Can the components of a cognitive model predict the severity of generalized anxiety disorder?

Over the past decade, a number of well-controlled studies have supported the validity of a cognitive model of generalized anxiety disorder (GAD) that has four main components: intolerance of uncertainty, positive beliefs about worry, negative problem orientation, and cognitive avoidance. Although these studies have shown that the model components are associated with high levels of worry in nonclinical samples and with a diagnosis of GAD in clinical samples, they have not addressed the question of whether the model components can predict the severity of GAD. Accordingly, the present study sought to determine if the model components are related to diagnostic severity, worry severity, and somatic symptom severity in a sample of 84 patients with a primary diagnosis of GAD. All model components were related to GAD severity, although positive beliefs about worry and cognitive avoidance were only modestly associated with the severity of the disorder. Intolerance of uncertainty and negative problem orientation had more robust relationships with the severity of GAD (and with worry severity, in particular). When participants were divided into Mild, Moderate, and Severe GAD groups, intolerance of uncertainty and negative problem orientation distinguished the Moderate and Severe GAD groups from the Mild GAD group, even when age, gender, and depressive symptoms were statistically controlled. Overall, the results lend further support to the validity of the model and suggest that intolerance of uncertainty and negative problem orientation are related to the severity of GAD, independently of sociodemographic and associated clinical factors. The theoretical and clinical implications of the findings are discussed.     

Penn State Worry Questionnaire: Findings Form Normative and Clinical Samples in Denmark

Anxiety disorders are among the most prevalent psychiatric disturbances in childhood. None-the-less, they often go unrecognized and untreated, which puts the child at risk for developing additional difficulties, such as academic difficulties, depression, and substance abuse. Further knowledge and valid assessment tools are essential to identify at-risk children. The present study investigates (i) the factor structure of the Penn State Worry Questionnaire for Children (PSWQ-C) using a large Danish community sample (N?=?933), and (ii) its treatment sensitivity in clinically anxious children (N?=?30) treated with cognitive behavioral therapy. Results from the community sample replicated previous findings supporting the strong psychometric properties of the PSWQ-C, and yielded Danish norms and clinical cut-offs for the measure. Clinically anxious children with a generalized anxiety disorder (GAD; N?=?10) diagnosis reported significantly higher levels of worry than anxious children without GAD (N?=?20). At post treatment, worry levels in children with GAD but not in anxious children without GAD were normalized. Findings regarding worry in the community sample are discussed in light of normal child development. Implications for the use of the PSWQ-C as a useful and important tool in clinical assessment by psychiatrists and psychologists in their treatment of anxious children and adolescents are also discussed.     

Generalisierte Angststörung

The core features of generalized anxiety disorder (GAD) are excessive worry about various topics which are perceived as uncontrollable and mostly last for at least 6 months. Worrying is accompanied by a number of symptoms (e.g. muscle tension and irritability). Various etiological models suggest that avoidance of internal processes (e.g. cognitive, emotional, and physical) by worrying is central to the development and maintenance of GAD. Empirically well supported cognitive-behavioral interventions are worry exposure, applied relaxation, treating metacognitions, intolerance of uncertainty and negative problem orientation. Initial studies indicate the efficacy of mindfulness and acceptance-based approaches as well as psychodynamic approaches to treat GAD. The present article reports central diagnostic procedures, important differential diagnoses and illustrates actual (psycho) therapeutic treatment options.     

Perceived attachment: relations to anxiety sensitivity, worry, and GAD symptoms

This investigation examined the relation between perceived alienation from parents and peers, anxiety sensitivity (AS), and current worry and generalized anxiety disorder (GAD) symptoms with the goal of expanding the knowledge base on factors that may contribute to the development of AS and its role in worry. The mediating role of AS between perceptions of alienation and current worry and GAD symptoms was also examined. Ninety-four non-clinical worriers completed self-report questionnaires assessing their perceptions of attachment, AS levels, and worry and GAD symptoms. Even after controlling for worry and GAD symptoms, greater perceptions of alienation from mothers and peers were significantly associated with higher AS symptoms. AS as a unitary construct mediated the relation between perceptions of alienation from mothers and peers and worry and GAD symptoms. The facets fear of publicly observable symptoms and fear of cognitive dyscontrol also mediated this relation. The role of alienation in relation to AS, worry, and GAD symptoms is discussed along with directions for future research.     

The language of worry: Examining linguistic elements of worry models

Despite strong evidence that worry is a verbal process, studies examining linguistic features in individuals with generalised anxiety disorder (GAD) are lacking. The aim of the present study is to investigate language use in individuals with GAD and controls based on GAD and worry theoretical models. More specifically, the degree to which linguistic elements of the avoidance and intolerance of uncertainty worry models can predict diagnostic status was analysed. Participants were 19 women diagnosed with GAD and 22 control women and their children. After participating in a diagnostic semi-structured interview, dyads engaged in a free-play interaction where mothers' language sample was collected. Overall, the findings provided evidence for distinctive linguistic features of individuals with GAD. That is, after controlling for the effect of demographic variables, present tense, future tense, prepositions and number of questions correctly classified those with GAD and controls such that a considerable amount of the variance in diagnostic status was explained uniquely by language use. Linguistic confirmation of worry models is discussed.     

Preliminary tests of a cognitive model of generalized anxiety disorder.

Although worry is the central feature of Generalised Anxiety Disorder (GAD), little is known about the factors that contribute to pathological or problematic worry. In a recent cognitive model of GAD, Wells, A. (1995) proposed that negative appraisal of worrying itself (meta-worry or type 2 worry) should be distinguished from other types of worrying (type 1 worry). A central feature of this model is the idea that individuals with GAD hold rigid positive beliefs about the usefulness of worrying as a coping strategy. However, these individuals also hold negative beliefs and appraise worrying as uncontrollable and dangerous. This combination of cognitions and associated responses leads to an increased frequency and generality of worrying, and thus to the pathological worry characteristic of GAD. This paper reports a preliminary test of the hypothesis that meta-worry contributes to problematic and pathological worrying, and this relationship is independent of the frequency of other types of worry. In testing for associations between worry dimensions we controlled for overlaps with Trait anxiety, and the controllability of worrying. Results of a series of regression analyses support the hypothesis that pathological worry is associated with meta-worry and this association is independent of Trait-anxiety and type 1 worry. The clinical implications of these data are briefly discussed.     

Searching for Danger: On the Link Between Worry and Threat-Related Confirmation Bias in Children

The present study examined the relationship between worry and threat-related confirmation bias in children. Forty non-clinical children aged 10–12 years completed the child version of the Penn State Worry Questionnaire as a cognitive index of anxiety proneness, and then were administered a modified version of the Wason Selection Task to assess verifying and falsifying reasoning strategies in response to conditional danger rules. Results demonstrated that children with high levels of worry displayed a stronger tendency towards verification and a weaker inclination towards falsification than children with low levels of worry. This finding indicates that confirmation bias occurs in individuals with a general vulnerability to anxiety, and fits well with current theoretical models in which cognitive distortions are viewed as risk factors predisposing to the development of fear and anxiety problems.     

Exposing Worry’s Deceit: Percentage of Untrue Worries in Generalized Anxiety Disorder Treatment

Theories of cognitive therapy have long proposed that those with generalized anxiety disorder (GAD) have inaccurate expectations. By challenging them with objective evidence, symptoms are thought to decrease. To test these premises, this study used ecological momentary assessment (EMA) during the Worry Outcome Journal (WOJ) treatment to determine the percentage of GAD worries that did not come true. We then analyzed the association between participants’ untrue worry percentages and GAD symptom change across treatment. Twenty-nine participants with GAD recorded worries when prompted for 10 days, reviewed them online nightly, and tracked their worry outcomes across 30 days. These recordings were then coded by independent raters. Analyses applied bias-correct bootstrapping path analysis on slopes extracted from longitudinal linear mixed models. Primary results revealed that 91.4% of worry predictions did not come true. Higher percentages of untrue worries significantly predicted lower GAD symptoms after treatment, as well as a greater slope of symptom reduction from pre- to post-trial. Participants’ average expected likelihoods of worries coming true were much greater than actual observed likelihoods. The most common percentage of untrue worries per person was 100%. Thus, worries in those with GAD were mostly inaccurate. Greater evidence of this inaccuracy predicted greater improvement in treatment. As theorized, disconfirming false expectations may significantly contribute to treatment’s effect.     

Cognitive Behavior Therapy for Women With Generalized Anxiety Disorder in the Perinatal Period: Impact on Problematic Behaviors

Generalized anxiety disorder (GAD) is the most frequently diagnosed anxiety disorder among women in the perinatal period (pregnancy to one year postpartum). Recent studies have examined the relationship between problematic behaviors and GAD symptoms. Studies in nonperinatal samples indicate that adults with GAD engage in avoidance and safety behaviors and these behaviors are associated with greater symptom severity. Little research has examined the use of problematic behaviors among pregnant or postpartum women. However, preliminary research suggests that these behaviors may have a negative impact on both anxious women and their children. Our aim was to examine the extent to which women with GAD in pregnancy or the postpartum engage in problematic behaviors and whether cognitive behavioral therapy is effective in reducing these behaviors. Fifty-eight women with GAD in pregnancy or postpartum were recruited from a larger clinical trial (Clinicaltrials.gov ID NCT02850523) evaluating the effectiveness of group-based cognitive behavioral therapy (CBGT) for perinatal anxiety disorders. The results indicated that women with perinatal GAD reported high levels of avoidance and safety behaviors and greater engagement in these behaviors was associated with higher levels of worry and related symptoms. CBGT was effective in reducing GAD symptoms and problematic behaviors and a bidirectional relationship was found between changes in worry and problematic behaviors during treatment. Limitations and future directions are discussed.     

Experience and appraisal of worry among high worriers with and without generalized anxiety disorder

Recent research has revealed that a large number of highly worried individuals do not qualify for a diagnosis of generalized anxiety disorder (GAD). This raises the intriguing question of why some high worriers are more impaired and distressed by their worrying than others, particularly when the severity of their worry is the same. The present investigation sought to address this question by examining whether GAD and non-GAD high worriers differ in their actual worry experiences, their subjective appraisals of worry experiences, or both experiences and appraisals of worry. GAD and non-GAD worriers, selected for matching levels of trait worry severity, completed an attention-focus task with thought sampling before and after a brief worry induction. They also completed questionnaires assessing their experiences during and after the worry induction, as well as their general beliefs about worry. GAD worriers experienced less control over negative intrusive thoughts immediately after worrying, reported greater somatic hyperarousal following worry, and endorsed several negative beliefs about worry more strongly than their worry-matched controls. Results suggest that GAD is associated with unique experiences and appraisals that distinguish it from other forms of severe worry.     

“Cold” Cognitive Control and Attentional Symptoms in Anxiety: Perceptions Versus Performance

Clinically significant anxiety is associated with an array of attentional symptoms (e.g., difficulty concentrating; unwanted thought) that are subjectively experienced as severe. However, neuropsychological findings are mixed with respect to the presence of cognitive deficits that can account for these symptoms. Contextualizing predictions from established clinical theories (e.g., Attentional Control Theory) within contemporary, neurobiologically derived models of cognitive control (Dual Mechanisms of Control Theory), the present study investigated the relationship between “cold” proactive and reactive cognitive control, task effort, and subjective attentional symptoms (difficulty concentrating; unwanted thought) in a mixed clinical sample of individuals with generalized anxiety disorder (GAD) and/or obsessive-compulsive disorder (OCD) and a comparison sample of healthy controls. Clinical status moderated the relationship between attentional symptoms (attentional focusing and trait worry) and proactive cognitive control response time. Clinical status also moderated the relationship between trait worry and task effort. Higher trait worry was associated with slower proactive control and lower effort in healthy participants, but faster proactive control in clinical participants. Self-reported attentional focusing showed differential validity vis-à-vis proactive control response time in clinical versus healthy participants. Post-hoc conditional effects analysis suggested more accurate self-appraisals in healthy controls, but was not significant after correction for multiple comparisons. Preliminary evidence suggested that differences in task effort in anxious versus healthy adults may relate to subjective attentional symptoms in GAD and OCD.     

The Role of Overt and Covert Avoidance Strategies in Generalized Anxiety Disorder Symptoms and Fear of Emotion

Models of generalized anxiety disorder (GAD) have largely focused on the role of cognitive (i.e. covert) processes in the maintenance of GAD symptoms, including cognitive avoidance (e.g., thought suppression). Researchers have begun to investigate more systematically the role of overt avoidance behaviors in GAD symptoms and processes. However, the contribution of both overt and covert avoidance strategies in GAD symptoms and emotional processes has not been examined yet. The aim of the present study was to investigate if both overt and covert avoidance strategies are related to (Objective 1) and make a unique contribution in the explanation of the variance of (Objective 2) GAD symptoms, chronic worry and emotional processes (i.e. fear of emotion). Individuals high in chronic worry and GAD symptoms (N?=?113) recruited from the community completed measures of the study variables. Greater use of overt and covert avoidance were both related to greater GAD symptoms, worry severity and fear of emotion. However, covert avoidance was the only unique correlate of GAD symptoms, worry severity and fear of emotion. The results suggest that covert avoidance makes a greater contribution to GAD symptoms and fear of emotion, than does overt avoidance. Future studies are needed to understand how overt avoidance behaviors fit into theoretical models of chronic worry and GAD.

     

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.     

Vagal influence during worry and cognitive challenge

Abstract

The primary foci of the study were exploration of the linkage between cognitive and autonomic inflexibility of worry and generalized anxiety disorder (GAD) and examination of the effects of an analog cognitive restructuring task on this relationship. Cardiac responses of GAD and non-GAD participants were measured to examine the sympathetic and parasympathetic effects of worry and cognitive challenge. Diagnostic groups of undergraduate students were determined via administration of a structured interview, yielding a GAD group (n=16) and a control group (n=19) of individuals without GAD, depression, or panic disorder diagnoses. Cardiac autonomic responses were acquired via electrocardiogram during rest, worry, and cognitive challenge conditions by an experimenter blind to diagnosis. Metrics were compared between the two groups and across the three conditions. Individuals diagnosed with GAD did not differ significantly from controls on autonomic indices. Worry was associated with significantly decreased parasympathetic influence and increased sympathetic activity. Cognitive challenge did not result in significant increased cardiac responsivity. The results indicate that worry behavior is associated with decreased vagal activity, suggest a linkage between autonomic and cognitive inflexibility, and provide further suggestions for improving protocols to assess the autonomic effects of cognitive therapy techniques.     

Evaluating the cognitive avoidance model of generalised anxiety disorder: Impact of worry on threat appraisal, perceived control and anxious arousal

Generalised anxiety disorder (GAD) is characterised by persistent and uncontrollable worry. According to the cognitive avoidance theory of GAD, worry may function as an affective dampening strategy motivated by intolerance of negative emotional states. By facilitating avoidance of more distressing cognitions and associated affect, worry is said to preclude modification of the fear representation in memory, maintaining threat associations and perpetuating further anxiety and worry. The present study evaluated these assumptions in a treatment-seeking GAD sample. Sixty-one participants were randomly allocated to conditions in which they were instructed to worry, imaginally process or relax in response to an anxiety trigger. Results supported the detrimental impact of worry, showing maintained threat expectancies and decreased control perceptions compared to other modes of processing. However, skin conductance level increased as a function of worry and there was no suggestion that worry suppressed affective responding. These findings highlight the need for clarification of the mechanisms involved in the maintenance of threat associations and worry in GAD.     

Relationship between self‐worrying and self‐critical messages in clients with generalised anxiety engaging in emotion‐focused worry dialogues

Emotion‐focused therapy (EFT) has recently been adapted as a treatment for generalised anxiety disorder (GAD). One intervention used in this adaptation is a worry dialogue, in which the client enacts worry in one chair (“worrier”) and is facilitated to experience the impact of this worry in another chair (“experiencer”). Although not formally studied, anecdotal observations from therapists in the EFT for GAD treatment development study suggested that within worry dialogues there might be a link between client's self‐worrying and self‐critical messages. This study used data from 47 worry dialogues from fourteen study clients who received EFT for GAD. An observation based qualitative analysis of clients' self‐directed messages as present in in‐session worry dialogues was conducted using video/audio recordings of relevant sessions. Results indicate a relationship between self‐worrying and self‐critical messages. A total of 90 paired self‐worry and self‐critic messages across the 47 worry dialogues were logged. Six recurring clusters of themes/relationships were observed: (a) I need to be prepared for future negative events because… I'm weak and a failure; (b) I need to stop worrying… I'm flawed for being a worrier; (c) People will negatively judge me if I engage with them… because I'm not good enough; (d) If I don't worry, there will be negative consequences… and I will be responsible and will be unable to bear it; (e) I worry/ruminate that I cause(d) some damage… because I'm incompetent; and, (f) I must always be prepared against others taking advantage of me… because I'm weak. Given the observed close link between self‐critical and worry processes, it is important that therapists differentiate between these processes and remember to address both in therapy for GAD.     

Changes in Decentering and Reappraisal Temporally Precede Symptom Reduction During Emotion Regulation Therapy for Generalized Anxiety Disorder With and Without Co-Occurring Depression

Emotion Regulation Therapy (ERT) has demonstrated efficacy in both open and randomized trials for generalized anxiety disorder (GAD) with and without co-occurring depression. An important goal in ERT is to teach clients adaptive emotion regulation, including healthier metacognitive abilities such as decentering and cognitive reappraisal. A few studies thus far have demonstrated a mediating role for these metacognitive abilities in other cognitive behavioral therapies (CBTs) for GAD. However, a drawback to most of these has been the ability to demonstrate a causal role for improved metacognitive abilities in outcome. In the present study, we utilized multilevel time-lagged segment analyses to explore the temporal dynamics between session-by-session changes in metacognition and anxiety outcomes from ERT. Thirty-one young adults diagnosed with GAD with and without co-occurring depression received 16 sessions of ERT. Prior to each session, participants completed questionnaires pertaining to metacognition (i.e., decentering and cognitive reappraisal) and anxiety symptoms (i.e., worry, trait anxiousness, and generalized anxiety). Changes in decentering temporally preceded changes in worry and trait anxiousness of a medium to large magnitude, and changes in cognitive reappraisal temporally preceded changes in all three outcomes of a medium to large magnitude. The reverse direction, where mediators were predicted by outcomes, was nonsignificant. These findings support the notion that adaptive metacognitive emotion regulation is involved in reducing worry and anxiety in GAD. Having a clearer understanding of the temporal dynamics between metacognitive abilities and symptoms of anxiety can inform and improve not only ERT but other CBTs for GAD, as well.     

Verbal and practical intelligence in general anxiety,obsessive compulsive and major depression disorders

IntroductionPrevious researches have shown that anxiety symptoms are negatively associated with measures of intelligence. However, recent findings indicate possible positive relationships between Generalized Anxiety Disorders (GAD) and intelligence. Also, Obsessive Compulsive Disorder (OCD) is associated with a moderate degree of underperformance on cognitive tests, including deficient processing. There are inconsistent results to present the relationship between Major Depression Disorder (MDD) and IQ. The present study has three main aims. The first aim of this study is to investigate the difference between IQ in individuals with GAD, OCD and major depressive disorder, and normal group. The second purpose is to perform a comparative study between the GAD, OCD and MDD groups on verbal and non-verbal intelligence. The third aim of this study is to examine the relationships between GAD, OCD and MDD as well as their underlying cognitive processes, including worry, rumination, and post-event processing, with verbal and non-verbal intelligence.ObjectiveThe present study is performed on four groups of participants including those with GAD, OCD, MDD and Healthy Volunteer (HV) group consisting of individuals without psychiatric disorders.MethodThe number of 50 healthy volunteers as the control group, 45 patients with GAD, 20 patients with OCD and 25 patients with MDD (n = 140) were selected as the case-referent groups. The present study was a cross-sectional type and the research was performed based on the causal-comparative method. Verbal and non-verbal intelligence was measured with the Wechsler Adult Intelligence Scale-3rd edition (WAIS-III). Rumination and post-event processing were measured by PSWQ, RRS-BR, and PEPQ, respectively.ResultsThe results indicate that Verbal Intelligence and Verbal Comprehension Index in GAD patients have significant differences in comparison to the OCD, MDD and control groups. While, the value of the Working Memory Index (WMI) in the normal group is higher than the value of the same index in the GAD, OCD and MDD groups. Also, the values of the Processing Speed Index (PSI) in normal and GAD groups are higher than the OCD and MDD groups. The worry, rumination, and post-event processing in patients with GAD are positively correlated with general and verbal intelligence. But, verbal and non-verbal intelligence had a negative correlation with worry, rumination and post-event processing in healthy volunteers.ConclusionInvestigation of the possible connections between intelligence and the cognitive processes underlying emotional disorders can provide therapeutic strategies for smart individuals who are at risk for GAD.     

Intolerance of Uncertainty–Focused Treatment for Adolescents With Excessive Worry: A Pilot Feasibility Study

Bouts of excessive worry are common across the lifespan, increasing in frequency and complexity during adolescence and adulthood, and are found in several psychiatric disorders, particularly the anxiety disorders. There are evidence-based treatments for adolescents with anxiety disorders but psychological treatments designed specifically to target excessive worrying in adolescents are rare. Intolerance of uncertainty (IU), a cognitive predisposition described as a fear of the unknown, is highly associated with worry among adolescents. This study investigated the feasibility, acceptability, and preliminary efficacy of IU-focused cognitive behavioral therapy (IU-CBT) for adolescents with excessive worry. Twelve participants (aged 13–17 years) with excessive worry, irrespective of psychiatric diagnosis, were provided weekly face-to-face sessions, primarily including therapist and self-guided exposure to situations involving uncertainty. Sessions were supplemented with an internet-delivered educational program for parents, designed to teach parents about worry, IU and helpful parental behaviors. The main outcome measure was the Penn-State Worry Questionnaire for Children (PSWQ-C). The treatment was well tolerated with no dropouts and families reporting being satisfied with the treatment. Participants were able to grasp the notion of IU and its relationship to worry and avoidance. Significant reductions were observed for self-reported worry, anxiety, depression, IU, and parent-reported worry, as were significant increases in global functioning. Based on a clinician rating, 58.3% were categorized as much or very much improved at posttreatment, rising to 66% at 3-month follow-up. Participants with generalized anxiety disorder (GAD) benefitted more from treatment than those with social anxiety disorder. The findings suggest that this IU-focused psychological intervention is acceptable and feasible to adolescents with excessive worry but may be most effective for those with GAD.