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 influence of context on the implementation of adaptive emotion regulation strategies

Putatively adaptive emotion regulation strategies (e.g., acceptance, problem solving, reappraisal) show weaker associations with psychopathology than putatively maladaptive strategies (e.g., avoidance, self-criticism, hiding expression, suppression of experience, worry, rumination). This is puzzling, given the central role that adaptive strategies play in a wide range of psychotherapeutic approaches. We explored this asymmetry by examining the effects of context (i.e., emotion intensity, type of emotion, social vs. academic circumstances) on the implementation of adaptive and maladaptive strategies. We asked 111 participants to describe 8 emotion-eliciting situations and identify which strategies they used in order to regulate their affect. We found support for a contextual model of emotion regulation, in which adaptive strategies were implemented with more cross-situational variability than maladaptive strategies. In addition, the variability in implementation of two adaptive strategies (acceptance, problem solving) predicted lower levels of psychopathology, suggesting that flexible implementation of such strategies in line with contextual demands is associated with better mental health. We discuss these findings by underscoring the importance of adopting a functional approach to the delineation of contextual factors that influence the implementation of emotion regulation strategies.     

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.     

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.     

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.

     

Utilizing an Ability-Based Measure to Detect Emotion Regulation Deficits in Generalized Anxiety Disorder

In recent years, the field of emotion regulation has advanced current conceptualizations of many forms of psychopathology. Difficulties with emotion regulation have been detected via self-report in several anxiety and depressive disorders, and in particular, generalized anxiety disorder (GAD). However, there is a paucity of research examining emotion regulation ability in this population, leaving open the possibility that self-report measures reflect an individual’s perception of his/her emotion regulation skills rather than skills themselves. The present study examined the utility of an ability-based measure of emotional intelligence in the assessment of emotion-related deficits in GAD as well as the concordance between the ability-based measure and self-reports of emotion regulation skills. Results revealed that individuals with GAD demonstrated significantly more difficulty regulating their emotions than control participants did on both ability-based and self-report measures. Further, these measures showed a moderate concordance with each other. Findings suggest it will be important to integrate ability-based measurement of emotion-related deficits with other assessment modalities.     

An examination of trait,spontaneous and instructed emotion regulation in dysphoria

Depression is thought to be characterised by impaired emotion regulation, although the mechanisms of that regulation are not yet well understood. The present study examined trait, spontaneous and instructed emotion regulation in dysphoric (n = 66) and non-dysphoric (n = 86) participants. Participants were randomly assigned to use reappraisal while watching a sadness-inducing film clip (instructed emotion regulation condition) or were not given specific viewing instructions (spontaneous emotion regulation condition). Participants also completed trait measures of emotion regulation. Dysphoric individuals reported greater spontaneous use of rumination and suppression than non-dysphoric individuals, and these strategies were associated with greater negative emotional reactivity to the sadness-inducing film clip. Both participant groups were able to effectively use reappraisal when instructed to do so. The clinical implications of these findings and future research directions are discussed.     

Intolerance of uncertainty and difficulties in emotion regulation: Proposal for an integrative model of generalized anxiety disorder

Introduction

The Intolerance of Uncertainty Model (IUM) is a well-tested model of generalized anxiety disorder (GAD).

Emotion regulation and biological stress responding: associations with worry,rumination, and reappraisal

ABSTRACT

Individual differences in the habitual use of emotion regulation strategies may play a critical role in understanding psychological and biological stress reactivity and recovery in depression and anxiety. This study investigated the relation between the habitual use of different emotion regulation strategies and cortisol reactivity and recovery in healthy control individuals (CTL; n?=?33) and in individuals diagnosed with social anxiety disorder (SAD; n?=?41). The tendency to worry was associated with increased cortisol reactivity to a stressor across the full sample. Rumination was not associated with cortisol reactivity, despite its oft-reported similarities to worry. Worry and rumination, however, were associated with increased cortisol during recovery from the stressor. The only difference between CTL and SAD participants was observed for reappraisal. In the CTL but not in the SAD group, reappraisal predicted recovery, such that an increased tendency to reappraise was associated with greater cortisol recovery. These results suggest an important role of the habitual use of emotion regulation strategies in understanding biological stress reactivity and recovery.     

Examining the relationship between emotion regulation deficits and borderline personality disorder features: A daily diary study

This study used a six-day daily diary methodology to precisely specify the nature of emotion regulation deficits associated with borderline personality disorder (BPD) features. Three possibilities were explored: that BPD features are associated with (1) the overall underuse of emotion regulation strategies; (2) the overuse of dysfunctional and the underuse of functional strategies; and (3) the lower perceived effectiveness of emotion regulation strategies. One hundred and fifty-four undergraduate participants completed self-report measures of BPD feature severity, and then reported their daily negative emotional intensity, whether or not they used various emotion regulation strategies, and whether or not the strategies that they used were effective across a six-day period. Higher BPD features were associated with (a) higher total frequency use of emotion regulation strategies; (b) higher frequency use of dysfunctional and functional emotion regulation strategies; and (c) less self-reported effectiveness of functional strategies. BPD features may be characterized by increased attempts to regulate emotions, without corresponding increases in perceived effectiveness.     

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 effects of analytical rumination, reappraisal, and distraction on anger experience

The manner in which individuals recall negative life events has important affective consequences. The present experiment investigated the effects of emotion regulation strategies on anger experience. One hundred and twenty-one undergraduates recalled an anger-inducing memory and were instructed to engage in either analytical rumination, cognitive reappraisal, or distraction for 20 minutes. In the remaining (control) condition, participants were instructed to write about their thoughts but were not given any emotion regulation instructions. Rumination maintained anger, whereas participants in the remaining conditions reported decreased anger following the writing task. Our results suggest that reappraisal facilitates adaptive processing of anger-inducing memories and distraction facilitates rapid reductions in anger experience. These findings have implications for the management of clinical populations that commonly experience difficulty with anger regulation.     

Spontaneous emotion regulation to positive and negative stimuli

The ability to regulate one’s emotions is an integral part of human social behavior. One antecedent emotion regulation strategy, known as reappraisal, is characterized by cognitively evaluating an emotional stimulus to alter its emotional impact and one response-focused strategy, suppression, is aimed at reducing behavioral output. People are capable of using these specific emotion regulation strategies when instructed to do so; however, it is equally important to investigate natural and self-selected strategy use. This study was designed to determine to what extent people spontaneously regulate their emotions and the emotion regulation strategies they choose to achieve their regulatory goals. Participants were given no instructions to regulate their emotions before they were shown a negative and a positive film clip, but were instead asked afterwards about the specific strategies that they had used. Participants reported regulating their emotions more to the negative film than to the positive film. Reappraisal was more frequently selected as an emotion regulation strategy than suppression. As expected, participants with high baseline respiratory sinus arrhythmia (RSA) adopted reappraisal strategies more than those with low RSA but, surprisingly, RSA was not associated with facial expressivity. Suggestions for future research in this relatively young field of spontaneous emotion regulation are offered.     

The relationship of thought-action fusion to pathologicial worry and generalized anxiety disorder

Meta-cognitive beliefs associated with pathological worry and generalized anxiety disorder (GAD) may encompass the likelihood subtype of thought-action fusion (TAF), the belief that one's thoughts can influence outside events. In the current study of 494 undergraduate college students, positive correlations between scores on the Penn State Worry Questionnaire (PSWQ) and the two Likelihood subscales of the TAF Scale were found, and participants endorsing at least some DSM-IV diagnostic criteria for GAD scored significantly higher on both TAF-Likelihood subscales than participants reporting no GAD symptoms. However, these TAF scales did not predict GAD diagnostic status with PSWQ included as a predictor. In contrast to previous research, the TAF-Moral scale did not correlate with worry. Relationships between TAF, pathological worry, and meta-cognition are discussed in relation to GAD.     

'Minor GAD': characteristics of subsyndromal GAD in older adults

Subsyndromal emotional symptoms are common in older adults and are associated with increased disability, health care utilization, and risk for developing psychiatric disorders. The purpose of this study was to examine subsyndromal generalized anxiety disorder (GAD) in older adults. Participants included 30 older adults with diagnosable GAD, 19 with subsyndromal anxiety symptoms [minor GAD; (MGAD)], and 21 normal control volunteers (NC). Participants were assessed using the Anxiety Disorders Interview Schedule for DSM-IV and completed self-report measures of anxiety, worry, depression, and life satisfaction. Excessive worry on more days than not, difficulty controlling worry, and clinically significant distress or impairment were the diagnostic criteria endorsed by MGAD participants least often. Therefore, these criteria may be useful in distinguishing between GAD and subsyndromal GAD. Self-reported anxiety and worry also systematically differed across groups in the expected directions, with a discriminant analysis yielding good classification of the GAD and NC groups based on these measures. Categorization of MGAD participants generally was poor, with most misclassified as GAD patients. Clinical implications of these findings are discussed.     

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.     

Attentional control in OCD and GAD: specificity and associations with core cognitive symptoms

Obsessive–compulsive disorder (OCD) and generalized anxiety disorder (GAD) are both defined by excessive negatively-valenced cognitions. Although obsessional thoughts are considered essential to OCD and perseverative worry is considered essential to GAD, these excessive cognitions have been found to co-occur in both disorders. Accordingly, a common diathesis may influence the emergence of excessive thoughts in both disorders. The present study examined deficits in attentional control as a cognitive vulnerability that may contribute to both obsessional thought and perseverative worry. Patients with OCD (n = 30), GAD (n = 29), and non-clinical controls (NCC; n = 29) completed measures of obsessional thoughts, perseverative worry, and attentional control. Deficits in self-reported attentional control were found in both OCD and GAD relative to the NCC. However, attentional control was only related to excessive cognition in the GAD patient group, where deficits were associated with increased perseverative worry. Mediational modeling suggested that trait anxiety mediated the relationship between attentional control and perseverative worry in GAD. Implications of these findings for conceptualizing the role of attentional control in the genesis of excessive cognitions in OCD and GAD are discussed.     

When trying is not enough: Emotion regulation and the effort-success gap in bipolar disorder

Bipolar disorder (BD) is presumed to involve difficulties in emotion regulation. Little is known, however, about the specific emotion regulation profile associated with this disorder. The present study examined the use of specific emotion regulation strategies among individuals with BD (n = 37) and healthy controls (n = 38). Participants' spontaneous use of reappraisal and suppression, as well as their associated effort and success at regulating their emotions, was measured in the context of three emotionally evocative films (neutral, happy, sad). Results indicated that the BD participants made greater use of spontaneous suppression and reappraisal across all films compared to the control group. BD participants also reported greater effort, but less success, when spontaneously regulating emotions. These findings suggest that bipolar disorder is associated with less success when regulating emotions despite a widespread engagement of regulatory efforts. Discussion focuses on the disjunction between troubled emotion functioning in bipolar disorder and sustained efforts to modify intense emotions. (PsycINFO Database Record (c) 2012 APA, all rights reserved).     

Emotion Regulatory Strategies in Complicated Grief: A Systematic Review

Prolonged grief disorder, characterized by severe, persistent, and disabling grief, has recently been included in the International Classification of Diseases-11 (ICD-11). Emotional disturbances are central to such complicated grief responses. Accordingly, emotion regulation is assumed critical in the development, persistence, and treatment of complicated grief. Yet, a comprehensive review on this topic is lacking. We conducted a systematic review (PROSPERO: CRD42017076061) searching PsycInfo, Web of Science, and PubMed to identify quantitative research examining relationships between emotion regulation and complicated grief. Sixty-four studies on 7,715 bereaved people were identified, focusing on a variety of emotion regulation strategies (i.e., experiential avoidance, behavioral avoidance, expressive suppression, rumination, worry, problem solving, cognitive reappraisal, positive thought, and mindfulness). Our synthesis showed strong evidence that experiential avoidance and rumination play a role in the persistence of complicated grief. More generally, surveys support positive associations between putative maladaptive emotion regulation strategies and complicated grief, and negative associations between putative adaptive emotion regulation strategies and complicated grief. Laboratory research yielded mixed results. Emotion regulation is critical in complicated grief, and in particular experiential avoidance and rumination form important targets in complicated grief treatments. We advise expanding current knowledge, by employing more advanced, intensive data collection methods and experiments across diverse samples. Increasing knowledge in this domain will improve clinical practice.