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.     

A preliminary investigation of impulsivity in generalized anxiety disorder

Few studies have examined the association between impulsivity and generalized anxiety disorder (GAD). This study examined whether individuals with probable GAD display impulsivity in a particular way, and the extent to which impulsivity uniquely predicts GAD severity and GAD status, over and above intolerance of uncertainty (IU), a key cognitive factor in GAD. Individuals with (n = 63) and without (n = 77) probable GAD completed self-report measures of impulsivity and IU. Results revealed that elevations in the severity of GAD symptoms and in IU were associated with impulsive actions in the face of negative affect (i.e., negative urgency), but also greater premeditation and lower “functional” impulsivity (i.e., the ability to take quick action when it is advantageous to do so). Impulsivity led to an increment in the prediction of GAD symptoms and GAD status, over and above IU. Negative urgency and lower functional impulsivity were significant unique predictors of GAD severity or GAD status. The findings highlight a need to consider impulsivity in theories that implicate intolerance of negative affect and uncertainty in excessive and uncontrollable worry.     

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.     

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.     

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.     

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

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

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.     

The effects of modifying interpretation bias on worry in generalized anxiety disorder

This study investigated whether facilitating a benign interpretive bias decreases negative thought intrusions in generalized anxiety disorder (GAD). Clients were randomly allocated to an interpretation modification condition in which they repeatedly accessed benign meanings of emotionally ambiguous homographs and scenarios, or to a control condition in which they accessed threat and benign meanings with equal frequency. Worry frequency was assessed using a breathing focus task that involved categorising the valence of thought intrusions before and after an instructed worry period. Interpretation bias was assessed during the modification tasks, and on a different measure of interpretation bias (sentence completion) following a period of worry. The experimental procedure modified interpretations made during training, and in the later sentence completion task. Furthermore, compared to the control group, the benign group showed fewer negative thought intrusions during breathing focus (as rated by both participants and an assessor). These findings show that it is possible to induce a more benign interpretive bias in GAD clients and that this reduces negative thought intrusions.     

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).

A pilot randomized trial of metacognitive therapy vs applied relaxation in the treatment of adults with generalized anxiety disorder

Metacognitive Therapy (MCT) and Applied Relaxation (AR) were compared in a pilot treatment trial of generalized anxiety disorder (GAD). Twenty outpatients meeting criteria for DSM-IV-TR GAD were assessed before treatment, after treatment and at 6 m and 12 m follow-up. The patients were randomized and treated individually for 8-12 weekly sessions. There was no drop-out from MCT and 10% at 6 m follow-up from AR. At post-treatment and at both follow-up points MCT was superior to AR. Standardized recovery rates for MCT at post-treatment were 80% on measures of worry and trait-anxiety compared with 10% following AR. At 6 m follow-up recovery rates for MCT were 70% on both measures compared with 10% and 20% for AR. At 12 m follow-up recovery rates for MCT were 80% (worry) and 60% (trait-anxiety) compared with 10% and 20% following AR. The recovery rates for MCT are similar to those obtained in an earlier uncontrolled trial (Wells & King, 2006). The effect sizes and standardized recovery rates for MCT suggest that it is a highly effective treatment.     

Interpretive cues and ambiguity in generalized anxiety disorder

The current study investigated whether generalized anxiety disorder (GAD) individuals rely on antecedent information to interpret ambiguity and whether reliance on such preceding cues persists in the absence of potential threat. Twenty-six GAD and 23 nonanxious control college students performed a lexical decision task, using homographs (i.e. words with multiple meanings) as ambiguous primes. In half the trials, a homograph prime that possessed both threat-related, as well as neutral meanings was followed by a target word related to one of these two meanings. In addition, each ambiguous prime was immediately preceded by a series of four antecedent words that were either: (a) associated with the threatening meaning of the prime; (b) associated with the neutral meaning of the prime; or (c) unrelated to either meaning of the homograph, as well as the target. Homographs for which both meanings were neutral in valence comprised the other half of the trials. Effect size statistics suggest that GAD participants utilized the antecedent words to interpret the homograph primes with threat-related meanings, unlike their nonanxious counterparts (p<0.06). When both meanings of the homograph prime were neutral in valence, the GAD group appeared deficient in the use of preceding information to interpret the ambiguous prime.     

Transdiagnostic emotion regulation processes in bipolar disorder and insomnia

Research and treatment have traditionally adopted a 'disorder-focused' approach by targeting one specific disorder, aiming to understanding its cause, maintenance and treatment. The aim of the present study was to contribute to the burgeoning interest in examining common, or 'transdiagnostic,' processes across disorders. Three candidate transdiagnostic processes involved in emotion regulation - rumination, worry, and automatic negative thoughts - were examined in euthymic bipolar I disorder (n=21) and insomnia (n=19), and a non-clinical control group (n=20). Rumination and worry were endorsed to a larger degree by the bipolar and insomnia groups compared to the control group. However, while the bipolar group had more negative automatic thoughts than the control group, there were no significant differences in negative automatic thoughts between the bipolar and insomnia groups or the insomnia and control groups. These results suggested that rumination and worry, but not negative automatic thoughts, might be common across bipolar disorder and insomnia. However, these findings no longer remained significant when current symptoms of anxiety and depression were controlled for. Prospective and experimental studies are needed to test the extent to which these processes contribute to the etiology or maintenance of insomnia and bipolar disorder.     

Written threat: Electrophysiological evidence for an attention bias to affective words in social anxiety disorder

Social anxiety disorder (SAD) is associated with heightened sensitivity to threat cues, typically represented by emotional facial expressions. To examine if this bias can be transferred to a general hypersensitivity or whether it is specific to disorder relevant cues, we investigated electrophysiological correlates of emotional word processing (alpha activity and event-related potentials) in 20 healthy participants and 20 participants with SAD. The experimental task was a silent reading of neutral, positive, physically threatening and socially threatening words (the latter were abusive swear words) while responding to a randomly presented dot. Subsequently, all participants were asked to recall as many words as possible during an unexpected recall test. Participants with SAD showed blunted sensory processing followed by a rapid processing of emotional words during early stages (early posterior negativity – EPN). At later stages, all participants showed enhanced processing of negative (physically and socially threatening) compared to neutral and positive words (N400). Moreover, at later processing stages alpha activity was increased specifically for negative words in participants with SAD but not in healthy controls. Recall of emotional words for all subjects was best for socially threatening words, followed by negative and positive words irrespective of social anxiety. The present findings indicate that SAD is associated with abnormalities in emotional word processing characterised by early hypervigilance to emotional cues followed by cognitive avoidance at later processing stages. Most importantly, the specificity of these attentional biases seems to change as a function of time with a general emotional bias at early and a more specific bias at later processing stages.     

Affective flexibility and generalized anxiety disorder: valence-specific shifting difficulties

ABSTRACT

Background: Growing evidence suggests that generalized anxiety disorder (GAD) is associated with poor affective flexibility, defined as the ability to switch between emotional aspects and non-emotional aspects of a situation. However, it is unclear whether affective inflexibility is valence-specific in GAD.

Methods: Participants with GAD (n?=?21) and non-clinical control participants (n?=?28) were tested on an Affective Switching Task during which participants were asked to categorize pictures either by the valence or by the number of humans present in the pictures.

Results: Individuals with GAD, but not healthy controls, exhibited greater difficulty shifting from emotional aspects of negative material compared to emotional aspects of positive material and shifting to the emotional aspects of positive material compared to emotional aspects of negative material.

Conclusions: These findings suggest that GAD is associated with valence-specific affective flexibility biases. The relevance of the findings and directions for future research are discussed.     

Patterns of situational appraisal in experiences of worry and anxiety

Abstract

Three studies investigating differences in people's appraisals of worry and anxiety situations are presented. First, data from a study by Reisenzein & Spielhofer (1994) were reanalyzed. Second, two further studies were conducted to replicate the findings of the reanalysis and to explore whether any additional appraisal dimensions were relevant for a differentiation of worry and anxiety situations. In sum, results showed that appraisals associated with situations in which worry and anxiety were experienced differed on eight appraisal dimensions. Compared to experiences of anxiety, experiences of worry were more often associated with positive self-evaluation, positive social-relationship evaluation, feelings of closeness, and sentiments of importance, and less often associated with feelings of inferiority. Moreover, in worry experiences, focus was often not on the self, but on other persons. Finally, with respect to temporal dimensions, worry situations were less often associated with notions of suddenness and momentariness than anxiety situations. Implications of these findings are discussed with respect to models of emotional appraisal and research on worry and generalized anxiety disorder.     

A comparison of cognitive-behavior therapy with interpersonal and cognitive behavior therapy in the treatment of generalized anxiety disorder

Objective: The aim of this study was to compare the effectiveness of cognitive behavior therapy with the combination of cognitive behavior therapy and interpersonal therapy on decreasing the excessiveness of pathological worry and increasing happiness of the individuals with generalized anxiety disorder.

Method: The sample consisted of 36 female undergraduate students who referred themselves to the Isfahan University Counseling Center and met the criteria for GAD. They were randomly assigned into three groups; namely, two experimental groups and one control group. Before receiving the interventions all of the groups completed Penn State Worry Questionnaire and Oxford Happiness Inventory. One of the experimental groups underwent cognitive behavior therapy and the other one received the integration of cognitive behavior therapy and interpersonal therapy. The control group received no intervention.

Result: The statistical analyses indicated that the differences between the CBT and CBT+ IPT groups on excessive worry and happiness in the post tests were not significant. But significant mean differences were observed in the follow-ups regarding pathological worry and happiness between two groups.

Conclusion: It can be concluded that the integration of cognitive behavior therapy and interpersonal therapy can be applied as an effective intervention for decreasing the rate of GADs’ relapses after cognitive behavior therapy.     

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.     

Interactions between emotion regulation strategies and affective style: Implications for trait anxiety versus depressed mood

Affective style reflecting approach and inhibition is thought to be associated in distinct ways with anxious versus depressed mood; relatively few studies, however, consider how the interaction between affective style and the strategies individuals use to regulate mood and emotion might influence these associations. Sixty-seven non-disordered adults self-reported on their use of two emotion regulation strategies (cognitive reappraisal and expressive suppression), behavioral approach (BAS) and behavioral inhibition sensitivity (BIS) dimensions of affective style, and anxious and depressed mood (trait anxiety and symptoms of depression). Trait anxiety versus depressed mood was associated with unique interactive patterns of emotion regulation and affective style: enhanced use of reappraisal was linked to less depressed mood in those reporting low BAS, whereas high suppression was linked to greater trait anxiety in those reporting low BIS. The implications of findings for typical emotional processes and for clinical disorders and interventions are discussed.     

Changes in proposed mechanisms of action during an acceptance-based behavior therapy for generalized anxiety disorder

Based on the theory that generalized anxiety disorder (GAD) is maintained through a reactive and fused relationship with one's internal experiences and a tendency towards experiential avoidance and behavioral restriction, an acceptance-based behavior therapy (ABBT) was developed to specifically target these elements. Since ABBT has been shown to be an efficacious treatment in previous studies, the current study focuses on proposed mechanisms of change over the course of therapy. Specifically, the current study focuses on session-by-session changes in two proposed mechanisms of change: acceptance of internal experiences and engagement in meaningful activities. Overall, clients receiving ABBT reported an increase in the amount of time spent accepting internal experiences and engaging in valued activities. Change in both acceptance and engagement in meaningful activities was related to responder status at post-treatment and change in these two proposed mechanisms predicted outcome above and beyond change in worry. In addition, change in acceptance was related to reported quality of life at post-treatment.     

Facets of mindfulness mediate behavioral inhibition systems and emotion dysregulation

Behavioral motivation is regulated through the behavioral inhibition system (BIS) and the behavioral approach system (BAS), which underlie responses to emotional stimuli and are thought to influence emotion dysregulation. Research shows that mindfulness may increase the efficacy of emotion regulation among those with psychological symptoms, but the relationships between behavioral motivation and mindfulness have been only minimally explored. This study examines relationships between behavioral motivation systems and emotion dysregulation as mediated by mindfulness facets. Mediation was tested in a sample of 246 college students (M_age = 19.28, 61.8% female, 81.3% Caucasian) using a multiple mediator bootstrapping method. Results revealed an indirect relationship between BIS sensitivity and increased emotion dysregulation through underutilization of three distinct mindfulness skills: act with awareness, non-judging, and non-reactivity. Mindfulness facets did not mediate relationships between BAS sensitivity and emotion dysregulation, though BAS Reward Responsiveness directly predicted increased emotion dysregulation while BAS Drive was marginally associated with decreased emotion dysregulation. Findings delineate specific relationships between BIS/BAS, mindfulness skills, and emotion dysregulation while suggesting mindfulness training may be useful for BIS sensitive individuals.