Generalized Anxiety Disorder 413
ory bias for threat but not increased physiological arousal. Thus it is possible that sup-
pression of worry might negatively influence how unwanted thoughts are appraised or
emotionally experienced (see Purdon, 1999, for discussion). There is consistent evidence
from questionnaire studies that increased effort at thought control is associated with
heightened scores on a broad range of psychopathological measures including various
process measures of worry (e.g., de Bruin, Muris, & Rassin, 2007; Sexton & Dugas,
2008).
A few studies have investigated whether high worriers engage in less effective
thought control strategies. Langlois et al. (2000b) found that students reported similar
coping strategies for worry and obsessional intrusive thoughts, with escape/avoidance
and problem- focused strategies associated with both types of repetitive thought. Wells
and Davies (1994) developed the Thought Control Questionnaire (TCQ) to assess vari-
ous mental control strategies associated with worry such as distraction, punishment,
reappraisal, worry (e.g., think about more minor worries), and social control (e.g., talk
to a friend). Coles and Heimberg (2005) found that GAD patients reported significantly
higher levels of TCQ punishment and worry and significantly lower use of social con-
trol and distraction than nonanxious controls. Both TCQ worry and punishment were
significantly correlated with the PSWQ, indicating that these control strategies have the
closest association with psychopathology (see also Fehm & Hoyer, 2004). Although
attempts to control worry by worrying about other issues in one’s life or being exces-
sively self- critical may contribute to pathological worry in GAD, these maladaptive
strategies may also be evident in other anxiety disorders (Coles & Heimberg, 2005;
Fehm & Hoyer, 2004).
The perception that worry is uncontrollable is so pervasive in GAD that it is now
entrenched as a key diagnostic criterion of the disorder. Moreover, there is some evidence
that individuals with GAD may try harder to control their worrisome thinking. How-
ever, the experimental research on thought suppression is divided on whether chronic
worriers are actually less successful at worry control than nonanxious individuals. In
addition it is not at all clear how excessive efforts at suppressing one’s worries might
influence its course. For example, thought suppression may have less direct influence on
the frequency of worry and more effects on biased information processing (Kircanski et
al., 2008), faulty appraisal, or emotional response (D. A. Clark, 2004; Purdon, 1999).
In addition it is likely that individuals with GAD do rely on less effective thought control
strategies but it is unlikely this is unique to the disorder. At this point we must consider
the empirical evidence for Hypothesis 5 tentative at best. More research is needed on
mental control, especially with GAD clinical samples, in order to explore this important
aspect of the worry process.
Clinician Guideline 10.13
Even though the research is still tentative, cognitive therapists must encourage individuals
with GAD to abandon their efforts to suppress worry. At the very least, the mental control
strategies employed in GAD have not proven effective and are probably counterproductive
in the long term.