title: Worry and generalized anxiety disorder: a review and theoretical synthesis of evidence on nature, etiology, mechanisms, and treatment.
abstract: Generalized anxiety disorder (GAD) is associated with substantial personal and societal cost yet is the least successfully treated of the anxiety disorders. In this review, research on clinical features, boundary issues, and naturalistic course, as well as risk factors and maintaining mechanisms (cognitive, biological, neural, interpersonal, and developmental), are presented. A synthesis of these data points to a central role of emotional hyperreactivity, sensitivity to contrasting emotions, and dysfunctional attempts to cope with strong emotional shifts via worry. Consistent with the Contrast Avoidance model, evidence shows that worry evokes and sustains negative affect, thereby precluding sharp increases in negative emotion. We also review current treatment paradigms and suggest how the Contrast Avoidance model may help to target key fears and avoidance tendencies that serve to maintain pathology in GAD.
authors.affiliation: Department of Psychology, The Pennsylvania State University, University Park, Pennsylvania 16802-3106, USA. mgn1@psu.edu
authors.forename: Michelle G
authors.initials: MG
authors.lastname: Newman
authors.forename: Sandra J
authors.initials: SJ
authors.lastname: Llera
authors.forename: Thane M
authors.initials: TM
authors.lastname: Erickson
authors.forename: Amy
authors.initials: A
authors.lastname: Przeworski
authors.forename: Louis G
authors.initials: LG
authors.lastname: Castonguay
mesh_terms: D001008:Anxiety Disorders / Q000209:etiology / Q000503:physiopathology / Q000628:therapy; D004644:Emotions / Q000502:physiology*; D019317:Evidence-Based Medicine / Q000379:methods / Q000639:trends; D006801:Humans; D008960:Models, Psychological
references.citation: Behav Res Ther. 2005 Oct;43(10):1281-310
references.pmid: 16086981
references.citation: Soc Psychiatry Psychiatr Epidemiol. 2006 Oct;41(10):796-805
references.pmid: 16871369
references.citation: J Pers Soc Psychol. 1997 Nov;73(5):1092-106
references.pmid: 9364763
references.citation: J Anxiety Disord. 2012 Jan;26(1):126-33
references.pmid: 22078242
references.citation: Psychosom Med. 2010 Jul;72(6):570-7
references.pmid: 20410249
references.citation: Behav Res Ther. 1990;28(1):69-73
references.pmid: 2302151
references.citation: J Am Acad Child Adolesc Psychiatry. 1997 May;36(5):637-44
references.pmid: 9136498
references.citation: J Nerv Ment Dis. 1997 May;185(5):314-9
references.pmid: 9171808
references.citation: Behav Ther. 2009 Mar;40(1):23-38
references.pmid: 19187814
references.citation: J Psychiatr Res. 2005 Jan;39(1):1-9
references.pmid: 15504418
references.citation: J Clin Psychiatry. 2008 Oct;69(10):1606-16
references.pmid: 19192444
references.citation: J Anxiety Disord. 2010 Mar;24(2):250-9
references.pmid: 20060680
references.citation: Psychol Med. 2008 Mar;38(3):365-74
references.pmid: 18047766
references.citation: J Anxiety Disord. 2008;22(2):263-72
references.pmid: 17383852
references.citation: J Am Acad Child Adolesc Psychiatry. 2008 Apr;47(4):435-442
references.pmid: 18388762
references.citation: Emotion. 2010 Oct;10(5):640-50
references.pmid: 21038947
references.citation: Psychol Med. 2007 Mar;37(3):441-52
references.pmid: 17201999
references.citation: J Consult Clin Psychol. 2012 Jun;80(3):490-6
references.pmid: 22506794
references.citation: Behav Ther. 2007 Dec;38(4):364-77
references.pmid: 18021951
references.citation: J Behav Ther Exp Psychiatry. 1995 Mar;26(1):25-30
references.pmid: 7642757
references.citation: J Anxiety Disord. 2011 Dec;25(8):1087-94
references.pmid: 21840164
references.citation: Eur Arch Psychiatry Clin Neurosci. 2009 Feb;259(1):37-45
references.pmid: 18575915
references.citation: Psychiatry Res. 2010 May 15;177(1-2):150-5
references.pmid: 20381878
references.citation: Behav Res Ther. 1993 Feb;31(2):211-3
references.pmid: 8442748
references.citation: J Consult Clin Psychol. 2000 Aug;68(4):549-55
references.pmid: 10965629
references.citation: Annu Rev Public Health. 2008;29:115-29
references.pmid: 18348707
references.citation: J Consult Clin Psychol. 2011 Apr;79(2):171-81
references.pmid: 21443321
references.citation: Psychol Med. 2010 Jan;40(1):117-24
references.pmid: 19419593
references.citation: Cogn Behav Ther. 2012;41(3):261-71
references.pmid: 22429207
references.citation: Br J Clin Psychol. 1997 Feb;36(1):101-19
references.pmid: 9051282
references.citation: Behav Res Ther. 2000 May;38(5):487-97
references.pmid: 10816907
references.citation: J Clin Epidemiol. 2009 Apr;62(4):452-6
references.pmid: 19013760
references.citation: J Consult Clin Psychol. 2008 Dec;76(6):1083-9
references.pmid: 19045976
references.citation: Behav Res Ther. 1988;26(6):531-4
references.pmid: 3240238
references.citation: Psychotherapy (Chic). 2012 Jun;49(2):163-72
references.pmid: 21688931
references.citation: Biol Psychiatry. 1999 Dec 1;46(11):1536-41
references.pmid: 10599481
references.citation: J Abnorm Psychol. 2011 May;120(2):286-98
references.pmid: 21553942
references.citation: Arch Gen Psychiatry. 2010 Jul;67(7):750-8
references.pmid: 20603456
references.citation: Behav Res Ther. 2010 Oct;48(10):1032-40
references.pmid: 20688319
references.citation: Anxiety Stress Coping. 2011 Mar;24(2):121-36
references.pmid: 20544417
references.citation: J Abnorm Psychol. 2002 Nov;111(4):665-9
references.pmid: 12428780
references.citation: J Pers Disord. 2001 Feb;15(1):60-71
references.pmid: 11236815
references.citation: J Abnorm Child Psychol. 2007 Jun;35(3):325-33
references.pmid: 17226094
references.citation: J Affect Disord. 2002 Dec;72(3):267-71
references.pmid: 12450644
references.citation: J Consult Clin Psychol. 2011 Aug;79(4):552-63
references.pmid: 21707138
references.citation: J Abnorm Psychol. 2007 May;116(2):313-28
references.pmid: 17516764
references.citation: Behav Ther. 2012 Sep;43(3):629-40
references.pmid: 22697450
references.citation: J Am Board Fam Med. 2008 Sep-Oct;21(5):398-407
references.pmid: 18772294
references.citation: Psychol Med. 2007 Mar;37(3):453-62
references.pmid: 17121688
references.citation: Behav Res Ther. 2007 Apr;45(4):699-713
references.pmid: 16904063
references.citation: Epidemiol Psichiatr Soc. 2009 Jan-Mar;18(1):23-33
references.pmid: 19378696
references.citation: Am J Psychiatry. 2006 May;163(5):857-64
references.pmid: 16648327
references.citation: J Consult Clin Psychol. 2002 Apr;70(2):288-98
references.pmid: 11952187
references.citation: Psychother Res. 2011 Nov;21(6):698-708
references.pmid: 21878034
references.citation: J Anxiety Disord. 2009 Dec;23(8):1106-17
references.pmid: 19665347
references.citation: Psychiatry Res. 2004 May 30;131(1):11-21
references.pmid: 15246451
references.citation: J Anxiety Disord. 2007;21(5):662-76
references.pmid: 17118626
references.citation: J Nerv Ment Dis. 2006 Feb;194(2):91-7
references.pmid: 16477186
references.citation: J Adolesc. 2006 Jun;29(3):407-17
references.pmid: 16169585
references.citation: Circulation. 1997 Feb 18;95(4):818-24
references.pmid: 9054737
references.citation: J Abnorm Psychol. 1998 May;107(2):179-92
references.pmid: 9604548
references.citation: Acta Psychiatr Scand Suppl. 1998;393:6-11
references.pmid: 9777041
references.citation: Int J Cogn Ther. 2010 Sep;3:245-261
references.pmid: 21132075
references.citation: J Anxiety Disord. 2009 Jun;23(5):684-93
references.pmid: 19278819
references.citation: Depress Anxiety. 2008;25(1):72-90
references.pmid: 17146763
references.citation: Aust N Z J Psychiatry. 2010 Sep;44(9):852-8
references.pmid: 20815673
references.citation: Arch Gen Psychiatry. 2009 Dec;66(12):1361-72
references.pmid: 19996041
references.citation: Psychol Med. 2009 Apr;39(4):615-24
references.pmid: 18667095
references.citation: Mol Psychiatry. 2011 Dec;16(12):1234-46
references.pmid: 20938433
references.citation: Int J Methods Psychiatr Res. 2002;11(3):99-111
references.pmid: 12459823
references.citation: Clin Psychol Rev. 2011 Apr;31(3):371-82
references.pmid: 21334285
references.citation: Arch Gen Psychiatry. 1994 May;51(5):355-64
references.pmid: 8179459
references.citation: Behav Ther. 2010 Mar;41(1):59-72
references.pmid: 20171328
references.citation: Arch Gen Psychiatry. 2003 Aug;60(8):789-96
references.pmid: 12912762
references.citation: J Anxiety Disord. 2004;18(5):587-607
references.pmid: 15275941
references.citation: Assessment. 2005 Sep;12(3):243-54
references.pmid: 16123246
references.citation: Psychosom Med. 2009 May;71(4):395-403
references.pmid: 19321850
references.citation: Am J Psychiatry. 2009 Mar;166(3):302-10
references.pmid: 19122007
references.citation: Behav Res Ther. 2011 Feb;49(2):106-13
references.pmid: 21159325
references.citation: Psychol Med. 2005 Dec;35(12):1747-59
references.pmid: 16202187
references.citation: Psychoneuroendocrinology. 2011 May;36(4):592-5
references.pmid: 21050668
references.citation: Psychosom Med. 2004 Mar-Apr;66(2):207-14
references.pmid: 15039505
references.citation: Dev Psychol. 2009 Jul;45(4):1051-60
references.pmid: 19586179
references.citation: J Anxiety Disord. 1998 Mar-Apr;12(2):139-52
references.pmid: 9560176
references.citation: J Clin Psychiatry. 2001;62 Suppl 11:37-42; discussion 43-5
references.pmid: 11414549
references.citation: J Abnorm Psychol. 2007 Aug;116(3):638-43
references.pmid: 17696721
references.citation: Am J Psychiatry. 2010 May;167(5):545-54
references.pmid: 20123913
references.citation: Psychol Med. 2011 May;41(5):1019-28
references.pmid: 20836909
references.citation: J Child Psychol Psychiatry. 2008 Jan;49(1):34-42
references.pmid: 18181879
references.citation: J Child Psychol Psychiatry. 2012 Feb;53(2):197-206
references.pmid: 22176136
references.citation: Perspect Psychol Sci. 2008 Sep;3(5):400-24
references.pmid: 26158958
references.citation: Am J Psychiatry. 1993 Apr;150(4):600-7
references.pmid: 8465877
references.citation: Arch Gen Psychiatry. 2010 Jan;67(1):47-57
references.pmid: 20048222
references.citation: Compr Psychiatry. 1990 Sep-Oct;31(5):409-15
references.pmid: 2225799
references.citation: Psychol Med. 2007 Mar;37(3):431-40
references.pmid: 17109776
references.citation: Psychol Med. 2010 Jun;40(6):899-909
references.pmid: 19719899
references.citation: J Abnorm Psychol. 2000 Nov;109(4):803-8
references.pmid: 11196008
references.citation: Psychol Med. 2008 Nov;38(11):1671-5
references.pmid: 18985867
references.citation: Psychotherapy (Chic). 2008 Jun 1;45(2):135-147
references.pmid: 19881891
references.citation: Eur Psychiatry. 2007 Nov;22(8):530-9
references.pmid: 17900875
references.citation: Int J Psychophysiol. 2007 Jan;63(1):39-47
references.pmid: 17020787
references.citation: J Consult Clin Psychol. 2013 Jun;81(3):405-14
references.pmid: 23398493
references.citation: Eur Child Adolesc Psychiatry. 2011 Jul;20(7):361-71
references.pmid: 21604192
references.citation: Behav Ther. 2012 Sep;43(3):546-59
references.pmid: 22697443
references.citation: J Psychiatr Res. 2012 Aug;46(8):1045-52
references.pmid: 22575329
references.citation: Depress Anxiety. 2011 May;28(5):427-34
references.pmid: 21449004
references.citation: J Abnorm Psychol. 2000 Nov;109(4):695-704
references.pmid: 11195993