Cognitive Behaviour Therapy, 2015

Vol. 44, No. 5, 389–405, http://dx.doi.org/10.1080/16506073.2015.1017529

Beyond Negative Affectivity: A Hierarchical Model

of Global and Transdiagnostic Vulnerabilities
for Emotional Disorders

Daniel J. Paulus1, Alexander M. Talkovsky1, Luke F. Heggeness1

and Peter J. Norton2
1
University of Houston, Houston, TX, USA; 2School of Psychological Sciences, Monash
University, Melbourne, Australia
Abstract. Background: Negative affectivity (NA) has been linked to anxiety and depression (DEP).
Identifying the common factors between anxiety and DEP is important when explaining their
overlap and comorbidity. However, general factors such as NA tend to have differential relationships
with different disorders, suggesting the need to identify mediators in order to explicate these
relationships. Methods: The current study tests a theoretically and empirically derived hierarchical
model of emotional disorders including both a general factor (NA) and transdiagnostic risk factors
[anxiety sensitivity (AS) and intolerance of uncertainty (IoU)] using structural equation modeling. AS
was tested as a mid-level factor between NA and panic disorder/agoraphobia, while IoU was tested as
a mid-level factor between NA and social phobia, generalized anxiety disorder, obsessive-compulsive
disorder, and DEP. Data from 642 clinical outpatients with a heterogeneous presentation of
emotional disorders were available for analysis. Results: The hierarchical model fits the data
adequately. Moreover, while a simplified model removing AS and IoU fits the data well, it resulted in
a significant loss of information for all latent disorder constructs. Limitations: Data were unavailable
to estimate post-traumatic stress disorder or specific phobias. Future work will need to extend to
other emotional disorders. Conclusions: This study demonstrates the importance of both general
factors that link disorders together and semi-specific transdiagnostic factors partially explaining their
heterogeneity. Including these mid-level factors in hierarchical models of psychopathology can
help account for additional variance and help to clarify the relationship between disorder constructs
and NA. Key words: anxiety; depression; negative affectivity; anxiety sensitivity; intolerance of
uncertainty; transdiagnostic.

Received 13 November 2014; Accepted 6 February 2015

Correspondence address: Daniel J. Paulus, MA, Department of Psychology, University of Houston,

Houston, TX 77024, USA. Tel: 713-743-8056. Fax: 713-743-8588. Email: djpaulus@uh.edu

Introduction of depressive disorders, and bipolar and

The trend in psychological nosology has been
to refine the description of psychological
disorders by adding more conditions and
specifiers. For example, in the DSM-5,
agoraphobia and panic disorder are con-
sidered distinct disorders. In addition, obses-
sive-compulsive disorder (OCD) and post-
traumatic stress disorder (PTSD) have been
removed from the anxiety disorder class and
placed into their own respective, though
related, disorder classes. A similar change
has occurred within the mood disorders,
which have been divided into separate classes
related disorders. Despite these refinements
in formal classification, a growing body of
evidence supports clustering emotional dis-
orders (anxiety and DEP) together (Barlow,
Allen, & Choate, 2004). The current paper
briefly reviews this evidence and evaluates the
fit of a hierarchical model of emotional
disorders (previously developed from an
undergrad sample) using a large clinical
sample.
Emotional disorders are highly comorbid
with one another (Brown, Campbell, Lehman,
Grisham, & Mancill, 2001) with significant
diagnostic overlaps among the specific

q 2015 Swedish Association for Behaviour Therapy

390 Paulus, Talkovsky, Heggeness and Norton
disorders (Brown & Barlow, 1992), at times
making distinctions between them difficult.
Perhaps, then, there is a more parsimonious
structure to psychological disorders (e.g.,
Caspi et al., 2014). Caspi et al. (2014) created
a hierarchical model of disorders linking
symptoms to an underlying psychopathology
factor ( p). Notably, their model identified a
sub-factor of p, which they called internalizing
disorders (DEP, generalized anxiety, fears/
phobias, and OCD1), supporting a clustering
approach. This organization structure is well
supported by previous research, as a number
of models have provided justification for the
grouping of anxiety and unipolar DEP
together (e.g., Brown, Chorpita, & Barlow,
1998; Krueger, 1999; Krueger, Caspi, Moffitt,
& Silva, 1998; Krueger & Finger, 2001; Slade
& Watson, 2006; Vollebergh et al., 2001;
Watson, 2005; Watson, O’Hara, & Stuart,
2008; Wright et al., 2013).
Given the overlap among the disorders, it is
not surprising that cognitive behavioral
therapies (CBTs) are effective for each of
the anxiety disorders as well as DEP
(Cuijpers et al., 2013; Norton & Price, 2007;
Olatunji, Cisler, & Deacon, 2010). Indeed,
the therapeutic ingredients (e.g., cognitive
restructuring and exposure) of these diag-
nosis-specific CBT protocols tend to be quite
similar (Barlow & Lehman, 1996). In line
with this idea, a number of transdiagnostic
treatments have been implemented across
emotional disorders, with promising results
(for review, see Reinholt & Krogh, 2014).
Encouragingly, initial evidence suggests that
transdiagnostic treatments may be able to
better ameliorate comorbid anxiety and DEP
symptoms (Norton et al., 2013), relative to
diagnosis-specific treatments, perhaps by
targeting of underlying common features of
emotional disorders, such as negative affec-
tivity (NA; Barlow et al., 2004).
By identifying and treating common factors,
it may be possible to treat a range of
difficulties, rather than specific symptom
clusters (e.g., McManus, Shafran, & Cooper,
2010).
A wide body of work has supported the
view that NA is a common factor linking the
emotional disorders (e.g., Brown et al., 1998;
Clark & Watson, 1991; Kotov, Gamez,
Schmidt, & Watson, 2010; Watson, Clark, &
Carey, 1988). NA has been conceptualized as a
COGNITIVE BEHAVIOUR THERAPY
higher order trait variable that is associated
with negative emotional states (Keogh &
Reidy, 2000). As a trait, NA is considered a
broad predisposition to experience negative
emotions such as anxiety, fear, and sadness
(Watson et al., 1988). Clark and Watson
(1991) viewed NA as an etiological factor
partially explaining the overlap of anxiety and
DEP.
Common factors, such as NA, explain only
a portion of the overlap between anxiety and
DEP (Simms, Grös, Watson, & O’Hara,
2008). Barlow (2004) triple vulnerability
model of emotional disorders specifies the
importance of general genetic, general psycho-
logical (e.g., NA), and disorder-specific, or
semi-specific (Taylor, 1998), factors in the
development of psychopathology. Models
explaining the comorbidity of different con-
ditions and demonstrating links to common
factors (e.g., NA) often fail to account for the
heterogeneity that occurs within emotional
disorders. Furthermore, NA is differentially
related to specific diagnostic subgroups of
emotional disorders (Kotov et al., 2010).
There is a need to investigate factors that
mediate the relationship between NA and the
specific manifestations of emotional disorders
(e.g., Taylor, 1998), as well as to evaluate the
relative contributions of general (NA) and
disorder-specific factors for the emotional
disorders (e.g., Watson, Clark, & Stasik,
2011).
In addition to higher order factors that link
various conditions together, such as NA,
additional factors that explain the divergence
and phenotypic differences of the disorders are
important in understanding the complexity of
psychopathology. Previous models of
emotional disorders have investigated the
relationships of two such specific factors:
anxiety sensitivity (AS) and intolerance of
uncertainty (IoU) in addition to NA (Norton
& Mehta, 2007; Norton, Sexton, Walker, &
Norton, 2005; Sexton, Norton, Walker, &
Norton, 2003). While meta-analytic evidence
suggests that cognitive vulnerabilities such as
AS and IoU share a common etiology and
operate transdiagnostically, heterogeneity in
the effect sizes between AS and IoU was
present (Hong & Cheung, 2014), suggesting
that this pair of vulnerabilities could
help differentiate sub-factors of emotional
disorders.
VOL 44, NO 5, 2015
AS is conceptualized as a fear of anxiety
sensations and is considered a key risk factor
for panic attacks and panic disorder
(McNally, 2002), although it is important to
note that AS is also elevated in emotional
disorders other than panic (Naragon-Gainey,
2010). However, meta-analytic evidence
suggests that AS is more strongly associated
with panic and PTSD, relative to other anxiety
disorders (Olatunji & Wolitzky-Taylor, 2009).
AS is also distinguishable from trait anxiety
though it is relatively stable over time and can
be considered a trait (Taylor, 2014). IoU is a
cognitive bias affecting how individuals
interpret and respond to uncertainty (Dugas,
Schwartz, & Francis, 2004). While IoU has
been considered a distinct etiological factor of
generalized anxiety disorder (GAD; Dugas,
Buhr, & Ladouceur, 2004), others have
proposed it as a transdiagnostic risk factor
across emotional disorders (Carleton et al.,
2012; Gentes & Ruscio, 2011) with studies
demonstrating links between IoU and OCD
(Tolin, Abramowitz, Brigidi, & Foa, 2003),
DEP (Yook, Kim, Suh, & Lee, 2010) and
social anxiety disorder (SOC; Carleton,
Collimore, & Asmundson, 2010).
There is valuable information that can be
obtained through a hierarchical conceptualiz-
ation of disorders, as it is useful to investigate
higher order factors that link disorders
together, as well as specific factors explaining
phenotypic heterogeneity (Watson et al.,
2011). Using an undergraduate sample, Sex-
ton et al. (2003) developed a hierarchical path
model of anxiety using NA as a higher order
factor and AS and IoU as second-order
factors. This model was modified to include
DEP and validated on a clinical sample
(Norton et al., 2005). Norton and Mehta
(2007) refined the model to include SOC and
used structural equation modeling to evaluate
model fit on an undergraduate sample. Over-
all, the models demonstrated the strong
relationship of NA on both AS and IoU as
well as the unique contributions that AS and
IoU have toward the different emotional
disorders. Specifically, Norton and Mehta
(2007) observed a significant direct
relationship of NA on AS and IoU and on
indices of panic, social anxiety, worry, obses-
sions/compulsions, and DEP. Furthermore,
AS mediated the relationship of NA and panic
symptoms while IoU mediated the
Beyond Negative Affectivity 391
relationship between NA and social anxiety,
generalized anxiety, and obsessions/compul-
sions, demonstrating the differentiating ability
of these risk factors.
While Sexton et al. (2003) model was
replicated on a clinical sample (Norton et al.,
2005), analyses in both studies used simple
regression-based path analyses. In addition,
neither model estimated a path for SOC—
one of the most prevalent emotional dis-
orders (Brown et al., 2001). Norton and
Mehta (2007) replicated the models and
included SOC (using structural equation
modeling); however, they did so with a non-
clinical sample, requiring replication in a
clinical population with a diverse range of
emotional disorders. Furthermore, all three
of these previous studies used only self-
report data. This study aimed to validate the
model of Norton and Mehta (2007) on a
large clinically diagnosed sample using
structural equation modeling to form a
hierarchical structure of five emotional
disorders: panic disorder with/without agor-
aphobia (PDA), SOC, GAD, OCD, and DEP
including both clinician-rated and patient
self-report information. NA was used as a
higher order factor, AS was included as a
mid-level factor with a link to PDA, and IoU
was a second mid-level factor with links to
SOC, GAD, OCD, and DEP2 (Figure 1).
An alternative hierarchical model was also
run, including a link from AS to SOC. While
this link was not significant in the Norton
and Mehta (2007) model, SOC was not
estimated in prior models by this research
group (Norton et al., 2005; Sexton et al.,
2003) and, given the wealth of evidence
implicating AS as a transdiagnostic risk
factor in emotional disorders including SOC
(Naragon-Gainey, 2010; Olatunji &
Wolitzky-Taylor, 2009), it was important to
test this relationship. This study also
included clinician-rated indicators from a
semi-structured diagnostic interview, allow-
ing multiple methods of measurement.
This study had two hypotheses. First, it was
expected that the hierarchical model would fit
the data well. Second, consistent with the
extant literature, it was expected that a one-
factor model of NA would also fit the data,
though it would result in significantly reduced
proportion of variance explained in the latent
variables.
392 Paulus, Talkovsky, Heggeness and Norton
PANAS-NA
ASI-SOM
AS
ASI-COG
ASI-PUB
PDA SOC
PDSS ADIS-PHYS SPDQ ADIS-FEAR
BAI BFNE
Figure 1. Model based on Norton and Mehta (2007).
Method
Participants
Participants were 642 outpatient treatment
seekers (54% female) presenting to a univer-
sity-based anxiety clinic at a large south-
western university, recruited by newspaper
advertisements, referrals from health pro-
fessions, and a clinic website for various
treatment-research studies. All patients were
aged 18 or older (M ¼ 32.59; SD ¼ 10.85).
Approximately half (51.6%) of the sample
identified as Caucasian, 10.1% African Amer-
ican, 0.3% Native American, 5.9% Asian
American, 19.5% Hispanic/Latino, 5.3% as
multi-racial or “other”, and 7.3% did not
disclose racial/ethnic identity. Individuals
were eligible for the study if there was a
primary or clinically significant comorbid
emotional disorder diagnosis for which they
were seeking treatment. Assessors determined
COGNITIVE BEHAVIOUR THERAPY
NA
IUS-NEG
IoU
IUS-UNF
GAD OCD DEP
GADQ ADIS-GADS YBOCS PI-WSUR BDI-II ADIS-DYSS
PSWQ ADIS-PERS ADIS-MDES
ADIS-
ADIS-FREQ
WDOM
primary diagnoses as per Anxiety Disorders
Interview Schedule (ADIS-IV) guidelines (e.g.,
most severe, distressing, and/or impairing).
For cases where multiple disorders were
deemed equally severe (i.e., co-primary),
patients were asked to choose which they
would prefer to treat first. Exclusion criteria
were the presence of psychosis, dementia, or
other neurocognitive disorders. Diagnoses
were made by student clinicians using the
ADIS for DSM-IV (ADIS-IV; Brown, Di
Nardo, & Barlow, 1994) under the training
and supervision of a Ph.D. level clinical
psychologist. Training consisted of watching
blinded recordings of prior ADIS sessions and
matching all diagnoses and severity ratings on
two consecutive tapes. The breakdown of
primary diagnoses was as follows: 39.2%
SOC, 24.6% PDA, 17.0% GAD, 4.4% OCD,
4.5% unspecified anxiety disorder, 3.6%
VOL 44, NO 5, 2015
specific phobia, 3.1% DEP, 1.4% PTSD,
0.8% adjustment disorder with anxiety, 0.5%
health anxiety, 0.5% bipolar I/II, 0.2%
excoriation, 0.2% insomnia disorder (with
non-sleep disorder comorbidity), and 0.2%
substance-induced anxiety disorder. There
was considerable comorbidity in the sample,
with 61.8% meeting criteria for at least one
comorbid diagnosis. Across all comorbid
diagnoses: 34.3% were DEP, 21.2% GAD,
15.4% SOC, 8.3% PDA, 6.7% specific
phobia, 4.2% OCD, 4.1% substance/alcohol
use disorder, 2.3% PTSD, 1.7% health
anxiety, 1.6% bipolar I/II, 0.9% unspecified
anxiety disorder, 0.6% adjustment disorder
with anxiety, 0.3% excoriation, and 0.3%
trichotillomania. Participants filled out a
battery of self-report questionnaires.
Measures
Positive Affect Negative Affect Schedule
(PANAS). The PANAS (Watson, Clark, &
Tellegen, 1988) is a 20-item self-report
measure with 10-item subscales for positive
affect (PA) and NA. respectively. It was
written so that PA and NA would be
orthogonal. The psychometric properties of
the PANAS have been demonstrated to be
acceptable in samples of anxiety and DEP
(Watson et al., 1988). For this study, trait
rather than state instructions for the PANAS-
NA (a ¼ .82) were used to indicate the NA
construct.
Anxiety Sensitivity Index (ASI). The ASI
(Peterson & Reiss, 1992) is a self-report
measure designed to assess AS. The ASI has
demonstrated good psychometric properties
in samples of anxiety and DEP (Peterson &
Reiss, 1992). The ASI consists of 16 items
answered on a five-point scale. These items
make up three sub-scales of the ASI that were
used as indicators of the AS construct: somatic
concerns (ASI-SOM; a ¼ .87), cognitive con-
cerns (ASI-COG; a ¼ .82), and public con-
cerns (ASI-PUB a ¼ .59).
Intolerance of Uncertainty Scale (IUS). The
IUS (Freeston, Rhéaume, Letarte, Dugas, &
Ladouceur, 1994) consists of 27 self-report
items and was developed in order to measure
emotional, cognitive, and behavioral
responses to various situations/scenarios of
uncertainty. Items are rated on a five-point
Likert scale. The IUS can be split into two
subscales (Sexton & Dugas, 2009): beliefs that
Beyond Negative Affectivity 393
(1) “uncertainty has negative behavioral and
self-referent implications” (IUS-NEG;
a ¼ .93) and (2) “uncertainty is unfair and
spoils everything” (IUS-UNF; a ¼ .91).
Because of its strong psychometric properties
(Sexton & Dugas, 2009) the two subscales of
IUS were used as indicators of IoU.
Panic Disorder Severity Scale—self report
(PDSS). The PDSS (Houck, Spiegel, Shear,
& Rucci, 2002) consists of seven items
assessing severity of panic disorder and
agoraphobia, each rated on a 0 –4 Likert
scale. The PDSS (a ¼ .89) demonstrates
strong psychometric properties, comparable
to the clinician-rated PDSS (Houck et al.,
2002) and was used as an indicator of PDA.
Beck Anxiety Inventory (BAI). The BAI
(Beck, Epstein, Brown, & Steer, 1988) is a
21-item measure designed to measure anxiety
severity. Respondents rate how much they
have been bothered by each anxiety-provok-
ing symptom over the past week on four-point
scales. The BAI has shown excellent reliability
(Beck et al., 1988). While widely considered a
general or non-specific anxiety measure, the
BAI has exhibited stronger links to PDA, with
items cross-loading nearly perfectly with other
panic-specific measures (Norton, 2006); there-
fore, the BAI (a ¼ .93) was used as an
indicator of PDA.
Brief Fear of Negative Evaluation Scale
(BFNE). The BFNE (Leary, 1983) is a 12-
item measure of fear of negative evaluation,
which some call the most prominent charac-
teristic of social anxiety. Respondents rate the
extent to which each of the items applies to
them on a five-point Likert scale. The BFNE
has shown strong reliability and validity in
both clinical and non-clinical samples (Leary,
1983; Weeks et al., 2005). The BFNE (a ¼ .93)
was used as an indicator of SOC.
Social Phobia Diagnostic Questionnaire
(SPDQ). The SPDQ (Newman, Kachin,
Zuellig, Constantino, & Cashman-McGrath,
2003) was developed to measure social phobia
based on DSM-IV criteria with items match-
ing the style of ADIS-IV. The SPDQ has
strong psychometric properties and correlates
strongly with other measures of social anxiety
(Newman et al., 2003). The SPDQ (a ¼ .95)
was used as an indicator of SOC.
Generalized Anxiety Disorder Questionnaire-
IV (GADQ). The GADQ (Newman et al.,
2002) is a nine-item questionnaire used to
394 Paulus, Talkovsky, Heggeness and Norton
measure GAD based on the diagnostic criteria
set by the DSM-IV. The GAD-Q-IV demon-
strates good convergent and discriminant
validity and successfully differentiates
between individuals who meet criteria for
GAD from individuals with individuals meet-
ing criteria for other diagnoses (Newman
et al., 2002). The GADQ (a ¼ .80) was used as
an indicator of GAD.
Penn State Worry Questionnaire (PSWQ).
The PSWQ (Meyer, Miller, Metzger, &
Borkovec, 1990) is a 16-item instrument
used to measure worry—a key feature of
GAD. Respondents answer items using a
five-point scale. The PSWQ demonstrates
excellent convergent and discriminant val-
idity when correlated with other measures
anxiety and mood disorders, and has been
shown to identify and distinguish individ-
uals with GAD from anxiety disorders
and from non-anxious controls (Brown,
Antony, & Barlow, 1992). The PSWQ
(a ¼ .90) was used as an indicator of
GAD.
Yale – Brown Obsessive Compulsive Scale—
self-report (YBOCS). The YBOCS
(Goodman et al., 1989) is an extensively
used measure of OCD symptom severity.
The YBOCS has shown excellent reliability
and validity when formatted as both an
observer and self-reported measure (Ste-
ketee, Frost, & Bogart, 1996). The YBOCS
(a ¼ .91) was used as an indicator of
OCD.
Washington State University Revision of the
Padua Inventory (PI-WSUR). The PI-WSUR
(Burns, Keortge, Formea, & Sternberger,
1996) is a 39-item questionnaire used to screen
for OCD. Each item in the PI-WSUR is rated
on a five-point scale based on the level of
disturbance caused by the thought or action.
It has demonstrated satisfactory reliability
and validity (Burns et al., 1996). The PI-
WSUR (a ¼ .94) was used as an indicator of
OCD.
Beck Depression Inventory-II (BDI-II). The
BDI-II (Beck, Steer, & Brown, 1996) is a
widely used measure of depressive symptoms
based on the criteria found in the DSM-IV for
depressive disorders. The BDI-II consists of 21
items with four options to indicate severity.
The BDI-II has exhibited excellent reliability
and validity when used in both clinical and
non-clinical samples (Beck et al., 1996). The
COGNITIVE BEHAVIOUR THERAPY
BDI-II (a ¼ .91) was used as an indicator of
DEP.
ADIS. In addition to diagnoses and severity,
additional information from the ADIS
(Brown et al., 1994) was gathered and used
for various indicators of the latent con-
structs. Within this research group, inter-
rater diagnostic agreement has been found to
be high, with 86% agreement (k ¼ .759,
p , .001; Chamberlain & Norton, 2013)3.
The average of panic attack symptom
severity (ADIS-PHYS; a ¼ .84) was used as
an indicator of PDA. The average of fear
ratings severity in social situations (ADIS-
FEAR; a ¼ .87) was used as an indicator of
SOC. Two indicators of GAD were obtained
from the ADIS: the average of the exces-
siveness ratings for the GAD worry domains
(ADIS-WDOM; a ¼ .78) and the average
GAD physiological symptom severity
(ADIS-GADS; a ¼ .74). For OCD, the
average of the persistence/distress of
thoughts ratings (ADIS-PERS; a ¼ .64)
and the average of the frequency of compul-
sions (ADIS-FREQ; a ¼ .61) were used as
indicators. Finally, for DEP, the average
severity of major depressive episode symp-
toms (ADIS-MDES; a ¼ .71) and the aver-
age severity of dysthymic disorder symptoms
(ADIS-DYSS; a ¼ .77) were used as
indicators.
Procedures
The university institutional review board
approved all procedures. Individuals were
screened via phone and provided verbal
consent to be mailed a packet of question-
naires. Participants then came into the clinic
and provided written consent for an assess-
ment (ADIS) and offered psychological
services or appropriate referrals during a
feedback session. All participants were admi-
nistered each questionnaire, regardless of their
diagnoses, which allowed continuous data
collection, and accounted for the range of
comorbid symptoms, rather than focusing on
primary diagnoses and risk losing valuable
information (Norton & Chase, 2015). Given
the diagnostic heterogeneity of the sample,
there are data both at and below the
diagnostic threshold for each observed
measure, which provides meaningful infor-
mation (Kessler et al., 2003).
VOL 44, NO 5, 2015 Beyond Negative Affectivity 395

Analytic plan Table 1. Univariate summaries of observed indicators

Model fit was tested with MPlus (Muthen &
Muthen, 2012) using Maximum Likelihood Measure M SD Range
for missing data. Structural equation model- PANAS-NA 29.25 7.22 12– 48
ing was employed to test model fit. The first ASI-SOM 15.00 7.74 0– 32
model, based on Norton and Mehta (2007), ASI-COG 6.87 4.39 0– 16
was hierarchical, including NA as a higher ASI-PUB 9.06 3.15 0– 16
order factor and two mid-level factors, AS and IUS-NEG 41.24 14.60 14– 75
IoU. AS was estimated for the latent construct IUS-UNF 36.26 11.16 12– 60
of PDA, while IoU was estimated in the PDSS 11.24 7.00 0– 28
estimation for the other four latent constructs: BAI 25.14 13.31 0– 58
ADIS-PHYS 3.77 1.65 0.07–7.43
SOC, GAD, OCD, and DEP. An alternative
SPDQ 15.26 7.16 0– 27
hierarchical model was then run adding a link BFNE 46.06 11.04 15– 60
between AS and SOC. The final model ADIS-FEAR 3.30 1.64 0–8
omitted AS and IoU, testing the fit of a GADQ 21.13 8.46 0– 33
model with only NA as a higher order factor PSWQ 58.73 12.19 21– 80
predicting all five latent disorder constructs. ADIS-WDOM 3.63 1.72 0.25–7.75
ADIS-GADS 4.81 1.73 0.5–8
PI-WSUR 21.55 19.47 0– 104
YBOCS 4.51 4.67 0– 19
Results ADIS-PERS 1.36 1.08 0.11–5.67
Descriptive statistics for each of the observed ADIS-FREQ 2.27 1.52 0.17–6.17
indicators are provided in Table 1. BDI-II 21.23 11.70 0– 56
ADIS-MDES 3.73 1.80 0.17–8
ADIS-DYSS 4.60 21.23 0.33–8
Structural modeling Note. PANAS-NA, Positive and Negative Affect
Figure 1 shows the theoretically derived Scale, Negative Affect; ASI, Anxiety Sensitivity
hierarchical model that was tested. Dependent Index; SOM, Somatic; COG, Cognitive; PUB,
latent variables were allowed to correlate (not Public; IUS, Intolerance of Uncertainty Scale;
shown in model). Method variance was NEG, Negative Implications; UNF, Unfair; PDSS,
Panic Disorder Severity Scale-self-report; BAI, Beck
accounted for by correlating self-report Anxiety Inventory; ADIS, Anxiety Disorder Inter-
measures together and ADIS measures, view Schedule-IV; PHYS, panic physiological symp-
respectively. Standardized root mean square tom severity ratings; SPDQ, Social Phobia
residual (SRMR) values , .08 have been Diagnostic Questionnaire; BFNE, Brief Fear of
Negative Evaluation Scale; FEAR, social anxiety
proposed as indicators of good fit (Hu & situational fear ratings; GADQ, Generalized Anxiety
Bentler, 1999). Root mean square error of Disorder Questionnaire; PSWQ, Penn State Worry
approximation (RMSEA) should ideally be Questionnaire; WDOM, severity of worry domains;
between .02 and .07 (Browne & Cudeck, 1992). GADS, severity of GAD symptoms; PI-WSUR,
Comparative fit index (CFI), as a rule of Washington State University Revision of the Padua
Inventory; YBOCS, Yale-Brown Obsessive-Compul-
thumb, should be . .90 (Marsh & Hau, 1996). sive Scale; PERS-persistence of thoughts ratings;
FREQ, frequency of behaviors ratings; BDI-II, Beck
Depression Inventory-II; MDES, major depressive
Hierarchical model episode symptoms; DYSS, dysthymia symptoms
As expected, the hierarchical model fit the
data adequately. SRMR for our model was .06
suggesting that the sample covariances were As shown in Figure 2, each observed
well reproduced by the model. RMSEA was indicator was highly associated with the
.065 and CFI was .919, both suggesting respective latent variable (Table 2), providing
adequate fit. The chi-square was significant support for the constructs. All but one of the
[x 2 (144, N ¼ 642) ¼ 535.934, p , .0001], proportions of variance explained in the
which can suggest poor fit; however, chi- observed variables were greater than 0.3
square is sensitive to sample size (Bollen, 1989) (0.317– 0.910). The exception was ASI-PUB
and when there are more than 400 cases (0.239), as it was in Norton and Mehta (2007)
(N ¼ 642 in this study), the chi-square is model. In this model, NA was measured by
frequently significant (e.g., Kenny, 2011). only one observed variable (PANAS-NA) and
 .125
396

.935
PANAS-NA NA

1.0

.613 .620

.367
.566
.171

ASI-SOM
.659 IUS-NEG
.910
.136 .225 .342 .197 .531
.359
.800 AS IoU .279
.849
ASI-COG
.489 IUS-UNF
.761 .625
Paulus, Talkovsky, Heggeness and Norton

.616

ASI-PUB

.732 .401 .553 .390 .416

PDA SOC GAD OCD DEP

0.324 0.677 0.342 0.713 0.271

0.741 0.685 0.954 0.815 0.773 0.721 0.725 0.933 0.905 0.719
0.848 0.741 0.592
0.728 0.563

PDSS ADIS-PHYS SPDQ ADIS-FEAR GADQ ADIS-GADS YBOCS PI-WSUR BDI-II ADIS-DYSS
0.669 0.602

0.452 0.530 0.090 0.335 0.403 0.480 0.475 0.130 0.180 0.483
BAI BFNE PSWQ ADIS-PERS ADIS-MDES

0.282 0.452 0.471 ADIS- 0.683 0.650

ADIS-FREQ
WDOM
0.552 0.637
COGNITIVE BEHAVIOUR THERAPY

Figure 2. Model with standardized path coefficients.

VOL 44, NO 5, 2015 Beyond Negative Affectivity 397

Table 2. Factor loading estimates of observed indicators on latent factors

Measure NA AS IoU PDA SOC GAD OCD DEP R2

PANAS-NA 1.000 0.875a
(0.000)
ASI-SOM 1.000 0.434*
(0.000)
ASI-COG 0.689* 0.641*
(0.057)
ASI-PUB 0.302* 0.239*
(0.034)
IUS-NEG 1.000 0.829*
(0.000)
IUS-UNF 0.713* 0.721*
(0.032)
PDSS 1.000 0.548*
(0.000)
BAI 2.147* 0.718*
(0.129)
ADIS-PHYS 0.224* 0.470*
(0.024)
SPDQ 1.000 0.910*
(0.000)
BFNE 1.211* 0.548*
(0.072)
ADIS-FEAR 0.211* 0.665*
(0.016)
GADQ 1.000 0.597*
(0.000)
PSWQ 1.320* 0.529*
(0.075)
ADIS-WDOM 0.178* 0.448*
(0.016)
ADIS-GADS 0.203* 0.520*
(0.018)
PI-WSUR 1.000 0.870*
(0.000)
YBOCS 0.188* 0.525*
(0.017)
ADIS-PERS 0.032* 0.317*
(0.007)
ADIS-FREQ 0.047* 0.363*
(0.010)
BDI-II 1.000 0.820*
(0.000)
ADIS-MDES 0.102* 0.350*
(0.010)
ADIS-DYSS 0.123* 0.517*
(0.015)
Note: R2, proportion of variance explained for each observed indicator. Values in parentheses are the standard
errors of the estimate. NA, negative affectivity; AS, anxiety sensitivity; IoU, intolerance of uncertainty; PDA,
panic disorder/agoraphobia; SOC, social anxiety disorder; GAD, generalized anxiety disorder; OCD, obsessive-
compulsive disorder; DEP, depression; PANAS, Positive and Negative Affect Scale; ASI, Anxiety Sensitivity
Index; SOM, Somatic; COG, Cognitive; PUB, Public; IUS, Intolerance of Uncertainty Scale; NEG, Negative
Implications; UNF, Unfair; PDSS, Panic Disorder Severity Scale-self-report; BAI, Beck Anxiety Inventory;
ADIS, Anxiety Disorder Interview Schedule-IV; PHYS, panic physiological symptom severity ratings; SPDQ,
Social Phobia Diagnostic Questionnaire; BFNE, Brief Fear of Negative Evaluation Scale; FEAR, social anxiety
situational fear ratings; GADQ, Generalized Anxiety Disorder Questionnaire; PSWQ, Penn State Worry
Questionnaire; WDOM, severity of worry domains; GADS, severity of GAD symptoms; PI-WSUR, Washington
State University Revision of the Padua Inventory; YBOCS, Yale-Brown Obsessive-Compulsive Scale; PERS-
persistence of thoughts ratings; FREQ, frequency of behaviors ratings; BDI-II, Beck Depression Inventory-II;
MDE, major depressive episode symptoms; DYS, dysthymia symptoms.
a
PANAS-NA factor loading was fixed to achieve an R2 equal to the reliability of the measure.
*p , 0.001.
398 Paulus, Talkovsky, Heggeness and Norton
the factor loading was constrained such that
the estimated R 2 was equal to the reliability
of the measure (0.875; Leue & Lange, 2011).
Accounting for NA influence, AS and IoU
were significantly related (r ¼ .367, p , .001).
Consistent with Norton and Mehta (2007),
NA was strongly associated with both mid-
level factors, AS and IoU, as well as each of
the latent constructs: PDA, SOC, GAD,
OCD, and DEP (Table 3). Furthermore,
controlling for NA, AS had an effect on
PDA and IoU had effects on SOC, GAD,
OCD, and DEP. Percentage of variance
explained (R 2) for the latent constructs ranged
from 0.287 to 0.729, all p’s , .001.
Alternative hierarchical model with
AS-SOC
A second hierarchical model was run includ-
ing direct and indirect links from AS to SOC.
Model fit was nearly identical:
RMSEA ¼ .065, CFI ¼ .919, SRMR ¼ .06.
AS accounted for less than 1% of the variance
either as both a direct predictor (2 0.01;
p ¼ .856) and a mediator (2 0.01; p ¼ .856)
and the more parsimonious hierarchical model
is described in more detail henceforth.
Simplified model
The simplified higher order only model fits the
data well (SRMR ¼ .04; RMSEA ¼ .046;
CFI ¼ .976), as expected. The percentage of
variance explained for the latent constructs
ranged from .153 to .598, all p’s , .001.
Consistent with our hypothesis, comparing
the R 2 for PDA, SOC, GAD, OCD, and
DEP between the hierarchical and the
simplified model yielded significant decreases
Table 3. Unstandardized regression coefficients
Variable AS IoU NA
PDA 0.744* .103*
SOC .202* .222*
GAD .274* .332*
OCD .534* .527*
DEP .336* .838*
AS .459*
IoU 1.211*
Note. AS, anxiety sensitivity; IoU, intolerance of
uncertainty; NA, negative affectivity; PDA, panic
disorder/agoraphobia; SOC, social anxiety disorder;
GAD, generalized anxiety disorder; OCD, obsessive-
compulsive disorder; DEP, depression.
COGNITIVE BEHAVIOUR THERAPY
in percentage of variance explained for all five
latent variables (all p’s , .0001; see Table 4).
Thus, while both models fit the data well,
adding in specific links of AS and IoU between
NA and the latent disorder constructs
explained a significantly larger proportion of
each construct, demonstrating the value of
both general and specific factors.
Direct and indirect effects of the
hierarchical model
Table 5 presents the results for the mediational
hypotheses of AS and IoU. NA accounted for
38.40% of the variance in IoU and 37.6% of
the variance in AS.
PDA. A 67.6% of the variability in PDA was
explained by the effects of NA and AS. NA
had a weak direct affect (0.14), accounting for
only 1.8% of the variance directly. AS was a
strong direct predictor and mediator, uniquely
contributing 33.4% directly (0.73) and an
additional 32.3% via mediation of NA (0.45).
SOC. NA and IoU explained 32.3% of the
variability in SOC via direct and indirect
effects. NA (0.23) contributed 5.1% directly.
IoU contributed an additional 17.3% as a
mediator (0.25) and an additional 9.9% of
unique variance (0.40).
GAD. A 65.8% of GAD variance was
explained, with NA (0.34) accounting for
11.7% directly and (0.34) 35.3% via IoU
mediation. IoU contributed an additional
18.8% (0.55) as a direct and unique predictor.
OCD. NA (0.20) was a weak direct predictor
of OCD, explaining only 3.9% of the variance.
A 15.5% (0.24) was explained by the
Table 4. Percentage of variance explained in latent
constructs for both models
R2
Variable Hierarchical Model NA-only model
PDA 0.676* 0.307
SOC 0.323* 0.219
GAD 0.658* 0.455
OCD 0.287* 0.153
DEP 0.729* 0.598
Note. R2, proportion of variance explained for each
latent construct; PDA, Panic Disorder/Agoraphobia;
SOC, Social Anxiety Disorder; GAD, Generalized
Anxiety Disorder; OCD, Obsessive-Compulsive
Disorder; DEP, Depression.
*p , 0.0001.
VOL 44, NO 5, 2015 Beyond Negative Affectivity 399

Table 5. Direct, indirect, and total effects

NA

Outcome Effect Unstandardized Standardized

PDA Indirect via AS 0.342* 0.449*
Total 0.445* 0.584*
Direct 0.103* 0.136*
SOC Indirect via IoU 0.245* 0.248*
Total 0.467* 0.474*
Direct 0.222* 0.225*
GAD Indirect via IoU 0.332* 0.343*
Total 0.664* 0.685*
Direct 0.332* 0.342*
OCD Indirect via IoU 0.646* 0.242*
Total 1.173* 0.439*
Direct 0.527* 0.197*
DEP Indirect via IoU 0.407* 0.258*
Total 1.245* 0.789*
Direct 0.838* 0.531*
Note. NA, negative affectivity; AS, anxiety sensitivity; IoU, intolerance of uncertainty; PDA, panic disorder/
agoraphobia; SOC, social anxiety disorder; GAD, generalized anxiety disorder; OCD, obsessive-compulsive
disorder; DEP, depression.
*p , .05.

mediation of IoU with an additional 9.4%
(0.39) coming directly from IoU. Overall,
28.7% of OCD variance was explained by the
model.
DEP. More than 70% of the variance in DEP
was accounted for. NA (0.53) was a much
stronger predictor of DEP accounting for
28.2% of the variance directly and 34.1%
indirectly through IoU (0.26). IoU (0.42)
uniquely contributed an additional 10.6%
directly.
Discussion
This study aimed to test a theoretically derived
model on a large clinical sample using
appropriate statistical techniques and to
demonstrate superior validity, with regard to
the percentage of variance explained in latent
variables, over a simplified higher order
factor-only model. While both the hierarchical
and NA-only model fit the data, a significant
amount of information was lost when remov-
ing the mid-level factors of AS and IoU. While
NA has long been considered a factor linking
emotional disorders together, this study high-
lights the importance of more complex
models. NA was strongly related to each
disorder, though there was considerable
variability in its impact, with stronger links
to DEP and GAD, consistent with past
research (e.g., Kotov et al., 2010). Further-
more, the NA relationship can be mediated by
other important factors, such as AS and IoU,
with the amount of variance directly and
uniquely accounted for by NA being quite
small in some cases (5% or less for SOC,
OCD, and PDA), showing the importance of
AS and IoU as explanatory variables, possibly
differentiating emotional disorders (e.g.,
Hong & Cheung, 2014).
Thus, in this study, AS could be serving as a
proxy for fear-based emotional disorders
(PDA, specific phobia) with IoU being more
representative of anxious-distress emotional
disorders (GAD, DEP, PTSD). Indeed, many
have proposed restructuring of emotional
disorders with sub-factors of anxious-misery
and fear, (e.g., Krueger, 1999; Krueger &
Markon, 2006; Prenoveau et al., 2010; Slade &
Watson, 2006; Watson, 2005; Watson et al.,
2008; Wright et al., 2013), at times with OCD
loading on a separate factor of emotional
disorders all together (Wright et al., 2013),
leaving the relationship between OCD and
other emotional disorders unclear (Watson
et al., 2008). The results of this study support
the inclusion of OCD as an emotional disorder
400 Paulus, Talkovsky, Heggeness and Norton
as it demonstrated significant associations
with the general NA factor and a
relationship with IoU, as do the other
“anxious-misery” conditions of GAD and
DEP. More work is needed in order to fully
understand the optimal placement of OCD, as
it is a heterogeneous disorder and many
hierarchical models have not included OCD—
a limitation noted by others (e.g., Caspi et al.,
2014; Vollebergh et al., 2001; Watson, 2009).
Furthermore, in this study, SOC was highly
related to IoU, suggesting links to the anxious-
misery cluster of disorders, while many have
proposed that SOC fall within the fear cluster.
Like OCD, SOC has shown links to both fear
and anxiety (Hettema, Prescott, Myers, Neale,
& Kendler, 2005). Importantly, a model was
tested with SOC linked to both AS and IoU.
The pattern of results was not different from
the main hierarchical model; AS was not
associated with SOC as a significant direct
predictor or mediator of NA and IoU
remained significantly linked to SOC, consist-
ent with results from Norton and Mehta
(2007). These findings highlight the need to
control for other risk factors when developing
models rather than studying them in isolation
(e.g., Brown & Naragon-Gainey, 2013). While
a wealth of information has linked AS to SOC
(Naragon-Gainey, 2010; Olatunji & Wolitzky-
Taylor, 2009), this study demonstrated that
AS explained less than 1% of SOC variance,
when accounting for IoU.
Our results were consistent with Starcevic
and Berle (2006) review, suggesting that AS
appears to be relatively more specific to PDA
than the other emotional disorders, and with a
growing body of work suggesting that IoU is a
transdiagnostic risk factor (Carleton et al.,
2012; Gentes & Ruscio, 2011). In the Hong
and Cheung (2014) meta-analysis of risk
factors, IoU had the strongest factor loading
to a one-factor model of emotional disorders,
which is supported in part by the current
model, linking AS only to PDA and IoU to
SOC, OCD, GAD, and DEP. While AS is also
considered transdiagnostic and has been
shown to be elevated in emotional disorders
other than PDA, meta-analytic evidence
suggests no difference between mood and
non-PDA anxiety disorders on AS (Olatunji &
Wolitzky-Taylor, 2009), further implicating
AS as a comparatively stronger component of
PDA relative to the other emotional disorders.
COGNITIVE BEHAVIOUR THERAPY
However, this study was unable to model
PTSD, specific phobias, or health anxiety,
which we would expect to load strongly on AS
(e.g., Norton et al., 2005; Olatunji &
Wolitzky-Taylor, 2009; Sexton et al., 2003).
Current results could be strengthened by
evaluating the hierarchical structures of these
disorders as well as the range of OCD- and
PTSD-related disorders (e.g., acute stress,
hoarding, and so on.)
Considering the importance of AS and IoU
over and above NA could have treatment
implications for the future. While transdiag-
nostic treatments have shown promise in
treating emotional disorders broadly
(Reinholt & Krogh, 2014), transdiagnostic
treatments targeting specific features that
cross-cut diagnoses such as AS (Keough &
Schmidt, 2012) and IoU (Dugas & Ladouceur,
2000) directly could improve treatment out-
come moving forward. Future work is needed
in order to determine how best to focus clinical
attention on higher order factors that link
emotional disorders together (e.g., NA;
Barlow, Sauer-Zavala, Carl, Bullis, & Ellard,
2014) as well as those such as AS and IoU,
which might differentiate them. By targeting
common factors in highly comorbid emotional
disorders, it is likely that treatment will be
more efficacious by addressing the underlying
source common to the comorbidity (e.g.,
Norton et al., 2013), such as NA, AS, or
IoU. Identifying and treating transdiagnostic
features is in line with movements in DSM-5 to
assess and treat cross-cutting symptoms,
defined as “mental health domains that are
important across psychiatric diagnoses”
(American Psychiatric Association, 2013).
Furthermore, this approach could help to
treat underlying features that may be part of
other disorders, not just the emotional
disorders discussed here. For example, AS
has been connected to substance and alcohol
misuse (Novak, Burgess, Clark, Zvolensky, &
Brown, 2003). In addition, our findings
demonstrate the important information con-
tained within these crosscutting features.
As nosology moves away from disorder-
specific symptom cluster assessments (e.g.,
Research Domain Criteria; RDoC), assess-
ment of continuous transdiagnostic features,
such as AS and IoU, that underlie traditional
diagnoses becomes all the more valuable (e.g.,
Slade, 2007). Indeed, newer assessment tools
VOL 44, NO 5, 2015
(e.g., Rosellini & Brown, 2014) are being
developed following hybrid dimensional-cat-
egorical models (Brown & Barlow, 2009) that
go beyond traditional disorder-specific
assessment.
While the current model fits the data well,
there are still improvements that can be made,
particularly for SOC and OCD where NA and
IoU only explained approximately 30% of the
variance in the two latent constructs. Future
work should advance upon the current model
by testing other relevant mediators. For SOC,
mediators such as estimated social cost,
perceived self-efficacy, and emotional control
have all been identified (Hofmann, 2000) and
could be included. In addition, thought action
fusion is a cognitive bias highly associated
with OCD and other emotional disorders
(Brown & Naragon-Gainey, 2013), making it
a key variable to be considered.
Of note, the current results were obtained
using the IUS, which has been said to use a
“GAD definition” of IoU (for review, see
Gentes & Ruscio, 2011). The IUS, though,
mapped onto GAD and OCD, as well as SOC
and DEP. However, the use of the IUS could
partially explain why a relatively lower
percentage of OCD variance was accounted
for in the model. Future work could aim to
replicate the current model using multiple
indicators of the IoU concept, including the
IoU domain of the Obsessional Beliefs
Questionnaire ( Obsessive Compulsive Cogni-
tions Working Group, 2003).
This study, though, follows a body of
literature demonstrating the underlying simi-
larities of the emotional disorders via their
link to NA. Moreover, the importance of
other transdiagnostic features (e.g., AS and
IoU) has been exhibited, potentially serving
as cross-cutting features indicating some
degree of heterogeneity (e.g., Hong &
Cheung, 2014). By incorporating such cross-
cutting risk factors, a significantly larger
proportion of variability in the latent
disorder constructs was explained relative to
a NA-only model. These mid-level risk
factors provide a significant amount of
unique information (over and above that
accounted for by NA). Results are in line with
past research (e.g., Caspi et al., 2014) that
hierarchical conceptualizations of emotional
disorders may be superior to one-factor
models. Accounting for higher order factors,
Beyond Negative Affectivity 401
as well as other more specific risk factors,
may allow for a more thorough under-
standing of both the comorbidity and
heterogeneity seen in these disorders.
Limitations
While the hierarchical model fits the data well
and was developed by replication and exten-
sion of previous models conducted by this
research team (Norton & Mehta, 2007;
Norton et al., 2005; Sexton et al., 2003),
future work is needed from other research
groups to provide converging evidence for the
results. In addition, there is a high rate of
comorbidity in the sample. While this is
typical of most clinical samples (e.g., Nemer-
off, 2002) and speaks of the representativeness
of the sample, future work should compare
samples of patients with one disorder with
those experiencing comorbidity to rule out the
possibility of differences in cognitive vulner-
abilities (AS and IoU) between the two groups
(e.g., McTeague & Lang, 2012). For example,
it might not be known whether responses on
AS or IoU measures were influenced by
primary or comorbid diagnosis symptoms. In
addition, the sample contained a majority of
primary anxiety patients. While DEP comor-
bidity was high, it will be important to
replicate models on samples balanced in
terms of primary (and comorbid) anxiety and
DEP.
Regarding measurement, this study
improves upon past models by including
clinician-rated information from the ADIS as
well as self-report data, but is still limited by
the lack of more objective indices (e.g., startle
reflex, attention bias/control indices, and so
on.) Furthermore, the dataset is archival and
is limited by measures available at the start of
the parent clinical trial. For example, this
study relies on the ASI to estimate the AS
construct, whereas updated measures (e.g.,
ASI-3) have been shown to be superior tools
and should be considered for future extension
models.
Acknowledgement
We thank Fanny Kuang for help with data
entry.
Disclosure statement: The authors have
declared that no conflict of interest exists.
402 Paulus, Talkovsky, Heggeness and Norton
Notes
1. OCD was placed on the thought disorder factor,
though the authors note that comparable results were
obtained when OCD was placed on the internalizing
factor with the anxiety disorders and DEP.
2. A link from IoU to DEP was included in this study
given the significant relationship in past clinical
samples (e.g., Norton et al., 2005).
3. Inter-rater reliability was established by having
additional blinded student clinicians watch record-
ings of ADIS sessions and determine diagnoses and
severity.
References
American Psychiatric Association (2013). Diagnos-
tic and statistical manual of mental disorders (5th
ed.). Washington, DC: APA.
Barlow, D.H. (2004). Anxiety and its disorders: The
nature and treatment of anxiety and panic. New
York, NY: Guilford Press.
Barlow, D.H., Allen, L.B., & Choate, M.L. (2004).
Toward a unified treatment for emotional
disorders. Behavior Therapy, 35, 205 – 230.
doi:10.1016/S0005-7894(04)80036-4
Barlow, D.H., & Lehman, C.L. (1996). Advances in
the psychosocial treatment of anxiety disorders:
Implications for national health care. Archives
of General Psychiatry, 53, 727– 735. doi:10.
1001/archpsyc.1996.01830080079013
Barlow, D.H., Sauer-Zavala, S., Carl, J.R.,
Bullis, J.R., & Ellard, K.K. (2014). The
nature, diagnosis, and treatment of neuroti-
cism back to the future. Clinical Psychologi-
cal Science, 2, 344 – 365. doi:doi:10.1177/
2167702613505532
Beck, A.T., Epstein, N., Brown, G., & Steer, R.A.
(1988). An inventory for measuring clinical
anxiety: Psychometric properties. Journal of
Consulting and Clinical Psychology, 56,
893–897. doi:10.1037/0022-006X.56.6.893
Beck, A.T., Steer, R.A., & Brown, G.K. (1996).
Manual for the Beck Depression Inventory-II.
San Antonio, TX: Psychological Corporation.
Bollen, K.A. (1989). Structural equations with latent
variables. New York, NY: Wiley.
Brown, T.A., Antony, M.M., & Barlow, D.H.
(1992). Psychometric properties of the Penn
State Worry Questionnaire in a clinical anxiety
disorders sample. Behaviour Research and
Therapy, 30, 33 – 37. doi:10.1016/0005-7967(92)
90093-V
Brown, T.A., & Barlow, D.H. (1992). Comorbidity
among anxiety disorders: Implications for
treatment and DSM-IV. Journal of Consulting
and Clinical Psychology, 60, 835– 844. doi:10.
1037/0022-006X.60.6.835
Brown, T.A., & Barlow, D.H. (2009). A proposal
for a dimensional classification system based on
the shared features of the DSM-IV anxiety and
mood disorders: Implications for assessment
and treatment. Psychological Assessment, 21,
256–271. doi:10.1037/a0016608
COGNITIVE BEHAVIOUR THERAPY
Brown, T.A., Campbell, L.A., Lehman, C.L.,
Grisham, J.R., & Mancill, R.B. (2001). Current
and lifetime comorbidity of the DSM-IV
anxiety and mood disorders in a large clinical
sample. Journal of Abnormal Psychology, 110,
585. doi:10.1037/0021-843X.110.4.585
Brown, T.A., Chorpita, B.F., & Barlow, D.H.
(1998). Structural relationships among dimen-
sions of the DSM-IV anxiety and mood
disorders and dimensions of negative affect,
positive affect, and autonomic arousal. Journal
of Abnormal Psychology, 107, 179– 192. doi:10.
1037/0021-843X.107.2.179
Brown, T.A., Di Nardo, P.A., & Barlow, D.H.
(1994). Anxiety Disorders Interview Schedule for
DSM-IV: Client interview schedule. New York,
NY: Oxford University Press.
Brown, T.A., & Naragon-Gainey, K. (2013).
Evaluation of the unique and specific contri-
butions of dimensions of the triple vulnerability
model to the prediction of DSM-IV anxiety and
mood disorder constructs. Behavior Therapy,
44, 277– 292. doi:10.1016/j.beth.2012.11.002
Browne, M.W., & Cudeck, R. (1992). Alternative
ways of assessing model fit. Sociological
Methods and Research, 21, 230– 258. doi:10.
1177/0049124192021002005
Burns, G.L., Keortge, S.G., Formea, G.M., &
Sternberger, L.G. (1996). Revision of the Padua
Inventory of obsessive compulsive disorder
symptoms: Distinctions between worry, obses-
sions, and compulsions. Behaviour Research and
Therapy, 34, 163– 173. doi:10.1016/0005-7967
(95)00035-6
Carleton, R.N., Collimore, K.C., & Asmundson,
G.J.G. (2010). It’s not just the judgements—It’s
that I don’t know: Intolerance of uncertainty as
a predictor of social anxiety. Journal of Anxiety
Disorders, 24, 189– 195. doi:10.1016/j.janxdis.
2009.10.007
Carleton, R.N., Mulvogue, M.K., Thibodeau,
M.A., McCabe, R.E., Antony, M.M., &
Asmundson, G.J.G. (2012). Increasingly certain
about uncertainty: Intolerance of uncertainty
across anxiety and depression. Journal of
Anxiety Disorders, 26, 468– 479. doi:10.1016/j.
janxdis.2012.01.011
Caspi, A., Houts, R.M., Belsky, D.W., Goldman-
Mellor, S.J., Harrington, H., Israel, S., . . . , &
Moffitt, T.E. (2014). The p factor one general
psychopathology factor in the structure of
psychiatric disorders? Clinical Psychological
Science, 2, 119 – 137. doi:10.1177/
2167702613497473
Chamberlain, L.D., & Norton, P.J. (2013). An
evaluation of the effects of diagnostic compo-
sition on individual treatment outcome within
transdiagnostic cognitive-behavioral group
therapy for anxiety. Cognitive Behaviour
Therapy, 42, 56 – 63. doi:10.1080/16506073.
2012.748090
Clark, L.A., & Watson, D. (1991). Tripartite model
of anxiety and depression: Psychometric evi-
dence and taxonomic implications. Journal of
VOL 44, NO 5, 2015
Abnormal Psychology, 100, 316. doi:10.1037/
0021-843X.100.3.316
Cuijpers, P., Berking, M., Andersson, G., Quigley,
L., Kleiboer, A., & Dobson, K.S. (2013). A
meta-analysis of cognitive-behavioural therapy
for adult depression, alone and in comparison
with other treatments. Canadian Journal of
Psychiatry (Revue Canadienne De Psychiatrie),
58, 376– 385.
Dugas, M.J., Buhr, K., & Ladouceur, R. (2004).
The role of intolerance of uncertainty in
etiology and maintenance. In R.G. Heimberg,
C.L. Turk, & D.S. Mennin (Eds.), Generalized
anxiety disorder: Advances in research and
practice (pp. 143 – 163). New York, NY:
Guilford Press.
Dugas, M.J., & Ladouceur, R. (2000). Treatment of
GAD targeting intolerance of uncertainty in
two types of worry. Behavior Modification, 24,
635– 657. doi:10.1177/0145445500245002
Dugas, M.J., Schwartz, A., & Francis, K. (2004).
Brief report: Intolerance of uncertainty, worry,
and depression. Cognitive Therapy and
Research, 28, 835 – 842. doi:10.1007/s10608-
004-0669-0
Freeston, M.H., Rhéaume, J., Letarte, H., Dugas,
M.J., & Ladouceur, R. (1994). Why do people
worry? Personality and Individual Differences,
17, 791– 802. doi:10.1016/0191-8869(94)90048-5
Gentes, E.L., & Ruscio, A.M. (2011). A meta-
analysis of the relation of intolerance of
uncertainty to symptoms of generalized anxiety
disorder, major depressive disorder, and obses-
sive-compulsive disorder. Clinical Psychology
Review, 31, 923– 933. doi:10.1016/j.cpr.2011.05.
001
Goodman, W., Price, L., Rasmussen, S., Mazure,
C., Fleischmann, R., Hill, C., . . . , & Charney,
D. (1989). The Yale-Brown Obsessive Compul-
sive Scale: I. Development, use, and reliability.
Archives of General Psychiatry, 46, 1006– 1011.
doi:10.1001/archpsyc.1989.01810110048007
Hettema, J.M., Prescott, C.A., Myers, J.M., Neale,
M.C., & Kendler, K.S. (2005). The structure of
genetic and environmental risk factors for
anxiety disorders in men and women. Archives
of General Psychiatry, 62, 182– 189. doi:10.
1001/archpsyc.62.2.182
Hofmann, S.G. (2000). Treatment of social phobia:
Potential mediators and moderators. Clinical
Psychology: Science and Practice, 7, 3 – 16.
doi:10.1093/clipsy.7.1.3
Hong, R.Y., & Cheung, M.W.-L. (2014). The
structure of cognitive vulnerabilities to
depression and anxiety evidence for a common
core etiologic process based on a meta-analytic
review. Clinical Psychological Science. doi:10.
1177/2167702614553789
Houck, P.R., Spiegel, D.A., Shear, M.K., & Rucci,
P. (2002). Reliability of the self-report version
of the panic disorder severity scale. Depression
and Anxiety, 15, 183– 185. doi:10.1002/da.10049
Hu, L., & Bentler, P.M. (1999). Cutoff criteria for
fit indexes in covariance structure analysis:
Conventional criteria versus new alternatives.
Beyond Negative Affectivity 403
Structural Equation Modeling: A Multidis-
ciplinary Journal, 6(1), 1 – 55. doi:10.1080/
10705519909540118
Kenny, D.A. (2011). Measuring model fit.
Retrieved from http://davidakenny.net/cm/fit.
htm
Keogh, E., & Reidy, J. (2000). Exploring the factor
structure of the Mood and Anxiety Symptom
Questionnaire (MASQ). Journal of Personality
Assessment, 74, 106 – 125. doi:10.1207/
S15327752JPA740108
Keough, M.E., & Schmidt, N.B. (2012). Refine-
ment of a brief anxiety sensitivity reduction
intervention. Journal of Consulting and Clinical
Psychology, 80, 766– 772. doi:10.1037/a0027961
Kessler, R.C., Merikangas, K.R., Berglund, P.,
Eaton, W.W., Koretz, D.S., & Walters, E.E.
(2003). Mild disorders should not be eliminated
from the DSM-V. Archives of General Psychia-
try, 60, 1117– 1122. doi:10.1001/archpsyc.60.11.
1117
Kotov, R., Gamez, W., Schmidt, F., & Watson, D.
(2010). Linking big personality traits to anxiety,
depressive, and substance use disorders:
A meta-analysis. Psychological Bulletin, 136,
768– 821. doi:10.1037/a0020327
Krueger, R.F. (1999). The structure of common
mental disorders. Archives of General Psychia-
try, 56, 921– 926. doi:10.1001/archpsyc.56.10.
921
Krueger, R.F., Caspi, A., Moffitt, T.E., & Silva, P.
A. (1998). The structure and stability of
common mental disorders (DSM-III-R):
A longitudinal-epidemiological study. Journal
of Abnormal Psychology, 107, 216– 227. doi:10.
1037/0021-843X.107.2.216
Krueger, R.F., & Finger, M.S. (2001). Using item
response theory to understand comorbidity
among anxiety and unipolar mood disorders.
Psychological Assessment, 13, 140– 151. doi:10.
1037/1040-3590.13.1.140
Krueger, R.F., & Markon, K.E. (2006). Reinter-
preting comorbidity: A model-based approach
to understanding and classifying psycho-
pathology. Annual Review of Clinical Psychol-
ogy, 2, 111– 133. doi:10.1146/annurev.clinpsy.2.
022305.095213
Leary, M.R. (1983). A brief version of the Fear of
Negative Evaluation Scale. Personality and
Social Psychology Bulletin, 9, 371 –375. doi:10.
1177/0146167283093007
Leue, A., & Lange, S. (2011). Reliability general-
ization: An examination of the Positive Affect
and Negative Affect Schedule. Assessment, 18,
487– 501. doi:10.1177/1073191110374917
Marsh, H.W., & Hau, K.-T. (1996). Assessing
goodness of fit: Is parsimony always desirable?
The Journal of Experimental Education, 64,
364– 390. doi:10.1080/00220973.1996.10806604
McManus, F., Shafran, R., & Cooper, Z. (2010).
What does a transdiagnostic approach have to
offer the treatment of anxiety disorders? British
Journal of Clinical Psychology, 49, 491–505.
doi:10.1348/014466509X476567
404 Paulus, Talkovsky, Heggeness and Norton
McNally, R.J. (2002). Anxiety sensitivity and panic
disorder. Biological Psychiatry, 52, 938– 946.
doi:10.1016/S0006-3223(02)01475-0
McTeague, L.M., & Lang, P.J. (2012). The anxiety
spectrum and the reflex physiology of defense:
From circumscribed fear to broad distress.
Depression and Anxiety, 29, 264– 281. doi:10.
1002/da.21891
Meyer, T.J., Miller, M.L., Metzger, R.L., &
Borkovec, T.D. (1990). Development and
validation of the Penn State Worry Question-
naire. Behaviour Research and Therapy, 28,
487–495. doi:10.1016/0005-7967(90)90135-6
Muthen, L.K., & Muthen, B.O. (2012). Mplus user’s
guide. Los Angeles, CA: Muthen & Muthen.
Naragon-Gainey, K. (2010). Meta-analysis of the
relations of anxiety sensitivity to the depressive
and anxiety disorders. Psychological Bulletin,
136, 128– 150. doi:10.1037/a0018055
Nemeroff, C.B. (2002). Comorbidity of mood and
anxiety disorders: The rule, not the exception?
The American Journal of Psychiatry, 159, 3 –4.
Newman, M.G., Kachin, K.E., Zuellig, A.R.,
Constantino, M.J., & Cashman-McGrath, L.
(2003). The Social Phobia Diagnostic Ques-
tionnaire: Preliminary validation of a new self-
report diagnostic measure of social phobia.
Psychological Medicine, 33, 623– 635. doi:10.
1017/S0033291703007669
Newman, M.G., Zuellig, A.R., Kachin, K.E.,
Constantino, M.J., Przeworski, A., Erickson,
T., & Cashman-McGrath, L. (2002). Prelimi-
nary reliability and validity of the Generalized
Anxiety Disorder Questionnaire-IV: A revised
self-report diagnostic measure of generalized
anxiety disorder. Behavior Therapy, 33,
215–233. doi:10.1016/S0005-7894(02)80026-0
Norton, P.J. (2006). Diagnostic measures and
underlying anxiety constructs: An analysis of
correspondence. Anxiety, Stress and Coping, 19,
227–239. doi:10.1080/10615800600679079
Norton, P.J., Barrera, T.L., Mathew, A.R.,
Chamberlain, L.D., Szafranski, D.D., Reddy,
R., & Smith, A.H. (2013). Effect of transdiag-
nostic CBT for anxiety disorders on comorbid
diagnoses. Depression and Anxiety, 30,
168–173. doi:10.1002/da.22018
Norton, P.J., & Chase, T.E. (2015). Is a gin and
tonic more like gin or tonic? A comparison of
comorbid and non-comorbid anxiety disorder
diagnostic pairs. Psychiatry Research, 225,
179–186. doi:10.1016/j.psychres.2014.11.017
Norton, P.J., & Mehta, P.D. (2007). Hierarchical
model of vulnerabilities for emotional dis-
orders. Cognitive Behaviour Therapy, 36,
240–254. doi:10.1080/16506070701628065
Norton, P.J., & Price, E.C. (2007). A meta-analytic
review of adult cognitive-behavioral treatment
outcome across the anxiety disorders. The
Journal of Nervous and Mental Disease, 195,
521–531.
Norton, P.J., Sexton, K.A., Walker, J.R., &
Norton, G. (2005). Hierarchical model of
vulnerabilities for anxiety: Replication and
extension with a clinical sample. Cognitive
COGNITIVE BEHAVIOUR THERAPY
Behaviour Therapy, 34, 50 – 63. doi:10.1080/
16506070410005401
Novak, A., Burgess, E.S., Clark, M., Zvolensky,
M.J., & Brown, R.A. (2003). Anxiety sensi-
tivity, self-reported motives for alcohol and
nicotine use, and level of consumption. Journal
of Anxiety Disorders, 17, 165– 180. doi:10.1016/
S0887-6185(02)00175-5
Obsessive Compulsive Cognitions Working Group
(2003). Psychometric validation of the Obses-
sive Beliefs Questionnaire and the Interpret-
ation of Intrusions Inventory: Part I. Behaviour
Research and Therapy, 41, 863. doi:10.1016/
S0005-7967(02)00099-2
Olatunji, B.O., Cisler, J.M., & Deacon, B.J. (2010).
Efficacy of cognitive behavioral therapy for
anxiety disorders: a review of meta-analytic
findings. The Psychiatric Clinics of North
America, 33, 557– 577. doi:10.1016/j.psc.2010.
04.002
Olatunji, B.O., & Wolitzky-Taylor, K.B. (2009).
Anxiety sensitivity and the anxiety disorders:
A meta-analytic review and synthesis. Psycho-
logical Bulletin, 135, 974 – 999. doi:10.1037/
a0017428
Peterson, R.A., & Reiss, S. (1992). Anxiety
Sensitivity Index revised test manual, Inter-
national Diagnostic Services (2nd ed.). Orland
Park, IL: International Diagnostic Systems.
Prenoveau, J.M., Zinbarg, R.E., Craske, M.G.,
Mineka, S., Griffith, J.W., & Epstein, A.M.
(2010). Testing a hierarchical model of anxiety
and depression in adolescents: a tri-level model.
Journal of Anxiety Disorders, 24, 334– 344.
doi:10.1016/j.janxdis.2010.01.006
Reinholt, N., & Krogh, J. (2014). Efficacy of
transdiagnostic cognitive behaviour therapy for
anxiety disorders: A systematic review and
meta-analysis of published outcome studies.
Cognitive Behaviour Therapy, 43(3), 1 – 14.
doi:10.1080/16506073.2014.897367
Rosellini, A.J., & Brown, T.A. (2014). Initial
interpretation and evaluation of a profile-
based classification system for the anxiety and
mood disorders: Incremental validity compared
to DSM-IV categories. Psychological Assess-
ment, 26, 1212– 1224. doi:10.1037/pas0000023
Sexton, K.A., & Dugas, M.J. (2009). Defining
distinct negative beliefs about uncertainty:
Validating the factor structure of the Intoler-
ance of Uncertainty Scale. Psychological Assess-
ment, 21, 176– 186. doi:10.1037/a0015827
Sexton, K.A., Norton, P.J., Walker, J.R., &
Norton, G.R. (2003). Hierarchical model of
generalized and specific vulnerabilities in
anxiety. Cognitive Behaviour Therapy, 32,
82 – 94. doi:10.1080/16506070302321
Simms, L.J., Grös, D.F., Watson, D., & O’Hara,
M.W. (2008). Parsing the general and specific
components of depression and anxiety with
bifactor modeling. Depression and Anxiety, 25,
E34– E46. doi:10.1002/da.20432
Slade, T. (2007). The descriptive epidemiology of
internalizing and externalizing psychiatric
dimensions. Social Psychiatry and Psychiatric
VOL 44, NO 5, 2015
Epidemiology, 42, 554 – 560. doi:10.1007/
s00127-007-0200-5
Slade, T., & Watson, D. (2006). The structure of
common DSM-IV and ICD-10 mental dis-
orders in the Australian general population.
Psychological Medicine, 36, 1593– 1600. doi:10.
1017/S0033291706008452
Starcevic, V., & Berle, D. (2006). Cognitive
specificity of anxiety disorders: A review of
selected key constructs. Depression and Anxiety,
23, 51 – 61. doi:10.1002/da.20145
Steketee, G., Frost, R., & Bogart, K. (1996). The
Yale-Brown Obsessive Compulsive Scale: Inter-
view versus self-report. Behaviour Research and
Therapy, 34, 675–684. doi:10.1016/0005-7967
(96)00036-8
Taylor, S. (1998). The hierarchic structure of fears.
Behaviour Research and Therapy, 36, 205– 214.
doi:10.1016/S0005-7967(98)00012-6
Taylor, S. (2014). Anxiety sensitivity: Theory,
research, and treatment of the fear of anxiety.
New York, NY: Routledge.
Tolin, D.F., Abramowitz, J.S., Brigidi, B.D., &
Foa, E.B. (2003). Intolerance of uncertainty in
obsessive-compulsive disorder. Journal of
Anxiety Disorders, 17, 233– 242. doi:10.1016/
S0887-6185(02)00182-2
Vollebergh, W.A., Iedema, J., Bijl, R.V., de Graaf,
R., Smit, F., & Ormel, J. (2001). The structure
and stability of common mental disorders: The
NEMESIS study. Archives of General Psychia-
try, 58, 597– 603. doi:10.1001/archpsyc.58.6.597
Watson, D. (2005). Rethinking the mood and
anxiety disorders: A quantitative hierarchical
model for DSM-V. Journal of Abnormal
Psychology, 114, 522– 536. doi:10.1037/0021-
843X.114.4.522
Watson, D. (2009). Differentiating the mood and
anxiety disorders: A quadripartite model.
Annual Review of Clinical Psychology, 5,
221– 247.
Watson, D., Clark, L.A., & Carey, G. (1988).
Positive and negative affectivity and their
Beyond Negative Affectivity 405
relation to anxiety and depressive disorders.
Journal of Abnormal Psychology, 97, 346.
doi:10.1037/0021-843X.97.3.346
Watson, D., Clark, L.A., & Stasik, S.M. (2011).
Emotions and the emotional disorders:
A quantitative hierarchical perspective. Inter-
national Journal of Clinical and Health Psychol-
ogy, 11, 429 – 442. Retrieved from http://
connection.ebscohost.com/c/articles/65546769/
emotions-emotional-disorders-quantitative-
hierarchical-perspective
Watson, D., Clark, L.A., & Tellegen, A. (1988).
Development and validation of brief measures
of positive and negative affect: The PANAS
scales. Journal of Personality and Social
Psychology, 54, 1063– 1070. doi:10.1037/0022-
3514.54.6.1063
Watson, D., O’Hara, M.W., & Stuart, S. (2008).
Hierarchical structures of affect and psycho-
pathology and their implications for the
classification of emotional disorders. Depression
and Anxiety, 25, 282– 288. doi:10.1002/da.20496
Weeks, J.W., Heimberg, R.G., Fresco, D.M., Hart,
T.A., Turk, C.L., Schneier, F.R., & Liebowitz,
M.R. (2005). Empirical validation and psycho-
metric evaluation of the Brief Fear of Negative
Evaluation Scale in patients with social anxiety
disorder. Psychological Assessment, 17,
179– 190. doi:10.1037/1040-3590.17.2.179
Wright, A.G.C., Krueger, R.F., Hobbs, M.J.,
Markon, K.E., Eaton, N.R., & Slade, T.
(2013). The structure of psychopathology:
Toward an expanded quantitative empirical
model. Journal of Abnormal Psychology, 122,
281– 294. doi:10.1037/a0030133
Yook, K., Kim, K.-H., Suh, S.Y., & Lee, K.S.
(2010). Intolerance of uncertainty, worry, and
rumination in major depressive disorder and
generalized anxiety disorder. Journal of Anxiety
Disorders, 24, 623– 628. doi:10.1016/j.janxdis.
2010.04.003
Copyright of Cognitive Behaviour Therapy is the property of Routledge and its content may
not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's
express written permission. However, users may print, download, or email articles for
individual use.