David M. Fresco, Ph.D.

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DEFICITS IN EMOTION REGULATION AS THE HALLMARK FEATURE OF GENERALIZED ANXIETY DISORDER: AN EMERGING THEORY WITH MOUNTING EVIDENCE David M. Fresco, Ph.D. Kent State University Kent, OH Before

1 DEFICITS IN EMOTION REGULATION AS THE HALLMARK FEATURE OF GENERALIZED ANXIETY DISORDER: AN EMERGING THEORY WITH MOUNTING EVIDENCE David M. Fresco, Ph.D. Kent State University Kent, OH Before I begin I would like to acknowledge my colleagues at Temple University: Richard Heimberg, Cindy Turk, and Doug Mennin who are collaborators on all of the studies I will be discussing today. 1

2 Generalized Anxiety Disorder DSM-IV-TR Diagnosis (APA, 2000) Excessive worry more days than not for at least 6 months Worry may concern a number of different domains or activities work; finances; family; health Worry must be difficult to control Worry occurs with at least 3 of these 6 symptoms restlessness; fatigue; impaired concentration; irritability; muscle tension; sleep disturbance The anxiety, worry, or physical symptoms must lead to significant distress or impairment -Just to review, the current criteria for generalized anxiety disorder, or GAD as it is often called for short, are as follows -Excessive worry occurring more days than not for at least 6 months -Worry may concern a number of different domains or activities (e.g., work, finances, family and health) -Worry must be difficult to control The worry, anxiety, or physical symptoms cause significant distress or impairment 2

3 Generalized Anxiety Disorder Clinical Characteristics 5% lifetime prevalence Early onset is typical 2:1 female to male ratio Chronic course with low remission Using DSM-III-R criteria, which are fairly comparable to DSM-IV, there was a 5% lifetime rate of GAD in the NCS sample Age of onset is, often in childhood, and almost always before age 20 Women outnumber men by 2 to 1 In the absence of treatment, once GAD always GAD 3

4 Generalized Anxiety Disorder Impairment, Quality of Life, & Comorbidity Significant role impairment separated/divorced, unemployed, social isolation Decreased work productivity Perceive low quality of life in multiple domains (Turk, et al., 2000) High rates of comorbidity with mood and anxiety disorders (Kessler et al., 1996) GAD temporally primary to depression (Kessler, 2000) In contrast to earlier views on GAD is little more than a nuisance, GAD is associated with profound impairment in a variety of contexts GAD individual s functional ability ( 82% of NCS - significant role impairment) Have decreased levels of work output compared with those without the condition/interference with daily activities (errands, bills) We found that GAD perceived their quality of lives as very low in satisfaction with finances, work, recreational activities and relationships compared to controls GAD is associated with high rates of comorbidity with other anxiety and mood disorders The GAD is temporally primary to the depression 4

5 Generalized Anxiety Disorder When does an anxiety disorder not not behave like an anxiety disorder? -The other anxiety disorders, specific phobia, social phobia, panic disorder have a more defined fear stimulus -Exposure based therapies are highly successful -In GAD, the fear stimulus is more of a moving target -Consequently, traditional exposure-based treatments are less effective -Studies conducted by Tom Borkovec or reviewed by Borkovec suggest that CBT is still the most effective psychotherapy for GAD However, one third to one half of patients do not respond to treatment Less than half of responders are restored to high endstate functioning at treatment s end. 5

6 Borkovec s s Avoidance Theory of Worry Worry in GAD Worry [is] phenomenologically experienced primarily as a negative, verbal linguistic (as opposed to imaginal) activity. When we worry, we are talking to ourselves in anxious ways. -Borkovec, Alcaine, & Behar (in press) -As I mentioned, the DSM-IV considers worry to be the central component of GAD It is really fitting to have Tom Borkovec as discussant on this panel. For one thing, he is responsible directly or indirectly for each of the panelists in getting started in GAD research. More importantly, his Penn State Group has taught us much of what we know about worry. They have taught us that worry is something associated with but distinct from anxiety and anxiety symptoms. 6

7 Borkovec s Avoidance Theory of Worry Worry Predominantly verbal thought Less characterized by imagery Less characterized by somatic arousal May serve to avoid images and somatic anxiety Negatively reinforced by avoidance -Borkovec has developed an Avoidance Theory of Worry which looks at and has demonstrated the function of worry First, worry can characterized as a predominantly verbal activity. When we talk to ourselves in words about a negatively affectively laden situation, it is harder to form a vivid image of that situation. The net effect is that we get less somatically aroused by these stressful situations. In essence, worry serves as a way to avoid images of stressful or negatively affect laden situations and the somatic anxiety that might be experienced by such situations. Worry also gets negatively reinforced by the success of avoiding these aversive experiences in the short run and before you know it becomes a way oflife for the person with GAD. 7

8 Worry in GAD The tail wagging the dog??? So, in GAD the fear stimulus is a moving target. We also know much more about the function of worry. Still, what we do know makes our group ask the question: That is with respect to GAD, is worry the tail wagging the dog? Is GAD primarily about worry? Or rather is worry what they do to confront some other core difficulty? 8

9 Worry and Emotion in GAD Worrying to avoid aversive emotions? -So for us, if worry is the tail, emotional experience is the dog! Taking this as our starting point, we have asked, Why is it that someone would need to avoid these things? After all, emotional experience may be good as well as bad, and many of us deal with negative emotions without needing to use worry or any other strategy to avoid it. -Our clinical experience with GAD patients over the last few years basically told us that these patients are overwhelmed by their emotional experience and lack the necessary and essential skills for the management and regulation of their emotional life. 9

10 Emotion as Adaptation Emotion Regulation the processes by which individuals influence which emotions they have, when they have them, and how they experience and express these emotions (Gross, 1998) Emotional Intelligence the ability to perceive accurately, appraise, and express emotion; the ability to access and/or generate feelings when they facilitate thought; the ability to understand emotion and emotional knowledge; and the ability to regulate emotions to promote emotional and intellectual growth. (Mayer & Salovey, 1997) So, as an extension of Borkovec s Avoidance Theory of Worry, we propose that work in emotion regulation and emotional intelligence may advance our understanding of GAD Specifically, we drew from James Gross work in emotion regulation. This work examines the processes influenced by and that influence emotional experience and expression - Salovey and colleagues work in emotional intelligence figures in here too. 10

11 Two types of emotion dysregulation Difficulties in modulation of emotional experience and/or expression (under-regulation) Frequent attempts to control or suppress emotional experience or expression (over-regulation) Finally, Cicchetti describes 2 prominent types of emotion dysregulation which involve underregulating and overregulating emotions: 1) difficulties in modulation of emotional experience and/or expression 2) frequent attempts to control or suppress emotional experience or expression (Cicchetti, Ackerman, & Izard, 1995; Cole, Michel, & O'Donnell-Teti, 1994) -In our approach, we conceptualize individuals with GAD has having difficulties with both kinds of emotion regulation 11

12 Deficits in Emotion Modulation Individuals with GAD may: Pay more attention to their emotions Experience their emotions as more intense Be overly expressive of emotions Have greater difficulty repairing their mood when they experience negative emotions -Modulation of emotion may be especially difficult for individuals with GAD -Experiences that have little effect on other people may trigger an emotional reaction in an individual with GAD -Individuals with GAD may have emotional reactions that occur more easily, quickly, and intensely than for most other people -They may also be overly expressive of emotions -and have greater difficulty getting over negative moods when they occur For example: former patient described being very sensitive to the noise made at night when people in his apartment building would honk their horns to alert the attendant to open the garage door In contrast, he reported that his wife had no difficulty ignoring the noise and did not understand his distress Late one evening when he was feeling particularly tense, he became startled and then intensely angry when someone began honking. The patient ran outside, yelling at his offending neighbor and punching the car window as the neighbor pulled away 12

13 Deficits in Accepting and Utilizing Emotion Individuals with GAD may also: Have greater difficulty identifying and describing emotions Have greater difficulty understanding and clarifying emotions Have greater need to control their emotional experience (e.g., through worrying) -In addition, because of oversensitivity to emotion, they may experience emotions as subjectively aversive -Individuals with GAD may use worry and other strategies to ineffectively and inappropriately control or suppress emotional experience -this recurrent avoidance may make it difficult for them to identify and understand these experiences 13

14 Study 1 Study 2 47 GAD Analogue 35 Patients with GAD 491 Control 28 Community Controls Measures Berkeley Expressivity Questionnaire (BEQ) (Study 1 Only) Trait Meta-Mood Scale (TMMS) Toronto Alexithymia Scale - 20 item version (TAS) Affective Control Scale (ACS) The Berkeley Expressivity Questionnaire (BEQ) which has subscales of Emotional Impulse Strength, Negative Expressivity, and Positive Expressivity The Toronto Alexithymia Scale (TAS-20) used Difficulty Identifying Feelings and Difficulty Describing Feelings subscales The Trait Meta-Mood Scale (TMMS) is a measure of emotional intelligence and is comprised of three subscales: Awareness of Emotion (Attention to Feelings), Understanding and Analyzing Emotions (Clarity of Feelings), and Reflective Regulation of Emotions (Mood Repair). The Affective Control Scale (ACS) assesses an individuals fears of losing control over their emotions and the behavioral reactions to these emotions. The ACS is made up of four subscales: Fear of Anger, Fear of Depression, Fear of Anxiety, and Fear of Positive Emotion. 14

15 Hypothesis 1: Deficits in Emotion Modulation GAD > Control BEQ Emotional Impulse Strength BEQ Negative and Positive Expressivity TMMS Attention to Emotions Control > GAD TMMS Repair of Emotions -The first hypothesis concerned deficits in emotion modulation -It was expected that individuals diagnosed with GAD in comparison to control individuals, would be characterized by: higher levels of emotional intensity as measured by the BEQ Impulse Strength subscale -In addition, they would show greater levels of emotional expression (BEQ) -and pay greater attention to their emotions (TMMS) -However, controls would report being better able to respond to negative emotions with a greater ability to repair their mood (TMMS) 15

16 Hypothesis 2: Deficits Accepting/Utilizing Emotion Control > GAD TMMS Clarity of Emotions GAD > Control TAS Difficulties in Identifying and Describing Emotions ACS Fear of Emotions (Anxiety, Depression, Anger, and Positive Emotions) -The second hypothesis was that individuals with GAD would also: experience greater deficits in ability to understand their emotional experience including identifying emotions, describing them, differentiating them, and clarifying what motivational information the emotion may be conveying In addition, GAD patients may have more difficulty accepting their emotional experience and fear these experience and, subsequently try to control having these experiences -This is most obviously the case for anxiety but may also be true for other negative emotions such as depression and anger but also positive emotions such as elation because they may be too arousal inducing -Specifically, it was hypothesized that Controls > GAD in clarity of emotions as measured by the TMMS -However, GADs would have more difficulty with identifying and describing their emotions on the TAS and fearing emotions of anxiety, depression, anger, and positive emotions as measured by the ACS 16

17 BERKELEY EXPRESSIVITY QUESTIONNAIRE Analogue GAD (n = 47) Control (n = 491) Cohen s d GAD Patients (n = 35) Control (n = 28) Cohen s d BEQ Impulse Strength 5.17 (1.02) 4.56 (.96).36 N/A N/A N/A BEQ Negative Expressivity 4.39 (.59) 3.99 (.62).32 N/A N/A N/A BEQ Positive Expressivity 4.98 (.94) 4.89 (.94).05 N/A N/A N/A Cohen s d effect size with small =.2, medium =.5, large =.8 Red ES correspond to statistically significant t test, white ES was not statistically significant 17

18 TRAIT METAMOOD SCALE Analogue GAD (n = 47) Control (n = 491) Cohen s d GAD Patients (n = 35) Control (n = 28) Cohen s d TMMS Attention to Emotions 3.65 (.63) 3.71 (.55) (.52) 3.77 (.61).38 TMMS Clarity of Emotions 2.85 (.57) 3.31 (.60) (.74) 3.80 (.51) 1.05 TMMS Repair a Bad Mood 2.95 (.73) 3.42 (.69) (.94) 4.06 (.47)

19 TORONTO ALEXITHYMIA SCALE Analogue GAD (n = 47) Control (n = 491) Cohen s d GAD Patients (n = 35) Control (n = 28) Cohen s d TAS Difficulty Identifying Emotions 3.07 (.73) 2.34 (.74) (.91) 1.73 (.56) 1.17 TAS Difficulty Describing Emotions 3.17 (.84) 2.72 (.79) (.97) 2.11 (.80).48 19

20 AFFECTIVE CONTROL SCALE Analogue GAD (n = 47) Control (n = 491) Cohen s d GAD Patients (n = 35) Control (n = 28) Cohen s d ACS Anxiety 4.17 (.91) 3.36 (.83) (.98) 2.30 (.71) 2.44 ACS Depression 4.12 (1.00) 3.13 (1.05) (1.28) 2.20 (.83) 1.69 ACS Anger 3.95 (.83) 3.52 (.85) (1.14) 2.82 (.68) 1.21 ACS Positive Emotions 3.50 (.65) 3.11 (.77) (.99) 2.35 (.67)

21 Emotion Regulation Deficits Identify GAD Emotion regulation will predict diagnosis of GAD Relationship between emotion regulation and GAD diagnosis significant beyond worry, anxiety symptoms, and depression Discriminant Function Analysis to predict group membership -The third hypothesis focused on the ability of emotion dysregulation to predict a diagnosis of GAD -How specific are these deficits to GAD? -Do these deficits really suggest that person has GAD? -We hypothesized that these measures of ER would be able to predict a diagnosis of GAD -In addition, this relationship between ER and GAD would be unique above and beyond the effects of GAD s own symptoms of worry and anxiety AND beyond depression which often co-ocurs with GAD 21

22 Discriminant Function Analysis Results Study 1 36 of 47 GAD Analogues correctly classified ( (76.6%) 380 of 411 Controls correctly classified ( (77.4%) Overall, 77.3% of sample correctly classified Study 2 32 of 35 GAD patients correctly classified ( (91.4%) 27of 28 Controls correctly classified ( (96.4%) Overall, 93.7% of sample correctly classified -To examine this hypothesis, we conducted a discriminant function analysis predicting the diagnosis of GAD with the previously mentioned subscales of emotion regulation. DFA, for those unfamiliar, allows one to classify a dichotomous variable using the linear combination of a number of predictors -Using the linear combination of these measures derived from the discriminant function analysis, a diagnosis of GAD was accurately predicted 77% of the time; as was the lack of a diagnosis -Considering that no item on any of these measures reflects any symptom of GAD, it is pretty surprising to see so many individuals classified as having this disorder based solely on ER -We also wanted to go a step further and make sure that emotion regulation was predictive of GAD beyond other common variables -We factor analyzed the emotion regulation measures and obtained a higher order emotion regulation factor which was entered into a logistic regression simultaneously with worry (as measured by PSWQ), trait anxiety (as measured by STAI), and depression (as measured by BDI) to predict a diagnosis of GAD -EVEN WITH THESE FACTORS IN THE MODEL, ER still significantly predicted a GAD Diagnosis at the.05 level 22

23 STUDY 3: Worry and Emotion Participants (Undergraduate Sample) 36 GAD Analogue 38 Non-GAD Control Objectives: To examine whether aversive emotional experience activates the worry process in individuals with GAD To examine whether such experiences activate other over- regulation strategies Drops in explanatory flexibility or the ability to view events with a balance of historical and contextual information In the third study, which by the way came from Doug Mennin s dissertation, we sought to examine whether worry is a pathological control strategy to manage emotional experience? 36 participants who met self-report DSM-IV criteria for GAD and 38 participants who do not meet GAD criteria were our sample here So, we wished to see if an emotional evocation task would start the worry process in participants with GAD In addition, we wish to see if other over-regulation strategies would also come into play So, other than worry, we wanted to see if individuals with GAD would show drops in explanatory flexibility after the evocation task. Explanatory flexibility has been my contribution to our work in GAD. Briefly, it represents a cognitive process counterpart to explanatory style, the cognitive diathesis in learned helplessness theory. We define it as the ability to view events with a balance of historical and contextual information. It is computed as the to an individual s s responses to Attributional Style Questionnaire items. A high SD is regarded as flexible 23

24 STUDY 3: Worry and Emotion Randomly assigned to Sad or Anxious music prime Prokofiev Russia under the Mongolian Yoke Schoenberg, Selections from Erwartung, Op. 17 Dependent Measures Worry Visual Analog Scale (WVAS) The Mood and Anxiety Symptom Questionnaire (MASQ) The Attributional Style Questionnaire (ASQ) The State Meta-Mood Scale (SMMS) -The study utilized an experimental design -Both GAD and control participants were randomly assigned to a depressed or anxious mood induction -Inductions were validated inductions that are often used: Sad Mood (Prokofiev s Russia Under the Mongolian Yolk) Anxious Mood (Schoenberg s Erwatung [Anticipation]) -Using the Multiple Affect Adjective Checklist-Revised (MAACL), I found that the manipulation did indeed increase targeted anxiety -Worry Visual Analog is a clinician administered single item scale of Worry -The MASQ was used to determine increases in generalized anxiety symptoms like muscle tension and gastrointestinal distress -The Attributional Style questionnaire which served as our way of assessing explanatory flexibility --Finally, the State Meta-Mood Scale was given only after the inductions--this measure is a state version of the TMMS that measures emotional metaevaluation and repair-only subscales of evaluation were used--these included emotional acceptance, clarity, influence and typicality 24

25 Hypotheses STUDY 3: Worry and Emotion All participants will show rise in negative mood following procedure GAD participants will have increases in in worry, lower levels of state emotional intelligence, and drops in in explanatory flexibility Compared to GAD participants, control participants will demonstrate greater ability to effectively manage emotional state following negative mood induction Hypotheses All participants will show rise in negative mood following procedure GAD participants will have increases in worry, lower levels of state emotional intelligence, and drops in explanatory flexibility To unpack the emotional intelligence hypothesis, compared to GAD participants, control participants will demonstrate greater ability to effectively manage 25

26 SMMS-MES Subscales after Negative Mood Induction 24 Acceptance Clarity Influence Typicality d =.52 d =.41 d =.60 d =.19 GAD Control Let s look at that hypothesis first -Controls were more accepting of their emotional experience compared to GADs -In addition, they were more clear about their emotions, what they were, and why they were having them -They also believed that they could have more influence over this mood than the GAD patients did -However, the control and GAD groups did not differ in terms of how typical they believed this mood to be 26

27 Change in FLEX following mood prime challenge Explanatory Flexibility Time 1 Time 2 Controls GAD Analogue Condition by Time Interaction F(1,72) = 5.64, p =.02, ES f =.29 Here s the explanatory flexibility graph Analog GAD participants showed a dramatic drop in flexibility scores following a mood priming challenge whereas control participants did not! That is, the analog GADs became significantly more rigid when confronted with an emotionally evocative task! Again, by Cohen standards, this difference is in the range of a medium effect size. 27

28 SMMS-MES Clarity after Negative Mood Induction a b c d n =13 n =13 n =10 n = 38 GAD Low FLEX a + b < c + d GAD Moderate FLEX t(70) = 2.90, p =.001, GAD High FLEX d =.69 Control Finally, what is the interplay of over-regulation strategies and one s emotional experience? To begin to answer that, we split the GADs into tertiles based on their post induction flexibility scores and then compared them on measures of emotional intelligence. So, this yellow column represents the non-gad controls. The red column from the earlier graph has been broken down to represent the flexibility tertiles with red representing low flexibility and orange representing high flexibility. With respect to clarity, we find that GADs that remained flexible showed clarity of emotional experience more like the non-gads and a contrast comparing columns A and B to C and D has an effect size that is approaching a large effect - 28

29 Future Directions Further tests of the emotion regulation deficits in GAD Delineation of the specific deficits in GAD versus general deficits associated with other psychopathology Development of a treatment that combines elements of CBT while cultivating adaptive emotion regulation 1. Emotional acceptance/understanding that emotions are an important source of information for decision-making 2. Identification, description, and differentiation of emotions 3. Decrease use of worry and other emotional avoidance strategies 4. Increased understanding of how one s emotions affect interpersonal relationships and are affected by them -If our ideas have merit, they suggest a number of additional points of therapeutic intervention -A relationship between EDR and GAD suggests that these patients may need to learn to: Identification, description, and differentiation of emotions Acceptance of emotional experience Learning that emotions are an important source of information for decisionmaking Increased understanding of how one s emotions affect interpersonal relationships and are affected by them -We are presently developing a treatment to address these areas of concern and will be piloting the treatment -In addition, we are carrying out a number of treatment analogue studies to determine if this type of emotional processing could be helpful -We are eager to see if we will be able to improve our ability to treat GAD Thank you. 29

David M. Fresco, Ph.D.

THE ASSOCIATION OF RUMINATION TO GENERALIZED ANXIETY DISORDER AND TO DEFICITS IN EMOTION REGULATION David M. Fresco, Ph.D. Kent State University Kent, OH. 1 Speak to me as to thy thinkings, As thou dost