Excessive worry is a common symptom in anxiety disorders and is the central feature of Generalized Anxiety Disorder (GAD). In  model of pathological worry three processes combine to maintain uncontrollable worry: emotional processing biases, impaired attentional control and the tendency to represent possible negative outcomes in over-general verbal form. The aim of the study reported here was to investigate the effects of different methods designed to modify this last process in pathological worriers with GAD.

Worry is predominantly verbal, as if talking to oneself about possible negative outcomes, whereas imagery is relatively infrequent, and tends to be brief (, ). In contrast, when instructed to relax, non-worriers report primarily images whereas those with GAD report similar amounts of verbal thought and imagery (). The latter authors suggested that verbal worry may be a strategy to avoid more distressing emotional representations, such as images (). In partial support of this idea,  found that instructions to worry (verbally) about a distressing film led to less anxiety immediately afterwards than did instructions to think about it in images. However, verbal worry led to more intrusive images in the days following than did thinking in images. Thus, even if verbal worry leads to temporary reductions in anxiety, it can maintain negative thought intrusions in the longer term.

Similarly, high worriers given instructions to worry verbally reported increased negative thought intrusions from pre- to post-worry, but those instructed to worry in images actually showed a decrease (). This suggests that verbal thinking style plays a causal role in maintaining intrusions, perhaps serving to trigger subsequent worry episodes. The question of why verbal-based worry elevates intrusive thoughts remains unanswered. One possibility is that verbal thoughts in worry tend to be relatively abstract and over-general, raising many vague possibilities but reducing the possibility of resolving them because they are not clearly defined (), which may instead maintain perceived threat ().

Alternatively, increased intrusive thoughts may arise from the detrimental effects of verbal worry on attention and attentional control ().  demonstrated that verbal worry in high worriers impairs attentional control (compared to non-worriers), but this group difference disappears after worrying using images. Furthermore,  demonstrated that verbal worry increased attentional bias towards threat, but worrying in imagery did not. This evidence suggests that verbal-based worry can maintain intrusive thoughts about threats, in contrast to imagery-based worry.

So far we have only considered thinking about negative (worry-related) rather than positive topics. Encouraging imagery of alternative positive outcomes might be particularly helpful, by competing in affective valence with the usual negative content of worry. Indeed,  found that practice in thinking about worry topics in more positive ways (whether verbally or in images) reduced subsequent intrusions compared with worry in verbal form, although this reduction was not significantly greater than that seen following similar practice using imagery of negative outcomes. However, only practice in thinking about alternative positive outcomes (whether as images or in verbal form) also reduced the rated cost of worry outcomes and increased perceived ability to cope with them. Thus it seems likely that practice with positive representations has benefits beyond those produced by worry-related imagery alone.

Alternatively, it could be that verbal worry is best countered by generating opposing positive thoughts in the same (verbal) modality, because this would more directly compete with the negative outcomes rehearsed in worry. It may be, for example, that worry-related intrusions (in verbal form) are more likely to prime alternative positive verbal outcomes that were rehearsed earlier, in comparison to positive images, which would require an additional shift from a semantic to a perceptual modality.

REFERENCES:
aKing’s College London, Institute of Psychology, Psychiatry and Neuroscience, London, UK
bCurtain University, Perth, Australia
cUniversity of California, Davis, USA
dBerkshire Healthcare NHS Foundation Trust, UK
Colette R. Hirsch: ku.ca.lck@hcsrih.etteloc
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