The effect of worry on cardiovascular response to phobic imagery

Specific emotion regulation difficulties and executive function explain the link between worry and subsequent stress: A prospective moderated mediation study

BACKGROUND

Worry is a transdiagnostic risk factor for stress-related mental health complaints such as anxiety, depression, and insomnia. Although worry may function as a form of avoidance of unwanted emotions and accordingly interfere with adaptive emotion regulation, the specific domains of emotion regulation that are perturbed by excessive worry to confer risk for stress-related symptoms are unclear. Further, it is unknown if cognitive control mechanisms that underlie successful emotion regulation influence the effect of worry on stress. The present study addressed these gaps in the literature by examining specific emotion regulation difficulties as mediators of the relationship between worry and subsequent stress, as well as executive function as a moderator of the mediated effects.

METHOD

656 community adults were assessed for trait worry, emotion dysregulation, stress, and executive dysfunction once per month for three months (time 1 - time 3).

RESULTS

The effect of worry (time 1) on subsequent stress (time 3) was partially mediated by difficulties with emotional clarity and difficulty engaging in goal-directed behavior when upset (time 2) after controlling for age, gender, and baseline stress. Moderated mediation models revealed that the indirect effect of worry on stress via difficulty with goal-directed behavior was significantly moderated by executive dysfunction, such that fewer executive function difficulties acted as a buffer against the harmful effects of worry.

LIMITATIONS

Limitations include reliance on self-report measures, lack of experimental manipulation, and a nonclinical sample.

CONCLUSIONS

Findings point to specific domains of emotion regulation as treatment targets for individuals with high worry proneness.

Introduction to a special issue on the contrast avoidance model

The current paper introduces the special issue on the Contrast Avoidance Model. The Contrast Avoidance Mmodel theorizes that chronic worriers are afraid of a sharp increase in negative emotion and/or sharp reduction in positive emotion (labeled negative emotional contrasts; NECs). They thus use perseverative thought as means to create and sustain negative emotion to prevent NECs if they were to experience negative events. Further, these individuals are uncomfortable with sustained positive emotion because it leaves them vulnerable to NECs. At the same time, worry increases the probability of positive emotional contrasts (PECs), or sharp increases in positive emotion or decreases in negative emotion when things turn out better than expected or positive events are experienced. Therefore, these individuals generate negative emotion via perseverative thought as a way to avoid NECs and increase the likelihood of PECs. The current special issue provides novel research on the model.

The Contrast Avoidance Model: Conclusion and synthesis of new research in the special issue

In this special series, new research on the Contrast Avoidance Model (CAM) was presented, including studies on the role of CAM in the maintenance of chronic worry, the incremental validity of CAM, CAM as a mediator of the association between generalized anxiety disorder (GAD) and other variables, CAM as transdiagnostic, and interpersonal behaviors as a means to avoid negative emotional contrasts (NECs). Furthermore, the role of perseverative thought in relation to positive emotional contrasts (PECs) was explored. Studies indicated that higher worry was positively and negatively reinforced, a factor that is likely to contribute to the maintenance of GAD. Further, research demonstrated that CAM contributed unique variance to understanding GAD above and beyond other variables associated with GAD, such as intolerance of uncertainty and negative problem orientation. Additional research revealed the transdiagnostic nature of contrast avoidance, as well as the association between contrast avoidance and problem-solving deficits. In addition, both worry and rumination increased the likelihood of PECs. Further, data suggested that anxious individuals may use interpersonal strategies to avoid NECs. Finally, savoring positive emotions was found to reduce contrast avoidance, providing a novel intervention strategy to address contrast avoidance in individuals with GAD.

Contrast avoidance prospectively mediates effects of fear of emotional responding, negative problem orientation, and sensitivity to low perceived control on generalized anxiety disorder symptoms

The Contrast Avoidance Model (CAM; Newman & Llera, 2011) has been well established in the literature on the etiology and maintenance of generalized anxiety disorder (GAD). Research has investigated other factors that may also characterize GAD, such as fear of emotional responding, negative problem orientation (NPO), and negative beliefs about control; however, these have yet to be explored within the context of the CAM regarding maintenance of GAD symptoms. The purpose of this study was to explore the predictive relationship between the above-mentioned factors and GAD symptoms, mediated by contrast avoidance. Participants (N = 99, 49.5% of whom scored in the upper range on GAD symptoms) completed a series of questionnaires across three time points, each one week apart. Results indicated that fear of emotional responding, NPO, and sensitivity to low perceived control predicted CA tendencies a week later. CA tendencies then mediated the relationship between each predictor and GAD symptoms in the following week. Findings suggested that known vulnerabilities for GAD predict coping with distressing internal responses via sustained negative emotionality (such as through chronic worry) as a way to avoid negative emotional contrasts. However, this coping mechanism itself may maintain GAD symptoms over time.

Generalized Worry in Patients With Chronic Fatigue Syndrome Following Cognitive Behavioral Therapy: A Prospective Cohort Study in Secondary Care

Research has shown that generalized anxiety disorder is commonly associated with Chronic Fatigue Syndrome (CFS). This prospective cohort study aimed to investigate the prevalence of generalized worry in CFS patients and its relationship with fatigue, anxiety and social functioning, before and after Cognitive Behavioral Therapy (CBT). Our cohort consisted of 470 patients diagnosed with CFS who received CBT at a secondary care, specialist clinic. Patients completed self-report measures investigating levels of generalized worry, fatigue, work and social adjustment, anxiety and depression at baseline (pretreatment), discharge from treatment, 3-month and 6-month follow up (posttreatment). Analysis indicated a high prevalence of generalized worry (72.4%) at assessment. A significant reduction in worry following CBT (M = -3.42, p < .001, 95% CIs: 2.26, 4.57) was observed at discharge, which remained stable at follow-up. Severe baseline worriers had greater overall fatigue score (M = 3.74, p = .026, 95% CIs: .33, 7.15) and worse overall work and social adjustment than mild worriers across time-points (M = 5.42, p = .035 95% CIs: .27, 10.58). Avoidance behavior mediated the association between generalized worry and work and social adjustment (95% bootstrap CIs: 013, .080). The majority of patients with CFS had comorbid generalized worry and severe worriers reported greater fatigue, anxiety, and worse work and social adjustment. This suggests that CFS patients may benefit from targeting generalized worry during CBT.

A Current Learning Theory Approach to the Etiology and Course of Anxiety and Related Disorders

The authors describe how contemporary learning theory and research provide the basis for models of the etiology and maintenance of anxiety and related disorders. They argue that contemporary learning theory accounts for much of the complexity associated with individual differences in the development and course of these disorders. These insights from modern research on learning overcome the limitations of earlier behavioral approaches, which were overly simplistic and have been justifiably criticized. The authors show how considerations of early learning histories and temperamental vulnerabilities affect the short- and long-term likelihood that experiences with stressful events will lead to the development of anxiety disorders. They also discuss how contextual variables during and after stressful learning experiences influence the maintenance of anxiety disorder symptoms. Thus, contemporary learning models provide a rich and nuanced understanding of the etiology and course of anxiety and related disorders. Expected final online publication date for the Annual Review of Clinical Psychology, Volume 18 is May 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Psychometric Properties and Prospective Predictive Utility of the Contrast Avoidance Questionnaires

Abstract. Recent theoretical research posits that a key factor in the development and maintenance of pathological worry is the avoidance of sudden emotional shifts. Recently two self-report instruments were developed to index this phenomenon (Contrast Avoidance Questionnaire – Worry [CAQ-W] and Contrast Avoidance Questionnaire – General Emotion [CAQ-GE]). This work employed a multi-study design to provide an independent evaluation of the latent structure of these measures; additionally, the validity and longitudinal predictive ability of the measures was examined. Findings of the factor analytic work support a two-factor solution for each of the questionnaires. These were defined as the following subscales: CAQ-W: Emotional Contrast; Negative Affect, and for the CAQ-GE: Avoidance; Discomfort. Test-retest reliability of the measure was strong and the identified subscales demonstrated differential predictive ability regarding future worry and depression. Results indicate that subscales related to the experience of negative affect rather than avoidance, display predictive utility of future symptoms. These findings are somewhat discrepant with extant literature on ecological momentary assessment (EMA) assessment of contrast avoidance indicating the need for refinement in the self-report measurement of this construct.

Rumination and worry as putative mediators explaining the association between emotional disorders and alcohol use disorder in a longitudinal study

INTRODUCTION

The high rate of comorbidity between alcohol use and emotional disorders is well demonstrated, but the mechanisms underlying their relationship remain largely unidentified. One possibility is maladaptive responding to negative affect, such as worry and rumination. The present study sought to examine worry and rumination as putative mediators explaining the link between emotional disorders and alcohol use disorders. Methods Mediational analyses were conducted using a sample (n = 232) derived from a larger late adolescence/early adulthood longitudinal dataset (Youth Emotion Project; Zinbarg et al., 2010). Results A significant indirect effect was observed for emotional disorder severity on alcohol use disorder severity via rumination, but not via worry or the shared variance between worry and rumination. Conclusions These findings suggest that rumination may specifically confer risk for the development of alcohol use disorder for individuals with emotional disorders. Further, ruminative thinking may serve as a specific treatment target to reduce vulnerability to alcohol use disorder.

Dynamic relations among COVID-19-related media exposure and worries during the COVID-19 pandemic

OBJECTIVES

This study investigated how COVID-19-related media exposure during the COVID-19 crisis was related to same-day and next-day COVID-19-related worries.

DESIGN

A 21-day diary study was conducted between late March and late April 2020 in Germany.

MAIN OUTCOME MEASURES

Hypotheses were tested in a sample of 561 participants (M_age = 42.79, SD_age = 6.12). Every evening, participants indicated their exposure to COVID-19-related media (e.g., TV, print, online) and their COVID-19-related worries.

RESULTS

Same-day analyses showed that participants reported more COVID-19-related worries on days with higher exposure to COVID-19-related media. Dynamical structural equation models provided evidence for a reciprocal cycle across days: Higher media exposure at one day predicted higher worries the next day, and higher worries at one day also predicted higher media exposure the next day. Individuals with high trait anxiety reported an enhanced general level of media exposure during the 21 days of assessment, and individuals high in neuroticism and anxiety reported an enhanced level of worries.

CONCLUSION

These findings suggest a self-reinforcing cycle whereby consuming crisis-related media and worrying reciprocally influence each other across days, possibly amplifying adverse effects of the COVID-19 crisis and other crises alike on mental and physical health.

Cognitive Control in Pediatric Obsessive-Compulsive and Anxiety Disorders: Brain-Behavioral Targets for Early Intervention

The DSM provides distinct criteria for obsessive-compulsive disorder (OCD) and various types of anxiety disorders, but phenomenological overlap, high rates of comorbidity, and early onset suggest common underlying mechanisms. This notion is further supported by use of the same treatments-cognitive behavioral therapy and serotonin reuptake inhibitor medication-for managing both OCD and non-OCD anxiety disorders in clinical settings. While early intervention with these gold standard treatments is recommended for pediatric OCD and anxiety disorders, young patients often remain symptomatic even after treatment. To guide the development of novel, mechanistically targeted treatments to better resolve OCD and anxiety symptoms, the identification of neural circuits underlying psychological constructs with relevance across disorders has been recommended. One construct that may be relevant for understanding pediatric OCD and anxiety disorders is cognitive control, given the difficulty that young patients experience in dismissing obsessions, compulsions, and worry despite recognition that these symptoms are excessive and unreasonable. In this review, we examine findings from a growing body of literature implicating brain-behavioral markers of cognitive control in pediatric OCD and anxiety disorders, including before and after treatment. We conclude by suggesting that interventions designed to enhance the functioning of the task control circuits underlying cognitive control may facilitate brain maturation to help affected youth overcome symptoms.

Effortful control moderates relationships between worry and symptoms of depression and anxious arousal

OBJECTIVES

Findings are inconsistent regarding the relationship between worry and anxious arousal (AA). Effortful control (EC) capacity may explain these inconsistent findings, such that only high worriers with higher EC are able to suppress autonomic arousal through worrying. The current study investigated these main and interactive effects of worry and EC on AA as well as depression.

METHODS

Participants (N = 1210, 779 females) were recruited from Amazon's Mechanical Turk website and completed self-report measures assessing worry, EC, AA, depression, and negative affect intensity.

RESULTS

Regression models revealed that EC moderated the relationship between worry and AA, with individuals lower in EC demonstrating a stronger positive relationship between worry and AA. EC also moderated the relationship between worry and depression, with individuals lower in EC demonstrating a stronger positive relationship between worry and depression. Results remained the same when controlling for age, gender, and negative affect intensity.

CONCLUSIONS

Results support the idea that low EC may help to explain a range of comorbid psychiatric symptoms.

PRACTITIONER POINTS

Individuals low in effortful control demonstrate a stronger association between worry and anxious arousal, as well as between worry and depression Those low in effortful control may be especially vulnerable to comorbid worry and depression High worriers who are high in effortful control may be motivated to continue worrying due to their ability to reduce anxious arousal during worry.

The effects of verbal and imaginal worry on panic symptoms during an interoceptive exposure task

Previous research has documented the inhibitory effects of worry on cardiovascular reactivity to subsequently presented fear-relevant stimuli. Although theoretical assertions point to the verbal-linguistic (as opposed to imagery-based) nature of worry as the cause of these inhibitory effects, extant research investigating the effects of worrisome thinking on subsequent anxiety-eliciting tasks has not isolated the verbal-linguistic nature of worry as the active ingredient in its suppressive effects on arousal. Furthermore, prior research has not examined the potential effects of worry on maintenance of panic symptoms. In this study, participants high in anxiety sensitivity were asked to engage in verbal worry, imaginal worry, or relaxation prior to each of three repeated presentations of an interoceptive exposure task. Relaxation was associated with lower initial subjective fear that remained low across repeated exposures, and related stable sympathetic arousal (and decreased heart rate) over time. Imagery-based worry was associated with moderate initial subjective fear that was sustained across repeated exposures, and sympathetic arousal (and heart rate) that was likewise stable over time. However, verbal worry was associated with high initial subjective fear that was sustained over time, but sympathetic arousal (and heart rate) that decreased across repeated exposures. Thus, verbal worry was uniquely associated with a lack of synchronous response systems and maintenance of anxious meaning over time. Theoretical and clinical implications are discussed.

Affect variability and emotional reactivity in generalized anxiety disorder

BACKGROUND AND OBJECTIVES

Research indicates that greater variability in affect and emotion over time is associated with depression and anxiety. However, it remains unclear whether individuals with generalized anxiety disorder (GAD) experience greater affect variability due to individual differences or differences in the stimuli they encounter. The current study investigated whether individuals with analogue GAD demonstrate greater affect variability in response to a standardized set of stimuli.

METHODS

Participants were 134 (95 female) undergraduate participants with analogue GAD (endorsing DSM-IV criteria A, B, C, and E on the GAD-Q-IV; n = 66) or with no symptoms of GAD (n = 68). Participants reported affective reactions (positive affect, negative affect, affective arousal, and affective dominance) to each of nine sets of standardized images varying in valence (positive, neutral, or negative) and arousal (low, medium, or high).

RESULTS

In a logistic regression model controlling for baseline measurements, higher variability of affective arousal across the nine sets of images uniquely predicted analogue GAD status, whereas variability in positive affect, negative affect, and affective dominance did not. Additional analyses revealed that lower mean affective arousal also uniquely predicted analogue GAD.

LIMITATIONS

Limitations include using self-report measures to determine analogue GAD status; using a short laboratory session for the assessment of affect variability; and potential repeated testing effects.

CONCLUSIONS

These findings suggest that individuals with GAD symptoms experience higher levels of affective arousal variability, even when the stimuli presented are held constant. Assessing variability in affective arousal may be helpful in both conceptualizing and treating individuals with GAD symptoms.

Psychosocial Functioning, BMI, and Nutritional Behaviors in Women at Cardiovascular Risk

Psychosocial factors such as depression, anxiety, and stress are associated with increased cardiovascular risk. Health behaviors may play a role in this relationship, as individuals experiencing elevated levels of anxiety, stress, and/or depression may be less likely to engage in risk-reducing behaviors such as diet and exercise. Some evidence suggests that this relationship is particularly relevant for women. This study explored the relationship between levels of anxiety, depression, stress, and specific nutritional behaviors in a sample of 187 women at cardiovascular risk. BMI was explored as a possible moderator of these relationships. Higher levels of depression in patients with high BMI was associated with increased fruit consumption, whereas this was not seen in highly depressed patients with normal BMI. The reverse pattern was seen for consumption of sweet drinks. Anxiety was found to have a complex relationship with consumption of sweetened drinks and white bread, with higher consumption at moderately elevated levels of anxiety and reduced consumption at the highest levels. Possible interpretations of these findings, as well as their implications for lifestyle interventions with this population are discussed. These findings suggest a number of questions for further research.

Emotional responses to illness imagery in young adults: Effects of attention to somatic sensations and levels of illness anxiety

This study investigated the effect of interoceptive attention on emotional responses during illness imagery, and the moderating role of illness anxiety. 101 students (81 female; 18-35 years old) with low, moderate and high levels of illness anxiety had to imagine personally relevant illness scenarios and standardized fearful, joyful and neutral scenarios, after undergoing an attention manipulation to direct their attention towards interoceptive or exteroceptive stimuli. Emotional responses assessed included self-reports of arousal, valence and somatic sensations, and psychophysiological measures of heart rate reactivity and variability, skin conductance level, and facial electromyography. Findings showed increased reports of emotional arousal, negative affect and somatic symptoms, accompanied by negative emotion expressions, but a hypo-arousal physiological response pattern (i.e. low heart rate reactivity) during illness imagery after interoceptive attention, irrespective of illness anxiety levels. Under directed attention, the observed emotional response to illness imagery may increase the risk for developing and perpetuating illness anxiety.

Attention and anticipation in response to varying levels of uncertain threat: An ERP study

Individual differences in responding to uncertainty have been proposed as a key mechanism of how anxiety disorders develop and are maintained. However, most empirical work has compared responding to uncertain versus certain threat dichotomously. This is a significant limitation because uncertainty in daily life occurs along a continuum of probability, ranging from very low to high chances of negative outcomes. The current study investigated (1) how varying levels of uncertainty impact attention and anticipatory emotion, and (2) how these effects are moderated by individual differences in risk factors for anxiety disorders, particularly intolerance of uncertainty (IU) and worry. Participants (n = 65) completed a card task in which the probability of shock varied across trials. Two event-related potential components were examined: the P2, an index of attention, and the stimulus-preceding negativity (SPN), an index of anticipation. The P2 tracked the level of uncertainty and was smaller for more uncertain outcomes. Participants higher in IU exhibited greater differences in the P2 across levels of uncertainty. The SPN did not track specific levels of uncertainty but was largest for uncertain threat compared with certain threat and safety. Greater worry was associated with blunting of the SPN in anticipation of all outcomes. Thus, attention appears to be sensitive to variations in uncertainty, whereas anticipation seems sensitive to uncertainty globally. The two processes appear to be distinctly related to anxiety risk factors. These results highlight the value of examining multiple aspects of anticipatory responding to varying levels of uncertainty for understanding risk for anxiety disorders.

Is repetitive negative thinking a transdiagnostic process? A comparison of key processes of RNT in depression, generalized anxiety disorder, obsessive-compulsive disorder, and community controls

BACKGROUND AND OBJECTIVES

The transdiagnostic view of repetitive negative thinking (RNT) claims that different forms of RNT are characterized by identical processes that are applied to disorder-specific content. The purpose of the study was to test whether the processes of RNT differ across major depression disorder (MDD), generalized anxiety disorder (GAD), and obsessive-compulsive disorder (OCD).

METHODS

Forty-two individuals diagnosed with MDD, 35 individuals with GAD, 41 individuals with OCD, and 35 community controls were asked to think of a typical RNT episode and to rate its processes (core processes; use of mental capacity, unproductivity, abstractness, verbal quality, duration). Ratings were compared across groups using planned contrasts and analysis of variance.

RESULTS

All individuals with a clinical diagnosis rated the key processes of RNT and avoidance function of RNT as higher than healthy controls. There were no differences between individuals diagnosed with MDD, GAD or OCD on key processes and avoidance function of RNT.

LIMITATIONS

Results are based on retrospective self-reports, which might restrict validity of the measurements.

CONCLUSIONS

Data support the transdiagnostic hypothesis of RNT. Transdiagnostic prevention and intervention techniques seem highly recommendable given these findings.

The Effects of Worry in Daily Life: An Ecological Momentary Assessment Study Supporting the Tenets of the Contrast Avoidance Model

The contrast avoidance model (CAM) suggests that worry increases and sustains negative emotion to prevent a negative emotional contrast (sharp upward shift in negative emotion) and increase the probability of a positive contrast (shift toward positive emotion). In Study 1, we experimentally validated momentary assessment items (N = 25). In Study 2, participants with generalized anxiety disorder (N = 31) and controls (N = 37) were prompted once per hour regarding their worry, thought valence, and arousal 10 times a day for 8 days. Higher worry duration, negative thought valence, and uncontrollable train of thoughts predicted feeling more keyed up concurrently and sustained anxious activation 1 hr later. More worry, feeling keyed up, and uncontrollable train of thoughts predicted lower likelihood of a negative emotional contrast in thought valence and higher likelihood of a positive emotional contrast in thought valence 1 hr later. Findings support the prospective ecological validity of CAM. Our findings suggest that naturalistic worry reduces the likelihood of a sharp increase in negative affect and does so by increasing and sustaining anxious activation.

Heterogeneity of the Anxiety-Related Attention Bias: A Review and Working Model for Future Research

The anxiety-related attention bias (AB) has been studied for several decades as a clinically-relevant output of the dynamic and complex threat detection-response system. Despite research enthusiasm for the construct of AB, current theories and measurement approaches cannot adequately account for the growing body of mixed, contradictory, and null findings. Drawing on clinical, neuroscience, and animal models, we argue that the apparent complexity and contradictions in the empirical literature can be attributed to the field's failure to clearly conceptualize AB heterogeneity and the dearth of studies in AB that consider additional cognitive mechanisms in anxiety, particularly disruptions in threat-safety discrimination and cognitive control. We review existing research and propose a working model of AB heterogeneity positing that AB may be best conceptualized as multiple subtypes of dysregulated processing of and attention to threat anchored in individual differences in threat-safety discrimination and cognitive control. We review evidence for this working model and discuss how it can be used to advance knowledge of AB mechanisms and inform personalized prevention and intervention approaches.

Generalized Anxiety Disorder

Generalized anxiety disorder (GAD) is a common and disabling illness that is often underdiagnosed and undertreated. Patients with GAD are at increased risk for suicide as well as cardiovascular-related events and death. Most patients can be diagnosed and managed by primary care physicians. Symptoms include chronic, pervasive anxiety and worry accompanied by nonspecific physical and psychological symptoms (restlessness, fatigue, difficulty concentrating, irritability, muscle tension, or sleep disturbances). Effective treatments include psychotherapy (often cognitive behavioral therapy) and pharmacotherapy, such as selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors.

Paranoid Delusions as an Adaptive Response to Social Evaluative Stress?

Abstract. Learning mechanisms may serve as a framework for understanding the formation of paranoia. Specifically, if paranoid thoughts after social stressors produce a short-term benefit for coping (e.g., downregulating arousal), the encountered negative reinforcement could lead to their excessive application and subsequently to long-term maladaptive convictions. The Trier Social Stress Test was utilized in healthy participants to examine this putative benefit. Participants rated paranoia at baseline and after the stressor. Subjective stress levels, negative affect, heart rate, and heart rate variability were assessed in the following rest phase (N = 59). Semipartial correlations showed that participants who responded with larger increases in paranoia were characterized by a lower heart rate in the subsequent rest phase. No associations were found with heart rate variability or psychological measures. Thus, paranoid thinking in healthy individuals could be an adaptive means for reestablishing some aspects of physiological homeostasis after a social stressor but further research is needed.

The verbal nature of worry in generalized anxiety: Insights from the brain

Background

The Cognitive Avoidance Theory of Worry argues that worry is a cognitive strategy adopted to control the physiological arousal associated with anxiety. According to this theory, pathological worry, as in Generalized Anxiety Disorder (GAD), is verbal in nature, negative and abstract, rather than concrete. Neuroimaging studies link the expression of worry to characteristic modes of brain functional connectivity, especially in relation to the amygdala. However, the distinctive features of worry (verbal, abstract, negative), and their relationship to physiological arousal, have not so far been mapped to brain function.

Methods

We addressed this omission by undertaking a resting-state functional magnetic resonance neuroimaging study of 19 patients with GAD and 21 controls, before and after induction of perseverative cognitions, while measuring emotional bodily arousal from heart rate (HR). Seed-based analyses quantified brain changes in whole brain functional connectivity from the amygdala.

Results

In GAD, the induction increased negative thoughts and their verbal content. In line with predictions, the verbal expression of worry in GAD was associated with higher HR at baseline and attenuated HR increases after induction of perseverative cognitions. Within brain, the increased use of words during worry, and the associated dampening of HR after induction were mediated by the strength of functional connectivity between the amygdala and default mode network ‘hubs’ and the opercular cortex. The negative content of worry was further related to functional communication between amygdala and cingulo-opercular and temporal cortices.

Conclusions

Findings provide a neurobiological basis for the impact of verbal worry on HR in GAD.

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More negative worrisome thoughts have more words in GAD and more images in controls.

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Thinking in words is associated with reduced cardiac reactivity during worry.

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Verbal, abstract, and negative features of worry have unique neural correlates.

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Amygdala functional connectivity mediates use of words and HR decrease during worry.

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A neurobiological basis for the impact of verbal worry on HR in GAD is provided.

Psychophysiological and self-reported reactivity associated with social anxiety and public speaking fear symptoms: Effects of fear versus distress

This study examines psychophysiological and subjective reactivity to anxiety-provoking situations in relation to social anxiety and public speaking fear. We hypothesized that social anxiety symptoms would be associated with similar reactivity across types of imaginary anxiety scenes and not specifically to social anxiety-related scenes. This would be attributed to co-existing depression symptoms. Public speaking fear was expected to be associated with more circumscribed reactivity to survival-threat scenes, due to its association with fearfulness. Community participants imagined standardized anxiety situations, including social anxiety and animal fear scenes, while their physiological reactivity and self-reported emotions were assessed. Findings supported that social anxiety was associated with undifferentiated physiological reactivity across anxiety-provoking situations, except with regards to skin conductance level, which was higher during social anxiety imagery. Public speaking fear was associated with increased reactivity to animal phobia and panic scenes. Covariance analyses indicated that the lack of response specificity associated with social anxiety could be attributed to depression levels, while the specificity associated with public speaking fear could be explained by fearfulness. Findings highlight the need to assess not only primary anxiety symptoms but also depression and fearfulness, which likely predict discrepant reactions of individuals to anxiogenic situations.

Prospective Investigation of the Contrast Avoidance Model of Generalized Anxiety and Worry

The factors that maintain generalized anxiety disorder (GAD) symptoms and worry over time are not entirely clear. The Contrast Avoidance Model (CAM) postulates that individuals at risk for pathological worry and GAD symptoms uniquely fear emotional shifts from neutral or positive emotions into negative emotional states, and consequently use worry to maintain negative emotion in order to avoid shifts or blunt the effect of negative contrasts. This model has received support in laboratory experiments, but has not been investigated prospectively in the naturalistic context of daily life. The present study tested the CAM in a longitudinal experience sampling study with a subclinical sample. Participants selected to represent a broad range of symptoms (N = 92) completed baseline measures of GAD and depression symptoms, and eight weekly assessments of worry, experiences of negative emotional contrasts during their worst event of the week, and situation-specific negative emotion. Consistent with the CAM, GAD symptoms prospectively predicted higher endorsement of negative contrast experiences as worst events, independent of depression symptoms. Unsurprisingly, higher negative contrasts predicted higher negative emotion. However, both higher baseline GAD symptoms and weekly worry uniquely moderated (reduced) this relationship, providing consistent support for the idea that worry may blunt the emotional effects of contrasts. Depression symptoms did not have the same moderating effect. These findings support the CAM in an ecologically valid context.

Development and validation of two measures of emotional contrast avoidance: The contrast avoidance questionnaires

The Contrast Avoidance (CA) model (Newman & Llera, 2011) proposed that individuals with generalized anxiety disorder (GAD) fear sharp emotional shifts (or contrasts), such as the shift from a pleasant or neutral state to one of sudden distress following a negative event. Further, the model suggests that chronic worry is employed by those with GAD to sustain negative emotionality as a means to avoid sudden shifts into negativity. The model has received empirical support; however, no validated measure exists to assess CA tendencies. In this paper we developed and tested two measures of CA: one focusing on worry, and another examining broader mechanisms of CA that could be used test whether CA is applicable to other disorders. In Study 1, Part 1, we used 3 samples of participants (each N=410) to perform item reduction, exploratory factor analysis, and confirmatory factor analysis. In Study 1, Part 2, we performed tests of construct validity. In Study 2, we used a new sample (N=126) to determine test-retest reliability. All data point to the strong psychometric properties of the CA questionnaires and their relationship to GAD. Both measures distinguished between participants reporting clinical levels of GAD symptoms and nonanxious controls, demonstrating their utility as complementary measures of CA tendencies.

Validity of the Associated Symptom Criteria for Generalized Anxiety Disorder: Observations From the Singapore Mental Health Study

Previous findings on the diagnostic validity and reliability of generalized anxiety disorder (GAD)-associated symptom criteria suggest need for further evaluation. The current study examined convergent validity and specificity of GAD-associated symptoms in a representative Singapore community sample. The Singapore of Mental Health Study a cross-sectional epidemiological survey conducted among 6166 Singapore residents aged 18 and older. The Composite International Diagnostic Interview version 3.0 was used to diagnose mental disorders. Associated symptoms in the GAD criteria and autonomic hyperactivity symptoms showed convergent validity with a GAD diagnosis. However, associated symptoms of GAD were also linked to major depressive disorder (MDD), bipolar disorder, and obsessive-compulsive disorder, suggesting lack of adequate specificity. The inability of the diagnostic criteria to differentiate GAD from symptoms of other conditions highlights the need to better define its associated symptoms criteria. The relationship of overlapping symptoms between GAD and MDD is also discussed.

Heterogeneity in Autonomic Arousal Level in Perseverative Worry: The Role of Cognitive Control and Verbal Thought

One puzzle in high worry and generalized anxiety disorder (GAD) is the heterogeneity in the level of autonomic arousal symptoms seen among affected individuals. While current models agree that worry persists, in part, because it fosters avoidance of unpleasant internal experiences, they disagree as to whether worry does so by suppressing activation of autonomic arousal or by fostering persistent autonomic hyperarousal. Our Cognitive Control Model predicts that which pattern of autonomic arousal occurs depends on whether or not a worrier has sufficient cognitive control capacity to worry primarily in a verbal versus imagery-based manner. Because this model has been supported by only one study to date, the present study sought to replicate and extend that study’s findings. Results from an online survey in an unselected sample of over 900 college students provide further support for our model’s central tenet and initial support for its prediction that higher effortful control is associated with a higher percentage of verbal thought during worry. Finally, we report tentative evidence that autonomic arousal symptoms in worry and GAD vary as a function of individual differences in cognitive control capacity because higher capacity is linked to a greater predominance of verbal thought during worry.

Concreteness of idiographic worry and anticipatory processing

BACKGROUND AND OBJECTIVES

Worry and anticipatory processing are forms of repetitive negative thinking (RNT) that are associated with maladaptive characteristics and negative consequences. One key maladaptive characteristic of worry is its abstract nature (Goldwin & Behar, 2012; Stöber & Borkovec, 2002). Several investigations have relied on inductions of worry that are social-evaluative in nature, which precludes distinctions between worry and RNT about social-evaluative situations. The present study examined similarities and distinctions between worry and anticipatory processing on potentially important maladaptive characteristics.

METHODS

Participants (N = 279) engaged in idiographic periods of uninstructed mentation, worry, and anticipatory processing and provided thought samples during each minute of each induction. Thought samples were assessed for concreteness, degree of verbal-linguistic activity, and degree of imagery-based activity.

RESULTS

Both worry and anticipatory processing were characterized by reduced concreteness, increased abstraction of thought over time, and a predominance of verbal-linguistic activity. However, worry was more abstract, more verbal-linguistic, and less imagery-based relative to anticipatory processing. Finally, worry demonstrated reductions in verbal-linguistic activity over time, whereas anticipatory processing demonstrated reductions in imagery-based activity over time.

LIMITATIONS

Worry was limited to non-social topics to distinguish worry from anticipatory processing, and may not represent worry that is social in nature. Generalizability may also be limited by use of an undergraduate sample.

CONCLUSIONS

Results from the present study provide support for Stöber's theory regarding the reduced concreteness of worry, and suggest that although worry and anticipatory processing share some features, they also contain characteristics unique to each process.

Comparative Autonomic Responses to Diagnostic Interviewing between Individuals with GAD, MDD, SAD and Healthy Controls

Dysregulation of the autonomic nervous system (ANS) has been well documented in individuals diagnosed with a range of psychological disorders, including generalized anxiety disorder (GAD) and major depressive disorder (MDD). Moreover, these disorders both confer an increased risk of cardiovascular disease-which may relate to increased sympathetic and decreased parasympathetic tone. Extant research has indicated a reduction in autonomic flexibility in GAD, and while reduced flexibility has also been seen in MDD, the specific physiological alterations have been more difficult to categorize due to methodological limitations, including high co-morbidity rates with anxiety disorders. Prior studies have largely assessed autonomic functioning in stress paradigms or at the trait level, yet to date, no research has investigated the ANS during a diagnostic interview, a ubiquitous task employed in both research and clinical settings. In this study we sought to identify physiological differences in both branches of the ANS across diagnostic categories in the context of a diagnostic interview. Participants (n = 82) were administered a structured clinical interview, during which heart rate (HR), respiratory sinus arrhythmia (RSA) and pre-ejection period (PEP) were recorded in participants carrying a diagnosis of GAD (n = 34), MDD (n = 22), Social Anxiety Disorder (SAD; n = 15) and healthy controls (n = 27). Person-specific linear regression models were employed to assess the level and slope for HR, RSA and PEP throughout the course of the interview. A multivariate analysis of variance (MANOVA) model was conducted to baseline differences in HR, RSA and PEP between diagnostic groups. Multiple regression models were then conducted to differences in slope of HR, RSA and PEP throughout the course of the interview amongst diagnostic groups, including both suppression and worry as moderators. Results indicated significant increases in RSA throughout the interview in MDD (p = 0.01) compared to healthy controls. Worry itself was found to be a more significant predictor of both decreased PEP (p = 0.02) and increased HR (p = 0.05). Suppression exhibited a dampening effect on individuals with worry and GAD, whereby those who suppressed had dampened HR responsiveness compared to those who did not suppress. These findings are consistent with existing literature supporting a decreased autonomic flexibility in certain psychological disorders, as well as indicate distinct physiological differences across certain transdiagnostic features of mood and anxiety disorders.

Goal Directed Worry Rules Are Associated with Distinct Patterns of Amygdala Functional Connectivity and Vagal Modulation during Perseverative Cognition

Excessive and uncontrollable worry is a defining feature of Generalized Anxiety Disorder (GAD). An important endeavor in the treatment of pathological worry is to understand why some people are unable to stop worrying once they have started. Worry perseveration is associated with a tendency to deploy goal-directed worry rules (known as "as many as can" worry rules; AMA). These require attention to the goal of the worry task and continuation of worry until the aims of the "worry bout" are achieved. This study examined the association between the tendency to use AMA worry rules and neural and autonomic responses to a perseverative cognition induction. To differentiate processes underlying the AMA worry rule use from trait worry, we also examined the relationship between scores on the Penn State Worry Questionnaire (PSWQ) and neural and autonomic responses following the same induction. We used resting-state functional magnetic resonance brain imaging (fMRI) while measuring emotional bodily arousal from heart rate variability (where decreased HRV indicates stress-related parasympathetic withdrawal) in 19 patients with GAD and 21 control participants. Seed-based analyses were conducted to quantify brain changes in functional connectivity (FC) with the amygdala. The tendency to adopt an AMA worry rule was associated with validated measures of worry, anxiety, depression and rumination. AMA worry rule endorsement predicted a stronger decrease in HRV and was positively associated with increased connectivity between right amygdala and locus coeruleus (LC), a brainstem noradrenergic projection nucleus. Higher AMA scores were also associated with increased connectivity between amygdala and rostral superior frontal gyrus. Higher PSWQ scores amplified decreases in FC between right amygdala and subcallosal cortex, bilateral inferior frontal gyrus, middle frontal gyrus, and areas of parietal cortex. Our results identify neural mechanisms underlying the deployment of AMA worry rules. We propose that the relationship between AMA worry rules and increased connectivity between the amygdala and prefrontal cortex (PFC) represents attempts by high worriers to maintain arousal and distress levels in order to feel prepared for future threats. Furthermore, we suggest that neural mechanisms associated with the PSWQ represent effortful inhibitory control during worry. These findings provide unique information about the neurobiological processes that underpin worry perseveration.

The effect of verbal and imagery-based worry versus distraction on the emotional response to a stressful in-vivo situation

BACKGROUND AND OBJECTIVES

According to the Contrast Avoidance Model of worry, worrying induces prolonged negative affect and arousal and thereby suppresses sharp shifts in negative affect. The verbal and abstract nature of worry may be responsible for these effects as verbal thinking has been found to lead to less emotional and physiological responding than imagery. The present study was designed to test the Contrast Avoidance Model and to examine the role of verbal vs. imagery-based thinking during worrying..

METHODS

125 participants were exposed to a social-evaluative stressor. Before the stressor, they were randomized into three different groups (1) verbal worrying about the upcoming stressor, (2) imagery-based worrying, or (3) distraction. Self-reported affect and physiological arousal, as well as heart rate, respiratory sinus arrhythmia and skin conductance level (SCL) were monitored.

RESULTS

In line with the Contrast Avoidance Model, worrisome thinking (1) led to immediately increased self-reported negative affect and arousal as well as SCL, but (2) attenuated a further increase in self-reported negative affect and arousal in response to the stressor. No effect of style of worrying (verbal vs. imagery) was found..

LIMITATIONS

Effects were rather small and mostly confined to self-report data.

CONCLUSION

By and large, our findings support the Contrast Avoidance Model of worry with regard to self-report measures and extend earlier findings by using an in-vivo stressor. The role of thinking style on the contrast avoidance effect as well as the contrast avoidance effect on physiological measures need to be explored in more detail..

The Impact of Written Exposure on Worry

The main goal of this study was to examine the effect of written exposure on generalized anxiety disorder (GAD)-related symptoms in high worriers. Thirty nonclinical high worriers were randomly assigned to either a written exposure condition or a control writing condition. Self-report measures were used to assess worry, GAD somatic symptoms, depression, and intolerance of uncertainty at four time points during the study. Using hierarchical linear modeling (HLM), the authors found that all symptoms (i.e., worry, GAD somatic symptoms, and depression) significantly decreased over time in the written exposure group (although GAD somatic symptoms also decreased in the control group). Moreover, consistent with previous findings that intolerance of uncertainty preceded changes in worry over the course of treatment, intolerance of uncertainty scores predicted subsequent scores on all symptom measures in the experimental group. In contrast, worry and depression scores predicted subsequent intolerance of uncertainty scores in the control group.

Cognitive Behavior Therapy for Atypical Generalized Anxiety Disorder (GAD)

Cognitive behavior therapy has been shown to be effective in the treatment of generalized anxiety disorder (GAD) and social phobia. However, little is known regarding best treatment practices when these disorders co-occur. The following is an illustration of a successful implementation of an empirically supported treatment for GAD with a gay Caucasian client with co-occurring social phobia and GAD in addition to concurrent depressive symptomatology. Particular emphasis was placed on the use of a functional assessment in case conceptualization and in treatment planning, which suggested that the client's socially anxious and depressive symptomatology were related to his chronic worry. At termination, criteria for GAD and social phobia were no longer met, and depressive symptomatology was reduced to minimal levels. Ongoing assessment demonstrated clinically significant treatment gains. Additionally, the importance of homework completion is demonstrated and discussed.

Intolerance of Uncertainty Is Associated With Increased Threat Appraisal and Negative Affect Under Ambiguity but Not Uncertainty

Intolerance of Uncertainty (IU) has gained increasing interest as a vulnerability factor for worry in Generalized Anxiety Disorder and other emotional disorders. We extended the procedure of Grupe and Nitschke (2011) to compare threat processing in High IU (n=29) and Low IU (n=26) participants. Participants viewed four cues: two reference cues that preceded aversive pictures on 100% or 0% of trials, and a target cue that preceded aversive pictures on 50% of trials (Uncertain condition). Participants were instructed about these probabilities in advance. In addition, we surprised participants with a second target cue that also preceded aversive pictures on 50% of trials but that had not been mentioned in the instructions (Ambiguous condition). Results provided preliminary evidence that High IU participants showed greater online threat expectancy, postexperimental covariation estimates and negative mood for the target cues compared to the reference cues. The results also suggest that among high IU individuals, ambiguity, rather than uncertainty per se, may be a particularly powerful trigger for biased threat appraisal and negative affect. Clinically, the results suggest that patients with high IU may benefit from interventions to help them calibrate the degree of risk in situations involving ambiguous threat.

Mechanisms of Change in Written Exposure Treatment of Posttraumatic Stress Disorder

Although the effectiveness of exposure therapy for PTSD is recognized, treatment mechanisms are not well understood. Emotional processing theory (EPT) posits that fear reduction within and between sessions creates new learning, but evidence is limited by self-report assessments and inclusion of treatment components other than exposure. We examined trajectories of physiological arousal and their relation to PTSD treatment outcome in a randomized controlled trial of written exposure treatment, a protocol focused on exposure to trauma memories. Hierarchical linear modeling was used to model reduction in Clinician Administered PTSD Scale score as a predictor of initial activation and within- and between-session change in physiological arousal. Treatment gains were significantly associated with initial physiological activation, but not with within- or between-session changes in physiological arousal. Treatment gains were associated with larger between-session reductions in self-reported arousal. These findings highlight the importance of multimethod arousal assessment and add to a growing literature suggesting refinements of EPT.

Episodic future thinking in generalized anxiety disorder

Research on future-oriented cognition in generalized anxiety disorder (GAD) has primarily focused on worry, while less is known about the role of episodic future thinking (EFT), an imagery-based cognitive process. To characterize EFT in this disorder, we used the experimental recombination procedure, in which 21 GAD and 19 healthy participants simulated positive, neutral and negative novel future events either once or repeatedly, and rated their phenomenological experience of EFT. Results showed that healthy controls spontaneously generated more detailed EFT over repeated simulations. Both groups found EFT easier to generate after repeated simulations, except when GAD participants simulated positive events. They also perceived higher plausibility of negative-not positive or neutral-future events than did controls. These results demonstrate a negativity bias in GAD individuals' episodic future cognition, and suggest their relative deficit in generating vivid EFT. We discuss implications for the theory and treatment of GAD.

Perceived Emotion Control Moderates the Relationship between Neuroticism and Generalized Anxiety Disorder

The relationships between neuroticism, perceived emotion control, and generalized anxiety disorder (GAD) severity were examined in 293 individuals diagnosed with GAD at a specialty anxiety disorders clinic. Hierarchical regression analyses performed within a structural equation modeling framework revealed that (1) neuroticism and perceived emotion control both predicted a latent variable of GAD in the expected direction, and (2) perceived emotion control moderated the relationship between neuroticism and GAD severity, such that lower levels of perceived emotion control were associated with a stronger relationship between neuroticism and GAD severity. The other dimensions of perceived control (i.e., stress and threat control) did not moderate the effect of neuroticism on GAD severity. The findings are discussed with regard to their implications to conceptual models of the psychopathology of GAD, and theory-based differential relationships between dimensions of vulnerability, perceived control, and anxiety disorders.

Rethinking Rumination

The response styles theory (Nolen-Hoeksema, 1991) was proposed to explain the insidious relationship between rumination and depression. We review the aspects of the response styles theory that have been well-supported, including evidence that rumination exacerbates depression, enhances negative thinking, impairs problem solving, interferes with instrumental behavior, and erodes social support. Next, we address contradictory and new findings. Specifically, rumination appears to more consistently predict the onset of depression rather than the duration, but rumination interacts with negative cognitive styles to predict the duration of depressive symptoms. Contrary to original predictions, the use of positive distractions has not consistently been correlated with lower levels of depressive symptoms in correlational studies, although dozens of experimental studies show positive distractions relieve depressed mood. Further, evidence now suggests that rumination is associated with psychopathologies in addition to depression, including anxiety, binge eating, binge drinking, and self-harm. We discuss the relationships between rumination and worry and between rumination and other coping or emotion-regulation strategies. Finally, we highlight recent research on the distinction between rumination and more adaptive forms of self-reflection, on basic cognitive deficits or biases in rumination, on its neural and genetic correlates, and on possible interventions to combat rumination.

Oscillatory brain activity in the alpha range is modulated by the content of word-prompted mental imagery

Mental imagery is a fundamental cognitive process of interest to basic scientists and clinical researchers. This study examined large-scale oscillatory brain activity in the alpha band (8-12 Hz) during language-driven mental imagery using dense-array EEG. Three experiments demonstrated relative increases in alpha amplitude: (1) during imagery prompted by words compared to fixation without imagery instruction, (2) during imagery of word content compared to imagery of geometric shapes, and (3) during imagery of emotionally evocative words compared to imagery of less emotionally arousing content. Alpha increases for semantically loaded imagery were observed in parieto-occipital regions, sustained throughout the imagery period. Findings imply that alpha oscillations index active memory and internal cognitive processing, reflecting neural communication in cortical networks representing motor, semantic, and perceptual aspects of the imagined scene.

Trait rumination moderates the effect of mentation type on heart rate responses to stressor recall

Ruminative thought about stressors has been linked to extended post-stressor cardiovascular activation, which in turn predicts negative long-term health outcomes. Past work indicates that the nature of thought (mental imagery or verbal thought) may shape cardiovascular responses. Some evidence suggests that individuals with rumination tendencies may be especially vulnerable to stress-related cardiovascular activation, although it is unclear to what extent type of thought (imagery or verbal thought) influences this relationship. This study included a laboratory stressor followed by a stressor recall task in which mentation type was manipulated. Healthy undergraduate students (N = 138; 47% female) underwent a speech stressor and then were randomly assigned to complete a stressor recall task using either mental imagery or verbal-linguistic mentation. Heart rate (HR) and blood pressure (BP) were measured throughout. Self-report trait rumination was measured at baseline. Results indicated that trait rumination and mentation type interacted to predict HR. Individuals with high trait rumination scores had significantly greater increases in HR during the verbal-linguistic conditions compared to the mental imagery conditions. There were no mentation type differences in the low trait ruminators, no differences in BP and no main effects of trait rumination. Results suggest that mentation type may be a key in understanding the relationship between rumination and cardiovascular activation, especially for trait ruminators.

Ruminations on Worry: Issues Related to the Study of an Elusive Construct

This review outlines the main theoretical and methodological issues relating to worry. The relationship of worry to anxiety and problem solving is discussed. Three models of worry are described: attention bias (Mathews, 1990), fear avoidance (Borkovec, Shadick, & Hopkins, 1991), and Tallis and Eysenck's (1994) stage model. Worry's proposed role in inhibiting emotional processing is discussed, and unresolved methodological and theoretical issues are considered. It is concluded that worry is elusive and difficult to study but greater understanding of worry is necessary.