Measuring repetitive thinking in Iran: Psychometric properties of Persian version of Perseverative Thinking Questionnaire

Personality and Individual Differences 148 (2019) 101–109

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Measuring repetitive thinking in Iran: Psychometric properties of Persian version of Perseverative Thinking Questionnaire

T

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Maryam Kamia, Reza Moloodib,c, , Mahdi Mazidid, Thomas Ehringe, Amin Khaje Mansoorif, Mojgan Bakhshi Nodooshang, Zahra Mazinania, Mohammad-Reza Molavia, Fereshte Momenia a

Department of Clinical Psychology, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran Substance Abuse and Dependence Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran c Department of Psychiatry, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran d Center for Advancement of Research on Emotion, School of Psychological Science, The University of Western Australia, Crawley, Australia e Department of Psychology, LMU Munich, Munich, Germany f Department of School Psychology, Faculty of Psychology and Education, University of Tehran, Iran. g Department of Clinical Psychology, Islamic Azad University, Yazd Branch, Yazd, Iran. b

A R T I C LE I N FO

A B S T R A C T

Keywords: Repetitive Negative Thinking Perseverative Thinking Questionnaire Psychometric properties

Objective: The aim of the present study was to evaluate the factor structure as well as the validity and reliability of the Persian version of Perseverative Thinking Questionnaire (PTQ). Method: Data were collected in three samples. A student sample (N = 894) completed the Generalized Anxiety Disorder Scale (GAD-7), the Difficulties in Emotion Regulation Scale (DERS) and the PTQ. Participants from the general population (N = 252) filled out a battery of questionnaires including the Penn State Worry questionnaire (PSWQ), the Ruminative response scale (RRS), the Depression, Anxiety, Stress Scale-21 (DASS-21) and the PTQ. Finally, psychotic inpatients (N = 193) filled in the PTQ, only. Results: Confirmatory factor analysis indicated that the second-order model with three lower-order factors model showed adequate fit with the data in all three samples. In addition, the PTQ had good internal consistency and test-retest reliability. As to validity, the PTQ scores showed positive correlation with the PSWQ, RRS, DERS, GAD-7 and DASS-21. In addition, the PTQ was found to discriminate the clinical sample from student and general population samples. Conclusions: The findings provided preliminary support for validity and reliability of the scores derived from Persian version of the PTQ.

1. Introduction 1.1. Repetitive Negative Thinking as transdiagnostic process Repetitive Negative Thinking (RNT) is an intrusive cognitive activity with negative content that is perceived as uncontrollable. Although repetitive thinking is a common cognitive process, there is extensive evidence on the dysfunctional effects of RNT on mood (Watkins, 2008). Importantly, RNT has been identified as a risk factor for the development and maintenance of mood disorders, anxiety disorders, eating disorders, sleep disorders, psychotic disorders, alcoholic use disorders, and borderline personality disorder (Ehring & Watkins, 2008). This makes RNT a promising target for both research and treatment of emotional disorders. Therefore, reliable and valid assessment instruments for RNT are needed. ⁎

The first generation of research conceptualized RNT in a contentspecific and disorder-specific way. For instance, rumination has been studied extensively in the context of depressive disorders (NolenHoeksema, Wisco, & Lyubomirsky, 2008), whereas research on worry has mostly focused on generalized anxiety disorder (Borkovec & Inz, 1990). In addition, post-event processing was considered as a maintenance factor for social anxiety disorder (Dannahy & Stopa, 2007). Various specific measures have been developed to assess RNT in each disorder. For example, the Ruminative Response Scale (RRS) was designed to assess depressive rumination (Treynor, Gonzalez, & NolenHoeksema, 2003). The Penn State Worry Questionnaire (PSWQ) is frequently used to measure worry in studies on GAD (Meyer, Miller, Metzger, & Borkovec, 1990), and the Post-Event Processing Questionnaire (PEPQ) has been developed specifically to assess RNT in social anxiety disorder (McEvoy & Kingsep, 2006).

Corresponding author. E-mail address: [email protected] (R. Moloodi).

https://doi.org/10.1016/j.paid.2019.05.012 Received 18 February 2019; Received in revised form 11 May 2019; Accepted 11 May 2019 Available online 29 May 2019 0191-8869/ © 2019 Elsevier Ltd. All rights reserved.

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symptom levels of anxiety and depression, verifying the predictive validity of the scale. Finally, the Turkish version of the PTQ and its subscales showed satisfactory internal consistency (ranged from .74 to .95).

In the past decade, researchers have increasingly highlighted that RNT displays common process characteristics across psychopathologies, whereby only the content of the RNT appears to be disorder-specific (Ehring et al., 2011; Ehring & Watkins, 2008; Harvey, Watkins, & Mansell, 2004). Ehring et al. (2011) summarized four supporting lines of evidence for this view. First, different questionnaires assessing RNT are strongly associated with severity of both depression and anxiety symptoms (De Jong-Meyer, Beck, & Riede, 2009; Fresco, N. Frankel, Mennin, Turk, & G.Heimberg, 2002; McEvoy, Watson, Watkins, & Nathan, 2013; Spinhoven, Drost, van Hemert, & Penninx, 2015). Second, a comparison between characteristics of worry and rumination showed that they are similar processes with few differences (Spinhoven et al., 2015; Watkins, 2008; Watkins, Moulds, & Mackintosh, 2005). Third, results from experimental studies indicate that the induction of different type of RNT lead to an increase of both depression and anxiety symptoms (Blagden & Craske, 1996; McLaughlin, Borkovec, & Sibrava, 2007). Finally, there is evidence that RNT shows similar process characteristics across different disorders, in that it can be described as a verbal and abstract process that is associated with negative and positive metacognitions (Ehring & Watkins, 2008).

1.4. Repetitive negative thinking in psychotic disorders Cognitive-behavioral models of paranoia emphasize an important role of perseverative thinking styles, such as worry and rumination, in the development and maintenance of psychotic beliefs (e.g., Freeman, Garety, Kuipers, Fowler, & Bebbington, 2002). This is supported by evidence from a number of empirical studies showing an association between repetitive negative thinking and paranoia (Simpson, MacGregor, Cavanagh, & Dudley, 2012; Startup, Freeman, & Garety, 2007). In addition, an experimental study on non-clinical participants showed that rumination led to maintained levels of paranoia, while distraction resulted in a reduction of levels of paranoia (Martinelli, Cavanagh, & Dudley, 2013). Lastly, one study explored the validity and reliability of the PTQ among patients with persecutory delusions (Cernis et al., 2016). Results indicated that the second-order singlefactor model with three lower-order factors of the PTQ fit with data of the clinical sample. The PTQ also showed good internal consistency (ranged from .92 to .96). Importantly, patients with persecutory delusions got higher scores in PTQ total and its subscales than non-clinical sample.

1.2. Perseverative Thinking Questionnaire as a measure of Repetitive Negative Thinking Based on the abovementioned findings, Ehring et al. (2011) developed the 15-item Perseverative Thinking Questionnaire (PTQ) to assess RNT as a transdiagnostic process. The PTQ was based on the following working definition: “Repetitive negative thinking … is a style of thinking about one's problems (current, past, or future) or negative experiences (past or anticipated) that shows three key characteristics: (1a) The thinking is repetitive, (1b) it is at least partly intrusive, (1c) and it is difficult to disengage from” (Ehring et al., 2011, p. 226). In addition, RNT is suggested to be characterized by two additional features, in that individuals experience the RNT as an unproductive activity and that RNT reduces mental capacity.

1.5. Repetitive negative thinking in the Iranian population A number of studies have shown a relationship between repetitive negative thinking and psychopathology, including depression and anxiety (Abdi, Chalabianloo, & Joorbonyan, 2016; Akbari, Roshan, Fata, Shabani, & Zarghami, 2014; Mohammadkhani, Pourshahbaz, Kami, Mazidi, & Abasi, 2016). In addition, a single case series study on three Iranian patients with comorbid anxiety and depressive disorders showed that a 12 sessions transdiagnostic treatment based on repetitive negative thinking could be effective in reduction of anxiety and depression symptoms (Akbari et al., 2015). Thus, it appears sensible to assume that there is a cross-cultural similarity between Iranian and western populations in terms of the role of repetitive negative thinking in emotional disorders. However, to our knowledge, no published study has yet tested the construct of the PTQ as well as its validity and relaibilty in eastern cultures, especially in Iranian population.

1.3. Validity and reliability of the PTQ Ehring et al. (2011) conducted confirmatory factor analyses of both German and English versions of the PTQ showing that a second-order single-factor model with three lower-order factors (including Core Features of RNT, Unproductiveness of RNT, and Mental Capacity Captured by RNT) showed the best fit with data of an internet sample, a general population sample and a clinical sample. In addition, the PTQ and its subscales significantly correlated with the Response Style Questionnaire (RSQ) (r = .72), PSWQ (r = .70), Rumination Scale (r = .62), and Inventory of Depressive Symptomatology scores (r = .58), confirming its validity. The PTQ and its subscales also indicated adequate to good internal consistency (ranged from .77 to 0.95) and temporal stability (r = .66). Similarly, Ehring et al. (2011) also found for the Dutch PTQ that the second-order single-factor model with three lower-order factors show good fit with the data. In addition, the Dutch version of the PTQ had satisfactory reliability and convergent validity (Ehring, Raes, Weidacker, & Emmelkamp, 2012). Devynck et al. (2017) reported that in French community sample the second-order single-factor model with three lower-order factors fit with the data. PTQ and its subscales significantly correlated with State Trait Anxiety Inventory (r = .63), PSWQ (r = .52), and RRS (r = .43). The French version of the PTQ showed good internal consistency (ranged from .82 to .89). AltanAtalay and Saritas-Atalar (2018) investigated validity and relaibilty of the Turkish version of the PTQ in an internet sample and a student sample. They reported that the original model of the PTQ fit well with their data. PTQ scores were siginficantly associated with the RRS (r = .57), the PSWQ (r = .62), and the White Bear Suppression Inventory (r = .69). In addition, PTQ scores substantially predicted

1.6. Aim of the present study Although it appears that both factor structure and psychometric properties of the PTQ are replicable cross-culturally, there is no published study examining the PTQ in Eastern cultures. Thus, the primary aim of the study was to evaluate the psychometric properties of a Persian version of the PTQ, using Confirmatory Factor Analysis (CFA) to test the factor structure, as well as examining convergent validity, discriminant validity, internal consistency, and temporal stability. Based on the literature, we expected that second-order model with three lower-order factors model of the PTQ fit with data of student, general population, and clinical sample. We hypothesized that the PTQ and its subscales would demonstrate positive significant correlations with, ruminative thinking, Worry, emotion dysregulation, and depression, anxiety and stress symptoms. Finally, we expected to find evidence of high discriminant validity when comparing three student and general population samples to clinical sample. 2. Method 2.1. Participants Three samples of participants were recruited. The student sample included 1000 undergraduate and postgraduate university students 102

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Item 1 Item 2

SRW=.61 SRW = .69

Item 3 SRW = .72

Item 6

SRW= .70 SRW = .66

Item 7

Core feature of RNT

SRW = .77 SRW = .75

Item 8

SRW = .63

Item 11

SRW = .90 SRW = .71

Item 12

Item 13

PTQ SRW = .88

Item 4 SRW = .66

Item 9

SRW = .67

Unproducve of RNT

SRW = .49

Item 14

SRW = .81 Item 5 SRW = .62

Item 10 Item 15

SRW = .72 SRW = .70

Mental capacity captured by RNT

Fig. 1. PTQ factor structure in the student sample. SRW = Standardized Regression Weight, PTQ = Perseverative Thinking Questionnaire.

selected via convenience sampling. The mean age of the general population sample was 33.66 (SD = 9.27, range: 18 to 57). One hundred ninety participants (76.19%) were married and 62 (24.60%) participants were single. In terms of education, 130 (51.58%) participants completed high school, 44 (17.46%) completed college, and 78 (30.95%) were bachelor or higher. The clinical sample consisted of 200 inpatients meeting DSM-IV-TR criteria for schizophrenia disorder, delusion disorder or schizoaffective disorder who were treated at Razi Educational and Therapeutic Psychiatric Center, Tehran, Iran. Patients who were on a stable dose of pharmacotherapy, did not received electroconvulsive therapy (ECT), and were aöready in the remission phase of their disorder were recruited. Seven patients had missing data on > 10% of the items and

from Shahid Beheshti University, Tehran, Iran recruited via convenience sampling. One hundred and six students had missing data on > 10% of the items and were therefore excluded from analyses. The final student sample thus consisted of 894 students (465 men, 429 women). The mean age of the students was 23.06 (SD = 4.45, range: 18 to 49). Six hundred seventy-nine were undergraduate and 215 were postgraduate students. The majority of participants (n = 768; 85.9%) were single, and a minority (n = 126; 14.09%) were married. In terms of ethnicity, 358 participants (40%) identified themselves as Pars, 201 (22.48%) as Turkish, 104 (11.63%) as Lur, 157 (17.56%) as Kurd, 24 (2.68%) as Turkmen, and 50 (5.59%) as other. The general population sample consisted of 252 subjects (125 men, 112 women) from the general population of Shiraz, Iran. They were

103

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Item 1 Item 2

SRW = .57 SRW = .68

Item 3 Item 6 Item 7

SRW = .70 SRW = .79 SRW = .73

Core feature of RNT

SRW = .78

Item 8 SRW = .73

Item 11

SRW = .66

Item 12

SRW = .71

SRW = .91

Item 13

SRW = .82 Item 4 Item 9

SRW = .61 SRW = .62

PTQ

Unproducve of RNT

SRW = .36

Item 14 SRW = .86 Item 5 SRW = .56

Item 10

SRW = .62 SRW = .62

Mental capacity captured by RNT

Item 15 Fig. 2. PTQ: factor structure in the general population. SRW = Standardized Regression Weight, PTQ = Perseverative Thinking Questionnaire.

subscales: core characteristics of repetitive thinking (9 items; e.g., “The same thoughts keep going through my mind again and again”), unproductiveness (3 items, e.g., “I think about many problems without solving of them”), and RNT capturing mental capacity (3 items, e.g., “I can't do anything else while thinking about my problems”). Participants were asked to answer the items using a five point Likert scale (ranging from 0 = never to 4 = almost always). As mentioned earlier, the original version of the PTQ has been shown to possess good psychometric properties (Ehring et al., 2011).

were therefore excluded from analyses (N = 193, men = 149, women = 44). The mean age of the patients was 35.41 (SD = 9.81, range: 18 to 59). Ninety-one (47.15%) participants were married and 102 (52.85%) were single. One hundred twenty-three participants (63.73%) completed high school, 45 (23.31%) participants completed college, 25 (12.95%) were bachelor or higher.

2.2. Material 2.2.1. Perseverative Thinking Questionnaire (PTQ) The PTQ (Ehring et al., 2011) is a 15-item scale that includes 3 104

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Item 1 SRW = .67

Item 2 SRW = .63

Item 3

Core feature of RNT

SRW = .72

SRW = .75

Item 6

SRW = .68

Item 7 SRW = .70

Item 8 SRW = .76

Item 11

SRW = .92

SRW = .72

Item 12

SRW = .76

Item 13

SRW = .87

PTQ

Item 4 SRW = .54

Item 9 Item 14

SRW = .62

Unproducve of RNT

SRW = .54

SRW = .82

Item 5 Item 10 Item 15

SRW= .55 SRW = .69

Mental capacity captured by RNT

SRW = .76

Fig. 3. PTQ factor structure in the inpatient samples. SRW = Standardized Regression Weight, PTQ = Perseverative Thinking Questionnaire.

worry. Participants are asked to rate items on a five-point Likert scale (ranging from 1 = not at all typical to 5 = very typical). The PSWQ is also used to screen generalized anxiety disorder. Several studies have shown high validity and reliability of the PSWQ in Western as well as Iranian populations (Borjali, Sohrabi, Dehshiri, & Golzari, 2010; Zhong, Wang, Li, & Liu, 2009). In the current study, only the general population sample completed the PSWQ. Internal consistency of the questionnaire was .85.

Table 1 McDonald's Omega coefficient of the Perseverative Thinking Questionnaire and its subscales in the student, general population, and clinical samples.

PTQ total Core Feature of RNT Unproductivity of RNT Mental Capacity Captured by RNT

Student sample (n = 894)

General population sample (n = 252)

Clinical sample (n = 193)

.95 .90 .74 .73

.92 .90 .73 .74

.94 .90 .74 .71

2.2.3. Depression Anxiety and Stress Scale-21 (DASS-21) The DASS-21 is a self-report scale consisted of three subscales which assess symptoms of depression (e.g., “I felt that I had nothing to look forward to”), anxiety (e.g., “I was aware of dryness of my mouth”), and stress (e.g., “I found it hard to wind down”) over the past week (Lovibond & Lovibond, 1995). Participants were asked to answer the items using a 0 (“did not apply to me at all”) to 3 (“apply to me very

PTQ = Perseverative Thinking Questionnaire; RNT = Repetitive Negative Thinking;

2.2.2. Penn State Worry Questionnaire (PSWQ) The PSWQ is 16-item self-report questionnaire developed by Meyer et al. (1990) in order to assess severe, excessive, and uncontrollable 105

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regulation disability (Gratz & Roemer, 2004). It contains six subscales: Non-acceptance of Emotional Responses, Difficulties Engaging in Goal Directed Behavior, Impulse Control Difficulties, Lack of Emotional Awareness, Limited Access to Emotion Regulation Strategies, Lack of Emotional Clarity. Items are rated on a 5-point scale (1 = almost never to 5 = almost always). Gratz and Roemer (2004) showed that the scale has good reliability, and construct and predictive validity. Kermani and Talepasand (2018) indicated that DERS has good psychometric properties in Iranian population. In the current study, the student sample answered the DERS, and its internal consistency was 0.88.

Table 2 Convergent validity of the PTQ.

Student sample GAD-7 DERS General population DASS-21Depression DASS-21-Anxiety DASS-21-Distress RRS PSWQ

PTQ total score

Core characteristic of RNT

Unproductivity of RNT

Mental capacity captured by RNT

.53 .50

.51 .64

.45 .59

.47 .65

sample .59

.54

.43

.48

.55 .64 .59 .57

.51 .59 .58 .54

.44 .55 .49 .46

.50 .55 .50 .52

2.3. Procedure The English version of PTQ was translated into Persian by the second author and back-translated into English by an independent translator. Seven assistant/or associate professors of clinical psychology who were experts in cognitive behavior therapy and native in Persian checked the translation to ensure the fluency and content validity of the items. The psychologists found the translated version of the PTQ items and its instruction comprehensible and friendly used. The back-translation was checked by the developer of the original PTQ to confirm equivalence of the two language versions. The Persian version of the PTQ would be available through contact with corresponding author. In order to gather data from the student sample, the second and third authors (who were M.Sc-level clinical psychologist) recruited participants from among students attending classes at university. They explained the purpose and procedure of the study to the students. Those who agreed to participate in the study first provided written informed consent and then completed the PTQ, DERS, and GAD-7. After 3 weeks, 66 of these students completed the PTQ a second time. For the general population sample, the 5th and 6th authors (who were M.Sc.-levels clinical psychologists) recruited participants from a population of visitors in health centers, parks, and cultural houses of Shiraz, Iran via convenience sampling. They first explained the purpose and procedure of the study, and those who agreed to take part first provided written informed consent and then were asked to complete the RRS, PSWQ, DASS-21 and PTQ. For the inpatient sample, the 7th, 8th authors (who were M.Sc-level clinical psychologists), and the 9th author (an assistant professor in clinical psychology) explored medical records and identified patients with schizophrenia disorder, delusion disorder and schizoaffective disorder based on the medical records. Then, the assessors approached to the patients and explained the purpose and procedure of the study. Those who signed a written consent to participate in the study were instructed about the PTQ and requested to complete it. The research procedure was approved by Ethical Review Board of University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.

PTQ = Perseverative Thinking Questionnaire; RNT = Repetitive Negative Thinking; GAD-7 = Generalized Anxiety Disorder Scale; DERS = Difficulties in Emotion Regulation Scale; DASS = Depression Anxiety and Stress Scale; RRS = Ruminative Responses Scale; PSWQ = Penn State Worry Questionnaire. All correlation coefficient was significant at p < .001.

much”) scale (Lovibond & Lovibond, 1995). The Persian version of the DASS-21 showed acceptable construct and convergent validity as well as internal consistency (Asghari Moghaddam, Saed, Dibajnia, & Zangeneh, 2008). In the current study, only the general population sample completed the PSWQ. Internal consistency of the scale and its subscales were as follow: DASS-21 total = .91; Depression = .87; Anxiety = .85; Stress = 0.82. 2.2.4. The Generalized Anxiety Disorder Scale (GAD-7) The GAD-7 scale is a 7-item scale that was developed by Spitzer, Kroenke, Williams, and Lowe (2006) to screen and assess the severity of generalized anxiety. Participant were asked to determine how often they experience generalized anxiety symptoms during the last 2 weeks using a four point Likert scale (ranging from 0 = not at all to 3 = nearly every day. The original study showed good reliability and criterion, factorial, and procedural validity for the measure. In addition, good psychometric properties of have been demonstrated in English, Spanish (Mills et al., 2014) and Persian populations (Naeinian, Shaeiri, Sharif, & Hadian, 2011; Omani-Samani, Maroufizadeh, Ghaheri, & Navid, 2018). In the current study, the student sample completed the GAD-7 and its internal consistency was .88. 2.2.5. Ruminative Response Scale (RRS) The RRS is a 22-item scale to assess ruminative thinking (NolenHoeksema & Morrow, 1991). Items are rated on a 4-point scale (1 = almost never to 4 = almost always). Validity and reliability of the English version (Treynor et al., 2003) and Persian version was established (Farnam, Bakhshipour Roodsari, Mansouri, & Aliloo, 2012). The general population sample filled out the RRS and its internal consistency was .91.

2.4. Data analysis Data Analysis was performed using SPSS-24 and AMOS-23. In order to test the second-order model with three lower-order factors, Confirmatory Factor Analysis (CFA) with maximum likelihood estimation and fixing a factor loading to 1 method was performed using AMOS 23. We checked multivariate normality with skewness and kurtosis. All

2.2.6. Difficulties in Emotion Regulation Scale (DERS) The DERS is a 36-item scale that measures subjective emotion

Table 3 Comparison of the student, general population and inpatient samples on PTQ scores.

PTQ total score Core Characteristic of RNT Unproductivity of RNT Mental Capacity Captured by RNT

Student (St) Mean (SD)

General Population (GP) Mean (SD)

Inpatient (Ip) Mean (SD)

F

P

Tamhane's T2

Effect size

24.91 (11.43) 14.96 (7.10) 5.10 (2.72) 4.84 (2.70)

22.60 (11.09) 13.83 (7.25) 4.49 (2.49) 4.27 (2.55)

27.31 (15.02) 16.96 (9.36) 5.06 (3.32) 5.27 (3.37)

8.54 9.58 4.80 7.35

0.0001 0.0001 0.008 0.001

GP < St < Ip GP = St < Ip GP < St GP = Ip Ip = St GP < St = Ip

0.03 0.04 0.02 0.03

PTQ = Perseverative Thinking Questionnaire, RNT = repetitive negative thinking. 106

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scores of PSWQ, RRS, and DASS-21 (Table 2).

items in the three samples showed normality. Goodness-of-fit indices were evaluated against the following criteria: Chi-2 with an acceptable ratio < 5 as acceptable ratio (Wheaton, Muthen, Alwin, & Summers, 1977), as well as Goodness-of-Fit Index (GFI), Adjusted Goodness-of-Fit Index (AGFI), Incremental Fit Index (IFI), Comparative Fit Index (CFI) with a cut-off ≥ .90 as acceptable (Hooper, Coughlan, & Mullen, 2008). We also considered the Root Mean Square Error of Approximation (RMSEA) with value ≤ .08 indicating adequate fit (Hooper et al., 2008). Since the Tau equivalence assumption violated, we used McDonald's Omega to estimate internal consistency. Test-retest reliability as well as convergent validity were examined using Pearson correlation coefficient. Discriminant validity was investigated using univariate analysis of variance between the student, general population and clinical samples with Tamhane's T2 post-hoc test. We used a significance level of .05 (one-tailed test).

3.5. Discriminant validity

3. Result

In order to estimate discriminant validity of the PTQ, scores of student sample (N = 894), general population sample (N = 252), and patients (N = 193) were compared through ANOVA (Table 2). The result showed that the inpatient sample scored significantly higher on the PTQ total than the student and general population samples. Also, students got higher scores on the PTQ total than the general population. Inpatient and student samples significantly scored higher than the general population sample on the core characteristics of RNT, and mental capacity captured by RNT subscales than general population sample. Finally, students got higher scores than the general population sample on the unproductivity of RNT subscale. However, the inpatient sample did not differ with student and general population samples on the unproductivity of RNT subscale (Table 3).

3.1. Confirmatory factor analysis

4. Discussion

CFA was used to test the second-order model with three lower-order factors model of the PTQ based on the original model of the PTQ Ehring et al. (2011) works. The goodness-of-fit indices validated that the second-order model with three lower-order factors showed adequate fit with the data of students (x2 (N = 894) = 3.95, p = .0001, GFI = 0.95, AGFI = 0.93, IFI = 0.96, TLI = 0.95, CFI = 0.96, RMSEA = 0.05, 90%CI [0.05, 0.06]) (Fig. 1). Similar results were found in the general population. The second-order model with three lower-order factors model of the PTQ provided adequate fit with the data of the general population (x2 (N = 252) = 1.99, p = .0001, GFI = 0.91, AGFI = 0.88, IFI = 0.95, TLI = 0.94, CFI = 0.95, RMSEA = 0.06, 90%CI [0.04, 0.07]) (Fig. 2). Finally, the CFA results indicated that the second-order model with three lower-order factors model of the PTQ fit with the data of inpatient sample (x2 (N = 193) = 1.69, p = .0001, GFI = 0.91, AGFI = 0.88, IFI = 0.96, TLI = 0.94, CFI = 0.96, RMSEA = 0.06, 90%CI [0.04, 0.07]) (Fig. 3).

To our knowledge, this is the first study investigating the validity and reliability of the Perseverative Thinking Questionnaire in an Eastern culture, Iran. Psychometric properties of the Persian version of the PTQ was examined in three separate samples (total N = 1339) and results provided first evidence for relatively good psychometric properties of the Persian PTQ. In addition, the factor structure of the PTQ found in earlier research could be replicated for this language version, too. Specifically, CFA results showed that the second-order model with three lower-order factors model of the PTQ provided adequate fit with the data in the student, general population and inpatient samples. This corresponds well with the proposed theory and the working definition of PTQ (Ehring et al., 2011). Also, this finding was in line with previous factor analytic studies which indicated that a second-order model with three lower-order factors model of the PTQ showed a good fit with the data in German and English populations (Ehring et al., 2011), in a Dutch sample (Ehring et al., 2012), a French population (Devynck et al., 2017), a Turkish population (Altan-Atalay & Saritas-Atalar, 2018), and a clinical English-speaking sample (Cernis et al., 2016). The higherorder factor reflects the overall construct of RNT, while the three lowerorder factors capture more specific characteristics of the RNT. In sum, the findings support the structural validity of the Persian version of the PTQ. Internal consistency of the PTQ total and its subscales were adequate to good (ranged from .71 to .95) and consistent with findings reported by previous studies on other language versions of the PTQ (Altan-Atalay & Saritas-Atalar, 2018; Devynck et al., 2017; Ehring et al., 2011). The PTQ showed high temporal stability in a 3-week timeframe (ranged from .70 to .82). These test-retest correlation coefficients were higher than those reported in Altan-Atalay and Saritas-Atalar (2018), and Ehring et al. (2011). The current findings also supported the convergent validity of the PTQ in three ways. First, PTQ scores were significantly associated with other measures of RNT in the general population (e.g. PSWQ and RRS). This finding is consistent with previous findings (Altan-Atalay & Saritas-Atalar, 2018; Cernis et al., 2016; Devynck et al., 2017; Ehring et al., 2011). Second, positive significant correlation between the PTQ and the Difficulties in Emotion Regulation Scale (DERS) in the student sample is in line with theories identifying RNT as a maladaptive cognitive emotion regulation strategy (Garnefski, Kraaij, & Spinhoven, 2001; Smith & Alloy, 2009). Papageorgiou and Wells (2001) discuss that individuals might utilize repetitive thinking to regulate their negative emotions by analyzing the situation, accessing to problem solving or processing of traumatic and negative information. RNT is also conceptualized as an avoidance strategy that prevent negative private experiences, but paradoxically exacerbate negative emotions (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996; Smith & Alloy, 2009). Third,

3.2. Internal consistency As shown in Table 1, in the student sample the McDonald's Omega coefficients of the PTQ total score and its three subscales were as follow: PTQ total = .95, Core Feature of RNT = .90, Unproductivity of RNT = .74, and Mental Capacity Captured by RNT = .73. In the general population, McDonald's Omega coefficients were as follow: PTQ total = .92, Core Feature of RNT = .90, Unproductivity of RNT = .73, and Mental Capacity Captured by RNT = .74. In the clinical sample, McDonald's Omega coefficients were as follow: PTQ total = .94, Core Feature of RNT = .90, Unproductivity of RNT = .74, and Mental Capacity Captured by RNT = .71. 3.3. Temporal stability In order to examine temporal stability, 66 participants from the student sample filled out the PTQ again after 3 weeks. The test-retest correlation was as follow: PTQ total score (r = .72; p < .001), Core Characteristics of RNT (r = .70; p < .001), Unproductiveness of RNT (r = .75; p < .001), RNT Capturing Mental Capacity (r = .81; p < .001). 3.4. Convergent validity In the student sample, the PTQ total and its subscales scores showed positive significant medium to large correlation with measures of generalized anxiety disorder (GAD-7) and difficulties in emotion regulation (DERS). In the sample of general population, the PTQ total and its subscales scores showed significant medium to large correlation with 107

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References

our results indicated that PTQ is associated with symptoms of GAD in a student sample, as well as depression, anxiety, and stress in the general population. These findings are in line with the literature which showed that RNT is a risk and maintaining factor of depression and anxiety disorders and predict severity of emotional disorders (Newby, Williams, & Andrews, 2014; Segerstrom, Tsao, Alden, & Craske, 2000; Topper, Emmelkamp, & Ehring, 2010; Topper, Emmelkamp, Watkins, & Ehring, 2017). Our results indicated that the PTQ and its core characteristic of RNT subscale were able to differentiate inpatients from general population and student samples. In line with earlier findings (e.g., Ehring et al., 2011), patient showed significantly higher PTQ scores than non-clinical groups with regard to the PTQ total score and the core characteristics of RNT. This supports the view that RNT as measured by the PTQ is related to psychopathology. Interestingly, results were slightly different for the two associated feature of RNT assessed with the PTQ. Specifically, the student sample reported higher unproductiveness of RNT as well as higher degree RNT capturing mental capacity than the general population sample; in addition, the student sample did not differ from the inpatient sample on these two subscales. One plausible explanation might be that students perceive their repetitive thinking more intrusive and useless because it decreases their cognitive functions (e.g. concentration and attention), which are necessary for academic achievement. Thus, due to the nature of the tasks they are faced with on a daily basis, they may be more aware of the dysfunctional effects of RNT on concentration and mental capacity than individuals from the general population. The current study shows a number of strengths, including the use of three different and adequately sized samples (student, general population, and inpatient samples). On the other hand, some limitations are noteworthy. First, a convenience sampling method was used and not all measures could be included in all samples. Second, the measures used in the student and general population samples were not counterbalanced. Although these samples completed a limited number of questionnaires, counterbalancing could prevent possible order effect. Third, temporal stability of the PTQ could only be assessed in the student sample. Fourth, the sole used of self-report instruments is another limitation of the study. Finally, the results of the current study are correlational and should not be considered as causal relationships. Thus, longitudinal studies would be logical next step to investigate the extent to which repetitive thinking predictors future psychopathology. Nevertheless, the current study provides important first evidence that the Persian version of the PTQ is a reliable and valid measure that can be used to assess RNT in Iran. Thus, Researchers and practitioners can use the PTQ to assess repetitive negative thinking of Iranian patients in research and clinical settings.

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Funding resource The study is supported by the University of Social Welfare and Rehabilitation Sciences, Tehran, Iran. The university had not a role in design, gathering and analyzing the data, and preparing manuscript.

Disclosure of Competing Interest The authors have no actual or potential conflicts of interest including any financial, personal or other relationships with other people or organizations within three years of beginning the work submitted that could inappropriately influence their work.

Acknowledgement The authors are gratefull to all participants. 108

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