Compulsive behavior in generalized anxiety disorder and obsessive-compulsive disorder

Short-term functions and long-term consequences of checking behavior as a transdiagnostic phenomenon: protocol for a systematic review

INTRODUCTION

Checking behaviour (CB) occurs in various mental health problems. Cognitive-behavioural models for these mental disorders share similar theoretical assumptions. Thus, they postulate a negative reinforcing effect of CB by reducing negative affect (ie, anxiety) and a maintenance of the pathology due to a lack of reality testing of concerns. This paper details methods for a systematic review that will be conducted to synthesise empirical evidence testing these theoretical assumptions across obsessive-compulsive, generalised anxiety, eating, body dysmorphic and illness anxiety disorder. The results are expected to foster our understanding of the mechanisms of action underlying CB, which is of high clinical relevance. Depending on whether or not the findings confirm the model assumptions regarding CB, the focus of treatments would need to be intensified or modified.

METHODS AND ANALYSIS

We will search PsycINFO, PubMed, PSYNDEX and Scopus for studies investigating the emotional state in which CB is being used as well as the immediate and longer-term effects of CB on cognitive and emotional measures in clinical and analogue samples. The selection process, data extraction and quality assessment of included studies will be performed by two independent reviewers. In the case of inconsistencies, a third reviewer will be involved. Study results will be reported in a narrative synthesis.

ETHICS AND DISSEMINATION

Ethics approval will not be required as this is a protocol for systematic review. The results are mainly disseminated through peer-reviewed publications.

PROSPERO REGISTRATION NUMBER

CRD42021238835.

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

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.

Maladaptive Behaviours Associated with Generalized Anxiety Disorder: An Item Response Theory Analysis

Background: Cognitive models of generalized anxiety disorder (GAD) suggest that maladaptive behaviours may contribute to the maintenance of the disorder; however, little research has concentrated on identifying and measuring these behaviours. To address this gap, the Worry Behaviors Inventory (WBI) was developed and has been evaluated within a classical test theory (CTT) approach. Aims: As CTT is limited in several important respects, this study examined the psychometric properties of the WBI using an Item Response Theory approach. Method: A large sample of adults commencing treatment for their symptoms of GAD (n = 537) completed the WBI in addition to measures of GAD and depression symptom severity. Results: Patients with a probable diagnosis of GAD typically engaged in four or five maladaptive behaviours most or all of the time in an attempt to prevent, control or avoid worrying about everyday concerns. The two-factor structure of the WBI was confirmed, and the WBI scales demonstrated good reliability across a broad range of the respective scales. Together with previous findings, our results suggested that hypervigilance and checking behaviours, as well as avoidance of saying or doing things that are worrisome, were the most relevant maladaptive behaviours associated with GAD, and discriminated well between adults with low, moderate and high degrees of the respective WBI scales. Conclusions: Our results support the importance of maladaptive behaviours to GAD and the utility of the WBI to index these behaviours. Ramifications for the classification, theoretical conceptualization and treatment of GAD are discussed.

The Worry Behaviors Inventory: Assessing the behavioral avoidance associated with generalized anxiety disorder

BACKGROUND

Understanding behavioral avoidance associated with generalized anxiety disorder (GAD) has implications for the classification, theoretical conceptualization, and clinical management of the disorder. This study describes the development and preliminary psychometric evaluation of a self-report measure of avoidant behaviors associated with GAD: the Worry Behaviors Inventory (WBI).

METHODS

The WBI was administered to treatment-seeking patients (N=1201). Convergent validity was assessed by correlating the WBI with measures of GAD symptom severity. Divergent validity was assessed by correlating the WBI with measures of general disability and measures of depression, social anxiety and panic disorder symptom severity.

RESULTS

Exploratory and confirmatory factor analyses supported a two-factor structure (Safety Behaviors and Avoidance). Internal reliability was acceptable for the 10-item WBI scale (α=.86), Safety Behaviors (α=.85) and Avoidance subscales (α=.75). Evidence of convergent, divergent, and discriminant validity is reported. WBI subscales demonstrated differential associations with measures of symptom severity. The Safety Behaviors subscale was more strongly associated with GAD symptoms than symptoms of other disorders, whereas the Avoidance subscale was as strongly correlated with GAD severity as it was with depression, social anxiety and panic disorder severity.

LIMITATIONS

Structured diagnostic interviews were not conducted therefor validity analyses are limited to probable diagnoses based on self-report. The cross-sectional design precluded examination of the WBI's temporal stability and treatment sensitivity.

CONCLUSIONS

Preliminary evidence supports the use of the WBI in research and clinical settings and may assist clinicians to identify behaviors that are theorized to maintain GAD and that can be targeted during psychological treatment.

Avoidance, safety behavior, and reassurance seeking in generalized anxiety disorder

BACKGROUND

The behavioral symptoms of Generalized Anxiety Disorder (GAD) are not well characterized. This study examines behavioral symptoms in patients with GAD compared to healthy participants, their change during behavioral therapy, and their role for predicting short- and long-term outcome.

METHODS

Secondary data analysis of 56 patients with DSM-IV GAD from a randomized controlled trial testing worry exposure (n = 29) and applied relaxation (n = 27), compared to 33 demographically matched healthy participants. Participants reported on attempts to control or prevent worry, specifically cognitive and behavioral avoidance, safety behavior, and reassurance, along with other GAD symptoms. The Hamilton Anxiety Scale served as immediate (post therapy) and the Penn State Worry Questionnaire as immediate and long-term (6-/12-month follow-up) treatment outcome measure.

RESULTS

GAD patients engage significantly more in attempts to control or prevent worry as reflected in cognitive and behavioral avoidance, safety behavior, and reassurance seeking than healthy comparison participants. Behavior therapy significantly reduces these behavioral strategies without substantial indication of differential effects of treatment type. However, only patients remitting from GAD reach the low symptom level of healthy participants. The initial level of behavioral symptoms is irrelevant for immediate treatment success, but higher degrees of cognitive and behavioral avoidance and safety behavior at the end of treatment predict worse long-term outcome.

CONCLUSIONS

Behavioral symptoms appear to be relevant features in GAD that improve with successful treatment. Further research is warranted to examine whether inclusion of behavioral symptoms in the definition of GAD would have beneficial effects on diagnostic recognition and treatment.

Generalized anxiety disorder: between neglect and an epidemic

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.

The effects of postnatal maternal depression and anxiety on the processing of infant faces

BACKGROUND

Postnatally depressed mothers have difficulties responding appropriately to their infants. The quality of the mother-child relationship depends on a mother's ability to respond to her infant's cues, which are largely non-verbal. Therefore, it is likely that difficulties in a mother's appraisal of her infants' facial expressions will affect the quality of mother-infant interaction. This study aimed to investigate the effects of postnatal depression and anxiety on the processing of infants' facial expressions.

METHOD

A total of 89 mothers, 34 with Generalised Anxiety Disorder, 21 with Major Depressive Disorder, and 34 controls, completed a 'morphed infants' faces task when their children were between 10 and 18 months.

RESULTS

Overall, mothers were more likely to identify happy faces accurately and at lower intensity than sad faces. Depressed compared to control participants, however, were less likely to accurately identify happy infant faces. Interestingly, mothers with GAD tended to identify happy faces at a lower intensity than controls. There were no differences between the groups in relation to sad faces.

LIMITATIONS

Our sample was relatively small and further research is needed to investigate the links between mothers' perceptions of infant expressions and both maternal responsiveness and later measures of child development.

CONCLUSION

Our findings have potential clinical implications as the difficulties in the processing of positive facial expressions in depression may lead to less maternal responsiveness to positive affect in the offspring and may diminish the quality of the mother-child interactions. Results for participants with GAD are consistent with the literature demonstrating that persons with GAD are intolerant of uncertainty and seek reassurance due to their worries.

Content and correlates of checking related to symptoms of obsessive compulsive disorder and generalized anxiety disorder

In addition to the central role of compulsive behaviors in obsessive compulsive disorder (OCD), recent data have documented the presence of compulsive behaviors in individuals with generalized anxiety disorder (GAD). However, there is a lack of information about potential similarities and differences with regard to the quality, or content, of checking associated with worry and obsessions. The two studies presented herein are an initial step towards gathering this information. Findings of Study 1, from a large unselected undergraduate sample, showed that symptoms of OCD and GAD were both significantly associated with checking behaviors. However, while OCD symptoms were associated with checking related to both objects and interpersonal situations, GAD symptoms were only significantly associated with interpersonal checking. Findings of Study 2, using a separate sample, suggest links between interpersonal checking and features characteristic of GAD, namely emotion regulation difficulties, and between object checking and a cognitive feature of OCD, namely thought-action fusion. In summary, the current studies add to a growing body of literature suggesting that checking may be important in numerous forms of psychopathology, while also suggesting that the nature and function of checking may differ for various symptom profiles.

Magical Thinking in Obsessive-Compulsive Disorder and Generalized Anxiety Disorder

Background: Magical thinking (MT), which has historically been associated with psychotic disorders, has more recently been found to be a central cognitive construct in Obsessive-Compulsive Disorder (OCD) that is associated with a poor prognosis (Einstein and Menzies, 2008). Although MT has been found to distinguish OCD from Panic Disorder (PD) (Einstein and Menzies, 2006), little is known about its role in other anxiety disorders. Aims: This study aimed to compare whether elevated levels of magical thinking could distinguish individuals with OCD from non-anxious controls and individuals with Generalized Anxiety Disorder (GAD). Method: The Magical Ideation Scale (MIS, Eckblad and Chapman, 1983) was used to compare levels of magical thinking in groups of individuals with OCD (n = 40), GAD (n = 15), and a normal control group (n = 19). Results: As expected, the mean MIS score of the OCD group was significantly higher than that of the non-clinical group. Interestingly, there was no significant difference between the mean MIS scores of the OCD and GAD group. However, the results of correlational analyses suggest that it may have differing roles in these disorders. Conclusions: Although elevated MT is evident in individuals with OCD, it may not be specific to OCD and may also be prominent in GAD. Further research is recommended to elucidate the exact role of this construct in these disorders.

Generalized worry disorder: a review of DSM-IV generalized anxiety disorder and options for DSM-V

BACKGROUND

Generalized anxiety disorder (GAD) has undergone a series of substantial classificatory changes since its first inclusion in DSM-III. The majority of these revisions have been in response to its poor inter-rater reliability and concerns that it may lack diagnostic validity. This article provides options for the revision of the DSM-IV GAD criteria for DSM-V.

METHOD

First, searches were conducted to identify the evidence that previous DSM Work Groups relied upon when revising the DSM-III-R GAD and the overanxious disorder classifications. Second, the literature pertaining to the DSM-IV criteria for GAD was examined.

CONCLUSIONS

The review presents a number of options to be considered for DSM-V. One option is for GAD to be re-labeled in DSM-V as generalized worry disorder. This would reflect its hallmark feature. Proposed revisions would result in a disorder that is characterized by excessive anxiety and worry generalized to a number of events or activities for 3 months or more. Worry acts as a cognitive coping strategy that manifests in avoidant behaviors. The reliability and validity of the proposed changes could be investigated in DSM-V validity tests and field trials.

The role of fear of anxiety and intolerance of uncertainty in worry: an experimental manipulation

The tendency to fear emotional experiences, such as anxiety, may be an important factor in the maintenance of excessive worry, which is the central feature of generalized anxiety disorder (GAD). The goal of the present study was to clarify the role of fear of anxiety in worry by assessing whether the experimental manipulation of fear of anxiety affects worry level. The study also assessed the combined effects of fear of anxious responding and intolerance of uncertainty (a factor already linked to pathological worry) on level of worry by grouping participants according to their tolerance for uncertainty. The results indicated that participants whose fear of anxiety was increased showed higher levels of worry compared to participants whose fear of anxiety was decreased. This finding provides preliminary support for the causal role of fear of anxiety in worry. Moreover, the results showed that increased fear of anxiety in combination with an intolerance for uncertainty led to the highest levels of worry, which suggests that these constructs have an additive effect on worry. The findings lend support to the integration of new conceptualizations of psychopathology with existing models of excessive worry, which could ultimately increase treatment efficacy for GAD.