Distress intolerance and worry: the mediating role of cognitive variables

Background and Objectives: Distress intolerance (DI) has been identified as a potential risk factor for a variety of maladaptive avoidance behaviors, including worry. However, mechanisms linking DI to specific behaviors remain poorly understood. One hypothesis is that DI is a general vulnerability that confers risk of particular avoidance behaviors via more specific, lower-order vulnerabilities. The current study examined associations between DI and worry-related cognitions. Design: A multiple mediator model tested the hypothesis that worry-related variables (intolerance of uncertainty [IU], cognitive avoidance, beliefs about worry, and negative problem orientation) mediated the association between DI and worry. Methods: An undergraduate student (n = 281) and a clinical (n = 123) sample completed self-report measures. Results: Across samples, worry was associated with higher levels of DI, IU, cognitive avoidance, beliefs about worry, and negative problem orientation. Mediation results differed somewhat between the two samples. In the undergraduate sample, IU, negative beliefs about worry, and positive beliefs about worry mediated the association between DI and worry. In the clinical sample, negative problem orientation and negative beliefs about worry mediated the association between DI and worry. Conclusions: Results provide initial evidence that DI may be associated with worry via unique risk factors.     

The Metacognitive Model of Generalized Anxiety Disorder in Children and Adolescents

Worry is a common phenomenon in children and adolescents, with some experiencing excessive worries that cause significant distress and interference. The metacognitive model of generalized anxiety disorder (Wells 1995, 2009) was developed to explain cognitive processes associated with pathological worry in adults, particularly the role of positive and negative beliefs about worry. This review evaluates the application of the model in understanding child and adolescent worry. Other key issues reviewed include the link between cognitive and metacognitive development and worry, and the measurement of worry and metacognitive worry in young people. Implications of these findings and directions for future research are discussed.     

Applicability of a cognitive model of worry to children and adolescents

BackgroundIntolerance of uncertainly (IU), cognitive avoidance (CA) and positive beliefs about worry (PB) independently predict worry frequency in older adolescents and adults, and when targeted together in treatment produce significant reductions in both worry and anxiety in this age range. The present study addresses a gap in the literature by testing whether a cognitive model of excessive worry and anxiety incorporating these process variables is applicable to children and adolescents.MethodPrimary and secondary school students (n = 515; aged 7–19 years) completed modified self-report measures of worry frequency, anxiety, IU, CA and PB and a path analysis undertaken to test whether IU was a higher order variable for CA and PB and whether the relationship between IU/CA/PB and anxiety was mediated by worry frequency.ResultsSignificant (bivariate) correlations were observed between the measures of IU, PB, CA, worry and anxiety across the age range. However separate path models had to be fitted for children (aged 7–12 years) and adolescents (aged 13–19) with PB being dropped from the child model. CA was related to anxiety only through worry in children while IU showed direct paths to worry and anxiety in both children and adolescents.ConclusionsCognitive models of persistent worry in adults and older adolescents may, with some modification, have applicability to children. Further testing and refinement of these cognitive models of worry may lead to improvements in existing treatments for anxious youth.     

Rumination, worry, cognitive avoidance, and behavioral avoidance: examination of temporal effects

Recently, cross-sectional research has demonstrated that depressive rumination is significantly associated with the tendency to engage in cognitive and behavioral avoidance. This evidence suggests that rumination may be the result of attempts to avoid personally threatening thoughts, in a manner suggested by multiple contemporary theories of worry. This investigation examined the temporal relationship among daily levels of cognitive avoidance, behavioral avoidance, rumination, worry, and negative affect. Seventy-eight adolescents completed baseline questionnaires and then electronically completed daily measures of rumination, worry, behavioral avoidance, and cognitive avoidance, as well as sad and anxious affect for 7 days. Lagged-effect multilevel models indicated that increases in daily sadness were predicted by greater daily rumination and cognitive avoidance. Increases in daily anxiety were predicted by greater daily rumination, worry, and both cognitive and behavioral avoidance. Further, both daily rumination and worry were positively predicted by daily cognitive, but not behavioral, avoidance. Mediation analyses suggested that rumination mediated the effect of cognitive avoidance on both sadness and anxiety. Also, worry mediated the effect of cognitive avoidance on anxiety. Implications for models of avoidance, rumination, and worry are discussed.     

Intolerance of Uncertainty–Focused Treatment for Adolescents With Excessive Worry: A Pilot Feasibility Study

Bouts of excessive worry are common across the lifespan, increasing in frequency and complexity during adolescence and adulthood, and are found in several psychiatric disorders, particularly the anxiety disorders. There are evidence-based treatments for adolescents with anxiety disorders but psychological treatments designed specifically to target excessive worrying in adolescents are rare. Intolerance of uncertainty (IU), a cognitive predisposition described as a fear of the unknown, is highly associated with worry among adolescents. This study investigated the feasibility, acceptability, and preliminary efficacy of IU-focused cognitive behavioral therapy (IU-CBT) for adolescents with excessive worry. Twelve participants (aged 13–17 years) with excessive worry, irrespective of psychiatric diagnosis, were provided weekly face-to-face sessions, primarily including therapist and self-guided exposure to situations involving uncertainty. Sessions were supplemented with an internet-delivered educational program for parents, designed to teach parents about worry, IU and helpful parental behaviors. The main outcome measure was the Penn-State Worry Questionnaire for Children (PSWQ-C). The treatment was well tolerated with no dropouts and families reporting being satisfied with the treatment. Participants were able to grasp the notion of IU and its relationship to worry and avoidance. Significant reductions were observed for self-reported worry, anxiety, depression, IU, and parent-reported worry, as were significant increases in global functioning. Based on a clinician rating, 58.3% were categorized as much or very much improved at posttreatment, rising to 66% at 3-month follow-up. Participants with generalized anxiety disorder (GAD) benefitted more from treatment than those with social anxiety disorder. The findings suggest that this IU-focused psychological intervention is acceptable and feasible to adolescents with excessive worry but may be most effective for those with GAD.     

Understanding adolescent worry: the application of a cognitive model

The relationship between worry and 4 cognitive variables, intolerance of uncertainty, positive beliefs about worry, negative problem orientation, and cognitive avoidance, was examined in an adolescent sample of 528 boys and girls aged 14–18. The participants completed questionnaires assessing worry, somatic anxiety symptoms, and the variables mentioned above. The results show that (a) intolerance of uncertainty, positive beliefs about worry, and negative problem orientation each account for a significant amount of variance in adolescent worry scores in the multiple regression, and (b) the discriminant function derived from the 4 variables is effective in classifying moderate and high worriers into their respective groups (72.8% correct classification). Furthermore, analyses demonstrate that intolerance of uncertainty has the strongest association with worry scores and is the most important variable in discriminating between moderate and high adolescent worriers. These results suggest that intolerance of uncertainty plays a key role in our understanding of adolescent worry.     

Examining incremental explanatory power in accounting for worry severity: negative metacognitive beliefs uniquely predict worry severity following a worry episode

Background and Objectives: Contemporary conceptual models posit that different core variables contribute to worry, including intolerance of uncertainty (IU), metacognitive beliefs, and experiential avoidance. To date, a concurrent investigation of the incremental explanatory power of these variables in accounting for worry severity remains unexamined. The present study sought to address that gap in the literature.

Design/Methods: Participants endorsing frequent worry (N?=?127) completed self-report measures assessing IU, metacognitive beliefs, and experiential avoidance during an online session. Participants later attended an in-person lab-based session where they completed a worry episode and in-vivo worry severity was assessed following the worry episode.

Results: IU, negative metacognitive beliefs, and experiential avoidance each shared a bivariate association with post-episode worry severity. However, in multivariate analyses, only baseline worry severity and negative metacognitive beliefs surrounding the dangerousness and uncontrollability of worry predicted post-episode worry severity.

Conclusions: The present results further underscore links between negative metacognitive beliefs and worry.     

Responsibility to continue thinking and worrying: evidence of incremental validity

This two-part study examined the role of the responsibility to continue thinking, beliefs that one needs prolonged thinking about stressful problems, in the prediction of excessive worry. This construct is considered to reflect high levels of motivation to continue inflexible thinking and the use of rigid stop rules. In Study 1, 122 students completed questionnaires. A regression analysis revealed that responsibility accounted for a unique variance beyond negative meta-cognitive beliefs about worry. One hundred and fifty students participated in Study 2, where worry was regressed on emotional instability (Neuroticism), responsibility, and other worry-related cognitive variables (intolerance of uncertainty, positive/negative meta-cognitive beliefs, poor problem-solving orientation, and cognitive avoidance). Again, responsibility was a significant predictor, after controlling for emotional instability (Neuroticism) and other worry-related cognitions. These results indicate the incremental validity of the responsibility to continue thinking.     

Positive beliefs about worry: A psychometric evaluation of the Why Worry-II

Positive beliefs about worry are theorized to maintain excessive and uncontrollable worry, the hallmark of generalized anxiety disorder (GAD; American Psychiatric Association, 2013). The Why Worry-II (WW-II) is a 25-item revised questionnaire designed to measure five positive beliefs about worry. These five beliefs are that worry: (1) facilitates problem solving; (2) enhances motivation; (3) protects against negative emotions; (4) prevents negative outcomes; and (5) reflects a positive personality trait. The main goal of this study was to assess the WW-II’s psychometric properties, including its factor structure. Undergraduate participants (N = 309) completed the WW-II, and measures of worry, depression, anxiety, and positive and negative beliefs about worry. Overall, the results suggest that the five-factor model is a good fit to the data. The WW-II demonstrated excellent internal consistency, good test–retest reliability at six weeks, and evidence of convergent and divergent validity. The WW-II also uniquely predicted worry severity. Overall, our findings suggest that the WW-II has a five-factor structure congruent with theoretical predictions, sound psychometric properties, and a unique relationship to excessive worry. The theoretical and clinical implications of these findings are discussed.     

Examining the role of emotional avoidance in the relationship between posttraumatic stress disorder symptom severity and worry

A growing body of literature suggests that worry is a cognitive activity functioning to avoid unpleasant internal experiences such as negative thoughts, emotions, and somatic responses. Given the highly aversive internal events associated with posttraumatic stress disorder (PTSD), individuals experiencing PTSD symptoms following exposure to a traumatic event may be particularly motivated to engage in avoidant regulation strategies such as worry. Surprisingly, however, few studies to date have examined the relationship between PTSD and worry as well as potential factors that might explain this association. Therefore, the goal of this study was to examine the association between PTSD symptom severity and worry and the extent to which emotional avoidance explains this relationship. To this end, 207 college students with a history of traumatic exposure (meeting Criterion A for a PTSD diagnosis) completed a series of questionnaires assessing history of exposure to potentially traumatic events, PTSD symptom severity, emotional avoidance tendencies, and worry. Results demonstrated that PTSD symptom severity was positively associated with worry and emotional avoidance. Further, emotional avoidance was found to fully account for this relationship, providing support for the proposed emotionally avoidant function of worry. The implications of these findings for future research and the treatment of worry among individuals with a history of traumatic exposure are discussed.     

Characteristics of illness intrusions in a non-clinical sample

This study examines whether illness intrusions can be distinguished from obsessional intrusions and worries. It also assesses the relationship between strategies, thought characteristics, and appraisal of illness intrusions. Two hundred and forty-three non-clinical participants identified an obsessive intrusive thought, a worry, and an illness intrusion. They evaluated each thought using items from the Cognitive Intrusions Questionnaire. The comparisons of intrusions showed that illness intrusions share characteristics of worries and obsessional intrusions, but also have their own characteristics. Illness intrusions seem to be particularly egosyntonic. The relationships between the strategies used to counter illness intrusions and their appraisal were also tested. Results support the idea that there are specific links between the evaluation of cognitive intrusions and the way they are processed. It demonstrated that escape/avoidance strategies are associated with the egodystonic nature of the thought and that problem-focused strategies are associated with the thought's basis in reality. Illness intrusions may be conceptualised as either obsessions or worries. This study demonstrated that the category of an intrusive thought might not be as important as the way it is processed. It seems more important to consider appraisal of the disturbing thought and the way in which the person subsequently reacts and behaves.     

Risk perceptions,worry, and attitudes about genetic testing for breast cancer susceptibility

This study assessed the unique associations of risk perceptions and worry with attitudes about genetic testing for breast cancer susceptibility. Women (general practitioner clinic attenders, university students, and first-degree relatives of breast cancer survivors; N?=?303) read information about genetic testing and completed measures assessing perceived cancer risk, cancer worry, and genetic testing attitudes and beliefs. Worry was associated with greater interest in genetic testing, stronger beliefs that testing has detrimental emotional consequences, and positive beliefs about benefits of testing and risk-reducing surgeries. Perceived risk was unrelated to interest and associated with more skeptical beliefs about emotional consequences and benefits of testing and risk-reducing surgeries. At low worry levels, testing interest increased with more positive beliefs about testing benefits; at high worry levels, interest was high regardless of benefits beliefs. The findings support Leventhal's Common-Sense Model of self-regulation delineating interactive influences of risk-related cognitions and emotions on information processing and behavior.     

Risk perceptions, worry, and attitudes about genetic testing for breast cancer susceptibility

This study assessed the unique associations of risk perceptions and worry with attitudes about genetic testing for breast cancer susceptibility. Women (general practitioner clinic attenders, university students, and first-degree relatives of breast cancer survivors; N?=?303) read information about genetic testing and completed measures assessing perceived cancer risk, cancer worry, and genetic testing attitudes and beliefs. Worry was associated with greater interest in genetic testing, stronger beliefs that testing has detrimental emotional consequences, and positive beliefs about benefits of testing and risk-reducing surgeries. Perceived risk was unrelated to interest and associated with more skeptical beliefs about emotional consequences and benefits of testing and risk-reducing surgeries. At low worry levels, testing interest increased with more positive beliefs about testing benefits; at high worry levels, interest was high regardless of benefits beliefs. The findings support Leventhal's Common-Sense Model of self-regulation delineating interactive influences of risk-related cognitions and emotions on information processing and behavior.     

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.     

Age and gender differences in adolescent worry

The purpose of the present study was to explore gender and age differences in adolescent worry. High school students filled out measures of worry, negative problem orientation, intolerance of uncertainty, and general mental health. Girls and boys of different ages were then compared and the relationships between gender, beliefs about worry, intolerance of uncertainty, negative problem orientation and mental health were also examined. Boys reported greater negative problem orientation and intolerance of uncertainty while girls reported more positive beliefs about worry. Findings also revealed certain age trends, indicating that the variables under study may be under the influence of developmental tasks. Regression analysis was performed and positive beliefs about worry emerged as a significant predictor of worry in both sexes. Positive beliefs about worry and negative problem orientation appear to be the key processes in adolescent anxiety and depression.     

Differences and similarities between obsessive intrusive thoughts and worry in a non-clinical population: study 2

Differences between obsessions and worry have been clearly demonstrated on several variables [Langlois, F., Freeston, M. H., & Ladouccur, R. (2000). Differences and similarities between obsessive intrusive thoughts and worry in a non-clinical population: study 1. Behaviour Research and Therapy, 38, 157-173.]. Previous factor analysis of obsessions or worries have typically been used in developing measures for OCD and GAD symptoms. These studies generally support the distinctiveness of obsessions and worries but there have been no direct comparisons of the factor structure of obsession and worry on the same measure. This study aimed to compare the general structure of worry and obsessional intrusions. It also attempted to identify the relations between the respective factors identified in the appraisals of intrusions and the factor structures of coping strategies used in reaction to the thoughts. 254 students participated in the study. They first identified an obsession-like intrusion and a worry and then evaluated them with the Cognitive Intrusion Questionnaire. Different factor structures were obtained for worry and obsessive intrusive thoughts. However, the factor structure for the strategies used to counter the thoughts were highly similar for both types of thought. Furthermore, regression analysis identified interesting relationships between the strategies, the thought characteristics and appraisal. Thus, despite the ability to find differences between obsessive intrusive thoughts and worry, and even to accurately categorize them based on these differences, there may in fact exist common processes that are shared over much of a continuum. Sharp differences in the processes involved may only become clear in prototypical cases. The implications for models of cognitive intrusion are discussed.     

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.     

Everyday worry in adolescents with and without chronic pain: a diary study

Young people report frequent worry, but we know little about the extent, character, or consequence of worry in adolescence, or individual differences associated with worry. Adolescents with chronic pain are one population that are known to have high levels of anxiety, which is associated with higher levels of disability and depression, impairing function. In this study we report a diary study: adolescents (N = 60; aged 16–18) recorded their worry over seven days. Our first aim was to describe the characteristics of adolescent worry and its consequences in a community sample. Our second aim was to compare the experience of girls to boys, and to compare the experience of those with and without chronic pain. Adolescents reported characteristics of each worry they had throughout the week, including content, frequency, strength, interference, emotion, and the strength of emotion associated with worry content. Adolescents reported the consequence for each content and the strength of the consequence. Worry content and consequences were categorised into four categories; health, relationship, personal competence, and other. Adolescents reported 675 unique episodes of worry over the seven-day period that were predominantly about personal competence. The strength of worry content was (M = 6.61, SD = 1.27) and the strength associated with the worry consequence was (M = 5.59, SD = 1.41). Worries were not reported as highly interfering (M = 4.14, SD = 1.61). Contrary to predictions, there were no differences in worry characteristics between adolescents with and without chronic pain. To conclude, worry is a frequent occurrence in older adolescents and the characteristics of worry are discussed. Adolescents worry mostly about personal competence. Adolescents with and without chronic pain reported similar worry characteristics.     

Psychometric properties of an insomnia-specific measure of worry: the Anxiety and Preoccupation about Sleep Questionnaire

The aim of this study was to examine the psychometric properties of the Anxiety and Preoccupation about Sleep Questionnaire (APSQ), with a focus on factorial validity and internal consistency as well as discriminative, convergent, and association with sleep parameters and daytime impairment. Among a randomly selected sample from the general population (N = 5,000), 2,333 participants completed a survey on nighttime symptoms, daytime symptoms, health outcomes, and psychological processes. The study sample consisted of 1800 participants who did not fulfill criteria for another sleep disorder than insomnia. A two-factor solution, accounting for 70.7% of the variance, was extracted from the 10 APSQ items. One six-item factor determined worries about the consequences of poor sleep (α = .91); the second factor, with four items, assessed worries about the uncontrollability of sleep (α = .86). The two factors were significantly intercorrelated (ρ = .65) and significantly associated with the total APSQ (ρs = .97 and .76, respectively). The APSQ and the two subscales showed discriminant validity between three sleep status groups (normal sleep, poor sleep, and insomnia disorder; R(2) = .33-.41). The APSQ and the subscales demonstrated convergent validity with measures on cognitive arousal, sleep-related beliefs, anxiety, and depression. They also were significantly correlated with sleep parameters and daytime impairment. The findings suggest that the APSQ is a psychometrically sound instrument for assessing worry in insomnia.