Worry themes in primary GAD, secondary GAD, and other anxiety disorders

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.

Pain catastrophizing and worry about health in generalized anxiety disorder

Because the diagnostic criteria of generalized anxiety disorder (GAD) are not tied to specific worry domains (worry is 'generalized'), research on the content of worry in GAD is lacking. To our knowledge, no study has addressed vulnerability for specific worry topics in GAD. The goal of the current study, a secondary analysis of data from a clinical trial, is to explore the relationship between pain catastrophizing and worry about health in a sample of 60 adults with primary GAD. All data for this study were collected at pretest, prior to randomization to experimental condition in the larger trial. The hypotheses were that (1) pain catastrophizing would be positively related to the severity of GAD, (2) the relationship between pain catastrophizing and the severity of GAD would not be explained by intolerance of uncertainty and psychological rigidity, and (3) pain catastrophizing would be greater in participants reporting worry about health compared to those not reporting worry about health. All hypotheses were confirmed, suggesting that pain catastrophizing may be a threat-specific vulnerability for health-related worry in GAD. The implications of the current findings include a better understanding of the ideographic content of worry, which could help focus treatment interventions for individuals with GAD.

To Leave is to Die a Little: Assessing the Symptom Structure of Separation Anxiety Disorder in Left-Behind Emerging Adults

The literature on separation anxiety disorder (SAD) presented two contentious issues relating to its assessment. First, studies are scarce in assessing the symptom structure of DSM-5 SAD among the adult population. Second, the accuracy in assessing the severity of SAD through measuring the intensity of disturbance and the frequency of occurrence of symptoms is yet to be studied. To address these limitations, the present study aimed to: (1) examine the latent factor structure of the newly developed separation anxiety disorder symptom severity inventory (SADSSI); (2) evaluate the necessity of using frequency or intensity formats through comparison of differences in the latent level; and (3) investigate SAD latent class analysis. Utilizing 425 left-behind emerging adults (LBA), the findings showed that a general factor with two dimensions (i.e., response formats) measuring frequency and intensity symptom severity separately has excellent fit and good reliability. Finally, the latent class analysis yielded a three-class solution best fitting to the data. Overall, the data provided evidence for the psychometric soundness of SADSSI as an assessment tool for separation anxiety symptoms among LBA.

Perceived manageability of debt and mental health during the COVID-19 pandemic: A UK population analysis

Objectives

This study examined the association between perceived manageability of debt and risk of depression, anxiety, and mental health help-seeking among a nationally representative sample of adults living in the United Kingdom (UK).

Methods

Data was derived from the COVID-19 Psychological Research Consortium (C19PRC) Study Wave 6 (August/September 2021) which examined the psychological, social, and economic effects of the COVID-19 pandemic on the UK adult population. Bivariate and logistic regression analyses were conducted to determine the association between different levels of perceived debt manageability (i.e., “easily manageable”, “some problems”, “quite serious problems”, “very serious problems”, “cannot manage at all”) and mental health related outcomes.

Results

Almost a quarter of the sample (24%, n = 494) reported debt management problems, and debt manageability associated with higher levels of anxiety, depression, and mental health help-seeking. After adjusting for demographic variables (e.g. income, receipt of benefits), logistic regression analysis demonstrated a dose-response association between increasing levels of debt manageability problems and mental health outcomes. Specifically, adjusted odds ratios for anxiety ranged from 2.28 (‘some problems’) to 11.18 (‘very serious problems’), for depression ranged from 2.80 (‘some problems’) to 16.21 (‘cannot manage at all’), and for mental health help-seeking ranged from 1.69 (‘some problems’) to 3.18 (‘quite serious problems’, ‘very serious problems’).

Conclusion

This study highlights that debt manageability problems represent a robust predictor of depression, anxiety, and mental-health help seeking.

Toward Linguistic Recognition of Generalized Anxiety Disorder

Background

Generalized anxiety disorder (GAD) refers to extreme, uncontrollable, and persistent worry and anxiety. The disorder is known to affect the social functioning and well-being of millions of people, but despite its prevalence and burden to society, it has proven difficult to identify unique behavioral markers. Interestingly, the worrying behavior observed in GAD is argued to stem from a verbal linguistic process. Therefore, the aim of the present study was to investigate if GAD can be predicted from the language people use to put their anxious worries into words. Given the importance of avoidance sensitivity (a higher likelihood to respond anxiously to novel or unexpected triggers) in GAD, this study also explored if prediction accuracy increases when individual differences in behavioral avoidance and approach sensitivity are taken into account.

Method

An expressive writing exercise was used to explore whether GAD can be predicted from linguistic characteristics of written narratives. Specifically, 144 undergraduate student participants were asked to recall an anxious experience during their university life, and describe this experience in written form. Clinically validated behavioral measures for GAD and self-reported sensitivity in behavioral avoidance/inhibition (BIS) and behavioral approach (BAS), were collected. A set of classification experiments was performed to evaluate GAD predictability based on linguistic features, BIS/BAS scores, and a concatenation of the two.

Results

The classification results show that GAD can, indeed, be successfully predicted from anxiety-focused written narratives. Prediction accuracy increased when differences in BIS and BAS were included, which suggests that, under those conditions, negatively valenced emotion words and words relating to social processes could be sufficient for recognition of GAD.

Conclusions

Undergraduate students with a high GAD score can be identified based on their written recollection of an anxious experience during university life. This insight is an important first step toward development of text-based digital health applications and technologies aimed at remote screening for GAD. Future work should investigate the extent to which these results uniquely apply to university campus populations or generalize to other demographics.

Revised Beckian cognitive therapy for generalised anxiety disorder

Since its inclusion in the DSM-III, various theories and treatment approaches have been developed for generalised anxiety disorder (GAD). Aaron T. Beck was the first to offer a cognitive conceptualisation of GAD in Anxiety Disorders and Phobias: A Cognitive Perspective. This original cognitive model of GAD was initially found to be promising in treating GAD but has not been developed further. Other theoretical models and treatments of GAD have gained more research attention, such as the Intolerance of Uncertainty model and Meta-Cognitive model. This article offers a brief overview of multiple theories and treatment approaches of GAD followed by an extensive discussion about the original cognitive model and a revised cognitive model of GAD in the Beckian tradition. Specifically, this paper describes how known key psychological maintenance factors of anxiety disorders, i.e. threat beliefs, safety-seeking behaviours and selective attention, can be used to conceptualise the experience of people with GAD and guide treatment. This is done with theoretical discussion as well as clinical examples. Finally, the paper offers suggestions for key ingredients to be included in cognitive therapy for GAD and future directions for research.

Key learning aims

(1)

Feeling safe: Judgements of safety and anxiety as a function of worry and intolerance of uncertainty

Safety perspectives of generalized anxiety disorder (GAD) propose that safety perception is critical to regulating anxiety. Reduced safety processing may contribute to persistent worry and anxiety that extend to recognizably safe contexts. We explored whether individuals higher in worry and intolerance of uncertainty (IU), central characteristics of GAD, display poorer recognition and use of safety cues, and whether safety perception is related to anxiety. One hundred and eighty-two adults were presented with unfolding potentially threatening scenarios, half of which contained safety information. Participants rated how safe and anxiety-provoking each scenario was as they received new information, as well as overall. Using multilevel modeling, results showed that individuals higher in worry and IU recognize safety information and use it to appraise the safety of a situation. A moderate correlation between safety and anxiety ratings, and inconsistent correspondence between ratings of safety and anxiety, suggest this relationship is complicated by additional factors. Individuals higher in worry and IU may have difficulty accepting their safety appraisals in order to inhibit their anxiety. The implications of the findings and future avenues of research are discussed.

The Association between 5-Hydroxytryptamine Receptor 1B rs13212041 Polymorphism and Trait Anxiety in Chinese Han College Subjects

Trait anxiety is a vulnerable personality factor for anxiety and depression. High levels of trait anxiety confer an elevated risk for the development of anxiety and other psychiatric disorders. There is evidence that 5-hydroxytryptamine receptor 1B (5-HT1B) gene polymorphisms play an important role in emotional disorders. Genotyping for four single-nucleotide polymorphisms (SNP) (rs11568817, rs130058, rs6297, and rs13212041) was conducted for 388 high trait anxious (HTA) individuals and 463 low traitanxious (LTA) individuals in Chinese Han college subjects. The results showed that the frequencies of the C-allele and TC + CC genotype of rs13212041 in the LTA individuals were higher than that in the HTA individuals (p = 0.025 and p = 0.014, respectively). Both the C-allele and TC + CC genotype were associated with trait anxiety decreasing (OR = 0.771 and OR = 0.71, respectively). Furthermore, different gene model analysis also showed that the C allele was a protective factor for trait anxiety in Chinese Han college subjects. These findings suggest that 5-HT1B rs13212014 may play a role in trait anxiety among China Han college subjects. The rs13212014 polymorphism may be involved in decreasing the risk of trait anxiety. These results also provide a novel insight into the molecular mechanism underlying trait anxiety.

Restlessness in Generalized Anxiety Disorder: Using Actigraphy to Measure Physiological Reactions to Threat

Generalized anxiety disorder (GAD) is characterized by excessive, uncontrollable worry accompanied by symptoms of physiological arousal. Although individuals with GAD report greater subjective arousal than healthy individuals, they show equivalent or even attenuated physiological reactions to threat. This may result from using physiological measures better suited to fear than anxiety. To test this possibility, 102 adults with and without GAD were assessed for restlessness, a core physiological symptom of GAD. They were exposed to an in vivo threat task designed to elicit anxiety in the laboratory. Throughout the task, restlessness was measured physiologically with actigraphy sensors on both ankles and both wrists, and subjectively with self-report ratings. The GAD group reported higher subjective restlessness than the no-GAD group, and in the subset of cases who had restlessness as a clinically significant symptom, actigraphy scores were reliably elevated as well. However, although actigraphy scores increased with proximity to the threat, the increases did not differ by group. These findings provide initial validation for actigraphy as a novel measure of motor restlessness in GAD. In addition, they underscore the value of measuring restlessness using multiple assessment methods. These methods suggest that, in GAD, restlessness reflects a chronic state of arousal rather than a heightened physiological reaction to threat.

Fear of Cancer Recurrence, Health Anxiety, Worry, and Uncertainty: A Scoping Review About Their Conceptualization and Measurement Within Breast Cancer Survivorship Research

Objective: Fear of Cancer Recurrence (FCR), Health Anxiety (HA), worry, and uncertainty in illness are psychological concerns commonly faced by cancer patients. In survivorship research, these similar, yet different constructs are frequently used interchangeably and multiple instruments are used in to measure them. The lack of clear and consistent conceptualization and measurement can lead to diverse or contradictory interpretations. The purpose of this scoping review was to review, compare, and analyze the current conceptualization and measurements used for FCR, HA, worry, and uncertainty in the breast cancer survivorship literature to improve research and practice.

Inclusion Criteria: We considered quantitative, qualitative, and mixed methods studies of breast cancer survivors that examined FCR, HA, worry, or uncertainty in illness as a main topic and included a definition or assessment of the constructs.

Methods and Analysis: The six-staged framework was used to guide the scoping review process. Searches of PubMed, CINAHL, and PsycINFO databases were conducted. The principle-based qualitative analysis and simultaneous content analysis procedures were employed to synthesize and map the findings.

Findings: After duplicate removal, the search revealed 3,299 articles, of which 82 studies met the inclusion criteria. Several critical attributes overlapped the four constructs, for example, all were triggered by internal somatic and external cues. However, several unique attributes were found (e.g., a sense of loss of security in the body is observed only among survivors experiencing FCR). Overall, findings showed that FCR and uncertainty in illness are more likely to be triggered by cancer-specific factors, while worry and HA have more trait-like in terms of characteristics, theoretical features, and correlates. We found that the measures used to assess each construct were on par with their intended constructs. Eighteen approaches were used to measure FCR, 15 for HA, 8 for worry, and 4 for uncertainty.

Conclusion: While consensus on the conceptualization and measurement of the four constructs has not yet been reached, this scoping review identifies key similarities and differences to aid in their selection and measurement. Considering the observed overlap between the four studied constructs, further research delineating the unique attributes for each construct is warranted.

Cognitive analysis of specific threat beliefs and safety-seeking behaviours in generalised anxiety disorder: revisiting the cognitive theory of anxiety disorders

BACKGROUND

Generalised anxiety disorder (GAD) has been an uneasy member of the anxiety disorders group since its inclusion in the third edition of the DSM. Multiple theories and treatment protocols for GAD and its defining symptom, excessive worry, have comparable efficacy in treating GAD symptoms. Crucially, these theories of GAD and excessive worry fail to explain when and why worry is excessive and when it is adaptive.

AIMS

In this paper we propose a cognitive behavioural account of the difference between excessive and adaptive states of worry and explore the theme of threat and the function of safety-seeking behaviours as seen in GAD. Specifically, we incorporate the concept of inflated responsibility in a cognitive behavioural analysis of threat appraisal and safety-seeking behaviours in excessive worry and GAD.

CONCLUSION

It is proposed that when worry is used as a strategy intended to increase safety from perceived social or physical threat then it should be conceptualised as a safety-seeking behaviour. However, when worry is used as a strategy to solve a problem which the person realistically can resolve or to deal explicitly with the feeling of anxiety then it functions as an adaptive coping behaviour. We also propose that the theme of threat in GAD centres on an inflated sense of responsibility for external everyday situations, and the function of safety-seeking behaviours is to attain certainty that responsibility has been fulfilled. The clinical implications of this cognitive behavioural analysis of excessive worry are discussed, as well as future research directions.

Interpretation Bias Across Body Dysmorphic, Social Anxiety and Generalized Anxiety Disorder—A Multilevel, Diffusion Model Account

Background

Interpretation biases are suggested to be transdiagnostic phenomena, but have rarely been compared across different disorders and current concerns.

Methods

We investigated explicit, decision-based, and more implicit, reaction time-based interpretation bias in individuals with body dysmorphic disorder (BDD; N = 29), social anxiety disorder (SAD; N = 36), generalized anxiety disorder (GAD; N = 22), and non-clinical controls (NC; N = 32), using an adapted Word Sentence Association Paradigm (WSAP).

Results

Results indicated that interpretation bias occurred transdiagnostically, while content-specific bias patterns varied meaningfully across groups. BDD and SAD shared explicit and, more inconsistently, implicit interpretation biases for appearance-related and social situations. The GAD group exhibited an explicit and implicit negative interpretation bias for general situations, and an additional implicit lack of positive bias. Mechanistic Wiener diffusion model analyses revealed that interpretation bias patterns were mainly driven by speeded information uptake, potentially mirroring disorder-specific associative memory organization.

Conclusions

These findings have important implications for understanding interpretation biases as both etiological and treatment factors.

Salient safety conditioning improves novel discrimination learning

Generalized fear is one purported mechanism of anxiety that is a target of clinical and basic research. Impaired fear discrimination has been primarily examined from the perspective of increased fear learning, rather than how learning about non-threatening stimuli affects fear discrimination. To address this question, we tested how three Safety Conditioning protocols with varied levels of salience allocated to the safety cue compared to classic Fear Conditioning in their impact on subsequent innate anxiety, and differential fear learning of new aversive and neutral cues. Using a high anxiety strain of mice (129SvEv, Taconic), we show that Fear Conditioned animals show little exploration of the anxiogenic center of an open field 24 h later, and poor discrimination during new differential conditioning 7 days later. Three groups of mice underwent Safety Conditioning, (i) the safety tone was unpaired with a shock, (ii) the safety tone was unpaired with the shock and co-terminated with a house light signaling the end of the safety period, and (iii) the safety tone was unpaired with the shock and its beginning co-occurred with a house light, signaling the start of a safety period. Mice from all Safety Conditioning groups showed higher levels of open field exploration than the Fear Conditioned mice 24 h after training. Furthermore, Safety Conditioned animals showed improved discrimination learning of a novel non-threat, with the Salient Beginning safety conditioned group performing best. These findings indicate that high anxiety animals benefit from salient safety training to improve exploration and discrimination of new non-threating stimuli.

The co-occurrence between symptoms of internet gaming disorder and psychiatric disorders in childhood and adolescence: prospective relations or common causes?

BACKGROUND

Internet gaming disorder (IGD) is highlighted as a condition for further study in the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5). Some studies indicate that IGD appears comorbid with other psychiatric disorders. We examine concurrent and prospective links between symptoms of IGD and symptoms of common psychiatric disorders in childhood and adolescence to determine whether observed comorbidity is a result of (a) reciprocal relations or (b) common underlying causes.

METHODS

A community sample (n = 702) of Norwegian children completed the Internet Gaming Disorder Interview (IGDI) to assess DSM-5 defined IGD symptoms at ages 10, 12 and 14 years. The Child and Adolescent Psychiatric Assessment (CAPA) assessed symptoms of depression, anxiety, attention-deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD) and conduct disorder (CD) at the same time points.

RESULTS

A Random Intercept Cross-lagged Panel Model (RI-CLPM), which captures pure within-person changes and adjusts for all unmeasured time-invariant factors (e.g., genetics, parent education) revealed no associations between IGD symptoms and psychopathology, except that increased IGD symptoms at ages 10 and 12 predicted decreased symptoms of anxiety two years later.

CONCLUSIONS

No support emerged for concurrent or prospective relations between IGD and psychiatric symptoms, except in one case: increased IGD symptoms forecasted reduction in anxiety symptoms. Observed co-occurrence between IGD symptoms and mental health problems can mainly be attributed to common underlying factors.

Six-month prevalence and correlates of generalized anxiety disorder among primary care patients aged 70 years and above: Results from the ESA-services study

OBJECTIVES

To estimate the 6-month prevalence of generalized anxiety disorder (GAD) in primary care patients aged 70 years and above and to describe their clinical profile, including types of worries.

METHODS/DESIGN

Participants (N = 1193) came from the Étude sur la Santé des Aînés (ESA) services study conducted in Quebec, Canada. An in-person structured interview was used to identify GAD and other anxiety/depressive disorders as well as to identify types of worries. Three groups were created (ie, patients with GAD, patients with another anxiety disorder, and patients without anxiety disorders) and compared on several sociodemographic and clinical characteristics using multinomial logistic regression analyses.

RESULTS

The 6-month prevalence of GAD was 2.7%. Findings also indicated that the most common types of worries were about health, being a burden for loved ones, and losing autonomy. Compared with respondents without anxiety disorders, older patients with GAD were more likely to be women, be more educated, suffer from depression, use antidepressants, be unsatisfied with their lives, and use health services. In comparison with respondents with another anxiety disorder, those with GAD were 4.5 times more likely to suffer from minor depression.

CONCLUSIONS

GAD has a high prevalence in primary care patients aged 70 years and above. Clinicians working in primary care settings should screen for GAD, since it remains underdiagnosed. In addition, it may be associated with depression and life dissatisfaction. Screening tools for late-life GAD should include worry themes that are specific to aging.

Focusing on situation-specific expectations in major depression as basis for behavioural experiments - Development of the Depressive Expectations Scale

OBJECTIVES

Dysfunctional expectations are considered to be core features of various mental disorders. The aim of the study was to develop the Depressive Expectations Scale (DES) as a depression-specific measure for the assessment of dysfunctional expectations. Whereas previous research primarily focused on general cognitions and attitudes, the DES assesses 25 future-directed expectations (originally 75 items) which are situation-specific and falsifiable.

DESIGN AND METHODS

To evaluate the psychometric properties of the DES, the scale was completed by 175 participants with and without severe depressive symptoms in an online survey. Participants additionally completed the Patient Health Questionnaire modules for depression (PHQ-9) and anxiety (GAD-7). People experiencing depressive symptoms were informed about the study with the help of self-help organizations.

RESULTS

Reliability analyses indicated excellent internal consistency of the scale. An exploratory factor analyses revealed four factors: social rejection, social support, mood regulation, and ability to perform. The DES sum score strongly correlated with the severity of depressive symptoms. The DES sum score also significantly correlated with symptoms of generalized anxiety.

CONCLUSION

The DES was shown to have excellent reliability; validity analyses were promising. As the DES items are situation-specific and falsifiable, they can be tested by the individual using behavioural experiments and may therefore facilitate cognitive restructuring. Thus, a structured assessment of patients' expectation with help of the DES can provide a basis for interventions within cognitive-behavioural treatment of depression.

PRACTITIONER POINTS

Assessing situation-specific expectations in patients experiencing depressive symptoms can provide a basis for the conduction of behavioural experiments to test patients' expectations. For the use of behavioural experiments, therapists should choose those dysfunctional expectations which a patient strongly agrees on. To modify patients' expectations, they should be exposed to situations where the discrepancy between patients' expectations and actual situational outcomes can be maximized. The Depressive Expectations Scale can be completed repeatedly to monitor a patient's progress within cognitive-behavioural treatment.

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.

Cognitive bias modification for interpretation with and without prior repetitive negative thinking to reduce worry and rumination in generalised anxiety disorder and depression: protocol for a multisession experimental study with an active control condition

INTRODUCTION

Worry and rumination are two forms of repetitive thinking characterised by their negative content and apparently uncontrollable nature. Although worry and rumination share common features and have been conceptualised as part of a transdiagnostic repetitive negative thinking (RNT) process, it remains unclear whether they share the same underlying cognitive mechanisms. This multisession experimental study investigates the tendency to make negative interpretations regarding ambiguous information as a cognitive mechanism underlying RNT. We compare multisession cognitive bias modification for interpretations (CBM-I) with an active control condition to examine whether repeatedly training positive interpretations reduces worry and rumination in individuals with generalised anxiety disorder or depression, respectively. Further, we examine the potential modulatory effects of engaging in RNT immediately prior to CBM-I.

DESIGN, METHODS AND ANALYSIS

A community sample of individuals meeting diagnostic criteria for either generalised anxiety disorder (n=60) or current major depressive episode (n=60) will be randomly allocated to CBM-I with prior RNT, CBM-I without prior RNT (ie, standard CBM-I), or an active control (no resolution of ambiguity) condition. All conditions receive a 3-week internet-based intervention consisting of one initial session at the first study visit and nine home-based sessions of CBM-I training (or active control). We will assess and compare the effects of CBM-I with and without prior RNT on 'near-transfer' measures of interpretation bias closely related to the training as well as 'far-transfer' outcomes related to RNT and emotional distress. Impact on questionnaire measures will additionally be assessed at 1-month follow-up. Multigroup analyses will be conducted to assess the impact of CBM-I on near-transfer and far-transfer outcome measures.

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.

Expectancy bias in anxious samples

Although it is well documented that anxious individuals have negative expectations about the future, it is unclear what cognitive processes give rise to this expectancy bias. Two studies are reported that use the Expectancy Task, which is designed to assess expectancy bias and illuminate its basis. This task presents individuals with valenced scenarios (Positive Valence, Negative Valence, or Conflicting Valence), and then evaluates their tendency to expect subsequent future positive relative to negative events. The Expectancy Task was used with low and high trait anxious (Study 1: n = 32) and anxiety sensitive (Study 2: n = 138) individuals. Results suggest that in the context of physical concerns, both high anxious samples display a less positive expectancy bias. In the context of social concerns, high trait anxious individuals display a negative expectancy bias only when negatively valenced information was previously presented. Overall, this suggests that anxious individuals display a less positive expectancy bias, and that the processes that give rise to this bias may vary by type of situation (e.g., social or physical) or anxiety difficulty.

Confirmatory factor analysis of the Dutch Intolerance of Uncertainty Scale: Comparison of the full and short version

BACKGROUND AND OBJECTIVES

The Intolerance of Uncertainty Scale (IUS) was developed for assessing reactions to ambiguous situations, uncertainty, and future events. The IUS has been validated in different languages, but equivocal factor structures, in combination with highly interrelated items and factors, resulted in a redundancy of the items of the English version. In the current study, the psychometric properties of the Dutch version of the IUS were examined, and compared with the shortened 12-item version (IUS-12).

METHODS

Confirmatory factor analyses were used to investigate different factor structures of both the full and short version of the IUS.

RESULTS

Results indicated that the IUS-12 model with two factors (Prospective Anxiety and Inhibitory Anxiety) provides the best fit. The reduced measure has equally good internal consistency, and is highly correlated with the full version.

LIMITATIONS

Future research could investigate whether the current findings generalize to clinical populations.

CONCLUSION

To summarize, the usage of the short 12-item version of the IUS should be encouraged in future research concerning intolerance of uncertainty.

Factors associated with generalized anxiety in workers undergoing work rehabilitation for persistent musculoskeletal pain

PURPOSE

To document in workers having a work disability due to a musculoskeletal disorder (MSD), the presence and variation over time of their intolerance of uncertainty and its maintenance factors as defined in Dugas et al.'s generalized anxiety disorder (GAD) model, i.e. worries, negative problem orientation, beliefs about the usefulness of worrying, cognitive avoidance and their consequences on depressive symptoms.

METHODS

An observational, prospective repeated-measures design was retained. Thirty-nine workers with an MSD having caused a work absence of over three months and who were beginning a work rehabilitation program were recruited and evaluated at four moments (beginning of rehabilitation program, first hours of work exposure, 50% of regular working hours and end of rehabilitation program). Validated self-report questionnaires measuring intolerance of uncertainty and its maintenance factors were administered. Finally, the Worry and Anxiety Questionnaire measured the presence and intensity of GAD symptoms as defined in the DSM-IV-TR.

RESULTS

Fifty percent of the workers initially exhibited GAD symptoms. Concerning the variation over time, improvements were noted in all GAD-related factors during the program, particularly with the first hours of work exposure. At the end of rehabilitation, only 21% of the participants still met GAD diagnostic criteria.

CONCLUSION

Workers with an MSD causing a work disability averaging one year in length and enrolled in a work rehabilitation program exhibited a high level of anxiety at the beginning of the work rehabilitation program. Workers perceived a usefulness in worrying and presented some intolerance of uncertainty and some cognitive avoidance strategies. According to Dugas et al.'s GAD model, the intensity of the symptoms associated with GAD development and maintenance factors was, however, not typical of a GAD. IMPLICATION FOR REHABILITATION: A reconceptualization of the problem in terms of reducing the work disability rather than reducing pain may constitute a promising avenue to reduce anxiety symptoms. Future studies should look at the specific impact of work exposure, not only on pain symptoms but also on worries. The high level of anxiety and the reported worries by workers stresses the importance of studying the hypothesis of a workplace phobia in order to improve clinical practice guidelines.

Interpretive style and intolerance of uncertainty in individuals with anxiety disorders: a focus on generalized anxiety disorder

Interpretations of negative, positive, and ambiguous situations were examined in individuals with generalized anxiety disorder (GAD), other anxiety disorders (ANX), and no psychiatric condition (CTRL). Additionally, relationships between specific beliefs about uncertainty (Uncertainty Has Negative Behavioral and Self-Referent Implications [IUS-NI], and Uncertainty Is Unfair and Spoils Everything [IUS-US]) and interpretations were explored. The first hypothesis (that the clinical groups would report more concern for negative, positive, and ambiguous situations than would the CTRL group) was supported. The second hypothesis (that the GAD group would report more concern for ambiguous situations than would the ANX group) was not supported; both groups reported similar levels of concern for ambiguous situations. Exploratory analyses revealed no differences between the GAD and ANX groups in their interpretations of positive and negative situations. Finally, the IUS-US predicted interpretations of negative and ambiguous situations in the full sample, whereas the IUS-NI did not. Clinical implications are discussed.

Time course of processing emotional stimuli as a function of perceived emotional intelligence, anxiety, and depression

An individual's self-reported abilities to attend to, understand, and reinterpret emotional situations or events have been associated with anxiety and depression, but it is unclear how these abilities affect the processing of emotional stimuli, especially in individuals with these symptoms. The present study recorded event-related brain potentials while individuals reporting features of anxiety and depression completed an emotion-word Stroop task. Results indicated that anxious apprehension, anxious arousal, and depression were associated with self-reported emotion abilities, consistent with prior literature. In addition, lower anxious apprehension and greater reported emotional clarity were related to slower processing of negative stimuli indexed by event-related potentials (ERPs). Higher anxious arousal and reported attention to emotion were associated with ERP evidence of early attention to all stimuli regardless of emotional content. Reduced later engagement with stimuli was also associated with anxious arousal and with clarity of emotions. Depression was not differentially associated with any emotion processing stage indexed by ERPs. Research in this area may lead to the development of therapies that focus on minimization of anxiety to foster successful emotion regulation.

Reliability and validity of the Korean version of the Penn State Worry Questionnaire in primary school children

Worry is a generalized psychological phenomenon seen among most people. When worry is excessive and nearly uncontrollable, people usually suffer psychological pain. The Penn State Worry Questionnaire for Children (PSWQ-C) was developed to measure worry objectively. It comprises 14 items for measuring excessive, generalized, and uncontrollable worry in children. This study, conducted with a large group of elementary children (3rd through 6th graders, ages 8-12 yr; N=973), investigated the reliability and validity of the Korean version of the Penn State Worry Questionnaire for Children (PSWQ-CK). The PSWQ-CK showed high reliability by test-retest and also excellent internal consistency results. To examine the validity of the PSWQ-CK, we calculated its correlation with the Revised Children's Manifest Anxiety Scale (RCMAS). The PSWQ-CK had a higher correlation with the worry/oversensitivity factor than with other subscales of the RCMAS, and it showed no correlation with the lie factor. When 3 reversed PSWQ-CK items were eliminated, the instrument showed higher internal consistency. However, this did not improve its correlation with other anxiety-measuring tools. In conclusion, the PSWQ-CK's reliability and validity were satisfactory, and it is a useful tool for objectively measuring the worry of Korean children of this age group.

Interoception in anxiety and depression

We review the literature on interoception as it relates to depression and anxiety, with a focus on belief, and alliesthesia. The connection between increased but noisy afferent interoceptive input, self-referential and belief-based states, and top-down modulation of poorly predictive signals is integrated into a neuroanatomical and processing model for depression and anxiety. The advantage of this conceptualization is the ability to specifically examine the interface between basic interoception, self-referential belief-based states, and enhanced top-down modulation to attenuate poor predictability. We conclude that depression and anxiety are not simply interoceptive disorders but are altered interoceptive states as a consequence of noisily amplified self-referential interoceptive predictive belief states.

Dimensions of Negative Thinking and the Relations with Symptoms of Depression and Anxiety in Children and Adolescents

The current study sought to examine three forms of negative, repetitive thinking in non-clinical children and adolescents aged between 10 and 18. More specifically, this study addressed the degree to which stress-reactive rumination can be differentiated from other forms of repetitive thinking, such as emotion-focused rumination and worry, and the associations between the various indices of repetitive thinking and symptoms of anxiety and depression. Participants completed a battery of self-report questionnaires including measures of stress-reactive rumination, emotion-focused rumination, worry, and symptoms of anxiety and depression. Results showed that stress-reactive rumination, emotion-focused rumination and worry are related but distinct forms of repetitive negative thinking. Positive associations were found between all indices of repetitive thinking and symptoms of depression and anxiety, but the effects of emotion-focused rumination disappeared when controlling for the other forms of repetitive thinking. The findings are discussed in the light of current theories and previous research, and directions for future research are provided.

Penn State Worry Questionnaire: structure and psychometric properties of the Chinese version

The Penn State Worry Questionnaire (PSWQ) is a measure of worry phenomena and has been demonstrated valid in cross-cultural populations. The present study examined the factor structure and psychometric properties of the Chinese version of PSWQ (Ch-PSWQ) in a Chinese college sample (n=1243). Exploratory factor analysis of the Ch-PSWQ revealed a two-factor solution (engagement of worry and absence of worry). Confirmatory factor analysis and model comparison supported that the model of one factor with method effect provided the best fit to the data. The Ch-PSWQ and its factors evidenced good internal consistency and both convergent and discriminate validity. The present study supports the opinion that the second factor of PSWQ not only contains the component of evaluating pathological worry, but also might represent other traits.

Parenting stress in pediatric oncology populations

The experience of childhood cancer can be one of the most severe stressors that parents endure. Studies using illness-specific measures of parental stress indicate that moderate-to-severe parenting stress is quite common in the first year of childhood cancer treatment, and as many as 5% to 10% of these parents go on to develop posttraumatic stress disorder. This review of the literature suggested that although parenting stress symptoms may be relatively transitory for most parents dealing with childhood cancer, the impact of these stress symptoms on parent and child functioning is substantive and worthy of therapeutic attention. The stresses entailed in childhood cancer should be viewed as complex and varied across stages of diagnosis and treatment. Factors associated with increased risk of parental posttraumatic stress symptoms include poor social support, adverse experience with invasive procedures, negative parental beliefs about the child's illness and/or associated treatment, and trait anxiety. For those parents with risk factors that might forebode more severe and enduring stress reactions to their children's cancer, therapeutic strategies are proposed to ameliorate their stress and reduce the development and/or maintenance of posttraumatic stress symptoms.

The role of neuroimaging for the diagnosis and treatment of anxiety disorders

Neuroimaging comprises a set of tools, which include different types of magnetic resonance imaging such as functional magnetic resonance imaging (fMRI), Magnetic Resonance Spectroscopy (MRS), Arterial Spin Labeling (ASL), and radiotracer imaging such as positron emission tomography and single photon emission computed tomography. The focus of this review is to address the question whether fMRI can contribute to the diagnosis and treatment of anxiety disorders. Key anxiety processes and neural substrates are reviewed. The main findings and shortcomings of fMRI in the context of anxiety are briefly summarized. Finally, the next stages of developing fMRI for diagnosis and treatment are highlighted. The main conclusion of this review is that fMRI could become a clinical tool for the diagnosis and treatment of anxiety disorders, but neuroimaging groups will need to better develop its specificity and sensitivity so that fMRI results can be meaningful for an individual patient not just for groups of individuals.

Assessing worry in older and younger adults: Psychometric properties of an abbreviated Penn State Worry Questionnaire (PSWQ-A)

Among older adults, recent work indicated that Penn State Worry Questionnaire (PSWQ) data fit poorly with previously established models, leading to use of model modification procedures to create an abbreviated worry questionnaire (PSWQ-A; Hopko, D. R., Stanley, M. A., Reas, D. L., Wetherell, J. L., Beck, J. G., Novy, D. M., et al. (2003). Assessing worry in older adults: Confirmatory factor analyses of the Penn State Worry Questionnaire and psychometric properties of an abbreviated model. Psychological Assessment, 15, 173-183). Given limitations of this prior study that included the post hoc statistical development of the scale and undefined relevance toward assessing worry in younger cohorts, psychometric properties of the PSWQ-A were explored among independent samples of older (n = 115) and younger adults (n = 183). Exploratory factor analyses supported a unidimensional model (breadth and control of worry) that accounted for substantial variance in older (57%) and younger adult samples (70%) and was associated with high factor loadings (.66-.89). Internal consistency (alpha = .89-.94) and test-retest reliability (r = .87-.95) was strong in both samples. Moderate to strong convergent validity with measures of worry and anxiety was evident (r = .46-.83), as was support for the construct validity of the PSWQ-A via its relation to the PSWQ (r = .65-.83) and similar relations with other anxiety and worry measures. Although further study is required, the PSWQ-A may be a parsimonious method to assess worry in older and younger adults.

Cognitive specificity of anxiety disorders: a review of selected key constructs

Cognitive models of anxiety disorders propose that certain cognitive constructs, that is, underlying beliefs and cognitive processes, may be specific for particular disorders. In this article, we review the specificity of four representative cognitive constructs-anxiety sensitivity, pathological worry, intolerance of uncertainty, and thought-action fusion-for particular disorders. Conceptual overlap, inconsistent definitions, and insufficient consideration of the components of these constructs are limitations of the existing literature. We suggest that the constructs are unlikely to be pathognomonic for any given disorder or to occur in isolation. Rather, the association of each cognitive construct is evident, to varying degrees, with different disorders. Relative to other disorders, anxiety sensitivity is to a certain extent specific for panic disorder, as are pathological worry for generalized anxiety disorder, intolerance of uncertainty for generalized anxiety disorder and obsessive-compulsive disorder, and thought-action fusion for obsessive-compulsive disorder. We discuss the implications of these findings for diagnostic systems and treatment, and suggest areas for further research.

The relation between worrying and concerns: the importance of perceived probability and cost

The relation between worrying and individuals' concerns was examined in a sample of 197 college students. Participants described the five undesirable outcomes that they thought about most often, indicated how likely they thought the outcomes were, and how upset they would be by them. Worry severity was measured using the Penn State Worry Questionnaire. The relation between worry severity and the life domains about which individuals were concerned was quite weak. In contrast, as predicted, greater worry was associated with higher probability and cost estimates. In addition, cost estimates moderated the relation between worry severity and probability estimates. The potential importance of perceived threat for understanding worrying is discussed.

What's the use of worrying? Its function and its dysfunction

OBJECTIVE

To provide an overview of theory and research regarding the phenomenology and function of worry.

METHOD

A systematic literature search focusing on conceptualizations of worry as a cognitive activity and worry research over the last 20 years was conducted.

RESULTS

Worry can be both functional and dysfunctional. Disruption to daily functioning, perceived uncontrollability, pervasiveness and extensive coverage of worry themes (including "remote" events and the presence of meta-worry), all have specificity to more severe and dysfunctional worry.

CONCLUSIONS

Research investigating both the relationship between worry and anxiety and the attributes of severe worriers, has brought attention to its role in fostering emotional disturbance and has clarified factors relevant to treatment.

Stability of worry content in GAD patients: a descriptive study

The stability of worry content was investigated in a sample of 27 individuals diagnosed with Generalized Anxiety Disorder. During an initial evaluation, participants were asked to describe the content of their current worries, and the examining psychiatrist rated the frequency and intensity of these topics. During the following year, the investigators interviewed the participants on a monthly basis assessing the intensity and frequency of original worries, intensity and frequency of new worries, overall worry level, and general anxiety level. Analysis of this longitudinal data indicated level of overall worry and anxiety remained fairly stable over a 12-month period. Although the intensity and frequency of original worries decreased over time, few original worry topics completely remitted. In fact, at the end of the 12-month monitoring period, worry content identified at baseline continued to account for over 65% of the overall worry variance. Most participants did identify new worry topics during the course of the 12-month period, and the frequency and intensity of the new worries were comparable to the decrease in frequency and intensity of the original worries.

A general anxiety-prone cognitive style in anxiety disorders

OBJECTIVE

This study compared scores on the Anxious Thoughts & Tendencies (AT&T) questionnaire, a putative measure of a general anxiety-prone cognitive style, among patients with panic disorder without agoraphobia (PD, n=62), panic disorder with agoraphobia (PDA, n=29), generalized anxiety disorder (GAD, n=43), limited social phobia (LSP, n=34), generalized social phobia (GSP, n=33), and community residents (n=319).

METHOD

Candidates for treatment studies completed a diagnostic interview and the AT&T. AT&T scores were compared among anxious groups using analysis of variance. Then depressed and non-depressed patients were compared. The final analysis compared anxious groups without comorbid depressive or anxiety disorders.

RESULTS

AT&T scores were highest in PDA patients, followed by patients with GAD or GSP, then patients with PD or LSP, with community residents lowest. Depressed patients were higher than non-depressed patients. Patients with current or past comorbid depressive disorders did not differ. The ranking of anxious groups on AT&T scores remained unchanged after exclusion of patients with comorbid disorders. Patients with PD or LSP without comorbidity had the same AT&T levels as the community sample.

CONCLUSIONS

The AT&T discriminates PDA and GAD from PD per our hypothesis. The low AT&T levels among patients with PD and LSP suggest no association with a general anxiety-prone cognitive style. LSP and GSP may be distinct disorders. The cognitive style assessed by the AT&T is also associated with depression and may be a marker for vulnerability to depression. Definitive conclusions about a pathogenic role for cognitions require their measurement before the onset of the disorder.