Introduction
Generalized anxiety disorder (GAD) is the most common anxiety disorder. Worry is an important component of GAD [4]. Many studies have shown an association between worry and symptoms of anxiety [5, 6]. Recent conceptualizations of worry have emphasized the importance of emotions, especially emotion regulation, in developing and perpetuating worry and GAD [8]. Salters et al. showed a relationship between cognitive dysfunctional emotion regulation and chronic worry [12]. Another strategy that offers different ways of dealing with emotions, pain, and distress is mindfulness. Mindfulness is a key element in raising self-awareness to empower in critical situations to prevent anxiety and always helps as a strong preventative stimulus [15]. So, emotion regulation and mindfulness are among the psychological components that play an important role in the relationship between worry and GAD. Despite recent studies on the importance of mindfulness and cognitive emotion regulation in GAD and worry, the role of these variables in the relationship between worry and GAD is not well understood. The present study aimed to examine the mediating role of cognitive emotion regulation and mindfulness in the relationship between anxiety and worry.
Materials and Methods
The present study follows a correlational design study. The study’s statistical population included all university students in Kashan City, Iran. The research sample included 248 students of Kashan universities studying in the 2017-2018 academic year. These individuals were randomly selected using the cluster sampling method. Data collection tools were 7-item generalized anxiety disorder (GAD-7) [20], Pennsylvania State worry questionnaire (PSWQ) [22], the Persian version of the cognitive emotion regulation questionnaire-short form (CERQ-P-short) [24], and five-factor mindfulness questionnaire (FFMQ) [26]. It should be noted that the Persian version of these questionnaires was used.
To fit the model, the most well-known goodness-of-fit indicators, including χ2/df, the goodness of fit index (GFI), comparative fit index (CFI), normed fit index (NFI), and root mean square error of approximation (RMSEA) were considered. Values smaller than 3 χ2/df indicate a good fit of the model, and the smaller the index, the better the fit of the model. Hu and Bentler [28] proposed a value of 0.90 for the GFI, adjusted GFI (AGFI), and CFI indices, indicating a good fit for the model. In general, the closer these indicators are to 1, the better the model fit. Finally, the data were analyzed using the SPSS v. 22 and AMOS v. 22 software.
Results
The Mean±SD age of participants was 21.85±3.82years. A total of 172 (69.4%) participants were female, and 76 (30.6%) were male. The Mean±SD scores of worry, generalized anxiety, cognitive emotion regulation, and mindfulness variables were 48.43±10.44, 7.78±4.29, 49±8.26, and 119.50±10.79, respectively. The results showed a significant relationship between anxiety and worry, worry and cognitive emotion regulation, worry and mindfulness, anxiety and cognitive emotion regulation, and anxiety and mindfulness (Table 1).


Based on the reported good fit of the model indices and according to Hu and Bentler [28], the proposed model was modified (Table 2).


In order to modify the model, the path coefficients in the initial model were investigated. The results of the structural equation modeling confirmed the mediating role of cognitive emotion regulation in the relationship between anxiety and worry. Also, the path coefficient of mindfulness and anxiety was removed from the model because it was not significant (Table 2).
Discussion
This study aimed to evaluate the proposed model in the relationship between worry and anxiety by considering the mediating role of cognitive emotion regulation and mindfulness. The results of this study, in line with the mentioned research in this field, showed that maladaptive emotion regulation strategies lead to the use of avoidance strategies such as worry and due to conflicts in the verbal-abstract nature of worry when dealing with disturbing emotional experiences, in purposeful behavior problems are experienced [30, 32].
People with emotional problems use maladaptive emotional regulation strategies such as hiding and ignoring emotions and avoiding and suppressing them [12]. Emotion regulation leads to a better understanding of the role of thoughts, feelings, and behaviors in emotional experiences, better awareness of emotional experiences, identification and correction of physical senses and behaviors resulting from emotion, and coping with emotional experiences during internal conflicts [14]. These approaches reduce the intensity of maladaptive emotional experiences and return emotions to a functional level, and generally reduce anxiety [11]. It can be said that worry makes a person susceptible to GAD, and emotion regulation skills reduce this vulnerability. As mentioned, the mediating role of mindfulness in the relationship between worry and generalized anxiety was not significant. Consistent with this finding, Beirami et al. reported that emotion regulation training is more effective than mindfulness-based cognitive therapy [37]. Emotion regulation involves informing people of positive and negative emotions and effectively accepting and coping with them [38]. As Linehan believed, emotion regulation is a range of skills that include accepting emotional problems to changing existing situations [39]. Mindfulness focuses on the present moment, purposeful awareness, and avoidance of judgment, so it seems that strategies beyond these are needed to reduce anxiety and worry because people experience many worries about their future career and family life during their youth and student life.
One of the most common of these strategies is cognitive strategies which refer to managing and manipulating the input of emotion-evoking information [11]. This condition regulates emotions and protects the person from being defeated by emotions [32]. Generally, cognitive emotion regulation plays a mediating role in the relationship between anxiety and worry. These findings seem applicable in the individual, family, educational, therapeutic, and interpersonal mental health fields.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of Kashan University of Medical Sciences (Code: IR.KAUMS.REC.1397.001). 

Funding
This research was supported by the research project (No. 96205), Funded by Kashan University of Medical Sciences.

Authors' contributions
All authors contributed equally in preparing all parts of the research.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgements
We appreciate the students' participation in this study. Also we thank the Vice-chancellor for Research, KUMS, and Iran for funding the research.



References

1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, (DSM-5®). Washington: American Psychiatric Publishing; 2013. [Link]
2. Hanrahan F, Field AP, Jones FW, Davey GC. A meta-analysis of cognitive therapy for worry in generalized anxiety disorder. Clin Psychol Rev. 2013; 33(1):120-32. [DOI:10.1016/j.cpr.2012.10.008] [PMID]
3. Noorbala A, Yazdi SB, Yasamy M, Mohammad K. Mental health survey of the adult population in Iran. Br J Psychiatry. 2004; 184(1):70-3. [DOI:10.1192/bjp.184.1.70] [PMID]
4. Sadock BJ, Sadock VA, Pedro R. Kaplan and Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry [F Rezaei, Persian trans]. Tehran: Arjmand; 2012. [Link]
5. Hong RY. Worry and rumination: Differential associations with anxious and depressive symptoms and coping behavior. Behav Res Ther. 2007; 45(2):277-90. [DOI:10.1016/j.brat.2006.03.006] [PMID]
6. Muris P, Roelofs J, Meesters C, Boomsma P. Rumination and worry in nonclinical adolescents. Cognit Ther Res. 2004; 28(4):539-54. [DOI:10.1023/B:COTR.0000045563.66060.3e]
7. Nasrabadi AN, Mazloom R, Nesari M, Goodarzi F. [Relation between worry domains and health related quality of life in medical sciences students (Persian)]. Payesh. 2009; 8(1):85-92. [Link]
8. Mennin DS, Heimberg RG, Turk CL, Fresco DM. Applying an emotion regulation framework to integrative approaches to generalized anxiety disorder. Clin Psychol: Sci Pract. 2002; 9(1):85-90. [DOI:10.1093/clipsy.9.1.85]
9. Roemer L, Salters K, Raffa SD, Orsillo SM. Fear and avoidance of internal experiences in GAD: Preliminary tests of a conceptual model. Cognit Ther Res. 2005; 29(1):71-88. [DOI:10.1007/s10608-005-1650-2]
10. Hughes ME, Alloy LB, Cogswell A. Repetitive thought in psychopathology: The relation of rumination and worry to depression and anxiety symptoms. J Cognit Psychother. 2008; 22(3):271-88. [DOI:10.1891/0889-8391.22.3.271]
11. Zlomke KR, Hahn KS. Cognitive emotion regulation strategies: Gender differences and associations to worry. Pers Individ Differ. 2010; 48(4):408-13. [DOI:10.1016/j.paid.2009.11.007]
12. Salters-Pedneault K, Roemer L, Tull MT, Rucker L, Mennin DS. Evidence of broad deficits in emotion regulation associated with chronic worry and generalized anxiety disorder. Cognit Ther Res. 2006; 30(4):469-80. [DOI:10.1007/s10608-006-9055-4]
13. Hayes SC, Strosahl K, Wilson KG, Bissett RT, Pistorello RT, Toarmino D, et al. Measuring experiential avoidance: A preliminary test of a working model. Psychol Rec. 2004; 54(4):553-8. [DOI:10.1007/BF03395492]
14. Fairholme CP, Boisseau CL, Ellard KK, Ehrenreich JT, Barlow DH. Emotions, emotion regulation, and psychological treatment: A unified perspective. In: Kring AM, Solan DM, editors. Emotion regulation and psychopathology: A transdiagnostic approach to etiology and treatment. New York: Guilford Press; 2010. [Link]
15. Brown KW, Ryan RM, Creswell JD. Addressing fundamental questions about mindfulness. Psychol Inq. 2007; 18(4):272-81. [DOI:10.1080/10478400701703344]
16. Esfahani A, Zeinali S, Kiani R. [Effect of acceptance and commitment therapy on pain-related anxiety and cognitive emotion regulation in breast cancer patients: A clinical trail (Persian)]. J Arak Uni Med Sci. 2020; 23(2):138-49. [DOI:10.32598/JAMS.23.2.3364.2]
17. Sharifi-Saki Sh AM, Alipor A, Fahimi Far A, Taghadosi M, Karimi R, Nadjafi M. [The effectiveness of mindfulness-based cognitive therapy in reducing anxiety and meta-worry in women with recurrent miscarriages (Persian)]. Feyz. 2015; 19(4):334-40. [Link]
18. Loehlin JC. Latent variable models: An introduction to factor, path, and structural equation analysis. New York: Psychology Press; 2004. [DOI:10.4324/9781410609823]
19. Garson D. Testing statistical assumptions. Raleigh: Statistical Publishing Associate 2012. [Link]
20. Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: The GAD-7. Arch Intern Med. 2006; 166(10):1092-7. [DOI:10.1001/archinte.166.10.1092] [PMID]
21. Naeinian M SM, Sharif M, Hadian M. [To study reliability and validity for a brief measure for assessing generalized anxiety disorder (GAD-7) (Persian). Clin Psy Pers. 2011; 2(4):41-50. [Link]
22. Meyer TJ, Miller ML, Metzger RL, Borkovec TD. Development and validation of the penn state worry questionnaire. Behav Res Ther. 1990; 28(6):487-95. [DOI:10.1016/0005-7967(90)90135-6]
23. Dehshiri GR, Golzari M, Borjali A, Sohrabi F. [Psychometrics particularity of Farsi version of Pennsylvania state worry questionnaire for college students (Persian)]. J Clin Psycol. 2009; 1(4):67-75. [DOI:10.22075/JCP.2017.1988]
24. Garnefski N, Kraaij V. Cognitive emotion regulation questionnaire-development of a short 18-item version (CERQ-short). Per Individl Differ. 2006; 41(6):1045-53. [DOI:10.1016/j.paid.2006.04.010]
25. Yousefi F. [Model emotional intelligence, cognitive development, emotion regulation strategies, cognitive and general health (Persian) (Dissertation). Shiraz: University of Shiraz; 2003.
26. Baer RA, Smith GT, Hopkins J, Krietemeyer J, Toney L. Using self-report assessment methods to explore facets of mindfulness. Assessment. 2006; 13(1):27-45. [DOI:10.1177/1073191105283504] [PMID]
27. Ahmadvand Z, Heydarnasab L, Shaeiri M. [An investigation of the validity and relibility of psychometric characteristics of five facet mindfulness questionnaire in Iranian non-clinical samples (Persian)]. J Behav Sci. 2013; 7(3):229-37. [Link]
28. Hu Lt, Bentler PM. Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Struct Equ Modeling. 1999; 6(1):1-55. [DOI:10.1080/10705519909540118]
29. Hosseini S, Khosravilaghab Z. [Identifying effective factors on leadership and entrepreneurship intent among female students (case study: Management students of public universities in city) (Persian)]. Q J Women Soc. 2017; C8(30):35-56. [Link]
30. McLaughlin KA, Mennin DS, Farach FJ. The contributory role of worry in emotion generation and dysregulation in generalized anxiety disorder. Behav Res Ther. 2007; 45(8):1735-52. [DOI:10.1016/j.brat.2006.12.004] [PMID]
31. O’Brien K, O’Keeffe N, Cullen H, Durcan A, Timulak L, McElvaney J. Emotion-focused perspective on generalized anxiety disorder: A qualitative analysis of clients’ in-session presentations. Psychother Res. 2019; 29(4):524-40. [DOI:10.1080/10503307.2017.1373206] [PMID]
32. Campbell-Sills L, Barlow DH. Incorporating emotion regulation into conceptualizations and treatments of anxiety and mood disorders. In: Gross JJ, editor. Handbook of emotion regulation. New York: Guilford Press; 2007. [Link]
33. Parmentier FB, García-Toro M, García-Campayo J, Yañez AM, Andrés P, Gili M. Mindfulness and symptoms of depression and anxiety in the general population: The mediating roles of worry, rumination, reappraisal and suppression. Front Psychol. 2019; 10:506. [DOI:10.3389/fpsyg.2019.00506] [PMID] [PMCID]
34. Pena M, Losada L. Test anxiety in spanish adolescents: Examining the role of emotional attention, and ruminative self-focus and regulation. Front Psychol. 2017; 8:1423. [DOI:10.3389/fpsyg.2017.01423] [PMID] [PMCID]
35. Segal ZV, Teasdale JD, Williams JMG. Mindfulness-based cognitive therapy: Theoretical rationale and empirical status. In: Hayes SC, Follette VM, Linehan MM, editors. Mindfulness and acceptance: Expanding the cognitive-behavioral tradition. New York: Guilford Press; 2004. [Link]
36. Salters-Pedneault K, Roemer L, Mennin D. Emotion regulation deficits in GAD: Examining specificity beyond symptoms and mindfulness processes. Manuscript in preparation. 2005.
37. Beirami M, Hashemi T, Bakhshipour A, Alilou M, Eghbali A. [Comparison of two methods of emotion regulation and cognitive therapy based on mindfulness-based cognitive emotion regulation strategies and psychological distress in mothers of mentally retarded children (Persian)]. J Mod Psychol Res. 2014; 9(33):43-59. [Link]
38. Dimeff L A, Rizvi S L, Koerner K. Dialectical behavior therapy in clinical practice. New York: Guilford Publications; 2020. [Link]
39. Linehan MM. Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Publications; 2018. [Link]
40. Fresco DM, Mennin DS, Heimberg RG, Ritter M. Emotion regulation therapy for generalized anxiety disorder. Cogn Behav Pract. 2013; 20(3):282-300. [DOI:10.1016/j.cbpra.2013.02.001] [PMID] [PMCID]