1.2- Generalized Anxiety Disorder

Case 1 - Clinical History: (pp. 1-5)

Key Answer: C) Depressed mood

Explanation:
DSM-5 defines GAD as excessive, hard-to-control worry occurring most days for at least 6 months, associated with ≥3 of 6 symptoms: restlessness or feeling keyed up/on edge, being easily fatigued, difficulty concentrating or mind going blank, irritability, muscle tension, and sleep disturbance. While depressed mood may co-occur with GAD (especially since DSM-5 allows comorbidity with mood disorders), it is not one of the six diagnostic criteria for GAD.

According to the DSM-5, which of the following is not one of the six core symptoms associated with Generalized Anxiety Disorder (GAD)?

A) Muscle tension
B) Irritability
C) Depressed mood
D) Sleep disturbance

Key Answer: B) Excessive and uncontrollable worry

Explanation:
Although some concern for children’s safety is normal, Adrian’s worry was excessive, disproportionate to the actual risk, and uncontrollable—hallmarks of GAD. Panic attacks and trauma-related hypervigilance are different clinical phenomena.

Adrian reported that she worried excessively about her children’s safety if she did not hear from them for a few hours. According to DSM-5 criteria, this is best described as:

A) Appropriate parental concern
B) Excessive and uncontrollable worry
C) Panic attack symptoms
D) Hypervigilance due to trauma

Key Answer: C) The diagnostic hierarchy rule was eliminated.

Explanation:
In DSM-IV, GAD was not diagnosed if symptoms occurred only during a mood disorder. DSM-5 removed this restriction, allowing a GAD diagnosis even in the presence of depressive or trauma-related symptoms.

Which change in DSM-5 allowed Adrian to be diagnosed with GAD even though she also displayed symptoms of low self-esteem and distress that overlap with depression?

A) GAD can no longer be diagnosed with depression.
B) The 6-month duration requirement was removed.
C) The diagnostic hierarchy rule was eliminated.
D) Comorbidity between GAD and social anxiety disorder is no longer allowed.

Key Answer: B) Her shyness and early onset of excessive worry in high school.

Explanation:
Predisposing factors increase long-term vulnerability. Adrian’s lifelong shyness and early onset of anxiety in adolescence set the stage for GAD. The divorce (A) and supervisor conflict (C) are precipitating stressors, while (D) reflects perpetuating behavior.

Which of the following represents a predisposing factor in Adrian’s case?

A) Her divorce and conflict with her ex-husband about where to raise the children.
B) Her shyness and early onset of excessive worry in high school.
C) Her supervisor’s criticism and advice to “get her head together.”
D) Spending extra time at work to avoid mistakes.

Key Answer: C) Supervisor criticism and job-related errors.

Explanation:
Precipitating factors are events that trigger or worsen the current episode. Adrian’s recent mistakes at work, her supervisor’s remark, and job stress directly precipitated her current exacerbation.

Which of the following is the most significant precipitating factor for the escalation of Adrian’s anxiety symptoms in adulthood?

A) A history of marijuana use in college.
B) Moving to a new school at age 14.
C) Supervisor criticism and job-related errors.
D) Having a family history of alcoholism.

Key Answer: A) Extra time spent at the office to prevent mistakes.

Explanation:
Perpetuating factors maintain symptoms. Adrian’s compensatory behaviors (working extra hours, over-checking decisions) reinforce worry and prevent her from learning she can cope without overpreparing.

Which of the following behaviors perpetuates Adrian’s GAD symptoms?

A) Extra time spent at the office to prevent mistakes.
B) Seeking reassurance from her family doctor about marijuana use.
C) Procrastinating on schoolwork in adolescence.
D) Divorce from her husband.

Key Answer: A) Her supportive teachers in high school who reassured her about her assignments.

Explanation:
Protective factors buffer against illness or aid recovery. Adrian’s supportive social environment (teachers, family, enduring friendships) has the potential to reduce her distress, even if reassurance alone was not enough.

Which of the following is a protective factor for Adrian?

A) Her supportive teachers in high school who reassured her about her assignments.
B) Her tendency to avoid making decisions.
C) Her history of excessive worry about her children.
D) Her migraine headaches.

Key Answer: B) They should be listed alongside psychiatric diagnoses as relevant medical conditions.

Explanation:
DSM-5 no longer uses the multiaxial system, but medical conditions that interact with psychiatric symptoms (e.g., hypertension worsened by stress) are still documented. They don’t exclude GAD unless they fully account for symptoms.

Comorbidity & Medical Conditions

Why are Adrian’s migraine headaches and borderline hypertension clinically relevant to her DSM-5 case formulation?

A) They rule out a GAD diagnosis because her anxiety symptoms are due to a medical condition.
B) They should be listed alongside psychiatric diagnoses as relevant medical conditions.
C) They indicate she has somatic symptom disorder instead of GAD.
D) They prove her anxiety is secondary to substance use.

Key Answer: A) Moving to a new school and worrying about failing honors classes.

Explanation:
This early stressor coincided with the onset of chronic worry, sleep disturbance, and performance-related anxiety, making it a key predisposing event.

Developmental History – Predisposing

Which developmental experience best represents a predisposing factor for Adrian’s later GAD?

A) Moving to a new school and worrying about failing honors classes.
B) Brief experimentation with marijuana in college.
C) Supervisor criticism at her banking job.
D) Divorce following conflict with her husband.

Key Answer: B) The birth of her children and conflict over moving abroad.

Explanation:
This marital conflict and eventual divorce triggered chronic worry about her children’s safety and stability, marking a turning point in symptom escalation.

Case History – Precipitating

What life event most directly precipitated the escalation of Adrian’s anxiety after college?

A) Her teachers offering reassurance in high school.
B) The birth of her children and conflict over moving abroad.
C) Her supportive friendships during childhood.
D) Her paternal grandfather’s alcoholism.

Key Answer: B) Believing her memory problems are due to past marijuana use.

Explanation:
Her catastrophic misinterpretation of minor cognitive lapses as brain damage maintains her anxiety and leads to further worry spirals.

Perpetuating – Cognitive

Which of Adrian’s thinking patterns perpetuates her anxiety symptoms?

A) Accepting reassurance from her doctor about marijuana use.
B) Believing her memory problems are due to past marijuana use.
C) Getting fewer headaches during periods of low stress.
D) Being reassured by family and teachers in adolescence.

Key Answer: A) Arriving early every day to plan excessively.

Explanation:
Her safety behaviors (overpreparing, over-checking) consume time, increase stress, and reinforce her anxiety, perpetuating symptoms.

Perpetuating – Behavioral

Which behavioral factor most strongly perpetuates Adrian’s difficulties at work?

A) Arriving early every day to plan excessively.
B) Visiting her children’s father during vacations.
C) Dating infrequently in college.
D) Playing with her children after work.

Key Answer: A) Supportive relationships with her children.

Explanation:
While her worries center on her children, her bond with them also provides social meaning and motivation for treatment, acting as a resilience factor.

Protective – Social Factors

Which factor could serve as a protective element in Adrian’s case?

A) Supportive relationships with her children.
B) Strict parenting during adolescence.
C) Perceived criticism from her supervisor.
D) Migraine headaches controlled by medication.

Key Answer: A) Adrian worries daily about her children’s well-being and minor life matters.

Explanation:
Generalized, uncontrollable worry across multiple domains (work, children, daily tasks) defines GAD. Social anxiety disorder involves fear of negative evaluation, which Adrian also has, but without pervasive avoidance.

Differential Diagnosis

Which of the following helps differentiate GAD from social anxiety disorder in Adrian’s case?

A) Adrian worries daily about her children’s well-being and minor life matters.
B) Adrian experiences anxiety when speaking in meetings or dating.
C) Adrian avoids most social interactions to prevent embarrassment.
D) Adrian developed shyness in childhood and adolescence.

Key Answer: A) Her awareness that her anxiety is excessive and distressing.

Explanation:
Insight into her symptoms increases treatment motivation and strengthens engagement, making it a protective factor.

Treatment Consideration – Protective

Which factor may support Adrian’s progress in therapy?

A) Her awareness that her anxiety is excessive and distressing.
B) Her tendency to avoid making decisions altogether.
C) Her belief that marijuana damaged her brain.
D) Her supervisor’s criticism at work.

5- Medication – Benzodiazepines

• Short-term effectiveness

• Cognitive/motor impairment risks

• Dependence/tolerance risk

6- Medication – Antidepressants (SSRIs/SNRIs)

• Better long-term outcome than benzodiazepines

• Biological mechanism explained (serotonin, norepinephrine)

• Combination with CBT

7- Biological Mechanisms

• GABA enhancement (benzos)

• Prefrontal-amygdala dysregulation in GAD

8- Psychoeducation

• Relapse risk

• Importance of CBT skills beyond medication

• Realistic expectations for patients

1. Prevalence & epidemiology

   • Lifetime prevalence (1.9–5.7%)

   • National Comorbidity Survey data

   • 2:1 female-to-male ratio

   • Elderly prevalence (7–10%)

   • Use of tranquilizers in older adults

2. Comorbidity

   • High rates of co-occurrence with mood and other anxiety disorders

   • 80–90% with another disorder

3. Onset & Course

   • Early adulthood / adolescence

   • Often gradual and lifelong anxiety

4. Impairment & Burden

   • 82% reported impairment (treatment-seeking, lifestyle interference)

   • GAD not “mild” compared to other anxiety disorders

Treatment Implementation

1. Early Sessions

   • Psychoeducation: nature of worry & anxiety.

   • Self-monitoring diary (anxiety, depression, triggers, % of day spent worrying).

2. Middle Sessions

   • Cognitive therapy: identify overestimation & catastrophic thoughts.

   • Behavioral experiments (clarifying supervisor’s remark, reducing children’s calls).

3. Later Sessions

   • Worry exposure (imaginal exposure to feared outcomes).

   • Building tolerance for uncertainty.

   • Relapse prevention: homework, continued worry scheduling.

Life Events & 4Ps

• Predisposing factors:

  • Temperamentally anxious, strong responsibility for others.

  • History of migraines (possible biological vulnerability).

• Precipitating factors:

  • Divorce → increased sense of rejection, relational insecurity.

  • Supervisor’s remark about vacation → immediate trigger for catastrophic thinking (“I’ll be fired”).

• Perpetuating factors:

  • Excessive checking on children.

  • Avoidance of clarification at work.

  • Cognitive style: probability overestimation + catastrophizing.

• Protective factors:

  • Insight, motivation for therapy.

  • Good work performance history.

  • Support from children.

3- Gradual Onset and Lifelong Nature.

• GAD often starts in childhood with a temperament of high behavioral inhibition or neuroticism.

• Suggests an enduring personality vulnerability rather than an acute, episodic illness.

• Likely involves a mix of genetic predisposition, early learning experiences, and chronic cognitive style (habitual worry as a coping attempt).

1- Differentiating Normal vs. Pathological Worry (DSM-5).

• Normal worry: Occasional, specific, manageable, does not impair functioning.

• GAD worry: Excessive, uncontrollable, persistent for ≥6 months, about multiple domains, and causes distress or impairment.

——————————————————————————————-

2- Adaptive vs. Maladaptive Worry.

• Adaptive qualities: Helps prepare for challenges, motivates planning, may prevent careless mistakes.

• Maladaptive in GAD: Becomes uncontrollable, consumes time/energy, leads to avoidance, maintains anxiety, and reinforces false beliefs (e.g., Adrian believing arriving early prevents mistakes).

• 300.02 Generalized anxiety disorder (principal diagnosis)

• 300.23 Social anxiety disorder

• Borderline hypertension, migraine headaches

DSM-5 Diagnosis

Based on this information, Adrian was assigned the following DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th ed.) (American Psychiatric Association, 2013) diagnoses: