Anxiety symptoms in Chinese and German adolescents: their relationship with early learning experiences, perfectionism, and learning motivation

The main aim of this study was to compare the frequency and correlates of DSM-IV anxiety disorder symptoms among non-referred adolescents in Germany and in Hong Kong. A total of 1,022 adolescents (594 from Germany and 428 from Hong Kong) between the ages of 12 and 17 years were investigated. Results showed that adolescents in Hong Kong reported significantly higher levels of anxiety symptoms than adolescents in Germany. Anxiety symptoms showed different correlates in different cultures. Specifically, academic motivational goals to compete to get good grades and to be rewarded for their performance correlated significantly with anxiety symptoms in Hong Kong. In Germany, anxiety symptoms correlated significantly with reinforcement received for anxiety-related problems (i.e., instrumental learning) and with parental verbal transmission about the danger of anxiety (i.e., informational learning). The findings underscore the importance of cultural factors on adolescent's anxiety.     

Comorbidity of anxiety disorders in patients with remitted bipolar disorder

Comorbidity between bipolar disorder and anxiety disorders has attracted considerable attention in recent years. However, a majority of the earlier studies examined anxiety disorders in acutely ill patients resulting in a possible confounding effect of the affective episodes. This study examines the prevalence of anxiety disorders in remitted bipolar subjects recruited from a psychiatric hospital in India and their effect on the severity of bipolar illness. A total of eighty remitted DSM-IV adult bipolar subjects and 50 non-psychiatric controls were recruited over a 10-month period. They were evaluated using a structured interview and various scales. The effect of anxiety disorders on bipolar severity was analyzed using multiple regression analyses. Anxiety disorders were highly prevalent in bipolar subjects compared to controls (49 [61%] vs. 7 [14%], χ² = 28.01, P < 0.001). Commonest lifetime anxiety disorder was obsessive-compulsive disorder (35%). Lifetime anxiety disorder had significant effect on all four indices of severity of illness, that included (1) percentage of time spent in episodes (Beta = 18.67, SE = 5.11, P < 0.001), (2) maximum period of continuous euthymia in the preceding 2 years (Beta = −5.26, SE = 1.71, P = 0.003), (3) presence of psychosis (Beta = 3.22, SE = 1.02, P = 0.002), and 4) response to mood stabilizers (Beta = −2.11, SE = 0.76, P = 0.006). The findings of this study confirm previous observations of the high prevalence and negative impact of comorbid anxiety disorders in bipolar disorder and also demonstrate that the findings are similar in culturally diverse settings. Future studies should systematically examine the various treatment options for anxiety disorders in bipolar patients. It is also necessary to examine the neurobiological and family/genetic correlates of anxious bipolar subjects to validate if they are a subgroup of bipolar disorders.     

Supplementary dimensional assessment in anxiety disorders

Anxiety disorders, as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), comprise a relatively heterogeneous group of clinical conditions that range from specific phobias to obsessive compulsive disorder (OCD) and post-traumatic stress disorder (PTSD). The grouping under one heading refers to the fact that these seemingly heterogeneous disorders share a number of common psychopathological features and also share at least some common principles in treatment. Among the shared elements are broadly defined prototypical anxiety reactions, panic attacks, anticipatory anxiety, avoidance behaviour, a predominantly early onset, and relatively high persistence rates over time. Many of the shared diagnostic features of anxiety disorders are by their nature dimensional, and hundreds of psychometric scales have been developed to measure these diagnostic constructs across anxiety disorder and for specific diagnostic classes. This paper explores different types of dimensional approaches used in the literature and discusses how an integrated categorical/dimensional strategy might enhance the usefulness of the DSM-V. We suggest the use of cross-cutting dimensional ratings that might ultimately lead to an improved classification model. We also suggest that a staging approach to illness, based upon supplementary dimensional rating could provide useful information for clinical and research purposes.     

Comorbidity of the anxiety disorders in a community-based older population in The Netherlands

OBJECTIVE: The aim of the study was to investigate patterns of comorbidity among the anxiety disorders in a community-based older population, and the relationship of these disorders with major depression, use of alcohol and benzodiazepines, cognitive impairment and chronic somatic illnesses. METHOD: The data were derived from the Longitudinal Aging Study Amsterdam (LASA) study. A two-stage screening design was adopted to identify respondents with anxiety disorders. RESULTS: In total, 10% of the elderly with an anxiety diagnosis suffered from two or more anxiety disorders. Major depression (13% vs. 3%), benzodiazepine use (24% vs. 11%) and chronic somatic diseases (12% vs. 7%) were significantly more prevalent in respondents with an anxiety disorder than in respondents without anxiety disorders. Heavy or excessive alcohol intake (5% vs. 4%) and cognitive impairment (11% vs. 13%) were not significantly associated with any anxiety disorder. CONCLUSION: When anxiety disorders are diagnosed, in older people there is a relatively high probability of comorbid conditions being present.     

Prevalence and relationship to delusions and hallucinations of anxiety disorders in schizophrenia

We investigated the prevalence of anxiety disorders in a sample of individuals with chronic schizophrenia, controlling for anxiety symptoms that may be related to delusions and hallucinations, and the possible differences in clinical variables between the groups. Individuals with a diagnosis of schizophrenia and able to give informed consent were recruited from the community. The Mini International Neuropsychiatric Interview (MINI) was administered to both confirm the DSM-IV diagnosis of schizophrenia and screen for comorbid anxiety disorders. If a comorbid anxiety disorder was found, its relation to the individual's delusions and hallucinations was examined. Clinical rating scales for schizophrenia were administered as well as rating scales for specific anxiety disorders where appropriate. Overall, anxiety disorders ranged from 0% [ for Post Traumatic Stress Disorder (PTSD)] to 26.7% [ for generalized anxiety disorder (GAD) and agoraphobia without panic] with lower rates when controlled for anxiety symptoms related to delusions and hallucinations. In investigating clinical variables, the cohort was initially divided into schizophrenics with no anxiety disorders and those with an anxiety disorder; with further analyses including schizophrenics with anxiety disorders related to delusions and hallucinations and those with anxiety disorders not related to delusions and hallucinations. The most consistent difference between all the groups was on the PANSS-G subscale. No significant differences were found on the remaining clinical variables. Comorbid anxiety disorders in schizophrenia can be related to the individual's delusions and hallucinations, though anxiety disorders can occur exclusive of these positive symptoms. Clinicians must be aware that this comorbidity exists in order to optimize an individual's treatment.     

Frequency and clinical correlates of adult separation anxiety in a sample of 508 outpatients with mood and anxiety disorders

Pini S, Abelli M, Shear KM, Cardini A, Lari L, Gesi C, Muti M, Calugi S, Galderisi S, Troisi A, Bertolino A, Cassano GB. Frequency and clinical correlates of adult separation anxiety in a sample of 508 outpatients with mood and anxiety disorders. Objective: To evaluate the frequency and clinical correlates of adult separation anxiety disorder in a large cohort of patients with mood and anxiety disorders. Method: Overall, 508 outpatients with anxiety and mood disorders were assessed by the structured clinical interview for diagnostic and statistical manual (IV edition) axis I disorders for principal diagnosis and comorbidity and by other appropriate instruments for separation anxiety into adulthood or childhood. Results: Overall, 105 subjects (20.7%) were assessed as having adult separation anxiety disorder without a history of childhood separation anxiety and 110 (21.7%) had adult separation anxiety disorder with a history of childhood separation anxiety. Adult separation anxiety was associated with severe role impairment in work and social relationships after controlling for potential confounding effect of anxiety comorbidity. Conclusion: Adult separation anxiety disorder is likely to be much more common in adults than previously recognized. Research is needed to better understand the relationships of this condition with other co‐occurring affective disorders.     

The relationship between anxiety disorders and physical disorders in the U.S. National Comorbidity Survey

Although depression has clearly been shown to be associated with physical disorders, few studies have examined whether anxiety disorders are independently associated with medical conditions after adjusting for comorbid mental disorders. We examined the relationship between anxiety disorders and a wide range of physical disorders in a nationally representative sample. Data came from the National Comorbidity Survey (N=5,877, range=age 15-54 years, response rate=82.4%). The Composite International Diagnostic Interview [Kessler et al., 1998] was used to make DSM-III-R [American Psychiatric Association, 1987] mental disorder diagnoses. Physical disorders were assessed based on a list of several conditions shown to respondents. All analyses utilized multiple logistic regression to examine the relationship between past-year anxiety disorder diagnosis and past-year chronic physical disorder. Anxiety disorders were positively associated with physical disorders even after adjusting for mood disorders, substance-use disorders, and sociodemographics. Among respondents with one or more physical disorders, a comorbid anxiety disorder diagnosis was associated with an increased likelihood of disability even after adjusting for severity of pain, comorbid mood, and substance use disorders. Among specific anxiety disorders, posttraumatic stress disorder, panic attacks, and agoraphobia were more likely to be associated with specific physical disorders than generalized anxiety disorder, social phobia, or simple phobia. There is a strong and unique association between anxiety disorders and physical disorders. Clinically, the presence of an anxiety disorder among patients with physical disorders may confer a greater level of disability.     

Frequency and patterns of mental health services utilization among adolescents with anxiety and depressive disorders

The main aim of this study was to examine the frequency and patterns of mental health services utilization among 12- to 17-year-old adolescents with anxiety and depressive disorders. Another aim was to examine the factors associated with the use of mental health services. The study population comprised 1,035 adolescents randomly recruited from 36 schools. Anxiety and depressive disorders were coded based on DSM-IV criteria using the computerized Munich version of the Composite International Diagnostic Interview. Only 18.2% of the adolescents who met DSM-IV criteria for anxiety disorders, and 23% of those with depressive disorders, used mental health services. Among adolescents with anxiety disorders, mental health services utilization was associated with past suicide attempt, older age, the presence of comorbid disorders, as well as parental anxiety and depression. The only factor that predicts the use of mental health service among adolescents with depressive disorder was a history of suicide attempt. The implication of the results in terms of tailoring services for children and adolescents with anxiety and depressive disorders are discussed.     

Comorbid depression, but not comorbid anxiety disorders, predicts poor outcome in anxiety disorders

Influence of type of comorbidity was studied over the course of 1 year in a sample of 141 outpatients with panic disorder with or without agoraphobia and generalized anxiety disorder, who were receiving different forms of cognitive behavior therapy. Influence of type of comorbidity was determined on the basis of change scores (linear regression analysis) and remission data (Kaplan-Meier survival analysis). Three categories, as assessed at baseline, were compared: no comorbidity, comorbidity among anxiety disorders, and comorbidity with mood disorders. Primary outcome variable: State-Trait Anxiety Inventory State subscale measured at four assessments (0, 12, 24, and 52 weeks). Analyses of change and remission indicated that comorbidity with mood disorders led to (i) less improvement and (ii) a lower remission rate than comorbidity among anxiety disorders and no comorbidity. Because comorbidity has a critical influence on prognosis, it seems to be important to make a reliable diagnosis of the disorders present.     

Frequency of panic attacks and panic disorder in adolescents

By using data from the Bremer Adolescent Study, this report presents findings on the frequency, comorbidity, and psychosocial impairment of panic disorder and panic attacks among 1,035 adolescents. The adolescents were randomly selected from 36 schools in the province of Bremen, Germany. Panic disorder and other psychiatric disorders were coded based on DSM-IV criteria using the computerized-assisted personal interview of the Munich version of the Composite International Diagnostic Interview. Panic disorder occurred rather rare, with only 0.5% of all the adolescents met the DSM-IV criteria for this disorder sometimes in their live. Panic attack occurred more frequently, with 18% of the adolescents reported having had at least one panic attack. Slightly more girls than boys had panic attack and panic disorder. The occurrence of panic attack and panic disorder were the greatest among the 14–15 year olds. The experience of having a panic attack was associated with a number of problems, the most frequent being avoiding the situation for fear of having another attack. Four most common symptoms associated with a panic attack were that of palpitations, trembling/shaking, nausea or abdominal distress, and chills or hot flushes. Panic disorder comorbid highly with other psychiatric disorders covered in our study, especially with that of major depression. Among those with a panic disorder, about 40% of them were severely impaired during the worst episode of their illness. Only one out of five adolescents with panic disorder sought professional help for emotional and psychiatric problems. The implication of our findings for research and clinical practice are discussed. Depression and Anxiety 9:19–26, 1999. © 1999 Wiley-Liss, Inc.     

Culture and the anxiety disorders: recommendations for DSM‐V

Background: The anxiety disorders specified in the fourth edition, text revision, of The Diagnostic and Statistical Manual (DSM‐IV‐TR) are identified universally in human societies, and also show substantial cultural particularities in prevalence and symptomatology. Possible explanations for the observed epidemiological variability include lack of measurement equivalence, true differences in prevalence, and limited validity or precision of diagnostic criteria. One central question is whether, through inadvertent “over‐specification” of disorders, the post‐DSM‐III nosology has missed related but somewhat different presentations of the same disorder because they do not exactly fit specified criteria sets. This review canvases the mental health literature for evidence of cross‐cultural limitations in DSM‐IV‐TR anxiety disorder criteria. Methods: Searches were conducted of the mental health literature, particularly since 1994, regarding cultural or race/ethnicity‐related factors that might limit the universal applicability of the diagnostic criteria for six anxiety disorders. Results: Possible mismatches between the DSM criteria and the local phenomenology of the disorder in specific cultural contexts were found for three anxiety disorders in particular. These involve the unexpectedness and 10‐minute crescendo criteria in Panic Disorder; the definition of social anxiety and social reference group in Social Anxiety Disorder; and the priority given to psychological symptoms of worry in Generalized Anxiety Disorder. Limited evidence was found throughout, particularly in terms of neurobiological markers, genetic risk factors, treatment response, and other DSM‐V validators that could help clarify the cross‐cultural applicability of criteria. Conclusions: On the basis of the available data, options and preliminary recommendations for DSM‐V are put forth that should be further evaluated and tested. Depression and Anxiety, 2010© 2009 Wiley‐Liss, Inc.     

Maternal anxiety predicts favourable treatment outcomes in anxiety-disordered adolescents

Objective: To determine the differential impact of maternal and paternal internalizing psychopathology on cognitive‐behavioural treatment (CBT) outcome of anxiety‐disordered children and adolescents. Method: Participants consisted of 127 children and 51 adolescents with a primary anxiety diagnosis. Children were randomly assigned to a standardized group CBT or individual CBT; adolescents received individual CBT. Parents received four training sessions. Participants were evaluated at pre‐ and post‐treatment with a clinical interview and with self‐ and parent‐reported questionnaires. Lifetime anxiety and mood disorders in parents were obtained with a clinical interview. Results: For children, no associations were found between maternal and paternal anxiety or mood disorders and treatment outcome. For adolescents, however, maternal lifetime anxiety disorders were positively associated with pre‐post‐treatment improvement in clinician severity ratings and with treatment success. Conclusion: Lifetime maternal anxiety disorders were significantly associated with favourable treatment outcomes in adolescents. Paternal disorders were not associated with treatment response.     

Comorbidity of depression and anxiety in nursing home patients

OBJECTIVES: To assess the occurrence and risk indicators of depression, anxiety, and comorbid anxiety and depression among nursing home patients and to determine whether depression and anxiety are best described in a dimensional or in a categorical classification system. METHODS: DSM and subthreshold anxiety disorders, anxiety symptoms, major and minor depression and depressive symptoms were assessed in 333 nursing home patients of somatic wards of 14 nursing homes in the north west of the Netherlands with the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) and the Geriatric Depression Scale (GDS). Comorbidity was studied along a severity gradient. Logistic regression analyses were carried out to identify demographic, health-related, psychosocial and care-related correlates of anxiety and depression. RESULTS: The prevalence of pure depression (PD) was 17.1%, of pure anxiety (PA) 4.8%, and of comorbid anxiety and depression (CAD) 5.1%. Comorbidity increased dependent on severity of both anxiety and depression. Different patterns of risk indicators were demonstrated for PA, PD and CAD for the investigated baseline characteristics. CONCLUSIONS: Comorbidity of anxiety and depression is most prevalent in the more severe depressive and anxious nursing home patients. The gradual increase of comorbidity of anxiety and depression dependent on the levels of severity of depression and anxiety suggests that for nursing home patients a dimensional classification of depression and anxiety is more appropriate than a categorical one. The observed differences in patterns of risk indicators for PA, PD and CAD support a distinguishing of anxiety and depression. Future studies are needed to assess the effect of treatment of PA, PD and CAD in nursing home patients.     

Management of anxiety disorders: the added challenge of comorbidity

Patients with anxiety present with a wide variety of disorders that cause significant impairment to their everyday lives. To complicate matters, patients seldom present with just one anxiety disorder. Such comorbidity, particularly where depression is also present, has important implications for both the patient and the physician. The patient typically suffers from a greater degree of everyday impairment, is more reliant on healthcare services, in particular mental health services, and may be at a greater risk of attempting suicide. For the physician, comorbidity in anxiety disorders presents a challenge as the patient's symptoms are often more severe, present earlier in life, and are frequently prolonged which makes their management more complex. This review will focus on the anxiety disorders: panic disorder, obsessive-compulsive disorder, social anxiety disorder, and post-traumatic stress disorder. The impact of co-existing multiple anxiety disorders, depression, or a history of substance abuse will be discussed with a view to choosing the appropriate management strategy. Treatment options will be reviewed.     

Associations between anxiety disorders and physical illness

Abstract. Objective: In contrast to the literature on the association of depression with medical illness, less is known about the comorbidity among anxiety and somatic disorders. Although associations between anxiety disorders and medical illnesses have been reported, prior studies have not adjusted for the effects of gender, substance abuse/dependence, and depression. This study examined the patterns of comorbidity of anxiety disorders and physical illnesses. Method: A total of 262 probands were selected from treatment settings or were randomly recruited from the community. DSM-III-R diagnoses were obtained based on direct interview (SADS) or family history information, and lifetime history of numerous medical illnesses were obtained. Results: Patients with a lifetime anxiety disorder reported higher rates of several medical illnesses than did persons without anxiety. After controlling for the effects of gender, comorbid substance abuse/dependence and/or depression, significant associations were found between anxiety disorder and cardiac disorders (OR = 4.6), hypertension (OR = 2.4), gastrointestinal problems (OR = 2.4), genitourinary disorders (OR = 3.5), and migraine (OR = 5.0). A similar pattern was observed for probands with panic or generalized anxiety disorder (GAD). Conclusions: Anxiety disorders were associated with a specific pattern of cardiac disorders, hypertension, gastrointestinal problems, genitourinary difficulties, and migraine; individuals presenting with anxiety disorders or medical illness need therefore to be evaluated carefully for comorbidity.     

Performance monitoring and response inhibition in anxiety disorders with and without comorbid ADHD

Anxiety disorder (ANX) is characterized by heightened arousal, psychosocial and academic difficulties, and comorbidity with other disorders, in particular, attention-deficit/hyperactivity disorder (ADHD). The heightened arousal contributes to cognitive impairment by adversely affecting executive control of cognition. The nature of the effect on executive control is poorly understood. Research in this area could inform intervention, diagnostic, and etiological research. Our objective was to characterize children with ANX on measures of executive functioning, while controlling for comorbid ADHD. We compared children ages 6-14 with ANX (N=21), ADHD (N=78), ANX+ADHD (N=38), and normal controls (NC; N=40) on the stop task, a measure of performance monitoring and response inhibition. No difference was observed between NC and ANX groups in performance monitoring. Compared to the NC group, the three clinical groups showed inhibition deficits, and both ADHD and ANX+ADHD groups monitored less after responses. ANX was not associated with performance monitoring or inhibition deficits once comorbid ADHD was considered. This emphasizes the importance of controlling for comorbid ADHD in studies of cognition and anxiety.     

Pretreatment attrition and dropout in an outpatient clinic for anxiety disorders

OBJECTIVE: Treatment attrition represents a considerable problem for efficient delivery of care for mental disorders. The present study examined rates and predictors of pretreatment attrition and dropout from outpatient treatment for anxiety disorders. METHOD: The influence of clinical, demographic, clinician and system variables on pretreatment attrition (treatment refusal or non-attendance) and dropout were analysed in a consecutive sample of 731 clients treated at an anxiety disorders clinic in Sydney. RESULTS: Pretreatment attrition was common (30.4%) but dropout once clients had commenced treatment was rare (10.3%). Milder pretreatment symptoms were associated with treatment dropout and comorbid depression or depressive symptoms were associated with higher probability of both pretreatment attrition and dropout. Demographic, clinician and system influences were present but less important. CONCLUSION: Targeting of individuals with comorbid anxiety and depression may reduce treatment attrition rates among individuals with anxiety disorders presenting for treatment.