Journal Pre-proof

Scale for time and space experience in anxiety (STEA):

Phenomenology and its clinical relevance

Cheng-Ju Lu, Josh Goheen, Angelika Wolman, Lorenzo Lucherini

Angeletti, Filipe Arantes-Gonçalves, Dusan Hirjak, Annemarie
Wolff, Georg Northoff

PII: S0165-0327(24)00710-9
DOI: https://doi.org/10.1016/j.jad.2024.04.099
Reference: JAD 17531

To appear in:

Received date: 17 January 2024

Revised date: 5 April 2024
Accepted date: 29 April 2024

Please cite this article as: C.-J. Lu, J. Goheen, A. Wolman, et al., Scale for time and
space experience in anxiety (STEA): Phenomenology and its clinical relevance, (2023),
https://doi.org/10.1016/j.jad.2024.04.099

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Scale for time and space experience in anxiety (STEA):

Phenomenology and its clinical relevance

Cheng-Ju Lu a, Josh Goheen b, Angelika Wolman b, Lorenzo Lucherini Angeletti b,

Filipe Arantes -Gonçalves c, Dusan Hirjak d, Annemarie Wolff b, Georg Northoff b

a
School of Medicine, College of Medicine, National Yang Ming Chiao Tung
University.
b
Institute of Mental Health Research, University of Ottawa, Ottawa, Canada
c
Department of Psychiatry, Clínica Psicodinâmica, Lisbon, Portugal
d
Department of Psychiatry and Psychotherapy, Central Institute of Mental Health,

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Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany

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Correspondence to: G. Northoff, Institute of Mental Health Research, University of
Ottawa, Ottawa, ON K1Z 7K4, Canada. -p
[email protected]
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Abstract
Anxiety is a pervasive emotional state where, phenomenologically, subjects often report
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changes in their experience of time and space. However, a systematic and quantified
examination of time and space experience in terms of a self-report scale is still missing
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which eventually could also be used for clinical differential diagnosis. Based on
historical phenomenological literature and patients’ subjective reports, we here
introduce, in a first step, the Scale for Time and Space Experience of Anxiety (STEA)
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in a smaller sample of 19 subjects with anxiety disorders and, in a second step, validate
its shorter clinical version (cSTEA) in a larger sample of 48 anxiety subjects. The main
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findings are (i) high convergent and divergent validity of STEA with both Beck Anxiety
Inventory (BAI) (r = 0.7325; p < 0.001) and Beck Depression Inventory (BDI) (r =
0.7749; p < 0.0001), as well as with spontaneous mind wandering (MWS) (r = 0.7343;
p < 0.001) and deliberate mind wandering (MWD) (r = 0.1152; p > 0.05), (ii) statistical
feature selection shows 8 key items for future clinical usage (cSTEA) focusing on the
experience of temporal and spatial constriction, (iii) the effects of time and space
experience (i.e., for both STEA and cSTEA scores) on the level of anxiety (BAI) are
mediated by the degree of spontaneous mind wandering (MWS), (iv) cSTEA allows for
differentiating high levels of anxiety from the severity of comorbid depressive
symptoms, (v) significant reduction in the cSTEA scores after a therapeutic intervention
(breathing therapy). Together, our study introduces a novel fully quantified and highly
valid self-report instrument, the STEA, for measuring time-space experiences in anxiety.
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Further we develop a shorter clinical version (cSTEA) which allows assessing time
space experience in a valid, quick, and simple way for diagnosis, differential diagnosis,
and therapeutic monitoring of anxiety.

Keywords: Anxiety, Time and space experience in anxiety, Phenomenology of

anxiety, Clinical differential diagnosis, Depression, Mind wandering

1. Introduction

Anxiety is a pervasive emotional state which is manifest as a transdiagnostic feature

across various psychiatric disorders, entangling psychological, physiological, and

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behavioral components to shape the overall anxious experience. To substantiate the
impact of psychological and physiological hallmark characteristics of anxiety on

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behavioral correlates, recent clinical and phenomenological studies focused on the
subjective experience of anxiety. Some authors, employing the Zimbardo Time
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Perspective Scale (ZTPS) (Zimbardo and Boyd, 1999), have displayed alterations in
subjects suffering from anxiety in their time perspective with respect to the experience
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of present, past and future (Anagnostopoulos and Griva, 2011; Åström et al., 2014;
Griffin and Wildbur, 2020; Kooij et al., 2018; Zimbardo and Boyd, 1999).
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These alterations are reflected in phenomenological reports on the subjective

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experience of anxiety such as "quickening subjective time" (Aho, 2020), "weakening

perception of the past and the future" (Doerr-Zegers, 2016; Minkowski et al., 1970),
"engaging in fatalistic thinking" (Doerr-Zegers, 2016; Minkowski et al., 1970), and
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"heightened perception of external non-psychological objects with specific temporal

structures" (Berenskötter, 2020; Reuther, 2014). Further, individuals with pathological
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anxiety also report abnormal experience of space in terms of a perceived shrinking of

the lived-space (i.e., the totality of space that an individual reflectively lives and
experiences) (Bollnow, 1961; Fuchs, 2007; Woodgate et al., 2021), as manifest in an
abnormal peripersonal space/PPS, i.e., the space surrounding the body that all the
physical interactions with the objects occur, Rabellino et al. (2020)) and other
individuals (personal space/PS, Chiara and Gian Domenico (2013)).

Despite the strong evidence for alterations in the experience of time and space in
anxious subjects, a valid quantified self-report questionnaire is still lacking in the
current literature. Therefore, the first aim of this study is to address this gap in the
current literature. For that purpose, we developed a series of questions for self-reporting
of subjective experience of time and space in anxiety and exploratorily probed them in
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a smaller sample of patients with anxiety disorders, undergoing slow breathing therapy.
We coined our scale “Scale for Time and Space Experience of Anxiety” (STEA).
Considering that anxiety frequently co-occurs with depression (Brown et al., 2001;
Lamers et al., 2011; Olfson et al., 1997), we validated the STEA by including standard
self-report instruments like Beck Anxiety Inventory (BAI) (Beck et al., 1988) and Beck
Depression Inventory (BDI) (Beck et al., 1961). Thus, validating the STEA was our
second specific aim in this exploratory study. As third aim of the study, we investigated
whether the STEA score would change during therapeutic intervention by breathing.

Patients with anxiety disorders commonly experience an escalation in particularly

negative thoughts (Spinhoven et al., 2015; Watkins, 2008) and exhibit concerns

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regarding future events (Borkovec et al., 1998). At the same time, they are strongly
distracted from their external environmental context (Bar-Haim et al., 2007; Eysenck,

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1988; Mathews and MacLeod, 2005; Najmi et al., 2012). This suggests close
relationship of anxiety with subjects’ thoughts like in mind wandering also known as
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"daydreaming", reflecting the "the dynamic nature of thought" (Singer, 1966).
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Recent studies classified mind wandering into two types: spontaneous
(unintentional) mind wandering and deliberate (intentional) mind wandering (Carriere
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et al., 2013; Christoff et al., 2016) with especially the former being closely related to
anxiety (Christoff et al., 2016; Seli et al., 2019). The exact relationship of spontaneous
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mind wandering with anxiety, including its abnormal time and space experience,
remains unclear, though. Addressing this is the fourth specific aim of our study. For that
purpose, we, in a fourth aim, also included two scales for probing mind wandering:
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spontaneous scale (MWS) and mind wandering: deliberate scale (MWD) from (Carriere
et al., 2013) in order to relate that, by using mediation models, to the STEA, the BAI,
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and the BDI. Finally, a fifth aim of our study consisted in using statistical feature
selection to test for a shorter version of the STEA, e.g., clinical or cSTEA, in a larger
sample to make it more feasible for clinical application. Presupposing the framework
of Spatiotemporal psychopathology(Northoff et al., 2023a) (we ultimately intend to use
the cSTEA as screening instrument for clinical diagnosis of anxiety including its
differential diagnosis from the often comorbid depression and schizophrenia.

2. Method

2.1. Participants

To validate STEA, 19 subjects with 13 females and 6 males are included in this
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exploratory study. As for the validation of the clinical version of STEA, i.e., cSTEA,
48 subjects with 29 females and 19 males are included. All the subjects are
participants from an ongoing study of breathing therapy for anxiety. The therapy
involved the participants performing slow breathing protocols (~ 6 breaths per minute)
twice daily for six weeks. Recent literature has shown similar breathing therapy reduce
levels of anxiety (Balban et al., 2023; Gitler et al., 2022; Sevoz-Couche and Laborde,
2022; Wang et al., 2020) while reducing the degree of mind wandering (Blum et al.,
2019; Nashiro et al., 2022). Among the subjects included in the study for the validation
of STEA, 13 of them were clinically diagnosed as anxiety disorder (GAD, SAD, PD)
and served as main group in the ongoing study. Among the subjects included in the
study for the validation of the cSTEA, 31 of them were clinically diagnosed as anxiety

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disorder and served as main group in the ongoing study. These subjects showed a wide
range of anxiety from moderate to high levels as shown in the BAI scores. Almost all

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subjects except one were on additional pharmacological therapy mostly serotoninergic
drugs while several subjects also received cognitive behavioral therapy. The remaining
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subjects were included as healthy control group in the ongoing trial. The total group of
subjects for the validation of STEA ranged in age from 19 to 68 years old (M = 41.47;
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Me = 40; SD = 13.65). Distributions of age in males (M = 43.50; Me = 41.5; SD = 9.89)
and females (M = 40.54; Me = 38; SD = 15.35) show no significant difference by
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student t-test (t = -0.4295; p = 0.6730). As for the subjects for the validation of cSTEA,
the total group range in age from 17 to 77 years old (M = 38.33; Me = 38; SD = 15.41).
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Distribution of age in males (M = 36.14; Me = 34; SD = 15.03) and females (M = 41.68;

Me = 40; SD = 15.78) show no significant difference by student t-test (t = -1.2260; p =
0.2265).
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2.2. Scale construction

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The question set for the scale is constructed according to previous studies about the
alteration of time (Aho, 2020; Anagnostopoulos and Griva, 2011; Åström et al., 2014;
Berenskötter, 2020; Doerr-Zegers, 2016; Griffin and Wildbur, 2020; Kooij et al., 2018;
Minkowski et al., 1970; Reuther, 2014; Rinaldi et al., 2017; Zimbardo and Boyd, 1999)
and space (Rabellino et al., 2020; Woodgate et al., 2021) experience in anxiety disorders.
Furthermore, the prevalent co-occurrence of anxiety disorders and depression reveals
overlapping characteristics in the experience of time within both conditions
(Anagnostopoulos and Griva, 2011; Fuchs, 2005, 2013; Griffin and Wildbur, 2020;
Kooij et al., 2018; Minkowski et al., 1970; Rinaldi et al., 2017; Thönes and Oberfeld,
2015; van Beek et al., 2011; Wang et al., 2021; Zimbardo and Boyd, 1999). Similarly,
we also included questions about space experience in our scale which can also be
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observed in depression (Barrett et al., 2016; Coll-Florit et al., 2021; Hou et al., 2021;
Kunzendorf et al., 2011; Riskind et al., 2014; Sass and Pienkos, 2013) for exploratory
investigation. In addition to referring to existing literatures, we also sought expert
opinion from one psychiatrist (GN) working in the field of anxiety research. 27 items
for time experience and 17 items for space experience are formulated (See Table. 1 and
Table. 2). The listed items are included in the final survey in a random manner in order
to minimize the “order effect.” The items were rated in a visual analog scale format (0
– 10, with incremental units of 1) (see Appendix 1).

Table 1. Construction and description of time experience items

Items Description Reference

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I think the current Based on the assumption that (Gu et al., 2020; Lake and
situation is quite perception of uncertainty is Labar, 2011; Penrod,

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uncertain involved in perception of 2001)
I think events temporal dynamics, we further
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occurring right diversify the interpretation of
now are perception of uncertainty by
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predictable elucidating the difference in
I think what will temporal categories – present,
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happen in the future, and transition.

future is quite
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uncertain.
I can tolerate
unpredictable
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future events.
I am uneasy about
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the changes
I can handle the
alteration of
current
situation.
I think time passes Perception of the speed of (Aho, 2020; Fuchs, 2013;
fast passage of time. The Mioni et al., 2023;
I feel that my thought interpretations are diversified Pollatos et al., 2014;
or behaviour based on the concepts of Thönes and Oberfeld,
are accelerated interoception and 2015; Van Hedger et al.,
I feel that everything exteroception. 2020; Wittmann, 2022;
surrounding me Zhang et al., 2018)
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is fast
I think that time
passes slowly
I feel that everything
near to me
slows down
It is hard for me to
catch on other’s
tempo
I think there is gap Sometimes being interpreted (Fuchs, 2005)
between present as “trapped in present,” it

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and future. suggests the inability to
I think there is gap normally perceive past and

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between present future in anxiety. In other way
and past. of interpretation, it involves
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Comparing with the discontinuity of time
future and past, perception on the temporal
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present is the dimension from present
only thing toward past and future.
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concrete to me
I think everything The fatalistic thinking is also (Anagnostopoulos and
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about me is suggested to be a feature in Griva, 2011; Åström et al.,

unchangeable individuals with anxiety. We 2014; Doerr-Zegers, 2016;
Everything, including hold that fatalistic thinking or Griffin and Wildbur,
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the future, is out attitude are also related to time 2020; Minkowski et al.,
of control. perception to lifetime, 1970; van Beek et al.,
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My life is involving the perception of 2011; Zimbardo and

determined. past, present, and future. Boyd, 1999)
I often perceive Unbalanced time perspectives (Anagnostopoulos and
something bad in past-negative orientation Griva, 2011; Åström et al.,
happened before and future orientation are 2014; Griffin and
to be far away observed in individuals with Wildbur, 2020; Kooij et
from me. anxiety. Based on this, we al., 2018; Rinaldi et al.,
I feel that the further diversify the 2017; van Beek et al.,
negative events interpretations by terms of 2011; Wang et al., 2021;
in the past have perception of past, present, and Zimbardo and Boyd,
influenced me a future. 1999)
lot.
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Myself right now has

long distance to
myself in the
past.
To me, the future is
distant.
I often think about
the future.
It seems that myself
in the future will
not be the same

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as myself right
now.

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I am often Under phenomenology and the (Berenskötter, 2020;
consciously concept of attachment theory, Reuther, 2014)
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aware my the sense of being in every
heartbeat moment is acquired implicitly
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I often focus on through the engagement in
things with a environment. We hold that this
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monotonous also serves for time perception

rhythm and may alter in anxiety. To
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I often do behaviors construct the items, we further

with a certain specified the interpretation
speed into certain interoceptive or
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exteroceptive events.
Table 2. Construction and description of space experience items
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Items Description Reference

I have the feeling that Loss of depth perception. Or it can (Hou et al.,
objects become also be comprehended as a form of 2021;
flatter. constriction of space perception. We Kunzendorf et
I have the feeling that diversify the interpretation with terms al., 2011)
my self becomes of object (exteroceptive), myself
flatter. (interoceptive), and others (social).
I have the feeling that
others become
flatter.
I think the space around In addition to constriction of space (Coll-Florit et
me is enclosed or perception, these items further capture al., 2021; Sass
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bounded. the boundness of space perception and Pienkos,

I think I am confined. between individual and surroundings. 2013)
I think that other things
are out of reach or
distant.
I think the distance
between me and
external objects or
other people is
long.
I often perceive objects In addition to the constriction and the (Barrett et al.,

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or other people boundness of space perception, these 2016; Hohwy,
approaching me items further capture the synchrony of 2016; Riskind

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lately or, saying, space perception, i.e., the ability to et al., 2014)
not quickly. engage with surroundings.
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My perception to the
surroundings is
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blurred or dull.
I have the sense of
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separation or
seclusion from the
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surroundings.
I think I am locked-in
from the external
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world.
I have the feeling that I Peripersonal space (PPS) refers to the (Rabellino et
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perceive more space perception of reachability from al., 2020)

things, including self toward surroundings or from
hearing things, surroundings toward self.
seeing things, etc.
I can quickly perceive
what is
approaching me.
The world is getting Under phenomenology and ecological (Fuchs, 2007;
more enclosed and psychology, lived-space is a spatial Woodgate et
surrounding me. and social relationship between al., 2021)
I have the feeling that I individual and surroundings. It
am getting closer to involves the concept of responsivity
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the edge or end of and exchange with the surrounding.

the world or events. The deformation of lived-space may
occur in certain mental illness.
I tend to avoid going to Under attachment theory, the sense of (Rabellino et
spaces that is being is acquired implicitly through al., 2020)
unfamiliar to me. the engagement in environment. This
I tend to stay in spaces may alter in mental illness.
that is familiar to
me.
2.3. Assessment of anxiety, depression, and mind-wandering

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The Beck anxiety inventory (BAI) (Beck et al., 1988), Beck depression inventory (BDI)
(Beck et al., 1961), mind wandering: spontaneous mind wandering scale (MWS)

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(Carriere et al., 2013), and mind wandering: deliberate mind wandering scale (MWD)
(Carriere et al., 2013) were included to assess, respectively, the degrees of anxiety,
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depression, spontaneous mind wandering, and deliberate mind wandering of the
participants. These instruments were assessed before breathing therapy as well as after
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three weeks of ongoing breathing therapy. Finally, at the timepoint when this study
ended, 1 of the subjects was assessed 6 times of the measurements. 1 of them was
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assessed 5 times. 1 of them was assessed 4 times. 6 of them were assessed 3 times. 1 of
them was assessed 2 times. 9 of them were assessed 1 time. Thus, 44 data points in total
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were assessed in this study. Moreover, 9 of the subjects completed the breathing therapy
before the end of this study. The measurements from these subjects were further used
for pre- and post-therapeutic analysis.
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2.4. Statistical analysis

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2.4.1. Assessment of Reliability and Validity

We involved Cronbach’s 𝛼 to assess the reliability of STEA and its time experience
subscale (T-STEA) and space experience subscale (S-STEA). We also conduct the
analysis for assessing validity of STEA. Two kinds of validity, i.e., convergent validity
and divergent validity, are assessed in this study. Convergent validity refers to how
closely an instrument is correlated with other instruments with similar construct.
Divergent validity indicates that the measurement of the instrument doesn’t correlate
too strong with other instruments measuring similar traits but with distinct constructs.
For the evaluation of convergent and divergent validity of STEA, we involved
Pearson’s correlation coefficient for the validation, measuring the correlation of STEA
with BAI and BDI as well as with both MWD and MWS. Furthermore, to probe the
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sensitivity of STEA to change, we conducted Paired T-test to assess the significance of

score changes of STEA, T-STEA, S-STEA, BAI, and BDI before and after three weeks
of breathing therapy.

2.4.2. Mediation Analysis and Structural equation modeling

In the mediation analysis and structural equation modeling, data were managed and
analyzed using a Python package – semopy (Igolkina and Meshcheryakov, 2020). Since
our data sample is small, we also included unweighted least squares (ULS) whose
efficacy has been validated (Tenenhaus, 2008). Furthermore, to assess the significance
of the models, Sobel test (Sobel, 1982) was used to evaluate the significance of the
mediation pathway. Also, for the validation of interaction models in SEM analysis,

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several variables including CFI, GFI, NFI, TLI, and RMSEA, are used to indicate the
quality of the proposed model.

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2.4.3. Feature Selection and the Validation of Short version of STEA for clinical
use, the cSTEA.
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In order to reduce the number of items for developing a short version of the STEA for
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clinical use, we used feature selection, a process of selecting most relevant
features/variables for construction of model, for this purpose. The data were managed
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and analyzed using a machine learning package in Python – Scikit-Learn (Pedregosa et

al., 2012) – and the Lasso method (Tibshirani, 1996) was involved for feature selection.
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The constant 𝛼 , which multiplies the L1 term, the sum of values of parameter
coefficients in the model, and controls the strength of regularization, was set to be 1 in
our analysis. For the reference data, BAI scores were taken as the predicting values for
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the model fitting.

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To assess the validity of the short version of the STEA, we calculated Spearman’s
correlation coefficient for the ordinal correlation analysis of ranked grouping data.
Furthermore, Receiver operating characteristic (ROC) curve, a plot that depicts the
diagnostic ability of a classifier in varied thresholds, and calculation of area under the
curve (AUC) were also used to assess the degree of separability of diagnostic positive
examples and diagnostic negative examples in the short STEA version (see Appendix
2).

3. Results

3.1. Scale reliability and convergent and divergent validity

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We first focused on testing the reliability as well as validity of the STEA which is based
on the subjects’ data before therapy of all 19 participants (n = 19, including both anxious
and depressed subjects). Subsequently, the supplementary evaluation encompasses all
data points in the time series of all participants (44 data points) (See supplementary
material). We first analyzed the reliability of STEA by including Cronbach’s 𝛼 as our
index of reliability. All three Total STEA ( 𝛼 = 0.9497 ), STEA Time Experience
Subscale (T-STEA) (𝛼 = 0.8930), and STEA Spatial Experience Subscale (S-STEA)
(𝛼 = 0.9510) showed good reliability according to the index.

To test for validity, we correlated the STEA (also with T-STEA and S-STEA) with
established scales like BAI, BDI, MWD and MWS (Table 3). Overall, the significant

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correlations of STEA and its subscales with BAI and BDI indicate good levels of
convergent validity. This is further supported by its significant relationship with

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spontaneous mind wandering which, in contrast, was not observed with deliberate mind
wandering. Albeit tentatively, the latter finding of non-significant relationship with
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deliberate mind wandering suggests first evidence for divergent validity of STEA.
Moreover, these results validity applied to the total STEA as well as to its two subscales,
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time and space. Together, this suggests good convergent and, albeit tentatively,
divergent validity of the STEA.
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Table 3. Correlation analysis for the validity of STEA

STEA T-STEA S-STEA BAI BDI MWD MW
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S
STEA - - - - - - -
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T- 0.9633*** - - - - - -
STEA *
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S- 0.9517*** 0.8343*** - - - - -
STEA * *
BAI 0.7325*** 0.7402*** 0.6575** - - - -
BDI 0.7749*** 0.8248*** 0.6478** 0.8641*** - - -
* * *
MWD 0.1152† 0.1677† 0.0446† 0.0906† 0.1046 - -
†
MWS 0.7343*** 0.6641** 0.7484** 0.5860** 0.5372 0.3464 -
* * †
† : insignificant ; * : p < 0.05 ; ** : p < 0.01 : *** : p < 0.001 : **** : p < 0.0001
3.2. Relationship of STEA with BAI and MWS
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To investigate the relationship of STEA with BAI and MWS, we utilized mediation-
structural equation modeling to test our hypothesis that MWS would serve as mediator
between STEA and BAI. The alternative model to our hypothesis includes spontaneous
mind wandering as independent variable, time or space experience as mediator, and
anxiety as dependent variable.

Our findings show that, spontaneous mind wandering significantly mediates the effects
of both time experience ( 𝑎 = 1.522; 𝑏 = 1.035; 𝑆𝐸𝑎 = 0.376; 𝑆𝐸𝑏 =
0.386; 𝑆𝑜𝑏𝑒𝑙 𝑡𝑒𝑠𝑡 𝑠𝑡𝑎𝑡𝑖𝑠𝑡𝑖𝑐 = 2.234; 𝑝 = 0.025 ) (Fig. 1(A)) and space experience
( 𝑎 = 2.226; 𝑏 = 1.269; 𝑆𝐸𝑎 = 0.696; 𝑆𝐸𝑏 = 0.414; 𝑆𝑜𝑏𝑒𝑙 𝑡𝑒𝑠𝑡 𝑠𝑡𝑎𝑡𝑖𝑠𝑡𝑖𝑐 =
2.212; 𝑝 = 0.027) (Fig. 1(B)) on the severity of anxiety symptoms (BAI). The power

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of the tests is assured (> 0.8) as our sample size (44 data points) is larger than the
suggested minimum sample size (nmin = 42 data points) according to (Fritz and

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Mackinnon, 2007). In contrast, the alternative model that considers time and space
experience as mediators for the effect of spontaneous mind wandering on anxiety did
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not show statistical significance (see supplementary material Fig. S1(A) and (B) for
alternative mediation model of time and space experience respectively).
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Fig. 1. Mediation models show that time (A) and space (B) experience (STEA) affect
the severity of anxiety symptoms (BAI) as mediated by spontaneous mind wandering
(MWS). The variable “time experience” is measured by the 27 temporal items in the
STEA scale. The variable “space experience” is measured by the 17 spatial items in
the STEA scale. As for other variables, “spontaneous mind wandering” is measured
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by the 4 items in MWS. The variable “anxiety” is measured by the 21 items in BAI
scale. (About the setup of the modeling and the mediation analysis, please see 2.4.2.
Mediation Analysis and Structural equation modeling)The alternative model with
time and space experience mediating the effects of spontaneous mind wandering on
anxiety did not yield any significance (see Supplementary material).

3.3. Feature Selection for short clinical version of STEA, the cSTEA

To extract those items most strongly associated with anxiety and to create a shorter
scale for clinical use, we employed Lasso regression as our feature selection method,
with the Beck Anxiety Inventory (BAI) as the reference for feature selection (see Fig.

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2 for the performance of Lasso model). Our analysis resulted in an 8-item scale,
comprising six items of time experience and two items of space experience, which all

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exhibited a high level of association with anxiety (see Table. 4) (see also Appendix 2).
This is further supported by replicating the mediation model findings for the shorter
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eight-item-version of the STEA, the cSTEA (with c standing for clinical), as described
above for the total STEA (See supplementary material Fig. S2).
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Fig 2. Performance of Lasso model in predicting BAI scores from cSTEA scores.

Table 4. Items of cSTEA

Items Positive/Negative
I am uneasy about the changes. Positive
I often consciously aware my heartbeat. Positive
I can tolerate unpredictable future events. Negative
Comparing with the future and the past, the present is the only Negative
thing concrete to me.
My life is determined. Negative
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My self right now has a long distance to my self in the past. Negative
I think the space around me is enclosed or bounded. Positive
I think I am locked-in from the external world. Positive
Caption for Table 4. The “positive/negative” stands for the positive or negative
correlation of the item with anxiety, i.e., the positive/negative items in cSTEA. These
are determined from the results of previous correlation analysis. In this case, the
calculation of the cSTEA score would be:
(Total of positive items scores) – (Total of negative items scores)
Under the 10-point scale, the possible cSTEA scores are ranging from -40 to 40.

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3.4. Validation and mediation models of the cSTEA

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To validate our cSTEA scale, we repeated the the correlation analysis and the mediation
analysis in a larger group of subjects (See 2.1.Participants for more information).
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Measurement of BAI, BDI, MWS, and MWD were also included in this correlation
analysis. The results of the correlation analysis are shown in Table 5. The results of the
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meditation analysis are shown in Fig 3. (B). Overall, the spontaneous mind wandering
significantly mediates the effects of time-space experience, which is measured by
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cSTEA, on the severity of anxiety ( 𝑎 = 0.264; 𝑏 = 0.665; 𝑆𝐸𝑎 = 0.0485; 𝑆𝐸𝑏 =

0.1972; 𝑆𝑜𝑏𝑒𝑙 𝑡𝑒𝑠𝑡 𝑠𝑡𝑎𝑡𝑖𝑠𝑡𝑖𝑐 = 2.8658; 𝑝 = 0.0042 ) and depression ( 𝑎 =
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0.259; 𝑏 = 0.568; 𝑆𝐸𝑎 = 0.0487; 𝑆𝐸𝑏 = 0.1952; 𝑆𝑜𝑏𝑒𝑙 𝑡𝑒𝑠𝑡 𝑠𝑡𝑎𝑡𝑖𝑠𝑡𝑖𝑐 =

2.5544; 𝑝 = 0.0106), while deliberate mind wandering insignificantly mediates the
effects of time-space experience on anxiety 𝑎 = 0.110; 𝑏 = 0.409; 𝑆𝐸𝑎 =
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0.0592; 𝑆𝐸𝑏 = 0.1617; 𝑆𝑜𝑏𝑒𝑙 𝑡𝑒𝑠𝑡 𝑠𝑡𝑎𝑡𝑖𝑠𝑡𝑖𝑐 = 1.4990; 𝑝 = 0.1339 ) and depression
( 𝑎 = 0.106; 𝑏 = 0.647; 𝑆𝐸𝑎 = 0.0591; 𝑆𝐸𝑏 = 0.1605; 𝑆𝑜𝑏𝑒𝑙 𝑡𝑒𝑠𝑡 𝑠𝑡𝑎𝑡𝑖𝑠𝑡𝑖𝑐 =
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1.6388; 𝑝 = 0.1013). In addition, a hypothesis-driven SEM analysis is also included

in this part (Fig 3. (A)) in order to show the central role of time space experience in
connecting anxiety, depression, and mind-wandering with each other.

Table 5. Correlation analysis for the validity of cSTEA

cSTEA T- S- BAI BDI MWD MW
cSTEA cSTEA S
cSTEA - - - - - - -
T- 0.8494** - - - - - -
cSTEA **
S- 0.6281** 0.1229† - - - - -
cSTEA **
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BAI 0.6026** 0.4568** 0.4598** - - - -

** ** **
BDI 0.5451** 0.3350** 0.5311** 0.7689** - - -
** * ** **
MWD 0.1904† 0.0044† 0.3516** 0.2814** 0.3602** - -
* *
MWS 0.4865** 0.3373** 0.4176** 0.4990** 0.4423** 0.3523* -
** * ** ** ** **
† : insignificant ; * : p < 0.05 ; ** : p < 0.01 : *** : p < 0.001 : **** : p < 0.0001

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Fig 3. (A) Here, we suggest a hypothesis-driven SEM analysis for testing the
relationship of time-space experience as in cSTEA with anxiety as in BAI, depression
as in BDI, and mind-wandering as in MWS and MWD. Our hypothesis is that time-
space experience may serve a more fundamental role compared with anxiety,
depression, and mind-wandering. The figure represents the significant interactions of
cSTEA, with the other variables measured by the scales mentioned earlier (for all
interactions, p-value < 0.0001). This indicates a key role of time-space experience in
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of anxiety. (CFI = 0.9701; GFI = 0.8755; NFI = 0.8755; TLI = 0.9635; RMSEA =
0.0525); (B) The mediation models that were significant in Fig 1. are repeated in the
larger sample with cSTEA. Similarly, spontaneous mind-wandering, rather than
deliberate mind-wandering, partially mediates the relationship of time-space
experience (measured by items in cSTEA) with anxiety (measured by items in BAI)
and depression (measured by items in BDI). This suggests a fundamental role for time
space experience among the different measures of anxiety, e.g., BAI, BDI and MWS.

3.5. Capacity of cSTEA for differential diagnosis of anxiety and depression

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In order to test the capacity of cSTEA for differentially assessing anxiety and the often
comorbid depression, the total group of anxiety subjects was divided into four

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subgroups by median cut on BAI and BDI scores. The median score of BAI in our total
group of subjects is 15. As for BDI, the median score is 22.5. According to the original
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articles, BAI score 15 is close to the distinction (16-17) between moderate and severe
anxiety vs minimal and mild anxiety (Beck et al., 1993). The BDI score of 22-23 is
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close to the cut-off score (25) reflecting the distinction between moderate to severe
depression vs minimal to mild (Beck, 1973).
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After grouping the data in this way, we divided the subjects into four groups: High
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anxiety with High depression (h/h), High anxiety with low depression (h/l), Low
anxiety with High depression (l/h), and Low anxiety with Low depression (l/l). These
four groups are represented in the box plots in Fig 4.(A) and the student t test is
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conducted to test for significant differences between the four groups. Significant
differences were obtained for h/h vs l/h (t = 4.0345; p = 0.0002) and h/h vs l/l (t =
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6.7955; p < 0.0001), while no significant differences was shown h/h vs h/l (t = 1.9503;
p = 0.0568) and l/h vs l/l (t = -0.3954; p = 0.6944).

Together, these findings suggest that the anxiety symptoms provide the main
contribution to the cSTEA scores among the individuals with depression. This means
that the cSTEA really targets the anxiety symptoms themselves rather than the often
comorbid depressive symptoms. Albeit tentatively, this suggests that the cSTEA has the
potential to serve for clinical differential diagnosis of anxiety and depression.

Furthermore, we conducted categorial correlation analysis (with three groups of

subjects: l/l, h/l, h/h) using Spearman’s rho and ROC analysis (on diagnosing anxiety
and anxiety with depression comorbidity). The significant correlation from low anxiety
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group to high anxiety group as well as from low the group without depression
comorbidity to the group with depression comorbidity is indicated (Spearman’s rho =
0.5991; p-value < 0.00001) (Fig 4.(B)). ROC analysis further indicates good
classification accuracy of cSTEA on diagnosing anxiety (AUC = 0.837) and anxiety
with depression comorbidity (AUC = 0.831) (Fig 4.(C)&(D)). Similar AUC scores from
the ROC analysis suggest minimal bias from depression comorbidity in diagnosing
anxiety and predicting the severity of anxiety. Together with the previous results, these
findings show that cSTEA can maintain its accuracy in the diagnosis/prediction of
anxiety with minimal bias from depression comorbidity. This strengthen its potential
role in serving for clinical differential diagnosis of anxiety and depression.

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Fig 4. (A) Box plots of the distribution of cSTEA scores among four groups of
subjects (h/h: High anxiety with High depression; h/l: High anxiety with Low
depression; l/h: Low anxiety with High depression; l/l: Low anxiety with Low
depression. According to the student t test, significant differences hold in h/h vs l/h
and h/h vs l/l, while no differences were obtained for h/h vs h/l and l/h vs l/l. (ns: p >
0.05; *: p < 0.05; **: p < 0.01; ***: p < 0.001; ****: p < 0.0001); (B) The results of
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categorial correlation analysis of cSTEA with three groups of subjects: l/l, h/l, h/h.
The significant correlations are indicated (Spearman’s rho = 0.5991, p-value <
0.00001). (C) and (D) are the ROC curve of cSTEA in diagnosing anxiety (AUC =
0.837) and anxiety with depression comorbidity (AUC = 0.831) respectively.

3.6. Capacity of cSTEA for therapeutic monitoring of anxiety

We finally tested whether the cSTEA is sensitive to therapeutic changes during

breathing therapy by investigating its pre-post therapeutic effects. We’ve collected all
pre- and post-intervention relationships from the data (n = 50) and compared the cSTEA,

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BAI, and BDI scores before and after standardized breathing therapy (see methods for
details), i.e., the pre- and post-score differences were calculated. The changing of scores

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of cSTEA, BAI, and BDI are illustrated in Fig 5.(A). From paired t test (one-tailed),
significant differences between pre- and post-scores of cSTEA (t = 2.1508; p-value =
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0.0182), BAI (t = 4.3969; p-value < 0.00001), and BDI (t = 3.0554; p-value = 0.0018)
were obtained. In order to make the pre- and post-score differences comparable between
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the different scales, we further standardized their values by dividing the respective scale
values with the total score range of the scale. The possible score of BAI or BDI is
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ranging from 0 to 63. Thus, the total score range of BAI or BDI is 63. The possible
score of cSTEA is ranging from -40 to 40. Thus, the total score range of cSTEA is 80.
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Furthermore, the standardized score differences of cSTEA, BAI, and BDI were
compared through correlation analysis (Fig 5.(B)&(C)) The results suggested
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significant correlation between standardized pre- and post-cSTEA-score differences

with both BAI (r = 0.6946; p < 0.00001) and BDI (r = 0.6424; p < 0.00001), indicating
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similar effects of the therapeutic intervention on the levels of both anxiety and
depression. Furthermore, the slopes of the linear regression (cSTEA vs BAI: 0.988;
cSTEA vs BDI: 0.9082) suggest similar sensitivity in detecting anxiety and depression
as per BAI and BDI respectively. This hints upon the capacity of the cSTEA for
detecting changes in the level of anxiety during therapy making it a suitable candidate
for serving as marker for therapeutic monnitoring.
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Fig 5. (A) The changes between pre- and post-therapeutic scores of cSTEA, BAI, and
BDI. Each line indicates a single subject. The left end of the lines represents the pre-
therapeutic scores and the right end of lines represents the post-therapeutic scores. (B)
The correlation of the standardized pre- and post-cSTEA score difference ( (post-
intervention cSTEA score -–pre-intervention cSTEA score)/80 ) with the standardized
pre- and post-BAI score difference ( (post-intervention BAI score -–pre-intervention
BAI score)/63 ). (C) The correlation of the standardized pre-and post-cSTEA score
difference with the standardized pre-and post-BDI score difference ( (post-
intervention BDI score -–pre-intervention BDI score)/63 ).

4. Discussion
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We here introduce a novel standardized quantified instrument for measuring time space
experience in anxiety, the STEA, in an exploratory study. We show that the STEA is (i)
valid and reliable, (ii) sensitive to therapeutic improvement, (iii) closely related with
spontaneous mind wandering, (iv) can differentiate between anxiety and the often
comorbid depression, and (v) can be condensed in a short more clinically applicable
form, cSTEA.

We show good convergent validity of the STEA with the self-report scales of anxiety
and depression BAI and BDI. This suggests that abnormal time space perception is
indeed an integral feature of anxiety. However, future studies are warranted that relate
the STEA to more observer-based anxiety and depression scales.

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On the more psychological level, we demonstrate close relationship of STEA with mind

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wandering [see also Christoff et al. (2016) and Scalabrini et al. (2022)]. Importantly, as
shown in our mediation model, the impact of STEA on the anxiety level was not direct
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but rather indirect as mediated through the mind wandering. This is in accordance with
the framework by Christoff et al. (2016), who consider the spontaneous, dynamic, and
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excessive automatic constraints on thought a core feature of anxiety. That, in turn, is
closely related to biased attention and abnormal processing of threat-related stimuli in
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individuals with anxiety (Bar-Haim et al., 2007; Eysenck, 1988; Najmi et al., 2012).
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The selected items of the shorter clinical form, the cSTEA, seem to all revolve around
one underlying core or basic disturbance, namely the perception of time and space as
highly constricted. These include “Comparing with the future and the past, present is
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the only thing concrete to me,” “Myself right now has long distance to myself in the
past,” “I think the space around me is enclosed or bounded,” and “I think I am locked
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in from the external world.”. Accordingly, the perception of time is constricted to either
the present or past without any perceived access to the future. Analogously so in the
domain of space which was also perceived as being constricted to the own body and
detached from the environment. Albeit tentatively, we therefore assume that
constriction of the perceived time and space may be considered a potential candidate
for a basic disturbance of anxiety (see Northoff, 2023; Northoff and Hirjak, 2022;
Northoff et al., 2023b for the notion of basic disturbance).

In addition to the easy and simple clinical applicability of the cSTEA in anxiety subjects,
our results also hint towards its potential value for clinical differential diagnosis. We
recently introduced a scale for the time space experience of psychosis, e.g., STEP
(Arantes-Gonçalves et al., 2022). Here, the perception of temporal and spatial
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fragmentation was a key feature which distinguished the psychotic subjects from those
suffering of mood disturbances (Fusar-Poli et al., 2022; Madeira et al., 2016; Röhricht
et al., 2020; Stanghellini and Raballo, 2015). Future studies are needed whether the
perception of temporospatial fragmentation versus perception of temporospatial
constriction allows differentiating psychotic and anxiety symptoms or syndromes.

Finally, we show that the cSTEA scores reduce considerable with therapeutic changes.
Note that the therapeutic intervention was nonpharmacological, i.e., breathing, which
complemented the additional pharmacological and or nonpharmacological therapy
given in almost all of our patients. While future placebo-controlled studies are needed
to directly relate anxiety reducing effects with the breathing therapy itself rather than

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some unspecific effect factor, the changes in cSTEA values clearly indicate the scale’s
sensitivity to therapeutic improvement. This renders the cSTEA scale a strong

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potential candidate to serve as therapeutic monitoring marker.
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4.1. Limitations and future directions
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A primary limitation of this study stems from the relatively small sample sizes utilized
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for data collection. This may limit the generalizability and external validity of the
proposed insights in our study. Although the suggested results in this study all show
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high degrees of statistical significance, future research should consider employing

larger and more diverse samples to further validate and extend the proposed insights,
thus, standing for the robustness of the conclusions. Another limitation of this study is
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the lack of statistical ground for the a priori concepts included within the construction
and interpretation of STEA and cSTEA. To further enhance the validity of our
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conceptual analysis in this study, future work on evaluating the proposed concepts by
statistical methods, e.g., factor analysis, clustering analysis, and structural equation
model (SEM), is needed in a larger sample size.

Future studies may also link the time space experience to the changes of the self
which is highly unstable and desynchronized in anxiety (Lucherini Angeletti et al.,
2023) assuming their close relationship (Dixon et al., 2022). This is even more likely
given that the self may be conceived as basis or fundamental function underlying
emotions like anxiety as conceived in the Basis model of self specificity (Northoff
and Stanghellini, 2016). Such basic or fundamental self is supposed to be constituted
by temporal and spatial coordinates and trajectories (Northoff and Stanghellini, 2016)
whose alterations in anxiety may be manifested in abnormal time and space
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experience. Given such fundamental nature of time-space experience, one may then
also assume that it may shape emotion regulation in an abnormal way resulting in
emotion dysregulation as suggested by the group around J.Gross (Dixon et al., 2022;
Keskin et al., 2023; Scalabrini et al., 2024). This is further supported by our
observation of the close relationship of time space experience with spontaneous mind
wandering which, in turn, is known to relate to emotion dysregulation (Scalabrini et
al., 2024).

5. Conclusion

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We introduce a novel scale for time and space experience in anxiety, the STEA and its
shorter clinical version cSTEA, by showing (i) its high convergent and divergent

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validity with related scales, (ii) its propensity to monitor therapeutic change, (ii) its
utility to allow for clinical differential diagnosis, (iv) its close relation with spontaneous
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thought or mind wandering, and (v) its clinical utility in a short clinical version, the
cSTEA. Importantly, our results demonstrate the close relationship of both time and
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space experience with spontaneous thoughts, e.g., mind wandering with the latter
mediating the former’s impact on the severity of anxiety symptoms. This points to a
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more fundamental role of time and space with the experience of temporal and spatial
constriction possibly constituting a “basic disturbance” of anxiety as distimguished
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from the basic disturbances of other mental disorders like MDD and schizophrenia
(Northoff, 2023; Northoff and Hirjak, 2022; Northoff et al., 2023b).
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More generally, our results show the theoretical and scientific fruitfulness of a
spatiotemporal framework for psychopathological symptoms like anxiety. This is
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hypothesized and developed in the recently developed Spatiotemporal

Psychopathology (Northoff, 2016a, b, 2022; Northoff and Hirjak, 2022; Northoff and
Hirjak, 2023; Northoff et al., 2023b; Northoff and Stanghellini, 2016). Going beyond
pure research, we tentatively hypothesize that such spatiotemporal framework also
carries major practical, e.g., clinical implications like the cSTEA’s potential usage as
both diagnostic and therapeutic marker of anxiety.
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Appendix 1

Scale for time and space experience in anxiety (STEA)

Time Experience Subscale

1. I think the current situation is quite
uncertain.
2. I think what will happen in the future is
quite uncertain.
3. I am uneasy about the changes.

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4. I think time passes fast.

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5. I think that time passes slowly.

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I think there is gap between present and
future.
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7. I think there is gap between present and
past.
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8. I think everything about me is

unchangeable.
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9. I often perceive something bad

happened before to be far away from
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10. To me, the future is distant.

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11. I am often consciously aware my

heartbeat.
12. I think events occurring right now are
predictable.
13. I can tolerate unpredictable future
events.
14. I can handle the alteration of current
situation.
15. I feel that my thought or behaviour are
accelerated.
16. I feel that everything near to me slows
down.
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17. Comparing with future and past, present

is the only thing concrete to me.
18. Everything, including the future, is out
of control.
19. I feel that the negative events in the past
have influenced me a lot.
20. I often think about the future.

21. I often focus on things with a

monotonous rhythm.
22. I feel that everything surrounding me

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fast.
23. It is hard for me to catch on other’s

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tempo.
24. My life is determined. -p
25. My self right now has long distance to
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myself in the past.
26. It seems that my self in the future will
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not be the same as my self right now.

27. I often do behaviors with a certain
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speed.
Space Experience Subscale
1. I have the feeling that objects become
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flatter.
2. I think the space around me is enclosed
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or bounded.
3. I think that other things are out of reach
or distant.
4. I often perceive objects or other people
approaching me lately or, saying, not
quickly.
5. I have the sense of separation or
seclusion from the surroundings.
6. I have the feeling that I perceive more
things, including hearing things, seeing
things, etc.
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7. The world is getting more enclosed and

surrounding me.
8. I tend to avoid going to spaces that is
unfamiliar to me.
9. I have the feeling that my self becomes
flatter.
10. I think I am confined.

11. I think the distance between me and

external objects or other people is long.
12. My perception to the surroundings is

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blurred or dull.
13. I think I am locked-in from the external

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world.
14. I can quickly perceive what is -p
approaching me.
15. I have the feeling that I am getting
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closer to the edge or end of the world or
events.
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16. I tend to stay in spaces that is familiar

to me.
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17. I have the feeling that others become

flatter.
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Appendix 2

Clinical Scale for time and space experience in anxiety

(cSTEA)
1. I am uneasy about the changes.

2. I often consciously aware my heartbeat.

3. I can tolerate unpredictable future

events.
4. Comparing with the future and the past,

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the present is the only thing concrete to
me.

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5. My life is determined.

6.
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My self right now has a long distance to
my self in the past.
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7. I think the space around me is enclosed
or bounded.
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8. I think I am locked-in from the external

world.
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Author Statement Contributors

C.L., J.G., and G.N. designed the research. C.L. constructed the Scale of time and
space experience in anxiety (STEA). *J.G. (main), A.W., and L.L.A. conducted the
investigation and collected the data. C.L. and G.N. analyzed the data. C.L. and G.N.
wrote the original manuscript. The manuscript was further reviewed and edited by all
the authors. All the authors agreed with the final version of the manuscript.

Fundings
This work is financially supported by Physicians Incorporated Services (PSI) and
Canada Institute of Health Research (CIHR) in Canada. The PSI and CIHR had no
further role in the writing of this commentary and in the decision to submit the paper

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Declaration of competing interest
All authors declared no competing interests for this study. There are no other
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disclosures.
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Acknowledgements
None
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Declaration of competing interest

All authors declared no competing interests for this study. There are no other
disclosures.

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⚫ Anxiety is closely related to constricted time and space experiences.

⚫ The dynamic of thoughts, i.e., mind wandering, may serve as the mediator
between the time and space experiences and anxiety.
⚫ cSTEA allow a valid and simple way to assess clinical phenomenology of
anxiety.

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