Stress mindset in athletes: Investigating the relationships between beliefs,challenge and threat with psychological wellbeing

ObjectiveStress is omnipresent in daily life and can be acutely experienced by athletes due to additional circumstances such as deselection and injury. Trait beliefs athletes have about the stress they experience as well as the cognitive appraisals of this stress may be important in determining psychological wellbeing. The present study aimed to investigate the relationships between stress mindset, irrational beliefs, cognitive appraisals and psychological wellbeing in athletes using path analysis. Broadly speaking, it was hypothesised that stress mindset would relate negatively to depressive symptoms and positively to vitality through appraisals (i.e., challenge and threat), while irrational beliefs would relate to positively to depressive symptoms and negatively to vitality through appraisals.Methods415 athletes (227 females, Mage = 33.86 years, SD = 17.73) completed an online questionnaire pack assessing stress mindset, irrational beliefs, challenge and threat appraisals, depressive symptoms, and vitality. Using path analysis, the tested hypothesised model demonstrated an excellent fit to the data.ResultsFindings demonstrate that the relationships between stress mindset, irrational beliefs and psychological wellbeing is linked by direct and indirect effects of challenge and threat in athletes. Stress mindset was positively associated with challenge and negatively associated with threat, whilst self-depreciation and awfulizing demonstrated significant positive associations with threat. Self-depreciation was found to significantly relate to stress mindset, challenge, threat and depressive symptoms to a greater extent than the other types of irrational beliefs.ConclusionsFindings suggest practitioners should be aware of the role that stress mindset and other irrational beliefs have in potentially influencing athlete psychological wellbeing.     

Sports specific metacognitions and competitive state anxiety in athletes: A comparison between different sporting types

This study investigated the relationship between sport related metacognitions with state anxiety dimensions, and compared how sporting categories affected these variables, among an online sample of athletes (N = 187). A MANOVA revealed there were significant differences between sporting types in metacognitive beliefs relating to the utility of rumination and arousal, the need to control thoughts, and levels of somatic anxiety. Correlations and multiple regressions showed that that in contrast to the relationships with self-confidence, cognitive and somatic state anxiety were positively associated with specific dysfunctional metacognitive beliefs, but negatively related to metacognitive processes. Overall, these findings highlight that: (a) athletes might adopt metacognitions to meet the different cognitive demands of sport types; and (b) metacognitions are in part responsible for the occurrence of state anxiety and self-confidence during competitions. The findings of this study have implications toward how researchers and sports practitioners approach the comprehensive nature of competitive anxiety.     

Irrational Beliefs in Employees with an Adjustment,a Depressive,or an Anxiety Disorder: a Prospective Cohort Study

It remains unclear if patients with different types of common mental disorders, such as adjustment, anxiety and depressive disorders, have the same irrational ideas. The aim of this prospective cohort study (n = 190) is to investigate differences in level and type of irrational beliefs among these groups and to examine whether a change in irrational beliefs is related to symptom recovery. Irrational beliefs (IBI) and symptoms were measured at four points in time: at baseline, after 3, 6 and 12 months. Results showed that diagnostic groups differed in their level of irrational beliefs and this effect remained over time. Highest levels of irrationality were observed in the double diagnosis group, followed by the anxiety disorder group and the depression group. Participants with adjustment disorders showed the lowest levels of irrationality, comparable to a community sample. We did not find differences in the type of irrational beliefs between diagnostic groups. The level of irrationality declined over time for all diagnostic groups. No differences in decrease were observed between diagnostic groups. The magnitude and direction of change in irrational beliefs were related to the magnitude of recovery of depressive, anxiety and stress symptoms over time. These results support the application of general cognitive interventions, especially for patients with a depressive or an anxiety disorder.     

Effects of psychological interventions on competitive anxiety in sport: A meta-analysis

ObjectivesThis study reviewed the effects of psychological interventions on competitive anxiety in sport.DesignMeta-analysis and systematic review.MethodPsycINFO, PsycARTICLES, SPORTDiscus, Web of Science, ProQuest, and Sage databases were searched for experimental studies that fulfilled the inclusion criteria. Risk of bias was assessed using the 12 criteria Cochrane Review Book Group tool. Hedge's g and 95% confidence intervals (CIs) were calculated and pooled using a random effects model employing the Hartung-Knapp-Sidik-Jonkman (HKSJ) method.ResultsThe search strategy identified 37 studies which fulfilled the inclusion criteria. The meta-analysis was conducted on 34 studies after removal of outliers. The results showed an overall small to medium-sized effect for psychological interventions on competitive anxiety in athletes (g = −0.42; 95% CI, −0.58 to −0.25). Subsequent subgroup analyses showed that this finding was robust regardless of experimental design, anxiety measure, anxiety type, gender, country, sport, intervention component, intervention delivery method, and intervention duration. The results indicated that the effects might be greater for athletes of higher levels of competition as compared to those from lower levels of competition. Separate meta-analyses also suggested that there were medium to large-sized effects for cognitive anxiety (g = −0.54) and self-confidence (g = 0.55) intensity, and a small to medium-sized effect for somatic anxiety (g = −0.36) intensity.ConclusionThe findings from this review study provide a robust evidence base for the use of psychological interventions to help reduce competitive anxiety in athletes. Future studies need to investigate how psychological interventions might affect the directional interpretation of anxiety symptoms.     

Competitive anxiety responses in the week leading up to competition: the role of intensity,direction and frequency dimensions

Objectives: To investigate the symptom responses associated with competitive anxiety through a fine-grained measurement approach. Incorporating dimensions of intensity, perceptions of direction, and frequency of intrusions, possible time-to-event changes were assessed with respect to the between-subjects variable of skill level.Method: Male athletes (N=82), separated into two skill classifications (club N=45 vs. national N=37), completed the competitive state anxiety inventory-2 (CSAI-2) modified to account for the dimensions of intensity, direction and frequency at five precompetition times (1 week, two days, one day, 2 h, 30 min).Results: Multivariate analysis of variance (skill level×time-to-competition) with follow-up analyses indicated main effects for skill level and time-to-competition with no interactions. For skill level differences, national athletes were more facilitative in their interpretation of the symptoms associated with cognitive and somatic anxiety. For change-over-time effects, intensities of cognitive and somatic anxiety increased and self-confidence decreased between 2 h and 30 min precompetition. Frequencies of cognitive anxiety increased from seven to two days, one day to 2 h and 2 h to 30 min precompetition; frequencies of somatic anxiety increased from seven days to two days and 2 h to 30 min pre-event; frequencies of self-confidence increased from seven to two days.Conclusions: Findings support the notion of measuring the separate dimensions of symptoms associated with competitive anxiety and emphasise the importance of assessing these constructs as processes that unfold over-time.     

To Flourish or Languish,that is the question: Exploring the mental health profiles of Danish elite athletes

ObjectivesThe purpose of this study was (a) to investigate mental well-being and the prevalence of anxiety and depressive symptoms in Danish male and female elite athletes, (b) to identify latent profiles in athletes based on their mental health and ill health, and (c) to examine whether the different profiles vary in selected protective and risk factors concerning mental health.MethodsA total of 612 Danish athletes (M = 18.99, SD = 4.29) from 18 different sports completed an online version of the Holistic Athlete Mental Health Survey that assessed well-being, depression, and anxiety together with potential risk and protective factors (e.g., injuries, stress, sleep, social support, sport environment).ResultsOverall, 13.9% of athletes reported moderate or severe anxiety symptoms while 21.1% reported moderate or severe depressive symptoms. Female athletes had a significantly higher prevalence of anxiety and depressive symptoms and lower mental well-being scores than male athletes. Through a latent profile analysis, three distinctive mental health profiles (flourishing, moderate mental health, languishing) were discovered. MANOVA following Kruskal-Wallis tests revealed substantial differences between these profiles regarding their perception of social support, sport environment, and stressors from different life domains.Conclusions: Danish elite athletes display similar levels of anxiety and depressive symptoms as the Danish general population. Flourishing athletes report lower stress levels, receive higher support from the private and sport domain, and perceive their sport environment as more supportive than athletes who are languishing. A tailored approach is proposed to support athletes' mental health.     

The Relationship Between Automatic Thoughts and Irrational Beliefs Predicting Anxiety and Depression

Cognitive behavioral approaches differ in their views on core cognitions and their hypothesized role in the etiology of depression and anxiety. The present study provides empirical evidence regarding the relationship between irrational beliefs and components of automatic thoughts and their role in the etiology of depression and anxiety. The present study utilized newer and improved questionnaires to assess components of irrational belief. Based on prior research by Safren et al. (Cogn Ther Res 24(3):327–344, 2000), a three-factor structure of the combined automatic thought questionnaires were utilized to measure components of automatic thoughts as they relate to depression and anxiety. Factor analytical methods were utilized to confirm the factor structure of the irrational beliefs and automatic thoughts components. Advanced path modeling was utilized to model the relationship between irrational beliefs and automatic thoughts in predicting anxiety and depression. The study used a sample of N = 542 undergraduate psychology students during stressful exam times. Results indicated that the irrational belief Demandingness represents a primary factor, followed by the secondary irrational beliefs as proposed by Rational Emotive Behavioral Theory. Selfdowning beliefs were fully mediated by depressive automatic thoughts in the case of depressive affect. Low frustration tolerance contributed unique variance to anxious and depressive affect that was not fully mediated by automatic thoughts. Results from the present study add empirical evidence that irrational beliefs indeed represent core and intermediary beliefs that lead to specific automatic thoughts, which is congruent with cognitive behavioral theory as proposed by Rational Emotive Behavioral Therapy.     

Maternal self-confidence during the first four months postpartum and its association with anxiety and early infant regulatory problems

Maternal self-confidence has become an essential concept in understanding early disturbances in the mother-child relationship. Recent research suggests that maternal self-confidence may be associated with maternal mental health and infant development. The current study investigated the dynamics of maternal self-confidence during the first four months postpartum and the predictive ability of maternal symptoms of depression, anxiety, and early regulatory problems in infants. Questionnaires assessing symptoms of depression (Edinburgh Postnatal Depression Scale), anxiety (State-Trait Anxiety Inventory), and early regulatory problems (Questionnaire for crying, sleeping and feeding) were completed in a sample of 130 women at three different time points (third trimester (T1), first week postpartum (T2), and 4 months postpartum (T3). Maternal self-confidence increased significantly over time. High maternal trait anxiety and early infant regulatory problems negatively contributed to the prediction of maternal self-confidence, explaining 31.8% of the variance (R = .583, F_3,96 = 15.950, p < .001).Our results emphasize the transactional association between maternal self-confidence, regulatory problems in infants, and maternal mental distress. There is an urgent need for appropriate programs to reduce maternal anxiety and to promote maternal self-confidence in order to prevent early regulatory problems in infants.     

Self-confidence and anxiety interpretation: A qualitative investigation

Objectives: To examine performers’ retrospective explanations for the relationship between self-confidence, competitive anxiety intensity, and symptom interpretation toward performance.Method: Semi-structured interviews were conducted with 10 elite performers to determine how self-confidence levels influenced the perceived effects of pre-competitive anxiety intensity and identify the confidence management strategies used to protect symptom interpretation.Results: Two causal networks were identified, showing self-confidence to influence the relationship between competitive anxiety intensity and symptom interpretation. In the absence of self-confidence, increases in competitive anxiety intensity were perceived as outside of the performers’ control and debilitating to performance. Under conditions of high self-confidence, increases in symptoms were reported to lead to positive perceptions of control and facilitative interpretations. To protect against debilitating interpretations of competitive anxiety, performers reported the use of cognitive confidence management strategies including mental rehearsal, thought stopping, and positive self-talk.Conclusions: The findings highlight self-confidence as an essential quality for elite athletes to possess in order to protect against potentially debilitating thoughts and feelings experienced in competitive situations.     

Macronutrient intake as a prospective predictor of depressive symptom severity: An exploratory study with adolescent elite athletes

BackgroundAppropriate availability of macro- and micronutrients has an important impact on cognitive performance, mood and mental health. Although the critical role of nutrition for elite athletes’ performance was recognized early on, little is known about whether consumption of specific macronutrients (carbohydrates, proteins, fat) predict the development of future depressive symptoms in adolescent elite athletes.MethodsParticipants were recruited from three Swiss Olympic Partner Schools (SOPS) in the Northwestern German speaking part of Switzerland. A total of 97 adolescent elite athletes (38% girls, M_age = 16.35 ± 1.19) participated in the study. Depressive symptoms (PHQ9) were assessed at baseline and after 10 months follow-up. A 3-day food recall was completed three months after the baseline assessment. Linear regression analyses were used to examine whether macronutrients predict depression symptom severity after controlling for covariates and baseline depressive symptoms.ResultsHigher protein consumption in athletes was a prospective predictor of lower depressive symptom severity at follow-up (β = −35, p < .05). Several deviations from recommended nutritional standards were observed in elite athletes.ConclusionsThe findings of this exploratory study support the notion that dietary behaviour may be prospectively associated with athletes’ mental health. However, more research is required with larger samples and more in-depth assessment techniques. Future research should also examine whether nutrition education and dietary modification can be used to prevent depressive symptoms among adolescent elite athletes.     

Social desirability and relations between goal orientations and competitive trait anxiety in young athletes

ObjectivesTo examine the impact of a social desirability response set on relations between goal orientation and performance anxiety in youth sports.DesignCorrelational field design.MethodData assessing goal orientation, performance anxiety, and social desirability were obtained from male (n=106) and female (n=75) adolescent athletes (M age=12.1 years; SD=1.3 years).ResultsFemale athletes reported significantly higher levels of task orientation and lower levels of ego orientation and concentration disruption, than males. As predicted, ego orientation was positively correlated with all indices of performance anxiety in males and females. Task orientation was negatively associated with all indices of performance anxiety in males but only concentration disruption in females. Social desirability was negatively related to ego orientation in males and females, and positively related to task orientation in females, but not males. Performance anxiety was negatively related to social desirability in females, but not males. Controlling for social desirability attenuated the observed relations between goal orientations and performance anxiety in females, but not males.ConclusionsThese results suggest the importance of incorporating measures of social desirability when studying psychosocial variables with either positive or negative connotations. Our results suggest that social desirability may contribute to relations between goal orientation and anxiety in athletes, particularly females.     

Macronutrient intake as a prospective predictor of depressive symptom severity: An exploratory study with adolescent elite athletes

BackgroundAppropriate availability of macro- and micronutrients has an important impact on cognitive performance, mood and mental health. Although the critical role of nutrition for elite athletes’ performance was recognized early on, little is known about whether consumption of specific macronutrients (carbohydrates, proteins, fat) predict the development of future depressive symptoms in adolescent elite athletes.MethodsParticipants were recruited from three Swiss Olympic Partner Schools (SOPS) in the Northwestern German speaking part of Switzerland. A total of 97 adolescent elite athletes (38% girls, M_age = 16.35 ± 1.19) participated in the study. Depressive symptoms (PHQ9) were assessed at baseline and after 10 months follow-up. A 3-day food recall was completed three months after the baseline assessment. Linear regression analyses were used to examine whether macronutrients predict depression symptom severity after controlling for covariates and baseline depressive symptoms.ResultsHigher protein consumption in athletes was a prospective predictor of lower depressive symptom severity at follow-up (β = −35, p < .05). Several deviations from recommended nutritional standards were observed in elite athletes.ConclusionsThe findings of this exploratory study support the notion that dietary behaviour may be prospectively associated with athletes’ mental health. However, more research is required with larger samples and more in-depth assessment techniques. Future research should also examine whether nutrition education and dietary modification can be used to prevent depressive symptoms among adolescent elite athletes.     

Sense of purpose and food insecurity during the COVID-19 pandemic

The COVID-19 pandemic brought new attention to the issues of food insecurity faced by individuals throughout the United States, a stressor exacerbated by disruptions to work status and supply chains. The burden of food insecurity likely carries consequences for whether individuals feel capable of pursuing their broad goals and life engagements; put differently, food insecurity may pose a threat to people perceiving a sense of purpose in life. The current study tested this claim across three samples taken during 2020 (n = 2009), 2021 (n = 1666), and 2022 (n = 1975). Participants completed inventories for perceived food insecurity, sense of purpose, depressive symptoms, and anxiety, among other measures. Results found consistent negative associations between food insecurity and sense of purpose across all three samples. In addition, food insecurity moderated associations between sense of purpose and depressive or anxiety symptoms. Sense of purpose was more strongly negatively associated with depressive and anxiety symptoms for those participants who reported no food insecurity. That said, sense of purpose remained negatively associated with psychological distress even among those reporting food insecurity.     

Does Worrying Mean Caring Too Much? Interpersonal Prototypicality of Dimensional Worry Controlling for Social Anxiety and Depressive Symptoms

Worry, social anxiety, and depressive symptoms are dimensions that have each been linked to heterogeneous problems in interpersonal functioning. However, the relationships between these symptoms and interpersonal difficulties remain unclear given that most studies have examined diagnostic categories, not accounted for symptoms’ shared variability due to general distress, and investigated only interpersonal problems (neglecting interpersonal traits, interpersonal goals, social behavior in daily life, and reports of significant others). To address these issues, students (Study 1; N = 282) endorsed symptoms and interpersonal circumplex measures of traits and problems, as well as event-contingent social behaviors during one week of naturalistic daily interactions (N = 184; 7,036 records). Additionally, depressed and anxious patients (N = 47) reported symptoms and interpersonal goals in a dyadic relationship, and significant others rated patients’ interpersonal goals and impact (Study 2). We derived hypotheses about prototypical interpersonal features from theories about the functions of particular symptoms and social behaviors. As expected, worry was uniquely associated with prototypically affiliative tendencies across all self-report measures in both samples, but predicted impacting significant others in unaffiliative ways. As also hypothesized, social anxiety was uniquely and prototypically associated with low dominance across measures, and general distress was associated with cold-submissive tendencies. Findings for depressive symptoms provided less consistent evidence for unique prototypical interpersonal features. Overall, results suggest the importance of multimethod assessment and accounting for general distress in interpersonal models of worry, social anxiety, and depressive symptoms.     

Psychosocial correlates of depressive rumination

The study examined the relationship between brooding, the maladaptive sub-component of depressive rumination, an important cognitive mechanism implicated in the aetiology of depression, and a range of depressogenic psychosocial factors, including insecure attachment styles and maladaptive interpersonal behaviours. It was hypothesised that brooding (but not the more adaptive reflection component) is associated with an attachment pattern characterised by fear of rejection, and an interpersonal style characterised by submissiveness. Currently depressed (n = 29), previously depressed (n = 42) and never-depressed (n = 32) adults completed self-report measures assessing depressive symptoms, rumination (brooding and reflection), attachment orientation and maladaptive interpersonal behaviours. The study hypotheses were partially supported: After controlling for gender and depressive symptoms, brooding was significantly associated with one indicator of underlying rejection concerns (rejection sensitivity, p = .05), but was not associated with another indicator of underlying rejection concerns (anxious attachment style) or with avoidant attachment style. After controlling for depressive symptoms, brooding was uniquely associated with the submissive interpersonal style (p < .01). Brooding was not correlated with needy or cold interpersonal styles after controlling for depressive symptoms.     

Integrating the Interpersonal Psychological Theory of Suicide Into the Depression/Suicidal Ideation Relationship: A Short-Term Prospective Study

We examined the hypothesis that depressive symptoms are associated with increased beliefs about perceived burdensomeness and thwarted belongingness identified in the interpersonal psychological theory of suicide and that these beliefs are associated with changes in suicidal ideation. Participants with clinical levels of depressive symptoms (n = 299) were selected from a larger group (n = 508) and completed measures of depressive symptoms, perceived burdensomeness and thwarted belongingness, and suicidal ideation twice over a period of 2 months. Results of a structural equation model found that depressive symptoms were associated with increases in burdensomeness and lack of belonging, which were associated with suicidal ideation. Moreover, this hypothesized integrated model demonstrated a significantly better fit than an alternative model that assumed burdensomeness and lack of belonging were associated with changes in depressive symptoms, which were associated with suicidal ideation. Our findings suggest that the well-established relationship between depressive symptoms and suicidal ideation is associated with changes in beliefs that one is a burden on others and lacks belonging. More generally, these results suggest that it may be fruitful to integrate theories of suicide risk to form a comprehensive model that can inform future research and clinical interventions.     

Cognitive-Behavioral and Personal Construct Therapies for Depression in Women with Fibromyalgia: A Randomized Controlled Trial

Background/ObjectiveFibromyalgia is a chronic pain syndrome that depressive symptoms can aggravate. The aim of the present study was to test the efficacy of Personal Construct Therapy (PCT), an approach that emphasizes identity features and interpersonal meanings as the focus of the treatment of depressive symptoms, in women with fibromyalgia.MethodWe compared PCT with Cognitive Behavioral Therapy (CBT) in a multicenter parallel randomized trial. Women with fibromyalgia and depressive symptoms (n = 106) were randomly allocated to CBT (n = 55) or PCT (n = 51) in individual and modular formats to adjust to their needs. Analysis was by linear mixed-effects models.ResultsParticipants in both conditions had significantly reduced depressive symptoms, and we found no significant difference when comparing groups both post-treatment (β = -0.47, t = -0.49, p = .63) and at follow-up (β = -1.12, t = -1.09, p = .28). Results were similar between conditions for anxiety, fibromyalgia's impact, and the distribution of clinically significant changes in depressive symptoms and pain.ConclusionsPCT and CBT seem to be equally effective in the treatment of depressive symptoms, making PCT a viable alternative treatment.     

Enhancing the academic success of competitive student athletes using a motivation treatment intervention (Attributional Retraining)

Competitive student athletes who experience the typical challenges inherent in high school-to-university transitions must also overcome sport-related difficulties which can undermine their academic motivation and class attendance due to competitions, fatigue, injuries, identity issues, and novel training environments (MacNamara & Collins, 2010; Simons et al., 1999). In an eight-month quasi-experimental, randomized treatment field study, an attribution-based motivation treatment (Attributional Retraining: AR) was administered to student athletes (n = 185) and non-athletes (n = 281) who differed in perceived control beliefs (±1 SD) in a two-semester, online course. Simple slope regression analyses revealed the AR (vs. no-AR) treatment assisted competitive student athletes who had low control beliefs by increasing perceived success in the course (b = 0.84, p = 0.038), post-treatment test performance (b = 11.68, p = 0.001), year-end course grades (b = 6.32, p = 0.017), and by reducing course withdrawals (b = −1.00, p = 0.034, OR = 0.37). These results demonstrate the benefits of an attribution-based motivation treatment for vulnerable student-athletes in terms of perceived course success, performance, and persistence in making the transition from high school to college.     

Social-contextual and intrapersonal antecedents of coaches' basic need satisfaction: The intervening variable effect of providing autonomy-supportive coaching

ObjectivesBased on Self-Determination Theory (SDT; Deci & Ryan, 2012) and in line with Mageau and Vallerand's (2003) motivational model of the coach-athlete relationship, a new model involving antecedents associated with coaches' self-report measure of total need satisfaction (TNS) was tested. This model hypothesized that: (1) coaches' perceptions of a socially united group of athletes and their self-determined motivation for coaching would relate positively to coaches' provision of autonomy-supportive coaching (ASC), whereas perception of parental pressure in the youth sport context would relate negatively to coaches' provision of ASC; (2) coaches' provision of ASC towards their athletes would, in turn, relate positively to their self-report measure of TNS; and (3) the relation between coaches' perceptions of the sport context, along with their self-determined motivation for coaching, and coaches' self-report measure of TNS would be mediated by coaches' own provision of ASC.DesignA cross-sectional study.MethodsParticipants were 222 (M_age = 42.3, SD = 6.1) youth soccer coaches.ResultsSEM analyses supported the hypothesized model in which coaches' perceptions of a socially united group of athletes and their self-determined motivation for coaching related positively to coaches' self-report measure of TNS through coaches' provision of ASC. In contrast, coaches' perceptions of parental pressure in the youth sport context was unrelated to coaches' self-report measure of TNS via coaches' provision of ASC.ConclusionsFindings support previous research by demonstrating the psychological benefit of providing autonomy support to others.     

The effects of a motivational general-arousal imagery intervention upon preperformance symptoms in male rugby union players

ObjectivesTo investigate the efficacy of a motivational general-arousal based imagery strategy in modifying precompetitive symptom interpretations.MethodA staggered multiple baseline single-subject design was employed with five male collegiate rugby union players (M = 24.5; SD = 3.05). The dependent variable was monitored over a full competitive season via measures of precompetitive anxiety and affect together with follow-up social validation procedures.ResultsMore facilitative interpretations of symptoms associated with competitive anxiety, and greater self-confidence levels were reported postintervention, together with changes in positive and negative affect.ConclusionsThe findings highlight the importance of employing individualized imagery with motivational general-arousal content to modify performers' perceptions of their precompetitive experiences. This effect is proposed to occur directly through adaptive changes in individuals' psychological response systems and indirectly via the protection mechanisms associated with enhanced efficacy expectations.