Rethinking the Role of Worry in Generalized Anxiety Disorder: Evidence Supporting a Model of Emotional Contrast Avoidance

The Contrast Avoidance model (Newman & Llera, 2011) proposes that individuals with generalized anxiety disorder (GAD) are hypersensitive to sharp upward shifts in negative emotion that typically accompany negative events, and use worry to maintain sustained intrapersonal negativity in an attempt to avoid these shifts. Although research shows that worry increases negative emotionality and mutes further emotional reactivity to a stressor when compared to the worry period (e.g., Llera & Newman, 2010), no study has tracked changes in negative emotionality from baseline to worry inductions followed by a range of emotional exposures. Further, no study has yet assessed participants’ subjective appraisals of prior worry on helping to cope with such exposures. The present study tested the main tenets of the Contrast Avoidance model by randomly assigning participants with GAD (n = 48) and nonanxious controls (n = 47) to experience worry, relaxation, and neutral inductions prior to sequential exposure to fearful, sad, and humorous film clips. Both physiological (nonspecific skin conductance responses [NS-SCRs]) and self-reported emotional changes were observed. Results indicated that worry boosted negative emotionality from baseline, which was sustained across negative exposures, whereas low negative emotionality during relaxation and neutral inductions allowed for sharp increases in response to exposures. Furthermore, GAD participants found worry to be more helpful than other conditions in coping with exposures, whereas control participants reported the opposite pattern. Results provide preliminary support for the Contrast Avoidance model. This suggests that treatment should focus on underlying avoidance patterns before attempting to reduce worry behavior.     

The contributory role of worry in emotion generation and dysregulation in generalized anxiety disorder

The role of worry in generalized anxiety disorder (GAD) has been posited to serve as an avoidance of emotional experience, and emotion regulation deficits in GAD have been found in several previous studies. It remains unclear whether those with GAD experience more dysregulated emotions during periods of euthymia and positive affect or whether these deficits occur only during periods of worry. Individuals with GAD (with and without co-occurring dysphoria) and non-anxious controls were randomly assigned to receive a worry, neutral, or relaxation induction. Following the induction, all participants viewed a film clip documented to elicit sadness. Intensity of emotions and emotion regulation were examined following the induction period and film clip. The results revealed that, regardless of co-occurring dysphoria, individuals with GAD in the worry condition experienced more intense depressed affect than GAD participants in the other conditions and controls participants. In contrast, presence of worry appeared to have less impact on indices of emotion dysregulation, which were greater in participants with GAD compared to controls, but largely insensitive to contextual effects of worry or of relaxation. Following film viewing, both GAD participants with and without dysphoria displayed poorer understanding, acceptance, and management of emotions than did controls. However, acceptance and management deficits were most pronounced in individuals with both GAD and co-occurring dysphoria. Implications for the role of emotions in conceptualization and treatment of GAD are discussed.     

Risk for mania and positive emotional responding: too much of a good thing?

Although positive emotion research has begun to flourish, the extremes of positive emotion remain understudied. The present research used a multimethod approach to examine positive emotional disturbance by comparing participants at high and low risk for episodes of mania, which involves elevations in positive emotionality. Ninety participants were recruited into a high or low mania risk group according to responses on the Hypomanic Personality Scale. Participants' subjective, expressive, and physiological emotional responses were gathered while they watched two positive, two negative, and one neutral film clip. Results suggested that participants at high risk for mania reported elevated positive emotion and irritability and also exhibited elevated cardiac vagal tone across positive, negative, and neutral films. Discussion focuses on the implications these findings have for the diagnosis and prevention of bipolar disorder, as well as for the general study of positive emotion.     

Emotion regulation difficulties associated with the experience of uncued panic attacks: evidence of experiential avoidance, emotional nonacceptance, and decreased emotional clarity

Emotion regulation difficulties among nonclinical uncued panickers were examined in two studies. In Study 1, participants with a recent history of uncued panic attacks (n  =  91), compared to a nonpanic sample (n  =  91), reported significantly greater levels of experiential avoidance, lack of emotional acceptance, and lack of emotional clarity. In Study 2, a subset of uncued panickers and nonpanickers from Study 1 (n = 17 per group) viewed positive and negative emotion-eliciting film clips. Despite comparable levels of self-reported distress and physiological arousal, panickers reported using more emotionally avoidant regulation strategies during both film clips. Panic participants also responded with greater negative emotion to the positive emotion-eliciting clip. Results are discussed in terms of their research and clinical implications.     

A standardised database of Chinese emotional film clips

Film clips are widely used in emotion research due to their relatively high ecological validity. Although researchers have established various film clip sets for different cultures, the few that exist related to Chinese culture do not adequately address positive emotions. The main purposes of the present study were to establish a standardised database of Chinese emotional film clips that could elicit more categories of reported positive emotions compared to the existing databases and to expand the available film clips that can be used as neutral materials. Two experiments were conducted to construct the database. In experiment 1, 111 film clips were selected from more than one thousand Chinese movies for preliminary screening. After 315 participants viewed and evaluated these film clips, 39 excerpts were selected for further validation. In experiment 2, 147 participants watched and rated these 39 film clips, as well as another 8 excerpts chosen from the existing databases, to compare their validity. Eventually, 22 film excerpts that successfully evoked three positive emotions (joy, amusement, and tenderness), four negative emotions (moral disgust, anger, fear, and sadness), and neutrality formed the standardised database of Chinese emotional film clips.     

Paradoxical cardiovascular effects of implementing adaptive emotion regulation strategies in generalized anxiety disorder

Recent models of generalized anxiety disorder (GAD) have expanded on Borkovec's avoidance theory by delineating emotion regulation deficits associated with the excessive worry characteristic of this disorder (see Behar, DiMarco, Hekler, Mohlman, & Staples, 2009). However, it has been difficult to determine whether emotion regulation is simply a useful heuristic for the avoidant properties of worry or an important extension to conceptualizations of GAD. Some of this difficulty may arise from a focus on purported maladaptive regulation strategies, which may be confounded with symptomatic distress components of the disorder (such as worry). We examined the implementation of adaptive regulation strategies by participants with and without a diagnosis of GAD while watching emotion-eliciting film clips. In a between-subjects design, participants were randomly assigned to accept, reappraise, or were not given specific regulation instructions. Implementation of adaptive regulation strategies produced differential effects in the physiological (but not subjective) domain across diagnostic groups. Whereas participants with GAD demonstrated lower cardiac flexibility when implementing adaptive regulation strategies than when not given specific instructions on how to regulate, healthy controls showed the opposite pattern, suggesting they benefited from the use of adaptive regulation strategies. We discuss the implications of these findings for the delineation of emotion regulation deficits in psychopathology.     

Eliciting positive,negative and mixed emotional states: A film library for affective scientists

We describe the creation of a film library designed for researchers interested in positive (amusing), negative (repulsive), mixed (amusing and repulsive) and neutral emotional states. Three hundred 20- to 33-second film clips videotaped by amateurs were selected from video-hosting websites and screened in laboratory studies by 75 female participants on self-reported amusement and repulsion (Experiments 1 and 2). On the basis of pre-defined cut-off values, 51 positive, 39 negative, 59 mixed and 50 neutral film clips were selected. These film clips were then presented to 411 male and female participants in a large online study to identify film clips that reliably induced the target emotions (Experiment 3). Depending on the goal of the study, researchers may choose positive, negative, mixed or neutral emotional film clips on the basis of Experiments 1 and 2 or Experiment 3 ratings.     

Individual differences in physiological flexibility predict spontaneous avoidance

People often regulate their emotions by resorting to avoidance, a putatively maladaptive strategy. Prior work suggests that increased psychopathology symptoms predict greater spontaneous utilisation of this strategy. Extending this work, we examined whether heightened resting cardiac vagal tone (which reflects a general ability to regulate emotions in line with contextual demands) predicts decreased spontaneous avoidance. In Study 1, greater resting vagal tone was associated with reduced spontaneous avoidance in response to disgust-eliciting pictures, beyond anxiety and depression symptoms and emotional reactivity. In Study 2, resting vagal tone interacted with anxiety and depression symptoms to predict spontaneous avoidance in response to disgust-eliciting film clips. The positive association between symptoms and spontaneous avoidance was more pronounced among participants with reduced resting vagal tone. Thus, increased resting vagal tone might protect against the use of avoidance. Our findings highlight the importance of assessing both subjective and biological processes when studying individual differences in emotion regulation.     

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.     

神经质程度和月经周期对女性主观情绪和生理反应的影响

分别选取两组神经质程度高、低女性16名和25名, 考察两组被试在月经周期不同阶段(经期、卵泡晚期、黄体中晚期)的激素(雌二醇、孕酮)波动以及观看情绪视频(中性、搞笑、悲伤、愤怒)的主观情绪感受和生理反应的差异。结果显示高神经质女性在月经周期中对负性情绪视频的主观情绪和生理反应变化明显, 黄体中晚期对愤怒视频主观情绪体验更低, 对悲伤视频生理反应更小, 而低神经质女性的情绪反应不受月经周期影响。研究表明高神经质女性的情绪反应更易受月经周期影响, 这可能与其对孕酮水平波动的敏感性高有关。     

Preliminary evidence for an emotion dysregulation model of generalized anxiety disorder

Three studies provide preliminary support for an emotion dysregulation model of generalized anxiety disorder (GAD). In study 1, students with GAD reported heightened intensity of emotions, poorer understanding of emotions, greater negative reactivity to emotional experience, and less ability to self-soothe after negative emotions than controls. A composite emotion regulation score significantly predicted the presence of GAD, after controlling for worry, anxiety, and depressive symptoms. In study 2, these findings were largely replicated with a clinical sample. In study 3, students with GAD, but not controls, displayed greater increases in self-reported physiological symptoms after listening to emotion-inducing music than after neutral mood induction. Further, GAD participants had more difficulty managing their emotional reactions. Implications for GAD and psychopathology in general 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.     

Turn down the volume or change the channel? Emotional effects of detached versus positive reappraisal

Cognitive reappraisal, or changing one's interpretation of an event in order to alter the emotional response to it, is thought to be a healthy and an effective emotion regulation strategy. Although researchers recognize several distinct varieties of reappraisal, few studies have explicitly compared the effects of multiple reappraisal strategies on emotional responding. The present study compares the effects of detached and positive reappraisal on thought content, subjective emotional experience, physiological reactivity, and facial expressions of emotion while viewing film clips evoking sadness and disgust. Although both forms of reappraisal reduced overall emotional responding to unpleasant stimuli, the effects of detached reappraisal were stronger in this regard, and positive reappraisal was more likely to maintain subjective experience and facial expression of stimulus-appropriate positive emotions. The two reappraisal strategies also produced somewhat different profiles of physiological responding. Differences between detached and positive reappraisal with respect to subjective experience and facial expression were more pronounced among men than women; the reverse was true for differences with respect to physiological responding. Beyond these effects on individual emotion response systems, detached and positive reappraisal also had somewhat different effects on coherence in change across response systems. Implications for our understanding of emotion regulation processes, and for emotion theory more broadly, are discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved).     

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.     

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.     

Autonomic, subjective, and expressive responses to emotional films in older and younger Chinese Americans and European Americans

Previously, the authors found that during idiosyncratic emotional events (relived emotions, discussions about marital conflict), older European American adults demonstrated smaller changes in cardiovascular responding than their younger counterparts (R. W. Levenson, L. L. Carstensen, W. V. Friesen, & P. Ekman, 1991; R. W. Levenson, L. L. Carstensen, & J. M. Gottman, 1994). This study examined whether such differences held when the emotional events were standardized, and whether they extend to another cultural group. Forty-eight old (70-85 years) and 48 young (20-34 years) European Americans and Chinese Americans viewed sad and amusing film clips in the laboratory while their cardiovascular, subjective (online and retrospective), and behavioral responses were measured. Consistent with previous findings, older participants evidenced smaller changes in cardiovascular responding than did younger participants during the film clips. Consistent with earlier reports, old and young participants did not differ in most subjective and behavioral responses to the films. No cultural differences were found.     

Treating chronic worry: Psychological and physiological effects of a training programme based on mindfulness

The present study examines psychological and physiological indices of emotional regulation in non-clinical high worriers after a mindfulness-based training programme aimed at reducing worry. Thirty-six female university students with high Penn State Worry Questionnaire scores were split into two equal intervention groups: (a) mindfulness, and (b) progressive muscle relaxation plus self-instruction to postpone worrying to a specific time of the day. Assessment included clinical questionnaires, daily self-report of number/duration of worry episodes and indices of emotional meta-cognition. A set of somatic and autonomic measures was recorded (a) during resting, mindfulness/relaxation and worrying periods, and (b) during cued and non-cued affective modulation of defence reactions (cardiac defence and eye-blink startle). Both groups showed equal post-treatment improvement in the clinical and daily self-report measures. However, mindfulness participants reported better emotional meta-cognition (emotional comprehension) and showed improved indices of somatic and autonomic regulation (reduced breathing pattern and increased vagal reactivity during evocation of cardiac defense). These findings suggest that mindfulness reduces chronic worry by promoting emotional and physiological regulatory mechanisms contrary to those maintaining chronic worry.     

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.

     

Mechanisms of mindfulness: emotion regulation following a focused breathing induction

The current study investigated whether a 15 min recorded focused breathing induction in a normal, primarily undergraduate population would decrease the intensity and negativity of emotional responses to affectively valenced picture slides and increase willingness to remain in contact with aversive picture slides. The effects of the focused breathing induction were compared with the effects of 15 min recorded inductions of unfocused attention and worrying. The focused breathing group maintained consistent, moderately positive responses to the neutral slides before and after the induction, whereas the unfocused attention and worry groups responded significantly more negatively to the neutral slides after the induction than before it. The focusing breathing group also reported lower negative affect and overall emotional volatility in response to the post-induction slides than the worry group, and greater willingness to view highly negative slides than the unfocused attention group. The lower-reported negative and overall affect in response to the final slide blocks, and greater willingness to view optional negative slides by the focused breathing group may be viewed as more adaptive responding to negative stimuli. The results are discussed as being consistent with emotional regulatory properties of mindfulness.     

An experimental investigation of the effect of worry on responses to a discrimination learning task

The current study examined the impact of both the tendency to worry (trait worry) and the process of worry (state worry) on subsequent behavioral responding in a schedule discrimination learning task. High and low trait worriers were randomly assigned to a state worry or relaxation incubation condition and completed a test of executive functioning and a dual contingency learning task that utilized neutral discriminative cues over the course of 2 contingency phases. Although state and trait worry did not impact executive functioning, the state worry condition was associated with diminished sensitivity to learning task contingencies over the course of the first contingency learning trials in comparison to the relaxation condition. This relationship was unique to the state worry condition above and beyond shared variance with subjective anxiety level. Results suggest that state worry may lead to a decrement in selective behavioral responding to neutral discriminative cues in the environment. The findings suggest that the process of worry may lead to less adaptive responding to neutral cues and interfere with adaptive behaviors, which may thereby contribute to and maintain anxiety.