Le trouble d'anxiété généralisée (TAG) est un syndrome psychiatrique très répandu entraînant des conséquences importantes pour la santé de l'individu qui en souffre. Les nombreux changements survenus dans la conceptualisation de ce trouble ont cependant fait en sorte de diminuer l'attention portée à l'identification des variables impliquées dans le développement et le maintien de ses symptômes. La présente étude a pour but d'établir un portrait général des connaissances actuelles du TAG en examinant les différentes théories et modèles explicatifs disponibles. Un modèle étiologique intégratif regroupant les facteurs psychologiques cognitifs, comportementaux et environnementaux est également proposé. Finalement, quelques recommandations sont apportées concernant les recherches futures portant sur le TAG et sa caractéristique centrale : l'inquiétude excessive et incontrôlable.
Generalized Anxiety disorder (GAD) is a widespread psychiatric syndrome involving significant consequences on people's health. However, recent data show that this disorder has received little attention when compared to other anxiety disorders. A review of the publication on GAD also stated that the majority of research has been conducted on descriptive issues, whereas etiological factors received lower rates of publication [25DUGAS MJ. Generalized anxiety disorder publications : so where do we stand ? J Anxiety Disord 2000 ; 14 : 31-40.
Cliccare qui per andare alla sezione Riferimenti]. This may be explained by the fact that changes in the conceptualization of GAD slowed down the progression of researches focussing on the identification of factors implicated in the development and the maintenance of its symptoms. For example, in the third version of the Diagnostic and Statistical Manual of Mental disorders (DSM) published in 1980 [1AMERICAN PSYCHIATRIC ASSOCIATION. Diagnostic and statistical manual of mental disorders (3e ed). Washington DC, 1980.
Cliccare qui per andare alla sezione Riferimenti], GAD could only be assigned if patients had a persistent anxiety without reporting specific symptoms of other anxiety disorders ( eg Specific Phobias, Panic Disorder, Obsessive-Compulsive Disorder). With DSM III-R [2AMERICAN PSYCHIATRIC ASSOCIATION. Diagnostic and statistical manual of mental disorders (3e ed rev). Washington DC, 1987.
Cliccare qui per andare alla sezione Riferimenti]and DSM IV [3AMERICAN PSYCHIATRIC ASSOCIATION. Diagnostic and statistical manual of mental disorders (4e ed). Washington DC, 1994.
Cliccare qui per andare alla sezione Riferimenti], excessive worry became the central feature of GAD, which increased its diagnostic validity. Taking that into account, where do we stand in the comprehension of GAD ? What are the etiological factors identified as playing a role in the development and the maintenance of GAD and its central feature, excessive and uncontrollable worry ? The goal of this article consists to provide answers to these questions by reviewing the literature of the current knowledge of GAD and examining various theories and explanatory models available. Firstly, many studies suggest that environmental factors are implicated in the development and maintenance of GAD [4ANGST J, VOLLRATH M. The natural history of anxiety disorders. Acta Psychiatr Scand 1991 ; 84 : 446-52.
Cliccare qui per andare alla sezione Riferimenti] [8BLAZER DC, HUGHES D, GEORGE LK. Stressfull life events and the onset of a generalized anxiety syndrome. Am J Psychiatry 1987 ; 144 : 1178-83.
Cliccare qui per andare alla sezione Riferimenti] [30FLISHER AJ, KRAMER RA, HOVEN CW et al. Psychosocial characteristics of physically abused children and adolescents. J Am Acad Child Adolesc Psychiatry 1997 ; 36 : 123-31.
Cliccare qui per andare alla sezione Riferimenti] [53NEWMAN SC, BLAND RC. Life events and the 1-year prevalence of major depressive episode, generalized anxiety disorder, and panic disorder in a community sample. Compr Psychiatry 1994 ; 35 : 76-82.
Cliccare qui per andare alla sezione Riferimenti]. However, the majority of researches rests on an out-of-date conceptualization of GAD. Furthermore, the nature of experimental designs used in researches limits their conclusion. The first environmental factor documented is negative life events. Researchers noted that the occurrence of one or more negative life events being significant and appearing in an unexpected way was associated with an increase in the risk to develop a GAD ( eg [8BLAZER DC, HUGHES D, GEORGE LK. Stressfull life events and the onset of a generalized anxiety syndrome. Am J Psychiatry 1987 ; 144 : 1178-83.
Cliccare qui per andare alla sezione Riferimenti]. Familial problems ( eg conflicts, abuses), considered as chronic stress-inducing situations, have also been suggested as etiological factor of GAD [4ANGST J, VOLLRATH M. The natural history of anxiety disorders. Acta Psychiatr Scand 1991 ; 84 : 446-52.
Cliccare qui per andare alla sezione Riferimenti] [7BEN-NOUN L. Generalized anxiety disorder in dysfonctional families. J Behav Ther Exp Psychiatry 1998 ; 29 : 115-22.
Cliccare qui per andare alla sezione Riferimenti] [46MATHEW RJ, WILSON WH, BLAZER D et al. Psychiatric disorders in adult children of alcoholics : data from the Epidemiologic Cathment Area project. Am J Psychiatry 1993 ; 150 : 793-800.
Cliccare qui per andare alla sezione Riferimenti]. Among the other environmental factors identified are separation during childhood [37KENDLER KS, NEALE MC, KESSLER RC et al. Generalized anxiety disorder in women : a population-based twin study. Arch Gen Psychiatry 1992a ; 49 : 267-72.
Cliccare qui per andare alla sezione Riferimenti] [60TALLIS F, EYSENCK MH. Worry : mechanisms and modulating influences. Behav Cogn Psychother 1994 ; 22 : 37-56.
Cliccare qui per andare alla sezione Riferimenti], role inversion during childhood [18CASSIDY J. Attachment and generalized anxiety disorder. In : Toth DC, Toth S, eds. Rochester symposium on developmental psychopathology : Emotion, cognition and representation. New York : University of Rochester Press, 1995 : 343-70.
Cliccare qui per andare alla sezione Riferimenti], lack of social interactions [29DURHAM RC, ALLAN T, HACKETT CA. On predicting improvement and relapse in generalized anxiety disorder following psychotherapy. Br J Clin Psychol 1997 ; 36 : 101-19.
Cliccare qui per andare alla sezione Riferimenti] [45MANCUSO DM, TOWNSEND MH, MERCANTE DE. Long-term follow-up of generalized anxiety disorder. Compr Psychiatry 1993 ; 34 : 441-6.
Cliccare qui per andare alla sezione Riferimenti] [68YONKERS YA, DYCK IR, WARCHAW M et al. Factor predicting the clinical course of generalized anxiety disorder. Br J Psychiatry 2000 ; 176 : 544-9.
Cliccare qui per andare alla sezione Riferimenti], poor life satisfaction [45MANCUSO DM, TOWNSEND MH, MERCANTE DE. Long-term follow-up of generalized anxiety disorder. Compr Psychiatry 1993 ; 34 : 441-6.
Cliccare qui per andare alla sezione Riferimenti], and modeling of a relative having an anxiety disorder [59SILVERMAN WK, CERNY JA, NELLES WB et al. Behavior problem in children of parents with anxiety disorders. J Am Acad Child Adolesc Psychiatry 1988 ; 27 : 779-84.
Cliccare qui per andare alla sezione Riferimenti]. The cognitive and behavioral approach has been widely used during the last two decades to precise the etiology of GAD. First of all, some studies have pointed out the function of worry, which is to suppress images associated with negative thoughts ( eg [9BORKOVEC TD, INZ J. The nature of worry in generalized anxiety disorder : a predominance of thought activity. Behav Res Ther 1990 ; 28 : 153-8.
Cliccare qui per andare alla sezione Riferimenti] [33FREESTON MH, DUGAS MJ, LADOUCEUR R. Thougths, images, worry and anxiety. Cogn Ther Res 1996 ; 20 : 265-73.
Cliccare qui per andare alla sezione Riferimenti] [34FREESTON MH, RHÉAUME J, LETARTE H et al. Why do people worry ? Pers Individ Dif 1994 ; 7 : 791-802.
Cliccare qui per andare alla sezione Riferimenti]. Thus, GAD patients seem to develop excessive worries in order to prevent more negative feeling associated with the images of a thought. Other authors suggested that a deficit of attention might be responsible of excessive worry [5AZAÏS F, GRANGER B, DEBRAY Q. Interférence sémantique et pathologie anxieuse : approche expérimentale dans l'anxiété généralisée. Soc Med Psychol 1994 ; 152 : 458-61.
Cliccare qui per andare alla sezione Riferimenti] [47MATHEWS A, MACLEOD C. Discrimination of threat cues without awareness in anxiety states. J Abnorm Psychol 1986 ; 95 : 131-8.
Cliccare qui per andare alla sezione Riferimenti] [51MOGG K, BRADLEY BP, WILLIAMS R et al. Subliminal processing of emotional information in anxiety and depression. J Abnorm Psychol 1993 ; 102 : 304-11.
Cliccare qui per andare alla sezione Riferimenti] [52MOGG K, MATHEWS A, WEIMAN J. Selective processing of threat cues in anxiety states : a replication. Behav Res Ther 1989 ; 27 : 317-23.
Cliccare qui per andare alla sezione Riferimenti] [60TALLIS F, EYSENCK MH. Worry : mechanisms and modulating influences. Behav Cogn Psychother 1994 ; 22 : 37-56.
Cliccare qui per andare alla sezione Riferimenti]. Finally, some cognitive variables such as intolerance of uncertainty [26DUGAS MJ, FREESTON MH, LADOUCEUR R. Intolerance of uncertainty and problem orientation in worry. Cogn Ther Res 1997 ; 21 : 593-606.
Cliccare qui per andare alla sezione Riferimenti] [27DUGAS MJ, GAGNON F, LADOUCEUR R et al. Generalized anxiety disorder : a preliminary test of a conceptual model. Behav Res Ther 1998 ; 36 : 215-26.
Cliccare qui per andare alla sezione Riferimenti] [34FREESTON MH, RHÉAUME J, LETARTE H et al. Why do people worry ? Pers Individ Dif 1994 ; 7 : 791-802.
Cliccare qui per andare alla sezione Riferimenti], false beliefs about worry [22DAVEY GCL, TALLIS F, CAPUZZO N. Beliefs about the consequences of worrying. Cogn Ther Res 1996 ; 5 : 499-520.
Cliccare qui per andare alla sezione Riferimenti] [27DUGAS MJ, GAGNON F, LADOUCEUR R et al. Generalized anxiety disorder : a preliminary test of a conceptual model. Behav Res Ther 1998 ; 36 : 215-26.
Cliccare qui per andare alla sezione Riferimenti] [34FREESTON MH, RHÉAUME J, LETARTE H et al. Why do people worry ? Pers Individ Dif 1994 ; 7 : 791-802.
Cliccare qui per andare alla sezione Riferimenti] [65WELLS A. Metacognition and worry : a cognitive model of generalized anxiety disorder. Behav Cogn Psychother 1995 ; 23 : 301-20.
Cliccare qui per andare alla sezione Riferimenti] [66WELLS A. A cognitive model of generalized anxiety disorder. Behav Modif 1999 ; 23 : 526-55.
Cliccare qui per andare alla sezione Riferimenti], negative problem orientation [20DAVEY GCL. Worrying, social problem-solving abilities, and social problem-solving confidence. Behav Res Ther 1994 ; 32 : 327-30.
Cliccare qui per andare alla sezione Riferimenti] [35GOSSELIN P, DUGAS MJ, LADOUCEUR R. Inquiétude et résolution de problèmes sociaux : le rôle de l'attitude négative face au problème. J Ther Comport Cogn 2002 ; 12 : 49-58.
Cliccare qui per andare alla sezione Riferimenti] [38LADOUCEUR R, BLAIS F, FREESTON MH et al. Problem solving and problem orientation in generalized anxiety disorder. J Anx Disord 1998 ; 12 : 139-52.
Cliccare qui per andare alla sezione Riferimenti]and cognitive avoidance [40LANGLOIS F, FREESTON MH, LADOUCEUR R et al. The Cognitive Avoidance Questionnaire : factor structure and convergent validity in an adolescent sample. Communication présentée au XXVII e congrès annuel de l'European Association for Behavioural and Cognitive Therapies, Venise, Italie, 1997.
Cliccare qui per andare alla sezione Riferimenti] [41LANGLOIS F, LACHANCE S, PROVENCHER M et al. Le Questionnaire d'évitement cognitif : analyses préliminaires. Communication par affiche présentée au congrès annuel de l'Association Francophone de la Formation et de la Recherche en Thérapie Comportementale et Cognitive (AFFORTECC), Annecy, France, 1996.
Cliccare qui per andare alla sezione Riferimenti]have been suggested as playing a determinant role in the development and maintenance of GAD. In order to resume the empirical findings available in the literature, an etiological model gathering the cognitive, behavioral, and environmental factors implicated in GAD is proposed. This model suggests that GAD is the result of a psychological vulnerability activated by a tension resulting from a negative event. Finally, recommendations are brought concerning future researches on GAD and its central characteristic, excessive and uncontrollable worry.
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