Generalized Anxiety Disorder

Generalized Anxiety Disorder (GAD)

• Excessive anxiety under most circumstances and worry
• Symptoms: restlessness, fatigue; difficulty concentrating, muscle tension, and/or sleep problems
• Symptoms must last at least six months
• The disorder is common in Western society
• Usually first appears in childhood or adolescence
• Around one-quarter of those with GAD are currently in treatment

As many as 4% of the US population have symptoms in any given year and ~6% at some time during their lives.  Women are diagnosed more often than men by a 2:1 ratio

GAD: The Sociocultural Perspective:  According to this theory, GAD is most likely to develop in people faced with social conditions that truly are dangerous

• Research supports this theory (example: Three Mile Island in 1979, Hurricane Katrina in 2005, Haiti earthquake in 2010)
• One of the most powerful forms of societal stress is poverty
• Why? Run-down communities, higher crime rates, fewer educational and job opportunities, and greater risk for health problems
• As would be predicted by the model, there are higher rates of GAD in lower SES groups

Since race is closely tied to stress in the U.S., it is not surprising that it is also tied to the prevalence of GAD.  In any given year, African Americans are 30% more likely than white Americans to suffer from GAD.  Multicultural researchers have not consistently found a heightened rate of GAD among Hispanics in the U.S., although they do note the prevalence of nervios in that population.  Although poverty and other social pressures may create a climate for GAD, other factors are clearly at work.  How do we know this?  Most people living in “dangerous” environments do not develop GAD. Other models attempt to explain why some people develop the disorder and others do not.

GAD: The Psychodynamic Perspective:

• Freud believed that all children experience anxiety
• Realistic anxiety when they face actual danger
• Neurotic anxiety when they are prevented from expressing id impulses
• Moral anxiety when they are punished for expressing id impulses
• Some children experience particularly high levels of anxiety, or their defense mechanisms are particularly inadequate, and they may develop GAD

Today’s psychodynamic theorists often disagree with specific aspects of Freud’s explanation. Researchers have found some support for the psychodynamic perspective: People with GAD are particularly likely to use defense mechanisms (especially repression). Adults, who as children suffered extreme punishment for expressing id impulses, have higher levels of anxiety later in life. Some scientists question whether these studies show what they claim to show.

Psychodynamic therapists use the same general techniques to treat all psychological problems:

• Free association
• Therapist interpretations of transference, resistance, and dreams
• Specific treatments for GAD
• Freudians focus less on fear and more on control of id
• Object-relations therapists attempt to help patients identify and settle early relationship problems

Controlled studies have typically found psychodynamic treatments to be of only modest help to persons with GAD. Short-term psychodynamic therapy may be the exception to this trend.

GAD: The Humanistic Perspective:

¨Theorists propose that GAD, like other psychological disorders, arises when people stop looking at themselves honestly and acceptingly

• This view is best illustrated by Carl Rogers’s explanation:
• Lack of “unconditional positive regard” in childhood leads to “conditions of worth” (harsh self-standards)
• These threatening self-judgments break through and cause anxiety, setting the stage for GAD to develop
• Practitioners using this “client-centered” approach try to show unconditional positive regard for their clients and to empathize with them
• Despite optimistic case reports, controlled studies have failed to offer strong support
• In addition, only limited support has been found for Rogers’s explanation of GAD and other forms of abnormal behavior

GAD: The Cognitive Perspective:

Initially, theorists suggested that GAD is caused by maladaptive assumptions

• Albert Ellis identified basic irrational assumptions:
• It is a dire necessity for an adult human being to be loved or approved of by virtually every significant person in his community
• It is awful and catastrophic when things are not the way one would very much like them to be
• When these assumptions are applied to everyday life and to more and more events, GAD may develop

Aaron Beck, another cognitive theorist, argued that those with GAD constantly hold silent assumptions that imply imminent danger. A situation/person is unsafe until proven safe. It is always best to assume the worst. Researchers have repeatedly found that people with GAD do indeed hold maladaptive assumptions, particularly about dangerousness.

New wave cognitive explanations:

• In recent years, several new explanations have emerged:
• Metacognitive theory
• Developed by Wells; suggests that the most problematic assumptions in GAD are the individual’s worry about worrying (meta-worry)
• Intolerance of uncertainty theory
• Certain individuals consider it unacceptable that negative events may occur, even if the possibility is very small; they worry in an effort to find “correct” solutions
• Avoidance theory
• Developed by Borkovec; holds that worrying serves a “positive” function for those with GAD by reducing unusually high levels of bodily arousal

All of these theories have received considerable research support.

GAD Cognitive Therapies:

Changing maladaptive assumptions:

• Ellis’s rational-emotive therapy (RET)
• Point out irrational assumptions
• Suggest more appropriate assumptions
• Assign related homework
• Studies suggest at least modest relief from treatment

Breaking down worrying:

• Therapists begin by educating clients about the role of worrying in GAD and have them observe their bodily arousal and cognitive responses across life situations
• In turn, clients become increasingly skilled at identifying their worrying and their misguided attempts to control their lives by worrying
• With continued practice, clients are expected to see the world as less threatening, to adopt more constructive ways of coping, and to worry less
• Research has begun to indicate that a concentrated focus on worrying is a helpful addition to traditional cognitive therapy
• This approach is similar to mindfulness-based cognitive therapy

GAD: The Biological Perspective:

Biological theorists believe that GAD is caused chiefly by biological factors

• Supported by family pedigree studies
• Biological relatives more likely to have GAD (~15%) than general population (~6%)
• The closer the relative, the greater the likelihood
• There is, however, a competing explanation of shared environment
• GABA inactivity
• 1950s – Benzodiazepines (Valium, Xanax) found to reduce anxietyWhy?
• Neurons have specific receptors (like a lock and key)
• Benzodiazepine receptors ordinarily receive gamma-aminobutyric acid (GABA, a common neurotransmitter in the brain)
• GABA carries inhibitory messages; when received, it causes a neuron to stop firing

In normal fear reactions:

• Key neurons fire more rapidly, creating a general state of excitability experienced as fear or anxiety
• A feedback system is triggered – brain and body activities work to reduce excitability
• Some neurons release GABA to inhibit neuron firing, thereby reducing experience of fear or anxiety
• Malfunctions in the feedback system are believed to cause GAD

Possible reasons: Too few receptors, ineffective receptors:

• Promising (but problematic) explanation
• Recent research has complicated the picture:
• Other neurotransmitters also bind to GABA receptors
• Issue of causal relationships

Do physiological events CAUSE anxiety? How can we know? What are alternative explanations?

Biological treatments:

• Antianxiety drug therapy
• Early 1950s: Barbiturates (sedative-hypnotics)
• Late 1950s: Benzodiazepines
• Provide temporary, modest relief
• Rebound anxiety with withdrawal and cessation of use
• Physical dependence is possible
• Produce undesirable effects (drowsiness, etc.)
• Mix badly with certain other drugs (especially alcohol)

More recently:  Antidepressant and antipsychotic medications: 

• Relaxation training
• Non-chemical biological technique
• Theory: Physical relaxation will lead to psychological relaxation
• Research indicates that relaxation training is more effective than placebo or no treatment
• Best when used in combination with cognitive therapy or biofeedback

Biofeedback:

• Therapist uses electrical signals from the body to train people to control physiological processes
• Electromyograph (EMG) is the most widely used; provides feedback about muscle tension
• Found to have a modest effect but has its greatest impact when used as an adjunct to other methods for treatment of certain medical problems (headache, back pain, etc.)

References:
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Comer, R.J. (2013). Abnormal Psychology (8th ed).  Worth Publishers
Diagnostic and Statistical Manual of Mental Disorders, (DSM-5) American Psychiatric Publishing, 2013
Feldman, R. (2013). Essentials of understanding psychology (11th ed.). New York, NY: McGraw-Hill.
Friedman, H.S. & Schustack, M.W. (2012), Personality: classic theories and modern research (5th ed). Boston: Pearson Allyn & Bacon.
McGraw-Hill.McGraw Hill Higher Education (2013), The McGraw Hill Companies, Inc.
Ryckman, R. M. (2013). Theories of personality (10th ed.). Mason, OH: Cengage Learning.
Sue,Sue, and Sue (2014).  Understanding Abnormal Behavior (10th Ed), Cengage Learning