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 (η(2)?=?.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 (η(2)?=?.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.     

Therapeutic alliance in guided internet-delivered cognitive behavioural treatment of depression, generalized anxiety disorder and social anxiety disorder

Guided internet-delivered cognitive behaviour therapy (ICBT) has been found to be effective in several controlled trials, but the mechanisms of change are largely unknown. Therapeutic alliance is a factor that has been studied in many psychotherapy trials, but the role of therapeutic alliance in ICBT is less well known. The present study investigated early alliance ratings in three separate samples. Participants from one sample of depressed individuals (N = 49), one sample of individuals with generalized anxiety disorder (N = 35), and one sample with social anxiety disorder (N = 90) completed the Working Alliance Inventory (WAI) modified for ICBT early in the treatment (weeks 3-4) when they took part in guided ICBT for their conditions. Results showed that alliance ratings were high in all three samples and that the WAI including the subscales of Task, Goal and Bond had high internal consistencies. Overall, correlations between the WAI and residualized change scores on the primary outcome measures were small and not statistically significant. We conclude that even if alliance ratings are in line with face-to-face studies, therapeutic alliance as measured by the WAI is probably less important in ICBT than in regular face-to-face psychotherapy.     

Applied relaxation vs. cognitive therapy in the treatment of generalized anxiety disorder

The present study investigated the efficacy of a coping-technique, applied relaxation (AR) and cognitive therapy (CT), in the treatment of generalized anxiety disorder. Thirty-six outpatients fulfilling the DSM-III-R criteria for generalized anxiety were assessed with independent assessor ratings and self-report scales before and after treatment and at a 1 yr follow-up. The patients were randomized and treated individually for 12 weekly sessions. The results showed that both treatments yielded large improvements, which were maintained, or furthered at follow-up. There was no difference between AR and CT on any measure. The drop-out rate was 12% for AR and 5% for CT. The proportions of clinically significantly improved patients were 53 and 62% at post-treatment and 67 and 56% at follow-up for AR and CT, respectively. Besides affecting generalized anxiety the treatments also yielded marked and lasting changes on ratings of worry, cognitive and somatic anxiety and depression. The conclusion that can be drawn is that both AR and CT have potential as treatments for generalized anxiety disorder but they have to be developed further in order to increase the efficacy to the level usually seen in panic disorder, 80-85% clinically improved.     

The hyperventilation syndrome in panic disorder, agoraphobia and generalized anxiety disorder

The symptom complex of panic disorder and generalized anxiety disorder suggests an etiological role for hyperventilation. The present study investigates the overlap between DSM-III-R panic disorder, panic disorder with agoraphobia and generalized anxiety disorder with hyperventilation syndrome (HVS). The anxiety disorder diagnoses were based on a structured interview, and HVS syndrome (HVS). The anxiety disorder diagnoses were based on a structured interview, and HVS determined by the so-called hyperventilation provocation test (a brief period of voluntary hyperventilation with recognition of symptoms). The overlap rates with HVS were: 48% for panic disorder, 83% for panic disorder with agoraphobia and 82% for generalized anxiety disorder. However, a pilot study on transcutaneous monitoring of carbon dioxide tension leads us to question the validity of the voluntary hyperventilation method that we used to determine HVS-status. It is unclear whether hyperventilation plays an important role in panic and general anxiety, as our overlap findings suggest. For patients who recognize the symptoms induced by voluntary hyperventilation, the hyperventilation provocation procedure provides a therapeutic means of exposure to feared bodily sensations.     

Cognitive therapy versus applied relaxation as treatment of generalized anxiety disorder

Cognitive therapy (CT) and applied relaxation (AR) as treatments of generalized anxiety disorder (GAD) were compared in a sample of 45 patients of a community mental health center, randomly allocated to condition. Patients were assessed before and after a 12-session treatment, and at one and six months follow-ups. There was a 20% drop out from CT and 15% from AR (NS), with some drop outs being considerably improved. Both completers and intention-to-treat analyses revealed that both treatments were effective (ESs of composite and specific measures ranging from 0.53 to 1.14). At one-month follow-up AR tended to do better than CT, with CT catching up with AR at six months. Recovery rates and proportions of patients showing reliable change were comparable to other studies on AR and CT, with 55% of CT and 53.3% of AR patients recovered on the STAI-trait at six-month follow-up. These results confirm that both CT and AR are effective treatments for GAD, and also that there is still room for improvement.     

Interpersonal subtypes within generalized anxiety disorder

In this study, we addressed the heterogeneity in interpersonal problems across patients with generalized anxiety disorder (GAD). We assessed interpersonal problems by the Inventory of Interpersonal Problems (IIP-C; Horowitz, Alden, Wiggins, & Pincus, 2000) in a sample of 78 GAD patients. We used IIP-C profiles describing interpersonal characteristics of the total GAD sample as well as clustered GAD interpersonal subtypes. Although the overall sample was located in the friendly submissive quadrant of the circumplex model, this was true only for the Exploitable cluster, which includes more than 50% of the patients. Importantly, clusters of GAD patients with other locations reporting predominantly Cold, Nonassertive, or Intrusive interpersonal problems were also identified. The 4 clusters did not differ in terms of gender, comorbid disorders, or the severity of depression or anxiety. Thus, the assessment of interpersonal problems provides additional diagnostic information covering the heterogeneity of GAD patients. This information could be used for differential indication and individual case formulation in GAD.     

Differentiating anxiety and depression in older adults with generalized anxiety disorder

To examine affect and cognition in differentiating anxiety and depression, 83 older participants with generalized anxiety disorder completed the Cognitive Checklist (CCL) and the Positive and Negative Affect Schedule (PANAS). A 3-factor solution was found for the PANAS: positive affect (PA), anxiety and anger (Negative Affect 1 [NA-1]), and guilt and shame (Negative Affect 2 [NA-2]). A 2-factor structure was noted for the CCL. Correlations with anxiety and depression measures suggested that the CCL Depression (CCL-D) subscale showed stronger correlations with depression, whereas the CCL Anxiety subscale did not uniquely correlate with anxiety. The NA-1 subscale correlated positively with measures of depression and anxiety, whereas the PA subscale showed negative correlations. Hierarchical regression suggested that the CCL-D subscale was a significant predictor of self-reported depression.     

Interpersonal pathoplasticity in individuals with generalized anxiety disorder

Recent theories of generalized anxiety disorder (GAD) have emphasized interpersonal and personality functioning as important aspects of the disorder. We examined heterogeneity in interpersonal problems in 2 studies of individuals with GAD (n = 47 and n = 83). Interpersonal subtypes were assessed with the Inventory of Interpersonal Problems-Circumplex (Alden, Wiggins, & Pincus, 1990). Across both studies, individuals with GAD exhibited heterogeneous interpersonal problems, and cluster analyses of these patients' interpersonal characteristics yielded 4 replicable clusters, identified as intrusive, exploitable, cold, and nonassertive subtypes. Consistent with our pathoplasticity hypotheses, clusters did not differ with GAD severity, anxiety severity, or depression severity. Clusters in Study 2 differed on rates of personality disorders, including avoidant personality disorder, further providing support for the validity of interpersonal subtypes. The presence of interpersonal subtypes in GAD may have important implications for treatment planning and efficacy.     

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.     

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.     

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.