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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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A Novel Theory of Experiential Avoidance in Generalized Anxiety Disorder: a Review and Synthesis of Research Supporting a Contrast Avoidance Model of Worry☆,☆☆ Clinical Psychology Review 31 (2011) 371–382 Contents lists available at ScienceDirect Clinical Psychology Review A novel theory of experiential avoidance in generalized anxiety disorder: A review and synthesis of research supporting a contrast avoidance model of worry☆,☆☆ Michelle G. Newman ⁎, Sandra J. Llera The Pennsylvania State University, United States article info abstract Article history: An important emphasis of the literature on generalized anxiety disorder (GAD) has been to achieve a greater Received 1 October 2010 understanding of the function of emotion (e.g., avoidance, dysregulation) in the etiology and maintenance of Received in revised form 14 January 2011 this disorder. The purpose of the following paper is to propose a new way of conceptualizing emotional Accepted 18 January 2011 sequelae in GAD by detailing the Contrast Avoidance Model of Worry. In presenting this model, we review Available online xxxx 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 Keywords: Generalized anxiety disorder GAD) is employed to prolong and maintain a negative emotional state thereby avoiding an unexpected negative Emotion emotional shift, or contrast experience. We also discuss implications for treatment given the presence of a Emotional processing new target for emotional exposure techniques. Finally, we establish the Contrast Avoidance Model within the Emotional avoidance framework of extant theories and models of pathogenic processes of GAD. Emotion-regulation © 2011 Elsevier Ltd. All rights reserved. Cognitive-behavioral therapy Contents 1. Avoidance models of worry ........................................................ 0 2. The causal role of worry in creating negative emotionality ......................................... 0 3. A new way of understanding the avoidance phenomenon ......................................... 0 4. Worry leads to sustained emotionality .................................................. 0 5. A new theory of experiential avoidance in GAD: avoidance of negative emotional contrast .......................... 0 6. Treatment implications .......................................................... 0 7. Comparison between contrast theory and extant theories of GAD ...................................... 0 7.1. Intolerance of Uncertainty (IU) Model of GAD............................................ 0 7.1.1. Areas of convergence with the Contrast Avoidance Model .................................. 0 7.1.2. Areas of divergence .................................................... 0 7.2. Metacognitive (MC) Model of GAD ................................................. 0 7.2.1. Areas of convergence with the Contrast Avoidance Model .................................. 0 7.2.2. Areas of divergence .................................................... 0 7.3. Acceptance-based (AB) Model of GAD ............................................... 0 7.3.1. Areas of convergence ................................................... 0 7.3.2. Areas of divergence .................................................... 0 7.4. Emotion Dysregulation (ED) Model of GAD ............................................. 0 7.4.1. Areas of convergence ................................................... 0 7.4.2. Areas of divergence .................................................... 0 7.5. Areas of divergence with all prior theories ............................................. 0 8. Concluding remarks ........................................................... 0 References .................................................................. 0 ☆ 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. ⁎ Corresponding author at: Department of Psychology, The Pennsylvania State University, 310 Moore Building, University Park, PA 16802-3103, United States. Tel.: +1 814 863 1148. E-mail address: [email protected] (M.G. Newman). 0272-7358/$ – see front matter © 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.cpr.2011.01.008 372 M.G. Newman, S.J. Llera / Clinical Psychology Review 31 (2011) 371–382 Among those who study generalized anxiety disorder (GAD), there Later theories have suggested that in addition to precluding has been great interest in understanding its emotional sequelae, and emotional processing, worrisome thinking may be associated with how worry (the cardinal feature of GAD) is associated with the avoidance of emotional experience or avoidance of emotional arousal etiology and maintenance of emotion regulation problems. Within (Mennin, Heimberg, Turk, & Fresco, 2002; Newman, Castonguay, this context, Borkovec and colleagues' Cognitive Avoidance Theory of Borkovec, & Molnar, 2004; Roemer, Salters, Raffa, & Orsillo, 2005). Worry (Borkovec, 1994; Borkovec, Alcaine, & Behar, 2004) has played Indeed, individuals with GAD do report greater fear of the negative a pivotal role in our understanding of the cyclical relationship consequences of a range of emotions than do non-anxious controls between worry and emotional dysfunction, spurring much intriguing (Llera & Newman, 2010; Mennin, Heimberg, Turk, & Fresco, 2005; discussion and empirical study of these phenomena. Nonetheless, Turk, Heimberg, Luterek, Mennin, & Fresco, 2005). Data also show that there is still room to improve upon our understanding of the people with GAD report greater fear of and discomfort with anxiety pathogenic processes within GAD. Therefore, in pursuit of greater and depression than do nonanxious control participants, as well as knowledge and insight into a complex clinical disorder, we endeavor greater fear of depression than participants with social anxiety to present a new perspective on the relationship between worry and disorder (Llera & Newman, 2010a; Roemer et al., 2005; Turk et al., emotional dysfunction in GAD. 2005 ). Moreover, when asked why they worry, GAD patients differed In the present paper, we will review and critique extant literature from nonworried anxious and control participants by indicating that pertaining to the perspective that worry enables emotional avoidance “worry helps distract me from more emotional topics,” (Borkovec & in GAD, explore the direct physiological and subjective emotional Roemer, 1995; Freeston, Rheaume, Letarte, Dugas, & Ladouceur, impact of worry, and present a new theory pertaining to experiential 1994), supporting theories that individuals with GAD use their worry avoidance in GAD. Specifically, we propose the Contrast Avoidance to try to control emotional arousal. Model of Worry as an extension and modification of the perspective Based on emotion theories, a number of new treatments have been that worry serves an emotional avoidance function, and we present developed to target avoidance of emotion in GAD. For example, some preliminary findings in support of this model. We also discuss Newman, Castonguay, Borkovec, and colleagues (Newman, Castonguay, possible clinical implications for a disorder that has been considered Borkovec, Fisher, & Nordberg, 2008; Newman et al., in press)have historically to be the least successfully treated of all anxiety disorders developed and tested an interpersonal and emotional processing (Borkovec & Ruscio, 2001; Newman & Erickson, 2010; Westen & therapy for GAD; Roemer, Orsillo, and Salters-Pedneault (2008) have Morrison, 2001). Finally, we provide a comparison between our new developed a mindfulness-based CBT for GAD; and Mennin (2006) has model and current leading models of worry and emotion in GAD. developed an emotion-regulation therapy for GAD. Each of these treatments is in various stages of testing with promising results from wait-list control and open trial pilot studies. To date, only one published 1. Avoidance models of worry study has directly compared an emotion-focused treatment to standard CBT (Newman et al., in press). Borkovec's model of GAD (Borkovec, 1994; Borkovec et al., 2004) If people with GAD avoid emotions and if such emotional suggests that worry functions as a cognitive avoidance response to avoidance negatively reinforces the worry process, the treatment perceived future threats. Among several types of avoidant functions proposed by Newman and colleagues (Newman et al., 2004) might posited for worry, two are most central to the theory. The first is that benefit such clients by using experiential techniques to expose worry is a cognitive attempt to generate ways to prevent bad events individuals with GAD to avoided emotions. Further, this treatment from happening and/or to prepare oneself for their occurrence. The should be effective in teaching people to attend to their emotions, that second is that worry just prior to fear-inducing images mutes aspects emotions are not dangerous, as well as in leading to habituation and of somatic response to those images. In both types, this cognitive decreasing worry. In addition, these effects should be more robust avoidance response is negatively reinforced and precludes the than those of standard CBT. However, in a recent randomized emotional processing of fear-related stimuli otherwise necessary for controlled trial of interpersonal and emotional processing therapy extinction of anxiety responses, thus leading to the maintenance of (I/EP) plus cognitive behavioral
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