Psychopathology in anxiety disorders

Complaints of anxiety, often meetingDiagnostic and Statistical Manual of Mental Disorders, 3rd ed. (DSM-III), criteria for anxiety disorder, are among the most common problems presenting to health practitioners. In spite of the frequency of anxiety and anxiety disorders, little is known about the basic psychopathology of these conditions that would lead to the development of more efficient and effective treatments and possible preventive efforts. Recently, there has been an increase in research on the psychopathology of anxiety disorders from biological, psychological, and social perspectives. The National Institute of Mental Health's Clinical Research Branch sponsored a 2-day workshop of investigators representing diverse research approaches to discuss emerging issues and research practices within the anxiety disorders. Discussions centered on a review of the general areas of classification, phenomenology, and etiology. A selective summary of this workshop is presented along with recommendations for specific research directions.     

Diagnosis of personality disorders: a case study

In this article, I report a case highlighting diagnostic uncertainty about psychopathology on both Axes I and II. It concerns in part the problem of comorbidity in relation to diagnostic classification of Axis II personality disorders. After commenting on these uncertainties in relation to categorical and dimensional models, I also consider a psychoanalytic explanation to illustrate an example in which a theoretical model informs diagnostic interviewing. I emphasize how the clinical information that unfolds from an interview based on this theoretical model generates inferences about psychopathology that extend clinical understanding beyond the formal diagnostic assessment of Axes I and II disorders and assessment by self-report.     

Diagnosis of Personality Disorders: A Case Study

In this article, I report a case highlighting diagnostic uncertainty about psychopathology on both Axes I and II. It concerns in part the problem of comorbidity in relation to diagnostic classification of Axis II personality disorders. After commenting on these uncertainties in relation to categorical and dimensional models, I also consider a psychoanalytic explanation to illustrate an example in which a theoretical model informs diagnostic interviewing. I emphasize how the clinical information that unfolds from an interview based on this theoretical model generates inferences about psychopathology that extend clinical understanding beyond the formal diagnostic assessment of Axes I and II disorders and assessment by self-report.     

Comparing factor structures of adolescent psychopathology

Research on the structure of adolescent psychopathology can provide information on broad factors that underlie different forms of maladjustment in youths. Multiple studies from the literature on adult populations suggest that 2 factors, Internalizing and Externalizing, meaningfully comprise the factor structure of adult psychopathology (e.g., Krueger, 1999) and presumably represent broad vulnerability for co-occurring disorders. Though this research was partially inspired by early work with children and adolescents (e.g., Achenbach & Edelbrock, 1984), the role of substance use in these models of youth psychopathology has not been fully explored. Toward this goal, we recruited 223 youths (10-17 years of age, M = 14.2) from mental health agencies and the community. We found evidence for a 3-factor model of youth psychopathology, including Internalizing (depression, generalized anxiety), Externalizing (conduct disorder, attention deficit, oppositional defiant disorder), and Substance Use (alcohol and cannabis). The 3-factor model showed the best fit to the data relative to other factor models tested, including across subsamples of adolescents who differed on level of psychopathology (treatment vs. community samples). Implications for the structure of adolescent psychopathology, including important developmental considerations, are discussed.     

Issues in diagnosing anxiety disorders

Research progress in the anxiety disorders is predicated on a useful classification system. In this paper, we review the reliability and validity data for theDiagnostic and Statistical Manual of Mental Disorders, 3rd ed. (DSM-III) anxiety disorders and discuss the salient issues associated with both the conceptualization of anxiety disorders and the diagnostic criteria offered in the DSM-III. It is concluded that the diagnostic reliability for these disorders is, overall, satisfactory. A dearth of validity data, however, hinders progress in both the diagnosis and the treatment of the anxiety disorders. Nevertheless, the DSM-III work group has proposed several changes in the diagnostic criteria for the anxiety disorders. We find some of these proposed changes helpful in that they clarify current diagnostic criteria; changes in diagnostic criteria that alter the basic classification schema, however, seem to be premature.Preparation of this paper was supported in part by MIMH Research Grant 1368.On sabbatical leave from Indiana State University.     

Psychopathology: A Simple Twist of Fate or a Meaningful Distortion of Normal Development? Toward an Etiologically Based Alternative for the DSM Approach

In this comment, I focus on a central issue that spans the entirety of Sidney Blatt's research career, namely his contributions to the development of a theoretically consistent and clinically relevant classification system of psychopathology. First, I discuss empirical evidence concerning the key assumptions underlying the currently dominant classification system of mental disorders, the Diagnostic and Statistical Manual of Mental Disorders (DSM). Second, I compare these assumptions with assumptions underlying Blatt's categorization of psychopathology based on his distinction between two developmental lines, that is, self-definition and relatedness, together with a discussion of recent research on these two developmental lines in the context of the development of a more etiologically based classification system of depression and other disorders. Finally, I argue that research concerning Blatt's model of normal and pathological development—aside from direct contributions—may also inform empirically derived criteria for the development of a theoretically consistent and clinically useful way of classifying psychopathology.     

Anxiety Disorders in Childhood: Casting a Nomological Net

Empirical research highlights the need for improving the childhood anxiety disorder diagnostic classification system. In particular, inconsistencies in the stability estimates of childhood anxiety disorders and high rates of comorbidity call into the question the utility of the current DSM criteria. This paper makes a case for utilizing a nomological net⁴ model for advancing the understanding of childhood anxiety disorders. In this article, we discuss measurement and assessment issues related to improving the childhood anxiety disorder diagnostic system and show how these issues can be addressed by employing the nomological net of childhood anxiety. Because employing the nomological net involves drawing from etiological process theories to facilitate classification and assessment, an integrative model of childhood anxiety disorders is presented as a tentative heuristic. Then evidence for the existing symptom sets is discussed in the context of how process theory mechanisms may be utilized to improve classification and assessment. Testable hypotheses are presented. Measurement, disorder definition, treatment, and policy implications are also discussed.A nomological net can be briefly defined as the theoretical structure of a construct.     

Specificity of autonomic arousal to DSM-IV panic disorder and posttraumatic stress disorder

Although research on the hierarchical model of anxiety and depression has confirmed that autonomic arousability (AA) is more germane to panic disorder with or without agoraphobia (PD/A) than other DSM-IV anxiety and mood disorders, studies have not evaluated the differential relevance of AA to posttraumatic stress disorder (PTSD). This issue was addressed in multivariate analytic models using 295 outpatients with anxiety and mood disorders. Consistent with prediction, the presence of current DSM-IV PTSD and PD/A was significantly predictive of AA, even when other forms of anxiety disorder comorbidity were held constant. Moreover, latent structural analyses indicated that PTSD and PD/A were the only DSM-IV anxiety disorder constructs to have significant direct effects on AA (in accord with previous findings, the DSM-IV constructs of generalized anxiety disorder, social phobia, and obsessive-compulsive disorder did not have significant structural relationships with AA). The current findings, which attest to the specificity of AA to PTSD and PD/A, are discussed in context of other clinically salient shared features of these disorders and their relevance to treatment and diagnostic classification.     

How Transdiagnostic Factors of Personality and Psychopathology Can Inform Clinical Assessment and Intervention

Research suggests that many mental disorders—mood and anxiety, substance use, and personality psychopathology—are related through relatively few latent transdiagnostic factors. With regard to the comorbidity of personality disorders and common mental disorders, factor structures such as internalizing–externalizing have been replicated in numerous samples, across the life span, and around the globe. One critical feature of transdiagnostic factors is that they serve as a point of intersection between personality and psychopathology, making them particularly relevant phenomena for applied clinical work. Although numerous studies have supported the significance of transdiagnostic factors for research and classification purposes, there has been comparatively less articulation of how such factors might be of benefit to practicing assessment clinicians. Herein, we present an overview of transdiagnostic factor research findings, and we apply these findings to the clinical topics of assessment, diagnosis, and treatment. For clinicians as well as researchers, the use of transdiagnostic constructs presents positive implications for efforts to understand, characterize, and ameliorate psychopathology—including its manifestations as personality disorder—in a valid, effective, and efficient way.     

A developmental psychopathology model of overgeneral autobiographical memory

Overgeneral memory (OGM) is a phenomenon that refers to difficulty retrieving specific autobiographical memories. The tendency to be overgeneral in autobiographical memory recall has been commonly observed among individuals with emotional disorders compared to those without emotional disorders. Despite significant advances in identifying mechanisms that underlie OGM, etiological models are not particularly developmental in nature and, instead, are focused on identifying isolated cognitive presentations of individuals with high OGM. The aim of the current paper is to utilize a developmental psychopathology framework, which emphasizes the interface between typical and atypical development, and risk and protective factors at multiple ecological levels, to propose a comprehensive model of OGM development. Specifically, (1) the progression of current etiological models of OGM is reviewed; (2) developmental theory and research on autobiographical memory that have relevance for OGM are discussed; and (3) an integrative model of OGM that includes processes at psychological, biological, social, and cultural levels is proposed. Directions for future research are formulated and treatment implications derived from this perspective are addressed.     

Hierarchical model of vulnerabilities for emotional disorders

Clark and Watson's (1991) tripartite model of anxiety and depression has had a dramatic impact on our understanding of the dispositional variables underlying emotional disorders. More recently, calls have been made to examine not simply the influence of negative affectivity (NA) but also mediating factors that might better explain how NA influences anxious and depressive syndromes (e.g. Taylor, 1998; Watson, 2005). Extending preliminary projects, this study evaluated two hierarchical models of NA, mediating factors of anxiety sensitivity and intolerance of uncertainty, and specific emotional manifestations. Data provided a very good fit to a model elaborated from preliminary studies, lending further support to hierarchical models of emotional vulnerabilities. Implications for classification and diagnosis are discussed.     

Family Factors in the Development and Management of Anxiety Disorders

Family variables are thought to play a key role in a wide variety of psychopathology according to many theories. Yet, specific models of the development of anxiety disorders place little emphasis on general family factors despite clear evidence that anxiety runs in families. The current review examines evidence for the involvement of a number of family-related variables in the development of anxiety disorders as well as the importance of families in their management. Evidence across most areas is shown to be weak and inconsistent, with the one exception being an extensive literature on the role of parenting in the development of anxiety. There is also currently little evidence that family factors have a strong role to play in the treatment of anxiety, aside from research demonstrating the value of parents and partners as non-critical supports in therapy. The promises and hints in the literature, combined with the currently inconsistent methods, suggest that considerably more research is needed to determine whether specific family factors may yet be shown to play a key role in the development and management of anxiety disorders.     

The role of defeat and entrapment in depression, anxiety, and suicide

Defeat and entrapment are psychological constructs that have played a central role in evolutionary accounts of depression. These concepts have since been implicated in theoretical accounts of anxiety disorders and suicidality. The current article reports on a systematic review of the existing research investigating the links among defeat, entrapment, and psychopathology in the domains of depression, suicidality, posttraumatic stress disorder (PTSD), and other anxiety syndromes. Fifty-one original research articles were identified and critically reviewed. There was strong convergent evidence for a link with depressive symptoms, across a variety of clinical and nonclinical samples. Preliminary support for an association with suicidality was also observed, with effects not readily explainable in terms of comorbid depression. There was strong evidence for an association between defeat and PTSD, although this may have been partly accounted for by comorbid depression. The findings for other anxiety disorders were less consistent. There was, however, evidence that social anxiety in individuals with psychosis may be related to perceptions of entrapment. Overall, there was evidence that perceptions of defeat and entrapment were closely associated with various forms of human psychopathology. These effects were often in the moderate to large range and superseded the impact of other environmental and psychological stressors on psychopathology. We provide a unified theoretical model of how defeat and entrapment may contribute to these different psychopathological conditions. Clinical implications and avenues for future research are discussed.     

Dimensional personality traits and the prediction of DSM-IV personality disorder symptom counts in a nonclinical sample

The third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III; APA, 1980) set forth a categorical system of personality psychopathology that is composed of discrete personality disorders (PDs), each with a distinct set of diagnostic criteria. Although this system is widely accepted and highly influential, alternative dimensional approaches to capturing personality psychopathology have been proposed. Three dimensional models of personality have garnered particular attention-the Five-Factor Model (FFM; Costa & McCrae, 1992), the Seven-Factor Psychobiological Model of Temperament and Character (Seven-Factor Model; Cloninger, Svrakic, & Przybeck, 1993); and the 18-factor model of personality pathology (18-factor model; Livesley, 1986). Although the personality traits from each of these models has been examined in relation to the ten personality disorders in the DSM-IV, no study has examined the comparative and incremental validity of these models in predicting PD symptoms for these ten disorders. Using self-report instruments that measure these models and the ten DSM-IV PDs, correlation and linear regression analyses indicate that traits from all three models had statistically significant associations with PD symptom counts. Hierarchical regressions revealed that the 18-factor model had incremental predictive validity over the FFM and Seven-Fac-tor Model in predicting symptom counts for all ten DSM-IV PDs. The FFM had incremental predictive validity over the Seven-Factor Model model for all ten disorders and the Seven-Factor was able to add incremental predictive validity over the 18-factor model for five of the ten PDs and for eight of the ten disorders relative to the FFM.     

The Contribution of Worry Behaviors to the Diagnosis of Generalized Anxiety Disorder

Worry behaviors (i.e., overt acts to avoid or cope with worry-induced distress) have been recognized as being important in the psychopathology and treatment of generalized anxiety disorder (GAD). This study evaluated the worry behaviors criterion proposed for DSM-5 GAD, but was ultimately not adopted due to insufficient evidence. In 800 outpatients with emotional disorders (366 with GAD), most patients with GAD (92.6%) met the proposed worry behaviors criterion, which was at a rate significantly higher than other patient groups (e.g., patients with mood disorders). Patients who met the worry behaviors criterion had more severe GAD than patients who did not. The worry behaviors criterion, and 3 of its 4 constituent behaviors, were associated with no better than “fair” interrater reliability. Diagnostic reliability of GAD was not improved in cases where both interviewers agreed the worry behaviors criterion was met. The worry behaviors criterion significantly predicted DSM-5 GAD holding core GAD features constant (e.g., excessive worry), but this contribution was weak and did not appreciably improve the classification accuracy of GAD diagnostic status. Mixed support was obtained for the discriminant validity of the worry behaviors criterion in relation to mood disorders. Raising the proposed threshold of the criterion (requiring 2 instead of 1 behaviors) did not result in a substantial improvement in reliability, prediction, and classification accuracy. Although additional research is warranted (e.g., importance of worry behaviors in the treatment and natural course of GAD), the results raise questions about the role of worry behaviors in the diagnostic classification of GAD.     

An Evaluation of the Two-Factor Model of Emotion: Clinical Moderators Within a Large,Multi-Ethnic Sample of Youth

The two-factor model of emotion clarifies the complexities of the relationship between anxiety and depression through their varying associations with positive and negative affect. Although this model’s structure has been validated in community samples of children, little research has evaluated the model among clinically referred youth. The present investigation aimed to confirm the two-factor model of emotion within a sample of clinically-referred children (N?=?879) and to investigate potential moderators of the model’s relationships within that group. Structural equation modeling demonstrated excellent fit for the two-factor model, and moderating effects for the model structure were found related to age and diagnostic category. These results support the model’s usefulness in describing patterns of psychopathology and temperament for clinically referred children and suggest the potential for a unified treatment approach to internalizing psychopathology.     

The relevance of recent developments in classical conditioning to understanding the etiology and maintenance of anxiety disorders

Current etiological models of anxiety disorders emphasize both internal diatheses, or risk factors, and external stressors as important in the development and maintenance of clinical anxiety. Although considerable evidence suggests personality, genetic, and environmental variables are important to these diathesis-stress interactions, this general approach could be greatly enriched by incorporating recent developments in experimental research on fear and anxiety learning. In this article, we attempt to integrate the experimental literature on fear/anxiety learning and the psychopathology literature on clinical anxiety, identify areas of inconsistency, and recommend directions for future research. First, we provide an overview of contemporary models of anxiety disorders involving fear/anxiety learning. Next, we review the literature on individual differences in associative learning among anxious and non-anxious individuals. We also examine additional possible sources of individual differences in the learning of both fear and anxiety, and indicate where possible parallels may be drawn. Finally, we discuss recent developments in basic experimental research on fear conditioning and anxiety, with particular attention to research on contextual learning, and indicate the relevance of these findings to anxiety disorders.     

Intimate Relationships and Psychopathology

Relationship functioning and individual mental health and well-being are strongly associated with one another. In this article, we first review the cross-sectional and longitudinal associations between relationship discord and various types of psychopathology, We then review findings suggesting that relationship discord is associated with poorer outcome for individual-based treatments for psychopathology and that, generally, relationship discord does not improve following individual-based treatments for psychopathology. Finally, we present a model for conceptualizing work with couples in which one partner has a psychiatric disorder and review the efficacy of couple-based interventions in the treatment for psychiatric disorders, with a focus on substance-related, mood, and anxiety disorders.