FROM ANXIETY DISORDERS TO SOCIO-EMOTIONAL DISORDERS,
THEIR PREVENTION AND INTERVENTION
Interview with Ronald M. Rapee
Ron Rapee is Professor in the Department of Psychology, Macquarie University, Sydney, Australia, and Director of the Centre for Emotional Health (CEH). He is a distinguished Professor, Founding Director of the Centre for Emotional Health, and a Laureate researcher. He is a clinical psychologist, and an important contributor about understanding and development of mental disorders, specially about emotional disorders. Many of his contributions are related with transdiagnostic perspective. He has developed various treatment programs and evaluating their efficacy, many of them targeting in children and adolescents. Many of his programs are used in many countries across the world. He is a Fellow of the Academy of Social Sciences in Australia.
This interview was carried out by Juan F. Rodríguez-Testal, professor of clinical psychopathology at the university of Seville, Spain, director of a research group focused on psychotic and personality disorders.
JFRT: First of all, it is a true honor for me to be able to maintain this contact with you. You are a reference for clinical psychology in general, and for research and psychopathology in particular. For many years, we have been following your contributions, which I would say span quite varied interests, from the sphere you are most related to, social anxiety, to the more general emotional disorders. However, you have also made very valuable contributions in the area of transdiagnosis more in fashion, but which was already in many of your first publications, in areas related to depression, eating behavior, body concerns and physical appearance, study of personality, intervention, prevention, to stuttering and even cognitive deterioration in old age. Attempting to cover all the key elements that you have taught us and those we have learned would be materially impossible with your almost 400 articles on an international scale and of the greatest impact, in addition to your books, alone or as coauthor. However, if you would allow me, it would be a real pleasure to be able to ask you a few questions that have come from reading some of your many studies.
RR: Thank you so very much, Juan – it is my absolute pleasure to contribute to this interview in these very unusual times.
JFRT: In one of your publications, Spence and Rapee (2016), you suggest: “There is insufficient evidence, as yet, to determine whether SAD is a cause or effect of such comorbid problems, or whether these patterns of comorbidity reflect common underlying causal factors” (pp. 52). Would you say that social anxiety, or more exactly, Social Anxiety Disorder (SAD), due to its relationship with depression, its relationship to drinking alcohol (as a way to alleviate emotional distress), especially due to its relationship with the possibility of being rejected by others, not seeming competent doing something, etc., is really a depressive phenomenon? Might social anxiety be the alarm that this is a vulnerable identity, perhaps of depressogenic construction?
RR: I’m not sure I would put them down to any single problem – eg saying they are all manifestations of depression or that depression is a manifestation of social anxiety is perhaps too specific. We recently published a hypothetical model of ways in which emotional disorders might be influenced by adolescent developmental characteristics. In that model we talked about social anxiety, generalized anxiety, depression, and disorders of body image as highly related and we referred to them as the “social-emotional” disorders. When we reviewed the evidence about their onset, the vast majority of risk factors appear to be more or less common across these disorders. In other words, I wouldn’t say that one is a manifestation of another, but rather that these disorders share more in common than their differences. This perspective is consistent with a body of literature (e.g. Krueger, Lahey, and others) on the hierarchical classification of mental disorder, that points out that the common (or shared) variance across all internalising disorders is far greater than differences between them.
Having said that, this doesn’t mean that one is not an “alarm” as you put it for another. In other words, precisely because they share so many of their characteristics and risks, when an individual experiences one of these problems, we know that they are at greatly increased risk for another. Because social anxiety most commonly begins before depression, it can indeed act as an “alarm”.
JFRT: In Rapee et al. (2019), you carried out an excellent review and updated an explanatory model of emotional disorders, giving social relations and cognitive processes, such as social comparison, enormous importance. What is the role of social media in the context of this model? Understanding that they are part of the reality we live in, what do social media enable us to anticipate as facilitating and disturbing in the child and adolescent’s development?
RR: The paper you are referring to was our recent theoretical model of the development of social-emotional disorders during adolescence. The purpose of this model wasn’t to describe a comprehensive developmental account, but to specifically highlight the characteristics of the adolescent period that makes them a high-risk window for these disorders. In this context, there is no doubt that social media is a critically important medium for adolescents. One of the most critical changes that occurs in adolescence is the dramatic increase in the importance and influence of peers. In this way, social media takes on vital importance.
It is very important to point out that social media is not necessarily “bad”. Social media can increase the focus, intensity, and immediacy of peer relationships. But peer relationships themselves can be both good and bad. In the same way, using social media can have many strengths, as well as potential risks – it all comes down to what is done on social media and how it is used. For adolescents who use social media to connect with their friends, obtain social support, and share normative information, using the internet is a positive experience and has the potential to protect from mental disorder. However, for adolescents who use social media to make frequent upward social comparisons, who don’t engage in mutual online chats, and who are victimized online, social media can be a very lonely place that can increase anxiety and depression.
JFRT: Two very interesting recent studies (Forbes, Magson, & Rapee, 2020; Forbes, Rapee, & Krueger, 2020) might infer that much of the symptomatology observed, especially in childhood and adolescence, are actually general ways of reacting, for example, to adversity, traumatic situations, or maladjusted development, where emotional manifestations and/or alterations in behavior dominate, more than specific syndromes for specific causes. Is that right? At these ages, would general intervention approaches directed precisely at dominating internalizing or externalizing characteristics make more sense than a diagnostic approach?
RR: This work follows on from some of the comments I made earlier about shared variance. To give some quick background: there is some moderately new research on the classification of mental disorders by a growing group of researchers, including Bob Krueger and others. What these researchers have done is to apply a purely empirical view to the classification of mental disorders by looking at their patterns of comorbidity. What they repeatedly find (which makes complete clinical sense to me) that the largest amount of variation between all forms of mental disorder is actually shared. In other words, when you look at the factor structure of all disorders in the DSM, you find that most of the variation is common across these disorders and the researchers have labeled this, “general psychopathology”. Once you statistically control or remove the variance accounted for by general psychopathology, the remaining variance usually falls into two broad groups – internalizing disorders and externalizing disorders (sometimes psychosis forms an additional spectrum). So what this means is that when you look at someone with an internalizing disorder, most of their characteristics are very similar to the characteristics of anyone who has any mental disorder. Then there is an additional set of characteristics that is similar to anyone with another internalizing disorder. And finally, there are some unique characteristics of the specific DSM disorder that the person has – but these are quite minimal. This has two treatment implications: First, it suggests that the biggest treatment effects will come if you address the largest components, which are actually transdiagnostic; but second, it suggests a more nuanced idea in which treatment and prevention can be organized hierarchically so that the first thing you treat are the very broad components (general psychopathology), then if a problem remains, you address the next largest component (internalizing), and only if a problem remains do you need to focus on the specific characteristics of a particular disorder.
JFRT: In line with what is particularly mentioned in Forbes, Rapee, and Krueger (2020), would it make sense that precisely the study of at-risk mental states (ARMS) of psychosis should be nonspecific, as shown in the literature and the clinic, starting out from that non-differentiation depending on their development and then going on from there specifying toward schizophrenia, toward bipolar disorder, or toward emotional disorders, as they progress to adulthood? Would an approach directed too much toward a specific diagnosis then be a risk for an adolescent, especially the earlier it is made, with respect to the development of the person being assessed?
RR: Based on the hierarchical classification models that I described above and based on our clinical and empirical knowledge of comorbidity, we know that a person diagnosed with one particular disorder at one stage of their life is very likely to present with a different disorder later in life. Clinically you often see this with psychosis – young people suffering their first episode of psychosis, often have a history of earlier diagnoses of generalized anxiety, social anxiety, depression, and so on.
The paper you refer to, Forbes et al 2020, was aimed at addressing the idea of prevention from very early childhood. What we suggested there, was that in very early childhood, it is extremely difficult to know the specific mental disorders that a person is going to experience across their life. Therefore, the most cost-effective focus of early intervention might be to try and reduce characteristics of general psychopathology. If this is done successfully, according to theory, it should prevent the development of all other forms of disorder.
JFRT: Another of your studies (Rapee et al., 2020) suggests some questions in the same direction: Certain cognitive processes, such as social comparison (comparison of appearance, self-rated attractiveness, comparison on social media) and other processes more related to social activity or affiliation, for example, could have to do with social anxiety, probably also depression, or eating behavior disorders. Would it not be more useful to make classifications of cognitive processes that have a demonstrated mediating role rather than diagnoses or disorders, as in the diagnostic classifications in use? And therefore, would it not be more advantageous to design intervention more toward cognitive processes than toward concrete diagnoses? Would these processes not really be transdiagnostic?
RR: Yes, I fully agree. As per my earlier comments, in that paper we tried to highlight some characteristics of normal adolescent development that might increase risk for mental disorders in some youth. The way we began was by looking at which mental disorders show a strong increased prevalence during the teenage years. It turns out that there are four: generalized anxiety, social anxiety, depression, and eating disorders (substance use also increases but for a range of reasons, we excluded this). So at the very least, these four disorders share a lot of common risk factors. On this basis, I completely agree – if we can develop programs to reduce these broad risk factors, then these programs should reduce the prevalence of a range of different disorders, rather than focusing specifically on one single disorder.
JFRT: In the same sense as the previous question, in an excellent study on perfectionism, more exactly, socially prescribed and self-orientated perfectionism (Magson, Oar, Fardouly, Johnco, & Rapee, 2019), the importance of this process, probably linked rather to very stable styles of functioning (personality) is drawn perfectly. How should preventive work be focused in this type of process?
RR: Perfectionism is another of the broad, transdiagnostic processes that characterizes several disorders. There is some excellent work from people like Roz Shafran in the UK and Sarah Egan and Tracy Wade in Australia that shows how reducing perfectionism can have downstream benefits for a range of mental disorders. Their interventions utilize many standard CBT strategies – cognitive restructuring, problem solving, and exposure to errors and imperfection. In a prevention context we might also want to focus on expectations and modeling from parents. There is no doubt that there is a strong inherited component to perfectionism. But young people can be taught very clear strategies to successfully manage their perfectionistic tendencies.
JFRT: In some of your recent studies, you suggest intervention by telematics, for example, analyzing adherence to these procedures (Titov et al., 2013). What is the future of intervention in emotional disorders? How could preventive procedures be developed, and who should be responsible for their development? And if I may, what is the future of clinical and psychopathological research, where should efforts be directed?
RR: Cognitive behavior therapy is based on educational principles of training people in practical, sensible skills. In the same way that any new skill can be taught in a variety of ways, CBT skills are very open to being learned through self-motivated methods. For many years we have shown that treatment can be very successfully delivered through printed materials (such as books). More recently of course, this information is now delivered via computers and smartphones. This should be no surprise and no threat to CBT therapists. What is disappointing however, is the number of people who try and create an “us vs them” mentality – either saying that treatment has to be done over the internet or in person. In reality the future of clinical research and therapy will be a blend of strategies. In some circumstances online treatments are the only answer, in other cases, some people only want to speak to a therapist in person. In Australia for example, some people live in areas where the nearest therapist may be more than 1,000 km away. For these people, internet treatment programs are a life-saver. However, the complexity of some problems may require an individualized approach.
We recently completed a study of stepped care for anxious young people. At the first step all participants did a self-help program and 40% needed no further intervention. The remaining 60% then went to manualised, face to face therapy and another 40% got better from that. The final 20% saw an experienced clinical psychologist for an individualized intervention. So in answer to your question, I think the future of clinical intervention is to work out the best combinations of blending and merging the various choices for treatment. We will need to balance, access, costs, people’s preference, and the type and complexity of their disorder.
Thank you for all your attention and detailed responses.
Forbes, M. K., Magson, N. R., & Rapee, R. M. (2020). Evidence that Different Types of Peer Victimization have Equivalent Associations with Transdiagnostic Psychopathology in Adolescence. Journal of Youth and Adolescence, 49(3), 590 604. https://doi.org/10.1007/s10964-020-01202-4
Forbes, M. K., Rapee, R. M., & Krueger, R. F. (2019). Opportunities for the prevention of mental disorders by reducing general psychopathology in early childhood. Behaviour Research and Therapy, 119(May), 103411. https://doi.org/10.1016/j.brat.2019.103411
Magson, N. R., Oar, E. L., Fardouly, J., Johnco, C. J., & Rapee, R. M. (2019). The Preteen Perfectionist: An Evaluation of the Perfectionism Social Disconnection Model. Child Psychiatry and Human Development, 50(6), 960–974. https://doi.org/10.1007/s10578-019-00897-2
Rapee, R. M., Forbes, M. K., Oar, E. L., Richardson, C. E., Johnco, C. J., Magson, N. R., & Fardouly, J. (2020). Testing a concurrent model of social anxiety in preadolescence. International Journal of Behavioral Development. https://doi.org/10.1177/0165025420912014
Spence, S. H., & Rapee, R. M. (2016). The etiology of social anxiety disorder: An evidence-based model. Behaviour Research and Therapy, 86, 50–67. https://doi.org/10.1016/j.brat.2016.06.007
Titov, N., Dear, B. F., Johnston, L., Lorian, C., Zou, J., Wootton, B., … Rapee, R. M. (2013). Improving Adherence and Clinical Outcomes in Self-Guided Internet Treatment for Anxiety and Depression: Randomised Controlled Trial. PLoS ONE, 8(7). https://doi.org/10.1371/journal.pone.0062873