Stress, cognitive fusion and comorbid depressive and anxiety symptomatology in dementia caregivers
Abstract
Comorbid depression and anxiety is linked to worse outcomes such as increased impairment, distress, and morbidity, as well as worse treatment outcomes. Transdiagnostic variables such as cognitive fusion are considered potential factors for explaining comorbidity. The aim of this study was to analyze the differences between symptom profiles of caregivers (comorbid, depressive, anxiety, and subclinical) in terms of demographic and contextual factors, stress variables, and cognitive fusion. Individual interviews were conducted with 553 caregivers of a relative with dementia. Sociodemographic variables, stressors, cognitive fusion, and depressive and anxiety symptoms were assessed. Caregivers were grouped into four symptom profiles, comorbid (n = 303), depressed (n = 40) anxiety (n = 86), and subclinical (n = 124), based on their depressive and anxiety symptoms. The likelihood of presenting a comorbid profile relative to the subclinical profile was higher in female caregivers. In addition, higher frequency of disruptive behaviors of the care recipient was a risk factor for presenting a comorbid profile relative to the other three profiles, and higher scores in cognitive fusion were a risk factor of comorbidity relative to the other profiles (anxiety, depressive, and subclinical). The findings suggest that the likelihood of presenting comorbid symptomatology is higher for female caregivers and those reporting higher levels of cognitive fusion and higher frequency of disruptive behaviors. These characteristics may describe a vulnerable profile of dementia family caregivers. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Previous studies within dementia caregiving have investigated the mediating or moderating role of experiential avoidance or cognitive fusion separately in the association between caregiving stressors and mental health outcomes.
“previous studies within dementia caregiving have investigated mediating or moderating role of experiential avoidance or cognitive fusion separately in the association between caregiving stressors and mental health outcomes (Barrera-Caballero et al., 2021; Mausbach et al., 2012; Romero-Moreno et al., 2016).”
From The role of experiential avoidance and cognitive fusion in the development of anxiety symptoms among family carers of people with dementia (2024) · cites this paper as Barrera-Caballero et al., 2021
Previous studies within dementia caregiving have separately investigated mediating roles of experiential avoidance or cognitive fusion in the association between caregiving stressors and mental health outcomes.
“Previous studies within dementia caregiving have separately investigated mediating roles of experiential avoidance or cognitive fusion in the association between caregiving stressors and mental health outcomes (Barrera- Caballero et al., 2021; Mausbach et al., 2012; Van Hout et al., 2023).”
From The role of experiential avoidance and cognitive fusion in the development of anxiety symptoms among family carers of people with dementia (2024) · cites this paper as Barrera- Caballero et al., 2021
Cognitive fusion is positively associated with the development of negative emotional states.
“Research has shown that cognitive fusion is positively associated with the development of negative emotional states [58].”
Psychological flexibility is a more effective strategy for emotion regulation than experiential avoidance.
“Psychological flexibility has been found to be a more effective strategy for emotion regulation than experiential avoidance, allowing nurses to reduce anxiety and depression symptoms by accepting painful thoughts, emotions, and feelings instead of overavoiding or controlling them in a way that leads to inflexibility [58].”
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LOU, V. W. Q., Cheng, C. Y. M., Yu, D. S. F., Wong, D. F. K., Lai, D. W. L., Chong, A. M. L., Chen, S., & Chou, K. (2022) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph192315711 · Cited by 1 · see citing works
Nash, C. (2024) · Preprints.org · doi:10.20944/preprints202406.0304.v1 · Cited by 1 · see citing works
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BackgroundInfluentialLancho, M. C. P., & González, M. T. (2024) · International Journal of Developmental and Educational Psychology Revista INFAD de psicología · doi:10.17060/ijodaep.2024.n1.v2.2701
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Sanna, K., Kościelniak, M., Michałowski, J. M., Losada‐Baltar, A., & Piotrowski, K. (2025) · PLoS ONE · doi:10.1371/journal.pone.0320850
Self-citationLiu, X., Jia, Y., Kuang, W., Shi, W., Cheng, B., Peng, J., Wen, Y., Li, C., & Shi, C. (2026) · BMC Geriatrics · doi:10.1186/s12877-026-07404-y
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Meyer, K., Bibriescas, N., Poe, A. A., Hebdon, M., & Puga, F. (2026) · Alzheimer s & Dementia Behavior & Socioeconomics of Aging · doi:10.1002/bsa3.70095
“40,41 Moreover, female and younger caregivers are more likely to report high financial strain.”
- Authors
- Barrera-Caballero, S., Romero-Moreno, R., del Sequeros Pedroso-Chaparro, M., Olmos, R., Vara-García, C., Gallego-Alberto, L., Cabrera, I., Márquez-González, M., Olazarán, J., & Losada-Baltar, A.
- Affiliations
- Universidad Autónoma de Madrid (ES)
- Universidad Rey Juan Carlos (ES)
- Hospital General Universitario Gregorio Marañón (ES)
- ORCID
- Venue
- Psychology and Aging
- Published
- 2021-08
- Volume
- 36
- Issue
- 5
- Pages
- 667-676
- ISSN
- 0882-7974 (ISSN-L)
- 1939-1498
- OpenAlex
- W3189742512
- Cited by
- 44
- References
- 0
- Citations by year
- 2026: 6 · 2025: 8 · 2024: 14 · 2023: 7 · 2022: 7 · 2021: 2
- FWCI
- 5.38
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Psychology and Aging (publishedVersion)
- PubMed (publishedVersion)
- BURJC Digital (King Juan Carlos University) (submittedVersion)
- Hispana (submittedVersion)
- Funders
- Spanish Ministry of Education (PSI2012-31293, FPU17/02548)
- Spanish Ministry of Economy and Competitiveness (PSI2015-65152-C2-1-R; PSI2015-65152-C2-2-R),)
- Ministry of Science and Innovation (PID2019-106714RB-C21)
- Topics
- Health Sciences › Medicine › Psychiatry and Mental health › Dementia and Cognitive Impairment Research
- Health Sciences › Health Professions › Pharmacy › Nursing care and research
- Social Sciences › Psychology › Clinical Psychology › Family Caregiving in Mental Illness
- Keywords
- dementia caregivers, caregiver stress, cognitive fusion, comorbid depression and anxiety, depressive symptoms, anxiety symptoms, symptom profiles, disruptive behavior, family caregivers, gender differences, transdiagnostic factors
- MeSH terms
- Adult, Aged, Aged, 80 and over, Alzheimer Disease, Anxiety, Cognition, Dementia, Depression, Family Health, Female, Humans, Male, Middle Aged, Stress, Psychological, Caregivers, Young Adult
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