Overanxious Disorder: A Review of Its Taxonomic Properties JOHN SCDTT WERRY, M.D.

Abstract. The taxonomic properties of overanxious disorder are reviewed using the diagnostic criteria and other features listed in the DSM-III-R manual as a template. The data suggest that overanxious disorder is only a modestly reliable, distinct and valid taxon, and that adjustments to the diagnostic items and criteria and improved sources and methods of data capture are needed. Such changes should be on the basis of empirical data. Since these data are not yet extant, better psychometric-type studies are needed, coupled to assessments of validity. Recently, there has been a distinct increase in number and quality of studies. Although some adjustments are needed, to alter overanxious disorder too much in DSM-IV could make past studies of doubtful relevance and could force a fresh start instead of building on current knowledge. l. Am. Acad. Child Adolesc. Psychiatry, 1991,30, 4:533-544. Key Words: overanxious disorder, anxiety disorders, DSM-lll-R, DSM-IV, diagnosis. Though overanxious disorder (DAD) was in DSM-ll, it appears to have provoked little research (Quay, 1978), and the long-standing tendency to treat anxiety disorders in childhood as a single entity called "emotional disorder" or "fears" seems to have persisted (Gittelman, 1986). Similarly, dimensional taxonomic systems that dominated research in nonpsychotic disorders in child psychopathology also had just one dimension/category variously referred to as anxiety-withdrawal or internalizing problems (Quay, 1986). In addition, the appearance of DSM-Ill with its creation of more child subcategories, such as separation anxiety disorder (SAD), its proliferation of adult subcategories, and its recasting of the diagnostic criteria for DAD would make previous research of limited relevance. Thus, there is no real, usable research on DAD before 1980. Unfortunately, the tendency to lump all childhood anxiety disorders together has been surprisingly persistent despite DSM-Ill, and so there has been less research in DAD than might have been expected. This makes for a rather thin review but probably sufficient to discern certain trends and to make some decisions derived from empirical data. Because this review is about the DSM-lll category of DAD, it will follow the outline in the DSM-Ill-R manual for DAD, which has two main categories of informationgeneral description/diagnostic criteria and features or correlates of the disorder. Studies will be critically reviewed following the usual methodological criteria required by most referred journals, although the sparsity of the data has required inclusion of several studies that ordinarily would not be considered of sufficient quality.

Critical Issues Most of these issues are in no way peculiar to DAD but relate to all childhood and adolescent disorders and to most DSM disorders. I. Can DAD be diagnosed reliably? 2. Are the diagnostic criteria in DSM-Ill-R appropriate? 3. Is DAD distinct from other childhood anxiety disorders and other disorders? 4. Is DAD sufficiently distinct from adult anxiety disorders to merit its continued separation among childhood disorders? 5. Are there enough specific correlates/features to suggest that DAD is a valid, useful diagnostic entity?

It can be seen that these issues are to some degree overlapping and interdependent, and so the empirical evidence will first be reviewed, and then the critical issues above addressed in the conclusion. Studies of OAD The studies that offer information on DAD are listed in Table I. To conserve space, only those studies that offer information on relevant variables are included in subsequent tables. Conspicuous by their absence are the DSM field trials that offer no usable data on DAD (Gittelman, 1986; Quay, 1986). It can be seen that with N = 22, studies are modestly numerous; but several are from overlapping samples of children, most provide only partial information, and many suffer from methodological problems. The most frequent of these problems are the following: very small numbers (of DAD, despite rather larger than usual total subject pools), potentially biased samples (such as special anxiety clinics or

Accepted November 7, 1990. Dr. Werry is Professor ofPsychiatry, University ofAuckland School of Medicine. This article is based on a review preparedfor the Anxiety Disorders Subcommittee of the DSM-IV Committee on Childhood Disorders. but the views expressed here are those of the author alone. Dr. Rachel Klein offered helpful suggestions. Reprint requests to Dr. Werry. School of Medicine, University of Auckland, P.8. Auckland I, New Zealand. 0890-8567/9113004-0533$03 .OOIO© 1991 by the American Academy of Child and Adolescent Psychiatry. l.Am.Acad. Child Adolesc. Psychiatry, 30:4,luly 1991

inpatients), which throw doubt on the generality of findings, and variations in diagnostic methods, diagnostic criteria, and sources of information. Nevertheless the quality of the studies illustrates the significant and continuing general improvement in research in child psychopathology. Dne study (Achenbach et al., 1989) that attempts to merge the dimensional and the categorical taxonomic approaches has been included. Although the instruments used do not provide a complete match with DSM-Ill defining items (Table 3, Bowen et al., 1990), there is clear semantic communality.

533

WERRY

TABLE 1. Studies and Their Characteristics Author Achenbach et al. (1989)

N (OAD)

Age

Source

SES Bias

Focus

6-16

Clinic

None

Dimensional

25 (10)

10.9

Clinic

None

Diagnostic

792 (23)

II

Cohort

None

976 (56)

15

Cohort

129 (11)

4/10

26 (13)

Contrast

Reliability

Comments SI different items; Checklist Dx only Mood!Anxiety Clinic, model reliability study Prevalence varies with sources

DSM-l//-R. CBCL, ACQ DSM-l//-R K-SADS

Other Dx/ Normal

Previous

Other Dx

Video

Epidemiology

DSM·l//. DISC, P&TQ

Other Dx/ Normal

Video

None

Epidemiology

DSM-l//-R, DISC, PQ

Other, Dx/ Normal

Video

Excellent data from age 11

Daypat

None

Follow-up

Other Dx

Previous

9-17

Clinic

Lower

School Refusal

DSM-l//. Structured Interview DSM-l//, DlCA

Other Dx

None

3,294 (42)

4-16

Stratified

None

4-16

None

Other Anxiety Normals

Cantwell & Baker (1989)

151 (8)

16

Clinicl Community Speech Clinic

DSM-l//-R, CBCL DSM·l//, DISC

Assumed

91 (?)

Epidemiology Screening

Combined anxiety at followup DAD with school phobia only Checklists, 1 item short Good reliability data

None

Follow-up

Other Dx

Initial only

Unusual sample

Costello (1989)

789 (20)

7-11

HMO

Mid/Up

Epidemiology

Other DXI Normal

Previous

Hershberg et al. (1982)

102 (7)

7-17

Clinic

Mood

None

25% refusal, high Dx threshold Not much data on OAD

Kashani & Orvachel (1988)

150 (11)

14-16

Stratified

None

Epidemiology

Other DX

At Training

Small sample, university city

Last (pers. commun. 1989) Last et al. (l987a,b,c,d)

(35)

M 13.6

Clinic

Upper

Clinicall Comparative All Anxiety Disorder

DSM-llI. DICA, P&TQ DSM-l//, DISC, Other DSM-l//. COl, Structured Interview DSM-l//, DlCA C & P DSM-l//R, K-SADS, ISC DSM-l//. CDI,ISC

Other Anxiety

Previous

Special anxiety clinic

Other Anxiety/Mood

Special anxiety Indeclinic pendent Interview Assumed Large N of OAD

Ambrosini et al. (1989)

Anderson et al. (1987 pers. commun., 1989) McGee et al. (pers. commun. 1989, 1990) Beitchman et al. (1987) Bernstein & Garfinkel (1986) Bowen et al. (1990) Canino et al. (1987)

Strauss et al. (1988) Livingston et al. (19851 1988) Mattison et al. (1987) Rey et al. (1989)

534

8,194

DX Criteria/ Method

?

69 (47)

5-18

Anxiety Clinic

Upper

(55)

5-19

Upper

Comparative

DevelopDSM-llI, mental CDI,ISC Comparative, DSM-llI, family DICA

95 (8)

8--1 I

Anxiety Clinic Inpatient

57 (16)

10.2

Clinic

Diagnostic

393 (10)

12-19

Adolescent Clinic

Diagnostic

Low/Mid

DSM-llI. K-SADS DSM-l//. Interview

Age 12, 11

Interview

IndeSevere cases pendent only Interview ADDH, Dys- Previous Also CBCL CMAS, thymia Also CBCL All Dx Independent Interview

Other Dx

J. Am. Acad. Child Adolesc.Psychiatry, 30:4, July 1991

OVERANXIOUS DISORDER TABLE I. Studies and Their Characteristics (continued) Author Silverman & Nelles (1988) Silverman et al. (1988) Velez et al. (1989)

1

Vuh,!"" ,I.

(1985), Verhulst & Akkerhuis, (1988) Weissman et al. (1984) Werry et al. (1983)

N (OAD)

Age

Source

SES Bias

Focus

DX Criterial Method

Contrast Other Anxiety

Reliability

Comments

Child/Par- Anxiety Clinicll Dx only entl Clinic

6-18

Anxiety Clinic

Upper

Diagnosisl Family

DSM-IIl, ADISC

776 (61)

13.7

None

All Ox

8-11

Epidemiology/Follow-up Epidemiology/Follow-up

DSM-IIl-R, DISC

400 (7)

Community Survey Stratified

DSM-IIl, CBCL, TRF,Interview

Other Oxl Normal

Video

194 (?5)

0-18

Parent Mood

Upper

Child disorder

DSM-IIl, DICA

Other Oxl Normal

195 (7)

5-14

Inpatient

None

Reliability

DSM-IIl, Clinical

Other Dx

Child of parent with mood disorder 2--4 Dxers Severe cases only

51 (7,6)

None

20% lost to follow-up Good data, only one Ox

None

Note: For brevity, all citations with more than two authors are "et al." For abbreviations of instruments, see text or original citation.

The paucity of studies of nonreferred samples of OAD like this one and the importance of trying to marry the dimensional and categorical systems warrants including this study, but the differences in items must be kept in mind. The same remarks apply to the large epidemiological study by Bowen et al. (1990) that also used the Achenbach instruments for its data capture but took considerable care to adjust items and diagnostic rules to those of DSM-III-R. Most of the studies use DSM-III, but apart from minor rewording and refining exclusion criteria, there has been little change in OAD in DSM-III-R, so that it seems reasonable to combine both III and III-R studies. Diagnostic Issues Reliability (Tables I and 2) The kinds of reliability of greatest interest are interrater between diagnosticians, cross-informant (Achenbach et al., 1987), and test/retest or stability over time. Most studies have addressed interrater reliability in some way. On the whole, it ranges from modest (kappa = 0.59) to very good (kappa = 0.85), with only two studies (Canino et al., 1987; Rey et al., 1989) giving a poor result (kappa = 0.35 or less). It seems reasonable to conclude that properly trained diagnosticians can usually reach an acceptable level of agreement--especially when structured instruments are used in academic settings and the diagnosticians have worked together for some time (which characterize the studies with the best results). Reliability in the ordinary clinical situation could well be very different. Occasional poor results, even under optimal circumstances (e.g., Canino et al., 1987; Rey et al., 1989) suggest that improvements in diagnostic criteria, sources, or methods are still needed. Although some (e.g., Quay, 1986; Rey et al., 1989) have argued against the subcategorization of anxiety disorder on the basis that better reliability can be obtained by maintaining a broader construct, it now seems that a robust OAD may be realizable with fine tuning. J. Am. Acad. Child Adolesc. Psychiatry, 30:4, July 1991

Whereas interrater reliability approaches a satisfactory level in most studies, this is not so with cross-informant reliability (unless the informants are of the same type, such as parents). Of four studies addressing this, all except one (Ambrosini et al., 1989) yield poor results. Children and adults seldom agree, with children and adolescents often reporting more symptoms than adults (Anderson et aI., 1987; Costello, 1989). This discrepancy becomes most acute in adolescence when adolescents become both more dissatisfied and more articulate, which may explain the concomitant large rise in prevalence when reliance is primarily on patientderived data (Bowen et al., 1990; McGee, pers. commun., 1989; McGee et aI., 1990). DSM gives no guidance as to who is supposed to report the symptoms, although as is general practice in child psychiatry, it seems assumed that multisourced data are essential (Anderson et al., 1987; Bowen et al., 1990, Canino et al., 1987; Rey et al., 1989; Werry et aI., 1983). If this is done, dramatic reductions in the prevalence of the disorder may result (Anderson et al., 1987; Bowen et al., 1990; Costello, 1989; McGee, pers. commun., 1990). Since anxiety is an intensely personal experience, it is doubtful if this external replicating requirement is necessarily valid (Herjanic and Reich, 1982). Certainly, diagnosis of adult anxiety disorders make no such requirement, relying almost entirely on self-report. The problem of cross-informant disagreement (when informants are dissimilar) is hardly a blow to DAD because it affects most childhood disorders (Achenbach et al., 1987; Quay, 1986) and is one that, so far, has not been properly confronted. These data on OAD, yet again, merely raise the issue of important unfinished business in childhood psychopathology. As far as test-retest reliability or stability with time of DAD is concerned, the picture is less satisfactory. The few follow-up studies detailed in the appropriate section (see below) show that DAD has a rather low stability in the long term. Some of this is hardly surprising because of some 535

WERRY TABLE

Author Achenbach et al. (1989)

Distinctiveness/ Comorbidity

Reliability

13 CBCL items, sum scores, norms, somatic did not load DSM-I1I-R, no other data DSM-I1I, common items future ability, self-consciousness DSM-III-R, sleep symptoms, life events also common

Items 0.899 test! retest 0.93 interparent Kappa = 0.85

No data

No data

Canino et al. (1987)

5 + CBCL symptoms 1.2%, somatic least DSM-I1I, no other data

Cantwell & Baker (1989)

DSM-Ill, no other data

Sources - poor, alpha =0.68 Kappa 0.35 (2nd lowest) 96% overall Ox

Costello (1989)

DSM-III, no other data

Hershberg et al. (1982) Kashani & Orvachel (1987) Last (pers. commun. 1989)

No data DSM-III, no other data

LMl " ,I. (1987 ',b,o,d)

6+ items in 70%, 95% future

Strauss et al. (1988)

Social/perform high, somatic 50%

Livingston et al. (1985/ 1988) Mattison et al. (1987)

Somatic not increased Somatic/withdraw least of 3 Ox DSM-III, no other data

Ambrosini et al. (1989) Anderson et al. (pers. commun. 1987) McGee et al. (pers. commun. 1989, 1990)

Bernstein & Garfinkel (1986) Bowen et al. (1990)

~

Defining Symptoms

2. Diagnostic Issues

Rey et al. (1989) Silverman & Nelles, (1988), Silverman et al. (1988) Velez et al. (1989) Verhulst et al. (1985), Verhulst & Akkerhuis (1988) Werry et al. (1983)

60% all except somatic 53%, future 88%, tension 79%

DSM-I1I, no other data

DSM-I1I-R, no other data DSM-III clinical judgment DSM-III, no other data

Poor agreement across sources of data Agreement across 2 sources only 21/ 46

Poor between sources No data Ox 100% agree pretest See Last et al.

2 minor depression items also loaded on factor With mood 2 times that alone 15/23 also other OX Disruptive commonest 50% comorbidity other anxiety (SAD, phobic) or mood disorder 50% mood, 2; 1 with SAD 50% other, SAD 20% No data

Adult Ox No data

No data No data

Comments Items not quite same No sex effects Very good reliability study Most self-report only Few "pervasive"

No data

No data No data

Atypical group (school refusal) CBCL items, threshold critical

No data Atypical group (language disorder)

Speech, other unusual Other child anxiety Mood infrequent 50% phobic, 80% mood 66% phobic, SAD 31% Phobic/OAD distinct 75--40% phobic, 40-10% mood, 40% ADD/OPP, avoid 27%, SAD age

No data No data

Ox agree 88%

Most SAD too

70% mood, alch

Good convergent validity Lowest kappa (0.14) Ox 0.59, Severity 0.95

Excluded

No data

Commoner in boys (all Ox) 4/7 other anxiety

No data Mat agor/panic

SAD & OAD distinct Mixed cases discarded

Parent Good risk factor psychiatric Ox study No age differences Parent moodanxiety

Only one Ox allowed

No data

Ox kappa 0.82

No data Dx kappa 0.95

Kappa 0.65

No data

85% mat. anx

No mood inc

Special anxiety clinic, center Special interest mood disorder Mothers 42% Hx OAD, GAD 45% No sex difference, 11 + more symptoms Inpatients only CMAS + CBCL 70% correct Ox Multisourced data Mat GAD/child OAD not related

Inpatients

Note: For brevity, all citations with more than two authors are "et al." For abbreviations of instruments, see text or original citation.

degree of remission of the disorder, but GAD has an unexpected tendency to change to or emerge from other disorders, including anxiety and disruptive disorders (Cantwell and Baker, 1989; McGee pers. commun., 1989; McGee et aI., 1990). It is not clear to what extent this is peculiar to 536

GAD or is part of a more general problem affecting other

childhood disorders. Nevertheless, two studies show that there is probably more stability in severe cases, which is reflected in both retrospective (Werry et aI., 1983) and prospective data (Cantwell and Baker, 1989). J. Am.Acad. Child Adolesc. Psychiatry, 30:4, July 1991

OVERANXIOUS DISORDER

Diagnostic Criteria (Table 2)

There are seven symptoms-in paraphrase these are the following: worry about future events, concern about past behavior, concern about competence, somatic complaints, self-consciousness, need for reassurance, and tension/ inability to relax. Symptoms have to be severe and be present for at least 6 months. Any four are required to meet the diagnostic threshold. Item analyses-especially of internal consistencies, redundancies, sensitivity, specificity, and positive and negative predictive power-seem infrequent, and one is left wondering how DSM arrived at the seven symptoms. Although this author was not a party to this process, there seem to have been a number of obvious difficulties regarding the task. The creation of DSM-III was governed by rather unusual imperatives, in a rather short time, to decide what the committees concerned thought should be in the taxonomy and then to "manufacture," as best they could, operational diagnostic criteria. In some areas, such as the adult psychoses, there was a wealth of precedent by which to operate. But in general, the psychometric properties of the diagnostic symptoms of most of the childhood disorders were and, to a large extent, are still unknown. Nevertheless, the symptoms are there, and the task is to examine them and to examine any supporting data. In OAD, there seems to be poor "face" validity to some items. For example, OAD has three items (concern about past behavior, concern about competence socially, selfconsciousness) reflecting social anxiety that also characterize avoidant disorder and social phobia. Some of the items (worry about future events, need for reassurance, and tension or inability to relax) seem likely to occur in any kind of anxiety disorder. Although disorders inevitably will share some features in common (e.g., fever in all infectious diseases), too many overlapping diagnostic items will lead inevitably to high comorbidity among anxiety disorders or to reduced interrater reliability. Moving on from face validity to empirical studies that have looked at diagnostic symptoms, any conclusions have to be rather tentative because only a minority (nine of 22) yield data, and few of these have used proper psychometric methods. They suggest the following: I. Somatic symptoms are probably noncontributory, are not covarying with the other six symptoms (Achenbach et al., 1989; Bowen et al., 1990), or are least frequent (Hershberg et al., 1982; Last, 1989 pers. commun.; Last et al. 1987a; Strauss et al., 1988), or are more common than in other disorders (Livingston et al., 1988). 2. Adolescents report more symptoms than children (Bowen et aI., 1990; McGee, pers. commun., 1989; McGee et al., 1990; Strauss et al., 1988). 3. The most common symptom is worry about future events (Anderson et al., 1987; Last, pers. commun. 1989; Strauss et al., 1988), especially in children; whereas in adolescence, more social concerns (exams, what others think) begin to become prominent (Last, pers. commun. 1989; McGee, pers. commun., 1989; McGee et al., 1990). 4. Individual symptoms are quite common in the population (Achenbach et al., 1989; Anderson et al. 1989), and J.Am.Acad. Child Adolesc. Psychiatry, 30:4, July 1991

the threshold number greatly influences the prevalence of the disorder (Achenbach et al., 1989; Bowen et al., 1990; Costello, 1989). as does severity (Anderson et al. 1989). Two studies showed that after age 11, over 70% of those with OAD in an anxiety disorders clinic have at least six of the seven symptoms (Last, pers. commun., 1989; Strauss et al., 1988), suggesting the present threshold of four could be too low and lead to oversensitivity. This would need to be examined in the population as a whole because this observation is derived from a rather biased and probably more severe sample (anxiety disorders clinic). 5. There may be additional useful symptoms for adolescents, especially sleep problems (McGee, pers. commun. 1989; McGee et al., 1990). The most cogent conclusion from this list is that item analysis needs to become an integral and urgent part of research on OAD. Such item analysis will need to be yoked to external validating studies. In addition to the positive criteria, DSM lists exclusion criteria of which the most important criteria relate to other anxiety disorders. Although OAD may coexist with another disorder, it is clear that it can only be diagnosed if the four requisite symptoms are different from those that make up the other disorder. Because, as already discussed, there is some overlap in symptoms between OAD and the other disorders, this could make OAD something of a residual diagnosis, made only when nothing else fits. Although there are no studies to test this problem directly, those reviewed here neither voice nor support this concern (see reliability above and nondiagnostic features below). Data Capture Methods

Reliability of the diagnosis and items cannot be divorced from the issue of the methods of eliciting the symptoms and rating their severity. Psychology has a long tradition of tightly structured data capture, but medical-dominated fields have been slow to follow. Even so, the research cited here reflects an increasing use of structured data-capture methods; however, there is a need to compare the effect of using structured methods with more usual informal clinical techniques before requiring clinicians to change their ways. Like the problem of which informant(s) to use, the data do not allow an answer to this question. In passing, it may be noted that, both as measured directly (Mattison et al., 1987) and in terms of findings (e.g., Achenbach et al., 1989; Bowen et al., 1990), there is good agreement between dimensional/questionnaire methods of obtaining data (adjusted to DSM-III-R diagnostic criteria) and more psychiatric methods (such as interviews). Diagnostic Specificity (Table 2)

Studies in Table 2 show that OAD is frequently found comorbidly with SAD in children (Costello, 1989; Last, pers. commun., 1989; Last et al., 1987a,c; Livingston et al., 1985, Strauss et al., 1988), with phobic disorders, especially social phobias, and in adolescents (Bernstein and Garfinkel, 1986; Kashani and Orvaschel, 1988; Last, pers. commun. 1989; McGee, pers. commun., 1989; McGee et

537

WERRY TABLE

Overanxious Disorder (DSM-llI and DSM-llI-R) A. Excessive unrealistic worry for 6/12 of 4 or more of I. Future events

3. Overanxious, General Anxiety, and Dimensional Symptomatology

Frequency at II (Anderson et aI., 1987) Moderate

Severe

36%

12%

2. Past behavior

10%

02%

3. Competence (school peers)

18%

04%

4. Somatic complaints

09%

07%

5. Self-consciousness 6. Need for reassurance

15% 15%

06% 05%

7. Tension, inability to relax

11%

05%

General Anxiety Disorder (DSM-llI-R) A. Excessive unrealistic anxiety, worry 6/12 about Two or more life circumstances, being bothered more days than not D. When anxious at least 6 of Motor tension 1. Trembling, twitching, shaking 2. Muscle tension, aches, soreness 3. Restlessness

4. Being fatigued Autonomic hyperactivity 5. Shortness of breath 6. Palpitations 7. Sweating 8. Dry mouth 9. Dizziness 10. Nausea, diarrhea II. Flushes, chills

Empirical Statistical (Achenbach et aI., 1989)

2-Year Stability (Verhulst & Akkerhuis, 1988)

1. Fearful, anxious 2. Worries

0.35 0.37

3. Fears impulses

0.13

4. Fears school 5. Lonely 6. Needs to be perfect

0.06 0.40 0.35

[7. Somatic symptoms do not load] 8. Self-conscious 9. Feels inferior 10. Feels unloved

0.36 0.34 0.37

11. Nervous and tense 12. Unhappy, sad, depressed

0.35 0.40

GAD (cont'd) Vigilance and scanning 14. Feeling keyed up 15. Exaggerated startled

12. Frequency 13. Lump in throat

aI., 1990), with anxiety disorders in general (Bowen et aI. , 1990; Last, 1989 pers. commun.; Silverman and Nelles, 1988). The consistency of this finding is probably even higher because not all of the studies reported on comorbidity (Canino et aI., 1987; Costello, 1989), and some even excluded subjects who exhibited it (Mattison et aI., 1987; Verhulst and Akkerhuis, 1988; e.g., Verhulst et aI., 1985). Although comorbidity is common, on average, 50% or more of cases show none. Also, even though commonly associated with other anxiety disorders, such as phobic or SAD, DAD, showed some distinctiveness in a number of correlates (age of onset and referral, types of fears, absence of family adversity) in the few studies that looked at this (Last, pers. commun., 1989; Last et aI., 1989; Velez et aI. 1989). In addition to comorbidity with anxiety disorders, there is also a strong association with mood disorders/symptoms (Achenbach et aI., 1989; Ambrosini et aI., 1989; Bernstein 538

16. Difficulty concentrating 17. Trouble falling asleep 18. Irritability

and Garfinkel, 1986; Kashani and Drvaschel, 1988; Last, pers. commun., 1989; Last et aI. 1987a,c; McGee, pers. commun., 1989; McGee et aI., 1990), although not all find this (Hershberg et aI., 1982; Weissman et aI., 1984). There is also a variable association with a variety of other childhood disorders, notably disruptive disorders like attention deficit hyperactivity disorder (ADHD) and oppositional disorder found by some (Anderson et aI., 1987; Last et aI., 1987a; McGee, pers. commun., 1989; McGee et aI., 1990) but not by all (e.g., Mattison et aI., 1987). There is one report of comorbidity with developmental language disorders (Cantwell and Baker, 1989). This study was also the only one reporting comorbidity data that did not find a high degree of covariance of DAD with other psychiatric disorders. In summary, about half of those with DAD have at least one other disorder, most often another anxiety or a mood l.Am.Acad. Child Adolesc.Psychiatry, 30:4, luly 1991

OVERANXIOUS DISORDER TABLE

Author

4. Nondiagnostic Features/Correlates Age of Onset

Associated Features

Course

Impairment

Achenbach et al. (1989)

Dysthymic symptoms

Slight increase 12-16

No data

A,',rnoo,,~.

Disruptive symptoms

Big increase after II,

OAD at 11, Social competence,

t

(1987) McGee et al. (pers. commun. 1989, 1990) Beitchman et al. (1987) Bernstein & Garfinkel (1986) Bowen et al. (1990) Cantwell & Baker (1989) Kashani & Orvachel (1988) Last (pers. commun. 1989)

Other anxiety symptoms

and between 15

gone by 15

Clinic cases worst

normals, other disorder

Complications No data No data No data

Most gone by 8? No data

No data

No data

Severe by selection

School refusal

No data

> than normals

No data

No data

Found cases at 4

Depression, SAD

No data

No data Speech/language disorder

Much commoner after 11 Any age, more later

25% chronic No data

Anxiety, depression

S I increase after 14

No data

No data

Irritable, low self-esteem

Mean 9 years

?Most chronic No data

50% severe, = all anxiety No data

Mood (after OAD)

No data

No data

No data

No data

No data

No data

No data

No data

No data

Declines/ males Low stability

No data

No data

No data

No data

66% 5 years

Hospitalized

No data

Fears, anxiety, depression { LM""L (l987a,b,c,d: pers. commun. 1989) Strauss et al. (1988) ADHD, oppositional disorder Livingston et al. Separation anxiety (1985, 1988) Mattison et al. (1987) Obsessive, depressive symptoms Velez et al. (1989) Pregnancy problems

More symptoms after 12

Verhulst et al. No data (1985), Verhulst & Akkerhuis (1988) Werry et al. (1983) No data

No age effect

No data

disorder, and this condition is not confined to clinic samples. Nevertheless, pure OAD exists in a substantial percentage, and there is some indication that symptomatology (and correlates) may be sufficiently distinctive to sustain its specificity in a positive sense, not just as a residual category left over after all other anxiety disorders have had first pickings. The problem of comorbidity is endemic throughout DSM and is therefore not necessarily a reflection on the integrity of OAD. However, data are sparse, and additional tests are needed that use externally validating criteria. Distinctiveness from Adult Disorders

There is little data on distinctiveness from adult disorders. However, if one examines the nearest equivalent adult disorder, generalized anxiety disorders (GAD), it can be seen in Table 3 that, although there are areas of symptoms in common, primarily involving trait or chronic anxiety, there are also substantial differences. First, GAD criteria reflect a more narrowly focused anxiety (two or more specific life situations rather than the more global ones in OAD, such as "future events"). Second, there is more emphasis on anxiety state or acute symptoms in GAD (criterion D, 18 J. Am. Acad. Child Adolesc. Psychiatry. 30:4 •July 1991

Other anxiety, ADHD No data

No data

symptoms of motor tension, autonomic hyperactivity, and vigilance/scanning) not seen in OAD criteria. Many of these latter acute symptoms in GAD are somatic and are among the least seen and least specific in OAD (see above). Necessary comparative studies applying GAD criteria to OAD children and OAD criteria to GAD adults to ascertain the overlap in diagnosis have not been done. Longitudinal and family studies, which also might help to settle this issue, are infrequent or too short in duration, but such as are available do not, so far, add credence to the view that GAD and GAD are identical. One study (Thyer et aI., 1985) shows that only 20% of adults with GAD report the onset of their disorder in childhood or adolescence, suggesting that at best OAD cannot be a major contributor to this disorder in adultsother anxiety disorders, such as obsessive-compulsive disorder and phobias have much higher frequencies of childhood onset. But more damning is the admittedly small amount of prospective data on children (see below) that is consistent in showing that most OAD disappears within 2 years. It is not impossible that OAD and GAD could be separated by a latent period, but this issue of continuity or similarity cannot be settled on the sparse data available.

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Nondiagnostic Criteria Associated Features (Table 4)

The association with other anxiety disorders, mood and disruptive disorders, or symptoms has been noted above. DSM-III-R mentions a number of associated features, such as hypermaturity, conformity, nervous habits, obsessionality, and so on. Although these seem reasonable, so far they lack supporting data. Course (Table 4)

Studies here are sparse, numbers are small in two of the studies (Beitchman, 1987; Cantwell and Baker, 1989), and age groups are different (preschool to adolescent). Such as they are then, the data suggest that in the majority of cases (perhaps two-thirds), OAD or its symptoms probably disappear or become subclinical within 2 years (Beitchman, 1987; Cantwell and Baker, 1989; McGee, pers. commun., 1989; McGee et al., 1990; Velez et al., 1989; Verhulst et al., 1985; Verhulst and Akkerhuis, 1988) and that this rate of remission is greater than in most other common disorders. Cantwell and Baker (1989) found, however, that OAD was more stable than other anxiety disorders. The remission rate may be higher in boys than girls because girls predominate in adolescence. On the other hand, retrospective data suggest that those cases of OAD seen in clinics (Last, pers. commun., 1989) or in inpatient care may have a much longer history (Werry et al., 1983). This suggests that an unknown minority run a chronic course. If the course continues into adulthood, it is premature to speculate what the adult equivalent is or are because data do not exist. In general, DSMlII-R shows a positivity about persistence ofOAD into adulthood (e.g., as generalized anxiety disorder or social phobia) that hardly reflects the true state of uncertainty. Nor is the stated mode of onset (sudden or gradual) of OAD well documented. Age of Onset (Table 4)

The earliest age reported in any study is 4 (Beitchman et al., 1987), although these "already present" are not true onset data. Age distribution in clinic samples (Baker and Cantwell, 1989; Last, pers. commun., 1989; Strauss et al., 1988), community prevalence (Anderson et al., 1987; Bowen et al., 1990; Kashani and Orvachel, 1988; Velez et al. 1989), and longitudinal studies (McGee, pers. commun., 1989; McGee et al., 1990) all suggest that OAD may begin at any age in childhood. There is conflict about age-specific rates, with some studies showing a decline in adolescence (Velez et al., 1989) and others showing that the frequency is low until adolescence when it increases markedly and continues to do so rather more slowly (Bowen et al., 1990; Kashani and Orvachel, 1988; McGee, pers. commun., 1989; McGee et al., 1990). As noted, this may be due in part to adolescents being better self-reporters (and more complaintive in general) than children. Impairment (Table 4)

OAD seen clinically is apparently disabling in at least 50% of those who suffer from the disorder, (Last, 1989) 540

and, occasionally, it is severe enough to require hospitalization (Livingston et al., 1985; Werry et al., 1983). In community samples, those with OAD can be distinguished on the basis of impairment from normals (Velez et al., 1989) although impairment is generally not as severe as that reported in mood or disruptive disorders (Bowen et al., 1990; McGee, pers. commun., 1989; McGee et al., 1990). In fact, some areas of function, such as school performance and peer relationships, may be reasonably normal (Bowen et al., 1990), highlighting the cross-informant or data source problem noted above (Achenbach et al., 1987) and suggesting that OAD, in some cases, may be more discomforting than dysfunctional. Complications (Table 4)

School refusal (Bernstein and Garfinkel, 1986; Last, pers. commun., 1989) and recurrent abdominal pain (Wasserman et al., 1988) have been reported in children with OAD. Underachievement does not seem to be as common a complication as in other disorders (McGee, pers. commun., 1989; McGee et al., 1990; Bowen et al., 1990). Because of conflicting data, it is not clear whether the often associated mood, separation anxiety, phobic, and other disorders are direct complications, risk factors, or correlated manifestations of a common underlying pathogenesis. One retrospective study suggests that OAD precedes depression (Last, pers. commun., 1989); another prospective study suggests that disruptive and mood disorders may precede OAD in adolescence (McGee, pers. commun., 1989; McGee et al., 1990); and yet another suggests that avoidant disorder became OAD in about 25% of cases 5 years later (Cantwell and Baker, 1989). Premorbid Personality (Table 5) There are few studies reporting premorbid personality, and they suggest that any childhood disorder may preexist, although there is little agreement about which particular disorders may be more commonly preceding (Cantwell and Baker, 1989; McGee, pers. commun., 1989; McGee et al., 1990). Predisposing Factors (Table 5)

Evidence relating to common etiological factors in childhood psychopathology is contradictory. One study showed that life events were no more common in OAD than in any other adolescent disorder (McGee, pers. commun., 1989; McGee et al., 1990), another found parental stress correlated (Costello, 1989), yet another found pregnancy difficulties and parental psychiatric disorder but not socioeconomic status (SES) nor most of the family adversity variables associated with SAD and the disruptive disorders (Velez et al., 1989). Although most clinic studies show a preponderance of children from upper SES groups, without comparative data on all their admissions and with no such overrepresentation of higher groups in community samples (Velez et al., 1989), it seems safer to assume that this is a referral bias in clinics rather than some predisposing factor. The issue of whether comorbid disorders constitute a risk factor has been discussed above. There is a regrettable tendJ. Am. Acad. Child Adolesc. Psychiatry, 30:4, July 1991

OVERANXIOUS DISORDER TABLE

5. Nondiagnostic Features (Continued)

Author

Premorbid

Achenbach et al. (1989) Ambrosini et al. (1989) Anderson et al. (1987)

No data No data ADHD, OPP/ CD At 11

No data ?MDD Life events not?

2% by definition 10/25 At 11 2.9%, 1% confirmed

SI inc F No data 11, 3:2

ADHD, OPP/CD?

15,2:5

No data

No data

1:4

SAD

No No No No No

No data Speech/lang disorder Parental stress No data No data

At 155.9%,2.2% confirm M (17)

SAD Other anxiety disorders No data

Verhulst et al. (1985), Verhulst & Akkerhuis (1988) Weissman et al. (1984)

No data

No data No data Pregnancy problems, parent psychiatric Ox No data

4%

6:1

No data

No data

No data

No data

No data

Werry et al. (1983)

No data

No data

Most uncommon of all anxiety 4.6% of IP, SAD

No data

No data

Note: For familial data, see Table 2 under "Adult"

ency to extrapolate from comorbidity data to antecedentconsequent relationships-according to one's prejudged view of how this relationship should be. As noted, there is no good evidence to clinch any such case.

Prevalence (Table 5) OAD is found most commonly in under 8% of the population (Anderson et al., 1987; Costello, 1989; Kashani and Orvachel, 1988; McGee, pers. commun., 1989; McGee et al., 1990; Verhulst et al., 1985; Verhulst and Akkerhuis, 1988); but if more stringent criteria, such as confirmation by an independent source are applied, the figure falls to around 2% to 4% (Achenbach et al., 1989; Anderson et al., 1987; Bowen et al., 1990; McGee, pers. commun., 1989; McGee et al., 1990). An exception is the very high figure of 19.1 % found in school-age children in upper New York State (Velez et al., 1989). OAD seems to constitute about 10% of cases seen in child psychiatric clinics (Beitchman et al., 1988; Hershberg et al. 1982). It is among the most common of anxiety disorders in children and adolescents in clinic and community samples (Ambrosini et al., 1989; Anderson et al., 1987; Cantwell and Baker, 1989; Costello, 1989; Hershberg et al., 1982; Kashani and Orveschal, 1988; Last et al., 1987a; McGee, pers. commun., 1989; McGee et aI., 1990; Velez et aI., 1989). J.Am.Acad. Child Adolesc. Psychiatry, 30:4, July 1991

Gender (Table 5) The sex ratio is probably nearly equal in both community and clinic samples until adolescence after which females predominate, although the degree varies (Achenbach et al., 1989; Anderson et al., 1987; Bowen et al., 1990; Costello, 1989; Kashani and Orvaschel, 1988; Last et al., 1987a; Livingston et aI., 1986; McGee, pers. commun., 1989; McGee et al., 1990; Silverman & Nelles, 1988; Velez et al., 1989). The studies by Cantwell and Baker (1989), Verhulst et al. (1985), and Verhulst and Akkerhuis (1988) are exceptions in reporting a marked excess of boys. This is almost certainly a result of the source of subjects (speech and language disorders clinic) in the former. In the Dutch study (Verhulst et al., 1985; Verhulst and Akkerhuis 1988), the excess of boys is not easy to explain, but, because this finding is so highly atypical, it too may reflect the sample studied.

Familial Pattern (Table 5) Studies of clinic cases show that OAD is probably linked to psychiatric disorder in parents, with three of the studies showing the type of disorder to be predominantly various anxiety disorders (Last et al., 1987b,d; Silverman et al., 1988; Weissman et al., 1984), whereas another study of more severe cases of OAD linked OAD to parental mood 541

WERRY

and alcohol disorders (Livingston et aI., 1988). Unfortunately, most of these studies have significant methodological problems, such as small numbers and/or confounding by locating OAD children through parents with a psychiatric disorder (e.g., Silverman et aI., 1988; Weissman et aI., 1984). Two studies suggest that mothers of children with OAD have an increased history of OAD as children themselves, although the frequency is under 40% (Last et aI., 1987a,d; Silvennan et aI., 1988). While GAD is twice as common in parents of children with OAD than those of nonnal children (Last et aI., 1987a), no study has shown any special relationship between OAD and parental GAD when compared with other anxiety disorders (see fuller discussion above). Differential Diagnosis (Table 5) It is clear from the comorbidity data that separation anxiety (in children), phobic (in adolescents), and mood disorders will present difficulties in differential diagnosis because of their common concurrence and related symptomatology. However, the studies also show that most researchers can differentiate OAD. In OAD, by definition, the anxiety is more general, involving a variety of areas, such as future events, academic performance, and peer relationships; whereas in phobic and separation anxiety disorders, the object of the anxiety is much more focused. Mood disorders may present more difficulty than phobic or separation anxiety disorder, because anxiety symptoms of all types are common in depression before adulthood (Bernstein and Garfinkel, 1986; Hershberg et aI., 1982). Two studies suggest that ADHD may also cause some confusion (McGee, pers. commun., 1989; McGee et aI., 1990; Last et aI., 1987a), presumably because of motor restlessness, although the source of this confusion is not stated.

Conclusions Operationally defined OAD is only 10 years old and has attracted a minimum but an increasing amount of research. Some research is of high quality, and some has employed unusually large, truly epidemiological samples. The clinical data are useful but more variable in quality. The questions about OAD posed at the beginning of this review are thus answerable with varying degrees of precision but, nevertheless, often in a valuable way. 1. Reliability. OAD can be reliably diagnosed, although this probably requires methods and research punctiliousness not readily available in the ordinary clinical situation. However, there is still too much variability in reliability to suggest that current diagnostic criteria, methods, and sources of information are either unifonn or satisfactory. 2. Appropriateness of diagnostic criteria. The current DSM-lII-R criteria cannot be readily evaluated except to say that somatic symptoms are the least frequent and least specific. The threshold criterion of four symptoms seems readily met, but resultant specificity and sensitivity are unknown. However, the obvious semantic overlap in some avoidant, social phobic, and OAD symptoms (principally those centered on social anxiety) and diagnostic symptoms 542

that reflect anxiety in general, such as worry about future events, self-consciousness, and tension, must result in loss of specificity. There are developmental differences in the number and possibly the type of symptoms (away from more life-threatening to social worries), with more symptoms being present at older ages. Regrettably, much of the research on diagnostic criteria has proceeded without availing itself of the 50-year development of test construction theory and methological tools, such as item analysis. This is not confined to OAD, however, but seems to reflect a general, but fortunately now rapidly diminishing, unawareness in medical taxonomists. Lists of symptoms seem to be derived from fallible "clinical wisdom" and are assigned equal weights and arbitrary thresholds. This is not to say that the results are wrong, just that the method precludes knowing until some years after the fact. This intuitive approach stands in sharp contrast to the development of dimensional taxonomic systems where the lists of symptoms have been painstakingly piloted, analyzed, and winnowed over as long as 30 years (Achenbach et aI., 1989; Quay, 1986). Serious thought, therefore, needs to be given to pooling the medical-categorical and dimensional-symptom domains, following the lead of Achenbach et al. (1989). 3. Distinctiveness from other childhood disorders. In about 50% of cases, OAD occurs alone, but even when it does not, most diagnosticians seem to be able to separate it from other anxiety and childhood disorders. Although comorbidity is greatest with other anxiety and mood disorders, this is only a matter of degree. There is insufficient evidence at the moment to say whether this comorbidity reflects predisposing or consequent factors or lack of diagnostic specificity. The problem of comorbidity is not confined to OAD and raises general issues that need to be resolved in DSM in general. As long as this is not done, there is no reason to jettison OAD simply because it has a strong tendency to comorbidity-to do so would require similar action on most of the childhood disorders. In any case, the proper approach to this problem is psychometric, and, if such methods were to be applied, this problem would be resolvable intelligently rather than capriciously. 4. Relationship to adult disorders. It is not yet possible to answer this issue. Although DSM seems to favor some link with GAD, this seems to have little empirical support. Although similar in concept (worrying about a lot of things), the defining criteria of the two disorders are qualitatively different; there seems to be no particular relationship between GAD in parents and OAD in their children, and the sex ratio may be different, especially between adolescents with OAD, where females predominate, and adults with GAD, where the sexes are said to be equal. Moreover, the evidence, such as it is, suggests that OAD is relatively shortlived (less than 2 years), making continuity with GAD unlikely but not impossible, because there is a small, severe group that seems more chronic. Also, OAD could be a "risk" factor for GAD rather than continuous with it. In short, it is too soon to posit any adult outcomes for OAD. Studies comparing symptomatology and correlates of OAD J.Am.Acad. Child Adolesc. Psychiatry, 30:4, July 1991

OVERANXIOUS DISORDER

in children with those in adults with GAD and with longitudinal studies of children with OAD are needed to resolve this issue. 5. Validity. The external validity ofOAD has some weak support in that it does have some defined gender, developmental, comorbidity, familial, outcome, prevalence, and impairment features. Although some of these (e.g., sex ratio, achievement, duration) differentiate OAD from the disruptive and psychotic disorders, it is not yet clear to what extent they do so from other anxiety disorders. In summary, should OAD be left unchanged, jettisoned, combined with GAD as a childhood variant, or substantially modified in DSM-IV? In favor of no change is that, although research is thin, it has at least made a start, and radical changes may make this research uninterpretable. Also against change is that this research has demonstrated that the diagnosis can be made reliably under certain circumstances and that when made, it carries some demographic, adaptive, family, symptomatological, comorbid, and prognostic connotations. In short, the strongest argument against change is the one of prima non nocere . Discarding OAD altogether would seem premature since there has been insufficient time to produce the definitive data for such an extreme position. Although the data do not clearly support the credentials of OAD, neither do they show that it is totally invalid. In support of some change is the high level of comorbidity that seems a logical consequence of the lack of specificity in the wording of the diagnostic criteria. Moreover, although some taxonomic features have been demonstrated for OAD, it is unclear whether these are specific to OAD and to what extent they are shared by other anxiety disorders. There is also some unproven concern that the exclusion criteria for OAD may make it largely a negative diagnosis, to be made only when there is anxiety that does not fit one of the other childhood anxiety disorders. The possibilities for change range from tidying up the diagnostic criteria, to making them more specific and clearly different from the other childhood disorders, to comparing GAD and OAD carefully in field trials and family studies to see whether they are variants of the same disorder. It is doubtful if the last can be achieved in time for DSM-IV. There can be no doubt, however, that after years of neglect of anxiety disorders in children (Gittelman, 1986), like DSM-III in general, OAD has proven a stimulus to research, which is showing a healthy increase in quantity and quality.

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Coming in the September Issue: Review of Developments in Mental Retardation Joel O. Bregman and Robert M. Hodapp Bias in Custody Evaluations Peter Ash and Melvin J. Guyer Special Section: The Impact of HIV Jacqueline Etemad and Lynn E. Ponton The Supreme Court and the Best Interests of the Child Ebrahim Kermani Cardiotoxicity of the Tricyclics Jon B. Tingelstad Treatment of ADHD with Fluoxetine Les Barrickman et al.

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