WEEK 4: GAD
1. A meta-analysis of the influence of comorbidity on treatment outcome in the anxiety disorders
(Olatunji et al., 2010).
12-month prevalence of anxiety disorders = 18%
They have a substantial negative impact on quality of life, especially in the case of comorbidities,
the rate of which is very high in anxiety disorders (70% have at least one more axis 1 diagnosis
and 92% of those with GAD have another DSM disorder).
Many empirically-based treatments like CBT have been criticized for being too specific and
manual-driven to be able to work in the ‘real world’.
Comorbidity is associated with higher anxiety disorder symptom levels after CBT, so even
specific treatments have been designed for comorbid disorders (for depressed people with OCD).
The extent to which treatment outcomes of different types of treatment are differentially
influenced by comorbidity is unclear.
Comorbidity is common in RCTs that investigate the effect of comorbidity on treatment outcome
hence, treatments deemed efficacious based on RCTs seem to be suitable for real world
patients.
The study examined the influence of diagnostic comorbidity on both active and inactive
treatment outcome in the anxiety disorders.
Findings:
o Comorbidity was generally unrelated to anxiety disorder treatment effect sizes, both for
treatments with specific and nonspecific mechanisms of action.
o 3 ways to conceptualize co-occurrence of multiple disorders:
1) chronological (primary diagnosis developed first)
2) causal (secondary diagnosis are caused by another co-existing disorder)
3) symptomatic predominance (primary diagnosis is associated with the greatest distress
and dysfunction).
Research suggests rather than modifying treatments to address the influences of comorbid
conditions, focusing specifically on core symptoms may maximize outcome for the anxiety
disorder as well as comorbid conditions.
Additionally, the relationship between comorbidity and treatment outcome may vary as a function
of diagnosis. The presence of psychiatric comorbidity is associated with more favorable outcome
for some anxiety disorders (panic disorder, PTSD, and OCD, but not social and specific phobia).
Some patients change more than other patients precisely because of their comorbidity. They show
bigger differential treatment effects = they respond better to active treatments.
o The presence of social phobia at pre-treatment is a significant predictor of favorable response
to treatment of panic disorder.
o A higher rate of developmental disorders may result in a higher rate of children who are better
able to benefit from some treatments and/or who are more likely to present with anxiety
symptoms that are more amenable to intervention.
This indicates there are some unique features to these 3 disorders in relation to other anxiety
disorders.
, o When comorbidity is observed, social and specific phobias are often viewed as independent
syndromes that coexist with other disorders, whereas panic disorder and PTSD (perhaps even
OCD) may be syndromes that are causal of, or have symptom predominance over, co-
occurring disorders.
o Differences in symptoms: unlike other anxiety disorders, panic disorder and PTSD are
characterized by persistent autonomic arousal, which may be a cause of co-occurring
conditions, such as depression or substance use.
Higher comorbidity rates were associated with lower post-treatment effect sizes only for mixed or
“neurotic” anxiety samples.
o Diagnosis and classification of anxiety disorders has important implications for treatment.
negative relationship between comorbidity and treatment outcome may be observed when the
anxiety disorder diagnosis is not well specified.
o There is a substantial overlap between anxiety disorders that stem from shared
genetic/psychological predispositions treatment should target the shared underlying
vulnerabilities instead of the symptoms of each specific disorder separately.
o Treatment outcome depends on which disorder is comorbid: those with comorbid depression
were significantly more likely to be in the treatment failure group.
o Additionally, some personality disorders may have an adverse impact upon treatment
outcome.
The presence of more comorbidity may not always translate into worse outcomes.
2. Prevention of anxiety disorders and depression by targeting excessive worry and rumination
in adolescents and young adults: A randomized controlled trial (Topper et al., 2017)
Although evidence-based treatments for anxiety disorders and depression exist:
o many people do not seek treatment
o do not respond to treatment
o or experience a new episode over time (relapse).
Hence, treatment alone is not sufficient to alleviate the individual and societal burden associated
with these disorders but needs to be complemented by prevention.
Types of prevention programs:
o universal prevention programs (offered to all individuals without pre-selection): for
depression as well as anxiety: small effect sizes at post-intervention and follow-up
o selective prevention programs (provided for those at risk for psychopathology)
o indicated prevention programs (offered to those showing early symptoms of a disorder): a bit
more favorable results small to moderate effect sizes for prevention of depression and
anxiety
However, a common critique: such comparison of symptom levels does NOT reflect true
prevention effects instead, incidence rates of disorders across intervention and control groups
1. A meta-analysis of the influence of comorbidity on treatment outcome in the anxiety disorders
(Olatunji et al., 2010).
12-month prevalence of anxiety disorders = 18%
They have a substantial negative impact on quality of life, especially in the case of comorbidities,
the rate of which is very high in anxiety disorders (70% have at least one more axis 1 diagnosis
and 92% of those with GAD have another DSM disorder).
Many empirically-based treatments like CBT have been criticized for being too specific and
manual-driven to be able to work in the ‘real world’.
Comorbidity is associated with higher anxiety disorder symptom levels after CBT, so even
specific treatments have been designed for comorbid disorders (for depressed people with OCD).
The extent to which treatment outcomes of different types of treatment are differentially
influenced by comorbidity is unclear.
Comorbidity is common in RCTs that investigate the effect of comorbidity on treatment outcome
hence, treatments deemed efficacious based on RCTs seem to be suitable for real world
patients.
The study examined the influence of diagnostic comorbidity on both active and inactive
treatment outcome in the anxiety disorders.
Findings:
o Comorbidity was generally unrelated to anxiety disorder treatment effect sizes, both for
treatments with specific and nonspecific mechanisms of action.
o 3 ways to conceptualize co-occurrence of multiple disorders:
1) chronological (primary diagnosis developed first)
2) causal (secondary diagnosis are caused by another co-existing disorder)
3) symptomatic predominance (primary diagnosis is associated with the greatest distress
and dysfunction).
Research suggests rather than modifying treatments to address the influences of comorbid
conditions, focusing specifically on core symptoms may maximize outcome for the anxiety
disorder as well as comorbid conditions.
Additionally, the relationship between comorbidity and treatment outcome may vary as a function
of diagnosis. The presence of psychiatric comorbidity is associated with more favorable outcome
for some anxiety disorders (panic disorder, PTSD, and OCD, but not social and specific phobia).
Some patients change more than other patients precisely because of their comorbidity. They show
bigger differential treatment effects = they respond better to active treatments.
o The presence of social phobia at pre-treatment is a significant predictor of favorable response
to treatment of panic disorder.
o A higher rate of developmental disorders may result in a higher rate of children who are better
able to benefit from some treatments and/or who are more likely to present with anxiety
symptoms that are more amenable to intervention.
This indicates there are some unique features to these 3 disorders in relation to other anxiety
disorders.
, o When comorbidity is observed, social and specific phobias are often viewed as independent
syndromes that coexist with other disorders, whereas panic disorder and PTSD (perhaps even
OCD) may be syndromes that are causal of, or have symptom predominance over, co-
occurring disorders.
o Differences in symptoms: unlike other anxiety disorders, panic disorder and PTSD are
characterized by persistent autonomic arousal, which may be a cause of co-occurring
conditions, such as depression or substance use.
Higher comorbidity rates were associated with lower post-treatment effect sizes only for mixed or
“neurotic” anxiety samples.
o Diagnosis and classification of anxiety disorders has important implications for treatment.
negative relationship between comorbidity and treatment outcome may be observed when the
anxiety disorder diagnosis is not well specified.
o There is a substantial overlap between anxiety disorders that stem from shared
genetic/psychological predispositions treatment should target the shared underlying
vulnerabilities instead of the symptoms of each specific disorder separately.
o Treatment outcome depends on which disorder is comorbid: those with comorbid depression
were significantly more likely to be in the treatment failure group.
o Additionally, some personality disorders may have an adverse impact upon treatment
outcome.
The presence of more comorbidity may not always translate into worse outcomes.
2. Prevention of anxiety disorders and depression by targeting excessive worry and rumination
in adolescents and young adults: A randomized controlled trial (Topper et al., 2017)
Although evidence-based treatments for anxiety disorders and depression exist:
o many people do not seek treatment
o do not respond to treatment
o or experience a new episode over time (relapse).
Hence, treatment alone is not sufficient to alleviate the individual and societal burden associated
with these disorders but needs to be complemented by prevention.
Types of prevention programs:
o universal prevention programs (offered to all individuals without pre-selection): for
depression as well as anxiety: small effect sizes at post-intervention and follow-up
o selective prevention programs (provided for those at risk for psychopathology)
o indicated prevention programs (offered to those showing early symptoms of a disorder): a bit
more favorable results small to moderate effect sizes for prevention of depression and
anxiety
However, a common critique: such comparison of symptom levels does NOT reflect true
prevention effects instead, incidence rates of disorders across intervention and control groups
