Journal of Anxiety Disorders 24 (2010) 250–259

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Journal of Anxiety Disorders

Differential patterns of physical symptoms and subjective processes in generalized anxiety disorder and unipolar depression
A. Aldao a,1, D.S. Mennin a,*, E. Linardatos b, D.M. Fresco b,2
a b

Department of Psychology, Yale University, P.O. Box 208205, New Haven, CT 06520, United States Department of Psychology, Kent State University, 226 Kent Hall Annex, P.O. Box 5190, Kent, OH 44242, United States

A R T I C L E I N F O

A B S T R A C T

Article history: Received 3 August 2009 Received in revised form 28 November 2009 Accepted 6 December 2009 Keywords: Generalized anxiety disorder Unipolar depression Emotion Intolerance of uncertainty Muscle tension Gastrointestinal symptoms

Given the substantial comorbidity between generalized anxiety disorder (GAD) and unipolar depressive disorders (UDDs), some have suggested that these disorders be combined in future editions of the DSM. However, decisions regarding nosology should not only account for current manifestations of symptom profiles, but also the potential diagnostic utility of associated characteristics, which, given past research, may suggest greater distinctiveness between these disorder classes. In the present investigation, we examined the role of one-item indices of physical, emotional/motivational, and cognitive symptoms in differentiating GAD from UDDs. We assessed these symptoms with one-item measures in order to provide an initial examination of the viability of these constructs as diagnostic criteria. In Study 1, in an unselected college sample, muscle pains and aches, gastrointestinal symptoms, emotion intensity, and intolerance of uncertainty were associated with GAD symptoms; conversely, low positive affect was associated with UDDs symptoms. In Study 2, we extended these findings to a clinical population and found that muscle pains and aches, positive affect, goal motivation, emotion intensity, and intolerance of uncertainty were higher in GAD than in UDDs. ß 2009 Elsevier Ltd. All rights reserved.

1. Introduction Generalized anxiety disorder (GAD) has historically received less conceptual attention as compared to other anxiety disorders (Dugas, 2000). Given diagnostic modifications throughout various editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM), delineating the essential pathological components of GAD was initially difficult and likely contributed to a slowing of its conceptual development. For instance, the criteria for GAD in the revised third edition of the Diagnostic and Statistical Manual (DSM-III-R; APA, 1987) included a number of symptoms that reflected acute arousal of the autonomic nervous system (ANS), which made it challenging to disentangle GAD from panic disorder (Marten et al., 1993; Starcevic, Fallon, Uhlenhuth, & Pathak, 1994). Not surprisingly, the resultant diagnostic specificity was poor, as can be shown by studies that attempted to discriminate patients with GAD from individuals with other

* Corresponding author. Tel.: +1 203 432 2516; fax: +1 203 432 7172. E-mail addresses: amelia.aldao@yale.edu (A. Aldao), doug.mennin@yale.edu (D.S. Mennin), elinarda@kent.edu (E. Linardatos), fresco@kent.edu (D.M. Fresco). 1 Tel.: +1 203 432 2516. 2 Tel.: +1 330 672 4049. 0887-6185/$ – see front matter ß 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.janxdis.2009.12.001

anxiety disorders (Di Nardo, Moras, & Barlow, 1993; Mannuzza et al., 1989). In DSM-IV (APA, 1994), further clarification of the diagnosis was achieved with the designation of uncontrollable worry and physical symptoms related to heightened chronic arousal (e.g., muscle tension) as well as the elimination of some of the symptoms that reflected acute ANS arousal (e.g., tachycardia, nausea). Although these changes to the GAD criteria have improved reliability of the disorder (Brown, Di Nardo, Lehman, & Campbell, 2001), distinguishing GAD from other conditions has remained challenging. For example, although modifications enacted in DSM-IV have effectively decreased overlap with panic disorder, GAD remains characterized by prominent comorbidity. In addition to its comorbidity with other anxiety disorders, GAD has demonstrated particularly high diagnostic overlap with unipolar depressive disorders (i.e., ‘‘UDDs’’) including major depression and dysthymic disorder (Hettema, 2008; Kessler et al., 2005a, 2005b). To address the high levels of comorbidity between GAD and UDDs, investigators have drawn from structural investigations of genotypic and phenotypic emotional characteristics and have suggested that these disorders be combined into a ‘‘distress disorder’’ category (Krueger, 1999; Vollbergh et al., 2001; Watson, 2005; Watson, O’Hara, & Stuart, 2008). This new category would also include

Dugas et al. Additionally. Scharff. 1998) and other anxiety disorders (Ladouceur et al. has shown subjective and physiological specificity to GAD and differentiation from UDDs (Hoehn-Saric & McLeod. 2008). Fresco. it is not surprising that many similarities are found when comparing GAD and UDDs (e. In this respect. & Barlow. Sherbourne.. which reflects the extent to which one believes that uncertainty is unacceptable (see Dugas et al. Strauss. Following a suggestion by Brown et al. & Zimmerli. Laugesen. Mennin. Similarly. approach motivation has also shown negative associations with UDDs.A. & Mennin.. Masand.g. Indeed. 2003. & Stein. A possibility is to focus on pain. it is necessary to determine whether a one-item measure of intolerance of uncertainty can produce differentiation between GAD and UDDs on par with that produced by longer measures of this construct. these investigators have shown that intolerance of uncertainty discriminated individuals with GAD from non-anxious controls (Dugas. Dugas. Mayer.3.. individuals scoring high on worry and anxiety have more doctor visits and present with more gastric complaints than those low in worry and anxiety (Belanger.g.g. Along these lines. Brown et al. Converging evidence comes from empirical studies showing diminished subjective and expressive emotional responses to positive stimuli in depression (Sloan. & Morin. 1988. Hettema.. difficulty concentrating. Ladouceur. Glowacki. Hoehn-Saric. & Barlow. Specificity in physical symptoms Examination of the diagnostic criteria for GAD reveals that four out of the six associated physical symptoms (i. & Fresco. social anxiety.g. APA. Although intuitively appealing given its parsimony in addressing these overlap issues. Consequently... Lydiard et al. 1997) thus producing equivocal evidence of the specificity of gastrointestinal symptoms. gastrointestinal symptoms. conceptualized as the subjective strength of an emotional response. 1. given recent work suggesting that muscular and stomach pain might be associated with GAD (Beesdo et al. Gagnon. 1999. & Barlow. and sleep difficulties) are part of the diagnostic criteria for dysthymic disorder. Holoway. GAD could be further refined to promote better separation from the mood disorders. result in a separation of GAD and PTSD from the rest of the anxiety disorders. 2005).. has been found to be elevated in GAD (Mennin. and intolerance of uncertainty (Blanchard. 2007). & Conway. & Clark. Dimoulas. emotion intensity.. 2005) and recent studies have found emotion intensity to be higher in GAD than in UDDs (Kerns. Drews & Hazlett-Stevens. which Joormann and Stoeber (1999) found to be more strongly related to depressive symptoms than to worry. Heimberg. 2000) are based on one-item measures of constructs (e. Watson. & Davidson.g.2. 2000). HazzlettStevens. Gupta. & Bruder.. & Iwata. one exception being difficulty concentrating. 1989. although the GAD physical symptoms have shown discriminant validity between GAD and the rest of the anxiety disorders (e. Marten et al. Joormann & Stoeber. 1. One sugges- . 2009) and could potentially differentiate this disorder from UDDs (Means-Christensen.. it may be premature to combine these diagnoses into a single diagnostic entity. Ladouceur. Lastly. & Bukowski. HazzlettStevens et al. Schwartz. (2001). & Ladouceur. Kaplan. Kendler.1.g. In addition to positive affect. Bradley. & Freeston.. 2005). Watson et al. and Neale (2005) found that the item reflecting nausea or stomach distress (which was removed in DSM-IV) was endorsed more frequently than some of symptoms that were retained. difficulty concentrating. Heimberg... Marten. & Spoont. Watson. worry.. Buhr. Chang. fatigue. Talbot. DSMIV..g. Moreover. & Sajatovic. excessive anxiety and worry). 2003). Aldao. have demonstrated a central role for intolerance of uncertainty in GAD. muscle tension. Craske. 1987. 2004). 1997. has emerged as a possible candidate to increase the specificity of GAD. Klein.. Consequently... 2007). which is part of the diagnostic criteria of GAD but not of UDDs. 1995). and autonomic arousal. and obsessive compulsive disorder) loaded on negative affect. 1. 2008) and three out of the six associated symptoms (e. 1990.e. 2008). fatigue. and (3) cognitive processes that have been shown to differentiate these disorders such as intolerance of uncertainty (Dugas. Johnson. 1997). Dugas. 2003.. Shankman. Given the high overlap between the diagnostic symptoms. Henriques. Specificity in emotionality Structural models of affect indicate that negative affect is associated with each of the anxiety and mood disorders (Brown. Watson et al. 2002. 1998. low positive affect has been associated with diminished approach motivation (Germans & Kring.. 2005. 2004a. Fresco. Quirk. Turner. McLeod. Chorpita. restlessness. and sleep difficulties) are also part of the diagnostic criteria for MDD (e. 2005. irritable bowel syndrome (IBS) has been associated with GAD. Suls. 2004b). evidence suggests that gastrointestinal symptoms might be important for the diagnosis of GAD. 1999). & Dugas. intolerance of uncertainty has been found to discriminate individuals with GAD from those with major depression (Dugas et al. Krauss. Specificity in cognitive process A cognitive construct that has shown greater elevations in GAD compared to MDD is intolerance of uncertainty. An important next step in our understanding of intolerance of uncertainty in GAD consists of evaluating how it can be used diagnostically to differentiate GAD from UDDs.g.. Given that our current diagnostic manuals (e. 1999). Present investigation Given the potential for these constructs to provide greater specificity between these conditions. Aldao et al. 2008. 2007). (1998) examined symptom structure in a sample of outpatients with mood and anxiety disorders and found that the best fitting model consisted of higher order factors of negative affect. Garakani et al. whereas all the disorders (MDD. they have not shown strong discrimination between GAD and UDDs (Brown.4.. 1998).g. Mineka. 2004b). 2009. 1991. Craske. panic disorder. Robichaud. independent of its relationship with worry (e. difficulty sleeping) and exclusion of physical symptom criteria that may be more likely to demonstrate specificity (e. 2003. Moore. Gros et al. Roy-Byrne.. Ladouceur. & Bhandary. Kubarych. 1994. Keefer et al. Clark & Watson. & Lang.. 1. 2008). dysthymic disorder. thus. / Journal of Anxiety Disorders 24 (2010) 250–259 251 posttraumatic stress disorder (PTSD) and. Aggen. emotional arousal. 1993). One way to address physical symptom overlap is to incorporate additional symptoms that might increase specificity between GAD and the UDDs (Barlow & Wincze. & Ritter. Starcevic and Bogojevic (1999) found that nausea or stomach distress was among the most frequently endorsed symptoms in GAD. as manifested subjectively. & Naliboff. GAD. Turk. 2004a. positive affect. However. but also with the rest of the mood and anxiety disorders (e. only UDDs and social anxiety disorder loaded (negatively) on positive affect. Tenke. In a number of correlational and experimental studies. 2003. Sloan. Similarly. Mennin et al.g. 2003). Most germane to the current investigation. 2008. & Heimberg. 1998. but no relationship with the anxiety disorders (Depue. Kring & Bachorowski. Further. (2) distinctions in emotional and motivational processes (Mennin. combining these disorders into one category ignores key issues in the relationship between GAD and UDDs including: (1) inclusion of physical symptom criteria that obscure between-group differences (e.

2. 2002) typically utilize a single item per diagnostic criterion.252 A. Given the heterogeneity of symptoms of muscle tension and gastrointestinal distress. They were assessed in groups and were asked to complete a battery of self-reported measures including those used in the present study (detailed below). Similarly.. Specifically. backaches.e. emotion intensity. 2. and intolerance of uncertainty would be higher in GAD than in UDDs and control participants. in which factors are hypothesized to be orthogonal. Indeed. Steer. we predicted that these constructs would differentiate GAD from UDDs.. ‘‘distress’’ disorders.8% did not identify their gender. / Journal of Anxiety Disorders 24 (2010) 250–259 tion has been to modify the somatic symptoms criteria (Barlow & Wincze. cognitive. & Brown. and a Direct Oblimin rotation. gastrointestinal distress). constipation. The mean age of this sample was 19. We evaluated these relationships in two studies: In Study 1. ulcers. constipation.1. and motivational domains. Additionally. 61. symptoms) and discretely (i.. to address overlapping symptoms between disorders. thus reflecting the hypothesized ‘‘muscle pains and aches’’ factor. 1. we conducted factor analyses in a separate sample of 389 students who filled out the PSS as part of prescreening procedures conducted in large lecture classes.. Utilizing these two samples allowed us to evaluate the relationship among the constructs of interest (i. Further.9% identified as female. 2000). somatic.4% Asian American. & Williams.1% identified as Caucasian).e.3% African American. 2001). or neither type of disorder. we utilized single item measures of these constructs as individual items are best reflective of DSM-IV diagnostic criteria (APA. diagnostic categories) in samples differing in the clinical severity of the disorders.1. in our sample..2. In terms of the gender distribution. we examined a sample of community-derived participants with a clinical diagnosis of GAD or UDDs. neck aches. Watson.. and other gastrointestinal problems. The time frame of six months was chosen to be consistent with the time frame with which worry is currently assessed in DSM-IV (APA.. covering the affective. 37. undergraduate sample).1. Each symptom is rated on a 4point scale.3 We used the findings from this factor analysis to create two corresponding composite scores for the analyses on the main study sample (as well as the diagnostic sample in Study 2). the symptoms assessed were: sore jaw muscles. the demographics were similar (i.. gastrointestinal symptoms. Participant and procedures Participants were 783 undergraduate students enrolled in an introductory level psychology course at a large Midwestern university who received credit towards fulfilling a class requirement in exchange for voluntary participation. (1995) found that many patients without GAD endorsed three of these associated symptoms. Factor 2 accounted for an additional 17. 2000).3% Native American. In Study 1 (i.60) and consisted of heartburn. and the remaining .9% did not disclose their ethnicity. 2005). These procedures took place over the course of two semesters at the same Midwestern university as the main sample in this study so..73% of the variance (eigenvalue 1. ulcers. Structured Clinical Interview for DSM-IV. and in the clinical sample we examined groups with either GAD or a UDD.e.54) and consisted of headaches.’’ and .03.g. especially since Brown et al. we examined an unselected undergraduate sample and. GAD and UDDs) both continuously (i. 68. in the present investigations we examined the potential of these variables to differentiate these disorders. Beck Depression Inventory II (BDI-II.1. Measures 2.e. Specifically. we predicted that muscle pains and aches. consisted of 4 items and ranged from 0 to 32 and the second summated score (a = .. The ethnic composition was as follows: 84. we compared GAD with a UDD group that included both MDD and dysthymic disorder. ‘‘gastrointestinal symptoms’’. Conversely. we expected that low levels of positive mood and goal motivation would be specific to UDDs symptoms when controlling for GAD symptoms.3% individuals identified as male. excessive gas. with higher scores indicating more depressive symptoms. These scores consisted of the sum of the scores on their individual items. and sore jaw muscles. 2.1. The first summated score.2. emotion intensity. To verify that these symptoms did correspond to the two distinct domains of muscle pains and aches and gastrointestinal difficulties. 1996. neck aches.94) and has been extensively used in the literature. a comorbid group consisting of individuals meeting diagnostic criteria for either. we explored each construct in the comorbid group: an effect of equivalent magnitude in the comorbid group and the GAD group would suggest that the construct is GAD-driven. Method 2. ulcers). Participants rated how frequently they have experienced each of these symptoms in the last six months on a 9-point scale ranging from 0 (‘‘not at all’’) to 8 (‘‘extremely’’). as expected. and other gastrointestinal problems (i. headaches. behavioral. thus reflecting the hypothesized ‘‘gastrointestinal difficulties’’ factor.. 1996) is a 21-item measure of depression symptoms.33% of the variance (eigenvalue 3. and 87. For the purposes of this 3 These findings were replicated with both a Varimax rotation.3% Hispanic.23 (SD = 2. Spitzer.78). . Physical Symptoms Scale.6% of the sample identified as female. Total scores can range from 0 to 63. a = .. diagnostic sample).9% Caucasian. 8. muscle tension) and heartburn. Newman et al. we compared GAD to a combined UDD group as a conservative test of the potential independence of these conditions. in the undergraduate sample we covaried the symptoms from the other disorder in regression analyses. we predicted that positive affect and goal motivation would be diminished in participants with UDDs compared to GAD and control participants. Since our interest was to provide an initial examination of the viability of these constructs as diagnostic criteria. consisted of 5 items and ranged from 0 to 40 (a = . .e.2.e. In Study 2. Depression and GAD measures. we hypothesized that muscle pains and aches. excessive gas.1. in Study 2. the mean age was 19. including items that have a low base rate (e. 1998). The Physical Symptoms Scale (PSS) was created for the purposes of this study to assess muscle tension and gastrointestinal distress. 2. in which factors are hypothesized to correlate strongly with one another (Tabachnick & Fidell.e. Aldao et al. gastrointestinal symptoms. we administered 9 items that assessed a variety of symptoms. Generalized Anxiety Disorder-Questionnaire-IV. It has a high internal consistency (Beck et al.e.g. Beck. and intolerance of uncertainty would be related to GAD symptoms even when accounting for the presence of UDDs symptoms. 1.81). In Study 2 (i. First..2. Gibbon.e. and headaches (i.g. Following these suggestions. whereas a similar effect in the comorbid and UDD groups would suggest that the construct is driven by UDDs.9% identified as ‘‘other.27). Given that the nosological independence of GAD has been questioned in relation to both mood disorders and that suggestions for subsuming GAD within the mood disorders have included it being combined with both UDDs (i. The demographics for this study are consistent with the general population of the university in which participants were recruited. Factor 1 accounted for 39.1. Study 1 2. assessments of diagnostic criteria such as clinical interviews (e.. We removed duplicated cases of participants who provided data for both samples. 2002) and self-report measures (e. ‘‘muscle pains and aches’’.

01). ranging from 0 (‘‘not at all’’) to 8 (‘‘extremely’’). ‘‘whenever you experience emotions.95 in our sample).01 . which consists of 5 items that reflect difficulties accomplishing goals when experiencing negative emotions... similar to others (e. emotion intensity was positively correlated with AIM Positive Affectivity (r = .82). we used the subscales that measure negative intensity (a = . Gratz & Roemer. (2002). we added two questions to the BDI-II that measured goal motivation and positive affect that were not part of the calculations for the total score. and Yarnold (1994) derived a four-factor solution differentiating intensity from reactivity in the positive and negative affect dimensions. under which.01. p < .05. p < . DERS – Difficulties in Emotion Regulation Scale. The total scores range from 0 to 13 (Newman et al.51) (4. p < . Rheaume. 1999).39.2.51** . Newman et al. Dugas. Higher scores on the goal motivation item represented more goal motivation.2. both when deriving the total score as well as when calculating different factors (Bryant & Yarnold.82) (13. distress. cognitive. p < . 2004) is a 36-item inventory that assesses emotion dysregulation in six dimensions. The IUS demonstrates high internal consistency (a = ..39** . For the purposes of this investigation.60 52. 2. The AIM is scored on a 6-point scale in which higher scores indicate greater intensity or reactivity.43) (18.17** .30 À. 2. and we utilized the Difficulties Engaging in Goal Directed Behavior Subscale. Findings indicate that the AIM possesses high test-retest reliability (Larsen. Six items ask about the physical symptoms outlined in the DSM-IV criteria for GAD. 2.01) and AIM Negative Intensity (r = . & Ladouceur. thus ranging from 0 (‘‘I am not motivated to achieve goals’’ or ‘‘there is no change in my ability to be happy’’) to 3 (‘‘I am extremely motivated to achieve goals’’ or ‘‘I have not been feeling any happiness. The total score for this subscale ranges from 5 to 25 (a = .10. we coded a DSM-IV symptom as present if it was given a rating or 4 or higher and absent if it was given a score lower than 4.95. Specifically. Typically. these items are assessed in a yes/no format. Bryant.06 . One item is open-ended and asks for a list of the most frequent worry topics.. A dimensional score was used in the regression analyses.10** .04 .3. Generalized Anxiety Disorder Questionnaire-IV (GADQ-IV. However. Variables 1.38** 6 .86) (6.e. 2004). test-retest reliability (Buhr & Dugas. how intense are they’’) to the GAD-Q-IV. For the purposes of this study.g.. we did not apply the skip-out rule and instead asked our participants to fill out all questions on the GADQ-IV.07* .45** À. it produces a distribution that is not continuous and highly skewed. 2002) is a 9-item inventory that assesses for GAD as delineated in DSM-IV (APA.31** . ** p < .50** 5 À.52** .01).. It has demonstrated construct and predictive validity (Gratz & Roemer. and behavioral reactions to ambiguous situations.65) (1.. and since we were precisely interested in the variance in associated symptoms (both the current ones and the novel ones we propose). This score has been shown to be highly correlated (r = .05 4 À.001) with the original scoring system (Rodebaugh. 2002). These two additional items were not incorporated into the total score for the BDI-II. 7. these additional items were not incorporated into total score calculations. Scores on the positive affect item were reversed so that higher scores represented more positive affect. with higher scores associated with higher dysregulation. Because this scoring system makes the associated symptoms.1. if an individual does not endorse worrying for more days than not over the course of six months. . Two items are on a scale from 0 to 8 and measure the clinical distress and functional impairment associated with excessive worry and anxiety. and attempts to control the future. 2008). 2002). positive affect was positively correlated with AIM Positive Affectivity (r = . content.18. characteristic strength of people’s responses to emotional stimuli) of individual’s subjective experience of positive and negative emotions. Results To support the validity of the one-item subjective measures.11. Items are rated on a 5-point scale.08* . p < ..e. and intolerance of uncertainty was positive correlated with IUS (r = . Freeston.27** . p < .11** . 6.44** À. Weinfurt. characteristic magnitude of emotions people feel) and reactivity (i. The Difficulties with Emotion Regulation Scale (DERS. 2009). Holaway. and impairment. 4. 1984) and high internal consistency. 1996). The total score can range from 27 to 135.47** Mean (SD). Most items are dichotomous and measure the excessiveness and uncontrollability of worry. the variance in the associated symptoms is eliminated. They were presented in a format similar to the BDI-II. 1994).. ´ The Intolerance of Uncertainty Scale (IUS.66 1. However. 3..01). Aldao et al. Letarte.10** 7 À. and discriminant ability between GAD and non-anxious controls (Dugas et al. It can be calculated as a total score or as 6 subscales. the scoring system proposed by Newman has a skip-out rule. Positive affect Goal motivation Emotion intensity Intolerance of uncertainty AIM Negative Intensity AIM Positive Affectivity DERS Difficulties with Goals IUS 2 . similar to the physical symptoms above. & Heimberg.31** . / Journal of Anxiety Disorders 24 (2010) 250–259 253 investigation. Items are rated on a 5-point scale.e. These items were presented on a 9-point scale. Thus. In order to calculate the total GADQ-IV score.96 32.51 13.88).11) Note: AIM – Affect Intensity Measure. Table 1 Bivariate correlations between one-item measures of subjective processes and validated scales (Study 1).81 (.18** .01). Larsen. We also added a one-item measure of intolerance of uncertainty (i. Roemer et al.87 65. keeping the variance associated with the symptoms was fundamental. 1994) is a 27-item inventory that measures emotional.51. Subjective process measures.A. 5.17 2. distress. and interference questions dependent on the response to a previous question. for each individual for which the skipout is applied. we first correlated these items with validated measures that assess the constructs of interest (see Table 1). The Affect Intensity Measure (AIM. Additionally.70) and positive intensity (a = .0 3 À. 1998) and other anxiety disorders (Ladouceur et al.10** .e. did you often have difficulty tolerating the anticipation of uncertain events?’’) and emotion intensity (i. This dimensional score was similar to the one suggested by Newman et al.27** À. she or he is instructed not to respond to the following questions that assess the associated symptoms.41** . ‘‘during this same period. 2. where higher scores indicate more intolerance of uncertainty.10* 8 .07) (1. implications of being uncertain. goal orientation was negatively correlated with DERS Difficulties with Goals (r = . * p < . IUS – Intolerance of Uncertainty Scale.40 4. 8. we assessed the DSM-IV symptoms on a 9-point scale in order to be congruent with the physiological symptoms.63) (1. or joy in my life’’). 1984) is a 40-item inventory that assesses the intensity (i.

we simultaneously entered the physical symptoms composite scores (muscle pains and aches items and gastrointestinal items) and the subjective items (positive affect.29** .85).13** . Positive affect. There were no significant differences between participants collected by D. p = . To this end.4% chose not to identify their ethnicity. however.20** . we recruited individuals from community and clinical settings with a primary diagnosis of GAD or a UDD (i.16** .79).02 À.15** .01 .02 .37 . and two had a primary diagnosis of major depressive disorder with comorbid dysthymic disorder (i.58 B . The sample resulted in a total of 142 participants.06). 2002) and BDI-II – Beck Depression Inventory II (Beck et al.. and D. and seven had a primary diagnosis of major depressive disorder and secondary GAD.04 . We then predicted BDI-II scores.11 1.04 À. 40 met a primary diagnosis of GAD (without comorbid MDD or dysthymic disorder.57 À.22 .01 .24** . we added GAD-Q-IV and.06 . Participants and procedures In this second study.05 . p < .02 .39 .40 . 3. & Barlow.18** . four had a primary diagnosis of GAD and a secondary diagnosis of dysthymic disorder. All primary diagnoses were assigned CSR scores above 4.01 . gender (x2 [1.39** Predicting BDI-II scores Step 1 Muscle pains and aches Gastrointestinal symptoms Positive affect Emotion intensity Goal motivation Intolerance of uncertainty Step 2 Muscle pains and aches Gastrointestinal symptoms Positive affect Emotion intensity Goal motivation Intolerance of uncertainty GAD-Q-IV scores DR2 . gender ([x2 [1. All participants were administered the Structured Clinical Interview Diagnosis for Axis I disorders (SCID.N = 142] = .19** . we added the BDI-II scores.90 .14** .12 .20 . 66.37. Together.20** À. 58 participants did not meet diagnostic criteria for any mood or anxiety disorder. as a result. ADIS-IV CSR. In terms of the ethnic background. 1996).37 . Method 3.92) and the unipolar disorders (k = 1.07 . Again.08 .32 . In order to analyze the role of the symptoms in discriminating GAD symptoms from UDDs symptoms.16 . * p < . 17 had a primary diagnosis of major depressive disorder.41).11 .01.57** . To determine primacy of symptom severity. three had a primary diagnosis of dysthymic disorder and no major depressive disorder. No demographic or outcome differences were found between those participants collected by D. 5.11 À.01 . goal orientation. p = .48 SeB .05.05). remained a significant predictor. 9. the Clinician’s Severity Rating (CSR) from the Anxiety Disorders Interview Schedule for DSM-IV (i. There were.F.27. (n = 122) or D.17 . Predicting GAD-Q-IV scores Step 1 Muscle pains and aches Gastrointestinal symptoms Positive affect Emotion intensity Goal motivation Intolerance of uncertainty Step 2 Muscle pains and aches Gastrointestinal symptoms Positive affect Emotion intensity Goal motivation Intolerance of uncertainty BDI-II scores DR2 . CSR scores range from 0 to 8 with a 4 denoting clinically significant symptom severity.M. ‘‘double depression’’).93 . 1994) was utilized. p = .N = 140] = 5.08 À7.30 .84 . there were no significant differences between participants recruited from the community or departmental clinics in terms of age (t [136] = . we conducted a series of stepwise regression analyses (Table 2).04 .5 In all cases.04 .07 . or number of secondary diagnoses of anxiety disorders (t [82] = . ‘‘UDD only’’)4 and 22 met diagnostic criteria for GAD and at least one UDD (‘‘GAD + UDD’’).F.05 . the results from the regression analyses suggest that muscle aches and pains.M or D.9% identified as female.M. and the remaining 1.20 .50** . gastrointestinal symptoms. comorbidities with other anxiety disorders were allowed. ethnicity was non-significant (p > . 2002) by graduate students and postbaccalaureate research assistants who were trained extensively in psychopathology and diagnostic assessment by D.N = 142] = . however.e.57 B . 5 Of these individuals. or number of secondary diagnoses of anxiety disorders (t [82] = . gastrointestinal symptoms.05 .03 .01 .15 b .05 .96).03 .).M.12 . In the second step. emotion intensity. Brown.254 A.69 SeB . and intolerance of uncertainty were no longer significant predictors.2% as African American. emotion intensity.02 . muscle pains and aches.F. and D. significant differences in terms of ethnicity between data collected by D.08 . The mean age for the sample was 27. and in departmental clinics.F.61).N = 140] = 6.15 . In this sample.. we sought to replicate the previous findings by examining the physical symptoms and subjective processes in a diagnosed sample.05 b .04. emotion intensity. . All of them were significant except for goal motivation. p = . Di Nardo..06 .26.1. / Journal of Anxiety Disorders 24 (2010) 250–259 Table 2 Predicting GAD-Q-IV and BDI-II scores with the one-item measures (Study 1). Secondary diagnoses were also considered to be present when above 4 but must have 4 Of these individuals.69). Only the positive affect item was no longer significantly related to GAD-Q-IV. major depressive disorder or dysthymic disorder).05) and between participants recruited from the community or the departmental clinics (x2 [1. We first predicted GAD-QIV. all were significant except for goal motivation.1.39. 10 had a primary diagnosis of GAD and secondary diagnosis of major depressive disorder. 22 met a primary diagnosis of a UDD (MDD or dysthymic disorder without comorbid GAD.00). and intolerance of uncertainty).e.M..1. However.05 . when entered in the analyses. and intolerance of uncertainty were more strongly associated with GAD-Q-IV scores whereas positive affect was more strongly associated with BDI-II scores. In the second step. Study 2 3.72 (SD = 7. The reliability of diagnoses of these diagnosticians was found to be high for both GAD (k = . 62. we simultaneously entered the physical symptoms composite scores and the subjective items.12 À. and D.24** .06 .10** À.10) and its inclusion did not affect results presented below.06.11 .1% as other. p < .7% identified as Caucasian. In the first step. (x2 [1..33 .21 À8. ** p < .15 . First et al. as long as GAD or UDDs were considered the primary diagnosis on the basis of symptom severity.6% as Hispanic.91. Aldao et al. with more Caucasian participants in the sample collected by D. (n = 20) or between those referred through the community (n = 105) or via departmental clinics (n = 37).15 .e.F.M. p = . p = .01 . Of these. in terms of age (t [136] = 1.38** Note: GAD-Q-IV – Generalized Anxiety Disorder Questionnaire IV (Newman et al.05 .21 . 2. 19% as Asian American. Each sample was collected by two of the authors (D. Similarly. respectively. In the initial step. one had a primary diagnosis of dysthymic disorder with major depressive disorder.59.12** À. ‘‘GAD only’’).05 ..

The contrasts were: GAD only and healthy controls. p = .67].09.08.91)a. Specifically.2. p = . p = . 1. UDD only and healthy controls. L = À.76.08).138] = 4.81] = 1. Sixth. p = . p = .37.03) (1.88.32) and not different from the GAD + UDD group (CI: [À1. those in the UDD only group did not differ from those in the GAD + UDD group (CI: [À4.34).b (1.c. L = .57].54.23]. specific phobia (n = 22).001)b (2.77 4.39).63. 3.39 Notes: Means with the same subscript are significantly different at the . h2 = .A. L = . L = 1. h2 = . the UDD only group did not differ from the GAD + UDD group (CI: [À.08].63]. Additionally. p < . L = . However. we examined group differences on the one item measure of intolerance of uncertainty and found a main effect of diagnostic group (F [3. .97. 2.28 2.18. Additionally.05.73) and the GAD + UDD group (CI: [.138] = . participants with a diagnosis of bipolar disorder or substance abuse or dependence were excluded. 2.1.83.49.34.18 5.07).08.94)c (1. p < .01. First. L = À.d b GAD + UDD (n = 22) 10. L = . 2. the UDDs only group did not differ from the GAD + UDD group (CI: [À1.49)a (.67 2.b 3.56). p = .05) and was lower than the control group (CI: [À1.34) or the control group (CI: [À.35). Planned contrasts suggested that the GAD only group was significantly higher than the control group (CI: [. .07).60. L = 3.01.23 (3.24) 1.161 F = 3.96) and higher than the control group (CI: [. panic disorder (n = 7). / Journal of Anxiety Disorders 24 (2010) 250–259 Table 3 Differences between diagnostic groups (Study 2).08 F = 4.88).32].68.N = 142] = .b (. p < . h2 = .05 level.99]. participants completed a battery of questionnaires.38).18). p < .44. Additionally.42). L = . the Levene test was non-significant for both. L = À1.50. . p < . h2 = .34. There were no significant differences among the psychopathology groups in terms of the number of secondary diagnoses of anxiety disorders (F [2. the GAD group did not differ from the GAD + UDD group (CI: [À.05. If group differences were found at the omnibus level. we examined the muscle tension composite score and found a significant main effect of diagnostic group (F [3. p < .68) or the controls (CI: [À1.91.12. Results To examine group differences in the one-item measures and physical symptoms composite scores.138] = . we examined group differences on the one item measure of emotion intensity and found a main effect of diagnostic group (F [3.20) (1. we first conducted univariate ANOVAs with diagnostic group as the between-group factor.82.95 (5.98]. L = À.05) and goal motivation item (F [3. 1. L = 1. .b 255 UDD (n = 22) 8. those with GAD only and control groups were comprised of the greatest rates of individuals from ethnic majority groups relative to minority groups.001.06)b (1.12]. À.138] = 2.31.91 1.97)a. p = .57) or gender (x2 [1. .57 4. p = .56) and goal orientation (F [3.01.81 (1. .18. p < . the UDD only group was significantly lower than the GAD + UDD group (CI: [À3. Some data were missing for the emotion intensity variable.82.05. h2 = .). we examined group differences in the gastrointestinal symptoms composite score and found a significant main effect of diagnostic group (F [3. L = . . and the UDDs only group (CI: [.85) 3. h2 = . L = .001. À.05.b a. there were no differences across the diagnostic groups in terms of age (F [3. muscle aches and pains (F [3. 1.12. p = . .2. UDD = 16.68].55 5. Fourth. p < . p < . À.29.10).50 (7.22. Second. we examined group differences on the one item measure of goal motivation and found a main effect of diagnostic group (F [3. ethnicity was a nonsignificant predictor and it did not affect the results of the analyses. p < . Additionally.04) and it was lower than the control group (CI: [À. p = . We then proceeded to run one ANOVA for each construct of interest.82. the Levene Test for homogeneity of variance was nonsignificant. L = À.25). 6 Unless otherwise noted. L = 1. h2 = .64). p = . L = 1.01. including the modified BDI-II and GADQ-IV administered in Study 1. p < .50)a.09.08 F = 29.05). p < .01. Planned contrasts suggested that the GAD only group was not significantly different from the control group (CI: [À. L = À. it was significantly higher than the UDD only group (CI: [. the UDD only group did not differ from the GAD + UDD group (CI: [À1. p = .69)a.60)b 1 (.48.62.44.15 (7.87)a (.84. we conducted non-orthogonal planned contrasts to determine which groups were significantly different from one another. it did not differ from the GAD + UDD group (CI: [À1. p = . but only marginally different from the UDD only group (CI: [À1.63 5.03]. . GAD + UDD = 18.18 F = 3.53].96.06) (4. p < .70. h2 = .35. p < .41.05.95)a.56].39.77. p = . Aldao et al.04)b.79 1.47).124] = 3. L = 2. 1. Measures Following completion of the SCID.87)a (1. the UDD only group did not differ from GAD + UDD group (CI: [À.20) and the UDD only group (CI: [. p = .84) (6. However.138] = 3. p < .03. L = À.36].12]. 4. . Measure Muscle pains and aches Gastrointestinal symptoms Positive affect Emotion intensity Goal orientation Intolerance of uncertainty GAD (n = 40) 12.50).65.02).71.79].12. been at least one point lower in severity than the primary GAD or UDD diagnosis. However.N = 140] = 7.001. The Levene Test indicated heterogeneity of variance for the muscle aches and pains composite score (F [3.89).48.04. Additional secondary diagnoses included social anxiety disorder (n = 15).06)a.129] = .161). We inspected variables for normality and conducted tests of heterogeneity of variance.76]. p < .07). resulting in the following sample sizes: GAD = 36.09. h2 = .01.50 (.61.86 1.58. controls = 58.01.11. . but not different than the GAD + UDD group (CI: [À. p < . 1.55 (2. p < .63) or from the control group (CI: [À.73. p < .08).25. p = .50]. L = . or obsessive-compulsive disorder (n = 2). We addressed this issue by conducting a square root transformation and as a result.09 (5.01)a (4.53. significantly higher than the UDD only group (CI: [.49.138] = 2.27.c 4.73. L = À.13]. 1. 4.36]. Additionally.78.138] = 29. p = .71) but was not different from the GAD + UDD group (CI: [À.6 Planned contrasts suggested that the GAD only group was significantly higher than the control group (CI: [.64.88)a (1. and UDD only to healthy controls (see Table 3). Planned contrasts suggested that the GAD only group was significantly higher than the control group (CI: [2. L = . 3. p < .84 1. L = 2. p = .05).06.07 F = 10.138] = 8.11. GAD only and GAD + UDD. p < . Planned contrasts suggested that the GAD only group was significantly higher than the control group (CI: [.07. p = . p = . L = À.72.37). L = 1.44 1.01. h2 = .05]. L = À1.18).34.68). Finally.01.01) (1. 3. 1. p = . p < .31.24. h2 = . Additionally.001.22 5. 1.001.60). Fifth.001.54 5.84.05). 3. 2. and differences were marginally significant for ethnicity (x2 [1.44)c Controls (n = 58) 6. p = .28].37.d F = 8.20) and the UDD group (CI: [.55 2.79]. .95]. h2 = . we examined group differences on the one item measure of positive affect and found a main effect of diagnostic group (F [3. L = . Planned contrasts suggested that the GAD only group was not significantly different from the control group (CI: [À. As mentioned previously.39.11].138] = 10.62.89]. L = À1.53]. UDD only and GAD + UDD. L = .79].01. Third.61). Additionally.

& Wilhelm. and sore jaws was associated with GAD symptoms when controlling for the presence of UDDs symptoms (Study 1) and was also higher in individuals with GAD only than in those with UDD only or no diagnosis (Study 2). In Study 2. and intolerance of uncertainty. Additionally. 1999. It is also feasible that the marginal significance of our findings be related to the relatively small sample size in Study 2. we found that individuals with GAD only experienced these gastrointestinal symptoms more frequently than individuals with no diagnosis. findings on gastrointestinal symptoms and muscle pains and aches provide preliminary evidence that these physical indices might provide a dimension with which to differentiate GAD from UDDs. 1997. whereas positive affect was associated with variance in UDDs symptoms when controlling for GAD symptoms. Specifically.. and intolerance of uncertainty were associated with variance in GAD symptoms when controlling for UDDs symptoms.. Discriminant function analysis (Study 2). canonical r = . constipation.8% of the variance (eigenvalue = . as well as a one-item assessment of goal motivation. Two canonical discriminant functions significantly discriminated the four diagnostic groups (Wilk’s L = . 4. Approach motivation also differentiated individuals with a diagnosis of GAD from those with a diagnosis of UDDs (Study 2). gastrointestinal symptoms. The first function (X axis. Overall. and one-item measures of emotion intensity. neck aches. and cognitive processes differentiated GAD from UDDs at the symptom (Study 1) and diagnostic (Study 2) levels.5% of the variance (eigenvalue = . thus suggesting that it differentiated GAD from UDDs. A composite score of muscle tension consisting of headaches. suggesting that some caution should be taken in concluding that gastrointestinal symptoms are more strongly related to GAD. Kubarych et al. we ran a discriminant function analysis (DFA) to evaluate whether our one-item measures and symptom scales would differentially predict group membership.. These findings are consistent with structural models of affect suggesting that positive affect is diminished in unipolar depression and SAD when compared to the rest of the anxiety disorders (Brown et al. A composite score of gastrointestinal symptoms consisting of heartburn. 2005). emotion intensity.80. motivation. In regards to emotion. a third non-significant canonical function (which accounted for an additional .. differed in the GAD and UDDs groups. 2002) as the problems associated with worrying may not reach a level of concern for some individuals until they experience them through bodily tension. emotion intensity.45. (p = . canonical r = .e. Watson et al. 1 demonstrates the relationship of the four diagnostic groups with these functions by plotting the unstandardized canonical discriminant functions for each group in a discriminant space. Similarly.46) and had the highest absolute correlations with positive affect and goal motivation. Lastly these findings suggests a potential cause for why individuals with GAD show an increase use of primary health care services (Roy-Byrne & Katon. these indices. canonical r = .09) had the highest absolute correlations with muscle pains and aches composite score. goal motivation) best discriminated individuals with GAD and controls from those with GAD + UDD and UDD only. Additionally. 2008). we found the difference between individuals with GAD only and UDDs only to be marginally significant. The second function (Y axis. in the diagnostic sample. this more precise assessment of pains associated with tension might help shed light on the equivocal concordance between self-reports of muscle tension and the corresponding physiological activity (Pluess. these results speak to the importance of carefully examining valence and arousal when evaluating the relationships between mood and anxiety disorders. thus suggesting that it differentiated GAD from nonGAD regardless of UDD comorbidity. Discussion In the present investigation. physiological assessment of gastrointestinal functioning might also indicate differences between GAD and UDDs. but also normative functioning. gastrointestinal symptoms) and one-item measures of emotion. discriminant function analyses showed that linear combinations of these subjective processes and physical symptoms discriminated individuals with GAD from those with UDDs. Additionally. DFA identifies the linear combinations of variables (canonical discriminant functions) that maximize separation among groups (Duarte Silva & Stam.27. For example.56. gastrointestinal symptoms. Cohen’s d = . excessive gas. Specifically.07. Wittchen. However. In regression analyses conducted in the unselected undergraduate sample. composite scores of muscle pains and aches. Conrad. 1995). p < . 1.256 A. we found that composite scores of physical symptoms (i. 1998. 1988). These results are consistent with previous findings demonstrating muscle tension in GAD (e. 2009). individuals with only GAD had higher levels of goal . The second canonical function accounted for an additional 26. more careful examination of gastrointestinal functioning should be conducted examining not only symptoms. x2 [18. muscle pains and aches. Aldao et al. / Journal of Anxiety Disorders 24 (2010) 250–259 Fig.N = 128] = 98.g. eigenvalue = . Finally. diminished positive affect was associated with UDDs symptoms when controlling for GAD symptoms (Study 1) and individuals with a diagnosis of GAD only had higher levels of dispositional positive affect compared to those with a diagnosis of UDDs and GAD + UDDs and on par with healthy controls (Study 2). backaches. The second function is plotted against the first function. and other gastrointestinal problems was associated with variance in GAD symptoms after controlling for UDDs symptoms (Study 1). The first canonical function demonstrated the strongest discrimination among diagnostic groups accounting for 72. In this respect.66) and had the highest absolute correlations with gastrointestinal symptoms composite score. and suggest that the muscle tension criteria for GAD may need to be expanded to assess for more specific symptoms related to muscular aches and pains. and intolerance of uncertainty) best discriminated individuals with GAD and GAD + UDD from those with UDD only and controls. emotion intensity was associated with GAD symptoms when controlling for depression (Study 1) and individuals with a diagnosis of only GAD symptoms endorsed higher emotion intensity than individuals with a diagnosis of only UDDs and healthy controls (Study 2).7% of the variance. it might be important to examine appetite or eating patterns. We then conducted a multivariate analysis.007. Together. indicating a medium effect size.001).. Fig.75. Cohen. ulcers. Joormann & Stoeber. positive affect. Similarly.

K.g. Diagnostic and Statistical Manual of Mental Disorders (4th ed. we hope that these findings provide preliminary support for a cautious approach in attempts to combine GAD and UDDs. (2000). Blanchard. 2008).). Watkins. The items that loaded on function 1 appear reflective of the preparedness associated with anxious apprehension. Mennin. although muscle pains and aches differentiated GAD from UDDs at the univariate level. Hoyer. Hofler. Additionally. Aldao et al.. F. On the other hand. K. Tsao. Watson et al. which could be readily incorporated into assessment protocols to continue to evaluate the relationship between these dimensions and GAD and UDDs. McDonald. this is a complex issue and future work should aim at identifying the degree to which one-item measures can provide reliable and practical assessment of psychological constructs. DC: Author. (1998). Suls. & Thayer. depressed mood. emotional arousal and valence. N. further research clarifying the role of both approach and avoidance motivations and their relationship to negative and positive emotions in GAD and MDD is clearly warranted. Intolerance of uncertainty was associated with GAD symptoms when controlling for UDDs symptoms (Study 1) and was higher in individuals with only GAD than those with only UDDs or healthy controls (Study 2). individuals with comorbid GAD and UDDs diagnosis endorsed higher intolerance of uncertainty than those with only unipolar depression and did not differ from those with only GAD (Study 2). (1996). J. Washington. intolerance of uncertainty is a cognitive process indicative of difficulties managing uncertainty associated with future events (see Dugas et al.. 684–693. Heller. Scharff. emotion intensity is indicative of producing strong responses in response to the environment. Future work should focus on teasing apart the relationship between GAD and both chronic and episodic forms of unipolar depression. Needless to say. this variable did not load on the two functions that discriminated GAD from unipolar depressive disorder. 1994). Weiss.-U. Ladouceur... goal motivation did not predict GAD symptoms or UDDs symptoms in any of the regression models. & Wincze. S. supporting the notion that intolerance of uncertainty could provide further diagnostic specificity to GAD compared to unipolar depressive disorders.g.01) and goal orientation and DERS Difficulties with Goals (r = À. and gastrointestinal symptoms in the context of mood and anxiety disorders might be associated with increase vigilance (Muth. Additionally. Conversely. R. self-esteem. at large. Second. e.. Robins et al. These results suggest that these physical symptoms and subjective processes might map onto the endophenotypes of anxious apprehension and anhedonia and that these endophenotypes might eventually provide a better source of nosological categorization. MDD and dysthymic disorder. M. However. future work should explore the multivariate relationships between these associated symptoms and processes. The role of anxiety and depression in the irritable bowel syndrome. Although the addition of worry helped solidify the diagnosis of GAD and increase its reliability. D..e. Despite these equivocal results. & Miller. Washington. (1990).). Turk. it is important to keep in mind that at the multivariate level. Jacobi. 1989. & Trzesniewski. San Antonio. J. in fact. (2009).. 1363–1369. We hope that our findings spur research to further examine these dimensions in GAD. we found that the aggregate of one-item subjective process and composite scores of physical symptoms discriminated GAD and unipolar depressive disorders through two distinct functions. .). Segerstrom. H. The answer to this question is likely going to vary depending on the degree to which the construct of interest is multi-faceted... Frankel. First. Robins.01) were small in magnitude. so that the random errors associated with each individual item cancel each other out (e. These results are consistent with previous findings on intolerance of uncertainty (Dugas et al. Low. In this respect. A. Imig. 51. / Journal of Anxiety Disorders 24 (2010) 250–259 257 motivation (i. Hendin. However. For example.g. 2001). These functions could possibly reflect the endophenotypes of anxious apprehension and anhedonia (Nitschke.. & Craske. although related to the constructs of interest. p < . 1999). the correlations between the one-item measures and the corresponding scales were small to moderate. This suggests that. American Psychiatric Association. This pattern of findings also underscores the need to simultaneously utilize both normative and clinical samples when studying psychopathology. clearly. approach motivation) than those with only UDDs and similar levels to those endorsed by the healthy controls.g.10. fear of having future panic attacks). L. Belanger. C. the items loading onto function 2 appear reflective of this process. This finding suggests that the ability of goal motivation to differentiate between disorder categories in Study 2 might have been a function of clinical severity. 23. 2002. 2004a. In this respect. H.. 2001). P... Stern. 2004a. a great deal of further research is necessary to explore this possibility. L. 28. UDDs. Journal of Anxiety Disorders.. anhedonia is characterized by diminished responding to the environment. Alden. this issue relates to the larger question of whether one-item measures can reliably assess psychological processes. Steer. 393(Suppl. J. Diagnostic and Statistical Manual of Mental Disorders (3rd ed. DC: Author. Barlow. Canadian Family Physician. Behaviour Research and Therapy. A. Future work should focus on improving phrasing for the items and conducting more extensive piloting to find the items with the highest construct validity. these results demonstrate that these dimensions can be assessed with one-item measures and a few physical symptoms. & Wittchen. R. 2008). 2004b) and are noteworthy given that the only cognitive process that is part of the diagnostic criteria for GAD is excessive and uncontrollable worry (APA. Beesdo. 2001). which have been shown to have unique relationships to GAD and unipolar depressive disorders. Additionally. given its strong relationship with other repetitive thought processes. Specifically. & Mendelsohn. Manual for the Beck Depression Inventory-II. p < .. despite the high comorbidity rates between GAD and UDDs. Washington. In this respect. Koch. This investigation had a few notable limitations. & Brown. H.. American Psychiatric Association. Schwartz. & Barlow. M. (2005). B. we examined the relationship between GAD and unipolar depressive disorders.. DSM-IV and beyond: what is generalized anxiety disorder? Acta Psychiatrica Scandinavica. reduced positive affect suggests that the positive reinforcement individuals get from interacting with the environment might not be present and diminished approach motivation indicates a lack of engagement with the environment. T. Additionally. DC: Author. somewhat more complex constructs are reliably assessed with one-item measures in our diagnostic manuals (e. Additionally. (1987). Specifically. G. there are. & Heimberg.. such as rumination (Fresco. Diagnostic and Statistical Manual of Mental Disorders (4th ed. 23–29. P. References American Psychiatric Association. the one-item measures of positive affect and goal orientation might be assessing a specific aspect of those constructs. Generalized anxiety disorder and health care use.). Beck.. reliability theory suggests that it is important to use multiple items to assess a construct. TX: Psychological Corporation. D. Russell.A. it might be partially responsible for the high overlap between GAD and UDDs. text rev. previous work has shown that one-item measures can reliably assess one-dimensional constructs (e. in Study 1. 2004b). (1994). In a discriminant function analysis. it might be necessary to broaden the cognitive criteria for GAD to include other processes that might capture core anxiety processes. & Morin. given the suggestions to diagnostically combine GAD with two forms of unipolar depression (i. The findings from this investigation suggest that.e. 401–405... 2000.. and the rest of the mood and anxiety disorders. Association between generalized anxiety levels and pain in a community sample: evidence for diagnostic specificity. C. the correlations between positive affect and AIM positive affectivity (r = 18. M. E.. a number of dimensions that can reliably distinguish these disorders and may be candidates for increasing diagnostic criteria specificity.. More immediately. Third.

Journal of Anxiety Disorders. M. Hoehn-Saric. 36. S. & Trzesniewski. (2003). M. K. F. S.. R. G. Gorman. J. Lackner. L. Erickson. P. (1998). L. Behaviour Research and Therapy. R. & Hazlett-Stevens. A. International Journal of Methods in Psychiatric Research. First. Fyer. D. 30. & Stoeber. Ladouceur. J. C. et al. & Naliboff. P. 290–296. Conrad. Win.. P. T. Turk. A. & Kring. M. S. Kendler. Structural relationships among dimensions of the DSM-IV anxiety and mood disorders and dimensions of negative affect. J. R. Archives of General Psychiatry. & Yarnold. Clark. Brown.. Mayer. Relationships among pain. Prevalence. Relationships between irritable bowel syndrome. L. P.. Mennin (Eds. R.. A. Craske. & Krasner. & Massand. Johnson. Generalized anxiety disorder: advances in research and practice. Reliability of DSM-III-R anxiety disorder categories. 28. P. & Zimmerli. J. J. L. 585–594. A. Muscle tension in generalized anxiety disorder: a critical review of the literature... 297–303. Chorpita. F. J... M. M. 284–302. Ohman (Eds.. Germans.). M.... D. F. ´ Ladouceur. Gender differences in worry and associated cognitive-behavioral variables. B. Erisman. R. M. (2003). A. Structured Clinical Interview for DSM-IV-TR Axis I Disorders. 429–436. 593–600. Letarte. and initial validation of the difficulties in emotion regulation scale. K. D.. F. Garakani. Distinguishing dimensions of anxiety and depression. Hoehn-Saric.. R.. A.. T. S. & Conway. R... (1984). & Wilhelm. Journal of Psychopathology and Behavioral Assessment.. Journal of Psychosomatic Research. American Journal of Therapeutics. Moras. (1987). Psychosomatic Medicine. Masand. (2001). 575–599. (2005). K. A.. Evaluation of the ratings comprising the associated symptom criterion of DSM-III-R generalized anxiety disorder. S. F. Blanchard. 85. D.. P... Personality and Individual Differences. Kachin. & Spoont. Mineka. Archives of General Psychiatry. & Heimberg. Martin. S. clinical practice. 179–192. D. severity. Hillsdale. S. 84-22112. & Ladouceur. A. & Stein. 377–412. & Iwata. The factor structure and dimensional scoring of the generalized anxiety disorder questionnaire for DSM-IV. T.. Brown. et al. 19. Kessler. Robins. P. Kaplan. J. Journal of Anxiety Disorders. Kring. Stang. M. & Stam. M.. R. Drews.). M. (2009). R.. and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey. (1994). (2002). R. (2003). Turner. L. M. (1999). 163–172. & Barlow. 215–226. A. Generalized anxiety disorder: a preliminary test of a conceptual model. K. Kaplan. The intolerance of uncertainty scale: psychometric properties of the English version. CA: Academic Press . Distinct and overlapping features of rumination and worry: the relationship of cognitive production to negative affective states. 21. M. & Barlow.. 1281–1310. (2009). Gratz. M.258 A. 460–466. (1988). D. Assessment.. G.. A. Anxiety Disorders Interview Schedule for DSM–IV. Orsillo.. Duarte Silva. M. A.. Psychophysiological responses to psychological stress.. (1995). & Mennin. Emotions and psychopathology. 50. Understanding adolescent worry: the application of a cognitive model. neuroticism. 38. D. M.. Mennin.. W. Sykes. J. Heller. R. A.. 14. K. R. E... Reliability of anxiety assessment: I. J. T. Delineating components of emotion and its dysregulation in anxiety and mood psychopathology. Grimm & P. (1997). W. P. D. & Swinson. P. 31. Sherbourne.. L. Behavior Therapy. D. J. A. (2005). A. A. 8. R. 27. Frankel. Dugas. Robichaud. and autonomic arousal. (2001)... Discriminant analysis.. L. Generalized anxiety disorder publications: so where do we stand? Journal of Anxiety Disorders. Lane. Brown. Annual Review of Psychology. J. Cognition and Emotion. Towards a better understanding of anxiety in irritable bowel syndrome: a preliminary look at worry and intolerance of uncertainty. & D. Journal of Anxiety Disorders... K. L. & Heimberg. Chang. 617–627. 61–67.. Means-Christensen.. Hendin. & Bhandary. Hettema. J.. Depression and Anxiety. Aldao et al. Moore. (2008). (2007). D. Zuellig. & Lydiard. (2008). (1999). K. International Journal of Clinical and Health Psychology.. N. The structure of common mental disorders. Comorbidity of irritable bowel syndrome in psychiatric patients: a review. Heimberg. In: R. 289–299.. Discriminant validity of the symptoms constituting the DSM-III-R and DSM-IV associated symptom criterion of generalized anxiety disorder. (2001). M. R. (2002). 355–371. R.. S. J. W.. Chiu. Imig. F.. Dugas. (2004). P. Glowacki. L.. K. 38. C. 25–36. 277–318). A. M. L. T. 26.. R.. Turk. 40. D. 63–69. Poster presented at the 42nd annual conference of the Association for Behavioral and Cognitive Therapies (ABCT). Endicott. McCable. H. Why do people worry? Personality and Individual Differences.. Reliability of DSMIV anxiety and mood disorders: implications for the classification of emotional disorders. Hedonic deficit in anhedonia: support for the role of approach motivation. A. Fresco. D. (2005). & Roemer. C.. J. 179– 188. & Walters. 49–58. 95–123). E. 41–54. Sanders.. & Fresco. J. Krueger. R. S. Reading and understanding multivariate statistics (pp. Dugas. Aggen. Journal of. D. Toward a measurement model of the affect intensity measure: a three-factor structure. & Mennin. & Campbell. . Dugas. Krauss. W. 1073–1082. (2000). 100. D. S. 46. G. H. Depression and Anxiety. R. 191–207. 181. Archives of General Psychiatry.. Journal of Anxiety Disorders. & Barlow. (1999). Yarnold (Eds. Mennin. Roy-Byrne. Buhr. Personality and Social Psychology Bulletin. S. Larsen. M. & Francis. (1996). Borkovec. Archives of General Psychiatry. 316–336. A. Y. M. D. A two-dimensional threshold model of seasonal bipolar affective disorder. M. K. J. Hettema. K. FL. L.. 103. 14. & Heimberg.. D. & Barlow. A. M. D. M. M. (1998). R. diagnostic agreement. Cognitive Therapy and Research. & Miller. 921–926. H. (1999). Journal of Abnormal Child Psychology. D. Cognitive Therapy and Research. (2008). Heimberg. R. (2009). 23. J. Comorbidity of anxiety and unipolar mood disorders. A. 251–256. & Bachorowski. K. T.. R.. Abnormal Psychology. & Ritter. T.. H. L. Marten. H.. 25. Multidimensional assessment of emotion regulation and dysregulation: development. Di Nardo. A. (1989). G. D. Albany. Roemer. S. G. W... M. 46. Koch. S. Gros.. M. S.. T. T. Cohen. Kessler. E.. S. (2003). worry. K. R. J. Henriques. Statistical power analysis for the behavioral sciences (2nd ed. New York: Biometrics Research.. S. Fresco. 49. P. Barlow. Virk. Mennin. 55. Roy-Byrne. Behaviour Research and Therapy. M. D. 2297B. (1994). D. G. Is generalized anxiety disorder an anxiety or mood disorder? Considering the multiple factors as we ponder the fate of GAD. New York: Guilford Press... 1113–1119. R. D. 375–386. 300–316. Abnormal Psychology. C. A. R. 835–842. University Microfilms No. 35. R. M. & Clark. (2005). Journal of Anxiety Disorders. 223–247. Spitzer. Gupta. M. 31–40. Rethinking the duration requirement for generalized anxiety disorder: evidence from the National Comorbidity Survey Replication. T. Mannuzza. 13. H. J... & Williams. 10. Aldao. Gallops. Mindfulness and emotion regulation difficulties in generalized anxiety disorder: preliminary evidence for independent and overlapping contributions.. Schwartz. C. M. (2000). Journal of Nervous and Mental Disease. In: L. Depression and Anxiety. Di Nardo. 25. M. Stein. et al. A. (1993). 317–328. R. B. M. Gagnon. P. & Davidson. J. Dugas.. Using the Anxiety Disorders Interview Schedule.... Endorsement frequencies and factor structure of DSM-III-R and DSM-IV generalized anxiety disorder symptoms in women: implications for future research. D. Behaviour Research and Therapy. B. and comorbidity. 791–802. M.. 107. D. 13. L. B. M. J. J. Prevalence of irritable bowel syndrome among university students: the roles of worry. Archives of General Psychiatry. Dugas. In: D. R.. J. and visceral anxiety. Rheaume... BIS/BAS levels and psychiatric disorder: an epidemiological study. 1093–1101. J. A.. S. Measuring global selfesteem: construct validation of a single-item measure and the Rosenberg SelfEsteem Scale. R. 30. Di Nardo. J. & Watson. S. and depression in primary care. 67. J. Behavior Therapy. Holoway. S. S.. Antony.. H. 26. F. D.. B. Shear. Salters-Pedneault. J. 215–233. Gibbon. (1997). anxiety sensitivity. Craske. 676–682. Lehman. H. L.. Laugesen. factor structure. Dissertation Abstracts International. M. T.. & Bukowski. P. A. (2004). (2005). Przeworski. Behavior Therapy. Washington.). P. S. A. R. 110.. M. N. Brown. A.. San Diego. F. 17.. C.. 25. A.. C. NY: Graywind. and worry-related constructs.. M.. H. D. & Dugas. E.. Kerns. M. Specificity of generalized anxiety disorder symptoms and processes. (2008). M. M. H.. E. Rodebaugh. 491–503. N. A. N.)... Effect of autonomic nervous system manipulations on gastric myoelectrical activity and emotional responses in healthy human subjects. O.. Brandenburg. E. W. R. Watson. P. R. M. (1989). (2004).. Journal of. McDonald. B. C. (1998). 245. Dugas. (1999). & Dugas. G. L. J. Behavior Modification. 23. (1994).. Preliminary evidence for an emotion regulation deficit model of generalized anxiety disorder. 25. R. N.... M. G. Frequency and severity of the symptoms of irritable bowel syndrome across the anxiety disorders and depression. 1–32. Freeston. Behavioral expressions of intolerance of uncertainty in worry. and depression. M.. Journal of Psychopathology and Behavioral Assessment. The nosologic relationship between generalized anxiety and major depression. S. B. Muth. 501–505. Stern. (2008).. Fresco. 33. R. Research Version. Newman... B. Ladouceur. Journal of Research in Personality. Psychiatric Clinics of North America... 15... & McLeod. Keefer.. anxiety.. R. D. Tripartite model of anxiety and depression: psychometric evidence and taxonomic implications. Behavior Therapy.. Blais. M. Brown. Intolerance of uncertainty. & Freeston. 639–672.. P. Bryant. Talbot. R. positive affect.. Holaway. J. 69–81.. Rheaume. et al. Cognitive Therapy and Research. Nitschke.. 1–11. T. & Neale. Heimberg. R.. 931– 945. G. J. I. classification. (2008). A. Patient Edition With Psychotic Screen... 9. Reward fails to alter response bias in depression.. A.. M. Irritable bowel syndrome and dysthymia: is there a relationship? Psychosomatics. Boisvert. J. M. H. (2002). Turk.. (2002). 62. pp. M... Marten. Theory and measurement of affect intensity as an individual difference characteristic. The peripheral sympathetic nervous system: its role in normal and pathological anxiety. J.. (1993). Dugas. F. NJ: Lawrence Erlbaum Associates. C. (1995). Hazzlett-Stevens. H. generalized anxiety disorder.. M. E. G. 343–350. Preliminary reliability and validity of the Generalized Anxiety Disorder Questionnaire-IV: a revised self-report diagnostic measure of generalized anxiety disorder. Gupta. K. DC: American Psychological Association. G. J. L. ´ Freeston. J. S. McLeod. Mennin. 17. New York State Psychiatric Institute. 28. M.. Magnuson & A. 501–516. H. Journal of Abnormal Psychology.. L. / Journal of Anxiety Disorders 24 (2010) 250–259 Joormann. M. M. (1991). & Ladouceur. A... Demler. The role of intolerance of uncertainty in etiology and maintenance. Somatic symptoms of generalized anxiety disorder from the DSM-IV: associations with pathological worry and depression symptoms in a nonclinical sample. Psychological Medicine.. 43. 56. Depue. B. (1988). Pluess. M... H. Kubarych. Orlando. 11. Journal of Cognitive Psychotherapy: An International Quarterly. M... A. An emotion regulation framework to discriminate generalized anxiety from depression: the role of emotion intensity and management. Lee. Journal of Abnormal Psychology. M. Buhr. Constantino. K. 55– 64. Somatic manifestations in women with generalized anxiety disorder. S. (2003)... 151–161. J. H.. & Thayer. D. C. Psychopathology: an interactional perspective (pp.. B.

Bryant. The concept of generalized anxiety disorder: between the too narrow and too wide diagnostic criteria. 57. Constructive and unconstructive repetitive thought. M. & Pathak. (2002). (1999). (2008). Affect grid: a single-item scale of pleasure and arousal. Generalized anxiety disorder in primary care: the precursor/modifier pathway to increased health care utilization.. (1994). Weiss.-U. L. O’Hara. W. 135–141. A. 116. G. R. A. 134. Worry and rumination: repetitive thought as a concomitant and predictor of negative mood. Using multivariate statistics (5th ed. Journal of Affective Disorders. D... S. F.. J. & Ormel. P. J. & Yarnold. Journal of Research in Personality. 5– 11.. P.. Generalized anxiety disorder: prevalence. W. C.. & Stuart. D. Wittchen. Tabachnick. V. Cognitive Therapy and Research. & Bogojevic. 162–171. Sloan. Journal of Clinical Psychiatry.. E. A. Uhlenhuth. D. M. 60. M. Dimoulas. 46. G. S. & Mendelsohn. C. E.. Psychopathology. Fallon.A. R. Klein. 314–331. & Lang. 597–603. 671–688.. 58. 282–288.. 28. J. P. Journal of Abnormal Psychology.. Looking at facial expressions: dysphoria and facial EMG. L. Iedema. Russell. Bijl. 34–38. S. (1997). Segerstrom. 58. (2005). (2002).. (2000). 493– 502. Journal of Abnormal Psychology. 24. & Craske. 16. (2001). F. Shankman. Hierarchical structures of affect and psychopathology and their implication for the classification of emotional disorders. 79–90. 95– 104. R. Bradley. The factor structure of the affect intensity measure: in search of a measurement model. P. Smit. Quirk. B. Watson. Aldao et al. K. D. S. W. M. 259 Starcevic. / Journal of Anxiety Disorders 24 (2010) 250–259 Roy-Byrne. N. Watson.... & Katon. The structure and stability of common mental disorders: The NEMESIS Study. de Graaf. Sloan.. (1994).). G. burden. 32. Vollbergh. Depression and Anxiety. (2007). Tenke. & Sajatovic.. and cost to society. Archives of General Psychiatry. Psychopathology. .. C.. Psychological Bulletin. Watkins. Depression and Anxiety. & Fidell. Subjective and expressive emotional responses in depression. E. B. M. (1997). & Bruder. 27. Strauss. (2008). Journal of Personality and Social Psychology.. R.. V. D. 25. G. J.. A. Boston: Allyn & Bacon. 522–536.. P. M. G.. Tsao. M. H. Comorbidity rates do not support the distinction between panic disorder and generalized anxiety disorder. Rethinking the mood and anxiety disorders: a quantitative hierarchical model for DSM-V.. S. V. D. E. E. S. M... Alden. A. Starcevic. 114. Reward sensitivity in depression: a biobehavioral study. H. E. 163–206. J. Biological Psychology. (1989). (2007). E. Weinfurt. 269–272.