lynne cox michelle deen maria elsdon ronelle...
TRANSCRIPT
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 &
R. A. Barkley (Eds.), Child psychopathology (2nd ed., pp. 279-329). New York: Guilford Press.
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
options for DSM-V. Depression and Anxiety, 27, 134-147.
Ash, D., & Galletly, C. (2009). Challenges in psychiatric classification: The case of generalized anxiety
disorder. Australasian Psychiatry, 17(6), 484-487. doi: 10.1080/10398560902964594
Barkley, R. A. & Mash, E. J. (2003). Child psychopathology, 2nd edition. New York: Guilford Press.
Brown, T. A., & Barlow, D. H. (2002). Classification of anxiety and mood disorders. In D. H. Barlow
(Ed.), The nature and treatment of anxiety and panic (2nd ed., pp. 292-327). New York: Guilford
Press.
ReferencesBehar, E., DiMarco, I. D., Hekler, E. B., Mohlman, J., & Staples, A. M. (2009). Current theoretical models of
generalized anxiety disorder (GAD): Conceptual review and treatment implications. Journal of Anxiety Disorders, 23(8), 1011-1023. doi:10.1016/j.janxdis.2009.07.006
Borkovec, T. D., Alcaine, O. M., & Behar, E. (2004). Avoidance theory of worry and generalized anxiety disorder. In D. S. Mennin (Ed.), Generalized anxiety disorder: Advances in research and practice. (pp. 77-108). New York, NY US: Guilford Press.
Davey, G., & Wells, A. (2006). Worry and its psychological disorders. Hoboken, NJ: Wiley.
Dugas, M. J., Buhr, K., & Ladouceur, R. (2004). The role of intolerance of uncertainty in etiology and maintenance. In D. S. Mennin (Ed.), Generalized anxiety disorder: Advances in research and practice. (pp. 143-163). New York, NY US: Guilford Press.
Ellis, D. M., & Hudson, J. L. (2010). The metacognitive model of generalized anxiety disorder in
children and adolescents. Clinical Child and Family Psychology Review, 13(2), 151-163. doi:
10.1007/s10567-010-0065-0
Fisher, P. L., & Wells, A. (2009). Psychological models of worry and generalized anxiety disorder. In M. B. Stein (Ed.), Oxford handbook of anxiety and related disorders. (pp. 225-237). New York, NY US: Oxford University Press.
Heimberg, R. G., Mennin, D. S., & Turk, C. L. (2004). Generalized anxiety disorder. New York: Guilford Press.
Liber, M.J., van Widenfelt, B.M., van der Leeden, A.J.M., Goedhart A.W., Utens E.M.W.J., & Treffers, P.D.A. (2010). The relation of severity and comorbidity to treatment outcome with cognitive behavioral therapy for childhood anxiety disorders. Journal of Abnormal Child Psychology, 38, 683-694.
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.
References
Nordahl, H.M., Wells, A., Olsson C.A., & Bjerkeset O., (2010). Association between abnormal psychosocial situations in childhood, generalized anxiety disorder and oppositional defiant disorder. Australian and New Zealand Journal of Psychiatry, 44, 852-858.
O’Neil, K.A., Podell, J.L., Benjamin, C.L., & Kendall, P.C., (2010). Comorbid depressive disorders in Anxiety-disordered youth: demographic, clinical, and family characteristics. Child Psychiatry Human Development, 41, 330-341.
Roemer, L., & Orsillo, S. M. (2002). Expanding our conceptualization of and treatment for generalized anxiety disorder: Integrating mindfulness/acceptance-based approaches with existing cognitive-behavioral models. Clinical Psychology: Science and Practice, 9(1), 54-68. doi:10.1093/clipsy/9.1.54
Roemer, L., & Orsillo, S. M. (2005). An acceptance-based behavior therapy for generalized anxiety disorder. In L. Roemer (Ed.), Acceptance and mindfulness-based approaches to anxiety: Conceptualization and treatment. (pp. 213-240). New York, NY US: Springer Science + Business Media. doi:10.1007/0-387-25989-9_9
Starcevic, V. (2008). Anxiety disorders no more? Australasian Psychiatry, 16(5), 317-321. doi: 10.1080/10398560801995277
Turner, S. M., & Beidel, D. C. (2005). Childhood anxiety disorders. Hove: Routledge.
Wells, A. (2006). The metacognitive model of worry and generalised anxiety disorder. In A. Wells (Ed.), Worry and its psychological disorders: Theory, assessment and treatment. (pp. 179-199). Hoboken, NJ US: Wiley Publishing.
References