The naturalistic reinforcement of worry from positive and negative emotional contrasts: Results from a momentary assessment study within social interactions

Savoring changes novel positive mindset targets of GAD treatment: Optimism, prioritizing positivity, kill-joy thinking, and worry mediation

This study analyzed effects of savoring on unstudied positive mindset targets of generalized anxiety disorder (GAD) treatment (ClinicalTrials.gov: NCT05040061). 85 students with GAD were randomly assigned to one of two ecological momentary interventions (EMIs) on smartphone for seven days. The SkillJoy EMI promoted practices for savoring positive emotions. An active control EMI mirrored SkillJoy, yet did not include savoring or positive emotion. Optimism, worry, kill-joy thinking (lessening positive emotion with cognition), and prioritization of positive emotion activities and goals were assessed at pre-trial, eighth-day, post-trial, and 30th-day follow-up. Savoring was assessed pre-trial and fifth-day mid-trial. Longitudinal linear mixed models and simple slope analyses examined change between and within conditions. Bias-corrected bootstrapping path analysis examined mediation of worry change by increased savoring. SkillJoy led to significantly greater increases in both optimism and prioritizing positivity than the control from pre-trial to post-trial and pre-trial to follow-up. Both interventions significantly reduced kill-joy thinking at both timepoints with Skilljoy leading to marginally greater change at post-trial. Pre- to mid-trial increases in savoring mediated the relationships between treatment condition and reductions in worry at both post-trial and follow-up.

Treatment condition as a moderator and change in trait mindfulness as a mediator of a brief mindfulness ecological momentary intervention for generalized anxiety disorder

BACKGROUND

Theories propose that judgment of and reactivity to inner experiences are mediators of the effect of mindfulness-based interventions on generalized anxiety disorder (GAD). However, no study has tested such theories using brief, mindfulness ecological momentary intervention (MEMI). We thus tested these theories using a 14-day MEMI versus self-monitoring app (SM) control for GAD.

METHODS

Participants (N = 110) completed self-reports of trait mindfulness (Five Facet Mindfulness Questionnaire), GAD severity (GAD-Questionnaire-IV), and trait perseverative cognitions (Perseverative Cognitions Questionnaire) at prerandomization, posttreatment, and 1-month follow-up (1MFU). Counterfactual mediation analyses with temporal precedence were conducted.

RESULTS

Improvement in pre-post mindfulness domains (acceptance of emotions, describing feelings accurately, acting with awareness, judgment of inner experience, and reactivity to inner experience) predicted pre-1MFU reduction in GAD severity and pre-1MFU reduction in trait perseverative cognitions from MEMI but not SM. MEMI reduced pre-post reactivity to inner experiences (but not other mindfulness domains) significantly more than SM. Only reduced pre-post reactivity significantly mediated stronger efficacy of MEMI over SM on pre-1MFU reductions in GAD severity (indirect effect: β = -2.970 [-5.034, -0.904], p = .008; b path: β = -3.313 [-6.350, -0.276], p = .033; percentage mediated: 30.5%) and trait perseverative cognitions (indirect effect: β = -0.153 [-0.254, -0.044], p = .008; b path: β = -0.145 [-0.260, -0.030], p = .014; percentage mediated: 42.7%). Other trait mindfulness domains were non-significant mediators.

CONCLUSIONS

Reactivity to inner experience might be a mindfulness-based intervention change mechanism and should be targeted to optimize brief MEMIs for GAD.

An initial test of the contrast avoidance model in bipolar spectrum disorders

The Contrast Avoidance Model suggests that individuals sensitive to negative emotional shifts use prior increases in negative affect to prevent further escalation in response to adverse situations, while the heightened negative affect amplifies positive emotional contrasts when encountering unexpected positive events. Individuals with bipolar spectrum disorders (BSDs), characterized by shifts between (hypo)manic and depressive episodes, may undergo more salient emotional contrasts. Drawing from the Contrast Avoidance Model, the shifts from depression to (hypo)mania can be conceptualized as positive emotional contrasts, potentially heightening the perceived pleasure during (hypo)manic episodes. On the other hand, the shifts from (hypo)manic to depressive episodes can be viewed as negative emotional contrasts, contributing to the challenges associated with depressive states. Despite the intriguing potential of this interplay, the link between the Contrast Avoidance Model and BSDs has never been empirically tested. Our study addressed this gap by examining group differences in contrast avoidance traits between individuals with BSDs, unipolar depression, and healthy controls in a large cohort study (N = 536). Results indicated that individuals with BSDs exhibited significantly higher scores in the total, and Discomfort with Negative Emotional Shifts and Avoidance of Negative Emotional Contrasts/Enhancement of Positive Emotional Contrasts factors, as well as separate item scores on the Contrast Avoidance Questionnaire-General Emotion (CAQ-GE), compared to those with unipolar depression and healthy controls. Although marginal, the BD II subtype demonstrated a stronger inclination to avoid negative emotional contrasts compared to BD I. These findings suggest that contrast avoidance may be a psychological mechanism implicated in BSDs.

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.

The transdiagnostic use of worry and rumination to avoid negative emotional contrasts following negative events: A momentary assessment study

The contrast avoidance model (CAM) suggests that individuals with generalized anxiety disorder (GAD) are sensitive to a sharp increase in negative and/or decrease in positive affect. They thus worry to increase negative emotion to avoid negative emotional contrasts (NECs). However, no prior naturalistic study has examined reactivity to negative events, or ongoing sensitivity to NECs, or the application of CAM to rumination. We used ecological momentary assessment to examine effects of worry and rumination on negative and positive emotion before and after negative events and intentional use of repetitive thinking to avoid NECs. Individuals with major depressive disorder (MDD) and/or GAD (N = 36) or without psychopathology (N = 27) received 8 prompts/day for 8 days and rated items on negative events, emotions, and repetitive thoughts. Regardless of group, higher worry/rumination before negative events was associated with less increased anxiety and sadness, and less decreased happiness from before to after the events. Participants with MDD/GAD (vs. controls) reported higher ratings on focusing on the negative to avoid NECs and greater vulnerability to NECs when feeling positive. Results support the transdiagnostic ecological validity for CAM extending to rumination and intentional engagement in repetitive thinking to avoid NECs among individuals with MDD/GAD.

Incremental validity of the contrast avoidance model: A comparison with intolerance of uncertainty and negative problem orientation

BACKGROUND

This study examined the incremental validity of the Contrast Avoidance Model (CAM) in predicting generalized anxiety disorder (GAD) symptoms when compared against well-established constructs in the GAD literature: intolerance of uncertainty (IU) and negative problem orientation (NPO).

METHOD

In this study, 185 students (108 of whom endorsed clinical levels of GAD symptoms) completed questionnaires to assess for all constructs. GAD symptoms were regressed on measures of contrast avoidance (CA; Contrast Avoidance-General Emotion and Contrast Avoidance-Worry Questionnaires; Llera & Newman, 2017) tendencies in addition to measures of IU and NPO in separate analyses. Commonality analyses explored the unique versus overlapping contributions of each factor in explaining GAD symptoms.

RESULTS

In all models, CA was a significant predictor after controlling for demographic variables (age, gender, race, and ethnicity) and both IU and NPO. This was also true when excluding CA items referencing worry. All variables contributed unique explanatory power in the prediction of GAD.

CONCLUSION

Results provide evidence of the incremental validity of the CAM as a model of GAD.

The mediating effect of stress reactivity in the 18-year bidirectional relationship between generalized anxiety and depression severity

BACKGROUND

Generalized anxiety disorder (GAD) and major depressive disorder (MDD) often precede and predict one another. Heightened stress reactivity may be a mediation mechanism underlying the long-term connections between GAD and MDD. However, cross-sectional studies on this topic have hindered directional inferences.

METHOD

The present study examined stress reactivity as a potential mediator of the sequential associations between GAD and MDD symptoms in a sample of 3,294 community-dwelling adults (M age = 45.6, range = 20-74). Participants completed three waves of measurement (T1, T2, and T3) spaced nine years apart. GAD and MDD symptom severity were assessed at T1, T2, and T3 (Composite International Diagnostic Interview-Short Form). Stress reactivity (Multidimensional Personality Questionnaire) was measured at T2.

RESULTS

Structural equation mediation modeling demonstrated that higher T1 GAD symptoms positively predicted more severe T3 MDD symptoms via T2 stress reactivity, controlling for T1 MDD (d = 0.45-0.50). However, T2 stress reactivity was not a significant mediator in the relationship between T1 MDD severity and T3 GAD symptoms after controlling for T1 GAD. Direct effects indicated that T1 GAD positively predicted T3 MDD 18 years later and vice versa (d = 1.29-1.65).

LIMITATIONS

Stress reactivity was assessed using a self-report measure, limiting conclusions to perceived (vs. physiologically indexed) stress reactivity.

CONCLUSIONS

These findings indicate that stress reactivity may be one mechanism through which GAD leads to later MDD over prolonged durations. Overall, results suggest that targeting stress reactivity in treatments for GAD may reduce the risk of developing subsequent MDD.

Worry and rumination enhance a positive emotional contrast based on the framework of the Contrast Avoidance Model

The Contrast Avoidance Model (CAM) suggests that worry increases negative affect and decreases positive affect. CAM also suggests that in response to a positive event, higher worry enhances the probability of experiencing greater decreased negative affect and increased positive affect (positive emotional contrasts; PECs). Consequently, worrying may be reinforced by repeated PECs. However, no study has tested whether rumination enhances PECs. Also, emotional specificity in these processes has not been considered. Therefore, we tested whether both rumination and worry enhanced PECs related to specific emotions. After resting baseline, participants with pure generalized anxiety disorder (GAD group, n = 91), pure depression symptoms (depression group, n = 91), and non-GAD and non-depressed healthy controls (HCs, n = 93) engaged with randomly assigned induction tasks (either worry, rumination, or relaxation), and then watched an amusement video. Regardless of group, both worry and rumination increased sadness and fear and decreased amusement more than relaxation from baseline. However, worry increased fear more than rumination, and rumination increased sadness more than worry. Although all inductions led to PECs during the video, worry enhanced fear PECs more than rumination, and rumination enhanced sadnessPECs more than worry. The GAD group who worried experienced the most salient PEC of amusement relative to other groups.

Interpersonal contrast avoidance as a mechanism for the maintenance of worry

Despite consistent links between interpersonal problems and worry, mechanisms explaining this relationship remain unknown. The Contrast Avoidance Model (CAM; Newman & Llera, 2011) posits that individuals at risk for chronic worry and generalized anxiety disorder (GAD) fear sudden negative mood shifts, using worry to perpetuate negative moods and avoid these negative emotional contrasts. We propose interpersonal (IP) contrast avoidance (e.g., acting friendly to prevent others from causing mood shifts) as a novel explanation for interpersonal dysfunction in worriers. This study investigated IP contrast avoidance and worry in two samples. A nonclinical sample ranging in GAD symptoms (Study 1; N = 92) reported IP problems at baseline then IP contrast avoidance and worry over eight weeks (637 diaries). As expected, baseline IP problems prospectively predicted worry indirectly through chronic IP contrast avoidance. Affiliative, submissive, cold, and total IP contrast avoidance strategies predicted same-week and lagged next-week worry increases; affiliative, submissive, and total strategies also predicted maintenance of worry over eight weeks in growth models. Lastly, Study 2 showed the relevance of IP contrast avoidance strategies in a treatment-seeking clinical sample (N = 40), correlating with interpersonal problems and worry. Overall, results provide proof-of-concept for extending the CAM to the interpersonal domain.

A transdiagnostic evaluation of contrast avoidance across generalized anxiety disorder, major depressive disorder, and social anxiety disorder

BACKGROUND

The contrast avoidance model (CAM) proposes that persons with generalized anxiety disorder (GAD) are sensitive to sharp increases in negative emotion or decreases in positive emotion (i.e., negative emotional contrasts; NEC) and use worry to avoid NEC. Sensitivity to and avoidance of NEC could also be a shared feature of major depressive disorder (MDD) and social anxiety disorder (SAD).

METHODS

In a large college sample (N = 1409), we used receiver operating characteristics analysis to examine the accuracy of a measure of emotional contrast avoidance in detecting probable GAD, MDD, and SAD.

RESULTS

Participants with probable GAD, MDD, and SAD all reported higher levels of contrast avoidance than participants without the disorder (Cohen's d = 1.32, 1.62 and 1.53, respectively). Area under the curve, a measure of predictive accuracy, was 0.81, 0.87, and 0.83 for predicting probable GAD, MDD, and SAD, respectively. A cutoff score of 48.5 optimized predictive accuracy for probable GAD and SAD, and 50.5 optimized accuracy for probable MDD.

CONCLUSION

A measure of emotional contrast avoidance demonstrated excellent ability to predict probable GAD, MDD, and SAD. Sensitivity to and avoidance of NEC appears to be a transdiagnostic feature of these disorders.

Reducing contrast avoidance in GAD by savoring positive emotions: Outcome and mediation in a randomized controlled trial

This secondary analysis of a randomized controlled trial (RCT) examined whether contrast avoidance (CA) in Generalized Anxiety Disorder (GAD) could be reduced through savoring-purposeful engagement with positive emotions. 85 participants were diagnosed with GAD by both questionnaire and clinical interview. They were then randomly assigned to one of two seven-day smartphone-delivered ecological momentary interventions (EMIs). The SkillJoy EMI facilitated in-the-moment practice of savoring positive emotions in participants' daily lives. The active self-monitoring control (ASM) was nearly identical to SkillJoy in ratings, activities, and language, yet omitted specific attention to positive emotion and savoring. CA was assessed by questionnaire at pre-trial and post-trial. Savoring was assessed by questionnaire at pre-trial and fifth-day mid-trial. Longitudinal linear mixed models and simple slope analyses examined CA change between and within conditions. Bias-corrected boot strapping path analysis examined mediation by savoring using individuals' CA slopes extracted from a multilevel model as outcome. Results showed that SkillJoy led to significant reductions in CA, whereas the ASM control did not. The relation between treatment condition and reduction in CA was mediated by increases in savoring from pre- to mid-trial. It may be possible for treatment to meaningfully reduce CA in GAD, specifically through savoring practices.