Investigating the Relationship between Automatic Negative Thoughts and Experiential Avoidance with Psychological Distress and the Mediating Role of Cognitive Emotion Regulation in Patients with a History of Suicide Attempt
-
Ahmad Alipour
,
Afsaneh Rahimi
,
Shahin Shadnia
,
Mitra Rahimi
,
Peyman Erfan Talab Evini
,
Sayed Masoud Hosseini
,
Babak Mostafazadeh
Abstract
Objective: Automatic negative thoughts have an important role in development of a persistent negative cognitive bias, which may ultimately result in suicidal ideation. The primary objective of the present study was to examine the relationship between automatic negative thoughts and experiential avoidance in relation to psychological distress.
Method: The study sample comprised 441 individuals who had attempted suicide. Participants underwent interviews utilizing standardized questionnaires including Automatic Thoughts Questionnaire, Kessler Psychological Distress Scale, Acceptance and Action Questionnaire–II, and Cognitive Emotion Regulation Questionnaire along with its nine subscales. After internal relationships assessment among the research variables, outlier detection was done using the boxplot analysis and standard deviation distance metrics. To analyze the direct and indirect associations between the input and output variables, Structural Equation Modeling (SEM) was employed. In addition, SPSS-28 and Amos 29 software were used to analyzed the data.
Results: The final model showed that automatic negative thoughts were significantly inversely associated with adaptive cognitive emotion regulation (β = -0.42, P ≤ 0.01) and significantly positively related to both maladaptive cognitive emotion regulation (β = 0.49, P ≤ 0.01) and psychological distress (β = 0.53, P < 0.01). Additionally, experiential avoidance showed a significant positive relationship with maladaptive cognitive emotion regulation (β = 0.22, P < 0.01).
Conclusion: This research demonstrated that automatic negative thoughts could worsen psychological distress through the regulation of cognitive emotion in those who had a history of suicide. By the clinical management of automatic negative thoughts and shifting individuals’ cognitive emotion regulation toward adaptive strategies, there is potential for a substantial reduction in suicidal ideation and attempts which can be evaluated in future clinical trials.
1. Organization WH. Suicide worldwide in 2019: global health estimates. 2021.
2. Beck AT. Cognitive therapy of depression: Guilford press; 1979.
3. Yeşiloğlu C, Tamam L, Demirkol ME, Namlı Z, Karaytuğ MO. Associations Between the Suicidal Ideation and the Tolerance for Psychological Pain and Tolerance for Physical Pain in Patients Diagnosed with Major Depressive Disorder. Neuropsychiatr Dis Treat. 2023;19:2283-94.
4. Secundino-Guadarrama G, Veytia-López M, Guadarrama-Guadarrama R, Míguez MC. Depressive symptoms and automatic negative thoughts as predictors of suicidal ideation in Mexican adolescents. Salud mental. 2021;44(1):3-10.
5. Shen Y, Chen D, Ying J, Wang C, You J. The association between negative automatic thoughts and suicidal ideation: a longitudinal serial mediation model. Current Psychology. 2024;43(11):9909-19.
6. Kashdan TB, Goodman FR, Machell KA, Kleiman EM, Monfort SS, Ciarrochi J, et al. A contextual approach to experiential avoidance and social anxiety: evidence from an experimental interaction and daily interactions of people with social anxiety disorder. Emotion. 2014;14(4):769-81.
7. Nielsen E, Sayal K, Townsend E. Exploring the Relationship between Experiential Avoidance, Coping Functions and the Recency and Frequency of Self-Harm. PLoS One. 2016;11(7):e0159854.
8. Angelakis I, Gooding P. Obsessive–Compulsive Disorder and Suicidal Experiences: The Role of Experiential Avoidance. Suicide and Life-Threatening Behavior. 2020;50(2):359-71.
9. Brereton A, McGlinchey E. Self-harm, Emotion Regulation, and Experiential Avoidance: A Systematic Review. Archives of Suicide Research. 2020;24(sup1):1-24.
10. O'Sullivan R. A Mixed Methods Study Investigating the Mediating Effects of Experiential Avoidance on the Relationship Between Alexithymia and Psychological Distress: University of East London; 2023.
11. Garnefski N, Kraaij V. Specificity of relations between adolescents’ cognitive emotion regulation strategies and symptoms of depression and anxiety. Cognition and emotion. 2018;32(7):1401-8.
12. Aldao A, Nolen-Hoeksema S. Specificity of cognitive emotion regulation strategies: A transdiagnostic examination. Behaviour Research and Therapy. 2010;48(10):974-83.
13. Popa CO, Rus AV, Lee WC, Cojocaru C, Schenk A, Văcăraș V, et al. The Relation between Negative Automatic Thoughts and Psychological Inflexibility in Schizophrenia. J Clin Med. 2022;11(3).
14. Kessler RC, Green JG, Gruber MJ, Sampson NA, Bromet E, Cuitan M, et al. Screening for serious mental illness in the general population with the K6 screening scale: results from the WHO World Mental Health (WMH) survey initiative. International journal of methods in psychiatric research. 2010;19(S1):4-22.
15. Yıldız M. Stressful life events and adolescent suicidality: An investigation of the mediating mechanisms. Journal of Adolescence. 2020;82:32-40.
16. Macintyre VG, Mansell W, Pratt D, Tai SJ. The psychological pathway to suicide attempts: a strategy of control without awareness. Frontiers in psychology. 2021;12:588683.
17. Henschel AV, Williams JL, Hardt MM. The role of experiential avoidance and emotion regulation in DSM-5 posttraumatic stress symptomatology. Journal of Loss and Trauma. 2021;26(6):527-39.
18. Rezaei F, Hosseini Ramaghani NA. Experiential avoidance and cognitive emotion regulation strategies as the mediators in the relationship between mindfulness and social anxiety disorder symptoms. Practice in Clinical Psychology. 2018;6(2):63-72.
19. Kord B, Mohammadi M. Predicting of students' anxiety on the basis of emotional regulation difficulties and negative automatic thoughts. Education Strategies in Medical Sciences. 2019;12(1):130-4.
20. Yaztappeh JS, Lorestani E, Zaheri Y, Rezaei M, Mohammadi H, Kakabraee K, et al. A Study of Emotion Regulation Difficulties, Repetitive Negative Thinking, and Experiential Avoidance in Adults with Stuttering: A Comparative Study. Iranian Journal of Psychiatry. 2024;19(1):79.
21. Popa CO, Rus AV, Lee WC, Cojocaru C, Schenk A, Văcăraș V, et al. The relation between negative automatic thoughts and psychological inflexibility in schizophrenia. Journal of Clinical Medicine. 2022;11(3):871.
22. Hayes SC, Wilson KG, Gifford EV, Follette VM, Strosahl K. Experiential avoidance and behavioral disorders: A functional dimensional approach to diagnosis and treatment. Journal of consulting and clinical psychology. 1996;64(6):1152.
23. Yaztappeh JS, Mousavi SE, Shahkaram H, Kianimoghadam AS, Bakhtiari M, Didar F, et al. Prediction of Emotional Disorders Based on Neuroticism with Emotion Regulation, Experiential Avoidance, and Repetitive Negative Thinking. International Journal of High Risk Behaviors and Addiction. 2023;12(2).
24. Lincoln TM, Schulze L, Renneberg B. The role of emotion regulation in the characterization, development and treatment of psychopathology. Nature Reviews Psychology. 2022;1(5):272-86.
25. Khanagha HB. Comparison of Cognitive Behavioral Therapy and Acceptance and Commitment Therapy on Negative Automatic Thoughts and Negative Affect in Depressed Women. Applied Family Therapy Journal (AFTJ). 2024;5(2):208-17.
26. Daneshvar S, Shafiei M, Basharpoor S. Group-based compassion-focused therapy on experiential avoidance, meaning-in-life, and sense of coherence in female survivors of intimate partner violence with PTSD: A randomized controlled trial. Journal of interpersonal violence. 2022;37(7-8):NP4187-NP211.
27. Abdollahian S, Rezaei A, Shishwan AJ, Moheb N. The effectiveness of group dialectical behavior therapy on cognitive emotion regulation in students with social anxiety disorder. Journal of Nursing Education (JNE). 2020;9(4).
28. Kline RB. Principles and practice of structural equation modeling: Guilford publications; 2023.
29. Hollon SD, Kendall PC. Cognitive self-statements in depression: Development of an automatic thoughts questionnaire. Cognitive therapy and research. 1980;4:383-95.
30. Ghassemzadeh H, Mojtabai R, Karamghadiri N, Ebrahimkhani N. Psychometric Properties of a Persian-Language Version of the Automatic Thoughts Questionnaire: ATQ-Persian. The International journal of social psychiatry. 2006;52:127-37.
31. Bond FW, Hayes SC, Baer RA, Carpenter KM, Guenole N, Orcutt HK, et al. Preliminary psychometric properties of the Acceptance and Action Questionnaire–II: A revised measure of psychological inflexibility and experiential avoidance. Behavior therapy. 2011;42(4):676-88.
32. Abasi E, Fti L, Molodi R, Zarabi H. Psychometric properties of Persian version of acceptance and action questionnaire–II. Psychological Methods and Models. 2012;3(10/Winter 2013):65-80.
33. Kessler RC, Andrews G, Colpe LJ, Hiripi E, Mroczek DK, Normand S-L, et al. Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychological medicine. 2002;32(6):959-76.
34. Ataei J, Morteza-Shamshirgaran S, Iranparvar M, Safaeian A, Malek A. Reliability and validity of the Persian version of the Kessler psychological distress scale among patients with type 2 diabetes. Journal of Research in Clinical Medicine. 2015;3(2):99-106.
35. Dadfar M, Atef Vahid MK, Lester D, Bahrami F. Kessler psychological distress scale (K6): psychometric testing of the Farsi form in psychiatric outpatients. Advances in Bioresearch. 2016;7(2):105-8.
36. Besharat ma, Bazzazian s. Psychometri properties of the Cognitive Emotion Regulation Questionnaire in a sample of Iranian population. Advances in Nursing & Midwifery. 2015;24(84):61-70.
37. Beck AT. The evolution of the cognitive model of depression and its neurobiological correlates. American journal of psychiatry. 2008;165(8):969-77.
38. Buschmann T, Horn RA, Blankenship VR, Garcia YE, Bohan KB. The relationship between automatic thoughts and irrational beliefs predicting anxiety and depression. Journal of Rational-Emotive & Cognitive-Behavior Therapy. 2018;36:137-62.
39. Nock MK, Borges G, Bromet EJ, Alonso J, Angermeyer M, Beautrais A, et al. Cross-national prevalence and risk factors for suicidal ideation, plans and attempts. The British journal of psychiatry. 2008;192(2):98-105.
40. Choon MW, Abu Talib M, Yaacob SN, Awang H, Tan JP, Hassan S, et al. Negative automatic thoughts as a mediator of the relationship between depression and suicidal behaviour in an at-risk sample of Malaysian adolescents. Child and Adolescent Mental Health. 2015;20(2):89-93.
41. Jakobsen JC, Hansen JL, Storebø OJ, Simonsen E, Gluud C. The effects of cognitive therapy versus ‘no intervention’for major depressive disorder. PLoS One. 2011;6(12):e28299.
42. Tull MT, Jakupcak M, McFadden ME, Roemer L. The role of negative affect intensity and the fear of emotions in posttraumatic stress symptom severity among victims of childhood interpersonal violence. The Journal of nervous and mental disease. 2007;195(7):580-7.
43. Gratz KL, Roemer L. Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the difficulties in emotion regulation scale. Journal of psychopathology and behavioral assessment. 2004;26:41-54.
44. Ellis TE, Rufino KA. Change in Experiential Avoidance is Associated with Reduced Suicidal Ideation over the Course of Psychiatric Hospitalization. Archives of Suicide Research. 2016;20(3):426-37.
45. Aldao A, Nolen-Hoeksema S, Schweizer S. Emotion-regulation strategies across psychopathology: A meta-analytic review. Clinical psychology review. 2010;30(2):217-37.
46. Garnefski N, Kraaij V, Spinhoven P. Negative life events, cognitive emotion regulation and emotional problems. Personality and Individual differences. 2001;30(8):1311-27.
47. Aldao A, Nolen-Hoeksema S. When are adaptive strategies most predictive of psychopathology? Journal of abnormal psychology. 2012;121(1):276.
48. Bacon AM, Charlesford JJ. Investigating the association between fantasy proneness and emotional distress: The mediating role of cognitive coping strategies. Personality and Individual Differences. 2018;135:157-65.
49. Quintana-Orts C, Mérida-López S, Rey L, Neto F, Extremera N. Untangling the emotional intelligence-suicidal ideation connection: The role of cognitive emotion regulation strategies in adolescents. Journal of clinical medicine. 2020;9(10):3116.
50. Azadi S, Khosravani V, King S, Mohammadzadeh A, Baseri A. Effects of Neuropsychological Systems on Psychopathology Through Cognitive Emotion Regulation Strategies in Individuals with Suicide Attempts. Cognitive Therapy and Research. 2020;44(1):229-39.
51. Panagioti M, Gooding P, Tarrier N. Post-traumatic stress disorder and suicidal behavior: A narrative review. Clinical psychology review. 2009;29(6):471-82.
2. Beck AT. Cognitive therapy of depression: Guilford press; 1979.
3. Yeşiloğlu C, Tamam L, Demirkol ME, Namlı Z, Karaytuğ MO. Associations Between the Suicidal Ideation and the Tolerance for Psychological Pain and Tolerance for Physical Pain in Patients Diagnosed with Major Depressive Disorder. Neuropsychiatr Dis Treat. 2023;19:2283-94.
4. Secundino-Guadarrama G, Veytia-López M, Guadarrama-Guadarrama R, Míguez MC. Depressive symptoms and automatic negative thoughts as predictors of suicidal ideation in Mexican adolescents. Salud mental. 2021;44(1):3-10.
5. Shen Y, Chen D, Ying J, Wang C, You J. The association between negative automatic thoughts and suicidal ideation: a longitudinal serial mediation model. Current Psychology. 2024;43(11):9909-19.
6. Kashdan TB, Goodman FR, Machell KA, Kleiman EM, Monfort SS, Ciarrochi J, et al. A contextual approach to experiential avoidance and social anxiety: evidence from an experimental interaction and daily interactions of people with social anxiety disorder. Emotion. 2014;14(4):769-81.
7. Nielsen E, Sayal K, Townsend E. Exploring the Relationship between Experiential Avoidance, Coping Functions and the Recency and Frequency of Self-Harm. PLoS One. 2016;11(7):e0159854.
8. Angelakis I, Gooding P. Obsessive–Compulsive Disorder and Suicidal Experiences: The Role of Experiential Avoidance. Suicide and Life-Threatening Behavior. 2020;50(2):359-71.
9. Brereton A, McGlinchey E. Self-harm, Emotion Regulation, and Experiential Avoidance: A Systematic Review. Archives of Suicide Research. 2020;24(sup1):1-24.
10. O'Sullivan R. A Mixed Methods Study Investigating the Mediating Effects of Experiential Avoidance on the Relationship Between Alexithymia and Psychological Distress: University of East London; 2023.
11. Garnefski N, Kraaij V. Specificity of relations between adolescents’ cognitive emotion regulation strategies and symptoms of depression and anxiety. Cognition and emotion. 2018;32(7):1401-8.
12. Aldao A, Nolen-Hoeksema S. Specificity of cognitive emotion regulation strategies: A transdiagnostic examination. Behaviour Research and Therapy. 2010;48(10):974-83.
13. Popa CO, Rus AV, Lee WC, Cojocaru C, Schenk A, Văcăraș V, et al. The Relation between Negative Automatic Thoughts and Psychological Inflexibility in Schizophrenia. J Clin Med. 2022;11(3).
14. Kessler RC, Green JG, Gruber MJ, Sampson NA, Bromet E, Cuitan M, et al. Screening for serious mental illness in the general population with the K6 screening scale: results from the WHO World Mental Health (WMH) survey initiative. International journal of methods in psychiatric research. 2010;19(S1):4-22.
15. Yıldız M. Stressful life events and adolescent suicidality: An investigation of the mediating mechanisms. Journal of Adolescence. 2020;82:32-40.
16. Macintyre VG, Mansell W, Pratt D, Tai SJ. The psychological pathway to suicide attempts: a strategy of control without awareness. Frontiers in psychology. 2021;12:588683.
17. Henschel AV, Williams JL, Hardt MM. The role of experiential avoidance and emotion regulation in DSM-5 posttraumatic stress symptomatology. Journal of Loss and Trauma. 2021;26(6):527-39.
18. Rezaei F, Hosseini Ramaghani NA. Experiential avoidance and cognitive emotion regulation strategies as the mediators in the relationship between mindfulness and social anxiety disorder symptoms. Practice in Clinical Psychology. 2018;6(2):63-72.
19. Kord B, Mohammadi M. Predicting of students' anxiety on the basis of emotional regulation difficulties and negative automatic thoughts. Education Strategies in Medical Sciences. 2019;12(1):130-4.
20. Yaztappeh JS, Lorestani E, Zaheri Y, Rezaei M, Mohammadi H, Kakabraee K, et al. A Study of Emotion Regulation Difficulties, Repetitive Negative Thinking, and Experiential Avoidance in Adults with Stuttering: A Comparative Study. Iranian Journal of Psychiatry. 2024;19(1):79.
21. Popa CO, Rus AV, Lee WC, Cojocaru C, Schenk A, Văcăraș V, et al. The relation between negative automatic thoughts and psychological inflexibility in schizophrenia. Journal of Clinical Medicine. 2022;11(3):871.
22. Hayes SC, Wilson KG, Gifford EV, Follette VM, Strosahl K. Experiential avoidance and behavioral disorders: A functional dimensional approach to diagnosis and treatment. Journal of consulting and clinical psychology. 1996;64(6):1152.
23. Yaztappeh JS, Mousavi SE, Shahkaram H, Kianimoghadam AS, Bakhtiari M, Didar F, et al. Prediction of Emotional Disorders Based on Neuroticism with Emotion Regulation, Experiential Avoidance, and Repetitive Negative Thinking. International Journal of High Risk Behaviors and Addiction. 2023;12(2).
24. Lincoln TM, Schulze L, Renneberg B. The role of emotion regulation in the characterization, development and treatment of psychopathology. Nature Reviews Psychology. 2022;1(5):272-86.
25. Khanagha HB. Comparison of Cognitive Behavioral Therapy and Acceptance and Commitment Therapy on Negative Automatic Thoughts and Negative Affect in Depressed Women. Applied Family Therapy Journal (AFTJ). 2024;5(2):208-17.
26. Daneshvar S, Shafiei M, Basharpoor S. Group-based compassion-focused therapy on experiential avoidance, meaning-in-life, and sense of coherence in female survivors of intimate partner violence with PTSD: A randomized controlled trial. Journal of interpersonal violence. 2022;37(7-8):NP4187-NP211.
27. Abdollahian S, Rezaei A, Shishwan AJ, Moheb N. The effectiveness of group dialectical behavior therapy on cognitive emotion regulation in students with social anxiety disorder. Journal of Nursing Education (JNE). 2020;9(4).
28. Kline RB. Principles and practice of structural equation modeling: Guilford publications; 2023.
29. Hollon SD, Kendall PC. Cognitive self-statements in depression: Development of an automatic thoughts questionnaire. Cognitive therapy and research. 1980;4:383-95.
30. Ghassemzadeh H, Mojtabai R, Karamghadiri N, Ebrahimkhani N. Psychometric Properties of a Persian-Language Version of the Automatic Thoughts Questionnaire: ATQ-Persian. The International journal of social psychiatry. 2006;52:127-37.
31. Bond FW, Hayes SC, Baer RA, Carpenter KM, Guenole N, Orcutt HK, et al. Preliminary psychometric properties of the Acceptance and Action Questionnaire–II: A revised measure of psychological inflexibility and experiential avoidance. Behavior therapy. 2011;42(4):676-88.
32. Abasi E, Fti L, Molodi R, Zarabi H. Psychometric properties of Persian version of acceptance and action questionnaire–II. Psychological Methods and Models. 2012;3(10/Winter 2013):65-80.
33. Kessler RC, Andrews G, Colpe LJ, Hiripi E, Mroczek DK, Normand S-L, et al. Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychological medicine. 2002;32(6):959-76.
34. Ataei J, Morteza-Shamshirgaran S, Iranparvar M, Safaeian A, Malek A. Reliability and validity of the Persian version of the Kessler psychological distress scale among patients with type 2 diabetes. Journal of Research in Clinical Medicine. 2015;3(2):99-106.
35. Dadfar M, Atef Vahid MK, Lester D, Bahrami F. Kessler psychological distress scale (K6): psychometric testing of the Farsi form in psychiatric outpatients. Advances in Bioresearch. 2016;7(2):105-8.
36. Besharat ma, Bazzazian s. Psychometri properties of the Cognitive Emotion Regulation Questionnaire in a sample of Iranian population. Advances in Nursing & Midwifery. 2015;24(84):61-70.
37. Beck AT. The evolution of the cognitive model of depression and its neurobiological correlates. American journal of psychiatry. 2008;165(8):969-77.
38. Buschmann T, Horn RA, Blankenship VR, Garcia YE, Bohan KB. The relationship between automatic thoughts and irrational beliefs predicting anxiety and depression. Journal of Rational-Emotive & Cognitive-Behavior Therapy. 2018;36:137-62.
39. Nock MK, Borges G, Bromet EJ, Alonso J, Angermeyer M, Beautrais A, et al. Cross-national prevalence and risk factors for suicidal ideation, plans and attempts. The British journal of psychiatry. 2008;192(2):98-105.
40. Choon MW, Abu Talib M, Yaacob SN, Awang H, Tan JP, Hassan S, et al. Negative automatic thoughts as a mediator of the relationship between depression and suicidal behaviour in an at-risk sample of Malaysian adolescents. Child and Adolescent Mental Health. 2015;20(2):89-93.
41. Jakobsen JC, Hansen JL, Storebø OJ, Simonsen E, Gluud C. The effects of cognitive therapy versus ‘no intervention’for major depressive disorder. PLoS One. 2011;6(12):e28299.
42. Tull MT, Jakupcak M, McFadden ME, Roemer L. The role of negative affect intensity and the fear of emotions in posttraumatic stress symptom severity among victims of childhood interpersonal violence. The Journal of nervous and mental disease. 2007;195(7):580-7.
43. Gratz KL, Roemer L. Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the difficulties in emotion regulation scale. Journal of psychopathology and behavioral assessment. 2004;26:41-54.
44. Ellis TE, Rufino KA. Change in Experiential Avoidance is Associated with Reduced Suicidal Ideation over the Course of Psychiatric Hospitalization. Archives of Suicide Research. 2016;20(3):426-37.
45. Aldao A, Nolen-Hoeksema S, Schweizer S. Emotion-regulation strategies across psychopathology: A meta-analytic review. Clinical psychology review. 2010;30(2):217-37.
46. Garnefski N, Kraaij V, Spinhoven P. Negative life events, cognitive emotion regulation and emotional problems. Personality and Individual differences. 2001;30(8):1311-27.
47. Aldao A, Nolen-Hoeksema S. When are adaptive strategies most predictive of psychopathology? Journal of abnormal psychology. 2012;121(1):276.
48. Bacon AM, Charlesford JJ. Investigating the association between fantasy proneness and emotional distress: The mediating role of cognitive coping strategies. Personality and Individual Differences. 2018;135:157-65.
49. Quintana-Orts C, Mérida-López S, Rey L, Neto F, Extremera N. Untangling the emotional intelligence-suicidal ideation connection: The role of cognitive emotion regulation strategies in adolescents. Journal of clinical medicine. 2020;9(10):3116.
50. Azadi S, Khosravani V, King S, Mohammadzadeh A, Baseri A. Effects of Neuropsychological Systems on Psychopathology Through Cognitive Emotion Regulation Strategies in Individuals with Suicide Attempts. Cognitive Therapy and Research. 2020;44(1):229-39.
51. Panagioti M, Gooding P, Tarrier N. Post-traumatic stress disorder and suicidal behavior: A narrative review. Clinical psychology review. 2009;29(6):471-82.
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| Emotional Adjustment Latent Class Analysis Mental Processes Psychological Distress Suicide | ||
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How to Cite
1.
Alipour A, Rahimi A, Shadnia S, Rahimi M, Erfan Talab Evini P, Hosseini SM, Mostafazadeh B. Investigating the Relationship between Automatic Negative Thoughts and Experiential Avoidance with Psychological Distress and the Mediating Role of Cognitive Emotion Regulation in Patients with a History of Suicide Attempt. Iran J Psychiatry. 2024;:1-10.
