Prefrontal-limbic connectivity during worry in older adults with generalized anxiety disorder.

OBJECTIVES: Although generalized anxiety disorder (GAD) is one of the most prevalent anxiety disorders in older adults, very little is known about the neurobiology of worry, the hallmark symptom of GAD in adults over the age of 60. This study investigated the neurobiology and neural circuitry of worry in older GAD patients and controls. METHOD: Twenty older GAD patients and 16 age-matched controls (mean age = 67.88) were compared on clinical measures and neural activity during worry using functional magnetic resonance imaging. RESULTS: As expected, worry elicited activation in frontal regions, amygdala, and insula within the GAD group, with a similar but less prominent frontal pattern was observed in controls. Effective connectivity analyses revealed a positive directional circuit in the GAD group extending from ventromedial through dorsolateral prefrontal cortices, converging on the amygdala. A less complex circuit was observed in controls with only dorsolateral prefrontal regions converging on the amygdala; however, a separate circuit passing through the orbitofrontal cortex converged on the insula. CONCLUSION: Results elucidate a different neurobiology of pathological versus normal worry in later life. A limited resource model is implicated wherein worry in GAD competes for the same neural resources (e.g. prefrontal cortical areas) that are involved in the adaptive regulation of emotion through cognitive and behavioral strategies.

Psychometric properties of the GAD-Q-IV and DERS in older, community-dwelling GAD patients and controls.

Thirty-seven community-dwelling, older generalized anxiety disorder (GAD) patients and 37 nonanxious controls completed the Generalized Anxiety Disorder Questionnaire for DSM-IV (GAD-Q-IV; Newman et al., 2002), the Difficulties in Emotion Regulation Scale (DERS; Gratz & Roemer, 2004), and other measures of anxiety and depression. The GAD-Q-IV and DERS were assessed for internal consistency reliability, construct validity, and test-retest reliability, with results indicating good psychometric performance. Receiver operating characteristic (ROC) analysis conducted on the full sample suggested that the optimal GAD-Q-IV cutoff for classifying GAD cases was 3.71, with .97 sensitivity and .92 specificity. The cutoff score for classifying those participants with GAD and comorbid conditions was higher, however. ROC analysis with the full sample revealed an optimal DERS cutoff score of 62.5, with .76 sensitivity and .86 specificity. Findings support the use of the GAD-Q-IV and DERS as screening instruments for GAD in older, community-dwelling adults in a research setting.

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 model's 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.