Week 4: GAD

Question 1

What is the difference between GAD worrying and other worrying?

Answer 1

1. negative meta-cognitions about worrying
2. worrying constantly switches to different topics

Question 2

GAD worrying VS Normal Worrying?

Answer 2

GAD Worrying:
1. worrying experiences as uncontrollable
2. worrying about multiple subjects
3. problems because of worrying
4. impaired function because of worrying
Normal Worrying:
1. worrying experienced as controllable
2. worrying mostly about one topic
3. no remaining problems
4. no impaired functioning

Question 3

OCD vs GAD, which is ego-dystonic vs egosyntonic?

Answer 3

OCD perceives their problems as ego-dystonic; not fitting with their personality, unwanted and forced and GAD perceives their problems as egosyntonic; fitting with their personality, often ambivalence against worrying

Question 4

How to differentiate quickly between GAD worrying and other types?

Answer 4

ask pt “ If the problem you are worrying about would be fixed would your complaints be over?”
- yes (Not GAD)
- no (possibly GAD)

Question 5

GAD vs OCD differential diagnosis

Answer 5

• egosyntonic (GAD) vs egodystonic (OCD)
• obsessions or compulsions are done to prevent worrying (GAD) vs if they are done to prevent danger (OCD)
• GAD worries center around realistic day-to-day topics while OCD obsessions are often odd and inappropriate
• GAD worries are mostly verbal (not in pictures) VS OCD obsessions are also in pictures
• GAD: Content of worries is dynamic VS OCD: obsessions are static and constant

Question 6

What is the functioning of worrying for GAD patients?

Answer 6

associated with motivation to prevent or avoid potential danger
- often perceived as a coping strategy but can become the focus of an individual concern
- often starts out as a coping (positive appraisal of worry) and then later develops into a concern (negative meta worry).
- GAD worries are predominately verbal (problematic as it visual worries can help see more objectively and thinking in words is harder to calm yourself down from)

Question 7

DSM 5 Diagnosis of GAD

Answer 7

a. excessive anxiety and worry (apprehensive expectation) occurring more days than not for at least 6 months about a number of events or activities
b. individual finds it difficult to control the worry
c. anxiety and worry are associated with three or more of the following symptoms ( some symptoms having been present for more days than not for the past 6 months)
- restlessness or feeling on edge
- being easily fatigued
- difficulty concentrating or mind going blank
- irritability
- muscle tension
- sleep disturbance ( difficulty falling sleep, staying asleep, restless, unsatisfying sleep)
D. anxiety, worry or physical symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning
E. disturbance is not attributable to the physiological effects of substance use or other medical conditions
f. disturbance is not better explained by another mental health disorder
make sure to explicitly ask “ do you worry?”

Question 8

Comorbidity with other disorders

Answer 8

1. High comorbidity with other mental disorders as well as with general medical conditions, both to which lead to complex clinical presentation
2. Amongst GAD patients, 66% had at least one concurrent psychiatric disorder
3. Frequently comorbid with MDD, other anxiety disorders, strongly associated with chronic pain conditions, medically unexplained somatic symptoms and sleep disorders
4. highest comorbid with MDD

Question 9

Overall GAD facts/ prognosis

Answer 9

• High severity and impairment
• No other anxiety disorders a rate of severity as high as that of GAS including having impairment in occupational or social functioning
• Associated with impairment in life satisfaction and well-being that is (at least) comparable to that of patients suffering from other prevalent psychological disorders
• Without treatment prognosis is poor
• Unrecognized GAD results in intensive use of healthcare facilities for a long period in which patients are confronted with unnecessary and often costly and ineffective medical examination and treatments
• Better recognition would allow for earlier and adequate treatment of GAD

Question 10

GAD is a strong predictor of?

Answer 10

• later depressive disorder
• other secondary disorders,
• Therapy resistance in comorbid depression
• GAD also worsens the prognosis of chronic physical conditions while successful treatment of gad leads to a considerable reduction of comorbid symptoms
• Pharmacological treatment of GAD significantly decreased the risk of subsequent onset of major depression

Question 11

What makes GAD so difficult compared to other anxiety disorders? and why does this happen?

Answer 11

Threat is unclear ;
In most anxiety disorders (social or phobia) it is generally clear what needs to be escaped or avoided (spiders, social situation) but in GAD there is no clear threat from what needs to be escaped or avoided or to escape or to attack
- GAD frequently observe threats, and in response to these anticipated dangers, fight- or flight reactions are activated

Question 12

Maladaptive Coping strategies of GAD

Answer 12

1. positive appraisal of worrying: Worrying is positively reinforced as it results in a decreased physiological and emotional response
   - Worrying negatively reinforced: as the feared catastrophes generally do not come true ( not many distaste actually occur day to day)
   ( see worrying as a way to prevent disasters)
2. Verbal-linguistic kind of thinking about upcoming problems serves to avoid the negative effect associated with the threat

Question 13

GAD vs Social Anxiety

Answer 13

SAD: fear will always be fear or being judged negatively or behaving in an embarrassing or humiliating matter
distinction : avoidance behavior: patients with SAD avoid the stimulus that they fear as much as possible and it seems to be primarily this avoidance behavior that disrupts their social and professional functioning
Pts with GAD also can report avoiding social situations or events that could lead to worrying but their suffering is mainly the result of their excessive and uncontrollable worrying

Question 14

Adjustment disorder VS GAD

Answer 14

1. The difference with GAD is that the symptoms of an adjustment disorder by definition may not exist for longer than 6 months after the stressor (or the consequences of the stressor)
2. Stressor of being in debt can go on for a long time and can lead to other stressors such as child bills, not having enough money for food etc - still adjustment disorder if patients do not ( or hardly) perceive the worrying as uncontrollable
3. If that stressor went away then their worrying would go away - adjustment

Question 15

Panic Disorder vs GAD

Answer 15

1. Main difference is the fear involved: panic disorder have a fear of passing out, losing control, going crazy, getting a heart attack etc while GAD think of the anxiety mainly as indication that the worrying is not good for them and that (In the future) they may get heart problems as a result of continuous worrying
2. Panic disorder often show agoraphobic avoidance whereas patients with GAD do not or hardly ever show such behavior

Question 16

OCD vs GAD

Answer 16

1. Patients with OCD tend to focus their checking on objects whereas GAD patients tend to focus their checking on relational situations and achievement
2. OCD behavior is performed to AVERT danger (e.g. contamination) whereas GAD patients seem to use checking behavior as a strategy to avoid (a) triggers that might start the worrying process or (B) affective experiences
3. GAD worrying: concerns realistic, everyday matters ( health, performance at work, the household, and relationships)
4. GAD: ambivalent attitude towards their worrying as is reflected in the positive and negative beliefs they hold about worrying
   5.Obsessions in OCD may occur as vivid images whereas worrying is mainly verbal - linguistic in nature
5. OCD: static content of obsessions as opposed to the dynamic content of worrying - ocd patients experience the same intrusion over and over again as GAD patients worry about wide variety of issues and once one issue is resolved, soon enough another one will come up

Question 17

Mood Disorder VS GAD

Answer 17

Mood disorders - ruminating which can feel uncontrollable similar to GAD but GAD are always in the future: worrying about future
Differentiate: what % do you worry about for the future and past?

Question 18

GAD vs Hypochondriac Disorder

Answer 18

• GAD : worrying about getting it, can be many medical concerns
• Hypo: HAVING a disorder, feel no relief from dr appointments when GAD pts do
• People with GAD also regularly visit GP but this is a result from worrying rather than to seek reassurance about whether they have a serious disease

Question 19

Insomnia vs GAD

Answer 19

1. Insomnia : worrying starts in the evening when patients think about going to bed and focus of worries is usually about the sleeping problems or related to that topic
2. Insomnia unresolved problem worries: pt report they are afraid that they cannot sleep if they do not solve the problem at hand
3. GAD pts think of all kinds of disasters that can happen if they do not solve such a problem
   Insomnia: think their complaints are the result of not sleeping
4. GAD: think their complaints/ see the worrying as the main problem

Question 20

Somatization disorders vs GAD

Answer 20

• Main difference: presence and the predominance of anxiety symptoms in GAD which is not typical of somatization disorders
• Somatization patients report problems fo recurrent thinking and mainly ruminate about the possible causes of their physical complaints and/or worry about their possible consequences

Question 21

MDD vs GAD

Answer 21

1. Relative thoughts
   - GAD: negative things that MIGHT happen in the future with the aim to avoid or prevent danger whereas depressed patients predominantly ruminate about negative things that have happened in the past in an attempt to establish understanding and meaning
   >MDD: “why?”
   >GAD: What if?
   - How to differentiate: whether the pt ruminates about the event as (yet) as another example of his failure (why) or whether he worries about the possible negative consequences of his mistake in the future ( e.g. negative job appraisal or dismissal. “ What if ?”)
2. Depressed mood
   Differentiate if patient is anhedonic, as low positive affect has been found to be characteristic of MDD but not of GAD
   - Can ask pt if the worrying is about future negative events is the problem or their sad mood
   - Pts with GAD will often say that if their worrying was resolved then their sadness would go away
   - Anhedonia: is a diverse array of deficits in hedonic function, including reduced motivation or ability to experience pleasure.

Question 22

Controversies surrounding the diagnostic criteria of GAD

Answer 22

• DSM-V could identify a clinically significant GAD if the duration threshold lowered
• No clear guidelines on defining worry as excessive
• And excessive and non excessive worrier who met all the other DSM criteria for GAD has been shown to differ only in terms of the onset and the severity of the symptoms
• Beneficial for the classification of GAD to provide further details on what excessive actually means (e.g. operationalization in terms of the amount of time per day spent on worrying) - today the dsm 5 says several times a week i believe
• Study found that requiring only two associated symptoms had little effect on the prevalence of
  GAD in community samples - seems there is little point to retaining this criterion for diagnosis GAD

Question 23

What is a distinguishing characteristic about GAD?

Answer 23

• negative beliefs about worrying
• Negative beliefs about worrying seem to distinguish between who does and does not meet GAD criteria
• Suggested that subjective interpretation of worrying might be the most important feature of GAD

Question 24

Perception of inability to have control over worries is associated with?

Answer 24

Increased anxiety - more control over worries results in fewer anxiety symptoms

Question 25

Main points from (Cuijpers et al 2014) reading
( treatment conclusions and resolution on GAD and MDD)

Answer 25

• Psychotherapies, especially CBT are effective in treating GAD in adults
• Some indication that CBT may be more effective than applied relaxation at the longer term but both equally effective at the short term - more research is needed to determine if there is a real difference
• Evidence that GAD often precedes depression, it is possible that if GAD symptoms remit following treatment, this may lead to reduction in depression symptoms as well

Question 26

Meta-Cognitive Theory on GAD

Answer 26

• everyone worries: content of normal worry and GAD worrying cant be distinguished
• the content of worrying is not the problem
  the problem is: the processes that play a role in developing and maintaining the worrying
• pathological worrying is associated with meta-cognitions about worrying (positive and negative)

Question 27

Step by step Meta-Cognitive model for GAD

Answer 27

1. trigger “ what if” thought that starts the worrying
2. positive meta-cognitions about worrying is activated
3. worrying about the trigger
4. negative meta cognitions about worrying get activated
5. worrying about the (ongoing) worrying
   leads to :
   - safety or avoidance behavior ( checking everything multiple times)
   - attempt to reduce or stop worrying
   ( asking for reassurance or seeking distraction )
   - emotion
   ( fear and anxiety)

3 bottom processes also feed into the cycle

Question 28

Treatment of GAD through meta- cognitive model

Answer 28

1. trigger “ what was the first thought you had when you started worrying?”
   > did i do the work task correctly?
2. Worrying “ what did you think next? “
   > will i get fired, if i get fired will my wife leave me, if my wife leaves me ill be homeless… (catastrophizing thoughts)
3. emotions “ how do you feel when you were worrying? “
   > anxious, scared, tense, sad etc.
4. worrying about worrying “when you ah that feeling what did you think next? “ or “ did you think something would happen if you kept worrying?”
   > i could get a panic attack or wouldn’t be able to sleep
5. activate negative meta-worrying
   “ what is the worst that could happen if you keep worrying? “
   - i can’t sleep, i will go crazy, I will get sick , lose my job etc
   * want to find the most feared meta-cognition
6. activating positive meta cognitions “ it seems that worrying is only problematic but are there any positive sides to worrying? “
   > prepares me for work, school, the worst, gives control
   ( don’t always have positive meta)
7. avoidance and safety behaviors
8. behavior to control or decrease worrying - seeking distraction or asking for reassurance

Question 29

Ways of Detecting meta-cognitions

Answer 29

1. asking about the judgement of worrying
2. list of advantages and disadvantages of worrying
3. finding thought-control behavior and asking function of it
4. doing an experiment; concentrating on worrying
   5.questionnares - meta cognition q

Question 30

meta cognitive therapy goals and steps

Answer 30

goal: changing the meta cognitins about worrying
- not controlling worrying or focused on the content of worries
order:
1. uncontrollability
2. danger of worrying
3. positive meta cog
4. expanding coping mechanisms
5. include behavioral experiments

Question 31

behaviroal experimenat for GAD meta cognition therapy

Answer 31

• postponement experiment:
  for negative:
  worry a lot and see if you actually went mad, got sick, did your worst fears come true?

For positive meta:
minimal vs max technique: worry a lot one week and little next and see how you feel

Question 32

most effective treatment for GAD?

Answer 32

Meta-cognitive therapy