Shared Psychopathology

According to Clark and Watson's (1991) tripartite theory, high negative affect is a common factor shared by both anxiety and depression, whereas low positive affect and high autonomic arousal are uniquely characteristic of depression and anxiety, respectively. Research testing the validity of the tripartite model in outpatients with anxiety and mood disorders has found that social phobia and depression are both distinguished by high negative affect and low positive affect, and that neither is characterized uniquely by physiological hyperarousal (Brown, Chorpita, & Barlow, 1998). Furthermore, psy-chopathology research indicates that social phobia and depressive disorders are characterized by some of the same exaggerated beliefs about the costs of negative social performance. For example, Wilson and Rapee (2005) found that individuals with social phobia tend to believe that social errors result in negative evaluations from others, and that the negative evaluations both reflect negative personal characteristics and herald long-term negative consequences. Moreover, depression is associated with an intensification of many of these beliefs. These findings are consistent with earlier reports of an intensification of core fears of negative evaluation in individuals with comorbid social phobia and major depression (Ball, Otto, Pollack, Uccello, & Rosenbaum, 1995).

Given the overlap in latent higher-order trait dimensions between social phobia and depression, as well as the ubiquity of negative self-related cognitions in both disorders, the unitary view of anxiety and depression might predict that CBT would target shared elements of affective and cognitive distress in anxiety and depression, leading to reciprocal and simultaneous changes in both. However, the results by Moscovitch, Hofmann, Suvak, and In-Albon (2005) suggest that in patients with social phobia, the treatment response to CBT is characterized by early, specific improvements in social phobia symptoms, which in turn leads to improvements in symptoms of depression. Therefore, although depression and social anxiety show considerable overlap in their psychopathology, the mechanisms of treatment change for the two syndromes appears to be separate, and CBT for social anxiety only indirectly targets depressive symptoms. Similar findings suggest that depression enhances core fears associated with panic disorder—fears of the somatic sensations of anxiety. Specifically, Otto, Pollack, Fava, Uccello, and Rosenbaum (1995) reported that depression was linked to moderate elevations on the anxiety sensitivity index, and that these scores dropped significantly with treatment of the depression. In addition, depression appears to sap coping resources, so that depressed patients are less able to buffer stress and engage adaptive problem-solving skills; many of these difficulties resolve with treatment of the depression (Otto et al., 1997). Finally, depression can be expected to sap energy and motivation while providing the neuro-vegative symptoms and dysfunctional attitudes that define depressive states.

Together, studies of depression and depression comorbidity relative to core fears associated with social phobia and panic disorder suggest that depression may well enhance these fears in a state-dependent fashion, while also decreasing coping skills and problem solving. One implication of these findings is that individuals with comorbid depression and anxiety disorders may present with greater phobic severity. Indeed, depression comorbidity with anxiety disorders is associated with increased symptom severity and disability (e.g., Fava et al., 2004; Katzelnick et al., 2001; Schneier et al., 1992). Furthermore, an association between panic disorder and suicide appears to be linked exclusively with the effects of comorbidity, including depression comorbidity, instead of being a direct risk associated with panic disorder itself (Vickers & McNally, 2004).

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