Jan Mohlman

Current theoretical models of generalized anxiety disorder (GAD): Conceptual review and treatment implications

Theoretical conceptualizations of generalized anxiety disorder (GAD) continue to undergo scrutiny and refinement. The current paper critiques five contemporary models of GAD: the Avoidance Model of Worry and GAD [Borkovec, T. D. (1994). The nature, functions, and origins of worry. In: G. Davey & F. Tallis (Eds.), Worrying: perspectives on theory assessment and treatment (pp. 5-33). Sussex, England: Wiley & Sons; Borkovec, T. D., Alcaine, O. M., & Behar, E. (2004). Avoidance theory of worry and generalized anxiety disorder. In: R. Heimberg, C. Turk, & D. Mennin (Eds.), Generalized anxiety disorder: advances in research and practice (pp. 77-108). New York, NY, US: Guilford Press]; the Intolerance of Uncertainty Model [Dugas, M. J., Letarte, H., Rheaume, J., Freeston, M. H., & Ladouceur, R. (1995). Worry and problem solving: evidence of a specific relationship. Cognitive Therapy and Research, 19, 109-120; Freeston, M. H., Rheaume, J., Letarte, H., Dugas, M. J., & Ladouceur, R. (1994). Why do people worry? Personality and Individual Differences, 17, 791-802]; the Metacognitive Model [Wells, A. (1995). Meta-cognition and worry: a cognitive model of generalized anxiety disorder. Behavioural and Cognitive Psychotherapy, 23, 301-320]; the Emotion Dysregulation Model [Mennin, D. S., Heimberg, R. G., Turk, C. L., & Fresco, D. M. (2002). Applying an emotion regulation framework to integrative approaches to generalized anxiety disorder. Clinical Psychology: Science and Practice, 9, 85-90]; and the Acceptance-based Model of GAD [Roemer, L., & Orsillo, S. M. (2002). Expanding our conceptualization of and treatment for generalized anxiety disorder: integrating mindfulness/acceptance-based approaches with existing cognitive behavioral models. Clinical Psychology: Science and Practice, 9, 54-68]. Evidence in support of each model is critically reviewed, and each models corresponding evidence-based therapeutic interventions are discussed. Generally speaking, the models share an emphasis on avoidance of internal affective experiences (i.e., thoughts, beliefs, and emotions). The models cluster into three types: cognitive models (i.e., IUM, MCM), emotional/experiential (i.e., EDM, ABM), and an integrated model (AMW). This clustering offers directions for future research and new treatment strategies.

The relation of worry to prefrontal cortex volume in older adults with and without generalized anxiety disorder.

Despite the widespread prevalence of generalized anxiety disorder (GAD) in later life, almost nothing is known about the neural aspects of worry in adults over the age of 60. Given the ongoing rapid increase in the older adult population, the relatively poor response rates to current interventions for late life GAD, and the effects of age-related changes to the brain, additional research on worry neurobiology is needed. The study group comprised 15 older GAD patients and 15 matched controls who were compared on clinical measures and brain volumes. It was expected that prefrontal cortex (PFC) volumes [medial orbital cortex (mOFC), dorsolateral cortex (DLPFC)] would show positive relations to worry scores, and weaker relations to more general measures of anxiety and depression. Negative relations were expected between amygdala volumes and worry scores. As expected, mOFC volumes were positively related to worry scores; however, DLPFC and amygdala volumes were not. The mOFC is involved in emotional decision-making under uncertain conditions and has the ability to suppress the amygdala, both of which are hypothesized functions of worry. Results are partly consistent with GAD theory and suggest that worry may involve neural areas that are also involved in the successful control of anxiety.

Improving recognition of late life anxiety disorders in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition: observations and recommendations of the Advisory Committee to the Lifespan Disorders Work Group

Recognition of the significance of anxiety disorders in older adults is growing. The revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM) provides a timely opportunity to consider potential improvements to diagnostic criteria for psychiatric disorders for use with older people. The authors of this paper comprise the Advisory Committee to the DSM5 Lifespan Disorders Work Group, the purpose of which was to generate informative responses from individuals with clinical and research expertise in the field of late‐life anxiety disorders.

Does Executive Dysfunction Affect Treatment Outcome in Late-Life Mood and Anxiety Disorders?

Rates of treatment response among the elderly are typically lower than those found in younger samples. This article discusses specific biological and psychological aspects of aging that may impact the effectiveness of treatments for late-life mood and anxiety disorders. Although empirical evidence for the role of executive skills in treatment outcome is currently quite limited, the small number of existing studies suggest that some older adults with deficits in executive skills may respond poorly to popular treatments for depression and anxiety compared with those with intact executive functions. However, there are likely to be additional mediating factors. This article provides a definition and description of executive functions, including a summary of popular assessment tools. The literature on treatment outcome is reviewed, and future directions are discussed.

Feasibility and acceptance of a nonpharmacological cognitive remediation intervention for patients with Parkinson disease.

Many patients with idiopathic Parkinson disease (PD) experience deficits in executive skills (ES; eg, attentional control, self-monitoring), which are associated with a range of impairing symptoms such as visual hallucinations, decreased motor control, and increased apathy. Pharmacological methods for improving ES in PD have shown to be somewhat unreliable. The goal of this study was to evaluate the feasibility and patient acceptance of a nonpharmacological cognitive remediation program that aimed to improve sustained, selective, alternating, and divided attentional abilities in a sample of 16 nondemented PD patients. Based on ratings of 4 feasibility dimensions (fatigue, effort, progress, enjoyment), patients with PD demonstrated a high degree of acceptance and successfully engaged in the program. As predicted, ratings of progress differed significantly across tasks according to difficulty level and were positively related to posttraining improvement in ES. Fatigue ratings showed negative associations with other indices across task types, suggesting that monitoring fatigue during cognitive remediation is essential. Patients’ ratings of enjoyment did not correspond to task difficulty, indicating that tasks could be simultaneously challenging and rewarding. Males reported exerting greater effort during the training than females. It was concluded that the intervention is appropriate for testing in a randomized controlled trial.

Cognitive-behavioral therapy for management of anxiety and medication taper in older adults.

OBJECTIVE The authors hypothesized that patients with late-life anxiety undergoing cognitive-behavioral therapy plus medical management for medication taper (CBT-MM) would realize greater reduction in medication use and greater improvement in psychological symptoms than a control group undergoing medical management alone (MM). METHODS Forty-two patients (age >60) who wanted to reduce anxiolytic medication were allocated to the two groups (CBT-MM versus MM), using a randomization plus difference-minimization procedure (to equate for medication use). RESULTS CBT-MM completers significantly reduced medication use, but not at a greater rate than MM completers. At the same time, CBT-MM completers experienced significantly greater alleviation of psychological symptoms than did MM completers. Some, but not all, treatment gains were maintained at 6-month follow-up. Intention-to-treat analyses using the mixed-effects model showed similar, but weaker, treatment effects than completer analyses. CONCLUSIONS Cognitive-behavioral therapy can alleviate psychological symptoms in elderly patients with anxiety even as patients reduce anxiolytic medication.

Anxiety Disorders in Older Adults: Looking to DSM5 and Beyond…

Anxiety in late life was for many years the ‘Cinderella’ of psychiatric disorders, often overshadowed by the focus on depression and dementia, and receiving little attention in research and clinical domains. As highlighted by an editorial published in this journal several years ago [1], the scientific study of anxiety in older age has a relatively brief history. Recently, however, there has been increased recognition of the prevalence and clinical consequences of anxiety disorders in older adults and lively debate about their nature and most appropriate diagnostic criteria [2, 3, 4]. The current evidence reveals that anxiety in older adults is more common than depression in community samples [5], often preceding depressive disorders [6]; moreover, co-morbid anxiety and depression has a poorer outcome than either condition alone [7]. Anxiety disorders are even more prevalent in clinical settings [8], and can have serious consequences for recovery from illness [9] and quality of life [10], as well as substantially increasing disability levels [11]. Therefore, anxiety disorders in older adults should be regarded as conditions of great public health importance.

Attention Mechanisms in Children with Anxiety Disorders and in Children with Attention Deficit Hyperactivity Disorder: Implications for Research and Practice.

Inattention is among the most commonly referred problems for school-aged youth. Research suggests distinct mechanisms may contribute to attention problems in youth with anxiety disorders versus youth with attention deficit hyperactivity disorder (ADHD). This study compared children (8–17 years) with anxiety disorders (n = 24) and children (8–16 years) with ADHD (n = 23) on neurocognitive tests of both general and emotion-based attention processes. As hypothesized, children with ADHD demonstrated poorer selective and sustained attention, whereas youth with anxiety disorders demonstrated greater attentional bias toward threatening faces on a visual probe task. Findings suggest the neuropsychological differentiation of attention problems in anxious and ADHD children, despite potentially similar phenotypes.

Emotional Stroop Performance in Older Adults: Effects of Habitual Worry

OBJECTIVE In clinically anxious individuals, selective attention to negative cues in the environment may perpetuate a vicious cycle of emotional dysfunction. However, very little is known regarding the role of negative attentional bias in anxious older adults. There is evidence that in older adults without clinical anxiety, the opposite bias (toward positive, and away from negative, emotional material) is present. We explored how these age-related changes in emotional processing interact with anxiety. METHOD Sixty older adults (age 60+) completed the emotional Stroop (eStroop) task, a widely used measure of attentional bias, which requires rapid identification of the color in which neutral and emotional words are printed. Participants were stratified into high-, mid-, and low-worry groups on the basis of a self-report measure, the Penn State Worry Questionnaire. RESULTS The high-worry group exhibited a bias toward threat-related words whereas the low- and mid-worry groups showed a bias away from threat-related words. By contrast, the low- and mid-worry groups showed a bias toward positive words, potentially consistent with an established positivity effect in older adults whereas the high-worry group showed a bias away from positive items. CONCLUSION Older adults who worry frequently exhibit a pattern of eStroop performance that is broadly consistent with the younger adult literature, suggesting that selective attention toward threat-related information may be seen as a relevant factor in older, as in younger, anxiety.

A Novel Approach to Treating Anxiety and Enhancing Executive Skills in an Older Adult with Parkinson’s Disease

Scientific interest in the nonmotoric symptoms of Parkinson’s disease (PD) has increased dramatically, and psychiatric symptoms (e.g., cognitive impairment, anxiety, and mood disorders) are now considered prime targets for treatment optimization. Psychiatric complications in PD are quite common, affecting as many as 60% to 80% of patients. This study describes the case of a 74-year-old male with PD who presented with complaints of anxiety and trouble with memory and attention. A combined cognitive behavior therapy (CBT) and cognitive enhancement intervention was delivered in ten 90-to-120 minute sessions.The patient showed a reduction in anxiety symptoms that was of sufficient magnitude to meet criteria for “responder” status. His cognitive skills were mostly unchanged, despite the rigorous rehabilitation practice. Implications for treatment and strategies for enhancing therapeutic benefits are discussed.