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14-09-2020 | Original Paper | Uitgave 1/2021

Cognitive Therapy and Research 1/2021

Bridges over Troubled Waters: Mapping the Interplay Between Anxiety, Depression and Stress Through Network Analysis of the DASS-21

Cognitive Therapy and Research > Uitgave 1/2021
Nathan Van den Bergh, Igor Marchetti, Ernst H. W. Koster
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The online version of this article (https://​doi.​org/​10.​1007/​s10608-020-10153-w) contains supplementary material, which is available to authorized users.
Nathan Van den Bergh and Igor Marchetti contributed equally to the manuscript and share first authorship.

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Symptoms of depression and anxiety often co-occur in the same individuals. In order to increase our understanding of concurrent depression and anxiety, it may be necessary to define and model psychopathology as a network of symptoms, that actively reinforce (or inhibit) one another. The current study set out to investigate how depression, anxiety and stress symptoms cluster together, and which symptoms act as bridges between these clusters.


Network analysis was used to investigate the symptom structure of the DASS-21 in a large international sample (N = 11,647). After checking whether the original symptom structure was replicated, the network was further investigated at multiple levels: individual symptoms that are central in the network (1) or function as bridges between clusters (2); symptom pairs that show especially strong associations (3), and the overall structure that may or may not differ between gender groups (4).


Items referring to panic, worry, worthlessness, hopelessness and meaninglessness of life emerged as potentially crucial symptoms in the interplay between depression and anxiety. When comparing female and male networks, the results suggest that the network structures are similar, but not identical.


Specific symptoms can function as bridges between depression, anxiety and stress, which is clinically relevant on top of being theoretically important.

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