The structure of distress following trauma: posttraumatic stress disorder, major depressive disorder, and generalized anxiety disorder

The current report used confirmatory factor analysis to examine the latent structures of both key features and associated symptoms of three disorders that commonly develop following a traumatic event: posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and generalized anxiety disorder (GAD). Participants were 228 motor-vehicle accident survivors who sought treatment for emotional difficulties. PTSD, MDD, and GAD were assessed with a combination of self-report and interview-based measures. The results of construct level analyses suggested that PTSD, MDD, and GAD are distinguishable but highly correlated disorders following a traumatic event. Symptom level analyses supported a model where the Reexperiencing, Avoidance, and Hypervigilance factors were subsumed under the PTSD construct. However, in this model the Dysphoria factor was a higher order construct correlated with the PTSD, MDD, and GAD factors, suggesting that the Dysphoria cluster may not be unique to PTSD. Diagnostic and theoretical implications of these results are discussed.     

Distress and Avoidance in Generalized Anxiety Disorder: Exploring the Relationships with Intolerance of Uncertainty and Worry

Theory and research suggest that treatments targeting experiential avoidance may enhance outcomes for patients with generalized anxiety disorder (GAD). The present study examined the role of experiential avoidance and distress about emotions in a treatment-seeking sample with a principal diagnosis of GAD compared with demographically matched nonanxious controls and sought to explore their shared relationship with two putative psychopathological processes in GAD: intolerance of uncertainty and worry. Patients with GAD reported significantly higher levels of experiential avoidance and distress about emotions compared with nonclinical controls while controlling for depressive symptoms, and measures of these constructs significantly predicted GAD status. Additionally, experiential avoidance and distress about anxious, positive, and angry emotions shared unique variance with intolerance of uncertainty when negative affect was partialed out, whereas only experiential avoidance and distress about anxious emotions shared unique variance with worry. Discussion focuses on implications for treatment as well as future directions for research.     

Worry and Rumination in Generalized Anxiety Disorder and Obsessive Compulsive Disorder

Ample work has already been conducted on worry and rumination as negative thought processes involved in the etiology of most of the anxiety and mood related disorders. However, minimal effort has been exerted to investigate whether one type of negative thought process can make way for another type of negative thought process, and if so, how it subsequently results in experiencing a host of symptoms reflective of one or the other type of psychological distress. Therefore, the present study was taken up to investigate whether rumination mediates the relationship between worry and generalized anxiety disorder (GAD), and between worry and obsessive compulsive disorder (OCD) in two clinical groups. Self-report questionnaires tapping worry, rumination, generalized anxiety disorder (GAD), and obsessive compulsive disorder (OCD) were administered to a clinical sample of 60 patients aged 30–40. Worry, rumination, generalized anxiety disorder (GAD), and obsessive compulsive disorder (OCD) correlated substantially with each other, however, rumination did not mediate the relationship between worry and generalized anxiety disorder (GAD) and between worry and obsessive compulsive disorder (OCD). We also analyzed differences of outcome variables within two clinical groups. These results showed that worry and rumination were significantly different between GAD and OCD groups.     

Perseverative thought: a robust predictor of response to emotional challenge in generalized anxiety disorder and major depressive disorder

Generalized anxiety disorder (GAD) and major depressive disorder (MDD) frequently co-occur, yet the reasons for their comorbidity remain poorly understood. In the present experiment, we tested whether a tendency to engage in negative, repetitive thinking constitutes a common risk process for the two disorders. A mixed sample of adults with comorbid GAD–MDD (n = 50), GAD only (n = 35), MDD only (n = 34), or no lifetime psychopathology (n = 35) was administered noncontingent failure and success feedback on consecutive performance tasks. Perseverative thought (PT), measured by negative thought intrusions during a baseline period of focused breathing, emerged as a powerful prospective predictor of responses to this experimental challenge. Participants reporting more frequent negative thought intrusions at baseline, irrespective of thought content or diagnostic status, exhibited a stronger negative response to failure that persisted even after subsequent success. Higher PT over the course of the experiment was associated with later behavioral avoidance, with negative affect and other traits closely linked to anxiety and depression, and with the presence and severity of GAD and MDD. These findings provide evidence for a broadly-defined PT trait that is shared by GAD and MDD and contributes to adverse outcomes in these disorders.     

Heterogeneity in the Strength of the Relation Between Social Support and Post-Trauma Psychopathology

Potentially traumatic events (PTEs) increase risk for psychopathology, including posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and generalized anxiety disorder (GAD). Social support (SS) is associated with reduced symptoms for each disorder. Each disorder, however, is highly heterogeneous such that they are comprised of clusters of different symptoms. It is unclear if SS is associated with all clusters equally. The current study examined the relation between SS and the symptom clusters of each disorder. Participants completed a battery of self-report assessments for PTSD, MDD, GAD, and SS. All participants experienced a Criterion A traumatic event. Although SS was significantly associated with all symptom clusters, the strength of relations varied. The relation between SS and MDD-affective was significantly stronger than its association with all other factors. The relations between SS and GAD, MDD-somatic, PTSD-AAR, and PTSD-NACM did not significantly differ. These relations were stronger than the relations between SS and the remaining PTSD factors. There was no significant difference in the relations between SS and PTSD-intrusions or PTSD-avoidance. These results suggest that SS is more closely aligned to specific aspects of post-trauma psychopathology.     

Intolerance of uncertainty and emotional distress following the death of a loved one

Abstract

Research has shown that intolerance of uncertainty (IU) – the tendency to react negatively to situations that are uncertain – is involved in worry and generalized anxiety disorder, as well as in other anxiety symptoms and disorders. To our knowledge, no studies have yet examined the association between IU and emotional distress connected with the death of a loved one. Yet, it seems plausible that those who have more difficulties to tolerate the uncertainties that oftentimes occur following such a loss experience more intense distress. The current study examined this assumption, using self-reported data from 134 bereaved individuals. Findings showed that IU was positively and significantly correlated with symptom levels of complicated grief and posttraumatic stress disorder (PTSD), even when controlling for time since loss (the single demographic/loss-related variable associated with symptom levels), and for neuroticism and worry, which are both correlates of IU. Furthermore, IU was specifically related with worry and symptom levels of PTSD, but not complicated grief, when controlling the shared variance between worry, complicated grief severity, and PTSD-severity. The present findings complement prior research that has shown that IU is a cognitive vulnerability factor for worry, and indicate that it may also be involved in emotional distress following loss.     

Genetic and Environmental Contributions to Common Psychopathologies of Childhood and Adolescence: A Study of Twins and Their Siblings

We report findings based on analyses of self-reports of six common adolescent psychopathologies (attention deficit/hyperactivity disorder, ADHD; conduct disorder, CD; oppositional defiant disorder, ODD; generalized anxiety disorder, GAD; separation anxiety disorder, SAD; and major depressive disorder, MDD) in a sample of 1,162 male and female adolescent (12–19 years) twin pairs and 426 siblings. Prevalence statistics for past year and lifetime reports confirm differences between genders for CD, GAD, SAD, and MDD, and a lack of differences between twins and their non-twin siblings. Biometrical modeling was conducted to ascertain the relative influences of genes, and shared and non-shared environments contributing to these disorders. A more robust estimate of these parameters was obtained by including non-twin siblings. Age-specific thresholds were integrated into the analyses to appropriately model the developmental patterns of behavior. We found evidence for both genetic and non-shared environmental influences for all disorders. Shared environmental influences also seem to be important for MDD and lifetime GAD.     

The NEO Five-Factor Inventory: latent structure and relationships with dimensions of anxiety and depressive disorders in a large clinical sample

The present study evaluated the latent structure of the NEO Five-Factor Inventory (NEO FFI) and relations between the five-factor model (FFM) of personality and dimensions of DSM-IV anxiety and depressive disorders (panic disorder, generalized anxiety disorder [GAD], obsessive-compulsive disorder, social phobia [SOC], major depressive disorder [MDD]) in a large sample of outpatients (N = 1,980). Exploratory structural equation modeling (ESEM) was used to show that a five-factor solution provided acceptable model fit, albeit with some poorly functioning items. Neuroticism demonstrated significant positive associations with all but one of the disorder constructs whereas Extraversion was inversely related to SOC and MDD. Conscientiousness was inversely related to MDD but demonstrated a positive relationship with GAD. Results are discussed in regard to potential revisions to the NEO FFI, the evaluation of other NEO instruments using ESEM, and clinical implications of structural paths between FFM domains and specific emotional disorders.     

Do mental disorders moderate the association between diabetes status and alcohol consumption?

Although heavy alcohol consumption is associated with diabetes-related complications, little is known about patterns of alcohol use among people with diabetes. Moreover, heavy drinking is more common among individuals with major depressive disorder (MDD), bipolar disorder (BD), and generalized anxiety disorder (GAD) than in the general population, and these disorders are often comorbid with diabetes. The present study tested the hypothesis that mental disorders moderate the association between diabetes status and alcohol consumption. A total of 14,302 adult participants aged 40-79 were included from the cross-sectional 2012 Canadian Community Health Survey-Mental Health (1,698 with diabetes). Data were analyzed using hierarchical linear regression models. MDD and BD, but not GAD, significantly moderated the association between diabetes status and alcohol quantity, such that the presence of diabetes was strongly and negatively associated with alcohol quantity if individuals had MDD or BD. There was no interaction between diabetes status and any of the mental disorders and alcohol frequency. This study suggests that among individuals with diabetes, those with comorbid MDD or BD drink less than those without MDD or BD. Further investigation of this association is needed and could help inform future alcohol-related interventions among individuals with diabetes.     

Intelligence and emotional disorders: Is the worrying and ruminating mind a more intelligent mind?

Previous research has shown that anxiety and depression symptoms are negatively associated with measures of intelligence. However, this research has often not taken state distress and test anxiety into account, and recent findings indicate possible positive relationships between generalized anxiety disorder (GAD), worry, and intelligence. The present study examined the relationships between GAD, depression, and social anxiety symptoms, as well as their underlying cognitive processes of worry, rumination, and post-event processing, with verbal and non-verbal intelligence in an undergraduate sample (N = 126). While the results indicate that verbal intelligence has positive relationships with GAD and depression symptoms when test anxiety and state negative affect were taken into account, these relationships became non-significant when overlapping variance was controlled for. However, verbal intelligence was a unique positive predictor of worry and rumination severity. Non-verbal intelligence was a unique negative predictor of post-event processing. The possible connections between intelligence and the cognitive processes that underlie emotional disorders are discussed.     

The Use of the Mirror Tracing Persistence Task as a Measure of Distress Tolerance in Generalized Anxiety Disorder

Behavioral tasks offer an objective index of processes associated with psychopathology. The mirror tracing persistence task (MTPT) has been used as a measure of distress tolerance, or the ability to endure negative internal states. In generalized anxiety disorder (GAD), a poor ability to tolerate aversive internal states may relate to the inability to adaptively regulate emotion. This study examined if those with GAD exhibit lower distress tolerance compared to controls as evidenced by length of time persisting on the MTPT. Participants underwent diagnostic interviews to determine the presence of absence of GAD and following group assignment, completed the MTPT. Results demonstrated that the groups differed significantly in time spent persisting on the task, with controls persisting longer than those with GAD, supporting the hypothesis that individuals with GAD exhibit lower distress tolerance than controls. These results provide support for the use of behavioral assessments as potential markers of distress tolerance.     

Maladaptive Core Beliefs and their Relation to Generalized Anxiety Disorder

Research has demonstrated that individuals with generalized anxiety disorder (GAD) hold unhelpful beliefs about worry, uncertainty, and the problem-solving process. Extant writings (e.g., treatment manuals) also suggest that other types of maladaptive beliefs may characterize those with GAD. However, these other beliefs have received limited empirical attention and are not an explicit component of cognitive theories of GAD. The present study examined the extent to which dysfunctional attitudes, early maladaptive schemas, and broad self-focused and other-focused beliefs explain significant variance in GAD symptoms, over and above negative and positive beliefs about worry, negative beliefs about uncertainty, and negative beliefs about problems. N = 138 participants classified into Probable GAD and Non-GAD groups completed self-report measures. After controlling for trait anxiety and depressive symptoms, only beliefs about worry, negative beliefs about uncertainty, and schemas reflecting unrelenting standards (e.g., “I must meet all my responsibilities all the time”), the need to self-sacrifice (e.g., “I'm the one who takes care of others”), and less positive views of other people and their intentions (e.g., lower endorsement of views such as “other people are fair”), were unique correlates of Probable GAD versus Non-GAD or GAD severity. Theoretical and clinical implications are discussed.     

An Examination of Distress Intolerance in Undergraduate Students High in Symptoms of Generalized Anxiety Disorder

People with generalized anxiety disorder (GAD) engage in maladaptive coping strategies to reduce or avoid distress. Evidence suggests that uncertainty and negative emotions are triggers for distress in people with GAD; however, there may also be other triggers. Recent conceptualizations have highlighted six types of experiences that people report having difficulty withstanding: uncertainty, negative emotions, ambiguity, frustration, physical discomfort, and the perceived consequences of anxious arousal. The present study examined the extent to which individuals high in symptoms of GAD are intolerant of these distress triggers, compared to individuals high in depressive symptoms, and individuals who are low in GAD and depressive symptoms. Undergraduate students (N = 217) completed self-report measures of GAD symptoms, depressive symptoms, and distress intolerance. Individuals high in GAD symptoms reported greater intolerance of all of the distress triggers compared to people low in symptoms of GAD and depression. Individuals high in GAD symptoms reported greater intolerance of physical discomfort compared to those high in depressive symptoms. Furthermore, intolerance of physical discomfort was the best unique correlate of GAD status, suggesting that it may be specific to GAD (versus depression). These findings support continued investigation of the transdiagnosticity and specificity of distress intolerance.     

Symptoms of Specific and Generalized Social Phobia: An Examination of Discriminant Validity and Structural Relations With Mood and Anxiety Symptoms

Current models divide social phobia into specific (SSP) and generalized (GSP) subtypes and suggest strong overlap between GSP and avoidant personality disorder (APD). Meanwhile, other research suggests reclassifying anxiety and mood disorders as fear and distress disorders. To unify these separate lines of research, this study was designed to test the hypothesis that SSP is more related to fear disorders (e.g., panic and phobias), whereas GSP and APD are more related to distress disorders (e.g., depression and generalized anxiety). Confirmatory factor analysis suggested the best-fitting model had symptoms of GSP, APD, and depression loading on one factor, and symptoms of SSP, panic, and specific phobias loading on a second factor. Key components of this model were (a) the inclusion of GAD symptoms reduced model fit and (b) GSP and APD symptoms significantly predicted SSP symptoms; this is consistent with conceptualizations of individuals with both GSP and SSP reporting performance anxiety.     

The “Brightening” Effect: Reactions to Positive Events in the Daily Lives of Individuals With Major Depressive Disorder and Generalized Anxiety Disorder

Depressed individuals are less reactive than healthy individuals to positive stimuli in the laboratory, but accumulating evidence suggests that they are more emotionally reactive to positive events in their daily lives. The present study probed the boundaries of this curious “mood brightening” effect and investigated its specificity to major depressive disorder (MDD) vis-à-vis generalized anxiety disorder (GAD), its closest boundary condition. We used ecological momentary assessment to measure reactions to positive events over one week in individuals with MDD (n = 38), GAD (n = 36), comorbid MDD-GAD (n = 38), and no psychopathology (n = 33). Depressed individuals responded to positive events with larger changes in affect, cognition, reported withdrawal (but not approach) behavior, and symptoms than healthy controls. More severe depression assessed before the sampling week predicted greater brightening. Altered reactivity to positive events was relatively specific to MDD when compared with GAD, similar to patterns found for other positive emotional processes. The robustness, scope, and relative specificity of the brightening effect highlights the need to resolve conflicting findings across laboratory and non-laboratory studies to advance understanding of altered reactivity in emotional disorders.     

Regulatory Focus and Anxiety: A Self-Regulatory Model of GAD-Depression Comorbidity

The etiology of generalized anxiety disorder (GAD), including its high degree of comorbidity with major depressive disorder (MDD), remains a conceptual and clinical challenge. In this article, we discuss the relevance of regulatory focus theory, an influential theory of self-regulation, for understanding vulnerability to GAD as well as GAD/MDD comorbidity. The theory postulates two systems for pursuing desired end states: the promotion and prevention systems. Drawing upon studies documenting the affective and motivational consequences of failing to attain promotion versus prevention goals, as well as the literature linking promotion failure with depression, we propose how dysfunction within the prevention system could lead to GAD - with, as well as without, MDD.     

Fear and perceived uncontrollability of emotion: Evaluating the unique contribution of emotion appraisal variables to prediction of worry and generalised anxiety disorder

Novel theoretical frameworks place the symptom profile of generalised anxiety disorder (GAD) within the context of dysfunctional emotional processes. It is suggested that fear and intolerance of emotions exacerbate subjective distress and motivate the use of maladaptive coping strategies, such as worry. To date, studies evaluating these models have suffered two key limitations. Firstly, few studies have involved treatment-seeking samples, and secondly, none have evaluated the unique variance attributable to emotion appraisal variables above and beyond previously established predictors of worry and GAD. The present study begins to address these limitations by assessing the contribution of fear and perceived uncontrollability of emotions in predicting worry and clinical GAD status after controlling for variance attributable to depressive symptoms, meta-cognitive beliefs, intolerance of uncertainty, and perceptions of external threat. Supporting current models, results showed that perceived control over emotional reactions was a unique predictor of GAD diagnostic status and both clinical and non-clinical worry.     

社会支持对震后青少年创伤后应激障碍和创伤后成长的影响:自我效能感的中介作用

本研究采用创伤暴露问卷、社会支持问卷、自我效能感量表、创伤后应激障碍症状核查表和创伤后成长问卷,在汶川地震8.5年后对地震极重灾区的1185名中学生进行调查,考察社会支持对创伤后应激障碍（PTSD）和创伤后成长（PTG）的影响,并检验自我效能感在其中的中介作用。结果发现：在控制创伤暴露程度、性别和年龄等变量后,社会支持不仅可以直接负向预测PTSD、正向预测PTG,也可以通过自我效能感的中介作用负向预测PTSD、正向预测PTG。这表明,自我效能感在社会支持与PTSD、社会支持与PTG的关系中都具有部分中介效应。     

The Contribution of Worry Behaviors to the Diagnosis of Generalized Anxiety Disorder

Worry behaviors (i.e., overt acts to avoid or cope with worry-induced distress) have been recognized as being important in the psychopathology and treatment of generalized anxiety disorder (GAD). This study evaluated the worry behaviors criterion proposed for DSM-5 GAD, but was ultimately not adopted due to insufficient evidence. In 800 outpatients with emotional disorders (366 with GAD), most patients with GAD (92.6%) met the proposed worry behaviors criterion, which was at a rate significantly higher than other patient groups (e.g., patients with mood disorders). Patients who met the worry behaviors criterion had more severe GAD than patients who did not. The worry behaviors criterion, and 3 of its 4 constituent behaviors, were associated with no better than “fair” interrater reliability. Diagnostic reliability of GAD was not improved in cases where both interviewers agreed the worry behaviors criterion was met. The worry behaviors criterion significantly predicted DSM-5 GAD holding core GAD features constant (e.g., excessive worry), but this contribution was weak and did not appreciably improve the classification accuracy of GAD diagnostic status. Mixed support was obtained for the discriminant validity of the worry behaviors criterion in relation to mood disorders. Raising the proposed threshold of the criterion (requiring 2 instead of 1 behaviors) did not result in a substantial improvement in reliability, prediction, and classification accuracy. Although additional research is warranted (e.g., importance of worry behaviors in the treatment and natural course of GAD), the results raise questions about the role of worry behaviors in the diagnostic classification of GAD.