L5: Generalised Anxiety Disorder

Question 1

Which version of the DSM was GAD introduced in as a distinct disorder?

Answer 1

DSM-III-R

Question 2

What are the six criteria for GAD in the DSM-5?

Answer 2

A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).

B. The individual finds it difficult to control the worry.

C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months): Note: Only one item is required in children.

Restlessness, Being easily fatigued, Difficulty concentrating, Irritability, Muscle tension, Sleep disturbance.

D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).

F. The disturbance is not better explained by another mental disorder

Question 3

What are five elements of normal worry?

Answer 3

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

Question 4

What are four major theories that seek to explain GAD?

Answer 4

• Problem solving theory
• Avoidance theory
• Intolerance of uncertainty theory
• Meta-cognitive theory

Question 5

How does problem solving theory conceptualise GAD?

Answer 5

• Worry involves problem solving attempts
• Problem solving attempts of pathological worriers are thwarted. -> biased threat perception.
• Social problem solving involves four elements: problem definition, generating alternative solutions, solution evaluation, solution selection.
• High worriers have difficulty with solution evaluation and selection, as they evaluate all solutions negatively and cannot commit to one.

Question 6

How does avoidance theory conceptualise GAD?

Answer 6

• Worry contains more verbal thought than imagery
• Images of possible negative event are highly aversive, and induce anxiety symptoms, which are themselves aversive
• Worry shifts the process from imagery to verbal content, reducing arousal and anxiety symptoms.
• Worry is a form of cognitive avoidance. Avoidance interferes with emotional processing, fear structures are maintained.

Question 7

How does experiential avoidance help maintain GAD?

Answer 7

• Worry is associated with 1. fear of anxiety/anxiety sensitivity, 2. Distress intolerance, 3. Experiential avoidance (worriers avoid internal experiences.
• Difficulties in emotional regulation. Worriers have difficulties in 1. clearly identifying emotion, 2. tolerating emotion, and 3. modulating emotion.

Question 8

How does intolerance of uncertainty theory conceptualise GAD?

Answer 8

• uncertainty thought to reflect badly on a person. Causes frustration and stress, and prevents action.
• worry to reduce uncertainty
• Leads to preoccupation with details
• interferes with problem solving
• worriers aim to reduce uncertainty to zero, but not possible. -> worry is maintained

Question 9

How does metacognitive theory conceptualise GAD?

Answer 9

• Worry (Type 1) and Metaworry (Type 2)
• Type 1 worry: perception of threat + positive beliefs about worry. -> worry to cope with threat.

Type 2 worry: worry + negative beliefs about worry -> metaworry -> ineffective thought control strategies -> increased anxiety and worry -> excessive and uncontrollable worry.

Question 10

How do the different models of worry guide different approaches to treatment?

Answer 10

• Biased threat perception: challenging beliefs re: probability and cost judgements.
• Problem solving: structured problem solving training.
• Avoidance: exposure to image of feared event, exposure to emotoinal experience/distress, exposure to uncertainty.
• Metacognitive: challenge beliefs about worry, both positive and negative.
• Treatment effects modest, with 50-60% improvement at followup.
• new approaches involve mindfulness as a form of exposure to internal states/somatic sensations. And interpersonal approaches.