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Thought–feeling discrimination in people with dementia: adaptation and preliminary validation of the first dementia-specific measure

  • Joshua Stott (a1), Tim Cadman (a2), Henry Potts (a3), Katrina Scior (a1), Janina Brede (a1) and Georgina Charlesworth (a1)...



There is emerging evidence that cognitive behavioral therapy (CBT) can be effective for treating anxiety and depression in people living with dementia (PLWD). Discriminating between thoughts and feelings is a critical element of CBT and also of relevance to emotional understanding more generally. The aim of the present study was the structured adaptation and preliminary validation of an existing measure of thought–feeling discrimination for use in PLWD.


The Behavior Thought Feeling Questionnaire (BTFQ) was adapted via expert and service-user consultation for use in PLWD. One hundred two PLWD and 77 people aged over 65 years who did not have measurable cognitive impairments completed the adapted measure along with two measures of emotional recognition and reasoning. The factor structure of this measure was examined and the measure reduced.


Factor analysis suggested a two-factor solution with thought and feeling items loading on separate factors. The behavior items were not included in scoring due to high cross-loading and ceiling effects, leaving a 14-item measure with two subscales. Thus, an adapted measure was created (named the BTFQ-D), which showed moderate convergent validity in the PLWD but not the older adult sample. Both thought and feeling subscales showed good internal consistency.


The BTFQ-D showed preliminary validity as a measure of thought–feeling discrimination in PLWD. It may have utility in measuring readiness for CBT as part of clinical assessment. Further validation is required.


Corresponding author

Correspondence should be addressed to: Joshua Stott, Research Department of Clinical, Educational and Health Psychology, University College London, London, WC1E 6BT, UK. Phone: +44 2076795950; Fax: +44 2079161989; Email:


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Ballard, C., Neill, D., O’brien, J., Mckeith, I., Ince, P. and Perry, R. (2000). Anxiety, depression and psychosis in vascular dementia: prevalence and associations. Journal of affective disorders, 59, 97106.
Banerjee, S. et al. (2011). Sertraline or mirtazapine for depression in dementia (HTA-SADD): a randomised, multicentre, double-blind, placebo-controlled trial. The Lancet, 378, 403411.
Dagnan, D., Chadwick, P. and Proudlove, J. (2000). Toward an assessment of suitability of people with mental retardation for cognitive therapy. Cognitive Therapy and Research, 24, 627636.
Dagnan, D., Chadwick, P., Stenfert Kroese, B., Dagnan, D. and Loumidis, K. (1997). Components of cognitive therapy with people with learning disabilities. In: Stenfert Kroese, B., Dagnan, D., and Loumidis, K. (Eds.), Cognitive Therapy for People with Learning Disabilities (pp. 110123). London: Routledge.
Dagnan, D., Mellor, K. and Jefferson, C. (2009). Assessment of cognitive therapy skills for people with learning disabilities. Advances in Mental Health and Learning Disabilities, 3, 2530.
Dening, K. H., Jones, L. and Sampson, E. L. (2012). Preferences for end-of-life care: a nominal group study of people with dementia and their family carers. Palliative medicine, 27, 409417.
Doherr, L., Reynolds, S., Wetherly, J. and Evans, E. H. (2005). Young children’s ability to engage in cognitive therapy tasks: associations with age and educational experience. Behavioural and Cognitive Psychotherapy, 33, 201215.
Emre, M. et al. (2007). Clinical diagnostic criteria for dementia associated with Parkinson’s disease. Movement Disorders, 22, 16891707.
Enache, D., Winblad, B. and Aarsland, D. (2011). Depression in dementia: epidemiology, mechanisms, and treatment. Current Opinion in Psychiatry, 24, 461472.
Fabrigar, L. R., Wegener, D. T., Maccallum, R. C. and Strahan, E. J. (1999). Evaluating the use of exploratory factor analysis in psychological research. Psychological Methods, 4, 272.
Field, A. (2013). Discovering Statistics Using IBM SPSS Statistics. UK: Sage.
Flavell, J. H. (1999). Cognitive development: children’s knowledge about the mind. Annual Review of Psychology, 50, 2145.
Gibbons, L. E., et al. (2002). Anxiety symptoms as predictors of nursing home placement in patients with Alzheimer’s disease. Journal of Clinical Geropsychology, 8, 335342.
Greenberger, D. and Padesky, C. A. (1995). Mind Over Mood: A Cognitive Therapy Treatment Manual for Clients. New York, USA: Guilford Press.
Greenberger, D. and Padesky, C. A. (2015). Mind Over Mood: Change How You Feel by Changing the Way You Think. New York, NY: Guilford Publications.
Guss, R. et al. (2014). Clinical Psychology in the Early Stage Dementia Care Pathway, London: The British Psychological Society.
Harter, L. (2003). Assessment of the suitability of older adults with dementia for cognitive therapy. D.Clin.Psy Doctoral. Lancaster University.
Hebblethwaite, A., Jahoda, A. and Dagnan, D. (2011). Talking about real-life events: an investigation into the ability of people with intellectual disabilities to make links between their beliefs and emotions within dialogue. Journal of Applied Research in Intellectual Disabilities, 24, 543553.
Hofmann, R. J. (1978). Complexity and simplicity as objective indices descriptive of factor solutions. Multivariate Behavioral Research, 13, 247250.
Hsieh, S., Schubert, S., Hoon, C., Mioshi, E. and Hodges, J. R. (2013). Validation of the Addenbrooke’s Cognitive Examination III in frontotemporal dementia and Alzheimer’s disease. Dementia and Geriatric Cognitive Disorders, 36, 242250.
Join Dementia Research. (2016). Available at:; last accessed 7 November 2016.
Kohler, C. G., Anselmo-Gallagher, G., Bilker, W., Karlawish, J., Gur, R. E. and Clark, C. M. (2005). Emotion-discrimination deficits in mild Alzheimer disease. American Journal of Geriatric Psychiatry, 13, 926933.
Kohler, C. G., Bilker, W., Hagendoorn, M., Gur, R. E. and Gur, R. C. (2000). Emotion recognition deficit in schizophrenia: association with symptomatology and cognition. Biological Psychiatry, 48, 127136.
Law, E., et al. (2013). Does the Addenbrooke’s Cognitive Examination-revised add to the Mini-Mental State Examination in established Alzheimer disease? Results from a national dementia research register. International Journal Geriatric Psychiatry, 28, 351355.
Lickel, A., Maclean, W. E. JR., Blakeley-Smith, A. and Hepburn, S. (2012). Assessment of the prerequisite skills for cognitive behavioral therapy in children with and without autism spectrum disorders. Journal of Autism & Developmental Disorders, 42, 9921000.
Livingston, G. et al. (2017). Dementia prevention, intervention, and care. The Lancet, 3990(10113), 26732734.
McKhann, G. M. et al. (2011). The diagnosis of dementia due to Alzheimer’s disease: recommendations from the National Institute on Aging-Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease. Alzheimer’s & Dementia, 7, 263269.
Mokkink, L. B. et al. (2010). The COSMIN study reached international consensus on taxonomy, terminology, and definitions of measurement properties for health-related patient-reported outcomes. Journal of Clinical Epidemiology, 63, 737745.
Neary, D. et al. (1998). Frontotemporal lobar degeneration A consensus on clinical diagnostic criteria. Neurology, 51, 15461554.
Oathamshaw, S. C., Barrowcliff, A. L. and Haddock, G. (2012). Cognitive-Behavioral Therapy for People with Intellectual Disabilities and Psychosis. In: Taylor, J., Lindsay, W., Hasings, R., and Hatton, C. (Eds.), Psychological Therapies for Adults with Intellectual Disabilities (pp. 157172). John Wiley and Sons.
Oathamshaw, S. C. and Haddock, G. (2006). Do people with intellectual disabilities and psychosis have the cognitive skills required to undertake cognitive behavioural therapy? Journal of Applied Research in Intellectual Disabilities, 19, 3546.
Orgeta, V., Qazi, A., Spector, A. E. and Orrell, M. (2014). Psychological treatments for depression and anxiety in dementia and mild cognitive impairment. Cochrane Database of Systematic Reviews, 1. doi: doi/10.1002/14651858.CD009125.pub2/pdf
Pearson, R. H. and Mundform, D. J. (2010). Recommended sample size for conducting exploratory factor analysis on dichotomous data. Journal of Modern Applied Statistical Methods, 9(2), 359368.
Pettersson, E. and Turkheimer, E. (2010). Item selection, evaluation, and simple structure in personality data. Journal of Research in Personality, 44, 407420.
Quakley, S., Coker, S., Palmer, K. and Reynolds, S. (2003). Can children distinguish between thoughts and behaviours? Behavioural and Cognitive Psychotherapy, 31, 159168.
Quakley, S., Reynolds, S. and Coker, S. (2004). The effect of cues on young children’s abilities to discriminate among thoughts, feelings and behaviours. Behaviour Research and Therapy, 42, 343356.
Reed, J. and Clements, J. (1989). Assessing the understanding of emotional states in a population of adolescents and young adults with mental handicaps. Journal of Mental Deficiency Research, 33, 229233.
Revelle, W. and Revelle, M. W. (2017). Psych: Procedures for Psychological, Psychometric, and Personality Research (Version 1.7.5). Retrieved from
Román, G. C. et al. (1993). Vascular dementia Diagnostic criteria for research studies: report of the NINDS‐AIREN International Workshop. Neurology, 43, 250250.
Roth, A. D. and Pilling, S. (2008). Using an evidence-based methodology to identify the competences required to deliver effective cognitive and behavioural therapy for depression and anxiety disorders. Behavioural and Cognitive Psychotherapy, 36, 129147.
Salmon, D. P. and Bondi, M. W. (2009). Neuropsychological assessment of dementia. Annual Review of Psychology, 60, 257.
Sams, K., Collins, S. and Reynolds, S. (2006). Cognitive therapy abilities in people with learning disabilities. Journal of Applied Research in Intellectual Disabilities, 19, 2533.
Seignourel, P. J., Kunik, M. E., Snow, L., Wilson, N. and Stanley, M. (2008). Anxiety in dementia: a critical review. Clinical Psychology Review, 28, 10711082.
Shimokawa, A. et al. (2001). Influence of deteriorating ability of emotional comprehension on interpersonal behavior in Alzheimer-type dementia. Brain and Cognition, 47, 423433.
Smith, S. et al. (2005). Measurement of health-related quality of life for people with dementia: development of a new instrument (DEMQOL) and an evaluation of current methodology. Health Technology Assessment (Winchester, England), 9, 193.
Spector, A. et al. (2015). Cognitive-behavioural therapy for anxiety in dementia: pilot randomised controlled trial. British Journal of Psychiatry, 206, 509516.
Stanley, M. A. et al. (2013). The Peaceful Mind program: a pilot test of a cognitive–behavioral therapy-based intervention for anxious patients with Dementia. The American Journal of Geriatric Psychiatry, 21, 696708.
Stewart, A. L., Thrasher, A. D., Goldberg, J. and Shea, J. A. (2012). A framework for understanding modifications to measures for diverse populations. Journal of Aging and Health, 24, 9921017.
Stott, J., Charlesworth, G. and Scior, K. (2017a). Measures of readiness for cognitive behavioural therapy in people with intellectual disability: a systematic review. Research in Developmental Disabilities, 60, 3751.
Stott, J., Orrell, M. and Charlesworth, G. (2017b). The interpretability of the Hospital Anxiety and Depression Scale in carers of people with dementia: clinical and research implications. Alzheimer’s & Dementia: The Journal of the Alzheimer’s Association, 13, P1238P1239.
Stott, J., Scior, K., Mandy, W. and Charlesworth, G. (2017c). Dementia screening accuracy is robust to premorbid IQ variation: evidence from the Addenbrooke’s Cognitive Examination-III and the test of premorbid function. Journal of Alzheimer’s Disease, 57, 12931302.
Stott, J., Spector, A., Orrell, M., Scior, K., Sweeney, J. and Charlesworth, G. (2016). Limited validity of the Hospital Anxiety and Depression Scale (HADS) in dementia: evidence from a confirmatory factor analysis. International Journal of Geriatric Psychiatry, 32(7), 805813.
Stott, J., Sweeney, J. M., Koschalka, L., O’Connor, L. and Mwale, A. (2017d). People with dementia as peer workers, challenges, and benefits: a thematic analysis and nominal groups study. International Psychogeriatrics, 29, 11851192.
Van De Ven, A. H. and Delbecq, A. L. (1972). The nominal group as a research instrument for exploratory health studies. American Journal of Public Health, 62, 337342.
Vereenooghe, L., Gega, L., Reynolds, S. and Langdon, P. E. (2016). Using computers to teach people with intellectual disabilities to perform some of the tasks used within cognitive behavioural therapy: a randomised experiment. Behaviour Research and Therapy, 76, 1323.
Verhoeven, K. J., Simonsen, K. L. and Mcintyre, L. M. (2005). Implementing false discovery rate control: increasing your power. Oikos, 108, 643647.
Wells, C. S. and Wollack, J. A. (2003). An instructor’s guide to understanding test reliability. Testing & Evaluation Services. University of Wisconsin. Retrieved from
Zigmond, A. S. and Snaith, R. P. (1983). The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica, 67, 361370.
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International Psychogeriatrics
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