Pathological worry, anxiety disorders and the impact of co-occurrence with depressive and other anxiety disorders

The Penn State Worry Questionnaire (PSWQ) was administered to 123 outpatients with principal diagnoses of generalized anxiety disorder (GAD), social anxiety disorder (SAD), panic disorder with agoraphobia, and panic disorder without agoraphobia (PD) to examine the specificity of pathological worry for GAD. The mean PSWQ scores in patients with GAD and SAD were significantly higher than the mean PSWQ scores in patients with PD, while not differing significantly in the subgroups without any co-occurring depressive or anxiety disorders. Patients with any co-occurring depressive or anxiety disorder scored significantly higher on the PSWQ. In a logistic regression analysis, high PSWQ scores independently predicted only GAD and SAD diagnoses. The study suggests that pathological worry is specific not only for GAD, and indicates that a significant relationship exists between pathological worry, GAD and SAD, and that depressive and anxiety disorders co-occurrence increases levels of pathological worry in patients with anxiety disorders.     

Intolerance of uncertainty and negative metacognitive beliefs as transdiagnostic mediators of repetitive negative thinking in a clinical sample with anxiety disorders

This study aimed to replicate and extend a hierarchical model of vulnerability to worry, with neuroticism and extraversion as higher-order factors and negative metacognitions and intolerance of uncertainty as second-order factors. The model also included a transdiagnostic measure of repetitive negative thinking (RNT) and depression symptoms as outcome variables to determine whether relationships would extend beyond worry, which has traditionally been studied within the context of generalized anxiety disorder (GAD). Participants (N = 99) were referrals to a specialist anxiety disorders clinic with a principal anxiety disorder who completed a battery of self-report questionnaires assessing neuroticism, extraversion, metacognitions, intolerance of uncertainty, worry, RNT, and depression symptoms. Mediational analyses using bootstrapping provided support for transdiagnostic and diagnosis-specific mediation effects. Negative metacognitions fully mediated the relationship between neuroticism and RNT for the whole sample and for subsamples with and without GAD. Intolerance of uncertainty mediated the relationship between neuroticism and worry (for the whole sample and for those with GAD) and between neuroticism and RNT (for those with GAD). Implications for theory, treatment, and nosology are discussed.     

A community-based epidemiological study of health anxiety and generalized anxiety disorder

This community-based study examined the frequency of worry about personal health in respondents with and without generalized anxiety disorder (GAD), and the impact of health anxiety on the disorder. A random community-based telephone survey of 5118 Chinese respondents aged 18–64 was conducted. A fully structured questionnaire covered the DSM-IV-TR criteria of GAD, major depressive episode (MDE), eight domains of worry, the seven-item Whiteley Index (WI-7), health service use, and socio-demographic information. Worry about personal health ranked fifth (75.6%) among eight domains of worries examined. GAD respondents with high level of health anxiety were significantly older, less educated, and had lower family income. High health anxiety significantly increased the occurrence of one-year MDE, previous persistent worry, previous persistent low mood, number of domains of worries, number of non-core DSM-IV-TR GAD symptoms, health service use, and mistrust of doctors. Health anxiety is common in GAD and may signify greater severity of the disorder.     

Characterization of worry according to severity of anxiety in elderly living in the community

The goals of this study were to analyse the characteristics of the phenomenon of worry in old age, to analyse differential characteristics of worry in the elderly according to severity of anxiety, and to explore the discriminative ability of different DSM-IV criteria for generalized anxiety disorder (GAD) to reveal the presence of this disorder. Starting from a randomized sample of 97 individuals, those 85 representing three levels of severity of the anxiety were retained: 74 non-clinical, four with sub-threshold anxiety and seven with GAD. They were assessed with different variables typically considered to be relevant for the analysis and characterization of worry. Results indicate that the most remarkable differences in contents of worry as a function of severity of anxiety occurred in the domains of worries about health and personal worries. Furthermore, elderly people with high levels of anxiety worry more frequently, and about more issues, and perceive less control over their worrying. Significant differences between groups in past and present orientation of worry were found. Worries were more frequent in GAD and they were oriented mainly towards the present and minor everyday problems in both GAD and non-clinical people. Moreover, worry about minor things together with the extent to which worry interferes in daily life were the best discriminant variables for GAD, being better than the core DSM-IV GAD criteria. We conclude that this pattern of results suggests that the potential of a specific worry to affect daily well-being and quality of life is strongly related to the presence of a disorder.     

A hierarchical model for the relationships between general and specific vulnerability factors and symptom levels of generalized anxiety disorder

The present study examined a hierarchical model for the relationships between general and specific vulnerability factors and symptom manifestations of generalized anxiety disorder (GAD). A clinical sample of patients with GAD (N = 137) completed a set of self-report questionnaires for measuring neuroticism, extraversion, intolerance of uncertainty, metacognitive beliefs, and symptoms of generalized anxiety (i.e., worry) and depression. A bootstrapping analysis yielded support for a model in which the relation between the general vulnerability factor of neuroticism and symptoms of GAD were mediated by the specific vulnerability factors of intolerance of uncertainty and negative metacognitions. Implications for the classification and treatment of GAD are discussed.     

A self-report diagnostic measure of generalized anxiety disorder

The present study tested the reliability of a self-report diagnostic measure of generalized anxiety disorder (GAD) based on DSM criteria. Among two samples of undergraduate students, 47–80% of the GAD diagnoses by questionnaire were confirmed by diagnostic interview, with the higher rate being associated with DSM-IV criteria. Categorization of a participant as Non-GAD by questionnaire was found to be 100% reliable by interview. Given these findings as well as prior empirical support for the validity of the measure, this questionnaire has utility for identifying analogue GAD and Non-GAD participants from undergraduate populations for use in preliminary investigations of the mechanisms and functions associated with chronic worry and GAD.     

Meta-cognitive profiles in anxiety disorders

This study had two distinct objectives. First, to examine the relationships between meta-cognitions and anxiety disorders. Second, to identify specific meta-cognitions as unique predictors of generalized anxiety (GAD), depression (DD) and obsessive–compulsive (OCD) disorders. A total of 180 cases were analyzed using the Meta-cognitions Questionnaire (MCQ), Anxious Thoughts Inventory (AnTI), and the Thought Control Questionnaire (TCQ). The results suggest that all the five types of negative metacognitive beliefs measured by the MCQ are significantly correlated with one another and with AnTI and TCQ scores except for cognitive self-consciousness, which failed to correlate with TCQ scores. Multivariate analysis revealed that the clinical cases differed from normal subjects in their beliefs about uncontrollability and danger, beliefs about cognitive competence, and general negative beliefs. Only OCD patients differed from both normal subjects and GAD patients in their cognitive self-consciousness. Health worry was elevated in GAD patients, while meta-worry was elevated in OCD patients. Furthermore, depressives tended to use worry while OCD patients tended to use distraction as meta-cognitive strategies to control intrusive and distressing thoughts. Discriminant analysis was performed with GAD, DD and OCD as dependent variables and the MCQ, AnTI and TCQ subscales as predictor variables. Overall the discriminant functions successfully predicted outcome for over 70% of cases. Findings provide support for the Self-Regulatory Executive Function model.     

Intolerance of uncertainty, hypochondriacal concerns, obsessive-compulsive symptoms, and worry

Intolerance of uncertainty (IU) has been found to be involved in several anxiety disorders, including generalized anxiety disorder and obsessive-compulsive disorder (OCD). Few studies have examined the role of IU in health anxiety (HA)/hypochondriacal concerns (HC). We conducted two studies exploring the associations between IU and HA/HC. The first study included undergraduates (n = 114) and indicated an association between IU and several HA/HC indices. When controlling for neuroticism, worry about illness was the single index of HA/HC that remained associated with IU. In the second study among bereaved adults (n = 126), IU was associated with one index of HA/HC but not when neuroticism and anxiety sensitivity were controlled. In both studies, IU was found to be more strongly associated with OCD symptoms and worry than with HA/HC.     

Further validation of a cognitive-behavioral model of generalized anxiety disorder: diagnostic and symptom specificity

The goal of this study was to investigate the diagnostic and symptom specificity of a model of GAD that has four main features: intolerance of uncertainty, positive beliefs about worry, poor problem orientation, and cognitive avoidance. The authors compared 17 patients with non-comorbid generalized anxiety disorder (GAD) to 28 patients with non-comorbid panic disorder with agoraphobia (PDA) and found that only intolerance of uncertainty showed evidence of diagnostic specificity, i.e., intolerance of uncertainty scores were higher in the GAD group relative to the PDA group. In terms of symptom specificity, when both groups were combined, all model variables were significantly related to worry but unrelated to fear of bodily sensations, agoraphobic cognitions, and behavioral avoidance. Taken together, these findings provide further support for the link between intolerance of uncertainty and GAD and underscore the importance of pursuing the issue of specificity from both a diagnostic and symptom perspective.     

Comparing anxiety disorders and anxiety-related traits in bipolar disorder and unipolar depression

The frequent comorbidity of anxiety disorders and mood disorders has been documented in previous studies. However, it remains unclear whether specific anxiety traits or disorders are more closely associated with unipolar major depression (MDD) or bipolar disorder (BPD). We sought to examine whether MDD and BPD can be distinguished by their association with specific types of anxiety comorbidity. Individuals with a primary lifetime diagnosis of either bipolar disorder (N=122) or major depressive disorder (N=114) received diagnostic assessments of anxiety disorder comorbidity, and completed questionnaires assessing anxiety sensitivity and neuroticism. The differential association of these anxiety phenotypes with MDD versus BPD was examined with multivariate modeling. Panic disorder and generalized anxiety disorder (GAD) specifically emerged amongst all the anxiety disorders as significantly more common in patients with BPD than MDD. After controlling for current mood state, anxiety sensitivity and neuroticism did not differ by mood disorder type. This study supports prior research suggesting a specific panic disorder-bipolar disorder connection, and suggests GAD may also be differentially associated with BPD. Further research is needed to clarify the etiologic basis of anxiety disorder/BPD comorbidity and to optimize treatment strategies for patients with these co-occurring disorders.     

The construct of generalized anxiety disorder in Alzheimer disease.

OBJECTIVES: The objectives of this study were to examine the criterion validity in Alzheimer disease (AD) of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and the International Classification of Diseases, 10th Revision (ICD-10) criteria for generalized anxiety disorder (GAD), to clarify the symptoms associated with excessive anxiety and worry in AD, to examine the co-occurrence of GAD and depression in these patients, and to determine the neuropsychologic and functional impact of GAD in AD. RESULTS: One hundred forty-four of a consecutive series of 552 patients with probable AD (26%) reported excessive anxiety and worry difficult to control for most of the 6 months before the psychiatric evaluation. Excessive anxiety and worry were significantly associated with restlessness, irritability, muscle tension, fears, and respiratory symptoms of anxiety. Using these symptoms as diagnostic criteria, 56 of the 552 patients (10%) met revised diagnostic criteria for GAD as compared with 15% when using DSM-IV criteria and 9% when using the ICD-10 criteria. GAD was present in 38 of the 144 patients (26%) with major depression and in 12 of the 261 patients (5%) without depression. Patients with both GAD and depression showed more severe cognitive deficits than patients with either GAD or depression only. CONCLUSION: The authors validated a set of diagnostic criteria for anxiety in dementia. These criteria include restlessness, irritability, muscle tension, fears, and respiratory symptoms in the context of excessive anxiety and worry. Anxiety in AD is a frequent comorbid condition of major depression.     

Intolerance of uncertainty and social anxiety

Research has shown that intolerance of uncertainty (IU)--the tendency to react negatively to situations that are uncertain--is involved in generalized anxiety disorder (GAD). There is uncertainty about the specificity of IU. Some studies have shown that IU is specific for GAD. Other studies have shown that IU is also involved in obsessive compulsive disorder (OCD). No studies have yet examined IU in social anxiety, although it is possible that IU plays a role in anxiety responses that can be experienced in social-evaluative situations. This study examined the relationship between IU and social anxiety among 126 adults. Findings revealed that IU explained a significant amount of variance in social anxiety severity when controlling for established cognitive correlates of social anxiety (e.g., fear of negative evaluation) and for neuroticism. Furthermore, it was found that IU was related with symptom levels of GAD, OCD, and social anxiety, but not depression, when controlling the shared variance among these symptoms.     

Cognitive-behavioral treatment of generalized anxiety disorder (GAD) for older adults

BACKGROUND: Generalized Anxiety Disorder (GAD) is one of the most prevalent anxiety disorders among the elderly. Estimates of prevalence vary from around 3% to 12%, depending on the minimum age considered and the assessment instruments. The present study tests a GAD-specific treatment recently validated among adults (Ladouceur et al., 2000) and adapted for older adults. METHOD: Eight older adults (aged from 60 to 71) were included in a single-case experimental multiple-baseline design across subjects. Assessments were conducted at pre-test, post-test and at 6- and 12-months follow-ups. The treatment consisted of awareness training, worry interventions and relapse prevention. The worry interventions targeted intolerance of uncertainty, beliefs about worry, problem-solving and cognitive avoidance. RESULTS: According to daily self-monitoring of worry, ADIS-IV ratings and self-reported questionnaire scores, seven out of eight participants showed clinically significant improvement at post-test. These therapeutic gains were maintained at 6- and 12-month follow-ups. CONCLUSIONS: This study shows that a cognitive-behavioral treatment that targets intolerance of uncertainty, erroneous beliefs about worry, poor problem orientation and cognitive avoidance is effective for treating GAD among elderly people.     

A study of the psychometric properties of the Obsessive Beliefs Inventory and Interpretations of Intrusions Inventory on clinical Italian individuals

Forty-three individuals with obsessive-compulsive disorder (OCD), 17 with generalized anxiety disorder (GAD) and 50 non-clinical controls (SC), completed the Italian versions of the Obsessive Beliefs Questionnaire (OBQ) and the Interpretations of Intrusions Inventory (III), along with measures of obsessive-compulsive (OC) symptoms, depression, anxiety and worry. OBQ and III showed an excellent reliability and temporal stability. The six OBQ subscales were reasonably distinct from each other, whereas the three subscales of the III were highly interrelated. The OBQ, and in less measure the III, discriminated between OCD, GAD, and normal controls. In the OCD cohort, the two instruments correlated moderately with a measure of obsessive-compulsive symptoms but also with a measure of worry. However, a linear regression analysis evidenced a specific relationship between the OBQ and obsessive-compulsive symptoms over and above worry. Overall, at least three cognitive domains (intolerance of uncertainty, excessive concern about the importance of controlling one's thoughts and perfectionism) seemed specific to OCD, whereas overimportance of thoughts and inflated responsibility barely discriminate clinically anxious individuals from non-clinical ones. It is concluded that OBQ and III are useful measures in Italian individuals and that more research is warranted to possibly refine these two instruments.     

Pathological worry in depressed and anxious patients

Anxious apprehension is present in all anxiety disorders and concerns have been raised that worry is not confined to Generalized Anxiety Disorder (GAD). The aims of the present project were three-fold. First, we reexamined whether the level of pathological worry is higher in patients with GAD than other anxiety disorders. Second, we compared worry scores of patients with "pure" GAD, "pure" MDD, and MDD with comorbid GAD. And third, to examine whether worry is specific to psychopathology in general rather than anxiety or depression, we included a control group (psychiatric outpatients without an affective or anxiety disorder). Twelve hundred outpatients were interviewed and completed the Penn State Worry Questionnaire (PSWQ) upon presentation for treatment. Patients with "pure" GAD had the highest scores. Depressed patients were similar to those with anxiety disorders other than GAD, and the control group showed worrying similar to that in general population and nonanxious samples.     

Anxiety, depression, and the content of worries.

Worry content as assessed by using a modified Worry Domains Questionnaire (WDQ) was compared among participants diagnosed with a depressive disorder, generalized anxiety disorder (GAD), and both a depressive disorder and GAD. A discriminant function analysis of worry domains yielded two significant functions. The worry domains Lack of Confidence, Aimless Future, Relationships, and Financial Concerns loaded significantly on Function 1, which was termed "Depressive Worries." The worry domain Loss of Control loaded significantly on Function 2, which was termed "Anxious Worries." The three participant groups differed in their pattern of worries in a way that lends support to the content-specificity hypothesis for both depression and anxiety. In addition, multiple regression analysis indicated that WDQ domain scores (in particular the Aimless Future domain) predicted the severity of depressive symptoms even after the variance contributed by anxiety symptoms was removed from the analysis. These findings suggest that the content of a person's worries may be significantly associated with the presence of depression, anxiety, or comorbid depression and anxiety.     

A cognitive model of generalized anxiety disorder.

A cognitive model of generalized anxiety disorder (GAD) is described. The model asserts that generalized anxiety is an abnormal worry state. In this model, GAD results from the usage of worrying as a coping strategy and subsequent negative evaluation of worrying. The use of worry as a strategy is supported by positive metabeliefs concerning worry, whereas the negative appraisal of worrying (worry about worry) is linked to negative metabeliefs developed out of previous experience. These beliefs center on the themes of uncontrollability of worries and the dangerous consequences of worrying. Negative appraisal of worrying is associated with behavioral and cognitive responses that serve to maintain unwanted thoughts, and preserve dysfunctional beliefs. A review of the literature indicates that the model is consistent with existing data. Predictions and treatment implications of the model are discussed.     

Comorbid generalized anxiety disorder in primary social phobia: symptom severity, functional impairment, and treatment response

As many as 50% of patients with a primary anxiety disorder may meet criteria for an additional anxiety disorder. However, there is insufficient research on the cooccurrence of the anxiety disorders, although investigations of this nature may facilitate our understanding of their cause, phenomenology, and treatment. The present study examined the occurrence of generalized anxiety disorder (GAD) among patients with social phobia (SP) compared with SP patients without GAD. Of 122 treatment-seeking patients meeting DSM-III-R criteria for SP, 29 (23.8%) also met criteria for an additional diagnosis of GAD. SP patients with comorbid GAD demonstrated greater severity on measures of social anxiety and avoidance, general anxiety, cognitive (but not somatic) symptoms of anxiety, depressed mood, functional impairment, and overall psychopathology. Group differences remained significant when comorbidity with other anxiety and mood disorders was controlled. The content of worry among the SP patients with GAD was not specific to social concerns and appeared similar to the reported content of worry in samples of patients with primary GAD. Nevertheless, SP patients with and without GAD responded similarly to cognitive-behavioral group therapy for social phobia. Implications for the understanding and treatment of comorbid SP and GAD are discussed.