Generalised Anxiety Disorder Flashcards
Prevalence of GAD
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
Fight or flight physiology
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
Psychophysiology of fear
fear response = first line of defence against threat (primitive)
neo-cortex and limbic system interact
two pathways: high road vs low road
High road
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
Low road
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
Is fight or flight response helpful?
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
Anxiety and fear
evolutionary fear response: body responds to specific and definite threat
anxiety: diffuse, unpleasant, vague sense of apprehension - usually error in perception
GAD
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
DSM-Criteria
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
Carter et al., 2001
69-93% co-morbidity rates
Borkovec et al., 1983
central feature of GAD - worry
Worry is a chain of thoughts and images, negatively affect laden and relatively uncontrollable
Consequently worry is closely related to the fear process
Nature of worry
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
Is worry normal?
38% people have at least one worry per day
it is on a continuum
High worry or GAD?
Hirsch, 2014
higher negative beliefs about worry lack of cognitive self-confidence higher need to control thinking more worry types high anxiety and depression levels
Newman, 2013
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
Aetiology:
Biological theory
some evidence for genetic component
but specific genetic component effect is modest (Hettema et al., 2001)
Aetiology:
Avoidance model of worry
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
Aetiology:
Second wave model
Intolerance of uncertainty
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
Aetiology:
Second wave model
Intolerance of uncertainty diagram
Dugas and Robichaud, 2007
what if –> positive beliefs about worry –> worry –> anxiety –> cognitive avoidance and negative problem orientation –> cycle restarts
Aetiology:
Second wave model
Meta-cognition model
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
Aetiology:
Cognitive model of worry
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
Support for cognitive model of worry
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
Treatment approaches general
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
Treatment approach:
medication
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
