Worry Episodes Research Articles

Worry and Positive Episodes in the Daily Lives of Individuals With Generalized Anxiety Disorder: An Ecological Momentary Assessment Study.

Worry is a central feature of generalized anxiety disorder (GAD). Although worry is related to anxiety and maintained by beliefs that worry is uncontrollable, there is scarce research on how individuals with GAD react to worry episodes in their daily life and how their positive experiences might impact reactions to worry episodes. The current study examined the level and variability of anxiety and controllability during high worry periods and positive experiences in GAD. Moreover, it investigated the influence of worry and positive experiences on later anxiety and perceived controllability within-persons. Finally, it examined change in anxiety level from previous to current episodes depending on previous episodes type. In the current study, 49 individuals with GAD (514 observations) registered their worry and positive episodes (i.e., episodes in which they had positive experiences) and reported on several variables during these episodes (i.e., anxiety and controllability of episodes and episode duration) using smartphone-based ecological momentary assessment for 7days. Results show anxiety and controllability differed by episode type (higher anxiety, lower controllability in worry episodes, and the opposite in positive episodes), and notable within-person variability in anxiety and controllability in both episode types. The time-lagged multilevel models showed episode type did not predict later anxiety during either episode type, although previous anxiety predicted current anxiety in worry episodes (but not positive episodes). Moreover, worry episodes did predict later controllability in worry episodes (but not positive episodes) and previous controllability predicted current controllability in both episode types. Furthermore, we obtained the increase in anxiety from t0−1 to t0 in a current worry episode to be significantly smaller when preceded by a worry (vs. positive) episode. Likewise, the reduction in anxiety from t0−1 to t0 in a current positive episode was significantly larger when preceded by a worry (vs. positive) episode. The novel findings in the current study that perceptions of controllability and anxiety vary within individuals with GAD, that greater controllability is experienced in positive episodes than worry episodes, and that worry may confer a sense of controllability at a later time could be seen as important contributions to the GAD literature.

Cognitive-Behavioral Treatment for Generalized Anxiety Disorder: Theoretical Foundations and Empirically Supported Strategies

Cognitive-behavioral therapy (CBT) is the most extensively studied psychotherapy for generalized anxiety disorder (GAD) and has demonstrated large effect sizes compared to waitlist and placebo control. CBT for GAD treatment protocols is based on several cognitive-behavioral models of the disorder that emphasize the role of worry as an avoidance strategy to escape from distressing internal experiences, such as negative emotions, uncomfortable physical sensations, and intrusive images. Cognitive-behavioral models also posit that positive and negative beliefs about worry are instrumental in maintaining the worry process. Common cognitive-behavioral treatment strategies to target these causal mechanisms include psychoeducation, self-monitoring of worry episodes, relaxation techniques, mindfulness exercises, cognitive reappraisal, behavioral experiments to test beliefs about worry, imaginal exposure to core fears, and commitment to valued actions. In this article, we provide an overview of cognitive-behavioral models of GAD and describe the evidence-based treatment strategies that emerged from these models. [ Psychiatr Ann . 2021;51(5):210–215.]

How do anxious children attempt to regulate worry? Results from a qualitative study with an experimental manipulation.

The objective of this study was to explore how anxiety-disordered children attempt to regulate their worry. An experimental manipulation was applied, followed by a qualitative interview. Thirty children aged 7-13 were enrolled in this study. Each child was presented with a black mystery box, was told that shortly he/she would have to feel what was inside the box, and was then left alone for 4min, prior to commencing the task. The purpose of the experimental manipulation was to induce slight levels of worry in the child, so that he/she could better report on worry regulation strategies. Afterwards, an interview about how the child had regulated worry during the experimental manipulation and in everyday life was undertaken. The interviews were coded using thematic analysis. Five main themes were uncovered. These were (1) internal regulation of worry, for example, thinking about something else and self-reassurance talk, (2) external regulation of worry, for example, behavioural avoidance and distraction, (3) perceived effect of strategies, (4) shifting between strategies, and (5) absence of a strategy. Our results demonstrate that anxious children use a variety of behavioural and cognitive strategies to regulate worry. They use these strategies in combination, they generally perceive them as ineffective, and they sometimes do not report any strategy for attempting to regulate their worry. These results indicate that clinicians should be curious about which strategies anxious children use to regulate their worry, how these strategies interact with each other, and how they are implemented by the child. Using an experimental manipulation followed by an interview, this study sought to investigate how anxious children seek to regulate their worries. Anxious children attempt to regulate their worry with use of behavioural regulation strategies, such as avoidance and distraction, and with use of cognitive regulation strategies, including thinking about something else, self-reassurance talk, and thought suppression. Sometimes, however, anxious children are not able to report a regulation strategy for a specific worry episode, suggesting that they may not always have a strategy or that they lack the introspective ability to report what they did. Clinicians should be aware that anxious children may use internal (cognitive) regulation strategies while at the same time using behavioural regulation strategies, such as avoidance.

Examining incremental explanatory power in accounting for worry severity: negative metacognitive beliefs uniquely predict worry severity following a worry episode

ABSTRACTBackground and Objectives: Contemporary conceptual models posit that different core variables contribute to worry, including intolerance of uncertainty (IU), metacognitive beliefs, and experiential avoidance. To date, a concurrent investigation of the incremental explanatory power of these variables in accounting for worry severity remains unexamined. The present study sought to address that gap in the literature.Design/Methods: Participants endorsing frequent worry (N = 127) completed self-report measures assessing IU, metacognitive beliefs, and experiential avoidance during an online session. Participants later attended an in-person lab-based session where they completed a worry episode and in-vivo worry severity was assessed following the worry episode.Results: IU, negative metacognitive beliefs, and experiential avoidance each shared a bivariate association with post-episode worry severity. However, in multivariate analyses, only baseline worry severity and negative metacognitive beliefs surrounding the dangerousness and uncontrollability of worry predicted post-episode worry severity.Conclusions: The present results further underscore links between negative metacognitive beliefs and worry.

Reductions in the diurnal rigidity of anxiety predict treatment outcome in cognitive behavioral therapy for generalized anxiety disorder

Generalized anxiety disorder (GAD) is a chronic and disabling disorder which is characterized by worrisome mentation about future outcomes. Because the evocative stimuli in GAD are largely internally derived, the feared outcomes contained in worry episodes can be invoked – and responded to – regardless of external context. We hypothesized that individuals with GAD would be entrained to internally-regulated, fixed patterns of anxiety on a day-to-day basis and that successful therapeutic intervention would serve to mitigate this entrainment. Thus, the present study examined the constructs of flexibility and rigidity as they apply to the daily fluctuation of anxious symptoms in individuals with GAD. We aimed to demonstrate that an apparently variable system can be conceptualized as rigid when the variability maps onto stable and predictable periodic oscillations. Sixty-nine individuals completed cognitive-behavioral treatment for GAD. Average age was 36.62 years (SD = 11.56), and participants were mostly Caucasian (89.5%) and female (68.4%). Daily-diary data indicating level of anxiety on a 0 to 100-point scale and collected four times per day were subjected to spectral analysis in order to determine the spectral power attributable to daily oscillations – which was related to the degree of rigidity in daily anxiety. Diurnal rigidity decreased throughout therapy and the degree to which rigidity was reduced significantly predicted reliable change at post-treatment. Thus, symptom rigidity can be conceptualized as stable periodic fluctuation and is discernible from other metrics of volatility in repeated measures data. Moreover, diurnal rigidity is significantly reduced during treatment, facilitating flexible responding to environmental demands.

Delineating the Role of Negative Verbal Thinking in Promoting Worry, Perceived Threat, and Anxiety.

Worry is characterized by streams of verbal thoughts about potential negative outcomes. Individuals with high levels of worry (and particularly those with generalized anxiety disorder) find it very difficult to control worry once it has started. What is not clear is the extent to which verbal negative thinking style maintains worry. Our study aimed to disentangle the effects of verbal versus imagery based thinking, and negative versus positive worry-related content on subsequent negative intrusive thoughts. High worriers were trained to engage in imagery or verbal processing, focusing on either negative or positive outcomes of their current main worry. Both thinking style and valence of worry content influenced later negative intrusive thoughts that play a role in initiating worry episodes. In contrast, only valence influenced subjective ratings of worry outcomes (i.e., cost, concern, and ability to cope, although not probability), with positive valence leading to lower ratings, irrespective of thinking style.

How Do Individuals with Persecutory Delusions Bring Worry to a Close? An Interpretive Phenomenological Analysis

Worry is a significant problem for individuals with paranoia, leading to delusion persistence and greater levels of distress. There are established theories concerning processes that maintain worry but little has been documented regarding what brings worry to a close. The aim was to find out what patients with persecutory delusions report are the factors that bring a worry episode to an end. Eight patients with persecutory delusions who reported high levels of worry participated. An open-ended semi-structured interview technique and IPA qualitative analysis was employed to encourage a broad elaboration of relevant constructs. Analyses revealed one theme that captured participants' detailed descriptions of their experience of worry and five themes that identified factors important for bringing worry episodes to a close: natural drift, distraction, interpersonal support, feeling better, and reality testing. Patients with persecutory delusions report worry being uncontrollable and distressing but are able to identify ways that a period of worry can stop. The present study suggests that building on individuals' distraction techniques, reality testing ability and their social support network could be of benefit. Research is needed to identify the most effective means of bringing paranoid worries to an end.

The online version of the Dutch Penn State Worry Questionnaire: Factor structure, predictive validity and reliability

The Penn State Worry Questionnaire (PSWQ) is a widely used self report scale to assess pathological worry. Several studies have shown that the paper-and-pencil version of the PSWQ shows satisfactory psychometric properties. Yet, it is unknown whether the PSWQ is suited to be administered on Internet. As the amount of assessments conducted online is vastly increasing, we examined the factor structure, predictive validity and reliability of the online version of the PSWQ in a large community sample (N=1025). Confirmatory factor analyses demonstrated that the best fit to the data was provided by a one factor model wherein the reverse-worded items also loaded on a separate method factor. In a second part of the study a self-selected subsample of the total sample (n=189) kept a log of the frequency and duration of worry episodes for six consecutive days. Worry frequency and worry duration were both predicted by the PSWQ, thereby lending support to its predictive validity. These findings provide preliminary evidence that the online version of the PSWQ possesses psychometric properties that are similar to the paper-and-pencil version.

Culture and the Anxiety Disorders: Recommendations for DSM-V

Background: The anxiety disorders specified in the fourth edition, text revision, of The Diagnostic and Statistical Manual (DSM-IV-TR) are identified universally in human societies, and also show substantial cultural particularities in prevalence and symptomatology. Possible explanations for the observed epidemiological variability include lack of measurement equivalence, true differences in prevalence, and limited validity or precision of diagnostic criteria. One central question is whether, through inadvertent “over-specification” of disorders, the post-DSM-III nosology has missed related but somewhat different presentations of the same disorder because they do not exactly fit specified criteria sets. This review canvases the mental health literature for evidence of cross-cultural limitations in DSM-IV-TR anxiety disorder criteria. Methods: Searches were conducted of the mental health literature, particularly since 1994, regarding cultural or race/ethnicity-related factors that might limit the universal...

Effects of momentary assessed stressful events and worry episodes on somatic health complaints

Somatic health complaints are extremely common and are responsible for a large part of human suffering and healthcare costs. It has been recognised that psychosocial stress can affect somatic health. According to the ‘perseverative cognition hypothesis’, stressful events affect somatic health because people keep on worrying about them. Worry would prolong stress-related physiological activity that can ultimately lead to health problems. In this ambulatory study we tested whether stressful events and worry predict daily somatic complaints, and whether worry mediates the effects of stressful events. In addition, it was tested whether these effects were independent from negative affect. Using electronic diaries, 69 teachers (age 21–60 years) from Dutch primary and secondary schools reported daily stressful events, worry episodes, negative affect and somatic complaints for a period of 6 days. Results showed that worry intensity predicted the number of somatic complaints and mediated the effect of stressful events on somatic complaints. Furthermore, these results were independent from biobehavioural variables and daily negative affect. These findings support the perseverative cognition hypothesis proposing that the negative somatic health effects of stressful events are largely due to the worry; that is, to the prolonged cognitive representation of stressors.

Worry, worry attacks, and PTSD among Cambodian refugees: A path analysis investigation

Among traumatized Cambodian refugees, this article investigates worry (e.g., the types of current life concerns) and how worry worsens posttraumatic stress disorder (PTSD). To explore how worry worsens PTSD, we examine a path model of worry to see whether certain key variables (e.g., worry-induced somatic arousal and worry-induced trauma recall) mediate the relationship between worry and PTSD. Survey data were collected from March 2010 until May 2010 in a convenience sample of 201 adult Cambodian refugees attending a psychiatric clinic in Massachusetts, USA. We found that worry was common in this group (65%), that worry was often about current life concerns (e.g., lacking financial resources, children not attending school, health concerns, concerns about relatives in Cambodia), and that worry often induced panic attacks: in the entire sample, 41% (83/201) of the patients had “worry attacks” (i.e., worry episodes that resulted in a panic episode) in the last month. “Worry attacks” were highly associated with PTSD presence. In the entire sample, generalized anxiety disorder was also very prevalent, and was also highly associated with PTSD. Path analysis revealed that the effect of worry on PTSD severity was mediated by worry-induced somatic arousal, worry-induced catastrophic cognitions, worry-induced trauma recall, inability to stop worry, and irritability. The final model accounted for 75% of the variance in PTSD severity among patients with worry. The public health and treatment implications of the study’s findings that worry may have a potent impact on PTSD severity in severely traumatized populations are discussed: worry and daily concerns are key areas of intervention for these worry-hypersensitive (and hence daily-stressor-hypersensitive) populations.

The emotional experience associated with worrying: anxiety, depression, or stress?

Avoidance theories propose that worrying results in a reduction of the physiological arousal symptoms of anxiety. However, relatively little is known about the emotional symptoms that remain associated with worrying. This study explored whether the emotional states of anxiety, depression, or stress are specifically associated with excessive and uncontrollable worry. A group of 126 university students were selected to represent a wide range on the dimension of worry proneness. They completed a worry questionaire, monitored the frequency and uncontrollability of their worry episodes for 1 week, and completed the Depression Anxiety Stress Scales (DASS) to indicate their level of negative affect during the monitoring period. Hierarchical regression analyses showed that all measures of worrying had a unique positive association with stress, over and above their associations with anxiety and depression. Item-level analyses showed that stress symptoms were uniformly strongly associated with worrying, while anxiety symptoms had the weakest associations. These results increase our knowledge regarding the phenomenology of worrying and underline the potential theoretical significance of the emotional state assessed by the DASS Stress scale. This scale fills the current need for a psychometrically sound instrument to assess the emotional experience associated with worrying.

Treating chronic worry: Psychological and physiological effects of a training programme based on mindfulness

The present study examines psychological and physiological indices of emotional regulation in non-clinical high worriers after a mindfulness-based training programme aimed at reducing worry. Thirty-six female university students with high Penn State Worry Questionnaire scores were split into two equal intervention groups: (a) mindfulness, and (b) progressive muscle relaxation plus self-instruction to postpone worrying to a specific time of the day. Assessment included clinical questionnaires, daily self-report of number/duration of worry episodes and indices of emotional meta-cognition. A set of somatic and autonomic measures was recorded (a) during resting, mindfulness/relaxation and worrying periods, and (b) during cued and non-cued affective modulation of defence reactions (cardiac defence and eye-blink startle). Both groups showed equal post-treatment improvement in the clinical and daily self-report measures. However, mindfulness participants reported better emotional meta-cognition (emotional comprehension) and showed improved indices of somatic and autonomic regulation (reduced breathing pattern and increased vagal reactivity during evocation of cardiac defense). These findings suggest that mindfulness reduces chronic worry by promoting emotional and physiological regulatory mechanisms contrary to those maintaining chronic worry.

Prolonged Cardiac Effects of Momentary Assessed Stressful Events and Worry Episodes

To test the hypothesize that increased heart rate (HR) and decreased heart rate variability (HRV) are not only due to concurrent stressful events and worries but also to stressors and worries occurring in the preceding hours or stressors anticipated to occur in the next hour. Worry was expected to mediate at least part of the prolonged effects of stressors. Ambulatory HR and HRV of 73 teachers were recorded for 4 days, during which the participants reported occurrence and duration of worry episodes and stressful events on an hourly basis, using computerized diaries. Multilevel regression models were used, accounting for effects of several biobehavioral variables. Stressful events were not associated with changes in HR or HRV. However, worry episodes had effects on concurrent HR and HRV (2.55 beats/minute; -5.76 milliseconds) and HR and HRV in the succeeding hour (3.05 beats/minute; -5.80 milliseconds) and 2 hours later (1.52 beats/minute; -3.14 milliseconds). These findings were independent of emotions, physical activity, posture, and other biobehavioral factors. Worry has effects on cardiac activity, and these effects were still visible after 2 hours. The latter finding suggests that a considerable part of prolonged activation may be induced by unconscious stress-related cognition.

The Relationship of Low Distress Tolerance to Excessive Worrying and Cognitive Avoidance

AbstractThis study explored the relationships between individuals' ability to tolerate emotional distress to their tendency to worry excessively, the amount of imagery they experience during worrying, and the concreteness of their worrisome thought. A group of 119 university students completed a thought-listing task recording their most severe current worry, estimated the amount of imagery and verbal thought during this worry episode, and completed questionnaires assessing their worry proneness, negative effect, and ability to tolerate emotional distress. The concreteness of thought-listed worry episodes was rated by independent judges. Consistent with expectations, lower distress tolerance was associated with more worrying, even when levels of negative affect were statistically controlled for. Excessive worriers also reported lower levels of imagery, but imagery and distress tolerance were unrelated. The findings concerning concreteness were in the opposite direction to those expected: more excessive worrying and lower distress tolerance were associated with more concreteness of worrisome thought. The results are consistent with avoidance theory, but future research is needed to investigate the mechanisms by which low distress tolerance may contribute to excessive worrying.

Generalized anxiety disorder with and without excessive worry in Hong Kong

Two previous U.S. studies found that although generalized anxiety disorder (GAD) without self-perceived excessive worry was milder than GAD with excessive worry, its persistence, impairment, and risk for subsequent onset of other mental disorders were still substantial. This study examined the implications of relaxing the "excessiveness" criterion on the prevalence and socio-demographic profile of GAD in a Chinese population sample by considering both self and others' perception of excessive worry. 2,005 respondents aged 15-65 years participated in a structured telephone interview that covered socio-demographic profile, 12-month DSM-IV diagnosis of GAD, core depressive symptoms, longest duration of worry episode, number of domains of worry, impairment measured by the Sheehan Disability Scale, and treatment-seeking. Excessive worry was assessed from the perception of both respondents and others as reported by respondents. The 12-month prevalence of GAD increased from 3.4 to 4% when the excessiveness requirement was relaxed. Excessive GAD and nonexcessive GAD had similar socio-demographic, symptom, chronicity, impairment, depressive symptom, and treatment-seeking profiles. GAD without excessive worry was less common than GAD with excessive worry but was likely to be a valid nosological entity. Future iterations of the DSM-IV should clarify whether excessive worry should be retained and, if so, how individuals who only reported excessive worries perceived by others should be optimally assessed.

Cardiac Effects of Momentary Assessed Worry Episodes and Stressful Events

To hypothesize that increased heart rate (HR) and decreased heart rate variability (HRV) occurs not only during stressful events but also during episodes in which stress is cognitively represented, but not necessarily present, i.e., during worry. Ambulatory HR and HRV of 73 female and male teachers were recorded for 4 days, during which they reported, on an hourly basis using computerized diaries, the number and characteristics of worry episodes and stressful events. Multilevel regression models were used, controlling for biobehavioral variables. Compared with neutral periods, worry episodes and stressful events had independent effects on HR (2.00 beats/min and 2.75 beats/min, respectively) and HRV (-1.07 ms and -1.05, respectively). Neither psychological traits nor biobehavioral variables influenced these results. Effects were most pronounced for work-related worry on HR (9.16 beats/min) and HRV (-1.19 ms), and for worry about anticipated future stress on HR (4.79 beats/min). Worry in daily life might have substantial cardiac effects in addition to the effects of stressful events, especially in the form of work-related and anticipatory stress, the latter being a type of stress that has been largely neglected in stress research.

Worry episodes and perceived problem solving: A diary-based approach

Thirty-nine university students monitored their naturally occurring worry episodes for 7 days. They rated each episode in terms of six cognitive content categories, labeled Negative Outcome Anticipation, Problem-Solving Process, Solution Selection, Self-Blame, Rumination, and Palliative Thoughts. The results reinforced previous findings that a large proportion of the self-reported cognitive content of worry reflects problem-solving attempts, and that these attempts can sometimes lead to a selection of subjectively satisfying solutions. Solution Selection was also reported as a frequently used worry termination strategy. Individuals who rated their worry episodes as more uncontrollable reported fewer instances of solution selection and engaged in more negative solution evaluation while worrying. They were also more likely to keep worrying until they became distracted by an external event. Collectively, the data support the notion that normal worry involves problem-solving attempts and suggest that difficulties at the solution evaluation and solution selection stages may be important mechanisms underlying excessive worry.

The Cognitive Content of Thought-Listed Worry Episodes in Clinic-Referred Anxious and Nonreferred Children

We investigated the cognitive content of worry in 8- to 13-year-old clinic-referred anxious (n = 38) and nonreferred (n = 51) children. The children were interviewed individually. They thought-listed their latest worry episodes, rated the uncontrollability of the episodes, and reported on the strategies they used to terminate worry. Content analyses showed that children's worry episodes contained predominantly thoughts reflecting negative outcome anticipation, but other types of thought content also were present. These included problem-solving, ruminating, and self-blaming thoughts. Compared to clinic-referred children, nonreferred children reported more problem solving and less ruminating. In the nonreferred group, increasing age was associated with more problem solving and less ruminating. No such age-related associations were found in the clinic-referred group. The 2 groups did not differ in the types of worry-termination strategies they reported, but clinic-referred children were more likely to keep worrying until the perceived threat was removed. The results suggest that the problem-solving function of worry is still emerging during late childhood and that developmental delays in problem solving may be associated with excessive and uncontrollable worrying.

Generalized anxiety disorder and clinical worry episodes in young women.

This article presents epidemiological data on the prevalence of DSM-IV generalized anxiety disorder (GAD) and sub-threshold GAD (fulfilling three out of four GAD criteria) in young women together with data on co-morbidity and psychosocial functioning. The prevalence of clinically relevant worry and its predictive validity for the diagnosis of GAD were also examined. Young women (N = 2064), aged between 18 and 25, from a representative German community sample were diagnosed with a structured clinical interview (ADIS-L, German research version). An additional interview questioned all the participants about the frequency/intensity and uncontrollability of diverse worry topics. Thirty-seven participants (1.8%) fulfilled the criteria of current GAD (1 week point prevalence) and 56 received a lifetime diagnosis (2.7%); a further 50 participants (2.3%) were diagnosed with sub-threshold GAD. Co-morbidity between GAD and other disorders was high for current (68%) and lifetime GAD (91%). GAD, as well as sub-threshold GAD, showed clearly reduced levels of psychosocial functioning. Whereas worries of low intensity and high controllability were ubiquitous in all subsamples, clinically defined worrying was rarely present in healthy subjects (0.89%) and of adequate predictive accuracy for GAD. Full GAD and sub-threshold GAD were moderately frequent in young women. Although DSM-IV worry criteria proved to be highly useful, the strictness of the complete GAD-criteria should not lead to absence of attention from subclinical generalized anxiety states in research and practice.