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.     

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.     

Inhibitory control and symptom severity in late life generalized anxiety disorder

Contemporary models of generalized anxiety disorder (GAD) posit that worry functions as an avoidance strategy. During worry, individuals inhibit threat-related imagery in order to minimize autonomic reactivity to phobic topics. This conceptualization of worry suggests a role for the executive system in exerting top-down inhibitory control (IC) over threat processing. We tested the hypothesis that better performance on an IC task would be associated with greater severity of worry and concomitant anxious mood. Forty-three older adults (age 60-77) with GAD completed the Stroop color word task and a battery of self-report symptom measures. Fifteen of the GAD patients were paired with age- and sex-matched non-anxious controls. In the full GAD sample, age-normed t-scores of Stroop performance were positively correlated with measures of worry and trait anxiety, but not anxious arousal or depression. Positive relationships between IC and symptom severity were upheld in the smaller subsample of GAD patients, while in the matched control group, no relationships between Stroop scores and clinical measures were observed. Patients and controls did not differ in Stroop performance. In the context of a disorder-specific tendency to make maladaptive use of executive functions, better IC may be associated with more severe symptomatology.     

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.

     

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.     

Restlessness in Generalized Anxiety Disorder: Using Actigraphy to Measure Physiological Reactions to Threat

Generalized anxiety disorder (GAD) is characterized by excessive, uncontrollable worry accompanied by symptoms of physiological arousal. Although individuals with GAD report greater subjective arousal than healthy individuals, they show equivalent or even attenuated physiological reactions to threat. This may result from using physiological measures better suited to fear than anxiety. To test this possibility, 102 adults with and without GAD were assessed for restlessness, a core physiological symptom of GAD. They were exposed to an in vivo threat task designed to elicit anxiety in the laboratory. Throughout the task, restlessness was measured physiologically with actigraphy sensors on both ankles and both wrists, and subjectively with self-report ratings. The GAD group reported higher subjective restlessness than the no-GAD group, and in the subset of cases who had restlessness as a clinically significant symptom, actigraphy scores were reliably elevated as well. However, although actigraphy scores increased with proximity to the threat, the increases did not differ by group. These findings provide initial validation for actigraphy as a novel measure of motor restlessness in GAD. In addition, they underscore the value of measuring restlessness using multiple assessment methods. These methods suggest that, in GAD, restlessness reflects a chronic state of arousal rather than a heightened physiological reaction to threat.     

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.     

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.     

Effects of worry on physiological and subjective reactivity to emotional stimuli in generalized anxiety disorder and nonanxious control participants

The present study examined the effect of worry versus relaxation and neutral thought activity on both physiological and subjective responding to positive and negative emotional stimuli. Thirty-eight participants with generalized anxiety disorder (GAD) and 35 nonanxious control participants were randomly assigned to engage in worry, relaxation, or neutral inductions prior to sequential exposure to each of four emotion-inducing film clips. The clips were designed to elicit fear, sadness, happiness, and calm emotions. Self reported negative and positive affect was assessed following each induction and exposure, and vagal activity was measured throughout. Results indicate that worry (vs. relaxation) led to reduced vagal tone for the GAD group, as well as higher negative affect levels for both groups. Additionally, prior worry resulted in less physiological and subjective responding to the fearful film clip, and reduced negative affect in response to the sad clip. This suggests that worry may facilitate avoidance of processing negative emotions by way of preventing a negative emotional contrast. Implications for the role of worry in emotion avoidance are discussed.     

The impact of mothers' trait anxiety on their expectations of approach‐avoidance behaviour in anxious and non‐anxious children

This study investigated estimates of approach and avoidance behaviour in clinically anxious and non‐anxious children, and whether mothers' expectations of their children's avoidance differed as a function of high trait anxiety (HTA) versus low trait anxiety (LTA). Participants were 62 clinically anxious and 60 non‐anxious children aged 7–12 years and their mothers. Estimates of avoidance were obtained using an analogue task in which children and mothers were given threat and pleasant information about two novel animals and were asked to estimate children's avoidance of the threat animal's habitat when the threat animal was present (threat condition) and absent (safe condition) from the habitat and when its presence was uncertain (ambiguous condition). Contrary to expectation, anxious children did not differ from controls in estimates of avoidance in any condition. However, relative to HTA mothers of anxious children and LTA mothers of non‐anxious children, HTA mothers estimated greater approach behaviour by their non‐anxious children in the threat condition. Findings suggest that mothers' expectations of children's approach‐avoidance behaviour is influenced by both maternal and child factors.     

Combining computerized home-based treatments for generalized anxiety disorder: an attention modification program and cognitive behavioral therapy

Generalized anxiety disorder (GAD) is a common and disabling condition associated with significant personal and societal costs. Although efficacious treatments exist for GAD, the majority of these individuals fail to access our most effective treatments. In the current paper, we report the results of an open trial that examined the efficacy of a computer-delivered home-based treatment program for GAD. Twenty-one individuals seeking treatment for GAD received a self-administered program over 6 weeks that comprised two components: (1) an Attention Modification Program (AMP) designed to facilitate attentional disengagement from threat-relevant stimuli and (2) brief computer-delivered cognitive and behavioral treatment modules (CCBT). Fourteen of the 21 enrolled participants (67%) completed the treatment program. Intent-to-treat and completer analyses revealed that AMP+CCBT resulted in significant reductions in clinician- and self-rated symptoms of anxiety, worry, depression, and functional impairment. Moreover, treatment completers displayed significant reductions in attentional bias for threat from pre- to postassessment. Change in attentional bias for threat from pre- to postassessment was associated with change in worry symptoms. Finally, 79% of participants no longer met DSM-IV criteria for GAD at postassessment and 36% were classified as remitted (Hamilton Rating Scale for Anxiety ≤7; Rickels et al., 2006). These results suggest that computer-delivered AMP+CCBT may serve as an effective and easily accessible treatment option for individuals with GAD.     

The everyday dynamics of rumination and worry: precipitant events and affective consequences

ABSTRACT

Rumination and worry are two perseverative, negatively valenced thought processes that characterise depressive and anxiety disorders. Despite significant research interest, little is known about the everyday precipitants and consequences of rumination and worry. Using an experience sampling methodology, we examined and compared rumination and worry with respect to their relations to daily events and affective experience. Participants diagnosed with Major Depressive Disorder (MDD), Generalized Anxiety Disorder (GAD), co-occurring MDD–GAD, or no diagnosis carried an electronic device for one week and reported on rumination, worry, significant events, positive affect (PA), and negative affect (NA). Across the clinical groups, occurrences of everyday events predicted subsequent increases in rumination, but not worry. Further, higher momentary levels of rumination, but not worry, predicted subsequent decreases in PA and increases in NA. Thus, in these clinical groups, rumination was more susceptible to daily events and produced stronger affective changes over time. We discuss implications for theory and clinical intervention.     

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.     

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.     

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.     

“Watch out!”: Effects of instructed threat and avoidance on human free‐operant approach–avoidance behavior

Approach–avoidance paradigms create a competition between appetitive and aversive contingencies and are widely used in nonhuman research on anxiety. Here, we examined how instructions about threat and avoidance impact control by competing contingencies over human approach–avoidance behavior. Additionally, Experiment 1 examined the effects of threat magnitude (money loss amount) and avoidance cost (fixed ratio requirements), whereas Experiment 2 examined the effects of threat information (available, unavailable and inaccurate) on approach–avoidance. During the task, approach responding was modeled by reinforcing responding with money on a FR schedule. By performing an observing response, participants produced an escalating “threat meter”. Instructions stated that the threat meter levels displayed the current probability of losing money, when in fact loss only occurred when the level reached the maximum. Instructions also stated pressing an avoidance button lowered the threat level. Overall, instructions produced cycles of approach and avoidance responding with transitions from approach to avoidance when threat was high and transitions back to approach after avoidance reduced threat. Experiment 1 revealed increasing avoidance cost, but not threat magnitude, shifted approach–avoidance transitions to higher threat levels and increased anxiety ratings, but did not influence the frequency of approach–avoidance cycles. Experiment 2 revealed when threat level information was available or absent earnings were high, but earnings decreased when inaccurate threat information was incompatible with contingencies. Our findings build on prior nonhuman and human approach–avoidance research by highlighting how instructed threat and avoidance can impact human AA behavior and self‐reported anxiety.     

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.     

Linking cognitive avoidance and GAD symptoms: The mediating role of fear of emotion

Although cognitive avoidance has been linked to generalized anxiety disorder (GAD), the mechanism that may account for this association has not been fully elucidated. The current study uses structural equation models to evaluate the relationship between cognitive avoidance and symptoms of GAD in a large unselected sample (n = 1220), and to examine whether subjective fear of emotion partially mediate this relationship. Results support partial mediation, and follow-up analyses suggest that the pattern of relations among fear of emotion, cognitive avoidance, and GAD symptoms is invariant for men and women. However, subsequent analysis revealed equivalence of meditational models where cognitive avoidance leads to GAD symptoms and vice versa. The implications of these findings for better understanding the etiology, maintenance, and treatment of GAD are discussed.     

The role of fear of anxiety and intolerance of uncertainty in worry: An experimental manipulation

The tendency to fear emotional experiences, such as anxiety, may be an important factor in the maintenance of excessive worry, which is the central feature of generalized anxiety disorder (GAD). The goal of the present study was to clarify the role of fear of anxiety in worry by assessing whether the experimental manipulation of fear of anxiety affects worry level. The study also assessed the combined effects of fear of anxious responding and intolerance of uncertainty (a factor already linked to pathological worry) on level of worry by grouping participants according to their tolerance for uncertainty. The results indicated that participants whose fear of anxiety was increased showed higher levels of worry compared to participants whose fear of anxiety was decreased. This finding provides preliminary support for the causal role of fear of anxiety in worry. Moreover, the results showed that increased fear of anxiety in combination with an intolerance for uncertainty led to the highest levels of worry, which suggests that these constructs have an additive effect on worry. The findings lend support to the integration of new conceptualizations of psychopathology with existing models of excessive worry, which could ultimately increase treatment efficacy for GAD.     

The impact of pretrauma analogue GAD and posttraumatic emotional reactivity following exposure to the September 11 terrorist attacks: a longitudinal study

The relation between analogue generalized anxiety disorder (GAD) assessed the day before the events of September 11, 2001 (9/11) and long-term outcome was examined in 44 young adults who were directly exposed the following day to the terrorist attacks in New York City. After controlling for high exposure to the attacks, preattack analogue GAD was associated with greater social and work disability, loss of psychosocial resources, anxiety and mood symptoms, and worry, but not symptoms of posttraumatic stress, assessed 12 months after 9/11. Fear and avoidance of emotions assessed 4 months after 9/11 statistically mediated the relation between preattack analogue GAD and social and work disability, loss of psychosocial support, mood and anxiety symptoms, and worry at 12-month follow-up. Avoidance of emotions 4 months after 9/11 also mediated the relation between preattack analogue GAD and posttraumatic stress symptoms 12 months after 9/11.