2 DSM-5 CriteriaCharacterized by uncontrollable and excessive worrying/anxietyfor more days than notfor at least 6 monthsabout several events and activitiescausing significant distress/impairment in functioningAnxiety/worry is out of proportion to actual likelihood or impact of event/activityWorries are more excessive, more distressing, have longer duration, and occur more spontaneously than those experienced by non-pathological individualsThree of the six following symptoms must be present for diagnosis in adults; Only one symptom must be present for children:Restlessness or feeling on edgeEasily fatiguedDifficulty concentrating or mind going blankIrritabilityMuscle TensionDifficulty sleepingGAD 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 CriteriaWorries 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, achesSymptoms 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 neuroticismTemperamental factors: Behavioral inhibition, negative affectivity/neuroticism, harm avoidanceEnvironmental factors: DSM does not identify any environmental factors for making diagnosis, although childhood adversity and parental overprotection may be associated with GADGenetic factors: DSM does not elaborate on this. I will elaborate on this laterTemperamental factors: DSM does not define or go into these, but I will explain laterEnvironmental factors: I will go into these later also(DSM-5, 2013)
4 DSM-5 in ChildrenChildren 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 dissatisfactionDSM 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 DisorderThe 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, IBSGenetic FactorsGAD Core Featuresworry, restlessness/feeling on edge, fatigue, difficulty concentrating,irritability, muscle tension,difficulty sleepingNeuroticismTemperamental Factorsbehavioral inhibition, negative affectivity, harm avoidanceNo environmental factors identified as specific to GADDSM also says nothing about treatmentsSecondary Featuresfunctional 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 necessaryThe symptom of worry was not required for diagnosis, but was listed as one of the 4 possible symptoms in criteriaUntil 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/PrevalenceOnset 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 rangeThose with GAD report feeling anxious/nervous their whole lives and symptoms are chronic across the lifespan12 month prevalence is 0.9% in adolescents and 2.9% in adultsLifetime 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 lifeMore 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 iscatastrophizing- 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 childrenUnderestimate their competencies and view themselves as being less influential than control children(Bogels & Zigterman, 2000)OVERESTIMATION of consequences and danger; UNDERESTIMATION of competenciesFindings suggest that CBT should be helpful in improving negative cognitive thinking and low self-esteem
10 ComorbidityCommonly comorbid with other anxiety disorders and depression in women and substance use in malesBased 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 GermanyInvestigated developmental factors and comorbidity of GAD with other anxiety disorders and depressionLooked into parental, temperamental (e.g., behavioral inhibition), and environmental factors3021 participants (14-24 years) at baseline. GAD diagnosis (n = 106).Follow-up at 3 time pointsResults 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 anotherHighest 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 phobiasDepressive DisordersGenetic 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 disorder22% had parents with a depressive disorder but no anxiety disorder (HR=1.77, p < .03)8% had parents with bothEnvironmental Factors:28% had experienced childhood separation events (HR=2.44, p < .001)- not included in DSM-53% 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-5Temperamental Factors:Only 6% showed harm avoidance (HR=1.69, p < .001) – matches up with DSM-5Only .5% showed behavioral inhibition (HR=1.97, p < .001) - matches up with DSM-5Only 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 functioningHR = ???? 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 doubtfulNegative Affectivity/Neuroticism: experience of negative emotions and poor self-concept/characterized by anxiety, fear, moodiness, worry, frustration, jealousy, and lonelinessThree temperamental factors listed by DSM-5Not defined in DSM, so defined hereAll temperamental traits highly associated with symptoms of anxiety/worryPretty much sound like characteristics of GADNeed 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 yearsDirect observations from childrenHigh reactive and inhibited infants are at a higher risk for having anxious symptoms later in developmentHighly reactive at 4 months:Frequent vigorous motor activityArching of the backFretting 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 children3 year follow-upChildren have higher rates of childhood-onset anxiety disordersBehavioral 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 besignificantly predictive of GAD diagnoses inexclusively Caucasian children(AUC = .791, P < .001)There were also children with high harmavoidance scores who did not qualify for adiagnosis 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 neuroticism5 year longitudinal studyEarly adolescents (n = 923, M = 12.4, 49% girls) and middle (n = 390, M = 16.7, 57% girls) adolescents from general populationResults:Neuroticism measured on Goldberg’s Big Five QuestionnaireGAD symptoms measured on Screen for Child Anxiety Related Emotional Disorders (SCARED)GAD and neurotic symptoms both stable over 5 yearsWere 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 ageThe 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 brainShow dysregulation in central fear circuits, including:anterior limbic network (ALN)connections between amygdala and ventromedial prefrontal cortex areaventrolateral 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 GADSSRIs increase activity in VLPFC in childrenDysregulation 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)
24 Neurobiological Factors- Amygdala Roy et al., 2013:There is evidence that GAD may affect functioning in the amygdalaInvestigated amygdala network dysfunction with resting state fMRI scans15 adolescents with GAD, 20 control adolescentsResults:Adolescents with GAD showed disruptions in amygdala-based intrinsic functional connectivity networks, including regions in medial prefrontal cortex, insula, and cerebellumAdolescents 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 GADEvidence of overlap of the right basolateral and centromedial amygdala networks in the adolescents with GAD
26 Environmental and Family Factors Hale, Engels & Meeus, 2006:Examined perceived parenting styles and GAD symptomsFound positive association between perceived parental alienation and rejection with GAD symptoms in adolescentsHale, Klimstra, Branje, Wijsbroek, & Meeus, 2013:Longitudinal community study923 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 symptomsGAD symptoms significantly predicted perception of parental interactions
27 Hale, Klimstra, Branje, Wijsbroek, & Meeus, 2013 Add notes to this slideHale, Klimstra, Branje, Wijsbroek, & Meeus, 2013
28 Hale, Klimstra, Branje, Wijsbroek, & Meeus, 2013 ADD NOTES TO THIS SLIDEHale, Klimstra, Branje, Wijsbroek, & Meeus, 2013
29 Diagnostic measuresGeneralized Anxiety Disorder Questionnaire (GADQ-IV; Newman et al., 2002)Y/N2 questions with a severity scale1 open-ended question on frequent worriesStrong psychometric propertiesAnxiety Disorders Interview Schedule for Children/Parents (ADIS C/P; Silverman & Albano, 1996)Semi-structured interview
30 Treatment of GADDivision 53 recognizes the following empirically supported treatments for working in relieving general symptoms of anxiety in young people:Individual CBTGroup CBT (without parents)Group CBT with parentsSocial skills trainingExposure 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 wellNew intervention: Targeted Behavioral Therapy (TBT; Alfano, 2010) targets anxiety and sleep problems4 children: 2 boys, 2 girls with GAD (7–12 years)TBT:sleep intervention (sleep improvement strategies)systematic desensitization for reducing intolerance of uncertaintyIn vivo exposures for anxietyAnxiety and sleep were rated weekly during 4-week baseline, 14-weeks of treatment, and followed up at post-treatment and 3-months follow upTherapists 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-structuredNo child had a GAD diagnosis at follow-upAnxiety 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—Revised9 week double-blind, randomly selected treatment:11 given SSRI, Sertraline (25 mg first week, 50 mg for duration)11 given placeboWeekly visits to check-up on medication effects and gather assessment of symptomsResults: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 9Only 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
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 weeksAnxiety 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 weeksCombination treatment of Sertraline and CBT for 12 weeks
38 Updated Schematic Neurological Factors Somatic Symptoms Amygdala disruptionsSomatic SymptomsSweating, Nausea, Diarrhea, Trembling, Soreness, Startled ResponsesCore FeaturesRestlessness/Feeling on edge, Fatigue, Difficulty concentrating,Irritability, Muscle Tension,Difficulty sleepingTemperamental FactorsSecondary FeaturesFunctional impairment, distress about competence and quality of performance, unsure of self, dissatisfactionDon’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 factorsFamily factors
39 ReferencesAmerican 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 fromGeneral Anxiety. (n. d.). Society of Clinical Child and Adolescent Psychology, Division 53, American Psychological Association. Retrieved fromHale, 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 ReferencesHale, 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 ReferencesRowa, 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 fromRoy, 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 generalizedanxiety 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 oftreatment 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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