Lynne Cox Michelle Deen Maria Elsdon Ronelle Krieger

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 GAD A. 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

Wells, 2006 Metacognitive Model 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 Model Mennin, 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 GAD 1. 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 with discriminative validity of anxiety disorders because of symptom overlap (Albano, Chorpita, & Barlow, 2003) Diagnostic unreliability (Brown & Barlow, 2002) Lack of specific criteria to assess levels of severity and intensity of disorders (Brown & Barlow, 2002) Issues inherent in the DSM system Little is known about the validity and reliability of the Generalized Anxiety Disorder diagnosis in children and adolescents (Andrews et al., 2010) DSM-IV-TR criteria assumptions (Andrews et al., 2010)

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 cooccuring 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 Function 1 Overprotection, parental pressures Acute life events Function 2 Parental abuse/hostility Interpersonal stress

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 Childhood Oppositional Defiant Disorder Abusive child-parent relationships and discordant relationships with teacher/school and /or peers Childhood Generalized Anxiety disorder Parental overprotection, parental pressures, inadequate supervision/control and acute threats (Nordahl et al., 2010)

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?

References Albano, A. M., Chorpita, B. F., & Barlow, D. H. (2003). Childhood anxiety disorders. In E. J. Mash & R. A. Barkley (Eds.), Child psychopathology (2 nd 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 (2 nd ed., pp. 292-327). New York: Guilford Press.

References Behar, 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.

References 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- BYsruQxEIZI8X1Sjq0Q#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 cognitivebehavioral 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.