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The Contribution of Worry Behaviors to the Diagnosis of Generalized Anxiety Disorder

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Abstract

Worry behaviors (i.e., overt acts to avoid or cope with worry-induced distress) have been recognized as being important in the psychopathology and treatment of generalized anxiety disorder (GAD). This study evaluated the worry behaviors criterion proposed for DSM-5 GAD, but was ultimately not adopted due to insufficient evidence. In 800 outpatients with emotional disorders (366 with GAD), most patients with GAD (92.6%) met the proposed worry behaviors criterion, which was at a rate significantly higher than other patient groups (e.g., patients with mood disorders). Patients who met the worry behaviors criterion had more severe GAD than patients who did not. The worry behaviors criterion, and 3 of its 4 constituent behaviors, were associated with no better than “fair” interrater reliability. Diagnostic reliability of GAD was not improved in cases where both interviewers agreed the worry behaviors criterion was met. The worry behaviors criterion significantly predicted DSM-5 GAD holding core GAD features constant (e.g., excessive worry), but this contribution was weak and did not appreciably improve the classification accuracy of GAD diagnostic status. Mixed support was obtained for the discriminant validity of the worry behaviors criterion in relation to mood disorders. Raising the proposed threshold of the criterion (requiring 2 instead of 1 behaviors) did not result in a substantial improvement in reliability, prediction, and classification accuracy. Although additional research is warranted (e.g., importance of worry behaviors in the treatment and natural course of GAD), the results raise questions about the role of worry behaviors in the diagnostic classification of GAD.

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Notes

  1. The No GAD and OSAD groups presented in Table 2 are not mutually exclusive because the No GAD group was comprised in part by patients who were assigned OSAD.

  2. Because the ADIS-5 ratings of excessiveness of worry and uncontrollability of worry were highly correlated (r = .92), uncontrollability of worry was not included as a predictor in these analyses.

  3. The worry behaviors criterion also remained a significant, albeit weak, predictor of GAD status when the presence/absence of a current mood disorder diagnosis was used as the depression covariate, OR = 2.72, LRT = 12.01, p < .001, ΔR2L = .01.

  4. Although dimensional approaches to disorder classification (e.g., Brown and Barlow 2009) have been proposed in part to reduce measurement error associated with imposing categorical cut-offs on symptom features that operate in a continuous fashion (e.g., binary thresholds of symptom counts and severity in DSM-5 diagnoses), it is interesting to note that the interrater reliability of the dimensional and categorical ratings of the worry behaviors did not appreciably differ (see Table 1).

  5. It is also noteworthy that “threshold” issues were a relatively less common reason for GAD disagreements (9%) in a study examining the sources of diagnostic unreliability of DSM-IV anxiety and mood disorders (Brown et al. 2001b).

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Acknowledgements

The authors thank Anthony J. Rosellini for his comments on this manuscript.

Funding

This research was funded by a grant from the National Institute of Mental Health. (R01 MH039096; PI: Brown).

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Authors and Affiliations

  1. Center for Anxiety & Related Disorders, Department of Psychological and Brain Sciences, Boston University, 648 Beacon Street, 6th floor, Boston, MA, 02215-2013, USA

    Timothy A. Brown & Esther S. Tung

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  1. Timothy A. Brown
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  2. Esther S. Tung
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Correspondence to Timothy A. Brown.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Conflict of Interest

Timothy A. Brown and Esther S. Tung declare that they have no conflict of interest.

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Informed consent was obtained from all individual participants included in the study.

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Brown, T.A., Tung, E.S. The Contribution of Worry Behaviors to the Diagnosis of Generalized Anxiety Disorder. J Psychopathol Behav Assess 40, 636–644 (2018). https://doi.org/10.1007/s10862-018-9683-5

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