Maladaptive Core Beliefs and their Relation to Generalized Anxiety Disorder.

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Maladaptive Core Beliefs and their Relation to Generalized Anxiety Disorder a

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Naomi Koerner , Kathleen Tallon & Andrea Kusec

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Department of Psychology, Ryerson University, Toronto, Canada Published online: 01 Jun 2015.

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Cognitive Behaviour Therapy, 2015 http://dx.doi.org/10.1080/16506073.2015.1042989

Maladaptive Core Beliefs and their Relation to Generalized Anxiety Disorder Naomi Koerner, Kathleen Tallon and Andrea Kusec


Department of Psychology, Ryerson University, Toronto, Canada Abstract. Research has demonstrated that individuals with generalized anxiety disorder (GAD) hold unhelpful beliefs about worry, uncertainty, and the problem-solving process. Extant writings (e.g., treatment manuals) also suggest that other types of maladaptive beliefs may characterize those with GAD. However, these other beliefs have received limited empirical attention and are not an explicit component of cognitive theories of GAD. The present study examined the extent to which dysfunctional attitudes, early maladaptive schemas, and broad self-focused and other-focused beliefs explain significant variance in GAD symptoms, over and above negative and positive beliefs about worry, negative beliefs about uncertainty, and negative beliefs about problems. N ¼ 138 participants classified into Probable GAD and Non-GAD groups completed self-report measures. After controlling for trait anxiety and depressive symptoms, only beliefs about worry, negative beliefs about uncertainty, and schemas reflecting unrelenting standards (e.g., “I must meet all my responsibilities all the time”), the need to self-sacrifice (e.g., “I’m the one who takes care of others”), and less positive views of other people and their intentions (e.g., lower endorsement of views such as “other people are fair”), were unique correlates of Probable GAD versus Non-GAD or GAD severity. Theoretical and clinical implications are discussed. Key words: worry; generalized anxiety; attitudes; core beliefs; maladaptive cognitions; cognitive-behavior therapy. Received 28 August 2014; Accepted 16 April 2015 Correspondence address: Naomi Koerner, PhD, Department of Psychology, Ryerson University, JOR 9th Floor, 350 Victoria Street, Toronto, ON, Canada M5B 2K3, Tel: 416-979-5000/2151. Email: [email protected]

When people are faced with problems in which the outcome is uncertain, they may worry. Worry that is chronic, unhelpful, and leads to distress or interference in functioning characterizes generalized anxiety disorder (GAD). The central feature of GAD is excessive anxiety and worry across several domains of importance to the individual (e.g., work, relationships; American Psychiatric Association, 2000, 2013). The anxiety and worry are accompanied by a range of symptoms such as muscle tension, and feelings of restlessness or being “on edge” (American Psychiatric Association, 2000, 2013). Many people with GAD report that they have worried for as long as they can remember; indeed, the trait-like quality of GAD has been noted (Sanderson, Wetzler, Beck, & Betz, 1994). Before GAD was recognized as a problem worthy of research and clinical attention, the factors contributing to excessive and q 2015 Swedish Association for Behaviour Therapy

uncontrollable worry were somewhat elusive. Over the last 25 years, a number of explanatory models of worry have been constructed. The models that have received the most empirical attention to date are those that implicate particular dysfunctional beliefs or attitudes in chronic worry. These beliefs sets are presumed to be stable and trait-like, but amenable to intervention. The Metacognitive Model (Wells, 1995) proposes that positive and negative beliefs about worry play a key role in unhelpful levels of worry. According to the model, when individuals encounter a threatening situation, positive beliefs about the usefulness of worry (e.g., “worrying helps me to avoid problems in the future”; Wells & Cartwright-Hatton, 2004) are activated, which in turn initiate worrying as a coping strategy. Wells proposes that when individuals engage in worry beyond its utility, somatic symptoms intensify and beliefs about


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Koerner, Tallon and Kusec

the dangerousness of worry are consequently triggered (e.g., “my worrying could make me go mad”; Wells & Cartwright-Hatton, 2004). Beliefs about worry distinguish individuals with GAD from individuals low in the tendency to worry (Cartwright-Hatton & Wells, 1997) and negative beliefs in particular have been shown to be a better predictor of pathological worrying in nonclinical samples (Wells & Carter, 1999) and of GAD status in clinical samples (Wells & Carter, 2001). The Intolerance of Uncertainty Model (Dugas, Gagnon, Ladouceur, & Freeston, 1998; Dugas & Robichaud, 2007) proposes that people’s negative beliefs about uncertainty (i.e., their intolerance of uncertainty; IU) play a key role in chronic worry. IU has been described as a “lens” through which individuals perceive the world (Dugas & Robichaud, 2007). According to the model, when individuals prone to excessive worry encounter uncertainty, this triggers beliefs about its consequences (e.g., “uncertainty spoils everything”; Sexton & Dugas, 2009). The activation of these beliefs then initiates maladaptive strategies (e.g., excessive information-seeking, reassurance-seeking) aimed at reducing or eliminating uncertainty and the attendant discomfort (Dugas & Robichaud, 2007). High IU is strongly correlated with excessive worry (Gentes & Ruscio, 2011). Robust positive associations between IU and excessive worry have been observed in nonclinical samples (e.g., Berenbaum, Bredemeier, & Thompson, 2008; Buhr & Dugas, 2002; Dugas, Gosselin, & Ladouceur, 2001; Sexton, Norton, Walker, & Norton, 2003) and in clinical samples (e.g., Norton, Sexton, Walker, & Norton, 2005; Stapinski, Abbott, & Rapee, 2010). Experimental activation of IU-related thoughts and beliefs causes people to catastrophize (Descheˆnes, Dugas, Radomsky, & Buhr, 2010; Meeten, Dash, Scarlet, & Davey, 2012). Changes in IU have also been shown to precede changes in worry during the cognitive-behavioral treatment (CBT) of GAD, which supports the temporal precedence of IU (Dugas & Ladouceur, 2000). The IU model also proposes that negative beliefs about problems and the problem-solving process (i.e., a negative problem orientation) contribute to excessive worry (Dugas et al., 1998). The finding that higher levels of worry are associated with a greater tendency to view

COGNITIVE BEHAVIOUR THERAPY

problems as insurmountable and threatening to one’s well-being supports this supposition (Robichaud & Dugas, 2005a). A negative problem orientation has shown greater specificity to the tendency to worry than to depressive symptoms, which speaks to the notion that negative beliefs about problems and one’s perceived capacity to solve them are particularly important to the understanding of maladaptive worry (Robichaud & Dugas, 2005b). Taken together, individuals with GAD report unhelpful, negative beliefs about the consequences of worry, uncertainty and problems, and these beliefs have been demonstrated to be involved in the initiation or maintenance of worry. In CBT, individuals are encouraged to engage in new behaviors with the goal of acquiring experiences that may challenge these beliefs. In metacognitive therapy (Wells, 2008), for example, individuals learn how to redirect their attention away from worry to challenge the beliefs that worry is uncontrollable and potentially dangerous. In IU-centered CBT (Dugas & Robichaud, 2007), individuals work on changing their attitudes toward uncertainty via exposure to regular “doses” of uncertainty. The same treatment also challenges people’s beliefs about the usefulness of worry by prompting them to consider times when worrying was not particularly useful in preventing a negative outcome. Finally, IU-based treatment modifies the belief that problems are threatening by bolstering confidence in the ability to manage difficult situations and make decisions. Although these CBTs are designed to target a range of unhealthy cognitive processes, there may very well be other kinds of maladaptive beliefs that are relevant to GAD that are worth assessing or targeting more explicitly in trials of CBT. Individuals with GAD are described in treatment manuals as having “many maladaptive expectations, assumptions, and rules” (Hazlett-Stevens, 2008); however, most of the empirical attention has been dedicated to the specific belief sets outlined in theoretical models of GAD, as reviewed earlier. Thus, the present study examined the extent to which other types of maladaptive core beliefs that are not currently included in the aforementioned cognitive models of GAD may contribute to variation in GAD symptoms. These include


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dysfunctional beliefs relating to achievement and approval (from hereon, “dysfunctional attitudes”), early maladaptive schemas, and self-focused and other-focused beliefs. In his early writings, Beck proposed that dysfunctional attitudes reflecting, for example, a need for approval and a need to avoid appearing weak confer vulnerability to depression (Beck, Brown, Steer, & Weissman, 1991). Weissman and Beck (1978) developed the Dysfunctional Attitude Scale (DAS) to measure the aforementioned cognitions. Although initially conceived within a depression framework, subsequent research suggested that the attitudes measured by the DAS traverse depression and anxiety (Beck et al., 1991). Even though these attitudes have been described in treatment manuals as core underlying processes in GAD (e.g., HazlettStevens, 2008), the unique explanatory value of DAS attitudes in the understanding of worry has been examined empirically in only one known study (Dugas, Schwartz, & Francis, 2004). In that study, regression analyses revealed that dysfunctional attitudes explained a significant proportion of the variance in excessive worry, over and above IU, and were also uniquely associated with higher levels of worry after controlling for statistical overlap with IU. Thus, dysfunctional attitudes and negative beliefs about uncertainty both appear to have explanatory value. However, no known studies have examined the degree to which dysfunctional attitudes are associated with GAD. Early maladaptive schemas (EMSs) have received no known attention in the literature on GAD, even though such schemas are described in GAD treatment manuals (e.g., Leahy, 2006). According to Young’s (1994) theory (derived from Beck’s (1967) cognitive theory of depression), EMSs are dysfunctional core beliefs that are stable and automatic (Dozois & Beck, 2008). They develop through interactions with caregivers early in life and continue to influence emotions and behavior into adulthood by directing information processing (Dozois & Beck, 2008). Empirical studies of Young’s model and the resultant self-report measure of EMSs (Cecero, Nelson, & Gillie, 2004; Samuel & Ball, 2013) suggest that the core beliefs that comprise the model can be distilled into three distinct and conceptually coherent higher order domains

Maladaptive Cognitions and Generalized Anxiety Disorder

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reflecting interpersonal detachment (e.g., “I feel like a loner”), interpersonal dependency (e.g., “I need other people even for very simple things”), and inflated standards, including selfsacrificial beliefs (e.g., “I listen to everybody’s problems”). EMSs have been examined within the context of only certain psychopathologies, including mood disorders (Harris & Curtin, 2002; Hawke, Provencher, & Arntz, 2011), social phobia (Pinto-Gouveia, Castilho, Galhardo, & Cunha, 2006), and borderline personality disorder (Lawrence, Allen, & Chanen, 2011). In their review of the literature on EMSs in the anxiety disorders, Hawke and Provencher (2011) did not find any research on EMSs in GAD; thus there is a gap to be filled. Finally, there is little research on broad positive and negative self-focused (e.g.,“I am valuable,” “I am weak”) and other-focused (e.g., “Others are good,” “Others are hostile”) beliefs in people with GAD, even though treatment manuals for GAD propose that maladaptive variants of these beliefs underpin excessive worry (e.g., Hazlett-Stevens, 2008; Leahy, 2006). Furthermore, these beliefs have been shown to be relevant to a range of other psychopathology (Fowler et al., 2006; Wearden, Peters, Berry, Barrowclough, & Liversidge, 2008). Other-focused beliefs were of particular interest in the current study as these are rarely assessed in anxiety disorders and when they are assessed, the beliefs are ultimately centered on the self (e.g., “If others really get to know me, they will reject me”; Clark & Wells, 1995; “Others think I am okay, even when I do not succeed”; Hewitt & Flett, 1991). There are findings that individuals who experience high levels of anxiety do endorse non-self focused beliefs about others. For example, individuals high in social anxiety believe that others are more socially adept (Koerner, Antony, Young, & McCabe, 2013) and also endorse the belief that others have malevolent or hostile intentions (Gilbert, Boxall, Cheung, & Irons, 2005). High levels of anger, in particular hostility toward others (e.g., “When people are especially nice, I wonder what they want”), have been observed in people high in GAD symptoms (Descheˆnes, Dugas, Fracalanza, & Koerner, 2012; Fracalanza, Koerner, Descheˆnes, & Dugas, 2014); thus, it was of interest to examine the relationship of other-oriented schematic beliefs to GAD symptoms in the


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present study. The extent to which people with GAD hold views of others that are negative (or less positive) has not received any known empirical attention. The goal of the present study was to assess the unique explanatory value of maladaptive cognitions that are currently not represented in conceptual models of GAD. It was predicted that relative to individuals scoring lower on a measure of GAD symptoms (from hereon, the Non-GAD group), those scoring higher on a measure of GAD symptoms (from hereon, the Probable GAD group) would endorse significantly stronger dysfunctional attitudes and EMSs, as well as self-focused and otherfocused beliefs that are more negative and less positive. It was further predicted that scores on measures of these cognitions would explain a significant proportion of the variance in categorical as well as dimensional measures of GAD symptoms, over and above scores on measures of already-established processes in GAD; specifically, positive and negative beliefs about worry, negative beliefs about uncertainty (i.e., IU), and negative beliefs about problems (i.e., a negative problem orientation). Trait anxiety and depressive symptoms were included as control variables to assess the potential specificity of the cognitions of interest to GAD. Given the dearth of research noted earlier, no a priori hypotheses were advanced regarding the unique predictors of GAD symptoms/categorical GAD status. In this study, we tested our hypotheses using categorical (logistic regression) and dimensional (hierarchical multiple regression) approaches to data analysis, as employing both has important merits in the study of psychopathology (see Kraemer, Noda, & O’Hara, 2004; Kraemer, 2007).

Method Participants

The study protocol received approval from the Ryerson University Research Ethics Board. One hundred and thirty-eight (N ¼ 138) adult participants were recruited through the Ryerson University Psychology Participant Pool (n ¼ 83), and from the community via posters and online advertisements (n ¼ 55). The sample included 92 women and 46 men with a mean age of 22.08 years (SD ¼ 3.97). Nearly


half (43%) of participants self-identified as Caucasian, followed by East Asian (20%), South Asian (12%), Black (6%), Arab (5%), Mixed (5%), Latin American (2%), or South East Asian (2%). Another 5% of participants self-identified as “Other ethnocultural background”. Based on an optimal cut score of 7.67 on the GAD-Q-IV (see Measures), n ¼ 91 were classed as lower in GAD symptoms (i.e., Non-GAD) and n ¼ 47 were classed as high in GAD symptoms (i.e., Probable GAD). A number of analyses were performed to compare the characteristics of the two groups. The mean score on the PSWQ in the Probable GAD group (62.77, SD ¼ 10.58) was significantly higher than that in the Non-GAD group (45.95, SD ¼ 11.86, d ¼ 1.50). The mean and standard deviation for the Probable GAD group on the PSWQ were comparable with those in clinical trials in treatment settings (e.g., Dugas et al., 2010; O¨st & Breitholtz, 2000). Likewise, the mean and standard deviation on the PSWQ for the NonGAD group were comparable with those in other low anxiety samples (Behar, Alcaine, Zuellig, & Borkovec, 2003; Descheˆnes et al., 2012). There were no significant differences between the Non-GAD and Probable GAD groups on age (t (136) ¼ .55, p . .05), femaleto-male ratio (x 2 (1) ¼ 1.03, p . .05), and source of recruitment (i.e., participant pool versus community advertisements ( x 2 (1) ¼ 0.72, p . .05)).

Measures and Procedure

The participants completed the following measures at Ryerson University: The Generalized Anxiety Disorder Questionnaire for DSM-IV (GAD-Q-IV; Newman et al., 2002) is a dimensional and categorical measure of GAD. Respondents circle “No” or “Yes” for items assessing DSM criteria. Respondents then rate their levels of distress and impairment on a scale from 0 (not at all) to 8 (very severely). The total score on the GAD-Q-IV ranges from 0 to 13. Newman et al. (2002) found that a cut score of 5.7 provided a good balance of sensitivity and specificity, and numerous studies have used this cut score to create analogue GAD groups (Moore, Anderson, Barnes, & Haigh, 2014). Group membership based on the 5.7 cut score


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has shown good stability over a 2-week period and has shown good convergent and discriminant validity (Newman et al., 2002). However, recent research (Moore et al., 2014) has indicated that a more stringent cut score of 7.67 is optimal in that it is better at reducing false positives and identifying “true cases” of probable GAD. Thus, the higher cut score of 7.67 was used in the present study. Given that the symptoms of GAD have not changed in DSM-5, research employing the GAD-Q-IV remains informative. Cronbach’s alpha for the total score was .86 in the present study. The Penn State Worry Questionnaire (PSWQ; Meyer, Miller, Metzger, & Borkovec, 1990) is a widely used 16-item measure of trait worry. Items are rated from 1 (not at all typical) to 5 (very typical) and the total score ranges from 16 to 80. The questionnaire has demonstrated reliability and validity in both clinical and nonclinical samples (Meyer et al., 1990). Cronbach’s alpha in the present study was .93. The Meta-Cognitions Questionnaire-30 (MCQ-30, Wells & Cartwright-Hatton, 2004) is a 30-item self-report measure of “cognitions about cognitions” (Wells, 2008). Items are rated from 1 (do not agree) to 4 (agree very much). Each of its five subscales has 6 items and scores ranging from 6 to 24. The subscales have demonstrated independence, good internal consistency and test re-test reliability, as well as predictive validity (Spada, Mohiyeddini, & Wells, 2008; Wells & CartwrightHatton, 2004). The scales assessing positive beliefs about worry (MCQ-Pos) and negative beliefs about the uncontrollability and dangerousness of worry (MCQ-UD) were used in the present study because of their relevance to conceptual models of GAD, as reviewed earlier. Cronbach’s alphas in the present study for the subscales were .88 and .88, respectively. The 27-item Intolerance of Uncertainty Scale (IUS; Freeston, Rhe´aume, Letarte, Dugas, & Ladouceur, 1994; English translation, Buhr & Dugas, 2002) is a self-report measure that assesses negative beliefs about uncertainty. Items are rated from 1 (not at all characteristic of me) to 5 (entirely characteristic of me), with the total score ranging from 27 to 135. The IUS has been the principal measure of intolerance of uncertainty in


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studies on worry and GAD. It has demonstrated excellent internal consistency, good stability over 5 weeks, as well as convergent and divergent validity (Buhr & Dugas, 2002; Sexton & Dugas, 2009). Cronbach’s alpha in the present study was .95. The Negative Problem Orientation Questionnaire (NPOQ; Gosselin, Pelletier, & Ladouceur, 2001; English translation, Robichaud & Dugas, 2005a) contains 12 items that measure negative beliefs about problems and the problem-solving process. Items are rated from 1 (not at all true of me) to 5 (extremely true of me) and possible total scores range from 12 to 60. The NPOQ has excellent internal consistency, good test – retest reliability, and good construct validity (Robichaud & Dugas, 2005a). Cronbach’s alpha in the present study was .93. The DAS (Weissman & Beck, 1978; Cane, Olinger, Gotlib, & Kuiper, 1986) contains 40 items that assess dysfunctional attitudes pertaining to performance, achievement, and need for approval from others. Items are rated from 1 (totally disagree) to 7 (totally agree) and possible total scores range from 40 to 280. The DAS has excellent internal consistency and test – retest reliability, as well as good construct validity (Cane et al., 1986). Cronbach’s alpha in the present study was .96. The Early Maladaptive Schema Questionnaire—Research version (EMSQ-R; Samuel & Ball, 2013) was adapted from the Young Schema Questionnaire (Young & Brown, 1999). Its 75 items measure “stable core underlying beliefs” across several domains. The items are rated from 0 (very false) to 3 (very true). A recent factor analysis yielded a higher-order structure consisting of four factors labeled Interpersonal Detachment, Interpersonal Dependency, Perfectionism (which encompasses unrelenting standards and self-sacrificial beliefs), and Impulsive Exploitation. Only the first three of these factors were used in analyses as Samuel and Ball (2013) found these to be similar in content to the three factors identified by Schmidt, Joiner, Young, and Telch (1995). In addition, items in the fourth factor had only modest loadings (Samuel & Ball, 2013). The EMSQ-R has demonstrated good concurrent validity when compared against clinical and demographic variables, and scores on other established measures of personality traits


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(Samuel & Ball, 2013). Cronbach’s alphas in the present study were .88, .88, and .53, respectively. The Brief Core Schema Scales (BCSS; Fowler et al., 2006) contains 24 items that measure negative and positive beliefs about the self and others. Participants indicate “Yes” or “No” to each item to indicate whether or not they endorse the belief. Endorsed items are then rated from 1 (believe it slightly) to 4 (believe it totally). Four scores are obtained: negative-self (NS; e.g., “I am unloved”), negative-other (NO; e.g., “Others are hostile”), positive-self (PS; e.g., “I am respected”), and positive-other (PO; e.g., “Others are supportive”). The BCSS has very good internal consistency and excellent test – retest reliability. It also has demonstrated convergent and discriminant validity (Fowler et al., 2006). Cronbach’s alphas in the present study were as follows: negative-self ¼ .76, negativeother ¼ .87, positive-self ¼ .88, and positiveother ¼ .89. The State-Trait Inventory for Cognitive and Somatic Anxiety—Trait Version (STICSA-T; Ree, French, MacLeod, & Locke, 2008) contains 21 items that assess a person’s typical experience of the cognitive and somatic symptoms of anxiety. The items are rated on a scale ranging from 1 (almost never) to 4 (almost always). The STICSA-T shows excellent internal consistency and evidence of convergent and discriminant validity (Gro¨s, Antony, Simms, & McCabe, 2007). Cronbach’s alpha in the present study was .92. The Center for Epidemiologic Studies— Depression Scale (CES-D; Radloff, 1977) is a commonly used 20-item self-report measure of 7-day depressive symptoms in the general population. The items are rated from 0 (less than 1 day) to 3 (5 to 7 days). The CES-D has good reliability and validity (Radloff, 1977). Cronbach’s alpha in the present study was .92.

Results Independent samples t-tests were performed to compare the Probable GAD group with the Non-GAD group on each of the study measures (see Table 1). There were significant between-group differences on all measures, and these differences were in the expected direction (Cohen’s d ranging from 3.63 (GADQ-IV) to 0.37 (BCSS-NO)).


It was hypothesized that scores on measures of dysfunctional attitudes (DAS), early maladaptive schemas (EMSQ-R), and negative and positive beliefs about the self and others (BCSS) would make a significant contribution to variance in GAD symptoms as well as GAD group membership (Probable GAD versus Non-GAD), over and above the contributions of trait anxiety (STICSA-T), depressive symptoms (CES-D), positive and negative beliefs about worry (MCQ-Pos and MCQUD, respectively), negative beliefs about uncertainty (IUS), and negative beliefs about problems (NPOQ). Categorical (logistic regression) and dimensional (multiple regression) approaches were used to test the hypotheses, as categorical approaches applied to cut scores can obscure potentially meaningful variation that may exist in a specified outcome, even when the cut score is optimal (see Kraemer et al., 2004; Kraemer, 2007). Prior to regression analysis, Pearson correlations were performed to examine relations of the predictors to Probable GAD versus NonGAD status, and GAD severity (see Table 2). Each of the predictors was significantly correlated with categorical GAD group membership (rpb ¼ .17 to rpb ¼ .60) and dimensional (r ¼ .23 to r ¼ .73) GAD-QIV scores. Most predictors were also significantly interrelated (see Table 3). Collinearity diagnostics (tolerance values and variance inflation factors) were all acceptable; there was no evidence of multicollinearity among the predictors. A logistic regression was performed with GAD group membership (Probable GAD versus Non-GAD) entered as the outcome variable. In step 1, scores on the measures of trait anxiety and depressive symptoms significantly predicted the presence of Probable GAD versus Non-GAD (R 2 ¼ .44, x 2 (2) ¼ 53.43, p , .001) and together correctly classified 76% of the sample. The addition of scores on the measures of positive beliefs about worry, negative beliefs about worry, negative beliefs about uncertainty, and negative beliefs about problems led to a significant increment in the prediction of Probable versus Non-GAD status (R 2 ¼ .64, x 2(4) ¼ 31.52, p , .001). With the addition of the measures of GAD-relevant beliefs, 85% of participants were correctly classified. In step 3, the addition of scores on measures of dysfunctional

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Table 1. Comparison of probable GAD group and Non-GAD group on study measures Probable GADa (n ¼ 47)


Measure GAD-Q-IV CESD STICSA-T MCQ-Pos MCQ-UD IUS NPOQ DAS EMSQ-R interpersonal detachment EMSQ-R interpersonal dependency EMSQ-R perfectionism BCSS—positive-self BCSS—negative-self BCSS—positive-other BCSS—negative-other

Non-GADa (n ¼ 91)

M

SD

M

SD

t (df)

p

d

9.82 27.30 47.34 13.72 17.34 85.28 35.32 147.38 36.20 34.09 25.74 11.55 4.70 8.06 5.30

1.30 9.21 11.00 4.46 4.49 20.35 10.03 22.47 10.87 10.86 3.71 5.33 3.81 4.93 4.46

2.71 14.49 35.64 10.02 10.98 57.05 24.38 122.62 24.35 22.16 22.10 15.69 1.80 11.63 3.57

2.22 8.81 9.97 3.64 3.91 16.60 8.90 27.41 10.84 10.49 4.94 5.34 2.63 5.76 4.79

20.25 7.97 6.31 5.24 8.61 8.75 6.55 5.34 6.08 6.25 4.45 4.32 5.25 3.61 2.05

, .001** , .001** , .001** , .001** , .001** , .001** , .001** , .001** , .001** , .001** , .001** , .001** , .001** , .001** , .05*

3.63 1.43 1.13 0.94 1.55 1.57 1.18 0.96 1.09 1.12 0.80 0.78 0.94 0.65 0.37

Notes. GAD-Q-IV ¼ Generalized Anxiety Disorder Questionnaire for DSM-IV; CESD ¼ Center for Epidemiologic Studies—Depression Scale; STICSA-T ¼ State-Trait Inventory for Cognitive and Somatic Anxiety—Trait Version; MCQ Pos ¼ Positive Beliefs subscale of the Metacognitions Questionnaire—30; MCQ UD ¼ Uncontrollability and Danger subscale of the MCQ – 30; IUS ¼ Intolerance of Uncertainty Scale; NPOQ ¼ Negative Problem Orientation Questionnaire; DAS ¼ Dysfunctional Attitude Scale; EMSQR ¼ Early Maladaptive Schema Questionnaire—Research Version; BCSS ¼ Brief Core Schema Scales **p , .01; *p , .05 a GAD status coded as probable GAD ¼ 1, Non-GAD ¼ 0 based on a 7.67 cut score on the GAD-Q-IV (Moore et al., 2014).

attitudes, EMSs, and self- and other-focused beliefs further incremented the prediction of GAD group membership (x 2(8) ¼ 16.92, p , .05). The final model including all predictors was significant (R 2 ¼ .72, x 2(14) ¼ 101.87, p , .001) and correctly classified 87% of participants into Probable GAD and Non-GAD groups. The strongest unique predictor of GAD group membership was perfectionism (encompassing unrelenting standards and self-sacrificial beliefs) (b ¼ .32, Wald x 2(1) ¼ 9.99, p , .01, OR ¼ 1.38, 95% CI ¼ 1.13 –1.69), followed by positive beliefs about worry (b ¼ .22, Wald x 2 (1) ¼ 7.05, p , .01, OR ¼ 1.25, 95% CI ¼ 1.06 –1.47), positive beliefs about others (b ¼ 2 .18, Wald x 2 (1) ¼ 4.98, p , .05, OR ¼ 0.85, 95% CI ¼ .72 – .98), depressive symptoms (b ¼ .10, Wald x 2 (1) ¼ 6.29, p , .05, OR ¼ 1.11, 95% CI ¼ 1.02 – 1.20), and negative beliefs about uncertainty (b ¼ .05, Wald x 2 (1) ¼ 4.95, p , .05, OR ¼ 1.05, 95% CI ¼ 1.00 –1.09). No other predictors emerged as significant unique correlates of GAD group membership.

A hierarchical multiple regression was performed with dimensional scores on the GAD-Q-IV entered as the outcome. In step 1, scores on the measures of trait anxiety and depressive symptoms were entered and accounted for 48% of the variance in GADQ-IV scores (F (2, 135) ¼ 62.34, p , .001). In step 2, scores on the measures of positive beliefs about worry, negative beliefs about worry, negative beliefs about uncertainty, and negative beliefs about problems were entered and accounted for an additional 18% of the variance (DF (4, 131) ¼ 17.42, p , .001). In step 3, scores on the measures of dysfunctional attitudes, EMSs, positive and negative beliefs about the self and others were entered, leading to a significant increment of 4.7% in the prediction of GAD-Q-IV scores (DF (8, 123) ¼ 2.49, p ¼ .02). The final model including all predictors was significant (R 2 ¼ .71, F (14, 123) ¼ 21.30, p , .001). Beliefs about the uncontrollability and dangerousness of worry (b ¼ .31, p , .001), depressive symptoms (b ¼ .27, p ¼ .001), negative beliefs about uncertainty (b ¼ .23, p ¼ .01), perfec-

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Table 2. Correlations between predictors and GAD severity and status (N ¼ 138)


Measure

GAD-Q-IV total score

GAD-Q-IVa status

.66** .58** .47** .73** .67** .56** .52** .58** .58** .46** 2 .42** .52** 2 .33** .23**

.56** .48** .41** .59** .60** .49** .42** .46** .47** .36** 2 .35** .41** 2 .30** .17*

CESD STICSA-T MCQ-Pos MCQ-UD IUS NPOQ DAS EMSQ-R interpersonal detachment EMSQ-R interpersonal dependency EMSQ-R perfectionism BCSS—positive-self BCSS—negative-self BCSS—positive-other BCSS—negative-other

Notes. CESD ¼ Center for Epidemiologic Studies—Depression Scale; STICSA-T ¼ State-Trait Inventory for Cognitive and Somatic Anxiety—Trait Version; MCQ-Pos ¼ Positive Beliefs subscale of the Metacognitions Questionnaire—30; MCQ-UD ¼ Uncontrollability and Danger subscale of the MCQ—30; IUS ¼ Intolerance of Uncertainty Scale; NPOQ ¼ Negative Problem Orientation Questionnaire; DAS ¼ Dysfunctional Attitude Scale; EMSQ-R ¼ Early Maladaptive Schema Questionnaire—Research Version; BCSS ¼ Brief Core Schema Scales; GAD-Q-IV ¼ Generalized Anxiety Disorder Questionnaire—IV. *p , .05, **p , .01. a GAD status coded as probable GAD ¼ 1, non-GAD ¼ 0 based on a 7.67 cutoff score on the GAD-Q-IV (Moore et al., 2014).

tionism (encompassing unrelenting standards and self-sacrificial beliefs) (b ¼ .23, p , .001), and positive beliefs about worry (b ¼ .18, p , .01) were the only significant unique correlates of GAD severity in the final model.

Discussion Although it is well-established that maladaptive beliefs about worry, uncertainty, problems, and the problem-solving process are associated with excessive worry and elevated GAD symptoms, very little research has explored the potential unique contributions of dysfunctional attitudes, EMSs, and selffocused and other-oriented beliefs to variation in GAD symptoms, even though such cognitions have been proposed to be relevant to excessive worry (e.g., in treatment manuals). The results of this initial study showed that beliefs about worry and negative beliefs about uncertainty independently predicted GAD, which supports existing cognitive models of GAD. Dysfunctional beliefs about problems, however, did not emerge as an independent correlate of GAD. This may have been due to the strong zero-order correlation

between scores on the NPOQ and the IUS (r ¼ .69). The current study considered the degree to which dysfunctional attitudes as per Beck’s cognitive theory, EMSs as per Young’s schema model, and negative self-focused and other-focused beliefs relate to GAD. Individuals with probable GAD were significantly different from those lower on GAD symptoms on all measures of these cognitive constructs. Among these, only (1) maladaptive schemas reflecting exaggerated self-standards (e.g., “one should not make mistakes”) and a need to place others’ needs ahead of one’s own and (2) less positive views of other people and their intentions uniquely predicted presence versus absence of probable GAD or greater GAD severity, when controlling for other belief sets, trait anxiety, and depressive symptoms. These are new findings. Individuals with GAD are widely regarded to be high in perfectionism and are described as such in the clinical literature. For example, Hazlett-Stevens (2008) proposed that people with GAD have rigid self-expectations. Dugas and Robichaud (2007) stated that people with GAD often strive to find “perfect” solutions to their problems. Although some research has

– .42** .47** .44** .24** .33** .32** .07 2 .25** .23** 2 .06 .08

1

– .70** .65** .51** .61** .61** .30** 2 .37** .56** 2 .30** .28**

2

– .69** .64** .59** .63** .27** 2 .39** .48** 2 .37** .24**

3

– .50** .60** .72** .18* 2.47** .47** 2.24** .28**

4

– .69** .62** .37** 2.55** .48** 2.44** .35**

5

– .76** .35** 2 .65** .63** 2 .47** .38**

6

– .28** 2 .59** .59** 2 .33** .27**

7

– 2 .20* .30** 2 .12 .19*

8

– 2.48** .49** 2.21*

9

– 2.31** .43**

10

– 2 .18*

11

–

12

Notes. MCQ-Pos ¼ Positive Beliefs subscale of the Metacognitions Questionnaire—30; MCQ-UD ¼ Uncontrollability and Danger subscale of the MCQ—30; IUS ¼ Intolerance of Uncertainty Scale; NPOQ ¼ Negative Problem Orientation Questionnaire; DAS ¼ Dysfunctional Attitude Scale; EMSQ-IDT ¼ Interpersonal Detachment subscale of the Early Maladaptive Schema Questionnaire—Research Version; EMSQ-IDP ¼ Interpersonal Dependency subscale of the EMSQ; EMSQP ¼ Perfectionism subscale of the EMSQ; BCSS-PS ¼ Positive Self subscale of the Brief Core Schema Scales; BCSS-NS ¼ Negative Self subscale of the BCSS; BCSS-PO ¼ Positive Other subscale of the BCSS; BCSS-NO ¼ Negative Other subscale of the BCSS. *p , .05, **p , .01.

1. MCQ-Pos 2. MCQ-UD 3. IUS 4. NPOQ 5. DAS 6. EMSQ-IDT 7. EMSQ-IDP 8. EMSQ-P 9. BCSS-PS 10. BCSS-NS 11. BCSS-PO 12. BCSS-NO

Measure

Table 3. Intercorrelations among predictor variables (N ¼ 138)

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linked worrying to perfectionism (Sto¨ber & Joormann, 2001), no known research has actually examined the degree to which individuals with GAD have exaggerated standards (as noted by Egan, Wade, & Shafran, 2011). Thus, more research is needed on perfectionism in people with GAD, including the domains in which they display perfectionism, the form that it takes, as well as its antecedents and its consequences. The results also suggest that people with GAD can have inflated views about the importance of sacrificing one’s own needs. There is no known empirical research on the role of this EMS in worry and GAD. However, studies examining the self-reported interpersonal styles of people with GAD (e.g., using the Inventory of Interpersonal Problems—Circumplex) suggest that they endorse behaving in ways that are consistent with this schema (e.g., overly nurturant; Przeworski et al., 2011; Salzer et al., 2008). More research is needed on the circumstances under which people with GAD are motivated to sacrifice their needs, the various ways in which the perceived necessity to prioritize others’ needs manifests itself, and the consequences of behaving in accord with this dysfunctional schema (e.g., the factors that reinforce and extinguish self-sacrificial behavior). The extant literature offers preliminary answers to some of these research questions. Borkovec, Ray, and Sto¨ber (1998) and Hazlett-Stevens (2008) proposed that some clients with GAD may hold the belief that if they place others’ needs ahead of their own, they will be rewarded with praise and love; these may be salient motivators for people with GAD. Salzer et al. (2008) observed that people with GAD endorsed being nonassertive in situations in which assertiveness is called for, and being overly nurturing; these interpersonal styles may be driven by a perceived need to self-sacrifice. A need for interpersonal security/safety and fears of disapproval, isolation, and failure (Hazlett-Stevens 2008; Mennin, 2006) may also underpin beliefs about the importance of setting aside or suppressing one’s own needs. As was noted earlier, little is known about the beliefs that people with GAD have about other people, even though other-focused beliefs are considered as relevant as selffocused beliefs to cognitive formulations of


psychopathology (Beck, Rush, Shaw, & Emery, 1979). Our data support the notion that negative and positive beliefs about others are not merely two sides of the same coin (Bradshaw & Hazan, 2006); indeed, the two were only weakly correlated in the present study. Although participants with probable GAD were found to hold less positive views and more negative views of other people compared with those lower in GAD symptoms, lower positive beliefs about others were unique correlates of positive GAD status, whereas negative beliefs about others were not. We looked to the broader literature to interpret this finding and in particular, the nonconcordant relationships of positive and negative beliefs about others to GAD status. In an investigation of parenting styles, attachment, and schemas, Wearden et al. (2008) found that after controlling for negative affectivity, lower positive beliefs about others, also measured via the Brief Core Schema Scales, were uniquely associated with anxious and avoidant attachment styles, whereas negative beliefs about others were not. Recent research on anger and GAD has provided some support for the observation that individuals with probable GAD perceive others less positively and more negatively. Studies have shown that individuals high in GAD symptoms endorse significantly higher levels of anger and hostility toward others than do individuals who are low in GAD symptoms in a range of situations including ones in which they perceive others to be behaving in a way that is “overly friendly” or “especially nice” (Descheˆnes et al., 2012). It may be that a not-so-positive view of others and their intentions causes people with GAD to question even positive interpersonal situations. People with GAD may adopt less positive views of others as a strategy to protect themselves emotionally against possible disappointments in interpersonal relationships. Stated differently, perhaps individuals with GAD prevent themselves from overvaluing others so as not to become vulnerable to, or overly invested in, others. This explanation is only speculative and more research is needed on the significance of less positive and more negative other-oriented beliefs and their impact on the relationships of persons with GAD. It may be, for example, that lower positive views of others only characterize a


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subset of people with GAD. To answer this question, person-oriented approaches to data analysis would need to be employed in future work. Person-oriented approaches are used to identify subsets of individuals who depart from the mean pattern with respect to a certain variable; such approaches complement variable-oriented approaches such as ANOVA without supplanting them (see von Eye, Bogat, & Rhodes, 2006 for a discussion of cluster analysis and configural frequency analysis as person-oriented approaches). There also is a need to reconcile the finding of less positive/more negative views of others with the finding that people with GAD also endorse self-sacrificial, overly nurturant behavior in relationships. Perhaps individuals with GAD develop less positive or more negative views of others when their self-sacrificial behavior is not rewarded or reciprocated. Resentment or hostility, as noted earlier may give way to views of others that are less positive or more negative, and may result in further problems in interpersonal relationships. Of interest, there was some variation in the findings depending on whether the hypotheses were tested categorically versus dimensionally, which underscores the utility and possibly the necessity of employing both approaches when studying phenomena that can be conceptualized as continuous or discrete, such as psychopathology (Kraemer, 2007). Although the findings were largely consistent across the analyses, there are three differences to note. One finding was that lower positive schemas about others uniquely distinguished those with probable GAD from their counterparts in the logistic regression analysis, but these beliefs were unrelated to GAD in the multiple regression. A second finding was that negative beliefs about worry were uniquely related to GAD in the multiple regression, but not in the logistic regression. Finally, a schema reflecting unrelenting standards and the need to self-sacrifice was the strongest unique correlate of probable GAD in the logistic regression, but was not the strongest unique correlate in the multiple regression, even though it emerged as statistically significant. It is difficult to know why the findings diverged across analyses in this way; however, such divergences are not uncommon when cut scores (even optimal ones) are applied to data that also are continuous.

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Limitations

Given the novelty of the research question addressed here, a cross-sectional, analogue approach was an appropriate first step. Future extensions of the present research would constitute testing the hypotheses in studies employing a longitudinal design. Although we applied a stringent cut score on the GAD-QIV to identify those with probable GAD, the next step is to validate the present findings in a treatment-seeking sample diagnosed via semistructured interview.

Research and clinical implications

The present findings provide new empirical support for the potential unique contribution of EMSs and other-oriented beliefs in the understanding of GAD, over and above unhelpful beliefs about: uncertainty (i.e., intolerance of uncertainty), worry (i.e., negative and positive metacognitive beliefs), and problems (i.e., a negative problem orientation). Currently, EMSs do not figure explicitly in cognitive models of GAD. Our findings suggest that there may be a place for such schemas in existing models. However, questions remain as to how these schemas relate to or interact with other cognitions. For example, are self-sacrificial beliefs higherorder structures that foster specific information processing biases and patterns of automatic thought in persons with GAD? It also is of note that current theories of GAD (and most others psychopathologies for that matter) tend to localize dysfunction within the individual. However, it is well known that persons high in GAD symptoms report interpersonal problems and worry about their relationships, as noted earlier. Thus, it could eventually be of interest to develop a testable dyadic theory of how beliefs about others and relationship schemas (Baldwin, 1992) more generally contribute to the interpersonal problems that persons with GAD report , and vice versa. Of interest as well would be examining the degree to which existing CBT approaches indeed modify EMSs as per Young’s model, as well as beliefs about others, in persons with GAD. EMSs in particular are conceptualized as “core underlying vulnerabilities” that are enduring (Renner, Lobbestael, Peeters, Arntz, & Huibers, 2012), thus there is a possibility


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that current CBTs that concentrate on modifying belief structures like intolerance of uncertainty and negative metacognitions, for example, may not substantially modify these other so-called “core underlying vulnerabilities.” Such “residual” cognitive vulnerability (see Renner et al., 2012) may need to be investigated more closely in treatment studies. On the other hand, if it is found that current CBTs do modify EMSs and other-oriented beliefs without direct application of strategies designed explicitly to do so, then this would speak to the broad effects of CBTs that are designed to target specific cognitive processes. Finally, more research is needed to determine whether strategies that target interpersonal functioning and interpersonal problems (see Newman et al., 2011) may effectively modify self-sacrificial beliefs and beliefs about others.

Conclusion In sum, the present study indicates a need for further empirical examination of the full spectrum of maladaptive cognitions that characterize people who are prone to excessive and uncontrollable worry and anxiety, particularly as outlined in clinician and client manuals. Our findings are the first to suggest that dysfunctional schemas related to perfectionism and the perceived need to selfsacrifice, and less positive mental representations of others, may have independent explanatory value alongside other well-established belief constructs, in determining variation in pathological worry. Given that the present study was cross-sectional in design, future studies will need to ascertain the degree to which these particular beliefs are causally related to worry and GAD.

Disclosure statement No potential conflict of interest was reported by the authors.

References American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author. American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders: Fifth Edition (DSM-5). Arlington, VA: Author.


Baldwin, M.W. (1992). Relational schemas and the processing of social information. Psychological Bulletin, 112, 461– 484. doi:10.1037/0033-2909. 112.3.461 Beck, A.T. (1967). Depression: Causes and treatment. Philadelphia: University of Pennsylvania Press. Beck, A.T., Brown, G., Steer, R.A., & Weissman, A.N. (1991). Factor analysis of the dysfunctional attitude scale in a clinical population. Psychological Assessment, 3, 478– 483. Beck, A.T., Rush, A., Shaw, B., & Emery, G.D. (1979). Cognitive therapy of depression. New York, NY: Guilford Press. Behar, E., Alcaine, O., Zuellig, A.R., & Borkovec, T.D. (2003). Screening for generalized anxiety disorder using the Penn State Worry Questionnaire: A receiver operating characteristic analysis. Journal of Behavior Therapy and Experimental Psychiatry, 34, 25 –43. doi:10. 1016/S0005-7916(03)00004-1 Berenbaum, H., Bredemeier, K., & Thompson, R.J. (2008). Intolerance of uncertainty: Exploring its dimensionality and associations with need for cognitive closure, psychopathology, and personality. Journal of Anxiety Disorders, 22, 117– 125. doi:10.1016/j.janxdis.2007.01.004 Borkovec, T.D., Ray, W.J., & Sto¨ber, J. (1998). Worry: A cognitive phenomenon intimately linked to affective, physiological, and interpersonal behavioral processes. Cognitive Therapy and Research, 22, 561– 576. doi:10. 1023/A:1018790003416 Bradshaw, C.P., & Hazan, C. (2006). Examining views of self in relation to views of others: Implications for research on aggression and self-esteem. Journal of Research in Personality, 40, 1209– 1218. doi:10.1016/j.jrp.2005.11.004 Buhr, K., & Dugas, M.J. (2002). The Intolerance of Uncertainty Scale: Psychometric properties of the English version. Behaviour Research and Therapy, 40, 931– 945. doi:10.1016/S0005-7967 (01)00092-4 Cane, D.B., Olinger, L., Gotlib, I.H., & Kuiper, N. A. (1986). Factor structure of the Dysfunctional Attitude Scale in a student population. Journal of Clinical Psychology, 42, 307– 309. doi:10. 1002/1097-4679(198603)42:2,307:AID-JCLP 2270420213.3.0.CO;2-J Cartwright-Hatton, S., & Wells, A. (1997). Beliefs about worry and intrusions: The meta-cognitions questionnaire and its correlates. Journal of Anxiety Disorders, 11, 279– 296. doi:10.1016/ S0887-6185(97)00011-X Cecero, J.J., Nelson, J.D., & Gillie, J.M. (2004). Tools and tenets of schema therapy: Toward the construct validity of the Early Maladaptive Schema Questionnaire – Research Version (EMSQ-R). Clinical Psychology & Psychotherapy, 11, 344–357. doi:10.1002/cpp.401 Clark, D.M., & Wells, A. (1995). A cognitive model of social phobia. In R. Heimberg, M.R. Liebowitz, D.A. Hope, & F.R. Schneier (Eds.), Social phobia: diagnosis, assessment, and treatment. New York: Guilford Press.


2015


Descheˆnes, S.S., Dugas, M.J., Fracalanza, K., & Koerner, N. (2012). The role of anger in generalized anxiety disorder. Cognitive Behaviour Therapy, 41, 261– 271. Descheˆnes, S.S., Dugas, M.J., Radomsky, A.S., & Buhr, K. (2010). Experimental manipulation of beliefs about uncertainty: Effects on interpretive processing and access to threat schemata. Journal of Experimental Psychopathology, 1, 52 – 70. Dozois, D.J.A., & Beck, A.T. (2008). Cognitive schemas, beliefs, and assumptions. In K. S. Dobson & D.J.A. Dozois (Eds.), Risk factors in depression (pp. 121– 143). San Diego, CA: Elsevier. Dugas, M.J., Brillon, P., Savard, P., Turcotte, J., Gaudet, A., Ladouceur, R., . . . & Gervais, N.J. (2010). A randomized clinical trial of cognitivebehavioral therapy and applied relaxation for adults with generalized anxiety disorder. Behavior Therapy, 41, 46 – 58. doi:10.1016/j.beth. 2008.12.004 Dugas, M.J., Gagnon, F., Ladouceur, R., & Freeston, M.H. (1998). Generalized anxiety disorder: A preliminary test of a conceptual model. Behaviour Research and Therapy, 36, 215– 226. doi:10.1016/S0005-7967(97)00070-3 Dugas, M.J., Gosselin, P., & Ladouceur, R. (2001). Intolerance of uncertainty and worry: Investigating specificity in a nonclinical sample. Cognitive Therapy and Research, 25, 551– 558. doi:10.1023/A:1005553414688 Dugas, M.J., & Ladouceur, R. (2000). Treatment of GAD: Targeting intolerance of uncertainty in two types of worry. Behavior Modification, 24, 635– 657. doi:10.1177/0145445500245002 Dugas, M.J., & Robichaud, M. (2007). Cognitivebehavioral treatment for generalized anxiety disorder: From science to practice. New York, NY: Routledge. Dugas, M.J., Schwartz, A., & Francis, K. (2004). Brief report: Intolerance of uncertainty, worry, and depression. Cognitive Therapy and Research, 28, 835 – 842. doi:10.1007/s10608004-0669-0 Egan, S.J., Wade, T.D., & Shafran, R. (2011). Perfectionism as a transdiagnostic process: A clinical review. Clinical Psychology Review, 31, 203– 212. doi:10.1016/j.cpr.2010.04.009 Fowler, D., Freeman, D., Smith, B., Kuipers, E., Bebbington, P., Bashforth, H., . . . & Garety, P. (2006). The Brief Core Schema Scales (BCSS): Psychometric properties and associations with paranoia and grandiosity in nonclinical and psychosis samples. Psychological Medicine, 36, 749 –759. Fracalanza, K., Koerner, N., Descheˆnes, S.S., & Dugas, M.J. (2014). Intolerance of uncertainty mediates the relation between generalized anxiety disorder symptoms and anger. Cognitive Behaviour Therapy, 43, 122– 132. doi:10.1080/ 16506073.2014.888754 Fracalanza, K., Koerner, N., McShane, K.E., & Antony, M.M. (2013, November). The meaning of being uncertain to individuals with and without

13

generalized anxiety disorder. Poster presented at the meeting of the Cognitive Therapy Special Interest Group, Association for Behavioral and Cognitive Therapies, Nashville, TN. Freeston, M.H., Rhe´aume, J., Letarte, H., Dugas, M.J., & Ladouceur, R. (1994). Why do people worry? Personality and Individual Differences, 17, 791– 802. doi:10.1016/0191-8869(94)90048-5 Gentes, E.L., & Ruscio, A.M. (2011). A metaanalysis of the relation of intolerance of uncertainty to symptoms of generalized anxiety disorder, major depressive disorder, and obsessive-compulsive disorder. Clinical Psychology Review, 31, 923– 933. doi:10.1016/j.cpr.2011.05. 001 Gilbert, P., Boxall, M., Cheung, M., & Irons, C. (2005). The relation of paranoid ideation and social anxiety in a mixed clinical population. Clinical Psychology & Psychotherapy, 12, 124– 133. doi:10.1002/cpp.438 Gosselin, P., Pelletier, O., & Ladouceur, R. (2001, July). The Negative Problem Orientation Questionnaire (NPOQ): Development and validation among a non-clinical sample. Poster presented at the annual meeting of the WCBCT, Vancouver, BC. Gro¨s, D.F., Antony, M.M., Simms, L.J., & McCabe, R.E. (2007). Psychometric properties of the State-Trait Inventory for Cognitive and Somatic Anxiety (STICSA): Comparison to the State-Trait Anxiety Inventory. Psychological Assessment, 19, 369– 381. Harris, A.E., & Curtin, L. (2002). Parental perceptions, early maladaptive schemas, and depressive symptoms in young adults. Cognitive Therapy and Research, 26, 405– 416. doi:10. 1023/A:1016085112981 Hawke, L.D., & Provencher, M.D. (2011). Schema theory and schema therapy in mood and anxiety disorders: A review. Journal of Cognitive Psychotherapy, 25, 257–276. doi:10.1891/08898391.25.4.257 Hawke, L.D., Provencher, M.D., & Arntz, A. (2011). Early maladaptive schemas in the risk for bipolar spectrum disorders. Journal of Affective Disorders, 133, 428– 436. doi:10.1016/ j.jad.2011.04.040 Hazlett-Stevens, H. (2008). Psychological approaches to generalized anxiety disorder: A clinician’s guide to assessment and treatment. New York, NY: Springer. Hewitt, P.L., & Flett, G.L. (1991). Perfectionism in the self and social contexts: Conceptualization, assessment, and association with psychopathology. Journal of Personality and Social Psychology, 60, 456– 470. doi:10.1037/0022-3514.60.3. 456 Koerner, N., Antony, M.M., Young, L., & McCabe, R.E. (2013). Changes in beliefs about the social competence of self and others following group cognitive-behavioral treatment. Cognitive Therapy and Research, 37, 256– 265. doi:10.1007/s10608-012-9472-5 Kraemer, H.C., Noda, A., & O’Hara, R. (2004). Categorical versus dimensional approaches to


14


diagnosis: Methodological challenges. Journal of Psychiatric Research, 38, 17 – 25. doi:10.1016/ S0022-3956(03)00097-9 Kraemer, H.C. (2007). DSM categories and dimensions in clinical and research contexts. International Journal of Methods in Psychiatric Research, 16, S8 –S15. doi:10.1002/mpr.211 Lawrence, K.A., Allen, J., & Chanen, A.M. (2011). A study of maladaptive schemas and borderline personality disorder in young people. Cognitive Therapy and Research, 35, 30 – 39. doi:10.1007/ s10608-009-9292-4 Leahy, R.L. (2006). The worry cure: Seven steps to stop worry from stopping you. New York, NY: Crown Publishing Group. Meeten, F., Dash, S.R., Scarlet, A.L.S., & Davey, G.C.L. (2012). Investigating the effect of intolerance of uncertainty on catastrophic worrying and mood. Behaviour Research and Therapy, 50, 690– 698. doi:10.1016/j.brat.2012. 08.003 Mennin, D.S. (2006). Emotion regulation therapy: An integrative approach to treatment-resistant anxiety disorders. Journal of Contemporary Psychotherapy, 36, 95 – 105. Meyer, T.J., Miller, M.L., Metzger, R.L., & Borkovec, T.D. (1990). Development and validation of the Penn State Worry Questionnaire. Behaviour Research and Therapy, 28, 487–495. doi:10.1016/0005-7967(90)90135-6 Moore, M.T., Anderson, N.L., Barnes, J.M., & Haigh, E.A.P. (2014). Using the GAD-Q-IV to identify generalized anxiety disorder in psychiatric treatment seeking and primary care medical samples. Journal of Anxiety Disorders, 28, 25– 30. doi:10.1016/j.janxdis.2013.10.009 Newman, M.G., Castonguay, L.G., Borkovec, T.D., Fisher, A.J., Boswell, J.F., Szkodny, L. E., & Nordberg, S.S. (2011). A randomized controlled trial of cognitive-behavioral therapy for generalized anxiety disorder with integrated techniques from emotion-focused and interpersonal therapies. Journal of Consulting and Clinical Psychology, 79, 171– 181. doi:10.1037/ a0022489 Newman, M.G., Zuellig, A.R., Kachin, K.E., Constantino, M.J., Przeworski, A., Erickson, T., & Cashman-McGrath, L. (2002). Preliminary reliability and validity of the generalized anxiety disorder questionnaire-IV: A revised self-report diagnostic measure of generalized anxiety disorder. Behavior Therapy, 33, 215–233. doi:10.1016/S0005-7894(02)80026-0 Norton, P.J., Sexton, K.A., Walker, J.R., & Norton, G.R. (2005). Hierarchical model of vulnerabilities for anxiety: Replication and extension with a clinical sample. Cognitive Behaviour Therapy, 34, 50 – 63. doi:10.1080/ 16506070410005401 O¨st, L.-G., & Breitholtz, E. (2000). Applied relaxation vs. cognitive therapy in the treatment of generalized anxiety disorder. Behaviour Research and Therapy, 38, 777– 790. Pinto-Gouveia, J., Castilho, P., Galhardo, A., & Cunha, M. (2006). Early maladaptive schemas


and social phobia. Cognitive Therapy and Research, 30, 571 – 584. doi:10.1007/s10608006-9027-8 Przeworski, A., Newman, M.G., Pincus, A.L., Kasoff, M.B., Yamasaki, A.S., Castonguay, L. G., & Berlin, K.S. (2011). Interpersonal pathoplasticity in individuals with generalized anxiety disorder. Journal of Abnormal Psychology, 120, 286– 298. doi:10.1037/a0023334 Radloff, L.S. (1977). The CES-D Scale: A selfreport depression scale for research in the general population. Applied Psychological Measurement, 1, 385 – 401. doi:10.1177/ 014662167700100306 Ree, M.J., French, D., MacLeod, C., & Locke, V. (2008). Distinguishing cognitive and somatic dimensions of state and trait anxiety: Development and validation of the state-trait inventory for cognitive and somatic anxiety (STICSA). Behavioural and Cognitive Psychotherapy, 36, 313– 332. doi:10.1017/S1352465808004232 Renner, F., Lobbestael, J., Peeters, F., Arntz, A., & Huibers, M. (2012). Early maladaptive schemas in depressed patients: Stability and relation with depressive symptoms over the course of treatment. Journal of Affective Disorders, 136, 581– 590. doi:10.1016/j.jad.2011.10.027 Robichaud, M., & Dugas, M.J. (2005a). Negative problem orientation (part I): Psychometric properties of a new measure. Behaviour Research and Therapy, 43, 391– 401. doi:10. 1016/j.brat.2004.02.007 Robichaud, M., & Dugas, M.J. (2005b). Negative problem orientation (part II): Construct validity and specificity to worry. Behaviour Research and Therapy, 43, 403– 412. doi:10. 1016/j.brat.2004.02.008 Salzer, S., Pincus, A.L., Hoyer, J., Kreische, R., Leichsenring, F., & Leibing, E. (2008). Interpersonal subtypes within generalized anxiety disorder. Journal of Personality Assessment, 90, 292– 299. doi:10.1080/00223890701885076 Samuel, D.B., & Ball, S.A. (2013). The factor structure and concurrent validity of the early maladaptive schema questionnaire: Research version. Cognitive Therapy and Research, 37, 150– 159. doi:10.1007/s10608-012-9439-6 Sanderson, W.C., Wetzler, S., Beck, A.T., & Betz, F. (1994). Prevalence of personality disorders among patients with anxiety disorders. Psychiatry Research, 51, 167–174. doi:10.1016/01651781(94)90036-1 Schmidt, N.B., Joiner, T.E., Young, J.E., & Telch, M.J. (1995). The Schema Questionnaire: Investigation of psychometric properties and the hierarchical structure of a measure of maladaptive schemas. Cognitive Therapy and Research, 19, 295– 321. doi:10.1007/BF02230402 Sexton, K.A., & Dugas, M.J. (2009). Defining distinct negative beliefs about uncertainty: Validating the factor structure of the Intolerance of Uncertainty Scale. Psychological Assessment, 21, 176– 186. doi:10.1037/a0015827 Sexton, K.A., Norton, P.J., Walker, J.R., & Norton, G.R. (2003). Hierarchical model of


2015


generalized and specific vulnerabilities in anxiety. Cognitive Behaviour Therapy, 32, 82 – 94. doi:10.1080/16506070302321 Spada, M.M., Mohiyeddini, C., & Wells, A. (2008). Measuring metacognitions associated with emotional distress: Factor structure and predictive validity of the Metacognitions Questionnaire 30. Personality and Individual Differences, 45, 238– 242. doi:10.1016/j.paid. 2008.04.005 Stapinski, L.A., Abbott, M.J., & Rapee, R.M. (2010). Fear and perceived uncontrollability of emotion: Evaluating the unique contribution of emotion appraisal variables to prediction of worry and generalised anxiety disorder. Behaviour Research and Therapy, 48, 1097– 1104. doi:10.1016/j.brat.2010.07.012 Sto¨ ber, J., & Joormann, J. (2001). Worry, procrastination, and perfectionism: Differentiating amount of worry, pathological worry, anxiety, and depression. Cognitive Therapy and Research, 25, 49 – 60. von Eye, A., Bogat, G.A., & Rhodes, J.E. (2006). Variable-oriented and person-oriented perspectives of analysis: The example of alcohol consumption in adolescence. Journal of Adolescence, 29, 981–1004. doi:10.1016/j.adolescence. 2006.06.007 Wearden, A., Peters, I., Berry, K., Barrowclough, C., & Liversidge, T. (2008). Adult attachment, parenting experiences, and core beliefs about self and others. Personality and Individual Differences, 44, 1246– 1257. doi:10.1016/j.paid. 2007.11.019

15

Weissman, A.N., & Beck, A.T. (1978, November). . Development and validation of the Dysfunctional Attitude Scale: A preliminary investigation. Paper presented at the meeting of the Association for the Advancement of Behavior Therapy, Chicago. Wells, A. (1995). Meta-cognition and worry: A cognitive model of generalized anxiety disorder. Behavioural and Cognitive Psychotherapy, 23, 301–320. doi:10.1017/S1352465800015897 Wells, A. (2008). Metacognitive therapy: Cognition applied to regulating cognition. Behavioural and Cognitive Psychotherapy, 36, 651– 658. doi:10. 1017/S1352465808004803 Wells, A., & Carter, K. (1999). Preliminary tests of a cognitive model of generalized anxiety disorder. Behaviour Research and Therapy, 37, 585– 594. doi:10.1016/S0005-7967(98)00156-9 Wells, A., & Carter, K. (2001). Further tests of a cognitive model of generalized anxiety disorder: Metacognitions and worry in GAD, panic disorder, social phobia, depression, and nonpatients. Behavior Therapy, 32, 85 – 102. doi:10. 1016/S0005-7894(01)80045-9 Wells, A., & Cartwright-Hatton, S. (2004). A short form of the metacognitions questionnaire: Properties of the MCQ-30. Behaviour Research and Therapy, 42, 385– 396. doi:10.1016/S00057967(03)00147-5 Young, J.E. (1994). Cognitive therapy for personality disorders: A schema-focused approach. Sarasota, FL: Professional Resource Press. Young, J.E., & Brown, G. (1999). Young Schema Questionnaire: Short version. New York, NY: Cognitive Therapy Center of New York.

Personality features related to generalized anxiety disorder.

Relationship Obsessive-Compulsive Disorder: Interference, Symptoms, and Maladaptive Beliefs.

Biological explanations of generalized anxiety disorder: effects on beliefs about prognosis and responsibility.

PET in generalized anxiety disorder.

Anxiety sensitivity distinguishes panic disorder from generalized anxiety disorder.

Pharmacotherapy of generalized anxiety disorder.

Generalized anxiety disorder: how to treat, and for how long?

Specifically altered brain responses to threat in generalized anxiety disorder relative to social anxiety disorder and panic disorder.

Intolerance of uncertainty mediates the relation between generalized anxiety disorder symptoms and anger.

Developmental risk factors in generalized anxiety disorder and panic disorder.

Biological markers of generalized anxiety disorder.

Agomelatine in treating generalized anxiety disorder.

Chest pain in generalized anxiety disorder.

Emotion Regulation Therapy for Generalized Anxiety Disorder.

Generalized anxiety disorder: some biochemical aspects.

Anger and anxiety responses to m-chlorophenylpiperazine in generalized anxiety disorder.

Rumination predicts heightened responding to stressful life events in major depressive disorder and generalized anxiety disorder.

Generalized Anxiety Disorder and Social Anxiety Disorder, but Not Panic Anxiety Disorder, Are Associated with Higher Sensitivity to Learning from Negative Feedback: Behavioral and Computational Investigation.

Emotion beliefs and cognitive behavioural therapy for social anxiety disorder.

Self-conscious emotions in worry and generalized anxiety disorder.

Generalized social anxiety disorder: A still-neglected anxiety disorder 3 decades since Liebowitz's review.

Acceptance and Commitment Therapy (ACT) For Generalized Anxiety Disorder.

Genetics of generalized anxiety disorder and related traits.

Pharmacotherapy of generalized anxiety disorder: focus and update on pregabalin.