Not one thing at a time:When concomitant multiple stressors produce a transdiagnostic clinical picture

A condition of exposure to multiple stressors resulting in a mixed clinical picture spanning conventional categories without meeting any of them in full,encompasses a risk for a list of comorbidities preventing appropriate prevention and treatment.New transformative transdiagnostic approaches suggest changes spanning conventional categories.They base their systems of classification on biomarkers as well as on brain structural and functional dysregulation as associated with behavioral and emotional symptoms.These new approaches received critiques for not being specific enough and for suggesting a few biomarkers for psychopathology as a whole.Therefore,they put the value of differential diagnosis at risk of avoiding appropriate derived prevention and treatment.Multiplicity of stressors has been considered mostly during and following catastrophes,without considering the resulting mixed clinical picture and life event concomitant stressors.We herewith suggest a new category within the conventional classification systems:The Complex Stress Reaction Syndrome,for a condition of multiplicity of stressors,which showed a mixed clinical picture for daily life in the post coronavirus disease 2019 era,in the general population.We argue that this condition may be relevant to daily,regular life,across the lifespan,and beyond conditions of catastrophes.We further argue that this condition may worsen without professional care and it may develop into a severe mental health disorder,more costly to health systems and the suffering individuals.Means for derived prevention and treatment are discussed.

International study of the Complex Stress Reaction Syndrome:Implications for transdiagnostic clinical practice

BACKGROUND The debate regarding diagnostic classification systems in psychiatry(categorial vs dimensional systems)has essential implications for the diagnosis,prevention and treatment of stress reactions.We previously found a unique pattern of stress reaction in a study executed during the coronavirus disease 2019 pandemic using large representative samples in two countries,and termed it the Complex Stress Reaction Syndrome(CSRS).AIM To investigate CSRS,Type A(psychiatric symptoms,spanning anxiety,depression,stress symptoms,and posttraumatic stress disorder(PTSD)),with or without long-coronavirus disease(COVID)residuals(CSRS,Type B,neuropsychiatric symptoms spanning cognitive deficits and fatigue,excluding systemic symptoms).Our two-tailed hypothesis was that CSRS is a condition related to an unrecognized type of stress reaction in daily life in the general population(Type A)or that it is related to the severe acute respiratory syndrome coronavirus 2 infection and its long-COVID residuals(Type B).METHODS 977 individuals in four continents(North America,Europe,Australia and the Middle East)completed the online study questionnaire in six languages using the Qualtrics platform.The study was managed by six teams in six countries that promoted the study on social media.The questionnaire assessed anxiety,depression,stress symptoms and PTSD(CSRS,Type A),cognitive deficits and fatigue(CSRS,Type B).The data were analyzed using Proportion Analyses,Multivariate Analysis of Co-Variance(MANCOVA),linear regression analyses and validated clinical cutoff points.RESULTS The results of the Proportion Analyses showed that the prevalence of 4 symptoms spanning anxiety,depression,stress symptoms,and PTSD was significantly higher than the most prevalent combinations of fewer symptoms across 4 continents,age groups,and gender.This supports the transdiagnostic argument embedded in the CSRS(Type A).The same pattern of results was found in infected/recovered individuals.The prevalence of the 4 psychiatric symptoms combination was significantly greater than that of 5 and 6 symptoms,when adding cognitive deficits and fatigue,respectively.MANCOVA showed a significant three-way interaction(age×gender×continent).Further analyses showed that the sources of this three-way interaction were threefold relating to two sub-populations at-risk:(1)Individuals that self-identified as non-binary gender scored significantly higher on all 4 psychiatric symptoms of the CSRS,Type A at young age groups(<50 years old)in North America compared to(self-identified)women and men located in the 4 continents studied,and to other ages across the adult life span;and(2)This pattern of results(CSRS,Type A)was found also in women at young ages(<40 years old)in North America who scored higher compared to men and women in other continents and other ages.Linear regression analyses confirmed the MANCOVA results.CONCLUSION These results show a combined mental health risk factor related to stress reactivity,suggesting that the CSRS is sensitive to populations at risk and may be applied to future identification of other vulnerable sub-populations.It also supports the transdiagnostic approach for more accurate prevention and treatment.Time will tell if such transdiagnostic syndromes will be part of the discussions on the next revisions of the traditional classification systems or whether the crisis in psychiatry further evolves.

Application of unified protocol as a transdiagnostic treatment for emotional disorders during COVID-19: An internet-delivered randomized controlled trial

BACKGROUND The coronavirus disease 2019(COVID-19)pandemic has been an emotionally challenging time,especially for young adults.It is associated with a substantial increase in the prevalence of mental health problems,negative symptoms,and stressful experiences that compromise well-being.In low-income countries,internet-delivered psychological services could have a remarkable impact on the population’s mental health,given the lack of mental health professionals.AIM To investigate the efficacy of internet-delivered cognitive-behavior therapy(CBT)-transdiagnostic intervention for adults with emotional disorders.METHODS In this internet-delivered randomized controlled trial,102 students with an emotional disorder(mean age=28.20 years,standard deviation=5.07)were randomly allocated to receive unified protocol(UP)(n=51)or treatment as the usual intervention.Following a semi-structured clinical interview,participants completed an online survey including the Overall Anxiety Severity and Impairment Scale,Overall Depression Severity and Impairment Scale,Difficulties in Emotion Regulation Scale,Positive and Negative Affect Schedule,and Emotional Style Questionnaire.RESULTS The participants showed a high degree of adherence.In total,78%(n=40)of the experimental group participants completed the UP treatment.Considering the intention to treat procedure,the results of the analysis of covariance indicated that participants who received UP showed statistically significant changes in depression symptoms[Cohen’s d=-1.50 with 95%confidence interval(CI):-1.90 to-1.10],anxiety(Cohen’s d=-1.06 with 95%CI:-1.48 to-0.65),difficulties with emotion regulation(Cohen’s d=-0.33 with 95%CI:-0.7 to-0.06),positive affect(Cohen's d=1.27 with 95%CI:0.85 to 1.68),negative affect(Cohen’s d=-1.04 with 95%CI:-1.46 to-0.63),and healthy emotionality(Cohen’s d=0.53 with 95%CI:0.09 to 0.13)compared with the control group.CONCLUSION This study’s findings highlight the potential value of transdiagnostic internet-delivered programs for young adults with an emotional disorder during the COVID-19 pandemic,and expand the research examining emotional well-being improvements resulting from CBT-transdiagnostic interventions.The findings suggest that UP,which generally concentrates on reducing negative effects,can increase positive effects.

Does COVID-19 related symptomatology indicate a transdiagnostic neuropsychiatric disorder?-Multidisciplinary implications

The clinical presentation that emerges from the extensive coronavirus disease 2019(COVID-19)mental health literature suggests high correlations among many conventional psychiatric diagnoses.Arguments against the use of multiple comorbidities for a single patient have been published long before the pandemic.Concurrently,diagnostic recommendations for use of transdiagnostic considerations for improved treatment have been also published in recent years.In this review,we pose the question of whether a transdiagnostic mental health disease,including psychiatric and neuropsychiatric symptomology,has emerged since the onset of the pandemic.There are many attempts to identify a syndrome related to the pandemic,but none of the validated scales is able to capture the entire psychiatric and neuropsychiatric clinical presentation in infected and non-infected individuals.These scales also only marginally touch the issue of etiology and prevalence.We suggest a working hypothesis termed Complex Stress Reaction Syndrome(CSRS)representing a global psychiatric reaction to the pandemic situation in the general population(Type A)and a neuropsychiatric reaction in infected individuals(Type B)which relates to neurocognitive and psychiatric features which are part(excluding systemic and metabolic dysfunctions)of the syndrome termed in the literature as long COVID.We base our propositions on multidisciplinary scientific data regarding mental health during the global pandemic situation and the effects of viral infection reviewed from Google Scholar and PubMed between February 1,2022 and March 10,2022.Search inclusion criteria were“mental health”,“COVID-19”and“Long COVID”,English language and human studies only.We suggest that this more comprehensive way of understanding COVID-19 complex mental health reactions may promote better prevention and treatment and serve to guide implementation of recommended administrative regulations that were recently published by the World Psychiatric Association.This review may serve as a call for an international investigation of our working hypothesis.

Investigating a comorbid pattern of ill-health among late adolescents in relation to transdiagnostic processes: A prospective community study

An increase in anxiety, depressed mood and sleep problems has been observed among adolescents. These symptoms have high rates of comorbidity and shared psychological processes have been proposed as maintaining factors. This study examined the occurrence and development of individual profiles of depressive symptoms, anxiety and sleeps problems and investigated them in relation to catastrophic thinking and cognitive avoidance. We used longitudinal data from a community sample of 379 senior high school students at two time points, one year apart. Five clusters were identified: a low scores cluster, a sleep problems cluster, a comorbidity cluster (high on all variables), a low mood cluster and a cluster with elevation on anxiety and depressed mood (“distress”). In general, the clusters showed stability across time. However, for the low mood and “distress” cluster, there was also an increased odds of developing sleep problems. The comorbidity and the “distress” cluster displayed the highest levels of catastrophic thinking. In conclusion, symptom patterns differed among adolescents and were stable over time. Anxiety and/or depressive symptoms were a risk factor for the development of sleep problems. Symptom constellations were related to differences in catastrophic thinking and cognitive avoidance and this may explain maintenance and exacerbation of problems over time.

Reduced homotopic interhemispheric connectivity in psychiatric disorders:evidence for both transdiagnostic and disorder specific features

There is considerable interest in the significance of structural and functional connections between the two brain hemispheres in terms of both normal function and in relation to psychiatric disorders.In recent years,many studies have used voxel mirrored homotopic connectivity analysis of resting state data to investigate the importance of connectivity between homotopic regions in the brain hemispheres in a range of neuropsychiatric disorders.The current review summarizes findings fromthese voxel mirrored homotopic connectivity studies in individuals with autism spectrum disorder,addiction,attention deficit hyperactivity disorder,anxiety and depression disorders,and schizophrenia,aswell as disorders such as Alzheimer’s disease,mild cognitive impairment,epilepsy,and insomnia.Overall,other than attention deficit hyperactivity disorder,studies across psychiatric disorders report decreased homotopic resting state functional connectivity in the default mode,attention,salience,sensorimotor,social cognition,visual recognition,primary visual processing,and reward networks,which are often associated with symptom severity and/or illness onset/duration.Decreased homotopic resting state functional connectivity may therefore represent a transdiagnostic marker for general psychopathology.In terms of disorder specificity,the extensive decreases in homotopic resting state functional connectivity in autism differ markedly from attention deficit hyperactivity disorder,despite both occurring during early childhood and showing extensive co-morbidity.A pattern of more posterior than anterior regions showing reductions in schizophrenia is also distinctive.Going forward,more studies are needed to elucidate the functions of these homotopic functional connections in both health and disorder and focusing on associations with general psychopathology,and not only on disorder specific symptoms.

Emotion regulation in bipolar disorder: Are emotion regulation abilities less compromised in euthymic bipolar disorder than unipolar depressive or anxiety disorders?

Objective: This study investigated the profile of emotion dysregulation in Bipolar Disorder (BD) and compared it to Unipolar Depression, Anxiety, and Healthy control groups. Methods: 148 euthymic patients diagnosed with BD (n = 48), Unipolar Depressive disorder (n = 50), Anxiety disorder (n = 50), and a Healthy Control (HC) group (n = 48) were evaluated using the Difficulties in Emotion Regulation Scale (DERS). The DERS yields a total score in addition to scores on six subcomponents believed to encapsulate the emotion dysregulation construct. Results: Compared to the healthy control group, all clinical groups (BD, Unipolar Depression, and Anxiety) reported significantly greater overall difficulties in emotion regulation (Total DERS) and difficulties specific to the DERS subcomponent measures: Goals, Impulse, and Strategies. The profile of emotion dysregulation was virtually identical for the Unipolar Depression and Anxiety groups, with BD demonstrating emotion regulation difficulties intermediate between controls and the two clinical groups. Specifically, emotion regulation in the BD group was significantly less compromised in the domains of acceptance of emotions, emotional awareness, and emotional clarity compared to the depression and anxiety groups. Conclusions: Emotion regulation abilities among people with euthymic BD were significantly less compromised than Unipolar Depression and Anxiety groups with regards to emotional awareness, acceptance of emotions, and understanding of emotions. However, emotion regulation abilities pertaining to engagement in goal directed behaviour, impulse control, and access to emotion regulation strategies were similarly compromised across all three clinical groups. This profile might help enrich extant adjunct psychological interventions for BD by enlisting emotion regulation strategies with the aim of decreasing the relapse rate that characterises BD.