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Stress responsivity and the structure of common mental disorders: Transdiagnostic internalizing and externalizing dimensions are associated with contrasting stress appraisal biases


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Biased stress appraisals critically relate to the origins and temporal course of many—perhaps most—forms of psychopathology. We hypothesized that aberrant stress appraisals are linked directly to latent internalizing and externalizing traits that, in turn, predispose to multiple disorders. A high-risk community sample of 815 adolescents underwent semistructured interviews to assess clinical disorders and naturalistic stressors at ages 15 and 20. Participants and blind rating teams separately evaluated the threat associated with acute stressors occurring in the past year, and an appraisal bias index (i.e., discrepancy between subjective and team-rated threat) was generated. A 2-factor (Internalizing and Externalizing) latent variable model provided an excellent fit to the diagnostic correlations. After adjusting for the covariation between the factors, adolescents’ threat overestimation prospectively predicted higher standing on Internalizing, whereas threat underestimation prospectively predicted elevations on Externalizing. Cross-sectional analyses replicated this pattern in early adulthood. Appraisals were not related to the residual portions of any diagnosis in the latent variable model, suggesting that the transdiagnostic dimensions mediated the connections between stress appraisal bias and disorder entities. We discuss implications for enhancing the efficiency of emerging research on the stress response and speculate how these findings, if replicated, might guide refinements to psychological treatments for stress-linked disorders.
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Stress Responsivity and the Structure of Common Mental Disorders:
Transdiagnostic Internalizing and Externalizing Dimensions Are Associated
With Contrasting Stress Appraisal Biases
Christopher C. Conway
College of William and Mary
Lisa R. Starr
University of Rochester
Emmanuel P. Espejo
Veterans Affairs San Diego Healthcare System, San Diego,
California, and University of California, San Diego
Patricia A. Brennan
Emory University
Constance Hammen
University of California, Los Angeles
Biased stress appraisals critically relate to the origins and temporal course of many—perhaps most—
forms of psychopathology. We hypothesized that aberrant stress appraisals are linked directly to latent
internalizing and externalizing traits that, in turn, predispose to multiple disorders. A high-risk commu-
nity sample of 815 adolescents underwent semistructured interviews to assess clinical disorders and
naturalistic stressors at ages 15 and 20. Participants and blind rating teams separately evaluated the threat
associated with acute stressors occurring in the past year, and an appraisal bias index (i.e., discrepancy
between subjective and team-rated threat) was generated. A 2-factor (Internalizing and Externalizing)
latent variable model provided an excellent fit to the diagnostic correlations. After adjusting for the
covariation between the factors, adolescents’ threat overestimation prospectively predicted higher stand-
ing on Internalizing, whereas threat underestimation prospectively predicted elevations on Externalizing.
Cross-sectional analyses replicated this pattern in early adulthood. Appraisals were not related to the residual
portions of any diagnosis in the latent variable model, suggesting that the transdiagnostic dimensions mediated
the connections between stress appraisal bias and disorder entities. We discuss implications for enhancing the
efficiency of emerging research on the stress response and speculate how these findings, if replicated, might
guide refinements to psychological treatments for stress-linked disorders.
General Scientific Summary
Biased perceptions of stressful or emotional events confer vulnerability to a wide array of psycho-
logical disorders. We found here that aberrant appraisals of real-world stressors directly predict
liability to Internalizing and Externalizing traits, which serve as substrates for diverse mental
disorders, but in markedly different ways. Exaggerated perceptions of stressor severity predicted
higher standing on the Internalizing trait—predisposing to anxiety and depression—whereas a
tendency to downplay stressor impact predicted elevations on externalizing—predisposing to anti-
social behavior and substance misuse.
Keywords: appraisal, externalizing, internalizing, stress reactivity, transdiagnostic
Editor’s Note. Jennifer L. Tackett served as the Guest Editor for this
Christopher C. Conway, Department of Psychology, College of William and
Mary; Lisa R. Starr, Department of Clinical and Social Sciences in Psychology,
University of Rochester; Emmanuel P. Espejo, Psychology Service, Veterans
Affairs San Diego Healthcare System, San Diego, California, and Department of
Psychiatry, University of California, San Diego; Patricia A. Brennan, Department
of Psychology, Emory University; Constance Hammen, Department of Psychol-
ogy, University of California, Los Angeles.
This research was supported by the National Health and Medical
Research Council, the Mater Misericordiae Mother’s Hospital in
Queensland, Australia, and the National Institute of Mental Health
Grant R01MH52239. We thank Jake Najman of the University of
Queensland and Mater Misericordiae Mothers’ Hospital-University of
Queensland Study of Pregnancy colleagues William Bor and Gail
Correspondence concerning this article should be addressed to Christo-
pher C. Conway, Department of Psychology, College of William and
Mary, Box 8795, Williamsburg, VA 23187. E-mail:
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Journal of Abnormal Psychology © 2016 American Psychological Association
2016, Vol. 125, No. 8, 1079–1089 0021-843X/16/$12.00
Psychopathology tends to be closely linked to environmental
stressors. Both acute stressful life events and chronically adverse
conditions can shape the onset, temporal course, and consequences
of depressive, bipolar, anxiety, substance use, antisocial, and psy-
chotic disorders (e.g., Conway, Rutter, & Brown, 2016;Hammen,
2005;Hlastala et al., 2000;Kim, Conger, Elder, & Lorenz, 2003;
Monroe, Slavich, & Georgiades, 2014;Myin-Germeys & van Os,
2007;Sinha, 2001). Thus, comprehensive models of the origins
and treatment of psychopathology require consideration of an
individual’s stressful environments and the mechanisms that link
such experiences to symptoms and disorders.
Clearly, however, serious stressors do not invariably trigger
psychopathology. Life stress research has revealed diverse trajec-
tories of vulnerability and resilience in response to adversity.
Adaptive stress responses, mediated by homeostatic biological and
psychological systems, are common. For instance, although a
significant stressor precedes most depressive episodes, only one in
five of those exposed to acute stress becomes depressed (Brown &
Harris, 1978). Pathological stress responses, in contrast, often
include hyperbolic cognitive-emotional reactions instigated by
misrepresentations of stressor impact and meaning. That is, ac-
cording to a large body of evidence on emotion regulation pro-
cesses (e.g., Gross & Jazaieri, 2014;Joormann & Vanderlind,
2014), faulty appraisals of stressor impact are largely responsible
for initiating maladaptive responses.
The most extensively studied instances of stress appraisal bias
involve depressed and anxious populations, consistent with Beck’s
(1976) classic cognitive theory, which posits that a tendency to
distort the significance of stressful situations— exaggerating
threat, depletion, and loss—sets the stage for, and later sustains,
internalizing symptoms. Over recent years, a vast amount of re-
search has found evidence for a variety of attentional, interpretive,
and memory biases associated with depression and anxiety that are
relevant to stress appraisal. Biases include preferential attention to
negative information, negative inferential style, overgeneral auto-
biographical memory, and difficulties disengaging from negative
information (e.g., reviews by Gotlib & Joormann, 2010;Joormann
& Vanderlind, 2014;Mathews & MacLeod, 2005;Yoon & Zin-
barg, 2008). These biases can accentuate the negative aspects of
life circumstances, creating and prolonging distressing emotions.
Less research has explored biased appraisals of personal stres-
sors as they relate to externalizing disorders. In contrast to ampli-
fied stress responses observed in internalizing populations, antiso-
cial behavior and substance use disorders generally feature
hyposensitivity to threatening, emotional, or stressful circum-
stances (e.g., Birbaumer et al., 2005;Dawes et al., 1999;Raine,
Venables, & Williams, 1990;Syngelaki, Fairchild, Moore, Savage,
& van Goozen, 2013). Some evidence suggests that malfunction-
ing inhibitory mechanisms account for this blunted reactivity (e.g.,
Krueger & South, 2009). For instance, inhibitory control deficits in
the face of probable punishment are commonly detected among
people at risk for externalizing problems (reviewed in Byrd, Loe-
ber, & Pardini, 2014;Frick & Dickens, 2006). Similarly, a variety
of studies document that impulsive and aggressive individuals
experience less negative emotional arousal when encountering
potential threat because they assess dangerous or stressful situa-
tions as nonthreatening (De Vries-Bouw et al., 2011). Thus, risky
and antisocial behaviors are theorized to be more common in these
populations because they are not deterred by fear of punishment or
negative outcomes (Raine et al., 1990).
Together, these lines of research signal discriminant validity
between, but not within, internalizing and externalizing disorder
domains. That is, stress overreactions pervade the anxiety and
depressive disorders, whereas insensitivity to stress characterizes
diverse antisocial behavior and substance use conditions. This lack
of discriminant validity among commonly co-occurring syndromes
is the norm in many research areas—not just research on the stress
response—and it has propelled the shift toward the Research
Domain Criteria (RDoC) initiative and other transdiagnostic mod-
els of psychopathology. One possible explanation for this pattern
of observations is that stress reactivity processes, such as stress
appraisal, are directly related to a small set of core psychopatho-
logical traits that underpin multiple disorders (e.g., Nolen-
Hoeksema & Watkins, 2011). From this perspective, diagnostic
entities (e.g., panic disorder, persistent depressive disorder) are
manifestations of underlying transdiagnostic traits, and they are
not expected to have strong associations with clinical outcomes
independent of those basic transdiagnostic dimensions (Krueger &
Markon, 2006).
There are two goals of the present article. First, we present a
method of measuring characteristic ways of appraising stressful
life events that is based on individuals’ own recent stressors.
Second, we test the hypothesis that transdiagnostic dimensions
underlying internalizing disorders and externalizing disorders are
each associated with aberrant stress appraisals, but in markedly
different ways.
Why do we propose a measure based on naturally occurring
stressors? We argue that much of the functional impairment ac-
companying psychological disorders results from maladaptive
emotions and behaviors that stem from misappraisals of life cir-
cumstances. In the real world, the ability to appropriately cope
with challenging events and situations requires accurate interpre-
tation of the likelihood, meaning, and consequences of actual
circumstances; these may be difficult to validly reproduce in the
laboratory setting. We operationalize appraisal bias as the discrep-
ancy between objective, contextually informed ratings of the se-
verity of participants’ recent stressful life events as rated by blind,
independent raters on the one hand, and participants’ subjective
judgments of stressor severity on the other. In an earlier study,
Espejo, Hammen, and Brennan (2012) reported that youth whose
stress appraisals were more negative than those of the objective
rating team were at heightened risk for new onsets of depressive
and anxiety disorders over late adolescence. In the current study,
we extend this method to create a bipolar appraisal bias construct,
in the sense that misperceptions can reflect either over- or under-
estimation of stressor impact relative to objective standards. The
stress assessment is based on a gold standard interview method of
evaluating occurrence and impact of stress based on the context in
which it occurs (Hammen, 2016; see also Monroe, 2008).
Construct Validity of a Quantitative Transdiagnostic
Model of Mental Disorders
We rely on recent developments in the quantitative modeling of
the latent structure of psychopathology to relate appraisal bias to
transdiagnostic traits. Structural research on the internalizing and
externalizing domains can be traced back to Achenbach’s (e.g.,
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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Achenbach, 1966) latent variable modeling of child behavior prob-
lems. In a pair of highly influential studies, Krueger and his
collaborators (Krueger, 1999;Krueger, Caspi, Moffitt, & Silva,
1998) extended this modeling framework by analyzing diagnostic
correlations from large community samples of adults. Paralleling
Achenbach’s early findings, Krueger et al. (1998) uncovered an
Internalizing factor underlying the anxiety and depressive disor-
ders and an Externalizing factor underlying the antisocial behavior
and substance use disorders. This two-factor configuration has
demonstrated impressive consistency across several large-scale
epidemiological studies (reviewed in Eaton, Rodriguez-Seijas,
Carragher, & Krueger, 2015). Additionally, research has shown
the Internalizing and Externalizing factors to be stable over time
and present across a variety of cultures and age ranges (Krueger et
al., 1998;Krueger, Chentsova-Dutton, Markon, Goldberg, &
Ormel, 2003).
The available research on the latent structure of disorders sum-
marized above has been largely descriptive. Expressed in latent
variable modeling terminology, the focus has been on the mea-
surement model, as compared with structural relations of the
transdiagnostic dimensions with external constructs. The next
phase, which is just beginning, will evaluate the predictive, con-
vergent, and discriminant validity of the Internalizing and Exter-
nalizing dimensions. The results of these investigations will deter-
mine the value of the proposed transdiagnostic model as a research
and diagnostic tool. Specifically, strong correlations between the
transdiagnostic dimensions and biobehavioral outcomes would
validate the Internalizing and Externalizing dimensions as useful
levels of analysis (Krueger & Markon, 2006). On the other hand,
weak correlations— either in absolute terms or relative to effects of
observed diagnostic categories— of the transdiagnostic dimensions
with external constructs would suggest limited utility.
A small group of existing studies has investigated the construct
validity of the Internalizing and Externalizing dimensions. This
research evaluates the extent to which the transdiagnostic dimen-
sions explain previously observed associations between psychos-
ocial factors and individual diagnostic categories. For instance,
South, Krueger, and Iacono (2011) found that the association
between marital problems and individual disorders (e.g., major
depression) was mediated by the overarching Internalizing and
Externalizing traits. That is, after adjusting for the transdiagnostic
dimensions, marital discord was unrelated to specific mental dis-
orders (cf. Krueger & Piasecki, 2002). Analogous patterns of
results have been reported in other substantive areas, such as
childhood maltreatment, intergenerational transmission of depres-
sion, and gender differences in psychopathology (Eaton et al.,
2012;Keyes et al., 2012;Starr, Conway, Hammen, & Brennan,
2014). Findings from this line of research carry potentially signif-
icant implications for research design strategies. For instance, in
the current research context, if aberrations in stress responding are
indeed traced to cross-cutting psychopathological traits, as op-
posed to specific diagnoses, then studies designed to compare a
single disorder to a healthy control group might be considered
inefficient. Instead, the maximally informative investigation would
examine correlations between stress responses and relevant trans-
diagnostic dimensions, which presumably represent the driving
forces behind prior evidence of association between categorical
disorders and the stress response.
Present Study
We applied the quantitative model of comorbidity to understand
the relationship between dysfunctional stress appraisals and com-
mon mental disorders. We focused on biased appraisals of natu-
ralistic stressors, which, as mentioned above, are conceptually
related to several cognitive processes previously investigated in
the context of internalizing disorders. Exploiting the hierarchical
organization of the quantitative model (see Krueger & Piasecki,
2002), we examined stress appraisal bias in relation to transdiag-
nostic and diagnosis-specific components of a latent variable
model of mental disorders.
The appraisal bias index was computed at two time periods in a
longitudinal study: mid-adolescence (age 15) and young adulthood
(age 20). We first examined the age 15 bias as a predictor of new
onsets of disorder occurring between ages 15 and 20 based on the
hypothesis that cognitive bias may serve as a developmental an-
tecedent to psychopathology. We then examined the age 20 bias as
a correlate of lifetime diagnoses up to age 20. Evidence from both
preclinical and human research suggests that stress reactivity peaks
in adolescence, and that stress-related disorders in adolescence and
early adulthood shape the trajectory of psychopathology and psy-
chosocial functioning long into adulthood (e.g., Dahl & Gunnar,
2009;Ge, Conger, & Elder, 2001;Rohde, Lewinsohn, Klein,
Seeley, & Gau, 2013). Thus, cognitive processes implicated in the
stress response during this time period are theorized to have
enduring, clinically significant consequences.
We hypothesized that overestimations of event impact would
predict higher standing on the Internalizing factor given prior
findings of hyperactive biological and cognitive-emotional stress
reactivity mechanisms in anxiety and depressive disorders (e.g.,
Craske et al., 2009;Mathews & MacLeod, 2005). In contrast, we
expected that Externalizing would be associated with underesti-
mation of event impact. As briefly reviewed above, externalizing
disorders are related to hypoactivation of several stress response
systems, which might contribute to a discounting of the possible
negative consequences of stressful situations (e.g., van Leeuwen,
Rodgers, Gibbs, & Chabrol, 2014). Finally, we hypothesized that
any associations between individual diagnoses and appraisal bias
would be comparatively small after statistically adjusting for the
effects of transdiagnostic dimensions.
Eight hundred fifteen mothers and their 15-year-old children
(412 males) were recruited from an ongoing birth cohort study of
health and social outcomes, originally consisting of 7,223 pregnant
women who gave birth between 1981 and 1984 in Brisbane,
Australia (Keeping et al., 1989). Women were recruited to repre-
sent a wide range of depressive experiences based on scores on a
questionnaire measure of depressive symptoms administered four
times between pregnancy and child age five (Delusions-Symp-
toms-States-Inventory; Bedford & Foulds, 1978). Depression di-
agnoses were later confirmed by diagnostic interview based on the
Structured Clinical Interview for DSM–IV (SCID; First, Spitzer,
Gibbon, & Williams, 1995) at youth age 15; 358 mothers had a
lifetime diagnosis of major depressive episode and/or dysthymic
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disorder, and 457 were never depressed. The families were pre-
dominantly lower middle/working class and 91.4% were Cauca-
sian (3.6% Asian, 5% other). Sixty-seven percent of the mothers
were currently married to the father of the child, 12% were
currently not married, and 21% were married to someone other
than the biological father. Further details of sample selection are
reported by Hammen and Brennan (2001).
At age 20, families were recontacted for follow-up and, among
those located, 705 youth agreed to participate (86.5%; 342 males).
There were no statistically significant differences in the rates of
participation at age 20 compared with age 15 by maternal depres-
sion status by youth age 15,
(1) 3.60, p.06, or youth
depressive diagnoses by 15,
(1) 0.25, p.25. However,
males were less likely retained at age 20,
(1) 8.71, p.01.
At ages 15 and 20, the youth and their mothers separately
completed interviews and questionnaires in their home. All par-
ticipants completed informed consent (assent) procedures at both
time points, and procedures were approved by institutional review
boards of the University of Queensland, Emory University, and the
University of California, Los Angeles.
Youth diagnoses. At age 15, youth current and lifetime men-
tal disorders were ascertained using the Schedule for Affective
Disorders and Schizophrenia for School-Age Children—Revised
for DSM–IV (K-SADS-E; Orvaschel, 1995), administered sepa-
rately to the parent and the child by interviewers blind to mothers’
depression status. Diagnostic decisions were reviewed by the clin-
ical rating team with best-estimate judgments based on all avail-
able information. In the current sample, weighted kappas for youth
diagnoses were .82 for current depressive diagnoses (major de-
pressive disorder or dysthymia) or subclinical depression, and .73
for past depressive diagnoses or subclinical depression. Reliabili-
ties for current anxiety, substance use, disruptive behavior (con-
duct disorder or oppositional defiant disorder), and “other” (pri-
marily eating) disorders ranged from .67 to 1.0, with a mean of .82;
reliabilities for past diagnoses ranged between .72 and 1.0, with a
mean of .81.
At the age 20 follow-up, youth were administered the SCID,
which covered the 5-year interval since the age 15 assessment.
Interrater reliabilities (i.e., kappa coefficients) for current diagno-
ses were .83 for depressive disorders, .94 for anxiety disorders, and
.79 for substance abuse disorders. The corresponding kappa values
for past disorders were .89, .89, and .96, respectively.
Stressful life events. At age 15 and age 20, the UCLA Life
Stress Interview (LSI; Hammen & Brennan, 2001;Hammen et al.,
1987) was administered to assess occurrence and severity of stress-
ful life events in the past 12 months. Similar to the Life Events and
Difficulties Schedules (Brown & Harris, 1978), the LSI is a
semistructured interview with two defining characteristics. First,
following identification and careful dating of each negative life
event, the event is probed to determine the factual elements of the
context in which it occurred in order to fully define the impact and
meaning of the event for that individual. Second, event impact/
severity is evaluated by an independent rating team following
presentation of a written narrative of each event and its context.
The ratings of severity on a 5-point scale (from no negative impact
to extremely negative impact) are assigned by consensus discus-
sion. The interviewer elicits the individual’s subjective appraisal of
each event on a 5-point scale (from no negative impact to ex-
tremely negative impact), but this information is not available to
the rating team. Various studies have reported on the reliability and
validity of the LSI for acute life events (Hammen & Brennan,
2001;Hammen, Brennan, Keenan-Miller, & Herr, 2008;Hammen,
Kim, Eberhart, & Brennan, 2009). In the current study, interrater
reliability estimates between independent rating teams for stressor
severity were .92 at .95 at age 15 and age 20, respectively.
Additionally, previous research has documented good test–retest
reliability of subjective ratings of stressor impact (Espejo et al.,
The appraisal bias score for each individual was based on
established methods for comparing subjective and objective rat-
ings (Cole, Martin, Peeke, Seroczynski, & Hoffman, 1998;De Los
Reyes & Prinstein, 2004;Krackow & Rudolph, 2008). Mean
subjective severity rating scores were regressed on mean objective
severity rating scores in the full sample, yielding an index of
subjective perceptions of stressfulness that adjusts for objective
levels of threat. The standardized residuals constitute the outcome
variables in the present analyses, with higher scores representing
perceptions of more negative impact (Conway et al., 2012).
Data Analytic Plan
Age 15 appraisal bias. We first examined the prospective
association between appraisal bias at age 15 and subsequent new
onsets of psychopathology (hereafter called the prospective
model). That is, the transdiagnostic outcomes in this analysis were
defined by diagnoses occurring for the first time between the age
15 and age 20 (inclusive) assessments. Indicators of the Internal-
izing factor were major depressive disorder (MDD), dysthymia
(DYS), generalized anxiety disorder (GAD), panic disorder
(PAN), social anxiety disorder (SOC), specific phobia (SPEC),
obsessive– compulsive disorder (OCD), and posttraumatic stress
disorder (PTSD) diagnoses, whereas Externalizing indicators were
alcohol abuse or dependence (ALC), and drug abuse or depen-
dence (DRUG) diagnoses. Conduct disorder (COND) and opposi-
tional defiant disorder (ODD) were assessed during this period, but
excluded as factor indicators due to low incidence during this
period (1 new onset of COND and 0 of ODD). (The prevalence of
all disorders prior to age 15 was too low to permit similar latent
variable analysis of disorders that onset before the age 15 assess-
The prospective model analyses proceeded in three parts:
1. We compared the correlated two-factor model with two
other configurations—labeled the three-factor model and
the bifactor model— of common mental disorders sup-
ported in prior structural research. In the three-factor
In supplementary analyses, we examined whether the association be-
tween appraisal bias and transdiagnostic factors changed if the number of
reported acute life events was included as a covariate. The pattern and
statistical significance of results were unchanged when we adjusted for the
count of acute stressors. Full results are available from Christopher C.
Conway upon request.
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model, the Internalizing factor bifurcated into Distress
and Fear subfactors, an arrangement that has been found
to fit in some samples but not others (Kessler et al., 2011;
Krueger & Markon, 2006). The Distress subfactor was
defined by MDD, DYS, GAD, and PTSD, whereas the
Fear subfactor was defined by PAN, SOC, OCD, and
SPEC (see Watson, 2005). In the bifactor model, each
diagnosis loaded onto a superordinate General Psycho-
pathology factor (termed the p-factor by Caspi et al.,
2014) and onto one specific factor representing Internal-
izing or Externalizing. This model has been found to fit
diagnostic- and symptom-based data well in several prior
studies (e.g., Caspi et al., 2014;Laceulle, Vollebergh, &
Ormel, 2015;Lahey et al., 2012;Tackett et al., 2013).
2. We regressed the transdiagnostic factors from the best
fitting model onto the age 15 appraisal bias index. Ad-
ditionally, given the moderate correlation between Inter-
nalizing and Externalizing observed here (see Results)
and in prior research, we carried out supplementary re-
gressions to determine the association between bias and
Internalizing while controlling for variation on External-
izing (and vice versa). This step was based on previous
findings that indicated the Internalizing and Externaliz-
ing factors exhibited different correlations with external
constructs once their overlap was partialed out (e.g.,
Caspi et al., 2014).
3. Modification indices from the regressions in the point
above (No. 2) were then inspected to determine whether
estimating any paths from age 15 appraisal bias to diag-
nostic residual terms would improve model fit. Following
prior conventions (Keyes et al., 2012), we set a modifi-
cation index threshold of 3.84 (i.e., critical chi-square
value for expected model improvement corresponding to
a .05 alpha level) to evaluate for the presence of statis-
tically significant diagnosis-specific associations. Any
statistically significant residual associations would indi-
cate that appraisal bias predicted unique portions of man-
ifest disorders while holding constant levels of the trans-
diagnostic factor of which the diagnosis is an indicator.
Age 20 appraisal bias. We next examined the correlations
between age 20 appraisal bias and lifetime psychopathology up to
age 20 (concurrent model). Transdiagnostic outcomes in this anal-
ysis were defined by current or past disorders documented at the
age 20 assessment point (i.e., combining information from the age
15 K-SADS-E evaluation and the age 20 SCID evaluation). The
factor indicators were the same as above, except that COND and
ODD were included as indicators of the Externalizing factor. We
followed the same sequence of analyses as the prospective model:
4. We compared the two-factor, three-factor, and bifactor
models for lifetime disorders.
5. We regressed the transdiagnostic factors from the best
fitting model onto the age 20 appraisal bias index. To
statistically control for the overlap between transdiagnos-
tic dimensions, we then covaried Externalizing in the
regression of Internalizing on appraisal bias and, like-
wise, covaried Internalizing when regressing Externaliz-
ing on appraisal bias.
6. We inspected modification indices from the regressions
in the point above (No. 5) to determine whether there
were any statistically significant disorder-specific asso-
ciations with age 20 appraisal bias.
To summarize, this latter set of analyses examined the correla-
tions between appraisal bias at age 20 and lifetime (i.e., ages 0 –20)
history of mental disorders. These analyses were considered a test
of concurrent validity, whereas the prospective model was consid-
ered a test of predictive validity. Results from these two models
allowed us to determine whether appraisal bias at age 20 showed
the same pattern of associations with psychopathology as bias at
age 15 despite variation across the different time periods in the
rates of disorder and latent variable model indicators.
Data were analyzed in Mplus (Version 7.11; Muthén & Muthén,
1998 –2014) using the weighted least squares means and variance
adjusted (WLSMV) estimator. We evaluated model goodness of fit
with the comparative fit index (CFI), the Tucker–Lewis index
(TLI), the root-mean-square error of approximation (RMSEA),
and the weighted root-mean-square residual (WRMR). Acceptable
fit was defined according to guidelines offered by Hu and Bentler
(1999): RMSEA values close to 0.06 or below, CFI and TLI values
close to .95 or above, and WRMR values close to 1.00 or below.
We also judged model fit on the basis of interpretability of param-
eter estimates and localized areas of strain (i.e., modification
Descriptive Statistics
Table 1 displays lifetime (to age 20) diagnostic frequencies and
correlations. As expected, internalizing disorders were more often
comorbid with each other than with externalizing disorders (and
vice versa). Rates of new disorder onsets after age 15 were as
follows: 148 MDD, 21 DYS, 43 GAD, 22 PAN, 114 SOC, 77
SPEC, 36 PTSD, 17 OCD, 190 ALC, and 164 DRUG.
Table 1 also shows that a history of internalizing disorder—with
the exception of specific phobia— generally was associated with
appraisal bias (i.e., overestimation of impact) at both assessment
waves. In contrast, externalizing diagnoses were largely unrelated
to appraisal bias (mean r.03).
Latent Structure of Mental Disorders
Prospective model. The initial correlated two-factor model
did not offer acceptable fit to the data,
(34) 57.85, p.01;
CFI .90; TLI 0.86; RMSEA 0.03; WRMR 0.91. The
factor loadings of all indicators (range: .40 –.77) were statistically
significant at the .001 alpha level, except for specific phobia (␭⫽
.21, p.05) and OCD (␭⫽.34, p.08). We removed these two
diagnoses from subsequent iterations of the prospective model.
The revised two-factor model (i.e., without SPEC and OCD)
yielded a much better fit to the data,
(19) 27.96, p.08;
CFI .97; TLI 0.95; RMSEA 0.03; WRMR 0.77. The
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correlation between the Internalizing and Externalizing factors in
this revised model was .43 (p.001).
Our attempt to fit a hierarchical three-factor model, in which a
second-order Internalizing factor bifurcated into Distress and Fear
subfactors, produced an improper solution. Specifically, the stan-
dardized factor loading of Fear on Internalizing was greater than
unity. Ad hoc inspection of an oblique three-factor model, in
which correlations between first-order Fear, Distress, and Exter-
nalizing factors were freely estimated, revealed a correlation
greater than one between Fear and Distress. We concluded that
Fear and Distress dimensions could not be meaningfully distin-
guished in these data. Similarly, attempts to fit the bifactor model
did not produce an interpretable solution (i.e., negative variance
estimates for the specific factors). Thus, the two-factor measure-
ment model was applied in subsequent structural analyses.
Concurrent model. The two-factor model fit the data well,
(53) 75.56, p.02; CFI .96; TLI 0.95; RMSEA 0.02;
WRMR 0.92. The factor loadings of all indicators (range:
.42–.82) were statistically significant at the .001 alpha level, ex-
cept for OCD (␭⫽.25, p.09). We therefore omitted OCD from
subsequent models. A revised two-factor model (i.e., excluding
OCD) produced a nearly identical pattern of factor loadings and
equivalent fit to the data,
(43) 64.43, p.02; CFI .96;
TLI 0.95; RMSEA 0.02; WRMR 0.93. The correlation
between the Internalizing and Externalizing factors in this revised
model was .39 (p.001). Attempts to fit more complicated
structural models were unsuccessful for the same reasons reported
for the prospective model above. Thus, the two-factor configura-
tion was applied in structural analyses involving the concurrent
model as well.
Transdiagnostic and Diagnosis-Specific Associations
With Stress Appraisal Bias
Prospective model. Internalizing and Externalizing factors
were regressed simultaneously on age 15 appraisal bias. As shown
in Figure 1, bias was positively related to Internalizing (b0.17,
SE 0.04, p.001, ␤⫽.27, f
.07) and negatively, though
nonsignificantly, related to Externalizing (b⫽⫺0.07, SE 0.05,
p.15, ␤⫽⫺.08, f
.01). Next, Internalizing was regressed on
age 15 appraisal bias while statistically controlling for variation in
Externalizing (and vice versa). As mentioned above, this step was
intended to partial out overlap among the transdiagnostic factors,
essentially computing a partial correlation between appraisal bias
and each factor. Holding Externalizing constant, the positive effect
of bias on Internalizing was even stronger (b0.19, SE 0.04,
p.001, ␤⫽0.30). In contrast, after adjusting for Internalizing,
the appraisal bias was significantly associated with Externalizing
but in the opposite direction (b⫽⫺0.17, SE 0.05, p.01,
␤⫽⫺.21). The direction of this effect indicated that, after
accounting for the overlap between Internalizing and Externaliz-
ing, more benign perceptions of stressor impact, relative to the
objective rating team, predicted higher Externalizing levels.
We followed up with a planned test of the equality of the
magnitude of structural associations of the Internalizing versus
Externalizing factors with appraisal bias. That is, we evaluated the
extent to which appraisals had divergent associations with Inter-
nalizing versus Externalizing. Chi-square difference tests (per-
formed with the DIFFTEST procedure in Mplus) indicated that
model fit deteriorated significantly when the effects of Internaliz-
ing and Externalizing were constrained to equality, diff
17.21, p.001, suggesting that the size—and, indeed, the direc-
tion— of these effects was significantly different. Comparison of
other model fit indices in the restricted (CFI
.96; TLI
0.02) versus unrestricted (CFI
.99; TLI
0.01) models corroborated this result.
We also used difference tests to examine gender as a moderator
of transdiagnostic effects on stress appraisal. Nonsignificant Wald
tests demonstrated that the associations of appraisal bias with
Internalizing and Externalizing did not differ by gender, diffs
2, ps.05. Likewise, Wald tests indicated that neither maternal
Table 1
Correlations Among Lifetime Mental Disorders and Appraisal Bias Indices
1 2 3 4 5 6 7 8 9 10 11 12 13 14
1. MDD
2. DYS .47
3. GAD .56
4. PAN .60
5. SOC .29
6. SPEC .13 .16 .32
.22 .25
7. PTSD .58
.09 .25
8. OCD .04 .01 .25 .24 .01 .02 .30
9. CON .22 .31
.08 .28 .18 .17 .04 .01 —
10. ODD .30
.03 .29
.10 .42
.09 .31
.31 .02
11. ALC .18
.01 .23
.12 .22
.04 .19
.18 .42
12. DRUG .20
.03 .30
.22 .63
13. BIAS15 .24
.15 .13
.08 .23
.00 .15 .01 .03 .09 —
14. BIAS20 .28
.02 .08 .26
.01 .04 .16 .01 .06 .16
N(%) 220 (27) 71 (9) 56 (7) 24 (3) 144 (18) 110 (13) 48 (6) 21 (3) 21 (3) 22 (3) 198 (24) 177 (22)
Note. Correlations among diagnoses are tetrachoric correlations. Nnumber of participants qualifying for a diagnosis; MDD major depressive
disorder; DYS dysthymia; GAD generalized anxiety disorder; PAN panic disorder; SOC social phobia; SPEC specific phobia; PTSD
posttraumatic stress disorder; OCD obsessive-compulsive disorder; CON conduct disorder; ODD oppositional defiant disorder; ALC alcohol
abuse/dependence; DRUG drug abuse/dependence; BIAS15 age 15 stress appraisal bias; BIAS20 age 20 stress appraisal bias.
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depression history (44% of sample) or psychiatric medication use
(3.4%) moderated the effects of age 15 appraisal bias on transdi-
agnostic dimensions, diffs
2(1) 3, ps.05. Moreover, the pattern
and statistical significance of results were unaltered if any or all of
these variables (i.e., gender, maternal depression, medication use)
were included as a covariate (full results available from Christo-
pher C. Conway upon request).
In a final step, we examined the diagnosis-specific pathways
between psychopathology and appraisal bias. We inspected the
modification indices to determine whether age 15 appraisal bias
had a statistically significant association with any residual com-
ponents of individual disorders. No modification index exceeded
our predetermined minimum value of 3.84. Thus, it appeared that
associations between diagnostic categories and appraisal bias were
accounted for by the transdiagnostic dimensions.
Concurrent model. As above, we began by regressing the
two factors simultaneously onto age 20 appraisal bias. Young adult
appraisal bias was positively associated with Internalizing (b
0.25, SE 0.04, p.001, ␤⫽.31, f
.10), but it was virtually
uncorrelated with Externalizing (b⫽⫺0.02, SE 0.04, p.46,
␤⫽⫺.04, f
.001). To evaluate the unique relationship of
appraisal bias with Internalizing, we added Externalizing as a
covariate. Holding Externalizing constant, appraisal bias had a
moderate, positive association with Internalizing levels (b0.45,
SE 0.08, p.001, ␤⫽0.34). Analogous to our prospective
model result, when adjusting for the overlap with Internalizing, a
statistically significant inverse association emerged between age
20 appraisal bias and Externalizing (b⫽⫺0.13, SE 0.04, p
.01, ␤⫽⫺.18).
As before, a chi-square difference test confirmed that the mag-
nitude of the association between appraisal bias and Internalizing
significantly differed from (i.e., was greater than) the association
between appraisal bias and Externalizing, diff
2(1) 29.26, p
.001 (restricted model: CFI
.89; TLI
0.87; RMSEA
unrestricted model: CFI
.96; TLI
0.94; RMSEA
Mirroring results from the prospective model, the connections
between young adult appraisal bias and the transdiagnostic dimen-
sions were equally strong across gender, maternal depression his-
tory, and medication status, diffs
2(1) 2, ps.05. Finally, there
was no evidence of statistically significant associations between
age 20 appraisal bias and any diagnostic residual (i.e., no modifi-
cation index value of 3.84 or greater).
Quantitative modeling of the latent structure of mental disorders
has provided compelling evidence for a transdiagnostic model
anchored by Internalizing and Externalizing dimensions that un-
derpin major forms of psychopathology. A new phase of investi-
gation now aims to evaluate the predictive validity of the transdi-
agnostic dimensions to determine their applied value. That is, it
remains to be seen whether transdiagnostic factors emerging from
quantitative structural research actually stand to improve mental
health research and treatment practices. In the present study, we
examined associations of the Internalizing and Externalizing di-
mensions with stress appraisal bias, a cognitive risk marker for a
wide array of disorders. Our data supported the discriminant va-
lidity of the transdiagnostic constructs. After adjusting for the
covariation between dimensions, adolescent stress hypersensitivity
was prospectively linked to higher Internalizing levels, whereas
stress hyposensitivity was prospectively related to higher Exter-
nalizing levels. Further, once standing on the Internalizing and
Externalizing factors was held constant, none of the constituent
diagnoses were linked to appraisal bias. Cross-sectional analyses
Figure 1. Path diagram (with standardized path coefficients) illustrating the contrasting predictive effects of
age 15 appraisal bias on Internalizing and Externalizing factors. These effects diverge further if the overlap
between factors is partialed out (see main text). MDD major depressive disorder; DYS dysthymia; GAD
generalized anxiety disorder; PAN panic disorder; SOC social phobia; PTSD posttraumatic stress
disorder; ALC alcohol abuse/dependence; DRUG drug abuse/dependence. All factor loadings are statis-
tically significant at the .001 alpha level.
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of appraisal bias and psychopathology in young adulthood re-
vealed an identical pattern of results.
Elevation on the Internalizing dimension was associated with
exaggerated cognitive responses to naturally occurring stressors.
This result aligns with data from an extensive body of observa-
tional and experimental research examining the stress response in
anxious and depressed populations. That is, investigators have
consistently documented abnormal cognitive styles—in both sub-
jective (e.g., attitudinal) and implicit (e.g., speeded information-
processing) domains (see Gotlib & Joormann, 2010)—in anxiety
and depressive disorders. Moreover, our findings concur with
laboratory studies that report disruptions in online biological pa-
rameters of the stress response (e.g., limbic metabolism, cortisol
secretion) in emotional disorders (e.g., Craske et al., 2009;Hariri,
Drabant, & Weinberger, 2006). We extend these lines of research
by finding cognitive distortions in response to naturally occurring,
as opposed to laboratory-based, stressors among those at risk for
anxiety and depression. More importantly, our results suggest that
the commonalities among the various internalizing disorders drive
the associations between these conditions and stress-related phe-
Our analysis of the Externalizing spectrum offers a new per-
spective on prior studies of antisocial behavior and substance use
disorders. These syndromes generally have been associated with
blunted biological and psychological responses to stressful and
emotional cues (e.g., Gao, Tuvblad, Schell, Baker, & Raine, 2015;
Syngelaki et al., 2013). In the present study, bivariate associations
between the Externalizing spectrum and stress appraisal bias re-
vealed little evidence of hyposensitivity. However, a very different
pattern of findings—wherein Externalizing was associated with
appraisals that discounted the potential negative impact accompa-
nying stressful events— emerged after adjusting for the overlap
between the transdiagnostic dimensions. It is a testament to the
scientific utility of the structural model that this association be-
tween the Externalizing spectrum and appraisal bias would have
been overlooked if either (a) individual antisocial behavior and
substance use diagnoses had been analyzed (i.e., the Externalizing
factor was greater than the sum of its parts), or (b) comorbidity
with Internalizing psychopathology had been neglected. The di-
vergence in biases characterizing Internalizing and Externalizing is
consistent with prior work by Caspi et al. (2014), who uncovered
different psychosocial correlates of Internalizing and Externalizing
traits once the overlap between these two dimensions was partialed
Our findings advance the growing research literature on the
concurrent and predictive validity of the Internalizing and Exter-
nalizing dimensions. Prior investigations have found that variation
on transdiagnostic dimensions parsimoniously accounts for asso-
ciations between categorical disorders and suicide, marital distress,
intergenerational transmission of psychopathology, and childhood
maltreatment (e.g., Keyes et al., 2012;South et al., 2011;Starr et
al., 2014). In combination with these previous studies, our findings
reinforce the notion that disorders historically examined indepen-
dently are, in many research contexts, better understood in terms of
their common elements (Krueger & Markon, 2006). Future inquiry
into the correlates (i.e., nomological network) of the transdiagnos-
tic traits is needed to evaluate that hypothesis across various
outcomes (e.g., biological, cognitive, interpersonal) and research
settings. Convincing empirical evidence of the superior construct
validity of transdiagnostic dimensions, relative to categorical dis-
orders, is needed for the transdiagnostic model to gain momentum
as a research and clinical tool.
If supported, the quantitative model has the potential to unify
research practices and treatment protocols that traditionally have
fractured along diagnostic lines. For instance, the present results
suggest that future studies on stress reactivity phenotypes may
benefit from focusing on transdiagnostic effects rather than com-
paring stress responses in one disorder category versus a healthy
control group. Thus, paralleling RDoC-informed recruitment strat-
egies (e.g., Cuthbert & Kozak, 2013), patients with any anxiety or
depressive disorder might be recruited for an investigation of the
Internalizing spectrum and stress responses. Aside from enhancing
the efficiency of investigations, transdiagnostic models may align
more closely with basic genetic, biological, and cognitive param-
eters that notoriously show a pattern of multifinality with respect
to mental disorder categories (Ofrat & Krueger, 2012). Thus,
transdiagnostic dimensions may serve as useful intermediate phe-
notypes in the causal chain from distal biological and cognitive
processes to complex clinical syndromes.
Analogous implications follow for the treatment and prevention
of psychological disorders. If closely related disorders have a
common substrate, perhaps that shared pathology could be an
effective target for psychological or psychotropic treatment. Ame-
liorating core psychopathological processes, including stress ap-
praisal biases, theoretically could address related conditions simul-
taneously, enhancing the efficiency of treatment for comorbid
conditions. Barlow and colleagues are leading the way in the
development of a transdiagnostic program for the treatment of
internalizing disorders based on quantitative models of anxiety and
depressive disorder comorbidity (Barlow, Sauer-Zavala, Carl, Bul-
lis, & Ellard, 2014; see also Reinholt & Krogh, 2014). Similarly,
if certain risk factors are shown to predispose to an array of related
disorders (e.g., Nolen-Hoeksema & Watkins, 2011), prevention
efforts might be streamlined by targeting these transdiagnostic
vulnerabilities. For instance, the present results suggest indirectly
that addressing the extremes of cognitive appraisals of stressful
circumstances might mitigate risk for internalizing and external-
izing conditions.
Our study’s contributions should be considered in the context of
several limitations. First, the temporal sequencing of bias and
disorder onset could be resolved only for the age 15 appraisal bias
index. The conceptual status of stress appraisal bias in young
adulthood as an antecedent versus correlate of psychopathology
could not be determined here. Second, coverage of clinical disor-
ders was limited. It is possible that the inclusion of additional, less
prevalent (e.g., bipolar, psychotic, eating) disorders could alter the
number and nature of transdiagnostic dimensions (e.g., Forbush &
Watson, 2013) or their pattern of association with stress appraisal
bias. Along these same lines, the incidence of new antisocial
behavior disorders in late adolescence was too low for them to be
included in prospective analyses, consistent with epidemiological
data showing that these disorders typically onset prior to age 15
(Kessler et al., 2005). As a consequence, the Externalizing factor
in these analyses was limited to substance use disorders. Although
it is encouraging that the prospective results were consistent with
those from the cross-sectional model, which included a wider
range of disorders, further work assessing a broader range of
psychopathology is needed. In fact, the rates of antisocial behavior
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disorders were low across the study timeframe, perhaps due to
recruitment procedures that overselected for maternal depression.
This imbalance in the rates of Internalizing and certain External-
izing disorders may limit, to some extent, generalizability of the
Third, recent quantitative research has pointed out that including
symptom dimensions, as opposed to diagnostic categories, as
manifest indicators of latent psychopathology constructs can re-
veal a more nuanced transdiagnostic architecture to psychopathol-
ogy (e.g., Markon, 2010;Prenoveau et al., 2010;Wright et al.,
2013). Symptom-level data were not available in the present study.
Thus, continuous factor indicators (e.g., a symptom-based ap-
proach) may have improved our chances of fitting more compli-
cated factor models (e.g., three-factor model including the subdi-
vision of Internalizing into Fear and Distress factors). Fourth, the
stability of the appraisal bias index across assessment waves was
lower than anticipated (r.16). It is possible that the changing
nature of stressors experienced from adolescence to adulthood, or
simply normative developmental changes in stress response pro-
cesses over the five years between assessment waves, contributed
to the relatively low autocorrelation. We hypothesize that stress
appraisal bias is a traitlike process, perhaps one that becomes more
stable with age. Finally, the present study concentrated on the
transition from adolescence to adulthood. It is conceivable that the
latent architecture of mental disorders or associations between
disorders and stress reactivity might differ across developmental
epochs (e.g., Wittchen et al., 2009). Similarly, the relatively high
prevalence of maternal depression may have altered the meaning
or configuration of transdiagnostic factors that emerged in our
analyses, relative to what might be observed in unselected sam-
In sum, we found that transdiagnostic Internalizing and Exter-
nalizing dimensions explained associations between common
mental disorders and stress appraisal biases. Additionally, we
provided novel evidence of discriminant validity for the transdi-
agnostic constructs, in that Internalizing and Externalizing were
associated with distinct appraisal bias profiles. Continued empir-
ical research into the transdiagnostic dimensions is needed to
determine whether these constructs help our theories and treat-
ments work better. Indeed, the transdiagnostic model has the
potential to compete with RDoC to serve as the organizing frame-
work for nosology, etiological research, and treatment going for-
ward. However, persuasive evidence for its concurrent and predic-
tive validity is needed before it can be accepted as a viable
research or diagnostic tool. The present findings provide promising
evidence that it can enhance the efficiency and validity of life
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Received October 22, 2015
Revision received March 23, 2016
Accepted March 23, 2016
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... The stress is considered a natural and adaptive reaction when experienced in the short term, through the existence of acute stressors (McEwen, 2000). However, after repeated exposures, it becomes chronic and maladaptive, commonly related to the development of mental disorders (Conway et al., 2016). Chronic stress is associated with psychological changes, including changing a state of awareness and relaxing ability (Bear et al., 2017); endocrine changes, such as increased cortisol indices (Looser et al., 2010) and physiological changes, by changing the balance between the sympathetic nervous system (SNS) and the parasympathetic nervous system (PNS), resulting in increased heart rate and in reduced heart rate variability (HRV) (Bear et al., 2017;Kim et al., 2018). ...
... Specifically at baseline (T1), it was possible to observe that there are significant differences in the presence of physiological stress between clinical (with and without RNT) and non-clinical (with and without RNT) groups. This result corroborates those indicated in the literature, pointing to an association between low baseline HRV and the presence of psychopathology (Conway et al., 2016). ...
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Background: The present study aimed to explore the association of repetitive negative thinking (RNT) and the physiological measure of heart rate variability (HRV). For this, we sought to understand whether the presence of induced stress by suggested negative thinking would change the HRV and to identify the differences in the HRV between the clinical (with and without RNT) and non-clinical (with and without RNT) groups. Method: Sixty individuals participated (76.7% women, age M = 28.53; SD = 5.85). These were divided into two groups: control (n = 30), without self-reported diagnosis of mental disorder (80% women, age M = 28.26; SD = 4.80) and clinical (n = 30), with self-reported of mental disorder (73.30% women, age M = 28.80; SD = 6.82). Subsequently, the groups were subdivided according to the presence of RNT indicators. A stress induction was performed by evaluating the RNT scores using self-report instruments. The measurement of HRV occurred through an experimental protocol. Results: The HRV was influenced by stress induction via suggested negative thought regardless of the presence of psychopathology. The presence of RNT did not change the reactivity to acute stress, but its recovery, showing a reduction in the HRV. Conclusions: These results corroborate the perspective of stress expansion, indicating that individuals with RNT tend to cognitively persevere on the stressful event, prolonging the physiological response to stress and leading to allostatic load. It was concluded that the RNT is a potential vulnerability factor for the maintenance of physiological stress and, consequently, for psychopathology.
... Internalizing problems include features such as anxiety, dissociation, and depression while externalizing problems encompass features such as conduct disorder, substance use disorder, and attention-deficit hyperactivity disorder. Internalizing and externalizing problems have been found to be significant predictors of PDs and to remain comorbid with PDs throughout development (Conway et al., 2015(Conway et al., , 2016. Furthermore, from a developmental perspective, gender differences are also important to consider as research indicates that personality pathology manifests differently amongst boys and girls, with boys displaying more aggressive behaviors, and girls displaying more internalizing features (De Bolle et al., 2012). ...
Introduction: Identifying longitudinal trajectories of emerging personality (EP) is crucial to highlight developmental patterns that might foster personality pathology in adolescence and early adulthood. Research on the exacerbation of personality pathology in adolescence identifies the significant contribution of internalizing and externalizing problems and suggests the importance of considering aspects such as mentalization, while accounting for gender differences. Methods: In our study, we adopted a mixed-model approach to (1) explore longitudinally EP (Adolescent Personality Structure Questionnaire; APS-Q) over 12 months in a sample of adolescents (N = 178, 62% females, mAGE = 15.04, SD = 1.27), accounting for gender effects. Moreover, (2) we assessed the longitudinal effect of internalizing and externalizing problems (Youth Self-Report; YSR-112) on EP. Finally, (3) we addressed the moderating role of mentalization (Movie Assessment for Social Cognition; MASC) in this developmental pathway. Results: Results highlighted a two-way pattern of EP. No changes were found in the level of difficulties in Self-acceptance, Investments and Goals, and Relationships with family dimensions. However, significant changes were found in personality functioning in the dimensions of Sense of Self, Aggression, and Relationships with friends. More, changes in difficulties in Sexuality emerged only in females. Also, gender differences emerged in the level of severity of EP. In addition, Internalizing and Externalizing problems differentially predicted difficulties in personality dimensions. Finally, mentalizing features moderated the relationship between Internalizing problems and Sense of Self and Internalizing problems and Self-acceptance, respectively. Conclusions: Our contribution aligns with recent developmental models of personality pathology, suggesting that different personality dimensions develop at different paces. More, it highlights the predictive power of externalizing and internalizing problems on difficulties in personality dimensions. Finally, it advances the discussion on the contribution of mentalizing abilities to EP.
... Network data were not normally distributed, and many items were heteroskedastic (namely from the SCI-9 and PHQ-9). Thus, partial correlations were estimated following nonparanormal transformation of the data [82,83]. Following listwise deletion of missing data, the training network comprised 1026 cases. ...
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Study objectives Insomnia, depression, and anxiety show high rates of comorbidity and functional impairment. Transdiagnostic symptom interactions may be implicated in this comorbidity. This network analysis sought to assess how symptoms of insomnia, depression, and anxiety may interact and individually predict impairment across several domains for individuals with insomnia. Methods Baseline psychometric data from a randomised controlled trial were analysed (N = 1711). A regularised partial correlation network was estimated from the symptom data. Centrality (symptom connectivity), community structure (symptom clustering), and bridging (inter-community connectivity) were assessed. The replicability of the network model was assessed via confirmatory analyses in a holdout sample. Separately, Shapley values were estimated to determine the relative importance of each symptom in predicting functioning (i.e., psychological wellbeing, psychosocial functioning, and physical health impairment). Results The most connected nodes were uncontrollable worrying; trouble relaxing; and depressed mood/hopelessness. Five communities were identified with trouble relaxing identified as the bridge symptom between communities. The model showed good fit in the holdout sample. Low energy and depressive affect symptoms (feelings of failure/guilt; depressed mood/hopelessness; anhedonia) were key predictors in the relative importance analysis across multiple domains of impairment. Conclusion Trouble relaxing may be of clinical and transdiagnostic significance in the context of insomnia. In terms of how symptoms relate to functioning, it was clear that, while low energy and feelings of failure/guilt were prominent predictors, a range of symptoms are associated with functional impairment. Consideration of both symptoms and functional impairment across domains may be useful in determining targets for treatment. Clinical trial registration This is a secondary analysis of an original clinical trial. Trial registration number: ISRCTN60530898. Registry URL:
... Together this research suggests that in contexts with ongoing sociopolitical violence, addressing factors contributing to youth and parental psychological distress, in addition to supporting positive family-wide processes is likely to be beneficial. Psychological research has identified emotion dysregulation and cognitive appraisal as two key processes underlying the emergence and maintenance of psychological distress in the context of adversity, including in the West Bank and Gaza [32][33][34]. Both of these processes are directly addressed in cognitive behavioral therapy, which has demonstrated effectiveness for a broad range of presenting problems in numerous contexts and with diverse populations, including in conflict-affected settings, in the Middle East, and with both adolescents and adults [35,36]. ...
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Background: A total of 450 million children are now living in active conflict zones. The negative consequences for children are significant and long lasting. In response to the urgent need for sustainable interventions for children and families, the current study evaluated a brief (12 hr, 8 session) family-based coping and support program, Promoting Positive Family Futures (PPFF), in Gaza. Methods: Families (n = 68, mother/father/adolescent triads) were randomized into the PPFF intervention or another lengthier (50 hr, 25 session) locally well-established psychosocial support program (treatment as usual; TAU). Results: Improvements were found for both conditions for paternal and maternal depression, emotion regulation using cognitive reappraisal, family-wide emotional security, and adolescent adjustment. Effect sizes were medium to large (d = 0.35–1.27). Fathers in the PPFF condition reported lower depression and higher emotion regulation using cognitive reappraisal at post-test than did fathers in the TAU condition. Mothers in the PPFF condition reported higher levels of emotion regulation using cognitive reappraisal at post-test than did mothers in the TAU condition. PPFF was also indirectly associated with improved depression at post-test for both mothers and fathers via improvements in emotion regulation using cognitive reappraisal and with adolescent adjustment at six months via improvements in maternal emotion regulation using cognitive reappraisal. Conclusions: These findings suggest that the PPFF intervention has many benefits comparable with a longer and locally well-established program. PPFF was also associated with unique positive implications for family-wide adjustment over time. Support was also identified for transdiagnostic processes of improvement associated with the PPPF intervention consistent with the theoretical models informing the approach.
... Associations found between childhood trauma and attachment dimensions which on their own were not significantly associated with trauma symptoms. (Cludius et al., 2020;Compas et al., 2014;Conway et al., 2016). Other mechanisms explored in the reviewed studies were found to be relevant to anxiety and depression only (e.g., attachment anxiety and psychological inflexibility), while others were shown to be relevant to specific disorders (e.g., self-compassion and shame for depression and attentional control for anxiety). ...
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Adverse childhood experiences (ACEs) are identified with increased risk of adult mental health difficulties and negative impacts on wellbeing. However, there is a need to go beyond simple associations and identify candidate mechanisms underpinning the ACEs‐mental health relationship. Further methodological heterogeneity points to issues around the operationalisation of ACEs and the importance of modelling data using robust research designs. The aim of the current review was to synthesize studies that utilised formal mediation and/or moderation analyses to explore psychological and social variables on the pathway between clearly defined ACEs (as measured by the ACE questionnaire and CTQ) and common mental health outcomes (depressive, anxiety, PTSD symptoms) across community samples aged over 18. A total of 31 papers were retrieved for critical appraisal. The majority of the studies explored factors mediating/moderating the link between child adversity and depression, and less on anxiety and trauma. Most mechanisms were tested in only single studies, limiting the consistency of evidence. Evidence indicated that the mechanisms underlying associations between ACEs and adult mental health are likely to reflect multiple intervening variables. Further, there are substantial methodological limitations in the extant literature including the proliferation of causal inferences from cross‐sectional designs, and both measurement and conceptual issues in operationalizing adversity. Consistent transdiagnostic mechanisms relevant to common mental health problems were identified, including perceived social support, emotion regulation, and negative cognitive appraisals/beliefs. Further research using longitudinal design is required to delineate the potential contribution of the identified mechanisms.
... However, personality disorders that load on internalizing (e.g., borderline and avoidant) often cross over into other spectra (externalizing and detachment, respectively 46,58 ). Table 1 demonstrates substantial support for subdividing internalizing into distress and fear subfactors, but evidence for the distress-fear distinction is not universal 46,52,55,56,67 . Some studies have found evidence for additional subfactors of internalizing, including sexual problems [93][94][95] and eating pathology 77,78 , although eating pathology may form a separate structural dimension 55 . ...
The Hierarchical Taxonomy of Psychopathology (HiTOP) is a quantitative nosological system that addresses shortcomings of traditional mental disorder diagnoses, including arbitrary boundaries between psychopathology and normality, frequent disorder co-occurrence, substantial heterogeneity within disorders, and diagnostic unreliability over time and across clinicians. This paper reviews evidence on the validity and utility of the internalizing and somatoform spectra of HiTOP, which together provide support for an emotional dysfunction superspectrum. These spectra are composed of homogeneous symptom and maladaptive trait dimensions currently subsumed within multiple diagnostic classes, including depressive, anxiety, trauma-related, eating, bipolar, and somatic symptom disorders, as well as sexual dysfunction and aspects of personality disorders. Dimensions falling within the emotional dysfunction superspectrum are broadly linked to individual differences in negative affect/neuroticism. Extensive evidence establishes that dimensions falling within the superspectrum share genetic diatheses, environmental risk factors, cognitive and affective difficulties, neural substrates and biomarkers, childhood temperamental antecedents, and treatment response. The structure of these validators mirrors the quantitative structure of the superspectrum, with some correlates more specific to internalizing or somatoform conditions, and others common to both, thereby underlining the hierarchical structure of the domain. Compared to traditional diagnoses, the internalizing and somatoform spectra demonstrated substantially improved utility: greater reliability, larger explanatory and predictive power, and greater clinical applicability. Validated measures are currently available to implement the HiTOP system in practice, which can make diagnostic classification more useful, both in research and in the clinic.
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Background: Generalized anxiety disorder (GAD) and major depressive disorder (MDD) often precede and predict one another. Heightened stress reactivity may be a mediation mechanism underlying the long-term connections between GAD and MDD. However, cross-sectional studies on this topic have hindered directional inferences. Method: The present study examined stress reactivity as a potential mediator of the sequential associations between GAD and MDD symptoms in a sample of 3294 community-dwelling adults (M age = 45.6, range = 20-74). Participants completed three waves of measurement (T1, T2, and T3) spaced nine years apart. GAD and MDD symptom severity were assessed at T1, T2, and T3 (Composite International Diagnostic Interview-Short Form). Stress reactivity (Multidimensional Personality Questionnaire) was measured at T2. Results: Structural equation mediation modeling demonstrated that higher T1 GAD symptoms positively predicted more severe T3 MDD symptoms via T2 stress reactivity, controlling for T1 MDD (d = 0.45-0.50). However, T2 stress reactivity was not a significant mediator in the relationship between T1 MDD severity and T3 GAD symptoms after controlling for T1 GAD. Direct effects indicated that T1 GAD positively predicted T3 MDD 18 years later and vice versa (d = 1.29-1.65). Limitations: Stress reactivity was assessed using a self-report measure, limiting conclusions to perceived (vs. behaviorally indexed) stress reactivity. Conclusions: These findings indicate that stress reactivity may be one mechanism through which GAD leads to later MDD over prolonged durations. Overall, results suggest that targeting stress reactivity in treatments for GAD may reduce the risk of developing subsequent MDD.
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While appraisal and coping are known to impact adolescent psychopathology, more vulnerable or resilient responses to stress may depend on individual temperament. This study examined early life temperament as a moderator of the prospective relations of pre-adolescent appraisal and coping with adolescent psychopathology. The sample included 226 (62% female, 14–15 years) adolescents with assessments starting at 3 years of age. Adolescents were predominately White (12% Black 9% Asian, 11% Latinx, 4% Multiracial, and 65% White). Observed early-childhood temperament (fear, frustration, executive control, and delay ability) were tested as moderators of pre-adolescent coping (active and avoidant) and appraisal (threat, positive) on internalizing and externalizing symptoms during the pandemic. Interaction effects were tested using regression in R . Sex and family context of stress were covariates. Early-childhood temperament was correlated with pre-adolescent symptoms, however, pre-adolescent appraisal and coping but not temperament predicted adolescent psychopathology. Frustration moderated the relations of active and avoidant coping and positive appraisal to symptoms such that coping and appraisal related to lower symptoms only for those low in frustration. Executive control moderated the associations of avoidant coping with symptoms such that avoidance reduced the likelihood of symptoms for youth low in executive control. Findings underscore the role of emotionality and self-regulation in youth adjustment, with the impact of coping differing with temperament. These findings suggest that equipping youth with a flexible assortment of coping skills may serve to reduce negative mental health outcomes.
Subjective stress severity appraisals have consistently emerged as better predictors of poor health than stressor exposure, but the reason for this is unclear. Subjective stress may better predict poor health for one of at least two reasons. First, because stressor exposure measures consider all stressors as equal, stress severity measures—which “weight” stressors by self‐reported severity—might better predict poor health simply by not treating all stressors as equal. Second, subjective stress appraisals may index important individual differences in stress vulnerability. We tested these two possibilities in this preregistered, two‐study manuscript. Across these two different studies, subjective stress severity was a better predictor of poor health than independently weighted stress severity or stressor exposure. These results demonstrate that, beyond weighting of stressful experiences, subjective stress severity indexes health‐relevant individual differences. Moreover, the results suggest that subjective stress severity may be the preferred stress summary metric even from imprecise stress assessment tools. This article is protected by copyright. All rights reserved.
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Many psychiatric disorders are widely thought to involve problematic patterns of emotional reactivity and emotion regulation. Unfortunately, it has proven far easier to assert the centrality of “emotion dysregulation” than to rigorously document the ways in which individuals with various forms of psychopathology differ from healthy individuals in their patterns of emotional reactivity and emotion regulation. In the first section of this article, we define emotion and emotion regulation. In the second and third sections, we present a simple framework for examining emotion and emotion regulation in psychopathology. In the fourth section, we conclude by highlighting important challenges and opportunities in assessing and treating disorders that involve problematic patterns of emotion and emotion regulation.
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This study aimed to replicate a study by Caspi and colleagues, which proposed that the structure of psychopathology is characterized by a general psychopathology factor, in addition to smaller internalizing and externalizing factors. Our study expanded the approach of the original by using continuous adolescent data and testing additional models, including both self- and parent-reported data, to bolster the robustness of the findings. Our findings indicate that the structure of psychopathology is best characterized by a model including a general factor, in addition to smaller internalizing and externalizing factors. These results emphasize the importance of this model for understanding the structure of psychopathology. Given the increasing emphasis on the importance of, and need for, replication, the overall evidence of a general factor seems rather robust.
Background and objectives: Stress is well known as a trigger of depressive reactions, fear, anxiety, and behavioral disorders. However, there are many gaps in the conceptualization and measurement of environmental stress. Results: Exciting developments in the neuroscience of stress have increasingly expanded our knowledge of mechanisms by which stress may affect emotional and behavioral adjustment. Ironically, environmental stress has often been a silent player in human studies of stress processes. There is significant need for increased efforts to include environmental stress variables in models of internalizing and other disorders. Measurement and conceptualization issues are prominent, and this article makes the case for improved methods of measuring acute, chronic, and early life stress, and for additional conceptualization of the dynamically changing and bidirectional effects of stress on disorder over time. Conclusions: There is a critical need for greater focus on and better measurement of the environment and its impact on emotional and other disorders, with emphasis on developmentally informed hypotheses. Empirical findings and new perspectives may contribute enormously to our understanding of normal and abnormal outcomes, and also to the challenge of effective interventions to promote mental health and optimal functioning.
Both acute stressful life events and ongoing strains are thought to confer vulnerability to emotional disorders. Unremitting stressful conditions may be particularly pathogenic, but prior research has struggled to delimit chronic versus transient stressful experiences. We aimed to isolate stable stressors-theorized to be indicators of a latent stress proneness trait-and to examine their effects on the temporal course of depression and panic disorder. We recruited 677 patients diagnosed with an emotional disorder and administered interviews for psychopathology and life stress 3 times over 12-month intervals. Trait-state-occasion modeling revealed that 74% of the variance in life stress was stable over the follow-up period. These stable stressors were associated with a more refractory course of depression and, to a smaller degree, panic disorder over time. In addition, neither gender nor participation in cognitive-behavioral therapy affected the persistence of environmental stress over the study time frame. We discuss implications of these findings for explaining depression recurrence, improving psychological interventions for emotional disorders, and the measurement and evaluation of stress proneness. (PsycINFO Database Record
• Previous studies have indicated that criminality is in part genetically determined, but it is not clear how this predisposition manifests itself at a biological level. This prospective study tests the hypothesis that a psychophysiological predisposition to criminality partly manifests itself through autonomic and central nervous system underarousal. Psychophysiological measures, taken at the age of 15 years, were related to criminality status that was assessed at the age of 24 years. Criminals had a significantly lower resting heart rate, skin conductance activity, and more slow-frequency electroencephalographic activity than noncriminals. Differences were not mediated by social, demographic, and academic factors. These results constitute the first clear evidence that implicates underarousal in all three response systems (electrodermal, cardiovascular, and cortical) in the development of criminality. Although arousal variables correctly classified 74.7% of all subjects, psychophysiological factors alone cannot fully account for criminal behavior and do not negate the potential role of social variables in predicting criminal behavior.
Sustained negative affect and difficulties experiencing positive affect are hallmark features of major depressive disorder. Recent research has suggested that difficulties in emotion regulation are at the core of these cardinal symptoms of major depressive disorder; depressed patients exhibit more frequent use of maladaptive emotion regulation and difficulties effectively implementing adaptive strategies. It remains unclear, however, what underlies these difficulties in emotion regulation. Cognitive theories of depression have a long tradition of focusing on cognitive factors that increase depression risk and maintain depressive episodes, but the link between cognitive and affective aspects of major depressive disorder remains to be explored. We propose that cognitive biases and deficits in cognitive control putatively associated with depression affect emotion regulation in critical ways, thereby setting the stage for maintained negative affect and diminished levels of positive affect. We close with a discussion of implications for treatment and future directions for research in this area.