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The Journal of Psychology:
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Worry and Rumination in
Generalized Anxiety Disorder
and Obsessive Compulsive
Disorder
Kaiser A. Dara & Naved Iqbala
a Jamia Millia Islamia (A Central University)
Published online: 13 Dec 2014.
To cite this article: Kaiser A. Dar & Naved Iqbal (2015) Worry and Rumination
in Generalized Anxiety Disorder and Obsessive Compulsive Disorder, The
Journal of Psychology: Interdisciplinary and Applied, 149:8, 866-880, DOI:
10.1080/00223980.2014.986430
To link to this article: http://dx.doi.org/10.1080/00223980.2014.986430
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The Journal of Psychology, 2015, 149(8), 866–880
Copyright C
2015 Taylor & Francis Group, LLC
doi: 10.1080/00223980.2014.986430
Worry and Rumination in Generalized
Anxiety Disorder and Obsessive
Compulsive Disorder
KAISER A. DAR
NAVED IQBAL
Jamia Millia Islamia (A Central University)
ABSTRACT. Ample work has already been conducted on worry and rumination as neg-
ative thought processes involved in the etiology of most of the anxiety and mood related
disorders. However, minimal effort has been exerted to investigate whether one type of
negative thought process can make way for another type of negative thought process, and
if so, how it subsequently results in experiencing a host of symptoms reflective of one
or the other type of psychological distress. Therefore, the present study was taken up to
investigate whether rumination mediates the relationship between worry and generalized
anxiety disorder (GAD), and between worry and obsessive compulsive disorder (OCD)
in two clinical groups. Self-report questionnaires tapping worry, rumination, generalized
anxiety disorder (GAD), and obsessive compulsive disorder (OCD) were administered to
a clinical sample of 60 patients aged 30–40. Worry, rumination, generalized anxiety disor-
der (GAD), and obsessive compulsive disorder (OCD) correlated substantially with each
other, however, rumination did not mediate the relationship between worry and generalized
anxiety disorder (GAD) and between worry and obsessive compulsive disorder (OCD). We
also analyzed differences of outcome variables within two clinical groups. These results
showed that worry and rumination were significantly different between GAD and OCD
groups.
Keywords: generalized anxiety disorder, obsessive compulsive disorder, rumination, worry
AMONG THE ANXIETY DISORDERS IN THE DSM-IV-TR (APA, 2000), two
are defined primarily by excessive negatively-valenced cognitions: obsessive com-
pulsive disorder (OCD) and generalized anxiety disorder (GAD) (Brown, Moras,
Zinbarg, & Barlow, 1993). In OCD, excessive emotionally-valenced cognition can
Address correspondence to Naved Iqbal, Department of Psychology, Jamia Millia Islamia
(A Central University), Jamia Nagar, New Delhi, 110025, India; navedi2005@gmail.com
(e-mail).
Color versions of one or more of the figures in the article can be found online at www.
tandfonline.com/vjrl.
866
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Dar & Iqbal 867
be seen in obsessions, which are unwanted, repetitive thoughts considered inap-
propriate or harmful. Obsessional thoughts motivate compulsions, rigid behaviors
performed ritualistically to undo harm related to obsessions (APA, 2000). In GAD,
excessive anxiogenic cognition takes the form of perseverative worry, which con-
sists of apprehensive thoughts about everyday concerns, such as finances, aca-
demic performance, and household maintenance (Burns, Keortge, Formea, &
Sternberger, 1996). Perseverative worry sustains a high level of negative affect
and physiological arousal, which may lead to tension, fatigue, and other somatic
complaints (APA, 2000). Research examining the nature of these excessive cog-
nitions supports their diagnostic specificity, as patients with OCD report more
obsessional thoughts than patients with GAD, and patients with GAD report more
perseverative worry than patients with OCD (Brown, Antony, & Barlow, 1992;
Brown et al.). However, obsessional thoughts and perseverative worry often co-
occur in clinical and nonclinical samples (Brown et al.; Clark & Claybourn, 1997).
Indeed, self-report measures of obsessional thoughts and perseverative worry have
been found to share a considerable degree of variance (Burns et al.; Freeston et al.,
1994; Zinbarg & Barlow, 1996).
Worry and rumination are cognitive processes characterized by thinking about
personal concerns in unproductive, repetitive ways, and experiencing difficulties
terminating these chains of thoughts (de Jong-Meyer, Beck, & Riede, 2009). Al-
though rumination and worry overlap, they have distinguishing features (Nolen-
Hoeksema, Wisco, & Lyubomirsky, 2008). Rumination is thought to be past
oriented while worrying is much more future oriented. Rumination is focused
on issues of self-worth, meaning, and loss, whereas worry concerns anticipated
threats. Where the conscious motive of ruminating is to gain insight in events, the
motive to worry is to anticipate and prepare for threats. Finally, the nonconscious
motive of rumination is to avoid aversive situations and the responsibility to take
action, whereas for worry it is to avoid core negative affect and painful images.
Thus far, worry has almost exclusively been studied in relation to anxiety,
whereas rumination has been examined in relation to mood in general and unipo-
lar depression in particular (Muris, Roelofs, Rassin, Franken, & Mayer, 2005).
According to Borkovec (1994), worry is predominantly verbal activity that is
reinforced because it enables individuals to avoid more emotionally arousing
imagery-based processing of threatening information. It interferes with emotional
processing and thus prevents the extinction of fear. Worried individuals prevent
themselves from deploying their most adaptive coping resources, which con-
tributes to the development and maintenance of anxiety (Borkovec).
Despite the specificity of theories linking worry to anxiety and rumination to
depression, recent research suggests that these links may not be so specific. Studies
in adults (Fresco, Frankel, Mennin, Turk, & Heimberg, 2002; Muris et al., 2005)
and children (Broeren, Muris, Bouwmeester, van der Heijden, & Abee, 2011) show
that both rumination and worry correlate significantly with anxiety and depressive
symptoms. Even when worry scores are partialed out of rumination and vice versa,
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868 The Journal of Psychology
worry and rumination are found to correlate significantly with depression and anx-
iety scores (Fresco et al.; Segerstrom, Tsao, Alden, & Craske, 2000). Exploratory
factor analyses demonstrate that worry and rumination not only share substantial
variance (Segerstrom et al., 2000), but also retain distinct characteristics (Fresco
et al.; Muris, Roclofs, Meesters, & Boomsma, 2004). Rumination and worry items
load on the same latent variable, namely repetitive thoughts (Segerstrom et al.,
2000), but also on separate ‘Rumination’ and ‘Worry’ factors (Fresco et al.; Muris
et al.). Consistent with these findings, Muris et al. (2004), in a study of adolescents,
found worry to be a significant predictor of anxiety symptoms when controlling
for rumination. However, unexpectedly they found that rumination was no longer
a predictor of depressive symptoms after controlling for worry.
Over the past decade, several studies have pointed to worry and rumination
as negative thought processes that appear to be involved in the etiology and main-
tenance of spectrum of anxiety and mood disorders, specifically to generalized
anxiety disorder (GAD) and major depressive disorder (MDD), respectively. How-
ever, insufficient attention has been devoted to how one negative thought process
(e.g., worry) can give rise to another negative thought process (e.g., rumination),
and which consequently leads to some psychological distress in the form of gen-
eralized anxiety disorder (GAD) and obsessive compulsive disorder (OCD).
Thus, one of the goals of this study was to investigate the relationships
between worry, rumination, generalized anxiety disorder (GAD), and obsessive
compulsive disorder (OCD) in a clinical sample and we expected that worry and
rumination would be related to both generalized anxiety disorder (GAD), and
obsessive compulsive disorder (OCD). In line with results reported by Muris
et al. (2004), we hypothesized that the relationship between worry and GAD as
well as between worry and OCD would be mediated by rumination. Another
purpose of this study was to investigate whether the repetitive thought (e.g.,
rumination) differently mediates the relationship between worry and generalized
anxiety disorder (GAD), and between Worry and obsessive compulsive disorder,
using a mediation model. Such a mediated relationship would suggest that worry
would be related to generalized anxiety disorder (GAD), and obsessive compulsive
disorder (OCD) differently through a repetitive thought (e.g., rumination).
Method
Participants
Participants were recruited on an outpatient basis from the Government Psy-
chiatric Diseases Hospital, Srinagar, from September to December, 2013. All
the participants reported anxiety symptoms and were diagnosed by a licensed
clinical psychologist using the Structured Clinical Interview for DSM-IV-TR dis-
orders (SCID-I). Of the recruited 69 patients, 60 patients (37 were women and
23 men) satisfied the DSM-IV-TR assumptions for pure GAD and OCD. The
clinical groups were composed of 27 participants with GAD, and 33 participants
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Dar & Iqbal 869
with OCD. Individuals suffering from comorbid disorders of any type and na-
ture were excluded from participation so as to maintain the content specificity
of DSM-IV-TR criteria. Participants ranged in age from 30 and 40 years, with a
mean age of 35.7 years (standard deviation, SD =9.4). The domicile composition
was as follows: 31.67% urban, 23.33% rural, 16.67% semi-urban, and 11.67%
semi-rural.
Procedure
A full description of the study was rendered to the participants, and thereby
a written informed consent was obtained from them. All the participants were
assessed individually and asked to complete a battery of self-reported measures
including those used in the present study. The questionnaires were filled by the
participants in a conducive and congenial room of the Psychiatric Diseases Hospi-
tal, Srinagar, where the sample of the present study was taken. The first author of
the study was available to answer the questions. However, most of the participants
were able to complete the questionnaires without any help.
Measures
Structured Clinical Interview for DSM-IV-TR
The Structured Clinical Interview for DSM-IV-TR (SCID-I; Michael, Robert,
Gibbon, & Williams, 2002) is a semi-structured interview for making major DSM-
IV-TR Axis 1 diagnoses. It is administered by a clinician or trained mental health
professional who is familiar with the DSM-IV-TR classification and diagnostic
criteria (APA, 2000). It is designed for use with subjects who are identified as
psychiatric patients. The SCID-I is an ideal choice for research purpose due to its
brevity and psychometrics (Lobbestael, Leurgans, & Arntz, 2010).
Generalized Anxiety Disorder Questionnaire–IV
The generalized anxiety disorder questionnaire (GADQ-IV; Newman et al.,
2002) is a nine-item, Likert scale measure screening for GAD based on the DSM-
IV-TR diagnostic criteria. It has good psychometric properties, with specificity =
.89, sensitivity =145.83, and 2-week test-retest reliability =.92 (Newman et al.).
The GADQ-IV is a good initial screening device for GAD—to tease out those not
meeting DSM-IV-TR criteria and before a costlier structured is used for further
assessment (Holmes & Newman, 2006). The scale measures excessiveness and
uncontrollability of worry, and severity of related somatic symptoms. For scor-
ing purposes, a cut off score of 5.7 has been the standard in assessing whether
individuals have GAD, rather than matching responses (Newman et al.). In the cur-
rent sample the measure demonstrated excellent to adequate internal consistency
(Cronbach’s α=.80).
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870 The Journal of Psychology
Obsessive–Compulsive Inventory: Revised
The obsessive compulsive inventory (OCI-R; Foa et al., 2002) is an 18-item
self-report inventory that measures obsessive–compulsive symptom severity. Par-
ticipants rate the degree to which they are bothered or distressed by OCD symp-
toms in the past month on a five–point scale from 0 (not at all) to 4 (extremely).
The OCI-R assesses a range of OCD symptomatology including washing, check-
ing/doubting, obsessing, mental neutralizing, ordering, and hoarding. The OCI-R
demonstrates good psychometric properties (Foa et al.; Hajcak, Huppert, Simons,
& Foa, 2004). In the present sample, Cronbach’s αof .93 was observed for OCI-R.
Penn State Worry Questionnaire
The Penn State Worry Questionnaire (PSWQ; Meyer, Miller, Metzger, &
Borkovec, 1990) is a 16-item inventory and is most frequently used to asses
pathological worry in both clinical and nonclinical populations. The PSWQ is
designed to measure the generality, excessiveness, and uncontrollability of patho-
logical worry. It has high internal consistency and good test–retest reliability .Items
included in PSWQ is rated on 1–5 point scale. In the present study, the PSWQ
demonstrated adequate internal consistency (Cronbach’s α=.95)
Ruminative Response Scale
The ruminative response scale (RSS; Nolen-Hoeksema & Morrow, 1991) is a
22–item scale that assesses an individual’s trait, or inherent levels of rumination.
Items are rated on a 4-point scale (almost never to almost always) for the extent
to which they reflect respondents’ thoughts or actions when feeling sad, down
or depressed. The RRS consists of items measuring how often people engage in
responses that are self- focused (e.g., “think ‘why am I the only person with these
problems”’), symptom-focused (e.g., “focus on the fact that I am always tired”),
and focused on the causes and consequences of having a depressed mood (e.g.,
“think ‘I won’t be able to do my job/work because I feel so badly”’). The RRS has
demonstrated a good 5–month test-retest reliability (r=.80, Nolen-Hoeksema,
Parker, & Larson, 1994) as well as high internal consistency (α=.89) and validity
in terms of predicting depression (Nolen-Hoeksema & Morrow, 1991). In the
present study a Cronbach’s alpha of .87 was observed for RRS.
Data Analysis
Although normality of the sampling distribution was questionable due to
our small sample size, normality was validated through the Shafiro–Wilk test.
Thus, parametric statistics were applied in this study. Continuous variables are
expressed as mean (SD), and the scores given in this study are sum scores of single
items. Pearson’s correlation analysis was used to investigate relationships between
outcome variables and group comparisons were analyzed by independent samples
t-test and Cohen’s (d) was also applied to examine the strength of difference
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Dar & Iqbal 871
between the groups. The hypothesized mediation model was assessed with SPSS-
16 by causal steps method developed by Baron and Kenny (1986). This is the
most commonly used and most frequently cited test of mediation in psychology.
To test the significance of indirect effect Sobel test was used because the utility and
performance of the test has been discussed and demonstrated frequently (Hoyle &
Kenny, 1999; MacKinnon, 1994; MacKinnon & Dwyer, 1993; MacKinnon et al.,
2001; MacKinnon, Warsi, & Dwyer, 1995; Stone & Sobel, 1990). MacKinnon,
Lockwood, Hoffman, West, and Sheets (2002), in their comparison of 14 methods
of assessing mediation effects, settle on the Sobel test (and its variants) as superior
in terms of power and intuitive appeal. In the case of simple mediation, the Sobel
test is conducted by comparing the strength of the indirect effect of Xon Yto
the point null hypothesis that it equals zero. The indirect effect of Xon Yin this
situation is defined as the product of the X→Mpath (a) and the M→Ypath (b),
or ab. In most situations, ab =(c–c), where cis the simple (i.e., total) effect of X
on Y, not controlling for M, and cis the X→Ypath coefficient after the addition
of Mto the model. Standard errors of aand bare represented, respectively, by sa
and sb. The standard error of the indirect effect (Sab) is provided by Aroian (1944);
Mood, Graybill, and Boes (1974); and Sobel (1982) as
Sab =b2s2
a+a2s2
b+s2
as2
b
In order to conduct the test, ab is divided by sab to yield a critical ratio
that is traditionally compared with the critical value from the standard normal
distribution appropriate for a given alpha level. The rough critical value for the
two-tailed version of the test, assuming that the sampling distribution of ab is
normal and that α=.05, is ±1.96.
Results
Descriptive Statistics
Descriptive statistics for each variable are presented in Table 1.
To estimate the differences of variables, an independent samples ttest was
conducted on GADQ-IV, OCI-R, PSWQ, and RRS within two groups (GAD and
OCD). The results of this test indicated that there was a significant difference
in GADQ-IV between the two groups, t(58) =8.15, p<.001. These results
suggest that the individuals in GAD group (M=14.00; SD =2.77) were more
reflective of GADQ-IV features than individuals in the OCD group (M=9.23;
SD =1.61). The size of this effect (d=1.92), as indexed by Cohen’s (1988)
coefficient, was found to exceed the convention for a large effect size (d=.80;
Table 1).
Significant difference was also found between the two groups on OCI-R,
t(58) =11.53, p<.001. The participants in OCD group (M=40.23; SD =5.01)
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872 The Journal of Psychology
TABLE 1. Means and Standard Deviations of All the Scales for the Total Sample
and for GAD and OCD Separately
Total sample GAD OCD
Mean (SD)(N=60) Mean (SD)(n=30) Mean (SD)(n=30) tp(d)
GAD–IV 11.62 (3.29) 14.00 (2.77) 9.23 (1.61) 8.15 .000 1.92
OCI–R 33.67 (7.94) 27.10 (3.71) 40.23 (5.01) 11.53 .000 2.98
PSWQ 39.40 (5.78) 42.10 (5.60) 36.70 (4.62) 4.07 .000 1.05
RRS 48.42 (5.04) 46.27 (3.66) 50.57 (5.36) 3.63 .001 0.94
Notes. GADQ–IV =generalized anxiety disorder questionnaire for DSM–IV; OIC–R =ob-
sessive compulsive inventory–revised; PSWQ =Penn State worry questionnaire; RSS =
ruminative response scale.
d=Cohen’s (1988) convention for effect size; small: d≥0.20; medium: d≥0.50; large: d≥
0.80 effects.
scored higher than their counterparts in the GAD group (M=27.10; SD =3.71).
The size of this effect (d=2.98) was also found to exceed the convention for a
large effect size (d=.80; Table 1).
The two groups also showed significant difference on PSWQ, t(58) =4.07,
p<.001. These results suggest that that the individuals in GAD group (M=
42.10; SD =5.60) were found more worrying than the individuals in the OCD
group (M=36.70; SD =4.62). The size of this effect (d=1.05) was again found
to exceed the convention for a large effect size (d=.80; Table 1).
The results also indicated that there was a significant difference in RRS
between the two groups, t(58) =3.63, p<.001. Therefore, these results suggest
that the participants in OCD group (M=50.57; SD =5.36) were found more
ruminating than their counterparts in the GAD group (M=46.27; SD =3.66).
The size of this effect (d=0.94) was also found to exceed the convention for a
large effect size (d=.80; Table 1).
Correlations
Correlational analyses were used to examine the differential relationships
between worry (PSWQ), and rumination (RRS), as well as between generalized
anxiety disorder (GADQ-IV) and obsessive compulsive disorder (OCI-R). As
indicated in Table 2, worry (PSWQ) correlated with both generalized anxiety
disorder (GAD) and obsessive-compulsive disorder (OCD). As expected, worry
and rumination were also correlated. Generalized anxiety disorder (GAD) and
obsessive-compulsive disorder (OCD) also showed significant correlation.
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Dar & Iqbal 873
TABLE 2. Zero-Order Correlation Between the Self-Report Measures (N=60)
12 3 4
1. GAD–IV .80 .69∗∗ .37∗∗ .35∗∗
2. OIC–R — .93 .41∗∗ .26∗
3. PSWQ — — .95 .28∗
4. RRS — — — .87
Note. GADQ–IV =generalized anxiety disorder questionnaire for DSM–IV; OCI–R =ob-
sessive compulsive inventory–revised; PSWQ =Penn State worry questionnaire; RRS =
ruminative response scale;
Numbers along the diagonal are internal consistencies of the scales.
∗p<0.05. ∗∗p<0.01 (two tailed).
Mediation Analyses
Characterization of Mediators and Mediation
A variable is said to mediate the relationship between a predictor variable
and an outcome (criterion) variable if the predictor variable first has an effect on
the mediator variable, and this in turn influences the outcome variable. Hence, a
mediator (M) accounts for the relationship between a predictor variable (X) and
the outcome variable (Y).
•Complete mediation exists if the predictor variable exerts its total influence
via the mediating variable (M).
•Partial mediation is given if the predictor variable exerts some of its influ-
ence via M, and it also exerts some of its influence directly on the outcome
variable and not via M.
Two mediation analyses were performed by using the guidelines of Judd
and Kenny (1981), and Baron and Kenny (1986) to test whether the relationship
between worry and generalized anxiety disorder, and the relationship between
worry and obsessive compulsive disorder are mediated by rumination. First, we
tested whether the relationship between worry and generalized anxiety disorder
was mediated by rumination. The estimates of 95% CIs and summary of media-
tion analyses are presented in Table 3 and Figure 1. The total and direct effects
of worry on generalized anxiety disorder were β=.37, p<.01, and β=.30,
p<.05. The difference between the total and direct effects was the total indi-
rect effect through the proposed mediator, with a point estimate of .075 and a
95% confidence interval of –.01105, .02740. Because zero is in the 95% confi-
dence interval, we can conclude that rumination does not mediate the worry–GAD
relationship.
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874 The Journal of Psychology
TABLE 3. Indirect Effect of Worry on Generalized Anxiety Disorder (GAD)
Through Rumination (N=60)
95% Confidence
Interval
Point estimate Z-value Std. Error Sig. (two-tailed) Lower Upper
Sobel 0.075 1.557 0.027 0.12 −.01105 .02740
Second, we investigated whether the relationship between worry and obsessive
compulsive disorder was mediated by rumination. The estimate of 95% CI and
summary of mediation analyses are presented in Table 4 and Figure 2. The total
and direct effects of worry on obsessive compulsive disorder were significant (β=
.41, p<.01; β=.37, p<. 01). The difference between the total and direct effects
was the total indirect effect through the proposed mediator, with a point estimate
of .043 and a 95% confidence interval of –.04687, .16592. Because zero is in the
95% confidence interval, we can conclude that rumination does not mediate the
worry–OCD association.
Discussion
Our study examined relationships between worry, rumination, and psycho-
logical distress in the form of generalized anxiety disorder (GAD) and obsessive
compulsive disorder (OCD) in two clinical groups of GAD and OCD. The major
FIGURE 1. Simple mediator model in the prediction of generalized anxiety
disorder. β=standardized Beta coefficients. The value outside of the paren-
theses represents the total effect of worry on generalized anxiety disorder prior
to the inclusion of the mediating variable. Value in the parentheses represents
the direct effect of worry on generalized anxiety disorder after the mediator is
included. ∗p<0.05. ∗∗p<0.01.
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Dar & Iqbal 875
TABLE 4. Indirect Effect of Worry on Obsessive Compulsive Disorder (OCD)
Through Rumination (N=60)
95% Confidence
Interval
Point estimate Z-value Std. Error Sig. (two-tailed) Lower Upper
Sobel 0.043 1.097 0.054 0.10 −.04687 .16592
findings can be summarized as follows. First, worry was correlated with not only
generalized anxiety disorder (GAD) but also with obsessive compulsive disorder
(OCD) and rumination. This is, consistent with previous results of Muris et al.
(2004) demonstrating a relationship among worry, rumination, and anxiety symp-
toms in a nonclinical sample. Despite the specificity of theories linking worry to
anxiety and rumination to depression, recent research suggests that these links
may not be so specific. Studies in adults (Fresco et al., 2002; Muris et al., 2005)
and children (Broeren et al., 2011) show that both rumination and worry correlate
significantly with anxiety and depressive symptoms. Even when worry scores are
partialed out of rumination and vice versa, worry and rumination are found to cor-
relate significantly with depression and anxiety scores (Fresco et al.; Segerstrom
et al., 2000). Second, even though worry, rumination, generalized anxiety disorder
(GAD), and obsessive compulsive disorder (OCD) correlated substantially with
each other, results showed that rumination did not mediate the relationship between
worry generalized anxiety disorder (GAD), and between worry and obsessive com-
pulsive disorder (OCD). This may be due to rumination being a more characteristic
FIGURE 2. Simple mediator model in the prediction of obsessive compulsive
disorder. β=standardized Beta coefficients. The value outside of the parenthe-
ses represents the total effect of worry on obsessive compulsive disorder prior
to the inclusion of the mediating variable. Value in the parentheses represents
the direct effect of worry on obsessive compulsive disorder after the mediator
is included. ∗p<0.05. ∗∗p<0.01.
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876 The Journal of Psychology
feature of the family of mood-related disorders. As Nolen-Hoeksema (2004) ar-
gues that a ruminative style of responding contributes to the onset, the severity, and
the persistence of depressive symptoms. Results of a recent meta-analytic review
reveal stable effect sizes for rumination, meaning that rumination is significantly
associated with concurrent levels of depression as well as the level of depres-
sive symptoms over time (Rood, Roelofs, B ¨
ogels, Nolen-Hoeksema, & Schouten,
2009). Moreover, exploratory factor analyses demonstrate that worry and
rumination not only share substantial variance (Segerstrom et al., 2000), but also
retain distinct characteristics (Fresco et al.; Muris et al., 2004). Even though
worry and rumination are similar in the way that they are both a form of repetitive
thinking as a coping mechanism to avoid or control potentially aversive situa-
tions, these processing differ in content. In a similar way, worry generated and
exacerbated in ambiguous situations could lead individuals to overestimate the
possibility of aversive future outcomes. Furthermore, worry tend to be defined as
repetitive, uncontrollable thoughts about potential negative future events, while
rumination has been found to be oriented toward the past and self-focused at-
tention (Segerstrom et al., 2000; Watkins, Moulds, & Mackintosh, 2005) These
differences between worry and rumination might be the possible and probable
cause of rumination not mediating the paths between worry and generalized
anxiety disorder (GAD), and between worry and obsessive compulsive disorder
(OCD).
We also analyzed differences of outcome variables within two clinical groups.
These results showed that the negative thought processes, such as worry and rumi-
nation, were substantially different between GAD and OCD groups. This finding
suggests that anxiety-related clinical features may be disorder-specific within
the spectrum of anxiety and obsessive compulsive-related disorders. Also, there
were significant differences in anxiety symptoms between GAD and OCD, and
this might be due to the DSM-IV-TR criteria which is categorical and symptom
specific (APA, 2000). The results also revealed that GAD group was more repre-
sentative of worry–related symptoms whereas OCD group was found to be high in
rumination, with strong effect sizes. This might be due to the fact that in GAD, ex-
cessive axiogenic cognition takes the form of preservative worry, which consists
of apprehensive thoughts about everyday concerns, such as finances, academic
performance, and household maintenance (Burns et al., 1996). Preservative worry
sustains a high level of negative affect and physiological arousal, which may lead
to tension, fatigue, and other somatic complaints (APA, 2000). Research examin-
ing the nature of these excessive cognitions supports their diagnostic specificity,
as patients with OCD report more obsessional thoughts than patients with GAD,
and patients with GAD report more preservative worry than patients with OCD
(Brown et al., 1992; Brown et al., 1993). Although rumination has been investi-
gated mostly in the context of depression (e.g., Nolen-Hoeksema, 1991); however,
increased rumination has also been observed in OCD (Fineberg, Fourie, Gale, &
Sivakumaran, 2005).
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Dar & Iqbal 877
Potential clinical implications of the current findings are worth mentioning.
Adults with a tendency to use negative repetitive thought processes (e.g., worry)
are at risk for anxiety symptoms, such as GAD and OCD. Given the results of
our study, this risk may be marginally reduced provided adults with high levels
of worry are helped to limit their tendency to use such negative process. The
treatment protocols for anxiety may focus on strategies that modify the worrying
tendency. Moreover, attention-training treatment can be used to obtain increased
metacognitive control (Wells, 2000).
Several limitations of this study should be noted. The first limitation of this
study is the relatively small sample size. This may have resulted in low statistical
power and Type 1 errors. Thus, further study will be needed examining larger
clinical samples in order to confirm our results. Second, sample selection may
represent a limitation of this study. As the current sample was limited to outpatients,
only those patients with GAD and OCD were included. Additionally, we did not
include nondisordered group; therefore, comparing variables between community
sample and clinical sample could not be investigated. Third, use of Sobel test
to test the significance of mediation might also constitute a limitation owing to
its assumption of large normally distributed samples. Although normality was
validated, still other nonparametric tests including bootstrapping could be used
for this purpose.
Despite limitations of this study, we believe we have provided implicative
data for future studies regarding the specificity of the clinical features involved in
the relationship between worry, rumination, generalized anxiety disorder (GAD),
and obsessive compulsive disorder (OCD). The present study demonstrated that
although worry, rumination, generalized anxiety disorder (GAD), and obsessive
compulsive disorder (OCD) correlated substantially with each other, rumination
could not reach to the statistical significance to mediate the relationship between
worry and generalized anxiety disorder (GAD), and between worry and obsessive
compulsive disorder (OCD). Thus, it may be concluded that worry is a component
more related to generalized anxiety disorder (GAD) and obsessive compulsive
disorder (OCD) than rumination.
AUTHOR NOTES
Kaiser A. Dar is a doctoral student at Jamia Millia Islamia (A Central Univer-
sity). His current research interests are personality–psychopathology link, religion
and well-being, and transdiagnostic factors across mood and anxiety disorders.
Naved Iqbal is a professor and head of the department of psychology at Jamia
Millia Islamia (A Central University). His current research interests are positive
psychology and well-being, Islamic perspective to human behavior, and meditation
and mental health.
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878 The Journal of Psychology
ACKNOWLEDGMENTS
We thank anonymous reviewers for their valuable suggestions. We also wish
to thank those who kindly volunteered to participate in the present study.
REFERENCES
American Psychiatric Association (APA). (2000). Diagnostic and statistical manual of
mental disorders (Text rev., 4th ed.). Washington, DC: Author.
Aroian, L. A. (1944). The probability function of the product of two normally distributed
variables. Annals of Mathematical Statistics,18, 265–271.
Baron, R. M., & Kenny, D. A. (1986). The moderator–mediator variable distinction in social
psychological research: Conceptual, strategic, and statistical considerations. Journal of
Personality and Social Psychology,51, 1173–1182.
Borkovec, T. D. (1994). The nature, functions, and origins of worry. In G. Davey & F.
Tallis (Eds.), Worrying: Perspectives on theory, assessment, and treatment (pp. 5–33).
New York, NY: Wiley.
Broeren, S., Muris, P., Bouwmeester, S., van der Heijden, K. B., & Abee, A. (2011). The role
of repetitive negative thoughts in the vulnerability for emotional problems in non-clinical
children. Journal of Child and Family Studies,20, 135–148. doi:10.1007/s10826-010-
9380-9
Brown, T., Moras, K., Zinbarg, R., & Barlow, D. H. (1993). Differentiating general-
ized anxiety disorder and obsessive compulsive behavior. Behavior Therapy,24, 227–
240.
Brown, T. A., Antony, M. M., & Barlow, D. H. (1992). Psychometric properties of the Penn
State worry questionnaire in a clinical anxiety disorders sample. Behaviour Research and
Therapy,30, 33–38.
Burns, G. L., Keortge, S. G., Formea, G. M., & Sternberger, L. G. (1996). Revision of the
Padua inventory of obsessive–compulsive disorder symptoms: Distinctiveness between
worry, obsessions, and compulsions. Behaviour Research and Therapy,34, 163–173.
Clark, D. A., & Claybourn, M. (1997). Process characteristics of worry and obsessive
intrusive thoughts. Behaviour Research and Therapy,35, 1139–1141.
Cohen, J. (1988). Statistical power analysis for the behavioural sciences. New York, NY:
Academy Press.
de Jong-Meyer, R., Beck, B., & Riede, K. (2009). Relationships between rumination,
worry, intolerance of uncertainty and metacognitive beliefs. Personality and Individual
Differences,46, 547–551.
Fineberg, N. A., Fourie, H., Gale, T. M., & Sivakumaran, T. (2005). Comorbid depression
in obsessive compulsive disorder (OCD): Symptomatic difference to major depressive
disorder. Journal of Affective Disorders,87, 327–330.
Foa, E. B., Huppert, J. D., Leiberg, S., Langner, R., Kichic, R., Hajcak, G., & Salkovskis,
P. (2002). The Obsessive–Compulsive Inventory: Development and validation of a short
version. Psychological Assessment,14, 485–496.
Freeston, M. H., Ladouceur, R., Rheaume, J., Letarte, H., Gagnon, F., & Thibodeau, N.
(1994). Self-report of obsessions and worry. Behaviour Research and Therapy,32,
29–36.
Fresco, D. M., Frankel, A. N., Mennin, D. S., Turk, C. L., & Heimberg, R. G. (2002).
Distinct and overlapping features of rumination and worry: The relationship of cognitive
production to negative affective states. Cognitive Therapy and Research,26, 179–188.
Downloaded by [Kaiser Dar] at 11:39 12 August 2015
Dar & Iqbal 879
Hajcak, G., Huppert, J. D., Simons, R. F., & Foa, E. B. (2004). Psychometric properties of
the OCI–R in a college sample. Behaviour Research and Therapy,42, 115–123.
Holmes, M., & Newman, M. G. (2006). Generalized anxiety disorder. In M. Hersen & J. C.
Thomas (Series Eds.), & F. Andrasik (Vol. Ed.), Comprehensive handbook of personality
and psychopathology: Vol. II. Adult psychopathology (pp. 101–120). New York, NY:
John Wiley & Sons.
Hoyle, R. H., & Kenny, D. A. (1999). Sample size, reliability, and tests of statistical medi-
ation. In R. Hoyle (Ed.), Statistical strategies for small sample research (pp. 195–222).
Thousand Oaks, CA: Sage.
Judd, C. M., & Kenny, D. A. (1981). Process analyses: Estimating mediation in evaluation
research. Evaluation Research,5, 602–619.
Lobbestael, J., Leurgans, M., & Arntz, M. (2010). Inter-rater reliability of the Structured
Clinical Interview for DSM-IV Axis I Disorders (SCID I) and Axis II Disorders (SCID
II). Clinical Psychology & Psychotherapy,18, 75–79.
MacKinnon, D. P. (1994). Analysis of mediating variables in prevention and intervention
research. In A. Cazares & L. A. Beatty (Eds.), Scientific methods for prevention interven-
tion research (NIDA Research Monograph 139. DHHS Pub. No. 94–3631, pp. 127–153).
Washington, DC: U.S. Government Printing Office.
MacKinnon, D. P., & Dwyer, J. H. (1993). Estimating mediated effects in prevention studies.
Evaluation Review,17, 144–158.
MacKinnon, D. P., Goldberg, L., Clarke, G. N., Elliot, D. L., Cheong, J., Lapin, A., Moe,
E., & Krull, J. L. (2001). Mediating mechanisms in a program to reduce intentions to
use anabolic steroids and improve exercise self-efficacy and dietary behavior. Prevention
Science,2, 15–28.
MacKinnon, D. P., Lockwood, C. M., Hoffman, J. M., West, S. G., & Sheets, V. (2002). A
comparison of methods to test mediation and other intervening variable effects. Psycho-
logical Methods,7, 83–104.
MacKinnon, D. P., Warsi, G., & Dwyer, J. H. (1995). A simulation study of mediated effect
measures. Multivariate Behavioral Research,30, 41–62.
Meyer, T. J., Miller, M. L., Metzger, R. L., & Borkovec, T. D. (1990). Development and
validation of the Penn State Worry Questionnaire. Behaviour and Research Therapy,28,
487–496.
Michael, B. F., Robert, L. P., Gibbon, M., & Williams, J. B. W. (2002). Structured Clinical
Interview for DSM-IV-TR Axis I Disorders, Research Version, Patient Edition (SCID-I/P).
New York, NY: Biometrics Research, New York State Psychiatric Institute.
Mood, A., Graybill, F. A., & Boes, D. C. (1974). Introduction to the theory of statistics.
New York, NY: McGraw-Hill.
Muris, P., Roelofs, J., Meesters, C., & Boomsma, P. (2004). Rumination and worry in
non-clinical adolescents. Cognitive Therapy and Research,28, 539–554.
Muris, P., Roelofs, J., Rassin, E., Franken, I., & Mayer, B. (2005). Mediating effects
of rumination and worry on the links between neuroticism, anxiety and depression.
Personality and Individual Differences,39, 1105–1111.
Newman, M. G., Zuelling, A. R., Kachin, K. E., Constantino, M. J., Przeworski, A.,
Erickson, T., & Cashman-McGrath, L. (2002). Preliminary reliability and validity of
the Generalized Anxiety Disorder Questionnaire-IV: A revised self-report diagnostic
measure of generalized anxiety disorder. Behavior Therapy,33, 215–233.
Nolen-Hoeksema, S. (1991). Responses to depression and their effects on the duration of
the depressive episode. Journal of Abnormal Psychology,100, 569–582.
Nolen-Hoeksema, S. (2004). The response style theory. In C. Papageorgiou & A. Wells
(Eds.), Descriptive rumination: Nature, theory and treatment (pp. 107–123). Chichester,
UK: Wiley.
Downloaded by [Kaiser Dar] at 11:39 12 August 2015
880 The Journal of Psychology
Nolen-Hoeksema, S., & Morrow, J. (1991). A prospective study of depression and post-
traumatic stress symptoms after a natural disaster: The 1989 Loma Prieta earthquake.
Journal of Personality and Social Psychology,61, 115–121.
Nolen-Hoeksema, S., Parker, L. E., & Larson, J. (1994). Ruminative coping with depressed
mood following loss. Journal of Personality and Social Psychology,67, 92–104.
Nolen-Hoeksema, S., Wisco, B. E., & Lyubomirsky, S. (2008). Rethinking rumination.
Perspectives on Psychological Science,5, 400–424.
Rood, L., Roelofs, J., B ¨
ogels, S., Nolen-Hoeksema, S., & Shcouten, E. (2009). The influence
of emotion-focused rumination and distraction on depressive symptoms in non-clinical
youth: A meta-analytic review. Clinical Psychology Review,29, 607–616.
Segerstrom, S. C., Tsao, J. C., Alden, L. E., & Craske, M. G. (2000). Worry and rumination:
Repetitive thoughts as a concomitant and predictor of negative mood. Cognitive Therapy
and Research,24, 671–688.
Sobel, M. E. (1982). Asymptotic confidence intervals for indirect effects in structural
equation models. In S. Leinhart (Ed.), Sociological methodology 1982 (pp. 290–312).
San Francisco, CA: Jossey-Bass.
Stone, C. A., & Sobel, M. E. (1990). The robustness of estimates of total indirect effects
in covariance structure models estimated by maximum likelihood. Psychometrika,55,
337–352.
Watkins, E., Moulds, M., & Mackintosh, B. (2005). Comparisons between rumination and
worry in a non-clinical population. Behavior and Therapy,43, 1577–1585.
Wells, A. (2000). Emotional disorders and metacognitions: Innovative cognitive therapy.
Chichester, UK: Wiley.
Zinbarg, R., & Barlow, D. H. (1996). The structure of anxiety and the DSM-III-
R anxiety disorders: A hierarchical model. Journal of Abnormal Psychology,105,
181–193.
Original manuscript received July 18, 2014
Final version accepted November 6, 2014
Downloaded by [Kaiser Dar] at 11:39 12 August 2015
