The University of Maine DigitalCommons@UMaine Electronic Theses and Dissertations Fogler Library 8-2006 Preventing Generalized Anxiety Disorder in an At- risk Sample of College Students: A Brief Cognitive- behavioral Approach Diana M. Higgins Follow this and additional works at:http://digitalcommons.library.umaine.edu/etd Part of theClinical Psychology Commons Recommended Citation Higgins, Diana M., "Preventing Generalized Anxiety Disorder in an At-risk Sample of College Students: A Brief Cognitive-behavioral Approach" (2006).Electronic Theses and Dissertations. 34. http://digitalcommons.library.umaine.edu/etd/34 This Open-Access Dissertation is brought to you for free and open access by DigitalCommons@UMaine. It has been accepted for inclusion in Electronic Theses and Dissertations by an authorized administrator of DigitalCommons@UMaine. 1 CHAPTER ONE: Introduction Generalized anxiety disorder (GAD) is a pervasive, chronic disorder affecting approximately 5% of the general population over the course of the lifespan (Wittchen, Zhao, Kessler, & Eaton, 1994). The impairment associated with GAD is as severe as that of depression with respect to work productivity, social functioning, and healthcare utilization (Wittchen & Hoyer, 2001). Given its high prevalence and cost to society, GAD is a mental health problem that warrants investigation of etiology, treatment, and prevention models. Despite several revisions in diagnostic criteria (American Psychiatric Association [APA], 1980, 1987, 2000) controversy exists regarding the status of GAD as a distinct disorder (Kessler, Keller, & Wittchen, 2001). It is highly comorbid with other anxiety and mood disorders and has been considered by some to be a prodrome of another disorder (Brown, Campbell, Lehman, Grisham, & Mancill, 2001). However, it appears that the main feature of GAD, worry, is integral to defining GAD as a separate disorder (Borkovec, 1994). Thus, worry has become a primary focus of etiological and theoretical models (e.g., Borkovec, Alcaine, & Behar, 2004; Hudson & Rapee, 2004) as well as treatment protocols for GAD (e.g., Borkovec & Costello, 1993; Ladouceur, et al., 2000). To date, cognitive-behavioral treatments have demonstrated the most evidence of efficacy among various psychotherapies applied to treat GAD (e.g., Borkovec & Costello, 1993; Ladouceur et al., 2000). However, the success rates are not as promising as those found for other anxiety disorders (e.g., Panic Disorder). The high 2 prevalence rate associated with GAD and the alleviation symptoms produced by cognitive-behavioral treatments indicates that alternative approaches (e.g., prevention) to ameliorating the effects of this disorder may be warranted. For example, recent research suggests that providing individuals at risk for developing certain mental health problems with cognitive-behavioral techniques can reduce the risk for future development of these problems (e.g., Gardenswartz & Craske, 2001; Seligman, Schulman, DeRubeis, & Hollon, 1999). Despite this surge of interest in prevention of mental illness, there have been no empirical studies examining preventative interventions for GAD. The present study investigated the efficacy of a preventative intervention for GAD. Because there have been no prevention protocols previously developed to target this disorder, a protocol was developed and modified over the course of two pilot studies. The pilot studies were conducted for the purpose of examining the utility of a secondary prevention program for GAD. The protocol includes cognitive- behavioral techniques commonly used in the treatment of GAD (e.g., description of anxiety and worry, cognitive restructuring, relaxation techniques, worry exposure, problem orientation and problem solving) presented in a brief, two-session workshop format. Both pilot studies yielded promising results in that state anxiety and worry symptoms were reduced following the intervention and these reductions were maintained for several weeks or months. The present study used the aforementioned prevention program in first-year college students determined to be at-risk for developing GAD based upon self- reported symptoms of worry. Participants were randomly assigned to either a 3 workshop or a control condition and were compared on several measures of anxiety and depression. The study employed a longitudinal design in which participants in both conditions were assessed on measures of worry, GAD symptomatology, depression, state anxiety, intolerance of uncertainty, and experiential avoidance on three occasions over the course of 12 months. It was hypothesized that individuals who participated in the preventative intervention, in contrast with control participants, would be less likely to develop GAD and would demonstrate a reduction in worry, depression, state anxiety, intolerance of uncertainty, and experiential avoidance that would be maintained for 12 months. Generalized Anxiety Disorder Since its inception, the diagnosis of GAD has undergone substantial change. GAD was first introduced as a unique anxiety disorder in the Diagnostic and Statistical Manual of Mental Disorders in 1980 ([DSM-III], APA, 1980). Prior to this version of the DSM, GAD was considered to be one of two core components of anxiety neurosis (Kessler, Keller, & Wittchen, 2001). The next revision of the DSM (DSM-III-R, APA, 1987) defined worry as the central characteristic of GAD. This change in the definition of GAD is important because it is one of the first instances in which the field of psychiatry has agreed about the existence of a disorder whose most prominent feature is a psychological process (Borkovec, 1994). The primary feature of worry in GAD has been retained with a subsequent version of the DSM (DSM-IV- TR, APA, 2000) and is the focus of cognitive-behavioral treatments for GAD. 4 Descriptive Psychopathology GAD is perhaps the most commonly diagnosed anxiety disorder. However, because its core features overlap with those of other disorders, GAD may be frequently misdiagnosed (Wittchen & Hoyer, 2001). A diagnosis of GAD is warranted when an individual has experienced excessive, uncontrollable worry and anxiety about a number of topics for a period of at least 6 months, in addition to 3 or more of the following symptoms: restlessness, becoming easily fatigued, difficulty concentrating, irritability, muscle tension, and sleep disturbance (APA, 2000). Generally, the anxiety and worry experienced by individuals with GAD exceeds the actual probability that the anxiety-provoking event will occur (APA, 2000). Individuals with GAD have difficulty controlling their worry and their anxiety and worry often interferes with attention needed to perform tasks. In addition, worries associated with GAD in adults often center on common life circumstances, including minor matters (e.g., punctuality, household chores), finances, health (self or others), career, and community and world affairs (APA, 2000). Similar to depression, patients with GAD commonly present to primary care physicians for treatment, perhaps because they are most likely to present with symptoms of somatic and sleeping problems, rather than complaints of anxiety (Wittchen & Hoyer, 2001). Studies using DSM-III-R criteria report that current and lifetime prevalence rates of GAD are 3.1% and 5.1%, respectively (Kessler et al., 1994). More recently, a report of the lifetime prevalence rate for GAD in the general 5 population using DSM-IV criteria indicates that it remains at approximately 5% (Wittchen & Hoyer, 2001). Prevalence rates for GAD are relatively low among adolescents and young adults, but increase dramatically with age (Wittchen & Hoyer, 2001). GAD appears to develop in the late teenage years or early adulthood, with an average age of onset of 20.6 years (Brown, Campbell, Lehman, Grisham, & Mancill, 2001). Incidence of GAD is also fairly high among older adults (Wittchen et al., 1994). Thus, it appears that GAD may have a bimodal age of onset, with some reporting onset late in life, precipitated by a stressful life event, and others reporting earlier onset with a more chronic course (Stanley & Beck, 2000). In addition to genetic influences and stress (Yonkers, Warshaw, Massion & Keller, 1996), some risk factors have been identified that may contribute to the onset of GAD. These include being previously married, older than age 24, unemployment, identifying oneself as a homemaker, and living in the northeastern geographic region of the United States (Wittchen et al., 1994). Epidemiological studies using community samples (e.g., Wittchen et al., 1994) as well as clinical samples (Yonkers et al., 1996) report that females are twice as likely as males to be diagnosed with GAD, but this finding may be culture-specific. A study of GAD in rural South Africa found higher rates among men than women (Bhagwangee, Parekh, Petersen, & Subedar as cited in Roemer, Orsillo, & Barlow, 2002). The course of the disorder is chronic and tends to worsen during stressful periods. The average reported length of the illness is 20 years, with most individuals reporting a stable pattern of symptoms (Yonkers et al., 1996). Approximately 38% of 6 individuals diagnosed with GAD are considered to be in full remission after five years (Kessler et al., 2001). The impairment caused by GAD is equivalent to depression in magnitude in terms of work productivity and social functioning impairment and is also associated with an increase in use of the health care system (Wittchen & Hoyer, 2001). In a prospective, naturalistic, longitudinal study, Yonkers and colleagues (1996) examined the phenomenology and course of GAD in participants with DSM-III-R defined anxiety disorders. These researchers found that 90% of their sample had a lifetime history of another disorder and 83% had a diagnosis of another anxiety disorder at the outset of the study. More than 1/3 of participants with GAD also had diagnoses of depression (Yonkers et al, 1996). Diagnostic Issues The worry and anxiety associated with GAD can be distinguished from non- pathological worry and anxiety (APA, 2000). Worry associated with GAD, in contrast with non-pathological worry, is not easily controlled and generally interferes with functioning. Worries related to GAD are more prominent, persistent, and upsetting. A diagnosis of GAD is more likely to be given when there is an increased number of life circumstances about which an individual worries. In addition, non- pathological worry is less likely to be associated with the physiological symptoms that generally accompany GAD (APA, 2000). There is high comorbidity among anxiety disorders and with other disorders (Brown & Barlow, 1992). Specifically, GAD as a principal diagnosis (when using DSM-III-R criteria) is associated with some of the highest comorbidity rates and is also frequently given as an additional diagnosis (Brown & Barlow, 1992). Findings 7 of high comorbidity may reflect overlap in definitional criteria or other artifacts (e.g., high base rates of some disorders; Brown, et al., 2001). Thus, questions have been raised regarding the diagnostic validity of standard criteria, actual prevalence in the general population, and the meaning and implications of comorbid anxiety and depressive disorders. In a large-scale study of comorbidity using DSM-IV criteria, Brown and colleagues (2001) found that 57% of participants with principal anxiety or mood disorders had at least one additional Axis I diagnosis. In the aforementioned study, comorbidity rates were examined both with and without the hierarchy rule for diagnosing GAD, wherein a diagnosis cannot be made if symptoms occur during the course of a mood disorder (Brown et al., 2001). Inclusion of this hierarchy rule indicated that with a principal diagnosis of major depressive disorder (MDD) or dysthymia, GAD co-occurred in only 5% of cases. However, when ignoring the hierarchy rule, comorbidity rates for GAD and MDD were 67% and 90% for dysthymia (Brown et al., 2001). This latter finding represents a drastic difference in comorbidity based solely on use (or lack thereof) of the hierarchy diagnostic criterion for GAD. When examining current comorbidity rates, 65% of individuals with a principal diagnosis of GAD had a comorbid diagnosis of another anxiety or mood disorder, 36% of whom reported comorbid social phobia, and 26% of whom reported comorbid major depressive disorder. Lifetime comorbidity rates for individuals with GAD as the index diagnosis indicate a 94% comorbidity rate with another anxiety or mood disorder, a 47% rate of co-occuring panic disorder, 46% comorbid social phobia, and 67% comorbid major depressive disorder (Brown et al., 2001). 8 Due to its poor diagnostic reliability (Brown & Barlow, 1992) and high comorbidity rates with other disorders (Brown et al., 2001), it has been suggested that GAD should not be considered an independent disorder. However, considerable evidence exists that counters the argument that GAD is better conceived as a prodrome, residual, or severity marker of another disorder (Kessler et al., 2001). For example, in the community, GAD does not have a higher prevalence rate than other anxiety or mood disorders. Onset of GAD occurred an average of seven years before onset of a major depressive disorder (Brown et al., 2001). In addition, the environmental determinants of GAD appear to differ from those of depression (Brown et al., 2001). The overall comorbidity rate for GAD did not differ significantly from that of other disorders. This latter finding suggests that arguments to remove GAD as a formal diagnostic category from DSM-IV due to high comorbidity rates were not supported by Brown et al.’s (2001) study. Studies investigating the temporal order of comorbid anxiety and depressive disorders have found that anxiety disorders are more likely to precede rather than follow depressive disorders (e.g., Brown et al., 2001). The aforementioned finding may support theories that conceptualize anxiety and depression as similar constructs falling on different points of a helplessness-hopelessness continuum (Brown & Barlow, 1992). Comorbidity of certain disorders (e.g., GAD) represents an issue that may have implications for both treatment and prevention efforts. For example, treatment protocols may need to be adjusted to account for comorbid disorders in order to achieve symptom reduction of the disorder targeted in treatment (Brown & Barlow, 1992). 9 Worry and Its Relation to GAD The Nature of Worry Worry has been described as playing a central role in the development and maintenance of GAD. Investigations of worry have also led researchers to deduce that worry may be a significant contributor to anxiety, not only for GAD, but perhaps for all other anxiety disorders (Borkovec, 1994). Worry can be defined as an “unwanted, uncontrollable, aversive cognitive activity associated with negative thoughts and some sense of emotional discomfort” (Davey, 1994, p. 36). According to Borkovec and colleagues (Borkovec & Inz, 1990), one of the essential features of worry is that it is a verbal-linguistic activity (i.e., involving thinking) rather than a process involving imagery. In contrast with other anxiety disorders, GAD appears to be characterized by cognitive, experiential forms of avoidance, rather than by behavioral avoidance. Worriers perceive worry as a method of problem solving that aids in determining actions that might prevent the occurrence of a feared event (Borkovec, 1994). The perception of worry as assisting with the prevention of a feared event may be understandable if one considers what an individual must confront during a worrisome episode. Threat cues that warn of a potential catastrophe are detected. These cues generate a “fight or flight” response. The threat in this instance refers to a future event that is nonexistent or that cannot be controlled, thus there is no one to fight and nowhere to flee. However, the threat still exists in an individual’s mind and therefore the person believes that it must be avoided (Borkovec, Ray, & Stober, 1998).
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