Generalized anxiety disorder (ICD‐10) in primary care from a cross‐cultural perspective: a valid diagnostic entity?

OBJECTIVE: Generalized anxiety disorder (GAD) is a common psychiatric disorder. The nosological status of this diagnostic entity was critically discussed because of the very high rate of comorbidity with other psychiatric disorders, the assumed low degree of social disability associated with GAD in the absence of other disorders, and an ambigious definition. METHOD: We explored the frequency and associated social disability of GAD, and examined whether the ICD-10 definition of GAD is appropriate. The analysis was based on the WHO study on 'Psychological Problems in Primary Care' conducted in a standardized manner in 14 countries. RESULTS: We found GAD (total and without another psychiatric disorder) to be common in primary care in nearly all countries (mean 1-month prevalence rate, 7.9%), with about 25% of these cases presenting with GAD in the absence of any comorbid psychiatric disorder. GAD in general, as well as non-comorbid GAD, are associated with social disability which is as severe as that in chronic somatic diseases. CONCLUSION: It remains questionable whether the current ICD-10 diagnosis of GAD defining 6 months as a minimum duration and requiring at least four associated symptoms for diagnosis is the most appropriate option. Using this definition, a substantial proportion of psychosocially disabled subjects characterized by anxiety, tension and worrying remain undetected, and are possibly therefore not adequately treated.     

Generalized anxiety disorder: prevalence,burden, and cost to society

Generalized anxiety disorder (GAD) is a prevalent and disabling disorder characterized by persistent worrying, anxiety symptoms, and tension. It is the most frequent anxiety disorder in primary care, being present in 22% of primary care patients who complain of anxiety problems. The high prevalence rate of GAD in primary care (8%) compared to that reported in the general population (12-month prevalence 1.9-5.1%) suggests that GAD patients are high users of primary care resources. GAD affects women more frequently than men and prevalence rates are high in midlife (prevalence in females over age 35: 10%) and older subjects but relatively low in adolescents. The natural course of GAD can be characterized as chronic with few complete remissions, a waxing and waning course of GAD symptoms, and the occurrence of substantial comorbidity particularly with depression. Patients with GAD demonstrate a considerable degree of impairment and disability, even in its pure form, uncomplicated by depression or other mental disorders. The degree of impairment is similar to that of cases with major depression. GAD comorbid with depression usually reveals considerably higher numbers of disability days in the past month than either condition in its pure form. As a result, GAD is associated with a significant economic burden owing to decreased work productivity and increased use of health care services, particularly primary health care. The appropriate use of psychological treatments and antidepressants may improve both anxiety and depression symptoms and may also play a role in preventing comorbid major depression in GAD thus reducing the burden on both the individual and society.     

Prevalence and disability of comorbid social phobia and obsessive–compulsive disorder in patients with panic disorder and generalized anxiety disorder

Objective. Generalized anxiety disorder (GAD) and panic disorder (PD) are disabling conditions, often comorbid with other anxiety disorders. The present study was aimed to assess prevalence and related disability of comorbid social phobia (SP) and obsessive–compulsive disorder (OCD) in 115 patients with GAD (57) or PD (58). Methods. Patients were classified as having threshold, subthreshold, or no comorbidity, and related prevalence rates, as well as disability (Sheehan Disability Scale, SDS), were compared across diagnostic subgroups. Results. SP and OCD comorbidities were present in 30.4% of the sample, with subthreshold comorbidities present at twice the rate of threshold ones (22.6% vs. 11.3%). Compared with GAD patients, PD patients showed significantly higher subthreshold and threshold comorbidity rates (27.6% and 13.8% vs. 17.5% and 8.8%, respectively). Comorbid PD patients had higher SDS scores than the comorbid and non-comorbid GAD subjects. The presence of threshold SP comorbidity was associated with the highest SDS scores. Conclusions. SP and OCD comorbidities were found to be prevalent and disabling among GAD and PD patients, with higher subthreshold than threshold rates, and a negative impact on quality of life. Present findings stress the importance of a dimensional approach to anxiety disorders, the presence of threshold and subthreshold comorbidity being the rule rather than the exception.     

Objective assessment of personality disorder in chronic fatigue syndrome

OBJECTIVES: This study aims to objectively assess the prevalence and nature of personality disorders in depressed and nondepressed chronic fatigue syndrome (CFS) patients and compare this to depressed and healthy control groups. METHODS: Sixty-one patients attending a tertiary referral clinic with chronic fatigue syndrome, 40 psychiatric inpatients with depressive disorder and 45 healthy medical students completed the Structured Clinical Interview for DSM-III-R Diagnoses (SCID-II) in addition to providing routine clinical and demographic information. RESULTS: Thirty-nine percent of the CFS group, 73% of the depressed group and 4% of the healthy group were diagnosed with personality disorders. Cluster C disorders were the most common in both the CFS and depressed group. The depressed CFS patients had more Cluster B personality disorders than nondepressed CFS patients. Overall for CFS patients there was no association between mood state and personality disorder. CONCLUSIONS: High levels of personality disorder are found on objective assessment of CFS patients attending a teaching hospital clinic. This cannot be accounted for by comorbid depression.     

Quality of life in geriatric generalized anxiety disorder: a preliminary investigation

OBJECTIVE: To examine the impact of late-life generalized anxiety disorder (GAD) on health-related quality of life. METHOD: We compared quality of life in 75 treatment-seeking older adults with GAD, 39 of whom had psychiatric comorbidity, with 32 older adults without psychiatric illness. We examined predictors of quality of life in these samples. We also compared data from the GAD patients to published norms from a large national sample of older adults with chronic medical conditions or major depression. RESULTS: Older GAD patients reported worse health-related quality of life across most domains than asymptomatic older individuals. There were no differences in quality of life between GAD patients with and without psychiatric comorbidity, and comorbidity did not predict quality of life in multivariate regression analyses. Presence of GAD or symptoms of anxiety or depression were significantly related to impairment in every domain of quality of life. Comparisons with national norms suggest that older GAD patients report overall worse quality of life than individuals with recent acute myocardial infarction or type II diabetes, and are comparable in quality of life to individuals with major depression. CONCLUSION: Results suggest that late-life GAD is associated with substantial impairment in quality of life, and these findings cannot be explained by psychiatric comorbidity.     

Posttraumatic stress disorder, tenderness and fibromyalgia

The aims of the present study were to inquire into the prevalence of fibromyalgia syndrome, to assess nonarticular tenderness, to measure fibromyalgia syndrome-related symptoms, quality of life, and functional impairment among posttraumatic stress disorder (PTSD) patients as compared with control subjects. Furthermore, the differences between the PTSD patients with and without fibromyalgia syndrome were studied. Twenty-nine PTSD patients and 37 control subjects were assessed as to the diagnosis of fibromyalgia syndrome according to the American College of Rheumatology. Tenderness was assessed manually and with a dolorimeter. Fibromyalgia syndrome-related symptoms, quality of life, physical functioning, PTSD symptomatology, and psychiatric features were assessed by valid and reliable self-report inventories. Results showed that the prevalence of fibromyalgia syndrome in the PTSD group was 21% vs. 0% in the control group. Furthermore, the PTSD group was more tender than the control group. PTSD subjects suffering from fibromyalgia syndrome were more tender, reported more pain, lower quality of life, higher functional impairment and suffered more psychological distress than the PTSD patients not having fibromyalgia syndrome. It is suggested that previous reports on diffuse pain in PTSD in fact described undiagnosed fibromyalgia syndrome. The link between psychological stress and pain syndromes is emphasized.     

Personality disorders in somatization disorder patients: a controlled study in Spain

OBJECTIVE: The aim of this paper is to assess personality disorder (PD) comorbidity in somatization disorder (SD) patients compared with psychiatric controls in a Spanish sample. METHODS: This is a case-control study. Selection of 70 consecutive SD patients was made, and an age-, sex-, and ethnic-group-matched control group of 70 mood and/or anxiety disorder patients recruited in psychiatric outpatient clinics was selected. PDs were measured using the International Personality Disorder Examination, and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Axis I morbidity was measured by means of the Standardized Polyvalent Psychiatric Interview. RESULTS: PD comorbidity in SD patients was 62.9%, compared to 28.2% in controls [odds ratio (OR)=3.7; 95% confidence interval (95% CI)=1.8-7.6]. The highest ORs of PD in SD patients, compared with controls, were for paranoid (OR=9.2; 95% CI=1.9-43), obsessive-compulsive (OR=6.2; 95% CI=1.2-53.6), and histrionic (OR=3.6; 95% CI=0.9-13.9) PDs. CONCLUSIONS: This is a controlled study with the largest sample of SD patients. The prevalence of PD comorbidity is similar to that of a previously published controlled study but is different from those of the most frequent PD subtypes.     

Psychiatric comorbidity in patients with spasmodic dysphonia: a controlled study

Objectives

To study the prevalence of psychiatric comorbidity assessed by a structured clinical interview in patients with spasmodic dysphonia (SD) compared with patients suffering from vocal fold paralysis (VFP).

Methods

In 48 patients with SD and 27 patients with VFP, overall psychiatric comorbidity was studied prospectively using the Structured Clinical Interview for DSM‐IV Axis I disorders. Physical disability and psychometric variables were assessed with standardised self‐rating questionnaires.

Results

41.7% of SD subjects and 19.5% of the control group met DSM‐IV clinical criteria for current psychiatric comorbidity (p<0.05). Significant predictors of psychiatric comorbidity in SD were severity of voice impairment and subjective assessment of “satisfaction with health”. As a limitation, the severity of voice impairment in patients with SD was nearly twice as high, and their illness had lasted nearly twice as long.

Conclusions

We found a high prevalence of psychiatric comorbidity in patients with SD. The significant correlation between current psychiatric comorbidity and the extent of voice pathology may point to an especially strong interaction between somatic and psychiatric complaints in SD.Adductor spasmodic dysphonia (SD), a chronic voice disorder, leads to a characteristic strained and strangled voice.¹ SD is regarded as a form of primary focal dystonia.² The aim of the study was to evaluate the prevalence of psychiatric comorbidity in patients with SD assessed by a structured clinical interview. We hypothesised that psychiatric comorbidity would be significantly higher in such patients than in those suffering from vocal fold paralysis (VFP) resulting from a lesion of the laryngeal nerve after surgery.     

Psychiatric comorbidity and hostility in patients with psychogenic nonepileptic seizures compared with somatoform disorders and healthy controls

PURPOSE: To investigate the prevalence of psychiatric comorbidity and level of anxiety, depression, and aggression in patients with psychogenic nonepileptic seizures compared with those in patients with somatoform disorders and healthy controls. METHODS: Twenty-three patients with psychogenic nonepileptic seizures (PNESs) and 23 age- and sex-matched patients with somatoform disorders (SDs) underwent a clinical and a semistructured psychiatric interview (MINI) and filled in the Hospital Anxiety and Depression scale (HAD) and the Aggression Questionnaire (AQ). Twenty-three sex- and age-matched controls without psychopathology also underwent a clinical interview and completed the HAD and AQ. RESULTS: PNES reported more minor head injuries in the past than did the two comparison groups, and more unspecific EEG dysrhythmias were observed on EEG. Twenty-one PNES patients and 18 with SDs had comorbid psychiatric diagnoses. However, the mean number of comorbid psychiatric diagnoses was higher in the PNES group (1.9 +/- 0.3 compared with 1.5 +/- 0.5 in the SD group; p = 0.003). Ten PNES patients additionally had a somatoform pain disorder, and seven had an undifferentiated somatoform disorder. Both patient groups reported significantly higher levels of anxiety, depression, and anger than did the healthy controls, but the PNES patients had significantly higher level of hostility than both comparison groups. CONCLUSIONS: Increased psychiatric comorbidity is known to be associated with poorer response to regular interventions, and hostility is associated with more hostile coping patterns, often interfering with treatment compliance. Thus the increased prevalence of soft neurologic signs and comorbid psychiatric disorders and increased hostility as well in the PNES group, emphasizes that assessment and treatment of patients with PNES referred to a tertiary center requires an integrated approach involving both neurologic and psychiatric resources.     

Anxiety comorbidity in referred children and adolescents with dysthymic disorder.

Anxiety disorders are common in patients with depressive disorders. This preliminary study investigated some clinical correlates of comorbidity between dysthymic disorder (DD) and generalized anxiety disorder (GAD) in a clinically referred sample of children and adolescents. After psychiatric evaluation, including a diagnostic clinical interview (DICA-R), 51 patients (25 males and 26 females, mean age 13.1 years) with an index diagnosis of DD associated with GAD were compared with 22 patients (13 males and 9 females, mean age 12.9 years) diagnosed as having pure DD. The comparison between subjects (DD with or without GAD) regarding the number of depressive symptoms did not show a significant main effect of group. Suicidal ideation was significantly more frequent in the group with comorbid GAD. Internalizing disorders were more frequent in the group of DD with GAD, while externalizing disorders were more frequent in the group without GAD. Functional impairment, assessed with the Children's Global Assessment Scale, did not show significant differences between the two groups. Data are discussed in the light of conceptualizations about the relationship between chronic anxiety and depressive disorders.     

One-year prevalence of subthreshold and threshold DSM-IV generalized anxiety disorder in a nationally representative sample

Several studies of representative populations have reported prevalence rates of DSM-III and DSM-III-R generalized anxiety disorder (GAD); however, no community study has examined the effect of the stricter DSM-IV criteria on prevalence estimates and patterns of comorbidity. Furthermore, past studies based on "lifetime" symptom assessments might have led to upper-bound 1-year and point prevalence estimates. Data is presented from a national representative sample study of 4,181 adults in Germany, 18-65 years old, who were interviewed for DSM-IV disorders with the 12-month version of the Munich-Composite International Diagnostic Interview. The prevalence rate of strictly defined, 12-month threshold DSM-IV GAD was estimated to be 1.5%; however, 3.6% of respondents presented with at least subthreshold syndromes of GAD during the past 12 months. Higher rates of worrying and GAD were found in women (worrying 10%, GAD 2.7%) and in older respondents (worrying 9.3%, TAD 2.2%). Taking into account a wider scope of diagnoses than previous studies, a high degree of comorbidity in GAD cases was confirmed: 59.1% of all 12-month GAD cases fulfilled criteria for major depression, and 55.9% fulfilled criteria for any other anxiety disorder. In conclusion, prevalence and comorbidity rates found for DSM-IV GAD are not substantially different from rates reported for DSM-III-R GAD. The minor differences in our findings compared to previous reports are more likely attributable to differences in study methodology rather than changes in diagnostic criteria for DSM-IV.     

Differences between patients with chronic fatigue syndrome and with chronic fatigue at an infectious disease clinic in Stockholm,Sweden

Background data were collected from patients presenting with fatigue at the clinic of infectious diseases at Huddinge University Hospital, Stockholm. The main purpose was to look for differences as to demographic and functional status for patients fulfilling criteria for chronic fatigue syndrome (CFS) and chronic fatigue (CF). A cross-sectional questionnaire survey was performed using a variety of instruments. A thorough medical investigation was performed. No difference was found as to social situation, occupation and illness attributions for patients in the two categories. Patients with CFS reported in general a higher degree of 'sickness' with more self-reported somatic symptoms, more self-reported functional impairment and more absence from work. A higher degree of psychiatric comorbidity was observed in CF than in CFS patients. A majority of CFS patients (80%) had an acute infectious onset compared to 43% in the CF group. Presently used criteria might, according to findings presented here, define two different patient categories in a population characterized by severe, prolonged fatigue. Because CFS patients (compared to patients with CF) have more somatic symptoms, more often report an infectious, sudden onset and have less psychiatric comorbidity, and CF patients seem to have more of an emotional, burn-out-like component one could speculate about the existence of different pathogenetic backgrounds behind the two diagnoses.     

The relation of sleep difficulties to fatigue, mood and disability in chronic fatigue syndrome

The relationship of sleep complaints to mood, fatigue, disability, and lifestyle was examined in 69 chronic fatigue syndrome (CFS) patients without psychiatric disorder, 58 CFS patients with psychiatric disorder, 38 psychiatric out-patients with chronic depressive disorders, and 45 healthy controls. The groups were matched for age and gender. There were few differences between the prevalence or nature of sleep complaints of CFS patients with or without current DSM-IIIR depression, anxiety or somatization disorder. CFS patients reported significantly more naps and waking by pain, a similar prevalence of difficulties in maintaining sleep, and significantly less difficulty getting off to sleep compared to depressed patients. Sleep continuity complaints preceded fatigue in only 20% of CFS patients, but there was a strong association between relapse and sleep disturbance. Certain types of sleep disorder were associated with increased disability or fatigue in CFS patients. Disrupted sleep appears to complicate the course of CFS. For the most part, sleep complaints are either attributable to the lifestyle of CFS patients or seem inherent to the underlying condition of CFS. They are generally unrelated to depression or anxiety in CFS.     

Psychiatric comorbidity in patients with pediatric bipolar disorder – A systematic review

Background

A growing body of evidence suggests that pediatric bipolar disorder (PBD) frequently co-occurs with comorbid psychiatric disorders that may impact functioning.

Objective

To review existing literature on the prevalence of psychiatric comorbidity and general functioning in patients with a primary diagnosis of PBD.

Methods

We performed a systematic literature search on the PubMed, Embase and PsycInfo databases on November 16th, 2022. We included original papers on patients ≤18 years with primary PBD and any comorbid psychiatric disorder, diagnosed according to a validated diagnostic tool. Risk of bias of the individual studies was assessed using the STROBE checklist. We calculated weighted means to assess the comorbidity prevalence. The review complied with PRISMA statement guidelines.

Results

Twenty studies with a total study population of 2722 patients with PBD were included (mean age = 12.2 years). We found an overall high prevalence of comorbidity in patients with PBD. The most common comorbidities were attention-deficit-hyperactivity disorder (ADHD) (60%) and oppositional defiant disorder (ODD) (47%). Anxiety disorders, obsessive–compulsive disorder, conduct disorder, tic disorders and substance-related disorders affected between 13.2% and 29% of patients, while one in 10 had comorbid mental retardation or autism spectrum disorder (ASD). The prevalence of comorbid disorders was lower in studies that assessed the current prevalence in patients in full or partial remission. General functioning was overall not specifically decreased in patients with comorbidity.

Conclusions

Comorbidity across a broad range of disorders was high in children diagnosed with PBD, especially regarding ADHD, ASD, behavioral and anxiety disorders including OCD. Future original studies should assess current prevalence of comorbidities in patients with PBD who are in remission to obtain more reliable estimates of psychiatric comorbidity in this patient group. The review highlights the clinical and scientific importance of comorbidity in PBD.     

Prevalence of social phobia and its comorbidity with psychiatric disorders in Iran

This study explored the prevalence of social phobia (SP) in the general population of Iran, the sociodemographic characteristics of subjects with SP, and its comorbidity with the other lifetime psychiatric disorders. Our study was part of the nationwide study on the prevalence of psychiatric disorders in Iran. Overall, 25,180 Iranian subjects, age 18 years and over, from urban and rural areas of Iran were selected by a clustered random sampling method and interviewed face-to-face by 250 trained clinical psychologists using DSM-IV diagnostic criteria. Out of 12,398,235 households, 7,795 households in the form of 1,559 clusters of five households were selected. The statistical framework was based on the household lists available from the Department of Health in the provinces. The response rate was 90%. The lifetime prevalence of SP was 0.82%. The rate was 0.4% in males and 1.3% in females. The rate was higher in younger age groups and widows/widowers. It was not related to educational level and residential area. Specific phobia (66.7%), obsessive-compulsive disorder (17.4%), major depressive disorder (15%), and panic disorder (12.1%) were the most common lifetime psychiatric disorders among subjects with SP. The rate of SP in Iran is more similar to that in other Asian countries, and it is lower than that in Western countries. The rate of other psychiatric disorders among subjects with SP is more than that in the general population, and the most common psychiatric disorders were the other anxiety disorders and major depressive disorder.     

Adult Attention Deficit Hyperactivity Disorder in an Anxiety Disorders Population

Adult Attention Deficit Hyperactivity Disorder (ADHD) is a life‐long, chronic disorder, which has its onset in childhood and is associated with significant functional impairment. ADHD appears to be highly comorbid with other psychiatric disorders, however, literature is lacking concerning ADHD/anxiety comorbidity. To that end, we examined the prevalence of ADHD in an anxiety disorder sample. Consecutive patients referred to an anxiety disorders clinic completed a variety of anxiety disorder self‐report measures as well as the Adult ADHD self‐report scale and were clinically assessed using the Structured Clinical Interview for DSM‐IV, and the ADHD module of the Mini International Neuropsychiatric Interview. Of the 129 patients assessed, the rate of adult ADHD was 27.9%. The mean age of the sample was 33.1 ± 12.5 years, and the mean baseline CGI‐S was 4.6 ± 1.1 (moderate to marked severity). The majority of the sample was female (63.6%) and single (49.5%). The most common comorbid disorders associated with ADHD were major depressive disorder (53.8%), social phobia (38.5%), generalized anxiety disorder (23.1%), and impulse control disorders (30.8%). Individuals with ADHD had higher symptom severity scores for obsessive‐compulsive disorder, (P≤ 0.05) and for GAD (P≤ 0.05) and reported a significantly earlier age of onset for depression as compared to those without (P≤ 0.05). The prevalence of adult ADHD was higher in our anxiety disorders clinic sample than found in the general population. Clinical implications of these findings are discussed.     

The relation of psychogenic excoriation with psychiatric disorders: a comparative study

Psychogenic excoriation (PE), characterized by excessive scratching or picking of the skin, is not yet recognized as a symptom of a distinct DSM-IV disorder. It is a chronic disorder with a high rate of psychiatric comorbidity. The purpose of this study was to compare patients diagnosed with PE and patients with another dermatological disease in terms of comorbid psychiatric disorders. Thirty-one consecutive subjects were recruited from an outpatient dermatology clinic. The control group was composed of 31 patients with chronic urticaria. All subjects were interviewed using the Structured Clinical Interview for DSM-III-R (SCID-I), Beck Depression Inventory (BDI), Hamilton Anxiety Rating Scale (HARS), and Yale-Brown Obsession and Compulsion Scale (Y-BOCS) and also completed a semistructured questionnaire. Current major depressive syndrome was the most common psychiatric disorder in the PE group. There was a statistically significant difference between the two groups in terms of current major depressive syndrome (PE group 58.1%, control group 6.5%, P<.01). In the PE group, 45.2% of subjects were diagnosed with obsessive compulsive disorder (OCD), while the rate of OCD was only 3.7% in the control group (P <.01). The PE group scored significantly higher on the BDI, HARS, and Y-BOCS. The results of this study point to the close relationship of PE to depression and OCD.     

Axis I and Axis II psychiatric disorders in patients with fibromyalgia

ObjectiveTo determine the current prevalence of Axis I and Axis II psychiatric disorders in patients with fibromyalgia.MethodThe study sample includes 103 patients with fibromyalgia and 83 control subjects. Axis I and Axis II disorders were determined by structured clinical interviews.ResultsThe rate of any Axis I psychiatric disorder (47.6% vs. 15.7%), major depression (14.6% vs. 4.8%), specific phobia (13.6% vs. 4.8%), any Axis II disorder (31.1% vs. 13.3%), obsessive–compulsive (23.3% vs. 3.6%) and avoidant (10.7% vs. 2.4%) personality disorders were significantly more common in the patient group compared to the control group.ConclusionOur results suggest that a considerable proportion of patients with fibromyalgia also present with Axis I and Axis II psychopathologies.     

The adjustment to illness in patients with generalized anxiety disorder is poorer than that in patients with end-stage renal disease

Although generalized anxiety disorder (GAD) is associated with significant occupational disability, it has, however, received little attention with regard to adjustment to illness. Subjects included 102 chronic dialysis (CD) patients, 58 kidney transplant (KT) patients, and 42 GAD patients. The evaluations included the Psychosocial Adjustment to Physical Illness Scale (PAIS), the Hamilton Anxiety Rating Scale (HAM-A) and the Hamilton Depression Rating Scale (HAM-D). Preanxiolytic treatment GAD patients had the most anxiety and depressive symptoms, followed by CD patients and KT patients. KT patients and anxiolytic-treated GAD patients showed similar anxiety and depressive symptoms. These two groups were both better than CD patients. However, the adjustment to illness of GAD patients after treatment is still worse than the other two groups (108.0+/-16.3(GAD), 102.0+/-14.5(CD), 81.4+/-22.2(KT); P<.001). The CD patients had a high rate of psychiatric morbidity and a low rate of psychiatric intervention (3%); however, end-stage renal disease (ESRD) patients received only one assessment while the GAD group received two in this study. In light of the chronicity of GAD, pharmacological treatment is not sufficient by itself. Clinicians should keep these in mind when treating either GAD or ESRD.