78 COGNITIVE THEORY AND RESEARCH ON ANXIETY
tional reasoning” could play an important role in the faulty appraisal of obsessional
intrusions. Any anxiety associated with an intrusion could be misinterpreted as con-
firming the significance and potential dangerousness of the thought. This would be an
example of “ex- consequentia reasoning” (Arntz et al., 1995) contributing to the faulty
appraisal and escalation of the intrusion (e.g., “If I feel anxious by the thought of being
dirty and potentially contaminating others, then I must be in danger of infecting oth-
ers.”).
There is a strong association between the subjective anxiousness or emotional dis-
tress of an intrusive thought, and its frequency, uncontrollability, and obsessionality (e.g.,
Freeston, Ladouceur, Thibodeau, & Gagnon, 1992; Parkinson & Rachman, 1981a; Pur-
don & Clark, 1993, 1994b; Salkovskis & Harrison, 1984). Moreover, individuals with
OCD rate their obsessions and other unwanted intrusions as more anxiety- provoking
than do nonobsessional controls (Calamari & Janeck, 1997; Janeck & Calamari, 1999;
Rachman & de Silva, 1978). In a diary study involving 28 patients with OCD the indi-
vidual’s most upsetting obsession was rated as more frequent and more meaningful in
terms of importance and control of thought than the least upsetting obsessions (Rowa,
Purdon, Summerfeldt, & Antony, 2005). These findings are consistent with the view
that OCD is characterized by a heightened sensitivity to certain OCD-related mental
intrusions that may in part be due to the anxiety- eliciting properties of the obsession.
However, research is needed that specifically investigates whether OCD is characterized
by a misinterpretation of anxious feelings associated with obsessional intrusions and
that this, in turn, contributes to a heightened state of general anxiousness.
Negative interpretation of anxious symptoms associated with trauma- related intru-
sions is a key process emphasized in cognitive theories of PTSD (Brewin & Holmes,
2003; Ehlers & Clark, 2000; Wells, 2000). Many studies have now shown that negative
interpretation of initial PTSD symptoms plays a causal role in the persistence of PTSD
(see review by Brewin & Holmes, 2003). In addition, negative appraisal of unwanted
trauma- relevant intrusive thoughts or images is predictive of the severity and persistence
of PTSD (Halligan, Michael, Clark, & Ehlers, 2003; Steil & Ehlers, 2000; Mayou,
Bryant, & Ehlers, 2001). These findings, then, are entirely consistent with Hypothesis
5, indicating that negative and threatening interpretations of trauma- related anxious
symptoms contribute significantly to the persistence of PTSD.
Summary
This brief review of the empirical research on enhanced negativity bias in the interpreta-
tion of anxious symptoms indicates strong empirical support for Hypothesis 5. Research
spanning all five anxiety disorders found evidence that enhanced negative interpretation
of anxiety or “fear of fear” was a contributor to the persistence of anxiety (see also
chapter 4 on the related concept of anxiety sensitivity). Panic disorder is characterized
by threat misinterpretations of the physical symptoms of anxiety, GAD by metaworry,
social phobia by heightened self- focused attention on internal states of anxiousness,
OCD by the anxiety- arousing properties of mental intrusions, and PTSD by physiologi-
cal arousal elicited by trauma- related internal and external triggers. In each case a ten-
dency to perceive anxiety itself in a threatening manner contributed to the persistence
of the unwanted emotional state.