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Symposium

Transdiagnostic and Therapeutic Processes
Symposium

Symposium 26 - Unveiling the Mechanisms of Internalizing Disorders: From Daily Affective Dynamics to Multidecade Trajectories and Scalable Interventions

Friday, June 26, 2026
11:00 AM - 12:30 PM PDT
Location: Yerba Buena Salon 7, B3 Level
CE: 1.5

Keywords: Substance Abuse , PTSD (Posttraumatic Stress Disorder), Translational Research
Level of Familiarity: All
Recommended Readings: Barber, K. E., Zainal, N. H., & Newman, M. G. (2023). The mediating effect of stress reactivity in the 18-year bidirectional relationship between generalized anxiety and depression severity. Journal of Affective Disorders, 325, 502-512. https://doi.org/10.1016/j.jad.2023.01.041,   Van Doren, N., Bray, B. C., Soto, J. A., & Linden-Carmichael, A. N. (2024). Associations between day-level affect profiles and same-day substance use among young adults. Psychology of Addictive Behaviors, 38(3), 323-333. https://doi.org/10.1037/adb0000979,   Luo, X., Che, X., Lei, Y., & Li, H. (2021). Investigating the influence of self-compassion-focused interventions on posttraumatic stress: A systematic review and meta-analysis. Mindfulness, 12(12), 2865-2876. https://doi.org/10.1007/s12671-021-01732-3,   Zainal, N. H., Soh, C. P., Van Doren, N., & Benjet, C. (2024). Do the effects of internet-delivered cognitive-behavioral therapy (i-CBT) last after a year and beyond? A meta-analysis of 154 randomized controlled trials (RCTs). Clinical Psychology Review, 114, 102518. https://doi.org/https://doi.org/10.1016/j.cpr.2024.102518,   Hayes, S. C., Hofmann, S. G., & Ciarrochi, J. (2020). A process-based approach to psychological diagnosis and treatment: The conceptual and treatment utility of an extended evolutionary meta model. Clinical Psychology Review, 82, 101908. https://doi.org/10.1016/j.cpr.2020.101908

The transition from syndrome-based diagnoses to process-based therapy necessitates rigorous delineation of mechanisms driving internalizing disorders. Although cognitive-behavioral therapies (CBT) are efficacious, the precise mediators and moderators of change remain elusive. This symposium integrates cutting-edge research across four levels of analysis: longitudinal modeling, daily diary assessment, clinical outcomes, and meta-analytic synthesis, offering multi-method evidence for affective and cognitive dynamics as transdiagnostic targets.

The first presentation leverages 18 years of data (N=735) to disentangle heterotypic continuity between Major Depressive Disorder (MDD) and Generalized Anxiety Disorder (GAD). Using structural equation mediation modeling, results reveal stress reactivity dynamics–both mean levels and day-to-day fluctuations–mediate the MDD-to-GAD pathway, but not the reverse. Risk appraisal plays a negligible role. These findings underscore emotional reactivity’s primacy over cognitive appraisal in comorbidity progression, suggesting that monitoring daily reactivity patterns serves as a vital early warning system for preventing diagnostic transitions.

The second presentation uses ecological momentary assessment (N=154, 1,878 person-days) to test the “affect regulation hypothesis” in young adults with substance use and internalizing symptoms. By modeling multidimensional “affective profiles,” the study reveals that depression and anxiety function as distal vulnerability factors biasing the daily “affective ecosystem”–trapping individuals in chronic low-arousal or volatile states–rather than as proximal triggers for use. Internalizing symptoms did not moderate the immediate affect-use link. These findings challenge the “self-medication” model, suggesting interventions must restructure daily affective contexts rather than solely target distress-use associations.

The third presentation examines self-compassion as a mechanism of change during a trauma-focused partial hospitalization program (N=59). Linear mixed models revealed significant improvements in self-compassion and trauma-coping self-efficacy during treatment and reduced posttraumatic stress, emotion dysregulation, and dissociation. Reductions in PTSD symptoms were significantly related to improved self-compassion (ρ=-.68). Self-compassion may be a promising mechanism to target during trauma-focused treatment.

The final presentation provides meta-analytic structural equation modeling synthesis of 549 randomized trials (N=134090) of digitally delivered CBT (d-CBT) for common mental disorders. While d-CBT yields robust direct effects on depression, anxiety, and quality of life, rigorous bias correction and sensitivity analyses consistently nullify previously significant mediators. This indicates the field has yet to robustly identify d-CBT’s unique change mechanisms, calling for urgent methodological refinements.

The discussant will synthesize these findings to propose a multi-level mechanism research framework, advocating for greater methodological rigor and focus on dynamic, context-dependent processes to enhance CBT’s precision.

Learning Objectives:

  • Differentiate between stress reactivity and risk appraisal as long-term mediators of the MDD-GAD link.
  • Explain the “affective ecosystem” hypothesis and how internalizing symptoms bias daily affect profiles.
  • Identify the temporal role of self-compassion as a mechanism in trauma-focused partial hospitalization.
  • Evaluate the robustness of change mechanisms in digitally delivered CBT using meta-analytic structural equation modeling.
  • Discuss the methodological challenges in identifying robust mediators in both longitudinal and intervention research.
  • Translate mechanistic findings into clinically actionable targets for personalizing internalizing disorder treatment.
  • Synthesize multi-level evidence to justify shifting from symptom reduction to process-based intervention in clinical settings.

Presentations:

  • 11:06 AM - 11:27 AM PDT
    (SYM 26) Testing How Digital Cognitive Behavioral Therapy Works for Anxiety and Depressive Symptoms: Meta-analytic Structural Equation Modeling of 549 Randomized Trials

    Speaker: Nur Hani Zainal, M.S., Ph.D. (she/her/hers) – National University of Singapore

    Co-Author: Sarah Josephine Rajendra, B.S. – Arizona State University (ASU)

    Co-Author: Jordan Wen Juin Chng, B.S. – National University of Singapore (NUS)

    Co-Author: Justina Sue Ching Tan, B.S. – National University of Singapore (NUS)

    Co-Author: Anna Petersen, B.S. Candidate – Brigham Young University (BYU)

    Co-Author: Natalia Van Doren, Ph.D. – UCSF

  • 11:27 AM - 11:48 AM PDT
    (SYM 26) Stress Reactivity and Risk Appraisal Mediate the Association Between Major Depressive Disorder and Generalized Anxiety Disorder Symptoms over 18 Years

    Speaker: Tian Liang, Other (she/her/hers) – National University of Singapore

    Co-Author: Nur Hani Zainal, M.S., Ph.D. (she/her/hers) – National University of Singapore

  • 11:48 AM - 12:09 PM PDT
    (SYM 26) Improvements in Self-compassion Are Associated with Reductions in Posttraumatic Stress During a Partial Hospitalization Program for Trauma-related and Dissociative Disorders

    Speaker: Annie-Lori Joseph Denk, Ph.D. (she/her/hers) – Massachusetts General Hospital/Harvard Medical School

    Co-Author: Annie-Lori Joseph Denk, Ph.D. (she/her/hers) – Massachusetts General Hospital/Harvard Medical School

    Co-Author: Matthew Jeram, PhD (he/him/his) – Suffolk University

    Co-Author: Amanda W. Baker, Ph.D. (she/her/hers) – Massachusetts General Hospital/Harvard Medical School

    Co-Author: Matthew Robinson, PhD (he/him/his) – McLean Hospital/Harvard Medical School

  • 12:09 PM - 12:30 PM PDT
    (SYM 26) Not All Bad Days Lead to Use: Depression and Anxiety Symptoms Predict Daily Affect Profiles Among Young Adults Who Use Alcohol and Cannabis

    Speaker: Natalia Van Doren, Ph.D. – UCSF

    Co-Author: Dusti Jones, Ph.D. – University of Utah

    Co-Author: Bethany Bray, PhD – The University of Illinois at Chicago

    Co-Author: Ashley Linden-Carmichael, Ph.D. – University of Oregon