GENERALIZED ANXIETY DISORDER (GAD)

IMPORTANT DEFINITIONS

DEFINE » Worry: An internal representation of future aversive events that cause anxiety in the absence of existing threat. It is the cognition component of anxiety (Clark & Beck, 2011).

It is a persistent awareness of possible future danger, which is repeatedly rehearsed without being resolved (Mathews, 1990)

A chain of thoughts and images, negatively affect-laden and relatively uncontrollable. The process represents an attempt to engage in mental problem-solving on an issue whose outcome is uncertain but contains the possibility of one or more negative outcomes (Borkovec. 1983)

DEFINE » Ego-dystonic: Experienced as non-characteristic of the self

DEFINE » Ego-syntonic: Experienced as a characteristic of the self and consistent with their desires and values

GENERALIZED ANXIETY DISORDER (GAD)

Occurs when individuals chronically worry about two or more life circumstances, and this constant worry is experienced as excessive and distressing

  • This generates chronic symptoms of motor tension and hypervigilance, fatigue, poor concentration and sleep

  • A defining feature of GAD is a perceived inability to stop worrying (or at least control / influence it) and this adds to the anxious distress

COURSE AND COMORBIDITY

  • In the USA, 50% had an onset under age 31, 85% of those with GAD also had a comorbid condition alongside GAD

  • GAD is chronic and unremitting, and is a socialeconomic burden (Newman. 2000; Newman et al., 2016)

  • Waxes and wanes with life stressors and expresses itself in other disorders and comorbidities

  • High relapse risk

  • Comorbid with MDD (62%) and SAD (34%)

RISK FACTORS

  • Heritability: 15-20% heritability, which is a lot lower than other conditions such as bi-polar disorder or schizophrenia (81%) (Hettema et al., 2001)

    • Some mild evidence that GAD and MDD share some genetics and neurotransmitter correlations (dopamine/serotonin) that are catalysed by different stressors

  • Older Adults: Poverty, separation, low child emotional support, parental mental illness

    • Female sex - middle-aged, widowed / separated / divorced / low income)

WORRY CHARACTERISTICS

OCD Worries: Ego-dystonic, distressing because they are experienced as saying something horrible about the person themselves for having thought it. These are things they would rather not thing about at all

GAD Worries: Ego-syntonic, the content of the thoughts are distressing because they do not want these feared future consequences to occur. It is something that would consider important to think about

  • KEY DIFFERENCES: Obsessions are shorter-lived and image-laden. Worry is more chronic and verbal (Wells & Morrison. 1994)

THEORETICAL MECHANISMS

  • Experiential Avoidance Approach (Borkovec & Newman, 1999)» The mental and verbal focus on worry is an attempt to avoid more emotionally distressing concerns, where thought-focused activity serves to inhibit vivid mental imagery and associated emotions. “What if” worries are superficial to the underlying fear

  • Intolerance of Uncertainty Approach (Dugas & Robichaud, 2007) » Uncertainty, like an allergy, is intolerable even in small amounts, and worry is a strategy used in an attempt to reduce this uncertainty

    • DEFINITION: an anxious disposition that emerges from beliefs about the negative consequences of being uncertain. “If I feel uncertain, this is potentially dangerous.”

      • May set the conditions for worry, but there is no guarantee that something will happen

    • Higher order process leading directly to worry and three cognitive processes:

      • Positive Beliefs About Worry: Facilitates the pursuit of certainty, rather than supporting cognitive problem solving

      • Negative Problem Orientation: A state where one’s attitude to problems ultimately prohibits their resolution. Common beliefs such as problems “are threatening,” “should be easily solved” and “I can’t solve problems” underpin the failure to accurately define worries well enough to solve them, reinforcing the negative problem orientation

      • Cognitive Avoidance: A range of strategies to reduce anxious arousal ranging from suppression, distraction, thought replacement, to constantly thinking verbally to suppress anxious imagery.

      • LIMITATIONS

        • Cannot explain when worry is adaptive and when it is not (Gustavsson, 2021)

        • does not demonstrate specificity to GAD when compared to depression and OCD (Gentes & Ruscio, 2011)

  • Metacognition (Wells, 1997; 2009) » The meaning of worry processes themselves can begin and perpetuate worry

METACOGNITIVE MODEL

  • Type 1 Worry

    • Common everyday concerns about concrete events such as bills, work, deadlines, conflicts (Hjemdal et al., 2013)

    • Worry used as a strategy for anticipating, avoiding, or dealing with potential future threats

    • Underpinned and sustained by positive worry beliefs such as “worry helps me avoid problems”

    • Worry continues until feel able to cope, hence feeling compelled to worry

    • Ultimately resolvable, controllable and do not cause significant distress

  • Type 2 Worry

    • Negative evaluations of the worry process such as “I am making myself sick,” “I am losing control”

    • Underpinned and sustained by negative beliefs that worry is uncontrollable and dangerous

  • Type 1 Worry develops into GAD when Type 2 worrying becomes activated. Unhelpful coping mechanisms then exacerbate anxiety, worry, and reinforce negative beliefs about uncontrollability and danger

Positive Metacognitive Beliefs

  • No difference between GAD and non-GAD samples (Davis & Valentiner, 2000)

  • But positive beliefs predicts GAD severity when capacity for top-down cognitive control is high (Fishback et al., 2020)

Negative Metacognitive Beliefs

  • GAD samples endorse negative beliefs and engage in type 2 worry (Cartwright-Hatton & Wells, 1997; Wells & Carter, 2001)

The Metacognitive Model

  • Good statistical fit for explaining GAD in clinical samples compared to poorly-fitting competing models (Nordahl et al., 2022)

  • Evidence supports Metacognitive Therapy is superior in retaining patients, recovery rates and duration effect compared to other recommendations

COMMON CRITICISMS OF METACOGNITIVE MODEL

  • Meta beliefs in GAD are transdiagnostic

  • Assumes temporal precedence of main characteristics over cognitive avoidance - evidence insufficient

  • Metacognition model assumes a causal, not concomitant, relationships between t1 and t2 worry