GAD & PTSD

Question 1

Generalised Anxiety Disorder

Answer 1

• First introduced in DSM-III-R (1980)
• DSM-IV (1994) and DSM-5 (2013) definition:
  o Excessive, uncontrollable worry about a variety ofν events / outcomes
  o Occurs more days than not for at least 6 months
  o At least 3 of 6 somatic symptoms:
  • Restlessness, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbance
  • Does not include autonomic arousal
• Need to distinguish from other disorders that also involve excessive worry

Question 2

Normal Worry

Answer 2

• Occurs in response to perceived future threat
• Focus: mainly social threat in adults, more about physical threat in older adults
• Contains verbal thought vs. imagery
• Perceived positive aspects:
  o Motivates action, helps to problem solve, avoid negative outcomes, distract from more distressing topics (Dugas et al, 1998, Freeston et al, 1994)
• Worry control:
  o Problem solving, distraction, social support (Davey et al, 1996, Szabo & Lovibond, 2002; 2006)

Question 3

Problem Solving Theories

Answer 3

• Worrying involves problem solving attempts
• Problem solving attempts of pathological worriers are ‘thwarted’
  o Biased threat perception
• Social Problem Solving (D’Zurilla & Maydeu-Olivares, 1995)
  o Problem definition
  o Generation of alternative solutions
  o Solution evaluation (positive / negative)
  o Solution selection
  • Last two stages are problematic in high worriers (Szabo & Lovibond, 2002; 2006)

Question 4

Metacognitive Theory

Answer 4

• Worry (Type 1) and Metaworry (Type 2) (Wells, 1995, Wells & Carter, 2001)
• Type 1 Worry:
  o Perception of threat + positive beliefs about worry → to cope with threat
  o Possible exit by problem solving or reassurance
• Type 2 Metaworry:
  o Worry + negative beliefs about worry → metaworry → ineffective thought control strategies → increased anxiety and worry
  o Excessive and uncontrollable worry

Question 5

Avoidance Theory

Answer 5

• Worry contains relatively more verbal thought than imagery
  o Images of possible negative event are highly aversive
  o Cause anxiety symptoms
  o Anxiety symptoms are highly aversive
• Reduced imagery => reduced arousal/anxiety
  o GAD is associated with tension symptoms
• Worry = cognitive avoidance (Borkovec, 1994)
  o Cognitive avoidance interferes with emotional processing
  o Fear structures are maintained

Question 6

Experiential Avoidance

Answer 6

-Worry is associated with
o Fear of anxiety/Anxiety sensitivity (Buhr & Dugas, 2009)
o Distress intolerance (Huang, Szabo & Han, 2010)
o Experiential avoidance (Hayes et al 1996)
• Worriers avoid internal experiences
- Difficulties in emotion regulation
o Worriers have difficulties in clearly identifying emotion, tolerating emotion, modulating emotion
o Mennin et al., 2005, Roemer et al., 2005

Question 7

Intolerance of Uncertainty Theory

Answer 7

• Intolerance of uncertainty (Ladouceur et al., 2000)
  o Uncertainty reflects badly on a person, causes frustration and stress, and prevents action
  o Worry to reduce uncertainty
  o Leads to preoccupation with details
  o Interferes with problem solving
  o Worriers aim to reduce uncertainly to zero
  • Not possible

Question 8

Treatment of GAD

Answer 8

• Biased threat perception
  o Probability and cost judgments
• ‘Problem solving’
  o Structured problem solving training
• ‘Metacognitive’
  o Challenge beliefs about worry (positive and negative)
• ‘Avoidance’
  o Exposure to vivid images of feared event
  o Exposure to emotional experience / distress
  o Exposure to uncertainty
• Treatment effects have been modest
  o About 50 – 60 % improvement at follow-up

Question 9

DSM-5 Trauma- and Stressor-Related Disorders

Answer 9

• Posttraumatic Stress Disorder
• Acute Stress Disorder
• Adjustment Disorders
• Reactive Attachment Disorder
• Disinhibited Social Engagement Disorder

Question 10

Post-traumatic Stress Disorder

Answer 10

• A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: ( Directly experiencing the traumatic event(s), witnessing, in person, the event(s) as it occurred to others, learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental, Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse)
• B. Intrusion symptoms (1 or more needed): Memories, dreams, flashbacks of the event
• C. Persistent avoidance of stimuli (1+): Memories etc, or external reminders of the event
• D. Negative changes in cognition, mood (2+): Fear, negative beliefs about self, others, the world
• E. Changes in arousal, reactivity (2 +): Anger, recklessness, self-destructive acts, sleep disturbance
• Duration of symptoms is 1 month or more

Question 11

Immediate Post-Trauma Phase

Answer 11

• 50-60% of people experience traumatic event
• About 25% develop post-traumatic problems
  o PTSD, depression, anxiety, substance abuse.
  o PTSD prevalence: 5-11%
• Normative response to trauma is to get over it.
  o People are distressed immediately after traumatic event
  o This is a perfectly normal reaction
  o Distress drops substantially within 3 months in about 75% of people.

Question 12

Risk For Later Problems

Answer 12

• Critical to identify people who need assistance to prevent post-trauma problems
• Risk factors → pre-trauma, trauma, post-trauma

Question 13

Risk Factors for PTSD

Answer 13

- Pre-trauma factors
o	Childhood trauma
o	Prior psychiatric history
o	Family instability
o	Substance abuse
o	Social/economic disadvantage
- Trauma factors
o	Degree of life threat (injury, death) or loss
o	Severity of exposure to traumatic elements
o	Location of trauma (safe place vs. elsewhere)
o	Individual’s role in the trauma (victim, helper)
o	Meaning (e.g. uncontrollability)
- Post-trauma factors
o	Social support
o	Coping style
o	Ongoing stressors

Question 14

Treatments for PTSD

Answer 14

• Biological treatments
  o Benzodiazephines, Antidepressants
• Cognitive Behavioural Therapies for PTSD:
  o Core treatment components, assess suitability, psychoeducation, anxiety management techniques, cognitive restructuring, prolonged exposure
• CBT is more effective than medication or supportive psychotherapy (e,g, Foa & Medows, 1997; Harvey et al, 2003)
• Eye Movement Desensitization and Reprocessing (EMDR) (Shapiro 1989; 1995)
  o Now used to treat a variety of anxiety disorders
  o Eye movements are the crucial components of the procedure and essential for its effectiveness
  o Training has to be provided by EMDR Institute
• Research evidence (Davidson & Parker, 2001; Harvey et al, 2003; Australian Centre for Posttraumatic Mental Health 2007).
  o EMDR is best seen as an exposure technique
  o Eye movements are not necessary for effectiveness