An experience sampling investigation of emotion and worry in people with generalized anxiety disorder

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Highlights

  • People with Generalized Anxiety Disorder experience intense and unstable emotions.

  • People with Generalized Anxiety Disorder get ‘stuck’ in negative emotional states.

  • Worry is associated with increased negative emotion and decreased positive emotion.

Abstract

Emotion-oriented theories (e.g., emotion dysregulation model, Mennin et al., 2005; contrast avoidance model; Newman & Llera, 2011) posit that people with Generalized Anxiety Disorder (GAD) have disturbances in emotion, experience negative emotion as aversive and in turn use maladaptive strategies, including worry, to regulate their distress. Much of what is known about emotion in the context of GAD is based on studies employing static methodologies. It is proposed that constructs and methodologies from the literature on emotion dynamics offer a complementary perspective. The principal aims of the study were to identify an emotion profile for people with GAD and to examine the direct effect of worry on subsequent negative and positive emotions via the experience sampling method. Participants included people with GAD (GAD group; n = 39) and people without GAD (nonclinical control [NCC] group; n = 41). Relative to the NCC group, the GAD group exhibited an emotion profile characterized by elevated mean intensity, greater instability and greater inertia of negative emotions and lower mean intensity, greater instability of positive emotions, but did not differ on inertia of positive emotions. People with GAD were found to have greater worry inertia and worry was also found to be associated with a subsequent increase in negative emotion, and this was more pronounced for the GAD group relative to the NCC group. The findings inform emotion-oriented models, provide unique insights into the dynamic emotional experiences of those with GAD and reinforce the benefits of the experience sampling methodology to study GAD-relevant processes.

Introduction

The ability to successfully regulate one’s emotions has important mental health implications as emotions can help people to respond adaptively to demands in their environment or can lead people to engage in self-destructive behavior (Gross and Muñoz, 1995, Parrott, 2001). Difficulties with emotion and emotion regulation have been identified in several clinical populations, including Generalized Anxiety Disorder (GAD; American Psychiatric Association, 2013), a condition characterized by chronic pathological worry.

Some theoretical models of GAD have incorporated components of emotion and emotion dysfunction to better understand this clinical population. The emotion dysregulation model, for example, posits that individuals with GAD experience heightened emotional intensity and difficulties with emotion management (Mennin et al., 2007, Mennin et al., 2009, Turk et al., 2005). Moreover, the contrast avoidance model (Newman & Llera, 2011), which is conceptually linked to the emotion dysregulation model, and seeks to extend Borkovec’s avoidance theory by clarifying the relationship between worry and aversive emotion. The avoidance theory suggests that worry, owing to its verbal-linguistic quality, dampens the intensity of negative affect (e.g., Borkovec, 1994; Borkovec, Alcaine, & Behar, 2004). However, research has not always demonstrated this theorized attenuating function of worry (Newman & Llera, 2011). According to the contrast avoidance model, worry is reinforced and becomes chronic, not because it dampens negative affect, but rather because it prevents the experience of a negative contrasting state. The theory posits that a sharp shift from a euthymic state to one that is intensely negative is far more intolerable than a constant state of tension and worry (Newman & Llera, 2011). Though theories differ in their specifics, emotion-oriented theories of chronic worry converge on the notion that dysfunctional emotional processes play a role in GAD.

Research on emotion and its relationship with worry in GAD has tended to rely on self-report questionnaires and laboratory experiments (see Fresco, Mennin, Heimberg, & Ritter, 2013; Newman & Llera, 2011; Newman et al., 2019). While highly valuable and informative, these methods also involve relatively “static” measurement that may or may not correspond with the real-life experience of emotion and worry (Newman et al., 2019, Trull and Ebner-Priemer, 2014). The experience sampling method (ESM), on the other hand, involves real-time assessments of experiences, multiple times a day over a pre-determined period (Csikszentmihalyi & Larson, 1987), making it well-suited to the study of fluctuations in psychological processes, including emotion and worry.

ESM involving multiple measurements per day has been used in GAD research; however, this is a relatively new development. Only 4 studies using ESM had been identified in a systematic review published 7 years ago, with three of these focusing on change in symptoms during cognitive-behavioural therapy (Waltz, Nauta, & aan het Rot, 2014). Since then, there has been increased use of ESM to study GAD-relevant cognitive and emotional processes. For example, using a 7-day, 56 prompt protocol, Ruscio et al. (2015) found in individuals with GAD that rumination following relatively mild stressful situations predicted increases in depressive and anxiety symptoms. More recently, Newman et al. (2019) reported on a study employing a 7-day, 80-prompt protocol to test specific tenets of the contrast avoidance model. The authors found that reported uncontrollability of thoughts, longer duration of worry, and feeling more keyed up predicted sustained feelings of being keyed up at the next prompt, suggesting avoidance of a negative contrast. They also found that these same variables predicted an increased probability of a positive contrast in thought valence at the subsequent prompt, which the authors interpreted as evidence of a transient reaction to non-negative outcomes associated with worries.

Thus, there is emerging evidence that ambulatory assessment has many useful applications in the study of chronic worry and emotional processes. In the present study, we employed ESM to study emotion dynamics in people with GAD. According to Kuppens, emotion dynamics “refers to the patterns and regularities characterizing the changes and fluctuations in people’s emotional and affective states over multiple points in time across seconds, hours, or days” (as cited in Houben, Van Den Noortgate, & Kuppens, 2015). We propose that emotion dynamic constructs can contribute to the understanding of emotion and its relationship with worry, in ways that may complement existing theories and empirical findings related to chronic worry. In the present study, we examined the dynamic constructs instability and inertia, which have been studied considerably in relation to psychological maladjustment and psychopathology (see Houben et al., 2015 for a review), but have not, to our knowledge, been studied in relation to worry and GAD.

Instability of emotional experiences is defined as the degree of change in the intensity of emotion from one moment to the next and is measured by averaging the differences between successive squared emotion intensity ratings (i.e., mean squared successive differences, MSSD; Jahng, Wood, & Trull, 2008). In contrast to emotional variability, which reflects how much people’s emotional experiences deviate from their average emotional state (Eid and Diener, 1999, Kuppens et al., 2010), instability accounts for both variability and temporal dependency between two successive emotion intensity ratings (Ebner-Priemer et al., 2009, Jahng et al., 2008). Emotional instability has been associated depression and anxiety disorders, such as social anxiety disorder (e.g., Farmer & Kashdan, 2013; Koval, Pe, Meers, & Kuppens, 2013; Thompson et al., 2012). Thus, instability of emotions appears to be associated with different forms of psychopathology but has yet to be studied via experience sampling in people with GAD.

Inertia of emotional experiences is defined as how well the emotion intensity at given time carries over to the next time point and is calculated as the autocorrelation between emotion intensity at one time and the next (Kuppens et al., 2010, Suls et al., 1998). Emotions with higher autocorrelation “carry over more across time, … linger, and show less homeostatic recovery compared with low autocorrelation” (Houben et al., 2015, p. 903). Thus, inertia is analogous to being “stuck” in an emotional experience (Koval, Kuppens, Allen, & Sheeber, 2012) and this may be problematic if the valence of the emotion is negative. In particular, greater inertia of negative emotions has been associated with lower psychological well-being (Houben et al., 2015), lower self-esteem (Kuppens et al., 2010) and greater depression severity (Koval et al., 2012). Some argue that the persistence of an emotion may be related to difficulties with emotion regulation, such as not having effective skills to upregulate or downregulate intense emotions (Koval & Kuppens, 2012).

Together, the dynamic emotion constructs of instability and inertia can be used to inform an emotion profile (Koval et al., 2013, Kuppens et al., 2010). That is, high instability and high inertia is suggestive of a profile that is characterized by large but slow changes in the intensity of an emotion. A person with this profile would experience marked shifts in the intensity of their emotions and the emotion would linger. In contrast, high instability and low inertia is suggestive of a profile that exhibits large and quick changes in the intensity of an emotion (Houben et al., 2015). No known studies have directly examined the instability or inertia of daily emotional experiences in people with GAD compared to those of people with no psychopathology; therefore, the present study makes an important contribution to the literature on emotion dynamics in people with GAD.

The present study had two aims. The first goal was to identify the emotion profile of people with GAD by examining the extent to which they differ from people with no psychopathology on their mean intensity, instability, and inertia of negative and positive emotion in daily life. The emotion-oriented theories of GAD do not provide direct statements about how people with GAD experience changes in emotion in daily life, but studies examining the tenets of these theories may offer some insight. For example, people with GAD are found to report greater reactivity in their negative emotions (i.e., intense reactions) following a negative mood induction relative to those without GAD (e.g., Mennin, Heimberg, Turk, & Fresco, 2005; Fitzgerald et al., 2017). Greater emotional reactivity to events may suggest that shifts in emotion in everyday life may also exhibit greater instability (i.e., large shifts in intensity from one moment to the next). Moreover, theories of GAD indirectly touch on the notion of sustained negative emotion. For example, the emotion dysregulation model posits that people with GAD have difficulty engaging in adaptive emotion regulation strategies to downregulate negative emotion (Fresco et al., 2013, Mennin et al., 2005), whereas the contrast avoidance model suggests that people with GAD endure negative emotional states to avoid negative emotional contrasts (Newman & Llera, 2011). Therefore, both theories touch indirectly on the notion that people with GAD may experience sustained, or inert, negative emotion. Based on these extant findings and theories, it was hypothesized that within the context of daily life, people with GAD would report experiencing greater mean intensity, greater instability and greater inertia of negative emotions relative to people with no psychopathology. Less is known about how people with GAD experience and react to positive emotions. GAD has been associated with negative reactivity to positive emotions (Mennin et al., 2005) and a tendency to dampen positive emotions (Eisner, Johnson, & Carver, 2009), whereas people without anxiety are found to have greater stability in their experience of positive emotions (Gruber, Kogan, Quoidbach, & Mauss, 2013). Based on these findings, it was hypothesized that people with GAD would exhibit greater instability, but lower intensity and lower inertia of positive emotions relative to people with no psychopathology.

The second goal was to examine the effects of worry on subsequent emotional experiences and whether these effects differ for people with GAD compared to people with no psychopathology. To fully understand the emotion profile of people with GAD it is necessary to examine how worry affects their emotional experiences. When people are instructed to worry, it has been found that they report increased negative affect and decreased positive affect (e.g., Llera & Newman, 2014; Stapinski, Abbott, & Rapee, 2010), however more could be known about whether this finding translates to daily life. It was hypothesized that worry would be associated with a subsequent increase in negative emotion, and that this would be significantly more pronounced in people with GAD compared to people with no psychopathology. It was also predicted that worry would be associated with a subsequent decrease in positive emotion, however, it was unknown whether the strength of this relationship would differentiate people with GAD from those with no psychopathology. Finally, to determine if the relationship between worry and emotion is bidirectional, the final aim was to determine if changes in negative or positive emotion are associated with a subsequent change in worry.

Section snippets

Participants

Eighty individuals participated in the study across two groups: 39 individuals who endorsed the criteria for DSM-5-defined GAD and where GAD was deemed to be their principal diagnosis (GAD Group), and 41 individuals who did not endorse the criteria for a current DSM-5-defined mental disorder (nonclinical control [NCC] group) (APA, 2013). Exclusion criteria across both samples included: current psychotherapy; current or past mania, hypomania, or psychosis; substance use disorder in the past 3

Clinical characteristics

The GAD group reported significantly greater worry (d = 3.11), greater cognitive and somatic symptoms of anxiety at the state (d = 1.43 and 1.33, respectively) and trait level (d = 2.29 and 1.74, respectively), and greater depression symptoms (d = 1.69; see Table 1). The mean score on the PSWQ for the GAD group was comparable to means seen in a clinical setting and the mean score for the NCC group was comparable to non-clinical groups observed in other research (e.g., Behar, Alcaine, Zuellig, &

Discussion

The present study examined the extent to which people with GAD differ from people with no psychopathology in the intensity, instability, and inertia of their negative and positive emotions in daily life. The relationship of worry to subsequent emotional experiences was also examined.

Acknowledgements

Funding and support

This work was supported by a Canadian Institutes of Health Research Doctoral Award – Frederick Banting and Charles Best Canada Graduate Scholarships awarded to the first author.

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    Permanent address: Anxiety Treatment and Research Clinic, St. Joseph’s Healthcare Hamilton, 100 West 5th Street, Hamilton, Ontario L8N 3K7, Canada

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    Permanent Address: PGSP-Stanford Psy.D. Consortium, Palo Alto University, Allen Calvin Main Campus, 1791 Arastradero Road, Palo Alto, CA 94304

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