. 2024 Oct 4;54(12):1-12.

doi: 10.1017/S003329172400182X. Online ahead of print.

The case for eliminating excessive worry as a requirement for generalized anxiety disorder: a cross-national investigation

Ayelet Meron Ruscio¹, Madeleine Rassaby², Murray B Stein^{3

4}, Dan J Stein⁵, Sergio Aguilar-Gaxiola⁶, Ali Al-Hamzawi⁷, Jordi Alonso^{8

9

10}, Lukoye Atwoli¹¹, Guilherme Borges¹², Evelyn J Bromet¹³, Ronny Bruffaerts¹⁴, Brendan Bunting¹⁵, Graça Cardoso¹⁶, Stephanie Chardoul¹⁷, Giovanni de Girolamo¹⁸, Peter de Jonge¹⁹, Oye Gureje²⁰, Josep Maria Haro^{21

22}, Elie G Karam^{23

24}, Aimee Karam²⁴, Andrzej Kiejna²⁵, Viviane Kovess-Masfety²⁶, Sue Lee²⁷, Fernando Navarro-Mateu^{10

28}, Daisuke Nishi²⁹, Marina Piazza³⁰, José Posada-Villa³¹, Nancy A Sampson²⁷, Kate M Scott³², Tim Slade³³, Juan Carlos Stagnaro³⁴, Yolanda Torres³⁵, Maria Carmen Viana³⁶, Cristian Vladescu^{37

38}, Zahari Zarkov³⁹, Ronald C Kessler²⁷; World Mental Health Survey collaborators

Affiliations

¹ Department of Psychology, University of Pennsylvania, Philadelphia, PA, USA.
² San Diego State University/University of California, San Diego Joint Doctoral Program in Clinical Psychology, CA, USA.
³ Department of Psychiatry and School of Public Health, University of California San Diego, La Jolla, CA, USA.
⁴ VA San Diego Healthcare System, San Diego, CA, USA.
⁵ Department of Psychiatry & Mental Health and South African Medical Council Research Unit on Risk and Resilience in Mental Disorders, University of Cape Town, South Africa.
⁶ Center for Reducing Health Disparities, UC Davis Health System, Sacramento, CA, USA.
⁷ College of Medicine, University of Al-Qadisiya, Diwaniya governorate, Iraq.
⁸ Health Services Research Unit, IMIM-Hospital del Mar Medical Research Institute, Barcelona, Spain.
⁹ Department of Medicine and Life Sciences, Pompeu Fabra University (UPF), Barcelona, Spain.
¹⁰ Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain.
¹¹ Brain and Mind Institute and Medical College East Africa, the Aga Khan University, Nairobi, Kenya.
¹² National Institute of Psychiatry Ramón de la Fuente Muñiz, Mexico City, Mexico.
¹³ Department of Psychiatry, Stony Brook University School of Medicine, Stony Brook, NY, USA.
¹⁴ Universitair Psychiatrisch Centrum - Katholieke Universiteit Leuven (UPC-KUL), Campus Gasthuisberg, Leuven, Belgium.
¹⁵ School of Psychology, Ulster University, Coleraine, UK.
¹⁶ Lisbon Institute of Global Mental Health and Chronic Diseases Research Center, NOVA Medical School, NOVA University of Lisbon, Lisbon, Portugal.
¹⁷ Survey Research Center, Institute for Social Research, University of Michigan, Ann Arbor, MI, USA.
¹⁸ IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, Brescia, Italy.
¹⁹ Department of Developmental Psychology, University of Groningen, Groningen, The Netherlands.
²⁰ Department of Psychiatry, University College Hospital, Ibadan, Nigeria.
²¹ Research, Teaching and Innovation Unit, Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Barcelona, Spain.
²² Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain.
²³ Department of Psychiatry and Clinical Psychology, St George Hospital University Medical Center, Beirut, Lebanon.
²⁴ Institute for Development, Research, Advocacy and Applied Care (IDRAAC), Beirut, Lebanon.
²⁵ Faculty of Applied Studies, University of Lower Silesia, Wroclaw, Poland.
²⁶ Institut de Psychologie, EA 4057, Université Paris Cité, Paris, France.
²⁷ Department of Health Care Policy, Harvard Medical School, Boston, MA, USA.
²⁸ Unidad de Docencia, Investigación y Formación en Salud Mental (UDIF-SM), Gerencia Salud Mental, Servicio Murciano de Salud, Murcia, Spain.
²⁹ Department of Mental Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
³⁰ School of Public Health and Administration, Universidad Peruana Cayetano Heredia, Lima, Peru.
³¹ Faculty of Social Sciences, Colegio Mayor de Cundinamarca University, Bogota, Colombia.
³² Department of Psychological Medicine, University of Otago, Dunedin, New Zealand.
³³ The Matilda Centre for Research in Mental Health and Substance Use, University of Sydney, Australia.
³⁴ Departamento de Psiquiatría y Salud Mental, Facultad de Medicina, Universidad de Buenos Aires, Argentina.
³⁵ Center for Excellence on Research in Mental Health, CES University, Medellín, Colombia.
³⁶ Department of Social Medicine, Postgraduate Program in Public Health, Federal University of Espírito Santo, Vitoria, Brazil.
³⁷ National Institute of Health Services Management, Bucharest, Romania.
³⁸ University Titu Maiorescu, Bucharest, Romania.
³⁹ Department of Mental Health, National Center of Public Health and Analyses, Sofia, Bulgaria.

PMID: 39364896
PMCID: PMC11496212
DOI: 10.1017/S003329172400182X

The case for eliminating excessive worry as a requirement for generalized anxiety disorder: a cross-national investigation

Ayelet Meron Ruscio et al. Psychol Med. 2024.

. 2024 Oct 4;54(12):1-12.

doi: 10.1017/S003329172400182X. Online ahead of print.

Authors

Affiliations

¹ Department of Psychology, University of Pennsylvania, Philadelphia, PA, USA.
² San Diego State University/University of California, San Diego Joint Doctoral Program in Clinical Psychology, CA, USA.
³ Department of Psychiatry and School of Public Health, University of California San Diego, La Jolla, CA, USA.
⁴ VA San Diego Healthcare System, San Diego, CA, USA.
⁵ Department of Psychiatry & Mental Health and South African Medical Council Research Unit on Risk and Resilience in Mental Disorders, University of Cape Town, South Africa.
⁶ Center for Reducing Health Disparities, UC Davis Health System, Sacramento, CA, USA.
⁷ College of Medicine, University of Al-Qadisiya, Diwaniya governorate, Iraq.
⁸ Health Services Research Unit, IMIM-Hospital del Mar Medical Research Institute, Barcelona, Spain.
⁹ Department of Medicine and Life Sciences, Pompeu Fabra University (UPF), Barcelona, Spain.
¹⁰ Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain.
¹¹ Brain and Mind Institute and Medical College East Africa, the Aga Khan University, Nairobi, Kenya.
¹² National Institute of Psychiatry Ramón de la Fuente Muñiz, Mexico City, Mexico.
¹³ Department of Psychiatry, Stony Brook University School of Medicine, Stony Brook, NY, USA.
¹⁴ Universitair Psychiatrisch Centrum - Katholieke Universiteit Leuven (UPC-KUL), Campus Gasthuisberg, Leuven, Belgium.
¹⁵ School of Psychology, Ulster University, Coleraine, UK.
¹⁶ Lisbon Institute of Global Mental Health and Chronic Diseases Research Center, NOVA Medical School, NOVA University of Lisbon, Lisbon, Portugal.
¹⁷ Survey Research Center, Institute for Social Research, University of Michigan, Ann Arbor, MI, USA.
¹⁸ IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, Brescia, Italy.
¹⁹ Department of Developmental Psychology, University of Groningen, Groningen, The Netherlands.
²⁰ Department of Psychiatry, University College Hospital, Ibadan, Nigeria.
²¹ Research, Teaching and Innovation Unit, Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Barcelona, Spain.
²² Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain.
²³ Department of Psychiatry and Clinical Psychology, St George Hospital University Medical Center, Beirut, Lebanon.
²⁴ Institute for Development, Research, Advocacy and Applied Care (IDRAAC), Beirut, Lebanon.
²⁵ Faculty of Applied Studies, University of Lower Silesia, Wroclaw, Poland.
²⁶ Institut de Psychologie, EA 4057, Université Paris Cité, Paris, France.
²⁷ Department of Health Care Policy, Harvard Medical School, Boston, MA, USA.
²⁸ Unidad de Docencia, Investigación y Formación en Salud Mental (UDIF-SM), Gerencia Salud Mental, Servicio Murciano de Salud, Murcia, Spain.
²⁹ Department of Mental Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
³⁰ School of Public Health and Administration, Universidad Peruana Cayetano Heredia, Lima, Peru.
³¹ Faculty of Social Sciences, Colegio Mayor de Cundinamarca University, Bogota, Colombia.
³² Department of Psychological Medicine, University of Otago, Dunedin, New Zealand.
³³ The Matilda Centre for Research in Mental Health and Substance Use, University of Sydney, Australia.
³⁴ Departamento de Psiquiatría y Salud Mental, Facultad de Medicina, Universidad de Buenos Aires, Argentina.
³⁵ Center for Excellence on Research in Mental Health, CES University, Medellín, Colombia.
³⁶ Department of Social Medicine, Postgraduate Program in Public Health, Federal University of Espírito Santo, Vitoria, Brazil.
³⁷ National Institute of Health Services Management, Bucharest, Romania.
³⁸ University Titu Maiorescu, Bucharest, Romania.
³⁹ Department of Mental Health, National Center of Public Health and Analyses, Sofia, Bulgaria.

PMID: 39364896
PMCID: PMC11496212
DOI: 10.1017/S003329172400182X

Abstract

Background: Around the world, people living in objectively difficult circumstances who experience symptoms of generalized anxiety disorder (GAD) do not qualify for a diagnosis because their worry is not 'excessive' relative to the context. We carried out the first large-scale, cross-national study to explore the implications of removing this excessiveness requirement.

Methods: Data come from the World Health Organization World Mental Health Survey Initiative. A total of 133 614 adults from 12 surveys in Low- or Middle-Income Countries (LMICs) and 16 surveys in High-Income Countries (HICs) were assessed with the Composite International Diagnostic Interview. Non-excessive worriers meeting all other DSM-5 criteria for GAD were compared to respondents meeting all criteria for GAD, and to respondents without GAD, on clinically-relevant correlates.

Results: Removing the excessiveness requirement increases the global lifetime prevalence of GAD from 2.6% to 4.0%, with larger increases in LMICs than HICs. Non-excessive and excessive GAD cases worry about many of the same things, although non-excessive cases worry more about health/welfare of loved ones, and less about personal or non-specific concerns, than excessive cases. Non-excessive cases closely resemble excessive cases in socio-demographic characteristics, family history of GAD, and risk of temporally secondary comorbidity and suicidality. Although non-excessive cases are less severe on average, they report impairment comparable to excessive cases and often seek treatment for GAD symptoms.

Conclusions: Individuals with non-excessive worry who meet all other DSM-5 criteria for GAD are clinically significant cases. Eliminating the excessiveness requirement would lead to a more defensible GAD diagnosis.

Keywords: classification; diagnosis; epidemiology; generalized anxiety disorder; global mental health; worry.

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Conflict of interest statement

In the past 3 years, Dr Kessler was a consultant for Cambridge Health Alliance, Canandaigua VA Medical Center, Child Mind Institute, Holmusk, Massachusetts General Hospital, Partners Healthcare, Inc., RallyPoint Networks, Inc., Sage Therapeutics and University of North Carolina. He has stock options in Cerebral Inc., Mirah, PYM (Prepare Your Mind), Roga Sciences and Verisense Health. The other authors declare that they have no conflicts of interest.

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The case for eliminating excessive worry as a requirement for generalized anxiety disorder: a cross-national investigation

Affiliations

The case for eliminating excessive worry as a requirement for generalized anxiety disorder: a cross-national investigation

Authors

Affiliations

Abstract

Conflict of interest statement

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