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This article criticizes five contemporary models of GAD and gives implications for
treatment. Borkovec began his model on avoidance of worry, which consists of various
mechanisms. Nowadays GAD further refined and tested. In 5 models, the emphasis is on
conceptual similarities and differences, after which a discussion followed about the
treatments that are based on each model.
*
Sleep problems.
Psychotropic medication and cognitive behavioral therapy (CBT) are both effective in
treating GAD, although the evidence is not consistent. Medication or has an effect on
reducing the symptoms of GAD, but does nothing to the worry.
^ CBT other hand, is an effective treatment relative to a placebo, no treatment, waiting list
and a non-directive supportive therapy. Moreover, there are still visible improvements CBT
after one year. In a meta-analysis was, moreover, an effect size of -1.15 found to reduce
fretting.
*
This model is based on the two-stage theory of fear of Mowrer and also makes use of the
model of emotional processing Foa and Kozak. AMW says worrying is a verbal and thoughts
based activity that inhibits vivid imagination and associated somatic and emotional
activation. This inhibition of somatic and emotional experience connect the emotional
processing of fear from that theoretically required for successful adaptation and extinction.
On the other hand, the increase of somatic and emotional experience lead to effective
processing of emotional cues. Adaptation and extinction can be achieved by exposure to the
full spectrum of anxiety cues including the feared stimulus itself, the response to the stimulus
and the potential meaning behind the fear ^ so worrying can be seen as an ineffective
cognitive attempt to solve problems and thus delete a threat, while at the same time the
aversive somatic and emotional experience which would normally occur during the process
of anxiety confrontation, can be avoided.
*
In addition, the experience of peaks is energized negative. Catastrophic mental images that
are replaced enter the worry process less stressful and less verbal activity. ^ worrying is
negatively reinforced by the removal of aversive and frightening images.
* Moreover worrying further confirmed by positive beliefs as worrying helps problem
solving, motivates performance and avoid negative future outcomes. Positive beliefs are
energized when negative future events do not occur or are effectively held in the hand so
there is less worried.
* Finally Borkovec claimed et al., Which poor interpersonal skills are likely to play a role in
the maintenance of GAD. Also, poor attachment and trauma can make a contribution to the
development of GAD. In case of poor attachment, the world is perceived as a dangerous
place, and people with GAD do not have good sources to deal with uncertain events.
- Empirical support: worrying is mainly verbal instead of imaginary. Worrying
reduce somatic arousal at rest and when exposed to threat. Patients with GAD
also probably need more time to go to basic levels of arousal. People with GAD
believe worrying a good distraction from emotional issues which proves that this
is used as a strategy to avoid emotional process. Also, poor attachment plays a
role, but more research is needed. People with GAD focus primarily on problems
in interpersonal relationships.
- Treatment: cognitive behavioral techniques, inter alia,
a. self-monitoring of external situations, thoughts, feelings, physiological reactions
and behavior
b. relaxation exercises such as progressive muscle training, breathing exercises
and
make nice performances in the imagination.
c. self-desensitization
d. Gradual stimulus by looking for a specific time + place for worrying.
e. cognitive restructuring, flexibility thinking promote
f. Monitors worrying behavior.
*
g.
Intolerance uncertainty plays an important role in the development and maintenance of GAD.
Uncertainty / ambiguity is stressful and creates negative emotions ^ constant worrying in
such situations. Patients with GAD believe that worrying causes certain events do not occur,
or that they are better than the situation can deal ^ negative problem orientation, and
cognitive avoidance ^ worrying is maintained.
* People who have experienced a negative problem orientation, inter alia suffer from: lack of
confidence in their problem-solving skills, problems are seen as threats, are easily frustrated
if they want to solve a problem and are pessimistic about the outcome of their problemsolving efforts.
* Schedule: situation ^ what if? ^ Positive beliefs about worrying ^ ^ worrying fear negative
problem orientation, and cognitive avoidance ^ what if? ^ Process leading to complete
exhaustion.
- Emperical support: uncertainty intolerance (IU) specific for GAD. IU and
positive beliefs about worry itself, worrying about non-cognitive events such
as external situations or physical symptoms. This stimulates a fear response but later
can actually reduce anxiety. For Type 1 worry, negative beliefs about worry activated.
1) Type 1:
^
2)
Patients with GAD will worry about Type 1 worry; they are afraid that the worrying is
uncontrollable and can be dangerous. This "worrying about worrying 'is Type 2: metaworry. Type 2 is the most important distinction between GAD and non-clinical
worriers.
- Empirical support: Individuals with GAD do not differ significantly in their
reported positive beliefs about worry. Evidence for Type 2 worry in GAD, but the
differences with others depend on what groups you compare disorders. E.g. same
levels of type 2 OCD and PD.
- Treatment: Change Type 2 worry. Teaching alternative coping. Changing
emphasis on cognitions related to seeing worrying if something good (type 1). For
treatment to be asked about thoughts of the client and is working on socialization
+ give homework.
^ MCT but not IUM gave significant improvements with regard to worrying and
anxiety with respect to monitoring and waiting list condition. No significant
differences in symptom reduction between MCT and IUM-treatments.
Comes from the theory of emotion and the regulation of emotional states in general. Consists
of 4 central components: emotional hyperarousal / intense (mostly negative) emotions, less
understanding of their emotions, more negative attitudes about emotions and maladaptive
emotion regulation so they end up in a worse emotional state than they started.
* Worrying is used as an ineffective strategy with emotions to go.
- Emperical Support: aid patients with GAD negative but not positive emotions
experienced stronger. Evidence for intense emotions and less understanding of
their own emotions. Even more emotional coping strategies. However, findings
are not consistent, not all components found in some studies.
-
Everyone is sometimes worried, but when it is excessive and unbearable, one can speak of
chronic worrying and thus: Generalized Anxiety Disorder (GAD). The central feature of it is
to make chronic concerns. The DSM-IV GAD is classified as anxiety disorders.
* This article has two goals:
a) Describing the processes
Concerns relating to dominance of (verbal) negative thoughts. Including: adverse events that
may occur. Imagination is less here.
GAD people compared with healthy people, about level of thoughts
imagination in a relaxed moment. Found that healthy people positive images and had little
thoughts, BUT GAD patients had just as many negative thoughts and imaginings. Following
whether one was concerned about a recent event, it turned out that they just had more
negative thoughts or imaginings. This was true for both groups.
^ The distinction between the two phenomena cognitive thought and imagination is very
important to understand their role in emotional disturbance and there treatment.
-E.g: thoughts about something scary recall little to no cardiovascular response, while
imagining about it did.
* Thoughts ensure that we do not immediately have to react to something, but we can
think about the best way of reaction and the possible consequences of that reaction.
*Exp Borkovec;
this, on the basis of therapeutic exposure techniques. The underlying idea is that a
conditioned response of the conditioned stimuli. Exposure is an important technique
to take place "extinction".
^ Worrying
*Functions of Worrying
1) Worry diminishes Somatic Activity: True for GAD patients
* Short-term: suppression of cardiovascular response, but how
2) Worrying is an attempt to avoid negative events, or to prepare for the worst: Not
true for GAD patients, make them only more worried about something that is not
actually present.
* Long-term; has asked GAD and healthy patients what their reasons for worry
(Borkovec):
a) It helps them to avoid future negative events.
b) It prepares them for the worst, it might can not be avoided.
* Cognitive Model of Worry (Eysenck): Worry would have three main functions:
a) Alarming: after you get external or internal threat information, the alarm function
this feature also leads to coping: First, you can try to avoid the negative occurrence
(prevention). Second, you can prepare for the event if you can not avoid
(Anticipatory coping).
* When going chronic worriers believe worrying about the problem has positive effects (eg
preventing nasty stuff) then it is a reinforcement (reinforcement) for the thoughts and
therefore a reason for them to have this behavior maintained.
Could be true for GAD patients, but is
still considering the speculative hypotheses.
GAD patients may worry about superficial things, to lead away from the worry about
the real underlying problem (loss of job means eg inability to care for oneself).
However, it is not real evidence for this. Other research has brought evidence, what
GAD patients report more traumatic experiences than normal people. Although they are
less concerned about disease / death or injury. The concerns they may therefore emanate from
the traumas they have experienced, that prove existence hazards. And this, they must
therefore anticipate again for next situation, and make sure all while providing a distraction
on their past.
a)
b) GAD patients have more problems in interpersonal relationships than the healthy
people. By worrying about other things, this is their avoidance of imminent danger.
People with and without GAD negative / neutral and threatening words to
be read: Turns out that GAD patients give a defensive response to negative words, but not the
neutral. People without GAD showed both no response.
In addition, educated people with GAD an orienting response to negative words
conditioned. So aversive words can provoke classically conditioned responses to previous
neutral stimuli. So, the (higher) conditioning can be seen as a partial cause of the occurrence
of hypersensitivity to the perception of threat and generalization of threatening cues.
*Exp (Borkovec):
Excessive worry can lead to maintain / enhance other disorders: OCD and Depression.
* Nolen/Hoeksema: are of the opinion that to worry ensures the maintenance of a
depressed state. A sense of hopelessness can cause GAD patients think they can
change nothing in the situation, and that which they fear will actually happen.
Risk factors for GAD development
* GAD is also found in people
GAD patients taking constant danger true, but this danger can not be avoided, because it is in their
thoughts and concerns future events. Because of this, fight or flight responses of no use and can only
be suppressed. This suppression can be achieved by mulling and to worry about. People with GAD
have a preattentive bias, and less inhibitory processes.
*
GAD patients have different brain activity. To make this clear it is by means of EEC
measured brain activity of people with GAD and people without GAD both
"relaxation phase" as in "make do" phase. GAD patients also received 14 sessions of
therapy. It turned out that GAD patients:
Showed more activity in the left hemisphere.
GAD patients and healthy people to worry and relax in different ways, mainly in the
alpha wave (8-13Hz). This finding is consistent with the idea that GAD patients
imagine less, but create more verbal concerns.
Further GAD patients showed more left frontal beta activity while worrying, Healthy
people are more theta. This shows that healthy people focus differently on the job
where you have to worry.
Normalization of brain activity ^ as therapy progressed, their brain activity was more
gone towards that of "healthy people".
activity which relates to the cognitive avoidance (avoidance of threatening = mental images)
which is also included in the model.
The aim of this study is to test the conceptual model of GAD, as there is anyway little
research has been done to GAD in itself. All the main features of the model are now included
in the same study. The study will help to obtain the relative importance of each of the
elements.
*
*Hypotheses:
Uncertainty Intolerance, beliefs about worry, poor problem orientation, and cognitive
avoidance GAD patients will discriminate against non-clinical control subjects.
2. Uncertainty Intolerance will be the most important variable in explaining differences
1.
*Method:
24 GAD-patients (17 women, 7 men) and 20 non-clinical control subjects (14 vrouwen, 6
Individuals with GAD also had social phobia (13), depression (4), PD
with agoraphobia (3), OCD (3), Dysthieme disorder (3), PD (2), and PTSD (1). The
classification is used questionnaires, inter alia IU questionnaire and anxiety questionnaire.
Also screening by psychiatrists.
*Results and discussion: * Significant difference between the groups on uncertainty
tolerance, beliefs about worry, thought suppression, problem orientation and problem solving
skills with p <.0001.
* There are still other analyzes done to look at the individual contributions of the variables.
Except for the problem-solving skills, the variables have contributed significantly to
distinguish between groups.
* First hypothesis is supported, as is the second hypothesis.
^ There is further research is needed because the GAD patients are compared to patients with
e.g. other anxiety disorders (in any case with clinical subjects). In other studies showed that
GAD patients have better knowledge about problem solving compared to patients with other
anxiety disorders.
* Moreover, there was a lot of co-morbidity. This may have exerted impact on the results,
many had also include social phobia. However, the severity of comorbid diagnoses was mild,
so the researchers do not believe that this has had a significant impact on the discriminant
capacity.
* The GAD patients were more depressed. They do have the same scores on uncertainty
tolerance, so is again assumed that this has no influence on the results.
mannen) participate.
* The
research team has also placed emphasis on two types worrying when a treatment is
done: 1. Concerns about immediate problems and 2. Concerns about improbable future
events.
* It should also be ensured that beliefs are corrected, as GAD patients often see more benefits
instead of disadvantages worrying. What helps is best cognitive exposure (imagination).
In summary:
future. However, individuals with GAD however make positive assumptions about the
benefits of worry as a coping strategy and thinking that worrying helps threat. Is
negatively reinforced by the frequent occurrence of the catastrophe.
* GAD is difficult to treat. Only 50% of patients improved with cognitive behavioral
therapy and there is great variability in the degree of improvement.
* The effectiveness of the treatment may improve if the treatment was based on a
specific cognitive model on the survival of GAD. In this model must cognitive and
behavioral factors are key contributing create chronic worries.
^Wells came with a cognitive model
that emphasizes the role of
metacognition in GAD. (See picture)
This article shows a study, which the
central prediction of this model test.
Explanation of this model: trigger;
stimulus / intrusive thoughts that
encourages thinking.
^ For example, you hear on the radio
that there was a car accident on the
highway, and you fear that your friend
is there.
^ This trigger activates your
metacognitive beliefs and provides
coping strategies (worry). People with
GAD believe have positive beliefs
about the benefits of worry as a coping strategy, as worrying for example, can bring solutions.
*Type 1 worring; this is the worrying about external events and non-cognitive internal events
(eg physical symptoms). These concerns may increase the anxiety and lead to cognitive and
somatic symptoms. The negative meta-beliefs are activated.
* When worrying conducted a time, and solutions have been found, anxiety will decrease. *
The feedback route of emotion type one cares, shows that reduction in emotion, as a result of
long-term worries, the type 1 worries can reduce in future threat. For example, you worry
about your brother ^ by calling him take off your emotions and worries. ^ In contrast, somatic
symptoms of anxiety can be interpreted in a negative way and they reinforce worries the Type
1.
*Type 2 Worrying/ meta worrying; At this stage makes one "concerned about his / her
worries." E.g: person with GAD develops the belief that worry will lead to a mental
breakdown. GAD patients develop so negative assumptions about their own concerns. In type
2 concerns, there are 3, there are processes that contribute to GAD in position and attitude
thereof, also can be seen in the model:
1) Behavior; there behavior is put into force to avoid situations / stimuli that can cause
worry. You keep worrying because you worries do not want. And this allows for the
preservation of type 2 concerns and negative assumptions. Avoiding them ensures that
you do not discover that worries may not catastrophic.
2) Control of mind; GAD patients suppress thinking of a stimulus that causes concern.
This, however, can lead to recurrent intrusive (undesirable) thoughts and an increase
in type 2 concerns.
Emotion; when type 2 activated worry, there is more anxiety by making the concerns
and find an increase in anxiety reactions take place. These emotions and anxiety
reactions are interpreted as evidence that the type 2 concerns and negative
assumptions are justified.
Method 2 measurements: PSWQ for people who worry at GAD level. And measurement of
subjective severity level associated with worry.
* Susceptibility to type 1 and type2-worries were measured Anxious Thoughts Inventory
(ANTI).
*Hypothesis: meta worries contribute to problematic worries problematic concerns. ^ If it is
found that type 2 worries is a greater predictor than one type of worries, then position the
model remains.
*140 subjects participated. They were students around 29.79 years.
3)
has been shown in the previous article of Dugas uncertainty which intolerance is an
important variable that is related to worry and GAD.
*
* The
aim of the present study is to clarify the relationship between these cognitive processes
and fretting, on the basis of the experimental manipulation of uncertainty intolerance.
* A procedure with gambling is used to increase the intolerance in the one group (N = 21),
and in order to reduce the intolerance in the other group (N = 21).
* The results show that those who increased uncertainty tolerance have higher levels of worry
were compared with those who had reduced uncertainty intolerance. ^ The results give a
better picture of this relationship and are consistent with the theoretical model of peaks and
GAD.
*Krohne was the first to name uncertainty intolerance in the General model of Anxiety.
Krohne was the first to describe the variables uncertainty intolerance and intolerance of
emotional arousal as underlying variables of anxiety disorders in a model.
- An increased level of uncertainty creates intolerance reactions of hypervigiliteit
(= excessive attention) where the individuals are faced with ambiguous problems.
- An increased level of intolerance of emotional arousal stimulates cognitive
avoidance reactions. Excessive anxiety arises because there are always switching
between a hyper vigilante state and a state of avoidance.
* Worrying is characterized by, inter alia,:
a) Tended to see ambiguous situations
b)
as threatening.
c)
* Uncertainty of the situation was acceptable for one group and unacceptable to the other,
without the objective chance of winning or change the consequences.
participants in the increased intolerance group will report a higher level of
fretting in comparison with the participants in the reduced intolerance group.
*Hypothesis: