Cognitive Therapy and Research, Vol. 29, No. 1, February 2005 ( C 2005), pp. 89–106
DOI: 10.1007/s10608-005-1651-1
Emotion Dysregulation in Generalized Anxiety
Disorder: A Comparison with Social Anxiety Disorder1
Cynthia L. Turk,2,3 Richard G. Heimberg,2,6 Jane A. Luterek,2
Douglas S. Mennin,4 and David M. Fresco5
From an emotion regulation framework, generalized anxiety disorder (GAD) can be
conceptualized as a syndrome involving heightened intensity of subjective emotional
experience, poor understanding of emotion, negative reactivity to emotional experience,
and the use of maladaptive emotion management strategies (including overreliance
on cognitive control strategies such as worry). The current study sought to
replicate previous findings of emotion dysregulation among individuals with GAD
and delineate which aspects of emotion dysregulation are specific to GAD or common
to GAD and another mental disorder (social anxiety disorder). Individuals with
GAD reported greater emotion intensity and fear of the experience of depression than
persons with social anxiety disorder and nonanxious control participants. Individuals
with social anxiety disorder indicated being less expressive of positive emotions,
paying less attention to their emotions, and having more difficulty describing their
emotions than either persons with GAD or controls. Measures of emotion differentiated
GAD, social anxiety disorder, and normal control groups with good accuracy
in a discriminant function analysis. Findings are discussed in light of theoretical and
treatment implications for both disorders.
KEY WORDS: generalized anxiety disorder; social anxiety disorder; emotion regulation.
Our theoretical model of generalized anxiety disorder (GAD) emphasizes the
importance of understanding worry, the central feature of GAD, in the context of
difficulties in emotion regulation that may motivate its use (Mennin, Heimberg,
Turk, & Fresco, 2002; Mennin, Turk, Heimberg, & Carmin, 2004). It builds upon
1An earlier version of this paper was presented at the Association for Advancement of Behavior Therapy,
Reno, NV, November, 2002.
2Adult Anxiety Clinic of Temple, Department of Psychology, Temple University, Pennsylvania.
3Department of Psychology, La Salle University, Pennsylvania.
4Department of Psychology, Yale University, New Haven, Connecticut.
5Department of Psychology, Kent State University, Kent, Ohio.
6Correspondence should be directed to Richard G. Heimberg, Adult Anxiety Clinic of Temple, Department
of Psychology, Temple University,Weiss Hall, 1701 North 13th Street, Philadelphia, Pennsylvania
19122-6085; e-mail: [email protected].
89
0147-5916/05/0200-0089/0 C 2005 Springer Science+Business Media, Inc.
90 Turk, Heimberg, Luterek, Mennin, and Fresco
the growing body of research examining the relationship between worry and emotional
arousal. One line of research suggests that worry is more characterized by
thoughts than images (e.g., Borkovec & Lyonfields, 1993; Borkovec & Inz, 1990;
Freeston, Dugas, & Ladouceur, 1996). This finding is important because thinking
about emotional material leads to very little physiological arousal, while visualizing
images of that same emotional material leads to significant physiological response
(Vrana, Cuthbert, & Lang, 1986). Additionally, worry has been shown to be associated
with reduced autonomic arousal upon exposure to images containing feared
material (e.g., Borkovec & Hu, 1990), and GAD is associated with a restricted range
of variability on measures such as skin conductance and heart rate (Hoehn-Saric &
McLeod, 1988; Hoehn-Saric, Mcleod, & Zimmerli, 1989). Borkovec, Alcaine, and
Behar (2004) synthesize these findings by suggesting that worry allows the individual
to process emotional material at an abstract, conceptual level and avoid aversive
images, autonomic arousal, and intense negative emotions in the short-run. Consistent
with models of emotional processing (e.g., Foa & Kozak, 1986), the short-term
avoidance provided by worry carries with it the cost of symptoms associated with
inadequate emotional processing, such as more frequent intrusive images about the
initial source of upset (e.g., Butler, Wells, & Dewick, 1995; Wells & Papageorgiou,
1995).
Worry and emotional arousal interact in a dynamic process that unfolds over
time. From this perspective, it is too simplistic to merely categorize individuals with
GAD as either emotionally blunted or excessively aroused. Indeed, the literature
suggests that individuals with GAD frequently endorse symptoms of autonomic
arousal (e.g., Brown, Marten, & Barlow, 1995; Butler, Fennell, Robson, & Gelder,
1991). However, as noted earlier, worry, the central feature of GAD, has been associated
with decreased autonomic arousal. Brown, Chorpita, and Barlow (1998) reconciled
these apparently contradictory findings based on structural equation modeling
suggesting that GAD is associated with high levels of negative affect, which
is, in turn, associated with increased autonomic arousal. However, after accounting
for variance in anxious arousal due to negative affect, worry was associated with
suppression of autonomic arousal.
In our model of GAD (see Mennin et al., 2002; 2004), we attempt to simultaneously
capture both the excessive negative affect and affect-dampening worry
processes that characterize GAD. We argue that emotional experience may become
dysregulated through a set of processes that involve 1) heightened intensity
of emotional experience; 2) poor understanding of emotions (e.g., relative inability
to identify discrete emotions and use them as a source of knowledge); 3) negative
reactivity to one’s emotional state (e.g., fear of emotion); and 4) maladaptive emotional
management responses.
We have suggested that individuals with GAD have emotional reactions that
occur more easily, quickly, and intensely than is the case for most other people
(i.e., heightened emotional intensity). They may frequently experience strong negative
affect, which may be elicited by situations that are not as evocative for other
people. Consistent with the research showing that higher levels of emotional intensity
are associated with greater emotion expressivity (Gross & John, 1997), individuals
with GAD may also express more of their emotions, especially negative
Emotion Dysregulation in Generalized Anxiety Disorder 91
emotions, than most other people. Being overly expressive of negative emotions
on a regular basis may lead to criticism or rejection by others, which, in turn, may
elicit high levels of negative affect. Research suggests that individuals with GAD
perceive their relationships with family, friends, and romantic partners as moderately
to severely impaired (Turk, Mennin, Fresco, & Heimberg, 2000), and evidence
is mounting that individuals with GAD may have interpersonal styles that
contribute to the relationship problems that they perceive. Pincus and Borkovec
(1994) and Eng and Heimberg (in press) found that the majority of individuals with
GAD endorsed interpersonal styles that were best characterized as overly nurturant
and intrusive. Other individuals with GAD were best characterized as socially
avoidant/nonassertive or cold/vindictive.
Individuals with GAD may also have difficulty identifying primary emotions
such as anger, sadness, fear, disgust, and joy, and instead experience their emotions
as undifferentiated, confusing, and overwhelming (i.e, poor understanding of emotions).
In this way, persons with GAD fail to access and utilize the adaptive information
conveyed by their emotions. Given strong emotional responses and a poor
understanding of them, individuals with GAD may experience emotions as aversive
and become anxious when they occur (i.e., negative reactivity to emotions).
We also hypothesize that individuals with GAD have difficulty knowing when
or how to enhance or diminish the intensity of their emotional experience in a manner
that is appropriate for the environmental context (i.e., maladaptive emotional
management). Given the salience of their emotion and both their lack of skills for
utilizing emotions and their negative reactions to them, we suggest that individuals
with GAD turn to a variety of maladaptive management approaches. These may
take the form of poor modulation of emotional episodes or the rigid control of emotional
experience, including excessive reliance on worry to avoid a perceived aversive
state. In the latter scenario, rather than processing the emotion associated with
the event (Foa & Kozak, 1986), the individual with GAD turns to worry or some
other maladaptive coping response (e.g., reassurance seeking) to avoid or dampen
the original affect.
A series of three studies provided the initial test of this emotion dysregulation
model of GAD (Mennin, Heimberg, Turk, & Fresco, in press). In the first
study, college students with and without GAD (as assessed by self-report; Newman
et al., 2002) were compared on their responses to a battery of measures assessing
aspects of emotion. Individuals with self-reported GAD endorsed greater intensity
of emotional experience and expressed more negative, but not positive, emotions
than did controls. They also endorsed marked difficulties in their ability to identify
and describe their emotional experience. Further, the analogue GAD group also
displayed more negative beliefs about their emotional reactions (including anxious,
depressed, angry and elating mood states) and their consequences, compared to the
control group. They also reported greater difficulty repairing negative mood states
than the control group. Using the linear combination of emotion measures derived
from a discriminant function analysis, 72% of individuals with GAD and 76% of
individuals without GAD were correctly classified. Furthermore, a composite factor
score of emotion measures significantly predicted the presence of GAD, controlling
for worry, trait anxiety, and depression. These results were encouraging, given that
92 Turk, Heimberg, Luterek, Mennin, and Fresco
none of the emotion measures included items reflecting the symptoms of GAD. In
our second study, these findings were largely replicated with a sample of treatmentseeking
individuals with a principal diagnosis of GAD and a comparison group of
individuals from the community with no current Axis I diagnosis (Mennin et al.,
in press). In the third study, college students with and without GAD (as assessed
by self-report; Newman et al., 2002) underwent a mood induction (Mennin et al.,
in press). Following induction of a negative mood, controls reported greater clarity
about what they were feeling, more acceptance of these emotions, and a greater belief
that they could influence this mood state than individuals withGAD. These findings
did not appear to be due to an increased familiarity with negative mood states
in the GAD group as the groups did not differ on typicality of the induced mood.
Recently, Roemer, Salters, Raffa, and Orsillo (2005) conducted a study of relevance
to our emotion dysregulation model of GAD. Specifically, fear of internal
experiences and fear of losing control over one’s emotions were each uniquely associated
with the severity of GAD symptoms, above and beyond their association
with chronic worry.
Although these initial findings are intriguing, a limitation is that only GAD and
nonanxious control groups have been examined in research to date. An alternative
explanation remains, which is that the pattern of emotion dysregulation observed
in previous research might have been observed in any clinical sample. Contrary to
this position, we hypothesize that different mental disorders exhibit some commonalties
but also disorder-specific difficulties in how emotions are typically regulated.
To test this hypothesis, we compared the responses of participants with GAD to
those of participants with another anxiety disorder on the battery of emotion measures
used in our earlier research. Social anxiety disorder, which is characterized by
the fear of negative evaluation and fear and avoidance of one or more social situations,
was chosen for this purpose. Social anxiety disorder and GAD have several
commonalities. Worry is the central feature of GAD, and pathological worry is elevated
among individuals with social anxiety disorder (Brown, Antony, & Barlow,
1992). Social anxiety disorder is characterized by interpersonal concerns, and significant
disability in interpersonal relationships is common (e.g., Schneier et al., 1994).
Similarly, evidence is mounting that interpersonal difficulty and disability are characteristic
of patients with GAD (Borkovec, Shadick, & Hopkins, 1991; Breitholtz,
Westling, & O¨ st, 1998; Eng & Heimberg, in press; Turk et al., 2000). The high degree
of overlap between the features, symptoms, and concerns of individuals with
GAD and social anxiety disorder provides a rigorous test of the ability of emotion
measures to differentiate these disorders.
METHOD
Participants
Participants were 766 undergraduate students (538 women) who took part in
the study for course credit. The racial composition of the sample was 44% Caucasian,
29% African American, 8% Asian/AsianAmerican, 3% Hispanic, 6% mixed
Emotion Dysregulation in Generalized Anxiety Disorder 93
racial heritage, and 9% individuals who endorsed “other.” The average age of participants
was 19.5 years (SD = 4.1).
Diagnostic and Symptom Measures
The Generalized Anxiety Disorder Questionnaire—IV (GAD-Q-IV; Newman
et al., 2002) is a self-report measure assessing DSM-IV (American Psychiatric Association
[APA], 1994) criteria for GAD. The original version of this scale (GAD-Q;
Roemer, Borkovec, Posa, & Borkovec, 1995) was scored by comparing individual
items to specific DSM-III-R (APA, 1987) criteria for GAD. In contrast, Newman
et al. (2002) recommend using a dimensional scoring system (range 0–13) with cutoff
scores to determine presence or absence of GAD. Thus, an individual may fail
to endorse an item on the GAD-Q-IV required by DSM-IV criteria (e.g., excessive
worries more days than not during the past 6 months) but still receive a diagnosis
of GAD. Newman et al. (2002) identified a cutoff score of 5.7 as achieving the optimal
balance between sensitivity and specificity. With this cutoff score, Newman
et al. (2002) found good agreement between the GAD-Q-IV and clinician diagnosis
based on the anxiety disorders interview schedule for DSM-IV (ADIS-IV; Brown,
DiNardo, & Barlow, 1994) or the anxiety disorders interview schedule for DSM-IV:
lifetime version (ADIS-IV-L; DiNardo, Brown, & Barlow, 1994), kappa = .67, with
88% of clinician-diagnosed participants correctly classified. In the current study, a
cutoff score of 5.7 resulted in 33% of the sample being classified as positive for
GAD. Matching item responses to specific DSM-IV criteria, as was done for the
original version of the scale, resulted in a more modest 14.5% of the sample being
classified as positive for GAD. The discrepancy between the two scoring systems
was due to the fact that the cutoff score of 5.7 identified 146 more cases of
GAD than the criterion-based scoring system. The criterion-based scoring system
did not classify any participant as having GAD that the cutoff score system did not.
Therefore, the more conservative criterion-based scoring system was used in this
study.
The Social Interaction Anxiety Scale (Mattick & Clarke, 1998) is a 20-item
self-report measure that assesses anxiety experienced in dyadic and group interactions.
The SIAS has been widely used in the assessment of social anxiety and
has evidenced good reliability and validity in a number of studies (for reviews
see Hart, Jack, Turk, & Heimberg, 1999, or Heimberg & Turk, 2002). Heimberg,
Mueller, Holt, Hope, and Liebowitz (1992) found that a cut-off score of 34 on the
SIAS classified 82% of patients with social anxiety disorder and 82% of community
controls into the correct group. This cut-off was cross-validated by Brown et al.
(1997).
The Penn State Worry Questionnaire (PSWQ; Meyer, Miller, Metzger, &
Borkovec, 1990) is a 16-item inventory designed to capture the generality, excessiveness,
and uncontrollability characteristic of pathological worry. Multiple studies
attest to the validity of the PSWQ, as well as to its good internal consistency and testretest
reliability (for a review see Molina & Borkovec, 1994, or Turk, Heimberg, &
Mennin, 2004).
94 Turk, Heimberg, Luterek, Mennin, and Fresco
Emotion Measures
The Affective Control Scale (Williams, Chambless, & Ahrens, 1997) is a 48-
item self-report measure assessing negative beliefs about emotional reactions centering
on fear of emotions and inability to control emotional experience. Subscales
include 1) fear of anxiety (e.g., “Once I get nervous, I think that my anxiety might
get out of hand”); 2) fear of depression (e.g., “Depression could really take me over,
so its important to fight off sad feelings”); 3) fear of anger (e.g., “I am afraid that
I will hurt someone if I get really furious”); and 4) fear of positive emotions (e.g.,
“Being filled with joy sounds great, but I am concerned that I could lose control over
my actions if I get too excited”). The subscales have demonstrated satisfactory internal
consistency (Berg, Shapiro, Chambless, & Ahrens, 1998; Williams et al., 1997).
The ACS total score is strongly correlated with neuroticism and emotional control
and minimally correlated with social desirability (Berg et al., 1998; Williams et al.,
1997).
The Toronto Alexithymia Scale-20 (TAS-20; Bagby, Parker, & Taylor, 1994a;
Bagby, Taylor, & Parker, 1994b) is a 20-item self-report measure that generates
three factor-analytically derived subscales including 1) difficulty identifying feelings
(e.g., “When I am upset, I don’t know if I am sad, frightened, or angry”); 2) difficulty
describing feelings (e.g., “It is difficult for me to find the right words for my
feelings”), and 3) externally oriented thinking. The externally oriented thinking subscale
was not used in this study. The factor scores have evidenced acceptable internal
consistency (Bagby et al., 1994a). As expected, TAS-20 factor scores correlate
negatively with measures assessing access to one’s feelings and openness to feelings
(Bagby et al., 1994b).
The Trait Meta-Mood Scale (Salovey, Mayer, Goldman, Turvey, & Palfai,
1995) is a 30-item self-report measure of emotional intelligence that is comprised
of three factor-analytically derived subscales: 1) attention to emotion (e.g., “I pay a
lot of attention to how I feel”); 2) clarity of emotions (e.g., “I am usually very clear
about my feelings”); and 3) mood repair (e.g., “When I become upset I remind myself
of all the pleasures in life”). Preliminary studies suggest that these subscales are
internally consistent and related to other measures of mood and mood management
(Salovey et al., 1995).
The Berkeley Expressivity Questionnaire (BEQ; Gross & John, 1997) is a 16-
item self-report measure that assesses both the strength of emotional response tendencies
and the degree to which these emotional impulses are expressed overtly. It
is comprised of three factor-analytically derived subscales: 1) impulse strength (e.g.,
“My body reacts very strongly to emotional situations”); 2) negative expressivity
(e.g., “Whenever I feel negative emotions, people can easily see exactly what I am
feeling”); and 3) positive expressivity (e.g., “When I’m happy, my feelings show”).
The BEQ subscales have been shown to have adequate internal consistency and
retest reliability (Gross & John, 1997).
Procedure
The GAD-Q-IV, SIAS, PSWQ, and emotion measures were administered as
part of a larger questionnaire battery given to introductory psychology students
Emotion Dysregulation in Generalized Anxiety Disorder 95
during the first week of the semester. Participants took the questionnaire packets
home and returned them the following week.
The GAD group was comprised of 68 individuals (60 women) meeting DSMIV
criteria for GAD based on the items that they endorsed on the GAD-Q-IV. The
social anxiety disorder group consisted of 105 individuals (66 women) with scores
greater than or equal to 34 on the SIAS. Individuals meeting criteria for both GAD
and social anxiety disorder (n = 43) were excluded from analyses. The remaining
550 individuals (369 women) who did not meet criteria for GAD or social anxiety
disorder served as normal controls.
Analysis Plan for the Emotion Measures
Measures of emotion were grouped to represent each of the components of
the model, including 1) heightened emotional intensity (i.e., BEQ impulse strength,
BEQ negative expressivity and BEQ positive expressivity); 2) poor understanding
of emotions (i.e., TMMS clarity of emotions, TAS difficulty identifying emotions,
TAS difficulty describing emotions); 3) negative reactivity to one’s emotional state
(i.e., TMMS attention to emotions; ACS fear of anxiety, ACS fear of depression,
ACS fear of anger, ACS fear of positive emotions); and 4) maladaptive emotional
management responses (i.e., TMMS mood repair). Emotional expressivity can be
seen as an instrumental act (e.g., to elicit reassurance or comfort from others) or an
unintentional reflection of emotional intensity (e.g., facial expression of wide eyes
and a broad smile associated with a strong feeling of joy). The BEQ taps the latter
of these types of expressivity. Hence, the BEQ expressivity subscales were considered
measures of heightened emotional intensity rather than maladaptive emotional
management responses.
ANOVAs utilizing planned non-orthogonal contrast tests were used to understand
the nature of the differences among the three groups (GAD, social anxiety
disorder, and control) for each measure of emotion within each domain. Bonferonni
correction was applied to the analyses in each domain with multiple indices
to control for alpha inflation. Cohen’s d is reported for tests of the main hypotheses
to address Type II error (d = .20 for small effect, d = .50 for a medium effect,
d = .80 for a large effect). A discriminant function analysis was conducted in which
the emotion measures were used to predict group membership and determine which
variables were most important in making that discrimination.
RESULTS
Preliminary Analyses
As expected, the GAD group achieved a significantly higher PSWQ score
than the social anxiety disorder group, which had a significantly higher score than
the control group (see Table I). This pattern of differences was replicated with
the GAD-Q-IV dimensional score. The group with social anxiety disorder had a
96 Turk, Heimberg, Luterek, Mennin, and Fresco
Table I. Group Differences in Measures of Worry, Social Anxiety, and Symptoms of Generalized
Anxiety Disorder (GAD)
Groups
GAD Social anxiety Control
Mean (SD) Mean (SD) Mean (SD) F
Penn StateWorry Questionnaire 63.46 (11.49) a 50.77 (11.39) b 44.80 (12.74) c F (2,718) = 72.5∗
GAD-Q-IV dimensional score 10.27 (1.25) a 5.80 (2.37) b 4.51 (2.48) c F (2,720) = 181.3∗
Social Interaction Anxiety Scale 19.25 (7.88) b 42.13 (6.85) a 16.57 (8.32) c F (2,720) = 442.0∗
Note. N varies between 721 and 723 due to missing data. GAD-Q-IV: Generalized Anxiety Disorder
Questionnaire-IV. Significant group differences according to follow-up tests are indicated by different
alphabets on the baseline.
∗p < .001.
significantly higher SIAS score than the GAD group, which had a significantly
higher score than the control group.
Sex differences were observed among GAD, social anxiety, and normal control
groups, χ2(2,N = 723) = 13.58, p < .001. Specifically, the GAD group consisted of
significantly fewermen than either the social anxiety group [χ2(1,N = 173) = 13.43,
p < .001] or the control group [χ2(1,N = 618) = 10.99, p < .001]. No sex differences
were observed between the social anxiety group and the control group,
χ2(1,N = 655) = 1.48, p = ns.
Sex differences among men and women on the emotion variables may influence
the interpretation of between-group differences. Therefore, a series of independentsample
t-tests was conducted comparing men and women on each of the emotion
variables. No significant differences between men and women emerged for TMMS
negative mood repair, TMMS clarity of emotions, TAS difficulty identifying emotions,
TAS difficulty describing emotions, ACS fear of depression, and ACS fear of
anxiety. However, relative to men, women indicated greater attention to emotions,
emotion impulse strength, negative expressivity, and positive expressivity. Men endorsed
more fear of anger and more fear of positive emotions than women. Given
these differences, for these variables, 3 (group: GAD, social anxiety, control) × 2
(sex: men, women) ANOVAs were conducted to determine whether there was an
interaction between group and sex. No significant interactions were observed.
Heightened Emotional Intensity
As mentioned earlier, measures of emotional intensity consisted of the BEQ
impulse strength, BEQ negative expressivity, and BEQ positive expressivity scales.
A Bonferonni correction was made for the multiple tests conducted in this domain
(p = .05/3 = .016).
Significant differences among groups were observed for all measures.However,
differences on BEQ negative expressivity were no longer significant after Bonferroni
adjustment (see Table II). Planned nonorthogonal contrasts revealed that, as
assessed by the BEQ impulse strength scale, individuals with GAD reported experiencing
their emotions more intensely than either socially anxious individuals
(d = .47) or controls (d = .55). Socially anxious individuals and controls did not
Emotion Dysregulation in Generalized Anxiety Disorder 97
Table II. Group Differences in Deficits in Emotion Intensity and Understanding of Emotions
Groups
GAD Social anxiety Control
Mean (SD) Mean (SD) Mean (SD) F
Heightened emotional intensity
BEQ impulse strength 5.29 (.84) a 4.48 (.84) b 4.48 (1.09) b F (2,720) = 19.2∗
BEQ negative expressivity 4.15 (.90) 3.81 (.73) 3.96 (.85) F (2,720) = 3.4†
BEQ positive expressivity 5.34 (.99) a 4.75 (.84) b 5.20 (1.05) a F (2,719) = 9.5∗
Poor understanding of emotions
TMMS clarity of emotions 3.08 (.59) b 3.03 (.51) b 3.45 (.56) a F (2,713) = 33.8∗
TAS difficulty identifying emotions 17.12 (5.17) a 18.30 (5.51) a 13.95 (5.36) b F (2,718) = 35.4∗
TAS difficulty describing emotions 13.93 (4.71) b 16.28 (4.12) a 12.44 (4.37) c F (2,718) = 34.9∗
Note. N varies between 716 and 723 due to missing data. BEQ: Berkeley Expressivity Questionnaire;
TAS: Toronto Alexithymia Scale-20 item version; TMMS: Trait Meta Mood Scale. Significant group
differences according to follow-up tests are indicated by different alphabets on the baseline.
∗p < .001. †p < .05, not significant after Bonferroni correction.
differ from each other (d = .00). Socially anxious individuals reported being less
expressive of positive emotions than individuals with GAD (d = .27) and controls
(d = .29). These latter two groups did not differ on this measure (d = .08).Although
only significant before alpha correction, individuals with GAD reported being more
expressive of their negative emotions than individuals with social anxiety disorder
(d = .19). Neither theGAD(d = .13) nor the social anxiety group (d = .12) differed
from the control group on this measure.
Our model suggests that higher levels of emotion intensity should elicit greater
use of worry as a control strategy. Consistent with this prediction, the PSWQ was
significantly and positively correlated with BEQ impulse strength, r = .35, p < .001.
A small but significant correlation was observed between worry and negative expressivity
(r = .14, p < .001); however, the correlation between worry and positive
expressivity was not significant (r = .06, p > .09).
Poor Understanding of Emotions
Measures of deficits in understanding emotions consisted of the following
scales: TMMS clarity of emotions, TAS difficulty identifying emotions, and TAS difficulty
describing emotions.ABonferonni correction was made for the multiple tests
conducted in this domain (p = .05/3 = .016). Significant differences among groups
were observed for all measures (see Table II). Planned non-orthogonal contrasts revealed
that individuals with GAD and individuals with social anxiety disorder were
less clear about what emotions they were experiencing than controls (d = .39 vs.
GAD and d = .53 vs. social anxiety disorder). Individuals with GAD and individuals
with social anxiety disorder did not differ from each other in terms of emotional
clarity (d = 0.04). Both GAD (d = 0.35) and social anxiety disorder (d = .55)
groups reported more difficulty identifying their emotions than control individuals
but did not differ from each other (d = .09). Lastly, individuals with GAD had more
difficulty describing their emotions than controls (d = .20). Individuals with social
98 Turk, Heimberg, Luterek, Mennin, and Fresco
Table III. Group Differences in Negative Reactivity to Emotions and Maladaptive Emotion
Management Responses
Groups
GAD Social anxiety Control
Mean (SD) Mean (SD) Mean (SD) F
Negative reactivity to emotions
TMMS attention to emotions 3.89 (.54) a 3.55 (.51) b 3.78 (.56) a F (2,713) = 9.7∗
ACS fear of anxiety 3.86 (.76) a 3.68 (.64) a 3.04 (.82) b F (2,716) = 54.6∗
ACS fear of depression 3.87 (1.07) a 3.55 (.94) b 2.98 (1.02) c F (2,714) = 32.9∗
ACS fear of anger 3.80 (.98) a 3.82 (.75) a 3.39 (.79) b F (2,715) = 18.2∗
ACS fear of positive emotions 3.23 (.87) a 3.34 (.69) a 2.92 (.76) b F (2,715) = 16.9∗
Maladaptive emotion management
TMMS mood repair 3.25 (.77) b 3.20 (.73) b 3.58 (.74) a F(2,715) =14.9∗
Note. N varies between 716 and 719 due to missing data. TMMS: Trait Meta Mood Scale; ACS: Affective
Control Scale. Significant group differences according to follow-up tests are indicated by different
alphabets on the baseline.
∗p < .001.
anxiety disorder had greater difficulty describing their emotions than individuals
with GAD (d = .24) or controls (d = .60). Higher levels of worry were also associated
with less emotional clarity (r = −.27, p < .001) and more difficulty identifying
(r = .25, p < .001) and describing emotions (r = .15, p < .001).
Negative Reactivity to Emotions
Measures of negative reactivity to emotions included the TMMS attention to
emotions, ACS fear of anxiety, ACS fear of depression, ACS fear of anger, and
ACS fear of positive emotions subscales. A Bonferonni correction was made for
the multiple tests conducted in this domain (p = .05/5 = .01). As shown in Table
III, the anxiety groups did not differ in fear of anxiety (d = .13), anger (d = .02), or
positive emotions (d = .08). Individuals with GAD reported more fear of depression
than individuals with social anxiety disorder (d = .15). Individuals in the GAD
group scored significantly greater than did controls on fear of anxiety (d = .62), depression
(d = .51), anger (d = .29), and positive emotion (d = .22). Similarly, individuals
in the social anxiety group scored significantly greater than controls on
fear of anxiety (d = .66), depression (d = .39), anger (d = .38), and positive emotion
(d = .38). Individuals with social anxiety disorder reported paying less attention
to emotions than either individuals with GAD (d = .29) or controls (d = .29). However,
the GAD group did not differ from the control group on attention to emotions
(d = .12).
Higher levels of worry were associated with higher scores on all subscales of the
ACS (r = .12–.38, all p < .001).Asmall but significant correlation was also observed
between worry and attention to emotions, r = .11, p < .004.
Maladaptive Emotional Management
Ability to manage emotions was measured by the TMMS mood repair subscale.
Individuals withGADand social anxiety disorder reported similar ability to repair a
Emotion Dysregulation in Generalized Anxiety Disorder 99
negative mood state (d = .03), significantly less than controls (d = .25 vs. GAD and
d = .35 vs. social anxiety disorder) (Table III). Lastly, higher levels of worry were
associated with less ability to repair a negative mood state, r = −.21, p < .001.
Prediction of Group Membership
Discriminant function analysis successively identifies the linear combinations
of variables (canonical discriminant functions) that maximize separation among
groups (Duarte Silva&Stam, 1995). Two canonical discriminant functions produced
good discrimination among the three groups according to Wilk’s lamba statistic (p <
.001). The emotion scales most strongly correlated with the first canonical discriminant
function (as determined by r > .50) were ACS fear of anxiety (r = .80), TMMS
clarity of emotions (r = −.64), TAS difficulty identifying emotions (r = .62), and
ACS fear of depression (r = .62). The emotion scales most strongly correlated with
the second canonical discriminant function were BEQ emotion impulse strength
(r = .67), TMMS attention to emotions (r = .58), TAS difficulty describing emotions
(r = −.58), and BEQ positive expressivity (r = .54). The mean scores of the
unstandardized canonical discriminant functions for each group are plotted in the
discriminant space in Figure 1. Figure 1 makes apparent that the first canonical dimension
accounts for most of the mean difference between the control group and
the anxiety groups. Additionally, Figure 1 also suggests that the second discriminant
function is the primary contributor to the separation of the two anxiety groups from
each other. The discriminant analysis accurately classified 46 of 67 (69%) individuals
with GAD, 60 of 102 (59%) individuals with social anxiety disorder, and 311 of
540 (58%) controls.
DISCUSSION
We have argued that heightened emotional intensity coupled with poor understanding
of emotions and discomfort with emotional experience may lead
Fig. 1. The mean scores of the two unstandardized canonical discriminant functions
for the generalized anxiety disorder (GAD) group, social anxiety group,
and normal control group plotted in the discriminant space.
100 Turk, Heimberg, Luterek, Mennin, and Fresco
individuals with GAD to use maladaptive coping strategies to manage this aversive
state. The present investigation examined whether deficits in this emotion regulatory
process are specific to GAD or may be present in other conditions, such as
social anxiety disorder. Individuals with GAD reported greater emotion impulse
strength than either controls or persons with social anxiety disorder. Further, the
experience of greater emotional intensity was associated with greater motivation to
engage in maladaptive strategies (e.g., worry) to control emotions.
Despite their perception that they experience emotions strongly, individuals
with GAD were not more expressive of their emotions and were not more attentive
to their emotions than controls. The differences between individuals with GAD and
individuals with social anxiety disorder in these areas were more the result of deficits
among persons with social anxiety disorder than excesses among persons with GAD.
In previous research, we had found that individuals with GAD were more expressive
of negative emotions than controls (Mennin et al., in press). Although worry
was positively correlated with negative expressivity and the group means were in
the expected direction, this study failed to find a (Bonferroni-corrected) significant
difference. The reasons for this failure to replicate are not clear, and additional research
is needed to reconcile these results.
Individuals with GAD indicated greater deficits than controls on most measures
assessing poor understanding of emotions and negative reactivity to emotions.
However, individuals withGADwere generally not more impaired in these domains
than individuals with social anxiety disorder. The one exception to this pattern was
that individuals with GAD reported more fear of and beliefs about the importance
of controlling depression than individuals with social anxiety disorder. Therefore,
we have only limited evidence that individuals with GAD are more fearful of experiencing
emotions than individuals with social anxiety disorder; rather, both of
these anxiety disorder groups seem to be fearful of experiencing emotions. Consistent
with our findings, Roemer and colleagues (2005) found that fear of depression
was positively associated with worry and GADseverity. Additionally, previous findings
that individuals with GAD have impairments in identifying emotions, clarifying
the information that emotions convey, and describing emotions to others were
replicated (Mennin et al., in press), but these deficits do not appear to be unique to
GAD. The finding that socially anxious participants experience deficits in identifying
and describing emotions has been observed in previous research (Cox, Swinson,
Shulman, & Bourdeau, 1995; Fukunishi, Kikuchi, Wogan, & Takubo, 1997).
Ability to identify discrete emotional experiences has been shown to be associated
with recovery from an induced negative mood (Salovey et al., 1995) and
increased regulation of negative emotions using a range of strategies (Feldman-
Barrett, Gross, Conner-Christensen, & Benvenuto, 2001). Individuals with GAD
and individuals with social anxiety disorder may both benefit from learning to better
identify and differentiate their emotions. Knowing how one feels provides an
additional source of information about the nature of the current situation, what
to do next, and available options for modifying one’s emotions (Feldman-Barrett
et al., 2001). Therefore, training in skills for identifying and differentiating emotions,
in addition to traditional cognitive behavioral techniques, may positively affect
the deficits in repairing negative mood states observed in both anxiety groups.
Emotion Dysregulation in Generalized Anxiety Disorder 101
Individuals in both anxiety groups, but especially individuals with social anxiety disorder,
may also benefit from practice describing their emotions to others.
The emotion measures, which contain no items assessing diagnostic criteria for
either disorder, were able to differentiate among the three groups (GAD, social
anxiety, control) with good accuracy in the discriminant function analysis. This result
suggests that, although there appear to be aspects of emotion dysregulation in
common between GAD and social anxiety disorder, there are also other aspects
of emotion dysregulation more closely associated with one disorder than the other.
The greater intensity of emotional experience among persons with GAD seems especially
important here. Other theoretical models of GAD (e.g., Borkovec et al.,
2004; Roemer & Orsillo, 2002) emphasize that individuals with GAD attempt to
control or avoid emotional experience, and this conceptualization is consistent with
our data. However, data from the discriminant function analysis suggest that poor
understanding of emotions and negative reactivity to emotional experiences are
most important in terms of differentiating the anxiety groups from the normal control
group.
Specificity of difficulties with emotion dysregulation toGADwas observed only
for emotion impulse strength and fear of depression. However, it is not necessary
for aspects of emotion dysregulation to be specific to GAD for them to be important
to how we understand and treat this disorder. An emotion regulation framework
may provide an understanding of how the cognitive, behavioral, physiological,
and interpersonal aspects of GAD are related. As previously described, among
individuals who experience their emotions strongly and have limited ability to utilize
or modulate emotions, worry may be used as a cognitive control strategy that
dampens physiological and emotional arousal. In addition to attempting to manage
strong emotions with worry, individuals with GAD may also behaviorally avoid
situations or aspects of situations that have the potential to be emotionally evocative.
Many of these emotionally evocative situations are likely to be interpersonal
in nature. Avoidance behaviors and difficulties expressing emotions may contribute
to the interpersonal dysfunction that is increasingly recognized among individuals
with GAD. However, this assertion requires further research as the difference between
persons with GAD and controls in expression of negative emotions was not
replicated in the present study.
Cognitive behavioral techniques such as relaxation training and cognitive restructuring,
which have been most frequently used in psychosocial treatment outcome
studies, provide GAD patients with more adaptive skills for managing their
emotional experience than worry. The literature suggests that these approaches benefit
patients with GAD (Borkovec & Ruscio, 2001). However, 50% of patients are
still symptomatic after cognitive behavioral treatment (Borkovec & Ruscio, 2001)
and extending the duration of cognitive behavioral treatment does not improve outcome
(Borkovec, Newman, Pincus, & Lytle, 2002). These findings suggest a need to
look toward other perspectives to achieve increments in treatment efficacy. From
an emotion regulation framework, although cognitive behavioral treatments may
positively impact the patient’s ability to manage his or her emotions, they may have
minimal impact upon the patient’s ability to access and utilize the adaptive information
conveyed by his or her emotional experience. Emotion-focused approaches to
102 Turk, Heimberg, Luterek, Mennin, and Fresco
psychopathology emphasize helping patients to experience their emotions, to clarify
what information their emotions convey regarding their needs and goals, and to
use their emotions to motivate adaptive behavior (e.g., Greenberg, Rice, & Elliott,
1993; McCullough-Vaillant, 1996). From our theoretical perspective, integration of
emotion-focused techniques with existing empirically supported cognitive behavioral
approaches may provide a potent treatment for GAD. The goal of this treatment
approach would be to help patients become more “emotionally intelligent.”
Mayer and Salovey (1997) define emotional intelligence as “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” (p. 10). Thus, the goal is for emotions to be experienced, expressed,
utilized, and regulated—with the environmental context determining what is optimal
at any given point in time. Indeed, in recent years, several research groups
have begun work to examine whether treatment of GAD can be improved by supplementing
cognitive-behavioral treatments with techniques that emphasize experiencing
and accepting emotions (e.g., Newman, Castonguay, Borkovec, & Molnar,
2004; Roemer & Orsillo, 2002).
Lastly, even where overlap in aspects of emotion dysregulation was observed
between GAD and social anxiety disorder, it is also important to recognize that the
same deficits may have different functions or consequences for each disorder. For
example, although both anxiety groups reported elevated fear of positive emotions,
individuals with GAD may primarily fear positive emotions because of a superstitious
belief that, if they allow themselves to feel good rather than worry, bad things
are more likely to happen. In contrast, individuals with social anxiety disorder may
primarily fear positive emotions because, if they are expressed, others may not reciprocate
or validate them.
Although not the primary focus of this study, these results also cast light on
which aspects of emotion dysregulation may be most characteristic of social anxiety
disorder. Socially anxious individuals described themselves as less expressive of
positive emotions than both controls and individuals with GAD. Individuals with
social anxiety disorder may engage in active attempts to suppress the expression
of positive emotions, perhaps as a strategy to avoid becoming the center of attention
or to protect themselves from being hurt if their feelings are not reciprocated.
Expressive suppression is associated with negative consequences such as increased
sympathetic activation of the cardiovascular system (Gross & Levenson, 1997) and
decreased memory for emotion-eliciting situations (Richards & Gross, 2000). Additionally,
deficits in expressing emotions are also likely to lead to negative interpersonal
consequences. Emotion-expressive behavior is essential for communicating
what one wants and influencing the actions and feelings of others (Gross &
Levenson, 1997). Indeed, expressive suppression has been associated with poorer
social support (Gross & John, 2003) and reduced feelings of rapport, motivation to
become further acquainted and increased physiological reactivity in an interaction
partner (Butler et al., 2003). Our data suggest that socially anxious individuals may
not exhibit expressive behaviors indicating happiness, warm feelings, or excitement
in appropriate contexts such as being approached for a conversation by someone
Emotion Dysregulation in Generalized Anxiety Disorder 103
they find interesting or attractive. Consequently, the other person may be unaware
of the socially anxious person’s interest. In this way, the affiliation and closeness
that individuals with social anxiety disorder so desperately want becomes less likely.
Furthermore, although only a trend in this study, deficits in expression of negative
emotions may lead to problems for socially anxious individuals. Previous research
suggests that individuals with social anxiety disorder experience more anger than
nonanxious persons (Erwin, Heimberg, Schneier, & Liebowitz, 2003; Meier, Hope,
Weilage, Elting, & Laguna, 1995). However, they are much more likely to suppress
the expression of anger (Erwin et al., 2003). If persons with social anxiety disorder
are angry at how they are being treated but do not show their anger, they decrease
their likelihood of receiving either reparations or better treatment in the future.
Socially anxious individuals also pay less attention to their emotions than both
controls and individuals with GAD. Insufficient attention to emotions or active efforts
to ignore emotions may contribute to the difficulties that individuals with social
anxiety have regarding clarifying and identifying what emotions they are having and
why they are having them.As previously discussed, individuals who are able to identify
and utilize their emotions are more prepared to respond flexibly and adaptively
to the current environment and to appropriately regulate their affect (Feldman-
Barrett et al., 2001).
These results have implications for the treatment of social anxiety. In addition
to helping individuals with social anxiety disorder confront feared social interactions
and pay attention to information inconsistent with their maladaptive beliefs about
themselves and others, it may also be beneficial to help them access and attend to
adaptive primary emotions associated with the social situation at hand. For example,
a socially anxious individual confronting a public speaking task may be aided
in accessing, attending to, and utilizing adaptive positive emotions associated with
giving a speech such as excitement about the topic or pride in the accomplishments
that resulted in the invitation to speak. Socially anxious individuals may also be encouraged
to express more of what they are feeling during social interactions as a
way of not only confronting another aspect of what they fear (i.e., the experience
and expression of emotions) but also to improve their ability to communicate with
others about what they want and increase the chance that they will get their own
needs met.
This study has several limitations. First, it used analogue GAD and social anxiety
disorder groups. More differences may have been observed between groups
if clinical samples had been used. Additionally, comorbid cases were excluded for
conceptual clarity. In clinical samples, comorbid patients could be diagnosed as having
principal GAD and secondary social anxiety disorder or vice versa, allowing
for a more naturalistic comparison between groups, especially given the high degree
of comorbidity between these two disorders. Another potential problem associated
with use of analogue samples is that levels of severity or impairment may
not be equivalent across the two groups. Therefore, replication of these findings
with treatment-seeking samples diagnosed with structured interviews is an important
agenda for future research, as is examining emotion dysregulation among persons
with other psychiatric disorders. Sex differences emerged for some of the emotion
variables, but our small sample of men with GAD (n = 8) prohibited a truly
104 Turk, Heimberg, Luterek, Mennin, and Fresco
adequate test of the interaction between sex and diagnosis for these variables. Additionally,
self-report methods for the assessment of emotion may be subject to considerable
bias (Davies, Stankov, & Roberts, 1998; Wagner & Waltz, 1998; Westen,
1994). Self-report measures assume that respondents are aware of their emotional
experiences and are accurate in their observations of their own self-regulatory behavior.
Therefore, it will be important for future research to employ more objective
methodologies.
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Not at all. All papers are written from scratch. There is no way your tutor or instructor will realize that you did not write the paper yourself. In fact, we recommend using our assignment help services for consistent results.
We check all papers for plagiarism before we submit them. We use powerful plagiarism checking software such as SafeAssign, LopesWrite, and Turnitin. We also upload the plagiarism report so that you can review it. We understand that plagiarism is academic suicide. We would not take the risk of submitting plagiarized work and jeopardize your academic journey. Furthermore, we do not sell or use prewritten papers, and each paper is written from scratch.
You determine when you get the paper by setting the deadline when placing the order. All papers are delivered within the deadline. We are well aware that we operate in a time-sensitive industry. As such, we have laid out strategies to ensure that the client receives the paper on time and they never miss the deadline. We understand that papers that are submitted late have some points deducted. We do not want you to miss any points due to late submission. We work on beating deadlines by huge margins in order to ensure that you have ample time to review the paper before you submit it.
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You fill all the paper instructions in the order form. Make sure you include all the helpful materials so that our academic writers can deliver the perfect paper. It will also help to eliminate unnecessary revisions.
Proceed to pay for the paper so that it can be assigned to one of our expert academic writers. The paper subject is matched with the writer’s area of specialization.
You communicate with the writer and know about the progress of the paper. The client can ask the writer for drafts of the paper. The client can upload extra material and include additional instructions from the lecturer. Receive a paper.
The paper is sent to your email and uploaded to your personal account. You also get a plagiarism report attached to your paper.
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Delivering a high-quality product at a reasonable price is not enough anymore.
That’s why we have developed 5 beneficial guarantees that will make your experience with our service enjoyable, easy, and safe.
You have to be 100% sure of the quality of your product to give a money-back guarantee. This describes us perfectly. Make sure that this guarantee is totally transparent.
Read moreEach paper is composed from scratch, according to your instructions. It is then checked by our plagiarism-detection software. There is no gap where plagiarism could squeeze in.
Read moreThanks to our free revisions, there is no way for you to be unsatisfied. We will work on your paper until you are completely happy with the result.
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