The Comparison of the Effectiveness of Metacognitive Therapy and Spiritual Therapy on Cognitive Dissonance and Feeling Loneliness in the Elderly living in Nursing Homes

Document Type : Original Article

Authors

1 Department of Psychology, Faculty of Literature and Humanities, Payame Noor University of Tehran, Iran

2 1 Department of Psychology, Faculty of Literature and Humanities, Payame Noor University of Tehran, Iran

Abstract

With age and the onset of the elderly, people are more prone to mental disorders including feeling of loneliness, anxiety, and depression, due to numerous losses such as loss of spouse, relatives, friends, occupation, social and economic status, beliefs, etc., as well as due to the reduction of physiological functions and mobility. Accordingly, this study aims to compare the effectiveness of metacognitive therapy and spiritual therapy on cognitive dissonance and feeling loneliness in the elderly living in nursing homes. This was a quasi-experimental study with pretest-posttest follow-up (PPF) and control group design. The statistical population consisted of all the elderly, aged from 60 to 75 years living in nursing homes of Tehran, Iran, among which Kahrizak nursing home was selected using convenience sampling method. In this way, 30 aged people (three groups of 10) with an average age of 60-75 years were selected using convenience sampling along with inclusion and exclusion criteria, and were randomly assigned into two experimental and one control groups. Participants were exposed to eight 90-minute sessions (2 sessions a week) of Wells’ metacognitive therapy and Boalhari’s spirituality therapy. The follow-up step was conducted one month after the posttest step. Utilized to collect data were Harmon-Jones ‌dissonance arousal reducing questioner and Dehshiri et al.’s loneliness questionnaires. Data were analyzed using univariate analysis of covariance (ANCOVA) and Bonferroni post-hoc test in SPSS-22. The results demonstrated that both metacognitive therapy and spiritual therapy groups had a significant difference with control group in terms of the components of cognitive dissonance and feeling of loneliness in posttest and follow-up steps (p < 0.05). However, there was no significant difference between two groups of metacognitive therapy and spiritual therapy in terms of the components of cognitive dissonance and loneliness (P>0.05). Given the findings of this study, metacognitive therapy and spiritual therapy can be effective in reducing cognitive dissonance and loneliness in the elderly.

References
Ahadi, H., & Jamhari, F. (2011). Developmental Psychology. Adolescence and adulthood, youth, middle age and old age). Tehran: Bright Future Publications. [Persian]
Askari, M., Mohammadi, H., Radmehr, H., & Jahangir, A. H. (2018). The Effect of spiritual–religious psychotherapy on enhancing quality of life and reducingsymptoms of anxiety and depression among the elderly. Journal of Research on Religion & Health, 4(2), 29-41. [Persian]
Aylaz, R., Aktürk, U., Erci, C., Özturk, H., & Aslan, H. (2014). Relationship between depression and loneliness in elderly and examination of influential factors. Archives of Gerontology and Geriatrics, 55(3), 684-699.
Barghi Irani, M., Abbasi, M., Khanbabaei Ghaleei, P., & Rezaei, Sh. (2020). The effectiveness of positive psychotherapy on death anxiety and loneliness in the elderly. The 4th National Conference on Psychology, Payame Noor University, Rasht. [Persian]
Barghi Irani, Z., Rajabi, M., Nazemi, M., & Begian Colehmers, M. J. (2017). The role of lifestyle, psychological capital and self-care behaviors in predicting the mental well-being of diabetic elderly. Journal of Health Psychology, 6 (3), 17-38. [Persian]
Boalhari, J., Naziri, Q., & Zamanian, S. (2012). The effectiveness of spiritual group therapy approach on reducing depression, anxiety and stress in women with breast cancer. Psychology Journal, 3 (1), 115-85. [Persian]

Cacioppo, J. T., Hughes, M. E., Waite, L. J., Hawkley, L. C., & Thisted, R. A. (2006). Loneliness as a specific risk factor for depressive symptoms: Cross-sectional and Longitudinal Analysis. Psychology and Aging, 21, 140-151.
Davidson, J. R., Ballenger, J. C., Lecrubier, Y., Nutt, D. J., Borkovec, T. D., & Rickels, K.(2001). Consensus statement on generalized anxiety disorder from the International Consensus Group on Depression and Anxiety. Journal of Clinical Psychiatry, 6(2), 53-58.
 Dehshiri, G., Sohrabi, F., Jafari, A., & Najafi, M. (2008). A Study of Psychometric Properties of Spiritual Well-Being Scale among Students, Psychological Studies, 2 (16), 137-123. [Persian]
Dinarvand, N. (2020a). Evaluation of the effectiveness of metacognitive therapy on learned helplessness, loneliness and death anxiety in the elderly with mobility disorders, Second Conference on Psychology, Educational Sciences, Social Sciences and Counseling, Padua, Italy. [Persian]
 Dinarvand, n. (2020b). Evaluation of the effectiveness of spiritual therapy on learned helplessness, loneliness and death anxiety in the elderly with mobility disorders, Second Conference on Psychology, Educational Sciences, Social Sciences and Counseling, Padua, Italy. [Persian]
Egan, L. C., Bloom, P., & Santos, L. R. (2010). Choice-induced preferences in the absence of choice: Evidence from a blind two choice paradigm with young children and capuchin monkeys. Journal of Experimental Social Psychology, 46(1), 204-207.
Festinger, L. (1957). A theory of cognitive dissonance. Stanford University Press
Ghaderi, D., & Mostafaei, A. (2014). The Relationship between Religious Orientation and Quality of Life in the Elderly Male Living at Home and Living in a Nursing Home. Elderly Journal, 9 (1), 21-14. [Persian]
Ghadmpour, A., Moradizadeh, S., & Shah Karami, M. (2019). Evaluation of the effectiveness of mindfulness training on reducing loneliness and death anxiety in the elderly in Siddiq Center of Khorramabad. Razi Journal of Medical Sciences, 26 (4), 44-53. [Persian]
Gwilliam P, Wells, A., & Cartwright-Hatton S. (2004). Dose meta-cognition or responsibility predict obsessive–compulsive symptoms: A Test of themetacognitive model. Clinical Psychology & Psychotherapy, 11(2), 137-144.
Harmon-Jones, E. (2000). Cognitive dissonance and experienced negative affect: Evidence that dissonance increases experienced negative affect even in the absence of aversive consequences. Personality and Social Psychology Bulletin, 26(12), 1490-1501.
Harrefors, C., Savenstedt, S., & Axelsson, K. (2009). Elderly people's perceptions of how they want to be cared for an interview study with healthy elderly couples in Northern Sweden. Scandinavian Journal of Caring Sciences, 23(2), 353-360.
Henrich, L. M., & Gullone, E. (2006). The clinical significance of loneliness: A literature review. Clinical Psychology Review, 27 (6), 695-718.
Kavosian, N., Kazemzadeh, H., Kazemi, H., & Carbro, A. (2018). The Relationship between Spiritual Health and Loneliness in the Elderly in Karaj. Journal of Research in Religion and Health, 4 (2), 15-7. [Persian]
 Kerch, d., Crash Field, R. S., & Blocky, A. S. (2008). The individual in the community, translated by Mahmoud Sanaei, Tehran: Zavar Publications. [Persian]
Khaleghipour, M., Masjidi, M. Sh., & Ahmadi, Z. (2016). The effectiveness of Islamic spiritual therapy on lifestyle and peripheral white blood molecules in depressed elderly. Journal of Research in Mental Health, 10 (3), 87-69. [Persian]
 Koushiar, H., Ghanbari Hashemabadi, b. A., & Ismaili, H. (2012). The effect of group reminiscence on the criterion of disability in old age. Iranian Journal of Aging, 7 (1), 29-21. [Persian]
Lee, Y., & Salman, A. (2018). The mediating effect of spiritual well-being on depressive symptoms and health-related quality of life among elders. Archives of Psychiatric Nursing, 32 (3), 418-424.
Liang, Y. J. (2016). Reading to make a decision or to reduce cognitive dissonance. Computers in Human Behavior, 64(1), 463-471.
Liu, L. J., & Guo, Q. (2007), Loneliness and health-related quality of life for the empty nest elderly in the rural area of a mountainous county in China. Quality of Life Research, 16(8), 1275- 1280.
Mansoori Sepehr, R., Heidari, M., Bagherian, F., & Shokri, A. (2018). The Effect of Choice Reversibility on Attitude Change in Cognitive Disorder: A Free Choice Paradigm. Journal of Applied Psychology, 12 (3), 319-337. [Persian]
McCoubrie, R. C., & Davies, A. N. (2006). “Is there a correlation between spirituality and anxiety and depression in patients with advanced cancer?” Support Care Cancer. Psychology Journal, 14 (4), 379-385.
Mirdrikund, F., Panahi, H., & Hosseini Ramghani, N. (2016). Feeling lonely in the elderly: the role of communication skills, social support and functional disability. Psychology of Aging, 2 (2), 113-103. [Persian]
Motamedi, N., Shafiee Darabi, M., & Amini, Z. (2018). Assessing the level of social and emotional loneliness in the elderly and its relationship with some social factors affecting health in Isfahan, Journal of Social Cognition, 36 (46), 756-750. [Persian]
Mr. Yousefi, A., Zare, H., Zare, M., & Shaghaghi, F. (2014). Investigating the role of decision-making styles in cognitive dissonance and the resulting physiological changes, Journal of Social Cognition, 7 (2), 81-67. [Persian]
Myers, S. G., & Wells, A. (2005). Obsessivecompulsive symptoms: the contribution of metacognitions and responsibility. Anxiety Disorders, 19(7), 817–806.
Nazemi Ardakani F., Alipour, A., & Abedi Jafari F., (2013). Investigating the Relationship between Cognitive Disorder and Personality Traits with Eating Disorder Symptoms. Research in mental health, 7(4), 11-20. [Persian]
Puchalski, C. M., Vitillo, R., Hull, S. K., & Reller, N. (2014). Improving the spiritual dimension of whole person care: reaching national and international consensus. Journal of Palliative Medicine, 17(6), 642-56.
Rostami, M., Rasouli, M., & Kasaei, A. (2018). Comparison of the effectiveness of group counseling based on spirituality-based therapy and therapy based on acceptance and commitment on the existential boredom of the elderly. Psychology of Aging, 4(3), 178-165. [Persian]
Sadri Demirchi, A., & Ramezani, Sh. (2016). The effectiveness of existential therapy on loneliness and death anxiety in the elderly. Psychology of Aging, 2 (1), 1- 12.[Persian]
 Sadri Demirchi, A., Mohammadi, N., Ramezani, Sh., & Amanzad, Z. (2018). Evaluation of the effectiveness of group spiritual therapy on happiness and psychological hardiness of elderly women. Research in Religion and Health, 4 (2), 42-53. [Persian]
 Saffarinia, M., Sharifi Saki, Sh., & Ahmadi, H. (2016). The effectiveness of life review treatment techniques on the cognitive status of retired elderly men in Tehran. Journal of Health Psychology, 5 (20), 33-21. [Persian]
Savikko, N., Routasalo, P., Tilvis, R. S., Strandberg, T. E., & Pitkala, K. H. (2005). Predictors and subjective causes of loneliness in an aged population. Archives of Gerontology and Geriatrics, (4), 223- 233.
Shabani, p. (2019). Evaluation of the effectiveness of metacognitive therapy on improving learned helplessness and Cognitive mismatch of the elderly with movement disorders (Unpublished Master Thesis). Payame Noor University, Tehran.
Shaykh al-Islami, F., Reza Masouleh, S. h., Khodadadi, N., & Yazdani, M. (2011). Feeling lonely and the general health of the elderly. Comprehensive Nursing and Midwifery, 2 (66), 38-24. [Persian]
Shechtman, D., & Pastor, B. (2012). The effect of positive self-talk training on conflicts interpersonal in students with specific learning disabilities. Unpublished doctoral dissertation, Mississippi state University.    
Shoja Fard, S. H. (2020). Study and comparison of cognitive dissonance and social exchange styles in female patients with major depressive disorder and healthy women. Journal of Cognitive Psychology and Psychiatry, 7(3), 135- 124. [Persian]
Velayai, N., & Zalipour, S. (2015). The effectiveness of semantic therapy on death anxiety in the elderly. Journal of Aging Psychology, 5(1), 55-49. [Persian]
Wakslak, C. J. (2012). The experience of cognitive dissonance in important and trivial domains: A Construal-level theory approach. Journal of Experimental Social Psychology, 48(6), 1361–1364.
Wells A., & Sembi, S. (2009). Metacognitive therapy for PTSD: A core treatment manual. Cognitive and Behavioral Practice, 11(7), 365-377.
Wells, A. (2011).Panic disorder in association with relaxation-induced-anxiety: An Attentional training approach to treatment. Behavior Therapy, 2(1), 273-280.
 
Wu, L. F., & Koo, M. (2016). Randomized controlled trial of a six‐week spiritual
reminiscence intervention on hope, life satisfaction, and spiritual well‐being in elderly with mild and moderate dementia. International Journal of Geriatric Psychiatry, 31(2), 120-127.
 
Xinyue, Z., Liwei, Z., Lixing, Z., & Nan, G. (2009). The act of rejecting reduces the desire to reconnect Evidence for a cognitive dissonance account. Journal of Experimental Social Psychology, 45(1), 44–50.
Zandi, A. (2010). Standardization of the Arousal and Coordination Reduction Questionnaire (DARQ) in students of Payame Noor University of Tehran (Unpublished Master Thesis). Payame Noor University, Tehran. [Persian]
 Zare, H., and Saffarinia, M., & Rezaei, P. (2013). Comparison of metacognitive learning strategies, perfectionism and cognitive arousal between top rankings and other candidates for university entrance exams. Knowledge and Research in Applied Psychology, 14 (1), 62-53. [Persian]
Zarghami, H., & Mahmoudian, H. (2016). Child migration and loneliness of rural elderly parents. Journal of Health Psychology, 5 (19), 116-99. [Persian]
 Zhang, Y., Chen, Y., & Ma, L. (2018). Depression and cardiovascular disease in elderly: current understanding. Journal of Clinical Neuroscience, 47 (1), 1-5.

Keywords


References
Ahadi, H., & Jamhari, F. (2011). Developmental Psychology. Adolescence and adulthood, youth, middle age and old age). Tehran: Bright Future Publications. [Persian]
Askari, M., Mohammadi, H., Radmehr, H., & Jahangir, A. H. (2018). The Effect of spiritual–religious psychotherapy on enhancing quality of life and reducingsymptoms of anxiety and depression among the elderly. Journal of Research on Religion & Health, 4(2), 29-41. [Persian]
Aylaz, R., Aktürk, U., Erci, C., Özturk, H., & Aslan, H. (2014). Relationship between depression and loneliness in elderly and examination of influential factors. Archives of Gerontology and Geriatrics, 55(3), 684-699.
Barghi Irani, M., Abbasi, M., Khanbabaei Ghaleei, P., & Rezaei, Sh. (2020). The effectiveness of positive psychotherapy on death anxiety and loneliness in the elderly. The 4th National Conference on Psychology, Payame Noor University, Rasht. [Persian]
Barghi Irani, Z., Rajabi, M., Nazemi, M., & Begian Colehmers, M. J. (2017). The role of lifestyle, psychological capital and self-care behaviors in predicting the mental well-being of diabetic elderly. Journal of Health Psychology, 6 (3), 17-38. [Persian]
Boalhari, J., Naziri, Q., & Zamanian, S. (2012). The effectiveness of spiritual group therapy approach on reducing depression, anxiety and stress in women with breast cancer. Psychology Journal, 3 (1), 115-85. [Persian]
Cacioppo, J. T., Hughes, M. E., Waite, L. J., Hawkley, L. C., & Thisted, R. A. (2006). Loneliness as a specific risk factor for depressive symptoms: Cross-sectional and Longitudinal Analysis. Psychology and Aging, 21, 140-151.
Davidson, J. R., Ballenger, J. C., Lecrubier, Y., Nutt, D. J., Borkovec, T. D., & Rickels, K.(2001). Consensus statement on generalized anxiety disorder from the International Consensus Group on Depression and Anxiety. Journal of Clinical Psychiatry, 6(2), 53-58.
 Dehshiri, G., Sohrabi, F., Jafari, A., & Najafi, M. (2008). A Study of Psychometric Properties of Spiritual Well-Being Scale among Students, Psychological Studies, 2 (16), 137-123. [Persian]
Dinarvand, N. (2020a). Evaluation of the effectiveness of metacognitive therapy on learned helplessness, loneliness and death anxiety in the elderly with mobility disorders, Second Conference on Psychology, Educational Sciences, Social Sciences and Counseling, Padua, Italy. [Persian]
 Dinarvand, n. (2020b). Evaluation of the effectiveness of spiritual therapy on learned helplessness, loneliness and death anxiety in the elderly with mobility disorders, Second Conference on Psychology, Educational Sciences, Social Sciences and Counseling, Padua, Italy. [Persian]
Egan, L. C., Bloom, P., & Santos, L. R. (2010). Choice-induced preferences in the absence of choice: Evidence from a blind two choice paradigm with young children and capuchin monkeys. Journal of Experimental Social Psychology, 46(1), 204-207.
Festinger, L. (1957). A theory of cognitive dissonance. Stanford University Press
Ghaderi, D., & Mostafaei, A. (2014). The Relationship between Religious Orientation and Quality of Life in the Elderly Male Living at Home and Living in a Nursing Home. Elderly Journal, 9 (1), 21-14. [Persian]
Ghadmpour, A., Moradizadeh, S., & Shah Karami, M. (2019). Evaluation of the effectiveness of mindfulness training on reducing loneliness and death anxiety in the elderly in Siddiq Center of Khorramabad. Razi Journal of Medical Sciences, 26 (4), 44-53. [Persian]
Gwilliam P, Wells, A., & Cartwright-Hatton S. (2004). Dose meta-cognition or responsibility predict obsessive–compulsive symptoms: A Test of themetacognitive model. Clinical Psychology & Psychotherapy, 11(2), 137-144.
Harmon-Jones, E. (2000). Cognitive dissonance and experienced negative affect: Evidence that dissonance increases experienced negative affect even in the absence of aversive consequences. Personality and Social Psychology Bulletin, 26(12), 1490-1501.
Harrefors, C., Savenstedt, S., & Axelsson, K. (2009). Elderly people's perceptions of how they want to be cared for an interview study with healthy elderly couples in Northern Sweden. Scandinavian Journal of Caring Sciences, 23(2), 353-360.
Henrich, L. M., & Gullone, E. (2006). The clinical significance of loneliness: A literature review. Clinical Psychology Review, 27 (6), 695-718.
Kavosian, N., Kazemzadeh, H., Kazemi, H., & Carbro, A. (2018). The Relationship between Spiritual Health and Loneliness in the Elderly in Karaj. Journal of Research in Religion and Health, 4 (2), 15-7. [Persian]
 Kerch, d., Crash Field, R. S., & Blocky, A. S. (2008). The individual in the community, translated by Mahmoud Sanaei, Tehran: Zavar Publications. [Persian]
Khaleghipour, M., Masjidi, M. Sh., & Ahmadi, Z. (2016). The effectiveness of Islamic spiritual therapy on lifestyle and peripheral white blood molecules in depressed elderly. Journal of Research in Mental Health, 10 (3), 87-69. [Persian]
 Koushiar, H., Ghanbari Hashemabadi, b. A., & Ismaili, H. (2012). The effect of group reminiscence on the criterion of disability in old age. Iranian Journal of Aging, 7 (1), 29-21. [Persian]
Lee, Y., & Salman, A. (2018). The mediating effect of spiritual well-being on depressive symptoms and health-related quality of life among elders. Archives of Psychiatric Nursing, 32 (3), 418-424.
Liang, Y. J. (2016). Reading to make a decision or to reduce cognitive dissonance. Computers in Human Behavior, 64(1), 463-471.
Liu, L. J., & Guo, Q. (2007), Loneliness and health-related quality of life for the empty nest elderly in the rural area of a mountainous county in China. Quality of Life Research, 16(8), 1275- 1280.
Mansoori Sepehr, R., Heidari, M., Bagherian, F., & Shokri, A. (2018). The Effect of Choice Reversibility on Attitude Change in Cognitive Disorder: A Free Choice Paradigm. Journal of Applied Psychology, 12 (3), 319-337. [Persian]
McCoubrie, R. C., & Davies, A. N. (2006). “Is there a correlation between spirituality and anxiety and depression in patients with advanced cancer?” Support Care Cancer. Psychology Journal, 14 (4), 379-385.
Mirdrikund, F., Panahi, H., & Hosseini Ramghani, N. (2016). Feeling lonely in the elderly: the role of communication skills, social support and functional disability. Psychology of Aging, 2 (2), 113-103. [Persian]
Motamedi, N., Shafiee Darabi, M., & Amini, Z. (2018). Assessing the level of social and emotional loneliness in the elderly and its relationship with some social factors affecting health in Isfahan, Journal of Social Cognition, 36 (46), 756-750. [Persian]
Mr. Yousefi, A., Zare, H., Zare, M., & Shaghaghi, F. (2014). Investigating the role of decision-making styles in cognitive dissonance and the resulting physiological changes, Journal of Social Cognition, 7 (2), 81-67. [Persian]
Myers, S. G., & Wells, A. (2005). Obsessivecompulsive symptoms: the contribution of metacognitions and responsibility. Anxiety Disorders, 19(7), 817–806.
Nazemi Ardakani F., Alipour, A., & Abedi Jafari F., (2013). Investigating the Relationship between Cognitive Disorder and Personality Traits with Eating Disorder Symptoms. Research in mental health, 7(4), 11-20. [Persian]
Puchalski, C. M., Vitillo, R., Hull, S. K., & Reller, N. (2014). Improving the spiritual dimension of whole person care: reaching national and international consensus. Journal of Palliative Medicine, 17(6), 642-56.
Rostami, M., Rasouli, M., & Kasaei, A. (2018). Comparison of the effectiveness of group counseling based on spirituality-based therapy and therapy based on acceptance and commitment on the existential boredom of the elderly. Psychology of Aging, 4(3), 178-165. [Persian]
Sadri Demirchi, A., & Ramezani, Sh. (2016). The effectiveness of existential therapy on loneliness and death anxiety in the elderly. Psychology of Aging, 2 (1), 1- 12.[Persian]
 Sadri Demirchi, A., Mohammadi, N., Ramezani, Sh., & Amanzad, Z. (2018). Evaluation of the effectiveness of group spiritual therapy on happiness and psychological hardiness of elderly women. Research in Religion and Health, 4 (2), 42-53. [Persian]
 Saffarinia, M., Sharifi Saki, Sh., & Ahmadi, H. (2016). The effectiveness of life review treatment techniques on the cognitive status of retired elderly men in Tehran. Journal of Health Psychology, 5 (20), 33-21. [Persian]
Savikko, N., Routasalo, P., Tilvis, R. S., Strandberg, T. E., & Pitkala, K. H. (2005). Predictors and subjective causes of loneliness in an aged population. Archives of Gerontology and Geriatrics, (4), 223- 233.
Shabani, p. (2019). Evaluation of the effectiveness of metacognitive therapy on improving learned helplessness and Cognitive mismatch of the elderly with movement disorders (Unpublished Master Thesis). Payame Noor University, Tehran.
Shaykh al-Islami, F., Reza Masouleh, S. h., Khodadadi, N., & Yazdani, M. (2011). Feeling lonely and the general health of the elderly. Comprehensive Nursing and Midwifery, 2 (66), 38-24. [Persian]
Shechtman, D., & Pastor, B. (2012). The effect of positive self-talk training on conflicts interpersonal in students with specific learning disabilities. Unpublished doctoral dissertation, Mississippi state University.    
Shoja Fard, S. H. (2020). Study and comparison of cognitive dissonance and social exchange styles in female patients with major depressive disorder and healthy women. Journal of Cognitive Psychology and Psychiatry, 7(3), 135- 124. [Persian]
Velayai, N., & Zalipour, S. (2015). The effectiveness of semantic therapy on death anxiety in the elderly. Journal of Aging Psychology, 5(1), 55-49. [Persian]
Wakslak, C. J. (2012). The experience of cognitive dissonance in important and trivial domains: A Construal-level theory approach. Journal of Experimental Social Psychology, 48(6), 1361–1364.
Wells A., & Sembi, S. (2009). Metacognitive therapy for PTSD: A core treatment manual. Cognitive and Behavioral Practice, 11(7), 365-377.
Wells, A. (2011).Panic disorder in association with relaxation-induced-anxiety: An Attentional training approach to treatment. Behavior Therapy, 2(1), 273-280.
 
Wu, L. F., & Koo, M. (2016). Randomized controlled trial of a six‐week spiritual
reminiscence intervention on hope, life satisfaction, and spiritual well‐being in elderly with mild and moderate dementia. International Journal of Geriatric Psychiatry, 31(2), 120-127.
 
Xinyue, Z., Liwei, Z., Lixing, Z., & Nan, G. (2009). The act of rejecting reduces the desire to reconnect Evidence for a cognitive dissonance account. Journal of Experimental Social Psychology, 45(1), 44–50.
Zandi, A. (2010). Standardization of the Arousal and Coordination Reduction Questionnaire (DARQ) in students of Payame Noor University of Tehran (Unpublished Master Thesis). Payame Noor University, Tehran. [Persian]
 Zare, H., and Saffarinia, M., & Rezaei, P. (2013). Comparison of metacognitive learning strategies, perfectionism and cognitive arousal between top rankings and other candidates for university entrance exams. Knowledge and Research in Applied Psychology, 14 (1), 62-53. [Persian]
Zarghami, H., & Mahmoudian, H. (2016). Child migration and loneliness of rural elderly parents. Journal of Health Psychology, 5 (19), 116-99. [Persian]
 Zhang, Y., Chen, Y., & Ma, L. (2018). Depression and cardiovascular disease in elderly: current understanding. Journal of Clinical Neuroscience, 47 (1), 1-5.