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What causes GAD? Biological factors

Biological factors:

Genetic factors:

- Genetic predisposition

- Family and twin studies indicate that genetic factors account for 30-40% of the variance of

causative factors

Neurotransmitter systems:

consistent Norepinephrine overactivity in GAD

alterations in GABA, serotonin system

Fear circuit:

components of the fear circuit that may be of particular relevance to GAD include medial

prefrontal cortex, amygdala, insular cortex

- irregularities in the functioning of the amygdala in GAD patients and its connection

to the prefrontal cortex (Etkin et al., 2009)


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What causes GAD? Psychological models

Worry as cognitive avoidance Borkovec et al. 1994, 2004

• Worry has an important function for people with GAD

helps people avoid experiencing negative emotions

• Does not allow deeper emotional processing

• Worry is thought to be a linguistic process that does not tap into deeper mental


• People can avoid negative emotions associated with the worry is processed

without mental imagery

• Studies

people who were worrying did not create imagery; rather worry was experienced

as negative verbal/linguistic activity (e.g. Borkovec&Inz, 1990)

people verbally articulating fear material created much less heart rate activity

than when imagining the situation (Vrana et al.1986)

verbal processing impedes environmental and experiential information from being

process, preventing learning of nonthreatening associations (e.g. Roemer &

Orsillio, 2002)

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Positive beliefs about worry (Marker & Aylward)


• Worry can help someone anticipate and plan for the future

• For people with GAD worry helps

- avoid or prevent bad events

People with GAD find it more difficult to tolerate and accept uncertainty than

people without GAD (Dugas et al. 1998)

- motivate oneself to get things done

- prepare for the worst

- problem-solve

- distract oneself from even more emotional topics

- and superstitiously lessen the likelihood of bad events

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Information-Processing Biases associated with GAD

• Processing bias to threat plays an important role in development and maintenance of anxiety

(Mogg & Bradley, 2005)

attention bias: for threatening words and pictures

Person with GAD hypervigilant in detecting particular threats, leading to worry

Interpretation bias: interpreting ambiguous stimuli as threatening

(e.g viewing news->personal threat)

• People with GAD display both biases (Mogg & Bradley, 2005)

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Metaworry (Wells & Matthews)

• worry about worry

• For people with GAD often belief that worry is associated with going crazy or

uncontrollability of worry

->start to worry about how much they are worrying

• Metaworry good discriminator between GAD and other anxiety disorders

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• During CBT therapists attempt to reduce low level of processing by having patients

“worry out “ their negative emotions -> exposure therapy to help processing worry

on a deeper level

• Although GAD mostly characterized by cognitive avoidance, behavioral avoidance

of situations (e.g. social situations) is seen in over half of the individuals

(Butler et al. 1987)

• CBT helps to reevaluate:

- the positive benefits of worrying

- interpretation biases of ambiguous stimuli

- their intolerance of uncertainty

- metaworry

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Psychological Treatment options for GAD

• Most frequently studied, evidence-based, psychological strategies for treating GAD


- Cognitive strategies

- Exposure-based strategies

- Acceptance based strategies

• CBT has been shown to be very effective for the treatment of GAD, with long term


• Clinical improvement in 38-63% of individuals who complete treatment

(Waters & Craske, 2005)

-> this number not as high as CBT for other anxiety disorders

(80% clinical improvement in panic disorder, Campbell & Brown, 2002)

• Adding of mindfulness components leads to improvement of existing CBT treatments,

clinical improvement in 78% of individuals (Roemer et al.2008)

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Pharmacological treatment options for GAD

• Evidence for pharmacological treatments:

large randomized placebo-controlled trials with GAD have been conducted with

Benzodiazepines and antidepressants

• Compared to placebo, benzodiazepines provide effective and rapid symptomatic relief

(Galenberg et al. 2000)

-> should not be used for more than 2-4 weeks

-> side effects: dependency, sedation and increased risks of neonatal and infant mortility when

used while breastfeeding or late pregnancy

• SSRI are the recommended treatment

-> pharmacological treatments reduce physical symptoms rather than worry

(Anderson & Palm, 2006)

-> works also for co-morbidities

-> long term efficacy of antidepressant with follow-up of years required

->efficacy over 6 months follow-up periods: greater remission rates than placebo at 6 months

(69% vs. 42-46%)

• Very few studies compared effectiveness CBT with medication treatments for GAD