Dynamic Network Analysis of Negative Emotions and DSM-5 Posttraumatic Stress Disorder Symptom Clusters During Conflict

Investigating dynamic associations between specific negative emotions and PTSD symptom clusters may provide novel insights into the ways in which PTSD symptoms interact with, emerge from, or are reinforced by negative emotions. The present study estimated the associations among negative emotions and the four DSM-5 PTSD symptom clusters (intrusions, avoidance, negative alterations in cognitions and mood [NACM], and arousal) in a sample of Israeli civilians (n = 96) during the Israel-Gaza War of July-August 2014. Data were collected using experience sampling methodology, with participants queried via smartphone about PTSD symptoms and negative emotions twice a day for 30 days. We used a multilevel vector auto-regression model to estimate temporal and contemporaneous temporal networks. Contrary to our hypothesis, in the temporal network, PTSD symptom clusters were more predictive of negative emotions than vice versa, with arousal emerging as the strongest predictor that negative emotions would be reported at the next measurement point; fear and sadness were also strong predictors of PTSD symptom clusters. In the contemporaneous network, negative emotions exhibited the strongest associations with the NACM and arousal PTSD symptom clusters. The negative emotions of sadness, stress, fear, and loneliness had the strongest associations to the PTSD symptom clusters. Our findings suggest that arousal has strong associations to both PTSD symptoms and negative emotions during ongoing trauma and highlights the potentially relevant role of arousal for future investigations in primary or early interventions.

Assessing vulnerability to panic: a systematic review of psychological and physiological responses to biological challenges as prospective predictors of panic attacks and panic disorder

Background

Cognitive–behavioural theories of panic disorder posit that panic attacks arise from a positive feedback loop between arousal-related bodily sensations and perceived threat. In a recently developed computational model formalising these theories of panic attacks, it was observed that the response to a simulated perturbation to arousal provided a strong indicator of vulnerability to panic attacks and panic disorder. In this review, we evaluate whether this observation is borne out in the empirical literature that has examined responses to biological challenge (eg, CO₂ inhalation) and their relation to subsequent panic attacks and panic disorder.

Method

We searched PubMed, Web of Science and PsycINFO using keywords denoting provocation agents (eg, sodium lactate) and procedures (eg, infusion) combined with keywords relevant to panic disorder (eg, panic). Articles were eligible if they used response to a biological challenge paradigm to prospectively predict panic attacks or panic disorder.

Results

We identified four eligible studies. Pooled effect sizes suggest that there is biological challenge response has a moderate prospective association with subsequent panic attacks, but no prospective relationship with panic disorder.

Conclusions

These findings provide support for the prediction derived from cognitive–behavioural theories and some preliminary evidence that response to a biological challenge may have clinical utility as a marker of vulnerability to panic attacks pending further research and development.

Trial registration number

135908.

Commentary on evidence in support of a grief-related condition as a DSM diagnosis

The death of a loved one is one of life's greatest stressors. Most bereaved individuals experience a period of acute grief that diminishes in intensity as they adapt to the changes brought about by their loss. Over the past four decades, a growing body of research has focused on a form of prolonged grief that is painful and impairing. There is a substantial and growing evidence base that supports the validity and significance of a grief-related disorder, including the clinical value of being able to diagnose it and provide effective targeted treatment. ICD-11 will include a new diagnosis of prolonged grief disorder (PGD). DSM-5 called this condition persistent complex bereavement disorder (PCBD) and included it in Section III, signaling agreement that a diagnosis is warranted while further research is needed to determine the optimal criteria. Given the remaining uncertainties, reading this literature can be confusing. There is inconsistency in naming the condition (including complicated grief as well as PGD and PCBD) and lack of uniformity in identifying it, with respect to the optimal threshold and timeframe for distinguishing it from normal grief. As an introductory commentary for this Depression and Anxiety special edition on this form of grief, the authors discuss the history, commonalities, and key areas of variability in identifying this condition. We review the state of diagnostic criteria for DSM-5 and the current ICD-11 diagnostic guideline, highlighting the clinical relevance of making this diagnosis.

Symptomatology following loss and trauma: Latent class and network analyses of prolonged grief disorder, posttraumatic stress disorder, and depression in a treatment-seeking trauma-exposed sample

BACKGROUND

Although bereavement is likely a common stressor among patients referred to a psychotrauma clinic, no study has yet examined the co-occurrence and relationships between symptoms of prolonged grief disorder (PGD), posttraumatic stress disorder (PTSD), and major depressive disorder symptoms in this population.

METHOD

In a sample of patients seeking treatment following psychological trauma (n = 458), we used latent class analysis to identify classes of patients sharing the same profile of PGD, PTSD, and depression symptoms. We then used network analysis to investigate the relationships among these symptoms and with loss-related variables.

RESULTS

Most participants (65%) were members of a class that exhibited elevated endorsement of PGD symptoms. PGD, PTSD, and depression symptoms hung together as highly overlapping but distinguishable communities of symptoms. Symptoms related to social isolation and diminished sense of self bridged these communities. Violent loss was associated with more difficulty accepting the loss. The loss of close kin was most strongly associated with difficulty moving on in life.

CONCLUSIONS

PGD symptoms are common in trauma-exposed bereaved adults and closely associated with symptoms of PTSD and depression, illustrating the importance of assessing bereavement and PGD symptoms in those seeking treatment following trauma.

Understanding the impact of complicated grief on combat related posttraumatic stress disorder, guilt, suicide, and functional impairment in a clinical trial of post-9/11 service members and veterans

BACKGROUND

Complicated grief (CG) is a bereavement-specific syndrome distinct from but commonly comorbid with posttraumatic stress disorder (PTSD). While bereavement is common among military personnel (Simon et al., 2018), there is little research on the impact of CG comorbidity on PTSD treatment outcomes.

METHODS

To evaluate the impact of comorbid CG on PTSD treatment outcomes we analyzed data from a randomized trial comparing prolonged exposure, sertraline, and their combination in veterans with a primary diagnosis of combat-related PTSD (n = 194). Assessment of PTSD, trauma-related guilt, functional impairment, and suicidal ideation and behavior occurred at baseline and weeks 6, 12, and 24 during the 24-week trial.

RESULTS

CG was associated with lower PTSD treatment response (odds ratio (OR) = 0.29, 95% confidence interval (CI) [0.12, 0.69], p = 0.005) and remission (OR = 0.28, 95% CI [0.11, 0.71], p = 0.007). Those with CG had greater severity of PTSD (p = 0.005) and trauma-related guilt (<0.001) at baseline and endpoint. In addition, those with CG were more likely to experience suicidal ideation during the study (CG: 35%, 14/40 vs. no CG 15%, 20/130; OR = 3.01, 95% CI [1.29, 7.02], p = 0.011).

CONCLUSIONS

Comorbid CG is associated with elevated PTSD severity and independently associated with poorer endpoint treatment outcomes in veterans with combat-related PTSD, suggesting that screening and additional intervention for CG may be needed.

Differential associations between interpersonal variables and quality-of-life in a sample of college students

PURPOSE

Humans are fundamentally social beings, and the relationships we form with others are crucial for our well-being. Research across a variety of domains has established the association between a variety of interpersonal factors and health outcomes, including quality-of-life. However, there is a need for a more integrative, holistic analysis of these variables and how they relate to one another.

METHODS

Undergraduate students (n = 1456) from four universities across the United States completed self-report measures of their quality-of-life and a variety of interpersonal factors identified as important predictors across the literature. We examined zero-order correlations between these measures and quality-of-life, estimated a path model to look at unique variance accounted for by each, and finally used network analysis to examine the network of direct and indirect associations among these variables and quality-of-life.

RESULTS

Loneliness had the strongest association with quality-of-life across all analyses. When examining the unique association between quality-of-life and each interpersonal variable, six remained statistically significant: loneliness, social support, social connectedness, emotional intelligence, intimacy with one's romantic partner, and empathic concern. These results were supported by the network model, which found direct associations between quality-of-life and these six variables as well as indirect associations with all other interpersonal variables in the model.

CONCLUSIONS

Results from this research suggest that interpersonal factors in general, and loneliness in particular, are strongly associated with quality-of-life. Future research is needed to establish the direction of these effects and examine for whom these findings are generalizable.

A network approach to eating disorder symptomatology: Do desire for thinness and fear of gaining weight play unique roles in the network?

This study used network analyses to test the hypotheses that desire for thinness and fear of gaining weight are related but distinct constructs that play a central role in disordered eating. Data from a sample of 251 college women were used. Sparse undirected eating disorder symptom networks were calculated. Bootstrapped difference tests for edge weights and centrality indices were used to compare the position of desire for thinness and fear of gaining weight. Desire for thinness and fear of gaining weight exhibited unique patterns of associations within the network. Desire for thinness was highly connected to body dissatisfaction, thoughts about dieting, and thoughts about binge eating. Fear of gaining weight was not. Desire for thinness emerged as the most central symptom. Our findings support the distinction between fear of gaining weight and desire for thinness and their different roles within the eating disorder symptom network.

The loss of a fellow service member: Complicated grief in post-9/11 service members and veterans with combat-related posttraumatic stress disorder

Bereavement is a potent and highly prevalent stressor among service members and veterans. However, the psychological consequences of bereavement, including complicated grief (CG), have been minimally examined. Loss was assessed in 204 post-9/11, when service members and veterans with combat-related posttraumatic stress disorder (PTSD) took part in a multicenter treatment study. Those who reported the loss of an important person completed the inventory of complicated grief (ICG; n = 160). Over three quarters (79.41%) of the sample reported an important lifetime loss, with close to half (47.06%) reporting the loss of a fellow service member (FSM). The prevalence of CG was 24.75% overall, and nearly one third (31.25%) among the bereaved. CG was more prevalent among veterans who lost a fellow service member (FSM) (41.05%, n = 39) compared to those bereaved who did not (16.92%, n = 11; OR = 3.41, 95% CI: 1.59, 7.36). CG was associated with significantly greater PTSD severity, functional impairment, trauma-related guilt, and lifetime suicide attempts. Complicated grief was prevalent and associated with adverse psychosocial outcomes in veterans and service members with combat-related PTSD. Clinicians working with this population should inquire about bereavement, including loss of a FSM, and screen for CG. Additional research examining CG in this population is needed.

A Bayesian network analysis of posttraumatic stress disorder symptoms in adults reporting childhood sexual abuse

Background: The network approach to mental disorders offers a novel framework for conceptualizing posttraumatic stress disorder (PTSD) as a causal system of interacting symptoms. Objective: In this study, we extended this work by estimating the structure of relations among PTSD symptoms in adults reporting personal histories of childhood sexual abuse (CSA; N = 179).   Method: We employed two complementary methods. First, using the graphical LASSO, we computed a sparse, regularized partial correlation network revealing associations (edges) between pairs of PTSD symptoms (nodes). Next, using a Bayesian approach, we computed a directed acyclic graph (DAG) to estimate a directed, potentially causal model of the relations among symptoms. Results: For the first network, we found that physiological reactivity to reminders of trauma, dreams about the trauma, and lost of interest in previously enjoyed activities were highly central nodes. However, stability analyses suggest that these findings were unstable across subsets of our sample. The DAG suggests that becoming physiologically reactive and upset in response to reminders of the trauma may be key drivers of other symptoms in adult survivors of CSA. Conclusions: Our study illustrates the strengths and limitations of these network analytic approaches to PTSD.

Identifying highly influential nodes in the complicated grief network

The network approach to psychopathology conceptualizes mental disorders as networks of mutually reinforcing nodes (i.e., symptoms). Researchers adopting this approach have suggested that network topology can be used to identify influential nodes, with nodes central to the network having the greatest influence on the development and maintenance of the disorder. However, because commonly used centrality indices do not distinguish between positive and negative edges, they may not adequately assess the nature and strength of a node's influence within the network. To address this limitation, we developed 2 indices of a node's expected influence (EI) that account for the presence of negative edges. To evaluate centrality and EI indices, we simulated single-node interventions on randomly generated networks. In networks with exclusively positive edges, centrality and EI were both strongly associated with observed node influence. In networks with negative edges, EI was more strongly associated with observed influence than was centrality. We then used data from a longitudinal study of bereavement to examine the association between (a) a node's centrality and EI in the complicated grief (CG) network and (b) the strength of association between change in that node and change in the remainder of the CG network from 6- to 18-months postloss. Centrality and EI were both correlated with the strength of the association between node change and network change. Together, these findings suggest high-EI nodes, such as emotional pain and feelings of emptiness, may be especially important to the etiology and treatment of CG. (PsycINFO Database Record

PTSD and Romantic Relationship Satisfaction: Cluster- and Symptom-Level Analyses

Previous studies have demonstrated bidirectional associations between posttraumatric stress disorder (PTSD) and romantic relationship dissatisfaction. Most of these studies were focused at the level of the disorder, examining the association between relationship dissatisfaction and having a diagnosis of PTSD or the total of PTSD symptoms endorsed. This disorder-level approach is problematic for trauma theorists who posit symptom-level mechanisms for these effects. In the present study, we examined the prospective, bidirectional associations between PTSD symptom clusters (e.g., reexperiencing) and relationship satisfaction using the data from 101 previously studied individuals who had had a recent motor vehicle accident. We also conducted exploratory analyses examining the prospective, bidirectional associations between individual PTSD symptoms and relationship satisfaction. Participants had completed the PTSD Checklist-Civilian Version and the Relationship Assessment Scale at 4, 10, and 16 weeks after the MVA. We performed time-lagged mixed-effects regressions to examine the effect of lagged relationship satisfaction on PTSD clusters and symptoms, and vice versa. No cluster effects were significant after controlling for a false discovery rate. Relationship satisfaction predicted prospective decreases in reliving the trauma (d = 0.42), emotional numbness (d = 0.46), and irritability (d = 0.49). These findings were consistent with the position that relationship satisfaction affects PTSD through symptom-level mechanisms.

The structure of feared social situations among race-ethnic minorities and Whites with social anxiety disorder in the United States

We investigated feared social situations in individuals with social anxiety disorder from different racial and ethnic groups in the United States. The sample included 247 African Americans, 158 Latinos, and 533 non-Latino Whites diagnosed with social anxiety disorder within the past 12 months from the integrated Collaborative Psychiatric Epidemiology Studies data set. After randomly splitting the full sample, we conducted an exploratory factor analysis with half of the sample to determine the structure of feared social situations in a more diverse sample than has been used in previous studies. We found evidence for a model consisting of three feared social domains: performance/public speaking, social interaction, and observational. We then conducted a confirmatory factor analysis on the remaining half of the sample to examine whether this factor structure varied significantly between the race-ethnic groups. Analyses revealed an adequate fit of this model across all three race-ethnic groups, suggesting invariance of the factor structure between the study groups. Broader cultural contexts within which these findings are relevant are discussed, along with important implications for comprehensive, culturally sensitive assessment of social anxiety.

THE STRUCTURED CLINICAL INTERVIEW FOR COMPLICATED GRIEF: RELIABILITY, VALIDITY, AND EXPLORATORY FACTOR ANALYSIS

BACKGROUND

Complicated grief (CG) has been recently included in the DSM-5, under the term "persistent complex bereavement disorder," as a condition requiring further study. To our knowledge, no psychometric data on any structured clinical interview for CG (SCI-CG) is available to date. In this manuscript, we introduce the SCI-CG, a 31-item "SCID-like" clinician-administered instrument to assess the presence of CG symptoms.

METHODS

Participants were 281 treatment-seeking adults with CG (77.9% [n = 219] women, mean age = 52.4, standard deviation [SD] = 17.8) who were assessed with the SCI-CG and measures of depression, posttraumatic stress, anxiety, functional impairment.

RESULTS

The SCI-CG exhibited satisfactory internal consistency (α = .78), good test-retest reliability (interclass correlation [ICC] 0.68, 95% CI [0.60-0.75]), and excellent interrater reliability (ICC = 0.95, 95% CI [0.89-0.98]). Exploratory factor analyses revealed that a five-factor structure, explaining 50.3% of the total variance, was the best fit for the data.

CONCLUSIONS

The clinician-rated SCI-CG demonstrates good internal consistency, reliability, and convergent validity in treatment-seeking individuals with CG and therefore can be a useful tool to assess CG. Although diagnostic criteria for CG have yet to be adequately validated, the SCI-CG may facilitate this process. The SCI-CG can now be used as a validated instrument in research and clinical practice.

Change in Decentering Mediates Improvement in Anxiety in Mindfulness-Based Stress Reduction for Generalized Anxiety Disorder

OBJECTIVE

We sought to examine psychological mechanisms of treatment outcomes of a mindfulness meditation intervention for Generalized Anxiety Disorder (GAD).

METHODS

We examined mindfulness and decentering as two potential therapeutic mechanisms of action of generalized anxiety disorder (GAD) symptom reduction in patients randomized to receive either mindfulness-based stress reduction (MBSR) or an attention control class (N=38). Multiple mediation analyses were conducted using a non-parametric cross product of the coefficients approach that employs bootstrapping.

RESULTS

Analyses revealed that change in decentering and change in mindfulness significantly mediated the effect of MBSR on anxiety. When both mediators were included in the model, the multiple mediation analysis revealed a significant indirect effect through increases in decentering, but not mindfulness. Furthermore, the direct effect of MBSR on decrease in anxiety was not significant, suggesting that decentering fully mediated the relationship. Results also suggested that MBSR reduces worry through an increase in mindfulness, specifically by increases in awareness and nonreactivity.

CONCLUSIONS

Improvements in GAD symptoms resulting from MBSR are in part explained by increased levels of decentering.

Anxiety sensitivity in bereaved adults with and without complicated grief

Complicated grief (CG) is a bereavement-specific syndrome chiefly characterized by symptoms of persistent separation distress. Physiological reactivity to reminders of the loss and repeated acute pangs or waves of severe anxiety and psychological pain are prominent features of CG. Fear of this grief-related physiological arousal may contribute to CG by increasing the distress associated with grief reactions and increasing the likelihood of maladaptive coping strategies and grief-related avoidance. Here, we examined anxiety sensitivity (AS; i.e., the fear of anxiety-related sensations) in two studies of bereaved adults with and without CG. In both studies, bereaved adults with CG exhibited elevated AS relative to those without CG. In study 2, AS was positively associated with CG symptom severity among those with CG. These findings are consistent with the possibility that AS contributes to the development or maintenance of CG symptoms.

Network analysis of persistent complex bereavement disorder in conjugally bereaved adults

Persistent complex bereavement disorder (PCBD) is a bereavement-specific syndrome characterized by prolonged and impairing grief. Most research on this syndrome rests on the traditional latent variable model, whereby symptoms reflect an underlying entity. The network (or causal system) approach offers an alternative framework for understanding PCBD that does not suffer from limitations inherent in the latent entity approach. The network approach to psychopathology conceptualizes the relation between symptoms and disorder as mereological, not reflective. That is, symptoms do not reflect an inferred, unobservable category or dimension, but rather are themselves constitutive of the disorder. Accordingly, we propose that PCBD constitutes a causal system of mutually reinforcing symptoms that arise following the death of a loved one and settle into a pathological equilibrium. In this study, we used data from the Changing Lives of Older Couples database to identify symptoms central to PCBD, to distinguish the PCBD network from an overlapping but distinct network of depression symptoms, and to examine how previously identified risk factors may contribute to the maintenance or development of PCBD. Together, these findings provide an important first step toward understanding the nature and etiology of the PCBD network.

Randomized controlled trial of mindfulness meditation for generalized anxiety disorder: effects on anxiety and stress reactivity

OBJECTIVE

Mindfulness meditation has met increasing interest as a therapeutic strategy for anxiety disorders, but prior studies have been limited by methodological concerns, including a lack of an active comparison group. This is the first randomized, controlled trial comparing the manualized Mindfulness-Based Stress Reduction (MBSR) program with an active control for generalized anxiety disorder (GAD), a disorder characterized by chronic worry and physiologic hyperarousal symptoms.

METHOD

Ninety-three individuals with DSM-IV-diagnosed GAD were randomly assigned to an 8-week group intervention with MBSR or to an attention control, Stress Management Education (SME), between 2009 and 2011. Anxiety symptoms were measured with the Hamilton Anxiety Rating Scale (HAMA; primary outcome measure), the Clinical Global Impressions-Severity of Illness and -Improvement scales (CGI-S and CGI-I), and the Beck Anxiety Inventory (BAI). Stress reactivity was assessed by comparing anxiety and distress during pretreatment and posttreatment administration of the Trier Social Stress Test (TSST).

RESULTS

A modified intent-to-treat analysis including participants who completed at least 1 session of MBSR (n = 48) or SME (n = 41) showed that both interventions led to significant (P < .0001) reductions in HAMA scores at endpoint, but did not significantly differ. MBSR, however, was associated with a significantly greater reduction in anxiety as measured by the CGI-S, the CGI-I, and the BAI (all P values < .05). MBSR was also associated with greater reductions than SME in anxiety and distress ratings in response to the TSST stress challenge (P < .05) and a greater increase in positive self-statements (P = .004).

CONCLUSIONS

These results suggest that MBSR may have a beneficial effect on anxiety symptoms in GAD and may also improve stress reactivity and coping as measured in a laboratory stress challenge.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01033851.

Are habitual overgeneral recollection and prospection maladaptive?

BACKGROUND AND OBJECTIVES

Individuals with depression exhibit difficulty retrieving specific memories and imagining specific future events when instructed to do so relative to non-clinical comparison groups. Instead of specific events, depressed individuals frequently retrieve or imagine "overgeneral" memories that span a long period of time or that denote a category of similar events. Recently, Raes, Hermans, Williams, and Eelen (2007) developed a sentence completion procedure (SCEPT) to assess the tendency to recall overgeneral autobiographical memories. They found that specificity on this measure was associated with depression and rumination. We aimed to replicate these findings and to examine the tendency to imagine overgeneral future events.

METHODS

We had 170 subjects complete past (SCEPT) and future-oriented (SCEFT) sentence completion tasks and measures of depression severity, PTSD severity, hopelessness, and repetitive negative thought.

RESULTS

Although specificities of past and future events were correlated, neither SCEPT nor SCEFT specificity was negatively associated with depression severity, posttraumatic stress symptoms, repetitive negative thought (RNT), or hopelessness.

LIMITATIONS

Our data are cross-sectional, preventing any determination of causality and limiting our assessment of whether specificity is associated with psychological distress following a stressful life event. In addition, we observed poor internal consistency for both the SCEPT and SCEFT.

CONCLUSIONS

These findings fail to support the hypothesis that overgeneral memory and prospection on these tasks are associated with psychological distress.

Periloss dissociation, symptom severity, and treatment response in complicated grief

BACKGROUND

Complicated grief (CG) is a bereavement-specific syndrome characterized by traumatic and separation distress lasting over 6 months. Little is known about the role of dissociation experienced during or immediately after the loss of a loved one (i.e., periloss dissociation [PLD]) in CG. The present study aimed to examine the psychometric properties of the PLD-adapted Peritraumatic Dissociative Experiences Questionnaire and its association with symptom severity, treatment response, and drop-out rate.

METHODS

PLD data collected as part of a randomized controlled trial of two loss-focused psychotherapy approaches for CG were examined. Treatment-seeking individuals with primary CG (n = 193) were assessed for PLD at the initial visit, 95 of whom were randomized and completed at least one treatment session.

RESULTS

The PLD-adapted Peritraumatic Dissociative Experiences Questionnaire was found to be internally consistent (α = 0.91) with good convergent and divergent validity. After controlling for age, gender, time since loss, and current comorbid psychiatric diagnosis, self-reported PLD was associated with greater CG symptom severity (P < .01). However, contrary to our hypotheses, after controlling for age, baseline symptoms severity, psychiatric comorbidity, and treatment arm, PLD was predictive of better treatment response (P < .05) and lower study discontinuation (P < .01).

CONCLUSIONS

PLD may be useful in identifying individuals at risk for CG and those who might respond to psychotherapy. Additional research should investigate the relationship of PLD with treatment outcome for different treatment approaches, and whether PLD prospectively predicts the development of CG.

Mood regulation and quality of life in social anxiety disorder: an examination of generalized expectancies for negative mood regulation

The present study examined negative mood regulation expectancies, anxiety symptom severity, and quality of life in a sample of 167 patients with social anxiety disorder (SAD) and 165 healthy controls with no DSM-IV Axis I disorders. Participants completed the Generalized Expectancies for Negative Mood Regulation Scale (NMR), the Beck Anxiety Inventory, and the Quality of Life Enjoyment and Satisfaction Questionnaire. SAD symptom severity was assessed using the Liebowitz Social Anxiety Scale. Individuals with SAD scored significantly lower than controls on the NMR. Among SAD participants, NMR scores were negatively correlated with anxiety symptoms and SAD severity, and positively correlated with quality of life. NMR expectancies positively predicted quality of life even after controlling for demographic variables, comorbid diagnoses, anxiety symptoms, and SAD severity. Individuals with SAD may be less likely to engage in emotion regulating strategies due to negative beliefs regarding their effectiveness, thereby contributing to poorer quality of life.