Generalized Anxiety Disorder Severity Research Articles

The association of mental health conditions with employment, interpersonal, and subjective functioning after intimate partner violence.

This study explored the associations of posttraumatic stress disorder (PTSD), generalized anxiety disorder (GAD), and depressive symptoms with employment, social support, and subjective functioning in 100 women who were seeking mental health assistance after intimate partner violence. Depressive disorders showed significant associations with low levels of social support, diminished self-esteem, reduced quality of life, and elevated negative social problem-solving orientation. PTSD severity was significantly associated with low self-esteem and elevated negative problem orientation, while severity of GAD was only associated with negative problem orientation. Results are discussed in light of current service models for women who have experienced intimate partner violence.

A study of worry and functional somatic symptoms in generalized anxiety disorder

ObjectiveTo study the phenomenon of worry and functional somatic symptoms in Generalized Anxiety Disorder (GAD). Method40 subjects with the diagnosis of GAD were assessed by using Penn State Worry Questionnaire (PSWQ) and Bradford Somatic Inventory (BSI). Severity of GAD was rated on Generalized Anxiety Disorder -7 (GAD-7) scale. ResultsThe mean total score on PSWQ was 59.62. All patients had somatic symptoms and the minimum number of somatic symptoms noted in a patient was 11 and maximum was 38. Seventy-five percent of the patients had more than 22 somatic symptoms as per BSI. Majority of the patients (90%) scored more than 10 on GAD-7 scale. ConclusionFuture nosological systems should not limit assessment of somatic symptoms to a list of 6 symptoms only in patients with GAD and should try to operationalise the definition of excessive worry by taking into consideration the common types of worries.

Teasing apart low mindfulness: Differentiating deficits in mindfulness and in psychological flexibility in predicting symptoms of generalized anxiety disorder and depression

BackgroundThis research investigated the differential ability of three components of low mindfulness to uniquely predict symptoms of generalized anxiety disorder (GAD) and depression, while controlling for psychological inflexibility, a construct conceptually related to low mindfulness. Also examined was the meditational role of several mindfulness facets in the relationship between psychological inflexibility and symptoms of each disorder. MethodsUsing a clinical sample (n=153) containing mostly patients with GAD or depression diagnoses, we conducted hierarchical multiple regression analyses and mediation analyses to determine unique relationships. ResultsWhereas deficits in adopting a non-reactive perspective exhibited incremental validity beyond psychological inflexibility in predicting symptoms of GAD, deficits in acting with awareness did so in predicting symptoms of depression. Results of mediation analyses corroborated this pattern, as the relationships psychological inflexibility exhibited with symptoms of GAD and of depression were mediated by non-reactivity and acting with awareness, respectively. LimitationsThe cross-sectional design of this study precludes causal interpretations of the mediation models. ConclusionFindings corroborate the following conclusions: (i) the lack of present oriented awareness experienced by individuals with symptoms of depression is not completely accounted for by psychological inflexibility nor by symptoms of GAD; (ii) the reactive approach to automatic thoughts adopted by those with symptoms of GAD is not completely accounted for by psychological inflexibility nor by symptoms of depression. These conclusions suggest that it would be profitable for mindfulness-based therapies to concentrate on these specific mindfulness deficits to ameliorate the severity of GAD and depression.

Economic and humanistic burden of illness in generalized anxiety disorder: an analysis of patient survey data in Europe.

BackgroundWhilst studies suggest that generalized anxiety disorder (GAD) represents a considerable health care burden in Europe, there is a paucity of published evidence. This study investigated the burden of illness associated with GAD across five European countries (France, Germany, Italy, Spain, and the UK).MethodsInformation from the 2008 European National Health and Wellness Survey database was analyzed. Bivariate, multivariate, and cost analyses were used to compare patients with GAD and propensity-matched controls.ResultsCompared with non-GAD controls, patients with GAD had more comorbidities and were more likely to smoke but less likely to be employed, use alcohol, or take exercise. They also had significantly worse health-related quality of life, and significantly greater work impairment and resource use, which increased as GAD severity increased. Within-country analyses demonstrated results similar to those for the five European countries overall, with the largest differences in resource use between patients with GAD and non-GAD controls documented in France and Germany. The average mean differences in direct costs were relatively small between the GAD groups and controls; however, indirect costs differed substantially. Costs were particularly high in Germany, mainly due to higher salaries leading to higher costs associated with absence from work. The limitation of this study was that the data were from a self-reported Internet survey, making them subject to reporting bias and possibly sample bias.ConclusionAcross all five European countries, GAD had a significant impact on work impairment, resource use, and economic costs, representing a considerable individual and financial burden that increased with severity of disease. These data may help us to understand better the burden and costs associated with GAD.

LAY PROVIDERS CAN DELIVER EFFECTIVE COGNITIVE BEHAVIOR THERAPY FOR OLDER ADULTS WITH GENERALIZED ANXIETY DISORDER: A RANDOMIZED TRIAL

The Institute of Medicine recommends developing a broader workforce of mental health providers, including nontraditional providers, to expand services for older adults. Cognitive behavior therapy (CBT) is effective for late-life generalized anxiety disorder (GAD), but no study has examined outcomes with delivery by lay providers working under the supervision of licensed providers. The current study examined the effects of CBT delivered by lay, bachelor-level providers (BLP) relative to Ph.D.-level expert providers (PLP), and usual care (UC) in older adults with GAD. Participants were 223 older adults (mean age, 66.9 years) with GAD recruited from primary care clinics at two sites and assigned randomly to BLP (n = 76), PLP (n = 74), or UC (n = 73). Assessments occurred at baseline and 6 months. CBT in BLP and PLP included core and elective modules (3 months: skills training; 3 months: skills review) delivered in person and by telephone, according to patient choice. CBT in both BLP and PLP groups significantly improved GAD severity (GAD Severity Scale), anxiety (Spielberger State-Trait Anxiety Inventory; Structured Interview Guide for the Hamilton Anxiety Scale), depression (Patient Health Questionnaire), insomnia (Insomnia Severity Index), and mental health quality of life (Short-Form-12), relative to UC. Response rates defined by 20% reduction from pre- to posttreatment in at least three of four primary outcomes were higher for study completers in BLP and PLP relative to UC (BLP: 38.5%; PLP: 40.0%; UC: 19.1%). Lay providers, working under the supervision of licensed providers, can deliver effective CBT.

Generalized Anxiety Disorder in Younger and Older Children: Implications for Learning and School Functioning

Few studies have examined differences between younger and older children with generalized anxiety disorder (GAD). The current study examined differences between children with GAD who were younger than the typical age of onset (i.e., ages 7–9) and children with GAD who were within the age range for typical age of onset (i.e., ages 10–13). These groups, defined as “younger” versus “older,” did not differ on demographic variables, but the older group had lower intelligence quotients. At the same time, mean values for both groups fell within the average range. Older children with GAD generally reported similar levels of worry as younger children with the exception of greater school-related worry, trouble paying attention, and getting upset easily. Younger children reported greater harm avoidance than older children. Parent reports did not generally differ between groups with the exception of greater perfectionism in younger children and greater school competence issues for older children. Teachers reported greater learning problems and less happiness in older children. Overall, limited differences were found on GAD severity and impairment, but some differences were found on cognitive and school functioning variables (e.g., intelligence, school-related worry, learning problems, school competence) and parent–child agreement on worry. Further, such differences did not appear to be accounted for by comorbid disorders or other variables. Overall, these findings suggest that GAD may be associated with different characteristics in younger and older children. Future studies, particularly prospective studies, are needed to understand the development of GAD and associated impairments such as academic functioning.

Clinical Experiences in Conducting Empirically Supported Treatments for Generalized Anxiety Disorder

Knowledge of the efficacy of cognitive-behavioral therapy (CBT) for generalized anxiety disorder (GAD) predominantly derives from randomized controlled trials (RCTs). However, there may be unique or complex issues encountered in practice, but not necessarily in the context of a controlled clinical trial. Therefore, launching a systematic dialogue between researcher and practicing clinician can be instrumental in augmenting evidence-based therapies through identification of variables that promote and interfere with clinical effectiveness. Through an initiative sponsored by the American Psychological Association’s Divisions 12 (Society for Clinical Psychology) and 29 (Psychotherapy), this study aimed to examine clinical experiences conducting CBT for GAD. The participants were 260 psychotherapists who completed an online survey on assessment and therapeutic intervention utilization and their experience of factors that limit successful GAD treatment and symptom reduction. The majority of respondents reported 20years or less experience using ESTs for GAD, typically treating clients in outpatient clinics, treatment centers, and private practice. Some of the most commonly used interventions address clients’ maladaptive cognitions and elevated anxiety and muscle tension typical of GAD. Approximately one half of respondents reported incorporating integrative techniques into treatment. Factors perceived as limiting effective GAD treatment included severity and chronicity of GAD, presence of comorbid conditions, stressful home and work environments, client motivation and resistance to treatment, and issues encountered when executing therapy techniques. This study provides researchers with clinically derived directions for future empirical investigation into enhancing efficacy of GAD treatment.

Alcohol use, anxiety, and insomnia in older adults with generalized anxiety disorder.

To examine alcohol consumption among older primary care patients with generalized anxiety disorder (GAD); its relationship to demographic variables, insomnia, worry, and anxiety; and its moderating role on the anxiety-insomnia relationship. We expected alcohol use to be similar to previous reports, correlate with higher anxiety and insomnia, and worsen the anxiety-insomnia relationship. Baseline data from a randomized controlled trial. Michael E. DeBakey VA Medical Center and Baylor College of Medicine. 223 patients, 60 years and older, with GAD. Frequency of alcohol use, insomnia (Insomnia Severity Index), worry (Penn State Worry Questionnaire - Abbreviated, Generalized Anxiety Disorder Severity Scale), and anxiety (State-Trait Anxiety Inventory - Trait subscale, Structured Interview Guide for the Hamilton Anxiety Rating Scale [SIGH-A]). Most patients endorsed alcohol use, but frequency was low. Presence and frequency were greater than in previous reports of primary care samples. Alcohol use was associated with higher education, female gender, less severe insomnia, and lower worry (Generalized Anxiety Disorder Severity Scale) and anxiety (State-Trait Anxiety Inventory-Trait subscale; SIGH-A). Whites reportedmore drinks/week than African-Americans. More drinks/week were associated with higher education and lower anxiety (SIGH-A). Weaker relationships between worry/anxiety and insomnia occurred for those drinking. Drink frequency moderated the positive association between the Penn State Worry Questionnaire-Abbreviated and insomnia, which was lower with higher frequency of drinking. Older adults with GAD use alcohol at an increased rate, but mild to moderate drinkers do not experience sleep difficulties. A modest amount of alcohol may minimize the association between anxiety/worry and insomnia among this group.

Should uncontrollable worry be removed from the definition of GAD? A test of incremental validity.

In its current instantiation in DSM-IV, a diagnosis of generalized anxiety disorder (GAD) requires the presence of excessive and uncontrollable worry. It has been proposed that the uncontrollability criterion be removed from future editions of the DSM, primarily on the basis of empirical and conceptual overlap between excessiveness and uncontrollability and a relative lack of research on uncontrollability. However, no research has directly investigated the incremental validity of the uncontrollability criterion-that is, the extent to which uncontrollability predicts important clinical information over and above excessiveness. This question was examined in a community sample of 126 adults diagnosed with GAD. After controlling for excessiveness, uncontrollability explained a significant proportion of additional variance in a variety of relevant clinical measures, including GAD severity, clinician-rated anxiety, number and severity of comorbid disorders, and use of psychotropic medication and psychotherapy. The results remained statistically significant even when other features of GAD were controlled. By contrast, excessiveness did not significantly predict any clinical measure over and above uncontrollability. These findings suggest that uncontrollability contributes to the validity of the GAD diagnosis and should be retained as a core feature of pathological worry.

A preliminary investigation of impulsivity in generalized anxiety disorder

Few studies have examined the association between impulsivity and generalized anxiety disorder (GAD). This study examined whether individuals with probable GAD display impulsivity in a particular way, and the extent to which impulsivity uniquely predicts GAD severity and GAD status, over and above intolerance of uncertainty (IU), a key cognitive factor in GAD. Individuals with (n=63) and without (n=77) probable GAD completed self-report measures of impulsivity and IU. Results revealed that elevations in the severity of GAD symptoms and in IU were associated with impulsive actions in the face of negative affect (i.e., negative urgency), but also greater premeditation and lower “functional” impulsivity (i.e., the ability to take quick action when it is advantageous to do so). Impulsivity led to an increment in the prediction of GAD symptoms and GAD status, over and above IU. Negative urgency and lower functional impulsivity were significant unique predictors of GAD severity or GAD status. The findings highlight a need to consider impulsivity in theories that implicate intolerance of negative affect and uncertainty in excessive and uncontrollable worry.

Information processing bias and pharmacotherapy outcome in older adults with generalized anxiety disorder

Information processing bias was evaluated in a sample of 25 older adults with generalized anxiety disorder (GAD) over the course of 12 weeks of escitalopram pharmacotherapy. Using the CANTAB Affective Go/No Go test, treatment response (as measured by the Hamilton Anxiety Rating Scale, Penn State Worry Questionnaire, and Generalized Anxiety Disorder Severity Scale) was predicted from a bias score (i.e., difference score between response latencies for negative and positive words) using mixed-models regression. A more positive bias score across time predicted better response to treatment. Faster responses to positive words relative to negative words were associated with greater symptomatic improvement over time as reflected by scores on the GADSS. There was a trend toward significance for PSWQ scores and no significant effects related to HAMA outcomes. These preliminary findings offer further insights into the role of biased cognitive processing of emotional material in the manifestation of late-life anxiety symptoms.

Metacognitive Beliefs in Late-Life Generalized Anxiety Disorder

The aim of this study was to determine the association between metacognitive beliefs, trait worry, and generalized anxiety disorder (GAD) among older adults. Sixty-six home health care clients aged 65 and older completed the Metacognitions Questionnaire-30 (MCQ-30) along with measures of worry and GAD severity Effect size estimates of differences on the MCQ-30 subscales between those diagnosed with and without GAD ranged from medium to large. The Positive Beliefs subscale was the strongest predictor of trait worry. However, negative beliefs about worry (specifically beliefs in the uncontrollability and dangers of worrying) predicted GAD symptom severity when also controlling for trait worry, and partially mediated the relationship between trait worry and GAD symptom severity. These findings suggest that theories positing a role for metacognitive beliefs in the etiology and maintenance of GAD may extend to older adults.

Pain Adversely Affects Outcomes to a Collaborative Care Intervention for Anxiety in Primary Care

Primary care patients with Panic Disorder (PD) and Generalized Anxiety Disorder (GAD) experience poorer than expected clinical outcomes, despite the availability of efficacious pharmacologic and non-pharmacologic treatments. A barrier to recovery from PD/GAD may be the co-occurrence of pain. To evaluate whether pain intensity interfered with treatment response for PD and/or GAD in primary care patients who had received collaborative care for anxiety disorders. A secondary data analysis of a randomized, controlled effectiveness trial comparing a telephone-delivered collaborative care intervention for primary care patients with severe PD and/or GAD to their doctor's "usual" care. Patients had to have a diagnosis of PD and/or GAD and a severe level of anxiety symptoms. The 124 patients randomized at baseline to the collaborative care intervention were analyzed. Participants were divided into two pain intensity groups based on their response to the SF-36 Bodily Pain scale (none or mild pain vs. at least moderate pain). Pain was assessed using the Bodily Pain scale of the SF-36. Anxiety symptoms were measured with the Hamilton Anxiety Rating Scale (HRS-A), Panic Disorder Severity Scale (PDSS) and Generalized Anxiety Disorder Severity Scale (GADSS). Measures were collected over 12 months. At baseline, patients with at least moderate pain were significantly more likely to endorse more anxiety symptoms on the HRS-A than patients with no pain or mild pain (P < .001). Among patients with severe anxiety symptoms, 65 % (80/124) endorsed experiencing at least moderate pain in the previous month. A significantly lesser number of patients achieved a 50 % improvement at 12 months on the HRS-A and GADSS if they had at least moderate pain as compared to patients with little or no pain (P = 0.01 and P = 0.04, respectively). Coexisting pain was common in a sample of primary care patients with severe PD/GAD, and appeared to negatively affect response to anxiety treatment.

Racial and ethnic differences in symptom severity of PTSD, GAD, and depression in trauma‐exposed, urban, treatment‐seeking adults

Urban, socially disadvantaged individuals are at high risk for traumatic event exposure and its subsequent psychiatric symptomatology. This study examined the association between race/ethnicity and symptom severity of posttraumatic stress disorder (PTSD), generalized anxiety disorder (GAD), and depression in an urban clinical sample of 170 trauma-exposed adults. In addition, this study investigated the role of socioeconomic position (SEP) and coping style in the relationship between race/ethnicity and posttrauma psychiatric symptom severity. Hierarchical regression analyses indicated that Blacks had lower depression symptom severity compared to Whites. No significant relationship was found between racial/ethnic group status and indices of SEP, PTSD, or GAD symptom severity. Adjustment for trauma exposure, gender, positive reframe coping, avoidance coping and negative coping accounted for 3%, 3%, 8%, 4%, and 3% of the variance in depression severity, respectively; however, Black race remained significantly associated with decreased depression symptom severity accounting for a statistically significant 5% of the variance in lower depression symptom severity. These preliminary findings and their clinical implications are discussed.

Dimensional indicators of generalized anxiety disorder severity for DSM-V

For DSM-V, simple dimensional measures of disorder severity will accompany diagnostic criteria. The current studies examine convergent validity and test–retest reliability of two potential dimensional indicators of worry severity for generalized anxiety disorder (GAD): percent of the day worried and number of worry domains. In study 1, archival data from diagnostic interviews from a community sample of individuals diagnosed with one or more anxiety disorders (n=233) were used to assess correlations between percent of the day worried and number of worry domains with other measures of worry severity (clinical severity rating (CSR), age of onset, number of comorbid disorders, Penn state worry questionnaire (PSWQ)) and DSM-IV criteria (excessiveness, uncontrollability and number of physical symptoms). Both measures were significantly correlated with CSR and number of comorbid disorders, and with all three DSM-IV criteria. In study 2, test–retest reliability of percent of the day worried and number of worry domains were compared to test–retest reliability of DSM-IV diagnostic criteria in a non-clinical sample of undergraduate students (n=97) at a large west coast university. All measures had low test–retest reliability except percent of the day worried, which had moderate test–retest reliability. Findings suggest that these two indicators capture worry severity, and percent of the day worried may be the most reliable existing indicator. These measures may be useful as dimensional measures for DSM-V.

Perseverative thought: A robust predictor of response to emotional challenge in generalized anxiety disorder and major depressive disorder

Generalized anxiety disorder (GAD) and major depressive disorder (MDD) frequently co-occur, yet the reasons for their comorbidity remain poorly understood. In the present experiment, we tested whether a tendency to engage in negative, repetitive thinking constitutes a common risk process for the two disorders. A mixed sample of adults with comorbid GAD–MDD (n=50), GAD only (n=35), MDD only (n=34), or no lifetime psychopathology (n=35) was administered noncontingent failure and success feedback on consecutive performance tasks. Perseverative thought (PT), measured by negative thought intrusions during a baseline period of focused breathing, emerged as a powerful prospective predictor of responses to this experimental challenge. Participants reporting more frequent negative thought intrusions at baseline, irrespective of thought content or diagnostic status, exhibited a stronger negative response to failure that persisted even after subsequent success. Higher PT over the course of the experiment was associated with later behavioral avoidance, with negative affect and other traits closely linked to anxiety and depression, and with the presence and severity of GAD and MDD. These findings provide evidence for a broadly-defined PT trait that is shared by GAD and MDD and contributes to adverse outcomes in these disorders.

Generalized Anxiety Disorder

This article describes the key features of generalized anxiety disorder (GAD) to help GPs recognize patients with the disorder and provide a management strategy that can be used in the primary care setting to support them. Management strategies are linked to recently updated National Institute for Health and Clinical Excellence (NICE) guidelines and include both drug treatments and psychological interventions. As a GP, the ability to screen at-risk patients, diagnose those with symptoms, assess the severity of GAD, provide education and self-help strategies and referral appropriately to specialist mental health services is important. Although the course of GAD tends to be relapsing and remitting, effective control of symptoms can help to allow patients to live a more normal life.

Interpersonal pathoplasticity in individuals with generalized anxiety disorder.

Recent theories of generalized anxiety disorder (GAD) have emphasized interpersonal and personality functioning as important aspects of the disorder. We examined heterogeneity in interpersonal problems in 2 studies of individuals with GAD (n = 47 and n = 83). Interpersonal subtypes were assessed with the Inventory of Interpersonal Problems-Circumplex (Alden, Wiggins, & Pincus, 1990). Across both studies, individuals with GAD exhibited heterogeneous interpersonal problems, and cluster analyses of these patients' interpersonal characteristics yielded 4 replicable clusters, identified as intrusive, exploitable, cold, and nonassertive subtypes. Consistent with our pathoplasticity hypotheses, clusters did not differ with GAD severity, anxiety severity, or depression severity. Clusters in Study 2 differed on rates of personality disorders, including avoidant personality disorder, further providing support for the validity of interpersonal subtypes. The presence of interpersonal subtypes in GAD may have important implications for treatment planning and efficacy.

Disorder-specific impact of coordinated anxiety learning and management treatment for anxiety disorders in primary care.

Anxiety disorders commonly present in primary care, where evidence-based mental health treatments often are unavailable or suboptimally delivered. To compare evidence-based treatment for anxiety disorders with usual care (UC) in primary care for principal and comorbid generalized anxiety disorder (GAD), panic disorder (PD), social anxiety disorder (SAD), and posttraumatic stress disorder (PTSD). A randomized controlled trial comparing the Coordinated Anxiety Learning and Management (CALM) intervention with UC at baseline and at 6-, 12-, and 18-month follow-up assessments. Seventeen US primary care clinics. Referred primary care sample, 1004 patients, with principal DSM-IV diagnoses of GAD (n = 549), PD (n = 262), SAD (n = 132), or PTSD (n = 61) (mean [SD] age, 43.7 [13.7] years; 70.9% were female). Eighty percent of the participants completed 18-month follow-up. CALM (cognitive behavior therapy and pharmacotherapy recommendations) and UC. Generalized Anxiety Disorder Severity Scale, Panic Disorder Severity-Self-report Scale, Social Phobia Inventory, and PTSD Checklist-Civilian Version scores. CALM was superior to UC for principal GAD at 6-month (-1.61; 95% confidence interval [CI], -2.42 to -0.79), 12-month (-2.34; -3.22 to -1.45), and 18-month (-2.37; -3.24 to -1.50), PD at 6-month (-2.00; -3.55 to -0.44) and 12-month (-2.71; -4.29 to -1.14), and SAD at 6-month (-7.05; -12.11 to -2.00) outcomes. CALM was superior to UC for comorbid SAD at 6-month (-4.26; 95% CI, -7.96 to -0.56), 12-month (-8.12, -11.84 to -4.40), and 18- month (-6.23, -9.90 to -2.55) outcomes. Effect sizes favored CALM but were not statistically significant for other comorbid disorders. CALM (cognitive behavior therapy and pharmacotherapy medication recommendations) is more effective than is UC for principal anxiety disorders and, to a lesser extent, comorbid anxiety disorders that present in primary care.

The role of values-consistent behavior in generalized anxiety disorder

Theory and research suggest that generalized anxiety disorder (GAD) is associated with diminished quality of life and restriction in valued action. The purpose of this study was to examine the relevance of values-consistent behavior (valued action) in understanding the impairment in quality of life in GAD. Treatment-seeking clients with a principal diagnosis of GAD (n = 30) were compared with demographically matched nonanxious controls (n = 30) using self-report measures. Participants with GAD reported significantly less valued action compared with controls, and within the GAD group, diminished valued action was not fully explained by depression comorbidity. Valued action was significantly correlated with measures of experiential avoidance, distress about emotions, and quality of life. Further, consistent with a theoretical model of GAD, restrictions in valued action contributed unique variance to diminished quality of life over and above the contributions of gender, GAD severity, experiential avoidance, distress about emotions, and depression comorbidity. Finally, an acceptance-based behavioral therapy significantly improved self-reports of valued action for GAD clients with 40% achieving clinically significant change in this domain. The findings provide preliminary support for the relevance of valued action in understanding the functional impairment associated with GAD, and the beneficial effects of an acceptance-based behavior therapy in increasing valued action.