Search

Individuals who develop a mental disorder often present with not only one diagnosis, but high rates of comorbidities over the course of their lives. Therefore, research has developed an interest in identifying transdiagnostic processes that can help explain dysfunction across disorders. At the same time, this offers the possibility to target different clinical pictures with a more general intervention and thus to potentially improve the efficacy of treatments. One process that has received much attention as a possible transdiagnostic factor is emotion regulation (ER). There is evidence that deficits in ER are associated with increased levels of symptoms across a number of psychological disorders, including depression and anxiety (Brockmeyer et al., 2012; Joormann & Stanton, 2016; Mennin et al., 2009). However, studies investigating deficits in ER as a transdiagnostic process have provided mixed results: On the one hand, some results indeed support the transdiagnostic nature of ER; on the other hand, there is empirical evidence that particular ER difficulties are rather disorder-specific (Aldao et al., 2016; Im & Kahler, 2022; Lukas et al., 2018). Shukla and Pandey (2021) proposed a combination by suggesting, that only some ER difficulties may be transdiagnostic while other ER difficulties may be unique to specific disorders. They empirically tested their assumption by examining different components of ER deficits, based on the framework proposed by (Gratz & Roemer, 2004). Gratz and Roemer (2004) suggested that ER deficits can occur in the following domains: awareness and understanding of emotions, acceptance of emotional experiences, the ability to engage in goal-directed behaviors and control impulsive behaviors while facing negative emotions, and the use of strategies to modulate emotions in accordance with the situational demands. Shukla and Pandey (2021) included a subclinical sample with symptoms of either anxiety or both anxiety and depression in their study. They found that both subclinical groups showed a higher total score of ER deficits than the healthy sample, with the mixed group showing the highest level of deficits. When zooming in to the specific domains of ER difficulties, certain ER difficulties, namely non-acceptance of emotional response, impulse control difficulties, and limited access to ER strategies were only found in the anxious-depressed group, while difficulties engaging in goal-directed behavior, lack of emotional awareness and emotional clarity were found in both subclinical groups (Shukla & Pandey, 2021). In this study we aim to investigate which ER deficits can be found in individuals with a depression or an anxiety disorder. Thereby, we follow and extend the analogue study of Shukla and Pandey (2021) by recruiting a clinical sample with diagnosed disorders of a) depression, b) an anxiety disorder and c) depression and anxiety disorder. Note, the individuals may have additional comorbid diagnoses (e.g., nonorganic insomnia, obsessive-compulsive disorder, etc. for inclusion in this study. In this way, we hope to provide further evidence to clarify which deficits in ER are present in both depression and anxiety-related disorders, or if stronger degrees of difficulties are merely due to comorbidity between these two disorders. In order to further examine this possible dose-response relationship in more detail, we will also examine the extent of ER deficits depending on the number of disorders or comorbidities regardless of the type of disorder. Research has generally suggested that deficits in ER are linked to specific ER strategies, like repetitive negative thinking (RNT) that impede ER. For RNT, as for ER deficits, a transdiagnostic relationship is often assumed. Furthermore, it has also been shown for RNT that it increases as the number of comorbid diagnoses increases (McEvoy et al., 2013). Therefore, we will additionally investigate this particular ER strategy with respect to its occurrence in the different diagnostic groups as well as depending on the numbers of comorbid disorders.

This research question is a part of the ImPuls study. The study protocol of the ImPuls study is published at https://doi.org/10.1186/s12888-021-03541-3 and registered in the German Clinical Trial Register (ID: DRKS00024152, 05/02/2021).

Although there are many studies that clearly show a relationship between mental health and trait emotional intelligence (TEI), there have been only few studies that have examined clinical samples (Andrei et al., 2014; Hansen et al., 2009). Furthermore, it is particularly noticeable that most studies only looked at global TEI scores. But since TEI has many facets, it may also be important to look at the subdimensions of TEI and especially whether disorders differ in terms of the association with these dimensions. The aim of this study is, therefore, to investigate whether individuals with different mental disorders, differ significantly from healthy control groups on different TEI facets, measured with the TEIQue. For this purpose, a large patient sample, with different diagnoses (including depression, anxiety-related disorder, or insomnia) was recruited. Matched healthy control groups will be recruited. We expect that participants with a depression, participants with an anxiety-related disorder, and participants with insomnia will score lower on the global TEI score as well as on all subscales of the TEIQue compared to the healthy controls.

These research question is a part of the ImPuls study. The study protocol of the ImPuls study is published at https://doi.org/10.1186/s12888-021-03541-3 and registered in the German Clinical Trial Register (ID: DRKS00024152, 05/02/2021). We know from literature that there are a lot of variables that may have an impact on the symptom severity in a transdiagnostic sample of different mental disorders. In the following section we will shortly present possible impact factors that are also assumed to be mechanisms of change within the pragmatic randomized controlled trial (RCT). Physical activity (PA) and PA-related health competence (PAHCO). There is a body of evidence assuming that PA that is planned, structured and repeated, with the primary aim to improve or maintain physical fitness (Caspersen et al., 1985) might represent a preventive factor as well as an effective treatment in patients suffering from mental disorders. In a recently published RCT, an exercise intervention was efficacious in improving global symptom severity in a transdiagnostic sample (Zeibig et al., 2021). The results indicate that the reduction of global symptom severity was predicted by an increase in the amount of PA (Zeibig et al., 2021). Furthermore, exercise-specific affect regulation as part of PAHCO (Schmid et al., 2020) seemed to underly treatment effects (Zeibig et al., under review). Repetitive negative thinking (RNT). RNT defined as “a mode of responding to distress that involves repetitively and passively focusing on symptoms of distress and the possible causes and consequences of these symptoms” (Nolen-Hoeksema et al., 2008) might be a transdiagnostic risk factor for severity of depression and anxiety (Spinhoven et al., 2018). Sleep quality. Sleep disturbance is a symptom of many axis I disorders, e.g. in posttraumatic stress disorder or depressive disorders. In fact, depressed patients who also suffer from insomnia report higher levels of symptom severity compared to depressed patients without insomnia (Sunderajan et al., 2010). Evidence that extends these results to patients with other psychiatric disorders indicate that impaired sleep quality is strongly associated with higher levels of psychiatric symptom severity, assessed by patients themselves and clinicians (Kallestad et al., 2012). Health-related quality of life (HRQoL). HRQoL describes the perceived physical and mental health of an individual over time and includes correlates of HRQoL as health risks, functional status and social support (Centers for Disease Control and Prevention, 2000). A general population survey revealed that depressive and anxiety disorders are associated with the poorest outcome of HRQoL (Saarni et al., 2007). Regarding symptom severity, HRQoL seems to be negatively correlated among depressive patients (Cao et al., 2013) and patients suffering from post-traumatic stress disorder (Nachar et al., 2013) as well as from insomnia (Kyle et al., 2010). Perceived stress. Stress is defined as situations “in which environmental demands, internal demands, or both, tax or exceed the adaptive resources of an individual, social system, or tissue system” (Monat & Lazarus, 1991). Acute stressful life events or chronic levels of stress are a risk factor for a broad range of mental disorders such as posttraumatic stress disorder, depression, insomnia and anxiety disorders (Basta et al., 2007; Smoller, 2016). At the same time, people suffering from mental disorders are more sensitive to stress and experience higher levels of stress than healthy people (Connor et al., 2007; Zorn et al., 2017). However, research regarding symptom severity in a clinical sample is still pending. Fear of the corona virus (FoC). During the Covid-19 pandemic, people were confronted with a new, fast-spreading virus that was associated with high mortality rates, lack of treatment methods and overstrained health systems (Meyerowitz-Katz & Merone, 2020; Wiersinga et al., 2020). This situation was associated with high FoC in the population (Luo et al., 2021) and first results suggest that FoC is positively associated with symptom severity in depression and anxiety disorders (Belen, 2021; Fink et al., 2021; Rogers et al., 2021). Emotional regulation (ER). ER is defined as the “extrinsic and intrinsic processes responsible for monitoring, evaluating, and modifying emotional reactions, especially their intensive and temporal features, to accomplish one’s goal” (Thompson, 1994). Deficits in ER may favor the development of depression (Berking et al., 2014) and among patients suffering from depression deficits are seen as one key factor in the maintenance of symptoms (Ehring et al., 2010). In turn, enhancing ER skills using specific interventions may reduce symptom severity in depressive patients (Radkovsky et al., 2014). Emotional intelligence (EI). EI is defined as „the ability to process your emotions and others’ emotions to guide your thinking and behavior” (Ahmed Okasha et al., 2022) and impaired EI is seen as one principal component in depressive disorders (Fisher et al., 2010). Thus, research implies that impaired self-perceived EI is correlated with symptom severity among depressive patients (Ahmed Okasha et al., 2022). Sociodemographic data. Among a representative adult German sample, the prevalence of common mental disorders (e.g. depression or anxiety disorders) is higher among females, except for substance use disorders (Klose & Jacobi, 2004). Furthermore, being single, separated, divorced or widowed as well as being unemployed is associated with an increased risk of any mental disorder. Regarding the prevalence of depressive or anxiety disorders, no age effects were found (Klose & Jacobi, 2004) and higher education seems to yield lower rates of mood disorders (Alonso et al., 2004). However, research regarding symptom severity in a clinical sample is still pending. To summarize we can say that there are various variables associated with symptom severity of different mental disorders. However, they are mainly investigated in disorder-specific samples which is not in line with growing evidence supporting transdiagnostic treatments in patients with mental disorders (Dalgleish et al., 2020). Thus, research regarding impact factors on global symptom severity in a transdiagnostic sample is necessary. These results could provide important information that could be used to create transdiagnostic therapy approaches focusing on those impact factors with the highest impact on global symptom severity.

Everyday people are confronted with the perception of stress caused by several problems and challenges. These so-called stressors reach from long lists of tasks at work over the car traffic at rush hour up to social conflicts at home. Furthermore, crises of world affairs such as the Covid-19 pandemic are additional stressors, associated with a high prevalence of stress among the general population (Salari et al., 2020). Stress is defined as situation “in which environmental demands, internal demands, or both, tax or exceed the adaptive resources of an individual, social system, or tissue system,” (Monat & Lazarus, 1991). Acute stressful life events or chronic levels of stress are a risk factor for a broad range of mental disorders such as posttraumatic stress disorder (PTSD), major depressive disorder (MDD), Insomnia and anxiety disorders (Basta et al., 2007; Smoller, 2016). At the same time, people suffering from mental disorders are more sensitive to stress and experience higher levels of stress than healthy people (Connor et al., 2007; Zorn et al., 2017). Therefore, these mental disorders are also called stress-related disorder (Smoller, 2016). Stress does not necessarily lead to the development of a mental disorder, but it is generally associated with a lower quality of life (QOL) (Chaudhury et al., 2018). QOL is defined as the “individuals' perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns” (WHOQOL, 1998, p. 1570). According to a systematic review the negative association between stress and QOL becomes even stronger if people also suffer from disorders such as sleep disorders, burnout or depression (Ribeiro et al., 2018). However, studies mainly compared stress and QOL from samples consisting of individuals with a specific mental disorder with healthy controls (Berghofer et al., 2020; Zorn et al., 2017). Although both constructs are shared relevant factors across all stress-related disorders, there is a gap in data from transdiagnostic analyses. One part of this study is therefore to fill this gap. Physical activity (PA), which is “any bodily movement produced by skeletal muscles that results in energy expenditure” (Caspersen et al., 1985, p. 128), has a contrary effect to stress on mental health in that it directly reduces the experience of stress but also elevates mood and increases QOL not only in healthy people but also in people suffering from mental disorders such as depression or anxiety disorder (Penedo & Dahn, 2005; White et al., 2017). The latter mechanism is attributed to the so-called stress-buffering hypothesis. According to this hypothesis, the increase, or a reduced decrease – compared to stronger decreases – in characteristics such as QOL is due to a reduction in the negative impact of stress (Gerber & Puhse, 2009). In one of the studies investigating the effect university students with more PA have been shown to be more satisfied in life and having higher positive affect than the group with lower levels of PA although they were confronted with the same academical stressors during this period (Wunsch et al., 2017). However, there is a lack of data on this hypothesis with regard to people suffering from mental disorders as – to our knowledge – it has only been tested on healthy people with provoked or naturally occurring stressors or people with physical diseases (Giessing et al., 2021; Klaperski & Fuchs, 2021; Schilling et al., 2020). Especially in terms of the underlying transdiagnostic mechanisms already mentioned, the idea of a stress buffer through PA does not seem to have been explored yet. Hence, this context gives rise to tow objectives for this study. In a first step we want to show that stress and QOL can be seen as underlying transdiagnostic factors in people with stress-related disorders. We expect higher levels of stress among the transdiagnostic sample and we also suspect that this group shows lower QOL due to the negative association of these two factors than the matched healthy sample. The second and also the main aim of this study is to shed light on the impact of PA on the association between stress and QOL in a transdiagnostic sample of people suffering from depression (mild, severe), insomnia, post-traumatic stress disorder and/or panic disorder (with or without agoraphobia).

Additional file 1. TIDieR-Checklist.pdf (TIDieR Checklist).

submitted by Thomas Studnitz Literaturverzeichnis: Blatt 77-83 Zusammenfassung in Deutsch und Englisch Paris-Lodron-University of Salzburg, Masterarbeit, 2020 (VLID)5595981