Further examination of the relationship between anxiety sensitivity and depression: the mediating role of experiential avoidance and difficulties engaging in goal-directed behavior when distressed

Experiential Avoidance as a Factor in Generalized Psychological Vulnerability: In the Relationship Between Chronic Pain and Pain Anxiety With Pain Disability

BACKGROUND

Pain is a major socio-psychological problem worldwide. Chronic pain has a negative effect on areas of psychological functioning such as depression, anxiety, and perceived stress.

AIM

The present study investigated the mediating role of experiential avoidance in the relationship between chronic pain and pain anxiety with pain disability.

METHODS

Participants were treatment-seeking patients (N = 361) at an outpatient pain clinic in Shiraz (Fars, Iran). The Multidimensional Pain Inventory (MPI), Pain Anxiety Symptom Scale (PASS-20), Pain Disability Questionnaire (PDQ), and Acceptance and Action Questionnaire-II (AAQ-II) were used to measure multidimensional pain, anxiety, pain disability, experiential avoidance, and pain severity.

RESULTS

The results of the correlation revealed that a significant relationship exists between multidimensional pain and pain anxiety, pain disability, and experiential avoidance. Experiential avoidance mediated the associations from multidimensional pain and pain disability significantly. Also, experiential avoidance moderated associations between pain anxiety and pain disability significantly. In general, Structural Equation Modeling (SEM) showed that experiential avoidance mediated the relationship between multidimensional pain and pain anxiety with pain disability.

CONCLUSION

In general, the results revealed that experiential avoidance can mediate the relationship among pain, pain anxiety, and pain disability as a maladaptive regulation strategy. The results obtained from this study seem to introduce experiential avoidance as a vulnerability factor effectively.

Transdiagnostic Approach and Obsessive Compulsive Disorder

The categorical approach of traditional psychiatric nosology has been a forceful approach for a very long time for explaining psychological disorders which are defined by symptom based diagnostic categories. However, in recent years, the importance of the "transdiagnostic" approach which is a new classification system is increasing. The transdiagnostic approach aims to examine dimensionally the common cognitive, behavioral, interpersonal and biological processes underlying many psychopathologies away from the categorical approach that classifies psychopathologies according to observable symptoms. This approach intends to treat the disorders through the common underlying processes and risk factors, thus heterogeneous and comorbid symptoms are better addressed and diagnostic categories that may change during treatment are avoided. In this review study, the current problems in diagnosing based on classification and gaps in the field were examined, and the approach itself was proposed as a solution. RDoC (Research Domain Criteria) which is a new classification system for psychiatric disorders within the scope of the approach, has created a new structure using modern research approaches in genetics, neuroscience and behavioral sciences. In the present study, the definition and emergence of the transdiagnostic approach, obsessive compulsive disorder and RDoC in the context of transdiagnostic approach and transdiagnostic treatment are explained. This review is intended to be a resource for both basic psychopathology research and the development of treatment methods within the framework of a transdiagnostic approach.

Depression mediates the relationship of experiential avoidance and internet addiction: a cross-lagged mediation analysis

Previous research has identified the contemporaneous association between experiential avoidance, depression, and Internet addiction. However, the mechanisms underlying this association are not well acknowledged. The present study aimed to use cross-lagged panel modeling to examine whether depression mediates the relation between experiential avoidance and Internet addiction and whether gender plays a role in the relation. A total of 2731 participants (934 male, Meanage=18.03) were recruited from a university at the baseline study (December 2019). Data was collected at all 3 time points across one year (2019?2020), using 6-month intervals. Experiential avoidance, depression and Internet addiction were assessed using the Acceptance and Action Questionnaire-II (AAQ-II), the Beck Depression Inventory-II (BDI-II) questionnaire, and Young?s Internet Addiction Test (IAT), respectively. Cross-lagged panel models were used to evaluate the longitudinal association and the mediating effect. Multigroup analyses were conducted to examine gender differences in the models.Cross-lagged models indicated that experiential avoidance significantly predicted subsequent depression, and depression significantly predicted subsequent Internet addiction. Furthermore, mediation analyses showed that depression has a mediating effect in the relation between experiential avoidance and Internet addiction (? = 0.010, 95%CI[0.003, 0.018], p>0.001). Multigroup analyses demonstrated that the pattern of structural relations stayed consistent across gender. The findings indicated that experiential avoidance is indirectly related to Internet addiction through depression, suggesting that treatments targeted at reducing experiential avoidance could help relieve depression and thus decrease the risk of Internet addiction.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12144-023-04511-6.

A Smartphone-Based Intervention for Anxiety and Depression in Racially and Ethnically Diverse Adults (EASE): Protocol for a Randomized Controlled Trial

BACKGROUND

Clear health disparities have emerged in the rates of COVID-19 exposure, hospitalization, and death among Black, Hispanic, and American Indian (BHAI) individuals, relative to non-Hispanic White (NHW) individuals. BHAI populations have been disproportionately affected by lower behavioral health access and heightened negative mental health outcomes during the pandemic.

OBJECTIVE

This project directly addresses health disparities in access to behavioral health care during the COVID-19 pandemic among BHAI populations via an adaptation of the established, initially validated, low-cost, mobile app Easing Anxiety Sensitivity for Everyone (EASE) among individuals with symptoms of elevated anxiety or depression or both.

METHODS

The EASE trial is a 2-arm, prospective, randomized, blinded-assessor study with intention-to-treat analysis. Participants (N=800; n=200, 25%, Black; n=200, 25%, Hispanic; n=200, 25%, American Indian; and n=200, 25%, NHW) are randomized to receive either EASE or an active comparison condition for anxiety and depression. Participants compete an online prescreener, an enrollment call to provide informed consent, a baseline survey, a 6-month intervention period, and 3- and 6-month postbaseline assessments. Select participants also complete a 3- and 6-month postbaseline qualitative interview via phone or an online platform (eg, Zoom). Participants complete 2 scheduled daily ecological momentary assessments (EMAs) during the 6-month study period. These twice-daily EMAs guide a just-in-time approach to immediate, personalized behavioral health care.

RESULTS

Outcomes include reductions in anxiety and depressive symptoms and functional impairment at 3 and 6 months postrandomization. We also will examine putative mechanisms (eg, anxiety sensitivity [AS] and COVID-19-specific stress and fear) of the intervention effects. Further, as treatment effects may differ across sociocultural factors, perceived discrimination, social support, and socioeconomic status (SES) will be evaluated as potential moderators of treatment effects on the primary outcomes. Process evaluation using data collected during the study, as well as individual interviews with participants, will complement quantitative data.

CONCLUSIONS

Data from this efficacy trial will determine whether EASE successfully improves symptoms of anxiety and depression and whether these improvements outperform an active comparison control app. If successful, findings from this study have the potential to decrease anxiety and depression symptoms among vulnerable populations determined to be most at risk of exacerbated, long-lasting negative health sequelae. Data from this study may be used to support an implementation and dissemination trial of EASE within real-world behavioral health and social service settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05074693; https://clinicaltrials.gov/ct2/show/NCT05074693.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/40713.

Anxiety-related activity of ventral hippocampal interneurons

Anxiety is an aversive mood reflecting the anticipation of potential threats. The ventral hippocampus (vH) is a key brain region involved in the genesis of anxiety responses. Recent studies have shown that anxiety is mediated by the activation of vH pyramidal neurons targeting various limbic structures. Throughout the cortex, the activity of pyramidal neurons is controlled by GABA-releasing inhibitory interneurons and the GABAergic system represents an important target of anxiolytic drugs. However, how the activity of vH inhibitory interneurons is related to different anxiety behaviours has not been investigated so far. Here, we integrated in vivo electrophysiology with behavioural phenotyping of distinct anxiety exploration behaviours in rats. We showed that pyramidal neurons and interneurons of the vH are selectively active when animals explore specific compartments of the elevated-plus-maze (EPM), an anxiety task for rodents. Moreover, rats with prior goal-related experience exhibited low-anxiety exploratory behaviour and showed a larger trajectory-related activity of vH interneurons during EPM exploration compared to high anxiety rats. Finally, in low anxiety rats, trajectory-related vH interneurons exhibited opposite activity to pyramidal neurons specifically in the open arms (i.e. more anxiogenic) of the EPM. Our results suggest that vH inhibitory micro-circuits could act as critical elements underlying different anxiety states.

Is Anxiety Sensitivity Associated with COVID-19 Related Distress and Adherence among Emerging Adults?

We investigated whether anxiety sensitivity (AS) is associated with increased distress and adherence to public health guidelines during the COVID-19 pandemic among undergraduates, and whether increased distress mediates the relationship between AS and increased adherence. An online cross-sectional survey was conducted with 1318 first- and second-year undergraduates (mean age of 19.2 years; 79.5% females) from five Canadian universities. Relevant subscales of the Substance Use Risk Profile Scale (SURPS) and the Big Five Inventory-10 (BFI-10) were used to assess AS and neuroticism. Three measures tapped distress: the Patient Health Questionnaire-9 (PHQ-9) for depressive symptoms, the Generalized Anxiety Disorder-7 (GAD-7) for anxiety symptoms, and the Brief COVID-19 Stress Scales (CSS-B) for COVID-19-specific distress. The COVID-19 Adherence scale (CAD) assessed adherence to COVID-19 containment measures. AS was significantly independently associated with higher general distress (both anxiety and depressive symptoms) and higher COVID-19-specific distress, after controlling age, sex, study site, and neuroticism. Moreover, AS indirectly predicted greater adherence to COVID-19 preventive measures through higher COVID-19-specific distress. Interventions targeting higher AS might be helpful for decreasing both general and COVID-19-specific distress, whereas interventions targeting lower AS might be helpful for increasing adherence to public health containment strategies, in undergraduates.

The Difficulties in Emotional Regulation among a Cohort of Females with Lipedema

BACKGROUND

Lipedema is a chronic and progressive adipose tissue disorder that causes significant morbidity and negatively influences mental health and quality of life, and increases the risk of depression, anxiety, and eating disorders. One construct of relevance to better understanding psychological disorders is emotion regulation (ER). Therefore, the aim of this study is to investigate the difficulties in ER among lipedema patients compared to healthy people without lipedema.

METHODS

This cross-sectional study assessed differences in ER and anxiety between two groups: 26 female patients with lipedema and 26 sex- and age-matched healthy controls. The Difficulties in Emotion Regulation Scale (DERS) assessed emotional regulation across six dimensions: Impulse control, goal-directed behavior, awareness, clarity, non-acceptance, and strategies. Anxiety was assessed by the Hamilton Anxiety Scale (HAM-A). ANOVA assessed differences in measures between lipedema and healthy control groups.

RESULTS

Lipedema patients presented with significantly more difficulties in ER and a higher level of anxiety than those without lipedema. Specifically, the lipedema group showed higher and significant differences in total DERS and anxiety scores and all DERS subscales scores compared to those without lipedema.

CONCLUSIONS

Lipedema patients showed significant difficulties with ER, and were associated with anxiety symptoms, indicating that ER difficulties may play a role in developing emotional disorders, such as anxiety, for patients with lipedema. The health care provider should pay more attention to ER difficulties and psychological status among lipedema patients.

Mindful Awareness Promotes Resilience: Buffered Links Among Childhood Sexual Abuse Severity, Goal-Directed Emotion Dysregulation, and Psychopathology

Objectives

Childhood sexual abuse is linked to long-term consequences, including depression and anxiety in adulthood. Although considerable progress has been made to understand mechanisms that may account for this relation, such as emotion dysregulation, less attention has been given to protective factors that may mitigate it. One such protective factor might be mindful awareness. Those who act with awareness in daily living tend to engage in healthy emotion regulation skills when faced with stressors and experience less depression and anxiety. In the current study, we aimed to replicate the positive associations among childhood sexual abuse severity, emotion dysregulation, and psychopathology across time, and also identify a personal strength-in this case, mindful awareness-that might mitigate these effects.

Methods

Participants were 491 women recruited from the community who completed self-report assessments at three time points over a 32-month period.

Results

A series of moderated mediation models revealed childhood sexual abuse severity predicted later reports of depression and anxiety symptoms through greater emotion dysregulation in the form of difficulties engaging in goal-directed behaviors. As expected, mindful awareness weakened the relation between goal-directed emotion dysregulation and symptoms of depression and anxiety, such that greater levels of mindful awareness fully buffered these effects.

Conclusions

Through a better understanding of natural resiliency processes among survivors, we can ultimately encourage continued examination of what might be effective additions to existing treatments for the mental health consequences of trauma and adversity.

Childhood maltreatment and emotional distress: The role of beliefs about emotion and psychological inflexibility

The current study aimed to investigate the mediating role of negative beliefs about emotion and psychological inflexibility on the relationship between childhood maltreatment and emotional distress. A total of 519 participants completed the Childhood Trauma Questionnaire (CTQ), Depression Anxiety Stress Scale-21 (DASS-21), the Leahy Emotional Schema Scale II (LESS-II), and the Acceptance and Action Questionnaire-II (AAQ-II). All scales were significantly correlated. Two mediation analyses were tested. In the first model negative beliefs about emotion and psychological inflexibility mediated the relationship between childhood maltreatment and emotional distress measured by DASS-21 total score. In the second model, negative beliefs about emotion and psychological inflexibility mediated the relationship between childhood maltreatment and depression, anxiety, and stress measured by the subscales of DASS-21. Results suggest that maltreatment in childhood is associated with the individuals' approaches, plans and strategies in response to emotions, and psychological inflexibility which together further determine emotional distress.

Anxiety and depressive symptoms among adults with obesity and chronic pain: the role of anxiety sensitivity

Obesity and chronic pain frequently co-occur, and this co-occurrence can have potential negative consequences, particularly as it relates to mental health. As such, there is a need to understand potential risk factors for poor mental health among this co-morbid population. Thus, the current study examined the predictive role of anxiety sensitivity (and its sub-facets) on anxiety and depressive symptoms among adults (82.5% female, M_age = 40.2 years, SD = 10.92) with obesity and chronic pain. Results revealed that greater levels of anxiety sensitivity were associated with greater levels of both anxiety and depressive symptoms, with medium to large effect sizes. Post hoc analyses also indicated that specific sub-facets of anxiety sensitivity (cognitive and social concerns) were significant predictors of the criterion variables. The current study highlights the potential clinical utility in targeting anxiety sensitivity among individuals with co-occurring obesity and chronic pain in the treatment of anxiety and depressive symptoms.

Emotion regulation and substance use: A meta-analysis

There has been exponential growth in research on emotion regulation and substance use in the past decade. The current meta-analysis evaluated variability in the magnitude of the relation between aspects of emotion regulation and substance use. A search of PsycINFO, Embase, PubMed, CINAHL Plus, and PILOTS in December 2020 resulted in 6642 initial studies, of which 95 met inclusion criteria (association between emotion regulation and substance use was reported, participants were > 18 years old, article was in English). A total of 445 effects were obtained (N = 156,025 participants; weighted M_age = 29.31; 59.5% female; 66.1% White; 76.6% non-clinical). Emotion regulation and substance use were significantly related (r = 0.19; p < 0.001; 95%CI [0.17, 0.20]). Emotion regulation abilities were generally more strongly related to substance use than emotion regulation strategies; this pattern was stronger for behavioral vs. cognitive abilities and extended to both negative and positive emotions. Relations were stronger for older and clinical samples; mixed effects were found for sex and no conclusive effects were found for race. Despite limitations of the existing literature (e.g., cross-sectional, self-reports), results indicated that the magnitude of the relation between emotion regulation and substance use varied considerably as a function of emotion regulation and substance use constructs and sample characteristics.

Examining depression symptoms within OCD: the role of experiential avoidance

BACKGROUND

Obsessive compulsive disorder (OCD) and depression commonly co-occur. Past research has evaluated underlying mechanisms of depression in the context of other diagnoses, but few to no studies have done this within OCD.

AIMS

This study examines the relationships between distress tolerance (DT), experiential avoidance (EA), depression, and OCD symptom severity across intensive/residential treatment (IRT) for OCD. It was hypothesized that all variables would be significantly moderately related and EA would emerge as a potential contributing factor to change in depression and OCD symptoms across IRT for OCD.

METHOD

The sample included 311 participants with a primary diagnosis of OCD seeking IRT. Correlations were performed between all variables at both admission and discharge. A two-step hierarchical regression with change in OCD symptoms and change in DT in the first block and change in EA in the second block examined if change in EA explained change in depression above and beyond change in OCD and DT ability.

RESULTS

At both admission and discharge, higher EA, lower DT, and higher OCD symptom severity were significantly associated with more depressive symptoms. Change in EA explained a significant amount of variance in change in depression above and beyond change in OCD symptom severity and change in DT.

CONCLUSIONS

This study expands past results within an OCD sample, emphasizing EA as an important treatment target in OCD. Future studies could utilize samples from other treatment contexts, use a measure of EA specific to OCD, and utilize a longitudinal model that takes temporal precedence into account.

Racial and ethnic differences in emotion regulation: A systematic review

OBJECTIVE

Emotion regulation is a transdiagnostic mechanism with relevance to the etiology, maintenance, and treatment of a wide range of clinically relevant outcomes. This study applied systematic review methods to summarize the existing literature examining racial and ethnic differences in emotion regulation.

METHODS

We systematically searched four electronic databases (PsycINFO, Embase, MEDLINE, and CINAHL Plus) using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

Of the initial 1253 articles, 25 met the inclusion criteria. Findings for emotion regulation strategies generally provide evidence for racial/ethnic differences (71% of reviewed studies), with ethnoracial minorities largely exhibiting greater use of emotion regulation strategies. Whereas the results for emotion regulation potential were slightly more mixed (63% of reviewed studies found racial/ethnic differences), ethnoracial minorities were also largely found to report lower emotion regulation potential.

CONCLUSION

This review advances the literature by providing additional support for racial and ethnic differences in emotion regulation.

Development and Initial Validation of the Relaxation Sensitivity Index

Relaxation sensitivity indexes the fear of relaxation-related events. The purpose of this study was to develop and provide initial validation of a self-report measure of relaxation sensitivity, the Relaxation Sensitivity Index (RSI). Three independent samples of undergraduate students (n=300 unselected, n=349 non-clinical, and n=197 clinical analogs with elevated anxiety/depression symptoms) completed self-report measures to examine the factor structure, reliability, and validity of the RSI. Results of exploratory and confirmatory factor analyses supported a three-factor structure (correlated Physical, Cognitive, and Social Concerns). The RSI demonstrated good internal consistency and construct validity as evidenced by expected correlations with measures of anxiety and depression symptoms. The RSI showed good predictive validity in terms of a history of fearful responding to relaxation. RSI scores were significantly higher in the symptomatic compared to non-clinical sample. Results suggest the RSI is a valid and reliable measure that may be useful in clinical and research settings.

Changes in Risk Factors During the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Adolescents

This study aimed to assess whether changes in potentially modifiable risk factors associated with the construct of neuroticism and common to emotional disorders (i.e., poor distress tolerance and heightened avoidance) occur in concordance with the administration of different treatment components of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Adolescents (UP-A) and with reductions in emotional disorder symptoms (i.e., anxiety and depressive symptoms) overall. Using single-case analytic strategies, including multiple-baseline design and modeling techniques, the authors treated 8 adolescents with emotional disorder diagnoses and evaluated trajectories of change in distress tolerance and experiential avoidance as well as in the sequencing of such change in regard to change in anxiety and depressive symptoms. Clinical outcomes were favorable based on parent, adolescent, and clinician-rated measures. Treatment-based change was demonstrated, at both group and individual levels, and at expected points in treatment, in regard to facets of neuroticism. Overall, self-reported change in experiential avoidance and distress tolerance tended to occur simultaneously to reductions in emotional disorder symptoms. This study helps to clarify the course of expected change in variables believed to be common among a range of emotional disorders during a transdiagnostic treatment and provides initial information regarding tailoring the UP-A for individuals with different clinical profiles.

The explanatory role of anxiety sensitivity in the association between effortful control and child anxiety and depressive symptoms

The present study examined the underlying role of anxiety sensitivity in the association between effortful control and anxiety and depressive symptoms in a sample of clinically anxious children. It was hypothesized that effortful control would exert an indirect effect through anxiety sensitivity in relation to child anxiety and depressive symptoms. Clinically anxious children (N= 105; Mage = 10.09 years, SD = 1.22; 56.7% female; 61% ethnic minority) and their mothers completed a diagnostic interview and a battery of questionnaires that included self- and mother-ratings of child effortful control, anxiety sensitivity, and anxiety and depressive symptoms. The indirect effect of effortful control via anxiety sensitivity on child anxiety and depressive symptoms was significant across child- and mother-completed measures. Among clinically anxious youth, greater effortful control was related to lower anxiety sensitivity, which was related to lower anxiety and depressive symptoms. Future work should evaluate whether targeting effortful control leads to clinically meaningful reductions in anxiety sensitivity and child anxiety and depressive symptoms.

Evaluating the empirical evidence for three transdiagnostic mechanisms in anxiety and mood disorders

High co-morbidity among mental disorders indicates that common transdiagnostic mechanisms underlie various psychopathology, yet there has been little research effort to empirically explicate transdiagnostic processes. A few existing studies are limited in the number of transdiagnostic mechanisms and mental disorder categories explored. The current study addresses these limitations by examining the relationship between three transdiagnostic processes (experiential avoidance, rumination, and emotion dysregulation) and symptom severity of five mental disorders (generalized anxiety disorder, panic disorder, social anxiety disorder, specific phobia, and depression) in a college sample (N = 266). Applying Structural Equation Modeling (SEM), three transdiagnostic models were evaluated, with the five latent variables of mental disorder regressed onto each transdiagnostic process. The results showed that all transdiagnostic models-except the emotion dysregulation model-generally fit the data well. Among the tested models, the strongest evidence was found for experiential avoidance as a transdiagnostic mechanism underlying multiple disorders, suggesting the need for further research effort to reduce experiential avoidance in diverse clinical populations.

Neuroticism as an underlying construct in youth emotional disorders

Structural research on neuroticism, as indicated by Big Five personality traits and/or internalizing symptoms, has been conducted with youth. However, no structural research has investigated neuroticism as characterized by transdiagnostic risk factors such as distress tolerance (DT), negative affect (NA), and avoidance. No study has investigated whether DT, NA, and avoidance, as a group, are associated with anxiety, depressive, obsessive-compulsive (OC) symptoms, and independent evaluator (lE)-rated symptom severity in a clinical sample of youth. The purpose of the current investigation was to understand the proportion of variance in anxiety, depressive, OC symptoms, and independent evaluator-rated global symptom severity by a latent construct of neuroticism, as indicated by these modifiable features in youth with emotional disorders among a sample of 121 adolescents (ages 13-18, 51.2% female). A latent neuroticism factor was significantly associated with greater youth- and parent-reported anxiety, depressive, and OC symptoms, and greater IE-rated global severity.

Anxiety Sensitivity and Children's Risk for Both Internalizing Problems and Peer Victimization Experiences

In this study, we examined the degree to which children's level of anxiety sensitivity (AS) was a precursor to both internalizing problems and peer victimization experiences. Participants were 581 fourth-grade children (M age = 9.31; 51.8% girls; 42.3% Hispanic/Latinx) and their teachers. Measures of AS, internalizing problems, and peer victimization were collected across a single academic year (Fall, Spring). Structural equation modeling and logistic regression analyses indicated AS predicted future internalizing symptoms as well as self- and teacher-reports of peer victimization. Also, children with heightened AS were 2.70 times more likely to reach elevated levels of self-rated peer victimization and 11.53 times more likely to have clinically elevated internalizing problems. This is the first study to examine prospectively the link between AS and children's peer victimization experiences. We discuss implications of the findings for developing preventative interventions for children at risk for peer victimization and internalizing difficulties.

The neural interface between negative emotion regulation and motivation for change in cocaine dependent individuals under treatment

BACKGROUND

Emotion regulation is important for cocaine addiction treatment success, particularly during early abstinence. In addition, the neural underpinnings of emotion processing overlap with those of motivation and goal-directed behavior. We examined if the neural underpinnings of emotion maintenance and its regulation correlate with cocaine treatment motivation.

METHODS

Forty-five cocaine dependent individuals (CDIs) starting outpatient treatment in a public specialized addiction treatment clinic in Granada (Spain) underwent fMRI scans while performing a Reappraisal task, and completed the University of Rhode Island Change Assessment Scale (URICA), to measure treatment motivation. We conducted correlation analyses to examine the association between emotion maintenance and regulation related brain activation and URICA's Readiness to Change scores. We also explored links between Emotional reports during the fMRI reappraisal task, duration of abstinence, and anxiety and depression symptoms.

RESULTS

Readiness to Change scores were positively correlated with activations in the right dorsolateral prefrontal and right parietal cortices, the midbrain (p ≤ 0.001, cluster extents ≥109 voxels), and basolateral amygdala (P_FWE-SVC<0.05), while negatively with emotion maintenance related activation in the same cortical areas and activations in the dorsomedial frontal cortex, the nucleus accumbens and the left fusiform gyrus. Emotional reactivity negatively correlated with right dorsolateral prefrontal cortex reappraisal related activation (r= -0.40, p = 0.007), and the Regulate score positively correlated with the left fusiform gyrus emotion maintenance related activation (r = 0.31, p = 0.04).

CONCLUSIONS

Emotional related activation in frontoparietal, accumbens, fusiform, amygdala and midbrain regions engaged during emotion regulation and its maintenance correlate with early treatment motivation in CDIs.

Exposure to Parental Threatening Behaviors and Internalizing Psychopathology in a Trauma-Exposed Inpatient Adolescent Sample: The Role of Difficulties With Goal-Directed Behaviors

Parental threatening behaviors have emerged as a subset of negative parental behaviors strongly related to internalizing symptoms among youth, yet the underlying mechanisms in this association have remained unexplored. The current investigation examined the role of difficulties engaging in goal-directed behavior while emotionally distressed in the association between exposure to maternal threatening behaviors and internalizing symptoms among trauma-exposed inpatient psychiatric youth. Participants (N = 50; mean [SD] age, 15.1 [0.51] years; age range, 12-17 years) completed measures of emotion dysregulation, exposure to maternal threatening behaviors, depression, anxiety, and posttraumatic stress disorder symptoms, as well as trauma-related functional impairment. Results revealed that inability to engage in goal-directed behavior while distressed significantly explained associations between exposure to maternal threatening behaviors and each of the three symptom classes, but not the association between exposure to maternal threatening behaviors and trauma-related functional impairment. These novel findings underscore the need for interventions that target the capacity for goal-directed behavior in the context of emotional distress, especially among trauma-exposed youth who have experienced parental threatening behaviors.

Negative psychological correlates of the pursuit of muscularity among women

OBJECTIVE

There is increasing public and scientific focus on women's pursuit of a muscular and toned appearance. However, the psychological correlates of women's drive for muscularity are currently unclear. Therefore, we examined the associations of drive for muscularity with four important negative psychological indices among women: eating disorder (ED) symptoms, and symptoms of depression, anxiety, and stress.

METHOD

A sample of 221 university women completed an online survey that included measures assessing the aforementioned constructs.

RESULTS

Drive for muscularity evidenced positive associations with all negative psychological indices, except for anxiety. Muscularity-oriented attitudes, as opposed to behaviors, demonstrated the strongest associations with ED and depression symptoms.

DISCUSSION

Our findings make a novel contribution to the scant literature by demonstrating that women who endorse attitudes and/or behaviors geared toward attaining the female muscular ideal may be susceptible to experiencing ED symptoms and negative emotional states. This study provides preliminary evidence that muscularity-oriented attitudes, in particular, may be a promising target for the treatment of EDs and negative emotional states in women with a preoccupation toward muscularity.

A Correlational Analysis of the Relationships among Intolerance of Uncertainty, Anxiety Sensitivity, Subjective Sleep Quality, and Insomnia Symptoms

In this study, we used structural equation modeling to investigate the interplay among Intolerance of Uncertainty (IU), Anxiety Sensitivity (AS), and sleep problems. Three hundred undergraduate students completed the Intolerance of Uncertainty Scale, the Intolerance of Uncertainty Inventory, the Anxiety Sensitivity Index, the Beck Depression Inventory, the State-Trait Anxiety Inventory, the Pittsburgh Sleep Quality Index and the Insomnia Severity Index. 68% and 40% of the students reported poor sleep quality or sub-threshold insomnia problems, respectively. Depression and anxiety levels were above the cut-off for about one-fourth of the participants. Structural equation modeling revealed that IU was strongly associated with AS, in turn influencing both insomnia severity and sleep quality via depression and anxiety. Significant indirect effects revealed that an anxious pathway was more strongly associated with insomnia severity, while a depression pathway was more relevant for worsening the quality of sleep. We discussed the results in the frameworks of cognitive models of insomnia. Viewing AS and IU as antecedents of sleep problems and assigning to AS a pivotal role, our study suggested indications for clinical interventions on a population at risk for sleep disorders.

Mediating role of experiential avoidance in the relationship between anxiety sensitivity and eating disorder psychopathology: A clinical replication

OBJECTIVE

This study sought to examine whether anxiety sensitivity was associated with eating disorder (ED) symptom severity among patients with severe EDs, and to determine whether this relationship was mediated by experiential avoidance.

METHOD

Adolescent and adult females (N = 625) seeking residential ED treatment completed self-report measures of anxiety sensitivity, experiential avoidance, and ED psychopathology. Linear regression evaluated the cross-sectional association between ED symptom severity and three dimensions of anxiety sensitivity (social, physical, and cognitive). Regression-based mediation analysis with bootstrapping tested the associations among the three dimensions of anxiety sensitivity and ED symptom severity through experiential avoidance.

RESULTS

The social dimension of anxiety sensitivity was positively associated with severity of ED psychopathology. Experiential avoidance mediated this association.

DISCUSSION

ED symptoms in this sample were more severe among patients who endorsed greater concern about appearing nervous or anxious to others. The current results indicate that this relationship was driven by a tendency to avoid experiences that evoke emotional discomfort. If replicated, these findings suggest that targeting both social anxiety sensitivity and experiential avoidance may improve ED treatment outcomes. Further study of the mechanistic relationships among social anxiety sensitivity, experiential avoidance, and ED psychopathology, is warranted.

Evaluating the Indirect Effects of Trait Mindfulness Facets on State Tripartite Components Through State Rumination and State Experiential Avoidance

The present study investigated whether specific trait mindfulness facets indirectly influenced state negative affect (NA), positive affect (PA), and physiological hyperarousal (PH) through state rumination and state experiential avoidance. Participants (n = 360, 68% female) rated trait mindfulness facets, then completed an interview task about life experiences intended to elicit state NA, PA, and PH. After the interview task, participants completed measures of state NA, PA, and PH, and state measures of rumination and experiential avoidance. Indirect effect results indicated that the relationships between Nonjudge, Nonreact, and Describe, and each of the state tripartite components indirectly flowed through state rumination. Further, there was a significant indirect effect of Nonjudge and Actaware on each of the three state tripartite components through experiential avoidance. Overall, strengthening the mindfulness skills of Nonjudge, Nonreact, Describe, and Actaware may have positive downstream effects via reducing reliance on maladaptive emotion regulation strategies, such as rumination or experiential avoidance.

Latent variable analysis of negative affect and its contributions to neural responses during shock anticipation

Negative affect is considered an important factor in the etiology of depression and anxiety, and is highly related to pain. However, negative affect is not a unitary construct. To identify specific targets for treatment development, we aimed to derive latent variables of negative affect and test their unique contributions to affective processing during anticipation of unpredictable, painful shock. Eighty-three subjects (43 with depression and anxiety spectrum disorders and 40 healthy controls) completed self-report measures of negative valence and underwent neuroimaging while exploring computer-simulated contexts with and without the threat of a painful, but tolerable, shock. Principal component analysis (PCA) extracted distinct components of general negative affect (GNA) and pain-related negative affect (PNA). While elevated GNA and PNA were both indicative of depression and anxiety disorders, greater PNA was more strongly related to task-specific anxious reactivity during shock anticipation. GNA was associated with increased precuneus and middle frontal gyrus activity, whereas PNA was related to increased bilateral anterior insula activity. Anterior insula activity mediated the relationship between PNA and task-specific anxious reactivity. In conclusion, GNA and PNA have distinct neural signatures and uniquely contribute to anxious anticipation. PNA, via insula activity, may relate to arousal in ways that could contribute to affective dysregulation, and thus may be an important treatment target.

Dialectical Behavior Therapy Skills Training in Alcohol Dependence Treatment: Findings Based on an Open Trial

BACKGROUND

Dialectical behavior therapy (DBT) has demonstrated efficacy in treating disorders such as alcohol dependence that are characterized by emotional dysregulation. Preliminary evidence has revealed the feasibility of DBT skills training (ST) as a stand-alone treatment for such disorders. Although emotional dysregulation plays a significant role in alcohol dependence, there are no previous reports of using DBT-ST to treat it.

OBJECTIVES

The aim of this study was to evaluate the duration of abstinence and changes in emotional regulation in a 3-month DBT-ST program for alcohol-dependent patients and to look for relations between abstinence and emotional regulation.

METHODS

We administered the Difficulties in Emotion Regulation Scale (DERS) and used urine toxicology screening to monitor alcohol/substance intake among the 244 subjects admitted to the program.

RESULTS

Among the 157 patients who completed the treatment, 73.2% were abstinent at the end of the program, and their emotional regulation improved. Improvement was independent of the initial severity of both alcohol use and emotional dysregulation. For substance use outcomes, we found a partial mediation role of improved emotional regulation.

CONCLUSIONS

This is the first open trial to show improved alcohol-related behavior and emotional regulation in alcohol-dependent patients treated with DBT-ST and to posit a partial but significant relation between improved emotional regulation and alcohol use outcomes. In the treatment of alcohol dependence, emotional regulation may be a relevant factor for therapists to consider.

Attitudes towards Ambiguity in Japanese Healthy Volunteers

Multi-dimensional structure of the Attitudes Towards Ambiguity Scale (ATAS: original Japanese version) and its relationship with the Acceptance and Action Questionnaire (AAQ) were investigated. We administered the ATAS and the Japanese version of the AAQ to 1019 Japanese healthy volunteers (513 females and 506 males; age range 18–78 years). Trial of exploratory factor analysis extracted four distinct clusters (Enjoyment; α = .83, Anxiety; α = .75, Exclusion; α = .75, and Noninterference; α = .65) from the ATAS item pool, suggestive of diversity in cognitive/ emotional/ behavioral responses to ambiguity. Confirmative factor analysis showed similar goodness in fit indices between the new four-factor model in the present study and the original five-factor model in our previous study (Nishimura 2007). Considering interpretability by using large number of representative samples with general population in the present study, we adopted the four-factor model. The ATAS Anxiety subscale was negatively correlated with the AAQ willingness subscale (r = −.39, p < .001), while the ATAS Enjoyment subscale was positively correlated with the AAQ Action subscale (r = .40, p < .001). It is thus suggested that one who enjoys ambiguous situations can adopt two distinct attitudes: Excluding ambiguity from active resolution, or not interfering with ambiguity due to good tolerance of this experience, which can lead to positive and flexible commitments in life. In contrast, one who tends to be anxious about ambiguity may be characterized by exclusion-based attitudes due to intolerance of ambiguity, leading to lowered acceptance of their feelings and of the reality of circumstances. Cognitive/emotional attitudes towards ambiguity may affect acceptance of inner experience and active commitment to reality.

Heterogeneity in emotion regulation difficulties among women victims of domestic violence: A latent profile analysis

BACKGROUND

Research over the past two decades supports emotion regulation as a transdiagnostic factor related to the etiology, maintenance, and treatment of a wide range of psychiatric difficulties and risky behaviors. However, prior investigations are limited by their focus on difficulties regulating negative (but not positive) emotions. Further, research has not accounted for the heterogeneity in difficulties regulating emotions.

METHODS

Participants were 210 female victims of domestic violence (DV; M age = 36.14, 48.6% African American) who completed measures assessing emotion regulation (Difficulties in Emotion Regulation Scale; Difficulties in Emotion Regulation Scale - Positive), posttraumatic stress disorder (PTSD; Posttraumatic Stress Diagnostic Scale), depression (Center for Epidemiologic Studies-Depression Scale), alcohol misuse (Alcohol Use Disorder Identification Test) and drug misuse (Drug Abuse Screening Test). Latent profile analysis was utilized to identify subgroups of DV-victimized women who were similar in endorsed difficulties in regulating negative and positive emotions. Differences in psychiatric difficulties (i.e., PTSD and depressive symptom severity) and risky behaviors (i.e., alcohol and drug misuse) were examined across these classes.

RESULTS

Three classes of DV-victimized women differentiated by levels of difficulties regulating negative and positive emotions were identified. Greater psychiatric difficulties were found among classes defined by higher levels of difficulties regulating emotions, regardless of emotion valence. Risky behaviors were more prevalent among the class defined by higher levels of difficulties regulating both negative and positive emotions.

LIMITATIONS

Although results add to the literature on difficulties regulating emotions and their correlates, findings must be interpreted in light of limitations present including use of a cross-sectional and correlation design, reliance on self-report measures, and assessment of a select sample of women victims of DV.

CONCLUSIONS

Results highlight the potential importance of tailoring interventions accounting for the heterogeneity in negative and positive emotion regulation dimensions among DV-victimized women.

A computer-based avatar task designed to assess behavioral inhibition extends to behavioral avoidance but not cognitive avoidance

Avoidance is a common feature of post-traumatic stress disorder (PTSD) as well as anxiety and depressive disorders. Avoidance can be expressed behaviorally as well as cognitively. Most personality assessments for avoidance involve self-report inventories which are susceptible to biased responding. The avatar task (Myers et al., 2016a) was developed as an objective measure of behavioral inhibition (BI) which is defined as a tendency for avoidance of unfamiliar people and situations. The avatar task has been demonstrated to screen avoidant behaviors related to BI, PTSD, as well as harm avoidance (HA) as measured by the Tridimensional Personality Questionnaire (TPQ). In the current work, the avatar task was tested with cognitive as well as behavioral avoidance as measured by the cognitive-behavioral avoidance scale (CBAS; Ottenbreit & Dobson, 2004). The CBAS includes four subscales which measure behavioral social (BS) avoidance, behavioral non-social (BN) avoidance, cognitive social (CS) avoidance, and cognitive non-social (CN) avoidance. It was hypothesized that avatar scores would be significantly positively related to behavioral, but not cognitive, avoidance. In addition, it was also hypothesized that performance on the avatar task would be more related to social than non-social behavioral avoidance. Participants completed the avatar task, the HA scale of the TPQ and the CBAS. Pearson's product moment correlations revealed that avatar scores were significantly related to CBAS total scores as well as BS and BN scores, but not CS and CN scores. In addition, BS has a stronger relationship with avatar scores than BN avoidance which fits with the social aspects of the scenarios in the avatar task. A median split of the avatar scores produced a significant difference in scores on the behavioral but not the cognitive subscales. Overall, the current results supported the idea that the avatar task is measuring behavioral avoidance, specifically in social situations, rather than cognitive avoidance. Future work could adapt the avatar task to include scenarios similar to the cognitive items on the CBAS to create an objective measure of cognitive avoidance which may be relevant in measuring avoidance in depression and behavioral avoidance associated with PTSD as well as anxiety disorders.

Experiential Avoidance as a Common Psychological Process in European Cultures

Abstract. Experiential avoidance, the tendency to rigidly escape or avoid private psychological experiences, represents one of the most prominent transdiagnostic psychological processes with a known role in a wide variety of psychological disorders and practical contexts. Experiential avoidance is argued to be based on a fundamental verbal/cognitive process: an overextension of verbal problem solving into the world within. Although cultures apparently differ in their patterns of emotional expression, to the extent that experiential avoidance is based on a fundamental verbal/cognitive process, measures of this process should be comparable across countries, with similar relationships to health outcomes regardless of the language community. This research tests this view in European countries. The psychometric properties of the Acceptance and Action Questionnaire-II, a measure of experiential avoidance, are compared across six languages and seven European countries, for a total of 2,170 nonclinical participants. Multiple group analysis showed that the instrument can be considered invariant across the language samples. The questionnaire constitutes a unidimensional instrument with similar relationships to psychopathology, and has good and very similar psychometric properties in each assessed country. Experiential avoidance reveals not just as transdiagnostic, but also as a transcultural process independent of a specific language community.

Examining predictors of help-seeking behaviours in patients with mood and anxiety symptoms

Relatively little is known about individual characteristics that factor into the decision to seek help for mood and anxiety symptoms. The current study was undertaken in order to examine factors that predict the likelihood of seeking help for mood and anxiety symptoms amongst a clinical population. Patients (N = 278) referred to a tertiary care clinic in Toronto, Canada were asked about their help-seeking behaviours (HSB) through initial intake assessments and self-administered questionnaires, including the Beck Anxiety Inventory, Anxiety Sensitivity Index, Intolerance of Uncertainty Scale, and Beck Depression Inventory-II. Correlates of anxiety and depression were examined to determine whether they could predict HSB amongst individuals with Generalized Anxiety Disorder with or without comorbid Major Depressive Disorder, as well as Panic Disorder and Social Anxiety Disorder. Psychiatric diagnoses were then examined to determine whether comorbidity and demographic factors impacted HSB. Results indicated that there were significant differences in anxiety and depression correlating mainly with anxiety sensitivity, as a predictor of HSB, and that there is a complex relationship between disorder type and demographic variables. The implications of these findings and suggested targeted interventions are discussed.

Affect Intensity Moderates the Association of Emotional Clarity with Emotion Regulation and Depressive Symptoms in Unselected and Treatment-Seeking Samples

Depression is associated with subjective difficulties identifying one's emotions, known as low emotional clarity, but the mediators and moderators of this relationship are not well understood. We hypothesized that the role of emotional clarity in emotion regulation and, in turn, depression depends on individual differences in negative affect intensity. In Study 1, conducted in an unselected sample (N=119), low emotional clarity more strongly predicted depression symptoms among individuals higher in affect intensity. In Study 2, conducted in a clinically diagnosed, treatment-seeking sample (N=245), we examined whether affect intensity moderated an indirect path of clarity through emotion regulation strategy use that has emerged in previous work. When affect intensity was very low, emotional clarity did not predict reappraisal, and when affect intensity was very high, emotional clarity did not predict non-acceptance or experiential avoidance. By contrast, rumination mediated associations of emotional clarity with depressive symptoms regardless of affect intensity. Findings support a process model of low emotional clarity in depression that integrates (1) emotion regulatory mediators and (2) moderation by negative affect intensity. Trait differences in affect intensity may determine whether and how emotional clarity and regulation processes factor into mood psychopathology.

Nested positive feedback loops in the maintenance of major depression: An integration and extension of previous models

Several theories of Major Depressive Disorder (MDD) have previously been proposed, focusing largely on either a psychological (i.e., cognitive/affective), biological, or neural/computational level of description. These theories appeal to somewhat distinct bodies of work that have each highlighted separate factors as being of considerable potential importance to the maintenance of MDD. Such factors include a range of cognitive/attentional information-processing biases, a range of structural and functional brain abnormalities, and also dysregulation within the autonomic, endocrine, and immune systems. However, to date there have been limited efforts to integrate these complimentary perspectives into a single multi-level framework. Here we review previous work in each of these MDD research domains and illustrate how they can be synthesized into a more comprehensive model of how a depressive episode is maintained. In particular, we emphasize how plausible (but insufficiently studied) interactions between the various MDD-related factors listed above can lead to a series of nested positive feedback loops, which are each capable of maintaining an individual in a depressive episode. We also describe how these different feedback loops could be active to different degrees in different individual cases, potentially accounting for heterogeneity in both depressive symptoms and treatment response. We conclude by discussing how this integrative model might extend understanding of current treatment mechanisms, and also potentially guide the search for markers to inform treatment selection in individual cases.

Transdiagnostic emotional vulnerabilities linking obsessive-compulsive and depressive symptoms in a community-based sample of adolescents

BACKGROUND

Transdiagnostic emotional vulnerabilities are suspected to underlie psychopathologic comorbidity but have received little attention in adolescent emotional pathology literature. We examined distress tolerance, anxiety sensitivity, and anhedonia as concomitant transdiagnostic mechanisms that account for (i.e., statistically mediate) the covariance between adolescent obsessive-compulsive disorder (OCD) and major depressive disorder (MDD) symptoms.

METHOD

Data on MDD, OCD, and the three aforementioned transdiagnostic vulnerabilities were collected from a community-based sample of 3,094 ninth graders in a large metropolitan area and analyzed using mixed effects modeling to evaluate mediation effects.

RESULTS

Individually and when controlling for each other, all three transdiagnostic vulnerabilities mediated the relation between OCD and MDD symptoms both before and after adjusting for demographics.

CONCLUSIONS

Distress tolerance, anxiety sensitivity, and anhedonia may be unique mechanisms accounting for comorbidity between OCD and MDD symptoms in youth. Longitudinal evaluation of these candidate transdiagnostic emotional vulnerabilities in adolescent OCD-MDD comorbidity is warranted.

Synergistic effects of pain intensity and experiential avoidance in relation to anxiety symptoms and disorders among economically disadvantaged latinos in a community-based primary care setting

Latinos are subject to numerous health inequalities, including mental health disparity for anxiety and its disorders. In fact, there is strikingly little understanding of transdiagnostic risk factors for the onset and development of anxiety symptoms and disorders among Latinos. To build knowledge in this domain, the present investigation examined the interactive effects of experiential avoidance and pain intensity in relation to anxious arousal, social anxiety, and anxiety disorders among 361 Latino adults with annual incomes of less than $30,000 (87.5% female; M_age=38.8, SD=11.4, and 98.5% used Spanish as their first language) who attended a community-based primary healthcare clinic. As hypothesized, the interaction between experiential avoidance and pain intensity was significantly related to anxious arousal, social anxiety, and a number of anxiety disorders over and above the effects of other factors. The form of the significant interactions indicated that participants reporting co-occurring higher levels of experiential avoidance and pain intensity evinced the greatest levels of anxious arousal, social anxiety, and anxiety disorders. These data provide novel empirical evidence suggesting that there is clinically-relevant interplay between experiential avoidance and pain intensity in regard to a relatively wide array of anxiety problems among Latinos in a primary care medical setting.

The relationship between positive affect and negative affect during treatment for major depressive disorder

OBJECTIVE

The present study examined the relationship between positive affect (PA) and negative affect (NA) along the course of combined cognitive behavior therapy and pharmacological treatment for major depressive disorder (MDD).

METHOD

Participants were 165 individuals who sought treatment for MDD in a partial hospital setting. Participants' PA, NA, and depressive symptoms were measured at pre- and post-treatment and PA and NA were measured at up to 10 additional measurements along the course of treatment.

RESULTS

Results indicated that PA at pre-treatment predicted depressive symptoms at post-treatment above and beyond NA and the PA*NA interaction. However, an analysis of patterns of change during treatment using lower level mediational modeling in a multilevel framework indicated that NA predicted subsequent PA to a greater extent than vice versa.

CONCLUSION

Though many treatments for MDD predominantly focus on reducing NA, our findings suggest that PA may be an important predictor of outcome in treatment for MDD, and that the inclusion of interventions to increase the experience of PA may help improve the efficacy of treatment.

The Role of Neuroticism and Experiential Avoidance in Predicting Anxiety and Depression Symptoms: Mediating Effect of Emotion Regulation

Background

Preliminary evidence supports the role of neuroticism, experiential avoidance and emotion regulation in anxiety and depression; however, the mechanism of these relationships is not known well.

Objectives

The present study mainly aimed to assess the mediating role of emotion regulation in the relationship between neuroticism and experiential avoidance and anxiety and depression symptoms.

Materials and Methods

By convenient sampling, 316 students from Tehran University of Medical Sciences, Iran University of Social Welfare and Rehabilitation Sciences and University of Tehran were selected and measures of experiential avoidance, neuroticism, emotion regulation, worry, anxiety and depression were administered among them, 2014-2015. Path analysis via regression according to Baron and Kenny evaluative criteria was used for data analysis.

Results

Experiential avoidance and neuroticism predicted anxiety, and depression symptoms and the predictions were mediated by emotion regulation and worry.

Conclusions

Emotion regulation deficits have an outstanding role in the mechanism of anxiety and depression which are so comorbid and further studies are needed to evaluate emotion regulation with more advanced methods and along with other transdiagnostic components.