Problem 6 - GAD Flashcards
Disorder + models + treatment
GAD - DSM + symptoms
Excessive and uncontrollable worry for a duration of at least 6 months.
Symptoms: irritability, poor concentration, sleep disturbances, muscle tension etc.
What is worry?
The recurrent negative cognition where undesirable outcomes are anticipated.
Primarily verbal-linguistic in nature.
Distinguished from normal by its severity, its impairment and its uncontrollability.
Types of worrying
Type 1: worrying about external events and non-cognitive internal events.
- Temporarily alleviates anxiety if solutions to these can be found, and if not, chronic worry occurs.
Type 2: meta-worrying - worrying about the act of worrying itself.
- Arises form negative beliefs about worrying
- Perpetuates the cycle of GAD by reinforcing avoidance behaviours, interfering with problem-solving efforts and amplifying symptoms.
- Contributes to pathological worry independently of type 1 worry.
- Addressing this is crucial for GAD.
Prevalence
3.7% lifetime and 1.8% one-year rate
Primarily in care settings
Course
Chronic (20 years)
Relapse rate is high (40%)
Comorbidity
High but pure cases are possible
Etiological factors - Negative valence systems
Avoidance (contrast) theory, emotion regulation, traits
- Worry = negative emotion
- Both state and trait levels
- Avoidance theory: worry is a maladaptive strategy to avoid negative internal experiences.
- Contrast avoidance theory: worry sustains negative emotions
- Worry modulates fear and anxiety = BNST active in the apprehension of uncertain harm.
- Emotion regulation deficits: disrupted top-down regulation of fear, altered connectivity (amygdala and PFC)
- Neuroticism associated with lower emotional reactivity.
Etiological factors - Cognitive systems (factors)
Attentional biases, neural activity, cognition, processes, beliefs
GAD is characterised by information-processing biases that direct attention toward threat-related stimuli
Factors:
- Attentional biases: focus on threat cues, unconscious, fast eye movements, negative interpretation of stimuli.
- Heightened neural activity to errors: increased sensitivity to threats/mistakes in environment.
- Difficulties in controlling cognition: deficits in executive functioning, regulation of emotions = PFC and ACC are over active in worry and under-active in emotion regulation
- Interference of worry with cognitive processes such as memory: impairment in WM, alterations in the hippocampus, impacts cognitive performance and daily functioning.
- Disorder-maintaining beliefs: positive or negative beliefs about worrying (problem-solving/preparation vs uncontrollable and dangerous)
Etiological factors - Arousal/regulatory systems
Sleep, arousal baseline, response to negative stimuli, circadian clock
- Physiological rigidity and reduced responsiveness to stressors.
- High sympathetic arousal at baseline (fast heart rate etc) + reduced HRV (less flexible emotional responding)
- Dampened response to negative emotional stimuli.
- Sleep disturbance: reduced sleep time, longer sleep onset latency, more time awake during the night etc.
- Bidirectional causal relationship between GAD and sleep disturbances
- Mutations of circadian clock genes
Etiological factors - Systems for social processes
traits, attachment, interpersonal functioning
- Deficits in interpersonal functioning lead to distress and impact treatment outcomes + predicts symptoms recurrence.
- Insecure attachment contributes to development + maintenance
- Affiliation-related dysfunction is prominent = stem from early experiences of role reversal for warm/submissive behaviours.
- Negative attributional style and emotional reactivity to negative facial emotions.
- Increased activation in PFC and ACC.
- Neuroticism traits
Features of GAD
Intolerance uncertainty, beliefs, problem orientation, avoidance
Intolerance of uncertainty:
- Crucial component.
- How individuals perceive and respond to uncertain/ambiguous situations.
Beliefs about worry:
- Believes about worry contribute to worry levels.
- Positive or negative
Poor problem orientation:
- Difficulties in problem perception, attribution and appraisal leading to reduced personal control over problem solving.
Cognitive avoidance:
- avoiding threatening mental images.
- Key component
- Cognitive exposure techniques targeting this can help to cope with uncertainty and effectively manage symptoms.
Treatment - Metacognitive therapy (MCT)
Aim, what/how, procedure, efficacy
- To modify beliefs about worry (positive and negative ones).
- Does not aim to reduce worry itself.
- Seeks to disrupt the cycle of negative metacognition and meta-worry
- Very effective! (reduction of symptoms, even long-term).
- Achieved through verbal cognitive restructuring techniques - questioning the evidence supporting negative beliefs etc.
- Behavioural experiments are also used - postponing worry and worry enhancement to test the controllability and utility of worry.
Procedure:
- Targeting negative beliefs
- Addressing positive beliefs about its usefulness.
- Exploring alternative strategies for processing threatening triggers - emphasis on letting go of thoughts.
Treatment - Intolerance of uncertainty therapy (IUT)
What, procedure, efficacy
- To decrease anxiety and the tendency to worry by developing the ability to tolerate, cope and accept uncertainty.
- Effective but not as much as MCT.
Procedure:
- Worry awareness training: distinguishing between worries controlled by problem solving and those that are not
- Problem solving training: addressing worries about soluble problems through problem definition, goal formulating, alternative solution etc.
- Worry exposure exercises: confrontation with images that are insoluble = to face care fears and prevent cognitive avoidance.
- Modification of positive beliefs about worry: questioning evidence supporting worrying.
