A novel theory of experiential avoidance in generalized anxiety disorder: A review and synthesis of research supporting a contrast avoidance model of worry,☆☆

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Abstract

An important emphasis of the literature on generalized anxiety disorder (GAD) has been to achieve a greater understanding of the function of emotion (e.g., avoidance, dysregulation) in the etiology and maintenance of this disorder. The purpose of the following paper is to propose a new way of conceptualizing emotional sequelae in GAD by detailing the Contrast Avoidance Model of Worry. In presenting this model, we review theory and data that led to our current position, which is that individuals with GAD are more sensitive to feeling emotionally vulnerable to unexpected negative events, and that worry (the key pathological feature of GAD) is employed to prolong and maintain a negative emotional state thereby avoiding an unexpected negative emotional shift, or contrast experience. We also discuss implications for treatment given the presence of a new target for emotional exposure techniques. Finally, we establish the Contrast Avoidance Model within the framework of extant theories and models of pathogenic processes of GAD.

Research Highlights

► We will review and critique extant literature pertaining to the perspective that worry enables emotional avoidance in GAD. ► We will explore the direct physiological and subjective emotional impacts of worry. ► We will present a new theory pertaining to experiential avoidance in GAD. Specifically, we propose the Avoidance of Negative Emotional Contrast model as an extension and modification of the perspective that worry serves an emotional avoidance function. ► We discuss possible clinical implications for a disorder that historically has been considered the least successfully treated of all anxiety disorders. ► Finally, we provide a comparison between our new model and current leading models of worry and emotion in GAD.

Section snippets

Avoidance models of worry

Borkovec's model of GAD (Borkovec, 1994, Borkovec et al., 2004) suggests that worry functions as a cognitive avoidance response to perceived future threats. Among several types of avoidant functions posited for worry, two are most central to the theory. The first is that worry is a cognitive attempt to generate ways to prevent bad events from happening and/or to prepare oneself for their occurrence. The second is that worry just prior to fear-inducing images mutes aspects of somatic response to

The causal role of worry in creating negative emotionality

A tenet of many of the later theoretical models of emotion and GAD is that worry functions to enable avoidance of the experience of distressing negative emotions. However, experimental studies supporting this perspective have focused primarily on the impact of worry on subsequent reactivity to exposure to emotional stimuli. In the following section we review the data as they pertain to the experiential impact of the worry process itself.

Contrary to the idea that worry enables emotional

A new way of understanding the avoidance phenomenon

A recent study by Llera and Newman (2010a) further illustrates the proposition that worry may not enable avoidance of emotion. We extended previous experimental studies of the impact of worry on fear imagery by using film clips that evoked a range of emotions. Thirty-eight participants with GAD and 35 nonanxious participants were assigned randomly to engage in worry, brief relaxation, or neutral inductions prior to sequential exposure to 4 emotion-inducing film clips. During worry, participants

Worry leads to sustained emotionality

Also contrary to the idea that worry enables emotional avoidance is evidence for the relationship between worry and sustained negative emotionality. Based on extant data, Brosschot and colleagues (Brosschot et al., 2005, Brosschot et al., 2007, Brosschot et al., 2006, Pieper and Brosschot, 2005) have proposed that worry may be a mechanism by which cognitive representation of a stressor and associated negative emotionality are prolonged. Worry or rumination leads to slow recovery of blood

A new theory of experiential avoidance in GAD: avoidance of negative emotional contrast

Despite the causal role of worry in sustaining negative affect, high worriers view worry as a positive coping strategy and they report actively using it as such. Such positive functions include “preparation for the worst”, “motivation”, “distraction from more emotional topics”, actually preventing bad things from happening (superstitious beliefs) and/or helping the individual figure out how to prevent bad things from happening (Borkovec and Roemer, 1995, Davey et al., 1996). In fact,

Treatment implications

Despite evidence for the failure of GAD participants to engage in successful emotional processing, traditional methods of treating GAD have not included exposure techniques that will achieve emotional processing (Borkovec & Newman, 1998). Moreover, cognitive therapy and self-control desensitization (SCD), two major components of standard CBT for GAD, appear insufficient to address emotional processing. Borkovec and Costello (1993) found that a reflective listening condition was significantly

Comparison between contrast theory and extant theories of GAD

As noted earlier, a number of models of the development and maintenance of GAD have incorporated the perspective that worry enables emotional avoidance. Below we summarize these models to highlight similarities and differences with our contrast theory. It is neither our goal to summarize all of the data supporting these models nor is it our goal to critique them (see Behar, DiMarco, Hekler, Mohlman, & Staples, 2009 for a full review of the research underlying these models). Importantly,

Concluding remarks

The goal of this paper was to review the current literature on the relationship between worry and emotion dysfunction in the development and maintenance of GAD. Using the tenets of emotional contrast theory as our foundation, we presented a new model that may explain many inconsistencies in the literature on emotion in GAD. Specifically, we suggest that in interpreting the extant literature, recent theories of emotion in GAD have failed to discriminate: a) somatic response to worry from somatic

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    We would like to thank Drs. Thomas D. Borkovec and Evelyn Behar for providing insightful and helpful feedback on earlier drafts of this paper.

    ☆☆

    This research was supported in part by National Institute of Mental Health Research Grant RO1 MH58593-02.

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