The perseverative worry bout: A review of cognitive, affective and motivational factors that contribute to worry perseveration

Abstract

This paper reviews the cognitive, affective and attentional factors that contribute to individual perseverative worry bouts. We describe how automatic biases in attentional and interpretational processes contribute to threat detection and to the inclusion of negative intrusive thoughts into the worry stream typical of the “what if …?” thinking style of pathological worriers. The review also describes processes occurring downstream from these perceptual biases that also facilitate perseveration, including cognitive biases in beliefs about the nature of the worry process, the automatic deployment of strict goal-directed responses for dealing with the threat, the role of negative mood in facilitating effortful forms of information processing (i.e. systematic information processing styles), and in providing negative information for evaluating the success of the worry bout. We also consider the clinical implications of this model for an integrated intervention programme for pathological worrying.

Introduction

Worry is an activity that most people experience on a regular basis. But for some people this activity can become pathological, uncontrollable and distressing, and lead to regular bouts of seemingly uncontrollable, anxious worry that negatively affects social, occupational, and familial functioning. When excessive and uncontrollable worry of this kind occurs, it is the defining feature of Generalized Anxiety Disorder (GAD) (DSM-5, American Psychiatric Association, 2013). As well as being the cardinal diagnostic feature of GAD, pathological worry¹ is also an important transdiagnostic process, which contributes to a number of other psychopathologies (Barlow, Allen, & Choate, 2004; Ehring & Watkins, 2008). These include panic disorder (Casey, Oei, & Newcombe, 2004), social phobia (Clark & Wells, 1995; Mellings & Alden, 2000), obsessive-compulsive disorder (Comer, Kendall, Franklin, Hudson, & Pimentel, 2004), and depression (Diefenbach et al., 2001; Nolen-Hoeksema, 1991). Individuals who exhibit high levels of worry (either with GAD, with sub-threshold GAD, or without a GAD diagnosis) also report poorer perceived physical health, greater levels of stress, and increased sleep difficulties (Kertz & Woodruff-Borden, 2011).

Pathological worry is defined by Barlow (2002) as excessive anxious apprehension relating to future negative or threatening events, and this type of worry is considered to be negatively valenced, distressing to the worrier (Borkovec, Robinson, Pruzinsky, & DePree, 1983; Davey, Eldridge, Drost & MacDonald, 2007), and predominately verbal (Borkovec, Ray, & Stober, 1998). Pathological worriers view their worries as being uncontrollable whereas infrequent worriers do not (Davey, Tallis, & Capuzzo, 1996), and one way in which uncontrollable worry manifests is in the process of catastrophising (Brietholtz, Westling, & Ost, 1998; Davey & Levy, 1998; Vasey & Borkovec, 1992), where individuals appear to apply a perseverative “what if?” questioning style to perceived problems. Key differences in duration and intensity of worry are also reported in high compared to low worriers. High worriers will continue with a worry episode for significantly longer and experience greater emotional discomfort than non-worriers (Startup & Davey, 2001; Vasey & Borkovec 1992).

While pathological worry is closely associated with anxiety and is a prominent feature of almost all of the anxiety disorders (Brown, Antony, & Barlow, 1992), it is an activity that is distinct from anxiety and not simply the cognitive component of anxiety. For example, Davey, Hampton, Farrell, and Davidson (1992) found that worry and anxiety can be understood as two separate constructs, each with their own unique sources of variance. They reported that worry was associated with adaptive problem focused coping strategies and an information seeking cognitive style, whereas trait anxiety was associated with poor problem solving confidence, poor perceived personal control, responsibility for negative but not positive outcomes, the tendency to perceive events as threats, and avoidant or emotion focused coping strategies. Thus, while worry is an attempt to address problems or find solutions suitable for dealing with future threats, this problem-solving process can often be thwarted by factors associated with high levels of anxiety (Davey, 1994a, Davey, 1994b), and this can result in perseveration of a worry bout and increases in self-reported distress during a worry bout (Davey et al., 2007; Vasey & Borkovec, 1992), both of which contribute to turning adaptive worrying into pathological worrying.

Most contemporary models of pathological worrying attempt to explain this psychopathology by alluding to pathological worrying as a dispositional characteristic found across a range of anxiety disorders and postulate explanations at the global level in terms of how worrying has become an endemic characteristic of an anxious individual (e.g. Burrell, Meares, Wilkinson & Freeston, 2011; Ladoucer, Talbot & Dugas, 1997; Pratt, Tallis, & Eysenck, 1997; Wells, 2007, Wells, 2010). However, proximal models of individual pathological worry bouts are much rarer (but see Ref. Hirsch & Mathews, 2012), but will be required to understand the individual psychological mechanisms which generate a worry experience that is perseverative, seemingly uncontrollable, and increasingly distressing as the bout continues.

This purpose of this paper is to review some of the cognitive, affective and attentional factors that contribute to the perseverative worry bout. At the proximal level we need to understand what triggers an individual worry bout, and what cognitive mechanisms cause the individual to perseverate that worry bout. We have focused on worry bout perseveration because it is one feature that operationalizes the inability to control the worry bout, and it is a characteristic of catastrophic worry where increasing levels of distress are caused by systematic inflation of the aversiveness of the worry as the bout progresses (Vasey & Borkovec, 1992). As such, perseveration embodies many of the critical characteristics that define worry as pathological. Processes involved in generating a perseverative bout include the role of cognitive biases in identifying threats, biases in beliefs about the nature of the worry process, biases in the deployment of goal-directed rules for worrying, and finally, biases in the way that experienced mood can influence the nature of the processing undertaken during a worry bout. The following sections in turn describe (1) the role of cognitive biases in identifying worries, (2) the determinants of perseveration during a worry bout, and finally (3) a description of how these processes may interact to generate worry perseveration. Because of the transdiagnostic nature of pathological worry and the involvement of basic psychological processes in perseverative worry, the evidence described in these sections comes from a combination of studies conducted on both clinical populations and experimental psychopathology studies conducted on healthy participants.