Abstract
Introduction
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.
Methods
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.
Results
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.
Limitations
Our sample was cross-sectional and a predominantly white, educated, industrialized, rich, and democratic (WEIRD) sample.
Conclusions
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.
Similar content being viewed by others
Notes
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.
References
Adams, G. C., Balbuena, L., Meng, X., & Asmundson, G. J. G. (2016). When social anxiety and depression go together: A population study of comorbidity and associated consequences. Journal of Affective Disorders, 206, 48–54. https://doi.org/10.1016/j.jad.2016.07.031
Anderson, E. R., & Mayes, L. C. (2010). Race/ethnicity and internalizing disorders in youth: A review. Clinical Psychology Review, 30(3), 338–348. https://doi.org/10.1016/j.cpr.2009.12.008
Beard, C., Millner, A. J., Forgeard, M. J., Fried, E. I., Hsu, K. J., Treadway, M. T., Leonard, C. V., Kertz, S. J., & Björgvinsson, T. (2016). Network analysis of depression and anxiety symptom relationships in a psychiatric sample. Psychological Medicine, 46(16), 3359–3369. https://doi.org/10.1017/S0033291716002300
Beevers, C. G., Mullarkey, M. C., Dainer-Best, J., Stewart, R. A., Labrada, J., Allen, J. J., McGeary, J. E. & Shumake, J. (2019). Association between negative cognitive bias and depression: A symptom-level approach. Journal of Abnormal Psychology, 128(3), 212.
Bernstein, E. E., Heeren, A., & McNally, R. J. (2017). Unpacking rumination and executive control: A network perspective. Clinical Psychological Science, 5(5), 816–826. https://doi.org/10.1177/2167702617702717
Bond, F. W., Hayes, S. C., Baer, R. A., Carpenter, K. M., Guenole, N., Orcutt, H. K., Waltz, T., & Zettle, R. D. (2011). Preliminary psychometric properties of the Acceptance and Action Questionnaire–II: A revised measure of psychological inflexibility and experiential avoidance. Behavior Therapy, 42(4), 676–688. https://doi.org/10.1016/j.beth.2011.03.007
Borsboom, D. (2008). Psychometric perspectives on diagnostic systems. Journal of Clinical Psychology, 64(9), 1089–1108. https://doi.org/10.1002/jclp.20503
Borsboom, D., Cramer, A. O. J., Schmittmann, V. D., Epskamp, S., & Waldorp, L. J. (2011). The Small World of Psychopathology. PLoS ONE, 6(11), e27407. https://doi.org/10.1371/journal.pone.0027407
Bowie, C. R., Milanovic, M., & Tran, T. (2019). Pathophysiology of cognitive impairment in depression. In J. Quevedo, A. F. Carvalho, & C. A. Zarate (Eds.), Neurobiology of depression (pp. 27–30). Elsevier. https://doi.org/10.1016/B978-0-12-813333-0.00004-4
Brockmeyer, T., Holtforth, M. G., Krieger, T., Altenstein, D., Doerig, N., Zimmermann, J., Backenstrass, M., Friederich, H. C., & Bents, H. (2015). Preliminary evidence for a nexus between rumination, behavioural avoidance, motive satisfaction and depression. Clinical Psychology & Psychotherapy, 22(3), 232–239.
Cernvall, M., Skogseid, E., Carlbring, P., Ljungman, L., Ljungman, G., & von Essen, L. (2016). Experiential avoidance and rumination in parents of children on cancer treatment: Relationships with posttraumatic stress symptoms and symptoms of depression. Journal of Clinical Psychology in Medical Settings, 23(1), 67–76. https://doi.org/10.1007/s10880-015-9437-4
Coussement, C., & Heeren, A. (2022). Sleep problems as a transdiagnostic hub bridging impaired attention control, generalized anxiety, and depression. Journal of Affective Disorders, 296, 305–308.
Cribb, G., Moulds, M. L., & Carter, S. (2006). Rumination and experiential avoidance in depression. Behaviour Change, 23(3), 165–176. https://doi.org/10.1375/bech.23.3.165
Der-Avakian, A., & Markou, A. (2012). The neurobiology of anhedonia and other reward-related deficits. Trends in Neurosciences, 35(1), 68–77. https://doi.org/10.1016/j.tins.2011.11.005
Drost, J., van der Does, W., van Hemert, A. M., Penninx, B. W. J. H., & Spinhoven, P. (2014). Repetitive negative thinking as a transdiagnostic factor in depression and anxiety: A conceptual replication. Behaviour Research and Therapy, 63, 177–183. https://doi.org/10.1016/j.brat.2014.06.004
Ehring, T., & Watkins, E. R. (2008). Repetitive negative thinking as a transdiagnostic process. International Journal of Cognitive Therapy, 1(3), 192–205. https://doi.org/10.1521/ijct.2008.1.3.192
Ehring, T., Zetsche, U., Weidacker, K., Wahl, K., Schönfeld, S., & Ehlers, A. (2011). The Perseverative Thinking Questionnaire (PTQ): Validation of a content-independent measure of repetitive negative thinking. Journal of Behavior Therapy and Experimental Psychiatry, 42(2), 225–232. https://doi.org/10.1016/j.jbtep.2010.12.003
Epskamp, S., Cramer, A. O. J., Waldorp, L. J., Schmittmann, V. D., & Borsboom, D. (2012). Qgraph: Network visualizations of relationships in psychometric data. Journal of Statistical Software, 48(4), 1–18.
Epskamp, S., Borsboom, D., & Fried, E. I. (2018). Estimating psychological networks and their accuracy: A tutorial paper. Behavior Research Methods, 50(1), 195–212. https://doi.org/10.3758/s13428-017-0862-1
Eronen, M. I. (2019). The levels problem in psychopathology. Psychological Medicine, 51, 927–933.
Fisher, A. J., Medaglia, J. D., & Jeronimus, B. F. (2018). Lack of group-to-individual generalizability is a threat to human subjects research. Proceedings of the National Academy of Sciences, 115(27), E6106–E6115. https://doi.org/10.1073/pnas.1711978115
Forgeard, M. J. C., Beard, C., Kirakosian, N., & Björgvinsson, T. (2018). Research in partial hospital settings. In R. T. Codd III. (Ed.), Practice-based research: A guide for clinicians. Routledge.
Fried, E. I., & Haslbeck, J. (2018). Using network analysis to examine links between individual depression symptoms, inflammatory markers, and covariates. Psychological Medicine, 50, 2682–2690.
Fried, E. I., & Nesse, R. M. (2015). Depression is not a consistent syndrome: An investigation of unique symptom patterns in the STAR*D study. Journal of Affective Disorders, 172, 96–102. https://doi.org/10.1016/j.jad.2014.10.010
Fried, E. I., Nesse, R. M., Zivin, K., Guille, C., & Sen, S. (2014). Depression is more than the sum score of its parts: Individual DSM symptoms have different risk factors. Psychological Medicine, 44(10), 2067–2076. https://doi.org/10.1017/S0033291713002900
Giorgio, J. M., Sanflippo, J., Kleiman, E., Reilly, D., Bender, R. E., Wagner, C. A., Liu, R. T., & Alloy, L. B. (2010). An experiential avoidance conceptualization of depressive rumination: Three tests of the model. Behaviour Research and Therapy, 48(10), 1021–1031. https://doi.org/10.1016/j.brat.2010.07.004
Harris, P. A., Taylor, R., Thielke, R., Payne, J., Gonzalez, N., & Conde, J. G. (2009). Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. Journal of Biomedical Informatics, 42(2), 377–381. https://doi.org/10.1016/j.jbi.2008.08.010
Haslbeck, J. M. B., & Fried, E. I. (2017). How predictable are symptoms in psychopathological networks? A reanalysis of 18 published datasets. Psychological Medicine, 47(16), 2767–2776. https://doi.org/10.1017/S0033291717001258
Haslbeck, J. M. B., & Waldorp, L. J. (2015b). Structure estimation for mixed graphical models in high-dimensional data. [Math, Stat]. Retrieved from http://arxiv.org/abs/1510.05677.
Haslbeck, J. M. B., & Waldorp, L. J. (2018). How well do network models predict observations? On the importance of predictability in network models. Behavior Research Methods, 50(2), 853–861. https://doi.org/10.3758/s13428-017-0910-x
Haslbeck, J. M. B., & Waldorp, L. J. (2020). mgm: Estimating time-varying mixed graphical models in high-dimensional data. Journal of Statistical Software, 93(8), 1–46. https://doi.org/10.18637/jss.v093.i08
Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. M., & Strosahl, K. (1996). Experimental avoidance and behavioral disorders: A functional dimensional approach to diagnosis and treatment. Journal of Consulting and Clinical Psychology, 64(6), 1152–1168.
Hayes, S. C., Strosahl, K., Wilson, K. G., Bissett, R. T., Pistorello, J., Toarmino, D., Polusny, M. A., Dykstra, T. A., Batten, S. V., Bergan, J., Stewart, S. H., et al. (2004). Measuring experiential avoidance: A preliminary test of a working model. The Psychological Record, 54(4), 553–578. https://doi.org/10.1007/BF03395492
Holm, S. (1979). A simple sequentially rejective multiple test procedure. Scandinavian Journal of Statistics, 6(2), 65–70.
Hsu, K. J., Beard, C., Rifkin, L., Dillon, D. G., Pizzagalli, D. A., & Björgvinsson, T. (2015). Transdiagnostic mechanisms in depression and anxiety: The role of rumination and attentional control. Journal of Affective Disorders, 188, 22–27.
Jones, P. J., Mair, P., & McNally, R. J. (2018). Visualizing psychological networks: A tutorial in R. Frontiers in Psychology. https://doi.org/10.3389/fpsyg.2018.01742
Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). LIfetime prevalence and age-of-onset distributions of DSM-IV disorders in the national comorbidity survey replication. Archives of General Psychiatry, 62(6), 593–602. https://doi.org/10.1001/archpsyc.62.6.593
Kessler, R. C., Gruber, M., Hettema, J. M., Hwang, I., Sampson, N., & Yonkers, K. A. (2008). Co-morbid major depression and generalized anxiety disorders in the National Comorbidity Survey follow-up. Psychological Medicine, 38(03), 365–374. https://doi.org/10.1017/S0033291707002012
Kim, J. M., & López, S. R. (2014). The expression of depression in Asian Americans and European Americans. Journal of Abnormal Psychology, 123(4), 754–763. https://doi.org/10.1037/a0038114
Krieger, T., Altenstein, D., Baettig, I., Doerig, N., & Holtforth, M. G. (2013). Self-compassion in depression: Associations with depressive symptoms, rumination, and avoidance in depressed outpatients. Behavior Therapy, 44(3), 501–513. https://doi.org/10.1016/j.beth.2013.04.004
Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9. Journal of General Internal Medicine, 16(9), 606–613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x
Lamers, F., van Oppen, P., Comijs, H. C., Smit, J. H., Spinhoven, P., van Balkom, A. J., Nolen, W. A., Zitman, F. G., Beekman, A. T., & Penninx, B. W. J. H. (2011). Comorbidity patterns of anxiety and depressive disorders in a large cohort study: The Netherlands Study of Depression and Anxiety (NESDA). The Journal of Clinical Psychiatry, 72(3), 341–348. https://doi.org/10.4088/JCP.10m06176blu
McElroy, E., & Patalay, P. (2019). In search of disorders: Internalizing symptom networks in a large clinical sample. Journal of Child Psychology and Psychiatry, 60(8), 897–906. https://doi.org/10.1111/jcpp.13044
McElroy, E., Fearon, P., Belsky, J., Fonagy, P., & Patalay, P. (2018). Networks of depression and anxiety symptoms across development. Journal of the American Academy of Child & Adolescent Psychiatry, 57(12), 964–973. https://doi.org/10.1016/j.jaac.2018.05.027
McEvoy, P. M., Hyett, M. P., Ehring, T., Johnson, S. L., Samtani, S., Anderson, R., & Moulds, M. L. (2018). Transdiagnostic assessment of repetitive negative thinking and responses to positive affect: Structure and predictive utility for depression, anxiety, and mania symptoms. Journal of Affective Disorders, 232, 375–384. https://doi.org/10.1016/j.jad.2018.02.072
McEvoy, P. M., Watson, H., Watkins, E. R., & Nathan, P. (2013). The relationship between worry, rumination, and comorbidity: Evidence for repetitive negative thinking as a transdiagnostic construct. Journal of Affective Disorders, 151(1), 313–320. https://doi.org/10.1016/j.jad.2013.06.014
McLaughlin, K. A., & Nolen-Hoeksema, S. (2011). Rumination as a transdiagnostic factor in depression and anxiety. Behaviour Research and Therapy, 49(3), 186–193. https://doi.org/10.1016/j.brat.2010.12.006
Moroz, M., & Dunkley, D. M. (2015). Self-critical perfectionism and depressive symptoms: Low self-esteem and experiential avoidance as mediators. Personality and Individual Differences, 87, 174–179. https://doi.org/10.1016/j.paid.2015.07.044
Mullarkey, M. C., Dobias, M., & Bluth, K. (2018). Understanding the unique relationships between self-compassion, mindfulness, and individual adolescent depressive symptoms: A network analysis. PsyArXiv. https://doi.org/10.31234/osf.io/kjdq6
Mullarkey, M. C., Marchetti, I., & Beevers, C. G. (2019). Using network analysis to identify central symptoms of adolescent depression. Journal of Clinical Child & Adolescent Psychology, 48(4), 656–668. https://doi.org/10.1080/15374416.2018.1437735
O’Mahen, H. A., Karl, A., Moberly, N., & Fedock, G. (2015). The association between childhood maltreatment and emotion regulation: two different mechanisms contributing to depression? Journal of Affective Disorders, 174, 287–295.
Raes, F. (2012). Repetitive negative thinking predicts depressed mood at 3-year follow-up in students. Journal of Psychopathology and Behavioral Assessment, 34(4), 497–501. https://doi.org/10.1007/s10862-012-9295-4
Redlich, R., Opel, N., Bürger, C., Dohm, K., Grotegerd, D., Förster, K., Zaremba, D., Meinert, S., Repple, J., Enneking, V., Leehr, E., et al. (2018). The limbic system in youth depression: Brain structural and functional alterations in adolescent in-patients with severe depression. Neuropsychopharmacology, 43(3), 546–554. https://doi.org/10.1038/npp.2017.246
Ron de, J., Fried, E. I., & Epskamp, S. (2019). Psychological networks in clinical populations: A tutorial on the consequences of Berkson’s Bias. Psychological Medicine, 51(1), 168–176.
Spinhoven, P., Drost, J., de Rooij, M., van Hemert, A. M., & Penninx, B. W. (2014). A longitudinal study of experiential avoidance in emotional disorders. Behavior Therapy, 45(6), 840–850. https://doi.org/10.1016/j.beth.2014.07.001
Spinhoven, P., Drost, J., van Hemert, B., & Penninx, B. W. (2015). Common rather than unique aspects of repetitive negative thinking are related to depressive and anxiety disorders and symptoms. Journal of Anxiety Disorders, 33, 45–52. https://doi.org/10.1016/j.janxdis.2015.05.001
Spinhoven, P., Drost, J., de Rooij, M., van Hemert, A. M., & Penninx, B. W. J. H. (2016). Is experiential avoidance a mediating, moderating, independent, overlapping, or proxy risk factor in the onset, relapse and maintenance of depressive disorders? Cognitive Therapy and Research, 40(2), 150–163.
Spitzer, R. L., Kroenke, K., Williams, J. B. W., & Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine, 166(10), 1092–1097. https://doi.org/10.1001/archinte.166.10.1092
Tibshirani, R. (1996). Regression shrinkage and selection via the lasso. Journal of the Royal Statistical Society: Series B (methodological), 58(1), 267–288.
Topper, M., Emmelkamp, P. M. G., Watkins, E., & Ehring, T. (2017). Prevention of anxiety disorders and depression by targeting excessive worry and rumination in adolescents and young adults: A randomized controlled trial. Behaviour Research and Therapy, 90, 123–136. https://doi.org/10.1016/j.brat.2016.12.015
van Borkulo, C. D., Borsboom, D., Epskamp, S., Blanken, T. F., Boschloo, L., Schoevers, R. A., & Waldorp, L. J. (2014). A new method for constructing networks from binary data. Scientific Reports, 4, 5918.
van Borkulo, C., Boschloo, L., Borsboom, D., Penninx, B. W., Waldorp, L. J., & Schoevers, R. A. (2015). Association of symptom network structure with the course of depression. JAMA Psychiatry, 72(12), 1219–1226.
von Stockert, S. H. H., Fried, E. I., Armour, C., & Pietrzak, R. H. (2018). Evaluating the stability of DSM-5 PTSD symptom network structure in a national sample of U.S. military veterans. Journal of Affective Disorders, 229, 63–68. https://doi.org/10.1016/j.jad.2017.12.043
WHO|Depression and Other Common Mental Disorders. (2018). WHO. Retrieved March 15, 2019, from http://www.who.int/mental_health/management/depression/prevalence_global_health_estimates/en/.
Acknowledgements
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.
Author information
Authors and Affiliations
Contributions
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
Ethics declarations
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.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Supplementary Information
Below is the link to the electronic supplementary material.
Rights and permissions
About this article
Cite this article
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 46, 1062–1074 (2022). https://doi.org/10.1007/s10608-022-10323-y
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10608-022-10323-y