Illness perception is the cognitive and emotional representations (Godoy-Izquierdo et al., 2007 and Petrie et al., 2007) that one has to make sense of their illness. It involves a cognitive component that can significantly impair one's ability to manage illness coping strategies and outcomes (Leventhal et al., 1992 and Philip et al., 2009). Illness perception has been shown to be associated with depression in patients with physical and chronic illness (Peterson et al., 1991, Godoy-Izquierdo et al., 2007, Husain et al., 2008 and Le Grande et al., 2012). However, there are limited studies examining the role of illness perception in depressive disorders (Lobban et al., 2002, Fortune et al., 2004 and Philip et al., 2009). Since depression is associated with stressful and negative life events which frequently involve the impairment of multiple domains of one's daily functioning and well-being (Blazer et al., 2005), it is likely that the illness perception of a depressed individual will influence the individual's illness coping style and self-management strategies, which will in turn affect depression outcomes.
Rumination is a response coping style that is prolonged and characterized by recurrent negative thoughts and mood that one has about his illness symptoms, causes and consequences (Nolen-Hoeksema, 1991 and Nolen-Hoeksema, 1998). There are many established evidence to show significant association between rumination and depression (Muris et al., 2005, Roelofs et al., 2008, de Jong-Meyer et al., 2009 and Michl et al., 2013). Rumination is reliably associated with vulnerability to depressed mood, onsets of depressive episodes, longer and more severe episodes of depression, as well as various depressive symptoms such as insomnia and suicidal thoughts (Gotlib et al., 1996, Abramson et al., 2002 and Morrison and O’Connor, 2008). While ruminative coping has been indicated to be maladaptive in depressive disorders in general, recent studies have suggested that depressive rumination is a multidimensional construct with both adaptive and maladaptive components (Watkins and Teasdale, 2004, Watkins et al., 2008, Di Schiena et al., 2011, Di Schiena et al., 2012 and Hamilton et al., 2011). Some researchers believe that rumination serves an adaptive function of goal progress by reducing the discrepancy between current negative health state and desired future goal in some patients (Fortune et al., 2004). This concept is based on the premise that these patients are active problem solvers who constructively ruminate about how to improve their health. The coping strategies they select are guided by their interpretation and evaluation of their illness. The outcome of these behaviours is then evaluated and fed back into their model of the illness, and/or used to shape future coping responses.
Most research however chose to focus primarily on rumination as a maladaptive process (Yoon and Joormann, 2012). Out of most forms of self-focused attention, rumination was most strongly and consistently linked to depressive symptoms (Mor and Winquist, 2002). Abramson et al. (2002) argued that cognitive vulnerabilities found in depressed individuals make it difficult for them to disengage from the self-regulatory process, thus trapping them in a cycle of ruminative thoughts instead of attaining the desired goal. The debate is still ongoing about whether rumination is an adaptive coping response or a detrimental form of emotional regulation (Nolen-Hoeksema et al., 2008).
Maladaptive rumination is characterized by negative inferential or attribution styles, dysfunctional attitudes, hopelessness, pessimism, self-criticism, low mastery, dependency, neediness, and neuroticism (Ciesla and Roberts, 2002, Flett et al., 2002, Lam et al., 2003, Lyubomirsky and Nolen-Hoeksema, 1995, Lyubomirsky et al., 1999, Nolen-Hoeksema and Jackson, 2001, Robinson and Alloy, 2003 and Spasojevic and Alloy, 2001). Engaging in benign and positive distractions such as watching a movie with friends is associated with adaptive rumination coping as it diverts attention away from the negative emotions and reduces negative effect of their disorder (Nolen-Hoeksema, 1991). Women are found to be more likely to ruminate than men (Butler and Nolen-Hoeksema, 1994, Grant et al., 2004, Nolen-Hoeksema and Davis, 1999, Nolen-Hoeksema and Jackson, 2001, Roberts et al., 1998 and Ziegert and Kistner, 2002), and they are more likely to develop major depressive disorders than men (Cyranowski et al., 2000). In addition, women reported higher levels of depressive moods than men (Nolen-Hoeksema, 1994). This may be because women focus more on their own emotions than men (Calmes and Roberts, 2008) and that they are more likely to use maladaptive rumination coping that prevails their negative emotions and symptoms. This leads us to our third hypothesis stated in the following paragraph.
Given the recurring and chronic nature of depression, information on illness perception would be highly useful when attempting to improve treatment efficacy, increase medication adherence, and reduce the occurrence of relapse episodes (Brown et al., 2001). In this present study, we aim to examine the relationship between illness perception, rumination and negative emotions in male and female patients with depressive disorders. Specifically, the following hypotheses will be tested: (1) the various dimensions of illness perception will have significant associations with negative emotional symptoms such as depression, anxiety and stress levels; (2) this relationship will be mediated by the patients’ ruminative coping responses; and (3) the nature of this hypothesized mediational model will differ for men and women, such that maladaptive rumination emerges as a stronger mediator for women, while adaptive rumination is a stronger mediator for men.
