Lecture 5 - Generalized Anxiety Disorder and Social Anxiety Disorder Flashcards
Where are GAD and SAD in the HiTOP model?
Internalizing
-Fear… SAD
-Distress…GAD
DSM-5 definition of GAD (Generalized Anxiety Disorder)
History:
*DSM-II lumped into broad
category of “Anxiety Neurosis”
*In DSM-III, GAD broken out
*DSM-III-R GAD changed to
have more of its own identity
-Worry begins to play a larger
role
-Pathological worry– has to be
about everyday situations,
not just about another
disorder
-Sometimes difficult
differential diagnosis (difficult to differentiate from other diagnoses)
DSM-IV
Simplified the criteria
-EXCESSIVE anxiety and worry
-More days than not
-At least 6 months
-About multiple events, activities,
objects
-Difficult to control the worry
-Cannot occur exclusively during (ex: can have comorbid mdd, but can’t be GAD if happens only when mdd episode)
DSM criteria
*Restlessness, feeling on edge
*Easily fatigued
*Difficulty concentrating
*Irritability
*Muscle tension
*Sleep disturbance
*Must cause significant
distress or impairment
Overlap with depression?
Controversial
*Almost ALWAYS comorbid with
something else (more than other
disorders)
*NA? (negative affectivity)
*Vulnerability marker? (Presymptomatic state of another disorder?)
Prevalence of GAD
- 5-6% lifetime
- 12-month prevalence: 3.1%
- 2F:1M
*Most commonly diagnosed Axis I
disorder in primary care
*As many as 90% of diagnosed cases
meet criteria for another disorder
-As many as 80% of dx cases meet
criteria for a mood disorder
-Also panic disorder, social anxiety
disorder, personality disorders
Problems in GAD
*Associated with increased health care
utilization
-More frequent visits to doctor
-In primary care… gastrointestinal problems
-headaches, stomach issues, jaw problems
* Increased health care costs
-Greater chance of concurrent
physical illness
*And significant social, academic, and
vocational impairment
-Days lost at work/school
-Damage to relationships
Course of GAD
*Symptoms often evident in
adolescence or earlier
*Median age of onset in the 30s
*But can onset at any time
*Gradual onset
*Chronic course (persists for a long time)
-Personality disorder
- 12-year follow-up study, the recovery
rate is 58%
-Of those who recover, the recurrence
rate is high
Familial Transmission
*Trait anxiety HIGHLY familial
*Strong genetic component
*GAD also runs in families
*Family Studies:
-Increased rates of GAD in
families of probands with GAD
-Higher rates than in probands
with panic disorder
-Suggests some specificity
GAD important distinctions from MDD
*Reliability of GAD diagnosis (inter-rater reliability)
*Predictive Validity (know about course of disease)
*Mechanisms of the disorders
-Attentional biases (direct attention to one thing in environment and not others (ex: more likely bias towards threat)
-Memory Biases (remember negative things in past than positive or neutral… and remember it as worse)
-Intolerance of Uncertainty
-Low PA (positive affect)
(wait are those in mdd or gad or both?)
*Precipitating Stressors
-Humiliation in MDD
-Danger events in GAD
*Response to laboratory stressors
-ECI (emotional context insensitivity) in MDD (same flat response to positive, neutral and negative things… disengagement from environment)
-Hyperresponsivity in GAD (hyper response to threat, normal response to positive and neutral)
*Temporal Course
-Not clear
-Extreme goal focus (GAD) (prevention focus)… leads to burn out to
motivational disengagement
(MDD)
*Uncertainty about the negativity of future events (GAD) to certainty
about the negativity of future
events (MDD)
*Beliefs of helplessness (GAD) (worry but don’t know what to do) to
beliefs of hopelessness (MDD) (not even gonna try anymore)
‘’Prototypical’’ anxiety disorders vs. GAD
*GAD doesn’t have concrete object of fear…. Usually fear of own emotions and thoughts… afraid of being overwhelmed by anxiety… catastrophizing
*Phobia avoidance= just walk away from the pigeon
*Cognitive avoidance… instead of feeling feelings in body, they do cognitive series of operations
*Negative reinforcement of worry with cognitive avoidance (if I worry, the bad things won’t happen, it worked the bad things didn’t happen! I’ll keep worrying… keep worrying to keep things from happening)
Tom Borkovec’s theory of Worry
*Most prominent current
theory of GAD comes from
Tom Borkovec
*Worry = cognitive avoidance
-Low probability events
*Worry= cognitive, verbal mental
operation
*Buffers GAD from high emotional
arousal
*Don’t get vivid imagery
-Exposure Tx: you need the imagery to
become emotionally aroused
-If never get aroused, never change your
fear structure
*Worry inhibits emotional processing
*Also evidence that GAD try to
control or suppress the worry
*Vicious cycle
*Inability to control worry
increases sense of lack of
control
*Increases intrusiveness of the
thoughts
*Cycle perpetuates itself
*Don’t think of a White Bear!
You have to feel the worse thing… feel the arousal of worse case (worry suppresses that)
But also people try to suppress worry (but ‘don’t think of a white bear’ cycle)
Cognitive factors in GAD
*Attentional biases (detect and spend more time looking and remember better) threatening info
*Biases towards neutral (interpret neutral, ambiguous, as more threatening)
-Hypervigilance to threat at first
-Vigilance avoidance (direct attention away from threat)
*Worry=GAD (fears of what will happen, future oriented, how to prevent bad) vs. rumination=MDD past oriented, rehearse or try to fix past interaction or event)
Ambiguous word stems
(see image)
Social Anxiety Disorder/Social Phobia (old name): Characteristics
- Second most common anxiety
disorder - 3rd most common psychiatric
disorder - Impairment: romantic and
other social relationships,
career, and education
DSM-5
* Criterion A: “Marked fear or
anxiety about one or more social
situations in which the individual is
exposed to possible scrutiny by
others.”
* Criterion B: person “fears that he
or she will actin a way or show
anxiety symptoms that will be
negatively evaluated (i.e., will be
humiliating or embarrassing; will
lead to rejection or offend
others.)”
*Criterion C: social situations
almost always provoke fear or
anxiety
*Criterion D: these situations are
avoided or endured with great
distress
*Criterion E: fear or anxiety is out
of proportion to the actual threat
posed by the social situation and
to the sociocultural context
*Fears often involve specific
situations
-Speaking in public
-Eating in public
-Writing in front of other
people
-Using public bathrooms
– slightly more common for
men
*Also a generalized Social
Phobia– multiple situations
are feared or avoided.
Epidemiology of SAD
*Social: 12%
*2F:1M
-Gender diff emerges in
adolescence
*Comorbidity very high
*Social Phobia: high standards,
very self-critical, tend to
scrutinize themselves
*High self-criticism in
Depression
Racial/Ethnic differences
* Rates similar in N and S America
* Prevalence far lower in East Asian countries
- less than 1% 1‐year prevalence (6-7% in N
America).
* East Asian race/ethnicity associated with
low prevalence in N. America as well.
* In N. American samples, Hispanic or Black
ethnicity/ race also associated with lower
risk compared to non‐Hispanic white.
* Genuine differences in psychopathology?
* Insufficient consideration of cultural aspects
of the DSM criteria, assessment
instruments, or influence of features
associated with race, ethnicity, and culture?
Why white people way more social anxiety? We don’t know for sure (my theory is that is has to do with individualism)
Age of Onset
*Animal phobias, mean age of
onset: 7
*Blood and injury: 9
*Dental Phobias: 11
*Social Phobia: 16
Cognitive Theories of Social Anxiety Disorder
*Social situations activate core set of
values or beliefs re: social
competencies
*Believe others will view them
negatively
*Schemas interfere with
interpretation of social situations
*Begin to see danger and threat
*The more anxious they feel, the
more likely they think rejection is
*Makes them more anxious
*Self-focus factor that maintains
the disorder
*Functions as “safety”/ avoidance
behavior
*Used to forestall social disasters
*Even after situation, a biased
memory for negative experiences
*Reinforces negative expectation of
self
*Vicious cycle
Research in support of theory
*Stroop studies
*Dot-probe
*Discrepancies?
*Vigilance-Avoidance
*Stimulus duration
Example of Social Vignettes
*It’s the first day of class, and you’re running late.
You walk into the room, and almost every chair is
taken. You see that a girl with a seat close to you is
sitting next to a chair with a bag on it. You approach
her and ask her if that seat is taken. She pauses for
a long time before answering.
*What does she say?
