Generalised Anxiety Disorder

Question 1

Describe worry in GAD

Answer 1

– The key defining feature of GAD is worry concerning a range of different topics.

– Worry has been defined as “a chain of thoughts and images, negatively affect-laden and relatively uncontrollable”. BORKOVEC et al (1983). The content of worries varies but it is typi- cally related to everyday events and the temporal focus can be past, current, and future oriented (TALLIS et al 1994).

– Whereas proneness to worry varies continuously across the normal population, individuals with GAD are often distinguished from individuals with non-pathological worry by their reported uncontrollability of worry once it is initiated. Difficulty controlling worry often results in prolonged bouts of worry that are difficult to switch off, which may cause the sufferer significant distress and impair functioning.
Research provides strong support for a dimensional structure of worry, with normal and pathological worry representing opposite ends of a continuum rather than discrete constructs. As such, it is useful to examine studies that have compared self-labelled low versus high worriers, as well as studies that have compared a clinical population of GAD clients with non-anxious controls.

– TREASURE et al - People with GAD hold the belief that their worrying holds an important function for preventing future disasters and is a necessary process even though it causes them severe stress and reduces their normal functioning – thus their belief is that the function of worrying outweighs the negative costs
This dysfunctional belief causes worrying to persist and causes a never ending cycle.

Question 2

Define GAD

Answer 2

DAVEY 2014: a pervasive condition in which the sufferer experiences continual apprehension and anxiety about future events, and this leads to chronic and pathological worrying about those events.

Question 3

What are the characteristics of GAD

Answer 3

Generalised anxiety disorder (GAD) is a chronic and disabling disorder often resulting in severe cognitive, occupational, and social dysfunction.

DAVEY 2014:

1. Worrying is a chronic and pathological activity triggered by major life change but also minor everyday hassles that others would not see as threatening (Tallis. Davey & Capuzzo, 1994).
2. Sufferer cannot control the onset or termination of their worrying
3. Worrying is associated with catastrophising of worriers where people with GAD suffer from increasing levels of anxiety and distress as the bout of worrying continues and worrying makes the problem worse than better

DSM:

• • Defining characteristic worry that is ‘chronic and pervasive’ and ‘uncontrollable’ with physiological hyperarousal, commonly muscle tension
• • Excessive relative to trigger, overestimation of threat in environment, especially when interpreting ambiguous cues

Question 4

What are the diagnostic criteria of GAD

Answer 4

APA, 2013
• Disproportionate fear or anxiety relating to areas of activity such as finances, health and family
• The individual experiences fear relating to at least two different areas fo activity and symptoms of intense anxiety will last for 3 months or more and will be present for the majority of the time during this period
• Feelings of anxiety or worry will be accompanied by symptoms of restlessness, agitation and muscle tension
• Anxiety are also associated with behaviours such as frequently seeking reassurance, avoidance of areas of activity that cause anxiety or excessive procrastination or effort in preparing for activities
• Symptoms cannot be explained by other mental disorders such as panic disorder

Question 5

Describe the prevalence of GAD

Answer 5

DAVEY 2014:
• Twice as common in women as in men
• Can persist from adolescence to old age
• Over 5% of the population will be diagnosed at some point in their lifetime
• Comorbidity is highly prevalent in sufferers of GAD – people diagnosed are suggested to suffer other problems such as depression and eating disorders
• 2nd most prevalent in primary care after depression

Important to understand why some people suffer from chronic and pathological worrying whilst others worry significantly less, even with stressful lifestyles.

Question 6

What is the meta-cognitive model of GAD

Answer 6

WELLS 1995:
This theory argues that the individual with GAD engages in worrying in response to negative thoughts as a means of trying to anticipate problems, avoid them or find a solution.
However, these individuals have developed metacognitive beliefs about worry that drive their worrying and also makes the process of worrying distressing such as positive beliefs that worrying will help them solve problems or negative believe that worrying will be uncontrollable or harmful – it is contradiction between the sets of beliefs that causes the worry related distress in GAD according to this model.

The meta-cognitive model makes an important distinction between two different types of worry in GAD where worrying about worrying is likely to extend normal worry episodes leading to maintenance of negative affect and cognitive disruption
– Of particular importance is the type called meta-worry (worry about worry) that emerges from negative metacognitive beliefs about worry itself. Meta-worry is a variable consisting of the negative appraisal of worry. Meta-worry can be distinguished from Type 1 worrying, which is worry about non-cognitive events such as external situations or internal physical symptoms.

Question 7

Define metacogntions

Answer 7

WELLS 1995: Meta-cognitions are overarching cognitive processes that are responsible for appraising, monitoring and controlling thinking and so have an important influence on what we think about and how long we will persist in thinking about something.

FLAVELL 1979: The appraisal of the content of thought or appraisal of cognitive processes is known as meta-cognition. Meta-cognition refers to a number of factors: stable knowledge or beliefs about one’s cognitive system and knowledge about factors that affect the functioning of the system; the regulation and awareness of the current state of cognition, and appraisal of the significance of thoughts and memories. It is conceivable that dysfunction at any of these levels could contribute to a subjective sense of loss of control of cognition and to a problem of intrusions.

Question 8

Describe the meta-cognitive model of GAD

Answer 8

It is proposed that individuals who develop GAD have a meta-cognitive dysfunction characterized by negative and positive beliefs about the effects of engaging in negative, perseverative appraisal, namely active worry. Moreover, worry for these individuals only becomes clinically problematic when they develop meta-worry. That is, when worry itself becomes the focus of rumination and of efforts at control.

Positive beliefs about worry contribute to the initial use of worry as a coping strategy but that negative beliefs about worry play a more important role in full-blown GAD

KEY FEATURE = TWO TYPES OF WORRY

• • Type 1 worries are general worries concerned with life events such as the social and health worries assessed by the two AnTI content dimen- sions, or the worry domains assessed by the Worry Domains Questionnaire (Tallis et al., 1992). Type 2 worries are a subset of meta-cognition and are concerned with worry about cognition; these worries are essentially meta- worries. I propose that normal worry consists of little or no Type 2 worry. whilst pathological worry like that found in GAD consists of both types of worry.
• • Type 2 worrying implies the direct accessing of knowledge about cognition (meta-beliefs). It is also closely linked to the execution of cognitive self-regulation strategies, and the monitoring of cognition. Type 2 worrying is involved in the transformation of normal worry into problematic varieties like that observed in GAD. There are several mechanisms by which this occurs:

1. Type 2 worry may lead to incomplete processing of Type 1 concerns by diverting processing resources (since Type 1 and Type 2 worries are probably limited by common resources).
2. Type 2 worry is likely to prime the controlled processing system for detection of worrying thoughts, thereby increasing sensitivity to worry triggers.
3. Type 2 worry can increase motivation for thought control attempts, some of which may be counterproductive.
4. Type 2 worry is capable of directly prolonging the activation of dys- functional meta-beliefs which may influence processing of other types of thought.

Question 9

How does meta worry occur

Answer 9

When worry itself becomes the source of worry; there are several potential pathways to meta-worry of this kind.

1. Repeated early practise of worrying will lead to a high level of automatization of the activity such that it may be elicited with little voluntary involvement (although its execution requires conscious deliberate processing) in response to an increased range of cues. Worry may therefore become increasingly disruptive and promote control attempts, which in turn incubate worry. In this way negative beliefs about the controllability of worry develop and these may be linked with other dysfunctional beliefs acquired through experience which influence the appraisal of the significance of subjectively impaired mental control (e.g., that is a sign of mental weakness, illness, or abnormality). These beliefs maintain meta-worry and distress associated with worrying.
2. Some individuals may not attempt to control their worries because they view them as positive or because they believe that such thoughts are uncontrol- lable. This may interfere with the development of strategies for control, and over-use of worry may contribute to the incubation of intrusions which in turn effects control beliefs.
3. Meta-worry results from life events that convey information that worry is potentially harmful or dangerous.

Question 10

Difference between worry in normal population compared to those with GAD

Answer 10

HIRSH 2014, When you have GAD you:

1. The worrying impairs daily functioning such as job and social life as the worry is uncontrollable.
2. Worries cause significant distress
3. Worries are not limited to specific things, but you worry about a range of topics even though there is a conscious awareness that you don’t need to be worrying
4. The worrying continues daily for a few months rather than a short period of time

Question 11

What were the early cognitive models of GAD

Answer 11

BORKOVEC et al. 1994: Avoidance model of worry

• Worry is a verbal/linguistic based activity which inhibits mental imagery and somatic/emotional activation (Beher & Bork, 2005; Borkovec & Inz, 1990)
• Worry is an unsuccessful cognitive attempt to problem solve a perceived threat whilst simultaneously preventing habituation of feared stimulus, however:
• Prevents emotional processing & corrective feedback
• Cognitive avoidance
• Ineffective problem solving

Question 12

Describe the Avoidance Model of Worry

Answer 12

– This model suggests that worry is a verbal, linguistic + thought- based activity (Behar, Zuellig, & Borkovec, 2005) that inhibits vivid mental imagery and associated somatic/emotional activation.
This inhibition prevents the emotional processing of fear that is theoretically needed for successful habituation and extinction. However, worry can be seen as an ineffective cognitive attempt to problem solve and thus remove a perceived threat as habituation/extinction are made possible through exposure to the entire spectrum of fear cues and emotional processing.
Given that avoidance can interfere with the emotional processing of fear (Foa & Kozak, 1986), the strategies used by individuals with GAD ultimately lead to the maintenance of high levels of worry and anxiety

– Worrying persists as it is negatively reinforced; catastrophic mental images that make their way into the mind are replaced by less distressing, less somatically activating verbal linguistic activity (worrying). Thus, worry is negatively reinforced by the removal of aversive and fearful images.

– Worry is further reinforced by positive beliefs, such as a belief that worry is helpful for problem-solving, motivating performance, and avoiding future negative outcomes. Positive beliefs are reinforced when negative future events do not occur or are effectively managed, thus further reinforcing the worry

Question 13

What is intolerance of uncertainty

Answer 13

The tendency to react negatively to situations that are uncertain — has been shown to be a relatively specific characteristic of persons with generalized anxiety disorder.

Although it is unclear whether the origin of this construct is experiential or genetic, the observation that a reduction in intolerance of uncertainty is an important mediator of outcomes of cognitive behavioral therapy provides support for its central role in this disorder

Question 14

Evaluation of methods in GAD

Answer 14

1. SELF-REPORTS are often used to diagnose patients: Brief questionnaires such as the Generalized Anxiety Disorder 7-Item (GAD-7) Questionnaire which takes only minutes for the patient to complete, can be used to screen for the disorder as well as to longitudinally monitor outcomes. However, patients may not fully be able to give information regarding themselves as they are unaware of their behaviour or are biased to seeing the positives/negatives. Also, patients rarely in primary care settings, however, report the symptom of worry which is a key feature of GAD. The predominant presentation in primary care (rather than mental health) settings is physical symptoms such as headaches or gastrointestinal distress Thus, validity of the data is reduced which comprises diagnostic ability - diagnostic interviews must also be held. STEIN+SAREEN 2015
2. Randomized, controlled trials provide strong evidence of the benefits of certain types of pharmacotherapy, psychotherapy, or both for generalized anxiety disorder.23-25 A stepped-care approach is recommended

Question 15

Evaluation of treatment methods for GAD

Answer 15

1. STEIN+SAREEN 2015: Although cognitive behavioral therapy and SSRI or SNRI agents are effective in reducing symptoms in up to 50% of patients with generalized anxiety disorder, it remains unclear how best to treat patients who have no response or only a partial response to those therapies. Furthermore, although most experts suggest that patients with generalized anxiety disorder who are treated with medication should continue to receive medication for at least 1 year, the most appropriate duration of maintenance treatment is not known.
2. STEIN+SAREEN 2015: Data from randomized trials are lacking to assess the effects of combinations of currently used therapies and also to assess complementary therapies (such as yoga and massage). Data are also lacking on the extent of use, usefulness, and safety of medicinal marijuana for generalized anxiety disorder

Question 16

Evaluation for Avoidance Model of Worry

Answer 16

1. EMPIRICAL SUPPORT:
   - - BEHAR+BROKVEC 2005: there is evidence supporting the notion that worry is primarily a verbal-linguistic as opposed to an imagery- based process
   - - BORKOVEC+ROEMER, 1995: There is also descriptive research suggesting that worry is reinforced among individuals with GAD via increased positive beliefs about worry. Individuals with GAD were shown to believe that worry serves as a distraction from more emotional topics, providing further evidence that it is used as a strategy to avoid emotional processing.
   - - worrying does appear to dampen somatic arousal at rest (Hoehn-Saric & McLeod, 1988; Hoehn-Saric, McLeod, & Zimmerli, 1989; Lyonfields, Borkovec, & Thayer, 1995; Thayer, Friedman, & Borkovec, 1996) and upon subsequent exposure to threat-related material

Question 17

Describe treatment for GAD based on Avoidance Model of Worry

Answer 17

BEHAR+BORKOVEC 2005 - Cognitive- behavioral techniques including:

(a) self-monitoring of external situations, thoughts, feelings, physiological reactions, and beha- viors;
(b) relaxation techniques such as progressive muscle relaxation, diaphragmatic breathing, and pleasant relaxing ima- gery;
(c) self-control desensitization, which entails the use of methods (e.g., imaginal rehearsal) to facilitate the acquisition of habitual coping responses;
(d) gradual stimulus control achieved by establishing a specific time and place for worrying;
(e) cognitive restructuring aimed at increasing clients’ flexibility in thinking and access to multiple, flexible perspectives;
(f) worry outcome monitoring in which clients keep regular diary entries in order to monitor specific worries, their feared outcomes, and the actual outcomes of those worries;
(g) the promotion of present-moment focus of attention
(h) expectancy-free living

Question 18

Describe the Intolerance of Uncertainty Model

Answer 18

DUGAS+KOERNER, 2005:
– According to this model individuals who are intolerant of uncertainty believe that uncertainty is stressful and upsetting, that being uncertain about the future is unfair, that unexpected events are negative and should be avoided, and that uncertainty interferes with one’s ability to function (Buhr & Dugas, 2002)

– The model has four main components, each of which can be conceptualized as a cognitive process involved in GAD: intolerance of uncertainty, positive beliefs about worry, negative problem orientation, and cognitive avoidance

– These individuals believe that worry will serve to either help them cope with feared events more effectively or to prevent those events from occurring at all.

– This worry, along with its accompanying feelings of anxiety, leads to negative problem orientation and cognitive avoidance, both of which serve to maintain the worry.

– IU serves to set off the chain of worrying, negative problem orientation, and cognitive avoidance, and argue that intolerance of uncertainty also directly affects one’s problem orientation and degree of cognitive avoidance. In this way, individuals with increased IU will be more prone to engaging in the worry process.

– Specifically, individuals who experience negative problem orientation (1) lack confidence in their problem solving ability, (2) perceive problems as threats, (3) become easily frustrated when dealing with a problem, and (4) are pessimistic about the outcome of problem-solving effort

Question 19

What is cognitive avoidance

Answer 19

Present in many models of GAD: (Borkovec, 1994), cognitive avoidance refers to the use of cognitive strategies (e.g., thought replacement, distraction, thought suppression) that facilitate avoidance of the cognitive arousal and threatening images associated with worry

Question 20

What are the different cognitive models of GAD

Answer 20

Several models of generalized anxiety disorder (GAD) have been proposed in recent years. Some emphasize the role of cognitive avoidance (i.e., Borkovec et al., 2004), whereas others focus on the function of metacognitive beliefs (i.e., Wells & Carter, 2001) or highlight the role of emotion dysregulation (i.e., Mennin et al., 2002). Alternatively, our clinical research group has developed a cognitive model that is based primarily on the idea that individuals with GAD have difficulty tolerating and dealing with the uncertainty of everyday life. (Dugas et al)

Question 21

What are the different treatments for GAD

Answer 21

1. Attentional Bias Modification
2. Drug Therapy
3. CBT

Question 22

Describe drug therapy for GAD

Answer 22

Based on biological approach to GAD:

• 50% sufferers advised to take antidepressants as first course of treatment e.g. SSRIs or serotonin-norepinephrine reuptake inhibitor (SNRIs)
• These are suggested to help as GAD is seen to be highly comorbid with depression + are more tolerated the anxiolytics
• benzodiazepine for the treatment of GAD in primary or secondary care except as a short-term measure during crises. (NICE)

Question 23

Evaluation of drug therapies

Answer 23

+ Short term effectiveness: Approximately, 40–60 % of patients will “respond” to placebo and 60–75 % to the SSRIs escitalopram, paroxetine, or sertraline, when using global measures of improvement. Similar findings are seen for the SNRIs duloxetine or venlafaxine and for the anxiolytic drug pregabalin (efficacy defined as a reduction in HAM-A score by 20 % or more)- BALDWIN 2007
– BUT GAD is usually regarded as a chronic disorder, waxing and waning in severity over many years, so long term methods are needed

• LADER 2015 Very few randomized controlled trials (RCTs) have directly assessed the relative efficacy of different drugs, when compared with placebo.
• BALDWIN 2005 Common concerns during longer-term treatment with SSRIs or SNRIs include the development of sexual dysfunction, weight gain, persistent disturbed sleep, and the potential for experiencing discontinuation symptoms on stopping the treatment:
  Anxiolytics show unwanted effects include sedation, disturbance of memory, and psychomotor function; other potential problems include development of tolerance, abuse and dependence, and distressing withdrawal symptoms.

Question 24

Describe CBT for GAD

Answer 24

Based on psychological approaches to GAD that explain the disorder as a result of cognitive biases and maladaptive beliefs which CBT aims to alter through certain steps; Borkovec & Newman, 1999: changes in one subsystem may lead to changes in the others. Thus, if people decrease their level of worry, which is first and foremost a cog- nitive phenomenon, this should lead to changes in their physio- logical responding, their subjective level of affect, and their worry- related behaviors.

1. SELF-MONITORING: the client is made aware of their fixed patterns of behaviour and what their triggers (thoughts about future events) for worry are and that these are often cognitively constructed rather than real.
2. RELAXATION TRAINING: aimed to deal chronic stress by administering progressive muscular relation (BERNSTEIN, 2000)
3. COGNITVE RESTRUCTURING: methods (such as outcome diary: client writes down daily worries and how likely they think they will happen and then what reality is) used to challenge the cog biases that the client has and aims to change these beliefs to reflect more accuracy
4. BEHAVIOURAL REHARSAL: actual/imagined rehearsal of adaptive coping responses that need to be deployed when a worry trigger is encountered

Question 25

Evaluation of CBT

Answer 25

+ LANG 2004- Effective: with or without drug therapy alongside.
MITT 2005: A carefully conducted 2005 meta-analysis of 65 randomized and nonrandomized controlled trials with 7739 participants found that CBT was effective for GAD, superior to no treatment (effect size = 0.82) [45]. Other meta-analyses have identified effect sizes for CBT compared to other control conditions: waiting list and placebo controls (effect size = 1.8) [46] and placebo controls only (effect size = 0.44 to 0.57)

+ DURHAM etal. 2003- Long term effectiveness

+ RICHARDS+RICHARDSON, 2015: Useful method as transferrable to modern technology: The meta-analysis supports the efficacy of internet-delivered treatments for GAD including the use of disorder-specific (4 studies) and transdiagnostic treatment protocols (7 studies).

• HANRAHAN+JONES 2013- meta analysis showing that some sufferers still fail to recover fully when using CBT: showed an effect size of d=1.81 for the effects of cognitive therapy compared to non-therapy controls for pathological worry, although effects were weaker in comparison to other therapies
• CRASKE 2003- Appropriateness: Individuals for whom CBT works best are generally highly motivated and value a problem-solving approach. CBT requires that the patient learns the skills of self-observation and of becoming a personal scientist, cognitive and behavioral coping skills, and to repeatedly practice the skills in anxiety-provoking contexts outside of the therapy setting
• – OLDER ADULTS vs. YOUNGER: Rates of response of GAD to CBT are generally lower in late-life samples compared to younger adults. (STANLEY etal. 2013) in a late-life sample with GAD treated with CBT in primary care, only 40 percent of the intent-to-treat sample was classified as responders compared to an average 56 percent response rate found in trials of non-late-life samples.
• Inconsistent results: It is unclear which components are critical to CBT’s effectiveness. Trials have provided evidence for the effectiveness of most of the components as stand-alone treatments. Trials comparing individual components have had mixed results.
  One trial found cognitive therapy to be superior to applied relaxation (BORKOVEC, 1993), but other trials found cognitive therapy and applied relaxation to be equally effective (DUGAS etal. 2010)

Question 26

Describe attention bias modification therapy for GAD

Answer 26

Based on information processing models that assume GAD is caused by interpretational/attentional biases towards threat that cause pathological worrying.

Aim: to reverse these biases and use experimental procedures that will neutralise them

Procedure: Uses dot-probe task, developed originally by Macleod et al. (1986). 2 stimuli are presented on screen. 1 of the stimuli is emotionally salient (a drug cue or threat cue) and the other is neutral. Stimuli (usually words or images) are presented and then one of the stimuli is replaced by a probe to which the participant must respond. Required responses are usually to indicate what side of the screen the probe is on or to indicate which direction the probe is pointing. The bias is seen by the difference in reaction time to the probe after it replaces a salient cue versus the reaction time to respond to a cue that replaces the neutral cue.

MATTHEWS, 2002
Attentional retraining attempts to retrain this automatic attentional process by using the dot-probe task and having the probe replace the neutral stimuli 100% of the time. Thus, the participant learns an implicit if-then rule: if both salient and neutral stimuli are present, then attend preferentially to the neutral stimuli.
Therefore, if attentional biases have a causal role on the maintenance of anxiety then lowering the attentional biases should therefore lower feelings of anxiety amongst the anxious.

Question 27

Evaluation of attention bias modification therapy

Answer 27

+ SEE, MACLEOD, BRIDLE, 2009: effective treatment - training procedure can give rise to significant attentional avoid- ance of negative information and shows that with repeated daily exposure to the training task, this attentional bias can endure beyond the boundaries of the training sessions.
— however, conducted only on Singaporean high school graduates and that the sole stressor considered was transition overseas to commence tertiary education, it would be prudent to replicate this work with different participants and with alternative life events before con- cluding that the observed effects generalize to other populations and naturalistic stressors.

+ AMIR, 2009: again effectiveness - Participants undergoing the Attention Modification Program demonstrated a decrease in attention bias to threat and a decrease in anxiety symptoms. Fifty percent of participants in the AMP were classified as responders (no longer meeting DSM diagnosis for GAD) compared to 13% of participants in the ACC