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Generalized Anxiety Disorder Lecture Overview. Nature Epidemiology Empirically-supported treatments Pharmacotherapy Psychotherapies Efficacy data Class discussion. Significance of GAD. Worry, the central feature of GAD, is pervasive in the anxiety and mood disorders. Significance of GAD.

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generalized anxiety disorder lecture overview
Generalized Anxiety DisorderLecture Overview
  • Nature
  • Epidemiology
  • Empirically-supported treatments
    • Pharmacotherapy
    • Psychotherapies
  • Efficacy data
  • Class discussion

Treatments of GAD

significance of gad
Significance of GAD
  • Worry, the central feature of GAD, is pervasive in the anxiety and mood disorders

Treatments of GAD

significance of gad3
Significance of GAD
  • Worry has been experimentally demonstrated to prevent emotional processing and thus may maintain any disorder wherein such processing is important for therapeutic change
  • Successful treatment of GAD results in dramatic reduction in comorbid conditions

Treatments of GAD

significance of gad4
Significance of GAD
  • One of the most common comorbid conditions in the anxiety and mood disorders
  • May be the basic anxiety disorder out of which other anxiety disorders emerge

Treatments of GAD

breakdown of comorbidity by diagnosis
Breakdown of Comorbidity by Diagnosis

Data from Moras et al (1991). Psychopharmacology Bulletin, 28(1), 1992, 27-33

Diagnoses are based on DSM-III-R criteria using the ADIS-R

Treatments of GAD

current diagnostic features of gad
Current Diagnostic Features of GAD
  • Excessive anxiety and worry, occurring more days than not for at least 6 months, about a number of events or activities
  • The person finds the worry difficult to control
  • The anxiety and worry are accompanied by at least 3 or more symptoms (i.e. irritability, difficulty concentrating)
  • Causes substantial impairment or distress.
  • Not due to physical condition or ingestion of substance

Treatments of GAD

characteristics of worry
Characteristics of Worry
  • A tendency to define ambiguous situations as threatening (Butler & Mathews, 1983)
  • An elevated estimation of risk (Vasey & Borkovec, 1992)
  • Tendency to generate negative scenarios in ambiguous situations (Macleod et al, 1991)

Treatments of GAD

inter rater reliability across the anxiety disorders
Inter-rater Reliability Across the Anxiety Disorders

Data from Brown & Barlow (1992). Journal of Consulting and Clinical Psychology, 6, 835-844.

Diagnoses are based on DSM-III-R criteria using the ADIS-R

Treatments of GAD

factors accounting for modest inter rater reliability of gad
Factors Accounting for Modest Inter-rater Reliability of GAD
  • Status as a residual category
  • Lack of agreement over disorder severity
  • Diagnostic overlap with other anxiety disorders
  • High rate of comorbidity (82%)

Treatments of GAD

epidemiology of generalized anxiety disorder
Epidemiology of Generalized Anxiety Disorder
  • Prevalence
    • DSM-III: 4% (ECA study Wave II)
    • DSM-III-R: 5.1% Lifetime (Kessler et al, 1994)

Treatments of GAD

epidemiology of generalized anxiety disorder12
Epidemiology of Generalized Anxiety Disorder
  • Onset
    • Early onset (mid-teens)
    • However, some suggest that there may be two subtypes – one early onset and one later onset in response to a stressful event

Treatments of GAD

epidemiology of generalized anxiety disorder13
Epidemiology of Generalized Anxiety Disorder
  • Genetics
    • Twin study by Kendler et al (1992)
      • GAD runs in families
      • The familial association is due to shared genetic as opposed to shared environmental factors
      • Heritability is estimated between 19- 30%
      • Heritability cannot be explained by PD or major depression
      • *Genetic factors seemed stronger for brief as opposed to more prolonged periods of GAD

Treatments of GAD

impact of gad on health care utilization
Impact of GAD on Health Care Utilization

GAD is second only to depression in prevalence of a psychiatric condition found in the primary care setting

Treatments of GAD

impact of gad on health care utilization15
Impact of GAD on Health Care Utilization
  • GAD is the most prevalent anxiety disorder found in primary care settings (Barrett et al, 1988)
  • GAD patients are twice as likely (44 vs. 22%) to seek treatment in a primary care setting as opposed to a psychiatric treatment setting (Wittchen et al, 1994)
  • Among patients classified high in medical care utilization 40% meet lifetime history of GAD and 22% meet current GAD diagnosis (Katon et al, 1993)

Treatments of GAD

common symptom presentations in primary care among gad patients
Common Symptom Presentations in Primary Care Among GAD Patients
  • Chest Pain
    • Among ER patients presenting with atypical chest pain, 23% met for GAD (Wulsin et al, 1991)
    • Among chest pain patients with normal coronary angiograms, 56% met for GAD (Kane et al, 1988)
  • Gastrointestinal
    • Among IBS patients, 34-54% meet for GAD lifetime (Walker et al, 1990; Lydiard et al, 1993)
    • Among IBS patients with comorbid GAD, 80% reported that their GAD symptoms preceded their IBS symptoms

Treatments of GAD

spheres of worry in gad
Spheres of Worry in GAD

Data from Sanderson & Barlow (1986) Paper presented at AABT, Chicago.

Treatments of GAD

how does gad worry differ from normal worry
How does GAD Worry Differ from “Normal” Worry?

Data from Dupuy, J.R. et al (2001). Behaviour Research and Therapy, 39 1249-1255.

Treatments of GAD

how does gad worry differ from normal worry20
How does GAD Worry Differ from “Normal” Worry?

Data from Dupuy, J.R. et al (2001). Behaviour Research and Therapy, 39 1249-1255.

Treatments of GAD

how does gad worries differ from ocd obsessions
How does GAD Worries Differ from OCD Obsessions?
  • Worries are more in agreement with one’s belief system (egosyntonic)
  • GAD worries occur as verbal thoughts whereas OCD obsessions can take the form of images, ideas, or impulses;
  • GAD worry is perceived as less intrusive and less likely to be resisted
  • The content of GAD worries are not perceived as unacceptable or senseless
  • GAD interfere more with functioning
  • GAD worries are more likely to have situational triggers
  • GAD worries remain in the background (omnipresent)

Treatments of GAD

basic research on the nature and functions of worry22
Basic Research on the Nature and Functions of Worry
  • Conceptualization of worry as a coping strategy to avoid threatening material (Borkovec, & Hu, 1990; Borkovec et al (1993)

Treatments of GAD

borkovec nau 1990
Borkovec & Nau (1990)

Data from Borkovec & Nau (1990). Behaviour Research and Therapy, 28, 69-71.

Treatments of GAD

basic research on the nature and functions of worry24
Basic Research on the Nature and Functions of Worry
  • Worry is negatively reinforcing by allowing the patient to cognitively avoid the negative affect
  • A significant consequence of this avoidance is the inhibition of emotional processing thereby resulting in the maintenance of anxious meanings despite daily exposures to threat material

Treatments of GAD

evidence supporting the threat avoidance function of worry
Evidence Supporting the Threat Avoidance Function of Worry
  • Phobic patients who think worrisome thoughts just prior to exposure to phobic images show no cardiovascular response to those images; Whereas phobics who think neutral or relaxing thoughts just prior to exposure display significant cardiovascular response (Borkovec & Hu, 1990).

Treatments of GAD

evidence supporting the threat avoidance function of worry26
Evidence Supporting the Threat Avoidance Function of Worry
  • Worry after exposure to a stressful event results in a failure to process emotional material (Butler et al; 1995; Wells et al, 1995)

Treatments of GAD

evidence supporting the threat avoidance function of worry27
Evidence Supporting the Threat Avoidance Function of Worry
  • GAD participants but not normal controls significantly endorse the item “Worrying about most things I worry about is a way to distract myself from worrying about even more emotional things” (Borkovec & Roemer, 1995)

Treatments of GAD

evidence supporting the threat avoidance function of worry28
Evidence Supporting the Threat Avoidance Function of Worry
  • GAD patients show higher prevalence of traumatic experiences than controls
  • GAD patients overpredict aversive outcomes and drastically underpredict their ability to cope with potential threats suggesting that they are not processing evidence that the world offers them

Treatments of GAD

evidence supporting the threat avoidance function of worry29
Evidence Supporting the Threat Avoidance Function of Worry
  • GAD patients show a preattentive bias to threat cues outside of awareness;
  • GAD patients display a rapid cognitive avoidance of detected threats such that explicit memory for threat material is reduced but implicit memory for the same material is increased

Treatments of GAD

what are the threats that gad patients are avoiding
What Are the Threats That GAD Patients Are Avoiding?
  • Negative attachment experiences
  • Current interpersonal problems
  • Trauma

Treatments of GAD

how does worry inhibit emotional processing
How Does Worry Inhibit Emotional Processing?
  • Lessened attentional resources for processing other information (Mathews, 1990)
  • Difficulty shifting thought away from negative thought activity (Parkinson & Rachman, 1981)
  • Less mismatch between information expected and information received

Treatments of GAD

status of psychotherapy outcome research in gad
Status of Psychotherapy Outcome Research in GAD
  • Systematic development and evaluation of psychotherapies for GAD have lagged behind that for other anxiety disorders
  • Early treatment research on GAD focused on somatic anxious experience and the use of relaxation to provide a generalizeable coping response to stress and anxiety

Treatments of GAD

reasons for the slow progress in psychotherapy development
Reasons for the Slow Progress in Psychotherapy Development
  • Historically, GAD has been an ambiguous disorder
  • Diffuse forms of anxiety did not fit into prevailing behavioral perspectives as readily as the other anxiety disorders

Treatments of GAD

reasons for the slow progress in psychotherapy development34
Reasons for the Slow Progress in Psychotherapy Development
  • Although exposure methods accrued considerable evidence for efficacy when circumscribed fear-provoking stimuli could be identified, their relevance was less clear for GAD wherein external triggers for anxiety were more obscure, pervasive, and constantly changing

Treatments of GAD

pharmacological treatments for generalized anxiety disorder
Pharmacological Treatments for Generalized Anxiety Disorder
  • Benzodiazepines
  • Antidepressants
  • Buspar

Treatments of GAD

things to know about the pharmacotherapy of gad
Things to Know About the Pharmacotherapy of GAD
  • More well-controlled trials than any other anxiety disorder;
  • Many of the earlier studies include patients who may not meet current criteria for GAD
  • Most use the Hamilton anxiety as their major outcome measure

Treatments of GAD

things to know about the pharmacotherapy of gad37
Things to Know About the Pharmacotherapy of GAD
  • Benzodiazepines (22 – 62% reduction on Hamilton) offer a modest short-term beneficial effect relative to pill placebo (18 to 48% reduction);
  • Benzodiazepines are associated with (a) cognitive impairment; (B) withdrawal effects; and (c) rebound anxiety
  • Buspar has been shown to have similar rates of improvement with fewer negative side effects

Treatments of GAD

contemporary cognitive behavioral treatment of gad
Contemporary Cognitive Behavioral Treatment of GAD
  • Procedural Components
    • Self-monitoring
    • Cognitive restructuring
    • Applied relaxation
    • Coping desensitization
    • Worry Exposure

Treatments of GAD

summary of randomized controlled clinical trials in gad
Summary of Randomized Controlled Clinical Trials in GAD

Data based on Gould et al (1997).

Treatments of GAD

efficacy estimates at posttreatment
Efficacy Estimates at Posttreatment

Data from Gould et al. (1997).Behavior Therapy, 28, 285-305.

Treatments of GAD

efficacy estimates at follow up
Efficacy Estimates at Follow-up

Data from Gould et al. (1997).Behavior Therapy, 28, 285-305.

Treatments of GAD

cognitive behavioral treatment of gad
Cognitive-Behavioral Treatment of GAD
  • Current Status of Outcome Research
    • CBT was associated with low drop-out rates and reductions in medication taking
    • At best only 50% of patients achieve recovery status

Treatments of GAD

efficacy data
Efficacy Data
  • Butler et al (1991)
    • CBT
    • BT
    • WL Control

Treatments of GAD

efficacy data47
Efficacy Data
  • Power et al (1990)
    • Diazepam
    • Pill placebo
    • CBT
    • DZ + CBT
    • PL + CBT

Treatments of GAD

efficacy data49
Efficacy Data
  • Barlow et al (1992)
    • Progressive muscle relaxation
    • Cognitive therapy
    • Progressive muscle relaxation + cognitive therapy
    • Wait-list

Treatments of GAD

efficacy data52
Efficacy Data
  • Borkovec & Costello (1993)
    • Applied relaxation
    • CBT (Applied relaxation, self-control desensitization, and brief cognitive therapy)
    • Reflective listening supportive psychotherapy

Treatments of GAD

efficacy data55
Efficacy Data
  • Borkovec et al (In progress)
    • Self-Control desensitization
    • Cognitive Therapy
    • Self-Control desensitization + Cognitive Therapy

Treatments of GAD

summary of treatments for gad
Summary of Treatments for GAD
  • Both pharmacotherapy and CBT lead to marked improvement in GAD symptoms in the short-term;
  • The effects of CBT are more durable than pharmacotherapy once treatment is discontinued;
  • CBT is associated with low drop-out rates and reductions in medication taking
  • Combined medication and CBT appear no more effective than either medication alone or CBT alone;
  • Presence of significant interpersonal problems among GAD patients predicts a negative response to CBT (Pincus & Borkovec, 1994);
  • No data available on the effectiveness of GAD treatments when delivered in the real world;
  • No data available as to whether these treatments lead to reductions in health care utilization

Treatments of GAD