DSM-III generalized anxiety disorder: an empirical investigation of more stringent criteria

Factors Related to Suicide Attempts: The Roles of Childhood Abuse and Spirituality

Objectives: The purpose of this article was to identify independent factors associated with suicide attempts in patients with depression and/or anxiety. Background and Aims: This study was conducted in order to examine whether risk and protective psychological factors influence the risk of suicide attempts among outpatients with anxiety and/or depressive disorders. In this regard, explanatory models have been reported to detect high-risk groups for suicide attempt. We also examined whether identified factors serve as mediators on suicide attempts. Materials and Methods: Patients from 18 to 65 years old from an outpatient clinic at Seoul St. Mary's Hospital were invited to join clinical studies. From September 2010 to November 2017, a total of 737 participants were included in the final sample. The Beck Depression Inventory (BDI), State-Trait Anxiety Inventory (STAI), Childhood Trauma Questionnaire (CTQ), Functional Assessment of Chronic Illness Therapy-Spiritual Well-being Scale (FACIT-Sp-12), and Functional Social Support Questionnaire (FSSQ) were used to assess psychiatric symptoms. An independent samples t-test, a chi-square test, hierarchical multiple regression analyses, and the Baron and Kenny's procedures were performed in order to analyze data. Results: Young age, childhood history of emotional and sexual abuse, depression, and a low level of spirituality were significant independent factors for increased suicide attempts. Depression was reported to mediate the relationship between childhood emotional and sexual abuse, spirituality, and suicide attempts. Conclusions: Identifying the factors that significantly affect suicidality may be important for establishing effective plans of suicide prevention. Strategic assessments and interventions aimed at decreasing depression and supporting spirituality may be valuable for suicide prevention.

Sleep problems as a risk factor for suicide: Are certain specific sleep domains associated with increased suicide risk?

OBJECTIVES

The purpose of this study was to examine the relationship between sleep problems and suicidal ideation in depressive patients.

BACKGROUND AND AIMS

Evidence from diverse settings and populations indicates that sleep problems are associated with suicidal ideation. However, relationships between them are not well defined. This study was conducted in order to explore whether poor sleep was associated with suicidal ideation above and beyond depression and whether specific domains of sleep were related to suicidal ideation. We also determined whether the association between sleep problems and suicidal ideation was mediated by depression.

MATERIALS AND METHODS

Patients aged 18-65 years from an outpatient clinic at Seoul St. Mary's Hospital were recruited for this study. From September 2010 to November 2017, a total of 909 participants were included in the final sample. The Beck Depression Inventory (BDI) and Pittsburgh Sleep Quality Index (PSQI) were used to assess psychiatric symptoms. Independent samples t-test, chi-square test, Pearson correlation analyses, hierarchical multiple regression analyses, and mediation analyses were performed using SPSS PROCESS macro.

RESULTS

The majority of participants with suicidal ideation also had sleep problems (94.9%). After controlling for age, marital status, and depressive symptoms, total sleep problems estimated by the PSQI global score were also significant associated with suicidal ideation. Among seven sleep components derived from the PSQI, several components including cough or snore loudly, have bad dreams, and use sleep medication were associated with increased suicide risk. Also, the relationship between sleep problems and suicidal ideation was mediated by depressive symptoms indirectly. There was no convincing direct relationship between sleep problems and suicidal ideation.

CONCLUSIONS

Investigating the pathways which connect sleep problems and suicidality is fundamental to the development of suicide prevention. While it might be premature to suggest specific interventions, it would be important for clinicians to consider evaluating and managing sleep problems in the context of suicidality.

The history of generalized anxiety disorder as a diagnostic category

From the 19th century into the 20th century, the terms used to diagnose generalized anxiety included “pantophobia” and “anxiety neurosis.” Such terms designated paroxysmal manifestations (panic attacks) as well as interparoxysmal phenomenology (the apprehensive mental state). Also, generalized anxiety was considered one of numerous symptoms of neurasthenia, a vaguely defined illness. Generalized anxiety disorder (GAD) appeared as a diagnostic category in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980, when anxiety neurosis was split into GAD and panic disorder. The distinct responses these two disorders had to imipramine therapy was one reason to distinguish between the two. Since the revised DSM-III (DSM-III-R), worry about a number of life circumstances has been gradually emphasized as the distinctive symptom of GAD. Thus, a cognitive aspect of anxiety has become the core criterion of GAD. The validity of GAD as an independent category has been questioned from DSM-III up to preparation of DSM-5. Areas of concern have included the difficulty to establish clear boundaries between GAD and (i) personality dimensions, (ii) other anxiety-spectrum disorders, and (iii) nonbipolar depression. The National Institute of Mental Health has recently proposed the Research Domain Criteria (RDoC), a framework destined to facilitate biological research into the etiology of mental symptoms. Within the RDoC framework, generalized anxiety might be studied as a dimension denominated “anxious apprehension” that would typically fit into the research domain called “negative valence systems” and the more specific construct termed “potential threat.”

Validity of the Associated Symptom Criteria for Generalized Anxiety Disorder: Observations From the Singapore Mental Health Study

Previous findings on the diagnostic validity and reliability of generalized anxiety disorder (GAD)-associated symptom criteria suggest need for further evaluation. The current study examined convergent validity and specificity of GAD-associated symptoms in a representative Singapore community sample. The Singapore of Mental Health Study a cross-sectional epidemiological survey conducted among 6166 Singapore residents aged 18 and older. The Composite International Diagnostic Interview version 3.0 was used to diagnose mental disorders. Associated symptoms in the GAD criteria and autonomic hyperactivity symptoms showed convergent validity with a GAD diagnosis. However, associated symptoms of GAD were also linked to major depressive disorder (MDD), bipolar disorder, and obsessive-compulsive disorder, suggesting lack of adequate specificity. The inability of the diagnostic criteria to differentiate GAD from symptoms of other conditions highlights the need to better define its associated symptoms criteria. The relationship of overlapping symptoms between GAD and MDD is also discussed.

CLASSIFICATION OF ANXIETY DISORDERS COMORBID WITH MAJOR DEPRESSION: COMMON OR DISTINCT INFLUENCES ON RISK?

BACKGROUND

Anxiety and depression display frequent comorbidity. Individuals with comorbid disorders also often have more extreme symptomatology than those with single disorders. This correlation between comorbidity and severity poses an interesting question: Are comorbid forms of anxiety and depression essentially just more severe versions of the pure disorders?

METHODS

In a large major depression (MD) case-control sample of individuals from the China, Oxford and VCU Experimental Research on Genetic Epidemiology project, we examined the patterns of lifetime anxiety comorbidity (including generalized anxiety disorder--GAD, panic disorder, and five phobia subtypes) among MD cases (N = 5,864) in this population. Binary and multinomial logistic regression was used to estimate associations between risk factors and outcomes including MD as well as latent class membership, which were compared using continuation ratios.

RESULTS

We found a five-class solution to fit best, and each resulting class had a distinct pattern of association with the tested risk factors. The use of continuation ratios suggests that a class characterized by high endorsement of GAD is comparable to a more severely affected "pure MD" group. The other three classes (characterized by agoraphobia, various specific phobias, and by high endorsement of all comorbid anxiety disorders, respectively) appear to differ meaningfully from MD alone.

CONCLUSIONS

Risk for MD resulting from environmental and psychosocial factors may also predispose individuals to GAD, and less consistently, other anxiety disorders. Presentations of MD with certain phobias display distinguishably different patterns of risk, however, and are therefore likely qualitatively distinct.

Common psychiatric disorders and caffeine use, tolerance, and withdrawal: an examination of shared genetic and environmental effects

BACKGROUND

Previous studies examined caffeine use and caffeine dependence and risk for the symptoms, or diagnosis, of psychiatric disorders. The current study aimed to determine if generalized anxiety disorder (GAD), panic disorder, phobias, major depressive disorder (MDD), anorexia nervosa (AN), or bulimia nervosa (BN) shared common genetic or environmental factors with caffeine use, caffeine tolerance, or caffeine withdrawal.

METHOD

Using 2,270 women from the Virginia Adult Twin Study of Psychiatric and Substance Use Disorders, bivariate Cholesky decomposition models were used to determine if any of the psychiatric disorders shared genetic or environmental factors with caffeine use phenotypes.

RESULTS

GAD, phobias, and MDD shared genetic factors with caffeine use, with genetic correlations estimated to be 0.48, 0.25, and 0.38, respectively. Removal of the shared genetic and environmental parameter for phobias and caffeine use resulted in a significantly worse fitting model. MDD shared unique environmental factors (environmental correlation=0.23) with caffeine tolerance; the genetic correlation between AN and caffeine tolerance and BN and caffeine tolerance were 0.64 and 0.49, respectively. Removal of the genetic and environmental correlation parameters resulted in significantly worse fitting models for GAD, phobias, MDD, AN, and BN, which suggested that there was significant shared liability between each of these phenotypes and caffeine tolerance. GAD had modest genetic correlations with caffeine tolerance, 0.24, and caffeine withdrawal, 0.35.

CONCLUSIONS

There was suggestive evidence of shared genetic and environmental liability between psychiatric disorders and caffeine phenotypes. This might inform us about the etiology of the comorbidity between these phenotypes.

A longitudinal etiologic model for symptoms of anxiety and depression in women

BACKGROUND

Designed as state measures to monitor treatment response, symptoms of anxiety and depression (SxAnxDep) also have trait-like characteristics. No comprehensive etiologic model for SxAnxDep has illuminated the inter-relationship between their state- and trait-like characteristics, while including key predictor variables.

METHOD

In a prospective three-wave study of 2395 female twins from the Virginia Adult Twin Study of Psychiatric and Substance Use Disorders (VATSPSUD), we examined, using structural equation modeling, how genes, childhood and past-year environmental stressors, personality and episodes of major depression (MD) and generalized anxiety disorder (GAD) influence SxAnxDep.

RESULTS

The best-fit model, which explained 68-74% of the variance in SxAnxDep, revealed two etiologic pathways. Stable levels of SxAnxDep resulted largely from neuroticism, which in turn was influenced by genetic and early environment risk factors. Occasion-specific influences resulted from stressful events mediated through episodes of MD or GAD. These two pathways, which had approximately equal influences on levels of SxAnxDep, were substantially correlated because the genetic, early environmental and personality factors that impacted on stable symptom levels also predisposed to event exposure and disorder onset. No significant interaction was seen between the two pathways.

CONCLUSIONS

SxAnxDep in women in the general population arise from two inter-related causal pathways. The first, the 'trait-like' pathway, reflects genetic and early environmental risk factors, and is mediated largely through personality. The second pathway is mediated through episodes of MD and GAD, and is the result of both recent environmental adversities and trait-like factors that influence event exposure and the probability of disorder onset.

Generalized anxiety disorder and anorexia nervosa: evidence of shared genetic variation

BACKGROUND

Previous studies have indicated a high prevalence of generalized anxiety disorder (GAD) in women with anorexia nervosa (AN). However, the shared genetic and environmental components of these disorders have not been explored. This study seeks to elucidate the shared genetic and environmental components between GAD and AN.

METHOD

Using 2,083 women from the Virginia Adult Twin Study of Psychiatric and Substance Use Disorders, structural equation modeling was used to obtain maximum likelihood estimates of the environmental genetic, shared and unique environmental components in 496 women with GAD, 47 women with AN, 43 women with GAD + AN, and 1,497 women without GAD or AN.

RESULTS

Results show that the heritability of GAD was 0.32 and AN was 0.31, and the genetic correlation between the two disorders was 0.20, indicating a modest genetic contribution to their comorbidity. Unique environment estimate was 0.68 for GAD and 0.69 for AN, with a unique environmental correlation of 0.18. All common environmental parameters were estimated at zero.

CONCLUSIONS

The modest shared genetic and unique environmental liability to both disorders may help explain the high prevalence of GAD in women with AN. This knowledge could help in the treatment and prevention of comorbid disorders.

Anxiety disorders diagnosis: some history and controversies

Treatment of and research on anxiety disorders depends on the adequate conceptualization and measurement of these conditions. We review the history of the nosology of anxiety disorders and note that divisions of "neurosis" have inadvertently taken attention away from what is shared among conditions now classified separately. We note the changes in the definition of agoraphobia over time and the striking differences between DSM-IV and ICD-10 definitions. We mention ongoing controversies in the diagnoses of posttraumatic stress disorder, acute stress disorder, and generalized anxiety disorder. Finally, we discuss controversies surrounding the proper placement of obsessive-compulsive disorder and putatively related conditions in future diagnostic classifications. We hope that reviewing controversial aspects of diagnosis is useful to clinicians and researchers interested in the neurobiology of anxiety disorders.

Anxiety: its role in the history of psychiatric epidemiology

BACKGROUND

The role played by anxiety in the history of psychiatric epidemiology has not been well recognized. Such lack of understanding retarded the incremental growth of psychiatric research in general populations. It seems useful to look back on this history while deliberations are being carried out about how anxiety will be presented in DSM-V.

METHOD

Drawing on the literature and our own research, we examined work that was carried out during and after the Second World War by a Research Branch of the United States War Department, by the Stirling County Study, and by the Midtown Manhattan Study. The differential influences of Meyerian psychobiology and Freudian psychoanalysis are noted.

RESULTS

The instruments developed in the early epidemiologic endeavors used questions about nervousness, palpitations, sweating, trembling, shortness of breath, upset stomach, etc. These symptoms are important features of what the clinical literature called 'manifest', 'free-floating' or 'chronic anxiety'. A useful descriptive name is 'autonomic anxiety'.

CONCLUSIONS

Although not focusing on specific circumstances as in Panic and Phobic disorders, a non-specific form of autonomic anxiety is a common, disabling and usually chronic disorder that received empirical verification in studies of several community populations. It is suggested that two types of general anxiety may need to be recognized, one dominated by excessive worry and feelings of stress, as in the current DSM-IV definition of Generalized Anxiety Disorder (GAD), and another emphasizing frequent unexplainable autonomic fearfulness, as in the early epidemiologic studies.

Implications of modifying the duration requirement of generalized anxiety disorder in developed and developing countries

BACKGROUND

A number of western studies have suggested that the 6-month duration requirement of generalized anxiety disorder (GAD) does not represent a critical threshold in terms of onset, course, or risk factors of the disorder. No study has examined the consequences of modifying the duration requirement across a wide range of correlates in both developed and developing countries.

METHOD

Population surveys were carried out in seven developing and 10 developed countries using the WHO Composite International Diagnostic Interview (total sample=85,052). Prevalence and correlates of GAD were compared across mutually exclusive GAD subgroups defined by different minimum duration criteria.

RESULTS

Lifetime prevalence estimates for GAD lasting 1 month, 3 months, 6 months and 12 months were 7.5%, 5.2%, 4.1% and 3.0% for developed countries and 2.7%, 1.8%, 1.5% and 1.2% for developing countries, respectively. There was little difference between GAD of 6 months' duration and GAD of shorter durations (1-2 months, 3-5 months) in age of onset, symptom severity or persistence, co-morbidity or impairment. GAD lasting >or=12 months was the most severe, persistently symptomatic and impaired subgroup.

CONCLUSIONS

In both developed and developing countries, the clinical profile of GAD is similar regardless of duration. The DSM-IV 6-month duration criterion excludes a large number of individuals who present with shorter generalized anxiety episodes which may be recurrent, impairing and contributory to treatment-seeking. Future iterations of the DSM and ICD should consider modifying the 6-month duration criterion so as to better capture the diversity of clinically salient anxiety presentations.

Generalized anxiety disorder within the course of major depressive disorder: examining the utility of the DSM-IV hierarchy rule

BACKGROUND

The current Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) specifies that generalized anxiety disorder (GAD) should not be diagnosed if it occurs exclusively during an episode of a major depressive disorder (MDD) or another mood disorder. This hierarchy rule was intended to promote diagnostic parsimony, but may result in the loss of important clinical information. The goal of this study was to compare individuals with MDD, comorbid MDD and GAD, and GAD within the course of MDD at intake and 12-month follow-up on self-report measures, clinician ratings, and rates of comorbidity.

METHODS

Participants were divided into three diagnostic groups: MDD without GAD (n=124), comorbid MDD and GAD (n=59), and GAD within the course of MDD (n=166). All the participants completed a semi-structured clinical interview and self-report measures assessing psychopathology, temperament, and functional impairment. A subset of the total sample completed a follow-up assessment of 12 months postintake.

RESULTS

Individuals with comorbid MDD and GAD and GAD within the course of MDD reported more psychopathology, negative affect, and functional impairment at intake than individuals with MDD only. The presence of GAD at intake, however, did not differentially predict symptom severity, functional impairment, or the presence of comorbidity at 12-month follow-up.

CONCLUSIONS

Cross-sectional findings indicate that individuals with GAD within the course of MDD experience levels of psychopathology, functional impairment, and comorbidity similar to those found in individuals with comorbid GAD and MDD. Preliminary longitudinal findings, however, suggest that the presence of GAD in patients with MDD does not have prognostic significance.

Co-morbid major depression and generalized anxiety disorders in the National Comorbidity Survey follow-up

BACKGROUND

Although generalized anxiety disorder (GAD) and major depressive episode (MDE) are known to be highly co-morbid, little prospective research has examined whether these two disorders predict the subsequent first onset or persistence of the other or the extent to which other predictors explain the time-lagged associations between GAD and MDE.

METHOD

Data were analyzed from the nationally representative two-wave panel sample of 5001 respondents who participated in the 1990-1992 National Comorbidity Survey (NCS) and the 2001-2003 NCS follow-up survey. Both surveys assessed GAD and MDE. The baseline NCS also assessed three sets of risk factors that are considered here: childhood adversities, parental history of mental-substance disorders, and respondent personality.

RESULTS

Baseline MDE significantly predicted subsequent GAD onset but not persistence. Baseline GAD significantly predicted subsequent MDE onset and persistence. The associations of each disorder with the subsequent onset of the other attenuated with time since onset of the temporally primary disorder, but remained significant for over a decade after this onset. The risk factors predicted onset more than persistence. Meaningful variation was found in the strength and consistency of associations between risk factors and the two disorders. Controls for risk factors did not substantially reduce the net cross-lagged associations of the disorders with each other.

CONCLUSIONS

The existence of differences in risk factors for GAD and MDE argues against the view that the two disorders are merely different manifestations of a single underlying internalizing syndrome or that GAD is merely a prodrome, residual, or severity marker of MDE.

Broadening the definition of generalized anxiety disorder: effects on prevalence and associations with other disorders in the National Comorbidity Survey Replication

Concerns have been raised that the DSM-IV requirements of 6-month duration, excessive worry, and three associated symptoms exclude a substantial number of people with clinically significant anxiety from a diagnosis of generalized anxiety disorder (GAD). We examined the implications of relaxing these three criteria for the estimated prevalence and predictive validity of GAD using nationally representative data from the US National Comorbidity Survey Replication. Relaxing all three criteria more than doubles the estimated prevalence of GAD. Broadly defined GAD significantly predicts the subsequent first onset of a wide range of temporally secondary disorders. The odds of secondary disorders are somewhat smaller for broadly defined than DSM-IV GAD, though few of these differences are statistically significant. Results suggest that subthreshold manifestations of GAD are significantly related to elevated risk of subsequent psychopathology. Further research is needed to determine whether broadening the current diagnostic criteria results in a more valid characterization of GAD.

Generalised anxiety disorder

Generalised anxiety disorder is a persistent and common disorder, in which the patient has unfocused worry and anxiety that is not connected to recent stressful events, although it can be aggravated by certain situations. This disorder is twice as common in women than it is in men. Generalised anxiety disorder is characterised by feelings of threat, restlessness, irritability, sleep disturbance, and tension, and symptoms such as palpitations, dry mouth, and sweating. These symptoms are recognised as part of the anxiety syndrome rather than independent complaints. The symptoms overlap greatly with those of other common mental disorders and we could regard the disorder as part of a spectrum of mood and related disorders rather than an independent disorder. Generalised anxiety disorder has a relapsing course, and intervention rarely results in complete resolution of symptoms, but in the short term and medium term, effective treatments include psychological therapies, such as cognitive behavioural therapy; self-help approaches based on cognitive behavioural therapy principles; and pharmacological treatments, mainly selective serotonin reuptake inhibitors.

Evaluation of the prophylactic efficacy of amitriptyline and citalopram, alone or in combination, in patients with comorbidity of depression, migraine, and tension-type headache

Antidepressants are used to treat chronic daily headache disorders such as migraine and chronic tension-type headache (TTH), which are often associated with depression and anxiety. Here, we studied the efficacy and tolerability of amitriptyline and citalopram, given alone or in combination, in patients with 'triple' comorbidity of depression, TTH, and migraine. Eighty-eight patients were enrolled in the study and randomly divided into two groups. The first group received amitriptyline and the second citalopram for 16 weeks. Patients were assessed at weeks 0, 4, 8, and 16. The two drugs were equally efficacious in relieving depressive symptoms, although amitriptyline was more efficacious than citalopram in reducing migraine and TTH attacks. Patients who did not respond to monotherapy (<30% of improvement in the clinical scores) were treated with a combination of the two drugs for 16 additional weeks. In these selected patients, the combined treatment produced a substantial improvement in depression, migraine and TTH without producing major side effects such as those commonly related to the 'serotonergic' syndrome. The results indicate that a combined therapy with amitriptyline and citalopram may be particularly beneficial for patients with TTH, migraine and comorbid depression that do not respond to monotherapy.

The World Mental Health (WMH) Survey Initiative Version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI)

This paper presents an overview of the World Mental Health (WMH) Survey Initiative version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI) and a discussion of the methodological research on which the development of the instrument was based. The WMH-CIDI includes a screening module and 40 sections that focus on diagnoses (22 sections), functioning (four sections), treatment (two sections), risk factors (four sections), socio-demographic correlates (seven sections), and methodological factors (two sections). Innovations compared to earlier versions of the CIDI include expansion of the diagnostic sections, a focus on 12-month as well as lifetime disorders in the same interview, detailed assessment of clinical severity, and inclusion of information on treatment, risk factors, and consequences. A computer-assisted version of the interview is available along with a direct data entry software system that can be used to keypunch responses to the paper-and-pencil version of the interview. Computer programs that generate diagnoses are also available based on both ICD-10 and DSM-IV criteria. Elaborate CD-ROM-based training materials are available to teach interviewers how to administer the interview as well as to teach supervisors how to monitor the quality of data collection.

Predicting panic disorder among patients with chest pain: an analysis of the literature

As many as 25% of patients with chest pain who come to hospital emergency departments have panic disorder. Rates of panic disorder are even higher among those who present for outpatient evaluation of their chest pain. Unfortunately, panic disorder remains largely undiagnosed and untreated in these settings. The authors reviewed studies published between 1970 and 2001 that addressed the prevalence of panic disorder among persons who seek treatment for chest pain in an emergency department or outpatient cardiology clinic. A meta-analysis of the findings revealed five variables that appear to correlate with higher rates of panic disorder among persons who present with chest pain: 1). absence of coronary artery disease, 2). atypical quality of chest pain, 3). female sex, 4). younger age, and 5). a high level of self-reported anxiety. Further studies of these and other variables associated with panic disorder should aid in the detection of this disabling but treatable cause of chest pain.

Improving homework compliance in the treatment of generalized anxiety disorder

Generalized anxiety disorder is a chronic condition characterized by beliefs that worry prepares and protects, but that excessive worry is out of control. In this article, I review the cognitive-behavioral model of generalized anxiety, focusing specifically on problems related to excessive worrying. Noncompliance in self-help homework is reflected in the patient's excessive focus on negative feelings, difficulty identifying automatic thoughts, demand for immediate results, and the belief that worries are realistic. Interventions for these problems are illustrated in the case of the treatment of a patient characterized by persistent worries, low self-confidence, procrastination, and avoidance.

A population-based twin study of generalized anxiety disorder in men and women

This study aimed to a) assess whether genetic or environmental effects are of similar magnitude in the etiology of GAD in men and women, and b) investigate whether familial (genetic or common environmental) risk factors are the same in men and women, or whether there are gender-specific effects. We obtained a lifetime history of DSM-IIII-R GAD, via face-to-face and telephone interviews, from 3100 complete male-male, female-female, and male-female twin pairs, ascertained through a population-based registry. Biometrical twin modeling was utilized to estimate the relative contributions of genetic and environmental factors to liability for GAD, allowing for gender-specific effects. The familial aggregation of GAD in this sample was only modest. In the best-fitting models, the heritability of GAD was the same in men and women, estimated at about 15% to 20%, with no effects of gender-specific genes detected.

The epidemiology of generalized anxiety disorder

The literature reviewed here is consistent in showing that GAD is a common mental disorder that typically has an early age of onset, a chronic course, and a high degree of comorbidity with other anxiety and mood disorders. Comorbid GAD is often temporally primary, especially in relation to mood disorders, and is associated with an increased risk for the subsequent onset and severity of secondary disorders. The weight of evidence reviewed here argues against the view expressed by early commentators that GAD is better conceptualized as a prodrome, residual, or severity marker of other disorders than as an independent disorder. Focused studies of comorbidity between GAD and major depression, in which comorbidity is high, lead to the same conclusion. The crucial evidence for this conclusion includes the following: 1. Contrary to the findings of clinical studies, GAD in the community does not have a higher comorbidity than do most other anxiety or mood disorders. 2. The symptoms of GAD form an empiric cluster distinct from the symptoms of major depression in studies of symptom profiles. 3. Family studies show distinct aggregation of GAD and major depression. 4. Twin studies show that the environmental determinants of GAD are different from the environmental determinants of major depression. 5. The sociodemographic predictors of GAD in epidemiologic studies are different from the predictors of major depression. 6. The clinical course of GAD is less consistently related to comorbidity than is the course of other anxiety and mood disorders. 7. The impairments associated with GAD are equivalent to, or greater than, those associated with other severely impairing chronic physical and mental disorders. These findings show that the status of GAD as an independent disorder is at least as strongly supported by available evidence as is that of other anxiety or mood disorders. This article also shows that uncertainty remains regarding even the basic epidemiologic characteristics of the GAD syndrome. Lingering concerns about the independence of GAD have conspired to exacerbate this problem by promoting repeated changes in the diagnostic criteria for GAD from the DSM-III to DSM-III-R and to DSM-IV. These successive changes have made it difficult to amass consistent long-term data on the natural history of GAD. Available evidence on the empiric validity of current diagnostic thresholds for GAD raises questions about the requirements, such as whether a 6-month minimum duration and four or more additional psychophysiologic symptoms are optimal for identifying all of the people in the general population who suffer from a clinically significant GAD syndrome. An additional source of potential bias in this regard is that the DSM system requires that anxiety be excessive or unrealistic for a diagnosis of GAD. Interestingly, there is no comparable DSM requirement that dysphoria must be excessive or unrealistic to qualify as major depression. These diagnostic uncertainties make it difficult to gain a clear understanding of the true breadth and depth of the GAD syndrome in the general population. Additional research is needed, ideally from unbiased epidemiologic samples, to resolve these basic uncertainties. The strong comorbidity between GAD and major depression, the fact that most people with this type of comorbidity report that the onset of GAD occurred before the onset of depression, and the fact that temporally primary GAD significantly predicts the subsequent onset of depression and other secondary disorders raise the question of whether early intervention and treatment of primary GAD would effectively prevent the subsequent first onset of secondary anxiety and depression. Unfortunately, little is known about this possibility because, as mentioned earlier, few people with pure GAD seek treatment. Why this is true is unknown. Given the early onset of GAD and its strong effects in predicting the subsequent onset, severity, and persistence of other disorders, efforts are needed to collect epidemiologic data on the reasons for the low rate of help seeking among people with pure GAD and to develop outreach strategies that may correct this situation.

Comorbidity in generalized anxiety disorder

GAD has rates of comorbidity that equal or exceed those of other anxiety disorders, and it is one of the most common comorbid conditions with other disorders. Depressive disorders, especially MDD, and other anxiety disorders, especially panic disorder, most commonly co-occur. The pattern of comorbidity is consistent in community and clinical populations and in children and elderly people. Comorbidity is associated with greater impairment, more treatment seeking, and worse outcome among persons with GAD compared with pure GAD. Likewise, patients with panic disorder and MDD who have coexisting GAD tend to have more severe symptoms and less favorable outcome. The relationship between GAD and MDD seems especially close, and data from twin studies suggest that these conditions share a genetic diathesis. Patients with GAD and coexisting conditions respond less well to psychological and pharmacologic treatment, but, for those who do respond, treatment for the primary disorder often also produces improvement in comorbid conditions. Thus, research continues to show that GAD is important as a primary and a comorbid disturbance.

Temporalis exteroceptive suppression in generalized anxiety disorder and major depression

The duration abnormality of the exteroceptive suppressions, or silent periods, of peripheral or jaw-closing muscle activities induced by transcranial magnetic or trigeminal electrical stimuli in patients suffering from anxiety or depression is ill-defined. We therefore studied the exteroceptive suppression periods of the temporalis muscle electromyography elicited by trigeminal territory electrical stimuli, Zuckerman-Kuhlman's Personality Questionnaire, and Plutchik-van Praag's Depression Inventory (PVP) in 12 patients suffering from generalized anxiety disorder (GAD) and 16 from major depression (MD) as well as in 17 healthy volunteers. Durations of the second suppression period (ES2) sociability scores were decreased in GAD patients, while PVP and neuroticism-anxiety scores were elevated in both GAD and MD patients. There was a positive correlation between ES2 duration and sociability score in the GAD group. This study indicates that anxiety can modify the temporalis ES2 duration through cortical descending inhibitory controls.

Depressive comorbidity in children and adolescents with generalized anxiety disorder

Aim of this study is to examine the effect of depressive comorbidity in 108 children and adolescents with Generalized Anxiety Disorder (GAD). Fifty-five patients with GAD and depression were compared with 53 patients with GAD without depression. Age, gender and socioeconomic status did not differentiate the groups. Patients with comorbid depression had significantly more anxiety symptoms than patients without depression. Clinical presentation of GAD and pattern of comorbidity was similar in the two groups. Subjects with comorbid depression showed a more severe functional impairment, assessed with C-GAS. Data are discussed in the light of conceptualizations about the relationship between anxiety and depression.

The complexity of psychiatric comorbidity: a conceptual and methodological discussion

Comorbidity is widely used in psychiatry, although few studies have considered the conceptual and methodological problems deriving from the transposition of this term from medicine to psychiatry. Comorbidity should be defined as two or more diseases, with distinct aetiopathogenesis (or, if the aetiology is unknown, with distinct pathophysiology of organ or system), that are present in the same individual in a defined period of time. In psychiatry, comorbidity is often an artefact for several reasons: (a) different assessment methods; (b) improper utilisation of the term comorbidity to indicate the association of symptoms instead of diseases; (c) number and characteristics of hierarchical exclusion rules used in classification systems; (d) nosologic classification in disorders (a generic term) instead of syndromes (a more precise concept, that allows clinicians to consider the hierarchy and the qualitative specificity of symptoms); (e) excessive splitting of classical syndromes into small disorders with inappropriate and overlapping boundaries; (f) too frequent revision of the diagnostic criteria, that changes diagnostic threshold; (g) number of clinical entities considered. Biological and psychological hypotheses that investigate the complexity of comorbidity findings are here presented; it is underlined that comorbidity should be the epidemiological descriptive starting point to build hypotheses that must be clear and rigorously defined, with specified usefulness and limits. Finally, the hypotheses should be tested with specific methodologies.

Generalized anxiety disorder and its comorbidities: disputes at the boundaries

This theoretical paper reviews the status of generalized anxiety disorder (GAD) and the Axis I and Axis II disorders with which it is often comorbid. Differences in comorbidity between the epidemiological and clinical literatures are discussed. Special attention is given to panic disorder, the symptoms of which are similar to those of GAD. The boundaries of GAD and its relationship to other Axis I disorders and to Axis II disorders raise important implications for its classification.

Toward a definition of generalized anxiety disorder as an anxious temperament type

Generalized anxiety disorder (GAD) is defined as an uncontrollable disposition to worry about one's welfare and that of one's immediate kin. Associated manifestations include arousal, vigilance, tension, irritability, unrestful sleep and gastrointestinal distress. There is growing evidence for the lifelong nature of this condition among many of its sufferers. This and other evidence reviewed in the present paper provide further support for the thesis that the chronic disposition to worry should probably be classified under constitutional or trait anxiety. GAD is best considered an exaggeration of a normal personality disposition that can be named 'Generalized anxious temperament' (GAT). Despite some overlap with anxious-phobic, inhibited and avoidant-sensitive temperaments, GAT seems to have a distinct profile with altruistic overtones; on the other hand, GAT is less easily distinguished from harm-avoidant and obsessive traits. That worrying would increase upon relaxation is not a paradox at all, and is understandable in an ethological perspective as subserving the defensive function of being vigilant of ever present yet uncertain external dangers--to oneself and one's kin--in day-to-day living. GAT can thus be considered as 'altruistic anxiety', subserving hypothetically the survival of one's extended phenotype in a 'kin selection' paradigm. Only when extreme does worrying manifest in a clinical context, impairing one's interpersonal life and functioning at work, and increasing use of general health care resources. Furthermore, generalized anxiety appears to predispose to and is often associated with depression, and a spectrum of phobic disorders, as well as alcohol and sedative use. These considerations place GAD (and the putative GAT) in the limelight and underscore the need for more research into its fundamental characteristics. Towards this aim, a self-rated GAT measure under development in our center is provided in an appendix to this paper.

DSM-IV and beyond: what is generalized anxiety disorder?

With the advent of DSM-III in the USA (1), a new disorder termed generalized anxiety disorder (GAD) was established separately from panic disorder. Because GAD was relegated to a residual category, it soon became a confusing diagnosis. Although revisions in DSM-III-R (2) removed GAD as a residual category, they also complicated the clinical examination necessary to arrive at a GAD diagnosis. With the publication of DSM-IV (3), GAD has been further refined in an attempt to improve the reliability and discriminability of the disorder. However, it continues to be controversial, and a number of issues remain unresolved.

Mixed Anxiety and Depression : Diagnosis and Treatment Options

Symptoms of anxiety and depression often appear together in patients, either as 2 discrete disorders, such as major depressive disorder and panic disorder, or as a combination of symptoms not meeting criteria for specific disorders. The social, economic, occupational and medical costs of such comorbid anxiety and depression can be enormous, affecting both the individual and society.The clinician must be creative when treating patients with mixed anxiety and depressive symptoms; psychopharmacological treatment can involve the use of a variety of mono- and polytherapies. Benzodiazepines can be effective in treating anxiety symptoms, but unwanted adverse effects limit their use to the short term. Tricyclic antidepressants, although proven to be effective in treating both anxiety and depressive symptoms, have numerous adverse effects, making them a second-choice therapy. Traditional monoamine oxidase inhibitors have proven efficacy in atypical depression, and the newer reversible and selective inhibitors of monoamine oxidase-A may prove to be very effective in treating both sets of symptoms. Of particular importance in the treatment of patients with anxiety and depressive symptoms are the selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors, nefazodone and the azapirones (including buspirone).

Characterizing generalized anxiety: temporal and symptomatic thresholds

We compared demographic and comorbidity profiles of subjects with varying levels of anxiety pathology to test if the clinical characteristics of generalized anxiety disorder (GAD) subjects differed from those of other subjects with generalized anxiety. Using Diagnostic Interview Schedule data from the 1993 follow-up study of the Baltimore cohort of the Epidemiologic Catchment Area Program, we divided subjects into the following five mutually exclusive symptom categories: a) DSM-III-R GAD; b) 6 months of worry or anxiety with six associated symptoms; c) 1 month of anxiety with or d) without six symptoms; and e) no anxiety. The first three groups were homogeneous with regard to demographic and comorbidity profiles, but their profiles differed from those of subjects with no anxiety or fewer than six symptoms. Thus, requiring six symptoms produced a group with a particular epidemiologic profile. Neither the nature of the subjects' worries nor the duration of symptoms influenced this profile. These results are discussed in terms of GAD's construct validity.

Sex differences in depression: a role for preexisting anxiety

The role of anxiety disorders in the development of sex differences in major depression is analyzed. Data come from a longitudinal epidemiologic study of young adults in the Detroit, Michigan area. The Diagnostic Interview Schedule, revised according to DSM-III-R, was used at baseline to measure lifetime psychiatric disorders and at follow-up to measure psychiatric disorders during the 3.5-year interval since baseline assessment. Consistent with previous reports, the lifetime prevalence of major depression was nearly two-fold higher in females than in males. The sex difference was primarily in major depression comorbid with anxiety disorders. Results from Cox-proportional hazards models, with time-dependent covariates, showed that prior anxiety disorder increased the risk for subsequent major depression in both sexes, with no evidence of an interaction. History of anxiety disorder, including number of prior anxiety disorders, accounted for a considerable part of the observed sex difference in major depression. Controlling for prior anxiety reduced by more than 50% the coefficient that estimates the association between gender and major depression. The results suggest that the higher occurrence of anxiety disorders in females than males beginning early in life might explain in large part the higher female risk for major depression. They emphasize the need for further research on sex differences in anxiety disorders.

The clinical characteristics of major depression as indices of the familial risk to illness

BACKGROUND

From both a clinical and an aetiological perspective, major depression (MD) is probably a heterogeneous condition. We attempt to relate these two domains.

METHOD

We examined which of an extensive series of clinical characteristics in 646 female twins from a population-based register with a lifetime diagnosis of MD predicts the risk for MD in co-twins. MD was defined by DSM-III-R criteria.

RESULTS

Four variables uniquely predicted an increased risk for MD in the co-twin: number of episodes, degree of impairment and co-morbidity with panic disorder or bulimia. One variable uniquely predicted decreased risk: co-morbidity with phobia. Variables that did not uniquely predict risk of MD in the co-twin included age at onset, number and kind of depressive symptoms, treatment seeking, duration of the longest episode and co-morbidity with generalised anxiety disorder and alcohol dependence.

CONCLUSIONS

Our results suggest that the clinical features of MD can be meaningfully related to the familial vulnerability to illness, particularly with respect to recurrence, impairment and patterns of co-morbidity.

Clinical characteristics of familial generalized anxiety disorder

The authors seek to determine whether the clinical characteristics of generalized anxiety disorder (GAD) differ in individuals with a high vs. low familial vulnerability to illness. We identified 486 personally interviewed female twins from a population-based register who had both an interviewed co-twin and a lifetime history of GAD using modified DSM-III-R criteria which required a one-month minimum duration of illness. We attempted to predict risk for GAD in the co-twin from the clinical features of the GAD in the proband twin using the Cox proportional hazard model, controlling for year of birth and zygosity. Only two variables uniquely predicted an increased risk for GAD in the co-twin: number of GAD symptoms endorsed and comorbidity with bulimia. Variables that did not uniquely predict risk of illness in the co-twin included age at onset, duration of the longest episode and number of episodes. The familial vulnerability to GAD can be meaningfully indexed by clinical features of the syndrome. These results suggest that if the syndrome of GAD is to be narrowed, it would, from a familial perspective, be more valid to increase the minimum number of required symptoms rather than to increase the minimum duration of illness.

Psychological treatment of generalised anxiety disorder. A review of the clinical significance of results in outcome studies since 1980

Comparative outcome studies of generalised anxiety disorder suggest that psychological therapy is a potentially valuable alternative to anxiolytic medication. However, on average psychological therapy results in modest improvements in symptoms, with about 50% of patients achieving normal functioning. Limited follow-up data indicate that these changes are maintained over six months. Cognitive therapy appears to be most effective, although comparisons with other therapies are limited and non-specific factors are clearly important. There is also evidence of considerable variability in outcome between studies, with the best results obtained with patients who are free of anxiolytic medication and recruited directly from primary care or other non-psychiatric settings. The effects on outcome of patient characteristics known to be associated with more severe illness and complexity of clinical presentation have yet to be explored. A balanced appraisal of the value of psychological therapy with this common condition requires a fuller description of sample characteristics and more systematic investigation of the clinical significance of treatment effects over the long term.

Anxiety disorders and anxiety symptoms in a clinic sample of seasonal and non-seasonal depressives

Thirty-eight patients with seasonal affective disorder (SAD) were compared with 33 non-seasonal recurrent major depressives (non-SAD) who presented during the winter months for differences in the prevalence of concurrent anxiety disorders and the impact of anxiety on treatment response. SAD patients received light therapy, whereas non-SAD patients received antidepressant medications. There was no differences in the prevalence of any anxiety disorder, or on scores of anxiety on the Hamilton Rating Scale for Depression between the SAD and non-SAD groups. The presence of any anxiety disorder was associated with a better response rate in SAD patients, and an inferior response rate in non-SAD patients. The findings refute previous suggestions that anxiety is more common in SAD than in non-SAD, but suggest that the presence of anxiety may be associated with differential treatment response rates.

The relationship between anxiety and depression: a clinical comparison of generalized anxiety disorder, dysthymic disorder, panic disorder, and major depressive disorder

This study examined the relationship between the chronic disorders, generalized anxiety disorder (GAD) and dysthymic disorder (DD), and the more acute disorders, panic disorder (PD) and major depressive disorder (MDD) in 110 psychiatric outpatients with diagnoses of either PD, MDD, GAD, or DD. Pure, mixed, and early-/late-onset forms of the chronic disorders were compared with each other and then with PD and MDD on clinical measures and psychiatric history. Minimal differences were found between pure GAD and mixed GAD or between pure DD and mixed DD. The chronic disorders, DD and GAD, had distinct clinical symptom profiles when compared with each other and appeared more closely related to their parent disorders than to each other. However, despite these similarities, there were significant differences between DD and MDD in contrast to the minimal differences between GAD and PD, providing less support for GAD as a valid diagnostic category separate from PD. Comparisons of early-/late-onset DD and GAD showed more severe symptoms in late-onset DD, in contrast to more severe symptoms in early-onset GAD. These varying patterns of symptom severity may warrant study for further syndromal delineation.

Relationship of anxiety and depression

There has been considerable controversy regarding the relationship between depression and anxiety. We review briefly the descriptive, longitudinal, genetic, biological, and treatment response data indicating that there is overlap between depression and anxiety. Several possible models are explored that provide different conceptions of how this relationship may best be understood: (1) that there are a variety of more or less discrete, but sometimes coexisting, syndromes within the spectrum of anxiety and depression; (2) that symptoms of depression and anxiety represent different external manifestations of a more basic underlying cause; (3) that one condition may predispose to the other; (4) that the association may be due to artifactual definitional overlap, particularly since the instruments used to measure depression and anxiety share so many items. All these propositions are supported. An important, practical question is discussed--should the mixed anxiety/depressive disorder that has been suggested by ICD-10 be included in DSM-IV?

Migraine, psychiatric disorders, and suicide attempts: an epidemiologic study of young adults

To determine the prevalence of migraine and the risks for psychiatric disorders and suicide attempts associated with it, we studied a random sample of 1,007 young adults from a large Health Maintenance Organization in the Detroit, MI area. The lifetime prevalence of migraine was 7% in males and 16.3% in females. The rate of migraine was higher in persons with lower education and was equal in whites and blacks. Persons with migraine were at increased risk for affective and anxiety disorders, nicotine dependence, and alcohol or illicit drug abuse or dependence. There was a consistent trend toward higher psychiatric comorbidity in migraine with aura than in migraine without aura. Coexisting anxiety, which generally preceded migraine, was associated with a marked increase in the odds of major depression. Persons with migraine had higher rates of suicide attempts than persons without migraine. The odds ratio for suicide attempts, adjusted for coexisting major depression and other psychiatric and substance use disorders, in migraine with aura was 3.0 (95% confidence interval, 1.4-6.6). The coexistence of migraine with major depression, anxiety disorders, and suicide attempts has important clinical and research implications.

Delimitation of generalized anxiety disorder: clinical comparisons with panic and major depressive disorders

We compared 40 outpatients with "pure" generalized anxiety disorder (GAD) with 152 panic disordered patients with varying degrees of phobic avoidance, and 241 primary major depressives with single and recurrent episodic patterns. Despite sociodemographic and symptomatologic overlaps with these comparison groups, GAD emerged as a relatively distinct disorder, characterized by chronic low-grade symptomatology with observed anxiety at interview, as well as nausea, headache, tension, and insomnia. These anxious "traits," which appear to be part of the habitual self of the patient, are subject to fluctuation over time, and may form the temperamental substrate or precursor of panic and other anxiety and depressive disorders.

Distinguishing anxiety and depression with field survey data

Data on self-reported symptoms collected in the East Baltimore site of the Epidemiologic Catchment Area Program are analysed in parallel fashion for the two syndromes of anxiety and depression. Patterns of relationships of anxiety and depression to sociodemographic factors, prior psychopathology, and life events fail markedly to distinguish the two syndromes.

Searching for evidence on the validity of generalized anxiety disorder: psychopathology in children of anxious mothers

The diagnostic validity of generalized anxiety disorder (GAD) is tested by examining the relationship between GAD in mothers and children's overanxious disorder (OAD), separation anxiety (SA), and anxious symptoms in 331 mother-child dyads from a geographically based probability sample. Data on the relationship between mothers' major depressive disorder (MDD) and children's depression are presented for comparison. The National Institute of Mental Health (NIMH) Diagnostic Interview Schedule (DIS) was used in mothers and the NIMH Diagnostic Interview Schedule for Children (DISC), in children. Children of mothers with GAD were not at increased risk for OAD, SA, or anxious symptoms. In contrast, MDD in mothers conferred a risk for OAD in younger children and of MDD in older children. Additionally, older children of depressed mothers exhibited significantly more depressive symptoms. The presence of diffuse anxiety in children of mothers with MDD may represent a nonspecific response pattern in psychiatrically vulnerable children. Like GAD in adults, these anxiety symptoms in children may constitute a prodromal manifestation of other disorders and transient responses to life stressors.

Schedule for Affective Disorders and Schizophrenia--Lifetime Version modified for the study of anxiety disorders (SADS-LA): rationale and conceptual development

The SADS-LA, a modification of the Lifetime Version of the Schedule for Affective Disorders and Schizophrenia, was designed specifically for studies requiring detailed lifetime information on anxiety disorders, symptoms and traits. This article focuses on current difficulties in assessing and conceptualizing anxiety disorders, as addressed in the SADS-LA. The following topics are discussed: conceptual differentiation of certain anxiety disorders; sub-threshold symptoms and syndromes; the relationship between affective and anxiety syndromes; the residual category, Generalized Anxiety Disorder. We emphasize a lifetime sequential approach to diagnostic assessment for a comprehensive understanding of the interrelationships between mental disorders.

Refining DSM-III criteria in Major Depression. An assessment of the descriptive validity of criterion symptoms

In this study we estimate the power of DSM-III Major Depression (MDD) symptoms to discriminate MDD from (1) Generalized Anxiety Disorder (GAD) and (2) no disorder. The NIMH-DIS was administered to 319 women exposed to chronic stress (all were mothers of disabled children). Two methods were used: (1) conditional probabilities, and (2) multiple regression analysis. Symptoms had greater utility in discriminating MDD from no disorder than from GAD. 'Gained weight' and 'thinking about death' had the least efficacy in either discrimination. 'Hypersomnia' and 'insomnia' contributed to the discrimination from no disorder, whereas 'fatigue' and 'sex disinterest' discriminated MDD from GAD. 'Guilt', 'trouble concentrating', 'lost appetite' and 'wanted to die' were important in both comparisons. Despite recent emphasis on observable behaviors and physiologic measures, guilt, a subjectively experienced inner state, was the most important symptom in MDD.

Depressive symptoms, major depression, and generalized anxiety: a comparison of self-reports on CES-D and results from diagnostic interviews

This study evaluates the validity of the Center for Epidemiologic Studies Depression Scale (CES-D) by comparing it to DSM-III diagnoses of major depression and generalized anxiety, using the National Institute of Mental Health Diagnostic Interview Schedule (DIS). Data were gathered on a sample of 310 mothers of children with chronic disabilities. The utility of the CES-D for detecting major depression was approximately equal to its utility for detecting generalized anxiety. Multivariate analysis revealed that the unique association of CES-D with current depression was equal to its association with current generalized anxiety and that the two disorders had additive effects on CES-D. The analysis did not identify any individual CES-D symptom as specific to either disorder. The findings, therefore, do not support the notion that the CES-D measures depression specifically.