Emerging Trends in The Social and Behavioral Sciences

What is Neuroticism, and Can We Treat it?

Media

Part of What is Neuroticism, and Can We Treat it?

Title

What is Neuroticism, and Can We Treat it?

extracted text

What Is Neuroticism,
and Can We Treat It?
AMANTIA AMETAJ, SHANNON SAUER-ZAVALA, and DAVID H. BARLOW

Abstract
We review the substantive role of neuroticism and related temperaments such as
extroversion in the development and maintenance of anxiety, mood, and related disorders subsumed under the term emotional disorders (EDs). We note that splitting these
disorders into discrete categories as in the current Diagnostic and Statistical Manual
(DSM-5) diagnoses may be highlighting relatively superficial differences. Research
on the structure of anxiety, mood, and related disorders indicates that neuroticism,
emerging from genetic, neurobiological, and psychological factors, is central to the
development of these disorders. We make a case for shifting the focus of psychological treatment of EDs to target core temperaments such as neuroticism, and discuss a
dimensional approach to assessing EDs that focuses on the underlying temperament.
We examine key issues requiring additional research to evaluate this possibility.

INTRODUCTION
WHAT IS NEUROTICISM?
The term temperament refers to an individual’s emotional nature, that is,
the typical way that one responds emotionally to his or her environment.
Temperament is hypothesized to arise from a combination of genetic and
environmental factors. Neuroticism is one trait under the larger umbrella of
temperament that refers to the dispositional tendency to experience frequent
and intense negative emotions (e.g., fear, anxiety, anger, sadness) in response
to internal and external stressors. Neuroticism is also characterized by a view
of the world as full of threatening and uncontrollable stressful situations
with which one has limited abilities to cope (Barlow, Sauer-Zavala, Carl,
Bullis, & Ellard, 2014b). Lastly, neuroticism is considered a risk factor for the
development of a variety of mental and physical health problems (Lahey,
Portions of this summary were presented by David H Barlow, PhD, ABPP as the James McKeen Cattell
address at the annual meeting of the Association for Psychological Science, May, 2012.
Emerging Trends in the Social and Behavioral Sciences. Edited by Robert Scott and Stephen Kosslyn.
© 2015 John Wiley & Sons, Inc. ISBN 978-1-118-90077-2.

1

2

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

2009), but its role in the development and maintenance of anxiety, mood,
and related emotional disorders is most often highlighted.
HOW HAS NEUROTICISM BEEN CONCEPTUALIZED IN MENTAL HEALTH?
In the early days of diagnostic classification, most disorders of emotion such
as anxiety, depression, and somatic symptom disorders were subsumed
under the large but nebulous category of “neurosis.” Since the publication
of the third edition of the Diagnostic and Statistical Manual of Mental Disorder
(DSM-III; APA, 1980) through the most recent edition (DSM-5; APA, 2013),
there has been an emphasis on splitting emotional disorders, such as anxiety
and depression, into finer categories (e.g., “neurosis” was divided into the
diagnostic categories of anxiety and mood such as panic disorder, major
depressive disorder, etc … ). This approach to diagnosis at first represented
an advancement for the field as a more objective and unifying classification system for emotional disorders and symptoms. However, splitting
anxiety, depressive, and related disorders into discrete categories seems
to exaggerate what may be superficial differences among these disorders.
In other words, although these disorders may have different defining
symptoms such as panic attacks in panic disorder and exaggerated worry
in generalized anxiety disorder, they may share at their core underlying
temperaments such as neuroticism that make these disorders fundamentally
similar with implications for diagnosis, assessment, and treatment. As
such, targeting neuroticism directly (as noted above), instead of the specific
disorders, may have implications for improving treatment outcomes by
addressing core dysfunctions rather than surface-level symptoms and by
providing a streamlined treatment that simultaneously addresses a range
of disorders. We will first discuss the foundational research supporting the
role of neuroticism and related temperaments in the development of the
range of anxiety, depressive, and related disorders, followed by more recent
studies highlighting new directions in diagnosis, assessment, and treatment
of emotional disorders.
FOUNDATIONAL RESEARCH
WHAT ARE THE SIMILARITIES AMONG ANXIETY, DEPRESSION, AND RELATED DISORDERS?
Interest in identifying core features common across the range of anxiety
and depressive disorders was influenced by three important findings. First,
there are high rates of comorbidity among these disorders, that is, anxiety
and depressive disorders often co-occur within the same individual (Brown,
Campbell, Lehman, Grisham, & Mancill, 2001). For example, a study of 1127
individuals reported that 55% of the patients with a principal diagnosis of

What Is Neuroticism, and Can We Treat It?

3

an anxiety disorder had at least one other anxiety or depressive disorder at
the time of the assessment, and 76% of the patients carried an additional
diagnosis at some point in their lifetime (Brown et al., 2001). Second, there
appears to be a broad and generalized treatment response across disorders
such that when a psychological intervention is administered for a specific
anxiety disorder, improvement is often seen in the comorbid anxiety or
depressive disorders not targeted explicitly by the intervention (Tsao,
Mystkowski, & Zucker, 2002). Finally, individuals with a range of anxiety
and depressive disorders demonstrate similar biological processes within
the nervous system, or neurobiological, abnormalities. Specifically, research
on individuals diagnosed with these disorders suggests overactivation in
the limbic system (the brain’s emotional center) coupled with decreased
ability to inhibit emotional responses by cortical structures (the brain’s
logical center) (Shin & Liberzon, 2010).
Taken together, these findings suggest that there may be common elements
across different diagnoses. For example, high rates of comorbidity among
anxiety and depressive disorders may be accounted for by shared core
dysfunction leading to the development of multiple disorders. Similarly,
by directly targeting only surface-level symptoms (e.g., panic attacks) in
treatment, we may be indirectly addressing this core problem, explaining
improvement in other diagnoses. Finally, the neurobiological similarities
described above provide further evidence for shared mechanisms, suggesting that although individual disorders may look different in terms of
symptom presentation, this appearance may be more trivial than the fact
that emotional disorders are being maintained by the same temperamental
functions.
HOW IS NEUROTICISM RELATED TO ANXIETY, DEPRESSION, AND RELATED DISORDERS?
Neuroticism has long been theorized as important for the development of
anxiety and depressive disorders. More recently, an additional temperamental trait, extraversion or positive affect––the tendency to experience positive
emotions––is also thought to influence the development of several of these
disorders characterized, in part, by low positive affect (anhedonia). These
two traits are included in every modern personality theory, underscoring
their fundamental importance for functioning (Eysenck & Eysenck, 1975;
McCrae & Costa, 1987). Indeed, high levels of neuroticism are demonstrated
in individuals diagnosed with the full range of anxiety and depressive
disorders (Weinstock & Whisman, 2006), and low levels of extraversion are
prevalent in individuals diagnosed primarily with unipolar depression,
social anxiety disorder, and agoraphobia (Rosellini, Lawrence, Meyer, &
Brown, 2010). Additionally, studies have shown that these temperamental

4

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

(Low)
extraversion

Neuroticism

Obsessivecompulsive
disorder

Generalized
anxiety
disorder

Panic
disorder

Agoraphobia

Major
depressive
disorder

Social
anxiety
disorder

Figure 1 Structural relationships among dimensions of DSM-IV anxiety and
mood disorders and dimensions of temperament. Source: Adapted with
permission from “Structural relationships among dimensions of the DSM–IV
anxiety and mood disorders and dimensions of negative affect, positive affect, and
autonomic arousal,” by T. A. Brown, B. F. Chorpita, and D. H. Barlow, 1998,
Journal of Abnormal Psychology, 107, p. 187. Copyright 1998 by the American
Psychological Association.

traits predict the onset of emotional disorders (Lahey, 2009). Further, influential theorists have proposed specific brain functions they believe to be
relevant to high neuroticism and low extraversion, specifically overactive
nervous system activation and underactive cortical inhibition, that map onto
the processes implicated in anxiety and depressive disorders (described
above). These findings forward the notion of investigating neuroticism as
a potential underlying, core vulnerability across anxiety and depressive
disorders as an important undertaking (Gray & McNaughton, 1996).
Recently, advances in statistical techniques have allowed researchers to
explore structural relationships among variables of interest. These types of
analyses can identify higher-order psychological dimensions that predict
or explain observable phenomena. Research on the structure of anxiety
and depressive disorders has found that neuroticism and extraversion
emerge as higher-order dimensions that explain many similarities among
the disorders in these categories (e.g., social anxiety disorder, major depressive disorder). In fact, all of the overlap among these disorders (e.g.,
comorbidity, temporal covariance) can be accounted for by temperamental
variables, largely neuroticism and in part extraversion (Brown, Chorpita,
& Barlow, 1998); see Figure 1 for a visual representation of the role of this
relationship.

What Is Neuroticism, and Can We Treat It?

5

More specifically, how neuroticism develops and how it leads to anxiety
and related disorders is explained by three separate but interacting vulnerabilities (Barlow, Ellard, Sauer-Zavala, Bullis, & Carl, 2014a). The first
vulnerability is biological, with genetic studies showing that up to 40%
of neuroticism can be explained by one’s genetic makeup (Shifman et al.,
2008). The second vulnerability is psychological and refers to a general
sense that stressful situations are uncontrollable and unpredictable. This
vulnerability seems to arise from early childhood experiences. Genetic
factors (biological vulnerability) and early life experiences (psychological
vulnerability) interact in the development of a neurotic temperament. Third,
a specific psychological vulnerability, also affected by environmental factors,
provides the basis for the emergence of one particular emotional disorder
versus another. For example, in addition to a genetic predisposition and a
general sense of uncontrollability (neuroticism), an individual with panic
disorder may have early experiences with illness, directing the focus of his
or her anxiety to unexplained or intense physical symptoms, more so than
someone without these experiences.
HOW DOES NEUROTICISM LEAD TO EMOTIONAL DISORDERS?
It is important to note that not all individuals demonstrating high levels
of negative affect, or neuroticism, go on to develop emotional disorders. In
addition to the experience of frequent and intense negative emotions, those
suffering from emotional disorders also display a greater aversion toward
negative emotions, particularly intense negative emotions, than healthy individuals most likely because of a “neurotic” sense that strong emotions themselves are unpredictable and uncontrollable (Barlow, 2002). Strong negative
reactions to emotional experiences, in turn, lead to attempts to suppress emotions (Aldao, Nolen-Hoeksema, & Schweizer, 2010), which have been shown
to, paradoxically, increase the intensity and duration of the negative emotional experience (Campbell-Sills, Barlow, Brown, & Hofmann, 2006).
Several psychological processes related to how individuals respond to
their emotions have been implicated in the development and maintenance of
emotional disorders, beyond the contribution of the tendency to experience
negative affect, or neuroticism, although these processes may be a consequence of neuroticism (Sauer-Zavala, Boswell, Gallagher, Bentley, Ametaj,
& Barlow, 2012). For example, individuals who demonstrate high levels of
anxiety sensitivity, the tendency to believe that symptoms of anxiety will
have negative physical consequences, are more likely to develop anxiety disorders (Boswell et al., 2013). Additionally, those who suffer from emotional
disorders also tend to show deficits in mindfulness (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996), defined as a present-focused nonjudgmental

6

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

awareness of experience (Kabat-Zinn, 1982). Research suggests that responding to negative emotions with mindfulness is more important in reducing
symptoms of anxiety and depression than the frequency of negative emotion
that one experiences (Sauer-Zavala et al., 2012). Another related construct
that has been implicated in the development and maintenance of emotional
disorders is experiential avoidance, defined as the unwillingness to remain
in contact with uncomfortable internal experiences (e.g., thoughts, emotions,
sensations, memories, urges; Hayes et al., 1996). Again, this variable has
been shown to contribute to the development of emotional disorders beyond
the contributions of frequency of negative affect (Pickett, Lodis, Parkhill, &
Orcutt, 2012). Taken together, these findings suggest that emotional disorder
symptoms are not simply a product of high levels of negative affect; instead,
the combination of strong negative emotions and how one relates to them
when they occur appears to be important for the development of these
disorders.
It is believed that the aversive responses to emotions described above lead
to attempts to avoid or escape emotional experiences. Avoidance can take
the form of overt behaviors that include evading social situations in social
anxiety disorder, avoiding reminders of traumatic events in posttraumatic
stress disorder, or refraining from engaging in activities in unipolar depression. More subtle forms of avoidance can include avoiding eye contact in
social situations for those with social anxiety disorder or avoiding exercise,
and thereby an increased heart rate and potential panic attack, for those
diagnosed with panic disorder. Patients also engage in mental forms of
avoidance, such as emotion suppression, defined as deliberately pushing
emotion-related stimuli (e.g., thoughts) out of awareness (Campbell-Sills
et al., 2006). There is ample research to suggest that engaging in avoidant
strategies backfires, paradoxically leading to increased frequency and
intensity of negative emotions (Rassin, Muris, Schmidt, & Merkelbach,
2000).
CUTTING-EDGE RESEARCH
NEW DIMENSIONAL SYSTEM OF DIAGNOSING DISORDERS
As noted above, the current classification system for mental disorders (e.g.,
DSM-5) splits anxiety, depressive, and related disorders into finer categories.
Although this has helped clinicians and scientists reliably diagnose disorders regardless of theoretical orientation, emerging research suggests that
these categories may be emphasizing relatively trivial symptom-level differences, while ignoring important commonalities. Rosellini and colleagues
(2014), updating Brown and Barlow (2009), propose a dimensional system for

What Is Neuroticism, and Can We Treat It?

7

diagnosing anxiety and depressive disorders that provides a profile, specifying levels of important characteristics that may be relevant across disorders,
rather than a specific diagnosis. This profile includes, in addition to ratings of
neuroticism and extraversion, specific and overlapping features seen among
emotional disorders that would help clinicians understand patients’ presenting problems and thus plan treatment accordingly to address the following:
1. Depressed mood represents excessive sadness and loss of pleasure in
activities, which is highly comorbid with emotional disorders (Brown
et al., 2001).
2. Autonomic arousal reflects the experience of panic that can occur in the
“context of any mental disorder,” such as flashbacks in posttraumatic
stress disorder (APA, 2013, p. 215).
3. Somatic anxiety consists of anxiety focused on one’s experience of bodily symptoms found across several emotional disorders (such as illness
anxiety disorder, panic disorder, generalized anxiety, etc.).
4. Social evaluation concerns represent anxiety focused on performance
situations and social interactions, which are at the core of social anxiety
disorder but span the spectrum of anxiety disorders (e.g., highlighted in
DSM-5 (APA, 2013, pp. 206–207)).
5. Intrusive cognitions reflect the experience of unwanted nonsensical
thoughts, images, and impulses (seen particularly in obsessive compulsive spectrum disorders and trauma spectrum disorders, and also in
other emotional disorders (APA, 2013, pp. 202, 225, 241).
6. Traumatic reexperiencing and dissociation not only consist of the experience of negative emotions triggered by past traumatic events, but also
include experiences of dissociating from reality (see DSM-5; APA, 2013
pp. 291, 296, 301 for an extensive discussion of the overlap of these disorders)
7. Avoidance, including experiential avoidance discussed above, is crucial
in assessing and treating emotional disorders and is included as a criterion for several diagnoses in DSM-5 (e.g., agoraphobia, specific phobia,
social anxiety disorder, posttraumatic stress disorder).
The advantages of this dimensional approach versus the current categorical system of diagnosis can be seen in the context of a hypothetical patient
meeting criteria for a single DSM-5 diagnosis of social anxiety disorder.
The dimensional profile includes high levels of neuroticism, low levels
of extraversion, situational avoidance, fear of social evaluation, trauma,
and panic symptoms. See Figure 2 for illustration of this hypothetical
profile. Under the current diagnostic system, unless a patient meets full
diagnostic criteria for a comorbid disorder, information on the dimensions

8

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

100
90
80
70
S
c
o
r
e

60
50
40
30
20
10
0
NT

PT/E

Temperament

DEP
Mood

SOM

AA

IC

SEC

TRM

AVD

Focus of anxiety

Figure 2 Example profile of patient evaluated with a dimensional classification
system. NT = neurotic temperament; PT/E = positive temperament/extraversion;
DEP = unipolar depression; SOM = somatic anxiety; AA = autonomic
arousal/panic; IC = intrusive cognitions; SEC = social evaluation concerns;
TRM = traumatic reexperiencing and dissociation; AVD = avoidance. Higher
scores on the y-axis (0–100) indicate higher levels of the x-axis dimension, but
otherwise the y-axis metric is arbitrary and is used for illustrative purposes.
Source: Adapted with permission from “Example profile of patient evaluated
with a dimensional classification system” by T. A. Brown, and D. H. Barlow, 2009,
Psychological Assessment, 21, p. 267. Copyright 2009 by the American
Psychological Association.

not associated with the primary diagnosis are discarded. In this case,
clinicians would not readily receive information about this patient’s anxiety
regarding trauma-related cues, as these symptoms are not associated with
a DSM-5 diagnosis of social anxiety disorder. Recently, a new measure, the
Multidimensional Emotional Disorder Inventory (MEDI), was developed to
assess these important characteristics of emotional disorders with a single
self-report assessment tool (Rosellini, 2013).
CAN WE TREAT NEUROTICISM?
Malleability of Neuroticism Although neuroticism, as a temperamental trait,
is thought to be relatively stable, several studies have shown that it may be
more malleable than originally thought. In the general population, studies
spanning across individuals’ lives show decreases in neuroticism with age
(Roberts, Walton, & Viechtbauer, 2006), with some individuals changing a
great deal and others remaining at relatively stable levels (Helson, Jones, &

What Is Neuroticism, and Can We Treat It?

9

Kwan, 2002). In clinical settings, research suggests that patients with higher
initial levels of neuroticism tend to show less change in this dimension over
time than those with lower initial levels of neuroticism, who tend to evidence
greater change (Brown, 2007).
Several studies have also examined treatment-related change in neuroticism in individuals receiving interventions for anxiety or depressive
disorders. For example, one study of 41 patients receiving treatment for
major depressive disorder found that, despite substantial improvements
in depressive symptoms, levels of neuroticism were remarkably stable
(Eaton, Krueger, & Oltmanns, 2011). Other studies, however, have found
shifts in neuroticism as a function of treatment. Brown (2007) found that,
in a sample of individuals diagnosed with a range of emotional disorders,
neuroticism evidenced a large degree of change that was highly predictive of
improvements on emotional disorder symptoms. Interestingly, the reverse
did not appear to be true, that is, change in DSM disorder symptoms did
not predict change in neuroticism (Naragon-Gainey, Gallagher, & Brown,
2013). In summary, evidence suggesting that neuroticism can be addressed
in treatment is mixed. One proposed explanation for these mixed findings is
that the treatments described above were not designed to address neuroticism specifically, but rather were developed to address presenting anxiety
and depressive symptoms.
Treating Neuroticism. More recently, several interventions directly targeting
temperament, specifically neuroticism, have emerged with promising
results. Some psychopharmacology approaches seem to influence temperament (for review, see Soskin, Carl, Alpert, & Fava, 2012). For example,
drug agents that increase levels of the neurotransmitter serotonin (e.g.,
SSRIs-selective serotonin reuptake inhibitors) are associated with decreases
in neuroticism. Explanations for why these medications seem to influence
temperament have been based on neurobiological properties. For example,
SSRIs have been shown to decrease overactivation of the amygdala and to
inhibit dopamine neurotransmitters in the prefrontal cortex, regions of the
brain that have been implicated in the maintenance of anxiety (Soskin et al.,
2012).
Currently, there are a few behavioral (nonmedication) treatments designed
to address temperamental vulnerabilities. One such treatment was developed by Rapee and colleagues (2010) for children identified as behaviorally
inhibited, a similar construct to neuroticism, to prevent the onset of anxiety
and related disorders. The program targets parents by teaching them about
the nature of anxiety, as well as cognitive–behavioral strategies for addressing personal concerns, and behavior management techniques to prevent

10

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

overprotective parenting (a condition that reduces the child’s sense of
control or self-efficacy). Results from controlled trials show that the program
is successful at preventing anxiety disorders and affecting temperament.
An intensive format with higher risk children resulted in reductions in the
measures of temperament for these children when compared to a group
that did not receive the treatment (Kennedy, Rapee, & Edwards, 2009). A
briefer version of the program prevented anxiety and related disorders,
but did not seem to impact temperament in the short-term, although more
long-term differences emerged, suggesting that interventions in childhood
might produce an increasing trajectory of change in temperament over the
years (Rapee, Kennedy, Ingram, Edwards, & Sweeney, 2010).
Given the clinical promise of addressing temperament, Barlow and
colleagues (2011) developed a cognitive–behavioral intervention targeting
neuroticism as a means to address anxiety and mood disorders. This treatment, the Unified Protocol (UP) for Transdiagnostic Treatment of Emotional
Disorders, described in detail elsewhere (Barlow et al., 2011), encourages
patients to develop a more accepting relationship with their emotional
experiences. Patients learn to tolerate and engage with their emotional
experience without judging it helping them to resist urges to engage in
avoidant coping strategies (Ellard, Fairholme, Boisseau, Farchione, &
Barlow, 2010). In turn, reduced avoidance changes the frequency and
intensity of future emotional experiences presumably through an extinction
process, and thereby impacts temperamental dimensions. The UP has been
shown as efficacious in improving the symptoms of a range of anxiety disorders (Ellard et al., 2010; Farchione et al., 2012) with stable improvements,
18 months following treatment (Bullis, Fortune, Farchione, & Barlow, in
press). Further, this treatment has been shown to produce moderate changes
on the levels of neuroticism compared with a wait-list group. These changes
in neuroticism are associated with improvements in symptoms, daily functioning, and quality of life (Carl, Gallagher, Sauer-Zavala, Bentley, & Barlow,
2013). Although preliminary, these results highlight the importance of how
changes in temperament may influence patients’ response to treatment.
KEY ISSUES FOR FUTURE RESEARCH
In summary, temperaments, particularly neuroticism, has emerged as an
important factor in the development of many psychological disorders. There
is preliminary evidence to suggest that this trait can be addressed directly
with psychological interventions and that treating neuroticism addresses the
core of symptoms of emotional disorders. It is important to note, however,
that the treatment of temperament is in its early stages and that continued
work in this area is necessary.

What Is Neuroticism, and Can We Treat It?

11

Several key issues arise from the foundational research reviewed above.
First, we have proposed a theory of how emotional disorders arise, implicating neuroticism as one of the core dimensions for the development
and maintenance of emotional disorders accompanied in some cases by
decreases in extraversion. However, some have argued that neuroticism is
not much more than an indicator of distress and a tautological descriptor
of psychopathology (McNally, 2011; Ormel, Rosmalen, & Farmer, 2004). At
the heart of these issues is the question of how emotional disorders develop
and are maintained. The answers to these issues are pursued by several
disciplines exploring the role of genes (e.g., geneticists), neurobiological
processes (e.g., neuroscientists), the environment (e.g., behaviorists), and
combinations of these domains (e.g., developmental psychologists and
clinical psychologists), and are contentiously debated. Studies that could
further answer the questions about the development and maintenance
of emotional disorders would include those that span longer periods of
time and include explorations of gene– environment interactions in the
development of temperament and emotional disorders.
Other key issues for future research include whether temperament can
change with treatment or over time. Some of the research we have reviewed
seems to indicate that neuroticism can change with treatment. However,
considering the complexity of temperament, more research is needed on
possible range restrictions on the malleability of temperament (e.g., age,
intensity level). Developmental psychology is a discipline that could aid
in answering questions about the malleability of temperament and possible prevention of neuroticism or closely related traits such as behavioral
inhibition (Kagan, 1994). Identification of early indicators of neuroticism in
infants and children may be important since it may be possible to intervene
on a public health scale before this trait is fully formed and negative consequences have not yet emerged (Barlow et al., 2014a). Another important
question is whether treating neuroticism, rather than symptoms of a specific
diagnosis (e.g., social anxiety disorder), indeed leads to better outcomes
for emotional disorders than treating these disorders with an intervention
specifically developed for a particular disorder. Finally, it will be important
to explore the clinical utility of the dimensional scheme for classifying
emotional disorders described above.
REFERENCES
Aldao, A., Nolen-Hoeksema, S., & Schweizer, S. (2010). Emotion-regulation strategies across psychopathology: A meta-analytic review. Clinical Psychology Review,
30, 217–237.
American Psychiatric Association (1980). Diagnostic and statistical manual of mental
disorders (3rd ed.). Washington, DC: Author.

12

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

American Psychiatric Association (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). Washington, DC: Author.
Barlow, D. H. (2002). Anxiety and its disorders: The nature and treatment of anxiety and
panic (2nd ed.). New York, NY: Guilford Press.
Barlow, D. H., Ellard, K. K., Fairholme, C., Farchione, T. J., Boisseau, C., Allen, L.,
& Ehrenreich-May, J. (2011). Unified protocol for the transdiagnostic treatment of emotional disorders. New York, NY: Oxford University Press.
Barlow, D. H., Ellard, K. K., Sauer-Zavala, S., Bullis, J. R., & Carl, J. R. (2014a). The
origins of neuroticism. Manuscript submitted for publication.
Barlow, D. H., Sauer-Zavala, S. E., Carl, J. R., Bullis, J. R., & Ellard, K. K. (2014b).
The nature, diagnosis, and treatment of neuroticism: Back to the future. Clinical
Psychological Science, 2(3), 344–365.
Boswell, J. F., Farchione, T. J., Sauer-Zavala, S. E., Murray, H. W., Fortune, M., &
Barlow, D. H. (2013). Anxiety sensitivity and interoceptive exposure: A transdiagnostic construct and change strategy. Behavior Therapy, 44, 417–431.
Brown, T. A. (2007). Temporal course and structural relationships among dimensions
of temperament and DSM–IV anxiety and mood disorder constructs. Journal of
Abnormal Psychology, 116, 313–328.
Brown, T. A., & Barlow, D. H. (2009). 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. Psychological Assessment, 21(3),
256–271.
Brown, T. A., Campbell, L. A., Lehman, C. L., Grisham, J. R., & Mancill, R. B. (2001).
Current and lifetime comorbidity of the DSM-IV anxiety and mood disorders in a
large clinical sample. Journal of Abnormal Psychology, 110, 49–58.
Brown, T. A., Chorpita, B. F., & Barlow, D. H. (1998). Structural relationships among
dimensions of the DSM-IV anxiety and mood disorders and dimensions of negative affect, positive affect, and autonomic arousal. Journal of Abnormal Psychology,
107, 179–192.
Bullis, J. R., Fortune, M. R., Farchione, T. J., & Barlow, D. H. (in press). A preliminary
investigation of the long-term outcome of the Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders. Comprehensive Psychiatry.
Campbell-Sills, L., Barlow, D. H., Brown, T. A., & Hofmann, S. G. (2006). Effects of
suppression and acceptance on emotional responses of individuals with anxiety
and mood disorders. Behaviour Research and Therapy, 44(9), 1251–1263.
Carl, J. R., Gallagher, M. W., Sauer-Zavala, S. E., Bentley, K. H., & Barlow, D. H. (2013).
A preliminary examination of the effects of the Unified Protocol on temperament.
Manuscript under review.
Eaton, N., Krueger, R., & Oltmanns, T. (2011). Aging and the structure and long-term
stability of the internalizing spectrum of personality and psychopathology. Psychology and Aging, 26, 987–993.
Ellard, K. K., Fairholme, C. P., Boisseau, C. L., Farchione, T. J., & Barlow, D. H. (2010).
Unified protocol for the transdiagnostic treatment of emotional disorders: Protocol
development and initial outcome data. Cognitive and Behavioral Practice, 17, 88–101.
doi:10.1016/j.cbpra.2009.06.002

What Is Neuroticism, and Can We Treat It?

13

Eysenck, H. J., & Eysenck, S. B. G. (1975). Manual of the eysenck personality questionnaire
(adult and junior). London, England: Hodder & Stoughton.
Farchione, T. J., Fairholme, C. P., Ellard, K. K., Boisseau, C. L., Thompson-Hollands,
J., Carl, J., … , Barlow, D. H. (2012) The unified protocol for the transdiagnostic
treatment of emotional disorders: A randomized controlled trial. Behavior Therapy,
43, 666–678.
Gray, J. A., & McNaughton, N. (1996). The neuropsychology of anxiety: A reprise. In
D. A. Hope (Ed.), Nebraska symposium on motivation: Vol. 43: Perspectives on anxiety,
panic, and fear (pp. 61–134). Lincoln, NE: University of Nebraska Press.
Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. M., & Strosahl, K. (1996). Experiential avoidance and behavioral disorders: A functional dimensional approach
to diagnosis and treatment. Journal of Consulting and Clinical Psychology, 64,
1152–1168.
Helson, R., Jones, C., & Kwan, V. S. (2002). Personality change over 40 years of adulthood: Hierarchical linear modeling analyses of two longitudinal samples. Journal
of Personality and Social Psychology, 83, 752–766.
Kabat-Zinn, J. (1982). An outpatient program in behavioral medicine for chronic pain
patients based on the practice of mindfulness meditation: Theoretical considerations and preliminary results. General Hospital Psychiatry, I, 33–47.
Kagan, J. (1994). Galen’s prophecy: Temperament in human nature. New York, NY: Basic
Books.
Kennedy, S. J., Rapee, R. M., & Edwards, S. L. (2009). A selective intervention
program for inhibited preschool-aged children of parents with an anxiety disorder: Effects on current anxiety disorders and temperament. Journal of the
American Academy of Child and Adolescent Psychiatry, 48, 602–609. doi:10.1097/
CHI.0b013e31819f6fa9
Lahey, B. B. (2009). Public health significance of neuroticism. American Psychologist,
64, 241–256.
McCrae, R. R., & Costa, P. T. (1987). Validation of the five factor model of personality
across instruments and observers. Journal of Personality and Social Psychology, 52,
81–90.
McNally, R. J. (2011). What is mental illness? Cambridge, MA: Harvard University
Press.
Naragon-Gainey, K., Gallagher, M. W., & Brown, T. A. (2013). Stable “trait” variance
of temperament as a predictor of the temporal course of depression and social
phobia. Journal of Abnormal Psychology, 122, 611–623.
Ormel, J., Rosmalen, J., & Farmer, A. (2004). Neuroticism: A non-informative marker
of vulnerability to psychopathology. Social Psychiatry and Psychiatric Epidemiology,
39, 906–912.
Pickett, S. M., Lodis, C. S., Parkhill, M. R., & Orcutt, H. K. (2012). Personality and
experiential avoidance: A model of anxiety sensitivity. Personality and Individual
Differences, 53, 246–250.
Rapee, R. M., Kennedy, S. J., Ingram, M., Edwards, S. L., & Sweeney, L. (2010). Altering the trajectory of anxiety in at-risk young children. The American Journal of
Psychiatry, 167, 1518–1525. doi:10.1176/appi.ajp.2010.09111619

14

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

Rassin, E., Muris, P., Schmidt, H., & Merkelbach, H. (2000). Relationship between
thought action fusion, thought suppression, and obsessive-compulsive symptoms: A structural equation model approach. Behaviour Research and Therapy, 38,
889–897.
Roberts, B. W., Walton, K. E., & Viechtbauer, W. (2006). Patterns of mean-level change
in personality traits across the life course: A meta-analysis of longitudinal studies.
Psychological Bulletin, 132, 1–25.
Rosellini A. J. (2013). Initial development and validation of a dimensional classification
system for the emotional disorders (Unpublished doctoral dissertation). Boston University, Boston, MA.
Rosellini, A. J., Boettcher, H., Brown, T. A., & Barlow, D. H. (2014). The development, validation, and assessment of a profile approach to emotional disorder classification.
Manuscript submitted for publication.
Rosellini, A. J., Lawrence, A. E., Meyer, J. F., & Brown, T. A. (2010). The effects of
extraverted temperament on agoraphobia in panic disorder. Journal of Abnormal
Psychology, 119, 420–426.
Sauer-Zavala, S., Boswell, J. F., Gallagher, M. W., Bentley, K. H., Ametaj, A., & Barlow,
D. H. (2012). The role of negative affectivity and negative reactivity to emotions
in predicting outcomes in the unified protocol for the transdiagnostic treatment of
emotional disorders. Behaviour Research and Therapy, 50, 551–557.
Shifman, S., Bhomra, A., Smiley, S., Wray, N. R. James, M. R., Martin, N. G., … , Flint,
J. (2008). A whole genome association study of neuroticism using DNA pooling.
Molecular Psychiatry, 13, 302–312.
Shin, L. M., & Liberzon, I. (2010). The neurocircuitry of fear, stress, and anxiety disorders. Neuropsychopharmacology, 35, 169–191.
Soskin, D. P., Carl, J. R., Alpert, J., & Fava, M. (2012). Antidepressant effects on emotional temperament: Toward a biobehavioral research paradigm for major depressive disorder. CNS Neuroscience & Therapeutics, 18, 441–451.
Tsao, J. C. I., Mystkowski, J. L., & Zucker, B. G. (2002). Effects of cognitive-behavioral
therapy for panic disorder on comorbid conditions: Replication and extension.
Behavior Therapy, 33, 493–509.
Weinstock, L. M., & Whisman, M. A. (2006). Neuroticism as a common feature of
the depressive and anxiety disorders: A test of the revised integrative hierarchical
model in a national sample. Journal of Abnormal Psychology, 115(1), 68–74.

FURTHER READING
Amazon web-link http://www.amazon.com/gp/product/0199772673/ref=pd_
lpo_k2_dp_sr_1?pf_rd_p=1535523722&pf_rd_s=lpo-top-stripe 1&pf_rd_t=201&
pf_rd_i=0199772665&pf_rd_m=ATVPDKIKX0DER&pf_rd_r=0X6P6WSH7279R
8S5Y6KS)
Barlow, D. H., Ellard, K. K., Fairholme, C., Farchione, T. J., Boisseau, C., Allen, L.,
& Ehrenreich-May, J. (2011). Unified protocol for the transdiagnostic treatment of emotional disorders. New York, NY: Oxford University Press.

What Is Neuroticism, and Can We Treat It?

15

Barlow, D. H., Sauer-Zavala, S., Carl, J. R., Bullis, J. R., & Ellard, K. K. (2014). The
nature, diagnosis, and treatment of neuroticism: Back to the future. Clinical Psychological Science, 2(3), 344–365.
Brown, T. A., & Barlow, D. H. (2009). 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. Psychological Assessment, 21(3),
256–271.
Campbell-Sills, L., Ellard, K. K., & Barlow, D. H. (2014). Incorporating emotion regulation into conceptualizations and treatments of anxiety and mood disorders. In
J. J. Gross (Ed.), Handbook of emotion regulation (2nd ed., pp. 393–412). New York,
NY: Guilford Press.
Farchione, T. J., Fairholme, C. P., Ellard, K. K., Boisseau, C. L., Thompson-Hollands,
J., Carl, J., … , Barlow, D. H. (2012). The unified protocol for the transdiagnostic
treatment of emotional disorders: A randomized controlled trial. Behavior Therapy,
43, 666–678.

AMANTIA AMETAJ SHORT BIOGRAPHY
Amantia Ametaj is a doctoral student at Boston University, where she
also completed her undergraduate degree. Her research interests include
understanding the psychological processes that lead to the development
and maintenance of emotional disorders, and exploring the mechanisms
of action implicated in psychological interventions that aid therapeutic
changes such as mindfulness and other emotion-regulatory processes.
SHANNON SAUER-ZAVALA SHORT BIOGRAPHY
Dr. Shannon Sauer-Zavala received her doctorate in Clinical Psychology
from the University of Kentucky. She completed her predoctoral internship
at Duke University Medical Center and her postdoctoral fellowship at
Boston University, focusing on cognitive–behavioral interventions for
anxiety disorders, depressive disorders, and borderline personality disorder.
Currently, Dr. Sauer-Zavala is a Research Assistant Professor at Boston University; her work is focused on exploring emotion-focused mechanisms that
maintain psychological symptoms, and using this information to develop
more targeted, easily disseminated intervention strategies.
DAVID H. BARLOW SHORT BIOGRAPHY
David H. Barlow is Professor of Psychology and Psychiatry and Founder and
Director Emeritus of the Center for Anxiety and Related Disorders at Boston
University. He received his PhD from the University of Vermont in 1969 and
has published over 500 articles and chapters, and over 60 books, mostly in the

16

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

area of the nature and treatment of emotional disorders. He is the recipient of
numerous awards, including the Distinguished Scientific Award for Applications of Psychology from the American Psychological Association and the
James McKeen Cattell Award from the Association for Psychological Science.
Web sites:
http://www.bu.edu/card/profile/david-h-barlow-ph-d/
http://bostonanxietytreatment.com/
RELATED ESSAYS
Peers and Adolescent Risk Taking (Psychology), Jason Chein
Delusions (Psychology), Max Coltheart
Misinformation and How to Correct It (Psychology), John Cook et al.
Problems Attract Problems: A Network Perspective on Mental Disorders
(Psychology), Angélique Cramer and Denny Borsboom
Controlling the Influence of Stereotypes on One’s Thoughts (Psychology),
Patrick S. Forscher and Patricia G. Devine
Depression (Psychology), Ian H. Gotlib and Daniella J. Furman
Positive Emotion Disturbance (Psychology), June Gruber and John Purcell
Family Relationships and Development (Psychology), Joan E. Grusec
Mental Imagery in Psychological Disorders (Psychology), Emily A. Holmes
et al.
Normal Negative Emotions and Mental Disorders (Sociology), Allan V.
Horwitz
Dissociation and Dissociative Identity Disorder (DID) (Psychology), Rafaële
J. C. Huntjens and Martin J. Dorahy
Computer Technology and Children’s Mental Health (Psychology), Philip C.
Kendall et al.
Cultural Neuroscience: Connecting Culture, Brain, and Genes (Psychology),
Shinobu Kitayama and Sarah Huff
Mechanisms of Fear Reducation (Psychology), Cynthia L. Lancaster and
Marie-H. Monfils
Disorders of Consciousness (Psychology), Martin M. Monti
Cognitive Remediation in Schizophrenia (Psychology), Clare Reeder and Til
Wykes
Cognitive Bias Modification in Mental (Psychology), Meg M. Reuland et al.
Clarifying the Nature and Structure of Personality Disorder (Psychology),
Takakuni Suzuki and Douglas B. Samuel
A Gene-Environment Approach to Understanding Youth Antisocial Behavior (Psychology), Rebecca Waller et al.
Rumination (Psychology), Edward R. Watkins



What Is Neuroticism,
and Can We Treat It?
AMANTIA AMETAJ, SHANNON SAUER-ZAVALA, and DAVID H. BARLOW

Abstract
We review the substantive role of neuroticism and related temperaments such as
extroversion in the development and maintenance of anxiety, mood, and related disorders subsumed under the term emotional disorders (EDs). We note that splitting these
disorders into discrete categories as in the current Diagnostic and Statistical Manual
(DSM-5) diagnoses may be highlighting relatively superficial differences. Research
on the structure of anxiety, mood, and related disorders indicates that neuroticism,
emerging from genetic, neurobiological, and psychological factors, is central to the
development of these disorders. We make a case for shifting the focus of psychological treatment of EDs to target core temperaments such as neuroticism, and discuss a
dimensional approach to assessing EDs that focuses on the underlying temperament.
We examine key issues requiring additional research to evaluate this possibility.

INTRODUCTION
WHAT IS NEUROTICISM?
The term temperament refers to an individual’s emotional nature, that is,
the typical way that one responds emotionally to his or her environment.
Temperament is hypothesized to arise from a combination of genetic and
environmental factors. Neuroticism is one trait under the larger umbrella of
temperament that refers to the dispositional tendency to experience frequent
and intense negative emotions (e.g., fear, anxiety, anger, sadness) in response
to internal and external stressors. Neuroticism is also characterized by a view
of the world as full of threatening and uncontrollable stressful situations
with which one has limited abilities to cope (Barlow, Sauer-Zavala, Carl,
Bullis, & Ellard, 2014b). Lastly, neuroticism is considered a risk factor for the
development of a variety of mental and physical health problems (Lahey,
Portions of this summary were presented by David H Barlow, PhD, ABPP as the James McKeen Cattell
address at the annual meeting of the Association for Psychological Science, May, 2012.
Emerging Trends in the Social and Behavioral Sciences. Edited by Robert Scott and Stephen Kosslyn.
© 2015 John Wiley & Sons, Inc. ISBN 978-1-118-90077-2.

1

2

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

2009), but its role in the development and maintenance of anxiety, mood,
and related emotional disorders is most often highlighted.
HOW HAS NEUROTICISM BEEN CONCEPTUALIZED IN MENTAL HEALTH?
In the early days of diagnostic classification, most disorders of emotion such
as anxiety, depression, and somatic symptom disorders were subsumed
under the large but nebulous category of “neurosis.” Since the publication
of the third edition of the Diagnostic and Statistical Manual of Mental Disorder
(DSM-III; APA, 1980) through the most recent edition (DSM-5; APA, 2013),
there has been an emphasis on splitting emotional disorders, such as anxiety
and depression, into finer categories (e.g., “neurosis” was divided into the
diagnostic categories of anxiety and mood such as panic disorder, major
depressive disorder, etc … ). This approach to diagnosis at first represented
an advancement for the field as a more objective and unifying classification system for emotional disorders and symptoms. However, splitting
anxiety, depressive, and related disorders into discrete categories seems
to exaggerate what may be superficial differences among these disorders.
In other words, although these disorders may have different defining
symptoms such as panic attacks in panic disorder and exaggerated worry
in generalized anxiety disorder, they may share at their core underlying
temperaments such as neuroticism that make these disorders fundamentally
similar with implications for diagnosis, assessment, and treatment. As
such, targeting neuroticism directly (as noted above), instead of the specific
disorders, may have implications for improving treatment outcomes by
addressing core dysfunctions rather than surface-level symptoms and by
providing a streamlined treatment that simultaneously addresses a range
of disorders. We will first discuss the foundational research supporting the
role of neuroticism and related temperaments in the development of the
range of anxiety, depressive, and related disorders, followed by more recent
studies highlighting new directions in diagnosis, assessment, and treatment
of emotional disorders.
FOUNDATIONAL RESEARCH
WHAT ARE THE SIMILARITIES AMONG ANXIETY, DEPRESSION, AND RELATED DISORDERS?
Interest in identifying core features common across the range of anxiety
and depressive disorders was influenced by three important findings. First,
there are high rates of comorbidity among these disorders, that is, anxiety
and depressive disorders often co-occur within the same individual (Brown,
Campbell, Lehman, Grisham, & Mancill, 2001). For example, a study of 1127
individuals reported that 55% of the patients with a principal diagnosis of

What Is Neuroticism, and Can We Treat It?

3

an anxiety disorder had at least one other anxiety or depressive disorder at
the time of the assessment, and 76% of the patients carried an additional
diagnosis at some point in their lifetime (Brown et al., 2001). Second, there
appears to be a broad and generalized treatment response across disorders
such that when a psychological intervention is administered for a specific
anxiety disorder, improvement is often seen in the comorbid anxiety or
depressive disorders not targeted explicitly by the intervention (Tsao,
Mystkowski, & Zucker, 2002). Finally, individuals with a range of anxiety
and depressive disorders demonstrate similar biological processes within
the nervous system, or neurobiological, abnormalities. Specifically, research
on individuals diagnosed with these disorders suggests overactivation in
the limbic system (the brain’s emotional center) coupled with decreased
ability to inhibit emotional responses by cortical structures (the brain’s
logical center) (Shin & Liberzon, 2010).
Taken together, these findings suggest that there may be common elements
across different diagnoses. For example, high rates of comorbidity among
anxiety and depressive disorders may be accounted for by shared core
dysfunction leading to the development of multiple disorders. Similarly,
by directly targeting only surface-level symptoms (e.g., panic attacks) in
treatment, we may be indirectly addressing this core problem, explaining
improvement in other diagnoses. Finally, the neurobiological similarities
described above provide further evidence for shared mechanisms, suggesting that although individual disorders may look different in terms of
symptom presentation, this appearance may be more trivial than the fact
that emotional disorders are being maintained by the same temperamental
functions.
HOW IS NEUROTICISM RELATED TO ANXIETY, DEPRESSION, AND RELATED DISORDERS?
Neuroticism has long been theorized as important for the development of
anxiety and depressive disorders. More recently, an additional temperamental trait, extraversion or positive affect––the tendency to experience positive
emotions––is also thought to influence the development of several of these
disorders characterized, in part, by low positive affect (anhedonia). These
two traits are included in every modern personality theory, underscoring
their fundamental importance for functioning (Eysenck & Eysenck, 1975;
McCrae & Costa, 1987). Indeed, high levels of neuroticism are demonstrated
in individuals diagnosed with the full range of anxiety and depressive
disorders (Weinstock & Whisman, 2006), and low levels of extraversion are
prevalent in individuals diagnosed primarily with unipolar depression,
social anxiety disorder, and agoraphobia (Rosellini, Lawrence, Meyer, &
Brown, 2010). Additionally, studies have shown that these temperamental

4

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

(Low)
extraversion

Neuroticism

Obsessivecompulsive
disorder

Generalized
anxiety
disorder

Panic
disorder

Agoraphobia

Major
depressive
disorder

Social
anxiety
disorder

Figure 1 Structural relationships among dimensions of DSM-IV anxiety and
mood disorders and dimensions of temperament. Source: Adapted with
permission from “Structural relationships among dimensions of the DSM–IV
anxiety and mood disorders and dimensions of negative affect, positive affect, and
autonomic arousal,” by T. A. Brown, B. F. Chorpita, and D. H. Barlow, 1998,
Journal of Abnormal Psychology, 107, p. 187. Copyright 1998 by the American
Psychological Association.

traits predict the onset of emotional disorders (Lahey, 2009). Further, influential theorists have proposed specific brain functions they believe to be
relevant to high neuroticism and low extraversion, specifically overactive
nervous system activation and underactive cortical inhibition, that map onto
the processes implicated in anxiety and depressive disorders (described
above). These findings forward the notion of investigating neuroticism as
a potential underlying, core vulnerability across anxiety and depressive
disorders as an important undertaking (Gray & McNaughton, 1996).
Recently, advances in statistical techniques have allowed researchers to
explore structural relationships among variables of interest. These types of
analyses can identify higher-order psychological dimensions that predict
or explain observable phenomena. Research on the structure of anxiety
and depressive disorders has found that neuroticism and extraversion
emerge as higher-order dimensions that explain many similarities among
the disorders in these categories (e.g., social anxiety disorder, major depressive disorder). In fact, all of the overlap among these disorders (e.g.,
comorbidity, temporal covariance) can be accounted for by temperamental
variables, largely neuroticism and in part extraversion (Brown, Chorpita,
& Barlow, 1998); see Figure 1 for a visual representation of the role of this
relationship.

What Is Neuroticism, and Can We Treat It?

5

More specifically, how neuroticism develops and how it leads to anxiety
and related disorders is explained by three separate but interacting vulnerabilities (Barlow, Ellard, Sauer-Zavala, Bullis, & Carl, 2014a). The first
vulnerability is biological, with genetic studies showing that up to 40%
of neuroticism can be explained by one’s genetic makeup (Shifman et al.,
2008). The second vulnerability is psychological and refers to a general
sense that stressful situations are uncontrollable and unpredictable. This
vulnerability seems to arise from early childhood experiences. Genetic
factors (biological vulnerability) and early life experiences (psychological
vulnerability) interact in the development of a neurotic temperament. Third,
a specific psychological vulnerability, also affected by environmental factors,
provides the basis for the emergence of one particular emotional disorder
versus another. For example, in addition to a genetic predisposition and a
general sense of uncontrollability (neuroticism), an individual with panic
disorder may have early experiences with illness, directing the focus of his
or her anxiety to unexplained or intense physical symptoms, more so than
someone without these experiences.
HOW DOES NEUROTICISM LEAD TO EMOTIONAL DISORDERS?
It is important to note that not all individuals demonstrating high levels
of negative affect, or neuroticism, go on to develop emotional disorders. In
addition to the experience of frequent and intense negative emotions, those
suffering from emotional disorders also display a greater aversion toward
negative emotions, particularly intense negative emotions, than healthy individuals most likely because of a “neurotic” sense that strong emotions themselves are unpredictable and uncontrollable (Barlow, 2002). Strong negative
reactions to emotional experiences, in turn, lead to attempts to suppress emotions (Aldao, Nolen-Hoeksema, & Schweizer, 2010), which have been shown
to, paradoxically, increase the intensity and duration of the negative emotional experience (Campbell-Sills, Barlow, Brown, & Hofmann, 2006).
Several psychological processes related to how individuals respond to
their emotions have been implicated in the development and maintenance of
emotional disorders, beyond the contribution of the tendency to experience
negative affect, or neuroticism, although these processes may be a consequence of neuroticism (Sauer-Zavala, Boswell, Gallagher, Bentley, Ametaj,
& Barlow, 2012). For example, individuals who demonstrate high levels of
anxiety sensitivity, the tendency to believe that symptoms of anxiety will
have negative physical consequences, are more likely to develop anxiety disorders (Boswell et al., 2013). Additionally, those who suffer from emotional
disorders also tend to show deficits in mindfulness (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996), defined as a present-focused nonjudgmental

6

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

awareness of experience (Kabat-Zinn, 1982). Research suggests that responding to negative emotions with mindfulness is more important in reducing
symptoms of anxiety and depression than the frequency of negative emotion
that one experiences (Sauer-Zavala et al., 2012). Another related construct
that has been implicated in the development and maintenance of emotional
disorders is experiential avoidance, defined as the unwillingness to remain
in contact with uncomfortable internal experiences (e.g., thoughts, emotions,
sensations, memories, urges; Hayes et al., 1996). Again, this variable has
been shown to contribute to the development of emotional disorders beyond
the contributions of frequency of negative affect (Pickett, Lodis, Parkhill, &
Orcutt, 2012). Taken together, these findings suggest that emotional disorder
symptoms are not simply a product of high levels of negative affect; instead,
the combination of strong negative emotions and how one relates to them
when they occur appears to be important for the development of these
disorders.
It is believed that the aversive responses to emotions described above lead
to attempts to avoid or escape emotional experiences. Avoidance can take
the form of overt behaviors that include evading social situations in social
anxiety disorder, avoiding reminders of traumatic events in posttraumatic
stress disorder, or refraining from engaging in activities in unipolar depression. More subtle forms of avoidance can include avoiding eye contact in
social situations for those with social anxiety disorder or avoiding exercise,
and thereby an increased heart rate and potential panic attack, for those
diagnosed with panic disorder. Patients also engage in mental forms of
avoidance, such as emotion suppression, defined as deliberately pushing
emotion-related stimuli (e.g., thoughts) out of awareness (Campbell-Sills
et al., 2006). There is ample research to suggest that engaging in avoidant
strategies backfires, paradoxically leading to increased frequency and
intensity of negative emotions (Rassin, Muris, Schmidt, & Merkelbach,
2000).
CUTTING-EDGE RESEARCH
NEW DIMENSIONAL SYSTEM OF DIAGNOSING DISORDERS
As noted above, the current classification system for mental disorders (e.g.,
DSM-5) splits anxiety, depressive, and related disorders into finer categories.
Although this has helped clinicians and scientists reliably diagnose disorders regardless of theoretical orientation, emerging research suggests that
these categories may be emphasizing relatively trivial symptom-level differences, while ignoring important commonalities. Rosellini and colleagues
(2014), updating Brown and Barlow (2009), propose a dimensional system for

What Is Neuroticism, and Can We Treat It?

7

diagnosing anxiety and depressive disorders that provides a profile, specifying levels of important characteristics that may be relevant across disorders,
rather than a specific diagnosis. This profile includes, in addition to ratings of
neuroticism and extraversion, specific and overlapping features seen among
emotional disorders that would help clinicians understand patients’ presenting problems and thus plan treatment accordingly to address the following:
1. Depressed mood represents excessive sadness and loss of pleasure in
activities, which is highly comorbid with emotional disorders (Brown
et al., 2001).
2. Autonomic arousal reflects the experience of panic that can occur in the
“context of any mental disorder,” such as flashbacks in posttraumatic
stress disorder (APA, 2013, p. 215).
3. Somatic anxiety consists of anxiety focused on one’s experience of bodily symptoms found across several emotional disorders (such as illness
anxiety disorder, panic disorder, generalized anxiety, etc.).
4. Social evaluation concerns represent anxiety focused on performance
situations and social interactions, which are at the core of social anxiety
disorder but span the spectrum of anxiety disorders (e.g., highlighted in
DSM-5 (APA, 2013, pp. 206–207)).
5. Intrusive cognitions reflect the experience of unwanted nonsensical
thoughts, images, and impulses (seen particularly in obsessive compulsive spectrum disorders and trauma spectrum disorders, and also in
other emotional disorders (APA, 2013, pp. 202, 225, 241).
6. Traumatic reexperiencing and dissociation not only consist of the experience of negative emotions triggered by past traumatic events, but also
include experiences of dissociating from reality (see DSM-5; APA, 2013
pp. 291, 296, 301 for an extensive discussion of the overlap of these disorders)
7. Avoidance, including experiential avoidance discussed above, is crucial
in assessing and treating emotional disorders and is included as a criterion for several diagnoses in DSM-5 (e.g., agoraphobia, specific phobia,
social anxiety disorder, posttraumatic stress disorder).
The advantages of this dimensional approach versus the current categorical system of diagnosis can be seen in the context of a hypothetical patient
meeting criteria for a single DSM-5 diagnosis of social anxiety disorder.
The dimensional profile includes high levels of neuroticism, low levels
of extraversion, situational avoidance, fear of social evaluation, trauma,
and panic symptoms. See Figure 2 for illustration of this hypothetical
profile. Under the current diagnostic system, unless a patient meets full
diagnostic criteria for a comorbid disorder, information on the dimensions

8

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

100
90
80
70
S
c
o
r
e

60
50
40
30
20
10
0
NT

PT/E

Temperament

DEP
Mood

SOM

AA

IC

SEC

TRM

AVD

Focus of anxiety

Figure 2 Example profile of patient evaluated with a dimensional classification
system. NT = neurotic temperament; PT/E = positive temperament/extraversion;
DEP = unipolar depression; SOM = somatic anxiety; AA = autonomic
arousal/panic; IC = intrusive cognitions; SEC = social evaluation concerns;
TRM = traumatic reexperiencing and dissociation; AVD = avoidance. Higher
scores on the y-axis (0–100) indicate higher levels of the x-axis dimension, but
otherwise the y-axis metric is arbitrary and is used for illustrative purposes.
Source: Adapted with permission from “Example profile of patient evaluated
with a dimensional classification system” by T. A. Brown, and D. H. Barlow, 2009,
Psychological Assessment, 21, p. 267. Copyright 2009 by the American
Psychological Association.

not associated with the primary diagnosis are discarded. In this case,
clinicians would not readily receive information about this patient’s anxiety
regarding trauma-related cues, as these symptoms are not associated with
a DSM-5 diagnosis of social anxiety disorder. Recently, a new measure, the
Multidimensional Emotional Disorder Inventory (MEDI), was developed to
assess these important characteristics of emotional disorders with a single
self-report assessment tool (Rosellini, 2013).
CAN WE TREAT NEUROTICISM?
Malleability of Neuroticism Although neuroticism, as a temperamental trait,
is thought to be relatively stable, several studies have shown that it may be
more malleable than originally thought. In the general population, studies
spanning across individuals’ lives show decreases in neuroticism with age
(Roberts, Walton, & Viechtbauer, 2006), with some individuals changing a
great deal and others remaining at relatively stable levels (Helson, Jones, &

What Is Neuroticism, and Can We Treat It?

9

Kwan, 2002). In clinical settings, research suggests that patients with higher
initial levels of neuroticism tend to show less change in this dimension over
time than those with lower initial levels of neuroticism, who tend to evidence
greater change (Brown, 2007).
Several studies have also examined treatment-related change in neuroticism in individuals receiving interventions for anxiety or depressive
disorders. For example, one study of 41 patients receiving treatment for
major depressive disorder found that, despite substantial improvements
in depressive symptoms, levels of neuroticism were remarkably stable
(Eaton, Krueger, & Oltmanns, 2011). Other studies, however, have found
shifts in neuroticism as a function of treatment. Brown (2007) found that,
in a sample of individuals diagnosed with a range of emotional disorders,
neuroticism evidenced a large degree of change that was highly predictive of
improvements on emotional disorder symptoms. Interestingly, the reverse
did not appear to be true, that is, change in DSM disorder symptoms did
not predict change in neuroticism (Naragon-Gainey, Gallagher, & Brown,
2013). In summary, evidence suggesting that neuroticism can be addressed
in treatment is mixed. One proposed explanation for these mixed findings is
that the treatments described above were not designed to address neuroticism specifically, but rather were developed to address presenting anxiety
and depressive symptoms.
Treating Neuroticism. More recently, several interventions directly targeting
temperament, specifically neuroticism, have emerged with promising
results. Some psychopharmacology approaches seem to influence temperament (for review, see Soskin, Carl, Alpert, & Fava, 2012). For example,
drug agents that increase levels of the neurotransmitter serotonin (e.g.,
SSRIs-selective serotonin reuptake inhibitors) are associated with decreases
in neuroticism. Explanations for why these medications seem to influence
temperament have been based on neurobiological properties. For example,
SSRIs have been shown to decrease overactivation of the amygdala and to
inhibit dopamine neurotransmitters in the prefrontal cortex, regions of the
brain that have been implicated in the maintenance of anxiety (Soskin et al.,
2012).
Currently, there are a few behavioral (nonmedication) treatments designed
to address temperamental vulnerabilities. One such treatment was developed by Rapee and colleagues (2010) for children identified as behaviorally
inhibited, a similar construct to neuroticism, to prevent the onset of anxiety
and related disorders. The program targets parents by teaching them about
the nature of anxiety, as well as cognitive–behavioral strategies for addressing personal concerns, and behavior management techniques to prevent

10

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

overprotective parenting (a condition that reduces the child’s sense of
control or self-efficacy). Results from controlled trials show that the program
is successful at preventing anxiety disorders and affecting temperament.
An intensive format with higher risk children resulted in reductions in the
measures of temperament for these children when compared to a group
that did not receive the treatment (Kennedy, Rapee, & Edwards, 2009). A
briefer version of the program prevented anxiety and related disorders,
but did not seem to impact temperament in the short-term, although more
long-term differences emerged, suggesting that interventions in childhood
might produce an increasing trajectory of change in temperament over the
years (Rapee, Kennedy, Ingram, Edwards, & Sweeney, 2010).
Given the clinical promise of addressing temperament, Barlow and
colleagues (2011) developed a cognitive–behavioral intervention targeting
neuroticism as a means to address anxiety and mood disorders. This treatment, the Unified Protocol (UP) for Transdiagnostic Treatment of Emotional
Disorders, described in detail elsewhere (Barlow et al., 2011), encourages
patients to develop a more accepting relationship with their emotional
experiences. Patients learn to tolerate and engage with their emotional
experience without judging it helping them to resist urges to engage in
avoidant coping strategies (Ellard, Fairholme, Boisseau, Farchione, &
Barlow, 2010). In turn, reduced avoidance changes the frequency and
intensity of future emotional experiences presumably through an extinction
process, and thereby impacts temperamental dimensions. The UP has been
shown as efficacious in improving the symptoms of a range of anxiety disorders (Ellard et al., 2010; Farchione et al., 2012) with stable improvements,
18 months following treatment (Bullis, Fortune, Farchione, & Barlow, in
press). Further, this treatment has been shown to produce moderate changes
on the levels of neuroticism compared with a wait-list group. These changes
in neuroticism are associated with improvements in symptoms, daily functioning, and quality of life (Carl, Gallagher, Sauer-Zavala, Bentley, & Barlow,
2013). Although preliminary, these results highlight the importance of how
changes in temperament may influence patients’ response to treatment.
KEY ISSUES FOR FUTURE RESEARCH
In summary, temperaments, particularly neuroticism, has emerged as an
important factor in the development of many psychological disorders. There
is preliminary evidence to suggest that this trait can be addressed directly
with psychological interventions and that treating neuroticism addresses the
core of symptoms of emotional disorders. It is important to note, however,
that the treatment of temperament is in its early stages and that continued
work in this area is necessary.

What Is Neuroticism, and Can We Treat It?

11

Several key issues arise from the foundational research reviewed above.
First, we have proposed a theory of how emotional disorders arise, implicating neuroticism as one of the core dimensions for the development
and maintenance of emotional disorders accompanied in some cases by
decreases in extraversion. However, some have argued that neuroticism is
not much more than an indicator of distress and a tautological descriptor
of psychopathology (McNally, 2011; Ormel, Rosmalen, & Farmer, 2004). At
the heart of these issues is the question of how emotional disorders develop
and are maintained. The answers to these issues are pursued by several
disciplines exploring the role of genes (e.g., geneticists), neurobiological
processes (e.g., neuroscientists), the environment (e.g., behaviorists), and
combinations of these domains (e.g., developmental psychologists and
clinical psychologists), and are contentiously debated. Studies that could
further answer the questions about the development and maintenance
of emotional disorders would include those that span longer periods of
time and include explorations of gene– environment interactions in the
development of temperament and emotional disorders.
Other key issues for future research include whether temperament can
change with treatment or over time. Some of the research we have reviewed
seems to indicate that neuroticism can change with treatment. However,
considering the complexity of temperament, more research is needed on
possible range restrictions on the malleability of temperament (e.g., age,
intensity level). Developmental psychology is a discipline that could aid
in answering questions about the malleability of temperament and possible prevention of neuroticism or closely related traits such as behavioral
inhibition (Kagan, 1994). Identification of early indicators of neuroticism in
infants and children may be important since it may be possible to intervene
on a public health scale before this trait is fully formed and negative consequences have not yet emerged (Barlow et al., 2014a). Another important
question is whether treating neuroticism, rather than symptoms of a specific
diagnosis (e.g., social anxiety disorder), indeed leads to better outcomes
for emotional disorders than treating these disorders with an intervention
specifically developed for a particular disorder. Finally, it will be important
to explore the clinical utility of the dimensional scheme for classifying
emotional disorders described above.
REFERENCES
Aldao, A., Nolen-Hoeksema, S., & Schweizer, S. (2010). Emotion-regulation strategies across psychopathology: A meta-analytic review. Clinical Psychology Review,
30, 217–237.
American Psychiatric Association (1980). Diagnostic and statistical manual of mental
disorders (3rd ed.). Washington, DC: Author.

12

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

American Psychiatric Association (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). Washington, DC: Author.
Barlow, D. H. (2002). Anxiety and its disorders: The nature and treatment of anxiety and
panic (2nd ed.). New York, NY: Guilford Press.
Barlow, D. H., Ellard, K. K., Fairholme, C., Farchione, T. J., Boisseau, C., Allen, L.,
& Ehrenreich-May, J. (2011). Unified protocol for the transdiagnostic treatment of emotional disorders. New York, NY: Oxford University Press.
Barlow, D. H., Ellard, K. K., Sauer-Zavala, S., Bullis, J. R., & Carl, J. R. (2014a). The
origins of neuroticism. Manuscript submitted for publication.
Barlow, D. H., Sauer-Zavala, S. E., Carl, J. R., Bullis, J. R., & Ellard, K. K. (2014b).
The nature, diagnosis, and treatment of neuroticism: Back to the future. Clinical
Psychological Science, 2(3), 344–365.
Boswell, J. F., Farchione, T. J., Sauer-Zavala, S. E., Murray, H. W., Fortune, M., &
Barlow, D. H. (2013). Anxiety sensitivity and interoceptive exposure: A transdiagnostic construct and change strategy. Behavior Therapy, 44, 417–431.
Brown, T. A. (2007). Temporal course and structural relationships among dimensions
of temperament and DSM–IV anxiety and mood disorder constructs. Journal of
Abnormal Psychology, 116, 313–328.
Brown, T. A., & Barlow, D. H. (2009). 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. Psychological Assessment, 21(3),
256–271.
Brown, T. A., Campbell, L. A., Lehman, C. L., Grisham, J. R., & Mancill, R. B. (2001).
Current and lifetime comorbidity of the DSM-IV anxiety and mood disorders in a
large clinical sample. Journal of Abnormal Psychology, 110, 49–58.
Brown, T. A., Chorpita, B. F., & Barlow, D. H. (1998). Structural relationships among
dimensions of the DSM-IV anxiety and mood disorders and dimensions of negative affect, positive affect, and autonomic arousal. Journal of Abnormal Psychology,
107, 179–192.
Bullis, J. R., Fortune, M. R., Farchione, T. J., & Barlow, D. H. (in press). A preliminary
investigation of the long-term outcome of the Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders. Comprehensive Psychiatry.
Campbell-Sills, L., Barlow, D. H., Brown, T. A., & Hofmann, S. G. (2006). Effects of
suppression and acceptance on emotional responses of individuals with anxiety
and mood disorders. Behaviour Research and Therapy, 44(9), 1251–1263.
Carl, J. R., Gallagher, M. W., Sauer-Zavala, S. E., Bentley, K. H., & Barlow, D. H. (2013).
A preliminary examination of the effects of the Unified Protocol on temperament.
Manuscript under review.
Eaton, N., Krueger, R., & Oltmanns, T. (2011). Aging and the structure and long-term
stability of the internalizing spectrum of personality and psychopathology. Psychology and Aging, 26, 987–993.
Ellard, K. K., Fairholme, C. P., Boisseau, C. L., Farchione, T. J., & Barlow, D. H. (2010).
Unified protocol for the transdiagnostic treatment of emotional disorders: Protocol
development and initial outcome data. Cognitive and Behavioral Practice, 17, 88–101.
doi:10.1016/j.cbpra.2009.06.002

What Is Neuroticism, and Can We Treat It?

13

Eysenck, H. J., & Eysenck, S. B. G. (1975). Manual of the eysenck personality questionnaire
(adult and junior). London, England: Hodder & Stoughton.
Farchione, T. J., Fairholme, C. P., Ellard, K. K., Boisseau, C. L., Thompson-Hollands,
J., Carl, J., … , Barlow, D. H. (2012) The unified protocol for the transdiagnostic
treatment of emotional disorders: A randomized controlled trial. Behavior Therapy,
43, 666–678.
Gray, J. A., & McNaughton, N. (1996). The neuropsychology of anxiety: A reprise. In
D. A. Hope (Ed.), Nebraska symposium on motivation: Vol. 43: Perspectives on anxiety,
panic, and fear (pp. 61–134). Lincoln, NE: University of Nebraska Press.
Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. M., & Strosahl, K. (1996). Experiential avoidance and behavioral disorders: A functional dimensional approach
to diagnosis and treatment. Journal of Consulting and Clinical Psychology, 64,
1152–1168.
Helson, R., Jones, C., & Kwan, V. S. (2002). Personality change over 40 years of adulthood: Hierarchical linear modeling analyses of two longitudinal samples. Journal
of Personality and Social Psychology, 83, 752–766.
Kabat-Zinn, J. (1982). An outpatient program in behavioral medicine for chronic pain
patients based on the practice of mindfulness meditation: Theoretical considerations and preliminary results. General Hospital Psychiatry, I, 33–47.
Kagan, J. (1994). Galen’s prophecy: Temperament in human nature. New York, NY: Basic
Books.
Kennedy, S. J., Rapee, R. M., & Edwards, S. L. (2009). A selective intervention
program for inhibited preschool-aged children of parents with an anxiety disorder: Effects on current anxiety disorders and temperament. Journal of the
American Academy of Child and Adolescent Psychiatry, 48, 602–609. doi:10.1097/
CHI.0b013e31819f6fa9
Lahey, B. B. (2009). Public health significance of neuroticism. American Psychologist,
64, 241–256.
McCrae, R. R., & Costa, P. T. (1987). Validation of the five factor model of personality
across instruments and observers. Journal of Personality and Social Psychology, 52,
81–90.
McNally, R. J. (2011). What is mental illness? Cambridge, MA: Harvard University
Press.
Naragon-Gainey, K., Gallagher, M. W., & Brown, T. A. (2013). Stable “trait” variance
of temperament as a predictor of the temporal course of depression and social
phobia. Journal of Abnormal Psychology, 122, 611–623.
Ormel, J., Rosmalen, J., & Farmer, A. (2004). Neuroticism: A non-informative marker
of vulnerability to psychopathology. Social Psychiatry and Psychiatric Epidemiology,
39, 906–912.
Pickett, S. M., Lodis, C. S., Parkhill, M. R., & Orcutt, H. K. (2012). Personality and
experiential avoidance: A model of anxiety sensitivity. Personality and Individual
Differences, 53, 246–250.
Rapee, R. M., Kennedy, S. J., Ingram, M., Edwards, S. L., & Sweeney, L. (2010). Altering the trajectory of anxiety in at-risk young children. The American Journal of
Psychiatry, 167, 1518–1525. doi:10.1176/appi.ajp.2010.09111619

14

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

Rassin, E., Muris, P., Schmidt, H., & Merkelbach, H. (2000). Relationship between
thought action fusion, thought suppression, and obsessive-compulsive symptoms: A structural equation model approach. Behaviour Research and Therapy, 38,
889–897.
Roberts, B. W., Walton, K. E., & Viechtbauer, W. (2006). Patterns of mean-level change
in personality traits across the life course: A meta-analysis of longitudinal studies.
Psychological Bulletin, 132, 1–25.
Rosellini A. J. (2013). Initial development and validation of a dimensional classification
system for the emotional disorders (Unpublished doctoral dissertation). Boston University, Boston, MA.
Rosellini, A. J., Boettcher, H., Brown, T. A., & Barlow, D. H. (2014). The development, validation, and assessment of a profile approach to emotional disorder classification.
Manuscript submitted for publication.
Rosellini, A. J., Lawrence, A. E., Meyer, J. F., & Brown, T. A. (2010). The effects of
extraverted temperament on agoraphobia in panic disorder. Journal of Abnormal
Psychology, 119, 420–426.
Sauer-Zavala, S., Boswell, J. F., Gallagher, M. W., Bentley, K. H., Ametaj, A., & Barlow,
D. H. (2012). The role of negative affectivity and negative reactivity to emotions
in predicting outcomes in the unified protocol for the transdiagnostic treatment of
emotional disorders. Behaviour Research and Therapy, 50, 551–557.
Shifman, S., Bhomra, A., Smiley, S., Wray, N. R. James, M. R., Martin, N. G., … , Flint,
J. (2008). A whole genome association study of neuroticism using DNA pooling.
Molecular Psychiatry, 13, 302–312.
Shin, L. M., & Liberzon, I. (2010). The neurocircuitry of fear, stress, and anxiety disorders. Neuropsychopharmacology, 35, 169–191.
Soskin, D. P., Carl, J. R., Alpert, J., & Fava, M. (2012). Antidepressant effects on emotional temperament: Toward a biobehavioral research paradigm for major depressive disorder. CNS Neuroscience & Therapeutics, 18, 441–451.
Tsao, J. C. I., Mystkowski, J. L., & Zucker, B. G. (2002). Effects of cognitive-behavioral
therapy for panic disorder on comorbid conditions: Replication and extension.
Behavior Therapy, 33, 493–509.
Weinstock, L. M., & Whisman, M. A. (2006). Neuroticism as a common feature of
the depressive and anxiety disorders: A test of the revised integrative hierarchical
model in a national sample. Journal of Abnormal Psychology, 115(1), 68–74.

FURTHER READING
Amazon web-link http://www.amazon.com/gp/product/0199772673/ref=pd_
lpo_k2_dp_sr_1?pf_rd_p=1535523722&pf_rd_s=lpo-top-stripe 1&pf_rd_t=201&
pf_rd_i=0199772665&pf_rd_m=ATVPDKIKX0DER&pf_rd_r=0X6P6WSH7279R
8S5Y6KS)
Barlow, D. H., Ellard, K. K., Fairholme, C., Farchione, T. J., Boisseau, C., Allen, L.,
& Ehrenreich-May, J. (2011). Unified protocol for the transdiagnostic treatment of emotional disorders. New York, NY: Oxford University Press.

What Is Neuroticism, and Can We Treat It?

15

Barlow, D. H., Sauer-Zavala, S., Carl, J. R., Bullis, J. R., & Ellard, K. K. (2014). The
nature, diagnosis, and treatment of neuroticism: Back to the future. Clinical Psychological Science, 2(3), 344–365.
Brown, T. A., & Barlow, D. H. (2009). 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. Psychological Assessment, 21(3),
256–271.
Campbell-Sills, L., Ellard, K. K., & Barlow, D. H. (2014). Incorporating emotion regulation into conceptualizations and treatments of anxiety and mood disorders. In
J. J. Gross (Ed.), Handbook of emotion regulation (2nd ed., pp. 393–412). New York,
NY: Guilford Press.
Farchione, T. J., Fairholme, C. P., Ellard, K. K., Boisseau, C. L., Thompson-Hollands,
J., Carl, J., … , Barlow, D. H. (2012). The unified protocol for the transdiagnostic
treatment of emotional disorders: A randomized controlled trial. Behavior Therapy,
43, 666–678.

AMANTIA AMETAJ SHORT BIOGRAPHY
Amantia Ametaj is a doctoral student at Boston University, where she
also completed her undergraduate degree. Her research interests include
understanding the psychological processes that lead to the development
and maintenance of emotional disorders, and exploring the mechanisms
of action implicated in psychological interventions that aid therapeutic
changes such as mindfulness and other emotion-regulatory processes.
SHANNON SAUER-ZAVALA SHORT BIOGRAPHY
Dr. Shannon Sauer-Zavala received her doctorate in Clinical Psychology
from the University of Kentucky. She completed her predoctoral internship
at Duke University Medical Center and her postdoctoral fellowship at
Boston University, focusing on cognitive–behavioral interventions for
anxiety disorders, depressive disorders, and borderline personality disorder.
Currently, Dr. Sauer-Zavala is a Research Assistant Professor at Boston University; her work is focused on exploring emotion-focused mechanisms that
maintain psychological symptoms, and using this information to develop
more targeted, easily disseminated intervention strategies.
DAVID H. BARLOW SHORT BIOGRAPHY
David H. Barlow is Professor of Psychology and Psychiatry and Founder and
Director Emeritus of the Center for Anxiety and Related Disorders at Boston
University. He received his PhD from the University of Vermont in 1969 and
has published over 500 articles and chapters, and over 60 books, mostly in the

16

EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

area of the nature and treatment of emotional disorders. He is the recipient of
numerous awards, including the Distinguished Scientific Award for Applications of Psychology from the American Psychological Association and the
James McKeen Cattell Award from the Association for Psychological Science.
Web sites:
http://www.bu.edu/card/profile/david-h-barlow-ph-d/
http://bostonanxietytreatment.com/
RELATED ESSAYS
Peers and Adolescent Risk Taking (Psychology), Jason Chein
Delusions (Psychology), Max Coltheart
Misinformation and How to Correct It (Psychology), John Cook et al.
Problems Attract Problems: A Network Perspective on Mental Disorders
(Psychology), Angélique Cramer and Denny Borsboom
Controlling the Influence of Stereotypes on One’s Thoughts (Psychology),
Patrick S. Forscher and Patricia G. Devine
Depression (Psychology), Ian H. Gotlib and Daniella J. Furman
Positive Emotion Disturbance (Psychology), June Gruber and John Purcell
Family Relationships and Development (Psychology), Joan E. Grusec
Mental Imagery in Psychological Disorders (Psychology), Emily A. Holmes
et al.
Normal Negative Emotions and Mental Disorders (Sociology), Allan V.
Horwitz
Dissociation and Dissociative Identity Disorder (DID) (Psychology), Rafaële
J. C. Huntjens and Martin J. Dorahy
Computer Technology and Children’s Mental Health (Psychology), Philip C.
Kendall et al.
Cultural Neuroscience: Connecting Culture, Brain, and Genes (Psychology),
Shinobu Kitayama and Sarah Huff
Mechanisms of Fear Reducation (Psychology), Cynthia L. Lancaster and
Marie-H. Monfils
Disorders of Consciousness (Psychology), Martin M. Monti
Cognitive Remediation in Schizophrenia (Psychology), Clare Reeder and Til
Wykes
Cognitive Bias Modification in Mental (Psychology), Meg M. Reuland et al.
Clarifying the Nature and Structure of Personality Disorder (Psychology),
Takakuni Suzuki and Douglas B. Samuel
A Gene-Environment Approach to Understanding Youth Antisocial Behavior (Psychology), Rebecca Waller et al.
Rumination (Psychology), Edward R. Watkins