2011. Vol.2, No.3, 150-154
Copyright © 2011 SciRes. DOI:10.4236/psych.2011.23024
The Role of Fear of Negative Evaluation in Predicting Depression
and Quality of Life Four Years after Bariatric Surgery in Women
Claire Elizabeth Adams1, Valerie Harwell Myers2, Brooke Louise Barbera1,
Phillip Jerome Brantley2
1Louisiana State University, Baton Rouge, USA;
2Pennington Biomedical Research Center, Baton Rouge, USA.
Received February 7th, 2011; revised April 15th, 2011; accepted May 17th, 2011.
The purpose of this study was to investigate the role of fear of negative evaluation (FNE) in predicting psycho-
social functioning (depression and quality of life (QOL)) as a function of amount of weight lost four years after
weight loss surgery among women. Four years after gastric bypass surgery, female participants (N = 29) com-
pleted measures of FNE, depression, and QOL via telephone. Height and weight (pre- and post-surgery) were
obtained from medical charts and current primary care physicians. FNE was not related to depression or QOL
among patients who lost less weight. However, FNE predicted greater depression and worse QOL among those
who had lost more weight four years after surgery. Several potential explanations are explored. Regardless of
why social concerns are related to mood and QOL for certain individuals post-surgery, psychosocial therapy that
addresses life transitions after weight loss, with particular focus on concerns about interpersonal evaluation,
might improve mental health outcomes for women after bariatric surgery.
Keywords: Bariatric Surgery, Obesity, Fear of Negative Evaluation, Social Anxiety, Quality of Life
Candidates for bariatric surgery often indicate feeling stig-
matized and having lower quality of life (QOL) due to their
weight (Sarwer, Fabricatore, Eisenberg, Sywulak, & Wadden,
2008). Obese individuals often experience high levels of inter-
personal sensitivity, social anxiety, and depression (Grilo,
Wilfley, Jones, Brownell, & Rodin, 1994; Petroni et al., 2007).
Fear of negative evaluation (FNE; Leary, 1983; Watson &
Friend, 1969), or concern about the prospect of being nega-
tively evaluated by others, may contribute to a great deal of
psychological distress and lower QOL for certain obese indi-
Much research suggests that dramatic weight loss can im-
prove mood, quality of life, and body image, and greater weight
loss is often associated with better psychological outcomes
(Foster, Wadden, & Vogt, 1997; Guisado, Vaz, Alarcón,
López-Ibor, Rubio, & Gaite, 2002; Herpertz, Kielmann, Wolf,
Langkafel, Senf, & Hedebrand, 2003; Karlsson, Taft, Rydén,
Sjöström, & Sullivan, 2007). However, some bariatric surgery
patients indicate significant symptoms of depression and body
dissatisfaction post-surgery (Sarwer et al., 2008). Furthermore,
patients who do experience mental health benefits often report a
peak in improvements after initial weight loss, with mental
health indices and health-related QOL diminishing over subse-
quent years (Karlsson et al., 2007; Mathus-Vliegen, 2007; Wa-
ters, Pories, Swanson, Meelheim, Flickinger, & May, 1991).
There is a need for more research utilizing specific measures of
psychological functioning rather than relying on global meas-
ures of mental health, as well as assessing long-term psycho-
logical outcomes, as initial gains may dissipate with time
(Bocchieri, Meana, & Fisher, 2002). Research should also in-
vestigate which patients are particularly prone to psychological
distress post-surgery and why.
FNE is defined as the extent to which people are concerned
about the prospect of negative interpersonal evaluation. Indi-
viduals with high levels of FNE tend to experience more anxi-
ety in social situations and attempt to avoid interpersonal en-
counters that they perceive to be threatening (Leary, 1983). A
great deal of research has described associations between FNE,
body dissatisfaction, and cognitions and behaviors related to
disordered eating among underweight and normal-weight
populations. For example, social anxiety is often comorbid with
eating disorders, and McClintock and Evans (2001) found a
direct link between FNE and disordered eating. Similarly, Gil-
bert and Meyer (2005) reported that FNE longitudinally pre-
dicted increased bulimic attitudes over a 7-month period. In
addition, Lundgren, Anderson, and Thompson (2004) reported
that fear of negative appearance evaluation predicted body im-
age dissatisfaction and dysfunctional eating attitudes. Taken
together, these findings suggest that FNE may contribute to
body dissatisfaction, dysfunctional eating, and associated psy-
chological distress and decreased QOL among individuals con-
cerned about their weight. FNE may be one important factor
contributing to psychological distress and decreased QOL for
patients after bariatric surgery. However, there is a dearth of
information on FNE in participants seeking weight loss treat-
Although research has documented psychosocial distress and
social anxiety among individuals with obesity and eating dis-
orders, specific relationships between FNE and QOL in obese
populations (and those receiving bariatric surgery) have not
been examined. The role of FNE post-bariatric surgery, as well
as its relation to depression and QOL after weight loss mainte-
nance, is unclear. For example, FNE and depression are typi-
C. E. ADAMS ET AL. 151
cally positively correlated (Duke, Krishnan, Faith, & Storch,
2006); however, relationships between FNE, depression, and
QOL in patients who lose more versus less weight are unknown.
The purpose of this study was to investigate the role of FNE in
psychosocial functioning after weight loss surgery.
The Office of Group Benefits (OGB), Louisiana’s managed
medical insurance program for state employees and their de-
pendents, initiated a study in 2003 with the Louisiana State
University School of Medicine to investigate outcomes of bari-
atric surgery. OGB teamed with Pennington Biomedical Re-
search Center for a follow-up study to examine outcomes four
years after surgery. Principal medical and psychosocial out-
comes are described elsewhere (Myers, Adams, Barbera, &
Brantley, in press). The present study is a sub-analysis of this
Participants were obese individuals (body mass index (BMI)
> 40 and < 60 kg/m2) between the ages of 35 and 60 who de-
nied comorbid malignancy or heart disease.
Weight. Pre-surgical weight and most current weight avail-
able were obtained from medical charts.
Short Form (36) Health Survey (SF-36; Ware, 1993). The
SF-36 is a self-report health profile that includes eight sub-
scales indicating QOL in several domains (physical function,
role function-physical, role function-emotional, bodily pain,
general health, social function, psychological well-being/mental
health, and vitality). Two summary scales, the Physical Com-
ponent Summary Score (PCS) and Mental Component Sum-
mary Score (MCS), are calculated. The SF-36 is widely used
and psychometrically sound. In the current study, there was
good evidence for reliability and validity of its administration
by telephone; internal consistency was excellent (Cronbach’s
alpha = 0.97 for the entire scale; ranged .83 - .96 for subscales),
and lower SF-36 scores were associated with higher levels of
Beck Depression Inventory-II (BDI-II; Beck, Steer, Ball, &
Ranieri, 1996). The BDI-II, a 21-item self-report scale, is a
widely-used measure of depressive symptoms with good psy-
chometric properties. Reliability of the telephone-administered
BDI-II in the current study was excellent (Cronbach’s alpha
Brief Fear of Negative Evaluation Scale (BFNE; Leary,
1983). The BFNE was created as a shortened form of Watson
and Friend’s (1969) 30-item FNE, designed to assess degree of
concern about the prospect of negative interpersonal evaluation.
Leary’s (1983) 12-item version of the scale showed good inter-
nal consistency and correlated highly with the original scale.
However, more recently researchers (e.g., Duke et al., 2006;
Rodebaugh, Woods, Thissen, Heimberg, Chambless, & Rapee,
2004) have suggested the use of only the eight straightfor-
wardly-worded items on the BFNE, as these items comprise a
single factor with excellent internal consistency and correlate as
expected with measures of loneliness and depression. Thus,
only these eight items were included in the present study.
In 2003, OGB informed 189, 398 insured members about a
study on gastric bypass surgery. All morbidly obese (BMI > 40)
adult members who wished to be considered for the surgery
were mailed packets including details of the study, a consent
form and HIPAA waiver. Those OGB members who returned
the documentation (N = 911) were mailed an additional letter
requesting a scheduled telephone interview. Additional screen-
ing processes included self-report anthropometric and health
information, and clinic visits in which standard diagnostic and
preoperative testing was conducted. To be eligible for the sur-
gery, participants needed to be between the ages of 35 and 60,
have a BMI greater than 40 but less than 60, and not be diag-
nosed with heart disease or malignancy. A total of 40 OGB
members were selected for the surgery. The surgeries (which
were all laparoscopic Roux-en-Y gastric bypass procedures)
occurred between April and November 2004. One postsurgical
In 2008, data collection was conducted via telephone and
chart review. Thirty of 39 patients completed psychosocial
measures via telephone; the remaining nine were unable to be
reached by telephone. Only one of the patients who completed
psychosocial measures was male; thus, the sample was re-
stricted to the 29 women who completed measures. Height and
weight (pre- and post-surgery) were obtained from medical
charts and current primary care physicians. All aspects of data
collection and management were reviewed and approved by the
Pennington Biomedical Research Center Institutional Review
Participants were predominantly Caucasian (22 Caucasians,
6 African Americans, 1 Hispanic). The average age was 51.9
(SD = 7.60 years). The sample was highly educated, with 75%
attending at least some college. Weight loss and psychological
outcomes are presented by Myers et al. (in press). Participants
in the current sample lost an average of 95.43 (SD = 22.40)
pounds (range 63 - 170 lbs.), or a loss of 33.62% of initial
weight (SD = 6.68%, ranging 21% - 49%). Average pre-surgi-
cal BMI was 47.95 (SD = 4.28; range 41.2 - 58.2). Average
BMI 4-years post-surgery was 31.82 (SD = 4.59; range 24.21 -
Participants’ mean BFNE total score was 14.10 (SD = 6.62),
suggesting a generally low degree of concern about interper-
sonal evaluation. Myers et al. (in press) reported that on the
BDI-II, the total sample reported minimal depressive symptoms,
and that SF-36 scores suggested good/normal levels of general
mental and physical QOL. Descriptive statistics for demo-
graphic variables, percent weight loss, and psychosocial meas-
ures are shown in Table 1. In addition, this information is given
for participants who lost relatively more versus less weight, as
defined by a median split (median percent weight lost = .33).
Independent samples t-tests and chi-square analyses indicated
that participants who lost more versus less weight did not differ
C. E. ADAMS ET AL.
significantly on demographic variables, baseline weight, FNE,
depression, or any type of QOL, ps > .14.
Relationships between FNE, Weight Loss, and
Psychosocia l O ut comes
First, Pearson product moment correlations were conducted
between FNE, BDI-II, mental and physical QOL scores from
the SF-36, and percent of weight loss. These correlations are
presented in Table 2. FNE was correlated with higher levels of
depressive symptoms. However, FNE was not related to physi-
cal or mental QOL, or percent of weight lost after surgery.
Next, a series of hierarchical regression analyses were con-
ducted predicting QOL and BDI-II from FNE, percentage of
weight lost, and the interaction between FNE and weight loss,
controlling for age, race, and education. Data were examined
for adherence to assumptions of normality and homoscedastic-
ity, and outliers greater than 3.3 standard deviations from their
predicted mean were removed (as suggested by Tabachnick &
There were no significant main effects of demographic vari-
ables, FNE, or percent weight loss on depression or QOL, ps
> .05. However, results revealed significant interactions be-
tween FNE and weight loss in predicting mental QOL (F(1,17)
= 7.21, p = .01, sr2 = .24), and depression (F(1,19) = 10.92, p
= .004, sr2 = .30). In addition, there was a marginally significant
interaction in predicting physical QOL (F(1,17) = 3.08, p = .09,
sr2 = .14).
Interactions were decomposed with analyses of simple slopes
at specified levels of weight loss as recommended by Aiken and
West (1991). In predicting mental QOL, FNE was not related to
MCS scores among participants who lost less weight (i.e., those
1 SD below the mean of percent weight loss), p = .56. However,
among participants who lost more weight (i.e. 1 SD above the
mean), FNE predicted worse mental QOL, t(21) = 3.67, p =
0.001, sr2 = .38. See Figure 1. The same pattern emerged for
physical QOL. FNE was not related to PCS scores among par-
ticipants who lost less weight, p = .21; however, among those
who lost more weight, FNE predicted worse physical QOL,
t(21) = 2.13, p = .04, sr2 = .17. Similarly, among participants
who lost less weight, FNE was not related to depression, p
= .48. However, among participants who lost more weight,
FNE predicted higher depression, t(23) = 4.42, p < .001, sr2
In examining specific aspects of QOL, significant interac-
tions between FNE and weight loss emerged for physical func-
tion (F(1,17) = 5.07, p = .04, sr2 = .19), general health (F(1,17)
= 6.47, p = .02, sr2 = .22), social function (F(1,17) = 9.69, p
= .006, sr2 = .30), and mental health (F(1,17) = 11.46, p = .004,
sr2 = .31). Post-hoc analyses of simple slopes for each subscale
were consistent with results for PCS and MCS indices; FNE
was not related to QOL among participants who lost less
weight; however, among those who lost more weight, FNE
predicted worse QOL related to physical function, general
health, social function, and mental health. Table 3 shows corre-
lations between FNE and domains of QOL for participants who
lost more versus less weight based on a median split (median
percent weight lost = .33).
Demographic Characteristics, Percent Weight Loss, and Psychosocial Variables for the Total Sample and Split by Percent Weight Loss (standard
deviations in parentheses).
Total Sample (n = 29) Less Weight Loss (21% - 32%; n = 12)More Weight Loss (34% - 49%; n = 15)
Age 51.90 (7.60) 54.25 (3.86) 48.73 (8.66)
% Caucasian 75.9% 83.3% 73.3%
% Attending at Least Some College 75.0% 75.0% 73.3%
Baseline BMI 47.95 (4.28) 48.13 (4.37) 47.71 (4.63)
% Weight Loss 4 Years after Surgery 33.62% (6.68%) 27.99% (3.72%) 38.12 (4.81)
FNE 14.10 (6.62) 15.58 (8.16) 13.20 (5.44)
BDI-II 5.69 (11.50) 4.67 (8.66) 6.20 (14.02)
PCS 49.96 (10.35) 50.80 (10.92) 51.51 (8.86)
MCS 52.77 (10.10) 53.43 (8.31) 53.36 (11.41)
BMI = Body Mass Index; FNE = Brief Fear of Negative Evaluation Scale; BDI-II = Beck Depression Inventory, 2nd Edition; PCS = Physical Component Summary Score
of Short-Form Health Survey (SF-36); MCS = Mental Component Summary Score of SF-36.
Correlations between Fear of Negative Evaluati o n, Depression, Quality of Life, and Weight Loss.
FNE BDI-II PCS MCS % Weight Loss
FNE 1 .36* −.17ns −.32ns −.08ns
BDI-II .36* 1 .77** .76** .07ns
PCS –.17ns .77** 1 .50** .14ns
MCS −.32ns .76** .50** 1 −.12ns
% Weight Loss −.08ns .07ns .14ns −.12ns 1
FNE = Brief Fear of Negative Evaluation Scale; BDI-II = Beck Depression Inventory, 2nd Edition; PCS = Physical Component Summary Score of Short-Form Health
Survey (SF-36); MCS = Mental Component Summary Score of SF-36. * p < .05; ** p < .01.
C. E. ADAMS ET AL. 153
Interaction of Fear of N e g ative Evaluation (FNE) by percent weight loss for Mental Quality of Life (QOL).
Correlations between Fear of Negative Evaluation, Depression, and Quality of Life Subscales among Participants who Lost More versus Less
Less Weight Loss (21% - 32%)
(n = 12)
More Weight Loss (34% - 49%)
(n = 15)
BDI-II .02 ns .68**
Physical Functioning .07 ns −.63*
Role-Physical .02 ns −.21
Bodily Pain −.24 ns −.38
General Health −.06 ns −.58*
Vitality −.09 ns −.60*
Social Functioning .008 ns −.71**
Role-Emotional −.05 ns −.37
Mental Health −.06 ns −.67**
BDI-II = Beck Depression Inventory, 2nd Edition. *p < .05; **p < .01.
FNE did not predict depression or QOL among women who
maintained less weight loss after bariatric surgery. However,
FNE was strongly related to depression and QOL among those
who maintained greater weight loss. We propose three potential
First, patients whose social concerns are closely tied to
evaluations of physical appearance and QOL may be more
inclined to maintain weight loss. That is, because these indi-
viduals’ level of social anxiety strongly affects their QOL, they
are more motivated to engage in behavioral strategies post-
surgery to maintain weight loss. We are unaware of research
investigating this possibility and encourage future studies to
examine weight loss outcomes in individuals whose social
concerns are strongly related to their QOL even before weight
A second potential explanation is related to social changes
after extreme weight loss. Individuals who have lost a great
deal of weight are more mobile and active in their communities,
more likely to receive social attention related to drastic weight
loss, and more likely to encounter social situations in which
fear of negative evaluation might lead to sad mood or worsened
QOL. Among patients who maintain considerable weight loss,
those who still have significant worries about interpersonal
evaluation may be especially prone to more psychological dis-
tress and lower quality of life. On the other hand, for people
who do not lose or maintain great amounts of weight, perhaps
these individuals remain generally concerned about their
physical health so that social concerns play less of a role in
In support of this explanation, Sogg and Gorman (2008)
noted that many weight loss surgery patients report receiving
more positive social attention as they lose weight; however,
some patients feel uncomfortable receiving compliments, and
some perceive such a striking increase in positive feedback as
evidence that people viewed them quite negatively before
weight loss. In addition, after surgery patients often receive
more romantic attention; although most patients are pleased
with this change, some may feel threatened or unsure of them-
selves if they did not develop the social skills for dating before
A third potential explanation is that after considerable weight
loss, attributions related to negative interpersonal evaluation
might change. That is, prior to weight loss, many participants
might have attributed negative evaluation directly to their obe-
sity. However, if they still perceive negative evaluation after
considerable weight loss, they might now attribute negative
evaluation to more internalized factors rather than their weight,
which may worsen mood and quality of life. In support of this
C. E. ADAMS ET AL.
explanation, Bocchieri, Meana, and Fisher (2002) suggested
that patients may experience psychological difficulties after
surgery if they tended to attribute preoperative difficulties (e.g.,
social rejection, low self-confidence) to their obesity. After
dramatic weight loss, they are no longer able to attribute per-
sistent life difficulties to their obesity.
The present study is limited by a small sample size and lack
of pre-surgical psychological assessment. Because the sample
includes only women and is largely Caucasian, we do not know
whether these results would generalize to more diverse groups.
In addition, because of the correlational nature of the analyses,
we cannot conclude causality. In other words, we cannot imply
that FNE causes greater depression or worse QOL among pa-
tients who lose more weight after surgery; we can only state
that FNE is strongly related to these other constructs. Further-
more, our study is limited by the use of telephone administra-
tion of psychosocial measures. However, although psychomet-
ric properties have not been previously reported on telephone
administration of the measures in the current study, our results
suggest telephone administration to be reliable and valid.
Although this is a preliminary study with clear limitations,
the current research has a number of strengths. For example,
this study is strengthened by a long-term follow-up period, use
of specific rather than global measures of psychological func-
tioning, examination of relationships between psychological
constructs as a function of amount of weight lost, and signifi-
cant results despite the small sample size. To our knowledge,
this is the first study to investigate relationships between FNE
and bariatric surgery outcomes.
Concerns about interpersonal evaluation are related to greater
depressive symptoms and worse QOL among women who lose
more weight after bariatric surgery. Future research is needed to
replicate these findings with larger, more diverse samples and
to test the validity of competing hypotheses for why FNE is
associated with depression and QOL for certain individuals
after surgery. Regardless of why social concerns are related to
mood and QOL for certain people post-surgery, psychosocial
therapy that addresses life transitions after weight loss, with
particular focus on concerns about interpersonal evaluation,
might improve mental health outcomes.
Aiken, L. S., & West, S. G. (1991). Multiple Regression: Testing and
Interpreting Interact ions. Thousand Oaks: Sage.
Bocchieri, L. E., Meana, M,. & Fisher, B. L. (2002). A review of psy-
chosocial outcomes of surgery for morbid obesity. Journal of Psy-
chosomatic Research, 52, 155-165.
Beck, A.T., Steer, R. A., Ball, R., & Ranieri, W. F. (1996). Comparison
of Beck Depression Inventories-1A and II in psychiatric outpatients.
Journal of Personality Assessment, 67, 588-597.
Duke, D., Krishnan, M., Faith, M., & Storch, E. A. (2006). The psy-
chometric properties of the Brief Fear of Negative Evaluation Scale.
Anxiety Disorders, 20, 807-817. doi:10.1016/j.janxdis.2005.11.002
Foster, G. D., Wadden, T. A., & Vogt, R. A. (1997). Body image in
obese women before, during, and after weight loss treatment. Health
Psychology, 16, 226-229. doi:10.1037/0278-6184.108.40.206
Gilbert, N., & Meyer, C. (2005). Fear of negative evaluation and the
development of eating psychopathology: A longitudinal study among
nonclinical women. International Journal of Eating Disorders, 37,
Grilo, C. M., Wilfley, D. E., Jones, A., Brownell, K. D., & Rodin, J.
(1994). The social self, body dissatisfaction, and binge eating in
obese females. Obesity Research, 2, 24-27.
Guisado, J. A., Vaz, F. J., Alarcón, J., López-Ibor, J. J., Rubio, M. A.,
& Gaite, L. (2002). Psychopathological status and interpersonal
functioning following weight loss in morbidly obese patients under-
going bariatric surgery. Obesity Surgery, 12, 835-840.
Herpertz, S., Kielmann, R., Wolf, A. M., Langkafel, M., Senf, W., &
Hedebrand, J. (2003). Does obesity surgery improve psychosocial
functioning? A systematic review. International Journal of Obesity,
27, 1300-1314. doi:10.1038/sj.ijo.0802410
Karlsson, J., Taft, C., Sjostrom, L., & Sullivan, M. (2007). Ten-year
trends in health-related quality of life after surgical and conventional
treatment for severe obesity: The SOS intervention study. Interna-
tional Journal of Obesity, 3 1 , 1248-1261. doi:10.1038/sj.ijo.0803573
Leary, M. R. (1983). A brief version of the Fear of Negative Evaluation
Scale. Personality and Social Psychology Bulletin, 9, 371-375.
Lundgren, J. D., Anderson, D. A., & Thompson, J. K. (2004). Fear of
negative appearance evaluation: Development and evaluation of a
new construct for risk factor work in the field of eating disorders.
Eating Behaviors, 5, 75-84. doi:10.1016/S1471-0153(03)00055-2
Mathus-Vliegen, E. M. H. (2007). Long-term health and psychosocial
outcomes from surgically induced weight loss: Results obtained in
patients not attending protocolled follow-up visits. International
Journal of Obesity, 31, 299-307. doi:10.1038/sj.ijo.0803404
McClintock, J. M., & Evans, I. M. (2001). The underlying psychopa-
thology of eating disorders and social phobia: A structural equation
analysis. Eating Behaviors, 2, 247-261.
Myers, V. H., Adams, C. E., Barbera, B., L., & Brantley, P. J. (in press).
Medical and psychosocial outcomes of laparoscopic Roux-en-Y gas-
tric bypass: Cross-sectional findings at 4-year follow-up. Obesity
Surgery, in press. doi:10.1007/s11695-010-0324-7
Petroni, M. L., Villanova, N., Avagnina, S., Fusco, M. A., Fatati, G., &
Compare, A., et al. (2007). Psychological distress in morbid obesity
in relation to weight history. Obesity Surgery, 17, 391-399.
Rodebaugh, T. L., Woods, C. M., Thissen, D. M., Heimberg, R. G.,
Chambless, D. L., & Rapee, R. M. (2004). More information from
fewer questions: The factor structure and item properties of the
Original and Brief Fear of Negative Evaluation Scale. Psychological
Assessment, 16, 169-181. doi:10.1037/1040-35220.127.116.11
Sarwer, D. B., Fabricatore, A. N., Eisenberg, M. H., Sywulak, L. A., &
Wadden, T. A. (2008). Self-reported stigmatization among candi-
dates for bariatric surgery. Obesity, 16, S75-S79.
Sogg, S., & Gorman, M. J. (2008). Interpersonal changes and chal-
lenges after weight-loss surgery. Primary Psychiatry, 15, 61-66.
Tabachnick, B. G., & Fidell, L. S. (2007). Using Multivariate Statistics
(5th ed.). Boston: Pearson.
Ware, J. E. (1993). SF-36 Healt h survey: Manual and interpretation guide.
Boston, MA: The Health Institute, New England Medical Center.
Waters, G. S., Pories, W. J., Swanson, M. S., Meelheim, H. D., Flick-
inger, E. G., & May, H. J. (1991). Long-term studies of mental health
after the Greenville gastric bypass operation for morbid obesity.
American Journal of Surgery, 161, 154-157.
Watson, D., & Friend, R. (1969). Measurement of social-evaluative
anxiety. Journal of Consulting and Clinical Psychology, 33, 448-457.