RESEARCH ARTICLE
Clinical significance of worry and physical symptoms in late-life generalized anxiety disorder Beyon Miloyan and Nancy A. Pachana School of Psychology, University of Queensland, Brisbane, Australia Correspondence to: B. Miloyan, E-mail: [email protected]
Worry is a hallmark feature of generalized anxiety disorder (GAD). However, age-related changes in symptom presentation raise questions about the clinical significance of these symptom clusters in later life. The aim of this study was to explore the relative contribution of worry and physical symptom frequency to clinical significance associated with late-life GAD. Methods: A sample of 637 self-reported worriers (aged 65 years and older) was extracted from Wave 1 of the National Epidemiological Survey of Alcohol and Related Conditions. Results: Consistent with previous findings, we observed reductions in worry frequency and increases in physical symptom frequency with increasing age of participants. Physical symptoms, but not worry symptoms, distinguished older adults with clinical and sub-threshold GAD. Whereas physical symptom count was associated with distress, occupational, and functional disability, worry count was only associated with distress. Conclusions: Among self-reported worriers, worry frequency provides limited clinical utility over and above physical symptom frequency. These findings suggest that physical symptom frequency may become an increasingly important feature of GAD in later life. Copyright # 2015 John Wiley & Sons, Ltd.
Objective:
Key words: worry; GAD; diagnostic; clinical significance; somatic; older adult History: Received 27 August 2014; Accepted 23 January 2015; Published online 20 February 2015 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/gps.4273
Functional impact of worry and physical symptoms in late-life generalized anxiety disorder Worry is a hallmark feature of generalized anxiety disorder (GAD). Cross-sectional and longitudinal studies have identified progressive age-related reductions in worry frequency with advancing age in clinical and non-clinical samples (Basevitz et al., 2008; Hunt et al., 2003; Gonçalves & Byrne, 2013; Gould & Edelstein, 2010; Lindesay et al., 2000). Age-related changes in the phenomenology of worry have also been identified, such that younger adults worry more about finances, work, and social and interpersonal situations, whereas older and younger adults worry similarly about health-related issues (Gonçalves & Byrne, 2013; Lindesay et al., 2000). Older adults also report being more tolerant of uncertainty, believe less in the functional value of worry, and report making fewer Copyright # 2015 John Wiley & Sons, Ltd.
attempts to cope with worry compared with younger adults (Basevitz et al., 2008; Hunt et al., 2003). Relative to younger age groups, fewer symptoms have been found to distinguish older adults with threshold and sub-threshold GAD, suggesting that age-related changes in the phenomenology of worry might contribute to challenges in the detection of late-life GAD (Miloyan et al., 2014a). Such age-related reductions in worry frequency also raise important questions about the functional impact of worry symptom count among older adults, which, to our knowledge, have remained unexplored. This is particularly important with regard to the clinical management of late-life GAD as older adults appear less concerned with handling worry effectively (Hunt et al., 2003; Gould & Edelstein, 2010). Concomitant with age-related decreases in worry frequency are age-related increases in vulnerability to physical impairment (Brault, 2012). Physical symptoms Int J Geriatr Psychiatry 2015; 30: 1186–1194
Worry physical GAD
are associated with late-life anxiety, and successful treatment of late-life anxiety has been found to be associated with decreases in physical symptoms, suggesting that this represents an increasingly important symptom cluster in later life (Forlani et al., 2014; Lenze et al., 2001; Lenze et al., 2005; Lindesay, 1989). However, little is known about the diagnostic significance and functional impact of physical symptoms in late-life GAD. The first aim of this study was to replicate the observed trends in the aforementioned studies in a distinct sample, namely the finding of age-related reductions in worry frequency and differences in worry frequency between clinical groups. We also sought to estimate cross-sectional trends in physical symptom frequency with advancing age. The second goal was to determine whether worry frequency would distinguish older adults with threshold and sub-threshold GAD, over and above sociodemographic, health, comorbidity variables, and physical symptom frequency. A sub-threshold GAD diagnosis was ascribed to participants who reported frequent worry for 6 or more months but did not meet 12-month DSM-IV GAD criteria. Finally, we sought to investigate whether worry frequency was associated with functional impact over and above physical symptom frequency, independently of diagnostic status. Method Sample
The sample was derived from the National Epidemiological Survey of Alcohol and Related Conditions (NESARC), which was conducted in 2001–2002 by the US Bureau of the Census and sponsored by the National Institute of Alcohol Abuse and Alcoholism. The NESARC consists of a nationally representative sample of 43,093 adults (18–98 years old) sampled from all 50 US states and the District of Columbia. African-Americans, Hispanics, and young adults were purposively oversampled, and data were adjusted for oversampling and non-response with sample weights based on census data. The overall response rate was 81%, and data were collected via face-to-face interviews conducted by trained lay interviewers using the Alcohol Use Disorder and Associated Disabilities Schedule—DSM-IV version (AUDADIS-IV) (Grant et al., 2003; Ruan et al., 2008). Participants who endorsed one of two screening questions (“ever had a 6+ month period during which you felt the following: (i) tense/nervous/worried most of the time or (ii) very tense/nervous/worried most of Copyright # 2015 John Wiley & Sons, Ltd.
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the time about everyday problems”) were included in this study, because they were administered the GAD portion of the diagnostic interview. The overall sample of self-reported worriers consisted of 3486 participants (aged 18–98 years). Of those, 637 participants (aged 65 years or older) were included in the present study, comprising approximately 18% of the overall sample of self-reported worriers. Measures
Sociodemographic, health, and comorbidity variables were accounted for in the regression and receiver operating characteristic (ROC) analyses. These included gender, education (some college or higher, completed high school, and less than high school), personal income (0–9999, 10,000–34,999, and 35,000+ US dollar), marital status (married/cohabiting, widowed/divorced/separated, and never married), urbanicity (urban and rural), self-perceived health (excellent, very good, good, fair, and poor), presence of one or more chronic medical conditions (selected from a finite list of variables), sub-threshold depressive symptoms, current mood disorders, current anxiety disorders (not including GAD), lifetime mood disorders, lifetime anxiety disorders, and lifetime personality disorders. All current (non-hierarchical) and lifetime mood, anxiety, and personality disorder diagnoses were based on DSM-IV criteria using the AUDADIS-IV diagnostic interview, which has been found to have good psychometric properties (Ruan et al., 2008). The following seven worry symptoms were obtained from the GAD portion of the AUDADIS-IV: “ever worry a lot about things you usually did not worry about,” “ever worry about more than one thing,” “ever find it difficult to stop being tense/nervous/worried,” “ever worry about things that were very unlikely to happen,” “ever think your worrying was excessive,” “ever worry about things that were not really serious,” and “ever worry about what other people might do or what would happen to them.” Together, these symptoms comprised the “total worry symptoms” variable, such that a response of “yes” to each of these questions was given a score of one and seven was the maximum. The two screening questions in the previous paragraph, although relevant to worry, were not included in the total worry symptoms variable, because they were used to determine the sample (i.e., those with threshold and sub-threshold GAD) in the first place, as per the AUDADIS-IV. The variables comprising the “total physical symptoms” variable included the following: “often felt Int J Geriatr Psychiatry 2015; 30: 1186–1194
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heartracing, skipping, or pounding in chest,” “often perspired/sweated,” “often had cold and clammy hands,” “often had dry mouth,” “often felt dizzy/lightheaded/like might faint,” “often felt nauseous, had upset stomach, or felt like might vomit or have diarrhea,” “often urinated frequently,” “often had trouble swallowing/felt like lump in throat,” “often had pain or pressure in chest,” “often found self trembling or shaking,” and “often had trouble catching breath/felt like smothering.” Finally, five self-reported items relevant to functional impact were also derived from the GAD portion of the AUDADIS-IV: distress (“felt uncomfortable about feeling nervous/anxious or by any of those things going on at the same time”), social (“had arguments/friction with family, friends, people at work, or anyone else”), occupational (“had difficulty doing things supposed to do—working, schoolwork, and taking care of house/family”), and functional impairment: (i) “restricted usual activity in any way” and (ii) “found was unable to do something wanted to do.” Statistical analyses
For the first binary logistic regression analysis, diagnostic status served as the outcome variable of interest, such that participants aged 65 years or older were divided into one of two diagnostic groups: 12-month DSM-IV GAD (non-hierarchical) or sub-threshold GAD (coded 1 and 0, respectively). Predictor variables consisted of sociodemographic, health, and comorbidity variables (as above), and “total worry” and “total physical” symptom variables entered at the end. Logistic regression was then used to test the predictive accuracy of this model. Sensitivity (true positive rate), specificity (true negative rate), and predictive accuracy scores (percentage of patients correctly classified) were obtained, and an ROC analysis was employed to display the overall fitness of the model. For the second set of binary logistic regression analyses, each of the five functional impact variables served as one outcome variable of interest. Predictor variables entered were the same as those from the first analysis. Once again, these analyses were only performed in participants aged 65 years or older. Significance levels were reset to p < 0.01 to account for type-1 error, because of the inclusion of a large number of variables in the analyses. Results Sociodemographic characteristics of the sample
The overall sample consisted of 637 participants aged 65 years or older, representing approximately one-fifth Copyright # 2015 John Wiley & Sons, Ltd.
B. Miloyan and N. A. Pachana
of all self-reported worriers (Mage = 75; 71% female) in the dataset. Of this group, 99 participants (16%) had a 12-month GAD diagnosis. Sixty-seven percent of participants completed at least a high school education. Eighty-six percent of participants reported an annual personal income of less than $35,000 (US dollar) per year. Thirty-four percent of participants were married or cohabiting; 62% were widowed, divorced, or separated; and 4% were never married. And approximately four-fifths of participants reported living in an urban area. Finally, slightly over half of the sample reported their selfperceived current health to be good, very good, or excellent, and 83% reported having at least one or Table 1 Sociodemographic characteristics of self-reported worriers aged 65 years and older Raw frequencies (and weighted proportions) Age Sex Male Female Education Some college or higher Completed high school Less than high school Personal income 35,000+ 10,000–34,999 0–9999 Marital status Married Widowed/divorced/separated Never married Urbanicity Rural Urban Self-perceived health Excellent Very good Good Fair Poor Chronic medical conditions None One or more Current anxiety No Yes Current mood No Yes Lifetime anxiety No Yes Lifetime mood No Yes Lifetime personality No Yes
75.03 ± 7.08 161 (29%) 476 (71%) 213 (29%) 198 (34%) 226 (37%) 127 (21%) 266 (41%) 244 (38%) 215 (47%) 394 (49%) 28 (4%) 139 (24%) 498 (76%) 54 (8%) 112 (19%) 190 (31%) 163 (25%) 118 (17%) 106 (17%) 531 (83%) 546 (87%) 91 (13%) 507 (81%) 130 (19%) 471 (73%) 166 (27%) 353 (57%) 284 (43%) 507 (81%) 130 (19%)
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more chronic medical conditions (from a finite list of conditions). See Table 1 for a summary of the sociodemographic characteristics of the sample.
4.08; 95% CI: 1.92–8.68). Worry frequency was not significantly associated with GAD diagnostic status. See Table 2 for the complete results of the analysis. The overall sensitivity, specificity, and predictive accuracy of the model were 27%, 96%, and 85%, respectively. The area under the ROC curve was approximately 85%, suggesting that the predictive model was good at differentiating between older adults with threshold and sub-threshold GAD (Figure 2). Further analysis of association between individual physical symptoms and GAD diagnostic status revealed that only one symptom (often felt dizzy/lightheaded/like might faint) was significantly associated with threshold GAD (OR: 2.45; 95% CI: 1.32–4.55).
Age-related changes in symptom frequency
Figure 1 illustrates a progressive age-related downward trend in worry frequency. Similar downward trends are observed for individuals with and without a diagnosis of GAD, suggesting a general influence of age on worry frequency, irrespective of diagnostic status. However, participants with threshold GAD consistently rated greater worry frequency than those with sub-threshold GAD, irrespective of age. In terms of physical symptoms, there was an age-related upward trend in symptom frequency only among participants with a GAD diagnosis.
Symptom clusters associated with functional impact
A set of five binary logistic regression analyses, applying the same predictive model to each functional impact variable, was conducted (Table 3). The outcome variable of the first analysis was distress (felt uncomfortable about feeling nervous/anxious or by any of those things going on at the same time), and physical symptom frequency (OR: 1.26; 95% CI: 1.15–1.37) and worry frequency (OR: 1.20; 95% CI: 1.06–1.37) were the only variables that distinguished distressed and non-distressed individuals. The outcome variable of the second analysis was social friction (had arguments/friction with family, friends, people at
Symptom clusters associated with diagnostic status
5 4 3 2
Symptom Frequency
6
Results of the first binary logistic regression analysis revealed that physical symptom frequency was a significant predictor of GAD diagnostic status (odds ratio (OR): 1.14; 95% confidence interval (CI): 1.04–1.25), distinguishing older adults with threshold and subthreshold GAD over and above sociodemographic, health, and comorbidity variables. A current diagnosis of any mood disorder was the only other variable that was significantly associated with threshold GAD (OR:
20
40
60
80
100
Age GAD Physical Sub-Threshold Physical
GAD Worry Sub-Threshold Worry
Figure 1 Cross-sectional trends in generalized anxiety disorder (GAD) symptom frequency in a sample of 3486 self-reported worriers with threshold and sub-threshold GAD (aged 18–98 years) derived from wave 1 of the National Epidemiological Survey of Alcohol and Related Conditions.
Copyright # 2015 John Wiley & Sons, Ltd.
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Table 2 Binary logistic regression with generalized anxiety disorder diagnosis as the outcome variable and sociodemographic, health, comorbidity, and symptom frequency variables as the predictors Odds ratios (and 95% CIs) Age Gender Male Female Education Some college or higher Completed high school Less than high school Personal income ≥$35,000 $10,000–$34,999 $0–$10,000 Marital status Married/cohabiting Widowed/ divorced/ separated Never married Urbanicity Rural Urban Self-perceived health Excellent Very good Good Fair Poor Chronic medical conditions None One or more Depressive symptoms No Yes Current mood disorder No Yes Current anxiety disorder No Yes Lifetime mood disorder No Yes Lifetime anxiety disorder No Yes Lifetime personality disorder No Yes Total physical symptoms Total worry symptoms
0.97 (0.93–1.00) 1 1.70 (0.80–3.60) 1 1.38 (0.70–2.71) 1.18 (0.55–2.51) 1 1.06 (0.41–2.75) 2.26 (0.85–6.05) 1 1.03 (0.54–1.96) 1.58 (0.41–6.11) 1 1.00 (0.53–1.89) 1 0.99 (0.23–4.29) 1.57 (0.42–5.87) 2.45 (0.64–9.40) 2.76 (0.71–10.81) 1 0.53 (0.23–1.22) 1 1.00 (0.46–2.20) 1 4.08 (1.92–8.68)** 1 1.97 (0.75–5.14) 1 0.81 (0.34–1.92) 1 0.84 (0.36–1.99) 1 1.55 (0.83–2.87) 1.14 (1.04–1.25)* 1.21 (1.03–1.42)
2
χ (22) = 125.96**VIF: 1.51
CIs, confidence intervals; VIF, variance inflation factor. *p < 0.01; **p < 0.0001.
work, or anyone else). Having less than a high school education (OR: 3.17; 95% CI: 1.51–6.66) and having a lifetime diagnosis of personality disorder (OR: 2.33; 95% CI: 1.32–4.10) were the only variables Copyright # 2015 John Wiley & Sons, Ltd.
significantly associated with social friction. Occupational disability served as the outcome variable for the third analysis (had difficulty doing things supposed to do—working, schoolwork, and taking care of house/family), and only physical symptom frequency was associated with occupational disability (OR: 1.19; 95% CI: 1.09–1.30). A functional disability variable (restricted usual activity in any way) served as the outcome variable for the fourth analysis, and total physical symptoms (OR: 1.21; 95% CI: 1.11–1.32) and a lifetime diagnosis of mood disorder (OR: 2.57; 95% CI: 1.38–4.76) were significantly associated with this functional disability measure. An additional functional disability variable served as the outcome for our fifth analysis (found was unable to do something wanted to do). Total physical symptoms and having been never married were positively (OR: 1.24; 95% CI: 1.13–1.36) and negatively (OR: 0.10; 95% CI: 0.02–0.49) associated with this functional disability measure, respectively. Discussion The purpose of this study was to determine the relative contribution of worry and physical symptoms to diagnostic and clinical outcomes in late-life GAD. Consistent with previous studies, we found an age-related decrease in worry frequency such that older adults reported fewer symptoms than their younger counterparts. Additionally, older adults with GAD reported a higher frequency of worry symptoms than those with sub-threshold GAD. We also found an age-related increase in physical symptoms among participants with a GAD diagnosis but not among those with sub-threshold GAD. Physical symptom count, but not worry symptom count, significantly distinguished older adults with threshold and subthreshold GAD. Physical symptom count was significantly associated with distress, occupational disability, and two functional disability measures, whereas worry symptom count was only significantly associated with distress. At first glance, our findings appear to be inconsistent with those of previous studies, which report that worry frequency continues to be useful for informing diagnosis of GAD among older adults, despite agerelated decreases in frequency (Diefenbach et al., 2003; Wetherell et al., 2003). We note that six out of seven symptoms included in our total worry variable were self-referential. Previous research suggests that there is a critical distinction between worry about “self” and “other” in later life, such that personalized Int J Geriatr Psychiatry 2015; 30: 1186–1194
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0.50 0.00
0.25
Sensitivity
0.75
1.00
Worry physical GAD
0.00
0.25
0.50
0.75
1.00
1 - Specificity Area under ROC curve = 0.8481
Figure 2 Receiver operating characteristic (ROC) curve for the binary logistic predictor model (including sociodemographic, health, comorbidity, and symptom frequency variables) against a 12-month DSM-IV generalized anxiety disorder diagnosis.
worry tends to be pathological and impersonal worry tends to be normal (Gonçalves & Byrne, 2013; Gould & Edelstein, 2010; Wetherell et al., 2003). In spite of this, worry frequency still appeared to have less utility than physical symptom frequency for (i) distinguishing participants with threshold and subthreshold GAD and (ii) distinguishing those who did and did not report meeting functional impact criteria. However, it is important to note that because of a design feature of the NESARC dataset, our sample included only participants who endorsed some tension, nervousness, or worry for at least a 6month period. Nonetheless, our findings question whether worry accurately represents the most consequential feature of GAD in later life. For instance, somatic symptoms represent a key symptom cluster in the context of late-life mental disorders, and previous findings suggest that late-life depression may be appropriately conceptualized as presenting somatically (Hegeman et al., 2012; Sheehan & Banerjee, 1999; Wijeratne et al., 2003). It is possible that late-life GAD may also be appropriately conceptualized as having a physical presentation. Indeed, anxiety is highly prevalent in the context of primary care and nursing homes, and successful treatment of late-life anxiety has been found to be associated with significant decreases in somatic symptoms (Lenze et al., 2005; Miloyan et al., 2014b). Given that our sample consisted entirely of Copyright # 2015 John Wiley & Sons, Ltd.
self-reported worriers, our findings do not suggest that physical symptoms should supersede worry as the central feature of GAD. Rather, our findings suggest that given age-related decreases in worry symptoms, worry in the absence of physical symptoms might not frequently be of functional impact. In other words, among those who worry, those who report experiencing a greater number of physical symptoms are also more likely to report experiencing disability and/or distress. We believe that this is an important observation, because according to DSM and International Classification of Diseases (ICD) diagnostic criteria, excessive worry and associated functional impact cannot be attributable to the physiological effects of a substance or a physical condition if these are to constitute a GAD diagnosis. Given the high prevalence of physical illness and medication use in older adults, it is often impractical to disentangle physical symptoms from excessive anxiety and associated disability/distress (Brault, 2012; WolitzkyTaylor et al., 2010). At first glance, it appears surprising that only one physical symptom (often felt dizzy/lightheaded/like might faint) was significantly associated with late-life GAD. This may be due to the variable presentation of GAD across individuals and particularly to the different constellations of physical symptoms that may manifest in older adulthood (i.e., as a result of comorbid medical conditions or side effects of medication). Int J Geriatr Psychiatry 2015; 30: 1186–1194
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Table 3 Binary logistic regression analyses with functional impact measures as the outcome variables and sociodemographic, health, comorbidity, and symptom frequency variables as the predictors Odds ratios (and 95% CIs) associated with functional impact variables
Social disability
Occupational disability
1.02 (0.98–1.05)
0.99 (0.95–1.03)
1.01 (0.98–1.05)
1.00 (0.97–1.04)
1.04 (1.00–1.08)
1 1.16 (0.67–2.03)
1 0.77 (0.41–1.43)
1 1.19 (0.67–2.12)
1 1.21 (0.69–2.11)
1 0.76 (0.43–1.36)
1 0.92 (0.52–1.64) 1.53 (0.83–2.82)
1 1.93 (0.95–3.92) 3.17 (1.51–6.66)*
1 1.63 (0.89–2.99) 1.51 (0.78–2.90)
1 0.97 (0.54–1.71) 1.33 (0.72–2.44)
1 0.67 (0.37–1.21) 1.24 (0.66–2.35)
1 1.27 (0.66–2.43) 1.08 (0.52–2.23)
1 1.54 (0.72–3.32) 1.90 (0.81–4.44)
1 0.84 (0.43–1.67) 0.80 (0.37–1.71)
1 1.61 (0.82–3.14) 1.15 (0.55–2.42)
1 1.41 (0.71–2.83) 1.96 (0.91–4.23)
1 1.00 (0.60–1.69)
1 0.54 (0.3–0.99)
1 0.64 (0.37–1.10)
1 0.78 (0.47–1.31)
1 1.01 (0.59–1.73)
2.27 (0.70–7.36)
0.55 (0.15–2.08)
0.54 (0.16–1.84)
0.20 (0.05–0.84)
0.10 (0.02–0.49)*
1 0.71 (0.42–1.19)
1 0.85 (0.47–1.55)
1 1.46 (0.84–2.55)
1 1.33 (0.79–2.25)
1 0.99 (0.57–1.70)
1 1.07 (0.32–2.22) 1.34 (0.45–2.82) 1.09 (0.38–2.61) 0.79 (0.30–2.11)
1 1.55 (0.48–5.02) 1.47 (0.48–4.48) 0.76 (0.23–2.53) 1.19 (0.36–3.96)
1 1.07 (0.37–3.10) 2.00 (0.75–5.34) 1.25 (0.45–3.49) 1.77 (0.62–5.06)
1 2.31 (0.83–6.43) 2.48 (0.94–6.54) 2.21 (0.81–6.01) 2.00 (0.71–5.61)
1 1.88 (0.65–5.39) 1.86 (0.68–5.11) 2.16 (0.76–6.15) 2.55 (0.87–7.48)
1 0.75 (0.39–1.43)
1 1.72 (0.73–4.02)
1 0.90 (0.44–1.82)
1 0.88 (0.45–1.72)
1 0.87 (0.44–1.71)
1 1.41 (0.77–2.61)
1 0.94 (0.45–1.98)
1 1.52 (0.78–2.97)
1 1.33 (0.71–2.49)
1 0.89 (0.46–1.71)
1 0.69 (.37–1.28)
1 1.39 (0.68–2.83)
1 0.72 (0.39–1.33)
1 0.69 (0.38–1.27)
1 1.46 (0.77–2.76)
1 1.23 (0.56–2.72)
1 1.65 (0.71–3.84)
1 1.72 (0.79–3.76)
1 1.85 (0.84–4.09)
1 1.44 (0.63–3.32)
1 1.40 (0.76–2.58)
1 1.05 (0.50–2.23)
1 2.22 (1.17–4.22)
1 2.57 (1.38–4.76)*
1 2.06 (1.08–3.93)
1 1.02 (0.53–1.97)
1 1.18 (0.57–2.46)
1 0.94 (0.48–1.83)
1 0.65 (0.33–1.27)
1 0.95 (0.48–1.90)
1 1.38 (0.82–2.34) 1.26 (1.15–1.37)** 1.20 (1.06–1.37)*
1 2.33 (1.32–4.10)* 1.06 (0.96–1.16) 1.22 (1.05–1.42)
1 0.93 (0.54–1.60) 1.19 (1.09–1.30)** 1.16 (1.01–1.33)
1 1.04 (0.61–1.77) 1.21 (1.11–1.32)** 1.04 (0.92–1.19)
1 1.54 (0.88–2.70) 1.24 (1.13–1.36)** 1.09 (0.95–1.25)
Distress Age Gender Male Female Education Some college or higher Completed high school Less than high school Personal income ≥$35,000 $10,000–$34,999 $0–$10,000 Marital status Married/cohabiting Widowed/divorced/ separated Never married Urbanicity Rural Urban Self-perceived health Excellent Very good Good Fair Poor Chronic medical conditions None One or more Depressive symptoms No Yes Current mood disorder No Yes Current anxiety disorder No Yes Lifetime mood disorder No Yes Lifetime anxiety disorder No Yes Lifetime personality disorder No Yes Total physical symptoms Total worry symptoms
2
χ (22) = 69.09** VIF: 1.51
2
χ (22) = 61.50** VIF: 1.51
2
χ (22) = 64.35** VIF: 1.51
Functional disability A
2
χ (22) = 65.01** VIF: 1.51
Functional disability B
2
χ (22) = 105.13** VIF: 1.51
VIF. variance inflation factor. *p < 0.01; **p < 0.0001.
Thus, it is also important to consider the extent to which physical symptoms associated with late-life GAD may be attributable to physical health Copyright # 2015 John Wiley & Sons, Ltd.
conditions. The findings of a recent study suggest that physical conditions (and associated symptoms) may represent both cause and consequence of late-life Int J Geriatr Psychiatry 2015; 30: 1186–1194
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GAD: arthritis was found to be associated with increased risk for incident GAD, and lifetime diagnosis of GAD was found to be associated with increased risk for gastrointestinal disease (El-Gabalawy et al., 2014). Future studies investigating the longitudinal relationship between late-life GAD symptoms, physical health conditions, and their relative functional impact would be informative. These findings may also be relevant to the clinical management of GAD. Particularly, the higher functional impact of physical symptoms relative to worry may help explain why some CBT interventions lack efficacy for treating late-life GAD (Gonçalves & Byrne, 2012; Lenze & Wetherell, 2009, 2011; Thorp et al., 2009). These interventions typically target the key cognitive symptoms associated with late-life GAD (i.e., worry), which may turn out to be mildly efficacious because older adults endorse few worries and report being minimally perturbed by these worries in the first place. Rather, shifting the emphasis toward physical symptoms may be more effective for treating late-life GAD. Indeed, treatment of latelife anxiety is associated with notable reductions in somatic symptoms (Lenze et al., 2005). Previous studies have also observed a reduction in the prevalence of mental health conditions among those who report regular engagement in physical activity and, specifically, that physical activity is associated with a reduction in anxiety symptoms (Goodwin, 2003; Herring et al., 2010). Physical activity, serving to counter some of the physical symptoms associated with late-life GAD, may be associated with reduced risk of developing late-life GAD. This study was not without limitations. First, data from asymptomatic participants relevant to worry were lacking, barring any additional comparison. Second, our functional impact variables were collected with dichotomous responses, preventing a more detailed understanding of how worry contributes to distress and/or disability. This represents a more general limitation of using pre-existing data, as we were unable to include variables that might have been more appropriate for late-life anxiety. Additionally, our functional impact measures were solely based on self-report, preventing analysis of the impact of worry and physical symptoms on more objective measures of functional impact. Studies assessing the relationship between GAD symptom clusters and more detailed functional impact measures in different samples are needed. Future studies investigating the longitudinal relationship between physical and worry symptoms and their clinical relevance are also needed. Copyright # 2015 John Wiley & Sons, Ltd.
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Conflict of interest None declared.
Key points
• •
There are age-related decreases in worry symptoms and age-related increases in physical symptoms associated with GAD. Among older self-reported worriers, physical symptom frequency is useful for (i) distinguishing those with threshold and sub-threshold GAD and (ii) distinguishing those who do and do not report functional impairment, independent of diagnostic status.
References Basevitz P, Pushkar D, Chaikelson J, Conway M, Dalton C. 2008. Age-related differences in worry and related processes. Int J Aging Hum Dev 66: 283–305. Brault MW. 2012. Americans with Disabilities: 2010. Household Economic Studies. Current Population Reports. US Census Bureau: Washington, DC. Diefenbach GJ, Hopko DR, Feigon S, et al. 2003. ‘Minor GAD’: characteristics of subsyndromal GAD in older adults. Behav Res Ther 41: 481–487. El-Gabalawy R, Mackenzie CS, Pietrzak RH, Sareen J. 2014. A longitudinal examination of anxiety disorders and physical health conditions in a nationally representative sample of U.S. older adults. Exp Gerontol 60: 46–56. Forlani M, Morri M, Murri MB, et al. 2014. Anxiety symptoms in 74+ communitydwelling elderly: associations with physical morbidity, depression and alcohol consumption. PLoS One 9: e89859. Gonçalves DC, Byrne GJ. 2012. Interventions for generalized anxiety disorder in older adults: systematic review and meta-analysis. J Anxiety Disord 26: 1–11. Gonçalves DC, Byrne GJ. 2013. Who worries most? Worry prevalence and patterns across the lifespan. Int J Geriatr Psychiatry 28: 41–49. Goodwin RD. 2003. Association between physical activity and mental disorders among adults in the United States. Prev Med 36: 698–703. Gould CE, Edelstein BA. 2010. Worry, emotion control, and anxiety control in older and young adults. J Anxiety Disord 24: 759–766. Grant BF, Dawson DA, Stinson FS, et al. 2003. The Alcohol Use Disorder and Associated Disabilities Interview Schedule-IV (AUDADIS-IV): reliability of alcohol consumption, tobacco use, family history of depression and psychiatric diagnostic modules in a general population sample. Drug Alc Depend 71: 7–16. Hegeman JM, Kok RM, van der Mast RC, Giltay EJ. 2012. Phenomenology of depression in older compared with younger adults: meta-analysis. Br J Psychiatry 200: 275–281. Herring MP, O’Connor PJ, Dishman RK. 2010. The effect of exercise training on anxiety symptoms among patients: a systematic review. Arch Intern Med 170: 321–331. Hunt S, Wisocki P, Yanko J. 2003. Worry and use of coping strategies among older and younger adults. J Anxiety Disord 17: 547–560. Lenze EJ, Rogers JC, Martire LM, et al. 2001. The association of late-life depression and anxiety with physical disability: a review of the literature and prospectus for future research. Am J Geriatr Psychiatry 9: 113–135. Lenze EJ, Karp JF, Mulsant BH, et al. 2005. Somatic symptoms in late-life anxiety: treatment issues. J Geriatr Psychiatry Neurol 18: 89–96. Lenze EJ, Wetherell JL. 2009. Bringing the bedside to the bench and then to the community: a prospectus for intervention research in late-life anxiety disorders. Int J Geriatr Psychiatry 24: 1–14. Lenze EJ, Wetherell JL. 2011. Anxiety disorders: new developments in old age. Am J Geriatr Psychiatry 19: 301–304. Lindesay J. 1989. Phobic disorders in the elderly. Br J Psychiatry 159: 531–541. Lindesay J, Baillon S, Brugha T, et al. 2000. Worry content across the lifespan: an analysis of 16- to 74-year-old participants in the British National Survey of Psychiatric Morbidity 2000. Psychol Med 36: 1625–1633. Miloyan B, Byrne GJ, Pachana NA. 2014a. Age-related changes in generalized anxiety disorder symptoms. Int Psychogeriatr 26: 565–572.
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1194 Miloyan B, Byrne GJ, Pachana NA. 2014b. Late-life anxiety. In Pachana NA, Laidlaw K (Eds.) Oxford Handbook of Clinical Geropsychology: International Perspectives (pp. 470–489). Oxford University Press: Oxford. Ruan WJ, Goldstein RB, Chou P, et al. 2008. The Alcohol Use Disorder and Associated Disabilities Interview Schedule-IV (AUDADIS-IV): reliability of new psychiatric diagnostic modules and risk factors in a general population sample. Drug Alc Depend 92: 27–36. Sheehan B, Banerjee S. 1999. Somatization in the elderly. Int J Geriatr Psychiatry 14: 1044–1049.
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B. Miloyan and N. A. Pachana Thorp SP, Ayers CR, Nuevo R, et al. 2009. Meta-analysis comparing different behavioural treatments for late-life anxiety. Am J Geriatr Psychiatry 17: 105–115. Wetherell JL, Le Roux H, Gatz M. 2003. DSM-IV criteria for generalized anxiety disorder in older adults: distinguishing the worried from the well. Psych Aging 18: 622–627. Wijeratne C, Brodaty H, Hickie I. 2003. The neglect of somatoform disorders by old age psychiatry: some explanations and suggestions for future research. Int J Geriatr Psychiatry 18: 812–819. Wolitzky-Taylor KB, Castriotta N, Lenze EJ, Stanley MA, Craske MG. 2010. Anxiety disorders in older adults: a comprehensive review. Depress Anxiety 27: 190.
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Clinical significance of worry and physical symptoms in late-life generalized anxiety disorder Beyon Miloyan and Nancy A. Pachana School of Psychology, University of Queensland, Brisbane, Australia Correspondence to: B. Miloyan, E-mail: [email protected]
Worry is a hallmark feature of generalized anxiety disorder (GAD). However, age-related changes in symptom presentation raise questions about the clinical significance of these symptom clusters in later life. The aim of this study was to explore the relative contribution of worry and physical symptom frequency to clinical significance associated with late-life GAD. Methods: A sample of 637 self-reported worriers (aged 65 years and older) was extracted from Wave 1 of the National Epidemiological Survey of Alcohol and Related Conditions. Results: Consistent with previous findings, we observed reductions in worry frequency and increases in physical symptom frequency with increasing age of participants. Physical symptoms, but not worry symptoms, distinguished older adults with clinical and sub-threshold GAD. Whereas physical symptom count was associated with distress, occupational, and functional disability, worry count was only associated with distress. Conclusions: Among self-reported worriers, worry frequency provides limited clinical utility over and above physical symptom frequency. These findings suggest that physical symptom frequency may become an increasingly important feature of GAD in later life. Copyright # 2015 John Wiley & Sons, Ltd.
Objective:
Key words: worry; GAD; diagnostic; clinical significance; somatic; older adult History: Received 27 August 2014; Accepted 23 January 2015; Published online 20 February 2015 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/gps.4273
Functional impact of worry and physical symptoms in late-life generalized anxiety disorder Worry is a hallmark feature of generalized anxiety disorder (GAD). Cross-sectional and longitudinal studies have identified progressive age-related reductions in worry frequency with advancing age in clinical and non-clinical samples (Basevitz et al., 2008; Hunt et al., 2003; Gonçalves & Byrne, 2013; Gould & Edelstein, 2010; Lindesay et al., 2000). Age-related changes in the phenomenology of worry have also been identified, such that younger adults worry more about finances, work, and social and interpersonal situations, whereas older and younger adults worry similarly about health-related issues (Gonçalves & Byrne, 2013; Lindesay et al., 2000). Older adults also report being more tolerant of uncertainty, believe less in the functional value of worry, and report making fewer Copyright # 2015 John Wiley & Sons, Ltd.
attempts to cope with worry compared with younger adults (Basevitz et al., 2008; Hunt et al., 2003). Relative to younger age groups, fewer symptoms have been found to distinguish older adults with threshold and sub-threshold GAD, suggesting that age-related changes in the phenomenology of worry might contribute to challenges in the detection of late-life GAD (Miloyan et al., 2014a). Such age-related reductions in worry frequency also raise important questions about the functional impact of worry symptom count among older adults, which, to our knowledge, have remained unexplored. This is particularly important with regard to the clinical management of late-life GAD as older adults appear less concerned with handling worry effectively (Hunt et al., 2003; Gould & Edelstein, 2010). Concomitant with age-related decreases in worry frequency are age-related increases in vulnerability to physical impairment (Brault, 2012). Physical symptoms Int J Geriatr Psychiatry 2015; 30: 1186–1194
Worry physical GAD
are associated with late-life anxiety, and successful treatment of late-life anxiety has been found to be associated with decreases in physical symptoms, suggesting that this represents an increasingly important symptom cluster in later life (Forlani et al., 2014; Lenze et al., 2001; Lenze et al., 2005; Lindesay, 1989). However, little is known about the diagnostic significance and functional impact of physical symptoms in late-life GAD. The first aim of this study was to replicate the observed trends in the aforementioned studies in a distinct sample, namely the finding of age-related reductions in worry frequency and differences in worry frequency between clinical groups. We also sought to estimate cross-sectional trends in physical symptom frequency with advancing age. The second goal was to determine whether worry frequency would distinguish older adults with threshold and sub-threshold GAD, over and above sociodemographic, health, comorbidity variables, and physical symptom frequency. A sub-threshold GAD diagnosis was ascribed to participants who reported frequent worry for 6 or more months but did not meet 12-month DSM-IV GAD criteria. Finally, we sought to investigate whether worry frequency was associated with functional impact over and above physical symptom frequency, independently of diagnostic status. Method Sample
The sample was derived from the National Epidemiological Survey of Alcohol and Related Conditions (NESARC), which was conducted in 2001–2002 by the US Bureau of the Census and sponsored by the National Institute of Alcohol Abuse and Alcoholism. The NESARC consists of a nationally representative sample of 43,093 adults (18–98 years old) sampled from all 50 US states and the District of Columbia. African-Americans, Hispanics, and young adults were purposively oversampled, and data were adjusted for oversampling and non-response with sample weights based on census data. The overall response rate was 81%, and data were collected via face-to-face interviews conducted by trained lay interviewers using the Alcohol Use Disorder and Associated Disabilities Schedule—DSM-IV version (AUDADIS-IV) (Grant et al., 2003; Ruan et al., 2008). Participants who endorsed one of two screening questions (“ever had a 6+ month period during which you felt the following: (i) tense/nervous/worried most of the time or (ii) very tense/nervous/worried most of Copyright # 2015 John Wiley & Sons, Ltd.
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the time about everyday problems”) were included in this study, because they were administered the GAD portion of the diagnostic interview. The overall sample of self-reported worriers consisted of 3486 participants (aged 18–98 years). Of those, 637 participants (aged 65 years or older) were included in the present study, comprising approximately 18% of the overall sample of self-reported worriers. Measures
Sociodemographic, health, and comorbidity variables were accounted for in the regression and receiver operating characteristic (ROC) analyses. These included gender, education (some college or higher, completed high school, and less than high school), personal income (0–9999, 10,000–34,999, and 35,000+ US dollar), marital status (married/cohabiting, widowed/divorced/separated, and never married), urbanicity (urban and rural), self-perceived health (excellent, very good, good, fair, and poor), presence of one or more chronic medical conditions (selected from a finite list of variables), sub-threshold depressive symptoms, current mood disorders, current anxiety disorders (not including GAD), lifetime mood disorders, lifetime anxiety disorders, and lifetime personality disorders. All current (non-hierarchical) and lifetime mood, anxiety, and personality disorder diagnoses were based on DSM-IV criteria using the AUDADIS-IV diagnostic interview, which has been found to have good psychometric properties (Ruan et al., 2008). The following seven worry symptoms were obtained from the GAD portion of the AUDADIS-IV: “ever worry a lot about things you usually did not worry about,” “ever worry about more than one thing,” “ever find it difficult to stop being tense/nervous/worried,” “ever worry about things that were very unlikely to happen,” “ever think your worrying was excessive,” “ever worry about things that were not really serious,” and “ever worry about what other people might do or what would happen to them.” Together, these symptoms comprised the “total worry symptoms” variable, such that a response of “yes” to each of these questions was given a score of one and seven was the maximum. The two screening questions in the previous paragraph, although relevant to worry, were not included in the total worry symptoms variable, because they were used to determine the sample (i.e., those with threshold and sub-threshold GAD) in the first place, as per the AUDADIS-IV. The variables comprising the “total physical symptoms” variable included the following: “often felt Int J Geriatr Psychiatry 2015; 30: 1186–1194
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heartracing, skipping, or pounding in chest,” “often perspired/sweated,” “often had cold and clammy hands,” “often had dry mouth,” “often felt dizzy/lightheaded/like might faint,” “often felt nauseous, had upset stomach, or felt like might vomit or have diarrhea,” “often urinated frequently,” “often had trouble swallowing/felt like lump in throat,” “often had pain or pressure in chest,” “often found self trembling or shaking,” and “often had trouble catching breath/felt like smothering.” Finally, five self-reported items relevant to functional impact were also derived from the GAD portion of the AUDADIS-IV: distress (“felt uncomfortable about feeling nervous/anxious or by any of those things going on at the same time”), social (“had arguments/friction with family, friends, people at work, or anyone else”), occupational (“had difficulty doing things supposed to do—working, schoolwork, and taking care of house/family”), and functional impairment: (i) “restricted usual activity in any way” and (ii) “found was unable to do something wanted to do.” Statistical analyses
For the first binary logistic regression analysis, diagnostic status served as the outcome variable of interest, such that participants aged 65 years or older were divided into one of two diagnostic groups: 12-month DSM-IV GAD (non-hierarchical) or sub-threshold GAD (coded 1 and 0, respectively). Predictor variables consisted of sociodemographic, health, and comorbidity variables (as above), and “total worry” and “total physical” symptom variables entered at the end. Logistic regression was then used to test the predictive accuracy of this model. Sensitivity (true positive rate), specificity (true negative rate), and predictive accuracy scores (percentage of patients correctly classified) were obtained, and an ROC analysis was employed to display the overall fitness of the model. For the second set of binary logistic regression analyses, each of the five functional impact variables served as one outcome variable of interest. Predictor variables entered were the same as those from the first analysis. Once again, these analyses were only performed in participants aged 65 years or older. Significance levels were reset to p < 0.01 to account for type-1 error, because of the inclusion of a large number of variables in the analyses. Results Sociodemographic characteristics of the sample
The overall sample consisted of 637 participants aged 65 years or older, representing approximately one-fifth Copyright # 2015 John Wiley & Sons, Ltd.
B. Miloyan and N. A. Pachana
of all self-reported worriers (Mage = 75; 71% female) in the dataset. Of this group, 99 participants (16%) had a 12-month GAD diagnosis. Sixty-seven percent of participants completed at least a high school education. Eighty-six percent of participants reported an annual personal income of less than $35,000 (US dollar) per year. Thirty-four percent of participants were married or cohabiting; 62% were widowed, divorced, or separated; and 4% were never married. And approximately four-fifths of participants reported living in an urban area. Finally, slightly over half of the sample reported their selfperceived current health to be good, very good, or excellent, and 83% reported having at least one or Table 1 Sociodemographic characteristics of self-reported worriers aged 65 years and older Raw frequencies (and weighted proportions) Age Sex Male Female Education Some college or higher Completed high school Less than high school Personal income 35,000+ 10,000–34,999 0–9999 Marital status Married Widowed/divorced/separated Never married Urbanicity Rural Urban Self-perceived health Excellent Very good Good Fair Poor Chronic medical conditions None One or more Current anxiety No Yes Current mood No Yes Lifetime anxiety No Yes Lifetime mood No Yes Lifetime personality No Yes
75.03 ± 7.08 161 (29%) 476 (71%) 213 (29%) 198 (34%) 226 (37%) 127 (21%) 266 (41%) 244 (38%) 215 (47%) 394 (49%) 28 (4%) 139 (24%) 498 (76%) 54 (8%) 112 (19%) 190 (31%) 163 (25%) 118 (17%) 106 (17%) 531 (83%) 546 (87%) 91 (13%) 507 (81%) 130 (19%) 471 (73%) 166 (27%) 353 (57%) 284 (43%) 507 (81%) 130 (19%)
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more chronic medical conditions (from a finite list of conditions). See Table 1 for a summary of the sociodemographic characteristics of the sample.
4.08; 95% CI: 1.92–8.68). Worry frequency was not significantly associated with GAD diagnostic status. See Table 2 for the complete results of the analysis. The overall sensitivity, specificity, and predictive accuracy of the model were 27%, 96%, and 85%, respectively. The area under the ROC curve was approximately 85%, suggesting that the predictive model was good at differentiating between older adults with threshold and sub-threshold GAD (Figure 2). Further analysis of association between individual physical symptoms and GAD diagnostic status revealed that only one symptom (often felt dizzy/lightheaded/like might faint) was significantly associated with threshold GAD (OR: 2.45; 95% CI: 1.32–4.55).
Age-related changes in symptom frequency
Figure 1 illustrates a progressive age-related downward trend in worry frequency. Similar downward trends are observed for individuals with and without a diagnosis of GAD, suggesting a general influence of age on worry frequency, irrespective of diagnostic status. However, participants with threshold GAD consistently rated greater worry frequency than those with sub-threshold GAD, irrespective of age. In terms of physical symptoms, there was an age-related upward trend in symptom frequency only among participants with a GAD diagnosis.
Symptom clusters associated with functional impact
A set of five binary logistic regression analyses, applying the same predictive model to each functional impact variable, was conducted (Table 3). The outcome variable of the first analysis was distress (felt uncomfortable about feeling nervous/anxious or by any of those things going on at the same time), and physical symptom frequency (OR: 1.26; 95% CI: 1.15–1.37) and worry frequency (OR: 1.20; 95% CI: 1.06–1.37) were the only variables that distinguished distressed and non-distressed individuals. The outcome variable of the second analysis was social friction (had arguments/friction with family, friends, people at
Symptom clusters associated with diagnostic status
5 4 3 2
Symptom Frequency
6
Results of the first binary logistic regression analysis revealed that physical symptom frequency was a significant predictor of GAD diagnostic status (odds ratio (OR): 1.14; 95% confidence interval (CI): 1.04–1.25), distinguishing older adults with threshold and subthreshold GAD over and above sociodemographic, health, and comorbidity variables. A current diagnosis of any mood disorder was the only other variable that was significantly associated with threshold GAD (OR:
20
40
60
80
100
Age GAD Physical Sub-Threshold Physical
GAD Worry Sub-Threshold Worry
Figure 1 Cross-sectional trends in generalized anxiety disorder (GAD) symptom frequency in a sample of 3486 self-reported worriers with threshold and sub-threshold GAD (aged 18–98 years) derived from wave 1 of the National Epidemiological Survey of Alcohol and Related Conditions.
Copyright # 2015 John Wiley & Sons, Ltd.
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Table 2 Binary logistic regression with generalized anxiety disorder diagnosis as the outcome variable and sociodemographic, health, comorbidity, and symptom frequency variables as the predictors Odds ratios (and 95% CIs) Age Gender Male Female Education Some college or higher Completed high school Less than high school Personal income ≥$35,000 $10,000–$34,999 $0–$10,000 Marital status Married/cohabiting Widowed/ divorced/ separated Never married Urbanicity Rural Urban Self-perceived health Excellent Very good Good Fair Poor Chronic medical conditions None One or more Depressive symptoms No Yes Current mood disorder No Yes Current anxiety disorder No Yes Lifetime mood disorder No Yes Lifetime anxiety disorder No Yes Lifetime personality disorder No Yes Total physical symptoms Total worry symptoms
0.97 (0.93–1.00) 1 1.70 (0.80–3.60) 1 1.38 (0.70–2.71) 1.18 (0.55–2.51) 1 1.06 (0.41–2.75) 2.26 (0.85–6.05) 1 1.03 (0.54–1.96) 1.58 (0.41–6.11) 1 1.00 (0.53–1.89) 1 0.99 (0.23–4.29) 1.57 (0.42–5.87) 2.45 (0.64–9.40) 2.76 (0.71–10.81) 1 0.53 (0.23–1.22) 1 1.00 (0.46–2.20) 1 4.08 (1.92–8.68)** 1 1.97 (0.75–5.14) 1 0.81 (0.34–1.92) 1 0.84 (0.36–1.99) 1 1.55 (0.83–2.87) 1.14 (1.04–1.25)* 1.21 (1.03–1.42)
2
χ (22) = 125.96**VIF: 1.51
CIs, confidence intervals; VIF, variance inflation factor. *p < 0.01; **p < 0.0001.
work, or anyone else). Having less than a high school education (OR: 3.17; 95% CI: 1.51–6.66) and having a lifetime diagnosis of personality disorder (OR: 2.33; 95% CI: 1.32–4.10) were the only variables Copyright # 2015 John Wiley & Sons, Ltd.
significantly associated with social friction. Occupational disability served as the outcome variable for the third analysis (had difficulty doing things supposed to do—working, schoolwork, and taking care of house/family), and only physical symptom frequency was associated with occupational disability (OR: 1.19; 95% CI: 1.09–1.30). A functional disability variable (restricted usual activity in any way) served as the outcome variable for the fourth analysis, and total physical symptoms (OR: 1.21; 95% CI: 1.11–1.32) and a lifetime diagnosis of mood disorder (OR: 2.57; 95% CI: 1.38–4.76) were significantly associated with this functional disability measure. An additional functional disability variable served as the outcome for our fifth analysis (found was unable to do something wanted to do). Total physical symptoms and having been never married were positively (OR: 1.24; 95% CI: 1.13–1.36) and negatively (OR: 0.10; 95% CI: 0.02–0.49) associated with this functional disability measure, respectively. Discussion The purpose of this study was to determine the relative contribution of worry and physical symptoms to diagnostic and clinical outcomes in late-life GAD. Consistent with previous studies, we found an age-related decrease in worry frequency such that older adults reported fewer symptoms than their younger counterparts. Additionally, older adults with GAD reported a higher frequency of worry symptoms than those with sub-threshold GAD. We also found an age-related increase in physical symptoms among participants with a GAD diagnosis but not among those with sub-threshold GAD. Physical symptom count, but not worry symptom count, significantly distinguished older adults with threshold and subthreshold GAD. Physical symptom count was significantly associated with distress, occupational disability, and two functional disability measures, whereas worry symptom count was only significantly associated with distress. At first glance, our findings appear to be inconsistent with those of previous studies, which report that worry frequency continues to be useful for informing diagnosis of GAD among older adults, despite agerelated decreases in frequency (Diefenbach et al., 2003; Wetherell et al., 2003). We note that six out of seven symptoms included in our total worry variable were self-referential. Previous research suggests that there is a critical distinction between worry about “self” and “other” in later life, such that personalized Int J Geriatr Psychiatry 2015; 30: 1186–1194
1191
0.50 0.00
0.25
Sensitivity
0.75
1.00
Worry physical GAD
0.00
0.25
0.50
0.75
1.00
1 - Specificity Area under ROC curve = 0.8481
Figure 2 Receiver operating characteristic (ROC) curve for the binary logistic predictor model (including sociodemographic, health, comorbidity, and symptom frequency variables) against a 12-month DSM-IV generalized anxiety disorder diagnosis.
worry tends to be pathological and impersonal worry tends to be normal (Gonçalves & Byrne, 2013; Gould & Edelstein, 2010; Wetherell et al., 2003). In spite of this, worry frequency still appeared to have less utility than physical symptom frequency for (i) distinguishing participants with threshold and subthreshold GAD and (ii) distinguishing those who did and did not report meeting functional impact criteria. However, it is important to note that because of a design feature of the NESARC dataset, our sample included only participants who endorsed some tension, nervousness, or worry for at least a 6month period. Nonetheless, our findings question whether worry accurately represents the most consequential feature of GAD in later life. For instance, somatic symptoms represent a key symptom cluster in the context of late-life mental disorders, and previous findings suggest that late-life depression may be appropriately conceptualized as presenting somatically (Hegeman et al., 2012; Sheehan & Banerjee, 1999; Wijeratne et al., 2003). It is possible that late-life GAD may also be appropriately conceptualized as having a physical presentation. Indeed, anxiety is highly prevalent in the context of primary care and nursing homes, and successful treatment of late-life anxiety has been found to be associated with significant decreases in somatic symptoms (Lenze et al., 2005; Miloyan et al., 2014b). Given that our sample consisted entirely of Copyright # 2015 John Wiley & Sons, Ltd.
self-reported worriers, our findings do not suggest that physical symptoms should supersede worry as the central feature of GAD. Rather, our findings suggest that given age-related decreases in worry symptoms, worry in the absence of physical symptoms might not frequently be of functional impact. In other words, among those who worry, those who report experiencing a greater number of physical symptoms are also more likely to report experiencing disability and/or distress. We believe that this is an important observation, because according to DSM and International Classification of Diseases (ICD) diagnostic criteria, excessive worry and associated functional impact cannot be attributable to the physiological effects of a substance or a physical condition if these are to constitute a GAD diagnosis. Given the high prevalence of physical illness and medication use in older adults, it is often impractical to disentangle physical symptoms from excessive anxiety and associated disability/distress (Brault, 2012; WolitzkyTaylor et al., 2010). At first glance, it appears surprising that only one physical symptom (often felt dizzy/lightheaded/like might faint) was significantly associated with late-life GAD. This may be due to the variable presentation of GAD across individuals and particularly to the different constellations of physical symptoms that may manifest in older adulthood (i.e., as a result of comorbid medical conditions or side effects of medication). Int J Geriatr Psychiatry 2015; 30: 1186–1194
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Table 3 Binary logistic regression analyses with functional impact measures as the outcome variables and sociodemographic, health, comorbidity, and symptom frequency variables as the predictors Odds ratios (and 95% CIs) associated with functional impact variables
Social disability
Occupational disability
1.02 (0.98–1.05)
0.99 (0.95–1.03)
1.01 (0.98–1.05)
1.00 (0.97–1.04)
1.04 (1.00–1.08)
1 1.16 (0.67–2.03)
1 0.77 (0.41–1.43)
1 1.19 (0.67–2.12)
1 1.21 (0.69–2.11)
1 0.76 (0.43–1.36)
1 0.92 (0.52–1.64) 1.53 (0.83–2.82)
1 1.93 (0.95–3.92) 3.17 (1.51–6.66)*
1 1.63 (0.89–2.99) 1.51 (0.78–2.90)
1 0.97 (0.54–1.71) 1.33 (0.72–2.44)
1 0.67 (0.37–1.21) 1.24 (0.66–2.35)
1 1.27 (0.66–2.43) 1.08 (0.52–2.23)
1 1.54 (0.72–3.32) 1.90 (0.81–4.44)
1 0.84 (0.43–1.67) 0.80 (0.37–1.71)
1 1.61 (0.82–3.14) 1.15 (0.55–2.42)
1 1.41 (0.71–2.83) 1.96 (0.91–4.23)
1 1.00 (0.60–1.69)
1 0.54 (0.3–0.99)
1 0.64 (0.37–1.10)
1 0.78 (0.47–1.31)
1 1.01 (0.59–1.73)
2.27 (0.70–7.36)
0.55 (0.15–2.08)
0.54 (0.16–1.84)
0.20 (0.05–0.84)
0.10 (0.02–0.49)*
1 0.71 (0.42–1.19)
1 0.85 (0.47–1.55)
1 1.46 (0.84–2.55)
1 1.33 (0.79–2.25)
1 0.99 (0.57–1.70)
1 1.07 (0.32–2.22) 1.34 (0.45–2.82) 1.09 (0.38–2.61) 0.79 (0.30–2.11)
1 1.55 (0.48–5.02) 1.47 (0.48–4.48) 0.76 (0.23–2.53) 1.19 (0.36–3.96)
1 1.07 (0.37–3.10) 2.00 (0.75–5.34) 1.25 (0.45–3.49) 1.77 (0.62–5.06)
1 2.31 (0.83–6.43) 2.48 (0.94–6.54) 2.21 (0.81–6.01) 2.00 (0.71–5.61)
1 1.88 (0.65–5.39) 1.86 (0.68–5.11) 2.16 (0.76–6.15) 2.55 (0.87–7.48)
1 0.75 (0.39–1.43)
1 1.72 (0.73–4.02)
1 0.90 (0.44–1.82)
1 0.88 (0.45–1.72)
1 0.87 (0.44–1.71)
1 1.41 (0.77–2.61)
1 0.94 (0.45–1.98)
1 1.52 (0.78–2.97)
1 1.33 (0.71–2.49)
1 0.89 (0.46–1.71)
1 0.69 (.37–1.28)
1 1.39 (0.68–2.83)
1 0.72 (0.39–1.33)
1 0.69 (0.38–1.27)
1 1.46 (0.77–2.76)
1 1.23 (0.56–2.72)
1 1.65 (0.71–3.84)
1 1.72 (0.79–3.76)
1 1.85 (0.84–4.09)
1 1.44 (0.63–3.32)
1 1.40 (0.76–2.58)
1 1.05 (0.50–2.23)
1 2.22 (1.17–4.22)
1 2.57 (1.38–4.76)*
1 2.06 (1.08–3.93)
1 1.02 (0.53–1.97)
1 1.18 (0.57–2.46)
1 0.94 (0.48–1.83)
1 0.65 (0.33–1.27)
1 0.95 (0.48–1.90)
1 1.38 (0.82–2.34) 1.26 (1.15–1.37)** 1.20 (1.06–1.37)*
1 2.33 (1.32–4.10)* 1.06 (0.96–1.16) 1.22 (1.05–1.42)
1 0.93 (0.54–1.60) 1.19 (1.09–1.30)** 1.16 (1.01–1.33)
1 1.04 (0.61–1.77) 1.21 (1.11–1.32)** 1.04 (0.92–1.19)
1 1.54 (0.88–2.70) 1.24 (1.13–1.36)** 1.09 (0.95–1.25)
Distress Age Gender Male Female Education Some college or higher Completed high school Less than high school Personal income ≥$35,000 $10,000–$34,999 $0–$10,000 Marital status Married/cohabiting Widowed/divorced/ separated Never married Urbanicity Rural Urban Self-perceived health Excellent Very good Good Fair Poor Chronic medical conditions None One or more Depressive symptoms No Yes Current mood disorder No Yes Current anxiety disorder No Yes Lifetime mood disorder No Yes Lifetime anxiety disorder No Yes Lifetime personality disorder No Yes Total physical symptoms Total worry symptoms
2
χ (22) = 69.09** VIF: 1.51
2
χ (22) = 61.50** VIF: 1.51
2
χ (22) = 64.35** VIF: 1.51
Functional disability A
2
χ (22) = 65.01** VIF: 1.51
Functional disability B
2
χ (22) = 105.13** VIF: 1.51
VIF. variance inflation factor. *p < 0.01; **p < 0.0001.
Thus, it is also important to consider the extent to which physical symptoms associated with late-life GAD may be attributable to physical health Copyright # 2015 John Wiley & Sons, Ltd.
conditions. The findings of a recent study suggest that physical conditions (and associated symptoms) may represent both cause and consequence of late-life Int J Geriatr Psychiatry 2015; 30: 1186–1194
Worry physical GAD
GAD: arthritis was found to be associated with increased risk for incident GAD, and lifetime diagnosis of GAD was found to be associated with increased risk for gastrointestinal disease (El-Gabalawy et al., 2014). Future studies investigating the longitudinal relationship between late-life GAD symptoms, physical health conditions, and their relative functional impact would be informative. These findings may also be relevant to the clinical management of GAD. Particularly, the higher functional impact of physical symptoms relative to worry may help explain why some CBT interventions lack efficacy for treating late-life GAD (Gonçalves & Byrne, 2012; Lenze & Wetherell, 2009, 2011; Thorp et al., 2009). These interventions typically target the key cognitive symptoms associated with late-life GAD (i.e., worry), which may turn out to be mildly efficacious because older adults endorse few worries and report being minimally perturbed by these worries in the first place. Rather, shifting the emphasis toward physical symptoms may be more effective for treating late-life GAD. Indeed, treatment of latelife anxiety is associated with notable reductions in somatic symptoms (Lenze et al., 2005). Previous studies have also observed a reduction in the prevalence of mental health conditions among those who report regular engagement in physical activity and, specifically, that physical activity is associated with a reduction in anxiety symptoms (Goodwin, 2003; Herring et al., 2010). Physical activity, serving to counter some of the physical symptoms associated with late-life GAD, may be associated with reduced risk of developing late-life GAD. This study was not without limitations. First, data from asymptomatic participants relevant to worry were lacking, barring any additional comparison. Second, our functional impact variables were collected with dichotomous responses, preventing a more detailed understanding of how worry contributes to distress and/or disability. This represents a more general limitation of using pre-existing data, as we were unable to include variables that might have been more appropriate for late-life anxiety. Additionally, our functional impact measures were solely based on self-report, preventing analysis of the impact of worry and physical symptoms on more objective measures of functional impact. Studies assessing the relationship between GAD symptom clusters and more detailed functional impact measures in different samples are needed. Future studies investigating the longitudinal relationship between physical and worry symptoms and their clinical relevance are also needed. Copyright # 2015 John Wiley & Sons, Ltd.
1193
Conflict of interest None declared.
Key points
• •
There are age-related decreases in worry symptoms and age-related increases in physical symptoms associated with GAD. Among older self-reported worriers, physical symptom frequency is useful for (i) distinguishing those with threshold and sub-threshold GAD and (ii) distinguishing those who do and do not report functional impairment, independent of diagnostic status.
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