Evelyn Behar

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 models 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.

Screening for generalized anxiety disorder using the Penn State Worry Questionnaire: a receiver operating characteristic analysis

The present study examined the usefulness of the Penn State Worry Questionnaire (PSWQ) as a means of screening for generalized anxiety disorder (GAD). Using receiver operating characteristic analyses, the accuracy of the PSWQ in screening for GAD was examined in both clinical and analogue diagnosed GAD samples. Given high comorbidity between GAD and other emotional disorders, we also investigated the usefulness of the PSWQ in selecting non-cases of GAD that were also free of PTSD, social phobia, or depression versus non-cases of GAD that met criteria for one of these conditions. The overall usefulness of the PSWQ as a screening device is discussed.

Thought and imaginal activity during worry and trauma recall

The present study examined the frequency with which participants experienced thoughts and images, as well as relaxed, anxious, and depressed affect, when worrying and when recalling past traumatic events. Unselected participants in Study 1, and participants selected on the basis of their GAD and past trauma status in Study 2, engaged in 5-minute counterbalanced worry and trauma recall inductions. Results indicated that while worry was experienced primarily as verbal thought, trauma recall was primarily experienced as imaginal. Furthermore, while both worry and trauma recall were associated with increased anxious and depressed affect, worry was particularly associated with anxious affect in the selected sample, and trauma recall was particularly associated with depressed affect in both unselected and selected samples. Finally, for individuals with both GAD and trauma symptoms, prior worrying was associated with decreased anxious and depressed affect during a subsequent trauma recall task. Theoretical and clinical implications of these findings are discussed.

The Reliability and Validity of the Panic Disorder Self-Report: A New Diagnostic Screening Measure of Panic Disorder

This study examined the Panic Disorder Self-Report (PDSR), a new self-report diagnostic measure of panic disorder based on the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994). PDSR diagnoses were compared with structured interview diagnoses of individuals with generalized anxiety disorder, social phobia, and panic disorder and nonanxious controls. Receiver operating characteristic analyses revealed that the PDSR showed 100% specificity and 89% sensitivity. The PDSR also demonstrated retest reliability, convergent and discriminant validity, and kappa agreement of .93 with a structured interview. Finally, the PDSR demonstrated clinical validity. Students who were identified as having panic disorder using the PDSR did not have significantly different scores on the Panic Disorder Severity Scale--Self-Report form (P. R. Houck, D. A. Speigel, M. K. Shear, & P. Rucci, 2002) than a panic disordered community sample. However, both groups had significantly higher scores than students identified as not meeting criteria for panic disorder.

Cortisol, stress, and attentional bias toward threat

Abstract Attentional bias toward threatening stimuli is a central characteristic of anxiety and acute stress. Recent small-scale studies have provided divergent perspectives on the association between the stress hormone cortisol and attentional bias toward threat cues. In a larger sample size than previous studies, we examined this association by investigating the impact of cortisol on attentional bias in two studies using a psychological stressor (N=35) and a physical stressor (N=65), respectively. Attentional bias and salivary cortisol were measured prior to and following the administration of a stressful task designed to increase cortisol levels. Results across these studies were equivocal relative to the association between baseline cortisol and baseline attentional bias. In addition, the association between acute change in cortisol and change in attentional bias appeared to differ as a function of the presence or absence of psychological stress. There was a trend toward a stronger negative association between acute cortisol change and attentional bias change among women relative to men. These results imply that the association between cortisol and attentional bias may be moderated by additional factors, such as gender or presence of stress.

Readability of self-report measures of depression and anxiety.

As the demand for accountability in service provision settings increases, the need for valid methods for assessing clinical outcomes is of particular importance. Self-report measures of functioning are particularly useful in the assessment of psychological functioning, but a vital factor in their validity and transportability is the reading level needed to comprehend them. We evaluated the reading grade levels required to comprehend the instructions and items from 105 evidence-based self-report measures of depression and anxiety. Results indicated substantial variability in readability among measures, with anxiety measures generally requiring a higher reading level relative to depression measures. In some cases, reading levels required for measure instructions were particularly high, and most measures were written at or above the mean reading grade level in the United States. This analysis provides information that may aid in selecting appropriate symptom measures in clinical and research settings. Future directions, including the development of measures for individuals with low levels of literacy, are discussed.

d-Cycloserine for the augmentation of an attentional training intervention for trait anxiety

The present study investigates the combination of two novel strategies for the treatment of anxiety that resulted from translational research. We examined whether the putative memory enhancer, d-cycloserine (DCS), offered benefit to procedures designed to train attention away from threat. Participants were 44 adults selected on the basis of high trait anxiety. In this randomized study, DCS or placebo was administered 1h prior to attentional training away from threat using the dot probe task. On the following day, the effectiveness of this training was assessed along with emotional reactivity following two stressful tasks. We found that the addition of DCS resulted in significantly stronger reduction in attentional bias toward threat relative to placebo, but found no additive effects for the DCS condition on subsequent emotional reactivity. These results provide initial support for the efficacy of DCS for augmenting attentional training tasks; potential strategies for enhancing these results are discussed.

Concreteness of Idiographic Periods of Worry and Depressive Rumination

Stöber (Behav Res Ther 36:751–756, 1998) asserts that worry is characterized by reduced concreteness of thought that interferes with successful emotional processing via reduction of imagery. Extant research has not examined concreteness of thought during a period of idiographic worry, nor has it directly compared concreteness during worrisome thinking to concreteness during other types of repetitive negative thinking such as depressive rumination. We sought to test Stöber’s theory as it relates to idiographic periods of worry, and further examined its applicability to periods of depressive rumination. Consistent with Stöber’s theory, we found that worry and depressive rumination were significantly and non-differentially more abstract than was baseline mentation. Contrary to Stöber’s theory, concreteness of thought was not related to degree of reported imagery during either worry or depressive rumination. Theoretical and clinical implications of these findings are discussed.

Concreteness of Positive, Negative, and Neutral Repetitive Thinking About the Future

Consistent with assertions that the adaptiveness of repetitive thinking is influenced by both its valence and style, Stöber (e.g., Stöber & Borkovec, 2002) has argued that worry is characterized by a reduced concreteness of thought content and that the resulting abstractness contributes to its inhibition of some aspects of anxious responding. However, extant research does not provide a direct test of Stöbers reduced concreteness theory of worry. We sought to test Stöbers theory and to examine the adaptiveness of repetitive worrisome thinking by randomly assigning 108 participants to engage in five consecutive periods of repetitive thinking about positively, negatively, or neutrally valenced potential future events. Results based on coding of thought data indicated that (a) repetitive thinking became increasingly less concrete as periods progressed; (b) contrary to Stöbers theory, both negative and positive repetitive future thinking were more concrete than neutral repetitive future thinking (and did not differ from each other); and (c) abstractness of thought during negative repetitive future thinking was associated with reduced reports of imagery-based activity. Results based on self-reported affect indicated that negatively valenced repetitive future thinking was uniquely associated with initial decreases in anxious affect, followed by increased anxious affect that coincided with increased imagery-based activity. This suggests that worry is associated with a sequential mitigation of anxious meaning followed by a strengthening of anxious meaning over time. Theoretical and clinical implications of these findings are discussed.

The effects of suppressing thoughts and images about worrisome stimuli

Several investigations have examined the potential role of mentation suppression in various psychological disorders. Existing studies do not, however, differentiate between the effects of suppressing imagery- versus thought-based mentation. This distinction is an especially important one for worry, given the predominantly thought-based nature of the worry process. The present study sought to distinguish between the effects of suppressing thoughts versus images about worrisome versus neutrally valenced topics. Consistent with past studies of worry suppression, results failed to find a rebound effect regardless of valence (worrisome, neutral) or mentation content (thoughts, images). However, results did indicate that a decrease in worrisome mentation across two consecutive expression periods was more pronounced when the worrisome material was imagery-based rather than thought-based in nature. Implications of these findings as they pertain to the perpetuation of worrisome activity and to treatment of generalized anxiety disorder are discussed.