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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
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A wealth of evidence attests to the extensive current and lifetime diagnostic comorbidity of the Diagnostic and Statistical Manual of Mental Disorders (4th ed., DSM-IV) anxiety and mood disorders. Research has shown that the considerable cross-sectional covariation of DSM-IV emotional disorders is accounted for by common higher order dimensions such as neuroticism/behavioral inhibition (N/BI) and low positive affect/behavioral activation. Longitudinal studies indicate that the temporal covariation of these disorders can be explained by changes in N/BI and, in some cases, initial levels of N/BI are predictive of the temporal course of emotional disorders. The marked phenotypal overlap of the DSM-IV anxiety and mood disorders is a frequent source of diagnostic unreliability (e.g., temporal overlap in the shared features of generalized anxiety disorder and mood disorders, situation specificity of panic attacks in panic disorder and specific phobia). Although extant dimensional proposals may address some drawbacks associated with the DSM nosology (e.g., inadequate assessment of individual differences in disorder severity), these proposals do not reconcile key problems in current classification, such as modest reliability and high comorbidity. This article considers an alternative approach that emphasizes empirically supported common dimensions of emotional disorders over disorder-specific criteria sets. Selection and assessment of these dimensions are discussed along with how these methods could be implemented to promote more reliable and valid diagnosis, prognosis, and treatment planning. For instance, the advantages of this system are discussed in context of transdiagnostic treatment protocols that are efficaciously applied to a variety of disorders by targeting their shared features.
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“Emotional disorders are characterized by a tendency to experience steep increases in affect in response to environmental stimuli and, subsequently, interpret these emotional experiences as harmful (Andrews, 1990; Andrews, 1996; Brown & Barlow, 2009).”
From The role of negative affectivity and negative reactivity to emotions in predicting outcomes in the unified protocol for the transdiagnostic treatment of emotional disorders (2012) · cites this paper as Brown & Barlow, 2009
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“psychological inflexibility as a transdiagnostic process has been described as a continuum or dimension that could contribute to most psychological disorders (Hayes et al., 2011), with a growing body of research increasingly supporting this parsimonious approach (Levin et al., 2014;Brown & Barlow, 2009).”
From Better living with illness: A transdiagnostic acceptance and commitment therapy group intervention for chronic physical illness (2016) · cites this paper as Brown & Barlow, 2009
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“This approach posits that ED are manifestations of a common psychopathological vulnerability underlying these disorders, with neuroticism/negative affect/behavioral inhibition and low extraversion/positive affect/behavioral activation as key transdiagnostic factors (Brown and Barlow, 2009).”
From Feasibility, acceptability, and preliminary efficacy of a blended transdiagnostic group CBT for the treatment of emotional disorders (2025) · cites this paper as Brown and Barlow, 2009
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“cross-sectional covariation of emotional disorders can be accounted for by a small set of latent variables, including high negative affectivity/neuroticism, low positive affectivity, and high autonomic arousal.[26][27][28][29]”
From The Classification of Anxiety and Fear-Related Disorders in the ICD-11: Review: Anxiety and Fear-Related Disorders in ICD-11 (2016) · cites this paper as [26]
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“and has been shown to underlie the origin of EDs, as well as the high comorbidity present in these disorders (Brown and Barlow, 2009).”
From Unified Protocol for the transdiagnostic treatment of emotional disorders in people with post COVID-19 condition: study protocol for a multiple baseline n-of-1 trial (2023) · cites this paper as Brown and Barlow, 2009
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“people with EDs have higher levels of N/NA/BI [8]”
From Negative and positive affect regulation in a transdiagnostic internet-based protocol for emotional disorders: Randomized controlled trial (2021) · cites this paper as [8]
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“N/NA and E/PA have been closely related to Gray’s (1987) constructs of BI and BA, respectively [24-26], and these terms are often used interchangeably as the most stable measures of temperament [8,15,26,27].”
From Negative and positive affect regulation in a transdiagnostic internet-based protocol for emotional disorders: Randomized controlled trial (2021) · cites this paper as [8]
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“Transdiagnostic approaches, therefore, offer a pragmatic and parsimonious response to complexity and facilitate the translation of evidence-based protocols into practice (Barlow et al., 2004; Brown and Barlow, 2009; Mitchell, 2011; Bearman and Weisz, 2015; Norton and Paulus, 2015; Marchette and Weisz, 2017).”
From An Emotion Regulation and Impulse Control (ERIC) Intervention for Vulnerable Young People: A Multi-Sectoral Pilot Study (2021) · cites this paper as Brown and Barlow, 2009
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“People with emotional disorders experience more intense emotion in dealing with environmental stimuli and interpret their emotional experiences as threats. 33”
From Emotion regulation as the mediator of reductions in anxiety and depression in the Unified Protocol (UP) for transdiagnostic treatment of emotional disorders: double-blind randomized clinical trial (2019) · cites this paper as [33]
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“There is strong empirical and theoretical support for development of transdiagnostic treatment approaches, as many of the cognitive, emotional, behavioural and interpersonal factors which drive symptomatology are consistent across disorders.12 13”
From The HARMONIC trial: Study protocol for a randomised controlled feasibility trial of Shaping Healthy Minds - A modular transdiagnostic intervention for mood, stressor-related and anxiety disorders in adults (2018) · cites this paper as [12]
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“If this is the case for IU, then it should be present as a shared factor in not just GAD and OCD, but other emotional disorders as well, which may help to explain the high degree of comorbidity observed across different emotional disorders (Brown & Barlow, 2009).”
From Intolerance of Uncertainty: A Common Factor in the Treatment of Emotional Disorders (2013) · cites this paper as Brown & Barlow, 2009
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“Disorder-specific symptomatology observed in categorical models is thought to emerge from the interaction between common vulnerability factors with select psychological or biological influences.[26,33]”
From The Classification of Anxiety and Fear-Related Disorders in the ICD-11: Review: Anxiety and Fear-Related Disorders in ICD-11 (2016) · cites this paper as [26]
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“The UP aims to address temperamental characteristics, particularly neuroticism and resulting emotion dysregulation, which are argued to be a common factor underlying all emotional disorders [46].”
From Effectiveness and mediators of change of an online CBT intervention for students with adjustment disorder—study protocol for a randomized controlled trial (2023) · cites this paper as [46]
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“transdiagnostic approaches have emerged that address the common characteristics found in cognitive, behavioral, emotional, and other dysregulation areas underlying different EDs, that is, the biological and psychological vulnerabilities shared by different mental disorders [7,8].”
From Negative and positive affect regulation in a transdiagnostic internet-based protocol for emotional disorders: Randomized controlled trial (2021) · cites this paper as [8]
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“certain disorders cluster together reliably (e.g., anxiety and depression; Brown and Barlow, 2009)”
From An Emotion Regulation and Impulse Control (ERIC) Intervention for Vulnerable Young People: A Multi-Sectoral Pilot Study (2021) · cites this paper as Brown and Barlow, 2009
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- Steenkamp M McLean CP Arditte KA Litz BT Antony MM Barlow DH in press Assessment of adults exposed to trauma Handbook of assessment, treatment planning, and outcome evaluation: Empirically supported strategies for psychological disorders 2 New York Guilford Press
- White KS Barlow DH Barlow DH 2002 Panic disorder and agoraphobia Anxiety and its disorders: The nature and treatment of anxiety and panic 2 328 379 New York Guilford Press
Cited by
Sorted by citations
Kotov, R., Krueger, R. F., Watson, D., Achenbach, T. M., Althoff, R. R., Bagby, R. M., Brown, T. A., Carpenter, W. T., Caspi, A., Clark, L. A., et al. (2017) · Journal of Abnormal Psychology · doi:10.1037/abn0000258 · Cited by 3,335
Self-citationUncertainty and anticipation in anxiety: an integrated neurobiological and psychological perspective
Grupe, D. W., & Nitschke, J. B. (2013) · Nature Reviews Neuroscience · doi:10.1038/nrn3524 · Cited by 2,007
Sloan, E., Hall, K., Moulding, R., Bryce, S., Mildred, H., & Staiger, P. K. (2017) · Clinical Psychology Review · doi:10.1016/j.cpr.2017.09.002 · Cited by 1,052
Reenvisioning Clinical Science: Unifying the Discipline to Improve the Public Health
Onken, L. S., Carroll, K. M., Shoham, V., Cuthbert, B. N., & Riddle, M. (2014) · Clinical Psychological Science · doi:10.1177/2167702613497932 · Cited by 872
“…exhibit considerable heterogeneity (British Psychological Society, 2011; Frances, 2009a, 2009b), our understanding of the basic processes of psychopathology that should be addressed in targeted treatments has substantially increased (T. A. Brown & Barlow, 2009; Cuthbert & Insel, 2013; Insel, 2012).”
Personality and depression: explanatory models and review of the evidence
Klein, D. N., Kotov, R., & Bufferd, S. J. (2011) · Annual Review of Clinical Psychology · doi:10.1146/annurev-clinpsy-032210-104540 · Cited by 886
Metadata
- Authors
- Brown, T. A., & Barlow, D. H.
- Affiliations
- Boston University (US)
- Venue
- Psychological Assessment
- Published
- 2009
- Volume
- 21
- Issue
- 3
- Pages
- 256-271
- ISSN
- 1040-3590 (ISSN-L)
- 1939-134X
- PMC
- PMC2845450
- OpenAlex
- W1999696094
- Cited by
- 639
- References
- 96
- Citations by year
- 2026: 17 · 2025: 18 · 2024: 30 · 2023: 47 · 2022: 38 · 2021: 47 · 2020: 43 · 2019: 48 · 2018: 42 · 2017: 64 · 2016: 36 · 2015: 39 · 2014: 50 · 2013: 30 · 2012: 38
- FWCI
- 37.66
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Psychological Assessment (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institute of Mental Health (R01MH039096)
- Topics
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Mental Health Research Topics
- Social Sciences › Psychology › Clinical Psychology › Personality Disorders and Psychopathology
- Keywords
- dimensional classification, anxiety disorders, mood disorders, DSM-IV, transdiagnostic treatment, diagnostic reliability, generalized anxiety disorder, panic disorder, specific phobia
- MeSH terms
- Anxiety Disorders, Humans, Longitudinal Studies, Male, Middle Aged, Models, Psychological, Psychotherapy, Temperament, Comorbidity, Mood Disorders, Diagnostic and Statistical Manual of Mental Disorders
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Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
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