Generalized Anxiety Disorder and the Proposed Associated Symptoms Criterion Change for DSM-5 in a Treatment-Seeking Sample of Anxious Youth

Abstract

Background A current proposal for the DSM-5 generalized anxiety disorder (GAD) definition is to remove fatigue, difficulty concentrating, irritability, and sleep disturbance from the list of associated symptoms, and to require the presence of one of two retained symptoms (restlessness or muscle tension) for diagnosis. Relevant evaluations in youth to support such a change are sparse. Methods The present study evaluated patterns and correlates of the DSM-IV GAD associated symptoms in a large outpatient sample of anxious youth (N=650) to empirically consider how the proposed diagnostic change might impact the prevalence and sample composition of GAD in children. Results Logistic regression found irritability to be the most associated, and restlessness to be the least associated, with GAD diagnosis. Fatigue, difficulty concentrating, and sleep disturbances—which have each been suggested to be nonspecific to GAD due to their prevalence in depression—showed sizable associations with GAD even after accounting for depression and attention problems. Among GAD youth, 10.9% would not meet the proposed DSM-5 associated symptoms criterion. These children were comparable to GAD youth who would meet the proposed criteria with regard to clinical severity, symptomatology, and functioning. Conclusions A substantial proportion of youth with excessive, clinically impairing worry may be left unclassified by the DSM-5 if the proposed GAD associated symptoms criterion is adopted. Despite support for the proposed criterion change in adult samples, the present findings suggest that in children it may increase the false negative rate. This calls into question whether the proposed associated symptoms criterion is optimal for defining childhood GAD.

Threshold and subthreshold generalized anxiety disorder among US adolescents: prevalence, sociodemographic, and clinical characteristics

“…Consistent with previous clinical studies of affected youth (Pina et al 2002; Kendall & Pimentel, 2003; Comer et al 2012b), in this general population sample of adolescents, poor concentration, restlessness, and irritability were the most common associated symptoms of GAD, while muscle tension was the least common symptom. Further, we found that nearly one-quarter of youth meeting all other criteria for GAD failed to endorse either restlessness or muscle tension, indicating that a substantial proportion of youth would fail to be identified if the array of associated symptoms were restricted to these domains.…”

Sleep Problems Predict and Are Predicted by Generalized Anxiety/Depression and Oppositional Defiant Disorder

“…Predictions from sleep problems to anxiety (including generalized anxiety) had been identified in one previous long-term longitudinal study, 10 and linkages between sleep disturbance and generalized anxiety disorder have also been highlighted in work with clinical samples of adolescents. 32, 33 Overall, these findings lend support to the notion that good sleep requires (and perhaps promotes) feelings of security and safety 2 —which may not be sufficiently present in children with generalized anxiety disorder. Furthermore, these findings also support the notion that generalized anxiety disorder and depression may be biologically similar.…”

Irritability and Severity of Anxious Symptomatology Among Youth With Anxiety Disorders

“…Whereas a small number of studies have begun exploring anxiety–irritability associations, 7,17,21 the present study is the first to go beyond between-group differences of controls with and without anxiety to consider anxiety severity continuously and to examine the extent to which anxiety–irritability links are not simply artifacts of anxiety co-presentations with depressive disorders and ODD. Given the very serious clinical correlates of irritability across the lifespan, 8,11 the present findings suggest that child anxiety assessment practices should systematically incorporate evaluations of irritability.…”

“…Irritability is included in the DSM-5 as a qualifying associated symptom of generalized anxiety disorder (GAD), and a recent study found roughly 90% of a sample of treatment-seeking youth with GAD showed persistent irritability. 17 Although irritability is specifically mentioned in the definition of GAD and research has most commonly found irritability to be predictive of GAD diagnosis among youth with anxiety, 17-20 research on adult populations and emerging research on child populations have found irritability may be associated with a range of anxiety disorders. 21,22 …”