge
between Chinese and Western samples in terms of the types of symptoms predicted by
dysfunctional attitudes More specifically cultural psychopathologists have proposed
that cultural factors shape the phenomenology of psychiatric symptoms as well as the
conceptualization and classification of disorders (Kleinman 2004 Mezzich et al
1999) As such the experience of psychopathology may exhibit unique features in
different cultures with diagnostic categories developed in one cultural context not being
valid in another (Kleinman 1977 1996) Neuresthenia known in China as shenjing
shuairuo (SJSR) is a diagnostic entity characterized by (1) physical and mental
weakness and fatigability (2) sleep disturbances (3) irritability and worry (4)
excitability (5) nervous pain and (6) memory difficulty (Taylor 2001) Historically
SJSR was a Western disease concept that subsequently evolved to become a widely
utilized diagnostic entity within China (Lee amp Wong 1995) Some cultural
psychopathologists have posited that SJSR represents a somatized form of depression
This claim however has been met with significant controversy (eg Lee 1997
7
Parker Gladstone amp Chee 2001 Xu JM 1987 Xu YX 1994 Zhang 1995)
Critics dispute the notion that Chinese psychiatric patients are ldquosomatizersrdquo who
manifest few or no emotional symptoms and who attribute distress to physical causes
Rather they argue that SJSR gained widespread acceptance in China as it was a non-
stigmatizing diagnosis that allowed individuals experiencing psychosocial distress to
seek help during a time in which traditional cultural beliefs and political influences led
to severe sanction and stigmatization of individuals suffering from mental illnesses
(Lee 1998 1999 Phillips 1998 Shixie 1989) At the same time other Chinese
researchers and clinicians have continued to defend neurasthenia as both a valid
diagnostic category and a clinically useful means of communicating with patients (Rin
amp Huang 1989 Yan 1989 Young 1989) Due to continued debate on this topic it is
essential that researchers examining models of vulnerability to depression within China
assess multiple symptom outcomes as the types of symptoms predicted by vulnerability
factors may vary as a function of cultural context Hence in the current study we also
assessed levels of anxious symptoms to provide a test of the specificity hypothesis of
Beckrsquos (1967 1983) cognitive theory
In order to provide a powerful examination of our hypotheses concerning (1) the
applicability of the diathesis-stress component of Beckrsquos (1967 1983) cognitive theory
to Chinese university students and (2) the specificity of dysfunctional attitudes as
predictors of depressive as opposed to anxious symptoms participantsrsquo scores on the
neuroticism subscale of the Five-factor Inventory (FFI-N) were included as a control
variable in all analyses Several critical reviews of the literature examining theories of
cognitive vulnerability to depression (eg Barnett amp Gotlib 1998 Coyne amp Whiffen
8
1995) have argued that cognitive vulnerabilities to depression such as that featured in
Beckrsquos cognitive theory may be equivalent to or reducible to trait neuroticism and thus
may not confer independent risk for depression In response to such claims a recent
study conducted with university students examining the degree of factorial
independence versus overlap between trait neuroticism and dysfunctional attitudes has
shown them to be distinct constructs each loading onto separate factors (Hankin et al
2007) At the same time however there remains a need to examine whether
dysfunctional attitudes and trait neuroticism represent unique risk factors for
depression particularly in young adults in China Hence in the current study
participantsrsquo scores on the neuroticism subscale of the Five-factor Inventory (FFI-N)
were included as a control variable in order to account for any of the variance in
fluctuations in depressive (and anxious) symptoms that may be shared between
dysfunctional attitudes and trait neuroticism thereby isolating and highlighting their
unique predictive effects
METHOD
Participants
Participants included 662 university students (aged 19-21) from Changsha ndash an
industrial city in the province of Hunan with a population of approximately 6000000
In terms of the annual gross domestic product Hunan ranks 23rd
(10336 RMB) out of
the 34 provinces in China placing it well below the national provincial average (micro =
29719 RMB SD = 47462 RMB National Bureau of Statistics of China 2006)
Demographic variables for the sample are presented in Table 1
9
Procedure
Consent forms were distributed to all students in participating classes Consent
rates were greater than 95 in all the classes After consent forms were collected
researchers returned to the school to meet with participating students Written consent
was obtained from each participant at the beginning of the initial assessment During
the initial assessment students completed a demographics form and each of the
following questionnaires (1) Center for Epidemiological Studies Depression Scale
(CES-D Radloff 1977) (2) Mood and Anxiety Symptom Questionnaire (MASQ
Clark amp Watson 1991) (3) Dysfunctional Attitudes Scale (DAS Weissman amp Beck
1978) and (4) NEO Five Factor Inventory- Neuroticism Subscale (FFI-N Costa amp
McCrae 1992) Once a month for the subsequent six-months researchers returned to
the school and met with participating students to conduct follow-up assessments At
each of these follow-up assessments students were asked to complete each of the
following questionnaires (1) CES-D (2) MASQ and (3) the General Academic
Social Hassles Scale for Students (GASHSS Blankstein amp Flett 1993)
Measures
The Chinese versions of all self-report measures were developed using the
back-translation method Original English versions were translated into Chinese by a
bilingual translator from the Psychology department at Second Xiangya Medical
College of Central South University Hunan Translated Chinese versions were then
back-translated into English by another bilingual translator from the Psychology
department at McGill University Quebec Original versions were then compared with
the back-translation If inconsistencies were found in the back-translation translators
10
worked together to make corrections to the final Chinese versions until all final
versions were agreed upon No items from any of the measures were removed or
significantly altered during the translation process
Depressive Symptoms Center for Epidemiological Studies Depression Scale
(CES-D Radloff 1977) The CES-D is a 20-item self-report measure designed to
assess depressive symptoms in the general population For each item participants are
asked to indicate how often they experienced the particular symptom over the last
week Responses range from 1 (eg rarely or none of the time) to 4 (eg most or all of
the time) Scores range from 20-80 with higher score indicating higher levels of
depressive symptoms In the current study the CES-D exhibited high internal
consistency with Cronbachrsquos alpha values ranging from 90 to 94 (micro = 2918 SD =
814) over the 7 time points
Anxious Symptoms Mood and Anxiety Symptom Questionnaire (MASQ
Watson amp Clark 1991) The MASQ is a 62-item questionnaire designed to assess both
specific and nonspecific depressive and anxious symptoms For each item participants
are asked to rate on a scale of 1 to 5 the extent to which they have felt this way ldquoduring
the past 24 hoursrdquo Within the current study we utilized the anxious symptoms (11
items) and anxious arousal (17 items) subscales which together provide an index of
overall anxious symptoms Higher scores on each subscale reflect greater levels of
anxious symptoms In the current study the MASQ exhibited high internal consistency
with Cronbachrsquos alpha values ranging from 90 to 95 (micro = 3847 SD = 1117) over the
7 time points
11
Dysfunctional Attitudes Dysfunctional Attitudes Scale (DAS Weissman amp
Beck 1978) The DAS (Form A) is a 40-item questionnaire designed to measure the
cognitive vulnerability factor featured in Beckrsquos cognitive theory Examples of items
include ldquoIf I do not do well all the time people will not respect merdquo ldquoIf a person asks
for help it is a sign of weaknessrdquo and ldquoMy value as a person depends greatly on what
others think of merdquo Items are rated on a 7-point Likert scale ranging from 1 (totally
disagree) to 7 (totally agree) providing a range of scores from 40 to 280 with higher
scores reflecting more dysfunctional attitudes In the current study the DAS exhibited
high internal consistency with Cronbachrsquos alphas of 89 and 88 obtained for the first
and second administrations respectively In addition a test-retest reliability coefficient
of 72 was obtained indicating strong stability over time
Neuroticism NEO Five Factor Inventory - Neuroticism Subscale (FFI-N
Costa amp McCrae 1992) The FFI-N is a 12- item self-report measure that assesses
neuroticism Examples of questions include I often feel inferior to others I am
seldom sad or depressed and Sometimes I feel completely worthless Items are rated
on a 5-point Likert scale ranging from 0 (strongly disagree) to 4 (strongly agree)
providing scores ranging from 0 to 48 with higher scores indicating higher levels of
neuroticism The NEO-FFI-N has proven reliable across different cultural samples and
item pools (Costa amp McCrae 1992) In the current study Cronbachs alpha was 81
indicating strong internal consistency
Negative Life Events General Academic Social Hassles Scale for Students
(GASHSS Blankstein amp Flett 1993) Participants completed a 30-item abbreviated
version of the GASHSS The measure is comprised of items assessing general hassles
12
(8 items) academic hassles (10 items) and social hassles (12 items) For each item
participants are asked to rate how persistent the given hassle was (ie its frequency and
duration) over the last 30 days (0 = no hassle not at all persistent to 6 = extremely
persistent hassle high frequency andor duration)
13
RESULTS
Descriptive Data
Means standard deviations and inter-correlations between Time 1 measures are
presented in Table 2
Prospective Diathesis-Stress Analyses - Depression
Multilevel modeling was used to test our hypothesis that higher levels of dysfunctional
attitudes would be associated with greater increases in depressive symptoms following
increases in stress Analyses were carried out using the SAS (version 81) MIXED
procedure and maximum likelihood estimation Our dependent variable was within-
subject fluctuations in CES-D scores during the follow-up interval (DEPRESSION)
Our primary predictors of DEPRESSION were DAS scores (DYSFUNCTIONAL
ATTITUDES) and fluctuations in GASHSS scores during the follow-up interval
(STRESS) As DYSFUNCTIONAL ATTITUDES is a between-subject predictor DAS
scores were standardized prior to analyses As STRESS is a within-subject predictor
STRESS reflects upward or downward fluctuations in an individualrsquos level of stress
compared to hisher mean level of stress
When fitting hierarchical linear models one must specify appropriate mean and
covariance structures Mean structures refer to the various fixed and random effect
components that can be included in the model Covariance structures refer to alternative
methods of specifying the pattern of covariance between observations taken from the
same subject at different time points It is important to note that mean and covariance
structures are not independent of one another Rather an appropriate covariance
structure is essential in order to obtain valid inferences for the parameters in the mean
14
structure Overparametrization of the covariance structure can lead to inefficient
estimation and poor assessment of standard errors (Altham 1984) On the other hand
too much restriction of the covariance structure can lead to invalid inferences when the
assumed structure does not hold (Altham 1984)
In our first set of analyses we were interested in examining the effects of
DYSFUNCTIONAL ATTITUDES STRESS and the DYSFUNCTIONAL
ATTITUDES STRESS interaction on participantrsquos CES-D scores during the follow-
up interval Consequently in line with Diggle Liang and Zegers (1994)
recommendation that one use a ldquosaturatedrdquo model for the mean structure while
searching for an appropriate covariance structure we chose a mean structure that
included DYSFUNCTIONAL ATTITUDES STRESS and the DYSFUNCTIONAL
ATTITUDES STRESS interaction Four additional effects were also included in this
mean structure First as different individuals report different levels of depressive
symptoms when at their own average level of stress a random effect for intercept was
included in the model Second given that STRESS is a within-subject predictor whose
effect is expected to vary from participant to participant a random effect for slope was
included in the model Third in order to control for individual differences in baseline
levels of depressive symptoms Time 1 CES-D scores were included in the model
Fourth in order to examine whether DYSFUNCTIONAL ATTITUDES represent a
vulnerability factor independent of neuroticism participantsrsquo FFI-N scores were
entered in the model
Commonly used covariance structures in studies in which multiple responses
are obtained from the same individual over time (and consequently within-subject
15
residuals over time are likely to be correlated) include compound symmetry first-order
autoregressive heterogeneous autoregressive and banded Toeplitz In order to select
one of these covariance structures for our analyses we fitted models using each
structure and chose the ldquobestrdquo fit based on Akaike information criterion (AIC and
AICC) and Schwarz Bayesian criterion (BIC) In all cases the best fit for our data was
a first-order heterogeneous autoregressive structure (ARH [1]) After choosing the
appropriate covariance structure we next examined the random-effects component of
our model
With respect to random effects the ARH [1] parameter (r = 31 plt001)
RE_INTERCEPT (plt001) and RE_SLOPE (plt001) were each significant and thus
were retained in the model The final results with respect to the fixed-effects
component of the model are presented in the upper section of Table 3 Of primary
importance the DYSFUNCTIONAL ATTITUDES STRESS interaction was a
significant predictor of fluctuations in depressive symptoms during the follow-up
interval In order to examine the form of this interaction the model summarized in the
upper section of Table 3 was used to calculate predicted CES-D scores for individuals
exhibiting either high or low levels of dysfunctional attitudes (plus or minus 15 SD)
who are experiencing either high or low levels of stress in comparison to their own
average level of stress (plus or minus 15 times mean within-subject SD) The results of
such calculations are presented in the left panel of Figure 1
Analyses were conducted for each DYSFUNCTIONAL ATTITUDES
condition examining whether the slope of the relationship between stress and
depressive symptoms significantly differed from 0 Analyses indicated that both
16
individuals exhibiting high (t(2459) = 862 p lt 0001) and low (t(2459) = 347 p lt
0001) levels of dysfunctional attitudes reported significantly higher levels of
depressive symptoms when experiencing high levels of stress than when experiencing
low levels of stress Planned comparisons of the slopes of the relationship between
stress and depressive symptoms however revealed that the slope was significantly
greater in individuals exhibiting high levels of dysfunctional attitudes (slope = 013)
than in individuals exhibiting low levels of dysfunctional attitudes (slope = 005
t(2459) = 328 p = 0001)
Prospective Diathesis-Stress Analyses - Anxiety
The same data-analytic approach as described above was used to examine
whether higher levels of dysfunctional attitudes would be associated with greater
increases in anxious symptoms following increases in stress Again in order to examine
whether DYSFUNCTIONAL ATTITUDES represent a vulnerability factor
independent of neuroticism participantsrsquo FFI-N scores were entered in the model
With respect to random effects the ARH[1] parameter (r = 23 p lt 001)
RE_INTERCEPT (plt001) and RE_SLOPE (plt001) were each significant and thus
were retained in the model The final results with respect to the fixed-effects
component of the model are presented in the lower section of Table 3 Of primary
importance the DYSFUNCTIONAL ATTITUDES STRESS interaction was a
significant predictor of within-subject fluctuations in anxious symptoms during the
follow-up interval In order to examine the form of this interaction the model
summarized in the lower section of Table 3 was used to calculate predicted MASQ
scores for individuals exhibiting either high or low levels of dysfunctional attitudes
17
(plus or minus 15 SD) who are experiencing either high or low levels of stress in
comparison to their own average level of stress (plus or minus 15 times mean within-
subject SD) The results of such calculations are presented on the right panel of in
Figure 1
Analyses were conducted for each DYSFUNCTIONAL ATTITUDES
condition examining whether the slope of the relationship between stress and anxious
symptoms significantly differed from 0 Analyses indicated that both individuals
exhibiting high (t(2470) = 768 p lt 0001) and low (t(2470) = 337 p lt 0001) levels of
dysfunctional attitudes reported higher levels of anxious symptoms when experiencing
high levels of stress than when experiencing low levels of stress Planned comparisons
of the slopes of the relationship between stress and anxious symptoms however
revealed that the slope was significantly greater in individuals exhibiting high levels of
dysfunctional attitudes (slope = 009) than in individuals exhibiting low levels of
dysfunctional attitudes (slope = 003 t(2470) = 278 p lt 001)
Additional Analyses
Given that the DYSFUNCTIONAL ATTITUDES STRESS interaction
prospectively predicted both symptoms of depression and anxiety two additional
analyses were conducted in order to examine (1) whether the DYSFUNCTIONAL
ATTITUDES STRESS interaction continued to be a significant predictor of within-
subject fluctuations in depressive symptoms after controlling for within-subject
fluctuations in anxious symptoms and (2) whether the DYSFUNCTIONAL
ATTITUDES STRESS interaction continued to predict within-subject fluctuations in
anxious symptoms after controlling for within-subject fluctuations in depressive
18
symptoms Such analyses allowed us to examine whether the above mentioned pattern
of findings may have been due to the high correlation observed in the current study
between depressive and anxious symptoms
Analyses were conducted in the same manner as described above with the
exception that an additional within-subject variable (ie DEPRESSION or ANXIETY)
was included in each model in order to control for within-subject fluctuations in the
alternate symptom With respect to the prediction of depressive symptoms the
DYSFUNCTIONAL ATTITUDES STRESS interaction remained a significant
predictor after controlling for within-subject fluctuations in anxious symptoms (β =
001 SE = 000 F = 410 p lt 05) With respect to the prediction of anxious
symptoms however the DYSFUNCTIONAL ATTITUDES STRESS interaction
was no longer a significant predictor after controlling for within-subject fluctuations in
depressive symptoms (β = 001 SE = 000 F = 148 p = 22)
DISCUSSION
The results of the current study provide support for the cross-cultural
applicability of Beckrsquos (1967 1983) cognitive theory to university students in Hunan
China More specifically consistent with hypotheses and with results obtained from
past research examining Beckrsquos cognitive theory in Western samples of university
students (Hankin et al 2004 Hankin et al 2005 Joiner et al 1999 Klocek et al
1997 Brown et al 1995) higher levels of dysfunctional attitudes were associated with
greater increases in depressive symptoms following increases in negative event
frequency during the six-month follow-up interval Given the considerable differences
between the current sample and Western samples in terms of demographic
19
characteristics and cultural factors such a finding strongly attests to the robustness of
Beckrsquos cognitive theory Moreover integrating the current findings with those obtained
in research examining Beckrsquos theory in other non-Western samples suggests that
Beckrsquos theory may represent a powerful explanatory model of the development of
depressive symptoms among individuals from diverse cultural settings For example
consistent with the theory higher levels of dysfunctional attitudes have been shown to
be associated with higher levels of depressive symptoms in Japanese (Tanaka et al
2006) Puerto-Rican (Bonilla Bernal Santos amp Santos 2003) Turkish (Sahin amp Sahin
1992) Norwegian (Chioqueta amp Stiles 2004) Singaporean (Oei Goh amp Kwon 1996)
and Swedish (Ohrt amp Thorell 1998) adult samples In addition it is important to note
that the current findings expand upon past correlational research examining the
association between dysfunctional attitudes and depression in Chinese samples through
the use of a multi-wave longitudinal design
When examining the specificity of dysfunctional attitudes as a predictor of
depressive symptoms the current study did not obtain support for specificity More
specifically contrary to the specificity hypothesis of Beckrsquos cognitive theory and to
results obtained in Western samples of university students (Alloy et al 2000 2006
Hankin et al 2004) higher levels of dysfunctional attitudes were associated with
greater increases in both depressive and anxious symptoms following increases in
negative event frequency There are two alternative ways of interpreting the non-
specificity finding observed in the current study First it is possible that the types of
thoughts individuals possessing high levels of dysfunctional attitudes experience
following negative events varies as a function of cultural context In other words in
20
Western samples such individuals may primarily experience the types of cognitions
that are associated with the development of depressive symptoms (ie appraisals of
personal loss and failure) In contrast in Chinese samples individuals possessing high
levels of dysfunctional attitudes may experience a wider array of cognitions some of
which are associated with the development of depressive symptoms and some of which
are associated with the development of anxious symptoms (ie evaluations of
impending threat or danger) Such an explanation would be consistent with Beckrsquos
cognitive content-specificity hypothesis (Clark amp Beck 1999) which posits that each
affective state and psychological disorder has a specific cognitive profile Second it is
possible that the types of symptoms individuals possessing high levels of dysfunctional
attitudes experience following negative events varies as a function of cultural context
More specifically it may be that dysfunctional attitudes specifically predict symptoms
of depression in both samples except that in Western samples depression manifests in
pure depressive symptoms whereas in Chinese samples depression manifests as a
combination of depressive and anxious symptoms Such an explanation would be
consistent with cultural psychopathologistsrsquo hypotheses that cultural factors shape the
phenomenology of psychiatric symptoms (Kleinman 2004 Mezzich et al 1999)
Moreover dysfunctional attitudes predicting a combination of depressive and anxious
symptoms in Chinese samples would be consistent with the construct of neurasthenia -
a construct hypothesized by some to represent a somatized form of depression that is
still widely seen within China (Lee amp Wong 1995)
Interesting in this regard and perhaps speaking to the primacy of depressive
symptoms in the current findings analyses indicated that the DYSFUNCTIONAL
21
ATTITUDES times STRESS interaction no longer predicted anxious symptoms after
controlling for depressive symptoms The reverse however was not true as the
DYSFUNCTIONAL ATTITUDES times STRESS interaction continued to predict
depressive symptoms after controlling for anxious symptoms
It is important to note that the current study employed a particularly
conservative approach to analyses in that we examined the effects of dysfunctional
attitudes on depressive and anxious symptoms after controlling for the effect of
neuroticism on such symptoms Providing particularly powerful support for Beckrsquos
(1967 1983) cognitive theory across analyses dysfunctional attitudes predicted levels
of depressive andor anxious symptoms experienced during the six month follow-up
interval independent of the effect of neuroticism Thus contrary to past critical reviews
of the cognitive literature (Barnett amp Gotlib 1998 Coyne amp Whiffen 1995) and
consistent with past findings (Hankin et al 2007) the current results indicate that
cognitive vulnerabilities to depression such as dysfunctional attitudes are not reducible
to trait neuroticism but rather represent factors that confer independent risk for
depression
Limitations and Future Directions
Several limitations of the current study should be noted First self-report
measures were used to assess depressive and anxious symptoms Although the CES-D
and MASQ both possess high degrees of reliability and validity it is difficult to draw
conclusions about clinically diagnosed depression or anxiety based on self-report
questionnaires Second self-report measures were used to assess stress Although
measures of stress that require participants only to indicate whether or not an event
22
occurred are less likely to be influenced by informant bias than those that ask
participants to rate the subjective impact of each event more sophisticated methods of
analysis such as interviewing procedures that assess contextual threat may provide
better assessments of stress Third the measures of dysfunctional attitudes stress and
depressive and anxious symptoms used in the current study were each Western-
developed Future research should examine these hypotheses using indigenous
measures in addition to Western-developed measures in order to assess possible
similarities andor differences in patterns of findings Fourth the current study only
examined depression and anxiety as symptom outcomes Future research conducted
within China should examine a wider array of symptom outcomes such as
somatization physical complaints and externalizing behaviors in order to provide a
more thorough and culturally sensitive test of the specificity hypotheses of Beckrsquos
cognitive model Fifth the current study examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese undergraduate students and thus the extent to which
our findings may be generalized to other demographics within Chinarsquos population is
unclear Last the current study broadly examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese university students Future research should examine
the constructs and processes posited by this model in greater detail in order to develop a
deeper understanding of how they may be uniquely molded by socio-cultural factors
Such research would benefit from examining the specific types of stressors experienced
by Chinese university students as they may vary as a function of socio-cultural factors
from those experienced by Western undergraduates For example severe pressure to
succeed academically in order to secure access to a limited number of post-
23
undergraduate educational opportunities - one of the few paths towards upward
mobility available to Chinese students seeking secure and gainful employment in what
has increasingly become a very highly competitive job market - may represent a
particularly salient stressor for the development of depressive symptoms among this
population (Qiang 2006)
In conclusion the results from the current study provide support for the
applicability of Beckrsquos cognitive theory to university students in mainland China More
specifically consistent with findings obtained in the West results indicate that
dysfunctional attitudes confer vulnerability to the development of depressive symptoms
following the occurrence of negative events in Chinese university students At the same
time however the current findings suggest cultural variation in the profile of
symptoms which emerge following the occurrence of negative events in cognitively
vulnerable individuals in Western and Chinese samples Specifically whereas in the
West dysfunctional attitudes have been shown to confer vulnerability to depressive
symptoms in Chinese university students dysfunctional attitudes appear to confer
vulnerability to a combined depressive and anxious symptom profile Future research
using more sophisticated assessments of stress and depressive symptoms more diverse
samples and symptom outcome measures and indigenously-developed measures is
likely to enhance our understanding of the cognitive and environmental mechanisms
underlying the development of depression in Chinese university students Discovering
that cognitive theories of vulnerability to depression extend to university students in
China highlights the potential role for cognitive-behavioral depression prevention and
treatment interventions in stemming the tide of distress experienced by this population
24
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Abela J R Z amp Hankin B L (2008) Cognitive vulnerability to depression in
children and adolescents A developmental psychopathology perspective In J
R Z Abela and B L Hankin (Eds) Handbook of child and adolescent
depression (pp 35-78) New York The Guilford Press
Alloy L B Abramson L Y Hogan M E Whitehouse W G Rose D T
Robinson MS Kim R S amp Lapkin J B (2000) The Temple-Wisconsin
cognitive vulnerability to depression project Lifetime history of axis-I
psychopathology in individuals at high and low cognitive risk for depression
Journal of Abnormal Psychology 109 403-418
Alloy L B Abramson L Y Whitehouse W G Hogan M E Panzarella C amp
Rose D T (2006) Prospective incidence of first onsets and recurrences of
depression in individuals at high and low cognitive risk for depression Journal
of Abnormal Psychology 115 145ndash156
Altham P M E (1984) Improving the precision of estimation by fitting a model
Journal of the Royal Statistical Society Series B 46 11
Barnett PA amp Gotlib I H (1988) Psychosocial functioning and depression
Distinguishing among antecedents concomitants and consequences
Psychological Bulletin 104 97-126
Beck AT (1967) Depression Clinical experimental and theoretical aspects New
York Harper amp Row
Beck AT (1983) Cognitive therapy of depression New perspectives In PJ Clayton
amp JE Barrett (Eds) Treatment of depression Old controversies and new
approaches New York Raven Press
Bian Q Yang K amp Li C (2007) Dysfunctional attitudes of patients with depression
or bipolar disorder Chinese Mental Health Journal 21 759-761
Blankstein K R amp Flett G L (1993) Development of the General Academic and
Social Hassles Scales for Students Unpublished manuscript
Bonilla J Bernal G Santos A amp Santos D (2003) A revised Spanish version of
the Beck Depression InventoryPsychometric properties with a Puerto Rican
sample of college students Journal of Clinical Psychology 60 119-130
Brown G P Hammen C L Craske M G amp Wickens T D (1995) Dimensions of
dysfunctional attitudes as vulnerabilities to depressive symptoms Journal of
Abnormal Psychology 104 431-435
25
Chioqueta A P amp Stiles T C (2004) Psychometric properties of the Norweigian
version of the Dysfunctional Attitude Scale (Form A) Cognitive Behaviour
Therapy 33 83-86
Clark DA amp Beck AT (1999) Cognitive theory and therapy of depression New
York John Wiley amp Sons Inc
Clark L A amp Watson D (1991) Tripartite model of anxiety and depression
Psychometric evidence and taxonomic implications Journal of Abnormal
Psychology 100 316ndash336
Costa P T amp McCrae R R (1992) NEO PI-R Professional manual Revised NEO
personality inventory NEO PR-R and NEO five-factor inventory NEO-RRI
Odessa FL Psychological Assessment Resources
Coyne J C amp Whiffen V E (1995) Issues in personality as diathesis for depression
The case of sociotropy-dependency and autonomy-self-criticism Psychological
Bulletin 118 358-378
Fang X Qian M Luo S amp Zi F (2009) A correlational study on college students
perfectionism parental rearing patterns and mental health Chinese Mental
Health Journal 23 56-59
Hankin B L Abramson L Y Miller N amp Haeffel G (2004) Cognitive
vulnerability-stress theories of depression Examining affective specificity in
the prediction of depression versus anxiety in three prospective studies
Cognitive Therapy and Research 28 309ndash345
Hankin BL Fraley RC amp Abela JRZ (2005) Daily depression and cognitions
about stress Evidence for a traitlike depressogenic cognitive style and the
prediction of depressive symptoms in a prospective daily diary study Journal of
Personality and Social Psychology 88 673-685
Hankin B L Lakdawalla Z Carter I L Abela J R Z amp Adams P (2007) Are
neuroticism cognitive vulnerabilities and self-esteem overlapping or distinct
risks for depression Evidence from confirmatory factor analyses Journal of
Social amp Clinical Psychology 26 29-63
Hankin B L Wetter E Cheely C amp Oppenheimer C W (2008) Becks cognitive
theory of depression in adolescence Specific prediction of depressive
symptoms and reciprocal influences in a multi-wave prospective study
International Journal of Cognitive Therapy 1 313-332
Ingram R E Miranda J amp Segal Z V (1998) Cognitive Vulnerability to
Depression New York NY Guilford Press
26
Ingram R E amp Luxton DD (2005) Vulnerability-stress models In BL Hankin amp
JRZ Abela (Eds) Development of psychopathology A vulnerability-stress
perspective (pp 32-46) Thousand Oaks CA Sage
Joiner T E Metalsky G I Lew A amp Klocek J (1999) Testing the causal
mediation component of Becks theory of depression Evidence for specific
mediation Cognitive Therapy and Research 23 401-412
Kleinman A (2004) Culture and depression New England Journal of Medicine 351
951-953
Kleinman A (1977) Depression somatization and the new cross-cultural psychiatry
Social Science and Medicine 11 3-10
Kleinman A (1996) How is culture important for DSM-IV In J E Mezzich A
Kleinmam H Fabrega Jr amp L Delores (Eds)Culture and psychiatric
diagnosis A DSM-IV perspective (pp 15-25) Washington DC US American
Psychiatric Association
Klocek J W Oliver J M amp Ross M J (1997) The role of dysfunctional attitudes
negative life events and social support in the prediction of depressive
dysphoria A prospective longitudinal study Social Behavior and Personality
25 23-136
Lee S (1997) A Chinese perspective on somatoform disorders Journal of
Psychosomatic Disorders 43 115-119
Lee S (1998) Estranged bodies simulated harmony and misplaced cultures
Neurasthenia in contemporary Chinese society Psychosomatic Medicine 60
448ndash457
Lee S (1999) Diagnosis postponed Shenjing shuairo and the transformation of
psychiatry in post-Mao China Culture Medicine and Psychiatry 23 349ndash380
Lee S amp Wong K C (1995) Rethinking neurasthenia the illness concepts of
shenjing shuairuo among Chinese undergraduates in Honk Kong Culture
Medicine and Psychiatry 19 91ndash111
Lee S Tsang A Huang YQ He YL Liu ZR Zhang MY Shen YC amp
Kessler RC (2009) The epidemiology of depression in metropolitan China
Psychological Medicine 39 735-747
Mezzich J E Kirmayer L J Kleinman A Fabrega Jr H Parron D L Good B
J Lin K amp Manson S M (1999) The place of culture in DSM-IV Journal
of Nervous and Mental Disease 187 457-464
27
Monroe S M amp Simons A D (1991) Diathesisndashstress theories in the context of life
stress research Implications for the depressive disorders Psychological
Bulletin 110 406ndash425
Murray C J L amp Lopez A D (1996) The global burden of disease Cambridge
Harvard University Press
National Bureau of Statistics of China (2006) The China 2005 statistical yearbook
China Statistics Press Beijing PR China
Oei T P S Goh Y Kwon S M(1996) A cross-cultural study of the integrated
cognitive model of depression Current Psychology of Cognition 15 265-281
Ohrt T amp Thorell L (1998) Dysfunctional Attitude Scale (DAS) Psychometrics and
norms of the Swedish version Scandinavian Journal of Behaviour Therapy 27
105-113
Parker G Gladstone G Chee KT (2001) Depression in the planetrsquos largest ethnic
group The Chinese American Journal of Psychiatry 158 857-864
Phillips M R Zhang J Shi Q Song Z Ding Z Pang S Li X Zhang Y amp
Wang Z (2009) Prevalence treatment and associated disability of mental
disorders in four provinces in China during 2001ndash05 an epidemiological
survey The Lancet 373 2041-2053
Phillips M R Li X amp Zhang Y (2002) Suicide rates in China Lancet 359 835-
840
Phillips M R (1998) The transformation of Chinarsquos mental health services The China
Journal 39 1ndash36
Qiang G (2006) Depression number one killer of Ivory Tower students China Daily
Retrieved from httpwwwchinadailycomcnchina2006-
1128content_744880htm
Radloff L S (1977) The CESndashD scale A self-report depression scale for research in
the general population Applied Psychological Measurement 1 385ndash401
Rin H amp Huang M G (1989) Neurasthenia as nosological dilemma Culture
Medicine and Psychiatry 13 215-226
Sahin NH amp Sahin N (1992) How dysfunctional are the dysfunctional attitudes in
another culture British Journal of Medical Psychology 65 17-26
Shixie L (1989) Neurasthenia in China Modern and traditional criteria for its
diagnosis Culture Medicine and Psychiatry 13 163-186
28
Tanaka N Uji M Hiramura H Chen Z Shikai N amp Kitamura T (2006)
Cognitive patterns and depression Study of a Japanese university student
population Psychiatry and Clinical Neuroscience 60 358-364
Taylor R E (2001) Death of neurasthenia and its psychological reincarnation a study
of neurasthenia at the National Hospital for the Relief and Cure of the Paralysed
and Epileptic Queen Square London 1870ndash1932 British Journal of
Psychiatry 179 550ndash557
Weissman A N amp Beck A T (1978 April) Development and validation of the
Dysfunctional Attitudes Scale A preliminary investigation Paper presented at
the annual meeting of the Educational Research Association Toronto Canada
Xiang M Z (1986) Epidemiological study of neuroses in 12 regions (districts) of
China Chinese Journal of Neurology and Psychiatry 19 87-91
Xu JM (1987) Some issues in the diagnosis of depression in China Canadian
Journal of Psychiatry 32 368-370
Xu Y X (1994) About ICD-10 Journal of Clinical Psychology and Medicine 4 224-
226
Xu Z Li Z amp Wang Z (2007) Dysfunctional attitudes and cognitive bias in major
depressive disorder Chinese Mental Health Journal 21 488-491
Yan H Q (1989) The necessity of retaining the diagnostic concept of neurasthenia
Culture Medicine and Psychiatry 13 139-145
Yang H (2007) The Test of the Chinese version of Frost Multi-dimensional
Perfectionism Scale Chinese Mental Health Journal 21 97-100
Yang H amp Zhang X (2004) Perfectionism and mental health of college students
(2004) Chinese Mental Health Journal 18 647-648
Young D (1989) Neurasthenia and related problems Culture Medicine and
Psychiatry 13 131-138
Zhang D (1995) Depression and culture A Chinese perspective Canadian Journal of
Counseling 29 227ndash233
29
TABLE(S)
Table 1 Demographic Variables
Age 2011
Gender Male
Female
472
523
Parentsrsquo Marital Status Married
Divorced
Single
Remarried
938
23
18
20
Fatherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
Government Official
51
356
187
95
124
91
Motherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
122
406
144
76
134
Fatherrsquos Education Some Primary School
Primary School
Some High School
High School
University
29
139
222
403
137
Motherrsquos Education Some Primary School
Primary School
Some High School
High School
University
63
192
264
350
76
Only Child No
Yes
331
667
Monthly Income lt 1000 RMB
1000 ndash 1500 RMB
1500 ndash 2000 RMB
2000 ndash 3000 RMB
3000 ndash 4000 RMB
4000 ndash 5000 RMB
gt 5000 RMB
334
204
175
140
59
20
20
30
Table 2 Means Standard Deviations and Inter-correlations Between Time 1 Measures
__________________________________________________________________
1 2 3
__________________________________________________________________
1 Depressive Symptoms 2963 (780)
2 Anxious Symptoms 52 3753 (918)
3 Dysfunctional Attitudes 48 33 18120 (2304)
4 Neuroticism 63 42 53 3110 (712)
_________________________________________________________________________
Note Means and standard deviations (in parentheses) are on the diagonal Depressive
Symptoms = Center for Epidemiological Studies Depression Scale Anxious Symptoms
= Mood and Anxiety Symptom Questionnaire Overall Anxiety subscale Dysfunctional
Attitudes = Dysfunctional Attitudes Scale Neuroticism = NEO Five Factor Inventory
Neuroticism subscale p lt 01
31
Table 3 Dysfunctional Attitudes Predicting Within-Subject Fluctuations in CES-D
Scores (upper section) and MASQ Scores (lower section) during the Follow-Up
Interval
______________________________________________________________________
β SE F df
______________________________________________________________________
Time 1 CESD-D 297 026 12987 1572
Stress 005 000 10860 12459
Neuroticism 134 027 2518 1572
Dysfunctional Attitudes -055 040 -183 1572
Dysfunctional Attitudes times Stress 001 000 1078 12459
______________________________________________________________________
Time 1 MASQ 502 033 23158 1575
Stress 006 000 8963 12470
Neuroticism 080 033 596 1575
Dysfunctional Attitudes -052 051 -106 1575
Dysfunctional Attitudes times Stress 002 001 774 12470
______________________________________________________________________
Note Time 1 CES-D = Time 1 Center for Epidemiological Studies Depression Scale
Stress = Within-Subject Fluctuations in General Academic Social Hassles Scale for
Students (GASHSS) scores during the follow-up interval Neuroticism = NEO Five
Factor Inventory Neuroticism subscale Dysfunctional Attitudes = Dysfunctional
Attitudes Scale Time 1 MASQ = Time 1 Mood and Anxiety Symptom Questionnaire
Overall Anxiety subscale p lt 05 p lt 01 p lt 001
32
FIGURES
Figure 1 Predicted slope of the relationship between stress and depressive
symptoms (left panel) and anxious symptoms (right panel) as a function of
dysfunctional attitudes
20
25
30
Low High
Pre
dic
ted
CE
S-D
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
25
30
35
40
Low High
Pre
dic
ted
MA
SQ
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
Intercept Intercept
6
predict increases in depressive symptoms but not symptoms of anxiety or other
disorders in both university student (Hankin et al 2004) and adolescent samples
(Hankin et al 2008) Similarly although university students possessing a high level of
dysfunctional attitudes have been found to be more likely than other university students
to report a past history of depressive episodes (Alloy et al 2000) and to experience
future depressive episodes (Alloy et al 2006) they have not been found to differ from
their low-risk counterparts in terms of past history or future occurrence of other
psychological disorders (Alloy et al 2000 2006)
With respect to the current study it is possible that differences may emerge
between Chinese and Western samples in terms of the types of symptoms predicted by
dysfunctional attitudes More specifically cultural psychopathologists have proposed
that cultural factors shape the phenomenology of psychiatric symptoms as well as the
conceptualization and classification of disorders (Kleinman 2004 Mezzich et al
1999) As such the experience of psychopathology may exhibit unique features in
different cultures with diagnostic categories developed in one cultural context not being
valid in another (Kleinman 1977 1996) Neuresthenia known in China as shenjing
shuairuo (SJSR) is a diagnostic entity characterized by (1) physical and mental
weakness and fatigability (2) sleep disturbances (3) irritability and worry (4)
excitability (5) nervous pain and (6) memory difficulty (Taylor 2001) Historically
SJSR was a Western disease concept that subsequently evolved to become a widely
utilized diagnostic entity within China (Lee amp Wong 1995) Some cultural
psychopathologists have posited that SJSR represents a somatized form of depression
This claim however has been met with significant controversy (eg Lee 1997
7
Parker Gladstone amp Chee 2001 Xu JM 1987 Xu YX 1994 Zhang 1995)
Critics dispute the notion that Chinese psychiatric patients are ldquosomatizersrdquo who
manifest few or no emotional symptoms and who attribute distress to physical causes
Rather they argue that SJSR gained widespread acceptance in China as it was a non-
stigmatizing diagnosis that allowed individuals experiencing psychosocial distress to
seek help during a time in which traditional cultural beliefs and political influences led
to severe sanction and stigmatization of individuals suffering from mental illnesses
(Lee 1998 1999 Phillips 1998 Shixie 1989) At the same time other Chinese
researchers and clinicians have continued to defend neurasthenia as both a valid
diagnostic category and a clinically useful means of communicating with patients (Rin
amp Huang 1989 Yan 1989 Young 1989) Due to continued debate on this topic it is
essential that researchers examining models of vulnerability to depression within China
assess multiple symptom outcomes as the types of symptoms predicted by vulnerability
factors may vary as a function of cultural context Hence in the current study we also
assessed levels of anxious symptoms to provide a test of the specificity hypothesis of
Beckrsquos (1967 1983) cognitive theory
In order to provide a powerful examination of our hypotheses concerning (1) the
applicability of the diathesis-stress component of Beckrsquos (1967 1983) cognitive theory
to Chinese university students and (2) the specificity of dysfunctional attitudes as
predictors of depressive as opposed to anxious symptoms participantsrsquo scores on the
neuroticism subscale of the Five-factor Inventory (FFI-N) were included as a control
variable in all analyses Several critical reviews of the literature examining theories of
cognitive vulnerability to depression (eg Barnett amp Gotlib 1998 Coyne amp Whiffen
8
1995) have argued that cognitive vulnerabilities to depression such as that featured in
Beckrsquos cognitive theory may be equivalent to or reducible to trait neuroticism and thus
may not confer independent risk for depression In response to such claims a recent
study conducted with university students examining the degree of factorial
independence versus overlap between trait neuroticism and dysfunctional attitudes has
shown them to be distinct constructs each loading onto separate factors (Hankin et al
2007) At the same time however there remains a need to examine whether
dysfunctional attitudes and trait neuroticism represent unique risk factors for
depression particularly in young adults in China Hence in the current study
participantsrsquo scores on the neuroticism subscale of the Five-factor Inventory (FFI-N)
were included as a control variable in order to account for any of the variance in
fluctuations in depressive (and anxious) symptoms that may be shared between
dysfunctional attitudes and trait neuroticism thereby isolating and highlighting their
unique predictive effects
METHOD
Participants
Participants included 662 university students (aged 19-21) from Changsha ndash an
industrial city in the province of Hunan with a population of approximately 6000000
In terms of the annual gross domestic product Hunan ranks 23rd
(10336 RMB) out of
the 34 provinces in China placing it well below the national provincial average (micro =
29719 RMB SD = 47462 RMB National Bureau of Statistics of China 2006)
Demographic variables for the sample are presented in Table 1
9
Procedure
Consent forms were distributed to all students in participating classes Consent
rates were greater than 95 in all the classes After consent forms were collected
researchers returned to the school to meet with participating students Written consent
was obtained from each participant at the beginning of the initial assessment During
the initial assessment students completed a demographics form and each of the
following questionnaires (1) Center for Epidemiological Studies Depression Scale
(CES-D Radloff 1977) (2) Mood and Anxiety Symptom Questionnaire (MASQ
Clark amp Watson 1991) (3) Dysfunctional Attitudes Scale (DAS Weissman amp Beck
1978) and (4) NEO Five Factor Inventory- Neuroticism Subscale (FFI-N Costa amp
McCrae 1992) Once a month for the subsequent six-months researchers returned to
the school and met with participating students to conduct follow-up assessments At
each of these follow-up assessments students were asked to complete each of the
following questionnaires (1) CES-D (2) MASQ and (3) the General Academic
Social Hassles Scale for Students (GASHSS Blankstein amp Flett 1993)
Measures
The Chinese versions of all self-report measures were developed using the
back-translation method Original English versions were translated into Chinese by a
bilingual translator from the Psychology department at Second Xiangya Medical
College of Central South University Hunan Translated Chinese versions were then
back-translated into English by another bilingual translator from the Psychology
department at McGill University Quebec Original versions were then compared with
the back-translation If inconsistencies were found in the back-translation translators
10
worked together to make corrections to the final Chinese versions until all final
versions were agreed upon No items from any of the measures were removed or
significantly altered during the translation process
Depressive Symptoms Center for Epidemiological Studies Depression Scale
(CES-D Radloff 1977) The CES-D is a 20-item self-report measure designed to
assess depressive symptoms in the general population For each item participants are
asked to indicate how often they experienced the particular symptom over the last
week Responses range from 1 (eg rarely or none of the time) to 4 (eg most or all of
the time) Scores range from 20-80 with higher score indicating higher levels of
depressive symptoms In the current study the CES-D exhibited high internal
consistency with Cronbachrsquos alpha values ranging from 90 to 94 (micro = 2918 SD =
814) over the 7 time points
Anxious Symptoms Mood and Anxiety Symptom Questionnaire (MASQ
Watson amp Clark 1991) The MASQ is a 62-item questionnaire designed to assess both
specific and nonspecific depressive and anxious symptoms For each item participants
are asked to rate on a scale of 1 to 5 the extent to which they have felt this way ldquoduring
the past 24 hoursrdquo Within the current study we utilized the anxious symptoms (11
items) and anxious arousal (17 items) subscales which together provide an index of
overall anxious symptoms Higher scores on each subscale reflect greater levels of
anxious symptoms In the current study the MASQ exhibited high internal consistency
with Cronbachrsquos alpha values ranging from 90 to 95 (micro = 3847 SD = 1117) over the
7 time points
11
Dysfunctional Attitudes Dysfunctional Attitudes Scale (DAS Weissman amp
Beck 1978) The DAS (Form A) is a 40-item questionnaire designed to measure the
cognitive vulnerability factor featured in Beckrsquos cognitive theory Examples of items
include ldquoIf I do not do well all the time people will not respect merdquo ldquoIf a person asks
for help it is a sign of weaknessrdquo and ldquoMy value as a person depends greatly on what
others think of merdquo Items are rated on a 7-point Likert scale ranging from 1 (totally
disagree) to 7 (totally agree) providing a range of scores from 40 to 280 with higher
scores reflecting more dysfunctional attitudes In the current study the DAS exhibited
high internal consistency with Cronbachrsquos alphas of 89 and 88 obtained for the first
and second administrations respectively In addition a test-retest reliability coefficient
of 72 was obtained indicating strong stability over time
Neuroticism NEO Five Factor Inventory - Neuroticism Subscale (FFI-N
Costa amp McCrae 1992) The FFI-N is a 12- item self-report measure that assesses
neuroticism Examples of questions include I often feel inferior to others I am
seldom sad or depressed and Sometimes I feel completely worthless Items are rated
on a 5-point Likert scale ranging from 0 (strongly disagree) to 4 (strongly agree)
providing scores ranging from 0 to 48 with higher scores indicating higher levels of
neuroticism The NEO-FFI-N has proven reliable across different cultural samples and
item pools (Costa amp McCrae 1992) In the current study Cronbachs alpha was 81
indicating strong internal consistency
Negative Life Events General Academic Social Hassles Scale for Students
(GASHSS Blankstein amp Flett 1993) Participants completed a 30-item abbreviated
version of the GASHSS The measure is comprised of items assessing general hassles
12
(8 items) academic hassles (10 items) and social hassles (12 items) For each item
participants are asked to rate how persistent the given hassle was (ie its frequency and
duration) over the last 30 days (0 = no hassle not at all persistent to 6 = extremely
persistent hassle high frequency andor duration)
13
RESULTS
Descriptive Data
Means standard deviations and inter-correlations between Time 1 measures are
presented in Table 2
Prospective Diathesis-Stress Analyses - Depression
Multilevel modeling was used to test our hypothesis that higher levels of dysfunctional
attitudes would be associated with greater increases in depressive symptoms following
increases in stress Analyses were carried out using the SAS (version 81) MIXED
procedure and maximum likelihood estimation Our dependent variable was within-
subject fluctuations in CES-D scores during the follow-up interval (DEPRESSION)
Our primary predictors of DEPRESSION were DAS scores (DYSFUNCTIONAL
ATTITUDES) and fluctuations in GASHSS scores during the follow-up interval
(STRESS) As DYSFUNCTIONAL ATTITUDES is a between-subject predictor DAS
scores were standardized prior to analyses As STRESS is a within-subject predictor
STRESS reflects upward or downward fluctuations in an individualrsquos level of stress
compared to hisher mean level of stress
When fitting hierarchical linear models one must specify appropriate mean and
covariance structures Mean structures refer to the various fixed and random effect
components that can be included in the model Covariance structures refer to alternative
methods of specifying the pattern of covariance between observations taken from the
same subject at different time points It is important to note that mean and covariance
structures are not independent of one another Rather an appropriate covariance
structure is essential in order to obtain valid inferences for the parameters in the mean
14
structure Overparametrization of the covariance structure can lead to inefficient
estimation and poor assessment of standard errors (Altham 1984) On the other hand
too much restriction of the covariance structure can lead to invalid inferences when the
assumed structure does not hold (Altham 1984)
In our first set of analyses we were interested in examining the effects of
DYSFUNCTIONAL ATTITUDES STRESS and the DYSFUNCTIONAL
ATTITUDES STRESS interaction on participantrsquos CES-D scores during the follow-
up interval Consequently in line with Diggle Liang and Zegers (1994)
recommendation that one use a ldquosaturatedrdquo model for the mean structure while
searching for an appropriate covariance structure we chose a mean structure that
included DYSFUNCTIONAL ATTITUDES STRESS and the DYSFUNCTIONAL
ATTITUDES STRESS interaction Four additional effects were also included in this
mean structure First as different individuals report different levels of depressive
symptoms when at their own average level of stress a random effect for intercept was
included in the model Second given that STRESS is a within-subject predictor whose
effect is expected to vary from participant to participant a random effect for slope was
included in the model Third in order to control for individual differences in baseline
levels of depressive symptoms Time 1 CES-D scores were included in the model
Fourth in order to examine whether DYSFUNCTIONAL ATTITUDES represent a
vulnerability factor independent of neuroticism participantsrsquo FFI-N scores were
entered in the model
Commonly used covariance structures in studies in which multiple responses
are obtained from the same individual over time (and consequently within-subject
15
residuals over time are likely to be correlated) include compound symmetry first-order
autoregressive heterogeneous autoregressive and banded Toeplitz In order to select
one of these covariance structures for our analyses we fitted models using each
structure and chose the ldquobestrdquo fit based on Akaike information criterion (AIC and
AICC) and Schwarz Bayesian criterion (BIC) In all cases the best fit for our data was
a first-order heterogeneous autoregressive structure (ARH [1]) After choosing the
appropriate covariance structure we next examined the random-effects component of
our model
With respect to random effects the ARH [1] parameter (r = 31 plt001)
RE_INTERCEPT (plt001) and RE_SLOPE (plt001) were each significant and thus
were retained in the model The final results with respect to the fixed-effects
component of the model are presented in the upper section of Table 3 Of primary
importance the DYSFUNCTIONAL ATTITUDES STRESS interaction was a
significant predictor of fluctuations in depressive symptoms during the follow-up
interval In order to examine the form of this interaction the model summarized in the
upper section of Table 3 was used to calculate predicted CES-D scores for individuals
exhibiting either high or low levels of dysfunctional attitudes (plus or minus 15 SD)
who are experiencing either high or low levels of stress in comparison to their own
average level of stress (plus or minus 15 times mean within-subject SD) The results of
such calculations are presented in the left panel of Figure 1
Analyses were conducted for each DYSFUNCTIONAL ATTITUDES
condition examining whether the slope of the relationship between stress and
depressive symptoms significantly differed from 0 Analyses indicated that both
16
individuals exhibiting high (t(2459) = 862 p lt 0001) and low (t(2459) = 347 p lt
0001) levels of dysfunctional attitudes reported significantly higher levels of
depressive symptoms when experiencing high levels of stress than when experiencing
low levels of stress Planned comparisons of the slopes of the relationship between
stress and depressive symptoms however revealed that the slope was significantly
greater in individuals exhibiting high levels of dysfunctional attitudes (slope = 013)
than in individuals exhibiting low levels of dysfunctional attitudes (slope = 005
t(2459) = 328 p = 0001)
Prospective Diathesis-Stress Analyses - Anxiety
The same data-analytic approach as described above was used to examine
whether higher levels of dysfunctional attitudes would be associated with greater
increases in anxious symptoms following increases in stress Again in order to examine
whether DYSFUNCTIONAL ATTITUDES represent a vulnerability factor
independent of neuroticism participantsrsquo FFI-N scores were entered in the model
With respect to random effects the ARH[1] parameter (r = 23 p lt 001)
RE_INTERCEPT (plt001) and RE_SLOPE (plt001) were each significant and thus
were retained in the model The final results with respect to the fixed-effects
component of the model are presented in the lower section of Table 3 Of primary
importance the DYSFUNCTIONAL ATTITUDES STRESS interaction was a
significant predictor of within-subject fluctuations in anxious symptoms during the
follow-up interval In order to examine the form of this interaction the model
summarized in the lower section of Table 3 was used to calculate predicted MASQ
scores for individuals exhibiting either high or low levels of dysfunctional attitudes
17
(plus or minus 15 SD) who are experiencing either high or low levels of stress in
comparison to their own average level of stress (plus or minus 15 times mean within-
subject SD) The results of such calculations are presented on the right panel of in
Figure 1
Analyses were conducted for each DYSFUNCTIONAL ATTITUDES
condition examining whether the slope of the relationship between stress and anxious
symptoms significantly differed from 0 Analyses indicated that both individuals
exhibiting high (t(2470) = 768 p lt 0001) and low (t(2470) = 337 p lt 0001) levels of
dysfunctional attitudes reported higher levels of anxious symptoms when experiencing
high levels of stress than when experiencing low levels of stress Planned comparisons
of the slopes of the relationship between stress and anxious symptoms however
revealed that the slope was significantly greater in individuals exhibiting high levels of
dysfunctional attitudes (slope = 009) than in individuals exhibiting low levels of
dysfunctional attitudes (slope = 003 t(2470) = 278 p lt 001)
Additional Analyses
Given that the DYSFUNCTIONAL ATTITUDES STRESS interaction
prospectively predicted both symptoms of depression and anxiety two additional
analyses were conducted in order to examine (1) whether the DYSFUNCTIONAL
ATTITUDES STRESS interaction continued to be a significant predictor of within-
subject fluctuations in depressive symptoms after controlling for within-subject
fluctuations in anxious symptoms and (2) whether the DYSFUNCTIONAL
ATTITUDES STRESS interaction continued to predict within-subject fluctuations in
anxious symptoms after controlling for within-subject fluctuations in depressive
18
symptoms Such analyses allowed us to examine whether the above mentioned pattern
of findings may have been due to the high correlation observed in the current study
between depressive and anxious symptoms
Analyses were conducted in the same manner as described above with the
exception that an additional within-subject variable (ie DEPRESSION or ANXIETY)
was included in each model in order to control for within-subject fluctuations in the
alternate symptom With respect to the prediction of depressive symptoms the
DYSFUNCTIONAL ATTITUDES STRESS interaction remained a significant
predictor after controlling for within-subject fluctuations in anxious symptoms (β =
001 SE = 000 F = 410 p lt 05) With respect to the prediction of anxious
symptoms however the DYSFUNCTIONAL ATTITUDES STRESS interaction
was no longer a significant predictor after controlling for within-subject fluctuations in
depressive symptoms (β = 001 SE = 000 F = 148 p = 22)
DISCUSSION
The results of the current study provide support for the cross-cultural
applicability of Beckrsquos (1967 1983) cognitive theory to university students in Hunan
China More specifically consistent with hypotheses and with results obtained from
past research examining Beckrsquos cognitive theory in Western samples of university
students (Hankin et al 2004 Hankin et al 2005 Joiner et al 1999 Klocek et al
1997 Brown et al 1995) higher levels of dysfunctional attitudes were associated with
greater increases in depressive symptoms following increases in negative event
frequency during the six-month follow-up interval Given the considerable differences
between the current sample and Western samples in terms of demographic
19
characteristics and cultural factors such a finding strongly attests to the robustness of
Beckrsquos cognitive theory Moreover integrating the current findings with those obtained
in research examining Beckrsquos theory in other non-Western samples suggests that
Beckrsquos theory may represent a powerful explanatory model of the development of
depressive symptoms among individuals from diverse cultural settings For example
consistent with the theory higher levels of dysfunctional attitudes have been shown to
be associated with higher levels of depressive symptoms in Japanese (Tanaka et al
2006) Puerto-Rican (Bonilla Bernal Santos amp Santos 2003) Turkish (Sahin amp Sahin
1992) Norwegian (Chioqueta amp Stiles 2004) Singaporean (Oei Goh amp Kwon 1996)
and Swedish (Ohrt amp Thorell 1998) adult samples In addition it is important to note
that the current findings expand upon past correlational research examining the
association between dysfunctional attitudes and depression in Chinese samples through
the use of a multi-wave longitudinal design
When examining the specificity of dysfunctional attitudes as a predictor of
depressive symptoms the current study did not obtain support for specificity More
specifically contrary to the specificity hypothesis of Beckrsquos cognitive theory and to
results obtained in Western samples of university students (Alloy et al 2000 2006
Hankin et al 2004) higher levels of dysfunctional attitudes were associated with
greater increases in both depressive and anxious symptoms following increases in
negative event frequency There are two alternative ways of interpreting the non-
specificity finding observed in the current study First it is possible that the types of
thoughts individuals possessing high levels of dysfunctional attitudes experience
following negative events varies as a function of cultural context In other words in
20
Western samples such individuals may primarily experience the types of cognitions
that are associated with the development of depressive symptoms (ie appraisals of
personal loss and failure) In contrast in Chinese samples individuals possessing high
levels of dysfunctional attitudes may experience a wider array of cognitions some of
which are associated with the development of depressive symptoms and some of which
are associated with the development of anxious symptoms (ie evaluations of
impending threat or danger) Such an explanation would be consistent with Beckrsquos
cognitive content-specificity hypothesis (Clark amp Beck 1999) which posits that each
affective state and psychological disorder has a specific cognitive profile Second it is
possible that the types of symptoms individuals possessing high levels of dysfunctional
attitudes experience following negative events varies as a function of cultural context
More specifically it may be that dysfunctional attitudes specifically predict symptoms
of depression in both samples except that in Western samples depression manifests in
pure depressive symptoms whereas in Chinese samples depression manifests as a
combination of depressive and anxious symptoms Such an explanation would be
consistent with cultural psychopathologistsrsquo hypotheses that cultural factors shape the
phenomenology of psychiatric symptoms (Kleinman 2004 Mezzich et al 1999)
Moreover dysfunctional attitudes predicting a combination of depressive and anxious
symptoms in Chinese samples would be consistent with the construct of neurasthenia -
a construct hypothesized by some to represent a somatized form of depression that is
still widely seen within China (Lee amp Wong 1995)
Interesting in this regard and perhaps speaking to the primacy of depressive
symptoms in the current findings analyses indicated that the DYSFUNCTIONAL
21
ATTITUDES times STRESS interaction no longer predicted anxious symptoms after
controlling for depressive symptoms The reverse however was not true as the
DYSFUNCTIONAL ATTITUDES times STRESS interaction continued to predict
depressive symptoms after controlling for anxious symptoms
It is important to note that the current study employed a particularly
conservative approach to analyses in that we examined the effects of dysfunctional
attitudes on depressive and anxious symptoms after controlling for the effect of
neuroticism on such symptoms Providing particularly powerful support for Beckrsquos
(1967 1983) cognitive theory across analyses dysfunctional attitudes predicted levels
of depressive andor anxious symptoms experienced during the six month follow-up
interval independent of the effect of neuroticism Thus contrary to past critical reviews
of the cognitive literature (Barnett amp Gotlib 1998 Coyne amp Whiffen 1995) and
consistent with past findings (Hankin et al 2007) the current results indicate that
cognitive vulnerabilities to depression such as dysfunctional attitudes are not reducible
to trait neuroticism but rather represent factors that confer independent risk for
depression
Limitations and Future Directions
Several limitations of the current study should be noted First self-report
measures were used to assess depressive and anxious symptoms Although the CES-D
and MASQ both possess high degrees of reliability and validity it is difficult to draw
conclusions about clinically diagnosed depression or anxiety based on self-report
questionnaires Second self-report measures were used to assess stress Although
measures of stress that require participants only to indicate whether or not an event
22
occurred are less likely to be influenced by informant bias than those that ask
participants to rate the subjective impact of each event more sophisticated methods of
analysis such as interviewing procedures that assess contextual threat may provide
better assessments of stress Third the measures of dysfunctional attitudes stress and
depressive and anxious symptoms used in the current study were each Western-
developed Future research should examine these hypotheses using indigenous
measures in addition to Western-developed measures in order to assess possible
similarities andor differences in patterns of findings Fourth the current study only
examined depression and anxiety as symptom outcomes Future research conducted
within China should examine a wider array of symptom outcomes such as
somatization physical complaints and externalizing behaviors in order to provide a
more thorough and culturally sensitive test of the specificity hypotheses of Beckrsquos
cognitive model Fifth the current study examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese undergraduate students and thus the extent to which
our findings may be generalized to other demographics within Chinarsquos population is
unclear Last the current study broadly examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese university students Future research should examine
the constructs and processes posited by this model in greater detail in order to develop a
deeper understanding of how they may be uniquely molded by socio-cultural factors
Such research would benefit from examining the specific types of stressors experienced
by Chinese university students as they may vary as a function of socio-cultural factors
from those experienced by Western undergraduates For example severe pressure to
succeed academically in order to secure access to a limited number of post-
23
undergraduate educational opportunities - one of the few paths towards upward
mobility available to Chinese students seeking secure and gainful employment in what
has increasingly become a very highly competitive job market - may represent a
particularly salient stressor for the development of depressive symptoms among this
population (Qiang 2006)
In conclusion the results from the current study provide support for the
applicability of Beckrsquos cognitive theory to university students in mainland China More
specifically consistent with findings obtained in the West results indicate that
dysfunctional attitudes confer vulnerability to the development of depressive symptoms
following the occurrence of negative events in Chinese university students At the same
time however the current findings suggest cultural variation in the profile of
symptoms which emerge following the occurrence of negative events in cognitively
vulnerable individuals in Western and Chinese samples Specifically whereas in the
West dysfunctional attitudes have been shown to confer vulnerability to depressive
symptoms in Chinese university students dysfunctional attitudes appear to confer
vulnerability to a combined depressive and anxious symptom profile Future research
using more sophisticated assessments of stress and depressive symptoms more diverse
samples and symptom outcome measures and indigenously-developed measures is
likely to enhance our understanding of the cognitive and environmental mechanisms
underlying the development of depression in Chinese university students Discovering
that cognitive theories of vulnerability to depression extend to university students in
China highlights the potential role for cognitive-behavioral depression prevention and
treatment interventions in stemming the tide of distress experienced by this population
24
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children and adolescents A developmental psychopathology perspective In J
R Z Abela and B L Hankin (Eds) Handbook of child and adolescent
depression (pp 35-78) New York The Guilford Press
Alloy L B Abramson L Y Hogan M E Whitehouse W G Rose D T
Robinson MS Kim R S amp Lapkin J B (2000) The Temple-Wisconsin
cognitive vulnerability to depression project Lifetime history of axis-I
psychopathology in individuals at high and low cognitive risk for depression
Journal of Abnormal Psychology 109 403-418
Alloy L B Abramson L Y Whitehouse W G Hogan M E Panzarella C amp
Rose D T (2006) Prospective incidence of first onsets and recurrences of
depression in individuals at high and low cognitive risk for depression Journal
of Abnormal Psychology 115 145ndash156
Altham P M E (1984) Improving the precision of estimation by fitting a model
Journal of the Royal Statistical Society Series B 46 11
Barnett PA amp Gotlib I H (1988) Psychosocial functioning and depression
Distinguishing among antecedents concomitants and consequences
Psychological Bulletin 104 97-126
Beck AT (1967) Depression Clinical experimental and theoretical aspects New
York Harper amp Row
Beck AT (1983) Cognitive therapy of depression New perspectives In PJ Clayton
amp JE Barrett (Eds) Treatment of depression Old controversies and new
approaches New York Raven Press
Bian Q Yang K amp Li C (2007) Dysfunctional attitudes of patients with depression
or bipolar disorder Chinese Mental Health Journal 21 759-761
Blankstein K R amp Flett G L (1993) Development of the General Academic and
Social Hassles Scales for Students Unpublished manuscript
Bonilla J Bernal G Santos A amp Santos D (2003) A revised Spanish version of
the Beck Depression InventoryPsychometric properties with a Puerto Rican
sample of college students Journal of Clinical Psychology 60 119-130
Brown G P Hammen C L Craske M G amp Wickens T D (1995) Dimensions of
dysfunctional attitudes as vulnerabilities to depressive symptoms Journal of
Abnormal Psychology 104 431-435
25
Chioqueta A P amp Stiles T C (2004) Psychometric properties of the Norweigian
version of the Dysfunctional Attitude Scale (Form A) Cognitive Behaviour
Therapy 33 83-86
Clark DA amp Beck AT (1999) Cognitive theory and therapy of depression New
York John Wiley amp Sons Inc
Clark L A amp Watson D (1991) Tripartite model of anxiety and depression
Psychometric evidence and taxonomic implications Journal of Abnormal
Psychology 100 316ndash336
Costa P T amp McCrae R R (1992) NEO PI-R Professional manual Revised NEO
personality inventory NEO PR-R and NEO five-factor inventory NEO-RRI
Odessa FL Psychological Assessment Resources
Coyne J C amp Whiffen V E (1995) Issues in personality as diathesis for depression
The case of sociotropy-dependency and autonomy-self-criticism Psychological
Bulletin 118 358-378
Fang X Qian M Luo S amp Zi F (2009) A correlational study on college students
perfectionism parental rearing patterns and mental health Chinese Mental
Health Journal 23 56-59
Hankin B L Abramson L Y Miller N amp Haeffel G (2004) Cognitive
vulnerability-stress theories of depression Examining affective specificity in
the prediction of depression versus anxiety in three prospective studies
Cognitive Therapy and Research 28 309ndash345
Hankin BL Fraley RC amp Abela JRZ (2005) Daily depression and cognitions
about stress Evidence for a traitlike depressogenic cognitive style and the
prediction of depressive symptoms in a prospective daily diary study Journal of
Personality and Social Psychology 88 673-685
Hankin B L Lakdawalla Z Carter I L Abela J R Z amp Adams P (2007) Are
neuroticism cognitive vulnerabilities and self-esteem overlapping or distinct
risks for depression Evidence from confirmatory factor analyses Journal of
Social amp Clinical Psychology 26 29-63
Hankin B L Wetter E Cheely C amp Oppenheimer C W (2008) Becks cognitive
theory of depression in adolescence Specific prediction of depressive
symptoms and reciprocal influences in a multi-wave prospective study
International Journal of Cognitive Therapy 1 313-332
Ingram R E Miranda J amp Segal Z V (1998) Cognitive Vulnerability to
Depression New York NY Guilford Press
26
Ingram R E amp Luxton DD (2005) Vulnerability-stress models In BL Hankin amp
JRZ Abela (Eds) Development of psychopathology A vulnerability-stress
perspective (pp 32-46) Thousand Oaks CA Sage
Joiner T E Metalsky G I Lew A amp Klocek J (1999) Testing the causal
mediation component of Becks theory of depression Evidence for specific
mediation Cognitive Therapy and Research 23 401-412
Kleinman A (2004) Culture and depression New England Journal of Medicine 351
951-953
Kleinman A (1977) Depression somatization and the new cross-cultural psychiatry
Social Science and Medicine 11 3-10
Kleinman A (1996) How is culture important for DSM-IV In J E Mezzich A
Kleinmam H Fabrega Jr amp L Delores (Eds)Culture and psychiatric
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Psychiatric Association
Klocek J W Oliver J M amp Ross M J (1997) The role of dysfunctional attitudes
negative life events and social support in the prediction of depressive
dysphoria A prospective longitudinal study Social Behavior and Personality
25 23-136
Lee S (1997) A Chinese perspective on somatoform disorders Journal of
Psychosomatic Disorders 43 115-119
Lee S (1998) Estranged bodies simulated harmony and misplaced cultures
Neurasthenia in contemporary Chinese society Psychosomatic Medicine 60
448ndash457
Lee S (1999) Diagnosis postponed Shenjing shuairo and the transformation of
psychiatry in post-Mao China Culture Medicine and Psychiatry 23 349ndash380
Lee S amp Wong K C (1995) Rethinking neurasthenia the illness concepts of
shenjing shuairuo among Chinese undergraduates in Honk Kong Culture
Medicine and Psychiatry 19 91ndash111
Lee S Tsang A Huang YQ He YL Liu ZR Zhang MY Shen YC amp
Kessler RC (2009) The epidemiology of depression in metropolitan China
Psychological Medicine 39 735-747
Mezzich J E Kirmayer L J Kleinman A Fabrega Jr H Parron D L Good B
J Lin K amp Manson S M (1999) The place of culture in DSM-IV Journal
of Nervous and Mental Disease 187 457-464
27
Monroe S M amp Simons A D (1991) Diathesisndashstress theories in the context of life
stress research Implications for the depressive disorders Psychological
Bulletin 110 406ndash425
Murray C J L amp Lopez A D (1996) The global burden of disease Cambridge
Harvard University Press
National Bureau of Statistics of China (2006) The China 2005 statistical yearbook
China Statistics Press Beijing PR China
Oei T P S Goh Y Kwon S M(1996) A cross-cultural study of the integrated
cognitive model of depression Current Psychology of Cognition 15 265-281
Ohrt T amp Thorell L (1998) Dysfunctional Attitude Scale (DAS) Psychometrics and
norms of the Swedish version Scandinavian Journal of Behaviour Therapy 27
105-113
Parker G Gladstone G Chee KT (2001) Depression in the planetrsquos largest ethnic
group The Chinese American Journal of Psychiatry 158 857-864
Phillips M R Zhang J Shi Q Song Z Ding Z Pang S Li X Zhang Y amp
Wang Z (2009) Prevalence treatment and associated disability of mental
disorders in four provinces in China during 2001ndash05 an epidemiological
survey The Lancet 373 2041-2053
Phillips M R Li X amp Zhang Y (2002) Suicide rates in China Lancet 359 835-
840
Phillips M R (1998) The transformation of Chinarsquos mental health services The China
Journal 39 1ndash36
Qiang G (2006) Depression number one killer of Ivory Tower students China Daily
Retrieved from httpwwwchinadailycomcnchina2006-
1128content_744880htm
Radloff L S (1977) The CESndashD scale A self-report depression scale for research in
the general population Applied Psychological Measurement 1 385ndash401
Rin H amp Huang M G (1989) Neurasthenia as nosological dilemma Culture
Medicine and Psychiatry 13 215-226
Sahin NH amp Sahin N (1992) How dysfunctional are the dysfunctional attitudes in
another culture British Journal of Medical Psychology 65 17-26
Shixie L (1989) Neurasthenia in China Modern and traditional criteria for its
diagnosis Culture Medicine and Psychiatry 13 163-186
28
Tanaka N Uji M Hiramura H Chen Z Shikai N amp Kitamura T (2006)
Cognitive patterns and depression Study of a Japanese university student
population Psychiatry and Clinical Neuroscience 60 358-364
Taylor R E (2001) Death of neurasthenia and its psychological reincarnation a study
of neurasthenia at the National Hospital for the Relief and Cure of the Paralysed
and Epileptic Queen Square London 1870ndash1932 British Journal of
Psychiatry 179 550ndash557
Weissman A N amp Beck A T (1978 April) Development and validation of the
Dysfunctional Attitudes Scale A preliminary investigation Paper presented at
the annual meeting of the Educational Research Association Toronto Canada
Xiang M Z (1986) Epidemiological study of neuroses in 12 regions (districts) of
China Chinese Journal of Neurology and Psychiatry 19 87-91
Xu JM (1987) Some issues in the diagnosis of depression in China Canadian
Journal of Psychiatry 32 368-370
Xu Y X (1994) About ICD-10 Journal of Clinical Psychology and Medicine 4 224-
226
Xu Z Li Z amp Wang Z (2007) Dysfunctional attitudes and cognitive bias in major
depressive disorder Chinese Mental Health Journal 21 488-491
Yan H Q (1989) The necessity of retaining the diagnostic concept of neurasthenia
Culture Medicine and Psychiatry 13 139-145
Yang H (2007) The Test of the Chinese version of Frost Multi-dimensional
Perfectionism Scale Chinese Mental Health Journal 21 97-100
Yang H amp Zhang X (2004) Perfectionism and mental health of college students
(2004) Chinese Mental Health Journal 18 647-648
Young D (1989) Neurasthenia and related problems Culture Medicine and
Psychiatry 13 131-138
Zhang D (1995) Depression and culture A Chinese perspective Canadian Journal of
Counseling 29 227ndash233
29
TABLE(S)
Table 1 Demographic Variables
Age 2011
Gender Male
Female
472
523
Parentsrsquo Marital Status Married
Divorced
Single
Remarried
938
23
18
20
Fatherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
Government Official
51
356
187
95
124
91
Motherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
122
406
144
76
134
Fatherrsquos Education Some Primary School
Primary School
Some High School
High School
University
29
139
222
403
137
Motherrsquos Education Some Primary School
Primary School
Some High School
High School
University
63
192
264
350
76
Only Child No
Yes
331
667
Monthly Income lt 1000 RMB
1000 ndash 1500 RMB
1500 ndash 2000 RMB
2000 ndash 3000 RMB
3000 ndash 4000 RMB
4000 ndash 5000 RMB
gt 5000 RMB
334
204
175
140
59
20
20
30
Table 2 Means Standard Deviations and Inter-correlations Between Time 1 Measures
__________________________________________________________________
1 2 3
__________________________________________________________________
1 Depressive Symptoms 2963 (780)
2 Anxious Symptoms 52 3753 (918)
3 Dysfunctional Attitudes 48 33 18120 (2304)
4 Neuroticism 63 42 53 3110 (712)
_________________________________________________________________________
Note Means and standard deviations (in parentheses) are on the diagonal Depressive
Symptoms = Center for Epidemiological Studies Depression Scale Anxious Symptoms
= Mood and Anxiety Symptom Questionnaire Overall Anxiety subscale Dysfunctional
Attitudes = Dysfunctional Attitudes Scale Neuroticism = NEO Five Factor Inventory
Neuroticism subscale p lt 01
31
Table 3 Dysfunctional Attitudes Predicting Within-Subject Fluctuations in CES-D
Scores (upper section) and MASQ Scores (lower section) during the Follow-Up
Interval
______________________________________________________________________
β SE F df
______________________________________________________________________
Time 1 CESD-D 297 026 12987 1572
Stress 005 000 10860 12459
Neuroticism 134 027 2518 1572
Dysfunctional Attitudes -055 040 -183 1572
Dysfunctional Attitudes times Stress 001 000 1078 12459
______________________________________________________________________
Time 1 MASQ 502 033 23158 1575
Stress 006 000 8963 12470
Neuroticism 080 033 596 1575
Dysfunctional Attitudes -052 051 -106 1575
Dysfunctional Attitudes times Stress 002 001 774 12470
______________________________________________________________________
Note Time 1 CES-D = Time 1 Center for Epidemiological Studies Depression Scale
Stress = Within-Subject Fluctuations in General Academic Social Hassles Scale for
Students (GASHSS) scores during the follow-up interval Neuroticism = NEO Five
Factor Inventory Neuroticism subscale Dysfunctional Attitudes = Dysfunctional
Attitudes Scale Time 1 MASQ = Time 1 Mood and Anxiety Symptom Questionnaire
Overall Anxiety subscale p lt 05 p lt 01 p lt 001
32
FIGURES
Figure 1 Predicted slope of the relationship between stress and depressive
symptoms (left panel) and anxious symptoms (right panel) as a function of
dysfunctional attitudes
20
25
30
Low High
Pre
dic
ted
CE
S-D
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
25
30
35
40
Low High
Pre
dic
ted
MA
SQ
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
Intercept Intercept
7
Parker Gladstone amp Chee 2001 Xu JM 1987 Xu YX 1994 Zhang 1995)
Critics dispute the notion that Chinese psychiatric patients are ldquosomatizersrdquo who
manifest few or no emotional symptoms and who attribute distress to physical causes
Rather they argue that SJSR gained widespread acceptance in China as it was a non-
stigmatizing diagnosis that allowed individuals experiencing psychosocial distress to
seek help during a time in which traditional cultural beliefs and political influences led
to severe sanction and stigmatization of individuals suffering from mental illnesses
(Lee 1998 1999 Phillips 1998 Shixie 1989) At the same time other Chinese
researchers and clinicians have continued to defend neurasthenia as both a valid
diagnostic category and a clinically useful means of communicating with patients (Rin
amp Huang 1989 Yan 1989 Young 1989) Due to continued debate on this topic it is
essential that researchers examining models of vulnerability to depression within China
assess multiple symptom outcomes as the types of symptoms predicted by vulnerability
factors may vary as a function of cultural context Hence in the current study we also
assessed levels of anxious symptoms to provide a test of the specificity hypothesis of
Beckrsquos (1967 1983) cognitive theory
In order to provide a powerful examination of our hypotheses concerning (1) the
applicability of the diathesis-stress component of Beckrsquos (1967 1983) cognitive theory
to Chinese university students and (2) the specificity of dysfunctional attitudes as
predictors of depressive as opposed to anxious symptoms participantsrsquo scores on the
neuroticism subscale of the Five-factor Inventory (FFI-N) were included as a control
variable in all analyses Several critical reviews of the literature examining theories of
cognitive vulnerability to depression (eg Barnett amp Gotlib 1998 Coyne amp Whiffen
8
1995) have argued that cognitive vulnerabilities to depression such as that featured in
Beckrsquos cognitive theory may be equivalent to or reducible to trait neuroticism and thus
may not confer independent risk for depression In response to such claims a recent
study conducted with university students examining the degree of factorial
independence versus overlap between trait neuroticism and dysfunctional attitudes has
shown them to be distinct constructs each loading onto separate factors (Hankin et al
2007) At the same time however there remains a need to examine whether
dysfunctional attitudes and trait neuroticism represent unique risk factors for
depression particularly in young adults in China Hence in the current study
participantsrsquo scores on the neuroticism subscale of the Five-factor Inventory (FFI-N)
were included as a control variable in order to account for any of the variance in
fluctuations in depressive (and anxious) symptoms that may be shared between
dysfunctional attitudes and trait neuroticism thereby isolating and highlighting their
unique predictive effects
METHOD
Participants
Participants included 662 university students (aged 19-21) from Changsha ndash an
industrial city in the province of Hunan with a population of approximately 6000000
In terms of the annual gross domestic product Hunan ranks 23rd
(10336 RMB) out of
the 34 provinces in China placing it well below the national provincial average (micro =
29719 RMB SD = 47462 RMB National Bureau of Statistics of China 2006)
Demographic variables for the sample are presented in Table 1
9
Procedure
Consent forms were distributed to all students in participating classes Consent
rates were greater than 95 in all the classes After consent forms were collected
researchers returned to the school to meet with participating students Written consent
was obtained from each participant at the beginning of the initial assessment During
the initial assessment students completed a demographics form and each of the
following questionnaires (1) Center for Epidemiological Studies Depression Scale
(CES-D Radloff 1977) (2) Mood and Anxiety Symptom Questionnaire (MASQ
Clark amp Watson 1991) (3) Dysfunctional Attitudes Scale (DAS Weissman amp Beck
1978) and (4) NEO Five Factor Inventory- Neuroticism Subscale (FFI-N Costa amp
McCrae 1992) Once a month for the subsequent six-months researchers returned to
the school and met with participating students to conduct follow-up assessments At
each of these follow-up assessments students were asked to complete each of the
following questionnaires (1) CES-D (2) MASQ and (3) the General Academic
Social Hassles Scale for Students (GASHSS Blankstein amp Flett 1993)
Measures
The Chinese versions of all self-report measures were developed using the
back-translation method Original English versions were translated into Chinese by a
bilingual translator from the Psychology department at Second Xiangya Medical
College of Central South University Hunan Translated Chinese versions were then
back-translated into English by another bilingual translator from the Psychology
department at McGill University Quebec Original versions were then compared with
the back-translation If inconsistencies were found in the back-translation translators
10
worked together to make corrections to the final Chinese versions until all final
versions were agreed upon No items from any of the measures were removed or
significantly altered during the translation process
Depressive Symptoms Center for Epidemiological Studies Depression Scale
(CES-D Radloff 1977) The CES-D is a 20-item self-report measure designed to
assess depressive symptoms in the general population For each item participants are
asked to indicate how often they experienced the particular symptom over the last
week Responses range from 1 (eg rarely or none of the time) to 4 (eg most or all of
the time) Scores range from 20-80 with higher score indicating higher levels of
depressive symptoms In the current study the CES-D exhibited high internal
consistency with Cronbachrsquos alpha values ranging from 90 to 94 (micro = 2918 SD =
814) over the 7 time points
Anxious Symptoms Mood and Anxiety Symptom Questionnaire (MASQ
Watson amp Clark 1991) The MASQ is a 62-item questionnaire designed to assess both
specific and nonspecific depressive and anxious symptoms For each item participants
are asked to rate on a scale of 1 to 5 the extent to which they have felt this way ldquoduring
the past 24 hoursrdquo Within the current study we utilized the anxious symptoms (11
items) and anxious arousal (17 items) subscales which together provide an index of
overall anxious symptoms Higher scores on each subscale reflect greater levels of
anxious symptoms In the current study the MASQ exhibited high internal consistency
with Cronbachrsquos alpha values ranging from 90 to 95 (micro = 3847 SD = 1117) over the
7 time points
11
Dysfunctional Attitudes Dysfunctional Attitudes Scale (DAS Weissman amp
Beck 1978) The DAS (Form A) is a 40-item questionnaire designed to measure the
cognitive vulnerability factor featured in Beckrsquos cognitive theory Examples of items
include ldquoIf I do not do well all the time people will not respect merdquo ldquoIf a person asks
for help it is a sign of weaknessrdquo and ldquoMy value as a person depends greatly on what
others think of merdquo Items are rated on a 7-point Likert scale ranging from 1 (totally
disagree) to 7 (totally agree) providing a range of scores from 40 to 280 with higher
scores reflecting more dysfunctional attitudes In the current study the DAS exhibited
high internal consistency with Cronbachrsquos alphas of 89 and 88 obtained for the first
and second administrations respectively In addition a test-retest reliability coefficient
of 72 was obtained indicating strong stability over time
Neuroticism NEO Five Factor Inventory - Neuroticism Subscale (FFI-N
Costa amp McCrae 1992) The FFI-N is a 12- item self-report measure that assesses
neuroticism Examples of questions include I often feel inferior to others I am
seldom sad or depressed and Sometimes I feel completely worthless Items are rated
on a 5-point Likert scale ranging from 0 (strongly disagree) to 4 (strongly agree)
providing scores ranging from 0 to 48 with higher scores indicating higher levels of
neuroticism The NEO-FFI-N has proven reliable across different cultural samples and
item pools (Costa amp McCrae 1992) In the current study Cronbachs alpha was 81
indicating strong internal consistency
Negative Life Events General Academic Social Hassles Scale for Students
(GASHSS Blankstein amp Flett 1993) Participants completed a 30-item abbreviated
version of the GASHSS The measure is comprised of items assessing general hassles
12
(8 items) academic hassles (10 items) and social hassles (12 items) For each item
participants are asked to rate how persistent the given hassle was (ie its frequency and
duration) over the last 30 days (0 = no hassle not at all persistent to 6 = extremely
persistent hassle high frequency andor duration)
13
RESULTS
Descriptive Data
Means standard deviations and inter-correlations between Time 1 measures are
presented in Table 2
Prospective Diathesis-Stress Analyses - Depression
Multilevel modeling was used to test our hypothesis that higher levels of dysfunctional
attitudes would be associated with greater increases in depressive symptoms following
increases in stress Analyses were carried out using the SAS (version 81) MIXED
procedure and maximum likelihood estimation Our dependent variable was within-
subject fluctuations in CES-D scores during the follow-up interval (DEPRESSION)
Our primary predictors of DEPRESSION were DAS scores (DYSFUNCTIONAL
ATTITUDES) and fluctuations in GASHSS scores during the follow-up interval
(STRESS) As DYSFUNCTIONAL ATTITUDES is a between-subject predictor DAS
scores were standardized prior to analyses As STRESS is a within-subject predictor
STRESS reflects upward or downward fluctuations in an individualrsquos level of stress
compared to hisher mean level of stress
When fitting hierarchical linear models one must specify appropriate mean and
covariance structures Mean structures refer to the various fixed and random effect
components that can be included in the model Covariance structures refer to alternative
methods of specifying the pattern of covariance between observations taken from the
same subject at different time points It is important to note that mean and covariance
structures are not independent of one another Rather an appropriate covariance
structure is essential in order to obtain valid inferences for the parameters in the mean
14
structure Overparametrization of the covariance structure can lead to inefficient
estimation and poor assessment of standard errors (Altham 1984) On the other hand
too much restriction of the covariance structure can lead to invalid inferences when the
assumed structure does not hold (Altham 1984)
In our first set of analyses we were interested in examining the effects of
DYSFUNCTIONAL ATTITUDES STRESS and the DYSFUNCTIONAL
ATTITUDES STRESS interaction on participantrsquos CES-D scores during the follow-
up interval Consequently in line with Diggle Liang and Zegers (1994)
recommendation that one use a ldquosaturatedrdquo model for the mean structure while
searching for an appropriate covariance structure we chose a mean structure that
included DYSFUNCTIONAL ATTITUDES STRESS and the DYSFUNCTIONAL
ATTITUDES STRESS interaction Four additional effects were also included in this
mean structure First as different individuals report different levels of depressive
symptoms when at their own average level of stress a random effect for intercept was
included in the model Second given that STRESS is a within-subject predictor whose
effect is expected to vary from participant to participant a random effect for slope was
included in the model Third in order to control for individual differences in baseline
levels of depressive symptoms Time 1 CES-D scores were included in the model
Fourth in order to examine whether DYSFUNCTIONAL ATTITUDES represent a
vulnerability factor independent of neuroticism participantsrsquo FFI-N scores were
entered in the model
Commonly used covariance structures in studies in which multiple responses
are obtained from the same individual over time (and consequently within-subject
15
residuals over time are likely to be correlated) include compound symmetry first-order
autoregressive heterogeneous autoregressive and banded Toeplitz In order to select
one of these covariance structures for our analyses we fitted models using each
structure and chose the ldquobestrdquo fit based on Akaike information criterion (AIC and
AICC) and Schwarz Bayesian criterion (BIC) In all cases the best fit for our data was
a first-order heterogeneous autoregressive structure (ARH [1]) After choosing the
appropriate covariance structure we next examined the random-effects component of
our model
With respect to random effects the ARH [1] parameter (r = 31 plt001)
RE_INTERCEPT (plt001) and RE_SLOPE (plt001) were each significant and thus
were retained in the model The final results with respect to the fixed-effects
component of the model are presented in the upper section of Table 3 Of primary
importance the DYSFUNCTIONAL ATTITUDES STRESS interaction was a
significant predictor of fluctuations in depressive symptoms during the follow-up
interval In order to examine the form of this interaction the model summarized in the
upper section of Table 3 was used to calculate predicted CES-D scores for individuals
exhibiting either high or low levels of dysfunctional attitudes (plus or minus 15 SD)
who are experiencing either high or low levels of stress in comparison to their own
average level of stress (plus or minus 15 times mean within-subject SD) The results of
such calculations are presented in the left panel of Figure 1
Analyses were conducted for each DYSFUNCTIONAL ATTITUDES
condition examining whether the slope of the relationship between stress and
depressive symptoms significantly differed from 0 Analyses indicated that both
16
individuals exhibiting high (t(2459) = 862 p lt 0001) and low (t(2459) = 347 p lt
0001) levels of dysfunctional attitudes reported significantly higher levels of
depressive symptoms when experiencing high levels of stress than when experiencing
low levels of stress Planned comparisons of the slopes of the relationship between
stress and depressive symptoms however revealed that the slope was significantly
greater in individuals exhibiting high levels of dysfunctional attitudes (slope = 013)
than in individuals exhibiting low levels of dysfunctional attitudes (slope = 005
t(2459) = 328 p = 0001)
Prospective Diathesis-Stress Analyses - Anxiety
The same data-analytic approach as described above was used to examine
whether higher levels of dysfunctional attitudes would be associated with greater
increases in anxious symptoms following increases in stress Again in order to examine
whether DYSFUNCTIONAL ATTITUDES represent a vulnerability factor
independent of neuroticism participantsrsquo FFI-N scores were entered in the model
With respect to random effects the ARH[1] parameter (r = 23 p lt 001)
RE_INTERCEPT (plt001) and RE_SLOPE (plt001) were each significant and thus
were retained in the model The final results with respect to the fixed-effects
component of the model are presented in the lower section of Table 3 Of primary
importance the DYSFUNCTIONAL ATTITUDES STRESS interaction was a
significant predictor of within-subject fluctuations in anxious symptoms during the
follow-up interval In order to examine the form of this interaction the model
summarized in the lower section of Table 3 was used to calculate predicted MASQ
scores for individuals exhibiting either high or low levels of dysfunctional attitudes
17
(plus or minus 15 SD) who are experiencing either high or low levels of stress in
comparison to their own average level of stress (plus or minus 15 times mean within-
subject SD) The results of such calculations are presented on the right panel of in
Figure 1
Analyses were conducted for each DYSFUNCTIONAL ATTITUDES
condition examining whether the slope of the relationship between stress and anxious
symptoms significantly differed from 0 Analyses indicated that both individuals
exhibiting high (t(2470) = 768 p lt 0001) and low (t(2470) = 337 p lt 0001) levels of
dysfunctional attitudes reported higher levels of anxious symptoms when experiencing
high levels of stress than when experiencing low levels of stress Planned comparisons
of the slopes of the relationship between stress and anxious symptoms however
revealed that the slope was significantly greater in individuals exhibiting high levels of
dysfunctional attitudes (slope = 009) than in individuals exhibiting low levels of
dysfunctional attitudes (slope = 003 t(2470) = 278 p lt 001)
Additional Analyses
Given that the DYSFUNCTIONAL ATTITUDES STRESS interaction
prospectively predicted both symptoms of depression and anxiety two additional
analyses were conducted in order to examine (1) whether the DYSFUNCTIONAL
ATTITUDES STRESS interaction continued to be a significant predictor of within-
subject fluctuations in depressive symptoms after controlling for within-subject
fluctuations in anxious symptoms and (2) whether the DYSFUNCTIONAL
ATTITUDES STRESS interaction continued to predict within-subject fluctuations in
anxious symptoms after controlling for within-subject fluctuations in depressive
18
symptoms Such analyses allowed us to examine whether the above mentioned pattern
of findings may have been due to the high correlation observed in the current study
between depressive and anxious symptoms
Analyses were conducted in the same manner as described above with the
exception that an additional within-subject variable (ie DEPRESSION or ANXIETY)
was included in each model in order to control for within-subject fluctuations in the
alternate symptom With respect to the prediction of depressive symptoms the
DYSFUNCTIONAL ATTITUDES STRESS interaction remained a significant
predictor after controlling for within-subject fluctuations in anxious symptoms (β =
001 SE = 000 F = 410 p lt 05) With respect to the prediction of anxious
symptoms however the DYSFUNCTIONAL ATTITUDES STRESS interaction
was no longer a significant predictor after controlling for within-subject fluctuations in
depressive symptoms (β = 001 SE = 000 F = 148 p = 22)
DISCUSSION
The results of the current study provide support for the cross-cultural
applicability of Beckrsquos (1967 1983) cognitive theory to university students in Hunan
China More specifically consistent with hypotheses and with results obtained from
past research examining Beckrsquos cognitive theory in Western samples of university
students (Hankin et al 2004 Hankin et al 2005 Joiner et al 1999 Klocek et al
1997 Brown et al 1995) higher levels of dysfunctional attitudes were associated with
greater increases in depressive symptoms following increases in negative event
frequency during the six-month follow-up interval Given the considerable differences
between the current sample and Western samples in terms of demographic
19
characteristics and cultural factors such a finding strongly attests to the robustness of
Beckrsquos cognitive theory Moreover integrating the current findings with those obtained
in research examining Beckrsquos theory in other non-Western samples suggests that
Beckrsquos theory may represent a powerful explanatory model of the development of
depressive symptoms among individuals from diverse cultural settings For example
consistent with the theory higher levels of dysfunctional attitudes have been shown to
be associated with higher levels of depressive symptoms in Japanese (Tanaka et al
2006) Puerto-Rican (Bonilla Bernal Santos amp Santos 2003) Turkish (Sahin amp Sahin
1992) Norwegian (Chioqueta amp Stiles 2004) Singaporean (Oei Goh amp Kwon 1996)
and Swedish (Ohrt amp Thorell 1998) adult samples In addition it is important to note
that the current findings expand upon past correlational research examining the
association between dysfunctional attitudes and depression in Chinese samples through
the use of a multi-wave longitudinal design
When examining the specificity of dysfunctional attitudes as a predictor of
depressive symptoms the current study did not obtain support for specificity More
specifically contrary to the specificity hypothesis of Beckrsquos cognitive theory and to
results obtained in Western samples of university students (Alloy et al 2000 2006
Hankin et al 2004) higher levels of dysfunctional attitudes were associated with
greater increases in both depressive and anxious symptoms following increases in
negative event frequency There are two alternative ways of interpreting the non-
specificity finding observed in the current study First it is possible that the types of
thoughts individuals possessing high levels of dysfunctional attitudes experience
following negative events varies as a function of cultural context In other words in
20
Western samples such individuals may primarily experience the types of cognitions
that are associated with the development of depressive symptoms (ie appraisals of
personal loss and failure) In contrast in Chinese samples individuals possessing high
levels of dysfunctional attitudes may experience a wider array of cognitions some of
which are associated with the development of depressive symptoms and some of which
are associated with the development of anxious symptoms (ie evaluations of
impending threat or danger) Such an explanation would be consistent with Beckrsquos
cognitive content-specificity hypothesis (Clark amp Beck 1999) which posits that each
affective state and psychological disorder has a specific cognitive profile Second it is
possible that the types of symptoms individuals possessing high levels of dysfunctional
attitudes experience following negative events varies as a function of cultural context
More specifically it may be that dysfunctional attitudes specifically predict symptoms
of depression in both samples except that in Western samples depression manifests in
pure depressive symptoms whereas in Chinese samples depression manifests as a
combination of depressive and anxious symptoms Such an explanation would be
consistent with cultural psychopathologistsrsquo hypotheses that cultural factors shape the
phenomenology of psychiatric symptoms (Kleinman 2004 Mezzich et al 1999)
Moreover dysfunctional attitudes predicting a combination of depressive and anxious
symptoms in Chinese samples would be consistent with the construct of neurasthenia -
a construct hypothesized by some to represent a somatized form of depression that is
still widely seen within China (Lee amp Wong 1995)
Interesting in this regard and perhaps speaking to the primacy of depressive
symptoms in the current findings analyses indicated that the DYSFUNCTIONAL
21
ATTITUDES times STRESS interaction no longer predicted anxious symptoms after
controlling for depressive symptoms The reverse however was not true as the
DYSFUNCTIONAL ATTITUDES times STRESS interaction continued to predict
depressive symptoms after controlling for anxious symptoms
It is important to note that the current study employed a particularly
conservative approach to analyses in that we examined the effects of dysfunctional
attitudes on depressive and anxious symptoms after controlling for the effect of
neuroticism on such symptoms Providing particularly powerful support for Beckrsquos
(1967 1983) cognitive theory across analyses dysfunctional attitudes predicted levels
of depressive andor anxious symptoms experienced during the six month follow-up
interval independent of the effect of neuroticism Thus contrary to past critical reviews
of the cognitive literature (Barnett amp Gotlib 1998 Coyne amp Whiffen 1995) and
consistent with past findings (Hankin et al 2007) the current results indicate that
cognitive vulnerabilities to depression such as dysfunctional attitudes are not reducible
to trait neuroticism but rather represent factors that confer independent risk for
depression
Limitations and Future Directions
Several limitations of the current study should be noted First self-report
measures were used to assess depressive and anxious symptoms Although the CES-D
and MASQ both possess high degrees of reliability and validity it is difficult to draw
conclusions about clinically diagnosed depression or anxiety based on self-report
questionnaires Second self-report measures were used to assess stress Although
measures of stress that require participants only to indicate whether or not an event
22
occurred are less likely to be influenced by informant bias than those that ask
participants to rate the subjective impact of each event more sophisticated methods of
analysis such as interviewing procedures that assess contextual threat may provide
better assessments of stress Third the measures of dysfunctional attitudes stress and
depressive and anxious symptoms used in the current study were each Western-
developed Future research should examine these hypotheses using indigenous
measures in addition to Western-developed measures in order to assess possible
similarities andor differences in patterns of findings Fourth the current study only
examined depression and anxiety as symptom outcomes Future research conducted
within China should examine a wider array of symptom outcomes such as
somatization physical complaints and externalizing behaviors in order to provide a
more thorough and culturally sensitive test of the specificity hypotheses of Beckrsquos
cognitive model Fifth the current study examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese undergraduate students and thus the extent to which
our findings may be generalized to other demographics within Chinarsquos population is
unclear Last the current study broadly examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese university students Future research should examine
the constructs and processes posited by this model in greater detail in order to develop a
deeper understanding of how they may be uniquely molded by socio-cultural factors
Such research would benefit from examining the specific types of stressors experienced
by Chinese university students as they may vary as a function of socio-cultural factors
from those experienced by Western undergraduates For example severe pressure to
succeed academically in order to secure access to a limited number of post-
23
undergraduate educational opportunities - one of the few paths towards upward
mobility available to Chinese students seeking secure and gainful employment in what
has increasingly become a very highly competitive job market - may represent a
particularly salient stressor for the development of depressive symptoms among this
population (Qiang 2006)
In conclusion the results from the current study provide support for the
applicability of Beckrsquos cognitive theory to university students in mainland China More
specifically consistent with findings obtained in the West results indicate that
dysfunctional attitudes confer vulnerability to the development of depressive symptoms
following the occurrence of negative events in Chinese university students At the same
time however the current findings suggest cultural variation in the profile of
symptoms which emerge following the occurrence of negative events in cognitively
vulnerable individuals in Western and Chinese samples Specifically whereas in the
West dysfunctional attitudes have been shown to confer vulnerability to depressive
symptoms in Chinese university students dysfunctional attitudes appear to confer
vulnerability to a combined depressive and anxious symptom profile Future research
using more sophisticated assessments of stress and depressive symptoms more diverse
samples and symptom outcome measures and indigenously-developed measures is
likely to enhance our understanding of the cognitive and environmental mechanisms
underlying the development of depression in Chinese university students Discovering
that cognitive theories of vulnerability to depression extend to university students in
China highlights the potential role for cognitive-behavioral depression prevention and
treatment interventions in stemming the tide of distress experienced by this population
24
REFERENCES
Abela J R Z amp Hankin B L (2008) Cognitive vulnerability to depression in
children and adolescents A developmental psychopathology perspective In J
R Z Abela and B L Hankin (Eds) Handbook of child and adolescent
depression (pp 35-78) New York The Guilford Press
Alloy L B Abramson L Y Hogan M E Whitehouse W G Rose D T
Robinson MS Kim R S amp Lapkin J B (2000) The Temple-Wisconsin
cognitive vulnerability to depression project Lifetime history of axis-I
psychopathology in individuals at high and low cognitive risk for depression
Journal of Abnormal Psychology 109 403-418
Alloy L B Abramson L Y Whitehouse W G Hogan M E Panzarella C amp
Rose D T (2006) Prospective incidence of first onsets and recurrences of
depression in individuals at high and low cognitive risk for depression Journal
of Abnormal Psychology 115 145ndash156
Altham P M E (1984) Improving the precision of estimation by fitting a model
Journal of the Royal Statistical Society Series B 46 11
Barnett PA amp Gotlib I H (1988) Psychosocial functioning and depression
Distinguishing among antecedents concomitants and consequences
Psychological Bulletin 104 97-126
Beck AT (1967) Depression Clinical experimental and theoretical aspects New
York Harper amp Row
Beck AT (1983) Cognitive therapy of depression New perspectives In PJ Clayton
amp JE Barrett (Eds) Treatment of depression Old controversies and new
approaches New York Raven Press
Bian Q Yang K amp Li C (2007) Dysfunctional attitudes of patients with depression
or bipolar disorder Chinese Mental Health Journal 21 759-761
Blankstein K R amp Flett G L (1993) Development of the General Academic and
Social Hassles Scales for Students Unpublished manuscript
Bonilla J Bernal G Santos A amp Santos D (2003) A revised Spanish version of
the Beck Depression InventoryPsychometric properties with a Puerto Rican
sample of college students Journal of Clinical Psychology 60 119-130
Brown G P Hammen C L Craske M G amp Wickens T D (1995) Dimensions of
dysfunctional attitudes as vulnerabilities to depressive symptoms Journal of
Abnormal Psychology 104 431-435
25
Chioqueta A P amp Stiles T C (2004) Psychometric properties of the Norweigian
version of the Dysfunctional Attitude Scale (Form A) Cognitive Behaviour
Therapy 33 83-86
Clark DA amp Beck AT (1999) Cognitive theory and therapy of depression New
York John Wiley amp Sons Inc
Clark L A amp Watson D (1991) Tripartite model of anxiety and depression
Psychometric evidence and taxonomic implications Journal of Abnormal
Psychology 100 316ndash336
Costa P T amp McCrae R R (1992) NEO PI-R Professional manual Revised NEO
personality inventory NEO PR-R and NEO five-factor inventory NEO-RRI
Odessa FL Psychological Assessment Resources
Coyne J C amp Whiffen V E (1995) Issues in personality as diathesis for depression
The case of sociotropy-dependency and autonomy-self-criticism Psychological
Bulletin 118 358-378
Fang X Qian M Luo S amp Zi F (2009) A correlational study on college students
perfectionism parental rearing patterns and mental health Chinese Mental
Health Journal 23 56-59
Hankin B L Abramson L Y Miller N amp Haeffel G (2004) Cognitive
vulnerability-stress theories of depression Examining affective specificity in
the prediction of depression versus anxiety in three prospective studies
Cognitive Therapy and Research 28 309ndash345
Hankin BL Fraley RC amp Abela JRZ (2005) Daily depression and cognitions
about stress Evidence for a traitlike depressogenic cognitive style and the
prediction of depressive symptoms in a prospective daily diary study Journal of
Personality and Social Psychology 88 673-685
Hankin B L Lakdawalla Z Carter I L Abela J R Z amp Adams P (2007) Are
neuroticism cognitive vulnerabilities and self-esteem overlapping or distinct
risks for depression Evidence from confirmatory factor analyses Journal of
Social amp Clinical Psychology 26 29-63
Hankin B L Wetter E Cheely C amp Oppenheimer C W (2008) Becks cognitive
theory of depression in adolescence Specific prediction of depressive
symptoms and reciprocal influences in a multi-wave prospective study
International Journal of Cognitive Therapy 1 313-332
Ingram R E Miranda J amp Segal Z V (1998) Cognitive Vulnerability to
Depression New York NY Guilford Press
26
Ingram R E amp Luxton DD (2005) Vulnerability-stress models In BL Hankin amp
JRZ Abela (Eds) Development of psychopathology A vulnerability-stress
perspective (pp 32-46) Thousand Oaks CA Sage
Joiner T E Metalsky G I Lew A amp Klocek J (1999) Testing the causal
mediation component of Becks theory of depression Evidence for specific
mediation Cognitive Therapy and Research 23 401-412
Kleinman A (2004) Culture and depression New England Journal of Medicine 351
951-953
Kleinman A (1977) Depression somatization and the new cross-cultural psychiatry
Social Science and Medicine 11 3-10
Kleinman A (1996) How is culture important for DSM-IV In J E Mezzich A
Kleinmam H Fabrega Jr amp L Delores (Eds)Culture and psychiatric
diagnosis A DSM-IV perspective (pp 15-25) Washington DC US American
Psychiatric Association
Klocek J W Oliver J M amp Ross M J (1997) The role of dysfunctional attitudes
negative life events and social support in the prediction of depressive
dysphoria A prospective longitudinal study Social Behavior and Personality
25 23-136
Lee S (1997) A Chinese perspective on somatoform disorders Journal of
Psychosomatic Disorders 43 115-119
Lee S (1998) Estranged bodies simulated harmony and misplaced cultures
Neurasthenia in contemporary Chinese society Psychosomatic Medicine 60
448ndash457
Lee S (1999) Diagnosis postponed Shenjing shuairo and the transformation of
psychiatry in post-Mao China Culture Medicine and Psychiatry 23 349ndash380
Lee S amp Wong K C (1995) Rethinking neurasthenia the illness concepts of
shenjing shuairuo among Chinese undergraduates in Honk Kong Culture
Medicine and Psychiatry 19 91ndash111
Lee S Tsang A Huang YQ He YL Liu ZR Zhang MY Shen YC amp
Kessler RC (2009) The epidemiology of depression in metropolitan China
Psychological Medicine 39 735-747
Mezzich J E Kirmayer L J Kleinman A Fabrega Jr H Parron D L Good B
J Lin K amp Manson S M (1999) The place of culture in DSM-IV Journal
of Nervous and Mental Disease 187 457-464
27
Monroe S M amp Simons A D (1991) Diathesisndashstress theories in the context of life
stress research Implications for the depressive disorders Psychological
Bulletin 110 406ndash425
Murray C J L amp Lopez A D (1996) The global burden of disease Cambridge
Harvard University Press
National Bureau of Statistics of China (2006) The China 2005 statistical yearbook
China Statistics Press Beijing PR China
Oei T P S Goh Y Kwon S M(1996) A cross-cultural study of the integrated
cognitive model of depression Current Psychology of Cognition 15 265-281
Ohrt T amp Thorell L (1998) Dysfunctional Attitude Scale (DAS) Psychometrics and
norms of the Swedish version Scandinavian Journal of Behaviour Therapy 27
105-113
Parker G Gladstone G Chee KT (2001) Depression in the planetrsquos largest ethnic
group The Chinese American Journal of Psychiatry 158 857-864
Phillips M R Zhang J Shi Q Song Z Ding Z Pang S Li X Zhang Y amp
Wang Z (2009) Prevalence treatment and associated disability of mental
disorders in four provinces in China during 2001ndash05 an epidemiological
survey The Lancet 373 2041-2053
Phillips M R Li X amp Zhang Y (2002) Suicide rates in China Lancet 359 835-
840
Phillips M R (1998) The transformation of Chinarsquos mental health services The China
Journal 39 1ndash36
Qiang G (2006) Depression number one killer of Ivory Tower students China Daily
Retrieved from httpwwwchinadailycomcnchina2006-
1128content_744880htm
Radloff L S (1977) The CESndashD scale A self-report depression scale for research in
the general population Applied Psychological Measurement 1 385ndash401
Rin H amp Huang M G (1989) Neurasthenia as nosological dilemma Culture
Medicine and Psychiatry 13 215-226
Sahin NH amp Sahin N (1992) How dysfunctional are the dysfunctional attitudes in
another culture British Journal of Medical Psychology 65 17-26
Shixie L (1989) Neurasthenia in China Modern and traditional criteria for its
diagnosis Culture Medicine and Psychiatry 13 163-186
28
Tanaka N Uji M Hiramura H Chen Z Shikai N amp Kitamura T (2006)
Cognitive patterns and depression Study of a Japanese university student
population Psychiatry and Clinical Neuroscience 60 358-364
Taylor R E (2001) Death of neurasthenia and its psychological reincarnation a study
of neurasthenia at the National Hospital for the Relief and Cure of the Paralysed
and Epileptic Queen Square London 1870ndash1932 British Journal of
Psychiatry 179 550ndash557
Weissman A N amp Beck A T (1978 April) Development and validation of the
Dysfunctional Attitudes Scale A preliminary investigation Paper presented at
the annual meeting of the Educational Research Association Toronto Canada
Xiang M Z (1986) Epidemiological study of neuroses in 12 regions (districts) of
China Chinese Journal of Neurology and Psychiatry 19 87-91
Xu JM (1987) Some issues in the diagnosis of depression in China Canadian
Journal of Psychiatry 32 368-370
Xu Y X (1994) About ICD-10 Journal of Clinical Psychology and Medicine 4 224-
226
Xu Z Li Z amp Wang Z (2007) Dysfunctional attitudes and cognitive bias in major
depressive disorder Chinese Mental Health Journal 21 488-491
Yan H Q (1989) The necessity of retaining the diagnostic concept of neurasthenia
Culture Medicine and Psychiatry 13 139-145
Yang H (2007) The Test of the Chinese version of Frost Multi-dimensional
Perfectionism Scale Chinese Mental Health Journal 21 97-100
Yang H amp Zhang X (2004) Perfectionism and mental health of college students
(2004) Chinese Mental Health Journal 18 647-648
Young D (1989) Neurasthenia and related problems Culture Medicine and
Psychiatry 13 131-138
Zhang D (1995) Depression and culture A Chinese perspective Canadian Journal of
Counseling 29 227ndash233
29
TABLE(S)
Table 1 Demographic Variables
Age 2011
Gender Male
Female
472
523
Parentsrsquo Marital Status Married
Divorced
Single
Remarried
938
23
18
20
Fatherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
Government Official
51
356
187
95
124
91
Motherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
122
406
144
76
134
Fatherrsquos Education Some Primary School
Primary School
Some High School
High School
University
29
139
222
403
137
Motherrsquos Education Some Primary School
Primary School
Some High School
High School
University
63
192
264
350
76
Only Child No
Yes
331
667
Monthly Income lt 1000 RMB
1000 ndash 1500 RMB
1500 ndash 2000 RMB
2000 ndash 3000 RMB
3000 ndash 4000 RMB
4000 ndash 5000 RMB
gt 5000 RMB
334
204
175
140
59
20
20
30
Table 2 Means Standard Deviations and Inter-correlations Between Time 1 Measures
__________________________________________________________________
1 2 3
__________________________________________________________________
1 Depressive Symptoms 2963 (780)
2 Anxious Symptoms 52 3753 (918)
3 Dysfunctional Attitudes 48 33 18120 (2304)
4 Neuroticism 63 42 53 3110 (712)
_________________________________________________________________________
Note Means and standard deviations (in parentheses) are on the diagonal Depressive
Symptoms = Center for Epidemiological Studies Depression Scale Anxious Symptoms
= Mood and Anxiety Symptom Questionnaire Overall Anxiety subscale Dysfunctional
Attitudes = Dysfunctional Attitudes Scale Neuroticism = NEO Five Factor Inventory
Neuroticism subscale p lt 01
31
Table 3 Dysfunctional Attitudes Predicting Within-Subject Fluctuations in CES-D
Scores (upper section) and MASQ Scores (lower section) during the Follow-Up
Interval
______________________________________________________________________
β SE F df
______________________________________________________________________
Time 1 CESD-D 297 026 12987 1572
Stress 005 000 10860 12459
Neuroticism 134 027 2518 1572
Dysfunctional Attitudes -055 040 -183 1572
Dysfunctional Attitudes times Stress 001 000 1078 12459
______________________________________________________________________
Time 1 MASQ 502 033 23158 1575
Stress 006 000 8963 12470
Neuroticism 080 033 596 1575
Dysfunctional Attitudes -052 051 -106 1575
Dysfunctional Attitudes times Stress 002 001 774 12470
______________________________________________________________________
Note Time 1 CES-D = Time 1 Center for Epidemiological Studies Depression Scale
Stress = Within-Subject Fluctuations in General Academic Social Hassles Scale for
Students (GASHSS) scores during the follow-up interval Neuroticism = NEO Five
Factor Inventory Neuroticism subscale Dysfunctional Attitudes = Dysfunctional
Attitudes Scale Time 1 MASQ = Time 1 Mood and Anxiety Symptom Questionnaire
Overall Anxiety subscale p lt 05 p lt 01 p lt 001
32
FIGURES
Figure 1 Predicted slope of the relationship between stress and depressive
symptoms (left panel) and anxious symptoms (right panel) as a function of
dysfunctional attitudes
20
25
30
Low High
Pre
dic
ted
CE
S-D
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
25
30
35
40
Low High
Pre
dic
ted
MA
SQ
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
Intercept Intercept
8
1995) have argued that cognitive vulnerabilities to depression such as that featured in
Beckrsquos cognitive theory may be equivalent to or reducible to trait neuroticism and thus
may not confer independent risk for depression In response to such claims a recent
study conducted with university students examining the degree of factorial
independence versus overlap between trait neuroticism and dysfunctional attitudes has
shown them to be distinct constructs each loading onto separate factors (Hankin et al
2007) At the same time however there remains a need to examine whether
dysfunctional attitudes and trait neuroticism represent unique risk factors for
depression particularly in young adults in China Hence in the current study
participantsrsquo scores on the neuroticism subscale of the Five-factor Inventory (FFI-N)
were included as a control variable in order to account for any of the variance in
fluctuations in depressive (and anxious) symptoms that may be shared between
dysfunctional attitudes and trait neuroticism thereby isolating and highlighting their
unique predictive effects
METHOD
Participants
Participants included 662 university students (aged 19-21) from Changsha ndash an
industrial city in the province of Hunan with a population of approximately 6000000
In terms of the annual gross domestic product Hunan ranks 23rd
(10336 RMB) out of
the 34 provinces in China placing it well below the national provincial average (micro =
29719 RMB SD = 47462 RMB National Bureau of Statistics of China 2006)
Demographic variables for the sample are presented in Table 1
9
Procedure
Consent forms were distributed to all students in participating classes Consent
rates were greater than 95 in all the classes After consent forms were collected
researchers returned to the school to meet with participating students Written consent
was obtained from each participant at the beginning of the initial assessment During
the initial assessment students completed a demographics form and each of the
following questionnaires (1) Center for Epidemiological Studies Depression Scale
(CES-D Radloff 1977) (2) Mood and Anxiety Symptom Questionnaire (MASQ
Clark amp Watson 1991) (3) Dysfunctional Attitudes Scale (DAS Weissman amp Beck
1978) and (4) NEO Five Factor Inventory- Neuroticism Subscale (FFI-N Costa amp
McCrae 1992) Once a month for the subsequent six-months researchers returned to
the school and met with participating students to conduct follow-up assessments At
each of these follow-up assessments students were asked to complete each of the
following questionnaires (1) CES-D (2) MASQ and (3) the General Academic
Social Hassles Scale for Students (GASHSS Blankstein amp Flett 1993)
Measures
The Chinese versions of all self-report measures were developed using the
back-translation method Original English versions were translated into Chinese by a
bilingual translator from the Psychology department at Second Xiangya Medical
College of Central South University Hunan Translated Chinese versions were then
back-translated into English by another bilingual translator from the Psychology
department at McGill University Quebec Original versions were then compared with
the back-translation If inconsistencies were found in the back-translation translators
10
worked together to make corrections to the final Chinese versions until all final
versions were agreed upon No items from any of the measures were removed or
significantly altered during the translation process
Depressive Symptoms Center for Epidemiological Studies Depression Scale
(CES-D Radloff 1977) The CES-D is a 20-item self-report measure designed to
assess depressive symptoms in the general population For each item participants are
asked to indicate how often they experienced the particular symptom over the last
week Responses range from 1 (eg rarely or none of the time) to 4 (eg most or all of
the time) Scores range from 20-80 with higher score indicating higher levels of
depressive symptoms In the current study the CES-D exhibited high internal
consistency with Cronbachrsquos alpha values ranging from 90 to 94 (micro = 2918 SD =
814) over the 7 time points
Anxious Symptoms Mood and Anxiety Symptom Questionnaire (MASQ
Watson amp Clark 1991) The MASQ is a 62-item questionnaire designed to assess both
specific and nonspecific depressive and anxious symptoms For each item participants
are asked to rate on a scale of 1 to 5 the extent to which they have felt this way ldquoduring
the past 24 hoursrdquo Within the current study we utilized the anxious symptoms (11
items) and anxious arousal (17 items) subscales which together provide an index of
overall anxious symptoms Higher scores on each subscale reflect greater levels of
anxious symptoms In the current study the MASQ exhibited high internal consistency
with Cronbachrsquos alpha values ranging from 90 to 95 (micro = 3847 SD = 1117) over the
7 time points
11
Dysfunctional Attitudes Dysfunctional Attitudes Scale (DAS Weissman amp
Beck 1978) The DAS (Form A) is a 40-item questionnaire designed to measure the
cognitive vulnerability factor featured in Beckrsquos cognitive theory Examples of items
include ldquoIf I do not do well all the time people will not respect merdquo ldquoIf a person asks
for help it is a sign of weaknessrdquo and ldquoMy value as a person depends greatly on what
others think of merdquo Items are rated on a 7-point Likert scale ranging from 1 (totally
disagree) to 7 (totally agree) providing a range of scores from 40 to 280 with higher
scores reflecting more dysfunctional attitudes In the current study the DAS exhibited
high internal consistency with Cronbachrsquos alphas of 89 and 88 obtained for the first
and second administrations respectively In addition a test-retest reliability coefficient
of 72 was obtained indicating strong stability over time
Neuroticism NEO Five Factor Inventory - Neuroticism Subscale (FFI-N
Costa amp McCrae 1992) The FFI-N is a 12- item self-report measure that assesses
neuroticism Examples of questions include I often feel inferior to others I am
seldom sad or depressed and Sometimes I feel completely worthless Items are rated
on a 5-point Likert scale ranging from 0 (strongly disagree) to 4 (strongly agree)
providing scores ranging from 0 to 48 with higher scores indicating higher levels of
neuroticism The NEO-FFI-N has proven reliable across different cultural samples and
item pools (Costa amp McCrae 1992) In the current study Cronbachs alpha was 81
indicating strong internal consistency
Negative Life Events General Academic Social Hassles Scale for Students
(GASHSS Blankstein amp Flett 1993) Participants completed a 30-item abbreviated
version of the GASHSS The measure is comprised of items assessing general hassles
12
(8 items) academic hassles (10 items) and social hassles (12 items) For each item
participants are asked to rate how persistent the given hassle was (ie its frequency and
duration) over the last 30 days (0 = no hassle not at all persistent to 6 = extremely
persistent hassle high frequency andor duration)
13
RESULTS
Descriptive Data
Means standard deviations and inter-correlations between Time 1 measures are
presented in Table 2
Prospective Diathesis-Stress Analyses - Depression
Multilevel modeling was used to test our hypothesis that higher levels of dysfunctional
attitudes would be associated with greater increases in depressive symptoms following
increases in stress Analyses were carried out using the SAS (version 81) MIXED
procedure and maximum likelihood estimation Our dependent variable was within-
subject fluctuations in CES-D scores during the follow-up interval (DEPRESSION)
Our primary predictors of DEPRESSION were DAS scores (DYSFUNCTIONAL
ATTITUDES) and fluctuations in GASHSS scores during the follow-up interval
(STRESS) As DYSFUNCTIONAL ATTITUDES is a between-subject predictor DAS
scores were standardized prior to analyses As STRESS is a within-subject predictor
STRESS reflects upward or downward fluctuations in an individualrsquos level of stress
compared to hisher mean level of stress
When fitting hierarchical linear models one must specify appropriate mean and
covariance structures Mean structures refer to the various fixed and random effect
components that can be included in the model Covariance structures refer to alternative
methods of specifying the pattern of covariance between observations taken from the
same subject at different time points It is important to note that mean and covariance
structures are not independent of one another Rather an appropriate covariance
structure is essential in order to obtain valid inferences for the parameters in the mean
14
structure Overparametrization of the covariance structure can lead to inefficient
estimation and poor assessment of standard errors (Altham 1984) On the other hand
too much restriction of the covariance structure can lead to invalid inferences when the
assumed structure does not hold (Altham 1984)
In our first set of analyses we were interested in examining the effects of
DYSFUNCTIONAL ATTITUDES STRESS and the DYSFUNCTIONAL
ATTITUDES STRESS interaction on participantrsquos CES-D scores during the follow-
up interval Consequently in line with Diggle Liang and Zegers (1994)
recommendation that one use a ldquosaturatedrdquo model for the mean structure while
searching for an appropriate covariance structure we chose a mean structure that
included DYSFUNCTIONAL ATTITUDES STRESS and the DYSFUNCTIONAL
ATTITUDES STRESS interaction Four additional effects were also included in this
mean structure First as different individuals report different levels of depressive
symptoms when at their own average level of stress a random effect for intercept was
included in the model Second given that STRESS is a within-subject predictor whose
effect is expected to vary from participant to participant a random effect for slope was
included in the model Third in order to control for individual differences in baseline
levels of depressive symptoms Time 1 CES-D scores were included in the model
Fourth in order to examine whether DYSFUNCTIONAL ATTITUDES represent a
vulnerability factor independent of neuroticism participantsrsquo FFI-N scores were
entered in the model
Commonly used covariance structures in studies in which multiple responses
are obtained from the same individual over time (and consequently within-subject
15
residuals over time are likely to be correlated) include compound symmetry first-order
autoregressive heterogeneous autoregressive and banded Toeplitz In order to select
one of these covariance structures for our analyses we fitted models using each
structure and chose the ldquobestrdquo fit based on Akaike information criterion (AIC and
AICC) and Schwarz Bayesian criterion (BIC) In all cases the best fit for our data was
a first-order heterogeneous autoregressive structure (ARH [1]) After choosing the
appropriate covariance structure we next examined the random-effects component of
our model
With respect to random effects the ARH [1] parameter (r = 31 plt001)
RE_INTERCEPT (plt001) and RE_SLOPE (plt001) were each significant and thus
were retained in the model The final results with respect to the fixed-effects
component of the model are presented in the upper section of Table 3 Of primary
importance the DYSFUNCTIONAL ATTITUDES STRESS interaction was a
significant predictor of fluctuations in depressive symptoms during the follow-up
interval In order to examine the form of this interaction the model summarized in the
upper section of Table 3 was used to calculate predicted CES-D scores for individuals
exhibiting either high or low levels of dysfunctional attitudes (plus or minus 15 SD)
who are experiencing either high or low levels of stress in comparison to their own
average level of stress (plus or minus 15 times mean within-subject SD) The results of
such calculations are presented in the left panel of Figure 1
Analyses were conducted for each DYSFUNCTIONAL ATTITUDES
condition examining whether the slope of the relationship between stress and
depressive symptoms significantly differed from 0 Analyses indicated that both
16
individuals exhibiting high (t(2459) = 862 p lt 0001) and low (t(2459) = 347 p lt
0001) levels of dysfunctional attitudes reported significantly higher levels of
depressive symptoms when experiencing high levels of stress than when experiencing
low levels of stress Planned comparisons of the slopes of the relationship between
stress and depressive symptoms however revealed that the slope was significantly
greater in individuals exhibiting high levels of dysfunctional attitudes (slope = 013)
than in individuals exhibiting low levels of dysfunctional attitudes (slope = 005
t(2459) = 328 p = 0001)
Prospective Diathesis-Stress Analyses - Anxiety
The same data-analytic approach as described above was used to examine
whether higher levels of dysfunctional attitudes would be associated with greater
increases in anxious symptoms following increases in stress Again in order to examine
whether DYSFUNCTIONAL ATTITUDES represent a vulnerability factor
independent of neuroticism participantsrsquo FFI-N scores were entered in the model
With respect to random effects the ARH[1] parameter (r = 23 p lt 001)
RE_INTERCEPT (plt001) and RE_SLOPE (plt001) were each significant and thus
were retained in the model The final results with respect to the fixed-effects
component of the model are presented in the lower section of Table 3 Of primary
importance the DYSFUNCTIONAL ATTITUDES STRESS interaction was a
significant predictor of within-subject fluctuations in anxious symptoms during the
follow-up interval In order to examine the form of this interaction the model
summarized in the lower section of Table 3 was used to calculate predicted MASQ
scores for individuals exhibiting either high or low levels of dysfunctional attitudes
17
(plus or minus 15 SD) who are experiencing either high or low levels of stress in
comparison to their own average level of stress (plus or minus 15 times mean within-
subject SD) The results of such calculations are presented on the right panel of in
Figure 1
Analyses were conducted for each DYSFUNCTIONAL ATTITUDES
condition examining whether the slope of the relationship between stress and anxious
symptoms significantly differed from 0 Analyses indicated that both individuals
exhibiting high (t(2470) = 768 p lt 0001) and low (t(2470) = 337 p lt 0001) levels of
dysfunctional attitudes reported higher levels of anxious symptoms when experiencing
high levels of stress than when experiencing low levels of stress Planned comparisons
of the slopes of the relationship between stress and anxious symptoms however
revealed that the slope was significantly greater in individuals exhibiting high levels of
dysfunctional attitudes (slope = 009) than in individuals exhibiting low levels of
dysfunctional attitudes (slope = 003 t(2470) = 278 p lt 001)
Additional Analyses
Given that the DYSFUNCTIONAL ATTITUDES STRESS interaction
prospectively predicted both symptoms of depression and anxiety two additional
analyses were conducted in order to examine (1) whether the DYSFUNCTIONAL
ATTITUDES STRESS interaction continued to be a significant predictor of within-
subject fluctuations in depressive symptoms after controlling for within-subject
fluctuations in anxious symptoms and (2) whether the DYSFUNCTIONAL
ATTITUDES STRESS interaction continued to predict within-subject fluctuations in
anxious symptoms after controlling for within-subject fluctuations in depressive
18
symptoms Such analyses allowed us to examine whether the above mentioned pattern
of findings may have been due to the high correlation observed in the current study
between depressive and anxious symptoms
Analyses were conducted in the same manner as described above with the
exception that an additional within-subject variable (ie DEPRESSION or ANXIETY)
was included in each model in order to control for within-subject fluctuations in the
alternate symptom With respect to the prediction of depressive symptoms the
DYSFUNCTIONAL ATTITUDES STRESS interaction remained a significant
predictor after controlling for within-subject fluctuations in anxious symptoms (β =
001 SE = 000 F = 410 p lt 05) With respect to the prediction of anxious
symptoms however the DYSFUNCTIONAL ATTITUDES STRESS interaction
was no longer a significant predictor after controlling for within-subject fluctuations in
depressive symptoms (β = 001 SE = 000 F = 148 p = 22)
DISCUSSION
The results of the current study provide support for the cross-cultural
applicability of Beckrsquos (1967 1983) cognitive theory to university students in Hunan
China More specifically consistent with hypotheses and with results obtained from
past research examining Beckrsquos cognitive theory in Western samples of university
students (Hankin et al 2004 Hankin et al 2005 Joiner et al 1999 Klocek et al
1997 Brown et al 1995) higher levels of dysfunctional attitudes were associated with
greater increases in depressive symptoms following increases in negative event
frequency during the six-month follow-up interval Given the considerable differences
between the current sample and Western samples in terms of demographic
19
characteristics and cultural factors such a finding strongly attests to the robustness of
Beckrsquos cognitive theory Moreover integrating the current findings with those obtained
in research examining Beckrsquos theory in other non-Western samples suggests that
Beckrsquos theory may represent a powerful explanatory model of the development of
depressive symptoms among individuals from diverse cultural settings For example
consistent with the theory higher levels of dysfunctional attitudes have been shown to
be associated with higher levels of depressive symptoms in Japanese (Tanaka et al
2006) Puerto-Rican (Bonilla Bernal Santos amp Santos 2003) Turkish (Sahin amp Sahin
1992) Norwegian (Chioqueta amp Stiles 2004) Singaporean (Oei Goh amp Kwon 1996)
and Swedish (Ohrt amp Thorell 1998) adult samples In addition it is important to note
that the current findings expand upon past correlational research examining the
association between dysfunctional attitudes and depression in Chinese samples through
the use of a multi-wave longitudinal design
When examining the specificity of dysfunctional attitudes as a predictor of
depressive symptoms the current study did not obtain support for specificity More
specifically contrary to the specificity hypothesis of Beckrsquos cognitive theory and to
results obtained in Western samples of university students (Alloy et al 2000 2006
Hankin et al 2004) higher levels of dysfunctional attitudes were associated with
greater increases in both depressive and anxious symptoms following increases in
negative event frequency There are two alternative ways of interpreting the non-
specificity finding observed in the current study First it is possible that the types of
thoughts individuals possessing high levels of dysfunctional attitudes experience
following negative events varies as a function of cultural context In other words in
20
Western samples such individuals may primarily experience the types of cognitions
that are associated with the development of depressive symptoms (ie appraisals of
personal loss and failure) In contrast in Chinese samples individuals possessing high
levels of dysfunctional attitudes may experience a wider array of cognitions some of
which are associated with the development of depressive symptoms and some of which
are associated with the development of anxious symptoms (ie evaluations of
impending threat or danger) Such an explanation would be consistent with Beckrsquos
cognitive content-specificity hypothesis (Clark amp Beck 1999) which posits that each
affective state and psychological disorder has a specific cognitive profile Second it is
possible that the types of symptoms individuals possessing high levels of dysfunctional
attitudes experience following negative events varies as a function of cultural context
More specifically it may be that dysfunctional attitudes specifically predict symptoms
of depression in both samples except that in Western samples depression manifests in
pure depressive symptoms whereas in Chinese samples depression manifests as a
combination of depressive and anxious symptoms Such an explanation would be
consistent with cultural psychopathologistsrsquo hypotheses that cultural factors shape the
phenomenology of psychiatric symptoms (Kleinman 2004 Mezzich et al 1999)
Moreover dysfunctional attitudes predicting a combination of depressive and anxious
symptoms in Chinese samples would be consistent with the construct of neurasthenia -
a construct hypothesized by some to represent a somatized form of depression that is
still widely seen within China (Lee amp Wong 1995)
Interesting in this regard and perhaps speaking to the primacy of depressive
symptoms in the current findings analyses indicated that the DYSFUNCTIONAL
21
ATTITUDES times STRESS interaction no longer predicted anxious symptoms after
controlling for depressive symptoms The reverse however was not true as the
DYSFUNCTIONAL ATTITUDES times STRESS interaction continued to predict
depressive symptoms after controlling for anxious symptoms
It is important to note that the current study employed a particularly
conservative approach to analyses in that we examined the effects of dysfunctional
attitudes on depressive and anxious symptoms after controlling for the effect of
neuroticism on such symptoms Providing particularly powerful support for Beckrsquos
(1967 1983) cognitive theory across analyses dysfunctional attitudes predicted levels
of depressive andor anxious symptoms experienced during the six month follow-up
interval independent of the effect of neuroticism Thus contrary to past critical reviews
of the cognitive literature (Barnett amp Gotlib 1998 Coyne amp Whiffen 1995) and
consistent with past findings (Hankin et al 2007) the current results indicate that
cognitive vulnerabilities to depression such as dysfunctional attitudes are not reducible
to trait neuroticism but rather represent factors that confer independent risk for
depression
Limitations and Future Directions
Several limitations of the current study should be noted First self-report
measures were used to assess depressive and anxious symptoms Although the CES-D
and MASQ both possess high degrees of reliability and validity it is difficult to draw
conclusions about clinically diagnosed depression or anxiety based on self-report
questionnaires Second self-report measures were used to assess stress Although
measures of stress that require participants only to indicate whether or not an event
22
occurred are less likely to be influenced by informant bias than those that ask
participants to rate the subjective impact of each event more sophisticated methods of
analysis such as interviewing procedures that assess contextual threat may provide
better assessments of stress Third the measures of dysfunctional attitudes stress and
depressive and anxious symptoms used in the current study were each Western-
developed Future research should examine these hypotheses using indigenous
measures in addition to Western-developed measures in order to assess possible
similarities andor differences in patterns of findings Fourth the current study only
examined depression and anxiety as symptom outcomes Future research conducted
within China should examine a wider array of symptom outcomes such as
somatization physical complaints and externalizing behaviors in order to provide a
more thorough and culturally sensitive test of the specificity hypotheses of Beckrsquos
cognitive model Fifth the current study examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese undergraduate students and thus the extent to which
our findings may be generalized to other demographics within Chinarsquos population is
unclear Last the current study broadly examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese university students Future research should examine
the constructs and processes posited by this model in greater detail in order to develop a
deeper understanding of how they may be uniquely molded by socio-cultural factors
Such research would benefit from examining the specific types of stressors experienced
by Chinese university students as they may vary as a function of socio-cultural factors
from those experienced by Western undergraduates For example severe pressure to
succeed academically in order to secure access to a limited number of post-
23
undergraduate educational opportunities - one of the few paths towards upward
mobility available to Chinese students seeking secure and gainful employment in what
has increasingly become a very highly competitive job market - may represent a
particularly salient stressor for the development of depressive symptoms among this
population (Qiang 2006)
In conclusion the results from the current study provide support for the
applicability of Beckrsquos cognitive theory to university students in mainland China More
specifically consistent with findings obtained in the West results indicate that
dysfunctional attitudes confer vulnerability to the development of depressive symptoms
following the occurrence of negative events in Chinese university students At the same
time however the current findings suggest cultural variation in the profile of
symptoms which emerge following the occurrence of negative events in cognitively
vulnerable individuals in Western and Chinese samples Specifically whereas in the
West dysfunctional attitudes have been shown to confer vulnerability to depressive
symptoms in Chinese university students dysfunctional attitudes appear to confer
vulnerability to a combined depressive and anxious symptom profile Future research
using more sophisticated assessments of stress and depressive symptoms more diverse
samples and symptom outcome measures and indigenously-developed measures is
likely to enhance our understanding of the cognitive and environmental mechanisms
underlying the development of depression in Chinese university students Discovering
that cognitive theories of vulnerability to depression extend to university students in
China highlights the potential role for cognitive-behavioral depression prevention and
treatment interventions in stemming the tide of distress experienced by this population
24
REFERENCES
Abela J R Z amp Hankin B L (2008) Cognitive vulnerability to depression in
children and adolescents A developmental psychopathology perspective In J
R Z Abela and B L Hankin (Eds) Handbook of child and adolescent
depression (pp 35-78) New York The Guilford Press
Alloy L B Abramson L Y Hogan M E Whitehouse W G Rose D T
Robinson MS Kim R S amp Lapkin J B (2000) The Temple-Wisconsin
cognitive vulnerability to depression project Lifetime history of axis-I
psychopathology in individuals at high and low cognitive risk for depression
Journal of Abnormal Psychology 109 403-418
Alloy L B Abramson L Y Whitehouse W G Hogan M E Panzarella C amp
Rose D T (2006) Prospective incidence of first onsets and recurrences of
depression in individuals at high and low cognitive risk for depression Journal
of Abnormal Psychology 115 145ndash156
Altham P M E (1984) Improving the precision of estimation by fitting a model
Journal of the Royal Statistical Society Series B 46 11
Barnett PA amp Gotlib I H (1988) Psychosocial functioning and depression
Distinguishing among antecedents concomitants and consequences
Psychological Bulletin 104 97-126
Beck AT (1967) Depression Clinical experimental and theoretical aspects New
York Harper amp Row
Beck AT (1983) Cognitive therapy of depression New perspectives In PJ Clayton
amp JE Barrett (Eds) Treatment of depression Old controversies and new
approaches New York Raven Press
Bian Q Yang K amp Li C (2007) Dysfunctional attitudes of patients with depression
or bipolar disorder Chinese Mental Health Journal 21 759-761
Blankstein K R amp Flett G L (1993) Development of the General Academic and
Social Hassles Scales for Students Unpublished manuscript
Bonilla J Bernal G Santos A amp Santos D (2003) A revised Spanish version of
the Beck Depression InventoryPsychometric properties with a Puerto Rican
sample of college students Journal of Clinical Psychology 60 119-130
Brown G P Hammen C L Craske M G amp Wickens T D (1995) Dimensions of
dysfunctional attitudes as vulnerabilities to depressive symptoms Journal of
Abnormal Psychology 104 431-435
25
Chioqueta A P amp Stiles T C (2004) Psychometric properties of the Norweigian
version of the Dysfunctional Attitude Scale (Form A) Cognitive Behaviour
Therapy 33 83-86
Clark DA amp Beck AT (1999) Cognitive theory and therapy of depression New
York John Wiley amp Sons Inc
Clark L A amp Watson D (1991) Tripartite model of anxiety and depression
Psychometric evidence and taxonomic implications Journal of Abnormal
Psychology 100 316ndash336
Costa P T amp McCrae R R (1992) NEO PI-R Professional manual Revised NEO
personality inventory NEO PR-R and NEO five-factor inventory NEO-RRI
Odessa FL Psychological Assessment Resources
Coyne J C amp Whiffen V E (1995) Issues in personality as diathesis for depression
The case of sociotropy-dependency and autonomy-self-criticism Psychological
Bulletin 118 358-378
Fang X Qian M Luo S amp Zi F (2009) A correlational study on college students
perfectionism parental rearing patterns and mental health Chinese Mental
Health Journal 23 56-59
Hankin B L Abramson L Y Miller N amp Haeffel G (2004) Cognitive
vulnerability-stress theories of depression Examining affective specificity in
the prediction of depression versus anxiety in three prospective studies
Cognitive Therapy and Research 28 309ndash345
Hankin BL Fraley RC amp Abela JRZ (2005) Daily depression and cognitions
about stress Evidence for a traitlike depressogenic cognitive style and the
prediction of depressive symptoms in a prospective daily diary study Journal of
Personality and Social Psychology 88 673-685
Hankin B L Lakdawalla Z Carter I L Abela J R Z amp Adams P (2007) Are
neuroticism cognitive vulnerabilities and self-esteem overlapping or distinct
risks for depression Evidence from confirmatory factor analyses Journal of
Social amp Clinical Psychology 26 29-63
Hankin B L Wetter E Cheely C amp Oppenheimer C W (2008) Becks cognitive
theory of depression in adolescence Specific prediction of depressive
symptoms and reciprocal influences in a multi-wave prospective study
International Journal of Cognitive Therapy 1 313-332
Ingram R E Miranda J amp Segal Z V (1998) Cognitive Vulnerability to
Depression New York NY Guilford Press
26
Ingram R E amp Luxton DD (2005) Vulnerability-stress models In BL Hankin amp
JRZ Abela (Eds) Development of psychopathology A vulnerability-stress
perspective (pp 32-46) Thousand Oaks CA Sage
Joiner T E Metalsky G I Lew A amp Klocek J (1999) Testing the causal
mediation component of Becks theory of depression Evidence for specific
mediation Cognitive Therapy and Research 23 401-412
Kleinman A (2004) Culture and depression New England Journal of Medicine 351
951-953
Kleinman A (1977) Depression somatization and the new cross-cultural psychiatry
Social Science and Medicine 11 3-10
Kleinman A (1996) How is culture important for DSM-IV In J E Mezzich A
Kleinmam H Fabrega Jr amp L Delores (Eds)Culture and psychiatric
diagnosis A DSM-IV perspective (pp 15-25) Washington DC US American
Psychiatric Association
Klocek J W Oliver J M amp Ross M J (1997) The role of dysfunctional attitudes
negative life events and social support in the prediction of depressive
dysphoria A prospective longitudinal study Social Behavior and Personality
25 23-136
Lee S (1997) A Chinese perspective on somatoform disorders Journal of
Psychosomatic Disorders 43 115-119
Lee S (1998) Estranged bodies simulated harmony and misplaced cultures
Neurasthenia in contemporary Chinese society Psychosomatic Medicine 60
448ndash457
Lee S (1999) Diagnosis postponed Shenjing shuairo and the transformation of
psychiatry in post-Mao China Culture Medicine and Psychiatry 23 349ndash380
Lee S amp Wong K C (1995) Rethinking neurasthenia the illness concepts of
shenjing shuairuo among Chinese undergraduates in Honk Kong Culture
Medicine and Psychiatry 19 91ndash111
Lee S Tsang A Huang YQ He YL Liu ZR Zhang MY Shen YC amp
Kessler RC (2009) The epidemiology of depression in metropolitan China
Psychological Medicine 39 735-747
Mezzich J E Kirmayer L J Kleinman A Fabrega Jr H Parron D L Good B
J Lin K amp Manson S M (1999) The place of culture in DSM-IV Journal
of Nervous and Mental Disease 187 457-464
27
Monroe S M amp Simons A D (1991) Diathesisndashstress theories in the context of life
stress research Implications for the depressive disorders Psychological
Bulletin 110 406ndash425
Murray C J L amp Lopez A D (1996) The global burden of disease Cambridge
Harvard University Press
National Bureau of Statistics of China (2006) The China 2005 statistical yearbook
China Statistics Press Beijing PR China
Oei T P S Goh Y Kwon S M(1996) A cross-cultural study of the integrated
cognitive model of depression Current Psychology of Cognition 15 265-281
Ohrt T amp Thorell L (1998) Dysfunctional Attitude Scale (DAS) Psychometrics and
norms of the Swedish version Scandinavian Journal of Behaviour Therapy 27
105-113
Parker G Gladstone G Chee KT (2001) Depression in the planetrsquos largest ethnic
group The Chinese American Journal of Psychiatry 158 857-864
Phillips M R Zhang J Shi Q Song Z Ding Z Pang S Li X Zhang Y amp
Wang Z (2009) Prevalence treatment and associated disability of mental
disorders in four provinces in China during 2001ndash05 an epidemiological
survey The Lancet 373 2041-2053
Phillips M R Li X amp Zhang Y (2002) Suicide rates in China Lancet 359 835-
840
Phillips M R (1998) The transformation of Chinarsquos mental health services The China
Journal 39 1ndash36
Qiang G (2006) Depression number one killer of Ivory Tower students China Daily
Retrieved from httpwwwchinadailycomcnchina2006-
1128content_744880htm
Radloff L S (1977) The CESndashD scale A self-report depression scale for research in
the general population Applied Psychological Measurement 1 385ndash401
Rin H amp Huang M G (1989) Neurasthenia as nosological dilemma Culture
Medicine and Psychiatry 13 215-226
Sahin NH amp Sahin N (1992) How dysfunctional are the dysfunctional attitudes in
another culture British Journal of Medical Psychology 65 17-26
Shixie L (1989) Neurasthenia in China Modern and traditional criteria for its
diagnosis Culture Medicine and Psychiatry 13 163-186
28
Tanaka N Uji M Hiramura H Chen Z Shikai N amp Kitamura T (2006)
Cognitive patterns and depression Study of a Japanese university student
population Psychiatry and Clinical Neuroscience 60 358-364
Taylor R E (2001) Death of neurasthenia and its psychological reincarnation a study
of neurasthenia at the National Hospital for the Relief and Cure of the Paralysed
and Epileptic Queen Square London 1870ndash1932 British Journal of
Psychiatry 179 550ndash557
Weissman A N amp Beck A T (1978 April) Development and validation of the
Dysfunctional Attitudes Scale A preliminary investigation Paper presented at
the annual meeting of the Educational Research Association Toronto Canada
Xiang M Z (1986) Epidemiological study of neuroses in 12 regions (districts) of
China Chinese Journal of Neurology and Psychiatry 19 87-91
Xu JM (1987) Some issues in the diagnosis of depression in China Canadian
Journal of Psychiatry 32 368-370
Xu Y X (1994) About ICD-10 Journal of Clinical Psychology and Medicine 4 224-
226
Xu Z Li Z amp Wang Z (2007) Dysfunctional attitudes and cognitive bias in major
depressive disorder Chinese Mental Health Journal 21 488-491
Yan H Q (1989) The necessity of retaining the diagnostic concept of neurasthenia
Culture Medicine and Psychiatry 13 139-145
Yang H (2007) The Test of the Chinese version of Frost Multi-dimensional
Perfectionism Scale Chinese Mental Health Journal 21 97-100
Yang H amp Zhang X (2004) Perfectionism and mental health of college students
(2004) Chinese Mental Health Journal 18 647-648
Young D (1989) Neurasthenia and related problems Culture Medicine and
Psychiatry 13 131-138
Zhang D (1995) Depression and culture A Chinese perspective Canadian Journal of
Counseling 29 227ndash233
29
TABLE(S)
Table 1 Demographic Variables
Age 2011
Gender Male
Female
472
523
Parentsrsquo Marital Status Married
Divorced
Single
Remarried
938
23
18
20
Fatherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
Government Official
51
356
187
95
124
91
Motherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
122
406
144
76
134
Fatherrsquos Education Some Primary School
Primary School
Some High School
High School
University
29
139
222
403
137
Motherrsquos Education Some Primary School
Primary School
Some High School
High School
University
63
192
264
350
76
Only Child No
Yes
331
667
Monthly Income lt 1000 RMB
1000 ndash 1500 RMB
1500 ndash 2000 RMB
2000 ndash 3000 RMB
3000 ndash 4000 RMB
4000 ndash 5000 RMB
gt 5000 RMB
334
204
175
140
59
20
20
30
Table 2 Means Standard Deviations and Inter-correlations Between Time 1 Measures
__________________________________________________________________
1 2 3
__________________________________________________________________
1 Depressive Symptoms 2963 (780)
2 Anxious Symptoms 52 3753 (918)
3 Dysfunctional Attitudes 48 33 18120 (2304)
4 Neuroticism 63 42 53 3110 (712)
_________________________________________________________________________
Note Means and standard deviations (in parentheses) are on the diagonal Depressive
Symptoms = Center for Epidemiological Studies Depression Scale Anxious Symptoms
= Mood and Anxiety Symptom Questionnaire Overall Anxiety subscale Dysfunctional
Attitudes = Dysfunctional Attitudes Scale Neuroticism = NEO Five Factor Inventory
Neuroticism subscale p lt 01
31
Table 3 Dysfunctional Attitudes Predicting Within-Subject Fluctuations in CES-D
Scores (upper section) and MASQ Scores (lower section) during the Follow-Up
Interval
______________________________________________________________________
β SE F df
______________________________________________________________________
Time 1 CESD-D 297 026 12987 1572
Stress 005 000 10860 12459
Neuroticism 134 027 2518 1572
Dysfunctional Attitudes -055 040 -183 1572
Dysfunctional Attitudes times Stress 001 000 1078 12459
______________________________________________________________________
Time 1 MASQ 502 033 23158 1575
Stress 006 000 8963 12470
Neuroticism 080 033 596 1575
Dysfunctional Attitudes -052 051 -106 1575
Dysfunctional Attitudes times Stress 002 001 774 12470
______________________________________________________________________
Note Time 1 CES-D = Time 1 Center for Epidemiological Studies Depression Scale
Stress = Within-Subject Fluctuations in General Academic Social Hassles Scale for
Students (GASHSS) scores during the follow-up interval Neuroticism = NEO Five
Factor Inventory Neuroticism subscale Dysfunctional Attitudes = Dysfunctional
Attitudes Scale Time 1 MASQ = Time 1 Mood and Anxiety Symptom Questionnaire
Overall Anxiety subscale p lt 05 p lt 01 p lt 001
32
FIGURES
Figure 1 Predicted slope of the relationship between stress and depressive
symptoms (left panel) and anxious symptoms (right panel) as a function of
dysfunctional attitudes
20
25
30
Low High
Pre
dic
ted
CE
S-D
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
25
30
35
40
Low High
Pre
dic
ted
MA
SQ
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
Intercept Intercept
9
Procedure
Consent forms were distributed to all students in participating classes Consent
rates were greater than 95 in all the classes After consent forms were collected
researchers returned to the school to meet with participating students Written consent
was obtained from each participant at the beginning of the initial assessment During
the initial assessment students completed a demographics form and each of the
following questionnaires (1) Center for Epidemiological Studies Depression Scale
(CES-D Radloff 1977) (2) Mood and Anxiety Symptom Questionnaire (MASQ
Clark amp Watson 1991) (3) Dysfunctional Attitudes Scale (DAS Weissman amp Beck
1978) and (4) NEO Five Factor Inventory- Neuroticism Subscale (FFI-N Costa amp
McCrae 1992) Once a month for the subsequent six-months researchers returned to
the school and met with participating students to conduct follow-up assessments At
each of these follow-up assessments students were asked to complete each of the
following questionnaires (1) CES-D (2) MASQ and (3) the General Academic
Social Hassles Scale for Students (GASHSS Blankstein amp Flett 1993)
Measures
The Chinese versions of all self-report measures were developed using the
back-translation method Original English versions were translated into Chinese by a
bilingual translator from the Psychology department at Second Xiangya Medical
College of Central South University Hunan Translated Chinese versions were then
back-translated into English by another bilingual translator from the Psychology
department at McGill University Quebec Original versions were then compared with
the back-translation If inconsistencies were found in the back-translation translators
10
worked together to make corrections to the final Chinese versions until all final
versions were agreed upon No items from any of the measures were removed or
significantly altered during the translation process
Depressive Symptoms Center for Epidemiological Studies Depression Scale
(CES-D Radloff 1977) The CES-D is a 20-item self-report measure designed to
assess depressive symptoms in the general population For each item participants are
asked to indicate how often they experienced the particular symptom over the last
week Responses range from 1 (eg rarely or none of the time) to 4 (eg most or all of
the time) Scores range from 20-80 with higher score indicating higher levels of
depressive symptoms In the current study the CES-D exhibited high internal
consistency with Cronbachrsquos alpha values ranging from 90 to 94 (micro = 2918 SD =
814) over the 7 time points
Anxious Symptoms Mood and Anxiety Symptom Questionnaire (MASQ
Watson amp Clark 1991) The MASQ is a 62-item questionnaire designed to assess both
specific and nonspecific depressive and anxious symptoms For each item participants
are asked to rate on a scale of 1 to 5 the extent to which they have felt this way ldquoduring
the past 24 hoursrdquo Within the current study we utilized the anxious symptoms (11
items) and anxious arousal (17 items) subscales which together provide an index of
overall anxious symptoms Higher scores on each subscale reflect greater levels of
anxious symptoms In the current study the MASQ exhibited high internal consistency
with Cronbachrsquos alpha values ranging from 90 to 95 (micro = 3847 SD = 1117) over the
7 time points
11
Dysfunctional Attitudes Dysfunctional Attitudes Scale (DAS Weissman amp
Beck 1978) The DAS (Form A) is a 40-item questionnaire designed to measure the
cognitive vulnerability factor featured in Beckrsquos cognitive theory Examples of items
include ldquoIf I do not do well all the time people will not respect merdquo ldquoIf a person asks
for help it is a sign of weaknessrdquo and ldquoMy value as a person depends greatly on what
others think of merdquo Items are rated on a 7-point Likert scale ranging from 1 (totally
disagree) to 7 (totally agree) providing a range of scores from 40 to 280 with higher
scores reflecting more dysfunctional attitudes In the current study the DAS exhibited
high internal consistency with Cronbachrsquos alphas of 89 and 88 obtained for the first
and second administrations respectively In addition a test-retest reliability coefficient
of 72 was obtained indicating strong stability over time
Neuroticism NEO Five Factor Inventory - Neuroticism Subscale (FFI-N
Costa amp McCrae 1992) The FFI-N is a 12- item self-report measure that assesses
neuroticism Examples of questions include I often feel inferior to others I am
seldom sad or depressed and Sometimes I feel completely worthless Items are rated
on a 5-point Likert scale ranging from 0 (strongly disagree) to 4 (strongly agree)
providing scores ranging from 0 to 48 with higher scores indicating higher levels of
neuroticism The NEO-FFI-N has proven reliable across different cultural samples and
item pools (Costa amp McCrae 1992) In the current study Cronbachs alpha was 81
indicating strong internal consistency
Negative Life Events General Academic Social Hassles Scale for Students
(GASHSS Blankstein amp Flett 1993) Participants completed a 30-item abbreviated
version of the GASHSS The measure is comprised of items assessing general hassles
12
(8 items) academic hassles (10 items) and social hassles (12 items) For each item
participants are asked to rate how persistent the given hassle was (ie its frequency and
duration) over the last 30 days (0 = no hassle not at all persistent to 6 = extremely
persistent hassle high frequency andor duration)
13
RESULTS
Descriptive Data
Means standard deviations and inter-correlations between Time 1 measures are
presented in Table 2
Prospective Diathesis-Stress Analyses - Depression
Multilevel modeling was used to test our hypothesis that higher levels of dysfunctional
attitudes would be associated with greater increases in depressive symptoms following
increases in stress Analyses were carried out using the SAS (version 81) MIXED
procedure and maximum likelihood estimation Our dependent variable was within-
subject fluctuations in CES-D scores during the follow-up interval (DEPRESSION)
Our primary predictors of DEPRESSION were DAS scores (DYSFUNCTIONAL
ATTITUDES) and fluctuations in GASHSS scores during the follow-up interval
(STRESS) As DYSFUNCTIONAL ATTITUDES is a between-subject predictor DAS
scores were standardized prior to analyses As STRESS is a within-subject predictor
STRESS reflects upward or downward fluctuations in an individualrsquos level of stress
compared to hisher mean level of stress
When fitting hierarchical linear models one must specify appropriate mean and
covariance structures Mean structures refer to the various fixed and random effect
components that can be included in the model Covariance structures refer to alternative
methods of specifying the pattern of covariance between observations taken from the
same subject at different time points It is important to note that mean and covariance
structures are not independent of one another Rather an appropriate covariance
structure is essential in order to obtain valid inferences for the parameters in the mean
14
structure Overparametrization of the covariance structure can lead to inefficient
estimation and poor assessment of standard errors (Altham 1984) On the other hand
too much restriction of the covariance structure can lead to invalid inferences when the
assumed structure does not hold (Altham 1984)
In our first set of analyses we were interested in examining the effects of
DYSFUNCTIONAL ATTITUDES STRESS and the DYSFUNCTIONAL
ATTITUDES STRESS interaction on participantrsquos CES-D scores during the follow-
up interval Consequently in line with Diggle Liang and Zegers (1994)
recommendation that one use a ldquosaturatedrdquo model for the mean structure while
searching for an appropriate covariance structure we chose a mean structure that
included DYSFUNCTIONAL ATTITUDES STRESS and the DYSFUNCTIONAL
ATTITUDES STRESS interaction Four additional effects were also included in this
mean structure First as different individuals report different levels of depressive
symptoms when at their own average level of stress a random effect for intercept was
included in the model Second given that STRESS is a within-subject predictor whose
effect is expected to vary from participant to participant a random effect for slope was
included in the model Third in order to control for individual differences in baseline
levels of depressive symptoms Time 1 CES-D scores were included in the model
Fourth in order to examine whether DYSFUNCTIONAL ATTITUDES represent a
vulnerability factor independent of neuroticism participantsrsquo FFI-N scores were
entered in the model
Commonly used covariance structures in studies in which multiple responses
are obtained from the same individual over time (and consequently within-subject
15
residuals over time are likely to be correlated) include compound symmetry first-order
autoregressive heterogeneous autoregressive and banded Toeplitz In order to select
one of these covariance structures for our analyses we fitted models using each
structure and chose the ldquobestrdquo fit based on Akaike information criterion (AIC and
AICC) and Schwarz Bayesian criterion (BIC) In all cases the best fit for our data was
a first-order heterogeneous autoregressive structure (ARH [1]) After choosing the
appropriate covariance structure we next examined the random-effects component of
our model
With respect to random effects the ARH [1] parameter (r = 31 plt001)
RE_INTERCEPT (plt001) and RE_SLOPE (plt001) were each significant and thus
were retained in the model The final results with respect to the fixed-effects
component of the model are presented in the upper section of Table 3 Of primary
importance the DYSFUNCTIONAL ATTITUDES STRESS interaction was a
significant predictor of fluctuations in depressive symptoms during the follow-up
interval In order to examine the form of this interaction the model summarized in the
upper section of Table 3 was used to calculate predicted CES-D scores for individuals
exhibiting either high or low levels of dysfunctional attitudes (plus or minus 15 SD)
who are experiencing either high or low levels of stress in comparison to their own
average level of stress (plus or minus 15 times mean within-subject SD) The results of
such calculations are presented in the left panel of Figure 1
Analyses were conducted for each DYSFUNCTIONAL ATTITUDES
condition examining whether the slope of the relationship between stress and
depressive symptoms significantly differed from 0 Analyses indicated that both
16
individuals exhibiting high (t(2459) = 862 p lt 0001) and low (t(2459) = 347 p lt
0001) levels of dysfunctional attitudes reported significantly higher levels of
depressive symptoms when experiencing high levels of stress than when experiencing
low levels of stress Planned comparisons of the slopes of the relationship between
stress and depressive symptoms however revealed that the slope was significantly
greater in individuals exhibiting high levels of dysfunctional attitudes (slope = 013)
than in individuals exhibiting low levels of dysfunctional attitudes (slope = 005
t(2459) = 328 p = 0001)
Prospective Diathesis-Stress Analyses - Anxiety
The same data-analytic approach as described above was used to examine
whether higher levels of dysfunctional attitudes would be associated with greater
increases in anxious symptoms following increases in stress Again in order to examine
whether DYSFUNCTIONAL ATTITUDES represent a vulnerability factor
independent of neuroticism participantsrsquo FFI-N scores were entered in the model
With respect to random effects the ARH[1] parameter (r = 23 p lt 001)
RE_INTERCEPT (plt001) and RE_SLOPE (plt001) were each significant and thus
were retained in the model The final results with respect to the fixed-effects
component of the model are presented in the lower section of Table 3 Of primary
importance the DYSFUNCTIONAL ATTITUDES STRESS interaction was a
significant predictor of within-subject fluctuations in anxious symptoms during the
follow-up interval In order to examine the form of this interaction the model
summarized in the lower section of Table 3 was used to calculate predicted MASQ
scores for individuals exhibiting either high or low levels of dysfunctional attitudes
17
(plus or minus 15 SD) who are experiencing either high or low levels of stress in
comparison to their own average level of stress (plus or minus 15 times mean within-
subject SD) The results of such calculations are presented on the right panel of in
Figure 1
Analyses were conducted for each DYSFUNCTIONAL ATTITUDES
condition examining whether the slope of the relationship between stress and anxious
symptoms significantly differed from 0 Analyses indicated that both individuals
exhibiting high (t(2470) = 768 p lt 0001) and low (t(2470) = 337 p lt 0001) levels of
dysfunctional attitudes reported higher levels of anxious symptoms when experiencing
high levels of stress than when experiencing low levels of stress Planned comparisons
of the slopes of the relationship between stress and anxious symptoms however
revealed that the slope was significantly greater in individuals exhibiting high levels of
dysfunctional attitudes (slope = 009) than in individuals exhibiting low levels of
dysfunctional attitudes (slope = 003 t(2470) = 278 p lt 001)
Additional Analyses
Given that the DYSFUNCTIONAL ATTITUDES STRESS interaction
prospectively predicted both symptoms of depression and anxiety two additional
analyses were conducted in order to examine (1) whether the DYSFUNCTIONAL
ATTITUDES STRESS interaction continued to be a significant predictor of within-
subject fluctuations in depressive symptoms after controlling for within-subject
fluctuations in anxious symptoms and (2) whether the DYSFUNCTIONAL
ATTITUDES STRESS interaction continued to predict within-subject fluctuations in
anxious symptoms after controlling for within-subject fluctuations in depressive
18
symptoms Such analyses allowed us to examine whether the above mentioned pattern
of findings may have been due to the high correlation observed in the current study
between depressive and anxious symptoms
Analyses were conducted in the same manner as described above with the
exception that an additional within-subject variable (ie DEPRESSION or ANXIETY)
was included in each model in order to control for within-subject fluctuations in the
alternate symptom With respect to the prediction of depressive symptoms the
DYSFUNCTIONAL ATTITUDES STRESS interaction remained a significant
predictor after controlling for within-subject fluctuations in anxious symptoms (β =
001 SE = 000 F = 410 p lt 05) With respect to the prediction of anxious
symptoms however the DYSFUNCTIONAL ATTITUDES STRESS interaction
was no longer a significant predictor after controlling for within-subject fluctuations in
depressive symptoms (β = 001 SE = 000 F = 148 p = 22)
DISCUSSION
The results of the current study provide support for the cross-cultural
applicability of Beckrsquos (1967 1983) cognitive theory to university students in Hunan
China More specifically consistent with hypotheses and with results obtained from
past research examining Beckrsquos cognitive theory in Western samples of university
students (Hankin et al 2004 Hankin et al 2005 Joiner et al 1999 Klocek et al
1997 Brown et al 1995) higher levels of dysfunctional attitudes were associated with
greater increases in depressive symptoms following increases in negative event
frequency during the six-month follow-up interval Given the considerable differences
between the current sample and Western samples in terms of demographic
19
characteristics and cultural factors such a finding strongly attests to the robustness of
Beckrsquos cognitive theory Moreover integrating the current findings with those obtained
in research examining Beckrsquos theory in other non-Western samples suggests that
Beckrsquos theory may represent a powerful explanatory model of the development of
depressive symptoms among individuals from diverse cultural settings For example
consistent with the theory higher levels of dysfunctional attitudes have been shown to
be associated with higher levels of depressive symptoms in Japanese (Tanaka et al
2006) Puerto-Rican (Bonilla Bernal Santos amp Santos 2003) Turkish (Sahin amp Sahin
1992) Norwegian (Chioqueta amp Stiles 2004) Singaporean (Oei Goh amp Kwon 1996)
and Swedish (Ohrt amp Thorell 1998) adult samples In addition it is important to note
that the current findings expand upon past correlational research examining the
association between dysfunctional attitudes and depression in Chinese samples through
the use of a multi-wave longitudinal design
When examining the specificity of dysfunctional attitudes as a predictor of
depressive symptoms the current study did not obtain support for specificity More
specifically contrary to the specificity hypothesis of Beckrsquos cognitive theory and to
results obtained in Western samples of university students (Alloy et al 2000 2006
Hankin et al 2004) higher levels of dysfunctional attitudes were associated with
greater increases in both depressive and anxious symptoms following increases in
negative event frequency There are two alternative ways of interpreting the non-
specificity finding observed in the current study First it is possible that the types of
thoughts individuals possessing high levels of dysfunctional attitudes experience
following negative events varies as a function of cultural context In other words in
20
Western samples such individuals may primarily experience the types of cognitions
that are associated with the development of depressive symptoms (ie appraisals of
personal loss and failure) In contrast in Chinese samples individuals possessing high
levels of dysfunctional attitudes may experience a wider array of cognitions some of
which are associated with the development of depressive symptoms and some of which
are associated with the development of anxious symptoms (ie evaluations of
impending threat or danger) Such an explanation would be consistent with Beckrsquos
cognitive content-specificity hypothesis (Clark amp Beck 1999) which posits that each
affective state and psychological disorder has a specific cognitive profile Second it is
possible that the types of symptoms individuals possessing high levels of dysfunctional
attitudes experience following negative events varies as a function of cultural context
More specifically it may be that dysfunctional attitudes specifically predict symptoms
of depression in both samples except that in Western samples depression manifests in
pure depressive symptoms whereas in Chinese samples depression manifests as a
combination of depressive and anxious symptoms Such an explanation would be
consistent with cultural psychopathologistsrsquo hypotheses that cultural factors shape the
phenomenology of psychiatric symptoms (Kleinman 2004 Mezzich et al 1999)
Moreover dysfunctional attitudes predicting a combination of depressive and anxious
symptoms in Chinese samples would be consistent with the construct of neurasthenia -
a construct hypothesized by some to represent a somatized form of depression that is
still widely seen within China (Lee amp Wong 1995)
Interesting in this regard and perhaps speaking to the primacy of depressive
symptoms in the current findings analyses indicated that the DYSFUNCTIONAL
21
ATTITUDES times STRESS interaction no longer predicted anxious symptoms after
controlling for depressive symptoms The reverse however was not true as the
DYSFUNCTIONAL ATTITUDES times STRESS interaction continued to predict
depressive symptoms after controlling for anxious symptoms
It is important to note that the current study employed a particularly
conservative approach to analyses in that we examined the effects of dysfunctional
attitudes on depressive and anxious symptoms after controlling for the effect of
neuroticism on such symptoms Providing particularly powerful support for Beckrsquos
(1967 1983) cognitive theory across analyses dysfunctional attitudes predicted levels
of depressive andor anxious symptoms experienced during the six month follow-up
interval independent of the effect of neuroticism Thus contrary to past critical reviews
of the cognitive literature (Barnett amp Gotlib 1998 Coyne amp Whiffen 1995) and
consistent with past findings (Hankin et al 2007) the current results indicate that
cognitive vulnerabilities to depression such as dysfunctional attitudes are not reducible
to trait neuroticism but rather represent factors that confer independent risk for
depression
Limitations and Future Directions
Several limitations of the current study should be noted First self-report
measures were used to assess depressive and anxious symptoms Although the CES-D
and MASQ both possess high degrees of reliability and validity it is difficult to draw
conclusions about clinically diagnosed depression or anxiety based on self-report
questionnaires Second self-report measures were used to assess stress Although
measures of stress that require participants only to indicate whether or not an event
22
occurred are less likely to be influenced by informant bias than those that ask
participants to rate the subjective impact of each event more sophisticated methods of
analysis such as interviewing procedures that assess contextual threat may provide
better assessments of stress Third the measures of dysfunctional attitudes stress and
depressive and anxious symptoms used in the current study were each Western-
developed Future research should examine these hypotheses using indigenous
measures in addition to Western-developed measures in order to assess possible
similarities andor differences in patterns of findings Fourth the current study only
examined depression and anxiety as symptom outcomes Future research conducted
within China should examine a wider array of symptom outcomes such as
somatization physical complaints and externalizing behaviors in order to provide a
more thorough and culturally sensitive test of the specificity hypotheses of Beckrsquos
cognitive model Fifth the current study examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese undergraduate students and thus the extent to which
our findings may be generalized to other demographics within Chinarsquos population is
unclear Last the current study broadly examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese university students Future research should examine
the constructs and processes posited by this model in greater detail in order to develop a
deeper understanding of how they may be uniquely molded by socio-cultural factors
Such research would benefit from examining the specific types of stressors experienced
by Chinese university students as they may vary as a function of socio-cultural factors
from those experienced by Western undergraduates For example severe pressure to
succeed academically in order to secure access to a limited number of post-
23
undergraduate educational opportunities - one of the few paths towards upward
mobility available to Chinese students seeking secure and gainful employment in what
has increasingly become a very highly competitive job market - may represent a
particularly salient stressor for the development of depressive symptoms among this
population (Qiang 2006)
In conclusion the results from the current study provide support for the
applicability of Beckrsquos cognitive theory to university students in mainland China More
specifically consistent with findings obtained in the West results indicate that
dysfunctional attitudes confer vulnerability to the development of depressive symptoms
following the occurrence of negative events in Chinese university students At the same
time however the current findings suggest cultural variation in the profile of
symptoms which emerge following the occurrence of negative events in cognitively
vulnerable individuals in Western and Chinese samples Specifically whereas in the
West dysfunctional attitudes have been shown to confer vulnerability to depressive
symptoms in Chinese university students dysfunctional attitudes appear to confer
vulnerability to a combined depressive and anxious symptom profile Future research
using more sophisticated assessments of stress and depressive symptoms more diverse
samples and symptom outcome measures and indigenously-developed measures is
likely to enhance our understanding of the cognitive and environmental mechanisms
underlying the development of depression in Chinese university students Discovering
that cognitive theories of vulnerability to depression extend to university students in
China highlights the potential role for cognitive-behavioral depression prevention and
treatment interventions in stemming the tide of distress experienced by this population
24
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Abela J R Z amp Hankin B L (2008) Cognitive vulnerability to depression in
children and adolescents A developmental psychopathology perspective In J
R Z Abela and B L Hankin (Eds) Handbook of child and adolescent
depression (pp 35-78) New York The Guilford Press
Alloy L B Abramson L Y Hogan M E Whitehouse W G Rose D T
Robinson MS Kim R S amp Lapkin J B (2000) The Temple-Wisconsin
cognitive vulnerability to depression project Lifetime history of axis-I
psychopathology in individuals at high and low cognitive risk for depression
Journal of Abnormal Psychology 109 403-418
Alloy L B Abramson L Y Whitehouse W G Hogan M E Panzarella C amp
Rose D T (2006) Prospective incidence of first onsets and recurrences of
depression in individuals at high and low cognitive risk for depression Journal
of Abnormal Psychology 115 145ndash156
Altham P M E (1984) Improving the precision of estimation by fitting a model
Journal of the Royal Statistical Society Series B 46 11
Barnett PA amp Gotlib I H (1988) Psychosocial functioning and depression
Distinguishing among antecedents concomitants and consequences
Psychological Bulletin 104 97-126
Beck AT (1967) Depression Clinical experimental and theoretical aspects New
York Harper amp Row
Beck AT (1983) Cognitive therapy of depression New perspectives In PJ Clayton
amp JE Barrett (Eds) Treatment of depression Old controversies and new
approaches New York Raven Press
Bian Q Yang K amp Li C (2007) Dysfunctional attitudes of patients with depression
or bipolar disorder Chinese Mental Health Journal 21 759-761
Blankstein K R amp Flett G L (1993) Development of the General Academic and
Social Hassles Scales for Students Unpublished manuscript
Bonilla J Bernal G Santos A amp Santos D (2003) A revised Spanish version of
the Beck Depression InventoryPsychometric properties with a Puerto Rican
sample of college students Journal of Clinical Psychology 60 119-130
Brown G P Hammen C L Craske M G amp Wickens T D (1995) Dimensions of
dysfunctional attitudes as vulnerabilities to depressive symptoms Journal of
Abnormal Psychology 104 431-435
25
Chioqueta A P amp Stiles T C (2004) Psychometric properties of the Norweigian
version of the Dysfunctional Attitude Scale (Form A) Cognitive Behaviour
Therapy 33 83-86
Clark DA amp Beck AT (1999) Cognitive theory and therapy of depression New
York John Wiley amp Sons Inc
Clark L A amp Watson D (1991) Tripartite model of anxiety and depression
Psychometric evidence and taxonomic implications Journal of Abnormal
Psychology 100 316ndash336
Costa P T amp McCrae R R (1992) NEO PI-R Professional manual Revised NEO
personality inventory NEO PR-R and NEO five-factor inventory NEO-RRI
Odessa FL Psychological Assessment Resources
Coyne J C amp Whiffen V E (1995) Issues in personality as diathesis for depression
The case of sociotropy-dependency and autonomy-self-criticism Psychological
Bulletin 118 358-378
Fang X Qian M Luo S amp Zi F (2009) A correlational study on college students
perfectionism parental rearing patterns and mental health Chinese Mental
Health Journal 23 56-59
Hankin B L Abramson L Y Miller N amp Haeffel G (2004) Cognitive
vulnerability-stress theories of depression Examining affective specificity in
the prediction of depression versus anxiety in three prospective studies
Cognitive Therapy and Research 28 309ndash345
Hankin BL Fraley RC amp Abela JRZ (2005) Daily depression and cognitions
about stress Evidence for a traitlike depressogenic cognitive style and the
prediction of depressive symptoms in a prospective daily diary study Journal of
Personality and Social Psychology 88 673-685
Hankin B L Lakdawalla Z Carter I L Abela J R Z amp Adams P (2007) Are
neuroticism cognitive vulnerabilities and self-esteem overlapping or distinct
risks for depression Evidence from confirmatory factor analyses Journal of
Social amp Clinical Psychology 26 29-63
Hankin B L Wetter E Cheely C amp Oppenheimer C W (2008) Becks cognitive
theory of depression in adolescence Specific prediction of depressive
symptoms and reciprocal influences in a multi-wave prospective study
International Journal of Cognitive Therapy 1 313-332
Ingram R E Miranda J amp Segal Z V (1998) Cognitive Vulnerability to
Depression New York NY Guilford Press
26
Ingram R E amp Luxton DD (2005) Vulnerability-stress models In BL Hankin amp
JRZ Abela (Eds) Development of psychopathology A vulnerability-stress
perspective (pp 32-46) Thousand Oaks CA Sage
Joiner T E Metalsky G I Lew A amp Klocek J (1999) Testing the causal
mediation component of Becks theory of depression Evidence for specific
mediation Cognitive Therapy and Research 23 401-412
Kleinman A (2004) Culture and depression New England Journal of Medicine 351
951-953
Kleinman A (1977) Depression somatization and the new cross-cultural psychiatry
Social Science and Medicine 11 3-10
Kleinman A (1996) How is culture important for DSM-IV In J E Mezzich A
Kleinmam H Fabrega Jr amp L Delores (Eds)Culture and psychiatric
diagnosis A DSM-IV perspective (pp 15-25) Washington DC US American
Psychiatric Association
Klocek J W Oliver J M amp Ross M J (1997) The role of dysfunctional attitudes
negative life events and social support in the prediction of depressive
dysphoria A prospective longitudinal study Social Behavior and Personality
25 23-136
Lee S (1997) A Chinese perspective on somatoform disorders Journal of
Psychosomatic Disorders 43 115-119
Lee S (1998) Estranged bodies simulated harmony and misplaced cultures
Neurasthenia in contemporary Chinese society Psychosomatic Medicine 60
448ndash457
Lee S (1999) Diagnosis postponed Shenjing shuairo and the transformation of
psychiatry in post-Mao China Culture Medicine and Psychiatry 23 349ndash380
Lee S amp Wong K C (1995) Rethinking neurasthenia the illness concepts of
shenjing shuairuo among Chinese undergraduates in Honk Kong Culture
Medicine and Psychiatry 19 91ndash111
Lee S Tsang A Huang YQ He YL Liu ZR Zhang MY Shen YC amp
Kessler RC (2009) The epidemiology of depression in metropolitan China
Psychological Medicine 39 735-747
Mezzich J E Kirmayer L J Kleinman A Fabrega Jr H Parron D L Good B
J Lin K amp Manson S M (1999) The place of culture in DSM-IV Journal
of Nervous and Mental Disease 187 457-464
27
Monroe S M amp Simons A D (1991) Diathesisndashstress theories in the context of life
stress research Implications for the depressive disorders Psychological
Bulletin 110 406ndash425
Murray C J L amp Lopez A D (1996) The global burden of disease Cambridge
Harvard University Press
National Bureau of Statistics of China (2006) The China 2005 statistical yearbook
China Statistics Press Beijing PR China
Oei T P S Goh Y Kwon S M(1996) A cross-cultural study of the integrated
cognitive model of depression Current Psychology of Cognition 15 265-281
Ohrt T amp Thorell L (1998) Dysfunctional Attitude Scale (DAS) Psychometrics and
norms of the Swedish version Scandinavian Journal of Behaviour Therapy 27
105-113
Parker G Gladstone G Chee KT (2001) Depression in the planetrsquos largest ethnic
group The Chinese American Journal of Psychiatry 158 857-864
Phillips M R Zhang J Shi Q Song Z Ding Z Pang S Li X Zhang Y amp
Wang Z (2009) Prevalence treatment and associated disability of mental
disorders in four provinces in China during 2001ndash05 an epidemiological
survey The Lancet 373 2041-2053
Phillips M R Li X amp Zhang Y (2002) Suicide rates in China Lancet 359 835-
840
Phillips M R (1998) The transformation of Chinarsquos mental health services The China
Journal 39 1ndash36
Qiang G (2006) Depression number one killer of Ivory Tower students China Daily
Retrieved from httpwwwchinadailycomcnchina2006-
1128content_744880htm
Radloff L S (1977) The CESndashD scale A self-report depression scale for research in
the general population Applied Psychological Measurement 1 385ndash401
Rin H amp Huang M G (1989) Neurasthenia as nosological dilemma Culture
Medicine and Psychiatry 13 215-226
Sahin NH amp Sahin N (1992) How dysfunctional are the dysfunctional attitudes in
another culture British Journal of Medical Psychology 65 17-26
Shixie L (1989) Neurasthenia in China Modern and traditional criteria for its
diagnosis Culture Medicine and Psychiatry 13 163-186
28
Tanaka N Uji M Hiramura H Chen Z Shikai N amp Kitamura T (2006)
Cognitive patterns and depression Study of a Japanese university student
population Psychiatry and Clinical Neuroscience 60 358-364
Taylor R E (2001) Death of neurasthenia and its psychological reincarnation a study
of neurasthenia at the National Hospital for the Relief and Cure of the Paralysed
and Epileptic Queen Square London 1870ndash1932 British Journal of
Psychiatry 179 550ndash557
Weissman A N amp Beck A T (1978 April) Development and validation of the
Dysfunctional Attitudes Scale A preliminary investigation Paper presented at
the annual meeting of the Educational Research Association Toronto Canada
Xiang M Z (1986) Epidemiological study of neuroses in 12 regions (districts) of
China Chinese Journal of Neurology and Psychiatry 19 87-91
Xu JM (1987) Some issues in the diagnosis of depression in China Canadian
Journal of Psychiatry 32 368-370
Xu Y X (1994) About ICD-10 Journal of Clinical Psychology and Medicine 4 224-
226
Xu Z Li Z amp Wang Z (2007) Dysfunctional attitudes and cognitive bias in major
depressive disorder Chinese Mental Health Journal 21 488-491
Yan H Q (1989) The necessity of retaining the diagnostic concept of neurasthenia
Culture Medicine and Psychiatry 13 139-145
Yang H (2007) The Test of the Chinese version of Frost Multi-dimensional
Perfectionism Scale Chinese Mental Health Journal 21 97-100
Yang H amp Zhang X (2004) Perfectionism and mental health of college students
(2004) Chinese Mental Health Journal 18 647-648
Young D (1989) Neurasthenia and related problems Culture Medicine and
Psychiatry 13 131-138
Zhang D (1995) Depression and culture A Chinese perspective Canadian Journal of
Counseling 29 227ndash233
29
TABLE(S)
Table 1 Demographic Variables
Age 2011
Gender Male
Female
472
523
Parentsrsquo Marital Status Married
Divorced
Single
Remarried
938
23
18
20
Fatherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
Government Official
51
356
187
95
124
91
Motherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
122
406
144
76
134
Fatherrsquos Education Some Primary School
Primary School
Some High School
High School
University
29
139
222
403
137
Motherrsquos Education Some Primary School
Primary School
Some High School
High School
University
63
192
264
350
76
Only Child No
Yes
331
667
Monthly Income lt 1000 RMB
1000 ndash 1500 RMB
1500 ndash 2000 RMB
2000 ndash 3000 RMB
3000 ndash 4000 RMB
4000 ndash 5000 RMB
gt 5000 RMB
334
204
175
140
59
20
20
30
Table 2 Means Standard Deviations and Inter-correlations Between Time 1 Measures
__________________________________________________________________
1 2 3
__________________________________________________________________
1 Depressive Symptoms 2963 (780)
2 Anxious Symptoms 52 3753 (918)
3 Dysfunctional Attitudes 48 33 18120 (2304)
4 Neuroticism 63 42 53 3110 (712)
_________________________________________________________________________
Note Means and standard deviations (in parentheses) are on the diagonal Depressive
Symptoms = Center for Epidemiological Studies Depression Scale Anxious Symptoms
= Mood and Anxiety Symptom Questionnaire Overall Anxiety subscale Dysfunctional
Attitudes = Dysfunctional Attitudes Scale Neuroticism = NEO Five Factor Inventory
Neuroticism subscale p lt 01
31
Table 3 Dysfunctional Attitudes Predicting Within-Subject Fluctuations in CES-D
Scores (upper section) and MASQ Scores (lower section) during the Follow-Up
Interval
______________________________________________________________________
β SE F df
______________________________________________________________________
Time 1 CESD-D 297 026 12987 1572
Stress 005 000 10860 12459
Neuroticism 134 027 2518 1572
Dysfunctional Attitudes -055 040 -183 1572
Dysfunctional Attitudes times Stress 001 000 1078 12459
______________________________________________________________________
Time 1 MASQ 502 033 23158 1575
Stress 006 000 8963 12470
Neuroticism 080 033 596 1575
Dysfunctional Attitudes -052 051 -106 1575
Dysfunctional Attitudes times Stress 002 001 774 12470
______________________________________________________________________
Note Time 1 CES-D = Time 1 Center for Epidemiological Studies Depression Scale
Stress = Within-Subject Fluctuations in General Academic Social Hassles Scale for
Students (GASHSS) scores during the follow-up interval Neuroticism = NEO Five
Factor Inventory Neuroticism subscale Dysfunctional Attitudes = Dysfunctional
Attitudes Scale Time 1 MASQ = Time 1 Mood and Anxiety Symptom Questionnaire
Overall Anxiety subscale p lt 05 p lt 01 p lt 001
32
FIGURES
Figure 1 Predicted slope of the relationship between stress and depressive
symptoms (left panel) and anxious symptoms (right panel) as a function of
dysfunctional attitudes
20
25
30
Low High
Pre
dic
ted
CE
S-D
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
25
30
35
40
Low High
Pre
dic
ted
MA
SQ
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
Intercept Intercept
10
worked together to make corrections to the final Chinese versions until all final
versions were agreed upon No items from any of the measures were removed or
significantly altered during the translation process
Depressive Symptoms Center for Epidemiological Studies Depression Scale
(CES-D Radloff 1977) The CES-D is a 20-item self-report measure designed to
assess depressive symptoms in the general population For each item participants are
asked to indicate how often they experienced the particular symptom over the last
week Responses range from 1 (eg rarely or none of the time) to 4 (eg most or all of
the time) Scores range from 20-80 with higher score indicating higher levels of
depressive symptoms In the current study the CES-D exhibited high internal
consistency with Cronbachrsquos alpha values ranging from 90 to 94 (micro = 2918 SD =
814) over the 7 time points
Anxious Symptoms Mood and Anxiety Symptom Questionnaire (MASQ
Watson amp Clark 1991) The MASQ is a 62-item questionnaire designed to assess both
specific and nonspecific depressive and anxious symptoms For each item participants
are asked to rate on a scale of 1 to 5 the extent to which they have felt this way ldquoduring
the past 24 hoursrdquo Within the current study we utilized the anxious symptoms (11
items) and anxious arousal (17 items) subscales which together provide an index of
overall anxious symptoms Higher scores on each subscale reflect greater levels of
anxious symptoms In the current study the MASQ exhibited high internal consistency
with Cronbachrsquos alpha values ranging from 90 to 95 (micro = 3847 SD = 1117) over the
7 time points
11
Dysfunctional Attitudes Dysfunctional Attitudes Scale (DAS Weissman amp
Beck 1978) The DAS (Form A) is a 40-item questionnaire designed to measure the
cognitive vulnerability factor featured in Beckrsquos cognitive theory Examples of items
include ldquoIf I do not do well all the time people will not respect merdquo ldquoIf a person asks
for help it is a sign of weaknessrdquo and ldquoMy value as a person depends greatly on what
others think of merdquo Items are rated on a 7-point Likert scale ranging from 1 (totally
disagree) to 7 (totally agree) providing a range of scores from 40 to 280 with higher
scores reflecting more dysfunctional attitudes In the current study the DAS exhibited
high internal consistency with Cronbachrsquos alphas of 89 and 88 obtained for the first
and second administrations respectively In addition a test-retest reliability coefficient
of 72 was obtained indicating strong stability over time
Neuroticism NEO Five Factor Inventory - Neuroticism Subscale (FFI-N
Costa amp McCrae 1992) The FFI-N is a 12- item self-report measure that assesses
neuroticism Examples of questions include I often feel inferior to others I am
seldom sad or depressed and Sometimes I feel completely worthless Items are rated
on a 5-point Likert scale ranging from 0 (strongly disagree) to 4 (strongly agree)
providing scores ranging from 0 to 48 with higher scores indicating higher levels of
neuroticism The NEO-FFI-N has proven reliable across different cultural samples and
item pools (Costa amp McCrae 1992) In the current study Cronbachs alpha was 81
indicating strong internal consistency
Negative Life Events General Academic Social Hassles Scale for Students
(GASHSS Blankstein amp Flett 1993) Participants completed a 30-item abbreviated
version of the GASHSS The measure is comprised of items assessing general hassles
12
(8 items) academic hassles (10 items) and social hassles (12 items) For each item
participants are asked to rate how persistent the given hassle was (ie its frequency and
duration) over the last 30 days (0 = no hassle not at all persistent to 6 = extremely
persistent hassle high frequency andor duration)
13
RESULTS
Descriptive Data
Means standard deviations and inter-correlations between Time 1 measures are
presented in Table 2
Prospective Diathesis-Stress Analyses - Depression
Multilevel modeling was used to test our hypothesis that higher levels of dysfunctional
attitudes would be associated with greater increases in depressive symptoms following
increases in stress Analyses were carried out using the SAS (version 81) MIXED
procedure and maximum likelihood estimation Our dependent variable was within-
subject fluctuations in CES-D scores during the follow-up interval (DEPRESSION)
Our primary predictors of DEPRESSION were DAS scores (DYSFUNCTIONAL
ATTITUDES) and fluctuations in GASHSS scores during the follow-up interval
(STRESS) As DYSFUNCTIONAL ATTITUDES is a between-subject predictor DAS
scores were standardized prior to analyses As STRESS is a within-subject predictor
STRESS reflects upward or downward fluctuations in an individualrsquos level of stress
compared to hisher mean level of stress
When fitting hierarchical linear models one must specify appropriate mean and
covariance structures Mean structures refer to the various fixed and random effect
components that can be included in the model Covariance structures refer to alternative
methods of specifying the pattern of covariance between observations taken from the
same subject at different time points It is important to note that mean and covariance
structures are not independent of one another Rather an appropriate covariance
structure is essential in order to obtain valid inferences for the parameters in the mean
14
structure Overparametrization of the covariance structure can lead to inefficient
estimation and poor assessment of standard errors (Altham 1984) On the other hand
too much restriction of the covariance structure can lead to invalid inferences when the
assumed structure does not hold (Altham 1984)
In our first set of analyses we were interested in examining the effects of
DYSFUNCTIONAL ATTITUDES STRESS and the DYSFUNCTIONAL
ATTITUDES STRESS interaction on participantrsquos CES-D scores during the follow-
up interval Consequently in line with Diggle Liang and Zegers (1994)
recommendation that one use a ldquosaturatedrdquo model for the mean structure while
searching for an appropriate covariance structure we chose a mean structure that
included DYSFUNCTIONAL ATTITUDES STRESS and the DYSFUNCTIONAL
ATTITUDES STRESS interaction Four additional effects were also included in this
mean structure First as different individuals report different levels of depressive
symptoms when at their own average level of stress a random effect for intercept was
included in the model Second given that STRESS is a within-subject predictor whose
effect is expected to vary from participant to participant a random effect for slope was
included in the model Third in order to control for individual differences in baseline
levels of depressive symptoms Time 1 CES-D scores were included in the model
Fourth in order to examine whether DYSFUNCTIONAL ATTITUDES represent a
vulnerability factor independent of neuroticism participantsrsquo FFI-N scores were
entered in the model
Commonly used covariance structures in studies in which multiple responses
are obtained from the same individual over time (and consequently within-subject
15
residuals over time are likely to be correlated) include compound symmetry first-order
autoregressive heterogeneous autoregressive and banded Toeplitz In order to select
one of these covariance structures for our analyses we fitted models using each
structure and chose the ldquobestrdquo fit based on Akaike information criterion (AIC and
AICC) and Schwarz Bayesian criterion (BIC) In all cases the best fit for our data was
a first-order heterogeneous autoregressive structure (ARH [1]) After choosing the
appropriate covariance structure we next examined the random-effects component of
our model
With respect to random effects the ARH [1] parameter (r = 31 plt001)
RE_INTERCEPT (plt001) and RE_SLOPE (plt001) were each significant and thus
were retained in the model The final results with respect to the fixed-effects
component of the model are presented in the upper section of Table 3 Of primary
importance the DYSFUNCTIONAL ATTITUDES STRESS interaction was a
significant predictor of fluctuations in depressive symptoms during the follow-up
interval In order to examine the form of this interaction the model summarized in the
upper section of Table 3 was used to calculate predicted CES-D scores for individuals
exhibiting either high or low levels of dysfunctional attitudes (plus or minus 15 SD)
who are experiencing either high or low levels of stress in comparison to their own
average level of stress (plus or minus 15 times mean within-subject SD) The results of
such calculations are presented in the left panel of Figure 1
Analyses were conducted for each DYSFUNCTIONAL ATTITUDES
condition examining whether the slope of the relationship between stress and
depressive symptoms significantly differed from 0 Analyses indicated that both
16
individuals exhibiting high (t(2459) = 862 p lt 0001) and low (t(2459) = 347 p lt
0001) levels of dysfunctional attitudes reported significantly higher levels of
depressive symptoms when experiencing high levels of stress than when experiencing
low levels of stress Planned comparisons of the slopes of the relationship between
stress and depressive symptoms however revealed that the slope was significantly
greater in individuals exhibiting high levels of dysfunctional attitudes (slope = 013)
than in individuals exhibiting low levels of dysfunctional attitudes (slope = 005
t(2459) = 328 p = 0001)
Prospective Diathesis-Stress Analyses - Anxiety
The same data-analytic approach as described above was used to examine
whether higher levels of dysfunctional attitudes would be associated with greater
increases in anxious symptoms following increases in stress Again in order to examine
whether DYSFUNCTIONAL ATTITUDES represent a vulnerability factor
independent of neuroticism participantsrsquo FFI-N scores were entered in the model
With respect to random effects the ARH[1] parameter (r = 23 p lt 001)
RE_INTERCEPT (plt001) and RE_SLOPE (plt001) were each significant and thus
were retained in the model The final results with respect to the fixed-effects
component of the model are presented in the lower section of Table 3 Of primary
importance the DYSFUNCTIONAL ATTITUDES STRESS interaction was a
significant predictor of within-subject fluctuations in anxious symptoms during the
follow-up interval In order to examine the form of this interaction the model
summarized in the lower section of Table 3 was used to calculate predicted MASQ
scores for individuals exhibiting either high or low levels of dysfunctional attitudes
17
(plus or minus 15 SD) who are experiencing either high or low levels of stress in
comparison to their own average level of stress (plus or minus 15 times mean within-
subject SD) The results of such calculations are presented on the right panel of in
Figure 1
Analyses were conducted for each DYSFUNCTIONAL ATTITUDES
condition examining whether the slope of the relationship between stress and anxious
symptoms significantly differed from 0 Analyses indicated that both individuals
exhibiting high (t(2470) = 768 p lt 0001) and low (t(2470) = 337 p lt 0001) levels of
dysfunctional attitudes reported higher levels of anxious symptoms when experiencing
high levels of stress than when experiencing low levels of stress Planned comparisons
of the slopes of the relationship between stress and anxious symptoms however
revealed that the slope was significantly greater in individuals exhibiting high levels of
dysfunctional attitudes (slope = 009) than in individuals exhibiting low levels of
dysfunctional attitudes (slope = 003 t(2470) = 278 p lt 001)
Additional Analyses
Given that the DYSFUNCTIONAL ATTITUDES STRESS interaction
prospectively predicted both symptoms of depression and anxiety two additional
analyses were conducted in order to examine (1) whether the DYSFUNCTIONAL
ATTITUDES STRESS interaction continued to be a significant predictor of within-
subject fluctuations in depressive symptoms after controlling for within-subject
fluctuations in anxious symptoms and (2) whether the DYSFUNCTIONAL
ATTITUDES STRESS interaction continued to predict within-subject fluctuations in
anxious symptoms after controlling for within-subject fluctuations in depressive
18
symptoms Such analyses allowed us to examine whether the above mentioned pattern
of findings may have been due to the high correlation observed in the current study
between depressive and anxious symptoms
Analyses were conducted in the same manner as described above with the
exception that an additional within-subject variable (ie DEPRESSION or ANXIETY)
was included in each model in order to control for within-subject fluctuations in the
alternate symptom With respect to the prediction of depressive symptoms the
DYSFUNCTIONAL ATTITUDES STRESS interaction remained a significant
predictor after controlling for within-subject fluctuations in anxious symptoms (β =
001 SE = 000 F = 410 p lt 05) With respect to the prediction of anxious
symptoms however the DYSFUNCTIONAL ATTITUDES STRESS interaction
was no longer a significant predictor after controlling for within-subject fluctuations in
depressive symptoms (β = 001 SE = 000 F = 148 p = 22)
DISCUSSION
The results of the current study provide support for the cross-cultural
applicability of Beckrsquos (1967 1983) cognitive theory to university students in Hunan
China More specifically consistent with hypotheses and with results obtained from
past research examining Beckrsquos cognitive theory in Western samples of university
students (Hankin et al 2004 Hankin et al 2005 Joiner et al 1999 Klocek et al
1997 Brown et al 1995) higher levels of dysfunctional attitudes were associated with
greater increases in depressive symptoms following increases in negative event
frequency during the six-month follow-up interval Given the considerable differences
between the current sample and Western samples in terms of demographic
19
characteristics and cultural factors such a finding strongly attests to the robustness of
Beckrsquos cognitive theory Moreover integrating the current findings with those obtained
in research examining Beckrsquos theory in other non-Western samples suggests that
Beckrsquos theory may represent a powerful explanatory model of the development of
depressive symptoms among individuals from diverse cultural settings For example
consistent with the theory higher levels of dysfunctional attitudes have been shown to
be associated with higher levels of depressive symptoms in Japanese (Tanaka et al
2006) Puerto-Rican (Bonilla Bernal Santos amp Santos 2003) Turkish (Sahin amp Sahin
1992) Norwegian (Chioqueta amp Stiles 2004) Singaporean (Oei Goh amp Kwon 1996)
and Swedish (Ohrt amp Thorell 1998) adult samples In addition it is important to note
that the current findings expand upon past correlational research examining the
association between dysfunctional attitudes and depression in Chinese samples through
the use of a multi-wave longitudinal design
When examining the specificity of dysfunctional attitudes as a predictor of
depressive symptoms the current study did not obtain support for specificity More
specifically contrary to the specificity hypothesis of Beckrsquos cognitive theory and to
results obtained in Western samples of university students (Alloy et al 2000 2006
Hankin et al 2004) higher levels of dysfunctional attitudes were associated with
greater increases in both depressive and anxious symptoms following increases in
negative event frequency There are two alternative ways of interpreting the non-
specificity finding observed in the current study First it is possible that the types of
thoughts individuals possessing high levels of dysfunctional attitudes experience
following negative events varies as a function of cultural context In other words in
20
Western samples such individuals may primarily experience the types of cognitions
that are associated with the development of depressive symptoms (ie appraisals of
personal loss and failure) In contrast in Chinese samples individuals possessing high
levels of dysfunctional attitudes may experience a wider array of cognitions some of
which are associated with the development of depressive symptoms and some of which
are associated with the development of anxious symptoms (ie evaluations of
impending threat or danger) Such an explanation would be consistent with Beckrsquos
cognitive content-specificity hypothesis (Clark amp Beck 1999) which posits that each
affective state and psychological disorder has a specific cognitive profile Second it is
possible that the types of symptoms individuals possessing high levels of dysfunctional
attitudes experience following negative events varies as a function of cultural context
More specifically it may be that dysfunctional attitudes specifically predict symptoms
of depression in both samples except that in Western samples depression manifests in
pure depressive symptoms whereas in Chinese samples depression manifests as a
combination of depressive and anxious symptoms Such an explanation would be
consistent with cultural psychopathologistsrsquo hypotheses that cultural factors shape the
phenomenology of psychiatric symptoms (Kleinman 2004 Mezzich et al 1999)
Moreover dysfunctional attitudes predicting a combination of depressive and anxious
symptoms in Chinese samples would be consistent with the construct of neurasthenia -
a construct hypothesized by some to represent a somatized form of depression that is
still widely seen within China (Lee amp Wong 1995)
Interesting in this regard and perhaps speaking to the primacy of depressive
symptoms in the current findings analyses indicated that the DYSFUNCTIONAL
21
ATTITUDES times STRESS interaction no longer predicted anxious symptoms after
controlling for depressive symptoms The reverse however was not true as the
DYSFUNCTIONAL ATTITUDES times STRESS interaction continued to predict
depressive symptoms after controlling for anxious symptoms
It is important to note that the current study employed a particularly
conservative approach to analyses in that we examined the effects of dysfunctional
attitudes on depressive and anxious symptoms after controlling for the effect of
neuroticism on such symptoms Providing particularly powerful support for Beckrsquos
(1967 1983) cognitive theory across analyses dysfunctional attitudes predicted levels
of depressive andor anxious symptoms experienced during the six month follow-up
interval independent of the effect of neuroticism Thus contrary to past critical reviews
of the cognitive literature (Barnett amp Gotlib 1998 Coyne amp Whiffen 1995) and
consistent with past findings (Hankin et al 2007) the current results indicate that
cognitive vulnerabilities to depression such as dysfunctional attitudes are not reducible
to trait neuroticism but rather represent factors that confer independent risk for
depression
Limitations and Future Directions
Several limitations of the current study should be noted First self-report
measures were used to assess depressive and anxious symptoms Although the CES-D
and MASQ both possess high degrees of reliability and validity it is difficult to draw
conclusions about clinically diagnosed depression or anxiety based on self-report
questionnaires Second self-report measures were used to assess stress Although
measures of stress that require participants only to indicate whether or not an event
22
occurred are less likely to be influenced by informant bias than those that ask
participants to rate the subjective impact of each event more sophisticated methods of
analysis such as interviewing procedures that assess contextual threat may provide
better assessments of stress Third the measures of dysfunctional attitudes stress and
depressive and anxious symptoms used in the current study were each Western-
developed Future research should examine these hypotheses using indigenous
measures in addition to Western-developed measures in order to assess possible
similarities andor differences in patterns of findings Fourth the current study only
examined depression and anxiety as symptom outcomes Future research conducted
within China should examine a wider array of symptom outcomes such as
somatization physical complaints and externalizing behaviors in order to provide a
more thorough and culturally sensitive test of the specificity hypotheses of Beckrsquos
cognitive model Fifth the current study examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese undergraduate students and thus the extent to which
our findings may be generalized to other demographics within Chinarsquos population is
unclear Last the current study broadly examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese university students Future research should examine
the constructs and processes posited by this model in greater detail in order to develop a
deeper understanding of how they may be uniquely molded by socio-cultural factors
Such research would benefit from examining the specific types of stressors experienced
by Chinese university students as they may vary as a function of socio-cultural factors
from those experienced by Western undergraduates For example severe pressure to
succeed academically in order to secure access to a limited number of post-
23
undergraduate educational opportunities - one of the few paths towards upward
mobility available to Chinese students seeking secure and gainful employment in what
has increasingly become a very highly competitive job market - may represent a
particularly salient stressor for the development of depressive symptoms among this
population (Qiang 2006)
In conclusion the results from the current study provide support for the
applicability of Beckrsquos cognitive theory to university students in mainland China More
specifically consistent with findings obtained in the West results indicate that
dysfunctional attitudes confer vulnerability to the development of depressive symptoms
following the occurrence of negative events in Chinese university students At the same
time however the current findings suggest cultural variation in the profile of
symptoms which emerge following the occurrence of negative events in cognitively
vulnerable individuals in Western and Chinese samples Specifically whereas in the
West dysfunctional attitudes have been shown to confer vulnerability to depressive
symptoms in Chinese university students dysfunctional attitudes appear to confer
vulnerability to a combined depressive and anxious symptom profile Future research
using more sophisticated assessments of stress and depressive symptoms more diverse
samples and symptom outcome measures and indigenously-developed measures is
likely to enhance our understanding of the cognitive and environmental mechanisms
underlying the development of depression in Chinese university students Discovering
that cognitive theories of vulnerability to depression extend to university students in
China highlights the potential role for cognitive-behavioral depression prevention and
treatment interventions in stemming the tide of distress experienced by this population
24
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Abela J R Z amp Hankin B L (2008) Cognitive vulnerability to depression in
children and adolescents A developmental psychopathology perspective In J
R Z Abela and B L Hankin (Eds) Handbook of child and adolescent
depression (pp 35-78) New York The Guilford Press
Alloy L B Abramson L Y Hogan M E Whitehouse W G Rose D T
Robinson MS Kim R S amp Lapkin J B (2000) The Temple-Wisconsin
cognitive vulnerability to depression project Lifetime history of axis-I
psychopathology in individuals at high and low cognitive risk for depression
Journal of Abnormal Psychology 109 403-418
Alloy L B Abramson L Y Whitehouse W G Hogan M E Panzarella C amp
Rose D T (2006) Prospective incidence of first onsets and recurrences of
depression in individuals at high and low cognitive risk for depression Journal
of Abnormal Psychology 115 145ndash156
Altham P M E (1984) Improving the precision of estimation by fitting a model
Journal of the Royal Statistical Society Series B 46 11
Barnett PA amp Gotlib I H (1988) Psychosocial functioning and depression
Distinguishing among antecedents concomitants and consequences
Psychological Bulletin 104 97-126
Beck AT (1967) Depression Clinical experimental and theoretical aspects New
York Harper amp Row
Beck AT (1983) Cognitive therapy of depression New perspectives In PJ Clayton
amp JE Barrett (Eds) Treatment of depression Old controversies and new
approaches New York Raven Press
Bian Q Yang K amp Li C (2007) Dysfunctional attitudes of patients with depression
or bipolar disorder Chinese Mental Health Journal 21 759-761
Blankstein K R amp Flett G L (1993) Development of the General Academic and
Social Hassles Scales for Students Unpublished manuscript
Bonilla J Bernal G Santos A amp Santos D (2003) A revised Spanish version of
the Beck Depression InventoryPsychometric properties with a Puerto Rican
sample of college students Journal of Clinical Psychology 60 119-130
Brown G P Hammen C L Craske M G amp Wickens T D (1995) Dimensions of
dysfunctional attitudes as vulnerabilities to depressive symptoms Journal of
Abnormal Psychology 104 431-435
25
Chioqueta A P amp Stiles T C (2004) Psychometric properties of the Norweigian
version of the Dysfunctional Attitude Scale (Form A) Cognitive Behaviour
Therapy 33 83-86
Clark DA amp Beck AT (1999) Cognitive theory and therapy of depression New
York John Wiley amp Sons Inc
Clark L A amp Watson D (1991) Tripartite model of anxiety and depression
Psychometric evidence and taxonomic implications Journal of Abnormal
Psychology 100 316ndash336
Costa P T amp McCrae R R (1992) NEO PI-R Professional manual Revised NEO
personality inventory NEO PR-R and NEO five-factor inventory NEO-RRI
Odessa FL Psychological Assessment Resources
Coyne J C amp Whiffen V E (1995) Issues in personality as diathesis for depression
The case of sociotropy-dependency and autonomy-self-criticism Psychological
Bulletin 118 358-378
Fang X Qian M Luo S amp Zi F (2009) A correlational study on college students
perfectionism parental rearing patterns and mental health Chinese Mental
Health Journal 23 56-59
Hankin B L Abramson L Y Miller N amp Haeffel G (2004) Cognitive
vulnerability-stress theories of depression Examining affective specificity in
the prediction of depression versus anxiety in three prospective studies
Cognitive Therapy and Research 28 309ndash345
Hankin BL Fraley RC amp Abela JRZ (2005) Daily depression and cognitions
about stress Evidence for a traitlike depressogenic cognitive style and the
prediction of depressive symptoms in a prospective daily diary study Journal of
Personality and Social Psychology 88 673-685
Hankin B L Lakdawalla Z Carter I L Abela J R Z amp Adams P (2007) Are
neuroticism cognitive vulnerabilities and self-esteem overlapping or distinct
risks for depression Evidence from confirmatory factor analyses Journal of
Social amp Clinical Psychology 26 29-63
Hankin B L Wetter E Cheely C amp Oppenheimer C W (2008) Becks cognitive
theory of depression in adolescence Specific prediction of depressive
symptoms and reciprocal influences in a multi-wave prospective study
International Journal of Cognitive Therapy 1 313-332
Ingram R E Miranda J amp Segal Z V (1998) Cognitive Vulnerability to
Depression New York NY Guilford Press
26
Ingram R E amp Luxton DD (2005) Vulnerability-stress models In BL Hankin amp
JRZ Abela (Eds) Development of psychopathology A vulnerability-stress
perspective (pp 32-46) Thousand Oaks CA Sage
Joiner T E Metalsky G I Lew A amp Klocek J (1999) Testing the causal
mediation component of Becks theory of depression Evidence for specific
mediation Cognitive Therapy and Research 23 401-412
Kleinman A (2004) Culture and depression New England Journal of Medicine 351
951-953
Kleinman A (1977) Depression somatization and the new cross-cultural psychiatry
Social Science and Medicine 11 3-10
Kleinman A (1996) How is culture important for DSM-IV In J E Mezzich A
Kleinmam H Fabrega Jr amp L Delores (Eds)Culture and psychiatric
diagnosis A DSM-IV perspective (pp 15-25) Washington DC US American
Psychiatric Association
Klocek J W Oliver J M amp Ross M J (1997) The role of dysfunctional attitudes
negative life events and social support in the prediction of depressive
dysphoria A prospective longitudinal study Social Behavior and Personality
25 23-136
Lee S (1997) A Chinese perspective on somatoform disorders Journal of
Psychosomatic Disorders 43 115-119
Lee S (1998) Estranged bodies simulated harmony and misplaced cultures
Neurasthenia in contemporary Chinese society Psychosomatic Medicine 60
448ndash457
Lee S (1999) Diagnosis postponed Shenjing shuairo and the transformation of
psychiatry in post-Mao China Culture Medicine and Psychiatry 23 349ndash380
Lee S amp Wong K C (1995) Rethinking neurasthenia the illness concepts of
shenjing shuairuo among Chinese undergraduates in Honk Kong Culture
Medicine and Psychiatry 19 91ndash111
Lee S Tsang A Huang YQ He YL Liu ZR Zhang MY Shen YC amp
Kessler RC (2009) The epidemiology of depression in metropolitan China
Psychological Medicine 39 735-747
Mezzich J E Kirmayer L J Kleinman A Fabrega Jr H Parron D L Good B
J Lin K amp Manson S M (1999) The place of culture in DSM-IV Journal
of Nervous and Mental Disease 187 457-464
27
Monroe S M amp Simons A D (1991) Diathesisndashstress theories in the context of life
stress research Implications for the depressive disorders Psychological
Bulletin 110 406ndash425
Murray C J L amp Lopez A D (1996) The global burden of disease Cambridge
Harvard University Press
National Bureau of Statistics of China (2006) The China 2005 statistical yearbook
China Statistics Press Beijing PR China
Oei T P S Goh Y Kwon S M(1996) A cross-cultural study of the integrated
cognitive model of depression Current Psychology of Cognition 15 265-281
Ohrt T amp Thorell L (1998) Dysfunctional Attitude Scale (DAS) Psychometrics and
norms of the Swedish version Scandinavian Journal of Behaviour Therapy 27
105-113
Parker G Gladstone G Chee KT (2001) Depression in the planetrsquos largest ethnic
group The Chinese American Journal of Psychiatry 158 857-864
Phillips M R Zhang J Shi Q Song Z Ding Z Pang S Li X Zhang Y amp
Wang Z (2009) Prevalence treatment and associated disability of mental
disorders in four provinces in China during 2001ndash05 an epidemiological
survey The Lancet 373 2041-2053
Phillips M R Li X amp Zhang Y (2002) Suicide rates in China Lancet 359 835-
840
Phillips M R (1998) The transformation of Chinarsquos mental health services The China
Journal 39 1ndash36
Qiang G (2006) Depression number one killer of Ivory Tower students China Daily
Retrieved from httpwwwchinadailycomcnchina2006-
1128content_744880htm
Radloff L S (1977) The CESndashD scale A self-report depression scale for research in
the general population Applied Psychological Measurement 1 385ndash401
Rin H amp Huang M G (1989) Neurasthenia as nosological dilemma Culture
Medicine and Psychiatry 13 215-226
Sahin NH amp Sahin N (1992) How dysfunctional are the dysfunctional attitudes in
another culture British Journal of Medical Psychology 65 17-26
Shixie L (1989) Neurasthenia in China Modern and traditional criteria for its
diagnosis Culture Medicine and Psychiatry 13 163-186
28
Tanaka N Uji M Hiramura H Chen Z Shikai N amp Kitamura T (2006)
Cognitive patterns and depression Study of a Japanese university student
population Psychiatry and Clinical Neuroscience 60 358-364
Taylor R E (2001) Death of neurasthenia and its psychological reincarnation a study
of neurasthenia at the National Hospital for the Relief and Cure of the Paralysed
and Epileptic Queen Square London 1870ndash1932 British Journal of
Psychiatry 179 550ndash557
Weissman A N amp Beck A T (1978 April) Development and validation of the
Dysfunctional Attitudes Scale A preliminary investigation Paper presented at
the annual meeting of the Educational Research Association Toronto Canada
Xiang M Z (1986) Epidemiological study of neuroses in 12 regions (districts) of
China Chinese Journal of Neurology and Psychiatry 19 87-91
Xu JM (1987) Some issues in the diagnosis of depression in China Canadian
Journal of Psychiatry 32 368-370
Xu Y X (1994) About ICD-10 Journal of Clinical Psychology and Medicine 4 224-
226
Xu Z Li Z amp Wang Z (2007) Dysfunctional attitudes and cognitive bias in major
depressive disorder Chinese Mental Health Journal 21 488-491
Yan H Q (1989) The necessity of retaining the diagnostic concept of neurasthenia
Culture Medicine and Psychiatry 13 139-145
Yang H (2007) The Test of the Chinese version of Frost Multi-dimensional
Perfectionism Scale Chinese Mental Health Journal 21 97-100
Yang H amp Zhang X (2004) Perfectionism and mental health of college students
(2004) Chinese Mental Health Journal 18 647-648
Young D (1989) Neurasthenia and related problems Culture Medicine and
Psychiatry 13 131-138
Zhang D (1995) Depression and culture A Chinese perspective Canadian Journal of
Counseling 29 227ndash233
29
TABLE(S)
Table 1 Demographic Variables
Age 2011
Gender Male
Female
472
523
Parentsrsquo Marital Status Married
Divorced
Single
Remarried
938
23
18
20
Fatherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
Government Official
51
356
187
95
124
91
Motherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
122
406
144
76
134
Fatherrsquos Education Some Primary School
Primary School
Some High School
High School
University
29
139
222
403
137
Motherrsquos Education Some Primary School
Primary School
Some High School
High School
University
63
192
264
350
76
Only Child No
Yes
331
667
Monthly Income lt 1000 RMB
1000 ndash 1500 RMB
1500 ndash 2000 RMB
2000 ndash 3000 RMB
3000 ndash 4000 RMB
4000 ndash 5000 RMB
gt 5000 RMB
334
204
175
140
59
20
20
30
Table 2 Means Standard Deviations and Inter-correlations Between Time 1 Measures
__________________________________________________________________
1 2 3
__________________________________________________________________
1 Depressive Symptoms 2963 (780)
2 Anxious Symptoms 52 3753 (918)
3 Dysfunctional Attitudes 48 33 18120 (2304)
4 Neuroticism 63 42 53 3110 (712)
_________________________________________________________________________
Note Means and standard deviations (in parentheses) are on the diagonal Depressive
Symptoms = Center for Epidemiological Studies Depression Scale Anxious Symptoms
= Mood and Anxiety Symptom Questionnaire Overall Anxiety subscale Dysfunctional
Attitudes = Dysfunctional Attitudes Scale Neuroticism = NEO Five Factor Inventory
Neuroticism subscale p lt 01
31
Table 3 Dysfunctional Attitudes Predicting Within-Subject Fluctuations in CES-D
Scores (upper section) and MASQ Scores (lower section) during the Follow-Up
Interval
______________________________________________________________________
β SE F df
______________________________________________________________________
Time 1 CESD-D 297 026 12987 1572
Stress 005 000 10860 12459
Neuroticism 134 027 2518 1572
Dysfunctional Attitudes -055 040 -183 1572
Dysfunctional Attitudes times Stress 001 000 1078 12459
______________________________________________________________________
Time 1 MASQ 502 033 23158 1575
Stress 006 000 8963 12470
Neuroticism 080 033 596 1575
Dysfunctional Attitudes -052 051 -106 1575
Dysfunctional Attitudes times Stress 002 001 774 12470
______________________________________________________________________
Note Time 1 CES-D = Time 1 Center for Epidemiological Studies Depression Scale
Stress = Within-Subject Fluctuations in General Academic Social Hassles Scale for
Students (GASHSS) scores during the follow-up interval Neuroticism = NEO Five
Factor Inventory Neuroticism subscale Dysfunctional Attitudes = Dysfunctional
Attitudes Scale Time 1 MASQ = Time 1 Mood and Anxiety Symptom Questionnaire
Overall Anxiety subscale p lt 05 p lt 01 p lt 001
32
FIGURES
Figure 1 Predicted slope of the relationship between stress and depressive
symptoms (left panel) and anxious symptoms (right panel) as a function of
dysfunctional attitudes
20
25
30
Low High
Pre
dic
ted
CE
S-D
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
25
30
35
40
Low High
Pre
dic
ted
MA
SQ
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
Intercept Intercept
11
Dysfunctional Attitudes Dysfunctional Attitudes Scale (DAS Weissman amp
Beck 1978) The DAS (Form A) is a 40-item questionnaire designed to measure the
cognitive vulnerability factor featured in Beckrsquos cognitive theory Examples of items
include ldquoIf I do not do well all the time people will not respect merdquo ldquoIf a person asks
for help it is a sign of weaknessrdquo and ldquoMy value as a person depends greatly on what
others think of merdquo Items are rated on a 7-point Likert scale ranging from 1 (totally
disagree) to 7 (totally agree) providing a range of scores from 40 to 280 with higher
scores reflecting more dysfunctional attitudes In the current study the DAS exhibited
high internal consistency with Cronbachrsquos alphas of 89 and 88 obtained for the first
and second administrations respectively In addition a test-retest reliability coefficient
of 72 was obtained indicating strong stability over time
Neuroticism NEO Five Factor Inventory - Neuroticism Subscale (FFI-N
Costa amp McCrae 1992) The FFI-N is a 12- item self-report measure that assesses
neuroticism Examples of questions include I often feel inferior to others I am
seldom sad or depressed and Sometimes I feel completely worthless Items are rated
on a 5-point Likert scale ranging from 0 (strongly disagree) to 4 (strongly agree)
providing scores ranging from 0 to 48 with higher scores indicating higher levels of
neuroticism The NEO-FFI-N has proven reliable across different cultural samples and
item pools (Costa amp McCrae 1992) In the current study Cronbachs alpha was 81
indicating strong internal consistency
Negative Life Events General Academic Social Hassles Scale for Students
(GASHSS Blankstein amp Flett 1993) Participants completed a 30-item abbreviated
version of the GASHSS The measure is comprised of items assessing general hassles
12
(8 items) academic hassles (10 items) and social hassles (12 items) For each item
participants are asked to rate how persistent the given hassle was (ie its frequency and
duration) over the last 30 days (0 = no hassle not at all persistent to 6 = extremely
persistent hassle high frequency andor duration)
13
RESULTS
Descriptive Data
Means standard deviations and inter-correlations between Time 1 measures are
presented in Table 2
Prospective Diathesis-Stress Analyses - Depression
Multilevel modeling was used to test our hypothesis that higher levels of dysfunctional
attitudes would be associated with greater increases in depressive symptoms following
increases in stress Analyses were carried out using the SAS (version 81) MIXED
procedure and maximum likelihood estimation Our dependent variable was within-
subject fluctuations in CES-D scores during the follow-up interval (DEPRESSION)
Our primary predictors of DEPRESSION were DAS scores (DYSFUNCTIONAL
ATTITUDES) and fluctuations in GASHSS scores during the follow-up interval
(STRESS) As DYSFUNCTIONAL ATTITUDES is a between-subject predictor DAS
scores were standardized prior to analyses As STRESS is a within-subject predictor
STRESS reflects upward or downward fluctuations in an individualrsquos level of stress
compared to hisher mean level of stress
When fitting hierarchical linear models one must specify appropriate mean and
covariance structures Mean structures refer to the various fixed and random effect
components that can be included in the model Covariance structures refer to alternative
methods of specifying the pattern of covariance between observations taken from the
same subject at different time points It is important to note that mean and covariance
structures are not independent of one another Rather an appropriate covariance
structure is essential in order to obtain valid inferences for the parameters in the mean
14
structure Overparametrization of the covariance structure can lead to inefficient
estimation and poor assessment of standard errors (Altham 1984) On the other hand
too much restriction of the covariance structure can lead to invalid inferences when the
assumed structure does not hold (Altham 1984)
In our first set of analyses we were interested in examining the effects of
DYSFUNCTIONAL ATTITUDES STRESS and the DYSFUNCTIONAL
ATTITUDES STRESS interaction on participantrsquos CES-D scores during the follow-
up interval Consequently in line with Diggle Liang and Zegers (1994)
recommendation that one use a ldquosaturatedrdquo model for the mean structure while
searching for an appropriate covariance structure we chose a mean structure that
included DYSFUNCTIONAL ATTITUDES STRESS and the DYSFUNCTIONAL
ATTITUDES STRESS interaction Four additional effects were also included in this
mean structure First as different individuals report different levels of depressive
symptoms when at their own average level of stress a random effect for intercept was
included in the model Second given that STRESS is a within-subject predictor whose
effect is expected to vary from participant to participant a random effect for slope was
included in the model Third in order to control for individual differences in baseline
levels of depressive symptoms Time 1 CES-D scores were included in the model
Fourth in order to examine whether DYSFUNCTIONAL ATTITUDES represent a
vulnerability factor independent of neuroticism participantsrsquo FFI-N scores were
entered in the model
Commonly used covariance structures in studies in which multiple responses
are obtained from the same individual over time (and consequently within-subject
15
residuals over time are likely to be correlated) include compound symmetry first-order
autoregressive heterogeneous autoregressive and banded Toeplitz In order to select
one of these covariance structures for our analyses we fitted models using each
structure and chose the ldquobestrdquo fit based on Akaike information criterion (AIC and
AICC) and Schwarz Bayesian criterion (BIC) In all cases the best fit for our data was
a first-order heterogeneous autoregressive structure (ARH [1]) After choosing the
appropriate covariance structure we next examined the random-effects component of
our model
With respect to random effects the ARH [1] parameter (r = 31 plt001)
RE_INTERCEPT (plt001) and RE_SLOPE (plt001) were each significant and thus
were retained in the model The final results with respect to the fixed-effects
component of the model are presented in the upper section of Table 3 Of primary
importance the DYSFUNCTIONAL ATTITUDES STRESS interaction was a
significant predictor of fluctuations in depressive symptoms during the follow-up
interval In order to examine the form of this interaction the model summarized in the
upper section of Table 3 was used to calculate predicted CES-D scores for individuals
exhibiting either high or low levels of dysfunctional attitudes (plus or minus 15 SD)
who are experiencing either high or low levels of stress in comparison to their own
average level of stress (plus or minus 15 times mean within-subject SD) The results of
such calculations are presented in the left panel of Figure 1
Analyses were conducted for each DYSFUNCTIONAL ATTITUDES
condition examining whether the slope of the relationship between stress and
depressive symptoms significantly differed from 0 Analyses indicated that both
16
individuals exhibiting high (t(2459) = 862 p lt 0001) and low (t(2459) = 347 p lt
0001) levels of dysfunctional attitudes reported significantly higher levels of
depressive symptoms when experiencing high levels of stress than when experiencing
low levels of stress Planned comparisons of the slopes of the relationship between
stress and depressive symptoms however revealed that the slope was significantly
greater in individuals exhibiting high levels of dysfunctional attitudes (slope = 013)
than in individuals exhibiting low levels of dysfunctional attitudes (slope = 005
t(2459) = 328 p = 0001)
Prospective Diathesis-Stress Analyses - Anxiety
The same data-analytic approach as described above was used to examine
whether higher levels of dysfunctional attitudes would be associated with greater
increases in anxious symptoms following increases in stress Again in order to examine
whether DYSFUNCTIONAL ATTITUDES represent a vulnerability factor
independent of neuroticism participantsrsquo FFI-N scores were entered in the model
With respect to random effects the ARH[1] parameter (r = 23 p lt 001)
RE_INTERCEPT (plt001) and RE_SLOPE (plt001) were each significant and thus
were retained in the model The final results with respect to the fixed-effects
component of the model are presented in the lower section of Table 3 Of primary
importance the DYSFUNCTIONAL ATTITUDES STRESS interaction was a
significant predictor of within-subject fluctuations in anxious symptoms during the
follow-up interval In order to examine the form of this interaction the model
summarized in the lower section of Table 3 was used to calculate predicted MASQ
scores for individuals exhibiting either high or low levels of dysfunctional attitudes
17
(plus or minus 15 SD) who are experiencing either high or low levels of stress in
comparison to their own average level of stress (plus or minus 15 times mean within-
subject SD) The results of such calculations are presented on the right panel of in
Figure 1
Analyses were conducted for each DYSFUNCTIONAL ATTITUDES
condition examining whether the slope of the relationship between stress and anxious
symptoms significantly differed from 0 Analyses indicated that both individuals
exhibiting high (t(2470) = 768 p lt 0001) and low (t(2470) = 337 p lt 0001) levels of
dysfunctional attitudes reported higher levels of anxious symptoms when experiencing
high levels of stress than when experiencing low levels of stress Planned comparisons
of the slopes of the relationship between stress and anxious symptoms however
revealed that the slope was significantly greater in individuals exhibiting high levels of
dysfunctional attitudes (slope = 009) than in individuals exhibiting low levels of
dysfunctional attitudes (slope = 003 t(2470) = 278 p lt 001)
Additional Analyses
Given that the DYSFUNCTIONAL ATTITUDES STRESS interaction
prospectively predicted both symptoms of depression and anxiety two additional
analyses were conducted in order to examine (1) whether the DYSFUNCTIONAL
ATTITUDES STRESS interaction continued to be a significant predictor of within-
subject fluctuations in depressive symptoms after controlling for within-subject
fluctuations in anxious symptoms and (2) whether the DYSFUNCTIONAL
ATTITUDES STRESS interaction continued to predict within-subject fluctuations in
anxious symptoms after controlling for within-subject fluctuations in depressive
18
symptoms Such analyses allowed us to examine whether the above mentioned pattern
of findings may have been due to the high correlation observed in the current study
between depressive and anxious symptoms
Analyses were conducted in the same manner as described above with the
exception that an additional within-subject variable (ie DEPRESSION or ANXIETY)
was included in each model in order to control for within-subject fluctuations in the
alternate symptom With respect to the prediction of depressive symptoms the
DYSFUNCTIONAL ATTITUDES STRESS interaction remained a significant
predictor after controlling for within-subject fluctuations in anxious symptoms (β =
001 SE = 000 F = 410 p lt 05) With respect to the prediction of anxious
symptoms however the DYSFUNCTIONAL ATTITUDES STRESS interaction
was no longer a significant predictor after controlling for within-subject fluctuations in
depressive symptoms (β = 001 SE = 000 F = 148 p = 22)
DISCUSSION
The results of the current study provide support for the cross-cultural
applicability of Beckrsquos (1967 1983) cognitive theory to university students in Hunan
China More specifically consistent with hypotheses and with results obtained from
past research examining Beckrsquos cognitive theory in Western samples of university
students (Hankin et al 2004 Hankin et al 2005 Joiner et al 1999 Klocek et al
1997 Brown et al 1995) higher levels of dysfunctional attitudes were associated with
greater increases in depressive symptoms following increases in negative event
frequency during the six-month follow-up interval Given the considerable differences
between the current sample and Western samples in terms of demographic
19
characteristics and cultural factors such a finding strongly attests to the robustness of
Beckrsquos cognitive theory Moreover integrating the current findings with those obtained
in research examining Beckrsquos theory in other non-Western samples suggests that
Beckrsquos theory may represent a powerful explanatory model of the development of
depressive symptoms among individuals from diverse cultural settings For example
consistent with the theory higher levels of dysfunctional attitudes have been shown to
be associated with higher levels of depressive symptoms in Japanese (Tanaka et al
2006) Puerto-Rican (Bonilla Bernal Santos amp Santos 2003) Turkish (Sahin amp Sahin
1992) Norwegian (Chioqueta amp Stiles 2004) Singaporean (Oei Goh amp Kwon 1996)
and Swedish (Ohrt amp Thorell 1998) adult samples In addition it is important to note
that the current findings expand upon past correlational research examining the
association between dysfunctional attitudes and depression in Chinese samples through
the use of a multi-wave longitudinal design
When examining the specificity of dysfunctional attitudes as a predictor of
depressive symptoms the current study did not obtain support for specificity More
specifically contrary to the specificity hypothesis of Beckrsquos cognitive theory and to
results obtained in Western samples of university students (Alloy et al 2000 2006
Hankin et al 2004) higher levels of dysfunctional attitudes were associated with
greater increases in both depressive and anxious symptoms following increases in
negative event frequency There are two alternative ways of interpreting the non-
specificity finding observed in the current study First it is possible that the types of
thoughts individuals possessing high levels of dysfunctional attitudes experience
following negative events varies as a function of cultural context In other words in
20
Western samples such individuals may primarily experience the types of cognitions
that are associated with the development of depressive symptoms (ie appraisals of
personal loss and failure) In contrast in Chinese samples individuals possessing high
levels of dysfunctional attitudes may experience a wider array of cognitions some of
which are associated with the development of depressive symptoms and some of which
are associated with the development of anxious symptoms (ie evaluations of
impending threat or danger) Such an explanation would be consistent with Beckrsquos
cognitive content-specificity hypothesis (Clark amp Beck 1999) which posits that each
affective state and psychological disorder has a specific cognitive profile Second it is
possible that the types of symptoms individuals possessing high levels of dysfunctional
attitudes experience following negative events varies as a function of cultural context
More specifically it may be that dysfunctional attitudes specifically predict symptoms
of depression in both samples except that in Western samples depression manifests in
pure depressive symptoms whereas in Chinese samples depression manifests as a
combination of depressive and anxious symptoms Such an explanation would be
consistent with cultural psychopathologistsrsquo hypotheses that cultural factors shape the
phenomenology of psychiatric symptoms (Kleinman 2004 Mezzich et al 1999)
Moreover dysfunctional attitudes predicting a combination of depressive and anxious
symptoms in Chinese samples would be consistent with the construct of neurasthenia -
a construct hypothesized by some to represent a somatized form of depression that is
still widely seen within China (Lee amp Wong 1995)
Interesting in this regard and perhaps speaking to the primacy of depressive
symptoms in the current findings analyses indicated that the DYSFUNCTIONAL
21
ATTITUDES times STRESS interaction no longer predicted anxious symptoms after
controlling for depressive symptoms The reverse however was not true as the
DYSFUNCTIONAL ATTITUDES times STRESS interaction continued to predict
depressive symptoms after controlling for anxious symptoms
It is important to note that the current study employed a particularly
conservative approach to analyses in that we examined the effects of dysfunctional
attitudes on depressive and anxious symptoms after controlling for the effect of
neuroticism on such symptoms Providing particularly powerful support for Beckrsquos
(1967 1983) cognitive theory across analyses dysfunctional attitudes predicted levels
of depressive andor anxious symptoms experienced during the six month follow-up
interval independent of the effect of neuroticism Thus contrary to past critical reviews
of the cognitive literature (Barnett amp Gotlib 1998 Coyne amp Whiffen 1995) and
consistent with past findings (Hankin et al 2007) the current results indicate that
cognitive vulnerabilities to depression such as dysfunctional attitudes are not reducible
to trait neuroticism but rather represent factors that confer independent risk for
depression
Limitations and Future Directions
Several limitations of the current study should be noted First self-report
measures were used to assess depressive and anxious symptoms Although the CES-D
and MASQ both possess high degrees of reliability and validity it is difficult to draw
conclusions about clinically diagnosed depression or anxiety based on self-report
questionnaires Second self-report measures were used to assess stress Although
measures of stress that require participants only to indicate whether or not an event
22
occurred are less likely to be influenced by informant bias than those that ask
participants to rate the subjective impact of each event more sophisticated methods of
analysis such as interviewing procedures that assess contextual threat may provide
better assessments of stress Third the measures of dysfunctional attitudes stress and
depressive and anxious symptoms used in the current study were each Western-
developed Future research should examine these hypotheses using indigenous
measures in addition to Western-developed measures in order to assess possible
similarities andor differences in patterns of findings Fourth the current study only
examined depression and anxiety as symptom outcomes Future research conducted
within China should examine a wider array of symptom outcomes such as
somatization physical complaints and externalizing behaviors in order to provide a
more thorough and culturally sensitive test of the specificity hypotheses of Beckrsquos
cognitive model Fifth the current study examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese undergraduate students and thus the extent to which
our findings may be generalized to other demographics within Chinarsquos population is
unclear Last the current study broadly examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese university students Future research should examine
the constructs and processes posited by this model in greater detail in order to develop a
deeper understanding of how they may be uniquely molded by socio-cultural factors
Such research would benefit from examining the specific types of stressors experienced
by Chinese university students as they may vary as a function of socio-cultural factors
from those experienced by Western undergraduates For example severe pressure to
succeed academically in order to secure access to a limited number of post-
23
undergraduate educational opportunities - one of the few paths towards upward
mobility available to Chinese students seeking secure and gainful employment in what
has increasingly become a very highly competitive job market - may represent a
particularly salient stressor for the development of depressive symptoms among this
population (Qiang 2006)
In conclusion the results from the current study provide support for the
applicability of Beckrsquos cognitive theory to university students in mainland China More
specifically consistent with findings obtained in the West results indicate that
dysfunctional attitudes confer vulnerability to the development of depressive symptoms
following the occurrence of negative events in Chinese university students At the same
time however the current findings suggest cultural variation in the profile of
symptoms which emerge following the occurrence of negative events in cognitively
vulnerable individuals in Western and Chinese samples Specifically whereas in the
West dysfunctional attitudes have been shown to confer vulnerability to depressive
symptoms in Chinese university students dysfunctional attitudes appear to confer
vulnerability to a combined depressive and anxious symptom profile Future research
using more sophisticated assessments of stress and depressive symptoms more diverse
samples and symptom outcome measures and indigenously-developed measures is
likely to enhance our understanding of the cognitive and environmental mechanisms
underlying the development of depression in Chinese university students Discovering
that cognitive theories of vulnerability to depression extend to university students in
China highlights the potential role for cognitive-behavioral depression prevention and
treatment interventions in stemming the tide of distress experienced by this population
24
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Abela J R Z amp Hankin B L (2008) Cognitive vulnerability to depression in
children and adolescents A developmental psychopathology perspective In J
R Z Abela and B L Hankin (Eds) Handbook of child and adolescent
depression (pp 35-78) New York The Guilford Press
Alloy L B Abramson L Y Hogan M E Whitehouse W G Rose D T
Robinson MS Kim R S amp Lapkin J B (2000) The Temple-Wisconsin
cognitive vulnerability to depression project Lifetime history of axis-I
psychopathology in individuals at high and low cognitive risk for depression
Journal of Abnormal Psychology 109 403-418
Alloy L B Abramson L Y Whitehouse W G Hogan M E Panzarella C amp
Rose D T (2006) Prospective incidence of first onsets and recurrences of
depression in individuals at high and low cognitive risk for depression Journal
of Abnormal Psychology 115 145ndash156
Altham P M E (1984) Improving the precision of estimation by fitting a model
Journal of the Royal Statistical Society Series B 46 11
Barnett PA amp Gotlib I H (1988) Psychosocial functioning and depression
Distinguishing among antecedents concomitants and consequences
Psychological Bulletin 104 97-126
Beck AT (1967) Depression Clinical experimental and theoretical aspects New
York Harper amp Row
Beck AT (1983) Cognitive therapy of depression New perspectives In PJ Clayton
amp JE Barrett (Eds) Treatment of depression Old controversies and new
approaches New York Raven Press
Bian Q Yang K amp Li C (2007) Dysfunctional attitudes of patients with depression
or bipolar disorder Chinese Mental Health Journal 21 759-761
Blankstein K R amp Flett G L (1993) Development of the General Academic and
Social Hassles Scales for Students Unpublished manuscript
Bonilla J Bernal G Santos A amp Santos D (2003) A revised Spanish version of
the Beck Depression InventoryPsychometric properties with a Puerto Rican
sample of college students Journal of Clinical Psychology 60 119-130
Brown G P Hammen C L Craske M G amp Wickens T D (1995) Dimensions of
dysfunctional attitudes as vulnerabilities to depressive symptoms Journal of
Abnormal Psychology 104 431-435
25
Chioqueta A P amp Stiles T C (2004) Psychometric properties of the Norweigian
version of the Dysfunctional Attitude Scale (Form A) Cognitive Behaviour
Therapy 33 83-86
Clark DA amp Beck AT (1999) Cognitive theory and therapy of depression New
York John Wiley amp Sons Inc
Clark L A amp Watson D (1991) Tripartite model of anxiety and depression
Psychometric evidence and taxonomic implications Journal of Abnormal
Psychology 100 316ndash336
Costa P T amp McCrae R R (1992) NEO PI-R Professional manual Revised NEO
personality inventory NEO PR-R and NEO five-factor inventory NEO-RRI
Odessa FL Psychological Assessment Resources
Coyne J C amp Whiffen V E (1995) Issues in personality as diathesis for depression
The case of sociotropy-dependency and autonomy-self-criticism Psychological
Bulletin 118 358-378
Fang X Qian M Luo S amp Zi F (2009) A correlational study on college students
perfectionism parental rearing patterns and mental health Chinese Mental
Health Journal 23 56-59
Hankin B L Abramson L Y Miller N amp Haeffel G (2004) Cognitive
vulnerability-stress theories of depression Examining affective specificity in
the prediction of depression versus anxiety in three prospective studies
Cognitive Therapy and Research 28 309ndash345
Hankin BL Fraley RC amp Abela JRZ (2005) Daily depression and cognitions
about stress Evidence for a traitlike depressogenic cognitive style and the
prediction of depressive symptoms in a prospective daily diary study Journal of
Personality and Social Psychology 88 673-685
Hankin B L Lakdawalla Z Carter I L Abela J R Z amp Adams P (2007) Are
neuroticism cognitive vulnerabilities and self-esteem overlapping or distinct
risks for depression Evidence from confirmatory factor analyses Journal of
Social amp Clinical Psychology 26 29-63
Hankin B L Wetter E Cheely C amp Oppenheimer C W (2008) Becks cognitive
theory of depression in adolescence Specific prediction of depressive
symptoms and reciprocal influences in a multi-wave prospective study
International Journal of Cognitive Therapy 1 313-332
Ingram R E Miranda J amp Segal Z V (1998) Cognitive Vulnerability to
Depression New York NY Guilford Press
26
Ingram R E amp Luxton DD (2005) Vulnerability-stress models In BL Hankin amp
JRZ Abela (Eds) Development of psychopathology A vulnerability-stress
perspective (pp 32-46) Thousand Oaks CA Sage
Joiner T E Metalsky G I Lew A amp Klocek J (1999) Testing the causal
mediation component of Becks theory of depression Evidence for specific
mediation Cognitive Therapy and Research 23 401-412
Kleinman A (2004) Culture and depression New England Journal of Medicine 351
951-953
Kleinman A (1977) Depression somatization and the new cross-cultural psychiatry
Social Science and Medicine 11 3-10
Kleinman A (1996) How is culture important for DSM-IV In J E Mezzich A
Kleinmam H Fabrega Jr amp L Delores (Eds)Culture and psychiatric
diagnosis A DSM-IV perspective (pp 15-25) Washington DC US American
Psychiatric Association
Klocek J W Oliver J M amp Ross M J (1997) The role of dysfunctional attitudes
negative life events and social support in the prediction of depressive
dysphoria A prospective longitudinal study Social Behavior and Personality
25 23-136
Lee S (1997) A Chinese perspective on somatoform disorders Journal of
Psychosomatic Disorders 43 115-119
Lee S (1998) Estranged bodies simulated harmony and misplaced cultures
Neurasthenia in contemporary Chinese society Psychosomatic Medicine 60
448ndash457
Lee S (1999) Diagnosis postponed Shenjing shuairo and the transformation of
psychiatry in post-Mao China Culture Medicine and Psychiatry 23 349ndash380
Lee S amp Wong K C (1995) Rethinking neurasthenia the illness concepts of
shenjing shuairuo among Chinese undergraduates in Honk Kong Culture
Medicine and Psychiatry 19 91ndash111
Lee S Tsang A Huang YQ He YL Liu ZR Zhang MY Shen YC amp
Kessler RC (2009) The epidemiology of depression in metropolitan China
Psychological Medicine 39 735-747
Mezzich J E Kirmayer L J Kleinman A Fabrega Jr H Parron D L Good B
J Lin K amp Manson S M (1999) The place of culture in DSM-IV Journal
of Nervous and Mental Disease 187 457-464
27
Monroe S M amp Simons A D (1991) Diathesisndashstress theories in the context of life
stress research Implications for the depressive disorders Psychological
Bulletin 110 406ndash425
Murray C J L amp Lopez A D (1996) The global burden of disease Cambridge
Harvard University Press
National Bureau of Statistics of China (2006) The China 2005 statistical yearbook
China Statistics Press Beijing PR China
Oei T P S Goh Y Kwon S M(1996) A cross-cultural study of the integrated
cognitive model of depression Current Psychology of Cognition 15 265-281
Ohrt T amp Thorell L (1998) Dysfunctional Attitude Scale (DAS) Psychometrics and
norms of the Swedish version Scandinavian Journal of Behaviour Therapy 27
105-113
Parker G Gladstone G Chee KT (2001) Depression in the planetrsquos largest ethnic
group The Chinese American Journal of Psychiatry 158 857-864
Phillips M R Zhang J Shi Q Song Z Ding Z Pang S Li X Zhang Y amp
Wang Z (2009) Prevalence treatment and associated disability of mental
disorders in four provinces in China during 2001ndash05 an epidemiological
survey The Lancet 373 2041-2053
Phillips M R Li X amp Zhang Y (2002) Suicide rates in China Lancet 359 835-
840
Phillips M R (1998) The transformation of Chinarsquos mental health services The China
Journal 39 1ndash36
Qiang G (2006) Depression number one killer of Ivory Tower students China Daily
Retrieved from httpwwwchinadailycomcnchina2006-
1128content_744880htm
Radloff L S (1977) The CESndashD scale A self-report depression scale for research in
the general population Applied Psychological Measurement 1 385ndash401
Rin H amp Huang M G (1989) Neurasthenia as nosological dilemma Culture
Medicine and Psychiatry 13 215-226
Sahin NH amp Sahin N (1992) How dysfunctional are the dysfunctional attitudes in
another culture British Journal of Medical Psychology 65 17-26
Shixie L (1989) Neurasthenia in China Modern and traditional criteria for its
diagnosis Culture Medicine and Psychiatry 13 163-186
28
Tanaka N Uji M Hiramura H Chen Z Shikai N amp Kitamura T (2006)
Cognitive patterns and depression Study of a Japanese university student
population Psychiatry and Clinical Neuroscience 60 358-364
Taylor R E (2001) Death of neurasthenia and its psychological reincarnation a study
of neurasthenia at the National Hospital for the Relief and Cure of the Paralysed
and Epileptic Queen Square London 1870ndash1932 British Journal of
Psychiatry 179 550ndash557
Weissman A N amp Beck A T (1978 April) Development and validation of the
Dysfunctional Attitudes Scale A preliminary investigation Paper presented at
the annual meeting of the Educational Research Association Toronto Canada
Xiang M Z (1986) Epidemiological study of neuroses in 12 regions (districts) of
China Chinese Journal of Neurology and Psychiatry 19 87-91
Xu JM (1987) Some issues in the diagnosis of depression in China Canadian
Journal of Psychiatry 32 368-370
Xu Y X (1994) About ICD-10 Journal of Clinical Psychology and Medicine 4 224-
226
Xu Z Li Z amp Wang Z (2007) Dysfunctional attitudes and cognitive bias in major
depressive disorder Chinese Mental Health Journal 21 488-491
Yan H Q (1989) The necessity of retaining the diagnostic concept of neurasthenia
Culture Medicine and Psychiatry 13 139-145
Yang H (2007) The Test of the Chinese version of Frost Multi-dimensional
Perfectionism Scale Chinese Mental Health Journal 21 97-100
Yang H amp Zhang X (2004) Perfectionism and mental health of college students
(2004) Chinese Mental Health Journal 18 647-648
Young D (1989) Neurasthenia and related problems Culture Medicine and
Psychiatry 13 131-138
Zhang D (1995) Depression and culture A Chinese perspective Canadian Journal of
Counseling 29 227ndash233
29
TABLE(S)
Table 1 Demographic Variables
Age 2011
Gender Male
Female
472
523
Parentsrsquo Marital Status Married
Divorced
Single
Remarried
938
23
18
20
Fatherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
Government Official
51
356
187
95
124
91
Motherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
122
406
144
76
134
Fatherrsquos Education Some Primary School
Primary School
Some High School
High School
University
29
139
222
403
137
Motherrsquos Education Some Primary School
Primary School
Some High School
High School
University
63
192
264
350
76
Only Child No
Yes
331
667
Monthly Income lt 1000 RMB
1000 ndash 1500 RMB
1500 ndash 2000 RMB
2000 ndash 3000 RMB
3000 ndash 4000 RMB
4000 ndash 5000 RMB
gt 5000 RMB
334
204
175
140
59
20
20
30
Table 2 Means Standard Deviations and Inter-correlations Between Time 1 Measures
__________________________________________________________________
1 2 3
__________________________________________________________________
1 Depressive Symptoms 2963 (780)
2 Anxious Symptoms 52 3753 (918)
3 Dysfunctional Attitudes 48 33 18120 (2304)
4 Neuroticism 63 42 53 3110 (712)
_________________________________________________________________________
Note Means and standard deviations (in parentheses) are on the diagonal Depressive
Symptoms = Center for Epidemiological Studies Depression Scale Anxious Symptoms
= Mood and Anxiety Symptom Questionnaire Overall Anxiety subscale Dysfunctional
Attitudes = Dysfunctional Attitudes Scale Neuroticism = NEO Five Factor Inventory
Neuroticism subscale p lt 01
31
Table 3 Dysfunctional Attitudes Predicting Within-Subject Fluctuations in CES-D
Scores (upper section) and MASQ Scores (lower section) during the Follow-Up
Interval
______________________________________________________________________
β SE F df
______________________________________________________________________
Time 1 CESD-D 297 026 12987 1572
Stress 005 000 10860 12459
Neuroticism 134 027 2518 1572
Dysfunctional Attitudes -055 040 -183 1572
Dysfunctional Attitudes times Stress 001 000 1078 12459
______________________________________________________________________
Time 1 MASQ 502 033 23158 1575
Stress 006 000 8963 12470
Neuroticism 080 033 596 1575
Dysfunctional Attitudes -052 051 -106 1575
Dysfunctional Attitudes times Stress 002 001 774 12470
______________________________________________________________________
Note Time 1 CES-D = Time 1 Center for Epidemiological Studies Depression Scale
Stress = Within-Subject Fluctuations in General Academic Social Hassles Scale for
Students (GASHSS) scores during the follow-up interval Neuroticism = NEO Five
Factor Inventory Neuroticism subscale Dysfunctional Attitudes = Dysfunctional
Attitudes Scale Time 1 MASQ = Time 1 Mood and Anxiety Symptom Questionnaire
Overall Anxiety subscale p lt 05 p lt 01 p lt 001
32
FIGURES
Figure 1 Predicted slope of the relationship between stress and depressive
symptoms (left panel) and anxious symptoms (right panel) as a function of
dysfunctional attitudes
20
25
30
Low High
Pre
dic
ted
CE
S-D
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
25
30
35
40
Low High
Pre
dic
ted
MA
SQ
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
Intercept Intercept
12
(8 items) academic hassles (10 items) and social hassles (12 items) For each item
participants are asked to rate how persistent the given hassle was (ie its frequency and
duration) over the last 30 days (0 = no hassle not at all persistent to 6 = extremely
persistent hassle high frequency andor duration)
13
RESULTS
Descriptive Data
Means standard deviations and inter-correlations between Time 1 measures are
presented in Table 2
Prospective Diathesis-Stress Analyses - Depression
Multilevel modeling was used to test our hypothesis that higher levels of dysfunctional
attitudes would be associated with greater increases in depressive symptoms following
increases in stress Analyses were carried out using the SAS (version 81) MIXED
procedure and maximum likelihood estimation Our dependent variable was within-
subject fluctuations in CES-D scores during the follow-up interval (DEPRESSION)
Our primary predictors of DEPRESSION were DAS scores (DYSFUNCTIONAL
ATTITUDES) and fluctuations in GASHSS scores during the follow-up interval
(STRESS) As DYSFUNCTIONAL ATTITUDES is a between-subject predictor DAS
scores were standardized prior to analyses As STRESS is a within-subject predictor
STRESS reflects upward or downward fluctuations in an individualrsquos level of stress
compared to hisher mean level of stress
When fitting hierarchical linear models one must specify appropriate mean and
covariance structures Mean structures refer to the various fixed and random effect
components that can be included in the model Covariance structures refer to alternative
methods of specifying the pattern of covariance between observations taken from the
same subject at different time points It is important to note that mean and covariance
structures are not independent of one another Rather an appropriate covariance
structure is essential in order to obtain valid inferences for the parameters in the mean
14
structure Overparametrization of the covariance structure can lead to inefficient
estimation and poor assessment of standard errors (Altham 1984) On the other hand
too much restriction of the covariance structure can lead to invalid inferences when the
assumed structure does not hold (Altham 1984)
In our first set of analyses we were interested in examining the effects of
DYSFUNCTIONAL ATTITUDES STRESS and the DYSFUNCTIONAL
ATTITUDES STRESS interaction on participantrsquos CES-D scores during the follow-
up interval Consequently in line with Diggle Liang and Zegers (1994)
recommendation that one use a ldquosaturatedrdquo model for the mean structure while
searching for an appropriate covariance structure we chose a mean structure that
included DYSFUNCTIONAL ATTITUDES STRESS and the DYSFUNCTIONAL
ATTITUDES STRESS interaction Four additional effects were also included in this
mean structure First as different individuals report different levels of depressive
symptoms when at their own average level of stress a random effect for intercept was
included in the model Second given that STRESS is a within-subject predictor whose
effect is expected to vary from participant to participant a random effect for slope was
included in the model Third in order to control for individual differences in baseline
levels of depressive symptoms Time 1 CES-D scores were included in the model
Fourth in order to examine whether DYSFUNCTIONAL ATTITUDES represent a
vulnerability factor independent of neuroticism participantsrsquo FFI-N scores were
entered in the model
Commonly used covariance structures in studies in which multiple responses
are obtained from the same individual over time (and consequently within-subject
15
residuals over time are likely to be correlated) include compound symmetry first-order
autoregressive heterogeneous autoregressive and banded Toeplitz In order to select
one of these covariance structures for our analyses we fitted models using each
structure and chose the ldquobestrdquo fit based on Akaike information criterion (AIC and
AICC) and Schwarz Bayesian criterion (BIC) In all cases the best fit for our data was
a first-order heterogeneous autoregressive structure (ARH [1]) After choosing the
appropriate covariance structure we next examined the random-effects component of
our model
With respect to random effects the ARH [1] parameter (r = 31 plt001)
RE_INTERCEPT (plt001) and RE_SLOPE (plt001) were each significant and thus
were retained in the model The final results with respect to the fixed-effects
component of the model are presented in the upper section of Table 3 Of primary
importance the DYSFUNCTIONAL ATTITUDES STRESS interaction was a
significant predictor of fluctuations in depressive symptoms during the follow-up
interval In order to examine the form of this interaction the model summarized in the
upper section of Table 3 was used to calculate predicted CES-D scores for individuals
exhibiting either high or low levels of dysfunctional attitudes (plus or minus 15 SD)
who are experiencing either high or low levels of stress in comparison to their own
average level of stress (plus or minus 15 times mean within-subject SD) The results of
such calculations are presented in the left panel of Figure 1
Analyses were conducted for each DYSFUNCTIONAL ATTITUDES
condition examining whether the slope of the relationship between stress and
depressive symptoms significantly differed from 0 Analyses indicated that both
16
individuals exhibiting high (t(2459) = 862 p lt 0001) and low (t(2459) = 347 p lt
0001) levels of dysfunctional attitudes reported significantly higher levels of
depressive symptoms when experiencing high levels of stress than when experiencing
low levels of stress Planned comparisons of the slopes of the relationship between
stress and depressive symptoms however revealed that the slope was significantly
greater in individuals exhibiting high levels of dysfunctional attitudes (slope = 013)
than in individuals exhibiting low levels of dysfunctional attitudes (slope = 005
t(2459) = 328 p = 0001)
Prospective Diathesis-Stress Analyses - Anxiety
The same data-analytic approach as described above was used to examine
whether higher levels of dysfunctional attitudes would be associated with greater
increases in anxious symptoms following increases in stress Again in order to examine
whether DYSFUNCTIONAL ATTITUDES represent a vulnerability factor
independent of neuroticism participantsrsquo FFI-N scores were entered in the model
With respect to random effects the ARH[1] parameter (r = 23 p lt 001)
RE_INTERCEPT (plt001) and RE_SLOPE (plt001) were each significant and thus
were retained in the model The final results with respect to the fixed-effects
component of the model are presented in the lower section of Table 3 Of primary
importance the DYSFUNCTIONAL ATTITUDES STRESS interaction was a
significant predictor of within-subject fluctuations in anxious symptoms during the
follow-up interval In order to examine the form of this interaction the model
summarized in the lower section of Table 3 was used to calculate predicted MASQ
scores for individuals exhibiting either high or low levels of dysfunctional attitudes
17
(plus or minus 15 SD) who are experiencing either high or low levels of stress in
comparison to their own average level of stress (plus or minus 15 times mean within-
subject SD) The results of such calculations are presented on the right panel of in
Figure 1
Analyses were conducted for each DYSFUNCTIONAL ATTITUDES
condition examining whether the slope of the relationship between stress and anxious
symptoms significantly differed from 0 Analyses indicated that both individuals
exhibiting high (t(2470) = 768 p lt 0001) and low (t(2470) = 337 p lt 0001) levels of
dysfunctional attitudes reported higher levels of anxious symptoms when experiencing
high levels of stress than when experiencing low levels of stress Planned comparisons
of the slopes of the relationship between stress and anxious symptoms however
revealed that the slope was significantly greater in individuals exhibiting high levels of
dysfunctional attitudes (slope = 009) than in individuals exhibiting low levels of
dysfunctional attitudes (slope = 003 t(2470) = 278 p lt 001)
Additional Analyses
Given that the DYSFUNCTIONAL ATTITUDES STRESS interaction
prospectively predicted both symptoms of depression and anxiety two additional
analyses were conducted in order to examine (1) whether the DYSFUNCTIONAL
ATTITUDES STRESS interaction continued to be a significant predictor of within-
subject fluctuations in depressive symptoms after controlling for within-subject
fluctuations in anxious symptoms and (2) whether the DYSFUNCTIONAL
ATTITUDES STRESS interaction continued to predict within-subject fluctuations in
anxious symptoms after controlling for within-subject fluctuations in depressive
18
symptoms Such analyses allowed us to examine whether the above mentioned pattern
of findings may have been due to the high correlation observed in the current study
between depressive and anxious symptoms
Analyses were conducted in the same manner as described above with the
exception that an additional within-subject variable (ie DEPRESSION or ANXIETY)
was included in each model in order to control for within-subject fluctuations in the
alternate symptom With respect to the prediction of depressive symptoms the
DYSFUNCTIONAL ATTITUDES STRESS interaction remained a significant
predictor after controlling for within-subject fluctuations in anxious symptoms (β =
001 SE = 000 F = 410 p lt 05) With respect to the prediction of anxious
symptoms however the DYSFUNCTIONAL ATTITUDES STRESS interaction
was no longer a significant predictor after controlling for within-subject fluctuations in
depressive symptoms (β = 001 SE = 000 F = 148 p = 22)
DISCUSSION
The results of the current study provide support for the cross-cultural
applicability of Beckrsquos (1967 1983) cognitive theory to university students in Hunan
China More specifically consistent with hypotheses and with results obtained from
past research examining Beckrsquos cognitive theory in Western samples of university
students (Hankin et al 2004 Hankin et al 2005 Joiner et al 1999 Klocek et al
1997 Brown et al 1995) higher levels of dysfunctional attitudes were associated with
greater increases in depressive symptoms following increases in negative event
frequency during the six-month follow-up interval Given the considerable differences
between the current sample and Western samples in terms of demographic
19
characteristics and cultural factors such a finding strongly attests to the robustness of
Beckrsquos cognitive theory Moreover integrating the current findings with those obtained
in research examining Beckrsquos theory in other non-Western samples suggests that
Beckrsquos theory may represent a powerful explanatory model of the development of
depressive symptoms among individuals from diverse cultural settings For example
consistent with the theory higher levels of dysfunctional attitudes have been shown to
be associated with higher levels of depressive symptoms in Japanese (Tanaka et al
2006) Puerto-Rican (Bonilla Bernal Santos amp Santos 2003) Turkish (Sahin amp Sahin
1992) Norwegian (Chioqueta amp Stiles 2004) Singaporean (Oei Goh amp Kwon 1996)
and Swedish (Ohrt amp Thorell 1998) adult samples In addition it is important to note
that the current findings expand upon past correlational research examining the
association between dysfunctional attitudes and depression in Chinese samples through
the use of a multi-wave longitudinal design
When examining the specificity of dysfunctional attitudes as a predictor of
depressive symptoms the current study did not obtain support for specificity More
specifically contrary to the specificity hypothesis of Beckrsquos cognitive theory and to
results obtained in Western samples of university students (Alloy et al 2000 2006
Hankin et al 2004) higher levels of dysfunctional attitudes were associated with
greater increases in both depressive and anxious symptoms following increases in
negative event frequency There are two alternative ways of interpreting the non-
specificity finding observed in the current study First it is possible that the types of
thoughts individuals possessing high levels of dysfunctional attitudes experience
following negative events varies as a function of cultural context In other words in
20
Western samples such individuals may primarily experience the types of cognitions
that are associated with the development of depressive symptoms (ie appraisals of
personal loss and failure) In contrast in Chinese samples individuals possessing high
levels of dysfunctional attitudes may experience a wider array of cognitions some of
which are associated with the development of depressive symptoms and some of which
are associated with the development of anxious symptoms (ie evaluations of
impending threat or danger) Such an explanation would be consistent with Beckrsquos
cognitive content-specificity hypothesis (Clark amp Beck 1999) which posits that each
affective state and psychological disorder has a specific cognitive profile Second it is
possible that the types of symptoms individuals possessing high levels of dysfunctional
attitudes experience following negative events varies as a function of cultural context
More specifically it may be that dysfunctional attitudes specifically predict symptoms
of depression in both samples except that in Western samples depression manifests in
pure depressive symptoms whereas in Chinese samples depression manifests as a
combination of depressive and anxious symptoms Such an explanation would be
consistent with cultural psychopathologistsrsquo hypotheses that cultural factors shape the
phenomenology of psychiatric symptoms (Kleinman 2004 Mezzich et al 1999)
Moreover dysfunctional attitudes predicting a combination of depressive and anxious
symptoms in Chinese samples would be consistent with the construct of neurasthenia -
a construct hypothesized by some to represent a somatized form of depression that is
still widely seen within China (Lee amp Wong 1995)
Interesting in this regard and perhaps speaking to the primacy of depressive
symptoms in the current findings analyses indicated that the DYSFUNCTIONAL
21
ATTITUDES times STRESS interaction no longer predicted anxious symptoms after
controlling for depressive symptoms The reverse however was not true as the
DYSFUNCTIONAL ATTITUDES times STRESS interaction continued to predict
depressive symptoms after controlling for anxious symptoms
It is important to note that the current study employed a particularly
conservative approach to analyses in that we examined the effects of dysfunctional
attitudes on depressive and anxious symptoms after controlling for the effect of
neuroticism on such symptoms Providing particularly powerful support for Beckrsquos
(1967 1983) cognitive theory across analyses dysfunctional attitudes predicted levels
of depressive andor anxious symptoms experienced during the six month follow-up
interval independent of the effect of neuroticism Thus contrary to past critical reviews
of the cognitive literature (Barnett amp Gotlib 1998 Coyne amp Whiffen 1995) and
consistent with past findings (Hankin et al 2007) the current results indicate that
cognitive vulnerabilities to depression such as dysfunctional attitudes are not reducible
to trait neuroticism but rather represent factors that confer independent risk for
depression
Limitations and Future Directions
Several limitations of the current study should be noted First self-report
measures were used to assess depressive and anxious symptoms Although the CES-D
and MASQ both possess high degrees of reliability and validity it is difficult to draw
conclusions about clinically diagnosed depression or anxiety based on self-report
questionnaires Second self-report measures were used to assess stress Although
measures of stress that require participants only to indicate whether or not an event
22
occurred are less likely to be influenced by informant bias than those that ask
participants to rate the subjective impact of each event more sophisticated methods of
analysis such as interviewing procedures that assess contextual threat may provide
better assessments of stress Third the measures of dysfunctional attitudes stress and
depressive and anxious symptoms used in the current study were each Western-
developed Future research should examine these hypotheses using indigenous
measures in addition to Western-developed measures in order to assess possible
similarities andor differences in patterns of findings Fourth the current study only
examined depression and anxiety as symptom outcomes Future research conducted
within China should examine a wider array of symptom outcomes such as
somatization physical complaints and externalizing behaviors in order to provide a
more thorough and culturally sensitive test of the specificity hypotheses of Beckrsquos
cognitive model Fifth the current study examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese undergraduate students and thus the extent to which
our findings may be generalized to other demographics within Chinarsquos population is
unclear Last the current study broadly examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese university students Future research should examine
the constructs and processes posited by this model in greater detail in order to develop a
deeper understanding of how they may be uniquely molded by socio-cultural factors
Such research would benefit from examining the specific types of stressors experienced
by Chinese university students as they may vary as a function of socio-cultural factors
from those experienced by Western undergraduates For example severe pressure to
succeed academically in order to secure access to a limited number of post-
23
undergraduate educational opportunities - one of the few paths towards upward
mobility available to Chinese students seeking secure and gainful employment in what
has increasingly become a very highly competitive job market - may represent a
particularly salient stressor for the development of depressive symptoms among this
population (Qiang 2006)
In conclusion the results from the current study provide support for the
applicability of Beckrsquos cognitive theory to university students in mainland China More
specifically consistent with findings obtained in the West results indicate that
dysfunctional attitudes confer vulnerability to the development of depressive symptoms
following the occurrence of negative events in Chinese university students At the same
time however the current findings suggest cultural variation in the profile of
symptoms which emerge following the occurrence of negative events in cognitively
vulnerable individuals in Western and Chinese samples Specifically whereas in the
West dysfunctional attitudes have been shown to confer vulnerability to depressive
symptoms in Chinese university students dysfunctional attitudes appear to confer
vulnerability to a combined depressive and anxious symptom profile Future research
using more sophisticated assessments of stress and depressive symptoms more diverse
samples and symptom outcome measures and indigenously-developed measures is
likely to enhance our understanding of the cognitive and environmental mechanisms
underlying the development of depression in Chinese university students Discovering
that cognitive theories of vulnerability to depression extend to university students in
China highlights the potential role for cognitive-behavioral depression prevention and
treatment interventions in stemming the tide of distress experienced by this population
24
REFERENCES
Abela J R Z amp Hankin B L (2008) Cognitive vulnerability to depression in
children and adolescents A developmental psychopathology perspective In J
R Z Abela and B L Hankin (Eds) Handbook of child and adolescent
depression (pp 35-78) New York The Guilford Press
Alloy L B Abramson L Y Hogan M E Whitehouse W G Rose D T
Robinson MS Kim R S amp Lapkin J B (2000) The Temple-Wisconsin
cognitive vulnerability to depression project Lifetime history of axis-I
psychopathology in individuals at high and low cognitive risk for depression
Journal of Abnormal Psychology 109 403-418
Alloy L B Abramson L Y Whitehouse W G Hogan M E Panzarella C amp
Rose D T (2006) Prospective incidence of first onsets and recurrences of
depression in individuals at high and low cognitive risk for depression Journal
of Abnormal Psychology 115 145ndash156
Altham P M E (1984) Improving the precision of estimation by fitting a model
Journal of the Royal Statistical Society Series B 46 11
Barnett PA amp Gotlib I H (1988) Psychosocial functioning and depression
Distinguishing among antecedents concomitants and consequences
Psychological Bulletin 104 97-126
Beck AT (1967) Depression Clinical experimental and theoretical aspects New
York Harper amp Row
Beck AT (1983) Cognitive therapy of depression New perspectives In PJ Clayton
amp JE Barrett (Eds) Treatment of depression Old controversies and new
approaches New York Raven Press
Bian Q Yang K amp Li C (2007) Dysfunctional attitudes of patients with depression
or bipolar disorder Chinese Mental Health Journal 21 759-761
Blankstein K R amp Flett G L (1993) Development of the General Academic and
Social Hassles Scales for Students Unpublished manuscript
Bonilla J Bernal G Santos A amp Santos D (2003) A revised Spanish version of
the Beck Depression InventoryPsychometric properties with a Puerto Rican
sample of college students Journal of Clinical Psychology 60 119-130
Brown G P Hammen C L Craske M G amp Wickens T D (1995) Dimensions of
dysfunctional attitudes as vulnerabilities to depressive symptoms Journal of
Abnormal Psychology 104 431-435
25
Chioqueta A P amp Stiles T C (2004) Psychometric properties of the Norweigian
version of the Dysfunctional Attitude Scale (Form A) Cognitive Behaviour
Therapy 33 83-86
Clark DA amp Beck AT (1999) Cognitive theory and therapy of depression New
York John Wiley amp Sons Inc
Clark L A amp Watson D (1991) Tripartite model of anxiety and depression
Psychometric evidence and taxonomic implications Journal of Abnormal
Psychology 100 316ndash336
Costa P T amp McCrae R R (1992) NEO PI-R Professional manual Revised NEO
personality inventory NEO PR-R and NEO five-factor inventory NEO-RRI
Odessa FL Psychological Assessment Resources
Coyne J C amp Whiffen V E (1995) Issues in personality as diathesis for depression
The case of sociotropy-dependency and autonomy-self-criticism Psychological
Bulletin 118 358-378
Fang X Qian M Luo S amp Zi F (2009) A correlational study on college students
perfectionism parental rearing patterns and mental health Chinese Mental
Health Journal 23 56-59
Hankin B L Abramson L Y Miller N amp Haeffel G (2004) Cognitive
vulnerability-stress theories of depression Examining affective specificity in
the prediction of depression versus anxiety in three prospective studies
Cognitive Therapy and Research 28 309ndash345
Hankin BL Fraley RC amp Abela JRZ (2005) Daily depression and cognitions
about stress Evidence for a traitlike depressogenic cognitive style and the
prediction of depressive symptoms in a prospective daily diary study Journal of
Personality and Social Psychology 88 673-685
Hankin B L Lakdawalla Z Carter I L Abela J R Z amp Adams P (2007) Are
neuroticism cognitive vulnerabilities and self-esteem overlapping or distinct
risks for depression Evidence from confirmatory factor analyses Journal of
Social amp Clinical Psychology 26 29-63
Hankin B L Wetter E Cheely C amp Oppenheimer C W (2008) Becks cognitive
theory of depression in adolescence Specific prediction of depressive
symptoms and reciprocal influences in a multi-wave prospective study
International Journal of Cognitive Therapy 1 313-332
Ingram R E Miranda J amp Segal Z V (1998) Cognitive Vulnerability to
Depression New York NY Guilford Press
26
Ingram R E amp Luxton DD (2005) Vulnerability-stress models In BL Hankin amp
JRZ Abela (Eds) Development of psychopathology A vulnerability-stress
perspective (pp 32-46) Thousand Oaks CA Sage
Joiner T E Metalsky G I Lew A amp Klocek J (1999) Testing the causal
mediation component of Becks theory of depression Evidence for specific
mediation Cognitive Therapy and Research 23 401-412
Kleinman A (2004) Culture and depression New England Journal of Medicine 351
951-953
Kleinman A (1977) Depression somatization and the new cross-cultural psychiatry
Social Science and Medicine 11 3-10
Kleinman A (1996) How is culture important for DSM-IV In J E Mezzich A
Kleinmam H Fabrega Jr amp L Delores (Eds)Culture and psychiatric
diagnosis A DSM-IV perspective (pp 15-25) Washington DC US American
Psychiatric Association
Klocek J W Oliver J M amp Ross M J (1997) The role of dysfunctional attitudes
negative life events and social support in the prediction of depressive
dysphoria A prospective longitudinal study Social Behavior and Personality
25 23-136
Lee S (1997) A Chinese perspective on somatoform disorders Journal of
Psychosomatic Disorders 43 115-119
Lee S (1998) Estranged bodies simulated harmony and misplaced cultures
Neurasthenia in contemporary Chinese society Psychosomatic Medicine 60
448ndash457
Lee S (1999) Diagnosis postponed Shenjing shuairo and the transformation of
psychiatry in post-Mao China Culture Medicine and Psychiatry 23 349ndash380
Lee S amp Wong K C (1995) Rethinking neurasthenia the illness concepts of
shenjing shuairuo among Chinese undergraduates in Honk Kong Culture
Medicine and Psychiatry 19 91ndash111
Lee S Tsang A Huang YQ He YL Liu ZR Zhang MY Shen YC amp
Kessler RC (2009) The epidemiology of depression in metropolitan China
Psychological Medicine 39 735-747
Mezzich J E Kirmayer L J Kleinman A Fabrega Jr H Parron D L Good B
J Lin K amp Manson S M (1999) The place of culture in DSM-IV Journal
of Nervous and Mental Disease 187 457-464
27
Monroe S M amp Simons A D (1991) Diathesisndashstress theories in the context of life
stress research Implications for the depressive disorders Psychological
Bulletin 110 406ndash425
Murray C J L amp Lopez A D (1996) The global burden of disease Cambridge
Harvard University Press
National Bureau of Statistics of China (2006) The China 2005 statistical yearbook
China Statistics Press Beijing PR China
Oei T P S Goh Y Kwon S M(1996) A cross-cultural study of the integrated
cognitive model of depression Current Psychology of Cognition 15 265-281
Ohrt T amp Thorell L (1998) Dysfunctional Attitude Scale (DAS) Psychometrics and
norms of the Swedish version Scandinavian Journal of Behaviour Therapy 27
105-113
Parker G Gladstone G Chee KT (2001) Depression in the planetrsquos largest ethnic
group The Chinese American Journal of Psychiatry 158 857-864
Phillips M R Zhang J Shi Q Song Z Ding Z Pang S Li X Zhang Y amp
Wang Z (2009) Prevalence treatment and associated disability of mental
disorders in four provinces in China during 2001ndash05 an epidemiological
survey The Lancet 373 2041-2053
Phillips M R Li X amp Zhang Y (2002) Suicide rates in China Lancet 359 835-
840
Phillips M R (1998) The transformation of Chinarsquos mental health services The China
Journal 39 1ndash36
Qiang G (2006) Depression number one killer of Ivory Tower students China Daily
Retrieved from httpwwwchinadailycomcnchina2006-
1128content_744880htm
Radloff L S (1977) The CESndashD scale A self-report depression scale for research in
the general population Applied Psychological Measurement 1 385ndash401
Rin H amp Huang M G (1989) Neurasthenia as nosological dilemma Culture
Medicine and Psychiatry 13 215-226
Sahin NH amp Sahin N (1992) How dysfunctional are the dysfunctional attitudes in
another culture British Journal of Medical Psychology 65 17-26
Shixie L (1989) Neurasthenia in China Modern and traditional criteria for its
diagnosis Culture Medicine and Psychiatry 13 163-186
28
Tanaka N Uji M Hiramura H Chen Z Shikai N amp Kitamura T (2006)
Cognitive patterns and depression Study of a Japanese university student
population Psychiatry and Clinical Neuroscience 60 358-364
Taylor R E (2001) Death of neurasthenia and its psychological reincarnation a study
of neurasthenia at the National Hospital for the Relief and Cure of the Paralysed
and Epileptic Queen Square London 1870ndash1932 British Journal of
Psychiatry 179 550ndash557
Weissman A N amp Beck A T (1978 April) Development and validation of the
Dysfunctional Attitudes Scale A preliminary investigation Paper presented at
the annual meeting of the Educational Research Association Toronto Canada
Xiang M Z (1986) Epidemiological study of neuroses in 12 regions (districts) of
China Chinese Journal of Neurology and Psychiatry 19 87-91
Xu JM (1987) Some issues in the diagnosis of depression in China Canadian
Journal of Psychiatry 32 368-370
Xu Y X (1994) About ICD-10 Journal of Clinical Psychology and Medicine 4 224-
226
Xu Z Li Z amp Wang Z (2007) Dysfunctional attitudes and cognitive bias in major
depressive disorder Chinese Mental Health Journal 21 488-491
Yan H Q (1989) The necessity of retaining the diagnostic concept of neurasthenia
Culture Medicine and Psychiatry 13 139-145
Yang H (2007) The Test of the Chinese version of Frost Multi-dimensional
Perfectionism Scale Chinese Mental Health Journal 21 97-100
Yang H amp Zhang X (2004) Perfectionism and mental health of college students
(2004) Chinese Mental Health Journal 18 647-648
Young D (1989) Neurasthenia and related problems Culture Medicine and
Psychiatry 13 131-138
Zhang D (1995) Depression and culture A Chinese perspective Canadian Journal of
Counseling 29 227ndash233
29
TABLE(S)
Table 1 Demographic Variables
Age 2011
Gender Male
Female
472
523
Parentsrsquo Marital Status Married
Divorced
Single
Remarried
938
23
18
20
Fatherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
Government Official
51
356
187
95
124
91
Motherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
122
406
144
76
134
Fatherrsquos Education Some Primary School
Primary School
Some High School
High School
University
29
139
222
403
137
Motherrsquos Education Some Primary School
Primary School
Some High School
High School
University
63
192
264
350
76
Only Child No
Yes
331
667
Monthly Income lt 1000 RMB
1000 ndash 1500 RMB
1500 ndash 2000 RMB
2000 ndash 3000 RMB
3000 ndash 4000 RMB
4000 ndash 5000 RMB
gt 5000 RMB
334
204
175
140
59
20
20
30
Table 2 Means Standard Deviations and Inter-correlations Between Time 1 Measures
__________________________________________________________________
1 2 3
__________________________________________________________________
1 Depressive Symptoms 2963 (780)
2 Anxious Symptoms 52 3753 (918)
3 Dysfunctional Attitudes 48 33 18120 (2304)
4 Neuroticism 63 42 53 3110 (712)
_________________________________________________________________________
Note Means and standard deviations (in parentheses) are on the diagonal Depressive
Symptoms = Center for Epidemiological Studies Depression Scale Anxious Symptoms
= Mood and Anxiety Symptom Questionnaire Overall Anxiety subscale Dysfunctional
Attitudes = Dysfunctional Attitudes Scale Neuroticism = NEO Five Factor Inventory
Neuroticism subscale p lt 01
31
Table 3 Dysfunctional Attitudes Predicting Within-Subject Fluctuations in CES-D
Scores (upper section) and MASQ Scores (lower section) during the Follow-Up
Interval
______________________________________________________________________
β SE F df
______________________________________________________________________
Time 1 CESD-D 297 026 12987 1572
Stress 005 000 10860 12459
Neuroticism 134 027 2518 1572
Dysfunctional Attitudes -055 040 -183 1572
Dysfunctional Attitudes times Stress 001 000 1078 12459
______________________________________________________________________
Time 1 MASQ 502 033 23158 1575
Stress 006 000 8963 12470
Neuroticism 080 033 596 1575
Dysfunctional Attitudes -052 051 -106 1575
Dysfunctional Attitudes times Stress 002 001 774 12470
______________________________________________________________________
Note Time 1 CES-D = Time 1 Center for Epidemiological Studies Depression Scale
Stress = Within-Subject Fluctuations in General Academic Social Hassles Scale for
Students (GASHSS) scores during the follow-up interval Neuroticism = NEO Five
Factor Inventory Neuroticism subscale Dysfunctional Attitudes = Dysfunctional
Attitudes Scale Time 1 MASQ = Time 1 Mood and Anxiety Symptom Questionnaire
Overall Anxiety subscale p lt 05 p lt 01 p lt 001
32
FIGURES
Figure 1 Predicted slope of the relationship between stress and depressive
symptoms (left panel) and anxious symptoms (right panel) as a function of
dysfunctional attitudes
20
25
30
Low High
Pre
dic
ted
CE
S-D
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
25
30
35
40
Low High
Pre
dic
ted
MA
SQ
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
Intercept Intercept
13
RESULTS
Descriptive Data
Means standard deviations and inter-correlations between Time 1 measures are
presented in Table 2
Prospective Diathesis-Stress Analyses - Depression
Multilevel modeling was used to test our hypothesis that higher levels of dysfunctional
attitudes would be associated with greater increases in depressive symptoms following
increases in stress Analyses were carried out using the SAS (version 81) MIXED
procedure and maximum likelihood estimation Our dependent variable was within-
subject fluctuations in CES-D scores during the follow-up interval (DEPRESSION)
Our primary predictors of DEPRESSION were DAS scores (DYSFUNCTIONAL
ATTITUDES) and fluctuations in GASHSS scores during the follow-up interval
(STRESS) As DYSFUNCTIONAL ATTITUDES is a between-subject predictor DAS
scores were standardized prior to analyses As STRESS is a within-subject predictor
STRESS reflects upward or downward fluctuations in an individualrsquos level of stress
compared to hisher mean level of stress
When fitting hierarchical linear models one must specify appropriate mean and
covariance structures Mean structures refer to the various fixed and random effect
components that can be included in the model Covariance structures refer to alternative
methods of specifying the pattern of covariance between observations taken from the
same subject at different time points It is important to note that mean and covariance
structures are not independent of one another Rather an appropriate covariance
structure is essential in order to obtain valid inferences for the parameters in the mean
14
structure Overparametrization of the covariance structure can lead to inefficient
estimation and poor assessment of standard errors (Altham 1984) On the other hand
too much restriction of the covariance structure can lead to invalid inferences when the
assumed structure does not hold (Altham 1984)
In our first set of analyses we were interested in examining the effects of
DYSFUNCTIONAL ATTITUDES STRESS and the DYSFUNCTIONAL
ATTITUDES STRESS interaction on participantrsquos CES-D scores during the follow-
up interval Consequently in line with Diggle Liang and Zegers (1994)
recommendation that one use a ldquosaturatedrdquo model for the mean structure while
searching for an appropriate covariance structure we chose a mean structure that
included DYSFUNCTIONAL ATTITUDES STRESS and the DYSFUNCTIONAL
ATTITUDES STRESS interaction Four additional effects were also included in this
mean structure First as different individuals report different levels of depressive
symptoms when at their own average level of stress a random effect for intercept was
included in the model Second given that STRESS is a within-subject predictor whose
effect is expected to vary from participant to participant a random effect for slope was
included in the model Third in order to control for individual differences in baseline
levels of depressive symptoms Time 1 CES-D scores were included in the model
Fourth in order to examine whether DYSFUNCTIONAL ATTITUDES represent a
vulnerability factor independent of neuroticism participantsrsquo FFI-N scores were
entered in the model
Commonly used covariance structures in studies in which multiple responses
are obtained from the same individual over time (and consequently within-subject
15
residuals over time are likely to be correlated) include compound symmetry first-order
autoregressive heterogeneous autoregressive and banded Toeplitz In order to select
one of these covariance structures for our analyses we fitted models using each
structure and chose the ldquobestrdquo fit based on Akaike information criterion (AIC and
AICC) and Schwarz Bayesian criterion (BIC) In all cases the best fit for our data was
a first-order heterogeneous autoregressive structure (ARH [1]) After choosing the
appropriate covariance structure we next examined the random-effects component of
our model
With respect to random effects the ARH [1] parameter (r = 31 plt001)
RE_INTERCEPT (plt001) and RE_SLOPE (plt001) were each significant and thus
were retained in the model The final results with respect to the fixed-effects
component of the model are presented in the upper section of Table 3 Of primary
importance the DYSFUNCTIONAL ATTITUDES STRESS interaction was a
significant predictor of fluctuations in depressive symptoms during the follow-up
interval In order to examine the form of this interaction the model summarized in the
upper section of Table 3 was used to calculate predicted CES-D scores for individuals
exhibiting either high or low levels of dysfunctional attitudes (plus or minus 15 SD)
who are experiencing either high or low levels of stress in comparison to their own
average level of stress (plus or minus 15 times mean within-subject SD) The results of
such calculations are presented in the left panel of Figure 1
Analyses were conducted for each DYSFUNCTIONAL ATTITUDES
condition examining whether the slope of the relationship between stress and
depressive symptoms significantly differed from 0 Analyses indicated that both
16
individuals exhibiting high (t(2459) = 862 p lt 0001) and low (t(2459) = 347 p lt
0001) levels of dysfunctional attitudes reported significantly higher levels of
depressive symptoms when experiencing high levels of stress than when experiencing
low levels of stress Planned comparisons of the slopes of the relationship between
stress and depressive symptoms however revealed that the slope was significantly
greater in individuals exhibiting high levels of dysfunctional attitudes (slope = 013)
than in individuals exhibiting low levels of dysfunctional attitudes (slope = 005
t(2459) = 328 p = 0001)
Prospective Diathesis-Stress Analyses - Anxiety
The same data-analytic approach as described above was used to examine
whether higher levels of dysfunctional attitudes would be associated with greater
increases in anxious symptoms following increases in stress Again in order to examine
whether DYSFUNCTIONAL ATTITUDES represent a vulnerability factor
independent of neuroticism participantsrsquo FFI-N scores were entered in the model
With respect to random effects the ARH[1] parameter (r = 23 p lt 001)
RE_INTERCEPT (plt001) and RE_SLOPE (plt001) were each significant and thus
were retained in the model The final results with respect to the fixed-effects
component of the model are presented in the lower section of Table 3 Of primary
importance the DYSFUNCTIONAL ATTITUDES STRESS interaction was a
significant predictor of within-subject fluctuations in anxious symptoms during the
follow-up interval In order to examine the form of this interaction the model
summarized in the lower section of Table 3 was used to calculate predicted MASQ
scores for individuals exhibiting either high or low levels of dysfunctional attitudes
17
(plus or minus 15 SD) who are experiencing either high or low levels of stress in
comparison to their own average level of stress (plus or minus 15 times mean within-
subject SD) The results of such calculations are presented on the right panel of in
Figure 1
Analyses were conducted for each DYSFUNCTIONAL ATTITUDES
condition examining whether the slope of the relationship between stress and anxious
symptoms significantly differed from 0 Analyses indicated that both individuals
exhibiting high (t(2470) = 768 p lt 0001) and low (t(2470) = 337 p lt 0001) levels of
dysfunctional attitudes reported higher levels of anxious symptoms when experiencing
high levels of stress than when experiencing low levels of stress Planned comparisons
of the slopes of the relationship between stress and anxious symptoms however
revealed that the slope was significantly greater in individuals exhibiting high levels of
dysfunctional attitudes (slope = 009) than in individuals exhibiting low levels of
dysfunctional attitudes (slope = 003 t(2470) = 278 p lt 001)
Additional Analyses
Given that the DYSFUNCTIONAL ATTITUDES STRESS interaction
prospectively predicted both symptoms of depression and anxiety two additional
analyses were conducted in order to examine (1) whether the DYSFUNCTIONAL
ATTITUDES STRESS interaction continued to be a significant predictor of within-
subject fluctuations in depressive symptoms after controlling for within-subject
fluctuations in anxious symptoms and (2) whether the DYSFUNCTIONAL
ATTITUDES STRESS interaction continued to predict within-subject fluctuations in
anxious symptoms after controlling for within-subject fluctuations in depressive
18
symptoms Such analyses allowed us to examine whether the above mentioned pattern
of findings may have been due to the high correlation observed in the current study
between depressive and anxious symptoms
Analyses were conducted in the same manner as described above with the
exception that an additional within-subject variable (ie DEPRESSION or ANXIETY)
was included in each model in order to control for within-subject fluctuations in the
alternate symptom With respect to the prediction of depressive symptoms the
DYSFUNCTIONAL ATTITUDES STRESS interaction remained a significant
predictor after controlling for within-subject fluctuations in anxious symptoms (β =
001 SE = 000 F = 410 p lt 05) With respect to the prediction of anxious
symptoms however the DYSFUNCTIONAL ATTITUDES STRESS interaction
was no longer a significant predictor after controlling for within-subject fluctuations in
depressive symptoms (β = 001 SE = 000 F = 148 p = 22)
DISCUSSION
The results of the current study provide support for the cross-cultural
applicability of Beckrsquos (1967 1983) cognitive theory to university students in Hunan
China More specifically consistent with hypotheses and with results obtained from
past research examining Beckrsquos cognitive theory in Western samples of university
students (Hankin et al 2004 Hankin et al 2005 Joiner et al 1999 Klocek et al
1997 Brown et al 1995) higher levels of dysfunctional attitudes were associated with
greater increases in depressive symptoms following increases in negative event
frequency during the six-month follow-up interval Given the considerable differences
between the current sample and Western samples in terms of demographic
19
characteristics and cultural factors such a finding strongly attests to the robustness of
Beckrsquos cognitive theory Moreover integrating the current findings with those obtained
in research examining Beckrsquos theory in other non-Western samples suggests that
Beckrsquos theory may represent a powerful explanatory model of the development of
depressive symptoms among individuals from diverse cultural settings For example
consistent with the theory higher levels of dysfunctional attitudes have been shown to
be associated with higher levels of depressive symptoms in Japanese (Tanaka et al
2006) Puerto-Rican (Bonilla Bernal Santos amp Santos 2003) Turkish (Sahin amp Sahin
1992) Norwegian (Chioqueta amp Stiles 2004) Singaporean (Oei Goh amp Kwon 1996)
and Swedish (Ohrt amp Thorell 1998) adult samples In addition it is important to note
that the current findings expand upon past correlational research examining the
association between dysfunctional attitudes and depression in Chinese samples through
the use of a multi-wave longitudinal design
When examining the specificity of dysfunctional attitudes as a predictor of
depressive symptoms the current study did not obtain support for specificity More
specifically contrary to the specificity hypothesis of Beckrsquos cognitive theory and to
results obtained in Western samples of university students (Alloy et al 2000 2006
Hankin et al 2004) higher levels of dysfunctional attitudes were associated with
greater increases in both depressive and anxious symptoms following increases in
negative event frequency There are two alternative ways of interpreting the non-
specificity finding observed in the current study First it is possible that the types of
thoughts individuals possessing high levels of dysfunctional attitudes experience
following negative events varies as a function of cultural context In other words in
20
Western samples such individuals may primarily experience the types of cognitions
that are associated with the development of depressive symptoms (ie appraisals of
personal loss and failure) In contrast in Chinese samples individuals possessing high
levels of dysfunctional attitudes may experience a wider array of cognitions some of
which are associated with the development of depressive symptoms and some of which
are associated with the development of anxious symptoms (ie evaluations of
impending threat or danger) Such an explanation would be consistent with Beckrsquos
cognitive content-specificity hypothesis (Clark amp Beck 1999) which posits that each
affective state and psychological disorder has a specific cognitive profile Second it is
possible that the types of symptoms individuals possessing high levels of dysfunctional
attitudes experience following negative events varies as a function of cultural context
More specifically it may be that dysfunctional attitudes specifically predict symptoms
of depression in both samples except that in Western samples depression manifests in
pure depressive symptoms whereas in Chinese samples depression manifests as a
combination of depressive and anxious symptoms Such an explanation would be
consistent with cultural psychopathologistsrsquo hypotheses that cultural factors shape the
phenomenology of psychiatric symptoms (Kleinman 2004 Mezzich et al 1999)
Moreover dysfunctional attitudes predicting a combination of depressive and anxious
symptoms in Chinese samples would be consistent with the construct of neurasthenia -
a construct hypothesized by some to represent a somatized form of depression that is
still widely seen within China (Lee amp Wong 1995)
Interesting in this regard and perhaps speaking to the primacy of depressive
symptoms in the current findings analyses indicated that the DYSFUNCTIONAL
21
ATTITUDES times STRESS interaction no longer predicted anxious symptoms after
controlling for depressive symptoms The reverse however was not true as the
DYSFUNCTIONAL ATTITUDES times STRESS interaction continued to predict
depressive symptoms after controlling for anxious symptoms
It is important to note that the current study employed a particularly
conservative approach to analyses in that we examined the effects of dysfunctional
attitudes on depressive and anxious symptoms after controlling for the effect of
neuroticism on such symptoms Providing particularly powerful support for Beckrsquos
(1967 1983) cognitive theory across analyses dysfunctional attitudes predicted levels
of depressive andor anxious symptoms experienced during the six month follow-up
interval independent of the effect of neuroticism Thus contrary to past critical reviews
of the cognitive literature (Barnett amp Gotlib 1998 Coyne amp Whiffen 1995) and
consistent with past findings (Hankin et al 2007) the current results indicate that
cognitive vulnerabilities to depression such as dysfunctional attitudes are not reducible
to trait neuroticism but rather represent factors that confer independent risk for
depression
Limitations and Future Directions
Several limitations of the current study should be noted First self-report
measures were used to assess depressive and anxious symptoms Although the CES-D
and MASQ both possess high degrees of reliability and validity it is difficult to draw
conclusions about clinically diagnosed depression or anxiety based on self-report
questionnaires Second self-report measures were used to assess stress Although
measures of stress that require participants only to indicate whether or not an event
22
occurred are less likely to be influenced by informant bias than those that ask
participants to rate the subjective impact of each event more sophisticated methods of
analysis such as interviewing procedures that assess contextual threat may provide
better assessments of stress Third the measures of dysfunctional attitudes stress and
depressive and anxious symptoms used in the current study were each Western-
developed Future research should examine these hypotheses using indigenous
measures in addition to Western-developed measures in order to assess possible
similarities andor differences in patterns of findings Fourth the current study only
examined depression and anxiety as symptom outcomes Future research conducted
within China should examine a wider array of symptom outcomes such as
somatization physical complaints and externalizing behaviors in order to provide a
more thorough and culturally sensitive test of the specificity hypotheses of Beckrsquos
cognitive model Fifth the current study examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese undergraduate students and thus the extent to which
our findings may be generalized to other demographics within Chinarsquos population is
unclear Last the current study broadly examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese university students Future research should examine
the constructs and processes posited by this model in greater detail in order to develop a
deeper understanding of how they may be uniquely molded by socio-cultural factors
Such research would benefit from examining the specific types of stressors experienced
by Chinese university students as they may vary as a function of socio-cultural factors
from those experienced by Western undergraduates For example severe pressure to
succeed academically in order to secure access to a limited number of post-
23
undergraduate educational opportunities - one of the few paths towards upward
mobility available to Chinese students seeking secure and gainful employment in what
has increasingly become a very highly competitive job market - may represent a
particularly salient stressor for the development of depressive symptoms among this
population (Qiang 2006)
In conclusion the results from the current study provide support for the
applicability of Beckrsquos cognitive theory to university students in mainland China More
specifically consistent with findings obtained in the West results indicate that
dysfunctional attitudes confer vulnerability to the development of depressive symptoms
following the occurrence of negative events in Chinese university students At the same
time however the current findings suggest cultural variation in the profile of
symptoms which emerge following the occurrence of negative events in cognitively
vulnerable individuals in Western and Chinese samples Specifically whereas in the
West dysfunctional attitudes have been shown to confer vulnerability to depressive
symptoms in Chinese university students dysfunctional attitudes appear to confer
vulnerability to a combined depressive and anxious symptom profile Future research
using more sophisticated assessments of stress and depressive symptoms more diverse
samples and symptom outcome measures and indigenously-developed measures is
likely to enhance our understanding of the cognitive and environmental mechanisms
underlying the development of depression in Chinese university students Discovering
that cognitive theories of vulnerability to depression extend to university students in
China highlights the potential role for cognitive-behavioral depression prevention and
treatment interventions in stemming the tide of distress experienced by this population
24
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Abela J R Z amp Hankin B L (2008) Cognitive vulnerability to depression in
children and adolescents A developmental psychopathology perspective In J
R Z Abela and B L Hankin (Eds) Handbook of child and adolescent
depression (pp 35-78) New York The Guilford Press
Alloy L B Abramson L Y Hogan M E Whitehouse W G Rose D T
Robinson MS Kim R S amp Lapkin J B (2000) The Temple-Wisconsin
cognitive vulnerability to depression project Lifetime history of axis-I
psychopathology in individuals at high and low cognitive risk for depression
Journal of Abnormal Psychology 109 403-418
Alloy L B Abramson L Y Whitehouse W G Hogan M E Panzarella C amp
Rose D T (2006) Prospective incidence of first onsets and recurrences of
depression in individuals at high and low cognitive risk for depression Journal
of Abnormal Psychology 115 145ndash156
Altham P M E (1984) Improving the precision of estimation by fitting a model
Journal of the Royal Statistical Society Series B 46 11
Barnett PA amp Gotlib I H (1988) Psychosocial functioning and depression
Distinguishing among antecedents concomitants and consequences
Psychological Bulletin 104 97-126
Beck AT (1967) Depression Clinical experimental and theoretical aspects New
York Harper amp Row
Beck AT (1983) Cognitive therapy of depression New perspectives In PJ Clayton
amp JE Barrett (Eds) Treatment of depression Old controversies and new
approaches New York Raven Press
Bian Q Yang K amp Li C (2007) Dysfunctional attitudes of patients with depression
or bipolar disorder Chinese Mental Health Journal 21 759-761
Blankstein K R amp Flett G L (1993) Development of the General Academic and
Social Hassles Scales for Students Unpublished manuscript
Bonilla J Bernal G Santos A amp Santos D (2003) A revised Spanish version of
the Beck Depression InventoryPsychometric properties with a Puerto Rican
sample of college students Journal of Clinical Psychology 60 119-130
Brown G P Hammen C L Craske M G amp Wickens T D (1995) Dimensions of
dysfunctional attitudes as vulnerabilities to depressive symptoms Journal of
Abnormal Psychology 104 431-435
25
Chioqueta A P amp Stiles T C (2004) Psychometric properties of the Norweigian
version of the Dysfunctional Attitude Scale (Form A) Cognitive Behaviour
Therapy 33 83-86
Clark DA amp Beck AT (1999) Cognitive theory and therapy of depression New
York John Wiley amp Sons Inc
Clark L A amp Watson D (1991) Tripartite model of anxiety and depression
Psychometric evidence and taxonomic implications Journal of Abnormal
Psychology 100 316ndash336
Costa P T amp McCrae R R (1992) NEO PI-R Professional manual Revised NEO
personality inventory NEO PR-R and NEO five-factor inventory NEO-RRI
Odessa FL Psychological Assessment Resources
Coyne J C amp Whiffen V E (1995) Issues in personality as diathesis for depression
The case of sociotropy-dependency and autonomy-self-criticism Psychological
Bulletin 118 358-378
Fang X Qian M Luo S amp Zi F (2009) A correlational study on college students
perfectionism parental rearing patterns and mental health Chinese Mental
Health Journal 23 56-59
Hankin B L Abramson L Y Miller N amp Haeffel G (2004) Cognitive
vulnerability-stress theories of depression Examining affective specificity in
the prediction of depression versus anxiety in three prospective studies
Cognitive Therapy and Research 28 309ndash345
Hankin BL Fraley RC amp Abela JRZ (2005) Daily depression and cognitions
about stress Evidence for a traitlike depressogenic cognitive style and the
prediction of depressive symptoms in a prospective daily diary study Journal of
Personality and Social Psychology 88 673-685
Hankin B L Lakdawalla Z Carter I L Abela J R Z amp Adams P (2007) Are
neuroticism cognitive vulnerabilities and self-esteem overlapping or distinct
risks for depression Evidence from confirmatory factor analyses Journal of
Social amp Clinical Psychology 26 29-63
Hankin B L Wetter E Cheely C amp Oppenheimer C W (2008) Becks cognitive
theory of depression in adolescence Specific prediction of depressive
symptoms and reciprocal influences in a multi-wave prospective study
International Journal of Cognitive Therapy 1 313-332
Ingram R E Miranda J amp Segal Z V (1998) Cognitive Vulnerability to
Depression New York NY Guilford Press
26
Ingram R E amp Luxton DD (2005) Vulnerability-stress models In BL Hankin amp
JRZ Abela (Eds) Development of psychopathology A vulnerability-stress
perspective (pp 32-46) Thousand Oaks CA Sage
Joiner T E Metalsky G I Lew A amp Klocek J (1999) Testing the causal
mediation component of Becks theory of depression Evidence for specific
mediation Cognitive Therapy and Research 23 401-412
Kleinman A (2004) Culture and depression New England Journal of Medicine 351
951-953
Kleinman A (1977) Depression somatization and the new cross-cultural psychiatry
Social Science and Medicine 11 3-10
Kleinman A (1996) How is culture important for DSM-IV In J E Mezzich A
Kleinmam H Fabrega Jr amp L Delores (Eds)Culture and psychiatric
diagnosis A DSM-IV perspective (pp 15-25) Washington DC US American
Psychiatric Association
Klocek J W Oliver J M amp Ross M J (1997) The role of dysfunctional attitudes
negative life events and social support in the prediction of depressive
dysphoria A prospective longitudinal study Social Behavior and Personality
25 23-136
Lee S (1997) A Chinese perspective on somatoform disorders Journal of
Psychosomatic Disorders 43 115-119
Lee S (1998) Estranged bodies simulated harmony and misplaced cultures
Neurasthenia in contemporary Chinese society Psychosomatic Medicine 60
448ndash457
Lee S (1999) Diagnosis postponed Shenjing shuairo and the transformation of
psychiatry in post-Mao China Culture Medicine and Psychiatry 23 349ndash380
Lee S amp Wong K C (1995) Rethinking neurasthenia the illness concepts of
shenjing shuairuo among Chinese undergraduates in Honk Kong Culture
Medicine and Psychiatry 19 91ndash111
Lee S Tsang A Huang YQ He YL Liu ZR Zhang MY Shen YC amp
Kessler RC (2009) The epidemiology of depression in metropolitan China
Psychological Medicine 39 735-747
Mezzich J E Kirmayer L J Kleinman A Fabrega Jr H Parron D L Good B
J Lin K amp Manson S M (1999) The place of culture in DSM-IV Journal
of Nervous and Mental Disease 187 457-464
27
Monroe S M amp Simons A D (1991) Diathesisndashstress theories in the context of life
stress research Implications for the depressive disorders Psychological
Bulletin 110 406ndash425
Murray C J L amp Lopez A D (1996) The global burden of disease Cambridge
Harvard University Press
National Bureau of Statistics of China (2006) The China 2005 statistical yearbook
China Statistics Press Beijing PR China
Oei T P S Goh Y Kwon S M(1996) A cross-cultural study of the integrated
cognitive model of depression Current Psychology of Cognition 15 265-281
Ohrt T amp Thorell L (1998) Dysfunctional Attitude Scale (DAS) Psychometrics and
norms of the Swedish version Scandinavian Journal of Behaviour Therapy 27
105-113
Parker G Gladstone G Chee KT (2001) Depression in the planetrsquos largest ethnic
group The Chinese American Journal of Psychiatry 158 857-864
Phillips M R Zhang J Shi Q Song Z Ding Z Pang S Li X Zhang Y amp
Wang Z (2009) Prevalence treatment and associated disability of mental
disorders in four provinces in China during 2001ndash05 an epidemiological
survey The Lancet 373 2041-2053
Phillips M R Li X amp Zhang Y (2002) Suicide rates in China Lancet 359 835-
840
Phillips M R (1998) The transformation of Chinarsquos mental health services The China
Journal 39 1ndash36
Qiang G (2006) Depression number one killer of Ivory Tower students China Daily
Retrieved from httpwwwchinadailycomcnchina2006-
1128content_744880htm
Radloff L S (1977) The CESndashD scale A self-report depression scale for research in
the general population Applied Psychological Measurement 1 385ndash401
Rin H amp Huang M G (1989) Neurasthenia as nosological dilemma Culture
Medicine and Psychiatry 13 215-226
Sahin NH amp Sahin N (1992) How dysfunctional are the dysfunctional attitudes in
another culture British Journal of Medical Psychology 65 17-26
Shixie L (1989) Neurasthenia in China Modern and traditional criteria for its
diagnosis Culture Medicine and Psychiatry 13 163-186
28
Tanaka N Uji M Hiramura H Chen Z Shikai N amp Kitamura T (2006)
Cognitive patterns and depression Study of a Japanese university student
population Psychiatry and Clinical Neuroscience 60 358-364
Taylor R E (2001) Death of neurasthenia and its psychological reincarnation a study
of neurasthenia at the National Hospital for the Relief and Cure of the Paralysed
and Epileptic Queen Square London 1870ndash1932 British Journal of
Psychiatry 179 550ndash557
Weissman A N amp Beck A T (1978 April) Development and validation of the
Dysfunctional Attitudes Scale A preliminary investigation Paper presented at
the annual meeting of the Educational Research Association Toronto Canada
Xiang M Z (1986) Epidemiological study of neuroses in 12 regions (districts) of
China Chinese Journal of Neurology and Psychiatry 19 87-91
Xu JM (1987) Some issues in the diagnosis of depression in China Canadian
Journal of Psychiatry 32 368-370
Xu Y X (1994) About ICD-10 Journal of Clinical Psychology and Medicine 4 224-
226
Xu Z Li Z amp Wang Z (2007) Dysfunctional attitudes and cognitive bias in major
depressive disorder Chinese Mental Health Journal 21 488-491
Yan H Q (1989) The necessity of retaining the diagnostic concept of neurasthenia
Culture Medicine and Psychiatry 13 139-145
Yang H (2007) The Test of the Chinese version of Frost Multi-dimensional
Perfectionism Scale Chinese Mental Health Journal 21 97-100
Yang H amp Zhang X (2004) Perfectionism and mental health of college students
(2004) Chinese Mental Health Journal 18 647-648
Young D (1989) Neurasthenia and related problems Culture Medicine and
Psychiatry 13 131-138
Zhang D (1995) Depression and culture A Chinese perspective Canadian Journal of
Counseling 29 227ndash233
29
TABLE(S)
Table 1 Demographic Variables
Age 2011
Gender Male
Female
472
523
Parentsrsquo Marital Status Married
Divorced
Single
Remarried
938
23
18
20
Fatherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
Government Official
51
356
187
95
124
91
Motherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
122
406
144
76
134
Fatherrsquos Education Some Primary School
Primary School
Some High School
High School
University
29
139
222
403
137
Motherrsquos Education Some Primary School
Primary School
Some High School
High School
University
63
192
264
350
76
Only Child No
Yes
331
667
Monthly Income lt 1000 RMB
1000 ndash 1500 RMB
1500 ndash 2000 RMB
2000 ndash 3000 RMB
3000 ndash 4000 RMB
4000 ndash 5000 RMB
gt 5000 RMB
334
204
175
140
59
20
20
30
Table 2 Means Standard Deviations and Inter-correlations Between Time 1 Measures
__________________________________________________________________
1 2 3
__________________________________________________________________
1 Depressive Symptoms 2963 (780)
2 Anxious Symptoms 52 3753 (918)
3 Dysfunctional Attitudes 48 33 18120 (2304)
4 Neuroticism 63 42 53 3110 (712)
_________________________________________________________________________
Note Means and standard deviations (in parentheses) are on the diagonal Depressive
Symptoms = Center for Epidemiological Studies Depression Scale Anxious Symptoms
= Mood and Anxiety Symptom Questionnaire Overall Anxiety subscale Dysfunctional
Attitudes = Dysfunctional Attitudes Scale Neuroticism = NEO Five Factor Inventory
Neuroticism subscale p lt 01
31
Table 3 Dysfunctional Attitudes Predicting Within-Subject Fluctuations in CES-D
Scores (upper section) and MASQ Scores (lower section) during the Follow-Up
Interval
______________________________________________________________________
β SE F df
______________________________________________________________________
Time 1 CESD-D 297 026 12987 1572
Stress 005 000 10860 12459
Neuroticism 134 027 2518 1572
Dysfunctional Attitudes -055 040 -183 1572
Dysfunctional Attitudes times Stress 001 000 1078 12459
______________________________________________________________________
Time 1 MASQ 502 033 23158 1575
Stress 006 000 8963 12470
Neuroticism 080 033 596 1575
Dysfunctional Attitudes -052 051 -106 1575
Dysfunctional Attitudes times Stress 002 001 774 12470
______________________________________________________________________
Note Time 1 CES-D = Time 1 Center for Epidemiological Studies Depression Scale
Stress = Within-Subject Fluctuations in General Academic Social Hassles Scale for
Students (GASHSS) scores during the follow-up interval Neuroticism = NEO Five
Factor Inventory Neuroticism subscale Dysfunctional Attitudes = Dysfunctional
Attitudes Scale Time 1 MASQ = Time 1 Mood and Anxiety Symptom Questionnaire
Overall Anxiety subscale p lt 05 p lt 01 p lt 001
32
FIGURES
Figure 1 Predicted slope of the relationship between stress and depressive
symptoms (left panel) and anxious symptoms (right panel) as a function of
dysfunctional attitudes
20
25
30
Low High
Pre
dic
ted
CE
S-D
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
25
30
35
40
Low High
Pre
dic
ted
MA
SQ
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
Intercept Intercept
14
structure Overparametrization of the covariance structure can lead to inefficient
estimation and poor assessment of standard errors (Altham 1984) On the other hand
too much restriction of the covariance structure can lead to invalid inferences when the
assumed structure does not hold (Altham 1984)
In our first set of analyses we were interested in examining the effects of
DYSFUNCTIONAL ATTITUDES STRESS and the DYSFUNCTIONAL
ATTITUDES STRESS interaction on participantrsquos CES-D scores during the follow-
up interval Consequently in line with Diggle Liang and Zegers (1994)
recommendation that one use a ldquosaturatedrdquo model for the mean structure while
searching for an appropriate covariance structure we chose a mean structure that
included DYSFUNCTIONAL ATTITUDES STRESS and the DYSFUNCTIONAL
ATTITUDES STRESS interaction Four additional effects were also included in this
mean structure First as different individuals report different levels of depressive
symptoms when at their own average level of stress a random effect for intercept was
included in the model Second given that STRESS is a within-subject predictor whose
effect is expected to vary from participant to participant a random effect for slope was
included in the model Third in order to control for individual differences in baseline
levels of depressive symptoms Time 1 CES-D scores were included in the model
Fourth in order to examine whether DYSFUNCTIONAL ATTITUDES represent a
vulnerability factor independent of neuroticism participantsrsquo FFI-N scores were
entered in the model
Commonly used covariance structures in studies in which multiple responses
are obtained from the same individual over time (and consequently within-subject
15
residuals over time are likely to be correlated) include compound symmetry first-order
autoregressive heterogeneous autoregressive and banded Toeplitz In order to select
one of these covariance structures for our analyses we fitted models using each
structure and chose the ldquobestrdquo fit based on Akaike information criterion (AIC and
AICC) and Schwarz Bayesian criterion (BIC) In all cases the best fit for our data was
a first-order heterogeneous autoregressive structure (ARH [1]) After choosing the
appropriate covariance structure we next examined the random-effects component of
our model
With respect to random effects the ARH [1] parameter (r = 31 plt001)
RE_INTERCEPT (plt001) and RE_SLOPE (plt001) were each significant and thus
were retained in the model The final results with respect to the fixed-effects
component of the model are presented in the upper section of Table 3 Of primary
importance the DYSFUNCTIONAL ATTITUDES STRESS interaction was a
significant predictor of fluctuations in depressive symptoms during the follow-up
interval In order to examine the form of this interaction the model summarized in the
upper section of Table 3 was used to calculate predicted CES-D scores for individuals
exhibiting either high or low levels of dysfunctional attitudes (plus or minus 15 SD)
who are experiencing either high or low levels of stress in comparison to their own
average level of stress (plus or minus 15 times mean within-subject SD) The results of
such calculations are presented in the left panel of Figure 1
Analyses were conducted for each DYSFUNCTIONAL ATTITUDES
condition examining whether the slope of the relationship between stress and
depressive symptoms significantly differed from 0 Analyses indicated that both
16
individuals exhibiting high (t(2459) = 862 p lt 0001) and low (t(2459) = 347 p lt
0001) levels of dysfunctional attitudes reported significantly higher levels of
depressive symptoms when experiencing high levels of stress than when experiencing
low levels of stress Planned comparisons of the slopes of the relationship between
stress and depressive symptoms however revealed that the slope was significantly
greater in individuals exhibiting high levels of dysfunctional attitudes (slope = 013)
than in individuals exhibiting low levels of dysfunctional attitudes (slope = 005
t(2459) = 328 p = 0001)
Prospective Diathesis-Stress Analyses - Anxiety
The same data-analytic approach as described above was used to examine
whether higher levels of dysfunctional attitudes would be associated with greater
increases in anxious symptoms following increases in stress Again in order to examine
whether DYSFUNCTIONAL ATTITUDES represent a vulnerability factor
independent of neuroticism participantsrsquo FFI-N scores were entered in the model
With respect to random effects the ARH[1] parameter (r = 23 p lt 001)
RE_INTERCEPT (plt001) and RE_SLOPE (plt001) were each significant and thus
were retained in the model The final results with respect to the fixed-effects
component of the model are presented in the lower section of Table 3 Of primary
importance the DYSFUNCTIONAL ATTITUDES STRESS interaction was a
significant predictor of within-subject fluctuations in anxious symptoms during the
follow-up interval In order to examine the form of this interaction the model
summarized in the lower section of Table 3 was used to calculate predicted MASQ
scores for individuals exhibiting either high or low levels of dysfunctional attitudes
17
(plus or minus 15 SD) who are experiencing either high or low levels of stress in
comparison to their own average level of stress (plus or minus 15 times mean within-
subject SD) The results of such calculations are presented on the right panel of in
Figure 1
Analyses were conducted for each DYSFUNCTIONAL ATTITUDES
condition examining whether the slope of the relationship between stress and anxious
symptoms significantly differed from 0 Analyses indicated that both individuals
exhibiting high (t(2470) = 768 p lt 0001) and low (t(2470) = 337 p lt 0001) levels of
dysfunctional attitudes reported higher levels of anxious symptoms when experiencing
high levels of stress than when experiencing low levels of stress Planned comparisons
of the slopes of the relationship between stress and anxious symptoms however
revealed that the slope was significantly greater in individuals exhibiting high levels of
dysfunctional attitudes (slope = 009) than in individuals exhibiting low levels of
dysfunctional attitudes (slope = 003 t(2470) = 278 p lt 001)
Additional Analyses
Given that the DYSFUNCTIONAL ATTITUDES STRESS interaction
prospectively predicted both symptoms of depression and anxiety two additional
analyses were conducted in order to examine (1) whether the DYSFUNCTIONAL
ATTITUDES STRESS interaction continued to be a significant predictor of within-
subject fluctuations in depressive symptoms after controlling for within-subject
fluctuations in anxious symptoms and (2) whether the DYSFUNCTIONAL
ATTITUDES STRESS interaction continued to predict within-subject fluctuations in
anxious symptoms after controlling for within-subject fluctuations in depressive
18
symptoms Such analyses allowed us to examine whether the above mentioned pattern
of findings may have been due to the high correlation observed in the current study
between depressive and anxious symptoms
Analyses were conducted in the same manner as described above with the
exception that an additional within-subject variable (ie DEPRESSION or ANXIETY)
was included in each model in order to control for within-subject fluctuations in the
alternate symptom With respect to the prediction of depressive symptoms the
DYSFUNCTIONAL ATTITUDES STRESS interaction remained a significant
predictor after controlling for within-subject fluctuations in anxious symptoms (β =
001 SE = 000 F = 410 p lt 05) With respect to the prediction of anxious
symptoms however the DYSFUNCTIONAL ATTITUDES STRESS interaction
was no longer a significant predictor after controlling for within-subject fluctuations in
depressive symptoms (β = 001 SE = 000 F = 148 p = 22)
DISCUSSION
The results of the current study provide support for the cross-cultural
applicability of Beckrsquos (1967 1983) cognitive theory to university students in Hunan
China More specifically consistent with hypotheses and with results obtained from
past research examining Beckrsquos cognitive theory in Western samples of university
students (Hankin et al 2004 Hankin et al 2005 Joiner et al 1999 Klocek et al
1997 Brown et al 1995) higher levels of dysfunctional attitudes were associated with
greater increases in depressive symptoms following increases in negative event
frequency during the six-month follow-up interval Given the considerable differences
between the current sample and Western samples in terms of demographic
19
characteristics and cultural factors such a finding strongly attests to the robustness of
Beckrsquos cognitive theory Moreover integrating the current findings with those obtained
in research examining Beckrsquos theory in other non-Western samples suggests that
Beckrsquos theory may represent a powerful explanatory model of the development of
depressive symptoms among individuals from diverse cultural settings For example
consistent with the theory higher levels of dysfunctional attitudes have been shown to
be associated with higher levels of depressive symptoms in Japanese (Tanaka et al
2006) Puerto-Rican (Bonilla Bernal Santos amp Santos 2003) Turkish (Sahin amp Sahin
1992) Norwegian (Chioqueta amp Stiles 2004) Singaporean (Oei Goh amp Kwon 1996)
and Swedish (Ohrt amp Thorell 1998) adult samples In addition it is important to note
that the current findings expand upon past correlational research examining the
association between dysfunctional attitudes and depression in Chinese samples through
the use of a multi-wave longitudinal design
When examining the specificity of dysfunctional attitudes as a predictor of
depressive symptoms the current study did not obtain support for specificity More
specifically contrary to the specificity hypothesis of Beckrsquos cognitive theory and to
results obtained in Western samples of university students (Alloy et al 2000 2006
Hankin et al 2004) higher levels of dysfunctional attitudes were associated with
greater increases in both depressive and anxious symptoms following increases in
negative event frequency There are two alternative ways of interpreting the non-
specificity finding observed in the current study First it is possible that the types of
thoughts individuals possessing high levels of dysfunctional attitudes experience
following negative events varies as a function of cultural context In other words in
20
Western samples such individuals may primarily experience the types of cognitions
that are associated with the development of depressive symptoms (ie appraisals of
personal loss and failure) In contrast in Chinese samples individuals possessing high
levels of dysfunctional attitudes may experience a wider array of cognitions some of
which are associated with the development of depressive symptoms and some of which
are associated with the development of anxious symptoms (ie evaluations of
impending threat or danger) Such an explanation would be consistent with Beckrsquos
cognitive content-specificity hypothesis (Clark amp Beck 1999) which posits that each
affective state and psychological disorder has a specific cognitive profile Second it is
possible that the types of symptoms individuals possessing high levels of dysfunctional
attitudes experience following negative events varies as a function of cultural context
More specifically it may be that dysfunctional attitudes specifically predict symptoms
of depression in both samples except that in Western samples depression manifests in
pure depressive symptoms whereas in Chinese samples depression manifests as a
combination of depressive and anxious symptoms Such an explanation would be
consistent with cultural psychopathologistsrsquo hypotheses that cultural factors shape the
phenomenology of psychiatric symptoms (Kleinman 2004 Mezzich et al 1999)
Moreover dysfunctional attitudes predicting a combination of depressive and anxious
symptoms in Chinese samples would be consistent with the construct of neurasthenia -
a construct hypothesized by some to represent a somatized form of depression that is
still widely seen within China (Lee amp Wong 1995)
Interesting in this regard and perhaps speaking to the primacy of depressive
symptoms in the current findings analyses indicated that the DYSFUNCTIONAL
21
ATTITUDES times STRESS interaction no longer predicted anxious symptoms after
controlling for depressive symptoms The reverse however was not true as the
DYSFUNCTIONAL ATTITUDES times STRESS interaction continued to predict
depressive symptoms after controlling for anxious symptoms
It is important to note that the current study employed a particularly
conservative approach to analyses in that we examined the effects of dysfunctional
attitudes on depressive and anxious symptoms after controlling for the effect of
neuroticism on such symptoms Providing particularly powerful support for Beckrsquos
(1967 1983) cognitive theory across analyses dysfunctional attitudes predicted levels
of depressive andor anxious symptoms experienced during the six month follow-up
interval independent of the effect of neuroticism Thus contrary to past critical reviews
of the cognitive literature (Barnett amp Gotlib 1998 Coyne amp Whiffen 1995) and
consistent with past findings (Hankin et al 2007) the current results indicate that
cognitive vulnerabilities to depression such as dysfunctional attitudes are not reducible
to trait neuroticism but rather represent factors that confer independent risk for
depression
Limitations and Future Directions
Several limitations of the current study should be noted First self-report
measures were used to assess depressive and anxious symptoms Although the CES-D
and MASQ both possess high degrees of reliability and validity it is difficult to draw
conclusions about clinically diagnosed depression or anxiety based on self-report
questionnaires Second self-report measures were used to assess stress Although
measures of stress that require participants only to indicate whether or not an event
22
occurred are less likely to be influenced by informant bias than those that ask
participants to rate the subjective impact of each event more sophisticated methods of
analysis such as interviewing procedures that assess contextual threat may provide
better assessments of stress Third the measures of dysfunctional attitudes stress and
depressive and anxious symptoms used in the current study were each Western-
developed Future research should examine these hypotheses using indigenous
measures in addition to Western-developed measures in order to assess possible
similarities andor differences in patterns of findings Fourth the current study only
examined depression and anxiety as symptom outcomes Future research conducted
within China should examine a wider array of symptom outcomes such as
somatization physical complaints and externalizing behaviors in order to provide a
more thorough and culturally sensitive test of the specificity hypotheses of Beckrsquos
cognitive model Fifth the current study examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese undergraduate students and thus the extent to which
our findings may be generalized to other demographics within Chinarsquos population is
unclear Last the current study broadly examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese university students Future research should examine
the constructs and processes posited by this model in greater detail in order to develop a
deeper understanding of how they may be uniquely molded by socio-cultural factors
Such research would benefit from examining the specific types of stressors experienced
by Chinese university students as they may vary as a function of socio-cultural factors
from those experienced by Western undergraduates For example severe pressure to
succeed academically in order to secure access to a limited number of post-
23
undergraduate educational opportunities - one of the few paths towards upward
mobility available to Chinese students seeking secure and gainful employment in what
has increasingly become a very highly competitive job market - may represent a
particularly salient stressor for the development of depressive symptoms among this
population (Qiang 2006)
In conclusion the results from the current study provide support for the
applicability of Beckrsquos cognitive theory to university students in mainland China More
specifically consistent with findings obtained in the West results indicate that
dysfunctional attitudes confer vulnerability to the development of depressive symptoms
following the occurrence of negative events in Chinese university students At the same
time however the current findings suggest cultural variation in the profile of
symptoms which emerge following the occurrence of negative events in cognitively
vulnerable individuals in Western and Chinese samples Specifically whereas in the
West dysfunctional attitudes have been shown to confer vulnerability to depressive
symptoms in Chinese university students dysfunctional attitudes appear to confer
vulnerability to a combined depressive and anxious symptom profile Future research
using more sophisticated assessments of stress and depressive symptoms more diverse
samples and symptom outcome measures and indigenously-developed measures is
likely to enhance our understanding of the cognitive and environmental mechanisms
underlying the development of depression in Chinese university students Discovering
that cognitive theories of vulnerability to depression extend to university students in
China highlights the potential role for cognitive-behavioral depression prevention and
treatment interventions in stemming the tide of distress experienced by this population
24
REFERENCES
Abela J R Z amp Hankin B L (2008) Cognitive vulnerability to depression in
children and adolescents A developmental psychopathology perspective In J
R Z Abela and B L Hankin (Eds) Handbook of child and adolescent
depression (pp 35-78) New York The Guilford Press
Alloy L B Abramson L Y Hogan M E Whitehouse W G Rose D T
Robinson MS Kim R S amp Lapkin J B (2000) The Temple-Wisconsin
cognitive vulnerability to depression project Lifetime history of axis-I
psychopathology in individuals at high and low cognitive risk for depression
Journal of Abnormal Psychology 109 403-418
Alloy L B Abramson L Y Whitehouse W G Hogan M E Panzarella C amp
Rose D T (2006) Prospective incidence of first onsets and recurrences of
depression in individuals at high and low cognitive risk for depression Journal
of Abnormal Psychology 115 145ndash156
Altham P M E (1984) Improving the precision of estimation by fitting a model
Journal of the Royal Statistical Society Series B 46 11
Barnett PA amp Gotlib I H (1988) Psychosocial functioning and depression
Distinguishing among antecedents concomitants and consequences
Psychological Bulletin 104 97-126
Beck AT (1967) Depression Clinical experimental and theoretical aspects New
York Harper amp Row
Beck AT (1983) Cognitive therapy of depression New perspectives In PJ Clayton
amp JE Barrett (Eds) Treatment of depression Old controversies and new
approaches New York Raven Press
Bian Q Yang K amp Li C (2007) Dysfunctional attitudes of patients with depression
or bipolar disorder Chinese Mental Health Journal 21 759-761
Blankstein K R amp Flett G L (1993) Development of the General Academic and
Social Hassles Scales for Students Unpublished manuscript
Bonilla J Bernal G Santos A amp Santos D (2003) A revised Spanish version of
the Beck Depression InventoryPsychometric properties with a Puerto Rican
sample of college students Journal of Clinical Psychology 60 119-130
Brown G P Hammen C L Craske M G amp Wickens T D (1995) Dimensions of
dysfunctional attitudes as vulnerabilities to depressive symptoms Journal of
Abnormal Psychology 104 431-435
25
Chioqueta A P amp Stiles T C (2004) Psychometric properties of the Norweigian
version of the Dysfunctional Attitude Scale (Form A) Cognitive Behaviour
Therapy 33 83-86
Clark DA amp Beck AT (1999) Cognitive theory and therapy of depression New
York John Wiley amp Sons Inc
Clark L A amp Watson D (1991) Tripartite model of anxiety and depression
Psychometric evidence and taxonomic implications Journal of Abnormal
Psychology 100 316ndash336
Costa P T amp McCrae R R (1992) NEO PI-R Professional manual Revised NEO
personality inventory NEO PR-R and NEO five-factor inventory NEO-RRI
Odessa FL Psychological Assessment Resources
Coyne J C amp Whiffen V E (1995) Issues in personality as diathesis for depression
The case of sociotropy-dependency and autonomy-self-criticism Psychological
Bulletin 118 358-378
Fang X Qian M Luo S amp Zi F (2009) A correlational study on college students
perfectionism parental rearing patterns and mental health Chinese Mental
Health Journal 23 56-59
Hankin B L Abramson L Y Miller N amp Haeffel G (2004) Cognitive
vulnerability-stress theories of depression Examining affective specificity in
the prediction of depression versus anxiety in three prospective studies
Cognitive Therapy and Research 28 309ndash345
Hankin BL Fraley RC amp Abela JRZ (2005) Daily depression and cognitions
about stress Evidence for a traitlike depressogenic cognitive style and the
prediction of depressive symptoms in a prospective daily diary study Journal of
Personality and Social Psychology 88 673-685
Hankin B L Lakdawalla Z Carter I L Abela J R Z amp Adams P (2007) Are
neuroticism cognitive vulnerabilities and self-esteem overlapping or distinct
risks for depression Evidence from confirmatory factor analyses Journal of
Social amp Clinical Psychology 26 29-63
Hankin B L Wetter E Cheely C amp Oppenheimer C W (2008) Becks cognitive
theory of depression in adolescence Specific prediction of depressive
symptoms and reciprocal influences in a multi-wave prospective study
International Journal of Cognitive Therapy 1 313-332
Ingram R E Miranda J amp Segal Z V (1998) Cognitive Vulnerability to
Depression New York NY Guilford Press
26
Ingram R E amp Luxton DD (2005) Vulnerability-stress models In BL Hankin amp
JRZ Abela (Eds) Development of psychopathology A vulnerability-stress
perspective (pp 32-46) Thousand Oaks CA Sage
Joiner T E Metalsky G I Lew A amp Klocek J (1999) Testing the causal
mediation component of Becks theory of depression Evidence for specific
mediation Cognitive Therapy and Research 23 401-412
Kleinman A (2004) Culture and depression New England Journal of Medicine 351
951-953
Kleinman A (1977) Depression somatization and the new cross-cultural psychiatry
Social Science and Medicine 11 3-10
Kleinman A (1996) How is culture important for DSM-IV In J E Mezzich A
Kleinmam H Fabrega Jr amp L Delores (Eds)Culture and psychiatric
diagnosis A DSM-IV perspective (pp 15-25) Washington DC US American
Psychiatric Association
Klocek J W Oliver J M amp Ross M J (1997) The role of dysfunctional attitudes
negative life events and social support in the prediction of depressive
dysphoria A prospective longitudinal study Social Behavior and Personality
25 23-136
Lee S (1997) A Chinese perspective on somatoform disorders Journal of
Psychosomatic Disorders 43 115-119
Lee S (1998) Estranged bodies simulated harmony and misplaced cultures
Neurasthenia in contemporary Chinese society Psychosomatic Medicine 60
448ndash457
Lee S (1999) Diagnosis postponed Shenjing shuairo and the transformation of
psychiatry in post-Mao China Culture Medicine and Psychiatry 23 349ndash380
Lee S amp Wong K C (1995) Rethinking neurasthenia the illness concepts of
shenjing shuairuo among Chinese undergraduates in Honk Kong Culture
Medicine and Psychiatry 19 91ndash111
Lee S Tsang A Huang YQ He YL Liu ZR Zhang MY Shen YC amp
Kessler RC (2009) The epidemiology of depression in metropolitan China
Psychological Medicine 39 735-747
Mezzich J E Kirmayer L J Kleinman A Fabrega Jr H Parron D L Good B
J Lin K amp Manson S M (1999) The place of culture in DSM-IV Journal
of Nervous and Mental Disease 187 457-464
27
Monroe S M amp Simons A D (1991) Diathesisndashstress theories in the context of life
stress research Implications for the depressive disorders Psychological
Bulletin 110 406ndash425
Murray C J L amp Lopez A D (1996) The global burden of disease Cambridge
Harvard University Press
National Bureau of Statistics of China (2006) The China 2005 statistical yearbook
China Statistics Press Beijing PR China
Oei T P S Goh Y Kwon S M(1996) A cross-cultural study of the integrated
cognitive model of depression Current Psychology of Cognition 15 265-281
Ohrt T amp Thorell L (1998) Dysfunctional Attitude Scale (DAS) Psychometrics and
norms of the Swedish version Scandinavian Journal of Behaviour Therapy 27
105-113
Parker G Gladstone G Chee KT (2001) Depression in the planetrsquos largest ethnic
group The Chinese American Journal of Psychiatry 158 857-864
Phillips M R Zhang J Shi Q Song Z Ding Z Pang S Li X Zhang Y amp
Wang Z (2009) Prevalence treatment and associated disability of mental
disorders in four provinces in China during 2001ndash05 an epidemiological
survey The Lancet 373 2041-2053
Phillips M R Li X amp Zhang Y (2002) Suicide rates in China Lancet 359 835-
840
Phillips M R (1998) The transformation of Chinarsquos mental health services The China
Journal 39 1ndash36
Qiang G (2006) Depression number one killer of Ivory Tower students China Daily
Retrieved from httpwwwchinadailycomcnchina2006-
1128content_744880htm
Radloff L S (1977) The CESndashD scale A self-report depression scale for research in
the general population Applied Psychological Measurement 1 385ndash401
Rin H amp Huang M G (1989) Neurasthenia as nosological dilemma Culture
Medicine and Psychiatry 13 215-226
Sahin NH amp Sahin N (1992) How dysfunctional are the dysfunctional attitudes in
another culture British Journal of Medical Psychology 65 17-26
Shixie L (1989) Neurasthenia in China Modern and traditional criteria for its
diagnosis Culture Medicine and Psychiatry 13 163-186
28
Tanaka N Uji M Hiramura H Chen Z Shikai N amp Kitamura T (2006)
Cognitive patterns and depression Study of a Japanese university student
population Psychiatry and Clinical Neuroscience 60 358-364
Taylor R E (2001) Death of neurasthenia and its psychological reincarnation a study
of neurasthenia at the National Hospital for the Relief and Cure of the Paralysed
and Epileptic Queen Square London 1870ndash1932 British Journal of
Psychiatry 179 550ndash557
Weissman A N amp Beck A T (1978 April) Development and validation of the
Dysfunctional Attitudes Scale A preliminary investigation Paper presented at
the annual meeting of the Educational Research Association Toronto Canada
Xiang M Z (1986) Epidemiological study of neuroses in 12 regions (districts) of
China Chinese Journal of Neurology and Psychiatry 19 87-91
Xu JM (1987) Some issues in the diagnosis of depression in China Canadian
Journal of Psychiatry 32 368-370
Xu Y X (1994) About ICD-10 Journal of Clinical Psychology and Medicine 4 224-
226
Xu Z Li Z amp Wang Z (2007) Dysfunctional attitudes and cognitive bias in major
depressive disorder Chinese Mental Health Journal 21 488-491
Yan H Q (1989) The necessity of retaining the diagnostic concept of neurasthenia
Culture Medicine and Psychiatry 13 139-145
Yang H (2007) The Test of the Chinese version of Frost Multi-dimensional
Perfectionism Scale Chinese Mental Health Journal 21 97-100
Yang H amp Zhang X (2004) Perfectionism and mental health of college students
(2004) Chinese Mental Health Journal 18 647-648
Young D (1989) Neurasthenia and related problems Culture Medicine and
Psychiatry 13 131-138
Zhang D (1995) Depression and culture A Chinese perspective Canadian Journal of
Counseling 29 227ndash233
29
TABLE(S)
Table 1 Demographic Variables
Age 2011
Gender Male
Female
472
523
Parentsrsquo Marital Status Married
Divorced
Single
Remarried
938
23
18
20
Fatherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
Government Official
51
356
187
95
124
91
Motherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
122
406
144
76
134
Fatherrsquos Education Some Primary School
Primary School
Some High School
High School
University
29
139
222
403
137
Motherrsquos Education Some Primary School
Primary School
Some High School
High School
University
63
192
264
350
76
Only Child No
Yes
331
667
Monthly Income lt 1000 RMB
1000 ndash 1500 RMB
1500 ndash 2000 RMB
2000 ndash 3000 RMB
3000 ndash 4000 RMB
4000 ndash 5000 RMB
gt 5000 RMB
334
204
175
140
59
20
20
30
Table 2 Means Standard Deviations and Inter-correlations Between Time 1 Measures
__________________________________________________________________
1 2 3
__________________________________________________________________
1 Depressive Symptoms 2963 (780)
2 Anxious Symptoms 52 3753 (918)
3 Dysfunctional Attitudes 48 33 18120 (2304)
4 Neuroticism 63 42 53 3110 (712)
_________________________________________________________________________
Note Means and standard deviations (in parentheses) are on the diagonal Depressive
Symptoms = Center for Epidemiological Studies Depression Scale Anxious Symptoms
= Mood and Anxiety Symptom Questionnaire Overall Anxiety subscale Dysfunctional
Attitudes = Dysfunctional Attitudes Scale Neuroticism = NEO Five Factor Inventory
Neuroticism subscale p lt 01
31
Table 3 Dysfunctional Attitudes Predicting Within-Subject Fluctuations in CES-D
Scores (upper section) and MASQ Scores (lower section) during the Follow-Up
Interval
______________________________________________________________________
β SE F df
______________________________________________________________________
Time 1 CESD-D 297 026 12987 1572
Stress 005 000 10860 12459
Neuroticism 134 027 2518 1572
Dysfunctional Attitudes -055 040 -183 1572
Dysfunctional Attitudes times Stress 001 000 1078 12459
______________________________________________________________________
Time 1 MASQ 502 033 23158 1575
Stress 006 000 8963 12470
Neuroticism 080 033 596 1575
Dysfunctional Attitudes -052 051 -106 1575
Dysfunctional Attitudes times Stress 002 001 774 12470
______________________________________________________________________
Note Time 1 CES-D = Time 1 Center for Epidemiological Studies Depression Scale
Stress = Within-Subject Fluctuations in General Academic Social Hassles Scale for
Students (GASHSS) scores during the follow-up interval Neuroticism = NEO Five
Factor Inventory Neuroticism subscale Dysfunctional Attitudes = Dysfunctional
Attitudes Scale Time 1 MASQ = Time 1 Mood and Anxiety Symptom Questionnaire
Overall Anxiety subscale p lt 05 p lt 01 p lt 001
32
FIGURES
Figure 1 Predicted slope of the relationship between stress and depressive
symptoms (left panel) and anxious symptoms (right panel) as a function of
dysfunctional attitudes
20
25
30
Low High
Pre
dic
ted
CE
S-D
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
25
30
35
40
Low High
Pre
dic
ted
MA
SQ
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
Intercept Intercept
15
residuals over time are likely to be correlated) include compound symmetry first-order
autoregressive heterogeneous autoregressive and banded Toeplitz In order to select
one of these covariance structures for our analyses we fitted models using each
structure and chose the ldquobestrdquo fit based on Akaike information criterion (AIC and
AICC) and Schwarz Bayesian criterion (BIC) In all cases the best fit for our data was
a first-order heterogeneous autoregressive structure (ARH [1]) After choosing the
appropriate covariance structure we next examined the random-effects component of
our model
With respect to random effects the ARH [1] parameter (r = 31 plt001)
RE_INTERCEPT (plt001) and RE_SLOPE (plt001) were each significant and thus
were retained in the model The final results with respect to the fixed-effects
component of the model are presented in the upper section of Table 3 Of primary
importance the DYSFUNCTIONAL ATTITUDES STRESS interaction was a
significant predictor of fluctuations in depressive symptoms during the follow-up
interval In order to examine the form of this interaction the model summarized in the
upper section of Table 3 was used to calculate predicted CES-D scores for individuals
exhibiting either high or low levels of dysfunctional attitudes (plus or minus 15 SD)
who are experiencing either high or low levels of stress in comparison to their own
average level of stress (plus or minus 15 times mean within-subject SD) The results of
such calculations are presented in the left panel of Figure 1
Analyses were conducted for each DYSFUNCTIONAL ATTITUDES
condition examining whether the slope of the relationship between stress and
depressive symptoms significantly differed from 0 Analyses indicated that both
16
individuals exhibiting high (t(2459) = 862 p lt 0001) and low (t(2459) = 347 p lt
0001) levels of dysfunctional attitudes reported significantly higher levels of
depressive symptoms when experiencing high levels of stress than when experiencing
low levels of stress Planned comparisons of the slopes of the relationship between
stress and depressive symptoms however revealed that the slope was significantly
greater in individuals exhibiting high levels of dysfunctional attitudes (slope = 013)
than in individuals exhibiting low levels of dysfunctional attitudes (slope = 005
t(2459) = 328 p = 0001)
Prospective Diathesis-Stress Analyses - Anxiety
The same data-analytic approach as described above was used to examine
whether higher levels of dysfunctional attitudes would be associated with greater
increases in anxious symptoms following increases in stress Again in order to examine
whether DYSFUNCTIONAL ATTITUDES represent a vulnerability factor
independent of neuroticism participantsrsquo FFI-N scores were entered in the model
With respect to random effects the ARH[1] parameter (r = 23 p lt 001)
RE_INTERCEPT (plt001) and RE_SLOPE (plt001) were each significant and thus
were retained in the model The final results with respect to the fixed-effects
component of the model are presented in the lower section of Table 3 Of primary
importance the DYSFUNCTIONAL ATTITUDES STRESS interaction was a
significant predictor of within-subject fluctuations in anxious symptoms during the
follow-up interval In order to examine the form of this interaction the model
summarized in the lower section of Table 3 was used to calculate predicted MASQ
scores for individuals exhibiting either high or low levels of dysfunctional attitudes
17
(plus or minus 15 SD) who are experiencing either high or low levels of stress in
comparison to their own average level of stress (plus or minus 15 times mean within-
subject SD) The results of such calculations are presented on the right panel of in
Figure 1
Analyses were conducted for each DYSFUNCTIONAL ATTITUDES
condition examining whether the slope of the relationship between stress and anxious
symptoms significantly differed from 0 Analyses indicated that both individuals
exhibiting high (t(2470) = 768 p lt 0001) and low (t(2470) = 337 p lt 0001) levels of
dysfunctional attitudes reported higher levels of anxious symptoms when experiencing
high levels of stress than when experiencing low levels of stress Planned comparisons
of the slopes of the relationship between stress and anxious symptoms however
revealed that the slope was significantly greater in individuals exhibiting high levels of
dysfunctional attitudes (slope = 009) than in individuals exhibiting low levels of
dysfunctional attitudes (slope = 003 t(2470) = 278 p lt 001)
Additional Analyses
Given that the DYSFUNCTIONAL ATTITUDES STRESS interaction
prospectively predicted both symptoms of depression and anxiety two additional
analyses were conducted in order to examine (1) whether the DYSFUNCTIONAL
ATTITUDES STRESS interaction continued to be a significant predictor of within-
subject fluctuations in depressive symptoms after controlling for within-subject
fluctuations in anxious symptoms and (2) whether the DYSFUNCTIONAL
ATTITUDES STRESS interaction continued to predict within-subject fluctuations in
anxious symptoms after controlling for within-subject fluctuations in depressive
18
symptoms Such analyses allowed us to examine whether the above mentioned pattern
of findings may have been due to the high correlation observed in the current study
between depressive and anxious symptoms
Analyses were conducted in the same manner as described above with the
exception that an additional within-subject variable (ie DEPRESSION or ANXIETY)
was included in each model in order to control for within-subject fluctuations in the
alternate symptom With respect to the prediction of depressive symptoms the
DYSFUNCTIONAL ATTITUDES STRESS interaction remained a significant
predictor after controlling for within-subject fluctuations in anxious symptoms (β =
001 SE = 000 F = 410 p lt 05) With respect to the prediction of anxious
symptoms however the DYSFUNCTIONAL ATTITUDES STRESS interaction
was no longer a significant predictor after controlling for within-subject fluctuations in
depressive symptoms (β = 001 SE = 000 F = 148 p = 22)
DISCUSSION
The results of the current study provide support for the cross-cultural
applicability of Beckrsquos (1967 1983) cognitive theory to university students in Hunan
China More specifically consistent with hypotheses and with results obtained from
past research examining Beckrsquos cognitive theory in Western samples of university
students (Hankin et al 2004 Hankin et al 2005 Joiner et al 1999 Klocek et al
1997 Brown et al 1995) higher levels of dysfunctional attitudes were associated with
greater increases in depressive symptoms following increases in negative event
frequency during the six-month follow-up interval Given the considerable differences
between the current sample and Western samples in terms of demographic
19
characteristics and cultural factors such a finding strongly attests to the robustness of
Beckrsquos cognitive theory Moreover integrating the current findings with those obtained
in research examining Beckrsquos theory in other non-Western samples suggests that
Beckrsquos theory may represent a powerful explanatory model of the development of
depressive symptoms among individuals from diverse cultural settings For example
consistent with the theory higher levels of dysfunctional attitudes have been shown to
be associated with higher levels of depressive symptoms in Japanese (Tanaka et al
2006) Puerto-Rican (Bonilla Bernal Santos amp Santos 2003) Turkish (Sahin amp Sahin
1992) Norwegian (Chioqueta amp Stiles 2004) Singaporean (Oei Goh amp Kwon 1996)
and Swedish (Ohrt amp Thorell 1998) adult samples In addition it is important to note
that the current findings expand upon past correlational research examining the
association between dysfunctional attitudes and depression in Chinese samples through
the use of a multi-wave longitudinal design
When examining the specificity of dysfunctional attitudes as a predictor of
depressive symptoms the current study did not obtain support for specificity More
specifically contrary to the specificity hypothesis of Beckrsquos cognitive theory and to
results obtained in Western samples of university students (Alloy et al 2000 2006
Hankin et al 2004) higher levels of dysfunctional attitudes were associated with
greater increases in both depressive and anxious symptoms following increases in
negative event frequency There are two alternative ways of interpreting the non-
specificity finding observed in the current study First it is possible that the types of
thoughts individuals possessing high levels of dysfunctional attitudes experience
following negative events varies as a function of cultural context In other words in
20
Western samples such individuals may primarily experience the types of cognitions
that are associated with the development of depressive symptoms (ie appraisals of
personal loss and failure) In contrast in Chinese samples individuals possessing high
levels of dysfunctional attitudes may experience a wider array of cognitions some of
which are associated with the development of depressive symptoms and some of which
are associated with the development of anxious symptoms (ie evaluations of
impending threat or danger) Such an explanation would be consistent with Beckrsquos
cognitive content-specificity hypothesis (Clark amp Beck 1999) which posits that each
affective state and psychological disorder has a specific cognitive profile Second it is
possible that the types of symptoms individuals possessing high levels of dysfunctional
attitudes experience following negative events varies as a function of cultural context
More specifically it may be that dysfunctional attitudes specifically predict symptoms
of depression in both samples except that in Western samples depression manifests in
pure depressive symptoms whereas in Chinese samples depression manifests as a
combination of depressive and anxious symptoms Such an explanation would be
consistent with cultural psychopathologistsrsquo hypotheses that cultural factors shape the
phenomenology of psychiatric symptoms (Kleinman 2004 Mezzich et al 1999)
Moreover dysfunctional attitudes predicting a combination of depressive and anxious
symptoms in Chinese samples would be consistent with the construct of neurasthenia -
a construct hypothesized by some to represent a somatized form of depression that is
still widely seen within China (Lee amp Wong 1995)
Interesting in this regard and perhaps speaking to the primacy of depressive
symptoms in the current findings analyses indicated that the DYSFUNCTIONAL
21
ATTITUDES times STRESS interaction no longer predicted anxious symptoms after
controlling for depressive symptoms The reverse however was not true as the
DYSFUNCTIONAL ATTITUDES times STRESS interaction continued to predict
depressive symptoms after controlling for anxious symptoms
It is important to note that the current study employed a particularly
conservative approach to analyses in that we examined the effects of dysfunctional
attitudes on depressive and anxious symptoms after controlling for the effect of
neuroticism on such symptoms Providing particularly powerful support for Beckrsquos
(1967 1983) cognitive theory across analyses dysfunctional attitudes predicted levels
of depressive andor anxious symptoms experienced during the six month follow-up
interval independent of the effect of neuroticism Thus contrary to past critical reviews
of the cognitive literature (Barnett amp Gotlib 1998 Coyne amp Whiffen 1995) and
consistent with past findings (Hankin et al 2007) the current results indicate that
cognitive vulnerabilities to depression such as dysfunctional attitudes are not reducible
to trait neuroticism but rather represent factors that confer independent risk for
depression
Limitations and Future Directions
Several limitations of the current study should be noted First self-report
measures were used to assess depressive and anxious symptoms Although the CES-D
and MASQ both possess high degrees of reliability and validity it is difficult to draw
conclusions about clinically diagnosed depression or anxiety based on self-report
questionnaires Second self-report measures were used to assess stress Although
measures of stress that require participants only to indicate whether or not an event
22
occurred are less likely to be influenced by informant bias than those that ask
participants to rate the subjective impact of each event more sophisticated methods of
analysis such as interviewing procedures that assess contextual threat may provide
better assessments of stress Third the measures of dysfunctional attitudes stress and
depressive and anxious symptoms used in the current study were each Western-
developed Future research should examine these hypotheses using indigenous
measures in addition to Western-developed measures in order to assess possible
similarities andor differences in patterns of findings Fourth the current study only
examined depression and anxiety as symptom outcomes Future research conducted
within China should examine a wider array of symptom outcomes such as
somatization physical complaints and externalizing behaviors in order to provide a
more thorough and culturally sensitive test of the specificity hypotheses of Beckrsquos
cognitive model Fifth the current study examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese undergraduate students and thus the extent to which
our findings may be generalized to other demographics within Chinarsquos population is
unclear Last the current study broadly examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese university students Future research should examine
the constructs and processes posited by this model in greater detail in order to develop a
deeper understanding of how they may be uniquely molded by socio-cultural factors
Such research would benefit from examining the specific types of stressors experienced
by Chinese university students as they may vary as a function of socio-cultural factors
from those experienced by Western undergraduates For example severe pressure to
succeed academically in order to secure access to a limited number of post-
23
undergraduate educational opportunities - one of the few paths towards upward
mobility available to Chinese students seeking secure and gainful employment in what
has increasingly become a very highly competitive job market - may represent a
particularly salient stressor for the development of depressive symptoms among this
population (Qiang 2006)
In conclusion the results from the current study provide support for the
applicability of Beckrsquos cognitive theory to university students in mainland China More
specifically consistent with findings obtained in the West results indicate that
dysfunctional attitudes confer vulnerability to the development of depressive symptoms
following the occurrence of negative events in Chinese university students At the same
time however the current findings suggest cultural variation in the profile of
symptoms which emerge following the occurrence of negative events in cognitively
vulnerable individuals in Western and Chinese samples Specifically whereas in the
West dysfunctional attitudes have been shown to confer vulnerability to depressive
symptoms in Chinese university students dysfunctional attitudes appear to confer
vulnerability to a combined depressive and anxious symptom profile Future research
using more sophisticated assessments of stress and depressive symptoms more diverse
samples and symptom outcome measures and indigenously-developed measures is
likely to enhance our understanding of the cognitive and environmental mechanisms
underlying the development of depression in Chinese university students Discovering
that cognitive theories of vulnerability to depression extend to university students in
China highlights the potential role for cognitive-behavioral depression prevention and
treatment interventions in stemming the tide of distress experienced by this population
24
REFERENCES
Abela J R Z amp Hankin B L (2008) Cognitive vulnerability to depression in
children and adolescents A developmental psychopathology perspective In J
R Z Abela and B L Hankin (Eds) Handbook of child and adolescent
depression (pp 35-78) New York The Guilford Press
Alloy L B Abramson L Y Hogan M E Whitehouse W G Rose D T
Robinson MS Kim R S amp Lapkin J B (2000) The Temple-Wisconsin
cognitive vulnerability to depression project Lifetime history of axis-I
psychopathology in individuals at high and low cognitive risk for depression
Journal of Abnormal Psychology 109 403-418
Alloy L B Abramson L Y Whitehouse W G Hogan M E Panzarella C amp
Rose D T (2006) Prospective incidence of first onsets and recurrences of
depression in individuals at high and low cognitive risk for depression Journal
of Abnormal Psychology 115 145ndash156
Altham P M E (1984) Improving the precision of estimation by fitting a model
Journal of the Royal Statistical Society Series B 46 11
Barnett PA amp Gotlib I H (1988) Psychosocial functioning and depression
Distinguishing among antecedents concomitants and consequences
Psychological Bulletin 104 97-126
Beck AT (1967) Depression Clinical experimental and theoretical aspects New
York Harper amp Row
Beck AT (1983) Cognitive therapy of depression New perspectives In PJ Clayton
amp JE Barrett (Eds) Treatment of depression Old controversies and new
approaches New York Raven Press
Bian Q Yang K amp Li C (2007) Dysfunctional attitudes of patients with depression
or bipolar disorder Chinese Mental Health Journal 21 759-761
Blankstein K R amp Flett G L (1993) Development of the General Academic and
Social Hassles Scales for Students Unpublished manuscript
Bonilla J Bernal G Santos A amp Santos D (2003) A revised Spanish version of
the Beck Depression InventoryPsychometric properties with a Puerto Rican
sample of college students Journal of Clinical Psychology 60 119-130
Brown G P Hammen C L Craske M G amp Wickens T D (1995) Dimensions of
dysfunctional attitudes as vulnerabilities to depressive symptoms Journal of
Abnormal Psychology 104 431-435
25
Chioqueta A P amp Stiles T C (2004) Psychometric properties of the Norweigian
version of the Dysfunctional Attitude Scale (Form A) Cognitive Behaviour
Therapy 33 83-86
Clark DA amp Beck AT (1999) Cognitive theory and therapy of depression New
York John Wiley amp Sons Inc
Clark L A amp Watson D (1991) Tripartite model of anxiety and depression
Psychometric evidence and taxonomic implications Journal of Abnormal
Psychology 100 316ndash336
Costa P T amp McCrae R R (1992) NEO PI-R Professional manual Revised NEO
personality inventory NEO PR-R and NEO five-factor inventory NEO-RRI
Odessa FL Psychological Assessment Resources
Coyne J C amp Whiffen V E (1995) Issues in personality as diathesis for depression
The case of sociotropy-dependency and autonomy-self-criticism Psychological
Bulletin 118 358-378
Fang X Qian M Luo S amp Zi F (2009) A correlational study on college students
perfectionism parental rearing patterns and mental health Chinese Mental
Health Journal 23 56-59
Hankin B L Abramson L Y Miller N amp Haeffel G (2004) Cognitive
vulnerability-stress theories of depression Examining affective specificity in
the prediction of depression versus anxiety in three prospective studies
Cognitive Therapy and Research 28 309ndash345
Hankin BL Fraley RC amp Abela JRZ (2005) Daily depression and cognitions
about stress Evidence for a traitlike depressogenic cognitive style and the
prediction of depressive symptoms in a prospective daily diary study Journal of
Personality and Social Psychology 88 673-685
Hankin B L Lakdawalla Z Carter I L Abela J R Z amp Adams P (2007) Are
neuroticism cognitive vulnerabilities and self-esteem overlapping or distinct
risks for depression Evidence from confirmatory factor analyses Journal of
Social amp Clinical Psychology 26 29-63
Hankin B L Wetter E Cheely C amp Oppenheimer C W (2008) Becks cognitive
theory of depression in adolescence Specific prediction of depressive
symptoms and reciprocal influences in a multi-wave prospective study
International Journal of Cognitive Therapy 1 313-332
Ingram R E Miranda J amp Segal Z V (1998) Cognitive Vulnerability to
Depression New York NY Guilford Press
26
Ingram R E amp Luxton DD (2005) Vulnerability-stress models In BL Hankin amp
JRZ Abela (Eds) Development of psychopathology A vulnerability-stress
perspective (pp 32-46) Thousand Oaks CA Sage
Joiner T E Metalsky G I Lew A amp Klocek J (1999) Testing the causal
mediation component of Becks theory of depression Evidence for specific
mediation Cognitive Therapy and Research 23 401-412
Kleinman A (2004) Culture and depression New England Journal of Medicine 351
951-953
Kleinman A (1977) Depression somatization and the new cross-cultural psychiatry
Social Science and Medicine 11 3-10
Kleinman A (1996) How is culture important for DSM-IV In J E Mezzich A
Kleinmam H Fabrega Jr amp L Delores (Eds)Culture and psychiatric
diagnosis A DSM-IV perspective (pp 15-25) Washington DC US American
Psychiatric Association
Klocek J W Oliver J M amp Ross M J (1997) The role of dysfunctional attitudes
negative life events and social support in the prediction of depressive
dysphoria A prospective longitudinal study Social Behavior and Personality
25 23-136
Lee S (1997) A Chinese perspective on somatoform disorders Journal of
Psychosomatic Disorders 43 115-119
Lee S (1998) Estranged bodies simulated harmony and misplaced cultures
Neurasthenia in contemporary Chinese society Psychosomatic Medicine 60
448ndash457
Lee S (1999) Diagnosis postponed Shenjing shuairo and the transformation of
psychiatry in post-Mao China Culture Medicine and Psychiatry 23 349ndash380
Lee S amp Wong K C (1995) Rethinking neurasthenia the illness concepts of
shenjing shuairuo among Chinese undergraduates in Honk Kong Culture
Medicine and Psychiatry 19 91ndash111
Lee S Tsang A Huang YQ He YL Liu ZR Zhang MY Shen YC amp
Kessler RC (2009) The epidemiology of depression in metropolitan China
Psychological Medicine 39 735-747
Mezzich J E Kirmayer L J Kleinman A Fabrega Jr H Parron D L Good B
J Lin K amp Manson S M (1999) The place of culture in DSM-IV Journal
of Nervous and Mental Disease 187 457-464
27
Monroe S M amp Simons A D (1991) Diathesisndashstress theories in the context of life
stress research Implications for the depressive disorders Psychological
Bulletin 110 406ndash425
Murray C J L amp Lopez A D (1996) The global burden of disease Cambridge
Harvard University Press
National Bureau of Statistics of China (2006) The China 2005 statistical yearbook
China Statistics Press Beijing PR China
Oei T P S Goh Y Kwon S M(1996) A cross-cultural study of the integrated
cognitive model of depression Current Psychology of Cognition 15 265-281
Ohrt T amp Thorell L (1998) Dysfunctional Attitude Scale (DAS) Psychometrics and
norms of the Swedish version Scandinavian Journal of Behaviour Therapy 27
105-113
Parker G Gladstone G Chee KT (2001) Depression in the planetrsquos largest ethnic
group The Chinese American Journal of Psychiatry 158 857-864
Phillips M R Zhang J Shi Q Song Z Ding Z Pang S Li X Zhang Y amp
Wang Z (2009) Prevalence treatment and associated disability of mental
disorders in four provinces in China during 2001ndash05 an epidemiological
survey The Lancet 373 2041-2053
Phillips M R Li X amp Zhang Y (2002) Suicide rates in China Lancet 359 835-
840
Phillips M R (1998) The transformation of Chinarsquos mental health services The China
Journal 39 1ndash36
Qiang G (2006) Depression number one killer of Ivory Tower students China Daily
Retrieved from httpwwwchinadailycomcnchina2006-
1128content_744880htm
Radloff L S (1977) The CESndashD scale A self-report depression scale for research in
the general population Applied Psychological Measurement 1 385ndash401
Rin H amp Huang M G (1989) Neurasthenia as nosological dilemma Culture
Medicine and Psychiatry 13 215-226
Sahin NH amp Sahin N (1992) How dysfunctional are the dysfunctional attitudes in
another culture British Journal of Medical Psychology 65 17-26
Shixie L (1989) Neurasthenia in China Modern and traditional criteria for its
diagnosis Culture Medicine and Psychiatry 13 163-186
28
Tanaka N Uji M Hiramura H Chen Z Shikai N amp Kitamura T (2006)
Cognitive patterns and depression Study of a Japanese university student
population Psychiatry and Clinical Neuroscience 60 358-364
Taylor R E (2001) Death of neurasthenia and its psychological reincarnation a study
of neurasthenia at the National Hospital for the Relief and Cure of the Paralysed
and Epileptic Queen Square London 1870ndash1932 British Journal of
Psychiatry 179 550ndash557
Weissman A N amp Beck A T (1978 April) Development and validation of the
Dysfunctional Attitudes Scale A preliminary investigation Paper presented at
the annual meeting of the Educational Research Association Toronto Canada
Xiang M Z (1986) Epidemiological study of neuroses in 12 regions (districts) of
China Chinese Journal of Neurology and Psychiatry 19 87-91
Xu JM (1987) Some issues in the diagnosis of depression in China Canadian
Journal of Psychiatry 32 368-370
Xu Y X (1994) About ICD-10 Journal of Clinical Psychology and Medicine 4 224-
226
Xu Z Li Z amp Wang Z (2007) Dysfunctional attitudes and cognitive bias in major
depressive disorder Chinese Mental Health Journal 21 488-491
Yan H Q (1989) The necessity of retaining the diagnostic concept of neurasthenia
Culture Medicine and Psychiatry 13 139-145
Yang H (2007) The Test of the Chinese version of Frost Multi-dimensional
Perfectionism Scale Chinese Mental Health Journal 21 97-100
Yang H amp Zhang X (2004) Perfectionism and mental health of college students
(2004) Chinese Mental Health Journal 18 647-648
Young D (1989) Neurasthenia and related problems Culture Medicine and
Psychiatry 13 131-138
Zhang D (1995) Depression and culture A Chinese perspective Canadian Journal of
Counseling 29 227ndash233
29
TABLE(S)
Table 1 Demographic Variables
Age 2011
Gender Male
Female
472
523
Parentsrsquo Marital Status Married
Divorced
Single
Remarried
938
23
18
20
Fatherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
Government Official
51
356
187
95
124
91
Motherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
122
406
144
76
134
Fatherrsquos Education Some Primary School
Primary School
Some High School
High School
University
29
139
222
403
137
Motherrsquos Education Some Primary School
Primary School
Some High School
High School
University
63
192
264
350
76
Only Child No
Yes
331
667
Monthly Income lt 1000 RMB
1000 ndash 1500 RMB
1500 ndash 2000 RMB
2000 ndash 3000 RMB
3000 ndash 4000 RMB
4000 ndash 5000 RMB
gt 5000 RMB
334
204
175
140
59
20
20
30
Table 2 Means Standard Deviations and Inter-correlations Between Time 1 Measures
__________________________________________________________________
1 2 3
__________________________________________________________________
1 Depressive Symptoms 2963 (780)
2 Anxious Symptoms 52 3753 (918)
3 Dysfunctional Attitudes 48 33 18120 (2304)
4 Neuroticism 63 42 53 3110 (712)
_________________________________________________________________________
Note Means and standard deviations (in parentheses) are on the diagonal Depressive
Symptoms = Center for Epidemiological Studies Depression Scale Anxious Symptoms
= Mood and Anxiety Symptom Questionnaire Overall Anxiety subscale Dysfunctional
Attitudes = Dysfunctional Attitudes Scale Neuroticism = NEO Five Factor Inventory
Neuroticism subscale p lt 01
31
Table 3 Dysfunctional Attitudes Predicting Within-Subject Fluctuations in CES-D
Scores (upper section) and MASQ Scores (lower section) during the Follow-Up
Interval
______________________________________________________________________
β SE F df
______________________________________________________________________
Time 1 CESD-D 297 026 12987 1572
Stress 005 000 10860 12459
Neuroticism 134 027 2518 1572
Dysfunctional Attitudes -055 040 -183 1572
Dysfunctional Attitudes times Stress 001 000 1078 12459
______________________________________________________________________
Time 1 MASQ 502 033 23158 1575
Stress 006 000 8963 12470
Neuroticism 080 033 596 1575
Dysfunctional Attitudes -052 051 -106 1575
Dysfunctional Attitudes times Stress 002 001 774 12470
______________________________________________________________________
Note Time 1 CES-D = Time 1 Center for Epidemiological Studies Depression Scale
Stress = Within-Subject Fluctuations in General Academic Social Hassles Scale for
Students (GASHSS) scores during the follow-up interval Neuroticism = NEO Five
Factor Inventory Neuroticism subscale Dysfunctional Attitudes = Dysfunctional
Attitudes Scale Time 1 MASQ = Time 1 Mood and Anxiety Symptom Questionnaire
Overall Anxiety subscale p lt 05 p lt 01 p lt 001
32
FIGURES
Figure 1 Predicted slope of the relationship between stress and depressive
symptoms (left panel) and anxious symptoms (right panel) as a function of
dysfunctional attitudes
20
25
30
Low High
Pre
dic
ted
CE
S-D
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
25
30
35
40
Low High
Pre
dic
ted
MA
SQ
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
Intercept Intercept
16
individuals exhibiting high (t(2459) = 862 p lt 0001) and low (t(2459) = 347 p lt
0001) levels of dysfunctional attitudes reported significantly higher levels of
depressive symptoms when experiencing high levels of stress than when experiencing
low levels of stress Planned comparisons of the slopes of the relationship between
stress and depressive symptoms however revealed that the slope was significantly
greater in individuals exhibiting high levels of dysfunctional attitudes (slope = 013)
than in individuals exhibiting low levels of dysfunctional attitudes (slope = 005
t(2459) = 328 p = 0001)
Prospective Diathesis-Stress Analyses - Anxiety
The same data-analytic approach as described above was used to examine
whether higher levels of dysfunctional attitudes would be associated with greater
increases in anxious symptoms following increases in stress Again in order to examine
whether DYSFUNCTIONAL ATTITUDES represent a vulnerability factor
independent of neuroticism participantsrsquo FFI-N scores were entered in the model
With respect to random effects the ARH[1] parameter (r = 23 p lt 001)
RE_INTERCEPT (plt001) and RE_SLOPE (plt001) were each significant and thus
were retained in the model The final results with respect to the fixed-effects
component of the model are presented in the lower section of Table 3 Of primary
importance the DYSFUNCTIONAL ATTITUDES STRESS interaction was a
significant predictor of within-subject fluctuations in anxious symptoms during the
follow-up interval In order to examine the form of this interaction the model
summarized in the lower section of Table 3 was used to calculate predicted MASQ
scores for individuals exhibiting either high or low levels of dysfunctional attitudes
17
(plus or minus 15 SD) who are experiencing either high or low levels of stress in
comparison to their own average level of stress (plus or minus 15 times mean within-
subject SD) The results of such calculations are presented on the right panel of in
Figure 1
Analyses were conducted for each DYSFUNCTIONAL ATTITUDES
condition examining whether the slope of the relationship between stress and anxious
symptoms significantly differed from 0 Analyses indicated that both individuals
exhibiting high (t(2470) = 768 p lt 0001) and low (t(2470) = 337 p lt 0001) levels of
dysfunctional attitudes reported higher levels of anxious symptoms when experiencing
high levels of stress than when experiencing low levels of stress Planned comparisons
of the slopes of the relationship between stress and anxious symptoms however
revealed that the slope was significantly greater in individuals exhibiting high levels of
dysfunctional attitudes (slope = 009) than in individuals exhibiting low levels of
dysfunctional attitudes (slope = 003 t(2470) = 278 p lt 001)
Additional Analyses
Given that the DYSFUNCTIONAL ATTITUDES STRESS interaction
prospectively predicted both symptoms of depression and anxiety two additional
analyses were conducted in order to examine (1) whether the DYSFUNCTIONAL
ATTITUDES STRESS interaction continued to be a significant predictor of within-
subject fluctuations in depressive symptoms after controlling for within-subject
fluctuations in anxious symptoms and (2) whether the DYSFUNCTIONAL
ATTITUDES STRESS interaction continued to predict within-subject fluctuations in
anxious symptoms after controlling for within-subject fluctuations in depressive
18
symptoms Such analyses allowed us to examine whether the above mentioned pattern
of findings may have been due to the high correlation observed in the current study
between depressive and anxious symptoms
Analyses were conducted in the same manner as described above with the
exception that an additional within-subject variable (ie DEPRESSION or ANXIETY)
was included in each model in order to control for within-subject fluctuations in the
alternate symptom With respect to the prediction of depressive symptoms the
DYSFUNCTIONAL ATTITUDES STRESS interaction remained a significant
predictor after controlling for within-subject fluctuations in anxious symptoms (β =
001 SE = 000 F = 410 p lt 05) With respect to the prediction of anxious
symptoms however the DYSFUNCTIONAL ATTITUDES STRESS interaction
was no longer a significant predictor after controlling for within-subject fluctuations in
depressive symptoms (β = 001 SE = 000 F = 148 p = 22)
DISCUSSION
The results of the current study provide support for the cross-cultural
applicability of Beckrsquos (1967 1983) cognitive theory to university students in Hunan
China More specifically consistent with hypotheses and with results obtained from
past research examining Beckrsquos cognitive theory in Western samples of university
students (Hankin et al 2004 Hankin et al 2005 Joiner et al 1999 Klocek et al
1997 Brown et al 1995) higher levels of dysfunctional attitudes were associated with
greater increases in depressive symptoms following increases in negative event
frequency during the six-month follow-up interval Given the considerable differences
between the current sample and Western samples in terms of demographic
19
characteristics and cultural factors such a finding strongly attests to the robustness of
Beckrsquos cognitive theory Moreover integrating the current findings with those obtained
in research examining Beckrsquos theory in other non-Western samples suggests that
Beckrsquos theory may represent a powerful explanatory model of the development of
depressive symptoms among individuals from diverse cultural settings For example
consistent with the theory higher levels of dysfunctional attitudes have been shown to
be associated with higher levels of depressive symptoms in Japanese (Tanaka et al
2006) Puerto-Rican (Bonilla Bernal Santos amp Santos 2003) Turkish (Sahin amp Sahin
1992) Norwegian (Chioqueta amp Stiles 2004) Singaporean (Oei Goh amp Kwon 1996)
and Swedish (Ohrt amp Thorell 1998) adult samples In addition it is important to note
that the current findings expand upon past correlational research examining the
association between dysfunctional attitudes and depression in Chinese samples through
the use of a multi-wave longitudinal design
When examining the specificity of dysfunctional attitudes as a predictor of
depressive symptoms the current study did not obtain support for specificity More
specifically contrary to the specificity hypothesis of Beckrsquos cognitive theory and to
results obtained in Western samples of university students (Alloy et al 2000 2006
Hankin et al 2004) higher levels of dysfunctional attitudes were associated with
greater increases in both depressive and anxious symptoms following increases in
negative event frequency There are two alternative ways of interpreting the non-
specificity finding observed in the current study First it is possible that the types of
thoughts individuals possessing high levels of dysfunctional attitudes experience
following negative events varies as a function of cultural context In other words in
20
Western samples such individuals may primarily experience the types of cognitions
that are associated with the development of depressive symptoms (ie appraisals of
personal loss and failure) In contrast in Chinese samples individuals possessing high
levels of dysfunctional attitudes may experience a wider array of cognitions some of
which are associated with the development of depressive symptoms and some of which
are associated with the development of anxious symptoms (ie evaluations of
impending threat or danger) Such an explanation would be consistent with Beckrsquos
cognitive content-specificity hypothesis (Clark amp Beck 1999) which posits that each
affective state and psychological disorder has a specific cognitive profile Second it is
possible that the types of symptoms individuals possessing high levels of dysfunctional
attitudes experience following negative events varies as a function of cultural context
More specifically it may be that dysfunctional attitudes specifically predict symptoms
of depression in both samples except that in Western samples depression manifests in
pure depressive symptoms whereas in Chinese samples depression manifests as a
combination of depressive and anxious symptoms Such an explanation would be
consistent with cultural psychopathologistsrsquo hypotheses that cultural factors shape the
phenomenology of psychiatric symptoms (Kleinman 2004 Mezzich et al 1999)
Moreover dysfunctional attitudes predicting a combination of depressive and anxious
symptoms in Chinese samples would be consistent with the construct of neurasthenia -
a construct hypothesized by some to represent a somatized form of depression that is
still widely seen within China (Lee amp Wong 1995)
Interesting in this regard and perhaps speaking to the primacy of depressive
symptoms in the current findings analyses indicated that the DYSFUNCTIONAL
21
ATTITUDES times STRESS interaction no longer predicted anxious symptoms after
controlling for depressive symptoms The reverse however was not true as the
DYSFUNCTIONAL ATTITUDES times STRESS interaction continued to predict
depressive symptoms after controlling for anxious symptoms
It is important to note that the current study employed a particularly
conservative approach to analyses in that we examined the effects of dysfunctional
attitudes on depressive and anxious symptoms after controlling for the effect of
neuroticism on such symptoms Providing particularly powerful support for Beckrsquos
(1967 1983) cognitive theory across analyses dysfunctional attitudes predicted levels
of depressive andor anxious symptoms experienced during the six month follow-up
interval independent of the effect of neuroticism Thus contrary to past critical reviews
of the cognitive literature (Barnett amp Gotlib 1998 Coyne amp Whiffen 1995) and
consistent with past findings (Hankin et al 2007) the current results indicate that
cognitive vulnerabilities to depression such as dysfunctional attitudes are not reducible
to trait neuroticism but rather represent factors that confer independent risk for
depression
Limitations and Future Directions
Several limitations of the current study should be noted First self-report
measures were used to assess depressive and anxious symptoms Although the CES-D
and MASQ both possess high degrees of reliability and validity it is difficult to draw
conclusions about clinically diagnosed depression or anxiety based on self-report
questionnaires Second self-report measures were used to assess stress Although
measures of stress that require participants only to indicate whether or not an event
22
occurred are less likely to be influenced by informant bias than those that ask
participants to rate the subjective impact of each event more sophisticated methods of
analysis such as interviewing procedures that assess contextual threat may provide
better assessments of stress Third the measures of dysfunctional attitudes stress and
depressive and anxious symptoms used in the current study were each Western-
developed Future research should examine these hypotheses using indigenous
measures in addition to Western-developed measures in order to assess possible
similarities andor differences in patterns of findings Fourth the current study only
examined depression and anxiety as symptom outcomes Future research conducted
within China should examine a wider array of symptom outcomes such as
somatization physical complaints and externalizing behaviors in order to provide a
more thorough and culturally sensitive test of the specificity hypotheses of Beckrsquos
cognitive model Fifth the current study examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese undergraduate students and thus the extent to which
our findings may be generalized to other demographics within Chinarsquos population is
unclear Last the current study broadly examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese university students Future research should examine
the constructs and processes posited by this model in greater detail in order to develop a
deeper understanding of how they may be uniquely molded by socio-cultural factors
Such research would benefit from examining the specific types of stressors experienced
by Chinese university students as they may vary as a function of socio-cultural factors
from those experienced by Western undergraduates For example severe pressure to
succeed academically in order to secure access to a limited number of post-
23
undergraduate educational opportunities - one of the few paths towards upward
mobility available to Chinese students seeking secure and gainful employment in what
has increasingly become a very highly competitive job market - may represent a
particularly salient stressor for the development of depressive symptoms among this
population (Qiang 2006)
In conclusion the results from the current study provide support for the
applicability of Beckrsquos cognitive theory to university students in mainland China More
specifically consistent with findings obtained in the West results indicate that
dysfunctional attitudes confer vulnerability to the development of depressive symptoms
following the occurrence of negative events in Chinese university students At the same
time however the current findings suggest cultural variation in the profile of
symptoms which emerge following the occurrence of negative events in cognitively
vulnerable individuals in Western and Chinese samples Specifically whereas in the
West dysfunctional attitudes have been shown to confer vulnerability to depressive
symptoms in Chinese university students dysfunctional attitudes appear to confer
vulnerability to a combined depressive and anxious symptom profile Future research
using more sophisticated assessments of stress and depressive symptoms more diverse
samples and symptom outcome measures and indigenously-developed measures is
likely to enhance our understanding of the cognitive and environmental mechanisms
underlying the development of depression in Chinese university students Discovering
that cognitive theories of vulnerability to depression extend to university students in
China highlights the potential role for cognitive-behavioral depression prevention and
treatment interventions in stemming the tide of distress experienced by this population
24
REFERENCES
Abela J R Z amp Hankin B L (2008) Cognitive vulnerability to depression in
children and adolescents A developmental psychopathology perspective In J
R Z Abela and B L Hankin (Eds) Handbook of child and adolescent
depression (pp 35-78) New York The Guilford Press
Alloy L B Abramson L Y Hogan M E Whitehouse W G Rose D T
Robinson MS Kim R S amp Lapkin J B (2000) The Temple-Wisconsin
cognitive vulnerability to depression project Lifetime history of axis-I
psychopathology in individuals at high and low cognitive risk for depression
Journal of Abnormal Psychology 109 403-418
Alloy L B Abramson L Y Whitehouse W G Hogan M E Panzarella C amp
Rose D T (2006) Prospective incidence of first onsets and recurrences of
depression in individuals at high and low cognitive risk for depression Journal
of Abnormal Psychology 115 145ndash156
Altham P M E (1984) Improving the precision of estimation by fitting a model
Journal of the Royal Statistical Society Series B 46 11
Barnett PA amp Gotlib I H (1988) Psychosocial functioning and depression
Distinguishing among antecedents concomitants and consequences
Psychological Bulletin 104 97-126
Beck AT (1967) Depression Clinical experimental and theoretical aspects New
York Harper amp Row
Beck AT (1983) Cognitive therapy of depression New perspectives In PJ Clayton
amp JE Barrett (Eds) Treatment of depression Old controversies and new
approaches New York Raven Press
Bian Q Yang K amp Li C (2007) Dysfunctional attitudes of patients with depression
or bipolar disorder Chinese Mental Health Journal 21 759-761
Blankstein K R amp Flett G L (1993) Development of the General Academic and
Social Hassles Scales for Students Unpublished manuscript
Bonilla J Bernal G Santos A amp Santos D (2003) A revised Spanish version of
the Beck Depression InventoryPsychometric properties with a Puerto Rican
sample of college students Journal of Clinical Psychology 60 119-130
Brown G P Hammen C L Craske M G amp Wickens T D (1995) Dimensions of
dysfunctional attitudes as vulnerabilities to depressive symptoms Journal of
Abnormal Psychology 104 431-435
25
Chioqueta A P amp Stiles T C (2004) Psychometric properties of the Norweigian
version of the Dysfunctional Attitude Scale (Form A) Cognitive Behaviour
Therapy 33 83-86
Clark DA amp Beck AT (1999) Cognitive theory and therapy of depression New
York John Wiley amp Sons Inc
Clark L A amp Watson D (1991) Tripartite model of anxiety and depression
Psychometric evidence and taxonomic implications Journal of Abnormal
Psychology 100 316ndash336
Costa P T amp McCrae R R (1992) NEO PI-R Professional manual Revised NEO
personality inventory NEO PR-R and NEO five-factor inventory NEO-RRI
Odessa FL Psychological Assessment Resources
Coyne J C amp Whiffen V E (1995) Issues in personality as diathesis for depression
The case of sociotropy-dependency and autonomy-self-criticism Psychological
Bulletin 118 358-378
Fang X Qian M Luo S amp Zi F (2009) A correlational study on college students
perfectionism parental rearing patterns and mental health Chinese Mental
Health Journal 23 56-59
Hankin B L Abramson L Y Miller N amp Haeffel G (2004) Cognitive
vulnerability-stress theories of depression Examining affective specificity in
the prediction of depression versus anxiety in three prospective studies
Cognitive Therapy and Research 28 309ndash345
Hankin BL Fraley RC amp Abela JRZ (2005) Daily depression and cognitions
about stress Evidence for a traitlike depressogenic cognitive style and the
prediction of depressive symptoms in a prospective daily diary study Journal of
Personality and Social Psychology 88 673-685
Hankin B L Lakdawalla Z Carter I L Abela J R Z amp Adams P (2007) Are
neuroticism cognitive vulnerabilities and self-esteem overlapping or distinct
risks for depression Evidence from confirmatory factor analyses Journal of
Social amp Clinical Psychology 26 29-63
Hankin B L Wetter E Cheely C amp Oppenheimer C W (2008) Becks cognitive
theory of depression in adolescence Specific prediction of depressive
symptoms and reciprocal influences in a multi-wave prospective study
International Journal of Cognitive Therapy 1 313-332
Ingram R E Miranda J amp Segal Z V (1998) Cognitive Vulnerability to
Depression New York NY Guilford Press
26
Ingram R E amp Luxton DD (2005) Vulnerability-stress models In BL Hankin amp
JRZ Abela (Eds) Development of psychopathology A vulnerability-stress
perspective (pp 32-46) Thousand Oaks CA Sage
Joiner T E Metalsky G I Lew A amp Klocek J (1999) Testing the causal
mediation component of Becks theory of depression Evidence for specific
mediation Cognitive Therapy and Research 23 401-412
Kleinman A (2004) Culture and depression New England Journal of Medicine 351
951-953
Kleinman A (1977) Depression somatization and the new cross-cultural psychiatry
Social Science and Medicine 11 3-10
Kleinman A (1996) How is culture important for DSM-IV In J E Mezzich A
Kleinmam H Fabrega Jr amp L Delores (Eds)Culture and psychiatric
diagnosis A DSM-IV perspective (pp 15-25) Washington DC US American
Psychiatric Association
Klocek J W Oliver J M amp Ross M J (1997) The role of dysfunctional attitudes
negative life events and social support in the prediction of depressive
dysphoria A prospective longitudinal study Social Behavior and Personality
25 23-136
Lee S (1997) A Chinese perspective on somatoform disorders Journal of
Psychosomatic Disorders 43 115-119
Lee S (1998) Estranged bodies simulated harmony and misplaced cultures
Neurasthenia in contemporary Chinese society Psychosomatic Medicine 60
448ndash457
Lee S (1999) Diagnosis postponed Shenjing shuairo and the transformation of
psychiatry in post-Mao China Culture Medicine and Psychiatry 23 349ndash380
Lee S amp Wong K C (1995) Rethinking neurasthenia the illness concepts of
shenjing shuairuo among Chinese undergraduates in Honk Kong Culture
Medicine and Psychiatry 19 91ndash111
Lee S Tsang A Huang YQ He YL Liu ZR Zhang MY Shen YC amp
Kessler RC (2009) The epidemiology of depression in metropolitan China
Psychological Medicine 39 735-747
Mezzich J E Kirmayer L J Kleinman A Fabrega Jr H Parron D L Good B
J Lin K amp Manson S M (1999) The place of culture in DSM-IV Journal
of Nervous and Mental Disease 187 457-464
27
Monroe S M amp Simons A D (1991) Diathesisndashstress theories in the context of life
stress research Implications for the depressive disorders Psychological
Bulletin 110 406ndash425
Murray C J L amp Lopez A D (1996) The global burden of disease Cambridge
Harvard University Press
National Bureau of Statistics of China (2006) The China 2005 statistical yearbook
China Statistics Press Beijing PR China
Oei T P S Goh Y Kwon S M(1996) A cross-cultural study of the integrated
cognitive model of depression Current Psychology of Cognition 15 265-281
Ohrt T amp Thorell L (1998) Dysfunctional Attitude Scale (DAS) Psychometrics and
norms of the Swedish version Scandinavian Journal of Behaviour Therapy 27
105-113
Parker G Gladstone G Chee KT (2001) Depression in the planetrsquos largest ethnic
group The Chinese American Journal of Psychiatry 158 857-864
Phillips M R Zhang J Shi Q Song Z Ding Z Pang S Li X Zhang Y amp
Wang Z (2009) Prevalence treatment and associated disability of mental
disorders in four provinces in China during 2001ndash05 an epidemiological
survey The Lancet 373 2041-2053
Phillips M R Li X amp Zhang Y (2002) Suicide rates in China Lancet 359 835-
840
Phillips M R (1998) The transformation of Chinarsquos mental health services The China
Journal 39 1ndash36
Qiang G (2006) Depression number one killer of Ivory Tower students China Daily
Retrieved from httpwwwchinadailycomcnchina2006-
1128content_744880htm
Radloff L S (1977) The CESndashD scale A self-report depression scale for research in
the general population Applied Psychological Measurement 1 385ndash401
Rin H amp Huang M G (1989) Neurasthenia as nosological dilemma Culture
Medicine and Psychiatry 13 215-226
Sahin NH amp Sahin N (1992) How dysfunctional are the dysfunctional attitudes in
another culture British Journal of Medical Psychology 65 17-26
Shixie L (1989) Neurasthenia in China Modern and traditional criteria for its
diagnosis Culture Medicine and Psychiatry 13 163-186
28
Tanaka N Uji M Hiramura H Chen Z Shikai N amp Kitamura T (2006)
Cognitive patterns and depression Study of a Japanese university student
population Psychiatry and Clinical Neuroscience 60 358-364
Taylor R E (2001) Death of neurasthenia and its psychological reincarnation a study
of neurasthenia at the National Hospital for the Relief and Cure of the Paralysed
and Epileptic Queen Square London 1870ndash1932 British Journal of
Psychiatry 179 550ndash557
Weissman A N amp Beck A T (1978 April) Development and validation of the
Dysfunctional Attitudes Scale A preliminary investigation Paper presented at
the annual meeting of the Educational Research Association Toronto Canada
Xiang M Z (1986) Epidemiological study of neuroses in 12 regions (districts) of
China Chinese Journal of Neurology and Psychiatry 19 87-91
Xu JM (1987) Some issues in the diagnosis of depression in China Canadian
Journal of Psychiatry 32 368-370
Xu Y X (1994) About ICD-10 Journal of Clinical Psychology and Medicine 4 224-
226
Xu Z Li Z amp Wang Z (2007) Dysfunctional attitudes and cognitive bias in major
depressive disorder Chinese Mental Health Journal 21 488-491
Yan H Q (1989) The necessity of retaining the diagnostic concept of neurasthenia
Culture Medicine and Psychiatry 13 139-145
Yang H (2007) The Test of the Chinese version of Frost Multi-dimensional
Perfectionism Scale Chinese Mental Health Journal 21 97-100
Yang H amp Zhang X (2004) Perfectionism and mental health of college students
(2004) Chinese Mental Health Journal 18 647-648
Young D (1989) Neurasthenia and related problems Culture Medicine and
Psychiatry 13 131-138
Zhang D (1995) Depression and culture A Chinese perspective Canadian Journal of
Counseling 29 227ndash233
29
TABLE(S)
Table 1 Demographic Variables
Age 2011
Gender Male
Female
472
523
Parentsrsquo Marital Status Married
Divorced
Single
Remarried
938
23
18
20
Fatherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
Government Official
51
356
187
95
124
91
Motherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
122
406
144
76
134
Fatherrsquos Education Some Primary School
Primary School
Some High School
High School
University
29
139
222
403
137
Motherrsquos Education Some Primary School
Primary School
Some High School
High School
University
63
192
264
350
76
Only Child No
Yes
331
667
Monthly Income lt 1000 RMB
1000 ndash 1500 RMB
1500 ndash 2000 RMB
2000 ndash 3000 RMB
3000 ndash 4000 RMB
4000 ndash 5000 RMB
gt 5000 RMB
334
204
175
140
59
20
20
30
Table 2 Means Standard Deviations and Inter-correlations Between Time 1 Measures
__________________________________________________________________
1 2 3
__________________________________________________________________
1 Depressive Symptoms 2963 (780)
2 Anxious Symptoms 52 3753 (918)
3 Dysfunctional Attitudes 48 33 18120 (2304)
4 Neuroticism 63 42 53 3110 (712)
_________________________________________________________________________
Note Means and standard deviations (in parentheses) are on the diagonal Depressive
Symptoms = Center for Epidemiological Studies Depression Scale Anxious Symptoms
= Mood and Anxiety Symptom Questionnaire Overall Anxiety subscale Dysfunctional
Attitudes = Dysfunctional Attitudes Scale Neuroticism = NEO Five Factor Inventory
Neuroticism subscale p lt 01
31
Table 3 Dysfunctional Attitudes Predicting Within-Subject Fluctuations in CES-D
Scores (upper section) and MASQ Scores (lower section) during the Follow-Up
Interval
______________________________________________________________________
β SE F df
______________________________________________________________________
Time 1 CESD-D 297 026 12987 1572
Stress 005 000 10860 12459
Neuroticism 134 027 2518 1572
Dysfunctional Attitudes -055 040 -183 1572
Dysfunctional Attitudes times Stress 001 000 1078 12459
______________________________________________________________________
Time 1 MASQ 502 033 23158 1575
Stress 006 000 8963 12470
Neuroticism 080 033 596 1575
Dysfunctional Attitudes -052 051 -106 1575
Dysfunctional Attitudes times Stress 002 001 774 12470
______________________________________________________________________
Note Time 1 CES-D = Time 1 Center for Epidemiological Studies Depression Scale
Stress = Within-Subject Fluctuations in General Academic Social Hassles Scale for
Students (GASHSS) scores during the follow-up interval Neuroticism = NEO Five
Factor Inventory Neuroticism subscale Dysfunctional Attitudes = Dysfunctional
Attitudes Scale Time 1 MASQ = Time 1 Mood and Anxiety Symptom Questionnaire
Overall Anxiety subscale p lt 05 p lt 01 p lt 001
32
FIGURES
Figure 1 Predicted slope of the relationship between stress and depressive
symptoms (left panel) and anxious symptoms (right panel) as a function of
dysfunctional attitudes
20
25
30
Low High
Pre
dic
ted
CE
S-D
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
25
30
35
40
Low High
Pre
dic
ted
MA
SQ
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
Intercept Intercept
17
(plus or minus 15 SD) who are experiencing either high or low levels of stress in
comparison to their own average level of stress (plus or minus 15 times mean within-
subject SD) The results of such calculations are presented on the right panel of in
Figure 1
Analyses were conducted for each DYSFUNCTIONAL ATTITUDES
condition examining whether the slope of the relationship between stress and anxious
symptoms significantly differed from 0 Analyses indicated that both individuals
exhibiting high (t(2470) = 768 p lt 0001) and low (t(2470) = 337 p lt 0001) levels of
dysfunctional attitudes reported higher levels of anxious symptoms when experiencing
high levels of stress than when experiencing low levels of stress Planned comparisons
of the slopes of the relationship between stress and anxious symptoms however
revealed that the slope was significantly greater in individuals exhibiting high levels of
dysfunctional attitudes (slope = 009) than in individuals exhibiting low levels of
dysfunctional attitudes (slope = 003 t(2470) = 278 p lt 001)
Additional Analyses
Given that the DYSFUNCTIONAL ATTITUDES STRESS interaction
prospectively predicted both symptoms of depression and anxiety two additional
analyses were conducted in order to examine (1) whether the DYSFUNCTIONAL
ATTITUDES STRESS interaction continued to be a significant predictor of within-
subject fluctuations in depressive symptoms after controlling for within-subject
fluctuations in anxious symptoms and (2) whether the DYSFUNCTIONAL
ATTITUDES STRESS interaction continued to predict within-subject fluctuations in
anxious symptoms after controlling for within-subject fluctuations in depressive
18
symptoms Such analyses allowed us to examine whether the above mentioned pattern
of findings may have been due to the high correlation observed in the current study
between depressive and anxious symptoms
Analyses were conducted in the same manner as described above with the
exception that an additional within-subject variable (ie DEPRESSION or ANXIETY)
was included in each model in order to control for within-subject fluctuations in the
alternate symptom With respect to the prediction of depressive symptoms the
DYSFUNCTIONAL ATTITUDES STRESS interaction remained a significant
predictor after controlling for within-subject fluctuations in anxious symptoms (β =
001 SE = 000 F = 410 p lt 05) With respect to the prediction of anxious
symptoms however the DYSFUNCTIONAL ATTITUDES STRESS interaction
was no longer a significant predictor after controlling for within-subject fluctuations in
depressive symptoms (β = 001 SE = 000 F = 148 p = 22)
DISCUSSION
The results of the current study provide support for the cross-cultural
applicability of Beckrsquos (1967 1983) cognitive theory to university students in Hunan
China More specifically consistent with hypotheses and with results obtained from
past research examining Beckrsquos cognitive theory in Western samples of university
students (Hankin et al 2004 Hankin et al 2005 Joiner et al 1999 Klocek et al
1997 Brown et al 1995) higher levels of dysfunctional attitudes were associated with
greater increases in depressive symptoms following increases in negative event
frequency during the six-month follow-up interval Given the considerable differences
between the current sample and Western samples in terms of demographic
19
characteristics and cultural factors such a finding strongly attests to the robustness of
Beckrsquos cognitive theory Moreover integrating the current findings with those obtained
in research examining Beckrsquos theory in other non-Western samples suggests that
Beckrsquos theory may represent a powerful explanatory model of the development of
depressive symptoms among individuals from diverse cultural settings For example
consistent with the theory higher levels of dysfunctional attitudes have been shown to
be associated with higher levels of depressive symptoms in Japanese (Tanaka et al
2006) Puerto-Rican (Bonilla Bernal Santos amp Santos 2003) Turkish (Sahin amp Sahin
1992) Norwegian (Chioqueta amp Stiles 2004) Singaporean (Oei Goh amp Kwon 1996)
and Swedish (Ohrt amp Thorell 1998) adult samples In addition it is important to note
that the current findings expand upon past correlational research examining the
association between dysfunctional attitudes and depression in Chinese samples through
the use of a multi-wave longitudinal design
When examining the specificity of dysfunctional attitudes as a predictor of
depressive symptoms the current study did not obtain support for specificity More
specifically contrary to the specificity hypothesis of Beckrsquos cognitive theory and to
results obtained in Western samples of university students (Alloy et al 2000 2006
Hankin et al 2004) higher levels of dysfunctional attitudes were associated with
greater increases in both depressive and anxious symptoms following increases in
negative event frequency There are two alternative ways of interpreting the non-
specificity finding observed in the current study First it is possible that the types of
thoughts individuals possessing high levels of dysfunctional attitudes experience
following negative events varies as a function of cultural context In other words in
20
Western samples such individuals may primarily experience the types of cognitions
that are associated with the development of depressive symptoms (ie appraisals of
personal loss and failure) In contrast in Chinese samples individuals possessing high
levels of dysfunctional attitudes may experience a wider array of cognitions some of
which are associated with the development of depressive symptoms and some of which
are associated with the development of anxious symptoms (ie evaluations of
impending threat or danger) Such an explanation would be consistent with Beckrsquos
cognitive content-specificity hypothesis (Clark amp Beck 1999) which posits that each
affective state and psychological disorder has a specific cognitive profile Second it is
possible that the types of symptoms individuals possessing high levels of dysfunctional
attitudes experience following negative events varies as a function of cultural context
More specifically it may be that dysfunctional attitudes specifically predict symptoms
of depression in both samples except that in Western samples depression manifests in
pure depressive symptoms whereas in Chinese samples depression manifests as a
combination of depressive and anxious symptoms Such an explanation would be
consistent with cultural psychopathologistsrsquo hypotheses that cultural factors shape the
phenomenology of psychiatric symptoms (Kleinman 2004 Mezzich et al 1999)
Moreover dysfunctional attitudes predicting a combination of depressive and anxious
symptoms in Chinese samples would be consistent with the construct of neurasthenia -
a construct hypothesized by some to represent a somatized form of depression that is
still widely seen within China (Lee amp Wong 1995)
Interesting in this regard and perhaps speaking to the primacy of depressive
symptoms in the current findings analyses indicated that the DYSFUNCTIONAL
21
ATTITUDES times STRESS interaction no longer predicted anxious symptoms after
controlling for depressive symptoms The reverse however was not true as the
DYSFUNCTIONAL ATTITUDES times STRESS interaction continued to predict
depressive symptoms after controlling for anxious symptoms
It is important to note that the current study employed a particularly
conservative approach to analyses in that we examined the effects of dysfunctional
attitudes on depressive and anxious symptoms after controlling for the effect of
neuroticism on such symptoms Providing particularly powerful support for Beckrsquos
(1967 1983) cognitive theory across analyses dysfunctional attitudes predicted levels
of depressive andor anxious symptoms experienced during the six month follow-up
interval independent of the effect of neuroticism Thus contrary to past critical reviews
of the cognitive literature (Barnett amp Gotlib 1998 Coyne amp Whiffen 1995) and
consistent with past findings (Hankin et al 2007) the current results indicate that
cognitive vulnerabilities to depression such as dysfunctional attitudes are not reducible
to trait neuroticism but rather represent factors that confer independent risk for
depression
Limitations and Future Directions
Several limitations of the current study should be noted First self-report
measures were used to assess depressive and anxious symptoms Although the CES-D
and MASQ both possess high degrees of reliability and validity it is difficult to draw
conclusions about clinically diagnosed depression or anxiety based on self-report
questionnaires Second self-report measures were used to assess stress Although
measures of stress that require participants only to indicate whether or not an event
22
occurred are less likely to be influenced by informant bias than those that ask
participants to rate the subjective impact of each event more sophisticated methods of
analysis such as interviewing procedures that assess contextual threat may provide
better assessments of stress Third the measures of dysfunctional attitudes stress and
depressive and anxious symptoms used in the current study were each Western-
developed Future research should examine these hypotheses using indigenous
measures in addition to Western-developed measures in order to assess possible
similarities andor differences in patterns of findings Fourth the current study only
examined depression and anxiety as symptom outcomes Future research conducted
within China should examine a wider array of symptom outcomes such as
somatization physical complaints and externalizing behaviors in order to provide a
more thorough and culturally sensitive test of the specificity hypotheses of Beckrsquos
cognitive model Fifth the current study examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese undergraduate students and thus the extent to which
our findings may be generalized to other demographics within Chinarsquos population is
unclear Last the current study broadly examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese university students Future research should examine
the constructs and processes posited by this model in greater detail in order to develop a
deeper understanding of how they may be uniquely molded by socio-cultural factors
Such research would benefit from examining the specific types of stressors experienced
by Chinese university students as they may vary as a function of socio-cultural factors
from those experienced by Western undergraduates For example severe pressure to
succeed academically in order to secure access to a limited number of post-
23
undergraduate educational opportunities - one of the few paths towards upward
mobility available to Chinese students seeking secure and gainful employment in what
has increasingly become a very highly competitive job market - may represent a
particularly salient stressor for the development of depressive symptoms among this
population (Qiang 2006)
In conclusion the results from the current study provide support for the
applicability of Beckrsquos cognitive theory to university students in mainland China More
specifically consistent with findings obtained in the West results indicate that
dysfunctional attitudes confer vulnerability to the development of depressive symptoms
following the occurrence of negative events in Chinese university students At the same
time however the current findings suggest cultural variation in the profile of
symptoms which emerge following the occurrence of negative events in cognitively
vulnerable individuals in Western and Chinese samples Specifically whereas in the
West dysfunctional attitudes have been shown to confer vulnerability to depressive
symptoms in Chinese university students dysfunctional attitudes appear to confer
vulnerability to a combined depressive and anxious symptom profile Future research
using more sophisticated assessments of stress and depressive symptoms more diverse
samples and symptom outcome measures and indigenously-developed measures is
likely to enhance our understanding of the cognitive and environmental mechanisms
underlying the development of depression in Chinese university students Discovering
that cognitive theories of vulnerability to depression extend to university students in
China highlights the potential role for cognitive-behavioral depression prevention and
treatment interventions in stemming the tide of distress experienced by this population
24
REFERENCES
Abela J R Z amp Hankin B L (2008) Cognitive vulnerability to depression in
children and adolescents A developmental psychopathology perspective In J
R Z Abela and B L Hankin (Eds) Handbook of child and adolescent
depression (pp 35-78) New York The Guilford Press
Alloy L B Abramson L Y Hogan M E Whitehouse W G Rose D T
Robinson MS Kim R S amp Lapkin J B (2000) The Temple-Wisconsin
cognitive vulnerability to depression project Lifetime history of axis-I
psychopathology in individuals at high and low cognitive risk for depression
Journal of Abnormal Psychology 109 403-418
Alloy L B Abramson L Y Whitehouse W G Hogan M E Panzarella C amp
Rose D T (2006) Prospective incidence of first onsets and recurrences of
depression in individuals at high and low cognitive risk for depression Journal
of Abnormal Psychology 115 145ndash156
Altham P M E (1984) Improving the precision of estimation by fitting a model
Journal of the Royal Statistical Society Series B 46 11
Barnett PA amp Gotlib I H (1988) Psychosocial functioning and depression
Distinguishing among antecedents concomitants and consequences
Psychological Bulletin 104 97-126
Beck AT (1967) Depression Clinical experimental and theoretical aspects New
York Harper amp Row
Beck AT (1983) Cognitive therapy of depression New perspectives In PJ Clayton
amp JE Barrett (Eds) Treatment of depression Old controversies and new
approaches New York Raven Press
Bian Q Yang K amp Li C (2007) Dysfunctional attitudes of patients with depression
or bipolar disorder Chinese Mental Health Journal 21 759-761
Blankstein K R amp Flett G L (1993) Development of the General Academic and
Social Hassles Scales for Students Unpublished manuscript
Bonilla J Bernal G Santos A amp Santos D (2003) A revised Spanish version of
the Beck Depression InventoryPsychometric properties with a Puerto Rican
sample of college students Journal of Clinical Psychology 60 119-130
Brown G P Hammen C L Craske M G amp Wickens T D (1995) Dimensions of
dysfunctional attitudes as vulnerabilities to depressive symptoms Journal of
Abnormal Psychology 104 431-435
25
Chioqueta A P amp Stiles T C (2004) Psychometric properties of the Norweigian
version of the Dysfunctional Attitude Scale (Form A) Cognitive Behaviour
Therapy 33 83-86
Clark DA amp Beck AT (1999) Cognitive theory and therapy of depression New
York John Wiley amp Sons Inc
Clark L A amp Watson D (1991) Tripartite model of anxiety and depression
Psychometric evidence and taxonomic implications Journal of Abnormal
Psychology 100 316ndash336
Costa P T amp McCrae R R (1992) NEO PI-R Professional manual Revised NEO
personality inventory NEO PR-R and NEO five-factor inventory NEO-RRI
Odessa FL Psychological Assessment Resources
Coyne J C amp Whiffen V E (1995) Issues in personality as diathesis for depression
The case of sociotropy-dependency and autonomy-self-criticism Psychological
Bulletin 118 358-378
Fang X Qian M Luo S amp Zi F (2009) A correlational study on college students
perfectionism parental rearing patterns and mental health Chinese Mental
Health Journal 23 56-59
Hankin B L Abramson L Y Miller N amp Haeffel G (2004) Cognitive
vulnerability-stress theories of depression Examining affective specificity in
the prediction of depression versus anxiety in three prospective studies
Cognitive Therapy and Research 28 309ndash345
Hankin BL Fraley RC amp Abela JRZ (2005) Daily depression and cognitions
about stress Evidence for a traitlike depressogenic cognitive style and the
prediction of depressive symptoms in a prospective daily diary study Journal of
Personality and Social Psychology 88 673-685
Hankin B L Lakdawalla Z Carter I L Abela J R Z amp Adams P (2007) Are
neuroticism cognitive vulnerabilities and self-esteem overlapping or distinct
risks for depression Evidence from confirmatory factor analyses Journal of
Social amp Clinical Psychology 26 29-63
Hankin B L Wetter E Cheely C amp Oppenheimer C W (2008) Becks cognitive
theory of depression in adolescence Specific prediction of depressive
symptoms and reciprocal influences in a multi-wave prospective study
International Journal of Cognitive Therapy 1 313-332
Ingram R E Miranda J amp Segal Z V (1998) Cognitive Vulnerability to
Depression New York NY Guilford Press
26
Ingram R E amp Luxton DD (2005) Vulnerability-stress models In BL Hankin amp
JRZ Abela (Eds) Development of psychopathology A vulnerability-stress
perspective (pp 32-46) Thousand Oaks CA Sage
Joiner T E Metalsky G I Lew A amp Klocek J (1999) Testing the causal
mediation component of Becks theory of depression Evidence for specific
mediation Cognitive Therapy and Research 23 401-412
Kleinman A (2004) Culture and depression New England Journal of Medicine 351
951-953
Kleinman A (1977) Depression somatization and the new cross-cultural psychiatry
Social Science and Medicine 11 3-10
Kleinman A (1996) How is culture important for DSM-IV In J E Mezzich A
Kleinmam H Fabrega Jr amp L Delores (Eds)Culture and psychiatric
diagnosis A DSM-IV perspective (pp 15-25) Washington DC US American
Psychiatric Association
Klocek J W Oliver J M amp Ross M J (1997) The role of dysfunctional attitudes
negative life events and social support in the prediction of depressive
dysphoria A prospective longitudinal study Social Behavior and Personality
25 23-136
Lee S (1997) A Chinese perspective on somatoform disorders Journal of
Psychosomatic Disorders 43 115-119
Lee S (1998) Estranged bodies simulated harmony and misplaced cultures
Neurasthenia in contemporary Chinese society Psychosomatic Medicine 60
448ndash457
Lee S (1999) Diagnosis postponed Shenjing shuairo and the transformation of
psychiatry in post-Mao China Culture Medicine and Psychiatry 23 349ndash380
Lee S amp Wong K C (1995) Rethinking neurasthenia the illness concepts of
shenjing shuairuo among Chinese undergraduates in Honk Kong Culture
Medicine and Psychiatry 19 91ndash111
Lee S Tsang A Huang YQ He YL Liu ZR Zhang MY Shen YC amp
Kessler RC (2009) The epidemiology of depression in metropolitan China
Psychological Medicine 39 735-747
Mezzich J E Kirmayer L J Kleinman A Fabrega Jr H Parron D L Good B
J Lin K amp Manson S M (1999) The place of culture in DSM-IV Journal
of Nervous and Mental Disease 187 457-464
27
Monroe S M amp Simons A D (1991) Diathesisndashstress theories in the context of life
stress research Implications for the depressive disorders Psychological
Bulletin 110 406ndash425
Murray C J L amp Lopez A D (1996) The global burden of disease Cambridge
Harvard University Press
National Bureau of Statistics of China (2006) The China 2005 statistical yearbook
China Statistics Press Beijing PR China
Oei T P S Goh Y Kwon S M(1996) A cross-cultural study of the integrated
cognitive model of depression Current Psychology of Cognition 15 265-281
Ohrt T amp Thorell L (1998) Dysfunctional Attitude Scale (DAS) Psychometrics and
norms of the Swedish version Scandinavian Journal of Behaviour Therapy 27
105-113
Parker G Gladstone G Chee KT (2001) Depression in the planetrsquos largest ethnic
group The Chinese American Journal of Psychiatry 158 857-864
Phillips M R Zhang J Shi Q Song Z Ding Z Pang S Li X Zhang Y amp
Wang Z (2009) Prevalence treatment and associated disability of mental
disorders in four provinces in China during 2001ndash05 an epidemiological
survey The Lancet 373 2041-2053
Phillips M R Li X amp Zhang Y (2002) Suicide rates in China Lancet 359 835-
840
Phillips M R (1998) The transformation of Chinarsquos mental health services The China
Journal 39 1ndash36
Qiang G (2006) Depression number one killer of Ivory Tower students China Daily
Retrieved from httpwwwchinadailycomcnchina2006-
1128content_744880htm
Radloff L S (1977) The CESndashD scale A self-report depression scale for research in
the general population Applied Psychological Measurement 1 385ndash401
Rin H amp Huang M G (1989) Neurasthenia as nosological dilemma Culture
Medicine and Psychiatry 13 215-226
Sahin NH amp Sahin N (1992) How dysfunctional are the dysfunctional attitudes in
another culture British Journal of Medical Psychology 65 17-26
Shixie L (1989) Neurasthenia in China Modern and traditional criteria for its
diagnosis Culture Medicine and Psychiatry 13 163-186
28
Tanaka N Uji M Hiramura H Chen Z Shikai N amp Kitamura T (2006)
Cognitive patterns and depression Study of a Japanese university student
population Psychiatry and Clinical Neuroscience 60 358-364
Taylor R E (2001) Death of neurasthenia and its psychological reincarnation a study
of neurasthenia at the National Hospital for the Relief and Cure of the Paralysed
and Epileptic Queen Square London 1870ndash1932 British Journal of
Psychiatry 179 550ndash557
Weissman A N amp Beck A T (1978 April) Development and validation of the
Dysfunctional Attitudes Scale A preliminary investigation Paper presented at
the annual meeting of the Educational Research Association Toronto Canada
Xiang M Z (1986) Epidemiological study of neuroses in 12 regions (districts) of
China Chinese Journal of Neurology and Psychiatry 19 87-91
Xu JM (1987) Some issues in the diagnosis of depression in China Canadian
Journal of Psychiatry 32 368-370
Xu Y X (1994) About ICD-10 Journal of Clinical Psychology and Medicine 4 224-
226
Xu Z Li Z amp Wang Z (2007) Dysfunctional attitudes and cognitive bias in major
depressive disorder Chinese Mental Health Journal 21 488-491
Yan H Q (1989) The necessity of retaining the diagnostic concept of neurasthenia
Culture Medicine and Psychiatry 13 139-145
Yang H (2007) The Test of the Chinese version of Frost Multi-dimensional
Perfectionism Scale Chinese Mental Health Journal 21 97-100
Yang H amp Zhang X (2004) Perfectionism and mental health of college students
(2004) Chinese Mental Health Journal 18 647-648
Young D (1989) Neurasthenia and related problems Culture Medicine and
Psychiatry 13 131-138
Zhang D (1995) Depression and culture A Chinese perspective Canadian Journal of
Counseling 29 227ndash233
29
TABLE(S)
Table 1 Demographic Variables
Age 2011
Gender Male
Female
472
523
Parentsrsquo Marital Status Married
Divorced
Single
Remarried
938
23
18
20
Fatherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
Government Official
51
356
187
95
124
91
Motherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
122
406
144
76
134
Fatherrsquos Education Some Primary School
Primary School
Some High School
High School
University
29
139
222
403
137
Motherrsquos Education Some Primary School
Primary School
Some High School
High School
University
63
192
264
350
76
Only Child No
Yes
331
667
Monthly Income lt 1000 RMB
1000 ndash 1500 RMB
1500 ndash 2000 RMB
2000 ndash 3000 RMB
3000 ndash 4000 RMB
4000 ndash 5000 RMB
gt 5000 RMB
334
204
175
140
59
20
20
30
Table 2 Means Standard Deviations and Inter-correlations Between Time 1 Measures
__________________________________________________________________
1 2 3
__________________________________________________________________
1 Depressive Symptoms 2963 (780)
2 Anxious Symptoms 52 3753 (918)
3 Dysfunctional Attitudes 48 33 18120 (2304)
4 Neuroticism 63 42 53 3110 (712)
_________________________________________________________________________
Note Means and standard deviations (in parentheses) are on the diagonal Depressive
Symptoms = Center for Epidemiological Studies Depression Scale Anxious Symptoms
= Mood and Anxiety Symptom Questionnaire Overall Anxiety subscale Dysfunctional
Attitudes = Dysfunctional Attitudes Scale Neuroticism = NEO Five Factor Inventory
Neuroticism subscale p lt 01
31
Table 3 Dysfunctional Attitudes Predicting Within-Subject Fluctuations in CES-D
Scores (upper section) and MASQ Scores (lower section) during the Follow-Up
Interval
______________________________________________________________________
β SE F df
______________________________________________________________________
Time 1 CESD-D 297 026 12987 1572
Stress 005 000 10860 12459
Neuroticism 134 027 2518 1572
Dysfunctional Attitudes -055 040 -183 1572
Dysfunctional Attitudes times Stress 001 000 1078 12459
______________________________________________________________________
Time 1 MASQ 502 033 23158 1575
Stress 006 000 8963 12470
Neuroticism 080 033 596 1575
Dysfunctional Attitudes -052 051 -106 1575
Dysfunctional Attitudes times Stress 002 001 774 12470
______________________________________________________________________
Note Time 1 CES-D = Time 1 Center for Epidemiological Studies Depression Scale
Stress = Within-Subject Fluctuations in General Academic Social Hassles Scale for
Students (GASHSS) scores during the follow-up interval Neuroticism = NEO Five
Factor Inventory Neuroticism subscale Dysfunctional Attitudes = Dysfunctional
Attitudes Scale Time 1 MASQ = Time 1 Mood and Anxiety Symptom Questionnaire
Overall Anxiety subscale p lt 05 p lt 01 p lt 001
32
FIGURES
Figure 1 Predicted slope of the relationship between stress and depressive
symptoms (left panel) and anxious symptoms (right panel) as a function of
dysfunctional attitudes
20
25
30
Low High
Pre
dic
ted
CE
S-D
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
25
30
35
40
Low High
Pre
dic
ted
MA
SQ
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
Intercept Intercept
18
symptoms Such analyses allowed us to examine whether the above mentioned pattern
of findings may have been due to the high correlation observed in the current study
between depressive and anxious symptoms
Analyses were conducted in the same manner as described above with the
exception that an additional within-subject variable (ie DEPRESSION or ANXIETY)
was included in each model in order to control for within-subject fluctuations in the
alternate symptom With respect to the prediction of depressive symptoms the
DYSFUNCTIONAL ATTITUDES STRESS interaction remained a significant
predictor after controlling for within-subject fluctuations in anxious symptoms (β =
001 SE = 000 F = 410 p lt 05) With respect to the prediction of anxious
symptoms however the DYSFUNCTIONAL ATTITUDES STRESS interaction
was no longer a significant predictor after controlling for within-subject fluctuations in
depressive symptoms (β = 001 SE = 000 F = 148 p = 22)
DISCUSSION
The results of the current study provide support for the cross-cultural
applicability of Beckrsquos (1967 1983) cognitive theory to university students in Hunan
China More specifically consistent with hypotheses and with results obtained from
past research examining Beckrsquos cognitive theory in Western samples of university
students (Hankin et al 2004 Hankin et al 2005 Joiner et al 1999 Klocek et al
1997 Brown et al 1995) higher levels of dysfunctional attitudes were associated with
greater increases in depressive symptoms following increases in negative event
frequency during the six-month follow-up interval Given the considerable differences
between the current sample and Western samples in terms of demographic
19
characteristics and cultural factors such a finding strongly attests to the robustness of
Beckrsquos cognitive theory Moreover integrating the current findings with those obtained
in research examining Beckrsquos theory in other non-Western samples suggests that
Beckrsquos theory may represent a powerful explanatory model of the development of
depressive symptoms among individuals from diverse cultural settings For example
consistent with the theory higher levels of dysfunctional attitudes have been shown to
be associated with higher levels of depressive symptoms in Japanese (Tanaka et al
2006) Puerto-Rican (Bonilla Bernal Santos amp Santos 2003) Turkish (Sahin amp Sahin
1992) Norwegian (Chioqueta amp Stiles 2004) Singaporean (Oei Goh amp Kwon 1996)
and Swedish (Ohrt amp Thorell 1998) adult samples In addition it is important to note
that the current findings expand upon past correlational research examining the
association between dysfunctional attitudes and depression in Chinese samples through
the use of a multi-wave longitudinal design
When examining the specificity of dysfunctional attitudes as a predictor of
depressive symptoms the current study did not obtain support for specificity More
specifically contrary to the specificity hypothesis of Beckrsquos cognitive theory and to
results obtained in Western samples of university students (Alloy et al 2000 2006
Hankin et al 2004) higher levels of dysfunctional attitudes were associated with
greater increases in both depressive and anxious symptoms following increases in
negative event frequency There are two alternative ways of interpreting the non-
specificity finding observed in the current study First it is possible that the types of
thoughts individuals possessing high levels of dysfunctional attitudes experience
following negative events varies as a function of cultural context In other words in
20
Western samples such individuals may primarily experience the types of cognitions
that are associated with the development of depressive symptoms (ie appraisals of
personal loss and failure) In contrast in Chinese samples individuals possessing high
levels of dysfunctional attitudes may experience a wider array of cognitions some of
which are associated with the development of depressive symptoms and some of which
are associated with the development of anxious symptoms (ie evaluations of
impending threat or danger) Such an explanation would be consistent with Beckrsquos
cognitive content-specificity hypothesis (Clark amp Beck 1999) which posits that each
affective state and psychological disorder has a specific cognitive profile Second it is
possible that the types of symptoms individuals possessing high levels of dysfunctional
attitudes experience following negative events varies as a function of cultural context
More specifically it may be that dysfunctional attitudes specifically predict symptoms
of depression in both samples except that in Western samples depression manifests in
pure depressive symptoms whereas in Chinese samples depression manifests as a
combination of depressive and anxious symptoms Such an explanation would be
consistent with cultural psychopathologistsrsquo hypotheses that cultural factors shape the
phenomenology of psychiatric symptoms (Kleinman 2004 Mezzich et al 1999)
Moreover dysfunctional attitudes predicting a combination of depressive and anxious
symptoms in Chinese samples would be consistent with the construct of neurasthenia -
a construct hypothesized by some to represent a somatized form of depression that is
still widely seen within China (Lee amp Wong 1995)
Interesting in this regard and perhaps speaking to the primacy of depressive
symptoms in the current findings analyses indicated that the DYSFUNCTIONAL
21
ATTITUDES times STRESS interaction no longer predicted anxious symptoms after
controlling for depressive symptoms The reverse however was not true as the
DYSFUNCTIONAL ATTITUDES times STRESS interaction continued to predict
depressive symptoms after controlling for anxious symptoms
It is important to note that the current study employed a particularly
conservative approach to analyses in that we examined the effects of dysfunctional
attitudes on depressive and anxious symptoms after controlling for the effect of
neuroticism on such symptoms Providing particularly powerful support for Beckrsquos
(1967 1983) cognitive theory across analyses dysfunctional attitudes predicted levels
of depressive andor anxious symptoms experienced during the six month follow-up
interval independent of the effect of neuroticism Thus contrary to past critical reviews
of the cognitive literature (Barnett amp Gotlib 1998 Coyne amp Whiffen 1995) and
consistent with past findings (Hankin et al 2007) the current results indicate that
cognitive vulnerabilities to depression such as dysfunctional attitudes are not reducible
to trait neuroticism but rather represent factors that confer independent risk for
depression
Limitations and Future Directions
Several limitations of the current study should be noted First self-report
measures were used to assess depressive and anxious symptoms Although the CES-D
and MASQ both possess high degrees of reliability and validity it is difficult to draw
conclusions about clinically diagnosed depression or anxiety based on self-report
questionnaires Second self-report measures were used to assess stress Although
measures of stress that require participants only to indicate whether or not an event
22
occurred are less likely to be influenced by informant bias than those that ask
participants to rate the subjective impact of each event more sophisticated methods of
analysis such as interviewing procedures that assess contextual threat may provide
better assessments of stress Third the measures of dysfunctional attitudes stress and
depressive and anxious symptoms used in the current study were each Western-
developed Future research should examine these hypotheses using indigenous
measures in addition to Western-developed measures in order to assess possible
similarities andor differences in patterns of findings Fourth the current study only
examined depression and anxiety as symptom outcomes Future research conducted
within China should examine a wider array of symptom outcomes such as
somatization physical complaints and externalizing behaviors in order to provide a
more thorough and culturally sensitive test of the specificity hypotheses of Beckrsquos
cognitive model Fifth the current study examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese undergraduate students and thus the extent to which
our findings may be generalized to other demographics within Chinarsquos population is
unclear Last the current study broadly examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese university students Future research should examine
the constructs and processes posited by this model in greater detail in order to develop a
deeper understanding of how they may be uniquely molded by socio-cultural factors
Such research would benefit from examining the specific types of stressors experienced
by Chinese university students as they may vary as a function of socio-cultural factors
from those experienced by Western undergraduates For example severe pressure to
succeed academically in order to secure access to a limited number of post-
23
undergraduate educational opportunities - one of the few paths towards upward
mobility available to Chinese students seeking secure and gainful employment in what
has increasingly become a very highly competitive job market - may represent a
particularly salient stressor for the development of depressive symptoms among this
population (Qiang 2006)
In conclusion the results from the current study provide support for the
applicability of Beckrsquos cognitive theory to university students in mainland China More
specifically consistent with findings obtained in the West results indicate that
dysfunctional attitudes confer vulnerability to the development of depressive symptoms
following the occurrence of negative events in Chinese university students At the same
time however the current findings suggest cultural variation in the profile of
symptoms which emerge following the occurrence of negative events in cognitively
vulnerable individuals in Western and Chinese samples Specifically whereas in the
West dysfunctional attitudes have been shown to confer vulnerability to depressive
symptoms in Chinese university students dysfunctional attitudes appear to confer
vulnerability to a combined depressive and anxious symptom profile Future research
using more sophisticated assessments of stress and depressive symptoms more diverse
samples and symptom outcome measures and indigenously-developed measures is
likely to enhance our understanding of the cognitive and environmental mechanisms
underlying the development of depression in Chinese university students Discovering
that cognitive theories of vulnerability to depression extend to university students in
China highlights the potential role for cognitive-behavioral depression prevention and
treatment interventions in stemming the tide of distress experienced by this population
24
REFERENCES
Abela J R Z amp Hankin B L (2008) Cognitive vulnerability to depression in
children and adolescents A developmental psychopathology perspective In J
R Z Abela and B L Hankin (Eds) Handbook of child and adolescent
depression (pp 35-78) New York The Guilford Press
Alloy L B Abramson L Y Hogan M E Whitehouse W G Rose D T
Robinson MS Kim R S amp Lapkin J B (2000) The Temple-Wisconsin
cognitive vulnerability to depression project Lifetime history of axis-I
psychopathology in individuals at high and low cognitive risk for depression
Journal of Abnormal Psychology 109 403-418
Alloy L B Abramson L Y Whitehouse W G Hogan M E Panzarella C amp
Rose D T (2006) Prospective incidence of first onsets and recurrences of
depression in individuals at high and low cognitive risk for depression Journal
of Abnormal Psychology 115 145ndash156
Altham P M E (1984) Improving the precision of estimation by fitting a model
Journal of the Royal Statistical Society Series B 46 11
Barnett PA amp Gotlib I H (1988) Psychosocial functioning and depression
Distinguishing among antecedents concomitants and consequences
Psychological Bulletin 104 97-126
Beck AT (1967) Depression Clinical experimental and theoretical aspects New
York Harper amp Row
Beck AT (1983) Cognitive therapy of depression New perspectives In PJ Clayton
amp JE Barrett (Eds) Treatment of depression Old controversies and new
approaches New York Raven Press
Bian Q Yang K amp Li C (2007) Dysfunctional attitudes of patients with depression
or bipolar disorder Chinese Mental Health Journal 21 759-761
Blankstein K R amp Flett G L (1993) Development of the General Academic and
Social Hassles Scales for Students Unpublished manuscript
Bonilla J Bernal G Santos A amp Santos D (2003) A revised Spanish version of
the Beck Depression InventoryPsychometric properties with a Puerto Rican
sample of college students Journal of Clinical Psychology 60 119-130
Brown G P Hammen C L Craske M G amp Wickens T D (1995) Dimensions of
dysfunctional attitudes as vulnerabilities to depressive symptoms Journal of
Abnormal Psychology 104 431-435
25
Chioqueta A P amp Stiles T C (2004) Psychometric properties of the Norweigian
version of the Dysfunctional Attitude Scale (Form A) Cognitive Behaviour
Therapy 33 83-86
Clark DA amp Beck AT (1999) Cognitive theory and therapy of depression New
York John Wiley amp Sons Inc
Clark L A amp Watson D (1991) Tripartite model of anxiety and depression
Psychometric evidence and taxonomic implications Journal of Abnormal
Psychology 100 316ndash336
Costa P T amp McCrae R R (1992) NEO PI-R Professional manual Revised NEO
personality inventory NEO PR-R and NEO five-factor inventory NEO-RRI
Odessa FL Psychological Assessment Resources
Coyne J C amp Whiffen V E (1995) Issues in personality as diathesis for depression
The case of sociotropy-dependency and autonomy-self-criticism Psychological
Bulletin 118 358-378
Fang X Qian M Luo S amp Zi F (2009) A correlational study on college students
perfectionism parental rearing patterns and mental health Chinese Mental
Health Journal 23 56-59
Hankin B L Abramson L Y Miller N amp Haeffel G (2004) Cognitive
vulnerability-stress theories of depression Examining affective specificity in
the prediction of depression versus anxiety in three prospective studies
Cognitive Therapy and Research 28 309ndash345
Hankin BL Fraley RC amp Abela JRZ (2005) Daily depression and cognitions
about stress Evidence for a traitlike depressogenic cognitive style and the
prediction of depressive symptoms in a prospective daily diary study Journal of
Personality and Social Psychology 88 673-685
Hankin B L Lakdawalla Z Carter I L Abela J R Z amp Adams P (2007) Are
neuroticism cognitive vulnerabilities and self-esteem overlapping or distinct
risks for depression Evidence from confirmatory factor analyses Journal of
Social amp Clinical Psychology 26 29-63
Hankin B L Wetter E Cheely C amp Oppenheimer C W (2008) Becks cognitive
theory of depression in adolescence Specific prediction of depressive
symptoms and reciprocal influences in a multi-wave prospective study
International Journal of Cognitive Therapy 1 313-332
Ingram R E Miranda J amp Segal Z V (1998) Cognitive Vulnerability to
Depression New York NY Guilford Press
26
Ingram R E amp Luxton DD (2005) Vulnerability-stress models In BL Hankin amp
JRZ Abela (Eds) Development of psychopathology A vulnerability-stress
perspective (pp 32-46) Thousand Oaks CA Sage
Joiner T E Metalsky G I Lew A amp Klocek J (1999) Testing the causal
mediation component of Becks theory of depression Evidence for specific
mediation Cognitive Therapy and Research 23 401-412
Kleinman A (2004) Culture and depression New England Journal of Medicine 351
951-953
Kleinman A (1977) Depression somatization and the new cross-cultural psychiatry
Social Science and Medicine 11 3-10
Kleinman A (1996) How is culture important for DSM-IV In J E Mezzich A
Kleinmam H Fabrega Jr amp L Delores (Eds)Culture and psychiatric
diagnosis A DSM-IV perspective (pp 15-25) Washington DC US American
Psychiatric Association
Klocek J W Oliver J M amp Ross M J (1997) The role of dysfunctional attitudes
negative life events and social support in the prediction of depressive
dysphoria A prospective longitudinal study Social Behavior and Personality
25 23-136
Lee S (1997) A Chinese perspective on somatoform disorders Journal of
Psychosomatic Disorders 43 115-119
Lee S (1998) Estranged bodies simulated harmony and misplaced cultures
Neurasthenia in contemporary Chinese society Psychosomatic Medicine 60
448ndash457
Lee S (1999) Diagnosis postponed Shenjing shuairo and the transformation of
psychiatry in post-Mao China Culture Medicine and Psychiatry 23 349ndash380
Lee S amp Wong K C (1995) Rethinking neurasthenia the illness concepts of
shenjing shuairuo among Chinese undergraduates in Honk Kong Culture
Medicine and Psychiatry 19 91ndash111
Lee S Tsang A Huang YQ He YL Liu ZR Zhang MY Shen YC amp
Kessler RC (2009) The epidemiology of depression in metropolitan China
Psychological Medicine 39 735-747
Mezzich J E Kirmayer L J Kleinman A Fabrega Jr H Parron D L Good B
J Lin K amp Manson S M (1999) The place of culture in DSM-IV Journal
of Nervous and Mental Disease 187 457-464
27
Monroe S M amp Simons A D (1991) Diathesisndashstress theories in the context of life
stress research Implications for the depressive disorders Psychological
Bulletin 110 406ndash425
Murray C J L amp Lopez A D (1996) The global burden of disease Cambridge
Harvard University Press
National Bureau of Statistics of China (2006) The China 2005 statistical yearbook
China Statistics Press Beijing PR China
Oei T P S Goh Y Kwon S M(1996) A cross-cultural study of the integrated
cognitive model of depression Current Psychology of Cognition 15 265-281
Ohrt T amp Thorell L (1998) Dysfunctional Attitude Scale (DAS) Psychometrics and
norms of the Swedish version Scandinavian Journal of Behaviour Therapy 27
105-113
Parker G Gladstone G Chee KT (2001) Depression in the planetrsquos largest ethnic
group The Chinese American Journal of Psychiatry 158 857-864
Phillips M R Zhang J Shi Q Song Z Ding Z Pang S Li X Zhang Y amp
Wang Z (2009) Prevalence treatment and associated disability of mental
disorders in four provinces in China during 2001ndash05 an epidemiological
survey The Lancet 373 2041-2053
Phillips M R Li X amp Zhang Y (2002) Suicide rates in China Lancet 359 835-
840
Phillips M R (1998) The transformation of Chinarsquos mental health services The China
Journal 39 1ndash36
Qiang G (2006) Depression number one killer of Ivory Tower students China Daily
Retrieved from httpwwwchinadailycomcnchina2006-
1128content_744880htm
Radloff L S (1977) The CESndashD scale A self-report depression scale for research in
the general population Applied Psychological Measurement 1 385ndash401
Rin H amp Huang M G (1989) Neurasthenia as nosological dilemma Culture
Medicine and Psychiatry 13 215-226
Sahin NH amp Sahin N (1992) How dysfunctional are the dysfunctional attitudes in
another culture British Journal of Medical Psychology 65 17-26
Shixie L (1989) Neurasthenia in China Modern and traditional criteria for its
diagnosis Culture Medicine and Psychiatry 13 163-186
28
Tanaka N Uji M Hiramura H Chen Z Shikai N amp Kitamura T (2006)
Cognitive patterns and depression Study of a Japanese university student
population Psychiatry and Clinical Neuroscience 60 358-364
Taylor R E (2001) Death of neurasthenia and its psychological reincarnation a study
of neurasthenia at the National Hospital for the Relief and Cure of the Paralysed
and Epileptic Queen Square London 1870ndash1932 British Journal of
Psychiatry 179 550ndash557
Weissman A N amp Beck A T (1978 April) Development and validation of the
Dysfunctional Attitudes Scale A preliminary investigation Paper presented at
the annual meeting of the Educational Research Association Toronto Canada
Xiang M Z (1986) Epidemiological study of neuroses in 12 regions (districts) of
China Chinese Journal of Neurology and Psychiatry 19 87-91
Xu JM (1987) Some issues in the diagnosis of depression in China Canadian
Journal of Psychiatry 32 368-370
Xu Y X (1994) About ICD-10 Journal of Clinical Psychology and Medicine 4 224-
226
Xu Z Li Z amp Wang Z (2007) Dysfunctional attitudes and cognitive bias in major
depressive disorder Chinese Mental Health Journal 21 488-491
Yan H Q (1989) The necessity of retaining the diagnostic concept of neurasthenia
Culture Medicine and Psychiatry 13 139-145
Yang H (2007) The Test of the Chinese version of Frost Multi-dimensional
Perfectionism Scale Chinese Mental Health Journal 21 97-100
Yang H amp Zhang X (2004) Perfectionism and mental health of college students
(2004) Chinese Mental Health Journal 18 647-648
Young D (1989) Neurasthenia and related problems Culture Medicine and
Psychiatry 13 131-138
Zhang D (1995) Depression and culture A Chinese perspective Canadian Journal of
Counseling 29 227ndash233
29
TABLE(S)
Table 1 Demographic Variables
Age 2011
Gender Male
Female
472
523
Parentsrsquo Marital Status Married
Divorced
Single
Remarried
938
23
18
20
Fatherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
Government Official
51
356
187
95
124
91
Motherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
122
406
144
76
134
Fatherrsquos Education Some Primary School
Primary School
Some High School
High School
University
29
139
222
403
137
Motherrsquos Education Some Primary School
Primary School
Some High School
High School
University
63
192
264
350
76
Only Child No
Yes
331
667
Monthly Income lt 1000 RMB
1000 ndash 1500 RMB
1500 ndash 2000 RMB
2000 ndash 3000 RMB
3000 ndash 4000 RMB
4000 ndash 5000 RMB
gt 5000 RMB
334
204
175
140
59
20
20
30
Table 2 Means Standard Deviations and Inter-correlations Between Time 1 Measures
__________________________________________________________________
1 2 3
__________________________________________________________________
1 Depressive Symptoms 2963 (780)
2 Anxious Symptoms 52 3753 (918)
3 Dysfunctional Attitudes 48 33 18120 (2304)
4 Neuroticism 63 42 53 3110 (712)
_________________________________________________________________________
Note Means and standard deviations (in parentheses) are on the diagonal Depressive
Symptoms = Center for Epidemiological Studies Depression Scale Anxious Symptoms
= Mood and Anxiety Symptom Questionnaire Overall Anxiety subscale Dysfunctional
Attitudes = Dysfunctional Attitudes Scale Neuroticism = NEO Five Factor Inventory
Neuroticism subscale p lt 01
31
Table 3 Dysfunctional Attitudes Predicting Within-Subject Fluctuations in CES-D
Scores (upper section) and MASQ Scores (lower section) during the Follow-Up
Interval
______________________________________________________________________
β SE F df
______________________________________________________________________
Time 1 CESD-D 297 026 12987 1572
Stress 005 000 10860 12459
Neuroticism 134 027 2518 1572
Dysfunctional Attitudes -055 040 -183 1572
Dysfunctional Attitudes times Stress 001 000 1078 12459
______________________________________________________________________
Time 1 MASQ 502 033 23158 1575
Stress 006 000 8963 12470
Neuroticism 080 033 596 1575
Dysfunctional Attitudes -052 051 -106 1575
Dysfunctional Attitudes times Stress 002 001 774 12470
______________________________________________________________________
Note Time 1 CES-D = Time 1 Center for Epidemiological Studies Depression Scale
Stress = Within-Subject Fluctuations in General Academic Social Hassles Scale for
Students (GASHSS) scores during the follow-up interval Neuroticism = NEO Five
Factor Inventory Neuroticism subscale Dysfunctional Attitudes = Dysfunctional
Attitudes Scale Time 1 MASQ = Time 1 Mood and Anxiety Symptom Questionnaire
Overall Anxiety subscale p lt 05 p lt 01 p lt 001
32
FIGURES
Figure 1 Predicted slope of the relationship between stress and depressive
symptoms (left panel) and anxious symptoms (right panel) as a function of
dysfunctional attitudes
20
25
30
Low High
Pre
dic
ted
CE
S-D
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
25
30
35
40
Low High
Pre
dic
ted
MA
SQ
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
Intercept Intercept
19
characteristics and cultural factors such a finding strongly attests to the robustness of
Beckrsquos cognitive theory Moreover integrating the current findings with those obtained
in research examining Beckrsquos theory in other non-Western samples suggests that
Beckrsquos theory may represent a powerful explanatory model of the development of
depressive symptoms among individuals from diverse cultural settings For example
consistent with the theory higher levels of dysfunctional attitudes have been shown to
be associated with higher levels of depressive symptoms in Japanese (Tanaka et al
2006) Puerto-Rican (Bonilla Bernal Santos amp Santos 2003) Turkish (Sahin amp Sahin
1992) Norwegian (Chioqueta amp Stiles 2004) Singaporean (Oei Goh amp Kwon 1996)
and Swedish (Ohrt amp Thorell 1998) adult samples In addition it is important to note
that the current findings expand upon past correlational research examining the
association between dysfunctional attitudes and depression in Chinese samples through
the use of a multi-wave longitudinal design
When examining the specificity of dysfunctional attitudes as a predictor of
depressive symptoms the current study did not obtain support for specificity More
specifically contrary to the specificity hypothesis of Beckrsquos cognitive theory and to
results obtained in Western samples of university students (Alloy et al 2000 2006
Hankin et al 2004) higher levels of dysfunctional attitudes were associated with
greater increases in both depressive and anxious symptoms following increases in
negative event frequency There are two alternative ways of interpreting the non-
specificity finding observed in the current study First it is possible that the types of
thoughts individuals possessing high levels of dysfunctional attitudes experience
following negative events varies as a function of cultural context In other words in
20
Western samples such individuals may primarily experience the types of cognitions
that are associated with the development of depressive symptoms (ie appraisals of
personal loss and failure) In contrast in Chinese samples individuals possessing high
levels of dysfunctional attitudes may experience a wider array of cognitions some of
which are associated with the development of depressive symptoms and some of which
are associated with the development of anxious symptoms (ie evaluations of
impending threat or danger) Such an explanation would be consistent with Beckrsquos
cognitive content-specificity hypothesis (Clark amp Beck 1999) which posits that each
affective state and psychological disorder has a specific cognitive profile Second it is
possible that the types of symptoms individuals possessing high levels of dysfunctional
attitudes experience following negative events varies as a function of cultural context
More specifically it may be that dysfunctional attitudes specifically predict symptoms
of depression in both samples except that in Western samples depression manifests in
pure depressive symptoms whereas in Chinese samples depression manifests as a
combination of depressive and anxious symptoms Such an explanation would be
consistent with cultural psychopathologistsrsquo hypotheses that cultural factors shape the
phenomenology of psychiatric symptoms (Kleinman 2004 Mezzich et al 1999)
Moreover dysfunctional attitudes predicting a combination of depressive and anxious
symptoms in Chinese samples would be consistent with the construct of neurasthenia -
a construct hypothesized by some to represent a somatized form of depression that is
still widely seen within China (Lee amp Wong 1995)
Interesting in this regard and perhaps speaking to the primacy of depressive
symptoms in the current findings analyses indicated that the DYSFUNCTIONAL
21
ATTITUDES times STRESS interaction no longer predicted anxious symptoms after
controlling for depressive symptoms The reverse however was not true as the
DYSFUNCTIONAL ATTITUDES times STRESS interaction continued to predict
depressive symptoms after controlling for anxious symptoms
It is important to note that the current study employed a particularly
conservative approach to analyses in that we examined the effects of dysfunctional
attitudes on depressive and anxious symptoms after controlling for the effect of
neuroticism on such symptoms Providing particularly powerful support for Beckrsquos
(1967 1983) cognitive theory across analyses dysfunctional attitudes predicted levels
of depressive andor anxious symptoms experienced during the six month follow-up
interval independent of the effect of neuroticism Thus contrary to past critical reviews
of the cognitive literature (Barnett amp Gotlib 1998 Coyne amp Whiffen 1995) and
consistent with past findings (Hankin et al 2007) the current results indicate that
cognitive vulnerabilities to depression such as dysfunctional attitudes are not reducible
to trait neuroticism but rather represent factors that confer independent risk for
depression
Limitations and Future Directions
Several limitations of the current study should be noted First self-report
measures were used to assess depressive and anxious symptoms Although the CES-D
and MASQ both possess high degrees of reliability and validity it is difficult to draw
conclusions about clinically diagnosed depression or anxiety based on self-report
questionnaires Second self-report measures were used to assess stress Although
measures of stress that require participants only to indicate whether or not an event
22
occurred are less likely to be influenced by informant bias than those that ask
participants to rate the subjective impact of each event more sophisticated methods of
analysis such as interviewing procedures that assess contextual threat may provide
better assessments of stress Third the measures of dysfunctional attitudes stress and
depressive and anxious symptoms used in the current study were each Western-
developed Future research should examine these hypotheses using indigenous
measures in addition to Western-developed measures in order to assess possible
similarities andor differences in patterns of findings Fourth the current study only
examined depression and anxiety as symptom outcomes Future research conducted
within China should examine a wider array of symptom outcomes such as
somatization physical complaints and externalizing behaviors in order to provide a
more thorough and culturally sensitive test of the specificity hypotheses of Beckrsquos
cognitive model Fifth the current study examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese undergraduate students and thus the extent to which
our findings may be generalized to other demographics within Chinarsquos population is
unclear Last the current study broadly examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese university students Future research should examine
the constructs and processes posited by this model in greater detail in order to develop a
deeper understanding of how they may be uniquely molded by socio-cultural factors
Such research would benefit from examining the specific types of stressors experienced
by Chinese university students as they may vary as a function of socio-cultural factors
from those experienced by Western undergraduates For example severe pressure to
succeed academically in order to secure access to a limited number of post-
23
undergraduate educational opportunities - one of the few paths towards upward
mobility available to Chinese students seeking secure and gainful employment in what
has increasingly become a very highly competitive job market - may represent a
particularly salient stressor for the development of depressive symptoms among this
population (Qiang 2006)
In conclusion the results from the current study provide support for the
applicability of Beckrsquos cognitive theory to university students in mainland China More
specifically consistent with findings obtained in the West results indicate that
dysfunctional attitudes confer vulnerability to the development of depressive symptoms
following the occurrence of negative events in Chinese university students At the same
time however the current findings suggest cultural variation in the profile of
symptoms which emerge following the occurrence of negative events in cognitively
vulnerable individuals in Western and Chinese samples Specifically whereas in the
West dysfunctional attitudes have been shown to confer vulnerability to depressive
symptoms in Chinese university students dysfunctional attitudes appear to confer
vulnerability to a combined depressive and anxious symptom profile Future research
using more sophisticated assessments of stress and depressive symptoms more diverse
samples and symptom outcome measures and indigenously-developed measures is
likely to enhance our understanding of the cognitive and environmental mechanisms
underlying the development of depression in Chinese university students Discovering
that cognitive theories of vulnerability to depression extend to university students in
China highlights the potential role for cognitive-behavioral depression prevention and
treatment interventions in stemming the tide of distress experienced by this population
24
REFERENCES
Abela J R Z amp Hankin B L (2008) Cognitive vulnerability to depression in
children and adolescents A developmental psychopathology perspective In J
R Z Abela and B L Hankin (Eds) Handbook of child and adolescent
depression (pp 35-78) New York The Guilford Press
Alloy L B Abramson L Y Hogan M E Whitehouse W G Rose D T
Robinson MS Kim R S amp Lapkin J B (2000) The Temple-Wisconsin
cognitive vulnerability to depression project Lifetime history of axis-I
psychopathology in individuals at high and low cognitive risk for depression
Journal of Abnormal Psychology 109 403-418
Alloy L B Abramson L Y Whitehouse W G Hogan M E Panzarella C amp
Rose D T (2006) Prospective incidence of first onsets and recurrences of
depression in individuals at high and low cognitive risk for depression Journal
of Abnormal Psychology 115 145ndash156
Altham P M E (1984) Improving the precision of estimation by fitting a model
Journal of the Royal Statistical Society Series B 46 11
Barnett PA amp Gotlib I H (1988) Psychosocial functioning and depression
Distinguishing among antecedents concomitants and consequences
Psychological Bulletin 104 97-126
Beck AT (1967) Depression Clinical experimental and theoretical aspects New
York Harper amp Row
Beck AT (1983) Cognitive therapy of depression New perspectives In PJ Clayton
amp JE Barrett (Eds) Treatment of depression Old controversies and new
approaches New York Raven Press
Bian Q Yang K amp Li C (2007) Dysfunctional attitudes of patients with depression
or bipolar disorder Chinese Mental Health Journal 21 759-761
Blankstein K R amp Flett G L (1993) Development of the General Academic and
Social Hassles Scales for Students Unpublished manuscript
Bonilla J Bernal G Santos A amp Santos D (2003) A revised Spanish version of
the Beck Depression InventoryPsychometric properties with a Puerto Rican
sample of college students Journal of Clinical Psychology 60 119-130
Brown G P Hammen C L Craske M G amp Wickens T D (1995) Dimensions of
dysfunctional attitudes as vulnerabilities to depressive symptoms Journal of
Abnormal Psychology 104 431-435
25
Chioqueta A P amp Stiles T C (2004) Psychometric properties of the Norweigian
version of the Dysfunctional Attitude Scale (Form A) Cognitive Behaviour
Therapy 33 83-86
Clark DA amp Beck AT (1999) Cognitive theory and therapy of depression New
York John Wiley amp Sons Inc
Clark L A amp Watson D (1991) Tripartite model of anxiety and depression
Psychometric evidence and taxonomic implications Journal of Abnormal
Psychology 100 316ndash336
Costa P T amp McCrae R R (1992) NEO PI-R Professional manual Revised NEO
personality inventory NEO PR-R and NEO five-factor inventory NEO-RRI
Odessa FL Psychological Assessment Resources
Coyne J C amp Whiffen V E (1995) Issues in personality as diathesis for depression
The case of sociotropy-dependency and autonomy-self-criticism Psychological
Bulletin 118 358-378
Fang X Qian M Luo S amp Zi F (2009) A correlational study on college students
perfectionism parental rearing patterns and mental health Chinese Mental
Health Journal 23 56-59
Hankin B L Abramson L Y Miller N amp Haeffel G (2004) Cognitive
vulnerability-stress theories of depression Examining affective specificity in
the prediction of depression versus anxiety in three prospective studies
Cognitive Therapy and Research 28 309ndash345
Hankin BL Fraley RC amp Abela JRZ (2005) Daily depression and cognitions
about stress Evidence for a traitlike depressogenic cognitive style and the
prediction of depressive symptoms in a prospective daily diary study Journal of
Personality and Social Psychology 88 673-685
Hankin B L Lakdawalla Z Carter I L Abela J R Z amp Adams P (2007) Are
neuroticism cognitive vulnerabilities and self-esteem overlapping or distinct
risks for depression Evidence from confirmatory factor analyses Journal of
Social amp Clinical Psychology 26 29-63
Hankin B L Wetter E Cheely C amp Oppenheimer C W (2008) Becks cognitive
theory of depression in adolescence Specific prediction of depressive
symptoms and reciprocal influences in a multi-wave prospective study
International Journal of Cognitive Therapy 1 313-332
Ingram R E Miranda J amp Segal Z V (1998) Cognitive Vulnerability to
Depression New York NY Guilford Press
26
Ingram R E amp Luxton DD (2005) Vulnerability-stress models In BL Hankin amp
JRZ Abela (Eds) Development of psychopathology A vulnerability-stress
perspective (pp 32-46) Thousand Oaks CA Sage
Joiner T E Metalsky G I Lew A amp Klocek J (1999) Testing the causal
mediation component of Becks theory of depression Evidence for specific
mediation Cognitive Therapy and Research 23 401-412
Kleinman A (2004) Culture and depression New England Journal of Medicine 351
951-953
Kleinman A (1977) Depression somatization and the new cross-cultural psychiatry
Social Science and Medicine 11 3-10
Kleinman A (1996) How is culture important for DSM-IV In J E Mezzich A
Kleinmam H Fabrega Jr amp L Delores (Eds)Culture and psychiatric
diagnosis A DSM-IV perspective (pp 15-25) Washington DC US American
Psychiatric Association
Klocek J W Oliver J M amp Ross M J (1997) The role of dysfunctional attitudes
negative life events and social support in the prediction of depressive
dysphoria A prospective longitudinal study Social Behavior and Personality
25 23-136
Lee S (1997) A Chinese perspective on somatoform disorders Journal of
Psychosomatic Disorders 43 115-119
Lee S (1998) Estranged bodies simulated harmony and misplaced cultures
Neurasthenia in contemporary Chinese society Psychosomatic Medicine 60
448ndash457
Lee S (1999) Diagnosis postponed Shenjing shuairo and the transformation of
psychiatry in post-Mao China Culture Medicine and Psychiatry 23 349ndash380
Lee S amp Wong K C (1995) Rethinking neurasthenia the illness concepts of
shenjing shuairuo among Chinese undergraduates in Honk Kong Culture
Medicine and Psychiatry 19 91ndash111
Lee S Tsang A Huang YQ He YL Liu ZR Zhang MY Shen YC amp
Kessler RC (2009) The epidemiology of depression in metropolitan China
Psychological Medicine 39 735-747
Mezzich J E Kirmayer L J Kleinman A Fabrega Jr H Parron D L Good B
J Lin K amp Manson S M (1999) The place of culture in DSM-IV Journal
of Nervous and Mental Disease 187 457-464
27
Monroe S M amp Simons A D (1991) Diathesisndashstress theories in the context of life
stress research Implications for the depressive disorders Psychological
Bulletin 110 406ndash425
Murray C J L amp Lopez A D (1996) The global burden of disease Cambridge
Harvard University Press
National Bureau of Statistics of China (2006) The China 2005 statistical yearbook
China Statistics Press Beijing PR China
Oei T P S Goh Y Kwon S M(1996) A cross-cultural study of the integrated
cognitive model of depression Current Psychology of Cognition 15 265-281
Ohrt T amp Thorell L (1998) Dysfunctional Attitude Scale (DAS) Psychometrics and
norms of the Swedish version Scandinavian Journal of Behaviour Therapy 27
105-113
Parker G Gladstone G Chee KT (2001) Depression in the planetrsquos largest ethnic
group The Chinese American Journal of Psychiatry 158 857-864
Phillips M R Zhang J Shi Q Song Z Ding Z Pang S Li X Zhang Y amp
Wang Z (2009) Prevalence treatment and associated disability of mental
disorders in four provinces in China during 2001ndash05 an epidemiological
survey The Lancet 373 2041-2053
Phillips M R Li X amp Zhang Y (2002) Suicide rates in China Lancet 359 835-
840
Phillips M R (1998) The transformation of Chinarsquos mental health services The China
Journal 39 1ndash36
Qiang G (2006) Depression number one killer of Ivory Tower students China Daily
Retrieved from httpwwwchinadailycomcnchina2006-
1128content_744880htm
Radloff L S (1977) The CESndashD scale A self-report depression scale for research in
the general population Applied Psychological Measurement 1 385ndash401
Rin H amp Huang M G (1989) Neurasthenia as nosological dilemma Culture
Medicine and Psychiatry 13 215-226
Sahin NH amp Sahin N (1992) How dysfunctional are the dysfunctional attitudes in
another culture British Journal of Medical Psychology 65 17-26
Shixie L (1989) Neurasthenia in China Modern and traditional criteria for its
diagnosis Culture Medicine and Psychiatry 13 163-186
28
Tanaka N Uji M Hiramura H Chen Z Shikai N amp Kitamura T (2006)
Cognitive patterns and depression Study of a Japanese university student
population Psychiatry and Clinical Neuroscience 60 358-364
Taylor R E (2001) Death of neurasthenia and its psychological reincarnation a study
of neurasthenia at the National Hospital for the Relief and Cure of the Paralysed
and Epileptic Queen Square London 1870ndash1932 British Journal of
Psychiatry 179 550ndash557
Weissman A N amp Beck A T (1978 April) Development and validation of the
Dysfunctional Attitudes Scale A preliminary investigation Paper presented at
the annual meeting of the Educational Research Association Toronto Canada
Xiang M Z (1986) Epidemiological study of neuroses in 12 regions (districts) of
China Chinese Journal of Neurology and Psychiatry 19 87-91
Xu JM (1987) Some issues in the diagnosis of depression in China Canadian
Journal of Psychiatry 32 368-370
Xu Y X (1994) About ICD-10 Journal of Clinical Psychology and Medicine 4 224-
226
Xu Z Li Z amp Wang Z (2007) Dysfunctional attitudes and cognitive bias in major
depressive disorder Chinese Mental Health Journal 21 488-491
Yan H Q (1989) The necessity of retaining the diagnostic concept of neurasthenia
Culture Medicine and Psychiatry 13 139-145
Yang H (2007) The Test of the Chinese version of Frost Multi-dimensional
Perfectionism Scale Chinese Mental Health Journal 21 97-100
Yang H amp Zhang X (2004) Perfectionism and mental health of college students
(2004) Chinese Mental Health Journal 18 647-648
Young D (1989) Neurasthenia and related problems Culture Medicine and
Psychiatry 13 131-138
Zhang D (1995) Depression and culture A Chinese perspective Canadian Journal of
Counseling 29 227ndash233
29
TABLE(S)
Table 1 Demographic Variables
Age 2011
Gender Male
Female
472
523
Parentsrsquo Marital Status Married
Divorced
Single
Remarried
938
23
18
20
Fatherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
Government Official
51
356
187
95
124
91
Motherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
122
406
144
76
134
Fatherrsquos Education Some Primary School
Primary School
Some High School
High School
University
29
139
222
403
137
Motherrsquos Education Some Primary School
Primary School
Some High School
High School
University
63
192
264
350
76
Only Child No
Yes
331
667
Monthly Income lt 1000 RMB
1000 ndash 1500 RMB
1500 ndash 2000 RMB
2000 ndash 3000 RMB
3000 ndash 4000 RMB
4000 ndash 5000 RMB
gt 5000 RMB
334
204
175
140
59
20
20
30
Table 2 Means Standard Deviations and Inter-correlations Between Time 1 Measures
__________________________________________________________________
1 2 3
__________________________________________________________________
1 Depressive Symptoms 2963 (780)
2 Anxious Symptoms 52 3753 (918)
3 Dysfunctional Attitudes 48 33 18120 (2304)
4 Neuroticism 63 42 53 3110 (712)
_________________________________________________________________________
Note Means and standard deviations (in parentheses) are on the diagonal Depressive
Symptoms = Center for Epidemiological Studies Depression Scale Anxious Symptoms
= Mood and Anxiety Symptom Questionnaire Overall Anxiety subscale Dysfunctional
Attitudes = Dysfunctional Attitudes Scale Neuroticism = NEO Five Factor Inventory
Neuroticism subscale p lt 01
31
Table 3 Dysfunctional Attitudes Predicting Within-Subject Fluctuations in CES-D
Scores (upper section) and MASQ Scores (lower section) during the Follow-Up
Interval
______________________________________________________________________
β SE F df
______________________________________________________________________
Time 1 CESD-D 297 026 12987 1572
Stress 005 000 10860 12459
Neuroticism 134 027 2518 1572
Dysfunctional Attitudes -055 040 -183 1572
Dysfunctional Attitudes times Stress 001 000 1078 12459
______________________________________________________________________
Time 1 MASQ 502 033 23158 1575
Stress 006 000 8963 12470
Neuroticism 080 033 596 1575
Dysfunctional Attitudes -052 051 -106 1575
Dysfunctional Attitudes times Stress 002 001 774 12470
______________________________________________________________________
Note Time 1 CES-D = Time 1 Center for Epidemiological Studies Depression Scale
Stress = Within-Subject Fluctuations in General Academic Social Hassles Scale for
Students (GASHSS) scores during the follow-up interval Neuroticism = NEO Five
Factor Inventory Neuroticism subscale Dysfunctional Attitudes = Dysfunctional
Attitudes Scale Time 1 MASQ = Time 1 Mood and Anxiety Symptom Questionnaire
Overall Anxiety subscale p lt 05 p lt 01 p lt 001
32
FIGURES
Figure 1 Predicted slope of the relationship between stress and depressive
symptoms (left panel) and anxious symptoms (right panel) as a function of
dysfunctional attitudes
20
25
30
Low High
Pre
dic
ted
CE
S-D
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
25
30
35
40
Low High
Pre
dic
ted
MA
SQ
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
Intercept Intercept
20
Western samples such individuals may primarily experience the types of cognitions
that are associated with the development of depressive symptoms (ie appraisals of
personal loss and failure) In contrast in Chinese samples individuals possessing high
levels of dysfunctional attitudes may experience a wider array of cognitions some of
which are associated with the development of depressive symptoms and some of which
are associated with the development of anxious symptoms (ie evaluations of
impending threat or danger) Such an explanation would be consistent with Beckrsquos
cognitive content-specificity hypothesis (Clark amp Beck 1999) which posits that each
affective state and psychological disorder has a specific cognitive profile Second it is
possible that the types of symptoms individuals possessing high levels of dysfunctional
attitudes experience following negative events varies as a function of cultural context
More specifically it may be that dysfunctional attitudes specifically predict symptoms
of depression in both samples except that in Western samples depression manifests in
pure depressive symptoms whereas in Chinese samples depression manifests as a
combination of depressive and anxious symptoms Such an explanation would be
consistent with cultural psychopathologistsrsquo hypotheses that cultural factors shape the
phenomenology of psychiatric symptoms (Kleinman 2004 Mezzich et al 1999)
Moreover dysfunctional attitudes predicting a combination of depressive and anxious
symptoms in Chinese samples would be consistent with the construct of neurasthenia -
a construct hypothesized by some to represent a somatized form of depression that is
still widely seen within China (Lee amp Wong 1995)
Interesting in this regard and perhaps speaking to the primacy of depressive
symptoms in the current findings analyses indicated that the DYSFUNCTIONAL
21
ATTITUDES times STRESS interaction no longer predicted anxious symptoms after
controlling for depressive symptoms The reverse however was not true as the
DYSFUNCTIONAL ATTITUDES times STRESS interaction continued to predict
depressive symptoms after controlling for anxious symptoms
It is important to note that the current study employed a particularly
conservative approach to analyses in that we examined the effects of dysfunctional
attitudes on depressive and anxious symptoms after controlling for the effect of
neuroticism on such symptoms Providing particularly powerful support for Beckrsquos
(1967 1983) cognitive theory across analyses dysfunctional attitudes predicted levels
of depressive andor anxious symptoms experienced during the six month follow-up
interval independent of the effect of neuroticism Thus contrary to past critical reviews
of the cognitive literature (Barnett amp Gotlib 1998 Coyne amp Whiffen 1995) and
consistent with past findings (Hankin et al 2007) the current results indicate that
cognitive vulnerabilities to depression such as dysfunctional attitudes are not reducible
to trait neuroticism but rather represent factors that confer independent risk for
depression
Limitations and Future Directions
Several limitations of the current study should be noted First self-report
measures were used to assess depressive and anxious symptoms Although the CES-D
and MASQ both possess high degrees of reliability and validity it is difficult to draw
conclusions about clinically diagnosed depression or anxiety based on self-report
questionnaires Second self-report measures were used to assess stress Although
measures of stress that require participants only to indicate whether or not an event
22
occurred are less likely to be influenced by informant bias than those that ask
participants to rate the subjective impact of each event more sophisticated methods of
analysis such as interviewing procedures that assess contextual threat may provide
better assessments of stress Third the measures of dysfunctional attitudes stress and
depressive and anxious symptoms used in the current study were each Western-
developed Future research should examine these hypotheses using indigenous
measures in addition to Western-developed measures in order to assess possible
similarities andor differences in patterns of findings Fourth the current study only
examined depression and anxiety as symptom outcomes Future research conducted
within China should examine a wider array of symptom outcomes such as
somatization physical complaints and externalizing behaviors in order to provide a
more thorough and culturally sensitive test of the specificity hypotheses of Beckrsquos
cognitive model Fifth the current study examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese undergraduate students and thus the extent to which
our findings may be generalized to other demographics within Chinarsquos population is
unclear Last the current study broadly examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese university students Future research should examine
the constructs and processes posited by this model in greater detail in order to develop a
deeper understanding of how they may be uniquely molded by socio-cultural factors
Such research would benefit from examining the specific types of stressors experienced
by Chinese university students as they may vary as a function of socio-cultural factors
from those experienced by Western undergraduates For example severe pressure to
succeed academically in order to secure access to a limited number of post-
23
undergraduate educational opportunities - one of the few paths towards upward
mobility available to Chinese students seeking secure and gainful employment in what
has increasingly become a very highly competitive job market - may represent a
particularly salient stressor for the development of depressive symptoms among this
population (Qiang 2006)
In conclusion the results from the current study provide support for the
applicability of Beckrsquos cognitive theory to university students in mainland China More
specifically consistent with findings obtained in the West results indicate that
dysfunctional attitudes confer vulnerability to the development of depressive symptoms
following the occurrence of negative events in Chinese university students At the same
time however the current findings suggest cultural variation in the profile of
symptoms which emerge following the occurrence of negative events in cognitively
vulnerable individuals in Western and Chinese samples Specifically whereas in the
West dysfunctional attitudes have been shown to confer vulnerability to depressive
symptoms in Chinese university students dysfunctional attitudes appear to confer
vulnerability to a combined depressive and anxious symptom profile Future research
using more sophisticated assessments of stress and depressive symptoms more diverse
samples and symptom outcome measures and indigenously-developed measures is
likely to enhance our understanding of the cognitive and environmental mechanisms
underlying the development of depression in Chinese university students Discovering
that cognitive theories of vulnerability to depression extend to university students in
China highlights the potential role for cognitive-behavioral depression prevention and
treatment interventions in stemming the tide of distress experienced by this population
24
REFERENCES
Abela J R Z amp Hankin B L (2008) Cognitive vulnerability to depression in
children and adolescents A developmental psychopathology perspective In J
R Z Abela and B L Hankin (Eds) Handbook of child and adolescent
depression (pp 35-78) New York The Guilford Press
Alloy L B Abramson L Y Hogan M E Whitehouse W G Rose D T
Robinson MS Kim R S amp Lapkin J B (2000) The Temple-Wisconsin
cognitive vulnerability to depression project Lifetime history of axis-I
psychopathology in individuals at high and low cognitive risk for depression
Journal of Abnormal Psychology 109 403-418
Alloy L B Abramson L Y Whitehouse W G Hogan M E Panzarella C amp
Rose D T (2006) Prospective incidence of first onsets and recurrences of
depression in individuals at high and low cognitive risk for depression Journal
of Abnormal Psychology 115 145ndash156
Altham P M E (1984) Improving the precision of estimation by fitting a model
Journal of the Royal Statistical Society Series B 46 11
Barnett PA amp Gotlib I H (1988) Psychosocial functioning and depression
Distinguishing among antecedents concomitants and consequences
Psychological Bulletin 104 97-126
Beck AT (1967) Depression Clinical experimental and theoretical aspects New
York Harper amp Row
Beck AT (1983) Cognitive therapy of depression New perspectives In PJ Clayton
amp JE Barrett (Eds) Treatment of depression Old controversies and new
approaches New York Raven Press
Bian Q Yang K amp Li C (2007) Dysfunctional attitudes of patients with depression
or bipolar disorder Chinese Mental Health Journal 21 759-761
Blankstein K R amp Flett G L (1993) Development of the General Academic and
Social Hassles Scales for Students Unpublished manuscript
Bonilla J Bernal G Santos A amp Santos D (2003) A revised Spanish version of
the Beck Depression InventoryPsychometric properties with a Puerto Rican
sample of college students Journal of Clinical Psychology 60 119-130
Brown G P Hammen C L Craske M G amp Wickens T D (1995) Dimensions of
dysfunctional attitudes as vulnerabilities to depressive symptoms Journal of
Abnormal Psychology 104 431-435
25
Chioqueta A P amp Stiles T C (2004) Psychometric properties of the Norweigian
version of the Dysfunctional Attitude Scale (Form A) Cognitive Behaviour
Therapy 33 83-86
Clark DA amp Beck AT (1999) Cognitive theory and therapy of depression New
York John Wiley amp Sons Inc
Clark L A amp Watson D (1991) Tripartite model of anxiety and depression
Psychometric evidence and taxonomic implications Journal of Abnormal
Psychology 100 316ndash336
Costa P T amp McCrae R R (1992) NEO PI-R Professional manual Revised NEO
personality inventory NEO PR-R and NEO five-factor inventory NEO-RRI
Odessa FL Psychological Assessment Resources
Coyne J C amp Whiffen V E (1995) Issues in personality as diathesis for depression
The case of sociotropy-dependency and autonomy-self-criticism Psychological
Bulletin 118 358-378
Fang X Qian M Luo S amp Zi F (2009) A correlational study on college students
perfectionism parental rearing patterns and mental health Chinese Mental
Health Journal 23 56-59
Hankin B L Abramson L Y Miller N amp Haeffel G (2004) Cognitive
vulnerability-stress theories of depression Examining affective specificity in
the prediction of depression versus anxiety in three prospective studies
Cognitive Therapy and Research 28 309ndash345
Hankin BL Fraley RC amp Abela JRZ (2005) Daily depression and cognitions
about stress Evidence for a traitlike depressogenic cognitive style and the
prediction of depressive symptoms in a prospective daily diary study Journal of
Personality and Social Psychology 88 673-685
Hankin B L Lakdawalla Z Carter I L Abela J R Z amp Adams P (2007) Are
neuroticism cognitive vulnerabilities and self-esteem overlapping or distinct
risks for depression Evidence from confirmatory factor analyses Journal of
Social amp Clinical Psychology 26 29-63
Hankin B L Wetter E Cheely C amp Oppenheimer C W (2008) Becks cognitive
theory of depression in adolescence Specific prediction of depressive
symptoms and reciprocal influences in a multi-wave prospective study
International Journal of Cognitive Therapy 1 313-332
Ingram R E Miranda J amp Segal Z V (1998) Cognitive Vulnerability to
Depression New York NY Guilford Press
26
Ingram R E amp Luxton DD (2005) Vulnerability-stress models In BL Hankin amp
JRZ Abela (Eds) Development of psychopathology A vulnerability-stress
perspective (pp 32-46) Thousand Oaks CA Sage
Joiner T E Metalsky G I Lew A amp Klocek J (1999) Testing the causal
mediation component of Becks theory of depression Evidence for specific
mediation Cognitive Therapy and Research 23 401-412
Kleinman A (2004) Culture and depression New England Journal of Medicine 351
951-953
Kleinman A (1977) Depression somatization and the new cross-cultural psychiatry
Social Science and Medicine 11 3-10
Kleinman A (1996) How is culture important for DSM-IV In J E Mezzich A
Kleinmam H Fabrega Jr amp L Delores (Eds)Culture and psychiatric
diagnosis A DSM-IV perspective (pp 15-25) Washington DC US American
Psychiatric Association
Klocek J W Oliver J M amp Ross M J (1997) The role of dysfunctional attitudes
negative life events and social support in the prediction of depressive
dysphoria A prospective longitudinal study Social Behavior and Personality
25 23-136
Lee S (1997) A Chinese perspective on somatoform disorders Journal of
Psychosomatic Disorders 43 115-119
Lee S (1998) Estranged bodies simulated harmony and misplaced cultures
Neurasthenia in contemporary Chinese society Psychosomatic Medicine 60
448ndash457
Lee S (1999) Diagnosis postponed Shenjing shuairo and the transformation of
psychiatry in post-Mao China Culture Medicine and Psychiatry 23 349ndash380
Lee S amp Wong K C (1995) Rethinking neurasthenia the illness concepts of
shenjing shuairuo among Chinese undergraduates in Honk Kong Culture
Medicine and Psychiatry 19 91ndash111
Lee S Tsang A Huang YQ He YL Liu ZR Zhang MY Shen YC amp
Kessler RC (2009) The epidemiology of depression in metropolitan China
Psychological Medicine 39 735-747
Mezzich J E Kirmayer L J Kleinman A Fabrega Jr H Parron D L Good B
J Lin K amp Manson S M (1999) The place of culture in DSM-IV Journal
of Nervous and Mental Disease 187 457-464
27
Monroe S M amp Simons A D (1991) Diathesisndashstress theories in the context of life
stress research Implications for the depressive disorders Psychological
Bulletin 110 406ndash425
Murray C J L amp Lopez A D (1996) The global burden of disease Cambridge
Harvard University Press
National Bureau of Statistics of China (2006) The China 2005 statistical yearbook
China Statistics Press Beijing PR China
Oei T P S Goh Y Kwon S M(1996) A cross-cultural study of the integrated
cognitive model of depression Current Psychology of Cognition 15 265-281
Ohrt T amp Thorell L (1998) Dysfunctional Attitude Scale (DAS) Psychometrics and
norms of the Swedish version Scandinavian Journal of Behaviour Therapy 27
105-113
Parker G Gladstone G Chee KT (2001) Depression in the planetrsquos largest ethnic
group The Chinese American Journal of Psychiatry 158 857-864
Phillips M R Zhang J Shi Q Song Z Ding Z Pang S Li X Zhang Y amp
Wang Z (2009) Prevalence treatment and associated disability of mental
disorders in four provinces in China during 2001ndash05 an epidemiological
survey The Lancet 373 2041-2053
Phillips M R Li X amp Zhang Y (2002) Suicide rates in China Lancet 359 835-
840
Phillips M R (1998) The transformation of Chinarsquos mental health services The China
Journal 39 1ndash36
Qiang G (2006) Depression number one killer of Ivory Tower students China Daily
Retrieved from httpwwwchinadailycomcnchina2006-
1128content_744880htm
Radloff L S (1977) The CESndashD scale A self-report depression scale for research in
the general population Applied Psychological Measurement 1 385ndash401
Rin H amp Huang M G (1989) Neurasthenia as nosological dilemma Culture
Medicine and Psychiatry 13 215-226
Sahin NH amp Sahin N (1992) How dysfunctional are the dysfunctional attitudes in
another culture British Journal of Medical Psychology 65 17-26
Shixie L (1989) Neurasthenia in China Modern and traditional criteria for its
diagnosis Culture Medicine and Psychiatry 13 163-186
28
Tanaka N Uji M Hiramura H Chen Z Shikai N amp Kitamura T (2006)
Cognitive patterns and depression Study of a Japanese university student
population Psychiatry and Clinical Neuroscience 60 358-364
Taylor R E (2001) Death of neurasthenia and its psychological reincarnation a study
of neurasthenia at the National Hospital for the Relief and Cure of the Paralysed
and Epileptic Queen Square London 1870ndash1932 British Journal of
Psychiatry 179 550ndash557
Weissman A N amp Beck A T (1978 April) Development and validation of the
Dysfunctional Attitudes Scale A preliminary investigation Paper presented at
the annual meeting of the Educational Research Association Toronto Canada
Xiang M Z (1986) Epidemiological study of neuroses in 12 regions (districts) of
China Chinese Journal of Neurology and Psychiatry 19 87-91
Xu JM (1987) Some issues in the diagnosis of depression in China Canadian
Journal of Psychiatry 32 368-370
Xu Y X (1994) About ICD-10 Journal of Clinical Psychology and Medicine 4 224-
226
Xu Z Li Z amp Wang Z (2007) Dysfunctional attitudes and cognitive bias in major
depressive disorder Chinese Mental Health Journal 21 488-491
Yan H Q (1989) The necessity of retaining the diagnostic concept of neurasthenia
Culture Medicine and Psychiatry 13 139-145
Yang H (2007) The Test of the Chinese version of Frost Multi-dimensional
Perfectionism Scale Chinese Mental Health Journal 21 97-100
Yang H amp Zhang X (2004) Perfectionism and mental health of college students
(2004) Chinese Mental Health Journal 18 647-648
Young D (1989) Neurasthenia and related problems Culture Medicine and
Psychiatry 13 131-138
Zhang D (1995) Depression and culture A Chinese perspective Canadian Journal of
Counseling 29 227ndash233
29
TABLE(S)
Table 1 Demographic Variables
Age 2011
Gender Male
Female
472
523
Parentsrsquo Marital Status Married
Divorced
Single
Remarried
938
23
18
20
Fatherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
Government Official
51
356
187
95
124
91
Motherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
122
406
144
76
134
Fatherrsquos Education Some Primary School
Primary School
Some High School
High School
University
29
139
222
403
137
Motherrsquos Education Some Primary School
Primary School
Some High School
High School
University
63
192
264
350
76
Only Child No
Yes
331
667
Monthly Income lt 1000 RMB
1000 ndash 1500 RMB
1500 ndash 2000 RMB
2000 ndash 3000 RMB
3000 ndash 4000 RMB
4000 ndash 5000 RMB
gt 5000 RMB
334
204
175
140
59
20
20
30
Table 2 Means Standard Deviations and Inter-correlations Between Time 1 Measures
__________________________________________________________________
1 2 3
__________________________________________________________________
1 Depressive Symptoms 2963 (780)
2 Anxious Symptoms 52 3753 (918)
3 Dysfunctional Attitudes 48 33 18120 (2304)
4 Neuroticism 63 42 53 3110 (712)
_________________________________________________________________________
Note Means and standard deviations (in parentheses) are on the diagonal Depressive
Symptoms = Center for Epidemiological Studies Depression Scale Anxious Symptoms
= Mood and Anxiety Symptom Questionnaire Overall Anxiety subscale Dysfunctional
Attitudes = Dysfunctional Attitudes Scale Neuroticism = NEO Five Factor Inventory
Neuroticism subscale p lt 01
31
Table 3 Dysfunctional Attitudes Predicting Within-Subject Fluctuations in CES-D
Scores (upper section) and MASQ Scores (lower section) during the Follow-Up
Interval
______________________________________________________________________
β SE F df
______________________________________________________________________
Time 1 CESD-D 297 026 12987 1572
Stress 005 000 10860 12459
Neuroticism 134 027 2518 1572
Dysfunctional Attitudes -055 040 -183 1572
Dysfunctional Attitudes times Stress 001 000 1078 12459
______________________________________________________________________
Time 1 MASQ 502 033 23158 1575
Stress 006 000 8963 12470
Neuroticism 080 033 596 1575
Dysfunctional Attitudes -052 051 -106 1575
Dysfunctional Attitudes times Stress 002 001 774 12470
______________________________________________________________________
Note Time 1 CES-D = Time 1 Center for Epidemiological Studies Depression Scale
Stress = Within-Subject Fluctuations in General Academic Social Hassles Scale for
Students (GASHSS) scores during the follow-up interval Neuroticism = NEO Five
Factor Inventory Neuroticism subscale Dysfunctional Attitudes = Dysfunctional
Attitudes Scale Time 1 MASQ = Time 1 Mood and Anxiety Symptom Questionnaire
Overall Anxiety subscale p lt 05 p lt 01 p lt 001
32
FIGURES
Figure 1 Predicted slope of the relationship between stress and depressive
symptoms (left panel) and anxious symptoms (right panel) as a function of
dysfunctional attitudes
20
25
30
Low High
Pre
dic
ted
CE
S-D
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
25
30
35
40
Low High
Pre
dic
ted
MA
SQ
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
Intercept Intercept
21
ATTITUDES times STRESS interaction no longer predicted anxious symptoms after
controlling for depressive symptoms The reverse however was not true as the
DYSFUNCTIONAL ATTITUDES times STRESS interaction continued to predict
depressive symptoms after controlling for anxious symptoms
It is important to note that the current study employed a particularly
conservative approach to analyses in that we examined the effects of dysfunctional
attitudes on depressive and anxious symptoms after controlling for the effect of
neuroticism on such symptoms Providing particularly powerful support for Beckrsquos
(1967 1983) cognitive theory across analyses dysfunctional attitudes predicted levels
of depressive andor anxious symptoms experienced during the six month follow-up
interval independent of the effect of neuroticism Thus contrary to past critical reviews
of the cognitive literature (Barnett amp Gotlib 1998 Coyne amp Whiffen 1995) and
consistent with past findings (Hankin et al 2007) the current results indicate that
cognitive vulnerabilities to depression such as dysfunctional attitudes are not reducible
to trait neuroticism but rather represent factors that confer independent risk for
depression
Limitations and Future Directions
Several limitations of the current study should be noted First self-report
measures were used to assess depressive and anxious symptoms Although the CES-D
and MASQ both possess high degrees of reliability and validity it is difficult to draw
conclusions about clinically diagnosed depression or anxiety based on self-report
questionnaires Second self-report measures were used to assess stress Although
measures of stress that require participants only to indicate whether or not an event
22
occurred are less likely to be influenced by informant bias than those that ask
participants to rate the subjective impact of each event more sophisticated methods of
analysis such as interviewing procedures that assess contextual threat may provide
better assessments of stress Third the measures of dysfunctional attitudes stress and
depressive and anxious symptoms used in the current study were each Western-
developed Future research should examine these hypotheses using indigenous
measures in addition to Western-developed measures in order to assess possible
similarities andor differences in patterns of findings Fourth the current study only
examined depression and anxiety as symptom outcomes Future research conducted
within China should examine a wider array of symptom outcomes such as
somatization physical complaints and externalizing behaviors in order to provide a
more thorough and culturally sensitive test of the specificity hypotheses of Beckrsquos
cognitive model Fifth the current study examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese undergraduate students and thus the extent to which
our findings may be generalized to other demographics within Chinarsquos population is
unclear Last the current study broadly examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese university students Future research should examine
the constructs and processes posited by this model in greater detail in order to develop a
deeper understanding of how they may be uniquely molded by socio-cultural factors
Such research would benefit from examining the specific types of stressors experienced
by Chinese university students as they may vary as a function of socio-cultural factors
from those experienced by Western undergraduates For example severe pressure to
succeed academically in order to secure access to a limited number of post-
23
undergraduate educational opportunities - one of the few paths towards upward
mobility available to Chinese students seeking secure and gainful employment in what
has increasingly become a very highly competitive job market - may represent a
particularly salient stressor for the development of depressive symptoms among this
population (Qiang 2006)
In conclusion the results from the current study provide support for the
applicability of Beckrsquos cognitive theory to university students in mainland China More
specifically consistent with findings obtained in the West results indicate that
dysfunctional attitudes confer vulnerability to the development of depressive symptoms
following the occurrence of negative events in Chinese university students At the same
time however the current findings suggest cultural variation in the profile of
symptoms which emerge following the occurrence of negative events in cognitively
vulnerable individuals in Western and Chinese samples Specifically whereas in the
West dysfunctional attitudes have been shown to confer vulnerability to depressive
symptoms in Chinese university students dysfunctional attitudes appear to confer
vulnerability to a combined depressive and anxious symptom profile Future research
using more sophisticated assessments of stress and depressive symptoms more diverse
samples and symptom outcome measures and indigenously-developed measures is
likely to enhance our understanding of the cognitive and environmental mechanisms
underlying the development of depression in Chinese university students Discovering
that cognitive theories of vulnerability to depression extend to university students in
China highlights the potential role for cognitive-behavioral depression prevention and
treatment interventions in stemming the tide of distress experienced by this population
24
REFERENCES
Abela J R Z amp Hankin B L (2008) Cognitive vulnerability to depression in
children and adolescents A developmental psychopathology perspective In J
R Z Abela and B L Hankin (Eds) Handbook of child and adolescent
depression (pp 35-78) New York The Guilford Press
Alloy L B Abramson L Y Hogan M E Whitehouse W G Rose D T
Robinson MS Kim R S amp Lapkin J B (2000) The Temple-Wisconsin
cognitive vulnerability to depression project Lifetime history of axis-I
psychopathology in individuals at high and low cognitive risk for depression
Journal of Abnormal Psychology 109 403-418
Alloy L B Abramson L Y Whitehouse W G Hogan M E Panzarella C amp
Rose D T (2006) Prospective incidence of first onsets and recurrences of
depression in individuals at high and low cognitive risk for depression Journal
of Abnormal Psychology 115 145ndash156
Altham P M E (1984) Improving the precision of estimation by fitting a model
Journal of the Royal Statistical Society Series B 46 11
Barnett PA amp Gotlib I H (1988) Psychosocial functioning and depression
Distinguishing among antecedents concomitants and consequences
Psychological Bulletin 104 97-126
Beck AT (1967) Depression Clinical experimental and theoretical aspects New
York Harper amp Row
Beck AT (1983) Cognitive therapy of depression New perspectives In PJ Clayton
amp JE Barrett (Eds) Treatment of depression Old controversies and new
approaches New York Raven Press
Bian Q Yang K amp Li C (2007) Dysfunctional attitudes of patients with depression
or bipolar disorder Chinese Mental Health Journal 21 759-761
Blankstein K R amp Flett G L (1993) Development of the General Academic and
Social Hassles Scales for Students Unpublished manuscript
Bonilla J Bernal G Santos A amp Santos D (2003) A revised Spanish version of
the Beck Depression InventoryPsychometric properties with a Puerto Rican
sample of college students Journal of Clinical Psychology 60 119-130
Brown G P Hammen C L Craske M G amp Wickens T D (1995) Dimensions of
dysfunctional attitudes as vulnerabilities to depressive symptoms Journal of
Abnormal Psychology 104 431-435
25
Chioqueta A P amp Stiles T C (2004) Psychometric properties of the Norweigian
version of the Dysfunctional Attitude Scale (Form A) Cognitive Behaviour
Therapy 33 83-86
Clark DA amp Beck AT (1999) Cognitive theory and therapy of depression New
York John Wiley amp Sons Inc
Clark L A amp Watson D (1991) Tripartite model of anxiety and depression
Psychometric evidence and taxonomic implications Journal of Abnormal
Psychology 100 316ndash336
Costa P T amp McCrae R R (1992) NEO PI-R Professional manual Revised NEO
personality inventory NEO PR-R and NEO five-factor inventory NEO-RRI
Odessa FL Psychological Assessment Resources
Coyne J C amp Whiffen V E (1995) Issues in personality as diathesis for depression
The case of sociotropy-dependency and autonomy-self-criticism Psychological
Bulletin 118 358-378
Fang X Qian M Luo S amp Zi F (2009) A correlational study on college students
perfectionism parental rearing patterns and mental health Chinese Mental
Health Journal 23 56-59
Hankin B L Abramson L Y Miller N amp Haeffel G (2004) Cognitive
vulnerability-stress theories of depression Examining affective specificity in
the prediction of depression versus anxiety in three prospective studies
Cognitive Therapy and Research 28 309ndash345
Hankin BL Fraley RC amp Abela JRZ (2005) Daily depression and cognitions
about stress Evidence for a traitlike depressogenic cognitive style and the
prediction of depressive symptoms in a prospective daily diary study Journal of
Personality and Social Psychology 88 673-685
Hankin B L Lakdawalla Z Carter I L Abela J R Z amp Adams P (2007) Are
neuroticism cognitive vulnerabilities and self-esteem overlapping or distinct
risks for depression Evidence from confirmatory factor analyses Journal of
Social amp Clinical Psychology 26 29-63
Hankin B L Wetter E Cheely C amp Oppenheimer C W (2008) Becks cognitive
theory of depression in adolescence Specific prediction of depressive
symptoms and reciprocal influences in a multi-wave prospective study
International Journal of Cognitive Therapy 1 313-332
Ingram R E Miranda J amp Segal Z V (1998) Cognitive Vulnerability to
Depression New York NY Guilford Press
26
Ingram R E amp Luxton DD (2005) Vulnerability-stress models In BL Hankin amp
JRZ Abela (Eds) Development of psychopathology A vulnerability-stress
perspective (pp 32-46) Thousand Oaks CA Sage
Joiner T E Metalsky G I Lew A amp Klocek J (1999) Testing the causal
mediation component of Becks theory of depression Evidence for specific
mediation Cognitive Therapy and Research 23 401-412
Kleinman A (2004) Culture and depression New England Journal of Medicine 351
951-953
Kleinman A (1977) Depression somatization and the new cross-cultural psychiatry
Social Science and Medicine 11 3-10
Kleinman A (1996) How is culture important for DSM-IV In J E Mezzich A
Kleinmam H Fabrega Jr amp L Delores (Eds)Culture and psychiatric
diagnosis A DSM-IV perspective (pp 15-25) Washington DC US American
Psychiatric Association
Klocek J W Oliver J M amp Ross M J (1997) The role of dysfunctional attitudes
negative life events and social support in the prediction of depressive
dysphoria A prospective longitudinal study Social Behavior and Personality
25 23-136
Lee S (1997) A Chinese perspective on somatoform disorders Journal of
Psychosomatic Disorders 43 115-119
Lee S (1998) Estranged bodies simulated harmony and misplaced cultures
Neurasthenia in contemporary Chinese society Psychosomatic Medicine 60
448ndash457
Lee S (1999) Diagnosis postponed Shenjing shuairo and the transformation of
psychiatry in post-Mao China Culture Medicine and Psychiatry 23 349ndash380
Lee S amp Wong K C (1995) Rethinking neurasthenia the illness concepts of
shenjing shuairuo among Chinese undergraduates in Honk Kong Culture
Medicine and Psychiatry 19 91ndash111
Lee S Tsang A Huang YQ He YL Liu ZR Zhang MY Shen YC amp
Kessler RC (2009) The epidemiology of depression in metropolitan China
Psychological Medicine 39 735-747
Mezzich J E Kirmayer L J Kleinman A Fabrega Jr H Parron D L Good B
J Lin K amp Manson S M (1999) The place of culture in DSM-IV Journal
of Nervous and Mental Disease 187 457-464
27
Monroe S M amp Simons A D (1991) Diathesisndashstress theories in the context of life
stress research Implications for the depressive disorders Psychological
Bulletin 110 406ndash425
Murray C J L amp Lopez A D (1996) The global burden of disease Cambridge
Harvard University Press
National Bureau of Statistics of China (2006) The China 2005 statistical yearbook
China Statistics Press Beijing PR China
Oei T P S Goh Y Kwon S M(1996) A cross-cultural study of the integrated
cognitive model of depression Current Psychology of Cognition 15 265-281
Ohrt T amp Thorell L (1998) Dysfunctional Attitude Scale (DAS) Psychometrics and
norms of the Swedish version Scandinavian Journal of Behaviour Therapy 27
105-113
Parker G Gladstone G Chee KT (2001) Depression in the planetrsquos largest ethnic
group The Chinese American Journal of Psychiatry 158 857-864
Phillips M R Zhang J Shi Q Song Z Ding Z Pang S Li X Zhang Y amp
Wang Z (2009) Prevalence treatment and associated disability of mental
disorders in four provinces in China during 2001ndash05 an epidemiological
survey The Lancet 373 2041-2053
Phillips M R Li X amp Zhang Y (2002) Suicide rates in China Lancet 359 835-
840
Phillips M R (1998) The transformation of Chinarsquos mental health services The China
Journal 39 1ndash36
Qiang G (2006) Depression number one killer of Ivory Tower students China Daily
Retrieved from httpwwwchinadailycomcnchina2006-
1128content_744880htm
Radloff L S (1977) The CESndashD scale A self-report depression scale for research in
the general population Applied Psychological Measurement 1 385ndash401
Rin H amp Huang M G (1989) Neurasthenia as nosological dilemma Culture
Medicine and Psychiatry 13 215-226
Sahin NH amp Sahin N (1992) How dysfunctional are the dysfunctional attitudes in
another culture British Journal of Medical Psychology 65 17-26
Shixie L (1989) Neurasthenia in China Modern and traditional criteria for its
diagnosis Culture Medicine and Psychiatry 13 163-186
28
Tanaka N Uji M Hiramura H Chen Z Shikai N amp Kitamura T (2006)
Cognitive patterns and depression Study of a Japanese university student
population Psychiatry and Clinical Neuroscience 60 358-364
Taylor R E (2001) Death of neurasthenia and its psychological reincarnation a study
of neurasthenia at the National Hospital for the Relief and Cure of the Paralysed
and Epileptic Queen Square London 1870ndash1932 British Journal of
Psychiatry 179 550ndash557
Weissman A N amp Beck A T (1978 April) Development and validation of the
Dysfunctional Attitudes Scale A preliminary investigation Paper presented at
the annual meeting of the Educational Research Association Toronto Canada
Xiang M Z (1986) Epidemiological study of neuroses in 12 regions (districts) of
China Chinese Journal of Neurology and Psychiatry 19 87-91
Xu JM (1987) Some issues in the diagnosis of depression in China Canadian
Journal of Psychiatry 32 368-370
Xu Y X (1994) About ICD-10 Journal of Clinical Psychology and Medicine 4 224-
226
Xu Z Li Z amp Wang Z (2007) Dysfunctional attitudes and cognitive bias in major
depressive disorder Chinese Mental Health Journal 21 488-491
Yan H Q (1989) The necessity of retaining the diagnostic concept of neurasthenia
Culture Medicine and Psychiatry 13 139-145
Yang H (2007) The Test of the Chinese version of Frost Multi-dimensional
Perfectionism Scale Chinese Mental Health Journal 21 97-100
Yang H amp Zhang X (2004) Perfectionism and mental health of college students
(2004) Chinese Mental Health Journal 18 647-648
Young D (1989) Neurasthenia and related problems Culture Medicine and
Psychiatry 13 131-138
Zhang D (1995) Depression and culture A Chinese perspective Canadian Journal of
Counseling 29 227ndash233
29
TABLE(S)
Table 1 Demographic Variables
Age 2011
Gender Male
Female
472
523
Parentsrsquo Marital Status Married
Divorced
Single
Remarried
938
23
18
20
Fatherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
Government Official
51
356
187
95
124
91
Motherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
122
406
144
76
134
Fatherrsquos Education Some Primary School
Primary School
Some High School
High School
University
29
139
222
403
137
Motherrsquos Education Some Primary School
Primary School
Some High School
High School
University
63
192
264
350
76
Only Child No
Yes
331
667
Monthly Income lt 1000 RMB
1000 ndash 1500 RMB
1500 ndash 2000 RMB
2000 ndash 3000 RMB
3000 ndash 4000 RMB
4000 ndash 5000 RMB
gt 5000 RMB
334
204
175
140
59
20
20
30
Table 2 Means Standard Deviations and Inter-correlations Between Time 1 Measures
__________________________________________________________________
1 2 3
__________________________________________________________________
1 Depressive Symptoms 2963 (780)
2 Anxious Symptoms 52 3753 (918)
3 Dysfunctional Attitudes 48 33 18120 (2304)
4 Neuroticism 63 42 53 3110 (712)
_________________________________________________________________________
Note Means and standard deviations (in parentheses) are on the diagonal Depressive
Symptoms = Center for Epidemiological Studies Depression Scale Anxious Symptoms
= Mood and Anxiety Symptom Questionnaire Overall Anxiety subscale Dysfunctional
Attitudes = Dysfunctional Attitudes Scale Neuroticism = NEO Five Factor Inventory
Neuroticism subscale p lt 01
31
Table 3 Dysfunctional Attitudes Predicting Within-Subject Fluctuations in CES-D
Scores (upper section) and MASQ Scores (lower section) during the Follow-Up
Interval
______________________________________________________________________
β SE F df
______________________________________________________________________
Time 1 CESD-D 297 026 12987 1572
Stress 005 000 10860 12459
Neuroticism 134 027 2518 1572
Dysfunctional Attitudes -055 040 -183 1572
Dysfunctional Attitudes times Stress 001 000 1078 12459
______________________________________________________________________
Time 1 MASQ 502 033 23158 1575
Stress 006 000 8963 12470
Neuroticism 080 033 596 1575
Dysfunctional Attitudes -052 051 -106 1575
Dysfunctional Attitudes times Stress 002 001 774 12470
______________________________________________________________________
Note Time 1 CES-D = Time 1 Center for Epidemiological Studies Depression Scale
Stress = Within-Subject Fluctuations in General Academic Social Hassles Scale for
Students (GASHSS) scores during the follow-up interval Neuroticism = NEO Five
Factor Inventory Neuroticism subscale Dysfunctional Attitudes = Dysfunctional
Attitudes Scale Time 1 MASQ = Time 1 Mood and Anxiety Symptom Questionnaire
Overall Anxiety subscale p lt 05 p lt 01 p lt 001
32
FIGURES
Figure 1 Predicted slope of the relationship between stress and depressive
symptoms (left panel) and anxious symptoms (right panel) as a function of
dysfunctional attitudes
20
25
30
Low High
Pre
dic
ted
CE
S-D
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
25
30
35
40
Low High
Pre
dic
ted
MA
SQ
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
Intercept Intercept
22
occurred are less likely to be influenced by informant bias than those that ask
participants to rate the subjective impact of each event more sophisticated methods of
analysis such as interviewing procedures that assess contextual threat may provide
better assessments of stress Third the measures of dysfunctional attitudes stress and
depressive and anxious symptoms used in the current study were each Western-
developed Future research should examine these hypotheses using indigenous
measures in addition to Western-developed measures in order to assess possible
similarities andor differences in patterns of findings Fourth the current study only
examined depression and anxiety as symptom outcomes Future research conducted
within China should examine a wider array of symptom outcomes such as
somatization physical complaints and externalizing behaviors in order to provide a
more thorough and culturally sensitive test of the specificity hypotheses of Beckrsquos
cognitive model Fifth the current study examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese undergraduate students and thus the extent to which
our findings may be generalized to other demographics within Chinarsquos population is
unclear Last the current study broadly examined the applicability of Beckrsquos (1967
1983) cognitive theory to Chinese university students Future research should examine
the constructs and processes posited by this model in greater detail in order to develop a
deeper understanding of how they may be uniquely molded by socio-cultural factors
Such research would benefit from examining the specific types of stressors experienced
by Chinese university students as they may vary as a function of socio-cultural factors
from those experienced by Western undergraduates For example severe pressure to
succeed academically in order to secure access to a limited number of post-
23
undergraduate educational opportunities - one of the few paths towards upward
mobility available to Chinese students seeking secure and gainful employment in what
has increasingly become a very highly competitive job market - may represent a
particularly salient stressor for the development of depressive symptoms among this
population (Qiang 2006)
In conclusion the results from the current study provide support for the
applicability of Beckrsquos cognitive theory to university students in mainland China More
specifically consistent with findings obtained in the West results indicate that
dysfunctional attitudes confer vulnerability to the development of depressive symptoms
following the occurrence of negative events in Chinese university students At the same
time however the current findings suggest cultural variation in the profile of
symptoms which emerge following the occurrence of negative events in cognitively
vulnerable individuals in Western and Chinese samples Specifically whereas in the
West dysfunctional attitudes have been shown to confer vulnerability to depressive
symptoms in Chinese university students dysfunctional attitudes appear to confer
vulnerability to a combined depressive and anxious symptom profile Future research
using more sophisticated assessments of stress and depressive symptoms more diverse
samples and symptom outcome measures and indigenously-developed measures is
likely to enhance our understanding of the cognitive and environmental mechanisms
underlying the development of depression in Chinese university students Discovering
that cognitive theories of vulnerability to depression extend to university students in
China highlights the potential role for cognitive-behavioral depression prevention and
treatment interventions in stemming the tide of distress experienced by this population
24
REFERENCES
Abela J R Z amp Hankin B L (2008) Cognitive vulnerability to depression in
children and adolescents A developmental psychopathology perspective In J
R Z Abela and B L Hankin (Eds) Handbook of child and adolescent
depression (pp 35-78) New York The Guilford Press
Alloy L B Abramson L Y Hogan M E Whitehouse W G Rose D T
Robinson MS Kim R S amp Lapkin J B (2000) The Temple-Wisconsin
cognitive vulnerability to depression project Lifetime history of axis-I
psychopathology in individuals at high and low cognitive risk for depression
Journal of Abnormal Psychology 109 403-418
Alloy L B Abramson L Y Whitehouse W G Hogan M E Panzarella C amp
Rose D T (2006) Prospective incidence of first onsets and recurrences of
depression in individuals at high and low cognitive risk for depression Journal
of Abnormal Psychology 115 145ndash156
Altham P M E (1984) Improving the precision of estimation by fitting a model
Journal of the Royal Statistical Society Series B 46 11
Barnett PA amp Gotlib I H (1988) Psychosocial functioning and depression
Distinguishing among antecedents concomitants and consequences
Psychological Bulletin 104 97-126
Beck AT (1967) Depression Clinical experimental and theoretical aspects New
York Harper amp Row
Beck AT (1983) Cognitive therapy of depression New perspectives In PJ Clayton
amp JE Barrett (Eds) Treatment of depression Old controversies and new
approaches New York Raven Press
Bian Q Yang K amp Li C (2007) Dysfunctional attitudes of patients with depression
or bipolar disorder Chinese Mental Health Journal 21 759-761
Blankstein K R amp Flett G L (1993) Development of the General Academic and
Social Hassles Scales for Students Unpublished manuscript
Bonilla J Bernal G Santos A amp Santos D (2003) A revised Spanish version of
the Beck Depression InventoryPsychometric properties with a Puerto Rican
sample of college students Journal of Clinical Psychology 60 119-130
Brown G P Hammen C L Craske M G amp Wickens T D (1995) Dimensions of
dysfunctional attitudes as vulnerabilities to depressive symptoms Journal of
Abnormal Psychology 104 431-435
25
Chioqueta A P amp Stiles T C (2004) Psychometric properties of the Norweigian
version of the Dysfunctional Attitude Scale (Form A) Cognitive Behaviour
Therapy 33 83-86
Clark DA amp Beck AT (1999) Cognitive theory and therapy of depression New
York John Wiley amp Sons Inc
Clark L A amp Watson D (1991) Tripartite model of anxiety and depression
Psychometric evidence and taxonomic implications Journal of Abnormal
Psychology 100 316ndash336
Costa P T amp McCrae R R (1992) NEO PI-R Professional manual Revised NEO
personality inventory NEO PR-R and NEO five-factor inventory NEO-RRI
Odessa FL Psychological Assessment Resources
Coyne J C amp Whiffen V E (1995) Issues in personality as diathesis for depression
The case of sociotropy-dependency and autonomy-self-criticism Psychological
Bulletin 118 358-378
Fang X Qian M Luo S amp Zi F (2009) A correlational study on college students
perfectionism parental rearing patterns and mental health Chinese Mental
Health Journal 23 56-59
Hankin B L Abramson L Y Miller N amp Haeffel G (2004) Cognitive
vulnerability-stress theories of depression Examining affective specificity in
the prediction of depression versus anxiety in three prospective studies
Cognitive Therapy and Research 28 309ndash345
Hankin BL Fraley RC amp Abela JRZ (2005) Daily depression and cognitions
about stress Evidence for a traitlike depressogenic cognitive style and the
prediction of depressive symptoms in a prospective daily diary study Journal of
Personality and Social Psychology 88 673-685
Hankin B L Lakdawalla Z Carter I L Abela J R Z amp Adams P (2007) Are
neuroticism cognitive vulnerabilities and self-esteem overlapping or distinct
risks for depression Evidence from confirmatory factor analyses Journal of
Social amp Clinical Psychology 26 29-63
Hankin B L Wetter E Cheely C amp Oppenheimer C W (2008) Becks cognitive
theory of depression in adolescence Specific prediction of depressive
symptoms and reciprocal influences in a multi-wave prospective study
International Journal of Cognitive Therapy 1 313-332
Ingram R E Miranda J amp Segal Z V (1998) Cognitive Vulnerability to
Depression New York NY Guilford Press
26
Ingram R E amp Luxton DD (2005) Vulnerability-stress models In BL Hankin amp
JRZ Abela (Eds) Development of psychopathology A vulnerability-stress
perspective (pp 32-46) Thousand Oaks CA Sage
Joiner T E Metalsky G I Lew A amp Klocek J (1999) Testing the causal
mediation component of Becks theory of depression Evidence for specific
mediation Cognitive Therapy and Research 23 401-412
Kleinman A (2004) Culture and depression New England Journal of Medicine 351
951-953
Kleinman A (1977) Depression somatization and the new cross-cultural psychiatry
Social Science and Medicine 11 3-10
Kleinman A (1996) How is culture important for DSM-IV In J E Mezzich A
Kleinmam H Fabrega Jr amp L Delores (Eds)Culture and psychiatric
diagnosis A DSM-IV perspective (pp 15-25) Washington DC US American
Psychiatric Association
Klocek J W Oliver J M amp Ross M J (1997) The role of dysfunctional attitudes
negative life events and social support in the prediction of depressive
dysphoria A prospective longitudinal study Social Behavior and Personality
25 23-136
Lee S (1997) A Chinese perspective on somatoform disorders Journal of
Psychosomatic Disorders 43 115-119
Lee S (1998) Estranged bodies simulated harmony and misplaced cultures
Neurasthenia in contemporary Chinese society Psychosomatic Medicine 60
448ndash457
Lee S (1999) Diagnosis postponed Shenjing shuairo and the transformation of
psychiatry in post-Mao China Culture Medicine and Psychiatry 23 349ndash380
Lee S amp Wong K C (1995) Rethinking neurasthenia the illness concepts of
shenjing shuairuo among Chinese undergraduates in Honk Kong Culture
Medicine and Psychiatry 19 91ndash111
Lee S Tsang A Huang YQ He YL Liu ZR Zhang MY Shen YC amp
Kessler RC (2009) The epidemiology of depression in metropolitan China
Psychological Medicine 39 735-747
Mezzich J E Kirmayer L J Kleinman A Fabrega Jr H Parron D L Good B
J Lin K amp Manson S M (1999) The place of culture in DSM-IV Journal
of Nervous and Mental Disease 187 457-464
27
Monroe S M amp Simons A D (1991) Diathesisndashstress theories in the context of life
stress research Implications for the depressive disorders Psychological
Bulletin 110 406ndash425
Murray C J L amp Lopez A D (1996) The global burden of disease Cambridge
Harvard University Press
National Bureau of Statistics of China (2006) The China 2005 statistical yearbook
China Statistics Press Beijing PR China
Oei T P S Goh Y Kwon S M(1996) A cross-cultural study of the integrated
cognitive model of depression Current Psychology of Cognition 15 265-281
Ohrt T amp Thorell L (1998) Dysfunctional Attitude Scale (DAS) Psychometrics and
norms of the Swedish version Scandinavian Journal of Behaviour Therapy 27
105-113
Parker G Gladstone G Chee KT (2001) Depression in the planetrsquos largest ethnic
group The Chinese American Journal of Psychiatry 158 857-864
Phillips M R Zhang J Shi Q Song Z Ding Z Pang S Li X Zhang Y amp
Wang Z (2009) Prevalence treatment and associated disability of mental
disorders in four provinces in China during 2001ndash05 an epidemiological
survey The Lancet 373 2041-2053
Phillips M R Li X amp Zhang Y (2002) Suicide rates in China Lancet 359 835-
840
Phillips M R (1998) The transformation of Chinarsquos mental health services The China
Journal 39 1ndash36
Qiang G (2006) Depression number one killer of Ivory Tower students China Daily
Retrieved from httpwwwchinadailycomcnchina2006-
1128content_744880htm
Radloff L S (1977) The CESndashD scale A self-report depression scale for research in
the general population Applied Psychological Measurement 1 385ndash401
Rin H amp Huang M G (1989) Neurasthenia as nosological dilemma Culture
Medicine and Psychiatry 13 215-226
Sahin NH amp Sahin N (1992) How dysfunctional are the dysfunctional attitudes in
another culture British Journal of Medical Psychology 65 17-26
Shixie L (1989) Neurasthenia in China Modern and traditional criteria for its
diagnosis Culture Medicine and Psychiatry 13 163-186
28
Tanaka N Uji M Hiramura H Chen Z Shikai N amp Kitamura T (2006)
Cognitive patterns and depression Study of a Japanese university student
population Psychiatry and Clinical Neuroscience 60 358-364
Taylor R E (2001) Death of neurasthenia and its psychological reincarnation a study
of neurasthenia at the National Hospital for the Relief and Cure of the Paralysed
and Epileptic Queen Square London 1870ndash1932 British Journal of
Psychiatry 179 550ndash557
Weissman A N amp Beck A T (1978 April) Development and validation of the
Dysfunctional Attitudes Scale A preliminary investigation Paper presented at
the annual meeting of the Educational Research Association Toronto Canada
Xiang M Z (1986) Epidemiological study of neuroses in 12 regions (districts) of
China Chinese Journal of Neurology and Psychiatry 19 87-91
Xu JM (1987) Some issues in the diagnosis of depression in China Canadian
Journal of Psychiatry 32 368-370
Xu Y X (1994) About ICD-10 Journal of Clinical Psychology and Medicine 4 224-
226
Xu Z Li Z amp Wang Z (2007) Dysfunctional attitudes and cognitive bias in major
depressive disorder Chinese Mental Health Journal 21 488-491
Yan H Q (1989) The necessity of retaining the diagnostic concept of neurasthenia
Culture Medicine and Psychiatry 13 139-145
Yang H (2007) The Test of the Chinese version of Frost Multi-dimensional
Perfectionism Scale Chinese Mental Health Journal 21 97-100
Yang H amp Zhang X (2004) Perfectionism and mental health of college students
(2004) Chinese Mental Health Journal 18 647-648
Young D (1989) Neurasthenia and related problems Culture Medicine and
Psychiatry 13 131-138
Zhang D (1995) Depression and culture A Chinese perspective Canadian Journal of
Counseling 29 227ndash233
29
TABLE(S)
Table 1 Demographic Variables
Age 2011
Gender Male
Female
472
523
Parentsrsquo Marital Status Married
Divorced
Single
Remarried
938
23
18
20
Fatherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
Government Official
51
356
187
95
124
91
Motherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
122
406
144
76
134
Fatherrsquos Education Some Primary School
Primary School
Some High School
High School
University
29
139
222
403
137
Motherrsquos Education Some Primary School
Primary School
Some High School
High School
University
63
192
264
350
76
Only Child No
Yes
331
667
Monthly Income lt 1000 RMB
1000 ndash 1500 RMB
1500 ndash 2000 RMB
2000 ndash 3000 RMB
3000 ndash 4000 RMB
4000 ndash 5000 RMB
gt 5000 RMB
334
204
175
140
59
20
20
30
Table 2 Means Standard Deviations and Inter-correlations Between Time 1 Measures
__________________________________________________________________
1 2 3
__________________________________________________________________
1 Depressive Symptoms 2963 (780)
2 Anxious Symptoms 52 3753 (918)
3 Dysfunctional Attitudes 48 33 18120 (2304)
4 Neuroticism 63 42 53 3110 (712)
_________________________________________________________________________
Note Means and standard deviations (in parentheses) are on the diagonal Depressive
Symptoms = Center for Epidemiological Studies Depression Scale Anxious Symptoms
= Mood and Anxiety Symptom Questionnaire Overall Anxiety subscale Dysfunctional
Attitudes = Dysfunctional Attitudes Scale Neuroticism = NEO Five Factor Inventory
Neuroticism subscale p lt 01
31
Table 3 Dysfunctional Attitudes Predicting Within-Subject Fluctuations in CES-D
Scores (upper section) and MASQ Scores (lower section) during the Follow-Up
Interval
______________________________________________________________________
β SE F df
______________________________________________________________________
Time 1 CESD-D 297 026 12987 1572
Stress 005 000 10860 12459
Neuroticism 134 027 2518 1572
Dysfunctional Attitudes -055 040 -183 1572
Dysfunctional Attitudes times Stress 001 000 1078 12459
______________________________________________________________________
Time 1 MASQ 502 033 23158 1575
Stress 006 000 8963 12470
Neuroticism 080 033 596 1575
Dysfunctional Attitudes -052 051 -106 1575
Dysfunctional Attitudes times Stress 002 001 774 12470
______________________________________________________________________
Note Time 1 CES-D = Time 1 Center for Epidemiological Studies Depression Scale
Stress = Within-Subject Fluctuations in General Academic Social Hassles Scale for
Students (GASHSS) scores during the follow-up interval Neuroticism = NEO Five
Factor Inventory Neuroticism subscale Dysfunctional Attitudes = Dysfunctional
Attitudes Scale Time 1 MASQ = Time 1 Mood and Anxiety Symptom Questionnaire
Overall Anxiety subscale p lt 05 p lt 01 p lt 001
32
FIGURES
Figure 1 Predicted slope of the relationship between stress and depressive
symptoms (left panel) and anxious symptoms (right panel) as a function of
dysfunctional attitudes
20
25
30
Low High
Pre
dic
ted
CE
S-D
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
25
30
35
40
Low High
Pre
dic
ted
MA
SQ
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
Intercept Intercept
23
undergraduate educational opportunities - one of the few paths towards upward
mobility available to Chinese students seeking secure and gainful employment in what
has increasingly become a very highly competitive job market - may represent a
particularly salient stressor for the development of depressive symptoms among this
population (Qiang 2006)
In conclusion the results from the current study provide support for the
applicability of Beckrsquos cognitive theory to university students in mainland China More
specifically consistent with findings obtained in the West results indicate that
dysfunctional attitudes confer vulnerability to the development of depressive symptoms
following the occurrence of negative events in Chinese university students At the same
time however the current findings suggest cultural variation in the profile of
symptoms which emerge following the occurrence of negative events in cognitively
vulnerable individuals in Western and Chinese samples Specifically whereas in the
West dysfunctional attitudes have been shown to confer vulnerability to depressive
symptoms in Chinese university students dysfunctional attitudes appear to confer
vulnerability to a combined depressive and anxious symptom profile Future research
using more sophisticated assessments of stress and depressive symptoms more diverse
samples and symptom outcome measures and indigenously-developed measures is
likely to enhance our understanding of the cognitive and environmental mechanisms
underlying the development of depression in Chinese university students Discovering
that cognitive theories of vulnerability to depression extend to university students in
China highlights the potential role for cognitive-behavioral depression prevention and
treatment interventions in stemming the tide of distress experienced by this population
24
REFERENCES
Abela J R Z amp Hankin B L (2008) Cognitive vulnerability to depression in
children and adolescents A developmental psychopathology perspective In J
R Z Abela and B L Hankin (Eds) Handbook of child and adolescent
depression (pp 35-78) New York The Guilford Press
Alloy L B Abramson L Y Hogan M E Whitehouse W G Rose D T
Robinson MS Kim R S amp Lapkin J B (2000) The Temple-Wisconsin
cognitive vulnerability to depression project Lifetime history of axis-I
psychopathology in individuals at high and low cognitive risk for depression
Journal of Abnormal Psychology 109 403-418
Alloy L B Abramson L Y Whitehouse W G Hogan M E Panzarella C amp
Rose D T (2006) Prospective incidence of first onsets and recurrences of
depression in individuals at high and low cognitive risk for depression Journal
of Abnormal Psychology 115 145ndash156
Altham P M E (1984) Improving the precision of estimation by fitting a model
Journal of the Royal Statistical Society Series B 46 11
Barnett PA amp Gotlib I H (1988) Psychosocial functioning and depression
Distinguishing among antecedents concomitants and consequences
Psychological Bulletin 104 97-126
Beck AT (1967) Depression Clinical experimental and theoretical aspects New
York Harper amp Row
Beck AT (1983) Cognitive therapy of depression New perspectives In PJ Clayton
amp JE Barrett (Eds) Treatment of depression Old controversies and new
approaches New York Raven Press
Bian Q Yang K amp Li C (2007) Dysfunctional attitudes of patients with depression
or bipolar disorder Chinese Mental Health Journal 21 759-761
Blankstein K R amp Flett G L (1993) Development of the General Academic and
Social Hassles Scales for Students Unpublished manuscript
Bonilla J Bernal G Santos A amp Santos D (2003) A revised Spanish version of
the Beck Depression InventoryPsychometric properties with a Puerto Rican
sample of college students Journal of Clinical Psychology 60 119-130
Brown G P Hammen C L Craske M G amp Wickens T D (1995) Dimensions of
dysfunctional attitudes as vulnerabilities to depressive symptoms Journal of
Abnormal Psychology 104 431-435
25
Chioqueta A P amp Stiles T C (2004) Psychometric properties of the Norweigian
version of the Dysfunctional Attitude Scale (Form A) Cognitive Behaviour
Therapy 33 83-86
Clark DA amp Beck AT (1999) Cognitive theory and therapy of depression New
York John Wiley amp Sons Inc
Clark L A amp Watson D (1991) Tripartite model of anxiety and depression
Psychometric evidence and taxonomic implications Journal of Abnormal
Psychology 100 316ndash336
Costa P T amp McCrae R R (1992) NEO PI-R Professional manual Revised NEO
personality inventory NEO PR-R and NEO five-factor inventory NEO-RRI
Odessa FL Psychological Assessment Resources
Coyne J C amp Whiffen V E (1995) Issues in personality as diathesis for depression
The case of sociotropy-dependency and autonomy-self-criticism Psychological
Bulletin 118 358-378
Fang X Qian M Luo S amp Zi F (2009) A correlational study on college students
perfectionism parental rearing patterns and mental health Chinese Mental
Health Journal 23 56-59
Hankin B L Abramson L Y Miller N amp Haeffel G (2004) Cognitive
vulnerability-stress theories of depression Examining affective specificity in
the prediction of depression versus anxiety in three prospective studies
Cognitive Therapy and Research 28 309ndash345
Hankin BL Fraley RC amp Abela JRZ (2005) Daily depression and cognitions
about stress Evidence for a traitlike depressogenic cognitive style and the
prediction of depressive symptoms in a prospective daily diary study Journal of
Personality and Social Psychology 88 673-685
Hankin B L Lakdawalla Z Carter I L Abela J R Z amp Adams P (2007) Are
neuroticism cognitive vulnerabilities and self-esteem overlapping or distinct
risks for depression Evidence from confirmatory factor analyses Journal of
Social amp Clinical Psychology 26 29-63
Hankin B L Wetter E Cheely C amp Oppenheimer C W (2008) Becks cognitive
theory of depression in adolescence Specific prediction of depressive
symptoms and reciprocal influences in a multi-wave prospective study
International Journal of Cognitive Therapy 1 313-332
Ingram R E Miranda J amp Segal Z V (1998) Cognitive Vulnerability to
Depression New York NY Guilford Press
26
Ingram R E amp Luxton DD (2005) Vulnerability-stress models In BL Hankin amp
JRZ Abela (Eds) Development of psychopathology A vulnerability-stress
perspective (pp 32-46) Thousand Oaks CA Sage
Joiner T E Metalsky G I Lew A amp Klocek J (1999) Testing the causal
mediation component of Becks theory of depression Evidence for specific
mediation Cognitive Therapy and Research 23 401-412
Kleinman A (2004) Culture and depression New England Journal of Medicine 351
951-953
Kleinman A (1977) Depression somatization and the new cross-cultural psychiatry
Social Science and Medicine 11 3-10
Kleinman A (1996) How is culture important for DSM-IV In J E Mezzich A
Kleinmam H Fabrega Jr amp L Delores (Eds)Culture and psychiatric
diagnosis A DSM-IV perspective (pp 15-25) Washington DC US American
Psychiatric Association
Klocek J W Oliver J M amp Ross M J (1997) The role of dysfunctional attitudes
negative life events and social support in the prediction of depressive
dysphoria A prospective longitudinal study Social Behavior and Personality
25 23-136
Lee S (1997) A Chinese perspective on somatoform disorders Journal of
Psychosomatic Disorders 43 115-119
Lee S (1998) Estranged bodies simulated harmony and misplaced cultures
Neurasthenia in contemporary Chinese society Psychosomatic Medicine 60
448ndash457
Lee S (1999) Diagnosis postponed Shenjing shuairo and the transformation of
psychiatry in post-Mao China Culture Medicine and Psychiatry 23 349ndash380
Lee S amp Wong K C (1995) Rethinking neurasthenia the illness concepts of
shenjing shuairuo among Chinese undergraduates in Honk Kong Culture
Medicine and Psychiatry 19 91ndash111
Lee S Tsang A Huang YQ He YL Liu ZR Zhang MY Shen YC amp
Kessler RC (2009) The epidemiology of depression in metropolitan China
Psychological Medicine 39 735-747
Mezzich J E Kirmayer L J Kleinman A Fabrega Jr H Parron D L Good B
J Lin K amp Manson S M (1999) The place of culture in DSM-IV Journal
of Nervous and Mental Disease 187 457-464
27
Monroe S M amp Simons A D (1991) Diathesisndashstress theories in the context of life
stress research Implications for the depressive disorders Psychological
Bulletin 110 406ndash425
Murray C J L amp Lopez A D (1996) The global burden of disease Cambridge
Harvard University Press
National Bureau of Statistics of China (2006) The China 2005 statistical yearbook
China Statistics Press Beijing PR China
Oei T P S Goh Y Kwon S M(1996) A cross-cultural study of the integrated
cognitive model of depression Current Psychology of Cognition 15 265-281
Ohrt T amp Thorell L (1998) Dysfunctional Attitude Scale (DAS) Psychometrics and
norms of the Swedish version Scandinavian Journal of Behaviour Therapy 27
105-113
Parker G Gladstone G Chee KT (2001) Depression in the planetrsquos largest ethnic
group The Chinese American Journal of Psychiatry 158 857-864
Phillips M R Zhang J Shi Q Song Z Ding Z Pang S Li X Zhang Y amp
Wang Z (2009) Prevalence treatment and associated disability of mental
disorders in four provinces in China during 2001ndash05 an epidemiological
survey The Lancet 373 2041-2053
Phillips M R Li X amp Zhang Y (2002) Suicide rates in China Lancet 359 835-
840
Phillips M R (1998) The transformation of Chinarsquos mental health services The China
Journal 39 1ndash36
Qiang G (2006) Depression number one killer of Ivory Tower students China Daily
Retrieved from httpwwwchinadailycomcnchina2006-
1128content_744880htm
Radloff L S (1977) The CESndashD scale A self-report depression scale for research in
the general population Applied Psychological Measurement 1 385ndash401
Rin H amp Huang M G (1989) Neurasthenia as nosological dilemma Culture
Medicine and Psychiatry 13 215-226
Sahin NH amp Sahin N (1992) How dysfunctional are the dysfunctional attitudes in
another culture British Journal of Medical Psychology 65 17-26
Shixie L (1989) Neurasthenia in China Modern and traditional criteria for its
diagnosis Culture Medicine and Psychiatry 13 163-186
28
Tanaka N Uji M Hiramura H Chen Z Shikai N amp Kitamura T (2006)
Cognitive patterns and depression Study of a Japanese university student
population Psychiatry and Clinical Neuroscience 60 358-364
Taylor R E (2001) Death of neurasthenia and its psychological reincarnation a study
of neurasthenia at the National Hospital for the Relief and Cure of the Paralysed
and Epileptic Queen Square London 1870ndash1932 British Journal of
Psychiatry 179 550ndash557
Weissman A N amp Beck A T (1978 April) Development and validation of the
Dysfunctional Attitudes Scale A preliminary investigation Paper presented at
the annual meeting of the Educational Research Association Toronto Canada
Xiang M Z (1986) Epidemiological study of neuroses in 12 regions (districts) of
China Chinese Journal of Neurology and Psychiatry 19 87-91
Xu JM (1987) Some issues in the diagnosis of depression in China Canadian
Journal of Psychiatry 32 368-370
Xu Y X (1994) About ICD-10 Journal of Clinical Psychology and Medicine 4 224-
226
Xu Z Li Z amp Wang Z (2007) Dysfunctional attitudes and cognitive bias in major
depressive disorder Chinese Mental Health Journal 21 488-491
Yan H Q (1989) The necessity of retaining the diagnostic concept of neurasthenia
Culture Medicine and Psychiatry 13 139-145
Yang H (2007) The Test of the Chinese version of Frost Multi-dimensional
Perfectionism Scale Chinese Mental Health Journal 21 97-100
Yang H amp Zhang X (2004) Perfectionism and mental health of college students
(2004) Chinese Mental Health Journal 18 647-648
Young D (1989) Neurasthenia and related problems Culture Medicine and
Psychiatry 13 131-138
Zhang D (1995) Depression and culture A Chinese perspective Canadian Journal of
Counseling 29 227ndash233
29
TABLE(S)
Table 1 Demographic Variables
Age 2011
Gender Male
Female
472
523
Parentsrsquo Marital Status Married
Divorced
Single
Remarried
938
23
18
20
Fatherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
Government Official
51
356
187
95
124
91
Motherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
122
406
144
76
134
Fatherrsquos Education Some Primary School
Primary School
Some High School
High School
University
29
139
222
403
137
Motherrsquos Education Some Primary School
Primary School
Some High School
High School
University
63
192
264
350
76
Only Child No
Yes
331
667
Monthly Income lt 1000 RMB
1000 ndash 1500 RMB
1500 ndash 2000 RMB
2000 ndash 3000 RMB
3000 ndash 4000 RMB
4000 ndash 5000 RMB
gt 5000 RMB
334
204
175
140
59
20
20
30
Table 2 Means Standard Deviations and Inter-correlations Between Time 1 Measures
__________________________________________________________________
1 2 3
__________________________________________________________________
1 Depressive Symptoms 2963 (780)
2 Anxious Symptoms 52 3753 (918)
3 Dysfunctional Attitudes 48 33 18120 (2304)
4 Neuroticism 63 42 53 3110 (712)
_________________________________________________________________________
Note Means and standard deviations (in parentheses) are on the diagonal Depressive
Symptoms = Center for Epidemiological Studies Depression Scale Anxious Symptoms
= Mood and Anxiety Symptom Questionnaire Overall Anxiety subscale Dysfunctional
Attitudes = Dysfunctional Attitudes Scale Neuroticism = NEO Five Factor Inventory
Neuroticism subscale p lt 01
31
Table 3 Dysfunctional Attitudes Predicting Within-Subject Fluctuations in CES-D
Scores (upper section) and MASQ Scores (lower section) during the Follow-Up
Interval
______________________________________________________________________
β SE F df
______________________________________________________________________
Time 1 CESD-D 297 026 12987 1572
Stress 005 000 10860 12459
Neuroticism 134 027 2518 1572
Dysfunctional Attitudes -055 040 -183 1572
Dysfunctional Attitudes times Stress 001 000 1078 12459
______________________________________________________________________
Time 1 MASQ 502 033 23158 1575
Stress 006 000 8963 12470
Neuroticism 080 033 596 1575
Dysfunctional Attitudes -052 051 -106 1575
Dysfunctional Attitudes times Stress 002 001 774 12470
______________________________________________________________________
Note Time 1 CES-D = Time 1 Center for Epidemiological Studies Depression Scale
Stress = Within-Subject Fluctuations in General Academic Social Hassles Scale for
Students (GASHSS) scores during the follow-up interval Neuroticism = NEO Five
Factor Inventory Neuroticism subscale Dysfunctional Attitudes = Dysfunctional
Attitudes Scale Time 1 MASQ = Time 1 Mood and Anxiety Symptom Questionnaire
Overall Anxiety subscale p lt 05 p lt 01 p lt 001
32
FIGURES
Figure 1 Predicted slope of the relationship between stress and depressive
symptoms (left panel) and anxious symptoms (right panel) as a function of
dysfunctional attitudes
20
25
30
Low High
Pre
dic
ted
CE
S-D
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
25
30
35
40
Low High
Pre
dic
ted
MA
SQ
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
Intercept Intercept
24
REFERENCES
Abela J R Z amp Hankin B L (2008) Cognitive vulnerability to depression in
children and adolescents A developmental psychopathology perspective In J
R Z Abela and B L Hankin (Eds) Handbook of child and adolescent
depression (pp 35-78) New York The Guilford Press
Alloy L B Abramson L Y Hogan M E Whitehouse W G Rose D T
Robinson MS Kim R S amp Lapkin J B (2000) The Temple-Wisconsin
cognitive vulnerability to depression project Lifetime history of axis-I
psychopathology in individuals at high and low cognitive risk for depression
Journal of Abnormal Psychology 109 403-418
Alloy L B Abramson L Y Whitehouse W G Hogan M E Panzarella C amp
Rose D T (2006) Prospective incidence of first onsets and recurrences of
depression in individuals at high and low cognitive risk for depression Journal
of Abnormal Psychology 115 145ndash156
Altham P M E (1984) Improving the precision of estimation by fitting a model
Journal of the Royal Statistical Society Series B 46 11
Barnett PA amp Gotlib I H (1988) Psychosocial functioning and depression
Distinguishing among antecedents concomitants and consequences
Psychological Bulletin 104 97-126
Beck AT (1967) Depression Clinical experimental and theoretical aspects New
York Harper amp Row
Beck AT (1983) Cognitive therapy of depression New perspectives In PJ Clayton
amp JE Barrett (Eds) Treatment of depression Old controversies and new
approaches New York Raven Press
Bian Q Yang K amp Li C (2007) Dysfunctional attitudes of patients with depression
or bipolar disorder Chinese Mental Health Journal 21 759-761
Blankstein K R amp Flett G L (1993) Development of the General Academic and
Social Hassles Scales for Students Unpublished manuscript
Bonilla J Bernal G Santos A amp Santos D (2003) A revised Spanish version of
the Beck Depression InventoryPsychometric properties with a Puerto Rican
sample of college students Journal of Clinical Psychology 60 119-130
Brown G P Hammen C L Craske M G amp Wickens T D (1995) Dimensions of
dysfunctional attitudes as vulnerabilities to depressive symptoms Journal of
Abnormal Psychology 104 431-435
25
Chioqueta A P amp Stiles T C (2004) Psychometric properties of the Norweigian
version of the Dysfunctional Attitude Scale (Form A) Cognitive Behaviour
Therapy 33 83-86
Clark DA amp Beck AT (1999) Cognitive theory and therapy of depression New
York John Wiley amp Sons Inc
Clark L A amp Watson D (1991) Tripartite model of anxiety and depression
Psychometric evidence and taxonomic implications Journal of Abnormal
Psychology 100 316ndash336
Costa P T amp McCrae R R (1992) NEO PI-R Professional manual Revised NEO
personality inventory NEO PR-R and NEO five-factor inventory NEO-RRI
Odessa FL Psychological Assessment Resources
Coyne J C amp Whiffen V E (1995) Issues in personality as diathesis for depression
The case of sociotropy-dependency and autonomy-self-criticism Psychological
Bulletin 118 358-378
Fang X Qian M Luo S amp Zi F (2009) A correlational study on college students
perfectionism parental rearing patterns and mental health Chinese Mental
Health Journal 23 56-59
Hankin B L Abramson L Y Miller N amp Haeffel G (2004) Cognitive
vulnerability-stress theories of depression Examining affective specificity in
the prediction of depression versus anxiety in three prospective studies
Cognitive Therapy and Research 28 309ndash345
Hankin BL Fraley RC amp Abela JRZ (2005) Daily depression and cognitions
about stress Evidence for a traitlike depressogenic cognitive style and the
prediction of depressive symptoms in a prospective daily diary study Journal of
Personality and Social Psychology 88 673-685
Hankin B L Lakdawalla Z Carter I L Abela J R Z amp Adams P (2007) Are
neuroticism cognitive vulnerabilities and self-esteem overlapping or distinct
risks for depression Evidence from confirmatory factor analyses Journal of
Social amp Clinical Psychology 26 29-63
Hankin B L Wetter E Cheely C amp Oppenheimer C W (2008) Becks cognitive
theory of depression in adolescence Specific prediction of depressive
symptoms and reciprocal influences in a multi-wave prospective study
International Journal of Cognitive Therapy 1 313-332
Ingram R E Miranda J amp Segal Z V (1998) Cognitive Vulnerability to
Depression New York NY Guilford Press
26
Ingram R E amp Luxton DD (2005) Vulnerability-stress models In BL Hankin amp
JRZ Abela (Eds) Development of psychopathology A vulnerability-stress
perspective (pp 32-46) Thousand Oaks CA Sage
Joiner T E Metalsky G I Lew A amp Klocek J (1999) Testing the causal
mediation component of Becks theory of depression Evidence for specific
mediation Cognitive Therapy and Research 23 401-412
Kleinman A (2004) Culture and depression New England Journal of Medicine 351
951-953
Kleinman A (1977) Depression somatization and the new cross-cultural psychiatry
Social Science and Medicine 11 3-10
Kleinman A (1996) How is culture important for DSM-IV In J E Mezzich A
Kleinmam H Fabrega Jr amp L Delores (Eds)Culture and psychiatric
diagnosis A DSM-IV perspective (pp 15-25) Washington DC US American
Psychiatric Association
Klocek J W Oliver J M amp Ross M J (1997) The role of dysfunctional attitudes
negative life events and social support in the prediction of depressive
dysphoria A prospective longitudinal study Social Behavior and Personality
25 23-136
Lee S (1997) A Chinese perspective on somatoform disorders Journal of
Psychosomatic Disorders 43 115-119
Lee S (1998) Estranged bodies simulated harmony and misplaced cultures
Neurasthenia in contemporary Chinese society Psychosomatic Medicine 60
448ndash457
Lee S (1999) Diagnosis postponed Shenjing shuairo and the transformation of
psychiatry in post-Mao China Culture Medicine and Psychiatry 23 349ndash380
Lee S amp Wong K C (1995) Rethinking neurasthenia the illness concepts of
shenjing shuairuo among Chinese undergraduates in Honk Kong Culture
Medicine and Psychiatry 19 91ndash111
Lee S Tsang A Huang YQ He YL Liu ZR Zhang MY Shen YC amp
Kessler RC (2009) The epidemiology of depression in metropolitan China
Psychological Medicine 39 735-747
Mezzich J E Kirmayer L J Kleinman A Fabrega Jr H Parron D L Good B
J Lin K amp Manson S M (1999) The place of culture in DSM-IV Journal
of Nervous and Mental Disease 187 457-464
27
Monroe S M amp Simons A D (1991) Diathesisndashstress theories in the context of life
stress research Implications for the depressive disorders Psychological
Bulletin 110 406ndash425
Murray C J L amp Lopez A D (1996) The global burden of disease Cambridge
Harvard University Press
National Bureau of Statistics of China (2006) The China 2005 statistical yearbook
China Statistics Press Beijing PR China
Oei T P S Goh Y Kwon S M(1996) A cross-cultural study of the integrated
cognitive model of depression Current Psychology of Cognition 15 265-281
Ohrt T amp Thorell L (1998) Dysfunctional Attitude Scale (DAS) Psychometrics and
norms of the Swedish version Scandinavian Journal of Behaviour Therapy 27
105-113
Parker G Gladstone G Chee KT (2001) Depression in the planetrsquos largest ethnic
group The Chinese American Journal of Psychiatry 158 857-864
Phillips M R Zhang J Shi Q Song Z Ding Z Pang S Li X Zhang Y amp
Wang Z (2009) Prevalence treatment and associated disability of mental
disorders in four provinces in China during 2001ndash05 an epidemiological
survey The Lancet 373 2041-2053
Phillips M R Li X amp Zhang Y (2002) Suicide rates in China Lancet 359 835-
840
Phillips M R (1998) The transformation of Chinarsquos mental health services The China
Journal 39 1ndash36
Qiang G (2006) Depression number one killer of Ivory Tower students China Daily
Retrieved from httpwwwchinadailycomcnchina2006-
1128content_744880htm
Radloff L S (1977) The CESndashD scale A self-report depression scale for research in
the general population Applied Psychological Measurement 1 385ndash401
Rin H amp Huang M G (1989) Neurasthenia as nosological dilemma Culture
Medicine and Psychiatry 13 215-226
Sahin NH amp Sahin N (1992) How dysfunctional are the dysfunctional attitudes in
another culture British Journal of Medical Psychology 65 17-26
Shixie L (1989) Neurasthenia in China Modern and traditional criteria for its
diagnosis Culture Medicine and Psychiatry 13 163-186
28
Tanaka N Uji M Hiramura H Chen Z Shikai N amp Kitamura T (2006)
Cognitive patterns and depression Study of a Japanese university student
population Psychiatry and Clinical Neuroscience 60 358-364
Taylor R E (2001) Death of neurasthenia and its psychological reincarnation a study
of neurasthenia at the National Hospital for the Relief and Cure of the Paralysed
and Epileptic Queen Square London 1870ndash1932 British Journal of
Psychiatry 179 550ndash557
Weissman A N amp Beck A T (1978 April) Development and validation of the
Dysfunctional Attitudes Scale A preliminary investigation Paper presented at
the annual meeting of the Educational Research Association Toronto Canada
Xiang M Z (1986) Epidemiological study of neuroses in 12 regions (districts) of
China Chinese Journal of Neurology and Psychiatry 19 87-91
Xu JM (1987) Some issues in the diagnosis of depression in China Canadian
Journal of Psychiatry 32 368-370
Xu Y X (1994) About ICD-10 Journal of Clinical Psychology and Medicine 4 224-
226
Xu Z Li Z amp Wang Z (2007) Dysfunctional attitudes and cognitive bias in major
depressive disorder Chinese Mental Health Journal 21 488-491
Yan H Q (1989) The necessity of retaining the diagnostic concept of neurasthenia
Culture Medicine and Psychiatry 13 139-145
Yang H (2007) The Test of the Chinese version of Frost Multi-dimensional
Perfectionism Scale Chinese Mental Health Journal 21 97-100
Yang H amp Zhang X (2004) Perfectionism and mental health of college students
(2004) Chinese Mental Health Journal 18 647-648
Young D (1989) Neurasthenia and related problems Culture Medicine and
Psychiatry 13 131-138
Zhang D (1995) Depression and culture A Chinese perspective Canadian Journal of
Counseling 29 227ndash233
29
TABLE(S)
Table 1 Demographic Variables
Age 2011
Gender Male
Female
472
523
Parentsrsquo Marital Status Married
Divorced
Single
Remarried
938
23
18
20
Fatherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
Government Official
51
356
187
95
124
91
Motherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
122
406
144
76
134
Fatherrsquos Education Some Primary School
Primary School
Some High School
High School
University
29
139
222
403
137
Motherrsquos Education Some Primary School
Primary School
Some High School
High School
University
63
192
264
350
76
Only Child No
Yes
331
667
Monthly Income lt 1000 RMB
1000 ndash 1500 RMB
1500 ndash 2000 RMB
2000 ndash 3000 RMB
3000 ndash 4000 RMB
4000 ndash 5000 RMB
gt 5000 RMB
334
204
175
140
59
20
20
30
Table 2 Means Standard Deviations and Inter-correlations Between Time 1 Measures
__________________________________________________________________
1 2 3
__________________________________________________________________
1 Depressive Symptoms 2963 (780)
2 Anxious Symptoms 52 3753 (918)
3 Dysfunctional Attitudes 48 33 18120 (2304)
4 Neuroticism 63 42 53 3110 (712)
_________________________________________________________________________
Note Means and standard deviations (in parentheses) are on the diagonal Depressive
Symptoms = Center for Epidemiological Studies Depression Scale Anxious Symptoms
= Mood and Anxiety Symptom Questionnaire Overall Anxiety subscale Dysfunctional
Attitudes = Dysfunctional Attitudes Scale Neuroticism = NEO Five Factor Inventory
Neuroticism subscale p lt 01
31
Table 3 Dysfunctional Attitudes Predicting Within-Subject Fluctuations in CES-D
Scores (upper section) and MASQ Scores (lower section) during the Follow-Up
Interval
______________________________________________________________________
β SE F df
______________________________________________________________________
Time 1 CESD-D 297 026 12987 1572
Stress 005 000 10860 12459
Neuroticism 134 027 2518 1572
Dysfunctional Attitudes -055 040 -183 1572
Dysfunctional Attitudes times Stress 001 000 1078 12459
______________________________________________________________________
Time 1 MASQ 502 033 23158 1575
Stress 006 000 8963 12470
Neuroticism 080 033 596 1575
Dysfunctional Attitudes -052 051 -106 1575
Dysfunctional Attitudes times Stress 002 001 774 12470
______________________________________________________________________
Note Time 1 CES-D = Time 1 Center for Epidemiological Studies Depression Scale
Stress = Within-Subject Fluctuations in General Academic Social Hassles Scale for
Students (GASHSS) scores during the follow-up interval Neuroticism = NEO Five
Factor Inventory Neuroticism subscale Dysfunctional Attitudes = Dysfunctional
Attitudes Scale Time 1 MASQ = Time 1 Mood and Anxiety Symptom Questionnaire
Overall Anxiety subscale p lt 05 p lt 01 p lt 001
32
FIGURES
Figure 1 Predicted slope of the relationship between stress and depressive
symptoms (left panel) and anxious symptoms (right panel) as a function of
dysfunctional attitudes
20
25
30
Low High
Pre
dic
ted
CE
S-D
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
25
30
35
40
Low High
Pre
dic
ted
MA
SQ
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
Intercept Intercept
25
Chioqueta A P amp Stiles T C (2004) Psychometric properties of the Norweigian
version of the Dysfunctional Attitude Scale (Form A) Cognitive Behaviour
Therapy 33 83-86
Clark DA amp Beck AT (1999) Cognitive theory and therapy of depression New
York John Wiley amp Sons Inc
Clark L A amp Watson D (1991) Tripartite model of anxiety and depression
Psychometric evidence and taxonomic implications Journal of Abnormal
Psychology 100 316ndash336
Costa P T amp McCrae R R (1992) NEO PI-R Professional manual Revised NEO
personality inventory NEO PR-R and NEO five-factor inventory NEO-RRI
Odessa FL Psychological Assessment Resources
Coyne J C amp Whiffen V E (1995) Issues in personality as diathesis for depression
The case of sociotropy-dependency and autonomy-self-criticism Psychological
Bulletin 118 358-378
Fang X Qian M Luo S amp Zi F (2009) A correlational study on college students
perfectionism parental rearing patterns and mental health Chinese Mental
Health Journal 23 56-59
Hankin B L Abramson L Y Miller N amp Haeffel G (2004) Cognitive
vulnerability-stress theories of depression Examining affective specificity in
the prediction of depression versus anxiety in three prospective studies
Cognitive Therapy and Research 28 309ndash345
Hankin BL Fraley RC amp Abela JRZ (2005) Daily depression and cognitions
about stress Evidence for a traitlike depressogenic cognitive style and the
prediction of depressive symptoms in a prospective daily diary study Journal of
Personality and Social Psychology 88 673-685
Hankin B L Lakdawalla Z Carter I L Abela J R Z amp Adams P (2007) Are
neuroticism cognitive vulnerabilities and self-esteem overlapping or distinct
risks for depression Evidence from confirmatory factor analyses Journal of
Social amp Clinical Psychology 26 29-63
Hankin B L Wetter E Cheely C amp Oppenheimer C W (2008) Becks cognitive
theory of depression in adolescence Specific prediction of depressive
symptoms and reciprocal influences in a multi-wave prospective study
International Journal of Cognitive Therapy 1 313-332
Ingram R E Miranda J amp Segal Z V (1998) Cognitive Vulnerability to
Depression New York NY Guilford Press
26
Ingram R E amp Luxton DD (2005) Vulnerability-stress models In BL Hankin amp
JRZ Abela (Eds) Development of psychopathology A vulnerability-stress
perspective (pp 32-46) Thousand Oaks CA Sage
Joiner T E Metalsky G I Lew A amp Klocek J (1999) Testing the causal
mediation component of Becks theory of depression Evidence for specific
mediation Cognitive Therapy and Research 23 401-412
Kleinman A (2004) Culture and depression New England Journal of Medicine 351
951-953
Kleinman A (1977) Depression somatization and the new cross-cultural psychiatry
Social Science and Medicine 11 3-10
Kleinman A (1996) How is culture important for DSM-IV In J E Mezzich A
Kleinmam H Fabrega Jr amp L Delores (Eds)Culture and psychiatric
diagnosis A DSM-IV perspective (pp 15-25) Washington DC US American
Psychiatric Association
Klocek J W Oliver J M amp Ross M J (1997) The role of dysfunctional attitudes
negative life events and social support in the prediction of depressive
dysphoria A prospective longitudinal study Social Behavior and Personality
25 23-136
Lee S (1997) A Chinese perspective on somatoform disorders Journal of
Psychosomatic Disorders 43 115-119
Lee S (1998) Estranged bodies simulated harmony and misplaced cultures
Neurasthenia in contemporary Chinese society Psychosomatic Medicine 60
448ndash457
Lee S (1999) Diagnosis postponed Shenjing shuairo and the transformation of
psychiatry in post-Mao China Culture Medicine and Psychiatry 23 349ndash380
Lee S amp Wong K C (1995) Rethinking neurasthenia the illness concepts of
shenjing shuairuo among Chinese undergraduates in Honk Kong Culture
Medicine and Psychiatry 19 91ndash111
Lee S Tsang A Huang YQ He YL Liu ZR Zhang MY Shen YC amp
Kessler RC (2009) The epidemiology of depression in metropolitan China
Psychological Medicine 39 735-747
Mezzich J E Kirmayer L J Kleinman A Fabrega Jr H Parron D L Good B
J Lin K amp Manson S M (1999) The place of culture in DSM-IV Journal
of Nervous and Mental Disease 187 457-464
27
Monroe S M amp Simons A D (1991) Diathesisndashstress theories in the context of life
stress research Implications for the depressive disorders Psychological
Bulletin 110 406ndash425
Murray C J L amp Lopez A D (1996) The global burden of disease Cambridge
Harvard University Press
National Bureau of Statistics of China (2006) The China 2005 statistical yearbook
China Statistics Press Beijing PR China
Oei T P S Goh Y Kwon S M(1996) A cross-cultural study of the integrated
cognitive model of depression Current Psychology of Cognition 15 265-281
Ohrt T amp Thorell L (1998) Dysfunctional Attitude Scale (DAS) Psychometrics and
norms of the Swedish version Scandinavian Journal of Behaviour Therapy 27
105-113
Parker G Gladstone G Chee KT (2001) Depression in the planetrsquos largest ethnic
group The Chinese American Journal of Psychiatry 158 857-864
Phillips M R Zhang J Shi Q Song Z Ding Z Pang S Li X Zhang Y amp
Wang Z (2009) Prevalence treatment and associated disability of mental
disorders in four provinces in China during 2001ndash05 an epidemiological
survey The Lancet 373 2041-2053
Phillips M R Li X amp Zhang Y (2002) Suicide rates in China Lancet 359 835-
840
Phillips M R (1998) The transformation of Chinarsquos mental health services The China
Journal 39 1ndash36
Qiang G (2006) Depression number one killer of Ivory Tower students China Daily
Retrieved from httpwwwchinadailycomcnchina2006-
1128content_744880htm
Radloff L S (1977) The CESndashD scale A self-report depression scale for research in
the general population Applied Psychological Measurement 1 385ndash401
Rin H amp Huang M G (1989) Neurasthenia as nosological dilemma Culture
Medicine and Psychiatry 13 215-226
Sahin NH amp Sahin N (1992) How dysfunctional are the dysfunctional attitudes in
another culture British Journal of Medical Psychology 65 17-26
Shixie L (1989) Neurasthenia in China Modern and traditional criteria for its
diagnosis Culture Medicine and Psychiatry 13 163-186
28
Tanaka N Uji M Hiramura H Chen Z Shikai N amp Kitamura T (2006)
Cognitive patterns and depression Study of a Japanese university student
population Psychiatry and Clinical Neuroscience 60 358-364
Taylor R E (2001) Death of neurasthenia and its psychological reincarnation a study
of neurasthenia at the National Hospital for the Relief and Cure of the Paralysed
and Epileptic Queen Square London 1870ndash1932 British Journal of
Psychiatry 179 550ndash557
Weissman A N amp Beck A T (1978 April) Development and validation of the
Dysfunctional Attitudes Scale A preliminary investigation Paper presented at
the annual meeting of the Educational Research Association Toronto Canada
Xiang M Z (1986) Epidemiological study of neuroses in 12 regions (districts) of
China Chinese Journal of Neurology and Psychiatry 19 87-91
Xu JM (1987) Some issues in the diagnosis of depression in China Canadian
Journal of Psychiatry 32 368-370
Xu Y X (1994) About ICD-10 Journal of Clinical Psychology and Medicine 4 224-
226
Xu Z Li Z amp Wang Z (2007) Dysfunctional attitudes and cognitive bias in major
depressive disorder Chinese Mental Health Journal 21 488-491
Yan H Q (1989) The necessity of retaining the diagnostic concept of neurasthenia
Culture Medicine and Psychiatry 13 139-145
Yang H (2007) The Test of the Chinese version of Frost Multi-dimensional
Perfectionism Scale Chinese Mental Health Journal 21 97-100
Yang H amp Zhang X (2004) Perfectionism and mental health of college students
(2004) Chinese Mental Health Journal 18 647-648
Young D (1989) Neurasthenia and related problems Culture Medicine and
Psychiatry 13 131-138
Zhang D (1995) Depression and culture A Chinese perspective Canadian Journal of
Counseling 29 227ndash233
29
TABLE(S)
Table 1 Demographic Variables
Age 2011
Gender Male
Female
472
523
Parentsrsquo Marital Status Married
Divorced
Single
Remarried
938
23
18
20
Fatherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
Government Official
51
356
187
95
124
91
Motherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
122
406
144
76
134
Fatherrsquos Education Some Primary School
Primary School
Some High School
High School
University
29
139
222
403
137
Motherrsquos Education Some Primary School
Primary School
Some High School
High School
University
63
192
264
350
76
Only Child No
Yes
331
667
Monthly Income lt 1000 RMB
1000 ndash 1500 RMB
1500 ndash 2000 RMB
2000 ndash 3000 RMB
3000 ndash 4000 RMB
4000 ndash 5000 RMB
gt 5000 RMB
334
204
175
140
59
20
20
30
Table 2 Means Standard Deviations and Inter-correlations Between Time 1 Measures
__________________________________________________________________
1 2 3
__________________________________________________________________
1 Depressive Symptoms 2963 (780)
2 Anxious Symptoms 52 3753 (918)
3 Dysfunctional Attitudes 48 33 18120 (2304)
4 Neuroticism 63 42 53 3110 (712)
_________________________________________________________________________
Note Means and standard deviations (in parentheses) are on the diagonal Depressive
Symptoms = Center for Epidemiological Studies Depression Scale Anxious Symptoms
= Mood and Anxiety Symptom Questionnaire Overall Anxiety subscale Dysfunctional
Attitudes = Dysfunctional Attitudes Scale Neuroticism = NEO Five Factor Inventory
Neuroticism subscale p lt 01
31
Table 3 Dysfunctional Attitudes Predicting Within-Subject Fluctuations in CES-D
Scores (upper section) and MASQ Scores (lower section) during the Follow-Up
Interval
______________________________________________________________________
β SE F df
______________________________________________________________________
Time 1 CESD-D 297 026 12987 1572
Stress 005 000 10860 12459
Neuroticism 134 027 2518 1572
Dysfunctional Attitudes -055 040 -183 1572
Dysfunctional Attitudes times Stress 001 000 1078 12459
______________________________________________________________________
Time 1 MASQ 502 033 23158 1575
Stress 006 000 8963 12470
Neuroticism 080 033 596 1575
Dysfunctional Attitudes -052 051 -106 1575
Dysfunctional Attitudes times Stress 002 001 774 12470
______________________________________________________________________
Note Time 1 CES-D = Time 1 Center for Epidemiological Studies Depression Scale
Stress = Within-Subject Fluctuations in General Academic Social Hassles Scale for
Students (GASHSS) scores during the follow-up interval Neuroticism = NEO Five
Factor Inventory Neuroticism subscale Dysfunctional Attitudes = Dysfunctional
Attitudes Scale Time 1 MASQ = Time 1 Mood and Anxiety Symptom Questionnaire
Overall Anxiety subscale p lt 05 p lt 01 p lt 001
32
FIGURES
Figure 1 Predicted slope of the relationship between stress and depressive
symptoms (left panel) and anxious symptoms (right panel) as a function of
dysfunctional attitudes
20
25
30
Low High
Pre
dic
ted
CE
S-D
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
25
30
35
40
Low High
Pre
dic
ted
MA
SQ
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
Intercept Intercept
26
Ingram R E amp Luxton DD (2005) Vulnerability-stress models In BL Hankin amp
JRZ Abela (Eds) Development of psychopathology A vulnerability-stress
perspective (pp 32-46) Thousand Oaks CA Sage
Joiner T E Metalsky G I Lew A amp Klocek J (1999) Testing the causal
mediation component of Becks theory of depression Evidence for specific
mediation Cognitive Therapy and Research 23 401-412
Kleinman A (2004) Culture and depression New England Journal of Medicine 351
951-953
Kleinman A (1977) Depression somatization and the new cross-cultural psychiatry
Social Science and Medicine 11 3-10
Kleinman A (1996) How is culture important for DSM-IV In J E Mezzich A
Kleinmam H Fabrega Jr amp L Delores (Eds)Culture and psychiatric
diagnosis A DSM-IV perspective (pp 15-25) Washington DC US American
Psychiatric Association
Klocek J W Oliver J M amp Ross M J (1997) The role of dysfunctional attitudes
negative life events and social support in the prediction of depressive
dysphoria A prospective longitudinal study Social Behavior and Personality
25 23-136
Lee S (1997) A Chinese perspective on somatoform disorders Journal of
Psychosomatic Disorders 43 115-119
Lee S (1998) Estranged bodies simulated harmony and misplaced cultures
Neurasthenia in contemporary Chinese society Psychosomatic Medicine 60
448ndash457
Lee S (1999) Diagnosis postponed Shenjing shuairo and the transformation of
psychiatry in post-Mao China Culture Medicine and Psychiatry 23 349ndash380
Lee S amp Wong K C (1995) Rethinking neurasthenia the illness concepts of
shenjing shuairuo among Chinese undergraduates in Honk Kong Culture
Medicine and Psychiatry 19 91ndash111
Lee S Tsang A Huang YQ He YL Liu ZR Zhang MY Shen YC amp
Kessler RC (2009) The epidemiology of depression in metropolitan China
Psychological Medicine 39 735-747
Mezzich J E Kirmayer L J Kleinman A Fabrega Jr H Parron D L Good B
J Lin K amp Manson S M (1999) The place of culture in DSM-IV Journal
of Nervous and Mental Disease 187 457-464
27
Monroe S M amp Simons A D (1991) Diathesisndashstress theories in the context of life
stress research Implications for the depressive disorders Psychological
Bulletin 110 406ndash425
Murray C J L amp Lopez A D (1996) The global burden of disease Cambridge
Harvard University Press
National Bureau of Statistics of China (2006) The China 2005 statistical yearbook
China Statistics Press Beijing PR China
Oei T P S Goh Y Kwon S M(1996) A cross-cultural study of the integrated
cognitive model of depression Current Psychology of Cognition 15 265-281
Ohrt T amp Thorell L (1998) Dysfunctional Attitude Scale (DAS) Psychometrics and
norms of the Swedish version Scandinavian Journal of Behaviour Therapy 27
105-113
Parker G Gladstone G Chee KT (2001) Depression in the planetrsquos largest ethnic
group The Chinese American Journal of Psychiatry 158 857-864
Phillips M R Zhang J Shi Q Song Z Ding Z Pang S Li X Zhang Y amp
Wang Z (2009) Prevalence treatment and associated disability of mental
disorders in four provinces in China during 2001ndash05 an epidemiological
survey The Lancet 373 2041-2053
Phillips M R Li X amp Zhang Y (2002) Suicide rates in China Lancet 359 835-
840
Phillips M R (1998) The transformation of Chinarsquos mental health services The China
Journal 39 1ndash36
Qiang G (2006) Depression number one killer of Ivory Tower students China Daily
Retrieved from httpwwwchinadailycomcnchina2006-
1128content_744880htm
Radloff L S (1977) The CESndashD scale A self-report depression scale for research in
the general population Applied Psychological Measurement 1 385ndash401
Rin H amp Huang M G (1989) Neurasthenia as nosological dilemma Culture
Medicine and Psychiatry 13 215-226
Sahin NH amp Sahin N (1992) How dysfunctional are the dysfunctional attitudes in
another culture British Journal of Medical Psychology 65 17-26
Shixie L (1989) Neurasthenia in China Modern and traditional criteria for its
diagnosis Culture Medicine and Psychiatry 13 163-186
28
Tanaka N Uji M Hiramura H Chen Z Shikai N amp Kitamura T (2006)
Cognitive patterns and depression Study of a Japanese university student
population Psychiatry and Clinical Neuroscience 60 358-364
Taylor R E (2001) Death of neurasthenia and its psychological reincarnation a study
of neurasthenia at the National Hospital for the Relief and Cure of the Paralysed
and Epileptic Queen Square London 1870ndash1932 British Journal of
Psychiatry 179 550ndash557
Weissman A N amp Beck A T (1978 April) Development and validation of the
Dysfunctional Attitudes Scale A preliminary investigation Paper presented at
the annual meeting of the Educational Research Association Toronto Canada
Xiang M Z (1986) Epidemiological study of neuroses in 12 regions (districts) of
China Chinese Journal of Neurology and Psychiatry 19 87-91
Xu JM (1987) Some issues in the diagnosis of depression in China Canadian
Journal of Psychiatry 32 368-370
Xu Y X (1994) About ICD-10 Journal of Clinical Psychology and Medicine 4 224-
226
Xu Z Li Z amp Wang Z (2007) Dysfunctional attitudes and cognitive bias in major
depressive disorder Chinese Mental Health Journal 21 488-491
Yan H Q (1989) The necessity of retaining the diagnostic concept of neurasthenia
Culture Medicine and Psychiatry 13 139-145
Yang H (2007) The Test of the Chinese version of Frost Multi-dimensional
Perfectionism Scale Chinese Mental Health Journal 21 97-100
Yang H amp Zhang X (2004) Perfectionism and mental health of college students
(2004) Chinese Mental Health Journal 18 647-648
Young D (1989) Neurasthenia and related problems Culture Medicine and
Psychiatry 13 131-138
Zhang D (1995) Depression and culture A Chinese perspective Canadian Journal of
Counseling 29 227ndash233
29
TABLE(S)
Table 1 Demographic Variables
Age 2011
Gender Male
Female
472
523
Parentsrsquo Marital Status Married
Divorced
Single
Remarried
938
23
18
20
Fatherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
Government Official
51
356
187
95
124
91
Motherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
122
406
144
76
134
Fatherrsquos Education Some Primary School
Primary School
Some High School
High School
University
29
139
222
403
137
Motherrsquos Education Some Primary School
Primary School
Some High School
High School
University
63
192
264
350
76
Only Child No
Yes
331
667
Monthly Income lt 1000 RMB
1000 ndash 1500 RMB
1500 ndash 2000 RMB
2000 ndash 3000 RMB
3000 ndash 4000 RMB
4000 ndash 5000 RMB
gt 5000 RMB
334
204
175
140
59
20
20
30
Table 2 Means Standard Deviations and Inter-correlations Between Time 1 Measures
__________________________________________________________________
1 2 3
__________________________________________________________________
1 Depressive Symptoms 2963 (780)
2 Anxious Symptoms 52 3753 (918)
3 Dysfunctional Attitudes 48 33 18120 (2304)
4 Neuroticism 63 42 53 3110 (712)
_________________________________________________________________________
Note Means and standard deviations (in parentheses) are on the diagonal Depressive
Symptoms = Center for Epidemiological Studies Depression Scale Anxious Symptoms
= Mood and Anxiety Symptom Questionnaire Overall Anxiety subscale Dysfunctional
Attitudes = Dysfunctional Attitudes Scale Neuroticism = NEO Five Factor Inventory
Neuroticism subscale p lt 01
31
Table 3 Dysfunctional Attitudes Predicting Within-Subject Fluctuations in CES-D
Scores (upper section) and MASQ Scores (lower section) during the Follow-Up
Interval
______________________________________________________________________
β SE F df
______________________________________________________________________
Time 1 CESD-D 297 026 12987 1572
Stress 005 000 10860 12459
Neuroticism 134 027 2518 1572
Dysfunctional Attitudes -055 040 -183 1572
Dysfunctional Attitudes times Stress 001 000 1078 12459
______________________________________________________________________
Time 1 MASQ 502 033 23158 1575
Stress 006 000 8963 12470
Neuroticism 080 033 596 1575
Dysfunctional Attitudes -052 051 -106 1575
Dysfunctional Attitudes times Stress 002 001 774 12470
______________________________________________________________________
Note Time 1 CES-D = Time 1 Center for Epidemiological Studies Depression Scale
Stress = Within-Subject Fluctuations in General Academic Social Hassles Scale for
Students (GASHSS) scores during the follow-up interval Neuroticism = NEO Five
Factor Inventory Neuroticism subscale Dysfunctional Attitudes = Dysfunctional
Attitudes Scale Time 1 MASQ = Time 1 Mood and Anxiety Symptom Questionnaire
Overall Anxiety subscale p lt 05 p lt 01 p lt 001
32
FIGURES
Figure 1 Predicted slope of the relationship between stress and depressive
symptoms (left panel) and anxious symptoms (right panel) as a function of
dysfunctional attitudes
20
25
30
Low High
Pre
dic
ted
CE
S-D
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
25
30
35
40
Low High
Pre
dic
ted
MA
SQ
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
Intercept Intercept
27
Monroe S M amp Simons A D (1991) Diathesisndashstress theories in the context of life
stress research Implications for the depressive disorders Psychological
Bulletin 110 406ndash425
Murray C J L amp Lopez A D (1996) The global burden of disease Cambridge
Harvard University Press
National Bureau of Statistics of China (2006) The China 2005 statistical yearbook
China Statistics Press Beijing PR China
Oei T P S Goh Y Kwon S M(1996) A cross-cultural study of the integrated
cognitive model of depression Current Psychology of Cognition 15 265-281
Ohrt T amp Thorell L (1998) Dysfunctional Attitude Scale (DAS) Psychometrics and
norms of the Swedish version Scandinavian Journal of Behaviour Therapy 27
105-113
Parker G Gladstone G Chee KT (2001) Depression in the planetrsquos largest ethnic
group The Chinese American Journal of Psychiatry 158 857-864
Phillips M R Zhang J Shi Q Song Z Ding Z Pang S Li X Zhang Y amp
Wang Z (2009) Prevalence treatment and associated disability of mental
disorders in four provinces in China during 2001ndash05 an epidemiological
survey The Lancet 373 2041-2053
Phillips M R Li X amp Zhang Y (2002) Suicide rates in China Lancet 359 835-
840
Phillips M R (1998) The transformation of Chinarsquos mental health services The China
Journal 39 1ndash36
Qiang G (2006) Depression number one killer of Ivory Tower students China Daily
Retrieved from httpwwwchinadailycomcnchina2006-
1128content_744880htm
Radloff L S (1977) The CESndashD scale A self-report depression scale for research in
the general population Applied Psychological Measurement 1 385ndash401
Rin H amp Huang M G (1989) Neurasthenia as nosological dilemma Culture
Medicine and Psychiatry 13 215-226
Sahin NH amp Sahin N (1992) How dysfunctional are the dysfunctional attitudes in
another culture British Journal of Medical Psychology 65 17-26
Shixie L (1989) Neurasthenia in China Modern and traditional criteria for its
diagnosis Culture Medicine and Psychiatry 13 163-186
28
Tanaka N Uji M Hiramura H Chen Z Shikai N amp Kitamura T (2006)
Cognitive patterns and depression Study of a Japanese university student
population Psychiatry and Clinical Neuroscience 60 358-364
Taylor R E (2001) Death of neurasthenia and its psychological reincarnation a study
of neurasthenia at the National Hospital for the Relief and Cure of the Paralysed
and Epileptic Queen Square London 1870ndash1932 British Journal of
Psychiatry 179 550ndash557
Weissman A N amp Beck A T (1978 April) Development and validation of the
Dysfunctional Attitudes Scale A preliminary investigation Paper presented at
the annual meeting of the Educational Research Association Toronto Canada
Xiang M Z (1986) Epidemiological study of neuroses in 12 regions (districts) of
China Chinese Journal of Neurology and Psychiatry 19 87-91
Xu JM (1987) Some issues in the diagnosis of depression in China Canadian
Journal of Psychiatry 32 368-370
Xu Y X (1994) About ICD-10 Journal of Clinical Psychology and Medicine 4 224-
226
Xu Z Li Z amp Wang Z (2007) Dysfunctional attitudes and cognitive bias in major
depressive disorder Chinese Mental Health Journal 21 488-491
Yan H Q (1989) The necessity of retaining the diagnostic concept of neurasthenia
Culture Medicine and Psychiatry 13 139-145
Yang H (2007) The Test of the Chinese version of Frost Multi-dimensional
Perfectionism Scale Chinese Mental Health Journal 21 97-100
Yang H amp Zhang X (2004) Perfectionism and mental health of college students
(2004) Chinese Mental Health Journal 18 647-648
Young D (1989) Neurasthenia and related problems Culture Medicine and
Psychiatry 13 131-138
Zhang D (1995) Depression and culture A Chinese perspective Canadian Journal of
Counseling 29 227ndash233
29
TABLE(S)
Table 1 Demographic Variables
Age 2011
Gender Male
Female
472
523
Parentsrsquo Marital Status Married
Divorced
Single
Remarried
938
23
18
20
Fatherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
Government Official
51
356
187
95
124
91
Motherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
122
406
144
76
134
Fatherrsquos Education Some Primary School
Primary School
Some High School
High School
University
29
139
222
403
137
Motherrsquos Education Some Primary School
Primary School
Some High School
High School
University
63
192
264
350
76
Only Child No
Yes
331
667
Monthly Income lt 1000 RMB
1000 ndash 1500 RMB
1500 ndash 2000 RMB
2000 ndash 3000 RMB
3000 ndash 4000 RMB
4000 ndash 5000 RMB
gt 5000 RMB
334
204
175
140
59
20
20
30
Table 2 Means Standard Deviations and Inter-correlations Between Time 1 Measures
__________________________________________________________________
1 2 3
__________________________________________________________________
1 Depressive Symptoms 2963 (780)
2 Anxious Symptoms 52 3753 (918)
3 Dysfunctional Attitudes 48 33 18120 (2304)
4 Neuroticism 63 42 53 3110 (712)
_________________________________________________________________________
Note Means and standard deviations (in parentheses) are on the diagonal Depressive
Symptoms = Center for Epidemiological Studies Depression Scale Anxious Symptoms
= Mood and Anxiety Symptom Questionnaire Overall Anxiety subscale Dysfunctional
Attitudes = Dysfunctional Attitudes Scale Neuroticism = NEO Five Factor Inventory
Neuroticism subscale p lt 01
31
Table 3 Dysfunctional Attitudes Predicting Within-Subject Fluctuations in CES-D
Scores (upper section) and MASQ Scores (lower section) during the Follow-Up
Interval
______________________________________________________________________
β SE F df
______________________________________________________________________
Time 1 CESD-D 297 026 12987 1572
Stress 005 000 10860 12459
Neuroticism 134 027 2518 1572
Dysfunctional Attitudes -055 040 -183 1572
Dysfunctional Attitudes times Stress 001 000 1078 12459
______________________________________________________________________
Time 1 MASQ 502 033 23158 1575
Stress 006 000 8963 12470
Neuroticism 080 033 596 1575
Dysfunctional Attitudes -052 051 -106 1575
Dysfunctional Attitudes times Stress 002 001 774 12470
______________________________________________________________________
Note Time 1 CES-D = Time 1 Center for Epidemiological Studies Depression Scale
Stress = Within-Subject Fluctuations in General Academic Social Hassles Scale for
Students (GASHSS) scores during the follow-up interval Neuroticism = NEO Five
Factor Inventory Neuroticism subscale Dysfunctional Attitudes = Dysfunctional
Attitudes Scale Time 1 MASQ = Time 1 Mood and Anxiety Symptom Questionnaire
Overall Anxiety subscale p lt 05 p lt 01 p lt 001
32
FIGURES
Figure 1 Predicted slope of the relationship between stress and depressive
symptoms (left panel) and anxious symptoms (right panel) as a function of
dysfunctional attitudes
20
25
30
Low High
Pre
dic
ted
CE
S-D
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
25
30
35
40
Low High
Pre
dic
ted
MA
SQ
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
Intercept Intercept
28
Tanaka N Uji M Hiramura H Chen Z Shikai N amp Kitamura T (2006)
Cognitive patterns and depression Study of a Japanese university student
population Psychiatry and Clinical Neuroscience 60 358-364
Taylor R E (2001) Death of neurasthenia and its psychological reincarnation a study
of neurasthenia at the National Hospital for the Relief and Cure of the Paralysed
and Epileptic Queen Square London 1870ndash1932 British Journal of
Psychiatry 179 550ndash557
Weissman A N amp Beck A T (1978 April) Development and validation of the
Dysfunctional Attitudes Scale A preliminary investigation Paper presented at
the annual meeting of the Educational Research Association Toronto Canada
Xiang M Z (1986) Epidemiological study of neuroses in 12 regions (districts) of
China Chinese Journal of Neurology and Psychiatry 19 87-91
Xu JM (1987) Some issues in the diagnosis of depression in China Canadian
Journal of Psychiatry 32 368-370
Xu Y X (1994) About ICD-10 Journal of Clinical Psychology and Medicine 4 224-
226
Xu Z Li Z amp Wang Z (2007) Dysfunctional attitudes and cognitive bias in major
depressive disorder Chinese Mental Health Journal 21 488-491
Yan H Q (1989) The necessity of retaining the diagnostic concept of neurasthenia
Culture Medicine and Psychiatry 13 139-145
Yang H (2007) The Test of the Chinese version of Frost Multi-dimensional
Perfectionism Scale Chinese Mental Health Journal 21 97-100
Yang H amp Zhang X (2004) Perfectionism and mental health of college students
(2004) Chinese Mental Health Journal 18 647-648
Young D (1989) Neurasthenia and related problems Culture Medicine and
Psychiatry 13 131-138
Zhang D (1995) Depression and culture A Chinese perspective Canadian Journal of
Counseling 29 227ndash233
29
TABLE(S)
Table 1 Demographic Variables
Age 2011
Gender Male
Female
472
523
Parentsrsquo Marital Status Married
Divorced
Single
Remarried
938
23
18
20
Fatherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
Government Official
51
356
187
95
124
91
Motherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
122
406
144
76
134
Fatherrsquos Education Some Primary School
Primary School
Some High School
High School
University
29
139
222
403
137
Motherrsquos Education Some Primary School
Primary School
Some High School
High School
University
63
192
264
350
76
Only Child No
Yes
331
667
Monthly Income lt 1000 RMB
1000 ndash 1500 RMB
1500 ndash 2000 RMB
2000 ndash 3000 RMB
3000 ndash 4000 RMB
4000 ndash 5000 RMB
gt 5000 RMB
334
204
175
140
59
20
20
30
Table 2 Means Standard Deviations and Inter-correlations Between Time 1 Measures
__________________________________________________________________
1 2 3
__________________________________________________________________
1 Depressive Symptoms 2963 (780)
2 Anxious Symptoms 52 3753 (918)
3 Dysfunctional Attitudes 48 33 18120 (2304)
4 Neuroticism 63 42 53 3110 (712)
_________________________________________________________________________
Note Means and standard deviations (in parentheses) are on the diagonal Depressive
Symptoms = Center for Epidemiological Studies Depression Scale Anxious Symptoms
= Mood and Anxiety Symptom Questionnaire Overall Anxiety subscale Dysfunctional
Attitudes = Dysfunctional Attitudes Scale Neuroticism = NEO Five Factor Inventory
Neuroticism subscale p lt 01
31
Table 3 Dysfunctional Attitudes Predicting Within-Subject Fluctuations in CES-D
Scores (upper section) and MASQ Scores (lower section) during the Follow-Up
Interval
______________________________________________________________________
β SE F df
______________________________________________________________________
Time 1 CESD-D 297 026 12987 1572
Stress 005 000 10860 12459
Neuroticism 134 027 2518 1572
Dysfunctional Attitudes -055 040 -183 1572
Dysfunctional Attitudes times Stress 001 000 1078 12459
______________________________________________________________________
Time 1 MASQ 502 033 23158 1575
Stress 006 000 8963 12470
Neuroticism 080 033 596 1575
Dysfunctional Attitudes -052 051 -106 1575
Dysfunctional Attitudes times Stress 002 001 774 12470
______________________________________________________________________
Note Time 1 CES-D = Time 1 Center for Epidemiological Studies Depression Scale
Stress = Within-Subject Fluctuations in General Academic Social Hassles Scale for
Students (GASHSS) scores during the follow-up interval Neuroticism = NEO Five
Factor Inventory Neuroticism subscale Dysfunctional Attitudes = Dysfunctional
Attitudes Scale Time 1 MASQ = Time 1 Mood and Anxiety Symptom Questionnaire
Overall Anxiety subscale p lt 05 p lt 01 p lt 001
32
FIGURES
Figure 1 Predicted slope of the relationship between stress and depressive
symptoms (left panel) and anxious symptoms (right panel) as a function of
dysfunctional attitudes
20
25
30
Low High
Pre
dic
ted
CE
S-D
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
25
30
35
40
Low High
Pre
dic
ted
MA
SQ
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
Intercept Intercept
29
TABLE(S)
Table 1 Demographic Variables
Age 2011
Gender Male
Female
472
523
Parentsrsquo Marital Status Married
Divorced
Single
Remarried
938
23
18
20
Fatherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
Government Official
51
356
187
95
124
91
Motherrsquos Job Unemployed
Farmer
Worker
Small Business
Professional
122
406
144
76
134
Fatherrsquos Education Some Primary School
Primary School
Some High School
High School
University
29
139
222
403
137
Motherrsquos Education Some Primary School
Primary School
Some High School
High School
University
63
192
264
350
76
Only Child No
Yes
331
667
Monthly Income lt 1000 RMB
1000 ndash 1500 RMB
1500 ndash 2000 RMB
2000 ndash 3000 RMB
3000 ndash 4000 RMB
4000 ndash 5000 RMB
gt 5000 RMB
334
204
175
140
59
20
20
30
Table 2 Means Standard Deviations and Inter-correlations Between Time 1 Measures
__________________________________________________________________
1 2 3
__________________________________________________________________
1 Depressive Symptoms 2963 (780)
2 Anxious Symptoms 52 3753 (918)
3 Dysfunctional Attitudes 48 33 18120 (2304)
4 Neuroticism 63 42 53 3110 (712)
_________________________________________________________________________
Note Means and standard deviations (in parentheses) are on the diagonal Depressive
Symptoms = Center for Epidemiological Studies Depression Scale Anxious Symptoms
= Mood and Anxiety Symptom Questionnaire Overall Anxiety subscale Dysfunctional
Attitudes = Dysfunctional Attitudes Scale Neuroticism = NEO Five Factor Inventory
Neuroticism subscale p lt 01
31
Table 3 Dysfunctional Attitudes Predicting Within-Subject Fluctuations in CES-D
Scores (upper section) and MASQ Scores (lower section) during the Follow-Up
Interval
______________________________________________________________________
β SE F df
______________________________________________________________________
Time 1 CESD-D 297 026 12987 1572
Stress 005 000 10860 12459
Neuroticism 134 027 2518 1572
Dysfunctional Attitudes -055 040 -183 1572
Dysfunctional Attitudes times Stress 001 000 1078 12459
______________________________________________________________________
Time 1 MASQ 502 033 23158 1575
Stress 006 000 8963 12470
Neuroticism 080 033 596 1575
Dysfunctional Attitudes -052 051 -106 1575
Dysfunctional Attitudes times Stress 002 001 774 12470
______________________________________________________________________
Note Time 1 CES-D = Time 1 Center for Epidemiological Studies Depression Scale
Stress = Within-Subject Fluctuations in General Academic Social Hassles Scale for
Students (GASHSS) scores during the follow-up interval Neuroticism = NEO Five
Factor Inventory Neuroticism subscale Dysfunctional Attitudes = Dysfunctional
Attitudes Scale Time 1 MASQ = Time 1 Mood and Anxiety Symptom Questionnaire
Overall Anxiety subscale p lt 05 p lt 01 p lt 001
32
FIGURES
Figure 1 Predicted slope of the relationship between stress and depressive
symptoms (left panel) and anxious symptoms (right panel) as a function of
dysfunctional attitudes
20
25
30
Low High
Pre
dic
ted
CE
S-D
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
25
30
35
40
Low High
Pre
dic
ted
MA
SQ
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
Intercept Intercept
30
Table 2 Means Standard Deviations and Inter-correlations Between Time 1 Measures
__________________________________________________________________
1 2 3
__________________________________________________________________
1 Depressive Symptoms 2963 (780)
2 Anxious Symptoms 52 3753 (918)
3 Dysfunctional Attitudes 48 33 18120 (2304)
4 Neuroticism 63 42 53 3110 (712)
_________________________________________________________________________
Note Means and standard deviations (in parentheses) are on the diagonal Depressive
Symptoms = Center for Epidemiological Studies Depression Scale Anxious Symptoms
= Mood and Anxiety Symptom Questionnaire Overall Anxiety subscale Dysfunctional
Attitudes = Dysfunctional Attitudes Scale Neuroticism = NEO Five Factor Inventory
Neuroticism subscale p lt 01
31
Table 3 Dysfunctional Attitudes Predicting Within-Subject Fluctuations in CES-D
Scores (upper section) and MASQ Scores (lower section) during the Follow-Up
Interval
______________________________________________________________________
β SE F df
______________________________________________________________________
Time 1 CESD-D 297 026 12987 1572
Stress 005 000 10860 12459
Neuroticism 134 027 2518 1572
Dysfunctional Attitudes -055 040 -183 1572
Dysfunctional Attitudes times Stress 001 000 1078 12459
______________________________________________________________________
Time 1 MASQ 502 033 23158 1575
Stress 006 000 8963 12470
Neuroticism 080 033 596 1575
Dysfunctional Attitudes -052 051 -106 1575
Dysfunctional Attitudes times Stress 002 001 774 12470
______________________________________________________________________
Note Time 1 CES-D = Time 1 Center for Epidemiological Studies Depression Scale
Stress = Within-Subject Fluctuations in General Academic Social Hassles Scale for
Students (GASHSS) scores during the follow-up interval Neuroticism = NEO Five
Factor Inventory Neuroticism subscale Dysfunctional Attitudes = Dysfunctional
Attitudes Scale Time 1 MASQ = Time 1 Mood and Anxiety Symptom Questionnaire
Overall Anxiety subscale p lt 05 p lt 01 p lt 001
32
FIGURES
Figure 1 Predicted slope of the relationship between stress and depressive
symptoms (left panel) and anxious symptoms (right panel) as a function of
dysfunctional attitudes
20
25
30
Low High
Pre
dic
ted
CE
S-D
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
25
30
35
40
Low High
Pre
dic
ted
MA
SQ
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
Intercept Intercept
31
Table 3 Dysfunctional Attitudes Predicting Within-Subject Fluctuations in CES-D
Scores (upper section) and MASQ Scores (lower section) during the Follow-Up
Interval
______________________________________________________________________
β SE F df
______________________________________________________________________
Time 1 CESD-D 297 026 12987 1572
Stress 005 000 10860 12459
Neuroticism 134 027 2518 1572
Dysfunctional Attitudes -055 040 -183 1572
Dysfunctional Attitudes times Stress 001 000 1078 12459
______________________________________________________________________
Time 1 MASQ 502 033 23158 1575
Stress 006 000 8963 12470
Neuroticism 080 033 596 1575
Dysfunctional Attitudes -052 051 -106 1575
Dysfunctional Attitudes times Stress 002 001 774 12470
______________________________________________________________________
Note Time 1 CES-D = Time 1 Center for Epidemiological Studies Depression Scale
Stress = Within-Subject Fluctuations in General Academic Social Hassles Scale for
Students (GASHSS) scores during the follow-up interval Neuroticism = NEO Five
Factor Inventory Neuroticism subscale Dysfunctional Attitudes = Dysfunctional
Attitudes Scale Time 1 MASQ = Time 1 Mood and Anxiety Symptom Questionnaire
Overall Anxiety subscale p lt 05 p lt 01 p lt 001
32
FIGURES
Figure 1 Predicted slope of the relationship between stress and depressive
symptoms (left panel) and anxious symptoms (right panel) as a function of
dysfunctional attitudes
20
25
30
Low High
Pre
dic
ted
CE
S-D
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
25
30
35
40
Low High
Pre
dic
ted
MA
SQ
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
Intercept Intercept
32
FIGURES
Figure 1 Predicted slope of the relationship between stress and depressive
symptoms (left panel) and anxious symptoms (right panel) as a function of
dysfunctional attitudes
20
25
30
Low High
Pre
dic
ted
CE
S-D
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
25
30
35
40
Low High
Pre
dic
ted
MA
SQ
sco
re
Level of stress
High dysfunctional attitudes
Low dysfunctional attitudes
Intercept Intercept
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