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.     

The relationship between negative urgency and generalized anxiety disorder symptoms: the role of intolerance of negative emotions and intolerance of uncertainty

Background and Objectives: GAD symptoms are associated with greater negative urgency, a dimension of impulsivity defined as the tendency to act rashly when distressed. This study examined the degree to which intolerance of negative emotional states and intolerance of uncertainty account for the association between negative urgency and GAD symptoms. Design: An analysis of indirect effects evaluated whether intolerance of negative emotions and intolerance of uncertainty uniquely account for the association between negative urgency and GAD symptom severity. Methods: Undergraduate students (N?=?308) completed measures of GAD symptoms, trait anxiety, negative urgency, distress tolerance, and intolerance of uncertainty. Results: Greater symptoms of GAD, intolerance of negative emotional states, and intolerance of uncertainty were associated with greater negative urgency. There was an indirect relationship between negative urgency and GAD symptoms through intolerance of negative emotional states and intolerance of uncertainty even when controlling for trait anxiety. Intolerance of negative emotional states and intolerance of uncertainty each had an indirect relationship with GAD severity through negative urgency, suggesting possible bi-directional relations. Conclusions: Future studies should examine the role of intolerance of negative emotional states and intolerance of uncertainty in the impulsive behavior of individuals with GAD, and whether impulsive behavior reinforces these processes.     

Intolerance of uncertainty,causal uncertainty,causal importance,self-concept clarity and their relations to generalized anxiety disorder

Although numerous studies have provided support for the notion that intolerance of uncertainty plays a key role in pathological worry (the hallmark feature of generalized anxiety disorder (GAD)), other uncertainty-related constructs may also have relevance for the understanding of individuals who engage in pathological worry. Three constructs from the social cognition literature, causal uncertainty, causal importance, and self-concept clarity, were examined in the present study to assess the degree to which these explain unique variance in GAD, over and above intolerance of uncertainty. N = 235 participants completed self-report measures of trait worry, GAD symptoms, and uncertainty-relevant constructs. A subgroup was subsequently classified as low in GAD symptoms (n = 69) or high in GAD symptoms (n = 54) based on validated cut scores on measures of trait worry and GAD symptoms. In logistic regressions, only elevated intolerance of uncertainty and lower self-concept clarity emerged as unique correlates of high (vs. low) GAD symptoms. The possible role of self-concept uncertainty in GAD and the utility of integrating social cognition theories and constructs into clinical research on intolerance of uncertainty are discussed.     

Examining the Role of Perfectionism and Intolerance of Uncertainty in Postevent Processing in Social Anxiety Disorder

Postevent processing (PEP) is proposed to be a key maintenance factor of social anxiety disorder (SAD; e.g., Clark and Wells 1995). The goal of the current study was to examine the independent roles of two transdiagnostic variables, namely perfectionism and intolerance of uncertainty (IU), as unique predictors of PEP in SAD above and beyond social anxiety and depressive symptoms. Fifty-six adults with SAD and high levels of speech anxiety completed measures of perfectionism, IU, social anxiety, and depression. They gave an impromptu speech to induce PEP, and completed measures assessing degree of PEP and its associated distress. Significant positive correlations were found between perfectionism and negative PEP degree and distress, as well as between IU and negative PEP distress. The perfectionism subscales of parental expectations and parental criticism significantly predicted negative PEP degree and distress over and above social anxiety and depressive symptoms. Perfectionism, as well as IU, were significantly and positively correlated with positive PEP distress, and significantly predicted positive PEP distress above and beyond social anxiety and depressive symptoms. The study design was cross-sectional; hence, experimental and longitudinal studies are needed to further understand the roles of perfectionism and IU as they relate to PEP. Individuals with SAD who are high in perfectionism or IU appear to be more prone to engaging in, or experiencing distress associated with, negative PEP. Specific strategies for decreasing negative PEP in this vulnerable population, especially for those high in perfectionism, may be necessary for optimal treatment outcome.     

Intolerance of Uncertainty Mediates the Relation Between Generalized Anxiety Disorder Symptoms and Anger

Previous research has shown that individuals with generalized anxiety disorder (GAD) report elevated anger compared with nonanxious individuals; however, the pathways linking GAD and anger are currently unknown. We hypothesized that negative beliefs about uncertainty, negative beliefs about worry and perfectionism dimensions mediate the relationship between GAD symptoms and anger variables. We employed multiple mediation with bootstrapping on cross-sectional data from a student sample (N = 233) to test four models assessing potential mediators of the association of GAD symptoms to inward anger expression, outward anger expression, trait anger and hostility, respectively. The belief that uncertainty has negative personal and behavioural implications uniquely mediated the association of GAD symptoms to inward anger expression (confidence interval [CI] = .0034, .1845, P_M = .5444), and the belief that uncertainty is unfair and spoils everything uniquely mediated the association of GAD symptoms to outward anger expression (CI = .0052, .1936, P_M = .4861) and hostility (CI = .0269, .2427, P_M = .3487). Neither negative beliefs about worry nor perfectionism dimensions uniquely mediated the relation of GAD symptoms to anger constructs. We conclude that intolerance of uncertainty may help to explain the positive connection between GAD symptoms and anger, and these findings give impetus to future longitudinal investigations of the role of anger in GAD.     

Fear and perceived uncontrollability of emotion: Evaluating the unique contribution of emotion appraisal variables to prediction of worry and generalised anxiety disorder

Novel theoretical frameworks place the symptom profile of generalised anxiety disorder (GAD) within the context of dysfunctional emotional processes. It is suggested that fear and intolerance of emotions exacerbate subjective distress and motivate the use of maladaptive coping strategies, such as worry. To date, studies evaluating these models have suffered two key limitations. Firstly, few studies have involved treatment-seeking samples, and secondly, none have evaluated the unique variance attributable to emotion appraisal variables above and beyond previously established predictors of worry and GAD. The present study begins to address these limitations by assessing the contribution of fear and perceived uncontrollability of emotions in predicting worry and clinical GAD status after controlling for variance attributable to depressive symptoms, meta-cognitive beliefs, intolerance of uncertainty, and perceptions of external threat. Supporting current models, results showed that perceived control over emotional reactions was a unique predictor of GAD diagnostic status and both clinical and non-clinical worry.     

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.     

Cognitive content-specificity in future expectancies: role of hopelessness and intolerance of uncertainty in depression and GAD symptoms

The present study examined cognitive content-specificity in future-event predictions associated with symptoms of depression and generalized anxiety disorder (GAD). College undergraduates (N=284) completed measures of depression, GAD, and rated their certainty that a given set of positive and negative outcomes were or were not likely to happen in their future. Participants also completed measures of hopelessness and intolerance of uncertainty (IU). Individuals (N=263) completed the same measures again 6 weeks later. Certainty in an absence of positive future outcomes was associated with symptoms of depression but not GAD, and hopelessness mediated this relationship - concurrently and when examining change scores over 6 weeks. Certainty in negative outcomes was concurrently associated with both symptoms of depression and GAD, and hopelessness partially mediated these relationships. IU predicted concurrent increases in depression and GAD symptoms, and negative-outcome certainty partially mediated the IU-depression but not the IU-GAD symptom relationship. Change in certainty did not mediate the relationship between changes in IU and GAD symptoms but partially mediated the relationship between change in IU and depression symptoms over time. Hopelessness appears to play a unique role in the relationship between reduced anticipation of positive future outcomes and depression. Although less clearly suggested by the data, IU may contribute to both depression and GAD symptoms but may do so through different pathways.     

Maladaptive Core Beliefs and their Relation to Generalized Anxiety Disorder

Research has demonstrated that individuals with generalized anxiety disorder (GAD) hold unhelpful beliefs about worry, uncertainty, and the problem-solving process. Extant writings (e.g., treatment manuals) also suggest that other types of maladaptive beliefs may characterize those with GAD. However, these other beliefs have received limited empirical attention and are not an explicit component of cognitive theories of GAD. The present study examined the extent to which dysfunctional attitudes, early maladaptive schemas, and broad self-focused and other-focused beliefs explain significant variance in GAD symptoms, over and above negative and positive beliefs about worry, negative beliefs about uncertainty, and negative beliefs about problems. N = 138 participants classified into Probable GAD and Non-GAD groups completed self-report measures. After controlling for trait anxiety and depressive symptoms, only beliefs about worry, negative beliefs about uncertainty, and schemas reflecting unrelenting standards (e.g., “I must meet all my responsibilities all the time”), the need to self-sacrifice (e.g., “I'm the one who takes care of others”), and less positive views of other people and their intentions (e.g., lower endorsement of views such as “other people are fair”), were unique correlates of Probable GAD versus Non-GAD or GAD severity. Theoretical and clinical implications are discussed.     

Individuals Intolerant of Uncertainty: The Maintenance of Worry and Distress Despite Reduced Uncertainty

The intolerance of uncertainty model of worry posits that individuals worry as a means to cope with the discomfort they feel when outcomes are uncertain, but few experimental studies have investigated the causal relationships between intolerance of uncertainty, situational uncertainty, and state worry. Furthermore, existing studies have failed to control for the likelihood of future negative events occurring, introducing an important rival hypothesis to explain past findings. In the present study, we examined how individuals with high and low trait intolerance of uncertainty differ in their behavioral, cognitive, and emotional reactions to situational uncertainty about an upcoming negative event (watching emotionally upsetting film clips), holding constant the likelihood of that negative event taking place. We found that although individuals high in trait prospective intolerance of uncertainty reported a higher degree of belief that being provided with detailed information about the upcoming stressor would make them feel more at ease, they did not experience an actual decrease in distress or state worry upon being provided with more information, during anticipation of the film clips, or during the film clips themselves. Our results suggest that heightened distress regarding negative events may be more central than intolerance of uncertainty to the maintenance of worry.     

Look before you leap: the role of negative urgency in appraisals of ambiguous and unambiguous scenarios in individuals high in generalized anxiety disorder symptoms

Negative interpretation bias, the propensity to make threatening interpretations of ambiguous information, is associated with symptoms of generalized anxiety disorder (GAD). Apart from its relationship with intolerance of uncertainty (IU), little is known about what explains the presence of this cognitive bias in GAD. One factor may be negative urgency (NU), the tendency to take rash action when distressed, which is related to GAD symptoms and to cognitive biases in nonclinical populations. The aim of the present study was to examine the relationship between NU and interpretation bias in individuals high in GAD symptoms (N = 111). IU, trait anxiety, and other forms of impulsivity were examined concurrently as competing correlates of interpretation bias. Greater NU and IU were found to be unique correlates of greater threatening interpretations of ambiguous scenarios. Greater NU was also a unique correlate of greater threatening interpretations of negative and positive scenarios. No other forms of impulsivity were uniquely related to interpretation bias. The findings suggest that greater NU may have a role in the tendency for individuals high in GAD symptoms to make threatening interpretations in response to ambiguous scenarios, overtly threatening situations, and situations without indication of threat or danger. Theoretical implications of these findings are discussed.     

The Relationship Between Frustration Intolerance,Unhealthy Emotions,and Assertive Behaviour in Italian Students

The aim of the present research was to investigate the relationship between frustration intolerance and emotional-behavioural problems. Specifically, the study explored whether frustration intolerance beliefs were associated with difficulties in assertive behaviour, anxiety, depression, and anger in a non-clinical student sample (N = 250). For this purpose an Italian version of the Frustration Discomfort Scale (FDS) was developed. The findings supported a multidimensional model of frustration intolerance and the relationship between specific frustration intolerance beliefs and emotional-behavioural problems. Regarding unhealthy emotions, structural equation modeling (SEM) analyses (model A) indicated that discomfort intolerance and emotional intolerance had a significant relationship with state anxiety, trait anxiety, and depression. The discomfort intolerance and entitlement sub-scales had a significant relationship with state anger and trait anger, while entitlement directly predicted trait anger. Regarding assertiveness, SEM analyses (model B) indicated that emotional intolerance had a significant relationship with distress when being assertive. More generally, the FDS full scale score (model C) was significantly related to unhealthy emotions and (model D) unassertive behaviour (distress). The present study provided evidence of the cross-cultural applicability of the FDS.     

A Multifaceted Assessment of Emotional Tolerance and Intensity in Hoarding

Hoarding is characterized by emotionally reinforced saving behaviors, which often combine with excessive acquisition to give rise to clutter, distress, and impairment. Despite the central role emotional processes are thought to play in hoarding, very little research has directly examined this topic. There is suggestive evidence linking hoarding with several facets of emotional intolerance and avoidance, though one key limitation of this past research has been the exclusive reliance on self-report questionnaires. The aim of the current study was to conduct a multimethod investigation of the relationship between hoarding and perceptions of, and cognitions about, negative emotional states. A large unselected sample of nonclinical young adults (N = 213) completed questionnaires, behavioral tasks, and a series of negative mood inductions to assess distress tolerance (DT), appraisals of negative emotions, and emotional intensity and tolerance. Hoarding symptoms were associated with lowered tolerance of negative emotions, as well as perceiving negative emotions as more threatening. Individuals high in hoarding symptoms also experienced more intense emotions during the mood inductions than individuals low in hoarding symptoms, though there was no association with poorer performance on a behavioral index of DT. Across measures, hoarding was consistently associated with experiencing negative emotions more intensely and reporting lower tolerance of them. This relationship was particularly pronounced for the difficulty discarding and acquiring facets of hoarding. Our results offer initial support for the important role of emotional processes in the cognitive-behavioral model of hoarding. A better understanding of emotional dysfunction may play a crucial role in developing more effective treatments for hoarding.     

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.     

Health stresses and depressive symptomatology in the elderly: the importance of health engagement control strategies.

The study presents cross-sectional (N = 127) and longitudinal (n = 111) analyses examining relations between health engagement control strategies (HECSs), depressive symptoms, and health stresses in elderly individuals. HECS was measured as people's behavioral and cognitive investments toward attaining health goals. HECS was related to low levels of depressive symptoms, particularly among people experiencing acute physical symptoms. Moreover, HECS predicted reduction of depressive symptoms over time, and depressive symptomatology predicted negative change in HECS. The findings show that active investments of HECSs significantly moderate the negative affective consequences of health threats. Individuals who are characterized by low levels of HECS and high levels of depressive symptoms may be at increased risk of accelerated decline in their physical and mental health.     

The Relation Between Emotional Dysregulation and Anxiety and Depressive Symptoms, Pain-Related Anxiety, and HIV-Symptom Distress Among Adults with HIV/AIDS

The current study investigated the relations between emotional dysregulation and anxiety and depressive symptoms, pain-related anxiety, and HIV-symptom distress among individuals living with HIV/AIDS. This research is important in its explanatory value regarding the unique effects of emotional dysregulation as it relates to psychological and disease-specific distress given high rates of distress specific to HIV infection (e.g. medicatin side-effects, stigma). Participants included 164 adults (17.1 % female, Mage = 48.40, SD?=?9.57) with HIV/AIDS. Results indicated that emotional dysregulation was significantly and positively related to anxiety and depressive symptoms, pain-related anxiety, and HIV-symptom distress. All emotional dyregulation effects were evidenced above and beyond the variance accounted for by demographic and HIV-specific characteristics, and the main effects of anxiety sensitivity and distress intolerance. Findings are discussed in terms of the importance of emotional dysregulation in negative affective experiences within the HIV/AIDS population.     

The Roles of Social Support and Self-Efficacy in Physical Health’s Impact on Depressive and Anxiety Symptoms in Older Adults

Physical illness may precipitate psychological distress among older adults. This study examines whether social support and self-efficacy moderate the associations between physical health and depression and anxiety. Predictions were tested in 222 individuals age 60 or older presenting for help with worry. Physical health was assessed through self-report (subjective) and physical diagnoses (objective). Objective physical health did not have a significant association with depression or anxiety. Worse subjective physical health was associated with increased somatic anxiety, but not with depression or worry. The relationship between subjective physical health and depressive symptoms was moderated by self-efficacy and social support. As predicted, when self-efficacy was low, physical health had its strongest negative association with depressive symptoms such that as physical health improved, depressive symptoms also improved. However, the moderation effect was not as expected for social support; at high levels of social support, worse physical health was associated with increased depressive affect.     

Examining the specific dimensions of distress tolerance that prospectively predict perceived stress

We examined five dimensions of distress tolerance (i.e. uncertainty, ambiguity, frustration, negative emotion, physical discomfort) as prospective predictors of perceived stress. Undergraduate students (N = 135) completed self-report questionnaires over the course of two assessment sessions (T1 and T2). Results of a linear regression in which the five dimensions of distress tolerance and covariates (i.e. T1 perceived stress, duration between T1 and T2) served as predictor variables and T2 perceived stress served as the outcome variable showed that intolerance of uncertainty was the only dimension of distress tolerance to predict T2 perceived stress. To better understand this prospective association, we conducted a post hoc analysis simultaneously regressing two subdimensions of intolerance of uncertainty on T2 perceived stress. The subdimension representing beliefs that “uncertainty has negative behavioral and self-referent implications” significantly predicted T2 perceived stress, while the subdimension indicating that “uncertainty is unfair and spoils everything” did not. Results support a growing body of research suggesting intolerance of uncertainty as a risk factor for a wide variety of maladaptive psychological outcomes. Clinical implications will be discussed.     

Specific Pathways from Parental Distress Reactions to Adolescent Depressive Symptoms: The Mediating Role of Youths’ Reactions to Negative Life Events

The current multimethod longitudinal study examines how parents’ distress reactions to adolescents’ negative emotions may shape youths’ own perceptions of negative life events and subsequent increases in depressive symptomology. Ninety adolescents (41 girls, 49 boys, average age?=?16.5 years old) and their parents were assessed over three timepoints. We found that greater parent-reported distress reactions to adolescents’ emotions predicted subsequent increase in youths’ own self-reported negative reactions to stressful experiences over a two-week period, which in turn predicted steeper increases in youth-reported depressive symptoms across this same two-week period. Moreover, youths’ negative reactions mediated the relation between parent emotion socialization and increases in adolescent depressive symptoms. These findings support the use of interventions that simultaneously target parent and child distress to prevent the onset of adolescent depression.

     

Intraindividual relations between the intensity and disclosure of daily emotional events: The moderating role of depressive symptoms

Individuals with high levels of depressive symptoms tend to engage in lower levels of emotional disclosure than individuals who are lower in depressive symptoms. However, little is known about how depressive symptoms relate to the intraindividual relation between daily disclosure and the intensity of the daily events. The authors addressed these relations using a daily diary methodology. College students (N = 239) completed a measure of depression symptoms. They then completed measures of the intensity of the day's most unpleasant event and their disclosure of that event each day for 7 days. Results indicated that depression moderated the intensity-disclosure relation such that depression symptoms were associated with diminished emotional disclosure for high-intensity events but not for low-intensity events. Individuals with relatively higher levels of depressive symptoms also experienced unpleasant daily events at a higher intensity level than did individuals with relatively fewer symptoms. Sex differences emerged such that men were less likely than women to disclose high-intensity negative events. These findings extend the use of the diary methodology to the study of emotional disclosure and also suggest possible interventions for counseling psychology practitioners.