Distressing intrus ive thoughts
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128 Attentional content
(Borkovec, Shadick, & Hopkins, 1991). Borkovec and colleagues defi ne worry as a predom in antly concep tual, verbal linguistic, as opposed to imaginal activ ity in both normals and GAD clients.
Beck (1967) used the term auto matic thoughts to refer to the thoughts which seemed to char ac ter ise the stream of conscious ness in anxious and depressed patients. The term was inten ded to refl ect the nature of such thoughts which occur without delib er a tion and seem invol un tary. Beck et al. (1985) assert that negat ive auto matic thoughts are exper i enced as intrus ive, repet it ive and intu it- ively plaus ible. Moreover, they may occur so rapidly that the indi vidual is often unaware of their occur rence, though the thoughts are amen able to conscious intro spec tion. The descrip tion of auto matic thoughts offered by Beck et al. (1985) suggests a differ ent class of events from that defi ned as worry by Borkovec and colleagues. Negative auto matic thoughts seem to be more tele graphic and less consciously medi ated than worry. Kendall and Ingram (1987) argue that many of the cognit ive products asso ci ated with anxiety take the form of “What if . . .”
ques tions. Each ques tion repres ents a sense of impend ing incom pet ence. Perhaps auto matic thoughts repres ent well- rehearsed negat ive answers to “what if ” ques- tions, while worry is an attempt to examine new answers and formu late coping responses.
The other class of cognit ive products to be considered here are intrus ive thoughts. Intrusive thoughts resemble clin ical obses sions (Parkinson & Rachman, 1981a). Rachman (1981, p. 89) defi nes intrus ive thoughts as “repet it ive thoughts, images or impulses that are unac cept able and/or unwanted. They are gener ally accom pan ied by subject ive discom fort”. He also specifi es the criteria which are neces sary and suffi cient for defi n ing a thought as intrus ive:
1. The subject ive report that the thought inter rupts ongoing activ ity.
2. The thought, image or impulse is attrib uted to an internal origin.
3. The thought is diffi cult to control.
However, there are limit a tions to this defi n i tion because a variety of cognit ive phenom ena aside from obses sions, such as worry and auto matic thoughts, can be classed as intrus ive thoughts. Nevertheless, a feature of obses sions which differ- en ti ates them from worry and auto matic thoughts is that they are often exper i- enced as sense less and unac cept able, for example having the thought of harming one’s child even though one would not want to do so.
There also appear to be differ ences between intrus ive thoughts, images and impulses. Parkinson and Rachman (1981a) asked 60 adult subjects to rate their intrus ive thoughts, images and impulses on several char ac ter ist ics such as intens ity, discom fort, unac cept ab il ity and distrac tion. The follow ing differ ences emerged:
1. Intrusive images were more unac cept able than intrus ive thoughts but were easier to dismiss and control. Subjects found it easier to distract them selves from intrus ive images.
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Varieties of thought in emotional disorders 129
2. Intrusive impulses were more intense than thoughts and also more distress ing.
They were also more frequent than intrus ive thoughts.
3. Impulses were signi fi c antly more intense, more stress ful and more diffi cult to dismiss than images.
Turner, Beidel and Stanley (1992) reviewed the liter at ure on worry and obses- sions and concluded that there were several differ ences between these types of event. First, the content of worries is typic ally related to normal daily exper i ences, whereas obses sions include themes of dirt, contam in a tion, etc. Second, worry in patient groups is more often perceived as triggered by an internal or external event compared with obses sions. Third, worry usually occurs as thought, whereas obses- sions can occur as thoughts, images and impulses. Fourth, worry does not appear to be resisted as strongly as obses sions and it is perceived as less intrus ive. Finally, the content of clin ical worries is not perceived as unac cept able as is typical of intrus ive thoughts in obsess ive- compuls ive disorder. While these data suggest partic u lar differ ences between worry and obses sions, the conclu sions are some what tent at ive due to the scarcity of empir ical data directly compar ing these types of event in the same indi vidual. In an attempt to over come this problem, Wells and Morrison (in press) invest ig ated dimen sions of natur ally occur ring worry and intrus ive thoughts in 30 normal subjects. The subjects were asked to keep a diary over a 2-week period and to record in it the fi rst two worries and intrus ive thoughts which they exper i- enced. They were also asked to rate each thought on the follow ing dimen sions:
(i) Degree of verbal thought/imagery involved (ii) Intrusiveness
(iii) How real istic the thought was (iv) How invol un tary the thought was (v) How control lable it was
(vi) How dismiss able it was (vii) How distract ing
(viii) How much the thought grabbed atten tion (ix) Degree of distress asso ci ated with the thought (x) Intensity of compul sion to act on the thought (xi) Degree of resist ance to the thought
(xii) Degree of success in controlling the thought.
The subjects were provided with a general defi n i tion of worry and intrus ive thoughts on the diary, in order to make discrim in a tion possible. Given the defi n- i tions, the subjects were able to make a reas on ably valid distinc tion between the two types of thought. The inter- rater agree ment (kappa- coef fi cient) was 0.63 for the subjects’ clas si fi c a tion and that of an exper i enced clin ical psycho lo gist using clin ical judge ment alone and not the defi n i tions given to subjects. Figure 7.1 . shows all signi fi c ant differ ences between the two types of thought. The dimen- sions not displayed did not differ signi fi c antly.
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130 Attentional content
These data show that normal worry was exper i enced as predom in antly verbal rather than imaginal, whereas the converse was true for normal intrus ive thoughts.
Worry was also rated as more real istic, less invol un tary, harder to dismiss, more distract ing and of longer dura tion than intrus ive thoughts. In addi tion, worry was asso ci ated with a greater compul sion to act than intrus ive thoughts were.
Traditionally, obses sions and not worry have been linked to compuls ive or resti- tu tional beha viours. However, if we accept that worry is a problem- solving activ ity, it is reas on able to assume that it has motiv a tional prop er ties for the imple ment a tion of problem- solving strategies, and this may under lie its compuls ive quality. An altern at ive explan a tion for the contrast in compul sion to act, could be that worries were appraised as more real istic than intrus ive thoughts and there fore they could not be discoun ted as easily. However, the correl a tion between realism and compul sion was not signi fi c ant for partic u lar types of thought or when all thoughts were combined.
In summary, it appears that there are differ ences between worry and intrus ive thoughts, and perhaps differ ences between these events and negat ive auto matic thoughts. These vari et ies of thought do, however, share certain char ac ter ist ics, which leads to diffi culties in discrim in a tion. An import ant ques tion concerns whether or not a discrim in a tion would prove useful for better concep tu al ising cognit ive processing in emotional disorders. As we shall see later in this chapter, there is reason to believe that differ ent vari et ies of thought may be related to stress in differ ent ways and they may serve differ ent func tions. Moreover, an inter ac- tion between certain types of thought may account for the main ten ance of certain emotional prob lems. In view of this, a differ en ti ation between vari et ies of thought in emotional dysfunc tion seems warran ted.
FIGURE 7.1 Signifi cant differ ences in the char ac ter ist ics of natur ally occur ring worries and intrus ive thoughts in normals ( n = 30) (Wells & Morrison, unpub lished).
, worry; ■, intrus ive thought.
100 90 80 70 S 60 0
~ 50
'" .:1 g' 40
30 20 10
Imagery Verbal
% % Realistic Involuntary Easily Distracting Compelled
dismissable to act
Dimension
Duration of thought
20
15
=I ~
10 S' 3 S'
~
15
15
15 15
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The content of thought in anxiety and depres sion 131
The content of thought in anxiety and depres sion
In anxiety the content of negat ive thoughts is concerned with the themes of danger (Beck, 1976; Beck et al., 1985), whereas in depres sion thoughts concern ing loss and self- devalu ation predom in ate (Beck et al., 1979). This differ ent atten- tional content is termed “content specifi city” and has been valid ated by the Cognition Checklist (Beck et al., 1987). Structured inter view studies with patients suffer ing from panic or gener al ised anxiety disorder have demon strated that all patients inter viewed report the exper i ence of negat ive thoughts in verbal or imagery form occur ring just prior to or during an anxiety episode. These thoughts were concerned with the themes of phys ical and psychoso cial threat (Beck, Laude, & Bohnert, 1974; Hibbert, 1984). In patients with panic disorder, the most frequently repor ted sequence of events was the percep tion of an unpleas ant body sensa tion followed by negat ive thoughts repres ent ing cata- strophic misin ter pret a tion of symp toms and then full- blown panic (Hibbert, 1984). The patients in Hibbert’s study repor ted that their thoughts were more intrus ive, more cred ible and harder to dismiss the more severe their exper i ence of anxiety. Consistent with these fi nd ings, Ottaviani and Beck (1987) demon strated that patients with panic disorder had thoughts concern ing phys ical cata strophe such as dying, having a heart attack, faint ing, suffoc at ing and having a seizure. In addi tion, patients also feared mental cata strophe such as losing control or going crazy. Almost half of the patients also feared social humi li ation as a result of phys- ical or mental calam ity. Rachman, Lopatka and Levitt (1988a) exposed panic disorder patients to feared situ ations and showed that thoughts about passing out, acting fool ishly, losing control and fear of panic were among their most common cogni tions. Other self- monit or ing studies have sought to elicit patients’ cogni- tions during a panic attack. Westling, Stjernbof and Ost (1989) asked panic disorder patients to record their cogni tions during an attack in a diary. All patients had at least one attack asso ci ated with cata strophic cogni tions.
Agoraphobia has been viewed as devel op ing from panic attacks. Moreover, panick ers who go on to develop agora pho bia appear to be more sens it ive to body sensa tions and inter per sonal situ ations than those who do not (de Ruiter &
Garssen, 1989). Chambless, Caputo, Bright and Gallagher (1984) developed the Agoraphobic Cognitions Questionnaire to measure thoughts about the negat ive consequences of anxiety. Two factors have been empir ic ally derived from the scale: phys ical concerns (e.g. heart attack, choke to death) and social concerns (e.g. go crazy, act foolish). Comparison of panic disorder, agora phobic with panic, social phobic, obsess ive- compuls ive, gener al ised anxiety, and depressed patients showed that patients with panic had signi fi c antly higher scores on the phys ical concerns factor than the other groups, but the groups could not be distin guished on thoughts that anxiety would lead to social embar rass ment or loss of control (Chambless & Gracely, 1989).
Fear of bodily sensa tions appears to discrim in ate between anxious groups of patients, with panick ers report ing more fear than other anxious patients or
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132 Attentional content
normal controls (Foa, 1988). However, other anxious patients do report health concerns. Craske, Rapee, Jackel and Barlow (1989a) compared 19 patients with gener al ised anxiety disorder with 26 normal controls on responses to a ques tion- naire. The subjects were asked to complete the ques tion naire as soon as possible after they noticed them selves worry ing. The types of worries repor ted were categor ised by inde pend ent judges. The most frequently repor ted GAD worries concerned illness/health or injury followed by family/home and personal rela- tion ship issues.
In social phobia, negat ive thoughts are more common than posit ive self- state- ments in social encoun ters, and they centre on the themes of self- deprec a tion and fear of negat ive eval u ation by others (e.g. Beidel, Turner, & Dancu, 1985; Glass, Merluzi, Biever, & Larsen, 1982). Several protocol analysis and ques tion naire meas ures of cogni tions (both cognit ive products and beliefs) in social anxiety have been developed (see Arnkoff & Glass, 1989, for a review).
Turning to depres sion, the content of cogni tion is char ac ter ised by what Beck and asso ci ates refer to as the negat ive cognit ive triad (e.g. Beck et al., 1979), in which the depressed indi vidual has negat ive thoughts about the self, the world and the future. These thoughts are concerned with the themes of loss and failure (Beck, 1976; Beck et al., 1979; Beck & Clark, 1988). Studies using ques tion naires such as the Automatic Thoughts Questionnaire (Hollon & Kendall, 1980) and the Cognition Checklist (Beck et al., 1987) have produced evid ence confi rm ing that depressed patients show a predom in ance of negat ive thoughts of this type.
Moreover, the cogni tion check list is capable of reli ably distin guish ing between the thoughts char ac ter istic of anxiety and those char ac ter istic of depres sion.
Dimensions of worry and their meas ure ment
The endorse ment of worry as the primary feature of gener al ised anxiety disorder (GAD) has stim u lated research attempts aimed at elucid at ing and meas ur ing dimen sions of worry. Questionnaires have been developed which measure worry as an undif fer en ti ated vari able or as a multi di men sional vari able (e.g. Meyer, Miller, Metzger, & Borkovec, 1990; Tallis, Eysenck, & Mathews, 1992; Wells, 1987; 1994a).
Meyer et al. (1990) devised the Penn State Worry Questionnaire (PSWQ) to measure the tend ency to worry. The scale contains items relat ing to the frequency and intens ity of worry in general, for example: “my worries over whelm me; once I start worry ing I cannot stop”. While prin cipal compon ents factor analysis of the scale yielded one general factor, several smaller factors also emerged refl ect ing the follow ing themes: concern over health and phys ical safety, social eval u ation, belief in worry as a posit ive coping strategy, depres sion, and concerns about future success in rela tion ships. The PSWQ shows favour able psycho met ric prop- er ties in normal samples and also samples of GAD patients (Brown, Antony, &
Barlow, 1992; Meyer et al., 1990). However, it is limited in its poten tial for explor ing contrast ing char ac ter ist ics of normal and patho lo gical worries because
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Dimensions of worry and their meas ure ment 133
it meas ures a single undif fer en ti ated tend ency to worry. Moreover, some of the items confound the distress asso ci ated with worry with dimen sions of the worry process itself, for example control lab il ity.
Tallis et al. (1992) construc ted a general worry ques tion naire based on a wide range of worries listed by 71 subjects. The ques tion naire was completed by a sample of 95 subjects and the data subjec ted to cluster analysis. Six clusters were obtained refl ect ing differ ent worry content: rela tion ships; lack of confi d ence;
aimless future; work incom pet ence; fi nan cial concerns; socio- polit ical concerns.
These clusters formed the basis of a fi nal Worry Domains Questionnaire (WDQ) inten ded to measure differ ent content domains of worry. Although this measure assesses multiple dimen sions of worry, it focuses exclus ively on the content of worries and it neglects poten tially import ant process dimen sions. It is also uncer- tain whether the dimen sions are genu inely distinct; several of the inter- scale correl a tions are as high as 0.6–0.7 (Tallis et al., 1992).
The PSWQ and the WDQ repres ent two differ ent approaches to worry measure ment, the former based on the assess ment of the frequency and intens ity of worry in general, and the latter based on the content of worries. The content of normal and GAD worries are highly similar, and they tend to differ more in terms of their process dimen sions such as degree of control lab il ity (Craske et al., 1989a; Turner et al., 1992). As a result, undif fer en ti ated meas ures and meas ures of content alone are poten tially less inform at ive about patho lo gical versus normal worry distinc tions than process meas ures. In view of this, Wells (1987; 1994a) developed the Anxious Thoughts Inventory (AnTI) to measure indi vidual differ- ences in prone ness to multiple dimen sions of worry, includ ing both content and process dimen sions. The fi rst set of items used in ques tion naire construc tion was based on the worries elicited in a struc tured inter view with 33 GAD patients. Six ration ally derived worry dimen sions were obtained: worry about minor issues;
health worries; worry about loss of cognit ive and beha vi oural control; social worry; anti cip a tion of calam it ies such as acci dents; and thoughts of personal failure and help less ness. Forty- four items were devised to sample these domains, and an initial factor analysis was performed on the responses of 101 under gradu ate students. A six- factor solu tion was chosen based on the results of the Scree test (Cattell, 1978). One of the factors was unin ter pretable but the remain ing fi ve factors sugges ted that the ques tion naire was assess ing the follow ing worry dimen- sions: general worry over minor issues; worry about health; worry about future calam it ies; worry about repet it ive thoughts and help less ness; social worry.
Subsequent revi sions and two further factor analyses of the ques tion naire with samples of 110 and 239 students, respect ively, produced a fi nal three- factor solu- tion account ing for 37.2% of the total vari ance. Factor one refl ec ted social worry (e.g. “I worry about making a fool of myself ”), and factor two refl ec ted health worry (e.g. “if I exper i ence unex pec ted phys ical symp toms I have a tend ency to think the worst possible thing is wrong with me”). The third and last factor refl ec ted a preoc cu pa tion with meta- cogni tion in terms of worry ing about worry ing and exper i en cing worry as uncon trol lable. This dimen sion was labelled