Abstract
This essay tackles with Generalized Anxiety Disorder attempting to look upon it's debatable nature. For this reason, diagnostic criteria are analysed along with its epidemiology and comorbidity. Furthermore two causal theories are examined with respect to two different treatment methods. The difficulty of diagnosing GAD is thoroughly elaborated through the analysis of the diagnosing criteria, epidemiology data and comorbidity issues. So far as causal theories are concerned, cognitive approaches are presented, as well as the stand of psychoanalysis. Respectively, the elements of Cognitive - Behavioural Treatment (CBT) are displayed followed by a review of psychodynamic approaches and treatment methods.
Introduction
"Anxiety is the dizziness of freedom" (Kierkegraard, Hannay, 2014) wrote the Danish
philosopher in 1844, who identified -long before Freud-anxiety as a profound human condition. Today, anxiety is recognized as a normal future - oriented mood state which, along the continuum, may result in an anxiety disorder when a person takes up maladaptive behaviours in response to a threat.
Generalized anxiety disorder (GAD), in particular, has proved to be one of the more controversial members of the family of anxiety disorders due to the criteria of the disorder itself. GAD is a relatively new disorder making its appearance for the first time in the Third edition of the Diagnostic and Statistical Manual of Mental Disorders, in which it was defined as a residual diagnostic category suitable for patients affected by chronic and sustained anxiety without panic attacks (American Psychiatric Association, 1980) and only a one month duration of symptoms was required. DSM-IV (American Psychiatric Association, 1994) provided a checklist of symptoms useful to distinguish between normal and pathologic anxiety. In 2010, the DSM-IV-TR (American Psychiatric Association, 2000) was introduced and the last version of the DSM (DSM-V) (American Psychiatric Association, 2013) does not significantly differ. The continuous amendments to diagnostic criteria of GAD and the controversies still surrounding some criteria, such as excessive worry and symptoms duration, threaten the reliability of epidemiological data and, overall, their comparability over time (Weisberg, 2009).
In the recent study conducted by Faraveli et al (2012), the findings significantly challenged the real validity of the DSM-IV definition of GAD on the ground that "DSM-IV criteria for GAD seem to be inappropriate for identifying clear pathognomonic features for this disorder and in guiding clinicians through the differential diagnosis between GAD and other psychiatric conditions"
Diagnostic criteria
"GAD is a chronic and impairing mental disorder characterized by prolonged and excessive worrying not restricted to particular circumstances. It is characterized by physical as well as psychological symptoms and is considered to be one of the most
common mental disorders (Guglielmo, Janirii, Pozzi, 2014)".
In DSM - V (American Psychiatric Association, 2013), excessive anxiety and worry (apprehensive expectation), occurring more days that not for at least six months, about a number of events or activities remains the first diagnostic criteria for GAD. Worry pertains to something in the future, either minor and unrealistic or serious and important, and is perceived negatively and with much apprehension.
Additionally, the individual finds it difficult to control the worry and the anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past six months) 1) restlessness or feeling keyed up or on edge, 2) being easily fatigued, 3) difficulty concentrating or mind going blank, 4) irritability, 5) muscle tension and 6) sleep disturbance. Furthermore, the anxiety, worry or physical symptoms cause clinically significant distress or impairment in social occupational or other areas of functioning and the disturbance is not attributable to the direct physiological effects of a substance or other medical condition.
Finally, the disturbance is not better explained by another mental disorder such as specific phobias and anxiety disorders or schizophrenia and delusional disorders.
Epidemiology and comorbidity
Generalized Anxiety Disorder is a long-term illness highly likely to re-occur. It is a common syndrome with lifetime prevalence estimated approximately 5% to around 12% and a 12-month prevalence rate of 3,1% in the US population, according to DSM criteria (Kessler et al., 2005; Weisberg, 2009; Kessler et al., 2012; Kessler et al., 2008). European data reported that lifetime prevalence is estimated 4,3% - 5,9% (Wittchen and Jacobi, 2005) whereas the 12-month prevalence is considered 1,7%-3,4% (Wittchen et al, 2011). Variability of data is also connected to gender, age and race. Women have a two-to-three fold increased risk for GAD showing a higher lifetime and 12-month prevalence (Vesga - Lopez et al, 2008). Groups that have a low risk of developing GAD are Asian, Latino and black adults. (Weisberg, 2009). With respect to age, it is difficult to determine the age of onset due to its gradual development. However, it is estimated that most commonly it occurs between the late teens and 20s despite the fact that first manifestations may appear in childhood and adolescence. It may also appear in the third decade of life or later in life but in that case, it is often associated with a stressful event. In adults, risk factors for the development of the disorder is low income, being widowed or divorced. Additionally, GAD is the most common disorder seen in primary care being second to that of depression (Starcevic, 2010). At last, subjects with a lifetime diagnosis of GAD present with high rates of medical illness such as migraine, gastrointestinal problems, cardiac disorders and respiratory diseases (Culpepper, 2009).
GAD co-occurs so frequently with other disorders that prompts some to call it a "comorbid disease" with increased psychological and social impairment, need for additional treatment and extended course poorer outcome (Nutt et al., 2006) . It frequently occurs with major depressive and bipolar disorder, anorexia nervosa, panic and social anxiety disorder, specific phobia, post-traumatic stress disorder and substance use disorders (Simon, 2009; Dellava et al., 2011; Nutt et al., 2006). According to the National Comorbidity Survey, only 16% of subjects with GAD have no lifetime mood disorders, while 67% and 17% have, respectively, unipolar and bipolar disorder. In the study of Faravelli et al (2012), among the findings of the study were that GAD is usually associated with other diagnoses, its occurrence alone being relatively rare. To increase prevalence, diminish comorbidity associated with GAD and help early diagnosis of additional disorders, Ruscio et al (2007) suggest broadening the definition of GAD by reducing the minimum duration to one month and eliminating the excessive worry requirement.
With regards to depression, it has been supported that, GAD and major depressive disorder share a single genetic diathesis and are genetically indistinguishable (Kendler et al, 1996). Furthermore, it has been reported that the two conditions share common vulnerability traits and other personality risk - factors, such as high levels of neuroticism and negative affect/emotionality (Watson et al, 2005). It has been supported (Alloy et al, 1990) that within a single episode, as well as in lifetime comorbidity, anxiety symptoms (or disorder) is more likely to precede depressive symptoms (or mood disorder) than the reverse. In addition, pure depression, without simultaneous anxiety, is rarer than the other way around. Therefore, the earlier syndrome may represent a prodromal manifestation of the other. Bowlby' s theory of attachment provides an interesting explanation of this relationship. According to this, pure depression is infrequent because people first become anxious about a threat of a loss (or respond to an actual loss). If the loss does not occur (or is substituted) , then depression nay never occur (Mineka, Watson and Clark, 1998).
Although in depression, the risk of suicide is greater than any other single diagnosis (Wilson et al, 1996), co - presence of anxiety increases the risk of suicide over the risk associated with pure depression (Bronisch & Wittchen, 1994). Associations between threshold, as well as subthreashold GAD, and suicide ideation have presently been reported in a study conducted in Canada (Gilmour, 2016).
In the end, GAD has been characterised as a chronic condition but evidence supports that its clinical features tend to persist in a cyclic mode, better described as recurrent with symptom - free periods between exacerbations (Angst et al, 2009).
Cognitive approaches and CBT treatment
The pathognomic symptom of GAD is worry which has taken a prominent role as the main diagnostic criteria for GAD. Tom Brokovec was the first who attempted to provide a definition of worry. "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 outcome is uncertain but contains the possibility of one or more negative outcomes; worry relates closely to the fear process (Borkovec et al, 1983)". Later on, he formulated the Cognitive Avoidance Model arguing that "worry allows individuals to process emotional topics at an abstract, conceptual level and consequently, avoid aversive images, autonomic arousal, and intense negative emotions in the short run (Borkovec 1994; Borkovec, Alcaine & Behar, 2004)". Roemer and Orsillo (Mennin et al, 2002), connected Borkovec' s conceptualization of GAD to the work of Hayes, Stroshal and Wilson (1999) who focused on experiential avoidance occurring "when a person is unwilling to remain in contact with particular private experiences". Newman et al (2004), incorporated an interpersonal perspective, thus expanding Borkovec' s avoidance model.
In 2007, Dugas and Robichaud provided a clear and concise cognitive model for GAD proposing that GAD is the result of specific cognitive processes that serve to maintain and reinforce the chronic nature of the illness (Dugas and Robichaud, 2007). This model has four key components described as: 1) Intolerance of uncertainty (IU) is considered the core defining feature of the disorder represented as a belief that uncertainty is stressful and interferes with the ability to function; thus uncertain or unexpected events should be avoided (Buhr and Dugas, 2002). " It is posited that the general state of uncertainty is what triggers worry, hence the disparate nature of worry topics (Robichaud, 2013)". 2) The positive beliefs associated with GAD worry include the unrealistic notions that worry helps problem solving, provides motivation, is a positive personality trait, can prevent negative outcomes, and protects against negative emotions. 3) Furthermore, individuals with GAD report a strong negative problem orientation viewing problems as threatening, doubting their ability to solve them and being pessimistic about the outcome (Robichaud and Dugas, 2005a; 2005b). Thus, it is not that they are unable to solve their problems, they don’t. 4) Cognitive avoidance strategies include substituting threatening thoughts with neutral or positive ones, using distraction tactics and avoiding stimuli that will trigger worry (Dugas et al, 2007; Dugas and Koerner, 2005). This way, cognitive avoidance maintains worry through negative reinforcement and by reducing somatic arousal, individuals do not experience full emotional processing of feared events.
Newman & Llera (2011) reviewed the findings regarding worrying and negative emotionality and proposed the Contrast Avoidance model arguing that “individuals with GAD engage in chronic negativity worry because they prefer to experience a sustained state of distress as a way to be emotionally prepared for the worst possible outcome to various events.” Koerner et al (2015), have more recently examined the extent to which dysfunctional beliefs relating to achievement and approval (dysfunctional attitudes), early maladaptive schemas and broad self - focused and other - focused beliefs explain "significant variance in GAD symptoms, over and above negative and positive beliefs about worry, negative beliefs about uncertainty and negative beliefs about problems".
Literature provides ample evidence that Cognitive - Behavioral Therapy (CBT) is the most effective form of psychotherapy in dealing with with GAD patients. It has been supported that it reduces acute symptoms with a two year maintenance sustainability (Borkovec & Ruscio, 2001), as well as that it reduces comorbid anxiety disorders, predominantly when GAD symptoms have been successfully reduced (Newman et al, 2010).
At first, cognitive - behavioural treatments for GAD developed on Beck's approach to depression (1967, 1979) and, later on, on anxiety disorders. The therapeutic intervention is basically organized around the idea that the environment is thought to be dangerous and the self as unable to cope. Thus, therapists target the expressed negative automatic thoughts, cognitive biases and dysfunctional beliefs by encouraging individuals to engage in new behaviours with the purpose of attaining new experiences that may challenge these beliefs. The core elements that of CBT are: "1) psychoeducation, 2) self - monitoring, 3) cognitive restructuring, 4) relaxation, 5) worry exposure and worry behavioural control and 6) problem solving (La Mela, Fiammeto and Farina, 2014)". However there are different practices according to the theory that supports it.
In metacognitive therapy (Wells, 2008), based on Well's Metacognitive Model (Wells, 1995), "individuals learn how to redirect their attention away from worry to challenge the beliefs that worry is uncontrollable and potentially dangerous". In IU - centred CBT (Dugas and Robichaud, 2007), individuals work on altering their stance toward uncertainty through systematic exposure to uncertainty. Furthermore, it dares peoples' beliefs about the efficacy of worry by encouraging them to consider cases when worrying was not so helpful in preventing negative outcome. Finally, this type of treatment aims at modifying the belief that problems are threatening by strengthening confidence that people are able to manage difficult situations as well as to make decisions. The protocol followed in CBT-IU includes "1) psychoeducation and worry awareness training, 2) uncertainty and exposure, 3) re-evaluation of positive beliefs about the usefulness of worry, 4) problem - solving training and 5) processing core fears through imaginal exposure (Robichaud, 2013)" The primary goal of this type of treatment is to learn how to tolerate and accept uncertainty in everyday life.
Roemer and Orsillo (2002) present a treatment approach that combines "cognitive - behavioural therapy with acceptance - based and mindfulness techniques" aiming at "controlling emotional experience, an allowance of feelings and their processing, and an end to experiential avoidance as a habitual mode of coping". Subsequently Mennin et al (2002), have argued that "these integrative approaches can be further strengthened through incorporation of an emotion regulation framework". Moreover, Newman et al (2004), have examined an integration of the traditional cognitive - behavioural techniques with both interpersonal, by addressing maladaptive patterns of relating, and experiential, by addressing emotional avoidance, techniques.
Finally, it has been stated that the utility of pshychodynamic psychotherapy for GAD " will depend on its efficacy relative to CBT, which has solid research evidence based in this area (Chambless, 2008)".
Psychoanalysis, psychodynamic approaches and treatment
Freud introduced the term Angstneurose (anxiety neurosis) in 1895 in order to separate neurasthenia from neurotic syndromes that were more closely related to each other and differed in there aetiological mechanism. This complex of symptoms consists of four major clinical syndromes: general irritability, chronic apprehension/anxious expectation, anxiety attacks and secondary phobic avoidance. In addition, Freud recognised that anxiety neurosis can frequently appear with other neuroses, such as hysteria, neurasthenia and obsessions, in a condition called mixed neurosis. Later in his life, the concept is reconsidered and becomes Realangst, anxiety of something real; a signal of the appearance of danger.
In his first formulations of the aetiology of neurosis, Freud conceptualized anxiety as being a direct result of unsatisfactory sexual life. The origin of anxiety was traced in the Oedipal phase and the resolution of the danger faced with the threat of castration be processed in psychism. "When certain frustrations, in certain objects, reveal a faulty dimension in this process of structural elaboration, it returns to the repressed. Suffering, discomfort and anxiety are indicative of the relative inconsistency of the identity of gender achieved. The identity does not properly channel the desires at the genital level and is exposed to danger that arises from the castration complex once again activated or from the superego (Rotemberg, 2013)".
In the ground-breaking Inhibitions, symptoms and anxiety (1926[1925]/1959) he supported that the mental content of the affect of anxiety is determined by later existential experiences and subsequent psychological reworkings of the affects. By suggesting that anxiety is experienced by the ego but not produced by it, Freud returned to his theory of anxiety by making repression not the cause but the result of anxiety. "It is always the ego' s attitude of anxiety which is the primary thing and which sets repression going. Anxiety never arises from repressed libido (Freud (1926[1925]/1959)." Thus, Freud reconsidered with regards to castration, or something traceable to castration, as being the dangerous situation and acknowledges challenges to the libido theory. "If anxiety is a reaction of the ego to danger, we shall be tempted to see the traumatic neuroses…as a direct result of fear of death (or fear of life) and dismiss from our minds the question of castration…(1926[1925]/1959)" It is very interesting to note that in this later work, Freud reverted the old concept of defence which, in earlier times, was solely identified as repression. "A defence against an unwelcome internal process will be modelled upon the defence against an external stimulus that the ego wards off internal and external dangers alike along similar lines (1926[1925]/1959)."
Concisely, what is involved is not "automatic anxiety" but "signal anxiety", which "reflects the significant adaptive and maturational progress of the child to the extent that anxiety is no longer a simple reaction to object loss but an anticipation of the threat of the loss of love from the object (Encyclopedia.com)". Signal anxiety is more typically encountered in GAD with its key feature being the predominance of anxious anticipation, worry and/or "free-floating" anxiety", which serves as a signal to the ego to strengthen its defences and indicates the presence of unconscious unresolved intrapsychic conflicts.
Kohut' theory of anxiety "emerges from a developmental period where the primary concern is the structuralisation of the self. The anxiety is not essentially created by drive - superego conflict but is located within the experience of the self, and determined by the factors that enhance or weaken its integration (Newman, 2013)". Thus, the emphasis shifted to the way caregivers helped the psych of the child to strengthen through meeting its developmental need in a good - enough way. Therefore, a reorganisation of psychoanalytic therapy should include a new relationship to objects and the analyst must become available for the use of transferential needs providing conditions of safety as well as needed relationship that serves as a scaffold to a new, reinforced self.
Psychoanalysis moved forward in diluting Freud' s theory by moving away from the unique significance of sexual experiences and focusing instead on reformulating the libido theory into 1) a theory of sexuality and aggression, 2) a drive theory and 3) an inner conflict theory (Sletvold, 2016). Finally, even though it is recognised that Freud' s work remains valuable until today, "a study of anxiety and fear encompassing findings from neurosciense offers a new perspective which can be helpful in advancing psychoanalytic thinking (Nersessian, 2013).
In 1984, Lubosky formulated a universal concept of supportive - expressive (SE) psychodynamic psychotherapy that aims to help the client to master ongoing interpersonal problems targeting primarily symptom relief and only limited characterological change. The focus of SE therapy is on core problematic relationship patterns, which are conceptualized with the use of the Core Conflictual Relationship Theme (CCRT). CCRT refers to the central repetitive relational pattern of the individual in its relationships. The therapy includes both “expressive” and “supportive” interventions drawing on the core principles of analytic/dynamic therapy through the transference relationship and non-directive, interpretative techniques (Luborsky and Crits-Christoph, 1990). A study conducted in patients with GAD showed that SE treatment produced significant improvements on a range of outcome measures (Crits - Christoph et al, 1996). In a more recent study of Crits - Chistoph and his colleagues (2005) examined interpersonal problems and changes in such problems using interpersonally oriented psychodynamic psychotherapy for GAD and found evidence of relevant improvement in interpersonal problems, which was an important aspect of recovery from GAD symptoms.
Intensive Short - Term Dynamic Psychotherapy (ISTDP), an emotion - focused, experiential psychodynamic treatment model, has also been proposed as beneficial for GAD patients. This is because in-session activation and processing of complex emotions related to adverse attachment experiences, which a central concept of ISTDP, is related to better treatment effects in avoidance of negative emotional states, a core feature of GAD (Lilliengren et al, 2017).
Psychodynamic psychotherapy (PDT) focuses on underlying processes of disorders, such a unresolved conflicts or impairments of ego functions . In contrast, CBT focuses on disorder - specific treatment needs, thus considered to have greater efficacy with regards to specific mental disorders such as GAD. Leichsenring and Salzer (2014) support that the transdiagnostic origin of psychodynamic therapy, focusing on underlying core conflicts instead of specific symptoms, can provide an advantage compared with other approaches and propose that with unified protocol, PDT goes back to the roots. To this direction they support the concept of and treatment principles of UPP - ANXIETY, which includes both supportive principles, such as establishing a helping alliance and setting treatment goals, and expressive principles, such as focusing on unresolved core conflictual relationship themes associated with symptoms of anxiety, in order to target the core processes underlying anxiety disorders.
Maybe it is a better idea to turn into an integrative treatment that incorporates different approaches that address the multiple aspects of GAD, cognitive, affective, interpersonal, behavioural and physiological. This way, psychology and psychotherapy may be able to assist individuals with coping anxiety and, by extension with themselves.
References
Alloy, L., Kelly, K., Mineka, S., Clements, C. (1990). Comorbidity in anxiety and depressive disorders: a helplessness/hopelessness perspective. In Maser, J.D. and Cloninger, C.R. Comorbidity of Mood and Anxiety Disorders, Washington DC: American Psychiatry Press, pp 499 - 543
American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders, Third Edition. Washington DC: American Psychiatric Association
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, Fourth Edition. Washington DC: American Psychiatric Association
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders, Fourth Edition Text Revision. Washington DC: American Psychiatric Association
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington DC: American Psychiatric Association
Angst, J., Gamma, A., Baldwin, D.S., Ajdacic - Gross, V., Rossler, W. The generalized anxiety spectrum: prevalence, onset, course and outcome. Eur Arch Psychiatry Clin Neurosci. 2009, 259(1), 37-45
Beck, A.T. (1967). Depression: Causes and treatment. Philadelphia: University of Pennsylvania Press
Beck, A.T., Rush, A., Shaw, B., Emery, G.D. (1979). Cognitive therapy of depression. New York, NY: Guilford Press
Brokovec T. D., Robinson, E., Pruzinsky, T. De Pree, J. (1983). Preliminary explanation of worry: Some characteristics and processes. Behaviour Research and Therapy, 21, 9 - 16
Borkovec, T.D. (1994). The nature, functions and origins of worry. In G.C.L. Davey & F. Tallis. Worrying Perspectives in theory, assessment and treatment. England: John Wiley & Sons, pp. 5 - 33
Borkovec, T.D., Ruscio, A.M. (2001). Psychotherapy for generalized anxiety disorder. J Clin Psychiatriy, 62, 37 - 45
Brokovec, T.D., Alcaine, O., Behar, E.S. (2004). Avoidance theory of worry and
generalized anxiety disorder. In R. Heimberg, D. Mennin & C. Turk. Generalized anxiety disorder: Advances in research and practice. New York, N.Y.: Guilford, pp. 77 - 108
Bronich, T. Wittchen, H.U. Suicidal ideation and suicide attempts: comorbidity with depression, anxiety disorders and substance abuse disorders. Eur. Arch. Psychiatry Clin. Neurosci., 244, 93 - 98
Buhr, K., Dugs, M.J. (2002). The intolerance of uncertainty scale: Psychometric properties of the English version. Behaviour Research and Therapy, 40, 931 - 945
Chambless, S.J. (2008). Specificity of treatment effects: cognitive therapy and relaxation for generalized anxiety and panic disorders. J Consult Clin Psychol, 75, 513 - 522
Crits - Christoph, P., Conolly, M.B., Azarian, K., Crits - Christoph, K., Shappel, S. (1996). An open trial of brief supportive - expressive psychotherapy in the treatment of generalized anxiety disorder. Psychotherapy, 33, 418 - 430
Crits - Christoph, P., Conolly, M.B., Narducci, J., Schamberger, M., Gallop, R. (2005). Interpersonal Problems and the Outcome of Interpersonally oriented psychodynamic treatment of GAD. Psychotherapy: Theory, Research, Practice, Training, 42 (2), 211 - 224
Culpepper, L. (2009). Generalized anxiety disorder and medical illness. J. Clin. Psychiatry, 70, 20 - 24
Dellava, J. E., Kendler, K. S., Neale, M. C. (2011). Generalized anxiety disorder and anorexia nervosa: evidence of shared genetic variation. Depress. Anxiety,28, 728-733
Dugas, M., Hedayati, M., Karavidas, A., Buhr, K., Francis, K., & Phillips, N. (2005). Intolerance of Uncertainty and Information Processing: Evidence of Biased Recall and Interpretations. Cognitive Therapy and Research, 29 (1), 57-70. 76
Dugas, M. J., Koerner, N. (2005). The cognitive-behavioral treatment for generalized anxiety disorder: Current status and future directions. Journal of Cognitive Psychotherapy: An International Quarterly, 19, 61-81.
Dugas, M.J., Freeston, M. & Ladouceur, R. (1997). Intolerance of Uncertainty and Problem Orientation in Worry. Cognitive Therapy and Research, 21(6), 593 - 606
Dugas, M.J., Robichaud, M. (2007). Generalized Anxiety Disorder: From Science to Practice. Routledge
Faravelli, C., Castellini, G., Benni, L., Brugnera, A., Landi, M., La Sauro, C., Pietrini, F., Rotella, F., Ricca, V. (2012). Generalized anxiety disorder: is there any symptom? Comprehensive Psychiatry, 53, 1056 - 1062
Freud, S. (1895). On the Grounds for Detaching a Particular Syndrome from Neurasthenia under the Name "anxiety neurosis". In Neurologisces Centralblatt, 14(2), 50 - 66
Gilmour, H. (2016). Threshold and subthreshold Generalized Anxiety Disorder (GAD) and suicide ideation. Statistics Canada Catalogue no 82 - 003 X. Health Reports, 27(11), 13 - 21
Guglielmo, R., Janiri, L., Pozzi, G. (2014). New Perspectives on Generalized Anxiety Disorder. New York: Nova Science Publishers, Inc.
Hayes, S.C., Stroshal, K.D., Wilson, K.G. (1999). Acceptance and concomitant therapy: An experiential approach to behaviour change. New York: Simon & Schuster
"Inhibitions, Symptoms, and Anxiety." International Dictionary of Psychoanalysis. . Retrieved January 28, 2018 from Encyclopedia.com: http://www.encyclopedia.com/psychology/dictionaries-thesauruses-pictures- and-press-releases/inhibitions-symptoms-and-anxiety
Kendler, K.S. (1996). Major depression and generalized anxiety disorder. Same genes, (partly) different environments - revisited. Br. J. Psychiatry, Suppl. 30, 68 - 75
Kessler R.C., Chiu W.T., Demler O., Merikangas K.R. & Walters E.E. (2005). Prevalence, severity, and commorbidity of 12-months DSM-IV disorders in the National Commorbidity Survey Replication, Arch Gen Psychiatry ,62, 617-627
Kessler, R. C., Gruber, M., Hettema, J. M., Hwang, I., Sampson, N., Yonkers, K. A. (2008). Co-morbid major depression and generalized anxiety disorders in the National Comorbidity Survey follow-up. Psychol. Med., 38, 365-74.
Kessler, R. C., Petukhova, M., Sampson, N. A., Zaslavsky, A. M., Wittchen, H. U. (2012). Twelve-month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States. Int. J. Methods Psychiatr. Res., 21, 169-84.
Kierkegraard S., Hannay A. (2014). The Concept of Anxiety: A simple
Psychologically oriented Deliberation in view of the Dogmatic Problem of Hereditary Sin. Liveright
Koerner, N., Kathleen T., Kusec, A. (2015). Maladaptive Core Beliefs and their Relation in Generalized Anxiety Disorder. Cognitive Behaviour Therapy, 44, 441 - 455
La Mela, C., Cosci, F., Farina, B. (2014). Cognitive Behavioural Therapy for Generalized Anxiety Disorder. In Guglielmo R., Janiri, L. and Pozzi G. New Perspectives on Generalized Anxiety Disorder. New York: Nova Science Publishers, Inc.
Leichsenring, F., Salzer, S. (2014). A Unified Protocol for the Transdiagnostic Psychodynamic Treatment of Anxiety Disorders: An Evidence - Based Approach. Psychoterapy, 51 (2), 224 - 245
Lilliengren, P., Johansson, R., Town, J.M., Kisely, S, Abbass, A. (2017). Intensive Short - Term Dynamic Psychotherapy for Generalized Anxiety Disorder: A pilot effectiveness and process - outcome study. Clinical Psychology and Psychotherapy,(in press), DOI: 10.1002/cpp.2101
Luborsky, L. (1984). Principles in psychoanalytic psychotherapy: A manual for supportive - expressive treatment. New York: Basic Books
Luborsky, L. (1990). Understanding transference: The Core Conflictual Relationship Theme method. New York: Basic Books
Mennin, D.S., Heimberg, R.G., Turk, C.L. and Fresco, D.M. (2002). Applying an Emotion Regulation Framework to Integrative Approaches to Generalized Anxiety Disorders. Clinical Psychology Science and Practice, 9(1), 85 - 90
Mineka, S., Watson, D., Clark, L.A. (1998). Comorbidity of Anxiety and Unipolar Mood Disorders. Annual Rev. Psychol, 49, 377 - 412
Nersessian, E. (2013. Psychoanalitic theory of anxiety: proposals for reconsideration. In Arbiser, S. and Schneider, J. On Freud' s "Inhibitions,Symptoms and Anxiety. London: Karnak Books, pp. 172 - 184
Newman, K.M. (2013). Winnicot and Kohut: Theories of anxiety. In Arbiser, S. and Schneider, J. On Freud' s "Inhibitions,Symptoms and Anxiety. London: Karnak Books, pp. 133 - 141
Newman, M.G., Castonguay, L.G., Borkovec, T.D., Monar, C. (2004). Integrative therapy for generalized anxiety disorder. In R. Heimberg, D. Mennin & C. Turk. Generalized anxiety disorder: Advances in research and practice. New York, N.Y.: Guilford
Newman, M.G., Errikson, T.M. (2010). Generalized anxiety disorder. In Beck J.G. Interpersonal Processes in the Anxiety Disorders: Implications for understanding Psychopathology and Treatment. Washington, DC: American Psychology Association, pp. 235 - 259
Newman, M.G., Llera, S.J. (2011). A novel theory of experiential avoidance in generalized anxiety disorder: A review and synthesis of research supporting a contrast avoidance model of worry. Clinical Psychology Review, 31, 372 - 382
Nutt, D. Argyropoulos S., Hood, S., Protocar, J. (2006). Generalized Anxiety Disorder: A comorbid disease. Eur. Neuropsychopharmacol, 16, Suppl 2, S 109 - 118
Ruscio, A.M., Chiu, W.T., Roy-Byrne, P. Stang, P.E., Stein, D.J., Wittchen, H.U. and Kessler, R.C. (2007). Broadening the definition of generalized anxiety disorder: Effects on prevalence and association with other disorders in the National Comorbidity Survey Replication. Journal of Anxiety Disorders, 21, 662 - 676
Robichaud M., Dugas, M.J. (2005a). Negative problem orientation (part I): Psychometric properties of a new measure. Behaviour Research and Therapy, 43, 391 - 401
Robichaud, M., Dugas, M. J. (2005b). Negative problem orientation (Part II): Construct validity and specificity in worry. Behaviour Research and Therapy, 43, 403 - 412
Robichaud, M. (2013). Generalized anxiety disorder: Targeting intolerance of uncertainty. In Simos G., Hofmann S. CBT for anxiety disorders: A practitioner book. Wiley - Blackwell, 57 - 85
Rotemberg, H. (2013). The correlation between anxiety and danger: vicissitudes of mental functioning. In Arbiser, S. and Schneider, J. On Freud' s "Inhibitions, Symptoms and Anxiety. London: Karnak Books, pp. 103 -118
Simon, N.M. (2009). Generalized anxiety disorders and psychiatric comorbidities such as depression, bipolar disorder and substance abuse. J. Clin. Psychiatry, Suppl (2), 10 - 14
Sletvold, J. (2016). Freud' s theory of Neurosis: Towards a Contemporary Theory of Trauma and Defence. Psychoanalytic Dialogues, 26, 460 - 475
Starcevic V. (2010). Anxiety Disorders in Adults A Clinical Guide: A Clinical Guide.
Oxford University Press
Vesga - Lopez, O., Schneier, F.R., Wang, S., Heimber, R.G., Liu, S.M., Hassin, D.S.,
& Blanco, C. (2008). Gender differences in generalized anxiety disorder:
Results from the National Epidemiologic Survey on Alcohol and Related
Conditions (NESARC), Journal of Clinic Psychiatry, 69, 1606 - 1616
Watson, D., Gamez, W., Simms, LJ. (2005). Basic dimensions of temperament and their relation to anxiety and depression: A symptom - based perspective. Journal of research in personality, 39, 46 - 66
Weisberg, R. B. (2009). Overview of generalized anxiety disorder: epidemiology, presentation and course, J. Clin. Psychiatry, 70, Suppl.2, 4-9
Wells, A. (1995). Meta-cognition and worry: A cognitive model of generalized anxiety disorder. Behavioural and Cognitive Psychotherapy, 23, 301 - 320
Wells, A. (2008). Metacognitive therapy: Cognition applied to regulationg cognition.
Behavioural and Cognitive Psychotherapy, 36, 651 - 658
Wilson, G.T., Natan, P.E., O' Leary, K.D., Clark, L.A. (1996). Abnormal Psychology: Integrating Perspectives. Boston: Allyn & Bacon
Wittchen, H.U., Zhao, S., Kessler, R.C., & Eaton, W.W. (1994). DSM-III-R generalized anxiety disorder in the National Commorbidity Survey. Archives of General Psychiatry, 51, 355 - 364
Wittchen, H.U., Jacobi, F. (2005). Size and burden of mental disorders in Europe - a c critical review and appraisal of 27 studies. Eur. Neuropshychopharmacol., 15, 357
Wittchen, H. U., Jacobi, F., Rehm, J. (2011). The size and burden of mental disorders and other disorders of the brain in Europe 2010, Eur. Neuropshychopharmacol., 21, 655 - 679