Perceived helpfulness of treatment for generalized anxiety disorder: a World Mental Health Surveys report.

BACKGROUND: Treatment guidelines for generalized anxiety disorder (GAD) are based on a relatively small number of randomized controlled trials and do not consider patient-centered perceptions of treatment helpfulness. We investigated the prevalence and predictors of patient-reported treatment helpfulness for DSM-5 GAD and its two main treatment pathways: encounter-level treatment helpfulness and persistence in help-seeking after prior unhelpful treatment. METHODS: Data came from community epidemiologic surveys in 23 countries in the WHO World Mental Health surveys. DSM-5 GAD was assessed with the fully structured WHO Composite International Diagnostic Interview Version 3.0. Respondents with a history of GAD were asked whether they ever received treatment and, if so, whether they ever considered this treatment helpful. Number of professionals seen before obtaining helpful treatment was also assessed. Parallel survival models estimated probability and predictors of a given treatment being perceived as helpful and of persisting in help-seeking after prior unhelpful treatment. RESULTS: The overall prevalence rate of GAD was 4.5%, with lower prevalence in low/middle-income countries (2.8%) than high-income countries (5.3%); 34.6% of respondents with lifetime GAD reported ever obtaining treatment for their GAD, with lower proportions in low/middle-income countries (19.2%) than high-income countries (38.4%); 3) 70% of those who received treatment perceived the treatment to be helpful, with prevalence comparable in low/middle-income countries and high-income countries. Survival analysis suggested that virtually all patients would have obtained helpful treatment if they had persisted in help-seeking with up to 10 professionals. However, we estimated that only 29.7% of patients would have persisted that long. Obtaining helpful treatment at the person-level was associated with treatment type, comorbid panic/agoraphobia, and childhood adversities, but most of these predictors were important because they predicted persistence rather than encounter-level treatment helpfulness. CONCLUSIONS: The majority of individuals with GAD do not receive treatment. Most of those who receive treatment regard it as helpful, but receiving helpful treatment typically requires persistence in help-seeking. Future research should focus on ensuring that helpfulness is included as part of the evaluation. Clinicians need to emphasize the importance of persistence to patients beginning treatment.

Normal Versus Pathological Mood: Implications for Diagnosis.

Is there a clear line between normal and abnormal mood? Studies of manifest and latent structure provide strong support for a continuum that extends from asymptomatic to subsyndromal to syndromal cases of increasing severity. Subsyndromal symptoms are impairing, predict syndrome onset and relapse, and account for more doctor's visits and suicide attempts than the full syndromes, yet they are not recognized in the current classification. For most research and some clinical activities, dimensional diagnoses are recommended, and examples are offered for how such diagnoses could be made. For clinical activities requiring decisions, a multithreshold model is proposed in which both lower (e.g., mild depression, capturing subsyndromal cases) and upper (e.g., major depression, capturing clinically significant cases) diagnostic categories are used to inform clinical care. Beyond its implications for diagnosis, the dimensionality of depression and anxiety has implications for etiology and for research aimed at understanding how emotions become disrupted in psychopathology.

Childhood adversities and post-traumatic stress disorder: evidence for stress sensitisation in the World Mental Health Surveys.

BackgroundAlthough childhood adversities are known to predict increased risk of post-traumatic stress disorder (PTSD) after traumatic experiences, it is unclear whether this association varies by childhood adversity or traumatic experience types or by age.AimsTo examine variation in associations of childhood adversities with PTSD according to childhood adversity types, traumatic experience types and life-course stage.MethodEpidemiological data were analysed from the World Mental Health Surveys (n = 27 017).ResultsFour childhood adversities (physical and sexual abuse, neglect, parent psychopathology) were associated with similarly increased odds of PTSD following traumatic experiences (odds ratio (OR) = 1.8), whereas the other eight childhood adversities assessed did not predict PTSD. Childhood adversity-PTSD associations did not vary across traumatic experience types, but were stronger in childhood-adolescence and early-middle adulthood than later adulthood.ConclusionsChildhood adversities are differentially associated with PTSD, with the strongest associations in childhood-adolescence and early-middle adulthood. Consistency of associations across traumatic experience types suggests that childhood adversities are associated with generalised vulnerability to PTSD following traumatic experiences.

Perseverative thinking is associated with features of spoken language.

Perseverative thinking (PT), such as rumination or worry, is a transdiagnostic process implicated in the onset and maintenance of emotional disorders. Existing measures of PT are limited by demand and expectancy effects, cognitive biases, and reflexivity, leading to calls for unobtrusive, behavioral measures. In response, we developed a behavioral measure of PT based on language. A mixed sample of 188 participants with major depressive disorder, generalized anxiety disorder, or no psychopathology completed self-report PT measures. Participants were also interviewed, providing a natural language sample. We examined language features associated with PT, then built a language-based PT model and examined its predictive power. PT was associated with multiple language features, most notably I-usage (e.g., "I", "me"; ß = 0.25) and negative emotion language (e.g., "anxiety", "difficult"; ß = 0.19). In machine learning analyses, language features accounted for 14% of the variance in self-reported PT. Language-based PT predicted the presence and severity of depression and anxiety, psychiatric comorbidity, and treatment seeking, with effects in the r = 0.15-0.41 range. PT has face-valid linguistic correlates and our language-based measure holds promise for assessing PT unobtrusively. With further development, this measure could be used to passively detect PT for deployment of "just-in-time" interventions.

A transdiagnostic, dimensional classification of anxiety shows improved parsimony and predictive noninferiority to DSM.

The current conceptualization of anxiety in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)-which includes 11 anxiety disorders plus additional anxiety-related conditions-does not align with accumulating evidence that anxiety is transdiagnostic and dimensional in nature. Transdiagnostic dimensional anxiety models have been proposed, yet they measure anxiety at either a very broad (e.g., "anxiety") or very narrow (e.g., "performance anxiety") level, overlooking intermediate properties of anxiety that cut across DSM disorders. Using indicators from a well-validated semistructured interview of anxiety-related disorders, we constructed intermediate-level transdiagnostic dimensions representing the intensity, avoidance, pervasiveness, and onset of anxiety. We captured these content-agnostic dimensions in a sample representing varying levels and forms of anxiety (N = 268), including individuals with generalized anxiety disorder, social anxiety disorder, panic disorder, agoraphobia, specific phobia, separation anxiety disorder, posttraumatic stress disorder, and obsessive-compulsive disorder (n = 205) and individuals with no psychopathology (n = 63). In preregistered analyses, our dimensional anxiety model showed noninferiority to DSM-5 diagnoses in predicting concurrent and prospective measures of anxiety-related impairment, anxiety vulnerabilities, comorbid depression, and suicidal ideation. These results held regardless of whether the dimensions were combined into a single composite or retained as separate components. Our transdiagnostic dimensional model offers meaningful gains in parsimony over DSM, with no loss of predictive power. This project provides a methodological framework for the empirical evaluation of other transdiagnostic dimensional models of psychopathology that have been proposed as alternatives to the DSM. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Depression and anxiety have distinct and overlapping language patterns: Results from a clinical interview.

Depression has been associated with heightened first-person singular pronoun use (I-usage; e.g., "I," "my") and negative emotion words. However, past research has relied on nonclinical samples and nonspecific depression measures, raising the question of whether these features are unique to depression vis-à-vis frequently co-occurring conditions, especially anxiety. Using structured questions about recent life changes or difficulties, we interviewed a sample of individuals with varying levels of depression and anxiety (N = 486), including individuals in a major depressive episode (n = 228) and/or diagnosed with generalized anxiety disorder (n = 273). Interviews were transcribed to provide a natural language sample. Analyses isolated language features associated with gold standard, clinician-rated measures of depression and anxiety. Many language features associated with depression were in fact shared between depression and anxiety. Language markers with relative specificity to depression included I-usage, sadness, and decreased positive emotion, while negations (e.g., "not," "no"), negative emotion, and several emotional language markers (e.g., anxiety, stress, depression) were relatively specific to anxiety. Several of these results were replicated using a self-report measure designed to disentangle components of depression and anxiety. We next built machine learning models to detect severity of common and specific depression and anxiety using only interview language. Individuals' speech characteristics during this brief interview predicted their depression and anxiety severity, beyond other clinical and demographic variables. Depression and anxiety have partially distinct patterns of expression in spoken language. Monitoring of depression and anxiety severity via language can augment traditional assessment modalities and aid in early detection. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

A Novel Measure of Real-Time Perseverative Thought.

Perseverative thinking (PT), or repetitive negative thinking, has historically been measured using global self-report scales. New methods of assessment are needed to advance understanding of this inherently temporal process. We developed an intensive longitudinal method for assessing PT. A mixed sample of 77 individuals ranging widely in trait PT, including persons with PT-related disorders (generalized anxiety disorder, major depression) and persons without psychopathology, used a joystick to provide continuous ratings of thought valence and intensity following exposure to scenarios of differing valence. Joystick responses were robustly predicted by trait PT, clinical status, and stimulus valence. Higher trait perseverators exhibited more extreme joystick values overall, greater stability in values following threatening and ambiguous stimuli, weaker stability in values following positive stimuli, and greater inertia in values following ambiguous stimuli. The joystick method is a promising measure with the potential to shed new light on the dynamics and precipitants of perseverative thinking.

Patterns and correlates of patient-reported helpfulness of treatment for common mental and substance use disorders in the WHO World Mental Health Surveys.

Patient-reported helpfulness of treatment is an important indicator of quality in patient-centered care. We examined its pathways and predictors among respondents to household surveys who reported ever receiving treatment for major depression, generalized anxiety disorder, social phobia, specific phobia, post-traumatic stress disorder, bipolar disorder, or alcohol use disorder. Data came from 30 community epidemiological surveys - 17 in high-income countries (HICs) and 13 in low- and middle-income countries (LMICs) - carried out as part of the World Health Organization (WHO)'s World Mental Health (WMH) Surveys. Respondents were asked whether treatment of each disorder was ever helpful and, if so, the number of professionals seen before receiving helpful treatment. Across all surveys and diagnostic categories, 26.1% of patients (N=10,035) reported being helped by the very first professional they saw. Persisting to a second professional after a first unhelpful treatment brought the cumulative probability of receiving helpful treatment to 51.2%. If patients persisted with up through eight professionals, the cumulative probability rose to 90.6%. However, only an estimated 22.8% of patients would have persisted in seeing these many professionals after repeatedly receiving treatments they considered not helpful. Although the proportion of individuals with disorders who sought treatment was higher and they were more persistent in HICs than LMICs, proportional helpfulness among treated cases was no different between HICs and LMICs. A wide range of predictors of perceived treatment helpfulness were found, some of them consistent across diagnostic categories and others unique to specific disorders. These results provide novel information about patient evaluations of treatment across diagnoses and countries varying in income level, and suggest that a critical issue in improving the quality of care for mental disorders should be fostering persistence in professional help-seeking if earlier treatments are not helpful.

Restlessness in Generalized Anxiety Disorder: Using Actigraphy to Measure Physiological Reactions to Threat.

Generalized anxiety disorder (GAD) is characterized by excessive, uncontrollable worry accompanied by symptoms of physiological arousal. Although individuals with GAD report greater subjective arousal than healthy individuals, they show equivalent or even attenuated physiological reactions to threat. This may result from using physiological measures better suited to fear than anxiety. To test this possibility, 102 adults with and without GAD were assessed for restlessness, a core physiological symptom of GAD. They were exposed to an in vivo threat task designed to elicit anxiety in the laboratory. Throughout the task, restlessness was measured physiologically with actigraphy sensors on both ankles and both wrists, and subjectively with self-report ratings. The GAD group reported higher subjective restlessness than the no-GAD group, and in the subset of cases who had restlessness as a clinically significant symptom, actigraphy scores were reliably elevated as well. However, although actigraphy scores increased with proximity to the threat, the increases did not differ by group. These findings provide initial validation for actigraphy as a novel measure of motor restlessness in GAD. In addition, they underscore the value of measuring restlessness using multiple assessment methods. These methods suggest that, in GAD, restlessness reflects a chronic state of arousal rather than a heightened physiological reaction to threat.

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

BACKGROUND: Generalized anxiety disorder (GAD) has undergone a series of substantial classificatory changes since its first inclusion in DSM-III. The majority of these revisions have been in response to its poor inter-rater reliability and concerns that it may lack diagnostic validity. This article provides options for the revision of the DSM-IV GAD criteria for DSM-V. METHOD: First, searches were conducted to identify the evidence that previous DSM Work Groups relied upon when revising the DSM-III-R GAD and the overanxious disorder classifications. Second, the literature pertaining to the DSM-IV criteria for GAD was examined. CONCLUSIONS: The review presents a number of options to be considered for DSM-V. One option is for GAD to be re-labeled in DSM-V as generalized worry disorder. This would reflect its hallmark feature. Proposed revisions would result in a disorder that is characterized by excessive anxiety and worry generalized to a number of events or activities for 3 months or more. Worry acts as a cognitive coping strategy that manifests in avoidant behaviors. The reliability and validity of the proposed changes could be investigated in DSM-V validity tests and field trials.

Subtyping social anxiety disorder in developed and developing countries.

BACKGROUND: Although social anxiety disorder (SAD) is classified in the fourth edition of The Diagnostic and Statistical Manual (DSM-IV) into generalized and non-generalized subtypes, community surveys in Western countries find no evidence of disjunctions in the dose-response relationship between number of social fears and outcomes to support this distinction. We aimed to determine whether this holds across a broader set of developed and developing countries, and whether subtyping according to number of performance versus interactional fears would be more useful. METHODS: The World Health Organization's World Mental Health Survey Initiative undertook population epidemiological surveys in 11 developing and 9 developed countries, using the Composite International Diagnostic Interview to assess DSM-IV disorders. Fourteen performance and interactional fears were assessed. Associations between number of social fears in SAD and numerous outcomes (age-of-onset, persistence, severity, comorbidity, treatment) were examined. Additional analyses examined associations with number of performance fears versus number of interactional fears. RESULTS: Lifetime social fears are quite common in both developed (15.9%) and developing (14.3%) countries, but lifetime SAD is much more common in the former (6.1%) than latter (2.1%) countries. Among those with SAD, persistence, severity, comorbidity, and treatment have dose-response relationships with number of social fears, with no clear nonlinearity in relationships that would support a distinction between generalized and non-generalized SAD. The distinction between performance fears and interactional fears is generally not important in predicting these same outcomes. CONCLUSION: No evidence is found to support subtyping SAD on the basis of either number of social fears or number of performance fears versus number of interactional fears.

Social phobia: further evidence of dimensional structure.

OBJECTIVE: Social phobia is a common mental disorder associated with significant impairment. Current research and treatment models of social phobia rely on categorical diagnostic conceptualizations lacking empirical support. This study aims to further research exploring whether social phobia is best conceptualized as a dimension or a discrete categorical disorder. METHODS: This study used three distinct taxometric techniques (mean above minus below a cut, maximum Eigen value and latent mode) to explore the latent structure of social phobia in two large epidemiological samples, using indicators derived from diagnostic criteria and associated avoidant personality traits. RESULTS: Overall, outcomes from multiple taxometric analyses supported dimensional structure. This is consistent with conceptualizations of social phobia as lying on a continuum with avoidant personality traits. CONCLUSIONS: Support for the dimensionality of social phobia has important implications for future research, assessment, treatment, and public policy.

The Positive Valence Systems Scale: Development and Validation.

We present the Positive Valence Systems Scale (PVSS), a measure of the National Institute of Mental Health's Research Domain Criteria Positive Valence Systems domain. An initial long form of the scale (45 items) providing a broad assessment of the domain was distilled into a short form (21 items) measuring responses to a wide range of rewards (Food, Physical Touch, Outdoors, Positive Feedback, Social Interactions, Hobbies, and Goals). Across three diverse samples, the PVSS-21 demonstrated strong internal consistency, retest reliability, and factorial validity. It was more strongly related to reward than punishment sensitivity, positive than negative affect, and depression than anxiety. PVSS-21 scores discriminated depressed from nondepressed individuals and predicted anhedonia severity even when controlling for depression status. Hobbies emerged as the strongest predictor of clinical outcomes and the best differentiator of depressed and nondepressed individuals. Results highlight the potential of the PVSS for advancing understanding of reward-related abnormalities in depression and other disorders.

The "Brightening" Effect: Reactions to Positive Events in the Daily Lives of Individuals With Major Depressive Disorder and Generalized Anxiety Disorder.

Depressed individuals are less reactive than healthy individuals to positive stimuli in the laboratory, but accumulating evidence suggests that they are more emotionally reactive to positive events in their daily lives. The present study probed the boundaries of this curious "mood brightening" effect and investigated its specificity to major depressive disorder (MDD) vis-à-vis generalized anxiety disorder (GAD), its closest boundary condition. We used ecological momentary assessment to measure reactions to positive events over one week in individuals with MDD (n = 38), GAD (n = 36), comorbid MDD-GAD (n = 38), and no psychopathology (n = 33). Depressed individuals responded to positive events with larger changes in affect, cognition, reported withdrawal (but not approach) behavior, and symptoms than healthy controls. More severe depression assessed before the sampling week predicted greater brightening. Altered reactivity to positive events was relatively specific to MDD when compared with GAD, similar to patterns found for other positive emotional processes. The robustness, scope, and relative specificity of the brightening effect highlights the need to resolve conflicting findings across laboratory and non-laboratory studies to advance understanding of altered reactivity in emotional disorders.

Risk factors for the incidence and persistence of suicide-related outcomes: a 10-year follow-up study using the National Comorbidity Surveys.

BACKGROUND: We report prospective associations of baseline risk factors with the first onset and persistence of suicide-related outcomes (SROs; ideation, plans, gestures, and attempts) over a 10-year interval among respondents who participated in both the 1990-02 National Comorbidity Survey (NCS) and the 2000-02 National Comorbidity Survey follow-up (NCS-2). METHODS: A total of 5001 NCS respondents were re-interviewed (87.6% of baseline sample) in the NCS-2. Three sets of baseline (NCS) risk factors were considered as predictors of the first onset and persistence of SROs: socio-demographics, lifetime DSM-III-R disorders, and SROs. RESULTS: New onsets included 6.2% suicide ideation, 2.3% plan, 0.7% gesture, and 0.9% attempts. More than one-third of respondents with a baseline history of suicide ideation continued to have suicide ideation at some time over the intervening decade. Persistence was lower for other SROs. The strongest predictors of later SROs were baseline SROs. Prospective associations of baseline mental disorders with later SROs were largely limited to the onset and persistence of ideation. LIMITATIONS: Although data were gathered prospectively, they were based on retrospective reports at both baseline and follow-up. CONCLUSIONS: Baseline history of SROs explained much of the association of mental disorders with later SROs. It is important clinically to note that many of the risk factors known to predict onset of SROs also predict persistence of SROs.

Important questions remain to be addressed before adopting a dimensional classification of mental disorders.

Comments on the original article "Plate tectonics in the classification of personality disorder: Shifting to a dimensional model," by T. A. Widiger and T. J. Trull. Widiger and Trull raised important nosological issues that warrant serious consideration not only for the personality disorders but for all mental disorders as the Diagnostic and Statistical Manual of Mental Disorders (DSM) is revised during the next few years. As argued compellingly by these authors, dimensional classification may indeed offer substantial improvement over the present categorical system. Several questions remain to be addressed in evaluating whether this is the case and, if so, how dimensional classification can be implemented to best serve the disparate users of the DSM.

The epidemiology of panic attacks, panic disorder, and agoraphobia in the National Comorbidity Survey Replication.

CONTEXT: Only limited information exists about the epidemiology of DSM-IV panic attacks (PAs) and panic disorder (PD). OBJECTIVE: To present nationally representative data about the epidemiology of PAs and PD with or without agoraphobia (AG) on the basis of the US National Comorbidity Survey Replication findings. DESIGN AND SETTING: Nationally representative face-to-face household survey conducted using the fully structured World Health Organization Composite International Diagnostic Interview. PARTICIPANTS: English-speaking respondents (N=9282) 18 years or older. MAIN OUTCOME MEASURES: Respondents who met DSM-IV lifetime criteria for PAs and PD with and without AG. RESULTS: Lifetime prevalence estimates are 22.7% for isolated panic without AG (PA only), 0.8% for PA with AG without PD (PA-AG), 3.7% for PD without AG (PD only), and 1.1% for PD with AG (PD-AG). Persistence, lifetime number of attacks, and number of years with attacks increase monotonically across these 4 subgroups. All 4 subgroups are significantly comorbid with other lifetime DSM-IV disorders, with the highest odds for PD-AG and the lowest for PA only. Scores on the Panic Disorder Severity Scale are also highest for PD-AG (86.3% moderate or severe) and lowest for PA only (6.7% moderate or severe). Agoraphobia is associated with substantial severity, impairment, and comorbidity. Lifetime treatment is high (from 96.1% for PD-AG to 61.1% for PA only), but 12-month treatment meeting published treatment guidelines is low (from 54.9% for PD-AG to 18.2% for PA only). CONCLUSION: Although the major societal burden of panic is caused by PD and PA-AG, isolated PAs also have high prevalence and meaningful role impairment.

Broadening the definition of generalized anxiety disorder: effects on prevalence and associations with other disorders in the National Comorbidity Survey Replication.

Concerns have been raised that the DSM-IV requirements of 6-month duration, excessive worry, and three associated symptoms exclude a substantial number of people with clinically significant anxiety from a diagnosis of generalized anxiety disorder (GAD). We examined the implications of relaxing these three criteria for the estimated prevalence and predictive validity of GAD using nationally representative data from the US National Comorbidity Survey Replication. Relaxing all three criteria more than doubles the estimated prevalence of GAD. Broadly defined GAD significantly predicts the subsequent first onset of a wide range of temporally secondary disorders. The odds of secondary disorders are somewhat smaller for broadly defined than DSM-IV GAD, though few of these differences are statistically significant. Results suggest that subthreshold manifestations of GAD are significantly related to elevated risk of subsequent psychopathology. Further research is needed to determine whether broadening the current diagnostic criteria results in a more valid characterization of GAD.

Cross-sectional Comparison of the Epidemiology of DSM-5 Generalized Anxiety Disorder Across the Globe.

Importance: Generalized anxiety disorder (GAD) is poorly understood compared with other anxiety disorders, and debates persist about the seriousness of this disorder. Few data exist on GAD outside a small number of affluent, industrialized nations. No population-based data exist on GAD as it is currently defined in DSM-5. Objective: To provide the first epidemiologic data on DSM-5 GAD and explore cross-national differences in its prevalence, course, correlates, and impact. Design, Setting, and Participants: Data come from the World Health Organization World Mental Health Survey Initiative. Cross-sectional general population surveys were carried out in 26 countries using a consistent research protocol and assessment instrument. A total of 147 261 adults from representative household samples were interviewed face-to-face in the community. The surveys were conducted between 2001 and 2012. Data analysis was performed from July 22, 2015, to December 12, 2016. Main Outcomes and Measures: The Composite International Diagnostic Interview was used to assess GAD along with comorbid disorders, role impairment, and help seeking. Results: Respondents were 147 261 adults aged 18 to 99 years. The surveys had a weighted mean response rate of 69.5%. Across surveys, DSM-5 GAD had a combined lifetime prevalence (SE) of 3.7% (0.1%), 12-month prevalence of 1.8% (0.1%), and 30-day prevalence of 0.8% (0). Prevalence estimates varied widely across countries, with lifetime prevalence highest in high-income countries (5.0% [0.1%]), lower in middle-income countries (2.8% [0.1%]), and lowest in low-income countries (1.6% [0.1%]). Generalized anxiety disorder typically begins in adulthood and persists over time, although onset is later and clinical course is more persistent in lower-income countries. Lifetime comorbidity is high (81.9% [0.7%]), particularly with mood (63.0% [0.9%]) and other anxiety (51.7% [0.9%]) disorders. Severe role impairment is common across life domains (50.6% [1.2%]), particularly in high-income countries. Treatment is sought by approximately half of affected individuals (49.2% [1.2%]), especially those with severe role impairment (59.4% [1.8%]) or comorbid disorders (55.8% [1.4%]) and those living in high-income countries (59.0% [1.3%]). Conclusions and Relevance: The findings of this study show that DSM-5 GAD is more prevalent than DSM-IV GAD and is associated with substantial role impairment. The disorder is especially common and impairing in high-income countries despite a negative association between GAD and socioeconomic status within countries. These results underscore the public health significance of GAD across the globe while uncovering cross-national differences in prevalence, course, and impairment that require further investigation.

Prevalence and correlates of estimated DSM-IV child and adult separation anxiety disorder in the National Comorbidity Survey Replication.

OBJECTIVE: Despite its inclusion in DSM-IV, little is known about the prevalence or correlates of adult separation anxiety disorder or its relationship to the childhood disorder. Results of the first epidemiological study of adult separation anxiety disorder, to the authors' knowledge, and its relationship to childhood separation anxiety disorder are presented. METHOD: Data were from the National Comorbidity Survey Replication (NCS-R), a nationally representative survey of U.S. households. A fully structured, lay-administered diagnostic interview assessed a wide range of DSM-IV disorders, including separation anxiety disorder. No independent clinical validation was obtained of the assessment. RESULTS: Lifetime prevalence estimates of childhood and adult separation anxiety disorders were 4.1% and 6.6%, respectively. Approximately one-third of the respondents who were classified as childhood cases (36.1%) had an illness that persisted into adulthood, although the majority classified as adult cases (77.5%) had first onset in adulthood. The assessment of separation anxiety disorder in the NCS-R was comorbid with other NCS-R or DSM-IV disorders and associated with severe role impairment in roughly half of the comorbid cases and one-fourth of the pure cases. The majority of people with estimated adult separation anxiety disorder are untreated, even though many obtain treatment for comorbid conditions. CONCLUSIONS: Criteria for adult separation anxiety disorder should be refined in future editions of DSM because the disorder is likely to be much more common in adults than previously recognized. Research is needed to develop and evaluate treatments that take into consideration its high comorbidity with other DSM-IV disorders.