An Examination of the Tripartite Model of Anxiety and Depression and Its Application to Youth

The ability to differentiate anxiety and depression has been a topic of discussion in the adult and youth literatures for several decades. The tripartite model of anxiety and depression proposed by L. A. Clark and D. Watson (1991) has helped focus the discussion. In the tripartite model, anxiety is characterized by elevated levels of physiological hyperarousal (PH), depression is characterized by low levels of positive affect (PA), and negative affect (NA) or generalized emotional distress is common to both. The advent of the model led to the development of measures of tripartite constructs and subsequent validity studies. The tripartite model and resultant activity concerning the model was largely devoted to adult samples. However, those interested in anxiety and depression among youth are now incorporating the tripartite model in their work. This paper examines the current influence of the tripartite model in the youth literature, especially with regard to measuring anxiety and depression.     

Assessment of Tripartite Factors of Emotion in Children and Adolescents II: Concurrent Validity of the Affect and Arousal Scales for Children

The authors assessed the reliability and validity of the Affect and Arousal Scale for Children (AFARS; Chorpita, Daleiden, Moffitt, Yim, & Umemoto, 2000). The AFARS is a new measure of children's positive affect (PA), negative affect (NA), and physiological hyperarousal (PH). In the first study, 176 school children, 7 to 17 years of age, were administered measures of childhood worry, anxiety sensitivity, and autonomic arousal and their parents completed a child behavior problem checklist. In a second study, two groups of 100 and 114 school children, 8 to 18 years of age, were administered measures of childhood depression and anxiety, respectively, Also, 120 of these children took part in a 1-week retest administration of the AFARS. These studies provided preliminary evidence of acceptable 1-week test–retest reliability, convergent validity, and discriminant validity for the AFARS PA, NA, and PH scales. However, the predicted pattern of convergent and discriminant relations with parent-reported criterion only emerged for children over 11 years of age. Further, a consistent positive relation emerged between NA and PH, yet each of these scales accounted for unique variance in the prediction of criterion measures.     

Assessment of Tripartite Factors of Emotion in Children and Adolescents I: Structural Validity and Normative Data of an Affect and Arousal Scale

The authors developed and evaluated a self-report measure for children designed to assess factors of the tripartite model of emotion (Clark & Watson, 1991). Factor analytic results from a large, multi-ethnic sample (n = 1,289) supported the structural validity of the scale, with the additional suggestion that negative affect appeared to contain two lower order dimensions in the item pool. Confirmatory factor analysis in an independent sample of 300 children and adolescents suggested favorable structure. Consistent with prediction, positive and negative affect emerged as relatively orthogonal dimensions. Physiological hyperarousal was found to be positively correlated with negative affect. Normative data are presented, and tests for differences by sex, grade level, and ethnicity demonstrated nonsignificant or minimal differences between groups. The implications for the assessment of tripartite factors and their relation to psychopathology in youth are discussed.     

Anxiety and Depression in Children and Adolescents: A Factor-Analytic Examination of the Tripartite Model

The tripartite model of Clark and Watson (1981) suggests that the oft-observed covariation between anxiety and depression can best be understood by examining three related yet distinct constructs: negative affectivity, positive affectivity, and elevated physiological arousal. In the present study, 510 boys and girls in the 4th, 7th, and 10th grades completed the Children's Depression Inventory and the Revised Children's Manifest Anxiety Scale. Confirmatory factor analyses were conducted to determine the goodness of fit of single-factor (i.e., negative affectivity), two-factor (i.e., anxiety and depression), and three-factor models (i.e., negative affectivity, positive affectivity, and physiological arousal). Analyses were conducted by examining each of the models in the whole sample first and then separately for boys and girls and for fourth, seventh, and tenth grade youths. Results failed to support the tripartite theory; rather, the findings supported a two-factor model in all cases. These factors represented the general constructs of anxiety and depression, and these factors remained significantly interrelated. Consistent with previous findings, the strength of these relations was stronger for boys than girls and for children than adolescents.     

A Test of the Tripartite Model of Anxiety and Depression in Elementary and High School Boys and Girls

The applicability of the tripartite model of emotion, which distinguishes the shared aspect of depression and anxiety, negative affect (NA), from their respective specific components of low positive affect (PA) and physiological hyperarousal (PH), was examined in 472 elementary and high school students. The relations among depression, anxiety, and the three tripartite dimensions were examined for the total sample and across four subgroups based on age and gender. High school girls reported more depression, anxiety, NA, and PH than the other groups, and lower PA as assessed by the PANAS-C, but not the AFARS. Using structural equation modeling, the tripartite model proved to be a reasonably good fit for the total sample. Among the subgroups, the best fit was found for high school girls. However, several findings for the total sample and for individual subgroups were not consistent with the tripartite model, raising issues related to the independence and specificity of the tripartite constructs and their measurement. Alternative age- and gender-specific models to better account for the shared and unique aspects of depression and anxiety in children need to be explored.     

Depression and Anxiety: Integrating the Tripartite and Cognitive Content-Specificity Assessment Models

The cognitive content-specificity hypothesis proposes that depression and anxiety can be discriminated on the basis of unique cognitive profiles. Alternatively, the Tripartite model suggests that, although depression and anxiety share a general distress factor, anhedonia is a characteristic of depression with anxious arousal a characteristic of anxiety. Past research devoted to integrating these two models has been limited in a number of ways. To remedy these limitations, this study attempted to assess the complete Tripartite model and used a multidimensional cognitive assessment tool to handle the heterogeneity of anxious cognitive content. Results on data collected from 411 clients seeking services at a university counseling center suggested that a one-to-one mapping between Tripartite dimensions and cognitive content was possible. Further, variables from each model simultaneously explained unique variance in depression and anxiety ratings.     

Emotion Regulation Therapy: An Integrative Approach to Treatment-Resistant Anxiety Disorders

Cognitive-behavioral, psychodynamic, and experiential approaches have historically been characterized by differing definitions of emotions and beliefs concerning their role in psychopathological process and treatment. However, given recent advances in the basic psychological sciences of emotion and emotion regulation, theoretical orientations are converging on similar viewpoints as to the functional role of emotions in conceptualizing and treating of a variety of disorders. One such area where emotions and their regulation may play a significant role is in chronic, complex, and treatment-resistant forms of anxiety disorders such as generalized anxiety disorder (GAD). A review of the historical approaches to emotions in the major theoretical orientations is presented. Following this, a model of emotion disruption and dysregulation is presented as it relates to anxiety disorders and GAD, in particular. Finally, a new treatment for GAD, emotion regulation therapy, aimed at ameliorating dysfunctional affective processes, is described.     

Responses to Conflict and Cooperation in Adolescents with Anxiety and Mood Disorders

This study examined patterns of behavioral and emotional responses to conflict and cooperation in adolescents with anxiety/mood disorders and healthy peers. We compared performance on and emotional responses to the Prisoner’s Dilemma (PD) game, an economic exchange task involving conflict and cooperation, between adolescents with anxiety/depressive disorders (A/D) (N=21) and healthy comparisons (n = 29). Participants were deceived to believe their co-player (a pre-programmed computer algorithm) was another study participant. A/D adolescents differed significantly from comparisons in patterns of play and emotional response to the game. Specifically, A/D participants responded more cooperatively to cooperative overtures from their co-players; A/D girls also reported more anger toward co-players than did comparison girls. Our findings indicate that A/D adolescents, particularly females, respond distinctively to stressful social interchanges. These findings offer a first step toward elucidating the mechanisms underlying social impairment in youth with internalizing disorders. This research was supported by the Intramural Research Program of the NIH, NIMH.     

Self-Report Differentiation of Anxiety and Depression in a Mood Disorders Sample

Several lines of research suggest there is considerable overlap between anxiety and depression and that it is difficult to distinguish between these two constructs. However, a few studies utilizing factor analytic procedures have provided evidence that anxiety and depression can be differentiated when measures of these constructs are considered at the item level. In addition, there is some evidence that differentiation can be accomplished in samples experiencing high levels of anxiety (i.e., a clinically anxious sample; B. J. Cox, R. P. Swinson, L. Kuch, & J. Reichman, 1993). In the present study, this research strategy was extended to a sample of patients with high levels of depressed mood (i.e., a mood disorders sample; N = 378). Their responses to widely used measures of depression (i.e., Beck Depression Inventory; A. T. Beck, C. H. Ward, M. Mendelson, J. Mock, & J. Erbaugh, 1961) and anxiety (i.e., Spielberger State-Trait Anxiety Inventory—State subscale; C. D. Spielberger, R. L. Gorsuch, & R. E. Lushene, 1970) were entered into a principal-components analysis with oblique rotation. A 4-factor solution was retained. This solution was comprised of factors representing anxiety, anxiety absent (a reverse scored factor), cognitive symptoms of depression, and somatic/vegetative symptoms of depression. These findings indicated that anxiety and depression, as emotional states, can be differentiated within a mood disorders sample, using existing popular self-report measures. The clinical and research implications of these findings are briefly discussed.     

Analogue Measures of DSM-IV Mood and Anxiety Disorders Based on Behavior Checklists

Although symptom checklists are commonly used to assess childpsychopathology, confusion arises due to differences between empirically derived checklist syndromes and rationally derived DSM-IV diagnostic categories. This paper explores analogue measures of DSM-IV mood and anxiety disorders created using items from the Youth Self-Report and Child Behavior Checklist (T. M. Achenbach, 1991a, 1991b) that parallel DSM-IV symptoms. In a matched sample of clinically referred and nonreferred adolescents, analogue measures demonstrated expected patterns of age differences, sex differences, and comorbidity. Meeting criteria for an analogue diagnosis was also associated with referral for mental health services and poor social competence. Informant effects are highlighted and the potential benefits and limitations of using existing behavior checklists to assess DSM disorders are discussed. These findings suggest the utility of checklists in identifying analogues of anxiety and mood disorders in children and adolescents.     

The Role of Emotion Regulation in the Treatment of Child Anxiety Disorders

In this review, we examine the role of emotion regulation in the treatment of children with anxiety disorders. Cognitive-behavioral therapy (CBT) has been shown to “work” for children with anxiety disorders and it has been categorized as an evidence-based treatment. However, most studies have shown that the treatment is effective for about 60–70% of children, leaving the remaining children symptomatic and oftentimes with persisting psychological disorders. Of importance, it has also been shown that many children with anxiety disorders demonstrate poor emotion regulation skills. Despite these findings, little attention has been directed toward incorporating emotion regulation strategies into these relatively effective cognitive-behavioral treatments. It is possible that CBT programs do not work as well for a portion of children because their emotion regulation deficits, if present, are not being targeted sufficiently. In this review, it is suggested that adding an emotion regulation component could increase treatment efficacy. In addition, strategies aimed at improving emotion regulation at the individual level and at the family level are introduced. Details of how improved emotion regulation skills could be beneficial in bringing about change are discussed. Finally, issues of measurement and the clinical implications for research and practice are considered.     

Stress Sensitization and Adolescent Depressive Severity as a Function of Childhood Adversity: A Link to Anxiety Disorders

The goal of the present study was to determine whether exposure to adversity in childhood contributes to a differential threshold at which stressful life events provoke depressive reactions in adolescence. In addition, to address empirical and conceptual questions about stress effects, the moderating effect of anxiety disorder history was also explored. This examination was conducted in a sample of 816 children of depressed and nondepressed mothers, who were followed from birth to age 15. Information on adversities experienced in childhood was collected both from mothers during the first five years of their youth's life and from the youths themselves at age 15, and included information on the mother's relationship with her partner, maternal psychopathology, as well as youth-reported abuse. Results indicated that youths with both greater exposure to adversity in childhood and a history of an anxiety disorder displayed increased depressive severity following low levels of episodic stress compared to youths with only one or neither of these risk factors. The results are speculated to reflect the possibility that early anxiety disorders associated with exposure to adversity in childhood may be a marker of dysregulated stress responses, and may help to account for the comorbidity of depression and anxiety in some individuals.     

Relapse Prevention Techniques in the Treatment of Childhood Anxiety Disorders: A Case Example

Research has shown that cognitive behavioral therapy (CBT) is an efficacious treatment for children and adolescents with anxiety disorders. CBT incorporates techniques such as cognitive restructuring and exposure, which foster symptom reduction. While these components promote sustained fear reduction, greater attention to relapse prevention (RP) may be warranted, particularly given the comorbidity associated with anxiety disorders. A case example demonstrates a comprehensive relapse prevention (RP) component. Specifically, parental involvement was emphasized as well as the creation of a bound book that consolidated skills and provided a concrete resource for potential future anxious episodes.     

Hierarchical Model of Vulnerabilities for Anxiety: Replication and Extension with a Clinical Sample

This study served to replicate and extend our previously obtained hierarchical model of the relationships among general anxiety vulnerabilities, specific anxiety vulnerabilities and specific anxiety manifestations including panic symptoms, health anxiety, obsessive‐compulsive symptoms and worry. Questionnaires assessing these variables, as well as positive affectivity and depressiveness, were administered to 125 outpatients seeking treatment for panic disorder, social anxiety disorder, obsessive‐compulsive disorder, generalized anxiety disorder or major depressive disorder. The results, using a clinical sample, were highly consistent with the hierarchical model obtained in the previous study using a student sample. A more elaborate model, based on published theoretical and empirical evidence, was identified and tested, and similar results were obtained. Negative affectivity had expected direct positive effects on all of the specific anxiety and depression manifestations, with the exception of health anxiety, which showed a negative relationship, and OCD symptoms, which showed no relationship. Positive affectivity was found to be a specific risk factor for depression, while intolerance of uncertainty was found to be a specific risk factor for worry and depression. Finally, anxiety sensitivity appears to be a significant risk factor for panic and health anxiety.     

Prospective Longitudinal Associations Between Persistent Sleep Problems in Childhood and Anxiety and Depression Disorders in Adulthood

The objective of this study was to examine the associations between persistent childhood sleep problems and adulthood anxiety and depression. Parents of 943 children (52% male) participating in the Dunedin Multidisciplinary Health and Development Study provided information on their childrens sleep and internalizing problems at ages 5, 7, and 9 years. When the participants were 21 and 26 years, adult anxiety and depression were diagnosed using a standardized diagnostic interview. After controlling for childhood internalizing problems, sex, and socioeconomic status, persistent sleep problems in childhood predicted adulthood anxiety disorders (OR (95% CI) = 1.60 (1.05–2.45), p = .030) but not depressive disorders (OR (95% CI) = .99 (.63–1.56), p = .959). Persistent sleep problems in childhood may be an early risk indicator of anxiety in adulthood.     

Screening HIV-Infected Patients with Chronic Pain for Anxiety and Mood Disorders with the Beck Anxiety and Depression Inventory-Fast Screens for Medical Settings

The Beck Anxiety (BAI-FS) and Depression (BDI-FS) Inventory-Fast Screens for Medical Settings were administered to 63 HIV-infected outpatients seeking treatment at a chronic pain clinic to evaluate how effectively these 7-item instruments would, respectively, differentiate those who were and were not diagnosed with DSM-IV anxiety, mood, or both disorders. The Anxiety and Mood Modules from the Primary Care Evaluation of Mental Disorders (PRIME-MD) were employed to establish the diagnoses. The coefficient 's for the BAI- and BDI-FS were, respectively, .80 and .84. A BAI-FS cut-off score of 4 and above yielded 82% sensitivity and 59% specificity rates for identifying patients with and without anxiety disorders, whereas a BDI-FS cut-off score of 4 and above had 90% sensitivity and 74% specificity rates for detecting patients with and without mood disorders. It was concluded that the BDI-FS was a useful instrument for screening HIV-infected patients with chronic pain for mood disorders.     

Relations Between Anxiety Sensitivity and Attachment Style Dimensions

This study replicated and extended the work of C. F. Weems, S. L. Berman, W. K. Silverman, and E. T. Rodriquez (2002) by investigating relations between anxiety sensitivity (AS) and attachment dimensions in a sample of young adults. Two hundred and twenty-six undergraduate students completed self-report measures including the Anxiety Sensitivity Index and the measure of adult romantic attachment used by C. F. Weems et al. (2002). In order to investigate the association between AS and a different domain of attachment, a measure of adult attachment referring to close relationships was included. As defined by both measures, insecurely attached individuals, specifically those classified as preoccupied and fearful (i.e., those with negative Models of Self), reported significantly higher levels of AS than those with secure and dismissing attachment styles (i.e., those with positive Models of Self). Results indicated that across both measures the Model of Self attachment dimension accounted for unique variance in AS levels beyond that contributed by trait anxiety. The Model of Others attachment dimension had a more limited association with AS.     

The tripartite model and dimensions of anxiety and depression: an examination of structure in a large school sample

This study was designed to build on recent findings that (a) factors of the tripartite model in adults are not uniformly related to all anxiety disorder dimensions as recent research has suggested (T. A. Brown, B. F. Chorpita, & D. H. Barlow, 1998; S. Mineka, D. W. Watson, & L. A. Clark, 1998), and (b) the tripartite model of emotion appears to have increasing support and utility in child samples (e.g., C. J. Lonigan, E. S. Hooe, C. F. David, & J. A. Kistner, 1999). The structural relations were evaluated among tripartite factors and dimensions representing selected anxiety disorders and depression in a large multiethnic school sample of children and adolescents. General aspects of the tripartite model were supported. For example, Negative Affect was positively related with all anxiety and depression scales, and Positive Affect was negatively correlated with the depression scale. Consistent with previous observations in adult samples, Physiological Hyperarousal was positively related with Panic only, and was not significantly positively correlated with other anxiety syndromes. The structure of the best fitting model appeared robust across different grade levels and gender. In follow-up analyses, several interactions of grade level with structural parameters emerged, such that the relation of some of the tripartite factors with anxiety and depression were noted to increase or decrease across grade level.