مرزبندی مرزهای اختلال اضطراب فراگیر: تمایز نگران بالا با و بدون اختلال اضطراب فراگیر
|کد مقاله||سال انتشار||مقاله انگلیسی||ترجمه فارسی||تعداد کلمات|
|34990||2002||24 صفحه PDF||سفارش دهید||9812 کلمه|
Publisher : Elsevier - Science Direct (الزویر - ساینس دایرکت)
Journal : Journal of Anxiety Disorders, Volume 16, Issue 4, 2002, Pages 377–400
Investigations of the boundary between generalized anxiety disorder (GAD) and normal worry have relied primarily on comparisons of GAD-diagnosed individuals with nonanxious controls. One limitation of this approach has been its inability to determine whether characteristics associated with GAD are unique to the disorder or are typical of severe worry more generally. The present studies made this differentiation using a virtually unstudied population: severe worriers failing to meet the diagnostic criteria for GAD. These studies assessed the prevalence of non-GAD high worriers in several college samples and identified features distinguishing them from individuals with GAD. Non-GAD high worriers far outnumbered GAD high worriers and reported many of the same symptoms as their GAD-diagnosed counterparts. However, results revealed several characteristics that consistently distinguished the two groups. Implications for the conceptualization, assessment, and investigation of worry and GAD are discussed.
Since its metamorphosis from a residual diagnostic category into a principal Axis I disorder with its own defining characteristics in DSM-III-R ( American Psychiatric Association, 1987), generalized anxiety disorder (GAD) has been a source of continued controversy. GAD was established as an anxiety disorder distinguishable from other disorders primarily by its cardinal feature: chronic, excessive worry ( Borkovec, 1994 and Craske, 1999). However, the preponderance of worry among other anxiety disorders and depression ( Barlow, Blanchard, Vermilyea, Vermilyea, & DiNardo, 1986; Brown, Antony, & Barlow, 1992; Starcevic, 1995), the extensive comorbidity between GAD and these disorders ( Brawman-Mintzer et al., 1993; Brown & Barlow, 1992), and the relatively poor diagnostic reliability of GAD itself ( DiNardo, Moras, Barlow, Rapee, & Brown, 1993) have caused some to question the validity of this disorder (see Brown, 1997; Brown, Barlow, & Liebowitz, 1994 for reviews). These questions share a common concern about the boundaries that separate GAD from normal worry and from other comorbid conditions. In response to these questions, a growing number of studies have attempted to explicate the boundary between GAD and normal worry (e.g., Craske, Rapee, Jackel, & Barlow, 1989; England & Dickerson, 1988; Eysenck, Mogg, May, Richards, & Matthews, 1990; MacLeod, Matthews, & Tata, 1986; Roemer, Molina, & Borkovec, 1997). As a group, these studies have relied almost exclusively on methodological designs comparing the worry experiences of GAD-diagnosed individuals with those of nonanxious controls, the latter carefully selected for their very low levels of worry and absence of anxiety symptoms. These studies have identified several potentially important characteristics that distinguish individuals with GAD from nonanxious participants, leading researchers such as Brown et al. (1994) to conclude that “the alterations in criteria for DSM-IV seem to have provided … a threshold between this diagnosis and the absence of mental disorder” (pp. 1278–1279). However, by virtue of their control samples, these studies provided only a very liberal test of the threshold between normal worry and GAD. By restricting their comparison to GAD and nonanxious extremes, the studies overlooked a group of individuals whose boundary with GAD may be far more tenuous than that of nonanxious controls—namely, severe worriers who do not meet the criteria of GAD. A close examination of the worry and GAD literatures suggests that there may be an implicit assumption in these fields of inquiry about the existence of two types of worry: “normal worry,” which is mild, transient, generally limited in scope, and experienced by the majority of individuals; and “pathological worry,” which is excessive, chronic, pervasive, and experienced only by individuals with GAD. An important effect of this assumption is that pathological worry is often treated as though it were synonymous with a GAD diagnosis, and individuals reporting high levels of worry are generally presumed to have GAD (see Borkovec, Shadick, & Hopkins, 1991; Brown, 1997; Davey & Tallis, 1994). Moreover, the reverse is also taken to be true: individuals who are not treatment-seeking and do not have GAD (i.e., “normal worriers”) are presumed not to experience pathological worry and are often assumed to have relatively low levels of worry in daily life. The problem with these assumptions is that the very qualities that designate worry as pathological—excessiveness, pervasiveness, and uncontrollability—may not be limited to GAD. Such worry may be evident not only in other diagnosed groups (e.g., Brown et al., 1992), but in nondiagnosed individuals as well. Although severe worry is the cardinal feature of GAD, the disorder is not diagnosed solely on the basis of worry quality. Several additional symptoms must also be present to warrant a diagnosis, including frequent incidence of three or more of motor tension, vigilance, or scanning symptoms; frequent experience of worry over a period of at least 6 months; and significant distress and/or functional impairment associated with worry and related symptoms of anxiety (American Psychiatric Association, 1994). Thus, although it has become customary to equate pathological worry with GAD, this convention may have had the unfortunate effect of obscuring a more complex relationship between GAD and its primary characteristic of severe worry.1 One significant consequence of this convention is that virtually all research investigating the nature of pathological worry has been conducted with GAD-diagnosed participants (see Borkovec et al., 1991). As a result, little to nothing is known about high worriers who fail to meet diagnostic criteria for GAD. The existence of individuals who experience worry with severe intensity and uncontrollability, yet who do not meet criteria for GAD, would challenge current formulations of normal and pathological worry and provide an important test of the relationship between worry and GAD. Such a test would help to determine whether worry characteristics ascribed to GAD in prior studies (e.g., excessiveness, uncontrollability) are unique to GAD or are typical of severe worry more generally. The existence of high worriers without GAD would also raise questions about the nature of this previously unstudied group, its prevalence in nonclinical samples, and its potential to benefit from clinical intervention. In particular, exploration of the ways in which severe worriers without GAD are distinguishable from those with GAD may enhance our understanding of the primary features that separate the disorder from normal experiences of worry and anxiety. The present paper describes two studies examining worry experiences and GAD symptoms in several large college samples. These studies sought to determine what proportion of high worriers fail to meet DSM-IV diagnostic criteria for GAD and to identify features of these worriers that differentiate them from high worriers diagnosed with GAD. Although most college students are considered to be normal worriers (e.g., Tallis, Davey, & Capuzzo, 1994), college samples typically include the full range of worry severity scores on measures like the Penn State Worry Questionnaire ( Meyer, Miller, Metzger, & Borkovec, 1990; Molina & Borkovec, 1994), suggesting that this population might be ideal for identifying and studying non-GAD high worriers. In addition, at least some of the symptoms of college students diagnosed with GAD are equally severe as those of GAD patients in clinical settings ( Molina & Borkovec, 1994; Roemer, Borkovec, Posa, & Borkovec, 1995), suggesting that GAD-related findings of the present studies may have generalizability to GAD patients in clinical settings. Although it was hypothesized that a portion of individuals reporting severe levels of worry would not meet diagnostic criteria for GAD, it was not clear before empirical examination how large that proportion would be, nor how these worriers might differ from those diagnosed with GAD. Therefore, given the exploratory nature of this research, all analyses in the two studies were performed in both an original sample and a replication sample to ensure the reliability of the results.