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.     

Worry and Rumination in Generalized Anxiety Disorder and Obsessive Compulsive Disorder

Ample work has already been conducted on worry and rumination as negative thought processes involved in the etiology of most of the anxiety and mood related disorders. However, minimal effort has been exerted to investigate whether one type of negative thought process can make way for another type of negative thought process, and if so, how it subsequently results in experiencing a host of symptoms reflective of one or the other type of psychological distress. Therefore, the present study was taken up to investigate whether rumination mediates the relationship between worry and generalized anxiety disorder (GAD), and between worry and obsessive compulsive disorder (OCD) in two clinical groups. Self-report questionnaires tapping worry, rumination, generalized anxiety disorder (GAD), and obsessive compulsive disorder (OCD) were administered to a clinical sample of 60 patients aged 30–40. Worry, rumination, generalized anxiety disorder (GAD), and obsessive compulsive disorder (OCD) correlated substantially with each other, however, rumination did not mediate the relationship between worry and generalized anxiety disorder (GAD) and between worry and obsessive compulsive disorder (OCD). We also analyzed differences of outcome variables within two clinical groups. These results showed that worry and rumination were significantly different between GAD and OCD groups.     

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.     

The Role of Anger in Generalized Anxiety Disorder

Little is known about the role of anger in the context of anxiety disorders, particularly with generalized anxiety disorder (GAD). The aim of study was to examine the relationship between specific dimensions of anger and GAD. Participants (N = 381) completed a series of questionnaires, including the Generalized Anxiety Disorder Questionnaire (GAD-Q-IV; Newman et al., 2002, Behavior Therapy, 33, 215–233), the State-Trait Anger Expression Inventory (STAXI-2; Spielberger 1999, State-Trait Anger Expression Inventory-2: STAXI-2 professional manual, Odessa, FL: Psychological Assessment Resources) and the Aggression Questionnaire (AQ; Buss & Perry 1992, Journal of Personality and Social Psychology, 63, 452–459). The GAD-Q-IV identifies individuals who meet diagnostic criteria for GAD (i.e. GAD analogues) and those who do not (non-GAD). The STAXI-2 includes subscales for trait anger, externalized anger expression, internalized anger expression, externalized anger control and internalized anger control. The AQ includes subscales for physical aggression, verbal aggression, anger and hostility. The GAD-Q-IV significantly correlated with all STAXI-2 and AQ subscales (r's ranging from .10 to .46). Multivariate analyses of variance revealed that GAD analogues significantly differed from non-GAD participants on the combined STAXI-2 subscales (η² = .098); high levels of trait anger and internalized anger expression contributed the most to GAD group membership. GAD analogue participants also significantly differed from non-GAD participants on the combined AQ subscales (η² = .156); high levels of anger (affective component of aggression) and hostility contributed the most to GAD group membership. Within the GAD analogue group, the STAXI-2 and AQ subscales significantly predicted GAD symptom severity (R ² = .124 and .198, respectively). Elevated levels of multiple dimensions of anger characterize individuals who meet diagnostic criteria for GAD.     

Behavioral Experiments for Intolerance of Uncertainty: Challenging the Unknown in the Treatment of Generalized Anxiety Disorder

Intolerance of uncertainty (IU) is implicated in the development and maintenance of generalized anxiety disorder (GAD). Although an efficacious cognitive-behavioral treatment (CBT) targeting IU and associated factors has been established, approximately 20–30% of participants do not achieve full remission by posttreatment. IU remains elevated in these individuals. In addition, GAD treatments need greater parsimony and efficiency. To that end, we developed a novel, focused CBT protocol exclusively targeting IU via behavioral experiments. Treatment consists of three modules applied over 12 sessions: (a) psychoeducation and uncertainty awareness training, (b) behavioral experiments targeting IU, and (c) relapse prevention. The present article describes each treatment component, as well as additional considerations for therapists. We conducted a preliminary investigation of efficacy with seven (N = 7) participants with a primary diagnosis of GAD. Results indicated substantial decreases in GAD symptoms, general psychopathology, and IU by posttreatment that were generally maintained at 6-month follow-up. Six of seven participants demonstrated moderate to high end-state functioning at posttreatment and 6-month follow-up. Research and clinical implications are discussed.     

广泛性焦虑障碍的元认知理论

广泛性焦虑障碍（GAD）是一种以担忧为核心心理特征的,并伴有机体紧张等躯体症状的焦虑障碍。Wells的元认知模型通过探讨GAD患者的病态性担忧的形成、运作和循环,提出了GAD患者存在两种担忧的假设——Ⅰ型担忧和Ⅱ型担忧（元担忧）,并认为元担忧是导致患者的弥漫的、持续的以及难以控制的担忧的核心因素。由该模型发展起来的元认知疗法在治疗GAD过程中体现出有效的作用。     

Generalized Anxiety Disorder in Hispanics: Symptom Characteristics and Prediction of Severity

Literature suggests that an increasing number of Hispanic people suffer with GAD, and possible associated problems include high costs for treatment and elevated risk of severe impairment. The current study examined components of anxiety, as measured by currently available assessment instruments in both English and Spanish languages, among bilingual Hispanic individuals with GAD. Participants completed all instruments in both languages. Relations between these self-report measures and clinician-rated GAD severity were also studied. In factor analyses, the Spanish measures yielded two factors, the first of which included all instruments assessing physiological components of anxiety and one content specific measure of worry. The second factor included one worry scale and one trait anxiety scale. The English measures yielded a single factor solution. Regression analyses revealed that for the English measures, the BAI and PSWQ were statistically significant predictors of GAD severity. For the Spanish measures, the BAI was the only statistically significant predictor.     

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.     

Psychometric Properties of the Generalized Anxiety Disorder Questionnaire for DSM-IV Among Four Racial Groups

The Generalized Anxiety Disorder Questionnaire-IV (GAD-Q-IV) is a self-report diagnostic measure of generalized anxiety disorder. Previous studies have established the psychometric properties of the GAD-Q-IV, revealing excellent diagnostic specificity and sensitivity as well as good test–retest reliability and convergent and discriminant validity (Newman et al., 2002). Recent analyses with other measures of anxiety symptoms have revealed differences across racial or national groups. Given that the GAD-Q-IV was tested primarily on Caucasians (78%), the purpose of this study was to demonstrate the psychometric properties of the GAD-Q-IV across four racial groups: African American, Caucasian, Hispanic/Latino, and Asian. A student sample of 585 undergraduate psychology students completed the GAD-Q-IV as well as other measures of anxiety symptoms. A clinical replication sample included 188 participants who completed the GAD-Q-IV as part of a larger psychotherapy study. Results indicated excellent and very similar factor structures in the student sample and similar psychometric properties in both samples across the racial groups. Implications for the use of the GAD-Q-IV across racial groups are discussed.     

A Contemporary View of Applied Relaxation for Generalized Anxiety Disorder

Applied relaxation (AR), originally developed by Lars-Göran Öst, is a long-standing, efficacious treatment for generalized anxiety disorder (GAD). While newer treatments are continuing to be developed, AR remains one of the most efficacious treatments for GAD. However, AR has received less in-depth attention more recently, particularly in terms of potential mechanisms of action. This article is written to honor the development and history of AR and to highlight the ways that it has continued to be adapted. In this article, AR treatment strategies are presented, which include: noticing early signs of anxiety, learning relaxation skills, and applying relaxation at the first sign of anxiety. Then, additional adaptations to AR are presented along with recommendations of how AR may be enhanced by understanding potential mechanisms of change. Finally, recommendations are made for the continued evolution of AR as a powerful and efficacious treatment for GAD.     

An Examination of Distress Intolerance in Undergraduate Students High in Symptoms of Generalized Anxiety Disorder

People with generalized anxiety disorder (GAD) engage in maladaptive coping strategies to reduce or avoid distress. Evidence suggests that uncertainty and negative emotions are triggers for distress in people with GAD; however, there may also be other triggers. Recent conceptualizations have highlighted six types of experiences that people report having difficulty withstanding: uncertainty, negative emotions, ambiguity, frustration, physical discomfort, and the perceived consequences of anxious arousal. The present study examined the extent to which individuals high in symptoms of GAD are intolerant of these distress triggers, compared to individuals high in depressive symptoms, and individuals who are low in GAD and depressive symptoms. Undergraduate students (N = 217) completed self-report measures of GAD symptoms, depressive symptoms, and distress intolerance. Individuals high in GAD symptoms reported greater intolerance of all of the distress triggers compared to people low in symptoms of GAD and depression. Individuals high in GAD symptoms reported greater intolerance of physical discomfort compared to those high in depressive symptoms. Furthermore, intolerance of physical discomfort was the best unique correlate of GAD status, suggesting that it may be specific to GAD (versus depression). These findings support continued investigation of the transdiagnosticity and specificity of distress intolerance.     

A Pilot Study of Emotion Regulation Therapy for Generalized Anxiety and Depression: Findings From a Diverse Sample of Young Adults

Emotion regulation therapy (ERT) for generalized anxiety disorder (GAD) and accompanying major depressive disorder (MDD) is a theoretically derived, evidence-based treatment that integrates principles from traditional and contemporary cognitive-behavioral and experiential approaches with basic and translational findings from affect science to offer a blueprint for improving intervention by focusing on the motivational responses and corresponding self-referential regulatory characteristics. Preliminary evidence supports the efficacy of a 20-session version of ERT. However, previous trials of ERT and other traditional and contemporary cognitive-behavioral therapies have often utilized relatively homogeneous samples. Various contextual and demographic factors may be associated with challenges that increase risk for negative mental and social outcomes for young adults ages 18–29, particularly for individuals from diverse backgrounds. The aim of this pilot study was to examine the effectiveness of a briefer 16-session version of ERT in a racially and ethnically diverse sample of young adults. Participants (N = 31) were enrolled at an urban-based, commuter college who consented to treatment for anxiety, worry, or depression at an on-campus counseling center. Open-trial results demonstrate strong ameliorative changes in worry, rumination, self-reported and clinician-rated GAD and MDD severity, social disability, quality of life, attentional flexibility, decentering/distancing, reappraisal, trait mindfulness, and negative emotionality from pre- to posttreatment. These gains were maintained throughout a 3- and 9-month follow-up. These findings provide preliminary evidence for the efficacy of ERT in treating a racially and ethnically heterogeneous population. Further, this study highlights comparable effectiveness of a briefer 16-session version of ERT.     

Working Memory and Motor Activity: A Comparison Across Attention-Deficit/Hyperactivity Disorder,Generalized Anxiety Disorder,and Healthy Control Groups

Converging findings from recent research suggest a functional relationship between attention-deficit/hyperactivity disorder (ADHD)-related hyperactivity and demands on working memory (WM) in both children and adults. Excessive motor activity such as restlessness and fidgeting are not pathognomonic symptoms of ADHD, however, and are often associated with other diagnoses such as generalized anxiety disorder (GAD). Further, previous research indicates that anticipatory processing associated with anxiety can directly interfere with storage and rehearsal processes of WM. The topographical similarity of excessive motor activity seen in both ADHD and anxiety disorders, as well as similar WM deficits, may indicate a common relationship between WM deficits and increased motor activity. The relationship between objectively measured motor activity (actigraphy) and PH and visuospatial WM demands in adults with ADHD (n = 21), adults with GAD (n = 21), and healthy control adults (n = 20) was examined. Although all groups exhibited significant increases in activity from control to WM conditions, the ADHD group exhibited a disproportionate increase in activity, while activity exhibited by the GAD and healthy control groups was not different. Findings indicate that ADHD-related hyperactivity is uniquely related to WM demands, and appear to suggest that adults with GAD are no more active relative to healthy control adults during a cognitively demanding laboratory task.     

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.     

Effectiveness of the Hamilton Anxiety Rating Scale with Older Generalized Anxiety Disorder Patients

To expand the collection of instruments available for assessment of anxiety in the elderly, this report examined the original and revised Hamilton anxiety scales in a sample of 50 older adults diagnosed with Generalized Anxiety Disorder (GAD) and 93 normal community participants (ages 55–82). Although the revised anxiety scale had better discriminant validity (lower correlation with the revised Hamilton depression scale) than the original anxiety and depression scales, a considerable amount of shared variance still existed (41% shared variance, GAD sample alone; 17% control sample alone; 74% shared variance, both samples combined). Near-perfect group classification was possible using 7 items from the original anxiety scale and 10 items from the revised anxiety scale. Results are discussed in light of their implications for use of the Hamilton anxiety rating scale with older anxiety-disordered patients.     

Clinical Experiences in Conducting Empirically Supported Treatments for Generalized Anxiety Disorder

Knowledge of the efficacy of cognitive-behavioral therapy (CBT) for generalized anxiety disorder (GAD) predominantly derives from randomized controlled trials (RCTs). However, there may be unique or complex issues encountered in practice, but not necessarily in the context of a controlled clinical trial. Therefore, launching a systematic dialogue between researcher and practicing clinician can be instrumental in augmenting evidence-based therapies through identification of variables that promote and interfere with clinical effectiveness. Through an initiative sponsored by the American Psychological Association’s Divisions 12 (Society for Clinical Psychology) and 29 (Psychotherapy), this study aimed to examine clinical experiences conducting CBT for GAD. The participants were 260 psychotherapists who completed an online survey on assessment and therapeutic intervention utilization and their experience of factors that limit successful GAD treatment and symptom reduction. The majority of respondents reported 20 years or less experience using ESTs for GAD, typically treating clients in outpatient clinics, treatment centers, and private practice. Some of the most commonly used interventions address clients’ maladaptive cognitions and elevated anxiety and muscle tension typical of GAD. Approximately one half of respondents reported incorporating integrative techniques into treatment. Factors perceived as limiting effective GAD treatment included severity and chronicity of GAD, presence of comorbid conditions, stressful home and work environments, client motivation and resistance to treatment, and issues encountered when executing therapy techniques. This study provides researchers with clinically derived directions for future empirical investigation into enhancing efficacy of GAD treatment.     

Interpersonal Problems,Mindfulness, and Therapy Outcome in an Acceptance-Based Behavior Therapy for Generalized Anxiety Disorder

Objective: To better understand the role interpersonal problems play in response to two treatments for generalized anxiety disorder (GAD); an acceptance-based behavior therapy (ABBT) and applied relaxation (AR), and to examine how the development of mindfulness may be related to change in interpersonal problems over treatment and at follow-up. Method: Eighty-one individuals diagnosed with GAD (65.4% female, 80.2% identified as white, average age 32.92) were randomized to receive 16 sessions of either ABBT or AR. GAD severity, interpersonal problems, and mindfulness were measured at pre-treatment, post-treatment, 6-month follow-up, and 12-month follow-up. Results: Mixed effect regression models did not reveal any significant effects of pre-treatment interpersonal problems on GAD severity over treatment. After controlling for post-treatment GAD severity, remaining post-treatment interpersonal problems predicted 6- but not 12-month GAD severity. Participants in both conditions experienced a large decrease in interpersonal problems over treatment. Increases in mindfulness over treatment and through follow-up were associated with decreases in interpersonal problems, even when accounting for reductions in overall GAD severity. Conclusions: Interpersonal problems may be an important target of treatment in GAD, even if pre-treatment interpersonal problems are not predictive of outcome. Developing mindfulness in individuals with GAD may help ameliorate interpersonal difficulties among this population.     

Therapist Awareness of Client Resistance in Cognitive-Behavioral Therapy for Generalized Anxiety Disorder

Clients' resistance relates negatively to their retention and outcomes in psychotherapy; thus, it has been increasingly identified as a key process marker in both research and practice. This study compared therapists' postsession ratings of resistance with those of trained observers in the context of 40 therapist–client dyads receiving 15 sessions of cognitive-behavioral therapy for generalized anxiety disorder. Therapist and observer ratings were then examined as correlates of proximal (therapeutic alliance quality and homework compliance) and distal (posttreatment worry severity) outcomes. Although there was reasonable concordance between rater perspectives, observer ratings were highly and consistently related to both proximal and distal outcomes, while therapist ratings were not. These findings underscore the need to enhance therapists' proficiency in identifying important and often covert in-session clinical phenomena such as the cues reflecting resistance and noncollaboration.     

Treatment of Comorbid Pica and Generalized Anxiety Disorder: A Case Study

This case report describes the assessment and treatment of a treatment-naïve 36-year-old Hispanic/Latina female with comorbid pica and generalized anxiety disorder (GAD), and iron-deficiency anemia. At the onset of treatment, the client consumed chalkboard chalk and vermiculite from potting soil approximately three times per week and presented with moderate-severity GAD. Assessment and treatment occurred over 24 weekly outpatient individual sessions. Treatment was delivered in concert with medical intervention to address anemia. A cognitive-behavioral case formulation was developed from multiple assessment sources. A process-based cognitive-behavioral therapy (CBT) intervention approach was used to target GAD and pica simultaneously, which included psychoeducation, self-monitoring, arousal reduction skills, cognitive training (reappraisal, distancing), and behavior modification/stimulus control techniques. Barriers to treatment and their solutions are discussed. At the end of treatment, the client demonstrated increased insight and understanding of her worry symptoms and pica behavior, acquired cognitive skills and arousal reduction strategies for managing GAD, and reported less than one episode of pica per week. The identified assessment and treatment approach is worthy of future investigation to inform empirically based treatment development efforts, especially for pica.     

Combined Medication and CBT for Generalized Anxiety Disorder With African American Participants: Reliability and Validity of Assessments and Preliminary Outcomes

Using data from a study of combined cognitive behavioral therapy (CBT) and venlafaxine XR in the treatment of generalized anxiety disorder (GAD), the current article examines the reliability and convergent validity of scales, and preliminary outcomes, for African American compared with European American patients. Internal consistency and short-term stability coefficients for African Americans (n = 42) were adequate and similar or higher compared with those found for European Americans (n = 164) for standard scales used in GAD treatment research. Correlations among outcome measures among African Americans were in general not significantly different for African Americans compared with European Americans. A subset of patients with DSM-IV–diagnosed GAD (n = 24 African Americans; n = 52 European Americans) were randomly selected to be offered the option of adding 12 sessions of CBT to venlafaxine XR treatment. Of those offered CBT, 33.3% (n = 8) of the African Americans and 32.6% (n = 17) of the European Americans accepted and attended at least one CBT treatment session. The outcomes for African Americans receiving combined treatment were not significantly different from European Americans receiving combined treatment on primary or secondary efficacy measures.