Beth has always been a worrier; she currently spends the better part of each day thinking about her finances, her ability to complete her schoolwork, and her health and safety. Marty experiences panic attacks (an intense rush of fear, accompanied by racing heart rate, shortness of breath, a lump in his throat, nausea and sweating) several times a week. He is especially likely to have them in situations where he feels it would be difficult to escape. Amira has long struggled to make friends, worrying that other people will find her ‘awkward and weird’. Since starting university, she has held back from asking questions in class because she is afraid her teachers will think she is stupid. These difficulties have been weighing on Amira, and she has been feeling increasingly down.
How can the challenges faced by the people described above be best understood? A mental health professional will likely recognise symptoms of generalised anxiety disorder in Beth, panic disorder and agoraphobia in Marty, and social anxiety disorder and depression in Amira. Indeed, focusing on the differences between these people is one way to think about them.
However, there are similarities among these presentations that offer an alternative – and potentially more effective – path for understanding their difficulties. Beth, Marty and Amira all experience frequent and intense negative emotions. In other words, they exhibit high levels of neuroticism, or the tendency to have strong surges of negative emotions (such as anxiety, fear, guilt, anger or sadness) in response to stressors. Additionally, neuroticism is characterised by the sense that the world is a dangerous and threatening place, along with the belief that stressors, when they come up, cannot be managed.
There is strong evidence that avoiding emotions backfires in the long run, leading to increased negative emotions
Neuroticism is one of five broad personality traits that are commonly used by psychologists to characterise the differences between people. Individuals vary considerably in the degree to which their negative emotions can be triggered. We all likely know someone who isn’t easily bothered by potentially stressful events – they show low neuroticism. On the other hand, we probably also know someone who is quite reactive to stressors, feels negative emotions more strongly, and takes longer to calm down – they exhibit high neuroticism. Those who are higher in neuroticism are at a greater risk for developing a range of common mental health conditions, including depressive and anxiety disorders. This trait might also affect how people function in their relationships and at work, and even their physical health.
How does a personality trait develop into a mental health condition? The strong tendency to experience negative emotions is an important prerequisite – necessary, yet not sufficient. Research suggests that how one responds to those negative emotions can determine whether one’s experiences evolve into something so interfering that they constitute an anxiety or depressive disorder. People with common mental health conditions often display aversive reactions to their emotions. They might regard their emotions as signs of weakness, an indication of impending danger, or simply too uncomfortable to bear (eg, It is weak to feel this way; A racing heart means I’m going to have a heart attack; I hate this feeling). Aversive reactions in the face of strong emotional experiences, in turn, lead to efforts to avoid or suppress them. While this might provide some short-term relief (Amira feels less anxious when she skips class), there is strong evidence that avoiding emotions backfires in the long run, leading to increased negative emotions (Amira feels even more anxiety when she finally returns to class).
Thus, aversive reactions to emotions can lead to the chronic emotional avoidance represented in symptoms of anxiety (eg, checking, reassurance-seeking or avoiding social situations) and depression (eg, withdrawal), and they can exacerbate the frequency of negative emotions – reinforcing the temperament of neuroticism.
Given the evidence that symptoms of diverse mental health conditions are different manifestations of the same underlying syndrome (high neuroticism), why not address these problems at their root with a neuroticism-focused treatment? Historically, because neuroticism is a personality trait, it was considered stable over time. However, emerging research suggests that this tendency to experience negative emotions is more malleable than originally believed.
Imagine directly targeting this trait in the context of care for Beth, Marty and Amira. Focusing on neuroticism – rather than on the symptoms that brought them to treatment (social anxiety, low mood, worry, panic) – is a streamlined approach to co-occurring emotional problems, one that could benefit the many patients who exhibit symptoms of more than one mental disorder (in Amira’s case, social anxiety and depression). A neuroticism-focused treatment can also allow therapists to use a single, evidence-supported approach with most of the patients on their caseload, as opposed to applying different disorder-specific treatments to each client. (Learning a different treatment protocol for every condition is time-consuming and costly. As a result, many busy therapists fall back on supportive care, such as asking patients about their week and providing support and validation.)
Patients begin to understand that emotions provide useful information and should not be avoided
The Unified Protocol (UP) for transdiagnostic treatment of emotional disorders, which I co-developed, is a well-supported, neuroticism-focused treatment. In keeping with the research described above, its five core treatment modules are designed to reduce distress in response to the experience of strong emotions. The UP is a form of cognitive behavioural therapy (CBT) and contains familiar elements such as psychoeducation, mindfulness, cognitive flexibility and behaviour-change strategies. However, instead of focusing these skills on symptoms of discrete disorders, this approach targets emotions themselves. By reducing negative reactions to difficult emotions, it aims to decrease reliance on avoidant coping strategies, leading to less frequent and intense negative emotions over time – that is, lower levels of neuroticism. In essence, there is emerging evidence that the UP can alter a high-risk personality trait so that patients are less susceptible to mental health difficulties.
How does a neuroticism-focused intervention teach people to view their emotions with a more accepting stance? If you were seeing a therapist who uses the UP, you would first receive information about the adaptive functions of emotions: fear protects you, anxiety helps you prepare, and so on. This starting point helps patients begin to understand that emotions provide useful information and should not be avoided.
Many patients describe their emotions as overwhelming, so you would be taught to break down your own emotional experiences into more manageable parts – physical sensations, thoughts and behavioural urges. Take Marty’s experience: he might begin to notice that, during a panic attack, his physical sensations (such as racing heart) prompt negative thoughts (I’m having a heart attack), which then exacerbate his heart rate until an avoidant behaviour (pulling over to the side of the road) disrupts the cycle. Patients explore the consequences of such avoidant behaviours. For example, pulling over when driving during a panic attack feeds into the belief that panic symptoms are dangerous (they’re not!), increasing the likelihood of panic in the future.
After learning about the problems with avoidance, you would receive instruction on exactly how to engage willingly with your emotions. You would learn the benefits of a present-focused, non-judgmental (in other words, mindful) attitude toward emotions. For instance, instead of telling yourself, I’m going to freak out if I see my ex-partner at the party – I can’t believe I’m not over them yet, you might learn to zero in on how you’re currently feeling (a little nervous right now) and give yourself a break for feeling that way (It makes sense that I’m still sensitive about this break-up because we were together for three years). Experiential exercises employed in the UP can help with developing mindful awareness of emotions. These include practising a brief guided mindfulness meditation (such as one of these) in the context of a neutral mood in order to gain experience – and later, using a personally relevant, emotionally evocative piece of music to apply mindful awareness under more challenging circumstances.
Treatment culminates with exposure, wherein patients deliberately bring on the feelings they have previously avoided
To better handle their emotional experiences, patients also learn to be more flexible in the way they think about stressful situations. Say you received no response to a text message and thought, This person must be ignoring me on purpose; a therapist might encourage you to consider alternative perspectives (such as: Maybe their phone died).
Importantly, as part of the UP, you would identify the specific ways you avoid your own emotions, which could include:
- overt situational avoidance (for example, refusing to drive on the highway in case you have a panic attack);
- subtle behavioural avoidance (playing on your phone in social situations to look busy);
- safety signals (carrying around a bottle of anti-anxiety pills even though you never take them, just in case); or
- emotion-driven behaviours (asking for reassurance when feeling insecure).
By acting counter to avoidant behaviours such as these, patients can begin to accumulate evidence that emotions are temporary and can be tolerated. Beth, who struggles with chronic worry, might challenge herself to go a week without checking her bank balance in order to learn that her excessive checking is not preventing any problems. In this vein, treatment culminates with modules focused on exposure, a therapeutic technique wherein patients deliberately bring on the feelings they have previously avoided. Guided by a therapist, they cultivate a greater tolerance of the physical sensations that are part of their emotional experiences and engage in a series of activities that serve as learning opportunities (such as making small talk in social situations, or leaving the anti-anxiety medication at home). Through this practice, negative reactions to emotions are gradually diminished.
The UP has garnered considerable scientific support for its use with a wide range of problems – including anxiety, depression, eating disorders, borderline personality disorder, post-traumatic stress disorder and obsessive-compulsive disorder. So, this neuroticism-focused approach is an effective treatment not only for neuroticism itself, but also various conditions related to this trait.
Targeting underlying risk factors such as neuroticism represents a more efficient approach to addressing common mental health conditions. Given the enormous public health significance of neuroticism in particular, directly addressing this trait has the potential to help ease the burden of mental illness on a global scale.