The Impact of Written Exposure on Worry

Self-guided imagery rescripting for worry images: A preliminary experimental investigation

BACKGROUND

Mental images of feared events are overactive and intrusive in generalized anxiety disorder (GAD). Imagery rescripting involves integration of positive or neutral imagery and corrective information into images to facilitate emotional processing, reduce imagery intrusions, and re-structure underlying schema. Yet only one known study has applied the technique to treatment of worry. The present study aimed first to examine the relationship between trait worry and properties of future-oriented worry images, and second to examine the efficacy of a self-guided imagery rescripting intervention in improving individuals' response to their worries.

METHODS

Participants recruited through Amazon Mechanical Turk (N = 365) identified their major worry and wrote the script of a worst-case scenario mental image. Participants were randomized to three conditions: re-writing the same worry image script (exposure), or writing scripts of either one or three positive alternative future-oriented images (rescripting conditions).

RESULTS

In preliminary analyses, trait worry negatively predicted participants' ratings of worry images, including valence and ability to cope, and positively predicted distress, anticipated cost, and belief in their negative meaning. In experimental analyses, linear mixed-effects models revealed anxious response and cognitive appraisal of the threat were significantly lower among participants allocated to rescripting relative to exposure. There was no effect of rescripting type.

CONCLUSIONS

This investigation demonstrated the impact of a future-oriented imagery rescripting task on anxiety and cognitive biases associated with real worries in an unselected sample. Results may contribute to the development of imagery rescripting interventions for GAD.

Written Imaginal Exposure for Hoarding Disorder: A Preliminary Pilot Study

ABSTRACT

Hoarding disorder (HD) is marked by difficulty discarding possessions. Many refuse treatment or drop out, which may be due to treatment's incorporation of in-home decluttering, which is feared and avoided. Thus, strategies to prepare patients for decluttering/discarding are needed. Imaginal exposure (IE), or imagining one's worst fears about discarding, could be one such strategy. This pilot preliminarily tested a short-duration IE intervention compared with a control intervention. Over 3 days, adults diagnosed with HD (n = 32) were randomly assigned to either write about and imagine their worst fears about discarding (IE condition) or a neutral topic (control writing [CW] condition). The IE condition showed significant improvements in HD symptoms from preintervention to 1-week follow-up, with medium to large effects; however, the CW condition did as well. Comparing change scores between conditions, the IE condition's improvements were not significantly different than the CW condition's. Overall, IE was helpful in improving HD symptoms, but this pilot did not indicate that it was more helpful than CW. This raises important questions about possible demand characteristics, placebo effects, or regression to the mean, and it has implications for the design and methodology of other studies assessing IE's utility.

The Moderating Role of Intolerance of Uncertainty in the Relationship Between Health Anxiety and Pandemic-Related Stress

Background and Objectives

Global pandemics, including COVID-19, have a significant effect on mental health, and this may be especially true for individuals with health anxiety. Although health anxiety is related to both pandemic-related fears and perceptions of health risks, there is a paucity of research on individual difference variables that might exert an influence on these relationships. The present study examined intolerance of uncertainty (IU) as a potential moderator of the relationship between health anxiety and COVID-related stress, and the relationship between health anxiety and perceived risk of contracting COVID.

Design and Methods

A nationally representative sample of North American adults (N = 204) completed self-report measures of health anxiety, IU, COVID-related stress, and perceived risk of contracting COVID.

Results

Prospective IU moderated the positive relationship between health anxiety and COVID-related stress, as the relationship was strengthened at average and higher levels of prospective IU. Neither IU subscale moderated the relationship between health anxiety and perceived risk.

Conclusion

These results suggest that individuals with elevated health anxiety and high prospective IU may be at higher risk of experiencing COVID-related stress, illuminating the interplay of risk factors that place anxious populations at an increased risk of experiencing stress during acute health risks.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10608-023-10365-w.

Psychological interventions for generalized anxiety disorder: Effects and predictors in a naturalistic outpatient setting

OBJECTIVE

Numerous randomized controlled trials (RCTs) demonstrate the efficacy of cognitive behavioral therapy (CBT), metacognitive therapy (MCT), and methods to reduce intolerance of uncertainty (IU-CBT) in the treatment of generalized anxiety disorder (GAD). However, few studies have investigated these treatments under conditions of routine clinical care. The main objective of this study was to investigate the effectiveness of psychotherapy for GAD in an outpatient setting and to identify factors influencing treatment outcome.

METHODS

Fifty-nine GAD patients received naturalistic CBT (including MCT and IU-CBT) in an outpatient clinic and postgraduate training center for psychotherapy. Patients completed self-report questionnaires at the beginning and end of therapy regarding the main outcome worry as well as metacognitions, intolerance of uncertainty, depression, and general psychopathology.

RESULTS

Worry, negative metacognitions, intolerance of uncertainty, depression, and general psychopathology decreased significantly (p's < .001) with large effect sizes for all symptoms (d = 0.83-1.49). A reliable change in the main outcome worry was observed in 80% of patients, and recovery occurred in 23%. Higher worry scores at posttreatment were predicted by higher pretreatment scores, female sex, and less change in negative metacognitive beliefs during treatment.

CONCLUSIONS

Naturalistic CBT for GAD appears to be effective in routine clinical care for worry as well as depressive symptoms, with particular benefits associated with altering negative metacognitions. However, a recovery rate of only 23% is lower than the rates reported in RCTs. Treatment needs to be improved, especially for patients with more severe GAD and for women.

Longitudinal changes in intolerance of uncertainty and worry severity during CBT for generalized anxiety disorder

Intolerance of uncertainty (IU) is a key construct in generalized anxiety disorder (GAD), but little is known about the concurrent and temporal patterns of associations between IU and GAD symptom severity during treatment. In addition, most of the extant literature focuses on IU as a unidimensional construct, whereas some researchers conceptualize IU as being comprised of two dimensions, inhibitory and prospective IU. Ninety individuals with GAD completed measures of IU and worry severity at pre-treatment, session 4, session 8, and end of treatment (session 12), during group-based cognitive behavior therapy (CBT) for GAD. Longitudinal multilevel modeling showed that IU predicted worry severity concurrently, but not prospectively over time; this pattern of associations was found with the total IUS score and the inhibitory (but not prospective) subscale score. Further, the relationship between IU total scores and worry severity became stronger over time. The relationship between inhibitory (but not prospective) IU and worry also became stronger over time. When the order of the variables in the model was reversed, worry severity also predicted concurrent but not future IU. Therefore, change in IU is associated with change in worry throughout the course of CBT, particularly as treatment progresses, though its directional association as a cause and/or effect remains unclear.

Psychotherapeutic treatments for generalized anxiety disorder: cognitive and behavioral therapies, enhancement strategies, and emerging efforts

INTRODUCTION

Generalized anxiety disorder (GAD) is common and disabling. Different versions of cognitive behavioral therapy (CBT) have been tested, but no treatment works for everyone. Therefore, researchers have attempted approaches to enhance CBT.

AREAS COVERED

The current narrative review examines meta-analyses and individual trials of CBT-based treatments for GAD. We focus on CBT and its cognitive and behavioral components as well as efforts to enhance CBT and its dissemination and generalizability. Enhancement efforts included interpersonal and emotional processing therapy, mindfulness-based CBT, emotion regulation therapy, intolerance of uncertainty therapy, the unified protocol, metacognitive therapy, motivational interviewing, and contrast avoidance targeted treatment. Emerging strategies to enhance dissemination have focused on technologically based treatments. Attempts at generalizability have included examination of efficacy within diverse racial and ethnic groups.

EXPERT OPINION

We conclude that CBT is efficacious, and a number of enhancement efforts have shown some promise in improving upon CBT in single trials. However, more research is needed, particularly efforts to determine which enhancements work best for which individuals and what are the mechanisms of change. Furthermore, few technological interventions have been compared to active treatments. Finally, much more attention needs to be paid to ethnic and racial diversity in randomized controlled trials.

Disentangling the effects of trait and state worry on error-related brain activity: Results from a randomized controlled trial using worry manipulations

Enhanced amplitudes of the error-related negativity (ERN) have been suggested to be a transdiagnostic neural risk marker for internalizing psychopathology. Previous studies propose worry to be an underlying mechanism driving the association between enhanced ERN and anxiety. The present preregistered study focused on disentangling possible effects of trait and state worry on the ERN by utilizing a cross sectional observational and a longitudinal randomized controlled experimental design. To this end, we examined the ERN of n = 90 students during a flanker task (T0), which were then randomly assigned to one of three groups (worry induction, worry reduction, passive control group). Following the intervention, participants performed another flanker task (T1) to determine potential alterations of their ERN. Manipulation checks revealed that compared to the control group, state worry increased in the induction but also in the reduction group. ERN amplitudes did not vary as a function of state worry. An association of trait worry with larger ERN amplitudes was only observed in females. Furthermore, we found larger ERN amplitudes in participants with a current or lifetime diagnosis of internalizing disorders. In summary, our findings suggest that the ERN seems to be insensitive to variations in state worry, but that an elevated ERN is associated with the trait-like tendency to worry and internalizing psychopathology, which is consistent with the notion that the ERN likely represents a trait-like neural risk associated with anxiety.

Relationships between worry and depressive symptoms during two group therapies for generalized anxiety disorder

ABSTRACT Objective: Generalized anxiety disorder (GAD) is a chronic and disabling disorder associated with various impairments and shows a significant prevalence in the worldwide and Brazilian populations. This study aimed to investigate the longitudinal relationship of two symptoms relevant to the disorder (worry and depressive symptoms) in the context of a randomized clinical trial (RCT) by using a cross-lagged panel model (CLPM) analysis. Methods: A total of 92 adult patients with GAD were randomized to receive ten sessions of either acceptance‐based group behavioral therapy (ABBT) or nondirective supportive group therapy (NDST). Treatment had four time-point measures. Worries were measured using the Penn State Worry Questionnaire (PSWQ), and depression was measured using the Depression Anxiety Stress Scales (DASS-D). Results: The NDST model revealed significant paths from worry to depression (first wave) and from depression to worry (second wave). There was no other significant cross-lagged effect. These data show that there was an influence between symptoms only during one of the treatment groups, and without a homogeneous and constant pattern in any of the cross-lagged routes. Conclusion: A supportive group psychotherapy potentially interferes with the pattern of the direct relationship between worries and depressive symptoms in adults with GAD.

Efficacy of an acceptance-based group behavioral therapy for generalized anxiety disorder

BACKGROUND

Generalized anxiety disorder (GAD) shows the weakest treatment response among anxiety disorders. This study aimed at examining whether an acceptance-based group behavioral therapy (ABBT) for patients in a Brazilian anxiety disorders program, combining mindfulness and exposure strategies, can improve clinical outcome when compared with a standard nondirective supportive group therapy (NDST).

METHODS

Ninety-two individuals diagnosed with GAD were randomized to receive 10 sessions of either ABBT or NDST. Assessments at pretreatment, midtreatment, posttreatment, and 3-month follow-up comprised the following outcome measures: Hamilton Anxiety Rating Scale (HAM-A), Penn State Worry Questionnaire (PSWQ), Depression Anxiety and Stress Scale (DASS), and the Clinical Global Impressions (CGI). The World Health Organization Quality of Life (WHOQOL) was administered at pretreatment and posttreatment.

RESULTS

The mixed-effects regression models for DASS-stress, Hamilton Anxiety Interview, and CGI showed a significant effect for Time and the Time × Treatment effect, but not for the Treatment main effect. Similarly, there was a significant Time × Treatment effect for the PSWQ, but not main effects of Time or Treatment. Altogether, these data indicate that symptoms decreased in both conditions across treatment and follow-up, and that the rate of change was more rapid for those participants in the ABBT condition. We found no differences between groups from pretreatment to posttreatment in DASS-anxiety or any secondary outcome measure, but for the physical health domain of WHOQOL, which was faster in ABBT.

CONCLUSIONS

Both groups showed good clinical outcomes, but in general, participants of the ABBT group improved faster than those in the NDST group.

The feasibility of verbal and virtual reality exposure for youth with academic performance worry

With exposure emerging as a key ingredient in anxiety treatment for childhood anxiety disorders (CADs), expansion of exposure techniques is a promising avenue for improving treatment efficacy. The present study examined use of imaginal exposure (IE), a technique understudied in the treatment of CADs. Specifically, the study tested whether two forms of exposure to worries (verbal IE and virtual reality exposure therapy, VRET) would be effective and acceptable forms of exposure with youth. Twenty youth with fears of academic failure completed both types of worry exposure, presented in randomized order. Regardless of order of presentation, both verbal IE and VRET elicited moderate anxiety that decreased to mild over the span of the exposures. Both were found to be acceptable by youth and neither was associated with negative side effects. Youth found VRET to be slightly more interesting and novel, but noted that verbal IE was more realistic and individualized. The present study supports the use of standalone worry exposure as an effective and acceptable treatment for general worries in youth and suggests VRET could be more effective with improved realism.

Eating disorder symptoms and core eating disorder fears decrease during online imaginal exposure therapy for eating disorders

BACKGROUND

Few evidence-based treatments for eating disorders (EDs) exist. Imaginal exposure therapy is a key component of effective treatment for anxiety disorders and post-traumatic stress disorder. However, imaginal exposure has not been systematically tested as a treatment for EDs. The current study aimed to develop and test online imaginal exposure as a treatment for EDs.

METHODS

The current study tested a four-week trial of online imaginal exposure for EDs (N = 229 participants with EDs recruited globally). Participants completed diagnostic interviews and four sessions of weekly online imaginal exposure, in which they wrote about and imagined a core ED fear (identified with a therapist). Participants completed measures of ED symptoms and fears (i.e., fear of weight gain, food) at pre-imaginal exposure, post-imaginal exposure, and six-month follow-up. Participants were recruited and participated in the protocol from November 2016 to October 2018.

RESULTS

All primary outcomes (ED symptoms, ED fears) significantly decreased at study completion and six-month follow-up with medium-to-large effect sizes. State anxiety across the exposure and follow-ups significantly decreased, specifically from initial sessions to follow-up. Worry, but not depression, significantly decreased.

LIMITATIONS

This study was an open case trial and did not include a control condition.

CONCLUSIONS

Significant decreases in ED symptoms and fears occurred during the course of imaginal exposure treatment. Online imaginal exposure is a feasible treatment for EDs and is associated with decreases in core ED symptomatology, which are comparable in magnitude to decreases seen from other evidence-based treatments. A future randomized-controlled trial is needed.

CLINICAL TRIALS REGISTRATION

ClinicalTrials.gov identifier NCT03712748.

How thinking hurts: Rumination, worry, and avoidance processes in adjustment to bereavement

Repetitive negative thought plays an important role in the maintenance of mental health problems following bereavement. To date, bereavement researchers have primarily focused on rumination (i.e., repetitive thought about negative events and/or negative emotions), yet the interest in worry (i.e., repetitive thought about uncertain future events) is increasing. Both cognitive processes potentially lead to poorer adaptation to bereavement by contributing to loss‐related avoidance and behavioural avoidance of activities. The current study aims to establish the differential associations of rumination and worry with symptoms of depression and prolonged grief and clarify if avoidance processes mediate the associations of rumination and worry with symptom levels. Four hundred seventy‐four recently bereaved adults (82% female) filled out questionnaires assessing rumination, worry, loss‐related and behavioural avoidance, and depression and prolonged grief symptoms. Rumination and worry were both uniquely associated with depression and prolonged grief symptoms. Compared with worry, rumination related more strongly to prolonged grief symptoms, whereas correlations of both cognitive styles with depression symptoms did not differ. Loss‐related avoidance and behavioural avoidance partially mediated the associations of rumination and worry with prolonged grief symptoms. Behavioural avoidance partially mediated the associations of rumination and worry with depression symptoms. Findings suggest that exposure and behavioural activation may be effective interventions to reduce repetitive thinking and psychopathology after bereavement.

Exposure to a Standardized Catastrophic Scenario in Virtual Reality or a Personalized Scenario in Imagination for Generalized Anxiety Disorder

The cognitive behavioral treatment of generalized anxiety disorder (GAD) often involves exposing patients to a catastrophic scenario depicting their most feared worry. The aim of this study was to examine whether a standardized scenario recreated in virtual reality (VR) would elicit anxiety and negative affect and how it compared to the traditional method of imagining a personalized catastrophic scenario. A sample of 28 participants were first exposed to a neutral non-catastrophic scenario and then to a personalized scenario in imagination or a standardized virtual scenario presented in a counterbalanced order. The participants completed questionnaires before and after each immersion. The results suggest that the standardized virtual scenario induced significant anxiety. No difference was found when comparing exposure to the standardized scenario in VR and exposure to the personalized scenario in imagination. These findings were specific to anxiety and not to the broader measure of negative affect. Individual differences in susceptibility to feel present in VR was a significant predictor of increase in anxiety and negative affect. Future research could use these scenarios to conduct a randomized control trial to test the efficacy and cost/benefits of using VR in the treatment of GAD.

A Feasibility Open Trial of a Brief Internet-Delivered Written Exposure Therapy for Worry

Background: Cognitive exposure, a treatment of choice for hypothetical fears, involves listening repeatedly to a recorded scenario of one's worst hypothetical fear. A major limitation, however, is that the script cannot be easily modified. Aims: The current study assessed the feasibility of a brief guided internet-based written exposure therapy (iWET) for hypothetical fears, Mind at Peace. Method: Fifty-three adults presenting clinical levels of anxiety (GAD-7 ≥ 8) and worry (PSWQ ≥ 45) were recruited. A single group pre-test/post-test design including a 3-month follow-up was used. Mind at Peace is a 6-week iWET consisting of psychoeducation and five 30-minute weekly writing exposure sessions. Feasibility outcome measures included treatment adherence, attrition, treatment acceptability and preliminary efficacy. Primary outcome measures were the Generalized Anxiety Disorder-7 (GAD-7) and the Penn State Worry Questionnaire (PSWQ). Results: Attrition was higher (57%) and adherence lower (28%) than expected. Intent-to-treat repeated measures ANOVAs revealed significant and large improvements on the GAD-7 (ƞp2 = 0.36) and the PSWQ (ƞp2 = 0.23) with similar findings among study completers. Remission rates were higher on the GAD-7 than on the PSWQ, suggesting that Mind at Peace may primarily target general symptoms of generalized anxiety. Rates of acceptability varied, but nearly all study completers reported that they would recommend this treatment to a friend. Conclusions: This study provided valuable information on Mind at Peace. Methodological changes are proposed to improve its feasibility. A more definitive trial incorporating suggested methodological improvements is recommended.

Internet-Based Extinction Therapy for Worry: A Randomized Controlled Trial

Worry is a common phenotype in both psychiatric patients and the normal population. Worry can be seen as a covert behavior with primary function to avoid aversive emotional experiences. Our research group has developed a treatment protocol based on an operant model of worry, where we use exposure-based strategies to extinguish the catastrophic worry thoughts. The aim of this study was to test this treatment delivered via the Internet in a large-scale randomized controlled trial. We randomized 140 high-worriers (defined as > 56 on the Penn State Worry Questionnaire [PSWQ]) to either Internet-based extinction therapy (IbET) or to a waiting-list condition (WL). Results showed that IbET was superior to WL with an overall large between-group effect size of d = 1.39 (95% confidence interval [1.04,1.73]) on the PSWQ. In the IbET group, 58% were classified as responders. The corresponding figure for WL participants was 7%. IbET was also superior to the WL on secondary outcome measures of anxiety, depression, meta-cognitions, cognitive avoidance, and quality of life. Overall treatment results were maintained for the IbET group at 4- and 12-month follow-up. The results from this trial are encouraging as they indicate that worry can be targeted with an accessible and novel intervention for worry. Replication trials with active control group are needed.

Cognitive-Behavioral Therapy: Nature and Relation to Non-Cognitive Behavioral Therapy

Since the introduction of Beck's cognitive theory of emotional disorders, and their treatment with psychotherapy, cognitive-behavioral approaches have become the most extensively researched psychological treatment for a wide variety of disorders. Despite this, the relative contribution of cognitive to behavioral approaches to treatment are poorly understood and the mechanistic role of cognitive change in therapy is widely debated. We critically review this literature, focusing on the mechanistic role of cognitive change across cognitive and behavioral therapies for depressive and anxiety disorders.

Impact of Mindfulness-Based Cognitive Therapy on Intolerance of Uncertainty in Patients with Panic Disorder

OBJECTIVE

Intolerance of uncertainty (IU) is a transdiagnostic construct in various anxiety and depressive disorders. However, the relationship between IU and panic symptom severity is not yet fully understood. We examined the relationship between IU, panic, and depressive symptoms during mindfulness-based cognitive therapy (MBCT) in patients with panic disorder.

METHODS

We screened 83 patients with panic disorder and subsequently enrolled 69 of them in the present study. Patients participating in MBCT for panic disorder were evaluated at baseline and at 8 weeks using the Intolerance of Uncertainty Scale (IUS), Panic Disorder Severity Scale-Self Report (PDSS-SR), and Beck Depression Inventory (BDI).

RESULTS

There was a significant decrease in scores on the IUS (p<0.001), PDSS (p<0.001), and BDI (p<0.001) following MBCT for panic disorder. Pre-treatment IUS scores significantly correlated with pre-treatment PDSS (p=0.003) and BDI (p=0.003) scores. We also found a significant association between the reduction in IU and PDSS after controlling for the reduction in the BDI score (p<0.001).

CONCLUSION

IU may play a critical role in the diagnosis and treatment of panic disorder. MBCT is effective in lowering IU in patients with panic disorder.

Reducing worry and subjective health complaints: A randomized trial of an internet-delivered worry postponement intervention

OBJECTIVES

Several studies have shown that perseverative, worrisome thoughts are prospectively related to subjective health complaints (SHC) and that a short worry postponement intervention can decrease these complaints. As SHC and worry are prevalent and costly, we tested whether the intervention can be offered online to reduce these complaints in the general population.

DESIGN

A randomized parallel-group trial was conducted with self-selected participants from the general population.

METHODS

Via the research website, 996 participants were instructed to register their worrying for 6 consecutive days. The intervention group was instructed to postpone worry to a special 30-min period in the early evening. The Subjective Health Complaints inventory, as administered before and after the intervention, and daily worry frequency and duration were considered the primary outcomes.

RESULTS

Three hundred and sixty-one participants completed the study. Contrary to our expectation, the registration group (n = 188) did not differ from the intervention group (n = 163) in SHC (ηp² = .000, CI [0.000-0.003]), or in worry frequency or duration. Nevertheless, the different worry parameters were moderately related to SHC (r between .238 and .340, p ≤ .001).

CONCLUSIONS

In contrast to previous studies using pen-and-pencil versions of the worry postponement intervention, this study suggests that a direct online implementation was not effective in reducing SHC and worry. Overall, participants had high trait worry levels and reported difficulty with postponing worrying. Reducing SHC and worries via the Internet might require more elaborate interventions that better incorporate the advantages of delivering interventions online.

STATEMENT OF CONTRIBUTION

What is already known on this subject? The perseverative cognition hypothesis argues that perseverative cognition, such as worry and rumination, acts as a mediator by which psychosocial stress may produce negative health effects. Prior research has indeed shown that worry and subjective health complaints (SHC) are prospectively related, but causality studies - that is, showing that changes in worry induce changes in health outcomes - are scarce and have mainly been conducted in young samples. These studies showed that reducing worry, using a worry postponement intervention, can reduce daily worrying and SHC. What does this study add? Trait and daily worrying are associated with SHC. An online worry postponement intervention is ineffective in reducing worry and SHC. Paper-and-pencil interventions cannot directly be used as online interventions.

Intolerance of uncertainty as a mediator of reductions in worry in a cognitive behavioral treatment program for generalized anxiety disorder

Growing evidence suggests that intolerance of uncertainty (IU) is a cognitive vulnerability that is a central feature across diverse anxiety disorders, including generalized anxiety disorder (GAD). Although cognitive behavioral therapy (CBT) has been shown to reduce IU, it remains to be established whether or not reductions in IU mediate reductions in worry. This study examined the process of change in IU and worry in a sample of 28 individuals with GAD who completed CBT. Changes in IU and worry, assessed bi-weekly during treatment, were analyzed using multilevel mediation models. Results revealed that change in IU mediated change in worry (ab = -0.20; 95% CI [-.35, -.09]), but change in worry did not mediate change in IU (ab = -0.16; 95% CI [-.06, .12]). Findings indicated that reductions in IU accounted for 59% of the reductions in worry observed over the course of treatment, suggesting that changes in IU are not simply concomitants of changes in worry. Findings support the idea that IU is a critical construct underlying GAD.

Evaluation of a brief 4-session psychoeducation procedure for high worriers based on the mood-as-input hypothesis

BACKGROUND & OBJECTIVES

Given the ubiquity of worrying as a consuming and distressing activity at both clinical and sub-clinical levels, it is important to develop theory-driven procedures that address worrying and allow worriers to manage this activity. This paper describes the development and testing of a psychoeducation procedure based on mood-as-input hypothesis, which is a transdiagnostic model that describes a proximal mechanism for perseverative worrying. The study used nonclinical participants meeting IAPT criteria indicating GAD symptomatology.

METHODS

In 4 sessions, participants in experimental groups received psychoeducation about the basic principles of the mood-as-input hypothesis and received guidance on how to identify and change worry-relevant goal-directed decision rules and negative moods. Participants in the psychoeducation conditions were compared with participants in a befriending control group.

RESULTS

Psychoeducation about the model significantly reduced PSWQ scores at follow-up compared with the befriending control condition (a between-groups large effect size, Cohen's d = 1.05), and the homework tasks undertaken by the psychoeducation groups raised mood and reduced worry immediately. At follow up 48.2% of participants in the psychoeducation groups were below the recommended cut-off for identifying GAD symptomatology compared with 20% of participants in the control condition.

LIMITATIONS

This study was conducted on a small sample, high-worry student population, without a formal diagnosis.

CONCLUSIONS

This brief, low-intensity procedure is potentially adaptable to online or self-help procedures, and can be integrated into fuller cognitive therapy packages.

Testing a procedural variant of written imaginal exposure for generalized anxiety disorder

This experiment examined the degree to which it is more beneficial for individuals with generalized anxiety disorder (GAD) to engage in repeated exposure to mental imagery of the same feared scenario versus varying the exposure content. On three consecutive days, individuals with GAD (N=57) spent 20min writing about: (1) the same worst case scenario (consistent exposure; CE), (2) variations of their worst case scenario (varied exposure; VE), or (3) a neutral topic (neutral control; NC). Participants in the CE condition displayed significant decreases in worry, acute cognitive avoidance, and intolerance of uncertainty from baseline to 1-week follow-up; participants in the VE and NC conditions did not. Initial activation of self-reported anxiety (observed in the CE and VE conditions) and between-session reduction in anxiety (observed in the CE condition only) were associated with improvement in worry. Including more references to negative emotion and writing in the present tense were also associated with greater improvement in worry in the CE condition. These findings suggest that writing repeatedly about the same worst case scenario may benefit people with GAD. The study also provides information on potential mechanisms of change.

Changes in intolerance of uncertainty during cognitive behavior group therapy for social phobia

BACKGROUND AND OBJECTIVES

Recent research suggests that intolerance of uncertainty (IU), most commonly associated with generalized anxiety disorder, also contributes to symptoms of social phobia. This study examines the relationship between IU and social anxiety symptoms across treatment.

METHOD

Changes in IU, social anxiety symptoms, and depression symptoms were examined following cognitive behavior group therapy (CBGT) for social phobia (N=32).

RESULTS

CBGT led to significant improvements in symptoms of social anxiety and depression, as well as reductions in IU. Reductions in IU were associated with reductions in social anxiety but were unrelated to improvements in depression symptoms. Reductions in IU were predictive of post-treatment social phobia symptoms after controlling for pre-treatment social phobia symptoms and changes in depression symptoms following treatment.

LIMITATIONS

The relationship between IU and social anxiety requires further examination within experimental and longitudinal designs, and needs to take into account additional constructs that are thought to maintain social phobia.

CONCLUSIONS

Current findings suggest that the enhancing tolerance of uncertainty may play a role in the optimal management of social phobia. Theoretical and clinical implications are discussed.

An experimental investigation of the role of negative mood in worry: the role of appraisals that facilitate systematic information processing

BACKGROUND AND OBJECTIVES

Negative mood is associated with increased worry levels, and also with deployment of a systematic information processing style. An experimental study assessed the potential role of systematic information processing in mediating the facilitative effect of negative mood on worry (e.g. Johnston & Davey, 1997).

METHOD

Participants underwent appropriate vignette-based mood inductions (negative, neutral, and cognitive priming). Participants completed visual analogue scales measuring variables that reflect a raised processing sufficiency threshold and are known to increase systematic processing (responsibility, accountability, desire for control, and need for cognition), a measure of 'as many as can' worry stop rule deployment, and two measures of worry (the catastrophising interview and the Penn State Worry Questionnaire, PSWQ, Meyer, Miller, Metzger, & Borkovec, 1990).

RESULTS

Experimentally-induced negative mood facilitated the endorsement of cognitive appraisals known to increase systematic as opposed to heuristic information processing. In addition, a meditational analysis showed that the systematic processing facilitators measure together with a measure of 'as many as can' worry stop rule deployment fully mediated the relationship between negative mood and a measure of worry frequency (PSWQ).

LIMITATIONS

Future studies should develop and validate direct measures of systematic processing.

CONCLUSIONS

Similarities and differences between systematic processing and chronic worrying as effortful forms of information processing are discussed, and a role for systematic processing as an information processing style relevant to understanding worrisome thought is described.

Conscious and unconscious perseverative cognition: is a large part of prolonged physiological activity due to unconscious stress?

Prolonged physiological activity is believed to be a key factor mediating between stress and later disease outcomes. Few studies, however, have investigated the crucial psychological factors that cause prolonged activity. This article proposes that conscious as well as unconscious perseverative cognition are the critical factors. Perseverative cognition indicates repetitive or sustained activation of cognitive representations of past stressful events or feared events in the future. In daily life, most prolonged physiological activity is not due to stressful events but to perseverative cognition about them. We and others have already found evidence that conscious perseverative cognition, i.e., worry, has physiological effects, in both laboratory and real life settings, and that perseverative cognition mediates prolonged responses to stressful events. Yet, there are convincing reasons to expect that unconscious perseverative cognition has an even larger role in stress-related prolonged activity. Firstly, since the greater part of cognitive processing operates without awareness, a considerable part of perseverative cognition is likely to be unconscious too. People may not be aware of most of their stress-related cognitive processes. Secondly, our recent studies have shown that increased activity of the autonomic nervous system continues after conscious perseverative cognition has stopped: It goes on for several hours and even during sleep. This and several other findings suggest that a considerable part of increased physiological activity may be due to unconscious perseverative cognition. The article closes with suggesting methods to test unconscious perseverative cognition and ways to change it, and concludes with stating that the notion of unconscious perseverative cognition potentially opens an entirely new area within stress research.

Efficacy of self-administered treatments for pathological academic worry: A randomized controlled trial

Research on treatments for reducing pathological worry is limited. In particular, academic worry is a common theme in generalized anxiety disorder (GAD) samples as well as non-clinical student samples. Given the high cost of anxiety disorders to society, research is needed to examine the efficacy of self-administered treatments designed to reduce pathological worry. The primary goal of this study was to investigate the benefits of three self-administered interventions for reducing academic worry. College students (N = 113) experiencing clinically significant academic worry were randomized to either: (a) worry exposure (WE); (b) expressive writing (EW); (c) relaxation consisting of pulsed audio-photic stimulation (APS); or (d) waitlist control (WLC). Participants were instructed to practice their interventions three times per week for one month and completed home practice logs online to track treatment adherence. Academic worry, general anxiety, and perceived stress were assessed at baseline and post-treatment. Academic worry and general anxiety were also assessed at a three-month follow-up. Those assigned to the WE and APS conditions showed significant improvement relative to EW and WLC at post-treatment. All treatment conditions showed continued improvement by follow-up, with no between-group differences. Treatment and public health implications are discussed.

Current theoretical models of generalized anxiety disorder (GAD): conceptual review and treatment implications

Theoretical conceptualizations of generalized anxiety disorder (GAD) continue to undergo scrutiny and refinement. The current paper critiques five contemporary models of GAD: the Avoidance Model of Worry and GAD [Borkovec, T. D. (1994). The nature, functions, and origins of worry. In: G. Davey & F. Tallis (Eds.), Worrying: perspectives on theory assessment and treatment (pp. 5-33). Sussex, England: Wiley & Sons; Borkovec, T. D., Alcaine, O. M., & Behar, E. (2004). Avoidance theory of worry and generalized anxiety disorder. In: R. Heimberg, C. Turk, & D. Mennin (Eds.), Generalized anxiety disorder: advances in research and practice (pp. 77-108). New York, NY, US: Guilford Press]; the Intolerance of Uncertainty Model [Dugas, M. J., Letarte, H., Rheaume, J., Freeston, M. H., & Ladouceur, R. (1995). Worry and problem solving: evidence of a specific relationship. Cognitive Therapy and Research, 19, 109-120; Freeston, M. H., Rheaume, J., Letarte, H., Dugas, M. J., & Ladouceur, R. (1994). Why do people worry? Personality and Individual Differences, 17, 791-802]; the Metacognitive Model [Wells, A. (1995). Meta-cognition and worry: a cognitive model of generalized anxiety disorder. Behavioural and Cognitive Psychotherapy, 23, 301-320]; the Emotion Dysregulation Model [Mennin, D. S., Heimberg, R. G., Turk, C. L., & Fresco, D. M. (2002). Applying an emotion regulation framework to integrative approaches to generalized anxiety disorder. Clinical Psychology: Science and Practice, 9, 85-90]; and the Acceptance-based Model of GAD [Roemer, L., & Orsillo, S. M. (2002). Expanding our conceptualization of and treatment for generalized anxiety disorder: integrating mindfulness/acceptance-based approaches with existing cognitive behavioral models. Clinical Psychology: Science and Practice, 9, 54-68]. Evidence in support of each model is critically reviewed, and each model's corresponding evidence-based therapeutic interventions are discussed. Generally speaking, the models share an emphasis on avoidance of internal affective experiences (i.e., thoughts, beliefs, and emotions). The models cluster into three types: cognitive models (i.e., IUM, MCM), emotional/experiential (i.e., EDM, ABM), and an integrated model (AMW). This clustering offers directions for future research and new treatment strategies.