Generalized Anxiety Disorder and Worrying

A Comprehensive Handbook for Clinicians and Researchers

Alexander Gerlach, Andrew Gloster, Alexander Gerlach, Andrew Gloster

• Publisher: Wiley-Blackwell
• Year: 2020
• ISBN:
  9781119189893
• Edition: 1
• Topic: Psicologia
• Subtopic: Psicologia clinica

A comprehensive and authoritative guide to anxiety disorder and worry

Generalized Anxiety Disorder offers a comprehensive review of the most current research and therapeutic modalities related to generalized anxiety disorder and worry (GAD). With contributions from an international panel of experts, the Handbook links the basic science of anxiety and worry to the effective treatments that can be applied to help those who suffer from these conditions.

Reflecting the most recent research and developments on the topic, the Handbook contains information on cross-cultural issues, transdiagnostic questions, as well as material on learning theory, biological theory, psychotherapy, and psychopharmacology. The contributors offer an in-depth examination of a range of topics such as rumination and obsessions and contains several novel approaches to treating the disorder. This comprehensive resource:

• Contains the most current information available on the topic
• Explores the consequences of worrying and other mental disorders such as illness anxiety and sleep disorders
• Includes contributions from an international panel of experts
• Offers insight into the future of treatment outcomes and translational research

Written for practitioners, researchers, and trainees of clinical psychology and psychiatry, Generalized Anxiety Disorder addresses the assessment and empirically supported treatment of generalized anxiety disorder.

1
Worry, Generalized Anxiety Disorder (GAD), and their Importance

Alexander L. Gerlach¹ and Andrew T. Gloster²

¹ Department of Psychology, Clinical Psychology and Psychotherapy, University of Cologne, Cologne, Germany

² Department of Psychology, Division of Clinical Psychology and Intervention Science, University of Basel, Basel, Switzerland

What is Worry—What is GAD?

Everyone worries. Some people worry occasionally or transitorily, while others worry frequently or uncontrollably. The ubiquity of worry makes its study far‐reaching, important, and exciting. Worry—like most concepts in mental health nomenclature—is not a technical term, however, but rather stems from everyday language's attempt to describe inner‐psychic experiences. This, in turn, makes the study of worry difficult and sometimes messy. For example, if you simply ask a person to worry, will this instruction result in the same type of worry that occurs naturally? Worrying at night, when trying to fall asleep, is probably one of the most common situations in which people worry. However, why do we worry some nights and not others? Is it really simply a question of triggers being responsible for a worry episode starting? Interestingly, in some treatments, asking individuals to worry is used therapeutically. This often results in the new experience that when one actively worries, it is actually less anxiety provoking and much less associated with a feeling of losing control than when worrying occurs spontaneously (compare Gerlach & Stevens, 2014). However, to date, it remains unknown why there are such striking differences in the experience of worry, dependent on circumstances. Nonetheless, this approach (instructing somebody to worry) is one of the most common forms of worry induction used to study, for example, the acute physiological effects of worrying (e.g., Andor, Gerlach, & Rist, 2008; Borkovec & Inz, 1990; Stefanopoulou, Hirsch, Hayes, Adlam, & Coker, 2014). Other examples of worry induction are the use of materials such as film clips about worrisome topics. The use of such materials as triggers, however, does not necessarily result in increased worrying, even in individuals diagnosed with GAD (e.g., Upatel & Gerlach, 2008). Some authors have attempted to induce worrying by employing the catastrophizing interview technique (e.g., Davey & Levy, 1998; O'Leary & Fisak, 2015). Arguably, all these attempts to induce worry are qualitatively different from the actual experience of worry that occurs spontaneously. Therefore, research looking at worry in its natural environment (e.g., ecological momentary assessment) is of special importance. Definitions of worry usually concentrate on future‐oriented anxiety or apprehension about possible negative events and, in some cases, the reaction of the afflicted individual to this experience (Craske, 2003, chapter 2; Gerlach & Stevens, 2014). Research on worry aims to specify its nature and impact on mental health, and that is also the goal of this book. A number of authors have previously attempted to define worry. We would like to highlight a few different definitions that each contribute to better understanding the concept of worry as it has been studied in recent years. The definition quoted most often was suggested by Borkovec, Robinson, Pruzinsky, and DePree (1983): “Worry is a chain of thoughts and images, negatively affect‐laden and relatively uncontrollable; it represents an attempt to engage in mental problem‐solving on an issue whose future outcome is uncertain but contains the possibility of one or more negative outcomes; consequently, worry is related closely to fear process” (p. 10). Borkovec (1994) has added the notion to this definition that “worry is a predominantly verbal–linguistic attempt to avoid future aversive events” (p. 7). Mathews (1990) highlighted the link between worry and problem‐solving by defining worry as the constant rehearsal of a threatening outcome or threat scenario that may hinder successful problem‐solving. Interestingly, Barlow (2002) argued that worry can be conceptualized as an attempt to solve an upcoming problem and Wells (1997) even argued that worrying is an actively initiated strategy to cope with future threats. Beekman et al. (1998) defined worry somewhat more technically by stating that worries are “cognitions that a state of an object (self, in‐group, society, or world) in one or more domains of life (health, safety, environment, social relations, meaning, achievement, or economic) will become or remain discrepant from its desired state” (p. 778). Importantly, these authors distinguished between worries concerned with self and close others (micro worries) and worries about society or the entire world (macro worries), and only micro worries were shown to be related to poor mental health. Macro worries, in contrast, were positively related to mental health. Finally, Gerlach and Stevens (2014) have highlighted that a fear image (worry) is usually considered to be acting as an initial element within the mental process of worrying. In their view, perceived threats (worries) should be considered the central force driving the act of worrying, which may include self‐soothing or problem‐solving related cognitions.

The definition of GAD is somewhat more straightforward, if not less controversial. The diagnosis “generalized anxiety disorder” was first introduced with DSM‐III (American Psychiatric Association [APA], 1980). In this original conceptualization, generalized anxiety disorder was considered to encompass persistent anxiety of at least 1 month's duration. This state of persistent anxiety was suggested to generally entail motor tension, autonomic hyperactivity, apprehensive expectation, vigilance, and scanning. In other words, originally, generalized anxiety disorder was a diagnosis with only a few specific symptoms in mind. In the description of the disorder, it was even stressed that patients should not exhibit specific symptoms that characterize phobic disorders (phobias), panic disorder (panic attacks), or obsessive‐compulsive disorder (obsessions or compulsions). With DSM‐III‐R (American Psychiatric Association [APA], 1987) unrealistic or excessive anxiety and worry (apprehensive expectation) about two or more life circumstances was highlighted as criterion A of generalized anxiety disorder. Thus, for the first time, worry, accompanied by 18 symptoms of motor tension, autonomic hyperactivity, and vigilance and scanning, was considered to be at the core of this debilitating disorder. In addition, the necessary duration for the disorder was extended from 1 to 6 months in order to exclude transient anxiety reactions. This version also stipulated that the symptoms of GAD were not to occur exclusively during a mood or psychotic disorder (i.e., during an episode of major depression). With DSM‐IV, criterion A changed such that only excessive anxiety and worry were required. Unrealistic worries were no longer necessary to allow diagnosis of GAD. In addition, criterion B was added stipulating that the person must find it difficult to control their worries. Also, the number of symptoms accompanying worrying was considerably shortened to the list still in place in the current DSM‐5. This decision was mainly based on 1 interview study with 204 subjects by Marten et al. (1993), who found that most of the 18 symptoms were reported by less than 60% of participants, which therefore led to the suggested removal of these symptoms. Note, that in ICD‐10 autonomic arousal symptoms still are highlighted in the definition of the disorder. ICD‐10 (World Health Organization [WHO], 1992) defines GAD as follows: “Anxiety that is generalized and persistent but not restricted to, or even strongly predominating in, any particular environmental circumstances (i.e., it is ‘free‐floating’). The dominant symptoms are variable but include complaints of persistent nervousness, trembling, muscular tensions, sweating, lightheadedness, palpitations, dizziness, and epigastric discomfort. Fears that the patient or a relative will shortly become ill or have an accident are often expressed.” According to DSM‐5 (American Psychiatric Association [APA], 2013), GAD consists of: (a) anxiety and worry that is excessive and occurs more days than not ab...