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Symptom-Level Network Analysis Distinguishes Unique Associations of Repetitive Negative Thinking and Experiential Avoidance with Depression and Anxiety in a Transdiagnostic Clinical Sample



Repetitive negative thinking and experiential avoidance have been hypothesized to be related, transdiagnostic maintenance factors for depression and anxiety, yet is unclear how these processes overlap or diverge. Here we use a symptom-level approach to address this question.


Adults presenting for treatment to an intensive CBT program (n = 492) completed measures of depression and anxiety symptom severity, repetitive negative thinking, and experiential avoidance. Our pre-registered network analysis approach examined the contribution of these transdiagnostic maintenance factors to the predictability of a depression and anxiety symptom network. Exploratory analyses used permutation testing to formally evaluate the predictability of the symptom network.


Permutation testing indicates that repetitive negative thinking significantly improved the predictability of worrying and poor concentration, whereas experiential avoidance improved the predictability of difficulties relaxing, being afraid something bad was going to happen, and feeling like a failure.


Our sample was cross-sectional and a predominantly white, educated, industrialized, rich, and democratic (WEIRD) sample.


Repetitive negative thinking and experiential avoidance each were associated with symptoms of depression and anxiety but did not overlap across the comorbid symptom network. More broadly, applying network analysis helps to more precisely identify which symptoms of depression and anxiety are associated with transdiagnostic maintenance factors, thus providing insight into how these factors may contribute to the maintenance of co-occurring disorders.

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  1. To attempt to contextualize the importance of repetitive negative thinking and experiential avoidance, we also permuted each individual symptom using a similar process to examine how overall network predictability and individual symptom predictability are impacted. As it is not possible to compare whether the increase in predictability across these different permuted networks significantly differ, these results are only included in the Supplemental Materials.


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Many thanks go to Jason Shumake for serving as a consultant regarding the development of formal testing of differences in predictability across the measured and synthetic networks. Thanks also go to Josie Lee for her dedicated efforts with data collection.

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Authors and Affiliations



KJH, MM, and TB designed the study and wrote the protocol. KJH and MM managed the literature searches. MM conducted the statistical analyses and MD reproduced the analyses. KJH wrote the first draft of the manuscript. All authors contributed to revisions following the first draft and have approved the final manuscript.

Corresponding author

Correspondence to Kean J. Hsu.

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Conflict of Interest

Kean J. Hsu, Michael Mullarkey, Mallory Dobias, Christopher G. Beevers, Thröstur Björgvinsson declare that they have no conflict of interest.

Ethical Approval

This study was conducted in accordance with the Declaration of Helsinki and APA ethical standards, and all procedures were approved by McLean Hospital’s IRB.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

Research Involving Human and Animal Participants

No animal studies were carried out by the authors for this article.

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Supplementary Information

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Supplementary file1 (DOCX 462 KB)

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Hsu, K.J., Mullarkey, M., Dobias, M. et al. Symptom-Level Network Analysis Distinguishes Unique Associations of Repetitive Negative Thinking and Experiential Avoidance with Depression and Anxiety in a Transdiagnostic Clinical Sample. Cogn Ther Res (2022).

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  • Transdiagnostic
  • Repetitive negative thinking
  • Experiential avoidance
  • Depression
  • Anxiety
  • Network analysis