Lecture 4-General Anxiety Disorders+ Panic disorders- dont revise Flashcards
what is GAD
a pervasive disorder where the patient experiences anxiety about a wide range of events and social situations, however may not be able to pinpoint what is worrying them. They are often usually easily startled and on edge. Sometimes these feelings lead to more severe anxiety, such as panic attacks. These anxious feeling are often associated with somatic complaints such as stomach cramps, diarrhoea and skin rashes.
what is Panic disorder
- key feature= panic attacks
many people have panic attacks but people with disorder experience them more often
often fearful and reluctant to leaving their home
as a consequent its related to agoraphobia
Describe the DSM for GAD
- Excessive anxiety and worry occuring more days than not- for at least 6 months about a no. of events and actitives
- person find its difficult to control worry
- anx and worry associated with 3 (+) thibgs of following symtpoms
- restlessness
- easily fatigued
- hard to concentrate
- muscle tension
- irritability
- sleep disturbance
anx/ worry causes signif clinical impairment
not due to anything else eg meds or mental disoder
Prevalence for GAD
Wittchen et al 2011
1.7-3.4% OF POPULATION
8.9 million
f/m ratio = 2:1
Kessler 2005
lifetime prev of 5.7 %
high levels of comorbidity between SAD AND DEPRESSION
comorbidity between GAD and other illnesses
High levels of co-morbidity between GAD and other psychological diagnoses, particularly SAD and depression, avoidant and dependent PDs
- High levels of co-morbidity between GAD and physical diagnoses, particularly gastrointestinal problems – stomach ulcers, IBS
things people with GAD worry about
AD patients worry about several things, sometimes quite minor (Tyrer & Baldwin, 2006)
o Job performance
o College/university work
o Relationships
o Health and death
o Being late
- Worries can shift focus across day, from one thing to another
- GAD is exhausting – being constantly anxious wears people down
Gad aitology : psychoanalytic theories
Unconscious unresolved conflict between ego and id impulses
o E.g. Young child repeatedly punished for expression of id impulses
- E.g. Toddler punished for demanding food or for genital exploration
- And/or ego defence mechanisms not strong enough to cope with normal levels of anxiety
o E.g. Over-protected child, does not experience the usual frustrations and threats of growing up, or not sufficiently strongly to develop effective defence mechanisms
- Contemporary psychodynamic theorists might disagree with some of the details of Freudian theory
o But they still see the roots of GAD in an inadequate relationship between child and parents (Sharf, 2012)
Gad aitology : biological theories
Evidence of reductions in some neurotransmitters
o e.g. serotonin (Mogg et al. 2004)
- Gamma aminobutyric acid (GABA)
o GABA usually inhibits anxiety under stress
- Hypothalamic–pituitary–adrenal (HPA) axis
o Controls reactions to stress
o May play a less significant role in GAD than it does in other anxiety disorders
- Genetic factors (see Hettema, et al 2001)
o Modest but significant role of genetic heritability for GAD
- Twin studies ð .32 heritability (always between 0 & 1)
o Strong evidence of underlying genetic predisposition
- But clear evidence of role of environment/ experience too
Gad aitology : cognitive theories
Metacognitive Model of GAD (Wells, 1995; 2007)
- Individuals with GAD experience two types of worry:
- Type 1 Worry
o Active strategy for coping with anticipated danger and threat
o Often triggered by external events and non-cognitive internal experiences such as physical symptoms
o Once triggered, positive metacognitive beliefs (e.g. “If I worry, I’ll be prepared;” “worrying keeps me safe”) lead people with GAD to repeatedly consider a series of danger-related “what if” questions
o Until they feel they have generated acceptable coping strategies; that they will cope if the feared threat materializes
- Type 2 worry
o During the course of Type 1 worry, negative beliefs about worry are activated: ‘Worry about worry’ or ‘meta-worry’
o E.g. “Worrying could make me go crazy”; “Worrying is uncontrollable”; “Worrying can damage my body”
o Attempts are then made to avoid worry
o Type 2 worry distinguishes between GAD and non-clinical worry
GAD treatment: Biological
Benzodiazepine drugs (such as Valium)
o Increase availability of GABA
o Show some benefits in short-term use
o But should be avoided long-term
o Show good efficacy vs. placebo in double-blind RCTs
o But side effects are a major problem:
- Over-sedation, muscle relaxation
- Deficits to attention, cognitive, and memory function
- Physical dependence
- Tricyclic antidepressants (TCAs)
o e.g. imipramine associated with successful treatment
o Better long-term efficacy than benzodiazepines o Greater evidence of side effects
o But less serious than benzos
- Selective Serotonin Reuptake Inhibitors (SSRIs)
o Paroxetine licensed for GAD treatment
o Several RCTs have shown SSRIs effective in treating GAD
o But some side effects reported with SSRIs
- Nausea, fatigue, sexual dysfunction, insomnia
- Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) also useful
o e.g. venlafaxin
define worry
o “Worry is a chain of thoughts and images, negatively affect-laden and relatively uncontrollable. The worry process represents an attempt to engage in mental problem-solving on an issue whose outcome is uncertain but contains the possibility of one or more negative outcomes.” (Borkovec, Robinison, Pruzinsky, & DePree, 1983)
why was GAD treated as a residual diagnosis
people with signif anx who did not meet the criteria for any pther diagnosis said to have GAD
Behavioural treatments for GAD
Initial treatments sought to target specific fear/ avoidance
o But finding specific cause in GAD not easy
o Cognitive-behavioural interventions
o CBT most common psychological treatment for GAD
o Cognitive restructuring and relaxation
o Tackle distorted thoughts and information processing
o Reduce catastrophisising of minor events
o Reduce tension
o Example of more specific, model-based intervention: Metacognitive Th
WHAT IS METACOGNITIVE THERAPY
General CBT might focus on challenging content of Type 1 worrying
- This can result in resistance and worry substitution
- MCT emphasizes the importance of examining the patient’s metacognitions (Type 2 worrying) that drive the implementation of maladaptive coping
- 5 key components: o Case formulation o Socialisation to the treatment
o Modifying negative beliefs about uncontrollability of worry
o Modifying beliefs about the danger of worry
o Modifying positive beliefs about worry
evaluate the treatments for GAD
Despite success, CBT/contemporary cognitive therapies are still less common than pharmacotherapy (Dinan, 2006)
o This has probably changed through IAPT in the UK
- Evidence that joint therapy has additional benefits (Gosselin, et al. 2006)
