Criticism of discrete classification systems for mental disorders has led to a focus on identification of mechanisms that cut across symptom clusters, known as transdiagnostic factors. One such proposed factor is negative repetitive thought (NRT), or a perseverative, often uncontrollable, focus on negative information, experiences, or expectations. Worry and rumination are two major constructs thought to compose NRT. No confirmatory factor analyses have investigated whether worry and rumination might compose a general NRT factor, discrete factors, or some combination of the two. The first purpose of the current study was to use confirmatory factor analyses to uncover whether worry and rumination are best characterized as separate or common constructs. In addition to this purpose, the study investigated NRT as a transdiagnostic factor for psychopathology. Finally, it examined incremental associations of NRT with mental illness symptoms, after controlling for negative emotionality, the most well established transdiagnostic risk factor. A bi-factor conceptualization of worry and rumination, in which there was a common NRT factor and specific worry and rumination factors, yielded the best fit to the data across three separate samples. The NRT factor was associated with both internalizing and externalizing psychopathology; however, it demonstrated significant overlap with negative emotionality. Further exploration of this overlap using bi-factor modeling demonstrated that NRT and negative emotionality are likely best thought of as a unidimensional general negative affect construct, and this structure was replicated across samples. Importantly, evidence was found that this tendency to experience negative affect was also a common liability for mental illness symptoms.

Repetitive thought, or the recurrent, often cyclical, focus on self-relevant concerns and experiences, is one liability that may be common across internalizing (INT) and externalizing (EXT) disorders. One particular area of interest for examining repetitive thought as a transdiagnostic process is in relation to alcohol use because alcohol abuse and dependence are the most common, and possibly most costly, EXT disorders. This study experimentally induced abstract repetitive thought, concrete repetitive thought, or distraction to test if repetitive thought and construal level have an effect on drinking behavior. It was hypothesized that individuals in both repetitive thought conditions would drink more than those in the distraction condition. Second, it was expected that individuals in the abstract condition would drink more than those in the concrete condition. Neither of these hypotheses was supported. Additionally, to assess for evidence of repetitive thought as a transdiagnostic process, the interaction between repetitive thought and INT was examined. If repetitive thought is truly transdiagnostic, then the relationship between repetitive thought and drinking should be stronger for individuals with more internalizing symptoms. Results did not indicate a significant interaction effect. The lack of findings in this study may be due to an ineffective experimental manipulation. Alternatively, they may suggest that repetitive thought does not have an effect on drinking.

Despite the existence of evidence-based interventions for anxiety disorders, many barriers impede access to effective treatment services (e.g., distance from services, comorbidity). This dissertation aimed to investigate ways to overcome some of these barriers by exploring (1) the efficacy of therapist-supported distance cognitive behavior therapy (CBT) for anxiety disorders in adults, (2) the suitability of anxiety sensitivity (AS; a fear of arousal-related physiological sensations) as a target for transdiagnostic treatment, and (3) the efficacy of a distance CBT intervention for reducing high AS and its associated mental health and substance use symptoms. In Study 1, a systematic review showed that therapist-supported distance CBT was more efficacious than a waiting list and as efficacious as face-to-face CBT in reducing anxiety symptoms, increasing the likelihood of diagnostic remission, and improving quality of life. In Study 2, AS was associated with panic, posttraumatic stress, social phobia, and depressive symptoms. Of its lower order subscales, physical concerns predicted unique variance in panic, cognitive concerns predicted unique variance in depressive symptoms, and social phobia was predicted by social concerns. Together, Studies 1 and 2 suggest that distance CBT for anxiety is efficacious and that AS may be a suitable target for transdiagnostic interventions. As such, Studies 3 and 4 report on a randomized controlled trial investigating the efficacy and transdiagnostic implications of a telephone-delivered CBT intervention for high AS. The treatment significantly reduced AS relative to a waiting list and led to significant reductions in panic, posttraumatic stress, and social phobia symptoms (though not generalized anxiety or depressive symptoms). Treatment-related reductions in AS mediated these anxiety symptom changes. Participants in the treatment, vs. control, group also showed a significantly greater reduction in number of mental health diagnoses and in functional disability. Treatment also significantly reduced coping-with-anxiety drinking motives and physical alcohol-related problems for the treatment but not waiting list group. Reductions in AS mediated changes in coping-with-anxiety motives, while coping-with-anxiety motives mediated changes in physical alcohol-related problems. Taken together, findings from this dissertation provide evidence that distance-based and transdiagnostic AS-focused interventions may be two important and efficacious ways to overcome several barriers to anxiety treatment.

Interventions targeting processes that commonly maintain different psychological disorders have demonstrated promising effectiveness data. However, very few studies have examined brief transdiagnostic groups. Qualitative explorations of the acceptability of both transdiagnostic and brief groups are also very limited. A brief transdiagnostic group, the Take Control Course (TCC), has been developed for clients with common mental health problems in primary care services. This thesis examined the effectiveness and acceptability of the TCC, which is a 6-session transdiagnostic group intervention. The TCC is explicitly theory-driven and targets mechanisms of psychological change specified by Perceptual Control Theory (PCT). Three papers are presented within this thesis that examined: i) the empirical and conceptual background of the TCC; ii) whether the TCC was non-inferior compared to an active control (individual low-intensity Cognitive Behavioural Therapy, CBT); iii) whether the TCC was acceptable to participants using qualitative examination of participants’ experience of the TCC and perceptions of what contributed to psychological change (or lack of change). The thesis comprises: i) a narrative review; ii) a non-inferiority RCT; iii) a qualitative interview study using Thematic Analysis. The thesis utilised mixed methods in order to understand the TCC from multiple perspectives. The overall programme of research that the thesis is part of is strongly informed by the Medical Research Council (MRC) framework for developing and evaluating complex interventions. Although the MRC guidelines stress the utility of randomised experimental designs in evaluating an intervention, they also recognise the contribution that qualitative methodologies make to such evaluations. The narrative review outlined how the development of a transdiagnostic intervention, which targets specific transdiagnostic processes, could provide an efficient way of promoting psychological change. It explicitly detailed how the theoretical basis informed intervention components. Within the RCT, intention-to-treat analyses at 6-month follow-up found that the TCC was non-inferior to individual low-intensity CBT on anxiety and depression outcomes, functioning and an idiosyncratic problem measure. 156 clients were randomised. Secondary, per-protocol analyses, found inconclusive evidence of non-inferiority. This was the first randomised trial providing evidence for the non-inferiority of a brief transdiagnostic group compared to established individual therapy. The qualitative study of 12 in-depth interviews indicated that the flexible group format of the TCC was appreciated, as participants felt able to engage at their own pace and adapt components. Greater clarity regarding what was within participants’ control reduced distress and enabled effective pursuit of valued goals. This was the first qualitative study of participant experience of a brief transdiagnostic group. Findings indicated that TCC was acceptable and non-inferior to an established CBT intervention. This adds to the evidence base for transdiagnostic interventions.

Racial and ethnic discrimination is a prevalent issue in the United States, with 63% of minorities reporting experiencing discrimination. Few studies have examined psychopathology as transdiagnostic dimensional factors when investigating its association with discrimination and racial/ethnic identification. Also, little research has established measurement invariance prior to making comparisons across race/ethnicity. To address these shortcomings, the current study (1) assessed for measurement invariance to ensure that observed differences reflected true differences in the latent factors and (2) examined how internalizing (INT) and externalizing (EXT) psychopathology are associated with experiences of discrimination, responses to discrimination, and racial/ethnic identification across White, Black, American Indian/Alaska Native, Asian/Native Hawaiian/Other Pacific Islander, and Hispanic groups using the NESARC-III (n = 36,309). Findings from multiple-group confirmatory factor analysis showed evidence for strong measurement invariance for all latent factors across race/ethnicity. Results from multiple-group structural equation modeling showed that discrimination experiences were associated with higher INT and EXT across all race/ethnic groups. Active responses to discrimination and racial/ethnic identification showed differential effects on psychopathology across groups, providing implications for coping strategies amidst systemic racism and underscoring the importance of recognizing heterogeneity across diverse groups. This study contributes to understanding mental health disparities and emphasizes the need for culturally competent and nuanced interventions in addressing discrimination-related psychopathology across racial/ethnic groups.

Perfectionism has been seen to predict treatment outcome and symptom severity in clinically relevant diagnoses such as depression and anxiety disorders. It has also been suggested to be a transdiagnostic phenomenon. The aim of this study was to investigate, for the first time, predictors of change in Internet-based cognitive behaviour therapy for perfectionism. The chosen predictors were perfectionism severity, comorbid diagnosis and degree of self-compassion. The study was a part of the Devin-project; a randomized controlled trial with 150 participants that were allocated to active treatment (N=73) or a waitlist condition (N=77). Multiple linear regression analysis was used for the analyses. Variables chosen a priori did not significantly predict the treatment outcome (R2=.10, p = .099). A post hoc-analysis showed that perfectionism severity, as measured with CPQ, predicted symptom change after treatment (B = .783, β = .56 p < .001). The results indicate that perfectionism severity doesn’t impair the treatment effects and that the treatment is effective, independent of comorbid diagnoses. Self-compassion was investigated on an explorative basis but the results can indicate that the variable is not a risk factor nor a protective factor for perfectionism. As Devin is the largest randomized controlled study of internet-based cognitive behaviour therapy for perfectionism to date, this study generates important implications and suggestions for future research. / Devin

No description available.

Denna tvärsnittsstudie syftade till att undersöka samförekomst av smärtrelaterad rädsla och social ångest i ett kliniskt sample med kronisk smärtproblematik. Syftet var också att beskriva och kontrastera samvariation av transdiagnostiska faktorer i eventuella subgrupper. Datan bestod av enkätsvar från 196 deltagare i Social ångest smärta-projektet som leds av Örebro universitet och Akademiska sjukhuset i Uppsala. En klusteranalys fick fram fyra subgrupper bland deltagarna. En subgrupp utmärkte sig för hög komorbiditet. Denna grupp visade höga nivåer av tänkbara transdiagnostiska faktorer som ångestkänslighet och negativ affekt, samt hög smärtkatastrofiering. Det diskuterades kring dessa faktorers roll som sårbarhets- och vidmakthållandeprocesser, utifrån aktuella teoretiska modeller. Studiens kliniska implikationer belyser behovet av hänsyn till dessa faktorers roll vid behandling och framtida forskning. / This cross-sectional study aimed to explore co-occurrence of pain-related fear and social anxiety in a clinical sample with chronic pain. The purpose was also to describe and contrast co-variation of transdiagnostic factors in potential subgroups. The data consisted of 196 answered questionnaires from the Social anxiety pain-project led by Örebro University and the Uppsala University Hospital. A cluster analysis produced four subgroups among the participants. One subgroup was salient for its high comorbidity. This group showed high levels of potential transdiagnostic factors such as anxiety sensitivity and negative affect, as well as high pain catastrophizing. These factors are discussed in terms of their role as vulnerability and maintaining factors, in the light of current theoretical models. The clinical implications of this study suggest taking the role of these factors into account in aspects of treatment and future research.

Delay discounting is a measure of impulsive decision making that is associated with different forms of problem behavior. This study examined the transdiagnostic effect of Acceptance and Commitment Therapy (ACT) on delay discounting in a community sample. Forty adults were randomized into eight individual sessions of ACT or an inactive control. Participants completed pre-, mid-, and post-assessments for delay discounting, psychological flexibility, distress tolerance, overall psychological symptoms, behavior change, and valued living. Data were analyzed with multilevel modeling of growth curves. Significant interaction effects of time and condition were present for psychological flexibility, distress tolerance, psychological symptoms, and the obstruction subscale of valued living. No significant interaction effect was found for two delay discounting tasks nor the progression subscale of valued living. The ACT condition had a significantly larger reduction of problem behavior at post-, but not mid-assessment. Treatment was provided in a competent and ACT-consistent manner and was rated as highly satisfactory by treatment completers. The results support use of ACT as a transdiagnostic treatment. The lack of changes in delay discounting are in contrast to previous research. The clinical implications of delay discounting need to be explored further.

Anxiety and depressive disorders are prevalent among youth and are often experienced concurrently or sequentially during development (Kroes et al., 2001; Costello, Erklani, & Angold, 2006). These disorders are also associated with weaker cognitive behavioral treatment (CBT) outcomes when experienced simultaneously in youth (e.g. Berman, Weems, Silverman, & Kurtines, 2000). Treatment research has begun to investigate the feasibility and efficacy of treating comorbid emotional disorders using transdiagnostic treatment approaches (Barlow et al., 2010; Ehrenreich et al., 2008). Evidence from adult and adolescent populations indicates that these more broadly focused treatment programs may offer benefits above and beyond disorder- and domain-specific protocols, leading to improvements in diagnostic severity and emotion regulation across a range of disorders and emotions (Ellard, Fairholme, Boisseau, Farchione, & Barlow, 2010; Ehrenreich-May & Remmes, 2010). The current study extends transdiagnostic treatment research to school-age children, ages 7-12, in a mental health clinic setting by investigating preliminary post-treatment outcomes and treatment acceptability in a recent open trial (N enrolled= 16; N completed treatment=13) of the Emotion Detectives Treatment Protocol (EDTP; Ehrenreich-May & Laird, 2009). Results revealed that participants experienced significant improvements in clinical severity ratings of principal and all related diagnoses, as well as in parent reported anxious and parent and child reported depressive symptoms at the post-treatment assessment. Additionally, parents reported gains in child coping and improvements in dysregulation across emotional domains (including worry, sadness, and anger). The EDTP had good retention rates, moderately good attendance, and parents and children reported high levels of treatment satisfaction. The results of this open trial provide preliminary evidence for the utility and acceptability of a transdiagnostic group protocol to treat both clinical anxiety disorders, as well as self- and parent-reported anxious and depressive symptoms for youth within a mental health setting. These results suggest that children may uniquely benefit from a more generalized, emotion-focused treatment modality, such as the EDTP, that can offer flexibility in its treatment targets to families as well as mental health clinicians.