The Relationship of Rumination and Experiential Avoidance with Depression and Social Anxiety: The Mediating Role of Worry

The Relationship of Rumination and Experiential Avoidance with Depression and Social Anxiety: The Mediating Role of Worry | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Relationship of Rumination and Experiential Avoidance with Depression and Social Anxiety: The Mediating Role of Worry Mohammad Irani, Imanollah Bigdeli, Ali Mashhadi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7335833/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract The trans-diagnostic approach is a therapeutic approach focusing on the comorbidity of disorders so that it goes beyond just focusing on symptoms and diagnoses and targets common underlying components in disorders. The present research aims to investigate the relationship of the two trans-diagnostic components of rumination and experiential avoidance with depression symptoms and social anxiety mediated by worry. The method used in this research is correlational-descriptive, which has also been assessed using the path analysis of the mediating role of worry. The statistical population consisted of the students of Mashhad universities, among which 420 people were selected. The Rumination Response Scale (RRS), the Acceptance and Action Questionnaire (AAQ), the Pennsylvania State Worry Questionnaire (PSWQ), the Beck Depression Inventory-Second Edition (BDI-II), and Connor’s Social Phobia Inventory (SPIN) were used to collect data, and path analysis method was used for data analysis. The results revealed that the model had a good fit. The direct effects of rumination and experiential avoidance on depression symptoms and social anxiety were significant (P ≤ 0.01), and worry played a mediating role in the relationship of rumination and experiential avoidance with depression symptoms and social anxiety (P ≤ 0.01). Thus, worry plays a mediating role in the relationship of rumination and experiential avoidance with depression symptoms and social anxiety. Hence, targeting these three components in extra-diagnostic treatments to improve depression symptoms and social anxiety is very important and effective in the treatment of these individuals. Social anxiety Depression Rumination Experiential avoidance Worry Figures Figure 1 Introduction Anxiety and depression disorders are greatly prevalent among psychological disorders so that the prevalence of depression disorder reaches 31%, with a significant amount. There is a high rate of this disorder in different populations (Holdaway et al., 2023 ). The prevalence of anxiety disorder also reaches 29% (Kessler et al., 2005 ). Anxiety disorders are debilitating, one of which is social anxiety disorder. Individuals with this disorder are afraid of and avoid social situations (Heimberg et al., 2014 ). Social anxiety disorder is highly comorbid with depression disorder. This issue has also been well confirmed in previous studies, being reported by Gorman to be 20–70% (Coombes et al., 2022 ; Gorman, 1996 ; Kessler et al., 2005 ). Depression is one of the most debilitating and chronic mental disorders (Kessler et al., 2009 ), and is among the diseases that impose heavy economic burden and costs on any society (Üstün, 2004 ). This disorder is highly comorbid with anxiety disorders so that individuals with one of these two disorders are 28–63% likely to have the other disorder as well (Brown et al., 2001 ). The cause of this comorbidity can be due to the common components in these disorders. One of the most recent approaches that target these factors is the trans-diagnostic integrated approach (Barlow et al., 2020 ; Besharat & Shahidi, 2010 ). Two trans-diagnostic components that can impact depression and social anxiety are rumination and experiential avoidance. Rumination refers to repetitive and negative thoughts, typically about the past, causing inconsistent problem-solving (Besharat & Shahidi, 2010 ). Rumination causes depression and plays a crucial role in its maintenance (Cano-López et al., 2022 ; Lyubomirsky et al., 2015 ; Zhu et al., 2024 ). According to the response style theory, rumination is the process of repetitive thinking about oneself and depression symptoms instead of adaptive resolution of symptoms (Nolen-Hoeksema, 2001 ). Among other mental disorders that are associated with rumination and have been confirmed by previous studies is social anxiety, which has been shown that rumination resulting from stress is particularly connected to social anxiety (Cheng et al., 2022 ; Laicher et al., 2022 ; VĂLENAŞ & SZENTAGOTÁI-TĂTAR, 2015 ). Another research (Elhai et al., 2018 ) also indicates that rumination, depression, and social anxiety are significantly correlated so that these individuals have permanent and repetitive thoughts about themselves after social interactions (Kashdan et al., 2008 ). Another component related to depression and social anxiety is experiential avoidance. Avoiding the events that occur to us and are not in accordance with our desires, generally, leads to unpleasant feelings, thoughts, and physical reactions in us (Kashdan et al., 2009 ). The experiential avoidance means that an individual escapes and avoids unwanted and unpleasant internal experiences and does not experience them (Weathers et al., 1991 ). It may have beneficial effects in the short run, but it will cause problems in the long run (Bardeen, 2015 ). One of these problems that are related to the meta-diagnostic concept of experiential avoidance is depression (Cookson et al., 2020 ; McCracken et al., 2014 ). The fear of encountering internal experiences culminates in anxiety in situations in which those internal events happen to the individual (Barlow, 2000 ). One of these anxieties is social anxiety in social situations. Although numerous studies have not been conducted on the role of experiential avoidance in social anxiety modeling, research also indicates the existence of a relationship between experiential avoidance and social anxiety (Cookson et al., 2020 ; Kashdan, 2007 ). When individuals with social anxiety experience more social anxiety, they report less positive events and attempt to avoid and suppress their internal unpleasant feelings (Kashdan & Steger, 2006 ). Based on the explanations provided and the existing background, rumination and experiential avoidance influence social anxiety and depression. Nevertheless, do these two trans-diagnostic components directly influence these disorders or is there a mediating variable that is both related to rumination and experiential avoidance and influenced by them and is also related to depression and social anxiety and plays a substantial role in their creation. Considering the outstanding role of worry as a mediating variable and a trans-diagnostic component that impacts these two disorders, the investigation of this variable in a multifactorial structure is of great importance. Worry is a process of repetitive thinking with the content of preventing or coping with negative events (Borkovec & Roemer, 1995 ). Worry is defined as a concern and presentiment about future negative events (Brown et al., 2001 ). Research shows that different forms of negative thinking, including worry, play a critical role in depression. Furthermore, worry causes the onset and maintenance of depression in individuals (Bajaj et al., 2020 ; Gustavson et al., 2018 ). There is a correlation between worry and social anxiety (Boelen et al., 2010 ; Clark & Beck, 2023 ) and between worry and rumination. According to research, both cause depression and anxiety (Segerstrom et al., 2000 ), there is a strong correlation between worry and rumination (Baik & Newman, 2023 ; Kim & Newman, 2023 ; Stade & Ruscio, 2023 ), and these two trans-diagnostic components are related to anxiety and depression. In Berkovic’s model (Borkovec et al., 2004 ), worry is formed in two ways. One is in the thoughts with which an individual tries to prevent future events, and the other is in stopping physical responses to worry-related mental images. In both cases, there is a type of cognitive avoidance based on which it can be suggested that an individual’s avoidance can lead to worry. Worry is linked to experiential avoidance in the emergence of mental disorders (Baik & Newman, 2023 ). In addition, there is a relationship between worry and experiential avoidance in creating social anxiety (Roemer et al., 2005 ). This research is important and necessary from multiple dimensions. In general, the comorbidity of depression and anxiety disorders is high and 25% of the individuals referring to medical centers have these disorders; comorbidity between these two disorders has been reported to be high (Nguyen et al., 2023 ). Also, the percentage of relapse of these disorders in patients is high after treatment (Kessler et al., 2009 ). Considering the high comorbidity of these two emotional disorders, the presence of an approach that can assess and target common underlying factors in the incidence of these disorders is really necessary for therapists and researchers. The trans-diagnostic approach is an approach that has eliminated many drawbacks of traditional approaches, including ignoring the serious factors and variables in disorders, focusing on the symptoms, and ignoring the comorbidity of the disorders, by focusing on the common fundamental processes instead of focusing on the symptoms. The review of previous studies conducted based on the trans-diagnostic approach has several limitations, including not investigating trans-diagnostic components as mediating variables and relying on their direct effects on disorders. Moreover, the model investigated in this research has not been addressed in any of the previous studies. This model can add a new dimension to trans-diagnostic literature and increase the effects of psychotherapy with a trans-diagnostic approach. Given the association of worry with rumination and experiential avoidance and the impacts of rumination and experiential avoidance on depression and anxiety, the current study primarily aims to investigate the mediating role of worry in the effects of these two trans-diagnostic components on depression and social anxiety. Explaining the interactive relationships of these variables can play a substantial role in both the formulation and application of therapeutic interventions. Accordingly, it is hypothesized that rumination and experiential avoidance are directly related to depression symptoms and social anxiety; rumination and experiential avoidance are directly related to anxiety; and worry is directly related to depression symptoms and social anxiety. It is also hypothesized that worry plays a mediating role in the relationship of rumination and experiential avoidance with depression symptoms and social anxiety. Method The present research is a descriptive-correlational study investigated using the path analysis of the mediating role of worry. The statistical population consisted of the students of Mashhad universities. Using Morgan’s table, 372 people should have been selected as a sample. Thus, 420 people were selected as a sample, considering the dropout in the number of subjects. The inclusion criterion for participation in the research included no significant clinical symptoms of anxiety and mood disorders, which were assessed by clinical interview. The research process was as follows: The self-report questionnaires of the Rumination Response Scale (RRS), the Acceptance and Action Questionnaire (AAQ), the Pennsylvania State Worry Questionnaire (PSWQ), the Beck depression Inventor-second edition (BDI-II), and the Social Phobia Inventory (SPIN) were provided to volunteer students both online and in person after giving the required explanations about no need for identity information and also confidentiality of information. - The Rumination Response Scale (RRS) This questionnaire, designed by Nolen-Hoeksema and Maro (Nolen-Hoeksema & Morrow, 1991 ), contains 22 items that are categorized on a 4-point scale (almost never = 1 to almost always = 4). The RRS evaluates 4 various types of response to negative mood and consists of two scales, including ruminative responses and distracting responses. This questionnaire has a high internal validity (Treynor et al., 2003 ), with a test-retest validity of 0.67 (Papageorgiou & Wells, 2004 ). Also, Cronbach's alpha of 0.90 was obtained in Iran by Mansouri et al.’s research (Malehmir et al., 2021 ; Mansouri et al., 2010 ). - The Acceptance and Action Questionnaire (AAQ) This scale, designed by Hayes et al. (Hayes et al., 2004 ), aims to measure acceptance, experiential avoidance, and psychological inflexibility. This scale contains 10 items with a 7-point Likert scale, which is scored from never (1) to always (7). A high score denotes a greater tendency to experimental avoidance. Bund et al. (Bond et al., 2011 ) reported the test-retest validity of this scale to be 0.81 and its internal consistency to be 0.87. Besharat et al. (Besharat & Shahidi, 2010 ) reported the validity of this questionnaire to be 0.78. - The Pennsylvania State Worry Questionnaire (PSWQ) This 16-item questionnaire was designed by Meyer, Miller, Metzger, and Bokovec (Meyer et al., 1990 ) to measure the trait of worry and the extreme, pervasive, and uncontrollable characteristics of pathological worry. This questionnaire is scored on a 5-point Likert scale from 1 (not at all true) to 5 (completely true). Cronbach's alpha of the PSWQ was reported in foreign research to be 0.86 and its test-retest alpha coefficient to be 0.80 (Meyer et al., 1990 ). The questionnaire was also normalized in Iran by Dashiri, Golzari, and Sohrabi(Dehshiri et al., 2009 ), with a Cronbach's alpha of 0.88 and a test-retest coefficient of 0.79. - The Beck Depression Inventory-Second Edition (BDI-II) This questionnaire, designed by Beck et al. (Beck, 1996 ), contains 21 questions and aims to measure the severity of depression symptoms in adults and adolescents over 13 years old. This questionnaire measures depression based on a 4-point Likert scale ranging from 0 to 3. The total score of the questionnaire ranges from 0 to 63, in which a score of 0–13 indicates partial depression, a score of 14–19 indicates mild depression, a score of 20–28 indicates moderate depression, and a score of 29–36 indicates severe depression. The studies conducted by Beck et al. (Beck, 1996 ) in the second edition of this questionnaire show an internal stability of 0.92 − 0.73, and Cronbach's alpha coefficients of 0.86 and 0.81 for the patient group and the non-patient group, respectively. In addition, Dobson and Mohammad Khani (Dobson & Mohammadkhani, 2007 ) measured Cronbach's alpha coefficients of 0.92 for outpatients and 0.93 for students. In Iran, Fatta et al. (Fata et al., 2005 ) reported this coefficient to be between 0.73 and 0.92. - The Connor’s Social Phobia Inventory (SPIN) This questionnaire, designed by Connor et al. (Connor et al., 2000 ) to assess social phobia, contains 17 items and 3 subscales, including fear, avoidance, and physiological discomfort. Each item is graded on a 5-point Likert scale. The test-retest reliability was reported to be 0.87–0.89 in groups diagnosed with social anxiety, with an internal consistency or alpha coefficient being 0.94 for the normal group for the total scale. In Iran, the content and face validity of this questionnaire was reported to be high for the first time in Abdi et al.’s research (2006). The test-retest reliability was obtained to be 0.83 and Cronbach's alpha was obtained to be 0.93. Results The gender distribution of the sample showed that 82.2% of the participants were female and 17.8% were male. Before performing the statistical analysis, the data screening was carried out and the missing values ​​were replaced with the mean scores. Then, univariate outliers were identified with a box plot, and the data were screened considering the standard score of Z = ± 3. Multivariate outliers were assessed by calculating Mahalanobis distances. The results revealed no outlier data. Descriptive indices and correlation coefficients of research variables are provided in Table 1 . Table 1 Descriptive statistics and Pearson`s correlation coffiecinets variables Mean SD kurtosis skewness 1 2 3 4 1. Ruminative responses 49.87 11.85 0.39 -0.42 - 3. Experiential avoidance 37.31 7.88 0.13 -0.40 0.60** - 3. Worry 41.63 10.13 0.22 -0.68 0.69** 0.62** - 4. Depression 18.51 13.38 0.67 -0.32 0.73** 0.61** 0.65** - 5. Social anxiety 40.21 15.38 0.62 -0.31 0.51** 0.49** 0.54** 0.49** Note: SD = standard deviation; **p < 0.01; *p < 0.05 According to Table 1 , rumination, experiential avoidance, and worry have positive and significant correlations with depression and social anxiety (P ≥ 0.01). Before conducting the path analysis, the assumptions were assessed. Table 1 showed that considering the skewness of ± 2 (Schumacker & Lomax, 2004 ) and kurtosis of ± 7 (West et al., 1995 ), the skewness and kurtosis in all variables were at a favorable level, and the univariate normality has been established. The univariate and multivariate normality of distribution of variables, lack of multicollinearity, independence of errors, and equality of variances have been dealt with. In assessing the multivariate normality, after calculating the values ​​of the standardized residuals, the distribution of the residuals was evaluated using the one-way Kolmogorov-Smirnov test. According to the results, the distribution of residuals is normal (P < 0.05, df = 427, Z = 0.04). In assessing the lack of multicollinearity, the tolerance index of the predictor variables ranged from 0.44 to 0.51 and the variance inflation factor (VIF) ranged from 1.97 to 2.28. The Durbin-Watson statistic was equal to 2.01, showing that the error independence assumption was established. The scatter plot also indicated that the equality of variance or heteroscedasticity assumption was established. Model estimation was performed using the maximum likelihood method. The fitness index of the model was at a desirable level (χ2/df = 1.884, goodness of fit index [GFI] = 0.998, comparative fit index [CFI] = 0.999, incremental fit index [IFI] = 0.999, root mea-square error of approximation [RMSEA] = 0.046) Standardized path coefficients are presented in Fig. 1 . Based on the path analysis, the explained variance amounts of depression and social anxiety based on rumination, experiential avoidance, and worry were R 2 = 0.348 and R 2 = 0.580, respectively. It means that predictor variables explain 35% of depression changes and 58% of avoidant anxiety changes. The direct and indirect path coefficients are provided in Table 2 . Indirect effects were estimated by the bootstrap method. Table 2 The path coefficient of rumination and experiential avoidance to depression symptoms and social anxiety Paths b β sig Rumination → Depression symptoms 0/525 0/465 0/003 Experimental avoidance → Depression symptoms 0/268 0/158 0/002 Rumination → Social anxiety 0/238 0/184 0/002 Experimental avoidance → Social anxiety 0/356 0/183 0/002 Rumination → Worry 0/416 0/488 0/002 Experimental avoidance → Worry 0/384 0/299 0/003 Worry → Depression symptoms 0/302 0/288 0/002 Worry → Social anxiety 0/458 0/302 0/003 Rumination → Worry→ Depression symptoms 0/126 0/111 0/001 Experimental avoidance → Worry → Depression symptoms 0/116 0/068 0/001 Rumination → Worry→ Social anxiety 0/191 0/147 0/002 Experimental avoidance → Worry → Social anxiety 0/176 0/090 0/002 Table 2 shows that all direct effects are positive and significant (P ≥ 0.01). Other results demonstrate that the direct effect of rumination (β = 0.465) on depression symptoms is greater than the direct effect of experimental avoidance (β = 0.158) on this variable. The direct effect of rumination on social anxiety is greater than the direct effect of experiential avoidance on this variable (β = 0.184 versus β = 0.183). The direct effect of rumination on worry is also greater than the direct effect of experiential avoidance on this variable (β = 0.488 versus β = 0.299). The direct effect of worry on social anxiety is greater than the direct effect of this variable on depression symptoms (β = 0.302 versus β = 0.288). The indirect effect of rumination on depression symptoms with the mediating role of worry is positive and significant (P < 0.01, β = 0.111). Experiential avoidance also has a positive and significant indirect effect on depression symptoms through worry (P < 0.01, β = 0.068). The comparison of indirect effects indicates that worry plays a greater mediating role in the relationship between rumination and depressive symptoms compared to the relationship between experiential avoidance and this variable (β = 0.111 versus β = 0.068). The indirect effect of rumination on social anxiety with the mediating role of worry is positive and significant (P < 0.01, β = 0.147). Experiential avoidance also has a positive and significant indirect effect on social anxiety through worry (P < 0.01, β = 0.090). The comparison of indirect effects reveals that worry plays a greater mediating role in the relationship between rumination and social anxiety compared to the relationship between experiential avoidance and this variable (β = 0.147 versus β = 0.090). Discussion and Conclusion The present research aimed to investigate the relationship of rumination and experiential avoidance with depression and social anxiety with the mediating role of worry. According to the research results, the direct relationship between rumination, depression, and social anxiety, and the relationship of rumination and experiential avoidance with worry, and also the relationship between worry, social anxiety, and depression was significantly observed. Moreover, the mediating role of worry in the relationship of rumination and experiential avoidance with depression and social anxiety was confirmed. There are consistent studies regarding the relationship of rumination and experiential avoidance with depression and social anxiety. Noda et al. (Noda et al., 2022 ) demonstrated that sensitivity to rejection affects individuals with social anxiety and depression through rumination. In another study by Kashdan et al. (Kashdan et al., 2013 ), it was found that individuals with social anxiety and depression symptoms had weaker positive emotions and relatively higher experiential avoidance than the control group. This relationship is also aligned with studies referenced (Akbari et al., 2022 ; Asher et al., 2021 ; Cheng et al., 2022 ; Laicher et al., 2022 ). Experiential avoidance, the tendency to avoid unwanted internal experiences, such as thoughts, feelings, and bodily sensations, intensifies rumination and preserves psychopathology. In In addition, rumination and experiential avoidance are components of emotion regulation that are associated with depression and social anxiety(Selby et al., 2016 ). Individuals with depression and social anxiety disorder often engage in rumination as an ineffective coping strategy that indirectly strengthens negative emotions and impairs problem-solving abilities. The relationship between rumination and depression can also be explored through childhood experiences and parenting styles. Parents who do not teach their children how to manage and regulate their emotions are more prone to increased rumination and are at a higher risk of developing depression in adulthood(Selby et al., 2016 ). Depression typically arises in the absence of reward and positive reinforcement, and experiential avoidance and rumination are two strategies that generally prove ineffective and lead to reward deprivation(Valderrama et al., 2016 ). Individuals with social anxiety often engage in more rumination in social situations, continuously overestimating the risks. These individuals may struggle to cope with their anxiety, which leads them to avoid anxiety-provoking situations(Valderrama et al., 2016 ). In another part, the relationship between rumination and experiential avoidance with worry was examined, and the results also indicated a significant association. In Aktar et al.’s study (Aktar et al., 2017 ) on parents of anxious children, in was found that these parents usually raised the child in such a way that he/she should avoid strong emotions and worry about them. Kathieh et al. indicated in a research that worry and rumination were correlated and their increase led to increasing negative affect and decreasing positive affect in subjects (McLaughlin et al., 2007 ). This correlation was also confirmed in studies conducted by Akbari et al.(Akbari & Khanipour, 2018 ) and Carrick et al. (McCarrick et al., 2021 ). Worry and rumination are two similar methods in content and evaluation, and their difference appears only when worry is focused on the future and rumination is focused on the past. Worry and rumination both cause negative affect in individuals; worry is the principal characteristic of pervasive anxiety and rumination is the principal characteristic of depression. The high comorbidity of these two disorders (Hu et al., 2022 ) can be a sign of the relationship between rumination and worry. Worry, rumination, and experiential avoidance increase simultaneously in an ambiguous situation(Aftab & Shams, 2020 ; Di Giuseppe & Taylor, 2021 ; Hassannejad Emamchay & Zabihi, 2024 ). so that increased ambiguity in a situation causes increased worry, rumination, and avoidance. These three components can reduce cognitive control in individuals; lack of cognitive control leads to many disorders, such as depression and anxiety (Watkins et al., 2005 ). In general, rumination and worry are less observed in individuals who have higher mental health. Worry in individuals causes the occurrence of negative emotions; avoiding unpleasant internal experiences and excessive experiential avoidance in individuals also lead to experiencing negative emotions and, subsequently, depression and anxiety. Regarding individuals with pervasive anxiety, whose primary characteristic is worry about the future, research has indicated that they have high experiential avoidance and imagine that not thinking about problems prevents them from happening(Newman & Llera, 2011 ). In our study, a relationship between worry, depression symptoms, and social anxiety was observed, which was consistent with the findings of some similar studies, such as those by Taylor and Snyder (Taylor & Snyder, 2021 )and Hall et al. (Arditte Hall et al., 2019 ). One of the chief characteristics of depression disorder is unpleasant feelings and low mood. In social anxiety disorder, there is also negative feeling and general self-attack. In individuals who experience worry, there are states of negative feeling and pessimism toward the future (Wullenkord & Ojala, 2023 ). They experience sadness and lack of pleasure in the long term, which are the main depression symptoms. Also, worrying about the others’ judgments constantly causes anxiety in individuals who feel anxious in social situations. Thus, according to the literature, it can be said that worry is one of the factors associated with depression symptoms and social anxiety. Worry also causes negative self-talks. This characteristic is very common in depressed individuals about pessimism about the future and the worthlessness of the world, and in social anxiety about upcoming social situations, such as presentation in a class. One of the obvious characteristics of worry belongs to a potential problem. As in social anxiety the individual’s anxiety is due to social situations and fear of an event that has not happened, in depression, it also is due to pessimism about the future and an unrealized feeling of emptiness. Worry causes the use of cognitive errors (Hecker & Sedek), such as catastrophizing. Self-attribution is a common cognitive error in social anxiety disorder and depression. As worry is an uncontrollable negative thought, this feature also exists in depressed and socially anxious individuals, and negative thinking about the future is out of their control. Furthermore, in the present study, the mediating role of worry in the relationship between rumination and experiential avoidance with depression and social anxiety was confirmed. According to previous studies, the impact of experiential avoidance on worry is greater than the opposite (Buhr & Dugas, 2012 ; Santanello & Gardner, 2007 ). However, we did not find any domestic or foreign research to confirm the direct effect of rumination about past events on increasing worry about the future, but this relationship was confirmed in our research. Also, as explained, worry itself also greatly affects depression symptoms and social anxiety. Despite these relationships, it was expected that the mediating role of worry becomes significant. There are also studies inconsistent with our research, indicating that rumination and worry are inversely related to experiential avoidance, and also rumination and worry are reduced by avoiding a subject or event, leading to increased positive emotions (Kim & Newman, 2023 ; Rashtbari & Saed, 2020 ). A reason for this discrepancy can be explained by the fact that the focus of the aforementioned studies has been on the short term. The direct relationship of rumination and experiential avoidance with depression and social anxiety was stronger than the indirect relationship in our model, showing that rumination and experiential avoidance are more general components in the development of depression symptoms and social anxiety, and worry can be considered another trans-diagnostic component. In the literature review of the intended domestic and foreign studies, we found no research consistent with our model. Conducting this research can provide therapists with a new model in the treatment of the comorbidity of depression and social anxiety disorders. Moreover, further attention should be paid to important trans-diagnostic components, such as rumination, experiential avoidance, and worry, which can create many symptoms of mental disorders. This model had not been worked on in the domestic and foreign studies, which we did. It is suggested that more research be conducted in the future on other trans-diagnostic components on the comorbidity of depression and social anxiety disorders. It is also hoped that the trans-diagnostic approach will expand, and even models will be designed to explain personality disorders and their comorbidity. Limitations One limitation of this study is that the data were collected through a self-report questionnaire, which may introduce the possibility of exaggeration or bias in participants' responses. Additionally, the sample used in this study consisted of university students rather than a clinical sample, limiting the generalizability of the findings to clinical populations. Furthermore, the study had a small sample size and used a convenience sampling method, which further restricts the ability to generalize the results. Future research could benefit from using a larger clinical sample and employing a variety of data collection methods to more accurately explore the relationships between rumination, experiential avoidance, depression, and social anxiety. Declarations Consent for publication: Not Applicable Acknowledgements: The authors would like to thank all the participants for their generous collaboration in this study. Data Availability : The datasets generated for this study are available on request to the corresponding author Ethics Approval : Research Ethics Committee of Ferdowsi University of Mashhad approved this study, and all participants signed a written informed consent.. The study was conducted in accordance with the principles outlined in the Declaration of Helsinki(World Medical Association, 1964) on ethical research involving human participants, with respect for their rights, safety, and well-being. "This study was not interventional, and data were collected only from participants who provided informed consent. The questionnaires were completed voluntarily, with participants' names and personal identifiers omitted to ensure confidentiality and privacy of their responses." Conflict of Interest : The authors declare no competing interests. Funding Declaration: This research did not receive any specific funding from public, commercial, or non-profit funding agencies. 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Health effects of psychological interventions for worry and rumination: A meta-analysis. Health Psychol. 2021;40(9):617. McCracken LM, Barker E, Chilcot J. Decentering, rumination, cognitive defusion, and psychological flexibility in people with chronic pain. J Behav Med. 2014;37:1215–25. McLaughlin KA, Borkovec TD, Sibrava NJ. The effects of worry and rumination on affect states and cognitive activity. Behav Ther. 2007;38(1):23–38. Meyer TJ, Miller ML, Metzger RL, Borkovec TD. Development and validation of the penn state worry questionnaire. Behav Res Ther. 1990;28(6):487–95. Newman MG, Llera SJ. A novel theory of experiential avoidance in generalized anxiety disorder: A review and synthesis of research supporting a contrast avoidance model of worry. Clin Psychol Rev. 2011;31(3):371–82. Nguyen N, Peyser ND, Olgin JE, Pletcher MJ, Beatty AL, Modrow MF, Carton TW, Khatib R, Djibo DA, Ling PM. Associations between tobacco and cannabis use and anxiety and depression among adults in the United States: Findings from the COVID-19 citizen science study. PLoS ONE. 2023;18(9):e0289058. Noda S, Masaki M, Kishimoto T, Kaiya H. Effect of rejection sensitivity on the development of anxious-depressive attack in Japanese outpatients: The mediating roles of rumination, social anxiety, and depressive symptoms. Front Psychol. 2022;13:1016879. Nolen-Hoeksema S. (2001). Ruminative coping and adjustment to bereavement. Nolen-Hoeksema S, Morrow J. A prospective study of depression and posttraumatic stress symptoms after a natural disaster: the 1989 Loma Prieta Earthquake. J Personal Soc Psychol. 1991;61(1):115. Papageorgiou C, Wells A. Depressive rumination: Nature, theory and treatment. Wiley Online Library; 2004. Rashtbari A, Saed O. Contrast avoidance model of worry and generalized anxiety disorder: A theoretical perspective. Cogent Psychol. 2020;7(1):1800262. Roemer L, Salters K, Raffa SD, Orsillo SM. Fear and avoidance of internal experiences in GAD: Preliminary tests of a conceptual model. Cogn Therapy Res. 2005;29:71–88. Santanello AW, Gardner FL. The role of experiential avoidance in the relationship between maladaptive perfectionism and worry. Cogn Therapy Res. 2007;31:319–32. Schumacker RE, Lomax RG. A beginner's guide to structural equation modeling. psychology; 2004. Segerstrom SC, Tsao JC, Alden LE, Craske MG. Worry and rumination: Repetitive thought as a concomitant and predictor of negative mood. Cogn Therapy Res. 2000;24:671–88. Selby EA, Kranzler A, Panza E, Fehling KB. Bidirectional-compounding effects of rumination and negative emotion in predicting impulsive behavior: Implications for emotional cascades. J Pers. 2016;84(2):139–53. Stade EC, Ruscio AM. A meta-analysis of the relationship between worry and rumination. Clin Psychol Sci. 2023;11(3):552–73. Taylor MM, Snyder HR. Repetitive negative thinking shared across rumination and worry predicts symptoms of depression and anxiety. J Psychopathol Behav Assess. 2021;43(4):904–15. Treynor W, Gonzalez R, Nolen-Hoeksema S. Rumination reconsidered: A psychometric analysis. Cogn Therapy Res. 2003;27:247–59. Üstün T. (2004). Ayuso-Mateos, j. L., Chatterji, S., Mathers, C., & Murray, C. j. L , 386–392. Valderrama J, Miranda R, Jeglic E. Ruminative subtypes and impulsivity in risk for suicidal behavior. Psychiatry Res. 2016;236:15–21. VĂLENAŞ SP, SZENTAGOTÁI-TĂTAR A. (2015). The relationships between stress, negative affect, rumination and social anxiety. J evidence-based psychotherapies, 15 (2). Watkins E, Moulds M, Mackintosh B. Comparisons between rumination and worry in a non-clinical population. Behav Res Ther. 2005;43(12):1577–85. Weathers FW, Huska JA, Keane TM. PCL-C for DSM-IV. Boston: National Center for PTSD-Behavioral Science Division; 1991. West SG, Finch JF, Curran PJ. Structural equation models with nonnormal variables. Problems and remedies; 1995. Wullenkord MC, Ojala M. Climate-change worry among two cohorts of late adolescents: Exploring macro and micro worries, coping, and relations to climate engagement, pessimism, and well-being. J Environ Psychol. 2023;90:102093. World Medical Association. Declaration of Helsinki. Ethical Principles for Medical Research Involving Human Subjects; 1964. Zhu J, Zhang W, Chen Y, Teicher MH. (2024). Joint trajectories of depression and rumination: experiential predictors and risk of nonsuicidal self-injury. J Am Acad Child Adolesc Psychiatry. Additional Declarations No competing interests reported. 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1","display":"","copyAsset":false,"role":"figure","size":95536,"visible":true,"origin":"","legend":"\u003cp\u003eThe\u003cstrong\u003e \u003c/strong\u003eStandard path coefficients of the depression and social anxiety prediction model\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7335833/v1/544a38e4ba50ea513411e5c4.png"},{"id":91990884,"identity":"9c79c6c9-14f9-483f-a181-2877441d2f88","added_by":"auto","created_at":"2025-09-23 12:42:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":693396,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7335833/v1/d3f3bf7e-d0b9-4b1c-a779-3e62934ab5a1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Relationship of Rumination and Experiential Avoidance with Depression and Social Anxiety: The Mediating Role of Worry","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAnxiety and depression disorders are greatly prevalent among psychological disorders so that the prevalence of depression disorder reaches 31%, with a significant amount. There is a high rate of this disorder in different populations (Holdaway et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). The prevalence of anxiety disorder also reaches 29% (Kessler et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2005\u003c/span\u003e). Anxiety disorders are debilitating, one of which is social anxiety disorder. Individuals with this disorder are afraid of and avoid social situations (Heimberg et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Social anxiety disorder is highly comorbid with depression disorder. This issue has also been well confirmed in previous studies, being reported by Gorman to be 20\u0026ndash;70% (Coombes et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Gorman, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e1996\u003c/span\u003e; Kessler et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2005\u003c/span\u003e). Depression is one of the most debilitating and chronic mental disorders (Kessler et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2009\u003c/span\u003e), and is among the diseases that impose heavy economic burden and costs on any society (\u0026Uuml;st\u0026uuml;n, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e2004\u003c/span\u003e). This disorder is highly comorbid with anxiety disorders so that individuals with one of these two disorders are 28\u0026ndash;63% likely to have the other disorder as well (Brown et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2001\u003c/span\u003e). The cause of this comorbidity can be due to the common components in these disorders. One of the most recent approaches that target these factors is the trans-diagnostic integrated approach (Barlow et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Besharat \u0026amp; Shahidi, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). Two trans-diagnostic components that can impact depression and social anxiety are rumination and experiential avoidance. Rumination refers to repetitive and negative thoughts, typically about the past, causing inconsistent problem-solving (Besharat \u0026amp; Shahidi, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). Rumination causes depression and plays a crucial role in its maintenance (Cano-L\u0026oacute;pez et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Lyubomirsky et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Zhu et al., \u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). According to the response style theory, rumination is the process of repetitive thinking about oneself and depression symptoms instead of adaptive resolution of symptoms (Nolen-Hoeksema, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e2001\u003c/span\u003e). Among other mental disorders that are associated with rumination and have been confirmed by previous studies is social anxiety, which has been shown that rumination resulting from stress is particularly connected to social anxiety (Cheng et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Laicher et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; VĂLENAŞ \u0026amp; SZENTAGOT\u0026Aacute;I-TĂTAR, \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Another research (Elhai et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) also indicates that rumination, depression, and social anxiety are significantly correlated so that these individuals have permanent and repetitive thoughts about themselves after social interactions (Kashdan et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2008\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAnother component related to depression and social anxiety is experiential avoidance. Avoiding the events that occur to us and are not in accordance with our desires, generally, leads to unpleasant feelings, thoughts, and physical reactions in us (Kashdan et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). The experiential avoidance means that an individual escapes and avoids unwanted and unpleasant internal experiences and does not experience them (Weathers et al., \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e1991\u003c/span\u003e). It may have beneficial effects in the short run, but it will cause problems in the long run (Bardeen, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). One of these problems that are related to the meta-diagnostic concept of experiential avoidance is depression (Cookson et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; McCracken et al., \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). The fear of encountering internal experiences culminates in anxiety in situations in which those internal events happen to the individual (Barlow, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2000\u003c/span\u003e). One of these anxieties is social anxiety in social situations. Although numerous studies have not been conducted on the role of experiential avoidance in social anxiety modeling, research also indicates the existence of a relationship between experiential avoidance and social anxiety (Cookson et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Kashdan, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). When individuals with social anxiety experience more social anxiety, they report less positive events and attempt to avoid and suppress their internal unpleasant feelings (Kashdan \u0026amp; Steger, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). Based on the explanations provided and the existing background, rumination and experiential avoidance influence social anxiety and depression. Nevertheless, do these two trans-diagnostic components directly influence these disorders or is there a mediating variable that is both related to rumination and experiential avoidance and influenced by them and is also related to depression and social anxiety and plays a substantial role in their creation. Considering the outstanding role of worry as a mediating variable and a trans-diagnostic component that impacts these two disorders, the investigation of this variable in a multifactorial structure is of great importance.\u003c/p\u003e\u003cp\u003eWorry is a process of repetitive thinking with the content of preventing or coping with negative events (Borkovec \u0026amp; Roemer, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e1995\u003c/span\u003e). Worry is defined as a concern and presentiment about future negative events (Brown et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2001\u003c/span\u003e). Research shows that different forms of negative thinking, including worry, play a critical role in depression. Furthermore, worry causes the onset and maintenance of depression in individuals (Bajaj et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Gustavson et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). There is a correlation between worry and social anxiety (Boelen et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Clark \u0026amp; Beck, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) and between worry and rumination. According to research, both cause depression and anxiety (Segerstrom et al., \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e2000\u003c/span\u003e), there is a strong correlation between worry and rumination (Baik \u0026amp; Newman, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Kim \u0026amp; Newman, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Stade \u0026amp; Ruscio, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), and these two trans-diagnostic components are related to anxiety and depression. In Berkovic\u0026rsquo;s model (Borkovec et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2004\u003c/span\u003e), worry is formed in two ways. One is in the thoughts with which an individual tries to prevent future events, and the other is in stopping physical responses to worry-related mental images. In both cases, there is a type of cognitive avoidance based on which it can be suggested that an individual\u0026rsquo;s avoidance can lead to worry. Worry is linked to experiential avoidance in the emergence of mental disorders (Baik \u0026amp; Newman, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). In addition, there is a relationship between worry and experiential avoidance in creating social anxiety (Roemer et al., \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2005\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThis research is important and necessary from multiple dimensions. In general, the comorbidity of depression and anxiety disorders is high and 25% of the individuals referring to medical centers have these disorders; comorbidity between these two disorders has been reported to be high (Nguyen et al., \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Also, the percentage of relapse of these disorders in patients is high after treatment (Kessler et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). Considering the high comorbidity of these two emotional disorders, the presence of an approach that can assess and target common underlying factors in the incidence of these disorders is really necessary for therapists and researchers. The trans-diagnostic approach is an approach that has eliminated many drawbacks of traditional approaches, including ignoring the serious factors and variables in disorders, focusing on the symptoms, and ignoring the comorbidity of the disorders, by focusing on the common fundamental processes instead of focusing on the symptoms. The review of previous studies conducted based on the trans-diagnostic approach has several limitations, including not investigating trans-diagnostic components as mediating variables and relying on their direct effects on disorders. Moreover, the model investigated in this research has not been addressed in any of the previous studies. This model can add a new dimension to trans-diagnostic literature and increase the effects of psychotherapy with a trans-diagnostic approach.\u003c/p\u003e\u003cp\u003eGiven the association of worry with rumination and experiential avoidance and the impacts of rumination and experiential avoidance on depression and anxiety, the current study primarily aims to investigate the mediating role of worry in the effects of these two trans-diagnostic components on depression and social anxiety. Explaining the interactive relationships of these variables can play a substantial role in both the formulation and application of therapeutic interventions. Accordingly, it is hypothesized that rumination and experiential avoidance are directly related to depression symptoms and social anxiety; rumination and experiential avoidance are directly related to anxiety; and worry is directly related to depression symptoms and social anxiety. It is also hypothesized that worry plays a mediating role in the relationship of rumination and experiential avoidance with depression symptoms and social anxiety.\u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003eThe present research is a descriptive-correlational study investigated using the path analysis of the mediating role of worry. The statistical population consisted of the students of Mashhad universities. Using Morgan\u0026rsquo;s table, 372 people should have been selected as a sample. Thus, 420 people were selected as a sample, considering the dropout in the number of subjects. The inclusion criterion for participation in the research included no significant clinical symptoms of anxiety and mood disorders, which were assessed by clinical interview. The research process was as follows: The self-report questionnaires of the Rumination Response Scale (RRS), the Acceptance and Action Questionnaire (AAQ), the Pennsylvania State Worry Questionnaire (PSWQ), the Beck depression Inventor-second edition (BDI-II), and the Social Phobia Inventory (SPIN) were provided to volunteer students both online and in person after giving the required explanations about no need for identity information and also confidentiality of information.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e- The Rumination Response Scale (RRS)\u003c/h2\u003e\u003cp\u003eThis questionnaire, designed by Nolen-Hoeksema and Maro (Nolen-Hoeksema \u0026amp; Morrow, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e1991\u003c/span\u003e), contains 22 items that are categorized on a 4-point scale (almost never\u0026thinsp;=\u0026thinsp;1 to almost always\u0026thinsp;=\u0026thinsp;4). The RRS evaluates 4 various types of response to negative mood and consists of two scales, including ruminative responses and distracting responses. This questionnaire has a high internal validity (Treynor et al., \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e2003\u003c/span\u003e), with a test-retest validity of 0.67 (Papageorgiou \u0026amp; Wells, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e2004\u003c/span\u003e). Also, Cronbach's alpha of 0.90 was obtained in Iran by Mansouri et al.\u0026rsquo;s research (Malehmir et al., \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Mansouri et al., \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2010\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003e- The Acceptance and Action Questionnaire (AAQ)\u003c/h3\u003e\n\u003cp\u003eThis scale, designed by Hayes et al. (Hayes et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2004\u003c/span\u003e), aims to measure acceptance, experiential avoidance, and psychological inflexibility. This scale contains 10 items with a 7-point Likert scale, which is scored from never (1) to always (7). A high score denotes a greater tendency to experimental avoidance. Bund et al. (Bond et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2011\u003c/span\u003e) reported the test-retest validity of this scale to be 0.81 and its internal consistency to be 0.87. Besharat et al. (Besharat \u0026amp; Shahidi, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2010\u003c/span\u003e) reported the validity of this questionnaire to be 0.78.\u003c/p\u003e\n\u003ch3\u003e- The Pennsylvania State Worry Questionnaire (PSWQ)\u003c/h3\u003e\n\u003cp\u003eThis 16-item questionnaire was designed by Meyer, Miller, Metzger, and Bokovec (Meyer et al., \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e1990\u003c/span\u003e) to measure the trait of worry and the extreme, pervasive, and uncontrollable characteristics of pathological worry. This questionnaire is scored on a 5-point Likert scale from 1 (not at all true) to 5 (completely true). Cronbach's alpha of the PSWQ was reported in foreign research to be 0.86 and its test-retest alpha coefficient to be 0.80 (Meyer et al., \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e1990\u003c/span\u003e). The questionnaire was also normalized in Iran by Dashiri, Golzari, and Sohrabi(Dehshiri et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2009\u003c/span\u003e), with a Cronbach's alpha of 0.88 and a test-retest coefficient of 0.79.\u003c/p\u003e\n\u003ch3\u003e- The Beck Depression Inventory-Second Edition (BDI-II)\u003c/h3\u003e\n\u003cp\u003eThis questionnaire, designed by Beck et al. (Beck, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e1996\u003c/span\u003e), contains 21 questions and aims to measure the severity of depression symptoms in adults and adolescents over 13 years old. This questionnaire measures depression based on a 4-point Likert scale ranging from 0 to 3. The total score of the questionnaire ranges from 0 to 63, in which a score of 0\u0026ndash;13 indicates partial depression, a score of 14\u0026ndash;19 indicates mild depression, a score of 20\u0026ndash;28 indicates moderate depression, and a score of 29\u0026ndash;36 indicates severe depression. The studies conducted by Beck et al. (Beck, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e1996\u003c/span\u003e) in the second edition of this questionnaire show an internal stability of 0.92\u0026thinsp;\u0026minus;\u0026thinsp;0.73, and Cronbach's alpha coefficients of 0.86 and 0.81 for the patient group and the non-patient group, respectively. In addition, Dobson and Mohammad Khani (Dobson \u0026amp; Mohammadkhani, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2007\u003c/span\u003e) measured Cronbach's alpha coefficients of 0.92 for outpatients and 0.93 for students. In Iran, Fatta et al. (Fata et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2005\u003c/span\u003e) reported this coefficient to be between 0.73 and 0.92.\u003c/p\u003e\n\u003ch3\u003e- The Connor’s Social Phobia Inventory (SPIN)\u003c/h3\u003e\n\u003cp\u003eThis questionnaire, designed by Connor et al. (Connor et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2000\u003c/span\u003e) to assess social phobia, contains 17 items and 3 subscales, including fear, avoidance, and physiological discomfort. Each item is graded on a 5-point Likert scale. The test-retest reliability was reported to be 0.87\u0026ndash;0.89 in groups diagnosed with social anxiety, with an internal consistency or alpha coefficient being 0.94 for the normal group for the total scale. In Iran, the content and face validity of this questionnaire was reported to be high for the first time in Abdi et al.\u0026rsquo;s research (2006). The test-retest reliability was obtained to be 0.83 and Cronbach's alpha was obtained to be 0.93.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe gender distribution of the sample showed that 82.2% of the participants were female and 17.8% were male.\u003c/p\u003e\u003cp\u003eBefore performing the statistical analysis, the data screening was carried out and the missing values ​​were replaced with the mean scores. Then, univariate outliers were identified with a box plot, and the data were screened considering the standard score of Z\u0026thinsp;=\u0026thinsp;\u0026plusmn;\u0026thinsp;3. Multivariate outliers were assessed by calculating Mahalanobis distances. The results revealed no outlier data. Descriptive indices and correlation coefficients of research variables are provided in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDescriptive statistics and Pearson`s correlation coffiecinets\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003evariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ekurtosis\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eskewness\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1. Ruminative responses\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e49.87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e-0.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3. Experiential avoidance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e37.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7.88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e-0.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.60**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3. Worry\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e41.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e-0.68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.69**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.62**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4. Depression\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e18.51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e-0.32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.73**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.61**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.65**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5. Social anxiety\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e40.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e15.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e-0.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.51**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.49**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.54**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.49**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"9\"\u003eNote: SD\u0026thinsp;=\u0026thinsp;standard deviation; **p\u0026thinsp;\u0026lt;\u0026thinsp;0.01; *p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAccording to Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, rumination, experiential avoidance, and worry have positive and significant correlations with depression and social anxiety (P\u0026thinsp;\u0026ge;\u0026thinsp;0.01).\u003c/p\u003e\u003cp\u003eBefore conducting the path analysis, the assumptions were assessed. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e showed that considering the skewness of \u0026plusmn; 2 (Schumacker \u0026amp; Lomax, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e2004\u003c/span\u003e) and kurtosis of \u0026plusmn; 7 (West et al., \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e1995\u003c/span\u003e), the skewness and kurtosis in all variables were at a favorable level, and the univariate normality has been established. The univariate and multivariate normality of distribution of variables, lack of multicollinearity, independence of errors, and equality of variances have been dealt with. In assessing the multivariate normality, after calculating the values ​​of the standardized residuals, the distribution of the residuals was evaluated using the one-way Kolmogorov-Smirnov test. According to the results, the distribution of residuals is normal (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05, df\u0026thinsp;=\u0026thinsp;427, Z\u0026thinsp;=\u0026thinsp;0.04). In assessing the lack of multicollinearity, the tolerance index of the predictor variables ranged from 0.44 to 0.51 and the variance inflation factor (VIF) ranged from 1.97 to 2.28. The Durbin-Watson statistic was equal to 2.01, showing that the error independence assumption was established. The scatter plot also indicated that the equality of variance or heteroscedasticity assumption was established.\u003c/p\u003e\u003cp\u003eModel estimation was performed using the maximum likelihood method. The fitness index of the model was at a desirable level (χ2/df\u0026thinsp;=\u0026thinsp;1.884, goodness of fit index [GFI]\u0026thinsp;=\u0026thinsp;0.998, comparative fit index [CFI]\u0026thinsp;=\u0026thinsp;0.999, incremental fit index [IFI]\u0026thinsp;=\u0026thinsp;0.999, root mea-square error of approximation [RMSEA]\u0026thinsp;=\u0026thinsp;0.046)\u003c/p\u003e\u003cp\u003eStandardized path coefficients are presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eBased on the path analysis, the explained variance amounts of depression and social anxiety based on rumination, experiential avoidance, and worry were R\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.348 and R\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.580, respectively. It means that predictor variables explain 35% of depression changes and 58% of avoidant anxiety changes. The direct and indirect path coefficients are provided in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Indirect effects were estimated by the bootstrap method.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThe path coefficient of rumination and experiential avoidance to depression symptoms and social anxiety\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePaths\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eb\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eβ\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003esig\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRumination \u0026rarr; Depression symptoms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0/525\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0/465\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0/003\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExperimental avoidance \u0026rarr; Depression symptoms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0/268\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0/158\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0/002\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRumination \u0026rarr; Social anxiety\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0/238\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0/184\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0/002\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExperimental avoidance \u0026rarr; Social anxiety\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0/356\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0/183\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0/002\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRumination \u0026rarr; Worry\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0/416\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0/488\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0/002\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExperimental avoidance \u0026rarr; Worry\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0/384\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0/299\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0/003\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWorry \u0026rarr; Depression symptoms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0/302\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0/288\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0/002\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWorry \u0026rarr; Social anxiety\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0/458\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0/302\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0/003\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRumination \u0026rarr; Worry\u0026rarr; Depression symptoms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0/126\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0/111\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0/001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExperimental avoidance \u0026rarr; Worry \u0026rarr; Depression symptoms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0/116\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0/068\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0/001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRumination \u0026rarr; Worry\u0026rarr; Social anxiety\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0/191\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0/147\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0/002\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExperimental avoidance \u0026rarr; Worry \u0026rarr; Social anxiety\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0/176\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0/090\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0/002\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows that all direct effects are positive and significant (P\u0026thinsp;\u0026ge;\u0026thinsp;0.01). Other results demonstrate that the direct effect of rumination (β\u0026thinsp;=\u0026thinsp;0.465) on depression symptoms is greater than the direct effect of experimental avoidance (β\u0026thinsp;=\u0026thinsp;0.158) on this variable. The direct effect of rumination on social anxiety is greater than the direct effect of experiential avoidance on this variable (β\u0026thinsp;=\u0026thinsp;0.184 versus β\u0026thinsp;=\u0026thinsp;0.183). The direct effect of rumination on worry is also greater than the direct effect of experiential avoidance on this variable (β\u0026thinsp;=\u0026thinsp;0.488 versus β\u0026thinsp;=\u0026thinsp;0.299). The direct effect of worry on social anxiety is greater than the direct effect of this variable on depression symptoms (β\u0026thinsp;=\u0026thinsp;0.302 versus β\u0026thinsp;=\u0026thinsp;0.288). The indirect effect of rumination on depression symptoms with the mediating role of worry is positive and significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01, β\u0026thinsp;=\u0026thinsp;0.111). Experiential avoidance also has a positive and significant indirect effect on depression symptoms through worry (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01, β\u0026thinsp;=\u0026thinsp;0.068). The comparison of indirect effects indicates that worry plays a greater mediating role in the relationship between rumination and depressive symptoms compared to the relationship between experiential avoidance and this variable (β\u0026thinsp;=\u0026thinsp;0.111 versus β\u0026thinsp;=\u0026thinsp;0.068). The indirect effect of rumination on social anxiety with the mediating role of worry is positive and significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01, β\u0026thinsp;=\u0026thinsp;0.147). Experiential avoidance also has a positive and significant indirect effect on social anxiety through worry (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01, β\u0026thinsp;=\u0026thinsp;0.090). The comparison of indirect effects reveals that worry plays a greater mediating role in the relationship between rumination and social anxiety compared to the relationship between experiential avoidance and this variable (β\u0026thinsp;=\u0026thinsp;0.147 versus β\u0026thinsp;=\u0026thinsp;0.090).\u003c/p\u003e"},{"header":"Discussion and Conclusion","content":"\u003cp\u003eThe present research aimed to investigate the relationship of rumination and experiential avoidance with depression and social anxiety with the mediating role of worry. According to the research results, the direct relationship between rumination, depression, and social anxiety, and the relationship of rumination and experiential avoidance with worry, and also the relationship between worry, social anxiety, and depression was significantly observed. Moreover, the mediating role of worry in the relationship of rumination and experiential avoidance with depression and social anxiety was confirmed.\u003c/p\u003e\u003cp\u003eThere are consistent studies regarding the relationship of rumination and experiential avoidance with depression and social anxiety. Noda et al. (Noda et al., \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) demonstrated that sensitivity to rejection affects individuals with social anxiety and depression through rumination. In another study by Kashdan et al. (Kashdan et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2013\u003c/span\u003e), it was found that individuals with social anxiety and depression symptoms had weaker positive emotions and relatively higher experiential avoidance than the control group. This relationship is also aligned with studies referenced (Akbari et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Asher et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Cheng et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Laicher et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Experiential avoidance, the tendency to avoid unwanted internal experiences, such as thoughts, feelings, and bodily sensations, intensifies rumination and preserves psychopathology. In In addition, rumination and experiential avoidance are components of emotion regulation that are associated with depression and social anxiety(Selby et al., \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Individuals with depression and social anxiety disorder often engage in rumination as an ineffective coping strategy that indirectly strengthens negative emotions and impairs problem-solving abilities. The relationship between rumination and depression can also be explored through childhood experiences and parenting styles. Parents who do not teach their children how to manage and regulate their emotions are more prone to increased rumination and are at a higher risk of developing depression in adulthood(Selby et al., \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Depression typically arises in the absence of reward and positive reinforcement, and experiential avoidance and rumination are two strategies that generally prove ineffective and lead to reward deprivation(Valderrama et al., \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Individuals with social anxiety often engage in more rumination in social situations, continuously overestimating the risks. These individuals may struggle to cope with their anxiety, which leads them to avoid anxiety-provoking situations(Valderrama et al., \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e2016\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn another part, the relationship between rumination and experiential avoidance with worry was examined, and the results also indicated a significant association. In Aktar et al.\u0026rsquo;s study (Aktar et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) on parents of anxious children, in was found that these parents usually raised the child in such a way that he/she should avoid strong emotions and worry about them. Kathieh et al. indicated in a research that worry and rumination were correlated and their increase led to increasing negative affect and decreasing positive affect in subjects (McLaughlin et al., \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). This correlation was also confirmed in studies conducted by Akbari et al.(Akbari \u0026amp; Khanipour, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) and Carrick et al. (McCarrick et al., \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Worry and rumination are two similar methods in content and evaluation, and their difference appears only when worry is focused on the future and rumination is focused on the past. Worry and rumination both cause negative affect in individuals; worry is the principal characteristic of pervasive anxiety and rumination is the principal characteristic of depression. The high comorbidity of these two disorders (Hu et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) can be a sign of the relationship between rumination and worry. Worry, rumination, and experiential avoidance increase simultaneously in an ambiguous situation(Aftab \u0026amp; Shams, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Di Giuseppe \u0026amp; Taylor, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Hassannejad Emamchay \u0026amp; Zabihi, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). so that increased ambiguity in a situation causes increased worry, rumination, and avoidance. These three components can reduce cognitive control in individuals; lack of cognitive control leads to many disorders, such as depression and anxiety (Watkins et al., \u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e2005\u003c/span\u003e). In general, rumination and worry are less observed in individuals who have higher mental health. Worry in individuals causes the occurrence of negative emotions; avoiding unpleasant internal experiences and excessive experiential avoidance in individuals also lead to experiencing negative emotions and, subsequently, depression and anxiety. Regarding individuals with pervasive anxiety, whose primary characteristic is worry about the future, research has indicated that they have high experiential avoidance and imagine that not thinking about problems prevents them from happening(Newman \u0026amp; Llera, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2011\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn our study, a relationship between worry, depression symptoms, and social anxiety was observed, which was consistent with the findings of some similar studies, such as those by Taylor and Snyder (Taylor \u0026amp; Snyder, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e2021\u003c/span\u003e)and Hall et al. (Arditte Hall et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). One of the chief characteristics of depression disorder is unpleasant feelings and low mood. In social anxiety disorder, there is also negative feeling and general self-attack. In individuals who experience worry, there are states of negative feeling and pessimism toward the future (Wullenkord \u0026amp; Ojala, \u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). They experience sadness and lack of pleasure in the long term, which are the main depression symptoms. Also, worrying about the others\u0026rsquo; judgments constantly causes anxiety in individuals who feel anxious in social situations. Thus, according to the literature, it can be said that worry is one of the factors associated with depression symptoms and social anxiety. Worry also causes negative self-talks. This characteristic is very common in depressed individuals about pessimism about the future and the worthlessness of the world, and in social anxiety about upcoming social situations, such as presentation in a class. One of the obvious characteristics of worry belongs to a potential problem. As in social anxiety the individual\u0026rsquo;s anxiety is due to social situations and fear of an event that has not happened, in depression, it also is due to pessimism about the future and an unrealized feeling of emptiness. Worry causes the use of cognitive errors (Hecker \u0026amp; Sedek), such as catastrophizing. Self-attribution is a common cognitive error in social anxiety disorder and depression. As worry is an uncontrollable negative thought, this feature also exists in depressed and socially anxious individuals, and negative thinking about the future is out of their control.\u003c/p\u003e\u003cp\u003eFurthermore, in the present study, the mediating role of worry in the relationship between rumination and experiential avoidance with depression and social anxiety was confirmed. According to previous studies, the impact of experiential avoidance on worry is greater than the opposite (Buhr \u0026amp; Dugas, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Santanello \u0026amp; Gardner, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). However, we did not find any domestic or foreign research to confirm the direct effect of rumination about past events on increasing worry about the future, but this relationship was confirmed in our research. Also, as explained, worry itself also greatly affects depression symptoms and social anxiety. Despite these relationships, it was expected that the mediating role of worry becomes significant. There are also studies inconsistent with our research, indicating that rumination and worry are inversely related to experiential avoidance, and also rumination and worry are reduced by avoiding a subject or event, leading to increased positive emotions (Kim \u0026amp; Newman, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Rashtbari \u0026amp; Saed, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). A reason for this discrepancy can be explained by the fact that the focus of the aforementioned studies has been on the short term.\u003c/p\u003e\u003cp\u003eThe direct relationship of rumination and experiential avoidance with depression and social anxiety was stronger than the indirect relationship in our model, showing that rumination and experiential avoidance are more general components in the development of depression symptoms and social anxiety, and worry can be considered another trans-diagnostic component. In the literature review of the intended domestic and foreign studies, we found no research consistent with our model. Conducting this research can provide therapists with a new model in the treatment of the comorbidity of depression and social anxiety disorders. Moreover, further attention should be paid to important trans-diagnostic components, such as rumination, experiential avoidance, and worry, which can create many symptoms of mental disorders. This model had not been worked on in the domestic and foreign studies, which we did. It is suggested that more research be conducted in the future on other trans-diagnostic components on the comorbidity of depression and social anxiety disorders. It is also hoped that the trans-diagnostic approach will expand, and even models will be designed to explain personality disorders and their comorbidity.\u003c/p\u003e"},{"header":"Limitations","content":"\u003cp\u003eOne limitation of this study is that the data were collected through a self-report questionnaire, which may introduce the possibility of exaggeration or bias in participants' responses. Additionally, the sample used in this study consisted of university students rather than a clinical sample, limiting the generalizability of the findings to clinical populations. Furthermore, the study had a small sample size and used a convenience sampling method, which further restricts the ability to generalize the results. Future research could benefit from using a larger clinical sample and employing a variety of data collection methods to more accurately explore the relationships between rumination, experiential avoidance, depression, and social anxiety.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConsent for publication: Not Applicable\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank all the participants for their generous collaboration in this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated for this study are available on request to the corresponding author\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResearch Ethics Committee of Ferdowsi University of Mashhad approved this study, and all participants signed a written informed consent.. The study was conducted in accordance with the principles outlined in the Declaration of Helsinki(World Medical Association, 1964) on ethical research involving human participants, with respect for their rights, safety, and well-being. \u0026quot;This study was not interventional, and data were collected only from participants who provided informed consent. The questionnaires were completed voluntarily, with participants\u0026apos; names and personal identifiers omitted to ensure confidentiality and privacy of their responses.\u0026quot;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Declaration:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific funding from public, commercial, or non-profit funding agencies.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAftab R, Shams A. Relationship between integrated self-knowledge and resilience with anxiety of being infected by COVID-19: The mediating role of intolerance of ambiguity, worry, and physical activity. 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J Am Acad Child Adolesc Psychiatry.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Social anxiety, Depression, Rumination, Experiential avoidance, Worry","lastPublishedDoi":"10.21203/rs.3.rs-7335833/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7335833/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe trans-diagnostic approach is a therapeutic approach focusing on the comorbidity of disorders so that it goes beyond just focusing on symptoms and diagnoses and targets common underlying components in disorders. The present research aims to investigate the relationship of the two trans-diagnostic components of rumination and experiential avoidance with depression symptoms and social anxiety mediated by worry. The method used in this research is correlational-descriptive, which has also been assessed using the path analysis of the mediating role of worry. The statistical population consisted of the students of Mashhad universities, among which 420 people were selected. The Rumination Response Scale (RRS), the Acceptance and Action Questionnaire (AAQ), the Pennsylvania State Worry Questionnaire (PSWQ), the Beck Depression Inventory-Second Edition (BDI-II), and Connor\u0026rsquo;s Social Phobia Inventory (SPIN) were used to collect data, and path analysis method was used for data analysis. The results revealed that the model had a good fit. The direct effects of rumination and experiential avoidance on depression symptoms and social anxiety were significant (P\u0026thinsp;\u0026le;\u0026thinsp;0.01), and worry played a mediating role in the relationship of rumination and experiential avoidance with depression symptoms and social anxiety (P\u0026thinsp;\u0026le;\u0026thinsp;0.01). Thus, worry plays a mediating role in the relationship of rumination and experiential avoidance with depression symptoms and social anxiety. Hence, targeting these three components in extra-diagnostic treatments to improve depression symptoms and social anxiety is very important and effective in the treatment of these individuals.\u003c/p\u003e","manuscriptTitle":"The Relationship of Rumination and Experiential Avoidance with Depression and Social Anxiety: The Mediating Role of Worry","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-23 12:26:50","doi":"10.21203/rs.3.rs-7335833/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-12-14T15:39:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"130445603954360009421121738075001566776","date":"2025-11-15T07:23:15+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-15T08:43:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-09T07:08:02+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-22T14:36:27+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-19T20:23:55+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychology","date":"2025-08-19T20:20:31+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5164ed0b-6629-443b-b92a-7ed64c946254","owner":[],"postedDate":"September 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-09-23T12:26:50+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-23 12:26:50","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7335833","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7335833","identity":"rs-7335833","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}