Conceptual,methodological, and clinical issues in the assessment of anxiety disorders

Many conceptual, methodological, and clinical issues remain unresolved in the assessment of anxiety disorders. Despite the prevalence, incidence, chronicity, and severity of anxiety disorders, research efforts and funding have fallen behind with regard both to other disorders and to addressing critical issues in the field. The primary objective of this paper is to provide a scientific critique regarding a number of often ignored yet salient considerations in anxiety-disorders assessment. Critical analyses of and recommendations regarding the multidimensional nature of anxiety, comorbidity, uniformity myths, synchrony, normative comparisons, psychometric properties of measures, and treatment integrity are offered. Finally, promising areas of clinical research are presented to enhance further the current understanding of the complexities inherent in assessing anxiety disorders.Preparation of this paper was supported in part by NIMH Grant MH36299.     

Social phobia features across the DSM-III-R anxiety disorders

One hundred sixty subjects meeting DSM-III-R criteria for the five major anxiety disorders were compared on the extent to which they reported features characteristic of social phobia. The results indicated that many patients in the anxiety disorder categories experience some degree of social anxiety. The differences between subjects with a primary diagnosis of social phobia and subjects with other anxiety disorders appear to be chiefly quantitative on this feature. Compared to the other anxiety disorders, social phobics report fear and avoidance in response to a greater number of social situations and report greater interference in their lives due to social phobic concerns. Among the anxiety disorders, generalized anxiety disorder appears to be associated with the greatest degree of social anxiety, and simple phobia with the least.     

Electrodermal lability in anxiety disorders

Twenty-eight anxiety patients, aged below 50 years, were diagnosed according to DSM-III-R criteria (panic disorder with and without agoraphobia, generalised anxiety disorder, and anxiety disorder not otherwise specified). The patients were characterised by high levels of state and trait anxiety and neuroticism, compared with the controls. However, there were no differences between patients and controls in electrodermal habituation rate, non-specific activity, or skin resistance level. When the patients were divided into electrodermally labile and stable subjects, significant differences were found between patients and controls in both electrodermal activity and Eysenck's personality dimensions. The labile patients were more introverted and attained higher psychoticism scores than either the stable patients or controls. Duration of anxiety symptoms removed the difference found in extroversion, but not in any other variable. The results are discussed in relation to the utility of electrodermal measurements in validation of diagnostic entities. It is concluded, that from the psychophysiological point of view, anxiety disorders may be examined within a dimensional framework.     

Comorbidity between and within childhood externalizing and internalizing disorders: reflections and directions

The term and concept of lcomorbidity has been mired in controversy, although there is little question that the existence of covariation among psychiatric diagnoses poses significant challenges to current models of psychiatric classification and diagnosis. The papers in this Special Section underscore a number of important issues relevant to the comorbidity between and within childhood externalizing and internalizing disorders, and illustrate both methodological and substantive reasons for such comorbidity. Weiss, Susser, and Catron's distinction among common, broad-band specific, and narrow-band specific features provides a helpful framework for understanding the comorbidity of childhood externalizing and internalizing disorders (B, Weiss, K. Susser, & T. Catron, 1998). Hierarchical models of psychopathology help to dissolve the distinction between splitters and lumpers and point to variables that may elucidate the etiology of externalizing and internalizing disorders.     

Threat interpretation bias as a vulnerability factor in childhood anxiety disorders

The present study examined threat interpretation biases in children 7-12 years of age with separation, social and generalised anxiety disorders (N=15), non-anxious offspring at risk due to parental anxiety (N=16) and non-anxious controls of non-anxious parents (N=14). Children provided interpretations of ambiguous situations to assess cognitive, emotional and behavioural responses. In comparison with non-anxious control children and at-risk children who did not differ from each other, anxious children reported stronger negative emotion and less ability to influence ambiguous situations. These results suggest that threat interpretation bias may be a cognitive factor associated with ongoing childhood anxiety but not a vulnerability factor associated with parental anxiety.     

Attention bias for social threat in youth with tic disorders: Links with tic severity and social anxiety

Many individuals with Tourette syndrome and chronic tic disorders (TS/CTDs) report poor social functioning and comorbid social anxiety. Yet limited research has investigated the role of cognitive factors that highlight social threats in youth with TS/CTD, and whether these biases underlie tic severity and co-occurring social anxiety. This study examined whether selective attention to social threat is enhanced young people with TS/CTDs compared to healthy controls, and whether attention biases are associated with tic severity and social anxiety. Twenty seven young people with TS/CTDs and 25 matched control participants completed an experimental measure of attention bias toward/away from threat stimuli. A clinician-rated interview measuring tic severity/impairment (YGTSS Total Score) and questionnaire measures of social anxiety were completed by participants and their parents. Young people with TS/CTD showed an attention bias to social threat words (relative to benign words) compared to controls but no such bias for social threat faces. Attention bias for social threat words was associated with increasing YGTSS Total Score and parent-reported social anxiety in the TS/CTDs group. Mediation analysis revealed a significant indirect path between YGTSS Total Score and social anxiety, via attention to social threat. Tentatively, these associations appeared to be driven by impairment rather than tic severity scores. Preliminary data suggests that youth with TS/CTD have enhanced attention to threat, compared to controls, and this is associated with impairment and social anxiety. Attention to threat could offer a cognitive mechanism connecting impairment and social anxiety, and so be a valuable trans-diagnostic treatment target.     

The importance of assessing treatment integrity: An example in the anxiety disorders

One purpose of this investigation was to examine the importance of assessing treatment integrity in a study evaluating a treatment for specific anxiety disorders. Three subjects, two social phobics and one simple phobic, received self-instruction training (Phase I) followed by exposure and self-instruction training (Phase II) in a multiple baseline across subjects design. All subjects were assessed during a pretreatment baseline and throughout treatment using measures of treatment integrity and measures of change in phobic severity. Improvement took place at different times for different subjects. Measures of treatment integrity, which consisted of monitoring of self-statements as well as practice outside the session, indicated that treatment was not always received as intended and that improvement was correlated with practice. The usefulness of measures of treatment integrity in both clinical and research settings is highlighted.     

Cultural considerations using the structured clinical interview for DSM-III for mood and anxiety disorders assessment

This paper focuses on the impact that culture has upon standardized or structured interviews. It briefly reviews how these interviews evolved from a primary research function, what they can teach us about clinical work, and the multiple ways that culture influences these supposedly objective instruments and the diagnoses which follow from their use. Although the use of structured interviews and standardized diagnostic criteria has been a major advance for the field in terms of reliability, care needs to be exercised when evaluating individuals from disparate cultural backgrounds.     

Parents' perceptions of pharmacological and cognitive-behavioral treatments for childhood anxiety disorders

Cognitive-behavioral therapy (CBT) and pharmacotherapy are the most well-established treatments for childhood anxiety disorders. This study examined how parents (N=71) seeking treatment for their child's anxiety disorder perceive the acceptability, believability, and effectiveness of these treatments. While both treatments were perceived favorably, CBT was rated as more acceptable, believable, and effective in the short- and long-term. Children's treatment history influenced parents' perceptions of pharmacotherapy, with parents of children with no treatment history perceiving medication treatment as less acceptable and believable than parents of children with a history of medication alone or in combination with behavior therapy. No effect of treatment history was found for perceptions of CBT. Significant positive correlations emerged between parents' perceived acceptance and believability for pharmacotherapy and child age and level of dysfunction due to their child's anxiety, respectively. The level of the child's anxiety was not significantly correlated with parents' perceptions of either CBT or pharmacotherapy. Our results suggest that parents of anxious children prefer CBT to medication for the treatment of their child's anxiety disorder. Directions for future research are discussed.     

An examination of the interactions between mothers and children with anxiety disorders

This study examined the association between parenting styles and mother and child anxiety. Maternal overinvolvement and negativity/criticism were evaluated during a speech preparation task (N = 135 dyads) and a Five Minute Speech Sample (FMSS) from mothers (N = 155). During the speech task interaction, mothers of anxious children (aged 4–16 years), regardless of their own anxiety, were observed to be more overinvolved than mothers of nonanxious children. Similarly, the FMSS showed that mothers of anxious children (aged 4–17 years) were more overprotective, self-sacrificing, or nonobjective than mothers of nonanxious children, irrespective of maternal anxiety status. No differences in maternal negativity were found on the speech task between any of the groups. However, the FMSS showed that mothers of anxious children were more critical than mothers of nonanxious children, regardless of maternal anxiety status. These results support the relationship between overinvolved, critical parenting and child anxiety, but suggest that maternal anxiety is not associated with increased overinvolvement or criticism. Theoretical implications are discussed.     

Rationale and principles for early intervention with young children at risk for anxiety disorders

Anxiety disorders are one of the most prevalent categories of disorder among adults and children. Children of parents with anxiety disorders are known to be at higher risk for anxiety disorders themselves, with manifestations of this risk often appearing in toddlerhood or early childhood. Yet because affected parents are often unskilled in anxiety management, they often have difficulty in helping their young children learn to manage anxiety. Literature on the course of anxiety disorders through childhood and on effective cognitive-behavioral interventions suggests that preventive interventions even with very young children could potentially be of benefit in mitigating the course of these often debilitating disorders. This paper outlines the rationale for offering early or preventive interventions to preschool-age children at risk and their parents and discusses means of identifying children to target for intervention and the importance of parental involvement. Drawing upon the literature on parental factors in childhood anxiety disorders as well as on effective intervention strategies with preschool-age children, it delineates principles for intervention with parents and effective components of intervention with youngsters in this age range.     

Infant–mother attachment security and children's anxiety and aggression at first grade

With a large and diverse sample of children from the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development, the role of infant–mother attachment security as a protective factor against the development of children's anxious and aggressive behaviors at first grade was examined. When child's sex, family income, maternal sensitivity, and prior levels of anxiety and aggression were controlled for, attachment security at 15 months of age was found to moderate the effects of negative life events families experienced, thereby protecting children from experiencing symptoms of anxiety, but not aggression, at 4.5 years of age. Children classified as insecurely attached at 15 months of age who experienced many stressful life events exhibited more anxiety symptoms in first grade than children classified as securely attached who similarly experienced many negative life events. These findings are interpreted within attachment theory, which predicts that early attachment security has a unique role in children's anxiety experiences later in childhood.     

An Evolutionary Life History Framework for Psychopathology

In this article, I outline a general framework for the evolutionary analysis of mental disorders based on the concepts of life history theory. I synthesize and extend a large body of work showing that individual differences in life history strategy set the stage for the development of psychopathology. My analysis centers on the novel distinction between fast spectrum and slow spectrum disorders. I describe four main causal pathways from life history strategies to psychopathology, argue that psychopathology can arise at both ends of the fast–slow continuum of life history variation, and provide heuristic criteria for classifying disorders as fast or slow spectrum pathologies. I then apply the fast–slow distinction to a diverse sample of common mental disorders: externalizing disorders, schizophrenia and autism spectrum disorders, obsessive-compulsive disorders, eating disorders, and depression. The framework integrates previously disconnected models of psychopathology within a common frame of reference and has far-reaching implications for the classification of mental disorders.     

NR3C1基因多态性及单倍型、父母教养方式对青少年焦虑障碍的影响

NR3C1参与HPA轴调节,与应激相关的身心疾病关系密切。以往针对NR3C1与焦虑障碍的研究基本以成人为考察对象,且大多关注负性生活事件等个体层面环境变量。本研究采用病例-对照设计,以238名青少年为被试(焦虑障碍117人,对照121人),旨在考察NR3C1常见位点rs6191、rs6196、rs41423247的多态性、单倍型以及父母不同类型教养方式对焦虑障碍的影响。结果表明rs6191 GG基因型、rs6196 AA基因型、rs41423247 GG基因型与低焦虑障碍风险相关。父母过多的过度保护与冷漠拒绝、父亲过少的温暖关怀可预测较高的焦虑障碍风险。rs41423247多态性与母亲温暖关怀存在交互作用:rs41423247 GG基因型只在母亲温暖关怀较多时能降低焦虑障碍风险,在母亲温暖关怀较少时与焦虑障碍并无显著相关。此外,rs6191-rs6196-rs41423247构成的单倍型GAG与低焦虑障碍风险显著关联,TGC与高焦虑障碍风险显著关联,且二者与母亲温暖关怀、母亲过度保护分别存在交互作用。未来可采用追踪研究,从表观遗传层面探讨教养方式与NR3C1影响焦虑障碍的内在机制。     

Behavioral testing of anxiety: Issues,diagnosis, and practice

This paper cites certain issues of concern in the area of assessment of anxiety and the anxiety disorders. It attempts to describe, in general terms, the potential of behavioral testing for clarifying these issues and for using these tests to supplement clinical interviews, rating scales, and self-report measures. Moreover, the paper describes a potential compatibility between objective behavioral testing and the most recent (third revision)Diagnostic and Statistical Manual of Mental Disorders.The opinions expressed in this paper are those of the author alone and do not necessarily reflect the position of the National Institute of Mental Health.     

Parenting behaviors in parents with anxiety disorders

Anxiety disorders are familial, and although considerable evidence supports the role of genetic/biological parameters in their development, these alone do not entirely explain their etiology. In this study, the role of parenting behavior as a possible factor in the transmission of anxiety from parent to child was examined. Using interview, self-report, and direct behavioral observation, behaviors of parents with an anxiety disorder were compared to those of parents without an anxiety disorder on a number of dimensions, but particularly with respect to whether anxious parents actively inhibited their children from engaging in normal age appropriate activities. These behaviors were assessed during routine activities and in a structured non-conflictual play task. Although anxious parents did not overtly restrict their child's behavior in either type of activity, they reported higher levels of distress when their children were engaged in these activities. Similarly, the "emotional climate" in families with an anxious parent differed significantly from families without an anxious parent. The results are discussed in terms of how parenting behaviors might influence the development of maladaptive anxiety via social learning and information transfer, and their heuristic implications.     

Most people with mental disorders are happy: A 3-year follow-up in the Dutch general population

The nature of the associations between life satisfaction, anxiety, and depression remains elusive. Using questionnaire data from a large population-based sample (N = 6326) of young adult Norwegian twins (aged 18–31 years) we explored the extent to which latent genetic and environmental factors are (1) common or distinct, and (2) sex-specific. Phenotypic correlations ranged between 0.44 and 0.70 in females, and between 0.41 and 0.69 in males. Environmental influences accounted for 75% of these correlations in females, and less than 50% in males. Genetic and environmental sources of life satisfaction, symptoms of anxiety, and symptoms of depression were shared mostly, but the magnitude of the effects was different in males and females. In both sexes, however, aetiological factors enhancing life satisfaction were simultaneously protecting against feelings of sadness and displeasure, but contributed less to countervailing anxiety and tension.     

Comorbid anxiety and mood disorders among persons with social anxiety disorder.

Axis I comorbidity is associated with greater severity of social anxiety disorder. However, the differential effects of comorbid mood and anxiety disorders on symptom severity or treatment outcome have not been investigated. We evaluated 69 persons with uncomplicated social anxiety disorder, 39 persons with an additional anxiety disorder, and 33 persons with an additional mood disorder (with or without additional anxiety disorders). Those with comorbid mood disorders reported greater duration of social anxiety than those with uncomplicated social anxiety disorder. They were also judged, before and after 12 weeks of cognitive-behavioral group treatment and at follow-up, to be more severely impaired than those with no comorbid diagnosis. In contrast, persons with comorbid anxiety disorders were rated as more impaired than those with no comorbid diagnosis on only a single measure. Type of comorbid diagnosis did not result in differential rates of improvement of social anxiety disorder.     

Prospective Relations Between Organized Activity Participation and Psychopathology During Adolescence

This longitudinal study examined psychopathology as a predictor and outcome of organized activity involvement during high school among 198 adolescents who varied in risk for psychopathology as a function of their mother's depression history. Higher levels of internalizing and externalizing symptoms in eighth grade significantly predicted lower levels of involvement in academic clubs during high school, over and above risk and SES. Tobacco use prior to high school predicted lower levels of involvement overall and in academic clubs and performance arts. Controlling for psychopathology prior to high school, higher levels of activity involvement were associated with lower levels of externalizing symptoms, less tobacco use, and fewer diagnoses of behavior disorders and substance abuse in 12th grade. The positive association between risk and adolescent psychopathology was not buffered by adolescent activity involvement. Overall, these findings suggest that involvement in organized activities may contribute to lower levels of externalizing psychopathology during high school even when controlling for prior psychopathology.