Research & Publications

dr. garamoni, depression, anxiety, stress, cognitive therapy, states of mind model


Dr. Garamoni's published works on stress, anxiety, and depression have contributed to the understanding and treatment of these conditions. His research has addressed the following questions:

  • How well do people respond to cognitive therapy for depression?

  • What is the role of stressful life events in depression?

  • How does depression affect sleep and sexual functioning?

  • Are people with certain personality styles vulnerable to cardiovascular disease?

  • How should we assess positive and negative thoughts?

  • Does happiness depend on keeping an optimal balance between positive and negative thoughts?

  • Do people become emotionally ill when the balance between their positive and negative thoughts is too low -- or too high?

Within the scientific community, Dr. Garamoni is best known for the “States of Mind Model,” which over the past 22 years has generated substantial research on patterns of healthy and unhealthy thinking. The theory proposes that healthy functioning is characterized by an optimal balance of positive (P) and negative (N) cognitions or affects (P/(P + N) = 0.63), and that psychopathology is marked by deviations from the optimal balance. The model predicts, for example, that people in a depressive episode are excessively negative, whereas people in a manic episode are excessive positive.


Garamoni, G.L., Reynolds, C.F., Thase, M.E., Frank, E., & Berman, S.R. (1992). The balance between positive and negative affects during episodes of major depression: A further test of the states of mind model. Psychiatry Research, 39, 99‑108.

The States of Mind (SOM) model provided a framework for assessing the balance between self-reported positive and negative affects in a sample of 39 outpatients with major depression and 43 healthy control subjects. The SOM model proposes that healthy functioning is characterized by an optimal balance of positive (P) and negative (N) cognitions or affects (P/(P + N) approximately 0.63), and that psychopathology is marked by deviations from the optimal balance. Research thus far has focused on the functional significance of cognitive rather than affective balance. Within this framework, we hypothesized that patients in untreated episodes of major depression would balance their positive and negative affects at the same level where depressed patients in other studies have balanced their positive and negative cognitions--namely, at P/(P + N) approximately 0.37. Points and confidence interval (CI) estimation procedures yielded results (mean = 0.35, 95% CI = 0.30 - 0.40) consistent with this hypothesis in a sample of 39 depressed male outpatients. Correlational analysis indicated that affect balance is inversely related to symptom severity as measured by self-report (Beck) and clinician-rating (Hamilton) scales.

Garamoni, G.L., Thase, M.E., Reynolds, C.F., Frank, E., & Yeager, A. (1992). Shifts in affective balance during cognitive therapy of depression. Journal of Consulting and Clinical Psychology, 60, 260‑266.

Thirty-two outpatient depressives were treated by experienced therapists during a 16- to 20-week, 20- to 24-session cognitive-behavioral therapy (CBT) protocol. Patients were classified as CBT responders (n = 22) or nonresponders (n = 10) on the basis of independent clinical ratings of Hamilton (1960) depression severity. Point and confidence interval estimation procedures yielded results consistent with hypotheses derived from the states-of-mind (SOM; Schwartz & Garamoni, 1986) model. At posttreatment, CBT responders shifted the balance of positivity and negativity to the optimal range, whereas nonresponders remained in a predominantly negative SOM. Response status was related more strongly to change in positivity than in negativity. Findings support the view that clinical response to CBT depends on reducing negativity and increasing positivity until an optimal balance is achieved.

Garamoni, G.L. (1990). A reformulation of the states of mind model and a related study of euthymic, depressed, and hypomanic states of mind in a nonclinical population. Dissertation, University of Pittsburgh. Chairman: Scott M. Monroe, Ph.D.

Principles of information theory were used to model the relationship between psychopathology and the balance of positivity and negativity in information processing. This model is a reformulation of our earlier states of mind model (Schwartz & Garamoni, 1984, 1986, 1989). The original model incorporated the hypothesis (Benjafield & Adamss-Webber, 1976) that people tend to balance their positive (P) and negative (N) cognititions at a proportion known as the golden section: P/(P+N) = (Square root of 5-1)/2 = .618. A re-analysis of data from 40 studies yieded findings consistent with this hypothesis, but alternative points in the vicinity of the golden section could not be rejected. A compelling explanation of the golden section's presumed significance actually specifies that a slightly higher point of balance (P/(P+N) = .632) is funtionally optimal: Negative events are maxially salient at this point, and, presumably, the tendency to maintain this balance has evolved because noticing threatening events has survival value. The reformulated model retains the negative strikingness hypothesis, but abandons the golden section hypothesis. The revised model is consequently more parsimonious and internally consistent than the original model. The implications of information theory are formally elucidated to explain the psychpathological significance of alternative states of mind. The structural, functional, and dynamic properties of different states of mind are systematically specified. The more differentiated hypothesis is advanced that specific states of mind are opimal for functioning under specific circumstances. In a related study, psychometrically defined subsamples of euthymic (n = 176), depressed (n = 39), and hypomanic (n = 35) subjects were selected from a larger nonclinical sample (N = 372) of undergraduates. Subjects completed retropective self-reports on positive and negative affects and depressive and hypomanic symptoms experienced during a prior one week period. One-sample t-tests and 99% confidence intervals were used to test the precise hypotheses that euthymic states of mind are balanced within the theoretically optimal range (P/(P+N) = .632 +/- .066, depressed states of mind are below this range (P/(P+N) < .566), and hypomanic states of mind are above this range (P/(P+N) > .698). The results of these and secondary analyses were consistent with the hypotheses. Methodological, theoretical, and clinical implications are discussed.

Garamoni, G.L., & Schwartz, R.M. (1986). Type A behavior pattern and compulsive personality: Toward a psychodynamic‑behavioral integration. Clinical Psychology Review, 6, 311‑336.

The present review outlines conceptual and empirically based similarities between Type A Behavior Pattern (TABP) and Compulvive Personality (CP), a correspondence that suggests avenues for further theoretical development and research. Both clinical description and empirical data indicate that TABP and CP are defined by the same cluster of traits. Furthermore, both have been conceptualized as an attempt to gain and maintain a sense of control. These similarities suggest that TABP may be a subtype of CP (i.e., "compulsive achievement"). Implications of this psychodynamic-behavioral integration for the etiology and treatment of TABP are explored.

McQuaid, J.R., Monroe, S.M., Roberts, J.R., Johnson, S.L., Garamoni, G., Kupfer, D.J., and Frank, E. (1992). Toward the standardization of life stress assessments: Definitional discrepancies and inconsistencies in methods. Stress Medicine, 8, 47-56.

There has been considerable controversy about methods for assessing life stress. However, self-report checklists and interview-based measures (the predominant approaches used in current research) differ in several respects, ranging from basic definitions through theoretical assumptions. Most research comparing these two approaches has focused on golbal comparisons in predicting disorder, which fail to take into account more speific information on how the methods vary. The present article outilines three stages of assessment for life stress: definiton, operalization, and quantification. Detailed examination of these stages with a sample of depressed patients helps to demonstrate in an explicit manner how self-report checklists and interview-based methods differ at successive stages of the measurement process. Data are presented that indicate large endpoint discrepancies attributable to specific differences in the definitional and operational procedures used in the two assessment approaches. The nature of the discrepancies found is discussed, along with the implications for assesing life stress and testing its implications for health and well-being.

Nofzinger, E.A., Fasiczka, A.L., Thase, M.E., Reynolds, C.F., Frank, E., Jennings, J.R., Garamoni, G.L., Mattzie, J.V., & Kupfer, D.J. (1993). Are buckling force measurements reliable in nocturnal penile tumescence studies? Sleep, 16, 156‑162.

The study of nocturnal penile tumescence (NPT) is frequently used to evaluate male erectile dysfunction. Buckling force, a measure of rigidity, is an important part of this evaluation, but its reliability is unknown. Accordingly, we studied the reliability of buckling force measurement and the stability of "maximum buckling force" between consecutive NPT series repeated in the same subject. For individual subjects, we correlated buckling forces for separate episodes of sleep-related tumescence that were of comparable fullness (0-100%) as rated by a technician's visual estimates. For healthy control subjects, test-retest correlations were > 0.8 both within-night and across study series separated by an average of 70 weeks. In depressed men, correlations within nights were > 0.9, but fell to 0.64 across study series separated by an average of 21 weeks. Despite the high reliability of buckling force measurement, we found little stability of "maximum buckling force" between NPT series for individual subjects. Considerable variability in the maximum degree of penile rigidity was seen over time despite a constant level of reported daytime erectile function. We conclude that although penile rigidity is one of the more important variables in the assessment of male erectile dysfunction and can be measured reliably, the instability of maximum rigidity during sleep-related erections suggests that it is, at best, an imprecise correlate of daytime erectile function.

Nofzinger, E.A., Schwartz, R.M., Reynolds, C.F., Thase, M.E., Jennings, J.R., Frank, E., Fasiczka, A.L., Garamoni, G.L., & Kupfer, D.J. (1993). Correlation of nocturnal penile tumescence and daytime affect intensity in depressed men. Psychiatry Research, 49, 139‑150.

Although depressed patients have been shown to have diminished nocturnal penile tumescence (NPT), there remains considerable variability of NPT in depression. We hypothesized that affective experience during the day accounts for some of this variability. Forty-five depressed men had assessments of affect intensity and affect balance, NPT, and daytime sexual function, both before and after treatment with Beck's cognitive behavior therapy (CBT). Forty-three normal control subjects were studied for comparison. Daytime affect intensity in depressed men, but not in control subjects, correlated significantly and positively with measures of NPT duration and rigidity both before and after treatment, regardless of the adequacy of daytime sexual function. When the effect of daytime affect on REM activity was controlled, the observed correlations became nonsignificant at pretreatment, but remained significant at posttreatment. Neuropharmacologically mediated changes in arousal responsivity associated with depression may underlie the observed relation between daytime affect intensity, rapid eye movement activity, and NPT.

Nofzinger, E.A., Schwartz, R.M., Reynolds, C.F., Thase, M.E., Jennings, J.R., Frank, E., Fasiczka, A.L., Garamoni, G.L., & Kupfer, D.J. (1993). Affect intensity in phasic REM sleep in depressed men before and after treatment with cognitive behavioral therapy. Journal of Consulting and Clinical Psychology, 62, 83‑91.

This article explored the relationship between daytime affect and REM sleep in 45 depressed men before and after treatment with cognitive-behavioral therapy and in a control group of 43 healthy subjects. The intensity of daytime affect (as measured by the sum of positive and negative affects) in depressed men correlated significantly and positively with phasic REM sleep measures at both pre- and posttreatment. This relationship was not found in healthy control subjects. In depressed men, both affect intensity and phasic REM sleep measures decreased over the course of treatment. The results suggest a relationship between phasic REM sleep and intensity of affect reported by depressed men. On the basis of this preliminary observation, it was hypothesized that abnormalities in phasic REM sleep in depressed patients are related, in part, to fundamental alterations in the intensity of their affective experience.

Nofzinger, E.A., Thase, M.E., Reynolds, C.F., Frank, E., Jennings, J.R., Garamoni, G.L., Fasiczka, A.L., & Kupfer, D.J. (1993). Sexual functioning in depressed men: Assessment using self‑report, behavioral and nocturnal penile tumescence measures before and after treatment with cognitive behavioral therapy. Archives of General Psychiatry, 50, 24‑30.

Clinicians have long associated depression with alterations in sexual function, predominantly loss of sexual interest. In a longitudinal study measuring self-report, behavioral, and nocturnal penile tumescence variables before and after treatment with cognitive behavior therapy in an unmedicated sample of 40 outpatient depressed men, we found, contrary to expectation, that sexual activity per se was not reduced during the depressed state. Rather, loss of sexual interest appeared to be related to the cognitive set of depression, ie, loss of sexual satisfaction that then improved with remission from depression. Depressed men were heterogeneous, however, with respect to sexual behavior, eg, an anxious and more chronically depressed subgroup of men who did not have remissions with cognitive behavior therapy reported increased sexual interest and sexual activity. Also, contrary to expectation, nocturnal penile tumescence abnormalities in depressed men did not reverse when measured in early remission, nor did nocturnal penile tumescence measures correlate significantly with behavioral measures of sexual function. Nocturnal penile tumescence alterations in depression may thus be similar to other persistent electroencephalographic sleep abnormalities seen in depressed patients in remission, in being more trait-like than state-like.

Schwartz, R.M., & Garamoni, G.L. (1989). Cognitive balance and psychopathology: Evaluation of an information-processing model of positive and negative states of mind. Clinical Psychology Review, 9, 271‑294.

This article describes an information-processing model of positive and negative cognition and evaluates the fit between the model and existing empirical data. The model proposes five distinct states of mind that are conceptualized in terms of cognitive balance and quantitatively defined by homeostatic set point ratios of positive to total positive plus negative cognitions. One of these states of mind (positive dialogue) is considered functionally optimal because of information processing properties that render negative events maximally salient. States of mind that deviate from this optimal balance are assocaited with psychopathology. Statistical analyses of 27 studies of normal, anxious, and depressed subjects indicate that the model fits existing data for three of the five stataes of mind. Insufficient data were avaliable to directly evaluate the two extreme states of mind. Implications of cognitive balance for psychpathology and psychotherapy are discussed.

Schwartz, R.M., & Garamoni, G.L. (1986). A structural model of positive and negative states of mind: Asymmetry in the internal dialogue. In P.C. Kendall (Ed.), Advances in cognitive‑behavioral research and therapy (Vol. 5). New York: Academic Press.

Abstract not available.

Schwartz, R.M., & Garamoni, G.L. (1986). Cognitive assessment: A multibehavior‑multimethod-multiperspective approach. Journal of Psychopathology and Behavioral Assessment, 8, 185‑197.

Clarifying methodological and assessment issues is fundamental to the further development of cognitive-behavioral approaches. The present work examines potential method confounds in several cognitive assessment techniques (e.g., self-statement inventories, postperformance videotape reconstruction) in light of social psychological research on objective self-awareness. On the basis of this analysis, a conceptual framework is proposed to organize research on the assessment of clinical cognition.

Thase, M.E., Reynolds, C.F., Frank, E., Jennings, J.R., Nofzinger, E.A., Fascizka, A.L., Garamoni, G.L., & Kupfer, D.J. (1994). Polysomnographic studies of unmedicated depressed men before and after cognitive behavior therapy. American Journal of Psychiatry, 151:11, 1615‑1622.

OBJECTIVE: Differentiation of stable, trait-like characteristics from more episodic or state-dependent disturbances will be helpful in gaining a better understanding of the pathophysiology of depression. However, research in this area has been complicated by artifactual and clinical problems associated with pharmacologic treatment. In this investigation the authors used EEG sleep studies to assess medication-free depressed male patients before and after cognitive behavioral therapy. METHOD: Forty-five male patients with the diagnosis of major depression according to the DSM-III-R criteria and the Research Diagnostic Criteria underwent EEG sleep studies before and after 16 weeks of cognitive behavioral therapy, during which they were free of medication. In addition to the documentation of changes within these patients, the findings were compared with those for 47 healthy subjects, including 15 who were restudied 12-24 months after their baseline assessments. RESULTS: The EEG sleep profiles of the depressed patients showed a significant reduction in REM sleep density after treatment, suggesting "normalization" of an abnormal state-dependent process. By contrast, slow wave sleep and tonic REM measures, including reduced REM latency, were unchanged after treatment. CONCLUSIONS: These findings suggest that early in remission there is disaggregation of irreversible, trait-like correlates of depression (e.g., diminished slow wave sleep and reduced REM latency) from more reversible disturbances (e.g., increased REM density).

Thase, M.E., Reynolds, C.F., Frank, E., Jennings, J.R., Garamoni, G.L., Yeager, A., & Kupfer, D.J. (1992). Early return to REM sleep after nocturnal awakening in depression. Biological Psychiatry, 31, 171‑176.

Sixteen male outpatients with major depression and 20 age-equated healthy controls were awakened from rapid eye movement (REM) sleep between 1:30 and 3:30 AM, and the rapidity of return to REM sleep was determined. The time it took to return to REM sleep was reduced in depressives compared with controls: 61.6 (17.9 SD) min versus 80.6 (24.9 SD) min, respectively (p = 0.01). The time elapsed until the return to REM sleep was significantly correlated with baseline REM latency in controls (but not depressives). In contrast, return to REM time was significantly correlated with depression severity scores in depressives (but not controls). There was no evidence to support the hypothesis that the more rapid return to REM sleep in depression was caused by a slow wave sleep deficit. The mechanism underlying the rapid return of REM sleep in depression thus may be related to a severity-linked disturbance, such as a proposed increase in REM "pressure."

Thase, M.E., Reynolds, C.F., Frank, E., Simons, A.D., Garamoni, G.L., McGeary, J., Harden, T., Fascizka, A.L. Cahalane, J.F. (1994). Response to cognitive‑behavior therapy in chronic depression. The Journal of Psychotherapy Practice and Research, 3, 204‑214.

To study the effectiveness of psychotherapy for chronic depression, outcomes were examined for 62 men treated in a 16-week cognitive-behavioral therapy (CBT) protocol. Forty patients with acute major depression were compared with 22 patients with chronic depression who met DSM-III-R criteria for either major depression superimposed on dysthymic disorder ("double depression," n = 15) or chronic major depression (episodes of > or = 2 years' duration; n = 7). Chronically depressed patients had slower and less complete responses to CBT, paralleling prior findings for antidepressant pharmacotherapy. Modified or intensifed CBT may be needed for better results with chronic depression. The effectiveness in chronic depression of other forms of psychotherapy, alone and in combination with pharmacotherpy, requires study.

Thase, M.E., Reynolds, C.F., Frank, E., Simons, A.D., McGeary, J., Fascizka, A.L., Garamoni, G.L., Jennings, J.R., & Kupfer, D.J. (1994). Do depressed men and women respond similarly to cognitive behavior therapy? American Journal of Psychiatry, 151:4, 500‑505.

OBJECTIVE: A great majority of the evidence pertaining to the effectiveness of the time-limited psychotherapies as treatments of major depression are derived from studies of either predominantly or entirely female subject groups. Depressed men and women differ in a number of important respects that may alter the course of affective disorder, and as a result, they may also differ in their responses to psychotherapy. In this study the outcomes of 40 men and 44 women treated with cognitive behavior therapy were compared. METHOD: The patients were interviewed with the Schedule for Affective Disorders and Schizophrenia and diagnosed according to the Research Diagnostic Criteria and DSM-III-R criteria. Subsequently, they were assessed every other week (with the Hamilton Depression Rating Scale, Beck Depression Inventory, and Global Assessment Scale) during a standardized, time-limited cognitive behavior therapy protocol. The outcomes of the men and women were compared by means of a series of analyses of variance and covariance and survival analyses. RESULTS: There were several significant pretreatment differences, and the men attended significantly fewer therapy sessions than the women. Although the men and women generally had comparable responses, patients with higher pretreatment levels of depressive symptoms, particularly women, had poorer outcomes. CONCLUSIONS: This study provides further evidence of gender-specific differences in depressed patients' symptoms and treatment utilization. Cognitive behavior therapy appears to be a comparably useful outpatient treatment for men and women. However, either more intensive cognitive behavior therapy or alternative methods of treatment may be warranted for patients with more severe syndromes.

Thase, M.E.; Reynolds, C.F.; Jennings J.R.; Frank E; Garamoni G.L.; Nofzinger E.A.; Fascizka A.L.; & Kupfer D.J. (1992). Diminished nocturnal penile tumescence in depression: a replication study. Biological Psychiatry, 31:11, 1136-1142.

A descriptive study was conducted in a new sample of 51 men with DSM-III-R research diagnostic criteria (RDC) major depression in order to replicate earlier observations that measures of nocturnal penile tumescence (NPT) and penile rigidity are disturbed in depressive states. When compared to both the age-equated patient (n = 34) and normal control (n = 28) groups reported in our 1988 study, the new sample manifested significant abnormalities of NPT and diminished penile rigidity. Such disturbances were not, however, significantly correlated with psychobiological indicators of severe or endogenous depression.

Editorial Experience

Dr. Garamoni has reviewed articles for the following journals:

  • Journal of Clinical Psychology
  • Journal of Sex Education & Therapy
  • Cognitive Therapy & Research

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