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Generalized Anxiety Disorder.

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Presentation on theme: "Generalized Anxiety Disorder."— Presentation transcript:

1 Generalized Anxiety Disorder

2 DSM-5 Criteria Characterized by uncontrollable and excessive worrying/anxiety for more days than not for at least 6 months about several events and activities causing significant distress/impairment in functioning Anxiety/worry is out of proportion to actual likelihood or impact of event/activity Worries are more excessive, more distressing, have longer duration, and occur more spontaneously than those experienced by non-pathological individuals Three of the six following symptoms must be present for diagnosis in adults; Only one symptom must be present for children: Restlessness or feeling on edge Easily fatigued Difficulty concentrating or mind going blank Irritability Muscle Tension Difficulty sleeping GAD symptoms are more pervasive, pronounced, and affect psychosocial functioning. The more life circumstances that people worry about, the more likely they are to fit criteria for GAD. What do you think of only one item needing to be present in children? (DSM-5, 2013)

3 DSM-5 Criteria Worries and distress must not be attributable to substances or other medical conditions. Cannot be better explained by another mental disorder (e.g., another anxiety disorder, worry about weight gain in anorexia, delusional beliefs in schizophrenia) Somatic symptoms include sweating, nausea, diarrhea, IBS, trembling, soreness, aches Symptoms of autonomic hyperarousal, such as increased heart rate, shortness of breath, dizziness, are less prominent in GAD than other anxiety disorders (e.g., panic disorder) Genetic factors: account for 1/3rd of the risk of GAD, including overlap of neuroticism Temperamental factors: Behavioral inhibition, negative affectivity/neuroticism, harm avoidance Environmental factors: DSM does not identify any environmental factors for making diagnosis, although childhood adversity and parental overprotection may be associated with GAD Genetic factors: DSM does not elaborate on this. I will elaborate on this later Temperamental factors: DSM does not define or go into these, but I will explain later Environmental factors: I will go into these later also (DSM-5, 2013)

4 DSM-5 in Children Children with GAD often worry about competence or quality of performance, especially relating to school and sports, and/or catastrophic events (e.g., earthquakes) Children may be overly conforming, perfectionistic, unsure of themselves, and/or redo tasks because of excessive dissatisfaction DSM claims that GAD may be over-diagnosed in children and emphasizes making sure to rule out alternative diagnoses such as Social Anxiety Disorder, Separation Anxiety Disorder, and Obsessive Compulsive Disorder The DSM claims of over-diagnosis in children is especially interesting when looking at the diagnostic criteria

5 DSM-5 Schematic Somatic Symptoms Genetic Factors
sweating, nausea, diarrhea, trembling, soreness, startled responses, IBS Genetic Factors GAD Core Features worry, restlessness/feeling on edge, fatigue, difficulty concentrating, irritability, muscle tension, difficulty sleeping Neuroticism Temperamental Factors behavioral inhibition, negative affectivity, harm avoidance No environmental factors identified as specific to GAD DSM also says nothing about treatments Secondary Features functional impairment, distress about competence and quality of performance, unsure of self, dissatisfaction

6 GAD Child Example “John is a 10-year-old fifth grader who always seems to be worrying. He constantly worries about such things as his grades, being good enough at baseball, his appearance, arriving on time to classes and activities, and the health of his mother and father. John worries about these things almost everyday and has been worrying like this for almost a year now. When he worries he often feels restless, becomes TIRED and irritated easily, has trouble concentrating, and has difficulty falling asleep. In fact, John worries so much that he just cannot seem to have fun or concentrate on his school work anymore. For example, while planning his 10th birthday, John worried for two weeks about whether his friends would come, whether it would rain, whether there would be enough food, whether everyone would have fun, etc.” -Society of Clinical Child and Adolescent Psychology, Division 53, American Psychological Association

7 History First made appearance in the DSM-III in 1980.
Only 1 month symptom duration necessary The symptom of worry was not required for diagnosis, but was listed as one of the 4 possible symptoms in criteria Until the DSM-III-R (1987), GAD was not defined well enough and was used as an “other” diagnostic category for individuals who did not fit diagnosis of other anxiety disorders (Rowa, Hood, Antony, 2013) Reasons for over-diagnosis in past?

8 Onset/Prevalence Onset is rarely before adolescence. Onset is less common in childhood than other anxiety disorders (e.g., Social Anxiety Disorder, Separation Anxiety Disorder) Median onset of GAD is 30 years, but age at onset is spread over a broad range Those with GAD report feeling anxious/nervous their whole lives and symptoms are chronic across the lifespan 12 month prevalence is 0.9% in adolescents and 2.9% in adults Lifetime morbid risk is 9% Female to male ratio of prevalence is 2:1 (DSM-5, 2013) 5.7% Lifetime Prevalence (Kessler, et al., 2005) The earlier the onset, the higher the symptoms severity and comorbidity to other disorders (Campbell, Brown, & Grisham, 2003) DSM: Diagnosis usually peaks in middle age and declines throughout later years of life More prevalent in individuals of European descent (not as common in Asian, African, Native American, Pacific Islander populations)

9 Cognitive Processes Anxious children: Children with GAD exhibit:
probability overestimation- thinking a feared consequence is more likely to occur than it truly is catastrophizing- assuming an outcome will be much more unmanageable than it actually is (Suarez & Bell-Dolan, 2001) Anxious children: Interpret ambiguous events as being negative and/or dangerous more often than externalizing, borderline, or control children Underestimate their competencies and view themselves as being less influential than control children (Bogels & Zigterman, 2000) OVERESTIMATION of consequences and danger; UNDERESTIMATION of competencies Findings suggest that CBT should be helpful in improving negative cognitive thinking and low self-esteem

10 Comorbidity Commonly comorbid with other anxiety disorders and depression in women and substance use in males Based on the DSM-5’s criteria, GAD symptoms should be present before an onset or after remission of depression in order for a comorbid diagnosis (DSM-5, 2013) 90.4% lifetime comorbidity in people with a history of GAD (National Comorbidity Survey; Wittchen, Zhao, Kessler & Eaton, 1994)

11 Comorbidity and Risk Factors of GAD
Beesdo, Pine, Lieb, 2010: Longitudinal community study in Germany Investigated developmental factors and comorbidity of GAD with other anxiety disorders and depression Looked into parental, temperamental (e.g., behavioral inhibition), and environmental factors 3021 participants (14-24 years) at baseline. GAD diagnosis (n = 106). Follow-up at 3 time points Results showed strong associations with panic and phobias (odds ratio, 7.06; 95% CI, ; p < .001) and depressive disorders (odds ratio, 4.44; 95% CI, ; p < .001) Phobias and panic disorder, GAD, and depressive disorders significantly predicted the onset of one another Highest HRs emerged for GAD predicting anxiety disorders (HR, 4.14) and anxiety disorders predicting GAD (HR, 5.05) HRs- Hazard Ratios

12 -29% of those with GAD, had parents with GAD
-15% had parents with an anxiety disorder, but no depressive disorder -22% had parents with a depressive disorder but no anxiety disorder -8% had parents with both -Only 6% showed harm avoidance -Only .5% showed behavioral inhibition -28% had had childhood separation events (Beesdo, Pine, Lieb, 2010)

13 (Beesdo, Pine, Lieb, 2010) -Parental GAD (HR=3.77, p < .001)
-Parental depressive but no anxiety disorder (HR=1.77, p < .03) -Behavioral inhibition (HR=1.97, p < .001) - matches up with DSM-5 -Harm Avoidance (HR=1.69, p < .001) – matches up with DSM-5 -Reward Dependence (HR=.84, p < .02) -Childhood Separation Events (HR=2.44, p < .001)- does not match up with DSM-5 -Parental Overprotection (HR=1.48, p < .02) - does not match up with DSM-5 -Dysfunctional family functioning (HR=1.48, p < .02) - does not match up with DSM-5 (Beesdo, Pine, Lieb, 2010)

14 Comorbidity and Risk Factors of GAD
Panic and phobias Depressive Disorders Genetic Factors: 29% of those with GAD, had parents with GAD (HR=3.77, p < .001) 15% had parents with an anxiety disorder, but no depressive disorder 22% had parents with a depressive disorder but no anxiety disorder (HR=1.77, p < .03) 8% had parents with both Environmental Factors: 28% had experienced childhood separation events (HR=2.44, p < .001)- not included in DSM-5 3% had Parental Overprotection (HR=1.48, p < .02) –not included in DSM-5 .5% had Dysfunctional family functioning (HR=1.48, p < .02) - not included in DSM-5 Temperamental Factors: Only 6% showed harm avoidance (HR=1.69, p < .001) – matches up with DSM-5 Only .5% showed behavioral inhibition (HR=1.97, p < .001) - matches up with DSM-5 Only 4% showed reward dependence (HR=.84, p < .02) Environmental factors not listed in the DSM that were associated with GAD include: Childhood separation events, parental overprotection, and dysfunctional family functioning HR = ???? explain

15 Temperamental Factors and GAD
Behavioral Inhibition: tendency for children to be afraid or anxious of new situations, causing them to be distressed and sometimes withdraw. Common symptom of social anxiety. Harm Avoidance: characterized by excessive worrying, pessimism, shyness, and being fearful and doubtful Negative Affectivity/Neuroticism: experience of negative emotions and poor self-concept/characterized by anxiety, fear, moodiness, worry, frustration, jealousy, and loneliness Three temperamental factors listed by DSM-5 Not defined in DSM, so defined here All temperamental traits highly associated with symptoms of anxiety/worry Pretty much sound like characteristics of GAD Need to explain how a construct such as ‘neuroticism’ can be used to explain a construct such as GAD excessive worrying…affirming the consequent/tautological thinking

16 Temperamental Factors- Behavioral Inhibition
Followed up from 4 months to 7.5 years Direct observations from children High reactive and inhibited infants are at a higher risk for having anxious symptoms later in development Highly reactive at 4 months: Frequent vigorous motor activity Arching of the back Fretting and crying (Kagan & Snidman, 1999) Include their graphs/figures

17 Temperamental Factors- Behavioral Inhibition
Only .5% showed behavioral inhibition (Beesdo, Pine, Lieb, 2010) Longitudinal study of behavioral inhibition as a predictor of anxiety disorders in children 3 year follow-up Children have higher rates of childhood-onset anxiety disorders Behavioral inhibition may present familial risk for anxiety disorders (Rosenbaum, et. al, 1993) Research from 1993 using DSM III-R’s criteria for GAD, so may have been over-diagnosed/may not be reliable. Not enough information

18 Temperamental Factors- Harm Avoidance
6% of children with GAD exhibited harm avoidance (Beesdo, Pine, Lieb, 2010) In a sample of exclusively Caucasian children (N = 334, M = 10.4 years): Harm avoidance scores were shown to be significantly predictive of GAD diagnoses in exclusively Caucasian children (AUC = .791, P < .001) There were also children with high harm avoidance scores who did not qualify for a diagnosis of GAD (Rettew, Doyle, Kwan, Stanger, & Hudziak, 2006) -Study used Vermont Structured Diagnostic Interview to make diagnoses (parental report of children) and Temperament and Character Inventory for measuring Harm Avoidance -ROC analyses

19 Temperamental Factors- Neuroticism
Hale, Klimstra, & Meeus, 2010: Study of the GAD symptom of worry in relation to neuroticism 5 year longitudinal study Early adolescents (n = 923, M = 12.4, 49% girls) and middle (n = 390, M = 16.7, 57% girls) adolescents from general population Results: Neuroticism measured on Goldberg’s Big Five Questionnaire GAD symptoms measured on Screen for Child Anxiety Related Emotional Disorders (SCARED) GAD and neurotic symptoms both stable over 5 years Were related at every time point and both predicted the other across time points

20 -GAD and neurotic symptoms both stable over 5 years
-2 were related at every time point, and both predicted the other across timepoints -Differences in Chi-square tests showed that pathway from GAD symptoms to neuroticism were stronger than neuroticism to GAD symptoms. In other words, GAD symptoms better predicted neuroticism than the other way around. -no differences between gender and age The pathway from GAD symptoms to neuroticism were stronger than neuroticism to GAD symptoms (Hale, Klimstra, & Meeus, 2010)

21 Neurobiological Factors
GAD known to affect fear networks in brain Show dysregulation in central fear circuits, including: anterior limbic network (ALN) connections between amygdala and ventromedial prefrontal cortex area ventrolateral prefrontal cortex (VLPFC) rostal insula (ACC) subgenual and rostral anterior cingulate cortex (Yamasaki, LaBar, & McCarthy, 2002) Serotonergic area is linked to the ALN, which is why SSRIs are effective in medicating children with GAD SSRIs increase activity in VLPFC in children Dysregulation in these areas can also be seen in those who have other anxiety disorders and major depressive disorder, which GAD is often comorbid with (Strawn, Wehry, DelBello, Rynn, & Strakowski, 2012)

22 (Strawn, Wehry, DelBello, Rynn, & Strakowski, 2012)

23 (Strawn, Wehry, DelBello, Rynn, & Strakowski, 2012)

24 Neurobiological Factors- Amygdala
Roy et al., 2013: There is evidence that GAD may affect functioning in the amygdala Investigated amygdala network dysfunction with resting state fMRI scans 15 adolescents with GAD, 20 control adolescents Results: Adolescents with GAD showed disruptions in amygdala-based intrinsic functional connectivity networks, including regions in medial prefrontal cortex, insula, and cerebellum Adolescents with GAD displayed alterations in amygdala circuits involved in emotion processing, which is similar to findings in adults, as well as, in fear processing and the coding of interoceptive states. Anxiety severity scores and amygdala functional connectivity with insula and superior temporal gyrus were positively related for adolescents with GAD Evidence of overlap of the right basolateral and centromedial amygdala networks in the adolescents with GAD

25 (Roy et al., 2013)

26 Environmental and Family Factors
Hale, Engels & Meeus, 2006: Examined perceived parenting styles and GAD symptoms Found positive association between perceived parental alienation and rejection with GAD symptoms in adolescents Hale, Klimstra, Branje, Wijsbroek, & Meeus, 2013: Longitudinal community study 923 adolescents (M = 12.4 years; 49.3% girls, 50.7% boys) SEM conducted to examine relationship between perceived parental interactions (parental rejection, over-control, attachment behaviors)and adolescents’ GAD symptoms GAD symptoms significantly predicted perception of parental interactions

27 Hale, Klimstra, Branje, Wijsbroek, & Meeus, 2013
Add notes to this slide Hale, Klimstra, Branje, Wijsbroek, & Meeus, 2013

28 Hale, Klimstra, Branje, Wijsbroek, & Meeus, 2013
ADD NOTES TO THIS SLIDE Hale, Klimstra, Branje, Wijsbroek, & Meeus, 2013

29 Diagnostic measures Generalized Anxiety Disorder Questionnaire (GADQ-IV; Newman et al., 2002) Y/N 2 questions with a severity scale 1 open-ended question on frequent worries Strong psychometric properties Anxiety Disorders Interview Schedule for Children/Parents (ADIS C/P; Silverman & Albano, 1996) Semi-structured interview

30 Treatment of GAD Division 53 recognizes the following empirically supported treatments for working in relieving general symptoms of anxiety in young people: Individual CBT Group CBT (without parents) Group CBT with parents Social skills training Exposure treatment

31 Treatment- CBT Empirically effective Cognitive-Behavioral Therapy:
Includes components of: psychoeducation, relaxation training, monitoring cues and targets of worrying, imaginal exposure, cognitive restructure

32 Treatment- TBT Clementi & Alfano, 2010:
Kids with GAD have found to have sleep problems as well New intervention: Targeted Behavioral Therapy (TBT; Alfano, 2010) targets anxiety and sleep problems 4 children: 2 boys, 2 girls with GAD (7–12 years) TBT: sleep intervention (sleep improvement strategies) systematic desensitization for reducing intolerance of uncertainty In vivo exposures for anxiety Anxiety and sleep were rated weekly during 4-week baseline, 14-weeks of treatment, and followed up at post-treatment and 3-months follow up Therapists were blind to all weekly ratings -IQ had to be over 80, no other treatment/medication

33 Treatment- TBT Results:
Anxiety Disorders Interview Schedule for Children/Parents (ADIS C/P; Silverman & Albano, 1996). Semi-structured No child had a GAD diagnosis at follow-up Anxiety Disorders Interview Schedule for Children/Parents (ADIS C/P; Silverman & Albano, 1996). Semi-structured.

34 Treatment- SSRIs Rynn, Siqueland, & Rickels, 2001
22 children/adolescents with primary diagnosis of GAD (5-17 years) Anxiety Disorders Interview Schedule for Children—Revised 9 week double-blind, randomly selected treatment: 11 given SSRI, Sertraline (25 mg first week, 50 mg for duration) 11 given placebo Weekly visits to check-up on medication effects and gather assessment of symptoms Results: From week 4 onward, scores improved for SSRI group on the Hamilton Anxiety Rating Scale (HARS) and Clinical Global Impression Severity (CGI) 10/11 kids on Sertraline rated themselves as “improved” on the CGI at week 9 Only 1/11 kid on placebo rated self as “improved” on the CGI at week 9 -Met criteria for DSM IV -All patients responded well to medication (no adverse effects), so no need for adjustments in mgs -4 side effects: leg spasms, dry mouth, drowsiness, restlessness -psychotherapy, except for CBT, was allowed -Do not make it clear how rating scales were completed? Parental report for younger or given orally? -Excluded from study if had a comorbid mental disorder

35 Rynn, Siqueland, & Rickels, 2001

36 Treatment-Type and Results
Children randomly assigned to medication (Sertraline, Venlafaxine ER, Fluoxetine, or Fluvoxamine), CBT, placebo, or combination of medication and CBT for either 8, 9, or 12 weeks Anxiety scores on the Pediatric Anxiety Rating Scale (PARS) or Hamilton Anxiety Rating Scale (HAM-A) Significant improvements of anxiety scores in children who received: Treatment of SSRI (Sertraline) for 9 weeks Combination treatment of Sertraline and CBT for 12 weeks

37 (Strawn, Wehry, DelBello, Rynn, & Strakowski, 2012)

38 Updated Schematic Neurological Factors Somatic Symptoms
Amygdala disruptions Somatic Symptoms Sweating, Nausea, Diarrhea, Trembling, Soreness, Startled Responses Core Features Restlessness/Feeling on edge, Fatigue, Difficulty concentrating, Irritability, Muscle Tension, Difficulty sleeping Temperamental Factors Secondary Features Functional impairment, distress about competence and quality of performance, unsure of self, dissatisfaction Don’t you think that operant conditioning factors play a role wherein children who experience severe somatic symptoms and excessive fearfulness avoid/escape those situations which in turn strengthens the GAD-like behaviors? Environmental factors Family factors

39 References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. Beesdo, K., Pine, D. S., Lieb, R., & Wittchen, H. (2010). Incidence and risk patterns of anxiety and depressive disorders and categorization of generalized anxiety disorder. Archives of General Psychiatry, 67(1), Bogels, S. M. & Zigterman, D. (2002). Dysfunctional cognitions in children with social phobia, separation anxiety disorder, and generalized anxiety disorder. Journal of Abnormal Child Psychology, 28(2), Campbell, L.A., Brown, T. A., & Grisham, J. R. (2003). The relevance of age of onset to the psychopathology of generalized anxiety disorder. Behavior Therapy, 34(1), Clementi, M. A., & Alfano, C. A. Targeted behavioral therapy for childhood generalized anxiety disorder: A time-series analysis of changes in anxiety and sleep. Journal of Anxiety Disorders, 28(2), General Anxiety. (n. d.). Society of Clinical Child and Adolescent Psychology, Division 53, American Psychological Association. Retrieved from General Anxiety. (n. d.). Society of Clinical Child and Adolescent Psychology, Division 53, American Psychological Association. Retrieved from Hale, W. W., Engels, R., & Meeus, W. (2006). Adolescent's perceptions of parenting behaviours and its relationship to adolescent generalized anxiety disorder symptoms. Journal of Adolescence, 29(3),

40 References Hale, W. W., Klimstra, T. A., Branje, S. J. T., Wijsbroek, S. A. M., & Meeus, W. H. J. (2013). Is adolescent generalized anxiety disorder a magnet for negative parental interpersonal behaviors. Depression and Anxiety, 30(9), Hale, W. W., Klimstra, T. A., Meeus, W. H. J. (2010). Is the generalized anxiety disorder symptom of worry just another form of neuroticism? A 5 year longitudinal study of adolescents from the general population. The Journal of Clinical Psychiatry, 71(7), Kagan, J. & Snidman, N. (1999). Early childhood predictors of adult anxiety disorders. Biological Psychiatry, 46(11), Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of onset distributions of DSM-IV disorders in the national comorbidity survey replication. Archives of General Psychiatry, 65(6), Rettew, D. C., Doyle, A. C., Kwan, M., Stanger, C., & Hudziak, J. J. (2006). Exploring the boundary between temperament and generalized anxiety disorder: A receiver operating characteristic analysis. Journal of Anxiety Disorders, 20(7), Rosenbaum, J. F., Biederman, J., Bolduc-Murphy, E. A., Faraone, S. V., Chaloff, J., Hirshfeld, D. R., & Kagan, J. (1993). Behavioral inhibition in childhood: A risk factor for anxiety disorders. Harvard Review of Psychiatry, 1(1), 2-16.

41 References Rowa, K., Hood, H. K., & Antony, M. M. (2013). Generalized anxiety disorder. In W. E. Craighead, D. J. Miklowitz, & L. W. Craighead (Eds.), Psychopathology: History, diagnosis, and empirical foundations. (pp ). Retrieved from Roy, A. K., Fudge, J. L., Kelly, C., Perry, J. S. A., Daniele, T., Carlisi, C., Benson, B., Castellanos, F. X., Milham, M. P., Pine, D. S., & Ernst, M. (2013). Intrinsic functional connectivity of amygdala-based networks in adolescent generalized anxiety disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 52(3), Rynn, M. A., Siqueland, L. & Rickels, K. (2001). Placebo-controlled trial of Sertraline in the treatment of children with generalized anxiety disorder. The American Journal of Psychiatry, 158(12), Strawn, J. R., Wehry, A. M., DelBello, M. P., Rynn, & Strakowski, S. (2012). Establishing the neurobiologic basis of treatment in children and adolescents with generalized anxiety disorder. Depression and Anxiety, 29, Suarez, L. & Bell-Dolan, D. (2001). The relationship of child worry to cognitive biases: Threat interpretation and likelihood of event occurrence. Behavior Therapy, 32(3), Wittchen, H., Zhao, S., Kessler, R. C., & Eaton, W. W. (1994). DSM-III-R Generalized Anxiety Disorder in the National Comorbidity Survey. Archives of General Psychiatry, 51(5), Yamasaki, H., LaBar, K. S., & McCarthy, G. (2002). Dissociable prefrontal brain systems for attention and emotion. Proceedings of the National Academy of Sciences of the United States of America, 99(17), 11447–11451.


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