Transdiagnostic Anxiety Research Articles

Tri-Level Anxiety and Depression Symptom Trajectory in Adolescents:the Role of Emotion Regulation Diversity

Anxiety and depression are associated with impaired emotion regulation (ER). Recently, a novel construct named ER diversity has been proposed to assess the diversity in ER strategy use. Low ER diversity, particularly under stressful circumstances, may be a transdiagnostic vulnerability factor for anxiety and depression. This study utilized a longitudinal design to examine the association between ER diversity and transdiagnostic anxiety and depressive symptom trajectory in adolescents (N = 627 at baseline), while accounting for life stress. Measures of ER strategy use, chronic interpersonal life stress, neuroticism, and transdiagnostic dimensional symptoms of anxiety and depression were assessed. The ER diversity index and the traditional ER sum score were computed. Higher ER diversity index was associated with steeper decline in the Fears symptom factor over time, above and beyond the ER sum score and neuroticism. Moreover, chronic interpersonal life stress influenced these associations. When chronic interpersonal life stress was low, Fears declined over time regardless of the ER diversity level; when chronic interpersonal life stress was high, Fears only declined when ER diversity was high. Thus, low diversity in ER strategy use, particularly under stressful circumstances, may be a vulnerability factor for fear symptom development.

Parental care and overprotection predict worry and anxiety symptoms in emerging adult students

Anxiety disorders represent a prevalent mental health concern, with escalating rates, especially among emerging adults. University students, in particular, face a myriad of academic and life stressors that can amplify feelings of worry and anxiety. While early parental bonding seem to predict anxiety disorders later in life, the applicability to emerging adult students and its applicability to predict sub-clinical and transdiagnostic anxiety features remain unclear. This study aims to examine i) the relationship between demographic variables and key features of anxiety disorders (i.e., worry and anxiety symptoms); and ii) the predictive association between early parental bonding and anxiety-related features. A sample of 370 university students in Italy (n = 279 females; M age = 20.84 years, SD age = 1.81 years) completed the Parental Bonding Instrument, the Penn State Worry Questionnaire, and the Beck Anxiety Inventory. Females reported higher levels of worry and anxiety compared to males. Significantly higher worry and anxiety symptoms were reported by individuals who experienced affectionless control (low care and high overprotection) as compared to those exposed to optimal parenting (high care and low overprotection). Predictive models indicated that scores of parental care (i.e., the principal component between maternal and paternal care scores) and parental overprotection (i.e., the principal component between maternal and paternal overprotection scores) are robust predictors of worry and anxiety symptoms. However, this relationship showed a gender-specific pattern: lower parental care was more significant in predicting anxiety features in males, while high overprotection was more significant in females. The findings contribute to the comprehension of the risk factors influencing the susceptibility of emerging adult students to anxiety disorders.

Longitudinal associations among adult attachment orientations, emotion regulation tendencies, and transdiagnostic anxiety and depression symptoms in young adults

Adult attachment orientations can influence emotion regulation. Such influence on the tendency to employ two strategies, cognitive reappraisal (which aims to modify emotional experiences) and expressive suppression (which inhibits emotional expression) and later symptoms is understudied. This longitudinal study evaluated indirect associations between adult attachment orientations—with a focus on the dimension of security—and transdiagnostic anxiety and depression symptoms (General Distress; GD) through reappraisal and suppression. Correlational analyses examined cross-sectional associations among constructs across four timepoints. A cross-lagged panel model was fit to examine prospective hypotheses using 30-month longitudinal data from young adults ( N = 270 at baseline). Correlational evidence provided support for expected cross-sectional associations. In prospective analyses, there was a significant unique effect of attachment-related avoidance on expressive suppression such that higher attachment-related avoidance predicted higher use of subsequent expressive suppression. There were significant unique effects of emotion regulation on symptoms such that higher reappraisal predicted lower subsequent GD and higher suppression predicted higher subsequent GD. There was no evidence for significant direct or indirect effects of attachment orientations on GD. Results suggest that adult attachment orientation may inform how one expresses emotions in the future, and how one regulates emotions may inform subsequent shared symptoms of depression and anxiety. There was no evidence that attachment orientations informed future transdiagnostic symptoms of depression and anxiety.

Personality predicts pre-COVID-19 to COVID-19 trajectories of transdiagnostic anxiety and depression symptoms.

This study aimed to characterize within-person pre-COVID-19 and coronavirus pandemic (COVID-19) transdiagnostic anxiety and depression symptom trajectories in emerging adults and determine the roles of neuroticism and behavioral activation in predicting these COVID-19-related changes. We recruited a sample of 342 emerging adults (aged 18-19 at baseline) who were screened on neuroticism and behavioral activation and completed symptom questionnaires on multiple occasions before and after the start of the pandemic. We examined estimates of the symptom factors of General Distress, Anhedonia-Apprehension, and Fears at each wave. The stress amplification model predicts a multiplicative neuroticism-adversity interaction with those high on neuroticism showing the greatest symptom increases to the pandemic. The stably elevated negative affect model is an additive model and predicts that persons high on neuroticism will display elevated symptoms at every wave. General Distress and Anhedonia-Apprehension showed large increases from the pre-COVID-19 to COVID-19 transition then decreased thereafter. The increase brought the average General Distress score to clinical levels at the first COVID-19 wave. There was a small decrease in Fears from the pre-COVID-19 to COVID-19 transition followed by a large increase. Thus, COVID-19 was associated with both increases in psychological symptoms and some resilience. Neuroticism positively predicted the pre-COVID-19 to COVID-19 transition change in Fears but was associated with a dampening of increases in General Distress and Anhedonia-Apprehension. The results disconfirmed the stress amplification model of neuroticism but partially supported the stably elevated negative affect model. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Supplemental Material for Personality Predicts Pre-COVID-19 to COVID-19 Trajectories of Transdiagnostic Anxiety and Depression Symptoms

Supplemental Material for Personality Predicts Pre-COVID-19 to COVID-19 Trajectories of Transdiagnostic Anxiety and Depression Symptoms

Childhood behavioral inhibition and overcontrol: Relationships with cognitive functioning, error monitoring, anxiety and obsessive-compulsive symptoms.

Anxiety and obsessive-compulsive disorders are common childhood psychiatric disorders. Behavioral inhibition (BI) is a widely studied risk factor for anxiety. Less is known about overcontrol, a related behavioral phenotype characterized by concern for errors, perfectionism, and inflexibility and also associated with anxiety and obsessive-compulsive disorder. Both BI and overcontrol show associations with aberrant cognitive control and neural error responding (via the error-related negativity; ERN) yet it is unknown whether each imparts differential risk. Understanding whether overcontrol demonstrates independent associations from BI with cognitive functioning, neural error monitoring, and childhood anxiety and obsessive-compulsive presentations could aid in identifying a novel mechanistic treatment target. We assessed BI, overcontrol, cognitive functioning and psychopathology in a cross-sectional sample of 5-6 year old children (N = 126). Children completed an electroencephalogram (EEG) to assess the ERN. Overcontrol was associated with worse cognitive shifting, worse inhibitory control and higher anxiety and obsessive-compulsive symptoms, beyond BI. BI was associated with worse cognitive shifting, better inhibitory control and higher anxiety symptoms, beyond overcontrol. When assessed simultaneously, only overcontrol demonstrated a significant relationship with a blunted ERN. Moreover, overcontrol mediated (cross-sectionally) the well-established relationship between ERN and anxiety and obsessive-compulsive symptoms. BI and overcontrol impart differential risk for child cognitive functioning and anxiety while overcontrol demonstrates additional risk for aberrant neural error monitoring, anxiety and obsessive-compulsive presentations. Overcontrol may also be a mechanistic pathway between the ERN and transdiagnostic anxiety and obsessive-compulsive symptoms. Overcontrol may be a target warranted for early-childhood intervention in anxiety and OCD.

Prospective relations between anxiety sensitivity and transdiagnostic anxiety following cognitive-behavioral therapy: Evidence from the Coordinated Anxiety Learning management trial

Previous research has implicated reductions in anxiety sensitivity (AS) – the dispositional tendency to fear anxiety-related sensations – as critical to change during cognitive behavioral therapy (CBT) for anxiety. However, the relationship of AS to anxiety symptom remittance following CBT remains largely unknown. To address this gap, the current study evaluated prospective associations between AS and symptoms of various anxiety disorders following completion of the Coordinated Anxiety Learning and Management (CALM) study– a large clinical trial evaluating the efficacy of a brief, computer-facilitated CBT intervention for transdiagnostic anxiety within primary care. Participants were randomized to CALM (n = 460) or a control treatment (n = 501) and completed self-report measures of general and disorder-specific anxiety symptoms at pretreatment and at 6-month, 12-month, and 18-month follow-up. Longitudinal relations between AS and each anxiety measure across timepoints and within each treatment group were assessed using cross-lagged panel models. Results indicated that higher AS following CALM predicted greater anxiety symptoms at the subsequent timepoint for all anxiety symptoms except social anxiety symptoms. Higher anxiety following treatment also predicted later AS. These findings implicate AS as an indicator of transdiagnostic anxiety remittance and suggest that targeting AS could be useful for reducing clinical anxiety relapse following CBT.

Experiences of a transdiagnostic anxiety cognitive behaviour therapy group for people living with bipolar disorder: a qualitative study

ABSTRACT Background Participant experiences of transdiagnostic bipolar disorder treatment groups has been largely under-explored. The present study aimed to explore the experiences of people living with bipolar disorder who participated in a pilot study of a transdiagnostic cognitive behaviour therapy for comorbid anxiety. Methods Ten participants (five male) diagnosed with bipolar disorder took part in an interview at the completion of the programme. Participants were asked open-ended questions about the programme and their experiences of participation in the group. Data were analysed using thematic analysis. Results Key themes identified included: (1) “Content and techniques – applications outside of the group”, where participants reported using the content learnt for the management of anxiety and other symptoms, including co-occurring conditions; (2) ‘Being part of the group – “feeling normal”, where participants reported feeling supported within a group that was specific to bipolar disorder; and (3) “Group structure – enabling process, content and research”, where participants reported that structural elements, such as participation in research, added meaning to their experience. Conclusions This research provides evidence for the value of transdiagnostic approaches in the treatment of bipolar disorder, with participants reporting that they applied the skills learnt to anxiety, substance use and bipolar disorder-specific symptoms.

Dynamic Alterations in Neural Networks Supporting Aversive Learning in Children Exposed to Trauma: Neural Mechanisms Underlying Psychopathology

BackgroundAltered aversive learning represents a potential mechanism through which childhood trauma (CT) might influence risk for psychopathology. This study examines the temporal dynamics of neural activation and patterns of functional connectivity during aversive learning in children with and without exposure to CT involving interpersonal violence and evaluates whether these neural patterns mediate the association of CT with psychopathology in a longitudinal design. MethodsA total of 147 children (aged 8–16 years, 77 with CT) completed a fear conditioning procedure during a functional magnetic resonance imaging scan. Dynamic patterns of neural activation were examined, and functional connectivity was assessed with generalized psychophysiological interaction analyses. We evaluated whether the associations between CT and psychopathology symptoms at baseline and 2-year follow-up were mediated by neural activation and connectivity during aversive learning. ResultsChildren exposed to trauma displayed blunted patterns of neural activation over time to the conditioned threat versus safety stimuli (CS+>CS−) in the right amygdala. In addition, trauma was associated with reduced functional connectivity of right amygdala with the hippocampus, posterior parahippocampal gyrus, and posterior cingulate cortex and with elevated connectivity with the anterior cingulate cortex to CS+>CS−. The longitudinal association between CT and later externalizing symptoms was mediated by blunted activation in the right amygdala. Reduced amygdala-hippocampal connectivity mediated the association of CT with transdiagnostic anxiety symptoms, and elevated amygdala–anterior cingulate cortex connectivity mediated the association of CT with generalized anxiety symptoms. ConclusionsCT is associated with poor threat-safety discrimination and altered functional coupling between salience and default mode network regions during aversive learning. These altered dynamics may be key mechanisms linking CT with distinct forms of psychopathology.

Diverging patterns of EEG alpha asymmetry in anxious apprehension and anxious arousal

Anxious apprehension and anxious arousal are central transdiagnostic anxiety dimensions and have been linked to divergent patterns of frontal and parietal alpha asymmetry. The present study examined the relationship between alpha asymmetry and anxiety dimensions in 130 individuals whose electroencephalogram (EEG) was recorded at rest. We applied a 2 (anxious apprehension: low vs. high) × 2 (anxious arousal, low vs. high) design to contrast brain lateralization in four groups. Results revealed that anxious apprehension was associated with more left-than-right frontal brain activity in the lower alpha band, an effect driven by decreased right frontal activity. Exploratory analyses showed more left-than-right brain activity at central sites associated with anxious apprehension. Parietal activity was not lateralized as a function of anxiety dimensions. Taken together, the current results support that anxious apprehension is associated with more left-than-right frontal and central activity, and suggest a broader distribution of alpha asymmetries associated with anxious apprehension than previously thought.

Deliberative Choice Strategies in Youths: Relevance to Transdiagnostic Anxiety Symptoms

Aberrant decision-making characterizes various pediatric psychopathologies; however, deliberative choice strategies have not been investigated. A transdiagnostic sample of 95 youths completed a child-friendly sequential sampling paradigm. Participants searched for the best offer by sampling a finite list of offers. Participants’ willingness to explore was measured as the number of offers sampled, and ideal task performance was modeled using a Markov decision-process model. As in previous findings in adults, youths explored more offers when lists were long compared with short, yet participants generally sampled fewer offers relative to model-estimated ideal performance. Searching deeper into the list was associated with choosing better price options. Analyses examining the main and interactive effects of transdiagnostic anxiety and irritability symptoms indicated a negative correlation between anxiety and task performance ( p = .01, η p2 = .08). Findings suggest the need for more research on exploratory decision impairments in youths with anxiety symptoms.

Development of a cognitive bias modification intervention for anxiety disorders in primary care.

There is a great need for low-intensity, scalable treatments in primary care, where most anxious patients first present for treatment. We describe Stage IA treatment development and a Stage IB feasibility trial of cognitive bias modification (CBM) for transdiagnostic anxiety in primary care. The online intervention, Mental Habits, comprised eight sessions of a personalized CBM targeting attention and interpretation biases. Coaches assisted patients in using the website, monitored progress via a dashboard, and shared information with primary care providers. We evaluated Mental Habits in an open trial (N = 14) and a randomized controlled trial (RCT) (N = 40) in primary care patients with anxiety disorders. We compared results to a priori benchmarks of clinically meaningful outcomes. In the open trial, Mental Habits met feasibility, acceptability, and efficacy benchmarks. In the pilot RCT, there was greater dropout at one study site which ultimately closed. In the intent-to-treat analyses, Mental Habits met the benchmark for self-report, but not the interview measure of anxiety. Symptom Tracking did not meet the benchmark for self-report or interview measures of anxiety. In per-protocol analyses, Mental Habits exceeded the benchmark for both self-report and interview measures, whereas Symptom Tracking met the benchmark for self-report. Interpretation bias improved in the Mental Habits group, but not in Symptom Tracking. No effects were observed for attention bias. The online CBM intervention demonstrated good acceptability and, when delivered at a stable primary care clinic, preliminary effectiveness in primary care. A larger RCT is warranted to test effectiveness. A personalized, transdiagnostic Cognitive Bias Modification (CBM) intervention for anxiety in primary care is acceptable to primary care patients with social anxiety disorder, generalized anxiety disorder, and/or panic disorder /agoraphobia. With training and supervision from licensed mental health clinicians, bachelor's-level coaches can assist primary care patients to self-administer CBM. Offering a low-intensity, self-directed anxiety intervention in primary care can greatly expand the reach of anxiety treatment, with minimal need for additional resources. Interpretation bias may be an important clinical target for primary care patients with anxiety.

Time course of pupillary response to threat words before and after attention bias modification for transdiagnostic anxiety disorders: A randomized controlled trial.

IntroductionAltered attention to threatening stimuli at initial and sustained stages of processing may be dissociable dimensions that influence the development and maintenance of transdiagnostic symptoms of anxiety, such as vigilance, and possibly require distinct intervention. Attention bias modification (ABM) interventions were created to implicitly train attention away from threatening stimuli and have shown efficacy in treating anxiety. ABM alters neurocognitive functioning during initial stages of threat processing, but less is known regarding effects of ABM on neural indices of threat processing at sustained (i.e., intermediate and late) stages, or if ABM‐related neural changes relate to symptom response. The current study utilized pupillary response as a temporally sensitive and cost‐effective peripheral marker of neurocognitive response to ABM.Materials and MethodsIn a randomized controlled trial, 79 patients with transdiagnostic anxiety provided baseline data, 70 were randomized to receive eight sessions of twice‐weekly ABM (n = 49) or sham training (n = 21), and 65 completed their assigned treatment condition and returned for post‐training assessment.ResultsAmong ABM, but not sham, patients, pupillary response to threat words during initial and intermediate stages decreased from pre‐ to post‐training. Pre‐ to post‐training reductions in intermediate and late pupillary response to threat were positively correlated with reductions in patient‐reported vigilance among ABM, but not sham, patients.ConclusionsAll measured stages of threat processing had relevance in understanding the neural mechanisms of ABM, with overlapping yet dissociable roles exhibited within a single neurophysiological marker across an initial–intermediate–late time continuum. Pupillometry may be well suited to measure both target engagement and treatment outcome following ABM.

Time Course and Neural Underpinnings of Pupillary Response to Threat Words Before and After Attention Bias Modification for Transdiagnostic Anxiety Disorders: A Randomized Controlled Trial

Altered attention to threatening stimuli at initial and sustained stages of processing are thought to be dissociable dimensions that underlie anxiety disorders and possibly require distinct intervention. Attention Bias Modification (ABM) interventions implicitly train attention away from threatening stimuli and show efficacy in treating anxiety. ABM alters neurocognitive functioning during initial stages of threat processing, but less is known regarding ABM effects at sustained (i.e., intermediate and late) processing stages, or if ABM-related neural changes relate to symptom response.

Neural Connectivity Subtypes Predict Discrete Attentional Bias Profiles Among Heterogeneous Anxiety Patients.

On average, anxious patients show altered attention to threat-including early vigilance towards threat and later avoidance of threat-accompanied by altered functional connectivity across brain regions. However, substantial heterogeneity within clinical, neural, and attentional features of anxiety is overlooked in typical group-level comparisons. We used a well-validated method for data-driven parsing of neural connectivity to reveal connectivity-based subgroups among 60 adults with transdiagnostic anxiety. Subgroups were externally compared on attentional patterns derived from independent behavioral measures. Two subgroups emerged. Subgroup A (68% of patients) showed stronger executive network influences on sensory processing regions and a paradigmatic "vigilance-avoidance" pattern on external behavioral measures. Subgroup B was defined by a larger number of limbic influences on sensory regions and exhibited a more atypical and inconsistent attentional profile. Neural connectivity-based categorization revealed an atypical, limbic-driven pattern of connectivity in a subset of anxious patients that generalized to atypical patterns of selective attention.

Exploring perceived control, a low-control task, and a brief acceptance intervention in a low and high transdiagnostic anxiety sample

BackgroundLimited perceived control has been theorized and measured to be a cognitive aspect of anxiety disorder development and maintenance. The goal of the present study was to investigate perceived internal and external control as transdiagnostic features of anxiety in a diverse urban sample. MethodsWe explored the relations between anxiety, perceived control, and acceptance skills experimentally using a low control computer task and a brief acceptance intervention between task trials. ResultsData revealed significant negative correlations between perceived internal and external control and levels of transdiagnostic anxiety. The high anxiety group reported lower acceptance skills at baseline and greater levels of anxiety across trials of the low control task. There was evidence of an anxiety reduction effect via the acceptance intervention across all participants compared to the control group, but we did not see the hypothesized interaction between group and anxiety level (possibly due in part to sampling randomization failure, as acceptance group had significantly higher anxiety at baseline). DiscussionOur findings validate previous research linking low trait perceived control and high trait anxiety in a diverse sample and provide evidence that acceptance-based interventions may provide more adaptive strategies for navigating low control situations.

Pinpointing mechanisms of a mechanistic treatment: Dissociable roles for overt and covert attentional processes in acute and long-term outcomes following Attention Bias Modification.

Biased patterns of attention towards threat are implicated as key mechanisms in anxiety which can be modified through automated intervention (Attention Bias Modification; ABM). Intervention refinement and personalized dissemination efforts are substantially hindered by gaps in understanding the precise attentional components that underlie ABM's effects on symptoms-particularly with respect to longer-term outcomes. Seventy adults with transdiagnostic anxiety were randomized to receive 8 sessions of active ABM (n=49) or sham training (n=21). Reaction time and eyetracking data, collected at baseline, post-training, and 1-month follow-up, dissociated multiple core attentional processes, spanning overt and covert processes of engagement and disengagement. Self-reported symptoms were collected out to 1-year follow-up. Covert disengagement bias was specifically reduced by ABM, unlike all other indices. Overt disengagement bias at baseline predicted acute post-ABM outcomes, while covert engagement bias was non-specifically predictive of symptom trajectories out to 1-year follow-up. Results suggest unique and dissociable roles for each discrete mechanism.

Towards personalized, brain-based behavioral intervention for transdiagnostic anxiety: Transient neural responses to negative images predict outcomes following a targeted computer-based intervention.

Clinical anxiety is prevalent, highly comorbid with other conditions, and associated with significant medical morbidity, disability, and public health burden. Excessive attentional deployment toward threat is a transdiagnostic dimension of anxiety seen at both initial and sustained stages of threat processing. However, group-level observations of these phenomena mask considerable within-group heterogeneity that has been linked to treatment outcomes, suggesting that a transdiagnostic, individual differences approach may capture critical, clinically relevant information. Seventy clinically anxious individuals were randomized to receive 8 sessions of attention bias modification (ABM; n = 41 included in analysis), a computer-based mechanistic intervention that specifically targets initial stages of threat processing, or a sham control (n = 21). Participants completed a mixed block/event-related functional MRI task optimized to discriminate transient from sustained neural responses to threat. Larger transient responses across a wide range of cognitive-affective regions (e.g., ventrolateral prefrontal cortex, anterior cingulate cortex, amygdala) predicted better clinical outcomes following ABM, in both a priori anatomical regions and whole-brain analyses; sustained responses did not. A spatial pattern recognition algorithm using transient threat responses successfully discriminated the top quartile of ABM responders with 68% accuracy. Neural alterations occurring on the relatively transient timescale that is specifically targeted by ABM predict favorable clinical outcomes. Results inform how to expand on the initial promise of neurocognitive treatments like ABM by fine-tuning their clinical indications (e.g., through personalized mechanistic intervention relevant across diagnoses) and by increasing the range of mechanisms that can be targeted (e.g., through synergistic treatment combinations and/or novel neurocognitive training protocols designed to tackle identified predictors of nonresponse). (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Integrated cognitive behavioral therapy for comorbid cannabis use and anxiety disorders: A pilot randomized controlled trial

Cannabis use disorder (CUD) is the most common illicit substance use disorder and individuals with CUD have high rates of comorbid anxiety disorders. Comorbidity between CUD and anxiety disorders is of public health relevance given that although motivation enhancement therapy (MET) combined with cognitive-behavioral therapy (CBT) is an efficacious intervention for CUD, outcomes are worse for patients with elevated anxiety. The current study tested the acceptability and efficacy of the integration of a transdiagnostic anxiety CBT (i.e., treatment of patients with any anxiety disorder) with MET-CBT (integrated cannabis and anxiety reduction treatment, or ICART) for CUD compared to MET-CBT alone. Treatment-seeking cannabis users (56.4% male, Mage = 23.2, 63.3% non-Hispanic White) with CUD and at least one comorbid anxiety disorder were randomly assigned to ICART (n = 27) or MET-CBT (n = 28). Patients in the ICART condition attended significantly more treatment sessions than those in the MET-CBT condition. Patients in the ICART condition were more likely to be abstinent post-treatment than those in MET-CBT. Further, treatment produced decreases in cannabis use and related problems. Notably, therapy type did not moderate the impact of treatment on frequency of use and related problems. Together, these data suggest that ICART may be at least as efficacious as a gold-standard psychosocial CUD treatment, MET-CBT, for a difficult-to-treat subpopulation of cannabis users.

Supplemental Material for Towards Personalized, Brain-Based Behavioral Intervention for Transdiagnostic Anxiety: Transient Neural Responses to Negative Images Predict Outcomes Following a Targeted Computer-Based Intervention

Supplemental Material for Towards Personalized, Brain-Based Behavioral Intervention for Transdiagnostic Anxiety: Transient Neural Responses to Negative Images Predict Outcomes Following a Targeted Computer-Based Intervention