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Internalizing disorders such as anxiety and depression are the most common psychiatric disorders, frequently begin in youth, and exhibit marked heterogeneity in treatment response and clinical course. It is increasingly recognized that symptom-based classification approaches to internalizing disorders do not align with underlying neurobiology. An alternative to classifying psychopathology based on clinical symptoms is to identify neurobiologically-informed subtypes based on brain imaging data. We used a recently developed semi-supervised machine learning method (HYDRA) to delineate patterns of neurobiological heterogeneity within youth with internalizing symptoms using structural imaging data collected at 3T from a large community-based sample of 1,141 youth. Using volume and cortical thickness, cross-validation methods indicated a highly stable solution (ARI=.66; permutation-based pfdr < .001) and identified two subtypes of internalizing youth. Subtype 1, defined by smaller brain volumes and reduced cortical thickness, was marked by impaired cognitive performance and higher levels of psychopathology than both Subtype 2 and typically developing youth. Using resting-state fMRI and diffusion images not considered during clustering, we found that Subtype 1 also showed reduced amplitudes of low-frequency fluctuations in fronto-limbic regions at rest, as well as reduced fractional anisotropy in white matter tracts such as the parahippocampal cingulum bundle and the uncinate fasciculus. In contrast, Subtype 2 showed intact cognitive performance, greater volume, cortical thickness, and amplitudes during rest compared to Subtype 1 and typically developing youth, despite still showing clinically significant levels of psychopathology. Identification of biologically-grounded subtypes of internalizing disorders may assist in targeting early interventions and assessing longitudinal prognosis.

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