Generalised Anxiety Disorder

Question 1

Prevalence of GAD

Answer 1

twice as common in women than men
Witchen and Hoyer, 2001 - 5% + of population will be diagnosed with GAD at some point in their life
50% begins in childhood or adolescence
NICE, 2011 - usually 35-55 yer olds present to services

Question 2

Fight or flight physiology

Answer 2

Dizzy/lightheaded - due to adrenaline and increased oxygen levels
Dry mouth - cortisol shutting down inessential systems reduces saliva in mouth
people feel anxious at physical effects of fight or flight - some fear of physiology itself causes major ongoing social fear issue

Question 3

Psychophysiology of fear

Answer 3

fear response = first line of defence against threat (primitive)
neo-cortex and limbic system interact
two pathways: high road vs low road

Question 4

High road

Answer 4

Thalamus (receives sensory information)
To sensory cortex (information analysis for threatening stimuli)
To hippocampus (uses memory to determine likely threat)
To hypothalamus (activates fight or flight)
Adrenal-cortical system or sympathetic nervous system activated

Question 5

Low road

Answer 5

Thalamus (receives sensory information)
To amygdala (determines threat and emotional significance)
To hypothalamus (activates fight or flight)
Adrenal-cortical system or sympathetic nervous system activated

Question 6

Is fight or flight response helpful?

Answer 6

yes: real life application (emergency stops, response to spider on leg)
if you have no adrenal glands and cannot produce adrenaline you know you should feel fear but you don’t

Question 7

Anxiety and fear

Answer 7

evolutionary fear response: body responds to specific and definite threat
anxiety: diffuse, unpleasant, vague sense of apprehension - usually error in perception

Question 8

GAD

Answer 8

condition of suffering continual apprehension and anxiety about future events, leading to chronic and pathological worrying about those events
it is disabling and a source of extreme emotional discomfort

Question 9

DSM-Criteria

Answer 9

excessive anxiety/worry occur for at least 6-months
there is difficulty in controlling the worry
worry is accompanied by (3+): restlessness, difficulty concentrating, sleep disturbance, easily fatigued, irritability, muscle tension
focus of anxiety is not confined to features of other Axis 1 disorders
causes significant distress or dysfunction
there is no effect from substance problem or general medical condition

Question 10

Carter et al., 2001

Answer 10

69-93% co-morbidity rates

Question 11

Borkovec et al., 1983

central feature of GAD - worry

Answer 11

Worry is a chain of thoughts and images, negatively affect laden and relatively uncontrollable
Consequently worry is closely related to the fear process

Question 12

Nature of worry

Answer 12

what if statements
focus on everyday events - relates to potential future danger
trigger behaviour to control worry
beliefs about worry are central (helpful and prevents things happening)
lasts minutes to hours
usually distressing, easily precipitated

Question 13

Is worry normal?

Answer 13

38% people have at least one worry per day

it is on a continuum

Question 14

High worry or GAD?

Hirsch, 2014

Answer 14

higher negative beliefs about worry
lack of cognitive self-confidence
higher need to control thinking
more worry types
high anxiety and depression levels

Question 15

Newman, 2013

Answer 15

likely childhood attachment link to GAD - ambivalent or anxious/avoidant
hypersensitivity in amygdala - vulnerable to threat
history of trauma
greater intensity of emotional experience
slower recovery from negative experiences

Question 16

Aetiology:

Biological theory

Answer 16

some evidence for genetic component

but specific genetic component effect is modest (Hettema et al., 2001)

Question 17

Aetiology:

Avoidance model of worry

Answer 17

Borkovec, 1994
based on Mowrer, 1946 two-stage model
worry is verbal, linguistic based activity which inhibits mental imagery and somatic/emotional activation
worry is an avoidance/coping strategy prevent fight-or-flight response
it’s an unsuccessful cognitive attempt to problem-solve (prevents emotional processing and corrective feedback; cognitive avoidance; ineffective problem-solving)
reinforced by worry beliefs

Question 18

Aetiology:
Second wave model
Intolerance of uncertainty

Answer 18

uncertain/ambiguous situations are key stressors
problems seen as threats, worry is coping mechanism or preventative mechanism
- intolerance of uncertainty
- cognitive avoidance
- positive beliefs about worry
- negative problem orientation
intolerance of uncertainty leads to worry and anxiety

Question 19

Aetiology:
Second wave model
Intolerance of uncertainty diagram

Answer 19

Dugas and Robichaud, 2007
what if –> positive beliefs about worry –> worry –> anxiety –> cognitive avoidance and negative problem orientation –> cycle restarts

Question 20

Aetiology:
Second wave model
Meta-cognition model

Answer 20

Wells, 1995
cognitive attentional syndrome
two types of worry:
type one- worry about non-cognitive events
two two- worry about worry
positive and negative beliefs about worry reinforce worrying as strategy
ineffective coping strategies

Question 21

Aetiology:

Cognitive model of worry

Answer 21

Information processing bias7those with GAD have biases in interpreting, storing or recalling information - may give rise to dysfunctional behaviour and may maintain hypervigilance for threat and anxiety
Hirsch and Matthews, 2012
- biases in emotional processing
- depleted/misdirected executive control
- verbal worry
bias to threat cues in environment result in increased perception of danger, more frequent intense experiences of anxiety/worry

Question 22

Support for cognitive model of worry

Answer 22

Kircanski et al., 2015 - biases increase likelihood of attention/intrusion of threat related information and depleted executive control leads to onset of worry
Yiend, 2015 - delayed disengagement maintains worry episode - but recent studies suggest faster disengagement from negative faces
Mogg and Bradley, 1998 - those with GAD preferentially allocate attention to threatening stimuli and threatening information - happens pre-attentatively and for verbal and physical stimuli

Question 23

Treatment approaches general

Answer 23

cognitive models mostly
influenced by Beck
recent adaptations to CBT focus treatment on underlying processes - i.e. intolerance of uncertainty (Dugas et al., 2007); beliefs about worry (Wells, 1999)
drugs or psychological therapy - drugs for short-term, psychological for long-term

Question 24

Treatment approach:

medication

Answer 24

anxiolytics (i.e. benzodiazepine) usually first line of treatment
Apter and Allen, 1999 0 these are more effective than placebos for sufferers
but usually only short-term solution

Question 25

Treatment approach:

CBT

Answer 25

cognitive part helps change thinking patterns supporting the fears
behavioural part help change the reaction to anxiety-provoking situations
exposure is key - but only when client is ready and has guidelines on how to respond
therapy usually lasts 12 weeks - can be done in group or individually
examples: self-monitoring, relaxation training, cognitive restructuring and behavioural rehearsal

Question 26

Treatment efficacy CBT

Answer 26

Hunot et al., 2007 - CBT is effective in reducing anxiety symptoms - maintained at 1 year
Covin et al., 2007 - using a more stringent meta-analysis found CBT to be most effective for younger adults with individual treatments - but all showed maintenance of gains at 6 and 12 month follow-up
Evans et al., 2007 - CBT effective for GAD but suggested the mindfulness-based cognitive therapy may be an acceptable alternative with similar effectiveness

Question 27

Treatment mechanisms

Answer 27

Donegan and Dugas, 2012 - treatments have similar efficacies but different mechanisms -consistent with theoretical underpinnings of treatment

Question 28

Criticisms of the evidence (4)

Answer 28

mostly analogue data
high co-morbidity - so how can you know it’s effective for anxiety and not the other disorder
threats to ecological validity: artificial situations and induced worry
questionnaire use: common priming and post-hoc rationalisations

Question 29

CBT

Answer 29

Assessment: analysis of worry episodes, relevant background factors, impact on daily life
Goals and problem list
Conceptualisation and formulation: cross-sectional and longitudinal, formulation dictates intervention
Psycho-education: physiology of anxiety to correct misconceptions, explanation of various vicious cycles
Behavioural interventions
Cognitive interventions
Relapse prevention