The generalized anxiety spectrum: prevalence, onset, course and outcome (original) (raw)

Abstract

Background

Generalized anxiety disorder (GAD) is generally considered to be a chronic condition, waxing and waning in severity; however prospective investigation of the course of GAD in community samples is lacking. This study seeks to fill that gap, by identifying the whole spectrum of generalized anxiety syndromes, sub-typing them according to their duration and frequency of occurrence, and evaluating their long-term course and outcome in the community.

Method

The prospective Zurich Study assessed psychiatric and somatic syndromes in a community sample of young adults (N = 591) (aged 20 years at first interview) by six interviews over a period of 20 years (1979–1999). GAD syndromes were defined by DSM-III symptom criteria without applying any exclusion criteria. A spectrum of generalized anxiety was defined by duration: 6 months (DSM-IV), 1 month (DSM-III), ≤2 weeks (with weekly occurrence over one year), and anxiety symptoms. From 1978 (screening) to 1999 the annual presence of symptoms and treatment was assessed. Persistence of anxiety was defined by the almost daily presence of symptoms over the previous 12 months.

Results

The annual incidence of DSM-III GAD increased considerably between the ages of 20 and 40. The average age of onset of symptoms was 15.6 years; in 75% of cases it occurred before the age of 20. 75 of 105 DSM-III GAD cases had at least one follow-up. At their individual last follow-up, 12 of those 75 subjects (16%) were re-diagnosed as having GAD, 22 (29%) manifested subthreshold syndromes or anxiety symptoms, while 39 cases, the majority, (52%) were symptom-free; 5 of the 12 re-diagnosed GAD cases were persistent (corresponding to 7% of all 75 initial GAD cases). In their twenties they were treated at some time in 6% of all years, but in their thirties this figure rose to 12%. At their individual last follow-up 26% of 6-month GAD subjects and 22% of 1-month GAD subjects were still being treated. Treated vs. non-treated subjects did not differ in terms of gender but did differ in severity, persistence and in comorbidity with bipolar-II disorder, social phobia, obsessive-compulsive syndromes and substance-use disorders.

Limitations

Results are based on a relatively small sample and cannot be generalized to adults aged over 40 years.

Conclusions

The course of DSM-III-defined GAD may not be chronic, as previously suggested, but mainly recurrent with intervening symptom-free periods of recovery in about half of cases. Over a period of 20 years there was more improvement than progression within the anxiety spectrum.

Access this article

Log in via an institution

Subscribe and save

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

References

  1. American Psychiatric Association (2000) Diagnostic and statistical manual of mental disorders: DSM-IV-TR. American Psychiatric Association, Washington
    Google Scholar
  2. Anderson DJ, Noyes R, Crowe RR (1984) A comparison of panic disorder and generalized anxiety disorder. Am J Psychiatry 141:572–576
    PubMed CAS Google Scholar
  3. Angst J, Dobler-Mikola A, Binder J (1984) The Zurich Study—a prospective epidemiological study of depressive, neurotic and psychosomatic syndromes. I. Problem, methodology. Eur Arch Psychiatr Neurol Sci 234:13–20
    Article CAS Google Scholar
  4. Angst J, Gamma A, Benazzi F, Ajdacic V, Eich D, Rössler W (2003) Toward a re-definition of subthreshold bipolarity: epidemiology and proposed criteria for bipolar-II, minor bipolar disorders and hypomania. J Affect Disord 73:133–146
    Article PubMed Google Scholar
  5. Angst J, Gamma A, Bienvenu OJ, Eaton WW, Ajdacic V, Eich D, Rössler W (2006) Varying temporal criteria for generalized anxiety disorder: prevalence and clinical charactersitics in a young age cohort. Psychol Med 36:1283–1292
    Article PubMed Google Scholar
  6. Angst J, Gamma A, Neuenschwander M, Ajdacic-Gross V, Eich D, Rössler W, Merikangas KR (2005) Prevalence of mental disorders in the Zurich cohort study: a 20 year prospective study. Epidemiol Psichiatr Soc 14:68–76
    PubMed Google Scholar
  7. Angst J, Merikangas KR (1997) The depressive spectrum: diagnostic classification and course. J Affect Disord 45:31–40
    Article PubMed CAS Google Scholar
  8. Angst J, Wicki W (1992) The Zurich study: XIII. Recurrent brief anxiety. Eur Arch Psychiatry Clin Neurosci 241:296–300
    Article PubMed CAS Google Scholar
  9. Ballenger JC, Davidson JRT, Lecrubier Y, Nutt DJ, Borkovec TD, Rickels K, Stein DJ, Wittchen HU (2001) Consensus statement on generalized anxiety disorder from the international consensus group on depression and anxiety. J Clin Psychiatry 62:53–58
    PubMed Google Scholar
  10. Barlow DH, Blanchard EB, Vermilyea JA, Vermilyea BB, Dinardo PA (1986) Generalized anxiety disorder: description and reconceptualization. Am J Psychiatry 143:40–44
    PubMed CAS Google Scholar
  11. Bienvenu OJ, Nestadt G, Eaton WW (1998) Characterizing generalized anxiety: temporal and symptomatic thresholds. J Nerv Ment Dis 186:51–56
    Article PubMed CAS Google Scholar
  12. Blazer DG, Hughes D, George LK, Swartz M, Boyer R (1991) Generalized anxiety disorder. In: Robins LN, Regier DA (eds) Psychiatric disorders in America: the epidemiologic catchment area study. The Free Press, New York, pp 180–203
    Google Scholar
  13. Bruce SE, Yonkers KA, Otto MW, Eisen JL, Weisberg RB, Pagano M, Shea MT, Keller MB (2005) Influence of psychiatric comorbidity on recovery and recurrence in generalized anxiety disorder, social phobia, and panic disorder: a 12-year prospective study. Am J Psychiatry 162:1179–1187
    Article PubMed Google Scholar
  14. Carter RM, Wittchen HU, Pfister H, Kessler RC (2001) One-year prevalence of subthreshold and threshold DSM-IV generalized anxiety disorder in a nationally representative sample. Depress Anxiety 13:78–88
    Article PubMed CAS Google Scholar
  15. Cayedo N, Griez EJL (2001) Generalised anxiety disorder. In: Griez EJL, Faravelli C, Nutt D, Zohar J (eds) Anxiety disorders. An introduction to clinical management and research. Wiley, Chichester, pp 187–204
    Google Scholar
  16. Derogatis LR (1977) SCL-90. Administration, scoring and procedures manual-I for the R (revised) version and other instruments of the psychopathology rating scale series. Johns Hopkins University School of Medicine, Chicago
    Google Scholar
  17. Dunn G, Pickles A, Tansella M, Vazquez-Barquero J-L (1999) Two-phase epidemiological surveys in psychiatry. Br J Psychiatry 174:95–100
    Article PubMed CAS Google Scholar
  18. Eich D, Ajdacic-Gross V, Condrau M, Huber H, Gamma A, Angst J, Rössler W (2003) The Zurich study: participation patterns and symptom checklist 90-R scores in six interviews, 1979–99. Acta Psychiatr Scand 108:S11–S14
    Article Google Scholar
  19. Judd LL, Kessler RC, Paulus MP, Zeller PV, Wittchen H-U, Kunovac JL (1998) Comorbidity as a fundamental feature of generalized anxiety disorders: results from the national comorbidity study (NCS). Acta Psychiatr Scand 98:6–11
    Article Google Scholar
  20. Kessler RC (2000) The epidemiology of pure and comorbid generalized anxiety disorder: a review and evaluation of recent research. Acta Psychiatr Scand 102:7–13
    Article Google Scholar
  21. Kessler RC, Brandenburg N, Lane M, Roy-Byrne P, Stang PD, Stein DJ, Wittchen HU (2005) Rethinking the duration requirement for generalized anxiety disorder: evidence from the national comorbidity survey replication. Psychol Med 35:1073–1082
    Article PubMed Google Scholar
  22. Kessler RC, Wittchen HU (2002) Patterns and correlates of generalized anxiety disorder in community samples. J Clin Psychiatry 63:4–10
    PubMed Google Scholar
  23. Lester H, Gask L (2006) Delivering medical care for patients with serious mental illness or promoting a collaborative model of recovery? Br J Psychiatry 188:401–402
    Article PubMed Google Scholar
  24. Rickels K, Rynn MA (2001) What is generalized anxiety disorder? J Clin Psychiatry 62:4–12
    PubMed Google Scholar
  25. Rubio G, López-Ibor JJ (2007) Generalized anxiety disorder: a 40-year follow-up study. Acta Psychiatr Scand 115:372–379
    Article PubMed CAS Google Scholar
  26. Stein DJ (2001) Comorbidity in generalized anxiety disorder: impact and implications. J Clin Psychiatry 62:29–34
    PubMed Google Scholar
  27. Wittchen HU (2002) Generalized anxiety disorder: prevalence, burden, and cost to society. Depress Anxiety 16:162–171
    Article PubMed Google Scholar
  28. Wittchen HU, Hoyer J (2001) Generalized anxiety disorder: nature and course. J Clin Psychiatry 62:15–19
    PubMed Google Scholar
  29. Wittchen HU, Zhao S, Kessler RC, Eaton WW (1994) DSM-III-R generalized anxiety disorder in the national comorbidity survey. Arch Gen Psychiatry 51:355–364
    PubMed CAS Google Scholar
  30. Woodman CL, Noyes R, Black DW, Schlosser S, Yagla S (1999) A 5-year follow-up study of generalized anxiety disorder and panic disorder. J Nerv Ment Dis 187:3–9
    Article PubMed CAS Google Scholar
  31. Yonkers KA, Bruce SE, Dyck IR, Keller MB (2003) Chronicity, relapse, and illness—course of panic disorder, social phobia, and generalized anxiety disorder: findings in men and women from 8 years of follow-up. Depress Anxiety 17:173–179
    Article PubMed Google Scholar

Download references

Acknowledgments

This work was supported by Grant 3200-050881.97/1 of the Swiss National Science Foundation.

Author information

Authors and Affiliations

  1. Zurich University Psychiatric Hospital, Lenggstrasse 31, P.O. Box 1931, 8032, Zurich, Switzerland
    Jules Angst, Alex Gamma, Vladeta Ajdacic-Gross & Wulf Rössler
  2. Clinical Neuroscience Division, School of Medicine, University of Southampton, Southampton, UK
    David S. Baldwin

Authors

  1. Jules Angst
    You can also search for this author inPubMed Google Scholar
  2. Alex Gamma
    You can also search for this author inPubMed Google Scholar
  3. David S. Baldwin
    You can also search for this author inPubMed Google Scholar
  4. Vladeta Ajdacic-Gross
    You can also search for this author inPubMed Google Scholar
  5. Wulf Rössler
    You can also search for this author inPubMed Google Scholar

Corresponding author

Correspondence toJules Angst.

Rights and permissions

About this article

Cite this article

Angst, J., Gamma, A., Baldwin, D.S. et al. The generalized anxiety spectrum: prevalence, onset, course and outcome.Eur Arch Psychiatry Clin Neurosci 259, 37–45 (2009). https://doi.org/10.1007/s00406-008-0832-9

Download citation

Keywords