This experiment examined the degree to which it is more beneficial for individuals with generalized anxiety disorder (GAD) to engage in repeated exposure to mental imagery of the same feared scenario versus varying the exposure content. On three consecutive days, individuals with GAD (N = 57) spent 20 min writing about: (1) the same worst case scenario (consistent exposure; CE), (2) variations of their worst case scenario (varied exposure; VE), or (3) a neutral topic (neutral control; NC). Participants in the CE condition displayed significant decreases in worry, acute cognitive avoidance, and intolerance of uncertainty from baseline to 1-week follow-up; participants in the VE and NC conditions did not. Initial activation of self-reported anxiety (observed in the CE and VE conditions) and between-session reduction in anxiety (observed in the CE condition only) were associated with improvement in worry. Including more references to negative emotion and writing in the present tense were also associated with greater improvement in worry in the CE condition. These findings suggest that writing repeatedly about the same worst case scenario may benefit people with GAD. The study also provides information on potential mechanisms of change.
According to the most recent editions of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2000 and American Psychiatric Association, 2013), generalized anxiety disorder (GAD) is a common and debilitating disorder marked by excessive and uncontrollable worry and anxiety. Borkovec and colleagues suggested that individuals with GAD engage in cognitive avoidance strategies to dampen mental images of feared scenarios and the anxious arousal brought on by these images (Sibrava and Borkovec, 2006 and Stöber and Borkovec, 2002). Stöber, 1998 and Stöber, 2000 proposed that individuals with GAD achieve this dampening effect by thinking about feared scenarios in an abstract manner, since abstract thinking produces mental images that are less vivid and emotionally-evocative than concrete thinking (Paivio & Marschark, 1991). As a consequence, however, abstract thinking may prevent the “emotional processing” of fears (Sibrava and Borkovec, 2006, Stöber, 1998, Stöber, 2000 and Stöber and Borkovec, 2002).
Emotional processing theory (EPT; Foa & Kozak, 1986; update, Foa, Huppert, & Cahill, 2006) explains that for “emotional processing” to occur, a person must engage in repeated, systematic exposure to the object or situation that he or she is avoiding. During this exposure the full “fear structure” encompassing stimulus, response and meaning elements, must be activated. Anxious arousal during the first exposure session is taken as an indicator of such activation. In addition, new information that is incompatible with the fear structure must be integrated into it, which is thought to be shown by a reduction in anxious arousal across exposure sessions.1 Because abstract thinking dulls mental imagery, and consequently, emotional arousal, it may prevent the complete activation of fear structures and impede emotional processing (see Sibrava & Borkovec, 2006).
If avoidance of threatening mental images plays a role in maintaining chronic worry, then confronting these images and the anxious arousal that they evoke may be helpful to individuals with GAD, as it may promote emotional processing (van der Heider and ten Broeke, 2009 and Zinbarg et al., 2006). In many anxiety disorders, the feared stimuli are tangible objects or situations (e.g., snakes, driving) that can be approached in vivo. However, according to Stöber and Borkovec (2002), for people with GAD the feared stimuli are mental images of hypothetical worst case scenarios (WCSs) and the anxious arousal associated with these images. Based on this, exposure for GAD involves recounting the WCS coming true in as much emotional detail as possible, in the first person, and in the present tense (see Dugas and Robichaud, 2007 and Rygh and Sanderson, 2004), which is thought to help concretize feared mental images and promote a sense of actually being in the situation.
