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Cognitive Therapy and Research, Vol. 29, No. 1, February 2005 ( C 2005), pp. 47­56 DOI: 10.1007/s10608-005-1647-x

Thought Control Strategies in Generalized Anxiety Disorder

Meredith E. Coles1,3 and Richard G. Heimberg2

Generalized anxiety disorder (GAD) is characterized by excessive anxiety and worry that is difficult to control; but methods of thought control among persons with GAD have not been previously investigated. Forty-two patients with GAD and 55 non-anxious controls (NACs) completed the Thought Control Questionnaire (TCQ; A. Wells & M. I. Davies, 1994). Patients with GAD reported significantly greater use of worry and punishment strategies, and less use of distraction and social control strategies, than NACs. Further, worry and punishment strategies were positively correlated with depressive symptoms and excessive worry, while distraction and social control strategies were negatively correlated with these measures of psychopathology. Higher life satisfaction was associated with greater use of distraction and social control strategies, and lesser use of worry and punishment strategies.

KEY WORDS: generalized anxiety disorder; thought control strategies.

THOUGHT CONTROL STRATEGIES IN GENERALIZED ANXIETY DISORDER Generalized anxiety disorder (GAD) is characterized by excessive anxiety and worry that the person finds difficult to control (American Psychiatric Association [APA], 1994). This excessive and uncontrollable worry, and associated symptoms (e.g., muscle tension, irritability) cause significant distress or impairment in important areas of functioning. Cognitive-behavioral treatment of GAD seeks to reduce the excessive and uncontrollable nature of worry. For example, stimulus control techniques are used to delay worry until a specifically allocated period of time. Worry-monitoring records are used to identify worry triggers in an effort to decrease feelings of unpredictability and uncontrollability. Cognitive reappraisal techniques seek to decrease the uncontrollable nature of worry by teaching clients to question

1 Department 2 Department

of Psychology, Binghamton University, Binghamton, New York. of Psychology, Adult Anxiety Clinic of Temple University, Temple University, Binghamton, New York. 3 Correspondence should be directed to Meredith E. Coles, Department of Psychology, Binghamton University (SUNY), Binghamton, New York 13902-6000; e-mail: [email protected] 47

0147-5916/05/0200-0047/0

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2005 Springer Science+Business Media, Inc.

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the validity of their worries. Considering the centrality of uncontrollable thoughts in GAD, it is striking that there are no published studies examining methods of thought control in individuals with GAD. While we are unaware of any studies examining thought control strategies in individuals with GAD, there is a growing body of work examining the relationship between thought control strategies and anxiety. Much of this work has utilized the Thought Control Questionnaire (TCQ), developed by Wells and Davies (1994). The TCQ assesses five strategies for controlling unpleasant and unwanted thoughts: Distraction (attempts to keep oneself busy and think about other topics), Punishment (getting angry with oneself and utilizing methods such as shouting at oneself or slapping or pinching oneself to control thoughts), Reappraisal (attempts to reinterpret the thought via methods such as challenging the thought's validity or trying a different way of thinking about it), Social Control (talking to a friend about the thought or asking friends how they deal with similar thoughts), and Worry (efforts to think about more minor problems, dwell on smaller worries, or to replace the thought with more trivial bad thoughts). The TCQ worry scale assesses worry as a coping strategy for controlling thoughts, not as a symptom of anxiety. In a non-clinical sample, Wells and Davies (1994) found the TCQ total score and the punishment and worry subscales to be significantly correlated with levels of trait anxiety, pathological worry (as measured by the Penn State Worry Questionnaire (PSWQ); Meyer, Miller, Metzger, & Borkovec, 1990), and levels of social and meta-worry reported on the Anxious Thoughts Inventory (Wells, 1994). Several recent studies have examined methods of thought control in individuals with various anxiety disorders. Two studies have found that individuals with obsessive­compulsive disorder use the thought control strategies of punishment and worry more and use distraction less than non-clinical participants (Abramowitz, Whiteside, Kalsy, & Tolin, 2003; Amir, Cashman, & Foa, 1997). In contrast, findings regarding the use of reappraisal and social control strategies were not consistent across studies. Three studies have examined use of thought control strategies in individuals with acute stress disorder or post-traumatic stress disorder (Holeva, Tarrier, & Wells, 2001; Reynolds & Wells, 1999; Warda & Bryant, 1998). Two of these studies suggest that elevated levels of worry and punishment are related to negative post-trauma reactions (Holeva et al., 2001; Warda & Bryant, 1998). Further evidence suggests that use of distraction and social control strategies are related to more positive post-trauma reactions (Holeva et al., 2001; Reynolds & Wells, 1999). In summary, existing data suggest that several of the anxiety disorders are characterized by heightened use of the thought control strategies of punishment and worry. What predictions can be made regarding the use of thought control strategies among persons with GAD? First, based on both empirical findings and theoretical models, we propose that individuals with GAD will report elevated levels of worry and punishment. Indeed, high use of these two strategies has been shown to characterize other anxiety disorders. Further, worry is at the core of GAD, and use of worry strategies is proposed to maintain anxiety. Indeed, worry itself may be a strategy used to distract from more distressing emotionally laden topics (Borkovec & Inz, 1990). However, worry may be an ineffective method for controlling thoughts over the long term. For example, Wells and Papageorgiou (1995)

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found that participants, who were instructed to worry about a stressful film for 4 min after it ended, experienced more intrusions over the following 3 days than participants who were allowed to "settle down" after the stressor. The ineffectiveness of worry in reducing intrusive thoughts may lead to frustration and thereby elevated levels of punishment as a method of thought control. While previous studies provide less guidance for proposals regarding the use of social control and distraction strategies, theory and clinical experience would suggest that individuals with GAD are likely to use these strategies less than the comparison sample. Regarding the use of social control, there is mounting evidence of interpersonal difficulties in individuals with GAD (Borkovec, Newman, Pincus, & Lytle, 2002; Crits-Christoph, 2002). Further, Newman, Castonguay, Borkovec, and Molnar (2004) have proposed that individuals with GAD may avoid letting others know about themselves (e.g., their feelings, etc.) to protect themselves from predicted criticism or rejection. Therefore, it is reasonable to propose that individuals with GAD may be less likely to seek support from others regarding their intrusive thoughts (i.e., they will be less likely to use social control to control unwanted thoughts). Finally, given that individuals with GAD often have positive beliefs about the usefulness of their worry (Freeston, ´ Rheaume, Letarte, Dugas, & Ladouceur, 1994), they may be less motivated to distract themselves from it. Goals of the Current Study The main goal of the current study was to examine the methods of thought control used by individuals with GAD. Therefore, we compared individuals with a principal diagnosis of GAD to non-anxious controls (NACs) on the five types of thought control strategies assessed by the TCQ (Wells & Davies, 1994). We proposed that individuals with GAD would report greater use of punishment and worry strategies, and less use of social control and distraction strategies, than NACs. No specific predictions were made about the use of reappraisal. In addition, we examined the relative levels of use of the various thought control methods within each group (GAD and NACs). Finally, we examined the relationship of thought control strategies to levels of worry, depressive symptoms, and perceived quality of life. METHOD Participants and Procedure The clinical sample consisted of 42 individuals who sought treatment for excessive and uncontrollable worry and who met DSM-IV (APA, 1994) criteria for a principal diagnosis of GAD. The comparison sample was comprised of 55 NAC participants who were recruited through advertisements in local newspapers and flyers soliciting the paid participation of individuals who did not experience problems with anxiety or depression. All participants were screened using the Anxiety Disorders Interview Schedule for DSM-IV, Lifetime Version (ADIS-IV-L; DiNardo, Brown, & Barlow, 1994). The ADIS-IV-L has been shown to have good to excellent reliability for the majority of DSM-IV categories (Brown, DiNardo, Lehman, &

50 Table I. Characteristics of the Study Sample GADs Mean SD Age PSWQ total BDI total QOLI total Gender Female (%) Male (%) Educational level High School or less (%) College (%) Post-graduate education (%) 34.58 69.33 15.52 0.00 12.82 3.97 8.24 1.78 67 33 8 67 25

Coles and Heimberg

NACs Mean SD 29.91 31.63 2.31 2.40 10.34 9.78 2.60 1.36 59 41 20 63 18

Note. PSWQ = Penn State Worry Questionnaire; BDI = Beck Depression Inventory; QOLI = Quality of Life Inventory. Groups differed at p < .05. Groups differed at p < .001.

Campbell, 2001). Diagnosticians in the current study were either clinical psychologists or advanced doctoral students in clinical psychology, and all were trained to strict reliability standards as delineated by Brown et al. (2001). NACs could not meet the criteria for any current or past-year Axis I diagnosis other than specific phobia. Groups were not found to differ significantly on gender ratio [2 (1, N = 104) = .66, ns] or level of education [2 (2, N = 104) = 2.99, ns]. However, the GAD group was significantly older than the NAC group [t(102) = 2.06, p = .04].4 Sample characteristics are presented in Table I. Measures The TCQ (Wells & Davies, 1994) is a 30-item self-report measure developed and validated to identify the frequency of use of five strategies of thought control: distraction, punishment, reappraisal, social control, and worry. Each subscale consists of six items rated on a four-point Likert-type scale (from 1 = "never" to 4 = "almost always"), and the subscales have been shown to have moderate to strong internal consistency (s = .64­.79; Wells & Davies, 1994). Finally, consistent with the instructions to indicate what thought control strategies one typically uses, scores on the TCQ have been shown to be reliable over period of 6 weeks (test­retest coefficients, rs = .67­.83). The PSWQ (Meyer et al., 1990) is a 16-item self-report inventory designed to assess trait worry, and to capture the generality, excessiveness and uncontrollability characteristic of pathological worry (e.g., "My worries overwhelm me"; "I worry all the time"). Each item is rated on a 1 ("not at all typical of me") to 5 ("very

4 Given

the group differences in age, we examined the relationship between age and the five thought control strategies assessed by the TCQ. This analysis failed to reveal any significant correlations, and the correlations were all small in magnitude (r .07). Therefore, group differences in age are not a likely explanation for any group differences in thought control strategies.

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typical of me") Likert-type scale. In undergraduate samples, the PSWQ has repeatedly demonstrated good internal consistency and good retest reliability over intervals as long as 8­10 weeks (Meyer et al., 1990). Individuals with a principal diagnosis of GAD score higher on the PSWQ than community controls and patients with panic disorder, panic disorder with agoraphobia, social phobia, simple phobia, or OCD (Brown, Antony, & Barlow, 1992). Molina and Borkovec (1994), and Turk, Heimberg, and Mennin (2004) provide more detailed reviews of the psychometric properties of the PSWQ. The Beck Depression Inventory (BDI; Beck, Rush, Shaw, & Emery, 1979) is a 21-item self-report scale, which focuses primarily on the cognitive symptoms of depression. Each item is rated on a scale of 0­3, with higher scores indicative of greater severity. The BDI exhibits good internal consistency in both psychiatric and non-psychiatric samples (mean = .86 and .81, respectively) and good concurrent validity with other measures of depression (Beck, Steer, & Garbin, 1988). For a detailed discussion of the use of the BDI over the past 25 years, see Beck et al. (1988). The Quality of Life Inventory (QOLI; Frisch, 1994) is a self-report questionnaire that assesses the importance of, and satisfaction with, 16 life domains (e.g., friends, work, community, health). Importance and satisfaction ratings for each domain are multiplied to form a weighted satisfaction score for each domain. Weighted satisfaction scores range from -6 to +6, with higher scores indicating increased satisfaction. A total score across all domains can be computed by summing the weighted satisfaction scores (i.e., all items with non-zero importance ratings). The QOLI has demonstrated acceptable retest reliability (rs = .80­.91) and internal consistency (s = .77­.89) across clinical and nonclinical samples (Frisch, Cornell, Villanueva, & Retzlaff, 1992).

RESULTS Comparisons of GADs and NACs on Use of Thought Control Strategies Independent samples t-tests were utilized to compare the groups on reported levels of each thought control method. Individuals with GAD reported significantly higher levels of worry and punishment strategies than NACs [t(95) = 5.98, p < .001; and t(95) = 4.70, p < .001, respectively]. In contrast, individuals with GAD reported significantly lower levels of social control and distraction strategies than NACs [t(95) = 3.04, p < .01; and t(95) = 2.78, p = .01, respectively].5 Finally, the two groups were not found to differ on their reported levels of reappraisal [t(95) = 1.15, p = .25] (see Figure 1).

5 Given

high rates of comorbidity between GAD and social phobia, we compared our GAD clients with and without comorbid social phobia (n = 17 and 25, respectively) on their TCQ social control scores. This analysis failed to reveal a significant difference [t(40) = .54, p = .59], suggesting that comorbid social phobia does not account for the low social control scores found in the current sample.

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Fig. 1. Thought control strategies in individuals with generalized anxiety disorder (GADs) and non-anxious controls (NACs).

Relative Use of Various Thought Control Strategies Within Group Next we examined the relative use of various thought control strategies within groups. Given that we did not have specific predictions for the results, and the large number of paired t-tests that would be required to test all combinations of the five TCQ subscales, repeated measures ANOVAs were conducted (see Table II). For individuals with GAD, this analysis revealed a significant main effect of Type of Thought Control Strategy [F (4, 164) = 6.60, p < .001]. Follow-up tests revealed that the patients with GAD utilized punishment significantly less than all other strategies and worry significantly less than distraction.6 For the NACs, there was also a significant main effect of Type of Thought Control Strategy [F (4, 216) = 70.60, p < .001]. Follow-up tests revealed that the NACs utilized the punishment and worry strategies significantly less than the reappraisal, distraction and social control strategies. Correlations Between Thought Control Strategies, Worry, Depressive Symptoms, and Life Satisfaction Next we examined the relationships between the thought control strategies, worry, depressive symptoms, and life satisfaction (see Table III). In order to prevent suppression of correlations due to a restricted range of scores, these correlations were conducted for the entire sample (GADs and NACs combined). Before combining the two groups, we confirmed that the scores on these measures were relatively normally distributed by examining the skew and kurtosis for each measure. Examination of the correlations revealed that greater use of worry and punishment strategies, and less use of distraction and social control strategies were associated with higher levels of pathological worry and depressive symptoms. A parallel pattern of results was found regarding relationships to life satisfaction; higher levels of worry and punishment thought control strategies were correlated with lower life satisfaction, whereas higher levels of distraction and social control strategies were

6 Given

the large number of comparisons a Bonferroni-corrected alpha level of .005 was utilized for the post hoc tests.

Thought Control in GAD Table II. Thought Control Strategies in Individuals With Generalized Anxiety Disorder (GADs) and Non-Anxious Controls (NACs) and Results of Within Group Post Hoc Tests TCQ subscale Punishment Worry Social control Reappraisal Distraction GADs Mean SD 10.19a 12.17b 12.88bc 13.33bc 13.38c 2.33 3.23 4.58 3.01 3.39 NACs Mean SD 8.09a 8.65a 15.53b 14.16b 15.65b 2.06 2.55 3.99 3.85 4.38

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Note. TCQ = Thought Control Questionnaire. Means with different subscripts within each column indicate different frequency of usage of thought control strategies within groups (post hoc t-tests with Bonferroni correction).

associated with greater life satisfaction. Levels of reappraisal were not significantly correlated with pathological worry, depressive symptoms, or quality of life. DISCUSSION This is the first study to empirically demonstrate that individuals with GAD utilize different methods for controlling their unwanted thoughts than non-anxious individuals. Specifically, individuals with GAD reported greater use of worry and punishment strategies, and less use of distraction and social control strategies than did NACs. Further, worry and punishment strategies were positively correlated with depressive symptoms and excessive worry, while distraction and social control strategies were negatively correlated with these measures of psychopathology. Finally, higher levels of life satisfaction were correlated with greater use of distraction and social control strategies, and less use of worry and punishment strategies. Elevated use of worry and punishment strategies in GAD is consistent with previous findings in individuals with obsessive­compulsive disorder (Abramowitz et al., 2003; Amir et al., 1997) and acute stress disorder (Warda & Bryant, 1998).

Table III. Correlations Between Thought Control Strategies, Levels of Worry, Depressive Symptoms, and Life Satisfaction TCQ distraction PSWQ total BDI total QOLI total -.26 -.29 .31 TCQ social control -.28 -.30 .21 TCQ worry .58 .37 -.48 TCQ punishment .50 .39 -.39 TCQ reappraisal -.12 -.18 .03

Note. TCQ = Thought Control Questionnaire; PSWQ = Penn State Worry Questionnaire; BDI = Beck Depression Inventory; QOLI = Quality of Life Inventory. N = 97 for the PSWQ and BDI, and N = 90 for the QOLI. Correlation is significant at p < .05. Correlation is significant at p < .01.

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This suggests that elevated use of worry and punishment may characterize several of the anxiety disorders. However, data from a small sample of individuals with panic disorder (n = 12) failed to show elevated use of worry or punishment in this group (Abramowitz et al., 2003). It is important to interpret these results with caution, as the small sample size is associated with limited power to detect group differences. Further examinations of thought control strategies in anxious samples, and with larger ns, are needed before firm conclusions can be drawn. It is important for future studies to examine the shared and unique methods of thought control across the anxiety disorders. Given the heightened use of worry and punishment strategies in anxious compared to non-anxious individuals, it is also interesting to consider the potential meaning of these strategies. For example, use of self-punishment as a thought control strategy may be related to attributional style (e.g., blaming oneself for intrusive thoughts) or thought­action fusion (believing that thinking something is as bad as doing it or having bad thoughts means that one is bad). Use of worry as a thought control strategy may be related to the experiential avoidance proposed to maintain anxiety. Future studies can examine such possibilities. Findings regarding the relative use of reappraisal, distraction, and social control have been less consistent across the anxiety disorders. Turning to the relationship between these thought control methods and psychopathology, both the current study and Warda and Bryant (1998) show that social control strategies (e.g., "I talk to a friend about the thought.") are inversely related to measures of anxiety and depression. Use of distraction was also inversely correlated with measures of psychopathology in both studies, although these relationships were only statistically significant in the current study. In further support of distraction as an adaptive method of thought control, its use has been proposed to alleviate depression (Nolen-Hoeksema, 1987). In summary, there is growing evidence that social control and distraction may be adaptive methods of thought control, and the utility of attempts to increase the use of these methods of thought control among persons with GAD should be examined. That the reappraisal scale was unrelated to measures of psychopathology and life satisfaction in this and other studies calls its utility into question. It is also important to note that the design of the current study does not allow for causal conclusions. Longitudinal or experimental designs will be important for examining causal relationships between thought control strategies and anxiety. It is it worthwhile to consider how the TCQ subscales map onto commonly used constructs. For example, the worry scale of the TCQ measures the use of worry as a method for controlling thoughts by replacing them with thoughts about smaller, or less distressing, concerns. This definition of worry fits well with the avoidance model of pathological worry proposed by Borkovec (1994). It is also worthwhile to consider the nature of the distraction scale of the TCQ. Findings suggesting that distraction is an adaptive method of thought control may seem at odds with models proposing that lack of emotional processing underlies pathological anxiety (Foa & Kozak, 1986). However, examination of the distraction items of the TCQ suggests that this scale does not assess efforts to stop or block negative thoughts, but instead a letting go and a shift to present moment focus (e.g., "I do something that I enjoy"). This is consistent with recent emphasis on the benefits of focusing attention on presentmoment experience (Borkovec, 2002).

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As noted, elevated use of worry (as measured by the TCQ) to control unwanted thoughts is clearly consistent with Borkovec's avoidance theory of worry (see Borkovec, Alcaine, & Behar, 2004). In this model, Borkovec and colleagues propose that the cognitive nature of worry allows individuals to process emotional topics at an abstract conceptual level, thereby reducing intrusive images and emotional arousal. However, given that elevated levels of worry as a thought control strategy have been found in numerous other anxiety disorders, what are the implications for models of GAD? In addition, it is not readily apparent how current models of GAD would explain elevated use of punishment as a thought control strategy. One possible explanation is that the ineffectiveness of worry in reducing intrusive thoughts may lead to frustration, and thereby, elevated levels of punishment as a method of thought control. Use of punishment in response to worry may also be related to negative meta-cognitive beliefs about worry, such as those discussed by Wells (2004). These possibilities remain to be examined empirically. Finally, given current conceptualizations of GAD that emphasize experiential/emotional avoidance (Mennin, Turk, Heimberg, & Carmin, 2003; Roemer & Orsillo, 2002), it will be interesting to examine the interplay between methods of controlling both thoughts and emotions in GAD. One possibility is that the thought control strategies utilized in GAD (worry and punishment) may be utilized as a means to avoid or stop the emotional arousal associated with distressing thoughts. In other words, thought control strategies may be engaged to moderate the relationship between worry and emotional arousal. Future studies can test such moderating relationships and could also examine the relative impacts of manipulating emotional, and cognitive avoidance on levels of worry. ACKNOWLEDGMENT This project was supported in part by National Institute of Mental Health Grants 13006 and 44119, awarded to the first and second authors, respectively. REFERENCES

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