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

An examination of worry and self-distancing as coping strategies for anxiety-provoking experiences in individuals high in worry

OBJECTIVES

This preliminary online study investigated the short-term effects of self-distancing, worry, and distraction on anxiety and worry-related appraisals among individuals high in worry.

DESIGN AND METHODS

N = 104 community members high in trait worry were randomly assigned to think about a personally identified worry-provoking situation using self-distancing (SC), worry (WC), or distraction (DC). Participants rated their anxiety (Visual Analogue Scale for Anxiety) and appraisals of the situation (Perceived Probability, Coping, and Cost Questions) at post-task and one-day follow-up.

RESULTS

Mixed factorial ANOVAs revealed an increase in anxiety within the WC (d = .475) and no difference in anxiety within the SC (d = .010) from pre- to post-task. There was no difference in anxiety within the DC (p = .177). Participants within the SC reported a decrease in the perceived cost associated with their identified situation from pre- to post-task (d = .424), which was maintained at one-day follow-up (d = .034). Participants reported an increase in perceived ability to cope from post-task to one-day follow-up (d = .236), and from pre-task to one-day follow-up (d = .338), regardless of condition.

CONCLUSIONS

Self-distancing may prevent increases in anxiety and catastrophizing while reflecting on a feared situation.

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.

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.

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

BACKGROUND

The Contrast Avoidance Model (Newman & Llera, 2011) proposes that worry is reinforced by avoiding a negative contrast and increasing the likelihood of a positive contrast.

OBJECTIVE

To determine if reinforcement of worry occurs naturalistically via contrasts in both negative and positive emotion.

METHOD

Using event-contingent momentary assessment we assessed social interactions, pre-interaction state worry and pre-post interaction positive and negative emotion. Participants with generalized anxiety disorder (GAD; N = 83) completed an online questionnaire after social interactions lasting at least 1 min for 8 days. Three-level multilevel models were conducted.

RESULTS

Higher worry was concurrently associated with increased negative emotion and decreased positive emotion. Regardless of pre-interaction worry level, negative emotion decreased, and positive emotion increased from before to after interactions, suggesting that most interactions were benign or positive. At lower levels of pre-interaction worry, participants experienced increased negative emotion and decreased positive emotion from before to after interactions. At higher levels of pre-interaction worry, participants experienced decreased negative emotion and increased positive emotion from before to after interactions.

CONCLUSION

Among persons with GAD, worrying before social interactions may be both negatively and positively reinforced; furthermore, not worrying before social interactions may be both negatively and positively punished.

Visual worry in patients with schizophrenia

OBJECTIVE

Worrying is a pervasive transdiagnostic symptom in schizophrenia. It is most often associated in the literature with verbal modality due to many studies of its presence in generalised anxiety disorder. The current study aimed to elucidate worry in different sensory modalities, visual and verbal, in individuals with schizophrenia.

METHOD

We tested persons with schizophrenia (n = 92) and healthy controls (n = 138) in a cross-sectional design. We used questionnaires of visual and verbal worry (original Worry Modality Questionnaire), trait worry (Penn State Worry Questionnaire) and general psychopathology symptoms (General Functioning Questionnaire-58 and Brief Psychiatric Rating Scale).

RESULTS

Both visual and verbal worry were associated with psychotic, anxiety and general symptoms of psychopathology in both groups with medium to large effect sizes. Regression analyses indicated that visual worry was a single significant predictor of positive psychotic symptoms in a model with verbal and trait worry, both in clinical and control groups (β's of 0.49 and 0.38, respectively). Visual worry was also a superior predictor of anxiety and general psychopathology severity (β's of 0.34 and 0.37, respectively) than verbal worry (β's of 0.03 and -0.02, respectively), under control of trait worry, in the schizophrenia group. We also proposed two indices of worry modality dominance and analysed profiles of dominating worry modality in both groups.

CONCLUSIONS

Our study is the first to demonstrate that visual worry might be of specific importance for understanding psychotic and general psychopathology symptoms in persons with schizophrenia.

Mood and Affective Balance of Spaniards Confined by COVID-19: A Cross-Sectional Study

The aim of this study was to analyze the mood and affective balance of Spaniards in quarantine and determine the predictive role of sociodemographic variables and mood on the negative affective balance. This cross-sectional study was carried out with a sample of 1014 Spanish adults, 67.2% were women and 32.8% men. The age ranged from 17 to 76. The instruments used were the Mood Assessment Scale and the Affective Balance Scale, which were implemented as a CAWI survey (Computer Aided Web Interviewing). Results showed that age correlated negatively with Sadness-Depression, Anxiety, and Happiness. Women had more Sadness-Depression, Anxiety, and negative affect, while men showed more Happiness and higher positive affect. Thus, the risk of a negative affective balance during confinement was greater for women and those who showed an emotional state marked by sadness-depression and anxiety, while older age and higher scores in happiness were associated with lower risk. In conclusion, knowing which groups are at risk of emotional and affective alteration can facilitate the detection and prevention of later disorders, such as severe stress and posttraumatic stress disorder, avoiding their generalized presence, and becoming a new public health problem derived from COVID-19.

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.

Concreteness of thoughts and images during suppression and expression of worry

The avoidance theory of worry (Borkovec, Alcaine, & Behar, 2004) posits that the verbal-linguistic (versus imagery-based) nature of worry elicits abstract (versus concrete) processing, which inhibits affective responding and generates a host of negative consequences. Although suppression of worrisome thinking is maladaptive (Purdon, 1999), expression of worry using vivid imagery may increase concreteness of worrisome thinking and facilitate more adaptive emotional responding. The present study examined whether the valence, content, and expression of mentation impacts concreteness of thought. Participants (N = 62) were randomly assigned to verbalize their thoughts while engaging in either verbal-linguistic- or imagery-based mentation about both worrisome and neutral topics. Participants were also randomly assigned to engage in a 5-min period of suppressing or expressing the target stimuli before engaging in 5-min of freely expressing the targets. Verbalizations of mental content were coded for level of abstractness/concreteness. For neutral stimuli, imagery-based mentation led to greater concreteness than did verbal-linguistic mentation; however, for worrisome stimuli, imagery-based mentation did not enhance concreteness. In addition, for neutral (but not worrisome) stimuli, an initial period of suppression was associated with increased concreteness during subsequent expression. Imagery-based mentation about worrisome stimuli may not enhance concreteness; moreover, unlike suppression of neutral stimuli, suppression of worrisome stimuli may maintain, rather than ameliorate, abstractness of thought.

Worry as a mediator between psychosocial stressors and emotional sequelae: Moderation by contrast avoidance

BACKGROUND

Worry is the core feature of generalized anxiety disorder (GAD), which is prevalent among emerging adults. The contrast avoidance model proposes that individuals with GAD use worry to avoid negative emotional contrasts by maintaining a state of negative affect. Research suggests worry in response to stressors increases anxiety, but more research is needed to examine depression as an outcome and the predictions of contrast avoidance in the context of multiple stressor subtypes. The current study examined whether worry may be associated with increased symptoms of anxiety and depression, regardless of stressors, due to the use of worry as an avoidance strategy, moderating these associations.

METHODS

367 undergraduate college students from a medium-sized, public university completed self-report questionnaires online.

RESULTS

Worry significantly mediated the associations from academic stressors and social stressors to symptoms of anxiety and depression. Contrast avoidance significantly moderated associations between academic stressors and worry as well as worry and anxiety. For those high in contrast avoidance, worry was relatively high regardless of academic stressors; for those low in contrast avoidance, students with fewer academic stressors reported less worry.

LIMITATIONS

The present study relied on self-report. In addition, the cross-sectional design limits the ability to draw conclusions about temporal relations.

CONCLUSIONS

Contrast avoidance elevated worry regardless of academic stressors, and strengthened the association between worry and anxiety but not worry and depression. Individuals who experience high levels of contrast avoidance may benefit from cognitive interventions focusing on reducing beliefs about the perceived benefits of worry.

How imagining personal future scenarios influences affect: Systematic review and meta-analysis

Imagining the future is a fundamental human capacity that occupies a large part of people's waking time and impacts their affective well-being. In this meta-analysis, we examined the effect of (1) positive future imagination and (2) negative future imagination on affect, and (3) compared the affective responses between imagining the future and remembering the past; lastly, we (4) examined potential moderating variables in this regard. We identified 63 experimental studies (N = 6813) from different research areas and combined studies that applied the best possible self imagination task, future worry induction, and episodic future simulation, respectively. Findings yielded that imagining the future has a moderate to strong impact on affect, and it has a stronger influence on affect compared to remembering the past. Relevant moderator variables in each research area were also identified. We discuss the findings for the field of psychology in general and clinical psychology in particular. More elaborate research on personal future imagination seems crucial for the further advancement of clinical applications for mental health complaints. We conclude with recommendations for future research on the impact of future imagination on affective well-being.

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.

Effect of expressive and neutral writing on respiratory sinus arrhythmia response over time

BACKGROUND AND OBJECTIVES

Parasympathetic activity, as indexed by respiratory sinus arrhythmia (RSA), underlies key aspects of emotional and cognitive self-regulation. Examining time-varying RSA response during expressive writing about trauma may help inform theory about mechanisms of this intervention. The present study investigated changes in RSA during expressive writing.

METHODS

Participants (N = 246, M_age = 21.5 years, 72% female) were randomly assigned to expressive or neutral writing conditions and wrote for three 20-min sessions. RSA was measured continuously during the first and third writing session.

RESULTS

Linear mixed model analyses of RSA changes within and across sessions by writing groups found that neutral writers, but not expressive writers, exhibited change in RSA. The overall RSA changes during expressive and neutral writing are consistent with theory about the relationship between cognitive and emotional processing mechanisms and vagal activation.

LIMITATIONS

As the present study was not a clinical sample selected on trauma exposure, findings should be considered preliminary. Additionally, engagement of affective and cognitive processes was only hypothesized, as manipulation checks were not performed.

CONCLUSIONS

The present study illustrates the benefits of examining changes in RSA over time. Future work with clinical samples should include additional measures and tasks to better define these mechanisms and rule out alternative hypotheses.

Effects of a training in mental imagery on worry: A proof-of-principle study

Worry is characterized by a predominance of verbal thinking and relatively little mental imagery. This cognitive bias of verbal and abstract processing has been found to impair emotional processing of worry topics so that worrisome thoughts are maintained. On the other hand, engaging in mental imagery during the worry process fosters emotional processing of worry themes. In the present study, we examined whether training high worriers (n=71) to use more mental imagery in their everyday lives is an effective intervention to reduce pathological worry. Results indicated that our novel training in mental imagery (TMI) led to a significant reduction of worry and impairment, assessed both one and five weeks after the training. Furthermore, in highly anxious participants TMI had beneficial effects on controllability of worry, state anxiety, and positive mood. Theoretical and clinical implications of our findings and methodological limitations of this proof-of-principle study are discussed.