Lecture 7 - Generalised Anxiety Disorder

Question 1

Generalised Anxiety Disorder - Description, Onset and Prevalence & Course

Answer 1

• excessive anxiety most of the time, with worries about a variety of topics, even when there is no reason to worry. The worry is hard to control and can interfere with daily functioning, and often has physical symptoms.
  
  • Onset and Prevalence – 30ish years, increasing prevalence with age. 2:1 female to males. 2.7% 12 month prevalence, 6% across lifespan.
  • Course – 6-12 year most clients still affected, and 8-14 years after treatment only 1/3 still in remission. Chronic course with a much higher cost associated with it than other anxiety disorders in sick leave and health resources.

Question 2

Generalised Anxiety Disorder - Aetiology

Answer 2

• Risk factors – 1/3 genetic risk; stress; parental overprotection and insecure attachment relationships; and an inhibited temperament.
• Avoidance Model of Worry – perception of threat results in worry, with worry being a cognitive, verbal process that can be used to inhibit vivid imagery and somatic/emotional activation. Worry is negatively reinforced because the distress is lowered and the negative situations that they are worrying about usually don’t occur. They also hold positive beliefs that worry helps problem solve. They do not effectively emotionally process fear so that the threat never reduces.
• Metacognitive Model – trigger activates positive beliefs about worry which results in Type I worry about external situations or physical symptoms. Worry is used as an inflexible and dominant coping strategy and is characterised by catastrophic what if thinking. Following Type I worry, negative beliefs are activated (worry is harmful, or unable to emotionally regulate within Type I worry). This leads to Type II worry, with the beliefs that worry is uncontrollable and harmful or dangerous. Maintained through avoidance, seeking reassurance, using substances, attempting to avoid worry, and suppressing thoughts.

Question 3

Generalised Anxiety Disorder - Assessment

Answer 3

• Anxiety Disorders Interview Schedule (ADIS) – assesses for all anxiety disorders and screens for other diagnoses. Tests for onset and severity of GAD symptoms. 4+/7 is in the clinical range. Assesses content and uncontrollability of worry. Good diagnostic reliability.
• Structured Clinical Interview for DSM-IV – low interrater reliability and test-retest reliability with GAD diagnosis.
• Depression Anxiety Stress Scales (DASS) – stress dimension correlates with GAD. Session-to-session feelings and treatment tracking. Not precise enough for diagnosis.
• Penn State Worry Questionnaire (PSWQ) – severity of worry, used for treatment tracking. Good psychometrics.
• GAD Specific Questionnaires – 5.7/9 clinical cut-off. GAD-7 most commonly used – good reliability, validity and ease of administration.

Question 4

Generalised Anxiety Disorder - Diagnosis

Answer 4

• excessive anxiety and worry occurring more days than not for at least 6 months about a number of activities. The individual finds it difficult to control the worry. The anxiety or worry is associated with (3/6) symptoms – restlessness/on edge, easily fatigued, difficulty concentrating or mind blanks, irritability, muscle tension, and sleep disturbance. They cause clinically significant distress or impairment, and is not attributable to the physiological effects of a substance.
  
  • Comorbidity – highly comorbid with anxiety and depressive disorders. 34% of GAD clients had 2 other disorders. Mostly panic disorder, MDD, and social phobia.
  • Differential diagnosis – worries in other anxiety disorders (panic, phobias, SAD, etc.) except the content of the worry is more diverse. Obsessions in OCD.

Question 5

Generalised Anxiety Disorder - EBT

Answer 5

• In vivo exposure is almost impossible in GAD thanks to the fact that it often isn’t characterised by physical avoidance.
• CBT is the first line treatment and gold standard, with brief psychodynamic therapy and self-help and MBCT having growing levels of support. ACT also has an RCT that shows it performing equally to CBT.
  
  • Cochrane – 46% CBT responded vs 14% TAU, with anxiety, depression, and worry also significantly reduced in CBT. CBT had higher response rates than PD therapy, supportive therapy or BT.
  • CBT highly effective at reducing pathological worry – individual > group, younger > older.
• Behar & Borkovec treatment – self-monitoring, relaxation, self-control desensitisation (vivid imagination and emotional processing of distressing imagery), interpersonal and emotional processing (social skills), worry periods, cognitive challenging and restructuring (rehearsal and deployment of multiple perspectives, worry outcome diary, motivation in the moment, present moment living).
• Wells treatment – psychoeducation about Type II metaworry, worry thought record, socialising experiments (what if & suppression to demonstrate the unhelpfulness of worrying), modifying metaworry (challenging thoughts and beliefs around worry, using competing activities to displace worry). Behavioural experiments (controlled worry periods and attempting loss of control during those periods).
• Psychoeducation**, **self-monitoring**, and **coping with internal experiences are common across all GAD treatments.
• Medication – can use benzodiazepines or antidepressants (or both, tapering off the BZD and bringing in the SSRIs). Fluoxetine is most efficacious but Sertraline is the most tolerated. Pharmacotherapy is generally more effective than CBT but CBT is much better tolerated.