GAD Flashcards
GAD: Brief History of DSM Diagnosis
1980 -‐ DSM-‐III -‐ “residual” disorder characterized by hyper-‐arousal
1987 -‐ DSM-‐III-‐R -‐ primary disorder
major revision: worry is central component
1994 -‐ DSM-‐IV -‐ minor revisions remains primary disorder
worry remains as cardinal feature
2013 – DSM-‐5
worry remains cardinal feature
- 3 mos duration from 6 mos
- addition of changes in behavior as a result of the worry
DSM-5 Checklist
Generalized Anxiety Disorder:
- Excessive or ongoing anxiety and worry, for at least 3 months, concerning two or more activities or events
- Restlessness And/or Muscle Tension
- Behavior May Be Affected by Anxiety or Worry
- Significant Distress or Impairment
Worry vs Anticipatory Anxiety vs Fear
Worry – focus on POTENTIAL future threat
Anticipatory Anxiety – focus on future threat
Fear – imminent threat
Pathological worry vs Normal worry
Frequency, intensity, duration of worry
- excessive
- unrealistic
Individual’s ability to control the worry
Functional impairment as a result of worry
Differential Diagnosis
Worry is a common feature of almost all anxiety disorders (e.g. social phobia, panic) as well as other disorders (e.g. hypochondriasis)
GAD dx:
Worry cannot be confined to features of another disorder
*e.g. worry about having a panic attack; worry about social situation, worry about contamination
GAD Comorbidity
93% of patients with GHD are diagnosed with at least one additional disorder
46% comorbid with major depression or dysthymia
*Estimates of 50% of alcohol abusers have prior dx of GAD
GAD prevalence
3.1% of US population (6.8 million individuals)
10% – sub-threshold GAD
“worriers”
Worry Functionality
Worry is an attempt at problem solving
Given the prevalence of worry, something so widespread must of had an adaptive function
*without worry, unable to anticipate potential negative events
Information Processing Model of Anxiety
Anxiety =
Appraisal of risk/danger
+
Appraisal of coping with the risk/danger
Psychopathology of GAD
Increased risk perception
Decreased coping ability
Increased risk perception
Information processing is driven by a core sense (schema) of vulnerability
Vulnerability leads to over estimation of risk
*both probability and severity
Decreased Coping Ability
Problem-solving is impaired, overrun by anxiety
Replaced by cognitive avoidance and safety seeking behaviors
Thus – perception of coping ability is decreased
GAD as Personality Disorder
- Lifelong and chronic history of anxiety with no clear onset, or onset stemming from childhood or adolescence
- Generalized anxiety (worry) is a very common feature of normal behavior
* it is a basic psychological dimension that is present in everyone to some degree
Treatment Implications of GAD as Personality Disorder
More chronic may mean more treatment required
Ego-syntonic – is there a motivation to change?
GAD evidence-based interventions
Cognitive Restructuring
Worry Exposure
Stimulus – Control Procedures
Problem-Solving Training
Relaxation Training
ERP Of Behavioral Component
GAD assessment
Clinical interview
Penn State Worry Questionnaire
M = 68 SD = 9
BAI: anxious arousal
CBT for GAD
Psychoeducation
Strategies to address the following components:
Cognitive
Physiological/Somatic
Behavioral
Existential component
Need to develop tolerance/acceptance of risk/uncertainty
Manage risks rather than eliminate
Anxiety the shadow of intelligence? The specter of death”
GAD Psychoeducation
- The function of worry
- The 4 systems/components of anxiety:
* affect
* physiology
* cognition
* behavior - When is it a disorder? – Normal versus pathological worry
- Rationale of CBT treatment, components:
Cognitive
Physiological
Behavioral - Discuss role of homework and monitoring of triggers for emotional reactions (thought record)
Rationale of CBT treatment: Cognitive Component
Cognitive Restructuring–logical analysis
Stimulus control – Scheduling “worry time”
Worry exposure – processing and habituation
Problem-solving training – increase coping skills
Rationale of CBT treatment: Physiological Component
Progressive Muscle Relaxation (PMR)
Rationale: decrease hyperarousal
In Session: practice skills to make sure patient is implying skill properly
HW: Twice daily – Approximate 15 Minutes
Homework
Explains that homework will become an integral part of treatment
To increase compliance:
Set time/day in session, give “prescription” patient
Audiotaped instructional sessions
Use a monitoring form
- triggers for emotional reactions
- thoughts and symptoms (thought record)
Ask patient call in or email and report results
Therapist follow-up session – problem solved noncompliance
*Never think of the patient as “resistant”
Rationale of CBT treatment: Cognitive Component
Basic cognitive model: appraisal theory
Cognitive Restructuring
- identify distorted, exaggerated thoughts that stem from the enhanced sense of vulnerability
- have patient deliberately modify these anxious appraisals (create cognitive flexibility)
The Nature of Cognition (Information Processing):
- Confirmatory Bias
- Mood Congruent Processing
Cognitive Themes in GAD
Stem from a core sense of
- Vulnerability
- Lack of control (helplessness)
The Magic of Worry
Worriers fear the impact of not worrying:
Letting guard down
Superstition
BS–major challenge to tx
Sometimes even just conversation in session is too threatening–at some level, patient feels that they might be setting up future challenges to their worry–too distressing
Cognitive Restructuring: Broad Steps
- Identify cognitions
* automatic thoughts with discrete predictions or interpretations - Examine how these automatic thoughts affect one’s emotional reactions and behavior
* validation - Subject each thought to “logical analysis” and identify cognitive distortions
* introduce cognitive flexibility - Generate a “rational response”
Generating Alternatives
Automatic thoughts represent one interpretation of events
Interpretation of events is largely influenced by distorted information processing
Before assuming any one interpretation is correct, patients are asked to consider all the possibilities for generating alternative hypotheses
The strategy is intended to move patients away from the exclusive use of negatively biased information processing
*the goal is to generate as many plausible alternative explanations as possible, since psychopathological thinking is rigid
Problem-Solving: Increasing coping when negative thoughts are accurate
Brainstorming, Pros and Cons, Solutions
- Brainstorming solutions
* generating as many solutions as possible without stopping to evaluate them
* encourage the patient to be creative and thorough - Pros and cons
* have the patient list the advantages and disadvantages of each proposed solution - Choose the best solution and carry it out
* have the patient consider the importance of the various pros and cons
* based upon that analysis, choose a solution that seems best
* take concrete steps to carry it out
Stimulus Control and Worry Exposure
Goals
Decrease cues that initiate worry
Desensitize anxiety response to specific worries
Facilitate processing of worries
- distancing
- problem-solving
Stimulus Control and Worry Exposure
Procedure
- Set a time and place to worry each day – 30 minutes
- Each time the patient has a worry, write it down and postpone worry until later
- Teach patient to focus attention on immediate environment as a way of distracting from the immediate worry
* mindfulness training - Patient uses worry time to focus on the worries in detail
* encourage patient to take it to its most extreme form to maximize anxiety
Behavioral Component
Exposure and Response Prevention
Focus on behaviors that ultimately maintain worry process – negative reinforcement
Avoidance
Reassurance seeking
Over preparation
Excessive checking
Procrastination
- Identify specific behaviors and implement systematic gradual change in behavior
GAD as “platform” disorder
Is GAD just Neuroticism? (more of a PD?)
It is a ‘basic’ disorder–worry, anxiety and fear are common to all anxiety disorders
By definition ‘Generalized’–can be anxiety about literally anything
OCD vs. Worry
Obsessive thoughts–ritualistic and unrealistic
*very unusual, highly unlikely, and focused on a certain theme
Worry–more grounded in reality, of events that could happen
