Lynne Cox

Michelle Deen

Maria Elsdon

Ronelle Krieger

Presentation Outline Types of anxiety disorders

Diagnostic Criteria for Generalized Anxiety Disorder

Epidemiology

History of Generalized Anxiety Disorder

Psychological Models of Generalized Anxiety Disorder

Issues in the Conceptualization and Identification of

Generalized Anxiety Disorder

Recent Research

What I Know ……

General Anxiety Disorder (GAD) In the DSM-IV-TR, children can be diagnosed with any of the

following 9 anxiety disorders:

- separation anxiety disorder,

- agoraphobia,

- panic disorder,

- social phobia,

- specific phobia,

- obsessive compulsive disorder,

- posttraumatic stress disorder,

- acute disorder,

- general anxiety disorder.

Diagnostic Criteria for 300.02

GADA. Excessive anxiety and worry, occurring more days than not, for at least 6

months, about a number and variety of events or activities.

B. The person finds it difficult to control the worry.

C. The anxiety and worry are associated with the following six symptoms:

Restlessness or feeling „keyed up‟ or on edge,

Being easily fatigued

Difficulty concentrating or mind going blank

Irritability

Muscle tension

Sleep disturbance

It’s important to note that for adults, at least 3 out of the following 6 symptoms must be present; however, for children, only 1 symptom is required.

Diagnostic Criteria for 300.02 GAD (continued)

D. The focus of the anxiety and worry is not confined to features of an Axis 1

disorder

E. The anxiety, worry, or physical symptoms cause clinical significant distress or

impairment in social, occupational, or other important areas of functioning

F. The disturbance is not due to the direct physiological effects of a substance or a

general medical condition.

Epidemiology

According to Keeton, Kolos, and Walkup (2009) Pediatric

GAD occurs in over 10% of children and adolescents, and has

an average age of onset of 8.5 years. Pediatric GAD is more

often reported in girls than boys.

Kessler, Ruscio, Shear & Wittchen (2009) found that the

lifetime prevalence of GAD is estimated to be between 1-6 %

and that it is also more often reported in women as compared to

men.

History of GAD

DSM-II (1968) – Overanxious reaction

DSM-III (1980) – OAD

DSM-III-R (1987) – OAD and GAD

DSM-IV (1994) - GAD

Psychological Models of GAD

Five basic psychological models of worry and GAD

1. Cognitive Avoidance Theory

2. Metacognitive Model of GAD

3. Intolerance of Uncertainty Theory

4. Emotional Dysregulation Model

5. Acceptance-Based Model of GAD

Cognitive Avoidance Theory Borkovec, Alcaine, & Behar, 2004

Worry...

is an abstract, verbal linguistic activity

lessens mental imagery & somatic arousal

can be negatively reinforced

distracts from emotionally distressing topics

Individuals with GAD have positive beliefs about worry

Cognitive Avoidance Theory

Metacognitive Model Wells, 2006

Type 1 worry: external events, internal (non-cognitive)

Type 2 worry: a.k.a. metaworry

Children with GAD have a negative view of worrying

Negative view of worrying increases

anxiety and extends worry

Individuals avoid settings/thoughts

that trigger worry

Failure to avoid feels like loss of control

Metacognitive Model

Intolerance of Uncertainty Model Dugas, Buhr, & Ladoucer, 2004

Intolerance of uncertainty: a cognitive lens

Strong need for control and security

Uncertain/ambiguous situations are stressful

Leads to chronic worry & negative problem orientation

Negative problem orientation

Low confidence in solving abilities

Perception of problems as threats

Frustration dealing with problems

Pessimism re: problem-solving outcomes

Intolerance of Uncertainty Model

Emotional Dysregulation ModelMennin, Turk, & Heimberg, 2004

Why are affective states or emotional experiences so

distressing they are avoided?

Four interacting components:

1. Heightened intensity of emotions

2. Limited understanding of emotions

3. Negative responses to emotions

4. Unhelpful regulation and management of emotions

Emotional Dysregulation Model

Acceptance-Based Model Roemer & Orsillo (2002, 2005)

Individuals react negatively to internal experiences

Individuals use cognitive and behavioural strategies to avoid internal experiences

4 components:

1. Internal experiences

2. Problematic relationship with int exp

Negative reactions to int exp

Fusion of internal experiences

3. Experiential avoidance

4. Behavioural restriction

Acceptance-Based Model

Limitations of GAD Models In general…

Models based on adult populations

Worry is difficult to report/measure

Specific Limitations

A. Cognitive Avoidance Theory

B. Metacognitive Model of GAD

C. Intolerance of Uncertainty Theory

D. Emotional Dysregulation Model

E. Acceptance-Based Model of GAD

Issues in the Conceptualization and Identification

of GAD1. Normal vs. Pathological (Albano, Chorpita, & Barlow, 2003)

Reflection

Which of the following situations represents GAD? Why?

A young boy with an abusive father constantly worries about his mother‟s

and his own safety.

OR

A 24 year old mechanic seems to worry about everything and anything. He

is always tense and he is apprehensive about disasters that could befall him

as he works and interacts with other people. He has also had a long history

of difficulties in interpersonal relationships, which have led to him being

fired from several jobs.

Issues in the Conceptualization and Identification of GAD

(continued)

2. DSM-IV-TR Criteria for GAD

Issues inherent in the DSM

system

Diagnostic unreliability

(Brown & Barlow, 2002) Lack of specific

criteria to assess levels of severity and intensity of disorders

(Brown & Barlow, 2002)

DSM-IV-TR criteria assumptions (Andrews

et al., 2010)

Little is known about the validity and reliability of the Generalized Anxiety

Disorder diagnosis in children and adolescents

(Andrews et al., 2010)

Issues with discriminative validity

of anxiety disorders because of symptom

overlap (Albano, Chorpita, & Barlow,

2003)

Issues in the Conceptualization and Identification of

GAD (continued)

3. Comorbidity

Situations where anxiety is comorbid with an externalizing disorder or

depression(Albano, Chorpita, & Barlow, 2003)

Generalized Anxiety Disorder is present in all of the anxiety disorders

(Ash & Galletly, 2009)

Boundaries between various anxiety disorders are questionable

(Starcevic, 2008)

Considerable comorbidity between Generalized Anxiety Disorder and the

mood disorders (Ash & Galletly, 2009)

Issues in the Conceptualization and

Identification of GAD (continued) 4. Internalizing vs. Externalizing Problems (Albano, Chorpita, & Barlow,

2003)

1. Inadequate identification of internalizing problems, such as anxiety

disorders, in children

2. Underutilization of mental health services for children with anxiety

disorders

5. Assessing Generalized Anxiety Disorder

1. Diagnostic disagreement between informants (Andrews et al., 2010)

2. Diagnosis can be dependent on which reporter‟s information the clinician

emphasizes (Manassis, Tannock, & Monga, 2009)

3. Parental reports of child anxiety are sometime reflective of parental

anxiety (Manassis, Tannock, & Monga, 2009)

4. Maternal psychopathology (Manassis, Tannock, & Monga, 2009)

Recent Research

Classification changes

DSM-III

“Confusing stepchild amongst the anxiety disorders”

DSM-IV

“General Anxiety Disorder is not a trivial disorder”

(Andrews et al., 2010)

Recent Research (continued)

• Problems

• Poor discriminate validity between classifications

• High rate of comorbidity

• DSM-IV –separate discrete diagnostic categories

-true relationship between depression and anxiety?

Child and adolescent clinic-referred samples-anxiety and depression are often co-

occuring

Rates ranging

• 32% (Kovacs et al., 1989-62% (Masi et al., 1999) (as cited in McMillan et al., 2008)

• High comorbidity rates in children and adolescents

• Growing Literature base in adult populations

Rethinking the organization? (e.g., Krueger 1999, Mineka et al., 1998; Watson 2005)

Recent Research (continued) Study by Nordahl, Wells, Olsson & Bjerkeset, 2010

Are core dimensions of stressful psychosocial situations differentially associated

with childhood generalized anxiety disorder and oppositional defiant disorder?

2 significant dimensions

• Overprotection, parental pressures

• Acute life events

Function

1

• Parental abuse/hostility

• Interpersonal stressFunction 2

Recent Research (continued) psychosocial adversity predicted functional impairment in children with

GAD

but not in children with other anxiety disorder (Manassis and Hood,1998)

children with GAD may be sensitized to danger and may learn the utility of

anticipating threat as a means of coping ( Nordhel et al., 2010)

-Specific dimensions of the ICD-10 psychosocial situations seem to be

specifically associated with GAD and ODD in children (Nordahl et al.,

2010).

Results

• Abusive child-parent relationships and discordant relationships with teacher/school and /or peersChildhood Oppositional Defiant

Disorder

• Parental overprotection, parental pressures, inadequate supervision/control and acute threats

• (Nordahl et al., 2010)

Childhood Generalized Anxiety disorder

Treatment

Relation of Severity and Comorbidity to Treatment Outcome with

Cognitive Behavioral Therapy (Liber et al., 2010)

• Combined impact of comorbidity and overall severity on the

potency of treatments for various primary diagnosis

• Genetic programs

• Combined modular or prescriptive treatments

• Stepped Care approach (Liber et al., 2010)

Metacognitive Therapy

Modifying beliefs about worry (Wells & King, 2006)

Metacognitive Therapy

The underlying cognitive processes of pathological worry

Identify and modify negative metacognitive beliefs (Wells, 2009)

Positive Beliefs

„detached mindfulness‟

Rumination and worrying

Applying this model to children and adolescents enhances the understanding

of child and adolescent worry (Ellis & Hudson, 2010)

Assessment of worry and the applicability of the metacognitive model in

child and adolescent population are areas that have been identified that may

benefit from further research (Ellis & Hudson, 2010)

GAD Video

http://www.youtube.com/watch?v=U4dC8RgV9MQ

Reflection Question

Do you think that Generalized Anxiety

Disorder is its own distinct disorder and

therefore, should remain a separate

disorder in future editions of the DSM?

ReferencesAlbano, A. M., Chorpita, B. F., & Barlow, D. H. (2003). Childhood anxiety disorders. In E. J. Mash &

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American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental

Disorders: Fourth Edition: Text Revision. Washington, DC.

Andrews, G., Hobbs, M. J., Borkovec, T. D., Beesdo, K., Craske, M. G., Heimberg, R. G., . . . Stanley, M.

A. (2010). Generalized worry disorder: A review of DSM-IV generalized anxiety disorder and

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Ash, D., & Galletly, C. (2009). Challenges in psychiatric classification: The case of generalized anxiety

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Keeton, C. P., Kolos, A. C., & Walkup, J. T. (2009). Pediatric generalized anxiety disorder: Epidemiology, diagnosis, and management. Pediatric Drugs, 11(3), 171-183.

Kessler, R., Ruscio, A., Shear, K., & Wittchen, H. (2009). Epidemiology of anxiety disorders. In M. Anthony & M. Stein (eds.), Oxford Handbook of Anxiety and Related Disorders (pp.21-35). Retrieved from http://books.google.ca.ezproxy.lib.ucalgary.ca/books?hl=en&lr=&id=DKDDqOw6Y7wC&oi=fnd&pg=PA19&dq=Kessler,+Ruscio,+Shear+%26+Wittchen+&ots=oQuQQWiBe-&sig=FVO2E6-BYsruQxEIZI8X1S-jq0Q#v=onepage&q=Kessler%2C%20Ruscio%2C%20Shear%20%26%20Wittchen&f=false

Manassis, K., Tannock, R., & Monga, S. (2009). Anxious by maternal – versus self-report: Are they the same children. Journal of Canadian Child Adolescent Psychiatry, 18(2), 103-109.

Nordahl H.M. (2009) Effectiveness of brief metacognitive therapy versus cognitive-behavioral therapy in a general outpatient setting. International Journal of Cognitive Therapy, 2(2), 152-159.

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