Performance of clinician versus self-report measures to identify obsessive-compulsive disorder in children and adolescents

OBJECTIVE: The aim of this study was to study agreement between clinician-rated measures and self-report measures previously used in epidemiologic studies to identify obsessive-compulsive disorder (OCD) in youth and to determine the adequacy of self-report measures as screening instruments. METHOD: Leyton Obsessional Inventory-Child Version (LOI-CV) survey form self-report and Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS) clinician-report measures were compared in a sample of 81 OCD-affected youths diagnosed using structured diagnostic interviews and the best-estimate method. Sensitivities and agreement between tests are determined for different cutoff scores. RESULTS: The LOI-CV survey form total (item+interference) score is correlated with KSADS-E OCD severity (r=0.37, p=0.001) but not clinician-rated GAF scores (r=-0.18, p=0.12). LOI-CV survey form sensitivities at cutoff scores of 15, 20, 25, and 30 are 55%, 36%, 28%, and 19%, respectively. CY-BOCS scores are correlated with subject-rated interview severity (p<0.001) and clinician-rated GAF scores (por=0.03), but correlate with the CY-BOCS compulsion subscore. CONCLUSIONS: The clinician-rated CY-BOCS measure using parent and child reporting performs superiorly to the subject-rated LOI-CV measure using child reporting to identify pediatric OCD in a clinically referred population. Because self-report measures have been used in epidemiological studies, youth OCD prevalence rates may be higher than previously reported.     

Generalized anxiety disorder: between neglect and an epidemic

ABSTRACT: This article reviews the main issues associated with the concept and the diagnosis of generalized anxiety disorder (GAD) and examines the proposed DSM-5 diagnostic criteria for GAD. The lack of specific features, which is the primary issue for GAD, will not be addressed in DSM-5. The hallmark of the condition will remain pathological worry, although it also characterizes other disorders. Likewise, the proposed behavioral diagnostic criteria lack specificity for GAD, and it is not clear how these will be assessed. The proposed changes will lower the diagnostic threshold for GAD in DSM-5. Although this will not necessarily lead to a better recognition of GAD and an improvement in the perception of its relevance and clinical utility, many currently subthreshold cases will qualify for this diagnosis. The likely inclusion of many such "false-positives" will result in an artificial increase in the prevalence of GAD and will have further negative consequences.     

Guided self-help for generalized anxiety disorder in older adults

Objective: The main objective of this study was to examine the efficacy of a guided self-help treatment based on cognitive behavioral principles (CBT-GSH) for generalized anxiety disorder (GAD) in older adults.

Methods: Three older adults aged from 66 to 70 and diagnosed with GAD were included in a single-case experimental multiple-baseline protocol. Data were collected using daily self-monitoring, standardized clinician ratings, and self-report questionnaires at pretest, posttest, and 6-month and 12-month follow-ups. Treatment consisted of awareness training, worry interventions, relaxation training, pleasant activities scheduling, and relapse prevention. Participants used a manual presenting weekly readings and at-home practice exercises. They also received weekly supportive phone calls from a therapist.

Results: At posttest, participants showed improvement on worries and GAD severity, on psychological process variables targeted by treatment (intolerance of uncertainty, negative problem orientation, cognitive avoidance, and perceived usefulness of worry), and on secondary variables associated with GAD (anxiety, depression, sleep difficulties, cognitive functioning, and disability). These results were generally maintained at 12 months after the end of treatment. Participants had favorable opinions toward the treatment.

Conclusion: The results of this study suggest that CBT-GSH is both feasible and effective for the treatment of GAD in older adults.     

Attentional biases in older adults with generalized anxiety disorder

Cognitive theories of anxiety propose that selective attention to negative information plays a central role in the development and maintenance of anxiety. The presence of such attentional bias has been confirmed in younger adults. Nevertheless, there are few studies that have explored anxiety-linked attentional bias in older adults, and the available results are inconclusive. Conversely, the socioemotional selectivity theory posits that there are age-related changes in emotional information processing and, consistent with this account, it has been found that older adults preferentially pay more attention to positive stimuli compared with younger adults (“positivity effect”). The present study aimed to explore attentional bias towards negative and positive information in a sample of older adults with generalized anxiety disorder (GAD) compared with a control group. The results showed that older adults with GAD displayed an attentional preference for negative information and attentional avoidance for positive information, whereas healthy older adults showed the reverse pattern of attentional deployment. These results suggest that selective attention toward negative information and selective avoidance of positive information may be a relevant factor in clinically anxious older adults.     

Concordance between clinician and patient ratings as predictors of response, remission, and recurrence in major depressive disorder

We conducted a secondary analysis of data from the Prevention of Recurrent Episodes of Depression With Venlafaxine Extended Release (ER) for Two Years (PREVENT) trial to evaluate whether discrepancies between clinician and patient ratings of depression severity were predictive of response, remission, and recurrence during treatment for a depressive episode. Patients who self-rated depression severity in concordance with the clinician (“concordant patients”) were defined as having a standardized patient-rated Inventory of Depressive Symptoms-Self Report (IDS-SR₃₀) score minus standardized clinician-rated Hamilton Rating Scale for Depression (HAM-D₁₇) score <1 SD from mean. Non-concordant patients (“underrating patients” [−1 SD], “overrating patients” [+1 SD]) were identified. Cohorts were compared for remission and response on the HAM-D₁₇, Clinician Global Impression--Severity (CGI-S), and IDS-SR₃₀ during acute and continuation therapy and time to recurrence during maintenance therapy. During acute treatment female patients were more likely to overrate their depression severity compared to the clinician; older age predicted overrating during continuation treatment. Overrating patients had a slower onset of response on the HAM-D₁₇ during acute treatment (P = 0.004). There were no differences between cohorts for remission or response on the HAM-D₁₇ or CGI-S. Overrating patients at week 10 had lower remission and response rates on the IDS-SR₃₀ during continuation therapy (32% and 50%, respectively; P ≤ 0.001) compared with underrating patients (76%, 77%) or concordant patients (64%, 78%). Patient concordance at the end of continuation therapy did not predict recurrence during maintenance therapy, indicating that patient rating scales may be useful in tracking recurrence during maintenance therapy. Poor agreement between patient- and clinician-ratings of depression severity is primarily a state phenomenon, although it is trait-like for some patients.     

Distinguishing generalized anxiety disorder, panic disorder, and mixed anxiety states in older treatment-seeking adults

Eighty treatment-seeking adults age 60 or over with panic disorder, generalized anxiety disorder, and mixed anxiety states (generalized anxiety with panic attacks, panic disorder with secondary generalized anxiety) completed a clinical assessment and battery of self report measures. Several hypotheses were tested from the domains of distinguishing symptoms, associated features, and rates of comorbidity with other disorders. Greater between- than within-group variance was found on a subset of measures suggesting that the distinction between GAD and PD is generally valid in the older adult population. Higher scores on measures of sympathetic arousal, agoraphobic avoidance, and rates of comorbid somatization disorder and alcohol dependence distinguished those with PD from those with GAD. Higher scores on measures of depression and hostility, but not trait anxiety or worry, distinguished the GAD group. Results indicate that distinguishing features of GAD and PD in older treatment-seeking adults may be fewer and slightly different from those of younger adults.     

Interventions for generalized anxiety disorder in older adults: systematic review and meta-analysis

IntroductionGeneralized anxiety disorder (GAD) is one of the most common anxiety disorders in later life, with widespread consequences for individuals and society.ObjectiveTo perform a systematic review of the efficacy of controlled interventions for GAD in adults aged 55 years and older.MethodDirect search of digital databases and the main publications on aging and iterative searches of the references from retrieved articles.ResultsTwenty-seven trials (14 pharmacological, 13 psychotherapeutic) fulfilled the inclusion criteria, reporting results from 2373 baseline participants. There were no differences between trials in their overall quality. Pooled treatment effects for pharmacological (OR = 0.32, 95% CI: 0.18, 0.54) and psychotherapeutic (OR = 0.33, 95% CI: 0.17, 0.66) trials were similar, with findings in each case favoring active interventions over control conditions.ConclusionsOlder adults with GAD benefited from both pharmacological and psychotherapeutic interventions. Future studies should investigate combined treatment with medication and psychotherapy.     

Quality of life in older adults with generalized anxiety disorder

Improving the quality of life is an important goal in the treatment of psychiatric disorders. The current study described subjective quality of life, or life satisfaction, in a sample of older adults with generalized anxiety disorder (GAD). Patients with GAD were compared to other anxious and nonpsychiatric samples on measures of life satisfaction. Older adults with GAD reported lower quality of life than did nonpsychiatric samples; levels of life satisfaction were comparable between older adults with GAD and younger adults with social phobia. Predictors of quality of life for the GAD sample were examined. Severity of depression predicted decreased life satisfaction as measured by both the Quality of Life Inventory (QOLI) and the Life Satisfaction Index (LSI-Z). Severity of anxiety predicted poorer quality of life as measured by the QOLI, and optimism predicted better life satisfaction as measured by the LSI-Z. The findings suggest that quality of life is diminished in older adults with GAD, and that additional factors also affect quality of life for these patients.     

Generalized anxiety disorder severity scale (GADSS): a preliminary validation study

To assist researchers and clinicians in primary care with assessment and treatment of generalized anxiety disorder (GAD), we developed a simple standardized instrument, similar to the Panic Disorder Severity Scale. Independent evaluators used the six-item Generalized Anxiety Disorder Severity Scale (GADSS) to conduct telephone assessments of 330 patients from four primary care facilities with DSM-IV diagnoses of GAD and/or panic disorder who were participating in a study of the effectiveness of collaborative care treatment. Participants were also evaluated at a 12-month follow-up. Internal consistency, convergent and discriminant validity, and sensitivity to change were determined. The GADSS had high internal consistency, and showed good validity and sensitivity to change. Change in GADSS scores discriminated between two different treatment strategies. GADSS is a simple, efficient way to rate severity over the telephone in patients with established diagnoses of GAD.     

Generalized anxiety disorder in adolescents and young adults with mild mental retardation

This report examines clinical features of generalized anxiety disorder in adolescents and young adults with mild mental retardation (MR), compared with children and adolescents with normal IQ. Frequency of symptoms, comorbidity, agreement between reports of subjects and parents, correlation between IQ and severity of disorder, and comparison between frequency of symptoms in the experimental and control groups are described. Twenty-two subjects with MR (12 males and 10 females aged 11-25 years; mean age = 16.3), 30 children (19 males and 11 females aged 7-11.11; mean age = 10), and 30 adolescents (18 males and 12 females aged 12.1-18; mean age = 15.2) participated in the study. All the subjects were comprehensively diagnosed with diagnostic interviews (K-SADS or DICA-R). According to our data, generalized anxiety disorder can be diagnosed in adolescents with mild MR, with high agreement between self-reports and parent reports. Phenomenology of GAD in mildly developmentally delayed persons grossly paralleled that of normal IQ people, except for brooding, somatic complaints, and sleep disorders. Number and severity of symptoms did not correlate with Full Scale and Verbal IQs. High rates of comorbidity with depression were evident both in normal IQ and in developmentally delayed subjects.     

Relationship between ADIS clinician's severity rating and self-report measures among social phobics

Although global clinical rating scales have been a mainstay of clinical research, little is known about the relationship between these measures and other assessment modalities. The present study examined the Clinician's Severity Rating (CSR) from the Anxiety Disorders Interview Schedule in a sample of 186 social phobics. It was hypothesized that the CSR would be related to higher fear of negative evaluation, behavioral avoidance, social anxiety, and dysphoria, and that four self-report measures reflecting each of these common features of social phobia would contribute individually to predict clinicians' judgments of clinical severity using the CSR. Multiple regression analyses supported these hypotheses, accounting for nearly 33% of the variance in the CSR. The role of subtype of social phobia was also investigated. Overall, these results support the utility of the CSR for use with social phobics, but the relatively low proportion of variance accounted for raises further questions. Directions for future research are also discussed. Depression and Anxiety 4:120–125, 1996/1997.© 1997 Wiley-Liss, Inc.     

Validity of clinical and patient ratings of tremor disability among older adults

OBJECTIVE: To evaluate the validity of the clinical tremor disability interview using a performance-based measure, patient ratings of tremor disability, and bedside tremor severity ratings of upper extremity (UE) action/intention (A/I) and postural (P) tremor. METHOD: Sixteen older adult essential tremor patients (mean age=75.4 years, sd=5.7 years) took part in a study evaluating the validity of clinical and self-rating scales of tremor disability. A neurologist obtained bedside clinical ratings of UE A/I and P tremor of each limb and completed a clinical tremor disability rating. A second investigator, blind to neurological exam results obtained a clinical disability rating using the same measure, patient rated tremor disability ratings and conducted a performance-based disability assessment. RESULTS: Clinical tremor disability ratings were not significantly related to functional performance-based or patient ratings of tremor disability. Bedside clinical ratings of tremor severity also were not associated with clinical or patient-rated tremor disability. Patient ratings were significantly correlated with performance-based ratings. CONCLUSIONS: Further research is needed to validate a brief, sensitive clinical rating scale of tremor disability among older adults. Use of bedside ratings of tremor severity may be problematic and possibly estimate tremor disability. Empirical evaluation of differences in rating methods needs to be directly addressed.     

Generalized anxiety disorder in the classroom

Interventions for students with generalized anxiety disorder require attention to contextual factors both within and outside the classroom. They often are based on the principles of increasing environmental predictability and increasing the student’s sense of self-efficacy. Good judgment is sometimes needed to determine which strategies constitute reasonable accommodations to the student’s anxiety and which constitute an excessive deviation from usual school expectations. The latter can single out students unnecessarily or limit their academic progress. Working closely with parents and mental health professionals involved in the student’s care is most likely to ensure a consistently helpful approach.     

Clinical characteristics of generalized anxiety disorder: older vs. young adults

Background: Generalized anxiety disorder (GAD) is one of the most common anxiety disorders in older people. Although GAD in older adults seems to differ in many aspects like clinical presentation, severity and treatment response, there is a paucity of comparative research.

Aims: The aim of the study is to compare the clinical presentation of GAD between older and young adults.

Methods: One hundred and two non-demented older patients (age ≥65) and 64 young patients (age <45) who were diagnosed with GAD according to the DSM-IV-TR criteria were included to the study. Socio-demographic Data Form, the Structured Clinical Interview for DSM Disorders-1 (SCID-1), the Questionnaire for the Suggested Behavioral Criteria of GAD for DSM-5, the Hamilton Depression Scale (HAM-D), the Generalized Anxiety Disorder Severity Scale (GADSS) and the Sheehan Disability Scale (SDS) were applied to both groups.

Results and conclusions: Older GAD patients had more disturbances of sleep, less reassurance seeking behaviors, higher rates of depression and higher depression severity when compared to the young patients. Although older people seemed to have a lower severity of GAD, they had higher disability due to worries. Older patients worried more about their own health and family well-being, whereas young patients worried more about future and other’s health.     

Age at onset of generalized anxiety disorder in older adults.

OBJECTIVE: The authors explored the distribution and correlates of age-at-onset of late-life generalized anxiety disorder (GAD). METHODS: Authors examined the distribution of age at onset in a sample of 67 older adults with GAD recruited for a psychotherapy study. They compared those with an early onset of symptoms (before age 50) to those with a late onset (after 50) on demographic variables and measures of psychopathology and health-related quality of life. RESULTS: There was a bimodal distribution of age at onset, with 57% reporting early onset and 43% reporting a late onset. Patients with an early onset of symptoms had a higher rate of psychiatric comorbidity and psychotropic medication use and more severe worry. Patients with a late onset of symptoms reported more functional limitations due to physical problems. CONCLUSIONS: Although most older GAD patients report an onset in childhood or adolescence, almost half develop the disorder in late life. Older adults with an early onset of GAD appear to have a more severe course, characterized by pathological worry, than those with a later onset. Role disability may be a risk factor for onset of GAD in late life.     

Prefrontal-limbic connectivity during worry in older adults with generalized anxiety disorder

Objectives: Although generalized anxiety disorder (GAD) is one of the most prevalent anxiety disorders in older adults, very little is known about the neurobiology of worry, the hallmark symptom of GAD in adults over the age of 60. This study investigated the neurobiology and neural circuitry of worry in older GAD patients and controls.

Method: Twenty older GAD patients and 16 age-matched controls (mean age = 67.88) were compared on clinical measures and neural activity during worry using functional magnetic resonance imaging.

Results: As expected, worry elicited activation in frontal regions, amygdala, and insula within the GAD group, with a similar but less prominent frontal pattern was observed in controls. Effective connectivity analyses revealed a positive directional circuit in the GAD group extending from ventromedial through dorsolateral prefrontal cortices, converging on the amygdala. A less complex circuit was observed in controls with only dorsolateral prefrontal regions converging on the amygdala; however, a separate circuit passing through the orbitofrontal cortex converged on the insula.

Conclusion: Results elucidate a different neurobiology of pathological versus normal worry in later life. A limited resource model is implicated wherein worry in GAD competes for the same neural resources (e.g. prefrontal cortical areas) that are involved in the adaptive regulation of emotion through cognitive and behavioral strategies.     

Generalized anxiety and generalized anxiety disorder: description and reconceptualization

One hundred eight patients complaining of anxiety were diagnosed using the Anxiety Disorders Interview Schedule and classified into the various anxiety disorder categories as well as major depression. Although patients with a primary diagnosis of generalized anxiety disorder were more chronic than were panic disorder patients, most patients in each category met the DSM-III criteria for generalized anxiety disorder with the exception of simple phobic patients. On the basis of these data, it would seem that generalized anxiety disorder is a residual category within the anxiety disorders, since generalized anxiety disorder symptoms are almost always present. But if one distinguishes anticipatory anxiety, which is often part of panic or phobic disorders, from generalized anxiety, an independent anxiety disorder category emerges. This category is characterized by apprehensive expectation or chronic worry focused on multiple life situations.     

Cognitive errors, symptom severity, and response to cognitive behavior therapy in older adults with generalized anxiety disorder.

OBJECTIVE: Recent research by Wetherell et al. investigating the differential response to group-administered cognitive behavior therapy (CBT) for generalized anxiety disorder (GAD) in older adults found that GAD severity, homework adherence, and psychiatric comorbidity predicted statistically significant improvement. The current study investigated whether the presence/absence of cognitive errors on separate domains of the Mini-Mental State Exam (MMSE) predicted baseline differences in symptom severity and improvement following CBT, above and beyond already established predictors. METHODS: Baseline characteristics were investigated in a sample of 208 older patients diagnosed with GAD. Predictors of treatment response were examined in a subsample of 65 patients who completed CBT and were included in a prior study by Wetherell et al. of response predictors. RESULTS: Results from the baseline sample indicated that only subjects who committed an error on the MMSE Working Memory domain exhibited increased severity in anxiety and depressive symptoms. Results from the treatment sample indicated that an error on the MMSE Orientation domain was a significant predictor of outcome at 6-month follow-up, while controlling for previously established predictors. Patients who committed at least one error in this domain showed decreased response relative to patients who committed no errors. CONCLUSION: In this sample of older adults diagnosed with GAD, poor performance on the MMSE Working Memory domain was associated with increased baseline anxiety and depression, while baseline performance differences on the MMSE Orientation domain predicted outcome six months after CBT intervention.     

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. Depression and Anxiety, 2009. © 2009 Wiley‐Liss, Inc.