The relations among worry, meta-worry, intolerance of uncertainty and attentional bias for threat in men at high risk for generalized anxiety disorder: a network analysis

Ren et al. BMC Psychiatry (2020) 20:452 https://doi.org/10.1186/s12888-020-02849-w RESEARCH ARTICLE Open Access The relations among worry, meta-worry, intolerance of uncertainty and attentional bias for threat in men at high risk for generalized anxiety disorder: a network analysis Lei Ren1†, Zhou Yang2†, Yidi Wang3†, Long-Biao Cui1, Yinchuan Jin1, Zhujing Ma1, Qintao Zhang1, Zhongying Wu1, Hua-Ning Wang4* and Qun Yang1* Abstract Background: Improving the psychotherapies for generalized anxiety disorder (GAD) is dependent on a deeper understanding of the relations between GAD and its associated cognitive factors. In the present study, we investigate how the core feature of GAD (i.e., worry) and its associated cognitive factors, such as meta-worry, intolerance of uncertainty, and attention bias towards threat, relate to each other in men at high risk for GAD. Methods: We used network analysis to explore the relations among these variables in a cross-sectional sample of 122 men at high risk for generalized anxiety disorder. Specifically, we computed the expected influence and predictability of each variable. Results: In the final network, we found that worry and meta-worry had the highest expected influence and predictability. In contrast, attention bias towards threat showed the lowest expected influence and predictability. The estimates of the expected influence of the nodes were stable (correlation stability coefficient = 0.52). Conclusions: The present study is the first to investigate the relations among worry, meta-worry, intolerance of uncertainty, and attention bias towards threat in men at high risk for generalized anxiety disorder. These findings indicate that worry and meta-worry may play important roles in the present network. The implications for clinical interventions and future studies are discussed. Keywords: Generalized anxiety disorder, High risk, Network analysis, Attention bias, Meta-worry, Intolerance of uncertainty, Worry * Correspondence: ; † Lei Ren, Zhou Yang and Yidi Wang contributed equally to this work. 4 Department of Psychiatry, Xijing Hospital, Fourth Military Medical University, Xi’an, China 1 Department of Clinical Psychology, School of Medical Psychology, Fourth Military Medical University, Xi’an, China Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Ren et al. BMC Psychiatry (2020) 20:452 Background Generalized anxiety disorder (GAD) is characterized by excessive and uncontrollable worry about a series of events or activities and is usually accompanied by other nonspecific psychological and physical symptoms that last at least 6 months [1]. This chronic anxiety disorder is one of the most common mental health problems and some representative epidemiological surveys show that the lifetime prevalence is 4.3–5.9% [2]. Additionally, GAD is particularly prevalent in primary care settings and occurs in 7–8% of patients [3]. Individuals with GAD have considerable role impairment and a high comorbidity with depression [4]. If GAD is not treated promptly, its prognosis is poor [5]. Both pharmacotherapies and psychotherapies have shown efficacy in the treatment of GAD [6, 7]. However, with GAD, clinicians and patients are more likely to consider psychotherapies than pharmacotherapies [2]. Among these psychotherapies, cognitive behavioral therapy (CBT) is often considered a first-line therapy because the evidence for the use of CBT is strongest compared with other psychotherapies [7]. Although CBT can effectively reduce symptoms in as many as 50% patients with GAD, it is unclear how best to treat patients who do not respond to these therapies or who respond only partially [8]. Improving the psychotherapies for GAD is dependent on a deeper understanding of the relations between GAD and its associated cognitive factors [9]. There are several cognitive models that focus on cognitions as key factors driving the development and maintenance of GAD (specifically, the core symptom of GAD: worry) [9]. These models include the intolerance of uncertainty model (IUM) [10, 11], the metacognitive model (MCM) [12], and the cognitive-motivational framework (CMF) [13]. These three cognitive models interpret generalized anxiety from different cognitive perspectives, with relevant empirical supports and theory-based treatment strategies [9]. The IUM emphasizes intolerance of uncertainty (IU) as a crucial factor in the development and maintenance of GAD [14, 15]. Previous studies have found that there is a strong correlation between IU and worry [9, 15]. IU is defined as “a dispositional characteristic that arises from a set of negative beliefs about uncertainty and its connotations and consequences” [16]. IU often triggers a chain reaction of worry, negative problem orientation, and cognitive avoidance [17]. Furthermore, individuals who have high IU are more inclined to treat ambiguous phenomena as unacceptable and threatening, thus causing a negative problem orientation, an inability to take action, and an avoidance response style [18, 19]. Thus, they will be more likely to fall into the process of worry. Under this model, the main goals of GAD therapy are increasing the patient’s tolerance and acceptance of uncertainty [20]. Some randomized clinical trial results with moderate to large effects also support this intervention [21–23]. Page 2 of 11 The MCM proposes negative metacognitive beliefs that consist of the uncontrollability of worry and the dangerousness of worry (e.g., “I can’t control my worries” or “my worries will make me ill”) as a central component in the development and maintenance of GAD [24]. In the MCM, two different types of worry exist in individuals with GAD [24–26]. Type-1 worry is worry about external events and internal noncognitive events. It is a strategic choice to cope with a potentially threatening situation, dependent on the activation of (...truncated)