CoChat
Sign Up
Cited by 606Anxiety, Depression, Psychometrics, Treatment, Cognitive ProcessesObsessive-Compulsive Spectrum DisordersPsychotherapy Techniques and Applications

A novel theory of experiential avoidance in generalized anxiety disorder: A review and synthesis of research supporting a contrast avoidance model of worry

Open access
Newman, Michelle G., Llera, Sandra J.·2011·Clinical Psychology Review
DOI 10.1016/j.cpr.2011.01.008PMC PMC3073849
Open this paper in CoChat — free account

Abstract

An important emphasis of the literature on generalized anxiety disorder (GAD) has been to achieve a greater understanding of the function of emotion (e.g., avoidance, dysregulation) in the etiology and maintenance of this disorder. The purpose of the following paper is to propose a new way of conceptualizing emotional sequelae in GAD by detailing the Contrast Avoidance Model of Worry. In presenting this model, we review theory and data that led to our current position, which is that individuals with GAD are more sensitive to feeling emotionally vulnerable to unexpected negative events, and that worry (the key pathological feature of GAD) is employed to prolong and maintain a negative emotional state thereby avoiding an unexpected negative emotional shift, or contrast experience. We also discuss implications for treatment given the presence of a new target for emotional exposure techniques. Finally, we establish the Contrast Avoidance Model within the framework of extant theories and models of pathogenic processes of GAD. © 2011 Elsevier Ltd.

AI snapshot

Written from the paper’s full text.

TL;DR

The paper proposes that generalized anxiety disorder is maintained by worry used to avoid a sudden shift into negative emotion, rather than by avoidance of negative emotion itself. It reviews evidence that worry creates sustained negative arousal and presents preliminary lab data showing GAD participants find worry helpful for coping with emotional films.

Key findings

  • The authors argue prior avoidance accounts conflate several constructs: somatic response to worry versus later stress, resting versus worry baselines, initial reactivity versus absolute emotionality during a feared stimulus, and emotional avoidance versus failure of emotional processing.
  • Reviewed studies link worry to increased cardiovascular, electrodermal, EEG, endocrine/immune, and subjective negative affect; some null findings may reflect failure to measure parasympathetic activity.
  • In Llera and Newman (2010a), 38 GAD and 35 nonanxious participants were randomized to worry, relaxation, or neutral induction before four emotion-inducing film clips. Worry produced higher physiological activation than relaxation and higher negative affect than both other inductions; prior worry reduced further reactivity to fear (vs. relaxation d = 1.0; vs. neutral d = 1.2 for subjective response) and sadness (vs. relaxation d = 1.19; vs. neutral d = .92), but absolute negative affect during clips did not differ.
  • In Llera and Newman (2010b), GAD participants rated worry as more helpful for coping than nonanxious controls did (d = .88); within GAD, worry was rated more helpful than neutral (d = 1.2) and relaxation (d = .84), while nonanxious controls rated relaxation (d = 1.35) and neutral (d = 1.2) as more helpful than worry. The paper also notes that feared outcomes fail to occur 84% of the time (Borkovec et al., 1999), reinforcing relief.

Methods

  • Theoretical review and synthesis of prior literature on worry, emotion, and GAD; the Contrast Avoidance Model is compared with intolerance-of-uncertainty, metacognitive, acceptance-based, and emotion-dysregulation models.
  • Includes preliminary experimental data from two laboratory studies: Llera and Newman (2010a) with 38 GAD and 35 nonanxious participants randomized to worry, brief relaxation, or neutral induction before four emotion-inducing film clips; Llera and Newman (2010b) replicated this and added post-film coping ratings.
  • Main analysis uses experimental group comparisons of physiological and subjective reactivity, reported with effect sizes, plus narrative synthesis rather than meta-analysis.

Limitations

  • The paper does not state a formal limitations section; the authors describe the supporting findings as preliminary and the treatment implications as hypotheses.
  • Evident from the text: the proposed contrast-exposure treatment is not directly tested, and the authors’ earlier randomized trial found no significant advantage of interpersonal/emotional processing therapy plus CBT over CBT plus supportive listening on GAD symptoms.
  • Evident from the text: the evidence relies on laboratory inductions, film clips, self-report, and selected samples, with the key contrast-avoidance mechanism inferred from indirect reactivity and coping ratings.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1016/j.cpr.2011.01.008

Cites

149 of 149 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

1 of 110 cited sources checked · 1 supported · 0 flagged

  • Premisecitation

    Earlier attempts to use exposure in GAD relied on imagery to bring up worrisome fears.

    “Prior efforts to implement exposure within GAD used techniques that induced worrisome fears via imagery (Hoyer et al., 2009; Zinbarg, Lee, & Yoon, 2007).”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites Hoyer et al., 2009 source
    • cites Zinbarg, Lee, & Yoon, 2007 source
  • Findingown data

    Prior worry led to less subjective reactivity than either relaxation or neutral inductions in response to the sad clip.

    “Prior worry also led to less subjective reactivity than either relaxation (d = 1.19) or neutral inductions (d = .92) in response to the sad clip.”
    Quote in the paperSubstantial claim
  • Findingcitation

    Data from Llera and Newman (2010a) show equivalence in absolute levels of negative affect following negative film clips regardless of prior induction, suggesting that worry does not facilitate avoidance of negative emotion.

    “However, data from Llera and Newman (2010a) show equivalence in absolute levels of negative affect following negative film clips regardless of prior induction, suggesting that worry does not facilitate avoidance of negative emotion.”
    Quote in the paperSubstantial claim
  • Findingown data

    Absolute levels of negative affect during exposure to the sad clip were not actually lower in participants who had worried previously than in participants in the neutral or relaxation inductions.

    “Nonetheless, as with the fearful film, absolute levels of negative affect during exposure to the sad clip were not actually lower in participants who had worried previously than in participants in the neutral or relaxation inductions.”
    Quote in the paperSubstantial claim
  • Findingcitation

    Nonanxious controls more often said neutral inductions made them feel better able to cope, compared with GAD participants.

    “Similarly, GAD participants rated relaxation (d = 1.33) and neutral inductions (d = 1.54) as having made them feel less able to cope during the film clip than did nonanxious controls, whereas nonanxious controls were more likely to indicate that relaxation and neutral inductions helped them feel more able to cope compared to those with GAD.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Llera & Newman, 2010b source
  • May combine two claims. 48
  • Classified as probably not a substantial claim. 22

  • May combine two claims.

    Findingown data

    There were no differential effects of worry, neutral, or relaxation inductions on reactivity to a happy film clip, suggesting that worry does not preclude positive affect associated with happy emotions.

    “There were also no differential effects of worry, neutral, or relaxation inductions on reactivity to a happy film clip, suggesting that worry does not preclude positive affect associated with happy emotions.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    There was no evidence of avoidance of fearful emotions during the fear induction; no differences between prior worry, relaxation, or neutral activity in absolute levels of negative emotionality during the fear clip.

    “Importantly, there was no evidence of avoidance of fearful emotions during the fear induction. Specifically, there were no differences between prior worry, relaxation, or neutral activity in absolute levels of negative emotionality (either subjective or physiological) during the fear clip.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Prior relaxation and neutral inductions led to increased sad affect, whereas prior worry led to a decrease in reported sadness during the sad clip from previously heightened levels experienced during worry.

    “On the other hand, whereas prior relaxation and neutral inductions led to increased sad affect, prior worry led to a decrease in reported sadness during the sad clip from previously heightened levels experienced during worry.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation

    During worry, participants with GAD had higher physiological activation than during relaxation, with a neutral induction falling nonsignificantly in between.

    “During worry, participants with GAD had higher physiological activation than they did during relaxation, with a neutral induction falling nonsignificantly in between.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation

    Participants in the worry induction reported higher negative affect than those in both relaxation and neutral inductions, which were statistically similar.

    “Those in the worry induction also reported higher negative affect than both relaxation and neutral inductions, which were statistically similar.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    In response to the fear clip, prior worry led to significantly less initial physiological and subjective responding than prior relaxation, and to less subjective responding than the neutral induction.

    “Consistent with prior studies using worry as the comparison baseline, in response to the fear clip, prior worry led to significantly less initial physiological (Cohen's d effect size = 1.0) and subjective responding than prior relaxation (d = 1.35), and to less subjective responding than did the neutral induction (d = 1.2).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation

    Even though they said worry helped them cope, GAD participants rated their overall negative affect higher than controls did across worry and later negative clips.

    “Ironically, despite reporting that worry helped them cope with negative emotion, participants with GAD also rated their absolute level of negative affect as being significantly higher than did controls across both worry and subsequent negative clips.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Llera & Newman, 2010b source

  • May combine two claims.

    Findingcitation

    Nonanxious controls felt less negative affect but still found worry less helpful as a coping strategy than GAD participants did.

    “However, nonanxious controls, despite experiencing less negative affect, found worry as a coping strategy to be less helpful than those with GAD.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Llera & Newman, 2010b source

  • May combine two claims.

    Findingreasoning

    The overwhelming evidence indicates that worry prevents emotional processing but does not allow avoidance of emotional experiencing.

    “the overwhelming evidence suggests that although worry precludes emotional processing, worry does not enable avoidance of emotional experiencing.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Our data indicate that GAD clients already create negative emotion through worry; they do not avoid it.

    “However, our data show that rather than avoid negative emotionality, GAD clients already actively generate negative emotionality via worry.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation

    Worry is linked to sustained tonic somatic activation, which reduces acute reactivity to brief images.

    “substantial data suggest that worry is associated with sustained tonic somatic activation (and as a result it mutes acute reactivity to brief images).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingreasoning

    Worry creates and maintains a sustained negative emotional state and may only inhibit further increases in activation in response to stressors.

    “worry facilitates and maintains a sustained negative emotional state, and may simply inhibit additional increases in activation in response to stressors.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationcitation

    Worry does not produce avoidance of negative emotion; instead, it creates or sustains a negative emotional state.

    “Taken together, these data suggest that worry does not lead to avoidance of a negative emotional state, but rather creates or sustains a negative state.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    People with GAD report stronger emotions and slower recovery from negative moods than nonanxious controls.

    “Moreover, those with GAD report heightened emotional intensity and greater difficulty recovering from a negative mood state than nonanxious control participants (Mennin et al., 2005; Turk et al., 2005).”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites Mennin et al., 2005 source
    • cites Turk et al., 2005 source

  • May combine two claims.

    Premisecitation

    Only GAD participants who exhibited sympathetic arousal at baseline showed muted reactivity to a stressor; those without such arousal showed reactivity comparable to nonanxious control participants.

    “Moreover, Fisher, Granger and Newman (2010) showed that only GAD participants who exhibited sympathetic arousal at baseline (as measured by salivary alpha-amylase) showed muted reactivity to a stressor. Those GAD participants without sympathetic arousal at baseline (perhaps individuals who were not in the midst of worrying about something) showed reactivity comparable to nonanxious control partici”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Fisher, Granger and Newman (2010) source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Depression and GAD are commonly comorbid disorders.

    “Depression and GAD are commonly comorbid disorders (Kessler et al., 2002).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Kessler et al., 2002 source

  • May combine two claims.

    Premisecitation

    People with generalized anxiety disorder may have chronically low vagal tone, characterized by high stable heart rates and low heart rate variability, which has been linked causally to worry.

    “In addition, people with GAD may have chronically low vagal tone (high stable heart rates and low heart rate variability), which has also been linked causally to worry”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites Brosschot, 2010 source
    • cites Brosschot & Thayer, 2003 source
    • cites Hoehn-Saric et al., 2004 source

  • May combine two claims.

    Premisecitation

    If one or both of these domains do not demonstrate reactivity to an emotional stimulus, the full fear structure has not been accessed and habituation is unlikely.

    “If one or both of these domains do not demonstrate reactivity to an emotional stimulus, the full fear structure has not been accessed and habituation is unlikely.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Foa and Kozak (1986) source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Borkovec (1985) proposed that worry functions to maintain anxiety.

    “Borkovec (1985) has also theorized that the functional effect of worry may be the maintenance of anxiety.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Borkovec, 1985 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Depressive rumination, which may be similar in process and emotional content to worrisome thinking in GAD, is a factor that can maintain the depressive state.

    “Several studies have shown that depressive rumination, which may be similar in process and emotional content to the worrisome thinking in GAD, is a factor that can maintain the depressive state (for a review, see Kuehner, Huffziger, & Liebsch, 2009).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Kuehner, Huffziger, & Liebsch, 2009 source

  • May combine two claims.

    Interpretationreasoning

    People with generalized anxiety disorder neither avoid nor process negative emotions.

    “Taken together, these findings suggest that people with GAD neither avoid nor process negative emotions.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    According to Foa and Kozak (1986), a demonstration of emotional processing requires reactivity upon exposure at both subjective and physiological levels.

    “According to Foa and Kozak (1986), however, a demonstration of emotional processing requires reactivity upon exposure at both subjective and physiological levels.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Foa and Kozak (1986) source

  • May combine two claims.

    Premisecitation

    Ruminative self-focus in depressed and dysphoric participants is positively associated with both negative affect and negative mood reactivity to daily stressful events.

    “Ruminative self-focus in depressed and dysphoric participants is positively associated with both negative affect and negative mood reactivity to daily stressful events (Moberly & Watkins, 2008a, 2008b).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Moberly & Watkins, 2008a, 2008b

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Interpretationcitation

    People with GAD react more aversively and are more sensitive to negative emotional contrast than nonanxious people.

    “Based on this cognitive psychology literature, as well as our own findings (Llera & Newman, 2010a), we theorized that individuals with GAD have developed a stronger aversive reaction and are even more sensitive to a negative emotional contrast than are nonanxious individuals, and that it is the avoidance of this contrast that motivates their worry.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Llera & Newman, 2010a source

  • May combine two claims.

    Premisecitation

    Worry is credited with functions such as preparing for the worst, motivating action, distracting from more emotional topics, preventing bad outcomes, and helping plan how to prevent them.

    “Such positive functions include “preparation for the worst”, “motivation”, “distraction from more emotional topics”, actually preventing bad things from happening (superstitious beliefs) and/or helping the individual figure out how to prevent bad things from happening (Borkovec & Roemer, 1995; Davey, Tallis, & Capuzzo, 1996).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites Borkovec & Roemer, 1995 source
    • cites Davey et al., 1996 source

  • May combine two claims.

    Interpretationreasoning

    GAD and worry alter information processing so that learning from experience is hindered and anxious meanings for stimuli persist.

    “GAD and worry also impact information processing in ways that interfere with learning from experience and that contribute to the maintenance of anxious meanings attributed to various stimuli.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    High worriers see worry as a helpful coping strategy and say they use it deliberately, even though worry sustains negative affect.

    “Despite the causal role of worry in sustaining negative affect, high worriers view worry as a positive coping strategy and they report actively using it as such.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites Borkovec & Roemer, 1995 source
    • cites Davey et al., 1996 source

  • May combine two claims.

    Interpretationreasoning

    Worry may block emotional processing not only by avoiding emotionality but also by sustaining negative emotion and blunting emotional learning.

    “Thus, rather than via avoidance of emotionality, another mechanism by which worry may prevent emotional processing may be via sustained negative emotionality, and a dampening of emotional learning.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Believing depressive rumination is positive is linked to more negative ruminative thinking.

    “Similar data indicate that positive beliefs about depressive rumination are associated with a tendency to engage in negative ruminative thinking (Brosschot, 2010).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Brosschot, 2010 source

  • Classified as probably not a substantial claim.

    Premisecitation

    People may self-generate distress to prevent even worse pain later.

    “Our model is also consistent with the viewpoint of Borkovec, Alcaine and Behar (2004) that people may create distress for themselves as a means to preclude even greater subsequent pain.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Borkovec, Alcaine and Behar, 2004

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Classified as probably not a substantial claim.

    Premisecitation

    Affective contrast theory holds that how an emotional experience affects us depends on how much it contrasts with the prior emotional state.

    “This theory states that the impact of an emotional experience is contingent on its degree of contrast with a preceding emotional state (Bacon, Rood, & Washburn, 1914).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Bacon, Rood, & Washburn, 1914 source

  • May combine two claims.

    Interpretationreasoning

    GAD participants found a negative contrast more upsetting than nonanxious controls did, which is not just a fear of negative emotions.

    “This suggests that the experience of a negative contrast (i.e., as opposed to worry, feeling relaxed or neutral would create a contrast relative to fear or sadness) was more upsetting for the GAD participants than nonanxious controls, which differs from simply a fear of negative emotions.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    Worry does not avoid arousal and threatening images; instead, it rehearses reactions to feared negative outcomes.

    “Our theory does not support the idea that such arousal and images are avoided. Rather, we argue that an alternative coping strategy is achieved via worry, such that reactions to feared negative outcomes are in fact rehearsed.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    Worry is reinforced by relief when the feared outcome does not happen and by successful avoidance of a negative emotional contrast when the feared event occurs, rather than by emotional avoidance.

    “instead of worry being reinforced by emotional avoidance, it is the relief (when the feared outcome does not happen) as well as the successful avoidance of a negative emotional contrast (when the feared event occurs) that leads to a reinforcement of worry.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Interpretationreasoning

    People with GAD hold both positive and negative views of worry and use worry to cope with threats and regulate emotion.

    “In addition, the two theories converge on the idea that persons with GAD hold both positive and negative views of worry and that these individuals use their worry as a means to cope with threats as well as to regulate emotion.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationnone given

    Worry provides an illusion of control.

    “We would further agree that worry does provide the illusion of control.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    Worrying draws people into a cycle that ends up being negatively reinforcing.

    “The theories are also similar with respect to the idea that the process of worrying engages individuals in a cycle that is ultimately negatively reinforcing.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    None of the prior theories address negative emotional contrast, so none discuss helping people cope with such contrasts, and none of the new treatments based on these theories include an emotional contrast exposure component.

    “Because none of the prior theories address the idea of negative emotional contrast, none discuss the importance of helping individuals learn to cope with such contrasts, and as such none of the new treatments based on these theories have incorporated an emotional contrast exposure component.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationcitation

    Two main parts of standard CBT for GAD, cognitive therapy and self-control desensitization, seem inadequate for emotional processing.

    “Moreover, cognitive therapy and self-control desensitization (SCD), two major components of standard CBT for GAD, appear insufficient to address emotional processing.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Standard GAD treatments have lacked exposure methods that produce emotional processing, even though GAD patients appear unable to process emotions successfully.

    “Despite evidence for the failure of GAD participants to engage in successful emotional processing, traditional methods of treating GAD have not included exposure techniques that will achieve emotional processing (Borkovec & Newman, 1998).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Borkovec & Newman, 1998 source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Interpretationreasoning

    Beliefs about worry drive maladaptive coping through worry, which ultimately causes a failure to process emotions appropriately.

    “Similar to the MC Model, our model purports that beliefs about worry fuel maladaptive coping using worry and that this ultimately leads to a failure to process emotions appropriately.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    With contrast avoidance behaviors present, worry causes problems in processing stressors and keeps anxious associations going.

    “Although our model does not include theories regarding Type II worry, we do believe that in the presence of contrast avoidance behaviors, worry leads to deficits in emotional processing of stressors and maintains anxious associations.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    Worry has more than one stage.

    “We also agree that worry has more than one stage.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    Worry serves an avoidant function and is maintained through reinforcement.

    “The two theories also converge on the idea that worry serves an avoidant function and that such worry is maintained via reinforcement.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    People with GAD use worry as a dysfunctional way to cope with threats and to regulate emotion.

    “The two theories also converge on the idea that persons with GAD use worry as a dysfunctional means to cope with threats as well as to regulate emotion.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    This perspective may be key to developing more effective treatments for GAD.

    “This perspective may be the key to developing more effective treatments for GAD.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationcitation

    The Emotion Dysregulation Model includes emotional exposure techniques, but unless clients are first put into a relaxed or euthymic mood state, they are not exposed to a negative emotional contrast and may not reduce their fear of emotional contrasts.

    “although the ED Model also includes emotional exposure techniques as part of treatment (as was the case with the Newman et al. (in press) treatment), unless clients are first induced into a relaxed or euthymic mood state then clients are not exposed to a negative emotional contrast and thus may fail to reduce their fear of emotional contrasts.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Newman et al. (in press)

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Premisecitation

    Davey and colleagues' stop-rules work indicates that worry-related negative mood drives persistence and 'as many as you can' stop rules, which also blocks worry termination.

    “This idea is also consistent with the stop rules research and theory of Davey and colleagues who suggest that a negative mood associated with worry motivates persistence and the use of “as many as you can” stop rules, which also interferes with worry termination (Davey, Startup, MacDonald, Jenkins, & Patterson, 2005).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Davey et al., 2005 source

  • Classified as probably not a substantial claim.

    Premisecitation

    Craske et al. (2008) argue that tolerating distress, rather than reducing it, is key to inhibitory learning.

    “According to Craske et al. (2008), a focus on distress tolerance rather than distress diminishment is important in the creation of inhibitory learning.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Craske et al., 2008 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationnone given

    People with GAD experience heightened emotional intensity.

    “we agree that people with GAD do experience heightened emotional intensity.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    Gray's neurophysiological theory says that anxiety can be triggered by detecting a mismatch between what is expected and what is encountered.

    “This new hypothesis is consistent with Gray's (1982) neurophysiological theory of anxiety, which states that one trigger for anxious responding is the detection of a mismatch between expected and encountered stimuli in the environment.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Gray, 1982 source

  • May combine two claims.

    Interpretationreasoning

    Individuals with GAD fear negative emotional contrast experiences and use worry to avoid feeling vulnerable to such an experience.

    “individuals with GAD fear negative emotional contrast experiences and use worry in order to avoid feeling vulnerable to having such an experience.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    Adding emotional contrast exposure techniques to GAD treatments will help target and reduce the avoidance central to the emotional pathology of GAD.

    “We propose that the incorporation of such techniques in treatments for GAD will help to target and reduce the avoidance central to the emotional pathology of GAD.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationnone given

    Once worry reaches an extended stage, stopping worry and controlling distress becomes less possible.

    “However, once worry reaches this stage it is less possible to stop worrying and/or control distress.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    Neither the Metacognitive nor Acceptance-based treatment models propose a specific emotional contrast exposure component in their treatment recommendations.

    “neither the MC nor AB treatment models propose a specific emotional contrast exposure component in their treatment recommendations.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    The specific negative appraisal of a negative emotional contrast causes emotion regulation difficulties, which can interfere with emotional experience at multiple levels, including subjective intensity and understanding.

    “we propose that it is the specific negative appraisal of a negative emotional contrast that leads to difficulties of emotion regulation, and such difficulties can interfere with emotional experience on many levels, including subjective intensity as well as understanding.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationnone given

    Recent theories of emotion in GAD have failed to distinguish between somatic response to worry and somatic response to stress after worry, between resting baseline and worry baseline, between initial reactivity to a feared stimulus and absolute emotionality during that stimulus, and between emotional avoidance and emotional processing avoidance.

    “recent theories of emotion in GAD have failed to discriminate: a) somatic response to worry from somatic response to stress following worry, b) use of a resting baseline from use of a worry baseline, c) initial reactivity to a feared stimulus from absolute levels of emotionality during a feared stimulus, and d) emotional avoidance from emotional processing avoidance.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    People with GAD may much prefer pleasant surprise to unexpected disappointment and upset, which also positively reinforces worry.

    “Therefore, these individuals may greatly prefer to feel emotions associated with being pleasantly surprised (i.e., a positive emotional contrast) over unexpectedly disappointed and upset (i.e., a negative emotional contrast), thus also leading to positive reinforcement of the worry process.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    When a negative contrast is avoided or the worrisome outcome does not occur, the person feels relief, which reinforces the belief that worry helped them cope.

    “Nonetheless, when a negative contrast is avoided and/or the worrisome outcome does not happen, the person experiences relief, which ultimately reinforces their view that worry helped them to cope.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Interpretationnone given

    Worry enables avoidance of emotional processing.

    “Moreover, we would agree that worry enables avoidance of emotional processing.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationcitation

    Reflective listening increased emotional processing yet did not improve outcome, suggesting that the kind of processing it produced did not matter for therapy effects.

    “The fact that reflective listening produced greater levels of emotional processing but failed to achieve greater outcome suggests that the type of emotional processing that occurred was not relevant for therapeutic effects to occur.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    The main threat for individuals with GAD is feeling vulnerable and not braced for a negative emotional contrast, and worry becomes functionally involved through attempts to avoid this contrast.

    “we propose a more targeted emphasis of the negative appraisal of emotions, in that feeling vulnerable and not braced for a negative emotional contrast is the main focus of threat, and it is through attempts to avoid this contrast that worry becomes functionally involved in the model.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Interpretationreasoning

    Intensive worrying becomes self-sustaining, and after prolonged worrying individuals with GAD likely try to control their worry and distress.

    “At the same time, it is clear that intensive worrying takes on a life of its own and once individuals with GAD have been worrying for an extended period they would likely try to intervene to control their worry and the associated distress.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Interpretationnone given

    Individuals with GAD fail to regulate emotions appropriately, and this dysregulation interferes with emotional processing.

    “we also suggest that individuals with GAD fail to regulate their emotions appropriately and that such dysregulation interferes with emotional processing.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    The worry cycle is negatively reinforced by relief when the feared event fails to happen or by avoiding a contrast if it does, so this anxiety signal likely restarts worry.

    “Because the worry cycle has been negatively reinforced via relief when the feared event does not occur and/or avoidance of an emotional contrast if it does occur, this anxiety signal will most likely lead to a reactivation of the worry state.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    People with GAD feel more discomfort in uncertain situations partly because they fear the emotional consequences of a negative experience.

    “if individuals with GAD experience greater discomfort in uncertain situations (especially if the anticipated outcome is negative and/or they have poor confidence in their problem-solving skills), this could be in part because they fear the emotional ramifications of this negative experience.”
    Quote in the paperSubstantial claim
66 of 66

  • The paper relies on this without support.

    Worry is the key pathological feature of generalized anxiety disorder.

    “worry (the key pathological feature of GAD)”

  • The paper relies on this without support.

    There is room to improve upon understanding of the pathogenic processes within generalized anxiety disorder.

    “Nonetheless, there is still room to improve upon our understanding of the pathogenic processes within GAD.”

  • The paper relies on this without support.

    For exposure to happen, clients must face a stimulus they both fear and avoid.

    “exposure is not taking place unless clients are exposed to a stimulus that is both feared and avoided.”

  • The paper relies on this without support.

    Worry in GAD is chronic.

    “which is likely given the chronic nature of worry in GAD”
4 of 4

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • CBTs integrating acceptance/mindfulness and an emotional/interpersonal focus have improved treatment gains across acute and follow-up periods, especially high end-state functioning.

    “CBTs integrating newer conceptualizations such as acceptance/mindfulness and an emotional/interpersonal focus have improved treatment gains throughout acute and follow-up periods, especially in demonstrating improved indices of high end-state functioning (i.e., symptomatic response within 1 standard deviation of normative levels; e.g., Newman et al., 2011; Roemer et al., 2005).”

    From A Pilot Study of Emotion Regulation Therapy for Generalized Anxiety and Depression: Findings From a Diverse Sample of Young Adults. (2018) · cites this paper as Newman et al., 2011

    In §1, “Avoidance models of worry” (page unavailable), the review reports promising pilot results for newer GAD treatments, but says its trial found no significant symptom difference between CBT plus interpersonal/emotional processing and the comparison treatment. It explicitly describes a failure to demonstrate an added benefit, contrary to the attributed claim of improved treatment gains. The cited passages also do not report acute or follow-up gains in high end-state functioning. (LLM, conf=0.86)

    Checked by a reasoning model — may be wrong.

    Experimental — accuracy not yet measured

  • Worry is reinforced by making negative emotional experiences more predictable, often at the expense of positive and rewarding states.

    “More recently, conceptualizations of worry show that it becomes reinforced by increasing the predictability of negative emotional experience, often to the cost of experiencing greater variations in positive and rewarding states (Newman & Llera, 2011).”

    From A Pilot Study of Emotion Regulation Therapy for Generalized Anxiety and Depression: Findings From a Diverse Sample of Young Adults. (2018) · cites this paper as Newman & Llera, 2011

    Section 5 (page unavailable) proposes that people with GAD use worry to maintain a negative emotional state, avoid an unexpected shift into negative emotion, and thereby reinforce worry. This supports the predictability and reinforcement part of the paraphrase. It does not establish a cost to positive or rewarding experiences; Section 3 (page unavailable) reports that worry did not preclude positive affect during a happy film clip. (LLM, conf=0.85)

    Experimental — accuracy not yet measured

  • The Contrast Avoidance model suggests that people with generalized anxiety disorder use worry to maintain a negative emotional state to avoid shifts in emotions, attenuating negative emotional contrast in response to stressful events.

    “CAM also suggests that people with GAD use worry to maintain a negative emotional state to avoid such shifts in emotions, attenuating the experience of NEC in response to stressful events.”

    From Psychotherapeutic treatments for generalized anxiety disorder: cognitive and behavioral therapies, enhancement strategies, and emerging efforts (2022) · cites this paper as [108]

  • The theory suggests that although those with generalized anxiety disorder also worry to increase the probability of a positive emotional contrast, they are uncomfortable with sustained positive or euthymic states because it leaves them vulnerable to a negative emotional contrast.

    “The theory also suggests that although those with GAD also worry to increase the probability of a positive emotional contrast (i.e., greater relief when situations one worried about do not occur), they are uncomfortable with sustained positive or euthymic states because it leaves them vulnerable to a negative emotional contrast.”

    From Psychotherapeutic treatments for generalized anxiety disorder: cognitive and behavioral therapies, enhancement strategies, and emerging efforts (2022) · cites this paper as [108]

  • The Contrast Avoidance model posits that people with generalized anxiety disorder fear sharp increases in their negative emotions.

    “Specifically, CAM posits that people with GAD fear sharp increases in their negative emotions.”

    From Psychotherapeutic treatments for generalized anxiety disorder: cognitive and behavioral therapies, enhancement strategies, and emerging efforts (2022) · cites this paper as [108]

Cites

Flagged first, then by citations

23 of the 172 references couldn’t be matched to a known paper.

Research works printed but not linked: 4

  1. Albu, 2008, Automatic and intentional inhibition in patients with generalized anxiety disorder, Cognitie Creier Comportament, 12, 233
  2. Faure, 1949, Contribution à l'EEG de l'anxiété./Contribution to the EEG in anxiety, Electroencephalography and Clinical Neurophysiology, 1, 124
  3. Gastaut, 1964, Electroencephalographic and clinical study of diurnal and nocturnal anxiety in attacks, Electroencephalography and Clinical Neurophysiology, 17, 475
  4. Wells, 1999, A metacognitive model and therapy for generalized anxiety disorder, Clinical Psychology and Psychotherapy, 6, 86, 10.1002/(sici)1099-0879(199905)6:2 · DOI · Paper page

Cited by

Sorted by citations

Related

Authors
Newman, M. G., & Llera, S. J.
Affiliations
Pennsylvania State University (US)
Corresponding author
Newman, Michelle G.
ORCID
Venue
Clinical Psychology Review
Publisher
Elsevier BV
Published
2011-04
Volume
31
Issue
3
Pages
371-382
ISSN
0272-7358 (ISSN-L)
DOI
10.1016/j.cpr.2011.01.008
PMC
PMC3073849
OpenAlex
W2125566957
Cited by
598
References
172
Citations by year
2026: 46 · 2025: 43 · 2024: 54 · 2023: 53 · 2022: 57 · 2021: 54 · 2020: 55 · 2019: 35 · 2018: 34 · 2017: 42 · 2016: 32 · 2015: 20 · 2014: 25 · 2013: 25 · 2012: 17
FWCI
3.05
Type
journal article
Language
en
Open access
Licence
Locations
  • Clinical Psychology Review (publishedVersion)
  • PubMed (publishedVersion)
  • Europe PMC (PubMed Central) (acceptedVersion)
  • PubMed Central (acceptedVersion)
  • ScholarSphere (Penn State Libraries) (submittedVersion, cc-by)
  • SSRN Electronic Journal (submittedVersion)
Funders
National Institute of Mental Health (R01 MH58593-02, R01MH058593, R01MH039172)
Topics
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
  • Social Sciences › Psychology › Clinical Psychology › Obsessive-Compulsive Spectrum Disorders
  • Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
Keywords
generalized anxiety disorder, experiential avoidance, worry, emotional vulnerability, emotion regulation, anxiety maintenance
MeSH terms
Anxiety, Anxiety Disorders, Emotions, Humans, Models, Psychological, Cognitive Behavioral Therapy

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read under definition version 3 (extract-v3) on 2026-09-28.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-09-28.

Cited sources are checked by gpt-6-sol.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

Are you an author, or do you see a problem with this page? Request a review