On evaluation of Isabella’s symptoms, it was ruled out that she did not suffer from a panic disorder, but rather she suffered from panic attacks associated with an anxiety disorder. A joint diagnosis of Generalised Anxiety Disorder and Social Phobia Disorder was given which accounted for the symptoms that Isabella was presenting with in accordance to the DSM-IV and proposed DSM-V.To further analyse the cause and treatment of such disorders, meta-cognition theory and uncertainty theory were evaluated to determine the role that worry plays in the negative feedback system of a GAD sufferer.
Both theories provide interesting insight into Isabella’s case however, as every case is unique, more research and insight is needed. Isabella, a 29-year-old woman, first presented to her GP complaining of breathing difficulties, heart problems, sweating and faintness.Her GP found no evidence to suggest a physical problem and hence suspected that she may have a panic disorder. Upon further analysis of Isabella’s symptoms however, we find that although Isabella does seem to suffer from panic attacks, her symptoms are not entirely consistent with Panic Disorder (PD) as outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).
Although some of Isabella’s self-reported symptoms are consistent with the DSM-IV (American Psychiatric Association, 2000) diagnostic criteria for PD, not all the criteria is appropriately satisfied.From the information we have obtained from Isabella so far, it does seem that her reports of feeling like she was suffering a heart attack is consistent with the DSM-IV PD criteria of persistent concern of the implications of the attack. Similarly, the attacks do not seem to be the result of any substance abuse, since there is no evidence that Isabella is suffering from a substance abuse problem. Furthermore, for an accurate diagnosis of PD, DSM-IV states the symptoms must not be better explained by another anxiety disorder.
A panic attack is a likely explanation of the symptoms that Isabella presented with to her GP.Her four symptoms of breathing difficulty, heart palpitations, sweating and faintness fall within the required symptoms of a panic attack. Panic attacks can occur in the context of any Anxiety Disorder. A deeper look reveals a more accurate diagnosis of General Anxiety Disorder (GAD) is more relevant to Isabella’s symptoms.
According to the DSM-IV, GAD is characterized by “excessive anxiety and worry, occurring more days than not for at least 6 months, about a number of events or activities”, Isabella’s symptoms are consistent with this criteria.Furthermore, the worry that she is feeling over everyday situations is consistent with this diagnosis. The DSM-IV for GAD requires at least three of six criteria be met for a successful diagnosis of GAD. Isabella’s reports of chronic fatigue, irritability, sleep disturbance and restlessness satisfy four of these criteria.
It is also important to note that Isabella’s cultural variation may be a factor in regards to her expression of anxiety, however due to the severity of her described symptoms, it would seem that this shouldn’t impact on the diagnosis of GAD (Goldenberg, 1996).Similarly, a diagnosis of Social Anxiety Disorder seems accurate under the DSM-IV due to Isabella reporting a clear avoidance of social situations at work in which she is terrified of making a fool of herself in front of others. Although Isabella only reports these feelings when at work, Specific Phobia has been ruled out due to Isabella not avoiding the stimulus (the workplace), but rather the people in the workplace. Thus, we cannot rule out an Axis 1 disorder, although it seems that a diagnosis of GAD is much encompassing of Isabella’s daily routine.
As well as General Anxiety Disorder, it may also be that Isabella suffers from Dysthymic Disorder according to the diagnostic criteria of the DSM-IV. Isabella reports going through periods in her life where she feels intense sadness and questions the meaningfulness of her life, this suggests a depressed mood with early onset yet no atypical features. She also experiences at least two of the necessary criteria for a diagnosis of Dysthymic Disorder including low energy, fatigue and low self-esteem. The symptoms also cause significant distress or impairment in social and occupational areas of functioning.
Similarly, she doesn’t seem to have a major depressive episode which rules out Major Depressive Disorder. Our only issue with a diagnosis of Dysthymic Disorder is that we can’t say with certainty that Isabella hasn’t had a major depressive episode in the first two years of her dysthymic symptoms, which is apart of criterion D of DSM-IV, furthermore, it may not be possible to gain such information since Isabella reports having had these symptoms for a long period of time and may not remember whether she suffered a depressive episode.Proposed changes to the DSM-IV may see the way that mental disorders are diagnosed changed forever under the new DSM-V model (Coutinho et al, 2010). In relation to Generalised Anxiety Disorders, one such proposed change has been to criterion C.
Andrews G et al (2010), suggest that there is limited evidence for the DSM-IV threshold of 3 or more symptoms but rather one of two symptoms: restlessness or feeling keyed up or on edge; and muscle tension. With particular reference to Isabella, this may see her diagnosis of GAD completely changed.Isabella never specifically states that she is restless or on edge, however she does report that she finds it difficult to relax. The problem with the new criteria is that it may not be specific enough to diagnose Isabella’s disorder; alternatively we may just need to obtain additional information from Isabella or her treating physician.
The admission of criterion D in the proposed DSM-V would however, make the diagnosis of GAD much more suitable to patients such as Isabella as it identifies certain behaviours where at least one must be observed (in this case, avoidance).In regards to Dysthymic Disorder, with the modification of criterion D under the proposed DSM-V, a diagnosis of Dysthymic Disorder would be much more easily applied. The new criterion states, “over the last 2 years, there is a period of two months or longer during which the full criteria for a major depressive episode are not met” (American Psychological Association, 2012). Thus, although we were previously hesitant to diagnose a Dysthymic Disorder, under the DSM-V model, a diagnosis is much more easily applied.
With the proposed DSM-V getting closer to completion, the definition and features of GAD and other disorders are being updated and changed. Thus, as an extension, theories attempting to explain Generalised Anxiety Disorder (GAD) are also being changed with the emergence of many different theories to try and explain the disorder. With particular reference to GAD, one of the most closely studied criteria is the worry that GAD sufferers feel, with approximately only 50% of patients showing “high end state functioning” after treatment (Wells, 1990).Two prominent theories attempting to explain worry in GAD is the Uncertainty Model (Ladouceur, Talbot & Dugas, 2000; Krohne, 1989) and the Metacognition Model (Flavell, 1979; Wells, 1999).
Krohne (1989) was the first to theorise that the main variables underlying anxiety disorders were the constructs of intolerance and uncertainty. He suggested “an elevated level of intolerance of uncertainty provokes reactions of hyper vigilance when individuals are faced with uncertain or ambiguous problems, while an elevated level of intolerance to emotional arousal stimulates cognitive avoidance reactions” (Ladouceur et al, 2000).From this theory, Ladouceur et al (2000) theorised that there was a positive correlation between intolerance of uncertainty and worry whereby the more uncertain individuals were of a situation, the more worried they became. In their experiment Ladouceur et al (2000) found evidence supporting their claim however noted that the exact nature of the link was unclear.
In another study carried out in 2001, Dugas, Gosselin & Ladouceur found that in order to decrease their anxiety, sufferers will try to increase their level of certainty when facing a situation that is uncertain.Those that were highly intolerant of uncertainty, tended to try and avoid situations in which they were uncertain of the outcome yet found difficulty functioning, when unable to avoid such events (Buhr & Dugas, 2006). This theory is particular relevant in relation to Isabella. She continuously is faced with uncertain events, which cause her to become stressed and anxious.
Her avoidance of social situations at work is clearly a mechanism used to avoid the stimuli that she believes is out of her control.Thus, Isabella’s difficulties dealing with uncertainty causes her to gain unnecessary worry and anxiety over the most basic things in day-to-day life. This would explain her increased anxiety and bouts of depression. Metacognition refers to knowledge or cognitive process that is involved in “appraisals about thinking and the processes of monitoring and controlling thoughts” (Wells, 1999).
Under this model, GAD is emphasised in relation to the role of metacognitive beliefs and appraisals rather than the misinformed beliefs that can lead to anxiety and intense worry in GAD sufferers (Wells, 2007).Like the Uncertainty model, emphasis is placed on the role of worry in GAD and how it is not just simply a symptom of anxiety. Wells (1999) identifies two different types of worries with respect to metacognition. Type 1 worry refers to when individual’s worries tend to “focus on external events and non-cognitive internal events, e.
g. physical symptoms or social concerns” (Wells, 1999). Wells and Carter (2001) stress the importance of worry, which is present in all individuals as a positive motivator.Wells and King (2006) say that such worry is helpful with the ability to help cope with future problems, which acts like a mechanism, whereby internal signals stop the worry.
Type 2 worry (or meta-worry) occurs when the individual feels that the worry they feel is uncontrollable, harmful or dangerous (Wells, 2005). Wells (1999), warns that this is one of the worst forms of worry. He says that individuals with GAD have positive beliefs about worrying and negative ‘metacognitive’ beliefs about the worry process.Hence, they worry about their worrying intensifying their anxiety causing panic.
The cycle ends up becoming a negative feedback system in which the mechanism to cease the worry becomes unavailable to the sufferer taking it’s toll on the individuals emotions. This type of worry is particularly relevant to Isabella’s case. As was seen in her presentation, her worrying about worrying caused her to go into a panic attack because she was so concerned about worrying strengthening the internal worrying negative beliefs.More recent research has show that this metacognitive model can be helpful in actually diminishing anxiety by experiencing the effects of worrying (Ellis & Hudson, 2010).
This can cause problems for GAD patients however, who instead of experiencing the worry and learn the controllable associations involved, they actually avoid and suppress the triggers embracing certain suppression and distraction mechanisms. Although the link between uncertainty and worry remains unclear, further research may be able to attempt to shed light on its current relationship (Buhr and Dugas et al, 2001).One of the hardest obstacles for abnormal Psychologists is the diagnosis and treatment of mental disorders. It becomes necessary to rule out what a patient is not suffering from as a wrong diagnosis can have detrimental effects on the wellbeing of a patient.
Furthermore, once a correct diagnosis is reached, there is no guarantee that the patient will be able to get better. The ongoing research into GAD and the links it has with worry are just one of the many promising areas of research that will increase our understanding and diagnosis of anxiety disorders such as that suffered by Isabella.
