Reinterpreting comorbidity: a model-based approach to understanding and classifying psychopathology

Prevalence of self-reported subthreshold phenotypes of major mental disorders and their association with functional impairment, treatment and full-threshold syndromes in a community-residing cohort of young adults

AIM

Subthreshold syndromes (STS) frequently precede the onset of full-threshold syndromes (FTS) of the corresponding mental disorder (homotypic continuity). This study examines whether subthreshold conditions are comorbid and whether there is heterotypic continuity also between STS and FTS.

METHODS

Data were extracted from the Brisbane "19Up" cohort study of twins and siblings (N = 1838; 56% female) on individuals who (i) completed self-report ratings of depression-like (DLE), hypomanic-like (HMLE) and psychotic-like experiences (PLE) and (ii) were assessed for mood and psychotic FTS using the Composite International Diagnostic Interview (CIDI). Associations between STS and FTS were estimated using adjusted prevalence ratios (APR) and 95% confidence intervals (CI).

RESULTS

STS are prevalent, with 22% reporting DLE, 14% HMLE and 5% PLE; 7% reported >1 STS, with PLE most likely to demonstrate comorbidity. Individuals with DLE were likely to meet CIDI criteria for depression (APR: 3.71, 95% CI: 2.83, 4.89), hypo/mania (APR: 3.62, 95% CI: 2.21, 5.94) and psychotic disorders (APR: 1.74, 95% CI 1.08, 2.83). Individuals with HMLE were likely to meet CIDI criteria for depression (APR: 2.29, 95% CI: 1.58, 3.31) and hypo/mania (APR: 2.51, 95% CI: 1.29, 4.91); those with PLE were likely to meet criteria for hypo/mania (APR: 5.8, 95% CI: 1.90, 17.70) and psychotic disorders (APR: 17.27, 95% CI: 7.54, 39.65).

CONCLUSIONS

The findings suggest that STS are common among young adults and show heterotypic as well as homotypic continuity with FTS and support the need for more trans-diagnostic research on the evolution of major mental disorders.

The comorbidity structure of fear, distress and compulsive disorders in an acute psychiatric sample

Body dysmorphic disorder (BDD) and obsessive-compulsive disorder (OCD), collectively referred to as compulsive disorders, have typically not been included in structural research on the internalizing spectrum due to low prevalence in community samples. The current study examined the higher-order structure of anxiety, depressive and compulsive disorders among patients in a psychiatric partial hospital program (N = 2,178). We applied confirmatory factor analysis to diagnostic data obtained at admission and compared several competing models of the comorbidity structure. A one-factor model accounted well for the co-occurrence of all the disorders. A two-factor model comprised of fear and distress factors, wherein compulsive disorders loaded on fear, also fit the data well. However, a very large factor correlation (r = 0.86) suggested limited discriminant validity of fear and distress in the sample. Alternate models that featured a distinct compulsivity factor were not viable owing to large correlations between fear and compulsive disorders. Overall, our findings indicate that a broad internalizing dimensions underlies not only anxiety and depression, but also compulsive disorders, in an acute psychiatric population. Future studies using symptom-level data are needed to replicate these results and determine the structure of internalizing disorders from the bottom up, starting with narrowly defined symptom components.

A detailed hierarchical model of psychopathology: From individual symptoms up to the general factor of psychopathology

Much of our knowledge about the relationships among domains of psychopathology is built on the diagnostic categories described in the Diagnostic and Statistical Manual of Mental Disorders (DSM), with relatively little research examining the symptom-level structure of psychopathology. The aim of this study was to delineate a detailed hierarchical model of psychopathology-from individual symptoms up to a general factor of psychopathology-allowing both higher- and lower-order dimensions to depart from the structure of the DSM. We explored the hierarchical structure of hundreds of symptoms spanning 18 DSM disorders, in two large samples-one from the general population in Australia (n = 3175), and the other a treatment-seeking clinical sample from the USA (n = 1775). There was marked convergence between the two samples, offering new perspectives on higher-order dimensions of psychopathology. We also found several noteworthy departures from the structure of the DSM in the symptom-level data.

Foster children's complex psychopathology in the context of cumulative childhood trauma: The interplay of ICD-11 complex PTSD, dissociation, depression, and emotion regulation

BACKGROUND

Foster children experience maltreatment at exceptionally high rates with increased risk to develop ICD-11 complex posttraumatic stress disorder (CPTSD). While rates of comorbidity between CPTSD and various disorders are high, the interplay between constituent aspects of psychopathology is not clearly understood. No study used network analysis to model the interplay between these aspects as potentially maintaining a stable condition of psychopathology, and research on the etiology and maintenance of CPTSD in children is especially scarce.

METHODS

Altogether, 208 Austrian foster children completed a set of standardized measures, resulting in a final sample of N = 122 foster children meeting the inclusion criteria. Experiences of childhood trauma, ICD-11 CPTSD, depression, dissociation, adaptive, and maladaptive emotion regulation were assessed. Following an exploratory approach, analyses were conducted using latent single indicator factor scores in two network models.

RESULTS

Domains of CPTSD, PTSD and disturbances in self-organization (DSO), evidenced as most central factors in children's complex psychopathology. Including cumulative childhood trauma did not influence the connectedness of factors in any relevant way. Shortest direct paths from cumulative childhood trauma to CPTSD included dissociation (PTSD) and adaptive emotion regulation (DSO) as mediating factors.

LIMITATIONS

Results are based on a small sample of highly-traumatized foster children, potentially limiting current findings' generalizability.

CONCLUSIONS

CPTSD identified as central in children's complex psychopathology, while the role of childhood trauma seems stronger for the onset than the maintenance of such psychopathology. The current network revealed central disorders and distinct mediating factors as important targets for treatment strategies and future research.

Problems with Centrality Measures in Psychopathology Symptom Networks: Why Network Psychometrics Cannot Escape Psychometric Theory

Understanding patterns of symptom co-occurrence is one of the most difficult challenges in psychopathology research. Do symptoms co-occur because of a latent factor, or might they directly and causally influence one another? Motivated by such questions, there has been a surge of interest in network analyses that emphasize the putatively direct role symptoms play in influencing each other. In this critical paper, we highlight conceptual and statistical problems with using centrality measures in cross-sectional networks. In particular, common network analyses assume that there are no unmodeled latent variables that confound symptom co-occurrence. The traditions of clinical taxonomy and test development in psychometric theory, however, greatly increase the possibility that latent variables exist in symptom data. In simulations that include latent variables, we demonstrate that closeness and betweenness are vulnerable to spurious covariance among symptoms that connect subgraphs (e.g., diagnoses). We further show that strength is redundant with factor loading in several cases. Finally, if a symptom reflects multiple latent causes, centrality metrics reflect a weighted combination, undermining their interpretability in empirical data. Our results suggest that it is essential for network psychometric approaches to examine the evidence for latent variables prior to analyzing or interpreting patterns at the symptom level. Failing to do so risks identifying spurious relationships or failing to detect causally important effects. Altogether, we argue that centrality measures do not provide solid ground for understanding the structure of psychopathology when latent confounding exists.

Temperaments and characters: incompatible or complementary components for criterion B of the alternative model in predicting DSM-5 section II personality disorders?

BACKGROUND

Many studies have found clear correspondence among the domains of the five-factor model of personality (FFM) and the alternative model of personality disorders (AMPD) in DSM-5-III, which is assessed with the Personality Inventory for DSM-5 (PID-5). However, very few studies have compared the PID-5 with the other well-known established dimensional models of personality such as Cloninger's model. The present study examined whether the Temperament and Character Inventory (TCI-125) dimensions, PID-5 dimensions, or a combination would represent PD-scale scores more accurately.

PARTICIPANTS AND PROCEDURE

In this regard, 437 college students completed the Persian version of the PID-5, TCI-125 and SCID-II Screening Questionnaire.RESULTS The results indicated that cooperativeness (low), self-directedness (low), and self-transcendence (high) characters of the TCI-125 and the psychoticism (high) domain of the PID-5 are the most consistent predictors of all PD-scale scores.

CONCLUSIONS

Overall, the findings showed that an integrative model, combining dimensions of the TCI-125 and PID-5, represented the features of PD-scale scores most effectively.

Factorial invariance in hierarchical factor models of mental disorders in African American and European American youths

BACKGROUND

There is converging evidence that mental disorders are more optimally conceptualized in a hierarchical framework (i.e., the Hierarchical Taxonomy of Psychopathology, HiTOP) that transcends the categorical boundaries of the Diagnostic and Statistical Manual of Mental Disorders (DSM). However, the majority of this evidence comes from studies that draw upon predominantly European American or Caucasian populations. Whether a hierarchical conceptualization of mental disorders generalizes across racial-ethnic groups, including for African American (AA) populations, is unclear.

METHODS

We tested multidimensional and bifactor models of 15 DSM diagnoses and psychiatric traits in two groups, including AA (n = 3,088) and European American (EA; n = 5,147) youths aged 8-21 from the Philadelphia Neurodevelopmental Cohort (PNC). We also conducted multigroup confirmatory factor analyses to test for factorial invariance between the best fitting AA and EA multidimensional and bifactor models.

RESULTS

In the multidimensional model tests, a three-factor model, specifying internalizing, externalizing, and thought dimensions, emerged as the best fitting model for AAs and EAs. In the bifactor model tests, a three-factor model (i.e., internalizing, externalizing, and thought dimensions) that also specified a general factor emerged as the optimal for both AAs and EAs. The general factor accounted for a significant proportion of the covariation between the secondary factors and the individual disorders and traits. Furthermore, both models were factorially invariant, indicating no significant difference in the factor structure of mental disorders between AAs and EAs in PNC.

CONCLUSIONS

Results suggest that the hierarchical factor structure of mental disorders may be racial-ethnically robust. This finding has implications for etiological and epidemiological studies focused on racial-ethnic subgroup comparisons, particularly with respect to identifying similarities and differences in prevalence rates or sociodemographic risk factors for mental disorders.

The General Factor of Psychopathology in the Adolescent Brain Cognitive Development (ABCD) Study: A Comparison of Alternative Modeling Approaches

Many models of psychopathology include a single general factor of psychopathology (GFP) or "p factor" to account for covariation across symptoms. The Adolescent Brain Cognitive Development (ABCD) Study provides a rich opportunity to study the development of the GFP. However, a variety of approaches for modeling the GFP have emerged, raising questions about how modeling choices impact estimated GFP scores. We used the ABCD baseline assessment (ages 9-10 years-old; N=11,875) of the parent-rated Child Behavior Checklist (CBCL) to examine the implications of modeling the GFP using items versus scales; using a priori CBCL scales versus data-driven dimensions; and using bifactor, higher-order, or single-factor models. Children's rank-ordering on the GFP was stable across models, with GFP scores similarly related to criterion variables. Results suggest that while theoretical debates about modeling the GFP continue, the practical implications of these choices for rank-ordering children and assessing external associations will often be modest.

Genetic Liability for Internalizing Versus Externalizing Behavior Manifests in the Developing and Adult Hippocampus: Insight From a Meta-analysis of Transcriptional Profiling Studies in a Selectively Bred Rat Model

BACKGROUND

For more than 16 years, we have selectively bred rats for either high or low levels of exploratory activity within a novel environment. These bred high-responder (bHR) and bred low-responder (bLR) rats model temperamental extremes, exhibiting large differences in internalizing and externalizing behaviors relevant to mood and substance use disorders.

METHODS

We characterized persistent differences in gene expression related to bHR/bLR phenotype across development and adulthood in the hippocampus, a region critical for emotional regulation, by meta-analyzing 8 transcriptional profiling datasets (microarray and RNA sequencing) spanning 43 generations of selective breeding (postnatal day 7: n = 22; postnatal day 14: n = 49; postnatal day 21: n = 21; adult: n = 46; all male). We cross-referenced expression differences with exome sequencing within our colony to pinpoint candidates likely to mediate the effect of selective breeding on behavioral phenotype. The results were compared with hippocampal profiling from other bred rat models.

RESULTS

Genetic and transcriptional profiling results converged to implicate multiple candidate genes, including two previously associated with metabolism and mood: Trhr and Ucp2. Results also highlighted bHR/bLR functional differences in the hippocampus, including a network essential for neurodevelopmental programming, proliferation, and differentiation, centering on Bmp4 and Mki67. Finally, we observed differential expression related to microglial activation, which is important for synaptic pruning, including 2 genes within implicated chromosomal regions: C1qa and Mfge8.

CONCLUSIONS

These candidate genes and functional pathways may direct bHR/bLR rats along divergent developmental trajectories and promote a widely different reactivity to the environment.

A developmental perspective on personality and psychopathology across the life span

Taking a developmental perspective, guided by core principles of developmental science and developmental psychopathology, is necessary to move the fields of personality science and psychopathology forward. Personality and psychopathology can be delineated using hierarchical models of individual differences, as evidenced by decades of converging evidence across community and psychiatric samples, countries and cultures, and ages and developmental periods. A large body of empirical research likewise documents associations between personality and various forms of psychopathology. Cross-sectional investigations of personality-psychopathology links in samples of adults now yield diminishing returns. Prospective, longitudinal investigations that assess personality, psychopathology, and their co-development across the life span are needed to determine their temporal ordering, capture dynamic associations over time and development, and elucidate causal origins and underlying mechanisms. We lay out a developmental framework that integrates across the developmental, personality, and psychopathology literatures in order to further understanding and guide future investigations of the nature of personality-psychopathology links.

Pervasively Thinner Neocortex as a Transdiagnostic Feature of General Psychopathology

OBJECTIVE

Neuroimaging research has revealed that structural brain alterations are common across broad diagnostic families of disorders rather than specific to a single psychiatric disorder. Such overlap in the structural brain correlates of mental disorders mirrors already well-documented phenotypic comorbidity of psychiatric symptoms and diagnoses, which can be indexed by a general psychopathology or p factor. The authors hypothesized that if general psychopathology drives the convergence of structural alterations common across disorders, then 1) there should be few associations unique to any one diagnostic family of disorders, and 2) associations with the p factor should overlap with those for the broader diagnostic families.

METHODS

Analyses were conducted on structural MRI and psychopathology data collected from 861 members of the population-representative Dunedin Multidisciplinary Health and Development Study at age 45.

RESULTS

Study members with high scores across three broad diagnostic families of disorders (externalizing, internalizing, thought disorder) exhibited highly overlapping patterns of reduced global and widely distributed parcel-wise neocortical thickness. Study members with high p factor scores exhibited patterns of reduced global and parcel-wise neocortical thickness nearly identical to those associated with the three broad diagnostic families.

CONCLUSIONS

A pattern of pervasively reduced neocortical thickness appears to be common across all forms of mental disorders and may represent a transdiagnostic feature of general psychopathology. As has been documented with regard to symptoms and diagnoses, the underlying brain structural correlates of mental disorders may not exhibit specificity, and the continued pursuit of such specific correlates may limit progress toward more effective strategies for etiological understanding, prevention, and intervention.

Hierarchical models of psychopathology: empirical support, implications, and remaining issues

There is an ongoing revolution in psychology and psychiatry that will likely change how we conceptualize, study and treat psychological problems.- Many theorists now support viewing psychopathology as consisting of continuous dimensions rather than discrete diagnostic categories. Indeed, recent papers have proposed comprehensive taxonomies of psychopathology dimensions to replace the DSM and ICD taxonomies of categories. The proposed dimensional taxonomies, which portray psychopathology as hierarchically organized correlated dimensions, are now well supported at phenotypic levels. Multiple studies show that both a general factor of psychopathology at the top of the hierarchy and specific factors at lower levels predict different functional outcomes. Our analyses of data on a large representative sample of child and adolescent twins suggested the causal hypothesis that phenotypic correlations among dimensions of psychopathology are the result of many familial influences being pleiotropic. That is, most genetic variants and shared environmental factors are hypothesized to non-specifically influence risk for multiple rather than individual dimensions of psychopathology. In contrast, person-specific experiences tend to be related to individual dimensions. This hierarchical causal hypothesis has been supported by both large-scale family and molecular genetic studies. Current research focuses on three issues. First, the field has not settled on a preferred statistical model for studying the hierarchy of causes and phenotypes. Second, in spite of encouraging progress, the neurobiological correlates of the hierarchy of dimensions of psychopathology are only partially described. Third, although there are potentially important clinical implications of the hierarchical model, insufficient research has been conducted to date to rec-ommend evidence-based clinical practices.

Brief Research Report: A Pilot Study of Cognitive Behavioral Regulation Therapy (CBT-REG) for Young People at High Risk of Early Transition to Bipolar Disorders

Attempts to increase early identification of individuals in the early stages of bipolar disorders (i.e., individuals at high risk of bipolar disorders and/or experiencing a subthreshold syndrome with bipolar symptoms) have highlighted the need to develop high benefit-low risk interventions. We suggest that any new psychological therapy should (i) be acceptable to young people seeking help for the first time, (ii) be applicable to "at risk" conditions and sub-syndromal states and (iii) consider pluripotent factors that may be linked to illness progression not only for bipolar disorders specifically but also for other potential disease trajectories. However, evidence indicates that current interventions for youth with emerging mood disorders mainly represent approaches abbreviated from "disorder-specific" therapies used with older adults and are primarily offered to first episode cases of bipolar disorders who are also receiving psychotropic medication. This brief report discusses empirical findings used to construct core targets for therapeutic interventions that might reduce or delay transition to full-threshold bipolar disorders. We describe an intervention that includes strategies for problem-solving, reducing sleep-wake cycle disturbances, self-management of rumination and that addresses the needs of individuals with "sub-threshold" presentations who are probably at risk of developing a bipolar or other major mental disorders. Outcome data from a case series of 14 youth indicates that the intervention appears to demonstrate a relatively high benefit-to-risk ratio, promising levels of engagement with the therapy modules, and the therapy appears to be acceptable to a wide range of help-seeking youth with early expressions of bipolar psychopathology.

Comorbidity Between Math and Reading Problems: Is Phonological Processing a Mutual Factor?

There is a relationship between reading and math skills, as well as comorbidity between reading and math disorders. A mutual foundation for this comorbidity could be that the quality of phonological representations is important for both early reading and arithmetic. In this study, we examine this hypothesis in a sample traced longitudinally from preschool to first grade (N = 259). The results show that phonological awareness does not explain development in arithmetic, but that there is an indirect effect between phoneme awareness in preschool and arithmetic in first grade via phoneme awareness in first grade. This effect is, however, weak and restricted to verbal arithmetic and not arithmetic fluency. This finding is only partly in line with other studies, and a reason could be that this study more strongly controls for confounders and previous skills than other studies.

Personality types revisited-a literature-informed and data-driven approach to an integration of prototypical and dimensional constructs of personality description

A new algorithmic approach to personality prototyping based on Big Five traits was applied to a large representative and longitudinal German dataset (N = 22,820) including behavior, personality and health correlates. We applied three different clustering techniques, latent profile analysis, the k-means method and spectral clustering algorithms. The resulting cluster centers, i.e. the personality prototypes, were evaluated using a large number of internal and external validity criteria including health, locus of control, self-esteem, impulsivity, risk-taking and wellbeing. The best-fitting prototypical personality profiles were labeled according to their Euclidean distances to averaged personality type profiles identified in a review of previous studies on personality types. This procedure yielded a five-cluster solution: resilient, overcontroller, undercontroller, reserved and vulnerable-resilient. Reliability and construct validity could be confirmed. We discuss wether personality types could comprise a bridge between personality and clinical psychology as well as between developmental psychology and resilience research.

Etiological Overlap Between Sex Under the Influence and Number of Lifetime Sexual Partners

Drug and alcohol use is associated with risky sexual behavior (RSB). It is unclear whether this association is due to correlated liabilities (e.g., third variables influencing both traits), or whether use of drugs and alcohol during sexual decision making increases RSB. This study addresses this question by fitting a series of biometrical models using over 800 twin pairs assessed in early adulthood (m = 25.21 years). Measures included an index of sex under the influence (e.g., frequency that drugs or alcohol affect sexual decision making), number of lifetime sexual partners, and a general measure of substance use. Analyses suggest the covariance among these measures is explained by both genetic and environmental correlated liabilities. The overlap was not specific to sex under the influence, but was shared with a measure of general substance use. Models testing necessary but not sufficient parameters for direction of causation suggest that sex under the influence is unlikely to cause an increase in RSB; more evidence for reverse causation was found.

Total and cause-specific mortality in patients with personality disorders: the association between comorbid severe mental illness and substance use disorders

PURPOSE

To investigate the mortality in both in- and outpatients with personality disorders (PD), and to explore the association between mortality and comorbid substance use disorder (SUD) or severe mental illness (SMI).

METHODS

All residents admitted to Norwegian in- and outpatient specialist health care services during 2009-2015 with a PD diagnosis were included. Standardized mortality ratios (SMRs) with 95% confidence intervals (CI) were estimated in patients with PD only and in patients with PD and comorbid SMI or SUD. Cox proportional hazards models were used to estimate adjusted hazard ratios (HRs) with 95% CIs in patients with PD and comorbid SMI or SUD compared to patients with PD only.

RESULTS

Mortality was increased in both in- and outpatients with PD. The overall SMR was 3.8 (95% CI 3.6-4.0). The highest SMR was estimated for unnatural causes of death (11.0, 95% CI 10.0-12.0), but increased also for natural causes of death (2.2, 95% CI 2.0-2.5). Comorbidity was associated with higher SMRs, particularly due to poisoning and suicide. Patients with comorbid PD & SUD had almost four times higher all-cause mortality HR than patients with PD only; young women had the highest HR.

CONCLUSION

The SMR was high in both in- and outpatients with PD, and particularly high in patients with comorbid PD & SUD. Young female patients with PD & SUD were at highest risk. The higher mortality in patients with PD cannot, however, fully be accounted for by comorbidity.

Why do depression, conduct, and hyperactivity symptoms co-occur across adolescence? The role of stable and dynamic genetic and environmental influences

Depression, conduct, and hyperactivity symptoms are chronic and frequently co-occur in adolescence. Common genetic and environmental vulnerability to these conditions have previously been demonstrated, however, the manner in which common versus disorder-specific etiological influences operate across development and maintain symptom co-occurrence is unclear. Thus, the current study investigated the role of common genetic and environmental influences in the comorbidity of depression, conduct, and hyperactivity across adolescence. Over 10,000 twins and their parents reported adolescents' symptoms at mean ages 11 and 16 years. Biometric independent pathway models were fitted to estimate genetic and environmental contributions to the continuity of symptom co-occurrence over time, as well as time- and symptom-specific influences. Results found that a common stable genetic factor accounted for the concurrent and longitudinal co-occurrence of depression, conduct, and hyperactivity symptoms. New genetic influences common to these three symptom scales emerged at 16 years, and further contributed to symptom co-occurrence. Conversely, environmental influences largely contributed to the time-specific associations. The findings were generally consistent for self- and parent-reported symptoms. Overall, the results suggest that stable, overlapping genetic influences contribute to the co-occurrence of depression, conduct, and hyperactivity symptoms across adolescence. The results are in line with hierarchical causal models of psychopathology, which posit that much of the developmental co-occurrence between different symptoms is due to common liability. Specifically, current findings indicate that only genetic influences constitute common liability over time. Future studies should identify genetically influenced transdiagnostic risk and maintenance factors to inform prevention and treatment of comorbid internalizing and externalizing symptoms in adolescence.

Confounding of Big Five Personality Assessments in Emotional Disorders by Comorbidity and Current Disorder

Foremost cross–sectional studies of personality in common mental disorders show similar Big Five trait profiles [i.e. high neuroticism (N), low conscientiousness (C) and low extraversion (E)]. It remains undecided whether this lack of distinct personality profiles is partly due to comorbidity among disorders or contamination by current state. Using data from the Netherlands Study of Depression and Anxiety, we investigated 1046 participants with panic disorder (PD), social anxiety disorder (SAD) and/or major depressive disorder (MDD) and 474 healthy controls. Personality traits at baseline and two–year follow–up were assessed with the NEO–Five Factor Inventory. The Composite International Diagnostic Interview was used to determine the presence of emotional disorders at baseline and at two–year follow–up; the Life Chart Interview determined symptom severity in the month prior to baseline and during follow–up. By analysing pure cases and investigating the effects in remitted cases, PD participants were found to be higher in N, but not lower in E and C than controls. Pure PD participants were also lower in N and higher in E than SAD and MDD participants. Both SAD and MDD participants were characterized by high levels of N and low levels of E, irrespective of comorbidity or current disorder state. Future studies should be more attentive to confounding of personality profiles by comorbidity and state effects. Copyright © 2012 John Wiley & Sons, Ltd.

Co‐occurrence of depression and delinquency in personality types

Although the co‐occurrence between adolescent depression and delinquency has been well‐studied, the nature of the longitudinal associations is not yet clear. To clarify this we examined whether personality type is a moderator in the longitudinal co‐occurrence of depression and delinquency. A total of 338 young and middle adolescents completed questionnaires about depression, delinquency and personality in 3 yearly waves of the CONflict And Management Of RElationships (CONAMORE). We found that the stable overcontrollers showed the highest mean level on depression and that the stable undercontrollers showed the highest mean level on delinquency. Furthermore, we demonstrated that the longitudinal co‐occurrence between depression and delinquency was best described by means of a stability model, in which personality type membership proved to be an important moderator. The three personality types differed significantly on the rank‐order stability of both depression and delinquency. Copyright © 2006 John Wiley & Sons, Ltd.

The Role of Diagnostic Instruments in Dual and Differential Diagnosis in Autism Spectrum Disorder Across the Lifespan

The heterogeneity inherent in autism spectrum disorder (ASD) makes the identification and diagnosis of ASD complex. We survey a large number of diagnostic tools, including screeners and tools designed for in-depth assessment. We also discuss the challenges presented by overlapping symptomatology between ASD and other disorders and the need to determine whether a diagnosis of ASD or another diagnosis best explains the individual's symptoms. We conclude with a call to action for the next steps necessary for meeting the diagnostic challenges presented here to improve the diagnostic process and to help understand each individual's particular ASD profile.

Short communication: Self-reported sleep-wake disturbances preceding onset of full-threshold mood and/or psychotic syndromes in community residing adolescents and young adults

BACKGROUND

Insomnia may predict onset of mental disorders in adults. However, it is unclear whether the same directional relationship exists during the peak age range for the onset of major mental disorders and/or whether other types of sleep-wake disturbance, such as hypersomnia, show similar associations.

METHODS

Longitudinal follow-up of >1800 community residing twins and non-twin siblings (mean age ~26; 57% female). Adjusted relative risk ratios and 95% confidence intervals (Adj RR and 95% CI) were estimated for onset of depression, hypomania and psychosis in individuals with prior self-reported exposure to Insomnia and/or Hypersomnia or proxies for insomnia disorder (Insomnia and Daytime Impairment) and atypical symptom profile (Hypersomnia and Anergia).

RESULTS

Risk of onset differed somewhat according to type of syndrome and the nature of sleep-wake disturbance (e.g. Insomnia alone increased risk of first onset of psychosis). Overall, the risk for onset of any syndrome was best identified using composite measures (Adj RR were ~1.5-2.5) such as Insomnia and Hypersomnia, Insomnia and Daytime Impairment, or Hypersomnia and Anergia, rather than singular items describing night-time disruption only.

CONCLUSIONS

The magnitude of risk of onset of major mental health problems and the availability of effective, low-cost, individual and population-based interventions for sleep-wake disturbances, suggest that it is justifiable to introduce screening for and strategies to overcome sleep problems in youth.

DSM-5 Level 1 cross-cutting measure in an online sample: evaluating its latent dimensionality and utility detecting nonspecific psychological distress

Included in the most recent Diagnostic and Statistical Manual of Mental Disorders is the Level 1 Cross-Cutting Symptom Measure (CCSM), a self-report checklist with 23 items assessing 13 major psychiatric symptom clusters. To date, minimal literature has examined the factor structure of the CCSM and its utility identifying significant psychological distress, and existing studies pose notable limitations. Four hundred (400) American adults (M age = 34.13; 50.2% female) participated online via Amazon Mechanical Turk as part of a larger study, which included the CCSM. The sample was randomly split to conduct exploratory and confirmatory factor analyses (EFAs and CFAs). EFAs revealed structures with one (general psychopathology) and two (externalizing/serious mental illness and internalizing/affective) factors accounting for 67.3% and 73.7% of the variance, respectively. CFAs indicated good fit for both models, though statistical comparison of the models via χ² difference test revealed the two-factor model provided significantly better fit. Areas under the receiver operating curve (AUCs) suggested that all CCSM variables of interest poorly differentiated those currently receiving mental health treatment from those who have never received mental health treatment (AUCs ranged from .57 to .68). Implications of these findings, various limitations, and recommendations for future lines of inquiry were discussed.

The role of distress and fear transdiagnostic dimensions in emotion regulation choice

BACKGROUND

Most research in the area of psychopathology and emotion regulation has focused on specific disorder categories and maladaptive strategy implementation. This study aimed to extend previous research by examining emotion regulation choice in higher-order dimensions (i.e., the distress and fear transdiagnostic dimensions) predisposing individuals toward commonly co-occurring internalizing syndromes.

METHODS

The sample consisted of 127 college students with varying levels of distress and fear proneness. They were randomly assigned to a short- or long-term goal condition and were asked to select between two strategies, distraction and reappraisal, in response to pictures of differing emotional intensity. The moderating effects of distress and fear dimensions were explored to assess whether they interact with emotional intensity and goal proximity to influence strategy selection.

RESULTS

Fear proneness was positively, and distress proneness was negatively, associated with the odds of choosing distraction. Fear proneness was a significant moderator in our analysis, suggesting that increased fear magnifies the effect of emotional intensity on choosing distraction as a regulatory strategy.

LIMITATIONS

Although an effort was made to select individuals from the full range of the internalizing spectrum, this was a college student sample and thus results should be replicated in clinical samples. Additionally, the response rate in this study was low.

CONCLUSION

These findings expand our understanding of emotion regulation choice in internalizing psychopathology by identifying common tendencies of individuals who share dispositions toward fear and distress.

The Structure of Psychopathology in a Sample of Clinically Referred, Emotionally Dysregulated Early Adolescents

This investigation answers and amplifies calls to model the transdiagnostic structure of psychopathology in clinical samples of early adolescents and using stringent psychometric criteria. In 162 clinically referred, clinically evaluated 11-13-year-olds, we compared a correlated two-factor model, containing latent internalizing and externalizing factors, to a bifactor model, which added a transdiagnostic general factor. We also evaluated the bifactor model psychometrically, including criterion validity with broad indicators of psychosocial functioning. In doing so, we compared alternative approaches to defining and interpreting criterion validity: a recently proposed incremental definition based on amounts of variance in criterion factors explained, and the more typical definition based on the presence of conceptually meaningful relationships. While traditional fit statistics favored the bifactor model as expected, psychometric analyses added important nuance. Despite moderate reliability, the general factor was not fully transdiagnostic (i.e., was not informed by several externalizing scores), and was partially redundant with internalizing scores. Approaches to criterion validity yielded opposing results. Compared to the correlated two-factor model, the bifactor model redistributed, without incrementally increasing, the total variance explained in criterion indicators of psychosocial functioning. Yet, the bifactor model did improve the precision of clinically important relationships to psychosocial functioning, raising questions about meaningful tests of bifactor psychopathology models.

Development of the Macquarie Anxiety Behavioural Scale (MABS): A parent measure to assess anxiety in children and adolescents including young people with autism spectrum disorder

OBJECTIVE

This study examined measurement variance for Autism Spectrum Disorder (ASD) in the Spence Children's Anxiety Scale - Parent Form (SCAS-P; Spence, 1999). In addition, we developed and evaluated a new parent report measure for anxiety (Macquarie Anxiety Behavioural Scale; MABS).

METHOD

The sample consisted of 734 parents of children aged 3-19 years (i) who were seeking help for their child's anxiety, (ii) who had received a diagnosis of ASD, or (iii) from the community.

RESULTS

Evidence for measurement variance of the SCAS-P and MABS was found, revealing different factor structures between the ASD and non-ASD groups. MIMIC modelling showed that the scales performed significantly different across ASD and non-ASD groups. Differential item functioning on a number of the SCAS-P and MABS items was also found.

LIMITATIONS

This study relied on parent report of symptoms and of community acquired diagnoses of ASD.

CONCLUSION

The MABS is a new parent measure to assess anxiety in children and adolescents and the proposed factor structure produced a reasonably good fit for the data. Similar to the SCAS-P, ASD was found to impact on some of the MABS items indicating that ASD influences parental responding. Eighteen MABS items showed measurement invariance across the anxious and ASD groups and can be considered suitable items for the assessment of anxiety in ASD.

A trait-like propensity to experience internalizing symptoms is associated with problem alcohol involvement across adulthood, but not adolescence

There are stable between-person differences in an internalizing "trait," or the propensity to experience symptoms of internalizing disorders, such as social anxiety, generalized anxiety disorder, and depression. Trait internalizing may serve as a marker of heightened risk for problem alcohol outcomes (such as heavier drinking, binge drinking, or alcohol dependence). However, prior research on the association between internalizing symptoms and alcohol outcomes has been largely mixed in adolescence, with more consistent support for an association during adulthood. It may be that trait internalizing is only associated with problem alcohol outcomes in adulthood, after individuals have gained experience with alcohol. Some evidence suggested that these effects may be stronger for women than men. We used data from a community sample (n = 790) interviewed during adolescence (ages 14-16) and again at ages 21, 24, 27, 30, 33, and 39. Using generalized estimating equations, we tested the association between trait internalizing and alcohol outcomes during both adolescence and adulthood, and tested whether adult trait internalizing mediated the association between adolescent trait internalizing and adult alcohol outcomes. Trait internalizing in adulthood (but not adolescence) was associated with more frequent alcohol use, binge drinking and symptoms of alcohol use disorders, and mediated the effects of adolescent trait internalizing on alcohol outcomes. We observed no moderation by gender or change in these associations over time. Understanding the developmental pathways of trait internalizing may provide further insights into preventing the emergence of problem alcohol use behavior during adulthood. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

A bibliometric analysis of multimorbidity from 2005 to 2019

Context:

Multimorbidity is frequently seen in primary care. We aimed to identify and analyze publications on multimorbidity, including those that most influenced this field.

Method:

A bibliometric analysis of publications from 2005 to 2019 in the PubMed database containing “multimorbidity” or “multi-morbidity” identified with the tool iCite. We analyzed the number of publications, total citations, the article-level metric Relative Citation Ratio (RCR), type of study, and journals with the most cited articles.

Results:

The number of publications using “multimorbidity” has continuously increased since 2005 (2005–2009: 138; 2010–2014: 823; 2015–2019: 3068). The median number of total citations per article was 3. The median RCR was 1.04. Articles with RCR at or above the 97th percentile (RCR = 7.43) were analyzed in detail (n = 104). In 34 publications of this subgroup (33%), the word multimorbidity was used but was not the subject of study. The remaining top 70 publications included 32 observational studies, 22 reviews, five guideline statements, three analysis papers, two randomized trials, three qualitative studies, two measurement development reports, and one conceptual framework development report. The publications were produced by authors from 32 countries. They were published in 37 different journals, ranging from one to four articles in the same journal.

Conclusions:

We found a continuous increase in the number of publications about multimorbidity since 2005. However, our study suggests that the numbers should be considered only a general trend because multimorbidity was not the main subject in 33% of publications in a subgroup of 104 analyzed in detail.

Finding specificity in structural brain alterations through Bayesian reverse inference

In the field of neuroimaging reverse inferences can lead us to suppose the involvement of cognitive processes from certain patterns of brain activity. However, the same reasoning holds if we substitute "brain activity" with "brain alteration" and "cognitive process" with "brain disorder." The fact that different brain disorders exhibit a high degree of overlap in their patterns of structural alterations makes forward inference-based analyses less suitable for identifying brain areas whose alteration is specific to a certain pathology. In the forward inference-based analyses, in fact, it is impossible to distinguish between areas that are altered by the majority of brain disorders and areas that are specifically affected by certain diseases. To address this issue and allow the identification of highly pathology-specific altered areas we used the Bayes' factor technique, which was employed, as a proof of concept, on voxel-based morphometry data of schizophrenia and Alzheimer's disease. This technique allows to calculate the ratio between the likelihoods of two alternative hypotheses (in our case, that the alteration of the voxel is specific for the brain disorder under scrutiny or that the alteration is not specific). We then performed temporal simulations of the alterations' spread associated with different pathologies. The Bayes' factor values calculated on these simulated data were able to reveal that the areas, which are more specific to a certain disease, are also the ones to be early altered. This study puts forward a new analytical instrument capable of innovating the methodological approach to the investigation of brain pathology.

Sexual orientation concealment and mental health: A conceptual and meta-analytic review

Identity concealment affects all sexual minority individuals, with potentially complex mental health implications. Concealing a sexual minority identity can simultaneously generate the stress of hiding, protect against the stress of discrimination, and keep one apart from sexual minority communities and their norms and supports. Not surprisingly, existing studies of the association between sexual orientation concealment and mental health problems show contradictory associations-from positive to negative to null. This meta-analysis attempts to resolve these contradictions. Across 193 studies (n = 92,236) we find a small positive association between sexual orientation concealment and internalizing mental health problems (i.e., depression, anxiety, distress, problematic eating; ESr = 0.126; 95% CI [0.102, 0.151]) and a small negative association between concealment and substance use problems (ESr = -0.061; 95% CI [-0.096, -0.026]). The association between concealment and internalizing mental health problems was larger for those studies that assessed concealment as lack of open behavior, those conducted recently, and those with younger samples; it was smaller in exclusively bisexual samples. Year of data collection, study location, and sample gender, education, and racial/ethnic composition did not explain between-study heterogeneity. Results extend existing theories of stigma and sexual minority mental health, suggesting potentially distinct stress processes for internalizing problems versus substance use problems, life course fluctuations in the experience of concealment, distinct experiences of concealment for bisexual individuals, and measurement recommendations for future studies. Small overall effects, heavy reliance on cross-sectional designs, relatively few effects for substance use problems, and the necessarily coarse classification of effect moderators in this meta-analysis suggest future needed methodological advances to further understand the mental health of this still-increasingly visible population. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Genetic and environmental contributions to psychopathological symptoms in adulthood: Clarifying the role of individual and parental risk factors

Psychopathology-related suicide attempts and deaths are increasing, and the research focus remains on mental disorder in childhood and adolescence. We examined the genetic and environmental contributions to internalizing, externalizing, and general psychopathological distress to clarify the role of individual/parental risk factors for suicide in young adults. Data from 1206 young adults were obtained from a publicly available dataset from the Human Connectome Project. Heritability estimates were analyzed by twin modelling using OpenMx and data from a subsample of 402 monozygotic and dizygotic twins. The estimated prevalence of psychopathological symptoms ranged from 9 to 16%. The heritability of internalizing, externalizing, and general psychopathological distress reached significance, with estimates ranging from 22 to 46%. Shared (common) environments contributed to aggressive behavior (30 %). Determining factors for psychopathological distress (internalizing, externalizing, general) were evaluated using logistic regression analysis. Household income (<$50,000), childhood conduct problems, and maternal drug or alcohol problems were common risk factors of internalizing, externalizing, and general psychopathological distress. Marijuana dependence and maternal anxiety were additional risk factors of externalizing distress. The presence of alcohol and maternal drug or alcohol problems was linked to general psychopathological distress. The results highlight risk factors associated with psychopathological symptoms that should be considered in the early detection of high-risk groups and implementation of family-based interventions. Providing continuous care and/or follow-up in at-risk children and young adults may improve mental health and well-being.

Traumatic Events in Dual Disorders: Prevalence and Clinical Characteristics

Psychological trauma has been identified in substance use disorders (SUD) as a major etiological risk factor. However, detailed and systematic data about the prevalence and types of psychological trauma in dual disorders have been scarce to date. In this study, 150 inpatients were recruited and cross-sectionally screened on their substance use severity, psychological trauma symptoms, comorbidities, and clinical severity. One hundred patients fulfilled criteria for a dual disorder, while 50 patients were diagnosed with only SUD. Ninety-four percent of the whole sample suffered from at least one lifetime traumatic event. The prevalence rates of Posttraumatic Stress Disorder diagnosis for dual disorder and only SUD was around 20% in both groups; however, patients with dual disorder presented more adverse events, more childhood trauma, more dissociative symptoms, and a more severe clinical profile than patients with only SUD. Childhood maltreatment can also serve as a predictor for developing a dual disorder diagnosis and as a risk factor for developing a more complex and severe clinical profile. These data challenge our current clinical practice in the treatment of patients suffering from dual disorder or only SUD diagnosis and favor the incorporation of an additional trauma-focused therapy in this population. This may improve the prognosis and the course of the illness in these patients.

The relationship between maladaptive personality functioning and problematic technology use in adolescence: A cluster analysis approach

In the last two decades, scientific research has explored the problematic use of internet, videogames and mobile phones. However, there is still little consistent knowledge regarding the co-occurrence of problematic technology use and the role of maladaptive personality characteristics in adolescence. The present study aimed to investigate adolescents' styles of technology use with a cluster analysis approach focusing on personality functioning. The sample comprised 408 Italian adolescents (46.3% males) aged 11 to 18 years (M _age  = 13.80; SD = 2.08). Data were collected using the Internet Addiction Test, the Videogame Dependency Scale, the Test of Mobile-Phone Dependence Brief Form and the Personality Inventory for DSM5 Brief Form. Results provided a four-cluster solution based on the co-occurrence of problematic technology use. The four clusters were labeled as follows: cluster 1: "Above average internet and mobile-phone use"; cluster 2: "Below average technology use"; cluster 3: "Above average videogame use"; and cluster 4: "Problematic technology use." Analyses on demographic variables (e.g., gender and age) demonstrated significant differences between the four groups. Adolescents with high levels of problematic technology use reported greater overall personality dysfunction than the other three groups. This finding supported our hypothesis on maladaptive personality functioning in adolescents at risk for addiction. Finally, the Antagonism domain played a specific role in differentiating the severity of adolescents' involvement in technology use. Further studies are needed to confirm our findings and to plan preventive interventions as well as therapeutic treatments.

Steps Towards a Unified Theory of Psychopathology: The Phase Space of Meaning Model

The hypothesis of a general psychopathology factor (p factor) has been advanced in recent years. It is an innovation with breakthrough potential, in the perspective of a unified view of psychopathology; however, what remains a controversial topic is how its nature might be conceptualized. The current paper outlines a semiotic, embodied and psychoanalytic conceptualization of psychopathology - the Phase Space of Meaning (PSM) model - aimed at providing ontological grounds to the p factor hypothesis. Framed within a more general model of how the mind works, the PSM model maintains that the p factor can be conceived as the empirical marker of the degree of rigidity of the meaning-maker's way of interpreting experience, namely of the dimensions of meanings used to map the environment's variability. As to the clinical implications, two main aspects are outlined. First, according PSM model, psychopathology is not an invariant condition, and does not have a set dimensionality, but is able to vary it locally, in order to address the requirement of situated action. Second, psychopathology is conceived as one of the mind's modes of working, rather than the manifestation of its disruption. Finally, the puzzling issue of the interplay between stability and variability in the evolutionary trajectories of patients along with their life events is addressed and discussed.

Testing relationships between multimodal modes of brain structural variation and age, sex and polygenic scores for neuroticism in children and adolescents

Human brain development involves spatially and temporally heterogeneous changes, detectable across a wide range of magnetic resonance imaging (MRI) measures. Investigating the interplay between multimodal MRI and polygenic scores (PGS) for personality traits associated with mental disorders in youth may provide new knowledge about typical and atypical neurodevelopment. We derived independent components across cortical thickness, cortical surface area, and grey/white matter contrast (GWC) (n = 2596, 3-23 years), and tested for associations between these components and age, sex and-, in a subsample (n = 878), PGS for neuroticism. Age was negatively associated with a single-modality component reflecting higher global GWC, and additionally with components capturing common variance between global thickness and GWC, and several multimodal regional patterns. Sex differences were found for components primarily capturing global and regional surface area (boys > girls), but also regional cortical thickness. For PGS for neuroticism, we found weak and bidirectional associations with a component reflecting right prefrontal surface area. These results indicate that multimodal fusion is sensitive to age and sex differences in brain structure in youth, but only weakly to polygenic load for neuroticism.

Using an adoption design to test genetically based differences in risk for child behavior problems in response to home environmental influences

Differential susceptibility theory (DST) posits that individuals differ in their developmental plasticity: some children are highly responsive to both environmental adversity and support, while others are less affected. According to this theory, "plasticity" genes that confer risk for psychopathology in adverse environments may promote superior functioning in supportive environments. We tested DST using a broad measure of child genetic liability (based on birth parent psychopathology), adoptive home environmental variables (e.g., marital warmth, parenting stress, and internalizing symptoms), and measures of child externalizing problems (n = 337) and social competence (n = 330) in 54-month-old adopted children from the Early Growth and Development Study. This adoption design is useful for examining DST because children are placed at birth or shortly thereafter with nongenetically related adoptive parents, naturally disentangling heritable and postnatal environmental effects. We conducted a series of multivariable regression analyses that included Gene × Environment interaction terms and found little evidence of DST; rather, interactions varied depending on the environmental factor of interest, in both significance and shape. Our mixed findings suggest further investigation of DST is warranted before tailoring screening and intervention recommendations to children based on their genetic liability or "sensitivity."

Appropriate Use of Bifactor Analysis in Psychopathology Research: Appreciating Benefits and Limitations

Co-occurrence of psychiatric disorders is well documented. Recent quantitative efforts have moved toward an understanding of this phenomenon, with the general psychopathology or p-factor model emerging as the most prominent characterization. Over the past decade, bifactor model analysis has become increasingly popular as a statistical approach to describe common/shared and unique elements in psychopathology. However, recent work has highlighted potential problems with common approaches to evaluating and interpreting bifactor models. Here, we argue that bifactor models, when properly applied and interpreted, can be useful for answering some important questions in psychology and psychiatry research. We review problems with evaluating bifactor models based on global model fit statistics. We then describe more valid approaches to evaluating bifactor models and highlight 3 types of research questions for which bifactor models are well suited to answer. We also discuss the utility and limits of bifactor applications in genetic and neurobiological research. We close by comparing advantages and disadvantages of bifactor models with other analytic approaches and note that no statistical model is a panacea to rectify limitations of the research design used to gather data.

Approaches to Defining Common and Dissociable Neurobiological Deficits Associated With Psychopathology in Youth

Psychiatric disorders show high rates of comorbidity and nonspecificity of presenting clinical symptoms, while demonstrating substantial heterogeneity within diagnostic categories. Notably, many of these psychiatric disorders first manifest in youth. We review progress and next steps in efforts to parse heterogeneity in psychiatric symptoms in youths by identifying abnormalities within neural circuits. To address this fundamental challenge in psychiatry, a number of methods have been proposed. We provide an overview of these methods, broadly organized into dimensional versus categorical approaches and single-view versus multiview approaches. Dimensional approaches including factor analysis and canonical correlation analysis aim to capture dimensional associations between psychopathology and brain measures across a continuous spectrum from health to disease. In contrast, categorical approaches, such as clustering and community detection, aim to identify subtypes of individuals within a class of symptoms or brain features. We highlight several studies that apply these methods to samples of youths and discuss issues to consider when using these approaches. Finally, we end by highlighting avenues for future research.

Associations between conduct problems in childhood and adverse outcomes in emerging adulthood: a longitudinal Swedish nationwide twin cohort

BACKGROUND

We examined whether childhood conduct problems predicted a wide range of adverse outcomes in emerging adulthood and whether the association with internalizing problems remained after adjusting for general comorbidity and externalizing problems.

METHODS

Participants were 18,649 twins from the Child and Adolescent Twin Study in Sweden. At age 9/12, parents rated their children on eight conduct problems. Adverse outcomes were retrieved from national registers in emerging adulthood (median follow-up time = 9.2 years), including diagnoses of six psychiatric disorders, prescriptions of antidepressants, suicide attempts, criminality, high school ineligibility, and social welfare recipiency. We estimated risk for the separate outcomes and examined if conduct problems predicted an internalizing factor above and beyond a general comorbidity and an externalizing factor. We used twin analyses to estimate genetic and environmental contributions to these associations.

RESULTS

On the average, each additional conduct symptom in childhood was associated with a 32% increased risk of the adverse outcomes in emerging adulthood (mean hazard ratio = 1.32; range = 1.16, 1.56). A latent childhood conduct problems factor predicted the internalizing factor in emerging adulthood (β_boys  = .24, standard error, SE = 0.03; β_girls  = .17, SE = 0.03), above and beyond its association with the externalizing (β_boys  = 0.21, SE = 0.04; β_girls  = 0.17, SE = 0.05) and general factors (β_boys  = 0.45, SE = 0.03; β_girls  = 0.34, SE = 0.04). These associations were differentially influenced by genetic and environmental factors.

CONCLUSIONS

It is important to monitor boys and girls with conduct problems not only for future externalizing problems, but also for future internalizing problems. Prevention of specific outcomes, however, might require interventions at different levels.

Causes and Consequences of Diagnostic Heterogeneity in Depression: Paths to Discovering Novel Biological Depression Subtypes

Depression is a highly heterogeneous syndrome that bears only modest correlations with its biological substrates, motivating a renewed interest in rethinking our approach to diagnosing depression for research purposes and new efforts to discover subtypes of depression anchored in biology. Here, we review the major causes of diagnostic heterogeneity in depression, with consideration of both clinical symptoms and behaviors (symptomatology and trajectory of depressive episodes) and biology (genetics and sexually dimorphic factors). Next, we discuss the promise of using data-driven strategies to discover novel subtypes of depression based on functional neuroimaging measures, including dimensional, categorical, and hybrid approaches to parsing diagnostic heterogeneity and understanding its biological basis. The merits of using resting-state functional magnetic resonance imaging functional connectivity techniques for subtyping are considered along with a set of technical challenges and potential solutions. We conclude by identifying promising future directions for defining neurobiologically informed depression subtypes and leveraging them in the future for predicting treatment outcomes and informing clinical decision making.

An empirically derived recommendation for the classification of body dysmorphic disorder: Findings from structural equation modeling

Body dysmorphic disorder (BDD), together with its subtype muscle dysmorphia (MD), has been relocated from the Somatoform Disorders category in the DSM-IV to the newly created Obsessive-Compulsive and Related Disorders category in the DSM-5. Both categorizations have been criticized, and an empirically derived classification of BDD is lacking. A community sample of N = 736 participants completed an online survey assessing different psychopathologies. Using a structural equation modeling approach, six theoretically derived models, which differed in their allocation of BDD symptoms to various factors (i.e. general psychopathology, somatoform, obsessive-compulsive and related disorders, affective, body image, and BDD model) were tested in the full sample and in a restricted sample (n = 465) which indicated primary concerns other than shape and weight. Furthermore, measurement invariance across gender was examined. Of the six models, only the body image model showed a good fit (CFI = 0.972, RMSEA = 0.049, SRMR = 0.027, TLI = 0.959), and yielded better AIC and BIC indices than the competing models. Analyses in the restricted sample replicated these findings. Analyses of measurement invariance of the body image model showed partial metric invariance across gender. The findings suggest that a body image model provides the best fit for the classification of BDD and MD. This is in line with previous studies showing strong similarities between eating disorders and BDD, including MD. Measurement invariance across gender indicates a comparable presentation and comorbid structure of BDD in males and females, which also corresponds to the equal prevalence rates of BDD across gender.

Couple-Level Stress Proliferation and Husbands' and Wives' Distress During the Life Course

OBJECTIVE

The present study investigated the factorial structure of the dyadic stress proliferation process in couples in enduring marriages leading to their psychological distress in later years.

BACKGROUND

Stress proliferation during short and long periods of time has been shown to drive complex stress-distress processes during the life course. This research has largely been limited to individual-level stress proliferation with less research demonstrating stress proliferation in the context of enduring relationships.

METHODS

Using data from 224 dual-earner couples in long-term marriages, the present study examined the aggregation of individual stress (as defined by role-related stress experiences including provider, work, spousal, and parental roles) into couple-level stress constructs. These couple-level stress constructs were examined as predictors of husbands' and wives' psychological distress over 27 years (1991-2017) independent of individual-level stress.

RESULTS

Couple-level socioeconomic and relationship stress was highly stable over time, suggesting that stress within a domain proliferates across the life course. Individual-level psychological distress was significantly associated with couple-level stress constructs at midlife and in later life after controlling for previous distress.

CONCLUSION

Evidence suggests that husbands' and wives' psychological distress is significantly affected by couple-level stress processes. Findings have implications for intervention and prevention programs focusing on the well-being of married couples in later life.

The erring brain: Error-related negativity as an endophenotype for OCD-A review and meta-analysis

Obsessive-compulsive disorder (OCD) is a complex and heterogeneous disorder that is associated with high personal and societal costs. Feelings of doubt, worry, and repetitive behavior, key symptoms of OCD, have been linked to hyperactive error signals in the brain. The error-related negativity (ERN) represents a validated marker of error processing in the ERP. Increased ERN amplitudes in OCD have been reported very robustly over the last 20 years. This article integrates results from 38 studies analyzing the ERN in OCD, using a quantitative meta-analysis. Meta-regressions were used to examine potential moderators such as task type, symptom severity, age, and sample size. The meta-analysis reveals a robust increase of ERN in OCD patients compared to healthy participants in response-conflict tasks (SMD -0.55) that is not modulated by symptom severity and age. No increase in ERN in OCD was observed in tasks that do not induce response conflict (SMD -0.10). In addition to the meta-analysis, the current article reviews evidence supporting that increased ERN amplitudes in OCD fulfill central criteria for an endophenotype. Further, the specificity of increased ERN amplitudes for OCD and its suitability as a potential transdiagnostic endophenotype is discussed. Finally, the clinical utility and clinical applications are examined. Overall, the evidence that increased ERN amplitudes represent a promising endophenotype indicating vulnerability for OCD is compelling. Furthermore, alterations in ERN are not limited to OCD and may constitute a transdiagnostic endophenotype. Altered neural error signals might serve as a diagnostic or predictive marker and represent a promising target for interventions.

Psychometric Properties of the Externalizing Spectrum Inventory: Replication and Extension across Clinical and Non-Clinical Samples

The Externalizing Spectrum Inventory aims at assessing personality features that underlie externalizing disorders such as substance abuse and antisocial behaviors. The objective was to replicate the psychometric properties of the 160-item Externalizing Spectrum Inventory in Dutch clinical and non-clinical samples. First, Cronbach's alpha, test-retest reliability and the factor structure were analyzed on a mixed sample of inpatients (n = 149), undergraduates (n = 227), and community participants (n = 178). The factor structure was evaluated through confirmatory and exploratory factor analyses; for the latter Parallel Analysis was used, based on Minimum Rank Factor Analysis. Next, the criterion validity was analyzed using the Aggression Questionnaire and the NEO-Five Factor Inventory as external measures. The Dutch Externalizing Spectrum Inventory subscales showed sufficient reliability (α=.68-.94; ICC=.68-.91), except in the undergraduate sample (α=.49-.96; ICC=.43-.97). The factor structure of the Externalizing Spectrum Inventory was not confirmed and the exploratory analysis yielded different factor solutions across samples. The criterion validity was supported with regard to trait aggression and partly supported with regard to the Five Factor Model. The results suggest that the ESI-160 and its original factor model can be used for prediction purposes. However, further research of the factor structure is strongly recommended.