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Cognitive analysis of specific threat beliefs and safety-seeking behaviours in generalised anxiety disorder: revisiting the cognitive theory of anxiety disorders

Published online by Cambridge University Press:  12 March 2021

Sævar M. Gústavsson ,
Paul M. Salkovskis  and
Jón F. Sigurðsson
Sævar M. Gústavsson*
Affiliation:
Department of Psychology, Reykjavik University, Reykjavik, Iceland School of Psychology and Clinical Language Science, University of Reading, Reading, UK
Paul M. Salkovskis
Affiliation:
Department of Experimental Psychology, University of Oxford, Oxford, UK
Jón F. Sigurðsson
Affiliation:
Department of Psychology, Reykjavik University, Reykjavik, Iceland Faculty of Medicine, University of Iceland, Reykjavik, Iceland
*
*Corresponding author. Email: [email protected]
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Abstract

Background:

Generalised anxiety disorder (GAD) has been an uneasy member of the anxiety disorders group since its inclusion in the third edition of the DSM. Multiple theories and treatment protocols for GAD and its defining symptom, excessive worry, have comparable efficacy in treating GAD symptoms. Crucially, these theories of GAD and excessive worry fail to explain when and why worry is excessive and when it is adaptive.

Aims:

In this paper we propose a cognitive behavioural account of the difference between excessive and adaptive states of worry and explore the theme of threat and the function of safety-seeking behaviours as seen in GAD. Specifically, we incorporate the concept of inflated responsibility in a cognitive behavioural analysis of threat appraisal and safety-seeking behaviours in excessive worry and GAD.

Conclusion:

It is proposed that when worry is used as a strategy intended to increase safety from perceived social or physical threat then it should be conceptualised as a safety-seeking behaviour. However, when worry is used as a strategy to solve a problem which the person realistically can resolve or to deal explicitly with the feeling of anxiety then it functions as an adaptive coping behaviour. We also propose that the theme of threat in GAD centres on an inflated sense of responsibility for external everyday situations, and the function of safety-seeking behaviours is to attain certainty that responsibility has been fulfilled. The clinical implications of this cognitive behavioural analysis of excessive worry are discussed, as well as future research directions.

Keywords

cognitive theory of anxietyexcessive worrygeneralised anxiety disordersafety-seeking behavioursthreat beliefs
Type
Empirically Grounded Clinical Interventions
Information
Behavioural and Cognitive Psychotherapy , Volume 49 , Issue 5 , September 2021 , pp. 526 - 539
Copyright
© The Author(s), 2021. Published by Cambridge University Press on behalf of the British Association for Behavioural and Cognitive Psychotherapies

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References

American Psychiatric Association (1980). Diagnostic and Statistical Manual of Mental Disorders (3rd edn). Washington, DC.Google Scholar
American Psychiatric Association (1987). Diagnostic and Statistical Manual of Mental Disorders (3rd edn rev.). Washington, DC.Google Scholar
American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders (4th edn). Washington, DC.Google Scholar
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th edn). Washington, DC.Google Scholar
Barlow, D. H., Blanchard, E. B., Vermilyea, J. A., Vermilyea, B. B., & DiNardo, P. A. (1986). Generalised anxiety and generalised anxiety disorder: description and reconceptualization. American Journal of Psychiatry, 143, 40–44. https://doi.org/10.1176/ajp.143.1.40 Google Scholar
Beck, A. T., Emery, G., & Greenberg, R. L. (1985). Anxiety Disorders and Phobias: A Cognitive Perspective. Basic Books.Google Scholar
Beesdo-Baum, K., Jenjahn, E., Höfler, M., Lueken, U., Becker, E. S., & Hoyer, J. (2012). Avoidance, safety behavior, and reassurance seeking in generalised anxiety disorder. Depression and Anxiety, 29, 948–957. https://doi.org/10.1002/da.21955 CrossRefGoogle Scholar
Behar, E., DiMarco, I. D., Hekler, E. B., Mohlman, J., & Staples, A. M. (2009). Current theoretical models of generalised anxiety disorder (GAD): conceptual review and treatment implications. Journal of Anxiety Disorders, 23, 1011–1023. https://doi.org/10.1016/j.janxdis.2009.07.006 CrossRefGoogle Scholar
Borkovec, T. D., Alcaine, O., & Behar, E. (2004). Avoidance theory of worry and generalised anxiety disorder. In Heimberg, R. G., Turk, C. L. & Mennin, D. S. (eds), Generalised Anxiety Disorder: Advances in Research and Practice (pp. 77–108). New York, USA: Guilford Press.Google Scholar
Borkovec, T. D., Hazlett-Stevens, H., & Diaz, M. L. (1999). The role of positive beliefs about worry in generalised anxiety disorder and its treatment. Clinical Psychology and Psychotherapy, 6, 126–138. https://doi.org/10.1002/(SICI)1099-0879(199905)6:2<126:AID-CPP193>3.0.CO;2-M3.0.CO;2-M>CrossRefGoogle Scholar
Borkovec, T. D., Robinson, E., Pruzinsky, T., & DePree, J. A. (1983). Preliminary exploration of worry: some characteristics and processes. Behaviour Research and Therapy, 21, 9–16. https://doi.org/10.1016/0005-7967(83)90121-3 CrossRefGoogle ScholarPubMed
Breitholtz, E., Johansson, B., & Öst, L. G. (1999). Cognitions in generalised anxiety disorder and panic disorder patients. A prospective approach. Behaviour Research and Therapy, 37, 533–544. https://doi.org/10.1016/S0005-7967(98)00147-8 CrossRefGoogle Scholar
Breitholtz, E., Westling, B. E., & Öst, L. G. (1998). Cognitions in generalised anxiety disorder and panic disorder patients. Journal of Anxiety Disorders, 12, 567–577. https://doi.org/10.1016/S0887-6185(98)00034-6 CrossRefGoogle Scholar
Brown, T. A., Antony, M. M., & Barlow, D. H. (1992). Psychometric properties of the Penn State Worry Questionnaire in a clinical anxiety disorders sample. Behaviour Research and Therapy, 30, 33–37. https://doi.org/10.1016/0005-7967(92)90093-V CrossRefGoogle Scholar
Brown, T. A., Barlow, D. H., & Liebowitz, M. R. (1994). The empirical basis of generalised anxiety disorder. American Journal of Psychiatry, 151, 1272–1280. https://doi.org/10.1176/ajp.151.9.1272 Google Scholar
Brown, T. A., Campbell, L. A., Lehman, C. L., Grisham, J. R., & Mancill, R. B. (2001). Current and lifetime comorbidity of the DSM-IV anxiety and mood disorders in a large clinical sample. Journal of Abnormal Psychology, 110, 585–599. https://doi.org/10.1037/0021-843X.110.4.585 CrossRefGoogle Scholar
Butler, G., & Mathews, A. (1983). Cognitive processes in anxiety. Advances in Behaviour Research and Therapy, 5, 51–62. https://doi.org/10.1016/0146-6402(83)90015-2 CrossRefGoogle Scholar
Carleton, N. R., Mulvogue, M. K., Thibodeau, M. A., McCabe, R. E., Antony, M. M., & Asmundson, G. J. G. (2012). Increasingly certain about uncertainty: intolerance of uncertainty across anxiety and depression. Journal of Anxiety Disorders, 26, 468–479. https://doi.org/10.1016/j.janxdis.2012.01.011 CrossRefGoogle ScholarPubMed
Clark, D. A., & Beck, A. T. (2011). Cognitive Therapy of Anxiety Disorders: Science and Practice. New York, USA: Guilford Press.Google Scholar
Clark, D. M. (1986). A cognitive approach to panic. Behaviour Research and Therapy, 24, 461–470. https://doi.org/10.1016/0005-7967(86)90011-2 CrossRefGoogle ScholarPubMed
Clark, D. M. (1999). Anxiety disorders: why they persist and how to treat them. Behaviour Research and Therapy, 37 (suppl. 1), 5–27. https://doi.org/10.1016/S0005-7967(99)00048-0 CrossRefGoogle Scholar
Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In Liebowitz, M., Hope, D. A., Schneier, E., & Heimberg, R. G. (eds), Social Phobia: Diagnosis, Assessment and Treatment. New York, USA: Guilford Press.Google Scholar
Craske, M. G., Rapee, R. M., Jackel, L., & Barlow, D. H. (1989). Qualitative dimensions of worry in DSM-III-R generalised anxiety disorder subjects and nonanxious controls. Behaviour Research and Therapy, 27, 397–402. https://doi.org/10.1016/0005-7967(89)90010-7 CrossRefGoogle Scholar
Crocq, M. A. (2017). The history of generalised anxiety disorder as a diagnostic category. Dialogues in Clinical Neuroscience, 19, 107–115. https://doi.org/10.4324/9781315079097-30 Google Scholar
Dash, S. R., & Davey, G. C. L. (2012). An experimental investigation of the role of negative mood in worry: the role of appraisals that facilitate systematic information processing. Journal of Behavior Therapy and Experimental Psychiatry, 43, 823–831. https://doi.org/10.1016/j.jbtep.2011.12.002 CrossRefGoogle ScholarPubMed
Davey, G. C. L. (1994a). Pathological worrying as exacerbated problem-solving. In Davey, G. C. L. & Tallis, F. (eds), Wiley Series in Clinical Psychology. Worrying: Perspectives on Theory, Assessment and Treatment (pp. 35–59). John Wiley & Sons.Google Scholar
Davey, G. C. L. (1994b). Worrying, social problem-solving abilities, and social problem-solving confidence. Behaviour Research and Therapy, 32, 327–330. https://doi.org/10.1016/0005-7967(94)90130-9 CrossRefGoogle ScholarPubMed
Davey, G. C. L., & Meeten, F. (2016). The perseverative worry bout: a review of cognitive, affective and motivational factors that contribute to worry perseveration. Biological Psychology, 121, 233–243. https://doi.org/10.1016/j.biopsycho.2016.04.003 CrossRefGoogle ScholarPubMed
Davey, G. C. L., Hampton, J., Farrell, J., & Davidson, S. (1992). Some characteristics of worrying: evidence for worrying and anxiety as separate constructs. Personality and Individual Differences, 13, 133–147. https://doi.org/10.1016/0191-8869(92)90036-O CrossRefGoogle Scholar
Davey, G. C. L., Startup, H. M., MacDonald, C. B., Jenkins, D., & Patterson, K. (2005). The use of ‘as many as can’ versus ‘feel like continuing’ stop rules during worrying. Cognitive Therapy and Research, 29, 155–169. https://doi.org/10.1007/s10608-005-3162-5 CrossRefGoogle Scholar
Di Nardo, P. A., O’Brien, G. T., Barlow, D. H., Waddell, M. T., & Blanchard, E. B. (1983). Reliability of DSM-III anxiety disorder categories using a new structured interview. Archives of General Psychiatry, 40, 1070–1074.CrossRefGoogle ScholarPubMed
Dugas, M. J., Freeston, M. H., Ladouceur, R., Rhéaume, J., Provencher, M., & Boisvert, J. M. (1998a). Worry themes in primary GAD, secondary GAD, and other anxiety disorders. Journal of Anxiety Disorders, 12, 253–261. https://doi.org/10.1016/S0887-6185(98)00013-9 CrossRefGoogle ScholarPubMed
Dugas, M. J., Gagnon, F., Ladouceur, R., & Freeston, M. H. (1998b). Generalised anxiety disorder: a preliminary test of a conceptual model. Behaviour Research and Therapy, 36, 215–226. https://doi.org/10.1016/S0005-7967(97)00070-3 CrossRefGoogle Scholar
Dugas, M., & Robichaud, M., (2007). Cognitive-Behavioural Treatment for Generalised Anxiety Disorder: From Science to Practice. New York, USA: Routledge.Google Scholar
Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy, 38, 319–345. https://doi.org/10.1016/S0005-7967(99)00123-0 CrossRefGoogle ScholarPubMed
Halldorsson, B., & Salkovskis, P. M. (2017). Treatment of obsessive compulsive disorder and excessive reassurance seeking in an older adult: a single case quasi-experimental design. Behavioural and Cognitive Psychotherapy, 45, 616–628.CrossRefGoogle Scholar
Halldorsson, B., Salkovskis, P. M., Kobori, O., & Pagdin, R. (2016). I do not know what else to do: caregivers’ perspective on reassurance seeking in OCD. Journal of Obsessive-Compulsive and Related Disorders, 8, 21–30. https://doi.org/10.1016/j.jocrd.2015.11.003 CrossRefGoogle Scholar
Holaway, R. M., Heimberg, R. G., & Coles, M. E. (2006). A comparison of intolerance of uncertainty in analogue obsessive-compulsive disorder and generalised anxiety disorder. Journal of Anxiety Disorders, 20, 158–174. https://doi.org/10.1016/j.janxdis.2005.01.002 CrossRefGoogle Scholar
Jones, M., & Rakovshik, S. (2019). Inflated sense of responsibility, explanatory style and the cognitive model of social anxiety disorder: a brief report of a case control study. the Cognitive Behaviour Therapist, 12. https://doi.org/10.1017/S1754470X19000047 CrossRefGoogle Scholar
Ladouceur, R., Blais, F., Freeston, M. H., & Dugas, M. J. (1998). Problem solving and problem orientation in generalised anxiety disorder. Journal of Anxiety Disorders, 12, 139–152. https://doi.org/10.1016/S0887-6185(98)00002-4 CrossRefGoogle Scholar
Ladouceur, R., Dugas, M. J., Freeston, M. H., Rhéaume, J., Blais, F., Boisvert, J. M., Gagnon, F., & Thibodeau, N. (1999). Specificity of generalised anxiety disorder symptoms and processes. Behavior Therapy, 30, 191–207. https://doi.org/10.1016/S0005-7894(99)80003-3 CrossRefGoogle Scholar
Llera, S. J., & Newman, M. G. (2020). Worry impairs the problem-solving process: results from an experimental study. Behaviour Research and Therapy, 135, 103759. https://doi.org/10.1016/j.brat.2020.103759 CrossRefGoogle ScholarPubMed
Lucock, M. P., & Salkovskis, P. M. (1988). Cognitive factors in social anxiety and its treatment. Behaviour Research and Therapy, 26, 297–302. https://doi.org/10.1016/0005-7967(88)90081-2https://doi.org/10.1016/0005-7967(88)90081-2 CrossRefGoogle ScholarPubMed
MacLeod, C., & Rutherford, E. (2004). Information processing approaches to generalised anxiety disorder: assessing the selective functioning of attention, interpretation, and memory in GAD patients. In Heimberg, R. G., Turk, C. L., & Mennin, D. S. (eds), Generalised Anxiety Disorder: Advances in Research and Practice (pp. 109–142). New York, USA: Guilford Press.Google Scholar
Mathews, A. (1990). Why worry? The cognitive function of anxiety. Behaviour Research and Therapy, 28, 455–468. https://doi.org/10.1016/0005-7967(90)90132-3 CrossRefGoogle ScholarPubMed
Meeten, F., & Davey, G. C. L. (2011). Mood-as-input hypothesis and perseverative psychopathologies. Clinical Psychology Review, 31, 1259–1275. https://doi.org/10.1016/j.cpr.2011.08.002 CrossRefGoogle ScholarPubMed
Mennin, D. S., Heimberg, R. G., & Turk, C. L. (2004). Clinical presentation and diagnostic features. In Heimberg, R. G., Turk, C. L., & Mennin, D. S. (eds), Generalised Anxiety Disorder: Advances in Research and Practice (pp. 3–28). New York, USA: Guilford Press.Google Scholar
Mowrer, O. H. (1960). Learning Theory and Behavior. John Wiley & Sons Inc. https://doi.org/10.1037/10802-000 CrossRefGoogle Scholar
Neal, R. L., & Radomsky, A. S. (2019). How do I say this? An experimental comparison of the effects of partner feedback styles on reassurance seeking behaviour. Cognitive Therapy and Research, 43, 748–758. https://doi.org/10.1007/s10608-019-10007-0 CrossRefGoogle Scholar
Neal, R. L., & Radomsky, A. S. (2020). What do you really need? Self- and partner-reported intervention preferences within cognitive behavioural therapy for reassurance seeking behaviour. Behavioural and Cognitive Psychotherapy, 48, 25–37. https://doi.org/10.1017/S135246581900050X CrossRefGoogle Scholar
Öst, L.G., & Breitholtz, E. (2000). Applied relaxation vs. cognitive therapy in the treatment of generalized anxiety disorder. Behaviour Research and Therapy, 38, 777–790. doi: 10.1016/s0005-7967(99)00095-9 CrossRefGoogle ScholarPubMed
Purdon, C., & Harrington, J. (2006). Worry in psychological disorders. In Davey, G. C. L., & Wells, A. (eds), Worry and Psychological Disorders: Theory, Assessment and Treatment (pp. 41–50). Chichester, UK: Wiley.CrossRefGoogle Scholar
Rachman, S. (1976). The passing of the two-stage theory of fear and avoidance: fresh possibilities. Behaviour Research and Therapy, 14, 125–131. https://doi.org/10.1016/0005-7967(76)90066-8 CrossRefGoogle ScholarPubMed
Rachman, S. (2002). A cognitive theory of compulsive checking. Behaviour Research and Therapy, 40, 625–639. https://doi.org/10.1016/S0005-7967(01)00028-6 CrossRefGoogle ScholarPubMed
Rachman, S., Thordarson, D. S., Shafran, R., & Woody, S. R. (1995). Perceived responsibility: structure and significance. Behaviour Research and Therapy, 33, 779–784. https://doi.org/10.1016/0005-7967(95)00016-Q CrossRefGoogle ScholarPubMed
Radomsky, A. S., Gilchrist, P. T., & Dussault, D. (2006). Repeated checking really does cause memory distrust. Behaviour Research and Therapy, 44, 305–316. https://doi.org/10.1016/j.brat.2005.02.005 CrossRefGoogle ScholarPubMed
Roemer, L., & Orsillo, S. M. (2002). Expanding our conceptualization of and treatment for generalised anxiety disorder: integrating mindfulness/acceptance-based approaches with existing cognitive-behavioral models. Clinical Psychology: Science and Practice, 9, 54–68. https://doi.org/10.1093/clipsy/9.1.54 Google Scholar
Roemer, L., Molina, S., & Borkovec, T. D. (1997). An investigation of worry content among generally anxious individuals. Journal of Nervous and Mental Disease, 185, 314–319. https//doi.org/10.1097/00005053-199705000-00005 CrossRefGoogle ScholarPubMed
Romero-Sanchiz, P., Nogueira-Arjona, R., Godoy-ávila, A., Gavino-Lázaro, A., & Freeston, M. H. (2015). Narrow specificity of responsibility and intolerance of uncertainty in obsessive-compulsive behavior and generalised anxiety symptoms. International Journal of Cognitive Therapy, 8, 239–257. https://doi.org/10.1521/ijct_2015_8_04 CrossRefGoogle Scholar
Salkovskis, P. M. (1985). Obsessional-compulsive problems: a cognitive-behavioural analysis. Behaviour Research and Therapy, 23, 571–583.CrossRefGoogle ScholarPubMed
Salkovskis, P. M. (1991). The importance of behaviour in the maintenance of anxiety and panic: a cognitive account. Behavioural Psychotherapy, 19, 6–19. https://doi.org/10.1017/S0141347300011472 CrossRefGoogle Scholar
Salkovskis, P. M. (1996a). Avoidance behaviour is motivated by threat beliefs: a possible resolution of the cognition-behaviour debate. In Salkoskis, P. M. (ed), Trends in Cognitive and Behavioural Therapies (pp. 25–42).Google Scholar
Salkovskis, P. M. (1996b). The cognitive approach to anxiety: threat beliefs, safety-seeking behaviour, and the special case of health anxiety and obsessions. In Salkovskis, P. M. (ed), Frontiers of Cognitive Therapy (pp. 48–75). New York, USA: Guilford Press.Google Scholar
Salkovskis, P. M., Rachman, S. J., Ladouceur, R., Freeston, M., Taylor, S., Kyrios, M., & Sica, C. (1996). Defining Responsibility in Obsessional Problems: Proceedings of the Smith College Women’s Room – After the Toronto Cafeteria.Google Scholar
Startup, H. M., & Davey, G. C. L. (2001). Mood as input and catastrophic worrying. Journal of Abnormal Psychology, 110, 83–96. https://doi.org/10.1037/0021-843X.110.1.83 CrossRefGoogle ScholarPubMed
Startup, H. M., & Davey, G. C. L. (2003). Inflated responsibility and the use of stop rules for catastrophic worrying. Behaviour Research and Therapy, 41, 495–503. https://doi.org/10.1016/S0005-7967(02)00245-0 CrossRefGoogle ScholarPubMed
Sugiura, Y., & Fisak, B. (2019). Inflated responsibility in worry and obsessive thinking. International Journal of Cognitive Therapy, 12, 97–108. https://doi.org/10.1007/s41811-019-00041-x CrossRefGoogle Scholar
Tolin, D. F., Worhunsky, P., & Maltby, N. (2006). Are ‘obsessive’ beliefs specific to OCD? A comparison across anxiety disorders. Behaviour Research and Therapy, 44, 469–480. https://doi.org/10.1016/j.brat.2005.03.007 CrossRefGoogle ScholarPubMed
Tyrer, P., & Baldwin, D. (2006). Generalised anxiety disorder. Lancet, 368, 2156–2166. https://doi.org/10.1016/S0140-6736(06)69865-6 CrossRefGoogle ScholarPubMed
van Den Hout, M., & Kindt, M. (2003). Repeated checking causes memory distrust. Behaviour Research and Therapy, 41, 301–316. https://doi.org/10.1016/S0005-7967(02)00012-8 CrossRefGoogle ScholarPubMed
Wahl, K., Salkovskis, P. M., & Cotter, I. (2008). ‘I wash until it feels right’: the phenomenology of stopping criteria in obsessive-compulsive washing. Journal of Anxiety Disorders, 22, 143–161.CrossRefGoogle ScholarPubMed
Warwick, H. M., & Salkovskis, P. M. (1990). Hypochondriasis. Behaviour Research and Therapy, 28, 105–117.CrossRefGoogle ScholarPubMed
Watson, D. (2005). Rethinking the mood and anxiety disorders: a quantitative hierarchical model for DSM-V. Journal of Abnormal Psychology, 114, 522. https://doi.org/10.17077/f3hq-s8cb CrossRefGoogle ScholarPubMed
Wells, A. (1999). A cognitive model of generalised anxiety disorder. Behavior Modification, 23, 526–555. https://doi.org/10.1177/0145445599234002 CrossRefGoogle Scholar
Wells, A. (2008). Metacognitive therapy: cognition applied to regulating cognition. Behavioural and Cognitive Psychotherapy, 36, 651–658. https://doi.org/10.1017/S1352465808004803 CrossRefGoogle Scholar
Wells, A., & Matthews, G. (1996). Modelling cognition in emotional disorder: the S-REF model. Behaviour Research and Therapy, 34, 881–888. https://doi.org/10.1016/S0005-7967(96)00050-2 CrossRefGoogle ScholarPubMed
Wells, A., & Morrison, A. P. (1994). Qualitative dimensions of normal worry and normal obsessions: a comparative study. Behaviour Research and Therapy, 32, 867–870. https://doi.org/10.1016/0005-7967(94)90167-8 CrossRefGoogle ScholarPubMed
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