The review, by Chen Yang of Nanjing University of Science and Technology, defines RNT as persistent, repetitive and difficult-to-disengage negative thinking. It encompasses depressive rumination and anxiety-related worry, which are generally directed toward different time frames but share recurrent engagement with distressing content, negative affect and difficulty disengaging. Meta-analytic evidence cited in the paper indicates substantial overlap between rumination and worry, supporting their treatment as related manifestations of a broader process rather than symptoms confined to separate diagnoses.

The author used a structured search of PubMed/MEDLINE, Scopus, Web of Science Core Collection, PsycINFO and Google Scholar for publications from January 2000 through June 2026. The searches yielded 1,352 records; after removal of 318 duplicates, 1,034 records underwent title-and-abstract screening and 124 were assessed in full text. Sixty-two publications were retained, including primary studies, systematic reviews, meta-analyses, theoretical articles and mechanistic studies. Because the literature varied substantially in populations, measures and designs, the author conducted a narrative synthesis rather than a meta-analysis and did not perform a formal risk-of-bias assessment.

Childhood adversity was treated in the review as a developmental risk factor rather than a sufficient or inevitable cause of depression. The synthesis associated emotional, physical and sexual abuse, neglect and other adverse experiences with greater later vulnerability to depressive symptoms and major depressive disorder. Outcomes nevertheless varied with trauma type, severity, chronicity, developmental timing and cumulative exposure. Potential pathways included altered stress reactivity, impaired emotion regulation, negative cognitive processing and changes in neural systems involved in threat and reward. The author concluded that trauma history alone cannot explain why some exposed individuals develop depression while others do not.

Stress sensitization was proposed as one biological component of that variability. Studies summarized in the review found both heightened and diminished cortisol or adrenocorticotropic hormone responses among people with maltreatment histories, while maltreated children with internalizing symptoms showed altered cortisol regulation. The direction and magnitude of these changes varied with developmental stage, trauma characteristics, current psychiatric status and adaptation. The review also discussed associations between early adversity and inflammation, autonomic regulation, neuroplasticity and brain-network organization, but did not treat any single biological marker as specific to trauma-related depression.

RNT may persist because people struggle to redirect attention, switch perspectives or disengage from distressing content. The review cited findings of delayed attention disengagement from angry faces among physically abused children, threat-related attentional differences associated with abuse severity, poorer task switching among adolescents exposed to early-life stress, and weaker executive functioning among some trauma-exposed children. It also described reduced autobiographical-memory specificity and greater negative self-representations in maltreated children, as well as structural and network alterations involving the hippocampus, amygdala, medial prefrontal cortex, cingulate cortex, precuneus and insula. These observations provide plausible mechanisms, but direct evidence connecting trauma-related neural changes to RNT remains limited.

Emotion regulation flexibility was presented as a potential interacting mechanism. Rather than classifying individual strategies as universally adaptive or maladaptive, this approach emphasizes whether a response fits the demands of a particular context and can be revised when circumstances change. Flexible regulation involves monitoring emotional feedback, selecting among strategies and recovering after activation. Reduced flexibility may make it harder to interrupt unproductive RNT, while RNT may itself narrow attention and weaken sensitivity to contextual information. The review characterized these relationships as potentially reciprocal, although studies directly testing the interaction between emotion regulation flexibility and RNT remain scarce.

Intervention research summarized in the review included a randomized trial of 145 people with recurrent major depression in which mindfulness-based cognitive therapy reduced relapse or recurrence risk; a 60-person concreteness-training trial that reported reduced depressive symptoms and rumination; a 42-person rumination-focused cognitive behavioral therapy trial that reported improved residual depression, with effects mediated by reduced rumination; and a 432-person trial among inpatients with major depressive disorder in which emotion regulation skills training plus cognitive behavioral therapy produced greater reductions in depression than standard cognitive behavioral therapy alone. These trials support interventions that can affect related processes in specific populations, but they do not establish that RNT is the causal bridge from childhood trauma to depression.

The review’s central conclusion is therefore bounded. RNT is proposed as a transdiagnostic cognitive phenotype that could help explain how trauma-related biological, emotional and cognitive vulnerabilities translate into persistent depressive symptoms. The evidence remains heterogeneous, and the predominance of cross-sectional research prevents firm conclusions about whether RNT is an antecedent, mediator or consequence of depression. Differences in assessment, trauma characteristics and developmental timing further limit generalization, while the reliance on English-language publications and predominantly Western samples may restrict applicability. The authors call for longitudinal and mechanistic studies using standardized measures, neuroimaging, ecological momentary assessment and other multimodal methods to clarify these pathways.

Subject of Research: Narrative review of repetitive negative thinking, childhood trauma and depression vulnerability

Article Title: Repetitive negative thinking as a transdiagnostic bridge between childhood trauma and depression: Integrating emotion regulation flexibility, stress sensitization, and neurocognitive mechanisms

Article References: Yang, C. (2026). Repetitive negative thinking as a transdiagnostic bridge between childhood trauma and depression: Integrating emotion regulation flexibility, stress sensitization, and neurocognitive mechanisms. Frontiers in Psychiatry, 17, Article 1941842. https://doi.org/10.3389/fpsyt.2026.1941842

Image Credits: AI Generated

DOI: 10.3389/fpsyt.2026.1941842

Keywords: repetitive negative thinking, childhood trauma, depression, transdiagnostic mechanisms, emotion regulation flexibility, stress sensitization, neurocognition, narrative review, Repetitive, negative, thinking, transdiagnostic

The intervention, known by the acronym CHAPTER, which stands for Combined Healthy lifestyle intervention Aimed at Psychiatric outpatients Targeting Enhanced Recovery, was designed to be transdiagnostic, meaning it was not tailored to a single psychiatric label but offered to outpatients across diagnoses, including depression, personality disorders and autism spectrum disorder. Rather than targeting one behavior, CHAPTER addressed eight lifestyle domains in an integrated way: physical activity, nutrition, relaxation, sleep, substance use, spirituality, social participation and nature. The recovery-oriented philosophy behind the design reflects a growing consensus in psychiatry that recovery is more than symptom reduction, encompassing personal, societal and functional dimensions of a patient’s life.

In the pilot trial, forty-six outpatients were randomized in a one-to-one ratio to either the intervention or treatment as usual. The intervention consisted of twelve weekly group sessions followed by three follow-up sessions, delivered by trained lifestyle coaches in specialist mental healthcare settings in the Netherlands. Outcomes were administered at baseline, post-intervention and follow-up, and the research team evaluated three categories of results: feasibility, measured through recruitment, retention and adherence; acceptability, assessed through participant evaluations and trainer feedback; and preliminary exploratory effectiveness, captured with self-report questionnaires and physical measurements across several recovery outcomes, including the Recovery Assessment Scale as the primary effect measure.

The feasibility results form the technical heart of the study. Intervention attendance reached seventy-one percent, a relatively high figure for a population often described as difficult to engage in group programs, and the dropout rate was just thirteen percent. Overall study retention, meaning participants who completed outcome assessments across all measurement points, stood at eighty-three percent. For a pilot trial in specialist mental healthcare, these numbers indicate that both the intervention protocol and the research procedures could be delivered in real-world clinical practice with minimal risks reported by trainers and participants.

Acceptability data reinforced that picture. Participants rated the intervention 7.4 out of 10, and they particularly valued the sessions on relaxation and spirituality. The content and its difficulty were reported as appropriate, suggesting the program struck a workable balance between accessibility and substance. Trainers, however, flagged organizational factors that require attention for broader implementation, including staff capacity, high workload and organizational instability within mental healthcare institutions. These findings matter because even a well-designed intervention can fail in practice if the surrounding organizational infrastructure cannot support it.

On preliminary effectiveness, the exploratory analyses suggested positive trends across various recovery domains, notably on the long term for societal and personal recovery. Participants in the intervention group showed encouraging movement on measures of recovery, quality of life and functioning compared with those receiving treatment as usual. The researchers were careful, however, to note that the effect estimates were imprecise, with ninety-five percent confidence intervals that included zeros, meaning the observed trends could reflect chance. These exploratory findings should be interpreted with caution, and the study was not powered to detect effectiveness with statistical certainty.

The technical design of the pilot reflects methodological rigor for an early-stage trial. The trial was preregistered on 30 May 2023 in the Overview of Medical Research in the Netherlands under registration number NL-OMON53239, with CCMO register number NL83935.042.23, and the research protocol was approved by the Medical Ethical Committee of the University Medical Centre Groningen. The research team used modern statistical approaches for handling missing data, including multiple imputation using chained equations and last observation carried forward, and they assessed determinants of implementation with the Measurement Instrument for Determinants of Innovations. Physical measurements included body mass index alongside self-report questionnaires such as the Outcome Questionnaire 45 and the World Health Organization Disability Assessment Schedule.

What makes this pilot noteworthy in the broader scientific conversation is its inclusive, transdiagnostic approach. Most lifestyle intervention studies in psychiatry focus on a single diagnosis, most commonly depression or psychosis, and on a single behavior, most commonly physical activity. By contrast, CHAPTER was offered to a heterogeneous sample of outpatients across diagnoses and targeted eight domains simultaneously. The researchers argue that this inclusive multidomain design appears feasible and well received, and that the results encourage further testing in a fully powered randomized controlled trial with a larger sample and longer follow-up.

The recovery-oriented framework underlying the intervention also deserves attention. The Recovery Assessment Scale, used as the primary effect measure, captures how patients themselves experience their recovery, including confidence in personal goals, willingness to seek help and the ability to manage symptoms in daily life. The positive long-term trends on societal and personal recovery align with the idea that lifestyle change can support functional and existential dimensions of wellbeing that symptom-focused treatment alone often leaves untouched. The particular appreciation for relaxation and spirituality sessions suggests that patients value domains that conventional psychiatric care rarely addresses in a structured group format.

As with any pilot study, the limitations are real. The sample of forty-six participants is small, the follow-up period is limited, and the imprecise effect estimates mean the preliminary effectiveness findings cannot yet be considered evidence of impact. Organizational barriers flagged by trainers, including workload and instability, also complicate the path to routine implementation. Still, the combination of high attendance, low dropout, strong retention and favorable participant ratings marks this study as a promising proof of concept. If a fully powered trial confirms the exploratory trends, multidomain lifestyle interventions could become a structured, recovery-oriented complement to standard psychiatric outpatient care, offering patients a way to work on sleep, movement, nutrition, connection and meaning alongside their regular treatment.

Subject of Research: A pilot randomized controlled trial of a transdiagnostic multidomain lifestyle intervention for psychiatric outpatients

Article Title: A pilot randomized controlled trial of a transdiagnostic multidomain lifestyle intervention for psychiatric outpatients: feasibility, acceptability and preliminary effectiveness for improving recovery

Article References: Schillemans, C., Castelein, S., Steffek, E., Booij, S. H., & Hoenders, H. J. R. (2026). A pilot randomized controlled trial of a transdiagnostic multidomain lifestyle intervention for psychiatric outpatients: feasibility, acceptability and preliminary effectiveness for improving recovery. BMC Psychiatry. https://doi.org/10.1186/s12888-026-08552-6

Image Credits: AI Generated

DOI: 10.1186/s12888-026-08552-6

Keywords: pilot, randomized, controlled, trial, transdiagnostic, multidomain, lifestyle, intervention, psychiatric, outpatients, feasibility, acceptability

Misophonia, characterized by decreased tolerance to specific sounds and related stimuli, affects an estimated five percent of adults in the United States according to epidemiological studies. Central to the condition are triggers: repetitive or rhythmic sounds such as chewing, slurping, throat clearing, pen clicking, or keyboard tapping that provoke intense affective, behavioral, and cognitive responses. While previous research has identified neurological, psychological, and social correlates of misophonia, most studies have relied on cross-sectional snapshots, leaving scientists with limited understanding of how symptoms rise and fall in real time and which factors drive those fluctuations.

The research team recruited fifty-eight adults who screened positive for clinical misophonia symptoms through the soQuiet research pool, a nonprofit organization focused on misophonia support and awareness. Participants excluded were those reporting a diagnosis of autism spectrum disorder or psychotic disorder. After completing a baseline battery of questionnaires, each volunteer carried a digital survey program for thirty days, responding three times daily. The surveys used both interval-contingent prompts and event-contingent assessments triggered whenever participants encountered a bothersome sound, allowing the researchers to separate misophonia experiences during triggers from those occurring in their absence.

At the heart of the study were two transdiagnostic factors: anxiety sensitivity and distress tolerance. Anxiety sensitivity refers to the fear of anxiety-related sensations themselves, such as a racing heart or tight chest, and is a well-established risk factor for anxiety disorders. Distress tolerance describes a person’s perceived ability to withstand and manage negative emotional states. Both are considered malleable emotional-vulnerability factors that can be targeted in brief clinical interventions, making them attractive candidates for understanding and eventually treating misophonia symptom amplification.

The baseline measures included the sixteen-item Anxiety Sensitivity Index, the fifteen-item Distress Tolerance Scale, the eighteen-item Obsessive-Compulsive Inventory-Revised, and the six-item Amsterdam Misophonia Scale, all with good to excellent internal consistency. During the daily phase, participants rated momentary misophonia symptoms using an adapted version of the Duke-Vanderbilt Misophonia Screening Questionnaire, with the phrase right now added to capture in-the-moment experience. Momentary emotion dysregulation was assessed with a six-item version of the Difficulties in Emotion Regulation Scale covering domains such as impulse control, awareness, clarity, and non-acceptance of emotional responses.

The results revealed a nuanced pattern. In bivariate correlations, higher baseline anxiety sensitivity was associated with greater misophonia symptoms both during triggers and in their absence, while higher distress intolerance correlated with more severe symptoms during triggers but not when triggers were absent. Obsessive-compulsive symptoms and baseline misophonia severity also correlated with longitudinal symptom levels. However, when the researchers entered all predictors simultaneously into multilevel models that controlled for momentary emotion dysregulation, baseline misophonia, and obsessive-compulsive symptoms, most of these effects attenuated dramatically.

One exception stood out. Anxiety sensitivity remained a significant predictor of misophonia symptoms during triggers when analyzed in a standalone model, with individuals higher in anxiety sensitivity reporting more elevated symptoms in response to momentary trigger sounds. Yet even this effect faded when the researchers applied a Benjamini-Hochberg correction for multiple comparisons, yielding an adjusted p-value of 0.055 that fell just short of conventional significance thresholds. The authors emphasize that replication in larger samples is needed before firm conclusions can be drawn about anxiety sensitivity as an independent predictor.

The null findings for distress tolerance proved theoretically informative rather than disappointing. Exploratory mediation analyses suggested that momentary emotion dysregulation served as a mediator of the relation between distress intolerance and misophonia symptoms, both during and outside trigger episodes. In other words, people who cannot tolerate distress appear to experience misophonia symptoms indirectly through their struggles to regulate emotions in the moment. Anxiety sensitivity, by contrast, showed a pattern more consistent with a direct effect, since emotion dysregulation did not significantly mediate its relation with misophonia.

The researchers offer a compelling mechanistic explanation for the anxiety sensitivity finding. Individuals with high anxiety sensitivity tend to misinterpret innocuous bodily sensations as dangerous, for example interpreting a racing heart as a sign of a heart attack. People with misophonia commonly experience physiological arousal when anticipating or encountering triggers, including increased heart rate. This sensitivity to and catastrophization of arousal signals may amplify the emotional cascade that trigger sounds set off. Notably, anxiety and anger share similar markers of physiological arousal, and both emotions are commonly reported in response to misophonia triggers, suggesting that anxiety sensitivity may capture a broader tendency to catastrophize emotional arousal regardless of whether it manifests as fear or rage.

The clinical implications are significant. Anxiety sensitivity can be reduced through brief interventions, some delivered in as little as a single session, and prior randomized controlled trials have shown that decreases in anxiety sensitivity temporally mediate reductions in anger, hostility, and aggression. For individuals with misophonia and high distress intolerance, interventions targeting emotion regulation abilities may prove more appropriate. The authors caution that their sample was relatively homogeneous, predominantly White, female, and recruited from an advocacy organization, potentially limiting generalizability to the broader population of people with misophonia. They also note that the modest number of independent participants, despite the high volume of repeated daily observations, warrants caution. Future research should examine cognitive, behavioral, and physiological responses across all stages of trigger episodes, potentially using dynamic structural equation models to capture the temporal interplay between affective reactions and misophonia symptoms. For now, the study provides a roadmap for identifying malleable psychological targets that could eventually inform clinical interventions for a condition that remains poorly understood and difficult to treat.

Subject of Research: Longitudinal predictors of misophonia symptoms including anxiety sensitivity, distress tolerance, and emotion dysregulation

Article Title: Transdiagnostic and clinical predictors of longitudinal misophonia symptoms

Article References: Pavlacic, J. M., Gaines, A. N., Witcraft, S. M., Freshley, A., Buchanan, E. M., Cortese, B., Sege, C., Rheingold, A. A., Uhde, T., & Dixon, L. J. (2026). Transdiagnostic and clinical predictors of longitudinal misophonia symptoms. Frontiers in Cognition, 5, Article 1945899. https://doi.org/10.3389/fcogn.2026.1945899

Image Credits: AI Generated

DOI: 10.3389/fcogn.2026.1945899

Keywords: misophonia, anxiety sensitivity, distress tolerance, emotion dysregulation, ecological momentary assessment, trigger sounds, transdiagnostic factors, obsessive-compulsive symptoms, clinical psychology, longitudinal study, Transdiagnostic, clinical

The Constructive Aggression Behavioral System is a concept rooted in evolutionary psychology. It refers to an evolutionarily grounded pattern of behavior that allows individuals to assert their needs, interests, and boundaries in a non-violent and socially adaptive manner. Crucially, researchers distinguish it from destructive aggression: CABS is not about hostility, violence, or lashing out, but about the everyday ability to say no, defend personal limits, and pursue one’s own goals in socially acceptable ways. When this system is inhibited, the theory holds, people struggle to stand up for themselves, suppress legitimate anger, and accommodate others at their own expense. Over time, this chronic self-suppression has been proposed as a clinically relevant factor in emotional disorders, including depression, where feelings of helplessness, submissiveness, and unexpressed frustration are common features of the clinical picture.

To measure this construct, the team used the Aggressionshemmungs-Inventar, or AHI, a psychometric instrument designed to quantify the inhibition of constructive aggression. The study followed 416 inpatients with major depressive disorder, assessing them with the AHI and with the revised Beck Depression Inventory, the BDI-II, at two key points: admission to and discharge from inpatient treatment. The researchers then conducted three hierarchical multiple regression analyses. The first examined whether AHI scores at discharge were associated with the change in depressive symptoms from admission to discharge. The second tested whether those scores predicted depressive symptoms at six-month follow-up. The third asked whether they predicted psychiatric readmission within one year. Importantly, the analyses controlled for a range of potential confounders, including age, gender, suicidality, unemployment, comorbid anxiety, and antidepressant use, strengthening the case that the associations were not simply artifacts of these better-known risk factors.

The results were striking from the very first measurement. At admission, patients showed markedly elevated AHI scores, with a mean standardized value of 1.40, indicating substantial inhibition of constructive aggression across the group. In other words, people arriving for inpatient depression treatment were, on average, far more inhibited in their capacity for healthy assertiveness than the reference population. During the course of treatment, both depressive symptoms and AHI scores decreased significantly, suggesting that the two move together as patients recover. This parallel improvement hints at a possible coupling between the ability to assert oneself constructively and the severity of depressive symptoms, although the observational design of the study means the direction of that relationship cannot be determined with certainty.

The most consequential findings emerged from the follow-up analyses. AHI scores at discharge were associated not only with symptom change during treatment but also with depressive symptoms at the six-month follow-up and with readmission to psychiatric care within one year. Patients who left the hospital still highly inhibited in their constructive aggression were more likely to remain symptomatic and to end up back on the ward. Because the regression models adjusted for suicidality, unemployment, comorbid anxiety, antidepressant use, and demographic variables, the association appears to carry prognostic information beyond what these established risk factors capture. If replicated, this would make CABS inhibition a candidate transdiagnostic marker, one that could help clinicians flag depressed patients who need intensified aftercare, closer monitoring, or targeted psychotherapeutic work on assertiveness and boundary-setting.

Why might suppressed assertiveness matter so much for depression? Several theoretical threads converge on an answer. Evolutionary accounts suggest that the capacity to defend one’s interests is a fundamental behavioral adaptation; when it is chronically blocked, individuals may experience persistent frustration, powerlessness, and social defeat, all of which are known to be linked to depressive states. From a clinical perspective, patients who cannot say no or articulate their needs may remain locked in stressful interpersonal dynamics that continuously reinforce feelings of worthlessness and hopelessness. Standard antidepressant treatment, whether pharmacological or psychotherapeutic, does not always address this underlying pattern. The study’s authors frame CABS inhibition as a potentially transdiagnostic construct, meaning it may cut across diagnostic categories such as depression and anxiety rather than being specific to any single disorder, which would explain why it correlates with outcomes even after accounting for comorbid anxiety.

The authors are careful about what their data can and cannot show. Because the study is observational and naturalistic, meaning patients received routine clinical care rather than an experimental intervention, the results do not allow conclusions about causal effects. It remains possible that CABS inhibition is a consequence of depression rather than a contributor to it, or that a third factor drives both. Depressed patients may simply find it harder to assert themselves, and lingering inhibition at discharge may reflect residual illness rather than an independent risk factor. The researchers explicitly call for future longitudinal and experimental studies to examine whether changes in CABS inhibition are associated with changes in clinical outcomes, and to clarify the construct’s potential role in the onset and maintenance of emotional disorders. Only such studies, ideally with interventions designed to reduce constructive aggression inhibition, could establish whether targeting it improves recovery.

Even with those caveats, the practical implications are considerable. Depression remains one of the world’s most burdensome conditions, and readmission within a year of discharge is a persistent problem for psychiatric services. A simple, validated questionnaire such as the AHI could, in principle, be administered at discharge at negligible cost, offering clinicians an additional signal about who is at risk of relapse. If subsequent research confirms the predictive value of CABS inhibition, therapeutic modules aimed at strengthening constructive assertiveness, teaching patients to express needs and set boundaries without aggression, could be integrated into inpatient programs and aftercare planning. Such approaches would complement, not replace, existing treatments, but they might address a dimension of the illness that current protocols often overlook.

The study also speaks to a broader shift in psychiatric research away from purely symptom-based models and toward transdiagnostic mechanisms, traits, and behaviors that cut across diagnostic boundaries. Constructs like CABS inhibition sit at the intersection of evolutionary psychology, behavioral neuroscience, and clinical psychopathology, and they invite researchers to ask not only what is wrong in depression but what adaptive capacities have been suppressed. The Hamburg and Marienheide team’s work, conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of the Medical Association of Nordrhein, with written informed consent from all participants, offers a carefully controlled first step in that direction. Whether reducing the inhibition of constructive aggression proves to be a lever for better recovery will depend on the experimental and longitudinal studies the authors now call for, but the message of this naturalistic study is already clear: the ability to stand up for oneself, calmly and without hostility, may matter far more for mental health than psychiatry has traditionally assumed.

Subject of Research: The association between inhibition of the Constructive Aggression Behavioral System and treatment outcomes in major depressive disorder

Article Title: Inhibition of the Constructive Aggression Behavioral System (CABS) is associated with poor short- and long-term treatment outcomes and readmission among patients with major depression: a naturalistic study

Article References: Maß, R., Backhaus, K., Pütz, K., & Szelies, M. (2026). Inhibition of the Constructive Aggression Behavioral System (CABS) is associated with poor short- and long-term treatment outcomes and readmission among patients with major depression: a naturalistic study. BMC Psychiatry, 26(1), Article 720. https://doi.org/10.1186/s12888-026-08490-3

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DOI: 10.1186/s12888-026-08490-3

Keywords: constructive aggression, CABS, major depressive disorder, AHI, depression treatment outcomes, psychiatric readmission, assertiveness, transdiagnostic, evolutionary psychology, psychotherapy outcome, inhibition, prognosis

Rejection sensitivity, a construct first formalized by Geraldine Downey and Scott Feldman in 1996, describes a disposition to anxiously expect, readily perceive, and intensely react to social rejection. People high in rejection sensitivity scan their social world for cues of impending dismissal, interpret ambiguous signals as threatening, and respond with disproportionate emotional force. Decades of research have linked this trait to a strikingly wide range of outcomes, from jealousy and conflict in intimate relationships to aggression, withdrawal, and, increasingly, disordered eating attitudes and behaviors. The breadth of that list is precisely what created the conceptual puzzle the new study set out to solve.

The puzzle can be stated in the language of clinical theory. Psychopathology is often organized along two broad axes: internalizing disorders, in which distress is turned inward, producing anxiety, depression, and conditions such as eating disorders; and externalizing disorders, in which distress is directed outward, producing aggression, impulsivity, and conduct problems. Rejection sensitivity has been implicated in both domains. That raises a structural question about the architecture of risk. Is the pathway sequential, with rejection sensitivity first producing aggression, which then somehow manifests as disordered eating? Or are aggression and disordered eating parallel outputs, two independent translations of the same underlying social threat system into different behavioral currencies?

To answer it, Kuzgun recruited 344 university students, roughly 61 percent of them female, with a mean age of about 20 years. Emerging adulthood is a strategically chosen window for this kind of work: it is a period of intense social reorganization, identity formation, and heightened concern with peer evaluation, and it is also a period in which disordered eating attitudes frequently emerge or intensify. Participants completed validated self-report instruments measuring rejection sensitivity, aggression, and eating attitudes, including Turkish adaptations of established scales such as the Buss-Perry Aggression Questionnaire and the Eating Attitudes Test short form. The study received ethical approval from Istanbul Arel University in March 2025, and informed consent was obtained from all participants.

The analytical engine of the study was structural equation modeling, a statistical framework that allows researchers to test whether a network of hypothesized relationships is consistent with the observed patterns of covariance among measured variables. Crucially, this approach makes it possible to evaluate mediation: whether the effect of one variable on another travels through a third variable, or whether a direct pathway remains once the indirect route is accounted for. In this case, the model tested whether aggression carried the influence of rejection sensitivity onto disordered eating attitudes, or whether rejection sensitivity reached disordered eating on its own.

The descriptive findings were consistent with a large body of prior work. Rejection sensitivity was positively associated with both aggression and disordered eating attitudes, meaning that students who anxiously expected rejection also reported more hostile tendencies and more problematic attitudes toward food and eating. Up to that point, the data told a familiar story. The decisive test came next, when the model separated the direct pathway from the indirect one.

The result was unambiguous in one direction and null in the other. Rejection sensitivity significantly predicted aggression, replicating its well-established role as an externalizing risk factor. But aggression, once its own relationship with rejection sensitivity was modeled, was not associated with disordered eating attitudes. The indirect effect, the hypothesized chain running from rejection sensitivity through aggression to disordered eating, was not statistically significant. Instead, rejection sensitivity retained a significant direct association with disordered eating attitudes. In other words, the link between expecting rejection and eating pathologically did not depend on hostility toward others; it operated along its own channel.

The theoretical implication is that aggression and disordered eating are best understood as parallel rather than sequential responses to rejection sensitivity. One response externalizes, converting anticipated social pain into anger and aggression toward others. The other internalizes, converting the same anticipated pain into disturbed attitudes toward eating, a domain of behavior that is, notably, directed at the self. This framing refines current models of interpersonal vulnerability by suggesting that a single social-cognitive trait can be transduced into qualitatively different forms of psychopathology, and that clinicians and researchers should not assume that treating one manifestation will automatically defuse the other.

The study also reinforces a growing movement to treat rejection sensitivity as a transdiagnostic vulnerability, a risk factor that cuts across diagnostic categories rather than belonging to any single disorder. Recent work cited in the article points in the same direction: longitudinal research has linked rejection sensitivity and related justice sensitivity to eating disorder pathology over five-year spans, systematic reviews have documented the role of social rejection sensitivity in anorexia nervosa, and experimental and longitudinal studies have connected appearance-based and interpersonal rejection sensitivity to loss-of-control eating in youth. Some researchers have argued that sensitivity to rejection may matter even more than actual experiences of peer stress for the development of eating pathology, a claim that fits neatly with the new finding that the pathway is direct rather than mediated by outward hostility.

As with any single study, important caveats apply. The design is cross-sectional, capturing associations at one point in time rather than tracking how risk unfolds across development, so causal direction cannot be established from these data alone. The sample consists of university students rather than clinical patients, and eating attitudes were measured by self-report, which may not fully capture diagnosed eating disorders. The data are also not publicly available, though the author notes they can be requested. Even so, the study’s central contribution stands: by statistically disentangling two candidate pathways, it provides evidence that the road from rejection sensitivity to disordered eating does not run through aggression. For a field increasingly interested in identifying shared mechanisms of vulnerability, that is a meaningful piece of the map, suggesting that the anxious anticipation of rejection may be a common root from which both outward anger and inward struggles with food can grow, each on its own branch.

Subject of Research: Rejection sensitivity as a transdiagnostic risk factor linking aggression and disordered eating attitudes in young adults

Article Title: Rejection sensitivity and disordered eating: evidence for distinct internalizing and externalizing pathways

Article References: Kuzgun, T. B. (2026). Rejection sensitivity and disordered eating: evidence for distinct internalizing and externalizing pathways. Current Psychology, 45(20), Article 1611. https://doi.org/10.1007/s12144-026-10171-z

Image Credits: AI Generated

DOI: 10.1007/s12144-026-10171-z

Keywords: rejection sensitivity, disordered eating, aggression, internalizing, externalizing, structural equation modeling, transdiagnostic, eating attitudes, emerging adulthood, psychology, social cognition, emotion regulation

The research team recruited three carefully matched groups of adults, with fifty-one participants in each: individuals diagnosed with borderline personality disorder, psychiatric controls who experienced other mental health difficulties, and healthy controls with no psychiatric diagnosis. This three-group design is critical, because it allows researchers to distinguish what is specific to borderline personality disorder from what is shared across forms of psychological distress. Many symptoms once considered hallmark features of the disorder, including impulsivity and self-injury, turn out to be elevated in other clinical populations as well. By comparing all three groups on the same measures, the study could determine whether emptiness and its behavioral consequences truly set borderline personality disorder apart, or whether they represent a more general phenomenon of psychological suffering.

Methodologically, the study went beyond simple questionnaires. Participants completed the Subjective Emptiness Scale, a validated instrument measuring the depth and persistence of inner void experiences, along with a newly developed inventory assessing self-destructive behaviors that occur specifically in response to feelings of emptiness. This novel measure is an important technical advance, because prior research often conflated self-destructive acts driven by many different triggers. By asking participants to report harmful behaviors that follow emptiness episodes in particular, the researchers could isolate the pathway from the inner void to harmful action rather than measuring a general tendency toward self-harm that might stem from anger, shame, or other emotional states entirely.

The study’s most ambitious component involved measuring mentalizing, the capacity to understand behavior, both one’s own and that of others, in terms of underlying mental states such as thoughts, feelings, desires, and intentions. Mentalizing has become one of the most influential constructs in contemporary theories of borderline personality disorder, and mentalization-based treatment is a widely used therapeutic approach built on the idea that improving this capacity reduces symptoms. Participants completed two separate interviews coded with the Reflective Functioning Scale, a gold-standard scoring system in the field. The first interview assessed general mentalizing about relationships and life experiences. The second was a novel emptiness-focused interview, designed to capture what the researchers call emptiness-specific mentalizing: the ability to make sense of the experience of inner void itself, to reflect on what emptiness feels like, where it comes from, and what it means.

The results confirmed the centrality of emptiness in the disorder. Individuals with borderline personality disorder reported significantly greater emptiness than both psychiatric controls and healthy controls, and they also reported more self-destructive behaviors overall and more self-destructive behaviors specifically following episodes of emptiness. This pattern held even when compared against other people receiving mental health care, strengthening the argument that emptiness is not merely a nonspecific symptom of general distress but a distinctive and clinically significant feature of borderline personality disorder. For clinicians, the finding reinforces what many patients describe anecdotally: the void is not a side note to the disorder but one of its core, driving experiences.

Yet the study also produced a genuinely surprising result. Despite the theoretical prominence of mentalizing in models of borderline personality disorder, the BPD group did not differ from the comparison groups in either general mentalizing or emptiness-specific mentalizing as assessed in these retrospective interviews. This finding challenges a straightforward version of the mentalizing deficit hypothesis, at least as it applies to this population and this measurement approach. It suggests that when people with borderline personality disorder are interviewed in a structured, reflective setting about their experiences, their capacity to describe mental states may be comparable to that of other adults, including healthy ones. Deficits, if they exist, may be more state-dependent, emerging under emotional arousal or in interpersonal situations rather than in calm, retrospective reflection.

The central hypothesis of the study concerned moderation: the researchers predicted that stronger mentalizing would buffer the link between emptiness and self-destructive behavior, so that people who could make sense of their inner void would be less likely to act on it destructively. Across all three groups, emptiness did predict self-destructive behaviors, confirming the intuitive and clinically important association between the inner void and harmful action. However, neither group membership nor mentalizing moderated this association. In other words, the relationship between feeling empty and acting destructively held its strength regardless of how well participants could reflect on mental states in the interviews, and this pattern was consistent across people with borderline personality disorder, other psychiatric patients, and healthy controls.

This null moderation result carries real theoretical weight. It suggests that retrospective mentalizing, the reflective capacity measured in interview settings, may not be the protective factor that some clinical theories would predict. Several explanations are possible, and the authors are careful to frame the finding as an invitation for further research rather than a definitive refutation. Mentalizing may need to be measured in the moment, during an actual emptiness episode, to capture its protective potential; the ability to reflect calmly after the fact may not translate into the capacity to regulate oneself in the heat of an agonizing void. Alternatively, the specific form of mentalizing that matters may differ from what the Reflective Functioning Scale captures, or the sample size of fifty-one per group may have limited statistical power to detect a moderation effect of modest size. It is also possible that the link between emptiness and self-destruction is so direct and visceral that reflective understanding alone cannot interrupt it.

The cross-group consistency of the emptiness-to-harm pathway is arguably the study’s most broadly significant contribution. Emptiness predicted self-destructive behaviors not only in people with borderline personality disorder but across all participants, including healthy adults. This suggests that the inner void is a transdiagnostic risk factor, a dimension of human experience that can push anyone toward harmful action when it becomes severe enough. That framing has implications well beyond one diagnosis. Screening for emptiness in psychiatric assessment, regardless of the presenting diagnosis, may help identify individuals at risk for self-harm who would otherwise be missed by symptom checklists focused on mood or anxiety. It also resonates with a growing body of work on loneliness, meaninglessness, and disconnection as fundamental drivers of psychological suffering in modern life.

For the field of borderline personality disorder research, the study marks an important step toward treating emptiness as a legitimate scientific object rather than a vague clinical impression. The development of an emptiness-specific mentalizing interview and a targeted inventory of emptiness-driven self-destructive behavior gives researchers new tools to dissect the pathway from inner void to harmful action. Future work, the findings imply, should examine mentalizing in real time, test whether interventions that target emptiness directly, rather than the disorder as a whole, can reduce self-destructive behavior, and explore whether other capacities, such as emotion regulation or self-continuity, might serve as the true buffers between void and action. What is already clear is that the aching absence so many patients struggle to describe deserves a central place in both research and treatment, and that understanding it may be one of the keys to preventing some of the most dangerous consequences of psychological pain.

Subject of Research: The relationship between chronic emptiness, self-destructive behaviors, and mentalizing capacity in borderline personality disorder

Article Title: From inner void to harmful action: a controlled study of emptiness, self-destructive behaviors, and mentalizing in borderline personality disorder

Article References: Sheena-Peer, L., Basson, S. A., Steinberg, N., Livni, T., Moshe-Cohen, R., & Kivity, Y. (2026). From inner void to harmful action: a controlled study of emptiness, self-destructive behaviors, and mentalizing in borderline personality disorder. BMC Psychology. https://doi.org/10.1186/s40359-026-05687-9

Image Credits: AI Generated

DOI: 10.1186/s40359-026-05687-9

Keywords: borderline personality disorder, emptiness, mentalizing, self-destructive behavior, reflective functioning, psychiatric controls, transdiagnostic, inner void, self-harm, BMC Psychology, Bar-Ilan University, clinical psychology

The rationale behind the project rests on a well-documented gap. Schools are widely recognized as one of the best settings for promoting young people’s mental health, because they reach nearly every child regardless of family circumstances, and because the classroom is where much of adolescent life is actually lived. Yet most evidence-based interventions fail to survive the transition from clinical trial to routine practice. Programs designed by specialists often demand resources schools do not have, clash with teacher preferences, or simply feel alien to the students they are meant to help. The team behind CAMH Class, led by Tracy M. Stewart of the University of Edinburgh with colleagues including Gillean McCluskey, Debi Fry, Lesley McAra, and Josie N. Booth, set out to reverse that engineering order: start with the constraints of real classrooms and design the intervention to fit them, rather than expecting classrooms to bend around an intervention.

The design philosophy is explicitly transdiagnostic. Instead of targeting a single diagnosis such as depression or anxiety, transdiagnostic interventions address the shared underlying processes that cut across multiple forms of distress, such as emotional regulation, coping strategies, and social connection. This matters for schools because young people rarely present with neat diagnostic categories, and because a program that requires referral pathways or specialist screening creates bottlenecks that many institutions cannot sustain. A transdiagnostic, universal approach delivered to whole classes can promote wellbeing and prevent the onset or escalation of symptoms simultaneously, without singling anyone out, which also reduces the stigma that keeps many adolescents from engaging with mental health provision at all.

The development process itself was structured and sequential. In total, 32 participants aged between 15 and 63 took part, with a mean age of 32.72 years, organized into three distinct groups. The first group consisted of teachers, with a mean age of 36.80, who participated in four sequential development workshops. These workshops were the engine room of the project, where teachers identified the mental health priority areas most relevant to their classrooms and began shaping activities that could be woven into ordinary teaching. A second group, young people with a mean age of 15.85, attended a dedicated development workshop, ensuring that the student voice was not filtered entirely through the perspectives of adults. Finally, a fresh group of teachers who had played no part in the initial design took part in a refinement workshop, with a mean age of 37.38, providing an independent check on whether the emerging intervention made sense to people encountering it for the first time.

This layered structure reflects a core principle of co-production research: the people who deliver and receive an intervention hold knowledge that outside experts cannot replicate. Teachers know the rhythm of a school week, the practical limits of a fifty-minute lesson, the topics that will land with a particular year group, and the difference between an activity that sounds good on paper and one that works with a restless class on a Friday afternoon. Young people know what feels patronizing, what feels authentic, and what they would actually be willing to engage with in front of their peers. By bringing both groups together, the researchers aimed to produce something that neither could have designed alone, and to build a sense of ownership that increases the chances the intervention will be used long after any formal evaluation ends.

The workshops yielded a set of classroom activities mapped onto the priority areas that teachers and young people identified together. The key innovation is not any single exercise but the delivery mechanism: every activity is designed to be integrated directly into routine teaching, so that supporting mental health becomes part of how a lesson is taught rather than an additional subject competing for timetable space. This embedded approach addresses the single most common reason school interventions collapse, which is that they require dedicated time, trained external facilitators, or funding streams that evaporate. If the intervention lives inside ordinary pedagogy, its marginal cost approaches zero, and its sustainability no longer depends on grant cycles or the enthusiasm of a single champion within a school.

The feasibility findings are encouraging, though appropriately qualified. Both teachers and young people judged the intervention feasible and acceptable, but subject to contextual considerations, a phrase that carries real weight in implementation science. What works in one school may falter in another depending on leadership support, staff workload, class composition, and the wider culture of the institution. The researchers did not treat this context-dependence as a flaw to be engineered away; rather, the co-development process was explicitly designed to surface these contextual factors early, so that schools adopting the intervention can adapt it intelligently rather than discarding it when the first obstacle appears. That flexibility is characteristic of interventions built for the messy reality of public education rather than the controlled conditions of a trial.

Teachers who engaged with the activities reported observations that go beyond mental health narrowly defined. They perceived a positive impact on young people’s engagement, learning, energy, and overall enjoyment in class, alongside the intended benefits for wellbeing. This is a significant detail, because teachers are asked to invest their own effort in any classroom-based program, and an intervention that improves the experience of teaching, not just the outcomes for students, is far more likely to be sustained. It also hints at a virtuous cycle familiar from the broader literature on social and emotional learning: classrooms where students feel emotionally supported tend to be calmer and more productive, which in turn reduces stress for teachers, which further improves the emotional climate. CAMH Class appears positioned to exploit that feedback loop deliberately.

The study, published in December 2026, represents the development phase of a longer research program, and the authors are careful about what it does and does not establish. What it demonstrates is that co-production can produce a school-based mental health intervention that teachers and young people genuinely accept, that fits within routine teaching, and that targets transdiagnostic processes relevant to a wide range of outcomes. What remains to be tested, in future evaluation phases, is whether the intervention produces measurable and lasting improvements in mental health symptoms at scale. Even so, the translation problem it addresses is arguably the field’s most urgent challenge. Reviews of school-based mental health research repeatedly find effective programs that never reach the classrooms that need them, because the programs were never designed for routine conditions in the first place.

The broader significance of the work lies in its method as much as its product. If CAMH Class succeeds in subsequent trials, the template it offers, sequential workshops with teachers, a dedicated youth workshop, and independent refinement by fresh stakeholders, could be applied to interventions across education, public health, and beyond. The study’s authors describe their co-production approach as having the potential to bridge the gap in intervention translation to the classroom and ultimately benefit young people’s mental health. At a moment when adolescent mental health services are stretched thin across much of the world, the idea that prevention might be built into the ordinary fabric of the school day, at minimal cost and with the endorsement of the people in the room, is a proposition worth taking seriously. The classroom, this research suggests, may be the most underused mental health resource in the country, and the people best placed to unlock it were there all along.

Subject of Research: Co-development of a transdiagnostic, classroom-embedded mental health intervention for secondary schools

Article Title: Co-developing the Child and Adolescent Mentally Healthy Classroom (CAMH Class) intervention for use in routine teaching in secondary schools

Article References: Stewart, T. M., McCluskey, G., Johnson, H., Fry, D., McAra, L., & Booth, J. N. (2026). Co-developing the Child and Adolescent Mentally Healthy Classroom (CAMH Class) intervention for use in routine teaching in secondary schools. PLOS One, 21(10), e0359563. https://doi.org/10.1371/journal.pone.0359563

Image Credits: AI Generated

DOI: 10.1371/journal.pone.0359563

Keywords: adolescent mental health, school-based intervention, co-production, transdiagnostic, classroom, teachers, PLOS One, feasibility, prevention, wellbeing, secondary schools, intervention development

The concept at the heart of the paper is cognitive disorganization, a term that covers a cluster of observable difficulties: trouble sustaining attention, difficulty sequencing the steps of a task, problems accessing language when it is needed, and disruptions in discourse organization, the ability to assemble speech into a coherent, goal-directed flow. In help-seeking youth, these difficulties frequently appear alongside unusual experiences, such as odd perceptual events or strange beliefs, and alongside functional decline at school, at home, or among peers. The traditional clinical reflex is to read this combination as a signal of emerging psychosis risk. Niederlohmann does not dismiss that possibility, but he insists it is only one of several plausible readings, and that a responsible formulation must be able to distinguish between them rather than collapsing everything into a single ominous label.

The proposed framework rests on four questions. First, what is the young person’s developmental baseline, meaning the level of attentional, linguistic, and organizational functioning that was typical for them before the current difficulties emerged? Second, which functions vary within the person across cognitive load, context, and time, a question that probes whether the disorganization is stable or fluctuates predictably under stress, fatigue, or specific environmental demands? Third, what is actually happening in the environment, and how is the young person interpreting it, particularly with respect to threat? Fourth, do established clinical-risk indicators require formal assessment or referral, for example when unusual experiences or functional decline cross thresholds that standard instruments are designed to detect? Each question addresses a different assessment task, and the author emphasizes that they may be considered together as a proposed clinical heuristic rather than a rigid protocol.

The developmental-baseline question deserves particular attention because it changes the meaning of everything that follows. A young person whose discourse organization has always been somewhat fragile, perhaps due to a longstanding developmental language difference, presents a very different formulation picture from one whose speech became disorganized over the course of weeks. Without anchoring the assessment to a documented baseline, clinicians risk mistaking a stable trait for an acute deterioration, or vice versa. This is why the framework insists that formulation begin with what is known about the individual’s prior functioning, gathered from school records, family report, and previous clinical contacts, before any interpretive weight is placed on current presentation.

The second question, concerning within-person variability, draws on a body of acute-stress research showing that stress can affect specific executive outcomes under studied conditions. Executive functions, the umbrella term for abilities such as working memory, cognitive flexibility, and inhibitory control, are known to be sensitive to acute stressors in controlled experimental settings. Niederlohmann’s treatment of this evidence is notably careful. He argues that extrapolating these laboratory findings to discourse organization, to threat meanings, or to reality testing in help-seeking youth is not yet sufficiently supported by the literature. In other words, it is reasonable to hypothesize that a young person’s disorganized speech worsens under stress, but that remains a domain-specific formulation hypothesis to be tested, not an established property of the presentation. The distinction matters enormously in clinical practice, where a plausible-sounding stress explanation can quietly harden into an assumed fact.

The third question moves the assessment outward, into the environment itself. Cognitive disorganization does not develop in a vacuum, and the framework asks clinicians to document what is genuinely occurring in the young person’s life, including any actual harm, coercion, or danger, and separately to assess how the young person interprets those events. A teenager who lives in a genuinely threatening household and a teenager who misreads benign social cues as hostile may both present with vigilance, fragmented speech, and unusual beliefs, but the appropriate responses differ radically. The paper is emphatic on this point: assessment of genuine environmental harm, safeguarding needs, and urgent medical or psychiatric risk takes precedence over explanatory interpretation. Before any formulation is debated, the clinician must establish whether the young person is safe.

The fourth question functions as a safety net within the heuristic itself. Established clinical-risk indicators, the signs that research and practice guidelines have flagged as warranting formal assessment, must be checked systematically rather than assumed away by an elegant explanatory narrative. If a young person shows indicators associated with psychosis risk, the framework directs the clinician toward formal assessment or referral, regardless of how compelling an alternative developmental or stress-based explanation might appear. This ordering reflects a core epistemic commitment of the paper: explanatory hypotheses are useful only insofar as they do not displace the detection of established risk.

Perhaps the most methodologically interesting feature of the Perspective is its explicit distinction between three tiers of knowledge: direct evidence, adjacent findings, and clinical hypotheses. Direct evidence in this domain is comparatively thin; adjacent findings, such as the acute-stress effects on executive outcomes, are real but bounded to the conditions in which they were studied; and clinical hypotheses, such as the idea that stress sensitivity explains a particular young person’s disorganized discourse, must be held as testable propositions. The author proposes that prospective studies should measure these domains separately, assessing the reliability of the four-question heuristic, its incremental clinical value over existing approaches, and its safety, meaning its capacity to avoid missing genuine risk, against explicit alternative explanations and falsification criteria. This is a demanding research agenda, and the paper does not pretend the heuristic has already met it.

The publication also carries a transparent account of its own production. The author discloses that generative AI tools were used during early manuscript development for brainstorming and preliminary mapping of potentially relevant literature, and later for English-language copy editing, with all suggestions independently evaluated and all cited sources verified by the author, who accepts full responsibility for the content. The article reports no original research involving human participants; all clinical illustrations are constructed, and no participant data were collected. The author declares income from clinical practice, teaching, supervision, and psychotherapy training, as well as work as an author and translator of professional literature, as potentially relevant interests. No funding was received for the manuscript. These declarations sit within a growing norm of openness about how perspective papers are assembled, and they do not alter the substance of the argument, but they give readers the information needed to weigh it.

What, then, is the practical takeaway for clinicians, services, and researchers watching the field of youth mental health? The contribution, as Niederlohmann frames it, is organizational rather than discovery-based: the paper does not introduce new syndromes or new instruments, but arranges established assessment domains around observable difficulties and documented uncertainty. For a clinician confronting a disorganized, distressed young person, the four questions offer a sequence that starts with the individual’s own developmental history, maps the fluctuation of functions under load and context, examines the environment and its interpretation, and only then triggers formal risk pathways where indicators demand it. For researchers, the paper issues a challenge: stop treating stress sensitivity and disorganization as a single bundled phenomenon, and design studies that measure the domains separately, with explicit criteria for when a formulation hypothesis should be rejected. If that agenda is pursued, the heuristic could help services move beyond the binary of over-pathologizing unusual cognition and under-detecting genuine emerging illness, a balance that matters most for the young people whose futures depend on getting the interpretation right the first time.

Subject of Research: A transdiagnostic developmental formulation approach to cognitive disorganization in help-seeking youth

Article Title: Cognitive disorganization in help-seeking youth: a transdiagnostic developmental formulation perspective

Article References: Niederlohmann, E. (2026). Cognitive disorganization in help-seeking youth: a transdiagnostic developmental formulation perspective. Discover Psychology. https://doi.org/10.1007/s44202-026-00939-6

Image Credits: AI Generated

DOI: 10.1007/s44202-026-00939-6

Keywords: cognitive disorganization, clinical formulation, transdiagnostic, adolescent mental health, developmental psychopathology, psychosis risk, psychological assessment, safeguarding, stress sensitivity, executive function, help-seeking youth, clinical heuristics

The case begins with a problem that has haunted psychiatry for generations: the diagnostic categories themselves. The DSM and ICD systems carve mental distress into discrete boxes, yet decades of evidence show that patients rarely fit neatly into one box. Comorbidity is the norm rather than the exception; the National Comorbidity Survey Replication documented pervasive overlap among common disorders, and longitudinal work from the Dunedin Birth Cohort showed that mental health problems over four decades are better described by a single general dimension of vulnerability than by separate, stable diagnoses. Taxometric studies, meta-analyzed by Haslam and colleagues, consistently favor dimensional over categorical models of psychopathology. In other words, the boundaries between disorders appear to be conventions, not discoveries.

HiTOP is the most systematic attempt to replace those conventions with something empirical. Rather than starting from clinical tradition, HiTOP applies factor-analytic methods — the same statistical machinery behind principal component analysis — to the way symptoms actually co-occur in large samples. The result is a hierarchy: at the top sits a general factor of psychopathology, sometimes called the p factor, which captures overall severity; below it are broad superspectra such as internalizing, externalizing, and psychosis; below those are spectra, syndromes, and finally individual symptoms and traits. A 2023 meta-analysis by Ringwald, Forbes, and Wright found substantial structural evidence for this arrangement, and subsequent work has extended it to neurodevelopmental conditions and to a data-driven reconstruction of DSM-5 symptoms published in 2025. Crucially, HiTOP dimensions have shown real-world predictive value: higher-order internalizing dimensions predict treatment response in partial hospitalization programs, and the p factor forecasts long-term psychiatric and functional outcomes in anxious youth.

But HiTOP, by design, is descriptive. It tells us how psychopathology is structured, not why. Its dimensions are latent variables — statistical constructs inferred from covariation — and critics, including the authors themselves in earlier papers, have noted that latent variables alone do not constitute a theory of mechanism. This is precisely where computational psychiatry enters the picture. The field, crystallized in a landmark 2012 Trends in Cognitive Sciences paper by Montague, Dolan, Friston, and Dayan, aims to explain psychiatric phenomena using formal mathematical models of cognitive and neural processes: reinforcement learning models that quantify how people learn from reward and punishment, drift diffusion models that decompose decision-making into speed and caution, Bayesian models of belief updating, and dynamic causal models of brain circuits. Instead of asking whether a patient has depression, a computational psychiatrist asks whether that patient’s learning rate, reward prediction errors, or evidence-accumulation efficiency deviate from normative functioning — and by how much.

The Perspective distinguishes two cultures within computational psychiatry, echoing a well-known 2019 commentary by Bennett, Silverstein, and Niv. One is data-driven: machine learning approaches that mine neuroimaging, genetic, and behavioral data to predict diagnoses, treatment outcomes, or disease trajectories. The other is theory-driven: mechanistic modeling that begins with an explicit hypothesis about a cognitive process and fits it to behavior. Both cultures, the authors argue, are hampered by the same weakness — the messiness of the diagnostic labels they are asked to predict or explain. Machine learning models trained on DSM categories inherit the heterogeneity and label noise of those categories, which may partly explain why clinical prediction models have struggled to generalize. A 2024 commentary in JAMA Psychiatry asked pointedly whether psychiatric nosologies are limiting the success of clinical prediction models. Meanwhile, theory-driven studies that compare a single diagnostic group with healthy controls risk conflating distinct processes that happen to co-occur in one disorder.

This is where the two frameworks begin to fit together like puzzle pieces. HiTOP offers computational psychiatry something it badly needs: reliable, specific, empirically grounded phenotypes. Consider the growing literature on reinforcement learning in mood and anxiety disorders. Meta-analyses by Pike and Robinson and by Halahakoon and colleagues found that reward-processing deficits in depression are real but modest and heterogeneous when patients are defined by diagnosis. Studies that instead relate learning parameters to transdiagnostic symptom dimensions — such as anhedonia or compulsivity — tend to find cleaner signals. Claire Gillan’s work showed that deficits in goal-directed control relate to a self-reported compulsivity dimension more strongly than to an obsessive-compulsive disorder diagnosis per se. Similarly, Wise and Dolan linked aversive learning parameters to transdiagnostic symptoms in a general population sample, and a computational factor modeling approach by Wise, Robinson, and Gillan demonstrated that mechanisms can be identified across diagnoses when the phenotype is dimensional.

The integration also runs in the other direction: computational psychiatry gives HiTOP a path from description to explanation. The Perspective highlights examples where model-based measures behave like computationally defined traits. Efficiency of evidence accumulation, estimated with sequential sampling models, emerges as a task-general marker of cognitive efficiency that is more reliable than many traditional executive function measures and predicts substance use in emerging adulthood. Drift diffusion modeling has disentangled which components of externalizing psychopathology — antagonism rather than disinhibition — are tied to poor cognitive control. Neurocomputational studies of social exchange have illuminated mechanisms behind callousness, and model-based planning deficits in compulsivity have been traced to faulty neural representations of task structure. These are the kinds of findings that could eventually populate HiTOP’s dimensions with explanatory content: not just ‘this set of symptoms co-occurs,’ but ‘this set co-occurs because it reflects a common deviation in a specific neurocognitive process.’

The neurobiological evidence reinforces the case. Transdiagnostic neuroimaging studies have repeatedly found that brain signatures cut across DSM categories: common structural and functional disruptions span mood, psychotic, and anxiety disorders, and a transdiagnostic network for psychiatric illness has been derived from atrophy and lesion data. Normative modeling approaches, which quantify each individual’s deviation from expected brain development, show that transdiagnostic dimensions of psychopathology explain unique deviations in brain structure. Genetic studies point the same way: psychiatric disorders share substantial polygenic risk, and the genetic architecture aligns better with hierarchical dimensional models than with diagnostic categories. If biology does not respect the DSM’s boundaries, the authors argue, then a framework that organizes phenotypes dimensionally — and pairs them with computational measures of process — offers the most promising route to a genuinely mechanistic clinical neuroscience.

Yet the authors are candid about the barriers. Cross-field collaboration remains limited; HiTOP grew out of clinical psychology and quantitative psychometrics, while computational psychiatry has roots in cognitive neuroscience, machine learning, and even economics, and the two communities publish in different journals and attend different meetings. Multimodal data pose technical challenges: combining self-report, behavior, neuroimaging, and genomics requires measurement models that most studies lack. Measurement reliability is a persistent headache — many classic cognitive tasks show poor test–retest reliability at the individual level, and landmark analyses by Elliott and colleagues and by Marek and colleagues showed that reproducible brain–behavior associations often require thousands of participants. There are also unresolved conceptual questions about whether computational and biological measures should be allowed to revise the HiTOP structure itself, or whether the taxonomy should remain purely phenomenological. A 2025 meta-analysis asking whether cognitive functions belong in the HiTOP model illustrates how live this debate is.

The stakes of getting this right are enormous. The authors point to early evidence that computational measures can mediate treatment effects: reinforcement learning disruptions in depression predict sensitivity to cognitive behavioral therapy, neural correlates of reward prediction errors classify therapy response, and different components of cognitive-behavioral therapy have been shown to affect specific cognitive mechanisms. If HiTOP provides the reliable descriptive scaffolding and computational psychiatry supplies the mechanistic engine, the combination could transform how researchers stratify patients, predict outcomes, and design interventions — moving the field from a nosology of named boxes toward a quantitative science of mental processes. The Perspective is, in effect, an invitation: two of psychiatry’s most promising reform movements have been building toward the same destination from opposite ends, and the shortest path forward may be the one that connects them.

Subject of Research: Integration of the Hierarchical Taxonomy of Psychopathology with computational psychiatry to connect dimensional symptom models with neurocognitive mechanisms

Article Title: Integrating the Hierarchical Taxonomy of Psychopathology and computational psychiatry

Article References: Allen, T. A., Schreiber, A. M., Blain, S. D., Carlisi, C., DeYoung, C. G., Fornito, A., Gillan, C. M., Goghari, V. M., Hall, N. T., Homan, P., Kaczkurkin, A. N., Kotov, R., Krueger, R. F., Latzman, R. D., Okan, A., Tackett, J. L., The HiTOP Neurobiological Foundations Workgroup, & Hallquist, M. N. (2026). Integrating the Hierarchical Taxonomy of Psychopathology and computational psychiatry. Nature Reviews Psychology. https://doi.org/10.1038/s44159-026-00621-7

Image Credits: AI Generated

DOI: 10.1038/s44159-026-00621-7

Keywords: HiTOP, computational psychiatry, psychopathology, dimensional models, reinforcement learning, drift diffusion modeling, machine learning, neuroimaging, DSM, transdiagnostic, p factor, mental health research

The research team, led by Silvia Tempia Valenta of the University of Bologna together with colleagues in Italy, Belgium, Spain, and the United Kingdom, set out to answer two related questions. First, has men’s access to specialized eating disorder care changed over the past decade? Second, among the men who do reach specialist services, does their psychopathology differ from that of women in ways that standard diagnostic categories fail to capture? To address these questions, the researchers examined consecutive referrals rather than a selective sample, meaning every adult assessed at the center during the study period was included. This consecutive design matters, because it reduces the referral biases that can distort smaller, more selective studies.

Methodologically, the study was unusually comprehensive for a routine clinical cohort. Each patient completed the Eating Disorder Examination Questionnaire, or EDE-Q, a gold-standard self-report measure of core eating disorder psychopathology covering restraint, eating concern, shape concern, and weight concern. Body image disturbance was assessed with the Body Uneasiness Test, whose Global Severity Index captures distress related to body image across multiple domains. Depressive symptoms were measured with the Patient Health Questionnaire-9, anxiety with the State-Trait Anxiety Inventory Form Y, and personality pathology with the Structured Clinical Interview for DSM-5 Personality Disorders, a clinician-administered diagnostic interview rather than a brief screening tool. Diagnoses were assigned according to DSM-5 criteria, encompassing anorexia nervosa in its restrictive and binge-purge subtypes, bulimia nervosa, binge eating disorder, avoidant restrictive food intake disorder, and other specified feeding or eating disorders.

The diagnostic picture that emerged was sharply gendered. Anorexia nervosa and bulimia nervosa were more common among cisgender women, whereas binge eating disorder predominated among cisgender men. This pattern is consistent with a broader clinical literature suggesting that men with eating disorders more often present with loss-of-control overeating and associated weight gain rather than with the restrictive or purging presentations that have historically defined the field. Because binge eating disorder has only been a formal standalone diagnosis since DSM-5, introduced in 2013, its prominence among men in this cohort underscores how diagnostic frameworks themselves can influence who is recognized as ill and who is steered toward specialist treatment.

Beyond diagnosis, the researchers compared symptom burden across genders using standardized scores. Cisgender women reported significantly higher levels of eating disorder psychopathology on the EDE-Q, greater body uneasiness on the Body Uneasiness Test, and higher trait anxiety on the STAI-Y. Depression and personality disorder findings were also examined across the cohort. Importantly, however, the effect sizes for these gender differences were generally small to moderate, quantified using rank-biserial correlations for the non-normally distributed questionnaire data. In practical terms, this means that while women in the sample were, on average, more symptomatic on these measures, the distributions overlapped substantially, and many men showed clinically meaningful levels of distress. A small average difference between groups should not be mistaken for an absence of illness in the higher-scoring group.

The most innovative component of the study was its use of latent profile analysis, a statistical technique that identifies unobserved subgroups of patients who share similar patterns across multiple measured variables. Rather than sorting patients by diagnosis, latent profile analysis sorts them by overall severity and symptom configuration, allowing the researchers to ask whether men and women occupy the same or different positions along a transdiagnostic spectrum of illness. Three profiles emerged: low, moderate, and high severity. Cisgender men were more frequently classified in the moderate-severity profile, whereas cisgender women were overrepresented in the high-severity profile. The identification of these shared profiles across genders supports the authors’ conclusion that eating disorder severity can be meaningfully conceptualized within a common transdiagnostic framework, one that cuts across traditional diagnostic boundaries.

Why does this matter for clinical practice? If men who reach specialist care tend to sit in a moderate-severity band, they may present a clinical picture that screening tools calibrated on female populations underestimate. Instruments such as the EDE-Q were developed and validated largely in samples of women, and items probing drive for thinness or fear of weight gain may fail to capture the muscularity-oriented concerns, excessive exercise, and dietary rigidity that characterize many male presentations. A man with severe binge eating disorder and profound shame about his body may score lower on thinness-oriented items than a woman with anorexia nervosa, even though his overall illness burden is substantial. The transdiagnostic severity profiles identified in this study offer one way around that blind spot, because they assess overall symptom configuration rather than adherence to a stereotypical presentation.

The stability of the male proportion over ten years is arguably the study’s most sobering finding. Between 2014 and 2024, a period spanning major cultural shifts in how male body image is discussed, the share of men accessing the Bologna service remained fixed at roughly eight percent. This stagnation suggests that whatever awareness has grown in public discourse has not translated into more men reaching specialist assessment. The authors are careful to note that their data cannot disentangle the possible explanations: men may be less likely to recognize their symptoms as an eating disorder, primary care providers may be less likely to suspect one, stigma may deter help-seeking, or referral pathways may be less sensitive to male presentations. Each of these barriers operates at a different point in the care pathway, and each would require a different intervention.

There are also important limitations to weigh. The study was conducted at a single specialized center in one Italian city, and referral patterns there may not generalize to other health systems or countries. The cohort included cisgender men and women, and the authors frame their comparisons explicitly in those terms, leaving questions about transgender and gender-diverse patients for future work. Because the design was cross-sectional at the point of assessment, it captures who reaches care rather than who is ill in the community, so the findings speak to access and presentation rather than true prevalence. Effect sizes for many gender differences were small to moderate, and the latent profile analysis, while statistically rigorous in its use of information criteria such as the AIC and BIC to select the number of profiles, remains a model-based description of the data rather than a biological taxonomy.

Even with those caveats, the study delivers a clear and actionable message. Men remain markedly underrepresented in specialized eating disorder care, and the proportion has not budged in a decade. At the same time, the men who do reach services show meaningful psychopathology, with binge eating disorder predominating and a tendency toward moderate rather than high transdiagnostic severity. The shared severity architecture across genders suggests that the same continuum of illness runs through both populations, which means the same evidence-based treatments may be applicable once patients are identified. The challenge, then, is not to invent a separate psychiatry for men, but to build detection and referral systems that recognize how the same illness can wear different clothes. Until screening, training, and public health messaging catch up with that insight, the study’s title question will remain painfully current: men are still being missed.

Subject of Research: Gender differences in eating disorder psychopathology and access to specialized care

Article Title: Are men still being missed in eating disorder care? Gender differences in psychopathology and transdiagnostic severity profiles across a 10-year clinical sample

Article References: Tempia Valenta, S., Marcolini, F., Di Stani, M., Hubloue, I., De Ronchi, D., Fernandez-Aranda, F., & Atti, A. R. (2026). Are men still being missed in eating disorder care? Gender differences in psychopathology and transdiagnostic severity profiles across a 10-year clinical sample. Journal of Eating Disorders. https://doi.org/10.1186/s40337-026-01790-9

Image Credits: AI Generated

DOI: 10.1186/s40337-026-01790-9

Keywords: eating disorders, gender differences, male eating disorders, binge eating disorder, anorexia nervosa, bulimia nervosa, latent profile analysis, body image, transdiagnostic, psychopathology, mental health services, help-seeking